Neurosurgery最新文献

In 2019, the Congress of Neurological Surgeons published clinical practice guidelines for the management of myelomeningocele (MMC), which were informed by Level I evidence from the Management of Myelomeningocele Study trial and aimed to optimize clinical outcomes, particularly regarding prenatal vs postnatal repair. This study evaluates the perceived impact of these guidelines on the pediatric neurosurgical community. A cross-sectional survey was distributed to 700 members of the pediatric neurosurgery community, with 98 responses analyzed. The survey addressed practice patterns, familiarity with the guidelines, and barriers to guideline adherence. Among centers with higher volumes of MMC repairs, there was a reported increase in referrals for prenatal repair, with 25% of domestic and 5% of international respondents offering prenatal repair postguidelines. However, prenatal repair remains limited, particularly in lower-volume and international centers. Barriers such as insufficient training, lack of fetal surgery programs, and limited institutional resources were frequently cited. Regional differences in perceptions regarding ventriculomegaly and tethered cord syndrome further highlight the variability in guideline interpretation. Notably, 71% of international respondents believed persistent ventriculomegaly negatively affects neurocognition, compared with only 30% of domestic respondents. While the guidelines have influenced clinical practices, their implementation remains uneven. The findings underscore the influence of institutional capacity, volume of practice, and regional differences on guideline adoption. Although the 2019 Congress of Neurological Surgeons guidelines have made strides in improving MMC care, continued efforts are necessary to address these barriers, especially in resource-limited settings. Collaboration among academic institutions, policymakers, and healthcare providers is critical to enhancing global implementation of evidence-based practices for myelomeningocele management. Further research is needed to refine practices and standardize outcome measures.

Background and objectives: Chronic subdural hematoma (CSDH) often recurs after surgical evacuation, with rates ranging from 2% to 37%. Middle meningeal artery embolization (MMAE) has emerged as a potential adjunct to surgery to reduce recurrence. The aim of this study was to systematically review the added value of adjunctive MMAE to surgical treatment (MMAE+S) compared with surgical treatment alone (S) in managing CSDH with consideration to matching and randomization status of the 2 groups.

Methods: A systematic search identified 16 studies encompassing 1814 patients (939 MMAE+S, 1440 S). Five studies were randomized trials, 3 studies were matched studies, and the remaining were unmatched cohorts. Data on recurrence, radiological and functional outcomes, complications, and hospital stay were analyzed using a random-effects meta-analysis. The risk of bias was evaluated using Risk of Bias in Nonrandomized Studies of Interventions and Risk of Bias in Randomized Trials tools.

Results: The 2 treatment groups were comparable regarding all preoperative characteristics except for antithrombotic use which was higher in the MMAE+S group ( P = .03). Compared with surgery alone, the MMAE+S group had significantly lower recurrence rates (4.7% vs 17.7%, relative risk [RR] 0.31, P < .01) and reduced postoperative hematoma thickness (standardized mean difference [SMD] -0.17, P = .04), volume (SMD -0.25, P = .01), and midline shift (SMD -0.24, P = .01). Reduced recurrence was also observed in the subgroup of matched/randomized studies (RR 0.28, P < .01) and only randomized studies (RR 0.28, P < .01). Complication rates were comparable between the 2 groups when analyzing all (RR 0.90, P = .46), matched/randomized (RR 1.05, P = .62), and only randomized studies (RR 1.05, P = .63). The outcomes were influenced by the choice of embolic agent and timing of embolization, with liquid agents, and postoperative embolization showing slightly better outcomes compared with other embolization approaches. Functional outcomes, complications, mortality, and length of hospital stay were comparable between groups.

Conclusion: MMAE combined with surgery effectively reduces CSDH recurrence and improves radiological outcomes without increasing complications. These findings support MMAE as a valuable adjunct to surgical treatment, warranting further research to optimize its clinical application.

Background and objectives: This study sought to evaluate disparities in operative autonomy among young neurosurgical trainees in Andean Latin America. It also explored the distribution of operative resources in the Andean Community and their association with neuroanatomic excellence and operative autonomy.

Methods: Neurosurgical residents from training programs in Andean Latin America participated in a comprehensive survey to assess demographic information and their experiences with operative autonomy. The survey included inquiries regarding the cases performed autonomously, the availability of operative resources, and the locations of practice. Data were collected at 2 distinct time points: at the beginning and at the conclusion of the different educational interventions.

Results: A total of 132 neurosurgery residents participated in this study, with the majority being residents (108; 81.8%). Surgical autonomy varied significantly, with chief residents in capital programs performing 351 of 1108 (31.7%) reported cases independently (mean [SD], 11 [11] cases per chief resident) compared with only 23 of 185 (12.4%) in urban programs (mean [SD], 2.5 [1.3] cases per chief resident). In addition, access to functional operative resources correlated with autonomy; residents with working surgical microscopes (n = 59) and powered drills (n = 110) reported higher autonomy, emphasizing the critical role of these resources in enhancing operative experiences.

Conclusion: This study highlights the importance of surgical autonomy in neurosurgical training within low- and middle-income countries, particularly in the Andean region. Moreover, there is a clear disparity in operative resources distribution among different locations of practice. Addressing these barriers can promote greater autonomy, ultimately improving surgical outcomes and education in global neurosurgery.

Background and objectives: To restore lumbar lordosis in the context of deformity correction for degenerative sagittal imbalance (DSI), a cage is inserted using lateral lumbar interbody fusion. Nevertheless, a reduction in lordosis can be manifested during the follow-up period. This study assessed the alterations in lumbar lordosis within the fusion construct over the patient follow-up period and identified factors linked to the reduction of lumbar lordosis after a deformity correction in cases of DSI.

Methods: This retrospective analysis encompassed 124 patients who underwent deformity correction and had a follow-up exceeding 2 years postoperatively. Based on the criterion of a lordosis reduction ≥ 5° during the follow-up, patients were stratified into a lordosis maintenance group (Group M, n = 86) and a lordosis loss group (Group L, n = 38). We examined demographic, radiological, and surgical factors influencing lordosis reduction and delineated the trajectory of lordosis reduction throughout the follow-up.

Results: The degree of lordosis reduction averaged 9.79° ± 4.38° in Group L and 1.42° ± 1.94° in Group M (P < .001), with most occurring within 3 months postsurgery (from 62.0° ± 8.9° to 52.2° ± 8.64°, P < .001). Radiologically, endplate injury and cage subsidence did not significantly differ between the groups (P = .146, .200). Surgically, posterior column osteotomy was significantly more prevalent in Group L in multivariate analysis (adjusted odds ratio, 3.524; P = .020).

Conclusion: Approximately 30% (38/124) of patients experience fusion construct settling after deformity correction for DSI, predominantly within 3 months postoperation regardless of endplate injury and cage subsidence. The occurrence is notably higher in instances where a posterior column osteotomy is performed.

Background and objectives: Although microvascular decompression (MVD) is the most effective long-term treatment for trigeminal neuralgia (TN), its risks make some neurosurgeons favor ablative procedures in elderly patients, despite their limited durability and higher risk of sensory deficits, sparking debate over the optimal approach. This retrospective analysis aims to evaluate the safety and efficacy of MVD in octogenarian patients with TN compared with younger patients.

Methods: In this matched cohort analysis, a total of 280 patients were initially included, with 33 in the octogenarian group (≥80 years) and 247 in the nonoctogenarian group (<80 years). After 4:1 propensity score matching and excluding patients with previous MVD, 152 matched patients were selected for the main analysis.

Results: Octogenarians were more likely to have lower body mass index (25.8 kg/m 2 vs 28.1 kg/m 2 , P = .0175) and a preoperative diagnosis of arrhythmias (15.2% vs 3.4%, P = .0237) but otherwise did not have any significant differences in medical comorbidities and the nature of TN or previous treatments. The only postoperative complications higher in octogenarians was new or worsened arrhythmia (6.1% vs 0%, P = .0460). Length of stay, readmission rates, reoperation, and medical and surgical complications did not have any significant difference between age groups. Notably, octogenarians experienced similar reductions in pain postoperatively, with similar improvements in Barrow Neurological Institute pain scores as nonoctogenarians.

Conclusion: Octogenarians undergoing MVD for TN can achieve similar pain relief and postoperative outcomes to younger patients, despite a higher incidence of arrhythmia. Age alone should not preclude patients from receiving MVD; comprehensive evaluation of comorbidities and overall health is essential. MVD remains a viable option to improve quality of life in elderly patients with TN.

Background and objectives: Glioblastoma (GBM) isocitrate dehydrogenase-wildtype remains a devastating brain tumor with a poor prognosis despite optimal treatment. Even after supramaximal or complete contrast-enhancing (CE) resection, patient outcomes vary significantly, with some experiencing short-term survival (STS) and others long-term survival (LTS). This study aims to identify clinical and molecular markers predicting the survival of patients with GBM in these high-resection categories.

Methods: We retrospectively analyzed patients with newly diagnosed GBM who underwent supramaximal or complete CE resection, followed by next-generation sequencing at our institution (2009-2025). Patients were categorized as STS (survival ≤12 months), non-STS (survival >12 months), or LTS (survival ≥36 months). We compared clinical, radiological, and molecular features between these groups to identify potential prognostic markers.

Results: Among 85 patients who met the inclusion criteria, 24 (28%) were STSs and 61 were non-STS (from which 16 [18.8%] were LTSs), with no significant molecular differences observed between these groups. On comparing STS and LTS patients, CDKN2A/B loss (83.3% vs 43.8%, P = .01) and EGFR amplification (58.3% vs 25%, P = .05) were more frequent in STS patients vs LTS. Tumor location varied, with STS patients having more frontal lobe tumors (45.8%) and LTS patients having more temporal lobe tumors (62.5%). A trend, although not statistically significant, toward increased nonlocal recurrence rates was observed in STS patients (27.2%).

Conclusion: Despite aggressive extent of resection in GBM, the prevalence of STS patients remains notable at ∼28% and survival beyond 3 years remains limited at ∼18.8%. CDKN2A/B loss and EGFR amplification might correlate with shortened survival after supramaximal or complete CE resection. The impact of nonlocal recurrence remains uncertain among STSs. These findings highlight the need for collaborative studies to advance understanding of the biology of GBM as their behavior differs despite aggressive surgical and medical therapies.

Background and objectives: Cervical spine disease impairs quality of life through increased pain, discomfort, and altered sleep. Surgery is known to improve many quality of life domains as measured by patient-reported outcome measures, yet the interplay of sleep quality and surgical outcomes after cervical spine surgery remains understudied. This study aimed to characterize changes in sleep quality after cervical spine surgery over time using patient-reported outcome measurement information system (PROMIS) sleep disruption (PROMIS-SD) scores and identify factors associated with postoperative sleep improvement.

Methods: This single-center retrospective cohort study included patients 18 years and older who underwent cervical spine surgery for degenerative disease. Preoperative and postoperative PROMIS-SD scores quantified sleep quality changes. Repeated-measures analysis of variance analyzed trends in sleep disruption over time and by demographic and clinical factors whereas latent class analysis identified how sleep disruption affected surgical success through other PROMIS measure domains.

Results: Among 1015 patients (mean age: 61.5, 89.6% White), surgical approaches included anterior cervical diskectomy and fusion, arthroplasty, laminectomy and fusion, laminoplasty, and foraminotomy. Overall, PROMIS-SD scores improved postoperatively at 6 (P < .0001), 12 (P < .0001), 18 (P < .0001), and 24 months (P = .0419). Age at surgery (P = .0062) and preoperative sleep quality (P = .0007) were the strongest predictors of sleep improvement. Latent class analysis identified 6 patient outcome profiles. In our cohort, successfully meeting minimal clinically important difference for PROMIS mental health was only achieved in those patients also attaining minimal clinically important difference in either PROMIS physical health or PROMIS-SD.

Conclusion: Sleep improved or remained stable in >90% of patients after cervical spine surgery. Factors such as preoperative sleep scores and age most influenced changes in sleep improvement after surgery. Postoperative improvements in mental health were dependent on prerequisite improvements in physical health or sleep, and young patients with above average baseline sleep quality were most likely to experience postoperative sleep disruption.