Neurocirugia (English Edition)最新文献

Most cases of sciatica are caused by compression of lumbar nerve roots, although some originate from extraradicular structures, such as in ischiofemoral impingement syndrome. We present the case of a 64-year-old man with a 10-year history of right-sided sciatic pain occurring only while seated. He underwent several lumbar surgeries for spinal stenosis (L4-L5, then L3-L4, and later L5-S1 with fusion to S1), as well as multiple infiltrations and pulsed radiofrequency, without improvement. Neurophysiological and imaging studies showed no significant compression, except for edema at the ischial insertion of the quadratus femoris muscle. A diagnostic local anesthetic infiltration temporarily resolved the pain, confirming ischiofemoral impingement syndrome. He was treated with osteotomy of the lesser trochanter, achieving complete pain resolution and functional recovery. This case highlights the importance of considering extraradicular causes in patients with persistent sciatic pain after spinal surgery.

Introduction: Validated clinical scales for cervical myelopathy (CM) assess disease severity and treatment efficacy, but often fail to capture the patient's subjective perception of treatment effects. This study aimed to correlate commonly used clinical scales for CM with patient-perceived outcomes after surgical treatment. Additionally, it sought to establish minimum clinically important difference (MCID) thresholds for scales strongly correlating with patient perception Patients and Methods: A prospective, single-center observational study followed 47 patients with degenerative CM who underwent simple cervical laminectomy for one year. Patients were assessed using the mJOA, Nurick, cervical and brachial Visual Analogue Scales (VAS), the Neck Disability Index (IDC), and the EuroQol-5D (EQ5D). Patient perception of global effect (PGE) was assessed at 6 months and 1 year post-surgery using an anchor question asking if they perceived improvement, worsening, or no change. MCID was calculated using three anchor-based methods: mean difference, change difference, and the Youden index from Receiver Operating Characteristic (COR) curves. Definitive MCID thresholds were the average of these three methods Results: At the end of the follow-up, 25 patients (53.2%) had perceived clinical improvement with surgery, 15 (31.9%) had perceived no changes, and 7 (14.9%) had perceived worsening. The scales that showed the best correlation with patient perception were mJOA (η2=0.25; p=0.002), Nurick (η2=0.19; p=0.009), and NDI (η2=0.17; p=0.016). The definitive MCID thresholds for improvement were an increase in score ≥ 1.5 points in mJOA, a reduction of ≥0.56 points in the Nurick scale, and a reduction of ≥5 points in NDI. The definitive MCID thresholds for worsening were an increase of ≤0.23 points or a loss of score in mJOA, an increase of ≥0.33 points in the Nurick scale, and an increase of ≥1.26 points in NDI. According to the MCID thresholds, the majority of patients achieved clinically significant improvement: 59.6% in mJOA (compared to 25.5% with worsening), 27.7% in the Nurick scale (compared to 6.4% who worsened), and 42.5% in the NDI (versus 19.1% who worsened).

Conclusion: Patient perception of outcome following cervical laminectomy for spondylotic cervical myelopathy significantly correlates with functional scales like mJOA, Nurick, and NDI. The MCID thresholds indicate that patients require a more substantial change to perceive improvement than worsening, highlighting an asymmetry in subjective perception of treatment effects. These findings support using MCID, anchored in subjective perceptions, as a complementary tool to interpret the clinical relevance of quantitative changes in clinical scales.

The anterior approach to the cervical spine is a widely used technique in spinal surgery. Although its most common complications involve vascular, neural, or digestive structures, there is also the potential for injury to lymphatic vessels, which can lead to serious complications if not promptly diagnosed and treated. We present the case of a 70-year-old woman with a history of lumbar arthrodesis and a C5-C6 cervical prosthesis, who underwent an anterior microdiscectomy at C7-T1 via a right-sided approach. During dissection, a dense whitish fluid compatible with chyle was observed, indicating injury to a lymphatic vessel. Ligation with suture was performed and a prevertebral drain was placed. In the postoperative period, the patient developed a mild hematoma in the acromioclavicular region, without cervical collections. The drain was removed after four days of total fasting, followed by the introduction of a low-fat diet. The patient was discharged without complications. After five years of follow-up, no associated complications have been observed. Chyle fistula following anterior cervical discectomy is a rare complication (0.02%) and should be suspected in the presence of milky fluid in the surgical wound, drainage, and/or progressive accumulation. Early diagnosis and appropriate treatment are essential to prevent more severe outcomes. The risk is higher in left-sided approaches near C6 and low right-sided approaches (C7-T1), particularly in the presence of anatomical variants.

The experimental laboratory has been of paramount importance in the development and evolution of neurosurgey. In that research enviroment, many neurosurgical techniques were designed and the classsics approaches to different regions of the brain were refined, until turning neurological surgery into atraumatic procedure, fulfilling one of the founding axioms of this speciality, that of delicate treatment on brain tissue, advocated by Harvey Cushing and later optimized by professor Gazy Yasargil. The scenarios, their main characters, and the contributions they made to the development and progress of neurosurgey have all been analysed in this article from a historical standpoint.

Pituitary metastases from renal cell carcinoma (PM-RCC) are rare, with an unfavorable prognosis and survival ranging from 6 to 22 months. The objectives of this study were (1) to present a case of a 61-year-old male who achieved a 44-month survival, and (2) to analyze the literature focusing on survival and worldwide distribution. The reported case achieved one of the longest survivals documented after multimodal treatment including surgery, radiotherapy, and targeted therapy. The systematic review showed that PM-RCC predominantly affects males (73.7%) and has a mean survival of 10.9 months, lower than that reported for other pituitary metastases (median 16.5 months). Metastasis was initially suspected in only 13.1% of cases, and surgery was the most common treatment (84%), with wide variation in adjuvant therapy use. Most cases originated from high-income countries, with very limited or no representation from some regions. Relevant characteristics and prognostic factors are discussed.

Objectives: Strong evidence on the risk of haemorrhagic strokes for those with psychiatric conditions may lead to more effective interventions for mental health patients and inform future studies. This systematic review aimed to identify all the studies that compare the risk of haemorrhagic stroke for patients with and without depression, anxiety, schizophrenia, bipolar or personality disorders. It also aimed to provide a summary estimate of the risk, where possible, using meta-analysis.

Methods: Electronic searches were conducted in Embase, PsycINFO, PubMED, Scopus and the Web of Science, from database inception to the 11th of March 2025. A Random-effects model to estimate the pooled effect size with 95% confidence intervals was used.

Results: 17,214 references were initially identified. Eleven articles were included. Seven of them, five observational and two mendelian randomisation studies, investigated depression. In the meta-analysis depression showed a significant association with an increased risk of haemorrhagic stroke, with pooled HR: 1.28 (1.19-1.38) when only observational studies were included. When mendelian randomisation studies were added the result was a pooled HR: 1.26 (1.08-1.44). The risk of haemorrhagic stroke was increased in one of the three studies that investigated patients with anxiety disorders and in one of the three that looked at patients with schizophrenia. Two studies of bipolar disorder, and one of personality disorders, reported that patients with these conditions do not have an increased risk of haemorrhagic stroke.

Conclusion: Patients with depression have an increased risk of haemorrhagic stroke. The association of mental illness with haemorrhagic stroke needs further research.

Background and aim: There is no consensus regarding the best timing of vertebral augmentation (VA) procedures for the treatment of osteoporotic thoracolumbar fractures. This study aims to determine if early VA (performed during the first 2 weeks of evolution) show an advantage over delayed surgery in terms of efficacy and safety outcomes, and to evaluate the role of different modifiable therapeutic variables on the same outcomes.

Material and methods: Single-center retrospective study including all patients aged >50 years who underwent VA for thoracolumbar osteoporotic fracture from 2010 to 2023. Patients with two events in less than 3 months or incomplete follow-up were excluded. Pain relief, fracture progression and cement extravasation were assessed with regression analyses.

Results: One hundred fifty-four procedures were analyzed, with no significant difference in pain relief according to the timing of surgery. Early VA (1-14 days after symptoms onset) was associated with higher risk of fracture progression compared to intermediate (15-60 days; OR 15.2, p=0.001) and delayed (>60 days; OR 16.2, p=0.013) procedures; higher risk of cement leakage into the disc or vascular space (OR 3.2, p=0.025); but lower risk of spinal canal cement leakage (OR 0.16, p=0.027). No differences were observed between vertebroplasty and kyphoplasty.

Discussion and conclusion: Early VA showed equivalent but earlier effect on pain relief and reduced risk of spinal canal leakage when compared with delayed procedures, despite a non-clinically significant increased risk of fracture progression and cement leakage into the disc or drainage vessels. Thus, it was identified as the most effective strategy for balancing analgesic efficacy and procedural safety.

Background: Since gliomas have no cure, the quality of life (QoL) reported by patients assumes utmost importance in the therapeutic strategy. However, few studies have provided longitudinal data about how surgical resection impacts QoL as reported by patients, and even fewer have included preoperative assessments. The aim of this pilot study was to assess how glioma patients' QoL changes in the early postoperative period of glioma resection, at 1 month and 6 months, compared to preoperative.

Methods: Patients undergoing surgical resection of low-grade glioma (LGG) or high-grade glioma (HGG) were prospectively included from January 2022 to December 2022. To analyze patient-reported QoL we used EORTC QLQ-C30 and BN20 questionnaires applied preoperatively and at 1 and 6 months after surgery.

Results: We evaluated 34 patients (LGG-9; HGG-25). There were no differences in QoL at all evaluation time points between LGG and HGG groups. Within the LGG patients, QoL scores remained stable throughout 1- and 6-month evaluations. In patients with HGG, when compared to baseline, there were no meaningful variations in QoL at 1 month, but a clinically and statistically significant improvement (p=0.035) was found at 6 months. Total resection was associated with improved QoL in HGG patients at 6 months (p=0.025). At individual level, considering a minimum clinically significant value of 10, most HGG patients improved their QoL, while most LGG patients remained stable. Regarding subdomain analysis, a clinically and statistically significant improvement in future uncertainty was found in both LGG (p=0.042) and HGG (p=0.024) patients at 6 months.

Conclusions: Contrarily to previous studies that revealed a deterioration in HGG patients at 6 months, our preliminary data suggest an improvement in the QoL of these patients at 6 months. Additionally, total resection seems to be beneficial, as it was not associated with QoL deterioration, and can even improve QoL.

Intradural disk herniation (IDH) refers to the protrusion of the nucleus pulposus into the dural sac. While disk herniation is a relatively frequent condition, the intradural variant is exceptionally rare. Patients diagnosed with IDH often exhibit more pronounced clinical symptoms compared to those with extradural herniations. Establishing a definitive preoperative diagnosis remains challenging, as the pathophysiology and radiological features are not yet fully understood. Differentiating IDH from other intradural extramedullary pathologies, including schwannomas, neurofibromas, meningiomas, or metastatic lesions, can be complex. A systematic review was conducted on the diagnosis and treatment of cervical, thoracic and lumbar IDH, following PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and retrieving potentially relevant literature from PubMed and Embase. The search strategy included combinations of the terms "transdural" OR "intradural" AND "disc" AND "herniation". Age, sex, symptoms, herniated disk level, history of trauma, location of disk mass, imaging examination, pre- or intraoperative diagnosis and clinical outcomes were studied through the medical records. The type of surgery, the ventral dural defect management and the postoperative leakage of cerebrospinal fluid were also evaluated. One hundred and sixty-one articles involving 285 patients were selected. Cases of IDHs occurred at the lumbar (64.3%), thoracic (21.9%) and cervical (13.8%) levels. The most common level IDH was located at L4-L5 (27.6%). 49 patients exhibited cauda equina syndrome. Only 44 patients (15.4%) were diagnosed as having IDH preoperatively, while most patients were diagnosed intraoperatively. Neurological functions improved variably according to cervical, thoracic and lumbar locations (respectively 2.5%, 5.6% and 21.7%). IDH mostly involves the lumbar spine. Patients with IDH generally experience more severe symptoms than those with extradural disk herniation and have incomplete recovery of postoperative neurological functions. Diagnosing IDH remains challenging given its clinical presentations and radiographic features, and it is likely an underdiagnosed and underestimated condition.

We report the case of a 56-year-old female patient with controlled Human Immunodeficiency Virus (HIV) who presented with binocular diplopia and a known sixth cranial nerve palsy. Imaging revealed a lesion centered in the right cavernous sinus (CS) causing mass effect and displacement of adjacent structures. Progressive cranial nerve involvement led to surgical intervention. Intraoperative biopsy yielded inconclusive results, with initial suspicion pointing toward meningioma. Definitive diagnosis was only possible after paraffin-embedded histopathology confirmed a CS hemangioma. Postoperative management included pain control and corticosteroid tapering. The patient remains stable under multidisciplinary follow-up. This case underscores the diagnostic challenges of CS lesions and the limitations of intraoperative biopsy in differentiating vascular tumors from meningiomas and other CS neoplasms such as schwannomas should be taken into account.