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A New Classification of Complications in NeurosurgeryFederico Alfonso Landriel Ibañez, Santiago Hem, Pablo Ajler, Eduardo Vecchi, Carlos Ciraolo, Matteo Baccanelli,

Ruben Tramontano, Fernando Knezevich, Antonio Carrizo

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INTRODUCTION

The assessment of surgical complicationsis an important tool in neurosurgical prac-tice (11) because it can improve safety andquality of patient treatment (7, 14, 27, 43).The different views on and definitions ofwhat is considered a complication (11), cou-pled with the absence of a widely acceptedclassification of postoperative adverseevents, may lead to a subjective interpreta-tion of surgical negative outcomes (17, 41,42). Comparisons between two distincttime periods in a single hospital or betweendifferent institutions are almost impossiblebecause no standard reporting system ex-ists (17, 19, 25).

To illustrate the problem, we focus onthree extensive reports of complications de-rived from epilepsy surgery (9, 45, 48),which offer very different criteria for com-plications. In two of the reports, complica-tion severity was judged minor (transient)when the complication resolved within 1year of the surgical procedure and major(permanent) when the complication lastedfor more than 1 year postoperatively (9, 48).

Key words� Adverse outcome� Morbidity and mortality conference� Neurosurgical complications� Spine complications

Abbreviations and AcronymsCSF: Cerebrospinal fluidICU: Intensive care unitMMC: Morbidity and mortality conference

Department of Neurosurgery of the HospitalItaliano de Buenos Aires, Argentina

To whom correspondence should be addressed:Federico Alfonso Landriel Ibañez, M.D.[E-mail: [email protected]]

Citation: World Neurosurg. (2011) 75, 5/6:709-715.DOI: 10.1016/j.wneu.2010.11.010

Journal homepage: www.WORLDNEUROSURGERY.org

Available online: www.sciencedirect.com

1878-8750/$ - see front matter © 2011 Elsevier Inc.All rights reserved.

In the third report, events that resolved a

WORLD NEUROSURGERY 75 [5/6]: 709-7

ithin 3 months were regarded as minoromplications, whereas events that ex-ended for more than 3 months were con-idered to be major complications (45).here is disagreement about what is a med-

cal or a surgical complication; two reportsonsidered postoperative pneumonia, pul-onary embolism, and deep vein thrombo-

is to be surgical complications (9, 45),hereas the other report included these

omplications in a miscellaneous group48).

Black (11) presented neurosurgeons withhe results of a survey on what was listed ascomplication at their institutions. Diverseefinitions were provided. Black askedhether neurosurgeons could and should

� OBJECTIVE: To define and gradecomplications based on their need for

� METHODS: Complications were deostoperative course occurring withinroposed based on the therapy usedon–life-threatening complications treomplications requiring invasive manandovascular procedures; grade III,

reatment in an intensive care unit (Iomplications. Each grade was classifin observational test of this system wecember 2009 in a cohort of 1190 paires.

RESULTS: Of 167 complications, 129(3.19%) were classified as medical coaccounted for 31.73%, grade II (moderatgrade III (severe) complications account1.17%; 0.84% of deaths were directly re

� CONCLUSIONS: The authors preseduce way to report negative outcomesa complication. The main advantages ofsurgical results among different cenmedical and surgical complications,analyses.

dopt a uniform definition of complication. c

15, MAY/JUNE 2011 ww

In 1992, Clavien et al. (17) proposed alassification for general surgery complica-ions that focused on a therapy-oriented,our-level severity grading system. In 2004,indo et al. (19) revised and modified this

lassification for improved accuracy and ac-eptability in the surgical community androposed a therapy-based five-grade classi-cation. They showed the reproducibility of

heir classification through a worldwideurvey sent to 10 surgical centers. Our hos-ital was included in this study and used

his system in general surgery for more thanyears.In 2001, Bonsanto et al. (14) standard-

zed general adverse neurosurgical post-perative events to conform to a three-

rosurgical and spinal postoperativetment.

d as any deviation from the normalys of surgery. A four-grade scale was

reat the complications: grade I, anywithout invasive procedures; grade II,ent such as surgical, endoscopic, andhreatening adverse events requiringand grade IV, deaths as a result ofs a surgical or medical complication.onducted between January 2008 and

ts at the Hospital Italiano de Buenos

4%) were classified as surgical, and 38cations. Grade I (mild) complicationsmplications accounted for 25.74%, andr 34.13%. The overall mortality rate wasto surgical procedures.

simple, practical, and easy to repro-d on the therapy administered to treat

classification are the ability to compareand times, the ability to comparethe ability to perform future meta-

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FEDERICO ALFONSO LANDRIEL IBAÑEZ ET AL. COMPLICATIONS IN NEUROSURGERY

complications, (ii) neurosurgically com-licated courses, and (iii) medical nonsur-ical complications. In 2009, Houkin etl. (29) presented a quantitative analysisf complications in neurosurgery andlassified adverse events into five types,n the basis of adverse event avoidanceredictability and possibility.

In 2010, Lebude (32) conducted a surveyith more than 200 spine surgeons to es-

ablish what was considered a complica-ion. Based on the survey results, Lebuderesented a binary definition of complica-

ions, by virtue of which they were classifiednto minor and major adverse events.

We based our classification on the pro-osal of Clavien (17) and Dindo (19) andodified it to conform to neurosurgical and

pine procedures and outcomes more suit-bly. This classification focuses on generalostoperative morbidity. We used a four-rade severity scale based on the therapydministered to treat a postoperative ad-erse event and considered how it related tohe surgical procedure to come up with aimple, practical, and easy to reproduce wayo report negative outcomes.

ETHODS

omplications were defined as any devia-ion from the normal postoperative courseccurring within 30 days of surgery. We

Table 1. Classification of Neurosurgical C

Grade I Any non–life-threaterequiring invasive tre

Grade Ia Complication requirin

Grade Ib Complication requirin

Grade II Complication requirinendovascular interve

Grade IIa Complication requirin

Grade IIb Complication requirin

Grade III Life-threatening com

Grade IIIa Complication involvin

Grade IIIb Complication involvin

Grade IV Complication resultin

Surgical Complications Adverse events that

Medical Complications Adverse events that

ICU, intensive care unit.

sed “adverse postoperative event” and m

710 www.SCIENCEDIRECT.com

negative outcome” as synonyms of com-lication.

Grade I complications were defined asny non–life-threatening deviation fromhe normal postoperative course that coulde treated without invasive procedures.rade I adverse events were classified into

wo subgroups based on the drug treatmentequired: Grade Ia complications includedvents with spontaneous resolution, requir-ng no drug treatment (eg, transient nervealsy, asymptomatic arrhythmia), andrade Ib complications included events re-uiring drug therapy (eg, discitis or pneu-onia treated with antibiotics). Grade II

omplications included adverse postopera-ive events requiring invasive managementuch as surgical, endoscopic, and endovas-ular procedures. Grade II events were alsolassified into two subgroups, dependingn the need for general anesthesia: GradeIa comprised complications treated with-ut general anesthesia (eg, cerebrospinaluid [CSF] rhinorrhea requiring lumbarunctures or deep vein thrombosis requir-

ng a vena cava filter), whereas grade IIbomprised postoperative adverse eventsreated under general anesthesia (eg, hard-are malposition requiring reoperation or

sophageal or gastric bleeding requiringndoscopic treatment). Grade III complica-ions referred to life-threatening adversevents requiring treatment and care in a

lications

eviation from normal postoperative course, nott

rug treatment

treatment

sive treatment such as surgical, endoscopic, or

rvention without general anesthesia

rvention with general anesthesia

ns requiring management in ICU

le organ failure

tiple organ failure

eath

rectly related to surgery or surgical technique

t directly related to surgery or surgical technique

ore complex hospital area, such as an in-

WORLD NEUROSURGE

ensive care unit (ICU). These adversevents were classified into grade IIIa, whichncluded single organ dysfunction (eg,ostoperative intracerebral hematoma re-uiring reoperation or renal insufficiencyequiring dialysis), and grade IIIb, whichncluded multiple organ dysfunction, a con-ition of severe morbidity constituting aost frequent cause of death (eg, intracra-

ial hypertension and hemodynamic insta-ility or cardiopulmonary insufficiency).rade IV included death as a result of

omplications. Each grade was classifiednto medical or surgical complicationsTable 1).

We defined medical complications asdverse events that were not directly relatedo surgery or surgical techniques (eg, pneu-

onia, esophageal or gastric bleeding,ardiac thromboembolism, renal insuffi-iency, urinary tract infection). Complica-ions more directly associated with surgeryr surgical techniques (eg, CSF leak, sub-ural or epidural hematomas, discitis, isch-mia with sensory or motor involvement,nd vascular or neural injuries related tonstrumentation) were regarded as surgicalomplications. Patients developing a surgi-al and a clinical complication were in-luded in the surgical complications group.he medical complications group com-rised purely clinical adverse events with nourgical complication.

Certain ranges of expected adverse out-omes (eg, transient facial paralysis aftercoustic neuroma resection) were also in-luded in our classification despite the facthat they may be regarded as accepted ornavoidable outcomes of the procedure andonsidering that the patient was informedf their eventual occurrence when agreeing

o undergo surgery, and regardless of themeing still regarded as “bad” (11), especiallyrom the patient’s perspective. Transientomplications were defined as a new neuro-ogic deficit resulting from the procedure,

hich improved within 30 days of the sur-ical intervention. Persistent complicationsere defined as a new neurologic deficit ex-

ending more than 30 days after the surgicalrocedure. Both types can be added to eachlassification grade by including “T” forransient or “P” for persistent, indicating

worsened severity and the need of fur-her follow-up to evaluate neurologic out-ome.

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PEER-REVIEW REPORTS


present in a single patient, the major com-plication was assessed. Examples of surgi-cal and medical complications are listed inTable 2. There was a strong and simplecorrelation between the grade of complica-tion and the severity of adverse events.Grade I complications were considered tobe mild complications, whereas grade IIand grade III were regarded as moderateand severe.

Between January 2008 and December2009, 1190 patients were operated on in theNeurosurgical Department of the HospitalItaliano de Buenos Aires. Demographics,medical records, radiologic images, labora-tory data, and all documented deviationsfrom the normal postoperative course were

Table 2. Examples of Complication Grade

Grades S

Ia Transient new neuSubcutaneous CSFTransient diabetesHardware malposit

Ib Seizures requiringCSF infection requiDiscitis requiring aSinus thrombosis rDiabetes insipidus

IIa CSF fistula requirinDural laceration reDehiscent noninfecanesthesiaSubgaleal CSF accu

IIb CSF leaks requiringHardware malpositWound infection reStimulating electroShunt dysfunction

IIIa Acute hydrocephaluIntracerebral hemaEsophageal tear reSubepidural or epidAcute cerebral swe

IIIb Meningitis and pneIntracranial hypertePosterior fossa hemIschemic stroke an

IV Death

Suffix “T” (Transient) New neurologic de

Suffix “P” (Persistent) New neurologic de

CSF, cerebrospinal fluid.

analyzed from the computerized hospital c


ata system by a senior neurosurgical resi-ent and presented in the monthly morbid-

ty and mortality conference (MMC). Se-ected cases with neurosurgical and medicalomplications were analyzed in depth andiscussed. Data were objectively comparedith previous months, allowing for long-

erm quantifications and trend identifica-ion to be made.

ESULTS

cohort of 1190 patients who had under-one a cranial (72%) or spinal (28%) neuro-urgical intervention in our institution wasnalyzed. One or more complications oc-

al Complications

deficitulationus requiring no drugst requiring reoperation

LocalAcuteAtelecNoninGrade

nvulsantsntibioticsicsg anticoagulation

ing antidiuretic hormone

AllergUrinarPneumInfectiArrhyt

bar punctureslumbar drainage

ound requiring closure under local

ion requiring lumbar drainage

PneumCardiawith lPleuraDeep

cal repairquiring reoperationg surgical toilettesplacementng exploration

EsophLowerAtelec

uiring external ventricular drainageequiring reoperationsurgical closure

ematoma requiring drainageequiring intubation

AcuteRenalLung fNecroAcute

iaand hemodynamic instabilitya and renal failuremonia

CardioLung dSystemRenal

Death

proving within 30 days of surgical procedure; can b

xtending beyond 30 days of surgical procedure; can

urred in 14% of patients (n � 167). Surgical


complications were 10.84% (n � 129), andmedical complications were 3.19%.

The most frequent grade of general com-plication was Ib (18.55%), followed by IIIa(17.96%) and IIIb (16.16%). Grade Ia surgi-cal complications accounted for 10.17% ofthe adverse events; grade Ib, for 10.17%;grade IIa, for 8.98%; grade IIb, for 15.56%;grade IIIa, for 13.17%; and grade IIIb, for13.17%. Medical complications were gradeIa, 2.99%; grade Ib, 8.38%; grade IIa,1.19%; grade IIIa, 4.79%; and grade IIIb,2.99%. Of 167 patients with postoperativecomplications, 34.13% (n � 57) experi-enced a new transient neurologic deficit,and 11.97% (n � 20) had persistent deficits.

he overall mortality rate was 1.17% (n �

Medical Complications

tisy retentionrequiring physical therapys diarrheaaminar pneumothorax

tion requiring drug treatmentinfection requiring antibiotics

reated with antibioticsarrhea requiring antibioticsequiring drug reversion

x requiring chest tubeyarrhythmia requiring pacemaker implantation

nesthesiaates or transudates requiring drainagerombosis requiring vena cava filter

or gastric bleeding requiring endoscopyintestinal bleeding requiring colonoscopyequiring bronchoscopy

rdial infarctionciency requiring dialysisrequiring intubation

pancreatitisatory distress syndrome

nary insufficiencys and renal failureammatory response syndrome and pneumoniaciency and hemodynamic instability

ed to each grade of complication

ed to each grade of complication

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PEER-REVIEW REPORTS


surgical procedures was 0.84%. Of the totalcomplications, mild postoperative generalcomplications accounted for 31.73% (n �53), moderate adverse events accounted for25.74% (n � 43), and severe life-threaten-ng postoperative complications repre-ented 34.13% (n � 57).

ISCUSSION

MCs are a powerful teaching tool, and thebjective analysis of data conducted in theseonferences may help to improve the qualitynd safety of patient care through the inter-retation and discussion of adverse postop-rative events and the development of alter-ative approaches to medical decisionaking (14, 24, 26). A major effort should

e made to avoid criticizing, blaming, orntimidating an individual person or group14, 16, 21, 28, 30). The aim of the MMC is toreate an atmosphere that is productive inerms of training and education, one whereurgery residents and staff attendees are en-ouraged to discuss and comment on theifferent cases (3, 4, 13, 14, 28, 29, 34, 35,8, 40, 44, 47, 49). In brief, the MMC repre-ents a unique opportunity to foster profes-ionalism and improve communicationithin the neurosurgical group (38).Neurosurgical practice is considerably

iskier than other surgical specialties. Inhis practice, most errors and resulting ad-erse events are unavoidable and should beccepted as part of the surgical procedure14, 29). To eliminate any individual ten-ency to downgrade or deny complicationsnd to avoid the use of nonspecific termsuch as “minor” or “major” to characterizedverse events, systematic and stratifiedlassified data should be recorded in everyeurosurgical department (10, 14, 15, 18,9, 31, 38, 41-43); yet, how can we comparehe global morbidity or mortality of two or

ore different centers, with different tech-ology, at different times, if we do not use

he same language to characterize compli-ations?

Specialties such as general surgery andnesthesiology have successfully improvedhe quality of the care they provide and theafety of their patients by systematizing theomplication records and the MMC (2, 17,9, 30, 38). General, uniform, and multi-entric knowledge of complications notnly would improve patient outcomes,
atisfaction, and health care costs, but also s

ould protect physicians from medicolegalctions by providing them with well-rounded reliable information on thexpected general postoperative complica-ions. In her review of medicolegal mal-ractice lawsuits, Epstein (20) showed that

he second most frequent malpractice eventrompting suits was lack of informed con-ent. Houkin et al. (29) focused on manyescriptions of the adverse events and the

nevitable unpredictability associated withurgery and added them to the informedonsent document that patients are re-uired to sign. These data may lessen pa-

ient expectations and somehow diminishhe surgeon’s responsibility.

The idea of improving patient care ineurosurgery through learning from post-perative mistakes in neurosurgery is notew (1, 6, 7). In 1993, Apuzzo (5) devoted anntire two-volume textbook to the descrip-ion of complications resulting from neuro-urgical interventions and their avoidancend management. “Mastering the art ofvoidance of both intraoperative and post-perative problems is a key factor in opera-

ive excellence and optimization of out-ome” (5).

There are numerous different subclassi-cations of adverse events in the treatmentf specific diseases and neurosurgical orpinal interventions, and the absence oftandardized definitions makes compari-on difficult (8, 12, 22, 23, 36, 37, 46). Ad-itionally, few publications attempting tolassify general neurosurgical or spinalostoperative complications exist (14, 16,9, 32, 39, 41, 47). Some of them are pre-ented in Table 3.

In a screening and registration of adversevents, Bonsanto et al. (14) classified com-lications into three groups: (i) neurosurgi-al complications, (ii) neurosurgically com-licated courses, and (iii) nonsurgicalomplications. By observing this division,onsanto et al. (14) classified more than2.8% of the postoperative complications,ith only 7.2% of the cases assigned to the

other” subgroup. The sensitivity of non-urgical complications was lower, probablyecause events related to ICU data were ini-

ially excluded. These authors reported onlyomplications during hospitalization butncluded no assessment concerning the se-erity of each event.

Rampersaud et al. (41) recorded and clas-
ified intraoperative adverse events and d
WORLD NEUROSURGE

omplications of spinal surgical proce-ures and determined the clinical conse-uences of these events in the postoperativeeriod. The classification was based on

reatment requirements, sequelae, and hos-ital stay. They concluded that intraopera-

ive adverse events can occur with a fre-uency of 14%; however, most procedures76.5%) were not associated with complica-ions.

Houkin et al. (29) published a quantita-ive analysis of adverse events related toeurosurgical procedures. They classified

he nature of events as neurologic, local,nd systemic and ascribed the cause ofhese events to patient disease, technicaleasons, equipment, and diagnosis. In the

MC of their Neurosurgical Department,ll adverse events were classified into fiveypes on the basis of three factors: (i) rela-ion to the procedure, (ii) predictability ofhe event, and (iii) possibility of avoidance.n their study, the severity of the complica-ion was not invariably correlated with thevent type, and the inclusion of a complica-ion under “predictability or possibility ofvoidance” was based on the backgroundnd experience of the conference attendees.oukin et al. (29) also defined adverse

vents as events requiring additional treat-ent, resulting in transient or permanent

eficits, and requiring longer hospitaltays. Following the perspective of Dindo etl. (19), length of stay does not constituteor us a valid inclusion criterion or compli-ation score because each site follows a dif-erent standard of care.

More recently, Lebude et al. (32) con-ucted a survey with experienced spinal sur-eons in a set of different clinical scenariosf postoperative complications. The au-

hors provided no preset definitions andsked the surgeons to classify postoperativevents accordingly as different complica-ions and to stratify them into minor and

ajor categories or to regard them as a non-vent. Lebude et al. (32) showed that theirurgeon population considered medicalomplications to have occurred even whenhese were not directly related to a surgicalrocedure and should be included in thessessment of postoperative complica-ions. Based on the survey responses, Leb-de et al. (32) defined perioperative spinalomplications as (i) a major complication,n adverse perioperative event that pro-
uces a permanent detrimental effect or re-
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quires reoperation in the perioperative pe-riod (30 days from the time of surgery), and(ii) a minor complication, an adverse peri-

perative event that produces only a tran-ient detrimental effect in the perioperativeeriod.

Given the fact that cranial and spinal in-terventions were performed by the samephysicians in almost all of the Neurosurgi-cal Departments, a general classification ofcomplications should and could be applied.To our knowledge, none of these systemshas gained general acceptance. The classifi-cation we propose is based on the therapyused to treat the adverse event and focuseson the general postoperative morbidity ofthe patient. Documentation of treatment ofa complication is often included in detail inthe patient’s medical record and is easy toobtain and classify, whereas adverse eventsmay be missed or overlooked, especiallywhen they are regarded as “minor.” Sub-stantial differences arise in terms of com-plication evolution or severity. For example,a postoperative intracerebral hematoma may

Table 3. Previous Classifications of Gene

Author, Year Procedure

Bonsanto et al., 2001 (14) Cranial-spinal

Rampersaud et al., 2006 (41) Spinal

Houkin et al., 2009 (29) Cranial-spinal

Lebude et al., 2010 (32) Spinal

be followed only by observation, it may be c


reated with precise surgical evacuation fol-owed by an optimal recovery, or it may beurgically evacuated and then become com-licated with pneumonia requiring ICU fol-

ow-up. The postoperative complication is theame, but the severity is different.

We consider that absolutely all deviationsrom the ideal postoperative course shoulde included in the complications record,ven when they are asymptomatic and havespontaneous resolution. Every grade of

dverse event, regardless of it being surgicalr clinical in nature, should also becomeart of the record to have an accurate idea of

he eventual outcome. Complications thatre not directly related to surgery or a surgi-al technique also affect our patients, ande should be able to recognize them to im-rove overall multidisciplinary manage-ent of patients.General classifications can serve as a

uide to develop specific classifications (ie,lassifications that provide thorough detailoncerning special complications related topecific surgical procedures). As in any

eurosurgical and Spinal Complications

Complication Types

rgical complications Unexpected on accoun(literature) as an advedischarge.

rgically complicated Expected on account olikely to occur betwee

onsurgical complications Medical complicationsduring hospitalization.

inor Required 1 day or notreatment required.

oderate Warranted treatment,sequelae (�6 months

ajor Required significant lelong-term sequelae (�

ature Neurologic, local and

use Patient disease, technand unidentified cause

pe I Unrelated to procedur

pe II Related to procedure

pe III Related to procedure,

pe IV Related to procedure,

pe V Medical error.

inor Surgical and clinical t

ajor Surgical and clinical p

lassification, separation among groups is n


ased on arbitrary criteria. This generallassification attempts to provide principlesather than details. General classificationsf neurosurgical complications may lead toreating groups of adverse events that ap-arently should not belong to the same cat-gory; however, exhaustive subclassifica-ions prove difficult to implement and are

ore time-consuming. A balance betweeneneral and specific must be attained (17).

A widely accepted classification wouldventually lead to the unification of out-ome definitions and provide strong objec-ive experience to improve the quality of

edical care and reduce the number ofomplications. Through this scoring sys-em, we were able to grade every adversevent that had been submitted to us sinceanuary 2008, providing easy objective com-arisons across the different months andears covered. Further discussions in the

MC defined the nature and avoidanceossibility of each case and led us to modi-cations of surgical techniques to improveurgical results or prevent dangerous ma-

Definition

atural course of disease but empirically knownent likely to occur between admission and

ology and specific localization of lesion. Alsoission and discharge.

ring additional diagnosis or subsequent treatment

ion of hospital stay; minimal or no additional

al stay extended by 2–7 days; no long-term

f treatment, extension of stay for �7 days ornths).

ic.

asons, medical causes, equipment, diagnosis,

predictable.

table but unavoidable.

table and avoidable.

t detrimental effect (30 days from surgery).

ent detrimental effect (30 days from surgery).

ral N

Su t of nrse ev

Su f pathn adm

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M hospit).

M vels o6 mo

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Ca ical res.

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PEER-REVIEW REPORTS


CONCLUSIONS

There is unclear consensus when definingadverse postoperative results in neurosur-gery. Complication reports should sharethe same language and be based on thesame criteria so that results could be com-pared objectively across the different cen-ters and times, in pursuance of the ultimateaim of improving patient health care. Wehave presented a simple, practical, and easyto reproduce way to report negative out-comes and discussed how it could be ap-plied. Further discussion is expected withthe hope of reaching consensus about com-plication reporting practices.

“To learn only from one’s own mistakeswould be a slow and painful process, andunnecessarily costly to one’s patients. Ex-periences need to be pooled so that doctorsmay also learn from the errors of oth-ers.”—McIntyre and Popper (33).

ACKNOWLEDGMENTS

The authors thank Peter Black, M.D., Ph.D.,President of the World Federation of Neuro-logical Societies, for his helpful comments,suggestions, and assistance in preparing thisarticle.

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onflict of interest statement: The authors declare that therticle content was composed in the absence of anyommercial or financial relationships that could beonstrued as a potential conflict of interest.

eceived 12 August 2010; accepted 02 November 2010

itation: World Neurosurg. (2011) 75, 5/6:709-715.OI: 10.1016/j.wneu.2010.11.010

ournal homepage: www.WORLDNEUROSURGERY.org

vailable online: www.sciencedirect.com

878-8750/$ - see front matter © 2011 Elsevier Inc.
patients who underwent spinal surgery. J Neuro-surg Spine 10:578-584, 2009.
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