Neurological Surgery最新文献

Spinal arteriovenous(AV) shunt disease is rare, although many neurosurgeons may encounter patients with the disease. Recently, the pathological findings and classification of spinal AV shunt disease have been well described. The fundamental treatment of spinal AV shunt disease involves interruption of the shunt, which is achieved by endovascular treatment or direct surgery. Development in diagnostic imaging and technology for endovascular treatment has enabled us to treat many cases. Recently, several multicenter studies on spinal AV shunt diseases revealed that the treatment outcomes of direct surgery were better than those of endovascular treatment. However, in our institute, endovascular treatment is the first line because it is less invasiveness. Although the success and complication rates of endovascular treatment are inferior to those of direct surgery, endovascular treatment remains a therapeutic option for patients with spinal AV shunt disease if it could achieve low complication rates and direct surgery could be performed afterward to rescue the patient. In this article, we elaborate on this disease, surgical indications, limitations of endovascular treatment, and tips for direct surgery.

Vertebroplasty has shown excellent analgesic effects in patients with osteoporotic vertebral fractures. In Japan, percutaneous vertebroplasty, balloon kyphoplasty, and vertebral body stenting are commonly performed. All of these techniques require precise transpedicular vertebral puncture and complete cement filling without leakage. Puncture should only be performed after accurately identifying the upper and lower end plates of the vertebral body, lateral borders, and pedicles using combined frontal and lateral fluoroscopic images. In the frontal view, the puncture was made from the lateral cranial side of the pedicle toward the center of the vertebral body. In the lateral view, before passing through the medial wall, the tip had entered the vertebral body and advanced to the anterior quarter. Bone cement within the vertebral body can permeate the trabecular spaces or accumulate as a single mass. To prevent leakage, the movement of the injecting finger should be aligned precisely with the fluoroscopic images. Awareness of the three leakage patterns and basivertebral, segmental, and cortical veins, is crucial. Potential lateral leakage outside the vertebral body must be focused. The injection was terminated as the cement reached the posterior quarter.

Standard microscopic posterior decompression(MD) for lumbar disc herniation has been well established and is a familiar procedure to virtually all spinal neurosurgeons. Traditional surgical treatments are often associated with severe postoperative pain, disability, and dysfunction. This study aimed to describe the microendoscopic discectomy(MED) technique for lumbar disc herniation and report its surgical indications. This technique has been shown to provide symptomatic relief equivalent to that of microdiscectomy, with obvious reductions in operative hospital stay and narcotic use. No significant differences in outcome data between the two groups were observed. However, several patients in the MED group required surgical conversion to MD. The size of the disc herniation was the most important factor in the conversion. MED is an effective microendoscopic system with good long-term outcomes for the treatment of lumbar disc herniation. The endoscopic approach allows for smaller incisions and less tissue trauma than the standard open microdiscectomy. Strict adherence to well-defined preoperative selection criteria ensures optimal postoperative outcomes.

Adult spinal deformity(ASD) is a condition in which the spinopelvic alignment changes owing to age-related degeneration, making it difficult to maintain a standing position. The goal of surgery for ASD is to correct the spine and obtain normal alignment. Here, we discuss the pathophysiology of ASD, spinopelvic alignment, surgical methods, and complications. Circumferential minimally invasive surgery for ASD comprises an anterior approach using lateral lumbar interbody fusion and a posterior approach using percutaneous pedicle screws. Complications include perioperative and implant-related complications, both of which can be serious. Computer-assisted devices are useful for avoiding these complications. Circumferential minimally invasive surgery requires various spine surgery techniques, most of which are performed daily. Circumferential minimally invasive surgery can be achieved by gaining a solid understanding of the theory and improving the accuracies of the basic procedures.

Middle meningeal artery embolization(MMAE) is an effective treatment for chronic subdural hematoma(CSDH). Retrospective analyses have indicated that MMAE for CSDH is not only minimally invasive but also highly safe, and is associated with a significantly lower recurrence rate than that of conventional treatments. However, there is no consensus regarding treatment strategies, including the patient-selection criteria, embolic materials, and procedural techniques. Several randomized controlled trials have been conducted to compare conventional treatments with MMAE, and the results indicate that MMAE could potentially constitute a standard treatment option for CSDH in the future.

Lumbar foraminal stenosis is a common problem; however, correct diagnosis and appropriate surgical treatment are difficult. This article describes the author's techniques for imaging diagnosis using thin-slice magnetic resonance imaging(MRI) and the microsurgical technique of foraminal decompression through the intermuscular approach. Thin-slice MRI consists of 1-mm thickness continuous images of the lumbar spine using a T2-weighted-image-based sequence. With multiplanar reconstruction in three planes, all nerve roots are carefully observed from the lateral recess to the extraforaminal area. This technique provides the correct diagnosis of subtle nerve root compression in the foramen. The outlet of the intervertebral foramen is exposed using Wiltse's intermuscular approach. To avoid disorientation, several surgical landmarks and two basic routes to reach the outlet of the foramen are established. The foramen is carefully unroofed by using an ultrasonic bone curette. For complete decompression of the nerve root and ganglion, the inferomedial aspect of the pedicle and its medial and lateral limits should be determined. In addition, the yellow ligament must be completely removed, and the intertransverse ligament lateral to the nerve root should be sufficiently decompressed.

Historically, metastatic spinal tumors have been treated using open spinal fixation, invasive decompressive techniques, and low-dose palliative conventional external beam radiotherapy. As patients with metastatic disease are now living longer, the need for long-term local tumor control is becoming important. Spine stereotactic body radiotherapy has emerged as a valuable alternative option to achieve long-term local tumor control by delivering high doses of radiation to tumors and sparing the spinal cord. In recent years, minimally invasive spinal fixation and less-invasive decompressive techniques, such as separation surgery, have become increasingly important in the management of metastatic spinal tumors. In this review, we discuss the indications for these therapeutic options and the variables that should be considered when managing these patients.

Osteoporotic vertebral fractures are among the most common fractures associated with osteoporosis. Approximately 80% of cases heal by fusion in the natural process without the need for surgery, and if we include the so-called "incidental vertebral body fractures," which are discovered by chance during radiography, the frequency of prolongation of back pain due to pseudoarthrosis or delayed-onset neurological deficits is low. However, the prognosis of osteoporotic vertebral fractures is affected by the number of fractured vertebrae. In patients who become bedridden because of prolonged pain due to pseudoarthrosis or delayed neurological deficits, surgical treatment aimed at improving activities of daily living is required from the viewpoint of life prognosis. Here, we describe the indications for surgery and surgical methods for pathologies that require surgical treatment after osteoporotic vertebral fractures.

Anterior cervical fixation is an excellent surgical technique for the removal of anterior compressive elements affecting the spinal cord and nerve roots while addressing cervical instability. However, it is important to recognize the unique challenges posed by the proximity of critical structures, including the trachea, esophagus, carotid sheath, and recurrent laryngeal nerve. Access to the upper cervical spine is often limited to the mandible. A thorough understanding of the relevant anatomy is essential for careful consideration of surgical indications when selecting an appropriate technique. By ensuring accurate decompression and stabilization, optimal postoperative outcomes in terms of neural symptom relief and spinal stability can be achieved.

Hypertension is the most important risk factor for stroke. For both primary and secondary stroke prevention, the target blood pressure level is 130/80 mmHg in the current guidelines. Intensive blood pressure lowering is useful for the prevention of intracerebral hemorrhage; therefore, blood pressure control of<120/80 mmHg would be beneficial for patients at a high risk of hemorrhagic stroke, including those with factors such as a history of intracerebral hemorrhage, use of more than two antithrombotic drugs, and the presence of more than two cerebral microbleeds. For people without a history of stroke, the evaluation of cerebral small-vessel disease on brain magnetic resonance imaging(MRI)is useful for risk stratification of incident stroke. Brain MRI reveals white matter hyperintensities, lacunar infarctions, cerebral microbleeds, and enlarged perivascular spaces, which are representative of small vessel disease. The total small-vessel disease score has been developed to evaluate the total small vessel disease burden and ranges 0-4. People with at least one small-vessel disease have a higher risk of incident stroke; therefore, intensive blood pressure control is important for stroke prevention.