World neurosurgery最新文献

Background: Sleep disturbances, especially those lasting more than one hour, are under-researched in patients with degenerative cervical myelopathy (DCM). This study aims to investigate the prevalence and risk factors for such disturbances in DCM patients undergoing decompression surgery and to identify factors contributing to poor postoperative improvement.

Methods: A multicenter retrospective observational study was conducted on consecutive patients diagnosed with DCM who underwent cervical decompression surgery between April 2018 and August 2022. The Neck Disability Index sleep component was assessed at baseline and 12 months postsurgery. Univariate and multivariable logistic regression analyses were used to identify risk factors for persistent sleep disturbances and poor improvement.

Results: Of the 1912 patients included, 54.8% reported sleep disturbances, with 33.0% experiencing disturbances of more than one hour at baseline. Multivariable analysis identified male sex, high body mass index, high Numerical Rating Scale for arm pain, high Neck Disability Index, and high Core Outcome Measures Index Neck as significant risk factors for sleep disturbances. At 12 months, 35.2% of these patients continued to experience significant sleep issues. The presence of ossification of the posterior longitudinal ligament and high baseline Numerical Rating Scale for neck pain were significant predictors of poor improvement.

Conclusions: The study highlights that ossification of posterior longitudinal ligament and high baseline neck pain are significant risk factors for persistent sleep disturbances postsurgery in DCM patients. Early identification and targeted interventions may be necessary to improve outcomes.

Background: While studies have examined the relationship between sex and outcomes after lumbar fusion surgery, few have strictly controlled for other patient-level variables. In this study, we use coarsened exact matching (CEM) to determine the effect of patient-reported sex on spinal fusion outcomes.

Methods: Outcomes across 4680 consecutive adult single-level, posterior-only lumbar fusions at a multihospital academic medical center were retrospectively assessed. First, univariate analyses were performed to broadly examine the effect of sex on surgical outcomes, uncontrolled for other patient factors. Next, the population was split by sex (male vs. female) and matched 1:1 on demographic and medical factors known to influence outcomes (including age, race, smoking status, and past surgical history) using CEM. CEM effectively controls for confounding variable bias by creating pairs of matched samples and preserving the fidelity of each covariate through binning. Primary outcomes included 30-day and 90-day readmissions, emergency department visits, reoperations, and mortality. Secondary outcomes included discharge disposition and length of hospital stay.

Results: Between otherwise exactly matched male-female pairs, females were less likely to be discharged home (odds ratio 1.70, P < 0.001) and had a longer length of stay (mean: 95.7 vs. 87 hours, P < 0.001). No differences in readmissions or reoperations were observed between matched cohorts.

Conclusions: Female patients encountered longer hospital stays and higher odds of nonhome discharge after single-level lumbar fusion compared to otherwise exactly matched male patients.

Objective: This study aims to elucidate the anatomical principles governing the surrounding venous structures (VS) of the horizontal part of the third segment of the vertebral artery (V3h) and develop a safe and bloodless surgical technique for exposing V3h.

Methods: This study used 10 formalin-infused cadaveric head specimens. The dissections were performed stepwise to simulate the far lateral approach process, exposing the V3h with a novel technique. Additionally, we applied this technique to 10 patients undergoing far or extreme lateral approaches.

Results: The VS surrounding V3h is divided into 3 components: the vertebral venous plexus, suboccipital cavernous sinus, and the anastomotic vein. The posterior atlanto-occipital membrane (PAOM), a resilient fascial layer in the craniovertebral junction, extends from the periosteum of the occipital squama to the posterior arch of the atlas. It adheres ventrally to the VS within the suboccipital triangle (SOT), forming a tent-like structure that maintains tension and ensures fullness of the VS around V3h. We discovered that by releasing tension in this membrane and reducing strain on this tent-like structure, the collapse of the venous sinus within the SOT can be achieved, resulting in reduced intraoperative bleeding and improved surgical efficiency. Additionally, we successfully managed 10 clinical cases employing the PAOM tension release technique in clinical cases, with no reported incidents of intraoperative vertebral artery injury.

Conclusions: The application of the PAOM tension release technique effectively collapses the tent-like structure within the SOT, significantly reducing bleeding during V3h exposure in craniovertebral junction.

Background: Understanding the morphological patterns of degenerative and traumatic spinal conditions is essential for precise diagnosis and management plans. This study evaluates the sequence of structural changes in degenerative spinal disorder patients' disco-vertebral unit and the traumatic spinal injury patterns in a northwestern Nigerian population.

Methods: A hospital-based retrospective study reviewed radiologic images of 307 patients with spinal degeneration (n=269) and trauma (n=38) at two tertiary hospitals in Northwest Nigeria. The study presented descriptive and inferential statistics with a 95% confidence interval (CI) and significance level with a p-value ≤ 0.05.

Results: The average age of patients with spinal degeneration was 52.5 years, with females (60.6%) and those aged 41 and older (76.6%) predominant, while trauma patients averaged 36.3 years, predominantly male (78.9%) and aged 21 - 40 years (60.5%). Common clinical manifestations included radicular pain (53.9%) in degenerative cases and spinal shock (36.8%) in trauma. Correlation analysis showed significant links between mild/moderate straightening of spinal curvature and clinical manifestations (p=0.001). Age-influenced osteophyte and intervertebral disc (IVD) degeneration, especially in the 41 - 60 age group (p=0.001), with AO/Magerl Type A spinal injury was more common in males (p = 0.022) and the 21 - 40 age group (p = 0.019), indicating notable demographic trends. IVD degeneration peaks at L3, L4, and L5, notably Grade III (p = 0.001), and Modic II frequencies rise from L1 (16) to L5 (35) without significant association (p = 0.99).

Conclusion: This study reveals different morphological patterns in degenerative and traumatic spinal conditions in the study population, with considerable age, gender, and symptom correlations. These findings emphasize the importance of understanding these patterns for effective diagnosis and management strategies of spinal degeneration and trauma.

Background: Shunted hydrocephalus patients are at an inherent risk of developing chronic subdural hematomas (cSDHs) from overdrainage. The preliminary results of three much-anticipated clinical trials (STEM, EMBOLISE, MAGIC-MT) have recently been presented, showing efficacy of middle meningeal artery embolization (MMA-E) in reducing observational failure and the need for reoperation in non-shunted patients, but the effect of this procedure in shunted patients remains to be further investigated. In this series, we present our institution's experience with MMA-E in shunted normal pressure hydrocephalus patients in comparison to standard of care (=SOC).

Methods: We compared nine patients with normal pressure hydrocephalus, ventriculoperitoneal shunt, and shunt-induced cSDHs receiving SOC, shunt adjustment with or without burr hole drainage, to seven patients receiving SOC with MMA-E. Hematoma size and age of patients were matched. Patients were followed with serial head computed tomography scans. Symptoms, hematoma size, time to resolution, resolution status, and embolization details were monitored.

Results: Six of seven SDH patients receiving MMA-E resolved. One patient showed residual but stable 3 mm cSDH after reinitiation of hydrocephalus treatment. The median time to resolution was 139.5 and 89 days for SOC without and with surgery, and 309 or 88 days for SOC without and with surgery plus MMA-E. One MMA-E patient was lost to follow-up and presented more than one year later with decreasing SDH that resolved by post-MMA-E day 504.

Conclusions: MMA-E in shunt-induced cSDHs has not shown increased resolution speed compared to SOC and liberal use of MMA-E on this cohort may need to be further investigated.

Background: Distal junctional kyphosis (DJK) and distal junctional failure (DJF) are known complications of adult multilevel spinal fusion surgery. Previous literature has extensively investigated proximal junctional kyphosis and proximal junctional failure, but DJK and DJF are relatively understudied. This study investigates the association between bone mineral density (BMD) and DJK/DJF via a systematic review and meta-analysis.

Methods: A literature search was conducted across PubMed, Cochrane, Web of Science, Embase, and Scopus to find studies reporting DJK, DJF, and BMD. A 12-month minimum follow-up and radiographic biomarker for BMD (Hounsfield units [HU] or a T-score) individually reported for each patient type were required for inclusion. Studies that did not report individualized biomarkers but provided averaged estimates of the effect of BMD on DJK/DJF development were used for systematic review.

Results: Our search yielded 12 unique studies with 1094 patients, of which 5 studies with a total of 519 patients were suitable for comparison by meta-analysis. Patients who developed DJK/DJF had significantly lower HUs (113.17 ± 33.86) than patients who did not develop DJK/DJF (142.51 ± 41.39). No significant difference was found with regard to dual-energy X-ray absorptiometry measurements, age, or body mass index between patients who did and did not develop DJK/DJF.

Conclusions: Patients who developed DJK/DJF had significantly lower computed tomography-measured HU as compared to those without DJK/DJF. Our findings highlight the potential importance of BMD evaluation with computed tomography prior to multilevel spine fusion surgery, though further research would be helpful to evaluate the significance of dual-energy X-ray absorptiometry-based BMD measurements on DJK/DJF development.

Objective: To determine the effect of obesity on clinical, radiographic, and surgical outcomes after lateral lumbar interbody fusion (LLIF) versus minimally invasive surgery (MIS) transforaminal lumbar interbody fusion (TLIF) and compare the effectiveness of LLIF versus MIS TLIF in treating obese patients.

Methods: A retrospective comparative analysis of patients who underwent single-level L4-5 LLIF or MIS TLIF over a 7-year period was performed. Spinopelvic parameters were compared based on pre- and postoperative radiographs. Body mass index (BMI) ≥30 was deemed "high"; BMI <30 was deemed "low."

Results: In total, 154 patients underwent LLIF or MIS TLIF during the study period (33 TLIF high BMI, 45 TLIF low BMI, 28 LLIF high BMI, and 48 LLIF low BMI). Compared with TLIF high BMI patients, TLIF low BMI patients experienced superior posterior disc height (PDH) restoration (p=0.05), shorter operative duration (p=0.01), decreased revision surgery rate (p=0.02), reduced estimated blood loss (p=0.04), and shorter hospital length of stay (p=0.03). No differences in outcomes were seen in LLIF high BMI vs LLIF low BMI cohorts. Among obese patients, LLIF provided superior restoration in anterior disc height (p<0.001), PDH (p=0.003), and neuroforaminal height (p=0.002); shorter operative duration (p<0.001); and decreased estimated blood loss (p=0.008), compared with MIS TLIF.

Conclusions: Obesity was associated with poorer overall radiographic and surgical outcomes after MIS TLIF but not LLIF. In obese patients in our cohort, LLIF provided superior improvements in spinopelvic parameters and surgical characteristics. BMI should be considered when deciding between LLIF and MIS TLIF.

Background: Ventricular shunt infections lead to significant morbidity and mortality. This study aimed to identify risk factors for 30-day postoperative infection outcomes of ventricular shunts for pediatric hydrocephalus.

Methods: This was a retrospective cohort study using the National Surgical Quality Improvement Program (NSQIP) Pediatric database for years 2016-2021. Patients were included in this study if they were under 18 years of age and underwent ventricular shunt surgery. The primary outcome was 30-day postoperative shunt infection. A multivariable logistic regression analysis was performed using fourteen prognostic variables to determine factors associated with infection risk.

Results: A total of 10,878 patients were included in the study, with a mean age of 3.1 years (SD 4.83), and 44.2% were female. The overall 30-day postoperative shunt infection rate was 3.7%. We found that infection risk increased in patients on nutritional support, with longer operating room duration, and congenital hydrocephalus. Conversely, infection risk decreased with increasing patient age, delivery of intraoperative intraventricular antibiotics, and placement of first-time shunts. Variables that did not significantly affect the risk of 30-day postoperative shunt infection included sex, BMI, ostomy, tracheostomy, neuromuscular disease, structural pulmonary/airway abnormality, steroid use within 30 days, antibiotic-impregnated shunt use, and endoscopy for catheter placement.

Conclusion: Various modifiable and non-modifiable factors are associated with postoperative shunt infections. Recognizing and modifying risk factors can reduce pediatric shunt infections, thereby preventing revisions and improving therapeutic outcomes and quality of life.

Background: Neuroendovascular treatment of cerebral aneurysms is considered a basic procedure for neurosurgeons and interventional neuroradiologists; however, its critical technical nuances, termed "tacit knowledge," are challenging to impart. This study aimed to evaluate the efficacy of our novel video recording and editing method in enhancing trainees' experience.

Methods: A wearable camera (wearable recording) and multiple media sources in a hybrid operating room (hybrid recording) were used to capture procedural details such as audio and conversation, thus enabling a re-experience. Trainees condensed both recordings into summary videos and a supervisor subsequently evaluated them. Six trainees watched the following three videos: Video 1, only hybrid recording; Video 2, only wearable recording; and Video 3, both wearable and hybrid recordings synchronized, and then provided semi-quantitative evaluations ranging from 0 (not useful at all) to 5 (extremely useful).

Results: We examined 64 unruptured cerebral aneurysm coil embolizations using hybrid wearable recording methods. Video 3 received the highest rating among all participants (5±0 [mean ± standard deviation]), while Videos 1 and 2 received relatively lower ratings (Video 1:3.8±0.7; Video 2:4.2±0.4). The educational impact of video editing across all videos was rated highly (4.4±0.8). The respondents showed diverse opinions on editing time, with some perceiving it as less time-consuming than other surgery video edits (3.4±1.1).

Conclusion: Our hybrid and wearable recording and editing methods facilitated the propagation of tacit knowledge of coil embolization and enhanced surgical education by enabling more efficient learning of technical tips.

Objective: Cauda Equina Syndrome (CES) poses significant neurological risks if untreated. Diagnosis relies on clinical and radiological features. As the symptoms are often non specific and common, the diagnosis is usually made after a MRI scan. A huge number of MRI scans are done to exclude CES but nearly 80% of them will not have cauda equina syndrome. This study aimed to develop and validate a machine learning model for automated CES detection from MRI scans to enable faster triage of patients presenting with CES like clinical features.

Methods: MRI scans from suspected CES patients (2017-2022) were collected and categorized into normal scans/disc protrusion (0%-50% canal stenosis (CS)) and cauda equina compression (CEC, >50% CS). A convolutional neural network was developed and tested on a total of 715 images (80:20 split) Gradient descent heatmaps were generated to highlight regions crucial for classification.

Results: The model achieved an accuracy of 0.950 (0.921-0.971), a sensitivity of 0.969 (0.941-0.987), a specificity of 0.859 (0.742-0.937), a positive predictive value of 0.969 (0.944-0.984) and an area under the curve of 0.915 (0.865-0.958). Gradient descent heatmaps demonstrated accurate identification of any clinically relevant disc herniation into the spinal canal.

Conclusions: This study pilots a deep learning approach for predicting CEC presence, promising improved healthcare quality and timely CES management. As referrals rise, this tool can act as a fast triage system which can lead to prompt management of CES in environments where resources for radiological interpretation of mri scans is limited.