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Shizumasa Murata, Akihito Minamide, Masanari Takami, Hiroshi Iwasaki, Sae Okada, Kento Nonaka, Hiroshi Taneichi, Andrew J. Schoenfeld, Andrew K. Simpson, and Hiroshi Yamada

OBJECTIVE

Facet cysts may represent a sign of intrinsic facet disease and instability, increasing the importance of less-invasive approaches that limit tissue dissection and improve visualization. The authors developed an intraoperative cyst-dyeing technique, involving the injection of indigo carmine from the facet joint into the cyst, as an adjunct during decompression. This study aimed to evaluate the clinical outcomes and perioperative complication rates of microendoscopic spinal decompression for lumbar spinal stenosis (LSS) and lumbar foraminal stenosis (LFS), caused by facet cysts and to elucidate the efficacy of the cyst-dyeing method in microendoscopic surgery for facet cysts.

METHODS

Forty-eight consecutive patients who underwent surgical treatment with microendoscopic decompression for symptomatic LSS or LFS caused by facet cysts from 2011 to 2018 were reviewed. These patients were divided into two groups: a group that did not receive dye (N), with the patients undergoing surgery from April 2011 to May 2015; and a group that received dye (D), with patients undergoing surgery from June 2015 to March 2018. The authors evaluated the operative time, blood loss, perioperative complications, visual analog scale scores for low-back and leg pain, and Japanese Orthopaedic Association scores. Surgical outcome was evaluated 2 years postoperatively and was compared between groups D and N.

RESULTS

The clinical outcomes were generally excellent or good. Group N consisted of 36 patients and group D of 12 patients. Comparing the clinical results, it was found that the cyst-dyeing method reduced the perioperative complication rate, including reduction in dural tears to 0%, and shortened the average operative time by approximately 40 minutes.

CONCLUSIONS

In this study, the authors demonstrated that the clinical outcomes of microendoscopic spinal decompression in patients with LSS or LFS caused by facet-joint cysts are generally favorable. Additionally, the adjunctive cyst-dyeing method effectively delineated the cystic and dural boundaries, facilitating safer and more effective cyst separation and neural decompression. Microendoscopic surgery combined with this novel facet cyst-dyeing method is a safe and effective minimally invasive technique for facet-joint cysts.

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Akikazu Nakamura, Akitsugu Kawashima, Hugo Andrade-Barazarte, Takayuki Funatsu, Juha Hernesniemi, and Takakazu Kawamata

OBJECTIVE

Patients with pediatric moyamoya disease (PMMD) showing recurrent symptoms or decreased cerebral blood flow after initial revascularization therapy may require additional revascularization to improve their clinical condition. The authors evaluated the clinical and hemodynamic benefits of an occipital artery (OA)–middle cerebral artery (MCA) bypass for patients with PMMD who have undergone an initial revascularization procedure.

METHODS

The authors retrospectively identified 9 patients with PMMD who had undergone OA-MCA bypass between March 2013 and December 2017, and who had received a previous superficial temporal artery–MCA bypass. The following clinical data were collected: initial revascularization procedure, symptoms (presence or recurrence), pre- and postoperative cerebral blood flow and cerebrovascular reactivity (CVR) changes, posterior cerebral artery (PCA) stenosis, PCA-related and nonrelated symptoms, and latest follow-up.

RESULTS

Preoperatively, all patients (n = 9) suffered non–PCA-related recurrent symptoms, and 4 had PCA-related symptoms. At 1-year follow-up, all patients with PCA-related symptoms showed complete recovery. Additionally, 8 (89%) patients with non-PCA symptoms experienced improvement. Only 1 (11%) patient showed no improvement after the surgical procedure. The mean pre- and postoperative CVR values of the MCA territory were 14.8% and 31.3%, respectively, whereas the respective mean CVR values of the PCA territory were 22.8% and 40.0%.

CONCLUSIONS

The OA-MCA bypass is an effective rescue therapy to improve the clinical condition and hemodynamic changes caused by PMMD in patients who experience recurrent symptoms after initial revascularization.

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Jin-Sung Park, Se-Jun Park, Chong-Suh Lee, Tae-hoon Yum, and Bo-Taek Kim

OBJECTIVE

Several radiological parameters related to the aging spine have been reported as progression factors of early degenerative lumbar scoliosis (DLS). However, it has not been determined which factors are the most important. In this study the authors aimed to determine the risk factors associated with curve progression in early DLS.

METHODS

Fifty-one patients with early DLS and Cobb angles of 5°–15° were investigated. In total, 7 men and 44 women (mean age 61.6 years) were observed for a mean period of 13.7 years. The subjects were divided into two groups according to Cobb angle progression (≥ 15° or < 15°) at the final follow-up, and radiological parameters were compared. The direction of scoliosis, apical vertebral level and rotational grade, lateral subluxation, disc space difference, osteophyte difference, upper and lower disc wedging angles, and relationship between the intercrest line and L5 vertebra were evaluated.

RESULTS

During the follow-up period, the mean curve progression increased from 8.8° ± 3.2° to 19.4° ± 8.9°. The Cobb angle had progressed by ≥ 15° in 17 patients (33.3%) at the final follow-up. In these patients the mean Cobb angle increased from 9.4° ± 3.4° to 28.8° ± 7.5°, and in the 34 remaining patients it increased from 8.5° ± 3.1° to 14.7° ± 4.8°. The baseline lateral subluxation, disc space difference, and upper and lower disc wedging angles significantly differed between the groups. In multivariate logistic regression analysis, only the upper and lower disc wedging angles were significantly correlated with curve progression (OR 1.55, p = 0.035, and OR 1.89, p = 0.004, respectively).

CONCLUSIONS

Asymmetrical degenerative change in the lower apical vertebral disc, which leads to upper and lower disc wedging angles, is the most substantial factor in predicting early DLS progression.

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Shiro Horisawa, Atsushi Fukui, Hayato Yamahata, Yukiko Tanaka, Atsushi Kuwano, Oji Momosaki, Mutsumi Iijima, Magi Nanke, Takakazu Kawamata, and Takaomi Taira

OBJECTIVE

Neurosurgical ablation is an effective treatment for medically refractory motor symptoms of Parkinson’s disease (PD). A limited number of studies have reported the effect of ablation of the pallidothalamic tract for PD. In this study, the authors evaluated the safety and efficacy of unilateral pallidothalamic tractotomy for akinetic-rigid (AR)–PD.

METHODS

Fourteen AR-PD patients, who were enrolled in this prospective open-label study, underwent unilateral pallidothalamic tractotomy. The Movement Disorder Society–Unified Parkinson’s Disease Rating Scale (MDS-UPDRS) Part III and Part IV (dyskinesia and dystonia) scores and levodopa equivalent daily dose (LEDD) were evaluated at baseline and at 3 and 12 months postoperatively.

RESULTS

Of the 14 patients enrolled in the study, 4 were lost to follow-up and 10 were analyzed. The total MDS-UPDRS Part III score significantly improved from 45 ± 4.6 at baseline to 32.9 ± 4.8 at 12 months postoperatively (p = 0.005). Contralateral side rigidity and bradykinesia significantly improved from 4.4 ± 0.5 and 10.4 ± 1.5 at baseline to 1.7 ± 0.4 (p = 0.005) and 5.2 ± 1.4 (p = 0.011) at 12 months, respectively. While posture significantly improved with a 20% reduction in scores (p = 0.038), no significant improvement was found in gait (p = 0.066). Dyskinesia and dystonia were improved with a 79.2% (p = 0.0012) and 91.7% (p = 0.041) reduction in scores, respectively. No significant change was found in the LEDD. Hypophonia was noted in 2 patients, eyelid apraxia was noted in 1 patient, and a reduced response to levodopa, which resulted in an increase in the daily dose of levodopa, was noted in 3 patients. No serious permanent neurological deficits were observed.

CONCLUSIONS

Unilateral pallidothalamic tractotomy improved contralateral side rigidity and bradykinesia, dyskinesia, and dystonia in patients with AR-PD.

Clinical trial registration no.: UMIN000031138 (umin.ac.jp)

Open access

Michelle Roytman, Andrew B. Tassler, Ashutosh Kacker, Theodore H. Schwartz, Georgiana A. Dobri, Sara B. Strauss, Alyssa M. Capalbo, Rajiv S. Magge, Marissa Barbaro, Eaton Lin, Joseph R. Osborne, and Jana Ivanidze

BACKGROUND

Esthesioneuroblastoma (ENB), also known as olfactory neuroblastoma, is a rare sinonasal neuroectodermal malignancy with a slow onset of symptoms, favorable 5-year survival, and a propensity for delayed locoregional recurrence. Current treatment options include resection, adjuvant radiotherapy, and/or chemotherapy; however, because of its rarity and location, determining the optimal treatment for ENB has been challenging.

OBSERVATIONS

ENBs strongly express somatostatin receptors (SSTRs), particularly SSTR2, providing a molecular target for imaging and therapy.

LESSONs

The authors present a case series of ENBs imaged with [68Ga]-DOTATATE PET/MRI and PET/CT and discuss the emerging role of [68Ga]-DOTATATE PET for ENB diagnosis, staging, and treatment response monitoring.

Open access

Ahmad K. Alhaj, Tariq Al-Saadi, Marie-Noëlle Hébert-Blouin, Kevin Petrecca, and Roy W. R. Dudley

BACKGROUND

Endoscopic third ventriculostomy (ETV) is a successful procedure for treating noncommunicating hydrocephalus as an alternative to initial ventriculoperitoneal (VP) shunt placement and as a salvage procedure when a VP shunt fails. Physiological changes of pregnancy can lead to VP shunt failure and complicate the management of shunt malfunction, particularly in the third trimester.

OBSERVATIONS

The authors present a case in which an ETV was successfully used in the third trimester (31 weeks of gestation) of pregnancy for acute hydrocephalus due to VP shunt malfunction, and the patient went on to deliver a healthy baby at term; the patient remained well in the long-term follow-up. An English-language PubMed literature review revealed four cases of VP shunt failure successfully treated with an ETV in the first or second trimester but no such reports in the third trimester of pregnancy.

LESSONS

ETV appears to be a safe and effective alternative to VP shunt replacement in the late prenatal period of pregnancy.

Open access

Melissa M. J. Chua, Saksham Gupta, Walid Ibn Essayed, Dustin J. Donnelly, Habibullah Ziayee, Juan Vicenty-Padilla, Alvin S. Das, Rosalind P. M. Lai, Saef Izzy, and Mohammad Ali Aziz-Sultan

BACKGROUND

Pure arterial malformations (PAMs) are rare vascular anomalies that are commonly mistaken for other vascular malformations. Because of their purported benign natural history, PAMs are often conservatively managed. The authors report the case of a ruptured PAM leading to subarachnoid hemorrhage (SAH) with intraventricular extension that was treated endovascularly.

OBSERVATIONS

A 38-year-old man presented with a 1-day history of headaches and nausea. A computed tomography scan demonstrated diffuse SAH with intraventricular extension, and angiography revealed a right posterior inferior cerebellar artery–associated PAM. The PAM was treated with endovascular Onyx embolization.

LESSONS

To the authors’ knowledge, only 2 other cases of SAH associated with PAM have been reported. In those 2 cases, surgical clipping was pursued for definitive treatment. Here, the authors report the first case of a ruptured PAM treated using an endovascular approach, showing its feasibility as a treatment option particularly in patients in whom open surgery is too high a risk.

Open access

Ketan Yerneni, Harsh Wadhwa, Parastou Fatemi, and Corinna C. Zygourakis

BACKGROUND

“Conversion disorder” refers to bodily dysfunction characterized by either sensory or motor neurological symptoms that are unexplainable by a medical condition. Given their somatosensory context, such disorders often require extensive medical evaluation, and the diagnosis can only be made after structural disease is excluded or fails to account for the severity and/or spectrum of the patient’s deficits.

OBSERVATIONS

The authors briefly review functional psychiatric disorders and discuss the comprehensive workup of a patient with a functional postoperative neurological deficit, drawing from their recent experience with a patient who presented with conversion disorder immediately after undergoing anterior cervical discectomy and fusion.

LESSONS

Conversion disorder has been found to be associated with bodily stress, requiring surgeons to be aware of this condition in the postoperative setting. This is especially true in neurosurgery, given the overlap of true neurological pathology, postoperative complications, and manifestations of conversion disorder. Although accurately diagnosing and managing patients with conversion disorder remains challenging, an understanding of the multifactorial nature of its etiology can help clinicians develop a methodical approach to this condition.

Open access

David J. Park, Akash Mishra, Danielle Golub, Jian Y. Li, Karen S. Black, and Michael Schulder

BACKGROUND

Although craniopharyngioma and pituitary adenoma are common tumors of the sellar or suprasellar region, the development of papillary craniopharyngioma in the same sellar region after resection of a nonfunctioning pituitary adenoma has not been reported.

OBSERVATIONS

Here the authors report the first case of craniopharyngioma that developed long after resection of a pituitary adenoma. A 66-year-old male patient underwent endoscopic transsphenoidal resection for a large sellar mass, which histopathologically confirmed the diagnosis of a pituitary adenoma. He had an excellent recovery after surgery. For several years, he had no clinical or imaging evidence of tumor recurrence and then was lost to follow-up. Seven years after the initial surgery, the patient returned with a one-month history of visual field defects, and imaging confirmed a heterogeneous, cystic suprasellar mass. Endoscopic transsphenoidal resection of the tumor was performed, and histological examination showed it to be a papillary craniopharyngioma.

LESSONS

Neurosurgeons should be aware that after pituitary adenoma resection, a recurrent mass could be a craniopharyngioma, with implications for very different management recommendations.

Open access

Galih Indra Permana, M. Arifin Parenrengi, Wihasto Suryaningtyas, Dyah Fauziah, and Muhammad Azzam

BACKGROUND

Plexiform neurofibroma is a benign tumor of the peripheral nerves. It is an unusual variant of neurofibroma originating from all parts of the nerve. Plexiform neurofibroma is primarily pathognomonic and exhibits an unusual variant from neurofibromatosis type 1 (NF1). The possibility of malignancy and recurrence are the main reasons for long-term, close follow-up.

OBSERVATIONS

The authors report a case of a 14-year-old girl with a recurrent plexiform neurofibroma derived from the peripheral nerves, which also presented with a typical sign of NF1 disease. The aim of the tumor resection is symptomatic relief.

LESSONS

Accomplishing a good outcome can be related to good perioperative planning and a precise operative procedure. The result of anatomical pathology determines the prognosis of the patient. Clinical examination and radiological studies are needed to evaluate the recurrence of complications after surgical procedures.