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Predicting opioid use after lumbar spine fusion remains a challenge. The aim of this study was to identify clinical and demographic parameters that could be associated with opioid use trends during hospitalization after lumbar spine fusion.A cohort study of prospective data for all lumbar fusions performed by single surgeon for an 18-month period from 2019 to 2020 was conducted. Univariable and multivariable linear regression analyses were used to assess associations.Amongst the overall cohort of 136 lumbar fusion patients, the mean age was 66.1 ± 10 years, there was an average of 1.7 ± levels treated. Overall, mean opioid use for total stay was 276 ± 360 morphine milligram equivalents (MME), with the greatest amount on postoperative day 1 (POD1) with 81.6 ± 86 MME. Multivariable linear analysis identified older age (-9.9 MME/year; P 0.01), male gender (-130 MME; P = 0.03) and thoracolumbar interfascial plane (TLIP) block (-144 MME; P = 0.02) all independently were associated with significantly lower opioid use during overall hospitalization. Older age (P 0.01), POD1 pain in back (P 0.01), and TLIP use (P 0.02) also independently were associated significantly lower opioid use on POD1.Significant reductions in opioid use during hospitalization after lumbar spine fusion were associated with patients that were older, male, and had a TLIP block used. The maximum absolute opioid use was on POD1. We were able to quantify these trends on a daily gradient, which lays the conceptual groundwork to develop personalized algorithms which can model opioid use during hospitalization prior to surgery.

Diffuse leptomeningeal glioneuronal tumor (DLGNT), also known as oligodendrogliomatosis, is a rare neuro-oncologic condition along the neuraxis that remains poorly understood in children. We sought to describe our institutional experience and quantitively summarize the clinical survival and prognostic features of DLGNT in the pediatric population across the contemporary literature.We report four institutional cases of pediatric DLGNT diagnosed between 2000 and 2020 based on retrospective review of our records, and performed a comprehensive literature search for published cases from 2000 onwards to create an integrated cohort for analysis. Kaplan-Meier estimations, Fisher's exact test, and logistic regression were utilized to interrogate the data.Of our four cases, three females aged 2-, 3- and 13-years old at diagnosis survived 6-years, 3-years and 14-months respectively, and one male aged 5-years old at diagnosis was still alive 5 years later. Our overall integrated cohort consisted of 54 pediatric DLGNT patients, with 19 (35%) female and 35 (65%) male patients diagnosed at an average age of 6.4 years (range, 1.3-17 years) by means of surgical biopsy. Chemotherapy was used in 45 cases (83%), and mean follow-up time of 54 months (range, 3-204). Across the entire cohort, overall survival 1 month after diagnosis was 96% (95% CI 86-99%), and by 10 years was 69% (95% CI 49-82%). On multivariate analysis of complete data, chemotherapy treatment (HR=0.23, P = 0.04) was statistically predictive of longer overall survival.More than 2-out-of-3 pediatric DLGNT patients survive beyond one decade. Chemotherapy is statistically associated with longer survival in DLGNT pediatric patients and should form the core of any treatment regimen in this setting. Early detection by means of judicious imaging and surgical biopsy for tissue diagnosis can lead to earlier treatment and likely superior outcomes.

Objective Traditionally, extent of resection (EOR) has been seen as a surgical parameter that can predict survival outcomes of surgically managed WHO grade II gliomas. The aim of this study was to evaluate if such an influence was potentially affected by 1p/19q codeletion status based on a national cancer registry. Patient and methods All adults diagnosed with grade II gliomas between the years 2004 to 2014 were queried from the National Cancer Database (NCDB). The population was then divided based on 1p/19q codeletion status, and then Kaplan-Meier, univariate and multivariate Cox regression analyses were utilized to evaluate the prognostic effect of EOR. Results In total, 1,498 grade II gliomas satisfied inclusion for analysis, with the 1p/19q non-codeleted in 705 (47%) cases, and codeletion in 793 (53%) cases. When the cohort was divided based on codeletion status, Kaplan-Meier modelling and univariate regression analyses indicated that gross total resection (GTR) was significantly associated with greater 5-overall survival (OS) in both 1p/19q non-codeleted and codeletion groups. Upon multivariate analysis which incorporated adjuvant therapy status, the significance of GTR was only retained in the 1p/19q non-codeletion group after post-hoc adjustment. Conclusion Our findings indicate that the survival impact of GTR in grade II gliomas may be affected by 1p/19q codeletion status within the first five years after surgery based on overall survival. Therefore, molecular diagnostics have potential clinical application in surgery outcomes, and validation of the reported findings will assist in surgical planning if such an association can be thoroughly established.

Idarucizumab is the first Food and Drugs Administration (FDA) approved reversal agent for anticoagulant dabigatran, a direct thrombin inhibitor. Emerging evidence suggests idarucizumab can improve clinical outcome following dabigatran-associated hemorrhage, however, its specific use in intracranial hemorrhage has been poorly described. The aim of this study was to systematically review the available literature of idarucizumab in the setting of dabigatran-associated ICH to evaluate its efficacy in the stabilizing/resolving of the primary hemorrhage. A systematic search of 7 electronic databases from their earliest records to August 2018 was conducted following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. There were 864 articles identified for screening against selection criteria. The search identified 9 articles to be included in our analysis, describing hemorrhage outcomes in 23 dabigatran-associated cases of ICH managed by idarucizumab. Mean overall age was 76.2 years, with 43% females, and bleeding was subdural, subarachnoid and intracerebral in 43%, 13% and 43% cases respectively. Surgical intervention was pursued in 48% of cases. During the course of the hospitalization, the hemorrhages stabilized/resolved in 87% of patients, and worsened in 13%. In-hospital complications occurred in 4% of cases, and mortality occurred in 4% of cases as well. The available literature suggests that idarucizumab can be applied in the setting of ICH, for its therapeutic effect in patients presenting with dabigatran-associated ICH appears acceptable with no compromise to clinical safety. However, currently there is a paucity of data about various aspects that are involved in other aspects of ICH treatment, including recovery, that limits the significance of the current literature. As more evidence is published relating specifically to long-term ICH outcomes that have been treated by idarucizumab, we will be better placed to establish the optimal role of idarucizumab in the setting of dabigatran-associated ICH.

The resection of insular gliomas remains a neurosurgical challenge due to the close proximity of functionally-important cortical, white matter tracts, and vasculature structures. More recently, the feasibility of resection has gained traction, however, there is a lack of consolidated neurological deficit metrics. Thus, the aim of this study was to determine the incidences of neurological deficits following insular glioma resection to better guide selection algorithms and resource allocations. Searches of seven electronic databases from inception to August 2018 were conducted following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Data were extracted and pooled using meta-analysis of proportions. Meta-regression was used to identify potential sources of heterogeneity. Nineteen observational studies reported the neurological outcomes of 890 insular glioma patients. The pooled incidences of new temporary and permanent motor deficits were 11% (95% CI, 6-17%) and 4% (95% CI, 2-7%) respectively, and new temporary and permanent language deficits were 11% (95% CI, 6-17%) and 2% (95% CI, 0-4%) respectively. Single-surgeon series reported significantly lower incidences of both permanent motor (2% vs 7%; P 0.001) and language (1% vs 3%; P = 0.03) deficits. The incidences of motor and language neurological deficits following insular glioma resection have been quantified, and will assist in determining the suitability and appropriateness of pursuing surgical resection for insular glioma. We note that permanent neurological deficits are lowest when reported by series describing outcomes of a single surgeon, indicating most optimal outcomes may be best achieved after intense training and/or greater experience.

The incidence of extraosseous Ewing’s sarcoma, a highly malignant mesenchymal mass, is rare in the spinal cord and its clinical outcomes unknown. To date, few cases of primary intradural extramedullary Ewing’s sarcoma (PIEES) have been reported, with varying follow-up. Herein, we aimed to perform a comprehensive review of all cases published in the literature and update previously reported cases from our institution. Institutional medical records were searched for cases of PIEES of the spine managed at our institution between the years 2005 and 2018. We performed a systematic search of two electronic databases (Ovid Medline and Embase) from inception to August 2018 to obtain all published cases of primary intradural extraosseous Ewing’s sarcoma (PIEES).We used our institutional medical records to update cases reported from our institution. We identified a total of 44 cases with pIEES reported in the existing literature of which 5 have been from our department. Of the 41 cases, the median age of diagnosis was 31 years. The most common presentation pattern was PIEES in the lumbar/sacral region (61%, n = 27), with a majority (59%, n = 25) presenting initially with pain. The most common modality of treatment reported was surgery (41/41, 100%), followed by adjuvant chemotherapy (31/44, 70%) and local radiation therapy (29/44, 66%). Overall, recurrence was reported in 17/36 (46%) cases, with median progression free survival (PFS) of 12 months (range, 1–72). There were 12/37 (32.4%) deaths reported, with median overall survival (OS) of 14 months (range, 1–72). Hence, we present the most updated review of all reported cases of PIEES. While surgical resection is the mainstay of treatment, tumor recurrence is a great concern given the adhesive nature of the lesion preventing complete resection. Adjuvant chemotherapy and radiotherapy should be carefully considered to prevent recurrence and improve survival outcome.

Inferior petrosal sinus sampling (IPSS) offers a means of differentiating between Cushing disease and Cushing syndrome with lower false-positive and false-negative rates relative to traditional techniques. However, consolidated data on efficiency reflecting contemporary use is lacking. We present a comprehensive meta-analysis of IPSS as a means of diagnosing ACTH-cortisol axis derangements via both CRH and desmopressin-stimulated techniques.Searches of 7 electronic databases from inception to December 2020 were conducted following PRISMA guidelines. Articles were screened against pre-specified criteria. Outcomes were pooled by random-effects meta-analyses of proportions where possible. We performed a meta-analysis of sixty-eight unique publications, assessing each technique for positive predictive value (PPV), false positive rates, and overall changes in practice patterns over time.A total of 68 studies satisfied all criteria, with 3685 (3471, 94.2% confirmed) and 332 (285, 85.8% confirmed) patients tested for Cushing's disease and syndrome, respectively. Pooled analyses demonstrated an overall PPV of 89.3% (95%CI[83.6%, 94.0%]) in CRH stimulation diagnosis of Cushing disease. In desmopressin stimulation, our analyses demonstrated an overall PPV of 96.5% (95%CI[94.5%, 98.1%]) in diagnosis of Cushing disease. There was a significant decline in the use of CRH-stimulation IPSS in diagnosis of both Cushing disease (p = 0.0055) and Cushing syndrome (p = 0.013). Concurrently, there was a significant increase in the use of desmopressin-stimulation IPSS in diagnosis of both pathologies (p lt; 0.0001).Our findings demonstrate significant changes in practice patterns with respect to IPSS stimulation technique. Our pooled analyses demonstrate improved diagnostic performance in desmopressin stimulation procedures relative to CRH stimulation procedures. Further multi-institutional studies with special attention to acquiring quality data for sensitivity, specificity, and other critical analyses are necessary to truly evaluate this promising technique.

The prediction of outcome after mechanical thrombectomy (MT) of basilar artery occlusion (BAO) remains an area of investigation. The objective of this study was to evaluate the prognostic role of presenting National Institute Health of Stroke Scale (NIHSS) scores in predicting favorable 90-day functional outcome. A survey of 7 electronic databases from inception to May 2020 was conducted following PRISMA guidelines. Articles were screened against pre-specified criteria. Multivariate odds ratios (ORs) for favorable 90-day function outcome (modified Rankin Score 0-2) were extracted and pooled by meta-analysis of proportions with random effects modeling. A total of 10 individual studies satisfied criteria for selection and described a total of 941 BAO patients managed by MT. Analysis revealed 590 (63%) males with a mean age of 66.6 years. The median presenting NIHSS was 19, and 316 (34%) patients were reported to have a favorable functional status 90-days after treatment. Lower presenting NIHSS scores independently and significantly predicted favorable 90-day functional outcome in BAO patients with a pooled OR of 0.89 (95% CI, 0.87-0.92; I2 = 18%; P-heterogeneity = 0.28). Meta-regression did not detect any clinical parameter that influenced this trend direction or its significance, and bias assessments were unremarkable. We confirm in this study via a consensus within the literature that the presenting NIHSS score predicts 90-day functional outcome in BAO patients treated by MT. Further, its standardized use allows more meaningful comparisons between interventions and anatomical locations.

In the management of glioblastoma (GBM), there is a considerable predisposition to hyperglycemia due to significant integration of corticosteroid therapy to treat predictable clinical sequelae following diagnosis and treatment. The aim of this study was to quantify effect of hyperglycemia during the management of GBM on overall survival (OS). Searches of seven electronic databases from inception to January 2018 were conducted following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. There were 1475 articles identified for screening. Prognostic hazard ratios (HRs) derived from multivariate regression analysis were extracted, and analyzed using meta-analysis of proportions and linear regression. Six observational studies reporting prognostic HRs in 10 cohorts were included. They described 1481 GBM diagnoses, all surveyed for hyperglycemia during management. Hyperglycemia was found to confer a statistically significant poorer OS outcome (HR, 1.671; p 0.001). This trend and its significance was not modified by study year, size or proportion of pre-diagnostic diabetes mellitus. Hyperglycemia in GBM is an independent poor prognostic factor for OS. Heterogeneity in clinical course limits inter-study comparability. Future, prospective, randomized studies will validate the findings of this study, and ascertain the potential benefit of more rigorous monitoring for hyperglycemia and glycemic control.

Surgical resection of eloquent glioma can be achieved under general anesthesia (GA) or awake anesthesia (AA). The appeal of AA is that it facilitates intraoperative identification and avoidance of eloquent areas, which has the potential to minimize functional compromise. The aim of this meta-analysis was to compare the operative outcomes of eloquent glioma resection performed under GA compared to AA to assist in optimizing the decision algorithm between the two approaches. Searches of seven electronic databases from inception to December 2017 were conducted following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. There were 1037 articles identified for screening. Data were extracted and analyzed using meta-analysis of proportions. A total of 9 comparative studies were included for analysis. Resection of glioma involving eloquent areas achieved under AA is mostly comparable in terms of operative and functional outcomes to that of GA. AA did demonstrate significantly lower incidence of postoperative nausea and vomiting (PONV, OR, 0.17; p 0.001) and shorter length of stay (LOS, MD, -1.76 days; p = 0.02) when compared to GA. Future studies that are larger, prospective, randomized, and include long term quality of life metrics will assist in elucidating the true clinical benefit of AA in resecting glioma involving eloquent areas. This will assist in further developing management protocol of these glioma.

The role of prognostic factors in the management of glioblastoma (GBM) is very important given the stasis in improving its clinical outcomes. Patients who initially present with a positive seizure history at diagnosis have anecdotally experienced superior survival outcomes. The aim of this review was to perform a systematic review and meta-analysis to quantify the potential prognostic significance of positive seizure history in GBM patients. A search strategy was performed using the PRISMA guidelines for article identification, screening, eligibility and inclusion. Relevant articles were identified from six electronic databases from their inception to August 2017. These articles were screened against established criteria for inclusion into this study. Meta-analysis was conducted by pooling results with multivariate-adjusted hazard ratios (HRs). After screening, 6 relevant studies were included for analysis. There was a total cohort of 1836 GBM patients, of which 488 (27%) had a positive seizure history at initial presentation. There was a significant association found between positive seizure history in GBM patients and less mortality events, with an overall HR of 0.71 (95%CI=0.63-0.81, p

Although foreign medical graduates (FMGs) have been essential to the US physician workforce, the increasing competitiveness has made it progressively challenging for FMGs to match in US neurosurgery programs. We describe geographic origins and characteristics associated with successful match into US neurosurgery training programs.Retrospective review of AANS membership data (2007-2017). Scopus was used to collect bibliometrics.From 2009 neurosurgical residents, 165 (8.2%) were FMGs. Most were male (n = 148; 89.6%) with a median age of 34.0 years. Top six feeder countries (TFC) included India (13.9%; n = 23), Lebanon and Pakistan (9.1%; n = 15), Caribbean Region (7.2%; n = 12), Mexico (6.67%; n = 11), and Greece (3.6%; n = 6). Compared to FMGs from non-top feeder countries (NTFC), TFC FMGs had higher H-indices (2 vs 4, p = 0.049), greater number of publications (2 vs 5, p = 0.04), were more likely to have an MBBS/MBBCh (n = 38 vs n = 17, p = 0.03), and had twice as many candidates from major feeder medical schools that successfully matched into a US neurosurgery program (n = 43 vs NTFC = 20, p 0.001). NTFC FMGs were almost 3-times more likely to match at an affiliated neurosurgery program (8 vs TFC = 3, p = 0.03), while TFC FMGs were 1.5-times more likely to match at an NIH Top-40 program (33 vs NTFC = 21, p = 0.03).TFC graduates have higher bibliometrics, frequently come from major feeder schools, and have greater match success at a broader selection of programs and NIH top-40 programs. Future studies characterizing FMG country and medical school origins may enable foreign students to geographically target institutions of interest and could allow US programs to better evaluate foreign training environments.

The clinical management of medulloblastoma has undergone significant transformation since the recent dawn of the molecular era. The aim of this analysis was to evaluate citation and other bibliometric characteristics of the 100 most cited medulloblastoma articles in the literature to better understand the current state of our research efforts into this diagnosis. Elsevier's Scopus database was searched for the 100 most cited articles that focused on medulloblastoma. Articles were dichotomized as either primarily basic science (BSc) or clinical (CL) articles. Various bibliometric parameters were summarized and compared between BSc and CL articles using Pearson's Chi-square and Mann Whitney U tests. Of the 100 most cited articles, 52 were characterized as BSc articles and 48 as CL articles. Overall median (range) values were as follows: citation count 252 (164-1,270); citation rate per year 17.5 (2.5-110); number of authors 11 (1-135); and publication year 2005 (1925-2014). Articles were published in a total of 40 different journals, and the majority originated in the US (n = 60). When compared to CL articles, BSc articles reported significantly greater citation rates per year (P < 0.01), and more recent years of publication (P < 0.01). In summary, although similar in overall proportion, BSc articles demonstrated significantly increased bibliometric parameters of impact in this field by the successful clustering molecular subtypes. Moving forward, it will be of great interest to see how the findings from these impactful BSc articles will translate into future clinical initiatives and subsequently high-impact CL articles.

Intervention (surgery, embolization, and radiosurgery) is critical in maximizing outcomes of pediatric arteriovenous malformations (pAVMs). Although short-term functional outcomes following intervention have been stablished to be favorable, long-term outcomes have yet to be thoroughly consolidated. Searches of 7 electronic databases from inception to April 2019 were conducted following PRISMA guidelines. Articles were screened against pre-specified criteria. Favorable functional were modified Rankin Scale (mRS) scores ranging from 0 to 2, and the incidences were extracted and pooled by random-effects meta-analysis of proportions. Fourteen pertinent studies were identified describing outcomes of 699 pAVM patients, with median 75 % presenting with hemorrhage. Surgery, embolization and radiosurgery use were reported by 12 (86 %), 14 (100 %) and 10 (71 %) studies respectively. By median study follow-up time of 4.1 years, a favorable functional outcome was estimated to occur in 87 % (95 % CI, 82-91 %) of subjects respectively. Hemorrhagic versus non-hemorrhagic presentations did not statistically differ in incidence of this long-term outcome, 78 % (95 % CI, 67-87 %) and 91 % (95 % CI, 80-98 %) respectively. This study demonstrates that favorable long-term functional outlook of pAVM subjects after intervention can persist for many years after initial intervention. The certainty of achieving this outcome is moderate, irrespective of hemorrhagic presentation or intervention modality. Long-term functional deficit risk should not be the sole factor in deciding if intervention should be pursued.

The influence of obesity on spine surgery outcomes is highly controversial with a current clinical equipoise. Several studies suggest higher perioperative morbidity with obesity while other studies suggest otherwise. To address this gap in the literature, we conducted a systematic review and meta-analysis in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines with the objective of better defining the impact of obesity on outcomes following lumbar spine surgery. Risk of bias assessment was performed using the Newcastle-Ottawa Scale. Strength of evidence was assessed using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) Working Group system. Surgical outcomes such as blood loss, operative time, length of stay, complication and reoperation rates and functional outcomes represented by the change in Oswestry Disability Index and Visual Analog Scale-Back Pain were compared between obese and non-obese patients. A total of 32 studies with 23,415 patients were analyzed. Obese patients had slightly higher surgical blood loss (Mean Difference [MD]: 46.15 ml, CI: 20.21–72, p-value 40) patients as well.

Intracranial meningiomas such as olfactory groove meningioma (OGM) and tuberculum sellae meningioma (TSM) arising at the anterior skull base are amenable to surgical resection. Traditionally, this has been achieved by transcranial approaches (TCAs), however, there has been an evolution in an endoscopic endonasal approach (EEA) within recent years. The aim of this systematic review and meta-analysis was to determine if the EEA was superior to the TCA in managing these anterior skull base meningioma based on comparative studies only, and highlight the limitations of the current literature. Searches of seven electronic databases from inception to April 2018 were conducted following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. There were 1479 articles identified for screening. Data were extracted and analyzed using meta-analysis of proportions. A total of 10 comparative studies satisfied criteria for inclusions. Resection by the EEA resulted in significantly less likelihood of worse vision (OR, 0.318; p = 0.039) when compared to TCA in OGM. However, EEA resulted also in significantly greater likelihoods of olfactory loss in OGM (OR, 4.511; p = 0.038) and TSM (OR, 3.075; p = 0.017), and CSF leak (OR, 3.854; p = 0.013) in TSM. In terms of surgical and prognosis outcomes, there was no statistically significant trend in favor of either approach in OGM or TSM. The EEA appears to confer a different postoperative complication profile when compared to the TCA in resecting OGM vs TSM which validates previous case-series comparisons. There is a need for longer-term studies that are larger, prospective, randomized in order to fully elucidate efficacy given slow tendency for progression of meningioma in order to develop a more rigorous approach selection algorithm.

Glioblastoma (GBM) can often present with seizure. Attempts have been made to associate the use of anti-epileptic medication valproic acid (VPA) in standard of care management with survival benefit in the past; however, results to date have been conflicting, and most likely subjected to historical bias. This study aimed to quantify the overall survival (OS) effect of VPA in patients with GBM based on the current literature, and identify potential trend-modifying covariates. Searches of 7 electronic databases from inception to April 2018 were conducted following the appropriate guidelines. Hazard ratios (HRs) derived from Cox proportional hazard models, and mean differences (MDs), were analyzed using the random effects model. Meta-regression was used to identify potential trend-modifying covariates. Seven retrospective cohort studies satisfied selection criteria describing 2181 primary GBM diagnoses, with 534 (24%) receiving VPA in their treatment. Overall, VPA was shown to confer a statistically significant OS advantage (HR, 0.71; 95% CI, 0.56-0.91; p 0.01) compared to the control group by up to 2.4 months (95% CI, 1.51-3.21; p 0.01). However, upon meta-regression, this survival advantage as inferred by HRs trended towards the null in newer studies (slope, 1.15; p = 0.02) or in studies with older participants (slope, 1.13; p = 0.02). A similar result was seen with MDs. Based on the literature to date, VPA was significantly associated with better OS in GBM patients by 2.4 months when managed by current standard of care. However, this effect was particularly emphasized among older studies or studies conducted in younger participants indicating the need to exercise caution in assuming generalizability of the pooled effect. Overall, there is considerable bias risks in the current interpretation of the literature, and larger, prospective studies are required for validating our findings.

The purpose of this study was to systematically compare the effectiveness and safety of full-endoscopic discectomy (FED) and micro-endoscopic discectomy (MED) with open discectomy (OD) for the treatment of symptomatic lumbar disc herniation.Electronic searches were performed using six databases from their inception to February 2016, identifying all relevant randomized controlled trials and comparative observational studies comparing either FED or MED with OD. Data were extracted and analyzed according to predefined clinical endpoints.Twenty three studies were selected for analysis, including 421 FED, 6914 MED, and 21,152 OD cases. No significant difference was found between FED and OD in regards to postoperative visual analog scale (VAS) leg pain scores (WMD 0.03, P=0.93). Similar results were obtained for MED vs OD (WMD 0.09, P=0.18). In terms of postoperative Oswestry disability index (ODI), both FED and MED were similar to OD (WMD -2.60, P=0.32 and WMD -1.00, P=0.21, respectively). FED had a significantly shorter operative duration compared to OD (54.6 vs 102.6min, P=0.0001). MED alone and endoscopic approaches overall (including MED and FED) demonstrated significantly lower estimated blood loss (44.3 vs 194.4mL, P=0.03 and 38.2 vs 203.5mL, respectively, both p0.05). FED alone demonstrated a trend towards lower estimated blood loss in comparison to OD (3.3 vs 244.9mL, P=0.07). No difference was found in overall complications, recurrence or reoperation rates, dural tears, root injury, wound infections, and spondylodiscitis between FED vs OD, or MED vs OD.Based on this meta-analysis, FED and MED appear to be safe and efficacious alternatives to traditional approaches, but these results require further investigation and validation by prospective randomized studies.