Perioperative quality assurance in neurosurgery

Abstract

Abstract

Background Perioperative treatment for common neurosurgical conditions such as chronic subdural hematomas (CSDH) and meningiomas vary. The perioperative period is by definition the time span from 24 hours before surgery until 30 days postoperatively. Even if the surgical treatment in the operation theater can be exactly the same, complication rates differ, and results vary. The aim of the thesis was to compare recurrences after CSDH burr-hole surgery using three different drainage techniques, to establish the risk of recurrence in CSDH patients using antithrombotic (AT) medication, to clarify the risk/benefit ratio of prophylactic pharmacotherapy initiated the evening before craniotomy for meningioma, and to identify important predictors for complications in meningioma surgery. A future more large-scale aim was to clarify whether this pragmatic research design could be used for further quality work in practical neurosurgery. Methods A comparative effectiveness framework was created to conduct retrospective reviews in different Scandinavian cohorts from three different neurosurgical departments (Karolinska University Hospital, University Hospital of North Norway and St. Olavs University Hospital). The Scandinavian cohorts were all population-based, and all patients treated between 2005 and 2013. Studies included large number of patients ranging from 763 to 1260 patients. Results Active subgaleal drainage for 24 hours after surgery seems to be the most efficient and safest treatment strategy for chronic subdural hematoma. Patients with CSDH on antithrombotic therapy at the time of diagnosis, have similar recurrence rates and mortality compared to those without antithrombotic therapy. Early AT resumption is not associated with more recurrence, but with lower thromboembolic frequency. As needed perioperative administration of low molecular weight heparin, reserved for patients with excess risk because of delayed mobilization, is effective and appears to be the safest strategy, rather than routine administration. Severe complications after meningioma resection are more encountered in elderly patients (>70 years old), dependent patients (Karnofsky performance scale <70), and patients who undergo longer lasting surgery (>4 hours). Patient selection, including careful consideration of the individual risk-benefit ratio, is important in improving the safety of intracranial meningioma resection.

Conclusion The framework with its population-based studies provided valid results for the clinical questions raised. The researchers will continue to work on establishing evidence-based guidelines for common neurosurgical conditions within the established research platform.