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

Background:  The aim of this study is to evaluate the changes in radiologic parameters and clinical outcomes following unilateral biportal endoscopic unilateral laminotomy and bilateral decompression (UBE ULBD) for treatment of central lumbar spinal stenosis.

Methods:  Forty-one central lumbar spinal stenosis patients who underwent UBE ULBD were enrolled from April 2021 to February 2023. Visual analog scale (VAS) for back pain and leg pain, Oswestry Disability Index (ODI) score, and the modified MacNab criteria were assessed preoperatively and postoperatively. The preoperative and postoperative cross-sectional area of the spinal canal (CSAC), anteroposterior diameter, horizontal width, and ipsilateral and contralateral lateral recess height were calculated from axial computed tomography (CT) scans. Percentage of facet joint preservation measured on axial CT scans was obtained preoperation and postoperation.

Results:  The VAS for back and leg pain improved from 7.24 ± 0.80 and 7.59 ± 0.59 preoperatively to 2.41 ± 0.55 and 2.37 ± 0.62 (p < 0.05) postoperatively and 1.37 ± 0.54 and 1.51 ± 0.55 at the last follow-up (p < 0.05). For ODI, improvement from 60.37 ± 4.44 preoperatively to 18.90 ± 4.66 (p < 0.05) at the last follow-up was observed. CT scans demonstrated that the postoperative CSAC increased significantly from 287.84 ± 87.81 to 232.97 ± 88.42 mm (p < 0.05). The mean postoperative anteroposterior diameter and horizontal width increased significantly from 18.01 ± 3.13 and 19.57 ± 3.80 to 22.19 ± 4.56 and 21.04 ± 3.72 mm, respectively (p < 0.05). The ipsilateral lateral recess height and contralateral lateral recess height were 3.39 ± 1.12 and 3.20 ± 1.14 mm preoperatively and 4.03 ± 1.37 and 3.83 ± 1.32 mm (p < 0.05) postoperatively, with significant differences. The ipsilateral and contralateral facet joint preservations were 88.17 and 93.18%, respectively.

Conclusion:  The UBE ULBD surgery is a safe and effective treatment for central lumbar spinal stenosis, associated with significant improvement in clinical outcomes and radiologic parameters. Studies with larger samples and longer follow-up periods are needed for further research.

Background:  Endovascular therapy has revolutionized the treatment of cerebral aneurysms in recent years and decades. So-called intrasaccular devices (i.e., Woven EndoBridge [WEB], MicroVention, Aliso Viejo, California, United States; or Contour, Cerus Neurovascular, Fremont, California, United States) are a promising endovascular technology, especially for wide-based aneurysms. However, long-term outcome data are currently particularly scarce for Contour and strategies for failed Contour cases are lacking. Here, we report the feasibility of microsurgical clipping after failed Contour device embolization.

Methods:  Feasibility of microsurgical clipping after failed aneurysm embolization with a Contour intrasaccular device was assessed in a patient.

Results:  We present the case of a 36-year-old male patient diagnosed with Hunt and Hess grade 1 subarachnoid hemorrhage from an anterior communicating artery aneurysm. The ruptured aneurysm was initially treated with the Contour device. After 3 months, angiographic imaging showed a clear aneurysm residual deemed not endovascularly accessible. The patient was then successfully clipped using microsurgical techniques. The patient was discharged with no neurologic abnormalities.

Conclusion:  After thorough bibliographical research, this presents the first published case report of microsurgical clipping after failed embolization with Contour. The main insights gained after clipping were that the Contour does not significantly disturb or hinder clipping. In contrast to coils in aneurysms to be clipped, the Contour can be easily compressed by the clip blades and does not have to be removed. In addition, the Contour had not migrated into the subarachnoid space and there was no abnormal scarring. Clipping appears to be a reasonable treatment strategy for failure of embolization with Contour if endovascular means are not suitable.

Background:  The implantation of a spacer is a common practice after anterior diskectomy in cervical spine. Polyether ether ketone (PEEK) cages have replaced titanium implants due to their better radiologic visibility and appearance in postoperative magnetic resonance imaging (MRI) scans. However, PEEK showed apparently higher nonunion rates than titanium cages. The aim of the study was to evaluate the fusion behavior of plain PEEK cages in comparison to titanium-coated PEEK (TiPEEK) cages.

Method:  We randomized 104 patients with single-level cervical radiculopathy or mild myelopathy. They were divided into two groups of 52 patients each, receiving either a PEEK cage or the titanium-coated variant of the same cage type. The 1- and 2-year follow-ups were completed by 43 patients in the PEEK group and by 50 patients in the TiPEEK group. Fusion was determined by plain X-ray and lateral functional X-ray.

Results:  Two years after surgery, a complete fusion was observed in 37 patients of the PEEK group (86%). Six cases were considered as nonunions. In the TiPEEK group, we found 41 fusions (82%) and 9 nonunions at this time. The difference was not considered significant (p = 0.59). The clinical evaluation of the two groups showed no difference in the neurologic examination as well in the pain scores over the time period.

Conclusions:  Despite some assumptions about an advantage of TiPEEK over PEEK cages for fusion in cervical spine surgery, this prospective randomized controlled study did not find an accelerated or improved fusion using TiPEEK for anterior cervical diskectomy.

Background:  Tranexamic acid (TXA) is safe and effective in preventing bleeding during spinal surgery. However, there is currently no relevant research on the efficacy and safety of adding TXA to the saline irrigation fluid in percutaneous endoscopic interlaminar diskectomy (PEID). This study aimed to evaluate the efficacy and safety of topical saline irrigation with TXA for PEID in the treatment of lumbar disk herniation.

Methods:  In this single-center, retrospective cohort study, patients who underwent PEID for L5-S1 lumbar disk herniation were included and allocated to two groups according to whether they had been administered TXA. PEID was performed with saline irrigation fluid containing 0.33 g of TXA per 1 L of saline in the TXA group (n = 38). In the control group (n = 51), the saline irrigation fluid was injected with the same volume of normal saline. All PEIDs were performed by the same spine surgery team. The hidden blood loss (HBL), intraoperative blood loss (IBL), total blood loss (TBL), amount of fluid used, operation time, visual clarity, hospital stay, blood transfusion rate, coagulation index, and complication rate were compared between the two groups.

Results:  The TBL, HBL, and IBL in the TXA group were significantly lower than those of the control group. The postoperative hemoglobin in the TXA group was significantly higher than that of the control group. Visual clarity was significantly better and the operation time was significantly shorter in the TXA group. However, there was no significant difference in postoperative hematocrit, blood coagulation function, amount of fluid used, blood transfusion rate, and perioperative complications between the two groups.

Conclusion:  In PEID, the addition of TXA to topical saline irrigating fluid can significantly reduce the HBL, IBL, and TBL. The addition of TXA to topical saline irrigating fluid can improve visual clarity in the surgery and reduce operation time, but it does not change the coagulation function or the complication rate.

Background:  Thoracic disk herniations (TDHs) are relatively rare compared with their cervical and lumbar counterparts. Posterior approaches allow for a simpler and less invasive surgery than anterior and lateral approaches. A pedicle-sparing transfacet approach was initially described in 1995, and modified in 2010. A few clinical series have reported the outcome of this procedure in patients with TDH. This study aimed to evaluate the outcomes and complications of pedicle-sparing transfacet diskectomy with interbody fusion and segmental instrumentation in patients with TDH.

Methods:  Twenty-one consecutive patients with symptomatic TDH referred to our tertiary care center were included in this retrospective study. All patients underwent a pedicle-sparing transfacet diskectomy with polyetheretherketone (PEEK) cage interbody fusion and short segmental instrumentation. Distribution of TDH, operative duration, blood loss, Visual Analog Scale (VAS) pain scores, Nurick grades, modified Japanese Orthopaedic Association (mJOA) scores, and fusion rate were assessed.

Results:  All patients had single-level herniations. The most common location was T12-L1 (38.1%), followed by T11-T12 (33.3%). All patients were successfully operated on with no cerebrospinal fluid (CSF) leaks or wrong-level surgery. The VAS scores significantly diminished from 4.9 (preoperatively) to 2 (18 months after surgery). The average mJOA score increased from 4.6 to 8.5, and the average Nurick grade decreased from 3.1 to 1.6. All patients reported significant improvement in quality of life relative to their preoperative status.

Conclusion:  A modified pedicle-sparing transfacet diskectomy combined with PEEK cage interbody fusion and segmental instrumentation offers a safe and less invasive approach for the treatment of TDHs.

Background:  Intraforaminal lumbar disk herniations (IFDHs) represent a heterogeneous and relatively uncommon disease; their treatment is technically demanding due to the anatomical relationships with nerve roots and vertebral joints. Over time, several approaches have been developed without reaching a consensus about the best treatment strategy.

Materials and methods:  Authors comparatively analyze surgical operability and exposure in terms of quantitative variables between the different microsurgical approaches to IFDHs, defining the impact of each approach on surgical maneuverability and exposure on specific targets.A comparative microanatomical laboratory investigation was conducted. The operability score (OS) was applied for quantitative analysis of surgical operability.

Results:  Transarticular and combined translaminar-trans-pars-interarticularis approaches result in providing the best surgical exposure and maneuverability on all targets with surgical controls on both nerve roots, at the expense of a higher risk of iatrogenic instability. Trans-pars-interarticularis approach reaches comparable levels of operability, even limited to the pure foraminal area (lateral compartment); similar findings were recorded for partial facetectomy on the medial compartment. The contralateral interlaminar approach provides good visualization of the foramen without consensual favorable maneuverability, which should be considered the main drawback.

Conclusions:  Approach selection has to consider disease location, the possible migration of disk fragments, the degree of nerve root involvement, and risk of iatrogenic instability. According to the findings, authors propose an operative algorithm to tailor the surgical strategy, based both on the precise definition of anatomic boundaries of exposure of each approach and on surgical maneuverability on specific targets.

Background:  High-frequency oscillations (HFOs) are spontaneous electroencephalographic (EEG) events that occur within the frequency range of 80 to 500 Hz and consist of at least four distinct oscillations that stand out from the background activity. They can be further classified into "ripples" (80-250 Hz) and "fast ripples" (FR; 250-500 Hz) based on different frequency bands. Studies have indicated that HFOs may serve as important markers for identifying epileptogenic regions and networks in patients with refractory epilepsy. Furthermore, a higher extent of removal of brain regions generating HFOs could potentially lead to improved prognosis. However, the clinical application criteria for HFOs remain controversial, and the results from different research groups exhibit inconsistencies. Given this controversy, the aim of this study was to conduct a meta-analysis to explore the utility of HFOs in predicting postoperative seizure outcomes by examining the prognosis of refractory epilepsy patients with varying ratios of HFO removal.

Methods:  Prospective and retrospective studies that analyzed HFOs and postoperative seizure outcomes in epilepsy patients who underwent resective surgery were included in the meta-analysis. The patients in these studies were grouped based on the ratio of HFOs removed, resulting in four groups: completely removed FR (C-FR), completely removed ripples (C-Ripples), mostly removed FR (P-FR), and partial ripples removal (P-Ripples). The prognosis of patients within each group was compared to investigate the correlation between the ratio of HFO removal and patient prognosis.

Results:  A total of nine studies were included in the meta-analysis. The prognosis of patients in the C-FR group was significantly better than that of patients with incomplete FR removal (odds ratio [OR] = 6.62; 95% confidence interval [CI]: 3.10-14.15; p < 0.00001). Similarly, patients in the C-Ripples group had a more favorable prognosis compared with those with incomplete ripples removal (OR = 4.45; 95% CI: 1.33-14.89; p = 0.02). Patients in the P-FR group had better prognosis than those with a majority of FR remaining untouched (OR = 6.23; 95% CI: 2.04-19.06; p = 0.001). In the P-Ripples group, the prognosis of patients with a majority of ripples removed was superior to that of patients with a majority of ripples remaining untouched (OR = 8.14; 95% CI: 2.62-25.33; p = 0.0003).

Conclusions:  There is a positive correlation between the greater removal of brain regions generating HFOs and more favorable postoperative seizure outcomes. However, further investigations, particularly through clinical trials, are necessary to justify the clinical application of HFOs in guiding epilepsy surgery.

Background:  Patients with severe steno-occlusive disease of a main cerebral artery without causative lesions on magnetic resonance imaging (MRI) often develop cognitive impairment. However, the effects of revascularization surgery and the source of the cognitive impairment remain unclear. Therefore, we investigated the early postoperative course of cognitive function and its association with cerebral blood flow (CBF), cerebrovascular reserve (CVR), white matter disease (WMD), lacunar infarction, and cerebrovascular risk factors.

Methods:  Cognitive function was examined using neurobehavioral cognitive status examination (COGNISTAT) in 52 patients with steno-occlusive disease of a main cerebral artery before and at 6 months after superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis. We examined how cognition changed before and at 1, 3, and 6 months after STA-MCA anastomosis in 27 of 52 patients. CVR and CBF were calculated from ¹²³I-N-isopropyl-p-iodoamphetamine single photon emission computed tomography, in addition to other cerebrovascular risk factors in 34 of 52 patients. Cerebral infarction and WMD (periventricular hyperintensity [PVH] and deep subcortical white matter hyperintensity) were also evaluated preoperatively by MRI.

Results:  COGNISTAT scores improved at 1 month after STA-MCA anastomosis in patients with severe steno-occlusive disease of a main cerebral artery. Multiple stepwise regression analysis revealed that CVR (regression coefficient = -2.237, p = 0.0020) and PVH (regression coefficient = 2.364, p = 0.0029) were the best predictors of postoperative improvement in COGNISTAT scores (R ² = 0.415; p = 0.0017).

Conclusion:  Cognitive function improves in relation to preoperative CVR and PVH early after STA-MCA anastomosis in patients with steno-occlusive disease of a main cerebral artery.

Background:  The literature concerning the management of antiplatelet (AP) and anticoagulation (AC) medication in the perioperative phase of craniotomy remains scarce. The aim of this international survey was to investigate the current practice among neurosurgeons regarding their perioperative management of AP and AC medication.

Methods:  We distributed an online survey to neurosurgeons worldwide with questions concerning their perioperative practice with AP and AC medication in patients undergoing craniotomy. Descriptive statistics were performed.

Results:  A total of 130 replies were registered. The majority of responders practice neurosurgery in Europe (79%) or high-income countries (79%). Responders reported in 58.9 and 48.8% to have institutional guidelines for the perioperative management of AP and AC medication. Preoperative interruption time was reported heterogeneously for the different types of AP and AC medication with 40.4% of responders interrupting aspirin (ASA) for 4 to 6 days and 45.7% interrupting clopidogrel for 6 to 8 days. Around half of the responders considered ASA safe to be continued or resumed within 3 days for bypass (55%) or vascular (49%) surgery, but only few for skull base or other tumor craniotomies in general (14 and 26%, respectively). Three quarters of the responders (74%) did not consider AC safe to be continued or resumed early (within 3 days) for any kind of craniotomy. ASA was considered to have the lowest risk of bleeding. Nearly all responders (93%) agreed that more evidence is needed concerning AP and AC management in neurosurgery.

Conclusion:  Worldwide, the perioperative management of AP and AC medication is very heterogeneous among neurosurgeons.