Neurosurgery最新文献

Background and objectives: Hydrocephalus after Gamma Knife® stereotactic radiosurgery (SRS) for vestibular schwannomas is a rare but manageable occurrence. Most series report post-SRS communicating hydrocephalus in about 1% of patients, thought to be related to a release of proteinaceous substances into the cerebrospinal fluid. While larger tumor size and older patient age have been associated with post-SRS hydrocephalus, the influence of baseline ventricular anatomy on hydrocephalus risk remains poorly defined.

Methods: A single-institution retrospective cohort study examining patients who developed symptomatic communicating hydrocephalus after undergoing Gamma Knife® SRS for unilateral vestibular schwannomas from 2011 to 2021 was performed. Patients with prior hydrocephalus and cerebrospinal fluid diversion or prior surgical resection were excluded. Baseline tumor volume, third ventricle width, and Evans Index (EI)-maximum width of the frontal horns of the lateral ventricles/maximum internal diameter of the skull-were measured on axial postcontrast T1-weighted magnetic resonance imaging.

Results: A total of 378 patients met the inclusion criteria; 14 patients (3.7%) developed symptomatic communicating hydrocephalus and 10 patients (2.6%) underwent shunt placement and 4 patients (1.1%) were observed with milder symptoms. The median age of patients who developed hydrocephalus was 69 years (IQR, 67-72) and for patients younger than age 65 years, the risk was 1%. For tumor volumes <1 cm 3 , the risk of requiring shunting was 1.2%. The odds of developing symptomatic hydrocephalus were 5.0 and 7.7 times higher in association with a baseline EI > 0.28 ( P = .024) and tumor volume >3 cm 3 ( P = .007), respectively, in multivariate analysis. Fourth ventricle distortion on pre-SRS imaging was significantly associated with hydrocephalus incidence ( P < .001).

Conclusion: Patients with vestibular schwannoma with higher baseline EI, larger tumor volumes, and fourth ventricle deformation are at increased odds of developing post-SRS hydrocephalus. These patients should be counseled regarding risk of hydrocephalus and carefully monitored after SRS.

Background and objectives: Stereotactic radiosurgery (SRS) is effective for patients with medically refractory trigeminal neuralgia with a 75%-90% response rate. Consideration of the integral dose (ID) to the target nerve within the 50% isodose line was reported to help select prescription doses to maximize effectiveness and minimize bothersome numbness. The objective of this study was to externally validate the ID as a predictor of outcomes after SRS.

Methods: We reviewed the outcomes and parameters of 94 consecutive patients of type 1 trigeminal neuralgia who had SRS for the first time where nerve ID was calculated. 70% of the prescription doses were 80 Gy, with 28% at 85 Gy, and 2% at 70 Gy.

Results: The median follow-up time was 14.4 months. A total of 85 (90%) patients reported significant pain relief (Barrow Neurological Institute I-III) after initial SRS. The median pain recurrence-free survival was 82 months (95% CI 41.1-NA), and estimates at 1, 3, and 5 years were 80.5%, 65.5%, and 55.9%, respectively. The ID was not significantly associated with initial pain relief, or affect the risk of pain recurrence or sensory dysfunction after SRS using the Cox proportional hazards model. A nerve mean dose ≥65 Gy was associated with a reduced risk of pain recurrence on multivariate analysis (hazard ratio 0.408, P = .039). Twenty (21%) patients experienced sensory dysfunction after SRS with 3 (3%) requiring further medications, which was not correlated with the prescription dose or brainstem maximum dose.

Conclusion: The ID did not predict recurrence-free survival or sensory dysfunction. Our observations suggest improved nerve coverage by the most powerful area of the isocenter, for instance, by targeting a narrower segment if feasible, could result in more durable pain relief. Further studies to validate these findings are needed.

Minimally invasive spine surgery (MISS) has transformed spinal surgery by minimizing tissue disruption, reducing recovery times, and lowering complication rates compared with traditional open procedures. MISS uses smaller incisions, specialized tools, and advanced imaging to treat conditions such as degenerative disk disease, trauma, and tumors. Techniques such as endoscopic spine surgery and tubular retractors have expanded its applications, enabling effective treatment with less postoperative pain and faster mobilization. Patient selection is crucial to the success of MISS, requiring detailed imaging analysis and consideration of overall health and pathology. Although MISS provides significant benefits, it is less effective for complex spinal deformities that require extensive sagittal or coronal corrections. Technological advancements, including robotic assistance and augmented reality, are enhancing surgical precision and expanding the scope of MISS. Enhanced recovery after surgery protocols, when combined with MISS, improve outcomes by reducing hospital stays and postoperative pain. Complications such as dural tears and hardware misplacement, although less common than in open surgery, require careful management, with techniques such as intraoperative imaging and robotic navigation aiding in complication prevention. Continued innovation in MISS will broaden its application and improve safety and patient outcomes across various spinal pathologies.

Background and objectives: Full-endoscopic surgery is increasingly used for treating lumbar foraminal pathologies, though the specific indications remain unclear. This study aims to evaluate patient-reported outcomes after transforaminal full-endoscopic spine surgery for various lumbar foraminal conditions.

Methods: Multicenter cohort study of patients with intervertebral lumbar foraminal pathology who underwent full-endoscopic decompression at four medical centers. Postoperative patient-reported outcomes, including low back and leg pain as well as Oswestry Disability Index (ODI) scores, were prospectively tracked using a mobile app for 6 months. Six-month outcome measures (patient-reported outcome measures) were used as the primary outcome variable to determine treatment effectiveness regarding various foraminal pathologies.

Results: A total of 83 patients with a mean age of 57.04 ± 1.63 years were included. The most common operative levels were L4/5 for transforaminal endoscopic discectomies (59.6%) and L5/S1 for endoscopic foraminotomies (58.1%). Endoscopic discectomies resulted in significant improvements in Visual Analog Scale scores for low back pain (from 5.85 ± 0.43 to 3.02 ± 0.41; P < .001), leg pain (from 6.66 ± 0.34 to 3.12 ± 0.57; P < .001), and ODI scores (from 24.39 ± 1.35 to 12.32 ± 176; P < .001). Endoscopic foraminotomies also resulted in significant improvements in Visual Analog Scale scores for low back pain (from 5.58 ± 0.53 to 3.68 ± 0.58; P < .001) and leg pain (from 6.42 ± 0.47 to 4.21 ± 0.58; P < .001), as well as ODI scores (from 19.28 ± 1.41 to 14.67 ± 2.03; P < .01). The amount of improvement was independent of the severity of foraminal stenosis, as determined on preoperative MRI. However, vertical foraminal stenosis was associated with the lowest treatment response rate.

Conclusion: Endoscopic foraminotomies result in clinically meaningful symptomatic improvement for most lumbar foraminal pathologies. However, the effectiveness of decompression surgery for vertical foraminal stenosis is limited and requires further investigation.

Robotic-assisted spine surgery has significantly advanced surgical precision and safety. This is particularly pertinent in minimally invasive spine surgeries that rely on imaging and technologies for visualization and the ability to accomplish surgical goals through smaller surgical corridors. The ability to preoperatively plan and then place pedicle screws across a wide range of applications has reduced the difficulty of even complex surgeries that once may have been considered prohibitive for minimally invasive approaches. While challenges and limitations remain, ongoing research and development aim to address these to continually expand the benefits of robotic-assisted spine surgery.

Background and objectives: Cerebral ventriculitis remains a challenging neurosurgical condition because of poor outcomes including mortality rates of nearly 80% and a prolonged course of treatment in survivors. Despite current conventional management, outcomes in some cases remain unsatisfactory, with no definitive therapeutic guidelines. This feasibility study aims to explore the use of a novel active, continuous irrigation and drainage system (IRRA flow [IRRAS AB]) combined with intraventricular drug delivery for patients with cerebral ventriculitis.

Methods: We conducted a multicenter, international, retrospective study of patients with ventriculitis who were treated with use of the IRRA flow system. Data collected included patient demographics, comorbidities, admission Glasgow Coma Scale score, baseline modified Rankin Scale (mRS) score, and imaging findings. Catheter occlusions, infections, and shunt placement were recorded for outcome assessment, along with discharge mRS scores and in-hospital deaths.

Results: Four centers contributed data for a total of 21 patients who had IRRA flow placement for treatment of ventriculitis. Thirteen (61.9%) were men (mean age = 49.8 ± 14.87 years). The median baseline mRS score was 1. The median Glasgow Coma Scale score at admission was 13. The etiology of ventriculitis was iatrogenic in 12 (57.1%) patients and secondary to an abscess in 9 (42.9%). No cases reported hemorrhage or failure of IRRA flow placement. Antibiotics were administered through the IRRA flow system in 13 (61.9%) cases in addition to systemic dosing. Sixteen (76.2%) patients had significant clinical improvement and resolution of ventriculitis. Seven (33.3%) patients required shunt placement after resolution because of persistent hydrocephalus. There were 6 (28.6%) in-hospital deaths.

Conclusion: The use of active irrigation with drainage for continuous delivery of intraventricular irrigation fluid with antibiotics led to dramatically low mortality. In our case series, it led to a marked improvement in neurological status, imaging findings, and cerebrospinal fluid profiles, making it a technically feasible and safe treatment for ventriculitis.