Conducting the Pakistan brain tumour epidemiology study - report on the methodology.

Objectives: To combat the lack of brain tumour registries, the Pakistan Brain Tumour Epidemiology Study (PBTES) was conducted without any funding from an external source. METHODS: A retrospective analysis of patient data, including patients of all age groups diagnosed with all histopathological types of brain tumours from all over Pakistan, was performed. For this, Pakistan Brain Tumour Consortium (PBTC) was established, including 32 neurosurgical centres from around the country. Data was collected online through a proforma that included variables such as patient demographics, clinical characteristics, operative details, postoperative complications, survival indices, and current functional status. The data collection and analysis team included principal investigators, core leads, regional leads, regional associates, and student facilitators. Despite logistical concerns and lack of resources, the PBTES was conducted successfully, and a formal brain tumour surveillance database was formed without any external funding, which remains unheard of. CONCLUSIONS: The methods applied in this study are reproducible and can be employed not just to develop more robust brain tumour and other cancer registries but also to study the epidemiology of communicable and non-communicable diseases in resource-limited settings, both locally and globally.

A national overview of paediatric and adolescent and young adult surgical neuro-oncology in Pakistan.

OBJECTIVE: To build a comprehensive brain tumour database that will allow us to analyse in detail the prevalence, demographics, and outcomes of the disease in paediatric, adolescent, and young adult age groups. Method: A national cross-sectional study was conducted at 32 centres, and data regarding patient demographics and brain tumours were collected. This data was then stratified based on age groups, healthcare sectors, socioeconomic status, tumour types, and surgical outcomes. RESULTS: Most of the patients who were diagnosed with brain tumours belonged to a lower socioeconomic background and went to public sector hospitals. More males were diagnosed with and treated for brain tumours in the paediatric, adolescent, and young adult populations. The most common tumour in the paediatric population was medulloblastoma (23.7%) and the most common tumour in the adolescent (27.8%) and young adult population (34.7%) was glioma. Significant improvement in KPS scores were seen for: craniopharyngioma (p = 0.001), meningioma (p < 0.0005) and pituitary adenoma (p < 0.0005). CONCLUSIONS: This study shows that in all three age groups, there was a greater prevalence in males. Most of the patients belonged to a lower-middle-income class background and most patients presented to public sector hospitals. Greater knowledge of these parameters unique to each age group is the key to understanding and alleviating the burden of disease. Cancer registries, specifically brain tumour registries that keep up-to-date records of these patients, are essential to identify and keep track of these unique parameters to advance medical research and treatment strategies, ultimately lowering the disease burden.

Intramedullary spinal cord lesions in children.

Paediatric intramedullary spinal cord lesions are uncommon pathologies, prone to result in dismal prognosis if not managed promptly and aggressively. While children usually present in good functional grades compared to adults, early recognition and treatment is important to improve outcomes. In this review, we present tumour demographics, patient factors, and treatment modalities of intramedullary spinal cord lesions in paediatric patients.

Post-operative seizure control in patients with glioblastoma.

While the median survival in patients with glioblastoma has not improved significantly over the past decade, aggressive attempts have been made on palliation and improving quality of life in these patients. A confluence of two debilitating pathologies which massively distorts the normal day-to-day functioning of the patients who experience it, seizures in glioblastoma patients portends a poor prognosis. There exists a paucity of reported seizure outcomes after glioblastoma treatment in neurosurgical literature. Herein we present a review examining post-operative seizure control in patients with glioblastoma.

Role of Preoperative Embolization in Management of Central Nervous System Tumours.

Preoperative embolization plays a significant role as an adjunct to surgical intervention in the cases of certain vascular tumours of the brain. While the procedure has resulted in facilitated resection of the tumour, and has reduced morbidity and mortality, its application remains debatable within the neurosurgical community, owing to rare, but major post-procedural complications. Herein, we have reviewed the literature to assess the safety and efficacy of preoperative angiographic embolization for brain tumours.

Steriotactic Radiosurgery for Vestibular Schwannomas.

The approach to treating vestibular schwannomas ranges from wait-and-scan policies to micro-and radiosurgery. However, in the past few decades, Stereotac tic Radiosurgery (SRS) has emerged as an approved primary treatment option as well. In this review, we have assessed some of the existing literature on the role of SRS in the management of vestibular schwannomas, and to estimate its efficacy in tumour control and conservation of cranial nerve function.

Surgical outcomes of intramedullary spinal cord ependymomas.

Intramedullary Spinal Cord Ependymomas (ISCE) are uncommon pathologies that need to be aggressively managed before clinical deterioration sets in. Novel application of different therapeutic strategies is being assessed for improving long-term outcomes in patients presenting with these rare neoplasms. In this review, we have discussed the existing literature on ISCEs, and the role of surgery in determining outcomes in terms of neurological status, progression-free survival (PFS) and overall survival (OS).

Extra-neural Metastatic Potential of Primary Central Nervous System Malignancies.

Extraneural metastases of primary central nervous system malignancies are rare and challenging pathologies, with unknown metastatic mechanism and no consensus regarding the best treatment regimen. Herein, we have reviewed the literature to help elucidate characteristics, prognostic factors, and treatment outcomes of patients with metastatic primary brain tumours.

Primary Intracranial Malignant Melanoma.

Primary intracranial malignant melanoma (PIMM) are rare brain tumours; more infrequent than melanomas metastasizing to the brain or those extending to the brain from adjacent structures such as the orbit. Complete surgical excision with adjuvant chemotherapy and radiation remains the mainstay of treatment. Herein, we have reviewed the literature to find the treatment modalities for PIMMs that can lead to longer overall survivals and better patient outcomes.

Permanent pre-operative cerebrospinal fluid diversion in paediatric patients with posterior fossa tumours.

Management options for obstructive hydrocephalus in children with posterior fossa tumours have been debated upon throughout the course of neurosurgical practice. Permanent pre-operative CSF diversion via ventricular shunts or endoscopic third ventriculostomy have been employed to prevent the possible persistence of hydrocephalus after tumour removal, but is considered unnecessary and even dangerous amongst a large group of neurosurgeons. In this paper, we have reviewed the literature for the merits and demerits of pre-operative permanent CSF diversion in paediatric patients presenting with posterior fossa tumours.

Value of achieving a watertight dural closure, and the use of dural sealants after supratentorial cranial surgery.

Dural closure at the end of cranial surgery is considered an extremely important step to maintain anatomical continuity, separate the intradural space with the extradural one, and to prevent possible complications related to cerebrospinal fluid leak. Wherein its usefulness in posterior fossa craniotomy is established, many surgeons do not perform it routinely in supratentorial craniotomies, citing unnecessary delay and lack of evidence supporting it. Herein, we have reviewed the data to find evidence in support of watertight suture based dural closures compared to other dural closure techniques, in supratentorial craniotomies.

Peri-operative Lumbar Drains for Trans-Sphenoidal resection of Pituitary Adenomas.

Trans-sphenoidal approach for resection of pituitary adenomas is a safe and common neurosurgical procedure. It can be done both through microscopic or endoscopic methods, and both methods can be facilitated by a perioperative lumbar drain insertion, that in theory improves tumour resection and reduces risk of post-operative cerebrospinal fluid leak. Herein we have reviewed the literature to find out the evidence in support of perioperative lumbar drain insertion for trans-sphenoidal resections.

Enhanced Recovery after Elective Craniotomy for Brain Tumours.

Enhanced recovery after surgery (ERAS) is aimed at accelerated rehabilitation after surgery, and involves a multidisciplinary approach. Significant work has been published on this concept with regards to abdominal surgeries, however, the idea is relatively new for those undergoing neurosurgical procedures. We have reviewed literature on ERAS in patients undergoing craniotomy for brain tumours.

Patent bibliometrics in spinal deformity: the first bibliometric analysis of spinal deformity's technological literature.

PURPOSE: Bibliometric analyses have gained popularity for studying scientific literature, but their application to evaluate technological literature (patents) remains unexplored. We conducted a bibliometric analysis on the top 100 most-cited patents in scoliosis surgery. METHODS: Multiple databases were queried using The Lens to identify the top 100 scoliosis surgery patents, which were selected based on forward patent citations. These patents were then categorized into 8 groups based on technological descriptors and assessed based on various factors including earliest priority date, year issued, and expiration status. RESULTS: The top 100 most-cited patents included technology underlying anterolateral tethering and distraction systems (n = 11), posterior tethering and distraction systems (n = 23), posterior segmental bone anchor and rod engagement systems (n = 29), interbody devices (n = 10), biological and electrophysiological agents for scoliosis treatment and/or improved arthrodesis (n = 8), intraoperative arthroplasty devices (n = 5), orthotic devices (n = 12), and implantable devices for non-invasive, postoperative alterations of skeletal alignment (n = 2). Seventy-five patents were expired, 21 are still active, and 4 were listed as inactive. The late 1970s and early 2000s saw increased numbers of patent filings. Demonstrated trends showed no meaningful correlation between patent rank and earliest priority date (linear trendline y = 0.2648x - 477.27; R2 = 0.0114), while a very strong correlation was found between patent rank and citations per year (power trendline y = 118.82x--0.83; R2 = 0.8983). CONCLUSION: Patent bibliometric analyses in the field of spinal deformity surgery provide a means to assess past advancements, better understand what it takes to make a difference in the field, and to potentially facilitate the development of innovative technologies in the future. The method described is a reliable and reproducible technique for evaluating technological literature in our field.

Comparison of transforaminal and posterior lumbar interbody fusion outcomes in patients receiving a novel allograft versus rhBMP-2: a radiographic and patient-reported outcomes analysis.

OBJECTIVE: Recombinant human bone morphogenetic protein-2 (rhBMP-2) has been demonstrated to achieve the highest rates of arthrodesis in multilevel lumbar fusion but is also associated with possible perioperative morbidity. A novel allograft (OSTEOAMP) is a differentiated allograft that retains growth factors supporting bone healing. The authors sought to compare the clinical and radiographic outcomes of rhBMP-2 and the novel allograft in lumbar interbody arthrodesis to determine if the latter may be a safer and equally effective alternative to rhBMP-2 for single- and multilevel posterior or transforaminal lumbar interbody fusion (PLIF or TLIF). METHODS: Patients who underwent single- or multilevel TLIF or PLIF using either OSTEOAMP or rhBMP-2 at the authors' institution over a 2-year period were prospectively followed for 12 months. Healthcare utilization, safety measures, patient satisfaction, physical disability (measured on the Oswestry Disability Index [ODI]), back and leg pain (on the numeric rating scale [NRS]), quality of life (on the EQ-5D scale), and return to work (RTW) were prospectively recorded. For purposes of this study, this consecutive series was retrospectively analyzed and pseudarthrosis rates were assessed at 2 years of follow-up. All patients (100%) had both 12-month patient-reported outcome follow-up and 24-month clinical and radiographic follow-up. RESULTS: One thousand one hundred fifty-four patients (654 treated with OSTEOAMP, 500 with rhBMP-2) were prospectively enrolled in the institutional registry. After propensity score matching, there were no significant baseline differences between 330 novel allograft and 330 rhBMP-2 cases. Perioperative morbidity and 90-day hospital readmission (3.3% vs 2.4%, p = 0.485) did not significantly differ between the novel allograft and the rhBMP-2 cases. At the 2-year follow-up, symptomatic pseudarthrosis requiring revision surgery occurred in 8 patients (2.4%) with OSTEOAMP and 6 patients (1.8%) with rhBMP-2 (p = 0.589). The overall fusion rate at 2 years was similar between groups (p = 0.213). Both groups showed significant and equivalent improvement in patient-reported outcome measures (PROMs) from baseline to 12-month follow-up, with no significant difference in 1-year mean NRS leg pain score (2.5 vs 2.7), ODI (25 vs 26), quality-adjusted life years (0.73 vs 0.73), satisfaction (83% vs 80%), or RTW (6.6 vs 7 weeks). CONCLUSIONS: In the authors' institutional experience, OSTEOAMP is a clinically viable substitute for rhBMP-2 for single- and multilevel lumbar fusion. This novel allograft provides clinically effective arthrodesis and improvements in PROMs comparable to rhBMP-2 with a similar safety profile. Additional indications and outcome assessment in longitudinal studies are needed to further characterize this allogeneic graft.

Mental health comorbidities in workers' compensation patients and the effect on pain, disability, quality of life, and return to work after lumbar spine surgery.

OBJECTIVE: The impact of mental health comorbidities on outcomes after lumbar spine surgery in workers' compensation (WC) patients has not been robustly explored. The goal of this study was to examine the impact of mental health comorbidities on pain, disability, quality of life, and return to work after lumbar spine surgery in WC patients. METHODS: A nationwide, prospective surgical outcomes registry (National Neurosurgery Quality Outcomes Database [N2QOD]) was queried for all patients who underwent 1- to 4-level lumbar decompression and/or fusion from 2012 to 2021. Patients were stratified on the basis of compensation status into non-WC (25,507) and WC (1018) cohorts. Baseline demographic data, perioperative safety data, and patient-reported outcome measures were compared between groups. The WC cohort was further subdivided on the basis of mental health status into patients with anxiety and depression (n = 107) and those without anxiety and depression (n = 911). Propensity matching was used to generate parity between these subgroups, generating 214 patients (107 pairs) for analysis. Perioperative safety, facility utilization, 1-year patient-reported outcomes (back and leg pain, disability, and quality of life), and return to work were measured as a function of WC and mental health comorbidity status. RESULTS: A total of 26,525 patients (25,507 non-WC and 1018 WC) who underwent 1- to 4-level lumbar spine surgery were reviewed. WC patients were younger, healthier (lower American Society of Anesthesiologists class), more likely to be minorities, less educated, and more likely to smoke and had greater baseline back pain, disability, and quality of life compared to non-WC patients. The prevalence of anxiety and depression was similar between groups (11%). WC patients had worse outcomes for all measures and lower rates of return to work compared to non-WC patients. WC patients with anxiety and depression demonstrated even greater disparities in all outcomes. After propensity matching, WC patients with anxiety and depression continued to demonstrate significantly worse outcomes in comparison to WC patients without anxiety and depression. CONCLUSIONS: Disparities in outcomes after lumbar spine surgery in WC patients are exacerbated in patients with anxiety and depression. WC patients with mental health comorbidities receive the least benefit from lumbar spine surgery and may represent the most vulnerable subset of patients with spine pathology. Addressing mental health comorbidities preoperatively may represent an opportunity for valuable resource allocation and surgical optimization in the WC population.

Open Versus Percutaneous Stabilization of Thoracolumbar Fractures: A Large Retrospective Analysis of Safety and Reoperation Rates.

BACKGROUND: Thoracolumbar fractures (TLF) requiring surgical intervention can be treated with either open or percutaneous stabilization, each with some distinct risks and benefits. There is insufficient evidence available to support one approach as superior. METHODS: Patients who underwent spinal fixation for TLF between 2008 and 2020 were reviewed. Patients with one or two levels of fracture treated with either open or percutaneous stabilization were included. Exclusion criteria were more than two levels of fracture, patients requiring corpectomy, stabilization constructs that crossed the cervicothoracic or lumbosacral junction, history of previous thoracolumbar fusion at the same level, spinal neoplasm, anterior or lateral fixation, and spinal infection. Demographic, operative, and clinical data were collected for all patients. RESULTS: 691 patients (377 open, 314 percutaneous) met the inclusion criteria. Patients in the percutaneous cohort sustained lower estimated blood loss (73 vs 334 ml; p< 0.001) and shorter length of surgery (114 vs. 151 minutes; p< 0.001). No differences were observed in the length of hospital stay or overall reoperation rates. Asymptomatic (7.0% vs 0.8%) and symptomatic (3.5% vs 0.5%) hardware removal was more common with the percutaneous cohort, while the incidence of revision surgery due to hardware failure requiring the extension of the construct (1.9% vs 5.8%) and infection (1.9% vs 6.4%) was greater in the open group. CONCLUSION: Percutaneous stabilization for TLF was associated with shorter operative time, less blood loss, lower infection rate, higher rates of elective hardware removal, and lower rates of hardware failure requiring extension of the construct compared to open stabilization.

Expanding Clinician Access to High-Quality, Low-Cost Biomechanical Research: A Technical Report on the Carolina Neurosurgery and Spine Biomechanics Laboratory.

Spine biomechanical research helps us better understand the spine in physiologic and pathologic states and gives us a mechanism by which to evaluate surgical interventions, generate and evaluate models of spine pathologies, and develop novel, data-driven surgical strategies and devices. Access to a biomechanical testing laboratory is therefore potentially invaluable to those who specialize in treating spine pathologies. A number of barriers to access have precluded many clinicians from pursuing their biomechanical research interests, foremost among these is cost. The Carolina Neurosurgery and Spine Biomechanics Research Laboratory (CNSBL) was developed as a model of a low-cost, easy-to-access laboratory capable of generating high-quality data in tests of axial load, tension, torque, displacement, and pathological model testing. Our experience in developing this laboratory suggests that a large number of basic biomechanical research inquiries can be studied in a laboratory composed of less than $7500 USD of hardware. We hope that this model serves as a roadmap for any like-minded practitioners seeking broader access to biomechanical testing facilities.

Predictors of Survival in Patients with Metastatic Brain Tumors: Experience from a Low-to-Middle-Income Country.

Objective The interplay of static factors and their effect on metastatic brain tumor survival, especially in low-to-middle-income countries (LMICs), has been rarely studied. To audit our experience, and explore novel survival predictors, we performed a retrospective analysis of brain metastases (BM) patients at Shaukat Khanum Memorial Cancer Hospital (SKMCH), Pakistan. Materials and Methods A retrospective review was conducted of consecutive patients who presented with BM between September 2014 and September 2019 at SKMCH. Patients with incomplete records were excluded. Statistical Analysis SPSS (v.25 IBM, Armonk, New York, United States) was used to collect and analyze data via Cox-Regression and Kaplan-Meier curves. Results One-hundred patients (mean age 45.89 years) with confirmed BM were studied. Breast cancer was the commonest primary tumor. Median overall survival (OS) was 6.7 months, while the median progression-free survival (PFS) was 6 months. Age ( p = 0.001), gender ( p = 0.002), Eastern Cooperative Oncology Group ( p < 0.05), anatomical site ( p = 0.002), herniation ( p < 0.05), midline shift ( p = 0.002), treatment strategies ( p < 0.05), and postoperative complications (p < 0.05) significantly impacted OS, with significantly poor prognosis seen with extremes of age, male gender (hazard ratio [HR]: 2.0; 95% confidence interval [CI]: 1.3-3.1; p = 0.003), leptomeningeal lesions (HR: 5.7; 95% CI: 1.1-29.7; p = 0.037), and patients presenting with uncal herniation (HR: 3.5; 95% CI: 1.9-6.3; p < 0.05). Frontal lobe lesions had a significantly better OS (HR: 0.5; 95% CI: 0.2-1.0; p = 0.049) and PFS (HR: 0.08; 95% CI: 0.02-0.42; p = 0.003). Conclusion BM has grim prognoses, with comparable survival indices between developed countries and LMICs. Early identification of both primary malignancy and metastatic lesions, followed by judicious management, is likely to significantly improve survival.

Review: Patent Bibliometrics in Cranial Neurosurgery: The First Bibliometric Analysis of Neurosurgery's Technological Literature.

BACKGROUND: Bibliometric analyses of the scientific literature have grown increasingly popular in the past few decades. However, patent bibliometric studies, evaluation of technological literature, have not yet been applied in neurosurgery. OBJECTIVE: To perform a pilot patent bibliometric analysis of the top 100 most cited patents in cranial neurosurgery. METHODS: The Lens was used to query multiple databases, to select the top 100 cranial neurosurgical patents based upon forward patent citations. These were organized into 9 categories based on technological descriptors and were evaluated based on the earliest priority date, year issued, and expiration status, among others. RESULTS: The top 100 most cited patents included technology underlying 3D navigation (n = 31), pharmacology and implants (n = 20), vascular occlusion (n = 5), craniotomy closure (n = 9), focal lesioning and tissue resection (n = 8), brain and systemic cooling (n = 5), neuroendoscopy (n = 8), neuromonitoring and stimulation (6), and technologies improving surgeon performance (n = 8). Ninety-six patents were filed in the United States, 72 were expired, 19 are still active, and 9 were listed as inactive. The highest number of patents was applied for from the mid-1990s to the mid-2000s. Demonstrated trends showed no meaningful correlation between patent rank and earliest priority date (linear trendline y = 0.7107 x -1367.5; R2 = 0.0671), while a very strong correlation was found between patent rank and citations per year (power trendline y = 127.93 x -1.094; R2 = 0.8579). CONCLUSIONS: Patent bibliometrics allow evaluation of neurosurgical advancements from the past and enable subsequent development of cutting-edge technology in the future. The described method is a reproducible and reliable technique for evaluating our field's patent literature.