Evolution in practice: how has British neurosurgery changed in the last 10 years?

Temporal trends in neurosurgical volume and length of stay in a public healthcare system: A decade in review with a focus on the COVID-19 pandemic

Background

Over the past decade, neurosurgical interventions have experienced changes in operative frequency and postoperative length of stay (LOS), with the recent COVID-19 pandemic significantly impacting these metrics. Evaluating these trends in a tertiary National Health Service center provides insights into the impact of surgical practices and health policy on LOS and is essential for optimizing healthcare management decisions.

Methods

This was a single tertiary center retrospective case series analysis of neurosurgical procedures from 2012 to 2022. Factors including procedure type, admission urgency, and LOS were extracted from a prospectively maintained database. Six subspecialties were analyzed: Spine, Neuro-oncology, Skull base (SB), Functional, Cerebrospinal fluid (CSF), and Peripheral nerve (PN). Mann-Kendall temporal trend test and exploratory data analysis were performed.

Results

19,237 elective and day case operations were analyzed. Of the 6 sub-specialties, spine, neuro-oncology, SB, and CSF procedures all showed a significant trend toward decreasing frequency. A shift toward day case over elective procedures was evident, especially in spine (P < 0.001), SB (tau = 0.733, P = 0.0042), functional (tau = 0.156, P = 0.0016), and PN surgeries (P < 0.005). Over the last decade, decreasing LOS was observed for neuro-oncology (tau = -0.648, P = 0.0077), SB (tau = -0.382, P = 0.012), and functional operations, a trend which remained consistent during the COVID-19 pandemic (P = 0.01). Spine remained constant across the decade while PN demonstrated a trend toward increasing LOS.

Conclusion

Most subspecialties demonstrate a decreasing LOS coupled with a shift toward day case procedures, potentially attributable to improvements in surgical techniques, less invasive approaches, and increased pressure on beds. Setting up extra dedicated day case theaters could help deal with the backlog of procedures, particularly with regard to the impact of COVID-19.

Patterns and outcomes of neurosurgery in England over a five-year period: A national retrospective cohort study

BACKGROUND

Neurosurgical practice has seen major changes over several decades. There are no recent evaluations of national neurosurgical practice. The aim of this observational study was to describe neurosurgical practice in England and to use outcomes to assess and benchmark the quality of care in neurosurgery.

MATERIAL AND METHODS

This national retrospective cohort study analysed Hospital Episode Statistics (HES) data from April 2013 to March 2018 for all adult admissions with a specialty code for neurosurgery. The epidemiology of patients and RCS Charlson comorbidities were derived and procedure incidence rates per 100,000 person-years calculated. Post-operative outcomes for elective and non-elective patients included: median length of stay, the proportion of patients requiring additional inpatient neurosurgical procedures, the proportion of patients discharged to their usual address, and in-hospital mortality rates.

RESULTS

During the 5-year study period, there were 371,418 admissions to neurosurgery. The proportion of admissions involving a neurosurgical procedure was 77.3% (n = 287,077). Of these, 45% were for cranial surgery and 37% for spinal. Overall, 68.3% were elective procedures. The incidence rates of most procedures were low (<20 per 100,000 person-years). Following elective neurosurgical procedures, in-hospital mortality rates for cranial and spinal surgery were 0.5% (95% CI, 0.5-0.6) and 0.1% (95% CI, 0.04-0.1), respectively. After non-elective neurosurgery, mortality rates were 7.4% (95% CI, 7.2-7.6) and 1.3% (95% CI, 1.2-1.5) for cranial and spinal surgery, respectively. Approximately 1 in 4 patients had additional procedures following non-elective cranial surgery (24%; 95% CI, 23.6-24.3). Outcomes were highly variable across different subspecialty areas.

CONCLUSIONS

The incidence rates of neurosurgical procedures are low within England, and neurosurgical units have a high volume of non-surgical admissions. In-hospital mortality rates after elective neurosurgery are low but there may be opportunities for quality improvement programmes to improve outcomes for non-elective surgery as well as ensuring equitable access to treatment.

Current surgical practice for multi-level degenerative cervical myelopathy: Findings from an international survey of spinal surgeons

Degenerative cervical myelopathy (DCM) results from compression of the cervical spine cord as a result of age related changes in the cervical spine, and affects up to 2% of adults, leading to progressive disability. Surgical decompression is the mainstay of treatment, but there remains significant variation in surgical approaches used. This survey was conducted in order to define current practice amongst spine surgeons worldwide, as a possible prelude to further studies comparing surgical approaches.

METHODS

An electronic survey was developed and piloted by the investigators using SurveyMonkey. Collected data was categorical and is presented using summary statistics. Where applicable, statistical comparisons were made using a Chi-Squared test. The level of significance for all statistical analyses was defined as p < 0.05. All analysis, including graphs was performed using R (R Studio).

RESULTS

127 surgeons, from 30 countries completed the survey; principally UK (66, 52%) and North America (15, 12%). Respondents were predominantly Neurosurgeons by training (108, 85%) of whom 84 (75%) reported Spinal Surgery as the principal part of their practice. The majority indicated they selected their surgical procedure for multi-level DCM on a case by case basis (62, 49%). Overall, a posterior approach was more popular for multi-level DCM (74, 58%). Region, speciality or annual multi-level case load did not influence this significantly. However, there was a trend for North American surgeons to be more likely to favour a posterior approach.

CONCLUSIONS

A posterior approach was favoured and more commonly used to treat multi-level DCM, in an international cohort of surgeons. Posterior techniques including laminectomy, laminectomy and fusion or laminoplasty appeared to be equally popular.

Rapid Improvement Project: Improving Caregivers' Understanding of Safety Recommendations for Neurosurgical Devices

Supplemental Digital Content is available in the text.

There has been a proliferation in the development of indwelling neuromodulatory devices with varied safety recommendations, making it difficult for providers to remain up-to-date. This deficit presents an opportunity for significant improvement in patient safety.

Research-retreat-recovery: A potential model for organization and completion of research projects. Experience from a neurosurgery department in a developing country

Background:

In the current era of biomedical research, it is imperative that every research study at an institution is properly organized, and frequently audited to streamline efforts and maintain standards. Recently, a research retreat was organized by the Section of Neurosurgery at Aga Khan University Hospital, Karachi, Pakistan, and following that a recovery team was made with the aim of recovering “lost in translation” research projects. In the realm of our experience, the current model is being proposed as a means for organization of departmental research.

Methods:

The “research” component of the model comprised compilation of an abstract book of all research work done within the section during the last five years. The “retreat” component of the model was intended with objectives of analysis of past research and generation of fresh ideas. The “recovery” component of the model was accomplished by formation of a research recovery team with the aim of recovering unfinished, and/or unpublished research projects.

Results:

The abstract book comprised 103 abstracts: 52.4% original research studies, 12.6% review articles, and 34.9% case report/series. Only 8.7% abstracts were of basic science research whereas the remaining 91.3% were clinical research papers. Only 34% had been published in an article form in a biomedical research journal (51.4% in international journals and 48.6% in national journals); remaining papers were either in submission/preparation process or had been abandoned. As part of research recovery, 29.4% projects were recovered within 12 weeks of the retreat component.

Conclusion:

We conclude that the model of “research-retreat-recovery” is highly successful in the context of neurosurgery departments in developing countries without a proper research unit, and can result in better organization of departmental research, recovery of unfinished projects, and initiation of new research studies.

Neurosurgical research in Pakistan: trends of publication and quality of evidence

OBJECTIVE

To analyze the output and quality of neurosurgical research published from Pakistan in indexed peer reviewed journals.

METHODS

Indexed peer reviewed publications from 2003 to 2008 were searched for neurosurgical contributions from Pakistan. The retrieved articles were evaluated to analyze the trends of publication and quality of evidence.

RESULTS

Sixty-two neurosurgical research papers (10.3 per year, range 8-13) were published from Pakistan during the study period. Twenty-four (38.7%) publications were the contribution of just four primary authors; 25 (45.3%) of the publications were original research articles and 30 (48.4%) were either case reports or case series; and 38 (61.3%) of all the publications were from just three institutions in the country. Majority of publications were pertaining to neurooncology (n=23, 37.1%) and neurosurgical trauma (n=16, 25.8%). Overall, 48 (77.4%) papers were published in local indexed journals and only 14 (22.6%) in international journals. There were no basic science studies, and no papers offering level 1 or 2 evidence were published during the study period.

CONCLUSION

Neurosurgical research in Pakistan over the past six years has been unsatisfactory, both in terms of number and quality of publications. Analysis of six year publications also did not show any significant improvement in research trends.