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Yen-Mie Lai, Christa Boer, Roelant S. Eijgelaar, Charissa E. van den Brom, Philip de Witt Hamer, and Patrick Schober

OBJECTIVE

Awake craniotomies are often characterized by alternating asleep-awake-asleep periods. Preceding the awake phase, patients are weaned from anesthesia and mechanical ventilation. Although clinicians aim to minimize the time to awake for patient safety and operating room efficiency, in some patients, the time to awake exceeds 20 minutes. The goal of this study was to determine the average time to awake and the factors associated with prolonged time to awake (> 20 minutes) in patients undergoing awake craniotomy.

METHODS

Records of patients who underwent awake craniotomy between 2003 and 2020 were evaluated. Time to awake was defined as the time between discontinuation of propofol and remifentanil infusion and the time of extubation. Patient and perioperative characteristics were explored as predictors for time to awake using logistic regression analyses.

RESULTS

Data of 307 patients were analyzed. The median (IQR) time to awake was 13 (10–20) minutes and exceeded 20 minutes in 17% (95% CI 13%–21%) of the patients. In both univariate and multivariable analyses, increased age, nonsmoker status, and American Society of Anesthesiologists (ASA) class III versus II were associated with a time to awake exceeding 20 minutes. BMI, as well as the use of alcohol, drugs, dexamethasone, or antiepileptic agents, was not significantly associated with the time to awake.

CONCLUSIONS

While most patients undergoing awake craniotomy are awake within a reasonable time frame after discontinuation of propofol and remifentanil infusion, time to awake exceeded 20 minutes in 17% of the patients. Increasing age, nonsmoker status, and higher ASA classification were found to be associated with a prolonged time to awake.

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Kentaro Yamada, Hiromitsu Toyoda, Shinji Takahashi, Koji Tamai, Akinobu Suzuki, Masatoshi Hoshino, Hidetomi Terai, and Hiroaki Nakamura

OBJECTIVE

Both facet joint opening (FJO) on CT and facet joint effusion (FJE) on MRI are reportedly indicators of segmental instability in the lumbar facet joints of patients with lumbar spinal stenosis (LSS). However, no study has investigated both parameters simultaneously. Therefore, the association between these findings and which parameter is better for predicting clinical outcomes after surgical treatment remains unclear. The purpose of this study was to investigate the relationship between FJO and FJE in patients who underwent less invasive decompression procedures for LSS and to investigate the impact of these findings on clinical outcomes.

METHODS

This study included 1465 lumbar levels (L1–2 to L5–S1) in 293 patients who underwent less invasive surgery for LSS and had ≥ 5 years of follow-up. FJO was defined as joint space widening ≥ 2 mm on preoperative axial CT images. FJE was defined as fluid effusion in the facet joint on preoperative axial T2-weighted MR images. The characteristics and distributions of FJO and FJE were investigated with other preoperative radiological findings. The association between need for further surgery and FJO/FJE was analyzed according to intervertebral level.

RESULTS

FJO was observed at 402 levels (27%), and FJE was found at 306 levels (21%). The correspondence rate between FJO and FJE was 70% (kappa 0.195, p < 0.01). One hundred thirty-seven levels (9%) had both FJO and FJE. Levels with both FJO and FJE more commonly had lateral olisthesis, lateral wedging, and axial intervertebral rotation than other levels (p < 0.001). Levels with both FJO and FJE were more likely than other levels to need further surgery (OR 2.42, p = 0.027).

CONCLUSIONS

The correspondence rate between FJO and FJE was not high. However, multivariate analysis showed that levels with both FJO and FJE had a higher risk of requiring further surgery than those with other radiological findings, such as lateral olisthesis, lateral wedging, and axial intervertebral rotation. Patients with levels with both FJO and FJE need careful long-term follow-up after undergoing a less invasive decompression procedure.

Open access

Nizar Moayeri and Y. Raja Rampersaud

OBJECTIVE

Minimally invasive decompression (MID) is an effective procedure for lumbar spinal stenosis (LSS). Long-term follow-up data on reoperation rates are lacking. The objective of this retrospective cohort study was to evaluate reoperation rates in patients with LSS who underwent MID, stratified for degenerative lumbar spondylolisthesis (DLS), with a follow-up between 5 and 15 years.

METHODS

All consecutive patients with LSS who underwent MID between 2002 and 2011 were included. All patients had neurogenic claudication from central and/or lateral recess stenosis, without or with up to 25% of slippage (grade I spondylolisthesis), and no obvious dynamic instability on imaging (increase in spondylolisthesis by ≥ 5 mm demonstrated on supine-to-standing or flexion-extension imaging). Reoperation rates defined as any operation on the same or adjacent level were assessed. Revision decompression alone was considered if the aforementioned clinical and radiographic criteria were met; otherwise, patients underwent a minimally invasive posterior fusion.

RESULTS

A total of 246 patients (mean age 66 years) were included. Preoperative spondylolisthesis was present in 56.9%. The mean follow-up period was 8.2 years (range 5.0−14.9 years). The reoperation rates in patients with and without spondylolisthesis were 15.7% and 15.1%, respectively; fusion was required in 7.1% and 7.5%, with no significant difference (redecompression only, p = 0.954; fusion, p = 0.546). For decompression only, the mean times to reoperation were 3.9 years (95% CI 1.8−6.0 years) for patients with DLS and 2.8 years (95% CI 1.3−4.2 years) for patients without DLS; for fusion, the mean times to reoperation were 3.1 years (95% CI 1.0−5.3 years) and 3.1 years (95% CI 1.1−5.1 years), respectively.

CONCLUSIONS

In highly selected patients with stable DLS and leg-dominant pain from central or lateral recess stenosis, the long-term reoperation rate is similar between DLS and non-DLS patients undergoing MIS decompression.

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Rômulo A. S. Marques, Helioenai S. Alencar, Matheus A. Bannach, and Osvaldo Vilela-Filho

OBJECTIVE

One of the few resources for treating medically intractable pain is ablative surgery, but its indications have fallen dramatically over the last decades. One such procedure is mesencephalotomy. This study aims to determine current risks and benefits of MR-guided semidirect targeting–based stereotactic mesencephalotomy.

METHODS

This was a retrospective study based on a review of the medical records of 22 patients with nociceptive (n = 5), neuropathic (n = 10), or mixed (n = 7) refractory pain treated with unilateral mesencephalotomy alone (17 patients) or associated with bilateral anterior cingulotomy (5 patients) between 2014 and 2021 in the authors’ institutions. The confidence interval adopted in this study was 95%.

RESULTS

The sample included 12 women and 10 men with ages ranging from 23 to 80 years (mean 55.1 ± 17.1 years). Using MR-guided semidirect targeting, the following structures were targeted: spinoreticulothalamic (neuropathic/mixed pain, n = 17), trigeminothalamic (nociceptive/mixed pain in the face, n = 5), and neospinothalamic (nociceptive/mixed pain in the body, n = 7) pathways. The most common response to macrostimulation was central heat/moderate discomfort. Radiofrequency thermocoagulation was made with 70°C–75°C/60 sec.

A total of 86.3% (3 months) and 76.9% (12 months) of the patients achieved excellent or good results (improvement of pain > 50%), presenting with a significant mean pain relief of 80.1% at 3 months and 71.4% at 12 months postoperatively. The addition of bilateral anterior cingulotomy did not improve the results. Patients with upper limb, cervicobrachial, and face pain did significantly better than those with trunk pain. The worst results were seen in patients with neuropathic and/or trunk pain. The surgical failure (pain relief ≤ 25%) and recurrence rates were 9.1% each, apparently related to the use of lower lesioning parameters (70°C/60 sec) and to the presence of neuropathic and/or trunk pain. The morbidity rate was 8%, with both complications (vertical diplopia and confusion/agitation) happening in patients lesioned with 75°C/60 sec. There were no deaths in this series.

CONCLUSIONS

These results show that contemporary stereotactic mesencephalotomy is an effective, relatively low-risk, and probably underused procedure for treating medically intractable pain. Careful semidirect determination of the target coordinates associated with close attention to electrical macrostimulation responses certainly plays an important role in avoiding complications in most of the procedures. A higher lesioning temperature (75°C) apparently prevents recurrence, but at the cost of an increased risk of complications.

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Juan Antonio Simal-Julian, Laila Pérez de San Román-Mena, María Rosa Sanchis-Martín, Arnold Quiroz-Tejada, Pablo Miranda-Lloret, and Carlos Botella-Asunción

Endoscopic endonasal reconstruction techniques have improved CSF leak rates that were initially reported after surgery for cranial base and intradural lesions. However, wide surgical defects still pose a problem, especially if located in the clival region. The authors propose and describe a novel reconstruction technique they call a septal rhinopharyngeal flap (SRF) specifically designed to address this issue. The SRF is formed by three components of mucosa: 1) septal, 2) rhinopharyngeal roof, and 3) rhinopharyngeal posterior wall components, which allows for the coverage of the tuberculum/sellar region, midclivus, and lower clivus, respectively. A step-by-step procedure is described and its results analyzed in cases in which it has been used. The SRF was performed in 8 patients, which included diagnoses of 4 chordomas, 2 petroclival meningiomas, 1 invasive pituitary adenoma, and 1 chondrosarcoma. The size of the flap was considered optimal in all patients (100%). Postoperative MRI revealed contrast enhancement covering the entire surface of the flap. No CSF leaks were encountered after at least 1 postoperative year. The SRF is a novel vascularized reconstruction technique specifically indicated for wide endosanasal clivectomies focused on the middle clivus with caudal extension into the lower clivus and craniocervical junction, as well as rostral extensions into the tubercular or planum sphenoidale. This new reconstruction technique could be added to the skull base reconstruction armamentarium as a safe and optimal option.

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S. Harrison Farber, Komal Naeem, Malika Bhargava, and Randall W. Porter

OBJECTIVE

Lateral lumbar interbody fusion (LLIF) via a transpsoas approach is a workhorse minimally invasive approach for lumbar arthrodesis that is often combined with posterior pedicle screw fixation. There has been increasing interest in performing single-position surgery, allowing access to the anterolateral and posterior spine without requiring patient repositioning. The feasibility of the transpsoas approach in patients in the prone position has been reported. Herein, the authors present a consecutive case series of all patients who underwent single-position prone transpsoas LLIF performed by an individual surgeon since adopting this approach.

METHODS

A retrospective review was performed of a consecutive case series of adult patients (≥ 18 years old) who underwent single-position prone LLIF for any indication between October 2019 and November 2020. Pertinent operative details (levels, cage use, surgery duration, estimated blood loss, complications) and 3-month clinical outcomes were recorded. Intraoperative and 3-month postoperative radiographs were reviewed to assess for interbody subsidence.

RESULTS

Twenty-eight of 29 patients (97%) underwent successful treatment with the prone lateral approach over the study interval; the approach was aborted in 1 patient, whose data were excluded. The mean (SD) age of patients was 67.9 (9.3) years; 75% (21) were women. Thirty-nine levels were treated: 18 patients (64%) had single-level fusion, 9 (32%) had 2-level fusion, and 1 (4%) had 3-level fusion. The most commonly treated levels were L3–4 (n = 15), L2–3 (n = 12), and L4–5 (n = 11). L1–2 was fused in 1 patient. The mean operative time was 286.5 (100.6) minutes, and the mean retractor time was 29.2 (13.5) minutes per level. The mean fluoroscopy duration was 215.5 (99.6) seconds, and the mean intraoperative radiation dose was 170.1 (94.8) mGy. Intraoperative subsidence was noted in 1 patient (4% of patients, 3% of levels). Intraoperative lateral access complications occurred in 11% of patients (1 cage repositioning, 2 inadvertent ruptures of anterior longitudinal ligament). Subsidence occurred in 5 of 22 patients (23%) with radiographic follow-up, affecting 6 of 33 levels (18%). Postoperative functional testing (Oswestry Disability Index, SF-36, visual analog scale–back and leg pain) identified significant improvement.

CONCLUSIONS

This single-surgeon consecutive case series demonstrates that this novel technique is well tolerated and has acceptable clinical and radiographic outcomes. Larger patient series with longer follow-up are needed to further elucidate the safety profile and long-term outcomes of single-position prone LLIF.

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Megan M. J. Bauman, Kimberly Wang, Archis R. Bhandarkar, Kristen M. Scheitler, and Michelle J. Clarke

OBJECTIVE

At present, females constitute less than 10% of neurosurgeons in the US, despite representing approximately half of all medical students. Multiple barriers have been described for females entering the neurosurgical field, particularly academic neurosurgery. Understanding the environment that female neurosurgeons face and any potential barriers preventing career advancement is needed to recruit, promote, and retain females in neurosurgery.

METHODS

The gender composition of editorial boards for 5 high-impact neurosurgery journals was analyzed from 2000 to 2020. The names of editorial board members were obtained directly from the journal administration, physical copies of the published journal, or publicly available data through each journal’s website. The gender, degrees, academic titles, H-index, and country were determined for each individual and statistical tests were performed to identify significant differences.

RESULTS

Of the 466 identified individuals that served on at least one editorial board between 2000 and 2020, there were 36 females (7.7%) and 430 males (92.3%). There were no significant differences between males and females serving on multiple editorial boards. Most females possessed an additional graduate degree (58.3%), while only one-third of males (33.5%) obtained such a degree (p = 0.002). In addition, males had significantly higher average H-indices than females (p = 0.002). These trends were also observed when analyzing only US-based editorial board members. Although females were more likely overall to be identified as associate professors, males were more likely to be appointed as full professors (p = 0.001); this trend did not remain true in the US-based cohort. When analyzing the editorial boards for individual journals, all 5 journals experienced an increase of female representation since 2000 or since their inception after 2000. The highest proportion of females for a single journal was 27.3% in 2020. All other journals ranged from 11.0% to 13.5% in 2020.

CONCLUSIONS

When entering the field of neurosurgery, females continue to face significant social and academic barriers. While the proportion of females on editorial boards for neurosurgery journals in 2020 is consistent with the proportion of practicing female neurosurgeons, there is a statistically significantly higher likelihood that females possess additional graduate degrees and lower H-indices compared to their male counterparts. The authors encourage neurosurgical journals to continue expanding female representation on editorial boards.

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Adham M. Khalafallah, Maureen Rakovec, Katemanee Burapachaisri, Shirley Fung, Sharon L. Kozachik, Benita Valappil, Hussam Abou-Al-Shaar, Eric W. Wang, Carl H. Snyderman, Georgios A. Zenonos, Paul A. Gardner, Mustafa K. Baskaya, David Dornbos III, Garret Choby, Edward C. Kuan, Christopher Roxbury, Jonathan B. Overdevest, David A. Gudis, Victoria S. Lee, Joshua M. Levy, Andrew Thamboo, Rodney J. Schlosser, Judy Huang, Chetan Bettegowda, Nyall R. London Jr., Nicholas R. Rowan, Albert W. Wu, and Debraj Mukherjee

OBJECTIVE

Suprasellar meningioma resection via either the transcranial approach (TCA) or the endoscopic endonasal approach (EEA) is an area of controversy and active evaluation. Skull base surgeons increasingly consider patient-reported outcomes (PROs) when choosing an approach. No PRO measure currently exists to assess quality of life for suprasellar meningiomas.

METHODS

Adult patients undergoing suprasellar meningioma resection between 2013 and 2019 via EEA (n = 14) or TCA (n = 14) underwent semistructured interviews. Transcripts were coded using a grounded theory approach to identify themes as the basis for a PRO measure that includes all uniquely reported symptoms. To assess content validity, 32 patients and 15 surgeons used a Likert scale to rate the relevance of items on the resulting questionnaire and the general Patient-Reported Outcomes Measurement Information System–29 (PROMIS29). The mean scores were calculated for all items and compared for TCA versus EEA patient cohorts by using unpaired t-tests. Items on either questionnaire with mean scores ≥ 2.0 from patients were considered meaningful and were aggregated to form the novel Suprasellar Meningioma Patient-Reported Outcome Survey (SMPRO) instrument.

RESULTS

Qualitative analyses resulted in 55 candidate items. Relative to patients who underwent the EEA, those who underwent the TCA reported significantly worse future outlook before surgery (p = 0.01), tiredness from medications 2 weeks after surgery (p = 0.001), and word-finding and memory difficulties 3 months after surgery (p = 0.05 and < 0.001, respectively).

The items that patients who received a TCA were most concerned about included medication-induced lethargy after surgery (2.9 ± 1.3), blurry vision before surgery (2.7 ± 1.5), and difficulty reading due to blurry vision before surgery (2.7 ± 2.7). Items that patients who received an EEA were most concerned about included blurry vision before surgery (3.5 ± 1.3), difficulty reading due to blurry vision before surgery (2.4 ± 1.3), and problems with smell postsurgery (2.9 ± 1.3). Although surgeons overall overestimated how concerned patients were about questionnaire items (p < 0.0005), the greatest discrepancies between patient and surgeon relevance scores were for blurry vision pre- and postoperatively (p < 0.001 and < 0.001, respectively) and problems with taste postoperatively (p < 0.001). Seventeen meningioma-specific items were considered meaningful, supplementing 8 significant PROMIS29 items to create the novel 25-item SMPRO.

CONCLUSIONS

The authors developed a disease- and approach-specific measure for suprasellar meningiomas to compare quality of life by operative approach. If demonstrated to be reliable and valid in future studies, this instrument may assist patients and providers in choosing a personalized surgical approach.

Open access

Konrad Gag, Jonas Müller, Marie Süße, Robert Fleischmann, and Henry W. S. Schroeder

BACKGROUND

Acute disseminated encephalomyelitis (ADEM) is a rare, acquired demyelination syndrome that causes cognitive impairment and focal neurological deficits and may be fatal. The potentially reversible disease mainly affects children, often after vaccination or viral infection, but may be seen rarely in adults.

OBSERVATIONS

A 50-year-old woman presented with loss of visual acuity of the left eye. Magnetic resonance imaging (MRI) revealed an intra- and suprasellar mass, which was removed successfully. On postoperative day 1, MRI showed gross total resection of the lesion and no surgery-related complications. On postoperative day 2, the patient presented with a progressive left-sided hemiparesis, hemineglect, and decline of cognitive performance. MRI showed white matter edema in both hemispheres. Cerebrospinal fluid analysis revealed mixed pleocytosis (355/µL) without further evidence of infection. In synopsis of the findings, ADEM was diagnosed and treated with intravenous immunoglobulins. Shortly thereafter, the patient recovered, and no sensorimotor deficits were detected in the follow-up examination.

LESSONS

Pituitary gland pathologies are commonly treated by transsphenoidal surgery, with only minor risks for complications. A case of ADEM after craniopharyngioma resection has not been published before and should be considered in case of progressive neurological deterioration with multiple white matter lesions.

Open access

Yunjia Ni, Yuanzhi Xu, Xuemei Zhang, Pin Dong, Qi Li, Juan Shen, Jie Ren, Zhaoqi Yuan, Fei Wang, Anke Zhang, Yunke Bi, Qingwei Zhu, Qiangyi Zhou, Zhiyu Wang, Jingjue Wang, and Meiqing Lou

BACKGROUND

Teratocarcinosarcoma traversing the anterior skull base is rarely reported in literature. The heterogenous and invasive features of the tumor pose challenges for surgical planning. With technological advancements, the endoscopic endonasal approach (EEA) has been emerging as a workhorse of anterior skull base lesions. To date, no case has been reported of EEA totally removing teratocarcinosarcomas with intracranial extensions.

OBSERVATIONS

The authors provided an illustrative case of a 50-year-old otherwise healthy man who presented with left-sided epistaxis for a year. Imaging studies revealed a 31 × 60-mm communicating lesion of the anterior skull base. Gross total resection via EEA was achieved, and multilayered skull base reconstruction was performed.

LESSONS

The endoscopic approach may be safe and effective for resection of extensive teratocarcinosarcoma of the anterior skull base. To minimize the risk of postoperative cerebrospinal fluid leaks, multilayered skull base reconstruction and placement of lumbar drainage are vitally important.