Interdisciplinary Neurosurgery: Advanced Techniques and Case Management最新文献

Introduction

 The preparation of the pedicle and the insertion of a transpedicular screw is a high-risk procedure during spine surgeries. To avoid pedicle screw misplacement in posterior spinal deformity surgery, patient specific 3D‐printed guides can be used but technical issues reported in 17% of screw fixations. To address this concern, our team has developed single-level guide templates and a locking screw mechanism. We share our experience using a surgical planning and support system with 3D printed patient-specific guides that utilize a locking screw, highlighting the advantages of incorporating it into complex spine surgeries.

Materials and Methods

The surgical planning and support system is composed of six phases: (1) spine digitization, (2) segmental analysis and vertebral characterization, (3) planning of angulation, depth, and diameter of transpedicular screws, (4) 3D printing of the spine model, and the locking single level drill guides, (5) selection of surgical instruments, and (6) surgery.

Illustrative cases

High resolution tomographic images of two 15-year-old females and one 16-year-old male were processed through software analysis for segmental analysis and vertebral characterization. This process aimed to propose the most suitable plan in a multidisciplinary meeting. Sterilized 3D-printed patient-specific locking spine drill guide models were utilized for the spinal instrumentation.

Conclusions

 Multiple countries are now developing 3D printed drill guides for screw fixation in severe scoliosis. Our guide represents the first one using a transitory locking mechanism to improve accuracy of fixation. The 3D printed locking drill guides enabled accurate insertion and direction of the transpedicular screw, resulting in improvements in sagittal and coronal balance, and all screws classified as accurately placed and with minimal difference with the planned trajectory. Additional outcomes such as surgical time, intraoperative bleeding, radiation exposure, hospital stay, and postoperative complications should also be considered for further studies in this area.

A 68-year-old man suffered from slowly progressive proximal upper extremity weakness for 17 years. Examination revealed bilateral C5–C6 muscle weakness. Upon spinal magnetic resonance imaging (MRI), the T2-weighted images showed high-intensity signals in the anterior horns at the C3–C5 spinal levels, with ventral epidural fluid collection at the C6–T6 spinal levels. Brain MRI also revealed hemosiderin deposition in the cerebellum. The patient was ultimately diagnosed with brachial multisegmental amyotrophy caused by spontaneous spinal cerebrospinal fluid leak with superficial siderosis. During surgery, a dural defect was identified at the T2–T3 spinal level, which was subsequently repaired. At the 60-month follow-up, no signs of disease progression were noted. This disease could potentially be treated through surgery and should be included in the differential diagnosis of slowly progressive segmental amyotrophy.

Malignant deep brain stimulation (DBS) withdrawal syndrome constitutes a rare neurological emergency among advanced Parkinson's disease (PD) patients treated with the subthalamic nucleus (STN) Deep Brain Stimulation. Its clinical course mimics Neuroleptic Malignant Syndrome and when left untreated might lead to death.

We present a case of a 61 year old woman treated with STN DBS because of PD, who underwent under local anesthesia implantable pulse generator (IPG) replacement. The IPG stopped functioning several days before the replacement. Due to increased motor symptoms the patient was unable to intake medications several days prior to surgical intervention. Within immediate post-operative period she developed malignant DBS withdrawal syndrome. The successful treatment consisted of supportive care, dopaminergic medication and immediate restoration of the IPG.

Background

The rapid advancement of the digital revolution, normalization of portable smart gadgets, and internet-based communication have resulted in a perceptible shift and enhancement in human spine posture. They have also resulted however, in the emergence of health issues connected to the technique of usage. Neck pain, as well as other related symptoms, are the most commonly reported, as evidenced by the Coronavirus pandemic. People were urged to work from home when educational institutions and businesses were shut down. Students were given access to online learning facilities.

Aim

The aim of this study is to demonstrate and clarify the increase in the number of young patients who suffer from neck pain and its associated symptoms; especially during the COVID 19 pandemic. The objective of this study is to investigate the impact of the excessive use of smart portable devices on neck pain and associated symptoms. This is most likely related to the incorrect posture of the neck, spine and body during utilization of these technologies. In addition, it aims to educate people about possible methods to prevent these medical morbidities.

Methods

A cross-sectional study was conducted at Mediclinic City Hospital, Dubai Healthcare City, United Arab Emirates. Fifty-six patients were seen and evaluated as outpatients in the Neurosurgery clinic for neck pain. The Numerical Rating Pain Scale questionnaire (NMQ) was utilized to evaluate neck pain and other associated complaints such as back and musculoskeletal pain in general. The data was collected using a questionnaire with a 100% response rate from the patients. Cross tabulation and Chi Square analysis tool were designed to meet the study’s objective.

Results

The findings show that smart phone and laptop use have significant effects on pain severity ranking among patients. For the factors “Time spent using smart phone/day” and Time spent using Laptop/day” were found to have a P value of 0.041 and 0.023; respectively.

Conclusion

This research found a link between length of time spent using a mobile phone or laptop and the degree of neck discomfort.

Dural ossification (DO) is a degenerative phenomenon of endorhachis characterized by the displacement of dura by proliferative osseous tissue, which is a common complication of spinal ligament ossifications. Precisely preoperative diagnosis and elaborate surgical manipulation are the focus of clinicians since incorrect management of DO during surgery could induce cerebrospinal fluid leakage (CSF) and spinal cord injury (SCI). However, there has been no case of postoperative DO which was reported in ankylosing spondylitis (AS). Herein, we reported a 49-year-old AS patient who presented delayed incomplete paraplegia due to the development of extensive thoracolumbar DO after L3 pedicle subtraction osteotomy (PSO), aiming to help spinal surgeons to have a more comprehensive understanding of the possible pathogenic mechanism, diagnosis, surgical and prognostic implications of DO in AS patients.

Background

Cerebral cavernous malformations (CMs) are benign lesions of thin, hyalinized blood vessels without brain parenchyma. These lesions can result in various neurologic symptoms resulting from mass effect or focal neuropathies. A rare proportion of CMs have grown along the trigeminal nerve, causing trigeminal neuralgia as the principal presenting symptoms.

Observations

We report a recurrent case of a 63 year old female with a CM growing near the Obersteiner-Redlich zone of her right trigeminal nerve resulting in symptoms consistent with trigeminal neuralgia. This lesion was initially thought to be a neoplasm and was incompletely resected during the initial surgery with a plan to follow on final pathology. Interval growth of the lesion was appreciated over a period of 3 months, resulting in recurrence of her symptoms, making this case the first publication of recurrent trigeminal neuralgia secondary to cavernous malformation. A right retrosigmoid craniotomy was successfully performed for gross total resection of the lesion.

Lessons

This case highlights the importance of including CMs on the differential for trigeminal Obersteiner-Redlich zone lesions and emphasizes the necessity of gross total resection to prevent recurrence. It is the first published case report to include intraoperative video of the resection.

Objectives

To evaluate the evidence for Endoscopic Third Ventriculostomy vs. Ventriculoperitoneal Shunt in congenital hydrocephalus with Aqueductal Stenosis (AS). Materials and Methods: A PRISMA-based study selection is used to screen for studies, including (1) AS report cases and (2) the intervention undertaken, which can either be ETV or VPS. Furthermore, an extended criteria for quantitative analysis is added to include the following: (3) Comparing the failure rate between ETV vs VPS; (4) Infants aged < 24 months; and (5) Reporting the number of failed cases. A review of all the included studies was then summarized. Outcome Measure: ETV and VPS failure rates, specifically in infants younger than 24 months with aqueductal stenosis (AS). Results: Literatur search identified 628 studies from Pubmed, Directory of Open Access Journal (DOAJ), and manual search. Screening of the study resulted in 576 being excluded. Forty studies were screened for full article eligibility screening, resulting in 11 studies included in the systematic review and 3 in the meta-analysis. Meta-analysis indicated more failure in infant patients with AS < 24 months old who received ETV (OR 1.74, 95 % CI 0.85 – 3.58). Conclusion: This systematic review shows that ETV has a good and stable status, but in the age of infants, it indicates that ETV has a higher risk of failure than shunt despite the patient's external quality of life and long-term health status is no different between the two. Both primary and secondary ETV also do not show a significant difference in the degree of complications. As well as the technique of doing ETV is also increasingly expanding in efforts to increase the success of ETV itself. Our meta-analysis indicates a higher failure rate in ETV for infants less than two years of age with AS compared to VPS.

Background

TBI is a major global health issue due to its high morbidity and mortality rates. Persistent neurodegeneration following secondary brain injuries is a significant concern. Trehalose, a naturally occurring disaccharide, has shown potential therapeutic effects in preclinical TBI models. This study systematically reviews the preclinical and clinical data on trehalose as a potential TBI treatment.

Methods

We conducted a systematic review of trehalose’s role in TBI treatment following PRISMA guidelines. Our search spanned from the inception of PubMed, EMBASE, SCOPUS, and Web of Science until August 2023. Google Scholar was also manually searched. The quality of the studies was assessed using SYRCLE’s risk of bias tool for animal studies.

Results

Out of sixty-six records reviewed, four animal studies were included. These studies indicated that trehalose enhanced motor and cognitive functions, reduced oxidative damage and inflammation, regulated metal dyshomeostasis, increased neurotrophic factors and synaptic proteins, and improved autophagy and mitochondrial function in mouse/rat TBI models. However, a significant risk of bias was noted.

Conclusion

Trehalose demonstrates potential as a TBI treatment. However, more rigorous, and comprehensive research is needed to confirm its safety and efficacy in humans.

Iatrogenic distal posterior inferior cerebellar artery (PICA) aneurysms are rare, and parent artery occlusion (PAO) via Marathon microcatheters can be an option for coiling. We reported such a case. A 60-year-old woman with an epidermoid cyst of the posterior fossa suffered subarachnoid hemorrhage after open surgery for the removal of an epidermoid cyst and fell into a coma. Digital subtraction angiography confirmed a distal PICA iatrogenic dissecting aneurysm. Due to the PICA being tortuous, routine microcatheters that deliver coils cannot access the aneurysm. However, a Marathon microcatheter over a Synchro 10 guidewire was able to successfully access the aneurysm. An Axium Prime coil was advanced easily into a Marathon microcatheter. After the coil was detached in the Marathon microcatheter, the Synchro 10 guidewire was able to push the detached coil through the Marathon microcatheter tip into the dissecting aneurysm, and then another coil was deployed to complete PAO. Postoperatively, due to acute hydrocephalus, an Ommaya catheter with a reservoir was deployed into the lateral ventricle to aspirate cerebrospinal fluid. One week postoperatively, a computed tomography scan showed acute infarction of the cerebellar hemisphere with no mass effect. During follow-up, no rebleeding occurred. Six months later, the patient did not wake up and was declared to be in a vegetative state. By reporting this case, it was found that for iatrogenic distal PICA aneurysms, PAO is feasible with an Axium Prime coil deployed via a Marathon microcatheter.

Vestibular schwannomas (VS) are slow-growing benign tumors commonly found in the cerebellopontine angle, potentially compressing brain structures and cranial nerves, including the abducens nerve (AN), responsible for lateral gaze. Although large VSs may compress the AN, postsurgical AN palsy is rare, and the clinical significance of AN variations, particularly in VS cases, remains unclear. We report a unique case of a 29-year-old female with a large left vestibular schwannoma. The patient underwent a left-sided microsurgical two-stage excision with an uneventful recovery (House-Brackmann facial grade I). During surgery, a rare variant of the AN was identified. This AN originated as two separate trunks and merged 3 mm distal to its origin in the same segment. To the best of our knowledge, arising and merging in the cisternal segment of AN variation has not been reported previously. Recognizing AN variations is vital for successful skull base surgeries, especially in preserving both branches during vestibular schwannoma surgery and ensuring ocular function.