Surgical neurology international最新文献

Background: Tanycytic ependymomas (TEs) are rare spindle-cell variants of spinal ependymomas. They are classified as central nervous system World Health Organization grade II, and they usually behave like ordinary spinal ependymomas especially following gross total resection (GTR).

Case description: A 43-year-old male presented with a progressive paraparesis and sensory level at T4 (pain/ temperature loss). The magnetic resonance imaging showed an intradural intramedullary tumor extending from Th2 to Th5. Only a subtotal resection was performed as a central portion was tightly adherent to the spinal cord itself. Histology revealed a predominantly grade II TE; the main component showed a low proliferative index, whereas the anaplastic focus had a markedly elevated index. Despite craniospinal tomotherapy (36 Gy), tumor recurred 6 years 7 months later. Local tomotherapy was repeated 3 times (41.4, 40, and 30 Gy), but each treatment produced only transient shrinkage followed by regrowth at shorter intervals. Further irradiation was contraindicated due to cumulative dose constraints. Seventeen years after the first surgery, rapid enlargement over 3 months caused paraplegia and bladder-bowel dysfunction. Reoperation achieved GTR, and at this point the pathology showed a diffuse anaplastic ependymoma; the MR 6 months later showed no tumor recurrence.

Conclusion: Although TE is usually indolent, it can harbor an anaplastic subclone and progress to malignancy after subtotal resection. Long-term surveillance and early reoperation when regrowth is first observed should be considered and is likely due to the development of anaplastic features.

Background: Posterior full-endoscopic cervical discectomy (pFECD) is a minimally invasive technique for removing highly migrated cervical disc herniations (CDHs). However, the optimal working corridor and extent of bone resection must be individually tailored according to the direction and degree of disc migration in each patient.

Methods: Two cases of highly migrated CDH were treated using pFECD with tailored bone removal. Case 1 (previously published) involved caudal migration of a C5/6 disc, which required partial pediculotomy. Case 2 involved cephalad migration of a C6/7 CDH, which was treated with partial upper pediculectomy.

Results: In both cases, the migrated disc fragments - both cephalad and caudal - were completely removed without any neurological sequelae.

Conclusion: Partial cephalad and caudal pediculotomy represents a safe and effective technical modification of the pFECD approach for significantly migrated CDHs.

Background: Hypertrophic olivary degeneration (HOD) is a rare trans-synaptic degeneration of the inferior olivary nucleus resulting from disruption of the dentato-rubro-olivary pathway, also known as the Guillain- Mollaret triangle. Unlike most degenerative processes, it produces olivary hypertrophy rather than atrophy. In oncology patients with prior posterior fossa or brainstem involvement, this condition can simulate tumor recurrence or radiation necrosis, leading to unnecessary interventions if unrecognized.

Case description: A 38-year-old woman with a history of human epidermal growth factor receptor 2-positive invasive ductal carcinoma of the breast and previously treated brainstem metastasis presented with progressive right facial paresthesias and gait instability. Neurological examination revealed dysmetria, impaired rapid alternating movements, and gait ataxia without motor or sensory deficits. Magnetic resonance imaging (MRI) demonstrated a nodular enhancing pontine lesion due to the treated metastatic lesion and a new enlargement involving the rostral aspect of the left central tegmental tract with associated hypertrophic change of the inferior olivary nucleus, consistent with unilateral HOD. Magnetic resonance spectroscopy and perfusion imaging excluded neoplastic recurrence. A multidisciplinary neuro-oncology board concluded that the findings were secondary to radiation-induced tract injury. The patient continued maintenance chemotherapy and received symptomatic management and rehabilitative therapy, with serial MRI showing stability.

Conclusion: HOD should be considered in patients with prior brainstem surgery or radiotherapy who develop delayed cerebellar signs and characteristic MRI findings. Recognizing its benign and self-limited nature is crucial to prevent misdiagnosis as tumor recurrence and avoid unnecessary oncologic or surgical interventions. Integration of advanced MRI techniques and multidisciplinary evaluation allows precise diagnosis and tailored management, ensuring appropriate treatment and long-term follow-up.

Background: Sacral neuromodulation (SNM) is a treatment used to manage urinary symptoms of both overactive bladder and non-obstructive urinary retention. The use of SNM in managing these symptoms has yielded positive results, contributing to a reduction in symptoms and an improvement in quality of life (QoL) for patients. This article aims to report on the electrical neurostimulation of sacral nerves to treat idiopathic non-obstructive urinary retention.

Case description: A 27-year-old female presented with chronic non-obstructive idiopathic urinary retention, using intermittent bladder catheterization, who did not respond to various treatments such as behavioral therapy, pelvic floor physiotherapy, and alpha-blockers. She underwent a sphincter injection of botulinum toxin type A. Due to the refractoriness of all previous treatments, electrical neurostimulation of the sacral nerves was proposed as an alternative. Two electrodes were implanted to stimulate the sacral nerves percutaneously in the foramina of S4 on both sides and connected to the neurostimulation system.

Conclusion: After the procedure, the patient experienced a reduction in the average voiding residue (47% immediately postoperative and 29% after 1 year), a significant decrease in urinary tract infections and bladder catheterizations (50% reduction), along with improvements in urinary symptoms, abdominal discomfort, and a substantial enhancement in QoL.

Background: Intradiploic encephalocele (IE) is a rare condition with very few reported cases in the literature. IE is defined as a herniation of the brain parenchyma through a dural defect into the diploic space.

Case description: We present a 59-year-old man with intradiploic cerebellar encephalocele diagnosed in a background of clicks on the head when pressing over the ipsilateral occipital bone. Imaging confirmed right cerebellar brain herniation through the diploic space. Two years of follow-up imaging revealed herniation size progression with no neurology. The patient chose a watch-and-see approach given the potential morbidity of the surgical treatment.

Conclusion: Asymptomatic or paucisymptomatic IE does not require surgical treatment. However, both clinicians and patients need to be aware of potential radiological progression during the follow-up period.

Background: The brainstem tumors are rare and extremely heterogeneous, presenting significant challenges in the surgical approach. For lesions that are not candidates for surgical resection, a definitive diagnosis is primarily obtained through stereotactic biopsy. However, the diagnostic yield, safety, and complication rate of frameless stereotactic techniques are still subject of debates in the literature, especially in eloquent or deep regions such as the brainstem. The aim of this study is to demonstrate that the frameless technique can achieve similar results to the frame-based technique, by comparing the results of the both techniques, even in critical regions, such as the brainstem.

Methods: Twenty-nine frame-based stereotactic biopsies and 17 frameless biopsies of brainstem lesions were analyzed. Diagnostic confirmation of the lesions was performed through histopathological and immunohistochemical analysis and compared between the two groups of patients. The Statistical Package for the Social Science (IBM^® Statistical Package for the Social Sciences) software was used for statistical analysis, testing normality between groups with the Kolmogorov-Smirnov and Fisher's tests to assess the association of the use of each technique in the diagnosis, the complication rate and mortality, in addition to assessing whether the was a correlation between the effectiveness of the methods and the age group, gender, approaches, Karnofsky performance scale, location of the tumors, contrast-enhancing in images, with a 95% confidence interval.

Results: Furthermore, it was observed that the only factor studied that increased the efficacy rate was the use of the transfrontal route, with an overall efficacy rate of 78.3% (36 patients) and P = 0.001.

Conclusion: The frameless and frame-based stereotactic techniques not show statistically significant differences in terms of diagnostic yield, complications rates and mortality. Both can be used depending on the availability and experience of the service, offering flexibility in choosing the approach for biopsy of brainstem lesions.

Background: This study investigates whether patient satisfaction, as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, clinical and radiographic outcomes differ between unilateral and bilateral facetectomy when performing transforaminal lumbar interbody fusions (TLIFs).

Methods: We retrospectively reviewed 373 patients who underwent primary 1- or 2-level TLIF (2016-2023) at a tertiary care center; patients underwent unilateral (n = 160) or bilateral (n = 213) facetectomy. Demographic, surgical, and radiographic data were collected, along with patient-reported satisfaction using the HCAHPS survey.

Results: We found no significant differences in complication rates, reoperation rates, or radiographic outcomes between unilateral and bilateral facetectomy groups. HCAHPS scores showed no statistically significant differences in patient satisfaction across measured domains. Unilateral facetectomy was associated with a shorter hospital stay and more frequent use of minimally invasive techniques. Multivariable regression identified increased BMI associated with increased odds of postoperative infection and additional surgery. Increased operative time was associated with postoperative infection and intraoperative durotomy. Finally, increased length of stay was associated with increased odds of intraoperative durotomy and instrumentation failure.

Conclusion: For TLIF, unilateral versus bilateral facetectomy provided comparable clinical and radiographic outcomes, with no significant differences in patient satisfaction.

Background: In the event of clivus exhibiting longitudinal fractures, the basilar artery (BA) may become entrapped at the fracture site, although this occurrence is infrequent. Occlusion of bilateral BA perforators, accompanied by entrapment of the BA, can result in brainstem ischemia, which often leads to unfavorable outcomes. We report here the usefulness of slab maximum intensity projection (MIP) images of rotational angiography in evaluating the BA perforators.

Case description: A 73-year-old man fell from a two-meter stepladder and was transferred to the emergency department. His Glasgow Coma Scale score was 8. He had left hemiplegia. Head computed tomography (CT) revealed a diffuse subarachnoid hemorrhage; an acute epidural hematoma in the right middle cranial fossa; and fractures in the clivus, right frontal bone, right temporal bone, anterior and lateral wall of the maxillary sinus, zygomatic arch, and bilateral pyramidal bones. CT angiography revealed that the BA was entrapped within the clival fracture and exhibited signs of severe stenosis. Cerebral angiography was performed under general anesthesia. Angiography from the left vertebral artery showed severe stenosis of the BA, but there was no blood flow delay beyond the stenosis. The slab MIP images revealed the occlusion of perforators on the right side of the brainstem, situated at the level of the entrapped BA, as well as the occlusion of the right anterior inferior cerebellar artery. Due to concerns about the risk of bleeding from surgical repair, conservative treatment was performed. Anti-thrombotic treatment was not administered. One and a half months after the injury, his consciousness became clear. He had severe hearing loss due to a fracture of the bilateral pyramidal bone but was able to communicate with others in writing. The left hemiplegia remained. Six months after the injury, his modified Rankin scale was 4.

Conclusion: Slab MIP images of rotational angiography proved instrumental in evaluating the perforators in a case where the BA was found to be entrapped in the clival fracture site. Patients with occlusion of the bilateral perforators have a poor prognosis and may consider surgical treatment. The utilization of the slab MIP image of rotational angiography in the evaluation of the perforators may prove beneficial in determining the indication for surgical intervention.

Background: This video illustrates a minimally invasive neuroendoscopic transorbital technique used for the removal of a right orbital cyst accompanied by frontal sinus reconstruction. The approach enables a direct and efficient corridor to orbital and anterior skull base lesions, reducing the need for brain retraction while ensuring both functional and aesthetic benefits.

Case description: A 38-year-old male patient presented with progressive exophthalmos, double vision, and elevated intraocular pressure caused by a right orbital cyst. Radiological evaluation reveals a thick-walled cystic formation with hyperintense signal intensity on T1- and T2-weighted images. IV contrast-enhanced magnetic resonance ımaging was performed. No contrast enhancement was observed in the lesion. The lesion measures 35 × 30 × 26 mm and appears to be connected to the frontal sinus. Preoperative images showed that the lesion destroyed the frontal sinus and was connected to it. Eyebrow incision was preferred for intraoperative assessment of the frontal sinus to facilitate resection of the lesion within the frontal sinus and surgical maneuvers and reconstruction within the frontal sinus. Through a transorbital endoscopic route, the surgical team performed orbital rim drilling, complete cyst excision, and frontal sinus reconstruction using autologous fat graft material. Orbital rim drilling was performed at the orbital entrance within the skin incision margins, with the bone resection amount not exceeding 5 mm. The purpose of orbital rim drilling is to widen the endoscopic field of view and facilitate the maneuverability of surgical instruments. This did not cause any cosmetic problems. A 0° rigid endoscope and standard endoscopic endonasal surgical instruments were used. The postoperative period was uneventful, and the patient experienced immediate correction of exophthalmos. The histopathological evaluation was reported as an epidermoid cyst with hemorrhage. At the 4-week follow-up, eye movements and intraocular pressure were normal, and diplopia had completely resolved.

Conclusion: The transorbital endoscopic approach represents a safe, efficient, and cosmetically favorable option for treating orbital cystic lesions. It provides excellent visualization of the surgical field with minimal invasiveness, allowing for rapid recovery and optimal cosmetic outcomes. This experience underlines the versatility and clinical usefulness of this technique in properly selected cases.