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Chidinma M. Wilson, Evalyn S. Mackenzie, Mikhal A. Yudien, Antoinette J. Charles, Marianne I. J. Tissot, Sydney J. Churchill, Nolan J. Brown, Jared M. Shulkin, Donald K. E. Detchou, Vamsi P. Reddy, and Lola B. Chambless

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Hirotaka Hasegawa, Kunal Vakharia, Lucas P. Carlstrom, Jamie J. Van Gompel, Colin L. W. Driscoll, Matthew L. Carlson, Fredric B. Meyer, and Michael J. Link

OBJECTIVE

The authors’ objective was to reevaluate the role of microsurgery for epidermoid tumors by examining the associations between extent of resection (EOR), tumor control, and clinical outcomes.

METHODS

This was a retrospective study of patients with microsurgically treated intracranial epidermoid tumors. The recurrence-free and intervention-free rates were calculated using the Kaplan-Meier method. EOR was graded as gross-total resection (GTR) (total resection without residual on MRI), near-total resection (NTR) (a cyst lining was left in place), subtotal resection (STR) (> 90% resection), and partial resection (PR) (any other suboptimal resection) and used to stratify outcomes.

RESULTS

Sixty-three patients with mean clinical and radiological follow-up periods of 87.3 and 81.8 months, respectively, were included. Sixteen patients underwent second resections, and 5 underwent third resections. The rates of GTR/NTR, STR, and PR were 43%, 35%, and 22%, respectively, for the initial resections; 44%, 13%, and 44% for the second resections; and 40%, 0%, and 60% for the third resections (p < 0.001). The 5- and 10-year cumulative recurrence-free rates after initial resection were 64% and 32%, respectively. When stratified according to EOR, the 10-year recurrence-free rate after GTR/NTR was marginally better than that after STR (61% vs 35%, p = 0.130) and significantly better than that after PR (61% vs 0%, p < 0.001). The recurrence-free rates after initial microsurgery were marginally better than those after second surgery (p = 0.102) and third surgery (p = 0.065). The 5- and 10-year cumulative intervention-free rates after initial resection were 91% and 58%, respectively. When stratified according to EOR, the 10-year intervention-free rate after GTR/NTR was significantly better than that after STR (100% vs 51%, p = 0.022) and PR (100% vs 27%, p < 0.001). The 5-year intervention-free rate after initial surgery was marginally better than that after second surgery (52%, p = 0.088) and significantly better than that after third surgery (0%, p = 0.004). After initial, second, and third resections, permanent neurological complications were observed in 6 (10%), 1 (6%), and 1 (20%) patients, respectively. At the last follow-up visit, 82%, 23%, and 7% of patients were free from radiological recurrence after GTR/NTR, STR, and PR as the initial surgical procedure, respectively.

CONCLUSIONS

GTR/NTR seems to contribute to better disease control without significantly impairing functional status. Initial resection offers the best chance to achieve better EOR, leading to better disease control.

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Saniya S. Godil, Umberto Tosi, Mina Gerges, Andrew L. A. Garton, Georgiana A. Dobri, Ashutosh Kacker, Abtin Tabaee, Vijay K. Anand, and Theodore H. Schwartz

OBJECTIVE

Surgical management of craniopharyngiomas (CPAs) is challenging. Controversy exists regarding the optimal goals of surgery. The purpose of this study was to compare the long-term outcomes of patients who underwent gross-total resection with the outcomes of those who underwent subtotal resection of their CPA via an endoscopic endonasal approach.

METHODS

From a prospectively maintained database of all endoscopic endonasal approaches performed at Weill Cornell Medicine, only patients with CPAs with > 3 years of follow-up after surgery were included. The primary endpoint was radiographic progression. Data were collected on baseline demographics, imaging, endocrine function, visual function, and extent of resection.

RESULTS

A total of 44 patients with a mean follow-up of 5.7 ± 2.6 years were included. Of these patients, 14 (31.8%) had prior surgery. GTR was achieved in 77.3% (34/44) of all patients and 89.5% (34/38) of patients in whom it was the goal of surgery. Preoperative tumor volume < 10 cm3 was highly predictive of GTR (p < 0.001). Radiation therapy was administered within the first 3 months after surgery in 1 (2.9%) of 34 patients with GTR and 7 (70%) of 10 patients with STR (p < 0.001). The 5-year recurrence-free/progression-free survival rate was 75.0% after GTR and 25.0% after STR (45% in subgroup with STR plus radiotherapy; p < 0.001). The time to recurrence after GTR was 30.2 months versus 13 months after STR (5.8 months in subgroup with STR plus radiotherapy; p < 0.001). Patients with GTR had a lower rate of visual deterioration and higher rate of return to work or school compared with those with STR (p = 0.02). Patients with GTR compared to STR had a lower rate of CSF leakage (0.0% vs 30%, p = 0.001) but a higher rate of diabetes insipidus (85.3% vs 50%, p = 0.02).

CONCLUSIONS

GTR, which is possible to achieve in smaller tumors, resulted in improved tumor control, better visual outcome, and better functional recovery but a higher rate of diabetes insipidus compared with STR, even when the latter was supplemented with postoperative radiation therapy. GTR should be the goal of craniopharyngioma surgery, when achievable with minimal morbidity.

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Hideaki Nakajima, Kazuya Honjoh, Shuji Watanabe, Arisa Kubota, and Akihiko Matsumine

OBJECTIVE

The development of diffuse idiopathic skeletal hyperostosis (DISH) often requires further surgery after posterior decompression without fusion because of postoperative intervertebral instability. However, there is no information on whether fusion surgery is recommended for these patients as the standard surgery. The aim of this study was to review the clinical and imaging findings in lumbar spinal canal stenosis (LSS) patients with DISH affecting the lumbar segment (L-DISH) and to assess the indication for fusion surgery in patients with DISH.

METHODS

A total of 237 patients with LSS underwent 1- or 2-level posterior lumbar interbody fusion (PLIF) at the authors’ hospital and had a minimum follow-up period of 2 years. Patients with L-DISH were classified as such (n = 27, 11.4%), whereas those without were classified as controls (non-L-DISH; n = 210, 88.6%). The success rates of short-level PLIF were compared in patients with and those without L-DISH. The rates of adjacent segment disease (ASD), pseudarthrosis, postoperative symptoms, and revision surgery were examined in the two groups.

RESULTS

L-DISH from L2 to L4 correlated significantly with early-onset ASD, pseudarthrosis, and the appearance of postsurgical symptoms, especially at a lower segment and one distance from the segment adjacent to L-DISH, which were associated with the worst clinical outcome. Significantly higher percentages of L-DISH patients developed ASD and pseudarthrosis than those in the non-L-DISH group (40.7% vs 4.8% and 29.6% vs 2.4%, respectively). Of those patients with ASD and/or pseudarthrosis, 69.2% were symptomatic and 11.1% underwent revision surgery.

CONCLUSIONS

The results highlighted the negative impact of short-level PLIF surgery for patients with L-DISH. Increased mechanical stress below the fused segment was considered the reason for the poor clinical outcome.

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Kimihiko Sawakami, Kei Watanabe, Kazuhiro Hasegawa, Noriaki Yamamoto, Taketoshi Shimakura, Masayuki Ohashi, Hirokazu Shoji, Tatsuki Mizouchi, Yuki Tanaka, Hiroyuki Segawa, Seiichi Ishikawa, Toru Hirano, Hiroyuki Kawashima, Naoto Endo, and Hideaki E. Takahashi

OBJECTIVE

Teriparatide (TPTD) is a potent promoter of early-stage osteogenesis and may be a useful adjuvant therapy to reduce complications related to bone fragility in spinal surgery patients with osteoporosis. However, effective neoadjuvant TPTD therapy regimens remain poorly understood. This study aimed to examine the effect of preoperative TPTD administration on cancellous bone with bone histomorphometry and to clarify the timing of preoperative TPTD administration for patients with spinal fusion and osteoporosis.

METHODS

In this longitudinal multicenter study, 57 patients with spinal fusion and osteoporosis, who consented to undergo iliac biopsy, were allocated to the following treatment groups: neoadjuvant TPTD therapy group (n = 42) and no neoadjuvant therapy (NTC) group (n = 15). Patients in the TPTD group were categorized into subgroups on the basis of duration of preoperative TPTD administration, as follows: 1 month (n = 9), 2 months (n = 8), 3 months (n = 9), 4 months (n = 7), and 6 months (n = 9). All patient samples were preoperatively double labeled with tetracycline, and iliac biopsies were performed during spinal fusion surgery. Histomorphometric analyses were performed on nondecalcified, thin-sliced specimens. Specimens were classified on the basis of TPTD administration duration and subsequently compared with those of the NTC group. Postoperative complications and Oswestry Disability Index scores were evaluated at 1 and 2 years after surgery.

RESULTS

There were no demographic differences between groups. Mineralizing surface/bone surface, a key parameter of dynamic bone formation, started to increase after 1 month of TPTD administration; this increase became significant after 3 months of administration and peaked at 4 months, with a 6-fold increase relative to that of the NTC group. The patients who received preoperative TPTD for 3 months or more had superior clinical results in terms of the osteoporotic complication rate and Oswestry Disability Index scores, except for bisphosphonate-pretreated patients.

CONCLUSIONS

When considering neoadjuvant TPTD therapy, the authors recommend at least 3 months of preoperative administration to provide a more substantial anabolic effect from the early postoperative stage.

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Andrew A. Ronald, Vineeth Sadda, Nicholas M. Rabah, and Michael P. Steinmetz

OBJECTIVE

Patient complaints are associated with a number of surgical and medical outcomes. Despite high rates of patient complaints regarding spine surgeons and efforts to study patient complaints across medicine and surgery, few studies have analyzed the complaints of patients undergoing spinal surgery. The authors present a retrospective analysis that, to their knowledge, is the first study to directly investigate the complaints of spine surgery patients in the postoperative period.

METHODS

Institutional records were reviewed over a 5-year period (2015–2019) to identify patients who underwent spine surgery and submitted a complaint to the institution’s ombudsman’s office within 1 year of their surgery. A control group, comprising patients who underwent spine surgery without filing a complaint, was matched to the group that filed complaints by admission diagnosis and procedure codes through propensity score matching. Patient demographic and clinical data were obtained by medical record review and compared between the two groups. Patient complaints were reviewed and categorized using a previously established taxonomy.

RESULTS

A total of 52 patients were identified who submitted a complaint after their spine surgery. There were 56 total complaints identified (4 patients submitted 2 each) that reported on 82 specific issues. Patient complaints were most often related to the quality of care received and communication breakdown between the healthcare team and the patient. Patients who submitted complaints were more likely to be Black or African American, have worse baseline health status, and have had prior spine surgery. After their surgery, these patients were also more likely to have longer hospital stays, experience postoperative complications, and require reoperation.

CONCLUSIONS

Complaints were most often related to the quality of care received and communication breakdown. A number of patient-level demographic and clinical characteristics were associated with an increased likelihood of a complaint being filed after spine surgery, and patients who filed complaints were more likely to experience postoperative complications. Improving communication with patients could play a key role in working to address and reduce postoperative complaints. Further study is needed to better understand patient complaints after spine surgery and investigate ways to optimize the care of patients with risks for postoperative complaints.

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Abdallah Salemdawod, Johannes Wach, Mohammed Banat, Valeri Borger, Motaz Hamed, Hannes Haberl, Robert Sassen, Alexander Radbruch, Albert J. Becker, Hartmut Vatter, Rainer Surges, and Sevgi Sarikaya-Seiwert

OBJECTIVE

Focal cortical dysplasia (FCD) is a common cause of early-onset intractable epilepsy, and resection is a highly sufficient treatment option. In this study, the authors aimed to provide a retrospective analysis of pre- and postoperative factors and their impact on postoperative long-term seizure outcome.

METHODS

The postoperative seizure outcomes of 50 patients with a mean age of 8 ± 4.49 years and histologically proven FCD type II were retrospectively analyzed. Furthermore, pre- and postoperative predictors of long-term seizure freedom were assessed. The seizure outcome was evaluated based on the International League Against Epilepsy (ILAE) classification.

RESULTS

Complete resection of FCD according to MRI criteria was achieved in 74% (n = 37) of patients. ILAE class 1 at the last follow-up was achieved in 76% (n = 38) of patients. A reduction of antiepileptic drugs (AEDs) to monotherapy or complete withdrawal was achieved in 60% (n = 30) of patients. Twelve patients (24%) had a late seizure recurrence, 50% (n = 6) of which occurred after reduction of AEDs. A lower number of AEDs prior to surgery significantly predicted a favorable seizure outcome (p = 0.013, HR 7.63). Furthermore, younger age at the time of surgery, shorter duration of epilepsy prior to surgery, and complete resection were positive predictors for long-term seizure freedom.

CONCLUSIONS

The duration of epilepsy, completeness of resection, number of AEDs prior to surgery, and younger age at the time of surgery served as predictors of postoperative long-term seizure outcome, and, as such, may improve clinical practice when selecting and counseling appropriate candidates for resective epilepsy surgery. The study results also underscored that epilepsy surgery should be considered early in the disease course of pediatric patients with FCD type II.

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Ken Iijima, Hajime Yokota, Toshio Yamaguchi, Masayuki Nakano, Takahiro Ouchi, Futaba Maki, Masahito Takasaki, Yasuhiro Shimizu, Hiroki Hori, Hirokazu Iwamuro, Jinichi Sasanuma, Kazuo Watanabe, and Takashi Uno

OBJECTIVE

Sufficient thermal increase capable of generating thermocoagulation is indispensable for an effective clinical outcome in patients undergoing magnetic resonance–guided focused ultrasound (MRgFUS). The skull density ratio (SDR) is one of the most dominant predictors of thermal increase prior to treatment. However, users currently rely only on the average SDR value (SDRmean) as a screening criterion, although some patients with low SDRmean values can achieve sufficient thermal increase. The present study aimed to examine the numerical distribution of SDR values across 1024 elements to identify more precise predictors of thermal increase during MRgFUS.

METHODS

The authors retrospectively analyzed the correlations between the skull parameters and the maximum temperature achieved during unilateral ventral intermediate nucleus thalamotomy with MRgFUS in a cohort of 55 patients. In addition, the numerical distribution of SDR values was quantified across 1024 elements by using the skewness, kurtosis, entropy, and uniformity of the SDR histogram. Next, the authors evaluated the correlation between the aforementioned indices and a peak temperature > 55°C by using univariate and multivariate logistic regression analyses. Receiver operating characteristic curve analysis was performed to compare the predictive ability of the indices. The diagnostic performance of significant factors was also assessed.

RESULTS

The SDR skewness (SDRskewness) was identified as a significant predictor of thermal increase in the univariate and multivariate logistic regression analyses (p < 0.001, p = 0.013). Moreover, the receiver operating characteristic curve analysis indicated that the SDRskewness exhibited a better predictive ability than the SDRmean, with area under the curve values of 0.847 and 0.784, respectively.

CONCLUSIONS

The SDRskewness is a more accurate predictor of thermal increase than the conventional SDRmean. The authors suggest setting the SDRskewness cutoff value to 0.68. SDRskewness may allow for the inclusion of treatable patients with essential tremor who would have been screened out based on the SDRmean exclusion criterion.

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Nicholas Sader, Vivek Mehta, Shannon Hart, Lori Bliss, Hanna Moore, Melissa DaSilva, Ruksana Rashid, and Jay Riva-Cambrin

OBJECTIVE

Craniosynostosis represents the second most common reason for referral to pediatric neurosurgery. However, the quality of life and neurodevelopmental impact of leaving this physical disorder uncorrected is poorly understood.

METHODS

This multicenter cross-sectional study identified previously managed nonsyndromic infants (< 24 months of age) with single-suture craniosynostosis at both pediatric neurosurgical centers in Alberta, Canada. The primary variable of interest was the allocated treatment (surgical vs conservative). The primary outcome was the Pediatric Quality of Life Inventory (PedsQL), a validated measure of quality of life examining physical, emotional, social, and school functioning. Treatment decision satisfaction and the reasons for selected management were quantified and collected directly from caregivers.

RESULTS

One hundred fourteen children met the inclusion criteria: 78% underwent surgery and 22% had conservative treatment. The most common suture affected was sagittal (54%), followed by metopic (33%), coronal (10%), and lambdoid (3%). Caregivers most commonly opted for surgery because of severe appearance (80%). Seventy-six percent and 72% of the caregivers of children with conservative management did so due to concerns of surgical risks and mild appearance, respectively. There was a statistically significant relationship between both the parents’ (p < 0.001) and the surgeon’s (p = 0.001) impression of a severe head shape and surgical management. Parental satisfaction with their child’s appearance as well as satisfaction with their treatment decision did not differ between management types. Regarding quality of life, on univariate analysis, the conservative group had a statistically higher physical summary score (p = 0.01), psychosocial summary score (p = 0.004), and mean total scale score (p = 0.003) compared to the surgical group. However, after adjusting for severity and age at consult, no significant independent associations between management type and any of the PedsQL summary scores were found.

CONCLUSIONS

Alberta families have a high number of children with craniosynostosis treated with conservative management. Conservatively managed infants were largely minimally affected patients, particularly those with metopic synostosis. The study found no independent association between management type (surgery vs conservative) and quality of life when adjusted for important patient factors.

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Jenna-Lynn B. Senger, Karyne N. Rabey, Leah Acton, Ying-Ho S. Lin, Susanne Lingrell, K. Ming Chan, and Christine A. Webber

OBJECTIVE

Chronically injured nerves pose a significant clinical challenge despite surgical management. There is no clinically feasible perioperative technique to upregulate a proregenerative environment in a chronic nerve injury. Conditioning electrical stimulation (CES) significantly improves sensorimotor recovery following acute nerve injury to the tibial and common fibular nerves. The authors’ objective was to determine if CES could foster a proregenerative environment following chronically injured nerve reconstruction.

METHODS

The tibial nerve of 60 Sprague Dawley rats was cut, and the proximal ends were inserted into the hamstring muscles to prevent spontaneous reinnervation. Eleven weeks postinjury, these chronically injured animals were randomized, and half were treated with CES proximal to the tibial nerve cut site. Three days later, 24 animals were killed to evaluate the effects of CES on the expression of regeneration-associated genes at the cell body (n = 18) and Schwann cell proliferation (n = 6). In the remaining animals, the tibial nerve defect was reconstructed using a 10-mm isograft. Length of nerve regeneration was assessed 3 weeks postgrafting (n = 16), and functional recovery was evaluated weekly between 7 and 19 weeks of regeneration (n = 20).

RESULTS

Three weeks after nerve isograft surgery, tibial nerves treated with CES prior to grafting had a significantly longer length of nerve regeneration (p < 0.01). Von Frey analysis identified improved sensory recovery among animals treated with CES (p < 0.01). Motor reinnervation, assessed by kinetics, kinematics, and skilled motor tasks, showed significant recovery (p < 0.05 to p < 0.001). These findings were supported by immunohistochemical quantification of motor endplate reinnervation (p < 0.05). Mechanisms to support the role of CES in reinvigorating the regenerative response were assessed, and it was demonstrated that CES increased the proliferation of Schwann cells in chronically injured nerves (p < 0.05). Furthermore, CES upregulated regeneration-associated gene expression to increase growth-associated protein–43 (GAP-43), phosphorylated cAMP response element binding protein (pCREB) at the neuronal cell bodies, and upregulated glial fibrillary acidic protein expression in the surrounding satellite glial cells (p < 0.05 to p < 0.001).

CONCLUSIONS

Regeneration following chronic axotomy is impaired due to downregulation of the proregenerative environment generated following nerve injury. CES delivered to a chronically injured nerve influences the cell body and the nerve to re-upregulate an environment that accelerates axon regeneration, resulting in significant improvements in sensory and motor functional recovery. Percutaneous CES may be a preoperative strategy to significantly improve outcomes for patients undergoing delayed nerve reconstruction.