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David Ben-Israel, Jennifer A. Mann, Michael M. H. Yang, Albert M. Isaacs, Magalie Cadieux, Nicholas Sader, Sandeep Muram, Abdulrahman Albakr, Branavan Manoranjan, Richard W. Yu, Benjamin Beland, Mark G. Hamilton, Eldon Spackman, Paul E. Ronksley, and Jay Riva-Cambrin

OBJECTIVE

Endoscopic third ventriculostomy and choroid plexus cauterization (ETV+CPC) is a novel procedure for infant hydrocephalus that was developed in sub-Saharan Africa to mitigate the risks associated with permanent implanted shunt hardware. This study summarizes the hydrocephalus literature surrounding the ETV+CPC intraoperative abandonment rate, perioperative mortality rate, cerebrospinal fluid infection rate, and failure rate.

METHODS

This systematic review and meta-analysis followed a prespecified protocol and abides by Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive search strategy using MEDLINE, EMBASE, PsychInfo, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Scopus, and Web of Science was conducted from database inception to October 2019. Studies included controlled trials, cohort studies, and case-control studies of patients with hydrocephalus younger than 18 years of age treated with ETV+CPC. Pooled estimates were calculated using DerSimonian and Laird random-effects modeling, and the significance of subgroup analyses was tested using meta-regression. The quality of the pooled outcomes was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

RESULTS

After screening and reviewing 12,321 citations, the authors found 16 articles that met the inclusion criteria. The pooled estimate for the ETV+CPC failure rate was 0.44 (95% CI 0.37–0.51). Subgroup analysis by geographic income level showed statistical significance (p < 0.01), with lower-middle-income countries having a lower failure rate (0.32, 95% CI 0.28–0.36) than high-income countries (0.53, 95% CI 0.47–0.60). No difference in failure rate was found between hydrocephalus etiology (p = 0.09) or definition of failure (p = 0.24). The pooled estimate for perioperative mortality rate (n = 7 studies) was 0.001 (95% CI 0.00–0.004), the intraoperative abandonment rate (n = 5 studies) was 0.04 (95% CI 0.01–0.08), and the postoperative CSF infection rate (n = 5 studies) was 0.0004 (95% CI 0.00–0.003). All pooled outcomes were found to be low-quality evidence.

CONCLUSIONS

This systematic review and meta-analysis provides the most comprehensive pooled estimate for the ETV+CPC failure rate to date and demonstrates, for the first time, a statistically significant difference in failure rate by geographic income level. It also provides the first reported pooled estimates for the risk of ETV+CPC perioperative mortality, intraoperative abandonment, and CSF infection. The low quality of this evidence highlights the need for further research to improve the understanding of these critical clinical outcomes and their relevant explanatory variables and thus to appreciate which patients may benefit most from an ETV+CPC.

Systematic review registration no.: CRD42020160149 (https://www.crd.york.ac.uk/prospero/)

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Jun Torii, Satoshi Maesawa, Daisuke Nakatsubo, Takahiko Tsugawa, Sachiko Kato, Tomotaka Ishizaki, Sou Takai, Masashi Shibata, Toshihiko Wakabayashi, Takashi Tsuboi, Masashi Suzuki, and Ryuta Saito

OBJECTIVE

The efficacy of magnetic resonance–guided focused ultrasound (MRgFUS) ablation for essential tremor (ET) is well known; however, no prognostic factors have been established. The authors aimed to retrospectively investigate MRgFUS ablation outcomes and associated factors and to define the cutoff values for each prognostic factor.

METHODS

Sixty-four Japanese patients who underwent unilateral ventral intermediate nucleus thalamotomy with MRgFUS for ET were included. Follow-up evaluations were performed at 1 week and 1, 3, 6, 12, and 24 months postoperatively. Tremor suppression was evaluated using the Clinical Rating Scale for Tremor (CRST), and adverse effects were recorded postoperatively. Outcome-associated factors were examined preoperatively, intraoperatively, and postoperatively using multivariate analyses. The cutoff values for the prognostic factors were calculated using receiver operating characteristics.

RESULTS

Percentage improvements in the CRST scores of the affected upper limb were 82.4%, 72.2%, 68.6%, and 65.9% at 1, 3, 6, and 12 months, respectively. Preoperatively, a high skull density ratio (SDR) (p ≤ 0.047), low CRST part B score (used to assess tremors during several tasks) (cutoff value 25, p ≤ 0.041), and nonoccurrence of resting tremors (p = 0.027) were significantly associated with improved tremor control. An intraoperatively high maximum mean temperature (cutoff value 52.5°C, p ≤ 0.047), postoperatively large lesion (cutoff value 3.9 mm in the anterior-posterior direction, p ≤ 0.002; cutoff value 5.0–5.55 mm in the superior-inferior direction, p ≤ 0.026), and small transducer focus correction (p ≤ 0.015) were also associated with improved tremor control. No valid cutoff value was found for SDR. Adverse effects (limb weakness, sensory disturbance, ataxia/walking disturbance, dysgeusia, dysarthria, and facial swelling) occurred transiently and were associated with high SDR, high temperature, high number of sonication sessions, large lesion, and occurrence of resting tremor. Patients who developed leg weakness experienced greater percentage improvement in tremors at 3 months postoperatively than those who did not.

CONCLUSIONS

MRgFUS ablation could be used to achieve good tremor control with acceptable adverse effects in Japanese patients with ET. The relatively low SDR in Asian ethnic groups as compared with that of Western populations makes treatment difficult; however, the cutoff values obtained in this study may be useful for achieving good treatment outcomes even in such patients.

Clinical trial registration no.: UMIN000026952 (University Hospital Medical Information Network)

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Raphaële Charest-Morin, Christopher S. Bailey, Greg McIntosh, Y. Raja Rampersaud, W. Bradley Jacobs, David W. Cadotte, Jérome Paquet, Hamilton Hall, Michael H. Weber, Michael G. Johnson, Andrew Nataraj, Najmedden Attabib, Neil Manson, Philippe Phan, Sean D. Christie, Kenneth C. Thomas, Charles G. Fisher, and Nicolas Dea

OBJECTIVE

In multilevel posterior cervical instrumented fusion, extension of fusion across the cervicothoracic junction (CTJ) at T1 or T2 has been associated with decreased rates of reoperation and pseudarthrosis but with longer surgical time and increased blood loss. The impact on patient-reported outcomes (PROs) remains unclear. The primary objective was to determine whether extension of fusion through the CTJ influenced PROs at 3, 12, and 24 months after surgery. The secondary objective was to compare the number of patients who reached the minimal clinically important differences (MCIDs) for the PROs, modified Japanese Orthopaedic Association (mJOA) score, operative time, intraoperative blood loss, length of stay, discharge disposition, adverse events (AEs), reoperation within 24 months of surgery, and patient satisfaction.

METHODS

This was a retrospective observational cohort study of prospectively collected multicenter data of patients with degenerative cervical myelopathy. Patients who underwent posterior instrumented fusion of 4 levels or greater (between C2 and T2) between January 2015 and October 2020 and received 24 months of follow-up were included. PROs (scores on the Neck Disability Index [NDI], EQ-5D, physical component summary and mental component summary of SF-12, and numeric rating scale for arm and neck pain) and mJOA scores were compared using ANCOVA and adjusted for baseline differences. Patient demographic characteristics, comorbidities, and surgical details were abstracted. The proportions of patients who reached the MCIDs for these outcomes were compared with the chi-square test. Operative duration, intraoperative blood loss, AEs, reoperation, discharge disposition, length of stay, and satisfaction was compared by using the chi-square test for categorical variables and the independent-samples t-test for continuous variables.

RESULTS

A total of 198 patients were included in this study (101 patients with fusion not crossing the CTJ and 97 with fusion crossing the CTJ). Patients with a construct extending through the CTJ were more likely to be female and have worse baseline NDI scores (p > 0.05). When adjusted for baseline differences, there were no statistically significant differences between the two groups in terms of the PROs and mJOA scores at 3, 12, and 24 months. Surgical duration was longer (p < 0.001) and intraoperative blood loss was greater in the group with fusion extending to the upper thoracic spine (p = 0.013). There were no significant differences between groups in terms of AEs (p > 0.05). Fusion with a construct crossing the CTJ was associated with reoperation (p = 0.04). Satisfaction with surgery was not significantly different between groups. The proportions of patients who reached the MCIDs for the PROs were not statistically different at any time point.

CONCLUSIONS

There were no statistically significant differences in PROs between patients with a posterior construct extending to the upper thoracic spine and those without such extension for as long as 24 months after surgery. The AE profiles were not significantly different, but longer surgical time and increased blood loss were associated with constructs extending across the CTJ.

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Norio Ichimasu, Michihiro Kohno, Nobuyuki Nakajima, Hiroki Sakamoto, Ken Matsushima, Masanori Yoshino, and Kiyoaki Tsukahara

OBJECTIVE

Tumors around the cerebellopontine angle (CPA) and temporal bone can potentially affect hearing function. In patients with such tumors other than vestibular schwannomas (VSs), auditory tests were investigated before and after surgery to characterize the auditory effect of each tumor and to determine prognostic factors.

METHODS

A total of 378 patients were retrospectively evaluated for hearing functions before and after surgery. These 378 patients included 168 with CPA meningioma, 40 with trigeminal schwannoma (TS), 55 with facial nerve schwannoma (FNS), 64 with jugular foramen schwannoma (JFS), and 51 with CPA epidermoid cyst (EPD).

RESULTS

Preoperative hearing loss was observed in 124 (33%) of the 378 patients. Of these 124 patients, 38 (31%) experienced postoperative hearing improvement. Postoperative hearing deterioration occurred in 67 (18%) of the 378 patients. The prognostic factors for postoperative hearing improvement were younger age and the retrocochlear type of preoperative hearing disturbance. Tumor extension into the internal auditory canal was correlated with preoperative hearing loss and postoperative hearing deterioration. Preoperative hearing loss was observed in patients with FNS (51%), JFS (42%), and MGM (37%), and postoperative hearing improvement was observed in patients with JFS (41%), MGM (31%), and FNS (21%). Postoperative hearing deterioration was observed in patients with FNS (27%), MGM (23%), and EPD (16%).

CONCLUSIONS

According to the results of this study in patients with CPA and intratemporal tumors other than VS, preoperative retrocochlear hearing disturbance was found to be a prognostic factor for hearing improvement after surgery. Among the tumor types, JFS and MGM had a particularly favorable hearing prognosis. The translabyrinthine approach and cochlear nerve section should be avoided for these tumors, regardless of the patient’s preoperative hearing level.

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Risheng Xu, Joshua Materi, Divyaansh Raj, Safwan Alomari, Yuanxuan Xia, Sumil K. Nair, Pavan P. Shah, Nivedha Kannapadi, Timothy Kim, Judy Huang, Chetan Bettegowda, and Michael Lim

OBJECTIVE

Internal neurolysis (IN) and intraoperative glycerin rhizotomy (ioGR) are emerging surgical options for patients with trigeminal neuralgia without neurovascular contact. The objective of this study was to compare the neurological outcomes of patients who underwent IN with those of patients who underwent ioGR.

METHODS

The authors retrospectively reviewed all patients who underwent IN or ioGR for trigeminal neuralgia at our institution. Patient demographic characteristics and immediate postoperative outcomes, as well as long-term neurological outcomes, were compared.

RESULTS

Of 1044 patients who underwent open surgical treatment for trigeminal neuralgia, 56 patients underwent IN and 91 underwent ioGR. Of these 147 patients, 37 had no evidence of intraoperative neurovascular conflict. All patients who underwent IN and 96.7% of patients who underwent ioGR had immediate postoperative pain relief. At last follow-up, patients who underwent IN had lower Barrow Neurological Institute (BNI) pain intensity scores (p = 0.05), better BNI facial numbness scores (p < 0.01), and a greater degree of pain improvement (p = 0.05) compared with those who underwent ioGR. Patients who underwent IN also had significantly lower rates of symptomatic pain recurrence (p < 0.01) at last follow-up over an average of 9.5 months.

CONCLUSIONS

IN appears to provide patients with a greater degree of pain relief, lower rates of facial numbness, and lower rates of pain recurrence compared with ioGR. Future prospective studies will better characterize long-term pain recurrence and outcomes.

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Langston T. Holly, William W. Ashley Jr., Edjah K. Nduom, Brenton Pennicooke, Caple A. Spence, and Babu G. Welch

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Adriana Vázquez-Medina, Grazia Diano, Manthia A. Papageorgakopoulou, and Andrea Otamendi-Lopez

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Alexander Ramos, Joseph A. Carnevale, Kashif Majeed, Gary Kocharian, Ibrahim Hussain, Jacob L. Goldberg, Justin Schwarz, David I. Kutler, Jared Knopman, and Philip Stieg

OBJECTIVE

Carotid body tumors (CBTs) are rare, slow-growing neoplasms derived from the parasympathetic paraganglia of the carotid bodies. Although inherently vascular lesions, the role of preoperative embolization prior to resection remains controversial. In this report, the authors describe an institutional series of patients with CBT successfully treated via resection following preoperative embolization and compare the results in this series to previously reported outcomes in the treatment of CBT.

METHODS

All CBTs resected between 2013 and 2019 at a single institution were retrospectively identified. All patients had undergone preoperative embolization performed by interventional neuroradiologists, and all had been operated on by a combined team of cerebrovascular neurosurgeons and otolaryngology–head and neck surgeons. The clinical, radiographic, endovascular, and perioperative data were collected. All procedural complications were recorded.

RESULTS

Among 22 patients with CBT, 63.6% were female and the median age was 55.5 years at the time of surgery. The most common presenting symptoms included a palpable neck mass (59.1%) and voice changes (22.7%). The average tumor volume was 15.01 ± 14.41 cm3. Most of the CBTs were Shamblin group 2 (95.5%). Blood was predominantly supplied from branches of the ascending pharyngeal artery, with an average of 2 vascular pedicles (range 1–4). Fifty percent of the tumors were embolized with more than one material: polyvinyl alcohol, 95.5%; Onyx, 50.0%; and N-butyl cyanoacrylate glue, 9.1%. The average reduction in tumor blush following embolization was 83% (range 40%–95%). No embolization procedural complications occurred. All resections were performed within 30 hours of embolization. The average operative time was 173.9 minutes, average estimated blood loss was 151.8 ml, and median length of hospital stay was 4 days. The rate of permanent postoperative complications was 0%; 2 patients experienced transient hoarseness, and 1 patient had medical complications related to alcohol withdrawal.

CONCLUSIONS

This series reveals that endovascular embolization of CBT is a safe and effective technique for tumor devascularization, making preoperative angiography and embolization an important consideration in the management of CBT. Moreover, the successful management of CBT at the authors’ institution rests on a multidisciplinary approach whereby endovascular surgeons, neurosurgeons, and ear, nose, and throat–head and neck surgeons work together to optimally manage each patient with CBT.

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Andy Y. Wang, Vaishnavi Sharma, Wenya Linda Bi, William T. Curry, Jeffrey E. Florman, Michael W. Groff, Carl B. Heilman, Jennifer Hong, James Kryzanski, S. Scott Lollis, Gerald T. McGillicuddy, Jennifer Moliterno, Christopher S. Ogilvy, Dennis S. Oh, Adetokunbo A. Oyelese, Mark R. Proctor, Perry A. Shear, Andrew E. Wakefield, Robert G. Whitmore, and Ron I. Riesenburger

The New England Neurosurgical Society (NENS) was founded in 1951 under the leadership of its first President (Dr. William Beecher Scoville) and Secretary-Treasurer (Dr. Henry Thomas Ballantine). The purpose of creating the NENS was to unite local neurosurgeons in the New England area; it was one of the first regional neurosurgical societies in America. Although regional neurosurgical societies are important supplements to national organizations, they have often been overshadowed in the available literature. Now in its 70th year, the NENS continues to serve as a platform to represent the needs of New England neurosurgeons, foster connections and networks with colleagues, and provide research and educational opportunities for trainees. Additionally, regional societies enable discussion of issues uniquely relevant to the region, improve referral patterns, and allow for easier attendance with geographic proximity. In this paper, the authors describe the history of the NENS and provide a roadmap for its future. The first section portrays the founders who led the first meetings and establishment of the NENS. The second section describes the early years of the NENS and profiles key leaders. The third section discusses subsequent neurosurgeons who steered the NENS and partnerships with other societies. In the fourth section, the modern era of the NENS and its current activities are highlighted.