Operative Neurosurgery最新文献

Background and objective: A retro-odontoid pseudotumor (ROP) is commonly associated with atlantoaxial dislocation and rheumatoid arthritis in the craniovertebral junction. The formation of ROP without rheumatoid arthritis and atlantoaxial dislocation represents an extremely rare condition known as idiopathic retro-odontoid pseudotumor (IROP). The objective of this study is to investigate the pathogenesis of IROP subsequent to long-segment subaxial cervical spine fusion and assess the efficacy of atlantoaxial or occipitocervical fixation and fusion surgery in its management.

Methods: The characteristics of the patients, surgical strategies, complications, and prognosis were meticulously documented during a retrospective chart review conducted on 8 patients diagnosed with IROP who underwent posterior atlantoaxial or occipitocervical fixation and fusion procedures. The average follow-up period lasted for 20.38 ± 5.93 months, during which neurological function was evaluated using the Japanese Orthopedic Association score and pre- and postoperative MRI imaging measurements were used to assess the regression of IROP by examining retro-odontoid soft tissue maximum thickness. The pseudotumor regression rate was also calculated.

Results: The final follow-up showed that patients who underwent atlantoaxial or occipitocervical fusion without C1 laminectomy achieved regression of IROP. No perioperative complications associated with the surgery were observed, and the neurological function, as indicated by the Japanese Orthopedic Association score, significantly improved.

Conclusion: The formation of IROP is closely associated with the decrease in range of motion of cervical spine following long-segment fixation and fusion of subaxial cervical spine, as well as the increase in biomechanical stress, hyperplasia, and hypertrophy of the ligament around the odontoid process in the upper cervical spine. Following fixation and fusion of the upper cervical spine, IROP can spontaneously regress upon elimination of pathogenic factors. For such patients, C1 laminectomy is unnecessary, and preserving it serves to provide a bone graft bed for upper cervical spine bone fusion.

Background and objectives: Peripheral nerve decompression (PND), including carpal tunnel release and ulnar nerve decompression, is a common procedure performed by neurosurgeons, orthopedic surgeons, and plastic surgeons. Because of the lack of established assessment parameters and performance standards for Entrustable Professional Activities in PND in the current literature, we conducted this study to define these assessment parameters and identify the expected standards of performance for graduating residents across the fields of neurosurgery, plastic surgery, and orthopedic surgery.

Methods: Electronic survey was sent to neurosurgery, plastic surgery, and orthopedic surgery faculty to obtain their perspectives on parameters of assessment and the expected standard competence performance regarding PND.

Results: Sixty-one participants returned fully completed questionnaires giving a completion rate of 53%. The overall recommended number of assessments was 5, and the recommended number of assessors was 2. Regarding each specialty, there was no significant difference in the recommended number of assessments; however, neurosurgeons and orthopedic surgeons recommended a significantly fewer median number of assessors (n = 2) than plastic surgeons (n = 3) (P = .01). Based on total responses, 77% believed that PND was appropriate for the general practice of their specialties. The majority of respondents expected graduating residents to achieve level E (50.8%) or level D (42.6%) for PND. There was no significant difference in the belief that PND was appropriate for general practice of their specialty or considering entrustment level E as a graduation target across the specialties.

Conclusion: Our study found significant agreement across specialties in the parameters of assessment expected of residents and the expected levels of mastery for independent practice. These results are relevant to residency programs and certification bodies like the American Accreditation Council for Graduate Medical Education in designing the assessment of milestones related to peripheral nerve surgery. This study has important implications for the design of residency and fellowship education in peripheral nerve surgery internationally.

Background and objectives: Hemispherotomy represents definitive treatment for drug-resistant epilepsy with unilateral hemispheric onset. Traditional approaches involve a large incision and open craniotomy, with associated risks of blood loss, infection, poor wound healing, pain, cosmetic concerns, and long hospital stays. The authors describe a minimally invasive hemispherotomy technique through a single burr hole overlying the Sylvian fissure. A case series of the first cohort of patients to undergo this procedure is detailed to provide an initial evaluation of the safety and efficacy of this approach.

Methods: A retrospective analysis was performed on the first 7 patients to have undergone burr hole hemispherotomy at the Children's Hospital of Philadelphia. Data on demographics, hospital stay, complications, completeness of disconnection, and postoperative seizure control were collected.

Results: Hemispherotomy was performed through a 15 to 18 mm burr hole on 7 patients-4 with epilepsy due to perinatal stroke, 1 with hemispheric malformation including schizencephaly, and 2 with a history of traumatic brain injury. Patient ages ranged from 18 months to 21 years at surgery. Complete hemispheric disconnection was achieved in all cases. Estimated blood loss was minimal (mean 25.7 cc, median 20, range 20-50) with no perioperative blood transfusions, intraoperative complications, or deaths. One patient returned to the operating room for closure of a wound dehiscence secondary to a fall. Opioid usage was minimal, with an average total postoperative opioid usage through postoperative day 5 of 468.9 morphine µg/kg equivalents (median 372.6 µg/kg, range 0.0-1751.7 µg/kg). One patient experienced a delayed ipsilateral basal ganglia hemorrhage with self-limited symptoms. All patients experienced substantial reduction in seizure burden, with 71% (5/7) achieving Engel Class IA outcome. No patients developed hydrocephalus or shunt malfunction.

Conclusion: The burr hole hemispherotomy approach consistently achieved complete hemispheric disconnection and represents a viable surgical approach. Preliminary results suggest a favorable risk profile.

Background and importance: Giant aneurysms can present technical challenges during treatment with flow diversion including inability to access the aneurysm outflow directly. Encircling the aneurysm with a microwire/microcatheter has been well described; however, it can result in a twisted stent because of catheter twisting during the reduction maneuver, which, in turn, could lead to thromboembolic complications.

Case presentation: Here, we describe a novel technique to manage the twist of the flow diverter in a giant internal carotid artery aneurysm using a combination of angioplasty and off-label placement of a balloon-mounted cardiac stent within the flow diverter.

Conclusion: At 1 year, the aneurysm is completely occluded on digital subtraction angiography and MRI, and the patient is neurologically intact.

Background and objectives: In patients with spontaneous intracranial hypotension (SIH), microsurgical repair is recommended in Type 1 (ventral) dural leaks, when conservative measures fail. However, there is lacking consensus on the optimal surgical technique for permanent and safe closure of ventral leaks.

Methods: We performed a retrospective analysis of surgically treated SIH patients with Type 1 leaks at our institution between 2013 and 2023. Patients were analyzed according to the type of surgical technique: (1) Microsurgical suture vs (2) extradural and intradural patching (sealing technique). End points were resolution of spinal longitudinal epidural cerebrospinal fluid collection (SLEC), change in brain SIH-Score (Bern-Score), headache resolution after 3 months, surgery time, complications, and reoperation rates.

Results: In total, 85 (66% women) patients with consecutive SIH (mean age 47 ± 11 years) underwent transdural microsurgical repair. The leak was sutured in 53 (62%) patients (suture group) and patch-sealed in 32 (38%) patients (sealing group). We found no significant difference in the rates of residual SLEC and resolution of headache between suture and sealing groups (13% vs 22%, P = .238 and 89% vs 94%, P = .508). No changes were found in the postoperative Bern-Score between suture and sealing groups (1.4 [±1.6] vs 1.7 [±2.1] P = 1). Mean surgery time was significantly shorter in the sealing group than in the suture group (139 ± 48 vs 169 ± 51 minutes; P = .007). Ten patients of the suture and 3 of the sealing group had a complication (23% vs 9%, P = .212), whereas 6 patients of the suture and 2 patients of the sealing group required reoperation (11% vs 6%, P = .438).

Conclusion: Microsurgical suturing and patch-sealing of ventral dural leaks in patients with SIH are equally effective. Sealing alone is a significantly faster technique, requiring less spinal cord manipulation and may therefore minimize the risk of surgical complications.

Background and objectives: Stereotactic procedures are used to manage a diverse set of patients across a variety of clinical contexts. The stereotactic devices and software used in these procedures vary between surgeons, but the fundamental principles that constitute safe and accurate execution do not. The aim of this work is to describe these principles to equip readers with a generalizable knowledge base to execute and understand stereotactic procedures.

Methods: A combination of a review of the literature and empirical experience from several experienced surgeons led to the creation of this work. Thus, this work is descriptive and qualitative by nature, and the literature is used to support instead of generate the ideas of this framework.

Results: The principles detailed in this work are categorized based on 5 clinical domains: imaging, registration, mechanical accuracy, target planning and adjustment, and trajectory planning and adjustment. Illustrations and tables are used throughout to convey the concepts in an efficient manner.

Conclusion: Stereotactic procedures are complex, requiring a thorough understanding of each step of the workflow. The concepts described in this work enable functional neurosurgeons with the fundamental knowledge necessary to provide optimal patient care.