Neurosurgery最新文献

Background and objectives: Although plenty of evidence supports the effectiveness of sacral neuromodulation (SNM) in improving urination and defecation, few studies concerned its effect on the patients with spinal dysraphism (SD). This study aimed to evaluate the effects of SNM on SD-induced neurogenic bladder and bowel dysfunction.

Methods: We prospectively followed the patients with SD who underwent SNM in our department from May 2019 to June 2024. Fusion images of sacrococcygeal computed tomography and magnetic resonance sacral plexus nerve images were used as essential references for preoperative evaluation and intraoperative implantation. Patient's subjective improvement by ≥50% from baseline was defined as implantation procedure success. Among the included patients, urodynamics, urinary ultrasonography, daily urination frequency, daily urine leakage, and neurogenic bowel dysfunction score were compared before and after SNM and between unilateral and bilateral SNM.

Results: A total of 44 patients were included, of whom 97.73% reported improved symptoms and 47.73% achieved implantation procedure success. SNM significantly improved the average postvoid residual volume, maximum cystometric capacity, bladder compliance, daily urination frequency, daily urine leakage, and neurogenic bowel dysfunction score. We found a significantly higher success rate in the patients stimulated bilaterally compared with those stimulated unilaterally but no intergroup differences against age (between minors and adults), sex, lower urinary tract symptoms, and intestinal symptoms. Bilateral SNM performed significantly better in improving postvoid residual volume, daily urination frequency, and daily urine leakage than unilateral SNM. No SNM-related complications were reported during follow-up.

Conclusion: SNM can improve urination and defecation in the patients with SD safely and effectively. We strongly recommend fusion imaging of sacrococcygeal computed tomography and magnetic resonance sacral plexus imaging as a valuable and promising technique for preoperative evaluation and intraoperative implantation. A flexible implantation strategy involving electrode location and number helps achieve ideal modulation effects in the patients with SD.

Background and objectives: C5 nerve palsy is a debilitating complication of cervical spine surgery that can occur after certain approaches. To our knowledge, no previous systematic reviews have compared the rates of C5 nerve palsy after different cervical approaches, identifying the rate at which this complication becomes permanent. We aimed to compare the rates of C5 palsy after different cervical spine surgery approaches and the rates of recovery when C5 palsy was present.

Methods: A literature search of the PubMed and Embase databases from their inception to July 1, 2023, was completed to identify studies that focused on cervical spine surgery. Studies were excluded if they did not provide the rate of C5 palsy occurrence or define which surgical approaches were used. A pooled, weighted prevalence rate of C5 palsy was calculated for each approach, including the rate of permanent C5 palsy.

Results: A total of 155 studies met the inclusion criteria. Of these studies, 22 (14.2%) reported on laminectomies, 77 (49.7%) on laminoplasties, 38 (24.5%) on posterior cervical decompression and fusion, 39 (25.2%) on anterior cervical diskectomy and fusion, and 4 (2.6%) on corpectomies. Patients who had laminectomies had the highest incidence of C5 palsy at a pooled rate of 8%, of which 1.44% of cases were permanent. This was followed by posterior cervical decompression and fusion with a rate of 7.03% and a permanence rate of 1.02%. Patients receiving laminoplasties had a C5 palsy incidence of 5.11%; of these, 0.28% of cases were permanent. Patients who had corpectomies had an incidence of 4.16%; those who had anterior cervical diskectomy and fusions had the lowest incidence of 2.61%, of which 1.06% of cases were permanent.

Conclusion: C5 nerve palsy is a known complication after cervical spine surgeries, with increased rates in posterior approaches, although the rate of these complications becoming permanent is minimal.

Background and objectives: This study investigates the prevalence and determinants of defensive medicine among neurosurgeons in Sub-Saharan Africa (SSA). It examines how economic, cultural, and legal factors unique to SSA influence these practices, providing insights to guide regional policy-making and medical education.

Methods: A cross-sectional survey of 71 neurosurgeons in SSA was conducted via WhatsApp, LinkedIn, and conferences. The questionnaire, adapted to the SSA context from a Canadian study, explored demographics, practice types, liability profiles, defensive behaviors, and perceptions of the medicolegal environment. Data were analyzed using descriptive statistics in R software.

Results: Among 71 respondents, 91.5% were men, and 29.6% were undergoing residency or fellowship training. All respondents reported engaging in at least 1 defensive medical behavior, with varying degrees of frequency. Common strategies included patient discussions (24.2%) and specialist referrals (16.7%). Economic and resource limitations constrained practices such as ordering imaging (17.5%) and prescribing medications (10.8%). Despite perceived medicolegal risks, 93% of participants reported no lawsuits in the past 3 years.

Conclusion: Defensive medicine among neurosurgeons in SSA is less prevalent and intense than in high-income regions. Unique economic constraints, cultural norms, and weaker legal pressures limit defensive behaviors. These findings highlight the need for context-specific policies and educational strategies to balance medicolegal risk management with resource limitations in SSA.

Background and objectives: Resting-state functional MRI (rs-fMRI) is a noninvasive tool for studying brain function, with growing applications in clinical oncology, such as preoperative planning and brain reorganization mapping. Direct electrical stimulation (DES) during awake surgery remains the gold standard for causally identifying functional brain regions. Although previous studies have mapped the speech articulation network (SAN) from rs-fMRI using DES-positive points, the inclusion of DES-negative points remains unexplored. This study integrates both positive and negative DES data to create a more comprehensive SAN atlas and refine its functional borders using presurgical functional connectivity from glioma patients.

Methods: We analyzed 25 glioma patients (16 high-grade, 9 low-grade) who underwent awake surgery with DES mapping for speech articulation. Seventy-four DES points (32 positive, 42 negative) were identified in gray matter. Presurgical rs-fMRI data were used for seed-based connectivity analysis, with DES-positive and DES-negative points analyzed separately. Group SAN-positive and SAN-negative networks were assessed for overlap across each other and with regions from an anatomical atlas. DES-negative and DES-positive points were used to estimate the sensitivity and specificity of the group SAN-positive network at different thresholds for group frequency.

Results: The DES-positive SAN was bilaterally located in the rolandic operculum, inferior frontal gyrus, and superior temporal gyrus, consistent with previous studies. DES-negative points revealed distinct connectivity patterns, with only partial overlap, helping to delineate the SAN's functional borders, particularly in the central sulcus (posterior and anterior) and inferior frontal gyrus (pars triangularis and opercularis). Anticorrelated networks from DES-positive points further differentiated the roles of positive and negative sites within the SAN. A 41% threshold in the SAN-positive gives approximately 80% specificity and sensitivity.

Conclusion: DES-positive points define the SAN robustly. DES-negative points served to establish a threshold for the group SAN atlas and a more detailed definition of the functional SAN borders.

Background and objectives: Lumbar drain (LD) insertion is a common cerebrospinal fluid (CSF) diversion method in neurosurgery; however, infection remains a major complication with significant morbidity. We evaluated the incidence, etiology, and associated risk factors of LD infection across 4 neurosurgical units over 15 years.

Methods: This retrospective multicenter cohort study included all adults requiring a LD between January 2009 and February 2024. Demographic, clinical, and microbiological characteristics were analyzed. LD infections were defined by positive CSF cultures and clinical symptoms. Risk factors were assessed by multivariate logistic regression analysis using IBM SPSS®.

Results: A total of 1017 patients required a LD, and the overall infection rate was 11.4% (116 infections). Significant risk factors for LD infection identified by univariate analysis were preoperative use of oral steroids ( P < .001), previous CSF drainage ( P = .019), LD insertion for 2 or more days ( P = .001), out-of-hours surgery ( P = .008), and CSF leak at the operation site ( P = .007). Conversely, factors reducing the risk of infection were LD insertion during the primary surgery ( P = .015) and the reason for insertion ( P = .029). Multivariate analysis confirmed increased incidence of LD infection with oral steroid use ( P = .01), LD insertion >7 days after the primary surgery ( P = .019), no previous CSF drainage ( P = .029), LD removal ≥2 days ( P = .002), out-of-hours primary surgery ( P = .024), CSF leak from the LD puncture site >2 days after LD insertion ( P = .074), LD disconnection >3 days postinsertion ( P = .028), and bleeding from the LD puncture site >2 days after drain insertion ( P = .026).

Conclusion: We report a large patient series evaluating the factors associated with LD infections across multiple neurosurgical subspecialties. To reduce infection risk, LDs should be inserted during primary surgery, kept for the shortest duration, and promptly removed if disconnected, avoiding unnecessary sampling.

Background and objectives: Red blood cell transfusions are commonly required in pediatric cranial vault remodeling (CVR); however, they carry risks and potential complications. This study evaluates the evidence on perioperative blood conservation agents assessing their efficacy in optimizing and reducing transfusion requirements in CVR.

Methods: A systematic review was conducted using PubMed/MEDLINE, Scopus, Embase, Web of Sciences, and Google Scholar according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to assess articles discussing blood conservation agents in pediatric CVR. A network meta-analysis compared the effectiveness of different agents including tranexamic acid (TXA), aminocaproic acid (ACA), aprotinin, erythropoietin (EPO), and iron.

Results: Sixteen studies analyzing 1072 patients with a mean age of 15.6 months and weight of 8.78 kg were included. The most reported craniosynostosis subtypes were sagittal (30.2%) and metopic (13.8%). TXA and ACA were independently associated with lower transfusion rates and volumes compared with placebo (ACA: odds ratio [OR], 0.25; 95% CI, 0.08-0.80; TXA: OR, 0.17; 95% CI, 0.07-0.42). Combination therapy with TXA + EPO + iron (OR: 0.004, 95% CI: 0.002-0.10) or ACA + EPO (OR: 0.04, 95% CI: 0.01-0.32) were associated with reductions in transfusion rates. Network meta-analysis ranking revealed TXA + EPO + iron (Surface Under the Cumulative Ranking [SUCRA]: 98.90%) and ACA + EPO (SUCRA: 75.41%) as the most effective treatments for reducing transfusion rates. While TXA was associated with significant reductions in blood loss compared with placebo (standard mean difference: -1.26, 95% CI: -1.97 to -0.56), ACA ranked highest for blood loss reduction (ACA: SUCRA, 84.58% vs TXA: SUCRA, 72.43%). Combination of TXA + EPO + iron was associated with significantly reduced hospital length of stay (standard mean difference: -1.00, 95% CI: -1.71 to -0.29). No treatment significantly affected the duration of surgery, and there were no reported treatment-associated thromboembolic events.

Conclusion: Our meta-analysis reveals that TXA + ACA reduce red blood cell transfusion rates and volumes, with TXA + EPO + iron and ACA + EPO being most effective. This highlights the superiority of combination therapies and underscores the need for structured multimodal protocols in perioperative blood conservation for pediatric CVR.

Background and objectives: The Accreditation Council for Graduate Medical Education Neurosurgery Milestones were implemented to advance competency-based training in neurosurgery; however, research on milestones in neurosurgery has been more limited, and there has been no comprehensive study on the milestone ratings and the comparability of Milestones 1.0 and 2.0. The goal of this study was to describe the levels and trends of competency ratings across Milestones 1.0 and 2.0 for neurosurgical residents in the United States over the decade of implementation. Milestones 1.0 and 2.0 cover both nontechnical competencies and critical technical skills.

Methods: We conducted a retrospective analysis of milestone assessments from 2013 to 2023 across 124 US neurosurgery residency programs, encompassing both Milestones 1.0 (2013-2018) and Milestones 2.0 (2018-2023). We used descriptive statistics to examine the distributions of milestone ratings and identify performance trends in milestone ratings across postgraduate year (PGY) levels.

Results: The highest average rating across any milestone and all PGY levels in Milestones 1.0 was professionalism (mean = 3.17, SD 1.02) whereas the average resident rating for Patient Care was the lowest (mean = 2.89, SD = 1.03). However, a shift occurred for Milestones 2.0 where Interpersonal and Communication Skills became the highest for early PGY levels and Medical Knowledge for senior residents. Patient Care remained the lowest scoring competency under both systems. Subcompetencies such as Critical Care and Brain Tumor management consistently showed high scores, whereas areas such as Surgical Treatment of Epilepsy, Pain and Peripheral Nerves, and Pediatric Neurosurgery demonstrated lower scores.

Conclusion: A balance between nontechnical competencies and critical technical skills is necessary to ensure comprehensive neurosurgical training. Established benchmarks can enhance the utility of milestone data and support the development of well-rounded, competent neurosurgeons.

Background and objectives: Adverse events after cranioplasty remain a significant burden in postsurgical care, often necessitating reoperations. Identifying predictors of reoperation could optimize care. We investigated reoperation after cranioplasty and factors that correlate.

Methods: A retrospective analysis of 318 cranioplasty patients at our single institution was conducted. Clinical demographics, preoperative and perioperative parameters, and postoperative outcomes of patients were collected from electronic health records. Univariable and multivariable logistic regression were conducted to identify significant predictors of reoperation after cranioplasty. Patients who had previous cranioplasties or the bone flap replaced during the craniectomy were excluded.

Results: Of 318 cranioplasty patients, 62 (19.4%) required reoperation. These patients had shorter time intervals between craniectomy and cranioplasty relative to patients who did not require reoperation (median of 86 vs 140 days, IQR: 31-164 and 79-211, P ≤ .01). The reoperation group also had a greater frequency of cranioplasties done during their index hemicraniectomy hospital stay (21.3% vs 10.9%, P = .03), longer time interval to restarting antiplatelets or anticoagulants (median of 34 vs 11 days, IQR 18-102 and 7-16, P = .03), greater number of preoperative ventriculoperitoneal shunt patients (26.2% vs 12.9%, P = .01), and lower utilization of autologous bone implant (62.3% vs 80.0%, P ≤ .01). On multivariable analysis, use of autologous bone implant (odds ratio: 0.38 [0.15-0.94], P = .03) and postoperative subgaleal drain use (odds ratio: 0.35 [0.13-0.91], P = .03) were associated with a lower odds of reoperation, while greater fluid collection on postoperative computed tomography was linked to a higher odds of reoperation (odds ratio: 1.05 [1.01-1.11], P = .02).

Conclusion: Autologous bone implant, postoperative subgaleal drain use, and fluid collection on postoperative computed tomography are independent predictors of reoperations after cranioplasty. Further assessment of these factors may be beneficial for predictive modeling and surgical management of patients requiring cranioplasty.