Interdisciplinary Neurosurgery: Advanced Techniques and Case Management最新文献

This case report presents the therapeutic effect of restorative neurostimulation (ReActiv8®) on chronic low back pain (CLBP) in a 44-year-old male, where the primary etiology was not lumbar disc herniation (LDH). Despite presenting with LDH at L4-L5, clinical evaluations suggested lumbar microinstability and multifidus muscle dysfunction as the main contributors to his pain, without radicular symptoms. The patient had a 12-year history of CLBP, resistant to conventional treatments like physiotherapy, medications, and epidural injections. Opting for a minimally invasive approach, he underwent implantation of ReActiv8®, focusing on rehabilitating the impaired multifidus muscle. Over a 12-month therapy period, significant improvements were noted in pain levels, functionality, and quality of life, leading to a full return to work. Interestingly, follow-up imaging showed not only a substantial reduction in pain but also an unexpected resolution of the LDH at L4-L5, enhanced lumbar lordosis, and improved disc hydration, despite minor progressing Modic changes. This case underlines the potential of restorative neurostimulation in CLBP management, especially when the pain origin is non-discogenic. It emphasizes the importance of accurate pain source identification in CLBP treatment and suggests further research into the efficacy and applicability of neurostimulation in similar clinical scenarios.

Background

A chronic subdural hematoma (CSDH) is one of the most common neurosurgery operations. This study aimed to evaluate the effect of topical corticosteroids combined with surgery in patients with CSDH.

Materials and Methods

The present study is a clinical trial study on patients referred to hospitals associated with Ahvaz University of Medical Sciences with chronic subdural hematoma in 2019. Patients requiring surgical drainage of chronic subdural hematoma who met the inclusion criteria underwent open craniotomy surgery on the side of the hematoma. A drain was placed in the open craniotomy site. On the third day after the operation, before removing the drain, 40 mg of methylprednisolone sodium succinate was injected through the drain into the subdural space, after which the drain was pulled entirely. Patients were evaluated with the Markwalder Grading Scale (MGS) on the third day, third month, and sixth month after surgery for improved or worsened neurological symptoms. Also, in the third and sixth months after surgery, the patients underwent Computerized Tomography Scan imaging and were checked for recurrence.

Results

32 patients with CSDH entered the study, including 28 men and four women, with a mean age of 71.62 ± 9.85 years. Moreover, 87.5 % had a unilateral chronic subdural hematoma (uCSDH), and 12.5 % had a bilateral chronic subdural hematoma (bCSDH). Left and right uCSDHs had the same frequency (43. 8 %). After surgery, 26 patients had no postoperative complications, and six patients experienced pneumocephalus.

Conclusion

Topical dexamethasone injection through the potential CSDH cavity can result in desirable outcomes.

Objective

To assess the influence of clinical and imaging characteristics on the outcome of microsurgery treatment for cerebellopontine angle (CPA) epidermoid cyst (EC) presenting only with trigeminal neuralgia (TN).

Methods

A retrospective observational study describing 42 cases of CPA epidermoid cyst presenting only with TN n CPA for 10 years from 2011 to 2021 with the mean follow-up period was 37 months (range, 6–60 months). This study is the largest research with a long follow-up period reported so far worldwide for ECs with only TN symptom. We analyzed the clinical-radiological records of all the patients who met the rigorous requirements to find the distinct features of these tumors.

Results

The mean age was 40.1 ± 4.7 years. The time from symptom onset to surgery was 8.6 ± 3.9 months. Symptoms of multiple branches of the 5th nerve appeared in 71.4 %, the most common was V2V3 accounting for 42.9 %. Most of the tumors were located limited in the CPA, accounting for 66.7 %. Total resection reached 90.5 %. The effectiveness of pain relief of microsurgery reached 97.6 %, Barrow Neurological Institute (BNI) score I reached 73.8 % and pain relief was 23.8 %. The postoperative neurologic deficit was 14.3 %.

Conclusion

CPA epidermoid cysts presenting with TN as the sole symptom have favorable characteristics for total removing the tumor compared with other tumors in the remaining group. Total removing the tumor with the support of continuous intraoperative electromyography monitoring and decompressing the 5th nerve was ideal; it will not only increase the symptom improvement but also have a low rate of postoperative complications.

Neck or craniovertebral penetrating injury by in situ teta, used for fishing, is an extremely rare neurosurgical emergency. In this article, we present the management of such a case in Dhaka Medical College Hospital. This case report will emphasize the presentation, investigations, surgical, and other supportive management.

Background

Management of vertebral artery dissection (VAD), which is difficult to diagnose definitively on imaging, is a clinical concern. The aim of this study was to clarify the clinical characteristics of VAD without definitive imaging features and evaluate our clinical decisions and their consequences.

Methods

We searched our database to identify patients with VAD registered between January 2008 and December 2021. We performed a retrospective chart review to obtain detailed clinical information and compared the clinical characteristics and radiological findings between patients with definitive VAD and those with non-definitive VAD by radiological findings at the initial evaluation.

Results

Of 188 patients (mean age 52.7 ± 12.3 years, 121 male), 127 had definitive VAD. Patients in the definitive group had a younger average age and a high rate of intramural hematoma, while those in the non-definitive group were more likely to have a history of hypertension. Overall, the prognosis was good for the majority (n = 163), and there was no significant difference in the prognosis between two groups. Especially, the prognosis of non-definitive VAD patients without stroke was favorable.

Conclusions

Cases of non-definitive VAD are likely to be complicated by atherosclerotic changes. Therefore, clinicians should carefully evaluate the potential etiologies based on the clinical history and imaging data to provide patients with the optimal treatment options. Identification of IMH was an important factor to make a definitive diagnosis, and the vessel wall imaging is a useful imaging modality for the purpose.

The objective of the research is to simulate different forms of three-level hybrid surgeries, aiming to establish a foundational reference for the selection of suitable treatment strategies for multilevel noncontiguous cervical degenerative disease (CDD). For the development of precise finite element models (FEMs), this study utilized computed tomography (CT) data. Two cross-segment surgical approaches were primarily investigated: C3/4 cervical disc arthroplasty (CDA), C5/6 anterior cervical discectomy and fusion (ACDF), and C6/7 ACDF in the type Id model; C3/4 CDA, C5/6 CDA, and C6/7 ACDF in the type IId model. The follower load technique was employed to apply an initial axial load of 73.6 N at the motion center. Subsequently, a moment of 1.0 Nm was introduced at the center of the C2 vertebra to simulate the overall motion of the model. In contrast to type IId, type Id exhibited lower average intervertebral disc pressure in C4/5 across various motions. The average intervertebral disc pressure in C2/3 was higher in type Id compared to type IId in flexion and axial rotation, whereas the reverse was observed in lateral bending. Type IId exhibited notably lower facet joint contact stresses during extension in C2/3 and C4/5 when compared to type Id. Type Id has a better protective effect on IS, and can significantly reduce the average pressure of the intervertebral disc in IS compared with type IId. Type IId has a significant protective effect on the post-column structure of non-fused segments.

A 40-year-old male presented with progressive paresthesia and weakness of the lower limbs and sphincter dysfunction. He had a history of low back pain and disk herniation from five years ago. Magnetic resonance imaging (MRI) revealed a very large mass-like lesion at L5-S1 segments, and computed tomography (CT) showed destruction of L5 lamina. While the main diagnosis was a large extruded disc, the possibility of extradural masses such as chordoma was also considered. The patient was immediately started on corticosteroid therapy and underwent laminectomy and discectomy surgery to remove the large free fragment compressing the neural elements. The patient reported feeling improvement in his feet and perineum one day after surgery, but follow-up examinations one and three months after surgery described incomplete recovery in sphincter function. This case highlights the importance of considering other possible diagnoses based on physical examination and imaging findings, even when the initial diagnosis seems clear, and emphasizes the need for timely intervention in cases of spinal cord compression to prevent permanent damage to the neural elements.

Background

During the preoperative evaluation of a patient being considered for spinal surgery, Dual-energy x-ray absorptiometry (DEXA) has been traditionally used to diagnose poor bone mineral density (BMD) as a risk factor. As ordering a DEXA can add cost and delay diagnosis, spine surgeons have more recently began to use Hounsfield Units (HU) measured on computed tomography scans (CT) as a measure of BMD. The aim of our study was to evaluate associations between DEXA and HU on lumbar spine CT scans.

Methods

Forty-two patients (32 female, 10 male, mean age = 67.7 years) with DEXA and lumbar spine CT scans performed within one year of each other were identified. DEXA T-scores were collected from the hip, forearm and L1-L4. HU was determined using the maximum region of interest within the cancellous area in the mid-vertebral body from L1-L4 in the sagittal and axial planes.

Results

Using the lowest T-score, 8 (19 %) cases were osteoporotic and 25 (60 %) were osteopenic. Statistically significant differences in HU were seen in osteoporotic cases (Axial HU = 59.2, Sagittal HU = 61.1, p = 0.006) compared to osteopenic (Axial HU = 119.8, Sagittal HU = 122.9) and normal cases (Axial HU = 141.2, Sagittal HU = 142.3). There were moderate associations between the spine T-scores and CT HUs (Axial HU:r² = 0.50, Sagittal HU:r² = 0.49, p < 0.001), weak associations between the Axial HU (r² = 0.48, p < 0.000) and Sagittal HU (r² = 0.48, p < 0.000) with hip T-scores, and no correlations with forearm T-scores. There were strong associations between Axial HU and Sagittal HU (r² = 0.98, p < 0.001).

Clinical relevance

The results of the current study show a strong association between the sagittal and axial vertebral HU measurements, which supports the clinical use of either measurement technique. The weak correlation between T-scores and HU is consistent with prior studies and warrants future studies to determine which modality will better predict postoperative mechanical failures in patients undergoing spinal surgery.

Level of Evidence

III.

Background and purpose

Minimally invasive surgery for ICH has shown a significantly improved functional outcome for selected ICH patients. This study aimed to evaluate the factors influencing the outcome of supratentorial ICH patients treated with stereotactic computed tomographic (CT) guided recombinant tissue plasminogen activator (rt-PA).

Methods

We retrospectively evaluated data from 80 consecutive supratentorial ICH patients between December 2017 and July 2020, analyzing their 180-day outcomes, and identifying clinical, radiological factors for good prognosis within 180 days.

Results

The mean age was 55.6 years (SD 11.4). The median preoperative Glasgow Coma Scale (GCS) score was 9 (interquartile range - IQR 6–12). The mean final ICH volume was 26.5 ml (SD 27.5), with ICH volume reduction by an average of 66.7 %. Six months after the procedure, 40 patients (50 %) had favorable outcomes (modified Rankin Scale [mRS]) score 0–3). In multivariate analysis, age (odds ratio [OR] = 0.939, 95 % confidence interval (CI) = 0.894 – 0.986; p = 0.012), the GCS score before operation (OR = 1.525, 95 % CI = 1.008 – 2.309; p = 0.046), the initial midline shift (OR = 0.808, 95 % CI = 0.661 – 0.988; p = 0.038), and the residual volume hematoma (OR = 0.949, 95 % CI = 0.908 – 0.992, p = 0.020) were the significant predictors of a favorable 180-day outcome. Receiver operating characteristic curve analysis confirmed that the best cut-off point for predicting the good functional 180-day outcome was a GCS score of 9 before the procedure [area under the curve: 0.721, 95 % CI = 0.608 – 0.833, p = 0.001].

Conclusion

CT-guided thrombolysis and aspiration can be safe and effective in reducing ICH volume. A preoperation GCS score above or equal to 9 and younger age were associated with improved long-term outcomes in patients with supratentorial ICH.