British Journal of Neurosurgery最新文献

Aim: The aim of this study was to assess if patients undergoing redo microdiscectomy surgery, having scarectomy alone, reported having similar levels of pain relief to patients having surgery for recurrent disc. Scar tissue development is inevitable following lumbar surgery. Scar tissue can have a negative impact on patient's reported quality of life, however most surgeons are reluctant to operate primarily to remove this tissue for fear of a CSF leak and reported poor clinical outcomes. However, studies to date have reported only on outcomes following open surgery. Outcomes for microsurgical removal of scar tissue have not been reported.

Methods: We carried out a retrospective cohort study. We reviewed pre-op letters, operative notes and follow-up clinic letters for patients who underwent revision lumbar discectomy for radiculopathy between 2018 and 2022 at a single institution in Dublin. All patients had their pre and post operative level of pain recorded in clinic letters, using the visual analogue score (VAS).

Results: Our data suggests that complete resection of scar tissue alone seems to have similar improved VAS scores when compared to those having a revision microdiscectomy. Over 92% of patients in our study had an improvement in pain when undergoing removal of scar tissue.

Conclusion: Our small cohort study suggests there is improved post-operative pain scores for those patients who underwent scarectomy for recurrence of radiculopathy.

Purpose: Optimal management of unruptured, middle cerebral artery (MCA) aneurysms, remains undetermined between microsurgical clipping and endovascular intervention. This study aims to compare post-operative functional outcomes between microsurgically and endovascularly treated, unruptured MCA aneurysms.

Materials and methods: All cases of unruptured MCA aneurysms undergoing treatment during a 10-year time period were identified and included. Functional status (FS) was measured using the Modified Rankin Scale. FS was assessed pre-treatment and at 1-month, 6-months and 12-months post-treatment. Median FS was compared between groups and relative risk ratios (RR) calculated to compare the risk of post-operative deterioration between the microsurgical and endovascular cohort at each time point. Occlusion and retreatment rates were also compared.

Results: In total, 119 cases of treated, unruptured MCA aneurysms were identified, of which 40 (34%) were managed microsurgically and 79 (66%) endovascularly. Mean age was 55 years (SD ± 11). No significant difference was seen in any demographic domain pre-operatively. 30-day survival in both cohorts was 100%. No significant difference in median FS was seen between the cohorts at any time point post-treatment. There was a significantly increased risk of deterioration in FS amongst the microsurgical cohort at 1-month post-treatment (RR 1.98, 95% CI 1.08 - 3.62, p = 0.03). There was no significant risk of deterioration in FS at either the 6-month nor 12-month time point post-treatment. Complete occlusion in the microsurgical cohort was greater than the endovascular cohort (91% vs. 66%), demonstrating a significantly reduced RR of incomplete occlusion (RR 0.25, 95% CI: 0.08 - 0.77, p = 0.02).

Conclusions: At 1-month post-treatment, the risk of a decline in FS from baseline was almost twice as great in the microsurgical cohort. However, there was no significant difference in the risk of deterioration in FS at 6-months nor 12-months post-treatment.

Introduction: Lead fracture is a well-acknowledged form of hardware failure in deep brain stimulation (DBS) implants, with an incidence ranging from 1.46 to 5%. It has been noted to occur more frequently in patients with dystonia, and in terms of location in the cervical region. Impedance measurements serve as an objective means to assess the integrity of a DBS system, with increased impedance values typically indicative of lead fracture. We report a case of normal measured impedances in the presence of complete lead fracture.

Case report: A 12-year-old patient with a history of secondary dystonia due to cerebral palsy treated with GPi DBS (Boston Scientific^®) presented in dystonic crisis. Upon initial review the DBS system was considered intact based on measured impedances within normal range. Following further exploration, a chest X-ray was performed that showed fracture and dislocation of both extension leads.

Discussions: Normal impedance values in a system cannot be relied upon to ensure system integrity. If the impedance values are out of range then the system integrity is compromised, but if the impedance values are within range the system integrity might still be compromised. It is crucial for clinicians to include this possibility in any patient presenting with subtherapeutic therapy or undergoing MRI scanning.

Conclusion: Impedance measurements only may not provide a sufficient robust indication of system integrity in DBS implants, and in suspicion of a reduction in clinical effectiveness X-rays should also be performed to help establish system integrity.

Background: Arteriovenous malformations (AVM) carry a risk of haemorrhage and may also cause epilepsy or ischaemic steal phenomenon. Surgical resection leads to high rates of lesion obliteration but resection of AVMs located in eloquent cortex is associated with high rates of morbidity. The aim of this study was to assess the outcomes following surgical resection of AVMs in eloquent cortical locations with the use of intra-operative neuro-monitoring (IoNM).

Methods: A prospectively maintained database of AVM resections between 2012 and 2023 was reviewed. Data describing demographic details, AVM characteristics and outcomes of patients who underwent surgical resection of AVMs located in eloquent areas with IoNM were extracted. Functional status was assessed using the modified Rankin scale (mRS).

Results: 191 patients underwent resection of an AVM, of which 10/191 (5%) underwent resection with IoNM. 7/10 patients were female and the median age was 40 years (range 25-57). 5/10 (50%) of the AVMs were ruptured. The AVM was completely resected in 10/10 (100%) of cases. New neurological deficits occurred in 6/10 (60%) with no permanent neurological deficits observed. The median period of follow-up was 12 months (range 2-46) and the functional status of every patient improved or remained stable compared to their preoperative status.

Conclusion: IoNM may be a useful intra-operative adjunct during the resection of AVMs located within eloquent cortical areas. The use of IoNM should be considered when attempting surgical resection of AVMs located in eloquent cortical areas.

Objectives: The aim of this study is to help better understand whether length of stay (LOS) for patients admitted with spontaneous subarachnoid haemorrhage (SAH) is an appropriate quality indicator of care for comparison of NHS Neurosurgical department performance.

Methods: We utilised Hospital Episode Statistics (HES) at a unit level to demonstrate the number of spells between 2019 and 2023 for patients presenting with spontaneous SAH as well as those that had an endovascular or microsurgical procedure to secure the aneurysm. We captured data concerning average LOS and average readmission within 30 day rates for each centre throughout the period.

Results: We demonstrated a weak relationship between shorter LOS and increased readmission rates; however, when a single outlier institutions data were removed, this relationship disappeared. The mean LOS was 25.7 days with a mean readmission rate of 4.9% for treated spontaneous SAH patients. If each centre reduced LOS to that of the shortest, there is the potential for 10,000 bed days saved per year.

Conclusions: LOS for aneurysmal SAH patients has some promise as a quality indicator of care. We support a national quality improvement project going forwards to better understand the reasons for variation in LOS and to help eliminate unnecessary variability.

Background: Craniovertebral junction (CVJ) instability with irreducible basilar invagination (BI) and retroflexed odontoid poses a significant surgical challenge. Standard anterior decompression techniques-transoral or endoscopic transnasal-carry notable morbidity. Posterior approaches are rare and often invasive. We report the first clinical use of a purely posterior, extradural, transpedicular, monolateral odontoidectomy (PETMO) as a novel alternative in selected cases.

Methods: A 67-year-old woman with progressive myelopathy due to irreducible BI and os odontoideum underwent PETMO with occipitocervical fixation. The odontoid and os odontoideum were resected en bloc via a right C2 transpedicular corridor using an ultrasonic bone dissector. Intraoperative neurophysiological monitoring and micro-Doppler were employed.

Results: The patient showed steady neurological improvement, regaining independent ambulation at 1-year follow-up. Postoperative imaging confirmed complete resection, effective cervicomedullary decompression, and CVJ realignment.

Conclusion: PETMO offers a feasible posterior alternative for anterior CVJ decompression in selected patients with irreducible pathology and ligamentous insufficiency. It avoids the aerodigestive tract and minimizes neural and vascular manipulation. Though technically demanding, PETMO expands the surgical options for CVJ management and merits further investigation.

Purpose: The cerebral vasculature operates as a highly dynamic system that actively regulates blood flow to maintain the brain's physiological equilibrium while providing essential support for its functions. Therefore, enhancing our understanding of how cerebral blood flow is controlled, modified, or adapts in the presence of specific pathologies-such as stroke, Moyamoya disease, arteriovenous malformations (AVMs), or aneurysms-is critical for accurately evaluating the effects of these conditions and for developing effective therapeutic strategies for patients.

Materials and methods: A comprehensive literature review was performed with the aim of exploring recent advances in neuroimaging techniques used to assess hemodynamic alterations in the cerebral vasculature.

Results: We discuss the clinical applications of 3D time-of-flight magnetic resonance angiography (MRA), arterial spin labelling (ASL), 4D MRA, dynamic susceptibility contrast (DSC)-weighted bolus-tracking MR, perfusion computed tomography (CT), single-photon emission computed tomography (SPECT), quantitative digital subtraction angiography (DSA), and computational fluid dynamics (CFD) in the evaluation of aneurysms, stroke, AVMs, and Moyamoya disease, as relevant techniques in this field. Specific case examples of the benefit of each type of imaging were also explored.

Conclusions: By investigating these imaging modalities and their novel uses in understanding and guiding treatment, this review aims to offer a valuable resource for determining the most relevant parameters to be analysed when making clinical decisions regarding the management of these cerebrovascular conditions.

Introduction: This study addresses surgical scheduling within the Department of Neurosurgery at Aarhus University Hospital (AUH). The department provides neurosurgical care to a population of 1.3 million in central Denmark, and has treatment obligations for specific neurosurgical diseases for the entire country, which has a population of 5.8 million. Efficient utilisation of the department's four operating suites is crucial to ensure that patients have timely access to both non-elective and elective neurosurgical procedures. Historically, the elective operating room (OR) schedule was made without consideration of the possible arrival of non-elective patients; consequently, elective surgeries were often cancelled to accommodate those with more urgent indications. The challenge was thus to introduce a structured way of planning for these non-elective surgical procedures that would minimise the need for cancelling elective surgeries without decreasing overall productivity.

Methods: Using a mathematical model developed in a previous study at Leiden University Medical Center, the effect of allocating OR time during regular working hours for non-elective neurosurgical procedures at AUH was analysed, so that a weighted trade-off could be made between cancellations of elective patients due to an overflow of non-elective patients and unused OR time due to excessive reservation of time for non-elective patients. This allocation was tested in a six-week pilot study during weeks 24 & 25 and weeks 34-37 of 2020 before being implemented in 2021.

Results: In the 35 weeks following the implementation, the new allocation strategy resulted in a significant 77% decrease in the cancellation of elective neurosurgical procedures when compared with the same time period in 2019, with a significant 16% increase in surgical productivity.

Conclusions: This study shows that with mathematical modelling complex problems in the distribution of neurosurgical OR capacity can be solved, improving both patient safety and the working environment of neurosurgeons and OR staff.

Background: In multilevel posterior lumbar interbody fusion (PLIF) with posterior screw fixation, obtaining sufficient lumbar lordosis (LL) is difficult, especially in patients with osteoporosis. We performed intraoperative table modification (TM) using gravitational dropping of the patient's lumbar spine, to improve restoration of LL.

Methods: We retrospectively reviewed the medical records of patients who underwent three- or four-level PLIF between 2005 and 2019. One hundred eleven patients were enrolled, with 96 patients receiving non-TM-PLIF and 15 patients receiving TM-PLIF. Radiological parameters, including segmental lordosis (SL), LL, sacral slope (SS), pelvic incidence, and pelvic tilt, were measured. Clinical outcomes were measured using a visual analogue scale (VAS) for the back and leg preoperatively and at the last follow-up. Additionally, the correlation between the bone mineral density (BMD) and the radiological parameters was calculated for TM-PLIF. We performed propensity score matching between the groups to control the baseline difference.

Results: We found a statistically better correction between immediate and last follow-up postoperative SL (p = 0.04), as well as between preoperative and last follow-up SL (p < 0.01) in the TM-PLIF group compared to that in the non-TM-PLIF group. VAS for the back and leg were not significantly different between the two groups. Additionally, the efficacy of lordosis correction in the TM-PLIF group showed a statistically significant negative correlation between BMD and the SS change both before and after the surgery (rho = -0.60, p = 0.02).

Conclusion: Whilst further study is required to conclusively establish its efficacy, TM-PLIF (table modification using gravitational dropping) shows potential advantages for restoring and maintaining LL in multilevel lumbar fusion, particularly in cases with low BMD.

The diagnosis of multiple cerebral aneurysms in patients with a spontaneous aneurysmal subarachnoid haemorrhage is not uncommon. The incidence of rupture from a second aneurysm, whilst the patient is recovering from a first bleed is however extremely rare. We report a 21-year-old female with a WFNS grade 1 subarachnoid haemorrhage secondary to a ruptured 5mm right posterior communicating artery aneurysm which was secured with clipping. Sixteen days later, whilst an in-patient, she suffered a second SAH from a left anterior choroidal artery aneurysm which was subsequently coiled. Comparison of digital subtraction angiography showed an almost doubling of the aneurysm from 2.7x2 mm to 4.4x2.3 mm. We review the literature of previously reported simultaneous and sequential aneurysmal subarachnoid haemorrhage and add to the sparse literature on this rare phenomena.