Neurosurgery practice最新文献

Background and objectives: The nasoseptal flap (NSF) has been a versatile reconstructive option for extended endonasal skull base surgery, significantly decreasing postoperative cerebrospinal fluid (CSF) leakage rates. One failure mechanism of concern is NSF necrosis. It has been postulated that immediate postoperative MRI flap enhancement can predict flap necrosis. This retrospective study analyzes NSF enhancement to assess for flap viability and CSF leakage.

Methods: Patients from 2012 to 2020 who underwent extended endoscopic endonasal surgery with NSF reconstruction were assessed. Immediate postoperative MRI and delayed 3-month MRI were compared for NSF enhancement. Enhancement was graded as no enhancement, partial, or complete enhancement. Patient demographics, tumor type, intraoperative CSF leak grade, and postoperative CSF leakage were assessed based on flap enhancement patterns.

Results: Of 713 patients who underwent endoscopic endonasal surgery, 64 required NSF reconstruction. On the immediate postoperative MRI, 45 patients (70%) had complete flap enhancement, 9 (14%) had partial, and 10 (16%) no enhancement. On the 3-month MRI, 59 patients (92%) had complete flap enhancement and 5 (8%) had partial enhancement. There was significant improvement of flap enhancement between immediate postoperative and 3-month MRI (P = .002). All patients with no initial enhancement had complete enhancement at 3 months. Of those with partial enhancement, 2 remained partial and 7 had complete enhancement at 3 months. Overall, 44 patients (69%) had no change between MRI scans, 17 (27%) improved, and 3 (5%) had decreased enhancement. There was no correlation between intraoperative CSF leak rates and flap enhancement. Four patients had postoperative CSF leaks, 2 having complete immediate enhancement, 1 partial, and 1 without enhancement (P = .85).

Conclusion: Overall, immediate postoperative MRI NSF enhancement (or lack thereof) did not predict enhancement at the 3-month MRI and did not correlate with postoperative CSF leakage. Hence, one should not rely solely on postoperative flap enhancement to assess the viability of the dural reconstruction.

Background and objectives: Hemorrhagic subcortical vascular lesions such as cavernous malformations (CM) and arteriovenous malformations (AVM) can be neurologically devastating. Conventional open surgical resection is often associated with additional morbidity. The BrainPath® (NICO Corp.) transsulcal tubular retractor system offers a less-invasive corridor to deep-seated lesions. Our objective was to describe a single-center experience with the resection of subcortical hemorrhagic vascular lesions in adult and pediatric patients using the BrainPath® system.

Methods: The departmental database was queried for patients who underwent resection of a hemorrhagic CM, AVM, or cerebral aneurysm through the BrainPath® tubular retractor system between January 2017 and September 2021. All patients underwent either postoperative MRI (for patients with CM) or digital subtraction angiography (for patients with AVM or aneurysm). Demographic and clinical characteristics, preoperative and postoperative imaging features, operative details, and surgical and clinical outcomes were extracted through a retrospective review of the medical records.

Results: Fourteen patients (mean [SD] age 32.3 [23.9] years; 7 (50%) female) underwent BrainPath®-based resection of a deeply seated CM (n = 7), AVM (n = 6), or ruptured cerebral aneurysm (n = 1). The mean maximal lesion diameter was 21.5 (12.6) mm. The mean operative time was 134 (53) minutes. Residual lesion was present in 2 patients, both of which underwent repeat BrainPath®-assisted surgery for complete resection. All lesions were completely resected or obliterated on postoperative MRI or digital subtraction angiography. At a mean follow-up of 4.1 (1.1) years, the median modified Rankin Scale score was 1 (range 0-6).

Conclusion: In a well-selected cohort, we show the effective use of BrainPath® tubular retractors for resection or obliteration of subcortical hemorrhagic vascular lesions. This report further exemplifies the expanded role of the endoport system beyond that of intracerebral hemorrhage and tumor. Further study will elucidate the impact of this less-invasive brain retraction technique on clinical outcome in patients with vascular lesions.

Background and importance: Despite the advances in endovascular aortic repair techniques, type II endoleaks with aneurysm sac expansion remain frequent and challenging problems.

Clinical presentation: An elderly gentleman underwent a combined microsurgical and endovascular procedure to address a type 2 endoleak and the growth of a recurrent abdominal aortic aneurysm caused by direct puncture of a lumbar segmental artery. The patient tolerated the procedure well and was discharged without complications. Follow-up imaging revealed no further endoleak and a smaller aneurysm size.

Conclusion: This unique case presents a novel multidisciplinary surgical strategy for treating complex, recurrent aortic aneurysms with type II endoleaks. The approach is tailored to the individual patient and has shown effectiveness. Long-term follow-up data will be crucial for assessing the efficacy and durability of this approach.

Background and objectives: The Accreditation Council for Graduate Medical Education implemented a minimum of 6 weeks parental leave for residents in July 2022. The implementation and impact have not previously been studied in neurosurgery. Our primary study objectives were to determine whether an institution had a parental leave policy and quantify the Family and Medical Leave Act (FMLA) and total parental leave (TPL) time taken by neurosurgeons.

Methods: We conducted a cross-sectional survey (August 2023 to December 2023) of neurosurgeons (residents and faculty) in Accreditation Council for Graduate Medical Education-accredited programs. We elicited demographic information, experience with parental leave, and career satisfaction. Association between continuous variables was evaluated using Pearson's correlation. Data distribution was evaluated using the Shapiro-Wilks test. Central tendency comparison was performed using one-way analysis of variance, Kruskal-Wallis, or Mann-Whitney U tests.

Results: There were 147 anonymous survey respondents (response rate 15.7%), with an average age of 41 years. The majority (72.2% and 73%) were female and married. The mean age of first pregnancy was 32 years. On average, female residents and faculty took more TPL (7.7 weeks vs 9.0 weeks) and FMLA (6.0 weeks vs 6.8 weeks) than men (resident TPL:2.0 weeks, FMLA: 1.5 weeks. faculty TPL: 2.1 weeks, FMLA: 1.6 weeks). There was a significant difference between how much parental leave leadership believe residents have vs amount of FMLA (P-value = .004) and TPL (P-value = .001) residents took. There was a correlation between age and the amount of TPL (Pearson's R -0.307, P-value = .009).

Conclusion: Our survey demonstrates that neurosurgeons, in general, took less than the minimum suggested leave. Departmental leadership perceived that residents took more leave than they reported. This study highlights an opportunity to increase support for parental leave among neurosurgeons.

Background and importance: Spinal schwannomas are benign neoplasms originating from the spinal nerve sheath and account for around one-third of primary spine neoplasms. The most common treatment modality for these tumors is complete surgical resection. Compared with intradural tumors, the resection of an extradural spinal schwannoma is generally associated with a more complex approach, including longer incisions and increased lateral exposure. One useful surgical technique is the lateral extracavitary approach (LECA), which enables dorsal and ventrolateral access to the thoracolumbar spine with decreased rates of morbidity. Herein, the authors describe this approach for the resection of a giant extradural paraspinal schwannoma.

Clinical presentation: A 74-year-old female patient presented with right flank pain and difficulty breathing during strenuous exercise. Imaging revealed a large 8.5 × 5.2 × 6.3 cm solid paraspinal lesion spanning from T11-L2 vertebral body levels, with mass effect on the right posterior diaphragm and lung. Before surgical resection, the lesion was confirmed to be a schwannoma by needle biopsy. A LECA approach was used, achieving gross total resection. At 1-month follow-up, the patient reported great symptomatic resolution.

Conclusion: LECA proved to be an instrumental approach in a technically challenging resection of a giant extradural paraspinal schwannoma.

Background and objective: Burr hole craniostomy is performed for ventriculoperitoneal shunt insertion and endoscopic third ventriculostomy in patients with cerebrospinal fluid disorders. These burr holes are increasingly being used as windows for postoperative ultrasound, an investigational alternative to computed tomography or MRI for follow-up imaging of ventricular caliber. However, bone regrowth reduces ultrasound visibility, and little is known about burr hole regrowth rates in adults. Our study evaluates burr hole regrowth patterns and implications for transcranial ultrasound imaging.

Methods: We retrospectively analyzed 101 consecutive patients who had frontal burr hole craniostomy for new ventriculoperitoneal shunt insertion or endoscopic third ventriculostomy over a 3-year period. A mix of standard 14-mm burr holes and expanded 20-mm burr holes were used. Burr hole bone regrowth was assessed using serial follow-up computed tomography scans. Linear and logistic regression analyses examined if bone regrowth correlated with any clinical variables.

Results: There was wide variability in rate and degree of burr hole regrowth. The average percentage closure was 25% at 6 months, with minimal additional closure over the following 18 months. The mean residual diameter for 14-mm and 20-mm burr holes stabilized around 9.4 mm and 15.4 mm, respectively. Bone regrowth was not associated with patient characteristics, including age, sex, skull thickness, or etiology of cerebrospinal fluid disorder. Rate of bone regrowth was similar between both cohorts.

Conclusion: Bone regrowth after burr hole craniostomy is common, even in elderly patients, occurring rapidly within the first 6 to 12 months and subsequently stabilizing. It is frequently severe enough to restrict ultrasound visualization. Regrowth could not be predicted with any investigated variables, so uniform techniques are needed to block regrowth to allow for longitudinal ultrasound imaging, such as full-thickness cylindrical burr hole implants.

Background and objectives: With advances in surgical techniques over the past 40 years, single-level lumbar hemilaminectomy and microdiscectomy (HLMD) has become a standard outpatient surgery. Incidental durotomy is a common complication of lumbar decompression surgeries and often precludes same-day discharge based on preexisting paradigms, involving bedrest that have no empirical support, but often lead to increased complications in available evidence-based studies. Limited data exist regarding the safety of same-day discharge after lumbar decompression involving an incidental durotomy. The objective of this study was to establish the safety of same-day discharge after repair of incidental durotomy after single-level lumbar HLMD.

Methods: This study involved a retrospective review of the electronic medical record for all adult patients undergoing single-level lumbar hemilaminectomy and microdiscectomy by a single surgeon at our institution from 2013 through 2021. Descriptive statistics were used for data analysis.

Results: 346 lumbar single-level HLMD were performed during this time frame by a single surgeon. There were 17 incidental durotomies (4.9%), all primarily repaired. Of the 17 patients with incidental durotomy, all but 5 returned home on postoperative day 0, with the 5 who remained inpatient staying for reasons unrelated to the dural tear. Patients had no durotomy-associated complications, readmissions, or reoperations regardless of same-day discharge home.

Conclusion: Same-day discharge after primary repair of incidental durotomy in single-level lumbar HLMD seems to be safe and may significantly improve health care costs associated with HLMD. This investigation should be expanded to other one-level to two-level lumbar decompression surgeries and minimally invasive and endoscopic approaches.

Background and importance: Free bone flap craniotomy for open-wound depressed skull fractures poses a high risk of infection due to free bone fragments. This risk escalates in the presence of compound fractures with accompanying dural injuries. The primary objectives in managing depressed skull fractures include infection prevention and the correction of cosmetic deformities. This report describes the efficacy of vascularized flap craniotomy, which preserves blood flow to bone fragments, in reducing infection risks.

Clinical presentation: In this study, we present a 54-year-old man with a head injury and a Glasgow Coma Scale score of 8. He had an open wound in the left parietal temporal area and depressed skull fractures with compound bone fragments. The patient underwent vascularized flap craniotomy, focusing on maintaining blood supply to the bone fragments, resulting in successful wound healing without acute infections.

Conclusion: Vascularized flap craniotomy is an effective surgical option for treating open-wound depressed skull fractures, potentially reducing the risk of infection by maintaining blood flow to bone fragments. Further studies are required to validate its efficacy in larger patient populations.

Background and objectives: Deep white matter (DWM) is perfused by the medullary arteries from the cortex, and ischemia sometimes occurs after glioma resection. However, the clinical significance of postoperative medullary artery-related ischemia has not been well studied. We retrospectively reviewed cases of delayed DWM ischemia after awake craniotomy to elucidate the clinical characteristics, mechanisms, and management of delayed ischemia.

Methods: We identified 4 cases of intra-axial brain tumors, mainly gliomas, that underwent tumor resection by awake craniotomy at our hospital and developed DWM ischemic symptoms after surgery, despite no worsening of neurological symptoms at the end of surgery.

Results: Four patients (3 men and 1 woman) presented with glioblastoma, oligodendroglioma, astrocytoma, and brain metastasis. The median age at surgery was 47.5 years (41-73 years). The tumors were located in the watershed area in the frontal lobe (n = 2) and the parietal lobe (n = 2), all of which were left-sided (n = 4). DWM ischemic symptoms, such as motor dysfunction, aphasia, dysarthria, and dysgraphia, developed at an average of 24 hours (14-48 hours) after resection by awake craniotomy. All 4 patients showed symptom improvement within a week after surgery and completely recovered within a month.

Conclusion: DWM ischemia is caused by sacrifice of the medullary artery, which feeds the tumor and adjacent brain tissue during tumor resection, and should be considered when delayed aphasia or paralysis occurs postoperatively. These symptoms are often transient and recovery usually occurs. Tumors located in the frontal or parietal lobes, particularly in the watershed area, should be carefully monitored for postoperative ischemia.

Background and objectives: Pedicle screws with a central cannula and fenestrations allow cement augmentation, providing lower risk for screw loosening and pullout, especially in these patients with poor bone quality. This study aims to offer suggestions for resolving issues and reducing complications associated with the use of cement-augmented fenestrated pedicle screws.

Methods: A retrospective study was conducted across multiple centers on patients who received fenestrated pedicle screws with cement augmentation (CAFPS). Using 2-dimensional fluoroscopy guidance, we placed over 800 screws in 137 patients. Based on our analysis of common challenges and complications, 10 tips were compiled, that we believe are crucial for successfully implementing this technique, regardless of the brand or instrument used.

Results: The 10 tips included the following: (1) Indications of cement-augmented fenestrated pedicle screws; (2) use the K-wire blunt end in osteoporotic vertebrae; (3) know the longitude and diameter of the screw, by the measurement of the vertebrae to treat; (4) do not go bicortical; (5) clean the way of the screws fenestrae with saline; (6) protecting screw extensors with gauze; (7) measuring time and volume; (8) gently and smoothly introduce the cement; (9) do not panic. The presence of cement in the posterosuperior area adjacent to the pedicle does not necessarily indicate a leakage into the canal; and (10) fenestrated screw removal.

Conclusion: The implementation of these tips could enhance technique performance and minimize complications in cement-augmented fenestrated pedicle screw placement.