Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.
Neurology, Public Health and Disability Unit - Scientific Directorate, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.
Acta Neurochir Suppl. 2023;130:1-12. doi: 10.1007/978-3-030-12887-6_1.
Quality measurement and outcome assessment have recently caught an attention of the neurosurgical community, but lack of standardized definitions and methodology significantly complicates these tasks.
To identify a uniform definition of neurosurgical complications, to classify them according to etiology, and to evaluate them comprehensively in cases of intracranial tumor removal in order to establish a new, easy, and practical grading system capable of predicting the risk of postoperative clinical worsening of the patient condition.
A retrospective analysis was conducted on all elective surgeries directed at removal of intracranial tumor in the authors' institution during 2-year study period. All sociodemographic, clinical, and surgical factors were extracted from prospectively compiled comprehensive patient registry. Data on all complications, defined as any deviation from the ideal postoperative course occurring within 30 days of the procedure, were collected with consideration of the required treatment and etiology. A logistic regression model was created for identification of independent factors associated with worsening of the Karnofsky Performance Scale (KPS) score at discharge after surgery in comparison with preoperative period. For each identified statistically significant independent predictor of the postoperative worsening, corresponding score was defined, and grading system, subsequently named Milan Complexity Scale (MCS), was formed.
Overall, 746 cases of surgeries for removal of intracranial tumor were analyzed. Postoperative complications of any kind were observed in 311 patients (41.7%). In 223 cases (29.9%), worsening of the KPS score at the time of discharge in comparison with preoperative period was noted. It was independently associated with 5 predictive factors-major brain vessel manipulation, surgery in the posterior fossa, cranial nerve manipulation, surgery in the eloquent area, tumor size >4 cm-which comprised MCS with a range of the total score from 0 to 8 (higher score indicates more complex clinical situations). Patients who demonstrated KPS worsening after surgery had significantly higher total MCS scores in comparison with individuals whose clinical status at discharge was improved or unchanged (3.24 ± 1.55 versus 1.47 ± 1.58; P < 0.001).
It is reasonable to define neurosurgical complication as any deviation from the ideal postoperative course occurring within 30 days of the procedure. Suggested MCS allows for standardized assessment of surgical complexity before intervention and for estimating the risk of clinical worsening after removal of intracranial tumor. Collection of data on surgical complexity, occurrence of complications, and postoperative outcomes, using standardized prospectively maintained comprehensive patient registries seems very important for quality measurement and should be attained in all neurosurgical centers.
质量衡量和结果评估最近引起了神经外科学界的关注，但缺乏标准化的定义和方法学使得这些任务变得非常复杂。
确定神经外科并发症的统一定义，根据病因对其进行分类，并在颅内肿瘤切除的情况下进行全面评估，以建立一种新的、简单实用的分级系统，能够预测术后患者病情恶化的风险。
对作者所在机构在 2 年研究期间进行的所有择期颅内肿瘤切除术进行回顾性分析。从前瞻性编制的综合患者登记册中提取所有社会人口统计学、临床和手术因素。收集所有并发症的数据，定义为术后 30 天内出现的任何偏离理想术后过程的情况，并考虑所需的治疗和病因。创建逻辑回归模型，以确定与术前相比，手术出院时卡诺夫斯基表现量表（KPS）评分恶化的独立相关因素。对于每个被识别为术后恶化的统计学显著独立预测因子，定义相应的评分，并形成分级系统，随后命名为米兰复杂度评分（MCS）。
共分析了 746 例颅内肿瘤切除术。311 例（41.7%）患者出现任何类型的术后并发症。223 例（29.9%）患者在出院时的 KPS 评分与术前相比恶化。这与 5 个预测因素独立相关-大脑主要血管操作、后颅窝手术、颅神经操作、语言区手术、肿瘤大小>4cm-这些因素构成了 MCS，总评分范围为 0 至 8 分（分数越高表示临床情况越复杂）。与出院时临床状况改善或未改变的患者相比，手术后 KPS 恶化的患者总 MCS 评分明显更高（3.24±1.55 与 1.47±1.58；P<0.001）。
将术后 30 天内出现的任何偏离理想术后过程的情况定义为神经外科并发症是合理的。建议的 MCS 允许在干预前对手术复杂性进行标准化评估，并估计颅内肿瘤切除后临床恶化的风险。使用标准化的前瞻性维持的综合患者登记册收集手术复杂性、并发症发生和术后结果的数据，对于质量衡量非常重要，应在所有神经外科中心实现。
