BACKGROUND:Pain evaluation remains largely subjective in neurosurgical practice, but machine learning provides the potential for objective pain assessment tools.OBJECTIVE:To predict daily pain... Show moreBACKGROUND:Pain evaluation remains largely subjective in neurosurgical practice, but machine learning provides the potential for objective pain assessment tools.OBJECTIVE:To predict daily pain levels using speech recordings from personal smartphones of a cohort of patients with diagnosed neurological spine disease.METHODS:Patients with spine disease were enrolled through a general neurosurgical clinic with approval from the institutional ethics committee. At-home pain surveys and speech recordings were administered at regular intervals through the Beiwe smartphone application. Praat audio features were extracted from the speech recordings to be used as input to a K-nearest neighbors (KNN) machine learning model. The pain scores were transformed from a 0 to 10 scale to low and high pain for better discriminative capacity.RESULTS:A total of 60 patients were enrolled, and 384 observations were used to train and test the prediction model. Using the KNN prediction model, an accuracy of 71% with a positive predictive value of 0.71 was achieved in classifying pain intensity into high and low. The model showed 0.71 precision for high pain and 0.70 precision for low pain. Recall of high pain was 0.74, and recall of low pain was 0.67. The overall F1 score was 0.73.CONCLUSION:Our study uses a KNN to model the relationship between speech features and pain levels collected from personal smartphones of patients with spine disease. The proposed model is a stepping stone for the development of objective pain assessment in neurosurgery clinical practice. Show less
BACKGROUND: Core Outcome Sets (COSs) are necessary to standardize reporting in research studies. This is urgently required in the field of chronic subdural hematoma (CSDH), one of the most common... Show moreBACKGROUND: Core Outcome Sets (COSs) are necessary to standardize reporting in research studies. This is urgently required in the field of chronic subdural hematoma (CSDH), one of the most common disease entities managed in neurosurgery and the topic of several recent trials. To complement the development of aCOS, a standardized definition and baseline Data Elements (DEs) to be collected in CSDH patients, would further improve study quality and comparability in this heterogeneous population.OBJECTIVE: To, first, define a standardized COS for reporting in all future CSDH studies; and, second, to identify a unified CSDH Definition and set of DEs for reporting in future CSDH studies.METHODS: The overall study design includes a Delphi survey process among 150 respondents from 2 main stakeholder groups: healthcare professionals or researchers (HCPRs) and Patients or carers. HCPR, patients and carers will all be invited to complete the survey on the COS, only the HCPR survey will include questions on definition and DE.EXPECTED OUTCOMES: It is expected that the COS, definition, and DE will be developed through this Delphi survey and that these can be applied in future CSDH studies. This is necessary to help align future research studies on CSDH and to understand the effects of different treatments on patient function and recovery.DISCUSSION: This Delphi survey should result in consensus on a COS and a standardized CSDH Definition and DEs to be used in future CSDH studies. Show less
BACKGROUND: Indications and optimal timing for surgical treatment of degenerative cervical myelopathy (DCM) remain unclear, and data from daily clinical practice are warranted.OBJECTIVE: To... Show moreBACKGROUND: Indications and optimal timing for surgical treatment of degenerative cervical myelopathy (DCM) remain unclear, and data from daily clinical practice are warranted.OBJECTIVE: To investigate clinical outcomes following decompressive surgery for DCM.METHODS: Data were obtained from the Norwegian Registry for Spine Surgery. The primary outcome was change in the neck disability index (NDI) 1 yr after surgery. Secondary endpoints were the European myelopathy score (EMS), quality of life (EuroQoL 5D [EQ-5D]), numeric rating scales (NRS) for headache, neck pain, and arm pain, complications, and perceived benefit of surgery assessed by the Global Perceived Effect (GPE) scale.RESULTS: We included 905 patients operated between January 2012 and June 2018. There were significant improvements in all patient-reported outcome measures (PROMs) including NDI (mean -10.0, 95% CI -11.5 to -8.4, P<.001), EMS (mean 1.0, 95% CI 0.8-1.1, P<.001), EQ-5D index score (mean 0.16, 95% CI 0.13-0.19, P<.001), EQ-5D visual analogue scale (mean 13.8, 95% CI 11.7-15.9, P<.001), headache NRS (mean -1.1, 95% CI -1.4 to -0.8, P<.001), neck pain NRS (mean-1.8, 95% CI-2.0 to-1.5, P<.001), and arm pain NRS (mean -1.7, 95% CI -1.9 to -1.4, P<.001). According to GPE scale assessments, 229/513 patients (44.6%) experienced "complete recovery" or felt "much better" at 1 yr. There were significant improvements in all PROMs for both mild and moderate-to-severe DCM. A total of 251 patients (27.7%) experienced adverse effects within 3 mo.CONCLUSION: Surgery for DCM is associated with significant and clinically meaningful improvement across a wide range of PROMs. Show less
BACKGROUND: Many intracranial meningioma patients have an impaired health-related quality of life (HRQoL) and neurocognitive functioning up to 4 yr after intervention.OBJECTIVE: To assess the long... Show moreBACKGROUND: Many intracranial meningioma patients have an impaired health-related quality of life (HRQoL) and neurocognitive functioning up to 4 yr after intervention.OBJECTIVE: To assess the long-term (>= 5 yr) disease burden of meningioma patients.METHODS: In this multicenter cross-sectional study, patients >= 5 yr after intervention (including active magnetic resonance imaging (MRI) surveillance) were included and assessed for HRQoL (Short-Form Health Survey 36), neurocognitive functioning (neuropsychological assessment), anxiety and depression (Hospital Anxiety and Depression Scale), and work productivity (Short Form-Health and Labour Questionnaire). Multivariable and propensity score regression analyses were used to compare patients and controls, and different treatment strategies corrected for possible confounders. Clinically relevant differences were reported.RESULTS: At amedian of 9 yr follow-up after intervention, meningioma patients (n = 190) reported more limitations due to physical (difference 12.5 points, P = .008) and emotional (13.3 points, P = .002) health problems compared with controls. Patients also had an increased risk to suffer from anxiety (odds ratio [OR]: 2.6, 95% CI: 1.2-5.7) and depression (OR: 3.7, 95% CI: 1.3-10.5). Neurocognitive deficits were found in 43% of patients. Although postoperative complications, radiotherapy, and reresection were associated with worse verbal memory, attention, and executive functioning when compared to patients resected once, the only clinically relevant association was between reresection and worse attention (-2.11, 95% CI: -3.52 to -0.07). Patients of working age less often had a paid job (48%) compared with the working-age Dutch population (72%) and reported more obstacles at work compared with controls.CONCLUSION: In the long term, a large proportion of meningioma patients have impaired HRQoL, neurocognitive deficits, and high levels of anxiety or depression. Patients treated with 1 resection have the best neurocognitive functioning. Show less
BACKGROUND: The setting of a randomized trial can determine whether its findings are generalizable and can therefore apply to different settings. The contribution of low- and middle-income... Show moreBACKGROUND: The setting of a randomized trial can determine whether its findings are generalizable and can therefore apply to different settings. The contribution of low- and middle-income countries (LMICs) to neurosurgical randomized trials has not been systematically described before.OBJECTIVE: To perform a systematic analysis of design characteristics and methodology, funding source, and interventions studied between trials led by and/or conducted in high-income countries (HICs) vs LMICs.METHODS: From January 2003 to July 2016, English-language trials with >5 patients assessing any one neurosurgical procedure against another procedure, nonsurgical treatment, or no treatment were retrieved from MEDLINE, Scopus, and Cochrane Library. Income classification for each country was assessed using the World Bank Atlas method.RESULTS: A total of 73.3% of the 397 studies that met inclusion criteria were led by HICs, whereas 26.7% were led by LMICs. Of the 106 LMIC-led studies, 71 were led by China. If China is excluded, only 8.8% were led by LMICs. HIC-led trials enrolled a median of 92 patients vs a median of 65 patients in LMIC-led trials. HIC-led trials enrolled from 7.6 sites vs 1.8 sites in LMIC-led studies. Over half of LMIC-led trials were institutionally funded (54.7%). The majority of both HIC- and LMIC-led trials evaluated spinal neurosurgery, 68% and 71.7%, respectively.CONCLUSION: We have established that there is a substantial disparity between HICs and LMICs in the number of published neurosurgical trials. A concerted effort to invest in research capacity building in LMICs is an essential step towards ensuring context- and resource-specific high-quality evidence is generated. Show less
BACKGROUND Long-term results from the International Subarachnoid Hemorrhage Trial (ISAT) and Barrow Ruptured Aneurysm Trial (BRAT) indicate considerably higher retreatment rates for aneurysms... Show moreBACKGROUND Long-term results from the International Subarachnoid Hemorrhage Trial (ISAT) and Barrow Ruptured Aneurysm Trial (BRAT) indicate considerably higher retreatment rates for aneurysms treated with coiling compared to clipping, but do not report the outcome of retreatment.OBJECTIVE To evaluate retreatment related outcomes.METHODS A meta-analysis in accordance with PRISMA guidelines was conducted using Medline search engines PubMed and EMBASE to identify articles describing outcomes after retreatment for intracranial aneurysms. Pooled prevalence rates for complete occlusion rate and mortality were calculated. Outcomes of different treatment and retreatment combinations were not compared because of indication bias.RESULTS Twenty-five articles that met the inclusion criteria were included in the meta-analysis. Surgery after coiling had a pooled complete occlusion rate of 91.2% (95% confidence interval [CI]: 87.0-94.1) and a pooled mortality rate of 5.6% (95% CI: 3.7-8.3). Coiling after coiling had a pooled complete occlusion rate of 51.3% (95% CI: 22.1-78.0) and a pooled mortality rate of 0.8% (95% CI: 0.15-3.7). Surgery after surgery did not provide a pooled estimate for complete occlusion as only one study was identified but had a pooled mortality rate of 5.9% (95% CI: 3.1-11.2). Coiling after surgery had a pooled complete occlusion rate of 56.1% (95% CI: 11.4-92.7) and a pooled mortality rate of 9.3% (95% CI: 4.1-19.9). All pooled incidence rates were produced using random-effect models.CONCLUSION Surgical retreatment was associated with a high complete occlusion rate but considerable mortality. Conversely, endovascular retreatment was associated with low mortality but also a low complete occlusion rate. Show less
Long term results from the International Subarachnoid Hemorrhage Trial (ISAT) and Barrow Ruptured Aneurysm Trial (BRAT) indicate considerably higher retreatment rates for aneurysms treated with... Show moreLong term results from the International Subarachnoid Hemorrhage Trial (ISAT) and Barrow Ruptured Aneurysm Trial (BRAT) indicate considerably higher retreatment rates for aneurysms treated with coiling compared to clipping, but do not report the outcome of retreatment. The aim of this meta-analysis was to evaluate retreatment related outcomes.A meta-analysis in accordance with PRISMA guidelines was conducted using Medline search engines PubMed and EMBASE to identify articles describing outcomes after retreatment for intracranial aneurysms. Pooled prevalence rates for complete occlusion rate and mortality were calculated. Outcomes of different treatment and retreatment combinations were not compared because of indication bias. Twenty-five articles that met the inclusion criteria were included in the meta-analysis. Surgery after coiling had a pooled complete occlusion rate of 91.2% (95%-CI: 87.0-94.1) and a pooled mortality rate of 5.6% (95%-CI: 3.7-8.3). Coiling after coiling had a pooled complete occlusion rate of 51.3% (95%-CI: 22.1-78.0) and a pooled mortality rate of 0.8% (95%-CI: 0.15-3.7). Surgery after surgery did not provide a pooled estimate for complete occlusion as only one study was identified but had a pooled mortality rate of 5.9% (95%-CI: 3.1-11.2). Coiling after surgery had a pooled complete occlusion rate of 56.1% (95%-CI: 11.4- 92.7) and a pooled mortality rate of 9.3% (95%-CI: 4.1-19.9). All pooled incidence rates were produced using random-effect models.Conclusion:Surgical retreatment was associated with a high complete occlusion rate but considerable mortality. Conversely, endovascular retreatment was associated with low mortality but also a low complete occlusion rate. Show less
BACKGROUND: Conventional microdiskectomy is the most frequently performed surgery for patients with sciatica caused by lumbar disk herniation. Transmuscular tubular diskectomy has been introduced... Show moreBACKGROUND: Conventional microdiskectomy is the most frequently performed surgery for patients with sciatica caused by lumbar disk herniation. Transmuscular tubular diskectomy has been introduced to increase the rate of recovery, although evidence of its efficacy is lacking. OBJECTIVE: To determine whether a favorable cost-effectiveness for tubular diskectomy compared with conventional microdiskectomy is attained. METHODS: Cost utility analysis was performed alongside a double-blind randomized controlled trial conducted among 325 patients with lumbar disk related sciatica lasting >6 to 8 weeks at 7 Dutch hospitals comparing tubular diskectomy with conventional microdiskectomy. Main outcome measures were quality-adjusted life-years at 1 year and societal costs, estimated from patient reported utilities (US and Netherlands EuroQol, Short Form Health Survey-6D, and Visual Analog Scale) and diaries on costs (health care, patient costs, and productivity). RESULTS: Quality-adjusted life-years during all 4 quarters and according to all utility measures were not statistically different between tubular diskectomy and conventional microdiskectomy (difference for US EuroQol, -0.012; 95% confidence interval, -0.046 to 0.021). From the healthcare perspective, tubular diskectomy resulted in nonsignificantly higher costs (difference US $460; 95% confidence interval, -243 to 1163). From the societal perspective, a nonsignificant difference of US $1491 (95% confidence interval, -1335 to 4318) in favor of conventional microdiskectomy was found. The nonsignificant differences in costs and quality-adjusted life-years in favor of conventional microdiskectomy result in a low probability that tubular diskectomy is more cost-effective than conventional microdiskectomy. CONCLUSION: Tubular diskectomy is unlikely to be cost-effective compared with conventional microdiskectomy. Show less
BACKGROUND: Transmuscular tubular diskectomy has been introduced to increase the rate of recovery, although evidence is lacking. OBJECTIVE: To evaluate the 2-year results of tubular diskectomy... Show moreBACKGROUND: Transmuscular tubular diskectomy has been introduced to increase the rate of recovery, although evidence is lacking. OBJECTIVE: To evaluate the 2-year results of tubular diskectomy compared with conventional microdiskectomy. METHODS: Three hundred twenty-eight patients with persistent leg pain caused by lumbar disk herniation were randomly assigned to undergo tubular diskectomy (167 patients) or conventional microdiskectomy (161 patients). Main outcome measures were scores from Roland-Morris Disability Questionnaire for Sciatica, Visual Analog Scale for leg pain and low-back pain, and Likert self-rating scale of global perceived recovery. RESULTS: On the basis of intention-to-treat analysis, there was no significant difference between tubular diskectomy and conventional microdiskectomy in Roland-Morris Disability Questionnaire for Sciatica scores during 2 years after surgery (between-group mean difference [Delta] = 0.6; 95% confidence interval [CI], 20.3-1.6). Patients treated with tubular diskectomy reported more leg pain (Delta = 3.3 mm; 95% CI, 0.2-6.2) and more low-back pain (Delta = 3.0 mm; 95% CI, 20.2-6.3) than those patients treated with conventional microdiskectomy. At 2 years, 71% of patients assigned to tubular diskectomy documented a good recovery vs 77% of patients assigned to conventional microdiskectomy (odds ratio, 0.76; 95% CI, 0.45-1.28; P = .35). Repeated surgery rates within 2 years after tubular diskectomy and conventional microdiskectomy were 15% and 10%, respectively (P = .22). CONCLUSION: Tubular diskectomy and conventional microdiskectomy resulted in similar functional and clinical outcomes. Patients treated with tubular diskectomy reported more leg pain and low-back pain, although the differences were small and not clinically relevant. Show less
BACKGROUND: In patients with supraclavicular injuries of the brachial plexus, the suprascapular nerve (SSN) is frequently reconstructed with a sural nerve graft coapted to C5. As the C5 cross... Show moreBACKGROUND: In patients with supraclavicular injuries of the brachial plexus, the suprascapular nerve (SSN) is frequently reconstructed with a sural nerve graft coapted to C5. As the C5 cross-sectional diameter exceeds the graft diameter, inadequate positioning of the graft is possible. OBJECTIVE: To identify a specific area within the C5 proximal stump that contains the SSN axons and to determine how this area could be localized by the nerve surgeon, we conducted a microanatomic study of the intraplexal topography of the SSN. METHODS: The right-sided C5 and C6 roots, the upper trunk with its divisions, and the SSN of 20 adult nonfixed cadavers were removed and fixed. The position and area occupied by the SSN fibers inside C5 were assessed and registered under magnification. RESULTS: The SSN was monofascicular in all specimens and derived its fibers mainly from C5. Small contributions from C6 were found in 12 specimens (60%). The mean transverse area of C5 occupied by SSN fibers was 28.23%. In 16 specimens (80%), the SSN fibers were localized in the ventral (mainly the rostroventral) quadrants of C5, a cross-sectional area between 9 o'clock and 3 o'clock from the surgeon's intraoperative perspective. CONCLUSION: In reconstruction of the SSN with a sural nerve graft, coaptation should be performed in the rostroventral quadrant of C5 cross-sectional area (between 9 and 12 o'clock from the nerve surgeon's point of view in a right-sided brachial plexus exploration). This will minimize axonal misrouting and may improve outcome. Show less
