BACKGROUND:The EMBOLISE trial (The Embolization of the Middle Meningeal Artery With Onyx Liquid Embolic System in the Treatment of Subacute and Chronic Subdural Hematoma) demonstrated that middle meningeal artery embolization as an adjunct to surgical drainage reduces recurrence of symptomatic subacute and chronic subdural hematomas. We performed a subgroup analysis of the EMBOLISE surgical cohort to determine how the timing of embolization relative to surgery impacted various outcomes. METHODS:We performed a post hoc subgroup analysis to examine the association of the timing of embolization relative to surgery with the primary end point (hematoma reoperation within 90 days), secondary end points (clinical and radiographic outcomes), and safety end points (serious adverse events, neurological death, all-cause death, and stroke). RESULTS:Middle meningeal artery embolization before surgery (embolization-first group) and middle meningeal artery embolization after surgery (surgery-first group) were performed in 107 and 78 patients, respectively. Demographics and baseline clinical characteristics of the 2 groups were similar. The core laboratory confirmed the procedure to be successful in all patients with similar rates of distal penetration of Onyx into middle meningeal artery branches at the end of the embolization procedure in both groups (49.5% and 48.7%, respectively, P>0.99). Six of 103 patients in the embolization-first group (5.8%) and none in the surgery-first group needed reoperation within 90 days (analysis with observed data, P=0.08). Hematoma volumes at 90 and 180 days were similar except for lower hematoma thickness in the surgery-first group (2.3±3.0 mm versus 4.4±5.6 mm, P=0.03) at 180 days. Clinical and safety outcomes at 30, 90, and 180 days were similar. CONCLUSIONS:Performing surgical drainage before embolization in patients with subacute and chronic subdural hematomas may help minimize treatment failures and enhance hematoma resolution. REGISTRATION:URL: https://www.clinicaltrials.gov; Unique identifier: NCT04402632.

Background Chronic subdural hematomas (cSDHs) are associated with high recurrence risks following surgical evacuation. The EMBOLISE trial demonstrated that, compared with surgery alone, adjunctive middle meningeal artery embolization (MMAE) significantly reduced reoperation rates. However, given the limitations of the clinical end points of the trial, which may be subject to interrater variability and certain biases, the quantitative imaging metrics need to be evaluated. Purpose To evaluate the prespecified imaging end points of the EMBOLISE trial and assess the long-term resolution of cSDH through quantitative imaging analyses. Materials and Methods EMBOLISE was a multicenter, randomized, interventional trial conducted across 39 U.S. sites between December 2020 and August 2023. Prespecified secondary imaging end points included changes in hematoma volume and thickness and midline shifts from 24 hours to 90 days after the procedure at CT and MRI. The post hoc analyses performed herein extended the assessment to 180 days and included absolute hematoma metrics. Mixed-effects modeling was employed to adjust for confounders. Results Four hundred patients were enrolled in the EMBOLISE study, among whom 352 were included (mean age, 72 years ± 10.4 [SD]; 256 men). The mean cSDH volume was 126 mL at screening, with no intergroup differences. At 90 and 180 days, the MMAE plus surgery group had lower cSDH volumes (20.6 mL vs 28.9 mL [P = .03] and 19.4 mL vs 31.5 mL [P = .04], respectively). Mixed-effects models revealed a 6.9 mL (95% CI: -13.5, -0.40; approximately 25%) greater volume reduction and an 8.4 mL (95% CI: -15.2, -1.6; approximately 30%) lower absolute volume at 90 days in the MMAE group There was no evidence of a difference in the prespecified secondary imaging end points between the groups. Conclusion While the prespecified secondary imaging end points did not significantly differ, the absolute 90- and 180-day hematoma volumes were significantly lower in patients who received MMAE and surgery. Confounder-adjusted mixed-effects analysis indicated a greater reduction in hematoma volume with adjunctive MMAE. ClinicalTrials.gov identifier NCT04402632 © RSNA, 2026 Supplemental material is available for this article. See also the editorial by Ramasamy and Baker in this issue.

BACKGROUND:Randomized clinical trials have demonstrated that middle meningeal artery embolization (MMAe) reduces reoperation rates in surgically treated patients with subacute/chronic subdural hematoma (SDH). The effect of embolization on outcomes beyond reoperation remains to be determined. We analyzed the impact of reoperation and healthcare encounters among patients enrolled in the EMBOLISE trial. METHODS:Symptomatic subacute/chronic SDH patients were randomized to surgical evacuation alone (control) or surgical evacuation plus Onyx MMAe (treatment). Changes in modified Rankin Scale (mRS) scores, frequency of unscheduled follow-up visits, and radiographic evolution of hematomas in patients with versus without reoperation were analyzed. RESULTS:A total of 197 patients were randomly assigned to the treatment group and 203 to the control group. Patients who required reoperation compared with those who did not exhibited a ~threefold higher incidence of mRS >2 (37.0% vs 12.9%, P=0.0025) and an ~2.5 fold increase in mRS worsening (22.2% vs 9.5%, P=0.0503) at 180 days. In patients who did not receive MMAe, there was a ~threefold fold increase in rate of SDH recurrence/progression even among those who did not require reoperation (14.3% vs 5.3%, P=0.0045) and a ~twofold increase in unscheduled physician follow-up visits (27.1% vs 14.7%, P=0.0031). CONCLUSION:Among patients with symptomatic subacute/chronic SDH, reoperation was associated with increased rates of mRS worsening and higher mRS scores at follow-up. Adjunctive Onyx MMAe resulted in lower rates of hematoma recurrence/progression and fewer unscheduled physician follow-up visits. Thus, in addition to reducing surgical reoperation rates, adjunctive MMAe led to improved clinical outcomes and reduced healthcare encounters.

BackgroundCarotid endarterectomy (CEA) is one of the most effective operations in minimizing stroke risk in both symptomatic and asymptomatic patients with carotid stenosis in the United States. Awake CEA with regional anesthesia may decrease both perioperative complications and length of hospital stay. Techniques of performing awake CEA is not often described in published literature.ObjectiveTo describe our experience with CEA using regional anesthesia with a focus on patient selection, anatomic variations, and surgical technique including cervical regional block. We particularly focus on nuances of the awake approach.MethodsCEA using regional anesthesia is described in detail.ResultsSuccessful use of regional anesthesia during CEA without complication.ConclusionRegional anesthesia for CEA is an advantageous approach for cervical plaque removal in appropriate patients. Thoughtful patient selection, as well as understanding of anatomy and its variants, is required. Potential advantages and disadvantages are discussed.

Background Subacute and chronic subdural hematomas are common and frequently recur after surgical evacuation. The effect of adjunctive middle meningeal artery embolization on the risk of reoperation remains unclear. Methods In a prospective, multicenter, interventional, adaptive-design trial, we randomly assigned patients with symptomatic subacute or chronic subdural hematoma with an indication for surgical evacuation to undergo middle meningeal artery embolization plus surgery (treatment group) or surgery alone (control group). The primary end point was hematoma recurrence or progression that led to repeat surgery within 90 days after the index treatment. The clinical secondary end point was deterioration of neurologic function at 90 days, which was assessed with the modified Rankin scale in a noninferiority analysis (margin for risk difference, 15 percentage points). Results A total of 197 patients were randomly assigned to the treatment group and 203 to the control group. Surgery occurred before randomization in 136 of 400 patients (34.0%). Hematoma recurrence or progression leading to repeat surgery occurred in 8 patients (4.1%) in the treatment group, as compared with 23 patients (11.3%) in the control group (relative risk, 0.36; 95% confidence interval [CI], 0.11 to 0.80; P=0.008). Functional deterioration occurred in 11.9% of the patients in the treatment group and in 9.8% of those in the control group (risk difference, 2.1 percentage points; 95% CI, -4.8 to 8.9). Mortality at 90 days was 5.1% in the treatment group and 3.0% in the control group. By 30 days, serious adverse events related to the embolization procedure had occurred in 4 patients (2.0%) in the treatment group, including disabling stroke in 2 patients; no additional events had occurred by 180 days. Conclusions Among patients with symptomatic subacute or chronic subdural hematoma with an indication for surgical evacuation, middle meningeal artery embolization plus surgery was associated with a lower risk of hematoma recurrence or progression leading to reoperation than surgery alone. Further study is needed to evaluate the safety of middle meningeal artery embolization in the management of subdural hematoma. (Funded by Medtronic; EMBOLISE ClinicalTrials.gov number, NCT04402632.) Adjunctive Embolization for Subdural Hematoma In patients with subdural hematoma and an indication for surgical evacuation, middle meningeal artery embolization plus surgery led to a lower risk of reoperation for recurrence or progression within 90 days than surgery alone.

"Time trend analysis of database and registry use in the neurosurgical literature: evidence for the advance of registry science" published on 17 Dec 2021 by American Association of Neurological Surgeons.

OBJECTIVE:Neurosurgeons generate an enormous amount of data daily. Within these data lie rigorous, valid, and reproducible evidence. Such evidence can facilitate healthcare reform and improve quality of care. To measure the quality of care provided objectively, evaluating the safety and efficacy of clinical activities should occur in real time. Registries must be constructed and collected data analyzed with the precision akin to that of randomized clinical trials to accomplish this goal. METHODS:The Quality Outcomes Database (QOD) Tumor Registry was launched in February 2019 with 8 sites in its initial 1-year pilot phase. The Tumor Registry was proposed by the AANS/CNS Tumor Section and approved by the QOD Scientific Committee in the fall of 2018. The initial pilot phase aimed to assess the feasibility of collecting outcomes data from 8 academic practices across the United States; these outcomes included length of stay, discharge disposition, and inpatient complications. RESULTS:As of November 2019, 923 eligible patients have been entered, with the following subsets: intracranial metastasis (17.3%, n = 160), high-grade glioma (18.5%, n = 171), low-grade glioma (6%, n = 55), meningioma (20%, n = 184), pituitary tumor (14.3%, n = 132), and other intracranial tumor (24%, n = 221). CONCLUSIONS:The authors have demonstrated here, as a pilot study, the feasibility of documenting demographic, clinical, operative, and patient-reported outcome characteristics longitudinally for 6 common intracranial tumor types.

OBJECTIVE The development of new treatment approaches for degenerative lumbar spondylolisthesis (DLS) has introduced many questions about comparative effectiveness and long-term outcomes. Patient registries collect robust, longitudinal data that could be combined or aggregated to form a national and potentially international research data infrastructure to address these and other research questions. However, linking data across registries is challenging because registries typically define and capture different outcome measures. Variation in outcome measures occurs in clinical practice and other types of research studies as well, limiting the utility of existing data sources for addressing new research questions. The purpose of this project was to develop a minimum set of patient- and clinician-relevant standardized outcome measures that are feasible for collection in DLS registries and clinical practice. METHODS Nineteen DLS registries, observational studies, and quality improvement efforts were invited to participate and submit outcome measures. A stakeholder panel was organized that included representatives from medical specialty societies, health systems, government agencies, payers, industries, health information technology organizations, and patient advocacy groups. The panel categorized the measures using the Agency for Healthcare Research and Quality’s Outcome Measures Framework (OMF), identified a minimum set of outcome measures, and developed standardized definitions through a consensus-based process. RESULTS The panel identified and harmonized 57 outcome measures into a minimum set of 10 core outcome measure areas and 6 supplemental outcome measure areas. The measures are organized into the OMF categories of survival, clinical response, events of interest, patient-reported outcomes, and resource utilization. CONCLUSIONS This effort identified a minimum set of standardized measures that are relevant to patients and clinicians and appropriate for use in DLS registries, other research efforts, and clinical practice. Collection of these measures across registries and clinical practice is an important step for building research data infrastructure, creating learning healthcare systems, and improving patient management and outcomes in DLS.

The purpose of this report is to chronicle a 2-decade period of educational innovation and improvement, as well as governance reform, across the specialty of neurological surgery. Neurological surgery educational and professional governance systems have evolved substantially over the past 2 decades with the goal of improving training outcomes, patient safety, and the quality of US neurosurgical care. Innovations during this period have included the following: creating a consensus national curriculum; standardizing the length and structure of neurosurgical training; introducing educational outcomes milestones and required case minimums; establishing national skills, safety, and professionalism courses; systematically accrediting subspecialty fellowships; expanding professional development for educators; promoting training in research; and coordinating policy and strategy through the cooperation of national stakeholder organizations. A series of education summits held between 2007 and 2009 restructured some aspects of neurosurgical residency training. Since 2010, ongoing meetings of the One Neurosurgery Summit have provided strategic coordination for specialty definition, neurosurgical education, public policy, and governance. The Summit now includes leadership representatives from the Society of Neurological Surgeons, the American Association of Neurological Surgeons, the Congress of Neurological Surgeons, the American Board of Neurological Surgery, the Review Committee for Neurological Surgery of the Accreditation Council for Graduate Medical Education, the American Academy of Neurological Surgery, and the AANS/CNS Joint Washington Committee. Together, these organizations have increased the effectiveness and efficiency of the specialty of neurosurgery in advancing educational best practices, aligning policymaking, and coordinating strategic planning in order to meet the highest standards of professionalism and promote public health.

The proportion of elderly patients with intracranial meningiomas is increasing as the life expectancy has improved. Increasing age is classically believed to be associated with higher perioperative morbidity and mortality in neurosurgical patients.We performed a systematic literature search in 'PUBMED' and 'EMBASE' databases and reviewed all the studies comparing outcomes of surgery between young and elderly patients with intracranial meningiomas (IM). Data related to 3-month mortality rates, length of hospital stay and complications, preoperative status and comorbidity, meningioma size, location, histology, peritumoral edema, and grade of excision were extracted and analyzed.Thirteen retrospective studies fulfilled the eligibility criteria out of the 893 reviewed articles. Pooled analysis showed that the 3-month mortality rate (4.65% versus 1.42%) and length of stay (10d versus 6.8d) for elderly patients were significantly higher as compared to the young population. The rates of cardio-respiratory complications (16.3% v/s 8.3%), intracranial hemorrhage (10.2% v/s 4.2%) and new-onset neurologic deficit (20.7% v/s 10.1%) were also significantly high in the elderly group as compared to the young patients. Moreover, a higher prevalence of associated comorbidities and poor performance score was noted in the elderly patients of IM.The overall mortality rate and rates of perioperative complications (cardio-respiratory, neurologic, intracranial hemorrhage) after surgery in elderly patients with IM patients are higher as compared to young patients and should be kept in mind when formulating treatment strategy for IM in this patient population.

T o improve the quality of neurosurgical care and produce reliable clinical research, it is necessary for neurosurgeons to collect data on patient characteristics, processes of care, and clinically meaningful outcomes, to analyze these data, and to make the analysis available to individual neurosurgeons and the neurosurgical community.This is the Science of Practice algorithm.This issue of Neurosurgical Focus addresses the evolution of the Science of Practice and how it contributes to quality improvement now and how it will expand our opportunities for clinical research in the near future.We have lived our professional lives in the era of evidence-based medicine.However, despite multiple randomized trials, numerous guideline documents, and many millions of dollars spent, we still have not been able to reach consensus on the best management for many of our neurosurgical patients.Is this because neurosurgeons are simply recalcitrant and unwilling to be convinced by data, or because the constraints of randomized trials make neurosurgeons appropriately wary of applying their conclusions to their patients?Often, it is the latter.The Science of Practice approach to quality improvement and clinical research in neurosurgery will help to address this problem by generating real-world data that neurosurgeons can accept as applicable to the management of their patients.We believe that the Science of Practice will become an ever more important aspect of evidence-based medicine.

This review article analyzes the present evidence-based medicine (EBM) algorithm, compares it to the science of practice (SOP) algorithm, and demonstrates how the SOP can evolve from a quality assurance and quality improvement tool into a clinical research tool. Using appropriately constructed prospective observational databases (PODs), the SOP algorithm can be used to draw causal inferences from nonrandomized data, perform innovative comparative effectiveness research, and generate reliable information that can be used to guide treatment decisions.

We would like to thank Cambria and Conrad1Cambria R.P. Conrad M.F. Asymptomatic carotid stenosis: revisionist history is usually wrong.J Vasc Surg. 2020; 71: 2-4Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar for agreeing with us2Abbott A.L. Brunser A.M. Giannoukas A. Harbaugh R.E. Kleinig T. Lattanzi S. et al.Misconceptions regarding the adequacy of best medical intervention alone for asymptomatic carotid stenosis.J Vasc Surg. 2020; 71: 257-269Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar that transaortic carotid artery stenting (CAS) causes more stroke and death than carotid endarterectomy (CEA). However, it should be added that the periprocedural period cannot be ignored, and the CAS excess in stroke and death is measurable for as long as we have continued follow up in trials.2Abbott A.L. Brunser A.M. Giannoukas A. Harbaugh R.E. Kleinig T. Lattanzi S. et al.Misconceptions regarding the adequacy of best medical intervention alone for asymptomatic carotid stenosis.J Vasc Surg. 2020; 71: 257-269Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar Cambria and Conrad1Cambria R.P. Conrad M.F. Asymptomatic carotid stenosis: revisionist history is usually wrong.J Vasc Surg. 2020; 71: 2-4Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar have also provided opportunity to expose other important misconceptions regarding current best management of asymptomatic carotid stenosis (ACS):1.Paradigm shifts start with minority positions, practice guidelines can be flawed in ways that compromise patient welfare, and “level 1 evidence” (presumably referring to randomized trial results) can be outdated or biased.3Abbott A.L. Paraskevas K.I. Kakkos S.K. Golledge J. Eckstein H.H. Diaz-Sandoval L.J. et al.Systematic review of guidelines for the management of asymptomatic and symptomatic carotid stenosis.Stroke. 2015; 46: 3288-3301Crossref PubMed Scopus (139) Google Scholar2.Our work is not about distortion, ignoring relevant information or rewriting history. It is about interpreting historical facts without procedural bias and always putting patient welfare first.2Abbott A.L. Brunser A.M. Giannoukas A. Harbaugh R.E. Kleinig T. Lattanzi S. et al.Misconceptions regarding the adequacy of best medical intervention alone for asymptomatic carotid stenosis.J Vasc Surg. 2020; 71: 257-269Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar3.We used exemplar analytical and statistical methods to show that ipsilateral stroke rates have continued to fall with medical intervention alone since the 1980s and since randomized CEA trials (including the Asymptomatic Carotid Surgery Trial [ACST]) began.4Abbott A.L. Medical (nonsurgical) intervention alone is now best for prevention of stroke associated with asymptomatic severe carotid stenosis: results of a systematic review and analysis.Stroke. 2009; 40: e573-e583Crossref PubMed Scopus (509) Google Scholar,5Abbott A.L. Silvestrini M. Topakian R. Golledge J. Brunser A.M. de Borst G.J. et al.Optimizing the definitions of stroke, transient ischemic attack, and infarction for research and application in clinical practice.Front Neurol. 2017; 8: 537Crossref PubMed Scopus (23) Google Scholar This fall has been independently validated6Naylor A.R. Time to rethink management strategies in asymptomatic carotid artery disease.Nat Rev Cardiol. 2011; 9: 116-124Crossref PubMed Scopus (135) Google Scholar and now is ≥65%, despite possible incomplete compliance.5Abbott A.L. Silvestrini M. Topakian R. Golledge J. Brunser A.M. de Borst G.J. et al.Optimizing the definitions of stroke, transient ischemic attack, and infarction for research and application in clinical practice.Front Neurol. 2017; 8: 537Crossref PubMed Scopus (23) Google Scholar4.Medical intervention for arterial disease prevention is a combination of interventions involving the diagnosis and amelioration of risk factors using lifestyle modification and medication. It has been undervalued. One consequence is that the medical intervention used in all past ACS studies was poorly or not reported.4Abbott A.L. Medical (nonsurgical) intervention alone is now best for prevention of stroke associated with asymptomatic severe carotid stenosis: results of a systematic review and analysis.Stroke. 2009; 40: e573-e583Crossref PubMed Scopus (509) Google Scholar,5Abbott A.L. Silvestrini M. Topakian R. Golledge J. Brunser A.M. de Borst G.J. et al.Optimizing the definitions of stroke, transient ischemic attack, and infarction for research and application in clinical practice.Front Neurol. 2017; 8: 537Crossref PubMed Scopus (23) Google Scholar It evidently reflected common practice of the time. Furthermore, knowledge has evolved over decades across many specialties, and individual guidelines can be flawed.3Abbott A.L. Paraskevas K.I. Kakkos S.K. Golledge J. Eckstein H.H. Diaz-Sandoval L.J. et al.Systematic review of guidelines for the management of asymptomatic and symptomatic carotid stenosis.Stroke. 2015; 46: 3288-3301Crossref PubMed Scopus (139) Google Scholar There is uncertainty and confusion about what now constitutes best practice. To better characterize current optimal medical intervention, we plan to undertake critical comparative audits of guidelines for each major arterial disease risk factor. We will check for heterogeneity in recommendations and determine whether recommendations are supported by cited and other evidence.5.The shortfallings of all previous studies of medical intervention (including all mentioned by Cambria and Conrad1Cambria R.P. Conrad M.F. Asymptomatic carotid stenosis: revisionist history is usually wrong.J Vasc Surg. 2020; 71: 2-4Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar) are certain. These include missing a clear and scientifically justified definition and management approach for all modifiable risk factors, lacking an appropriate and clearly defined outcome measure (for carotid procedures, this should be clinically defined ipsilateral stroke),5Abbott A.L. Silvestrini M. Topakian R. Golledge J. Brunser A.M. de Borst G.J. et al.Optimizing the definitions of stroke, transient ischemic attack, and infarction for research and application in clinical practice.Front Neurol. 2017; 8: 537Crossref PubMed Scopus (23) Google Scholar retrospective design, underpowering, follow-up being too short, introducing effective interventions late, and being outdated. Whether studies in progress will address these challenges is still unknown.6.A potential benefit from CEA has only ever been shown for 50% to 99% or 60% to 99% ACS.2Abbott A.L. Brunser A.M. Giannoukas A. Harbaugh R.E. Kleinig T. Lattanzi S. et al.Misconceptions regarding the adequacy of best medical intervention alone for asymptomatic carotid stenosis.J Vasc Surg. 2020; 71: 257-269Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar It was only clearly statistically significant for highly selected men aged <75 to 80 years.2Abbott A.L. Brunser A.M. Giannoukas A. Harbaugh R.E. Kleinig T. Lattanzi S. et al.Misconceptions regarding the adequacy of best medical intervention alone for asymptomatic carotid stenosis.J Vasc Surg. 2020; 71: 257-269Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar Highest degrees of stenosis did not mean preferential CEA benefit in trials. Using “advanced ACS” to refer to 50% to 99% or 60% to 99% stenosis does not change the facts relevant to justifying carotid procedures.7.Many markers of “high stroke risk” have been proposed and none proven over current optimal medical intervention alone.7Naylor A.R. Ricco J.B. de Borst G.J. Debus S. de Haro J. Halliday A. et al.Management of atherosclerotic carotid and vertebral artery disease: 2017 clinical practice guidelines of the European Society for Vascular Surgery (ESVS).Eur J Vasc Endovasc Surg. 2018; 55: 3-81Abstract Full Text Full Text PDF PubMed Scopus (435) Google Scholar Using them could inappropriately justify CEA or CAS in just about any person with ACS.2Abbott A.L. Brunser A.M. Giannoukas A. Harbaugh R.E. Kleinig T. Lattanzi S. et al.Misconceptions regarding the adequacy of best medical intervention alone for asymptomatic carotid stenosis.J Vasc Surg. 2020; 71: 257-269Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar Before advocating routine CEA (or any other carotid procedure), Cambria and Conrad1Cambria R.P. Conrad M.F. Asymptomatic carotid stenosis: revisionist history is usually wrong.J Vasc Surg. 2020; 71: 2-4Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar (and all others7Naylor A.R. Ricco J.B. de Borst G.J. Debus S. de Haro J. Halliday A. et al.Management of atherosclerotic carotid and vertebral artery disease: 2017 clinical practice guidelines of the European Society for Vascular Surgery (ESVS).Eur J Vasc Endovasc Surg. 2018; 55: 3-81Abstract Full Text Full Text PDF PubMed Scopus (435) Google Scholar) need to start by providing contemporary randomized trial evidence that procedural intervention provides additional stroke prevention benefit. Asymptomatic carotid stenosis: Revisionist history is usually wrongJournal of Vascular SurgeryVol. 71Issue 1PreviewIn his landmark 1951 publication entitled “Occlusion of the Internal Carotid Artery,” C. Miller Fisher both described the pathogenesis of hemispheric stroke related to carotid bifurcation atherosclerosis and went on to speculate that “one day surgeons may even devise a way to remove the offending plaque and thereby prevent stroke.” His prophecy was soon realized when prophylactic carotid endarterectomy (CEA) was launched more or less simultaneously on three different continents in 1953. The fundamentals of this stroke preventive strategy remain clinically valid today, being supported by virtually every international practice guideline and in turn predicated on level 1 evidence. Full-Text PDF Misconceptions regarding the adequacy of best medical intervention alone for asymptomatic carotid stenosisJournal of Vascular SurgeryVol. 71Issue 1PreviewMedical intervention (risk factor identification, lifestyle coaching, and medication) for stroke prevention has improved significantly. It is likely that no more than 5.5% of persons with advanced asymptomatic carotid stenosis (ACS) will now benefit from a carotid procedure during their lifetime. However, some question the adequacy of medical intervention alone for such persons and propose using markers of high stroke risk to intervene with carotid endarterectomy (CEA) and/or carotid angioplasty/stenting (CAS). Full-Text PDF

BACKGROUND:Modern healthcare reforms focus on identifying and measuring the quality and value of care. Patient satisfaction is particularly important in the management of degenerative cervical radiculopathy (DCR) since it leads to significant neck pain and disability primarily affecting the patients' quality of life. OBJECTIVE:To determine the association of baseline and 12-mo Neck Disability Index (NDI) with patient satisfaction after elective surgery for DCR. METHODS:The Quality Outcomes Database cervical module was queried for patients who underwent elective surgery for DCR. A multivariable proportional odds regression model was fitted with 12-mo satisfaction as the outcome. The covariates for this model included patients' demographics, surgical characteristics, and baseline and 12-mo patient reported outcomes (PROs). Wald-statistics were calculated to determine the relative importance of each independent variable for 12-mo patient satisfaction. RESULTS:The analysis included 2206 patients who underwent elective surgery for DCR. In multivariable analysis, after adjusting for baseline and surgery specific variables, the 12-mo NDI score showed the highest association with 12-mo satisfaction (Waldχ2-df = 99.17, 58.1% of total χ2). The level of satisfaction increases with decrease in 12-mo NDI score regardless of the baseline NDI score. CONCLUSION:Our study identifies 12-mo NDI score as a very influential driver of 12-mo patient satisfaction after surgery for DCR. In addition, there are lesser contributions from other 12-mo PROs, baseline Numeric Rating Scale for arm pain and American Society of Anesthesiologists (ASA) grade. The baseline level of disability was found to be irrelevant to patients. They seemed to only value their current level of disability, compared to baseline, in rating satisfaction with surgical outcome.

The Quality Outcomes Database (QOD), formerly known as the National Neurosurgery Quality Outcomes Database (N(2)QOD), was established by the NeuroPoint Alliance (NPA) in collaboration with relevant national stakeholders and experts. The overarching goal of this project was to develop a centralized, nationally coordinated effort to allow individual surgeons and practice groups to collect, measure, and analyze practice patterns and neurosurgical outcomes. Specific objectives of this registry program were as follows: "1) to establish risk-adjusted national benchmarks for both the safety and effectiveness of neurosurgical procedures, 2) to allow practice groups and hospitals to analyze their individual morbidity and clinical outcomes in real time, 3) to generate both quality and efficiency data to support claims made to public and private payers and objectively demonstrate the value of care to other stakeholders, 4) to demonstrate the comparative effectiveness of neurosurgical and spine procedures, 5) to develop sophisticated 'risk models' to determine which subpopulations of patients are most likely to benefit from specific surgical interventions, and 6) to facilitate essential multicenter trials and other cooperative clinical studies." The NPA has launched several neurosurgical specialty modules in the QOD program in the 7 years since its inception including lumbar spine, cervical spine, and spinal deformity and cerebrovascular and intracranial tumor. The QOD Spine modules, which are the primary subject of this paper, have evolved into the largest North American spine registries yet created and have resulted in unprecedented cooperative activities within our specialty and among affiliated spine care practitioners. Herein, the authors discuss the experience of QOD Spine programs to date, with a brief description of their inception, some of the key achievements and milestones, as well as the recent transition of the spine modules to the American Spine Registry (ASR), a collaboration between the American Association of Neurological Surgeons and the American Academy of Orthopaedic Surgeons (AAOS).

"Editorial. Reflections on the first decade of neurosurgical science of practice: what has been accomplished; what ambitions remain to be fulfilled?" published on May 2020 by American Association of Neurological Surgeons.