Does preoperative imaging for scalp non-melanocytic skin cancer accurately predict invasion of the cranial vault? A systematic review and meta-analysis.

PURPOSE: This study aimed to determine the diagnostic accuracy of CT and MRI in the preoperative detection of bone involvement for non-melanoma skin cancers (NMSCs) located on the scalp. This study further aimed to evaluate the predictive value of these imaging modalities in determining the need for craniectomy and to identify gaps in the existing literature. METHODS: Electronic searches of the MEDLINE, Embase, Cochrane and Google Scholar databases were performed for English language studies of any type. Studies reporting detection or exclusion of histopathologically confirmed bone involvement through preoperative imaging were identified according to PRISMA guidelines. Studies reporting dural involvement, non-scalp tumours, and lacking tumour type(s) or outcome data were excluded. Outcomes were preoperative imaging result and histopathologically confirmed bone invasion. Meta-analysis was performed and sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated (excluding case report and MRI data due to insufficient quality and quantity respectively). RESULTS: Four studies with a total of 69 patients were included in the final review, of which two studies totalling 66 patients were included in the meta-analysis. Preoperative CT had a sensitivity of 38%, specificity of 98%, PPV of 90% and NPV of 73%. CONCLUSIONS: The available data suggests that a preoperative CT finding of calvarial involvement by a scalp NMSC is likely to be real, but the absence of such a finding is unreliable. Current evidence suggests that preoperative imaging cannot exclude the necessity for craniectomy and future research is needed, particularly on the role of MRI.

Displaced medial clavicle fractures: a systematic review of outcomes after nonoperative and operative management.

Background: Fractures of the medial clavicle are uncommon. There is no consensus regarding the optimal treatment of displaced medial clavicle fractures. Methods: A systematic review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed. PubMed, EMBASE, and the Cochrane Library were queried using the terms medial clavicle and fracture to identify all studies reporting on outcomes following either nonoperative or operative treatment of displaced medial clavicle fractures. Data extracted included patient demographics, fracture classification, surgical technique, patient-reported outcomes, physical, and radiographic findings. Study quality was evaluated using the Methodological Index for Non-Randomized Studies (MINORS) scoring system. Results: The analysis included 15 studies (mean MINORS score, 10 ± 1.5) with a total of 135 patients (85% male, mean age 47 ± 10.9 years [range, 15-87 years]). Five studies (39 patients) reported outcomes following nonoperative treatment. At a mean follow-up of 27 months, there were 5 (13%) symptomatic nonunions, 2 (5%) malunions, and 2 (5%) delayed unions. Eleven studies (96 patients) reported outcomes following surgical treatment with a mean follow-up of 23 months. There were no reported nonunions. Complications included plate prominence/ irritation (30%) and additional surgery was performed for plate removal (27%), fixation failure (3%), and wound débridement (1%). Conclusion: There is limited, low-quality evidence in the literature to guide treatment of displaced medial clavicle fractures. The available data suggest that surgical treatment is associated with good functional outcomes and a lower risk of nonunion and malunion, compared to nonoperative treatment but plate irritation and further surgery to remove the plate was common.

Hemi-hamate Arthroplasty for Base of Middle Phalanx Fracture: A Systematic Review.

Intra-articular fracture dislocations of the base of the middle phalanx are complex and debilitating injuries that present a management conundrum when nonreconstructable. Hemi-hamate arthroplasty (HHA) is a treatment modality of particular use in the setting of highly comminuted fractures. This systematic review aims to summarize the reported outcomes of HHA in this context. A literature search was conducted using MEDLINE, Embase, and PubMed, yielding 22 studies with 235 patients for inclusion. The weighted mean postoperative range of movement at the proximal interphalangeal joint was 74.3° (range, 62.0°-96.0°) and at the distal interphalangeal joint was 57.0° (range, 14.0°-80.4°). The weighted mean postoperative pain Visual Analog Scale was 1.0 (range, 0.0-2.0). The weighted mean postoperative grip strength was 87.1% (range, 74.5%-95.0%) of the strength on the contralateral side. Posttraumatic arthritis was reported in 18% of cases, graft collapse in 4.2%, and donor site morbidity in 3.0%, with a mean follow-up period of 28.4 months (range, 1-87 months). Hemi-hamate arthroplasty is a reliable and effective technique for the reconstruction of intra-articular base of middle phalangeal fracture dislocations, affording symptomatic relief and functional restoration. Further research is required to assess the true incidence of long-term complications.

The Impact of COVID-19 on Hand Trauma.

BACKGROUND: The Coronavirus Disease 2019 (COVID-19) pandemic has had a dramatic impact on individual and societal behaviors, as well as on health care systems. It confers a unique opportunity to examine the relationship among disease, policies, and patterns of activity, as well as their impacts on surgical unit functionality. This study aims to compare the distribution and patterns of injury at a tertiary hand surgery trauma center before and during the COVID-19 pandemic. METHODS: A retrospective analysis of all patients presenting to the Royal North Shore Hospital hand surgery service in the 5-week period from March 16 to April 21 in 2019 and 2020 was undertaken, forming 2 cohorts for comparison. Demographic, injury, and operative data were collected and compared descriptively using comparative statistics. RESULTS: There were 114 primary operative presentations during the 5-week period in 2020, representing a 27.4% decrease from the 157 presentations during the equivalent period in 2019. There was an increase in the proportion of emergency presentations from 73.9% in 2019 to 85.1% in 2020 (P = .03), with a corresponding decrease in elective presentations during 2020. The incidence of sporting injuries and motor vehicle accidents decreased in 2020, whereas falls and accidents involving knives and tools remained relatively constant. Operating times decreased in 2020, whereas the length of hospital stay remained constant. CONCLUSIONS: The COVID-19 pandemic and consequent restrictions of activity have had substantial impacts on the patterns of hand trauma and its management. These insights have implications for staff and resource management during times of social disruption in the future.

Proximal Interphalangeal Joint Arthrodesis Techniques: A Systematic Review.

Proximal interphalangeal joint (PIPJ) arthrodesis is a salvage option in the management of end-stage PIPJ arthropathy. Numerous techniques have been described, including screws, Kirschner wires, tension band wiring, intramedullary devices, and plate fixation. There remains no consensus as to the optimum method, and no recent summary of the literature exists. A literature search was conducted using the MEDLINE, EMBASE, and PubMed databases. English-language articles reporting PIPJ arthrodesis outcomes were included and presented in a systematic review. Pearson χ2 and 2-sample proportion tests were used to compare fusion time, nonunion rate, and complication rate between arthrodesis techniques. The mean fusion time ranged from 5.1 to 12.9 weeks. There were no statistically significant differences in fusion time between arthrodesis techniques. Nonunion rates ranged from 0.0% to 33.3%. Screw arthrodesis demonstrated a lower nonunion rate than wire fusion (3.0% and 8.5% respectively; P = .01). Complication rates ranged from 0.0% to 22.1%. Aside from nonunions, there were no statistically significant differences in complication rates between arthrodesis techniques. The available PIPJ arthrodesis techniques have similar fusion time, nonunion rate, and complication rate outcomes. The existing data have significant limitations, and further research would be beneficial to elucidate any differences between techniques.

Safety and efficacy of prothrombin complex concentrate (PCC) for anticoagulation reversal in patients undergoing urgent neurosurgical procedures: a systematic review and metaanalysis.

Anticoagulant therapy poses a significant risk for patients undergoing emergency neurosurgery procedures, necessitating reversal with prothrombin complex concentrate (PCC) or fresh frozen plasma (FFP). Data on PCC efficacy lack consistency in this setting. This systematic review and metaanalysis aimed to evaluate efficacy and safety of PCC for anticoagulation reversal in the context of urgent neurosurgery. Articles from PubMed, Embase, and Cochrane databases were screened according to the PRISMA checklist. Adult patients receiving anticoagulation reversal with PCC for emergency neurosurgical procedures were included. When available, patients who received FFP were included as a comparison group. Pooled estimates of observational studies were calculated for efficacy and safety outcomes via random-effects modeling. Initial search returned 4505 articles, of which 15 studies met the inclusion criteria. Anticoagulants used included warfarin (83%), rivaroxaban (6.8%), phenprocoumon (6.1%), apixaban (2.2%), and dabigatran (1.5%). The mean International Normalized Ratio (INR) prePCC administration ranged from 2.3 to 11.7, while postPCC administration from 1.1 to 1.4. All-cause mortality at 30 days was 27% (95%CI 21, 34%; I2 = 44.6%; p-heterogeneity = 0.03) and incidence of thromboembolic events was 6.00% among patients treated with PCC (95%CI 4.00, 10.0%; I2 = 0%; p-heterogeneity = 0.83). Results comparing PCC and FFP demonstrated no statistically significant differences in INR reversal, mortality, or incidence of thromboembolic events. This metaanalysis demonstrated adequate safety and efficacy for PCC in the reversal of anticoagulation for urgent neurosurgical procedures. There was no significant difference between PCC and FFP, though further trials would be useful in demonstrating the safety and efficacy of PCC in this setting.

The Surgical Resection of Brainstem Glioma: Outcomes and Prognostic Factors.

BACKGROUND: The management of brainstem glioma remains controversial, with increasing evidence supporting surgical resection as the primary treatment for a select subgroup of tumors. However, there remains no consensus on the specific benefits and risks, the selection of surgical candidates, and prognostic factors that may further refine surgical indications. METHODS: A retrospective single-surgeon chart review was performed for all patients who underwent surgical treatment for radiographically suspected brainstem glioma between 2000 and 2017. Preoperative and postoperative radiographic evaluations on magnetic resonance imaging were conducted. Survival outcomes were collected, and machine-learning techniques were used for multivariate analysis. RESULTS: Seventy-seven patients with surgical treatment of brainstem glioma were identified, with a median age of 9 years (range, 0-58 years). The cohort included 64% low-grade (I and II) and 36% high-grade (III and IV) tumors. For all patients, the 1-year and 5-year overall survival were 76.4% and 62.3%, respectively. Transient neurologic deficit was present in 34% of cases, and permanent deficit in a further 29%. CONCLUSIONS: The radical surgical resection of brainstem gliomas can be performed with acceptable risk in well-selected cases and likely confers survival advantage for what is otherwise a rapidly and universally fatal disease. Various radiographic features are useful during patient selection and may guide treatment selection.

Recurrent laryngeal nerve injury following single- and multiple-level anterior cervical discectomy and fusion: a meta-analysis.

BACKGROUND: Recurrent laryngeal nerve (RLN) palsy is a common and potentially debilitating complication of anterior cervical discectomy and fusion (ACDF). The relationship between the risk of RLN palsy and the number of operated levels remains unclear, and no previous studies address potential differences between short- and long-term RLN injury following ACDF. METHODS: Electronic searches of PubMed, Cochrane, ScienceDirect and Google Scholar were performed from database inception to June 2019. Relevant studies reporting the rate of RLN palsy for patients undergoing ACDF for cervical spine pathology were identified according to predetermined inclusion and exclusion criteria. Statistical analysis was performed using fixed effects and random effects modelling. I2 and Q statistics were used to explore heterogeneity. RESULTS: Five studies with a total of 3,514 patients were included in the meta-analysis. The incidence of RLN palsy was found to be 1.2%. There were no statistically significant differences in the rate of RLN palsy between multiple- and single-level ACDF [odds ratio (OR) 1.04; 95% CI: 0.56-1.95; P=0.891, I2=0%]. There were similarly no statistically significant differences in RLN palsy rates for multiple- and single-level ACDF when patients were stratified based on length of follow-up of less than or greater than 12 months. CONCLUSIONS: This analysis suggests that there is no statistically significant association between the number of ACDF operative levels and the risk of short- or long-term RLN palsy.

Dysphagia rates in single- and multiple-level anterior cervical discectomy and fusion surgery: a meta-analysis.

BACKGROUND: To conduct a meta-analysis to assess dysphagia complicating single-level and multiple-level (≥2) anterior cervical discectomy and fusion (ACDF) surgery. METHODS: Electronic searches were performed using four electronic databases from their inception to December 2017. Relevant studies reporting the rate of dysphagia as an endpoint for patients undergoing ACDF for degenerative disease, myelopathy, cervical canal stenosis or ossification of the posterior longitudinal ligament were identified according to prior inclusion and exclusion criteria. Statistical analysis was performed using a fixed effect model. P-scores were used to rank the levels of ACDF based on the rate of dysphagia. I2 was used to explore heterogeneity. RESULTS: Ten studies were identified and included in the systematic review and meta-analysis, with a total of 4,018 patients identified; 2,362 patients underwent single-level ACDF, while 1,656 underwent multiple level (≥2 ACDF). The mean age ranged from 49.45 to 57.77 years. Mean follow-up time ranged from 2 days to 27.3 months. Overall, meta-analysis demonstrated a statistically significant higher dysphagia rate for multiple-level ACDF (6.6%) than for single-level ACDF (4%) (P heterogeneity =0.151, OR =1.42, 95% CI: 1.05-1.91, I2=32%). CONCLUSIONS: Dysphagia is a relatively common complication in the early postoperative period following ACDF and may cause patients significant discomfort and distress. This meta-analysis demonstrates a higher rate of dysphagia with multiple-level ACDF than with single-level ACDF at a period of 12-24 months.

Keyhole retrosigmoid approach for large vestibular schwannomas: strategies to improve outcomes.

OBJECTIVE There are numerous treatment strategies in the management for large vestibular schwannomas, including resection only, staged resections, resections followed by radiosurgery, and radiosurgery only. Recent evidence has pointed toward maximal resection as being the optimum strategy to prevent tumor recurrence; however, durable tumor control through aggressive resection has been shown to occur at the expense of facial nerve function and to risk other approach-related complications. Through a retrospective analysis of their single-institution series of keyhole neurosurgical approaches for large vestibular schwannomas, the authors aim to report and justify key techniques to maximize tumor resection and reduce surgical morbidity. METHODS A retrospective chart review was performed at the Centre for Minimally Invasive Neurosurgery. All patients who had undergone a keyhole retrosigmoid approach for the resection of large vestibular schwannomas, defined as having a tumor diameter of ≥ 3.0 cm, were included in this review. Patient demographics, preoperative cranial nerve status, perioperative data, and postoperative follow-up were obtained. A review of the literature for resections of large vestibular schwannomas was also performed. The authors' institutional data were compared with the historical data from the literature. RESULTS Between 2004 and 2017, 45 patients met the inclusion criteria for this retrospective chart review. When compared with findings in a historical cohort in the literature, the authors' minimally invasive, keyhole retrosigmoid technique for the resection of large vestibular schwannomas achieved higher rates of gross-total or near-total resection (100% vs 83%). Moreover, these results compare favorably with the literature in facial nerve preservation (House-Brackmann I-II) at follow-up after gross-total resections (81% vs 47%, p < 0.001) and near-total resections (88% vs 75%, p = 0.028). There were no approach-related complications in this series. CONCLUSIONS It is the experience of the senior author that complete or near-complete resection of large vestibular schwannomas can be successfully achieved via a keyhole approach. In this series of 45 large vestibular schwannomas, a greater extent of resection was achieved while demonstrating high rates of facial nerve preservation and low approach-related and postoperative complications compared with the literature.