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1.
Implement Sci ; 14(1): 78, 2019 08 09.
Artigo em Inglês | MEDLINE | ID: mdl-31399105

RESUMO

BACKGROUND: Advanced physiotherapist-led services have been embedded in specialist orthopaedic and neurosurgical outpatient departments across Queensland, Australia, to ameliorate capacity constraints. Simulation modelling has been used to inform the optimal scale and professional mix of services required to match patient demand. The context and the value of simulation modelling in service planning remain unclear. We aimed to examine the adoption, context and costs of using simulation modelling recommendations to inform service planning. METHODS: Using an implementation science approach, we undertook a prospective, qualitative evaluation to assess the use of discrete event simulation modelling recommendations for service re-design and to explore stakeholder perspectives about the role of simulation modelling in service planning. Five orthopaedic and neurosurgical services in Queensland, Australia, were selected to maximise variation in implementation effectiveness. We used the consolidated framework for implementation research (CFIR) to guide the facilitation and analysis of the stakeholder focus group discussions. We conducted a prospective costing analysis in each service to estimate the costs associated with using simulation modelling to inform service planning. RESULTS: Four of the five services demonstrated adoption by inclusion of modelling recommendations into proposals for service re-design. Four CFIR constructs distinguished and two CFIR constructs did not distinguish between high versus mixed implementation effectiveness. We identified additional constructs that did not map onto CFIR. The mean cost of implementation was AU$34,553 per site (standard deviation = AU$737). CONCLUSIONS: To our knowledge, this is the first time the context of implementing simulation modelling recommendations in a health care setting, using a validated framework, has been examined. Our findings may provide valuable insights to increase the uptake of healthcare modelling recommendations in service planning.


Assuntos
Assistência Ambulatorial/normas , Assistência à Saúde/normas , Ciência da Implementação , Modelos Organizacionais , Neurocirurgia/normas , Ortopedia/normas , Pacientes Ambulatoriais , Técnicas de Planejamento , Melhoria de Qualidade , Grupos Focais , Necessidades e Demandas de Serviços de Saúde , Humanos , Pesquisa Qualitativa , Queensland
3.
World Neurosurg ; 130: e874-e879, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31301446

RESUMO

INTRODUCTION: Socioeconomic topics such as federal mandates/regulations, conflict of interest, and practice management have become increasingly important for all neurosurgeons. Graduating residents immediately need a host of skills to successfully navigate neurosurgical practice. Surgical and medical skills are closely evaluated through the American Board of Neurological Surgery, and a formal socioeconomic curriculum has been developed with defined milestones. Nevertheless, little has been done to evaluate neurosurgery resident competence in socioeconomic and medicolegal principles. The purpose of this study was to assess the competence of Accreditation Council for Graduate Medical Education neurosurgical residents in socioeconomic knowledge. METHODS: Neurosurgery resident members of the American Association of Neurological Surgeons (N = 1385) were sent a Survey Monkey of 10 questions. The survey covered the most basic of socioeconomic principles. Initial survey responses were collected across a 1-month period from April to May 2018. RESULTS: The response rate was 14% (194/1385). Overall, neurosurgery residents would have received a grade of D, with an average score of 67% on the survey. For 7 of the 10 questions, the majority (>50%) of neurosurgery residents answered correctly. Furthermore, for 3 questions, more than 90% of residents selected the correct answer. However, for one-half of all questions, residents averaged a score of less than 65%. Residents tended to answer questions correctly for physician compensation and compensation models, but incorrectly for topics of informed consent, Controlled Substances Act, and conflicts of interest. CONCLUSION: With the increasing complexity of neurosurgery practice, solid knowledge of socioeconomic topics is essential. The study confirms suspected deficiencies in socioeconomic proficiency among neurosurgery residents, despite the availability of a validated curriculum. This knowledge gap will likely affect career success and satisfaction. Nevertheless, this survey had a significantly low response rate, and it may be an incomplete representation of the neurosurgical resident mind. Focused educational initiatives through the neurosurgical Residency Review Committee and individual training programs must facilitate an action plan that ensures the effective implementation of socioeconomic curricula.


Assuntos
Competência Clínica/normas , Neurocirurgiões/normas , Neurocirurgia/normas , Procedimentos Neurocirúrgicos/normas , Fatores Socioeconômicos , Inquéritos e Questionários , Humanos , Neurocirurgiões/economia , Neurocirurgiões/educação , Neurocirurgia/economia , Neurocirurgia/educação , Procedimentos Neurocirúrgicos/economia , Procedimentos Neurocirúrgicos/educação , Estados Unidos/epidemiologia
4.
World Neurosurg ; 130: e112-e116, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31176838

RESUMO

INTRODUCTION: Quality assurance (QA) is a way to prevent mistakes in advance. Although it has been previously reported for surgical setup, there is no effective approach for minimizing microsurgical technical errors before an operation is done. Neurosurgery resident operative errors during brain aneurysm surgery could be foreseen by practicing in an ex vivo hybrid simulator with microscopic fluorescein vessel flow image. METHODS: Five vascular neurosurgeons and 8 junior/senior neurosurgical residents voluntarily joined this research initiative. The following methodology was adopted: 1) Identification of the 7 most-common resident operative performance errors during brain aneurysm surgery; 2) Design of exercises to prevent common mistakes in brain aneurysm microsurgery using a placenta simulator; and 3) Blinded staff neurosurgeon evaluation of resident performance during real brain aneurysm microsurgery. RESULTS: All key steps to perform such intervention were accomplished with a simulator that uses 2 placentas, a synthetic cranium, and microscopic fluorescein vessel flow image. Neurosurgery residents trained in this model had better surgical performance with fewer perioperative mistakes (P < 0.05). Fine microsurgical dissection of the arachnoid membrane and aneurysm sac were the most commonly improved tasks among the 7 common operative mistakes. Brain parenchyma traction with secondary bleeding was the only error not prevented after previous simulator training. CONCLUSIONS: There was a left-shift on the quality assurance line with residents who practiced brain aneurysm microsurgical errors in an ex vivo model. A multicentric prospective study is necessary to confirm the hypothesis that real operative error could be reduced after training in a realistic simulator.


Assuntos
Aneurisma Intracraniano/cirurgia , Microcirurgia/educação , Microcirurgia/normas , Neurocirurgia/educação , Neurocirurgia/normas , Procedimentos Neurocirúrgicos/educação , Procedimentos Neurocirúrgicos/normas , Competência Clínica , Humanos , Internato e Residência , Microcirurgia/efeitos adversos , Neurocirurgiões , Procedimentos Neurocirúrgicos/efeitos adversos , Garantia da Qualidade dos Cuidados de Saúde , Treinamento por Simulação
5.
Curr Opin Anaesthesiol ; 32(5): 574-579, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31157627

RESUMO

PURPOSE OF REVIEW: Transfusion is a common practice during neurosurgery. However, there is no evidence-based consensus on transfusion practice in neurosurgery. This review summarizes the evidence pertinent to the commonly used transfusion triggers in neurosurgical patients. RECENT FINDINGS: In the field of neurosurgery, there is only one randomized controlled trial, performed in patients with traumatic brain injury, to investigate the transfusion trigger of red blood cells. There is a lack-of-quality evidence pertinent to the transfusion triggers of other blood products. Most of the transfusion triggers used for neurosurgical patients are extrapolated from the evidence based on studies performed in nonneurosurgical patients. Clinical experience and expert opinions have played a major role in transfusion practice in neurosurgery. SUMMARY: There is a scarcity of high-quality outcome-based evidence for transfusion practice in neurosurgery. In the absence of quality evidence, the transfusion practice in neurosurgical patients should be based on the understanding of the complex pathophysiology related to anemia and coagulopathy and the balance between the risks and benefits associated with blood product transfusion. The practice guided by tissue oximeter and viscoelastic tests appears promising, but needs to be validated by future studies.


Assuntos
Perda Sanguínea Cirúrgica/prevenção & controle , Transfusão de Sangue/normas , Medicina Baseada em Evidências/normas , Procedimentos Neurocirúrgicos/efeitos adversos , Reação Transfusional/prevenção & controle , Adulto , Anemia/etiologia , Anemia/prevenção & controle , Transtornos da Coagulação Sanguínea/etiologia , Transtornos da Coagulação Sanguínea/prevenção & controle , Criança , Consenso , Humanos , Neurocirurgia/normas , Guias de Prática Clínica como Assunto
6.
Medicina (Kaunas) ; 55(5)2019 May 21.
Artigo em Inglês | MEDLINE | ID: mdl-31117234

RESUMO

Background and Objectives: Postoperative cognitive disturbances (POCD) can significantly alter postoperative recovery. Inadequate intraoperative cerebral oxygen supply is one of the inciting causes of POCD. Near-infrared spectroscopy (NIRS) devices monitor cerebral oxygen saturation continuously and can help to guide intraoperative patient management. The aim of the study was to evaluate the applicability of the NIRS-based clinical algorithm during spinal neurosurgery and to find out whether it can influence postoperative cognitive performance. Materials and Methods: Thirty four patients scheduled for spinal neurosurgery were randomized into a study group (n = 23) and a control group (n = 11). We monitored regional cerebral oxygen saturation (rScO2) throughout surgery, using a NIRS device (INVOS 4100). If rScO2 dropped bilaterally or unilaterally by more than 20% from baseline values, or under an absolute value of 50%, the NIRS-based algorithm was initiated in the study group. In the control group, rScO2 was monitored blindly. To evaluate cognitive function, Montreal-Cognitive Assessment (MoCA) scale was used in both groups before and after the surgery. Results: In the study group, rScO2 dropped below the threshold in three patients and the NIRS-based algorithm was activated. Firstly, we verified correct positioning of the head; secondly, we increased mean systemic arterial pressure in the three patients by injecting repeated intravenous bolus doses of Ephedrine, ultimately resulting in an rScO2 increase above the approved threshold level. None of the three patients showed POCD. In the control group, one patient showed a drop in rScO2 of 34% from baseline and presented with a POCD. RScO2 drop occurred with other stable intraoperative measurements. Conclusions: A significant rScO2 drop may occur during spinal surgery in prone position despite other intraoperative measurements remaining stable, allowing it to stay otherwise unrecognized. Use of the NIRS-based clinical algorithm can help to avoid POCD in patients after spinal surgery.


Assuntos
Algoritmos , Cognição , Complicações Pós-Operatórias/diagnóstico , Espectroscopia de Luz Próxima ao Infravermelho/métodos , Coluna Vertebral/cirurgia , Adulto , Idoso , Cérebro/irrigação sanguínea , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neurocirurgia/instrumentação , Neurocirurgia/métodos , Neurocirurgia/normas , Oximetria/instrumentação , Oximetria/métodos , Complicações Pós-Operatórias/fisiopatologia , Estudos Prospectivos , Espectroscopia de Luz Próxima ao Infravermelho/instrumentação , Espectroscopia de Luz Próxima ao Infravermelho/tendências
7.
J Appl Clin Med Phys ; 20(5): 27-36, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30950167

RESUMO

BACKGROUND: The stereotactic frame represents the mainstay of accuracy for targeting in stereotactic procedures. Any distortion of the frame may induce a significant source of error for the stereotactic coordinates. OBJECTIVE: To analyze the sources of distortion of the Leksell frame G induced by fixation to the patient's head and to evaluate the clinical impact of frame distortion on the accuracy of targeting in stereotactic procedures. METHODS: We analyzed the torques exerted on the fixation screws after frame placement in a series of patients treated stereotactically by an experienced team. We studied the risk for frame bending in an experimental model of stereotactic frame fixation, with increasing torque of fixation screws in a homogeneous and heterogeneous distribution of torques between the four screws. We assessed the impact of expanding dimensions of bending of the Leksell frame both on surgeries utilizing the stereotactic frame, and on radiosurgical procedures with the Gamma Knife. RESULTS: Frames were fixed clinically at a range of torques of 0.147-0.522 Nm (mean = 0.348 Nm). The torques did not vary significantly with time. Heterogeneity between the two opposite pairs of screws is often limited, but can reach 96.3%. Distortion of the frame may occur even at minimal levels of torque. Heterogeneity between the two opposite pairs of screws will significantly raise the amount of frame distortion. We found a direct correlation between measures of the frame distortion and extend of the deviation from the stereotactic target in clinical models of stereotactic procedures. CONCLUSION: Stereotactic frames were subjected to distortion due to the torque used for frame fixation. The risk of distortion increased with the torque used and the heterogeneity between the torques of the fixation screws. Distortion of the frame was a significant source of inaccuracy of targeting for stereotactic procedures in clinical practice.


Assuntos
Calibragem , Neoplasias/cirurgia , Neurocirurgia/instrumentação , Imagens de Fantasmas , Radiocirurgia/instrumentação , Técnicas Estereotáxicas/instrumentação , Desenho de Equipamento , Humanos , Neurocirurgia/normas , Radiocirurgia/normas
8.
World Neurosurg ; 127: 63-71, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30930320

RESUMO

BACKGROUND: An increasing body of literature describing use of high-fidelity surgical training models is challenging long-held dogma that cadavers provide the best medium for postgraduate surgical skills training. The purpose of this study was to describe a surgical skills course comprising entirely synthetic training models developed by resident and attending neurosurgeons and to evaluate their perceptions of the overall usefulness of this course and its usefulness compared with cadaveric courses. METHODS: Ten high-fidelity neurosurgical training models were developed. A neurosurgical skills course for residents was structured to include 7 spinal and 3 cranial learning stations, each with its own model and assigned attending expert. Resident and attending neurosurgeons were asked to complete surveys on their overall impressions of the course and models and on workload comparisons between models and real cases. Student t tests were used for statistical comparisons. RESULTS: Survey responses were collected from 9 of 16 participating residents (56.3%) and 3 of 10 attending neurosurgeons (30.0%). Both groups believed that the course was very helpful overall to resident education. Respondents furthermore believed that the course was more helpful overall than cadaveric courses. Task load index testing showed no significant workload difference between models and real cases (P ≥ 0.17), except in temporal demand (P < 0.001). CONCLUSIONS: Resident and attending neurosurgeons subjectively believe that high-fidelity synthetic models were superior to cadavers as a surgical skills teaching platform. This study raises the question of whether cadavers should remain the gold standard for surgical skills courses. Expanded use of these teaching models and further study are warranted.


Assuntos
Competência Clínica , Neurocirurgia/educação , Procedimentos Neurocirúrgicos/educação , Procedimentos Neurocirúrgicos/normas , Cadáver , Humanos , Internato e Residência/métodos , Modelos Anatômicos , Neurocirurgiões/educação , Neurocirurgia/normas , Inquéritos e Questionários
9.
World Neurosurg ; 127: e707-e716, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30947014

RESUMO

OBJECTIVE: Historically, medical student education in neurological surgery has generally limited student involvement to assisting in research projects with minimal formal clinical exposure before starting sub-internships and application for the neurosurgery match. Consequently, students have generally had little opportunity to acquire exposure to clinical neurosurgery and attain minimal proficiency. A medical student training camp was created to improve the preparation of medical students for the involvement in neurological surgery activities and sub-internships. METHODS: A 1-day course was held at Weill Cornell Medicine, which consisted of a series of morning lectures, an interactive resident lunch panel, and afternoon hands-on laboratory sessions. Students completed self-assessment questionnaires regarding their confidence in several areas of clinical neurosurgery before the start of the course and again at its end. RESULTS: A significant increase in self-assessed confidence was observed in all skill areas surveyed. Overall, rising fourth year students who were starting sub-internships in the subsequent weeks reported a substantial increase in their preparedness for the elective rotations in neurosurgery. CONCLUSIONS: The preparation of medical students for clinical neurosurgery can be improved. Single-day courses such as the described training camp are an effective method for improving knowledge and skill gaps in medical students entering neurosurgical careers. Initiatives should be developed, in addition to this annual program, to increase the clinical and research skills throughout medical student education.


Assuntos
Competência Clínica/normas , Currículo/normas , Neurocirurgia/educação , Neurocirurgia/normas , Estudantes de Medicina , Educação Médica/métodos , Educação Médica/normas , Humanos , Internato e Residência/métodos , Internato e Residência/normas , Neurocirurgia/métodos , Procedimentos Neurocirúrgicos/educação , Procedimentos Neurocirúrgicos/métodos , Procedimentos Neurocirúrgicos/normas , Inquéritos e Questionários/normas
11.
World Neurosurg ; 126: e1112-e1120, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30880201

RESUMO

BACKGROUND: Quality Improvement (QI) is essential for improving health care delivery and is now a required component of neurosurgery residency. However, neither a formal curriculum nor implementation strategies have been established by the Accreditation Council for Graduate Medical Education. METHODS: We describe our experience with implementing a formal QI curriculum, including structured didactics and resident led group-based QI projects. Course materials and didactics were provided by the Mayo Quality Academy. Participants were required to take a 30-question multiple-choice exam to demonstrate basic proficiency in QI methods following completion of didactic. An anonymous survey also was performed to elicit feedback from course participants. RESULTS: All of the 40 student participants (17 residents) were able to demonstrate basic proficiency in QI methods on a standardized exam upon course completion. Of the 9 attempted QI projects, 7 were completed, with 5 of those resulting in sustained process changes. The majority of participants felt formal training improved confidence in QI processes and was a valuable professional tool for their careers. CONCLUSIONS: A formal didactic curriculum and practical application of QI methodologies adds value to resident training. Further, it has the potential to positively impact practice. Consideration should be given to adopting a formal QI curriculum by other neurosurgery departments and perhaps standardization on national level.


Assuntos
Currículo/normas , Educação de Pós-Graduação em Medicina/métodos , Internato e Residência/normas , Neurocirurgia/normas , Melhoria de Qualidade/normas , Humanos
12.
Turk Neurosurg ; 29(1): 121-126, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30614509

RESUMO

AIM: To provide information on the process and the results of the Turkish Board of Neurological Surgery and increase the relevant awareness. MATERIAL AND METHODS: The number of applications to the written and oral board exams organized by the Turkish Neurosurgical Society Proficiency Board since 2006, the number of successful and unsuccessful participants, and the number of the neurosurgery residents and specialists who applied to the exam were evaluated. RESULTS: A total of 554 candidates took the exam since 2006 when the first TBNS was applied. Two hundred and sixty of the candidates were successful (46.9%), and 294 (53.1%) were unsuccessful. Two hundred and forty six (44.4%) of those who took the test were neurosurgeons, 308 (55.6%) were neurosurgery residents who had completed their 3rd year in their training. The highest score in the written exams was 93/100, and the lowest score was 33/100. In verbal exams, a total of 73 candidates participated, and 66 (90.4 %) of them were successful while 7 of them (9.6%) were unsuccessful. CONCLUSION: Board exams are inevitable to provide a certain level of education and standardization in the training of neurosurgery. Our duty as neurosurgeons is to participate in these exams and work to increase participation for continuing education.


Assuntos
Neurocirurgiões/educação , Neurocirurgiões/normas , Neurocirurgia/educação , Neurocirurgia/normas , Feminino , Humanos , Internato e Residência , Masculino , Conselhos de Especialidade Profissional/normas
13.
Neurosurgery ; 84(2): 537-543, 2019 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-29566181

RESUMO

Recent legislation has changed quality reporting in neurological surgery. The present study summarizes the reporting of objectives and measures outlined by the Quality Payment Program (QPP) and assesses how practices are preparing to comply. In February 2017, 220 neurosurgical practices were surveyed regarding their adherence to quality reporting objectives and measures. Survey responders were asked to report infrastructure-level data including practice type and number of providers. Furthermore, we evaluated the reporting of quality and advancing care measures outlined by the QPP. Assessment of quality measures was focused on those related to neurosurgical patient management. A total of 27 responses were obtained. Practices consisted of 8 academic (30%), 16 physician-owned (59%), and 3 hospital-owned (11%) neurosurgical practices. Of the 27 total responders, 18 indicated their adherence to a host of quality and advancing care measures. Practice type was strongly associated with the number of quality measures performed (P = .020, Wilcoxon rank-sum test). Physician-owned practices reported performing a median of 5 quality measures (interquartile range, 4.5-9.5), while practices in academic and hospital-owned groups reported performing 12 quality measures (interquartile range, 9.5-13.5). Forty-five percent of physician-owned practices reported performing at least 6 quality measures, whereas 100% of academic and hospital-owned practices reported the same benchmark (P = .038, Fisher's exact test). Performance of advancing care measures was not associated with practice type. Compared to other practice types, the rate of quality reporting among physician-owned neurosurgical practices appears to be modest thus far, which may influence future reimbursement adjustments.


Assuntos
Fidelidade a Diretrizes/estatística & dados numéricos , Neurocirurgia/normas , Garantia da Qualidade dos Cuidados de Saúde/métodos , Humanos , Neurocirurgiões/normas , Neurocirurgiões/estatística & dados numéricos , Garantia da Qualidade dos Cuidados de Saúde/normas , Garantia da Qualidade dos Cuidados de Saúde/estatística & dados numéricos , Inquéritos e Questionários
14.
Neurosurgery ; 84(1): E53-E55, 2019 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-30202868

RESUMO

QUESTION: Does early surgical intervention improve outcomes for patients with thoracic and lumbar fractures? RECOMMENDATIONS: There is insufficient and conflicting evidence regarding the effect of timing of surgical intervention on neurological outcomes in patients with thoracic and lumbar fractures. Strength of Recommendation: Grade Insufficient It is suggested that "early" surgery be considered as an option in patients with thoracic and lumbar fractures to reduce length of stay and complications. The available literature has defined "early" surgery inconsistently, ranging from <8 h to <72 h after injury. Strength of Recommendation: Grade B The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_10.


Assuntos
Vértebras Lombares/lesões , Vértebras Lombares/cirurgia , Neurocirurgia/normas , Procedimentos Neurocirúrgicos/métodos , Planejamento de Assistência ao Paciente , Traumatismos da Coluna Vertebral/cirurgia , Vértebras Torácicas/lesões , Vértebras Torácicas/cirurgia , Medicina Baseada em Evidências , Guias como Assunto , Humanos , Fraturas da Coluna Vertebral/cirurgia
15.
Neurosurgery ; 84(1): E24-E27, 2019 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-30202904

RESUMO

QUESTION 1: Are there classification systems for fractures of the thoracolumbar spine that have been shown to be internally valid and reliable (ie, do these instruments provide consistent information between different care providers)? RECOMMENDATION 1: A classification scheme that uses readily available clinical data (eg, computed tomography scans with or without magnetic resonance imaging) to convey injury morphology, such as Thoracolumbar Injury Classification and Severity Scale or the AO Spine Thoracolumbar Spine Injury Classification System, should be used to improve characterization of traumatic thoracolumbar injuries and communication among treating physicians. Strength of Recommendation: Grade B. QUESTION 2: In treating patients with thoracolumbar fractures, does employing a formally tested classification system for treatment decision-making affect clinical outcomes? RECOMMENDATION 2: There is insufficient evidence to recommend a universal classification system or severity score that will readily guide treatment of all injury types and thereby affect outcomes. Strength of Recommendation: Grade Insufficient The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_2.


Assuntos
Vértebras Lombares/cirurgia , Neurocirurgia/normas , Procedimentos Neurocirúrgicos/métodos , Traumatismos da Coluna Vertebral/classificação , Traumatismos da Coluna Vertebral/cirurgia , Vértebras Torácicas/cirurgia , Medicina Baseada em Evidências , Guias como Assunto , Humanos , Neurocirurgiões , Fraturas da Coluna Vertebral/cirurgia , Resultado do Tratamento
16.
Neurosurgery ; 84(1): E43-E45, 2019 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-30202931

RESUMO

QUESTION: Does the active maintenance of arterial blood pressure after injury affect clinical outcomes in patients with thoracic and lumbar fractures? RECOMMENDATIONS: There is insufficient evidence to recommend for or against the use of active maintenance of arterial blood pressure after thoracolumbar spinal cord injury. Grade of Recommendation: Grade Insufficient However, in light of published data from pooled (cervical and thoracolumbar) spinal cord injury patient populations, clinicians may choose to maintain mean arterial blood pressures >85 mm Hg in an attempt to improve neurological outcomes. Consensus Statement by the Workgroup The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_6.


Assuntos
Hemodinâmica , Vértebras Lombares/lesões , Neurocirurgia/normas , Traumatismos da Coluna Vertebral/terapia , Vértebras Torácicas/lesões , Medicina Baseada em Evidências , Guias como Assunto , Humanos , Traumatismos da Medula Espinal/cirurgia , Fraturas da Coluna Vertebral/fisiopatologia , Fraturas da Coluna Vertebral/terapia , Traumatismos da Coluna Vertebral/fisiopatologia
17.
Neurosurgery ; 84(1): E36-E38, 2019 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-30202962

RESUMO

QUESTION: Does the administration of a specific pharmacologic agent (eg, methylprednisolone) improve clinical outcomes in patients with thoracic and lumbar fractures and spinal cord injury? RECOMMENDATION: There is insufficient evidence to make a recommendation; however, the task force concluded, in light of previously published data and guidelines, that the complication profile should be carefully considered when deciding on the administration of methylprednisolone. Strength of recommendation: Grade Insufficient The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_5.


Assuntos
Vértebras Lombares/lesões , Neurocirurgia/normas , Traumatismos da Coluna Vertebral/tratamento farmacológico , Vértebras Torácicas/lesões , Medicina Baseada em Evidências , Guias como Assunto , Humanos , Metilprednisolona/uso terapêutico , Fraturas da Coluna Vertebral/tratamento farmacológico , Fraturas da Coluna Vertebral/cirurgia
18.
Neurosurgery ; 84(1): E28-E31, 2019 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-30202989

RESUMO

BACKGROUND: Radiological evaluation of traumatic thoracolumbar fractures is used to classify the injury and determine the optimal treatment plan. Currently, there remains a lack of consensus regarding appropriate radiological protocol. Most clinicians use a combination of plain radiographs, 3-dimensional computed tomography with reconstructions, and magnetic resonance imaging (MRI). OBJECTIVE: To determine, through evidence-based guidelines review: (1) whether the use of MRI to identify ligamentous integrity predicted the need for surgical intervention; and (2) if there are any radiological findings that can assist in predicting clinical outcomes. METHODS: A systematic review of the literature was performed using the National Library of Medicine/PubMed database and the Cochrane Library for studies relevant to thoracolumbar trauma. Clinical studies specifically addressing the radiological evaluation of thoracolumbar spine trauma were selected for review. RESULTS: Two of 2278 studies met inclusion criteria for review. One retrospective review (Level III) and 1 prospective cohort (Level III) provided evidence that the addition of an MRI scan in acute thoracic and thoracolumbar trauma can predict the need for surgical intervention. There was insufficient evidence that MRI can help predict clinical outcomes in patients with acute traumatic thoracic and thoracolumbar spine injuries. CONCLUSION: This evidence-based guideline provides a Grade B recommendation that radiological findings in patients with acute thoracic or thoracolumbar spine trauma can predict the need for surgical intervention. This evidence-based guideline provides a grade insufficient recommendation that there is insufficient evidence to determine if radiographic findings can assist in predicting clinical outcomes in patients with acute thoracic and thoracolumbar spine injuries. QUESTION 1: Are there radiographic findings in patients with traumatic thoracolumbar fractures that can predict the need for surgical intervention? RECOMMENDATION 1: Because MRI has been shown to influence the management of up to 25% of patients with thoracolumbar fractures, providers may use MRI to assess posterior ligamentous complex integrity, when determining the need for surgery. Strength of Recommendation: Grade B. QUESTION 2: Are there radiographic findings in patients with traumatic thoracolumbar fractures that can assist in predicting clinical outcomes? RECOMMENDATION 2: Due to a paucity of published studies, there is insufficient evidence that radiographic findings can be used as predictors of clinical outcomes in thoracolumbar fractures. Strength of Recommendation: Grade Insufficient The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_3.


Assuntos
Vértebras Lombares/diagnóstico por imagem , Neurocirurgia/normas , Procedimentos Neurocirúrgicos/métodos , Traumatismos da Coluna Vertebral/diagnóstico por imagem , Vértebras Torácicas/diagnóstico por imagem , Medicina Baseada em Evidências , Guias como Assunto , Humanos , Processamento de Imagem Assistida por Computador , Vértebras Lombares/cirurgia , Imagem por Ressonância Magnética , Traumatismos da Coluna Vertebral/cirurgia , Vértebras Torácicas/cirurgia , Tomografia Computadorizada por Raios X
19.
Neurosurgery ; 84(1): E50-E52, 2019 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-30203034

RESUMO

QUESTION 1: Does the surgical treatment of burst fractures of the thoracic and lumbar spine improve clinical outcomes compared to nonoperative treatment? RECOMMENDATION 1: There is conflicting evidence to recommend for or against the use of surgical intervention to improve clinical outcomes in patients with thoracolumbar burst fracture who are neurologically intact. Therefore, it is recommended that the discretion of the treating provider be used to determine if the presenting thoracic or lumbar burst fracture in the neurologically intact patient warrants surgical intervention. Strength of Recommendation: Grade Insufficient. QUESTION 2: Does the surgical treatment of nonburst fractures of the thoracic and lumbar spine improve clinical outcomes compared to nonoperative treatment? RECOMMENDATION 2: There is insufficient evidence to recommend for or against the use of surgical intervention for nonburst thoracic or lumbar fractures. It is recommended that the decision to pursue surgery for such fractures be at the discretion of the treating physician. Strength of Recommendation: Grade Insufficient The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_1.


Assuntos
Vértebras Lombares/lesões , Neurocirurgia/normas , Traumatismos da Coluna Vertebral/cirurgia , Traumatismos da Coluna Vertebral/terapia , Vértebras Torácicas/lesões , Medicina Baseada em Evidências , Guias como Assunto , Humanos , Fraturas da Coluna Vertebral/fisiopatologia , Fraturas da Coluna Vertebral/terapia
20.
Neurosurgery ; 84(1): E39-E42, 2019 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-30203078

RESUMO

QUESTION 1: Does routine screening for deep venous thrombosis prevent pulmonary embolism (or venous thromboembolism (VTE)-associated morbidity and mortality) in patients with thoracic and lumbar fractures? RECOMMENDATION 1: There is insufficient evidence to recommend for or against routine screening for deep venous thrombosis in preventing pulmonary embolism (or VTE-associated morbidity and mortality) in patients with thoracic and lumbar fractures. Strength of Recommendation: Grade Insufficient. QUESTION 2: For patients with thoracic and lumbar fractures, is one regimen of VTE prophylaxis superior to others with respect to prevention of pulmonary embolism (or VTE-associated morbidity and mortality)? RECOMMENDATION 2: There is insufficient evidence to recommend a specific regimen of VTE prophylaxis to prevent pulmonary embolism (or VTE-associated morbidity and mortality) in patients with thoracic and lumbar fractures. Strength of Recommendation: Grade Insufficient. QUESTION 3: Is there a specific treatment regimen for documented VTE that provides fewer complications than other treatments in patients with thoracic and lumbar fractures? RECOMMENDATION 3: There is insufficient evidence to recommend for or against a specific treatment regimen for documented VTE that would provide fewer complications than other treatments in patients with thoracic and lumbar fractures. Strength of Recommendation: Grade Insufficient. RECOMMENDATION 4: Based on published data from pooled (cervical and thoracolumbar) spinal cord injury populations, the use of thromboprophylaxis is recommended to reduce the risk of VTE events in patients with thoracic and lumbar fractures. Consensus Statement by the Workgroup The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_7.


Assuntos
Vértebras Lombares/lesões , Neurocirurgia/normas , Traumatismos da Coluna Vertebral/complicações , Traumatismos da Coluna Vertebral/terapia , Vértebras Torácicas/lesões , Tromboembolia/etiologia , Tromboembolia/terapia , Anticoagulantes/uso terapêutico , Medicina Baseada em Evidências , Guias como Assunto , Humanos , Traumatismos da Medula Espinal/complicações , Fraturas da Coluna Vertebral/complicações
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