Neurosurgical focus最新文献

Objective: This study aimed to compare pain outcomes and complication rates between reexploration microvascular decompression (MVD), percutaneous rhizotomy (PR), and stereotactic radiosurgery (SRS) as second-line treatments for recurrent or persistent trigeminal neuralgia (TN) following an initial MVD.

Methods: A systematic review and meta-analysis was performed in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and MOOSE (Meta-Analysis of Observational Studies in Epidemiology) guidelines. Studies were included if they reported outcomes of reexploration MVD, PR, or SRS in adult patients with classic or idiopathic TN after a failed initial MVD. Primary outcomes included early and long-term pain relief. Secondary outcomes included recurrence, facial numbness, and complications. Random-effects models were used for meta-analyses, and subgroup and sensitivity analyses were conducted.

Results: Twenty-seven studies including 886 patients were analyzed (MVD + MVD: 505; MVD + PR: 267; MVD + SRS: 114). Early pain relief rates were similar between the MVD + MVD (83%) and MVD + PR (88%) groups, but lower in the MVD + SRS (76%) group. Long-term pain relief was highest in the MVD + MVD (82%) group, followed by the MVD + PR (68%) and MVD + SRS (67%) groups. New facial numbness occurred most frequently in the MVD + PR (93%) group, compared with the MVD + MVD (29%) and MVD + SRS (12%) groups. Neurolysis during reexploration was associated with significantly improved pain outcomes (OR 4.0, p = 0.00017). No clinical variables significantly predicted early pain relief.

Conclusions: Reexploration MVD provides durable long-term pain relief but carries a risk of complications. PR offers comparable short-term efficacy with higher rates of sensory disturbance but lower surgical morbidity. The benefit of nerve manipulation even in the absence of neurovascular compression highlights the need to better understand the pathophysiology of recurrent TN and supports the necessity for randomized controlled trials to inform treatment algorithms.

Objective: Cranial nerve (CN) preservation remains a challenge for skull base neurosurgeons, and neurophysiological intraoperative monitoring presents many methods for CN identification and mapping. The blink reflex, which is the electrophysiological representation of the corneal reflex, can be used to test both trigeminal and facial nerve function. The objective of this study was to present a method for obtaining a reliable blink reflex response and maintaining it during the course of a procedure.

Methods: A method for robust blink reflex recording is presented. Electrode placement, recording parameters, stimulation parameters, anesthetic considerations, and reliability troubleshooting are described.

Results: This method has been iteratively developed at the authors' institution across multiple sites for more than 5 years. The blink reflex was monitored in multiple cranial approaches and for various pathologies. The most common cases monitored were vestibular schwannoma resections and microvascular decompressions. The most common cranial approaches were the translabyrinthine, retrosigmoid/suboccipital, and middle cranial fossa approaches.

Conclusions: To gain a more comprehensive understanding of the clinical utility of the blink reflex in surgical decision-making and outcome prediction, prospective studies involving larger patient cohorts are warranted. This report outlines a reproducible methodology and invites validation and constructive input from the broader neurosurgical and neuromonitoring communities.

Objective: The objective was to investigate whether complete intraoperative elimination of the lateral spread response (LSR) is essential during microvascular decompression (MVD) for hemifacial spasm (HFS) and to identify a quantitative intraoperative biomarker predictive of favorable outcomes.

Methods: The authors retrospectively analyzed 208 adult patients who underwent MVD for primary HFS. Intraoperative neurophysiological monitoring (IONM) included LSR recordings from three facial muscles. Based on clinical outcomes at the 6-month postoperative follow-up, patients were independently categorized into two binary outcome groups-completely resolved (CR) versus non-CR, and clinically improved (CI) versus non-CI-for separate analyses. The final-to-baseline amplitude change ratio (FBCR) of LSR amplitude was calculated. Predictive thresholds were identified using machine learning models including random forest and decision trees.

Results: LSR was most frequently observed in the mentalis (96.2%) and orbicularis oris (92.3%). Complete disappearance of LSR was not a prerequisite for achieving either CI or CR outcomes. FBCR ≥ 86.5% in the mentalis muscle predicted CR with 88% accuracy, 99% sensitivity, and 47% specificity. FBCR ≥ 48.5% predicted CI with 98% accuracy and 91% specificity. Multivariate models did not significantly improve prediction compared to mentalis FBCR alone.

Conclusions: Complete elimination of LSR is not essential for clinical success in MVD for HFS. A quantitative reduction in LSR amplitude, especially in the mentalis muscle, provides a robust and practical intraoperative predictor of both objective and subjective outcomes. These findings advocate for a shift toward a muscle-specific, threshold-driven strategy for intraoperative neurophysiological monitoring in HFS surgery.

Objective: Primary hemifacial spasm (HFS) is a rare neurological condition characterized by involuntary contractions of hemifacial mimic muscles. Microvascular decompression (MVD) with the interposition technique, in which a Teflon spacer is inserted between the nerve and the offending vessel, is the most commonly used treatment. However, the authors' institution has used autologous muscle pledgets for more than 15 years as an alternative spacer material, with satisfactory results. They report a single-center study of 75 consecutive patients treated with interposition MVD using autologous muscle pledgets between November 2012 and March 2023.

Methods: All patients had a minimum follow-up of 1 year. Surgical outcomes were assessed using the Japanese grading system of Kondo and colleagues, which evaluates both the efficacy of surgery and complications. Furthermore, a systematic review of recent series on HFS treated by the interposition technique was done, to compare the present study results and outcomes.

Results: Among the 75 patients, 31 (41.3%) were male, the median age was 52 years, and the median duration of the disease was 5 years. In 51 patients (68.0%), the neurovascular conflict (NVC) was due to single-vessel compression, while multiple vessels were found in 24 cases (32.0%). Complete resolution of HFS was achieved in 84% of patients, with an additional 6.7% reporting occasional mild spasms. Delayed resolution occurred in 18.7% of cases, typically within 30 days postsurgery. The overall complication rate was low, with 8.0% experiencing hearing deficits and 1.3% reporting persistent dysphonia. According to the Japanese grading system, excellent results (complete disappearance of HFS and no complications) were obtained in 62 patients (82.7%) and good results in 7 (9.3%). Involvement of the vertebral artery (VA) was associated with poorer outcomes, with a significant reduction in achieving complete resolution (OR 0.23, p = 0.031).

Conclusions: Interposition MVD using autologous muscle pads represents an effective and durable treatment for HFS, particularly when the offending vessel is not a large-caliber artery, such as the VA or basilar artery (BA). The present study results are in line with those of the best series evaluating long-term resolution of the spasm and surgical complications. Despite a limited rate of recurrences, the described technique provides a high rate of spasm resolution, minimal complications, and high patient satisfaction. In the case of an NVC near the VA or BA, interposition with stiffer materials or the transposition technique may ensure a higher rate of HFS control.

Objective: Trigeminal neuralgia (TN) is characterized by recurrent, unilateral episodes of electric shock-like facial pain, frequently triggered by routine activities, that can significantly impair quality of life. Although interventions such as microvascular decompression, stereotactic radiosurgery, and minimally invasive percutaneous procedures often provide rapid pain relief, recurrence remains a clinical challenge. Psychological comorbidities, particularly depressive disorder, may play a role in predicting outcomes after surgical intervention. This study aimed to determine whether a preexisting diagnosis of depressive disorder was independently associated with earlier recurrence of pain after surgical intervention.

Methods: This single-center retrospective study included patients with TN who underwent surgical intervention between March 30, 2017, and March 30, 2024. Exposure variables consisted of demographic data, comorbidities, preprocedural characteristics of TN, procedure type, and total number of interventions. Primary outcomes were defined as > 50% pain relief at the last follow-up and recurrence of pain during the follow-up period.

Results: A total of 150 patients with TN who underwent 193 procedures were included in this retrospective analysis. The mean follow-up duration was 11.4 months. Among these cases, 54 patients had a clinical diagnosis or were being treated for depressive disorder. Female sex (74.1%) and comorbid migraine (44.4%) were significantly more prevalent in the depressed cohort. Patients with depressive disorder also underwent balloon compression rhizotomy (52.1%) and radiosurgery (32.4%) at higher rates compared with those without depressive disorder. No other significant differences were observed between the two groups. Postoperatively, recurrence of any level of facial pain was significantly more common in patients with depressive disorder (70.4% vs 51.6%, p = 0.011). In a multivariable mixed-effects Cox regression model, depressive disorder emerged as an independent predictor of earlier pain recurrence during follow-up, alongside type of surgical intervention received.

Conclusions: Depressive disorder is a common psychiatric comorbidity among patients with TN. This study demonstrated that depressive disorder also serves as an independent predictor of earlier pain recurrence after surgical intervention. Recognizing depressive disorder alongside other preexisting conditions may aid clinicians in setting realistic expectations of surgical outcomes and guiding clinical decision-making. Further studies are necessary to validate the observed associations and further clarify the impact of psychological comorbidities on pain outcomes after surgery.

Objective: An abnormal muscle response (AMR) is an important electrophysiological indicator for the diagnosis, treatment, and prognosis of hemifacial spasm (HFS). The purpose of this study was to analyze the factors associated with and to establish a predictive model for the persistence of AMRs during microvascular decompression (MVD), while also evaluating the relationship between the disappearance of AMRs and delayed recovery.

Methods: In this retrospective study, authors collected clinical data from patients with HFS who underwent MVD at The First Affiliated Hospital of Dalian Medical University between August 2019 and August 2024. Factors associated with the persistence of AMRs were analyzed, and a predictive model for their persistence was developed.

Results: The results showed the disappearance of AMRs at a rate of 78.3% among the 157 patients included in the study. Factors influencing the persistence of AMRs included disease duration, preoperative symptom severity, carbamazepine use, number of responsible vessels, preoperative AMR amplitude, cerebellar retraction depth, and degree of responsible vessel displacement. The predictive model achieved an area under the curve of 0.931, indicating high accuracy. Follow-up data revealed that the persistence of AMRs was associated with recovery rates at 3 months postoperatively (p < 0.01).

Conclusions: Risk factors for the persistence of AMRs can be used to predict the probability of persistent intraoperative AMRs. An intraoperative AMR that persists despite having a low preoperative predicted probability may indicate inadequate facial nerve decompression or undetected offending vessels, requiring either additional surgical exploration or transposition of the offending vessels. Conversely, when an AMR persists in the context of a high preoperative predicted probability, the MVD procedure can be safely terminated after confirming adequate decompression to minimize surgical complications. Patients with persistent AMRs may experience delayed recovery, with symptom relief potentially taking 3 months. If symptoms persist without improvement for 6 months to a year, a second surgery can be considered.

Objective: The therapy of choice for classical trigeminal neuralgia (TN) is usually microvascular decompression (MVD). Although in most surgical procedures the view with the operating microscope is sufficient to inspect the entire course of the trigeminal nerve from the brainstem to Meckel's cave, anatomical abnormalities may hinder the view. In these conditions, visualization with an endoscope with an angulated view provides additional exposure and may identify a compression that was hidden on microscopic view. The authors report their experience with this endoscope-assisted microvascular decompression (EA-MVD) technique and provide long-term results.

Methods: Between 2000 and 2020, 182 patients with classic TN and radiologically and intraoperatively confirmed neurovascular conflict (NVC) underwent endoscope-assisted surgery. Follow-up was conducted via our outpatient clinic or by telephone interview. EA-MVD included endoscopic inspection and dissection, as well as bimanual dissection under the microscope. The influence of several factors on postoperative outcome was statistically analyzed.

Results: In total, 168 (92%) of the authors' patients showed complete pain relief immediately postoperatively, 12 only partial relief, and 2 reported no improvement at all (1 with venous compression). Seventeen patients were unavailable for follow-up. The mean (range) follow-up duration was 62 (3-240) months. On last follow-up, 143 patients (78.6%) had a very good outcome (Barrow Neurological Institute [BNI] score I/II), 34 (18.7%) reported a moderate outcome (BNI score III), and 5 patients' outcomes (2.8%) were classified as failures (BNI score IV/V). Twenty-five patients (13.7%) had recurrence of pain. The average pain-free interval until recurrence was 25 months. The use of the endoscope was classified as very beneficial in 29 operations (15.9%). Major complications occurred in 4 patients (2.2%). Only the number of affected trigeminal branches showed a significant impact on outcome, with a single affected branch associated with better outcome. Duration of symptoms, sex, affected side, type of compression, and number of NVCs showed no correlation with outcome.

Conclusions: The authors results confirmed that EA-MVD is a safe technique with a high success rate. The value of the endoscope is especially apparent in patients with a prominent suprameatal tubercle that obscures the straight view to Meckel's cave with the operating microscope.

Objective: Microvascular decompression (MVD) represents a milestone for the treatment of trigeminal neuralgia (TN). Nevertheless, several complications still occur and may negatively affect the outcome. The authors recently proposed a minimally invasive technique, including endoscopic assistance in instances of intraoperative hidden corners, with which they were able to achieve good results in terms of pain relief and minimize overall complication rates. The aim of this study was to verify the short- and long-term efficacy of the proposed refinement of the standard MVD technique in terms of pain relief and reduction of complication rates.

Methods: The authors analyzed the surgical and outcome data of 154 consecutive patients with TN over a 10-year period. Outcome variables included pain relief, facial numbness, muscular atrophy, local cutaneous occipital and temporal pain or numbness, cerebellar injury, hearing loss, cranial nerve deficits, wound infection, CSF leakage, recurrences, and mortality rate. The overall complication rate was defined as the occurrence of any of the aforementioned items.

Results: A total of 154 consecutive patients were included in the study. Pain relief was achieved in 97.4% immediately after surgery, while 92.9%, 85.7%, and 83.1% of patients were pain free at the 1-year, 5-year, and last follow-up, respectively. The mean follow-up was 71.18 months (range 11-120 months). The overall complication rate was 5.8%, but only 1.3% of patients experienced permanent neurological complications. The CSF leakage rate was 3.2%. Two patients (1.3%) developed complete hearing loss, and another patient developed mild temporary dysfunction of the eighth cranial nerve. One patient experienced postoperative ataxia but completely recovered in 1 month. No other complication or death was observed.

Conclusions: The proposed minimally invasive refinement of the standard MVD technique has been shown to be effective in maintaining excellent results in terms of pain relief, in both the short and long term, while minimizing the overall complication rate associated with this surgical approach.