Recovery from postoperative hearing loss is seldom observed in vestibular schwannoma surgery. The authors reported 5 rare cases of a return to useful hearing presenting after recovery from complete hearing deterioration occurring immediately after retrosigmoid removal of vestibular schwannoma. The first signs of useful hearing recovery can be determined by the patient's ability to recognize sound within 3 d after surgery (range 1-3 d, median 3 d). Furthermore, the duration until hearing ability recovered to a useful level (range 6-40 d, median 14 d) seems to correlate with the duration before speech identification could be confirmed (range 2-20 d, median 5 d). The percentage of a chance at the delayed hearing recovery in cases who lost the hearing immediately after the operation was 7.4% (5/68). The data on the time course of the change in hearing abilities are of great value in prognosticating the potential for hearing recovery in patients who complain of hearing loss after surgery.
{"title":"Recovery From Postoperative Hearing Loss in Retrosigmoid Vestibular Schwannoma Surgery: Report of 5 Cases and the Recovery Rate","authors":"T. Hitotsumatsu, Tomio Sasaki","doi":"10.1093/NEUOPN/OKAA024","DOIUrl":"https://doi.org/10.1093/NEUOPN/OKAA024","url":null,"abstract":"\u0000 \u0000 \u0000 Recovery from postoperative hearing loss is seldom observed in vestibular schwannoma surgery. The authors reported 5 rare cases of a return to useful hearing presenting after recovery from complete hearing deterioration occurring immediately after retrosigmoid removal of vestibular schwannoma.\u0000 \u0000 \u0000 \u0000 The first signs of useful hearing recovery can be determined by the patient's ability to recognize sound within 3 d after surgery (range 1-3 d, median 3 d). Furthermore, the duration until hearing ability recovered to a useful level (range 6-40 d, median 14 d) seems to correlate with the duration before speech identification could be confirmed (range 2-20 d, median 5 d). The percentage of a chance at the delayed hearing recovery in cases who lost the hearing immediately after the operation was 7.4% (5/68).\u0000 \u0000 \u0000 \u0000 The data on the time course of the change in hearing abilities are of great value in prognosticating the potential for hearing recovery in patients who complain of hearing loss after surgery.\u0000","PeriodicalId":93342,"journal":{"name":"Neurosurgery open","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-01-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1093/NEUOPN/OKAA024","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45325199","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
J. Ivanović, Kristin Å. Alfstad, P. B. Marthinsen, K. B. Olsen, P. G. Larsson, A. Pripp, M. Stanišić
Treatment of patients with pharmacoresistant temporal lobe epilepsy with hippocampal sclerosis and nonspecific pathology who failed initial resection is challenging, although selected patients may benefit from repeated surgery. To determine seizure outcome, postoperative morbidity, and possible predictors of seizure freedom after repeated ipsitemporal resection. We reviewed the results of comprehensive epilepsy evaluations performed before the initial and repeated resections in 10 patients with hippocampal sclerosis and 13 with nonspecific pathology. We assessed the Engel classification of seizure outcome 2 yr after repeated resection, evaluated postoperative morbidity, and examined the association of epilepsy and surgical characteristics with seizure freedom before and after reoperation. After reoperation, in patients with hippocampal sclerosis, seizure freedom (Engel class I) was achieved in 2 (20%), 1 (10%) experienced surgical complications, and 1 (10%) experienced permanent neurological impairment. Following reoperation in patients with nonspecific pathology, seizure freedom was achieved in 1 (8%), 3 (23%) experienced surgical complications, and 4 (31%) experienced permanent neurological impairment. Epilepsy and surgical characteristics before and after reoperation were not associated with seizure freedom. Patients with hippocampal sclerosis and nonspecific pathology who underwent a comprehensive initial work-up and failed original temporal lobe resection rarely become seizure-free after repeated ipsitemporal reoperation. Reoperations carry a high risk of surgical complications and neurological impairment. Predictors for seizure freedom could not be defined.
{"title":"Seizure Outcome After Ipsitemporal Reoperation in Pharmacoresistant Temporal Lobe Epilepsy Patients With Hippocampal Sclerosis and Nonspecific Pathology","authors":"J. Ivanović, Kristin Å. Alfstad, P. B. Marthinsen, K. B. Olsen, P. G. Larsson, A. Pripp, M. Stanišić","doi":"10.1093/NEUOPN/OKAB001","DOIUrl":"https://doi.org/10.1093/NEUOPN/OKAB001","url":null,"abstract":"\u0000 \u0000 \u0000 Treatment of patients with pharmacoresistant temporal lobe epilepsy with hippocampal sclerosis and nonspecific pathology who failed initial resection is challenging, although selected patients may benefit from repeated surgery.\u0000 \u0000 \u0000 \u0000 To determine seizure outcome, postoperative morbidity, and possible predictors of seizure freedom after repeated ipsitemporal resection.\u0000 \u0000 \u0000 \u0000 We reviewed the results of comprehensive epilepsy evaluations performed before the initial and repeated resections in 10 patients with hippocampal sclerosis and 13 with nonspecific pathology. We assessed the Engel classification of seizure outcome 2 yr after repeated resection, evaluated postoperative morbidity, and examined the association of epilepsy and surgical characteristics with seizure freedom before and after reoperation.\u0000 \u0000 \u0000 \u0000 After reoperation, in patients with hippocampal sclerosis, seizure freedom (Engel class I) was achieved in 2 (20%), 1 (10%) experienced surgical complications, and 1 (10%) experienced permanent neurological impairment. Following reoperation in patients with nonspecific pathology, seizure freedom was achieved in 1 (8%), 3 (23%) experienced surgical complications, and 4 (31%) experienced permanent neurological impairment. Epilepsy and surgical characteristics before and after reoperation were not associated with seizure freedom.\u0000 \u0000 \u0000 \u0000 Patients with hippocampal sclerosis and nonspecific pathology who underwent a comprehensive initial work-up and failed original temporal lobe resection rarely become seizure-free after repeated ipsitemporal reoperation. Reoperations carry a high risk of surgical complications and neurological impairment. Predictors for seizure freedom could not be defined.\u0000","PeriodicalId":93342,"journal":{"name":"Neurosurgery open","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-01-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1093/NEUOPN/OKAB001","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"43340135","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Mark D. Johnson, C. Carroll, D. Cass, N. Andaluz, B. Foreman, M. Goodman, Laura B. Ngwenya
Despite the widespread adoption of systemic antibiotic prophylaxis in civilian cranial gunshot wounds (cGSWs), there remains a lack of consensus on microbial coverage and duration of therapy. To analyze a 6-yr experience with prophylactic antibiotics in civilian cGSWs with a focus on infectious complications. Records were reviewed for demographic and injury characteristics that could influence the risk of intracranial infection. Patients over 16 yr of age with cGSWs who survived more than 48 h were included. Antimicrobial prophylaxis was initiated at the discretion of the treating neurosurgeon, with eligible patients divided into 3 groups: no prophylaxis, single agent, and multiagent. Univariate analysis and multivariable logistic regression were performed to determine variables contributing to the development of intracranial infection. Of 75 eligible patients, prophylactic antibiotics were utilized in 61 (81.3%) with a 5 d median duration. Injury Severity Score (ISS) was significantly higher and Glasgow Coma Scale (GCS) was significantly lower in those who received prophylaxis. Eight intracranial infections were documented (10.7%) over a range of 1 wk to 3 yr from injury. Antibiotic prophylaxis did not contribute to infection, but the presence of cerebrospinal fluid (CSF) leak was associated with intracranial infection risk in multivariable regression (odds ratio [OR] = 11.8, P = .013). In a cohort of cGSW patients, those with a more severe injury profile were more likely to receive multiagent antimicrobial prophylaxis. However, we found that multiagent antimicrobial prophylaxis did not confer an advantage, and that the presence of CSF leak may be a more important contributing variable to the development of intracranial infection.
{"title":"Single-Center Experience With Antibiotic Prophylaxis and Infectious Complications in Civilian Cranial Gunshot Wounds","authors":"Mark D. Johnson, C. Carroll, D. Cass, N. Andaluz, B. Foreman, M. Goodman, Laura B. Ngwenya","doi":"10.1093/neuopn/okaa013","DOIUrl":"https://doi.org/10.1093/neuopn/okaa013","url":null,"abstract":"\u0000 \u0000 \u0000 Despite the widespread adoption of systemic antibiotic prophylaxis in civilian cranial gunshot wounds (cGSWs), there remains a lack of consensus on microbial coverage and duration of therapy.\u0000 \u0000 \u0000 \u0000 To analyze a 6-yr experience with prophylactic antibiotics in civilian cGSWs with a focus on infectious complications.\u0000 \u0000 \u0000 \u0000 Records were reviewed for demographic and injury characteristics that could influence the risk of intracranial infection. Patients over 16 yr of age with cGSWs who survived more than 48 h were included. Antimicrobial prophylaxis was initiated at the discretion of the treating neurosurgeon, with eligible patients divided into 3 groups: no prophylaxis, single agent, and multiagent. Univariate analysis and multivariable logistic regression were performed to determine variables contributing to the development of intracranial infection.\u0000 \u0000 \u0000 \u0000 Of 75 eligible patients, prophylactic antibiotics were utilized in 61 (81.3%) with a 5 d median duration. Injury Severity Score (ISS) was significantly higher and Glasgow Coma Scale (GCS) was significantly lower in those who received prophylaxis. Eight intracranial infections were documented (10.7%) over a range of 1 wk to 3 yr from injury. Antibiotic prophylaxis did not contribute to infection, but the presence of cerebrospinal fluid (CSF) leak was associated with intracranial infection risk in multivariable regression (odds ratio [OR] = 11.8, P = .013).\u0000 \u0000 \u0000 \u0000 In a cohort of cGSW patients, those with a more severe injury profile were more likely to receive multiagent antimicrobial prophylaxis. However, we found that multiagent antimicrobial prophylaxis did not confer an advantage, and that the presence of CSF leak may be a more important contributing variable to the development of intracranial infection.\u0000","PeriodicalId":93342,"journal":{"name":"Neurosurgery open","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2020-12-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1093/neuopn/okaa013","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48547095","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2020-12-15eCollection Date: 2021-03-01DOI: 10.1093/neuopn/okaa020
Lesheng Wang, Keyao Zhou, Jincao Chen
To the Editor: When the 2019 novel coronavirus (COVID-19) was first reported in Wuhan (China) last December, and as warned by the World Health Organization (WHO),1 the Chinese government decided to seal Wuhan city on January 23 to prevent the spread of the virus across the world. On April 8, 2020, China lifted the lockdown of the first Chinese city of Wuhan and Hubei Province, and Wuhan’s borders were reopened based on the basically stable epidemic trend and no local infection. It is common knowledge that blockade measures cause delays in seeking medical attention for most patients. In this study, we retrospectively analyzed the attendance conditions in the neurosurgery department of our hospital during and after the lockdown of the city.
{"title":"Letter: The Impact of COVID-19 on the Neurosurgery Department During and After the Lockdown of Wuhan.","authors":"Lesheng Wang, Keyao Zhou, Jincao Chen","doi":"10.1093/neuopn/okaa020","DOIUrl":"https://doi.org/10.1093/neuopn/okaa020","url":null,"abstract":"To the Editor: When the 2019 novel coronavirus (COVID-19) was first reported in Wuhan (China) last December, and as warned by the World Health Organization (WHO),1 the Chinese government decided to seal Wuhan city on January 23 to prevent the spread of the virus across the world. On April 8, 2020, China lifted the lockdown of the first Chinese city of Wuhan and Hubei Province, and Wuhan’s borders were reopened based on the basically stable epidemic trend and no local infection. It is common knowledge that blockade measures cause delays in seeking medical attention for most patients. In this study, we retrospectively analyzed the attendance conditions in the neurosurgery department of our hospital during and after the lockdown of the city.","PeriodicalId":93342,"journal":{"name":"Neurosurgery open","volume":"2 1","pages":"okaa020"},"PeriodicalIF":0.0,"publicationDate":"2020-12-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1093/neuopn/okaa020","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"39506845","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2020-12-01Epub Date: 2020-09-05DOI: 10.1093/neuopn/okaa012
Gaousul Azam, Amit Agrawal, Luis Rafael Moscote-Salazar, Ezequiel Garcia-Ballestas, Moshiur Rahman
To the Editor: The COVID-19 pandemic has been terrifying for our world. In this situation, problems are confronting healthcare professionals worldwide, particularly neurosurgeons. This is of great concern that healthcare professionals with inadequate personal protective equipment are getting more infected during face-toface identification or due to aerosol production when sitting in the waiting room in the hospital. The cases of infection rise during ambulatory treatment due to silent transmission from a mixture of presymptomatic and asymptomatic infections. The distribution of services for both COVID-19 and non-COVID-19 patients in the COVID-19 period should be based on a few needful concepts. Global neurosurgical initiatives need to be taken that could rise to the cause of providing essential and uniform neurosurgical treatment in order to avoid infection due to silent transmission. Global leaders are continuously providing comprehensive literature to help us all manage neurosurgical patients with safety and produce good outcomes. The whole world is trying to cope with the current global pandemic of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and reduce infection spread not only among patients but also among treating neurosurgeons.1 In lowand middle-income countries, the patient flow management in hospitals is modified by local guidelines and resource allocation in outpatient departments. It is of great concern that the healthcare professionals with inadequate personal protective equipment are getting more infected during face-to-face registration or due to aerosol generation in the hospital waiting room.2 Neurosurgical patients undergo proper documentation of their medical history, very close clinical examination, evaluation of previous documents, and allocation of a new treatment plan, which increases exposure time. Exposure time may further increase for physically challenged patients. In the case of physically challenged patients, social distancing of about 2 m and exposure time of less than 10 min cannot be adequately maintained.3 The identification of asymptomatic carriers is done by reverse transcription polymerase chain reaction (RT-PCR), and the success rate is almost 56% to 80%.4 Such estimates using a targeted population provide an important insight into evaluating the prevalence of asymptomatic viral shedding.5 It is not always possible to run all the screening methods for the asymptomatic patient in the outpatient department, especially in low-resource countries. Allocating resources in the COVID19 era should be based on six principles: maximizing health benefits; prioritizing healthcare workers; not allocating in the manner of the first-come-first-served basis; being responsive to evidence-based medicine; recognizing research participation; and applying the same strategy to all COVID-19 and non-COVID19 patients.6 There is a lot of controversy regarding the spread of COVID19 from asymptomatic carriers. In one study,
{"title":"Letter: Outpatient Consultation and Silent Transmission of COVID-19: Risk for the Neurosurgeon?","authors":"Gaousul Azam, Amit Agrawal, Luis Rafael Moscote-Salazar, Ezequiel Garcia-Ballestas, Moshiur Rahman","doi":"10.1093/neuopn/okaa012","DOIUrl":"https://doi.org/10.1093/neuopn/okaa012","url":null,"abstract":"To the Editor: The COVID-19 pandemic has been terrifying for our world. In this situation, problems are confronting healthcare professionals worldwide, particularly neurosurgeons. This is of great concern that healthcare professionals with inadequate personal protective equipment are getting more infected during face-toface identification or due to aerosol production when sitting in the waiting room in the hospital. The cases of infection rise during ambulatory treatment due to silent transmission from a mixture of presymptomatic and asymptomatic infections. The distribution of services for both COVID-19 and non-COVID-19 patients in the COVID-19 period should be based on a few needful concepts. Global neurosurgical initiatives need to be taken that could rise to the cause of providing essential and uniform neurosurgical treatment in order to avoid infection due to silent transmission. Global leaders are continuously providing comprehensive literature to help us all manage neurosurgical patients with safety and produce good outcomes. The whole world is trying to cope with the current global pandemic of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and reduce infection spread not only among patients but also among treating neurosurgeons.1 In lowand middle-income countries, the patient flow management in hospitals is modified by local guidelines and resource allocation in outpatient departments. It is of great concern that the healthcare professionals with inadequate personal protective equipment are getting more infected during face-to-face registration or due to aerosol generation in the hospital waiting room.2 Neurosurgical patients undergo proper documentation of their medical history, very close clinical examination, evaluation of previous documents, and allocation of a new treatment plan, which increases exposure time. Exposure time may further increase for physically challenged patients. In the case of physically challenged patients, social distancing of about 2 m and exposure time of less than 10 min cannot be adequately maintained.3 The identification of asymptomatic carriers is done by reverse transcription polymerase chain reaction (RT-PCR), and the success rate is almost 56% to 80%.4 Such estimates using a targeted population provide an important insight into evaluating the prevalence of asymptomatic viral shedding.5 It is not always possible to run all the screening methods for the asymptomatic patient in the outpatient department, especially in low-resource countries. Allocating resources in the COVID19 era should be based on six principles: maximizing health benefits; prioritizing healthcare workers; not allocating in the manner of the first-come-first-served basis; being responsive to evidence-based medicine; recognizing research participation; and applying the same strategy to all COVID-19 and non-COVID19 patients.6 There is a lot of controversy regarding the spread of COVID19 from asymptomatic carriers. In one study,","PeriodicalId":93342,"journal":{"name":"Neurosurgery open","volume":"1 4","pages":"okaa012"},"PeriodicalIF":0.0,"publicationDate":"2020-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1093/neuopn/okaa012","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"39506844","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Benjamin S. Hopkins, N. Shlobin, K. Kesavabhotla, Z. Smith, N. Dahdaleh
Neurological surgery resident applicants seek out certain aspects of training, including case volume. While graduating Accreditation Council for Graduate Medical Education (ACGME) summary data are available yearly, they are not program specific and drawing conclusions is difficult. To model general benchmarks for resident case volume across US programs to increase transparency and allow comparison of programs. ACGME neurosurgical resident national reports from 2017 to 2019 were downloaded. Averages, standard deviations, and medians were recorded from each of the 27 procedural categories. Monte Carlo simulations were performed. Each distribution was run independently 1 to 4 times to represent the number of residents in a given program per year. Cases were divided into different categories: endovascular, open vascular, tumor, spine, and pediatrics. Average derived graduating case volumes were 1558 cases in 2017, 1599 cases in 2018, and 1618 cases in 2019. Programs with 3 residents per year averaged 4755 cases per year, with 90th percentile of 5401 cases per year. After removing endovascular cases, radiosurgery cases, and critical care procedures, the average was 3794 cases, with 90th percentile of 4197 cases per year. Categorically, the 90th percentile was 241 for open vascular, 373 for endovascular, 1600 for spine, 769 for tumor, and 352 for pediatrics. Case volume is an important part of neurosurgical training and a major factor in determining applicant residency program ranking. Through Monte Carlo simulation, the average case volume for programs with 3 residents per year was determined. Metrics and benchmarking remain an important part of applicant and program growth.
{"title":"Case Volume Analysis of Neurological Surgery Training Programs in the United States: 2017-2019","authors":"Benjamin S. Hopkins, N. Shlobin, K. Kesavabhotla, Z. Smith, N. Dahdaleh","doi":"10.1093/NEUOPN/OKAA017","DOIUrl":"https://doi.org/10.1093/NEUOPN/OKAA017","url":null,"abstract":"\u0000 \u0000 \u0000 Neurological surgery resident applicants seek out certain aspects of training, including case volume. While graduating Accreditation Council for Graduate Medical Education (ACGME) summary data are available yearly, they are not program specific and drawing conclusions is difficult.\u0000 \u0000 \u0000 \u0000 To model general benchmarks for resident case volume across US programs to increase transparency and allow comparison of programs.\u0000 \u0000 \u0000 \u0000 ACGME neurosurgical resident national reports from 2017 to 2019 were downloaded. Averages, standard deviations, and medians were recorded from each of the 27 procedural categories. Monte Carlo simulations were performed. Each distribution was run independently 1 to 4 times to represent the number of residents in a given program per year. Cases were divided into different categories: endovascular, open vascular, tumor, spine, and pediatrics.\u0000 \u0000 \u0000 \u0000 Average derived graduating case volumes were 1558 cases in 2017, 1599 cases in 2018, and 1618 cases in 2019. Programs with 3 residents per year averaged 4755 cases per year, with 90th percentile of 5401 cases per year. After removing endovascular cases, radiosurgery cases, and critical care procedures, the average was 3794 cases, with 90th percentile of 4197 cases per year. Categorically, the 90th percentile was 241 for open vascular, 373 for endovascular, 1600 for spine, 769 for tumor, and 352 for pediatrics.\u0000 \u0000 \u0000 \u0000 Case volume is an important part of neurosurgical training and a major factor in determining applicant residency program ranking. Through Monte Carlo simulation, the average case volume for programs with 3 residents per year was determined. Metrics and benchmarking remain an important part of applicant and program growth.\u0000","PeriodicalId":93342,"journal":{"name":"Neurosurgery open","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2020-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1093/NEUOPN/OKAA017","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48867587","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Anusha Pasumarthi, An-zhi Luo, Hemali Shah, Ian R Carroll
To the Editor: A review of the literature indicates that across the last 7 yr, there is a lack of studies regarding the correlation between cerebrospinal fluid (CSF) leaks and dural laxity in Ehlers-Danlos Syndrome (EDS) patients, possibly because EDS patients are considered high risk surgical candidates. A neurosurgeon may be hesitant to investigate an EDS patient for a leak due to increased risk of impaired wound healing from attenuated and fragile dura. Other factors potentially contributing to the neurosurgeon’s hesitancy include the overlap seen between CSF leak symptoms and other problems common in patients with EDS such as headaches, myelopathy, and cranio-cervical and spinal segmental instability. Perhaps worst of all, patients with Ehlers Danlos often suffer from chronic pain. The innate ligamentous laxity that riddles all forms of EDS confers substantial risk of chronic multifocal joint, tendon, and spinal pain.1 These other complaints may obscure the clarity of orthostatic headache in a brief clinical interview of EDS patients. There are 2 studies which address the aforementioned concerns. The most recent is by Reinstein et al2 wherein the authors analyzed data obtained from a prospective study that enrolled a group of 50 patients referred for CSF leak consultation. The patients were examined for the presence of connective tissue abnormalities based on echocardiography, eye exam, histopathological skin examination, and dural biopsies, which were then confirmed with genetic testing. A total of 9 patients were identified to have heritable connective tissue disorders, 4 of which were EDS hypermobility type and 2 EDS classic type. The study concluded that patients with spontaneous CSF leaks had higher chances of having an underlying connective tissue abnormality. A prior prospective study conducted by Schievink et al3 examined a group of 18 patients with connective tissue disorders who exhibited spontaneous CSF leaks as well. More specifically, 11% of patients had EDS Type 2, which had not been previously documented to present with spontaneous CSF leaks. The study also reported that the success rate of surgical CSF leak repair remains unchanged regardless of the presence of underlying hereditary connective tissue disorders.3 Nevertheless, further research is warranted to better stratify the associated surgical risks based on the correlation between the type and severity of EDS to the possibility of developing spontaneous CSF leaks. The tenacity needed by a neurosurgeon pursuing a CSF leak in this high risk group should be informed by four evolving understandings that disrupt the classic teachings about CSF leaks: 1) Opening pressure is most often normal in patients with CSF leaks and fails to distinguish between patients with and without CSF leaks visible on spinal imaging4; 2) Pachymeningeal enhancement on brain magnetic resonance imaging (MRI) may be present in only a minority of patients with CSF leaks5; 3) Subtle brainstem measurements
{"title":"Letter: Considering Cerebrospinal Fluid Leaks in Ehlers-Danlos Patients: Raising Awareness Amongst Neurosurgeons","authors":"Anusha Pasumarthi, An-zhi Luo, Hemali Shah, Ian R Carroll","doi":"10.1093/neuopn/okaa016","DOIUrl":"https://doi.org/10.1093/neuopn/okaa016","url":null,"abstract":"To the Editor: A review of the literature indicates that across the last 7 yr, there is a lack of studies regarding the correlation between cerebrospinal fluid (CSF) leaks and dural laxity in Ehlers-Danlos Syndrome (EDS) patients, possibly because EDS patients are considered high risk surgical candidates. A neurosurgeon may be hesitant to investigate an EDS patient for a leak due to increased risk of impaired wound healing from attenuated and fragile dura. Other factors potentially contributing to the neurosurgeon’s hesitancy include the overlap seen between CSF leak symptoms and other problems common in patients with EDS such as headaches, myelopathy, and cranio-cervical and spinal segmental instability. Perhaps worst of all, patients with Ehlers Danlos often suffer from chronic pain. The innate ligamentous laxity that riddles all forms of EDS confers substantial risk of chronic multifocal joint, tendon, and spinal pain.1 These other complaints may obscure the clarity of orthostatic headache in a brief clinical interview of EDS patients. There are 2 studies which address the aforementioned concerns. The most recent is by Reinstein et al2 wherein the authors analyzed data obtained from a prospective study that enrolled a group of 50 patients referred for CSF leak consultation. The patients were examined for the presence of connective tissue abnormalities based on echocardiography, eye exam, histopathological skin examination, and dural biopsies, which were then confirmed with genetic testing. A total of 9 patients were identified to have heritable connective tissue disorders, 4 of which were EDS hypermobility type and 2 EDS classic type. The study concluded that patients with spontaneous CSF leaks had higher chances of having an underlying connective tissue abnormality. A prior prospective study conducted by Schievink et al3 examined a group of 18 patients with connective tissue disorders who exhibited spontaneous CSF leaks as well. More specifically, 11% of patients had EDS Type 2, which had not been previously documented to present with spontaneous CSF leaks. The study also reported that the success rate of surgical CSF leak repair remains unchanged regardless of the presence of underlying hereditary connective tissue disorders.3 Nevertheless, further research is warranted to better stratify the associated surgical risks based on the correlation between the type and severity of EDS to the possibility of developing spontaneous CSF leaks. The tenacity needed by a neurosurgeon pursuing a CSF leak in this high risk group should be informed by four evolving understandings that disrupt the classic teachings about CSF leaks: 1) Opening pressure is most often normal in patients with CSF leaks and fails to distinguish between patients with and without CSF leaks visible on spinal imaging4; 2) Pachymeningeal enhancement on brain magnetic resonance imaging (MRI) may be present in only a minority of patients with CSF leaks5; 3) Subtle brainstem measurements","PeriodicalId":93342,"journal":{"name":"Neurosurgery open","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2020-11-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48862292","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Redi Rahmani, Stephen Susa, Stephen E. Sandwell, Kristopher T. Kimmell, P. Maurer, H. Silberstein, Jacob W Nadler, K. Walter
The sitting cervical position for elective posterior cervical decompression and fusion affords advantages over prone positioning, but remains unpopular due to concerns about venous air embolism (VAE). To demonstrate the safety and efficacy of sitting cervical surgery in our series and in the literature. To evaluate the incidence of complications, we retrospectively identified all adult patients who underwent elective sitting posterior cervical surgeries at our institution from 2009 to 2014. Using International Classification of Diseases-9 coding, we searched for incidences of air embolism, myocardial infarction, pulmonary embolism, and deep vein thrombosis. Operative time, estimated blood loss, and case type distribution were also recorded. We then calculated the incidence of clinically significant VAE in sitting cervical surgeries. Between 2009 and 2014, 558 surgeries were performed in the sitting cervical position. No VAE was identified. The average operative time was 1 h 25 min. A total of 30-d perioperative complications among sitting position patients included 3 myocardial infarctions, 1 pulmonary embolism attributed to venous thrombosis, and 2 patients with deep venous thrombosis for a total cardiovascular complication rate of 1.1%. The incidence of clinically significant VAE in the literature is 1.5%. We present the second largest case series to date on the sitting position for cervical surgeries, highlighting its safety and efficacy. This position provides a surgical field with superior visualization, allowing decreased operative time and blood loss. The risk of clinically significant VAE is low. Intraoperative monitoring for these events with less invasive means is safe and effective.
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