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Matthew R. Test, Kathryn B. Whitlock, Marcie Langley, Jay Riva-Cambrin, John R. W. Kestle and Tamara D. Simon

OBJECTIVE

Infection is a common complication of cerebrospinal fluid (CSF) shunts, occurring in 6%–20% of children. Although studies are limited, Staphylococcus aureus is thought to cause more rapid and aggressive infection than coagulase-negative Staphylococcus (CONS) or gram-negative organisms. The authors’ objective was to evaluate the relationship between the causative organisms of CSF shunt infection and the timing of infection.

METHODS

The authors performed a retrospective cohort study of children who underwent CSF shunt placement at a tertiary care children’s hospital over a 9-year period and subsequently developed a CSF shunt infection. The primary predictor variable was the causative organism recovered from CSF culture, characterized as S. aureus, CONS, or gram-negative organisms. The primary outcome was time to infection, defined as the number of days from most recent shunt intervention to the diagnosis of the infection. The association between causative organism and time to infection was visualized using Kaplan-Meier curves, and statistical comparisons were made using nonparametric Kruskal-Wallis tests.

RESULTS

Among 103 children in whom a CSF shunt infection developed, the causative organism was CONS in 57 (55%), S. aureus in 19 (18%), and gram-negative organisms in 9 (9%). The median time to infection did not differ (p = 0.81) for infections caused by CONS (20 days, IQR 11–40), S. aureus (26 days, IQR 12–95), and gram-negative organisms (23 days, IQR 17–34).

CONCLUSIONS

No significant difference in time to infection based on the causative organism was observed among children with a CSF shunt infection.

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Alexandre Boutet, Dave Gwun, Robert Gramer, Manish Ranjan, Gavin J. B. Elias, David Tilden, Yuexi Huang, Stanley Xiangyu Li, Benjamin Davidson, Hua Lu, Pascal Tyrrell, Ryan M. Jones, Alfonso Fasano, Kullervo Hynynen, Walter Kucharczyk, Michael L. Schwartz and Andres M. Lozano

OBJECTIVE

Transcranial MR-guided focused ultrasound (MRgFUS) is a minimally invasive treatment for movement disorders. Considerable interpatient variability in skull transmission efficiency exists with the current clinical devices, which is thought to be dependent on each patient’s specific skull morphology. Lower skull density ratio (SDR) values are thought to impede acoustic energy transmission across the skull, attenuating or preventing the therapeutic benefits of MRgFUS. Patients with SDR values below 0.4 have traditionally been deemed poor candidates for MRgFUS. Although considerable anecdotal evidence has suggested that SDR is a reliable determinant of procedural and clinical success, relationships between SDR and clinical outcomes have yet to be formally investigated. Moreover, as transcranial MRgFUS is becoming an increasingly widespread procedure, knowledge of SDR distribution in the general population may enable improved preoperative counseling and preparedness.

METHODS

A total of 98 patients who underwent MRgFUS thalamotomy at the authors’ institutions between 2012 and 2018 were analyzed (cohort 1). The authors retrospectively assessed the relationships between SDR and various clinical outcomes, including tremor improvement and adverse effects, as well as procedural factors such as sonication parameters. An SDR was also prospectively obtained in 163 random emergency department patients who required a head CT scan for various clinical indications (cohort 2). Patients’ age and sex were used to explore relationships with SDR.

RESULTS

In the MRgFUS treatment group, 17 patients with a thalamotomy lesion had an SDR below 0.4. Patients with lower SDRs required more sonication energy; however, their low SDR did not influence their clinical outcomes. In the emergency department patient group, about one-third of the patients had a low SDR (< 0.4). SDR did not correlate with age or sex.

CONCLUSIONS

Although lower SDR values correlated with higher energy requirements during MRgFUS thalamotomy, within the range of this study population, the SDR did not appreciably impact or provide the ability to predict the resulting clinical outcomes. Sampling of the general population suggests that age and sex have no relationship with SDR. Other variables, such as local variances in bone density, should also be carefully reviewed to build a comprehensive appraisal of a patient’s suitability for MRgFUS treatment.

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Hiroki Ohata, Takeo Goto, Alhusain Nagm, Narasinga Rao Kannepalli, Kosuke Nakajo, Hiroki Morisako, Hiroyuki Goto, Takehiro Uda, Shinichi Kawahara and Kenji Ohata

OBJECTIVE

The endoscopic endonasal approach (EEA) for skull base tumors has become an important topic in recent years, but its use, merits, and demerits are still being debated. Herein, the authors describe the nuances and efficacy of the endoscopic endonasal extradural posterior clinoidectomy for maximal tumor exposure.

METHODS

The surgical technique included extradural posterior clinoidectomy following lateral retraction of the paraclival internal carotid artery and extradural pituitary transposition. In cases with prominent posterior clinoid process, a midline sellar dura cut was added to facilitate extradural exposure. Forty-four consecutive patients, in whom this technique was performed between 2016 and 2018 at Osaka City University Hospital, were reviewed. The pathology included 19 craniopharyngiomas, 7 chordomas, 6 meningiomas, 6 pituitary adenomas, 4 chondrosarcomas, and 2 miscellaneous. Utilization and effectiveness of this approach were further demonstrated with neuroimaging.

RESULTS

Extradural posterior clinoidectomies were successfully applied in all patients without permanent neurovascular injury and with better maneuverability and greater resection rate of the tumors. Four patients experienced transient postoperative abducens nerve paresis, and 1 patient experienced transient postoperative oculomotor nerve paresis; however, the patients with deficits recovered within 3 months. On radiological examination, the surgical field was 2.2 times wider in cases with bilateral posterior clinoidectomy than in cases without posterior clinoidectomy.

CONCLUSIONS

The extended EEA with extradural posterior clinoidectomy creates an extra working space and allows adequate accessibility with safe surgical maneuverability to remove tumors that extend behind the posterior clinoid and dorsum sellae.

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Ossama Al-Mefty, Edward R. Laws and A. John Popp

As it does periodically, the United States healthcare system is, yet again, undergoing a period of change on multiple fronts, including internal initiatives in education, quality, and the workforce, as well as external pressure responding to changes in reimbursement and oversight. In such times, looking back at the foundations of our specialty is helpful, allowing often-beleaguered neurosurgeons to reflect upon what it means to be a neurosurgeon, and how they can be assured that our specialty will continue to flourish in the future. Harvey Cushing envisioned, espoused, and developed neurological surgery as a “special field”—a comprehensive, encompassing, and distinct discipline that studies the nervous system and manages neurological disorders. It provides surgical intervention for the treatment of neurological disorders; it by no means was meant to be developed as a mere technical or procedural skill; it is neither a subspecialty of surgery nor a branch of neurology; it is a “special field” that has flourished to become a crown jewel in the realm of medicine. Herein is a perspective that brings the inception and future of this concept to light. A specialty that is to live and flourish should stand on and recognize its roots.

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Christine M. E. Rustenburg, Sayf S. A. Faraj, Roderick M. Holewijn, Idsart Kingma, Barend J. van Royen, Agnita Stadhouder and Kaj S. Emanuel

OBJECTIVE

Degenerative lumbar scoliosis, or de novo degenerative lumbar scoliosis, can result in spinal canal stenosis, which is often accompanied by disabling symptoms. When surgically treated, a single-level laminectomy is performed and short-segment posterior instrumentation is placed to restore stability. However, the effects of laminectomy on spinal stability and the necessity of placing posterior instrumentation are unknown. Therefore, the aim of this study was to assess the stability of lumbar spines with degenerative scoliosis, characterized by the range of motion (ROM) and neutral zone (NZ) stiffness, after laminectomy and placement of posterior instrumentation.

METHODS

Ten lumbar cadaveric spines (T12–L5) with a Cobb angle ≥ 10° and an apex on L3 were included. Three loading cycles were applied per direction, from −4 Nm to 4 Nm in flexion/extension (FE), lateral bending (LB), and axial rotation (AR). Biomechanical evaluation was performed on the native spines and after subsequent L3 laminectomy and the placement of posterior L2–4 titanium rods and pedicle screws. Nonparametric and parametric tests were used to analyze the effects of laminectomy and posterior instrumentation on NZ stiffness and ROM, respectively, both on an individual segment’s motion and on the entire spine section. Spearman’s rank correlation coefficient was used to study the correlation between disc degeneration and spinal stability.

RESULTS

The laminectomy increased ROM by 9.5% in FE (p = 0.04) and 4.6% in LB (p = 0.01). For NZ stiffness, the laminectomy produced no significant effects. Posterior instrumentation resulted in a decrease in ROM in all loading directions (−22.2%, −24.4%, and −17.6% for FE, LB, and AR, respectively; all p < 0.05) and an increase in NZ stiffness (+44.7%, +51.7%, and +35.2% for FE, LB, and AR, respectively; all p < 0.05). The same changes were seen in the individual segments around the apex, while the adjacent, untreated segments were mostly unaffected. Intervertebral disc degeneration was found to be positively correlated to decreased ROM and increased NZ stiffness.

CONCLUSIONS

Laminectomy in lumbar spines with degenerative scoliosis did not result in severe spinal instability, whereas posterior instrumentation resulted in a rigid construct. Also, prior to surgery, the spines already had lower ROM and higher NZ stiffness in comparison to values shown in earlier studies on nonscoliotic spines of the same age. Hence, the authors question the clinical need for posterior instrumentation to avoid instability.

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Dong Hwa Heo, Dong Chan Lee and Choon Keun Park

OBJECTIVE

Recently, minimally invasive unilateral laminotomy with bilateral decompression (ULBD) has been performed for lumbar stenosis using endoscopic approaches. The object of this retrospective study was to compare the clinical and radiological outcomes of three types of minimally invasive decompressive surgery: microsurgery, percutaneous uniportal endoscopic surgery, and percutaneous biportal endoscopic surgery.

METHODS

In the period from March 2016 to December 2017, minimally invasive ULBD was performed using microscopy, a uniportal endoscopic approach, or a biportal endoscopic approach to treat lumbar canal stenosis. Patients were classified into three groups based on the surgery they had undergone. The angle of medial facetectomy area and postoperative dural expansion were measured using MR images. The visual analog scale (VAS) score for leg and back pain, Oswestry Disability Index (ODI), operation time, and complications were assessed. Clinical and radiological parameters were compared among the three groups.

RESULTS

There were 33 patients in the microscopy group, 37 in the biportal endoscopy group, and 27 in the uniportal endoscopy group. Preoperatively stenotic dural areas were significantly expanded in each of the three groups after surgery (p < 0.05). Mean dural expansion in the uniportal endoscopy group was significantly lower than that in the microscopy or biportal endoscopy group (p < 0.05). The mean angle of the facetectomy in the biportal endoscopic group was significantly lower than that in the microscopic group or uniportal endoscopic group (p < 0.05). On the 1st day after surgery, the VAS score for back pain was significantly higher in the microscopic group than in the uniportal or biportal endoscopic group (p < 0.05). However, there were no significant differences in the VAS score for back pain, VAS score for leg pain, or ODI at the final follow-up among the three groups (p > 0.05).

CONCLUSIONS

Although radiological results were different among the three groups of patients, postoperative clinical outcomes were significantly improved after each type of surgery. The percutaneous biportal or uniportal endoscopic approach offers the advantage of reduced immediate postoperative pain. A percutaneous uniportal or biportal endoscopic lumbar approach may be effective for the treatment of lumbar central stenosis and an alternative to conventional microsurgical decompression.

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Saqib Hasan, Lynn B. McGrath Jr., Rajeev D. Sen, Jason K. Barber and Christoph P. Hofstetter

OBJECTIVE

The management of lumbar spinal stenosis (LSS) with concurrent scoliosis and/or spondylolisthesis remains controversial. Full-endoscopic unilateral laminotomy for bilateral decompression (ULBD) facilitates neural decompression while preserving stabilizing osseoligamentous structures and may be uniquely suited for the treatment of LSS with concurrent mild to moderate degenerative deformity. The safety and efficacy of full-endoscopic versus minimally invasive surgery (MIS) ULBD in this patient population is studied here for the first time.

METHODS

A retrospective analysis of prospectively collected data was conducted on 45 consecutive LSS patients with concurrent scoliosis (≥ 10° coronal Cobb angle) and/or spondylolisthesis (≥ 3 mm). Patient demographics, operative details, complications, and imaging characteristics were reviewed. Outcomes were quantified using back and leg visual analog scale (VAS) scores and the Oswestry Disability Index (ODI) at 2 weeks, 3 months, and 1 year.

RESULTS

A total of 26 patients underwent full-endoscopic and 19 underwent MIS-ULBD with an average follow-up period of 12 months. The endoscopic cohort experienced a significantly shorter hospital length of stay (p = 0.014) and fewer adverse events (p = 0.010). Both cohorts experienced significant improvements in VAS and ODI scores at all time points (p < 0.001), but the endoscopic cohort demonstrated significantly better early ODI scores (p = 0.024).

CONCLUSIONS

Endoscopic and MIS-ULBD result in similar functional outcomes for LSS with mild to moderate deformity, while the endoscopic approach demonstrates a favorable rate of complications. Further studies are required to better delineate the characteristics of spinal deformities amenable to this approach and the durability of functional results.

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Andrew K. Chan, Erica F. Bisson, Mohamad Bydon, Steven D. Glassman, Kevin T. Foley, Eric A. Potts, Christopher I. Shaffrey, Mark E. Shaffrey, Domagoj Coric, John J. Knightly, Paul Park, Michael Y. Wang, Kai-Ming Fu, Jonathan R. Slotkin, Anthony L. Asher, Michael S. Virk, Panagiotis Kerezoudis, Mohammed Ali Alvi, Jian Guan, Regis W. Haid and Praveen V. Mummaneni

OBJECTIVE

The optimal minimally invasive surgery (MIS) approach for grade 1 lumbar spondylolisthesis is not clearly elucidated. In this study, the authors compared the 24-month patient-reported outcomes (PROs) after MIS transforaminal lumbar interbody fusion (TLIF) and MIS decompression for degenerative lumbar spondylolisthesis.

METHODS

A total of 608 patients from 12 high-enrolling sites participating in the Quality Outcomes Database (QOD) lumbar spondylolisthesis module underwent single-level surgery for degenerative grade 1 lumbar spondylolisthesis, of whom 143 underwent MIS (72 MIS TLIF [50.3%] and 71 MIS decompression [49.7%]). Surgeries were classified as MIS if there was utilization of percutaneous screw fixation and placement of a Wiltse plane MIS intervertebral body graft (MIS TLIF) or if there was a tubular decompression (MIS decompression). Parameters obtained at baseline through at least 24 months of follow-up were collected. PROs included the Oswestry Disability Index (ODI), numeric rating scale (NRS) for back pain, NRS for leg pain, EuroQol-5D (EQ-5D) questionnaire, and North American Spine Society (NASS) satisfaction questionnaire. Multivariate models were constructed to adjust for patient characteristics, surgical variables, and baseline PRO values.

RESULTS

The mean age of the MIS cohort was 67.1 ± 11.3 years (MIS TLIF 62.1 years vs MIS decompression 72.3 years) and consisted of 79 (55.2%) women (MIS TLIF 55.6% vs MIS decompression 54.9%). The proportion in each cohort reaching the 24-month follow-up did not differ significantly between the cohorts (MIS TLIF 83.3% and MIS decompression 84.5%, p = 0.85). MIS TLIF was associated with greater blood loss (mean 108.8 vs 33.0 ml, p < 0.001), longer operative time (mean 228.2 vs 101.8 minutes, p < 0.001), and longer length of hospitalization (mean 2.9 vs 0.7 days, p < 0.001). MIS TLIF was associated with a significantly lower reoperation rate (14.1% vs 1.4%, p = 0.004). Both cohorts demonstrated significant improvements in ODI, NRS back pain, NRS leg pain, and EQ-5D at 24 months (p < 0.001, all comparisons relative to baseline). In multivariate analyses, MIS TLIF—as opposed to MIS decompression alone—was associated with superior ODI change (β = −7.59, 95% CI −14.96 to −0.23; p = 0.04), NRS back pain change (β = −1.54, 95% CI −2.78 to −0.30; p = 0.02), and NASS satisfaction (OR 0.32, 95% CI 0.12–0.82; p = 0.02).

CONCLUSIONS

For symptomatic, single-level degenerative spondylolisthesis, MIS TLIF was associated with a lower reoperation rate and superior outcomes for disability, back pain, and patient satisfaction compared with posterior MIS decompression alone. This finding may aid surgical decision-making when considering MIS for degenerative lumbar spondylolisthesis.

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Mohamed A. R. Soliman and Ahmed Ali

OBJECTIVE

The aim of this study was to compare the radiological and clinical results of bilateral interlaminar canal decompression and classic laminectomy in lumbar canal stenosis (LCS).

METHODS

Two hundred eighteen patients with LCS were randomized to surgical treatment with classic laminectomy (group 1) or bilateral interlaminar canal decompression (group 2). Low-back and leg pain were evaluated according to the visual analog scale (VAS) both preoperatively and postoperatively. Disability was evaluated according to the Oswestry Disability Index (ODI) preoperatively and at 1 month, 1 year, and 3 years postoperatively. Neurogenic claudication was evaluated using the Zurich Claudication Questionnaire (ZCQ) preoperatively and 1 year postoperatively. The two treatment groups were compared in terms of neurogenic claudication, estimated blood loss (EBL), and intra- and postoperative complications.

RESULTS

Postoperative low-back and leg pain declined as compared to the preoperative pain. Both groups had significant improvement in VAS, ODI, and ZCQ scores, and the improvements in ODI and back pain VAS scores were significantly better in group 2. The average EBL was 140 ml in group 2 compared to 260 ml in group 1. Nine patients in the laminectomy group developed postoperative instability requiring fusion compared to only 4 cases in the interlaminar group (p = 0.15). Complications frequency did not show any statistical significance between the two groups.

CONCLUSIONS

Bilateral interlaminar decompression is an effective method that provides sufficient canal decompression with decreased instability in cases of LCS and increases patient comfort in the postoperative period.