The prognostic utility of neutrophil-lymphocyte ratio in spinal surgery: A systematic review and meta-analysis.

PURPOSE: Neutrophil-lymphocyte ratio (NLR) is reportedly an effective prognostic tool across various medical and surgical fields, but its value in spinal surgery is unestablished. We aim to investigate the relationship between elevated baseline/postoperative NLR and patient outcomes in spinal surgery. MATERIALS AND METHODS: We performed a systematic search in PubMed, EMBASE, and SCOPUS databases for studies investigating the prognostic value of NLR in spine patients.Odds ratios (ORs) and hazard ratios (HRs) with 95% confidence intervals (CIs) were analysed on the RevMan 5.4 software. Where meta-analysis was not possible, we vote-counted the direction of the effect of elevated NLR. The GRADE framework for prognostic factor research was utilised to assess the certainty of the evidence for each outcome measure. RESULTS: Five outcome measures (overall survival, mortality, disease-free survival, functional recovery and complications) were assessed across 16 studies involving 5471 patients. Elevated baseline NLR was associated with reduced overall survival (HR: 1.63, 95 % CI: 1.05 - 2.54) (GRADE: low) and worsened functional recovery (OR: 0.93, 95 % CI: 0.87 - 0.98) (GRADE: low). There was no association between baseline NLR and disease-free survival (HR: 2.42, 95 % CI: 0.49 - 11.83) (GRADE: very low) or mortality (OR: 1.39, 95 % CI: 0.41 - 4.75) (GRADE: very low). Elevated NLR levels measured on days 3-4 and days 6-7 postoperatively, but not NLR measured at baseline or on days 1-2 postoperatively, were associated with greater risks of complications (GRADE: low). CONCLUSIONS: NLR is an objective tool with the potential to identify the patients that would benefit from surgery and facilitate shared decision-making.

The prognostic utility of temporalis muscle thickness measured on magnetic resonance scans in patients with intra-axial malignant brain tumours: A systematic review and meta-analysis.

Introduction: Sarcopenia is associated with worsened outcomes in solid cancers. Temporalis muscle thickness (TMT) has emerged as a measure of sarcopenia. Hence, this study aims to evaluate the relationship between TMT and outcome measures in patients with malignant intra-axial neoplasms. Method: We searched Medline, Embase, Scopus and Cochrane databases for relevant studies. Event ratios with 95% confidence intervals (CI) were analysed using the RevMan 5.4 software. Where meta-analysis was impossible, vote counting was used to determine the effect of TMT on outcomes. The GRADE framework was used to determine the certainty of the evidence. Results: Four outcomes were reported for three conditions across 17 studies involving 4430 patients. Glioblastoma: thicker TMT was protective for overall survival (OS) (HR 0.59; 95% CI 0.46-0.76) (GRADE low), progression free survival (PFS) (HR 0.40; 95% CI 0.26-0.62) (GRADE high), and early discontinuation of treatment (OR 0.408; 95% CI 0.168-0.989) (GRADE high); no association with complications (HR 0.82; 95% CI 0.60-1.10) (GRADE low). Brain Metastases: thicker TMT was protective for OS (HR 0.73; 95% CI 0.67-0.78) (GRADE moderate); no association with PFS (GRADE low). Primary CNS Lymphoma: TMT was protective for overall survival (HR 0.34; 95% CI 0.19-0.60) (GRADE moderate) and progression free survival (HR 0.23; 95% CI 0.09-0.56) (GRADE high). Conclusion: TMT has significant prognostic potential in intra-axial malignant neoplasms, showing a moderate to high certainty for its association with outcomes following GRADE evaluation. This will enable shared decision making between patients and clinicians.

Video-Based Performance Analysis in Pituitary Surgery-Part 1: Surgical Outcomes.

BACKGROUND: Endoscopic pituitary adenoma surgery has a steep learning curve, with varying surgical techniques and outcomes across centers. In other surgeries, superior performance is linked with superior surgical outcomes. This study aimed to explore the prediction of patient-specific outcomes using surgical video analysis in pituitary surgery. METHODS: Endoscopic pituitary adenoma surgery videos from a single center were annotated by experts for operative workflow (3 surgical phases and 15 surgical steps) and operative skill (using modified Objective Structured Assessment of Technical Skills [mOSATS]). Quantitative workflow metrics were calculated, including phase duration and step transitions. Poisson or logistic regression was used to assess the association of workflow metrics and mOSATS with common inpatient surgical outcomes. RESULTS: 100 videos from 100 patients were included. Nasal phase mean duration was 24 minutes and mean mOSATS was 21.2/30. Mean duration was 34 minutes and mean mOSATS was 20.9/30 for the sellar phase, and 11 minutes and 21.7/30, respectively, for the closure phase. The most common adverse outcomes were new anterior pituitary hormone deficiency (n = 26), dysnatremia (n = 24), and cerebrospinal fluid leak (n = 5). Higher mOSATS for all 3 phases and shorter operation duration were associated with decreased length of stay (P = 0.003 &P < 0.001). Superior closure phase mOSATS were associated with reduced postoperative cerebrospinal fluid leak (P < 0.001), and superior sellar phase mOSATS were associated with reduced postoperative visual deterioration (P = 0.041). CONCLUSIONS: Superior surgical skill and shorter surgical time were associated with superior surgical outcomes, at a generic and phase-specific level. Such video-based analysis has promise for integration into data-driven training and service improvement initiatives.

Simultaneous occurrence of subarachnoid hemorrhage and cerebral venous sinus thrombosis: A systematic review of cases.

Although the leading causes of subarachnoid hemorrhage (SAH) are aneurysm rupture and arteriovenous malformations, cerebral venous sinus thrombosis (CVST) can, in rare cases, be associated with SAH. This phenomenon is an uncommon presentation, with less than a hundred cases reported based on our review of the literature. The purpose of this review is to highlight what is known regarding these cases, how they are managed and to highlight the need for further studies that will serve as a basis for the development of a standard management guideline across board. The following databases were searched: PubMed and Ovid Embase. A complementary search of Google Scholar and AJOL was done. Gray literature search was also conducted on the Google search engine for any additional relevant papers. We were able to extract data regarding 33 cases from 29 identified studies. The mean age was 46.6 ± 14.08. 17 (51.5%) of the cases were female, and the female-to-male ratio is 1.1:1. Headache was by far the commonest symptom, occurring in 82% of cases followed by seizures in 42% of cases. Four patients (12%) had loss of consciousness while 5 patients (15%) had some form of focal neurologic deficit. Twenty patients had cerebral venous sinus thrombosis in at least two different sinuses. The superior sagittal sinus was the most common location for CVSTs (79%), followed by the transverse sinus (57.5%). Twenty-nine cases (89%) were managed with anticoagulation alone and one case had a mechanical thrombectomy. We have performed a comprehensive review of cases that had the simultaneous occurrence of SAH and CVST and have identified their peculiarities and the challenges to management. Further research is needed in order to identify a causal relationship and to serve as a basis for the development of a standard management guideline across the board.

Spontaneous obliteration of brain arteriovenous malformations: illustrative cases.

BACKGROUND: Spontaneous angiographic obliteration of a brain arteriovenous malformation (AVM) is considered a rare outcome, with most cases in the literature related to prior hemorrhage in small brain AVMs. The authors present a prospective, single center, consecutive case series. The clinical course and radiographic features of four cases with spontaneous obliteration of brain AVM were analyzed. OBSERVATIONS: The median age of patients in this series was 47.6 years, with an equal gender split. The median maximum brain AVM diameter was 2 cm. The median time to spontaneous obliteration was 26 months, with hemorrhage preceding this in three out of four cases and a prolonged latency in the only case with a nidus size larger than 3 cm and no hemorrhage. LESSONS: The present study provides additional information to allow clinicians to counsel patients about the rare outcomes of conservative management. This work extends our understanding of when this phenomenon can occur by reporting on the differences associated with spontaneous obliteration of larger AVMs.

A Scoping Review of the Use of Improvised External Ventricular Drains in Africa.

Poor access to neurosurgical equipment is one of the problems limiting service delivery in Africa. Improvised surgical devices have long been used in Africa as replacements for high-cost standard versions. In this study, we aimed to see if improvised external ventricular drains (EVD) are being used, how these devices are made, and what their outcomes are. The PRISMA extension for scoping reviews was used in conducting this study. A search was conducted from inception to July 2022. PubMed, Ovid Embase, and African Journal Online were searched. Three studies were identified and used. The methods of making the EVD devices were compared and the incidence proportions of improvised EVD-related infections were calculated. The standard ventricular catheter was replaced by cheaper alternatives like a size 6/8 feeding tube or a 14-gauge central line catheter. The connecting tube had low-cost alternatives, and in a study, was replaced by a fluid infusion set. Aggregated outcomes from the three identified studies show that just over half of the sample survived post-EVD insertion (54%). The incidence proportion of EVD-related infections was 24%. This study describes the experience of African centers with an improvised version of the EVD devices and their outcomes. This will serve as a baseline for more research into the use of improvised EVD devices in low-resource settings.

Aspirin Compared With Other Anticoagulants for Use as Venous Thromboembolism Prophylaxis in Elective Orthopaedic Hip and Knee Operations: A Narrative Literature Review.

Although total hip and knee arthroplasty are effective methods for treating arthritis, they have an associated risk of venous thromboembolism (VTE). To reduce this risk, prophylactic agents including aspirin, low-molecular-weight Heparin, vitamin K antagonists, and direct oral anticoagulants are employed for up to 35 days after surgery. This narrative literature review utilised a systematic approach to critically assess the current evidence surrounding the use of aspirin for VTE prophylaxis compared to anticoagulants. An advanced multistage electronic search was performed in May 2021 using the OVID/Medline and Embase online libraries to identify available studies relevant to the subject from 1974. Additional studies identified during the review process were also included. The final studies meeting the inclusion criteria were then assessed using the Critical Appraisal Skills Programme tool. A total of 12 (60%) studies (two meta-analyses, three randomised trials, seven retrospective studies) favoured aspirin over anticoagulants for VTE prophylaxis. A total of 15 (75%) studies (two meta-analyses, three randomised trials, nine retrospective, one matched cohort) reported that aspirin had better bleeding profiles and complication rates, which was statistically significant in seven (46.7%) studies (one randomised trial, six retrospective studies). A total of eight studies (one randomised trial, six retrospective studies, one matched cohort) reported statistically significant results for aspirin. Five (62.5%) studies reported aspirin to be superior for VTE prophylaxis, while seven (87.5%) reported aspirin to be superior in terms of bleeding complications. The current evidence indicates that aspirin is superior to anticoagulants, in their various iterations, for VTE prophylaxis in terms of their bleeding profiles.