Advances and technical standards in neurosurgery最新文献

The selective dorsal rhizotomy (SDR) procedure is an efficient surgical treatment of spasticity in children with cerebral palsy. My training background of pediatric neurosurgery at the British Columbia's Children's Hospital, an experienced center for spasticity, allowed me to contribute to the start-up of the rhizotomy program in Ulaanbaatar, Mongolia, in September 2022. Five spastic children with cerebral palsy with GMFCS levels 2-4 were chosen for the first SDR procedures. Intensive physiotherapy and rehabilitation program were given to children after SDR. After 6 months, early results were satisfactory.My personal experience of performing first SDR surgeries in another country is that the minimum of a SDR surgery team consists of a neurosurgeon, an electrophysiology technician responsible for selection of nerve rootlets, and an anesthesiologist. The physiotherapist responsible for patient selection and rehabilitation follow-up and rehabilitation facilities and family support are essential.

Hybrid operating rooms (HORs) combine a conventional state-of-the-art microsurgical theater and advanced imaging technologies, usually an intraoperative digital subtraction angiography (DSA) system. Initially developed for peripheral vascular surgery, HORs are gaining popularity among neurosurgical teams around the world. Based on their recent experience, the authors describe the launch of such a hybrid room in the University Hospital of Dijon Bourgogne and, through a narrative review of the pertinent literature, try to define the specific vascular neurosurgery conditions that may benefit from this highly demanding multidisciplinary environment. The association between intraoperative diagnostic and interventional endovascular capabilities and microsurgical management in the same location provides the possibility of immediate assessment of the surgical results, the immediate conversion to one or other technique if needed without transferring the patient, and appears to provide a very high cure rate of neurovascular malformations while minimizing the morbidity and mortality.

Intraoperative neurophysiology (ION) plays a crucial role in dorsal rhizotomy, a procedure aimed at reducing spasticity while preserving neural function. ION encompasses monitoring and mapping, with the mapping of the root/rootlet constituting a significant component. Despite the acknowledged roles of ION, persistent controversies exist, and a universally accepted standard for integrating ION procedures into dorsal rhizotomy remains elusive. This chapter provides a detailed explanation of the author's approach to dorsal rhizotomy, with a primary focus on the decision-making process for root/rootlet cutting. This process involves tetanic electrical stimulation of dorsal root/rootlet for rhizotomy, pudendal mapping to prevent urological complications, and monitoring the bulbocavernosus reflex (BCR). Additionally, the chapter introduces the use of the F-wave for assessing spasticity. The author terms this ION-guided dorsal rhizotomy as "functional posterior rhizotomy," signifying a shift toward a more functionally oriented procedure extending beyond root selection. The application of ION in this procedure is systematic, ensuring both spasticity reduction and the preservation of urinary function. Decision-making for root/rootlet cutting is a multifactorial process, incorporating ION results, spasticity distribution, patient age, and preoperative function. This functional approach aims to minimize the cutting rate through the comprehensive utilization of ION procedures and a cutting rate formula correlating with the GMFM-88 score. In conclusion, ION proves integral to dorsal rhizotomy, facilitating functional root/rootlet selection for spasticity reduction, preserving neural function, and offering predictive insights into surgical outcomes.

Selective dorsal rhizotomy (SDR) is a surgical intervention aimed at reducing spasticity in children with cerebral palsy. This chapter introduces an innovative approach to SDR, utilizing crescendo single-pulse evoked compound muscle action potential (CMAP) interpretation for rootlet selection. The method combines preoperative spastic muscle identification, intraoperative neurophysiological monitoring, and a precise stimulation protocol to guide the selective sectioning of sensory nerve roots. The chapter outlines the setup for crescendo single-pulse stimulation-guided SDR, including preoperative muscle group identification, intraoperative monitoring channels, and surgical approach. It details the stimulation protocol and defines criteria for motor nerves, sphincter-associated sensory nerves, and lower limb-associated sensory nerves based on evoked CMAP patterns. The concept of a "rhizotomy ratio" is introduced as a potential metric correlating with the severity of the patient's condition. Midterm outcomes of this approach are presented, based on a cohort of 481 cases with a minimum 2-year follow-up across all 5 levels of the Gross Motor Function Classification System (GMFCS). Results show muscle tone decreased by an average of 1.0 level in spastic muscle groups immediately after surgery, with a tendency to continue reducing by an additional 0.8 level in the following 2 years post-SDR. Motor function improved significantly, with 39.1% of patients advancing by one or two GMFCS levels (in 432 cases with preop GMFCS levels II-V), concurrent with intensive rehabilitation programs. The greatest improvements were observed in children who underwent surgery before age six and those with less severe preoperative motor impairments. The chapter also discusses postoperative rehabilitation strategies tailored to the gradual reduction in muscle tone experienced by children following SDR. Gait analysis in mild cases indicates improved walking patterns post-SDR. Overall, this crescendo single-pulse stimulation-guided SDR approach demonstrates promising outcomes in reducing spasticity and improving motor function in children with cerebral palsy, with minimal complications reported.

The endoscopic endonasal approach is a major step forward in the treatment of clival chordomas. It has improved the resection rate and in the same time reduced the complications. Chordomas located in the upper and mid-clival regions are well-suited for a purely endoscopic endonasal resection. Although with angulated endoscopes and curved high-speed drills, lateral parts of the tumor can be resected, lower clival lesions often necessitating a combination of both endonasal and transcranial approaches. A major limitation is a caudal tumor extension beyond the dens axis. For more caudally located lesions, a transoral approach might be needed. Since chordomas of the lower clivus may destroy the condyles or the dens axis, a posterior stabilization is frequently required in a second step of the surgery. Even though a gross total resection has been achieved, chordoma has the tendency to recur. Therefore, the current standard of care is postoperative proton or carbon ion radiation. Chemotherapy is not effective in classic chordomas, but has its place in poorly differentiated tumor which mostly occur in children. Recently, molecular targeted therapies have given hope for effective medical treatment options in the future.

This chapter aims to provide insightful guidance drawn from an updated litera ture search and the long experience of our multidisciplinary team in the surgical management of Cushing's disease. We will first compare the two primary TSS tech niques-microscopic and endoscopic-emphasizing the importance of surgical expertise. We will also discuss new imaging modalities, which may improve the preoperative localization of corticotroph microadenomas. Addressing scenarios where extensive imaging fails to detect pituitary tumors, the chapter analyzes diag nostic challenges, offering guidance on improving localization and effective surgi cal strategies, including the contribution of neuronavigation systems and intraoperative MRI (iMRI). This comprehensive exploration aims to empower clini cians in managing the complexities of Cushing's disease, from accurate localization to advanced surgical techniques and beyond.

Selective dorsal rhizotomy (SDR) is becoming increasingly popular in the management of spasticity in children. Spasticity itself is a multifaceted clinical entity that requires a holistic approach in order to effectively care for and improve the quality of life of those affected. To deliver these goals, a broad multidisciplinary team is required. From the role of neurosurgery in undertaking the procedure, through to the comprehensive rehabilitation process supported by physiotherapy, this chapter aims to summarise the key features necessary for an SDR unit to succeed as a team when providing care to their patients.

The history of dorsal rhizotomy for the treatment of spasticity was reviewed, from its inception to future perspectives. The evolution of this surgical intervention was staged into five distinct phases: "Dawn and Decline," "Revival," "Establishment," "Development," and "Future." Key contributions during each period were highlighted, with particular focus on the progression of surgical techniques and the evolution of intraoperative neurophysiological procedure. Insights leant from this historical review provide valuable guidance for the future development of dorsal rhizotomy in the management of spasticity.

Given the concerns associated with the ageing process in adults with cerebral palsy (CP) and the significant number of children who have undergone selective dorsal rhizotomy (SDR) in the recent decades, there is an important clinical need to evaluate both the short- and long-term impacts of this invasive and irreversible neurosurgical procedure. To gain insight in the health condition, the International Classification of Functioning, Disability and Health (ICF) model was used. The ICF serves as a biopsychosocial model for evaluating individuals with disabilities, providing a comprehensive perspective that encompasses understanding both the 'body structure and function' of individuals and determining the level of 'activity and participation' within the community. Furthermore, this review incorporates the dimension 'quality of life' as an essential factor to be discussed in relation to the outcomes of SDR. Based on a narrative literature review, this chapter outlines the outcomes observed at 5-15 years and 15-25 years post-SDR. Additionally, insights into outcomes beyond 25 years after SDR have been provided, drawing on the experiences of the Cape Town research group in South Africa, where SDR was reintroduced on a large scale by Warwick Peacock in the 1980s. The chapter concludes with a discussion on complications following SDR. This review will provide the clinical community and parents with information about the short- and long-term outcomes of this neurosurgical intervention.

Spasticity, characterized by muscle hypertonia, in children poses long-term challenges, leading to motor dysfunction, joint contractures, and a decline in overall quality of life (QOL). This underscores the critical need for effective spasticity management in disabled children. Various interventions, including oral medications, neurorehabilitation, and surgical procedures, have been used in the management of childhood spasticity. Dorsal rhizotomy, a neurosurgical intervention, plays a vital role in this context, selectively and functionally severing roots/rootlets to manage spasticity. Treatment modalities for spasticity encompass basic and active management, with interventions like dorsal rhizotomy, intrathecal baclofen infusion (ITB), and local injection of botulinum toxin (BTX). A strategic approach involves a "spasticity first" policy, prioritizing spasticity reduction, followed by active management and functional improvement through neurorehabilitation and orthopedic surgery. Comparative assessment of treatments, considering factors like age and joint involvement, guides the selection of interventions. Dorsal rhizotomy stands out for its sustainable and cost-effective reduction of spasticity, offering broad applicability across severity levels and diverse pathologies. Despite its efficacy, dorsal rhizotomy has limitations, including its invasiveness, irreversible nature, and the need for postoperative lifelong neurorehabilitation. Careful patient selection by a multidisciplinary spasticity clinic is crucial. The procedure's distinctive role, effectiveness, and cost-effectiveness place dorsal rhizotomy as a valuable tool in comprehensive childhood spasticity management.