Consensus-based recommendations for diagnosis and surgical management of cranioplasty and post-traumatic hydrocephalus from a European panel.

Introduction: Planning cranioplasty (CPL) in patients with suspected or proven post-traumatic hydrocephalus (PTH) poses a significant management challenge due to a lack of clear guidance. Research question: This project aims to create a European document to improve adherence and adapt to local protocols based on available resources and national health systems. Methods: After a thorough non-systematic review, a steering committee (SC) formed a European expert panel (EP) for a two-round questionnaire using the Delphi method. The questionnaire employed a 9-point Likert scale to assess the appropriateness of statements inherent to two sections: "Diagnostic criteria for PTH" and "Surgical strategies for PTH and cranial reconstruction." Results: The panel reached a consensus on 29 statements. In the "Diagnostic criteria for PTH" section, five statements were deemed "appropriate" (consensus 74.2-90.3 %), two were labeled "inappropriate," and seven were marked as "uncertain."In the "Surgical strategies for PTH and cranial reconstruction" section, four statements were considered "appropriate" (consensus 74.2-90.4 %), six were "inappropriate," and five were "uncertain." Discussion and conclusion: Planning a cranioplasty alongside hydrocephalus remains a significant challenge in neurosurgery. Our consensus conference suggests that, in patients with cranial decompression and suspected hydrocephalus, the most suitable diagnostic approach involves a combination of evolving clinical conditions and neuroradiological imaging. The recommended management sequence prioritizes cranial reconstruction, with the option of a ventriculoperitoneal shunt when needed, preferably with a programmable valve. We strongly recommend to adopt local protocols based on expert consensus, such as this, to guide patient care.

European Medical Students' Views on Neurosurgery, with Emphasis on South-East Europe (Albania, Greece, Serbia, and Turkey).

BACKGROUND: Neurosurgery, an intricate and dynamic surgical specialty, faces challenges in attracting medical graduates. Despite its potential appeal, a decreasing trend in medical students opting for surgical specialties, including neurosurgery, is noted. This study aims to assess European medical students' perceptions of neurosurgery, focusing on South-East Europe, and address concerns about the declining interest in this field. METHODS: A comprehensive digital survey, comprising 33 questions, was distributed to 1115 medical students across 17 European countries. The survey, conducted over 9 months, gathered responses through European neurosurgical societies, the European Association of Neurosurgical Societies (EANS), and university channels. Statistical analysis utilized IBM Statistical Package for the Social Sciences, presenting data through counts, proportions, and χ2 tests. RESULTS: The study reveals that, over the survey period, 834 medical students completed the questionnaire, with a predominant representation from South-East Europe. While 43.2% of participants were considering a surgical career, neurosurgery emerged as the most preferred specialty (26.37%). Despite this interest, 80.2% reported insufficient knowledge about pursuing a neurosurgical career, with limited exposure during medical education. Concerns about work-life balance, heavy workload, and hierarchical structures were prominent among respondents. CONCLUSIONS: The findings underscore the need for targeted interventions to address concerns influencing medical students' decisions regarding neurosurgery. Improving neurosurgical education, dispelling misconceptions, and creating a supportive work environment are crucial steps to attract and retain diverse talented individuals in neurosurgery. These efforts will be vital in narrowing the gap between the demand for neurosurgeons and the number of medical graduates entering the field, ensuring a sustainable future for this essential surgical specialty.

Neurosurgery Training in Greece.

OBJECTIVE: The structure and specifics of neurosurgery residency training vary substantially across programs and countries, potentially leading to differences in clinical reasoning, surgical skills, and professionalism. The Greek neurosurgical training system is unique in numerous respects. This manuscript delineates the current state of neurosurgical residency training in Greece and outlines future directions. METHODS: A narrative review was conducted to describe the Greek neurosurgical residency training structure. The perspectives of the authors regarding challenges in training and future directions were synthesized. RESULTS: This manuscript describes the neurosurgery residency curriculum and board certification process, existing training programs, and key challenges in neurosurgery residency training in Greece. The authors propose future directions to reform neurosurgical training in Greece. CONCLUSIONS: Neurosurgery residency training in Greece has been largely unchanged for many years. This review leads to suggested modification of the existing training process may improve the quality of training and equip neurosurgeons to respond to the rapidly changing landscape of the field.

Cavernous malformations of the central nervous system: An international consensus statement.

Introduction: Cavernous malformations (CM) of the central nervous system constitute rare vascular lesions. They are usually asymptomatic, which has allowed their management to become quite debatable. Even when they become symptomatic their optimal mode and timing of treatment remains controversial. Research question: A consensus may navigate neurosurgeons through the decision-making process of selecting the optimal treatment for asymptomatic and symptomatic CMs. Material and methods: A 17-item questionnaire was developed to address controversial issues in relation to aspects of the treatment, surgical planning, optimal surgical strategy for specific age groups, the role of stereotactic radiosurgery, as well as a follow-up pattern. Consequently, a three-stage Delphi process was ran through 19 invited experts with the goal of reaching a consensus. The agreement rate for reaching a consensus was set at 70%. Results: A consensus for surgical intervention was reached on the importance of the patient's age, symptomatology, and hemorrhagic recurrence; and the CM's location and size. The employment of advanced MRI techniques is considered of value for surgical planning. Observation for asymptomatic eloquent or deep-seated CMs represents the commonest practice among our panel. Surgical resection is considered when a deep-seated CM becomes symptomatic or after a second bleeding episode. Asymptomatic, image-proven hemorrhages constituted no indication for surgical resection for our panelists. Consensus was also reached on not resecting any developmental venous anomalies, and on resecting the associated hemosiderin rim only in epilepsy cases. Discussion and conclusion: Our Delphi consensus provides an expert common practice for specific controversial issues of CM patient management.

Hemispherotomy Revised: A complication overview and a systematic review meta-analysis.

Introduction: Hemispherectomy/hemispherotomy has been employed in the management of catastrophic epilepsy. However, initial reports on the associated mortality and morbidity raised several concerns regarding the technique's safety. Their actual, current incidence needs to be systematically examined to redefine hemispherotomy's exact role. Research question: Our current study examined their incidence and evaluated the association of the various hemispherotomy surgical techniques with the reported complications. Material & methods: A PRISMA-compliant systematic review and meta-analysis was performed. We searched PubMed, Scopus, and Web of Science until December 2022. Fixed- and random-effects models were employed. Egger's regression test was used for estimating the publication bias, while subgroup analysis was utilized for defining the role of the different hemispherotomy techniques. Results: We retrieved a total of 37 studies. The overall procedure mortality was 5%, with a reported mortality of 7% for hemispherectomy and 3% for hemispherotomy. The reported mortality has decreased over the last 30 years from 32% to 2%. Among the observed post-operative complications aseptic meningitis and/or fever occurred in 33%. Hydrocephalus requiring a shunt insertion occurred in 16%. Hematoma evacuation was necessary in 8%, while subgaleal effusion in another 8%. Infections occurred in 11%. A novel post-operative cranial nerve deficit occurred in 11%, while blood transfusion was necessary in 28% of the cases. Discussion and conclusion: Our current analysis demonstrated that the evolution from hemispherectomy to hemispherotomy along with neuroanesthesia advances, had a tremendous impact on the associated mortality and morbidity. Hemispherotomy constitutes a safe surgical procedure in the management of catastrophic epilepsies.

Length of Survival, Outcome, and Potential Predictors in Poor-Grade Aneurysmal Subarachnoid Hemorrhage Patients Treated with Microsurgical Clipping.

BACKGROUND: Poor-grade aneurysmal subarachnoid hemorrhage (aSAH) has been associated with severe morbidity and high mortality. It has been demonstrated that early intervention is of paramount importance. The aim of our study is to evaluate the functional outcome and the overall survival of early microsurgically treated patients. MATERIAL AND METHODS: Poor-grade aSAH patients admitted at our institution over fifteen years (January 2008 - December 2022) were included in our retrospective study. All participants underwent brain Computed Tomography Angiography (CTA). Fisher scale was used to assess the severity of hemorrhage. All our study participants underwent microsurgical clipping, and their functional outcome was assessed with the Glasgow Outcome Scale (GOS). We used logistic regression analysis to identify any parameters associated with a favorable outcome at 12 months. Cox proportional hazard analysis was also performed, identifying factors affecting the length of survival. RESULTS: Our study included 39 patients with a mean age of 54 years. Thirty of our participants (76.9%) were Hunt and Hess grade V, while the vast majority (94.9%) were Fisher grade 4. The observed six-month mortality rate was 48.6%. The mean follow-up time was 18.6 months. The functional outcome at six months was favorable in 6 patients (16.2%), increased to 23.5% at 12 months. Our data analysis showed that the age, as well as the employment of temporary clipping during surgery, affected the overall outcome. CONCLUSION: Management of poor-grade aSAH patients has been dramatically changed. Microsurgical clipping provides promising results in carefully selected younger patients.

Greek reflections on global neurosurgery.

Introduction: Large populations in middle- and low-income countries in Africa, Asia, and Central and South Americas face a dramatic neurosurgical crisis. However, large social groups in high-income countries face similar limited access to neurosurgical services. Proper identification of such a problem, analysis of the underlying causes, and proposal of potential solutions may not only address the problem at a national level, but may also provide valuable reflections on the efficient management of global neurosurgical crisis. Research question: To evaluate if special social groups face similar problems in Greece. Material and methods: The structure of the Greek health system was examined. The national census along with the registry of practicing neurosurgeons of the Greek National Society, as well as the national health map were searched. Results: A series of socio-economic factors, language barriers, cultural and religion differences, geographical barriers, the COVID-19 pandemic aftermath, along with the inherent malfunctioning of the Greek health system have led to this national neurosurgical crisis. Discussion and conclusion: An extensive redrawing of the Greek health map, reorganization of the national health system, along with adaptation of all recent advances in telemedicine may alleviate the health burden in these populations. The results of this local reformation may be applied to a global level for managing the ongoing health crisis. Moreover, the development of a European taskforce by the European Association of Neurosurgical Societies (EANS) may well facilitate the development of realistic and efficacious global solutions, and contribute to the global effort for providing high-quality neurosurgical services worldwide.

Critical Assessment of the Guidelines-Based Management of Severe Traumatic Brain Injury with the Appraisal of Guidelines for Research and Evaluation II.

BACKGROUND: Severe traumatic brain injury constitutes a clinical entity with complex underlying pathophysiology. Management of patients with severe traumatic brain injury is guided by Clinical Practice Guidelines and Consensus Statements (CPG and CS). The published CPG and CS vary in quality, comprehensiveness, and clinical applicability. The value of critically assessing CPG and CS cannot be overemphasized. The aim of our study was to assess the quality of the published CPG and CS, based on the Appraisal of Guidelines for Research and Evaluation II instrument. METHODS: A systematic search was performed in PubMed, Scopus, Embase, and Web of Science focusing on guidelines and consensi about severe traumatic brain injury . The search terms used were "traumatic brain injury," "TBI," "brain injury," "cerebral trauma," "head trauma," "closed head injury," "head injury," "guidelines," "recommendations," "consensus" in any possible combination. The search period extended from 1964 to 2021 and was limited to literature published in English. The eligible studies were scored by 4 raters, using the Appraisal of Guidelines for Research and Evaluation II instrument. The inter-rater agreement was assessed using the Cronbach's alpha. RESULTS: Twelve CPG and CS were assessed. Overall, the study by Carney et al. was the most Appraisal of Guidelines for Research and Evaluation II compliant study. In general, the domains of clarity of presentation, and scope and purpose, achieved the highest scores. The lowest inter-rater agreement in our analysis was "fair." CONCLUSIONS: The purpose of our study for assessing the quality of CPG and CS was served. We present the strong and weak points of CPG and CS. Our findings support the idea of periodically updating guidelines and improving their rigor of development.

Valve-controlled chronic subdural hematoma drainage: A feasibility study.

Introduction: Pneumocephalus after chronic subdural hematoma (CSDH) evacuation is a potential predictor of hematoma recurrence. Research question: To study the feasibility and safety of a novel CSDH evacuation technique using a valve-controlled method to avoid pneumocephalus. Material and methods: In a retrospective case series, we evacuated CSDH using very low-pressure valve-controlled drains and recorded the neurological, radiological, and functional outcomes. Patients with primary CSDH, without previous neurosurgical intervention, and who did not receive antiplatelet or anticoagulant therapy the week prior to the index surgery, were included in the study. Exclusion criteria were the evacuation with other treatment techniques and incomplete data files. Patients were assessed according to the Bender grading system to record the neurological status. The hematoma volume was estimated using the formula for ellipsoid volumes. Results: Thirty-six patients with a mean age of 73 years (±9 years) fulfilled our eligibility criteria. Our technique was effective since it decreased the CSDH volume from 141 â€‹ml (IQR 97 â€‹ml) to 20.6 â€‹ml (IQR 26.59 â€‹ml; p â€‹< â€‹0.001) and improved the neurological status according to the Bender grading system from two (IQR 0.25) to 1 (IQR 0). However, pneumocephalus and hematoma recurrence occurred in one case each (2.8%). At six months, all patients returned to their previous status, except for two patients (5.6%) who died due to irrelevant pathologies. Conclusions: Valve-controlled CSDH evacuation aiming to decrease the postoperative pneumocephalus and hematoma recurrence constitutes an effective and safe alternative. However, larger randomized controlled studies are required to establish its role in CSDH management.

Gender differences in work-life balance of European neurosurgeons.

Introduction: Neurosurgery is one of the most demanding medical specialties. For neurosurgeons, balancing professional activity with personal life can be challenging. Research question: To evaluate gender differences in contribution of neurosurgeons in the household and child-rearing, as well as their impact on personal life and career. Material and methods: An anonymous, electronic, 59-item web-based survey was administered to National Neurosurgical Societies of Europe, and European Member Societies of the European Association of Neurosurgical Societies (June-October 2021). Results: A total of 205 European neurosurgeons (87 females and 118 males, mean age 40.7) are included in our survey. In neurosurgery, females are significantly more likely to be alone (37.9%), while males are significantly more likely to have children (66.9%). In terms of household efforts, females spend more time than males on the same tasks. Most participants (71.2%) view gender issues as a disadvantage in career pursuing. Women feel less accepted (54.3%) and having fewer opportunities (58.6%), while men believe that pregnancy/child-rearing (65.8%) and having many roles (51.3%) are the main obstacles. Both genders (77.6%) favor more convenient working conditions for young parents.Discussion and Conclusion. In our study we found that, women neurosurgeons take more responsibilities at home, especially in the child-rearing years. Female neurosurgeons are more likely to live alone or stay childless more often compared to their male colleagues. Supportive facilities, flexible programs, universal life policies and presumably curbing of the social stereotypes are of importance to overcome gender inequities that women are still facing in neurosurgery.

Critical Appraisal of Randomized Controlled Trials on Unruptured Brain Arteriovenous Malformations.

OBJECTIVE: Brain arteriovenous malformations management remains controversial despite the numerous, available treatment options. Randomized controlled trials (RCTs) theoretically provide the strongest evidence for the assessment of any therapeutic intervention. However, poorly designed RCTs may be associated with biases, inaccuracies, and misleading conclusions. The purpose of our study is to assess reporting transparency and methodological quality of the existing RCTs. METHODS: A search was performed in the PubMed, Scopus, Embase, clinicaltrials.gov, and Cochrane databases. The search was limited to English literature. We included all published RCTs reporting on the management of unruptured brain arteriovenous malformations. The eligible studies were evaluated by 5 blinded raters with the CONsolidated Standards of Reporting Trials 2010 statement and the risk-of-bias 2 tool. The inter-rater agreement was assessed with the Fleiss' Kappa. RESULTS: A randomized trial of unruptured brain arteriovenous malformations (ARUBA) and treatment of brain arteriovenous malformations (TOBAS) trials were evaluated. ARUBA achieved high CONsolidated standards of reporting trials compliance, while TOBAS showed a moderate one. In ARUBA the introduction, discussion, and other information sections reached the highest compliance rate (80%-86%). The lowest rates were recorded in the results and the methods (62% and 73%, respectively). The inter-rater agreement was moderate to substantial (54.1% to 78.4%). All the examined studies demonstrated a high risk of bias, mainly related to ill-defined intended interventions, missing outcome data, and selection of the reported results. CONCLUSIONS: Our study confirmed the high risk of bias mainly attributed to several protocol violations, deviations, minimal external validity and selection, attrition, and allocation biases of the ARUBA trial. Analysis of the TOBAS trial revealed a moderate overall reporting clarity and a high risk of bias.

Women Pursuing a Neurosurgical Career in Greece.

Traditionally, neurosurgery constitutes one of the most male-dominated scientific fields owing to several factors, including social stereotypes, nonequal opportunities for higher education, and historical circumstances. Currently, with the increasing number of women in neurosurgery all over the world, this stereotype seems to be slowly but steadily disappearing. Since 1989, Women in Neurosurgery has played a vital role in introducing and promoting talented women in neurosurgery and highlighting contributions of women to academic society and medical leadership worldwide. In Greece, although the majority of men neurosurgeons accept the idea of women entering their field, the role of women seems to remain minor, especially in academic neurosurgery. In this article, we present a brief history of Greek neurosurgery, with an emphasis on the first women neurosurgeons and their contribution to neurosurgery in Greece. We have outlined the role of Greek women neurosurgeons in neurosurgical leadership through their active involvement in the administration of national and international neurosurgical societies. Furthermore, we have attempted to explore the underrepresentation of women in the Greek academic neurosurgical community and to determine whether it is associated with lurking gender discrimination or deep-rooted social prejudice.

Methodological assessment of guidelines for the diagnosis and management of cerebral vasospasm using the AGREE-II tool.

OBJECTIVE: Rupture of an intracranial aneurysm is the most common cause of spontaneous subarachnoid hemorrhage. Despite the recent advances in its early detection, diagnosis, and proper treatment, the outcome of patients experiencing aneurysmal subarachnoid hemorrhage (aSAH) remains poor. It is well known that cerebral vasospasm is the most troublesome complication of aSAH, while delayed cerebral ischemia related to cerebral vasospasm constitutes the major cause of unfavorable outcomes in patients with aSAH. The need for evidence-based guidelines is of great importance for the prevention, early detection, and efficient management of aSAH-induced vasospasm. Moreover, guidelines provide young physicians with a valuable tool for practicing defensible medicine. However, the methodology, clinical applicability, reporting clarity, and biases of guidelines must be periodically assessed. In this study, the authors sought to assess the reporting clarity and methodological quality of published guidelines and recommendations. METHODS: A search was performed in the PubMed, Scopus, and Web of Science databases. The search terms used were "clinical practice guidelines," "recommendations," "stroke," "subarachnoid hemorrhage," and "vasospasm" in all possible combinations. The search period extended from 1964 to September 2021 and was limited to literature published in the English language. All published guidelines and recommendations reporting on the diagnosis and management of vasospasm were included. Studies other than those reporting guidelines and recommendations were excluded. The eligible studies were evaluated by three blinded raters, employing the Appraisal of Guidelines for Research & Evaluation II (AGREE-II) analysis tool. RESULTS: A total of 10 sets of guidelines were evaluated in this study. The American Heart Association/American Stroke Association issued guidelines found to have the highest methodological quality and reporting clarity, followed by the European Stroke Organization guidelines and the English edition of the Japanese guidelines issued by the Japanese Society on Surgery for Cerebral Stroke. The interrater agreement was moderate in the current analysis. CONCLUSIONS: These findings support the idea that improvement of currently existing guidelines is feasible in the following domains: the rigor of guidelines and recommendations development, clinical applicability, editorial independence, and stakeholder involvement. Furthermore, periodic updating of published guidelines requires improvement in the future.

Intermediate surgical outcome in patients suffering poor-grade aneurysmal subarachnoid hemorrhage. A single center experience.

BACKGROUND: It is known that patients suffering poor-grade aneurysmal subarachnoid hemorrhage (aSAH) have a dismal prognosis. The importance of early intervention is well established in the pertinent literature. Our aim was to assess the functional outcome and overall survival of these patients undergoing surgical clipping. MATERIAL AND METHODS: In the current retrospective study we included all consecutive poor-grade patients after spontaneous SAH who presented at our institution over an eight-year period. All participants suffering SAH underwent brain CT angiography (CTA) to identify the source of hemorrhage. We assessed the severity of hemorrhage according to the Fisher grade classification scale. All patients were surgically treated. The functional outcome was evaluated six months after the onset with the Glasgow Outcome Scale. Finally, we performed logistic and Cox regression analyses to identify potential prognostic risk factors. RESULTS: Our study included twenty-three patients with a mean age of 53 years. Five (22%) patients presented with Hunt and Hess grade IV, and eighteen (78%) with grade V. The mean follow-up was 15.8 months, while the overall mortality rate was 48%. The six-month functional outcome was favorable in 6 (26%) patients. The vast majority of our patients died between the 15th and the 60th post-ictal days. We did not identify any statistically significant prognostic factors related to the patient's outcome and/or survival. CONCLUSIONS: Poor-grade aSAH patients may have a favorable outcome with proper surgical management. Large-scale studies are necessary for accurately outlining the prognosis of this entity, and identifying parameters that could be predictive of outcome.

Post-Cranioplasty Complications: Lessons From a Prospective Study Assessing Risk Factors.

ABSTRACT: Complication rate related with cranioplasty is described as very high in most of relevant studies. The aim of our study was to try to identify possible factors, that could predict complications following cranioplasty. The authors hypothesized that some physical characteristics on the preoperative brain computed tomography (CT) scan can be predictive for complications.The authors carried out a prospective observational study. All patients were adults after decompressive craniectomy, planned for cranioplasty and had a brain CT scan the day before cranioplasty. Our data pool included demographics, reason of craniectomy, various radiological parameters, the time of cranioplasty after craniectomy, the type of cranioplasty bone flap, and the complications.Twenty-five patients were included in the study. The authors identified statistically significant correlation between time of cranioplasty after craniectomy and the complications, as well as between the type of cranioplasty implant and the complications. There was statistically significant correlation between complications and the distance of the free brain surface from the level of the largest skull defect dimension - free brain surface deformity (FBSD). Moreover, the correlation between FBSD and the time of cranioplasty was statistically significant.It seems that for adult patients with unilateral DC the shorter time interval between craniectomy and cranioplasty lowers the risk for complications. The risk seems to be decreased further, by using autologous bone flap. Low values of the FBSD increase the risk for complications. This risk factor can be avoided, by shortening the time between craniectomy and cranioplasty.

European women in neurosurgery: I - A chronology of trailblazers.

Neurosurgery as a distinct speciality has been around for 100 years. Some of the earliest women neurosurgeons were European, emerging from the 1920's onwards. Here we detail the rise of women in neurosurgery across Europe with a decade by decade account of big events and firsts across the continent. The emerging themes are seen in stories of pioneers with enormous resilience, camaraderie, trailblazing and triumphing in a system with great obstacles and challenges. Our journey through this chronology brings us to the modern day, where most European countries have or have had a woman neurosurgeon and the future for women in neurosurgery in the continent is very bright.

European women in neurosurgery: II - Historical characters and living legends.

A collaborative global working group of women neurosurgeons in multiple countries at different stages of their neurosurgical careers undertook the task of researching the history of European women in neurosurgery. While doing so, we happened upon many remarkable female neurosurgeons who overcame great adversity, made tremendous contributions to society and institutional neurosurgery, and displayed numerous talents beyond the operating room. In the first part of this paper, we recounted a chronology of female neurosurgeons in Europe, highlighting the most remarkable achievements of women in every decade, from the 1920's to 2020. In this paper, we honor fascinating women in European neurosurgery, both historical characters and living legends. These women have overcome great adversity and have also excelled in a huge variety of pursuits. While some were themselves refugees, we also have uncovered noteworthy examples of women who immersed themselves in humanitarian missions and who tried to better the world through political action. There are stories of women beating the odds, taking on biased institutions and proving their worth, in spite of the prevailing system. Most inspirational, we have discovered through our comprehensive research on the history of women in European neurosurgery that the future is increasingly female.

Arteriovenous Malformations: Congenital or Acquired Lesions?

OBJECTIVE: Arteriovenous malformations (AVMs) were believed to be congenital. However, an increasing number of de novo AVM cases have questioned this doctrine. METHODS: A consensus meeting of international experts attempted to establish a consensus on the nature of these relatively rare but challenging vascular lesions. In addition, an extensive search of the subject was performed using the PubMed medical database. RESULTS: All participants agreed that genetic factors may play a role in the pathogenesis of AVMs. All but 1 participant believed that an underlying genetic predisposition may be detected later on in a patient's life, whereas genetic variations may contribute to sporadic AVM formation. The presence of genetic variations alone may not be enough for an AVM formation. A second hit is probably required. This consensus opinion is also supported by our literature search. CONCLUSIONS: We discuss the literature on the genetics of AVMs and compare it with the consensus meeting outcomes. The congenital or noncongenital character of intracranial AVMs has an impact on the understanding their biological behavior, as well as their efficient short-term and long-term management.

Complications Associated with Surgery for Thoracic Disc Herniation: A Systematic Review and Network Meta-Analysis.

BACKGROUND: A systematic review and network meta-analysis (Prospero ID CRD42018106936) were performed. OBJECTIVE: The selection of the appropriate surgical approach for the management of thoracic disc herniation (TDH) is often challenging because of the frequency and variability of the associated complications. We evaluated the safety of the surgical approaches for TDH by estimating the mortality (Q1) and morbidity (Q2), and frequency of the most common complications (Q3). METHODS: We searched the medical literature for randomized controlled trials and observational studies reporting on the management of TDH. Postoperative complications were the outcome of interest. The absolute and relative risk estimates, along with the rank probability scores, were estimated for each approach, through a network meta-analysis. The results were read in the light of the quality of the available evidence. RESULTS: Fifteen studies with a total of 1036 patients fulfilled our eligibility criteria. Three deaths were reported. The overall morbidity was as high as 29%, largely attributed to medical (21%; 95% confidence interval [CI], 10%-38%), surgical site (11%; 95% CI, 5%-22%), cerebrospinal fluid-related (8%; 95% CI, 3%-8%), and neurologic complications (5%; 95% CI, 1%-24%). The anterior and lateral approaches were associated with a higher risk for medical and surgical complications compared with the posterolateral approach. CONCLUSIONS: Surgery for TDH is associated with minimal mortality but significant morbidity, with large variations among the available approaches. An understanding of the perioperative complications rates is important to develop complication avoidance strategies and to aid accurate patient-to-doctor communication.