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Marco V. Corniola, Jean-Michel Lemée, and Torstein R. Meling

OBJECTIVE

Intracranial meningiomas (ICMs) may be diagnosed in octogenarians. Since the lesions are rarely life-threatening, surgery is a questionable choice in this age group. The authors’ aim in this study was to analyze factors associated with the extent of resection (EOR), overall survival (OS), and postoperative complications in octogenarians undergoing ICM surgery, by using a cohort of septuagenarians as a reference.

METHODS

All patients ≥ 70 years of age who underwent surgery at Oslo University Hospital for an ICM between 1990 and 2010 were included in this study. Data on these cases were retrospectively (1990–2002) and prospectively (2003–2010) acquired from a databank belonging to Oslo University Hospital. All related preoperative imaging studies or reports (earlier cases) were reviewed to confirm tumor location, the presence of bone invasion, and the postoperative EOR.

RESULTS

In this study, 49 octogenarians (29 females [59.2%], mean age 83.3 ± 2.5 years) were compared with 272 septuagenarians (173 females [63.6%], mean age 74.3 ± 2.7 years). Forty octogenarians (81.6%) and 217 septuagenarians (79.8%) underwent gross-total resection. Simpson grade IV resection was achieved in 9 octogenarians (18.4%) and 4 septuagenarians (1.4%), while Simpson grade V resection was obtained in 4 septuagenarians (1.4%). Postoperative complications were similar in both groups, and 4 octogenarians (8.2%) and 11 septuagenarians (4.1%) died within 30 days after surgery (p = 0.25). No octogenarian underwent adjuvant radiotherapy. The OS was 4.2 ± 2.8 years in the octogenarians and 5.8 ± 4.4 years in the septuagenarians (p < 0.001). Female sex (OR 0.36, 95% CI 0.14–0.93; p = 0.03) and a preoperative Karnofsky Performance Scale score ≥ 70 (OR 0.27, 95% CI 0.10–0.72; p = 0.009) were correlated to the OS.

CONCLUSIONS

Octogenarians undergoing surgery for ICMs had an overall reduced OS compared to septuagenarians. However, the clinical relevance of this difference in OS is debatable and has to be put in perspective with expected survival without surgery. Data on symptoms upon admission, EOR, invasive tumor features, and postoperative complications in octogenarians are similar to those observed in septuagenarians. Therefore, the decision concerning whether surgery should be performed must be based on a case-by-case discussion, and surgery should not be immediately dismissed when it comes to ICMs in octogenarians.

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Marco V. Corniola, Bertrand Debono, Holger Joswig, Jean-Michel Lemée, and Enrico Tessitore

The concept of Enhanced Recovery After Surgery (ERAS) entails recovery facilitation of patients who undergo surgery through the implementation of a multidisciplinary and multimodal perioperative care approach. By its application, ERAS improves the overall functional outcome after surgery while maintaining high standards of care. A review of the essential aspects of ERAS in spine surgery was undertaken. Special consideration was given to the risks and benefits for patients and caregivers, as well as the medical and economical aspects of this concept.

Free access

Bertrand Debono, Marco V. Corniola, Raphael Pietton, Pascal Sabatier, Olivier Hamel, and Enrico Tessitore

OBJECTIVE

Enhanced Recovery After Surgery (ERAS) proposes a multimodal, evidence-based approach to perioperative care. Thanks to the improvement in care protocols and the fluidity of the patient pathway, the first goal of ERAS is the improvement of surgical outcomes and patient experience, with a final impact on a reduction in the hospital length of stay (LOS). The implementation of ERAS in spinal surgery is in the early stages. The authors report on their initial experience in applying an ERAS program to several degenerative spinal fusion procedures.

METHODS

The authors selected two 2-year periods: the first from before any implementation of ERAS principles (pre-ERAS years 2012–2013) and the second corresponding to a period when the paradigm was applied widely (post-ERAS years 2016–2017). Patient groups in these periods were retrospectively compared according to three degenerative conditions requiring fusion: anterior cervical discectomy and fusion (ACDF), anterior lumbar interbody fusion (ALIF), and posterior lumbar fusion. Data were collected on patient demographics, operative and perioperative data, LOSs, 90-day readmissions, and morbidity. ERAS-trained nurses were involved to support patients at each pre-, intra-, and postoperative step with the help of a mobile application (app). A satisfaction survey was included in the app.

RESULTS

The pre-ERAS group included 1563 patients (159 ALIF, 749 ACDF, and 655 posterior fusion), and the post-ERAS group included 1920 patients (202 ALIF, 612 ACDF, and 1106 posterior fusion). The mean LOS was significantly shorter in the post-ERAS group than in the pre-ERAS group for all three conditions. It was reduced from 6.06 ± 1.1 to 3.33 ± 0.8 days for the ALIF group (p < 0.001), from 3.08 ± 0.9 to 1.3 ± 0.7 days for the ACDF group (p < 0.001), and from 6.7 ± 4.8 to 4.8 ± 2.3 days for posterior fusion cases (p < 0.001). There was no significant difference in overall complications between the two periods for the ALIF (11.9% pre-ERAS vs 11.4% post-ERAS, p = 0.86) and ACDF (6.0% vs 8.2%, p = 0.12) cases, but they decreased significantly for lumbar fusions (14.8% vs 10.9%, p = 0.02). Regarding satisfaction with overall care among 808 available responses, 699 patients (86.5%) were satisfied or very satisfied, and regarding appreciation of the mobile e-health app in the perceived optimization of care management, 665 patients (82.3%) were satisfied or very satisfied.

CONCLUSIONS

The introduction of the ERAS approach at the authors’ institution for spinal fusion for three studied conditions resulted in a significant decrease in LOS without causing increased postoperative complications. Patient satisfaction with overall management, upstream organization of hospitalization, and the use of e-health was high. According to the study results, which are consistent with those in other studies, the whole concept of ERAS (primarily reducing complications and pain, and then reducing LOS) seems applicable to spinal surgery.

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Martin N. Stienen, Nicolas R. Smoll, Holger Joswig, Marco V. Corniola, Karl Schaller, Gerhard Hildebrandt, and Oliver P. Gautschi

OBJECTIVE

The Timed Up and Go (TUG) test is a simple, objective, and standardized method to measure objective functional impairment (OFI) in patients with lumbar degenerative disc disease (DDD). The objective of the current work was to validate the OFI baseline severity stratification (BSS; with levels of “none,” “mild,” “moderate,” and “severe”).

METHODS

Data were collected in a prospective IRB-approved 2-center study. Patients were assessed with a comprehensive panel of scales for measuring pain (visual analog scale [VAS] for back and leg pain), functional impairment (Roland-Morris Disability Index [RMDI] and Oswestry Disability Index [ODI]), and health-related quality of life (HRQOL; EQ-5D and SF-12). OFI BSS was determined using age- and sex-adjusted cutoff values.

RESULTS

A total of 375 consecutive patients scheduled for lumbar spine surgery were included. Each 1-step increase on the OFI BSS corresponded to an increase of 0.53 in the back pain VAS score, 0.69 in the leg pain VAS score, 1.81 points in the RMDI, and 5.93 points in the ODI, as well as to a decrease in HRQOL of −0.073 in the EQ-5D, −1.99 in the SF-12 physical component summary (PCS), and −1.62 in the SF-12 mental component summary (MCS; all p < 0.001). Patients with mild, moderate, and severe OFI had increased leg pain by 0.90 (p = 0.044), 1.54 (p < 0.001), and 1.94 (p < 0.001); increased ODI by 7.99 (p = 0.004), 12.64 (p < 0.001), and 17.13 (p < 0.001); and decreased SF-12 PCS by −2.57 (p = 0.049), −3.63 (p = 0.003), and −6.23 (p < 0.001), respectively.

CONCLUSIONS

The OFI BSS is a valid measure of functional impairment for use in daily clinical practice. The presence of OFI indicates the presence of significant functional impairment on subjective outcome measures.

Free access

Martin N. Stienen, Nicolai Maldaner, Holger Joswig, Marco V. Corniola, David Bellut, Peter Prömmel, Luca Regli, Astrid Weyerbrock, Karl Schaller, and Oliver P. Gautschi

OBJECTIVE

Patient-reported outcome measures (PROMs) are standard of care for the assessment of functional impairment. Subjective outcome measures are increasingly complemented by objective ones, such as the “Timed Up and Go” (TUG) test. Currently, only a few studies report pre- and postoperative TUG test assessments in patients with lumbar spinal stenosis (LSS).

METHODS

A prospective two-center database was reviewed to identify patients with LSS who underwent lumbar decompression with or without fusion. The subjective functional status was estimated using PROMs for pain (visual analog scale [VAS]), disability (Roland-Morris Disability Index [RMDI] and Oswestry Disability Index [ODI]), and health-related quality of life (HRQoL; 12-Item Short-Form Physical Component Summary [SF-12 PCS] and the EQ-5D) preoperatively, as well as on postoperative day 3 (D3) and week 6 (W6). Objective functional impairment (OFI) was measured using age- and sex-standardized TUG test results.

RESULTS

Sixty-four patients (n = 32 [50%] male, mean age 66.8 ± 11.7 years) were included. Preoperatively, they reported a mean VAS back pain score of 4.1 ± 2.7, VAS leg pain score of 5.4 ± 2.7, RMDI of 10.4 ± 5.3, ODI of 41.9 ± 16.2, SF-12 PCS score of 32.7 ± 8.3, and an EQ-5D index of 0.517 ± 0.226. The preoperative rates of severe, moderate, and mild OFI were 4.7% (n = 3), 12.5% (n = 8), and 7.8% (n = 5), respectively, and the mean OFI T-score was 116.3 ± 23.7. At W6, 60 (93.8%) of 64 patients had a TUG test result within the normal population range (no OFI); 3 patients (4.7%) had mild and 1 patient (1.6%) severe OFI. The mean W6 OFI T-score was significantly decreased (103.1 ± 13.6; p < 0.001). Correspondingly, the PROMs showed a decrease in subjective VAS back pain (1.6 ± 1.7, p < 0.001) and leg pain (1.0 ± 1.8, p < 0.001) scores, disability (RMDI 5.3 ± 4.7, p < 0.001; ODI 21.3 ± 16.1, p < 0.001), and increase in HRQoL (SF-12 PCS 40.1 ± 8.3, p < 0.001; EQ-5D 0.737 ± 0.192, p < 0.001) at W6. The W6 responder status (clinically meaningful improvement) ranged between 81.3% (VAS leg pain) and 29.7% (EQ-5D index) of patients.

CONCLUSIONS

The TUG test is a quick and easily applicable tool that reliably measures OFI in patients with LSS. Objective tests incorporating longer walking time should be considered if OFI is suspected but fails to be proven by the TUG test, taking into account that neurogenic claudication may not clinically manifest during the brief TUG examination. Objective tests do not replace the subjective PROM-based assessment, but add valuable information to a comprehensive patient evaluation.

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Vittorio Stumpo, Victor E. Staartjes, Ayesha Quddusi, Marco V. Corniola, Enrico Tessitore, Marc L. Schröder, Erich G. Anderer, Martin N. Stienen, Carlo Serra, and Luca Regli

OBJECTIVE

Enhanced Recovery After Surgery (ERAS) has led to a paradigm shift in perioperative care through multimodal interventions. Still, ERAS remains a relatively new concept in neurosurgery, and there is no summary of evidence on ERAS applications in cranial neurosurgery.

METHODS

The authors systematically reviewed the literature using the PubMed/MEDLINE, Embase, Scopus, and Cochrane Library databases for ERAS protocols and elements. Studies had to assess at least one pre-, peri-, or postoperative ERAS element and evaluate at least one of the following outcomes: 1) length of hospital stay, 2) length of ICU stay, 3) postoperative pain, 4) direct and indirect healthcare cost, 5) complication rate, 6) readmission rate, or 7) patient satisfaction.

RESULTS

A final 27 articles were included in the qualitative analysis, with mixed quality of evidence ranging from high in 3 cases to very low in 1 case. Seventeen studies reported a complete ERAS protocol. Preoperative ERAS elements include patient selection through multidisciplinary team discussion, patient counseling and education to adjust expectations of the postoperative period, and mental state assessment; antimicrobial, steroidal, and antiepileptic prophylaxes; nutritional assessment, as well as preoperative oral carbohydrate loading; and postoperative nausea and vomiting (PONV) prophylaxis. Anesthesiology interventions included local anesthesia for pin sites, regional field block or scalp block, avoidance or minimization of the duration of invasive monitoring, and limitation of intraoperative mannitol. Other intraoperative elements include absorbable skin sutures and avoidance of wound drains. Postoperatively, the authors identified early extubation, observation in a step-down unit instead of routine ICU admission, early mobilization, early fluid de-escalation, early intake of solid food and liquids, early removal of invasive monitoring, professional nutritional assessment, PONV management, nonopioid rescue analgesia, and early postoperative imaging. Other postoperative interventions included discharge criteria standardization and home visits or progress monitoring by a nurse.

CONCLUSIONS

A wide range of evidence-based interventions are available to improve recovery after elective craniotomy, although there are few published ERAS protocols. Patient-centered optimization of neurosurgical care spanning the pre-, intra-, and postoperative periods is feasible and has already provided positive results in terms of improved outcomes such as postoperative pain, patient satisfaction, reduced length of stay, and cost reduction with an excellent safety profile. Although fast-track recovery protocols and ERAS studies are gaining momentum for elective craniotomy, prospective trials are needed to provide stronger evidence.