Middle meningeal artery (MMA) embolization has been proposed as a minimally invasive treatment for chronic subdural hematoma (cSDH). The aim of this systematic review and meta-analysis is to compare outcomes after MMA embolization versus conventional management for cSDH. We performed a systematic review of PubMed, Embase, Oxford Journal, Cochrane, and Google Scholar databases from April 1987 to October 2020 in accordance with PRISMA guidelines. Studies reporting outcomes after MMA embolization for ≥3 patients with cSDH were included. A meta-analysis comparing MMA embolization with conventional management was performed. The analysis comprised 20 studies with 1416 patients, including 718 and 698 patients in the MMA embolization and conventional management cohorts, respectively. The pooled recurrence, surgical rescue, and in-hospital complication rates in the MMA embolization cohort were 4.8% (95% CI 3.2% to 6.5%), 4.4% (2.8% to 5.9%), and 1.7% (0.8% to 2.6%), respectively. The pooled recurrence, surgical rescue, and in-hospital complication rates in the conventional management cohort were 21.5% (0.6% to 42.4%), 16.4% (5.9% to 27.0%), and 4.9% (2.8% to 7.1%), respectively. Compared with conservative management, MMA embolization was associated with lower rates of cSDH recurrence (OR=0.15 (95% CI 0.03 to 0.75), p=0.02) and surgical rescue (OR=0.21 (0.07 to 0.58), p=0.003). In-hospital complication rates were comparable between the two cohorts (OR=0.78 (0.34 to 1.76), p=0.55). MMA embolization is a promising minimally invasive therapy that may reduce the need for surgical intervention in appropriately selected patients with cSDH. Additional prospective studies are warranted to determine the long-term durability of MMA embolization, refine eligibility criteria, and establish this endovascular approach as a viable definitive treatment for cSDH.
BackgroundCase reports and case control studies have suggested an association between chiropractic neck manipulation and cervical artery dissection (CAD), but a causal relationship has not been established. We evaluated the evidence related to this topic by performing a systematic review and meta-analysis of published data on chiropractic manipulation and CAD.MethodsSearch terms were entered into standard search engines in a systematic fashion. The articles were reviewed by study authors, graded independently for class of evidence, and combined in a meta-analysis. The total body of evidence was evaluated according to GRADE criteria.ResultsOur search yielded 253 articles. We identified two class II and four class III studies. There were no discrepancies among article ratings (i.e., kappa=1). The meta-analysis revealed a small association between chiropractic care and dissection (OR 1.74, 95% CI 1.26-2.41). The quality of the body of evidence according to GRADE criteria was “very low.”ConclusionsThe quality of the published literature on the relationship between chiropractic manipulation and CAD is very low. Our analysis shows a small association between chiropractic neck manipulation and cervical artery dissection. This relationship may be explained by the high risk of bias and confounding in the available studies, and in particular by the known association of neck pain with CAD and with chiropractic manipulation. There is no convincing evidence to support a causal link between chiropractic manipulation and CAD. Belief in a causal link may have significant negative consequences such as numerous episodes of litigation.
Objective
The objective was to determine the impact of the COVID-19 pandemic on operative case volume in 8 US neurosurgical residency training programs in early 2020 and to survey these programs regarding training activities during this period.
Methods
A retrospective review was conducted of monthly operative case volumes and types for 8 residency programs for 2019 and January-April 2020. Cases were grouped as elective cranial, elective spine, and non-elective emergent cases. Programs were surveyed regarding residents’ perceptions of the impact of COVID-19 on surgical training, didactics, and research participation. Data was analyzed for individual programs and pooled across programs.
Results
Across programs, the 2019 monthly case average was 211 (SD ± 82); 2020 average case volumes for January, February, March, and April were 228±93, 214±84, 180±73, and 107±45, respectively. Compared with 2019, March and April 2020 average cases declined 15% (p=0.003) and 49% (p=0.002), respectively. COVID-19 affected surgical case volume for all programs; 75% reported didactics negatively affected, and 90% reported COVID-19 resulted in increased research time. Several neurosurgery residents have required COVID-19 testing, however, to our knowledge, only one resident from the participating programs tested positive.
Conclusions
This study documents a significant reduction in operative volume in 8 neurosurgery residency training programs in early 2020. During this time, neurosurgery residents engaged in online didactics and research-related activities, reporting increased research productivity. Residency programs should collect data to determine the educational impact of the pandemic on resident operative case volumes, identify deficiencies, and develop plans to mitigate any effects.
After reviewing the data, there was insufficient evidence to recommended one method of treatment over the other. This highlights the importance of keeping a national registry in order to compare outcomes between the two methods of treatment.
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