Neurosurgery
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Meta Analysis Comparative Study
Timing of aneurysm surgery in subarachnoid hemorrhage: a systematic review of the literature.
Many practitioners favor early operation after aneurysmal rupture, but sound data supporting this practice are lacking. A systematic review was conducted to compare early aneurysm surgery (Days 0-3), intermediate surgery (Days 4-7), and late surgery (more than 7 d after subarachnoid hemorrhage). ⋯ This meta-analysis suggests that both early and intermediate surgical treatment improve outcome after aneurysmal subarachnoid hemorrhage--in particular for patients in good clinical condition at admission. However, this impression is derived only from an indirect comparison between different cohorts of patients. Sound evidence on the best timing of surgery is still lacking. Observational studies with better methods--and ideally a new randomized trial--are needed.
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Meta Analysis Comparative Study
Spinal cord stimulation for chronic low back pain: a systematic literature synthesis.
A systematic literature synthesis was performed to analyze the long-term risks and benefits of spinal cord stimulation for patients with failed back surgery syndrome. Relevant articles were identified through a MEDLINE search (January 1966-June 1994), bibliography reviews, searches of personal files, and literature supplied by a stimulator manufacturer. Two investigators independently reviewed each article to determine whether it met the following study inclusion criteria: 1) original data on return to work, pain, medication use, reoperations, functional disability, or stimulator use after permanent implantation of spinal cord stimulators in patients with chronic low back or leg pain despite previous back surgery; and 2) follow-up > or = 30 days for all patients. ⋯ At follow-up (mean, 16 mo; range, 1-45 mo), an average of 59% of patients had > or = 50% pain relief (range, 15-100% of patients). Complications occurred in 42% of patients but were generally minor. It seems that approximately 50 to 60% of patients with failed back surgery syndrome report > 50% pain relief with the use of spinal cord stimulation at follow-up; the lack of randomized trials precludes conclusions concerning the effectiveness of spinal cord stimulation relative to other treatments, placebo, or no treatment.
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Meta Analysis Comparative Study
The cost effectiveness of stereotactic radiosurgery versus surgical resection in the treatment of solitary metastatic brain tumors.
Solitary metastatic brain tumors are the most common intracranial neoplasms encountered by neurosurgeons. Surgical resection of brain metastasis with whole brain radiotherapy (WBR) significantly increases survival in comparison with WBR alone. Stereotactic radiosurgery (SR) seems to provide results that are similar to those of surgical resection. ⋯ A sensitivity analysis revealed that large changes in key assumptions would be required to change the analysis outcome. Equalization of the incremental cost effectiveness of the two treatments would require one of the following: 1) a 38.7% reduction in SR annual case volume, 2) a 34.7% increase in SR procedure cost, 3) a 18.8% reduction in surgical resection procedure cost, 4) a 240.5% increase in SR morbidity cost, 5) a 12.7% reduction in SR median survival, 6) a 16.8% increase in surgical resection median survival. Elimination of all surgical resection morbidity cost would still result in superior incremental cost effectiveness for SR.(ABSTRACT TRUNCATED AT 400 WORDS)
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A meta-analysis of published randomized studies comparing prophylactic antibiotics to placebo in craniotomies was performed. Ten studies were examined; eight met criteria for inclusion into the meta-analysis. The analysis showed an advantage of antibiotics over placebo at the P < 10-8 level. ⋯ Cumulative meta-analyses showed that this conclusion could have been confidently drawn by 1988, after only four of the eight eligible trials had been published. Trials published since that time have reinforced these conclusions but have not significantly altered them. Future studies should compare proposed new antibiotic regimens with one of those already demonstrated to be effective, not with a placebo.