Operative Neurosurgery最新文献

Background and objective: The idea of watertight dural closure (WTDC) seems extremely obvious to avoid complications such as cerebrospinal fluid (CSF) leak and infection, especially in spinal and posterior fossa surgeries. Nonetheless, several studies have shown that leaving the dura open is not associated with an increased risk of complications. The aim of this systematic review and meta-analysis is to compare non-WTDC and WTDC in patients undergoing supratentorial craniotomy regarding the risk of postoperative complications.

Methods: We searched PubMed, Web of Science, Embase, and Cochrane for randomized control trials and observational studies comparing non-WTDC with WTDC in patients undergoing supratentorial craniotomy. Outcomes of interest were CSF leak, overall infection, meningitis, and subgaleal fluid collection (SFC). Statistical analysis was performed using RStudio 2023.12.1 + 402. Heterogeneity was assessed using I 2 statistics.

Results: Of 1541 potential articles, 7 met the inclusion criteria. The review comprised 3 randomized control trials, 1 prospective study, and 3 retrospective cohort studies. Among the 1619 patients, 766 (47.3%) and 853 (52.7%) patients were in the non-WTDC and WTDC groups, respectively. There was no significant difference in CSF leak between the non-WTDC and WTDC groups (risk ratio [RR] 1.61; 95% CI 0.68-3.77; P = .276; I 2 = 0%). Furthermore, we did not find significant differences in overall infection (RR 1.62; 95% CI 0.95-2.76; P = .078; I 2 = 4%), meningitis (RR 1.87; 95% CI 0.64-5.46; P = .251; I 2 = 0%), and SFC (RR 1.53; 95% CI 0.64-3.65; P = .342; I 2 = 52%) between the non-WTDC and WTDC groups.

Conclusion: These findings suggest that non-WTDC is a safe method and is not associated with an increased risk of CSF leak, overall infection, meningitis, and SFC compared with WTDC.

Background and objectives: In endoscopic endonasal approaches (EEAs) for skull base pathologies, endoscope view obscuration remains a persistent, time-consuming, and distracting issue for surgeons and may result in increased operative time. The endonasal access guide (EAG) has been demonstrated as a possible adjunct to minimize these events. However, to date, there have been no comparative studies performed and the potential time savings by using EAGs have yet to be quantified. This cohort study aimed to determine the operative efficiency benefits of the EAG in EEA operations.

Methods: Analysis of EEA operative videos from an EAG cohort (n = 20) and a control cohort (n = 20) was performed, assessing 12-minute segments in the first, middle, and last third of each operation. The first segment in each cohort was selected before EAG placement, serving as an internal control. Every endoscope lens soiling instance was counted (measured as cleaning actions per minute), timed (obscuration time %), and identified as a withdrawal, irrigation, or other cleaning action. Perioperative variables including skull base repair and postoperative cerebrospinal fluid leakage were assessed.

Results: Within the EAG cohort, obscuration time was reduced in the middle and last third compared with the first third (3.73% [CI: 2.39-5.07] vs 12.97% [CI: 10.24-15.70], P < .001; 4.19% [CI: 2.83-5.55] vs 12.97% [CI: 10.24-15.70], P < .001) and cleaning actions were also significantly reduced by EAG (0.69/min [CI: 0.39-0.99] vs 1.67/min [CI: 1.34-2.00], P = .001; 0.66/min [CI: 0.35-0.97] vs 1.67/min [CI: 1.34-2.00], P < .001). Between the control and EAG cohorts, there was no significant difference between obscuration time and cleaning actions in the first third (9.33% vs 12.97%, P = .086; 1.34/min vs 1.67/min, P = .151) or in the middle third (6.24% vs 3.73%, P = .140; 0.80/min vs 0.69/min, P = .335), but there was a significant difference in the last third (9.25% [CI: 6.95-11.55] vs 4.19% [CI: 2.83-5.55], P < .001; 0.95/min [CI: 0.73-1.17] vs 0.66/min [CI: 0.35-0.97], P = .018).

Conclusion: EAG significantly reduces lens obscurations and cleaning events, particularly during the intradural portion of operations. This technology may offer a greater time-saving impact with patients undergoing long EEA operations.

Background and objectives: The most common treatment for hydrocephalus is ventriculoperitoneal (VP) shunting, which is problematic as shunts are prone to failure. Shunt disconnections account for a minority (8%-15%) of VP shunt failures but could be reduced through better shunt design. A better understanding of the mechanical properties of VP shunts would help explain why shunt disconnections occur. The objective of this study was to determine if the tensile properties of VP shunts differ by design.

Methods: Linear tensile testing was conducted on 5 different valve designs (Codman Certas Plus Programmable Valve, Medtronic Delta, Integra Orbis Sigma Valve II, Medtronic PS Medical, Medtronic Strata Adjustable Valve) at both the proximal and distal ends to determine the maximum load which could be applied to different shunt designs. Each valve was progressively subjected to increasing force until the catheter disconnected from the valve, the catheter fractured, or our maximum testing limits were reached.

Results: Catheters disconnected or fractured during testing with all valves. The maximum load resisted during tensile testing for similar locations in all valve designs were found to be statistically similar to one another. Only the PS Medical and Orbis Sigma II valves showed an increased maximum load at the distal end compared with the proximal end within the same device.

Conclusion: No single valve design was superior at preventing disconnections in VP shunts. Shunt disconnections remain a concerning problem as VP shunts are the gold standard for combating hydrocephalus.

Background and objectives: In cases where dumbbell-shaped cervical schwannoma encases the vertebral artery (VA), there is a risk of VA injury during surgery. The objective of this study is to propose a strategy for preserving the VA during the surgical excision of tumors adjacent to the VA through the utilization of anatomic layers.

Methods: A retrospective analysis was conducted on 37 patients who underwent surgery for dumbbell-shaped cervical schwannoma with contacting VA from January 2004 to July 2023. The VA encasement group consisted of 12 patients, and the VA nonencasement group included 25 patients.

Results: The perineurium acted as a protective barrier from direct VA exposure or injury during surgery. However, in the VA encasement group, 1 patient was unable to preserve the perineurium while removing a tumor adjacent to the VA, resulting in VA injury. The patient had the intact dominant VA on the opposite side, and there were no new neurological deficits or infarctions after the surgery. Gross total resection was achieved in 25 patients (67.6%), while residual tumor was confirmed in 12 patients (32.4%). Four patients (33.3% of 12 patients) underwent reoperation because of the regrowth of the residual tumor within the neural foramen. In the case of the 8 patients (66.7% of 12 patients) whose residual tumor was located outside the neural foramen, no regrowth was observed, and there was no recurrence of the tumor within the remaining perineurium after total resection.

Conclusion: In conclusion, when resecting a dumbbell-shaped cervical schwannoma contacting VA, subperineurium dissection prevents VA injury because the perineurium acts as a protective barrier.

Background and objectives: Härtel triangle provides surface landmarks for locating the foramen ovale (FO) when performing trigeminal nerve percutaneous procedures. Although widely adopted in clinical practice, there is no report that these landmarks have ever been formally validated through modern imaging techniques. Here we aim to validate Härtel anatomical landmarks using computed tomography scans and propose technical considerations for percutaneous trigeminal procedures.

Methods: Retrospective analysis of 198 FO from 99 adult head computed tomography scans. Measurements included distances from FO to external auditory canal (EAC), FO to midline, eye's midpupillary (MP) line to midline, and eye's inner canthus (IC) line to midline. Statistical analysis was performed, and results were compared with Härtel description.

Results: The mean distance from EAC to FO was 23.26 mm (SD: 3.00 mm). Distance from midline to FO was 25.43 mm overall (SD: 1.87 mm). Distance from midline to MP line was measured at 31.96 mm (SD: 1.89 mm). The mean distance from midline to IC line was 14.68 mm (SD: 1.73 mm).

Conclusion: Härtel landmarks can be adjusted for greater accuracy when performing percutaneous trigeminal nerve procedures. The FO is located closer to the EAC and more medially situated than previously assumed. Revised technique suggests aiming the needle trajectory approximately 2 to 2.5 cm anterior to the tragus and targeting a point between the IC and MP lines rather than directly along the MP line. Excessive medial and posterior needle displacement should be avoided to prevent inadvertent vascular injury. These adjustments could enhance procedural accuracy and safety, improving patient outcomes.

Background and objectives: The middle fossa approaches are tremendously versatile for treating small vestibular schwannomas, selected petroclival meningiomas, midbasilar trunk aneurysms, and lesions of the petrous bone. Our aim was to localize the internal acoustic canal and safely drill the petrous apex with these approaches. This study demonstrates a new method to locate the internal acoustic canal during surgery in the middle fossa.

Methods: The microsurgical anatomy of the middle fossa floor was studied in 11 formalin-fixed and silicone-injected cadaveric heads. Extradural dissection of the skull base was completed from the posterior to the anterior side. A zero-degree rigid endoscope was inserted perpendicularly into the external auditory canal. The light beam was first directed through the tympanic membrane, avoiding injury to the tympanic membrane. The room lights were dimmed to provide a clearer view of the transilluminated bony area. Drilling was performed with transillumination guidance.

Results: The transilluminated area included the tympanic and mastoid tegmen up to the arcuate eminence. The nonilluminated area was bounded posteriorly by the arcuate eminence, laterally by the greater superficial petrosal nerve, and posteromedially by the petrous ridge. In all specimens, drilling the transition line between the Kawase triangle and the transilluminated area unroofed the internal auditory canal (IAC). No transillumination of the carotid canal was seen after anterior petrosectomy in any of the specimens. The entire contents of the IAC were preserved in both anterior petrosectomy and unroofing of the IAC.

Conclusion: In this anatomical study, transillumination of the external auditory canal proved to be feasible, accurate, and safe in guiding the middle fossa approaches. The ease of implementation and cost-effectiveness of the technique may suggest a possible application in operative scenarios.

Background and importance: Superior oblique myokymia (SOM) is a rare, acquired aberration of the innervation of the superior oblique, resulting in episodic monocular contraction of the superior oblique muscle characterized by intermittent rotatory eye movement causing diplopia and oscillopsia. Several treatment modalities have been described to treat SOM, including medication and surgical interventions. There is a paucity of reports describing microvascular decompression (MVD) of the trochlear nerve near the root entry zone for the treatment of a neurovascular conflict. The authors describe a case report of a patient who presented with SOM by a supracerebellar infratentorial approach using microscopic and endoscopic visualization.

Clinical presentation: A 40-year-old woman presented with an 8-month history of rhythmic contractions of her right orbit with worsening double vision and occasional balance issues. Neuro-ophthalmological evaluation which revealed a right-sided SOM. MRI evaluation demonstrated a potential vascular compression by the superior cerebellar artery near the origin of the trochlear nerve. She underwent MVD by a supracerebellar infratentorial approach using microscopic and endoscopic visualization. The patient experienced resolution of her SOM in the immediate postoperative period and a Trochlear nerve palsy that resolved within 6 months.

Conclusion: The endoscopic supracerebellar infratentorial approach for MVD of the trochlear nerve is a safe and efficacious approach that provides superior visualization of the trochlear nerve at its origin and in the setting of SOM. This approach shows outcomes comparable with those used in previously described cases.

Background and importance: Fusiform middle cerebral artery (MCA) bifurcation aneurysms can be challenging to treat with standard endovascular or microsurgical techniques. The in situ side-to-side bypass technique represents an elegant revascularization option for these aneurysms when trapping becomes necessary.

Clinical presentation: A man in his 50s presented for evaluation of an incidentally found fusiform, 10 mm, right MCA bifurcation aneurysm with involvement of both the inferior and superior M2 trunks. Plan was initially made for a right pterional craniotomy for trapping of the aneurysm with exclusion of the inferior M2 trunk, preservation of the superior M2 trunk, with superficial temporal artery bypass to the inferior M2 trunk. Intraoperatively, after arachnoid dissection, it became clear that the distal superior and inferior M2 branches would lie in close approximation without tension, thus superficial temporal artery-M2 bypass was deferred, and instead in situ side-to-side M2 bypass was performed. Here in our operative video, we highlight the critical steps of in situ side-to-side M2 bypass technique.

Conclusion: We present a technical case instruction and operative video highlighting the in situ side-to-side bypass technique for treatment of a large fusiform MCA bifurcation aneurysm.