World neurosurgery最新文献

A 78-year-old male presented with an episode of confusion. CTA revealed an abnormal collection of vessels in the basal frontal region, and diagnostic cerebral angiogram revealed an ethmoidal dural arteriovenous fistula (dAVF). dAVFs are rare intracranial vascular lesions, comprising approximately 2-3% of all dAVFs.^{1, 2, 3} These fistulas are primarily supplied by the ethmoidal branches of the ophthalmic artery.^{1, 2, 3} A high-grade ethmoidal dural arteriovenous fistula characterized by cortical venous drainage or associated symptoms requires treatment.⁴ Intervention is necessary due to the potential risk of intracranial hypertension or hemorrhage⁴, which could lead to serious neurological deficits.⁵ Endovascular treatment of ethmoidal dural arteriovenous fistulas, while possible, could lead to blindness due to ethmoidal feeders branching from ophthalmic artery and risk of retrograde embolization.⁶ Given the fistula's angioarchitecture and supply solely from ethmoidal branches, microsurgery was elected as the primary treatment to mitigate the risk of visual compromise. The patient underwent microsurgical treatment for dAVF disconnection. The surgical strategy involved subarachnoid dissection, identification of the main draining vein, identification of fistulous arteries, coagulation of the feeders, and disconnection of the main draining vein. The patient made an excellent recovery, and his confusion resolved. He was initially discharged to home on post-operative day 2 but returned due to left-sided weakness and a right convexity hygroma requiring single burr hole drainage. A 1-month follow-up in clinic revealed the patient was neurologically intact, and a CT angiogram of the head revealed no residual fistula. At the 1-year follow-up, he was without neurological deficit. A follow up CTA showed no evidence of recurrence. This video article aims to demonstrate the key microsurgical steps, anatomical landmarks, and the efficacy of open surgery as a primary treatment for these unique fistulas.

Carotid body tumors are rare, highly vascular paragangliomas that arise from neural crest-derived chemoreceptor cells of the carotid body, a specialized structure located at the carotid bifurcation adjacent to the carotid sinus and involved in oxygen and carbon dioxide sensing. For symptomatic or enlarging lesions, surgical resection remains the definitive treatment. Preoperative embolization can reduce vascularity and improve intraoperative safety as supported by the literature demonstrating its safety and efficacy.^1-3 This video demonstrates the microsurgical technique for resection of a carotid body tumor in a 79-year-old woman presenting with a three-year history of left neck pain, paresthesia, and a palpable neck mass. Magnetic Resonance Angiography (MRA) revealed a 2.6×3.0 centimeters (cms) left carotid body tumor splaying the internal and external carotid arteries. After preoperative embolization, the patient was positioned supine with the head turned contralaterally. A linear incision was made along the anterior border of the sternocleidomastoid, and dissection proceeded through the platysma to expose the carotid bifurcation. The internal jugular vein was mobilized laterally, and the carotid arteries were skeletonized to identify and preserve adjacent cranial nerves and vascular structures. The tumor was completely resected with preservation of the normal carotid vasculature and vagus nerve. The patient was discharged on postoperative day one and remained asymptomatic at six-week follow-up. This case highlights the role of preoperative embolization, hybrid angiography-operating suites, and meticulous microdissection in achieving safe and definitive resection of complex carotid body tumors. Video Caption This video demonstrates a microsurgical approach for safe resection of a carotid body tumor following preoperative embolization, highlighting key steps in exposure, vascular control, and tumor removal while preserving critical neurovascular structures.

Objectives: Low back pain (LBP) is the leading cause of musculoskeletal disability worldwide. Lumbar disc herniation (LDH) commonly causes radiculopathy, yet conventional MRI may conflate symptomatic pathology with age-related change. We assessed quantitative T2-weighted signal-intensity ratios (SIRs) of herniated nucleus pulposus (NP) as an objective biomarker to stage LDH beyond morphology, using internal references (e.g., CSF) for normalized, comparable measurements.

Methods: This retrospective cross-sectional study analyzed 157 patients (64 % male) with MRI-confirmed LDH and radicular symptoms at a tertiary center (2021). Exclusions included prior surgery, infection, tumor, fracture, or suboptimal imaging. SIRs were calculated for herniated NP relative to cerebrospinal fluid (SIR-NP/CSF), anterior annulus fibrosus (SIR-NP/AF), and adjacent uninvolved NP (SIR-NP/adjNP). Symptom duration groups were acute (<2 weeks), subacute (2-4 weeks), and chronic (>4 weeks). Group differences were tested with ANOVA and Tukey post-hoc analyses, adjusting for phenotype (protrusion/extrusion), disc level, age, and sex.

Results: SIRs decreased significantly with longer symptom duration (P<0.001). Mean SIR-NP/CSF declined from 0.30 (acute) to 0.23 (subacute) to 0.12 (chronic) and was the most robust temporal marker. Posterior NP signal intensity decreased from 194 (acute) to 75 (chronic; F=136.9, P<0.001). Trends were consistent across ratios and were not explained by phenotype, level, age, or sex. An SIR-NP/CSF threshold <0.20 suggested subacute/chronic stages.

Conclusion: Quantitative T2 SIRs track NP dehydration and may support reproducible LDH staging; however, clinical applicability is limited without outcome correlation. Prospective multicenter validation with follow-up, including resorption assessment, is needed.

Objective: To determine the incidence of postoperative shoulder injuries and subsequent interventions in patients with C5 palsy, to inform clinical management and prevent injury following cervical spine surgery.

Methods: A retrospective review of medical records of patients who underwent cervical fusion between 2016 and 2024 at a tertiary academic hospital was performed. Patients with postoperative C5 palsy and/or deltoid weakness were identified via auto extraction to identify shoulder dysfunction or pathologies requiring orthopedic intervention due to postoperative C5 palsy.

Results: Of decompression and fusion procedures reviewed, 72 cases (4%) were complicated by new-onset postoperative C5 palsy and/or deltoid weakness, with a median onset of 5 days post-surgery. More decompressed levels was correlated with earlier C5 palsy onset (p = 0.039), but not the number of fused levels. Additional symptoms included upper extremity paresthesia (56%) and axial neck pain (40%). Shoulder imaging was performed in 21% cases. Among patients with C5 palsy, 11% required orthopedic interventions, occurring on average about one year after onset. Further intervention was not significantly associated with decompression or fusion levels but was linked to combined symptoms of sensory symptoms and weakness (p = 0.049). Only 25% experienced complete symptom resolution after intervention, and no cases saw full resolution of C5 palsy.

Conclusions: C5 palsy occurred in 4% of surgeries, consistent with existing literature. Increased laminectomy levels correlated with faster onset of C5 palsy, and persistent C5 palsy increased the risk for additional shoulder interventions with limited symptom resolution, underscoring the importance of early diagnosis and management.

Background: Multiple pituitary adenomas (MPA), particularly those involving functioning adenoma, represent a special subtype of pituitary adenomas that pose dual challenges in diagnosis and treatment. In this setting, the coexistence of hormonally active and silent lesions may result in a diagnostic pitfall when a radiologically dominant tumor does not correspond to the hormonally responsible lesion. This misleading lesion, often referred to as decoy lesion, can adversely influence surgical decision-making in patients with MPA.

Methods: We systematically reviewed English-language case reports of multiple pituitary adenomas published between 2000 and 2024 in PubMed, Web of Science, and Embase and present two illustrative cases. Lesions were classified as responsibility lesions or decoy lesions based on an operational definition incorporating endocrine outcomes, radiological features, and surgical findings.

Results: A total of 35 patients from 24 case reports met the inclusion criteria. The mean age was 40 years, with 12 male and 23 female patients. The most common clinical manifestations were acromegaly (n=13, 37%) and Cushing's syndrome (n=11, 31%). Our findings indicate that, compared with decoy lesions, responsibility lesions are less conspicuous on preoperative MRI and usually smaller in size. Overall, 43% of these patients (15/35) did not achieve biochemical remission after the initial surgery, with missed identification of the responsibility lesion reported in a substantial proportion of cases.

Conclusion: Identifying decoy lesion and distinguishing it from responsibility lesion may improve surgical planning and endocrine outcomes in complex MPA cases.

Objective: This systematic review and meta-analysis examined cohort studies investigating the relationship between vertebral Hounsfield unit (HU) measurements on preoperative computed tomography scans and postoperative cage subsidence (CS) in patients undergoing lateral lumbar interbody fusion (LLIF). As DEXA scans may inaccurately reflect local bone quality, vertebral HU of CT scans have emerged as a viable alternative to predict CS. This study aimed to identify a potential HU threshold predictive of CS in LLIF for future studies to explore and verify.

Methods: Four databases were searched for studies reporting CS rates and preoperative segmental HU in patients undergoing LLIF, including oblique lateral interbody fusion, extreme lateral interbody fusion, anterior-to-psoas, and transpsoas techniques for degenerative spinal conditions. Random-effects meta-analyses were conducted. Outcomes were pooled segmental HU values and the predictive performance of different HU thresholds for CS. Intra-study risk of bias was rated using the Newcastle-Ottawa scale, and evidence certainty was assessed using GRADE.

Results: Five retrospective cohort studies totaling 396 patients (271 non-CS, 125 CS) were included. The pooled segmental HU was 112 (95%CI: 96-128) for patients with CS and 143 (95%CI: 128-158) for non-CS patients. The pooled mean difference was 30 (95%CI: 14-45, p<0.01,p_egger=0.51). A threshold of ≤120 HU had the best predictive performance for CS (Sensitivity: 76%, 95%CI: 32%-96%, Specificity: 88%, 95%CI: 75%-95%, AUC: 0.903).

Conclusion: This study affirms HU as a potential predictive tool for CS in patients undergoing LLIF for degenerative spinal diseases. Future studies should explore the cut-off of 120 HU to validate its predictive capability.