Journal of neurosurgical sciences最新文献

Background: European regulations on medical devices have been introduced to improve medical standards. However, these changes are leading to the transient lack of medical tools with possible disadvantages. Herein, the problem is addressed for the first time in neurosurgery with regards to ventriculo-atrial shunt (VAS).

Methods: Children undergoing VAS in the 2020-2022 period at a single Institution were enrolled. Patients receiving VAS with Pudenz cardiac catheter (distal slit "valves") were assigned to group A (2020-2021) while those with VAS harboring proximal adjustable valve to group B (2021-2022, Pudenz no more available). The complications leading to shunt malfunction within 2 years from VAS were analyzed.

Results: Twenty-four children belonged to group A (M/F ratio: 2.4; mean age: 42.5 months) and 18 to group B (MF/ratio: 1.8, mean age: 48.1 months). Statistically significant differences were found about: 1) patients needing shunt revision: 7 cases (29%) in group A vs. 11 cases (61%) in group B; 2) number of shunt revisions: 8 in group A vs. 16 in group B; 3) number of children with mechanical complications: 2 (8.3%) in group A vs. 7 (39%) in group B; 4) number of mechanical complications: 2 (group A) vs. 9 (group B). No differences in other complications or placement-to-revision time were detected.

Conclusions: The lack of simple surgical tools (Pudenz catheter) may make VAS more prone to mechanical complications. Prospective and multicenter trials are needed to produce scientific evidence. In the meantime, a multidisciplinary discussion on the European regulation (including Doctors and Manufacturers) is welcome.

Background: To date, no shared algorithms with the aim of guiding surgical strategy in complex cases of degenerative cervical myelopathy (DCM) exist. Our purpose is to present the Cervical Surgical Score (CSS) which could help in identifying complex DCM cases, suggesting a surgical strategy.

Methods: We created the CSS based on multidisciplinary and literature-focused discussions, based on eight parameters including number of levels of cervical pathology and myelopathy, type and predominance of compression and grade of clinical myelopathy. We prospectively enrolled surgical DCM patients in a 15-months period, collecting clinical and radiological data. During outpatient clinic a specific surgical indication was offered to DCM patients. To validate the score, each outpatient clinic surgical indication was compared a posteriori to the one that resulted from multidisciplinary CSS scoring, focusing on patients for which both an anterior and posterior approach were considered suitable.

Results: A total of 100 patients operated on for DCM at our Institution between December 2021 and February 2023 were prospectively enrolled. In 53% of patients the pathology was present at more than two levels. According to CSS calculation, 14% of patients resulted in the "grey zone", where both an anterior and posterior approach were deemed feasible. Among them, in 42.8% of cases the CSS allowed a modification of the originally planned surgery. Looking at outcome, an improvement of m-JOA score in 62% of patients was disclosed.

Conclusions: This preliminary study showed the reliability and usefulness of CSS in detecting complex DCM cases, requiring further analysis by expert spine surgeons, suggesting a surgical strategy.

Introduction: Cervical spine (mostly atlanto-axial) accounts for over half of the acute traumatic disruptions of the spinal cord and its coverings; alongside its persisting neurological deficits. Two-thirds of the etiology were fairly evenly distributed between traffic crashes, falls, assault and other occupation-related injuries. We described the etiological mechanisms, neuro-anatomical level, severity, treatment and outcomes of traumatic cervical spinal-cord and spine injuries (C-SCI+SI).

Evidence acquisition: We systematically reviewed PubMed and Cochrane CENTRAL on 16th May 2023, using a prospectively registered protocol (CRD42023417530). The search strategy combined search words (from the keywords; "cervical spinal cord injury," "conservative" and "operative" "treatment") using Boolean operators. These yielded 787 and 55 records from PubMed (then 223 after delimiting to 10 years) and CENTRAL respectively; after records screening, 106 and 1 record were relevant respectively. Seventy-six reports were recruited for the quasi-quantitative synthesis following full-text review and methodological quality/bias assessment (using Joanna Briggs Institute critical appraisal tools).

Evidence synthesis: Seventy-six reports yielded 1645 pooled cases. Weighted-mean age (N.=1512) was 46.3 years, with male (70.2%; gender N.=1525) preponderance. C-SCI+SI were mostly caused (N.=1079) by falls (42.1%) and road traffic crashes (42.2%); presenting(N.=178) with neck pain (71.4%) mostly and under one-fifth had neurological deficits (-plegias or -paresis, 11.8%; radiculopathy, 6.2%). The commonest vertebral levels (N.=1525) were 23.9% for the second cervical vertebra (c2), c5(20.4%) and c6(20.0%). Treatment (N.=1297) was combined pre-operative non-operative [skull traction (72.0%/842), cervical collar (13.9%/163)] in 90.2%, with solely non-operative (33.9%/439) options also used. Operative implant-based arthrodeses (66.2%/858) were done, using anterior (68.5%), posterior (20.2%/173) and combined (10.4%/89) approaches. Good bony fusion (89.0%) and clinical improvements (43.2%) were reported.

Conclusions: Mostly low-level evidence showed C-SCI+SI occurring more amongst the middle-aged and men; following falls or road traffic crashes. The second, fifth and sixth cervical levels are mostly affected; with excellent post-intervention bony-union, with neurological improvements in two-fifths. Better international reporting standards are advocated.

Introduction: Postoperative cerebrospinal fluid (CSF) leaks and related complications are a major concern after intradural spinal surgeries. The role of prolonged bed rest in reducing the incidence of these complications has been debated. This meta-analysis aimed to evaluate whether early versus late mobilization affects the incidence of CSF leak-related complications (CLRC) after intradural spinal surgery.

Evidence acquisition: Following PRISMA guidelines, we conducted a systematic review and meta-analysis of comparative studies on early ambulation (EA) versus prolonged bed rest (PBR) in patients undergoing intradural spinal surgery. Studied considered for inclusion defined EA as mobilization on postoperative day 1, while PBR as mobilization on postoperative day 3. The primary outcome was the incidence of CLRC, defined as pseudomeningocele, durocutaneous fistula, or wound dehiscence. Secondary outcome was the incidence of medical complications.

Evidence synthesis: Three retrospective comparative studies with a total of 949 patients were included in the analysis. No significant difference was found in the incidence of CLRC between the EA and PBR groups. Length of hospital stay (LOS) and postoperative medical complications incidence were significantly lower in the EA group.

Conclusions: This meta-analysis found that EA does not increase the risk of CLRC compared to PBR, while shortening LOS and reducing medical complications occurrence. These findings suggest that early mobilization could be a safe and effective postoperative strategy, reducing hospital stay and complication rates.

Background: Surpass Evolve Flow Diverter (SE-FD; Stryker Neurovascular, Kalamazoo, MI, USA) was launched in 2019 as a new generation FD of Surpass Streamline. The aim of this study was to report the effectiveness and safety of SE-FD insertion for unruptured intracranial aneurysm at one-year follow-up.

Methods: Between November 2019 and October 2021, a total of 106 patients with 108 aneurysms were treated with FD in single institution. Of these, SE-FD insertion was performed in 40 patients with 41 aneurysms. At one-year follow-up, clinical and angiographic outcomes were retrospectively evaluated from electronic medical record and aneurysm database.

Results: There were 12 male and 28 female patients (mean age 59.1 years, 95% CI: 55.3-62.9). Fusiform aneurysm dissection was 46.3% (19/41). Mean maximum aneurysm diameter was 13.2 mm (SD 5.53), and 34.1% (14/41) of aneurysms were 15 mm or bigger. Among 41 aneurysms, complex aneurysm (recurred, thrombosed, or branch artery-incorporated) was accounted for 41.5% (17/41). All procedures were successfully conducted with 7.3% (3/41) of procedure-related complications. At one-year follow-up (N.=40), neurologic morbidity was noted in 2 cases (5.0%; both with modified Rankin Scale [mRS] 1) without any mortality. At one-year follow-up (N.=41), radiologic outcomes were adequate occlusion in 33 (80.5%) and complete occlusion in 29 (70.7%). There was no retreatment in our cohort.

Conclusions: Surpass Evolve Flow Diverter seemed to be safe and effective for the treatment of dissecting/fusiform or complex aneurysms at one-year follow-up. However, further study is needed to evaluate long term results.

Background: Restoring lumbar lordosis is one of the main goals in lumbar spinal fusion surgery. The Mazor X-Align^™ software allows for the prediction of postoperative segmental lumbar lordosis based on preoperative imaging. There is limited data on the accuracy of this preoperative prediction, especially in patients undergoing short segment lumbar fusion. The objective of our study was to determine the accuracy of predicted postoperative segmental lumbar lordosis using the Mazor X-Align^™ software in patients requiring short segmental fusion.

Methods: Retrospective analysis of adult patients undergoing pedicle screw spinal instrumentation of not more than four levels using the Mazor X^™ Robot (Medtronic Inc., Minneapolis, MN, USA) between July 2017 to June 2020. The robotic guidance software, Mazor X-Align^™ (Medtronic Inc., Minneapolis, MN, USA) was used to calculate the predicted segmental lumbar lordosis based on preoperative CT-imaging and the plan was executed under intraoperative robotic guidance. Predicted segmental lumbar lordosis was compared to achieved segmental lumbar lordosis on 1-month postoperative x-rays using the Cobb angle methodology.

Results: A total of 15 patients (46.6% female) with a mean age of 61.5±10.9 years were included. All patients underwent posterior lumbo-sacral spinal fusion with the Mazor X^™ robotic system with 11 patients (73.3%) undergoing anterior column reconstruction prior to posterior fixation. Instrumentation was performed across a mean of 2.6 levels per case. Preoperative, the mean segmental lumbar lordosis was 30.2±13.6 degrees. The mean planned segmental lumbar lordosis was 35.5±17.0 degrees while the mean achieved segmental lumbar lordosis was 35.8±16.7 degrees. There was no significant mean difference between the planned and achieved segmental lumbar lordosis (P=0.334).

Conclusions: The Mazor X^™ intraoperative robotic planning and guidance is accurate in predicting postoperative segmental lumbar lordosis after short segmental fusion. Our findings may assure surgical decision making and planning.

Background: Treatment of small vestibular schwannomas (VS) depends on size, growth pattern, age, symptoms, co-morbidities. Watchful waiting, stereotactic radiosurgery and microsurgery are three valid options of treatment.

Methods: We reviewed clinical sheets, surgical data and results of 100 consecutive patients with Koos Grade I-II VS, operated at our department via a retrosigmoid microsurgical approach between September 2010 and July 2021. Extent of resection was assessed as total, near-total or subtotal. The course of facial nerve (FN) around the tumor was classified as anterior (A), anterior-inferior (AI), anterior-superior (AS) and dorsal (D). FN function was assessed according to House-Brackmann (HB) Scale and hearing level according to AAO-HNS Classification.

Results: Mean tumor size was 1.52 cm. FN course was mainly AS (46.0%) in the overall cohort; in Koos I VS, FN was AS in 83.3%. Postoperative FN function was HB I in 97% and HB II in 3% of cases. Hearing preservation (AAO-HNS class A-B) was possible in 63.2% of procedures. Total/near-total removal was achieved in 98%. Postoperative mortality was zero. Transient complications were observed in 8% of patients; permanent complications never occurred. Tumor remnant progression was observed in one case, 5 years after subtotal removal.

Conclusions: Microsurgery represents a valid option for management of VS, including Koos I-II grades, with an acceptable complication rate. In particular, in small VS long-term FN facial outcome, HP and total/near-total removal rate are favorable.

Chronic subdural hematoma (cSDH) presents a multifaceted challenge in contemporary neurological practice, necessitating innovative therapeutic strategies. This comprehensive review explores the convergence of two promising interventions: statins and middle meningeal artery (MMA) Embolization. With cSDH incidence on the rise, particularly among the aging population and those with long-term anticoagulant usage, the traditional surgical avenues face limitations in recurrence rates and associated risk factors. Statins, heralded for their anti-inflammatory, vasculogenic, and angiogenic properties, are emerging as potential allies in cSDH management. Concurrently, MMA embolization offers a nuanced approach to target the neomembrane's blood supply, with evidence supporting its efficacy and safety. However, the synthesis of MMA embolization with statins remains relatively unexplored, presenting a complex interplay between inflammation modulation and blood supply interruption.

Introduction: Chronic subdural hematoma (CSDH) is a frequent neurological problem, especially in older adults. It often presents headache as a primary symptom. The optimal approach to managing CSDH through invasive treatments is still debated, with various procedures available. We conducted a systematic review of randomized clinical trials, based on the most recent available literature, to assess the efficacy and safety of invasive interventions for the treatment of CSDH.

Evidence acquisition: A comprehensive search of major databases was performed according to PRISMA guidelines with an extensive consultation with experts that independently conducted study selection, data extraction, and bias assessment. The GRADE approach and RoB 2 tool were used to assess evidence quality and risk of bias.

Evidence synthesis: It was identified 4 studies (N.=579) meeting the inclusion criteria. Invasive interventions included burr hole craniostomy, twist drill craniostomy, and subdural drainage systems. Findings varied across studies. A Chinese study suggested shorter hospital stays with twist drill craniostomy compared to simple burr hole craniostomy. A Denmark study showed that the 48-hour drainage has a significantly higher volume of postoperative drain production compared to the 24-hour group. An Iranian study suggested fewer hematomas with burr hole irrigation without drainage compared to with drainage.

Conclusions: Evidence on invasive interventions for CSDH is limited. Treatment decisions should be individualized based on patient factors and potential risks/benefits. Large-scale randomized controlled trials are needed to provide clearer guidelines for CSDH treatment.