Introduction: Assessing complexity and measuring outcome is mandatory to evaluate quality in neurosurgery. A new practical grading scale to estimate the risk of worsening in brain tumor surgery, the Milan Complexity Scale (MCS), is presented.
Methods: All elective brain tumor surgeries conducted at a tertiary referral neurological center in Milan (Fondazione Istituto Neurologico C. Besta) in a two years period were considered; surgery was always aimed at maximal safe resection (i.e. biopsies excluded). A prospective database dedicated to reporting complications and all clinical and radiological
data were retrospectively reviewed. The Karnofsky Performance Scale (KPS) was used to classify each patient’s health status. A logistic regression model was used to identify possible predictors of clinical worsening after surgery in terms of changes between the preoperative and discharge KPS scores. Statistically significant predictors were rated based on their odds ratios to build an ad hoc complexity scale.
Results: The case series was composed of 746 patients (mean age 51.3 ± 17.1). The mortality rate was 0.94%, the major complication rate was 9.1%, and the minor complication rate was 32.6%. At discharge, 523 (70.1%) patients improved or remained unchanged and 223 (29.9%) patients worsened. Five factors were found to be significant predictors of clinical worsening: tumor size>4 cm, cranial nerve manipulation, major brain vessel manipulation, posterior fossa location, and eloquent area involvement. A grading scale, the MCS (Table 1), was obtained with scores ranging between 0 and 8. Worsened patients showed preoperative MCS significantly higher than improved/unchanged ones. Scores higher than 3 were suggestive of worse clinical outcome.
Conclusions: The MCS enables to assess complexity and to estimate the risk of clinical worsening after brain tumor surgery. It is currently under internal and external validation. It could reveal a useful tool for research/educational purposes, for quality evaluation and to improve health system management.
Patient Care: The Milan Complexity Scale, through preoperative complexity assessment and worsening prediction, may improve patients' understanding of their pathology and facilitate patients' informed consent. It may also be useful for quality evaluation and improve health system management
Learning Objectives: By the conclusion of this session, participants should be able to:
1) Describe the importance of preoperative complexity assessment and measuring outcome in oncological surgery
2) Learn how to use the Milan Complexity Scale
3) Identify factors involved in clinical worsening after brain tumor surgery.
References: 1. Ferroli P, Broggi M, Schiavolin S, Acerbi F, Bettamio V, Caldiroli D, Cusin A, La Corte E, Leonardi M, Raggi A, Schiariti M, Visintini S, Franzini A, Broggi G. Predicting functional impairment in brain tumor surgery: the Big Five and the Milan Complexity Scale. Neurosug Focus. 2015 Dec 39(6):E14.
1. Ferroli P, Broggi M, Schiavolin S, Acerbi F, Bettamio V, Caldiroli D, Cusin A, La Corte E, Leonardi M, Raggi A, Schiariti M, Visintini S, Franzini A, Broggi G. Predicting functional impairment in brain tumor surgery: the Big Five and the Milan Complexity Scale. Neurosug Focus. 2015 Dec 39(6):E14.
2. Landriel Ibañez FA, Hem S, Ajler P, Vecchi E, Ciraolo C, Baccanelli M, et al: A new classification of complications in neurosurgery. World Neurosurg 2011 75:709–715.
3. Sarnthein J, Stieglitz L, Clavien PA, Regli L. A Patient Registry to Improve Patient Safety: Recording General Neurosurgery Complications. PLoS One. 2016 Sep 26;11(9):e0163154.