The Full Outline of UnResponsiveness (FOUR) score was previously developed for neurological assessment, but has not been validated in neurosurgical patients, so was compared to the Glasgow Coma Scale (GCS) in practice. Four groups of raters, expert clinicians, novice clinicians, experienced nurses, and inexperienced nurses, assessed 64 patients in awake, drowsy, stuporous, and comatose conditions to investigate rater reliability. Then, 36 patients were evaluated by 1 expert clinician and 1 from the other groups randomly to test the difference. Spearman's correlation was used to find the correlation between both scores from 68 patients. The estimation of FOUR score cut points was validated by weighted kappa compared with the GCS to establish the risk prognosis. Score feasibility was analyzed by nonparametric test. Intraclass correlation in each group was over 0.9, with no difference between expert and inexperienced raters (p À 0.05). The correlation was 0.78. Low, intermediate, and high risk prognosis were associated with 0-7, 8-14, and 15-16 FOUR scores with kappa of 0.92. The feasibility of the FOUR score was lower than that of the GCS (p º 0.01). The FOUR score is reliable and valid for consciousness evaluation with some consequences for practicability. Extensive implementation would increase familiarity.

SUMMARY The APACHE II scoring system is approved for its benchmarking and mortality predictions, but there are only a few articles published to demonstrate it in neurosurgical patients. Therefore, this study was performed to acknowledge this score and its predictive performance to hospital mortality in a tertiary referral neurosurgical intensive care unit (ICU). All patients admitted to the Neurosurgical ICU from February 1 to July 31, 2011 were recruited. The parameters indicated in APACHE II score were collected. The adjusted predicted risk of death was calculated and compared with the death rate observed. Descriptive statistics including the receiver operating characteristic curve (ROC) was performed. The results showed that 276 patients were admitted during the mentioned period. The APACHE II score was 16.56 (95% CI, 15.84-17.29) and 19.08 (95% CI, 15.40-22.76) in survivors and non-survivors, while the adjusted predicted death rates were 13.39% (95% CI, 11.83-14.95) and 17.49% (95% CI, 9.81-25.17), respectively. The observed mortality was only 4.35%. The area under the ROC of APACHE II score to the hospital mortality was 0.62 (95% CI, 0.44-0.79). In conclusion, not only the APACHE II score in neurosurgical patients indicated low severity, but its performance to predict hospital mortality was also inferior. Additional studies of predicting mortality among these critical patients should be undertaken.

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Background: The incidence of moderate to severe pain is high among patients undergoing spinal surgery. Nefopam can be used as an adjuvant analgesic postoperatively after spine surgery. The study aimed to assess the analgesic efficacy and side effects of nefopam on 24-hour postoperative morphine consumption after spine surgery. Methods: The study is a randomized, double-blinded, placebo-controlled trial. A total of 96 patients were randomized into 4 treatment groups, 24 each. In group 1, patients received normal saline before surgical incision and before the end of surgery. In group 2, patients received 30 mg nefopam before surgical incision and normal saline before the end of surgery. In group 3, patients received normal saline before surgical incision and 30 mg of nefopam before the end of surgery. In group 4, patients received 30 mg of nefopam in both timings. Patient-controlled analgesia morphine was used for the postoperative period. Outcomes were to determine 24-hour morphine consumption and incidence of side effects.  Results: Of 96 patients enrolled, 21 in placebo-placebo, 22 in nefopam-placebo, 22 in placebo-nefopam and 21 in nefopam-nefopam groups completed the study.  Analysis of the Kruskal-Wallis test on the intention-to-treat basis shows no significant difference in 24-hour postoperative morphine consumption between four groups, which were 18 [IQR 13.5-29], 20 [IQR 11-28.3], 17 [IQR 11.5-28.5], 13 [IQR 8.5-18.5] mg., respectively (p = 0.223). Incidence of side effects, including tachycardia, sedation, sweating and nausea/ vomiting, did not differ. Conclusions: Adding perioperative nefopam to opioid analgesic does not improve analgesic efficacy in patients who underwent spine surgery. Registration: Thai Clinical Trials Registry ID TCTR20171115001; registered on 15 November 2017.

Background: An increasing number of patients are opting for spine surgery despite the associated risk of cardiovascular complications. The evidence regarding the incidence and risk factors of cardiovascular complications in spine surgery is insufficient. Therefore, we aimed to determine the incidence and risk factors for cardiovascular complications that occur perioperatively in spine surgery. Methods: This retrospective study included all patients who underwent spine surgery between January 2018 and December 2019 at a single center. Demographic, clinical, and operative data were collected from electronic medical records. The incidence of perioperative cardiac complications was determined. Univariate and multivariate analyses were performed to identify risk factors for the development of perioperative cardiovascular complications in the participants. Results: Of the 1,002 eligible patients enrolled in the study, six developed cardiac complications. Acute myocardial infarction, cardiac arrest, and congestive heart failure occurred in one, two, and three patients, respectively. Risk factors for cardiovascular complications included scoliosis surgery (odds ratios (OR): 18.61; 95% confidence interval (CI): 1.346-257.35) and a history of congestive heart failure (OR: 120.97; 95% CI: 2.12-6898.80). Conclusion: The incidence of perioperative cardiovascular complications in patients who underwent spine surgery was 0.6%. High-risk patients should be closely monitored optimally managed throughout the perioperative period.