Operative Neurosurgery最新文献

Background and objectives: Patient frailty has been shown to be a powerful predictor of poor surgical outcome across specialties and may guide patient selection. In awake craniotomy, patient selection is particularly important for completion of intraoperative mapping and to reduce conversion to general anesthesia. We evaluated whether frailty is associated with unsuccessful awake craniotomy or poor outcome.

Methods: We performed a single-center retrospective study of adult patients with tumor, epilepsy, and vascular pathologies that underwent first-time awake craniotomy between 2018 and 2024. The Modified Frailty Index-11 (mFI-11) was calculated for each patient, and frailty was defined as a mFI-11 ≥2. We evaluated the association of frailty with unsuccessful awake craniotomy and postoperative complications.

Results: In total, 143 patients met inclusion criteria. There were 39 (27%) frail patients (mFI-11 ≥ 2) and 104 (73%) nonfrail patients (mFI-11 <2). Frail patients were significantly older ( P < .001), had a higher American Society of Anesthesia classification ( P = .015), higher rates of obstructive sleep apnea ( P = .001), higher body mass index ( P = .035), and glioblastoma ( P < .001) compared with the nonfrail group. Frail patients had longer length of stay ( P = .008) and had more than 2 times increased odds of discharge to skilled nursing facility or inpatient rehab facility ( P = .01). Frail patients had no significant increased risk of conversion to general anesthesia or incomplete mapping, intraoperative deficit, 24-hour postoperative deficit, 30-day readmission, or residual neurologic deficit at follow-up.

Conclusion: In our cohort, frailty was associated with higher anesthetic risk and longer length of stay but was not significantly associated with unsuccessful awake craniotomy, postoperative complications, or neurologic outcome.

Background and objectives: Using confocal endomicroscopy (CLE) in neurosurgery holds the potential for intraoperative diagnosis and correct identification of tumor margins. Still, the correct employment of such a promising technique requires either an external dedicated person to interact with the neurosurgeon during the operation to check the quality of the acquired images or the operator to look directly and frequently outside of the operative field while maintaining the confocal microscopy probe in the surgical cave, thus interrupting the surgical flow, potentially disturbing the correct execution of surgical maneuvers and hindering a correct image acquisition.

Methods: To overcome this problem, we integrated the confocal microscopy interface (Zeiss CONVIVO®) into the surgical view through the operative microscope (Heads-up display). We enrolled patients undergoing surgery with the use of CLE for different pathologies, and we randomly allocated them to be operated with the heads-up display integration or without it. The mean CLE employment time and the number of usable and nonusable captures were annotated.

Results: Twenty-two patients were enrolled of which 12 patients underwent the procedure without the heads-up integration (54.5%) and 10 (45.5%) with it. The mean usage time of the CONVIVO® was 137 (±134) seconds, 61.1 (±38) seconds for the heads-up display group, and 201.6 (±154.1) seconds for the non-heads-up display group ( P = .01). The heads-up display group showed a higher proportion of usable images (11 [±4] vs 50 [±37], 21.7%) than the non-heads-up display group (30 [±21] vs 163 [±33], 18.4%), although nonsignificant ( P = .06). A significant influence of the intraoperative visualization on overall employment of CLE and a reduced number of images collected (611 vs 2139; P = .007).

Conclusion: By allowing the operator to check the quality of the images directly while still looking inside the operating field, better-quality images and a reduced number of unemployable captures are obtained, resulting in more efficient and less time-consuming use of intraoperative confocal microscopy, ultimately leading to reduced operative length.

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.

Background and importance: Idiopathic spinal cord herniation through a defect in the ventral dura mater is rare and typically results in progressive myelopathy. Various surgical procedures to release the tethered spinal cord can prevent the progression of myelopathy; however, the optimal procedure has not yet been established. We describe techniques using endoscopic assistance to minimize spinal cord manipulation.

Clinical presentation: A 60-year-old woman presented with Brown-Séquard syndrome. Magnetic resonance imaging demonstrated ventral displacement of the spinal cord at T3-4. Right T2, T3, T4, and T5 hemilaminectomies and T4 pediculectomy were performed. After paramedian durotomy and transection of the dentate ligament, we identified a defect in the inner layer of the dura mater ventrally and found the spinal cord incarcerated in a pocket between the inner and outer layers. The spinal cord was adherent to the dura at the caudal end of the defect. The defect was extended caudally on the right under microscopic observation. On the left, which could not be visualized under the microscope, the adhesions were dissected under endoscopic guidance. After complete spinal cord untethering, the defect was closed using collagen matrix. The patient's motor weakness fully recovered, and she was walking independently at the time of discharge.

Conclusion: Endoscopic assistance for release of thoracic spinal cord herniation is useful for minimizing intraoperative spinal cord manipulation.

Background and objectives: Myelomeningocele (MMC) is a congenital anomaly frequently leading to motor deficits, urological dysfunction, and hydrocephalus. Fetal surgical repair improves motor function and reduces the need for cerebrospinal fluid diversion for hydrocephalus. One complication of MMC repair is spinal cord tethering at the site of surgical repair. Surgical techniques to reduce symptomatic tethering and achieve optimal motor function are an area of ongoing research. This study's objective is to evaluate a technique for interposing an amniotic membrane graft between the pia of the closed placode and the overlying dural closure in a prospectively treated cohort of patients with open fetal MMC closure. The theoretical advantage of this technique is that an amniotic membrane barrier may reduce the likelihood of tethering between surgically closed layers.

Methods: Under an approved, prospective protocol, open fetal MMC repair with an amniotic membrane interposition graft was performed by a single surgeon at 1 institution over a 1-year period. At the time of surgery, amniotic membrane was harvested from the edges of hysterotomy. This membrane was cleaned, trimmed, and secured over the closed pial surface of the repaired placode. The dura and overlying layers were closed in a standard fashion. Outcomes were obtained by interviews with patients' families.

Results: Open fetal MMC repairs were performed with amniotic membrane graft interposition. One of 8 patients with a 5-year follow-up subsequently underwent spinal cord detethering surgery.

Conclusion: Amniotic patch interposition for fetal MMC repair can be performed safely alongside standard MMC repair techniques. Evidence for effectiveness on rates of subsequent detethering surgeries requires larger studies with longer follow-up.