ABSTRACT
Objective: To compare the predictive abilities of two frailty indices on post-operative morbidity and mortality in patients undergoing pituitary adenoma resection. Methods: The National Surgical Quality Improvement Program (NSQIP) database was used to retrospectively collect data for patients undergoing pituitary adenoma resection between 2015-2019. To compare the predictive abilities of two of the most common frailty indices, the 5-point modified frailty index (mFI-5) and the risk analysis index (RAI), receiver operating curve analysis (ROC) and area under the curve (AUC)/Cstatistic were used. Results: In our cohort of 1,454 patients, the RAI demonstrated superior discriminative ability to the mFI-5 in predicting extended length of stay (C-statistic 0.59, 95% CI 0.56-0.62 vs. C-statistic 0.51, 95% CI: 0.48-0.54, p = 0.0002). The RAI only descriptively appeared superior to mFI-5 in determining mortality (C-statistic 0.89, 95% CI 0.74-0.99 vs. Cstatistic 0.63, 95% CI 0.61-0.66, p=0.11), and NHD (C-statistic 0.68, 95% CI 0.60-0.76 vs. C-statistic 0.60, 95% CI: 0.57-0.62, p=0.15). Conclusions: Pituitary adenomas account for one of the most common brain tumors in the general population, with resection being the preferred treatment for patients with most hormone producing tumors or those causing compressive symptoms. Although pituitary adenoma resection is generally safe, patients who experience post-operative complications frequently share similar pre-operative characteristics and comorbidities. Therefore, appropriate pre-operative risk stratification is imperative for adequate patient counseling and informed consent in these patients. Here we present the first known report showing the superior discriminatory ability of the RAI in predicting eLOS when compared to the mFI-5.
ABSTRACT
Introduction: Surgeons are frequently faced with challenging clinical dilemmas evaluating whether the benefits of surgery outweigh the substantial risks routinely encountered with spinal tumor surgery. The Clinical Risk Analysis Index (RAI-C) is a robust frailty tool administered via a patient-friendly questionnaire that strives to augment preoperative risk stratification. The objective of the study was to prospectively measure frailty with RAI-C and track postoperative outcomes after spinal tumor surgery. Methods: Patients surgically treated for spinal tumors were followed prospectively from 7/2020-7/2022 at a single tertiary center. RAI-C was ascertained during preoperative visits and verified by the provider. The RAI-C scores were assessed in relation to postoperative functional status (measured by modified Rankin Scale score [mRS]) at the last follow-up visit. Results: Of 39 patients, 47% were robust (RAI 0-20), 26% normal (21-30), 16% frail (31-40), and 11% severely frail (RAI 41+).). Pathology included primary (59%) and metastatic (41%) tumors with corresponding mRS>2 rates of 17% and 38%, respectively. Tumors were classified as extradural (49%), intradural extramedullary (46%), or intradural intramedullary (5.4%) with mRS>2 rates of 28%, 24%, and 50%, respectively. RAI-C had a positive association with mRS>2 âat follow-up: 16% for robust, 20% for normal, 43% for frail, and 67% for severely frail. The two deaths in the series had the highest RAI-C scores (45 and 46) and were patients with metastatic cancer. The RAI-C was a robust and diagnostically accurate predictor of mRS>2 in receiver operating characteristic curve analysis (C-statistic: 0.70, 95 CI: 0.49-0.90). Conclusions: The findings exemplify the clinical utility of RAI-C frailty scoring for prediction of outcomes after spinal tumor surgery and it has potential to help in the surgical decision-making process as well as surgical consent. As a preliminary case series, the authors intend to provide additional data with a larger sample size and longer follow-up duration in a future study.
ABSTRACT
Middle meningeal artery (MMA) embolization represents a promising novel treatment modality for chronic subdural hematoma (cSDH), yet utilization and efficacy data are limited. This study evaluates the utilization and short-term outcomes of MMA embolization for cSDH treatment in a large national inpatient registry. cSDH patients treated with MMA embolization and/or surgical evacuation (craniotomy/burr hole drainage) were identified using the National Inpatient Sample (NIS) during 2012-2018 period. Temporal trends, complications, and discharge disposition were evaluated, and propensity score matching was implemented for adjusted comparisons and to mitigate confounding by indication. Among 60,045 cSDH patients identified, 390 (0.6%) underwent MMA embolization. Embolized patients presented more with high acute illness severity subclasses in comparison with surgically evacuated patients (53% vs. 34%, p = 0.004) yet did not experience any procedure-related hemorrhagic or ischemic complications. Although discharge disposition did not differ from those surgically managed, embolized patients had longer mean hospital stays (13 vs. 8 days, p = 0.023) and accrued greater hospital charges (p < 0.001). Following propensity adjustment, length of stay and charges remained greater in the embolization cohort, yet rates of routine discharge increased appreciably (40% vs. 30%, p = 0.141) relative to surgically treated cSDH patients. The utilization of embolization increased exponentially after 2015, reaching an apex in 2018 (3.7% of treated cSDH). This population-based national assessment demonstrates exponential increases in utilization of MMA embolization for cSDH treatment in recent years. Embolized patients had uncomplicated clinical courses and similar discharge dispositions as surgical evacuation patients. Large-scale prospective trials are warranted to further assess the efficacy of this modality.
