Journal of neurosurgical sciences最新文献

Predictive modeling has the potential to improve preoperative planning and resource allocation in lumbar fusion surgery. This study aimed to identify the 20 most important variables for predicting prolonged postoperative length of stay (pLOS) using machine learning (ML). The ACS-NSQIP database was queried for lumbar fusion procedures performed between 2012 and 2022, including ALIF, PlatIF, PLIF, and combined PLIF+PlatIF. Variable selection was performed using MUVR and Boruta, followed by hierarchical clustering and 5-fold cross-validation to ensure feature robustness. The 20 selected features were used to train multiple ML models, including tree-based classifiers (Random Forest, XGBoost, CatBoost, LightGBM), support vector classifiers, neural networks, ensemble methods, and logistic regression. A total of 114,892 patients were included. Eleven patient-specific and nine procedural variables were identified as most predictive of prolonged pLOS. Among patient factors, dialysis, congestive heart failure, and bleeding disorders were strongest predictors. Among procedural factors, osteotomy, billing of additional fusion codes, and longer operation time had the greatest impact. The neural network achieved the highest accuracy (71.2%), recall (79.4%), and F1-score (73.8%), though all models performed similarly, with minimal variation in classification metrics. These findings underscore that model choice plays a limited role once optimal features are selected - feature selection was the most critical determinant of predictive performance.

Background: Spinal chondrosarcoma is a rare malignant tumor requiring complex resection due to its resistance to chemotherapy and radiation. This study aimed to identify predictors of both 30-day readmission and prolonged length of hospital stay (LOS) following surgical resection of spinal chondrosarcoma using data from the National Cancer Database (NCDB).

Methods: Using the NCDB, we conducted a retrospective analysis of adult patients diagnosed with spinal or sacral chondrosarcoma between 2004 and 2017 who underwent surgical resection. We collected patient demographics, tumor characteristics, and treatment details. Patients were grouped based on 30-day readmission. A separate analysis was conducted on LOS, defining prolonged LOS as >75^th percentile. Multivariable analyses identified risk factors for each outcome.

Results: Of the 1971 patients in the 30-day readmission analysis, 114 (5.8%) experienced readmission. Of the 1392 patients included in the LOS analysis, 341 (24.5%) experienced prolonged LOS. The risk factors of prolonged LOS included age (OR=1.015; 95% CI, 1.006-1.024; P<0.001), male sex (OR=1.440; 95% CI, 1.076-1.926; P=0.014), tumor volume >11 cm³ (OR=1.001; 95% CI, 1.000-1.002; P=0.018), sacral/coccygeal tumors (OR=1.831; 95% CI, 1.162-2.844; P<0.001), and gross total resection (GTR) (OR=1.514; 95% CI, 1.068-2.146; P=0.020). Multivariate regression identified no significant predictors of 30-day readmission.

Conclusions: Tumor volume, sex, and other factors influence 30-day readmission and prolonged LOS. Prolonged LOS was further associated with sacral/coccygeal tumors and GTR, reflecting the complexity of surgical management.

Introduction: Spontaneous supratentorial intracerebral hemorrhage (SSICH) is a severe neurological condition associated with high morbidity and mortality, posing significant challenges to clinical management. Among the potential therapeutic strategies, decompressive craniectomy (DC) has been employed to reduce intracranial pressure and prevent secondary brain injury in various contexts, including traumatic brain injury (TBI) and spontaneous intracerebral hemorrhage (sICH). While its benefits are better established in some of these conditions, the specific role and efficacy of DC in the treatment of SSICH remain uncertain. In light of these uncertainties, we conducted a systematic review and meta-analysis to synthesize the available evidence and evaluate the impact of DC - alone or in combination with best medical treatment (BMT) - on clinical outcomes in patients with SSICH.

Evidence acquisition: A systematic search was conducted in the PubMed, Embase, and Cochrane databases. Eligible studies included patients aged 18 to 75 years with SSICH, with the intervention being DC alone or DC combined with BMT, and the control group receiving BMT alone. Studies had to report the outcomes of interest, particularly the primary outcome of mortality. No specific time restrictions were applied, and only randomized controlled trials (RCTs) and observational studies were eligible. The risk of bias in the only RCT included was assessed using version 2 of the Cochrane Risk of Bias tool (RoB-2), while the five observational studies were evaluated using the Risk of Bias in Non-randomized Studies of Interventions tool (ROBINS-I).

Evidence synthesis: A total of six studies were included, comprising 492 patients (224 treated with DC and 268 with BMT alone). Mortality at 30 days, 3 months, 6 months, and 12 months was lower in the intervention group (DC) compared to the control group (BMT alone). Subgroup analyses demonstrated statistical significance across all four timepoints. However, there were no statistically significant differences between groups regarding the incidence of overall infections, pneumonia and urinary tract infections.

Conclusions: Our study concludes that DC reduces mortality in patients with SSICH compared to BMT, although the choice between these treatments does not appear to significantly affect the risk of pneumonia or urinary tract infections. Despite these findings, further studies - particularly RCTs - are needed to provide more robust evidence on this topic.

Introduction: Low-grade gliomas (LGGs) are slow-growing heterogeneous tumors that remain challenging when complete resection is not feasible. While maximal safe resection remains standard, the evolving World Health Organization (WHO) classification emphasizing molecular characteristics has shifted perspectives on adjuvant therapies. In this context, the role of stereotactic radiosurgery (SRS) continues to be explored. This systematic review synthesizes literature on radiosurgical management of pathology-proven LGGs across pre- and post-molecular classification eras.

Evidence acquisition: A systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses. PubMed, Scopus, and Web of Science were searched in August 2024 for studies on pathology-proven LGGs treated with SRS. An additional search was performed to incorporate studies reporting molecular characteristics.

Evidence synthesis: Of the initially included eight studies, none reported molecular characteristics required by the 2021 World Health Organization classification, and an additional search identified one study reporting molecular characteristics, which was added to the review. Nine studies with 308 patients were included. Local control rates ranged from 66% to 94%. Several studies reported superior outcomes with surgery for recurrence, adjuvant rather than salvage SRS, and no prior radiotherapy. Adverse events were predominantly mild to moderate, including headache, dizziness, nausea, and transient neurological symptoms.

Conclusions: SRS offers a non-invasive management option for selected LGGs with durable control and acceptable safety. Prognosis appears to be influenced by treatment history, including prior radiotherapy and surgical management. Lack of molecular stratification highlights the need for studies focused on IDH (isocitrate dehydrogenase)-mutant LGGs to clarify the role of SRS in the molecular era.

Background: Falcine/parasagittal lesions account for the largest rate of high-grade (WHO grade 2-3) lesions. The ability to preoperatively estimate the tumors' grade and outcome would be of great value in customizing treatment.

Methods: This is a single-center, retrospective study designed to assess the pre-operative peripheral blood markers' diagnostic and prognostic role in patients harboring falcine (FM) and parasagittal (PM) high-grade meningiomas. N=116 patients undergoing surgical resection were included. A propensity score-matched analysis accounted for gender imbalances in low-grade (LG) vs. high-grade (HG) cohorts.

Results: Seventy-three (N.=73) FM (63%) and 43 PM (37%) lesions were included. Patients harboring HG lesions showed significantly higher Hb levels than LG (mean 14.5±1.40 vs. 13.5±1.16 g/dL, P<0.001). Multivariate analysis controlling for demographics, lesion characteristics, blood markers, and steroid dose confirmed preoperative Hb as an independent predictive value of lesion grade (OR 1.75, 95% CI:1.01-3.07, P=0.04). Accordingly, patients showing increased Hb levels >15.4 g/dL achieved shorter OS (60.4 months, 95% CI: 14.7-106.1 vs. 134.7 months, 95% CI: 111.2-158.2) compared to patients with lower Hb values, P<0.001. Data were confirmed in matched cohorts.

Conclusions: Increased levels of circulating erythrocytic hemoglobin might be independent predictors for high-grade histology and be associated with shorter overall survival in falcine and parasagittal meningiomas.

This article was published in Volume 67, issue 4 of publishing year 2023, with a mistake in Figure 3. The correct Figure 3 is the one included in this erratum.

Introduction: Traumatic brain injury (TBI) is a critical condition where the management of oxygen levels plays a pivotal role in patient outcomes. While hypoxemia is known to worsen outcomes, the impact of hyperoxemia on mortality and neurological outcomes remains controversial. This systematic review and meta-analysis aims to evaluate the effects of hyperoxemia on these outcomes in TBI patients.

Evidence acquisition: This study followed PRISMA guidelines and was registered with PROSPERO (registration number: CRD42024537543). A comprehensive search was conducted across MEDLINE, Embase, and SCOPUS databases, identifying relevant studies on hyperoxemia and its impact on mortality and neurological outcomes in TBI patients. Both observational studies and randomized controlled trials were included, and data were synthesized and analyzed using a random-effects model.

Evidence synthesis: Fifteen studies including 38,718 patients were included in the qualitative synthesis, with 13 studies included in the quantitative meta-analysis. Hyperoxemia was not significantly associated with mortality (pooled OR=0.88 [0.66-1.16]; P=0.36; I²=86%) or with unfavorable neurological outcomes (pooled OR=1.04 [0.83-1.29]; P=0.75; I²=67%). Sensitivity analyses limited to studies with low or low/moderate risk of bias showed a statistically significant association between hyperoxemia and reduced mortality, although with high heterogeneity (OR=0.65 [0.48-0.88]; P=0.005; I²=82%). A subgroup analysis of studies assessing neurological outcome at 6 months suggested a trend toward improved functional outcomes with early moderate hyperoxemia (OR=1.32 [0.99-1.75]; P=0.06). An explorative meta-regression did not show a significant linear association between PaO2 thresholds and outcomes.

Conclusions: This systematic review and meta-analysis do not provide sufficient evidence to discourage the use of moderate hyperoxemia in TBI patients. Exploratory analyses suggesting potential benefits from early moderate hyperoxemia require further validation in selected patients. High-quality prospective studies are urgently needed to determine the optimal use of oxygen therapy in TBI.

Introduction: Giant intracranial aneurysms are rare vascular lesions consisting of cerebral aneurysms measuring ≥25 mm in diameter. Their formation is the result of multiple factors including their association with a unique genomic landscape, pathophysiologic processes associated with the pathognomonic, histopathological changes observed within the arterial wall, the physical effects of the cerebral vasculature's unique fluid dynamics, and slow growth rates. Because giant intracranial aneurysms are considered among the most complex to manage, we herein perform a systematic review of the extant evidentiary base found within the neurosurgical literature with the goal of profiling multimodality management strategies for these lesions. Additionally, we will highlight the importance of integrating neuroendovascular surgery into microsurgical treatment regimens for giant cerebral aneurysms.

Evidence acquisition: To this end, we performed a systematic review of the literature through the PubMed, Scopus and Web of Science databases according to PRISMA guidelines. By using predefined search terms, we intended to identify prior reports involving multimodality management of giant intracranial aneurysms. Specifically, we sought to highlight the integral role of both neuroendovascular and microsurgical interventions in treatment of these rare vascular lesions.

Evidence synthesis: Ten studies reporting outcomes for 91 patients met criteria for inclusion in the present meta-analysis. Within this cohort of patients, mean age varied from 39.0 to 60.1 years. Among the giant aneurysms in the present review, many were found extending off of the supraclinoid ICA, which is one of the most common sites for giant intracranial aneurysms to form. In 1988, Batjer described the earliest combined intervention included in the present study. Since then, two common approach type themes involved in multimodal management have evolved: combined strategies often consist of 1) an endovascular approach to vessel occlusion, such as embolization, and 2) a microsurgical method capable of eliminating the aneurysm following control of blood flow. In other words, achieving obliteration via clipping, bypass surgery, clip reconstruction, wrapping, and Hunterian ligation (among others). Review of the literature indicated an overall mortality rate associated with multimodal management of 5.4%. Radiographic obliteration rates were reported in three of ten studies. One of the studies reported an 82.9% rate of successful obliteration. Rates of good outcomes (mRS 0-2, GOS 4-5) ranged from 60% up to a maximum of 87.5%.

Conclusions: Combined, multimodality endovascular and microsurgical treatments appear to be most successful for the treatment of giant aneurysms because of their adaptability, the flexibility they confer, and the synergistic effect of combining the strengths of multiple modalities.