Yunus Kuntawi Aji | Universitas Airlangga (original) (raw)

Papers by Yunus Kuntawi Aji

Indonesian Journal of Neurosurgery, 2024

Background: Microvascular decompression (MVD) is a definitive treatment for hemifacial spasm (HFS... more Background: Microvascular decompression (MVD) is a definitive treatment for hemifacial spasm (HFS) patients. Research on HFS patients and their surgical outcomes in developing countries like Indonesia is limited. This study aimed to investigate the social background and surgical outcomes of patients who underwent MVD for HFS in Indonesia.
Methods: Demographic data, referral procedure to our clinic, previous treatments, and clinical characteristics were documented. Surgical outcomes were evaluated in spasm severity by Samsung Medical Center (SMC) grading and spasm frequency by the Jankovich Rating Scale (JRS). The overall surgical outcome with complications was evaluated using the Kondo scale. Bivariate and multivariate logistic regression were employed to analyze important prognostic factors for one-year post-operative outcomes.
Results: Sixty-nine patients were included in this study. Females were dominant (79.7%) with a mean age of 52 ± 8 years. Patients with low educational levels were found in 53.5%. Oral medications, herbal medicine, and acupuncture were performed in 97.1%, 11.6%, and 5.8%, respectively. Operative findings demonstrated the anterior inferior cerebellar artery was the most common offending vessel (46.3%). Following MVD procedures, spasm severity, and frequency declined significantly until postoperative one month (p = 0.032 and p = 0.033, respectively), with more than half of the patients becoming spasm-free immediately. Despite most patients (89.9%) exhibiting satisfactory outcomes, longer duration from onset, cardiovascular pathology, and repeated botulinum toxin injection significantly predict worse outcomes in regression analysis (p<0.05).
Conclusion: The Indonesian cohort exhibited a high prevalence of severe HFS due to poor awareness of the disease. Repeated conservative therapies should be discouraged because they may contribute to unfavorable surgical outcomes.

Indonesian Journal of Neurosurgery, 2024

Background: Cervicogenic headache is a common disorder with cervical spine-specific nociceptive h... more Background: Cervicogenic headache is a common disorder with cervical spine-specific nociceptive headache symptoms. Cervicogenic headaches have been studied for years, but diagnosis and treatment are continually evolving. Due to nonspecific criteria and its relationship with cervical degenerative illness, diagnosis may be underestimated. In many situations, it contributes to myelopathy or radiculopathy. Cervical decompression and/or fusion are often performed in situations of cervical myelopathy and/or radiculopathy.
Case presentation: Here we report a 57-year-old female with the chief complaint of headache, especially in the occipital region worsening in the last 1 year. The pain referred to retro-orbital and left face. She had a history of surgery for the left face pain. No abnormality was noted on neurological examination. Cervical x-ray showed cervical spondylosis with straight cervical and narrowing of intervertebral disc C4/C5, C5/C6, C6/C7 in flexion and extension position. Anterior cervical discectomy and fusion (ACDF) C4-5 and C5-6 were performed. After surgery, no new neurological abnormality or other complications developed. Early post-operation, the headache improved and completely resolved at one month post-operation.
Conclusion: The ACDF procedure is a successful intervention for the alleviation of cervicogenic headache symptoms in patients with concurrent cervical myelopathy and/or radiculopathy.

Journal of Clinical Neuroscience, 2023

Background: Microvascular decompression (MVD) is effective for refractory trigeminal neuralgia (T... more Background: Microvascular decompression (MVD) is effective for refractory trigeminal neuralgia (TN), but its accessibility is often limited in lower-to-middle-income countries (LMICs). This study aims to assess the impact of implementing a single-surgeon policy on MVD for TN in LMICs.
Methods: A prospective cohort study was conducted from 2014 to 2020, comparing outcomes between multisurgeon and single-surgeon policies. Residents were included in MVD procedures starting in 2019. The Barrow Neurological Institute (BNI) pain scale (P), numbness scale (N), and result conclusion scale (P + N) were used to evaluate outcomes (1 week, 1 month, 1 year, and yearly thereafter). Propensity score matching was performed before comparing the groups. Pain-free survival was assessed using Kaplan-Meier and Cox-regression analysis.
Results: We comprehensively analyzed data from 72 patients with a minimum one-year follow-up. The implementation of the single-surgeon policy had several notable impacts. Firstly, it led to an increased referral rate (p < 0.05) and a reduced duration to surgery (p < 0.05). During MVD, there was a significant increase in the identification of complex compression (p < 0.05) and a reduced frequency of internal neurolysis (p < 0.05). After surgery, the single-surgeon group exhibited a superior pain-control profile (RR 1.9, p < 0.001; ARR 26-36%), higher pain-free survival rate (p < 0.001), lower likelihood of pain recurrence (HR 0.2, p < 0.0001), and fewer additional surgical interventions compared to the multi-surgeon group. Moreover, the involvement of residents did not significantly impact surgical outcomes.
Conclusions: Implementing a single-surgeon policy for MVD in LMICs has the potential to improve surgical outcomes, provide social benefits, and offer educational opportunities.

Neurosurgical Review, 2023

Trigeminal neuralgia (TN) is a neuropathic pain that can be treated with microvascular decompress... more Trigeminal neuralgia (TN) is a neuropathic pain that can be treated with microvascular decompression (MVD) or percutaneous radiofrequency rhizotomy (PRR) when medications fail. However, the cost-effectiveness of these interventions is uncertain, and it is unclear whether TN should be considered as a single entity for cost-effectiveness analysis. To address these issues, a prospective cohort study was conducted between 2017 and 2020, documenting Burchiel et al.'s clinical classification, pain-free survival, complications, and costs. Two models of quality-adjusted life years (QALYs) were calculated: pain-specific (PQALY) and pain-complication-specific (PCQALY), based on pain-free survival and complications data, followed by cost-effectiveness analysis. The study included 112 patients, of whom 70 underwent MVD and 42 underwent PRR. Our findings revealed that MVD was less cost-effective in the PCQALY model than PRR, but more cost-effective in the PQALY model and had an incremental cost-effectiveness ratio (ICER) that met the World Health Organization costeffectiveness threshold in both models. Further clinical classification analysis showed that MVD was only cost-effective in type 1 TN patients, with an ICER of 0.9 and 1.3 times the GDP/capita, based on PQALY and PCQALY, respectively, meeting the cost-effectiveness criteria. Conversely, MVD was economically dominated by PRR for type 2 TN patients based on PQALY. These findings indicate that PRR may be more cost-effective for type 2 TN patients, while MVD remains the cost-effective option for type 1 TN patients. Our study highlights the importance of clinical classification and complication in determining the cost-effectiveness of MVD and PRR for refractory TN.

Indonesian Journal of Neurosurgery, 2023

Background: Ultrasound has been used as an intraoperative imaging option for spine surgery in 198... more Background: Ultrasound has been used as an intraoperative imaging option for spine surgery in 1982 and provides benefits as a great imaging modality for assessing soft tissue pathologies in real-time. Along with the development of technology and the presence of advanced imaging modalities, the role of ultrasound is often forgotten. In Indonesia, the role of intraoperative ultrasound has not become a routine modality for spinal tumor surgery despite its advantages and versatility. This study aimed to determine the role of intraoperative ultrasound for intradural spinal tumor surgery and to what extent the intraoperative ultrasound can be utilized based on our experience.
Methods: Two cases of intradural spinal tumors with different pathologies were presented. The initial diagnosis was made through contrast-enhanced magnetic resonance imaging scans. Intraoperative ultrasound was used to show the tumor in a sagittal fashion on three occasions, which were pre-removal, removal, and post-removal phase.
Results: We found intraoperative ultrasound to be a great and versatile modality in spine surgery, especially for intradural spinal tumors. This modality can be used for both total and hemilaminectomy and for both intra-and extramedullary pathology. Real-time evaluation can be performed quickly, radiation-free, cost-effective, and sensitive in assessing soft tissue.
Conclusion: Intraoperative ultrasound is a versatile modality for intradural spinal tumor surgery. The use of this modality needs to be introduced and taught in teaching programs and should become a routine modality for spinal tumor surgery, especially in developing countries where advanced intraoperative imaging modalities are not yet available.

The Lancet, 2023

Background The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as ind... more Background
The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index to support local elective surgical system strengthening and address growing backlogs.

Methods
First, we performed an international consultation through a four-stage consensus process to develop a multidomain index for hospital-level assessment (surgical preparedness index; SPI). Second, we measured surgical preparedness across a global network of hospitals in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) to explore the distribution of the SPI at national, subnational, and hospital levels. Finally, using COVID-19 as an example of an external system shock, we compared hospitals' SPI to their planned surgical volume ratio (SVR; ie, operations for which the decision for surgery was made before hospital admission), calculated as the ratio of the observed surgical volume over a 1-month assessment period between June 6 and Aug 5, 2021, against the expected surgical volume based on hospital administrative data from the same period in 2019 (ie, a pre-pandemic baseline). A linear mixed-effects regression model was used to determine the effect of increasing SPI score.

Findings
In the first phase, from a longlist of 103 candidate indicators, 23 were prioritised as core indicators of elective surgical system preparedness by 69 clinicians (23 [33%] women; 46 [67%] men; 41 from HICs, 22 from MICs, and six from LICs) from 32 countries. The multidomain SPI included 11 indicators on facilities and consumables, two on staffing, two on prioritisation, and eight on systems. Hospitals were scored from 23 (least prepared) to 115 points (most prepared). In the second phase, surgical preparedness was measured in 1632 hospitals by 4714 clinicians from 119 countries. 745 (45·6%) of 1632 hospitals were in MICs or LICs. The mean SPI score was 84·5 (95% CI 84·1–84·9), which varied between HIC (88·5 [89·0–88·0]), MIC (81·8 [82·5–81·1]), and LIC (66·8 [64·9–68·7]) settings. In the third phase, 1217 (74·6%) hospitals did not maintain their expected SVR during the COVID-19 pandemic, of which 625 (51·4%) were from HIC, 538 (44·2%) from MIC, and 54 (4·4%) from LIC settings. In the mixed-effects model, a 10-point increase in SPI corresponded to a 3·6% (95% CI 3·0–4·1; p<0·0001) increase in SVR. This was consistent in HIC (4·8% [4·1–5·5]; p<0·0001), MIC (2·8 [2·0–3·7]; p<0·0001), and LIC (3·8 [1·3–6·7%]; p<0·0001) settings.

Interpretation
The SPI contains 23 indicators that are globally applicable, relevant across different system stressors, vary at a subnational level, and are collectable by front-line teams. In the case study of COVID-19, a higher SPI was associated with an increased planned surgical volume ratio independent of country income status, COVID-19 burden, and hospital type. Hospitals should perform annual self-assessment of their surgical preparedness to identify areas that can be improved, create resilience in local surgical systems, and upscale capacity to address elective surgery backlogs.

Interdisciplinary Neurosurgery, 2023

Posterior stabilization using pedicle screw is a basic procedure in lumbar spine surgery. The suc... more Posterior stabilization using pedicle screw is a basic procedure in lumbar spine surgery. The success of this procedure requires learning curve, experience as well as knowledge on anatomical landmarks. Breach into vital structures of or around the spine due to mistakes in screw insertion may result in detrimental results. This technical note proposes a technique to insert lumbar pedicle screws in a relatively easier manner and more consistent for each lumbar vertebral level.

Frontiers In Surgery, Jul 22, 2022

Trigeminal Neuralgia is commonly triggered by stimuli in the area of the trigeminal nerve innerva... more Trigeminal Neuralgia is commonly triggered by stimuli in the area of the trigeminal nerve innervation. We report an exceptionally rare case of a 61year-old woman who complained of recurrent trigeminal neuralgia, which sole trigger was seeing a bright light. Teflon felt that was placed on the nerve root in the initial surgery was suspected of causing this rare type of trigeminal neuralgia. A reflex circuit linking luminance to trigeminal nerve activity may be implicated in activating a trigeminal nociceptive pathway by a bright light trigger.

The Lancet Neurology, 2022

Background: Traumatic brain injury (TBI) is increasingly recognised as being responsible for a su... more Background: Traumatic brain injury (TBI) is increasingly recognised as being responsible for a substantial proportion of the global burden of disease. Neurosurgical interventions are an important aspect of care for patients with TBI, but there is little epidemiological data available on this patient population. We aimed to characterise differences in casemix, management, and mortality of patients receiving emergency neurosurgery for TBI across different levels of human development.
Methods: We did a prospective observational cohort study of consecutive patients with TBI undergoing emergency neurosurgery, in a convenience sample of hospitals identified by open invitation, through international and regional scientific societies and meetings, individual contacts, and social media. Patients receiving emergency neurosurgery for TBI in each hospital’s 30-day study period were all eligible for inclusion, with the exception of patients undergoing insertion of an intracranial pressure monitor only, ventriculostomy placement only, or a procedure for drainage of a chronic subdural haematoma. The primary outcome was mortality at 14 days postoperatively (or last point of observation if the patient was discharged before this time point). Countries were stratified according to their Human Development Index (HDI)—a composite of life expectancy, education, and income measures—into very high HDI, high HDI, medium HDI, and low HDI tiers. Mixed effects logistic regression was used to examine the effect of HDI on mortality while accounting for and quantifying between-hospital and between-country variation.
Findings: Our study included 1635 records from 159 hospitals in 57 countries, collected between Nov 1, 2018, and Jan 31, 2020. 328 (20%) records were from countries in the very high HDI tier, 539 (33%) from countries in the high HDI tier, 614 (38%) from countries in the medium HDI tier, and 154 (9%) from countries in the low HDI tier. The median age was 35 years (IQR 24–51), with the oldest patients in the very high HDI tier (median 54 years, IQR 34–69) and the youngest in the low HDI tier (median 28 years, IQR 20–38). The most common procedures were elevation of a depressed skull fracture in the low HDI tier (69 [45%]), evacuation of a supratentorial extradural haematoma in the medium HDI tier (189 [31%]) and high HDI tier (173 [32%]), and evacuation of a supratentorial acute subdural haematoma in the very high HDI tier (155 [47%]). Median time from injury to surgery was 13 h (IQR 6–32). Overall mortality was 18% (299 of 1635). After adjustment for casemix, the odds of mortality were greater in the medium HDI tier (odds ratio [OR] 2·84, 95% CI 1·55–5·2) and high HDI tier (2·26, 1·23–4·15), but not the low HDI tier (1·66, 0·61–4·46), relative to the very high HDI tier. There was significant between-hospital variation in mortality (median OR 2·04, 95% CI 1·17–2·49).
Interpretation: Patients receiving emergency neurosurgery for TBI differed considerably in their admission characteristics and management across human development settings. Level of human development was associated with mortality. Substantial opportunities to improve care globally were identified, including reducing delays to surgery. Between-hospital variation in mortality suggests changes at an institutional level could influence outcome and comparative effectiveness research could identify best practices.

Indonesian Journal of Neurosurgery, Dec 31, 2018

Background: Vertex extradural hematomas (VEDHs) are a rare consequence of head injury which repre... more Background: Vertex extradural hematomas (VEDHs) are a rare consequence of head injury which represent another distinct group of EDHs. They may present with unusual clinical signs that can delay diagnosis and offer a dilemma as to indication for and timing of surgery. Aim: This case report aims to report a prompt decision to operate a patient with VED.
Case Report: A man with VEDHs was referred to our institution due to neurological deterioration and worsening symptoms after conservative treatment. An emergency craniotomy was conducted to the patient. Post-operatively, the patient made a good clinical improvement.
Conclusion: A prompt decision to surgery is vital for a good outcome of the patient with VEDHs.

Asian Journal of Neurosurgery, Mar 26, 2018

Traumatic supra- and infra-tentorial extradural hematoma (TSIEDH) is a rare lesion constituting <... more Traumatic supra- and infra-tentorial extradural hematoma (TSIEDH) is a rare lesion constituting <2% of all extradural hematomas. There are only a few published articles about TSIEDH. This study included three patients with TSIEDH who were treated and operated at Dr. Soetomo General Hospital, Surabaya, Indonesia, from August 2015 to July 2016. Two patients sustained injuries in traffic accidents and one patient was injured by fall. The male to female ratio was 1:2. Glasgow Coma Scale (GCS) score ≤8 was present in one and GCS score of 9–12 was present in two patients. The brain computed tomography scan verified linear fracture of occipital bone in one and linear fracture of occipital bone with lambdoid suture separation in two patients. Early diagnosis and early surgical intervention of TSIEDH are imperative because the deterioration of TSIEDH is sudden and quick. We presented our experience in treating patients with TSIEDH in Dr. Soetomo General Hospital, Surabaya, Indonesia.

Anaesthesia, Mar 9, 2021

Peri-operative SARS-CoV-2 infection increases postoperative mortality. The aim of this study was ... more Peri-operative SARS-CoV-2 infection increases postoperative mortality. The aim of this study was to determine the optimal duration of planned delay before surgery in patients who have had SARS-CoV-2 infection. This international, multicentre, prospective cohort study included patients undergoing elective or emergency surgery during October 2020. Surgical patients with pre-operative SARS-CoV-2 infection were compared with those without previous SARS-CoV-2 infection. The primary outcome measure was 30-day postoperative mortality. Logistic regression models were used to calculate adjusted 30-day mortality rates stratified by time from diagnosis of SARS-CoV-2 infection to surgery. Among 140,231 patients (116 countries), 3127 patients (2.2%) had a pre-operative SARS-CoV-2 diagnosis. Adjusted 30-day mortality in patients without SARS-CoV-2 infection was 1.5% (95%CI 1.4-1.5). In patients with a pre-operative SARS-CoV-2 diagnosis, mortality was increased in patients having surgery within 0-2 weeks, 3-4 weeks and 5-6 weeks of the diagnosis (odds ratio (95%CI) 4.1 (3.3-4.8), 3.9 (2.6-5.1) and 3.6 (2.0-5.2), respectively). Surgery performed ≥ 7 weeks after SARS-CoV-2 diagnosis was associated with a similar mortality risk to baseline (odds ratio (95%CI) 1.5 (0.9-2.1)). After a ≥ 7 week delay in undertaking surgery following SARS-CoV-2 infection, patients with ongoing symptoms had a higher mortality than patients whose symptoms had resolved or who had been asymptomatic (6.0% (95%CI 3.2-8.7) vs. 2.4% (95%CI 1.4-3.4) vs. 1.3% (95%CI 0.6-2.0), respectively). Where possible, surgery should be delayed for at least 7 weeks following SARS-CoV-2 infection. Patients with ongoing symptoms ≥ 7 weeks from diagnosis may benefit from further delay.

Neurologico Spinale Medico Chirurgico, Nov 5, 2020

Ossification of ligamentum flavum (OLF) is calcification of the ligamentum flavum, which might na... more Ossification of ligamentum flavum (OLF) is calcification of the ligamentum flavum, which might narrow the spinal canal and causes myeloradiculopathy. This condition mainly affects the lower thoracal segment. Published reports on OLF are mostly from East Asia. There was only one Indonesian OLF case that had been published. The majority of OLF involves a single level only. This is the first Indonesian case-report on multilevel OLF. Through this case report, we aim to describe the natural history of the patient and our treatment strategy in managing the multilevel OLF case. Delayed time to surgery is the key contributory factor in unfavorable surgical outcome in thoracic OLF. Choosing an appropriate surgical procedure is important. The neurological symptoms of the patient may not improve or worsen when an inadequate surgical procedure is used.

World Neurosurgery X, Sep 9, 2019

BACKGROUND: Because nearly 23,000 more neurosurgeons are needed globally to address 5 million ess... more BACKGROUND: Because nearly 23,000 more neurosurgeons are needed globally to address 5 million essential neurosurgical cases that go untreated each year, there is an increasing interest in task-shifting and task-sharing (TS/ S), delegating neurosurgical tasks to nonspecialists, particularly in low-and middle-income countries (LMICs). This global survey aimed to provide a cross-sectional understanding of the prevalence and structure of current neurosurgical TS/S practices in LMICs.
METHODS: The survey was distributed to a convenience sample of individuals providing neurosurgical care in LMICs with a Web-based survey link via electronic mailing lists of continental societies and various neurosurgical groups, conference announcements, e-mailing lists, and social media platforms. Country-level data were analyzed by descriptive statistics.
RESULTS: The survey yielded 127 responses from 47 LMICs; 20 countries (42.6%) reported ongoing TS/S. Most TS/S procedures involved emergency interventions, the top 3 being burr holes, craniotomy for hematoma evacuation, and external ventricular drain. Most (65.0%) believed that their Ministry of Health does not endorse TS/S (24.0% unsure), and only 11% believed that TS/S training was structured. There were few opportunities for TS/S providers to continue medical education (11.6%) or maintenance of certification (9.4%, or receive remuneration (4.2%).
CONCLUSIONS: TS/S is ongoing in many LMICs without substantial structure or oversight, which is concerning for patient safety. These data invite future clinical outcomes studies to assess effectiveness and discussions on policy recommendations such as standardized curricula, certification protocols, specialist oversight, and referral networks to increase the level of TS/S care and to continue to increase the specialist workforce.

Anesthesiology and Pain Medicine, Jun 29, 2021

Background: Peripheral glucocorticoid receptors (GRs) are altered by peripheral nerve injury and ... more Background: Peripheral glucocorticoid receptors (GRs) are altered by peripheral nerve injury and may modulate the development of neuropathic pain. Two central pathogenic mechanisms underlying neuropathic pain are neuroinflammation and N-methyl-Daspartate receptor (NMDAR)-dependent neural plasticity in the spinal cord.
Objectives: This study examined the effect of the non-competitive NMDAR antagonist dextromethorphan on partial sciatic nerve ligation (PSL)-induced neuropathic pain and the spinal expression of the glucocorticoid receptor (GR). Methods: Male mice were randomly assigned into a sham group and two groups receiving PSL followed by intrathecal saline vehicle or dextromethorphan (iDMP). Vehicle or iDMP was administered 8-14 days after PSL. The hotplate paw-withdrawal latency was considered to measure thermal pain sensitivity. The spinal cord was then sectioned and immunostained for GR.
Results: Thermal hyperalgesia developed similarly in the vehicle and iDMP groups prior to the injections (P = 0.828 and 0.643); however, it was completely mitigated during the iDMP treatment (P < 0.001). GR expression was significantly higher in the vehicle group (55.64 ± 4.50) than in the other groups (P < 0.001). The iDMP group (9.99 ± 0.66) showed significantly higher GR expression than the sham group (6.30 ± 1.96) (P = 0.043).
Conclusions: The suppression of PLS-induced thermal hyperalgesia by iDMP is associated with the downregulation of GR in the spinal cord, suggesting that this analgesic effect is mediated by inhibiting GR-regulated neuroinflammation.

World Neurosurgery, Sep 1, 2020

BACKGROUND: Abdominal dystonia is very rare. To our knowledge, no clinical study has reported its... more BACKGROUND: Abdominal dystonia is very rare. To our knowledge, no clinical study has reported its specific treatment. Stereotactic therapy has been used to treat several movement disorders, including focal and general dystonia. We investigated the use of internal globus pallidum (GPi) pallidotomy for abdominal dystonia after failed oral medication.
CASE DESCRIPTION: A 48-year-old man presented with abdominal dystonia and complaints of involuntary undulating and contraction movements of his left abdominal wall for 5 years. Treatment with oral medication for 4 years was ineffective. Lesioning of the right GPi successfully relieved his symptoms. The symptoms recurred at 3 months and right GPi pallidotomy was repeated with complete resolution of symptoms after the second procedure. There was no recurrence or focal deficit at the 2-year follow-up.
CONCLUSIONS: GPi pallidotomy is feasible and effective for the treatment of abdominal dystonia that is resistant to standard medical therapy.

British Journal of Surgery, Mar 24, 2021

Background: Preoperative SARS-CoV-2 vaccination could support safer elective surgery. Vaccine num... more Background: Preoperative SARS-CoV-2 vaccination could support safer elective surgery. Vaccine numbers are limited so this study aimed to inform their prioritization by modelling.
Methods: The primary outcome was the number needed to vaccinate (NNV) to prevent one COVID-19-related death in 1 year. NNVs were based on postoperative SARS-CoV-2 rates and mortality in an international cohort study (surgical patients), and community SARS-CoV-2 incidence and case fatality data (general population). NNV estimates were stratified by age (18-49, 50-69, 70 or more years) and type of surgery. Best-and worst-case scenarios were used to describe uncertainty.
Results: NNVs were more favourable in surgical patients than the general population. The most favourable NNVs were in patients aged 70 years or more needing cancer surgery (351; best case 196, worst case 816) or non-cancer surgery (733; best case 407, worst case 1664). Both exceeded the NNV in the general population (1840; best case 1196, worst case 3066). NNVs for surgical patients remained favourable at a range of SARS-CoV-2 incidence rates in sensitivity analysis modelling. Globally, prioritizing preoperative vaccination of patients needing elective surgery ahead of the general population could prevent an additional 58 687 (best case 115 007, worst case 20 177) COVID-19-related deaths in 1 year.
Conclusion: As global roll out of SARS-CoV-2 vaccination proceeds, patients needing elective surgery should be prioritized ahead of the general population.

Anaesthesia, Aug 24, 2021

SARS-CoV-2 has been associated with an increased rate of venous thromboembolism in critically ill... more SARS-CoV-2 has been associated with an increased rate of venous thromboembolism in critically ill patients. Since surgical patients are already at higher risk of venous thromboembolism than general populations, this study aimed to determine if patients with peri-operative or prior SARS-CoV-2 were at further increased risk of venous thromboembolism. We conducted a planned sub-study and analysis from an international, multicentre, prospective cohort study of elective and emergency patients undergoing surgery during October 2020. Patients from all surgical specialties were included. The primary outcome measure was venous thromboembolism (pulmonary embolism or deep vein thrombosis) within 30 days of surgery. SARS-CoV-2 diagnosis was defined as peri-operative (7 days before to 30 days after surgery); recent (1-6 weeks before surgery); previous (≥7 weeks before surgery); or none. Information on prophylaxis regimens or pre-operative anti-coagulation for baseline comorbidities was not available. Postoperative venous thromboembolism rate was 0.5% (666/123,591) in patients without SARS-CoV-2; 2.2% (50/2317) in patients with peri-operative SARS-CoV-2; 1.6% (15/953) in patients with recent SARS-CoV-2; and 1.0% (11/1148) in patients with previous SARS-CoV-2. After adjustment for confounding factors, patients with peri-operative (adjusted odds ratio 1.5 (95%CI 1.1-2.0)) and recent SARS-CoV-2 (1.9 (95%CI 1.2-3.3)) remained at higher risk of venous thromboembolism, with a borderline finding in previous SARS-CoV-2 (1.7 (95%CI 0.9-3.0)). Overall, venous thromboembolism was independently associated with 30-day mortality (5.4 (95%CI 4.3-6.7)). In patients with SARS-CoV-2, mortality without venous thromboembolism was 7.4% (319/4342) and with venous thromboembolism was 40.8% (31/76). Patients undergoing surgery with peri-operative or recent SARS-CoV-2 appear to be at increased risk of postoperative venous thromboembolism compared with patients with no history of SARS-CoV-2 infection. Optimal venous thromboembolism prophylaxis and treatment are unknown in this cohort of patients, and these data should be interpreted accordingly.

Surgical Neurology International, May 25, 2021

Background: As the largest and most complex cerebral artery, the middle cerebral artery (MCA) pat... more Background: As the largest and most complex cerebral artery, the middle cerebral artery (MCA) patterns and anomalies are not fully reported. At present, there is confusion about the criteria for the different subtypes. The study of MCA patterns and anomalies is important because variants such as accessories or duplicates represent a high risk of failure during endovascular embolization or navigation during treatment for ischemic stroke. This study conducted a systematic review of studies on the neuroangiography patterns and anomalies of MCA.
Methods: We conducted a systematic review of four articles online databases and included English articles from PubMed, the Cochrane Library, Directory of Open Access Journals, and EBSCOhost.
Results: The proportion of the MCA branching pattern was 1.9% (range from 0% to 6.3%) for monofurcation, 1.0% (range from 0% to 1.4%) for tetrafurcation, 69.9% (range from 58.1% to 92.7%) for bifurcation, and 27% (ranging from 7.3% to 40.4%) for trifurcation. e proportion of MCA anomalies for accessory is 0.03% (range from 0% to 1%), duplication is 0.17% (range from 0% to 3%), and fenestration is 0.15% (range from 0% to 2%).
Conclusion: The proportions of the branching pattern and anomalies of MCA based on the systematic review are described in this study. This study is the first to systematically review the neuroangiography pattern of MCA and neuroangiography variations/anomalies of MCA in the literature.

Child's Nervous System, Oct 30, 2021

OBJECTIVE: There are several reports regarding the epidemiology of pediatric primary brain tumors... more OBJECTIVE: There are several reports regarding the epidemiology of pediatric primary brain tumors. However, little is known about the profile in Indonesia, particularly in Surabaya. The authors report the results of epidemiological analysis of a retrospective review of childhood primary brain tumors in a single tertiary health-care center.
MATERIAL-METHODS: We conducted a retrospective study of all cases of primary brain tumors from 1 to 18 years diagnosed at the Department of Neurosurgery Faculty of Medicine Universitas Airlangga/dr. Soetomo General Academic Hospital, Surabaya, Indonesia between January 2015 and December 2019.
RESULTS: One hundred and fifty-one primary brain tumors were reviewed with a mean of 30.2 cases per year. Accord- ing to the gender, 56.9% (86 cases) of the tumors occurred in males. The mean age was 9.24 years. Of all the tumors, 55% were situated in the supratentorial compartment. In the infratentorial compartment, 78% (53 cases) of tumors are located in the cerebellum. In the supratentorial compartment, 35% (29 cases) of tumors are located in the sellar/suprasellar region. The most common types of tumors diagnosed were pilocytic astrocytoma and medulloblastoma together accounting for half of the cases (50%, 75 cases) (26.5% and 23.5% respectively), followed by glioblastoma multiforme (GBM) (6%, 9 cases), ependymoma (6%, 9 cases), germinoma (5.3%, 8 cases), craniopharyngioma (4.6%, 7 cases), ganglioglioma (3.3%, 5 cases), supratentorial central nervous system (CNS) embryonal tumor/primitive neuroectodermal tumor (PNET) (2.6%, 4 cases), and meningioma (2.6%, 4 cases). The other tumors represent 20.2%.
CONCLUSION: This retrospective study on 151 consecutive patients established a baseline of pediatric primary brain tumors pattern on the basis of histopathological experience at a tertiary health-care center in Surabaya, Indonesia.

Indonesian Journal of Neurosurgery, 2024

Background: Microvascular decompression (MVD) is a definitive treatment for hemifacial spasm (HFS... more Background: Microvascular decompression (MVD) is a definitive treatment for hemifacial spasm (HFS) patients. Research on HFS patients and their surgical outcomes in developing countries like Indonesia is limited. This study aimed to investigate the social background and surgical outcomes of patients who underwent MVD for HFS in Indonesia.
Methods: Demographic data, referral procedure to our clinic, previous treatments, and clinical characteristics were documented. Surgical outcomes were evaluated in spasm severity by Samsung Medical Center (SMC) grading and spasm frequency by the Jankovich Rating Scale (JRS). The overall surgical outcome with complications was evaluated using the Kondo scale. Bivariate and multivariate logistic regression were employed to analyze important prognostic factors for one-year post-operative outcomes.
Results: Sixty-nine patients were included in this study. Females were dominant (79.7%) with a mean age of 52 ± 8 years. Patients with low educational levels were found in 53.5%. Oral medications, herbal medicine, and acupuncture were performed in 97.1%, 11.6%, and 5.8%, respectively. Operative findings demonstrated the anterior inferior cerebellar artery was the most common offending vessel (46.3%). Following MVD procedures, spasm severity, and frequency declined significantly until postoperative one month (p = 0.032 and p = 0.033, respectively), with more than half of the patients becoming spasm-free immediately. Despite most patients (89.9%) exhibiting satisfactory outcomes, longer duration from onset, cardiovascular pathology, and repeated botulinum toxin injection significantly predict worse outcomes in regression analysis (p<0.05).
Conclusion: The Indonesian cohort exhibited a high prevalence of severe HFS due to poor awareness of the disease. Repeated conservative therapies should be discouraged because they may contribute to unfavorable surgical outcomes.

Indonesian Journal of Neurosurgery, 2024

Background: Cervicogenic headache is a common disorder with cervical spine-specific nociceptive h... more Background: Cervicogenic headache is a common disorder with cervical spine-specific nociceptive headache symptoms. Cervicogenic headaches have been studied for years, but diagnosis and treatment are continually evolving. Due to nonspecific criteria and its relationship with cervical degenerative illness, diagnosis may be underestimated. In many situations, it contributes to myelopathy or radiculopathy. Cervical decompression and/or fusion are often performed in situations of cervical myelopathy and/or radiculopathy.
Case presentation: Here we report a 57-year-old female with the chief complaint of headache, especially in the occipital region worsening in the last 1 year. The pain referred to retro-orbital and left face. She had a history of surgery for the left face pain. No abnormality was noted on neurological examination. Cervical x-ray showed cervical spondylosis with straight cervical and narrowing of intervertebral disc C4/C5, C5/C6, C6/C7 in flexion and extension position. Anterior cervical discectomy and fusion (ACDF) C4-5 and C5-6 were performed. After surgery, no new neurological abnormality or other complications developed. Early post-operation, the headache improved and completely resolved at one month post-operation.
Conclusion: The ACDF procedure is a successful intervention for the alleviation of cervicogenic headache symptoms in patients with concurrent cervical myelopathy and/or radiculopathy.

Journal of Clinical Neuroscience, 2023

Background: Microvascular decompression (MVD) is effective for refractory trigeminal neuralgia (T... more Background: Microvascular decompression (MVD) is effective for refractory trigeminal neuralgia (TN), but its accessibility is often limited in lower-to-middle-income countries (LMICs). This study aims to assess the impact of implementing a single-surgeon policy on MVD for TN in LMICs.
Methods: A prospective cohort study was conducted from 2014 to 2020, comparing outcomes between multisurgeon and single-surgeon policies. Residents were included in MVD procedures starting in 2019. The Barrow Neurological Institute (BNI) pain scale (P), numbness scale (N), and result conclusion scale (P + N) were used to evaluate outcomes (1 week, 1 month, 1 year, and yearly thereafter). Propensity score matching was performed before comparing the groups. Pain-free survival was assessed using Kaplan-Meier and Cox-regression analysis.
Results: We comprehensively analyzed data from 72 patients with a minimum one-year follow-up. The implementation of the single-surgeon policy had several notable impacts. Firstly, it led to an increased referral rate (p < 0.05) and a reduced duration to surgery (p < 0.05). During MVD, there was a significant increase in the identification of complex compression (p < 0.05) and a reduced frequency of internal neurolysis (p < 0.05). After surgery, the single-surgeon group exhibited a superior pain-control profile (RR 1.9, p < 0.001; ARR 26-36%), higher pain-free survival rate (p < 0.001), lower likelihood of pain recurrence (HR 0.2, p < 0.0001), and fewer additional surgical interventions compared to the multi-surgeon group. Moreover, the involvement of residents did not significantly impact surgical outcomes.
Conclusions: Implementing a single-surgeon policy for MVD in LMICs has the potential to improve surgical outcomes, provide social benefits, and offer educational opportunities.

Neurosurgical Review, 2023

Trigeminal neuralgia (TN) is a neuropathic pain that can be treated with microvascular decompress... more Trigeminal neuralgia (TN) is a neuropathic pain that can be treated with microvascular decompression (MVD) or percutaneous radiofrequency rhizotomy (PRR) when medications fail. However, the cost-effectiveness of these interventions is uncertain, and it is unclear whether TN should be considered as a single entity for cost-effectiveness analysis. To address these issues, a prospective cohort study was conducted between 2017 and 2020, documenting Burchiel et al.'s clinical classification, pain-free survival, complications, and costs. Two models of quality-adjusted life years (QALYs) were calculated: pain-specific (PQALY) and pain-complication-specific (PCQALY), based on pain-free survival and complications data, followed by cost-effectiveness analysis. The study included 112 patients, of whom 70 underwent MVD and 42 underwent PRR. Our findings revealed that MVD was less cost-effective in the PCQALY model than PRR, but more cost-effective in the PQALY model and had an incremental cost-effectiveness ratio (ICER) that met the World Health Organization costeffectiveness threshold in both models. Further clinical classification analysis showed that MVD was only cost-effective in type 1 TN patients, with an ICER of 0.9 and 1.3 times the GDP/capita, based on PQALY and PCQALY, respectively, meeting the cost-effectiveness criteria. Conversely, MVD was economically dominated by PRR for type 2 TN patients based on PQALY. These findings indicate that PRR may be more cost-effective for type 2 TN patients, while MVD remains the cost-effective option for type 1 TN patients. Our study highlights the importance of clinical classification and complication in determining the cost-effectiveness of MVD and PRR for refractory TN.

Indonesian Journal of Neurosurgery, 2023

Background: Ultrasound has been used as an intraoperative imaging option for spine surgery in 198... more Background: Ultrasound has been used as an intraoperative imaging option for spine surgery in 1982 and provides benefits as a great imaging modality for assessing soft tissue pathologies in real-time. Along with the development of technology and the presence of advanced imaging modalities, the role of ultrasound is often forgotten. In Indonesia, the role of intraoperative ultrasound has not become a routine modality for spinal tumor surgery despite its advantages and versatility. This study aimed to determine the role of intraoperative ultrasound for intradural spinal tumor surgery and to what extent the intraoperative ultrasound can be utilized based on our experience.
Methods: Two cases of intradural spinal tumors with different pathologies were presented. The initial diagnosis was made through contrast-enhanced magnetic resonance imaging scans. Intraoperative ultrasound was used to show the tumor in a sagittal fashion on three occasions, which were pre-removal, removal, and post-removal phase.
Results: We found intraoperative ultrasound to be a great and versatile modality in spine surgery, especially for intradural spinal tumors. This modality can be used for both total and hemilaminectomy and for both intra-and extramedullary pathology. Real-time evaluation can be performed quickly, radiation-free, cost-effective, and sensitive in assessing soft tissue.
Conclusion: Intraoperative ultrasound is a versatile modality for intradural spinal tumor surgery. The use of this modality needs to be introduced and taught in teaching programs and should become a routine modality for spinal tumor surgery, especially in developing countries where advanced intraoperative imaging modalities are not yet available.

The Lancet, 2023

Background The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as ind... more Background
The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index to support local elective surgical system strengthening and address growing backlogs.

Methods
First, we performed an international consultation through a four-stage consensus process to develop a multidomain index for hospital-level assessment (surgical preparedness index; SPI). Second, we measured surgical preparedness across a global network of hospitals in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) to explore the distribution of the SPI at national, subnational, and hospital levels. Finally, using COVID-19 as an example of an external system shock, we compared hospitals' SPI to their planned surgical volume ratio (SVR; ie, operations for which the decision for surgery was made before hospital admission), calculated as the ratio of the observed surgical volume over a 1-month assessment period between June 6 and Aug 5, 2021, against the expected surgical volume based on hospital administrative data from the same period in 2019 (ie, a pre-pandemic baseline). A linear mixed-effects regression model was used to determine the effect of increasing SPI score.

Findings
In the first phase, from a longlist of 103 candidate indicators, 23 were prioritised as core indicators of elective surgical system preparedness by 69 clinicians (23 [33%] women; 46 [67%] men; 41 from HICs, 22 from MICs, and six from LICs) from 32 countries. The multidomain SPI included 11 indicators on facilities and consumables, two on staffing, two on prioritisation, and eight on systems. Hospitals were scored from 23 (least prepared) to 115 points (most prepared). In the second phase, surgical preparedness was measured in 1632 hospitals by 4714 clinicians from 119 countries. 745 (45·6%) of 1632 hospitals were in MICs or LICs. The mean SPI score was 84·5 (95% CI 84·1–84·9), which varied between HIC (88·5 [89·0–88·0]), MIC (81·8 [82·5–81·1]), and LIC (66·8 [64·9–68·7]) settings. In the third phase, 1217 (74·6%) hospitals did not maintain their expected SVR during the COVID-19 pandemic, of which 625 (51·4%) were from HIC, 538 (44·2%) from MIC, and 54 (4·4%) from LIC settings. In the mixed-effects model, a 10-point increase in SPI corresponded to a 3·6% (95% CI 3·0–4·1; p<0·0001) increase in SVR. This was consistent in HIC (4·8% [4·1–5·5]; p<0·0001), MIC (2·8 [2·0–3·7]; p<0·0001), and LIC (3·8 [1·3–6·7%]; p<0·0001) settings.

Interpretation
The SPI contains 23 indicators that are globally applicable, relevant across different system stressors, vary at a subnational level, and are collectable by front-line teams. In the case study of COVID-19, a higher SPI was associated with an increased planned surgical volume ratio independent of country income status, COVID-19 burden, and hospital type. Hospitals should perform annual self-assessment of their surgical preparedness to identify areas that can be improved, create resilience in local surgical systems, and upscale capacity to address elective surgery backlogs.

Interdisciplinary Neurosurgery, 2023

Posterior stabilization using pedicle screw is a basic procedure in lumbar spine surgery. The suc... more Posterior stabilization using pedicle screw is a basic procedure in lumbar spine surgery. The success of this procedure requires learning curve, experience as well as knowledge on anatomical landmarks. Breach into vital structures of or around the spine due to mistakes in screw insertion may result in detrimental results. This technical note proposes a technique to insert lumbar pedicle screws in a relatively easier manner and more consistent for each lumbar vertebral level.

Frontiers In Surgery, Jul 22, 2022

Trigeminal Neuralgia is commonly triggered by stimuli in the area of the trigeminal nerve innerva... more Trigeminal Neuralgia is commonly triggered by stimuli in the area of the trigeminal nerve innervation. We report an exceptionally rare case of a 61year-old woman who complained of recurrent trigeminal neuralgia, which sole trigger was seeing a bright light. Teflon felt that was placed on the nerve root in the initial surgery was suspected of causing this rare type of trigeminal neuralgia. A reflex circuit linking luminance to trigeminal nerve activity may be implicated in activating a trigeminal nociceptive pathway by a bright light trigger.

The Lancet Neurology, 2022

Background: Traumatic brain injury (TBI) is increasingly recognised as being responsible for a su... more Background: Traumatic brain injury (TBI) is increasingly recognised as being responsible for a substantial proportion of the global burden of disease. Neurosurgical interventions are an important aspect of care for patients with TBI, but there is little epidemiological data available on this patient population. We aimed to characterise differences in casemix, management, and mortality of patients receiving emergency neurosurgery for TBI across different levels of human development.
Methods: We did a prospective observational cohort study of consecutive patients with TBI undergoing emergency neurosurgery, in a convenience sample of hospitals identified by open invitation, through international and regional scientific societies and meetings, individual contacts, and social media. Patients receiving emergency neurosurgery for TBI in each hospital’s 30-day study period were all eligible for inclusion, with the exception of patients undergoing insertion of an intracranial pressure monitor only, ventriculostomy placement only, or a procedure for drainage of a chronic subdural haematoma. The primary outcome was mortality at 14 days postoperatively (or last point of observation if the patient was discharged before this time point). Countries were stratified according to their Human Development Index (HDI)—a composite of life expectancy, education, and income measures—into very high HDI, high HDI, medium HDI, and low HDI tiers. Mixed effects logistic regression was used to examine the effect of HDI on mortality while accounting for and quantifying between-hospital and between-country variation.
Findings: Our study included 1635 records from 159 hospitals in 57 countries, collected between Nov 1, 2018, and Jan 31, 2020. 328 (20%) records were from countries in the very high HDI tier, 539 (33%) from countries in the high HDI tier, 614 (38%) from countries in the medium HDI tier, and 154 (9%) from countries in the low HDI tier. The median age was 35 years (IQR 24–51), with the oldest patients in the very high HDI tier (median 54 years, IQR 34–69) and the youngest in the low HDI tier (median 28 years, IQR 20–38). The most common procedures were elevation of a depressed skull fracture in the low HDI tier (69 [45%]), evacuation of a supratentorial extradural haematoma in the medium HDI tier (189 [31%]) and high HDI tier (173 [32%]), and evacuation of a supratentorial acute subdural haematoma in the very high HDI tier (155 [47%]). Median time from injury to surgery was 13 h (IQR 6–32). Overall mortality was 18% (299 of 1635). After adjustment for casemix, the odds of mortality were greater in the medium HDI tier (odds ratio [OR] 2·84, 95% CI 1·55–5·2) and high HDI tier (2·26, 1·23–4·15), but not the low HDI tier (1·66, 0·61–4·46), relative to the very high HDI tier. There was significant between-hospital variation in mortality (median OR 2·04, 95% CI 1·17–2·49).
Interpretation: Patients receiving emergency neurosurgery for TBI differed considerably in their admission characteristics and management across human development settings. Level of human development was associated with mortality. Substantial opportunities to improve care globally were identified, including reducing delays to surgery. Between-hospital variation in mortality suggests changes at an institutional level could influence outcome and comparative effectiveness research could identify best practices.

Indonesian Journal of Neurosurgery, Dec 31, 2018

Background: Vertex extradural hematomas (VEDHs) are a rare consequence of head injury which repre... more Background: Vertex extradural hematomas (VEDHs) are a rare consequence of head injury which represent another distinct group of EDHs. They may present with unusual clinical signs that can delay diagnosis and offer a dilemma as to indication for and timing of surgery. Aim: This case report aims to report a prompt decision to operate a patient with VED.
Case Report: A man with VEDHs was referred to our institution due to neurological deterioration and worsening symptoms after conservative treatment. An emergency craniotomy was conducted to the patient. Post-operatively, the patient made a good clinical improvement.
Conclusion: A prompt decision to surgery is vital for a good outcome of the patient with VEDHs.

Asian Journal of Neurosurgery, Mar 26, 2018

Traumatic supra- and infra-tentorial extradural hematoma (TSIEDH) is a rare lesion constituting <... more Traumatic supra- and infra-tentorial extradural hematoma (TSIEDH) is a rare lesion constituting <2% of all extradural hematomas. There are only a few published articles about TSIEDH. This study included three patients with TSIEDH who were treated and operated at Dr. Soetomo General Hospital, Surabaya, Indonesia, from August 2015 to July 2016. Two patients sustained injuries in traffic accidents and one patient was injured by fall. The male to female ratio was 1:2. Glasgow Coma Scale (GCS) score ≤8 was present in one and GCS score of 9–12 was present in two patients. The brain computed tomography scan verified linear fracture of occipital bone in one and linear fracture of occipital bone with lambdoid suture separation in two patients. Early diagnosis and early surgical intervention of TSIEDH are imperative because the deterioration of TSIEDH is sudden and quick. We presented our experience in treating patients with TSIEDH in Dr. Soetomo General Hospital, Surabaya, Indonesia.

Anaesthesia, Mar 9, 2021

Peri-operative SARS-CoV-2 infection increases postoperative mortality. The aim of this study was ... more Peri-operative SARS-CoV-2 infection increases postoperative mortality. The aim of this study was to determine the optimal duration of planned delay before surgery in patients who have had SARS-CoV-2 infection. This international, multicentre, prospective cohort study included patients undergoing elective or emergency surgery during October 2020. Surgical patients with pre-operative SARS-CoV-2 infection were compared with those without previous SARS-CoV-2 infection. The primary outcome measure was 30-day postoperative mortality. Logistic regression models were used to calculate adjusted 30-day mortality rates stratified by time from diagnosis of SARS-CoV-2 infection to surgery. Among 140,231 patients (116 countries), 3127 patients (2.2%) had a pre-operative SARS-CoV-2 diagnosis. Adjusted 30-day mortality in patients without SARS-CoV-2 infection was 1.5% (95%CI 1.4-1.5). In patients with a pre-operative SARS-CoV-2 diagnosis, mortality was increased in patients having surgery within 0-2 weeks, 3-4 weeks and 5-6 weeks of the diagnosis (odds ratio (95%CI) 4.1 (3.3-4.8), 3.9 (2.6-5.1) and 3.6 (2.0-5.2), respectively). Surgery performed ≥ 7 weeks after SARS-CoV-2 diagnosis was associated with a similar mortality risk to baseline (odds ratio (95%CI) 1.5 (0.9-2.1)). After a ≥ 7 week delay in undertaking surgery following SARS-CoV-2 infection, patients with ongoing symptoms had a higher mortality than patients whose symptoms had resolved or who had been asymptomatic (6.0% (95%CI 3.2-8.7) vs. 2.4% (95%CI 1.4-3.4) vs. 1.3% (95%CI 0.6-2.0), respectively). Where possible, surgery should be delayed for at least 7 weeks following SARS-CoV-2 infection. Patients with ongoing symptoms ≥ 7 weeks from diagnosis may benefit from further delay.

Neurologico Spinale Medico Chirurgico, Nov 5, 2020

Ossification of ligamentum flavum (OLF) is calcification of the ligamentum flavum, which might na... more Ossification of ligamentum flavum (OLF) is calcification of the ligamentum flavum, which might narrow the spinal canal and causes myeloradiculopathy. This condition mainly affects the lower thoracal segment. Published reports on OLF are mostly from East Asia. There was only one Indonesian OLF case that had been published. The majority of OLF involves a single level only. This is the first Indonesian case-report on multilevel OLF. Through this case report, we aim to describe the natural history of the patient and our treatment strategy in managing the multilevel OLF case. Delayed time to surgery is the key contributory factor in unfavorable surgical outcome in thoracic OLF. Choosing an appropriate surgical procedure is important. The neurological symptoms of the patient may not improve or worsen when an inadequate surgical procedure is used.

World Neurosurgery X, Sep 9, 2019

BACKGROUND: Because nearly 23,000 more neurosurgeons are needed globally to address 5 million ess... more BACKGROUND: Because nearly 23,000 more neurosurgeons are needed globally to address 5 million essential neurosurgical cases that go untreated each year, there is an increasing interest in task-shifting and task-sharing (TS/ S), delegating neurosurgical tasks to nonspecialists, particularly in low-and middle-income countries (LMICs). This global survey aimed to provide a cross-sectional understanding of the prevalence and structure of current neurosurgical TS/S practices in LMICs.
METHODS: The survey was distributed to a convenience sample of individuals providing neurosurgical care in LMICs with a Web-based survey link via electronic mailing lists of continental societies and various neurosurgical groups, conference announcements, e-mailing lists, and social media platforms. Country-level data were analyzed by descriptive statistics.
RESULTS: The survey yielded 127 responses from 47 LMICs; 20 countries (42.6%) reported ongoing TS/S. Most TS/S procedures involved emergency interventions, the top 3 being burr holes, craniotomy for hematoma evacuation, and external ventricular drain. Most (65.0%) believed that their Ministry of Health does not endorse TS/S (24.0% unsure), and only 11% believed that TS/S training was structured. There were few opportunities for TS/S providers to continue medical education (11.6%) or maintenance of certification (9.4%, or receive remuneration (4.2%).
CONCLUSIONS: TS/S is ongoing in many LMICs without substantial structure or oversight, which is concerning for patient safety. These data invite future clinical outcomes studies to assess effectiveness and discussions on policy recommendations such as standardized curricula, certification protocols, specialist oversight, and referral networks to increase the level of TS/S care and to continue to increase the specialist workforce.

Anesthesiology and Pain Medicine, Jun 29, 2021

Background: Peripheral glucocorticoid receptors (GRs) are altered by peripheral nerve injury and ... more Background: Peripheral glucocorticoid receptors (GRs) are altered by peripheral nerve injury and may modulate the development of neuropathic pain. Two central pathogenic mechanisms underlying neuropathic pain are neuroinflammation and N-methyl-Daspartate receptor (NMDAR)-dependent neural plasticity in the spinal cord.
Objectives: This study examined the effect of the non-competitive NMDAR antagonist dextromethorphan on partial sciatic nerve ligation (PSL)-induced neuropathic pain and the spinal expression of the glucocorticoid receptor (GR). Methods: Male mice were randomly assigned into a sham group and two groups receiving PSL followed by intrathecal saline vehicle or dextromethorphan (iDMP). Vehicle or iDMP was administered 8-14 days after PSL. The hotplate paw-withdrawal latency was considered to measure thermal pain sensitivity. The spinal cord was then sectioned and immunostained for GR.
Results: Thermal hyperalgesia developed similarly in the vehicle and iDMP groups prior to the injections (P = 0.828 and 0.643); however, it was completely mitigated during the iDMP treatment (P < 0.001). GR expression was significantly higher in the vehicle group (55.64 ± 4.50) than in the other groups (P < 0.001). The iDMP group (9.99 ± 0.66) showed significantly higher GR expression than the sham group (6.30 ± 1.96) (P = 0.043).
Conclusions: The suppression of PLS-induced thermal hyperalgesia by iDMP is associated with the downregulation of GR in the spinal cord, suggesting that this analgesic effect is mediated by inhibiting GR-regulated neuroinflammation.

World Neurosurgery, Sep 1, 2020

BACKGROUND: Abdominal dystonia is very rare. To our knowledge, no clinical study has reported its... more BACKGROUND: Abdominal dystonia is very rare. To our knowledge, no clinical study has reported its specific treatment. Stereotactic therapy has been used to treat several movement disorders, including focal and general dystonia. We investigated the use of internal globus pallidum (GPi) pallidotomy for abdominal dystonia after failed oral medication.
CASE DESCRIPTION: A 48-year-old man presented with abdominal dystonia and complaints of involuntary undulating and contraction movements of his left abdominal wall for 5 years. Treatment with oral medication for 4 years was ineffective. Lesioning of the right GPi successfully relieved his symptoms. The symptoms recurred at 3 months and right GPi pallidotomy was repeated with complete resolution of symptoms after the second procedure. There was no recurrence or focal deficit at the 2-year follow-up.
CONCLUSIONS: GPi pallidotomy is feasible and effective for the treatment of abdominal dystonia that is resistant to standard medical therapy.

British Journal of Surgery, Mar 24, 2021

Background: Preoperative SARS-CoV-2 vaccination could support safer elective surgery. Vaccine num... more Background: Preoperative SARS-CoV-2 vaccination could support safer elective surgery. Vaccine numbers are limited so this study aimed to inform their prioritization by modelling.
Methods: The primary outcome was the number needed to vaccinate (NNV) to prevent one COVID-19-related death in 1 year. NNVs were based on postoperative SARS-CoV-2 rates and mortality in an international cohort study (surgical patients), and community SARS-CoV-2 incidence and case fatality data (general population). NNV estimates were stratified by age (18-49, 50-69, 70 or more years) and type of surgery. Best-and worst-case scenarios were used to describe uncertainty.
Results: NNVs were more favourable in surgical patients than the general population. The most favourable NNVs were in patients aged 70 years or more needing cancer surgery (351; best case 196, worst case 816) or non-cancer surgery (733; best case 407, worst case 1664). Both exceeded the NNV in the general population (1840; best case 1196, worst case 3066). NNVs for surgical patients remained favourable at a range of SARS-CoV-2 incidence rates in sensitivity analysis modelling. Globally, prioritizing preoperative vaccination of patients needing elective surgery ahead of the general population could prevent an additional 58 687 (best case 115 007, worst case 20 177) COVID-19-related deaths in 1 year.
Conclusion: As global roll out of SARS-CoV-2 vaccination proceeds, patients needing elective surgery should be prioritized ahead of the general population.

Anaesthesia, Aug 24, 2021

SARS-CoV-2 has been associated with an increased rate of venous thromboembolism in critically ill... more SARS-CoV-2 has been associated with an increased rate of venous thromboembolism in critically ill patients. Since surgical patients are already at higher risk of venous thromboembolism than general populations, this study aimed to determine if patients with peri-operative or prior SARS-CoV-2 were at further increased risk of venous thromboembolism. We conducted a planned sub-study and analysis from an international, multicentre, prospective cohort study of elective and emergency patients undergoing surgery during October 2020. Patients from all surgical specialties were included. The primary outcome measure was venous thromboembolism (pulmonary embolism or deep vein thrombosis) within 30 days of surgery. SARS-CoV-2 diagnosis was defined as peri-operative (7 days before to 30 days after surgery); recent (1-6 weeks before surgery); previous (≥7 weeks before surgery); or none. Information on prophylaxis regimens or pre-operative anti-coagulation for baseline comorbidities was not available. Postoperative venous thromboembolism rate was 0.5% (666/123,591) in patients without SARS-CoV-2; 2.2% (50/2317) in patients with peri-operative SARS-CoV-2; 1.6% (15/953) in patients with recent SARS-CoV-2; and 1.0% (11/1148) in patients with previous SARS-CoV-2. After adjustment for confounding factors, patients with peri-operative (adjusted odds ratio 1.5 (95%CI 1.1-2.0)) and recent SARS-CoV-2 (1.9 (95%CI 1.2-3.3)) remained at higher risk of venous thromboembolism, with a borderline finding in previous SARS-CoV-2 (1.7 (95%CI 0.9-3.0)). Overall, venous thromboembolism was independently associated with 30-day mortality (5.4 (95%CI 4.3-6.7)). In patients with SARS-CoV-2, mortality without venous thromboembolism was 7.4% (319/4342) and with venous thromboembolism was 40.8% (31/76). Patients undergoing surgery with peri-operative or recent SARS-CoV-2 appear to be at increased risk of postoperative venous thromboembolism compared with patients with no history of SARS-CoV-2 infection. Optimal venous thromboembolism prophylaxis and treatment are unknown in this cohort of patients, and these data should be interpreted accordingly.

Surgical Neurology International, May 25, 2021

Background: As the largest and most complex cerebral artery, the middle cerebral artery (MCA) pat... more Background: As the largest and most complex cerebral artery, the middle cerebral artery (MCA) patterns and anomalies are not fully reported. At present, there is confusion about the criteria for the different subtypes. The study of MCA patterns and anomalies is important because variants such as accessories or duplicates represent a high risk of failure during endovascular embolization or navigation during treatment for ischemic stroke. This study conducted a systematic review of studies on the neuroangiography patterns and anomalies of MCA.
Methods: We conducted a systematic review of four articles online databases and included English articles from PubMed, the Cochrane Library, Directory of Open Access Journals, and EBSCOhost.
Results: The proportion of the MCA branching pattern was 1.9% (range from 0% to 6.3%) for monofurcation, 1.0% (range from 0% to 1.4%) for tetrafurcation, 69.9% (range from 58.1% to 92.7%) for bifurcation, and 27% (ranging from 7.3% to 40.4%) for trifurcation. e proportion of MCA anomalies for accessory is 0.03% (range from 0% to 1%), duplication is 0.17% (range from 0% to 3%), and fenestration is 0.15% (range from 0% to 2%).
Conclusion: The proportions of the branching pattern and anomalies of MCA based on the systematic review are described in this study. This study is the first to systematically review the neuroangiography pattern of MCA and neuroangiography variations/anomalies of MCA in the literature.

Child's Nervous System, Oct 30, 2021

OBJECTIVE: There are several reports regarding the epidemiology of pediatric primary brain tumors... more OBJECTIVE: There are several reports regarding the epidemiology of pediatric primary brain tumors. However, little is known about the profile in Indonesia, particularly in Surabaya. The authors report the results of epidemiological analysis of a retrospective review of childhood primary brain tumors in a single tertiary health-care center.
MATERIAL-METHODS: We conducted a retrospective study of all cases of primary brain tumors from 1 to 18 years diagnosed at the Department of Neurosurgery Faculty of Medicine Universitas Airlangga/dr. Soetomo General Academic Hospital, Surabaya, Indonesia between January 2015 and December 2019.
RESULTS: One hundred and fifty-one primary brain tumors were reviewed with a mean of 30.2 cases per year. Accord- ing to the gender, 56.9% (86 cases) of the tumors occurred in males. The mean age was 9.24 years. Of all the tumors, 55% were situated in the supratentorial compartment. In the infratentorial compartment, 78% (53 cases) of tumors are located in the cerebellum. In the supratentorial compartment, 35% (29 cases) of tumors are located in the sellar/suprasellar region. The most common types of tumors diagnosed were pilocytic astrocytoma and medulloblastoma together accounting for half of the cases (50%, 75 cases) (26.5% and 23.5% respectively), followed by glioblastoma multiforme (GBM) (6%, 9 cases), ependymoma (6%, 9 cases), germinoma (5.3%, 8 cases), craniopharyngioma (4.6%, 7 cases), ganglioglioma (3.3%, 5 cases), supratentorial central nervous system (CNS) embryonal tumor/primitive neuroectodermal tumor (PNET) (2.6%, 4 cases), and meningioma (2.6%, 4 cases). The other tumors represent 20.2%.
CONCLUSION: This retrospective study on 151 consecutive patients established a baseline of pediatric primary brain tumors pattern on the basis of histopathological experience at a tertiary health-care center in Surabaya, Indonesia.