Neurosurgery最新文献

Since its introduction into medical terminology by Lord Henry Cohen in 1941, the term "neurapraxia" has become established in the neurological and neurosurgical lexicon, although it is often misused or misspelled. It denotes a transient dysfunction of a peripheral nerve, as distinct from axonotmesis and neurotmesis, which describe more significant structural injuries to a peripheral nerve. To expand our understanding of neurapraxia, it is necessary to examine the phenomenon in both temporal and spatial contexts. This study examines neurapraxia in: (A) Time-(1) the origins of the term neurapraxia and (2) the time-course of a neurapraxic injury and its recovery, and (B) Space-(3) the microstructure of a neurapraxic injury and (4) the locations of neurapraxic injuries within the peripheral nervous system. We demonstrate that the term neurapraxia encompasses both a temporal and a spatial definition. In time, it applies to transient peripheral nerve palsy, from which recovery occurs before there is sufficient time for axonal regeneration, typically within a few weeks. In space, there is a histopathological change limited to localized demyelination in nerves lined by epineurium and myelinated by Schwann cells. Nerves distal to the spine qualify as nerves to which the term neurapraxia can apply; however, cranial nerves and spinal nerve roots (including cauda equina) are inconsistent with this owing to the variability in myelinating cells along their course (oligodendroglia proximally, i.e., central glial segment), the absence of an epineurial covering, and exposure to cerebrospinal fluid.

Background and objectives: Laser interstitial thermal therapy (LITT) has emerged as a minimally invasive alternative to open craniotomy for patients deemed unsuitable for surgery due to deep-seated or eloquent lesion location, age, frailty, or comorbidities. However, its use in newly diagnosed deep-seated low-grade glioma (nLGG) has not been elucidated. We aimed to evaluate the safety and efficacy of LITT for deep-seated nLGG compared with a similar surgical cohort.

Methods: We retrospectively reviewed patients with unifocal, deep-seated nLGG treated with either LITT or surgical resection between 2013 and 2024. Demographic, perioperative, and follow-up data were compared between groups. Kaplan-Meier assessed progression-free and overall survival outcomes. To address baseline tumor volume differences, a subset analysis was performed using a greedy nearest-neighbor algorithm to generate a 1:1 matched cohort based on tumor volume.

Results: A total of 15 patients in the study group (median age 46 [IQR: 34-53] years, 40.0% men) were compared with 51 patients (median age 38 [IQR: 29-54] years, 43.1% men) in the control group. There were no significant differences in in-hospital complications (P = .999), 30-day complications (P = .999), or complications between 30 days and 3 months (P = .713), new postoperative motor or speech deficits (0.999) between groups. Postoperative adjuvant chemotherapy (23.1% vs 46.9%, P = .217) and radiation (23.1% vs 44.7%, P = .210) rates did not differ significantly. Among high-risk patients, time to adjuvant chemotherapy (64.7 vs 77.7 days) and radiation (36.0 vs 53.6 days) was earlier in the LITT group, although not statistically significant. Kaplan-Meier analysis showed no statistically significant differences in progression-free survival or overall survival between groups. On matched pair analysis, there remained to be no statistically significant differences in outcomes observed between LITT and craniotomy groups.

Conclusion: This pilot study is the first to suggest that LITT is a safe treatment option for patients with deep-seated nLGG, offering comparable outcomes with surgical resection.

Background and objectives: Myelomeningocele is defined by the presence of a fluid-filled sac that contains the neural placode and cerebrospinal fluid (CSF) at the level of the spinal defect. Alternatively, the term myeloschisis is used when the neural placode is not contained within a CSF-filled sac. While both are eligible for prenatal closure, few studies have characterized the impact of the type of lesion on postnatal outcomes. This study compares the outcomes of these 2 types of open spinal dysraphism using data from the Fetal Myelomeningocele Consortium registry sponsored by the North American Fetal Therapy Network.

Methods: The prospective observational Fetal Myelomeningocele Consortium registry was used to extract deidentified data corresponding to patients who underwent fetal closure of myelomeningocele vs myeloschisis. Demographics, operative characteristics, perioperative complications, and postnatal outcomes were collected.

Results: A total of 1327 patients were identified, including 991 (74.7%) with myelomeningocele and 336 (25.3%) with myeloschisis. Compared with myelomeningocele, myeloschisis was associated with lower rates of prenatal talipes (11% vs 24%, P < .001) and higher rates of favorable prenatal movement (94% vs 86%, P < .001). Postnatally, myeloschisis conferred higher rates of leg movement (97% vs 90%, P = .002) and an increased likelihood of ambulation in the household (10.4% vs 4.1%, P = .009) and outside (7.2% vs 1.9%, P = .004) at 1 year. However, myeloschisis was also linked to greater use of skin patches during closure (49% vs 27%, P < .001), higher CSF leak rates among those with wound dehiscence (26% vs 8%, P = .014), and more frequent CSF diversion and tethered cord surgeries at follow-up.

Conclusion: Myeloschisis and myelomeningocele demonstrate distinct clinical profiles. Although patients with myeloschisis may have favorable motor outcomes, they are also characterized by higher rates of CSF leakage, CSF diversion, and tethered cord surgery. These findings highlight the need for lesion-specific prognostication and may inform surgical planning and parental counseling in the context of prenatal spina bifida closure.

Background and objectives: Myelomeningocele (MMC) is a neural tube defect and 1 of 3 forms of spina bifida. The management of this disease is a matter of discussion in the literature. To attempt to alleviate this gap in the current literature, the authors conducted a systematic review and comparative meta-analysis on this topic.

Methods: Fulfilling Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, the authors systematically searched the Embase, PubMed, and Web of Science databases to identify English articles reporting comparative cohorts of more than 4 patients with MMC being submitted for either prenatal or postnatal repair. Risk ratio (RR) with 95% CI was used to measure effects in comparative analysis with a random-effect model applied. Sensitivity analysis was used to explore cases of high heterogeneity.

Results: From 885 studies initially found, 20 studies with 2862 patients were included in the analysis. Of these patients 1587 were submitted to postnatal repair and 1275 to prenatal repair. No statistical difference between groups were found in mortality (RR 2.00 [0.71-5.63]; I2 = 0%), tethered cord syndrome (RR 1.40 [0.89-2.19]; I2 = 29%), and hindbrain herniation (RR 0.88 [0.74-1.04]; I2 = 81%). Hydrocephalus developed in 557 patients, significantly favoring prenatal repair 0.48 (RR 0.48 [0.41-0.56]; I2 = 5%). Shunt placement occurred in 360 patients, significantly favoring prenatal repair (RR 0.50 [0.43-0.58]; I2 = 47%). Motor dysfunctions happened in 197 patients significantly favoring prenatal repair 0.59 (RR 0.59 [0.49-0.71]; I2 = 0%).

Conclusion: Prenatal MMC repair was associated with a smaller risk of hydrocephalus development, shunt placement, and motor dysfunctions.

Background and objectives: Unrealistic or unmet expectations can contribute to lower satisfaction and decisional regret (DR), particularly as shared decision-making becomes more central in elective spine care. Understanding these dynamics in minimally invasive lumbar decompression may guide strategies to optimize preoperative counseling and patient-centered outcomes. Our study aims to evaluate the correlation between patient expectation-actuality differences and DR following minimally invasive lumbar decompression surgery and to identify other patient-reported outcomes associated with DR.

Methods: This prospective cohort study included adults undergoing elective one-level or two-level minimally invasive lumbar decompression. Patients completed preoperative Musculoskeletal Outcomes Data Evaluation and Management Systems (MODEMS) expectation surveys and postoperative MODEMS actuality surveys at 3 and 6 months, along with the Decisional Regret Scale at both time points. Expectation-outcome mismatch was calculated for each MODEMS domain. Predictors of DR were assessed using univariate linear regression, with significance set at P < .05.

Results: Among 104 patients (mean age 64.9 years, 54.5% male), 60% reported no regret and 11% high regret at 3 months, compared with 61% no regret and 6% high regret at 6 months. Across both time points, DR was strongly associated with greater expectation-outcome mismatch. In univariate regression, mismatch in pain relief, daily activity, exercise, sleep, return-to-work, and disability prevention significantly predicted higher regret, with pain relief showing the largest effect. Demographic and clinical factors, including age, sex, comorbidity burden, and preoperative disability, were not associated with regret. MODEMS mismatch remained the most consistent predictor at both follow-ups.

Conclusion: DR in minimally invasive lumbar decompression is strongly linked to expectation-actuality differences and reduced satisfaction, with pain relief, activity, and exercise emerging as key drivers. These findings highlight the importance of refining tools to assess expectations and identify unmet needs to reduce regret and improve patient-reported outcomes.

Background and objectives: Anterior cervical diskectomy and fusion (ACDF) and cervical disk replacement (CDR) are common options for cervical degenerative radiculopathy. While previous studies indicate comparable early outcomes at discrete time point, few have quantified cumulative postoperative disability over a year to compare these procedures. To develop novel cumulative postoperative disability and compare the metric between ACDF and CDR.

Methods: This is a retrospective study analyzing 327 patients undergoing primary 1- or 2-level ACDF or CDR for degenerative cervical radiculopathy between February 2016 and September 2024 in a single institution. Cumulative postoperative disability was quantified as the modified integrated health status (mIHS), which was area under the curve per week of the 1-year normalized Neck Disability Index modeled using mixed-effects regression. Baseline differences were adjusted using overlap weighting based on propensity scores.

Results: The mIHS demonstrated acceptable construct and modest concurrent validity. The mixed-effects model indicated significantly different recovery trajectories between groups (P < .001). The mIHS was significantly higher for ACDF than for CDR (3.71 vs 2.68; mean difference, 1.03 [95% CI, 0.80-1.25], P < .001). Level-specific analyses showed that 1-level CDR showed a 21.5% lower mIHS than 1-level ACDF (P < .001), whereas 2-level CDR had a 32.1% lower mIHS than 2-level ACDF (P < .001). The 2-level ACDF showed greater mIHS than 1-level ACDF (3.47 vs 3.89; P = .012), whereas 1-level CDR and 2-level CDR were comparable (2.76 vs 2.64; P = .59).

Conclusion: CDR was associated with less cumulative postoperative disability during the first year compared with ACDF. Two-level CDR resulted in disability comparable with 1-level CDR, whereas 2-level ACDF showed greater disability than 1-level ACDF.

Background and objectives: The utility of dynamic MRI (dMRI) in surgical planning and outcomes for degenerative cervical myelopathy (DCM) has not been validated in any prospective randomized trials.

Methods: In this hospital-based randomized controlled trial conducted between February 2023 and December 2024, patients with DCM were randomized into 2 groups: the Static MRI Group, where surgery was guided by conventional static MRI alone, and the dMRI Group, in which dMRI was performed, with the potential to alter the surgical approach. The primary outcome was recovery rate (RR) at 3 months. Secondary outcomes included postoperative changes in modified Japanese Orthopaedic Association scores and Nurick grades, surgical plan alterations, comparison of surgical approaches, and complication rates.

Results: Seventy-four patients were analyzed at a 3-month follow-up. The dMRI group had a significantly higher mean RR (55.42% ± 29.05%) than the Static group (46.76% ± 29.51%) (P = .044). A RR of ≥50% was observed in 91.9% of patients in the dMRI group, compared with 59.4% in the static MRI group (P = .002). Modified Japanese Orthopaedic Association scores improved more in the dMRI group (15.47 ± 2.62 vs 13.77 ± 2.66, P = .007). While Nurick grades improved in both groups, the intergroup difference was not statistically significant (P = .151). dMRI altered the surgical plan in 59.5% of cases. Anterior approaches yielded better RR but had more complications. By contrast, posterior approaches had fewer but more severe complications including mortality.

Conclusion: dMRI enhances the detection of clinically significant cord compression and may aid in surgical decision-making, potentially contributing to superior functional outcomes in DCM. Further studies are required to determine its impact on long-term functional outcomes.

Background and objectives: Prognosis of melanoma with leptomeningeal disease (LMD) is poor (median overall survival of 5.1 months). Intrathecal (IT) nivolumab appears safe, although its efficacy remains uncertain. We investigated the feasibility, safety, and efficacy of continuous IT nivolumab.

Methods: This was a retrospective analysis of 11 melanoma patients with progressive LMD (MelBase; NCT02828202) treated as part of the patients' care with continuous IT nivolumab administered through spinal (n = 10) or ventricular catheter (n = 1).

Results: Patients (5 women, median age 52) with Eastern Cooperative Oncology Group ≤1 (except for 1) and stable extracranial disease (except for 4) were treated over a median duration of 1.5 months and followed for 2.5 months. Seven presented symptomatic LMD. Primary tumors were mostly cutaneous (n = 8) and BRAF-mutated (n = 10). All patients had progressed on systemic immunotherapy; 7 had received brain radiotherapy (whole brain radiotherapy [n = 3]; stereotactic radiosurgery [n = 4]). Concomitant therapies included corticosteroids >10 mg (n = 5), intravenous nivolumab (first 3 months of IT therapy, n = 1), and targeted therapies (n = 7). The median overall survival was 2.5 months, with 3 patients surviving for more than a year. Reversible treatment-related adverse events occurred in 5 patients: meningoencephalitis (grade 3, n = 1), intracranial hemorrhage (grade 1, n = 1), intracranial hypotension (grade 2, n = 2; grade 1, n = 1). Baseline levels of nivolumab in the cerebrospinal fluid (CSF) were <2 µg/mL, even among patients with plasma detection. CSF concentrations of nivolumab at steady state varied from 36 to 97 µg/mL, with clearances of 4.3-15.7 mL/h. Next-generation sequencing identified CSF genomic profiles correlating with clinical progression in 4 patients.

Conclusion: These findings warrant further trials on IT nivolumab.

Background and objectives: Surgical decompression is commonly required to relieve symptoms of cervical radiculopathy and allow for functional recovery. There are only a handful of studies analyzing return-to-work (RTW) outcomes after cervical spine surgery for cervical radiculopathy. This study seeks to elucidate RTW outcomes and to identify predictors preventing RTW in patients surgically treated for cervical radiculopathy in a Swedish nationwide prospective registry.

Methods: A nationwide cohort analysis was conducted using prospectively gathered data from the Swedish Spine Registry. All patients with documented postoperative outcomes focusing on 1-year RTW rates were included. To identify predictive factors influencing RTW at 1 year postoperatively, separate univariable and multivariable logistic regression models were developed, incorporating demographic, functional and clinical, as well as preoperative and postoperative data, and occupational characteristics.

Results: A total of 3929 patients were included with an average age of 49.5 years, with most patients working in moderate- or high-intensity jobs and nearly half on sick leave before surgery. Most surgeries were elective, and an anterior approach was preferred. At the 1-year mark after surgery, 85% of patients had returned to work, with full-time RTW reaching 67% and part-time RTW 18%. In this cohort, 15% had not returned to work at all. Higher age, previous cervical spine surgery, high job intensity, preoperative full-time sick leave and full-time sickness benefits, longer preoperative arm pain durations as well as higher preoperative Neck Disability Index, and lower EuroQOL 5 dimensions scores were independently associated with a reduced likelihood of RTW at 1 year postoperatively.

Conclusion: Eighty-five percent of the patients surgically treated for radiculopathy RTW within 1 year. Higher age, jobs with greater physical demands, longer duration of arm pain, higher preoperative neck disability index and lower EuroQOL 5 dimensions scores, as well as being on full-time sick leave, were all linked to a reduced chance of RTW.

Background and objectives: The rapid expansion of oncologic systemic therapy has produced major advances for patients with cancer. This array of pharmacologic mechanisms also presents challenges for neurosurgeons. Many agents impair wound healing, hemostasis, and immune function, elevating perioperative risk. Yet, consolidated evidence-based guidance for neurosurgical drug management remains limited. Our goal is to provide a comprehensive, clinically actionable framework for perioperative management of targeted and biologic therapies in patients undergoing neurosurgical procedures.

Methods: We conducted a systematic review of pivotal clinical trials, US Food and Drug Administration safety data, meta-analyses, and society guidelines to assess the impact of key agents on surgical outcomes. Drug classes were evaluated based on pharmacokinetics, mechanism of action, and adverse events relevant to wound healing, bleeding, and immune dysregulation. Recommendations were stratified by risk level and supported by available evidence and expert consensus.

Results: Wound healing risk was highest with anti-vascular endothelial growth factor (VEGF) monoclonal antibodies and mammalian target of rapamycin inhibitors, warranting extended preoperative holds (≥4 weeks for VEGF inhibitors, ≥1 week for mammalian target of rapamycin agents) and postoperative delays of 2 to 4 weeks (fibroblast and angiogenesis suppression). Bleeding risk was most significant with VEGF receptor-tyrosine kinase inhibitors and Bruton's tyrosine kinase inhibitors (eg, ibrutinib), independent of platelet count, necessitating short-term holds of up to 1 week with resumption after 3 to 7 days. Immunosuppression noted with CDK4/6 inhibitors, janus kinase inhibitors, and biologic immunomodulators (eg, TNF, IL-6, CD20 blockers), increasing postoperative infection risk. These agents often require brief interruption (2-7 days) with resumption 1 to 2 weeks postoperative depending on half-life and schedule. For BRAF/MEK inhibitors and immune checkpoint inhibitors, perioperative data are limited.

Conclusion: Modern systemic therapies necessitate refinement of perioperative management in neurosurgical oncology. This review synthesizes data into a pragmatic framework for drug timing and risk mitigation. Considering interruption intervals is essential to balance surgical safety with oncologic control. Integrating these principles can reduce complications, standardize care, and improve outcomes for this complex patient population.