Operative Neurosurgery最新文献

Background and importance: Pyogenic ventriculitis is a rare, but fatal complication associated with community-acquired meningitis and invasive procedures. The blood-brain barrier poses a major challenge for systemic antibiotics to adequately treat infections confined to the ependyma of the ventricles.

Clinical presentation: In this case report, we demonstrate 2 cases of pyogenic ventriculitis that responded to active cerebrospinal fluid (CSF) exchange where continuous irrigation with antibiotics allowed for adequate CSF distribution. The first case is an 83-year-old man who acquired ventriculitis secondary to epidural injections for pain. The second case is that of a 60-year-old woman who developed ventriculitis as a complication of external ventricular drainage placement for left thalamic intracerebral hemorrhage with intraventricular extension.

Conclusion: Although both patients had a complex medical history, inpatient complications, and initially failed to respond to systemic antibiotic therapy, their infections were cleared rapidly on initiation of active CSF exchange. Larger scale studies will be needed to demonstrate efficacy of this novel technique.

Background and objectives: In a cohort of patients undergoing Adult Spinal Deformity (ASD) surgery, we sought to (1) report the rate of and reason for reoperation within 6 months of the index surgery and (2) determine the association between early reoperation and 2-year patient-reported outcome measures (PROMs).

Methods: A single-institution, retrospective cohort study was performed for patients undergoing ASD surgery from 2009 to 2021. The primary outcomes included early reoperations within 6 months and reason for reoperation, including proximal junctional kyphosis/failure (PJK/F), distal junctional kyphosis, pseudarthrosis/rod fracture, and implant failure. Secondary outcomes included all mechanical complications requiring reoperation beyond 6 months and PROMs. Descriptive statistics and multivariable logistic regression were performed.

Results: Of 238 patients undergoing ASD surgery, 19 (8%) underwent early reoperation within 6 months primarily for PJK/F (42%), distal junctional kyphosis (11%), implant failure (11%), and pseudarthrosis (11%). Early reoperation was significantly more likely in patients with 2+ comorbidities (63.2% vs 38.6%, P = .038) but did not predict future reoperation beyond 6 months (47.4% vs 58.0%; P = .159). At 2 years, patients with early reoperation had worse PROMs: higher Oswestry Disability Index (ODI) (53.9 vs 33.8, P = .001), Numeric Rating Scales for back pain (NRS-BP) (6.8 vs 4.7, P = .019), Numeric Rating Scales for leg pain (NRS-LP) (5.7 vs 2.8, P = .004) and lower EuroQoL Group questionnaire (EQ-5D) (0.50 vs 0.70, P = .003). There was less improvement in ODI (-16.6 vs -2.0, P = .025) and EQ-5D (0.0 vs 0.2, P = .038), with no significant change in NRS-BP ( P = .051) and NRS-LP ( P = .115). Early reoperation was linked to decreased odds of ODI improvement (OR 14.41, P = .028).

Conclusion: Reoperation within 6 months after ASD surgery occurred in 8% of patients at mean 85.5 days, primarily because of PJK/F (42%). Early reoperations did not significantly increase the rate of subsequent reoperations beyond 6 months. Patients with early reoperation within 6 months had worse ODI, NRS-BP, and NRS-LP and less improvement in ODI and EQ-5D, but no difference in change for NRS-BP and NRS-LP. Early reoperation significantly decreased odds of ODI improvement.

Background and objectives: Pain is the cardinal symptom of non-neurofibromatosis type 2 schwannomatosis (non- NF2 -SWN), and peripheral nerve schwannomas are the most frequent tumors encountered in this condition. The role of surgery in alleviating schwannoma-associated pain in schwannomatosis remains a matter of debate in the literature.

Methods: We conducted a retrospective chart review of all non- NF2 -SWN patients followed up at our Schwannomatosis Reference Center and included all patients operated from a peripheral nerve tumor. NF2 -related schwannomatosis was excluded on the basis of germline genetic study and/or absence of suggestive tumors on brain and spine MRIs.

Results: Fifty-nine patients were included, suffering mostly from a nonfamilial (50/59, 85%) and diffuse (40/59, 68%) non- NF2 -SWN. A germline genetic study of the NF2 , LZTR1 , and SMARCB1 genes was performed in 38 patients (64%) and demonstrated a LZTR1 gene variant in 19 cases (50%). The patients were operated from 103 peripheral nerve tumors, mainly located in major nerves (n = 67, 65%) compared with subcutaneous (n = 17, 16%) and intramuscular (n = 17, 16%) cases. Most tumors were classical discrete tumors (n = 88, 85%), while multinodular cases represented only 15% (n = 15) of cases. Pathological analysis confirmed the diagnosis of schwannoma except 2 cases of hybrid neurofibroma/schwannoma tumors. A complete resection was performed in 89% of cases with a complete relief of preoperative pain in 87% of cases. Postoperative motor and sensory deficits were encountered in 8 (8%) and 14 (14%) cases, respectively. Multinodular schwannomas were characterized by a decreased rate of complete pain relief (64% vs 90%, P = .007) and an increased rate of postoperative motor deficit (3% vs 35%, P < .001) compared with discrete tumors.

Conclusion: Nerve-sparing surgery using intraoperative neuro-monitoring remains effective in treating pain of non- NF2 -SWN-associated peripheral nerve schwannomas, with the notable exception of multinodular tumors, also characterized by an increased rate of postoperative motor deficits.

Background and objectives: The endoscopic endonasal approach (EEA) serves as the primary minimally invasive route to the ventral craniovertebral junction (CVJ). However, anatomic constraints limit its caudal reach. Multiport endoscopic approaches may complement a standard EEA providing additional reach. This anatomic study evaluates the EEA's anatomic limitations in accessing the CVJ and examines how contralateral nasofrontal trephination (CNT) port may overcome these constraints.

Methods: Thirty-two cadaveric specimens underwent EEA and CNT dissections. Key measurements included the nasoaxial line (NAxL) angle, anteroposterior frontal sinus distance, interorbital distance, and distance of odontoid process from the hard palate line. Area of exposure and surgical freedom were quantified using a surgical navigation. A clinical case treated using the CNT approach has been included to demonstrate the technique, instrument utilization, successful healing, and absence of complications.

Results: CNT significantly enhanced area of exposure of both odontoid (1720.41 vs 1086.62 mm 2 , P = <.001) and occipital condyle targets (613.32 vs 446.15 mm 2 , P = <.001), while EEA provided significant greater surgical freedom for both odontoid (1121.91 vs 1030.58 mm 3 , P = <.001) and occipital condyle (888.25 vs 827.74 mm 3 , P = <.001). Frontal sinus anteroposterior distance strongly correlated with CNT odontoid exposure (r = 0.889, P < .001) but not with the occipital condyle (r = -0.009, P = .966). CNT offered a wider angle of attack compared with EEA (49.8° vs 16.5°, P = <.001). NAxL angle inversely correlated with the distance of the odontoid process from the hard palate line level (r = -0.757, P < .001), while showing no significant correlation with EEA exposure area.

Conclusion: CNT augments traditional EEA by enhancing inferior access during the management of complex CVJ pathologies. Although NAxL angle may provide guidance in determining the inferior extent of the EEA, anatomic variability and its poor correlation with exposure area limit its standalone utility in surgical planning.

Background and objectives: Traumatic brain injury (TBI) and stroke constitute 60% of the global neurosurgical case volume. Although decompressive craniectomy (DC) has been historically used for treating elevated intracranial pressures (ICP), it remains a controversial technique and is also associated with cranioplasty-related complications and additional costs. Hinge craniotomy (HC) may offer a potentially safer and, importantly, cheaper alternative to DC in low- and middle-income countries (LMICs), which bear the greatest burden of TBI cases. In this article, we aimed to provide a comprehensive meta-analysis comparing patients undergoing HC vs those undergoing DC for elevated ICP.

Methods: The MEDLINE and Cochrane databases were systematically searched from inception to May 2024. We included all studies comparing outcomes in patients with elevated ICP undergoing HC vs those undergoing DC. Random effects models were used to pool dichotomous outcomes as risk ratios and continuous outcomes as mean differences.

Results: Seven observational studies and one randomized controlled trial comprising 1335 patients were included in our meta-analysis. Both surgical techniques achieved comparable intracranial volume expansion (mean differences: -9.94 mm 3 ) and had similar rates of postoperative hydrocephalus (risk ratio [RR]: 0.46), wound infections (RR: 0.61), and subdural hematoma (RR: 1.37). However, patients undergoing HC showed significant improvement in functional outcomes at discharge (RR: 3.32), although long-term outcomes in this respect were similar between the 2 arms (RR: 1.12).

Conclusion: Our meta-analysis, the first of its kind, depicts that HC offers an equally efficacious alternative to DC with the added benefit of achieving quicker functional recovery postoperatively. This is of particular clinical utility in LMICs which bear the greatest burden of TBI cases. However, in future, a cost-effectiveness analysis as well as adequately powered randomized controlled trials are needed to definitively delineate the optimal surgical approach needed to improve outcomes in our patient population.

Background and objectives: Spinal cord stimulation (SCS) is an effective neuromodulatory tool for various chronic pain conditions. Traditionally, the SCS procedure involved an open approach with laminotomy for paddle implants. The minimally invasive percutaneous lead placement has largely replaced open paddles. However, percutaneous leads are prone to migration and may be unfeasible in patients with preexisting epidural scarring, necessitating open paddle placement. An endoscopic approach to the spine would offer reduced morbidity with the stimulation benefits and security of open paddle. We therefore aimed to develop this technique.

Methods: An endoscopic method for SCS paddle implantation was developed initially in a cadaveric laboratory. We tested an anterograde and retrograde method of implantation. The retrograde method of implantation was chosen and subsequently used in 5 patients. A retrospective review of electronic medical records was subsequently undertaken to compare these endoscopic cases with consecutive concurrent open and percutaneous cases.

Results: The retrograde method of implantation was chosen because of reduced bony and soft tissue dissection required. In addition, more secure implantation was possible with this approach. We describe the endoscopic technique in detail. Five endoscopic cases were compared with 20 percutaneous and 13 open cases. Postoperative analgesia requirements for the endoscopic and percutaneous cases were similar, and both were significantly lower than for open cases ( P < .001). Operative time was expectantly longer for endoscopic cases. Same-day programming was possible with endoscopic cases, and with modified anesthetic and programming protocols, same-day discharge was possible for our last endoscopic case. With 6-month follow-up, we did not have any wound-related problems or hardware migration in these cases.

Conclusion: Our findings indicate that endoscopic SCS implantation is a safe and feasible option that combines key advantages of both open and percutaneous standard approaches for SCS implantation.

Background and objectives: With an aging population, the prevalence of spine pathology including degenerative spine disease continues to increase. These pathologies present a significant disease burden, often requiring long-term and expensive care. Recent literature has linked several socioeconomic determinants of health with outcomes after spine surgery. We sought to conduct a systematic review to determine the relationship between Area Deprivation Index (ADI), a measure of neighborhood-level socioeconomic status, and objective and patient-reported outcome (PRO) measures after spine surgery and to propose potential interventions.

Methods: An Embase and Medline search was conducted from inception to April 1st, 2024, for relevant articles assessing ADI and spine surgery outcomes. The inclusion criteria were all North American observational studies available in English that reported on the association of ADI and adult cervical, lumbar, neoplastic, or deformity spine surgery outcomes.

Results: Ten articles met the inclusion criteria resulting in a combined 56 925 patients who had undergone elective surgery for cervical, lumbar, spine metastases, and adult spine deformity pathologies. Two studies reported ADI to be associated with increased costs of care and postoperative lengths of stay after cervical spine surgery. Five studies found the association between high ADI with increased rates of respiratory failure, 90-day emergency room visits, longer lengths of stay, 90-day reoperation rates, and poor PROs after lumbar spine surgery. One study found an association with high ADI and increased 30-day and 90-day readmissions across all spine surgeries, and 1 study found no association between ADI and overall survival after surgery for spinal metastases.

Conclusion: Across available literature, high ADI seems to be associated with higher rates of postoperative readmissions and worse PROs. Further studies are needed to better understand the mechanisms underlying the effects of ADI on spine surgery outcomes and identify possible interventions to optimize outcomes.