Faculty Bibliography

Background/UNASSIGNED:MR/CT documented smaller cranial meningiomas in asymptomatic patients are often followed for years without requiring any intervention. Only a subset of patients who become symptomatic attributed to significant tumor growth, edema and/or mass effect may require stereotactic radiosurgery (SRS), and rarely, open surgery. Clearly, the decision for choosing any treatment modality must be made on a case by case basis and include an analysis of risks vs. benefits to the individual patient. Methods/UNASSIGNED:Patients with smaller benign asymptomatic meningiomas are followed with sequential MR studies that typically document lack of tumor progression, edema, or mass effect. Those who become symptomatic with the typical triad (i.e. headaches, seizures, or visual loss) and other focal neurological deficits may warrant SRS, and only occasionally, open surgery. Surgery may indeed be warranted in the presence of certain mitigating factors, (e.g. young age, lesions located adjacent to by not yet invading critical structures etc.). Results/UNASSIGNED:This review focused largely on smaller benign asymptomatic meningiomas. The non-operative/ conservative management vs. use of SRS vs. open surgery in select cases are discussed, along with a review of the morbidity/mortality of the respective interventions. Conclusion/UNASSIGNED:There are multiple treatment options for patients with smaller asymptomatic cranial meningiomas. SRS may be warranted for those who exhibit tumor growth, increasing edema, and/or mass effect. Only rarely is open operative intervention necessary; this must include consideration of other factors that may warrant early surgery. Notably, the 5-year survival rates for SRS ranged from 95.2% - 97%, while the 10-year survival rates varied from 88.6% - 94%.

Background/UNASSIGNED:Based upon a select review of the literature, in my opinion, spine surgeons, not just our medical/cardiological colleagues, need to know when to stop anticoagulant, anti-platelet aggregates, and non-steroidal anti-inflammatory (NSAIDs) medications prior to spine surgery to avoid perioperative bleeding complications. Methods/UNASSIGNED:Typically, medical/cardiological consultants, who "clear our patients" are not as aware as we are of the increased risks of perioperative bleeding if anticoagulant, anti-platelet, and NSAIDs are not stopped in a timely fashion prior to spine surgery (e.g. excessive intraoperative hemorrhage, and postoperative seromas, hematomas, and wound dehiscence). Results/UNASSIGNED:Different medications need to be discontinued at varying intervals prior to spinal operations. The anticoagulants include; Warfarin (stop at least 5 preoperative days), and Xa inhibitors (Eliquis (Apixaban: stop for 2 days) and Xarelto (Rivaroxaban: stop for 3 days)); note presently data vary. The anti-platelet aggregates include: Aspirin/Clopidogrel (stop >7-10 days preoperatively). The multiple NSAIDs should be stopped for varying intervals ranging from 1-10 days prior to spine surgery, and increase bleeding risks when combined with any of the anticoagulants or anti-platelet aggregates. NSAIDs (generic name/commercial names should be stopped preoperatively for at least; 1 day- Diclofenac (Voltaran), Ibuprofen (Advil, Motrin), Ketorolac (Toradol); 2 days- Etodolac (Lodine), Indomethacin (Indocin); 4-days-Meloxicam (Mobic) and Naproxen (Aleve, Naprosyn, Anaprox); 4 days- Nabumetone (Relafen); 6 days - Oxaprozin (Daypro); and 10 days- Piroxicam (Feldene). Conclusions/UNASSIGNED:Spine surgeons need to know when anti-platelet, anticoagulant, and NSAIDs therapies should be stopped prior to spine surgery to avoid perioperative bleeding complications.

Background/UNASSIGNED:Prior to spine surgery (SS), we ask whether and when to stop low-dose aspirin (LD-ASA), particularly in patients with significant cardiovascular disease (CAD). Although platelets typically regenerate in 10 days, it can take longer in older patients. Methods/UNASSIGNED:Here we reviewed several studies regarding the perioperative risks/complications [e.g. hemorrhagic complications, estimated blood loss (EBL), continued postoperative drainage] for continuing vs. stopping LD-ASA at various intervals prior to lumbar SS. Results/UNASSIGNED:Multiple studies confirmed the increased perioperative risks for continuing LD-ASA throughout SS, or when stopping it for just 3-7 preoperative days; however, there were no increased risks if stopped between 7 to 10 days postoperatively. Other studies documented no increased perioperative risk for continuing LD-ASA throughout SS, although some indicated increased morbidity (e.g., one patient developed a postoperative hematoma resulting in irreversible paralysis). Conclusions/UNASSIGNED:Several studies demonstrated more hemorrhagic complications if LD-ASA was continued throughout or stopped just 3 to up to 7 days prior to SS. However, there were no adverse bleeding events if stopped from 7-10 days preoperatively. As a spine surgeon who wishes to avoid a postoperative epidural hematoma/paralysis, I would recommend stopping LD-ASA 10 days or longer prior to SS. Nevertheless, each spine surgeon must determine what is in the "best interest" of their individual patient. Certainly, we need future randomized controlled trials to better answer: when and if to stop LD-ASA before spine surgery.

Background/UNASSIGNED:The concept "standard of care" (SOC) is invoked in legal cases, as well as evidence-based, and professional/ethical discussions in medicine and surgery. Methods/UNASSIGNED:We reviewed key legal cases and relevant evidence-based medical articles, and then explored the implications for professional societies seeking to set guidelines for their members testifying as expert witnesses. Results/UNASSIGNED:First, the legal concept of SOC plays a role in malpractice cases in assessing whether a physician's behavior was "within the SOC." The concept of SOC has evolved from a "standard of a responsible body of medical opinion" (Bolam case), which implicitly did not allow for multiple SOC, to a more evidence-based approach. Second, according to the evidence-based medical literature, there is more than one SOC in medicine and surgery, including neurosurgery. Third, professional, medical, and surgical societies have evoked the concept of SOC to set ethical guidelines for how their members should behave when testifying as expert witnesses. Specifically, the literature argues societies should avoid abusing singular, self-serving definitions of the SOC to sanction members, typically plaintiff's experts, who offer alternative SOC in depositions or in court. Conclusions/UNASSIGNED:Recent legal decisions suggest that testimony should be based upon scientific evidence. The scientific evidence indicates that there is often more than one SOC. Thus, any subspecialty society, including the American Association of Neurological Surgeons, that ignores evidence-based medicine and the existence of multiple SOC, risks the appearance of fostering self-interest at the expense of patient care.