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A New Classification of Complications in Neurosurgery

Federico Alfonso Landriel Ibaez, Santiago Hem, Pablo Ajler, Eduardo Vecchi, Carlos Ciraolo, Matteo Baccanelli,
Ruben Tramontano, Fernando Knezevich, Antonio Carrizo

Key words
Adverse outcome
Morbidity and mortality conference
Neurosurgical complications
Spine complications
Abbreviations and Acronyms
CSF: Cerebrospinal fluid
ICU: Intensive care unit
MMC: Morbidity and mortality conference
Department of Neurosurgery of the Hospital
Italiano de Buenos Aires, Argentina
To whom correspondence should be addressed:
Federico Alfonso Landriel Ibaez, M.D.
[E-mail: fedelandriel@gmail.com]
Citation: World Neurosurg. (2011) 75, 5/6:709-715.
DOI: 10.1016/j.wneu.2010.11.010
Journal homepage: www.WORLDNEUROSURGERY.org
Available online: www.sciencedirect.com
1878-8750/$ - see front matter 2011 Elsevier Inc.
All rights reserved.

INTRODUCTION
The assessment of surgical complications
is an important tool in neurosurgical practice (11) because it can improve safety and
quality of patient treatment (7, 14, 27, 43).
The different views on and denitions of
what is considered a complication (11), coupled with the absence of a widely accepted
classication of postoperative adverse
events, may lead to a subjective interpretation of surgical negative outcomes (17, 41,
42). Comparisons between two distinct
time periods in a single hospital or between
different institutions are almost impossible
because no standard reporting system exists (17, 19, 25).
To illustrate the problem, we focus on
three extensive reports of complications derived from epilepsy surgery (9, 45, 48),
which offer very different criteria for complications. In two of the reports, complication severity was judged minor (transient)
when the complication resolved within 1
year of the surgical procedure and major
(permanent) when the complication lasted
for more than 1 year postoperatively (9, 48).
In the third report, events that resolved

OBJECTIVE: To define and grade neurosurgical and spinal postoperative

complications based on their need for treatment.
METHODS: Complications were defined as any deviation from the normal
postoperative course occurring within 30 days of surgery. A four-grade scale was
proposed based on the therapy used to treat the complications: grade I, any
nonlife-threatening complications treated without invasive procedures; grade II,
complications requiring invasive management such as surgical, endoscopic, and
endovascular procedures; grade III, life-threatening adverse events requiring
treatment in an intensive care unit (ICU); and grade IV, deaths as a result of
complications. Each grade was classified as a surgical or medical complication.
An observational test of this system was conducted between January 2008 and
December 2009 in a cohort of 1190 patients at the Hospital Italiano de Buenos
Aires.
RESULTS: Of 167 complications, 129 (10.84%) were classified as surgical, and 38
(3.19%) were classified as medical complications. Grade I (mild) complications
accounted for 31.73%, grade II (moderate) complications accounted for 25.74%, and
grade III (severe) complications accounted for 34.13%. The overall mortality rate was
1.17%; 0.84% of deaths were directly related to surgical procedures.
CONCLUSIONS: The authors present a simple, practical, and easy to reproduce way to report negative outcomes based on the therapy administered to treat
a complication. The main advantages of this classification are the ability to compare
surgical results among different centers and times, the ability to compare
medical and surgical complications, and the ability to perform future metaanalyses.

within 3 months were regarded as minor

complications, whereas events that extended for more than 3 months were considered to be major complications (45).
There is disagreement about what is a medical or a surgical complication; two reports
considered postoperative pneumonia, pulmonary embolism, and deep vein thrombosis to be surgical complications (9, 45),
whereas the other report included these
complications in a miscellaneous group
(48).
Black (11) presented neurosurgeons with
the results of a survey on what was listed as
a complication at their institutions. Diverse
denitions were provided. Black asked
whether neurosurgeons could and should
adopt a uniform denition of complication.

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In 1992, Clavien et al. (17) proposed a

classication for general surgery complications that focused on a therapy-oriented,
four-level severity grading system. In 2004,
Dindo et al. (19) revised and modied this
classication for improved accuracy and acceptability in the surgical community and
proposed a therapy-based ve-grade classication. They showed the reproducibility of
their classication through a worldwide
survey sent to 10 surgical centers. Our hospital was included in this study and used
this system in general surgery for more than
6 years.
In 2001, Bonsanto et al. (14) standardized general adverse neurosurgical postoperative events to conform to a threecategory classication: (i) neurosurgical

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Table 1. Classification of Neurosurgical Complications

Grade I

Any nonlife-threatening deviation from normal postoperative course, not

requiring invasive treatment

Grade Ia

Complication requiring no drug treatment

Grade Ib

Complication requiring drug treatment

Grade II

Complication requiring invasive treatment such as surgical, endoscopic, or

endovascular interventions

Grade IIa

Complication requiring intervention without general anesthesia

Grade IIb

Complication requiring intervention with general anesthesia

Grade III

Life-threatening complications requiring management in ICU

Grade IIIa

Complication involving single organ failure

Grade IIIb

Complication involving multiple organ failure

Grade IV

Complication resulting in death

Surgical Complications

Adverse events that are directly related to surgery or surgical technique

Medical Complications

Adverse events that are not directly related to surgery or surgical technique

ICU, intensive care unit.

complications, (ii) neurosurgically complicated courses, and (iii) medical nonsurgical complications. In 2009, Houkin et
al. (29) presented a quantitative analysis
of complications in neurosurgery and
classied adverse events into ve types,
on the basis of adverse event avoidance
predictability and possibility.
In 2010, Lebude (32) conducted a survey
with more than 200 spine surgeons to establish what was considered a complication. Based on the survey results, Lebude
presented a binary denition of complications, by virtue of which they were classied
into minor and major adverse events.
We based our classication on the proposal of Clavien (17) and Dindo (19) and
modied it to conform to neurosurgical and
spine procedures and outcomes more suitably. This classication focuses on general
postoperative morbidity. We used a fourgrade severity scale based on the therapy
administered to treat a postoperative adverse event and considered how it related to
the surgical procedure to come up with a
simple, practical, and easy to reproduce way
to report negative outcomes.

METHODS
Complications were dened as any deviation from the normal postoperative course
occurring within 30 days of surgery. We
used adverse postoperative event and

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negative outcome as synonyms of complication.

Grade I complications were dened as
any nonlife-threatening deviation from
the normal postoperative course that could
be treated without invasive procedures.
Grade I adverse events were classied into
two subgroups based on the drug treatment
required: Grade Ia complications included
events with spontaneous resolution, requiring no drug treatment (eg, transient nerve
palsy, asymptomatic arrhythmia), and
Grade Ib complications included events requiring drug therapy (eg, discitis or pneumonia treated with antibiotics). Grade II
complications included adverse postoperative events requiring invasive management
such as surgical, endoscopic, and endovascular procedures. Grade II events were also
classied into two subgroups, depending
on the need for general anesthesia: Grade
IIa comprised complications treated without general anesthesia (eg, cerebrospinal
uid [CSF] rhinorrhea requiring lumbar
punctures or deep vein thrombosis requiring a vena cava lter), whereas grade IIb
comprised postoperative adverse events
treated under general anesthesia (eg, hardware malposition requiring reoperation or
esophageal or gastric bleeding requiring
endoscopic treatment). Grade III complications referred to life-threatening adverse
events requiring treatment and care in a
more complex hospital area, such as an in-

tensive care unit (ICU). These adverse

events were classied into grade IIIa, which
included single organ dysfunction (eg,
postoperative intracerebral hematoma requiring reoperation or renal insufciency
requiring dialysis), and grade IIIb, which
included multiple organ dysfunction, a condition of severe morbidity constituting a
most frequent cause of death (eg, intracranial hypertension and hemodynamic instability or cardiopulmonary insufciency).
Grade IV included death as a result of
complications. Each grade was classied
into medical or surgical complications
(Table 1).
We dened medical complications as
adverse events that were not directly related
to surgery or surgical techniques (eg, pneumonia, esophageal or gastric bleeding,
cardiac thromboembolism, renal insufciency, urinary tract infection). Complications more directly associated with surgery
or surgical techniques (eg, CSF leak, subdural or epidural hematomas, discitis, ischemia with sensory or motor involvement,
and vascular or neural injuries related to
instrumentation) were regarded as surgical
complications. Patients developing a surgical and a clinical complication were included in the surgical complications group.
The medical complications group comprised purely clinical adverse events with no
surgical complication.
Certain ranges of expected adverse outcomes (eg, transient facial paralysis after
acoustic neuroma resection) were also included in our classication despite the fact
that they may be regarded as accepted or
unavoidable outcomes of the procedure and
considering that the patient was informed
of their eventual occurrence when agreeing
to undergo surgery, and regardless of them
being still regarded as bad (11), especially
from the patients perspective. Transient
complications were dened as a new neurologic decit resulting from the procedure,
which improved within 30 days of the surgical intervention. Persistent complications
were dened as a new neurologic decit extending more than 30 days after the surgical
procedure. Both types can be added to each
classication grade by including T for
transient or P for persistent, indicating
a worsened severity and the need of further follow-up to evaluate neurologic outcome.
When more than one complication was

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Table 2. Examples of Complication Grades

Grades

Surgical Complications

Medical Complications

Ia

Transient new neurologic deficit

Subcutaneous CSF accumulation
Transient diabetes insipidus requiring no drugs
Hardware malposition not requiring reoperation

Local phlebitis
Acute urinary retention
Atelectasis requiring physical therapy
Noninfectious diarrhea
Grade 1 or laminar pneumothorax

Ib

Seizures requiring anticonvulsants

CSF infection requiring antibiotics
Discitis requiring antibiotics
Sinus thrombosis requiring anticoagulation
Diabetes insipidus requiring antidiuretic hormone

Allergic reaction requiring drug treatment

Urinary tract infection requiring antibiotics
Pneumonia treated with antibiotics
Infectious diarrhea requiring antibiotics
Arrhythmia requiring drug reversion

IIa

CSF fistula requiring lumbar punctures

Dural laceration requiring lumbar drainage
Dehiscent noninfected wound requiring closure under local
anesthesia
Subgaleal CSF accumulation requiring lumbar drainage

Pneumothorax requiring chest tube

Cardiac bradyarrhythmia requiring pacemaker implantation
with local anesthesia
Pleural exudates or transudates requiring drainage
Deep vein thrombosis requiring vena cava filter

IIb

CSF leaks requiring surgical repair

Hardware malposition requiring reoperation
Wound infection requiring surgical toilette
Stimulating electrodes displacement
Shunt dysfunction requiring exploration

Esophageal or gastric bleeding requiring endoscopy

Lower gastrointestinal bleeding requiring colonoscopy
Atelectasis requiring bronchoscopy

IIIa

Acute hydrocephalus requiring external ventricular drainage

Intracerebral hematoma requiring reoperation
Esophageal tear requiring surgical closure
Subepidural or epidural hematoma requiring drainage
Acute cerebral swelling requiring intubation

Acute myocardial infarction

Renal insufficiency requiring dialysis
Lung failure requiring intubation
Necrotizing pancreatitis
Acute respiratory distress syndrome

IIIb

Meningitis and pneumonia

Intracranial hypertension and hemodynamic instability
Posterior fossa hematoma and renal failure
Ischemic stroke and pneumonia

Cardiopulmonary insufficiency
Lung distress and renal failure
Systemic inflammatory response syndrome and pneumonia
Renal insufficiency and hemodynamic instability
Death

IV

Death

Suffix T (Transient)

New neurologic deficit improving within 30 days of surgical procedure; can be added to each grade of complication

Suffix P (Persistent)

New neurologic deficit extending beyond 30 days of surgical procedure; can be added to each grade of complication

CSF, cerebrospinal fluid.

present in a single patient, the major complication was assessed. Examples of surgical and medical complications are listed in
Table 2. There was a strong and simple
correlation between the grade of complication and the severity of adverse events.
Grade I complications were considered to
be mild complications, whereas grade II
and grade III were regarded as moderate
and severe.
Between January 2008 and December
2009, 1190 patients were operated on in the
Neurosurgical Department of the Hospital
Italiano de Buenos Aires. Demographics,
medical records, radiologic images, laboratory data, and all documented deviations
from the normal postoperative course were
analyzed from the computerized hospital

data system by a senior neurosurgical resident and presented in the monthly morbidity and mortality conference (MMC). Selected cases with neurosurgical and medical
complications were analyzed in depth and
discussed. Data were objectively compared
with previous months, allowing for longterm quantications and trend identication to be made.

RESULTS
A cohort of 1190 patients who had undergone a cranial (72%) or spinal (28%) neurosurgical intervention in our institution was
analyzed. One or more complications occurred in 14% of patients (n 167). Surgical

WORLD NEUROSURGERY 75 [5/6]: 709-715, MAY/JUNE 2011

complications were 10.84% (n 129), and

medical complications were 3.19%.
The most frequent grade of general complication was Ib (18.55%), followed by IIIa
(17.96%) and IIIb (16.16%). Grade Ia surgical complications accounted for 10.17% of
the adverse events; grade Ib, for 10.17%;
grade IIa, for 8.98%; grade IIb, for 15.56%;
grade IIIa, for 13.17%; and grade IIIb, for
13.17%. Medical complications were grade
Ia, 2.99%; grade Ib, 8.38%; grade IIa,
1.19%; grade IIIa, 4.79%; and grade IIIb,
2.99%. Of 167 patients with postoperative
complications, 34.13% (n 57) experienced a new transient neurologic decit,
and 11.97% (n 20) had persistent decits.
The overall mortality rate was 1.17% (n
14). The mortality rate directly related to

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surgical procedures was 0.84%. Of the total

complications, mild postoperative general
complications accounted for 31.73% (n
53), moderate adverse events accounted for
25.74% (n 43), and severe life-threatening postoperative complications represented 34.13% (n 57).

DISCUSSION
MMCs are a powerful teaching tool, and the
objective analysis of data conducted in these
conferences may help to improve the quality
and safety of patient care through the interpretation and discussion of adverse postoperative events and the development of alternative approaches to medical decision
making (14, 24, 26). A major effort should
be made to avoid criticizing, blaming, or
intimidating an individual person or group
(14, 16, 21, 28, 30). The aim of the MMC is to
create an atmosphere that is productive in
terms of training and education, one where
surgery residents and staff attendees are encouraged to discuss and comment on the
different cases (3, 4, 13, 14, 28, 29, 34, 35,
38, 40, 44, 47, 49). In brief, the MMC represents a unique opportunity to foster professionalism and improve communication
within the neurosurgical group (38).
Neurosurgical practice is considerably
riskier than other surgical specialties. In
this practice, most errors and resulting adverse events are unavoidable and should be
accepted as part of the surgical procedure
(14, 29). To eliminate any individual tendency to downgrade or deny complications
and to avoid the use of nonspecic terms
such as minor or major to characterize
adverse events, systematic and stratied
classied data should be recorded in every
neurosurgical department (10, 14, 15, 18,
29, 31, 38, 41-43); yet, how can we compare
the global morbidity or mortality of two or
more different centers, with different technology, at different times, if we do not use
the same language to characterize complications?
Specialties such as general surgery and
anesthesiology have successfully improved
the quality of the care they provide and the
safety of their patients by systematizing the
complication records and the MMC (2, 17,
19, 30, 38). General, uniform, and multicentric knowledge of complications not
only would improve patient outcomes,
satisfaction, and health care costs, but also

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would protect physicians from medicolegal

actions by providing them with wellgrounded reliable information on the
expected general postoperative complications. In her review of medicolegal malpractice lawsuits, Epstein (20) showed that
the second most frequent malpractice event
prompting suits was lack of informed consent. Houkin et al. (29) focused on many
descriptions of the adverse events and the
inevitable unpredictability associated with
surgery and added them to the informed
consent document that patients are required to sign. These data may lessen patient expectations and somehow diminish
the surgeons responsibility.
The idea of improving patient care in
neurosurgery through learning from postoperative mistakes in neurosurgery is not
new (1, 6, 7). In 1993, Apuzzo (5) devoted an
entire two-volume textbook to the description of complications resulting from neurosurgical interventions and their avoidance
and management. Mastering the art of
avoidance of both intraoperative and postoperative problems is a key factor in operative excellence and optimization of outcome (5).
There are numerous different subclassications of adverse events in the treatment
of specic diseases and neurosurgical or
spinal interventions, and the absence of
standardized denitions makes comparison difcult (8, 12, 22, 23, 36, 37, 46). Additionally, few publications attempting to
classify general neurosurgical or spinal
postoperative complications exist (14, 16,
29, 32, 39, 41, 47). Some of them are presented in Table 3.
In a screening and registration of adverse
events, Bonsanto et al. (14) classied complications into three groups: (i) neurosurgical complications, (ii) neurosurgically complicated courses, and (iii) nonsurgical
complications. By observing this division,
Bonsanto et al. (14) classied more than
92.8% of the postoperative complications,
with only 7.2% of the cases assigned to the
other subgroup. The sensitivity of nonsurgical complications was lower, probably
because events related to ICU data were initially excluded. These authors reported only
complications during hospitalization but
included no assessment concerning the severity of each event.
Rampersaud et al. (41) recorded and classied intraoperative adverse events and

complications of spinal surgical procedures and determined the clinical consequences of these events in the postoperative
period. The classication was based on
treatment requirements, sequelae, and hospital stay. They concluded that intraoperative adverse events can occur with a frequency of 14%; however, most procedures
(76.5%) were not associated with complications.
Houkin et al. (29) published a quantitative analysis of adverse events related to
neurosurgical procedures. They classied
the nature of events as neurologic, local,
and systemic and ascribed the cause of
these events to patient disease, technical
reasons, equipment, and diagnosis. In the
MMC of their Neurosurgical Department,
all adverse events were classied into ve
types on the basis of three factors: (i) relation to the procedure, (ii) predictability of
the event, and (iii) possibility of avoidance.
In their study, the severity of the complication was not invariably correlated with the
event type, and the inclusion of a complication under predictability or possibility of
avoidance was based on the background
and experience of the conference attendees.
Houkin et al. (29) also dened adverse
events as events requiring additional treatment, resulting in transient or permanent
decits, and requiring longer hospital
stays. Following the perspective of Dindo et
al. (19), length of stay does not constitute
for us a valid inclusion criterion or complication score because each site follows a different standard of care.
More recently, Lebude et al. (32) conducted a survey with experienced spinal surgeons in a set of different clinical scenarios
of postoperative complications. The authors provided no preset denitions and
asked the surgeons to classify postoperative
events accordingly as different complications and to stratify them into minor and
major categories or to regard them as a nonevent. Lebude et al. (32) showed that their
surgeon population considered medical
complications to have occurred even when
these were not directly related to a surgical
procedure and should be included in the
assessment of postoperative complications. Based on the survey responses, Lebude et al. (32) dened perioperative spinal
complications as (i) a major complication,
an adverse perioperative event that produces a permanent detrimental effect or re-

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Table 3. Previous Classifications of General Neurosurgical and Spinal Complications

Author, Year
Bonsanto et al., 2001 (14)

Rampersaud et al., 2006 (41)

Houkin et al., 2009 (29)

Lebude et al., 2010 (32)

Procedure
Cranial-spinal

Spinal

Cranial-spinal

Spinal

quires reoperation in the perioperative period (30 days from the time of surgery), and
(ii) a minor complication, an adverse perioperative event that produces only a transient detrimental effect in the perioperative
period.
Given the fact that cranial and spinal interventions were performed by the same
physicians in almost all of the Neurosurgical Departments, a general classication of
complications should and could be applied.
To our knowledge, none of these systems
has gained general acceptance. The classication we propose is based on the therapy
used to treat the adverse event and focuses
on the general postoperative morbidity of
the patient. Documentation of treatment of
a complication is often included in detail in
the patients medical record and is easy to
obtain and classify, whereas adverse events
may be missed or overlooked, especially
when they are regarded as minor. Substantial differences arise in terms of complication evolution or severity. For example,
a postoperative intracerebral hematoma may
be followed only by observation, it may be

Complication Types

Definition

Surgical complications

Unexpected on account of natural course of disease but empirically known

(literature) as an adverse event likely to occur between admission and
discharge.

Surgically complicated

Expected on account of pathology and specific localization of lesion. Also

likely to occur between admission and discharge.

Nonsurgical complications

Medical complications requiring additional diagnosis or subsequent treatment

during hospitalization.

Minor

Required 1 day or no extension of hospital stay; minimal or no additional

treatment required.

Moderate

Warranted treatment, hospital stay extended by 27 days; no long-term

sequelae (6 months).

Major

Required significant levels of treatment, extension of stay for 7 days or

long-term sequelae (6 months).

Nature

Neurologic, local and systemic.

Cause

Patient disease, technical reasons, medical causes, equipment, diagnosis,

and unidentified causes.

Type I

Unrelated to procedure.

Type II

Related to procedure but unpredictable.

Type III

Related to procedure, predictable but unavoidable.

Type IV

Related to procedure, predictable and avoidable.

Type V

Medical error.

Minor

Surgical and clinical transient detrimental effect (30 days from surgery).

Major

Surgical and clinical permanent detrimental effect (30 days from surgery).

treated with precise surgical evacuation followed by an optimal recovery, or it may be

surgically evacuated and then become complicated with pneumonia requiring ICU follow-up. The postoperative complication is the
same, but the severity is different.
We consider that absolutely all deviations
from the ideal postoperative course should
be included in the complications record,
even when they are asymptomatic and have
a spontaneous resolution. Every grade of
adverse event, regardless of it being surgical
or clinical in nature, should also become
part of the record to have an accurate idea of
the eventual outcome. Complications that
are not directly related to surgery or a surgical technique also affect our patients, and
we should be able to recognize them to improve overall multidisciplinary management of patients.
General classications can serve as a
guide to develop specic classications (ie,
classications that provide thorough detail
concerning special complications related to
specic surgical procedures). As in any
classication, separation among groups is

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based on arbitrary criteria. This general

classication attempts to provide principles
rather than details. General classications
of neurosurgical complications may lead to
creating groups of adverse events that apparently should not belong to the same category; however, exhaustive subclassications prove difcult to implement and are
more time-consuming. A balance between
general and specic must be attained (17).
A widely accepted classication would
eventually lead to the unication of outcome denitions and provide strong objective experience to improve the quality of
medical care and reduce the number of
complications. Through this scoring system, we were able to grade every adverse
event that had been submitted to us since
January 2008, providing easy objective comparisons across the different months and
years covered. Further discussions in the
MMC dened the nature and avoidance
possibility of each case and led us to modications of surgical techniques to improve
surgical results or prevent dangerous maneuvers.

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CONCLUSIONS

the thoracic and lumbar spine in adults: Review of

1223 procedures. Spine 20:1592-1599, 1995.

There is unclear consensus when dening

adverse postoperative results in neurosurgery. Complication reports should share
the same language and be based on the
same criteria so that results could be compared objectively across the different centers and times, in pursuance of the ultimate
aim of improving patient health care. We
have presented a simple, practical, and easy
to reproduce way to report negative outcomes and discussed how it could be applied. Further discussion is expected with
the hope of reaching consensus about complication reporting practices.
To learn only from ones own mistakes
would be a slow and painful process, and
unnecessarily costly to ones patients. Experiences need to be pooled so that doctors
may also learn from the errors of others.McIntyre and Popper (33).

7. Barach P, Small SD: Reporting and preventing medical mishaps: lessons from non-medical near miss
reporting systems. BMJ 320:759-763, 2000.
8. Baron EM, Albert TJ: Medical complications of surgical treatment of adult spinal deformity and how to
avoid them. Spine 19S:106-118, 2006.

23. Fujita T, Kostuik JP, Huckell CB, Sieber AN: Complications of spinal fusion in adult patients more
than 60 years of age. Orthop Clin North Am 29:669678, 1998.

9. Behrens E, Schramm J, Zentner J, Konig R: Surgical

and neurological complications in a series of 708
epilepsy surgery procedures. Neurosurgery 41:1-9,
1997.

24. Gore DC: National survey of surgical morbidity and

mortality conferences. Am J Surg 191:708-714,
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10. Benzel EC: Preface. In: Spine Surgery: Techniques,

Complications Avoidance, and Management, Vol 1.
New York: Churchill Livingstone; 1999:xviii-xix.
11. Black PMcL: What is a complication in neurosurgical
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Management, Vol 1. New York: Churchill Livingstone; 1993:xxv-xxvii.
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ACKNOWLEDGMENTS
The authors thank Peter Black, M.D., Ph.D.,
President of the World Federation of Neurological Societies, for his helpful comments,
suggestions, and assistance in preparing this
article.

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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.
received 12 August 2010; accepted 02 November 2010
Citation: World Neurosurg. (2011) 75, 5/6:709-715.
DOI: 10.1016/j.wneu.2010.11.010
Journal homepage: www.WORLDNEUROSURGERY.org
Available online: www.sciencedirect.com

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