Surgical Versus Non-Surgical Treatment for Thoracolumbar Burst Fractures Without Neurological Deficit: A Systematic Review and Meta-Analysis.

STUDY DESIGN: A systematic review and meta-analysis. OBJECTIVE: To update the systematic review comparing the outcomes between surgical and non-surgical treatment for thoracolumbar burst fractures without neurological deficit. METHODS: We registered a protocol in PROSPERO (ID: CRD42021291769) and searched Medline, Embase, Web of Science, and Google Scholar databases. Surgical and non-surgical treatments were compared in patients with thoracolumbar burst fractures without neurological deficits. Predefined outcomes at ≥6 months included pain (defined as a visual analog scale [VAS] of 0-100), functional outcomes (Oswestry Disability Index [ODI] of 0-50 and Roland-Morris Disability Questionnaire [RMDQ] of 0-24), and kyphotic angulation. RESULTS: Nineteen studies involving 1056 patients were included in the analyses. For outcomes at ≥6 months, little to no difference was found in pain VAS score (mean difference, .95 [95% confidence interval {CI}, -6.02 to 7.92]; 827 participants; 15 studies; I2 = 92%), ODI (mean difference, -1.40 [95% CI, -5.11 to 2.31]; 446 participants; 7 studies; I2 = 79%), and RMDQ (mean difference, -.73 [95% CI, -5.13 to 3.66]; 216 participants; 5 studies; I2 = 77%). The kyphotic angulation in the surgery group was 6.35° lower than that in the non-surgery group (mean difference, -6.56° [95% CI, -10.26° to -2.87°]; 527 participants; ten studies; I2 = 86%). The trial sequential analysis indicated all outcomes reached adequate statistical power. The certainty of the evidence for all 4 outcomes was very low. For the analysis of minimally invasive procedures compared to traditional open surgeries, a statistically significant subgroup difference was found for VAS and ODI (P < .01 and P < .04, respectively). CONCLUSION: Surgical and non-surgical treatments showed little or no difference in outcomes at ≥6 months. This review provides a conclusion with adequate statistical power by including non-randomized studies. However, non-randomized studies also lowered the certainty of the evidence to a very low level.

Overall Survival of Non-Small Cell Lung Cancer With Spinal Metastasis: A Systematic Review and Meta-Analysis.

OBJECTIVE: The long-term survival data of lung cancer patients with spinal metastases are crucial for informed treatment decision-making. However, most studies in this field involve small sample sizes. Moreover, survival benchmarking and an analysis of changes in survival over time are required, but data are unavailable. To meet this need, we performed a metaanalysis of survival data from small studies to obtain a survival function based on largescale data. METHODS: We performed a single-arm systematic review of survival function following a published protocol. Data of patients who received surgical, nonsurgical, and mixed modes of treatment were meta-analyzed separately. Survival data were extracted from published figures with a digitizer program and then processed in R. Median survival time was used as an effect size for moderator analysis to explain the heterogeneity. RESULTS: Sixty-two studies with 5,242 participants were included for pooling. The survival functions showed a median survival of 6.72 months for surgery (95% confidence interval [CI], 61.9-7.01; 2,367 participants; 36 studies), 5.99 months for nonsurgery (95% CI, 5.33-6.47; 891 participants; 12 studies), and 5.96 months for mixed (95% CI, 5.67-6.43; 1,984 participants; 18 studies). Patients enrolled since 2010 showed the highest survival rates. CONCLUSION: This study provides the first large-scale data for lung cancer with spinal metastasis that allows survival benchmarking. Data from patients enrolled since 2010 had the best survival and thus may more accurately reflect current survival. Researchers should focus on this subset in future benchmarking and remain optimistic in the management of these patients.

Influence of renal impairment on neurologic outcomes following mechanical thrombectomy in acute vertebrobasilar stroke.

PURPOSE: Renal impairment (RI) has been regarded as a risk factor for unfavorable neurologic outcomes after mechanical thrombectomy (MT) in acute ischemic stroke. However, most of the previous studies were conducted on patients with anterior circulation stroke. Accordingly, the influence of RI on MT outcomes has not been well elucidated in detail in acute vertebrobasilar stroke. METHODS: Consecutive stroke patients with MT due to acute vertebrobasilar artery occlusion between March 2015 and December 2020 at four institutions were included. Multivariable logistic regression analysis was conducted to assess the associations between RI and outcomes and mortality at 3 months, and the development of intracerebral hemorrhage (ICH) after the procedure. Additionally, the multivariable Cox proportional hazards model was performed to determine the influence of RI on survival probability after patient discharge. RESULTS: A total of 110 patients were included in the final analysis. The presence of RI (OR = 0.268, 95% CI: 0.077-0.935), National Institute of Health Stroke Scale scores (OR = 0.849, 95% CI: 0.791-0.910), and puncture-to-recanalization time (OR = 0.981, 95% CI: 0.966-0.997) were related to outcomes. There was no significant association between RI and 3-month mortality or ICH. The cumulative survival probability after adjusting for relevant risk factors demonstrated that RI remained significantly associated with poorer survival after MT compared to patients without RI (HR = 2.111, 95% CI: 0.919-4.847). CONCLUSION: RI was an independent risk factor for poor 3-month neurologic outcomes and survival probability after MT in patients with acute vertebrobasilar stroke.

Impact of renal impairment on short-term outcomes following endovascular thrombectomy for acute ischemic stroke: A systematic review and meta-analysis.

BACKGROUND: The impact of renal impairment on the outcomes of patients with acute ischemic stroke treated with endovascular thrombectomy was relatively limited and contradictory. We performed a systematic review and meta-analysis to investigate this. AIMS: We registered a protocol in September 2020 and searched MEDLINE, EMBASE, and Google Scholar accordingly. Renal impairment was defined as an estimated glomerular filtration rate <60 mL/min/1.73 m2. Predefined outcomes included functional independence (defined as a modified Rankin Scale of 0, 1, or 2) at three months, successful reperfusion, mortality, and symptomatic intracerebral hemorrhage. SUMMARY OF REVIEW: Eleven studies involving 3453 patients were included. For the unadjusted outcomes, renal impairment was associated with fewer functional independence (odds ratio (OR), 0.49; 95% confidence interval (CI), 0.39-0.62) and higher mortality (OR, 2.55; 95% CI, 2.03-3.21). Renal impairment was not associated with successful reperfusion (OR, 0.80; 95% CI 0.63-1.00) and symptomatic intracerebral hemorrhage (OR, 1.41; 95% CI, 0.95-2.10). For the adjusted outcomes, results derived from a multivariate meta-analysis were consistent with the respective unadjusted outcomes: functional independence (OR, 0.59; 95% CI, 0.45-0.77), mortality (OR, 2.23, 95% CI, 1.45-3.43), and symptomatic intracerebral hemorrhage (OR, 1.34; 95% CI, 0.85-2.10). CONCLUSIONS: We presented the first systematic review to demonstrate that renal impairment is associated with fewer functional independence and higher mortality. Future endovascular thrombectomy studies should publish complete renal estimated glomerular filtration rate data to facilitate prognostic studies and permit estimated glomerular filtration rate to be analyzed in a continuous variable.Systematic Review Registration: PROSPERO CRD42020191309.

Application of Near-Infrared Spectroscopy for the Detection of Delayed Cerebral Ischemia in Poor-Grade Subarachnoid Hemorrhage.

BACKGROUND: The objective of this study was to investigate the clinical feasibility of near-infrared spectroscopy (NIRS) for the detection of delayed cerebral ischemia (DCI) in patients with poor-grade subarachnoid hemorrhage (SAH) treated with coil embolization. METHODS: Cerebral regional oxygen saturation (rSO2) was continuously monitored via two-channel NIRS for 14 days following SAH. The rSO2 levels according to DCI were analyzed by using the Mann-Whitney U-test. A receiver operating characteristic curve was generated on the basis of changes in rSO2 by using the rSO2 level on day 1 as a reference value to determine the optimal cutoff value for identifying DCI. RESULTS: Twenty-four patients with poor-grade SAH were included (DCI, n = 8 [33.3%]; non-DCI, n = 16 [66.7%]). The rSO2 levels of patients with DCI were significantly lowered from 6 to 9 days compared with those in without DCI. The rSO2 level was 62.55% (58.30-63.40%) on day 6 in patients with DCI versus 65.40% (60.90-68.70%) in those without DCI. By day 7, it was 60.40% (58.10-61.90%) in patients with DCI versus 64.25% (62.50-67.10%) those without DCI. By day 8, it was 58.90% (56.50-63.10%) in patients with DCI versus 66.05% (59.90-69.20%) in those without DCI, and by day 9, it was 60.85% (58.40-65.20%) in patients with DCI versus 65.80% (62.70-68.30%) in those without DCI. A decline of greater than 14.5% in the rSO2 rate yielded a sensitivity of 92.86% (95% confidence interval: 66.1-99.8%) and a specificity of 88.24% (95% confidence interval: 72.5-96.7%) for identifying DCI. A decrease by more than 14.7% of the rSO2 level indicates a sensitivity of 85.7% and a specificity of 85.7% for identifying DCI. CONCLUSIONS: Near-infrared spectroscopy shows some promising results for the detection of DCI in patients with poor-grade SAH. Further studies involving a large cohort of the SAH population are required to confirm our results.

Endovascular Intervention Versus Surgery in Ruptured Intracranial Aneurysms in Equipoise: A Systematic Review.

Background and Purpose- The benefits of endovascular intervention over surgery in the treatment of ruptured aneurysms of anterior circulation remains uncertain. Recently, published studies did not find superiority of endovascular intervention, challenging earlier evidence from a clinical trial. The earlier evidence also had a higher than average proportion of patients in good clinical status, leading to uncertainty about external validity of earlier trials. Methods- We performed a systematic review of studies after 2005 under a protocol published in the International Prospective Register of Systematic Reviews. Primary outcomes were posttreatment rebleeding and adverse events (procedural complications). Secondary outcomes were dependency at 3 to 6 and 12 months, delayed cerebral ischemia, and seizures. Results- Rebleeding was more frequent after endovascular intervention (Peto OR, 2.18 [95% CI, 1.29-3.70]; 3104 participants; 15 studies; I2=0%, Grading of Recommendations, Assessment, Development and Evaluation: very low certainty of evidence). Fewer adverse events were reported with the endovascular intervention (RR, 0.71 [95% CI, 0.53-0.95]; 1661 participants; 11 studies; I2=14%, Grading of Recommendations, Assessment, Development and Evaluation: low certainty of evidence). Three to six months dependency (RR, 0.82 [95% CI, 0.73-0.93]; 4081 participants; 18 studies; I2=15%, Grading of Recommendations, Assessment, Development and Evaluation: low certainty of evidence) and 12-month dependency (RR, 0.76 [95% CI, 0.66-0.86]; 1981 participants; 10 studies; I2=0%, Grading of Recommendations, Assessment, Development and Evaluation: low certainty of evidence) were lower after endovascular intervention. Conclusions- This study found consistent results between recent studies and the earlier evidence, in that endovascular intervention results in lower chance of dependency compared with surgery for repair of ruptured anterior circulation aneurysms. A lower proportion of patients in good clinical status in this review supports the application of the earlier evidence. Registration- URL: https://www.crd.york.ac.uk/PROSPERO. Unique identifier: CRD42018090396.

Seizure incidence of angiogram-negative subarachnoid hemorrhage: An updated meta-analysis.

BACKGROUND: To provide updated information on seizure events and patterns in patients with angiogram-negative subarachnoid hemorrhage based on the initial hemorrhage patterns: perimesencephalic subarachnoid hemorrhage (PMH) vs non-PMH. METHODS: A review of online database literature from January 1990 to November 2017 was systematically performed. In case of heterogeneity <50%, a fixed effect model was used. Publication bias was determined using Begg funnel plot and the trim-and-fill method. RESULTS: A total of 9 studies with 645 patients were included for final analysis after excluding one study without any seizure within either cohort. PMH patients had lower seizure rates (odds ratio, 0.393; 95% CI, 0.158-0.978) compared with non-PMH patients. The funnel plot showed a relatively asymmetric pattern, suggesting possible publication bias. After correction of the forest plot, the adjusted odds ratio was 0.362 (95% CI, 0.148-0.886), indicating significant relationships between PMH and lower incidence of seizure. CONCLUSION: PMH is associated with lower seizure risk than non-PMH. However, possible publication bias could be a concern to the interpretation. Additional meta-analyses based on individual patient data from prospective large-scale studies are necessary.

Learning curve of full-endoscopic lumbar discectomy.

PURPOSE: To report the learning curve of full-endoscopic lumbar discectomy for a surgeon naive to endoscopic surgery but trained in open microdiscectomy. METHODS: From July 2006 to July 2009, 57 patients underwent full-endoscopic lumbar discectomy and 66 underwent open microdiscectomy. The clinical results were evaluated with a visual analog scale (VAS) and the Oswestry Disability Index (ODI). Spearman's coefficient of rank correlation (rho) was used to assess the learning curves for the transforaminal and interlaminar procedures of full-endoscopic lumbar discectomy. RESULTS: After full-endoscopic lumbar discectomy, the VAS and ODI results of the patients followed up were comparable with those of open microdiscectomy. A steep learning curve was observed for the transforaminal procedure, but not the interlaminar procedure. CONCLUSIONS: The learning curve of the transforaminal approach was steep and easy to learn, while the learning curve of the interlaminar approach was flat and hard to master.

Can cerebral hypoperfusion after sympathetic storm be used to diagnose brain death? A retrospective survey in traumatic brain injury patients.

BACKGROUND: The aim of this study was to identify the precise time of occurrence of irreversible coma from brain stem dysfunction that precedes brain death. Sympathetic storm, which is a cardiovascular hyperdynamic state manifested by brain stem ischemia, is known to be related to brain stem failure in animal models. We studied sympathetic storm in the clinical setting and compared the clinical findings observed before and after sympathetic storm to identify the precise time of occurrence of irreversible apneic coma. METHODS: We conducted a retrospective study of 15 comatose traumatic brain injury adult patients at the National Taiwan University Hospital's Neurosurgical Intensive Care Unit. Data on arterial blood pressure, heart rate, intracranial pressure, and clinical findings such as cerebral blood flow pattern, Glasgow Coma Scale, brain stem reflexes, utilizations of catecholamines, and occurrence of central diabetes insipidus throughout the course in the intensive care unit were collected retrospectively from medical records. RESULTS: Prolonged uncorrectable cerebral hypoperfusion was found after a characteristic irreversible apneic coma-associated sympathetic storm (IACASS) in all 15 patients. A mean cerebral perfusion pressure of 11.9 mm Hg +/- 10.3 mm Hg and 13 mm Hg +/- 3.5 mm Hg remained at 12 hours and 24 hours, respectively, after IACASS. Differences in clinical findings before and after IACASS that were statistically significant were cerebral circulation pattern (p = 0.0455), Glasgow Coma Scale (p = 0.0143), brain stem reflexes (p = 0.0143), utilization of catecholamines (p = 0.0254), and occurrence of central diabetes insipidus (p = 0.00468). CONCLUSIONS: Coma might have become irreversible immediately after IACASS because the prolonged duration of cerebral hypoperfusion could have caused irreversible cerebral tissue injury. Our study provides some preliminary findings suggesting that IACASS may be a predictor of impending brain death. A prospective study is the next step to understanding whether this phenomenon can be applied clinically to diagnose irreversible apneic coma.