Neurosurgical focus最新文献

Objective: This study investigated whether the selection of different dural substitutes and distinct dural repair techniques correlates with the incidence rate of postoperative CSF leak in a mixed population of adults and children with Chiari type I malformation (CM-I) who underwent posterior fossa decompression with enlargement duraplasty (PFDD) as the first surgical approach.

Methods: A retrospective analysis was conducted on all patients admitted to the authors' institution between 2006 and 2023 for PFDD to treat syringomyelia and/or symptoms due to CM-I. Clinical, radiological, and surgical data were extracted from a prospectively maintained database. Demographic information was collected from medical records. Surgical procedures were also scrutinized, specifically focusing on the type of dural graft used for duraplasty, alongside perioperative complications and the necessity for subsequent surgeries. Lastly, during follow-up, the occurrence of a CSF leak was assessed and analyzed in relation to the type of dural graft used during surgery. The type of dural substitute chosen changed over the years to reduce CSF fistulas, while the technique of PFDD remained the same. Consequently, large sequential homogeneous groups differing only by dural substitutes were available for comparison.

Results: The data from 409 patients with CM-I undergoing PFDD were analyzed. A total of 368 cases had complete surgical data and were included. Thirty patients received autologous duraplasty. The remaining 338 cases with heterologous duraplasty from equine and bovine pericardium were considered for the comparative statistical analysis. The mean follow-up duration ranged from 39 months in adults to 45 months in children. The CSF complication rate requiring revision was 6.5% in the total cohort, with a higher incidence in children (10.5%) compared with adults (3.9%). There was no significant difference in adverse events (CSF leak, revision surgery, or ventriculoperitoneal shunt placement) between the different dural patches by univariate analysis if applied to the total cohort, although the trend neared significance (p = 0.06). In pediatric cases, this value was significant (p = 0.01) in favor of equine pericardium, particularly when combined with a collagen matrix inlay graft.

Conclusions: This study on a large and homogeneous series of patients with CM-I undergoing PFDD with heterologous duraplasty demonstrated that CSF complications may be kept low. The dural substitutes derived from equine pericardium, particularly when combined with a collagen matrix inlay graft, exhibited a reduced rate of CSF leaks compared with substitutes derived from bovine pericardium.

Objective: Incidental durotomy during degenerative lumbar spine surgeries poses a complex medical challenge. Despite its relatively common occurrence, consensus on its management remains elusive due to the absence of robust, high-level evidence, resulting in significant variations in practice across medical institutions. The aim of this survey was to assess the current practices in Germany regarding early mobilization versus bed rest in the postoperative management of incidental durotomy during lumbar surgery to estimate the need for a randomized clinical trial.

Methods: A digital survey titled "Postoperative management of incidental durotomy in lumbar spine surgery" was conducted among 119 neurosurgical departments in Germany. Key questions included the use of bed rest postsurgery, timing of mobilization, and whether the practice depended on the complexity of the surgery or the quality of the dural tear repair. The survey also explored the role of lumbar drains in management and respondents' potential participation in a multicenter study on the benefits of bed rest.

Results: Invitations were sent in November 2023, and responses were collected during November and December 2023. A total of 89 (75%) departments completed the survey. Among them, 75% reported using bed rest in the postoperative management of incidental durotomy. For 57%, this practice depends on the complexity of the surgical procedure or the quality of the surgical repair of the dural tear, while 18% apply it independently. Twenty-nine of the 89 departments (33%) answered that mobilization is allowed 24 hours after surgery, 13 departments (15%) allow mobilization after 48 hours, and 19 departments (21%) allow it after 72 hours. Additionally, 34% reported using a lumbar drain in cases of persistent postoperative CSF leakage, 36% use it for secondary surgical revision, and 30% do not use it in either case. Furthermore, 55 departments (62%) expressed potential interest in participating in a multicenter randomized trial addressing the postoperative management of incidental durotomy.

Conclusions: The postoperative management of incidental durotomy during lumbar surgery exhibits significant variation across neurosurgical departments in Germany. Postoperative bed rest remains a common practice. To evaluate the true benefits of bed rest, a randomized multicenter study is recommended. A summary proposal for such a study is presented to address this need.

Objective: Symptomatic retethering in pediatric patients following complex spinal dysraphism surgery for lipomyelomeningocele (LMMC) repair occurs in approximately 20% of cases. Common complications after repeat surgery for retethering include infection, pseudomeningocele (PMC), and cerebrospinal fluid (CSF) fistula. The authors of this report aim to describe the treatment options for large PMCs or CSF fistulas in a series of patients who underwent repeat surgery for recurrent LMMC at their institution. Additionally, they review management strategies from the literature.

Methods: This retrospective, descriptive case series includes patients with LMMC who required revision surgery for postoperative PMC or CSF fistula after recurrent untethering procedures at the authors' institution between 2013 and 2023. The surgical strategies for managing PMC and CSF fistula were examined. References for the narrative literature review were sourced from the PubMed and MEDLINE databases.

Results: Eight patients underwent surgery for recurrent retethering due to worsening neurological deficits, including 2 (25.0%) patients who had undergone multiple previous untethering surgeries. The mean duration between symptom onset and repeat surgery was 11.30 ± 5.50 months. Of these 8 cases, 3 (37.5%) developed large postoperative PMCs and CSF fistulas. These patients required a mean of 4.7 ± 2.9 revision surgeries (range 3-8). Management often involved multiple techniques, including local wound revision, dural repair or sealing, mechanical coverage, tissue reconstruction, and external or internal fluid diversion. In all cases, PMCs and CSF fistulas were successfully treated, and at the final follow-up, all patients had stable neurological conditions compared to their preoperative status.

Conclusions: Managing symptomatic retethering after LMMC repair is challenging, often complicated by PMC and CSF fistulas due to missing normal anatomical tissue layers, large defects, and poor dorsal support. Successful treatment typically requires a combination of techniques to address CSF-related issues. In the authors' experience, a multifaceted approach and familiarity with these methods are essential for achieving optimal outcomes.

Objective: CSF fistulas are the weak spots of transnasal endoscopic and microsurgical skull base approaches. An autologous fat graft is considered the best substrate for clival dural reconstruction via transnasal approaches. However, potential gravitational displacement of the graft may result in CSF leakage. The authors have developed and described herein the fat graft fixation (FGF) technique to secure the fat graft against dislocation after transclival resection of chordomas invading the dura.

Methods: Seventy-five patients with cranial chordomas underwent surgical treatment at the authors' institution from September 2006 through June 2023. Of these, the authors collected demographic, clinical, radiological, surgical, and outcome data from 34 patients who underwent an endoscope-assisted microsurgical transclival approach via a transnasal, sublabial, or sublabial transmaxillary extended corridor. The FGF reconstruction technique was progressively implemented to improve clival reconstruction, with a focus on the results. With a custom-made 8-mm 3/8 round atraumatic surgical suture needle, a 4/0 Vicryl stitch was placed through the adjacent dural borders. An abdominal autologous fat graft was then placed over the dural defect. One triple knot was tied to secure the graft and prevent its delayed gravitational displacement. The primary outcome was to determine if the FGF group had a higher rate of early or late oronasal CSF fistula compared to the unlocked free graft group. Secondary outcomes included tension pneumocephalus, surgical site infection, and meningitis.

Results: The fat graft was not used in 8 (23.5%) of the 34 patients because the dura was intraoperatively intact. The unlocked free graft and FGF techniques were used in 20 (58.8%) and 6 (17.6%) patients, respectively. Of the 34 patients, no fistulas were observed in the group treated with the FGF technique, while 4 fistulas were found in the unlocked free graft group (p < 0.05), with 2 of these cases involving meningitis. Patients with a CSF fistula underwent a total of 7 surgical procedures: 3 revision surgical procedures, 2 lumboperitoneal shunts, and 2 ventriculoperitoneal shunts.

Conclusions: In the authors' preliminary experience, the FGF technique has shown promise in eliminating the risk of CSF fistula and other related complications after the transclival approach for clival chordomas involving the dura.

Objective: Sagittal synostosis is the most common type of craniosynostosis, resulting in deformity with distinctive morphological characteristics. These include occipital narrowing, parietal narrowing, anteriorly shifted vertex with parietal depression, and exaggerated frontal bossing. The traditional cephalic index affords limited reliability in quantifying initial severity and correction. The purpose of this study was to conceptualize and evaluate a set of novel metrics based on optical surface scanning (OSS) technology used for cranial remolding orthosis (CRO) treatment.

Methods: The 25 most recent infants to receive CRO treatment for sagittal synostosis at a single center were reviewed retrospectively. All treated patients underwent the endoscope-assisted craniectomy technique without barrel staving. OSS representations of each patient's head were acquired perioperatively and at cessation of CRO treatment. A novel set of metrics were developed, comprising the occipital contour angle to assess severity of occipital narrowing; the vertex proportionality index to assess the anterior vertex relative to the depressed posterior anatomy; the parietal-temporal index to assess proximal cranial narrowing; and the sellion-frontal index as a measure of frontal bossing. The pre- and posttreatment results for all indices were compared against each other and against a control group of 33 nonsynostotic infants with grossly normal head shapes.

Results: Initial treatment group means for all 4 indices demonstrated significant variance against both the final treatment group means and the control group means. No statistically significant differences were observed in the group means for occipital contour angle, parietal-temporal index, and sellion-frontal index between the posttreatment and control cohorts, which was suggestive of mean correction to normative levels for these morphological considerations. Despite an appreciable mean correction of parietal depression in the final treatment group, the mean vertex proportionality index values remained statistically different from the control group.

Conclusions: Sagittal synostosis is characterized by several characteristic deviations from normocephaly. These are effectively improved by endoscope-assisted craniectomy with CRO intervention. Importantly, head shape abnormalities differ between patients, and the individual subject can present normatively for some deformational categories. Therefore, a multimetric approach is essential to quantify initial presentation and subsequent outcome. The introduction of novel OSS-enabled craniometry may facilitate more patient-centric management of this complex deformity. Specifically, features with the greatest deviation from normative standards can be identified, enabling creation of discrete treatment plans with respect to the focus and length of postoperative helmeting.

Objective: Craniosynostoses are an underrecognized cause of intracranial hypertension (ICH), especially when associated with congenital syndromes. Alagille syndrome (ALGS) is a multisystem disorder with typical facial features and hepatobiliary, cardiac, vascular, skeletal, and ocular manifestations. The occurrence of craniosynostosis in ALGS is rare and can be associated with chronic ICH, requiring craniofacial surgery to increase the intracranial volume. The authors report a series of 6 patients with ALGS with craniosynostosis and discuss their neurosurgical management.

Methods: The authors included all patients with ALGS and craniosynostosis assessed in their national reference center between 2012 and 2024. They collected the following parameters: date of birth; sex; JAG1 mutation; hepatobiliary, cardiac, vascular, skeletal and ocular symptoms; type of craniosynostosis; presence of papilledema; head circumference; type of surgery (if needed); and clinical outcome.

Results: The 6 patients had a median age of 6 years at referral (range 15 months-6 years). Four patients presented with a history of ICH and papilledema. Craniofacial CT scans showed the fusion of all sutures (coronal, sagittal, and lambdoid) in 2 patients; bicoronal plus bilambdoid synostosis in 1 patient; and sagittal plus bilambdoid synostosis 1 patient. All patients required biparietal floating craniotomies, leading to prompt improvement of papilledema. Two patients without a history of ICH presented with single-suture synostosis without papilledema (anterior plagiocephaly and scaphocephaly).

Conclusions: The authors report single-suture and multisuture craniosynostosis associated with ALGS and its association with chronic ICH. They suggest systematic screening for craniosynostosis in patients with ALGS and papilledema to avoid unrecognized chronic ICH.

Objective: Patients with a history of surgery for single-suture craniosynostosis (SSC) as an infant often wish to participate in sports later in childhood. However, there are no established guidelines from neurosurgeons and craniofacial surgeons to guide parents in which sports their child should or should not participate. Therefore, this study aimed to evaluate the attitudes and practice patterns of experienced neurosurgeons and craniofacial surgeons regarding the counseling of caregivers of these patients about sports participation.

Methods: A survey was administered to neurosurgeons and craniofacial plastic surgeons of the Synostosis Research Group (SynRG), a group of 9 North American institutions, to identify attitudes toward sports participation in patients with past SSC surgery. Survey responses were collected anonymously in REDCap. Questions regarding specific sports participation recommendations for patients who underwent surgery as an infant for SSC with ideal healing and for those who required a delayed cranioplasty were answered. Questions pertained to patients with nonsyndromic SSC without associated Chiari malformation, syrinx, or other intracranial/intraspinal anomalies.

Results: Overall, 20 surgeons were invited to participate in the survey, with 18 (90%) (9 neurosurgeons and 9 craniofacial plastic surgeons) fully completing it. Only 1 (5.6%) surgeon counseled against any sports participation for patients with ideal healing. If cranioplasty was required, 39%-50% of surgeons counseled against some participation (most commonly restricting football/rugby, boxing, ice hockey, lacrosse, and wrestling), depending on the extent of the cranioplasty. Overall, more plastic surgeons (56%-67%) counseled against sports participation (including lower-contact sports such as baseball/softball, basketball, gymnastics, and soccer) than neurosurgeons (22%-33%) in patients who required cranioplasty.

Conclusions: SynRG surgeons generally did not counsel against sports participation (including contact sports) for children with a history of SSC surgery as an infant who had ideal healing. In patients requiring cranioplasty, 39%-50% of surgeons recommended against high-contact sports participation.