Tag: meta-analysis

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Endoscopic Versus Traditional Thoracic Discectomy: A Multicenter Retrospective Case Series and Meta-Analysis

Neurosurgery 96:152–171, 2025

Surgical treatment for symptomatic thoracic disc herniations (TDH) involves invasive open surgical approaches with relatively high complication rates and prolonged hospital stays. Although advantages of full endoscopic spine surgery (FESS) are well-established in lumbar disc herniations, data are limited for the endoscopic treatment of TDH despite potential benefits regarding surgical invasiveness. The aim of this study was to provide a comprehensive evaluation of potential benefits of FESS for the treatment of TDH.

METHODS: PubMed, MEDLINE, EMBASE, and Scopus were systematically searched for the term “thoracic disc herniation” up to March 2023 and study quality appraised with a subsequent meta-analysis. Primary outcomes were perioperative complications, need for instrumentation, and reoperations. Simultaneously, we performed a multicenter retrospective evaluation of outcomes in patients undergoing full endoscopic thoracic discectomy.

RESULTS: We identified 3190 patients from 108 studies for the traditional thoracic discectomy meta-analysis. Pooled incidence rates of complications were 25% (95% CI 0.22-0.29) for perioperative complications and 7% (95% CI 0.05-0.09) for reoperation. In this cohort, 37% (95% CI 0.26-0.49) of patients underwent instrumentation. The pooled mean for estimated blood loss for traditional approaches was 570 mL (95% CI 477.3-664.1) and 7.0 days (95% CI 5.91-8.14) for length of stay. For FESS, 41 patients from multiple institutions were retrospectively reviewed, perioperative complications were reported in 4 patients (9.7%), 4 (9.7%) required revision surgery, and 6 (14.6%) required instrumentation. Median blood loss was 5 mL (IQR 5-10), and length of stay was 0.43 days (IQR 0-1.23).

CONCLUSION: The results suggest that full endoscopic thoracic discectomy is a safe and effective treatment option for patients with symptomatic TDH. When compared with open surgical approaches, FESS dramatically diminishes invasiveness, the rate of complications, and need for prolonged hospitalizations. Full endoscopic spine surgery has the capacity to alter the standard of care for TDH treatment toward an elective outpatient surgery.

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Pedicle Subtraction Osteotomies for Surgical Correction of Fixed Sagittal Imbalance: A Meta-Analysis and Systematic Review

Neurosurgery 95:1223–1231, 2024

Disruption of the spine’s sagittal balance is associated with significant negative impacts on quality of life. Compared with other spinal osteotomies, pedicle subtraction osteotomy (PSO), which can potentially offer greater correction, is considered technically challenging and performed at lower rates. The aim of this study was to review the use of PSO to correct fixed sagittal imbalance and assess its efficacy and associated perioperative complications.

METHODS: In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, the PubMed, EBSCO host, MEDLINE, and Google Scholar databases were queried for full-text English manuscripts published from 1961 to 2022, exploring PSO for the management of fixed sagittal imbalance. Studies were included if they reported preoperative and postoperative radiographic measurements. The mean Methodological Index for Nonrandomized Studies (MINORS) for included articles was 9.6 ± 1.1. The outcomes of interest included etiology, operative time, blood loss, complications, radiographic outcomes, and patient-reported outcomes. Statistical analysis was performed using a random-effects, inverse variance-weighted meta-analysis of observational data. Pre and postoperative radiographic and clinical outcomes were compared using a Student t-test.

RESULTS: Fourteen studies with 595 patients were included. Meta-analysis showed that the mean operative time was 7.2 ± 2.0 hours, and the average blood loss was 2033 ± 629 mL. After PSO, there was a significant improvement in sagittal vertebral axis (12.41-3.92 cm, P = .0003), LL (13.35°-42.60°, P = .000002), PSO angle (5.11°to À26.91°, P = .0001), and Oswestry Disability Index (55.36-27.35, P = .02). Common complications include pseudarthrosis (8.1%), neurological deficits (7.8%), and proximal junctional failure (6.0%).

CONCLUSION: PSO offers significant correction of sagittal vertebral axis, lumbar lordosis, PSO angle, and Oswestry Disability Index scores despite its reduced utilization in recent years. Blood loss and high complication rates must be considered when evaluating the efficacy of this procedure; however, surgeon experience and operative techniques can be used to reduce morbidity.

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Efficacy and safety of tranexamic acid in the management of chronic subdural hematoma

J Neurosurg 141:945–954, 2024

Chronic subdural hematoma (CSDH) is a prevalent neurosurgical condition, particularly among the elderly. Various treatment options exist, but recurrence rates remain high. This systematic review and meta-analysis aims to assess the efficacy and safety of tranexamic acid (TXA) in the management of CSDH.

METHODS The authors conducted a comprehensive literature search adhering to the 2020 PRISMA guidelines, involving three primary databases (Scopus, PubMed, and Web of Science) that were searched for articles compiled from inception until October 20, 2023. The primary outcome was recurrence of CSDH, and secondary outcomes included complications and SDH volume following TXA treatment. The mean difference and odds ratios with 95% confidence intervals were calculated using the random-effects model.

RESULTS A total of 5 studies, involving 643 patients in the TXA group and 736 patients in the non-TXA group, met the inclusion criteria. The meta-analysis revealed that TXA use led to a significantly lower CSDH recurrence (OR 0.35, 95% CI 0.23–0.53; p < 0.01) without increasing complications (OR 1.84, 95% CI 0.43–7.95; p = 0.42). Additionally, TXA users had a significantly lower CSDH volume compared to the non-TXA group at 3-month follow-up (mean difference −4.56, 95% CI −8.76 to −0.36; p = 0.03).

CONCLUSIONS The findings suggest that TXA might be a promising agent for reducing the risk of CSDH recurrence without elevating the risk of complications. However, these results should be interpreted cautiously due to the limited number of studies included and the methodological heterogeneity. Further large-scale randomized controlled trials are needed to confirm these findings.

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Awake Versus Asleep Craniotomy for Patients With Eloquent Glioma: A Systematic Review and Meta-Analysis

Neurosurgery 94:38–52, 2024

Awake vs asleep craniotomy for patients with eloquent glioma is debatable. This systematic review and meta-analysis sought to compare awake vs asleep craniotomy for the resection of gliomas in the eloquent regions. METHODS: MEDLINE and PubMed were searched from inception to December 13, 2022. Primary outcomes were the extent of resection (EOR), overall survival (month), progression-free survival (month), and rates of neurological deficit, Karnofsky performance score, and seizure freedom at the 3-month follow-up. Secondary outcomes were duration of operation (minute) and length of hospital stay (LOS) (day).

RESULTS: Fifteen studies yielded 2032 patients, from which 800 (39.4%) and 1232 (60.6%) underwent awake and asleep craniotomy, respectively. The meta-analysis concluded that the awake group had greater EOR (mean difference [MD]= MD= 8.52 [4.28, 12.76], P < .00001), overall survival (MD = 2.86 months [1.35, 4.37], P = .0002), progression-free survival (MD = 5.69 months [0.75, 10.64], P = .02), 3-month postoperative Karnofsky performance score (MD = 13.59 [11.08, 16.09], P < .00001), and 3-month postoperative seizure freedom (odds ratio = 8.72 [3.39, 22.39], P < .00001). Furthermore, the awake group had lower 3-month postoperative neurological deficit (odds ratio = 0.47 [0.28, 0.78], P = .004) and shorter LOS (MD = -2.99 days [-5.09, -0.88], P = .005). In addition, the duration of operation was similar between the groups (MD = 37.88 minutes [-34.09, 109.86], P = .30).

CONCLUSION: Awake craniotomy for gliomas in the eloquent regions benefits EOR, survival, postoperative neurofunctional outcomes, and LOS. When feasible, the authors recommend awake craniotomy for surgical resection of gliomas in the eloquent regions.

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Optimizing surgical management of facet cysts of the lumbar spine: systematic review, meta-analysis, and local case series of 1251 patients

J Neurosurg Spine 39:793–806, 2023

Lumbar facet cysts (LFCs) can cause neurological dysfunction and intractable pain. Surgery is the current standard of care for patients in whom conservative therapy fails, those with neurological deficits, and those with evidence of spinal instability. No study to date has comprehensively examined surgical outcomes comparing the multiple surgical treatment options for LFCs. Therefore, the authors aimed to perform a combined analysis of cases both in the literature and of patients at a single institution to compare the outcomes of various surgical treatment options for LFC.

METHODS The authors performed a literature review in accordance with PRISMA guidelines and meta-analysis of the PubMed, Embase, and Cochrane Library databases and reviewed all studies from database inception published until February 3, 2023. Studies that did not contain 3 or more cases, clearly specify follow-up durations longer than 6 months, or present new cases were excluded. Bias was evaluated using Cochrane Collaboration’s Risk of Bias in Nonrandomised Studies–of Interventions (ROBINS-I). The authors also reviewed their own local institutional case series from 2015 to 2020. Primary outcomes were same-level cyst recurrence, same-level revision surgery, and perioperative complications. ANOVA, common and random-effects modeling, and Wald testing were used to compare treatment groups.

RESULTS A total of 1251 patients were identified from both the published literature (29 articles, n = 1143) and the authors’ institution (n = 108). Patients were sorted into 5 treatment groups: open cyst resection (OCR; n = 720), tubular cyst resection (TCR; n = 166), cyst resection with arthrodesis (CRA; n = 165), endoscopic cyst resection (ECR; n = 113), and percutaneous cyst rupture (PCR; n = 87), with OCR being the analysis reference group. The PCR group had significantly lower complication rates (p = 0.004), higher recurrence rates (p < 0.001), and higher revision surgery rates (p = 0.001) compared with the OCR group. Patients receiving TCR (3.01%, p = 0.021) and CRA (0.0%, p < 0.001) had significantly lower recurrence rates compared with those undergoing OCR (6.36%). The CRA group (6.67%) also had significantly lower rates of revision surgery compared with the OCR group (11.3%, p = 0.037).

CONCLUSIONS While PCR is less invasive, it may have high rates of same-level recurrence and revision surgery. Recurrence and revision rates for modalities such as ECR were not significantly different from those of OCR. While concomitant arthrodesis is more invasive, it might lead to lower recurrence rates and lower rates of subsequent revision surgery. Given the limitations of our case series and literature review, prospective, randomized studies are needed.

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Robot-assisted percutaneous pedicle screw placement accuracy compared with alternative guidance in lateral single-position surgery

J Neurosurg Spine 39:443–451, 2023

While single-position surgery (SPS) eliminates the need for patient repositioning, the placement of screws in the unconventional lateral position poses unique challenges related to asymmetry relative to the surgical table. Use of robotic guidance or intraoperative navigation can help to overcome this. The aim of this study was to compare the relative accuracies offered by these various navigation modalities for pedicle screws placed in lateral SPS.

METHODS According to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, the PubMed/Medline, Embase, and Cochrane Library databases were queried for studies reporting pedicle screw placement accuracy using fluoroscopic, CT-navigated, O-arm, or robotic guidance in lateral SPS, and a systematic review and meta-analysis was performed. Included studies all compared evaluated screw placement accuracy in lateral SPS using a single navigation method. Quality assessment was performed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system; risk of bias was assessed using the Newcastle-Ottawa Scale and the Joanna Briggs Institute checklist. The primary outcome, rate of pedicle screw breach, was analyzed using random-effects meta-analysis.

RESULTS Eleven studies were included comprising 548 patients who underwent the placement of instrumentation with 2488 screws. For the fluoroscopic, CT-navigated, O-arm, and robotic guidance cohorts, there were 3, 2, 3, and 3 studies, respectively. Breach rates by modality were as follows: fluoroscopic guidance (6.6%), CT navigation (4.7%), O-arm (3.9%), and robotic guidance (3.9%). Random-effects meta-analysis showed a significant difference between studies, with an overall breach rate of 4.9% (95% CI 3.1%–7.5%; p < 0.001); however, testing for subgroup differences failed to show a significant difference between guidance modalities (Q M = 0.69, df = 3; p = 0.88). Heterogeneity between studies was significant (I 2 = 79.0%, τ 2 = 0.41, χ 2 = 47.65, df = 10; p < 0.001).

CONCLUSIONS Robotic guidance of screws is noninferior to alternative guidance modalities in lateral SPS; however, additional prospective studies directly comparing different guidance types are merited.

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Middle Meningeal Artery Embolization Versus Conventional Management for Patients With Chronic Subdural Hematoma: A Systematic Review and Meta-Analysis

Neurosurgery 92:1142–1154, 2023

The results from studies that compare middle meningeal artery (MMA) embolization vs conventional management for patients with chronic subdural hematoma are varied.

OBJECTIVE: To conduct a systematic review and meta-analysis on studies that compared MMA embolization vs conventional management.

METHODS: Medline, PubMed, and Embase databases were searched. Primary outcomes were treatment failure and surgical rescue; secondary outcomes were complications, follow-up modified Rankin scale > 2, mortality, complete hematoma resolution, and length of hospital stay (day). The certainty of the evidence was determined using the GRADE approach.

RESULTS: Nine studies yielding 1523 patients were enrolled, of which 337 (22.2%) and 1186 (77.8%) patients received MMA embolization and conventionalmanagement, respectively.MMA embolization was superior to conventional management for treatment failure (relative risk [RR] = 0.34 [0.14-0.82], P = .02), surgical rescue (RR = 0.33 [0.14-0.77], P = .01), and complete hematoma resolution (RR = 2.01 [1.10-3.68], P = .02). There was no difference between the 2 groups for complications (RR= 0.93 [0.63-1.37], P = .72), follow-up modified Rankin scale >2 (RR= 0.78 [0.449-1.25], P= .31), mortality (RR= 1.05 [0.51-2.14], P = .89), and length of hospital stay (mean difference = 0.57 [ 2.55, 1.41], P = .57). ForMMAembolization, the number needed to treat for treatment failure, surgical rescue, and complete hematoma resolution was 7, 9, and 3, respectively. The certainty of the evidence was moderate to high for primary outcomes and low to moderate for secondary outcomes.

CONCLUSION: MMA embolization decreases treatment failure and the need for surgical rescue without furthering the risk of morbidity and mortality. The authors recommend considering MMA embolization in the chronic subdural hematoma management.

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Internal Ventricular Cerebrospinal Fluid Shunt for Adult Hydrocephalus: A Systematic Review and Meta-Analysis of the Infection Rate

Hydrocephalus is a common neurological condition that usually requires internal ventricular cerebrospinal fluid shunt (IVCSFS). The reported infection rate (IR) varies greatly from below 1% up to over 50%, but no meta-analysis to assess the overall IR has ever been performed.

OBJECTIVE: To determine the IVCSFS overall IR in the adult population and search for associated factors.

METHODS: Six databases were searched from January 1990 to July 2022. Only original articles reporting on adult IVCSFS IR were included. Random-effects meta-analysis with generalized linear mixed model method and logit transformation was used to assess the overall IR. RESULTS: Of 1703 identified articles, 44 were selected, reporting on 57259 patients who had IVCSFS implantation and 2546 infections. The pooled IR value and its 95% CI were 4.75%, 95% CI (3.8 to 5.92). Ninety-five percent prediction interval ranged from 1.19% to 17.1%. The patients who had IVCSFS after intracranial hemorrhage showed a higher IR (7.65%, 95% CI [5.82 to 10], P-value = .002). A meta-regression by year of publication found a decreasing IR (À0.031, 95% CI [À0.06 to 0.003], P-value = .032) over the past 32 years.

CONCLUSION: IVCSF is a procedure that every neurosurgeon should be well trained to perform. However, the complication rate remains high, with an estimated overall IR of 4.75%. The IR is especially elevated for hydrocephalic patients who require IVCSFS after intracranial hemorrhage. However, decades of surgical advances may have succeeded in reducing IR over the past 32 years.

Neurosurgery 92:894–904, 2023

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Sacrifice or preserve the superior petrosal vein in microvascular decompression surgery

J Neurosurg 138:390–398, 2023

In microvascular decompression (MVD) surgery through the retrosigmoid approach, the surgeon may have to sacrifice the superior petrosal vein (SPV). However, this is a controversial maneuver. To date, high-level evidence comparing the operative outcomes of patients who underwent MVD with and without SPV sacrifice is lacking. Therefore, this study sought to bridge this gap.

METHODS The authors searched the Medline and PubMed databases with appropriate Medical Subject Heading (MeSH) terms and keywords. The primary outcome was vascular-related complications; secondary outcomes were new neurological deficit, cerebrospinal fluid (CSF) leak, and neuralgia relief. The pooled proportions of outcomes and OR (95% CI) for categorical data were calculated by using the logit transformation and Mantel-Haenszel methods, respectively.

RESULTS Six studies yielding 1143 patients were included, of which 618 patients had their SPV sacrificed. The pooled proportion (95% CI) values were 3.82 (0.87–15.17) for vascular-related complications, 3.64 (1.0–12.42) for new neurological deficits, 2.85 (1.21–6.58) for CSF leaks, and 88.90 (84.90–91.94) for neuralgia relief. The meta-analysis concluded that, whether the surgeon sacrificed or preserved the SPV, the odds were similar for vascular-related complications (2.5% vs 1.5%, OR [95% CI] 1.01 [0.33–3.09], p = 0.99), new neurological deficits (1.2% vs 2.8%, OR [95% CI] 0.55 [0.18–1.66], p = 0.29), CSF leak (3.1% vs 2.1%, OR [95% CI] 1.16 [0.46–2.94], p = 0.75), and neuralgia relief (86.6% vs 87%, OR [95% CI] 0.96 [0.62–1.49], p = 0.84).

CONCLUSIONS SPV sacrifice is as safe as SPV preservation. The authors recommend intentional SPV sacrifice when gentle retraction fails to enhance surgical field visualization and if the surgeon encounters SPV-related neurovascular conflict and/or anticipates impeding SPV-related bleeding.

 

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Failure of Internal Cerebrospinal Fluid Shunt: A Systematic Review and Meta-Analysis of the Overall Prevalence in Adults

World Neurosurg. (2023) 169:20-30

Reported rates of failures of internal cerebrospinal fluid shunt (ICSFS) vary greatly from less than 5% to more than 50% and no meta-analysis to assess the overall prevalence has been performed. We estimated the failure rate after ICSFS insertion and searched for associated factors.

METHODS: Six databases were searched from January 1990 to February 2022. Only original articles reporting the rate of adult shunt failure were included. Random-effects meta-analysis with a generalized linear mixed model method and logit transformation was used to compute the overall failure prevalence. Subgroup analysis and meta-regression were implemented to search for associated factors.

RESULTS: Of 1763 identified articles, 46 were selected, comprising 70,859 ICSFS implantations and 13,603 shunt failures, suggesting an accumulated incidence of 19.2%. However, the calculated pooled prevalence value and its 95% confidence interval (CI) were 22.7% (95% CI, 19.8e5.8). The CI of the different estimates did not overlap, indicating a strong heterogeneity confirmed by a high I 2 of 97.5% (95% CI, 97.1e97.8; P < 0.001; s 2 [ 0.3). Ninety-five percent prediction interval of shunt failure prevalence ranged from 8.75% to 47.36%. A meta-regression of prevalence of publication found a barely significant decreasing failure rate of about 2% per year (e2.11; 95% CI, e4.02 to e0.2; P [ 0.031).

CONCLUSIONS: Despite being a simple neurosurgical procedure, ICSFS insertion has one of the highest risk of complications, with failure prevalence involving more than 1 patient of 5. Nonetheless, all efforts to lower this high level of shunt failure seem to be effective.

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Audiovestibular symptoms and facial nerve function comparing microsurgery versus SRS for vestibular schwannomas

Acta Neurochirurgica (2022) 164:3221–3233

Surgery and radiosurgery represent the most common treatment options forcvestibular schwannoma. A systematic review and meta-analysis were conducted to compare the outcomes of surgery versus stereotactic radiosurgery (SRS).

Methods The Cochrane library, PubMed, Embase, and clinicaltrials.gov were searched through 01/2021 to find all studies on surgical and stereotactic procedures performed to treat vestibular schwannoma. Using a random-effects model, pooled odds ratios (OR) and their 95% confidence intervals (CI) comparing post- to pre-intervention were derived for pre-post studies, and pooled incidence of adverse events post-intervention were calculated for case series and stratified by intervention type.

Results Twenty-one studies (18 pre-post design; three case series) with 987 patients were included in the final analysis. Comparing post- to pre-intervention, both surgery (OR: 3.52, 95%CI 2.13, 5.81) and SRS (OR: 3.30, 95%CI 1.39, 7.80) resulted in greater odds of hearing loss, lower odds of dizziness (surgery OR: 0.10; 95%CI 0.02, 0.47 vs. SRS OR: 0.22; 95%CI 0.05, 0.99), and tinnitus (surgery OR: 0.23; 95%CI 0.00, 37.9; two studies vs. SRS OR: 0.11; 95%CI 0.01, 1.07; one study). Pooled incidence of facial symmetry loss was larger post-surgery (14.3%, 95%CI 6.8%, 22.7%) than post-SRS (7%, 95%CI 1%, 36%). Tumor control was larger in the surgery (94%, 95%CI 83%, 98%) than the SRS group (80%, 95%CI 31%, 97%) for small-to-medium size tumors.

Conclusion Both surgery and SRS resulted in similar odds of hearing loss and similar improvements in dizziness and tinnitus among patients with vestibular schwannoma; however, facial symmetry loss appeared higher post-surgery.

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Comparison of anterior cervical discectomy and fusion versus artificial disc replacement for cervical spondylotic myelopathy: a meta-analysis

J Neurosurg Spine 37:569–578, 2022

Anterior cervical discectomy and fusion (ACDF) has long been regarded as a gold standard in the treatment of cervical myelopathy. Subsequently, cervical artificial disc replacement (c-ADR) was developed and provides the advantage of motion preservation at the level of the intervertebral disc surgical site, which may also reduce stress at adjacent levels. The goal of this study was to compare clinical and functional outcomes in patients undergoing ACDF with those in patients undergoing c-ADR for cervical spondylotic myelopathy (CSM).

METHODS A systematic literature review and meta-analysis were performed using the Embase, PubMed, and Cochrane Central Register of Controlled Trials databases from database inception to November 21, 2021. The authors compared Neck Disability Index (NDI), SF-36, and Japanese Orthopaedic Association (JOA) scores; complication rates; and reoperation rates for these two surgical procedures in CSM patients. The Mantel-Haenszel method and varianceweighted means were used to analyze outcomes after identifying articles that met study inclusion criteria.

RESULTS More surgical time was consumed in the c-ADR surgery (p = 0.04). Shorter hospital stays were noted in patients who had undergone c-ADR (p = 0.04). Patients who had undergone c-ADR tended to have better NDI scores (p = 0.02) and SF-36 scores (p = 0.001). Comparable outcomes in terms of JOA scores (p = 0.24) and neurological success rate (p = 0.12) were noted after the surgery. There was no significant between-group difference in the overall complication rates (c-ADR: 18% vs ACDF: 25%, p = 0.17). However, patients in the ACDF group had a higher reoperation rate than patients in the c-ADR group (4.6% vs 1.5%, p = 0.02).

CONCLUSIONS At the midterm follow-up after treatment of CSM, better functional outcomes as reflected by NDI and SF-36 scores were noted in the c-ADR group than those in the ACDF group. c-ADR had the advantage of retaining range of motion at the level of the intervertebral disc surgical site without causing more complications. A large sample size with long-term follow-up studies may be required to confirm these findings in the future.

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Surgical versus Nonsurgical Treatment for Adult Spinal Deformity: A Systematic Review and Meta-Analysis

World Neurosurg. (2022) 159:1-11

OBJECTIVE: To systematically evaluate the efficacy and safety of surgical and nonsurgical methods for the treatment of adult spinal deformity (ASD).

METHODS: The PubMed, Embase, and Cochrane Library databases were searched for relevant controlled studies of surgical and nonsurgical approaches for the treatment of ASD; all studies reported from database creation to October 2021 were eligible for inclusion. Stata 11.0 software was used for the metaanalysis. Publication bias was assessed using a Begg test. Heterogeneity was assessed using the I2 test, and fixed-effects or random-effects models were used, as appropriate. Meta-regression was used to determine the cause of heterogeneity. Subgroup analyses were performed to assess the effects of age on the outcomes. –

RESULTS: Eleven articles comprising 1880 participants met the inclusion criteria. Meta-analysis showed that surgical treatment was associated with a better improvement in function than was nonsurgical treatment (Scoliosis Research Society 22 questionnaire score change value: weighted mean difference [ 0.696; 95% confidence interval [CI], 0.686e0.705; P < 0.0001; Oswestry Dysfunction Index change value: WMD [ 11.222; 95% CI, 10.801e11.642; P < 0.0001). Surgical treatment was more effective in relieving pain and correcting the deformity (numeric rating scale pain score: WMD[3.341; 95% CI, 2.832e3.85; P < 0.0001; Cobb angle change value: WMD [ 15.036 ; 95% CI, 13.325e16.747; P < 0.0001). The complication rate in the surgical group was 17.6%e80.3%.

CONCLUSIONS: Surgical treatment is better than nonsurgical methods for improving the function of patients with ASD and achieving good pain improvement and deformity correction. Elderly patients with ASD can also obtain good symptomatic improvement through surgery

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Insular epilepsy surgery: lessons learned from institutional review and patient-level meta-analysis

J Neurosurg 136:523–535, 2022

Insular lobe epilepsy is a challenging condition to diagnose and treat. Due to anatomical intricacy and proximity to eloquent brain regions, resection of epileptic foci in that region can be associated with significant postoperative morbidity. The aim of this study was to review available evidence on postoperative outcomes following insular epilepsy surgery.

METHODS A comprehensive literature search (PubMed/MEDLINE, Scopus, Cochrane) was conducted for studies investigating the postoperative outcomes for seizures originating in the insula. Seizure freedom at last follow-up (at least 12 months) comprised the primary endpoint. The authors also present their institutional experience with 8 patients (4 pediatric, 4 adult).

RESULTS A total of 19 studies with 204 cases (90 pediatric, 114 adult) were identified. The median age at surgery was 23 years, and 48% were males. The median epilepsy duration was 8 years, and 17% of patients had undergone prior epilepsy surgery. Epilepsy was lesional in 67%. The most common approach was transsylvian (60%). The most commonly resected area was the anterior insular region (n = 42, 21%), whereas radical insulectomy was performed in 13% of cases (n = 27). The most common pathology was cortical dysplasia (n = 68, 51%), followed by low-grade neoplasm (n = 16, 12%). In the literature, seizure freedom was noted in 60% of pediatric and 69% of adult patients at a median follow-up of 29 months (75% and 50%, respectively, in the current series). A neurological deficit occurred in 43% of cases (10% permanent), with extremity paresis comprising the most common deficit (n = 35, 21%), followed by facial paresis (n = 32, 19%). Language deficits were more common in left-sided approaches (24% vs 2%, p < 0.001). Univariate analysis for seizure freedom revealed a significantly higher proportion of patients with lesional epilepsy among those with at least 12 months of follow-up (77% vs 59%, p = 0.032).

CONCLUSIONS These findings may serve as a benchmark when tailoring decision-making for insular epilepsy, and may assist surgeons in their preoperative discussions with patients. Although seizure freedom rates are quite high with insular epilepsy treatment, the associated morbidity needs to be weighed against the potential for seizure freedom.

 

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External Lumbar Drainage following Traumatic Intracranial Hypertension

Neurosurgery 89:395–405, 2021

Traumatic brain injury (TBI) often results in elevations in intracranial pressure (ICP) that are refractory to standard therapies. Several studies have investigated the utility of external lumbar drainage (ELD) in this setting.

OBJECTIVE: To evaluate the safety and efficacy of ELD or lumbar puncture with regard to immediate effect on ICP, durability of the effect on ICP, complications, and neurological outcomes in adults with refractory traumatic intracranial hypertension.

METHODS: A systematic review and meta-analysis were conducted beginning with a comprehensive search of PubMed/EMBASE. Two investigators reviewed studies for eligibility and extracted data. The strength of evidence was evaluated using GRADE methodology. Random-effects meta-analyses were performed to calculate pooled estimates.

RESULTS: Nine articles detailing 6 studies (N = 110) were included. There was moderate evidence that ELD has a significant immediate effect on ICP; the pooled effect size was –19.5 mmHg (95% CI –21.0 to –17.9 mmHg). There was low evidence to indicate a durable effect of ELD on ICP up to at least 24 h following ELD. There was low evidence to indicate that ELD was safe and associated with a low rate of clinical cerebral herniation or meningitis. There was very low evidence pertaining to neurological outcomes.

CONCLUSION: Given preliminary data indicating potential safety and feasibility in highly selected cases, the use of ELD in adults with severe TBI and refractory intracranial hypertension in the presence of open basal cisterns and absence of large focal hematoma merits further high-quality investigation; the ideal conditions for potential application remain to be determined.

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Occlusion Rate and Visual ComplicationsWith Flow-Diverter Stent Placed Across the Ophthalmic Artery’s Origin for Carotid-Ophthalmic Aneurysms: A Meta-Analysis

Neurosurgery 86:455–463, 2020

Flow-diverter stents (FDSs) have recently gained acceptance for the treatment of intracranial aneurysms, especially for carotid-ophthalmic aneurysms (COAs). However, complications have been reported after coverage of side branches, especially the ophthalmic artery (OA).

OBJECTIVE: To evaluate, through a meta-analysis, the occlusion rate, and the ophthalmic complications after treatment of COA by FDS.

METHODS:We reviewed on MEDLINE via PubMed, Embase via Ovid, and Cochrane central database via CENTRAL.We included all case serieswith at least 15 patients and clinical trials about flow diversion of aneurysms close to the OA’s origin. Among these studies, we only included articles with aneurysm occlusion rate and rate of new ophthalmic symptoms.

RESULTS: We included 16 studies with 913 COA treated by FDSs and covering the OA with a mean follow-up of 16.4 mo. The random-effect modeling analysis concerning the overall rate of new ophthalmic complications, after FDS deployment covering the OA, was 3.0% (CI95% 1.0-6.0). There was medium-high heterogeneity in the study reports P < .01, I2 = 70.2% [50.4%; 82.1%]. We were not able to statistically explain this heterogeneity with the performed analysis, which could be related to the design of the included studies. We found an overall aneurysm occlusion rate of 85.0% (95% CI 80.0-89.0).

CONCLUSION: Our meta-analysis found a high aneurysm occlusion rate (85%) and low rate of iatrogenic visual complications, with only 3.0% of new visual symptoms, after treatment of COA by FDS.

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Embolization of the middle meningeal artery in patients with chronic subdural hematoma—a systematic review and meta-analysis

Acta Neurochirurgica (2020) 162:777–784

Chronic subdural hematoma (CSDH) remains a neurosurgical condition with high recurrence rate after surgical treatment. The primary pathological mechanism is considered to be repeated microbleedings from fragile neo-vessels within the outer hematoma membrane. The neo-vessels are supplied from peripheral branches of the middle meningeal artery, and embolization of MMA (eMMA) has been performed to prevent re-bleeding episodes and thereby CSDH recurrence.

Objective To evaluate the published evidence for the effect of eMMA in patients with recurrent CSDH. Secondarily, to investigate the effect of eMMA as an alternative to surgery for primary treatment of CSDH. Method A systematic review of the literature on eMMA in patients with recurrent CSDH was conducted. PubMed, Embase, and Cochrane databases were reviewed using the search terms: Embolization, Medial Meningeal Artery, Chronic Subdural Haematoma, and Recurrence. Furthermore, the following mesh terms were used: Chronic Subdural Haematoma AND embolization AND medial meningeal artery AND recurrence. Eighteen papers were found and included. No papers were excluded. The number of patients with primary CSDH and the number of patients with recurrent CSDH treated with eMMA were listed. Furthermore, the number of recurrences in both categories was registered.

Results Eighteen papers with a total of 191 included patients diagnosed with CSDH treated with eMMA for primary and recurrent CSDH were identified. Recurrence rate for patients treated with eMMA for recurrent CSDH was found to be 2.4%, 95%CI (0.5%; 11.0%), whereas the recurrence rate for patients treated with eMMAfor primary CSDH was 4.1%, 95%CI (1.4%; 11.4%).

Conclusion eMMA is a minimally invasive procedure for treatment of CSDH. Although this study is limited by publication bias, it seems that this procedure may reduce recurrence rates compared with burr hole craniostomy for both primary and recurrent hematomas. A controlled study is warranted.

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Pain Outcomes Following Microvascular Decompression for Drug-Resistant Trigeminal Neuralgia: A Systematic Review and Meta-Analysis

Neurosurgery, Volume 86, Issue 2, February 2020, Pages 182–190

Microvascular decompression (MVD) is a potentially curative surgery for drug-resistant trigeminal neuralgia (TN). Predictors of pain freedom after MVD are not fully understood. OBJECTIVE: To describe rates and predictors for pain freedom following MVD.

METHODS: Using preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines, PubMed, Cochrane Library, and Scopus were queried for primary studies examining pain outcomes after MVD for TN published between 1988 and March 2018. Potential biases were assessed for included studies. Pain freedom (ie, Barrow Neurological Institute score of 1) at last follow-up was the primary outcome measure. Variables associated with pain freedom on preliminary analysis underwent formal meta-analysis. Odds ratios (OR) and 95% confidence intervals (CI) were calculated for possible predictors.

RESULTS: Outcome data were analyzed for 3897 patients from 46 studies (7 prospective, 39 retrospective). Overall, 76.0% of patients achieved pain freedom afterMVD with amean follow-up of 1.7 ± 1.3 (standard deviation) yr. Predictors of pain freedom on meta-analysis using random effectsmodels included (1) disease duration≤5 yr (OR=2.06, 95% CI=1.08- 3.95); (2) arterial compression over venous or other (OR = 3.35, 95% CI = 1.91-5.88); (3) superior cerebellar artery involvement (OR = 2.02, 95% CI = 1.02-4.03), and (4) type 1 Burchiel classification (OR = 2.49, 95% CI = 1.32-4.67).

CONCLUSION: Approximately three-quarters of patients with drug-resistant TN achieve pain freedom after MVD. Shorter disease duration, arterial compression, and type 1 Burchiel classification may predict more favorable outcome. These results may improve patient selection and provider expectations.

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Outcomes of Retreatment for Intracranial Aneurysms—A Meta-Analysis

Neurosurgery. 2019 Dec 1;85(6):750-761

Long-term results from the International Subarachnoid Hemorrhage Trial (ISAT) and Barrow Ruptured Aneurysm Trial (BRAT) indicate considerably higher retreatment rates for aneurysms treated with coiling compared to clipping, but do not report the outcome of retreatment.

OBJECTIVE: To evaluate retreatment related outcomes.

METHODS: A meta-analysis in accordance with PRISMA guidelines was conducted using Medline search engines PubMed and EMBASE to identify articles describing outcomes after retreatment for intracranial aneurysms. Pooled prevalence rates for complete occlusion rate and mortality were calculated. Outcomes of different treatment and retreatment combinations were not compared because of indication bias.

RESULTS: Twenty-five articles that met the inclusion criteria were included in the metaanalysis. Surgery after coiling had a pooled complete occlusion rate of 91.2% (95% confidence interval [CI]: 87.0-94.1) and a pooled mortality rate of 5.6% (95% CI: 3.7-8.3). Coiling after coiling had a pooled complete occlusion rate of 51.3% (95% CI: 22.1-78.0) and a pooled mortality rate of 0.8% (95% CI: 0.15-3.7). Surgery after surgery did not provide a pooled estimate for complete occlusion as only one study was identified but had a pooled mortality rate of 5.9% (95% CI: 3.1-11.2). Coiling after surgery had a pooled complete occlusion rate of 56.1% (95% CI: 11.4-92.7) and a pooled mortality rate of 9.3% (95% CI: 4.1- 19.9). All pooled incidence rates were produced using random-effect models.

CONCLUSION: Surgical retreatment was associated with a high complete occlusion rate but considerable mortality. Conversely, endovascular retreatment was associated with low mortality but also a low complete occlusion rate.

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Repeat Gamma Knife radiosurgery versus microvascular decompression following failure of GKRS in trigeminal neuralgia: a systematic review and meta-analysis

J Neurosurg 131:1197–1206, 2019

Gamma Knife radiosurgery (GKRS) has emerged as a promising treatment modality for patients with classical trigeminal neuralgia (TN); however, considering that almost half of the patients experience post-GKRS failure or lesion recurrence, a repeat treatment is typically necessary. The existing literature does not offer clear evidence to establish which treatment modality, repeat GKRS or microvascular decompression (MVD), is superior. The present study aimed to compare the overall outcome of patients who have undergone either repeat GKRS or MVD after failure of their primary GKRS; the authors do so by conducting a systematic review and meta-analysis of the literature and analysis of data from their own institution.

METHODS The authors conducted a systematic review and meta-analysis of the PubMed, Cochrane Library, Web of Science, and CINAHL databases to identify studies describing patients who underwent either repeat GKRS or MVD after initial failed GKRS for TN. The primary outcomes were complete pain relief (CPR) and adequate pain relief (APR) at 1 year. The secondary outcomes were rate of postoperative facial numbness and the retreatment rate. The pooled data were analyzed with R software. Bias and heterogeneity were assessed using funnel plots and I 2 tests, respectively. A retrospective analysis of a series of patients treated by the authors who underwent repeat GKRS or MVD after postGKRS failure or relapse is presented.

RESULTS A total of 22 studies met the selection criteria and were included for final data retrieval and meta-analysis. The search did not identify any study that had directly compared outcomes between patients who had undergone repeat GKRS versus those who had undergone MVD. Therefore, the authors’ final analysis included two groups: studies describing outcome after repeat GKRS (n = 17) and studies describing outcome after MVD (n = 5). The authors’ institutional study was the only study with direct comparison of the two cohorts. The pooled estimates of primary outcomes were APR in 83% of patients who underwent repeat GKRS and 88% of those who underwent MVD (p = 0.49), and CPR in 46% of patients who underwent repeat GKRS and 72% of those who underwent MVD (p = 0.02). The pooled estimates of secondary outcomes were facial numbness in 32% of patients who underwent repeat GKRS and 22% of those who underwent MVD (p = 0.11); the retreatment rate was 19% in patients who underwent repeat GKRS and 13% in those who underwent MVD (p = 0.74). The authors’ institutional study included 42 patients (repeat GKRS in 15 and MVD in 27), and the outcomes 1 year after retreatment were APR in 80% of those who underwent repeat GKRS and 81% in those who underwent MVD (p = 1.0); CPR was achieved in 47% of those who underwent repeat GKRS and 44% in those who underwent MVD (p = 1.0). There was no difference in the rate of postoperative facial numbness or retreatment.

CONCLUSIONS The current meta-analysis failed to identify any superiority of one treatment over the other with comparable outcomes in terms of APR, postoperative facial numbness, and retreatment rates. However, MVD was shown to provide a better chance of CPR compared with repeat GKRS.

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