Elsevier

World Neurosurgery

Volume 89, May 2016, Pages 101-107
World Neurosurgery

Original Article
Is Patient Age Associated with Perioperative Outcomes After Surgical Resection of Benign Cranial Nerve Neoplasms?

https://doi.org/10.1016/j.wneu.2016.01.089Get rights and content

Objective

Previous studies have demonstrated that increasing age is associated with decreased rates of operative management and gross total resection in patients with vestibular schwannomas.

Methods

The American College of Surgeons National Surgical Quality Improvement Program data registry was used for this retrospective cohort analysis. Patients enrolled in the registry from 2007 to 2013 with a diagnosis of a benign neoplasm of a cranial nerve were included. The association between age and postoperative morbidity and mortality was evaluated by the use of multivariable logistic regression analyses.

Results

Of 565 patients included for analysis, the mean (median) age was 51 (53) years. Three clusters were evaluated: <50, 50−69, and ≥70 years. Mortality (0% vs. 1.03% vs. 4.55%, P = 0.012), stroke (0% vs. 0.69% vs. 6.82%, P < 0.001), and ventilator weaning failure (0.43% vs. 2.41% vs. 6.82%, P = 0.014) increased with age. Mean age was significantly greater among patients who died (70.60 vs. 50.87 years, P = 0.002) or had a stroke (68.00 vs. 50.89 years, P = 0.006), cardiac arrest (71.50 vs. 50.89 years, P = 0.038), or coma (74.00 vs. 50.96 years, P = 0.020) and those who failed ventilator weaning (62.55 vs. 50.82, P = 0.006). Age as both a continuous (odds ratio 1.10, 95% confidence interval 1.03−1.18) and categorical variable (age 70+ years odds ratio 78.88, 95% confidence interval 3.41−1825.57) was associated with an increased odds of composite morbidity.

Conclusions

In patients undergoing surgery for benign cranial nerve neoplasms, increasing age is associated with increased mortality, stroke, coma, and ventilator weaning failure. Composite complication rates are significantly greater in patients ≥70 years, with a near 80-fold increased risk of complications.

Introduction

Vestibular schwannomas (VS) are the most common benign intracranial nerve neoplasms, occurring at a rate of approximately 1 per 100,000 population per year and accounting for 8% of all intracranial tumors.1, 2, 3 Almost one third of newly reported cases occur in patients older than 61 years of age.1 Although histologically benign, VS and other cranial nerve neoplasms can cause significant sensorineural hearing loss, disequilibrium, vertigo, or other symptoms associated with compression of intracranial structures.

Treatment options available to patients diagnosed with a benign neoplasm of a cranial nerve include observation, surgery, or radiation. With current practice patterns, one half of all patients diagnosed with VS undergo microsurgical resection.1, 4 Although potentially curative, surgical excision of these tumors carries significant risk. Previous reports have documented severe complications occurring in 4% of cases.5

In the case of microsurgical resection of VS, patient age is inversely related to the likelihood of surgical management even after controlling for tumor size.1 Moreover, when patients undergo surgical resection, age is inversely proportional to the likelihood of a gross total resection.2 The preference for conservative management in older patients is likely driven by the increased complication rates reported for this demographic.1, 4, 6 Moreover, recent data reveal only marginal differences in outcomes after use of available treatment modalities.7 It is, therefore, imperative that large studies examine surgical risk as a function of age to develop a robust body of literature that can facilitate evidence-based counseling of elderly patients with benign cranial nerve neoplasms. In this study, we used the National Surgical Quality Improvement Program (NSQIP) database to evaluate the association between patient age and perioperative complications among patients undergoing surgical resection of a benign cranial nerve neoplasm.

Section snippets

Inclusion and Exclusion Criteria

This was a retrospective cohort analysis that used The American College of Surgeons NSQIP dataset between the years of 2007 and 2013. More than 130 variables are recorded on 30-day postoperative morbidity and mortality outcomes, intraoperative variables, and patient preoperative risk factors. Data acquisition is accomplished by trained Surgical Clinical Reviewers at participating institutions. Data fidelity is maintained by standardized quality control processes involving audits for interrater

Results

There were 565 patients identified in the American College of Surgeons NSQIP database between 2007 and 2013 who received surgical management for a benign cranial nerve neoplasm. The mean (median) age of this patient population was 51.04 (53.00) years. There were 230 patients younger than the age of 50 (40.71%), 291 between the ages of 50 and 69 (51.50%), and 44 70 years of age or older (7.79%). Additional patient demographic data are presented in Table 1. The distribution of ages can be seen in

Discussion

Previous work has shown that older patients are offered surgery less frequently for the management of VS.1 Moreover, those undergoing surgery are less likely to receive a gross total resection.2 These data suggest a predisposition towards less-aggressive therapy in older patients. The likely explanation is that age is thought to be a general indicator of surgical risk and, therefore, a strong indication is required to proceed with surgery. In addition, in patients of advanced age, the risk of

References (34)

  • M.E. Sughrue et al.

    Beyond audiofacial morbidity after vestibular schwannoma surgery

    J Neurosurg

    (2011)
  • M.L. Carlson et al.

    Long-term quality of life in patients with vestibular schwannoma: an international multicenter cross-sectional study comparing microsurgery, stereotactic radiosurgery, observation, and nontumor controls

    J Neurosurg

    (2015)
  • B.A. McCutcheon et al.

    Thirty-day perioperative outcomes in spinal fusion by specialty within the NSQIP database

    Spine

    (2015)
  • K.E. Griffith

    Preoperative assessment and preparation

    Int Anesthesiol Clin

    (1994)
  • W.L. Aronson et al.

    Variability in the American Society of Anesthesiologists Physical Status Classification Scale

    AANA J

    (2003)
  • K. Hajian-Tilaki

    Receiver Operating Characteristic (ROC) Curve Analysis for Medical Diagnostic Test Evaluation

    Caspian J Intern Med

    (2013)
  • K.M. Van Abel et al.

    Vestibular schwannoma surgery in the elderly: a matched cohort study

    J Neurosurg

    (2014)
  • Cited by (16)

    • Vestibular Schwannoma Resection in a Consecutive Series of 502 Cases via the Retrosigmoid Approach: Technical Aspects, Complications, and Functional Outcome

      2019, World Neurosurgery
      Citation Excerpt :

      Tonn et al.34 also published CSF leaks (9.2%), air embolism (5.6% vs. 9.0% in our series), and cranial nerve deficits (4.7%) as the main complications of surgery (Table 9). Betka et al.35 reported a much higher rate of CSF leaks (62.5%), and McCutcheon et al.36 reported a lower one (<5%); other evaluated complications were comparable. Rössler et al.19 (N = 60) reported an advantage for the lateral position with a much lower number of CSF leaks (3.3%; n = 1) versus the semi-sitting position (10%; n = 3); however, they reported a lower hearing preservation rate in the lateral position (14% vs. 44% in the semi-sitting position).

    • Risk factors for postoperative pneumonia after microsurgery for vestibular schwannoma

      2017, Clinical Neurology and Neurosurgery
      Citation Excerpt :

      Decline in these functions may expose elderly patients to a higher risk of POP. A previous study focusing on the association between age and the complication after surgery for benign cranial nerve neoplasms reported that the incidence of POP increased with advancing age, however, the difference was not significant [12]. The inconsistency could be attributed to the different age cutoffs as well as different choices of statistical methods between studies and enrollment of a mixture of VS and other types of benign cranial nerve neoplasms in the previous study.

    • Micro vs. macrodiscectomy: Does use of the microscope reduce complication rates?

      2017, Clinical Neurology and Neurosurgery
      Citation Excerpt :

      Patient age, sex, gender, race, body mass index (BMI), functional status, and smoking status are among the demographic variables available. Patient health status markers including previous diagnoses of chronic obstructive lung disease (COPD), congestive heart failure (CHF), diabetes, hypertension, corticosteroid use for a chronic condition and American Society of Anesthesiologists (ASA) physical status classification scores were also included [12,13]. Hematocrit, platelet count, white blood cell count, albumin, International Normalized Ratio (INR), blood urea nitrogen (BUN), and creatinine from preoperative lab draws were also available for analysis. [12,13]

    • Morbid obesity increases risk of morbidity and reoperation in resection of benign cranial nerve neoplasms

      2016, Clinical Neurology and Neurosurgery
      Citation Excerpt :

      The other outcome variables specific to surgery of benign cranial nerve neoplasms were also only available after 2012 (meningitis, CSF leak, facial nerve injury, hydrocephalus) and given their incidence was less than 5%, these variables were not included in the multivariable models. The multivariable logistic regression analysis was performed to evaluate for the independent association of BMI with these patient outcomes [16]. The variables controlled for in the multivariable model included ASA physical status classification, race, gender, smoking status, diabetes, hypertension, steroid use, as well as composite variables of cardiac risk (including history of CHF, myocardial infarction, previous percutaneous coronary intervention or stenting, angina, chest pain at rest, and peripheral vascular disease), pulmonary risk (including history of COPD and pneumonia), renal risk (including renal failure and hemodialysis), and stroke risk (including transient ischemic attacks and cerebrovascular accidents).

    View all citing articles on Scopus

    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

    View full text