Journal of Korean Neurosurgical Society最新文献

Objective: In this study, we aimed to compare the clinical outcomes of unilateral biportal endoscopic (UBE) lumbar discectomy and open lumbar microdiscectomy (MD) for recurrent disc herniation.

Methods: Ninety patients who underwent discectomy, including 44 and 46 who underwent UBE and MD, respectively, were enrolled. All surgeries were performed between March 2020 and April 2023. Only patients with single-level recurrence were included; patients with multilevel recurrence or unstable disease, as well as those who had undergone surgery less than 6 months prior, were excluded. Visual analog scale (VAS) scores, recurrence rates, and complications were compared between the groups.

Results: The average follow-up periods were 19.09 and 20.45 months in the UBE revision and MD revision discectomy groups, respectively. The mean bleeding loss and hospital stay were shorter in the UBE group than in the MD group. Postoperative short-term back pain was lower in the UBE group (VAS score, 3.32) than in the MD group (VAS score, 7.89) (p<0.001). Radiating pain showed similar patterns in both groups at all time points. Recurrence was more frequent in the MD group; however, this difference did not reach statistical significance, likely owing to the small sample size (p=0.677). Similarly, incidental durotomy occurred less frequently in the UBE group (6.8% vs. 8.7%), but this difference was not statistically significant.

Conclusion: Both UBE and MD could achieve good long-term outcomes; however, UBE revision was superior in terms of short-term back pain, bleeding loss, and length of hospital stay after surgery.

Objective: This study aimed to retrospectively analyze consultations requested from the emergency departments (EDs) to the neurosurgery (NS) department of a tertiary care hospital, and to comprehensively evaluate the clinical characteristics, referral reasons, and diagnostic and therapeutic processes of these patients. In addition, the study aims to provide concrete recommendations for strategic objectives such as optimizing hospital workflow, enhancing interphysician coordination, and standardizing consultation processes.

Methods: This single-center, retrospective study evaluated patients who presented to the ED of a tertiary care hospital and for whom a neurosurgical consultation was requested between January 1, 2024 and December 31, 2024. Demographic data, consultation request notes prepared by emergency physicians, consultation responses provided by NS specialists, and radiological imaging findings of the patients were reviewed in detail.

Results: Of the patients, 69% were consulted for traumatic and 31% for non-traumatic reasons. Among traumatic cases, falls were identified as the most common cause, whereas headache and altered mental status were the leading reasons in non-traumatic cases. Of the 386 patients, did not require neurosurgical intervention and were safely directed to clinical follow-up, representing the majority of NS consultations (44.8%). Surgical intervention was performed in 40 of 386 patients (10.3%). The frequency of consultations was notably higher during the summer months.

Conclusion: The increase in admissions during the summer months demonstrates the necessity of planning adapted to seasonal workload. In pediatric head trauma, the application of the Pediatric Emergency Care Applied Research Network rules, and in suspected cauda equina syndrome, performing joint history-taking and physical examination, may enhance diagnostic accuracy and reduce unnecessary imaging. In cases of spontaneous subarachnoid hemorrhage and spontaneous intracerebral hemorrhage, rapid access can be strengthened through telemedicine, artificial intelligence-assisted analysis, and joint educational meetings.

Objective: Deep brain stimulation (DBS) of the internal globus pallidus (GPi) represents the standard treatment for medically refractory dystonia, with clinical efficacy critically dependent on precise electrode placement. While robotic stereotactic systems promise enhanced targeting accuracy, comparative data for dystonia populations remain limited. To compare stereotactic accuracy and clinical outcomes of KYMERO robot-assisted versus conventional frame-based GPi-DBS in dystonia patients.

Methods: A single-center, retrospective cohort study compared 35 patients (68 leads) who underwent KYMERO robot-assisted bilateral GPi-DBS (July 2023-June 2025) with 42 historical controls receiving frame-based procedures (March 2019-December 2020). All patients had medically refractory primary dystonia. Primary outcomes included stereotactic accuracy (radial and Euclidean error) and 6-month Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS) motor improvement. Secondary outcomes encompassed response rates, complications, and procedural consistency.

Results: KYMERO robot-assisted DBS achieved significantly superior targeting accuracy compared to frame-based procedures (mean radial error: 0.89 ± 0.30 mm vs. 1.92 ± 1.20 mm, p < 0.001; Euclidean error: 1.15 ± 0.38 mm vs. 2.80 ± 1.56 mm, p < 0.001). The proportion of electrodes within 1.5 mm of target was higher in the KYMERO group (94.1% vs. 66.7%, p < 0.001), with fewer targeting outliers exceeding 2 mm (2.9% vs. 23.8%). Clinical outcomes were equivalent between groups, with 6-month BFMDRS motor improvement of 66.9 ± 13.8% for KYMERO versus 64.7 ± 23.5% for frame-based procedures (p = 0.614). Response rates (≥50% improvement) were 85.7% and 78.6%, respectively. Complication rates were low and comparable (5.7% vs. 9.5%). The KYMERO cohort demonstrated reduced outcome variability, suggesting enhanced procedural reproducibility.

Conclusion: KYMERO robot-assisted GPi-DBS achieves significantly superior stereotactic accuracy compared to conventional frame-based approaches while maintaining equivalent clinical efficacy and safety. The enhanced precision and reduced outcome variability support robotic assistance as a valuable advancement for dystonia DBS procedures.

Objective: Gamma knife radiosurgery (GKRS) is an established treatment for cerebral arteriovenous malformations (AVMs). However, incomplete obliteration after initial GKRS continues to pose a risk of hemorrhage. Although repeat GKRS is used as a salvage treatment, specific guidelines and safety profiles remain to be fully defined. By analyzing the clinical outcomes of repeat GKRS in 60 patients with incompletely obliterated AVMs, this study aims to test the hypothesis that optimizing treatment-related variables, particularly the timing of retreatment, may improve the safety and efficacy of repeat GKRS for residual AVMs.

Methods: This retrospective study included 60 patients with AVMs who underwent repeat GKRS between 1992 and 2024. Clinical charts, radiologic imaging, and treatment parameters were analyzed to assess complete obliteration, hemorrhage after repeat GKRS, and adverse radiation effects (AREs). Kaplan-Meier survival analysis was performed to estimate obliteration and hemorrhage rates. Univariate and multivariate analyses were conducted to identify factors associated with complete obliteration, hemorrhage, and AREs.

Results: Complete obliteration was achieved in 40 patients (66.7%). The actuarial obliteration rates were 1.7%, 22.5%, 53.5%, and 73.9% at 1, 3, 5, and 10 years, respectively. A target volume reduction rate >50% (p = 0.004; hazard ratio [HR], 3.002; confidence interval [CI], 1.414-6.374) and lower initial Spetzler-Martin (SM) grade (p = 0.008; HR, 0.608; CI, 0.420-0.879) were independently associated with complete obliteration. Six patients (10%) experienced hemorrhage after repeat GKRS, corresponding to an annual hemorrhage rate of 2.3%. AVMs located in the posterior fossa (p = 0.005; HR, 80.958; CI, 3.891-1684.629) and hemorrhage prior to repeat GKRS (p = 0.020; HR, 19.075; CI, 1.576-230.805) were independently associated with hemorrhage. Seven patients (11.7%) experienced AREs after repeat GKRS. Larger repeat target volume (p = 0.042; OR, 3.170; CI, 1.044-9.626) and a shorter interval of months between initial and repeat treatment (p = 0.040; OR, 0.823; CI, 0.683-0.991) were independently associated with AREs.

Conclusion: Repeat GKRS for incompletely obliterated AVMs may provide favorable obliteration rates. Adequate volume response after initial GKRS and lower SM grades may predict successful complete obliteration. Patients with prior hemorrhage and AVMs located in the posterior fossa may be at greater risk of hemorrhage after repeat GKRS. Larger treatment volume and shorter intervals between initial and repeat GKRS were associated with AREs. Extending the interval between initial and repeat GKRS may reduce the risk of AREs and provide a safer approach for treating incompletely obliterated AVMs.

Objective: The aim of this study was to report the early clinical experience with stereotactic biopsy using the Medtronic Stealth Autoguide Cranial Robotic Guidance Platform, representing the first relevant clinical study in the Republic of Korea (ROK). We evaluated potential advantages and limitations related to workflow integration, instrument setup, procedural efficiency, accuracy, and safety.

Methods: A retrospective case series was conducted across three centers in the ROK. From April to July 2025, 17 consecutive patients underwent frameless stereotactic biopsy using the Stealth Autoguide system. Data on demographics, operative time, and complications were collected, and descriptive analyses were performed.

Results: Biopsy using the Stealth Autoguide was successfully completed in 16 of 17 patients. The median operative time was 48 minutes (interquartile range, 33-64), and the median target alignment error was 0.4 mm (interquartile range, 0.3-0.6). One case required conversion to the conventional manual method due to targeting inaccuracy. Three cases of asymptomatic intracerebral hemorrhage occurred, including one at the tissue-harvest site and two with cortical hemorrhage, all of which were managed conservatively.

Conclusion: The Stealth Autoguide system facilitates a more efficient frameless stereotactic biopsy than conventional methods by reducing operative time, enhancing accuracy, and allowing for a smaller, muscle-sparing incision. However, some concerns remain, and further clinical validation is needed to define its optimal indications and safety profile.

Objective: This study investigated the cerebrospinal fluid (CSF) dynamic changes before and after cranioplasty using phase-contrast cine magnetic resonance imaging (MRI).

Methods: We performed a prospective observational study in the patients who underwent cranioplasty in the neurosurgical department of our hospital between June 2022 and March 2025. We reviewed the changes of CSF flow parameters in the cerebral aqueduct before and after cranioplasty.

Results: Totally, nine patients were enrolled, including five males and four females, with a mean age of 48.1 years. The time interval between decompressive craniectomy (DC) and cranioplasty was 119.1 ± 45.1 days. The skull defect diameter and area were 10.7 ± 2.2 cm and 94.4 ± 34.6 cm², respectively. There are significant increases in forward flow volume (p = 0.002), backward flow volume (p = 0.002), net stroke volume (p = 0.012), absolute stroke volume (p = 0.001), mean flux (p = 0.005), mean velocity (p = 0.001), and peak velocity (p < 0.001) after cranioplasty when compared with those parameters before cranioplasty. No significant correlation was observed between patient characteristics and the improvement magnitude of CSF flow parameters caused by cranioplasty.

Conclusion: This study indicates that cranioplasty may have beneficial effects on CSF flow dynamics in the cerebral aqueduct after DC, which provides therapeutic potentials for complications related to CSF flow stagnancy after DC.

Objective: Epidural fibrosis (EF) is a major contributor to postoperative morbidity following laminectomy. This study investigated the antifibrotic, anti-inflammatory, and anti-angiogenic effects of nintedanib (NIN), a multi-tyrosine kinase inhibitor, in a rat model of post-laminectomy EF.

Methods: Twenty-one male Wistar albino rats were assigned to three groups: Control, Laminectomy (LAM), and Laminectomy + Nintedanib (NIN). The laminectomy procedure was performed at the L3 level. NIN administration, following laminectomy, was administered orally at a dose of 50 mg/kg/day for 28 days. Histopathological evaluations included hematoxylin-eosin staining for dura mater thickness and fibroblast density, and Masson's trichrome staining for collagen deposition and adhesion grading. α-smooth muscle actin (α-SMA) expression was evaluated using immunohistochemistry and RT-qPCR. Gene expression of tumor necrosis factor-α (TNF-α), interleukin-1β (IL-1β), vascular endothelial growth factor (VEGF), platelet-derived growth factor receptor (PDGFR), and transforming growth factor-β1 (TGF-β1) was quantified to characterize inflammatory, angiogenic, and fibrogenic responses. Statistical comparisons were conducted using one-way ANOVA or Kruskal-Wallis tests with appropriate post hoc analyses.

Results: The LAM group exhibited marked post-laminectomy changes, including increased dura mater thickness (8.20 ± 0.23 µm vs. 3.93 ± 0.08 µm in controls, p < 0.0001), elevated fibroblast density (p = 0.0006), severe collagen deposition, and high-grade epidural adhesions (Grade 3, p = 0.0006). NIN treatment attenuated these alterations, reducing dura mater thickness (4.80 ± 0.20 µm, p < 0.0001 vs. LAM), fibroblast density (p < 0.01), and adhesion grade (Grade 1, p = 0.0012). α-SMA immunoreactivity was high in LAM (Grade 3, p < 0.0001), whereas NIN significantly suppressed myofibroblast activation (Grade 1, p = 0.0012). NIN also significantly downregulated inflammatory mediators TNF-α (p < 0.001) and IL-1β (p < 0.001), as well as angiogenic markers VEGF (p < 0.001) and PDGF (p < 0.001), and fibrogenic mediators TGF-β1 (p < 0.001) and α-SMA (p < 0.01). These findings indicate that NIN suppresses fibroblast activation, extracellular matrix accumulation, and myofibroblast differentiation, thereby limiting epidural adhesion and scar maturation.

Conclusion: Nintedanib effectively mitigated epidural fibrosis after laminectomy through combined antifibrotic, anti-inflammatory, and anti-angiogenic actions. By improving the dural structure and reducing key molecules that contribute to scar formation, NIN shows significant promise as a treatment to prevent postoperative epidural adhesions. Future studies with extended follow-up may help clarify its clinical relevance.

Objective: This paper sets out to observe the comprehensive clinical effect and advantages of cryopreserved autogenous skull replantation.

Methods: We collected the data of 141 patients with skull defect. Among them, 111 patients underwent cryopreserved autogenous skull replantation, 68 cases were frozen without cryoprotectant and 43 cases were frozen with cryoprotectant. In addition, 30 patients received artificial skull repair. We collected several variables related to the occurrence of complications and explored their correlation, followed by clinical experiments.

Results: After treatment, all incisions of 141 patients healed in the first stage, and there was no infection or need for a second operation. During the follow-up period, bone resorption occurred in some of the 111 patients with autologous bone repair. The hospitalization cost of patients with autologous bone repair is lower than that of patients with artificial material repair. Internal repair within 60 days (the time interval between decompressive craniectomy and cranioplasty, that is the cryopreservation time of the bone flap is within 60 days) and cryopreservation using cryoprotectant can effectively reduce the absorption rating of the skull. Among them, the absorption rate is higher in diabetic patients. As for clinical experiments results, the cell activity decreases and the apoptosis rate rises with freezing time.

Conclusion: Revascularization was found in all the cryopreserved autogenous skulls after replantation. Cryopreservation can effectively reduce the absorption of autogenous bone.

Objective: Decompressive craniectomy (DC) is a surgical procedure in which a portion of the skull overlying edematous and vulnerable brain tissue is removed to reduce ICP. In cases where all other treatment modalities fail, DC can be life-saving. However, this procedure is not a "panacea";it can prolong the death process and condemn the patient to a life in need of care, with severe neurological sequelae.

Methods: This multicenter, retrospective study recorded patients' comorbidities, Glasgow Coma Scale, APACHE II and SOFA scores, as well as relevant laboratory parameters. Patients were categorized into three groups according to the Glasgow Outcome Scale (GOS).

Results: Among 201 patients, 41.3%ex, 33.8% survived with severe vegetative sequelae, and 24.9% had mild to moderate sequelae. Non-survivors had significantly lower preoperative and postoperative GCS scores (median 7 vs.9, p=0.010; 3 vs.10, p<0.001) and higher 24-hour peak glucose levels (186 vs.164 mg/dl,p=0.009). Steroid therapy was ineffective. Preoperative GCS scores were significantly lower in patients who later developed severe sequelae compared to those with better outcomes (median 8 vs.11; p<0.001). Postoperative GCS scores were also lower in this group (8 vs.13; p<0.001).Additionally, APACHE II(22 vs.18; p=0.002) and SOFA scores (4 vs.3; p<0.001) were higher, indicating greater disease severity.

Conclusion: DC can be a lifesaving procedure in selected patients with appropriate indications and appropriate timing. However, the possibility of this procedure resulting in high mortality and severe sequelae cannot be ignored. Therefore, the clinical outcomes that the patient and their families would find acceptable should be carefully considered.

Objective: The efficacy of brachial plexus decompression through a supraclavicular approach for neurogenic thoracic outlet syndrome (TOS) and its impact on surgical outcomes were investigated.

Methods: The outcomes of pain reduction and functional improvement were evaluated in 31 patients with neurogenic TOS who underwent a supraclavicular decompression. These patients were followed for at least 12 months. Pain reduction was quantified using a numerical rating scale-11 (NRS-11) score and percentage pain relief before and after the last follow-up. Functional and symptomatic outcomes were assessed using the QuickDASH (Disability of the Arm, Shoulder, and Hand 11-item version) questionnaire, and changes in functional disability were measured by the percentage change in QuickDASH scores. Success was defined as at least a 50% reduction in pain as measured by the NRS-11, and factors influencing surgical success were also explored.

Results: At a follow-up of 31.7±11.7 months, supraclavicular brachial plexus decompression was successful in 24 of 31 patients (77.4%), with a mean pain relief rate of 54.3±29.0. Functional outcomes assessed by QuickDASH scores improved significantly (from 52.7±12.6 to 23.6±17.9), with a percentage reduction of 56.36±31.56. There were no neurological complications associated with the surgery, although one reoperation was required due to postoperative chyle leakage.

Conclusion: Brachial plexus decompression through a supraclavicular approach proved effective in alleviating pain and functional disability in patients with neurogenic TOS.