"Wrong" scale used to evaluate results of brain surgery


The most common scale used to evaluate outcome of neurosurgical procedures, the modified rankin scale (mRS) � does not measure what is commonly assumed, concludes a study conducted at the Department of Neurosurgery of Helsinki University Hospital. The researchers state that previous treatment results must now be re-evaluated.

Surgery has become a volatile field during the past few years, with study after study challenging prevailing treatment practices. For example, surgical treatment of acute appendicitis (JAMA 2015) and arthroscopic surgery on degenerative knees (NEJM 2013) have been called into question by recent research results reached by Finnish researchers.

In neurosurgery, the evaluation of the success of treatment is challenging. Many patients undergoing surgery are either practically asymptomatic or extremely ill, meaning that the patient cannot himself or herself explain the impact of the surgery.

Consequently, the modified Rankin Scale (mRS) has been commonly used to evaluate outcome and even success of neurosurgical treatment. However, the scale was originally created to monitor the recovery process of stroke victims, not to assess the success of neurosurgery. The mRS runs from 0 to 6, and describes the patient�s ability to function in broad terms, with 0 indicating no symptoms and 6 meaning that the patient is deceased. For example, a patient classified as mRS 2 exhibits slight disability, caused by whatever reason.

At least three outcome studies on cerebrovascular surgery which resulted in significant changes to neurosurgical treatment everywhere in the world used the modified Rankin Scale to compare and evaluate treatment results (Lancet 2002; Lancet 2014; Lancet 2003).

A study at the Department of Neurosurgery at the Helsinki University Hospital � one of the largest neurosurgical units in the Western world � has now for the first time studied whether mRS is suitable for measuring the treatment results of brain surgery.

�We were astonished to see the results which indicate that mRS is very poorly suited to evaluating and reporting on the quality of neurosurgical treatment and related complications,� says Dr Elina Reponen, principal investigator and specialist in anaesthesiology and intensive care medicine.

According to the results, 24% of patients who underwent a normal procedure with no complications were classified with a worse mRS score 30 days after the procedure than before the surgery. This is to say that according to the mRS score, their ability to function decreased even when the treatment had been excellent and free from complications. On the other hand, 28% of We were astonished to see the results which indicate that mRS is very poorly suited to evaluating and reporting on the quality of neurosurgical treatment and related complications. patients who had experienced significant complications after surgery received an identical or better mRS score upon release. This means that the mRS score did not reflect the fact that the treatment may have been less than perfect and safe.

�The next surprise came when we found
out how difficult it was to get these negative results published,� Dr Reponen says.

The non-selective follow-up study monitored patients who underwent brain surgery at the Helsinki University Hospital during one year. This means that the study is based on real patient data from a major academic neurosurgical unit.

�This is the first study examining the applicability of mRS for the assessment of neurosurgical treatment results. Based on the research, we should perhaps reevaluate the previous studies in which the modified Rankin Scale has been used to measure treatment results and even to compare different forms of treatment. In any case, we are likely to see changes in outcomes reporting,� says Dr Reponen.

�Neurosurgeons rarely conduct extensive research themselves, since their work is hectic and they have scant time for research. Many neurosurgical studies are led by neurologists and radiologists, who understandably choose to employ research methods and indicators which are accepted and established in their own field. However, neurosurgeons should be aware of this and consider participating in the development of the indicators used to measure their work and not outsource this task to people who are less familiar with the field,� reasons neurosurgeon Miikka Korja, one of the authors of the new study.

According to Dr Hanna Tuominen, specialist in anaesthesiology and one of the authors of the study, anaesthesiologists have been pivotal in improving and measuring patient safety in many areas of surgery, and they also have a crucial role to play in neurosurgery.

�The anaesthesiologist is on the side of both the patient and the surgeon. It is in the anaesthesiologist�s interests to provide the best possible working conditions for the surgeon and the best possible outcome for the patient. This is why anaesthesiologists have been active in measuring patient safety and the quality of treatment.�


Cook Children's

What is deep brain stimulation surgery?

nto On Monday, 30 November 2015, Cook Children�s marked an important milestone in its quest to improve the quality of life for children struggling with debilitating movement disorders with its hundredth deep brain stimulation (DBS) surgery in Cook Children�s history.

Deep brain stimulation surgery involves two parts: implanting electrodes into the brain and a pacemaker under the skin of the chest. The two devices are connected by the surgeons and electrical impulses are sent from the pacemaker to the brain to correct the abnormal impulses of the movement disorder. The two surgeries take place about a week apart from each other. Following both procedures, the child usually goes home the next day.

The path to asleep DBS
When neurosurgeons at Cook Children�s first began performing DBS, patients had to be awake, which can be a traumatic event for kids to go through, even after the efforts to keep them pain free while awake in previous surgeries. Now, thanks to enhanced technology, patients can be under anesthesia and asleep. This change in the treatment�s technique came with the addition of an iMRI, which is essentially a giant magnet, at Cook Children�s. The iMRI allows neurosurgeons to have pinpoint accuracy while performing a delicate brain surgery.

�With all the technology we have, I know I am in the exact spot I want to be,� said John Honeycutt, M.D., medical director of Neurosurgery and co-directorof the Jane and John Justin Neurosciences Center at Cook Children�s. �My accuracy for DBS is 0.5 millimeters.� Dr Honeycutt is one of the world�s leaders when it comes to using DBS on patients with dystonia and performed the hundredth surgery. It will be the fifteenth asleep surgery for Cook Children�s.

Building a DBS program
Warren Marks, M.D., a neurologist and medical director of the Movement Disorder and Neurorehabilitation Program at Cook Children�s, says Cook Children�s DBS program grew as part of an evolution of the movement disorders program at the medical center.

Dr Marks said it took two years of hard work to develop the DBS program at Cook Children�s. It involved assembling and organizing two entire teams � one to do the evaluations and postoperative management and another to do the surgery.

Cook Children�s performed its first DBS surgery in 2007.

�We have slowly and methodically grown the program so we try and do it in the best way we can and try to provide for the most kids we can,� according to Dr Marks. �The program is somewhat unique in that we are really focused on children. When we started our program there was no adult program to work off of. Virtually all DBS programs where surgeries are performed on children are in conjunction with adult programs. We really did start from ground zero.�

Both Dr Honeycutt and Dr Marks take the hundredth procedure in their stride. The milestone reinforces their success, but they say they never looked at this program as a race. They have been very careful in their approach to the surgeries and the patients they are treating.

What excites them is the fact that the last 15 cases were performed while the children were asleep.

There will still be some surgeries where the patient has certain disorders that will require him or her to be awake. But for the most part, the surgeries will be done with the patients asleep.

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The surgeon: Helping kids like his own
A profile of Cook Children's medical director of Neurosurgery

Several key life experiences helped lead John Honeycutt, M.D., to become the chief neurosurgeon at Cook Children�s in Fort Worth. But none really shaped the doctor he is like the birth of his children.

�People told me everybody wants to work in pediatrics until you have kids,� Dr Honeycutt said. �They said, �Then you won�t want to work on kids any longer. It will be too much.� But it was the exact opposite. When I had my own kids I realized even more this was what I wanted. I wanted to help kids like my own. It gave me much more empathy. It made it much easier to take care of them. In my line of work, I�m asking parents to hand their kids off to me and take care of them. They entrust their kids� lives in my hands and I understand that.�

As a teenager, Dr Honeycutt saw first-hand the role a surgeon can play in helping a family after a traumatic event.

One afternoon in his hometown of Paragould, Arkansas, while �horsing around� after football practice, the then 15-year-old broke his neck.

A surgical scar remains on Dr Honeycutt�s neck and so do the memories of his time in the hospital. He describes the scene at the time like what you would see in a bad TV movie as he was placed in traction.

As a patient, he saw physicians changing patients� lives and making them better. The straight-A student discovered what he wanted to be when he grew up.

Then during medical school, Dr Honeycutt found his specialty.

�When I was doing my neurosurgery rotation, it all just clicked,� he said. �It clearly had all the parts I really enjoyed. I liked being a surgeon. I liked the neurosciences. I liked the workings of the brain. I just loved everything about it.�

While Dr Honeycutt is now an experienced neurosurgeon, he still strives to be at the forefront of the latest technology and technique. Working on a child�s brain requires not only a steady hand, but the latest in state-of-the-art technology.

Dr Honeycutt and his fellow neurosurgeons use their expertise to perform the most intricate and delicate surgeries, such as deep brain stimulation, iMRI-guided surgery and laser ablation surgery.

�It�s an exciting time right now because we are learning so much about the brain and how it works and at the same time our technology continues to improve with micro instruments, with robotics and computers,� Dr Honeycutt said. �If I don�t keep learning and keep up with what�s going on, I can get so far behind, rather quickly. One of the great things about Cook Children�s is we are always on the leading edge.�

Another aspect of Cook Children�s that Dr Honeycutt said makes it unique is the relationship between the neurologists and the neurosurgeons. As surprising as it may be, Dr Honeycutt says it�s rare for other hospitals to have the neurologists and neurosurgeons share a clinic together. He calls the working relationship between everyone involved in the Department of Neurosciences at Cook Children�s unbelievable. A lot of it has to do with that communication and the skill of the surgeons and physicians. They push each other constantly to do better.

At Cook Children�s, the neurologists and neurosurgeons can give each other immediate feedback on a patient. �You look at our situation and say, �Why doesn�t everyone do this?� It�s so silly that people don�t do this everywhere,� Dr Honeycutt said. �It�s one of the things that makes this place so special.�

Global surgery experts issue roadmap for improving access to surgical care

New paper in BMJ Global Health puts forth recommendations to reach five billion people with safe surgery and anaesthesia.

BMJ Global Health, a new publication launched by the BMJ, published a roadmap to expanding access to surgical care around the world. According to a landmark 2015 report by the Lancet Commission on Global Surgery, nearly a third of the global disease burden can be attributed to surgically treatable conditions, but an estimated 5 billion people cannot access surgery due to a lack of infrastructure, insufficient numbers of trained surgeons and anaesthesiologists, or the prohibitive costs of receiving care. 143 million additional surgical procedures each year are needed to save lives and prevent disability. But the case for action isn�t just humanitarian: investing in surgery would save developing countries approximately $12.3 trillion in lost GDP by 2030. As Dr Jim Yong Kim, president of the World Bank Group, said in his address to the Lancet Commission in May 2015: �The stakes are high, because failing to fix this problem will have a substantial impact on people�s lives, wellbeing, and even their economic health going forward.�

Building on this report, the paper released 7 April, entitled �Global Surgery 2030: A Roadmap for High Income Country Actors� outlines a series of actions that universities, hospitals, surgeons, biotech companies, and the media in wealthy countries can pursue to help bring access to those who need it most in low- and middle-income countries (LMICs). Written by an international group of surgeons, anaesthesiologists, business and biotechnology leaders, journalists, and advocates, the paper prioritizes the role of health professionals and policymakers who live and work in LMICs. Authors state that unilateral action by high-income country groups without an ethos of partnership is unlikely to bring about sustainable change. Instead, highincome country resources can be brought into the service of local interests, building sustainable health systems and providing a durable solution for the world�s poor.

�The goal is universal access to safe, affordable, surgical and anaesthesia care when needed,� said John G. Meara, MD, DMD, MBA, director of the Program in Global Surgery & Social Change at Harvard Medical School, Plastic Surgeonin- Chief at Boston Children�s Hospital, and co-chair of the Lancet Commission on Global Surgery. �This reports demonstrates a common policy agenda between major actors and provides a roadmap for maximizing benefit to surgical patients worldwide.�

The publication zeroes in on a series of actionable recommendations that those in high-income countries can take to enhance the world�s capacity to deliver surgical and anaesthesia care. Specifically, the paper calls on:

  • Colleges and academic medical centres to develop global partnerships for training and ongoing professional development and to support research efforts in quality, safety, and outcomes measurement
  • High-income country surgery and anaesthesia trainees to develop long-term clinical and research relationships with colleagues in LMICs
  • Academic surgeons and journals to support research by surgeons in LMICs and eliminate barriers to publishing and disseminating research in the communities where it was conducted
  • Global health funders to aggressively invest in health systems strengthening with a specific focus on surgery as a critical component of universal health coverage
  • The biomedical devices industry to design and manufacture user-centred equipment appropriate for resource-limited environments and to train LMIC health professionals and biomedical equipment technicians
  • Press and advocacy groups to develop public support by telling the stories of those affected by surgical disease, and to independently investigate the state of surgery around the world
  • �We�re thrilled to be launching this paper at such a crucial time for global surgery,� said Dr Paul Farmer, co-founder of Partners in Health and a Lancet Commissioner. �We have an opportunity to turn surgery from the �neglected stepchild of global public health� to a centrepiece of national health systems, averting millions of deaths and disabilities along the way.�

 Date of upload: 15th May 2016


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