World neurosurgery最新文献

Objective: The main aim was to determine the incidence, risk factors, clinical phenotypes, and response to shunt surgery in chronic, shunt-dependent hydrocephalus (SDHC) after aneurysmal subarachnoid hemorrhage (aSAH).

Methods: In this observational, single-center study, 849 aSAH patients treated at Uppsala University Hospital, between 2008-2018, were included. Variables on demography, injury severity, treatments, chronic hydrocephalus presentation, and outcome were evaluated.

Results: In total, 107 (13%) patients were treated with a shunt due to SDHC. In multivariate logistic regressions, risk factors for SDHC were worse neurological (WFNS) grade, larger ventricles (Evans' index) at admission, the need to insert an external ventricular drain (EVD), decompressive craniectomy, and complications with meningitis. Six different SDHC phenotypes were identified; impeded neurological recovery (55%), Hakim-Adams syndrome (17%), high-pressure symptoms (13%), failed EVD removal (8%), external brain herniation after decompressive craniectomy (DC; 6%), and subdural hygroma (1%). The former, three groups significantly improved in modified Rankin Scale (mRS) and 87-100% exhibited subjective symptomatic relief. There was no significant change in mRS for the latter three groups, but 60-100% experienced some subjective relief postoperatively.

Conclusion: Chronic SDHC was a common complication after aSAH, particularly in patients with severe primary brain injury, acute hydrocephalus, and treatment-related factors. The condition presents with distinct clinical phenotypes, which may influence treatment response. Recognizing these phenotypes could aid in optimizing patient selection and expectations for shunt surgery outcomes.

Study design: Retrospective cohort study.

Objectives: To evaluate the effect of spinopelvic parameters on anterior bone graft subsidence and functional outcomes after anterior interbody fusion (AIF) and posterior instrumented fusion (PIF) in pyogenic spondylodiscitis (PS).

Methods: Sixty-five patients who had received AIF+PIF for PS over July 2003 to December 2015 were enrolled. Based on the degree of bone graft subsidence, the patients were divided into groups A (minimal subsidence), B (moderate subsidence), and C (severe subsidence). Comparative analysis was performed evaluating patient demographics, spinopelvic parameters (kyphosis angle, involved segment's intervertebral height, pelvic incidence [PI], pelvic tilt, sacral slope, lumbar lordosis [LL], thoracolumbar kyphosis, and PI minus LL [PI-LL]), and clinical evaluation including Oswestry Disability Index (ODI) score and Visual Analog Scale (VAS) scores. The data were collected in a patient registry at perioperative, postoperative 3-month and 2-year to assess clinical and radiological outcomes. Receiver Operating Characteristic (ROC) analysis was applied for identification of cut-off points of LL and PI-LL in suggestion of clinical practice.

Results: The 65 included patients had a mean follow-up period of 35.09 ± 38.30 months. Generalized estimating equation analysis showed that LL and PI-LL changes in group A were significantly different from those in group C but not in group B, revealing that preoperative LL and postoperative PI-LL are bone graft subsidence type indicators. By contrast, preoperative ODI, postoperative 3-month VAS-back, preoperative VAS-leg, and postoperative 2-year VAS-leg scores were associated with bone graft subsidence type. ROC analysis identified preoperative LL < 40.79° and postoperative PI-LL > 15° as significant predictive markers for severe bone graft subsidence, providing valuable thresholds for surgical risk evaluation.

Conclusions: Among spinopelvic parameters, preoperative LL and postoperative PI-LL are important parameters associated with bone graft subsidence severity in patients who had received AIF+PIF for PS.

Background: The optimal management for treating progressive strokes caused by anterior circulation intracranial atherosclerotic large vessel occlusion (ICAS-LVO) remains unclear.

Methods: A retrospective analysis was conducted on our stroke database. Among the patients presenting with mild ischemic stroke (NIHSS ≤5), 273 were diagnosed with anterior circulation ICAS-LVO. Forty-five patients who experienced neurologic deterioration (NIHSS increase ≥4) between 24 hours to 7 days post-stroke, despite a persistent ischemic penumbra on CT perfusion, were retrospectively identified. These patients were allocated to either the endovascular-therapy group or the medical-therapy group based on their receipt of endovascular intervention. The modified Rankin Scale (mRS) score at 90 days, the rate of technically successful recanalization, and perioperative complications were assessed.

Results: Of the 45 patients, 27 underwent endovascular therapy, and 18 received medical therapy. Recanalization was technically successful in all cases within the endovascular group. The preferred treatment was direct angioplasty, with 12 patients receiving balloon angioplasty alone, 11 receiving balloon angioplasty and stent implantation, and 4 undergoing balloon angioplasty followed by mechanical thrombectomy. The rate of functional independence (mRS ≤2) at 90 days was significantly higher in the endovascular group (74.1%) compared to the medical group (33.3%, risk ratio 5.714; 95% CI, 1.55 to 21.06; P=0.007). The incidence of intracranial hemorrhage was slightly higher in the endovascular group, but not statistically significant.

Conclusions: Endovascular therapy may offer a viable treatment option for progressive stroke resulting from anterior circulation ICAS-LVO, even when the time from stroke onset to treatment exceeds 24 hours, in select patients.

Objective: This study compared postoperative opioid use for patients undergoing short segment primary versus revision lumbar fusion.

Methods: Patients who underwent primary or revision 1-2 level lumbar fusion (2017-2021) were included in this study. The state PDMP was reviewed for all patients to quantify preoperative and postoperative opioid, benzodiazepine, muscle relaxant, and gabapentin use. A 1:1 propensity match was performed to match primary lumbar fusion patients with revision lumbar fusion patients. Revision lumbar fusion patients were sub-stratified into those with or without persistent postoperative opioid use to identify demographic differences between these patient cohorts.

Results: The final cohort included 216 primary and 216 revision 1-2 level lumbar fusion patients. The average time between index procedure and revision was 7.54 ± 9.22 years. Opioid use was similar within one-year pre-operatively and at all postoperative time points (up to 1 year) between primary and revision fusion patients. Benzodiazepine, muscle relaxants, and gabapentinoid use was also similar at all pre-operative and post-operative time points. Further stratification of revision lumbar fusion patients found that persistent postoperative opioid use patients had a higher incidence of preoperative opioid use within the year prior to surgery with increased number of prescriptions (7.22 ± 7.62 vs. 1.38 ± 2.32; p<0.001) and MME totals (298 ± 565 vs. 45.6 ± 84.4; p<0.001).

Conclusions: Postoperative opioid requirements were similar amongst patients undergoing primary versus revision lumbar fusion. In the revision cohort, persistent postoperative opioid users had higher preoperative opioid use, which is supported by prior literature. Although revision lumbar fusion has been reported to lead to less pain improvement, this study's findings suggest these procedures may not lead to higher rates of persistent opioid use postoperatively.