Analysis of readmissions data among frail and non-frail patients presenting for acoustic neuroma

Endoscopic Repair of Anterior Skull Base Cerebrospinal Fluid Leaks is Successful in Frail Patients

OBJECTIVE

Surgical frailty estimates a patient's ability to withstand the physiologic stress of an intervention. There is limited data regarding the impact of frailty on endoscopic cerebrospinal fluid (CSF) leak repair.

METHODS

Patients undergoing CSF leak repair at two tertiary academic skull base programs were retrospectively reviewed. Demographic, treatment, and postoperative outcomes data were recorded. Frailty was calculated using validated indices, including the American Society of Anesthesiologists (ASA) classification, Charlson Comorbidity Index (CCI), and the Modified 5-Item Frailty Index (mFI-5). Outcomes included 30-day medical and surgical complications and readmission.

RESULTS

A total of 185 patients were included with 128 (69.2%) female patients and average age of 54 ± 14 years. The average body mass index was 34.6 ± 8.5. The most common identified etiology was idiopathic intracranial hypertension (IIH) in 64 patients (34.6%). A total of 125 patients (68%) underwent perioperative lumbar drain placement (primarily to measure intracranial pressures and diagnose IIH). Most patients were ASA class 3 (48.6%) with mean CCI 2.14 ± 2.23 and mFI-5 0.97 ± 0.90. Three patients had postoperative CSF leaks, with an overall repair success rate of 98.4%. There was no association between increased frailty and 30-day medical outcomes, surgical outcomes, or readmission (all p > 0.05).

CONCLUSIONS

Endoscopic CSF leak repair in a frail population, including lumbar drain placement and bed rest, was not associated with an increased rate of complications. Previous data suggests increased complications in open craniotomy procedures in patients with significant comorbidities. This study suggests that the endoscopic approach to CSF leak repair is well tolerated in the frail population.

LEVEL OF EVIDENCE

IV Laryngoscope, 134:2713-2717, 2024.

Frailty and postoperative outcomes in brain tumor patients: a systematic review subdivided by tumor etiology

PURPOSE

Frailty has gained prominence in neurosurgical oncology, with more studies exploring its relationship to postoperative outcomes in brain tumor patients. As this body of literature continues to grow, concisely reviewing recent developments in the field is necessary. Here we provide a systematic review of frailty in brain tumor patients subdivided by tumor type, incorporating both modern frailty indices and traditional Karnofsky Performance Status (KPS) metrics.

METHODS

Systematic literature review was performed using PRISMA guidelines. PubMed and Google Scholar were queried for articles related to frailty, KPS, and brain tumor outcomes. Only articles describing novel associations between frailty or KPS and primary intracranial tumors were included.

RESULTS

After exclusion criteria, systematic review yielded 52 publications. Amongst malignant lesions, 16 studies focused on glioblastoma. Amongst benign tumors, 13 focused on meningiomas, and 6 focused on vestibular schwannomas. Seventeen studies grouped all brain tumor patients together. Seven studies incorporated both frailty indices and KPS into their analyses. Studies correlated frailty with various postoperative outcomes, including complications and mortality.

CONCLUSION

Our review identified several patterns of overall postsurgical outcomes reporting for patients with brain tumors and frailty. To date, reviews of frailty in patients with brain tumors have been largely limited to certain frailty indices, analyzing all patients together regardless of lesion etiology. Although this technique is beneficial in providing a general overview of frailty's use for brain tumor patients, given each tumor pathology has its own unique etiology, this combined approach potentially neglects key nuances governing frailty's use and prognostic value.

The Influence of Modifiable Risk Factors on Postoperative Outcomes in Patients Receiving Surgery for Resection for Acoustic Neuroma

Acoustic neuromas are the most common tumor of the cerebellopontine angle that are associated with a number of symptoms that negatively impact a patient's quality of life. While the mainstay of treatment for these benign tumors remains microsurgical resection, there is limited research exploring how certain modifiable risk factors (MRFs) may affect the perioperative course. The purpose of this study was to investigate how MRFs including malnutrition, obesity, dyslipidemia, uncontrolled hypertension, and smoking may affect postoperative rates of readmission and nonroutine discharges. We utilized the 2016 and 2017 Healthcare Cost and Utilization Project Nationwide Readmissions Database. MRFs were queried using appropriate International Classification of Diseases, Tenth Revision (ICD-10) coding for categories including malnutrition, obesity, dyslipidemia, smoking, alcohol, and hypertension. The statistical analysis was done using RStudio (Version 1.3.959). Chi-squared tests were done to evaluate differences between categorical variables. The Mann-Whitney U-testing was utilized to evaluate for statistically significant differences in continuous data. The "Epitools" package was used to develop logistic regression models for postoperative complications and post hoc receiver operating characteristic curves were developed. Pertaining to nonroutine discharge, predictive models using malnutrition outperformed all other MRFs as well as those with no MRFs (P < .05). In the case of readmission, models using malnutrition outperformed those of obesity and smoking (P < .05). Again, an increase in predictive power is seen in models using dyslipidemia when compared to obesity, smoking, or uncontrolled hypertension. Lastly, models using no MRFs outperformed those of obesity, smoking, and uncontrolled hypertension (P < .05). This is the first study of its kind to evaluate the role of MRFs in those undergoing surgical resection of their acoustic neuroma. We concluded that certain MRFs may play a role in complicating a patient's perioperative surgical course.

Factors Influencing Personalized Management of Vestibular Schwannoma: A Systematic Review

Management of vestibular schwannoma (VS) is a complex process aimed at identifying a clinical indication for fractionated stereotactic radiotherapy (sRT) or microsurgical resection or wait and scan (WS). The aim of the review was to clarify which patient and tumor parameters may lead to different therapeutic choices, with a view to a personalized VS approach. A systematic review according to Preferred Reporting Items for Systematic Review and Meta-Analysis criteria was conducted between February and March 2022. The authors defined six parameters that seemed to influence decision-making in VS management: 1-incidental VS; 2-tumor size; 3-tumor regrowth after sRT; 4-subtotal resection; 5-patients' age; 6-symptoms. The initial search yielded 3532 articles, and finally, 812 articles were included. Through a qualitative synthesis of the included studies, management strategies were evaluated and discussed. An individualized proposal of procedures is preferable as compared to a single gold-standard approach in VS decision-making. The most significant factors that need to be considered when dealing with a VS diagnosis are age, tumor size and hearing preservation issues.

Worse cranial neurosurgical outcomes predicted by increasing frailty in patients with interhospital transfer status: Analysis of 47,736 patients from the National Surgical Quality Improvement Program (NSQIP) 2015-2019

INTRODUCTION

With limited healthcare resources and risks associated with unwarranted interhospital transfers (IHT), it is important to select patients most likely to have improved outcomes with IHT. The present study analyzed the effect of IHT and frailty on postoperative outcomes in a large database of patients who underwent cranial neurosurgical operations.

METHODS

The National Surgical Quality Improvement Program (NSQIP) database was queried for patients who underwent cranial neurosurgical procedures (2015-2019, N = 47,736). Baseline demographics, clinical characteristics, and outcome variables were compared between IHT and n-IHT patients. Univariate and multivariable analyses analyzed the effect of IHT status on postoperative outcomes and the utility of frailty (modified frailty index-5 [mFI-5] stratified into "pre-frail, "frail", and "severely frail") as a preoperative risk factor. Effect sizes from regression analyses were presented as odds ratio (OR) with associated 95% confidence intervals (95% CI).

RESULTS

Of 47,736 patients with cranial neurosurgical operations, 9612 (20.1%) were IHT. Patients with IHT were older, frailer, with a higher rate of functional dependence. In multivariable analysis adjusted for baseline covariates, IHT status was independent associated with 30-day mortality (OR: 2.0, 95% CI: 1.2-3.6), major complication (OR: 1.5, 95% CI: 1.1-2.1), extended hospital length of stay (eLOS) (OR: 3.8, 95% CI: 3.6-4.1), and non-routine discharge disposition (OR: 2.4, 95% CI: 1.8-3.2) (all p < 0.05). Within the IHT cohort, increasing frailty ("pre-frail", "frail", "severely frail") was independently associated with increasing odds of 30-day mortality (OR: 1.4, 1.9, 3.9), major complication (OR: 1.4, 1.9, 3.3), unplanned readmission (OR: 1.1, 1.4, 2.1), reoperation (OR: 1.3, 1.5, 1.9), eLOS (OR: 1.2, 1.3, 1.5), and non-routine discharge (OR: 1.4, 1.9, 4.4) (all p < 0.05). All levels of frailty were more strongly associated with postoperative outcomes than chronological age.

CONCLUSIONS

This novel analysis suggests that patients transferred for cranial neurosurgery operations are significantly more likely to have worse postoperative health outcomes. Furthermore, the analysis suggests that frailty (as measured by mFI-5) is a powerful independent predictor of outcomes in transferred cranial neurosurgery patients. The findings support the use of frailty scoring in the pre-transfer and preoperative setting for patient counseling and risk stratification.