Comparative effectiveness research has recently been the subject of intense discussion. With congressional support, there has been increasing funding and publication of studies using comparative effectiveness and related methodology. The neurosurgical field has been relatively slow to accept and embrace this approach. The author outlines the procedures and rationale of comparative effectiveness, illustrates how it applies to neurosurgical topics, and explains its importance.
Sherman C. Stein
The neurosurgical profession has taken a circuitous route to attain its current knowledge about timing for aneurysm surgery. While addressing the timing issue, neurosurgeons were beset by many pressures simultaneously. They were forced to justify not only optimal surgical techniques but the need for surgery at all in the treatment of ruptured aneurysms. The beliefs of surgeons with strong personalities, in addition to intuitive guesses, often served to guide surgery in the absence of scientific evidence. That any progress could be made against a background of desperately ill patients and frustrating early results is remarkable. The author briefly outlines the controversies and misdirection that accompanied this progress toward understanding surgical timing in the treatment of ruptured aneurysms.
Sherman C. Stein and Mark G. Burnett
Medical decisions often depend, in part, on cost-effectiveness concerns. Decision analysis is frequently used to help resolve these questions. Unfortunately, this technique has received little attention in neurosurgery. Using an example of moderate head injury, the authors illustrate the utility of this powerful tool in estimating the cost effectiveness of neurosurgical management options.
Shabbar F. Danish, Mark G. Burnett and Sherman C. Stein
Deep venous thrombosis (DVT) remains a source of significant morbidity and mortality in patients who undergo craniotomy procedures. Despite several studies in which the safety and efficacy of various prophylactic strategies were examined, there is still no consensus among clinicians. In this paper the authors review the literature with regard to epidemiological and pathophysiological features, screening methods, and prophylactic measures for DVT.
Sherman C. Stein, Joshua M. Levine, Seema Nagpal and Peter D. LeRoux
✓ The authors review literature that challenges the view that vasospasm involving large arteries is the exclusive cause of delayed ischemic neurological deficits (DINDs) following subarachnoid hemorrhage. They discuss alternative mechanisms and review the evidence supporting a potential role for thromboembolism. They conclude that vasospasm and thromboembolism play interrelated and additive roles in the development of DINDs, and that this interaction provides opportunities for novel therapeutic approaches.
A review of the literature
Shabbar F. Danish, Dean Barone, Bradley C. Lega and Sherman C. Stein
Decompressive hemicraniectomy is well accepted for the surgical treatment of intractable intracranial hypertension in cases in which medical management fails. Although it is performed as a life-saving procedure when death is imminent from intracranial hypertension, little is known about the functional outcomes for these patients on long-term follow-up. In this study, the authors performed a systematic review of the literature to examine neurological outcome after hemicraniectomy. A literature search revealed 29 studies that reported outcomes using GOS scores. The GOS scores were transformed to utility values for quality of life using a conversion method based on decision analysis modeling. Based on the literature, 1422 cases were analyzed. The average 6-month-postoperative mortality rate was 28.2%. The mean QOL value among survivors was 0.592, which corresponds roughly to a GOS score of 4. Although more studies are needed for validation of long-term neurological outcome after hemicraniectomy, the assumption that most patients remain in a vegetative state after this intervention is clearly incorrect.
Andrew H. Milby, Casey H. Halpern, Wensheng Guo and Sherman C. Stein
Diagnosis of cervical spinal injury (CSI) is an essential aspect of the trauma evaluation. This task is especially difficult in patients who are not clinically able to be evaluated (unevaluable) because of distracting painful injuries, intoxication, or concomitant head injury. For this population, the appropriate use of advanced imaging techniques for cervical spinal clearance remains undetermined. This study was undertaken to estimate the prevalence of unstable CSI, particularly among patients in whom clinical evaluation is impossible or unreliable.
Estimates of the prevalence of CSI in populations consisting of all trauma patients, alert patients only, and clinically unevaluable patients only were determined by variance-weighted pooling of data from 65 publications (281,864 patients) that met criteria for review.
The overall prevalence of CSI among all trauma patients was 3.7%. The prevalence of CSI in alert patients was 2.8%, whereas unevaluable patients were at increased risk of CSI with a prevalence of 7.7% (p = 0.007). Overall, 41.9% of all CSI cases were considered to exhibit instability.
Trauma patients who are clinically unevaluable have a higher prevalence of CSI than alert patients. Knowledge of the prevalence and risk of such injuries may help establish an evidence-based approach to the detection and management of clinically occult CSI.
Jared M. Pisapia, Casey H. Halpern, Noel N. Williams, Thomas A. Wadden, Gordon H. Baltuch and Sherman C. Stein
Roux-en-Y gastric bypass is the gold standard treatment for morbid obesity, although failure rates may be high, particularly in patients with a BMI > 50 kg/m2. With improved understanding of the neuropsychiatric basis of obesity, deep brain stimulation (DBS) offers a less invasive and reversible alternative to available surgical treatments. In this decision analysis, the authors determined the success rate at which DBS would be equivalent to the two most common bariatric surgeries.
Medline searches were performed for studies of laparoscopic adjustable gastric banding (LAGB), laparoscopic Roux-en-Y gastric bypass (LRYGB), and DBS for movement disorders. Bariatric surgery was considered successful if postoperative excess weight loss exceeded 45% at 1-year follow-up. Using complication and success rates from the literature, the authors constructed a decision analysis model for treatment by LAGB, LRYGB, DBS, or no surgical treatment. A sensitivity analysis in which major parameters were systematically varied within their 95% CIs was used.
Fifteen studies involving 3489 and 3306 cases of LAGB and LRYGB, respectively, and 45 studies involving 2937 cases treated with DBS were included. The operative successes were 0.30 (95% CI 0.247–0.358) for LAGB and 0.968 (95% CI 0.967–0.969) for LRYGB. Sensitivity analysis revealed utility of surgical complications in LRYGB, probability of surgical complications in DBS, and success rate of DBS as having the greatest influence on outcomes. At no values did LAGB result in superior outcomes compared with other treatments.
Deep brain stimulation must achieve a success rate of 83% to be equivalent to bariatric surgery. This high-threshold success rate is probably due to the reported success rate of LRYGB, despite its higher complication rate (33.4%) compared with DBS (19.4%). The results support further research into the role of DBS for the treatment of obesity.
Matthew R. Sanborn, Jayesh P. Thawani, Robert G. Whitmore, Michael Shmulevich, Benjamin Hardy, Conrad Benedetto, Neil R. Malhotra, Paul Marcotte, William C. Welch, Stephen Dante and Sherman C. Stein
There is considerable variation in the use of adjunctive technologies to confirm pedicle screw placement. Although there is literature to support the use of both neurophysiological monitoring and isocentric fluoroscopy to confirm pedicle screw positioning, there are no studies examining the cost-effectiveness of these technologies. This study compares the cost-effectiveness and efficacy of isocentric O-arm fluoroscopy, neurophysiological monitoring, and postoperative CT scanning after multilevel instrumented fusion for degenerative lumbar disease.
Retrospective data were collected from 4 spine surgeons who used 3 different strategies for monitoring of pedicle screw placement in multilevel lumbar degenerative disease. A decision analysis model was developed to analyze costs and outcomes of the 3 different monitoring strategies. A total of 448 surgeries performed between 2005 and 2010 were included, with 4 cases requiring repeat operation for malpositioned screws. A sample of 64 of these patients was chosen for structured interviews in which the EuroQol-5D questionnaire was used. Expected costs and quality-adjusted life years were calculated based on the incidence of repeat operation and its negative effect on quality of life and costs.
The decision analysis model demonstrated that the O-arm monitoring strategy is significantly (p < 0.001) less costly than the strategy of postoperative CT scanning following intraoperative uniplanar fluoroscopy, which in turn is significantly (p < 0.001) less costly than neurophysiological monitoring. The differences in effectiveness of the different monitoring strategies are not significant (p = 0.92).
Use of the O-arm for confirming pedicle screw placement is the least costly and therefore most cost-effective strategy of the 3 techniques analyzed.