Journal of Neurological Surgery Part B: Skull Base最新文献

Background Due to the escalating health care costs in the United States, the Centers for Medicare and Medicaid Services (CMS) implemented a cost transparency initiative on January 1, 2021. Hospitals lack functional cost estimators or fail to provide pricing information for common skull base procedures.

Methods A list of the top 70 neurosurgery and otolaryngology hospital systems according to the US News and World Report rankings was made. Google searches for each hospital's cost estimator tool were conducted, recording its presence and accessibility time. Using the cost estimator tool, specific skull base procedure prices, Current Procedural Terminology codes, and contact information for personalized estimates were searched.

Results Fifty-seven hospitals (81%) were privately funded. The majority were urban teaching hospitals (n = 68; 97%). Geographical locations included 19 (27%) in the Northeast, 21 (30%) in the Midwest, 20 (29%) in the South, and 10 (14%) in the West. Of the 70 hospitals, 4 (5.7%) did not have a cost estimation website. Of the 66 hospitals that did, the average time to locate the cost of the skull-based procedures was 17.8 seconds (range 12–28 seconds). Only two (2.9%) hospitals had information for skull base procedures; both were radiosurgery procedures. The most common stereotactic radiosurgery offered was gamma knife radiosurgery (n = 50; 71%). A total of 19 hospitals (27%) did not include contact information for personalized cost estimation.

Conclusion The CMS price transparency guidelines are not designed to encompass skull base procedures. Due to this ambiguity, patients are unable to make informed financial decisions when selecting treatment options.

Objectives Our objective was to compare transorbital neuroendoscopic surgery (TONES) with open craniotomy and analyze the effect of visualization technology on surgical freedom.

Design Anatomic dissections included supraorbital craniotomy (SOC), transorbital microscopic surgery (TMS), and TONES.

Setting The study was performed in a neurosurgical anatomy laboratory.

Participants Neurosurgeons dissecting cadaveric specimens were included in the study.

Main Outcome Measures Morphometric analysis of cranial nerve (CN) accessible lengths, frontal lobe base area of exposure, and craniocaudal and mediolateral angle of attack and volume of surgical freedom (VSF) of the paraclinoid internal carotid artery (ICA), terminal ICA, and anterior communicating artery (ACoA).

Results The mean (standard deviation [SD]) frontal lobe base parenchymal exposures for SOC, TMS, and TONES were 955.4 (261.7) mm², 846.2 (249.9) mm², and 944.7 (158.8) mm², respectively. Access to distal vasculature was hindered when using TMS and TONES. Multivariate analysis estimated that accessing the paraclinoid ICA with SOC would provide an 11.2- mm³ increase in normalized volume (NV) compared with transorbital corridors (p < 0.001). There was no difference between the three approaches for ipsilateral terminal ICA VSF (p = 0.71). Compared with TONES, TMS provided more access to the terminal ICA. For the ACoA, SOC produced the greatest access corridor maneuverability (mean [SD] NV: 15.6 [5.6] mm³ for SOC, 13.7 [4.4] mm³ for TMS, and 7.2 [3.5] mm³ for TONES; p = 0.01).

Conclusion SOC provides superior surgical freedom for targets that require more lateral maneuverability, but the transorbital corridor is an option for accessing the frontal lobe base and terminal ICA. Instrument freedom differs quantifiably between the microscope and endoscope. A combined visualization strategy is optimal for the transorbital corridor.

Introduction: The supraorbital keyhole approach (SOKHA) has been a less invasive alternative for anterior and middle skull base lesions. We aimed to review our data and understand the advantages and limitations of the approach.

Methods: We analyzed our data and reviewed 89 consecutive cases who underwent the SOKHA. We included the clinico-radiological parameters, pathology, use of endoscope, complications, etc. for analysis.

Results: A total of 47 patients were of aneurysm with a total of 48 aneurysms (39 were ruptured and 9 were unruptured) and Acomm artery aneurysm was the most common site. Meningiomas were the second most common pathology encountered (n = 29). Tuberculum sella meningioma being the most common type of meningiomas operated through this approach. Gross total resection was done in all except two cases in which a small part of the tumor was left behind as the tumor was adhered to blood vessels. Among the remaining cases, craniopharyngiomas (n = 7), optic pathway gliomas (n = 2), hypothalamic hamartomas (n = 2), dermoid (n = 1), and arteriovenous malformation (n = 1) were the other pathologies operated upon. Eight patients had opening of the frontal sinus. Four patients had wound bulge and one patient had cerebrospinal fluid (CSF) rhinorrhea. All these cases were managed conservatively.

Conclusion: SOKHA is an excellent approach for anterior cranial fossa lesions especially with properly chosen cases. Incidence of CSF leak in our study is 1.1% and majority can be managed by placement of lumbar drain. Intraoperative obliteration of the frontal sinus can reduce the risk of postoperative CSF leak. A large frontal sinus needs not be a contraindication for SOKHA.

Introduction Skull base meningiomas (SBMs) are often subtotally resected and there is a paucity of evidence regarding the long-term rates of postoperative tumor progression. We aimed to investigate the factors that influence tumor recurrence in patients with an extended period of follow-up.

Methods Surgically resected tumors with long-term radiological follow-up were included for analysis. Data were collected on patient demographics, anatomical location, Simpson grade, World Health Organization (WHO) grade, modality of reintervention, and functional status. Recurrence was defined as tumor progression requiring intervention. Kaplan–Meier method and log-rank test were used to calculate recurrence-free probability. Cox regression analysis was used to determine factors associated with tumor progression.

Results Sixty-one patients were identified. Median radiological follow-up was 11.25 (IQR 4.3) years. Median age at first surgery was 50 (IQR 17) years. A total of 55/61(90%) tumors were WHO grade I and 6/61(10%) were grade II. Gross total resection (GTR) was achieved in 37/61 (60.7%) patients with subtotal resection (STR) in 24/61 (39.3%). In total, 28/61(45.9%) demonstrated recurrence/regrowth with a median time to recurrence of 2.8 (IQR 5) years. Also, 15/37 (40.5%) and 13/24 (54.2%) patients with GTR and STR, respectively, had tumor recurrence. Of the 28 recurrences, 4/28 (14.3%) underwent reresection, 9/28 (32.1%) were managed with radiotherapy, and 15/28 (53.6%) received both reresection and radiotherapy. Tumor grade was the only significant predictor of tumor recurrence (p = 0.033). Neurological function at last follow-up was significantly worse (modified Rankin scale >2) in patients with recurrence (p = 0.035).

Conclusion Surgically resected SBMs are associated with a significant recurrence rate during prolonged follow-up, irrespective of the extent of resection achieved. We recommend a prolonged period of radiological surveillance for SBM following surgical resection.

Background The purpose of this study was to evaluate clinical outcomes after salvage microsurgery for vestibular schwannoma (VS) treated initially with modern radiotherapy techniques as compared to those treated with primary microsurgical resection.

Methods Patients who underwent microsurgical resection of sporadic VS undergoing a translabyrinthine approach at a single academic skull base tertiary referral center were included. Baseline and postoperative dynamic gait index, functional gait assessment, House–Brackmann facial nerve grading, and completeness of resection were prospectively recorded.

Results Of the 265 patients reviewed, 21 (7.9%) patients underwent prior radiation. Median age of the cohort was 55 years (interquartile range: 51–63). The likelihood of achieving a gross total resection was significantly lower for radiated as compared to nonradiated patients (odds ratio: 0.18, 95% confidence interval: 0.05–0.53, p = 0.004) when controlling for tumor size. Radiated patients had better postoperative facial nerve function on the first postoperative day, but this difference was not significant at long-term follow-up. Radiated patients had lower preoperative postural stability scores than nonradiated patients on FGA (26 vs. 23, p = 0.035). Postoperatively, radiated patients had comparable outcomes compared to nonradiated patients when controlling for age and tumor size.

Conclusions Compared to patients with VS treated with surgery alone, previously radiated patients are less likely to achieve gross total resection in the salvage setting. Radiated patients scored better on facial nerve outcomes compared to nonradiated patients in the initial postoperative period but demonstrated similar long-term outcomes.

Background and Objectives Endoscopic endonasal surgery (EES) has become increasingly popular, yet anatomical constraints posed by the nose and limitations of nonarticulated instruments render EES technically challenging, with a steep associated learning curve. Therefore, we developed a handheld robot to enhance dexterity in endoscopic neurosurgical procedures. A previous trial of the robot demonstrated its potential advantages in endoscopic neurosurgery but also the need for improvements. In this study, we assess the feasibility, acceptability, and comparative performance of the updated robotic prototype (version 0.2) against standard instruments in a preclinical phantom and cadaveric trial.

Methods Ethical approval was received. Participants were stratified according to their neurosurgical experience. In the phantom study, a randomized crossover design compared the robot against standard instruments at a phantom tumor resection task. Statistical analysis was performed using Mann–Whitney U tests and paired t-tests. In the cadaver-based user study, participants evaluated the device's functional domains through a qualitative interview design.

Results In the phantom study, the device demonstrated a learning curve: initial resection attempts favored the traditional instrument (84% vs. 59%, p = 0.055), but parity was achieved by the fifth attempt (80% vs. 83%, p = 0.76). Acceptability was evident, as most clinicians (7/8) preferred the robot for its superior range, ergonomics, and precision. Also, the robot exhibited a diminished cognitive workload. The cadaveric study underscored the robot's clinical feasibility, through sufficient workspace reach and force delivery.

Conclusion: Overall, our robot demonstrates promising acceptability and feasibility for endoscopic neurosurgery, yet further iterative developments are required before proceeding to in-human clinical trials.

Background The outcomes in pituitary surgery have dramatically changed over the past 130 years. Endoscopic endonasal transsphenoidal approaches are now an accepted method for operating on pituitary tumors, a skillset which takes time to develop. The Australian health care framework provides a unique mixture of public and private care for a geographically dispersed population. In this article, we aim to examine how outcomes for patients in South Australia changed as endoscopic pituitary surgery was adopted and how the Australian health care framework influenced the development of a skull base team.

Methods The case notes of all patients undergoing pituitary surgery between 2006 and 2020 in South Australia. All patients treated by this author group were included.

Results A total of 428 pituitary adenomas were surgically treated. Overall, 182 out of 249 patients (70%) had a complete resection with no recurrence at follow-up, and 49 patients (19%) had a residual that was observed and did not require treatment. Therefore, 89% of patients between the years 2006 and 2020 did not require any further treatment following their pituitary surgery. Upon examination of the 142 patients with functional adenomas, 112 (79%) patients had no recurrence in hormonal dysfunction following surgery, and the remaining 30 (21%) patients required further treatment.

Conclusion We have demonstrated that acceptable outcomes can be achieved in a low-to-moderate volume setting across multiple hospitals when a coordinated effort is made to consolidate these cases within a small group of subspeciality-trained surgeons, as opposed to a more generalist approach.

Objective The use of online teaching modalities to supplement surgical learning has increased recently, demonstrating promising results. Previous studies have analyzed the value and usefulness of YouTube as an educational source to learners, including teaching surgical skills to Otolaryngology–Head and Neck Surgery (OHNS) trainees. YouTube videos on endoscopic sinus surgery (ESS) still need to be explored as ESS remains a common, yet challenging surgery that OHNS residents encounter regularly. This study aimed to objectively evaluate the usefulness of YouTube videos on ESS for surgical education.

Design YouTube was searched using the following keywords: “uncinectomy,” “maxillary antrostomy,” “anterior ethmoidectomy,” and “ethmoid bulla resection.” These represent the initial ESS steps residents learn. Each video was assessed for eligibility by two independent reviewers.

Outcome Measures The LAParoscopic surgery Video Educational Guidelines (LAP-VEGaS) and ESS-specific criteria were used to assess educational quality. Video popularity index (VPI) was used to calculate video popularity.

Results Of the 38 videos that met inclusion criteria, the average LAP-VEGaS score was 6.59 (± ) 3.23 standard deviation. Most videos were designated low quality. There was a weak positive correlation between whether a video included ESS-specific criteria and LAP-VEGaS score (r = 0.269, p = 0.102). There was a significant positive correlation between VPI and LAP-VEGaS scores (r = 0.497, p = 0.003).

Conclusions Overall, the quality of included videos was poor. OHNS residents should not rely solely or primarily on YouTube videos to learn surgical skills relevant to ESS. To maximize potential of online teaching, high-quality videos should be used to compliment other methods of teaching.

[This corrects the article DOI: 10.1055/a-2235-9956.].

Background Cerebrospinal fluid (CSF) leaks from the lateral recess of the sphenoid sinus (LRS) occur due to a skull base defect and are important to treat due to the associated morbidity, e.g., life-threatening meningitis. Nontraumatic CSF leaks have a predilection toward obesity which is a rising phenomenon. LRS is notoriously difficult to access because of its lateral location and its associated neurovascular complications. An alternative surgical corridor has been explored which is the transorbital neuroendoscopic (TONES) approach.

Objective To compare the success rate of the endoscopic endonasal with the TONES approaches.

Rationale This is the first systematic review on the endoscopic endonasal and combined transorbital approaches to treat CSF leaks from the LRS.

Method A PRISMA-concordant systematic review. PubMed, MEDLINE, EMBASE, Web of Science, and SCOPUS were searched. The studies underwent abstract and full-text screening by two reviewers. The data collected included patient demographic, surgical approach, reconstruction method, layers and materials, follow-up period, ROBINS-I bias, complications, and success rate.

Results In total, 26 of 4,385 studies were included for further synthesis. Of these studies, a total of 336 patients were identified from a cohort of 910 patients. The endoscopic endonasal approach showed a repair success rate of 95.24% and the combined TONES and endonasal approach showed a success rate of 100%.

Conclusion Both the endoscopic endonasal and transorbital approach provide a good success rate. However, due to the small TONES sample, large, randomized control trials are needed.