Advances and technical standards in neurosurgery最新文献

Selective dorsal rhizotomy (SDR) in cerebral palsy care aims to improve gait and function in ambulatory children and enhance comfort in nonambulatory children. This assessment and planning process for SDR requires a multidisciplinary team to work closely with patients and families to weigh the benefits and risks of SDR. Preoperative assessments allow the clinical team to select suitable candidates, set realistic goals, and optimise outcomes. These evaluations include physical measures, assessment of gross motor function and functional daily living skills, and gait analysis to better quantify the impact of spasticity in the SDR candidate. Further orthopaedic evaluations are required to identify pain and musculoskeletal issues, guiding subsequent post-SDR interventions. Additionally, assessments of quality-of-life assessments ensure a comprehensive rehabilitation plan that includes psychosocial support. This chapter discusses the comprehensive preoperative rehabilitation assessments that assist clinicians and families in making shared decisions about SDR.

Cystic anomalies of the posterior fossa constitute an important chapter of the malformations of this region. Their interpretation is largely based on the existence of a pouch described by Joseph Blake in 1900. We have reviewed the ancient literature on which this description is based. All human data were obtained from only three fetuses. The histological and embryological analysis of these observations leads us to remain very cautious as to their significance. Indeed, this region of the posterior fossa is very fragile and subject to numerous technical artifacts. In addition, errors in fetal age lead us to believe that one of the observations cannot be used. It is therefore appropriate to be very careful when using this old literature. All these elements justify the need to revisit this problem in order to determine the normal development of this region in humans.

The treatment of craniosynostosis has evolved significantly over the past few decades. While open calvarial vault reconstruction remains a good treatment option, minimally invasive techniques have been shown to yield excellent results in children treated at a young age. This chapter details the use of endoscopic strip craniectomy with postoperative helmet therapy. This surgical option relies on early release of the fused suture to allow the child's own brain growth, plus use of a cranial molding helmet, to allow for correction of head shape. This chapter details the technique used to correct sagittal, metopic, and unicoronal craniosynostosis. Compared to open surgery, studies have shown that endoscopic surgery has comparable aesthetic outcomes and improved perioperative outcomes, such as blood loss, rate of blood transfusion, and time of surgery. This chapter reviews the techniques, aesthetic outcomes, cognitive outcomes, and advances in our knowledge of the genetics of craniosynostosis.

For almost as long as selective dorsal rhizotomy (SDR) has existed, there has been debate surrounding which patients should be eligible to undergo the procedure. The selection criteria used to identify suitable surgical candidates have remained largely unchanged for the last three decades, despite the popularity and use of the procedure increasing. Historically, those aged between 3 and 9 years, those of GMFCS level 2 or 3, and those without evidence of dystonia were considered for SDR. In recent years, as the procedure has continued to develop, however, these parameters are expanding, with evidence to suggest a much broader cohort of patients may benefit from SDR than once thought. This chapter seeks to review current practice in patient selection for SDR, as well as the potential directions that this controversial discussion may move towards in the future.

Selective dorsal rhizotomy (SDR) has been an important surgical treatment for spasticity for decades. Broadly, there are two surgical technique options-via a multilevel laminotomy/laminectomy or via a single-level laminectomy and conus approach. This latter approach is described in detail in this chapter, with discussion of patient selection and a focus on surgical techniques including the integration of electromyography (EMG).

To optimize the efficacy of dorsal rhizotomy (DRh) in treating spasticity associated with cerebral palsy, the authors advocate for individual access (intradurally) to all roots from L2 to S2. The initial step involves the use of electrical stimulation of the ventral root (VR) to confirm their anatomical identity and determine their corresponding myotomal territory of innervation, which is known to exhibit interindividual variability (anatomical mapping). The primary objective is then to employ dorsal root (DR) stimulation to assess their respective reflexive excitability levels (physiological testing). To mitigate the risk of spine destabilization, access is gained through enlarged interlaminar openings while preserving the spinous processes and interspinous ligaments. This approach is termed Keyhole Interlaminar Dorsal rhizotomy (KIDr). Intradural access to the roots is achieved at their preforaminal zone, through a L1-L2 opening for the L2 and L3 roots, L3-L4 opening for the L4 and L5 roots, and L5-S1 opening for the L5 and S1 roots. Under microsurgical visualization, at each exposed root level, the VR is stimulated to verify its myotomal distribution, and the DR is stimulated to estimate the segmental reflexive excitability using Fasano's grading system, allowing for the adjustment of the number of rootlets per root to be severed. In our practice, indications are primarily based on the Gross Motor Function Classification System (GMFCS): for individuals classified as levels III and IV, the goal is to enhance functional status and prevent or halt deformities; for those at level V and quadriplegic patients, the aim is to improve comfort, reduce pain, facilitate care, and alleviate upper limb disability through the "distant effects" often observed following lumbo-sacral rhizotomy. The timing of surgery is determined not only by age-related locomotor development but also by the plateau or deterioration of the Gross Motor Function Measure (GMFM) curve despite intensive rehabilitation efforts. As with all specialized centers, the surgical schedule is established in collaboration with a multidisciplinary team and documented in a comprehensive chart, alongside the Gain Attainment project.

Electromagnetic cranial navigation is a valuable alternative to the more commonly used optoelectric navigation, and it has several advantages in different neurosurgical indications enhancing the accuracy of surgery. Obviating the use of sharp head fixation, it has become a very helpful tool in shunt surgery and in pediatric neurosurgery. In addition, its usefulness has been shown in neuroendoscopy, tumor surgery, aneurysm surgery, and skull base approaches. Here, we provide an overview on the technique of electromagnetic navigation and summarize its main indications and advantages in cranial neuronavigation.

Selective dorsal rhizotomy (SDR) has been practiced for many years; however, standardization of processes such as the surgical technique and rehabilitation protocols are only relatively recent phenomenon. Comparing data from various studies can be limited due to temporal changes in practice, different selection criteria for SDR, the heterogeneity of cerebral palsy and variable rehabilitation protocols. This chapter reviews the available evidence in relation to best practice for rehabilitation following SDR and explores factors affecting the short- and long-term outcome following SDR. This includes more easily measurable factors, such as the child's preoperative Gross Motor Function Measurement (GMFM) and severity of spasticity, to social and cognitive factors which can affect participation in rehabilitation.

Background: Selective dorsal rhizotomy (SDR) has been instrumental in improving functionality and mitigating lower extremity spasticity originating from a myriad of central nervous system (CNS) etiologies. Existing literature on SDR extensively discusses its utility in cerebral palsy (CP)-associated spasticity management. There is a void on the utility and guidance in patient selection for SDR in pediatric patients with non-CP-related spasticity.

Methods: A systematic review was performed on studies describing SDR outcomes in pediatric patients identified from Medline and Embase databases. Publications between January 1970 and August 2023 were included. Combinations of search terms "selective dorsal rhizotomy," "selective posterior rhizotomy," and "spasticity" were utilized. Pediatric patient studies with clinical data on spasticity, ambulation, procedural variables, and follow-up outcomes were included. Articles including patients without cerebral palsy as a primary diagnosis were reviewed in detail for outcomes after intervention.

Results: A total of 114 publications were identified, and of these, 11 fit inclusion criteria for a total of 127 patients. Most common non-CP etiologies for spasticity included hereditary spastic paraparesis (27.8%, n = 34), congenital syndrome (n = 7), and spinal cord injury (21.9%, n = 6). Compared to their baseline, SDR in non-CP-related etiologies demonstrated tone normalization (93%, n = 43 out of 45 patients) in most and improvement in ambulation (49.2%, n = 58 out of 118 patients) in a significant proportion of patients.

Conclusion: This systematic review on SDR in pediatric patients revealed effective spasticity control and improvement in ambulatory functionality in selected patients without cerebral palsy. Appropriate patient selection is keystone in achieving sustained benefits in functionality and quality of life.

This paper provides an overview of optic pathway hypothalamic gliomas (OPHGs), neoplastic lesions that are mainly low-grade gliomas with predominance of pilocytic astrocytomas. They typically occur more frequently in children, but arise also in adults. While some tumors affect the optic nerve alone, the majority of them invade the hypothalamus and optic chiasm as well as adjacent structures. According to the pertinent literature, most authors consider extensive or curative tumor resection not feasible because of high risk for visual loss or severe hypothalamic side effects. Therefore, radiochemotherapy is a widely used modality to treat these challenging lesions. The authors of the present article describe a different strategy of selecting and treating surgically patients with OPHG. Similar to their management of low-grade gliomas in other intracranial location, they have treated a number of OPHGs microsurgically with curative intention. The present patient series comprises 56 individuals (42 pediatric and 14 adult patients). The authors achieved microsurgical gross total (99-100% tumor volume reduction) and near total tumor resection (90-98% volume reduction) in 42 patients (75.0%). There was no surgical mortality, and the rate of complications was low. Postoperatively, the patient's visual and endocrine function remained either intact or at a very satisfactory level in the vast majority of cases. These results differ from those found in previous publications dealing with OPHGs. In the author's experience, proper patient selection played an important role in achieving a good outcome. They conclude that microsurgical management should be considered an important part of the treatment plan in OPHGs. Patients should undergo surgery in an early stage before irreversible symptoms have occurred, and gross total tumor resection should be attempted in well-selected cases. Intentional partial OPHG resection and repeat surgery may help prolonging the symptom-free and tumor progression-free intervals.