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Yasuyuki Kinoshita, Akira Taguchi, Atsushi Tominaga, Kazunori Arita, and Fumiyuki Yamasaki

OBJECTIVE

Recovery from adult growth hormone deficiency (AGHD) after transsphenoidal surgery (TSS) has not been well discussed because of the lack of examinations including pituitary provocation tests (PPTs) before and after the procedure. This study aimed to evaluate the growth hormone (GH) axis function of patients with nonfunctioning pituitary adenoma (NFPA) via pre- and postoperative PPTs. Moreover, the predictive factors for recovery from AGHD after TSS were validated to facilitate surgery for AGHD in patients with NFPA.

METHODS

In total, 276 patients (median age 60.0 years) who underwent TSS for NFPA were included in this study. PPTs were performed before and 3 months after TSS. Then, the relationships between recovery from AGHD after TSS and clinical, surgical, and hormonal factors, including peak GH level based on PPTs, were evaluated statistically.

RESULTS

In this study, 114 patients were diagnosed with preoperative AGHD. Approximately 25.4% recovered from AGHD after TSS. In contrast, among the 162 patients without preoperative AGHD, 13 (8.0%) had newly developed postoperative AGHD. The predictive factors for recovery from AGHD were younger age, female sex, initial TSS, and high peak GH level based on preoperative PPT. According to the receiver operating characteristic curve analysis, patients who were aged ≤ 62.2 years and had a peak GH level of ≥ 0.74 μg/L based on preoperative PPT were likely to recover from AGHD (sensitivity: 82.8%, specificity: 72.9%, and area under the curve: 0.8229).

CONCLUSIONS

AGHD caused by NFPA can improve after initial TSS among young patients with certain peak GH levels assessed by preoperative PPT. Whether TSS for NFPA can promote recovery from AGHD is worth considering in some patients.

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Nikhil Jain, Mayur Sharma, Dengzhi Wang, Beatrice Ugiliweneza, Doniel Drazin, and Maxwell Boakye

OBJECTIVE

In degenerative cervical myelopathy (DCM) pathologies in which there exists a clinical equipoise in approach selection, a randomized controlled trial found that an anterior approach did not significantly improve patient-reported outcomes compared with posterior approaches. In this era of value and bundled payment initiatives, the cost profiles of various surgical approaches will form an important consideration in decision-making. The objective of this study was to compare 90-day and 2-year reimbursements for ≥ 2-level (multilevel) anterior cervical discectomy and fusion (mACDF), anterior cervical corpectomy and fusion (ACCF), posterior cervical laminectomy and fusion (LF), and cervical laminoplasty (LP) performed for DCM.

METHODS

The IBM MarketScan research database (2005–2018) was used to study beneficiaries 30–75 years old who underwent surgery using four approaches (mACDF, ACCF, LF, or LP) for DCM. Demographics, index surgery length of stay (LOS), complications, and discharge disposition were compared. Index admission (surgeon, hospital services, operating room) and postdischarge inpatient (readmission, revision surgery, inpatient rehabilitation), outpatient (imaging, emergency department, office visits, physical therapy), and medication-related payments were described. Ninety-day and 2-year bundled payment amounts were simulated for each procedure. All payments are reported as medians and interquartile ranges (IQRs; Q1–Q3) and were adjusted to 2018 US dollars.

RESULTS

A total of 10,834 patients, with a median age of 54 years, were included. The median 90-day payment was $46,094 (IQR $34,243–$65,841) for all procedures, with LF being the highest ($64,542) and LP the lowest ($37,867). Index hospital payment was 62.4% (surgery/operating room 46.6%) and surgeon payments were 17.5% of the average 90-day bundle. There were significant differences in the index, 90-day, and 2-year reimbursements and their distribution among procedures.

CONCLUSIONS

In a national cohort of patients undergoing surgery for DCM, LP had the lowest complication rate and simulated bundled reimbursements at 90 days and 2 years postoperatively. The lowest quartile 90-day payment for LF was more expensive than median amounts for mACDF, ACCF, and LP. If surgeons encounter scenarios of clinical equipoise in practice, LP is likely to result in maximum value because it is 70% less expensive on average than LF over 90 days.

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Panagiotis Kerezoudis, Brian N. Lundstrom, Fredric B. Meyer, Gregory A. Worrell, and Jamie J. Van Gompel

OBJECTIVE

Epilepsy originating from the central lobule (i.e., the primary sensorimotor cortex) is a challenging entity to treat given its involvement of eloquent cortex. The objective of this study was to review available evidence on treatment options for central lobule epilepsy.

METHODS

A comprehensive literature search (PubMed/Medline, EMBASE, and Scopus) was conducted for studies (1990 to date) investigating postoperative outcomes for central lobule epilepsy. The primary and secondary endpoints were seizure freedom at last follow-up and postoperative neurological deficit, respectively. The following procedures were included: open resection, multiple subpial transections (MSTs), laser and radiofrequency ablation, deep brain stimulation (DBS), responsive neurostimulation (RNS), and continuous subthreshold cortical stimulation (CSCS).

RESULTS

A total of 52 studies and 504 patients were analyzed. Most evidence was based on open resection, yielding a total of 400 patients (24 studies), of whom 62% achieved seizure freedom at a mean follow-up of 48 months. A new or worsened motor deficit occurred in 44% (permanent in 19%). Forty-six patients underwent MSTs, of whom 16% achieved seizure freedom and 30% had a neurological deficit (permanent in 12%). There were 6 laser ablation cases (cavernomas in 50%) with seizure freedom in 4 patients and 1 patient with temporary motor deficit. There were 5 radiofrequency ablation cases, with 1 patient achieving seizure freedom, 2 patients each with Engel class III and IV outcomes, and 2 patients with motor deficit. The mean seizure frequency reduction at the last follow-up was 79% for RNS (28 patients), 90% for CSCS (15 patients), and 73% for DBS (4 patients). There were no cases of temporary or permanent neurological deficit in the CSCS or DBS group.

CONCLUSIONS

This review highlights the safety and efficacy profile of resection, ablation, and stimulation for refractory central lobe epilepsy. Resection of localized regions of epilepsy onset zones results in good rates of seizure freedom (62%); however, nearly 20% of patients had permanent motor deficits. The authors hope that this review will be useful to providers and patients when tailoring decision-making for this intricate pathology.

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Mendel Castle-Kirszbaum, Jeremy Kam, Benjamin Dixon, Tony Goldschlager, James King, and Yi Yuen Wang

OBJECTIVE

The objective of this study was to establish the effect of endoscopic endonasal surgery on longitudinal quality of life (QOL) in patients with anterior skull base meningioma.

METHODS

A prospectively collected cohort of consecutively operated anterior skull base meningiomas was analyzed. All cases were performed using the endoscopic endonasal approach (EEA). Sinonasal-specific and overall QOL were measured using the 22-Item Sinonasal Outcome Test and the Anterior Skull Base Questionnaire longitudinally (at 3 weeks, 6 weeks, and 3, 6, and 12 months) across the first postoperative year. The relationship between surgical and QOL outcomes to clinical and radiological characteristics was analyzed using multivariate regression.

RESULTS

Fifty cases were available, with a mean age of 61.5 years and female predominance (74.0%). Visual dysfunction and headache were the most common presenting symptoms, and tumors commonly took origin from the planum (46.0%), tuberculum (44.0%), and olfactory groove (24.0%). Median tumor volume was 4.6 cm3. Visual improvement was noted in 73.1% of cases with preoperative field deficits, while nonimprovement was associated with greater tumor height (p = 0.04). Gross-total resection was not possible in patients with 360° vessel encasement and high-grade cavernous sinus extension with ophthalmoplegia. Postoperative diabetes insipidus was observed only in cases with suprasellar extension. Sinonasal-specific QOL worsened transiently after surgery but returned to baseline levels after 3 weeks. Olfaction and taste scores returned to preoperative baseline scores within the year. Overall QOL at presentation was worse in those with larger tumors (p = 0.04) and visual failure (p = 0.04) and better in those presenting with headache (p = 0.04). Transient worsening of QOL was seen in the first 3 weeks, which returned to baseline by 6 weeks, and then improved to above preoperative levels at 6 months and beyond. Worse QOL at baseline (p = 0.01) and visual improvement (p = 0.01) predicted QOL improvement after surgery.

CONCLUSIONS

Longitudinal QOL in anterior skull base meningioma has been examined for the first time. Endoscopic endonasal surgery improves overall QOL after a transient 3-week worsening due to the sinonasal morbidity of the approach. Visual function is intimately tied to QOL, with worse vision associated with worse preoperative QOL, and QOL improving in parallel with visual restoration after surgery. The EEA is associated with better visual outcomes and should be the preferred approach in accessible tumors.

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John Michael Duff, Patrick Omoumi, Lukas Bobinski, Amani Belouaer, Sonia Plaza Wuthrich, Fabio Zanchi, and Rodolfo Maduri

OBJECTIVE

The authors previously described the image merge tailored access resection (IMTAR) technique for resection of spinal intradural lesions (SIDLs). The authors reported their updated experience with the IMTAR technique and compared surgical results between patients who underwent operations with 2D or 3D fluoroscopic guidance.

METHODS

The authors reviewed 60 patients who underwent SIDL resection with transtubular techniques over a 14-year period. The earlier patients in the series underwent operations with 2D fluoroscopic image guidance. The latter patients underwent operations with the IMTAR technique based on 3D image guidance. The results of both techniques were analyzed.

RESULTS

Sixty patients were included: 27 females (45%) and 33 males (55%). The median (range) age was 50.5 (19–92) years. Gross-total resection (GTR) was achieved in 52 patients (86.7%). Subtotal resection was accomplished in 5 patients (8.3%). Neurological complications occurred in 3 patients (5%), and tumor recurrence occurred in 1 patient (1.7%). The non-IMTAR and IMTAR cohorts showed similar postoperative Nurick scale scores and rates of neurological complications and GTR. The median (interquartile range) bone resection surface area at the index level was 89.5 (51–147) mm2 in the non-IMTAR cohort and 35.5 (11–71) mm2 in the IMTAR cohort, with a statistically significant difference (p = 0.0112).

CONCLUSIONS

Surgery for SIDLs may be challenging, and meticulous surgical planning is crucial to optimize tumor access, maximize resection, and minimize risk of complications. Image-guided transtubular resection is an additional surgical technique for SIDLs and facilitates microsurgical tumor removal of ventrally located lesions with a posterolateral approach, without requiring potentially destabilizing bone resection.

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Scott L. Zuckerman, Christopher S. Lai, Yong Shen, Meghan Cerpa, Nathan J. Lee, Mena G. Kerolus, Alex S. Ha, Ian A. Buchanan, Eric Leung, Ronald A. Lehman, and Lawrence G. Lenke

OBJECTIVE

This study had 3 objectives: 1) to describe pelvic obliquity (PO) and leg-length discrepancy (LLD) and their relationship with coronal malalignment (CM); 2) to report rates of isolated PO and PO secondary to LLD; and 3) to assess the importance of preoperative PO and LLD in postoperative complications, readmission, reoperation, and patient-reported outcomes.

METHODS

Patients undergoing surgery (≥ 6-level fusions) for adult spinal deformity at a single institution were reviewed. Variables evaluated were as follows: 1) PO, angle between the horizontal plane and a line touching bilateral iliac crests; and 2) LLD, distance from the head to the tibial plafond. Coronal vertical axis (CVA) and sagittal vertical axis measurements were collected, both from C7. The cutoff for CM was CVA > 3 cm. The Oswestry Disability Index (ODI) was collected preoperatively and at 2 years.

RESULTS

Of 242 patients undergoing surgery for adult spinal deformity, 90 (37.0%) had preoperative CM. Patients with preoperative CM had a higher PO (2.8° ± 3.2° vs 2.0° ± 1.7°, p = 0.013), a higher percentage of patients with PO > 3° (35.6% vs 23.5%, p = 0.044), and higher a percentage of patients with LLD > 1 cm (21.1% vs 9.8%, p = 0.014). Whereas preoperative PO was significantly positively correlated with CVA (r = 0.26, p < 0.001) and maximum Cobb angle (r = 0.30, p < 0.001), preoperative LLD was only significantly correlated with CVA (r = 0.14, p = 0.035). A total of 12.2% of patients with CM had significant PO and LLD, defined as follows: PO ≥ 3°; LLD ≥ 1 cm. Postoperatively, preoperative PO was significantly associated with both postoperative CM (OR 1.22, 95% CI 1.05–1.40, p = 0.008) and postoperative CVA (β = 0.14, 95% CI 0.06–0.22, p < 0.001). A higher preoperative PO was independently associated with postoperative complications after multivariate logistic regression (OR 1.24, 95% CI 1.05–1.45, p = 0.010); however, 2-year ODI scores were not. Preoperative LLD had no significant relationship with postoperative CM, CVA, ODI, or complications.

CONCLUSIONS

A PO ≥ 3° or LLD ≥ 1 cm was seen in 44.1% of patients with preoperative CM and in 23.5% of patients with normal coronal alignment. Preoperative PO was significantly associated with preoperative CVA and maximum Cobb angle, whereas preoperative LLD was only associated with preoperative CVA. The direction of PO and LLD showed no consistent pattern with CVA. Preoperative PO was independently associated with complications but not with 2-year ODI scores.

Open access

Assaf Berger, Kristyn Galbraith, Matija Snuderl, John G. Golfinos, and Douglas Kondziolka

BACKGROUND

Late pathology after vestibular schwannoma radiosurgery is uncommon. The authors presented a case of a resected hemorrhagic mass 13 years after radiosurgery, when no residual tumor was found.

OBSERVATIONS

A 56-year-old man with multiple comorbidities, including myelodysplastic syndrome cirrhosis, received Gamma Knife surgery for a left vestibular schwannoma. After 11 years of stable imaging assessments, the lesion showed gradual growth until a syncopal event occurred 2 years later, accompanied by progressive facial weakness and evidence of intralesional hemorrhage, which led to resection. However, histopathological analysis of the resected specimen showed hemorrhage and reactive tissue but no definitive residual tumor.

LESSONS

This case demonstrated histopathological evidence for the role of radiosurgery in complete elimination of tumor tissue. Radiosurgery for vestibular schwannoma carries a rare risk for intralesional hemorrhage in select patients.

Open access

Hansen Deng, Diego D. Luy, Hussam Abou-Al-Shaar, John K. Yue, Pascal O. Zinn, Ava M. Puccio, and David O. Okonkwo

BACKGROUND

The occurrence of traumatic brain injury with spinal cord injury (SCI) in polytrauma patients is associated with significant morbidity. Clinicians face challenges from a decision-making and rehabilitative perspective. Management is complex and understudied. Treatment should be systematic beginning at the scene, focusing on airway resuscitation and hemodynamic stabilization, immobilization, and timely transport. Early operative interventions should be provided, followed by minimizing secondary pathophysiology. The authors present a case to delineate decision-making in the treatment of combined cranial and spinal trauma.

OBSERVATIONS

A 19-year-old man presented as a level I trauma patient after falling 30 feet as the result of scaffolding collapse. The patient was unresponsive and was intubated; he had an initial Glasgow Coma Scale score of 4. Computed tomography revealed multicompartmental bleeding and herniation, for which supra- and infratentorial decompressive craniectomies were performed. The patient also suffered from thoracic SCI that resulted in complete paraplegia. Multimodality monitoring was used. After stabilization and lengthy rehabilitation, the patient obtained significant functional improvement.

LESSONS

The approach to initial management of concomitant head and spine trauma is to establish intracranial stability followed by intraspinal stability. Patients can make considerable recovery, particularly younger patients, who are more likely to benefit from early aggressive interventions and medical treatment.

Open access

Woo Cheul Cho, Hyeong Jin Lee, Jung Koo Lee, and Jai Ho Choi

BACKGROUND

Eosinophilic meningitis is a rare known complication after brain surgery associated with duraplasty using artificial bovine graft. However, eosinophilic meningitis after craniotomy without bovine dural graft has not been reported.

OBSERVATIONS

A 48-year-old female presented with lateral medullary infarction caused by a vertebral artery dissecting aneurysm incorporating the posterior inferior cerebellar artery (PICA). The authors performed occipital artery–PICA anastomosis and repaired the dura by primary suture without bovine graft. Thereafter, endovascular internal trapping using coils was conducted. Severe headache developed at postoperative day 17, and the patient was diagnosed with eosinophilic meningitis. After administration of a high-dose corticosteroid for 2 weeks, her symptoms and laboratory findings were improved.

LESSONS

Postoperative eosinophilic meningitis is rarely related to craniotomy without using bovine graft. Neurosurgeons should consider the possibility of eosinophilic meningitis after craniotomy without a xenogeneic dural material.

Open access

Charles Swanson, Raju Z. Abraham, Michael Ruebhausen, and Juan Jimenez

BACKGROUND

Disruptions to the integrity of the inner table and trabeculae of the calvaria are rare phenomena. Increasingly rare is the phenomenon of herniation of brain parenchyma through the defects in the skull causing neurological deficit. Surgical intervention is commonly performed but is fraught with risk of brain tissue loss.

OBSERVATIONS

The authors present a case of a 78-year-old White male presenting with strokelike symptoms who was found to have an intradiploic encephalocele that was successfully treated with surgical intervention and neuroplastic reconstruction of the anatomical deficit. The patient had a marked recovery and had near-complete resolution of symptoms.

LESSONS

This notably rare phenomenon resolved with neurosurgical intervention, sparing the parenchyma, and provided the patient with perceivably normal contour of the head using a collaborative approach with neuroplastic intervention.