Intracranial arachnoid cyst surgery

Controversy still exists regarding the optimal option for the surgical management of intracranial arachnoid cysts.

Options

Neuroendoscopic fenestrations.

Microsurgical fenestrations +/- marsupialisation

Cystoperitoneal shunt.

In a retrospective case note review of all patients with intracranial arachnoid cysts treated surgically at the Department of Neurosurgery, Wessex Neurological Centre, Southampton General Hospital, over a 15 year period. Data on clinical presentations and outcomes was collected from the patient notes and the pre- and post-operative cyst volumes were calculated by creating 3-dimensional volumetric models.

Eighty-two patients were identified of which 45 were treated endoscopically, 34 microscopically and 3 underwent cysto-peritoneal shunting. The most common cyst location was the middle fossa (n = 25). Amongst the symptomatic patients, improvement or resolution of symptoms was seen in 35 out of 40 cysts treated endoscopically (88%), 28 out of 32 treated microsurgically (88%) and 3 out of 3 treated by shunting (100%, p = 0.79). The reoperation rate was not significantly different between the endoscopic and microsurgical groups (24.4% vs 14.7%, p = 0.49). The endoscopic and shunted groups had a shorter length of stay than the microsurgical group (3.0 vs 3.0 vs 4.5 days, p = 0.04). All three treatment modalities had a similar percentage reduction in cyst volume after surgery (30.0 vs 41.7 vs 30.9%, p = 0.98).

This cohort series shows that endoscopic and microsurgical approaches to treat intracranial arachnoid cysts produce comparable clinical and radiological outcomes. Endoscopic fenestration is associated with a shorter length of stay as would be expected from a minimally invasive procedure 1).


Open surgery advantages include, direct inspection of the cyst, biopsy sampling, fenestration in multilocular cysts and, in certain locations, cyst communication to basal cisterns 2).

Surgery for AC can be performed with a fairly low risk of complications and yields significant improvement in quality of life correlated to postoperative improvement in headache and dizziness. These findings may justify a more liberal approach to surgical treatment for AC 3).


Choi et al., analyzed pediatric patients under 18 years of age who underwent surgical management for intracranial AC between January 2000 and December 2011. Patients with a follow-up period of less than 1 year were excluded. A total of 75 patients were enrolled in this study. These patients were assessed by subjective symptoms and by a clinician’s objective evaluation. The radiological assessment of AC after surgery was also evaluated.

The median age of patients at the initial operation was 5 years. The median follow-up period was 38 months. The goal of surgery was achieved in 28% (21/75) of patients. The radiological alteration of AC after initial fenestration surgery was diverse. The results of the clinical and radiological assessments did not always coincide. A total of 35 complications occurred in 28 patients. Subdural fluid collection was the most common unexpected radiological complication.

The study showed that the fenestration procedure for AC produced unsatisfactory clinical improvements compared to the relatively high complication rate. Therefore, surgical treatment for AC should be strictly limited to patients who have symptoms directly related to AC 4).


A consecutive series of 68 adult patients (43 males, mean age 30.3 years, range 18-42 years) with IAC were surgically treated between January 2004 and January 2011 in the Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, China.

The cysts were supratentorial in location in 53 and infratentorial in 15 patients. Symptoms at presentation, location of the IAC, surgical treatment modalities, and postoperative complications were evaluated.

Of the 51 patients with headache, 44 (86.27%) patients had complete relief of the headache, five (9.80%) patients had significant improvement, and two (3.92%) had no worthwhile change. Three of the four patients with hydrocephalus and gait disturbances had relief of the symptoms and one patient had significant improvement. Of the five patients with cognitive decline and weakness, three (60.00%) patients showed improvement, and two (40.00%) patients had no significant change. Five (62.50%) of the eight patients with epilepsy had seizure remission, two (25.00%) patients had non-disabling seizures, and one had no change. Follow-up computed tomography (CT) scans showed variable change in the mass effect of IAC in 68 patients; cystic size was significantly reduced in 51 patients, no significant change in two patients of supratentorial arachnoid cysts. Cystic size was reduced in seven patients, but no significant change was observed in eight patients of infratentorial cysts. Three patients with enlarged head circumference had no further increase in the head circumference.

Adult patients with IAC symptoms should be treated efficiently. Surgical treatment is associated with significant improvement in the symptoms and signs 5).


Data from 69 patients with cerebral arachnoid cysts treated in our institution between 1997 and 2007 were reviewed.Cysts were located infratentorially in 20% (n = 14) and supratentorially in 80% (n = 55); of these 73% (n = 40) were in the middle cranial fossa. Mean cyst size was 61 mm (range 15-100 mm). The most common symptoms were headache (51%), dizziness (26%), cranial nerve dysfunction (23%), seizure (22%), nausea and vomiting (18%), and hemiparesis (13%). Surgery was performed in 83% (n = 57). First-line treatments were microsurgical fenestration (n = 30), endoscopic fenestration (n = 15), and cystoperitoneal/ventriculoperitoneal shunting (n = 11). More than one intervention was needed in 42% (n = 24). A particularly high rate of relapse (73%) was observed after endoscopic fenestration, following which 11 patients were admitted for reoperation. By comparison, only eight patients (28%) managed with microsurgical fenestration and four (36%) in the shunted group needed a second surgical procedure. Mean follow-up was 30 months. In the surgical series 79% (n = 45) had a good outcome.We conclude that the surgical treatment of arachnoid cysts has an overall good outcome. In our institution the best results were obtained with microsurgical decompression through craniotomy 6).

References

1)

Hall S, Smedley A, Rae S, Mathad N, Waters R, Chakraborty A, Sparrow O, Tsitouras V. Clinical and radiological outcomes following surgical treatment for intra-cranial arachnoid cysts. Clin Neurol Neurosurg. 2018 Dec 27;177:42-46. doi: 10.1016/j.clineuro.2018.12.018. [Epub ahead of print] PubMed PMID: 30599313.
2)

Saura Rojas JE, Horcajadas Almansa Á, Ros López B. [Microsurgical treatment of intracraneal arachnoid cysts]. Neurocirugia (Astur). 2015 Apr 16. pii: S1130-1473(15)00029-9. doi: 10.1016/j.neucir.2015.02.006. [Epub ahead of print] Spanish. PubMed PMID: 25891259.
3)

Mørkve SH, Helland CA, Amus J, Lund-Johansen M, Wester KG. Surgical Decompression of Arachnoid Cysts Leads to Improved Quality of Life: A Prospective Study. Neurosurgery. 2016 May;78(5):613-25. doi: 10.1227/NEU.0000000000001100. PubMed PMID: 26540351.
4)

Choi JW, Lee JY, Phi JH, Kim SK, Wang KC. Stricter indications are recommended for fenestration surgery in intracranial arachnoid cysts of children. Childs Nerv Syst. 2015 Jan;31(1):77-86. doi: 10.1007/s00381-014-2525-1. Epub 2014 Aug 16. PubMed PMID: 25123786.
5)

Wang C, Liu C, Xiong Y, Han G, Yang H, Yin H, Wang J, You C. Surgical treatment of intracranial arachnoid cyst in adult patients. Neurol India. 2013 Jan-Feb;61(1):60-4. doi: 10.4103/0028-3886.108013. PubMed PMID: 23466842.
6)

Holst AV, Danielsen PL, Juhler M. Treatment options for intracranial arachnoid cysts: a retrospective study of 69 patients. Acta Neurochir Suppl. 2012;114:267-70. doi: 10.1007/978-3-7091-0956-4_52. PubMed PMID: 22327706.

Insular glioma surgery

Shawn Hervey-Jumper and Berger from the UCSF Medical Center reviewed the literature for published reports focused on insular region anatomyneurophysiology, surgical approaches, and outcomes for adults with who grade II-IV gliomas.

While originally considered to pose too great a riskinsular glioma surgery can be performed safely due to the collective efforts of many individuals. Similar to resection of gliomas located within other cortical regions, maximal resection of gliomas within the insula offers patients greater survival time and superior seizure control for both newly diagnosed and recurrent tumors in this region. The identification and the preservation of M2 perforating and lateral lenticulostriate artery are critical steps to preventing internal capsulestroke and hemiparesis. The transcortical approach and intraoperative mapping are useful tools to maximize safety.

The insula’s proximity to middle cerebral and lenticulostriate arteries, primary motor areas, and perisylvian language areas makes accessing and resecting gliomas in this region challenging. Maximal safe resection of insular gliomas not only is possible but also is associated with excellent outcomes and should be considered for all patients with low- and high-grade gliomas in this area 1).


Advances in microsurgical anatomy and brain mapping techniques have allowed an increase in the extent of resection with acceptable morbidity rates. Transsylvian and transcortical approaches constitute the main surgical corridors, the latter providing considerable advantages and a high degree of reliability. Nevertheless, both surgical corridors yield remarkable difficulties in reaching the most posterior insular region.

see Insular tumor surgery.


Small deep infarcts constitute a well-known risk of motor and speech deficit in insulo-opercular glioma surgery. However, the risk of cognitive deterioration in relation to stroke occurrence in so-called silent areas is poorly known.

In a paper, Loit et al. propose to build a distribution map of small deep infarcts in glioma surgery, and to analyze patients’ cognitive outcome in relation to stroke occurrence.

They retrospectively studied a consecutive series of patients operated on for a diffuse glioma between June 2011and June 2017. Patients with lower-grade glioma were cognitively assessed, both before and 4 months after surgery. Areas of decreased apparent diffusion coefficient (ADC) on the immediate postoperative MRI were segmented. All images were registered in the MNI reference by ANTS algorithm, allowing to build a distribution map of the strokes. Stroke occurrence was correlated with the postoperative changes in semantic fluency score in the lower-grade glioma cohort.

One hundred fifteen patients were included. Areas of reduced ADC were observed in 27 out of 54 (50%) patients with a lower-grade glioma, and 25 out of 61 (41%) patients with a glioblastoma. Median volume was 1.6 cc. The distribution map revealed five clusters of deep strokes, corresponding respectively to callosal, prefrontal, insulo-opercular, parietal, and temporal tumor locations. No motor nor speech long-term deficits were caused by these strokes. Cognitive evaluations at 4 months showed that the presence of small infarcts correlated with a slight decrease of semantic fluency scores.

Deep small infarcts are commonly found after glioma surgery, but their actual impact in terms of patients’ quality of life remains to be demonstrated. Further studies are needed to better evaluate the cognitive consequences-if any-for each of the described hotspots and to identify risk factors other than the surgery-induced damage of microvessels 2).

Videos

Awake Brain Mapping in Dominant Side Insular Glioma Surgery: 2-Dimensional Operative Video 3).

References

1)

Hervey-Jumper SL, Berger MS. Insular glioma surgery: an evolution of thought and practice. J Neurosurg. 2019 Jan 1;130(1):9-16. doi: 10.3171/2018.10.JNS181519. Review. PubMed PMID: 30611160.
2)

Loit MP, Rheault F, Gayat E, Poisson I, Froelich S, Zhi N, Velut S, Mandonnet E. Hotspots of small strokes in glioma surgery: an overlooked risk? Acta Neurochir (Wien). 2018 Nov 10. doi: 10.1007/s00701-018-3717-3. [Epub ahead of print] PubMed PMID: 30415385.
3)

Hameed NUF, Zhu Y, Qiu T, Wu J. Awake Brain Mapping in Dominant Side Insular Glioma Surgery: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown). 2018 Feb 16. doi: 10.1093/ons/opx299. [Epub ahead of print] PubMed PMID: 29471530

EANS Basic Course in Cranial Surgery – Brno

EANS Basic Course in Cranial Surgery – Brno


Message from Course Chairmen Prof. Torstein R. Meling and Prof. Martin Smrcka:

It is our pleasure to welcome you to the second EANS Basic Course in Cranial Surgery in Brno. The event will be held from 20th to 23rd November 2018 and is organized in the Masaryk University Brno, Czech Republic. 

This dissection course is most suitable for neurosurgical residents in their first years of training as it will focus on the essential neurosurgical anatomy, the planning of surgical procedures, the handling of basic neurosurgical equipment, and the basic neurosurgical cranial approaches. The course capacity is limited to 20 participants.


Course dates:
 20 November (arrive in time for welcome dinner) – 23 November 2018


Venue:
 The course will take place at Masaryk University Brno, Faculty of Medicine, Anatomy Institute, Kamenice 3, 62500 Brno, Czech Republic


Target audience:
 All levels, but of the most benefit for neurosurgical residents in their first years of training.


Curriculum:
 Participants will learn the essential neurosurgical anatomy, the planning of surgical procedures, the handling of basic neurosurgical equipment, and the basic neurosurgical cranial approaches. Please click HERE for a more complete list.

Download the premliminary programme HERE.


2018 Faculty:

Course chairmen: T Meling (NO) / M Smrcka (CZ)

J Fiedler (CZ)
O Navratil (CZ)
V Priban (CZ)
S Rocka (LT)
M Sames (CZ)
E Simon (FR)
V Smolanka (UA)
N Velinov (BG)


Course Fee:

EANS Individual Member: €1150
Non-Member: €1250

The fee includes all tuition costs, subsistence during the course (lunches and coffee breaks) and the networking events listed below. Scrubs are provided. The fee does NOT include accommodation (please see accommodation suggestions below).


Networking opportunities:
 Welcome cocktail on Tuesday 20th November evening and Networking Dinner on Thursday 22nd November. Participants are free to make their own arrangements on Wednesday night.

Cancellation policy:
Cancellations received in writing before 20 days prior to the course start will be reimbursed.
Cancellations between 20 and 10 days prior to the course – minimum 50% refund.
Cancellations less than 10 days prior to the course – no refund (unless exceptional extenuating circumstances).


Accommodation suggestions:
 Campea Aparthotel, Studentská 1, Brno, 62500 – https://www.campea-aparthotel.cz

Travel: Brno has an international airport with particularly good connections to the UK (London Stansted and Luton) and Germany (Münich).

Participants can also arrive at either Vienna or Prague airports and take the train to Brno (slightly shorter transfer time from Vienna).

Please contact Petra Koubova for all inquiries.

 

First EANS Brno HandsOn Course

The inaugural EANS Brno HandsOn Course took place from 28 November to 1 December 2017, led by Course Chairmen, EANS Training Committee Chair Torstein Meling and Chief of Neurosurgery Department of University Hospital Brno Martin Smrcka.

The format was immediately successful and received excellent evaluations from the participations. Please see the testimonials below.

All the attendees were hard working and enthusistic. The atmosphere was serious while working but in free time we made friends and had fun:-)

I want to thank you for this course. It was great! Maybe it can be even better if we have a little bit more time for our approaches. Because, while we are residents, we really like do it precisely like it was discussed. And maybe we are not fast enough sometimes. Also I want to mention that we had some problems with brain tissue during our dissections. I understand that’s mostly because of the cadaveric status of the brain, but still if there is a way to improve it – it will even better than now. And I really want to thank all the faculty members. You were super friendly and useful during this course. I can’t wait to meet you once again. Thank you! Thank you so much for everything, enjoyed every second.

It was absolutely great! And I wish you all the best!

Good timing, everything was well balanced, maybe a bit more time for dissections.

It was amazing how the faculty was interested and enjoyed the time with us. And how they helped, gave advice…

International 36th Course for Percutaneous Endoscopic Spinal Surgery and Complementary Minimal Invasive Techniques of the International Society for Minimal Intervention in Spinal Surgery: ISMISS

September 7 — September 8

Homburg Saar, Germany

More Information: http://www.ismiss.com/4-0-meetings.html

UpToDate: Fluorescence guided surgery of glioma

Fluorescence guided surgery of glioma

It must be remembered that intraoperative visualization of fluorescence depends on the sensitivity of both the microscope filters and the cameraused 1).


The use of the optical contrast agent sodium fluorescein (NaFl) to guide resection of gliomas has been under investigation for decades. Although this imaging strategy assumes the agent remains confined to the vasculature except in regions of blood brain barrier (BBB) disruption, clinical studies have reported significant NaFl signal in normal brain tissue, limiting tumor-to-normal contrast. A possible explanation arises from earlier studies, which reported that NaFl exists in both pure and protein-bound forms in the blood, the former being small enough to cross the BBB.

A study of Folaron et al. from the Thayer School of Engineering and Department of Surgery Geisel School of Medicine, Dartmouth College, Hanover; and Section of Neurosurgery, and Norris Cotton Cancer Center, Dartmouth Hitchcock Medical CenterLebanonNew Hampshire, aimed to elucidate the kinetic binding behavior of NaFl in circulating blood and its effect on NaFl accumulation in brain tissue and tumor contrast. Additionally, they examined the blood and tissue kinetics, as well as tumor uptake, of a pegylated form of fluorescein selected as a potential optical analog of gadolinium-based MRI contrast agents.

Cohorts of mice were administered one of the following doses/forms of NaFl: 1) high human equivalent dose (HED) of NaFl, 2) low HED of NaFl, or 3) pegylated form of fluorescein. In each cohort, groups of animals were euthanized 15, 30, 60, and 120 minutes after administration for ex vivo analysis of fluorescein fluorescence. Using gel electrophoresis and fluorescence imaging of blood and brain specimens, the authors quantified the temporal kinetics of bound NaFl, unbound NaFl, and pegylated fluorescein in the blood and normal brain tissue. Finally, they compared tumor-to-normal contrast for NaFl and pegylated-fluorescein in U251 glioma xenografts.

Administration of NaFl resulted in the presence of unbound and protein-bound NaFl in the circulation, with unbound NaFl constituting up to 70% of the signal. While protein-bound NaFl was undetectable in brain tissue, unbound NaFl was observed throughout the brain. The observed behavior was time and dose dependent. The pegylated form of fluorescein showed minimal uptake in brain tissue and improved tumor-to-normal contrast by 38%.

Unbound NaFl in the blood crosses the BBB, limiting the achievable tumor-to-normal contrast and undermining the inherent advantage of tumor imaging in the brain. Dosing and incubation time should be considered carefully for NaFl-based fluorescence-guided surgery (FGS) of glioma. A pegylated form of fluorescein showed more favorable normal tissue kinetics that translated to higher tumor-to-normal contrast. These results warrant further development of pegylated-fluorescein for FGS of glioma 2).


Senders et al., systematically review all clinically tested fluorescent agents for application in FGS for glioma and all preclinically tested agents with the potential for FGS for glioma.

They searched the PubMed and Embase databases for all potentially relevant studies through March 2016.

They assessed fluorescent agents by the following outcomes: rate of gross total resection (GTR), overall and progression free survival, sensitivity and specificity in discriminating tumor and healthy brain tissue, tumor-to-normal ratio of fluorescent signal, and incidence of adverse events.

The search strategy resulted in 2155 articles that were screened by titles and abstracts. After full-text screening, 105 articles fulfilled the inclusion criteria evaluating the following fluorescent agents: 5 aminolevulinic acid (5-ALA) (44 studies, including three randomized control trials), fluorescein(11), indocyanine green (five), hypericin (two), 5-aminofluorescein-human serum albumin (one), endogenous fluorophores (nine) and fluorescent agents in a pre-clinical testing phase (30). Three meta-analyses were also identified.

5-ALA is the only fluorescent agent that has been tested in a randomized controlled trial and results in an improvement of GTR and progression-free survival in high-grade gliomas. Observational cohort studies and case series suggest similar outcomes for FGS using fluorescein. Molecular targeting agents (e.g., fluorophore/nanoparticle labeled with anti-EGFR antibodies) are still in the pre-clinical phase, but offer promising results and may be valuable future alternatives. 3).


Mounting evidence suggests that a more extensive surgical resection is associated with an improved life expectancy for both low grade glioma and high grade glioma patients. However, radiographically complete resections are not often achieved in many cases because of the lack of sensitivityand specificity of current neurosurgical guidance techniques at the margins of diffuse infiltrative gliomas. Intraoperative fluorescence imaging offers the potential to improve the extent of resection and to investigate the possible benefits of resecting beyond the radiographic margins.

Liu et al., in 2014 provided a review of wide-field and high-resolution fluorescence-imaging strategies that are being developed for neurosurgical guidance, with a focus on emerging imaging technologies and clinically viable contrast agents. The strengths and weaknesses of these approaches will be discussed, as well as issues that are being addressed to translate these technologies into the standard of care 4).


322 patients aged 23-73 years with suspected malignant glioma amenable to complete resection of contrast-enhancing tumour were randomly assigned to 20 mg/kg bodyweight 5-aminolevulinic acid for fluorescence-guided resection (n=161) or to conventional microsurgery with white light (n=161). The primary endpoints were the number of patients without contrast-enhancing tumour on early MRI (ie, that obtained within 72 h after surgery) and 6-month progression-free survival as assessed by MRI. Secondary endpoints were volume of residual tumour on postoperative MRI, overall survival, neurological deficit, and toxic effects. We report the results of an interim analysis with 270 patients in the full-analysis population (139 assigned 5-aminolevulinic acid, 131 assigned white light), which excluded patients with ineligible histological and radiological findings as assessed by central reviewers who were masked as to treatment allocation; the interim analysis resulted in termination of the study as defined by the protocol. Primary and secondary endpoints were analysed by intention to treat in the full-analysis population. The study is registered at http://www.clinicaltrials.gov as NCT00241670.

FINDINGS: Median follow-up was 35.4 months (95% CI 1.0-56.7). Contrast-enhancing tumour was resected completely in 90 (65%) of 139 patients assigned 5-aminolevulinic acid compared with 47 (36%) of 131 assigned white light (difference between groups 29% [95% CI 17-40], p<0.0001). Patients allocated 5-aminolevulinic acid had higher 6-month progression free survival than did those allocated white light (41.0% [32.8-49.2] vs 21.1% [14.0-28.2]; difference between groups 19.9% [9.1-30.7], p=0.0003, Z test). Groups did not differ in the frequency of severe adverse events or adverse events in any organ system class reported within 7 days after surgery.

INTERPRETATION: Tumour fluorescence derived from 5-aminolevulinic acid enables more complete resections of contrast-enhancing tumour, leading to improved progression-free survival in patients with malignant glioma 5).

References

1)

Moiyadi A, Syed P, Srivastava S. Fluorescence-guided surgery of malignant gliomas based on 5-aminolevulinic acid: paradigm shifts but not a panacea. Nat Rev Cancer. 2014 Feb;14(2):146. doi: 10.1038/nrc3566-c1. PubMed PMID: 24457418.
2)

Folaron M, Strawbridge R, Samkoe KS, Filan C, Roberts DW, Davis SC. Elucidating the kinetics of sodium fluorescein for fluorescence-guided surgery of glioma. J Neurosurg. 2018 Sep 7:1-11. doi: 10.3171/2018.4.JNS172644. [Epub ahead of print] PubMed PMID: 30192200.
3)

Senders JT, Muskens IS, Schnoor R, Karhade AV, Cote DJ, Smith TR, Broekman ML. Agents for fluorescence-guided glioma surgery: a systematic review of preclinical and clinical results. Acta Neurochir (Wien). 2017 Jan;159(1):151-167. doi: 10.1007/s00701-016-3028-5. Review. PubMed PMID: 27878374; PubMed Central PMCID: PMC5177668.
4)

Liu JT, Meza D, Sanai N. Trends in fluorescence image-guided surgery for gliomas. Neurosurgery. 2014 Jul;75(1):61-71. doi: 10.1227/NEU.0000000000000344. Review. PubMed PMID: 24618801; PubMed Central PMCID: PMC4062574.
5)

Stummer W, Pichlmeier U, Meinel T, Wiestler OD, Zanella F, Reulen HJ; ALA-Glioma Study Group. Fluorescence-guided surgery with 5-aminolevulinic acid for resection of malignant glioma: a randomised controlled multicentre phase III trial. Lancet Oncol. 2006 May;7(5):392-401. PubMed PMID: 16648043.

Innovations and Safety in Epilepsy Surgery

Innovations and Safety in Epilepsy Surgery

August 31 — September 1

Vienna, Austria

Programme

It is a satellite meeting to the 13th European Congress on Epileptology, which is held in Vienna from 26th – 30th August 2018. (https://epilepsyvienna2018.org)

Christian Dorfer

Medical University of Vienna,

Department of Neurosurgery

Thomas Czech

Medical University of Vienna,

Department of Neurosurgery

Bertil Rydenhag

University of Gothenburg,

Department of Clinical Neuroscience at Institute of Neuroscience and Physiology

Arthur Cukiert
Neurology and Neurosurgery Clinic Sao Paolo,
Clinica Neurologica Cukiert

New Trends in Craniovertebral Junction Surgery: Experimental and Clinical Updates for a New State of Art (Acta Neurochirurgica Supplement)

New Trends in Craniovertebral Junction Surgery: Experimental and Clinical Updates for a New State of Art (Acta Neurochirurgica Supplement)

Buy

This issue of Acta Neurochirurgica presents the latest surgical and experimental approaches to the craniovertebral junction (CVJ). It discusses anterior midline (transoral transnasal), posterior (CVJ craniectomy laminectomylaminotomyinstrumentation and fusion), posterolateral (far lateral) and anterolateral (extreme lateral) approaches using state-of-the-art supporting tools. It especially highlights open surgery, microsurgical techniques, neuronavigation, the O-arm system, intraoperative MR, neuromonitoring and endoscopy.

Endoscopy represents a useful complement to the standard microsurgical approach to the anterior CVJ: it can be used transnasally, transorally and transcervically; and it provides information for better decompression without the need for soft palate splitting, hard palate resection, or extended maxillotomy. While neuronavigation allows improved orientation in the surgical field, intraoperative fluoroscopy helps to recognize residual compression. Under normal anatomic conditions, there are virtually no surgical limitations to endoscopically assisted CVJ and this issue provides valuable information for the new generation of surgeons involved in this complex and challenging field of neurosurgery.

Intraoperative Neurophysiological Monitoring in Spine Surgery

Intraoperative Neurophysiological Monitoring in Spine Surgery

The objective of a systematic literature review was to evaluate if intraoperative neurophysiological monitoring (IONM) can prevent neurological injury during spinal operative surgical procedures.

IONM seems to have presumable positive effects in identifying neurological deficits. However, the role of IONM in the decrease of new neurological deficits remains unclear.

Using the Preferred Reporting Items for Systematic Reviews and MetaAnalyses (PRISMA) guidelines for systematic reviews and Meta-analysis, Daniel et al., from São Paulo, Brazil, reviewed clinical comparative study who evaluate the rate of new neurological events in patients who had a spinal surgery with and without IONM. Studies were then classified according to their level of evidence. Methodological quality was assessed according to methodological index for non-randomized studies instrument.

Six studies were evaluated comparing neurological events with and without IONM use by the random effects model. There was a great statistical heterogeneity. The pooled odds ratio (OR) was 0.72 {0.71; 1.79}, P = 0.4584. A specific analysis was done for two studies reporting the results of IONM for spinal surgery of intramedullary lesions. The OR was 0.1993 (0.0384; 1.0350), P = 0.0550.

IONM did not result into fewer neurological events with the obtained evidence of the included studies. For intramedullary lesions, there was a trend to fewer neurological events in patients who underwent surgery with IONM. Further prospective randomized studies are necessary to clarify the indications of IONM in spinal surgery 1).

1)

Daniel JW, Botelho RV, Milano JB, Dantas FR, Onishi FJ, Neto ER, Bertolini EF, Borgheresi MAD, Joaquim AF. Intraoperative Neurophysiological Monitoring in Spine Surgery: A Systematic Review and Meta-Analysis. Spine (Phila Pa 1976). 2018 Aug;43(16):1154-1160. doi: 10.1097/BRS.0000000000002575. PubMed PMID: 30063222.

Manual of Neuro-Surgery

Manual of Neuro-Surgery


Manual of Neuro-Surgery (Classic Reprint) Hardcover – April 21, 2018 by United States Surgeon General (Author)
Excerpt from Manual of Neuro-Surgery
ADD TO SHOPPING CART
Spine and Spinal Cord, by Dr. Charles H. Frazier; and from the technic of the suboccipital operation in Tumors of the Nervus Acusticus, by Dr. Harvey Cushing. Free use has been made of Diagnosis of Nervous Diseases, by Purves Stewart; of Tinel’s monograph on Nerve Wounds and of the Proceedings of the Royal Society of Medicine, 1915 – 16, Volume X, part 3. Valuable illustrations have been reproduced from Diseases of the Eye, by de Schweinitz.
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