British Journal of Neurosurgery最新文献

Background: The essential tremor (ET) course to 54 months post-unilateral VIM/PSA magnetic resonance-guided focused ultrasound (MRgFUS) in the treated arm (TA) and non-treated arm (NTA) of 12 patients is reported.

Methods: Tremor severity was rated using Bain Findley spirography (BFS) scores in the TA and NTA. We divided follow-up into 'Early' (0-6 months) and 'Late' (6-54 months) phases, to minimise the effect of peri-lesion oedema resolution on the latter.

Results: The mean baseline BFS score was 6.2 in TA and 5.7 in the NTA. After unilateral VIM/PSA MRgFUS, mean BFS improved in TA at all subsequent time points (p < 0.001), with no significant differences between BFS scores at consecutive assessments or between 1 and 54 months, while the NTA BFS scores worsened between 12 and 24 months (p < 0.003). Three patients showed worsening of their TA BFS scores and an increasing NTA-TA BFS difference, indicating slower tremor worsening in TA compared to NTA, whilst one patient showed a greater rate of worsening in the TA compared to NTA BFS.

Conclusion: After 54 months, the beneficial effect of MRgFUS is usually maintained with any worsening of BFS scores in TA slower than in NTA. Loss of treatment benefit is rare.

Background: Ambulatory anterior cervical discectomy and fusion (ACDF) is a promising method, but not common in Poland.

Objective: That is why the purpose of this study was to demonstrate the experience of performing ACDF in patients with degenerative spinal diseases.

Methods: This study at the Spine Centre involved a single-center, multi-surgeon evaluation of 100 patients undergoing ACDF.

Results: Outcomes assessed included pain severity, measured by the visual analogue scale, which improved from 4.28 ± 0.76 preoperatively to 1.11 ± 0.59 one month postoperatively. The Core Outcome Measures Index-neck (COMI-neck) scale also showed significant improvement: before surgery, 30% of patients scored their condition severity between 4-6, and 70% scored 7-10; 6 months postoperatively, the scores were 0-3 for 55% of patients, 4-6 for 45%, and 7-10 for none. Only 2% of patients experienced moderate, temporary complications, with no serious complications or postoperative hematomas observed.

Conclusion: The study supports the feasibility, safety, and efficacy of performing ACDF in an ambulatory setting, suggesting that with appropriate patient selection and surgical protocols, ambulatory ACDF can be more broadly implemented.

Background: Cervical foraminal stenosis on MRI may be assessed using the Kim, modified Kim or Siller methods. This study aimed to investigate which morphological features of cervical foraminal stenosis in patients with cervical radiculopathy correlated best with pre-operative and post-operative surgical outcome following Anterior Cervical Discectomy (ACD) or a Posterior Cervical Foraminotomy (PCF).

Methods: Pre-operative MRIs of adults with cervical radiculopathy were assessed by six raters. The following measurements were made; uncompressed nerve root diameter, maximal compressed nerve root diameter, anterior & posterior compression, length of the neuroforaminal canal where the diameter was less than the uncompressed nerve root diameter and the distance of maximum compression from the apex of the ligamentum flavum. The Kim, modified Kim and Siller grades were calculated. Neck Disability Index (NDI) was measured pre-operatively and six weeks post-operatively. The radiological measurements and grades were compared to the pre-operative and change in NDI.

Results: Mean NDI was higher in female (58.2) than male patients (45.6) p = 0.05. No other baseline, operative or radiological factors where significantly associated with the pre-operative NDI. The mean [±SD] post-operative NDI was 14.3 [±22.5]. This represents a change of 37.8 (p < 0.001). The pre-operative NDI correlated strongly with the post-operative NDI but no other patient, operation or radiological factors correlated significantly. Neither pre-operative NDI or change in NDI was statistically different in those treated with ACD and those treated with PCF.

Conclusion: There was no association between pre-operative NDI and any of the radiological measurements or radiological grades. Furthermore, whilst surgery significantly improved NDI, for those patients with anterior compression, there was no difference in outcome between those treated with an ACD and those treated with a PCF. Current axial MRIs do not adequately assess the cervical nerve root foramina or predict surgical approach, 3D isotropic acquisition and DTI should be explored.

Neurobrucellosis is a rare complication of brucella infection which presents as meningitis, meningoencephalitis, subdural empyema, brain abscess, myelitis, and radiculo- neuritis. We report the first case of neurobrucellosis presenting as an infected cerebellopontine cistern epidermoid cyst in a young immunocompetent male who presented with fever and acute raised intracranial pressure. MRI brain showed an extra-axial mass in the right cerebellopontine angle cistern with peripheral rim enhancement and diffusion restriction. Emergency surgery unveiled a well-encapsulated lesion containing thick pus and keratinous material, confirming an infected epidermoid cyst. Intriguingly, the culture revealed Brucella infection, but the source of the infection remained unclear.

Background and objectives: Around 20-40% of trigeminal schwannomas (TS) are dumbbell shaped, spanning the middle and posterior cranial fossa The petrous apex is often truncated in these patients, aiding surgical resection of both compartments through the middle fossa approach. However, a less eroded petrous creates a blind spot, making total resection difficult. This study describes the feasibility of an approach combining expanded Meckel cave access with tailored petrous bone drilling to optimize tumor visualization and resection.

Methods: Eleven patients with dumbbell TS and minimal petrous apex erosion underwent the described surgery. Surgical steps included temporo-orbito-zygomatic craniotomy, middle fossa floor drilling, navigation aided (tailored) extradural petrous bone drilling and extra-arachnoidal tumor excision. Extent of resection and postoperative outcomes were recorded.

Results: Patients presented with trigeminal nerve dysfunction (n = 9; sensory -9 and motor - 5), headache(8/11), ataxia (7/11) and pseudobulbar palsy (3/11). Complete tumor resection was achieved in all patients. Postoperatively, 8 out of 9 patients had transient increase in facial hypoesthesia with conjunctival injection in 3. It improved within 3-6 months, except in four cases wherein mild hypoesthesia persisted. Motor symptoms improved in 2 of 5 patients. Two developed transient 6th nerve paresis, that resolved in 2 months. Cerebellar and brainstem pressure symptoms resolved in all. No patients developed new onset permanent neurological deficit. Two patients reported mild post-craniotomy masticatory difficulty.

Conclusions: The additional tailored petrous bony drilling enhances the surgeon's view, allowing a higher chance of total resection with no major operative morbidity.

Pilocytic Astrocytomas are generally presenting as WHO grade 1 intracranial masses in the paediatric population with a favourable prognostic. In less common instances they can be found in the spinal cord. There have been rare cases of Anaplastic variants of the Cranial Pilocytic Astrocytomas. We report a rare instance of an adult patient with pilocytic astrocytoma of the cervical cord with anaplastic features. Our patient presented with 6 months history of neck pain and right-hand paraesthesia which partially responded to steroid treatment. MRI of the cervical spine demonstrated marked expansion of the cervical cord with oedema extending cranially to the medulla and caudally to the mid-thoracic cord. Post-gadolinium T1-weighted images showed intense intramedullary enhancement mainly centred at the level of the C3 vertebra. Diffusion Tensor Imaging Tractography showed the central location of the tumour expanding the cord and displacing the tracts circumferentially. Surgical resection was performed in two stages according to the Elsberg and Beer technique that assisted with safe margin tumour debulking. The histological sections revealed a glial lineage tumour with retained ATRX nuclear expression, positive for GFAP, Ki-67 estimated to 10% and a methylation class corresponding to an Anaplastic Pilocytic Astrocytoma. Subsequently, our patient underwent adjuvant radiotherapy and chemotherapy (10 cycles of Temozolamide and 6 cycles of CCNU). Symptomatic progression developed at 18 months from the initial surgery, radiological progression at 34 months and the overall survival was 40 months. We reviewed the literature and found only four other cases with similar histology.

Purpose: Lynch Syndrome (LS) is a cancer-predisposing condition resulting from hereditary mutation of DNA mismatch repair genes. Gastrointestinal, urogenital, and endometrial carcinomas are well-known to predominantly occur in LS patients. In contrast, there are only few reports on brain tumours in the context of LS and to date intracranial tumour manifestation appear to be rather coincidental.

Methods: We present the case of a 56-year-old female developing aggressive lactotroph pituitary adenoma following a history of multiple Lynch-associated malignomas and having a confirmed MSH2 mutation. Furthermore, we performed a literature review via PubMed using the search terms 'Lynch Syndrome', 'HNPCC', 'MMR mutation' combined with 'intracranial tumour', 'sellar tumour', 'pituitary adenoma', or 'pituitary carcinoma', focusing on other reported cases and treatment regimens.

Results: A handful of studies have indicated an increased frequency of brain tumours in the context of LS, predominantly glioblastoma and less frequently low-grade glioma or other brain tumours. Based on our literature review, we summarized the known instances of pituitary adenoma in LS patients, including the present case. Furthermore, we reviewed the common recommendation of using temozolomide (TMZ) for treatment of aggressive pituitary adenoma or carcinoma and found strong indication that it might be insufficient in LS patients, while PD-1 blockade could be a promising treatment option.

Conclusions: Combined with our case, there is a growing body of evidence that intracranial tumours and in particular those of the sellar region might be more prevalent in LS patients than previously assumed, due to their genetic profile substantially affecting viability and efficacy of treatment options. Clinical signs of aggressive tumour growth in combination with irresponsiveness to standard treatment in case of recurrence should lead to further diagnostic measures, because revelation of germline MMR mutations would call for an extended screening for other neoplastic manifestations and would markedly influence further treatment.

Purpose: To analyse the efficacy and safety of the transsphenoidal microsurgical approach with open sella technique (OST) for the treatment of pituitary adenoma (PA) with suprasellar extension.

Methods: We retrospectively reviewed 2305 consecutive patients with PA who underwent their first surgery through the transsphenoidal microsurgical approach at our department between 1990 and 2018. Focusing on tumours with suprasellar extension, in particular, grade B, C and D adenomas according to Wilson-Hardy's classification, 376 patients who received the OST surgery were identified. Outcomes and complications were evaluated and compared with those obtained in patients who underwent a standard transsphenoidal approach (TSM).

Results: Two-hundred and sixty-four of 376 patients (70.2%) were found to be suffering from a non-functioning pituitary adenoma, whereas 112 of 376 patients (29.8%) from a hormone-secreting PA. The mean craniocaudal diameter of the tumor was 30.6 ± 0.3 mm (range, 21-75 mm) and 151 patients (40.1%) had a cavernous sinus invasion too. An overall surgical remission rate of 50.3% was achieved in the OST group, whereas the recurrence rate was 10.5%. Patients were followed for a mean period of 68 ± 1.4 months (range, 6-96 months). Less postoperative intrasellar haemorrhages have been recorded in the OST group than the TSM one (1.1% vs. 4.6%, p = 0.02).

Conclusions: In experienced hands, OST represents an effective and safe treatment strategy for PA with suprasellar extension.

Purpose: To evaluate the correlation of intraoperative neuromonitoring (IONM) data in surgery for tethered cord syndrome (TCS) in children to the neurological outcome at 1-year follow-up.

Methods: 208 consecutive patients operated on for TCS, between January 2011 to February 2020, under electrophysiological monitoring in the Division of Paediatric Neurosurgery, AIMS, Kochi, India, were included. Their preoperative neurological, urological and orthopaedic status were compared with the postoperative status at 1 year follow-up.

Results: Our study prospectively collected the IONM data and retrospectively correlated it to the children's neurological outcome on follow-up. Out of 208 children, 28% (n = 59/208) had motor, 35% (n = 73/208) had bladder and 26% (n = 54/208) had bowel disturbances. Postsurgery, at one-year follow-up, 91% (n = 52/57) of the patients who had motor deficits had improvement, 82.3% (n = 51/62) of patients who had bladder deficits showed an improvement, and 88.8% (n = 48/54) with bowel deficits showed improvement. The monitorability for motor and sphincter potentials were 99.4% and 89.3%, respectively. Except for four patients (3 with bladder and 1 with motor worsening), all the patients who were monitorable with no deficits remained intact except for four patients, all the patients who had deficits and were monitorable improved after detethering (at 1 year). Clinical worsening corresponded to those who had a drop in amplitude of baseline TcMEP (n = 4). 18 events showed an increase in amplitude compared to the baseline TcMEP. These patients improved clinically on follow-up (at 1 year).

Conclusions: IONM complements the preoperative clinical details in predicting immediate and long-term outcomes.

Purpose: Compressive vertebral hemangiomas with neurological deficits (CVHND) form a rare, unique subset of lesions comprising of differing clinico-imaging findings, pathologic behavior and treatment, when compared to the commoner and usually incidental intra-osseus vertebral hemangiomas (VH). Though various surgical strategies and a broad array of adjuncts have evolved and changed over the years, there is paucity of comprehensive data from sizeable series of such patients treated surgically with long term follow up. The purpose of this study is to device an optimum management strategy in CVHND based on our surgical experience.

Materials and methods: The data from electronic medical records of 26 consecutive patients operated in our department from 2009 to 2019 were retrospectively analyzed.

Results: There were 11 males and 15 females with a mean age of 34.7 years. Neurological examination revealed paraparesis or paraplegia with myelopathy in all patients with Frankel score of B, C and D in 1 (3.9%), 11 (42.3%) and 14 (53.8%) patients respectively. Sixteen patients (61%) underwent laminectomy and gross total excision of extradural soft tissue component, 7 (27%) laminectomy with posterolateral fusion, three (12%) underwent additional anterior interbody support. The mean follow up was 72.4 months and at last follow-up 24 patients (92%) were Frankel E. Symptomatic recurrence was seen in two patients operated early in the series, they underwent re-surgery, gross total excision with posterolateral fusion, remaining neurologically intact at last follow up.

Conclusions: Pre-operative embolization, surgical excision of extradural component and intra-operative vertebroplasty form the mainstay of treatment for CVHND. Instrumented posterolateral fusion with optional anterior interbody support accomplished through the same approach is required only in a minority of cases. The long-term outcome following timely and appropriate treatment is excellent. Anterior or anterolateral approaches for intervertebral support and radical procedures like total en-bloc spondylectomy (TES) are not usually required.