Neurosurgery practice最新文献

Background and objectives: Liposomal bupivacaine (LB) is a long-lasting formulation of local anesthetic which can be effective up to 72 hours postoperatively. Although it is approved for postsurgical analgesia through local wound infiltration and has frequently been used in spine surgery, there is little evidence regarding the effect of LB on cranial surgery postoperative care.

Methods: We retrospectively reviewed 79 patients who underwent elective craniotomy for unruptured anterior circulation aneurysms, of which 44 were given LB and 35 were not. Postoperative pain scores, length of stay (LOS), opioid use, and cost of pain medication were all obtained from the patients' charts and analyzed.

Results: There was no significant difference in initial pain scores, average pain scores, opioid use, or intensive care unit or overall LOS. However, the total cost of pain medication when taking into account the cost of LB was significantly higher in the LB group compared with the control group ($647.84 ± 122.50 compared with $284.77 ± 113.44; P < .0001).

Conclusion: Our data illustrate that LB does not seem to affect average pain score, total opioid use, opioid cost, or LOS but does seem to be associated with an overall increase in total cost of pain medication owing to the significant cost of LB. We suspect that although pain control is important in cranial surgery, the effect of LB is not substantial enough to affect overall pain control in these patients and is not a primary driver of hospitalization. However, further prospective, randomized studies would be helpful to evaluate the overall benefit of LB on cranial surgery outcomes.

Background and importance: Giant cell tumors (GCT) are rare neoplasms that primarily affect the long bones, with cervical spine involvement being uncommon, particularly at the C2 level. Although GCTs are considered benign, their aggressive growth patterns and high recurrence rates present significant treatment challenges, making aggressive tumor resection the treatment of choice. Using bone cement to fill the resection cavity has been associated with reduced tumor recurrence. Using a transoral approach provides an optimal surgical corridor for achieving an ideal exposure of such lesions at the anterior craniocervical junction.

Clinical presentation: A 23-year-old man presented with persistent atraumatic neck pain and no neurological deficits. Imaging revealed an osteolytic lesion in the dens, confirmed as a GCT through a transoral biopsy. To prevent spinal instability, posterior stabilization with a C1 to C4 instrumentation was performed, followed by endovascular embolization of arterial tumor feeders. Tumor resection was achieved through a transoral approach, supported by neuronavigation and intraoperative cone-beam computed tomography imaging. The resection cavity was filled with bone cement, and the construct was further stabilized using a vertical inline plate.

Conclusion: The transoral approach proved to be an effective and minimally invasive route for resecting the GCT at the odontoid in this case. Postoperatively, the patient experienced mild, transient dysphagia without neurological deficits. Cementoplasty of the odontoid proved to be a safe and effective procedure in this case, with the use of neuronavigation and intraoperative cone-beam computed tomography providing valuable feedback for the surgeon.

Background and objectives: Work-life balance (WLB) is the individual's view that personal and professional activities in their life align with current life priorities. WLB is important for health and is thought to prevent burnout in the workplace. Although high rates of burnout exist in neurosurgery (NS), studies of WLB and the factors that influence WLB in NS are not known.

Methods: An electronic international survey using a physician wellness framework was conducted globally. χ² tests were used to analyze the association between WLB and age, sex, level of practice, and continent of practice.

Results: Of 446 respondents (65% staff, 35% trainees; median age range 35-44 years age category; 28% women), only 42% indicated the presence WLB. The presence of WLB was significantly lower in trainees compared with staff (χ² = 14.065, P = .0002, odds ratio [OR]: 0.45 [95% CI: 0.30-0.68]), those aged 44 years and below (χ² = 4.1464, P = .04172; OR: 0.63 [95% CI: 0.41-0.96]), and those in the African region compared with non-African region (χ² = 8.33, P = .0039, OR: 0.42 [95% CI: 0.24-0.75]).

Conclusion: Nearly two-thirds of those in NS report poor WLB with trainees and younger individuals at particular risk. Lack of sufficient numbers of neurosurgeons for the workload and the lack of support staff require urgent attention globally. There is an urgent need for healthcare organizations globally to take leadership in implementing practices to improve WLB. Evidence shows these changes will likely improve personal and organizational well-being, retention, and improve medical student interest in NS.

Background and objectives: Male breast cancer (MBC) is very rare, and previous reports of brain metastases (BM) from MBC are limited. To date, the genetic characteristics of MBC with BM have not been explored. In addition, there is only a single case report documenting the use of stereotactic radiosurgery (SRS) for MBC BM. The aim of this study was to summarize genetic alterations associated with BM in patients with MBC and evaluate the safety and efficacy of SRS in this population.

Methods: Four male patients with a total of 20 MBC BMs treated with SRS were retrospectively reviewed. We defined treatment response as complete response, partial response, stable disease, and local progression (LP), per Response Evaluation Criteria in Solid Tumors (RECIST) criteria. The Kaplan-Meier method was used to estimate cumulative incidence rate of LP.

Results: The median overall survival was 16.3 months (95% confidence interval: 1.4-31.3 months). The mean age at treatment was 59 years (IQR: 56-60.5 years). Three patients had estrogen receptor-positive lesions, whereas one patient had triple-negative disease. Three patients had notable pathogenic alterations (including in AURKA, BRCA1, BRCA2, CCND1, CHEK2, ERBB2, FLT3, RAF1, and SPINK1). The median lesion size was 5.7 mm (IQR: 3.9-8.6 mm). The median delivered dose was 23 Gy (IQR: 22-24 Gy). Follow-up imaging at 3 months showed a reduction in median lesion size (3.3 mm). The percentage of lesions which were classified as complete response:partial response:stable disease:LP was 0%:45%:55%:0%, respectively. Cumulative 6-month and 12-month local control rates were 100% and 100%, respectively. Only one lesion demonstrated LP at the last follow-up (15 months).

Conclusion: This is the first report of genetic profiling of MBC with BM and excellent SRS outcomes. The receptor status and genetic alterations across our patients with MBC BM suggest heterogeneity in disease. Larger studies are needed to further explore MBC BM characteristics and treatment outcomes.

Background and objectives: Acute subdural hematoma (aSDH) ranks among the most prevalent conditions in neurosurgery. Depending on the hematoma and neurological condition, management is surgical or conservative. Open craniotomy is the mainstay of therapy if evacuation is mandated but is associated with considerable risks. We present a novel minimally invasive approach-twist-drill craniostomy with pressure-controlled subdural fibrinolytic irrigation (TDC-FIT)-for safe and efficient removal of aSDH in patients not requiring immediate evacuation and evaluate the outcome.

Methods: From June to December 2023, 10 patients with aSDH, Glasgow Coma Scale ≥13, hematoma thickness ≥7 mm, moderate neurological deficits without symptom progression, and no need for immediate evacuation were treated with TDC-FIT. A catheter with pressure-controlled irrigation containing an electrolyte solution with 200 000 IU/L urokinase at a target rate of 100 mL/h was inserted into the aSDH through a 3.5 mm TDC under local anesthesia. Irrigation was performed until radiological clearance of the aSDH was obtained. Outcome was compared with 30 historical matched controls treated with open craniotomy (Craniotomy cohort).

Results: In the TDC-FIT cohort, a near-complete hematoma resolution was observed in 9 (90%) patients, with 1 later recurrence of a chronic SDH, which subsequently resolved without additional sequelae after a conventional TDC. A total of 9 (90%) patients achieved independence (modified Rankin Scale 0-3) at 3 months, compared with 17 (56.7%) in the Craniotomy cohort (P = .012). One (10%) patient necessitated an open craniotomy because of neurological deterioration. The Craniotomy cohort experienced perioperative complications in 17 (56.7%) cases. Aphasia occurred in 2 (6.7%), hemiparesis in 4 (13.3%), epilepsy in 8 (26.6%), rehemorrhage in 2 (6.7%), meningitis in 1 (3.3%), and death in 2 (6.7%) patients.

Conclusion: TDC-FIT on aSDH may offer a safe and effective alternative to open surgery in patients not requiring immediate evacuation.

Background and importance: Anterior cerebral artery aneurysms requiring bypass are rare; thus, the literature regarding the subsequent pathology related to the procedure is severely lacking. Hence, there is no consensus regarding the management strategy. The progressive enlargement of de novo para-anastomotic aneurysm carries a higher rupture risk of this abnormal vessel. The peculiar location, related vascular territory, and small corridor of interhemispheric fissure pose challenges to its management.

Clinical presentation: We present a 70-year-old woman with two simultaneous de novo para-anastomotic aneurysms after an A3-A3 bypass. Previously, she had an A3-A3 bypass and aneurysm trapping of left A2 dissecting aneurysm 7 years ago. On routine follow-up imaging, she had progressive enlargement of two aneurysm-liked lesions on top of anastomosis vessels. She underwent a modified trapping and superficial temporal artery-anterior cerebral artery bypass with excellent clinical outcome and no recurrence.

Conclusion: Managing de novo aneurysm formation after in situ A3-A3 bypass is challenging. Complex procedures are required to secure the aneurysm from circulation and ensure its vascularization at the distal site. Long-term follow-up is necessary for all bypass procedures.

Background and objectives: Traumatic thoracic spinal cord injury (SCI) is complicated by chronic neuropathic pain and neurological deficits including bowel and bladder dysfunction. Treatment with spinal cord stimulation (SCS) has demonstrated possible utility in previous observational studies. In this article, we discuss the protocol for an actively enrolling, NIH-funded clinical trial investigating the use of dual lead (thoracic and conus medullaris) SCS as a possible treatment of SCI.

Methods: The clinical trial is a single-blinded, 2-arm parallel study for patients with a history of chronic neuropathic pain after thoracic SCI. Patients are allocated 1:1 to SCS "on" or SCS "off" to which they are formally blinded for 3 months. At 3 months, a 1-way crossover will occur. The primary outcome is the change in the Pain Impact Score of the Multidimensional Pain Inventory-SCI from baseline to 3 months. Secondary outcomes include the changes in electromyography amplitudes, motor and sensory American Spinal Injury Association scores, functional status using the spinal cord independence measure, Visual Analog Scale for pain, active medication use, Patient Global Impression of Change scale, quality of life, bladder control diaries, and harness-supported walking. As the trial is ongoing, data are not yet available for public access. Details regarding data access will be provided in the subsequent publication.

Expected outcomes: We expect to see differential improvements in the Pain Impact Score of the Multidimensional Pain Inventory-SCI, motor and sensory American Spinal Injury Association score, Visual Analog Scale, spinal cord independence measure, and Patient Global Impression of Change in the initial "on" vs "off" groups at 3, 6, 9, and 12 months.

Discussion: Dual lead SCS may serve as a safe and viable treatment option for patients living with SCI. We anticipate patients who undergo SCS to have improved neuropathic pain and neurological function, with greater improvement in patients receiving longer SCS.

Background and objectives: Frameless neuronavigation-guided stereotactic biopsy (SB) is a common surgical technique for diagnosing intracranial lesions. A frameless SB is generally performed under general anesthesia; however, no reports are available on the efficacy and safety of frameless SBs under local anesthesia (LA). This study reports the surgical outcomes, diagnostic yield, and feasibility of molecular analyses after performing a frameless SB under LA (SB-LA).

Methods: The study retrospectively included patients who underwent a frameless SB-LA at our institute between March 2015 and January 2024. The clinical characteristics, intraoperative findings, completion rate of surgical procedure, complications, diagnostic yield, and feasibility of molecular analysis were analyzed retrospectively.

Results: The study included 80 patients. Surgical procedures were completed in 79 patients (98.7%); the diagnosis was confirmed in 76 cases (95.0%). The diagnoses included diffuse gliomas (n = 38, 47.5%), primary central nervous system lymphomas (PCNSL; n = 27, 33.8%), other brain tumors (n = 4, 5.0%), demyelinating diseases (n = 2, 2.5%), and normal brain/gliosis (n = 5, 6.3%). All samples were sufficient for basic molecular analyses of isocitrate dehydrogenase 1/2, telomerase reverse transcriptase promoter, H3 histone family 3A, serine/threonine kinase B-RAF, and O-6-methylguanine deoxyribonucleic acid methyltransferase promoter methylation in gliomas and myeloid differentiation primary response gene 88 for PCNSLs. A comprehensive genomic profiling test using next-generation sequencing was attempted in 9 cases and was feasible in 8. Asymptomatic hemorrhages occurred in 14 patients (17.5%); no symptomatic hemorrhage occurred. Neurological deficits were observed in 1 patient (1.3%) who developed symptomatic small cerebral infarction. The median period from the first visit to our hospital to surgery was 3 days (range 0-12) for PCNSL and 6.5 days (range 0-21) for primary glioblastoma, isocitrate dehydrogenase wild-type.

Conclusion: Frameless SB-LAs can be performed safely with a high diagnostic yield and feasibility for molecular analysis. Frameless SB-LAs improve early diagnoses and therapeutic interventions without compromising molecular information.

Background and importance: We report the first case of microvascular decompression (MVD) performed for superior oblique myokymia (SOM) caused by vascular compression of the peripheral trochlear nerve, leading to successful resolution of symptoms.

Clinical presentation: A 46-year-old man with no significant medical history experienced intermittent fluttering sensations in his left eye for 6 years. Initial examinations revealed an intorsional microtremor diagnosed as SOM. Conventional brain MRI showed no abnormalities. Despite using anticonvulsants with no relief, his condition worsened. A more detailed MRI revealed compression of the peripheral trochlear nerve by a branch of the superior cerebellar artery. MVD surgery was recommended. A lateral supracerebellar infratentorial approach was used during MVD surgery. The compressed nerve was identified and relieved by wrapping the compressing branch in Teflon felt and repositioning it. After the surgery, the symptoms ceased immediately, and the patient was discharged within a week. Although he initially had mild trochlear nerve palsy with double vision on downward gaze, this resolved within 9 months without recurrence at the 22-month follow-up. Previous cases treated with MVD showed symptom relief, although some experienced temporary nerve palsy. No deaths were reported from the procedure.

Conclusion: MVD is an effective treatment method for SOM that can occur not only at the root exit zone of the trochlear nerve but also due to peripheral trochlear nerve compression.

Background and objectives: Patients with newly diagnosed lower-grade glioma (World Health Organization grade II and III) are typically of working age. However, work resumption after surgical resection is uncertain, possibly due to loss of capacity from resection of tumor-infiltrated brain regions. Therefore, we explore the association between work resumption and the resection location in addition to other patient, tumor, and treatment characteristics.

Methods: This retrospective cohort consisted of adults undergoing first-time resection for lower-grade glioma between 2011 and 2020 in hospitals in France, Germany, and the Netherlands. Employment was evaluated at baseline and within 1 year after surgery to determine work resumption. The association between work resumption and patient, tumor, and treatment characteristics was analyzed using logistic regression. Resection cavities were segmented from postoperative MRI scans, registered to standard brain space and related to gray nuclei, cortical networks, and white matter tracts using atlas parcellations. To identify brain regions potentially involved with work resumption, the association between work resumption and resection location was analyzed using Bayesian hurdle regression. The identified regions and characteristics were jointly analyzed in their association with work resumption using multiple logistic regression.

Results: Of 207 patients, 181 (87%) were employed at baseline. Of these employed patients, 111 (61%) had resumed work at follow-up. Male sex, younger age, and larger extent of resection were independent significant predictors of work resumption. Resection location was not associated with work resumption.

Conclusion: Almost two-thirds of patients resumed work 1 year after surgery. Work resumption was associated with patient characteristics (male sex and younger age) and extent of resection, but not with resection location.