Operative Neurosurgery最新文献

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.

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.