Neurosurgery最新文献

Neuromonitoring in minimally invasive spine surgery (MISS) provides real-time feedback to surgeons and enhances surgical precision for improved patient safety. Since the 1970s, established techniques like somatosensory evoked potentials, motor evoked potentials, and electromyography have been integrated into spine surgeries, significantly reducing the risk of neurological complications. These neuromonitoring modalities have been crucial, particularly in complex procedures with limited direct visualization. Refinements in these techniques have led to greater confidence in nerve root safety, contributing to the success of MISS. Despite some debate regarding the routine use of neuromonitoring in noncomplex surgeries, its importance in complex cases is well-documented. Studies have demonstrated high sensitivity and specificity rates for these techniques, with multimodal approaches offering the best outcomes. Advancements in mechanomyography and its potential integration into neuromonitoring protocols highlight the continuous improvement in this field. This review explores the historical development, current techniques, clinical outcomes, and future directions of neuromonitoring in MISS. It emphasizes the critical role of these technologies in enhancing surgical outcomes and patient care. As MISS continues to evolve, adopting next-generation neuromonitoring systems, including artificial intelligence and machine learning, will play a pivotal role in advancing the efficacy and safety of spine surgeries.

Augmented reality (AR) is a technology that allows digital information to be superimposed onto a user's view of the real world, thereby enhancing the user's experience of a given real-world scenario. As recent advances in AR technology have made it more available for a variety of applications, hospitals and doctors have begun to test its utility in the operating room. AR technology allows surgeons to supplement their view of the operative field with useful patient-specific information for which they might otherwise need to turn their attention away from the task at hand. For spine surgeons in particular, AR has begun to emerge as a promising option to assist with surgical performance. The field of spine surgery is uniquely positioned to benefit from AR, given the extent to which many spine surgeons already rely on intraoperative navigation techniques for certain surgical tasks, including pedicle screw and interbody device placement. In this review, we outline the origins and history of AR in spine surgery and cover the current state of the literature regarding the applications, benefits, and drawbacks of its use within the field. Lastly, we speculate as to the future of AR in spine surgery and propose which gaps in knowledge must be addressed before the technology enjoys a degree of adoption on par with currently available intraoperative navigation techniques.

Background and objective: Patients who undergo gross total resection (GTR) of Central Nervous System World Health Organization (WHO) grade 1 meningioma constitute a "low-risk" group, but some low-risk meningiomas can recur despite reassuring clinical and histological features. In this study, gene expression values in newly diagnosed WHO grade 1 meningiomas that had undergone GTR were evaluated for their association with recurrence.

Methods: This was a retrospective, international, multicenter cohort study that included WHO grade 1 meningiomas that underwent GTR, as first treatment, based on postoperative magnetic resonance imaging. Normalized gene expression values from a previously validated 34-gene panel were evaluated for their association with recurrence. Kaplan-Meier, multivariable Cox proportional hazard analyses, and K-means clustering were performed to assess the association of genes of interest with recurrence and identify molecular subgroups among clinically and histologically low-risk meningiomas.

Results: In total, 442 patients with WHO grade 1 meningiomas that underwent GTR and had available gene expression profiling data were included in the study. The median follow-up was 5.0 years (interquartile range 2.6-7.7 years), local recurrence occurred in 36 patients (8.1%), 5-year local freedom from recurrence was 90.5%, and median time to recurrence was 2.9 years (range 0.5-10.7 years). Eleven genes were associated with local recurrence, including lower expression of ARID1B , ESR1 , LINC02593 , PGR , and TMEM30B and higher expression of CDK6 , CDKN2C , CKS2 , KIF20A , PGK1 , and TAGLN . Of these genes, PGK1 had the largest effect size. K-means clustering based on these 11 genes distinguished 2 molecular groups of clinically and histologically low-risk meningiomas with significant differences in local freedom from recurrence (hazard ratio 2.5, 95% CI 1.2-5.1, P = .016).

Conclusion: Gene expression profiling may help to identify newly diagnosed WHO grade 1 meningiomas that have an elevated risk of recurrence despite GTR.

Background and objectives: The aim of this study was to delineate the reconstructive endovascular treatment and periprocedural management of compensative-flow-related posterior circulation aneurysms with anterior circulation artery occlusion.

Methods: A total of 87 patients were enrolled in this retrospective double-center cohort study from May 2011 to November 2023. The baseline demographics, aneurysm characteristics, etiology and status of anterior circulation artery occlusion, treatment modalities, anesthesia management, complications, and clinical and angiographic outcomes of the patients were retrospectively analyzed in this study.

Results: Atherosclerosis and moyamoya disease were found to be the two main etiologies of anterior circulation artery occlusion. The mean American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology scores were significantly higher in patients with posterior communicating artery trunk collaterals than those with posterior cerebral artery pial collaterals ( P < .05). Treatment strategies included stent-assisted coiling (55, 63.2%), standard coiling (22, 25.3%), and flow diversion or flow diversion-assisted coiling (8, 9.2%). The overall rate of procedure-related ischemic and hemorrhagic complications (10.3%) was considered acceptable. The ischemic complication was significantly associated with a >20% drop in mean arterial pressure ( P < .05) during the procedure. Finally, 86.2% of all patients showed a modified Rankin Scale score of 0 to 2 at the final clinical follow-up.

Conclusion: Our study indicates that reconstructive endovascular treatments are feasible and effective strategies for compensative-flow-related posterior circulation aneurysms with anterior circulation artery occlusion. However, these treatments are associated with a risk of periprocedural ischemic complications, which can be reduced by collateral arterial assessment, appropriate periprocedural anesthesia management, and antiplatelet treatment.

The transforaminal lumbar interbody fusion (TLIF) technique, pioneered by Harms and Rolinger in 1982 and further refined in the early 2000s by Rosenberg and Mummaneni and later by Foley and Lefkowitz, uses Kambin triangle to access the disc space, thecal sac, and nerve roots. The minimally invasive surgery (MIS) approach to TLIF minimizes soft tissue disruption and spinal segment destabilization, offering benefits such as reduced operative times, blood loss, complications, and postoperative opiate use, with comparable fusion rates to open techniques. Despite these advantages, MIS interbody selection poses challenges, with the MIS TLIF preferred for L4-5 fusions when lordosis restoration is not needed. Key to the MIS TLIF technique is the use of expandable retractors, image-guided pedicle screw placement, and innovations like the expandable TLIF, which improves disc space lordosis. Navigation technologies, including 3-dimensional navigation, augmented reality, and robotics, may enhance surgical accuracy and visualization and may allow more precise screw and cage placement and reducing operative time and complications. Awake MIS TLIF, incorporating conscious sedation and local anesthesia, offers additional benefits of faster discharge and reduced postoperative pain. Some authors have also started using endoscopic techniques as well to further minimize tissue trauma. The integration of these advanced techniques and technologies in MIS TLIF continues to improve surgical outcomes and expands the applicability of this minimally invasive approach, making it a valuable tool in spine surgery.

Minimally invasive lumbar decompression surgery offers many advantages including reduced patient morbidity and quicker return to normal life. Endoscopic lumbar spine surgery, sometimes termed "ultra" minimally invasive, further pushes the envelope on reducing operative time, blood loss, and recovery time. Endoscopy offers the additional advantage to the surgeon of placing the surgeon's eye not 50 cm away through the lens of loupes or a microscope, but right at the spine pathology in high definition. Uniportal approach involves a single incision through which the endoscope and instruments are passed. Biportal approach involves two incisions, one for the endoscope and one for the instruments. In what follows we review the indications and efficacy of these procedures with case examples.

Background and objectives: Recent studies indicate that 123 I-iomazenil ( 123 I-IMZ) single-photon emission computed tomography (SPECT) can demonstrate neuronal viability. Although cognitive dysfunction has been recognized as an important issue in adult patients with moyamoya disease (MMD), no standard neuroradiological methods to define such conditions have been established. We examined the relationship between cognitive function and 123 I-IMZ SPECT before and after revascularization in patients with MMD.

Methods: The study participants were 16 adult patients with MMD whose cerebrovascular reactivities were decreased only on the surgical sides of combined revascularization. Cognitive function was examined using the Mini-Mental State Examination (MMSE; cutoff: 27) and the Frontal Assessment Battery (FAB; cutoff: 16) before and at 3 to 6 months after surgery. 123 I-iodoamphetamine ( 123 I-IMP) SPECT with acetazolamide challenge and 123 I-IMZ SPECT were performed concurrently while evaluating cognitive function. The radioreactivities of 123 I-IMZ SPECT in regions with decreased cerebrovascular reactivities on 123 I-IMP SPECT were investigated using affected-to-contralateral side asymmetry ratio (IMZ-ACR).

Results: Twelve patients showed normal cognitive function (MMSE: 29.8 ± 0.4, FAB: 18 ± 0) before surgery. No evident laterality of 123 I-IMZ uptake was seen (IMZ-ACR: 0.98 ± 0.04). Neither cognitive function nor 123 I-IMZ SPECT worsened after surgery (MMSE: 29.8 ± 0.3, FAB: 18 ± 0, IMZ-ACR: 1.00 ± 0.04). By contrast, 4 patients presented cognitive dysfunction (MMSE: 24.3 ± 3.9, FAB: 14.8 ± 2.7) before revascularization. Preoperative imaging of these patients showed decreased 123 I-IMZ uptake, and their IMZ-ACRs (0.83 ± 0.08) were significantly lower than those of the normal group. After revascularization, cognitive functions and 123 I-IMZ uptake tended to ameliorate (MMSE: 27.5 ± 1.7, FAB: 16.3 ± 2.2, IMZ-ACR: 0.94 ± 0.09).

Conclusion: Preoperative cognitive function was associated with 123 I-IMZ uptake in adult patients with MMD. After revascularization, cognitive function could be recovered in the viable areas of the brain, which is consistent with 123 I-IMZ SPECT findings.