Risk factors for venous thromboembolism in patients undergoing craniotomy for neoplastic disease

The Role of Injectables in the Treatment and Prevention of Cancer-Associated Thrombosis

Cancer-associated thrombosis (CAT) is a leading cause of death among patients with cancer. CAT can manifest itself as venous thromboembolism (VTE), in the form of deep vein thrombosis or pulmonary embolism, or arterial thromboembolism. The pathophysiology of CAT is complex and depends on cancer-, patient-, treatment- and biomarkers-related factors. Treatment of VTE in patients with cancer is complex and includes three major classes of anticoagulant agents: heparin and its derivatives, e.g., low molecular weight heparins, direct oral anticoagulants (DOACs), and vitamin K inhibitors. Given the tremendous heterogeneity of clinical situations in patients with cancer and the challenges of CAT, there is no single universal treatment option for patients suffering from or at risk of CAT. Initial studies suggested that patients seemed to prefer an anticoagulant that would not interfere with their cancer treatment, suggesting the primacy of cancer over VTE, and favoring efficacy and safety over convenience of route of administration. Recent studies show that when the efficacy and safety aspects are similar, patients prefer the oral route of administration. Despite this, injectables are a valid option for many patients with cancer.

Epidemiology, biology, and management of venous thromboembolism in gliomas: An interdisciplinary review

Patients with diffuse glioma are at high risk of developing venous thromboembolism (VTE) over the course of the disease, with up to 30% incidence in patients with glioblastoma (GBM) and a lower but nonnegligible risk in lower-grade gliomas. Recent and ongoing efforts to identify clinical and laboratory biomarkers of patients at increased risk offer promise, but to date, there is no proven role for prophylaxis outside of the perioperative period. Emerging data suggest a higher risk of VTE in patients with isocitrate dehydrogenase (IDH) wild-type glioma and the potential mechanistic role of IDH mutation in the suppression of production of the procoagulants tissue factor and podoplanin. According to published guidelines, therapeutic anticoagulation with low molecular weight heparin (LMWH) or alternatively, direct oral anticoagulants (DOACs) in patients without increased risk of gastrointestinal or genitourinary bleeding is recommended for VTE treatment. Due to the elevated risk of intracranial hemorrhage (ICH) in GBM, anticoagulation treatment remains challenging and at times fraught. There are conflicting data on the risk of ICH with LMWH in patients with glioma; small retrospective studies suggest DOACs may convey lower ICH risk than LMWH. Investigational anticoagulants that prevent thrombosis without impairing hemostasis, such as factor XI inhibitors, may carry a better therapeutic index and are expected to enter clinical trials for cancer-associated thrombosis.

Machine learning prediction of venous thromboembolism after surgeries of major sellar region tumors

PURPOSE

To describe and predict the risk of venous thromboembolism (VTE) after surgical resection of major sellar region tumors.

METHOD

Patients with sellar region tumors were identified from a database. The outcome was VTE, including deep vein thrombosis (DVT) and pulmonary embolism (PE) within 60 days after surgery. We trained regression and machine learning models to predict the outcome using baseline characteristics, surgical findings and postoperative laboratory tests.

RESULTS

Among 3818 patients included, 124 patients developed VTE after surgery. The total 60-day VTE incidence was 3.2 %, with incidence peak within ten days after the surgery. The risk increased in patients >65 years old (OR 2.96, p < 0.001), in patients with chordoma (OR 3.40, p = 0.006) or craniopharyngioma (OR 1.86, p = 0.036), in patients underwent craniotomy approach (OR 2.78, p = 0.017), in patients with high volume CSF leakage (OR 4.24, p < 0.001), and in patients with longer surgical duration (OR 1.78, p = 0.029). The linear discriminant analysis algorithm had the highest AUC (0.869, 95%CI, 0.840-0.898) in predicting the outcome. The specificity, accuracy, and sensitivity of the best model were 61.8 %, 93.6 %, and 92.8 %, respectively. Risk stratification using our best model suggested that 1.3 % and 24.5 % of the patient developed VTE in the low-risk group and in the high-risk group, respectively. We developed an online decision-support tool available on https://deepvep.shinyapps.io/VTEpred/.

CONCLUSION

The overall incidence of VTE after surgical resection of major sellar region tumors was clinically significant, especially in older patients with chordoma or craniopharyngioma.

Venous thromboembolic and hemorrhagic events after meningioma surgery: A single-center retrospective cohort study of risk factors

Microsurgical resection of meningiomas in a majority of cases leads to a favorable outcome. Therefore, severe postoperative adverse events are less acceptable. The main purpose of this study was to investigate the incidence of symptomatic venous thromboembolism (VTE) and hemorrhagic complications in patients after operative treatment of intracranial meningiomas and to identify the risk factors in this patient subgroup. Of 106 patients undergoing elective craniotomy for meningioma overall incidence of symptomatic VTE was noted in 5.7% (six patients). For the risk-factor analysis older age (57.20 ± 11.60 vs. 71.00 ± 0.90 years, p < 0.001), higher body mass index (27.60 ± 4.80 vs. 33.16 ± 0.60 kg/m², p < 0.001), WHO grade II (3.00% vs. 33.33%, p = 0.02), lower intraoperative blood loss (466.00 ± 383.70 vs. 216.70 ± 68.30 mL, p < 0.001), bedridden status and neurologic deficit (0.00% vs. 33.33%, p = 0.003 and 38.00% vs. 100.00%, p = 0.004) were associated with greater VTE risk. No risk factors for hemorrhagic complications were identified on univariate analysis. In conclusion, the incidence of VTE in meningioma patients is not negligible. Identified risk factors should be taken into account in the decision-making process for chemoprophylaxis when the risk of bleeding decreases.

Enhanced Recovery After Surgery (ERAS) for Cranial Tumor Resection: A Review

Enhanced Recovery After Surgery (ERAS) protocols describe a standardized method of preoperative, perioperative, and postoperative care to enhance outcomes and minimize complication risks surrounding elective surgical intervention. A growing body of evidence is being generated as we learn to apply principles of ERAS standardization to neurosurgical patients. First applied in spinal surgery, ERAS protocols have been extended to cranial neuro-oncological procedures. This review synthesizes recent findings to generate evidence-based guidelines to manage neurosurgical oncology patients with standardized systems and assess ability of these systems to coordinate multidisciplinary, patient-centric care efforts. Furthermore, we highlight the potential utility of multimedia, app-based communication platforms to facilitate patient education, autonomy, and team communication within each of the three settings.

A Retrospective Comparative Cohort Study of Craniotomy and Prophylactic Enoxaparin Timing

INTRODUCTION

 Post-operative venous thromboembolism (VTE) prophylaxis is the standard of care after craniotomy, but there is debate over when to initiate VTE prophylaxis to decrease the morbidity and mortality experienced by these patients. This study aims to determine the effects of starting enoxaparin on day one vs. day three after craniotomy.

METHODS

We used a multi-institutional health research network (TriNetX) to gather data from the electronic medical records of patients who started enoxaparin one day after craniotomy (cohort 1) and patients who started it three days later (cohort 2). Our primary endpoint was mortality, with the secondary endpoints of deep venous thrombosis (DVT), additional craniotomy, pulmonary embolism (PE), myocardial infarction (MI), ischemic stroke (IS), intracerebral hemorrhage (ICH), ventilator and tracheostomy dependence, or percutaneous endoscopic gastrostomy (PEG) tube dependence. Patients were propensity score-matched for demographics, common comorbidities, and anticoagulant and antiplatelet use.

RESULTS

After propensity score matching, 1,554 patients were identified in each cohort. In cohort 1, 21.171% of patients were deceased after five years vs. 26.126% in cohort 2 (p= 0.0012; OR 0.759, 95% CI (0.643,0.897)). The 30-day survival was 94.521% vs. 93.049%, the 90-day survival was 90.200% vs. 87.335%, and the 365-day survival was 80.619 vs. 76.817%. Deep venous thrombosis occurred in 5.277% of cohort 1 and 7.851% of cohort 2 (p=0.0038, OR 0.654, 95% CI [0.49,0.873]). There was no increase in intracerebral hemorrhage in cohort 1. There were no statistically significant differences in subsequent craniotomy rates, PE, MI, IS, ventilator/tracheostomy, or PEG tube dependence.

CONCLUSION

Starting enoxaparin on day one after craniotomy was associated with decreased mortality and DVTs, with no difference in rates of PE, MI, IS, tracheostomy/PEG dependence, or further craniotomy.

Operative duration and early outcomes in patients having a supratentorial craniotomy for brain tumor: A propensity matched analysis

It is unclear how variations in operative duration affect outcomes after craniotomy for supratentorial brain tumor. We characterized three populations of patients with typical, shorter, and longer durations of craniotomy for supratentorial brain tumor using prospectively collected clinical data from 16,335 patients in the 2012-2018 ACS National Surgical Quality Improvement Program (NSQIP) database. We compared baseline characteristics including demographics, comorbidities, tumor type, and operative features. We used propensity score matching to attain covariate balance and logistic regression to assess odds of unfavorable outcomes. Patients with the shortest operation durations tended to be older, with fewer males, higher ASA class, more metastatic brain tumors, more medical comorbidities, and less use of intraoperative microscope or ultrasound. Patients with the longest operative durations tended to be younger, with more males, fewer non-white minorities, more obesity, lower ASA classes, more intrinsic brain tumors, fewer medical comorbidities, fewer emergency operations, and increased use of intraoperative microscope. For patients with the shortest operations, after matching, we observed significantly decreased odds of prolonged length-of-stay (LOS), major complication, any complication, reoperation, and discharge to a facility; however, there was a significantly increased risk of 30-day mortality. For patients with the longest operations, after matching, we observed significantly increased odds of prolonged LOS; minor, major, and any complication; discharge to facility; and 30-day reoperation. After matching to balance baseline characteristics, operative duration has implications for outcomes following craniotomy for supratentorial brain tumor.

Unfractionated Heparin TID Dosing Regimen Is Associated With a Lower Rate of Pulmonary Embolism When Compared With BID Dosing in Patients Undergoing Craniotomy

BACKGROUND

Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), and intracranial hemorrhage (ICH) may complicate the post-operative course of patients undergoing craniotomy. While prophylaxis with unfractionated heparin (UFH) has been shown to reduce VTE rates, twice-daily (BID) and three-times-daily (TID) UFH dosing regimens have not been compared in neurosurgical procedures. The objective of this study was to explore the association between UFH dosing regimen and rates of VTE and ICH in craniotomy patients.

METHODS

A retrospective chart review was conducted for 159 patients at Northwestern University receiving 5000 units/0.5 mL UFH injections either BID (n = 132) or TID (n = 27). General linear regression models were run to predict rates of DVT, PE, and reoperation due to bleeding from UFH dosing regimen while controlling for age at surgery, sex, VTE history, craniotomy for tumor resection, surgery duration, length of stay, reoperation, infections, and IDH/MGMT mutations.

RESULTS

Receiving UFH TID was significantly associated with a lower rate of PE when compared with receiving UFH BID (β = -0.121, P = 0.044; TID rate = 0%, BID rate = 10.6%). UFH TID also showed a trend toward lower rates of DVT (β = -0.0893, P = 0.295; TID rate = 18.5%, BID rate = 21.2%) when compared with UFH BID. UFH TID showed no significant difference in rate of reoperation for bleeding when compared to UFH BID (β = -0.00623, P = 0.725; TID rate = 0%, BID rate = 0.8%).

CONCLUSIONS

UFH TID dosing is associated with lower rates of PE when compared with BID dosing in patients undergoing craniotomy.

Impaired contraction of blood clots precedes and predicts postoperative venous thromboembolism

Deep vein thrombosis (DVT) is a common but unpredictable complication of surgical interventions. To reveal an association between the blood clot contraction (retraction) and the incidence of postoperative venous thrombosis, 78 patients with brain tumors that were operated on were studied, of which 23 (29%) were diagnosed with postoperative DVT. A clot contraction assay, along with other hemostatic and hematologic tests, was performed 1–3 days before the surgery and on the 1st day and 5–7th days after the surgery. On the 1st postoperative day, clot contraction was significantly suppressed in patients who subsequently developed DVT, compared to the patients without DVT. Importantly, this difference was observed at least 5 days before DVT had developed. The weakening of contraction on the 1st postoperative day was more pronounced in the DVT patients with malignant versus benign brain tumors, atherosclerosis, hypertension, as well as in patients receiving steroids before and during the operation. These results indicate that impaired clot contraction in the postoperative period is associated with imminent DVT, suggesting that it is a prothrombotic risk factor and promotional mechanism. The clot contraction assay has a predictive value in assessing the threat of postoperative thrombosis in patients with benign and malignant brain tumors.

Preoperative and intraoperative predictors of deep venous thrombosis in adult patients undergoing craniotomy for brain tumors: A Chinese single-center, retrospective study

PURPOSE

Brain tumor resection by craniotomy is associated with a high risk of deep vein thrombosis (DVT). This study evaluated the incidence and preoperative and intraoperative risk factors for DVT within 30 days of surgery.

METHODS

The analysis included: 1) basic clinical variables (patient age, sex, body mass index [BMI], tumor location, and tumor histology); 2) blood test results before operation, such as leukocytes, platelets, and coagulation parameters; and 3) surgical factors (total amount of blood lost, anesthesia mode, and surgery duration).

RESULTS

Of the 1670 patients, 206 (12.34%) had DVT and nine (0.54%) had both DVT and pulmonary embolism (PE) after surgery. Preoperative and intraoperative factors independently associated with DVT/PE were: older age 46-55 years (odds ratio [OR]: 2.87; 95% confidence interval [CI]: 1.83-4.50; P < 0.001), age 56-65 years (OR: 5.24; 95% CI: 3.27-8.40; P < 0.001), age > 65 years (OR: 6.00; 95% CI: 3.45-10.45; P < 0.001), BMI (OR: 1.03; 95% CI: 1.00-1.05; P = 0.029), activated partial thromboplastin time [APTT] (OR: 0.91; 95% CI: 0.86-0.95; P = 0.000), D-dimer (OR: 1.69; 95% CI: 1.23-2.34; P = 0.001), high-grade glioma (OR: 2.09; 95% CI: 1.28-3.40; P = 0.003), glio-neuronal (OR: 3.30; 95% CI: 1.28-8.47; P = 0.013), craniopharyngioma (OR: 2.16; 95% CI: 1.13-4.10; P = 0.019), and surgery duration (OR: 1.82; 95% CI: 1.27-2.60; P = 0.001).

CONCLUSIONS

Older age, BMI, preoperative APTT, D-dimer, tumor histology, and surgery duration independently increased the risk of developing postoperative DVT/PE. These findings provide prognostic information that will guide therapies aimed at minimizing the development of DVT/PE during hospitalization.

Venous Duplex Ultrasound Surveillance in the Neurosurgical Population: A Single-Center Quality Improvement Initiative

BACKGROUND

Venous thromboembolism (VTE) represents a significant source of morbidity and mortality in the inpatient population and is considered a leading preventable cause of death among inpatients. Neurosurgical inpatients are of particular interest because of the greater rates of immobility, steroid use, and potential consequences of postoperative hemorrhage. A consensus protocol for VTE screening in this population has not yet been developed, and institutional protocols vary widely.

METHODS

We performed a retrospective review of lower extremity venous duplex ultrasonography (VDUS) usage at our institution and applied this information to the development of a neurosurgery department protocol, with consideration of high-risk patient risk factors and indications for VDUS ordering. We then implemented this protocol, which consisted of preoperative screening of patients at high risk of VTE and limited postoperative surveillance, for a 6-month period and compared VDUS usage and VTE occurrence.

RESULTS

Preoperative VDUS screening before nonemergent neurosurgical procedures in high-risk patients with active cancer, an inability to ambulate, or a history of deep vein thrombosis (DVT) identified proximal DVTs that were then treated. Postoperative routine surveillance VDUS scans only diagnosed incidental isolated calf DVT for which no clinically relevant sequelae occurred. Overall, postoperative surveillance VDUS usage decreased significantly (66.9% vs. 13.5%; P = 0.001).

CONCLUSIONS

Our findings lend support to preoperative screening of high-risk patients and suggest that routine postoperative VDUS surveillance of asymptomatic patients is unnecessary.

Risk Factors and Clinical Significance of D-Dimer in the Development of Postoperative Venous Thrombosis in Patients with Lung Tumor

BACKGROUND

The incidence of venous thromboembolism (VTE) is higher in patients with lung cancer. The aim of this study was to investigate the risk factors associated with postoperative VTE and explore the VTE predication capacity of D-dimer kinetics.

PATIENTS AND METHODS

Six hundred patients who had lung tumor surgery were analyzed retrospectively between January 2018 and August 2019, and venous ultrasound imaging and D-dimer examination before and after surgery were recommended to all operative patients. Of these 600 patients, 523 patients had venous thromboembolism after surgery, and 77 patients had not found. The general clinical data, postoperative prophylactic anticoagulant therapy, early systemic thromboprophylaxis, 50% increment of D-dimer, 100% increment of D-dimer, and perioperative (preoperative and days 1, 3, and 5 after surgery) D-dimer levels were collected. Logistic regression analysis was used to analyze the independent risk factors of postoperative VTE.

RESULTS

VTE developed in 77 (12.8%) patients. In a univariate analysis, age, surgical approach, tumor size, histology, postoperative preventive anticoagulation, postoperative limb compression therapy, postoperative hemostasis, duration of operation, early systemic thromboprophylaxis, 100% increment of D-dimer, preoperative and postoperative D-dimer level, intraoperative blood loss, and time spent in the hospital were significantly different between the thrombus group and nonthrombus group (P < 0.05). Multivariate analysis showed that age >60 years (P = 0.006) and D-dimer level on 5 days after surgery (P = 0.000) were significant independent risk factors for VTE. Postoperative D-dimer was significantly higher than the preoperative level (P < 0.001). Postoperative D-dimer level was significantly different between benign and malignant tumor groups (P < 0.05) and between the thrombus group and nonthrombus group (P < 0.001). Preventive anticoagulation and limb compression therapy starting from the first day after surgery was statistically significant between the thrombus group and the nonthrombus group (P < 0.05).

CONCLUSION

Continuous detection of D-dimer level after pulmonary tumor surgery combined with thrombotic-related risk factors can better evaluate the occurrence of VTE. Preventive anticoagulant therapy and limb compression therapy starting from the first day after surgery can effectively reduce the incidence of VTE.

Venous Thromboembolism in Patients With Brain Cancer: Focus on Prophylaxis and Management

Patients with primary and metastatic brain tumors are predisposed to thromboembolism. This review of the literature explores the high prevalence of venous thromboembolism and its negative impact on patients with brain cancer. It outlines the recommended prophylactic strategies to prevent venous thrombosis and analyzes the benefit versus risk of anticoagulation in this population, with a focus on the risk of intracranial bleeding associated with it. Additionally, it explores the exceedingly high prevalence of venous thromboembolism in the setting of brain cancer surgeries and provides guidance on the best methods used for prophylaxis in this setting and discusses the safety of each method perioperatively. Lastly, this review article provides guidance on how to manage venous thromboembolism in patients with brain cancer and discusses the use of vena cava filters in this population.

Venous thromboembolism in children undergoing surgery: incidence, risk factors and related adverse events

Background

Although less common in adults, venous thromboembolism (VTE) in children is a highly morbid, preventable adverse event. While VTE has been well studied among pediatric hospitalized and trauma patients, limited work has been done to examine postoperative VTE in children undergoing surgery.

Methods

Using data from National Surgical Quality Improvement Project Pediatric database (NSQIP-P) from 2012 to 2016, a retrospective cohort analysis was performed to determine the incidence of, and risk factors for, VTE in children undergoing surgery. Additionally, the relationships between VTE and other postoperative adverse outcomes were evaluated.

Results

Of 361 384 pediatric surgical patients, 378 (0.10%) were identified as experiencing postoperative VTE. After controlling for patient and surgical factors, we found that American Society of Anesthesiologists (ASA) class of II or greater, aged 16–18 years, non-elective surgery, general surgery (compared with several other surgical specialties), cardiothoracic surgery (compared with general surgery) and longer operative time were significantly associated with VTE in pediatric patients (p<0.001 for each comparison). Furthermore, a majority of adverse events were found to be associated with increased risk of subsequent VTE (p<0.001).

Conclusion

In a large pediatric surgical population, an incidence of postoperative VTE of 0.10% was observed. Defined patient and surgical factors, and perioperative adverse events were found to be associated with such VTE events.

Incidence and Risk Factors for Venous Thromboembolism Following Craniotomy for Intracranial Tumors: A Cohort Study

Context:

Venous thromboembolism (VTE) is a devastating complication of intracranial tumor surgery. The present study helps identify patients at the greatest risk of developing VTE.

Aims:

The aim of the study was to evaluate the incidence of and risk factors for VTE following craniotomy for intracranial tumors.

Setting and Designs:

This was a retrospective cohort study.

Methods:

Data from the institutional database (between January 2017 and December 2018) were reviewed. Consecutive patients with intracranial tumors who underwent craniotomy were included.

Statistical Analysis Used:

Patient characteristics were reported as descriptive data, and factors associated with VTE development were analyzed by the Cox regression model.

Results:

The study identified 177 patients. The incidence of VTE was 10.2% (deep-vein thrombosis [DVT], 8.5%; pulmonary embolism [PE] 1.7%; and simultaneous DVT and PE, 1.7%). In univariate analysis, VTE development was associated with diabetes mellitus (DM), operative duration of >420 min, blood transfusion, and new-onset postoperative motor deficits. DM and new-onset postoperative motor deficits were statistically significant factors in multivariable analysis, with hazard ratios of 4.52 (95% confidence interval [CI] = 1.38–14.82) and 3.46 (95% CI = 1.17–10.23), respectively.

Conclusions:

Postcraniotomy VTE was detected in 10.2% of patients with intracranial tumors. Risk factors for VTE included DM and new-onset postoperative motor deficits. Hence, intracranial tumor patients with these risk factors are the most likely to require VTE prophylaxis with an anticoagulant.

Patterns of seizure prophylaxis after oncologic neurosurgery

BACKGROUND

Evidence supporting routine postoperative antiepileptic drug (AED) prophylaxis following oncologic neurosurgery is limited, and actual practice patterns are largely unknown beyond survey data.

OBJECTIVE

To describe patterns and predictors of postoperative AED prophylaxis following intracranial tumor surgery.

METHODS

The MarketScan Database was used to analyze pharmacy claims data and clinical characteristics in a national sample over a 5-year period.

RESULTS

Among 5895 patients in the cohort, levetiracetam was the most widely used AED for prophylaxis (78.5%) followed by phenytoin (20.5%). Prophylaxis was common but highly variable for patients who underwent open resection of supratentorial intraparenchymal tumors (62.5%, reference) or meningiomas (61.9%). In multivariate analysis, biopsies were less likely to receive prophylaxis (44.8%, OR 0.47, 95% CI 0.33-0.67), and there was near consensus against prophylaxis for infratentorial (9.7%, OR 0.07, CI 0.05-0.09) and transsphenoidal procedures (0.4%, OR 0.003, CI 0.001-0.010). Primary malignancies (52.1%, reference) and secondary metastases (42.2%) were more likely to receive prophylaxis than benign tumors (23.0%, OR 0.63, CI 0.48-0.83), as were patients discharged with home services and patients in the Northeast. There was a large spike in duration of AED use at approximately 30 days.

CONCLUSIONS

Use of seizure prophylaxis following intracranial biopsies and supratentorial resections is highly variable, consistent with a lack of guidelines or consensus. Current practice patterns do not support a clear standard of care and may be driven in part by geographic variation, availability of post-discharge services, and electronic prescribing defaults rather than evidence. Given uncertainty regarding effectiveness, indications, and appropriate duration of AED prophylaxis, well-powered trials are needed.

Reporting Methodology of Neurosurgical Studies Utilizing the American College of Surgeons-National Surgical Quality Improvement Program Database: A Systematic Review and Critical Appraisal

BACKGROUND

Use of large databases such as the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) has become increasingly common in neurosurgical research.

OBJECTIVE

To perform a critical appraisal and evaluation of the methodological reporting for studies in neurosurgical literature that utilize the ACS-NSQIP database.

METHODS

We queried Ovid MEDLINE, EMBASE, and PubMed databases for all neurosurgical studies utilizing the ACS-NSQIP. We assessed each study according to number of criteria fulfilled with respect to Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement, REporting of studies Conducted using Observational Routinely-collected Health Data (RECORD) Statement, and Journal of American Medical Association–Surgical Section (JAMA-Surgery) Checklist. A separate analysis was conducted among papers published in core and noncore journals in neurosurgery according to Bradford's law.

RESULTS

A total of 117 studies were included. Median (interquartile range [IQR]) scores for number of fulfilled criteria for STROBE Statement, RECORD Statement, and JAMA-Surgery Checklist were 20 (IQR:19-21), 9 (IQR:8-9), and 6 (IQR:5-6), respectively. For STROBE Statement, RECORD Statement, and JAMA-Surgery Checklist, item 9 (potential sources of bias), item 13 (supplemental information), and item 9 (missing data/sensitivity analysis) had the highest number of studies with no fulfillment among all studies (56, 68, 50%), respectively. When comparing core journals vs noncore journals, no significant difference was found (STROBE, P = .94; RECORD, P = .24; JAMA-Surgery checklist, P = .60).

CONCLUSION

While we observed an overall satisfactory reporting of methodology, most studies lacked mention of potential sources of bias, data cleaning methods, supplemental information, and external validity. Given the pervasive role of national databases and registries for research and health care policy, the surgical community needs to ensure the credibility and quality of such studies that ultimately aim to improve the value of surgical care delivery to patients.

Adverse Events After Microvascular Decompression: A National Surgical Quality Improvement Program Analysis

BACKGROUND

Although microvascular decompression (MVD) is a durable treatment for medically refractory trigeminal neuralgia, hemifacial spasm, or glossopharyngeal neuralgia attributable to neurovascular conflict, few national studies have analyzed predictors of postoperative complications.

OBJECTIVE

To determine the incidence and risk factors for adverse events after MVD.

METHODS

Patients who underwent MVD were extracted from the prospectively collected National Surgical Quality Improvement Program registry (2006-2017). Multivariable logistic regression identified predictors of 30-day adverse events and unplanned readmission; multivariable linear regression analyzed predictors of a longer hospital stay.

RESULTS

Among the 1005 patients evaluated, the mortality was 0.3%, major neurologic complication rate 0.4%, and 2.8% had a nonroutine hospital discharge. Patient age was not a predictor of any adverse events. Statistically significant independent predictors both of any adverse event (9.2%) and of a longer hospitalization were American Society of Anesthesiologists (ASA) classification III-IV designation and longer operative duration (P ≤ 0.03) The 30-day readmission rate was 6.8%, and the most common reasons were surgical site infections (22.4%) and cerebrospinal fluid leakage (14.3%). Higher ASA classification, diabetes mellitus, and operative time were predictors of readmission (P < 0.04).

CONCLUSIONS

In this National Surgical Quality Improvement Program analysis, postoperative morbidity and mortality after MVD was low. Patient age was not a predictor of postoperative complications, whereas higher ASA classification, diabetes mellitus, and longer operative duration were predictive of any adverse event and readmission. ASA classification provided superior risk stratification compared with the total number of patient comorbidities or laboratory values. These data can assist with preoperative patient counseling and risk stratification.

The role of preoperative deep vein thrombosis screening in neurooncology

OBJECTIVEVenous thromboembolism (VTE) is a major cause of morbidity in patients undergoing neurosurgical intervention. The authors postulate that the introduction of a routine preoperative deep vein thrombosis (DVT) screening protocol for patients undergoing neurosurgical intervention for brain tumors would result in a more effective diagnosis of DVT in this high-risk subgroup, and subsequent appropriate management of the condition would reduce pulmonary embolism (PE) rates and improve patient outcomes.METHODSThe authors conducted a prospective study of 115 adult patients who were undergoing surgical intervention for a brain tumor. All patients underwent preoperative lower-limb Doppler ultrasonography scanning for DVT screening. Patients with confirmed DVT underwent a period of anticoagulation therapy, which was stopped prior to surgery. An inferior vena cava (IVC) filter was inserted to cover the perioperative period during which anticoagulation therapy was avoided due to bleeding risk before restarting the therapy at a later date. Patients underwent follow-up performed by a neurooncology multidisciplinary team, and subsequent complications and outcomes were recorded.RESULTSSeven (6%) of the 115 screened patients had DVT. Of these patients, one developed postoperative PE, and another had bilateral DVT postoperatively. None of the patients without preoperative DVT developed VTE postoperatively. Age, symptoms of DVT, and previous history of VTE were significantly higher in the group with preoperative DVT. There were no deaths and no complications from the anticoagulation or IVC filter insertion.CONCLUSIONSPreoperative screening for DVT is a worthwhile endeavor in patients undergoing neurosurgical intervention. A multidisciplinary approach in management of anticoagulation and IVC filter insertion is safe and can minimize further VTE in such patients.

Risk Factors and Associated Complications of Symptomatic Venous Thromboembolism in Patients with Craniotomy for Meningioma

OBJECTIVE

Patients undergoing surgical resection of meningioma are at increased risk for developing venous thromboembolism (VTE). The aim of this study was to assess occurrence of VTE in patients who underwent surgical resection of meningioma to determine risk factors and associated complications of VTE.

METHODS

The American College of Surgeons National Surgical Quality Improvement Project database from 2012 to 2015 was reviewed for patients who had undergone meningioma resection according to primary Current Procedural Terminology codes and International Classification of Diseases, Ninth Revision.

RESULTS

The study included 5036 patients with meningioma. Rate of VTE was 3.38%, with pulmonary embolism rate of 1.47% and deep venous thrombosis rate of 2.42%. During the first 30 days after surgery, patients with VTE had a mortality rate of 5.88% compared with 1.15% for patients without VTE. Multivariate binary logistic regression analysis determined 5 risk factors for VTE,: age ≥60 years, American Society of Anesthesiologists classification III, operative time ≥310 minutes, ventilator dependence, and preoperative transfusions. Univariate analysis revealed a number of complications significantly associated with VTE occurrence, including unplanned intubation, ventilator use for >48 hours, stroke, sepsis, septic shock, pneumonia, urinary tract infection, and transfusions.

CONCLUSIONS

Risk factors of VTE and associated complications were identified. Understanding these risk factors provides physicians with further insight in managing this subgroup of patients in a personalized fashion in the perioperative period to minimize the incidence and morbidity of VTE.

Predictors of Venous Thromboembolism After Nonemergent Craniotomy: A Nationwide Readmission Database Analysis

BACKGROUND

Venous thromboembolism (VTE) is responsible for many hospital readmissions each year, particularly among postsurgical cohorts. Because early and indiscriminate VTE prophylaxis carries catastrophic consequences in postcraniotomy cohorts, identifying factors associated with a high risk for thromboembolic complications is important for guiding postoperative management.

OBJECTIVE

To determine VTE incidence in patients undergoing nonemergent craniotomy and to evaluate for factors that predict 30-day and 90-day readmission with VTE.

METHODS

The 2010-2014 cohorts of the Nationwide Readmissions Database were used to generate a large heterogeneous craniotomy sample.

RESULTS

There were 89,450 nonemergent craniotomies that met inclusion criteria. Within 30 days, 1513 patients (1.69%) were readmitted with VTE diagnoses; among them, 678 (44.8%) had a diagnosis of deep vein thrombosis alone, 450 (29.7%) had pulmonary embolism alone, and 385 (25.4%) had both. The corresponding 30-day deep vein thrombosis and pulmonary embolism incidences were 1.19% and 0.93%, respectively. In multivariate analysis, several factors were significantly associated with VTE readmission, namely, craniotomy for tumor, corticosteroids, advanced age, greater length of stay, and discharge to institutional care.

CONCLUSIONS

Craniotomies for tumor, corticosteroids, advanced age, prolonged length of stay, and discharge to institutional care are significant predictors of VTE readmission. The implication of steroids, coupled with their ubiquity in neurosurgery, makes them a potentially modifiable risk factor and a prime target for VTE reduction in craniotomy cohorts. Furthermore, the fact that dose is proportional to VTE risk in the literature suggests that careful consideration should be given toward decreasing regimens in situations in which use of a lower dose might prove equally sufficient.

Predicting Readmission and Reoperation for Benign Cranial Nerve Neoplasms: A Nationwide Analysis

OBJECTIVE

Readmission and reoperation are risks in the resection of benign cranial nerve tumors (BCNTs). This report analyzes the impact of patient-level and surgical factors on these adverse outcomes.

METHODS

This retrospective cohort review comprised patients with a diagnosis of BCNT enrolled in the American College of Surgeons National Surgical Quality Improvement Program registry from 2011 to 2015. Multivariate logistic regression was used to determine the impact of select medical and operative factors on the primary outcomes of readmission and reoperation within 30 days, adjusted for relevant covariates.

RESULTS

We identified 996 patients who underwent resection of a BCNT. The most frequent major complications were readmission (11%), reoperation (8%), surgical site infections (2.6%), and venous thromboembolism (1.5%). The most frequent indications for readmission were management of infection (2.5%), cerebrospinal fluid leak (2.3%), and hydrocephalus (0.5%). Repair of cranial and meningeal defects (3.0%), correction of lagophthalmos (1.2%), and repair of middle ear defects (1.0%) were the most common indications for reoperation. Logistic regression revealed that extremes of age were associated with readmission, whereas preoperative steroid usage, long operative time, and postoperative length of stay >3 days were associated with reoperation (P < 0.05). Obesity trended toward an association with readmission and reoperation.

CONCLUSIONS

Extremes of age were associated with readmission; preoperative steroid use, long operative time, and postoperative length of stay >3 days were associated with reoperation. Surgeons should consider these factors when assessing risk of postoperative complications for BCNTs.

Platelet activation parameters and platelet-leucocyte-conjugate formation in glioblastoma multiforme patients

Patients with glioblastoma multiforme (GBM) suffer from an increased incidence of vascular thrombotic events. However, key influencing factors of the primary hemostasis have not been characterized in GBM patients to date. Thus, the present study determines the activation level of circulating platelets in GBM patients, in-vitro reactivity to agonist-induced platelet stimulation and the formation of circulating platelet-leucocyte conjugates as well as the plasma levels of the proinflammatory lipid mediator sphingosine-1-phosphate (S1P). The endogenous thrombin potential (ETP) was determined as global marker for hemostasis. The 21 GBM patients and 21 gender and age matched healthy individuals enrolled in this study did not differ in mean total platelet count. Basal surface expression of platelet CD63 determined by flow cytometry was significantly increased in GBM patients compared to controls as was observed for the concentration of soluble P-selectin in the plasma of GBM patients. While the ETP was not affected, the immunomodulatory lipid S1P was significantly decreased in peripheral blood in GBM. Interestingly, monocyte expression of PSGL-1 (CD162) was decreased in GBM patient blood, possibly explaining the rather decreased formation of platelet-monocyte conjugates. Our study reveals an increased CD63 expression and P-selectin expression/ secretion of circulating platelets in GBM patients. In parallel a down-modulated PSGL-1 expression in circulating monocytes and a trend towards a decreased formation of heterotypic platelet-monocyte conjugates in GBM patients was seen. Whether this and the observed decreased plasma level of the immunomodulatory S1P reflects a systemic anti-inflammatory status needs to be addressed in future studies.

Unplanned Reoperation After Craniotomy for Tumor: A National Surgical Quality Improvement Program Analysis

BACKGROUND

Reoperation has been increasingly utilized as a metric evaluating quality of care.

OBJECTIVE

To evaluate the rate of, reasons for, and predictors of unplanned reoperation after craniotomy for tumor in a nationally accrued population.

METHODS

Patients who underwent cranial tumor resection were extracted from the prospective National Surgical Quality Improvement Program registry (2012-2014). Multivariate logistic regression examined predictors of unplanned cranial reoperation. Predictors screened included patient age, sex, tumor location and histology, functional status, comorbidities, preoperative laboratory values, operative urgency, and time.

RESULTS

Of the 11 462 patients included, 3.1% (n = 350) underwent an unplanned cranial reoperation. The most common reasons for cranial reoperation were intracranial hematoma evacuation (22.5%), superficial or intracranial surgical site infections (11.9%), re-resection of tumor (8.4%), decompressive craniectomy (6.1%), and repair of cerebrospinal fluid leakage (5.6%). The strongest predictor of any cranial reoperation was preoperative thrombocytopenia (less than 100 000/μL, odds ratio [OR] = 2.51, 95% confidence interval [CI]: 1.23-5.10, P = .01). Thrombocytopenia, hypertension, emergent surgery, and longer operative time were predictors of reoperation for hematoma (P ≤ .004), while dependent functional status, morbid obesity, leukocytosis, and longer operative time were predictors of reoperation for infection (P < .05). Although any unplanned cranial reoperation was not associated with differential odds of mortality (OR = 1.68, 95% CI: 0.94-3.00, P = .08), hematoma evacuation was significantly associated with thirty-day death (P = .04).

CONCLUSION

In this national analysis, unplanned cranial reoperation was primarily associated with operative indices, rather than preoperative characteristics, suggesting that reoperation may have some utility as a quality indicator. However, hypertension and thrombocytopenia were potentially modifiable predictors of reoperation.

Reoperation and readmission after clipping of an unruptured intracranial aneurysm: a National Surgical Quality Improvement Program analysis

OBJECTIVE

Although reoperation and readmission have been used as quality metrics, there are limited data evaluating the rate of, reasons for, and predictors of reoperation and readmission after microsurgical clipping of unruptured aneurysms.

METHODS

Adult patients who underwent craniotomy for clipping of an unruptured aneurysm electively were extracted from the prospective National Surgical Quality Improvement Program registry (2011–2014). Multivariable logistic regression and recursive partitioning analysis evaluated the independent predictors of nonroutine hospital discharge, unplanned 30-day reoperation, and readmission. Predictors screened included patient age, sex, comorbidities, American Society of Anesthesiologists (ASA) classification, functional status, aneurysm location, preoperative laboratory values, operative time, and postoperative complications.

RESULTS

Among the 460 patients evaluated, 4.2% underwent any reoperation at a median of 7 days (interquartile range [IQR] 2–17 days) postoperatively, and 1.1% required a cranial reoperation. The most common reoperation was ventricular shunt placement (23.5%); other reoperations were tracheostomy, craniotomy for hematoma evacuation, and decompressive hemicraniectomy. Independent predictors of any unplanned reoperation were age greater than 51 years and longer operative time (p ≤ 0.04). Readmission occurred in 6.3% of patients at a median of 6 days (IQR 5–13 days) after discharge from the surgical hospitalization; 59.1% of patients were readmitted within 1 week and 86.4% within 2 weeks of discharge. The most common reason for readmission was seizure (26.7%); other causes of readmission included hydrocephalus, cerebrovascular accidents, and headache. Unplanned readmission was independently associated with age greater than 65 years, Class II or III obesity (body mass index > 35 kg/m2), preoperative hyponatremia, and preoperative anemia (p ≤ 0.04). Readmission was not associated with operative time, complications during the surgical hospitalization, length of stay, or discharge disposition. Recursive partitioning analysis identified the same 4 variables, as well as ASA classification, as associated with unplanned readmission. The most potent predictors of nonroutine hospital discharge (16.7%) were postoperative neurological and cardiopulmonary complications; other predictors were age greater than 51 years, preoperative hyponatremia, African American and Asian race, and a complex vertebrobasilar circulation aneurysm.

CONCLUSIONS

In this national analysis, patient age greater than 65 years, Class II or III obesity, preoperative hyponatremia, and anemia were associated with adverse events, highlighting patients who may be at risk for complications after clipping of unruptured cerebral aneurysms. The preponderance of early readmissions highlights the importance of early surveillance and follow-up after discharge; the frequency of readmission for seizure emphasizes the need for additional data evaluating the utility and duration of postcraniotomy seizure prophylaxis. Moreover, readmission was primarily associated with preoperative characteristics rather than metrics of perioperative care, suggesting that readmission may be a suboptimal indicator of the quality of care received during the surgical hospitalization in this patient population.

Venous thromboembolism and intracranial hemorrhage after craniotomy for primary malignant brain tumors: a National Surgical Quality Improvement Program analysis

Venous thromboembolism (VTE), including deep venous thrombosis (DVT) and pulmonary embolism (PE), frequently complicates the postoperative course of primary malignant brain tumor patients. Thromboprophylactic anticoagulation is commonly used to prevent VTE at the risk of intracranial hemorrhage (ICH). We extracted all patients who underwent craniotomy for a primary malignant brain tumor from the National Surgical Quality Improvement Program (NSQIP) registry (2005-2015) to perform a time-to-event analysis and identify relevant predictors of DVT, PE, and ICH within 30 days after surgery. Among the 7376 identified patients, the complication rates were 2.6, 1.5, and 1.3% for DVT, PE, and ICH, respectively. VTE was the second-most common major complication and third-most common reason for readmission. ICH was the most common reason for reoperation. The increased risk of VTE extends beyond the period of hospitalization, especially for PE, whereas ICH occurred predominantly within the first days after surgery. Older age and higher BMI were overall predictors of VTE. Dependent functional status and longer operative times were predictive for VTE during hospitalization, but not for post-discharge events. Admission two or more days before surgery was predictive for DVT, but not for PE. Preoperative steroid usage and male gender were predictive for post-discharge DVT and PE, respectively. ICH was associated with various comorbidities and longer operative times. This multicenter study demonstrates distinct critical time periods for the development of thrombotic and hemorrhagic events after craniotomy. Furthermore, the VTE risk profile depends on the type of VTE (DVT vs. PE) and clinical setting (hospitalized vs. post-discharge patients).

Incidence of Postoperative Hematomas Requiring Surgical Treatment in Neurosurgery: A Retrospective Observational Study

OBJECTIVE

We aimed to characterize the occurrence of postoperative hematoma (POH) after neurosurgery overall and according to procedure type and describe the prevalence of possible confounders.

METHODS

Patient data between 2010 and 2012 at the Department of Neurosurgery in Helsinki University Hospital were retrospectively analyzed. A data search was performed according to the type of surgery including craniotomies; shunt procedures, spine surgery, and spinal cord stimulator implantation. We analyzed basic preoperative characteristics, as well as data about the initial intervention, perioperative period, revision operation and neurologic recovery (after craniotomy only).

RESULTS

The overall incidence of POH requiring reoperation was 0.6% (n = 56/8783) to 0.6% (n = 26/4726) after craniotomy, 0% (n = 0/928) after shunting procedure, 1.1% (n = 30/2870) after spine surgery, and 0% (n = 0/259) after implantation of a spinal cord stimulator. Craniotomy types with higher POH incidence were decompressive craniectomy (7.9%, n = 7/89), cranioplasty (3.6%, n = 4/112), bypass surgery (1.7%, n = 1/60), and epidural hematoma evacuation (1.6%, n = 1/64). After spinal surgery, POH was observed in 1.1% of cervical and 2.1% of thoracolumbar operations, whereas 46.7% were multilevel procedures. 64.3% of patients with POH and 84.6% of patients undergoing craniotomy had postoperative hypertension (systolic blood pressure >160 mm Hg or lower if indicated). Poor outcome (Glasgow Outcome Scale score 1-3), whereas death at 6 months after craniotomy was detected in 40.9% and 21.7%. respectively, of patients with POH who underwent craniotomy.

CONCLUSIONS

POH after neurosurgery was rare in this series but was associated with poor outcome. Identification of risk factors of bleeding, and avoiding them, if possible, might decrease the incidence of POH.

Systematic Review of Safety and Cost-Effectiveness of Venous Thromboembolism Prophylaxis Strategies in Patients Undergoing Craniotomy for Brain Tumor

BACKGROUND

Studies have evaluated various strategies to prevent venous thromboembolism (VTE) in neuro-oncology patients, without consensus.

OBJECTIVE

To perform a systematic review with cost-effectiveness analysis (CEA) of various prophylaxis strategies in tumor patients undergoing craniotomy to determine the safest and most cost-effective prophylaxis regimen.

METHODS

A literature search was conducted for VTE prophylaxis in brain tumor patients. Articles reporting the type of surgery, choice of VTE prophylaxis, and outcomes were included. Safety of prophylaxis strategies was determined by measuring rates of VTE and intracranial hemorrhage. Cost estimates were collected based on institutional data and existing literature. CEA was performed at 30 d after craniotomy, comparing the following strategies: mechanical prophylaxis (MP), low molecular weight heparin with MP (MP+LMWH), and unfractionated heparin with MP (MP+UFH) to prevent symptomatic VTE. All costs were reported in 2016 US dollars.

RESULTS

A total of 34 studies were reviewed (8 studies evaluated LMWH, 12 for MP, and 7 for UFH individually or in combination; 4 studies used LMWH and UFH preoperatively). Overall probability of VTE was 1.49% (95% confidence interval (CI) 0.42-3.72) for MP+UFH, 2.72% [95% CI 1.23-5.15] for MP+LMWH, and 2.59% (95% CI 1.31-4.58) for MP, which were not statistically significant. Compared to a control of MP alone, the number needed to treat for MP+UFH is 91 and 769 for MP+LMWH. The risk of intracranial hemorrhage was 0.26% (95% CI 0.01-1.34) for MP, 0.74% (95% CI 0.09-2.61) for MP+UFH, and 2.72% (95% CI 1.23-5.15) for MP+LMWH, which were also not statistically significant. Compared to MP, the number needed to harm for MP+UFH was 208 and for MP+LMWH was 41. Fifteen studies were included in the final CEA. The estimated cost of treatment was $127.47 for MP, $142.20 for MP+UFH, and $169.40 for MP+LMWH. The average cost per quality-adjusted life-year for different strategies was $284.14 for MP+UFH, $338.39 for MP, and $722.87 for MP+LMWH.

CONCLUSION

Although MP+LMWH is frequently considered the optimal prophylaxis for VTE risk reduction, our model suggests that MP+UFH is the safest and most cost-effective measure to balance VTE and hemorrhage risks in brain tumor patients at lower risk of hemorrhage. MP+LMWH may be more effective for patients at higher risk of VTE.

Body habitus, serum albumin, and the outcomes after craniotomy for tumor: a National Surgical Quality Improvement Program analysis

OBJECTIVE

Although there is a growing body of research highlighting the negative impact of obesity and malnutrition on surgical outcomes, few studies have evaluated these parameters in patients undergoing intracranial surgery. The goal of this study was to use a national registry to evaluate the association of body mass index (BMI) and hypoalbuminemia with 30-day outcomes after craniotomy for tumor.

METHODS

Adult patients who underwent craniotomy for tumor were extracted from the prospective National Surgical Quality Improvement Program registry. Patients were stratified by body habitus according to the WHO classification, as well as by preoperative hypoalbuminemia (< 3.5 g/dl). Multivariable logistic regression evaluated the association of body habitus and hypoalbuminemia with 30-day mortality, complications, and discharge disposition. Covariates included patient age, sex, race or ethnicity, tumor histology, American Society of Anesthesiology class, preoperative functional status, comorbidities (including hypertension and diabetes mellitus), and additional preoperative laboratory values.

RESULTS

Among the 11,510 patients included, 28.7% were classified as normal weight (BMI 18.5–24.9 kg/m2), 1.9% as underweight (BMI < 18.5 kg/m2), 33.4% as overweight (BMI 25.0–29.9 kg/m2), 19.1% as Class I obese (BMI 30.0–34.9 kg/m2), 8.3% as Class II obese (BMI 35.0–39.9 kg/m2), 5.5% as Class III obese (BMI ≥ 40.0 kg/m2), and 3.1% had missing BMI data. In multivariable regression models, body habitus was not associated with differential odds of mortality, postoperative stroke or coma, or a nonroutine hospital discharge. However, the adjusted odds of a major complication were significantly higher for Class I obese (OR 1.28, 99% CI 1.01–1.62; p = 0.008), Class II obese (OR 1.53, 99% CI 1.13–2.07; p < 0.001), and Class III obese (OR 1.67, 99% CI 1.19–2.36; p < 0.001) patients compared with those of normal weight; a dose-dependent effect was seen, with increased effect size with greater adiposity. The higher odds of major complications was primarily due to significantly increased odds of a venous thromboembolism in overweight and obese patients, as well as of a surgical site infection in those with Class II or III obesity. Additionally, 41.0% of patients had an albumin level ≥ 3.5 g/dl, 9.6% had hypoalbuminemia, and 49.4% had a missing albumin value. Hypoalbuminemia was associated with significantly higher odds of mortality (OR 1.91, 95% CI 1.41–2.60; p < 0.001) or a nonroutine hospital discharge (OR 1.46, 95% CI 1.21–1.76; p < 0.001).

CONCLUSIONS

In this National Surgical Quality Improvement Program analysis evaluating patients who underwent craniotomy for tumor, body habitus was not associated with differential mortality or neurological complications. However, obese patients had increased odds of a major perioperative complication, primarily due to higher rates of venous thromboembolic events and surgical site infections. Preoperative hypoalbuminemia was associated with increased odds of mortality and a nonroutine hospital discharge, suggesting that serum albumin may have utility in stratifying risk preoperatively in patients undergoing craniotomy.

Thirty-Day Morbidity Associated with Pelvic Fixation in Adult Patients Undergoing Fusion for Spinal Deformity: A Propensity-Matched Analysis

STUDY DESIGN

Retrospective study of prospectively collected data.

OBJECTIVE

To determine if patients undergoing spinal deformity surgery with pelvic fixation are at an increased risk of morbidity.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program is a large multicenter clinical registry that prospectively collects preoperative risk factors, intraoperative variables, and 30-day postoperative morbidity and mortality outcomes from ~400 hospitals nationwide. Current Procedural Terminology codes were used to query the database between 2010 and 2014 for adults who underwent fusion for spinal deformity. Patients were separated into groups of those with and without pelvic fixation. Univariate analysis and multivariate logistic regression were used to analyze the effect of pelvic fixation on the incidence of postoperative morbidity and other surgical outcomes.

RESULTS

Multivariate analysis showed that pelvic fixation was a significant predictor of overall morbidity (odds ratio [OR] = 2.3, 95% confidence interval [CI]: 1.7 to 3.1, p = 0.0002), intra- or postoperative blood transfusion (OR = 2.3, 95% CI: 1.7 to 3.1 p < 0.0001), extended operative time (OR = 4.7, 95% CI: 3.1 to 7.0 p < 0.0001), and length of stay > 5 days (OR = 2.1, 95% CI 1.5 to 2.8, p < 0.0001) in patients undergoing fusion for spinal deformity. However, fusion to the pelvis did not lead to additional risk for other complications, including wound complications (p = 0.3191).

CONCLUSION

Adult patients undergoing spinal deformity surgery with pelvic fixation were not susceptible to increased morbidity beyond increased blood loss, greater operative time, and extended length of stay.

Readmission After Craniotomy for Tumor: A National Surgical Quality Improvement Program Analysis

BACKGROUND: Although readmission has become a common quality indicator, few national studies have examined this metric in patients undergoing cranial surgery.

OBJECTIVE: To utilize the prospective National Surgical Quality Improvement Program 2011-2013 registry to evaluate the predictors of unplanned 30-d readmission and postdischarge mortality after cranial tumor resection.

METHODS: Multivariable logistic regression was applied to screen predictors, which included patient age, sex, tumor location and histology, American Society of Anesthesiologists class, functional status, comorbidities, and complications from the index hospitalization.

RESULTS: Of the 9565 patients included, 10.7% (n = 1026) had an unplanned readmission. Independent predictors of unplanned readmission were male sex, infratentorial location, American Society of Anesthesiologists class 3 designation, dependent functional status, a bleeding disorder, and morbid obesity (all P ≤ .03). Readmission was not associated with operative time, length of hospitalization, discharge disposition, or complications from the index admission. The most common reasons for readmission were surgical site infections (17.0%), infectious complications (11.0%), venous thromboembolism (10.0%), and seizures (9.4%). The 30-d mortality rate was 3.2% (n = 367), of which the majority (69.7%, n = 223) occurred postdischarge. Independent predictors of postdischarge mortality were greater age, metastatic histology, dependent functional status, hypertension, discharge to institutional care, and postdischarge neurological or cardiopulmonary complications (all P &lt; .05).

CONCLUSION: Readmissions were common after cranial tumor resection and often attributable to new postdischarge complications rather than exacerbations of complications from the initial hospitalization. Moreover, the majority of 30-d deaths occurred after discharge from the index hospitalization. The preponderance of postdischarge mortality and complications requiring readmission highlights the importance of posthospitalization management.

Impact of operative length on post-operative complications in meningioma surgery: a NSQIP analysis

Many studies have implicated operative length as a predictor of post-operative complications, including venous thromboembolism [deep vein thrombosis (DVT) and pulmonary embolism (PE)]. We analyzed the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database from 2006 to 2014, to evaluate whether length of operation had a statistically significant effect on post-operative complications in patients undergoing surgical resection of meningioma. Patients were included for this study if they had a post-operative diagnosis of meningioma. Patient demographics, pre-operative comorbidities, and post-operative 30-day complications were analyzed. Of 3743 patients undergoing craniotomy for meningioma, 13.6 % experienced any complication. The most common complications and their median time to occurrence were urinary tract infection (2.6 %) at 10 days postoperatively (IQR 7-15), unplanned intubation (2.5 %) at 3 days (IQR 1-7), failure to wean from ventilator (2.4 %) at 2.0 days (IQR 2-4), and DVT (2.4 %) at 6 days (IQR 11-19). Postoperatively, 3.6 % developed VTE; 2.4 % developed DVT and 1.7 % developed PE. Multivariable analysis identified older age (third and upper quartile), obesity, preoperative ventilator dependence, preoperative steroid use, anemia, and longer operative time as significant risk factors for VTE. Separate multivariable logistic regression models demonstrated longer operative time as a significant risk factor for VTE, all complications, major complications, and minor complications. Meningioma resection is associated with various post-operative complications that increase patient morbidity and mortality risk. this large, multi-institutional patient sample, longer operative length was associated with increased risk for postoperative venous thromboembolisms, as well as major and minor complications.

Thirty-day readmission and reoperation after surgery for spinal tumors: a National Surgical Quality Improvement Program analysis

OBJECTIVE

The goal of this study was to use a large national registry to evaluate the 30-day cumulative incidence and predictors of adverse events, readmissions, and reoperations after surgery for primary and secondary spinal tumors.

METHODS

Data from adult patients who underwent surgery for spinal tumors (2011–2014) were extracted from the prospective National Surgical Quality Improvement Program (NSQIP) registry. Multivariable logistic regression was used to evaluate predictors of reoperation, readmission, and major complications (death, neurological, cardiopulmonary, venous thromboembolism [VTE], surgical site infection [SSI], and sepsis). Variables screened included patient age, sex, tumor location, American Society of Anesthesiologists (ASA) physical classification, preoperative functional status, comorbidities, preoperative laboratory values, case urgency, and operative time. Additional variables that were evaluated when analyzing readmission included complications during the surgical hospitalization, hospital length of stay (LOS), and discharge disposition.

RESULTS

Among the 2207 patients evaluated, 51.4% had extradural tumors, 36.4% had intradural extramedullary tumors, and 12.3% had intramedullary tumors. By spinal level, 20.7% were cervical lesions, 47.4% were thoracic lesions, 29.1% were lumbar lesions, and 2.8% were sacral lesions. Readmission occurred in 10.2% of patients at a median of 18 days (interquartile range [IQR] 12–23 days); the most common reasons for readmission were SSIs (23.7%), systemic infections (17.8%), VTE (12.7%), and CNS complications (11.9%). Predictors of readmission were comorbidities (dyspnea, hypertension, and anemia), disseminated cancer, preoperative steroid use, and an extended hospitalization. Reoperation occurred in 5.3% of patients at a median of 13 days (IQR 8–20 days) postoperatively and was associated with preoperative steroid use and ASA Class 4–5 designation. Major complications occurred in 14.4% of patients: the most common complications and their median time to occurrence were VTE (4.5%) at 9 days (IQR 4–19 days) postoperatively, SSIs (3.6%) at 18 days (IQR 14–25 days), and sepsis (2.9%) at 13 days (IQR 7–21 days). Predictors of major complications included dependent functional status, emergency case status, male sex, comorbidities (dyspnea, bleeding disorders, preoperative systemic inflammatory response syndrome, preoperative leukocytosis), and ASA Class 3–5 designation (p < 0.05). The median hospital LOS was 5 days (IQR 3–9 days), the 30-day mortality rate was 3.3%, and the median time to death was 20 days (IQR 12.5–26 days).

CONCLUSIONS

In this NSQIP analysis, 10.2% of patients undergoing surgery for spinal tumors were readmitted within 30 days, 5.3% underwent a reoperation, and 14.4% experienced a major complication. The most common complications were SSIs, systemic infections, and VTE, which often occurred late (after discharge from the surgical hospitalization). Patients were primarily readmitted for new complications that developed following discharge rather than exacerbation of complications from the surgical hospital stay. The strongest predictors of adverse events were comorbidities, preoperative steroid use, and higher ASA classification. These models can be used by surgeons to risk-stratify patients preoperatively and identify those who may benefit from increased surveillance following hospital discharge.

Silent pulmonary thromboembolism in neurosurgery patients: Report of 2 cases and literature review

BACKGROUND

The requirement of postoperative bedridden and immobilization renders neurosurgical patients with higher risk of deep vein thrombosis (DVT), then more vulnerable for pulmonary thromboembolism (PTE). But silent pulmonary thromboembolism (SPTE) can be the very early stage of any typical form of PTE, its diagnosis and management is therefore critical in neurosurgical departments. However, to date, perioperative SPTE has not been attached with enough attention.

METHODS

Here, we report 2 cases of perioperative SPTE in the Department of Neurosurgery, Peking Union Medical College Hospital, Beijing, China. Clinical data of 2 cases was collected and analyzed. Both patients were screened by quantitative D-dimer assay and lower limbs ultrasonography, while diagnoses were made according to computed tomographic pulmonary angiography (CTPA). Therapeutic medications include heparin, low molecular weight heparin, followed by long-term anticoagulation with oral warfarin. Both cases showed significantly elevated D-dimer before and after onset of SPTE. But in 1 case, ultrasonography reported negative venous thromboembolism. CTPA confirmed all diagnosis of SPTE. Repeated CTPA after anticoagulant therapy identified therapeutic efficacy. And during the follow-up period of 5 or 6 years, both patients acquired full recovery without clinical complications.

RESULTS

Significant decline of D-dimer was observed after the comprehensive management of SPTE (case 1: preop vs postop 573 vs 50 μg/L; case 2: preop vs postop 246 vs 50 μg/L). Ultrasonography was used for suspicious of DVT, while CTPA was used for confirming SPTE diagnosis.

CONCLUSION

Clinicians should be aware of the importance of early recognition of SPTE. Effective management of risk factors of hyper-coagulation state should be the key to prophylaxis. And routine monitor of D-dimer as well as regular check of lower limbs ultrasonography should be standardized and included in guidelines of neurosurgical patient management.

Length of hospital stay after craniotomy for tumor: a National Surgical Quality Improvement Program analysis

OBJECT

Although the length of hospital stay is often used as a measure of quality of care, data evaluating the predictors of extended hospital stay after craniotomy for tumor are limited. The goals of this study were to use multivariate regression to examine which preoperative characteristics and postoperative complications predict a prolonged hospital stay and to assess the impact of length of stay on unplanned hospital readmission.

METHODS

Data were extracted from the National Surgical Quality Improvement Program (NSQIP) database from 2007 to 2013. Patients who underwent craniotomy for resection of a brain tumor were included. Stratification was based on length of hospital stay, which was dichotomized by the upper quartile of the interquartile range (IQR) for the entire population. Covariates included patient age, sex, race, tumor histology, comorbidities, American Society of Anesthesiologists (ASA) class, functional status, preoperative laboratory values, preoperative neurological deficits, operative time, and postoperative complications. Multivariate logistic regression with forward prediction was used to evaluate independent predictors of extended hospitalization. Thereafter, hierarchical multivariate logistic regression assessed the impact of length of stay on unplanned readmission.

RESULTS

The study included 11,510 patients. The median hospital stay was 4 days (IQR 3-8 days), and 27.7% (n = 3185) had a hospital stay of at least 8 days. Independent predictors of extended hospital stay included age greater than 70 years (OR 1.53, 95% CI 1.28%-1.83%, p < 0.001); African American (OR 1.75, 95% CI 1.44%-2.14%, p < 0.001) and Hispanic (OR 1.68, 95% CI 1.36%-2.08%) race or ethnicity; ASA class 3 (OR 1.52, 95% CI 1.34%-1.73%) or 4-5 (OR 2.18, 95% CI 1.82%-2.62%) designation; partially (OR 1.94, 95% CI 1.61%-2.35%) or totally dependent (OR 3.30, 95% CI 1.95%-5.55%) functional status; insulin-dependent diabetes mellitus (OR 1.46, 95% CI 1.16%-1.84%); hematological comorbidities (OR 1.68, 95% CI 1.25%-2.24%); and preoperative hypoalbuminemia (OR 1.78, 95% CI 1.51%-2.09%, all p ≤ 0.009). Several postoperative complications were additional independent predictors of prolonged hospitalization including pulmonary emboli (OR 13.75, 95% CI 4.73%-39.99%), pneumonia (OR 5.40, 95% CI 2.89%-10.07%), and urinary tract infections (OR 11.87, 95% CI 7.09%-19.87%, all p < 0.001). The C-statistic of the model based on preoperative characteristics was 0.79, which increased to 0.83 after the addition of postoperative complications. A length of stay after craniotomy for tumor score was created based on preoperative factors significant in regression models, with a moderate correlation with length of stay (p = 0.43, p < 0.001). Extended hospital stay was not associated with differential odds of an unplanned hospital readmission (OR 0.97, 95% CI 0.89%-1.06%, p = 0.55).

CONCLUSIONS

In this NSQIP analysis that evaluated patients who underwent craniotomy for tumor, much of the variance in hospital stay was attributable to baseline patient characteristics, suggesting length of stay may be an imperfect proxy for quality. Additionally, longer hospitalizations were not found to be associated with differential rates of unplanned readmission.

Risk Modeling Predicts Complication Rates for Spinal Surgery

STUDY DESIGN

Retrospective review of clinical data registry.

OBJECTIVE

In the current era of quality reporting and pay for performance, neurosurgeons must develop models to identify patients at high risk of complications. We sought to identify risk factors for complications in spine surgery and to develop a score predictive of complications.

SUMMARY OF BACKGROUND DATA

We examined spinal surgeries from the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database. 22,430 cases were identified based on common procedural terminology.

METHODS

Univariate analysis followed by multivariate regression was used to identify significant factors.

RESULTS

The overall complication rate for the cohort was 9.9%. The most common complications were postoperative bleeding requiring transfusion (4.1%), nonwound infections (3.1%), and wound-related infections (2.2%). Multivariate regression analysis identified 20 factors associated with complications. Assigning 1 point for the presence of each factor a risk model was developed. The range of scores for the cohort was 0 to 13 with a median score of 4. Complication rates for a risk score of 0 to 4 was 3.7% and for scores 5 to 13 was 18.5%. The risk model robustly predicted complication rates, with complication rate of 1.2% for score of 0 (n = 412, 1.8% of total) and 63.6% and 100% for scores of 12 and 13 (n = 22 patients, 0.1% of total cohort) respectively (P < 0.001). The risk score also correlated strongly with total length of stay, mortality, and total work relative value units for the case.

CONCLUSION

Patient-specific risk factors including comorbidities are strongly associated with surgical complications, length of stay, cost of care, and mortality in spine surgery and can be used to develop risk models that are highly predictive of complications.

LEVEL OF EVIDENCE

3.