Neurosurgery practice最新文献

Background and objectives: Decompression without fusion is a surgical option for the treatment of lumbar spinal stenosis (LSS) with grade I degenerative spondylolisthesis (DS). However, the outcomes of full-endoscopic decompression remain unknown. This study aimed to investigate the clinical and radiological outcomes of lumbar full-endoscopic decompression for spinal stenosis with grade I DS.

Methods: A total 43 patients with LSS with grade I DS who underwent lumbar full-endoscopic unilateral laminotomy for bilateral decompression and were followed up for a minimum of 1 year were retrospectively reviewed. Data on demographic characteristics, operative details, radiological images, clinical outcomes, and complications were analyzed.

Results: Pain, evaluated using the visual analog scale, was significantly reduced in patients undergoing full-endoscopic decompression in both the leg and back; the Oswestry Disability Index scores also improved (P < .001). MacNab's outcome classification was excellent or good in 95% of patients. One patient eventually needed the fusion surgery, and two patients required further diskectomy surgery because of recurrent symptoms. During follow-up, an increase in the vertebral slip was observed in 46.5% of the patients, but it was not statistically significant (P = .46). The progression of DS, defined as percentage of slip >5%, was observed only in 7% of the patients. An increase in vertebral slip was not associated with the clinical outcomes. There was no difference in radiological outcomes, such as angular motion (P = .36) and translation (P = .13), compared with the preoperative state. The operation did not exacerbate spinal instability. Rather, fewer patients had spinal instability postoperatively.

Conclusion: Endoscopic decompression alone has comparably good clinical outcomes with those of other surgical techniques in patients with LSS and DS. Few postoperative spinal instability occurred. Rather, the number of patients with instability decreased postoperatively. Full-endoscopic decompression may be a treatment option for patients with grade 1 DS.

Background and importance: Cocaine-induced midline destructive lesions manifest as various degrees of distortion to normal anatomy. We present a rare case of substance-induced clival defect that underwent surgical repair.

Clinical presentation: This patient presented with transient neurological deficits and was found to have severe clival destruction and pontine pneumatosis secondary to prolonged cocaine use. Surgical reconstruction of the clival defect was performed using a combined open and endoscopic approach.

Discussion: When anatomical integrity is severely compromised, defects of the clival region can be repaired using a hybrid open-endoscopic approach. In this case, the lack of local mucosal tissue for reconstruction led to the use of a pedicled pericranial flap.

Conclusion: Complete clival resorption secondary to cocaine use is uncommon. In advanced cases, pontine inflammation is present on imaging studies. Combined endoscopic and open clival reconstruction is effective in restoring anatomic integrity.

Background and objectives: Only few studies have investigated the psychological profile of patient candidates for awake craniotomy (AC). The aim of this study was to describe the multidisciplinary clinical protocol adopted in our hospital and to retrospectively explore differences in psychological characteristic of 51 patients, analyzing association with the tolerability of the procedure.

Methods: During the preoperative neuropsychological assessment, the Pain Anxiety Symptoms Scale was administered to assess pain-related anxiety. Clinical characteristics and anesthesiological management were retrospectively recollected. The AC procedure was classified as "optimal" or "suboptimal" based on administration of rescue sedative midazolam doses because of psychomotor agitation or emotional distress in excess with respect to our anesthesiological protocol.

Results: The awake procedure was considered optimal in 33 cases (64.7% of total sample). General anesthesia was never required in our patients. No significant differences between optimal and suboptimal groups were found. No single variable was significant as a predictor of outcome on the univariate analysis, and no multivariate predictive model was possible.

Conclusion: Although in our experience the Pain Anxiety Symptoms Scale score was not useful in identifying candidates for AC procedures, our multidisciplinary approach provided good results with respect to the tolerability of AC surgery. However, more studies are required to identify psychological profiles and preoperative possible warning signs to find the best course of surgery for each patient.

Background and objectives: Stereotactic radiosurgery (SRS) has been well established and considered a safe alternative for primary central nervous system lymphomas (PCNSLs). However, in HIV-related PCNSL, the use of SRS remains controversial. The purpose of this study was to evaluate the efficacy and safety of SRS in HIV-related PCNSL.

Methods: Forty-two adult patients with confirmed PCNSL and no previous radiotherapy or chemotherapy were selected, with 16 receiving Gamma Knife Radiosurgery (GKRS) alone and 26 receiving Highly Active Antiretroviral Therapy (HAART) before GKRS. Follow-up evaluations were conducted at 3, 6, 12, and 24 months post-treatment using clinical and imaging techniques. Statistical analyses were performed using SPSS v22, assessing for new lesions, changes in lesion size, progression-free survival, and overall survival.

Results: HAART/GKRS showed a significantly higher rate of complete response compared with the GKRS group, with 53.8% vs 18.8% (P = .048). The mean progression-free survival for the HAART/GKRS group and the GKRS group was 39.7 months and 31.2 months, respectively (P = .0051). Patients with a delayed HAART initiation (>6 months) exhibited an increased burden of T2 white matter lesions and a higher number of large lesions (odds ratio = 1.9, 95% CI = 1.44-2.42, P = .001). However, no significant difference was observed between the two groups regarding radionecrosis.

Conclusion: The study highlights the potential benefits of adding HAART to GKRS for patients with PCNSL, leading to improved survival outcomes. An early initiation of HAART was associated with less tumor progression, underscoring the importance of timely administration of HAART in patients with AIDS-related PCNSL.

Background and importance: Solitary plasmacytoma of bone (SPB) is a rare tumor that forms from monoclonal plasma cells within bone. These tumors are typically found in patients in their fifth to sixth decade of life and often progress to multiple myeloma. Previous reports have noted the formation of these tumors at the site of previous procedures or trauma, yet none have reported the development of SPB at the same site of a previous spinal surgery.

Clinical presentation: The authors report on a 47-year-old woman who developed a de novo plasmacytoma 6 years after anterior cervical discectomy and fusion at the surgical site.

Conclusion: Although SPB is a rare tumor primarily seen in bone that has been unaffected by surgery, it should be included in the differential after finding a tumor at the site of a previous spine surgery. Furthermore, biopsy should be considered once a lesion is identified in the area of a previous spine surgery, as SPB may progress to multiple myeloma, resulting in worse outcomes.

Background and objectives: Despite standard of care with maximal safe resection and chemoradiation, glioblastoma is the most common and aggressive type of primary brain cancer. Surgical resection provides a window of opportunity to locally treat gliomas while the patient is recovering, and before initiating concomitant chemoradiation. To assess the safety and establish the maximum tolerated dose of adipose-derived mesenchymal stem cells (AMSCs) for the treatment of recurrent glioblastoma (GBM). Secondary objectives are to assess the toxicity profile and long-term survival outcomes of patients enrolled in the trial. Additionally, biospecimens will be collected to explore the local and systemic responses to this therapy.

Methods: We will conduct a phase 1, dose escalated, non-randomized, open label, clinical trial of GBM patients who are undergoing surgical resection for recurrence. Up to 18 patients will receive intra-cavitary application of AMSCs encapsulated in fibrin glue during surgical resection. All patients will be followed for up to 5 years for safety and survival data. Adverse events will be recorded using the CTCAE V5.0.

Expected outcomes: This study will explore the maximum tolerated dose (MTD) of AMSCs along with the toxicity profile of this therapy in patients with recurrent GBM. Additionally, preliminary long-term survival and progression-free survival outcome analysis will be used to power further randomized studies. Lastly, CSF and blood will be obtained throughout the treatment period to investigate circulating molecular and inflammatory tumoral/stem cell markers and explore the mechanism of action of the therapeutic intervention.

Discussion: This prospective translational study will determine the initial safety and toxicity profile of local delivery of AMSCs for recurrent GBM. It will also provide additional survival metrics for future randomized trials.

Background and importance: Ossified spinal meningiomas are a rare form of spinal tumor. The removal in narrow surgical space is challenging because of their hard consistency and strong adhesion to the neural tissue. These meningiomas are often located in the upper thoracic spine, and sometimes, even the identification of the correct intraoperative level is difficult.

Clinical presentation: We describe the clinical findings, surgical strategies, and histological findings of a patient with a thoracic ossified meningioma.

Discussion: We discuss the technical points, safety, and efficacy of the piezosurgery device in reducing the calcified mass.

Conclusion: The device has the potential to reduce the operating time and enhance surgical safety when removing ossified meningiomas.

Background and importance: In recent years, sellar arachnoid cysts (ACs) have been increasingly treated using an endoscopic transnasal approach. It is important to connect the subarachnoid space with the AC to prevent recurrence; however, a high frequency of postoperative cerebrospinal fluid (CSF) leakage has been reported with the endoscopic transnasal approach, and the suitability of the endoscopic transnasal approach for treating sellar ACs is questionable to begin with.

Clinical presentation: A man in his 40s underwent surgery for a sellar AC compressing the optic chiasm. The normal pituitary gland was compressed dorsally by the cyst, and an endoscopic supraorbital keyhole approach was adopted to reduce the risk of postoperative CSF leakage. A small incision was made in the right eyebrow, and a small craniotomy was performed. A rigid scope was used to approach the cyst and incise the arachnoid membrane of the prechiasmatic cistern and the anterior wall of the cyst. Postoperatively, the cyst shrank, and the preoperative visual field defects improved. The duration of the endoscopic manipulation was approximately 40 minutes.

Discussion: The endoscopic supraorbital keyhole approach eliminates the need to incise the dura mater of the anterior skull base and reduces the risk of CSF leakage compared with the transnasal approach. In addition, cumbersome dural reconstruction using fat and fascia is not required during the supraorbital keyhole approach, which reduces operation time.

Conclusion: The endoscopic supraorbital keyhole approach may be more suitable than the transnasal approach for surgery of sellar ACs.

Background and objectives: Despite standard of care with maximal safe resection and chemoradiation, glioblastoma (GBM) is the most common and aggressive type of primary brain cancer. Surgical resection provides a window of opportunity to locally treat gliomas while the patient is recovering and before initiating concomitant chemoradiation. The objective was to assess the safety and establish the maximum tolerated dose of adipose-derived mesenchymal stem cells (AMSCs) for the treatment of recurrent GBM. Secondary objectives were to assess the toxicity profile and long-term survival outcomes of patients enrolled in the trial. In addition, biospecimens will be collected to explore the local and systemic responses to this therapy.

Methods: We will conduct a phase 1, dose-escalated, nonrandomized, open-label, clinical trial of patients with GBM who are undergoing surgical resection for recurrence. Up to 18 patients will receive intracavitary application of AMSCs encapsulated in fibrin glue during surgical resection. All patients will be followed for up to 5 years for safety and survival data. Adverse events will be recorded using the CTCAE V5.0.

Expected outcomes: This study will explore the maximum tolerated dose of AMSCs along with the toxicity profile of this therapy in patients with recurrent GBM. In addition, preliminary long-term survival and progression-free survival outcome analysis will be used to power further randomized studies. Finally, cerebrospinal fluid and blood will be obtained throughout the treatment period to investigate circulating molecular and inflammatory tumoral/stem cell markers and explore the mechanism of action of the therapeutic intervention.

Discussion: This prospective translational study will determine the initial safety and toxicity profile of local delivery of AMSCs for recurrent GBM. It will also provide additional survival metrics for future randomized trials.

Background and objectives: Phase-contrast MRI is unstable and is not widely implemented in the imaging of Chiari malformation type I (CM-I) because of its low signal-to-noise ratio and the need for subsequent additional averaging. Time-spatial labeling inversion pulse MRI (T-SLIP MRI) is an emerging imaging modality with a high signal-to-noise ratio. This study is the first to examine cerebrospinal fluid (CSF) dynamics on the basis of velocity exclusively in patients with CM-I using T-SLIP MRI before and after posterior fossa decompression.

Methods: Eleven patients with CM-I underwent T-SLIP MRI before and/or after posterior fossa decompression. CSF dynamics were analyzed at 5 points around the craniovertebral junction. T-SLIP measurements included (1) targeted CSF labeling; (2) manual frame-by-frame annotation of the labeled CSF wave; (3) description of CSF flow in terms of wave functions calculated using computation software; and use of this function for (4) calculation of CSF velocity (rostral and caudal peak), total distance traveled by labeled CSF, and mean CSF velocity ( $\overline{V}$ ). Differences between preoperative and postoperative peak velocity (rostral and caudal) and $\overline{V}$ were assessed using paired t-test.

Results: Rostral and caudal peaks significantly increased at 2 of the 5 points (40%), whereas $\overline{V}$ significantly increased at 4 points (80%), altogether covering all observation points with significant changes. CSF filling the syrinx through the syrinx wall from the spinal subarachnoid space and complex CSF flow at the dorsal craniovertebral junction were captured preoperatively and postoperatively, respectively.

Conclusion: T-SLIP MRI data for patients with CM-I were successfully quantified on the basis of velocity. Tailor-made optimal decompression should be pursued based on both T-SLIP data with high accuracy and bibliographical craniometric data with surgical outcomes, which can now be easily and comprehensively analyzed using machine learning.