gms | German Medical Science

Objective: The French vascular surgeon René Leriche once said “Every surgeon carries about him a little cemetery [...]”, alluding to complications potentially encountered in any surgical procedure. In recent years there has been much greater scrutiny of adverse events in health care systems and a surgeon’s “little cemetery” is required to be formally analysed as a quality indicator of medical care. We sought to review the published classification systems and results for morbidity and mortality in paediatric neurosurgery.

Methods: A systematic literature review was performed for studies reporting morbidity and mortality in patients younger than 18 years of age undergoing neurosurgical procedures. Classification systems and results were analysed and common quality indicators were extracted for comparison.

Results: Seven studies were included in this analysis, reporting data from 8,694 patients. Five studies were limited to resection of paediatric brain tumours and one study to cranial procedures in general, whereas one study included both cranial and spinal operations. The duration of observation was defined as 30 days after index surgery in four studies, as duration of initial inpatient stay in one study and was not specified in two studies. Overall, these studies reported a severe adverse event (morbidity) rate of 33.8% (range 2.0-68.6%), a mortality rate of 3.0% (range 0.8-7.7%), a 30-day unscheduled reoperation rate of 12.5% (range 10.5-14.5%) and a surgical site infection rate of 7.6% (range 3.4-15.4%).

Conclusion: This review of classification systems and outcome data for morbidity and mortality in paediatric neurosurgery identified four key quality indicators commonly reported in all relevant studies: 1) severe adverse event rate, 2) mortality, 3) 30-day unscheduled reoperation rate and 4) surgical site infection rate. However, pooling of data revealed a significant variability between reported rates, arguably related to different definitions of critical events, such as morbidity or infection, or different case mixes. In summary, the literature reflects a consensus on key quality indicators, but lacks common data elements and definitions of critical events. Consensus definitions are essential to allow for prospective surveillance, transparent reporting and meaningful comparison of surgical quality on a national and international scale. Furthermore, paediatric neurosurgery requires specific classifications, definitions and benchmarks to reflect significant age-related and pathology-related differences compared to adult neurosurgery.