Influence of cumulative surgical experience on the outcome of poor-grade patients with ruptured intracranial aneurysm.

International audienceBACKGROUND:The expansion of endovascular techniques for intracranial aneurysms has led to a global decrease in vascular neurosurgery activity. This situation might impact neurosurgeons' level of expertise, even though they all might have to deal with this surgically challenging pathology. In that context, we wanted to assess the impact of cumulative surgical experience on the outcome of patients with poor-grade subarachnoid haemorrhage (SAH) and intracerebral haemorrhage (ICH) treated by microsurgery.METHODS:Sixty-seven patients who underwent surgery for a ruptured aneurysm with SAH and ICH, and a WFNS scale of IV/V, were included. Surgeries were performed by five surgeons, whose experience was judged by the total number of aneurysm surgeries performed. The outcome was assessed by three indicators: intraoperative rupture (IOR), early mortality, and the modified Rankin Scale at last follow-up. The time of IOR was reported on an IOR score. The correlation between surgical experience and outcome was assessed by linear regression. Nonlinear regression was used to assess the correlation of the data with a learning curve model.RESULTS:The analysis showed an influence of surgical experience on intraoperative rupture, with no effect on long-term outcome. No influence was found on early mortality. Increased surgical experience seems to reduce IOR during aneurysm dissection and clip repositioning. Intraoperative rupture data fit Wright's learning curve model.CONCLUSION:This study suggests a direct impact of cumulative experience on the course of ruptured aneurysm surgery and pleads for the use of training and simulation programmes dedicated to neurovascular surgery

Functional Outcome after odontoid fractures in the elderly

While several papers on mortality and the fusion rate in elderly patients treated surgically or non-surgically for odontoid fractures exist, little information is available on quality of life after treatment. The aim of treatment in these patients should not be fracture healing alone but also quality of life improvement. A literature search using PubMed identified seven papers including information on functional evaluation of 402 patients. Patients treated with anterior screw fixation had a good functional outcome in 92.6% of cases. This percentage seemed to decrease in octogenarians. Less information was available for patients treated with posterior approaches; it would seem that up to a half of such patients experienced pain and limitations in activities of daily living after surgery. Patients treated with a halo device had a functional outcome that was worse (or at least no better) than that of patients treated with surgery, with absence of limitations in activities of daily living in 77.3% of patients. Patients treated with a collar had a good functional outcome in the majority of cases, with absence of limitations in activities of daily living in 89% of patients. More studies are needed for evaluation of functional outcome, especially in patients treated with a collar, a halo device or a posterior approach