Neurosurgery最新文献

Background and objectives: En bloc sacrectomy is associated with sacral root transection causing loss of urinary bladder, rectum, and sexual function. The aim of the study was to determine the position of the pudendal branches (sensorimotor) and pelvic splanchnic nerves (parasympathetic) on the sacral roots relative to the sacrum, and the minimal and maximal defects in the sacral roots that can be reconstructed by grafting after various types of sacrectomy.

Methods: Five cadaveric pelves were dissected bilaterally. The lengths and widths of the S1-S4 roots and their branches were measured. Then, the minimal and maximal defects between the proximal and distal stumps of the sacrificed roots were measured following 3 models of sacrectomy (below S2, below S1, and total sacrectomy).

Results: The mean distance of the splanchnic nerves from the S2 and S3 anterior sacral foramina was 17.7 ± 7.3 and 23.6 ± 11.1 mm, respectively, and the mean distance of the pudendal S2 and S3 branches was 36.8 ± 13.7 and 30.2 ± 10.8 mm, respectively. The mean widths of the S2 and S3 roots were 9.3 ± 1.9 and 5.4 ± 1.2 mm, respectively. The mean maximal defects in S2 and S3 roots after various types of sacrectomies were between 61.8 ± 16.3 and 100.7 ± 14.3 mm and between 62.7 ± 20.2 and 84.7 ± 25.1 mm, respectively. There were no statistically significant differences between sides or sexes for all obtained measurements.

Conclusion: The reconstruction of the S2-S3 roots is anatomically feasible after partial or total sacrectomies in which the resection of the soft tissue does not extend further than approximately 1.5 to 2 cm ventrally from the sacrum.

Background and objectives: Studying malpractice claims is important to improve quality of health care and patient safety and to educate the individual healthcare providers. The objective of this study was to describe characteristics of neurosurgical claims in the Netherlands.

Methods: A nationwide retrospective observational study of neurosurgery-related claims closed by Centramed and MediRisk, 2 major insurance companies in the Netherlands, was performed. Relevant data, including type of neurosurgical pathology, theme and category of the claim, type and severity of injury, outcome, and financial burden, were extracted from anonymized claim files. The estimated annual risk was used to determine the risk for claims by adjusting for the number of annually practicing neurosurgeons in the Netherlands.

Results: A total of 388 claims against neurosurgeons were closed between 2007 and 2021. Liability was denied in a slight majority of claims (n = 230; 59%). The total burden during this period was €6 165 000 (amount paid out to patients: €5 497 000). The estimated annual risk per Dutch neurosurgeon for a claim was 15.5%, meaning 1 claim per 6.5 years. The case-level analysis of 238 available anonymized claims revealed that most claims were related to spinal pathology (81.5%), followed by cranial pathology (10.9%) and peripheral nerve (7.6%). The motivations for filing claims were mostly related to alleged surgical (56.3%) or diagnostic errors (22.3%). Most of these claims were denied (151/238; 63.4%), and fewer were settled (42/238; 17.6%), sustained (31/238; 13.0%), or closed without final decision (14/238; 5.9%).

Conclusion: Neurosurgery-related malpractice claims primarily involved spinal pathology and were mostly related to alleged treatment errors. Most claims did not result in compensation because there seemed to be no liability or culpable injury. However, the annual risk for a claim for Dutch neurosurgeons is considerable.

Background and objectives: Silent corticotroph adenoma (SCA) is a high-risk pituitary neuroendocrine tumor (PitNET) which exhibits more aggressive behavior than other nonfunctioning PitNETs. Some SCAs are observed to recur after total resection (TR). We aim to discuss the long-term outcomes after endoscopic endonasal surgery for SCAs and explore optimal treatment after operation.

Methods: Clinical data and intraoperative videos from 367 SCAs who underwent endoscopic endonasal surgery were retrospectively collected. Patients were categorized into TR and subtotal resection (STR) groups according to 3-month postoperative MRIs. Based on close-up intraoperative observation of the relationship between tumor and pituitary gland, diaphragm, and medial wall cavernous sinus, patients in the TR group were further subdivided into gross total resection (GTR) and near total resection (NTR) groups. Patients in the STR group were subdivided as STR followed by observation (STR + ob) and STR followed by adjuvant stereotactic radiosurgery (SRS) (STR + SRS). Kaplan-Meier analysis was used to compare the event-free survival among these subgroups.

Results: Headache (27.5%) and vision loss (55.3%) were the most common presenting symptoms. Cavernous sinus (CS) invasion was confirmed intraoperatively in 167 (45.5%) patients. After operation, 175 (47.7%), 83 (22.6%), 32 (8.7%), and 77 (21%) patients were divided into GTR, NTR, STR + ob, and STR + SRS groups, respectively. The mean follow-up time was 40.9 ± 25.8 months. There were 0, 17 (20.5%), 9 (28.1%), and 4 (5.2%) patients noted to have PitNET recurrence or progression in GTR, NTR, STR + ob, and STR + SRS groups, respectively. Event-free survival distribution in the NTR group was similar to that in the STR + ob group ( P = .696), which was significantly lower than that in the STR + SRS group ( P = .008). Adrenocorticotropic hormone (ACTH)-negative SCAs have lower preoperative ACTH levels and were more likely to invade CS than ACTH-positive SCAs.

Conclusion: CS invasion was commonly seen in SCAs, often precluding GTR. Radical surgery and close follow-up were proposed. Early postoperative adjuvant SRS for remnant tumor should be considered.

Background and objectives: Tobacco use is known to affect incidence and postoperative outcome for several neurosurgical disorders, but its relationship to trigeminal neuralgia (TN) is not known. We sought to identify unique population characteristics that correlate with tobacco use in a cohort of patients with TN who underwent microvascular decompression (MVD), including effect on long-term postoperative outcome.

Methods: Data about 171 patients with classic TN treated with MVD were obtained from a prospectively maintained registry. Patients were classified as smokers or nonsmokers based on the use of tobacco within the 6 months before surgery. Analysis of clinical characteristics and postoperative outcome was performed.

Results: Compared with nonsmokers with TN, MVD patients using tobacco were significantly younger (53 vs 62 years, P < .01) and less likely to report pain in a single distribution of the trigeminal nerve (36% vs 65%, P < .01). There was no difference between smokers and nonsmokers in the presence of some degree of continuous pain, severity of neurovascular compression, sex, race, obesity, pain duration before presentation, immediate postoperative outcome, length of stay, or postoperative complication profile. Among 128 patients followed for at least 6 months, smokers were significantly less likely to be pain-free off medications at the last follow-up (36% vs 57%, P < .05).

Conclusion: In patients undergoing MVD for TN, smoking is associated with younger age of TN onset, more widespread facial pain, and worse long-term postoperative outcome after MVD. These features suggest that TN in smokers may represent a more severe disease form compared with TN in nonsmokers with different responses to treatment.

Background and objectives: There remains significant debate regarding the performance of deep brain stimulation (DBS) procedures for Parkinson disease (PD) under local or general anesthesia. The aim of this meta-analysis was to compare the clinical outcomes between "asleep" DBS (general anesthesia) and "awake" DBS (local anesthesia) for PD.

Methods: We conducted a comprehensive literature review of all published studies on DBS for PD following PRISMA guideline on PubMed and Cochrane library from January 2004 to April 2023. Inclusion criteria included cohort ≥15 patients, clinical outcomes data which included Unified Parkinson's Disease Rating Scale (UPDRS) score and levodopa equivalent daily dosage (LEDD), and ≥3 months of follow-up. Analysis was conducted using Stata software.

Results: There were 18 articles that met inclusion criteria. On meta-analysis, there were no significant differences between awake or asleep DBS with regard to percent change in UPDRS III "off" med/"on" DBS condition ( P = .6) and LEDD score ( P = .99). On subgroup analysis, we found that the choice of target had no significant effect on improvement of UPDRS III ( P = 1.0) or LEDD ( P = .99) change for the asleep vs awake operative approach. There were also no statistically significant differences between microelectrode recording (MER) use and no MER use in postoperative UPDRS III ( P = 1.0) or LEDD improvement ( P = .90) between awake and asleep surgery.

Conclusion: There was no significant difference in the primary motor outcomes and LEDD improvement between asleep vs awake DBS. The variables of target selection and MER use had no statistically significant impact on outcome. We find that asleep techniques are both safe and effective compared with the awake technique.

Thoracolumbar minimally invasive spine surgery (MIS) has become widely adopted over the past two decades. MIS cervical fixation has lagged behind, largely because of complex and variable cervical spinal anatomy. Traditional open spine fixation techniques are associated with high fusion rates but are plagued by significant approach-related morbidity. This morbidity is due to paraspinal muscle denervation and atrophy secondary to disruption of the posterior musculoligamentous complex leading to wound healing difficulties, including relatively high rates of wound infection and dehiscence as well as aesthetic issues. Therefore, novel MIS fixation techniques have focused on percutaneous tissue-sparing approaches in an effort to decrease wound morbidity and hospital readmission. In addition, more biomechanically robust minimally invasive constructs may provide smaller alternative surgical solutions. Previously described fluoroscopic MIS cervical pedicle screw placement has been revitalized with the recent description of a navigated percutaneous minimally invasive technique. With the incorporation of new enabling navigation technologies, this technique is feasible, reproducible, and safe. In addition, these procedures have provided unique solutions for approaching cervical pathology in line with currently accepted MIS principles of the thoracolumbar spine. This review article discusses current minimally invasive posterior fusion strategies with a description of the technique and case demonstrations.

Background and objectives: Image guidance has transformed minimally invasive spine surgery (MISS), allowing for safer procedures without excessive bony exposure and reducing radiation exposure for the surgical team. Robotic platforms have enhanced the benefits of navigation by providing high precision and accuracy. Here we describe a case series to demonstrate the accuracy and low complication rates of real-time image-guided robotic-assisted (RA) MISS at a tertiary referral center. In addition, we performed a narrative review on how robotics and navigation facilitate MISS.

Methods: A retrospective chart review was conducted to obtain data for patients who underwent RA lumbar fusions with real-time navigation for degenerative lumbar pathology between September 1, 2021, and January 1, 2024. The Mazor X Stealth Edition (Medtronic) robotic platform was used. The accuracy of screw placement was determined according to Gertzbein-Robbins classification. Intraoperative and postoperative complication rates up to 90 days were recorded. Intraoperative variables and length of stay were compared between open and percutaneous groups.

Results: A total of 247 patients underwent insertion of 1156 pedicle screws. The mean patient age was 61.1 ± 11.5 years. The mean total operative time was 195.1 ± 80.8 minutes. The mean operative time per screw was 4.2 ± 1.4 minutes, with a mean of 4.6 ± 1.4 screws per case. The mean fluoroscopy time per screw was 6.4 ± 6.2 seconds. Eighty-five patients (34.4%) underwent open RA pedicle screw placement, and 162 (65.6%) underwent percutaneous RA pedicle screw placement. No differences in operative time, length of stay, fluoroscopy time, and surgical complications were found between groups. Intraoperatively, 2 patients (0.8%) experienced complications and 4 patients (1.6%) developed complications within 90 days. Screw placement accuracy was perfect in 1126 screws (97.4%) and clinically acceptable in 30 screws (2.6%). These results were consistent with those reported in the literature.

Conclusion: Robotic platforms have further enhanced navigation benefits by providing high precision and accuracy, with low complication rates.