Operative Neurosurgery最新文献

Background and objectives: The surgical intervention for hemivertebra removal is complex, leading to a lack of a definitive solution. We aim to compare the clinical efficacy of less invasive, partial hemivertebra resection vs total hemivertebra resection in children.

Methods: Between 2011 and 2016, a retrospective study was conducted on a cohort of 43 patients diagnosed with congenital scoliosis coexisting with hemivertebrae. This study evaluated the outcomes of a posterior-only surgical approach, dividing the cohort into 2 groups based on the surgical technique applied: 23 patients underwent total hemivertebrae resection (TR), whereas 20 patients received partial hemivertebrae resection (PR), accompanied by short-segment fusion.

Results: There were 43 patients with congenital scoliosis associated with hemivertebrae in both the PR and TR groups. The average age at the time of surgery was 6.3 ± 2.0 years for the PR group and 6.0 ± 1.9 years for the TR group. The PR group exhibited a comparable correction rate of the Cobb angle at postoperation (4.3 ± 4.9 and 2.2 ± 3.2, P = .174) and the last follow-up (7.8 ± 1.3 and 5.5 ± 2.3, P = .113) compared with the TR group.

Conclusion: Partial hemivertebra resection is efficient and secure. A less invasive technique obtained an equivalent, well-maintained correction rate to the total hemivertebra resection. However, this is the initial result, and the patients continue to be followed; we will await the results of the outcome at full-growth sprouts.

Background and importance: Untreated obturator nerve injury may result in weakness in thigh adduction, decreased medial thigh sensation, and groin pain. A neurosurgeon may be consulted intraoperatively for repair. Although there are reports of obturator nerve injury and repair in the gynecologic surgery literature, there are few reports detailing the specific steps of nerve repair after partial transection and the underlying principles of nerve coaptation, especially in the robotic-assisted setting.

Clinical presentation: A partial transection of the right obturator nerve was noted in a patient undergoing total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, and lymph node dissection using the da Vinci robot. Sutures were placed in the epineurium of the cut nerves to realign the fascicles. A porcine wrap was placed around the coaptation site and covered with fibrin glue. The right lower extremity was passively ranged to ensure no tension was present across the repair site. The patient had loss of right leg adduction after surgery, but she recovered full motor function 5 months after surgery with no numbness or pain.

Conclusion: The current report describes a repair strategy for partial-thickness obturator nerve injury in the setting of a laparoscopic surgery. Working in a multidisciplinary fashion, the tenets of nerve repair may be applied to robotic-assisted cases of obturator nerve injury, resulting in neurologic recovery.

Background and objectives: The impact of prior local therapies, including radiation and surgery, on reconstruction outcomes after endonasal surgery is currently not well known. Reconstruction nuances in the preoperative setting merit further evaluation to avoid potential postoperative complications that can hinder overall tumor management and negatively impact patient outcome. We sought to determine whether prior treatments increase risk of reconstruction-related postoperative morbidity and to evaluate the effectiveness of our current treatment paradigm for skull base reconstruction.

Methods: A retrospective review of all endonasal surgeries for tumor resection between March 2000 and March 2022 was performed. Patients were grouped based on treatment history. Patient demographics, operative, and postoperative reconstruction-related morbidity data were collected, including cerebrospinal fluid leak, sinonasal morbidity, and infectious complications. Variables significantly associated with postoperative complications in the univariate analysis were included in the multivariate Cox proportional hazards regression model. Complication-free survival curves were generated, and the log-rank test evaluated the relationship between complication-free survival and the different clinical, surgical, and treatment parameters. All statistical analyses were performed with SPSS 26 (IBM Corp) and Graph Pad 9.0 (GraphPad Software).

Results: A total of 418 patients were included. 291 patients had no prior treatments, 49 patients had previously received radiation, and 78 patients had prior surgeries. Of the 49 patients who had prior radiation, 27% underwent reconstruction with tunneled pericranial flaps vs 16% of treatment-naïve patients. On multivariate analysis, prior treatment was not significantly associated with reconstruction-related complications. Negative smoking history, no leak or small intraoperative leak, and use of vascularized flap in reconstruction were protective factors.

Conclusion: In patients undergoing endonasal surgery, prior radiation and/or surgery does not appear to significantly increase the risk of immediate or delayed reconstruction complications using our current reconstructive management plan, which incorporates an upfront regional flap for high-risk cases.

Background and objectives: Current surgical strategies for dumbbell nerve sheath tumors (DNSTs) with cord compression have primarily involved wide spinal exposures with total laminectomy and unilateral facetectomy, often leading to spinal destabilization and requiring fusion, or staged procedures separately addressing the intraspinal and extraforaminal tumor components. This study highlights technical nuances of a novel approach for DNST resection to minimize spinal destabilization and avoid fusion while facilitating safe, single-stage complete resection.

Methods: A retrospective chart review was conducted on patients undergoing DNST resection. Using unilateral subperiosteal dissection, hemilaminotomy and medial facetectomy procedures are performed. The extradural tumor component is resected, followed by internal decompression of the intradural tumor. A small horizontal incision at the origin of the nerve root sleeve releases the underlying dural stricture, facilitating delivery of the remaining intradural tumor and allowing section of the nerve root of origin. Ultrasonography confirms complete tumor resection and return of cord pulsation, and excludes intradural hemorrhagic complications. The dura is reconstructed using a dural substitute bolstered with fat graft and sealant.

Results: Twelve consecutive patients undergoing this approach from 2014 to 2021 were included. Mean patient age was 53.5 years, and 58.3% were male. Nine tumors were cervical and 3 were lumbar. Five patients presented with myelopathy, 4 with radiculopathy, and 4 with axial pain. Two cases had transient intraoperative neuromonitoring signal changes. Eleven tumors were diagnosed as schwannomas and 1 as neurofibroma. All patients had complete resection of the intraspinal component; 2 had far distal extraforaminal residual. No patient has had recurrence, progression of residual, or signs of spinal instability during follow-up (median 28.5 months, range 6-66 months).

Conclusion: This study highlights technical considerations for DNST resection, focusing the approach at the center of the tumor, with minimal bone removal and ligamentous disruption. Intraoperative ultrasound is instrumental in the safety of this approach.

An anterior clinoidectomy is an important skull-base technique to have in the armamentarium when managing pathology of the paraclinoid region. Drilling the anterior clinoid (AC) provides access to the clinoidal internal carotid artery and early decompression of the optic nerve. This technique is essential in the management of central skull base tumors and aneurysms, especially from the opticocarotid region. The intricate neurovascular anatomy associated with the AC can be difficult to master. There are 2 main techniques for drilling the AC, intradural and extradural, although hybrid techniques have been described. The goal of this article was to provide an up-to-date technical report on performing an anterior clinoidectomy supplemented by high-quality original dissections and a 4K 2-dimensional video as a resource for trainees and junior neurosurgeons.

Background and objectives: Jugular foramen schwannomas (JFS) are rare benign tumors arising from lower cranial nerves. In this study, we aim to compare the outcomes of surgical resection (SR) and stereotactic radiosurgery (SRS) in the treatment of JFS.

Methods: We conducted a retrospective analysis of 31 patients with JFS who underwent SRS (13 patients [41.9%]) or surgical resection (18 patients [58.1%]) as their primary management modality over a two-decade period. Outcomes included progression-free survival, post-treatment adverse events based on Common Terminology Criteria for Adverse Events, symptom improvement, overall survival, and the necessity for secondary interventions. Local tumor control was also evaluated in all patients who received SRS.

Results: Significant differences were observed in baseline characteristics between the SRS and SR groups, including median age (58 vs 48 years, P = .001), largest tumor diameter (32.0 vs 47.5 mm, P = .02), and total tumor volume (6.50 vs 20.5 mm3, P = .01). There were no significant differences in sex or lesion morphology (dumbbell vs nondumbbell shaped). After adjusting for baseline characteristics, no significant differences were noted in progression-free survival (90.9 vs 86.2%), overall survival (92.3 vs 100%), symptom improvement (61.5 vs 55.5%), or median Common Terminology Criteria for Adverse Events grade (1 in both groups) between the SRS and SR groups, respectively. SRS patients had significantly lower odds of requiring secondary treatment procedures after their primary intervention as compared with those who underwent SR (odds ratio = 0.02, 95% CI: 0.001-0.88, P-value = .04). Local tumor control in all SRS patients (19 patients) was 93.7% and 79.1% at six-month and five-year time points, respectively.

Conclusion: SRS and SR demonstrate comparable effectiveness in treating JFS. However, SRS may be a more favorable option because of a reduced need for secondary interventions. Future controlled prospective studies are needed to draw more definitive conclusions.

Background and objectives: Intracranial pressure (ICP) is the cornerstone for physiological neuromonitoring after traumatic brain injuries (TBIs). Optic nerve sheath diameter (ONSD) ultrasonography serves as a noninvasive alternative for the gold standard invasive ICP monitoring devices. We aimed to evaluate the use of ultrasound ONSD as a tool for early detection and follow-up of increasing ICP in TBI in a low socioeconomic developing country where invasive devices are not always available.

Methods: A prospective observational study was conducted on 50 polytrauma patients with TBI, who were older than 18 years with and Glasgow Coma Scale above 5, and a computed tomography (CT) brain in trauma survey showing signs of increasing ICP. All patients were recruited from the emergency department and intensive care unit at Cairo and October 6 University hospitals from January to May 2022. Clinical assessment, CT brain, and ONSD ultrasonography were performed on admission, after 12 hours, and after 48 hours. ONSD 5.0 mm was correlated with raised ICP in this study.

Results: ONSD ranged from 4.6 to 7.1 mm with mean ± SD of 5.93 ± 0.55 on admission. On the second follow-up, the range regressed to 4.5 to 6.0 mm with mean ± SD of 4.8 ± 0.48, suggesting a decrease in the measurements of ONSD after receiving treatment either medical or surgical. The correlation between the measurement of ONSD and the CT findings indicating raised or decreased ICP was found in 94%, 82%, and 90% of patients on admission, first follow-up, and second follow-up, respectively. The specificity of ONSD measurement was 100% on admission and second follow-up, and its accuracy was 94% and 90 % for both occasions, respectively.

Conclusion: Bedside ONSD measurements are highly correlated with CT brain findings and dynamic changes in ICP in response to head trauma management protocols. Hence, ultrasonic ONSD can replace invasive monitoring in following the ICP of patients with TBI.