Anshit Goyal

Operative Approaches for Lumbar Disc Herniation: A Systematic Review and Multiple Treatment Meta-Analysis of Conventional and Minimally Invasive Surgeries

BACKGROUNDnMinimally invasive surgery (MIS) techniques have emerged as viable and safe alternatives for lumbar disc herniation, including percutaneous discectomy, percutaneous endoscopic discectomy, and tubulardiscectomy (TD). We present here a systematic review and a multiple-treatment meta-analysis evaluating the operative outcomes and patient-reported outcomes of open/microdiscectomy (OD/MD) and all MIS approaches for lumbar disc herniation.nnnMETHODSnThe PICO approach and PRISMA (i.e., Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed to query existing online databases since their inception to 2016, which yielded 14 studies after we applied the inclusion/exclusion criteria. The Cochrane Collaborations tool for assessing risk of bias in randomized trials was used to assess the risk of bias in each study was used to assess the risk of bias in each study. Each outcome was assessed across all studies with the GRADE (i.e., Grading of Recommendations, Assessment, Development and Evaluations) criteria.nnnRESULTSnThere were 1707 patients analyzed, with 782 (45.81%) undergoing OD/MD, 491 (28.76%) undergoing TD, 199 (11.65%) undergoing percutaneous endoscopic discectomy, and 235 (13.76%) patients undergoing percutaneous discectomy. TD was found to be associated with significantly worse Oswestry Disability Index scores (mean difference 1.17, Pxa0= 0.03) whereas OD/MD was associated with worse Oswestry Disability Index scores compared with all other approaches (mean difference 2.61, Pxa0= 0.03), significantly longer duration of stay (mean difference 2.96, Pxa0= 0.04), and more blood loss (mean difference 30.53, P < 0.001). In terms of complications, TD was found to be associated with a greater rate of overall complications (odds ratio [OR] 1.49, Pxa0= 0.002), greater incidence of dural tears (OR 1.72 Pxa0= 0.04), and recurrent herniation (OR 2.09, Pxa0= 0.0007). Finally, OD/MD was associated with significantly lower incidence of revision surgery (OR 0.53, Pxa0= 0.0007).nnnCONCLUSIONSnOur meta-analysis revealed that tubular-discectomy and percutaneous-endoscopic-discectomy, the most commonly employed MIS techniques for discectomy, can be used as safe alternatives for open discectomy depending on the preference of the operating surgeon.

Surgical Treatment of Intramedullary Spinal Metastasis in Medulloblastoma: Case Report and Review of the Literature

BACKGROUNDnMedulloblastomas are common childhood central nervous system tumors that are prone to leptomeningeal spread. Intramedullary dissemination is rare with very few case reports existing in the available literature.nnnCASE DESCRIPTIONnThe authors here present a case of a 14-year-old boy with Li-Fraumeni syndrome and medulloblastoma who underwent surgical resection of spinal intramedullary spread. Histopathology revealed the tumor to be anaplastic medulloblastoma, same as the intracranial lesions. Genetic testing of the metastatic deposit revealed loss of functions mutations in SUFU, NOTCH3, and TP53 and TERC amplification. An improvement in ambulatory function at short-term follow-up was noted before the patient died of disseminated disease.nnnCONCLUSIONSnIntramedullary metastasis of medulloblastoma remains a rare disease. Surgical resection might play a possible role in management in addition to radiation and chemotherapy.

Glossopharyngeal Neuralgia Treatment Outcomes After Nerve Section, Microvascular Decompression, or Stereotactic Radiosurgery: A Systematic Review and Meta-Analysis

BACKGROUNDnGlossopharyngeal neuralgia (GPN) is a rare neuralgic pain syndrome amenable to neurosurgical treatments, including nerve section (NS), microvascular decompression (MVD), and stereotactic radiosurgery (SRS). However, thorough comparisons of the modalities have not been performed to date. The objective of the present study was to compare the pain and complication outcomes after these approaches to GPN.nnnMETHODSnSearches of 7 electronic databases from inception to June 2018 were conducted following the appropriate guidelines. The incidence rates (IRs) of short-term (≤3 months) and long-term (≥12 months) pain relief and complications were extracted and analyzed using a meta-analysis. Meta-regression was used to assess for heterogeneity.nnnRESULTSnA total of 792 GPN cases managed by NS, MVD, or SRS were described by 6, 11, and 6 studies, reporting outcomes for 282 (36%), 446 (56%), and 67 (8%) cases. The short-term pain relief rate was highest after NS postoperatively (IR, 94%; 95% confidence interval [CI], 88%-98%) and lowest after SRS at 3 months postoperatively (IR, 80%; 95% CI, 68%-96%). The postoperative complication rate was greatest after MVD (IR, 26%; 95% CI, 16%-38%) and lowest after SRS (IR, 0%; 95% CI, 0%-4%). The long-term pain relief rate was greatest after NS (IR, 96%; 95% CI, 91%-99%) and lowest after SRS (IR, 82%; 95% CI, 67%-94%). Statistically significant differences between the approaches were found for each outcome.nnnCONCLUSIONnNeurosurgical treatment of GPN is frequently performed by 1 of 3 modalities with unique outcomes profiles. NS might provide the most favorable treatment response, with respect to short- and long-term pain relief and postoperative outcomes.

The Potential of Minimally Invasive Surgery to Treat Metastatic Spinal Disease versus Open Surgery: A Systematic Review and Meta-Analysis

BACKGROUND AND OBJECTIVEnMetastasis to the spinal column is a common feature of primary tumors of the breast, prostate, lung, and other organs. Surgical intervention can be performed via the traditional open surgery (OS) approach or the minimally invasive surgery (MIS) approach. This study aims to assess the available evidence of perioperative outcomes of MIS versus OS for patients with metastatic spinal disease.nnnMETHODSnWe followed recommended PRISMA guidelines for systematic reviews. Six electronic databases were searched to identify all potentially relevant studies published from inception to October 2017. Data were extracted and analyzed using meta-analysis of proportions.nnnRESULTSnSix studies satisfied the criteria for inclusion into this study. There were 292 patients with metastatic spinal disease described in the cohort, treated with either MIS (nxa0= 155, 53%) or OS (nxa0= 137, 47%). Compared with OS, MIS resulted in statistically significant reduction in blood loss (mean difference,xa0-601.48 mL; P < 0.001) and length of stay (mean difference,xa0-4.60 days; Pxa0= 0.002). In terms of complications, MIS had a significantly reduced incidence compared with OS (21/155 [14%] and 37/136 [27%], respectively; odds ratio, 0.41; Pxa0= 0.005). In terms of operation duration (Pxa0= 0.43), postoperative functional (Pxa0= 0.76) and pain (Pxa0= 0.84) outcomes, MIS was noninferior to OS.nnnCONCLUSIONSnSurgical intervention by an MIS approach in patients with metastatic spinal disease seems to provide equivalent outcomes compared with OS and reduces morbidity and length of stay. Future studies that are larger, prospective, and longer-term will validate the findings of this study and elucidate the optimal role for MIS in the surgical management of metastatic spinal disease.

Olfactory groove and tuberculum sellae meningioma resection by endoscopic endonasal approach versus transcranial approach: A systematic review and meta-analysis of comparative studies

Intracranial meningiomas such as olfactory groove meningioma (OGM) and tuberculum sellae meningioma (TSM) arising at the anterior skull base are amenable to surgical resection. Traditionally, this has been achieved by transcranial approaches (TCAs), however, there has been an evolution in an endoscopic endonasal approach (EEA) within recent years. The aim of this systematic review and meta-analysis was to determine if the EEA was superior to the TCA in managing these anterior skull base meningioma based on comparative studies only, and highlight the limitations of the current literature. Searches of seven electronic databases from inception to April 2018 were conducted following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. There were 1479 articles identified for screening. Data were extracted and analyzed using meta-analysis of proportions. A total of 10 comparative studies satisfied criteria for inclusions. Resection by the EEA resulted in significantly less likelihood of worse vision (OR, 0.318; pu2009=u20090.039) when compared to TCA in OGM. However, EEA resulted also in significantly greater likelihoods of olfactory loss in OGM (OR, 4.511; pu2009=u20090.038) and TSM (OR, 3.075; pu2009=u20090.017), and CSF leak (OR, 3.854; pu2009=u20090.013) in TSM. In terms of surgical and prognosis outcomes, there was no statistically significant trend in favor of either approach in OGM or TSM. The EEA appears to confer a different postoperative complication profile when compared to the TCA in resecting OGM vs TSM which validates previous case-series comparisons. There is a need for longer-term studies that are larger, prospective, randomized in order to fully elucidate efficacy given slow tendency for progression of meningioma in order to develop a more rigorous approach selection algorithm.

The impact of hyperglycemia on survival in glioblastoma: A systematic review and meta-analysis

In the management of glioblastoma (GBM), there is a considerable predisposition to hyperglycemia due to significant integration of corticosteroid therapy to treat predictable clinical sequelae following diagnosis and treatment. The aim of this study was to quantify effect of hyperglycemia during the management of GBM on overall survival (OS). Searches of seven electronic databases from inception to January 2018 were conducted following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. There were 1475 articles identified for screening. Prognostic hazard ratios (HRs) derived from multivariate regression analysis were extracted, and analyzed using meta-analysis of proportions and linear regression. Six observational studies reporting prognostic HRs in 10 cohorts were included. They described 1481 GBM diagnoses, all surveyed for hyperglycemia during management. Hyperglycemia was found to confer a statistically significant poorer OS outcome (HR, 1.671; pu202f<u202f0.001). This trend and its significance was not modified by study year, size or proportion of pre-diagnostic diabetes mellitus. Hyperglycemia in GBM is an independent poor prognostic factor for OS. Heterogeneity in clinical course limits inter-study comparability. Future, prospective, randomized studies will validate the findings of this study, and ascertain the potential benefit of more rigorous monitoring for hyperglycemia and glycemic control.

Outcomes following minimally invasive lateral transpsoas interbody fusion for degenerative low grade lumbar spondylolisthesis: A systematic review

A variety of surgical approaches have been described to treat low grade lumbar degenerative spondylolisthesis (DS). Minimally invasive spinal fusion techniques were first introduced to minimize morbidities associated with invasive surgical treatments. Minimally invasive lateral transpsoas interbody fusion, also known as lateral lumbar interbody fusion (LLIF), is a relatively new method of lumbar arthrodesis that avoids various approach related complications compared to its posterior and anterior counterparts. A systematic and critical review of recent literature was conducted in accordance with PRISMA guidelines. The sources of the data were PubMed, MEDLINE, Embase, Cochrane and Scopus. Key search terms were transpsoas, interbody fusion, LLIF, XLIF and spondylolisthesis. Papers included in the review were original research articles in peer-reviewed journals. The articles were thoroughly examined and compared on the basis of study design, outcomes, and results. Only studies which met the eligibility criteria were included. Eight studies were included in the qualitative and quantitative analysis (three retrospective, four prospective, one randomized controlled trial). A total of 308 patients (227 females) (pooled age 64.5 years) and a total of 353 operated levels were analyzed. Mean follow up time ranged from 6.2 to 24 months. There were no reported cases of durotomies or pseudarthrosis in any study. All neurologic complications were reported to be transient with no permanent deficits. Mean improvement in ODI scores ranged between 19.5 (38.6%) to 36 (54.5%). Mean improvement in slip ranged from 47 to 67.5%. Three studies also reported that patient satisfaction and willingness to undergo the procedure again approached 90%. Minimally invasive transpsoas interbody fusion possibly leads to favorable clinical and radiological outcomes while avoiding the possible complications of its more traditional open and minimally invasive counterparts. Further studies are needed to better establish its role in the management of low grade degenerative lumbar spondylolisthesis.

Endoscopic versus open approach in craniosynostosis repair: a systematic review and meta-analysis of perioperative outcomes

IntroductionSurgery for craniosynostosis remains a crucial element in successful management. Intervention by both endoscopic and open approaches has been proven effective. Given the differences in timing and indications for these procedures, differences in perioperative outcomes have yet to be thoroughly compared between the two approaches. The aim of the systematic review and meta-analysis was to assess the available evidence of perioperative outcomes between the two approaches in order to better influence the management paradigm of craniosynostosis.MethodsWe followed recommended PRISMA guidelines for systematic reviews. Seven electronic databases were searched to identify all potentially relevant studies published from inception to February 2018 which were then screened against a set of selection criteria. Data were extracted and analyzed using meta-analysis of proportions.ResultsTwelve studies satisfied all the selection criteria to be included, which described a pooled cohort involving 2064 craniosynostosis patients, with 965 (47%) and 1099 (53%) patients undergoing surgery by endoscopic and open approaches respectively. When compared to the open approach, it was found that the endoscopic approach conferred statistically significant reductions in blood loss (MDu2009=u2009162.4xa0mL), operative time (MDu2009=u2009112.38xa0min), length of stay (MDu2009=u20092.56xa0days), and rates of perioperative complications (ORu2009=u20090.58), reoperation (ORu2009=u20090.37) and transfusion (ORu2009=u20090.09), where all pu2009<u20090.001.ConclusionBoth endoscopic and open approaches for the surgical management of craniosynostosis are viable considerations. The endoscopic approach confers a significant reduction in operative and postoperative morbidity when compared to the open approach. Given that specific indications for either approach should be considered when managing a patient, the difference in perioperative outcomes remain an important element of this paradigm. Future studies will validate the findings of this study and consider long-term outcomes, which will all contribute to rigor of craniosynostosis management.