Journal of neurosurgical anesthesiology最新文献

Background: Postoperative delirium is a common complication in older adults, associated with poor outcomes, morbidity, mortality, and higher health care costs. Older age is a strong predictor of delirium. Intraoperative burst suppression on the electroencephalogram (EEG) has also been linked to postoperative delirium and poor neurocognitive outcomes.

Methods: In this a secondary analysis of data from the Perioperative Anesthesia Neurocognitive Disorder Assessment-Geriatric (PANDA-G) observational study, the raw EEGs of 239 spine surgery patients were evaluated. Associations between delirium and age, device-generated burst suppression ratio, and visual detection of the raw EEG were compared.

Results: Demographics and anesthesia durations were similar in patients with and without delirium. There was a higher incidence of burst suppression identified by analysis of the raw EEG in the delirium group than in the no delirium group (73.45% vs. 50.9%; P=0.001) which appeared to be driven largely by a higher incidence of burst suppression during maintenance of anesthesia (67.2% vs. 46.3%; P=0.004). Burst suppression was more strongly associated with delirium than with age; estimated linear regression coefficient for burst suppression 0.182 (SE: 0.057; P=0.002) and for age 0.009 (SE: 0.005; P=0.082). There was no significant interaction between burst suppression and age (-0.512; SE: 0.390; P=0.190). Compared with visual detection of burst suppression, the burst suppression ratio overestimated burst suppression at low values, and underestimated burst suppression at high values.

Conclusion: Intraoperative burst suppression identified by visual analysis of the EEG was more strongly associated with delirium than age in older adults undergoing spine surgery. Further research is needed to determine the clinical importance of these findings.

The global demand for hospital care, driven by population growth and medical advances, emphasizes the importance of optimized resource management. Enhanced Recovery After Surgery (ERAS) protocols aim to expedite patient recovery and reduce health care costs without compromising patient safety or satisfaction. Its principles have been adopted in various surgical specialties but have not fully encompassed all areas of neurosurgery, including craniotomy. ERAS for craniotomy has been shown to reduce the length of hospital stay and costs without increasing complications. ERAS protocols may also reduce postoperative nausea and vomiting and perioperative opioid requirements, highlighting their potential to enhance patient outcomes and health care efficiency. Despite these benefits, guidelines, and strategies for ERAS in craniotomy remain limited. This narrative review explores the current global landscape of ERAS for craniotomy, assessing existing literature and highlighting knowledge gaps. Experts from 26 countries with diverse cultural and socioeconomic backgrounds contributed to this review, offering insights about current ERAS protocol applications, implementation challenges, and future perspectives, and providing a comprehensive global overview of ERAS for craniotomy. Representatives from all 6 World Health Organization geographical world areas reported that barriers to the implementation of ERAS for craniotomy include the absence of standardized protocols, provider resistance to change, resource constraints, insufficient education, and research scarcity. This review emphasizes the necessity of tailored ERAS protocols for low and middle-income countries, addressing differences in available resources. Acknowledging limitations in subjectivity and article selection, this review provides a comprehensive overview of ERAS for craniotomy from a global perspective and underscores the need for adaptable ERAS protocols tailored to specific health care systems and countries.

Objective: The frequency of duplex ultrasound screening (DUS) for deep vein thrombosis (DVT) in patients with brain tumors undergoing craniotomy is center-specific. We evaluated clinical conditions that increase the tendency to perform DUS, focusing on tumor type.

Methods: This is a single-center retrospective analysis to assess the association of intracranial tumor type with DVT as a major decision-making indicator for DUS. A primary analysis investigated the association between tumor pathology and preoperative DVT, and a secondary analysis investigated the development of DVT postoperatively. Confounding factors were defined and included in both analyses.

Results: Among 1478 patients, 751 had preoperative DUS and 35 (5%) had DVT. No significant difference in the odds of preoperative DVT was observed between patients having malignant glioma versus benign tumors (odds ratio [OR; 95% CI]: 1.68 [0.65, 4.35], P = 0.29), or metastatic tumors versus benign tumors (OR: 2.10; 95% CI: 0.75-5.89; P = 0.16). Among patients with negative preoperative DUS, 93 underwent postoperative evaluation and 20 (22%) were diagnosed with postoperative DVT. Malignant glioma or (OR: 1.69; 95% CI: 0.36-7.84; P = 0.50) metastatic tumors (OR: 1.84; 95% CI: 0.29-11.5; P = 0.52) were not associated with postoperative DVT versus benign tumors.

Conclusion: Brain tumor pathology may not increase the risk for DVT and may not be a good indicator for the selection of patients for DVT screening with DUS. The incidence of DVT in selective preoperative DUS was similar to studies that performed DUS on all patients. Further studies across multiple institutions are needed to develop criteria for DUS in brain tumor surgery.

In this review article, we explore the implementation and outcomes of enhanced recovery after spine surgery (spine ERAS) across different World Bank country-income levels. A systematic literature search was conducted through PubMed, Embase, Scopus, and CINAHL databases for articles on the implementation of spine ERAS in both adult and pediatric populations. Study characteristics, ERAS elements, and outcomes were analyzed and meta-analyses were performed for length of stay (LOS) and cost outcomes. The number of spine ERAS studies from low-middle-income countries (LMICs) increased since 2017, when the first spine ERAS implementation study was published. LMICs were more likely than high-income countries (HICs) to conduct studies on patients aged ≥18 years (odds ratio [OR], 6.00; 95% CI, 1.58-42.80), with sample sizes 51 to 100 (OR, 4.50; 95% CI, 1.21-22.90), and randomized controlled trials (OR, 7.25; 95% CI, 1.77-53.50). Preoperative optimization was more frequently implemented in LMICs than in HICs (OR, 2.14; 95% CI, 1.06-4.41), and operation time was more often studied in LMICs (OR 3.78; 95% CI, 1.77-8.35). Implementation of spine ERAS resulted in reductions in LOS in both LMIC (-2.06; 95% CI, -2.47 to -1.64 d) and HIC (-0.99; 95% CI, -1.28 to -0.70 d) hospitals. However, spine ERAS implementation did result in a significant reduction in costs. This review highlights the global landscape of ERAS implementation in spine surgery, demonstrating its effectiveness in reducing LOS across diverse settings. Further research with standardized reporting of ERAS elements and outcomes is warranted to explore the impact of spine ERAS on cost-effectiveness and other patient-centered outcomes.

Background: Physicians and patients are eager to know likely functional outcomes at different stages of treatment after acute ischemic stroke (AIS). The aim of this study was to develop and validate a 2-step model to assess prognosis at different time points (pre- and posttreatment) in patients with AIS having endovascular thrombectomy (EVT).

Methods: The prediction model was developed using a prospective nationwide Chinese registry (ANGEL-ACT). A total of 1676 patients with AIS who underwent EVT were enrolled into the study and randomly divided into development (n=1351, 80%) and validation (n=325, 20%) cohorts. Multivariate logistic regression, least absolute shrinkage and selection operator regression, and the random forest recursive feature elimination algorithm were used to select predictors of 90-day functional independence. We constructed the model via discrimination, calibration, decision curve analysis, and feature importance.

Results: The incidence of 90-day functional independence was 46.3% and 40.6% in the development and validation cohorts, respectively. The area under the curve (AUC) for model 1 which included 5 pretreatment predictors (age, admission National Institutes for Health Stroke Scale score, admission glucose level, admission systolic blood pressure, and Alberta Stroke Program Early Computed Tomography score) was 0.699 (95% confidence interval [CI], 0.668-0.730) in the development cohort and 0.658 (95% CI, 0.592-0.723) in the validation cohort. Two treatment-related predictors (time from stroke onset to puncture and successful reperfusion) were added to model 2 which had an AUC of 0.719 (95% CI, 0.688-0.749) and 0.650 (95% CI, 0.585-0.716) in the development cohort and validation cohorts, respectively.

Conclusions: The 2-step prediction model could be useful for predicting the functional independence in patients with AIS 90-days after EVT.

Background: Erector spinae plane block (ESPB) can has been used for analgesia after lumbar spine surgery. However, its effect on postoperative quality of recovery (QoR) remains underexplored in patients undergoing transforaminal lumbar interbody fusion (TLIF) or oblique lumbar interbody fusion (OLIF). This study hypothesized that ESPB would improve postoperative QoR in this patient cohort.

Methods: Patients undergoing TLIF or OLIF were randomized into ESPB (n=38) and control groups (n=38). In the ESPB group, 25 mL of 0.375% bupivacaine was injected into each erector spinae plane at the T12 level under ultrasound guidance before skin incision. Multimodal analgesia, including wound infiltration, was applied in both groups. The QoR-15 score was measured before surgery and 1 day (primary outcome) and 3 days after surgery. Postoperative pain at rest and during ambulation and postoperative ambulation were also evaluated for 3 days after surgery.

Results: Perioperative QoR-15 scores were not significantly different between the ESPB and control groups including at 1 day after surgery (80±28 vs. 81±25, respectively; P=0.897). Patients in the ESPB group had a significantly lower mean (±SD) pain score during ambulation 1 hour after surgery (7±3 vs. 9±1, respectively; P=0.013) and significantly shorter median (interquartile range) time to the first ambulation after surgery (2.0 [1.0 to 5.5] h vs. 5.0 [1.8 to 10.0] h, respectively; P=0.038). There were no between-group differences in pain scores at other times or in the cumulative number of postoperative ambulations.

Conclusion: ESPB, as performed in this study, did not improve the QoR after TLIF or OLIF with multimodal analgesia.

Objective: Multiple strategies exist to facilitate microdissection and obliteration of intracranial aneurysms during microsurgical clipping. Rapid ventricular pacing (RVP) can be used to induce controlled transient hypotension to facilitate aneurysm manipulation. We report the indications and outcomes of intraoperative RVP for clipping of ruptured and unruptured complex aneurysms.

Methods: We completed a retrospective review of adult patients who underwent RVP-facilitated elective and emergent microsurgical aneurysm clipping by a single senior neurosurgeon between 2016 and 2023. Intraoperative RVP was performed at a rate of 150 to 200 beats per minute through a transvenous pacing wire and repeated as needed based on surgical requirements. Intraoperative procedural and pacing data and perioperative cardiac and neurosurgical variables were collected.

Results: Forty patients were included in this study. The median (interquartile range) number of pacing episodes per patient was 8 (5 to 14), resulting in a median mean arterial pressure of 37 (30 to 40) mm Hg during RVP. One patient developed wide complex tachycardia intraoperatively, which resolved after cardioversion. Fifteen out of 36 (42%) patients who had postoperative troponin measurements had at least one troponin value above the 99th percentile upper reference limit. One patient had markedly elevated troponin with anterolateral ischemia in the context of massive postoperative intracranial hemorrhage. There were no other documented intraoperative or postoperative cardiac events.

Conclusions: This retrospective case series suggests that RVP could be an effective adjunct for clipping of complex ruptured and unruptured aneurysms, associated with transient troponin rise but rare postoperative cardiac complications.

Neurological and cardiovascular disorders are the leading causes of morbidity and mortality worldwide. While the effects of cardiovascular disease (CD) on the nervous system are well understood, understanding of the reciprocal relationship has only recently become clearer. Based on disability-adjusted life years, this systematic review and meta-analysis present the pooled incidence and association of CD in 4 selected common, noncommunicable neurological disorders: (1) migraine, (2) Alzheimer disease and other dementias, (3) epilepsy, and (4) head injury. Sixty-five studies, including over 4 and a half million patients, were identified for inclusion in this review. Among the 4 neurological disorders, the majority of patients (89.4%) had epilepsy, 9.6% had migraine, and 0.97% had head injury. Alzheimer disease and other dementias were reported in only 0.02% of patients. The pooled effect estimates (incidence and association) of CD in the 4 neurological disorders was 10% (95% CI: 5.8%-16.9%; I2 = 99.94%). When stratified by the neurological disorder, head injury was associated with the highest incidence of CD (28%). The 4 neurological disorders were associated with a 2-fold increased odds for developing CD in comparison to patients without neurological disorders. Epilepsy was associated with the greatest increased odds of developing CD (odds ratio: 2.25; 95% CI: 1.82-2.79; P = 0.04). In studies that reported this variable, the pooled hazard ratio was 1.64 (95% CI: 1.38-1.94), with head injury having the highest hazard ratio (2.17; 95% CI: 1.30-3.61). Large prospective database studies are required to understand the long-term consequences of CD in patients with neurological disorders.