Operative Neurosurgery最新文献

Background and objectives: The combined petrosal intertentorial approach (CPIA) has been proposed as an alternative to standard combined petrosal approach (SCPA). CPIA has been designed to maintain integrity of the temporal dura with a view to reduce temporal lobe morbidity and venous complications. This study has been designed to perform a quantitative comparison between these approaches.

Methods: Five human specimens were used for this study. CPIA was performed on one side and SCPA on the opposite side. The area of exposure (petroclival and brainstem), surgical freedom, and angles of attack to a predefined target were measured and compared.

Results: SCPA provided a significantly larger petroclival area of exposure (6.81 ± 0.60 cm 2 ) over the CPIA (5.59 ± 0.59 cm 2 ), P = .012. The area of brainstem exposed with SCPA was greater than with CPIA (7.17 ± 0.84 vs 5.63 ± 0.72, P = .014). The area of surgical freedom was greater in SCPA rather than in CPIA (8.59 ± 0.55 and 7.13 ± 0.96 cm 2 , respectively, P = .019). There was no significative difference between CPIA and SCPA in the vertical angles of attack for the Meckel cave, Dorello canal, and root entry zone of cranial nerve VII. Conversely, the horizontal angles of attack permitted by the CPIA were significantly smaller for the Meckel cave (52.36° ± 5.01° vs 64.4° ± 5.3°, P = .006) and root entry zone of cranial nerve VII (30.7° ± 4.4° vs 40.1° ± 6.2°, P = .025).

Conclusion: CPIA is associated with a reduction in terms of the area of surgical freedom (22%), skull base (18%), brainstem exposure (17%), and horizontal angles of attack (18%-23%) when compared with SCPA. This loss in terms of exposure is counterbalanced by the advantage of keeping the temporal lobe covered by an extra layer of meningeal tissue, thus possibly reducing the risk of temporal lobe injury and venous infarction. These results need to be validated with adequate clinical experience.

Background and objectives: To compare the safety and efficacy of carotid endarterectomy (CEA), carotid stenting (CAS), and optimal medical therapy (OMT) in patients with asymptomatic carotid stenosis.

Methods: Relevant randomized controlled trials were researched with PubMed, Web of Science, and the Cochrane Library databases. Fixed-effects model and random-effects model were used to estimate the relative risks and the hazard ratios (HRs). The results of the probabilistic analysis were reported as surfaces under the cumulative ranking curve.

Results: Eight randomized controlled trials were included. Data from 10 348 patients (CEA: n = 4758; CAS: n = 3919; OMT: n = 1673) were evaluated. Compared with the previous OMT, CEA, CAS, and the current OMT (c-OMT) were all effective in reducing the risk of stroke (CEA: HR, 0.52; CI, 0.40-0.66; CAS: HR, 0.58; CI, 0.42-0.81; c-OMT: HR, 0.40; CI, 0.15-0.94); CEA and CAS reduced the risk of ipsilateral stroke (CEA: HR, 0.41; CI, 0.28-0.59; CAS: HR, 0.51; CI, 0.31-0.84), and the risk of fatal or disabling stroke (CEA: HR, 0.59; CI, 0.43-0.81; CAS: HR, 0.57; CI, 0.34-0.95). Regarding reducing the risk of stroke, only CEA was statistically significant in patients with any degree of stenosis compared with the previous medical treatment (<80%: HR, 0.48; CI, 0.33%-0.70%; 80%-99%: HR, 0.53; CI, 0.38-0.73).

Conclusion: In the treatment of asymptomatic carotid stenosis, the perioperative outcomes of CAS were similar to that of CEA; CEA, CAS, and c-OMT shared similar long-term outcomes; and CEA and CAS may be more effective in patients with high levels of asymptomatic stenosis.

Background and importance: The surgical management of rostral disc herniations at L5-S1 poses challenges for conventional endoscopic approaches, particularly in patients who have had previous lumbar surgery. We present a full endoscopic transpedicular discectomy (FETD), whereby a pediculotomy is created to pass an endoscope through the pedicle for intracanal access. This addresses anatomic obstacles and potential complications associated with other endoscopic and minimally invasive or open techniques. To date, this is the only article to highlight this approach with a case report and intraoperative video.

Clinical presentation: A 76-year-old man with a history of L3-S1 laminectomy presented with left leg pain and a near-complete left foot drop. An MRI revealed a left paracentral rostrally migrated disc herniation arising from L5-S1 with impingement of the exiting left L5 nerve root at the inferomedial aspect of the pedicle of L5. The patient consented to the FETD procedure. Using sequential reamers of increasing diameter and a high-speed burr, a superolateral to inferomedial pediculotomy was performed. This approach allowed us to target the pathology at the point of maximum compression without traversing the prior operative field. A transforaminal endoscopic approach was not possible with the iliac crest obstructing rostral angulation. The disc was successfully removed without any intraoperative complications, and after surgery, the patient's radiculopathy resolved without any radiographic evidence of instability.

Conclusion: FETD is a unique approach that demonstrates the versatility of endoscopic spine surgery, offering advantages over conventional approaches particularly for rostral disc herniations at L5-S1 in the setting of prior lumbar surgery.

Background and objectives: Chronic subdural hematoma (CSDH) management involves various surgical techniques, with drainage systems playing a pivotal role. While passive drainage (PD) and active drainage (AD) are both used, their efficacy remains contentious. Some studies favor PD for lower recurrence rates, while others suggest AD superiority. A systematic review and meta-analysis were conducted to address this controversy, aiming to provide clarity on optimal drainage modalities post-CSDH evacuation.

Methods: This systematic review and meta-analysis followed preferred reporting items for systematic reviews guidelines, searching PubMed, Embase, and Web of Science until February 2024. Inclusion criteria focused on studies comparing active vs PD for subdural hematomas. Data extraction involved independent researchers, and statistical analysis was conducted using R software. The assessment of risk of bias was performed using the Risk of Bias in Non-Randomized Studies of Interventions framework and the Risk Of Bias 2 tool.

Results: In this meta-analysis, involving 1949 patients with AD and 1346 with PD, no significant differences were observed in recurrence rates between the active (13.6%) and passive (16.4%) drainage groups (risk ratio [RR] = 0.87; 95% CI: 0.58-1.31). Similarly, for complications, infection, hemorrhage, and mortality, no significant disparities were found between the 2 drainage modalities. Complication rates were 7.5% for active and 12.6% for PD (RR = 0.74; 95% CI: 0.36-1.52). Infection rates were available for 635 patients of the active group, counting for 2% and 2.6%, respectively (RR = 0.98; 95% CI: 0.24-4.01). Hemorrhage rates were also available for 635 patients of the active group, counting for 1.1% and 2.2%, respectively (RR = 0.44; 95% CI: 0.11-1.81). Mortality rates were 2.7% and 2.5%, respectively (RR = 0.94; 95% CI: 0.61-1.46).

Conclusion: Our study found no significant difference between passive and AD for managing complications, recurrence, infection, hemorrhage, or mortality in CSDH cases. Further large-scale randomized trials are needed for clarity.

Background and importance: Pseudomeningoceles are extradural accumulations of cerebrospinal fluid. In most cases, they appear as a complication of spinal operations. Omentomyelopexy is a surgery in which an autologous omentum flap is implanted over the dural opening. We describe a case of persistent pseudomeningocele treated with omentomyelopexy.

Clinical presentation: A 37-year-old man sustained a T12-L1 AO B3 fracture during a motorcycle accident. He underwent posterolateral fusion and then neurological rehabilitation. Two years later, however, his condition worsened, and he experienced progressive weakness-he was diagnosed with an intramedullary cyst, which was treated with laminectomy, arachnolysis and cystotomy. A pseudomeningocele developed afterward, and the patient underwent multiple reoperations in the following years, none of which were effective. Omentomyelopexy, a complex procedure aimed to facilitate cerebrospinal fluid absorption and subsequent formation of a permanent membrane, was offered to the patient as a "last resort." After undergoing omentomyelopexy, his pseudomeningocele resolved.

Conclusion: Although it should be reserved for exceptionally pertinent cases, omentomyelopexy is a viable option for managing persistent pseudomeningocele. However, further research is needed to better understand the effects and benefits of omentomyelopexy in this context.