Interrater Agreement of Height Assessment by Rigid Proctoscopy/Rectoscopy for Rectal Carcinoma.

BACKGROUND: Some guidelines for rectal carcinoma consider 12 cm, measured by rigid endoscopy, to be the cutoff tumor height for optional neoadjuvant chemoradiation therapy. Measuring differences of only a few centimeters may predetermine the choice of further therapy. However, rigid endoscopy may exhibit similar operator dependence to most other clinical examination methods. OBJECTIVES: Evaluation of concordance of rigid rectoscopic tumor height measurements performed by 4 experienced examiners, 2 measuring with patients in the lithotomy position and 2 in the left lateral position. Assessment of tumor palpability and distance of the anal verge to the anocutaneous line were also evaluated. DESIGN: This study used a prospective observational design. SETTING: This study was conducted at an academic teaching hospital that is a referral center for colorectal surgery. PATIENTS: There were 50 patients, of whom 35 were men (70%). The median age was 72.5 years (53-88 years). MAIN OUTCOME MEASURES: Interrater agreement of tumor height assessment and tumor height of less than or greater than the 12-cm height limit. RESULTS: With an intraclass correlation coefficient of 0.947 (95% CI, 0.918-0.967, p < 0.001), interrater reliability of tumor height assessment was statistically rated "excellent." Despite this, in 26% of patients, there was no agreement regarding the allocation of the tumor <12- or >12-cm height limit. Furthermore, there was also considerable disagreement concerning tumor palpability and the distance of the anal verge to the anocutaneous line. Patient positioning was not found to influence results. LIMITATIONS: Single-center study. CONCLUSIONS: Rigid rectal endoscopy may not be a sound pivotal basis for the consideration of optional chemoradiation therapy in rectal carcinoma. Application of a universally valid height limit ignores biological variability in body frame, gender, and acquired pelvic descent. Eligibility for neoadjuvant therapy should not rely on height measurements alone. Uniform MRI or CT imaging protocols, based on agreed upon terminology, including factors such as tumor height relative to the pelvic frame and peritoneal reflection, may be an important diagnostic addition to such a decision. See Video Abstract .Clinical trial registration: DRKS00012758 (German National Study Registry), ST-D 406 (German Cancer Society). ACUERDO ENTRE EVALUADORES EN LA EVALUACIN DE LA ALTURA MEDIANTE PROCTO/ RECTOSCOPIA RGIDA PARA EL CARCINOMA DE RECTO: ANTECEDENTES:Algunas guías para el carcinoma de recto consideran que 12 cm, medidos mediante endoscopia rígida, es la altura de corte del tumor para la quimiorradiación neoadyuvante opcional. Por lo tanto, una diferencia de medición de sólo unos pocos centímetros puede predeterminar la elección de una terapia adicional. Sin embargo, la endoscopia rígida puede presentar una dependencia del operador similar a la de la mayoría de los demás métodos de examen clínico.OBJETIVOS:Evaluación de la concordancia de las mediciones de la altura del tumor rectoscópico rígido realizadas por cuatro examinadores experimentados, dos en litotomía y dos en posición lateral izquierda. También se evaluó la evaluación de la palpabilidad del tumor y la distancia del borde anal a la línea anocutánea.DISEÑO:Estudio observacional prospectivo.LUGAR:Hospital universitario, centro de referencia para cirugía colorrectal.PACIENTES:50 pacientes, 35 varones (70%), mediana de edad 72,5 años (53-88 años).PRINCIPALES MEDIDAS DE RESULTADOS:Acuerdo entre evaluadores en la evaluación de la altura del tumor y la asignación del tumor por debajo o más allá del límite de altura de 12 cm.RESULTADOS:Con un coeficiente de correlación intraclase de 0,947 (IC del 95%: 0,918-0,967, p < 0,001), la confiabilidad entre evaluadores de la evaluación de la altura del tumor se calificó estadísticamente como "excelente". A pesar de esto, en el 26% de los pacientes no hubo acuerdo sobre la asignación del tumor por debajo o por encima del límite de 12 cm de altura. Además, también hubo un considerable desacuerdo con respecto a la palpabilidad del tumor y la distancia del borde anal a la línea anocutánea. No se encontró que la posición del paciente influyera en los resultados.LIMITACIONES:Estudio unicéntrico.CONCLUSIONES:La endoscopia rectal rígida puede no ser una base sólida y fundamental para considerar la quimiorradiación opcional en el carcinoma de recto. La aplicación de un límite de altura universalmente válido obviamente ignora la variabilidad biológica en la constitución corporal, el género y el descenso pélvico adquirido. La elegibilidad para la terapia neoadyuvante no debe depender únicamente de las mediciones de altura. Los protocolos uniformes de imágenes por resonancia magnética o tomografía computarizada, basados en una terminología acordada, incluidos factores como la altura del tumor en relación con la estructura pélvica y la reflexión peritoneal, pueden ser una adición diagnóstica importante para tal decisión. (Traducción-Yesenia Rojas-Khalil )Clinical trial registration: DRKS00012758 (German National Study Registry), ST-D 406 (German Cancer Society).

Does Early Mobilization Following Resection of Spinal Intra-Dural Pathology Increase the Risk of Cerebrospinal Fluid Leaks?-A Dual-Center Comparative Effectiveness Research.

Background and Objectives: Prolonged bed rest after the resection of spinal intradural tumors is postulated to mitigate the development of cerebrospinal fluid leaks (CSFLs), which is one of the feared postoperative complications. Nonetheless, the empirical evidence supporting this conjecture remains limited and requires further investigation. The goal of the study was to investigate whether prolonged bed rest lowers the risk of CSFL after the resection of spinal intradural tumors. The primary outcome was the rate of CSFL in each cohort. Materials and Methods: To validate this hypothesis, we conducted a comparative effectiveness research (CER) study at two distinct academic neurosurgical centers, wherein diverse postoperative treatment protocols were employed. Specifically, one center adopted a prolonged bed rest regimen lasting for three days, while the other implemented early postoperative mobilization. For statistical analysis, case-control matching was performed. Results: Out of an overall 451 cases, we matched 101 patients from each center. We analyzed clinical records and images from each case. In the bed rest center, two patients developed a CSFL (n = 2, 1.98%) compared to four patients (n = 4, 3.96%) in the early mobilization center (p = 0.683). Accordingly, CSFL development was not associated with early mobilization (OR 2.041, 95% CI 0.365-11.403; p = 0.416). Univariate and multivariate analysis identified expansion duraplasty as an independent risk factor for CSFL (OR 60.33, 95% CI: 0.015-0.447; p < 0.001). Conclusions: In this CER, we demonstrate that early mobilization following the resection of spinal intradural tumors does not confer an increased risk of the development of CSFL.

Resection of Intramedullary Hemangioblastoma: Timing of Surgery and Its Impact on Neurological Outcome and Quality of Life.

Background and Objectives: Spinal intramedullary hemangioblastomas (SIMH) are benign vascular lesions that are pathological hallmarks of von Hippel-Lindau disease (vHL) and constitute the third most common intramedullary neoplasm in adults. So far, maximal and safe resection is the first choice of treatment. However, as SIMH show no malignant transformation, it remains unclear whether surgical resection is beneficial for all patients. Materials and Methods: We retrospectively analyzed the surgical outcomes of 27 patients who were treated between 2014 and 2022 at our neurosurgical department and investigated potential risk factors that influence the surgical outcome. Pre- and postoperative neurological status were classified according to the McCormick scale. Furthermore, surgical quality indicators, such as length of hospital stay (LOS; days), 90-day readmissions, nosocomial infections, and potential risk factors that might influence the surgical outcome, such as tumor size and surgical approach, have been analyzed. In addition to that, patients were asked to fill out the EQ-5D-3L questionnaire to assess their quality of life after surgery. Results: Surgery on SIMH patients that display no or minor neurological deficits (McCormick scale I or II) is associated with a favorable postoperative outcome and overall higher quality of life compared to those patients that already suffer from severe neurological deficits (McCormick scale III or IV). Conclusion: Early surgical intervention prior to the development of severe neurological deficits may offer a better neurological outcome and quality of life.

The applicability of established clinical and histopathological risk factors for tumor recurrence during long-term postoperative care in meningioma patients.

Risk factors to predict late-onset tumor recurrence in meningioma patients are urgently needed to schedule control intervals during long-term follow-up. We therefore analyzed the value of established risk factors for postoperative meningioma recurrence for the prediction of long-term prognosis. Correlations of clinical and histopathological variables with tumor relapse after 3, 5, and 10 years following microsurgery were analyzed in uni- and multivariate analyses, and compared to findings in the entire cohort. In the entire cohort (N = 1218), skull base location (HR: 1.51, 95%CI 1.05-2.16; p = .026), Simpson ≥ IV resections (HR: 2.41, 95%CI 1.52-3.84; p < .001), high-grade histology (HR: 3.70, 95%CI 2.50-5.47; p < .001), and male gender (HR: 1.46, 95%CI 1.01-2.11; p = .042) were independent risk factors for recurrence. Skull base location (HR: 1.92, 95%CI 1.17-3.17; p = .010 and HR: 2.02, 95%CI 1.04-3.95; p = .038) and high-grade histology (HR: 1.87, 95%CI 1.04-3.38; p = .038 and HR: 2.29, 95%CI 1.07-4.01; p = .034) but not subtotal resection (HR: 1.53, 95%CI .68-3.45; p = .303 and HR: 1.75, 95%CI .52-5.96; p = .369) remained correlated with recurrence after a recurrence-free follow-up of ≥ 3 and ≥ 5 years, respectively. Postoperative tumor volume was related with recurrence in general (p < .001) but not beyond a follow-up of ≥ 3 years (p > .05). In 147 patients with a follow-up of ≥ 10 years, ten recurrences occurred and were not correlated with any of the analyzed variables. Skull base tumor location and high-grade histology but not the extent of resection should be considered when scheduling the long-term follow-up after meningioma surgery. Recurrences ≥ 10 years after surgery are rare, and predictors are lacking.

Applicability of contemporary quality indicators in vestibular surgery-do they accurately measure tumor inherent postoperative complications of vestibular schwannomas?

BACKGROUND: Due to rising costs in health care delivery, reimbursement decisions have progressively been based on quality measures. Such quality indicators have been developed for neurosurgical procedures, collectively. We aimed to evaluate their applicability in patients that underwent surgery for vestibular schwannoma and to identify potential new disease-specific quality indicators. METHODS: One hundred and three patients operated due to vestibular schwannoma were subject to analysis. The primary outcomes of interest were 30-day and 90-day reoperation, readmission, mortality, nosocomial infection and surgical site infection (SSI) rates, postoperative cerebral spinal fluid (CSF) leak, facial, and hearing function. The secondary aim was the identification of prognostic factors for the mentioned primary outcomes. RESULTS: Thirty-day (90-days) outcomes in terms of reoperation were 10.7% (14.6%), readmission 9.7% (13.6%), mortality 1% (1%), nosocomial infection 5.8%, and SSI 1% (1%). A 30- versus 90-day outcome in terms of CSF leak were 6.8% vs. 10.7%, new facial nerve palsy 16.5% vs. 6.1%. Hearing impairment from serviceable to non-serviceable hearing was 6.8% at both 30- and 90-day outcome. The degree of tumor extension has a significant impact on reoperation (p < 0.001), infection (p = 0.015), postoperative hemorrhage (p < 0.001), and postoperative hearing loss (p = 0.026). CONCLUSIONS: Our data demonstrate the importance of entity-specific quality measurements being applied even after 30 days. We identified the occurrence of a CSF leak within 90 days postoperatively, new persistent facial nerve palsy still present 90 days postoperatively, and persisting postoperative hearing impairment to non-serviceable hearing as potential new quality measurement variables for patients undergoing surgery for vestibular schwannoma.

Minimally Invasive Facetectomy and Fusion for Resection of Extensive Dumbbell Tumors in the Lumbar Spine.

Background and Objectives: Resection of dumbbell tumors can be challenging, and facet joint sparing approaches carry the risk of incomplete resection. In contrast, additional facetectomy may allow better surgical exposure at the cost of spinal stability. The aim of this study is to compare facet-sparing and facetectomy approaches for the treatment of lumbar spine dumbbell tumors. Materials and Methods: In a cohort study setting, we analyzed Eden type 2 and 3 tumors operated in our department. Conventional facet-sparing microsurgical or facetectomy approaches with minimally invasive fusions were performed according to individual surgeons' preference. Primary outcomes were extent of resection and tumor progression over time. Secondary outcomes were perioperative adverse events. Results: Nineteen patients were included. Nine patients were operated on using a facet-sparing technique. Ten patients underwent facetectomy and fusion. While only one patient (11%) in the facet-sparing group experienced gross total resection (GTR), this was achieved for all patients in the facetectomy group (100%). The relative risk (RR) for incomplete resection in the facet-sparing cohort was 18.7 (95% CI 1.23-284.047; p = 0.035). In addition, time to progression was shorter in the facet-sparing cohort (p = 0.022) and all patients with a residual tumor underwent a second resection after a median follow-up time of 42 months (IQR 25-66). Conclusions: Minimally invasive resection of lumbar Eden type 2 and 3 dumbbell tumors including facetectomy in combination with instrumentation appears to be safe and superior to the facet-sparing approach in terms of local tumor control.

Evaluation of 311 contemporary cases of stereotactic biopsies in patients with neoplastic and non-neoplastic lesions-diagnostic yield and management of non-diagnostic cases.

Stereotactic biopsies are an established tool for obtaining diagnosis of unclear brain lesions. However, non-diagnostic biopsies still occur. We aimed to analyze the contemporary diagnostic yield of stereotactic biopsies, predictors for non-diagnostic biopsies, outcome, and follow-up strategy after non-diagnostic biopsy. We conducted a single-center retrospective study of 311 adult patients undergoing stereotactic biopsies due to a newly diagnosed lesion at our department between 2012 and 2018. Patient data regarding comorbidities, presenting symptoms, imaging features, and non-invasive diagnostic procedures were obtained. The overall diagnostic yield was 86.2% and differed significantly between the various suspected diagnosis groups and was the highest when suspecting primary brain tumor compared with non-neoplastic lesions (91.2% vs. 73.3%, p > 0.001). Predicators for non-diagnostic biopsies were small lesion size, lack of contrast-enhancement, presence of sepsis, or underlying hemato-oncological disease. In case of non-diagnostic biopsy, a re-biopsy was performed in 12 cases, revealing a final diagnosis in 75%. In 16 cases, empiric therapy was started based on the suspected underlying disease. Close follow-up was performed in the remaining 15 cases. We showed that stereotactic biopsy is a safe procedure with reasonable diagnostic yield even for non-neoplastic lesions, when non-invasive diagnostic was inconclusive. In addition, we developed treatment recommendations for cases of non-diagnostic biopsies.

Virtual reality-based evaluation of neurovascular conflict for the surgical planning of microvascular decompression in trigeminal neuralgia patients.

OBJECTIVE: Trigeminal neuralgia (TN) is a lightning bolt of violent, electrifying, and stinging pain, often secondary to the neurovascular conflict (NVC). The vessels involved in NVC are mostly arteries and rarely veins. Evaluation of NVC in the deep infratentorial region is inseparably connected with cranial imaging. We retrospectively analyzed the potential influence of three-dimensional (3D) virtual reality (VR) reconstructions compared to conventional magnetic resonance imaging (MRI) scans on the evaluation of NVC for the surgical planning of microvascular decompression in patients with TN. METHODS: Medical files were retrospectively analyzed regarding patient- and disease-related data. Preoperative MRI scans were retrospectively visualized via VR software to detect the characteristics of NVC. A questionnaire of experienced neurosurgeons evaluated the influence of VR visualization technique on identification of anatomical structures involved in NVC and on surgical strategy. RESULTS: Twenty-four patients were included and 480 answer sheets were evaluated. Compared to conventional MRI, image presentation using 3D-VR modality significantly influenced the identification of the affected trigeminal nerve (p = 0.004), the vascular structure involved in the NVC (p = 0.0002), and the affected side of the trigeminal nerve (p = 0.005). CONCLUSIONS: In patients with TN caused by NVC, the reconstruction of conventional preoperative MRI scans and the spatial and anatomical presentation in 3D-VR models offers the possibility of increased understanding of the anatomy and even more the underlying pathology, and thus influences operation planning and strategy.

Load-Bearing Capacity and Design Advantages of a Custom-Made, Thin Pure-Titanium Cranioplasty (CranioTop).

BACKGROUND: Adequate and stable coverage of cranial contour and continuity defects of any origin is a common challenge in neurosurgical clinics. This study presents the results of investigations concerning the mechanical load-bearing capacity and design advantages of custom-made implants made from a thin, pure-titanium sheet (CranioTop) (CLinstruments, Attendorn, Germany) for covering complex cranial defects. METHODS: In 9 test series, the stability of three differently shaped and sized thin titanium sheet implants was tested using vertical, uniaxial compression with 3 different compression stamps, to investigate the behaviour of these implants in relation to punctiform as well as planar forces. RESULTS: All 9 model implants showed elastic behavior in the synchronously recorded force/displacement diagrams at an impression of up to 2 mm. The forces at 2 mm deformation were between 170.1 and 702.7 Newton. CONCLUSION: Cranioplasty using CranioTop is a stable procedure for covering skull defects, even those of large dimensions. An added advantage is the significant reduction in effort required to prepare the area of the bone margins compared to other current techniques of cranioplasty.

Repetitive percutaneous radiofrequency thermocoagulation for persistent idiopathic facial pain and central neuropathic pain attributed to multiple sclerosis-a retrospective monocentric analysis.

BACKGROUND: Persistent idiopathic facial pain (PIFP) is a debilitating chronic pain condition with pain radiating to trigeminal dermatomes. Typically, there are no pathological findings that can be identified during workup and therapy is symptomatic. Facial pain is common in patients with multiple sclerosis (central neuropathic pain attributed to MS). Our aim was to evaluate the effectiveness of percutaneous radiofrequency thermocoagulation (PRTC) of the gasserian ganglion and the duration of pain relief, as well as the identification of factors associated with its outcome. METHODS: Data on all the above-mentioned patients that have been treated with PRTC between 2009 and 2019 were included into the study. The outcome was assessed with a six-tiered score from 1 (complete remission) to 6 (no benefit). Univariate and multivariate analyses were performed in order to obtain factors associated with the outcome. RESULTS: A total of 52 patients were included. The total number of procedures performed was 114. 61.5% of patients who experienced temporary pain relief that lasted for a median of 60 days (range 3-1490 days). In patients with recurrence, the fraction of successful interventions was higher, and also transient, with successful pain amelioration in over 80% of patients. Successful responses to PRTC were observed in 27.9% after 1 year, 19.4% after 2 years, and 8.3% after 3 years. The only independent variable predicting pain relief was a repeat intervention with a history of ≥ 2 interventions (OR: 4.36, 95%-CI: 1.34-14.34, p = 0.015). No severe complications occurred. CONCLUSIONS: Our data showed good and immediate pain relief after PRTC in the majority of our patients. PRTC is a low-risk procedure that can be discussed as an option in case of failure of medical treatment even in critically ill patients and can be repeated with good results when necessary. Long-term pain amelioration, even with repeated procedures, was not possible and no patient was permanently cured.

The rise of quality indicators in neurosurgery: 30-day unplanned reoperation rate evaluated in 3760 patients-a single-center experience.

OBJECTIVE: Quality indicators are emerging as tools to evaluate health care outcomes. Few studies have evaluated indicators suitable for neurosurgery so far. Among others, reoperation rate has been suggested as a possible indicator. We aimed to evaluate the reoperation rate in a large neurosurgery adult collective. METHODS: In this exploratory post hoc analysis, we evaluated all patients operated in our service for elective and emergency surgery between January 2014 and May 2016. Planned and unplanned reoperations were filtered and a quantitative analysis, including uni- and multivariate analyses, was performed. RESULTS: A total of 3760 patients were included in this evaluation. From 378 reoperated patients within 30 days (10.1%), 51 underwent planned procedures (1.4%). Three hundred twenty-seven patients (8.7%) represented the analyzed collective of patients having undergone unplanned surgical procedures, causing a total of 409 from 4268 additional procedures (9.6%). Early unplanned 7-day reoperation rate was 4.5% (n = 193), occurring in 4.5% of patients (n = 193). Postoperative hemorrhage (n = 107, 26.2%) and external ventricle drainage-associated infections or dislocation (n = 105, 25.7 %) were the most common indication for unplanned surgery. CONCLUSION: Unplanned re-operation rate of a neurosurgical service can help to internally evaluate health care outcome and improve quality of care. Benchmarking with this indicator however is not recommendable as results can vary distinctly due to the heterogenic patient collective of each institution. We expect unplanned reoperation rates to be higher in large university hospitals and tertiary centers with complex cases, as compared to center with less complex cases treating patients with lower morbidity. In this study, we deliver an authentic portrait of a large neurosurgical center in Germany.

The 30-day readmission rate in neurosurgery-a useful indicator for quality assessment?

BACKGROUND: A shift in how we evaluate healthcare outcomes has driven the introduction of quality indicators as potential parameters to evaluate value-based healthcare delivery. So far, only few studies have been performed evaluating quality indicators in the context of neurosurgery, especially in the European region. The purpose of this study was to evaluate the 30-day readmission rate, identify reasons for readmission regarding the various neurosurgical diagnoses, and discuss the usefulness of this rate as a potential quality indicator. METHODS: During a 6-year period, a total of 8878 hospitalized patients in our neurosurgical department were retrospectively analyzed and included in this study. Reasons for readmission were identified. Patients' diagnoses and baseline characteristics were obtained in order to identify possible risk factors for readmission. RESULTS: The 30-day readmission rate was 2.9%. The most common reason for unplanned readmissions were surgical site infections. The reasons for readmissions varied significantly between the different underlying neurosurgical diseases (p < 0.001). Multivariate logistic regression revealed hydrocephalus (OR, 4) and shorter length of stay during index admission (OR, 0.9) as risk factors for readmission. CONCLUSIONS: We provided an analysis of reasons for readmission for various neurosurgical diseases in a large patient spectrum in Germany. Although readmission rates are easy to track and an attractive tool for quality assessment, the rate alone cannot be seen as an adequate measure for quality in neurosurgery as it lacks a homogenous definition and depends on the underlying health care system. In addition, strategies for risk adjustment are required.

5-ALA fluorescence-guided surgery in pediatric brain tumors-a systematic review.

BACKGROUND: 5-Aminolevulinic acid (5-ALA)-guided resection of gliomas in adults enables better differentiation between tumor and normal brain tissue, allowing a higher degree of resection, and improves patient outcomes. In recent years, several reports have emerged regarding the use of 5-ALA in other brain tumor entities, including pediatric brains tumors. Since gross total resection (GTR) of many brain tumors in children is crucial and the role of 5-ALA-guided resection of these tumors is not clear, we sought to perform a comprehensive literature review on this topic. METHODS: A systematic literature review of EMBASE and MEDLINE/PubMed databases revealed 19 eligible publications encompassing 175 5-ALA-guided operations on pediatric brain tumors. To prevent bias, publications were revised independently by two authors. RESULTS: We found that 5-ALA-guided resection enabled the surgeons to identify the tumor more easily and was considered helpful mainly in cases of glioblastoma (GBM, 21/27, 78%), anaplastic ependymoma WHO grade III (10/14, 71%), and anaplastic astrocytoma (4/6, 67%). In contrast, cases of pilocytic astrocytomas (PAs) and medulloblastomas 5-ALA-guided surgery did not show consistent fluorescent signals and 5-ALA was considered helpful only in 12% and 22% of cases, respectively. Accumulation of fluorescent porphyrins seems to depend on WHO tumor grading. One important finding is that when 5-ALA-guided resections were considered helpful, the degree of resection was higher than is cases where it was not helpful. The rate of adverse events related to 5-ALA was negligible, especially new postoperative sequelae. CONCLUSION: 5-ALA could play a role in resection of pediatric brain tumors. However, further prospective clinical trials are needed.

Spectroscopic measurement of 5-ALA-induced intracellular protoporphyrin IX in pediatric brain tumors.

OBJECTIVE: 5-Aminolevulinic acid (5-ALA)-guided resection of gliomas in adults enables better delineation between tumor and normal brain, allowing improved resection and improved patients' outcome. Recently, several reports were published regarding 5-ALA for resection of pediatric brain tumors. The aim of the study was to determine the intracellular fluorescence of protoporphyrin IX (PPIX) in pediatric brain tumors by hyperspectral imaging and to compare it with visually observed intraoperative fluorescence. METHODS: 5-ALA was administered orally 4 h prior to surgery. During tumor resection, the surgeon assessed the fluorescence signal to be strong, weak, or absent. Subsequently, fluorescence intensity of tumor samples was measured via spectroscopy. In addition, clinical data, imaging, and laboratory data were analyzed. RESULTS: Eleven children (1-16 years) were operated. Tumor entities included three (n = 3) medulloblastomas, two (n = 2) pilocytic astrocytomas (PA), two (n = 2) anaplastic ependymomas and one (n = 1) diffuse astrocytoma, anaplastic astrocytoma (n = 1), pilomyxoid astrocytoma (n = 1) and anaplastic pleomorphic xanthoastrocytoma (n = 1). Strong fluorescence was visible in all anaplastic tumors and one PA; one PA demonstrated weak fluorescence. Visible fluorescence was strongly associated with intracellular fluorescence intensity and PPIX concentration (P < 0.05). Within all tumors with visible fluorescence, the intracellular PPIX concentration was greater than 4 µg/ml. Except for moderate and transient elevation of liver enzymes, no 5-ALA related adverse events were reported. CONCLUSION: We demonstrate a strong association between intraoperative observations and spectrometric measurements of PPIX fluorescence in tumor tissue. As in former studies, fluorescence signal was more commonly observed in malignant glial tumors. Further prospective controlled trials should be conducted to investigate the feasibility of 5-ALA-guided resection of pediatric brain tumors.

Adverse events in brain tumor surgery: incidence, type, and impact on current quality metrics.

BACKGROUND: The aim of the study was to determine pre-operative factors associated with adverse events occurring within 30 days after neurosurgical tumor treatment in a German center, adjusting for their incidence in order to prospectively compare different centers. METHODS: Adult patients that were hospitalized due to a benign or malignant brain were retrospectively assessed for quality indicators and adverse events. Analyses were performed in order to determine risk factors for adverse events and reasons for readmission and reoperation. RESULTS: A total of 2511 cases were enrolled. The 30 days unplanned readmission rate to the same hospital was 5.7%. The main reason for readmission was tumor progression. Every 10th patient had an unplanned reoperation. The incidence of surgical revisions due to infections was 2.3%. Taking together all monitored adverse events, male patients had a higher risk for any of these complications (OR 1.236, 95%CI 1.025-1.490, p = 0.027). Age, sex, and histological diagnosis were predictors of experiencing any complication. Adjusted by incidence, the increased risk ratios greater than 10.0% were found for male sex, age, metastatic tumor, and hemiplegia for various quality indicators. CONCLUSIONS: We found that most predictors of outcome rates are based on preoperative underlying medical conditions and are not modifiable by the surgeon. Comparing our results to the literature, we conclude that differences in readmission and reoperation rates are strongly influenced by standards in decision making and that comparison of outcome rates between different health-care providers on an international basis is challenging. Each health-care system has to develop own metrics for risk adjustment that require regular reassessment.

Establishing risk-adjusted quality indicators in surgery using administrative data-an example from neurosurgery.

BACKGROUND: The current draft of the German Hospital Structure Law requires remuneration to incorporate quality indicators. For neurosurgery, several quality indicators have been discussed, such as 30-day readmission, reoperation, or mortality rates; the rates of infections; or the length of stay. When comparing neurosurgical departments regarding these indicators, very heterogeneous patient spectrums complicate benchmarking due to the lack of risk adjustment. OBJECTIVE: In this study, we performed an analysis of quality indicators and possible risk adjustment, based only on administrative data. METHODS: All adult patients that were treated as inpatients for a brain or spinal tumour at our neurosurgical department between 2013 and 2017 were assessed for the abovementioned quality indicators. DRG-related data such as relative weight, PCCL (patient clinical complexity level), ICD-10 major diagnosis category, secondary diagnoses, age and sex were obtained. The age-adjusted Charlson Comorbidity Index (CCI) was calculated. Logistic regression analyses were performed in order to correlate quality indicators with administrative data. RESULTS: Overall, 2623 cases were enrolled into the study. Most patients were treated for glioma (n = 1055, 40.2%). The CCI did not correlate with the quality indicators, whereas PCCL showed a positive correlation with 30-day readmission and reoperation, SSI and nosocomial infection rates. CONCLUSION: All previously discussed quality indicators are easily derived from administrative data. Administrative data alone might not be sufficient for adequate risk adjustment as they do not reflect the endogenous risk of the patient and are influenced by certain complications during inpatient stay. Appropriate concepts for risk adjustment should be compiled on the basis of prospectively designed registry studies.

Initial psycho-oncological counselling in neuro-oncology: analysis of topics and needs of brain tumour patients.

Diagnosis of a brain tumour is associated with a tremendous disruption of emotional, physical and social well-being. Due to the complexity of the disease and the affection of the central organ, the brain, brain tumour patients differ from other cancer patients. The purpose of this study was to evaluate the concerns and burdens presented by brain tumour patients during their initial psycho-oncological consultation. We performed a retrospective analysis of 53 patients with the diagnosis of either benign or malignant brain tumour, seeking counsel by a neurosurgeon specialised in psycho-oncology. We performed a thematic analysis of the interviews at first consultation identifying themes and patterns and created thematic categories. The main concerns of the patients presented during the first consultations were psychological problems, reported by 40 patients (75.5%). Death and dying was mentioned by more than half of the patients (n = 30, 56.6%). In addition, 62.3% of the patients (n = 33) asked for information regarding the medical treatment and diagnosis. With our study, we created greater awareness of the psychological needs of brain tumour patients in order to define treatment strategies for this important aspect of disease. We showed that there is a need for patients to talk about death even during the initial consultation. Psycho-oncologist in a neuro-oncological setting should be prepared for topics like that and should have a neurosurgical background or collaborate with members of the surgical team in order to provide the patients with medical details and to better understand the impact of the disease.

The evolution of cranial meningioma surgery-a single-center 25-year experience.

BACKGROUND: There have been major developments in diagnostic and surgical and non-surgical techniques used in the management of meningiomas over last three decades. We set out to describe these changes in a systematic manner. METHOD: Clinical and radiological data, surgical procedures, complications, and outcome of 817 patients who underwent surgery for primarily diagnosed meningioma between 1991 and 2015 were investigated. RESULTS: Median age at diagnosis increased significantly from 56 to 59 years (p = .042), while tumor location and preoperative Karnofsky performance status did not change during the observation period. Availability of preoperative MRI increased, and rates of angiography and tumor embolization decreased (p < .001, each). Median duration of total, pre-, and postoperative stay was 13, 2, and 9 days, respectively, and decreased between 1991 and 2015 (p < .001, each). Median incision-suture time varied annually (p < .001) but without becoming clearly longer or shorter during the entire observation period. The use of intraoperative neuronavigation and neuromonitoring increased, while the rates of Simpson grade I and III surgeries decreased (p < .001). Rates of postoperative hemorrhage (p = .997), hydrocephalus (p = .632), and wound infection (p = .126) did not change, while the frequency of early postoperative neurological deficits decreased from 21% between 1991 and 1995 to 13% between 2011 and 2015 (p = .003). During the same time, the rate of surgeries for postoperative cerebrospinal fluid leakage slightly increased from 2 to 3% (p = .049). Within a median follow-up of 62 months, progression was observed in 114 individuals (14%). Progression-free interval did not significantly change during observation period (p > .05). Multivariate analyses confirmed the lack of correlation between year of surgery and tumor relapse (HR: 1.1, p > .05). CONCLUSIONS: Preoperative diagnosis and surgery of meningiomas have been substantially evolved. Although early neurological outcome has improved, long-term prognosis remains unchanged.

Intraoperative myelography of traumatic spine injury in patients with ankylosing spondylitis. Technical note.

BACKGROUND: Ankylosing spondylitis (AS) is an autoimmune inflammatory arthritis causing ossifications and rigidity of the spinal column. Patients with AS have a high incidence of spinal fractures, especially in the cervical spine, with a high rate of epidural hematomas. These have hazardous consequences, including neurological sequelae, and high morbidity and mortality. Diagnostics rely on CT and MRI scans, and therapy, usually open decompression and fixation, has to be done as soon as possible to enable recovery. However, in many cases, performing MRI scans is not possible for several reasons. METHODS: We present a case of an AS patient with paraparesis below T-8 after a fall who was not able to undergo MRI scan due to severe obesity, hyperkyphosis, and mechanical ventilation. CT scan did not demonstrate any fractures or hemorrhages in the thoracic spine and in addition a standard myelography could not be performed due to ossifications of ligaments. As an alternative, we performed an intra-operative myeolgraphy. Intra-operative installation of a lumbar drain made a myelography and post-myelographic CT scan feasible. RESULTS: The scan revealed a contrast stop at T-10 and subsequently operative decompression and evacuation of the hematoma were performed. CONCLUSIONS: We present a quick and safe technique, performed in the operation room (OR), to detect intra-spinal lesions in patients with contraindications for MRI, or for cases where MRI scans cannot be performed.