Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts.
Department of Neurosurgery, University Hospital Inselspital and University of Bern, Bern, Switzerland.
Neurosurgery. 2019 Mar 1;84(3):655-661. doi: 10.1093/neuros/nyy088.
For sustainability of arteriovenous malformation (AVM) surgery, results from early career cerebrovascular neurosurgeons (ECCNs) must be acceptably safe.
To determine whether ECCNs performance of Spetzler-Ponce Class A AVM (SPC A) resection can be acceptably safe.
ECCNs completing a cerebrovascular fellowship (2004-2015) with the last author were included. Inclusion of the ECCN cases occurred if they: had a prospective database of all AVM cases since commencing independent practice; were the primary surgeon on SPC A; and had made the significant management decisions. All SPC A surgical cases from the beginning of the ECCN's independent surgical practice to a maximum of 8 yr were included. An adverse outcome was considered a complication of surgery leading to a new permanent neurological deficit with a last modified Rankin Scale score >1. A cumulative summation (Cusum) plot examined the performance of each surgery. The highest acceptable level of adverse outcomes for the Cusum was 3.3%, derived from the upper 95% confidence interval of the last author's reported series.
Six ECCNs contributed 110 cases for analysis. The median number of SPC A cases operated by each ECCN was 16.5 (range 4-40). Preoperative embolization was performed in 5 (4.5%). The incidence of adverse outcomes was 1.8% (95% confidence interval: <0.01%-6.8%). At no point during the accumulated series did the combined cohort become unacceptable by the Cusum plot.
ECCNs with appropriate training appointed to large-volume cerebrovascular centers can achieve results for surgery for SPC A that are not appreciably worse than those published from high-volume neurosurgeons.
为了使动静脉畸形（AVM）手术能够持续进行，早期职业脑血管神经外科医生（ECCN）的结果必须是安全的。
确定 ECCN 进行斯佩茨勒-庞塞 A 级动静脉畸形（SPC A）切除术的效果是否安全。
纳入在最后一位作者处完成脑血管神经外科住院医师培训（2004-2015 年）的 ECCN。如果符合以下条件，则纳入 ECCN 病例：具有自开展独立手术以来所有 AVM 病例的前瞻性数据库；是 SPC A 的主要外科医生；并做出了重要的管理决策。纳入了 ECCN 独立手术实践开始至最长 8 年期间所有 SPC A 手术病例。不良结局被认为是导致新的永久性神经功能缺损且改良 Rankin 量表评分>1 的手术并发症。累积总和（Cusum）图检查了每次手术的表现。Cusum 接受的不良结局最高可接受水平为 3.3%，该值源自最后一位作者报告的系列中上限 95%置信区间。
6 位 ECCN 贡献了 110 例分析病例。每位 ECCN 手术的 SPC A 病例中位数为 16.5 例（范围 4-40）。5 例（4.5%）进行了术前栓塞。不良结局的发生率为 1.8%（95%置信区间：<0.01%-6.8%）。在整个系列中，没有任何一点达到 Cusum 图中联合队列不可接受的程度。
在大型脑血管中心接受适当培训的 ECCN 可以达到 SPC A 手术的效果，其结果与高容量神经外科医生发表的结果相差不大。
