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World Neurosurgery May 2018To quantitatively assess and compare the effectiveness and safety of posterior fossa decompression with duraplasty (PFDD) and posterior fossa decompression (PFD) in... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To quantitatively assess and compare the effectiveness and safety of posterior fossa decompression with duraplasty (PFDD) and posterior fossa decompression (PFD) in treating patients with Chiari malformation type I.
METHODS
PubMed, Embase, and Cochrane Library were searched through May 2017. Fourteen cohort studies comprising 3666 patients with Chiari malformation type I were included. Studies were pooled, and the relative risk (RR) and corresponding 95% confidence interval (CI) were calculated.
RESULTS
The decrease in syringomyelia was better in patients in the PFDD group than in patients in the PFD group (RR = 1.57, 95% CI = 1.07-2.32, P = 0.042, I = 56.6%). The incidence of cerebrospinal fluid leak (RR = 5.23, 95% CI = 2.61-10.51, P = 0.830, I = 0%) and aseptic meningitis (RR = 4.02, 95% CI = 1.46-11.03, P = 0.960, I = 0%) significantly increased among patients in the PFDD group compared with patients in the PFD group. When stratifying by age, a significantly reduced risk in the reoperation rate was observed in the adult group. However, the clinical improvement and the incidence of wound infection were not significantly different between the 2 groups.
CONCLUSIONS
This study confirmed that the decrease in syringomyelia was better for patients treated with PFDD than for patients treated with PFD alone. However, no significant difference was found in the clinical improvement and the reoperation rate between the 2 groups.
Topics: Arnold-Chiari Malformation; Cranial Fossa, Posterior; Decompression, Surgical; Dura Mater; Humans; Reoperation; Treatment Outcome
PubMed: 29482005
DOI: 10.1016/j.wneu.2018.02.092 -
Neurosurgical Review Nov 2023Incidental durotomies are frequent complications of spine surgery associated with cerebrospinal fluid (CSF) leak-related symptoms. Management typically involves... (Meta-Analysis)
Meta-Analysis Review
Incidental durotomies are frequent complications of spine surgery associated with cerebrospinal fluid (CSF) leak-related symptoms. Management typically involves prolonged bed rest to reduce CSF pressure at the durotomy site. However, early ambulation may be a safer, effective alternative. PubMed, Web of Science, Embase, Cochrane, and Scopus were systematically searched for studies comparing early ambulation (bed rest ≤ 24 h) with prolonged bed rest (> 24 h) for patients with incidental durotomies in spine surgeries. The outcomes of interest were CSF leak, hypotensive headache, additional surgical repair, pseudomeningocele, and pulmonary complications. Systematic reviews and meta-analysis were performed following the Cochrane Handbook for Systematic Reviews of Interventions. We included a total of 704 patients from 6 studies. There was a significant reduction in the incidence of pulmonary complications (RR 0.23; 95% CI 0.08-0.67; p = 0.007) in the early mobilization group. The incidence of CSF leak (RR 1.34; 95% CI 0.83-2.14; p = 0.23), hypotensive headache (RR 0.72; 95% CI 0.27-1.90; p = 0.50), additional repair surgery (RR 1.29; 95% CI 0.76-2.2; p = 0.35), and pseudomeningocele (RR 1.29; 95% CI 0.20-8.48; p = 0.79) did not differ significantly. In patients with incidental durotomy following spinal surgery, early mobilization was associated with a lower incidence of pulmonary complications as compared with prolonged bed rest. There was no significant difference between groups in terms of CSF leak, need for additional repair, pseudomeningocele, and hypotensive headache.
Topics: Humans; Early Ambulation; Bed Rest; Spine; Neurosurgical Procedures; Headache; Cerebrospinal Fluid Leak; Dura Mater; Postoperative Complications
PubMed: 37989906
DOI: 10.1007/s10143-023-02201-2 -
Clinical Neurology and Neurosurgery Oct 2014Posterior fossa decompression is carried out to improve passage of cerebrospinal fluid (CSF) in patients with symptomatic Chiari 1 malformations (CM1), but the extent... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Posterior fossa decompression is carried out to improve passage of cerebrospinal fluid (CSF) in patients with symptomatic Chiari 1 malformations (CM1), but the extent and means of decompression remains controversial. Dural opening with subsequent duraplasty may contribute to clinical outcome, but may also increase complication risk. The aim of this systematic review and meta-analysis is to assess the effects of durotomy with subsequent duraplasty on clinical outcome in surgical treatment of adults with CM1.
DATA SOURCES AND STUDY ELIGIBILITY CRITERIA
We systematically searched MEDLINE, Embase and CENTRAL, and screened references in relevant articles and in UpToDate. Publications with previously untreated adults (>15 years) with CM1 with or without associated syringomyelia, treated in the period 1990-2013 were eligible.
INTERVENTIONS
Posterior fossa decompression with duraplasty (PFDD group) was compared to posterior fossa decompression with bony decompression alone (PFD group).
RESULTS
The search retrieved 233 articles. After the review we included 12 articles, but only 4 articles included posterior fossa decompression with both techniques. Only 2 out of 12 studies were prospective. The odds ratio (OR) for reoperation was 0.15 (95% CI 0.05-0.49) in the PFDD group compared to PFD (p=0.002). The OR of clinical failure at follow-up was 1.06 (95% CI 0.52-2.14) for PFDD compared to PFD (p=0.88). There was also no difference in syringomyelia improvement between techniques (p=0.60). The OR for CSF-related complications were 6.12 (95% CI 0.37-101.83) for PFDD compared to PFD (p=0.21).
CONCLUSION
This systematic review of observational studies reveals higher reoperation rates after bony decompression alone, but clinical improvement was not higher after primary decompression with duraplasty. There are so far no high-quality studies that offer guidance in the choice of decompressive technique in adult CM1 patients. We think that a randomized controlled trial on this topic is both needed and feasible.
Topics: Adult; Arnold-Chiari Malformation; Decompression, Surgical; Dura Mater; Humans; Observational Studies as Topic; Postoperative Complications; Syringomyelia; Treatment Outcome
PubMed: 25087160
DOI: 10.1016/j.clineuro.2014.07.019 -
Medicine Oct 2023Chronic subdural hematoma (CSDH) is a relatively common disease, especially in the elderly, for which there is no clear standard of treatment available. The authors... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Chronic subdural hematoma (CSDH) is a relatively common disease, especially in the elderly, for which there is no clear standard of treatment available. The authors systematically evaluated the efficacy of various surgical procedures for the treatment of chronic subdural hematoma.
METHODS
Electronic databases of PubMed, EmBase, Web of Science, Medicine, and the Cochrane Library were searched systematically. Based on the PRISMA template, we finally selected and analyzed 13 eligible papers to evaluate the effect of different drainage methods on CSDH. The primary outcomes were recurrence and clinical outcomes. Secondary outcomes were mortality and postoperative complications and other parameters.
RESULTS
The meta-analysis included 3 randomized controlled trials and 10 retrospective studies (non-randomized controlled trials) involving 3619 patients. The pooled results showed no statistically significant difference between non-subdural drainage (NSD) and subdural drainage (SD) in mortality and complication rates (P > 0.05). Additionally, overall pooled results showed that the use of NSD (10.9%) has a lower recurrence rate than the use of SD (11.7%), but the results were not statistically significant (relative risk ratio [RR] = 0.98; 95% confidence interval [CI] = 0.70-1.45; I2 = 47%; P = .92). However, the difference between NSD and SD in postoperative bleeding rate reached statistical significance (RR = 2.39; 95% CI = 1.31-4.36; I2 = 0 %; P = .004). Subgroup analysis showed that SD was associated with similar recurrent CSDH (RR = 0.75; 95% CI = 0.52-1.09; I2 = 0%; P = .14), good recovery (RR = 0.98; 95% CI = 0.93-1.04; I2 = 0%; P = .50), and mortality (RR = 0.98; 95% CI = 0.37-2.57; I2 = 0%; P = .96), compared to NSD.
CONCLUSIONS
These results suggest that NSD and SD are equally effective in the treatment of patients with CSDH, with no difference in final clinical characteristics and radiologic outcomes. However, in patients with limited subdural space after evacuation of a hematoma, NSD may be the preferred strategy to avoid iatrogenic brain injury.
Topics: Humans; Aged; Subdural Space; Hematoma, Subdural, Chronic; Retrospective Studies; Neoplasm Recurrence, Local; Drainage; Periosteum; Recurrence; Treatment Outcome
PubMed: 37904357
DOI: 10.1097/MD.0000000000035731 -
Epilepsy & Behavior : E&B Feb 2019Stereoelectroencephalography (sEEG) is a diagnostic procedure for patients with refractory focal epilepsies that is performed to localize and define the epileptogenic...
Invasive EEG-electrodes in presurgical evaluation of epilepsies: Systematic analysis of implantation-, video-EEG-monitoring- and explantation-related complications, and review of literature.
INTRODUCTION
Stereoelectroencephalography (sEEG) is a diagnostic procedure for patients with refractory focal epilepsies that is performed to localize and define the epileptogenic zone. In contrast to grid electrodes, sEEG electrodes are implanted using minimal invasive operation techniques without large craniotomies. Previous studies provided good evidence that sEEG implantation is a safe and effective procedure; however, complications in asymptomatic patients after explantation may be underreported. The aim of this analysis was to systematically analyze clinical and imaging data following implantation and explantation.
RESULTS
We analyzed 18 consecutive patients (mean age: 30.5 years, range: 12-46; 61% female) undergoing invasive presurgical video-EEG monitoring via sEEG electrodes (n = 167 implanted electrodes) over a period of 2.5 years with robot-assisted implantation. There were no neurological deficits reported after implantation or explantation in any of the enrolled patients. Postimplantation imaging showed a minimal subclinical subarachnoid hemorrhage in one patient and further workup revealed a previously unknown factor VII deficiency. No injuries or status epilepticus occurred during video-EEG monitoring. In one patient, a seizure-related asymptomatic cross break of two fixation screws was found and led to revision surgery. Unspecific symptoms like headaches or low-grade fever were present in 10 of 18 (56%) patients during the first days of video-EEG monitoring and were transient. Postexplantation imaging showed asymptomatic and small bleedings close to four electrodes (2.8%).
CONCLUSION
Overall, sEEG is a safe and well-tolerated procedure. Systematic imaging after implantation and explantation helps to identify clinically silent complications of sEEG. In the literature, complication rates of up to 4.4% in sEEG and in 49.9% of subdural EEG are reported; however, systematic imaging after explantation was not performed throughout the studies, which may have led to underreporting of associated complications.
Topics: Adolescent; Adult; Child; Drug Resistant Epilepsy; Electrodes, Implanted; Electroencephalography; Female; Humans; Male; Middle Aged; Minimally Invasive Surgical Procedures; Postoperative Complications; Preoperative Care; Retrospective Studies; Seizures; Stereotaxic Techniques; Subdural Space; Video-Assisted Surgery; Young Adult
PubMed: 29907526
DOI: 10.1016/j.yebeh.2018.05.012 -
Neurosurgical Review Apr 2012The cavernous sinus (CS) has one of the most complex anatomical networks of the skull base and because of the diversity of its contents is involved in many pathological... (Review)
Review
The cavernous sinus (CS) has one of the most complex anatomical networks of the skull base and because of the diversity of its contents is involved in many pathological processes. Nevertheless, anatomical literature concerning the CS is still controversial, so a systematic literature review was performed to find out the microanatomy of the medial wall of the CS and its clinical importance on sellar pathologies. Experimental studies from English-language literature between 1996 and 2010 were identified in MEDLINE, LILACS, and Cochrane databases. After analysis, two tables were prepared exhibiting the major points of each article. Fourteen experimental studies were included in the tables. Four studies concluded that the medial wall of the CS is composed of a loose, fibrous structure, and the remaining ten presumed that the medial wall is formed by a dural layer that constitutes the lateral wall of the sella. The lack of definition standards and of methodological criteria led to variation in the results among different studies. Thus, this hindered results comparison, possibly explaining the different observations.
Topics: Cavernous Sinus; Dura Mater; Humans; Pituitary Gland; Reference Values; Sella Turcica
PubMed: 22009493
DOI: 10.1007/s10143-011-0360-3 -
World Neurosurgery Oct 2018Cerebrospinal fluid (CSF) leakage is one of the most challenging complications in neurosurgery. We sought to evaluate the efficacy of dural sealants in preventing CSF... (Review)
Review
OBJECTIVE
Cerebrospinal fluid (CSF) leakage is one of the most challenging complications in neurosurgery. We sought to evaluate the efficacy of dural sealants in preventing CSF leakage after cranial surgery.
METHODS
A literature search was performed in the PubMed, Embase, and Cochrane databases. The inclusion criteria were defined to include articles describing regular cranial procedures combined with the use of any dural sealant reporting CSF leakage. The primary outcome was CSF leakage (pseudomeningocele formation or incisional CSF leakage), secondary outcomes were pseudomeningocele formation, incisional CSF leakage, and surgical-site infection.
RESULTS
Twenty articles were included. Ten of these were comparative studies (sealant vs. no sealant) including 3 randomized controlled trials. In the 20 articles, a total of 3682 surgical procedures were reported. The number of CSF leakages in general did not differ between the sealant group (8.2%) and control group (8.4%), risk ratio (RR) 0.84 (0.50-1.42), I = 56%. Exclusion of non-randomized controlled trials did not alter the results. Meta-analyses for secondary outcomes showed no difference between number of incisional CSF leakage, RR 0.30 (0.05-1.59), I = 38%. Also, no difference was found in the pseudomeningocele formation, RR 1.50 (0.43-5.17), I = 0%. Surgical-site infection was seen less in the sealant group (1.0%) compared with the control group (5.6%), RR 0.25 (0.13-0.48), I = 0%.
CONCLUSIONS
This systematic review showed that dural sealants did not reduce the number of CSF leaks in general, the number of incisional CSF leaks alone, or the number of pseudomeningocele formations alone. However, dural sealants reduced the risk of surgical-site infection.
Topics: Cerebrospinal Fluid Leak; Craniotomy; Dura Mater; Fibrin Tissue Adhesive; Humans; Neurosurgical Procedures; Postoperative Complications; Prospective Studies; Randomized Controlled Trials as Topic; Retrospective Studies; Treatment Outcome
PubMed: 29969744
DOI: 10.1016/j.wneu.2018.06.196 -
Epilepsia May 2013Implantation of subdural grids and invasive electroencephalography (EEG) monitoring is important to define the ictal-onset zone and eloquent cortex in selected patients... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
Implantation of subdural grids and invasive electroencephalography (EEG) monitoring is important to define the ictal-onset zone and eloquent cortex in selected patients with medically refractory epilepsy. The objective of this systematic review is to summarize data about adverse events related to this procedure.
METHODS
English-language studies published up to July 2012, reporting such adverse events were reviewed. Outcome measures included demographic variables; surgical protocol including number of subdural electrodes implanted per patient, duration of monitoring, antibiotic, and steroid prophylaxis; and adverse events.
KEY FINDINGS
Twenty-one studies were identified including a total of 2,542 patients. The reported mean number of electrodes per patient and duration of monitoring varied from 52 to 95 and 5 to 17 days, respectively. There is a trend toward more uniform use of antibiotics and steroids in the perioperative period. Neurologic infections (pooled prevalence 2.3%, 95% confidence interval 1.5-3.1), superficial infections (3.0%, 1.9-4.1), intracranial hemorrhage (4.0%, 3.2-4.8), and elevated intracranial pressure (2.4%, 1.5-3.3) were found to be the most common adverse events. Up to 3.5% of patients required additional surgical procedure(s) for management of these adverse events. Increased number of electrodes (≥67) was found to be independently associated with increased incidence of adverse events.
SIGNIFICANCE
Although providing critical information for patients with medically refractory epilepsy, subdural grids implantation and invasive EEG monitoring entails risks of infection, hemorrhage, and elevated intracranial pressure. The prevalence estimates, likely to be conservative due to selective reporting, are expected to be helpful in counseling patients.
Topics: Databases, Factual; Electroencephalography; Epilepsy; Female; Humans; Magnetic Resonance Imaging; Male; Monitoring, Physiologic; Postoperative Complications; Subdural Space; Time Factors
PubMed: 23294329
DOI: 10.1111/epi.12073 -
British Journal of Anaesthesia Sep 2010No clear consensus exists on how to best prevent severe headache from occurring after accidental dural puncture. We conducted a quantitative systematic review to... (Meta-Analysis)
Meta-Analysis Review
No clear consensus exists on how to best prevent severe headache from occurring after accidental dural puncture. We conducted a quantitative systematic review to identify all available evidence for the prevention of postdural puncture headache (PDPH) and included 17 studies with 1264 patients investigating prophylactic epidural blood patch (PEBP), epidural morphine, intrathecal catheters, and epidural or intrathecal saline. The relative risk (RR) for headache after PEBP was 0.48 [95% confidence interval (CI): 0.23-0.99] in five non-randomized controlled trials (non-RCTs) and 0.32 (0.10-1.03) in four randomized controlled trials (RCTs). The RR for epidural morphine (based on a single RCT) was 0.25 (0.08-0.78). All other interventions were based on non-RCTs and failed statistical significance, including long-term intrathecal catheters with an RR of 0.21 (0.02-2.65). There are a number of promising options to prevent PDPH, yet heterogeneity between the studies and publication bias towards small non-RCTs with positive results limits the available evidence. Thus, a large multicentre RCT is needed to determine the best preventative practices.
Topics: Analgesics, Opioid; Anesthesia, Epidural; Blood Patch, Epidural; Catheterization, Peripheral; Dura Mater; Humans; Morphine; Post-Dural Puncture Headache; Sodium Chloride
PubMed: 20682567
DOI: 10.1093/bja/aeq191 -
Minerva Anestesiologica Oct 2013Accidental dural puncture (ADP) after epidural analgesia (EDA) for labor pain may cause severe postdural puncture headache (PDPH) and may prolong hospital stay. We aimed... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Accidental dural puncture (ADP) after epidural analgesia (EDA) for labor pain may cause severe postdural puncture headache (PDPH) and may prolong hospital stay. We aimed to identify techniques that reduce the incidence of ADP.
METHODS
A systematic literature search was performed. Data on the occurrence of ADP and PDPH were extracted and subjected to meta-analysis. The random effects model was applied. Risk ratios (RR) and 95% confidence intervals (CI) were calculated.
RESULTS
We identified 54 articles, 13 non-randomized controlled trials and 41 randomized controlled trials (RCTs), reporting on a total of 98,869 patients. In non-RCTs, the use of liquid for the identification of the epidural space was associated with a reduced risk of ADP compared to the use of air (RR 0.55, 95% CI 0.39 to 0.79, P=0.001). In our analysis of RCTs this comparison did not produce a significant difference. No effect was found for combined spinal-epidural analgesia, maternal position, type of the catheter, needle size, bevel direction, operator experience, or use of ultrasound.
CONCLUSION
A reduction of the risk of ADP was found for liquid use for the loss of resistance, but only in lower quality studies. Based on current evidence, we cannot make a recommendation regarding any of the techniques under study. Therefore, clinicians should focus on measures to prevent or treat PDPH once ADP has occurred.
Topics: Adult; Analgesia, Epidural; Analgesia, Obstetrical; Clinical Trials as Topic; Dura Mater; Female; Humans; Intraoperative Complications; Post-Dural Puncture Headache; Pregnancy; Randomized Controlled Trials as Topic; Retrospective Studies
PubMed: 23857441
DOI: No ID Found