Comparison of patient and surgeon ratings of outcome 12 months after spine surgery: presented at the 2009 Joint Spine Section Meeting.

OBJECT: The contemporary assessment of spine surgical outcome primarily relies on patient-centered reports of symptoms and function. Such measures are considered to reduce bias compared with traditional surgeon-based outcome ratings. This study examined the agreement between patients' and surgeons' ratings of outcome 1 year after spine surgery. METHODS: The study involved 404 patients (mean age 56.6 +/- 16.4 years; 259 women, 145 men) and their treating surgeons. At baseline and 12 months postoperatively patients completed the Core Outcome Measures Index (COMI) rating pain, function, quality of life, and disability. At 12 months postoperatively, they also rated the global outcome of surgery and their satisfaction with treatment. The surgeon, blinded to the patient's evaluation, rated the global outcome of surgery as excellent, good, fair, or poor. RESULTS: Seventy-six percent of the patients who were considered by the surgeon to have an excellent or good outcome achieved the minimum clinically important difference (MCID) of a 2.2-point reduction on the COMI; 24% achieved less than the MCID. There was a significant correlation between the surgeons' and patients' global outcome ratings (Spearman rho = 0.56; p < 0.0001). The degree of absolute agreement between them was significantly influenced by surgeon seniority: senior surgeons "overrated" the outcome in 24.5% of cases (compared with patients' ratings) and "underrated" it in 17.5% of cases. Junior surgeons overrated in 7.8% of cases and underrated in 43.8% of cases (p < 0.0001). Surgeon overrating occurred significantly more frequently for patients with a poor self-rated outcome (measured as global outcome, COMI score, or satisfaction with treatment). In a multivariate model, the independent variables "senior surgeon" and "patient dissatisfaction with care" were the most significant unique predictors of surgeon overrating of the global outcome (p < 0.0001; adjusted R(2) for the model = 0.16). CONCLUSIONS: Overall, agreement between surgeon and patient was reasonably good. The majority of patients who were rated as excellent/good by the surgeons had achieved the MCID in the prospectively measured COMI score. Discrepancies in outcome ratings were influenced by surgeon seniority and patient satisfaction. For a balanced view of the surgical result, outcomes should be assessed from the perspectives of both the patient and the surgeon.

[Role of MGMT and clinical applications in brain tumours]. / Rôle de la MGMT et implications cliniques dans les tumeurs cérébrales.

Glioblastoma multiforme is the most common and most malignant primary brain tumour with a dismal prognosis. The advent of new chemotherapies with alkylating agents crossing the blood-brain barrier, like temozolomide, have permitted to notably ameliorate the survival of a subgroup of patients. Improved outcome was associated with epigenetic silencing of the MGMT (O6-methylguanin methyltransferase) gene by promotor methylation, thereby blocking its repair capability, thus rendering the alkylating agents more effective. This particularity can be tested by methylation specific PCR on resected tumour tissue, best on fresh frozen biopsies, and allows identification of patients more susceptible to respond favourably to the treatment.

Posterior temporal haematoma associated with anterior communicating artery aneurysm rupture.

We report the case of a 68-year-old man who presented with symptoms suggesting an intracranial haemorrhage. A computed tomography scan showed subarachnoid haemorrhage associated with a remote posterior temporal intracerebral haematoma. Angiography revealed the presence of an anterior communicating artery aneurysm, which was subsequently clipped. Possible causes for the association of a distant intracerebral haematoma with rupture of an anterior communicating artery aneurysm are discussed. This uncommon association should be recognised to avoid incorrect identification of the origin of haemorrhage.