Journal of Korean Neurosurgical Society最新文献

Objective: Cervical disc herniation (CDH) is one of the most common pathologies that cause pain and functional loss in cervical spine disorders. The primary reasons for cervical disc patients' presentations are brachialgia, radiculopathy, and myelopathy. Pain leads to a decrease in sleep quality, and the reduction in sleep quality, in turn, negatively affects pain, resulting in a decline in quality of life. In the literature, there are limited studies evaluating pain, sleep quality, quality of life, and daily living activities in patients undergoing CDH surgery. Moreover, these studies do not adequately assess all these criteria together. Our study represents the most homogeneous (disconly) and comprehensive study in the current literature. We believe it will provide clear insights into the effects of CDH surgery and serve as a guide for preoperative patient selection and management.

Methods: This research is a prospective study. Between July 2024 and December 2024, a total of 43 patients underwent surgery for CDH. The patients included in the study were evaluated preoperatively and on the 45th postoperative day using Visual analog scale (VAS), Pittsburgh sleep quality index (PSQI), European quality of life 5 dimensions 3 level version (EQ-5D-3L), Neck disability index (NDI), and Copenhagen neck functional disability scale (CNFDS) scales.

Results: Of the 43 patients included in the study, 28 (65.1%) were female, with a mean age of 43.16±9.82 years. Regarding the levels affected, 25 patients (58.1%) had involvement at the C5-6 level, while 18 patients (41.9%) were at the C6-7 level. Significant improvements were observed in all parameters during the preoperative and postoperative evaluation of VAS, PSQI, EQ-5D-3L, NDI, and CNFDS scales (p<0.001 for each).

Conclusion: In cervical disc patients with ineffective conservative treatment, radicular pain, muscle weakness, and extruded discs, as well as high preoperative scale scores, immediate surgical intervention will result in a reduction in pain and improvements in sleep, quality of life, and daily living activities.

Objective: Familial cerebral cavernous malformation (FCCM) is a genetically inherited condition involving the collection of abnormal slow-flow venous capillaries with no cerebral parenchyma in between. In this case series, we review the clinical, radiological, pathological, and genetic findings of seven blood relatives diagnosed with FCCM and discuss their treatment in light of the different presentations.

Methods: The patients with FCCMs were assessed in our neurosurgery clinic between April 2016 and October 2024. All patients underwent detailed clinical evaluation, radiological imaging, histopathological examination, and genetic testing. Functional outcomes were evaluated using the Karnofsky performance scale (KPS).

Results: Five of the seven patients were symptomatic, while the remaining two were asymptomatic carriers. On radiological examination, hemorrhagic type I lesions were detected in symptomatic cases, whereas the asymptomatic carriers had non-hemorrhagic type 4 lesions. Genetic testing revealed a heterozygous pathogenic mutation in the CCM1 gene in one of the symptomatic patients. The three symptomatic cases underwent surgery for complete resection of the lesions; no additional neurological deficit or residual lesion was detected postoperatively (postoperative KPS score, 100). Histopathological examination revealed benign cavernous angioma in all cases. Over the postoperative follow-up, no seizures were detected in patients who underwent surgery due to refractory epilepsy.

Conclusion: Advances in molecular genetic testing have allowed for prompt diagnosis and timely management of patients with FCCMs. Surgical treatment is an effective option in symptomatic cases with progressive neurological deficits and refractory epilepsy. Regular neurological monitoring and radiological assessment are recommended in symptomatic cases and asymptomatic carriers.

In spinal fusion surgery, autogenous bone grafting remains the gold standard for achieving optimal bone fusion; however, challenges such as donor site morbidity and limited graft availability have prompted active research into alternative options. Recombinant human bone morphogenetic protein-2 (rhBMP-2) exhibits excellent osteoinductive properties. Using rhBMP-2 was anticipated to promote early and effective fusion, particularly in challenging surgical scenarios involving elderly patients, those with low bone density, or individuals with multiple comorbidities, although in these populations, the biological response to rhBMP-2 may be attenuated and the risk of complications increased. This review provides a comprehensive overview of the development, characteristics, and dose-related adverse reactions of rhBMP-2 in spinal fusion, based on extensive clinical and experimental findings. Factors contributing to the decline in rhBMP-2 usage are also discussed. Furthermore, this review proposes a safer carrier with reduced rhBMP-2 doses to optimize delivery and minimize complications. Emphasis is placed on the critical role of carriers in improving bioavailability control, minimizing side effects, and better aligning with natural bone healing processes.

Objective: The current understanding and clinical prediction of brainstem glioma (BSG) are still limited. This study aimed to conduct a large-scale population-based study to construct a clinical predictive model.

Methods: Patients with BSG diagnosed histologically from 1973 to 2016 were identified using the SEER (Surveillance Epidemiology and End Results) database. According to World Health Organization grade, the whole population was divided into the low-grade BSG (LGBSG) cohort and the high-grade BSG (HGBSG) cohort. Univariate and multivariate cox regression analyses were employed to determine prognostic factors of overall survival (OS). All independently prognostic variables were further used to construct nomograms to predict the 1- and 2-year OS probability. The precision and reliability of the nomogram were evaluated by C-index and calibration plots.

Results: Cox regression analysis showed that four independent prognostic factors, were identified in the LGBSG cohort and two independent prognostic factors were identified in the HGBSG cohort. These independently prognostic factors and the main demographic data were further used to construct clinical nomograms for the LGBSG and HGBSG cohorts, respectively. The C-index for the internal validation was 0.89 (95% confidence interval [CI], 0.83-0.95) and 0.64 (95% CI, 0.60-0.68) in the LGBSG and HGBSG cohorts, respectively. The results of the calibration plots showed that the actual observation and prediction values obtained by the nomogram had good consistency in the LGBSG and HGBSG cohorts.

Conclusion: This study identified several independent prognostic variables and further constructed the clinical nomogram model. The nomogram model can provide valuable clinical reference and risk assessments for clinicians to further manage these patients with BSG.

Objective: High-ratio plasma transfusion is proposed as a strategy for treating polytrauma with severe traumatic brain injury (TBI). This study analyzed outcomes based on the ratio and timing of plasma transfusion.

Methods: The clinical characteristics and results were collected from March 2016 to December 2022. Subjects included patients with severe TBI and polytrauma who underwent massive transfusion (MT). Severe TBI was defined as head abbreviated injury score (AIS) ≥3, and MT was defined as packed red blood cells (pRBCs) ≥4 units in the first 4 hours and ≥10 units in the first 24 hours. The 4-hour ratios were assigned to the "early group," and the 24-hour ratios to the "catch-up group." Next, the ratio of each group was divided into "≥1 : 1 (plasma ≥ pRBC)" and "<1 : 1 (plasma < pRBC)" groups, respectively.

Results: In this study, 532 patients participated. Mortality rates between the 1 : 2 and 1 : 1.5 ratios did not differ statistically; however, a significant difference was noted only at the 1 : 1 ratio (p=0.006). In the early group, outcomes did not significantly differ. The logistic regression for 30-day mortality identified independent risk factors, including advanced age, low Glasgow coma scale (GOS) scores, high AIS head scores, and a ratio <1 : 1. For the catch-up group, the odds ratio for a favorable GOS at ≥1 : 1 was 1.61, with a 30-day mortality rate of 0.60 when comparing ≥1 : 1 to <1 : 1 ratios.

Conclusion: This study showed that maintaining a ≥1 : 1 plasma ratio for 24 hours improved functional outcomes and survival, without increased morbidity. Therefore, high-ratio plasma transfusion may be effective in the treatment of patients with polytrauma and severe TBI.

Objective: Recurrent lumbar disc herniation (RLDH) is a significant challenge following lumbar discectomy, with recurrence rates of 5%-15%. Established risk factors include male gender, diabetes mellitus, smoking, and obesity, but the role of paraspinal muscles in recurrence is unclear. This study was conducted to identify key risk factors for RLDH, including the volume of paraspinal muscles with machine learning.

Methods: We used data from 126 patients who underwent lumbar discectomy between January 2003 and September 2023 and had follow-up outpatient visits for more than 6 months at a single institution. Variables selected for the model, comprising demographic and clinical variables, medical history, LDH operation-related variables, and MRI measurements for RLDH. Based on clinical symptoms and radiologic results, the patients were classified into RLDH and non-RLDH groups, and RLDH was defined at the same surgical level on follow-up MRI.

Results: Totally, 38 patients were included in the RLDH group and 88 in the non-RLDH group. The volume of quadratus lumborum was identified as a risk factor for RLDH (odds ratio 7.894; P=0.001). Among the five different ML algorithms, XGBoost achieved the best result with an accuracy of 0.794 and area under the curve (AUC) of 0.811. In terms of SHAP value analysis, the weight, volume of quadratus lumborum, psoas major, and vertebra were key features for predicting RLDH.

Conclusion: The prediction model would be of great assistance for surgeons to make surgical decisions or establish observation intervals.

Objective: The 2024-2025 medical crisis in the Republic of Korea, triggered by mass trainee departures, caused severe staffing shortages in tertiary hospitals. The impact of this disruption on neurosurgeons' workload, lifestyle, and mental health has not been evaluated. In this study, we aimed to determine the prevalence of burnout among neurosurgeons during the crisis, assess associated changes in workload and lifestyle, and identify key factors linked to burnout severity.

Methods: We conducted a nationwide, questionnaire-based observational study from April 29 to June 4, 2025, targeting board-certified neurosurgeons in university hospitals across the Republic of Korea. Participants were recruited through departmental professional contacts and completed an online survey capturing baseline characteristics, paired pre-post crisis values for 14 workload and lifestyle variables, and 3 current-status items. Burnout was assessed using the Copenhagen Burnout Inventory (CBI) as the primary tool and the Maslach Burnout Inventory-Human Services Survey (MBI-HSS) as a supplementary measure.

Results: Of 61 respondents, 36 (59.0%) met high-burnout criteria. After the crisis onset, all workload and lifestyle factors shifted unfavorably, with the largest increases in weekend/holiday duty (86.9%), night duty (82.0%), and sleep disturbance call (68.9%), and the largest declines in number of colleagues (-50.8%), leisure time (-47.5%) and family time (-44.3%). High-burnout surgeons had greater workloads, more off-hour duties, and less recovery time than low-burnout peers. Burnout severity correlated with staffing levels, working hours, night duty, time spent with family and leisure activities, job satisfaction, intention to leave, and all MBI subscales.

Conclusion: Burnout among Korean neurosurgeons is widespread after the national medical crisis, with substantial deterioration in workload and lifestyle. Coordinated efforts at both hospital and national levels are essential to protect surgeon well-being and maintain the quality of neurosurgical care.

Objective: To evaluate the efficacy of individualized dual antiplatelet therapy (DAPT) using VerifyNow in reducing periprocedural ischemic complications following carotid artery stenting (CAS), particularly in patients with unstable plaques.

Methods: This retrospective, single-center study included 187 patients who underwent elective CAS between January 2018 and September 2024. Patients were divided into two groups: a conventional DAPT (c-DAPT) group treated with aspirin and clopidogrel (n = 89), and an individualized DAPT (i-DAPT) group (n = 98) where antiplatelet regimens were adjusted based on preoperative platelet reactivity measured by VerifyNow. The primary outcome was the incidence of ischemic lesions on diffusion-weighted imaging (DWI) following CAS. Risk factors and the impact of DAPT personalization on ischemic changes were analyzed using multivariate logistic regression.

Results: DWI-positive ischemic lesions were observed in 62.9% of the c-DAPT group and 51% of the i-DAPT group (p = 0.07). Although the difference was not statistically significant, there was a trend toward reduced ischemic changes with individualized therapy. Multivariate analysis identified hypertension, diabetes mellitus, and unstable plaque as independent predictors of post-CAS ischemic changes. Subgroup analysis showed that VerifyNow-guided i-DAPT significantly reduced ischemic events in patients with unstable plaques (odds ratio: 0.49, p = 0.03), whereas no significant effect was observed in other subgroups.

Conclusion: VerifyNow-guided personalization of antiplatelet therapy is a safe and may have the potential to reduce periprocedural ischemic complications in CAS, particularly in patients with unstable plaques. Further multicenter prospective studies are needed to validate these findings and optimize individualized antiplatelet regimens.

Objective: The leptomeningeal ivy sign is a distinctive finding of Moyamoya disease (MMD), characterized by a linear high signal intensity along the cortical sulci on contrast-enhanced T1 magnetic resonance imaging (MRI) and fluid-attenuated inversion-recovery (FLAIR) MRI. We recently identified a similar linear enhancement along the cortical sulci using gadolinium-enhanced vessel wall MRI (VWMR) in patients with MMD. The aim of this study was to introduce the concept of the "VWMR ivy sign (VIS)".

Methods: Eighteen MMD patients underwent gadolinium-enhanced VWMR. We identified the VIS in gadolinium-enhanced VWMR, represented by a linear high intensity along the cortical sulci. The VIS was assessed by comparing pre and postcontrast T1 black blood sequences on VWMR and was investigated in the precentral, central, and postcentral sulci. "VIS scores" were calculated by the sum of VIS in the three sulci, ranged from 0 to 3. We compared the VIS scores according to different stroke presentations (non-stroke, ischemic stroke, and hemorrhagic stroke). The inter-modality agreement for identifying VIS and FLAIR/cortical sulci on contrast-enhanced T1 MRI (CEMR) ivy sign was determined using Cohen's kappa statistics.

Results: The VIS scores were significantly different among the three groups (p=0.004). The VIS scores in both the ischemic and hemorrhagic groups were significantly higher than those in the non-stroke group (ischemic vs. non-stroke, p=0.009; hemorrhagic vs. non-stroke, p=0.004). After adjusting for age and sex using the non-stroke group as a reference group, the VIS scores were significantly higher in the ischemic and hemorrhagic groups (p=0.046; odds ratio [OR], 8.27; 95% confidence interval [CI], 1.03-66.19 and p=0.039; OR, 7.78; 95% CI, 1.11-54.48, respectively). The intermodality agreement between VIS and FLAIR ivy sign was substantial in the precentral region, perfect in the central region, and substantial in the postcentral region (precentral sulcus : κ=0.609; 95% CI, 0.213-1; central sulcus : κ=1; and postcentral sulcus : κ=0.769; 95% CI, 0.475-1). Inter-modality agreement between the VIS and CEMR ivy sign was substantial in the precentral, central, and postcentral sulci, respectively (precentral sulcus : κ=0.727; 95% CI, 0.384-1; central sulcus : κ=0.609; 95% CI, 0.384-1; and postcentral sulcus : κ=0.649, 95% CI, 0.310-0.998).

Conclusion: This preliminary series introduces the concept of VIS, possibly indicating slow and retrograde flow of sulcal vessels via leptomeningeal collaterals. Future studies are needed to develop an optimal scoring system for VIS and establish its clinical correlation with stroke presentations in MMD patients.