Acta Neurochirurgica最新文献

Purpose

For intradural spinal tumors, information on the degree of calcification is helpful to plan the surgery. Novel deep-learning algorithms allow to generate synthetic computed tomography (CT) images from magnetic resonance imaging (MRI).

Methods

We conducted a prospective observational cohort study, including n = 105 patients with spinal pathologies between 07/2022 – 09/2023, to validate the accuracy of BoneMRI (MRIGuidance BV©, Utrecht, the Netherlands). Patients underwent both conventional CT and MRI; synthetic CT images were generated from MRI source data with artificial intelligence (AI). For the scope of this post-hoc analysis, only patients with intradural tumors were selected.

Results

Five patients with intradural tumors of the spine were included (mean age 67.8 years; 4 (80%) female). The tumors were visible on 5/5 conventional CT images (100%), on average 19.6 × 11.6 mm in size and 4/5 (80%) were densely calcified (mean Hounsfield units (HU) 463.6). Although well-visible on the T1w/T2w/BoneMRI source data, none of the tumors showed up (0%) on synthetic CT. Visible tumor dimensions were 0 mm in both axial (p < 0.001) and sagittal planes (p = 0.017), with an average density of 20.9 HUs (p = 0.034).

Conclusions

BoneMRI generated synthetic CT is a promising, radiation-free alternative to conventional CT. Intradural tumors – even those with dense calcifications – were not visualized by synthetic CT images, highlighting that this novel technology is currently not able to capture lesions outside its main scope. Our analysis demonstrates powerfully that synthetic imaging must be cautiously applied to populations for which it was developed and validated, and that any extrapolation can be clinically misleading.

Background

Local bone grafts are commonly used as filling material in cages during anterior cervical discectomy and fusion (ACDF). Alternatively, cages without filling materials can be used. The literature comparing these approaches is limited, and their respective effects on patient-reported outcomes (PROM) have been scarcely studied. This study was conducted to compare surgical outcomes and PROMs between local bone graft-packed cages and empty cages in ACDF surgery.

Methods

This observational study utilized data from the Swedish nationwide registry, Swespine. All adults who underwent ACDF between 2006 and 2020 were considered for inclusion. Exclusion criteria included missing baseline or outcome data. Patients were grouped according to cage type (with vs. without local bone graft). The primary outcome was achievement of a minimal clinically important difference (MCID) for arm pain in radiculopathy patients and for the European Myelopathy Score (EMS) in myelopathy patients. Secondary outcomes included complications, reoperations, and length of hospital stay. Outcomes were analyzed using multivariable generalized linear models adjusted for clinically relevant covariates.

Results

A total of 6,571 patients were included, with 2,963 patients (45%) receiving cages with local bone graft and 3,608 patients (55%) receiving cages without local bone graft during ACDF. Achievement of MCID for arm pain (radiculopathy) (OR 0.90, 95% CI 0.79–1.04, p = 0.15) and for EMS (myelopathy) (OR 1.15, 95% CI 0.67–2.03, p = 0.62) did not differ between groups. Local bone graft use was associated with higher odds of reoperation (OR 1.69, 95% CI 1.20–2.39, p = 0.003) and a longer hospital stay (β = 0.31 days, 95% CI 0.21–0.40, p < 0.001).

Conclusion

This nationwide registry-based study demonstrates that ACDF performed with or without local bone graft is equally safe and effective, with comparable rates of PROM MCID achievement and similar adverse event profiles, although use of local bone graft was associated with higher reoperations and longer hospital stays.

Background

Surgery of insular gliomas remains one of the most demanding areas in neuro-oncology. Traditional classifications (Berger–Sanai, Yasargil) have limited prognostic value. We evaluated the Integrated Insular Phenotype (IIP), an ordinal system reflecting tumor complexity and its associations with surgical outcomes.

Methods

We retrospectively analyzed 167 patients with histologically confirmed insular gliomas. For each case, tumor topography was classified according to Berger–Sanai, Yasargil, and IIP systems. Three binary outcomes were assessed: extent of resection (EOR), seizure control, and persistent neurological deficit at day 90. Logistic regression models were applied to evaluate associations, and performance was assessed using odds ratios (OR), AUC, AIC, and LR χ².

Results

Increasing IIP complexity was associated with reduced likelihood of total/subtotal resection (OR = 3.83; p < 0.001), poorer seizure control (OR = 2.90; p < 0.001), and higher risk of persistent deficits (OR = 2.83; p = 0.004). IIP showed lower AIC and higher LR χ² values compared with Berger–Sanai and Yasargil, indicating superior prognostic performance. While Berger–Sanai yielded high point estimates, confidence intervals were wide, and Yasargil produced consistent but less discriminative results.

Conclusions

In this retrospective cohort, the Integrated Insular Phenotype (IIP) showed superior prognostic performance compared with the Berger–Sanai and Yasargil classifications. IIP more accurately reflected topographic complexity and may assist in balancing oncological radicality with functional safety. Further prospective multicenter validation is warranted.

Purpose

Augmented reality (AR) technology integrates intraoperative imaging into the surgical field through AR headsets, enabling real-time, heads-up surgical navigation. While previous work has demonstrated that AR navigation achieves excellent radiographic accuracy for instrumentation placement, no studies have reported long-term patient-reported outcomes (PROs) following AR-guided spine surgery.

Methods

In this retrospective study with prospective follow-up, patient electronic medical records were reviewed for demographic, clinical, and outcome data. Pre- and postoperative PROs were collected, including Oswestry Disability Index (ODI) and 36-Item Short Form Survey (SF-36). Mental (MCS) and physical (PCS) component scores were derived from SF-36 responses. Univariate statistics and paired Wilcoxon tests were used to analyze patient characteristics and PROs. Multivariate linear regression was used to assess predictors of postoperative improvement in outcomes of interest.

Results

We identified 59 patients who underwent AR-guided spine surgery with ≥ 10 months follow-up (34% male, median age: 61 years, median follow-up: 25 months). Nine patients (15.3%) underwent reoperation at a median of 19 months—three for adjacent segment disease, four for pseudarthrosis, and two for other indications. Preoperatively, median ODI was 44 (severe disability), and MCS and PCS were 41.3 and 27.0. Postoperatively, ODI was 24 (moderate disability), and MCS and PCS were 54.1 and 37.7—representing significant improvements that exceed the minimal clinically important differences reported in the literature (approximately 10 points for ODI and 4 points for PCS and MCS; p < 0.001, p = 0.03, and p = 0.001, respectively).

Conclusion

This study represents one of the first efforts to evaluate the clinical impact of augmented reality–assisted spinal surgery beyond intraoperative usage. While AR technology has been shown to enhance pedicle screw placement accuracy, our findings extend this knowledge by demonstrating sustained long-term improvements in physical functioning, mental health, and disability among patients undergoing AR-guided pedicle screw placement that are reasonably similar to those reported following other means of pedicle screw placement.

Preservation of the perforating arteries (PAs) supplying the pyramidal tract (PT-PAs) is essential during glioblastoma resection. A 60-year-old man presented with sensory aphasia caused by a left medial temporal glioblastoma. To determine the surgical indication and strategy, we assessed the tumor’s location and its relationship with the PT-PAs using intra-arterial computed tomography (CT) angiography combined with ultra-high-resolution CT (UHR-IA-CTA), gadolinium-enhanced T1-weighted magnetic resonance imaging, and tractography. Imaging revealed an amygdala glioblastoma without the involvement of PT-PAs. Total tumor resection was achieved without neurological deficits. This case highlights how integrating UHR-IA-CTA can guide surgical planning and enable safe, complete glioblastoma resection.

Background

Paediatric traumatic brain injury (TBI) is a major global health concern and a leading cause of mortality and disability in children. Despite extensive research, knowledge on incidence based on national health registers is scarce. This study aimed to estimate incidence rates (IR) of TBI across all severity levels over three decades in Danish children.

Methods

Through a nationwide, population-based registry study we identified all children aged 0 to < 15 years born in Denmark between 1977 and 2018. Children were included at birth or immigration and followed until their 15th birthday, death, emigration, or December 31st, 2018. Incident TBIs were classified as minimal, mild, moderate, or severe.

Results

Among 3,235,391 children, 127,158 had a TBI before age 15 (56.8% male). The overall IR declined over the study period, with a significant reduction from 498.2 (95% CI 491.6–504.9) per 100,000 person-years (pyrs) in 1985–1989 to 336.2 (95% CI 330.4–342.0) in 2015–2018,the lowest rate observed. IRs for mild, moderate, and severe TBI declined to 50.8, 3.5, and 3.5 per 100,000 pyrs, respectively. In contrast, IR of minimal TBI continued to increase over time. Males consistently exhibited higher IRs, although both sexes showed a steady decline after 1999.

Conclusion

Paediatric TBI incidence in Denmark has declined over three decades, likely reflecting national prevention strategies e.g. traffic regulations. Nevertheless, incidence remains high, particularly among children aged 0 to < 3 years and males. These findings provide essential data to inform public health initiatives, while highlighting the need for injury prevention.

Purpose

Meningioma resection remains partial in over 25% of cases, with few known predictors of residual disease progression. This study aims to assess if dural attachment, identified on postoperative imaging, influences meningioma progression following subtotal resection.

Methods

A retrospective cohort design was applied to patients who underwent subtotal meningioma resection at our institution. MRI data collected over time included remnant volumes, surface areas of contact with dura and signal intensity ratios. Progression was defined as an increase in remnant volume of at least 25%.

Results

Sixty-one (61) remnants in 59 patients were followed for an average of 71.1 months postoperatively. Mean preoperative tumor volume and first remnant volume were 30.01 cm³ and 2.51 cm³, respectively. Criteria for progression was met in 35 remnants (57.4%), with a mean time to progression of 18.1 months. Greater surface area of contact with dura relative to total remnant surface area was a significant predictor of progression in both univariate and multivariate analyses. Smaller remnant diameter and larger extent of resection were marginally associated with progression. Signal intensity ratios failed to demonstrate association with progression.

Conclusion

The degree of meningioma remnant attachment to dura appears associated with progression. Reduction of dural involvement in residual disease intentionally left in place may be considered when appropriate, with further studies needed to refine surgical considerations.

Background

Retroperitoneal and pelvic schwannomas and neurofibromas account about 10% of all retroperitoneal tumors. These tumors are almost invariably benign and slow growing. They are either asymptomatic or cause radicular or abdominal pain. The radiologic findings cannot distinguish schwannomas from other retroperitoneal neoplasms. To our knowledge, this study is the first neurosurgical series of this size to employ intraoperative electrophysiological monitoring during resection of schwannomas and neurofibromas arising in the retroperitoneal and pelvic regions.

Methods

A retrospective study conducted at the University Hospital Göttingen from 2015 to 2024 included 13 patients who underwent surgical treatment for schwannomas and neurofibromas arising in the retroperitoneal and pelvic regions. The study incorporated detailed surgical descriptions of the resection techniques and the approaches used for these tumors.

Results

The mean age was 51 ± 12 years. Symptomatic presentations included abdominal discomfort in 6 patients (46%), unilateral radicular pain in 5 patients (38%), and 4 patients (31%) were asymptomatic. Tumors exhibited a mean diameter of 6.2 ± 2.9 cm (range: 3.3–14 cm). Anatomic distribution included 7 cases (54%) in the presacral region, 5 cases (38%) in the lesser pelvis, and 4 cases (31%) involving the L5 or S1 neuroforamen with extension into the ventral prevertebral space. Transretroperitoneal approaches were utilized in 8 cases (62%), while 5 (38%) underwent transperitoneal resection. Gross total resection was achieved in 10 patients (77%). In one patient, a transient intraoperative decline in sphincter MEPs was observed, with a 48% drop in amplitude, followed by full postoperative recovery. Direct electrical stimulation of the tumor capsule elicited active motor responses in 5 patients (38%). In 3 of these cases, complete resection was not feasible due to intraoperative changes in MEPs signals. The mean operative duration was 271.8 ± 64.5 min (range: 180–400 min), with a mean blood loss of 700 ± 400 mL. Postoperatively, no motor or sensory deficits occurred, and symptoms resolved within one week. The mean hospital stay was 9.2 ± 3.5 days (range: 5–15 days). Histopathology confirmed benign tumors in all cases: 8 schwannomas (62%), 3 neurofibromas (23%), and 1 ganglioneuroma (8%). No recurrences were observed during a mean follow-up period of 24 ± 6 months.

Conclusion

Surgical resection of retroperitoneal and pelvic schwannomas and neurofibromas, while technically challenging, is safe and effective when performed by experienced surgeons and multidisciplinary preoperative planning. None of our patients experienced postoperative complications, which may, in part, be attributable to the use of intraoperative neuromonitoring. However, comparative and prospective studies are recommended to further validate these findings.

Rosai–Dorfman disease (RDD) is a rare non-Langerhans histiocytosis that involves the central nervous system (CNS) in approximately 5% of cases, most often presenting intracranially. While pediatric cases have been reported more frequently, adult intracranial RDD (IC-RDD) remains poorly characterized. We conducted a systematic review and individual patient data meta-analysis in accordance with PRISMA guidelines to define the epidemiology, clinical presentation, pathology, management strategies, and outcomes of adult IC-RDD. PubMed, Scopus, and the Cochrane Library were searched for histologically confirmed cases in adults over 18 years, and case reports, case series, and observational studies were included. Data were extracted on demographics, symptoms, imaging, histopathology, treatment, and outcomes. Primary endpoints were recovery and recurrence-free survival (RFS), with risk ratios (RRs) and 95% confidence intervals (CIs) calculated using random-effects models. A total of 327 patients from 186 studies met inclusion criteria. The median age was 43.6 years (range 18–83), with a male predominance (70.9%). The most common symptoms were headache (35.2%), seizures or loss of consciousness (28.7%), and visual disturbance (26.9%). Lesions were typically supratentorial intra-axial (52.9%) or extra-axial (20.5%). Surgical intervention was performed in 93.6% of patients, with gross total resection (GTR) achieved in 45.3%. At a median follow-up of 18.8 months, 37.9% achieved full recovery, 46.8% partial recovery, and 15.3% experienced recurrence, with a median RFS of 12 months. GTR was strongly associated with improved recovery (RR 0.26, 95% CI 0.19–0.37), whereas supratentorial intra-axial location (RR 0.56, 95% CI 0.41–0.75) and perilesional edema (RR 0.65, 95% CI 0.47–0.89) predicted poorer outcomes. These findings indicate that adult IC-RDD predominantly affects middle-aged men, presents with mass-effect symptoms, and has a location-dependent prognosis, with GTR conferring the best chance of recovery but recurrence remaining common and underscoring the need for long-term surveillance.

Background

Surgeries performed at night may carry higher risk due to provider fatigue and reduced staffing, but data from neurosurgical populations are limited. We evaluated whether nighttime evacuation of chronic subdural hematoma (CSDH) was associated with increased complications or recurrence.

Methods

We conducted a retrospective cohort study of adults undergoing CSDH surgery at a tertiary neurosurgical center between 2006 and 2023. The primary exposure was nighttime surgery, defined by procedure start time. Primary outcomes were moderate-to-severe complications (Landriel-Ibáñez grade II–IV within 30 days) and CSDH recurrence (reoperation within 6 months). Multivariable logistic regression was used to adjust for confounders.

Results

Of 2860 patients, 709 (25%) underwent nighttime surgery. Nighttime surgery was independently associated with an increased risk of moderate-to-severe complications (OR 1.58, 95% CI 1.04–2.37; p = 0.028). This risk peaked during the final hours of the night shift. Although CSDH recurrence was more common after nighttime surgery in unadjusted analysis (13% vs. 10%), this difference was not significant after confounder adjustment.

Conclusion

Nighttime surgery for CSDH was associated with an increased risk of moderate-to-severe complications. When feasible, surgery should be performed during daytime hours.