Pub Date : 2025-09-01Epub Date: 2025-07-16DOI: 10.1016/j.neuchi.2025.101702
J. Bride , R. Assaker , B. Ghannam , P. Haettel , B. Bouyer , H.A. Leroy
The occurrence of a vertebral fracture in a pregnant woman presents unique challenges in terms of diagnosis and therapeutic. Managing such cases requires multidisciplinary collaboration to minimize x-rays and preserve fetus development while ensuring efficient treatment of the fracture in the mother.
We report the case of an 18 y/o primiparous woman at 20 weeks of gestation who suffered a polytrauma without neurological deficit. Full body CT-scan reported an A2 M1 (AO Spine Classification) fracture of L3 and an A1 fracture of L2.
In this situation, both patient positioning and irradiation were challenging. The surgeons, anesthesiologists and physicists discussed the pros and cons between conservative treatment and various types of surgery (open technique, percutaneous). A left lateral decubitus robot-assisted percutaneous L2-L4 osteosynthesis was performed. We depict the procedure as well as the patient outcome and follow-up.
{"title":"Robot-assisted MIS surgery in a pregnant woman with lumbar traumatic fracture: A technical note","authors":"J. Bride , R. Assaker , B. Ghannam , P. Haettel , B. Bouyer , H.A. Leroy","doi":"10.1016/j.neuchi.2025.101702","DOIUrl":"10.1016/j.neuchi.2025.101702","url":null,"abstract":"<div><div>The occurrence of a vertebral fracture in a pregnant woman presents unique challenges in terms of diagnosis and therapeutic. Managing such cases requires multidisciplinary collaboration to minimize x-rays and preserve fetus development while ensuring efficient treatment of the fracture in the mother.</div><div>We report the case of an 18 y/o primiparous woman at 20 weeks of gestation who suffered a polytrauma without neurological deficit. Full body CT-scan reported an A2 M1 <em>(AO Spine Classification)</em> fracture of L3 and an A1 fracture of L2.</div><div>In this situation, both patient positioning and irradiation were challenging. The surgeons, anesthesiologists and physicists discussed the pros and cons between conservative treatment and various types of surgery (open technique, percutaneous). A left lateral decubitus robot-assisted percutaneous L2-L4 osteosynthesis was performed. We depict the procedure as well as the patient outcome and follow-up.</div></div>","PeriodicalId":51141,"journal":{"name":"Neurochirurgie","volume":"71 5","pages":"Article 101702"},"PeriodicalIF":1.5,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144656873","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-07-01Epub Date: 2025-04-05DOI: 10.1016/j.neuchi.2025.101666
François Zhu , Tim E. Darsaut , Jean Raymond
Background
Prognostic studies may inform individuals about the future course of their disease and help clinical decision making, but problems abound.
Methods
We summarize a study on the natural history of unruptured intracranial aneurysms (UIAs) and review the various steps in the construction of prognostic models. We emphasize the fundamental inductive problems of prognostic studies that attempt to use the backward road from the extension of patients suffering an event to create a new intensional definition of classes of patients at risk.
Results
The first step in a prognostic model is to identify candidate baseline variables to be entered into the model, according to background knowledge, previous studies, and statistical associations with the event of interest. This is a multivariate task. The modeler already knows the outcomes the model is supposed to ‘predict’, so that multiple models are tested against the data until a satisfactory fit is obtained. The variables used to construct the model should not be added in an ad hoc fashion to fit heterogeneous studies. They should be selected in such a fashion as to be exportable outside the study to new patients. An infinite number of models can fit the same data. Thus, the most important step is to validate the prognostic value of the model in patients that were not used to construct the model. In the case of UIAs, this has never been done.
Conclusion
Prognostic studies present multiple problems. Unvalidated models should not be used in clinical practice.
{"title":"Understanding prognostic models: The example of the PHASES score for unruptured intracranial aneurysms","authors":"François Zhu , Tim E. Darsaut , Jean Raymond","doi":"10.1016/j.neuchi.2025.101666","DOIUrl":"10.1016/j.neuchi.2025.101666","url":null,"abstract":"<div><h3>Background</h3><div>Prognostic studies may inform individuals about the future course of their disease and help clinical decision making, but problems abound.</div></div><div><h3>Methods</h3><div>We summarize a study on the natural history of unruptured intracranial aneurysms (UIAs) and review the various steps in the construction of prognostic models. We emphasize the fundamental inductive problems of prognostic studies that attempt to use the backward road from the extension of patients suffering an event to create a new intensional definition of classes of patients at risk.</div></div><div><h3>Results</h3><div>The first step in a prognostic model is to identify candidate baseline variables to be entered into the model, according to background knowledge, previous studies, and statistical associations with the event of interest. This is a multivariate task. The modeler already knows the outcomes the model is supposed to ‘predict’, so that multiple models are tested against the data until a satisfactory fit is obtained. The variables used to construct the model should not be added in an <em>ad hoc</em> fashion to fit heterogeneous studies. They should be selected in such a fashion as to be exportable outside the study to new patients. An infinite number of models can fit the same data. Thus, the most important step is to validate the prognostic value of the model in patients that were not used to construct the model. In the case of UIAs, this has never been done.</div></div><div><h3>Conclusion</h3><div>Prognostic studies present multiple problems. Unvalidated models should not be used in clinical practice.</div></div>","PeriodicalId":51141,"journal":{"name":"Neurochirurgie","volume":"71 4","pages":"Article 101666"},"PeriodicalIF":1.5,"publicationDate":"2025-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143776447","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-07-01Epub Date: 2025-05-19DOI: 10.1016/j.neuchi.2025.101684
Jean Raymond , George Nilton Nunes Mendes , Tim E. Darsaut
Background
The research-care separation encourages clinicians to experiment without methods within the care context and trialists to design studies that may not properly inform practice. Care trials integrated into practice may solve these problems.
Methods
We first discuss clinical decision-making for SAH patients prior to the ISAT trial which compared surgery with coiling, and how the ISAT results changed practices. We then review the ISAT-2 care trial and its impact on practice in the presence of clinical uncertainty.
Results
Historically, ruptured aneurysms were treated with surgical clipping, with endovascular treatment limited to patients judged difficult to clip. ISAT was a turning point when it showed that many patients routinely treated with surgery would have better outcomes with coiling. With the proliferation of new endovascular devices, practices evolved and more patients could be treated endovascularly, but uncertainty regarding best management remained for numerous ruptured aneurysm patients that were not part of ISAT. Practicing under uncertainty, outside of a trial, is like performing research without methods within care. Without a scientific method of assessment, the notion of good surgical care is impossible to define, so ISAT-2 was designed. After 10 years, ISAT-2 remained inconclusive, but because the trial balanced risks for each patient, practicing within ISAT-2 provided the opportunity to realize that trial methods optimized care in real-time, long before conclusive results could be shown.
Conclusion
Care trials are integral to a good clinical practice, whether they provide final results or not. The research-care separation should be revised to encourage care research.
{"title":"Understanding the meaning of care trials and why they are essential to good practice: An example from ISAT-2 on ruptured aneurysms","authors":"Jean Raymond , George Nilton Nunes Mendes , Tim E. Darsaut","doi":"10.1016/j.neuchi.2025.101684","DOIUrl":"10.1016/j.neuchi.2025.101684","url":null,"abstract":"<div><h3>Background</h3><div>The research-care separation encourages clinicians to experiment without methods within the care context and trialists to design studies that may not properly inform practice. Care trials integrated into practice may solve these problems.</div></div><div><h3>Methods</h3><div>We first discuss clinical decision-making for SAH patients prior to the ISAT trial which compared surgery with coiling, and how the ISAT results changed practices. We then review the ISAT-2 care trial and its impact on practice in the presence of clinical uncertainty.</div></div><div><h3>Results</h3><div>Historically, ruptured aneurysms were treated with surgical clipping, with endovascular treatment limited to patients judged difficult to clip. ISAT was a turning point when it showed that many patients routinely treated with surgery would have better outcomes with coiling. With the proliferation of new endovascular devices, practices evolved and more patients could be treated endovascularly, but uncertainty regarding best management remained for numerous ruptured aneurysm patients that were not part of ISAT. Practicing under uncertainty, outside of a trial, is like performing research without methods within care. Without a scientific method of assessment, the notion of good surgical care is impossible to define, so ISAT-2 was designed. After 10 years, ISAT-2 remained inconclusive, but because the trial balanced risks for each patient, practicing within ISAT-2 provided the opportunity to realize that trial methods optimized care in real-time, long before conclusive results could be shown.</div></div><div><h3>Conclusion</h3><div>Care trials are integral to a good clinical practice, whether they provide final results or not. The research-care separation should be revised to encourage care research.</div></div>","PeriodicalId":51141,"journal":{"name":"Neurochirurgie","volume":"71 4","pages":"Article 101684"},"PeriodicalIF":1.5,"publicationDate":"2025-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144090367","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-07-01Epub Date: 2025-05-10DOI: 10.1016/j.neuchi.2025.101677
Paweł Łajczak , Anna Łajczak , Stanisław Buczkowski, Kamil Jóźwik, Przemysław Nowakowski
Background
Hydrocephalus is an abnormal buildup of cerebrospinal fluid (CSF) deep within the brain, resulting in clinical symptoms, including disorientation, vision disturbances, headaches, cognitive and developmental impairment. Traditional non-navigated surgical treatment, with ventriculoperitoneal (VP) shunt and endoscopic third ventriculostomy (ETV), may lead to complications such as shunt obstruction and inaccurate catheter placement. Robotics-assisted (RA) surgery has potential to improve precision of procedures. The objective of this systematic review is to assess the clinical effectiveness, complications, and benefits of RA surgical interventions in the case of hydrocephalus.
Methods
PRISMA-guided literature search was done in databases including PubMed, Web of Science, Cochrane Reviews, Scopus, and Embase. Inclusion criteria encompassed English language, original, peer-reviewed journal articles in robotic-assisted surgical interventions in hydrocephalus. Patient demographics, robotic systems used, and results were extracted.
Results
In total, 12 of the articles discussed robotic-assisted interventions for hydrocephalus. The robotic systems used included ROSA, NaoTrac, Remebot, and more. The findings established that the robotic systems are accurate. Almost all the studies showed successful outcomes with minimum robot-related complications like minor bleeding or conversion to manual surgery.
Conclusions
The evidence supporting the use of robot-assisted surgery for hydrocephalus management remains very limited in the literature. There is currently insufficient evidence to suggest that it offers any significant additional benefits in terms of patient outcomes, safety, or cost-effectiveness compared to conventional neurosurgical methods. Moreover, given the high maintenance costs of robotic workstations and prolonged surgery times, well-designed prospective controlled trials are needed to evaluate robotic effectiveness, compared to navigation-based techniques.
脑积水是脑深部脑脊液（CSF）的异常积聚，可导致临床症状，包括定向障碍、视力障碍、头痛、认知和发育障碍。传统的非导航手术治疗，如脑室-腹膜（VP）分流和内镜下第三脑室造口术（ETV），可能导致分流阻塞和导管放置不准确等并发症。机器人辅助手术（RA）具有提高手术精度的潜力。本系统综述的目的是评估脑积水病例中RA手术干预的临床效果、并发症和益处。方法在PubMed、Web of Science、Cochrane Reviews、Scopus、Embase等数据库中进行sprima引导下的文献检索。纳入标准包括机器人辅助脑积水手术干预的英文、原创、同行评议的期刊文章。提取患者人口统计数据、使用的机器人系统和结果。结果总共有12篇文章讨论了机器人辅助脑积水干预。使用的机器人系统包括ROSA、NaoTrac、Remebot等。研究结果表明，机器人系统是精确的。几乎所有的研究都显示出成功的结果，与机器人相关的并发症（如小出血或转向手工手术）最少。结论：文献中支持使用机器人辅助手术治疗脑积水的证据仍然非常有限。目前还没有足够的证据表明，与传统的神经外科方法相比，它在患者预后、安全性或成本效益方面提供了任何显著的额外好处。此外，考虑到机器人工作站的高维护成本和延长的手术时间，与基于导航的技术相比，需要精心设计的前瞻性对照试验来评估机器人的有效性。
{"title":"Robotic hydrocephalus surgery: A systematic review of the effectiveness in neurosurgical interventions","authors":"Paweł Łajczak , Anna Łajczak , Stanisław Buczkowski, Kamil Jóźwik, Przemysław Nowakowski","doi":"10.1016/j.neuchi.2025.101677","DOIUrl":"10.1016/j.neuchi.2025.101677","url":null,"abstract":"<div><h3>Background</h3><div>Hydrocephalus is an abnormal buildup of cerebrospinal fluid (CSF) deep within the brain, resulting in clinical symptoms, including disorientation, vision disturbances, headaches, cognitive and developmental impairment. Traditional non-navigated surgical treatment, with ventriculoperitoneal (VP) shunt and endoscopic third ventriculostomy (ETV), may lead to complications such as shunt obstruction and inaccurate catheter placement. Robotics-assisted (RA) surgery has potential to improve precision of procedures. The objective of this systematic review is to assess the clinical effectiveness, complications, and benefits of RA surgical interventions in the case of hydrocephalus.</div></div><div><h3>Methods</h3><div>PRISMA-guided literature search was done in databases including PubMed, Web of Science, Cochrane Reviews, Scopus, and Embase. Inclusion criteria encompassed English language, original, peer-reviewed journal articles in robotic-assisted surgical interventions in hydrocephalus. Patient demographics, robotic systems used, and results were extracted.</div></div><div><h3>Results</h3><div>In total, 12 of the articles discussed robotic-assisted interventions for hydrocephalus. The robotic systems used included ROSA, NaoTrac, Remebot, and more. The findings established that the robotic systems are accurate. Almost all the studies showed successful outcomes with minimum robot-related complications like minor bleeding or conversion to manual surgery.</div></div><div><h3>Conclusions</h3><div>The evidence supporting the use of robot-assisted surgery for hydrocephalus management remains very limited in the literature. There is currently insufficient evidence to suggest that it offers any significant additional benefits in terms of patient outcomes, safety, or cost-effectiveness compared to conventional neurosurgical methods. Moreover, given the high maintenance costs of robotic workstations and prolonged surgery times, well-designed prospective controlled trials are needed to evaluate robotic effectiveness, compared to navigation-based techniques.</div></div>","PeriodicalId":51141,"journal":{"name":"Neurochirurgie","volume":"71 4","pages":"Article 101677"},"PeriodicalIF":1.5,"publicationDate":"2025-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143941149","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-07-01Epub Date: 2025-06-04DOI: 10.1016/j.neuchi.2025.101692
Baker Abojarad , Belal Aldabbour
Background
The Gaza Strip is a low-income, chronically unstable region. This study evaluates the outcomes of first VP shunt placements at the area’s largest tertiary hospital.
Methods
A retrospective study conducted at Shifa Medical Complex in the Gaza Strip examined VP shunts inserted between January 2020 and July 2022. The primary outcome was the shunt failure rates in the first year, while secondary outcomes included the causes of failure and surgical complications. The Chi-square test was used to assess the relationship between risk factors and failure rates. Univariate logistic regression analyzed the link between the duration of post-operative antibiotics and shunt failure rates.
Results
A total of 103 patients were included, with a median age of 11 months. Congenital hydrocephalus accounted for 60.2% of the etiologies. Failure rates were 7.8%, 19.4%, and 26.2% at one, six, and twelve months, respectively. Obstruction and infection were the commonest causes of initial (62.9% and 25.9%) and overall (46.2% and 36.5%) shunt failures. Failure risk increased with elective surgeries, surgeries performed by residents, congenital hydrocephalus, and in the 12-month or younger age group (p < 0.001, p = 0.035, p = 0.02, p < 0.001). Staphylococcus aureus and Staphylococcus epidermidis were the most commonly isolated bacteria. No significant association was found between the duration of postoperative IV antibiotics and the one-year shunt failure rate.
Conclusion
The outcomes of VP shunt surgery at Gaza’s largest tertiary center from 2020 to 2022 aligned with global trends. Prolonged IV antibiotics did not lower revision or complication rates.
加沙地带是一个低收入、长期不稳定的地区。本研究评估了该地区最大的三级医院首次VP分流安置的结果。方法在加沙地带Shifa医疗中心进行的一项回顾性研究检查了2020年1月至2022年7月期间插入的副静脉分流器。主要结果是第一年的分流失败率，而次要结果包括失败的原因和手术并发症。采用卡方检验评估危险因素与失败率之间的关系。单变量logistic回归分析了术后抗生素使用时间与分流管失败率之间的关系。结果共纳入103例患者，中位年龄11个月。先天性脑积水占病因的60.2%。1个月、6个月和12个月的失败率分别为7.8%、19.4%和26.2%。梗阻和感染是最初（62.9%和25.9%）和总体（46.2%和36.5%）分流失败最常见的原因。选择性手术、住院医师手术、先天性脑积水以及12个月及以下年龄组的手术失败风险增加(p <；0.001, p = 0.035, p = 0.02, p <；0.001)。金黄色葡萄球菌和表皮葡萄球菌是最常见的分离细菌。术后静脉抗生素使用时间与1年分流失败率无显著相关性。结论2020年至2022年在加沙最大的三级中心进行副静脉分流手术的结果与全球趋势一致。延长静脉注射抗生素并没有降低翻修率或并发症发生率。
{"title":"Surgical outcomes of ventriculoperitoneal shunts in the Gaza Strip: Insights from a conflict zone and low-resource setting","authors":"Baker Abojarad , Belal Aldabbour","doi":"10.1016/j.neuchi.2025.101692","DOIUrl":"10.1016/j.neuchi.2025.101692","url":null,"abstract":"<div><h3>Background</h3><div>The Gaza Strip is a low-income, chronically unstable region. This study evaluates the outcomes of first VP shunt placements at the area’s largest tertiary hospital.</div></div><div><h3>Methods</h3><div>A retrospective study conducted at Shifa Medical Complex in the Gaza Strip examined VP shunts inserted between January 2020 and July 2022. The primary outcome was the shunt failure rates in the first year, while secondary outcomes included the causes of failure and surgical complications. The Chi-square test was used to assess the relationship between risk factors and failure rates. Univariate logistic regression analyzed the link between the duration of post-operative antibiotics and shunt failure rates.</div></div><div><h3>Results</h3><div>A total of 103 patients were included, with a median age of 11 months. Congenital hydrocephalus accounted for 60.2% of the etiologies. Failure rates were 7.8%, 19.4%, and 26.2% at one, six, and twelve months, respectively. Obstruction and infection were the commonest causes of initial (62.9% and 25.9%) and overall (46.2% and 36.5%) shunt failures. Failure risk increased with elective surgeries, surgeries performed by residents, congenital hydrocephalus, and in the 12-month or younger age group (p < 0.001, p = 0.035, p = 0.02, p < 0.001). <em>Staphylococcus aureus</em> and <em>Staphylococcus epidermidis</em> were the most commonly isolated bacteria. No significant association was found between the duration of postoperative IV antibiotics and the one-year shunt failure rate.</div></div><div><h3>Conclusion</h3><div>The outcomes of VP shunt surgery at Gaza’s largest tertiary center from 2020 to 2022 aligned with global trends. Prolonged IV antibiotics did not lower revision or complication rates.</div></div>","PeriodicalId":51141,"journal":{"name":"Neurochirurgie","volume":"71 4","pages":"Article 101692"},"PeriodicalIF":1.5,"publicationDate":"2025-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144230305","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-07-01Epub Date: 2025-05-19DOI: 10.1016/j.neuchi.2025.101683
Jean Raymond , Tim E. Darsaut
Background and purpose
Pragmatic trial results are intrinsically heterogeneous and the ‘average treatment effect’, on which the paradigmatic verdict of explanatory trials is based may not suffice to translate trial results into clinically meaningful conclusions applicable in practice. Examining various subgroups is problematic because they are at risk of both false negative and false positive results.
Methods
We summarize FIAT, a pragmatic care trial on flow diversion where multiple subgroups were examined. The notions of average treatment effect and interaction tests are reviewed to better understand their application in pragmatic trials.
Results
The trial showed flow diversion to be superior to standard treatments, but the results do not apply to all intracranial aneurysms. The notion of a ‘true average treatment effect’ can hardly apply when there are multiple comparator interventions and clinical heterogeneity. Various subgroups were examined in spite of negative interaction tests, to help interpret the trial results. Subgroup findings can be credible so long as they are not data-dependent ‘fishing expeditions’. Meaningful clinical subgroups that have been pre-specified and integrated into the randomization scheme and power calculation provide the most credible conclusions.
Conclusion
Non-prespecified data-dependent subgroup analyses are at high risk of being incorrect and should not be used to make clinical decisions in practice. A critical assessment of pre-specified subgroup analyses can nonetheless help interpret heterogeneous pragmatic trial results.
{"title":"Understanding heterogeneity of pragmatic trial results and subgroup analyses: The FIAT example","authors":"Jean Raymond , Tim E. Darsaut","doi":"10.1016/j.neuchi.2025.101683","DOIUrl":"10.1016/j.neuchi.2025.101683","url":null,"abstract":"<div><h3>Background and purpose</h3><div>Pragmatic trial results are intrinsically heterogeneous and the ‘average treatment effect’, on which the paradigmatic verdict of explanatory trials is based may not suffice to translate trial results into clinically meaningful conclusions applicable in practice. Examining various subgroups is problematic because they are at risk of both false negative and false positive results.</div></div><div><h3>Methods</h3><div>We summarize FIAT, a pragmatic care trial on flow diversion where multiple subgroups were examined. The notions of average treatment effect and interaction tests are reviewed to better understand their application in pragmatic trials.</div></div><div><h3>Results</h3><div>The trial showed flow diversion to be superior to standard treatments, but the results do not apply to all intracranial aneurysms. The notion of a ‘true average treatment effect’ can hardly apply when there are multiple comparator interventions and clinical heterogeneity. Various subgroups were examined in spite of negative interaction tests, to help interpret the trial results. Subgroup findings can be credible so long as they are not data-dependent ‘fishing expeditions’. Meaningful clinical subgroups that have been pre-specified and integrated into the randomization scheme and power calculation provide the most credible conclusions.</div></div><div><h3>Conclusion</h3><div>Non-prespecified data-dependent subgroup analyses are at high risk of being incorrect and should not be used to make clinical decisions in practice. A critical assessment of pre-specified subgroup analyses can nonetheless help interpret heterogeneous pragmatic trial results.</div></div>","PeriodicalId":51141,"journal":{"name":"Neurochirurgie","volume":"71 4","pages":"Article 101683"},"PeriodicalIF":1.5,"publicationDate":"2025-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144090453","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Hearing outcomes are well-documented for patients with vestibular schwannoma (VS) treated with Gamma Knife stereotactic radiosurgery (GK-SRS). However, how GK-SRS affects patient-perceived balance and vestibular function remains unclear. This study therefore evaluated changes in these parameters one-year post-treatment.
Methods
A prospective, observational, before-and-after, pilot study was conducted on patients with unilateral VS treated with GK-SRS between June 2021 and July 2022. Balance-related handicap was assessed using the Dizziness Handicap Inventory (DHI). Objective vestibular function was evaluated through caloric tests and video head impulse tests (VHIT). Data were compared before treatment (0 M) and 12 months after treatment (12 M).
Results
Thirty-eight patients were included (median age 69 years, 52.6% male). Median total DHI scores significantly deteriorated (14 [5; 24] at 0 M vs. 18 [8;40] at 12 M, p = 0.027), with an increase in cases classed with moderate handicap (12%–29%, p = 0.025). We found a significant deterioration in median caloric deficit at low frequency (49 [29; 78]% vs. 72 [40; 87]%; p = 0.012) and a significant deterioration in median vestibulo-ocular reflex (VOR) gain of the anterior semicircular canal (SSC) at high frequency (0.94 [0.86;1.04] vs. 0.9 [0.72;0.98]; p = 0.012). Change in DHI score was only found weakly inversely correlated with change in VOR gain for the affected-side posterior SSC (r = −0.38; p = 0.04).
Conclusion
GK-SRS for VS can result in modest deterioration in subjective balance after one year. Changes in DHI were not strongly correlated with objective vestibular function deficits thus suggesting other factors can contribute to dizziness and balance outcomes.
{"title":"Changes in patient-perceived balance and vestibular function after Gamma-knife stereotactic radiosurgery for vestibular schwannoma: 12-month outcomes in a single-centre pilot study","authors":"Nadia El Fassi , Yohan Gallois , Olivier Deguine , Jacqueline Butterworth , Jean-François Sabatier , Oumar Sacko , Yassine Beltaïfa , Igor Latorzeff , Jean-Albert Lotterie , Sergio Boetto , Jean-Christophe Sol , Mathieu Marx","doi":"10.1016/j.neuchi.2025.101688","DOIUrl":"10.1016/j.neuchi.2025.101688","url":null,"abstract":"<div><h3>Background</h3><div>Hearing outcomes are well-documented for patients with vestibular schwannoma (VS) treated with Gamma Knife stereotactic radiosurgery (GK-SRS). However, how GK-SRS affects patient-perceived balance and vestibular function remains unclear. This study therefore evaluated changes in these parameters one-year post-treatment.</div></div><div><h3>Methods</h3><div>A prospective, observational, before-and-after, pilot study was conducted on patients with unilateral VS treated with GK-SRS between June 2021 and July 2022. Balance-related handicap was assessed using the Dizziness Handicap Inventory (DHI). Objective vestibular function was evaluated through caloric tests and video head impulse tests (VHIT). Data were compared before treatment (0 M) and 12 months after treatment (12 M).</div></div><div><h3>Results</h3><div>Thirty-eight patients were included (median age 69 years, 52.6% male). Median total DHI scores significantly deteriorated (14 [5; 24] at 0 M vs. 18 [8;40] at 12 M, p = 0.027), with an increase in cases classed with moderate handicap (12%–29%, p = 0.025). We found a significant deterioration in median caloric deficit at low frequency (49 [29; 78]% vs. 72 [40; 87]%; p = 0.012) and a significant deterioration in median vestibulo-ocular reflex (VOR) gain of the anterior semicircular canal (SSC) at high frequency (0.94 [0.86;1.04] vs. 0.9 [0.72;0.98]; p = 0.012). Change in DHI score was only found weakly inversely correlated with change in VOR gain for the affected-side posterior SSC (r = −0.38; p = 0.04).</div></div><div><h3>Conclusion</h3><div>GK-SRS for VS can result in modest deterioration in subjective balance after one year. Changes in DHI were not strongly correlated with objective vestibular function deficits thus suggesting other factors can contribute to dizziness and balance outcomes.</div></div>","PeriodicalId":51141,"journal":{"name":"Neurochirurgie","volume":"71 4","pages":"Article 101688"},"PeriodicalIF":1.5,"publicationDate":"2025-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144144254","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-07-01Epub Date: 2025-05-09DOI: 10.1016/j.neuchi.2025.101678
Dominique Batifol , Pierre-Jacques Finiels , Sophie Galmiche , Marie de Boutray
The use of botulinum toxin in pre- and post-operative management of pain in spinal surgery is described, following a specific administration protocol. The initial encouraging results (particularly the absence of opioid use in the post-operative period) support the potential role of BoNT-A (Botulinum Neurotoxin type A) as a targeted therapeutic option in this specific clinical setting.
{"title":"Comprehensive pain management in spinal surgery: The role of botulinum toxin","authors":"Dominique Batifol , Pierre-Jacques Finiels , Sophie Galmiche , Marie de Boutray","doi":"10.1016/j.neuchi.2025.101678","DOIUrl":"10.1016/j.neuchi.2025.101678","url":null,"abstract":"<div><div>The use of botulinum toxin in pre- and post-operative management of pain in spinal surgery is described, following a specific administration protocol. The initial encouraging results (particularly the absence of opioid use in the post-operative period) support the potential role of BoNT-A (Botulinum Neurotoxin type A) as a targeted therapeutic option in this specific clinical setting.</div></div>","PeriodicalId":51141,"journal":{"name":"Neurochirurgie","volume":"71 4","pages":"Article 101678"},"PeriodicalIF":1.5,"publicationDate":"2025-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143948229","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-07-01Epub Date: 2025-04-04DOI: 10.1016/j.neuchi.2025.101667
Jean Raymond , François Zhu , Tim E. Darsaut
Background
Decision making for preventive interventions in asymptomatic patients, such as the treatment of incidental intracranial aneurysms, is eminently uncertain and at risk of over-treatment. One approach suggests that the weighing of the natural risk of the disease against the risk of intervention should be replaced by a comparison of outcomes measured as expected quality-adjusted life-years survival.
Methods
We review the problems of over-diagnosis and over-treatment and how prognostic studies can help address the clinical uncertainty. We examine and compare the assumptions that underlie the mathematical transformations that are involved in the so-called outcome-based approach with the risk-based approach when they are both derived from observational data. Finally, we propose a more pragmatic approach.
Results
Both risk-based and outcome-based models depend on two strong assumptions: exchangeability of patients selected to be observed and patients selected to be treated (in other words ignorability of treatment assignment), and ii) dominance of time-to-event data (the only thing pertinent for decision making is the time to the first event in the patient’s history). The outcome-based approach needs an additional assumption: fatality (once a patient suffers a poor outcome from an event, recovery is impossible). These three theoretical assumptions are rarely verified in practice.
Conclusion
Clinical decision-making based on observational data relies on unrealistic assumptions. Clinical practice should instead be guided by conducting pragmatic clinical trials.
{"title":"Understanding decision making for preventive interventions: The unruptured intracranial aneurysm example","authors":"Jean Raymond , François Zhu , Tim E. Darsaut","doi":"10.1016/j.neuchi.2025.101667","DOIUrl":"10.1016/j.neuchi.2025.101667","url":null,"abstract":"<div><h3>Background</h3><div>Decision making for preventive interventions in asymptomatic patients, such as the treatment of incidental intracranial aneurysms, is eminently uncertain and at risk of over-treatment. One approach suggests that the weighing of the natural risk of the disease against the risk of intervention should be replaced by a comparison of outcomes measured as expected quality-adjusted life-years survival.</div></div><div><h3>Methods</h3><div>We review the problems of over-diagnosis and over-treatment and how prognostic studies can help address the clinical uncertainty. We examine and compare the assumptions that underlie the mathematical transformations that are involved in the so-called outcome-based approach with the risk-based approach when they are both derived from observational data. Finally, we propose a more pragmatic approach.</div></div><div><h3>Results</h3><div>Both risk-based and outcome-based models depend on two strong assumptions: exchangeability of patients selected to be observed and patients selected to be treated (in other words ignorability of treatment assignment), and ii) dominance of time-to-event data (the only thing pertinent for decision making is the time to the first event in the patient’s history). The outcome-based approach needs an additional assumption: fatality (once a patient suffers a poor outcome from an event, recovery is impossible). These three theoretical assumptions are rarely verified in practice.</div></div><div><h3>Conclusion</h3><div>Clinical decision-making based on observational data relies on unrealistic assumptions. Clinical practice should instead be guided by conducting pragmatic clinical trials.</div></div>","PeriodicalId":51141,"journal":{"name":"Neurochirurgie","volume":"71 4","pages":"Article 101667"},"PeriodicalIF":1.5,"publicationDate":"2025-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143768691","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
扫码关注我们
求助内容：
应助结果提醒方式：
京公网安备 11010802042870号