Journal of neurological surgery. Part A, Central European neurosurgery最新文献

Background:  In general, sufficient anchoring of screws in the bone material ensures the intended primary stability.

Methods:  Shape memory materials offer the option of using temperature-associated deformation energy in a targeted manner to compensate the special situation of osteoporotic bones or the potential lack of anchoring. An expansion screw was developed for these purposes. Using finite element analysis (FEA), the variability of screw configuration and actuator was assessed from shape memory. In particular, the dimensioning of the screw slot, the actuator length, and the actuator diameter as well as the angle of attack in relation to the intended force development were considered.

Results:  As a result of the FEA, a special configuration of expansion screw and shape memory element could be found. Accordingly, with an optimal screw diameter of 4 mm, an actuator diameter of 0.8 mm, a screw slot of 7.8 mm in length, and an angle of attack of 25 degrees, the best compromise between individual components and high efficiency in favor of maximum strength can be predicted.

Conclusion:  Shape memory material offers the possibility of using completely new forms of power development. By skillfully modifying the mechanical and shape memory elements, their interaction results in a calculated development of force in favor of a high primary stability of the screw material used. Activation by means of body temperature is a very elegant way of initializing the intended locking and screw strength.

Background:  Symptomatic cerebral vasospasms are deleterious complication of the rupture of a cerebral aneurysm and potentially lethal. The existing scales used to classify the initial presentation of a subarachnoid hemorrhage (SAH) offer a blink of the outcome and the possibility of occurrence of symptomatic cerebral vasospasms. Altogether, neither are they sufficient to predict outcome or occurrence of events reliably nor do they offer a united front. This study tests the common grading scales and factors that otherwise affect the outcome, in an artificial intelligence (AI) based algorithm to create a reliable prediction model for the occurrence of cerebral vasospasms.

Methods:  Applying the R environment, an easy-to-operate command line was programmed to prognosticate the occurrence of vasospasms. Eighty-seven patients with aneurysmal SAH during a 24-month period of time were included for study purposes. The holdout and cross-validation methods were used to evaluate the algorithm (65 patients constituted the validation set and 22 patients constituted the test set). The Support Vector Machines (ksvm) classification method provided a high accuracy. The medical dataset included demographic data, the Hunt and Hess scale (H&H), Fisher grade, Barrow Neurological Institute (BNI) scale, length of intervention for aneurysmal repair, etc. RESULTS:  Our prediction model based on the AI algorithm demonstrated an accuracy of 61 to 86% for the event of symptomatic vasospasms. For subgroup analysis, 28.8% (n = 13) patients in the surgical cohort developed symptomatic vasospasm. Of these, 50% (n = 7) were admitted with Fisher scale grade 4, 37.5% (n = 5) with H&H 5, and 28.5% (n = 4) with BNI 5. In the endovascular cohort, vasospasms occurred in 31.8% (n = 14) patients. Of these, 69% (n = 9) patients were admitted with Fisher grade 4, 23% (n = 3) patients with H&H 5, and 7% (n = 1) patients with BNI 5.

Conclusion:  From our data, we may believe that the algorithm presented can help in identifying patients with SAH who are at "high" or "low" risk of developing symptomatic vasospasms. This risk balancing might further allow the treating physician to go for an earlier intervention trying to prevent permanent sequelae. Certainly, accuracy will improve with a higher caseload and more statistical coefficients.

Background:  Neurovascular conflict between the oculomotor nerve and a posterior circulation cerebral artery is a relatively frequent radiologic finding; however, it manifests minimally clinically (by slower photoreaction on the ipsilateral side). Sustained paresis of the oculomotor nerve that arose directly due to neurovascular conflict between the superior cerebral artery (SCA) and the oculomotor nerve, and resolved after microvascular decompression, is extremely rare and has not yet been published.

Methods:  A 34-year-old female patient presented with an advancing ptosis and downward gaze on one side. Differential diagnostics ruled out all other causes of the oculomotor paresis. Magnetic resonance imaging showed significant compression of the oculomotor nerve by an aberrant SCA on the ipsilateral side. Neurovascular decompression performed microsurgically resulted in near complete resolution of the symptoms.

Results:  This case report aims to present a case of a rare clinical condition caused by a generally common anatomical variation. This variation proved to be the only cause of the patient's symptoms, which resolved after microsurgical restoration of the neuroanatomy.

Conclusions:  Oculomotor nerve paresis caused directly by neurovascular conflict is an extremely rare diagnosis. Microvascular decompression should be considered in these cases, if other causes have been excluded.

Background and Study Aim In contrast to the thoracolumbar spine, where pedicle screws can be inserted via a minimally invasive, percutaneous technique through small skin incisions, all previously available cervical instrumentation systems required a larger midline incision, especially for rod insertion. Screw placement via small incisions reduces the risk of wound healing disorders and blood loss, and patients can be mobilized more quickly and with less pain. In 2022, a cervical minimally invasive stabilization system became available for the complete percutaneous insertion of both cervical pedicle screws and rods. We report on the first results and experiences with this new technology. Methods In this retrospective case series, we included patients with cervical instability treated by minimally invasive percutaneous cervical und upper thoracic spine pedicle screw and rod insertion between August 2022 and August 2023. Intra- and postoperative complications as well as revision surgeries were recorded. The screw position was evaluated by three examiners in the postoperative CT using the Bredow classification. Results Our series includes six male patients (age=56.9±12.9 years; BMI=29.8±9.6 kg/m2). The indication for surgery was trauma, tumor and degenerative stenosis in two patients each. An excellent/good screw position (Bredow 1 and 2) was found in 84.4% of the screws (n = 27/32). None of the screws rated as Bredow 3 (n=2/32) or Bredow 4 (n=3/32) resulted in a neurological deficit or radicular pain and none had to be repositioned. No neurologic complication or revision surgery occurred. As a complication not directly related to the surgery technique, one patient died of a pulmonary lung embolism on the 7th postoperative day. Conclusion The results of this study indicate that minimally invasive percutaneous implantation of a pedicle screw-rod system is also possible in the cervical spine with sufficient accuracy using intraoperative navigation. However, technical details, possible pitfalls and finally careful patient selection must be taken into account.

Background and aim: Numerous studies have been conducted regarding vertebral restoration, development of kyphotic deformity, and pain control following balloon kyphoplasty. However, there is no consensus regarding the ideal time to perform kyphoplasty. Herein, we aimed to compare the results of treatment of different vertebral levels following early or late kyphoplasty.

Patients and methods: Between 2017 and 2022, 283 patients with single-level osteoporotic vertebral fractures were retrospectively reviewed. 100 patients who attended regular postoperative follow-ups, visual analog scale (VAS) values were recorded, and osteoporosis tests were performed were included in the study. Traumatic single-level fractures in patients with osteoporosis who were aged >60 years were included in the study. Patients with a history of malignancy, previous spinal surgery, or neurological deficits were not included in the study. A total of 50 patients underwent kyphoplasty within 3 days of sustaining the fracture (Group 1), and 50 patients underwent kyphoplasty more than 3 after sustaining the fracture (Group 2). Groups A, B, and C included fractures at the T7-T11 levels, T12-L1 levels (thoracolumbar junction), and L2-L5 levels, respectively. These groups were compared among themselves. Bilateral balloon kyphoplasty was performed under sedation in the prone position. Preoperative and postoperative VAS scores, anterior vertebral heights (AVH), and kyphotic angles (KA) were measured and recorded. The vertebral segments that underwent early and late kyphoplasty were also compared among themselves.

Results: In all the patients who underwent early or late kyphoplasty, there was a significant decrease in the kyphotic angle and a significant increase in vertebral heights during the early postoperative period (p < 0.001). There was no significant change in the vertebral heights and kyphotic angle between the early and late postoperative periods (p = 0.780). Early kyphoplasty demonstrated better pain control with a greater improvement in VAS score (p < 0.001) than late kyphoplasty.

Conclusion: Kyphoplasty plays an important role in reducing pain and ensuring early mobilization in older patients. In our study, the improvements in both symptoms and radiologic features are concrete evidences in favor of performing early kyphoplasty.

Object The risk factors for and molecular mechanisms of systemic metastasis of cerebral glioblastoma (GBM) remain to be evaluated. Patients and Methods Literature about adult GBM patients with systemic metastasis published before December 31, 2022, was searched in "PubMed" and "Web of Science," and the patients' clinical data were collected and compared with those of patients without metastasis to evaluate the risk factors. The molecular pathology results were summarized to evaluate the mechanism. Results One hundred forty-seven patients with metastasis in 113 papers published from 1928 to 2022 were included. Two hundred forty-nine patients without metastasis who underwent surgery in our department in 2017 were included. Comparison of the two groups showed that age ≤ 40 years was significantly correlated with metastasis (HR: 2.086, 95% CI: 1.124-3.871, P=0.020) and better overall survival (HR: 1.493, 95% CI: 1.067-2.083, P=0.019). Molecular pathology results were reported in 39 cases (39/147, 26.5%). The genetic results showed obvious heterogeneity. According to the frequency and positive ratio, IDH-wild type (positive rate 27/30), TERT promoter mutation (11/13), PTEN mutation (10/11), TP53 mutation (10/13) and RB1 mutation (8/9) were common gene changes. Conclusion In young adult GBM patients, especially those ≤ 40 years of age with long survival, attention should be given to the development of systemic metastases. Metastasis can be the result of multiclonal gene mutations, in which proliferation- and invasion-related gene changes, such as oncogene or tumor suppressor gene mutations and epithelial-mesenchymal transition-related genes, may play an important role in metastasis.

Background Tuberculum sellae meningiomas (TSM) tend to compress the optic apparatus and an ideal surgical route, whether transcranial or endonasal, is still debated. Another issue is if the minimally invasive supraorbital (SO) approach offers the same results compared to the more invasive craniotomy. Aiming to guide approach selection, preoperative grading systems have been described. Method All cases of TSM treated from 2013 to 2018 by extended endoscopic endonasal (EEA) or SO approach have been reviewed and classified according to three preoperative grading system: McDermott scale, Optic Nerve Laterality Score and Yaşargil criteria. Results A total of 15 patients with TSM were treated with the EEA (n=6) or the SO (n=9) approach. Globally, gross total resection was obtained in 87% (n=13) of cases and was higher with the SO (100%, n=9) compared to the EEA (67%, n=4). Visual function improved in all but one patient (n=14). Compared to the EEA group, patients treated by the SO approach had larger tumors (32.3 mm vs 24.5 mm), higher rate of optic canal invasion (4/9 vs 0/6) and arterial encasement (6/9 vs 1/5). Patients with McDermott total point of 1-2 (7/15) were treated mainly by the EEA; all patients with McDermott total score ≥3 (8/15) were treated by the SO approach. All patients with optic canal invasion (4/15) and lateral extension of the tumor (ONL score = 1-3) were treated by the SO approach. Conclusions The SO and EEA are two minimally invasive approaches safe and effective for treating TSM. For tumors with lateral extension (optic nerve laterality score = 1-3), larger diameter (> 30-35 mm), vascular encasement or optic canal involvement (McDermott total point = 2-3), the SO craniotomy is preferred. For small and median tumors with no optic canal invasion or vascular encasement (McDermott total point = 1-2), the EEA represents a valid option.

Study design: A retrospective analysis of prospectively collected data.

Background: There have been a few studies comparing surgical outcomes between revision lumbar fusion surgery and the same primary surgery.

Object: Using the Zurich Claudication Questionnaire (ZCQ), we compared clinical outcomes of revision posterior lumbar interbody fusion (PLIF) for late deterioration after laminotomy with those of primary PLIF to examine whether surgical outcomes of revision PLIF for late deterioration after laminotomy are inferior to those of primary PLIF.

Materials and methods: Sixteen consecutive patients undergoing revision single-level PLIF for late deterioration after single-level laminotomy (R group) and 61 consecutive patients undergoing primary single-level PLIF during the same period as the R group (P group) were enrolled. Before PLIF surgery and at 2-year postoperatively, clinical outcomes were assessed using the ZCQ. Achievement rates of the minimum clinically important difference (MCID) of each domain [Symptom severity (SS) and Physical function (PF)] on the ZCQ were calculated in each group.

Results: In the R group, mean SS and PF before revision PLIF and at 2-year after surgery were 3.429 and 2.8, and 1.946 and 1.6, respectively. In the P group, mean SS and PF before primary PLIF and at postoperative 2-year were 3.438 and 2.5, and 2.194 and 1.6, respectively. Both SS and PF significantly improved at postoperative 2-year in the both groups, and SS both before and after PLIF and PF at 2-year postoperatively showed no significant differences between the 2 groups. Achievement rates of the MCID of SS and PF were 81.3% and 68.8% in the R group, and 59.0% and 59.0% in the P group, respectively. None of the MCID achievement rates of SS and PF showed significant differences between the 2 groups.

Conclusion: Clinical outcomes of revision PLIF for late deterioration after laminotomy were equivalent to those of primary PLIF assessed with the ZCQ at 2 years after PLIF surgery.

Background: COVID-19 has attracted global attention primarily because of the severe acute respiratory symptoms associated with it. However, nearly one third of the patients also present with neurologic symptoms. This report describes a case of a previously healthy woman with acute COVID-19 infection, who developed acute facial nerve palsy and rapid progression to coma due to otogenic brain abscess.

Case description: A 63-year-old woman with acute COVID-19 infection exhibited acute facial nerve paresis, high fever and purulent secretion from her left ear within 48 hours after COVID-19 onset. Cranial CT scan confirmed acute mastoiditis, precipitating an urgent mastoidectomy. A postoperative contrast-enhanced MRI on the same day revealed a subdural empyema, which prompted an urgent craniotomy and decompression. Intraoperative microbiological swabs confirmed a Streptococcus pyogenes infection, however RT-PCR was negative for SARS-CoV-2. After immediate i.v. antibiotic treatment, extubation was achieved four days post-operation, and the patient was discharged without neurologic deficits 19 days after postoperatively.

Conclusion: This finding adds a layer of insight into the specific nature of the infection, suggesting a potential absence of SARS-CoV-2 involvement in otogenic subdural empyema. However, the impact of SARS-CoV-2 in otogenic brain abscess cannot be excluded to date and should be further prospectively investigated. The complete recovery of neurological status, emphasizes the importance of prompt and interdisciplinary interventions in managing rare and severe complications associated with COVID-19.

Background: Subarachnoid-pleural fistula is an abnormal communication between the subarachnoid and pleural spaces that can arise from blunt or penetrating trauma or as a complication of spinal surgery via the transthoracic approach. Uncontrolled cerebrospinal fluid (CSF) leakage with a fistulous condition after transthoracic spinal surgery could be more problematic than that after spinal surgery via the conventional posterior approach because of the negative pressure in the pleural cavity.

Case description: The authors reported subarachnoid-pleural fistula management using chest and lumbar spinal drainage in five patients with several troublesome complications, such as intracranial subdural hematoma or severe respiratory dysfunction. Chest drainage was managed for 2-3 days by continuous low negative pressure, whereas lumbar spinal drainage was managed for 5-7 days, aiming at an output volume of 150-200 ml/day and higher than that of chest drainage. Additionally, when examining changes in the accumulated pleural fluid were examined by standing chest X-ray immediately before operation and 1 month after operation, the pleural effusions in four of the five patients were assimilated 1 month postoperatively.

Conclusion: Compared with CSF management following standard posterior spinal surgery, management after the anterior transthoracic approach could be more troublesome because of intrapleural negative pressure. When chest and lumbar spinal drainage are used, it is important to consider that over-drainage of CSF could potentially cause severe respiratory dysfunction and intracranial subdural hematoma.