The World of Neurosurgery: New Articles Out Now

The World of Neurosurgery: New Articles Out Now

Neurosurgeons around the world are united by their desire to help patients, especially in these unpredictable times. In the latest articles from AANS Neurosurgeon, authors share experiences of global neurosurgery and how the field has developed over time. New today:

Roger Stupp, MD; Mark Youngblood, MD, PhD

Martina Stippler, MD, FAANS; Jaini Shah

H. Hunt Batjer, MD, FAANS

Clarence B. Watridge, MD, FAANS(L)

Gail Rosseau, MD, FAANS; Walter D. Johnson, MD, FAANS(L)

Scott C. Mitchell

Gary D. VanderArk, MD, FAANS

The Search for a Biological Link between Reactivated HSV and Neurological Disease

Without even knowing it, most of us carry around latent Herpes Simplex Virus (HSV) in our nervous system—a simple result of being born and living together with others carrying the virus.

Aerobic Exercise May Treat Persistent Post-concussive Symptoms in Adults

A new study will evaluate whether persistent symptoms following concussion, also known as post-concussion syndrome, can be treated using a personalized, progressive aerobic exercise program.

Novel use of Robotics for Neuroendovascular Procedures

Surgeons at the Sidney Kimmel Medical College at Thomas Jefferson University are pioneering the use of robotics in neuroendovascular procedures, which are performed via the blood vessels of the neck and brain.

Acta Editor’s Choice! Free access as of 7 May until 18 June 2020

Acta Editor’s Choice! Free access as of 7 May until 18 June 2020

  • Neurosurgery during the COVID-19 pandemic: update from Lombardy, Northern Italy. Read more
  • The impact of COVID-19 on neurosurgeons and the strategy for triaging non-emergent operations: a global neurosurgery study. Read more
  • Letter to the editor by Dobran Mauro, Paracino Riccardo, and Iacoangeli Maurizio regarding “Neurosurgery during the COVID-19 pandemic: update from Lombardy, northern Italy.” Zoia C, Bongetta D, Veiceschi P, Cenzato M, Di Meco F, Locatelli D, Boeris D, Fontanella MM. Acta Neurochir (Wien). 2020 Mar 28. doi: 10.1007/s00701-020-04305-w. Read more
  • The response during a pandemic is a blurred vision of the future. Reflections on the Lombardy reorganization of the neurosurgical emergencies during the COVID-19. Read more
  • Our darkest hours (being neurosurgeons during the COVID-19 war). Read more
  • Long-term excess mortality after chronic subdural hematoma. Read more. Read more
  • Intermediate-term clinical and radiographic outcomes with less invasive adult spinal deformity surgery: patients with a minimum follow-up of 4 years. Read more

Neurosurgical Randomized Controlled Trial

Neurosurgical Randomized Controlled Trial

randomized controlled trial (RCT) remains the pinnacle of clinical research design. However, RCTs in neurosurgery, especially those comparing surgery to non-operative treatment, are rare and their relevance and applicability have been questioned.

From 2000 to 2017, PubMed and Embase databases and four trial registries were searched. RCTs were evaluated for study design, funding, adjustments to reported outcome measures, accrual of patients, and academic impact.

Eighty-two neurosurgical RCTs were identified, 40 in spine disorders, 19 neurovascular and neurotrauma, 11 functional neurosurgery, ten peripheral nerve, and two pituitary surgery. Eighty-four RCTs were registered, of which some are ongoing. Trial registration rate differed per subspecialty. Funding was mostly from non-industry institutions (58.5%), but 25.6% of RCTs did not report funding sources. 36.4% of RCTs did not report a difference between surgical and non-operative treatment, 3.7% favored non-operative management. Primary and secondary outcome measures were changed in 13.2% and 34.2% of RCTs respectively and varied by subspecialty. 41.9% of RCTs subtracted ≥ 10% of the anticipated accrual and 12.9% of RCTs added ≥ 10%. 7.3% of registered RCTs were terminated, mostly due to too slow recruitment. Subspecialty, registration, funding, masking, population size, and changing outcome measures were not significantly associated with a reported benefit of surgery. High Jadad scores (≥ 4) were negatively associated with a demonstration of surgical benefit (P < 0.05).

Neurosurgical RCTs comparing surgical to non-operative treatment often find a benefit for surgical treatment. Changes to outcome measurements and anticipated accrual are common and funding sources are not always reported 1).


From January 1961 to June 2016Randomized Controlled Trials (RCTs) with >5 patients assessing any 1 neurosurgical procedure against another procedure, nonsurgical treatment, or no treatment were retrieved from MEDLINEScopus, and Cochrane Library.

The median sample size in the 401 eligible RCTs was 73 patients with a mean patient age of 49.6. Only 111 trials (27.1%) described allocationconcealment, 140 (34.6%) provided power calculations, and 117 (28.9%) were adequately powered. Significant efficacy or trend for efficacy was claimed in 226 reports (56.4%), no difference between the procedures was found in 166 trials (41.4%), and significant harm was reported in 9 trials (2.2%). Trials with a larger sample size were more likely to report randomization mode, specify allocation concealment, and power calculations (all P < .001). Government funding was associated with better specification of power calculations (P = .008) and of allocation concealment (P = .026), while industry funding was associated with reporting significant efficacy (P = .02). Reporting of funding, specification of randomization mode and primary outcomes, and mention of power calculations improved significantly (all, P < .05) over time.

Several aspects of the design and reporting of RCTs on neurosurgical procedures have improved over time. Better powered and accurately reported trials are needed in neurosurgery to deliver evidence based care and achieve optimal outcomes 2).

References

1)

Martin E, Muskens IS, Senders JT, DiRisio AC, Karhade AV, Zaidi HA, Moojen WA, Peul WC, Smith TR, Broekman MLD. Randomized controlled trials comparing surgery to non-operative management in neurosurgery: a systematic review. Acta Neurochir (Wien). 2019 Feb 23. doi: 10.1007/s00701-019-03849-w. [Epub ahead of print] Review. PubMed PMID: 30798479.
2)

Azad TD, Veeravagu A, Mittal V, Esparza R, Johnson E, Ioannidis JPA, Grant GA. Neurosurgical Randomized Controlled Trials-Distance Travelled. Neurosurgery. 2018 May 1;82(5):604-612. doi: 10.1093/neuros/nyx319. PubMed PMID: 28645203.
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