Novel Case of Streptococcus Mitis-infected Chronic Subdural Hematoma

PURPOSE

Subdural hematoma (SDH) is a common pathology found in neurosurgery. Infected SDH, however, is less common, and reports have typically identified Escherichia coli as the causative organism.

CASE REPORT

We present here a case of an infected chronic SDH caused by Streptococcus mitis, likely for the first time, following a burn injury in a 40-year-old male patient.

CONCLUSION

The workup for infected SDH should now include S. mitis as a possible culprit.

Intracranial Aneurysm "Clip Anchoring": Technical Note

Clip slippage and displacement during or after intracranial aneurysm surgery is associated with morbidity and can be detrimental. We report the usage of concomitant aneurysm clips and artery clips aiming to avoid this complication in a patient undergoing elective aneurysm surgical clipping.

European military surgical teams in combat theater: A survey study on deployment preparation and experience

INTRODUCTION

Adequate (predeployment) training of the nowadays highly specialized Western military surgical teams is vital to ensure a broad range of surgical skills to treat combat casualties. This survey study aimed to assess the self-perceived preparedness, training needs, deployment experience, and post-deployment impact of surgical teams deployed with the Danish, Dutch, or Finnish Armed Forces. Study findings may facilitate a customized predeployment training.

METHODS

A questionnaire was distributed among Danish, Dutch, and Finnish military surgical teams deployed between January 2013 and December 2020 (N = 142). The primary endpoint of self-perceived preparedness ratings, and data on the training needs, deployment experiences, and post-deployment impacts were compared between professions and nations.

RESULTS

The respondents comprised 35 surgeons, 25 anesthesiologists, and 39 supporting staff members, with a response rate of 69.7 % (99/142). Self-perceived deployment preparedness was rated with a median of 4.0 (IQR 4.0-4.0; scale: 1 [very unprepared]-5 [more than sufficient]). No differences were found among professions and nations. Skills that surgeons rated below average (median <6.0; scale: 1 [low]-10 [high]) included tropical disease management and maxillofacial, neurological, gynecological, ophthalmic, and nerve repair surgery. The deployment caseload was most often reported as <1 case per week (41/99, 41.4 %). The need for professional psychological help was rated at a median of 1.0 (IQR 1.0-1.0; scale: 1 [not at all]-5 [very much]).

CONCLUSIONS

Military surgical teams report overall adequate preparedness for deployment. Challenges remain for establishing broadly skilled teams because of a low deployment caseload and ongoing primary specializations. Additional training and exposure were indicated for several specialism-specific skill areas. The need for specific training should be addressed through customized predeployment programs.

Don't delay, but don't despair: symptom duration, comorbidity and outcome after closure of spinal cerebrospinal fluid leaks

OBJECTIVE

Microsurgical sealing of spinal cerebrospinal fluid (CSF) leaks is a viable treatment option in spontaneous intracranial hypotension (SIH). Several factors may influence the outcome, with symptom duration probably the most modifiable variable.

METHODS

Patients with closure of spinal CSF leaks between September 2020 and March 2023 and a follow-up period of 6 months were included in this retrospective single-center study. Pre- and postoperative scores for impact of headaches (Headache Impact Test, HIT-6) and quality of life (QoL, EQ-5D-5L) were systematically collected. Multiple regression modelling and subgroup analyses for different symptom durations and comorbidities were performed for these outcomes.

RESULTS

One hundred patients (61% female, median age 43.5 years) were included. Six months postoperatively, there was significant improvement in headache impact (HIT-6: 66 (IQR 62-69) to 52 (IQR 40-61, p < 0.001) and QoL (EQ-5D-5L VAS: 40 (IQR 30-60) to 79 (IQR 60-90); EQ-5D-5L Index: 0.67 (IQR 0.35-0.8) to 0.91 (IQR 0.8-0.94, p < 0.001, respectively). Subgroup analysis for a symptom duration above (74%) and below 90 days (26%) and comorbidity, as well as multiple regression analysis, revealed a trend in favor of early treatment and lower comorbidity. However, even after a prolonged symptom duration, improvements were significant.

CONCLUSION

As patients with shorter symptom duration show a trend for a better outcome, our results promote a timely diagnosis and treatment in SIH patients. However, a significant postoperative improvement can still be expected even after a prolonged symptom duration.

Hand function outcomes following surgical treatment of complete neonatal brachial plexus palsy

PURPOSE

Although re-innervation of the hand is considered a priority in the treatment of infants with complete brachial plexus injury, there is currently a paucity of publications investigating hand function outcomes following primary nerve reconstruction in infants with neonatal brachial plexus palsy (NBPP). This study therefore aimed to evaluate hand function outcomes in a series of patients with complete NBPP.

METHODS

This retrospective case series included all patients who underwent primary nerve surgery for complete neonatal brachial plexus palsy over an 8-year period. Outcomes were assessed using the Raimond Hand Scale. Classification of grade 3 or higher indicates a functional hand (assistance in bimanual activity).

RESULTS

Nineteen patients with a complete NBPP underwent primary nerve reconstruction at a mean age of 3.7 months. Periodic clinical evaluations were performed until at least 4 years of age. According to the Raimondi hand scale, one patient did not recover (grade 0), three patients attained grade 1, four grade 2, ten grade 3, and in one grade 4. Overall hand functional recovery was achieved in 57.8% (11/19) of patients.

CONCLUSION

Sufficient recovery of hand function to perform bimanual activity tasks in patients with complete NBPP lesions is possible and should be a priority in the surgical treatment of these infants.

Enhancing the quality of evidence, comparability, and reproducibility in brain arteriovenous malformations treated with open surgery research: a systematic review and proposal of a reporting guideline for surgical and clinical outcomes

Brain Arteriovenous Malformations (bAVMs) are rare but high-risk developmental anomalies of the vascular system. Microsurgery through craniotomy is believed to be the mainstay standard treatment for many grades of bAVMs. However, a significant challenge emerges in the existing body of clinical studies on open surgery for bAVMs: the lack of reproducibility and comparability. This study aims to assess the quality of studies reporting clinical and surgical outcomes for bAVMs treated by open surgery and develop a reporting guideline checklist focusing on essential elements to ensure comparability and reproducibility. This is a systematic literature review that followed the PRISMA guidelines with the search in Medline, Embase, and Web of Science databases, for studies published between January 1, 2018, and December 1, 2023. Included studies were scrutinized focusing on seven domains: (1) Assessment of How Studies Reported on the Baseline Characteristics of the Patient Sample; (2) Assessment and reporting on bAVMs grading, anatomical characteristics, and radiological aspects; (3) Angioarchitecture Assessment and Reporting; (4) Reporting on Pivotal Concepts Definitions; (5) Reporting on Neurosurgeon(s) and Staff Characteristics; (6) Reporting on Surgical Details; (7) Assessing and Reporting Clinical and Surgical Outcomes and AEs. A total of 47 studies comprising 5,884 patients were included. The scrutiny of the studies identified that the current literature in bAVM open surgery is deficient in many aspects, ranging from fundamental pieces of information of methodology to baseline characteristics of included patients and data reporting. Included studies demonstrated a lack of reproducibility that hinders building cumulative evidence. A bAVM Open Surgery Reporting Guideline with 65 items distributed across eight domains was developed and is proposed in this study aiming to address these shortcomings. This systematic review identified that the available literature regarding microsurgery for bAVM treatment, particularly in studies reporting clinical and surgical outcomes, lacks rigorous scientific methodology and quality in reporting. The proposed bAVM Open Surgery Reporting Guideline covers all essential aspects and is a potential solution to address these shortcomings and increase transparency, comparability, and reproducibility in this scenario. This proposal aims to advance the level of evidence and enhance knowledge regarding the Open Surgery treatment for bAVMs.

[Expert consensus on multidisciplinary diagnosis and treatment of brain arteriovenous malformation]

Brain arteriovenous malformation (BAVM) is a cerebral vasculature disorder caused by gene mutation. Current available treatment measures include surgical resection, interventional embolization and stereotactic radiosurgery. The three therapeutic methods have their own advantages for different vascular structures.However, due to the complex vascular architecture of the lesion and its close anatomical relationship with brain tissue, any single treatment can not safely and effectively treat all BAVM cases. Therefore, in order to better regulate and guide the clinical diagnosis and treatment of BAVM patients in China, the National Medical School for Neurological Diseases, the Professional Committee of Neurointervention of the Chinese Medical Doctor Association and the radio-neurosurgery Expert Committee of the World Chinese Neurosurgeons Association jointly discussed and formulated this expert consensus. After in-depth analysis of the evidence of evidence-based medicine at home and abroad, the expert group combined with the specific situation of China, and gave 33 recommendations on specific clinical diagnosis and treatment issues such as predictive factors of cerebral arteriovenous malformation hemorrhage, clinical risks during pregnancy, imaging diagnosis measures, and clinical treatment strategies, in order to provide guidance for the diagnosis and treatment of BAVM nationwide.

The effects of psychological distress after surgery in patients undergoing lumbar spinal fusion

BACKGROUND

The aim of this study was to evaluate the psychological distress pre-operatively, at 3, 6, and 12 months in patients who underwent lumbar spine fusion surgery.

METHODS

A total of 440 patients received instrumented lumbar spine fusion were enrolled. Psychological distress was evaluated using the Modified Somatic Perception Questionnaire (MSPQ) and the Modified Zung Depressive Index (ZDI). The results of lumbar fusion surgery were evaluated using the Oswestry Disability Index (ODI), the Japanese Orthopedic Association (JOA-29), and the visual analog scale (VAS).

RESULTS

Psychological distress was reported among 23% of patients and 7, 5.5, and 4.0% of the patients preoperatively, at 3, 6, and 12 months after lumbar surgery, respectively. The mean MSPQ score decreased from 8.78 (before surgery) to 4.30, 3.52, and 3.43 at 3, 6 and 12 months in after surgery, respectively, in patients with psychological distress patients (p < 0.001). The mean ZDI score decreased from 17.78 to 12.48, 10.35, and 9.61 (p < 0.001). The mean ODI score decreased from 22.91 to 11.78, 10.13, and 9.96 (P < 0.001). The mean JOA score increased from 13.65 to 22.30, 23.43, and 23.61 (P < 0.001). The mean low back pain (LBP) VAS score decreased from 4.48 to 1.96, 1.52, and 1.51 (P < 0.001); moreover, the mean leg pain (LP) VAS score decreased from 5.30 to 1.30, 1.04, and 1.03 (P < 0.001).

CONCLUSIONS

Patients with psychological distress may experience surgical intervention benefits equal to those of ordinary patients. Moreover, reduced pain and disability after surgical intervention may also alleviate psychological distress. Hence, we highly recommend that patients with psychological distress undergo surgical intervention as normal patients do, but appropriate screening measures and interventions are necessary.

Letter to editor : optimizing surgical approaches for anterior communicating artery aneurysms: development and internal validation of a novel surgical scoring system

The recent publication titled "Optimizing Surgical Approaches for Anterior Communicating Artery Aneurysms: Development and Internal Validation of a Novel Surgical Scoring System" presents a groundbreaking study in neurosurgery. This critique examines both the positive and negative impacts of the research. Positive aspects include the potential to improve patient outcomes through personalized surgical approaches guided by a standardized scoring system. Internal validation enhances the credibility of the scoring system. However, challenges such as the need for external validation and additional surgeon training are acknowledged. Overall, while the study offers promising advancements, further research and validation are essential for widespread implementation in clinical practice.

To corset or not to corset after lumbar spine fixation surgery?: A prospective randomized clinical trial and literature review

PURPOSE

Orthosis after lumbar fusion surgery is common. However, the evidence for benefit remains to be determined, especially in tropical areas with heavy workers. To investigate postoperative orthosis and whether it affects pain improvement, quality of life, and fusion rate.

METHOD

From May 2021 to May 2022, this single-center prospective randomized clinical trial enrolled 110 patients. We excluded 9 patients, and 101 people were analyzed finally. Corset group, in which participants used a corset for 3 months postoperatively; Non-corset group, in which participants didn't wear any orthosis. ODI and VAS scale were recorded before the surgery: 2 weeks, 1 month, 3 months, half a year, and 1 year postoperatively. The lumbar X-ray was done before the surgery, 6 months postoperatively. All complications in 1 year were recorded.

RESULTS

Significant decrease in VAS score in the non-corset group since post-operation day 5 (corset group 3.44 ± 1.77, non-corset group 3.36 ± 1.75, P = .0093) during admission, and also a decrease in admission duration (corset group 11.08 ± 2.39, non-corset group 9.55 ± 1.75, P = .0004) were found. There was a significantly better ODI score in the non-corset group since post-operation 1 month, while in the corset group until post-operation 3 months. Both groups had no significant difference in satisfaction, complication rates, and X-ray results, such as fusion, angular rotation, sagittal transition, and slip in the neutral position.

CONCLUSION

After the transpedicular screw fixation with posterolateral fusion surgery for degenerative spondylolisthesis, non-orthosis is a safe strategy. It can reduce the admission duration and has the trend for better functional outcomes.

A novel repair strategy using knotless squeeze anchors for lumbar disc herniation with endplate junction lesions under biportal endoscopic spinal surgery

BACKGROUND

Annulus fibrosus-endplate (AF-EP) junction lesions are important determinants for lumbar disc herniation (LDH). Utilizing biportal endoscopic spinal surgery (BESS), we introduce a novel repair method using bioabsorbable PushLock anchors with suture fibers to stretch disconnected AF tissues to the vertebral cortex.

METHODS

The viewing and working portals are established to excise herniated disc materials causing radiculopathy. Through the working portal, a suture strand is passed through the intact AF tissue near the lesion and retrieved using the Suture Crossing Device. Then, the knotless suture limbs are secured into the cortical bone socket of the vertebral body with a PushLock anchor.

CONCLUSION

The procedure is a simple, safe, and feasible knotless suturing technique for the treatment of LDH with AF-EP junction lesions.

Cerebral revascularization for complex vertebrobasilar artery dissecting aneurysms

Vertebrobasilar artery dissecting aneurysms (VBDAs) are the most surgically challenging type of aneurysm. Cerebral revascularization is the ultimate treatment for complex VBDAs. We retrospectively analysed the characteristics, surgical outcomes and follow-up data of 21 patients who underwent cerebral revascularization to treat complex VBDAs from 2015 to 2022. According to the location of the aneurysm and the anatomic relationship between the VBDA and the PICA, VBDA patients were classified into four groups: aneurysms located at the VA with PICA involvement (10 patients), aneurysms located at the VA without PICA involvement (1 patient), aneurysms located at the basilar apex segment (1 patient) and aneurysms located at the basilar trunk segment (9 patients). A surgical algorithm for complex VBDAs was determined primarily by the location of the aneurysm, the status of the aneurysm and the ability of retrograde blood flow to reach the proximal vertebrobasilar artery. Surgical modalities for patients with aneurysms in the VA with PICA involvement included low-flow (OA-PICA) bypasses with aneurysm trapping, aneurysm excision or reconstructive clip in 8 patients and STA-PCA bypass combined with PICA preservation and aneurysm trapping in 2 patients. In patients with aneurysms in the VA without PICA involvement, aneurysm excision was performed without cerebral bypass. In patients with aneurysms in the basilar apex segment, high-flow bypass (ECA-RA-P2) with aneurysm trapping was performed. In patients with aneurysms in the basilar trunk segment, surgical modalities included high-flow bypasses (ECA-RA-P2 and LVA-RA-P2) with aneurysm trapping or proximal occlusion in 6 patients, ECA-RA-P2 bypass with partial proximal occlusion in 1 patient, ECA-RA-P2 bypass alone in 1 patient, and STA-PCA bypass with R-VA narrowing in 1 patient. Of the 21 patients, 20 experienced clinical improvement or no change, and 17 of 21 patients achieved favourable functional outcomes (mRS ≤ 2). However, one patient died of infarction and respiratory failure postoperatively. Aneurysms were completely obliterated in 13 patients, shrank in 5 patients and stabilized in 2 patients. The median follow-up period was 32.5 months. During the follow-up period, all bypasses were patent, and further clinical improvement was observed in 11 patients. Cerebral revascularization appears to be safe and effective for the treatment of complex VBDAs, and cerebral revascularization could act as a complementary treatment strategy.

Effectiveness of lumbar braces after lumbar surgery: a systematic review and meta-analysis

OBJECTIVE

To systematically analyze the effectiveness of lumbar braces in patients after lumbar spine surgery.

METHODS

The databases, including PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI), were searched to identify the randomized controlled trials (RCTs), case-series or case-control studies on the use of lumbar braces after lumbar spine surgery. The two authors independently assessed the quality of the included study and extracted the data. The statistical analysis was performed using Revman 5.4 software.

RESULTS

9 English papers and 1 Chinese paper were included in the present work, involving a total of 2646 patients (2181 in the experimental group and 465 in the control group). The differences in preoperative VAS, postoperative VAS, preoperative ODI, postoperative ODI, length of hospital stay, postoperative complications, and surgical comparison were not statistically significant (p > 0.05). However, postoperative surgical site infection incidence was lower in the lumbar brace group than those without lumbar brace (p < 0.05).

CONCLUSION

Whether or not the use of lumbar braces after lumbar fixation has a negligible impact on clinical outcomes was studied. Subsequent studies could further demonstrate whether the use of lumbar braces after lumbar surgery could reduce the incidence of surgical site infections.

The transition from cranial surgery to neurosurgery in East London, 1760-1960

The emergence of neurosurgery from the practice of cranial surgery between the eighteenth and the twentieth centuries in London, UK, is well documented, including the role of Sir Victor Horsley, the first neurosurgical appointee at the National Hospital Queen Square in 1886. The process of this transition elsewhere in London and the subsequent foundation of other neurosurgical units are less well described. In East London, the status of St. Bartholomew's Hospital (Barts) as the oldest London hospital still active on its original site and its comprehensive archives allow an unusually long history of surgical practice in the specialty to be studied. Using these archives and other primary and secondary sources, this article describes the transition of cranial surgery in East London from the general surgeons, limited to the treatment of brain and skull injury, to the specialized discipline of neurosurgery. We discuss the culmination of this process in the foundation of three neurosurgical units at London Hospital, Whitechapel, by Sir Hugh B. Cairns from 1927; at Barts Hospital, Smithfield, by John E. A. O'Connell from 1937; and at Oldchurch Hospital, Romford, by Leslie C. Oliver from 1945. Two modern neurosurgical units, in Whitechapel and Romford, have taken forward the work begun by this group.

Anatomic Step-by-Step Dissection of Complex Skull Base Approaches for Trainees: Surgical Anatomy of the Infratemporal Fossa Approach to the Jugular Foramen

BACKGROUND AND OBJECTIVES

The infratemporal fossa (ITF) is a complex region bounded by the temporal bone, maxilla, sphenoid, pterygoid plates, and mandibular ramus. Containing a high density of neurovascular and musculoskeletal structures, the ITF can house a number of pathologies, and access is challenging. The ITF approach and its variations can be challenging due to complex anatomy and unfamiliarity by many surgeons. The objective of this study was to present a step-by-step 3-dimensional anatomic dissection for the classic Fisch Type A and modified ITF approach from the surgeon's perspective.

METHODS

Six sides of 3 formalin-fixed latex-injected specimens were dissected under microscopic magnification (JRD and AMN). Standard Fisch Type A and modified ITF approaches were performed on contralateral sides of each specimen. Representative high-quality 3-dimensional photography was performed for each key step.

RESULTS

The ITF approach affords excellent access to the posterior ITF and jugular foramen. Modifications to this approach include preservation of the ear canal and limiting facial nerve transposition, thus limiting morbidity while generally still providing sufficient access to key anatomic structures.

CONCLUSION

The ITF approach provides access to the lateral skull base for jugular foramen paraganglioma and other lesions. Modifications of the classic Fisch Type A technique can be used to access pathologies in this region without sacrificing conductive hearing or facial nerve function. Three dimensional operatively oriented neuroanatomy dissections provide surgeons with a valuable resource for learning this complex surgical approach.

Video-Assisted Cleft Palate Surgery: Preclinical Comparison Between Endoscope- and Exoscope-Based Approaches

Using both endoscope and exoscope in cleft soft palate surgery is not widespread, despite the potential advantages related to view magnification, ergonomic posture of the surgeon, and involvement of the surgical team.

The aim of the current study is to compare endoscopic (Olympus Visera©) and exoscopic (Karl-Storz Vitom©) assistance in cleft soft palate surgery in a preclinical cadaver setting.

A formalin fixed specimen was dissected to mimic the anatomical conditions of a cleft soft palate.

Ten young surgeons with limited experience in transoral surgery were involved in the exercitation on the specimen.

The exercitation consisted of 4 tasks: (1) device setting; (2) identification of muscle plane; (3) muscle suturing; (4) oral mucosa suturing.

Participants were timed while performing each task both with exoscope and endoscope and asked to fill in 2 questionnaires related to the visual systems used (NASA Task Load System TLS and VAS 1-10).

All surgeons completed the 4 tasks with both the endoscope and exoscope. The execution times were similar except for faster setting of the exoscope. Participants felt that completing surgical exercises using the exoscope required less physical, intellectual, and temporal efforts compared to the endoscope. The exoscope was also more appreciated for its handling, 3D visualization, and limited encumbrance.

Exoscope scored better both at NASA TLS and VAS 1-10 and required a faster setting than endoscope. Further clinical in-vivo studies are required to explore the advantages of these devices in cleft palate repair.

Internal Neurolysis for Trigeminal Neuralgia: Technical Nuances and a Single-Institution Experience

BACKGROUND

Trigeminal neuralgia is a facial pain syndrome most commonly caused by a neurovascular compression (NVC) of the trigeminal nerve. Microvascular decompression (MVD) is the most durable surgical treatment; however, patients without an NVC are not candidates for this procedure. Alternative treatments such as percutaneous rhizotomy and radiosurgery are effective but with higher recurrence rates. Internal neurolysis (IN) is a less frequently used procedure that aims to provide long-term relief to patients without NVC.

OBJECTIVE

We present the surgical techniques for IN developed at our institution. We also discuss the technical nuances related to nerve consistency and present a new classification based on these findings. We provide pain and numbness outcomes for our cohort of patients stratified by the extent of neurolysis and nerve consistency.

METHODS

Patients with medically intractable trigeminal neuralgia eligible for posterior fossa exploration are eligible for MVD and possible IN. If no NVC or a mild NVC is encountered, IN is performed. We have divided the procedure into 4 main steps: opening the outer connective sheath, fascicular dissection, inside-out dissection and the fascicular irrigation technique. Trigeminal nerve consistency has been classified into 3 main types: type 1 is soft and friable; type 2 is intermediate consistency and ideal for neurolysis; and type 3 is firm and presents a more challenging dissection.

CONCLUSIONS

In the absence of microvascular compression, we advocate for a thorough neurolysis using the techniques described in our article.

A perioperative overview of a retained surgical swab in spinal surgery: Case report and prevention protocol

INTRODUCTION

Retained wound swabs although classified as a 'never event' and well documented in many surgical specialties are uncommon in spinal surgery. The aim of this article is to highlight the perioperative circumstances of an incident of a retained surgical swab and present a prevention protocol, in an attempt to eliminate its incidence.

CASE REPORT

The perioperative management of a 53-year-old male undergoing spinal surgery in whom a surgical swab was retained is reported. In addition to existing safety procedures such as the World Health Organization checklist, a Retained Surgical Swab-Prevention Protocol was implemented in our hospital and is presented to eliminate the occurrence of this 'never event' occurring again.

CONCLUSION

Retained surgical swabs or instruments are rare in spinal surgery occurring mostly in the lumbar spine, during emergency and prolonged procedures in patients with high body mass index. Maintaining a high index of suspicion and utilising a prevention protocol will prevent further harm to the patient.

Outcomes of ulnar nerve decompression for double crush syndrome

BACKGROUND

Double crush syndrome (DCS) of the ulnar nerve, including cubital tunnel syndrome with ulnar tunnel syndrome (UTS), is uncommon. This study compares the postoperative outcomes of patients with isolated ulnar tunnel syndrome versus those with double crush syndrome of the elbow and ulnar tunnel.

METHODS

This study enrolled 22 patients: 12 underwent cubital tunnel surgery and ulnar tunnel surgery (double crush group); and 10 underwent only ulnar tunnel decompression (isolated UTS group). Postoperative effect evaluation of patients in both groups after at least 2.6 years (mean, 5.1 years and 5.7 years, respectively). Statistical analysis compared postoperative function, physical examination, and patient-reported satisfaction between groups.

RESULTS

In terms of postoperative grip strength, there was no difference between the postoperative states of the two groups (0.88 ± 0.04 versus 0.87 ± 0.05), while there was statistical difference in terms of the increment of the grip strength (p = 0.036); the two-point discrimination of isolated UTS group is better than the double crush group (90% versus 83.3%); double crush patients reported lower satisfaction than the UTS group (90% versus 83.3%).

CONCLUSIONS

At a minimum of 2.6 years after the nerve decompression, the patients of isolated UTS group are likely to have superior grip strength increment than patients with a history of double crush surgery, and there is no big difference in the final recovery situation. The sensation and satisfaction of isolated UTS group after nerve release were better compared with patients following double crush surgery.

The Current Landscape of Neurosurgical Oncology in Low-Middle-Income Countries (LMIC): Strategies for the Path Forward

OBJECTIVE

To promote global equity in research, innovation, and care, sharing knowledge and grasping current benchmarks is crucial. Despite LIC/LMIC constituting around 80% of the global population, their contribution to neurosurgery research is less than 5%. This study aims to assess the status of neurosurgical oncology in LIC/LMIC using published data, offering strategic insights for progress.

METHODS

Conducting a retrospective bibliometric analysis via PubMed and Scopus databases, we documented reports published (2015-2021) by neurosurgical department-affiliated investigators in LICs/LMICs. World Bank classifications identified LIC and LMIC. Reviewed papers underwent further scrutiny based on independent and associated keyword lists.

RESULTS

Our systematic approach revealed 189 studies from LMIC in 10 neurosurgery journals. Of these, 53% were case reports, with 88% focusing on brain pathologies and 12% on the spine. Intra-axial brain tumors (45.8%), extra-axial/skull base (38.4%), and metastasis (3.68%) were prominent. Among noncase report publications, surgical technique and outcome were common themes. India, Egypt, and Tunisia led in publications, with 94% appearing in journals with an impact factor below 5. No papers originated from LIC.

CONCLUSIONS

This study reinforces existing findings that data from LMIC inadequately represent their populations, impeding a comprehensive understanding of their neurosurgical oncology landscape. Language barriers and data collection difficulties contribute to this gap. Addressing these challenges could significantly enhance progress in shaping the future of neurosurgical oncology in these regions.

Surgical Management and Outcome of the Planum Sphenoidale Meningioma: A Single-Center Strobe Compliant Study

BACKGROUND

The resection of the jugum (planum) sphenoidale meningioma (JSM) is challenging, and there is a scarcity of available data in the literature. This study aimed to describe the surgical management and long-term outcome of jugum sphenoidale meningioma.

METHODS

This was a retrospective, single-center, cohort study of 91 JSM patients treated in our department from 2005 to 2022. All the included patients have undergone surgical treatment. Clinical, radiologic, and surgical data were extracted with specific attention to the age at onset, family history, duration from symptoms to diagnosis, clinical presentation, quality of excision, recurrence, and treatment outcome.

RESULTS

WHO grade I and grade II meningioma were 83.5% (n = 76) and 16.5% (n = 15) respectively. Fronto-lateral 42.9% (n = 39) and pterional approaches 57.1% (n = 52) were the 2 major surgical approaches used for the management of planum sphenoidale meningioma. Twelve patients needed emergency surgical treatment at admission: 4 (4.4%) External CSF Shunt and 8 (8.8%) VP-Shunt. We have found a statistically significant (P = 0.032) association between the quality of excision and the risk of recurrence. The GTR (Hazard ratio = 1) of the planum meningioma protects the patient from recurrence within 60 months of follow-up. Postoperative complications encountered were CSF-Leak in 2.2%, Meningitis 4.4%, surgical site infection 2.2%, and surgical site hematoma 3.3%. The overall postoperative favorable outcome was 68.1% (n = 62).

CONCLUSIONS

The pterional approach has allowed the achievement of GTR for jugum sphenoidale meningioma with protective odds from recurrence risk.

Sanford Larson, MD, PhD: a pioneering neurosurgeon, scientist, and educator

Dr. Sanford Larson, MD, PhD (1929-2012), was an influential figure in spinal neurosurgery. Dr. Larson played a pivotal role in establishing neurosurgery's foothold in spinal surgery by serving as the inaugural chair of the Joint Section on Disorders of the Spine and Peripheral Nerves and as a president of the Cervical Spine Research Society. He made many advances in spine care, most notably the modification and popularization of the lateral extracavitary approach to the thoracolumbar spine. Dr. Larson established the neurosurgery residency program at the Medical College of Wisconsin; he also instituted the program's spine fellowship, the first in the United States for neurological surgeons. His mentorship produced numerous leaders in organized neurosurgery and neurosurgical education, including Edward Benzel, MD, Dennis Maiman, MD, PhD, Joseph Cheng, MD, Shekar Kurpad, MD, PhD, and Christopher Wolfla, MD. Dr. Larson was a prominent leader in spinal neurosurgery and his legacy carries on today through his contributions to research, education, and surgical technique.

Use of Stroboscopic Goggles in Suture Training Improves Precision and Accuracy

BACKGROUND

This study aimed to quantify the impact of intermittent visual occlusion via stroboscopic goggles on suture accuracy and precision.

METHODS

This crossover study recruited and randomized 72 graduate students to train with stroboscopic goggles early or late in structured suture practice. Participants completed assessments of 10 running sutures with 2 training sessions between baseline and follow-up assessments. The procedure was repeated after crossover. Suture photos were analyzed using ImageJ. Total error among all measurements represented accuracy; standard deviation of error represented precision. Intra- and inter-group trends were identified with Wilcoxon rank-sum tests.

RESULTS

Both groups significantly improved in accuracy in the sessions immediately following goggle use, but the group that used goggles later in training continued improving in accuracy and precision while the group that trained with stroboscopic goggles early plateaued.

CONCLUSIONS

Using stroboscopic goggles showed quantifiable benefit for augmenting suture training with greatest effect after initial skill acquisition is completed.

Alfred Washington Adson: Perspectives on Intracranial Neurosurgery and the Responsibilities of the Neurosurgeon

In a period when the budding field of neurosurgery was believed to have little promise, Dr Alfred Washington Adson founded and led the first neurosurgical department at Mayo Clinic. He was not without reservations-surgical intervention for neurological conditions was rarely pursued because of poor outcomes and high complication rates, and Dr Adson acknowledged his early concerns about the future of neurosurgery in his memoirs. However, his education, mentorship, his training, and his first neurosurgical cases helped to shape the impact he ultimately had on the field and his legacy as a neurosurgeon. Dr Adson trained with several renowned Mayo general surgeons, notably his mentor Dr Emil Beckman, whose desire for operative precision shaped Dr Adson's drive to develop his own skills as a surgeon. Two years into his residency, he became the youngest staff surgeon and was tasked with managing the neurosurgical cases at Mayo. The five neurosurgical cases overseen by Dr Adson in the next year illuminated the opportunity for neurosurgery to drastically improve the lives of patients. Dr Adson, given the option of continuing as either a general surgeon or a neurosurgeon, ultimately chose to pursue neurosurgery. This article seeks to provide a historical perspective on the neurosurgeon Dr Alfred Washington Adson using primary and secondary accounts from the Mayo archives, highlighting his contributions to the early understanding of intracranial pathology and how his early experiences as a trainee developed into a personal passion for self-improvement, education, and advocacy for health care in America.

Intraoperative High-Resolution Color-Coded Ultrasound to Identify the Posterior Median Sulcus for Midline Myelotomy in Intramedullary Spinal Cord Surgery

A 14-year-old boy presented with a 2-year history of slowly increasing weakness and atrophy in the right forearm and leg. Magnetic resonance imaging (MRI) revealed an intramedullary diffusely infiltrating lateralized tumor at C3-7. An extended biopsy was planned. After laminotomy and durotomy, the swollen spinal cord was noted to be rotated by 45° with the right dorsal root entry zone being in the midline. A 15 MHz linear ultrasound probe was used to identify the midline by visualizing the dorsal median sulcal vein within the midline raphe. A myelotomy was made in that zone without deterioration of somatosensory evoked potentials (SEPs) and an extended biopsy was performed. Histological examination revealed a pilocytic astrocytoma. Modern intraoperative high-resolution color-coded ultrasound enables the identification of the midline in intramedullary spinal cord lesions even when the spinal cord anatomy is distorted.

Analysis of 10-year trends in Medicare Physician Fee Schedule payments in surgery

BACKGROUND

Medicare expenditures have steadily increased over the decades, and yet Medicare Physician Fee Schedule payments for individual services have declined. We examine trends in Medicare Physician Fee Schedule payments for office visits, inpatient visits, and surgical procedures.

METHODS

The Medicare Physician Fee Schedule Look-Up Tool was queried for payment data for office visits, inpatient visits, and surgical procedures between 2013 and 2023. All data were adjusted for inflation using the Consumer Price Index. Trends in payments were calculated for 5 common procedures in each surgical specialty. Trends in aggregate national health expenditures were compared to Medicare Physician Fee Schedule payments for physician services from 2013 to 2021.

RESULTS

The Consumer Price Index increased by 29.3% from 2013 to 2023. Inflation-adjusted per-visit Medicare Physician Fee Schedule payments decreased by 12.2% for outpatient office visits, 19.1% for inpatient visits, and 22.8% for surgical procedures from 2013 to 2023. This varied by surgical specialty: vascular (-25.8%), endocrine (-22.0%), general surgery (-27.0%), thoracic (-19.2%), surgical oncology (-22.1%), breast (-22.4%), urology (-2.2%), neurosurgery (-22.8%), obstetrics/gynecology (-19.9%), and orthopedics (-24.7%). Adjusted for inflation, national health expenditures increased by 33.9% for physician services from 2013 to 2021. In comparison, Medicare Physician Fee Schedule payments over the same time period 2013 to 2021 increased by 1.3% for outpatient office visits but decreased by 10.6% for inpatient visits and 9.8% for surgical procedures.

CONCLUSION

Controlling rising national health expenditures is important and necessary, but 10 years of declining Medicare Physician Fee Schedule payments on a per-procedure basis in surgery would suggest that this strategy alone may not achieve those goals and could ultimately threaten access to quality surgical care. Surgeons must advocate for permanent payment reforms.

Endoscopic resection of sellar and suprasellar epidermoid cyst: report of two cases and review of literature

INTRODUCTION

Epidermoid cysts (EC) are lesions developing from neuroectodermal epithelial cells. They represent 1-2% of all intracranial tumors and are usually found in cerebellopontine angle and parasellar regions. To the best of our knowledge, only 27 cases have been reported of EC in sellar and suprasellar region. In 12 cases out of the 27, surgery was done by craniotomy means. The 7 most recent manuscripts (with 15 patients described) share in common the use of endoscopic endonasal approach (EEA) to perform surgical removal.

RESULTS

In this paper, we report the safe removal of epidermoid cysts arising from the pituitary using an EEA in two patients, which should be the sixth such description in literature. In both cases, resection and evolution was favourable.

DISCUSSION

Surgical resection is the treatment standard for epidermoid cysts, with total resection including the cyst wall to prevent recurrence when possible. The degree of resection obtained is limited by adherence to nearby neural and vascular structures. The advent of EEA approaches has allowed safe maximal resection especially in midline lesions nearby sellar and suprasellar compartiments.

Prophylactic removal of a migratory missile from the cerebral ventricles: case report

BACKGROUND AND IMPORTANCE

Nonpowder firearm injuries to the head pose major health risks, with retained fragments potentially causing harmful sequelae that require neurosurgical intervention.

CLINICAL PRESENTATION

We report the case of 2-year-old girl who sustained an accidental gunshot wound to the head. She sustained a penetrating ballistic intracranial injury caused by a BB shot from a rifle. At presentation, she was neurologically intact with a punctate laceration on her left forehead. Head CT demonstrated a small depressed left frontal skull fracture, a small intracerebral hematoma, and a 5-mm metallic bullet fragment in the deep left frontal lobe near the frontal horn of the left lateral ventricle. She was admitted to the hospital and managed nonoperatively with levetiracetam and intravenous antibiotics, and discharged home in good condition. Follow-up CT in 1 week showed slight migration of the metallic bullet fragment to the left, placing it at the anterior horn of the lateral ventricle. Six weeks later, follow-up CT showed migration of the bullet to the temporal horn of the left lateral ventricle. Intraventricular migration of the bullet raised concern that it could move further to obstruct the foramen of Monro or cerebral aqueduct. Therefore, we removed the bullet through a small left temporal craniotomy with image guidance using a microsurgical approach through a translucent tube.

CONCLUSION

The authors discuss the rationale and technique for removing a nonpowder firearm bullet that has migrated within the cerebral ventricles.

Performance of the streamlined quality outcomes database web-based calculator: internal and external validation

BACKGROUND CONTEXT

With an increasing number of web-based calculators designed to provide the probabilities of an individual achieving improvement after lumbar spine surgery, there is a need to determine the accuracy of these models.

PURPOSE

To perform an internal and external validation study of the reduced Quality Outcomes Database web-based Calculator (QOD-Calc).

STUDY DESIGN

Observational longitudinal cohort.

PATIENT SAMPLE

Patients enrolled study-wide in Quality Outcomes Database (QOD) and patients enrolled in DaneSpine at a single institution who had elective lumbar spine surgery with baseline data to complete QOD-Calc and 12-month postoperative data.

OUTCOME MEASURES

Oswestry Disability Index (ODI), Numeric Rating Scales (NRS) for back and leg pain, EuroQOL-5D (EQ-5D).

METHODS

Baseline data elements were entered into QOD-Calc to determine the probability for each patient having Any Improvement and 30% Improvement in NRS leg pain, back pain, EQ-5D and ODI. These probabilities were compared with the actual 12-month postop data for each of the QOD and DaneSpine cases. Receiver-operating characteristics analyses were performed and calibration plots created to assess model performance.

RESULTS

24,755 QOD cases and 8,105 DaneSpine lumbar cases were included in the analysis. QOD-Calc had acceptable to outstanding ability (AUC: 0.694-0.874) to predict Any Improvement in the QOD cohort and moderate to acceptable ability (AUC: 0.658-0.747) to predict 30% Improvement. QOD-Calc had acceptable to exceptional ability (AUC: 0.669-0.734) to predict Any improvement and moderate to exceptional ability (AUC: 0.619-0.862) to predict 30% Improvement in the DaneSpine cohort. AUCs for the DaneSpine cohort was consistently lower that the AUCs for the QOD validation cohort.

CONCLUSION

QOD-Calc performs well in predicting outcomes in a patient population that is similar to the patients that was used to develop it. Although still acceptable, model performance was slightly worse in a distinct population, despite the fact that the sample was more homogenous. Model performance may also be attributed to the low discrimination threshold, with close to 90% of cases reporting Any Improvement in outcome. Prediction models may need to be developed that are highly specific to the characteristics of the population.

Placement of a Kickstand Rod in Adult Spinal Deformity Surgery: A Simple 8-Step Process With Intraoperative Images and Video

BACKGROUND AND OBJECTIVES

In adult spinal deformity (ASD) surgery, operative correction of coronal malalignment remains a challenging surgical task. Given the proven effectiveness and longevity of the kickstand rod (KSR) technique and its powerful ability to correct coronal malalignment, this technique is an important tool to have available. Therefore, we sought to provide a simple 8-step description of the KSR technique using intraoperative images and video in a patient undergoing combined sagittal and coronal malalignment correction.

METHODS

A 68-year-old female with a previous history of T11-S1 posterior spinal fusion presented with mid thoracic back pain, leg paresthesias, and a right-leaning posture. The patient underwent a T4-pelvis extension of fusion, T8-11 posterior column osteotomies, and placement of a right-sided KSR to address her coronal malalignment.

RESULTS

The KSR technique is summarized in the following steps: (1) place kickstand screw, (2) place contralateral main rod and tighten all set plugs, (3) place ipsilateral main rod and keep rod long distally, (4) place a domino in the lower/mid thoracic area, (5) place the KSR and leave the rod long proximally, (6) tighten the ipsilateral main rod above the domino, (7) loosen the ipsilateral main rod below the domino, and (8) place a rod gripper below the domino and distract. Postoperatively, the coronal vertical axis improved from 4.8 to 0.6 cm, and the sagittal vertical axis improved from 9.5 to 3.9 cm.

CONCLUSION

The current case report provides a simple 8-step description of the KSR technique to improve coronal malalignment accompanied by intraoperative images and video.

Does Preoperative Bilsky Score Predict Outcome Following Surgical Resection of Primary Tumors of the Spine?

OBJECTIVE

In patients undergoing surgery for primary bone tumors of the spine, we sought to compare Bilsky score 0-1 versus 2-3 in: 1) preoperative presentation, 2) perioperative variables, and 3) long-term outcomes.

METHODS

A single-center, retrospective cohort study was undertaken of patients undergoing surgery for extradural, primary bone tumors of the spine between January 2010 and January 2021. The primary exposure variable was Bilsky score, dichotomized as 0-1 versus 2-3. Survival analysis was performed to assess local recurrence (LR) and overall survival (OS).

RESULTS

Of 38 patients undergoing resection of primary spinal tumors, 19 (50.0%) patients presented with Bilsky 0-1 and 19 (50.0%) Bilsky 2-3 grades. The most common diagnosis was chondrosarcoma (33.3%), followed by chordoma (16.7%). There were 15 (62.5%) malignant tumors. Preoperatively, there was no significant difference in demographics, Karnofsky Performance Scale (KPS) (P > 0.999), or motor deficit (P > 0.999). Perioperatively, no difference was found in operative time (P = 0.954), blood loss (P = 0.416), length of stay (P = 0.641), neurologic deficit (P > 0.999), or discharge disposition (P = 0.256). No difference was found in Enneking resection status (69.2% vs. 54.5%, P = 0.675). Long-term, no differences were found regarding reoperation (P = 0.327), neurologic deficit (P > 0.999), postoperative KPS (P = 0.605) and modified McCormick Scale (MMS) (P = 0.870). No difference was observed in KPS (P = 0.418) and MMS (P = 0.870) at last follow-up. However, patients with Bilsky 2-3 had shorter time to LR (1715.0 vs. 513.0 ± 633.4 days, log-rank; P = 0.002) and shorter OS (2025.0 ± 1165.3 vs. 794.0 ± 952.6 days, log-rank; P = 0.002).

CONCLUSIONS

Bilsky 2-3 lesions were associated with shorter time to LR and shorter OS. Patients harboring primary spinal tumors with higher grade Bilsky score appear to be at a higher risk for worse outcomes.

Al-Zahrawi (936-1013 AD): On the Surgical Treatment of Neurological Disorders by the Father of Operative Surgery

BACKGROUND

Medical knowledge during the medieval ages flourished under the influence of great scholars of the Islamic Golden age such as Ibn Sina (Latinized as Avicenna), Abu Bakr al-Razi (Rhazes), and Abu al-Qasim Khalaf ibn al-Abbas al-Zahrawi, known as Albucasis. Much has been written on al-Zahrawi's innovation in various disciplines of medicine and surgery. In this article, we focus for on the contributions of al-Zahrawi toward the treatment of neurological disorders in the surgical chapters of his medical encyclopedia, Kitab al-Tasrif (The Method of Medicine).

METHODS

Excerpts from a modern copy of volume 30 of al-Zahrawi's Kitab al-Tasrif were reviewed and translated by the primary author from Arabic to English, to further provide specific details regarding his neurosurgical knowledge. In addition, a literature search was performed using PubMed and Google Scholar to review prior reports on al-Zahrawi's neurosurgical instructions.

RESULTS

In addition to what is described in the literature of al-Zahrawi's teachings in cranial and spine surgery, we provide insight into his diagnosis and management of cranial and spinal trauma, the devices he used, and prognostication of various traumatic injuries.

CONCLUSIONS

Al-Zahrawi was a renowned physician during the Islamic Golden age who made significant contributions to the diagnosis and treatment of neurological conditions, particularly cranial and spinal cord injuries. He developed innovative surgical techniques for trephination and spinal traction, which are still used in modern neurosurgery. His insights make him worthy of recognition as an important figure in the history of neurological surgery.

How to do an outside-in/outside-in microsuture for nerve repair

Peripheral nerve injuries are common and debilitating. The goals of nerve repair are to accurately approximate the fascicular tissue, whilst ensuring continuous overlying epineurium and eliminating external sprouting of neural tissue. We describe a modification of standard micro-suturing which allows superior epineural eversion and fascicular coaptation.

Quantitative noninvasive measurement of cerebrospinal fluid flow in shunted hydrocephalus

OBJECTIVE

Standard MRI protocols lack a quantitative sequence that can be used to evaluate shunt-treated patients with a history of hydrocephalus. The objective of this study was to investigate the use of phase-contrast MRI (PC-MRI), a quantitative MR sequence, to measure CSF flow through the shunt and demonstrate PC-MRI as a useful adjunct in the clinical monitoring of shunt-treated patients.

METHODS

The rapid (96 seconds) PC-MRI sequence was calibrated using a flow phantom with known flow rates ranging from 0 to 24 mL/hr. Following phantom calibration, 21 patients were scanned with the PC-MRI sequence. Multiple, successive proximal and distal measurements were gathered in 5 patients to test for measurement error in different portions of the shunt system and to determine intrapatient CSF flow variability. The study also includes the first in vivo validations of PC-MRI for CSF shunt flow by comparing phase-contrast-measured flow rate with CSF accumulation in a collection burette obtained in patients with externalized distal shunts.

RESULTS

The PC-MRI sequence successfully measured CSF flow rates ranging from 6 to 54 mL/hr in 21 consecutive pediatric patients. Comparison of PC-MRI flow measurement and CSF volume collected in a bedside burette showed good agreement in a patient with an externalized distal shunt. Notably, the distal portion of the shunt demonstrated lower measurement error when compared with PC-MRI measurements acquired in the proximal catheter.

CONCLUSIONS

The PC-MRI sequence provided accurate and reliable clinical measurements of CSF flow in shunt-treated patients. This work provides the necessary framework to include PC-MRI as an immediate addition to the clinical setting in the noninvasive evaluation of shunt function and in future clinical investigations of CSF physiology.

From Text to Insight: A Natural Language Processing-Based Analysis of Topics and Trends in Neurosurgery

BACKGROUND AND OBJECTIVES

Neurosurgical research is a rapidly evolving field, with new research topics emerging continually. To provide a clearer understanding of the evolving research landscape, our study aimed to identify and analyze the prevalent research topics and trends in Neurosurgery.

METHODS

We used BERTopic, an advanced natural language processing-based topic modeling approach, to analyze papers published in the journal Neurosurgery . Using this method, topics were identified based on unique sets of keywords that encapsulated the core themes of each article. Linear regression models were then trained on the topic probabilities to identify trends over time, allowing us to identify "hot" (growing in prominence) and "cold" (decreasing in prominence) topics. We also performed a focused analysis of the trends in the current decade.

RESULTS

Our analysis led to the categorization of 12 438 documents into 49 distinct topics. The topics covered a wide range of themes, with the most commonly identified topics being "Spinal Neurosurgery" and "Treatment of Cerebral Ischemia." The hottest topics of the current decade were "Peripheral Nerve Surgery," "Unruptured Aneurysms," and "Endovascular Treatments" while the cold topics were "Chiari Malformations," "Thromboembolism Prophylaxis," and "Infections."

CONCLUSION

Our study underscores the dynamic nature of neurosurgical research and the evolving focus of the field. The insights derived from the analysis can guide future research directions, inform policy decisions, and identify emerging areas of interest. The use of natural language processing in synthesizing and analyzing large volumes of academic literature demonstrates the potential of advanced analytical techniques in understanding the research landscape, paving the way for similar analyses across other medical disciplines.

Diagnostic utility of different types of somatosensory evoked potential changes in pediatric idiopathic scoliosis correction surgery

PURPOSE

To evaluate the diagnostic accuracy of intraoperative somatosensory evoked potential (SSEP) monitoring and types of SSEP changes in predicting the risk of postoperative neurological outcomes during correction surgery for idiopathic scoliosis (IS) in the pediatric age group (≤ 21 years).

METHODS

Database review was performed to identify literature on pediatric patients with IS who underwent correction with intraoperative neuromonitoring. The sensitivity, specificity, and diagnostic odds ratio (DOR) of transient and persistent SSEP changes and complete SSEP loss in predicting postoperative neurological deficits were calculated.

RESULTS

Final analysis included 3778 patients. SSEP changes had a sensitivity of 72.9%, specificity of 96.8%, and DOR of 102.3, while SSEP loss had a sensitivity of 41.8%, specificity of 99.3%, and DOR of 133.2 for predicting new neurologic deficits. Transient and persistent SSEP changes had specificities of 96.8% and 99.1%, and DORs of 16.6 and 59, respectively.

CONCLUSION

Intraoperative SSEP monitoring can predict perioperative neurological injury and improve surgical outcomes in pediatric scoliosis fusion surgery.

LEVEL OF EVIDENCE

Level 2. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .