British Journal of Neurosurgery最新文献

Introduction: Radiosurgery targeting the thalamus has long been used to treat refractory pain, with medial thalamotomy as a key approach. Traditionally, targeting relied on indirect methods based on anatomical atlases, which do not account for individual variations in brain connectivity. Recent advances in connectomic-guided stereotactic radiosurgery have improved precision in the treatment of movement disorders, but their application to pain management remains underexplored. This study evaluates the feasibility of connectomic-guided radiosurgery for refractory pain using Brainlab Elements, integrating auto-segmentation and manual contouring for patient-specific planning.

Methods: We analysed the thalamic target's structural and functional connectivity using the FMRIB Software Library and Advanced Normalisation Tools. The region of interest (ROI) was mapped using diffusion tensor imaging and functional magnetic resonance imaging to assess connectivity with pain-processing structures, including the periventricular grey (PVG) and ventroposteromedial (VPM) nucleus. Connectivity analysis was performed with Brainlab Elements and validated against independent connectomic studies. Dose-volume relationships for PVG and VPM were retrospectively assessed in patients treated with radiosurgery for chronic pain.

Results: Connectivity analysis showed that fibres within the ROI extend to primary motor (M1) and sensory (S1) cortices, while descending fibres reach the periaqueductal gray (PAG). Functional connectivity linked the ROI to key pain-processing regions, including the prefrontal cortex, insula, amygdala, and cerebellum. Retrospective dose-volume (DVs) analysis revealed clear differences between the volumes receiving more than 20 Gy in the original vs connectomic-based target. . The integration of Brainlab Elements facilitated connectomic-guided targeting, enabling a patient-specific approach to radiosurgery.

Conclusion: Connectomic-guided radiosurgery is a feasible approach that enables precise, patient-specific targeting pain management. Auto-segmentation of PVG and VPM allows dose-volume assessment, potentially correlating with clinical outcomes. Standardising connectomic-guided planning may enhance radiosurgical precision and support future clinical research in refractory pain.

Background: Traumatic brain injury (TBI) is associated with an increased risk of venous thromboembolism (VTE), which can complicate recovery from TBI, lead to long-term reductions in quality of life, and occasionally be fatal. There is no high-quality evidence to support recommendations for optimal timing, dosing or type of pharmacological thromboprophylaxis (PTP). This study aimed to characterise current clinical practice among healthcare professionals in the UK and Ireland regarding VTE prophylaxis in patients with TBI, to inform research.

Methods: An online survey was distributed to healthcare professionals across the UK and Ireland. The survey addressed types and timing of PTP in TBI patients, as well as factors influencing decision-making, use of imaging, ward-based scenarios, and local protocols.

Results: Responses were obtained from 61 individuals from 26 tertiary centres with neuroscience units. There was a heterogenous response with regards to the timing of PTP following TBI across all clinical scenarios, however, the most common factors contributing to decision making before starting VTE prophylaxis included progression of intracranial haemorrhage, new intracranial haemorrhage and prevention of VTE events. 85% of respondents agreed there is no high-quality evidence on the timing of starting pharmacological thromboprophylaxis after an acute TBI.

Discussion: This study underscores the lack of consensus for VTE prophylaxis in TBI patients. There is a pressing need for a randomised control trial to guide the optimal timing of PTP following TBI to improve patient care.

Introduction: Brain metastases require multimodal and multidisciplinary management. This paper is a descriptive analysis of our outcomes of surgically treated brain metastases along with a sub-analysis of multiple intracranial metastases and recurrent metastases resected following stereotactic radiosurgery.

Methods: A single institute, retrospective, statistical analysis of patients with surgically excised brain metastases over 10 years performed at Salford Royal Hospital, Manchester, UK. Patient records were accessed from the Neurooncology database and electronic records.

Results: A total of 345 patients had 379 surgeries for resection of brain metastases from January 2013 until December 2022. Mean age of the group was 59.49 ± 12.25 years. There were 138 patients with multiple metastases at the time of surgery, amongst which 23 underwent simultaneous resection of > 1 metastasis. There were 37 patients post-SRS who had surgery for an enlarging lesion. Mean overall survival (OS) was 31.083 months with a 2-year OS of 30.63% whereas mean progression free survival (PFS) was 22.33 months. Adjuvant therapy was the common statistically significant factor for both OS and PFS while redo surgery for OS and age for PFS was an additional significant parameter. Amongst surgically treated patients, ones receiving SRS before surgery and any adjuvant therapy had statistically significant longer OS (39 months) and PFS (20 months).

Conclusions: Multimodal approach encompassing surgical resection either at diagnosis or revisional for recurrence post SRS/surgery, offers the best survival and progression-free outcomes. Surgery for appropriately selected solitary or multiple brain metastases improves patient compliance for adjuvant therapy improving overall prognosis.

Background: Cerebrovascular training for neurosurgical residents has been impacted by the decrease in open surgery for aneurysms, the rise of endovascular treatments, and a decline in interventions for arteriovenous malformations (AVMs). Our aim was to explore the open vascular and endovascular experience recorded by residents in the United Kingdom (UK) over a 12-year period (2011-2022, inclusive).

Methods: A retrospective database review of 12 open vascular and endovascular procedures logged by UK residents over a 12-year period was conducted. The number of operations recorded as performed by the resident was evaluated.

Results: A total of 324neurosurgical residents' operative logbooks were included and 14,427 procedures were recorded during the study period. Clipping of anterior circulation aneurysms were the commonest operations recorded. Fewer trainees accounted for more of the recorded clipping cases as the study period progressed unlike AVM excisions, where a similar proportion of residents recorded performing them across the study. Endovascular procedures were recorded by a limited number of residents.

Conclusions: A large proportion of cerebrovascular procedures are performed by a select few trainees which may reflect centralisation of services, variations in treatment patterns, or trainee subspecialty interest. Implications for future service delivery are crucial as trainees' operative experience appears limited.

Purpose: In recent clinical practice, a rise in patients with multiple comorbidities including obesity has being identified among those being considered for elective spinal surgery. Literature shows conflicting results regarding the influence of obesity on patient-reported outcomes following single-level microdiscectomy. The aim of the study is to assess if Body Mass Index (BMI) is an appropriate determining factor of Patient-Reported Outcome Scores (PROMs) and complication rates following single-level microdiscectomy, and to determine if a weight reduction from obese to overweight could reduce complication rates and improve PROMs.

Material and methods: This retrospective study was conducted for a randomised sample of single-level microdiscectomy procedures completed between January 2012 to May 2023 at the University Hospitals Plymouth neurosurgery department. Ninety patients were randomly selected into three groups of 30 based on their BMI. Out of the 90 patients, 63 were eligible, having had a complete set of data, 36.51% were classed as obese (BMI $\ge$ 30), 41.27% as overweight (BMI 25-29) and 22.22% as normal-BMI (BMI $\le$ 24.9).

Results: Patients classed as having an obese BMI showed the greatest improvement of their PROMs, with their Visual Analogue Score (VAS) for leg pain showing a mean improvement of 6.263 out of 10. Importantly, the pre-operative mean leg pain was higher for obese patients than overweight and normal-BMI ones. Likewise, the obese patients' Oswestry Disability Index (ODI) showed a mean improvement of 29.091%. In regard to complication rates, obese patients experienced the highest complication rate, with 17.39% of obese patients experiencing complications compared to 7.69% and 7.13% of overweight and normal-BMI patients respectively.

Conclusion: The increased rate of complications among obese patients underlines the importance of weight reduction. The findings also indicate that BMI is not the sole determinant for better surgical outcomes, as obese patients showed the greatest improvements in their PROM scores.

Purpose: This study investigated the impact of preoperative clinical/biochemical factors and postoperative adenoma granulation patterns on short and long term responses to somatostatin analogue (SSA) therapy in acromegaly patients.

Methods: Sixty patients who did not achieve remission after initial surgery were included. Thirty achieved biochemical control at 1 year, while 30 did not respond to first-line SSA therapy.

Results: Hypointense adenomas on preoperative T2-weighted MRI were significantly associated with biochemical remission at 3 months and 1 year (70.6% and 53.3%, respectively; p = 0.001). Patients with diabetes at the time of diagnosis had lower response rates (6.7% vs. 21.6%, 11.7% vs. 38.3%; p = 0.102 and p = 0.008). Those with both diabetes and sparsely granulated adenomas were 5.867 times more likely to not have remission at 1 year (p = 0.041). Baseline GH and IGF-1 levels were not significantly predictive of treatment response (p > 0.05).

Conclusion: In acromegaly patients not cured by surgery, hyperintense MRI features, sparse granulation, and diabetes at diagnosis predict reduced short and long term responses to SSA therapy.

Introduction: Tremor is a disabling symptom of multiple sclerosis (MS), with limited treatment modalities. Thalamic ventral-intermediate-nucleus (VIM) deep brain stimulation (DBS) is a method of neuromodulation. We describe the long-term outcomes of our carefully selected patients who underwent VIM DBS for their MS-associated tremor.

Methods: Patients were referred from the regional neurology units. Pre-operative assessments included suitability for anesthesia, tremor quantification by the Fahn-Tolosa-Marin scores, and quality-of-life (EQ5D) measures. Exclusion criteria included prominent cerebellar symptoms such as ataxia and dysmetria, intracranial pathology such as ventriculomegaly, cerebellar plaques and thalamic abnormality, and comorbid psychiatric symptoms. Seven patients (3M:4F) underwent DBS for MS-associated tremor between September 2013 and February 2019. Mean age was 42 years (±SD 8 years). DBS was performed at a mean of 13 years (±SD 9 years) after diagnosis of MS.

Results: There were no postoperative surgical complications. All patients showed improvement in FTM tremor scores, by up to 61% at 6 months postoperatively. There was an improvement of 30-175% in quality-of-life scores at 6 months. Improvement of tremor and quality of life, over baseline, was sustained over a long period of follow-up (mean 26.6 months ± SD 20.7 months), including our longest duration at 72 months.

Conclusion: With careful selection, DBS is a safe, efficacious intervention for MS-tremor and can positively impact on tremor and quality of life, with effects over a long period. As patients live longer with MS and the advent of new therapies, DBS should be considered for selected patients.

Spinal tumours infrequently cause hydrocephalus, on rare occasions, they can also cause papilloedema, in the absence of ventriculomegaly. When the latter occurs, they can be a diagnostic challenge for physicians. In the absence of limb neurology, much of the initial diagnostic effort is focused solely on intra-cranial causes. This can result in diagnostic delay, misdiagnosis and mistreatment.We describe three cases of intradural spinal tumours that presented with isolated vision-threatening papilloedema. We compare and contrast these patients who had similar presentations, but different management strategies. The different operative management of their spinal tumours, as well as the acuity of visual deterioration determined their respective clinical course and patient journeys. We emphasise the need to preserve vision as a priority, through emergency cerebrospinal fluid (CSF) diversion if necessary. We remind our readers to 'think outside the box' in cases of unexplained papilloedema, and recognise spinal pathology as a possibility amongst the differentials.

Background: Perioperative Visual Loss (POVL) is a devastating complication for patients undergoing spine surgery. Consent process for POVL amongst spine surgeons and anaesthetist remains variable. The aim of this study is to evaluate their practice and views about it.

Methods: Two similar questionnaires were distributed to members of the Society of British Neurological Surgeons (SBNS), British Association of Spine Surgeons (BASS), and Neuroanaesthsia and Critical Care Society (NACCS).

Results: A total of 271 responses were received (SBNS/BASS n = 149, NACCS n = 122). Fewer surgeons considered POVL as a material risk for patients compared to the anaesthetists (57.7 versus 79.7%). Outpatient/pre-assessment clinics were considered as the optimal setting for discussing POVL by the majority of the clinicians (81.2 and 93.4%). POVL should be discussed by both specialists according to 75% of the anaesthetists. Estimated incidence of POVL was considered to be higher by the anaesthetists (0.03-0.2% by 63% of the anaesthetist versus 0.0001-0.004% by 57% of the surgeons). Twenty-three surgeons and 10 anaesthetists had a patient who suffered from POVL, which led to a change of practice in most of them. This questionnaire will lead to a change in practice/consent to 18.1% of the surgeons and 23.5% of the anaesthetists.

Conclusions: Most of the surgeons and anaesthetist feel that POVL is a material risk that ideally needs to be firstly discussed before the day of surgery, by both specialties. However, a significant number of clinicians have an opposite view. A national guidance from respective societies should encourage POVL to be discussed routinely.

Introduction: The 'kickstand screw-rod' technique has been recently described for correction of coronal malalignment. This technique utilizes powerful 'construct-to-ilium' distraction between a fixed multi-screw thoracic construct and the ilium, facilitated by a novel 'iliac kickstand screw'. The 'iliac kickstand screw' traverses a previously undescribed osseous corridor in the ilium.

Objective: Using a radiographic CT study, the objective is to describe a large osseous corridor within the ilium to accommodate the novel iliac kickstand screw.

Methods: 50 consecutive patients with pelvic CTs at an academic medical center were queried. Simulated iliac kickstand screw trajectories for the left and right hemipelvis were analyzed with 3D visualization software. Maximal screw lengths and dimensions, and trajectories in the osseous corridor were measured.

Results: 50 patients' (31 female, 19 male) pelvic CTs were measured with a total of 100 simulated screws. The mean age was 52.4 years and BMI 28.1 ± 7.9. The average length is 119.7 ± 6.6 mm (range 98.7 - 135.3). The narrowest width (maximum potential screw diameter) is 17.8 ± 2.9 mm (coronal) and 20.8 ± 5.3 mm (sagittal). The starting point to the top of the iliac crest is 66.4 mm lateral to midline, and 15.9° caudal in the sagittal and 6.1° lateral in the coronal planes.

Conclusions: The novel iliac kickstand screw traverses a consistent and large osseous corridor within the ilium. The average simulated screw length is 119.7 mm and maximum potential diameter of 17.8 mm. Starting points relative to the iliac crest are identified.