Neurosurgery Blog


Daily bibliographic review of the Neurosurgery Department. La Fe University Hospital. Valencia, Spain

Microsurgical Clipping of Ruptured Anterosuperior-Projecting Anterior Communicating Artery Aneurysms: How We Do It

World Neurosurg. (2018) 116:133-135

In anterosuperior-projecting anterior communicating artery (ACoA) aneurysms, the aneurysm dome usually adheres to 1 or both proximal A2 segments, which may present technical difficulties. This video demonstrates microsurgical clipping of a ruptured anterosuperior-projecting ACoA aneurysm. A 52-year-old male presented with a Hunt-Hess grade II subarachnoid hemorrhage. Computed tomography showed subarachnoid hemorrhage in the basal cisterns and sylvian and interhemispheric fissures. Angiography demonstrated a wide-necked ACoA aneurysm projecting anterosuperiorly. Considering the risk of recurrence, the patient decided to accept surgical treatment.

The patient was positioned supine, and the aneurysm was exposed via the lateral supraorbital approach. The carotid cistern and optic cistern were opened to release cerebrospinal fluid and achieve adequate brain relaxation. A subpial resection of a small portion of the gyrus rectus was performed to visualize the ipsilateral A2, recurrent artery of Heubner, and base of the aneurysm. A plane was dissected between the anterior aspect of both the A2 segment and posterior aspect of the aneurysm. A straight clip was placed parallel to the ACoA to completely obliterate the aneurysm. Postoperative angiography confirmed complete obliteration of the aneurysm. The patient recovered well without any complications.

Successful treatment requires preoperative surgical planning, precise dissection, and preservation of critical structures. With adherence to these general principles, these aneurysms can be treated safely and effectively.

The subatlantic triangle: gateway to early localization of the atlantoaxial vertebral artery

J Neurosurg Spine 29:18–27, 2018

Exposure of the vertebral artery (VA) between C-1 and C-2 vertebrae (atlantoaxial VA) may be necessary in a variety of pathologies of the craniovertebral junction. Current methods to expose this segment of the VA entail sharp dissection of muscles close to the internal jugular vein and the spinal accessory nerve. The present study assesses the technique of exposing the atlantoaxial VA through a newly defined muscular triangle at the craniovertebral junction.

METHODS Five cadaveric heads were prepared for surgical simulation in prone position, turned 30°–45° toward the side of exposure. The atlantoaxial VA was exposed through the subatlantic triangle after reflecting the sternocleidomastoid and splenius capitis muscles inferiorly. The subatlantic triangle was formed by 3 groups of muscles: 1) the levator scapulae and splenius cervicis muscles inferiorly and laterally, 2) the longissimus capitis muscle inferiorly and medially, and 3) the inferior oblique capitis superiorly. The lengths of the VA exposed through the triangle before and after unroofing the C-2 transverse foramen were measured.

RESULTS The subatlantic triangle consistently provided access to the whole length of atlantoaxial VA. The average length of the VA exposed via the subatlantic triangle was 19.5 mm. This average increased to 31.5 mm after the VA was released at the C-2 transverse foramen.

CONCLUSIONS The subatlantic triangle provides a simple and straightforward pathway to expose the atlantoaxial VA. The proposed method may be useful during posterior approaches to the craniovertebral junction should early exposure and control of the atlantoaxial VA become necessary.


Minimally Invasive Surgery is Superior to Conventional Craniotomy in Patients with Spontaneous Supratentorial Intracerebral Hemorrhage: A Systematic Review and Meta-Analysis

World Neurosurg. (2018) 115:266-273

Outcomes of minimally invasive surgery (MIS) versus conventional craniotomy (CC) for patients with spontaneous supratentorial intracerebral hemorrhage (SICH) have not been compared previously. We reviewed the current evidence regarding the safety and efficacy of MIS compared with CC in patients with SICH.

METHODS: We conducted a meta-analysis of studies comparing MIS and CC in patients with computed tomography confirmed SICH published between January 2000 and April 2018 in MEDLINE, Embase, and the Cochrane Controlled Trials Register based on PRISMA inclusion and exclusion criteria. Binary outcomes comparisons between MIS and CC were described using odds ratios (ORs).

RESULTS: Five randomized controlled trials (RCTs) and 9 prospective controlled studies (non-RCTs), involving a total of 2466 patients, met our inclusion criteria. There was a statistically significant difference in mortality rate between MIS and CC (OR, 0.76; 95% confidence interval [CI], 0.60e0.97). MIS was associated with a lower rate of rebleeding (OR, 0.42; 95% CI, 0.28e0.64) and a higher rate of good recovery compared with CC (OR, 2.27; 95% CI, 1.34e3.83).

CONCLUSIONS: Patients with SICH may benefit more from MIS than CC. Our study could help clinicians optimize treatment strategies in SICH

Total Hospital Costs and Length of Stay of Endovascular Coiling Versus Neurosurgical Clipping for Unruptured Intracranial Aneurysms: Systematic Review and Meta-Analysis

World Neurosurg. (2018) 115:393-399

OBJECTIVE: Comparison of feasibility and safety between endovascular
coiling versus neurosurgical clipping for the management of unruptured intracranial aneurysms (UIAs) has been incrementally reported. However, economic comparison has been rarely reported. This meta-analysis aims at qualitatively and quantitatively analyzing the difference of hospital costs and length of stay between endovascular versus neurosurgical treatment in UIA.

METHODS: MEDLINE, the Cochrane database, EMBASE, and Web of Science
database were searched for cohort studies describing economic hospital cost or length of stay in patients with UIA. Two authors independently assessed study eligibility and rated quality using the Newcastle Ottawa Scale. Ravmen 5.2 was used to perform forest plot analysis.

RESULTS: Nine studies describing 24,856 UIAs treated with neurosurgical
clipping and 31,309 UIAs treated with endovascular coiling were included.
Meta-analysis revealed that the total hospital costs (THCs) were similar between coiling and clipping in UIA patients (standard mean difference
[SMD]: -0.33, 95% confidence interval: -0.68 to 0.02, f = 99%, P [ 0.07).
Subgroup analysis showed that THCs of coiling were significantly lower than
clipping in the United States but opposite in South Korea. One-year medical
costs of coiling were similar in both groups (SMD: -0.04, 95% CI: -0.08 to 0.00, f = 0%, P [ 0.07). In addition, the length of stay of coiling were significantly shorter than that of clipping (SMD: 0.69, 95% CI: 0.56e0.81, f = 95%, P < 0.001).

CONCLUSION: Generally, no significant difference in THCs and 1-year medical
costs between coiling versus clipping in UIAs was observed. However, the
length of stay of endovascular coiling was much shorter than neurosurgical
clipping and decreased over time.

Preoperative full-length standing radiographs and revision rates in lumbar degenerative scoliosis

J Neurosurg Spine 28:581–585, 2018

Full-length (36-inch) standing spine radiographs are commonly used by spine surgeons to evaluate patients with lumbar degenerative scoliosis (LDS). Despite this practice, the impact of these images on preoperative decision making and the rate of revision surgery has not been analyzed. The purpose of this study is to determine if preoperative full-length standing spine radiographs improve surgical decision making by decreasing the rate of revision surgery in patients with LDS.

METHODS From the Health Care Service Corporation administrative claims database, the authors identified patients 50–80 years of age with LDS who had undergone surgery including posterior lumbar decompression and fusion over 2–6 levels and with at least 5 years of continuous coverage after the index surgery. Patients were stratified into the following groups, according to the preoperative imaging studies performed within 6 months before their index surgery: lumbar spine MRI studies only, lumbar spine MRI studies and standard lumbar spine radiographs, CT myelograms, and full-length standing spine radiographs. Survival analysis was performed with the occurrence of a revision within 5 years of the index surgery as the outcome of interest.

RESULTS A total of 411 patients were included in the study after applying the inclusion and exclusion criteria. Revision surgery within 5 years after the index procedure was most frequent in the patients with preoperative MRI only (41.8%), followed by the patients with a CT myelogram (30.4%) and those with MRI and standard radiographs (24.8%). The lowest revision rate was seen among those with long-cassette standing radiographs (11.1%). Patients whose preoperative evaluation included full-length standing radiographs (OR 0.353, p = 0.034) and MRI studies plus radiographs (OR 0.650, p = 0.022) were less likely to require revision surgery at 5 years after the index procedure.

CONCLUSIONS An assessment of standing alignment using full-length (36-inch) standing radiographs may be beneficial in reducing the risk of revision surgery in patients with lumbar scoliosis. This observation was not limited to patients with large curves or substantial deformity.

Adjacent Segment Degeneration After Anterior Cervical Discectomy and Fusion With an Autologous Iliac Crest Graft: A Magnetic Resonance Imaging Study of 59 Patients With a Mean Follow-up of 27 Years

Neurosurgery, 82, 6, 799–807, 2018

Anterior cervical decompression and fusion (ACDF) is a widely accepted surgical technique for the treatment of degenerative disc disease. ACDF is associated with adjacent segment degeneration (ASD).
OBJECTIVE: To assess whether physiological aging of the spine would overcome ASD by comparing adjacent to adjoining segments more than 18 yr after ACDF.
METHODS: Magnetic resonance imaging of 59 (36 male, 23 female) patients who underwent ACDF was performed to assess degeneration. The mean follow-up was 27 yr (18-45 yr). Besides measuring the disc height, a 5-step grading system (segmental degeneration index [SDI]) including disc signal intensity, anterior and posterior disc protrusion, narrowing of the disc space, and foraminal stenosis was used to assess the grade of adjacent and adjoining segments.
RESULTS: The SDI of cranial and caudal adjacent segments was significantly higher compared to adjoining segments (P < .001). The disc height of cranial and caudal adjacent segments was significantly lower compared to adjoining segments (P < .001, P < .01). The SDI of adjacent segments in patients with repeat cervical procedure was significantly higher than in patients without repeat procedure (P = .02, P = .01). The disc height of the cranial adjacent segments in patients with repeat procedure was significantly lower than in patients without repeat procedure (P = .01).
CONCLUSION: The physiological aging of the cervical spine does not overcome ASD. The disc height and the SDI in adjacent segment are significantly worse compared to adjoining segments. Patients who underwent repeat procedure had even worse findings of disc height and SDI.

Complications of Full-Endoscopic Versus Microendoscopic Foraminotomy for Cervical Radiculopathy: A Systematic Review and Meta-Analysis

World Neurosurg. (2018) 114:217-227

Minimally invasive surgery of posterior cervical foraminotomy (PCF) for symptomatic radiculopathy has gained popularity in the last decade. It remains to be determined whether the 2 dominant operation techniques, full-endoscopic (FE) or microendoscopic (MI), are associated with fewer complications.

METHODS: An electronic retrieval from PubMed, Embase, and Web of Science was performed to identify comparative or single-arm studies concerning FE-PCF and MI-PCF. The pooled incidence of complications was calculated.

RESULTS: A total of 26 studies with 2028 patients (FE, 402; MI, 1626) were identified. The overall complication rate was 5.8% for FE-PCF and 3.5% for MIPCF, with no significant difference (P [ 0.115). The pooled complication rate for single-level radiculopathy showed no statistical difference (FE, 4.5%; MI, 3.5%; P[0.471), either. However, constituent of complications showed apparent disparity, with transient root palsy in FE-PCF (15/19, 78.9%) and dural tear (20/47, 42.6%) in MI-PCF being the most commonly reported. As for the subgroup analysis, both incidence of dural tear (FE, 1.5%; MI, 1.8%; P [ 0.672) and superficial wound infection (FE, 2.2%; MI, 1.0%; P [ 0.109) showed no statistical difference. Nevertheless, transient root palsy occurred at a higher incidence in the FE group than in the MI group (FE, 4.5%; MI, 1.5%; P [ 0.002).

CONCLUSIONS: Both FE-PCF and MI-PCF can offer relatively safe treatment for cervical radiculopathy. There is no significant difference in overall complication rate between the 2 techniques. Dural tear is the most commonly reported complication of MI-PCF, whereas transient root palsy deserves to be noticed for surgeons performing FE-PCF.

The timing of stereotactic radiosurgery for medically refractory trigeminal neuralgia

Acta Neurochirurgica (2018) 160:977–986

Diffusion tensor imaging (DTI) is a novel MRI technique that enables noninvasive evaluation of microstructural alterations in white matter of brain. Initially, DTI was used in intra- or inter-hemispheric association bundles. Recent technical advances are overcoming the challenges of imaging small white matter bundles, such as the cranial nerves. In this study, we use DTI to shed more light on the microstructure changes in long-standing trigeminal neuralgia. We also utilize DTI to study the effect of early stereotactic radiosurgery (SRS) on the microstructures of the trigeminal nerve and to predict the effectiveness of early SRS in the treatment of medically refractory trigeminal neuralgia (TN).

Methods To analyze the presentation of trigeminal nerve, the DTI was reconstructed in 21 cases pre- and post-SRS. DTI parameters recorded include fractional anisotropy (FA), mean diffusivity (MD), radial diffusivity (RD), axial diffusivity (AD), linear anisotropy coefficient (Cl), planar anisotropy coefficient (Cp), and spherical anisotropy coefficient (Cs). Comparisons between ipsilateral (symptomatic) and contralateral (asymptomatic) trigeminal nerves and symptomdurations of < 5 and ≧ 5 years were performed.

Results The study cohort comprised 21 patients with TN with a median age of 66 years. Initial adequate facial pain relief (Barrow Neurological Institute facial pain scores I–IIIb) was achieved in 16 (76%) patients. For the pre-SRS DTI findings, ipsilateral trigeminal nerve was associated with higher baseline root entry zone (REZ) Cs compared to contralateral nerve (0.774 vs. 0.743, p = 0.04). Ipsilateral trigeminal nerve with symptoms of < 5 years was associated with higher baseline FA compared to trigeminal nerve with symptoms of ≧ 5 years (0.314 vs. 0.244, p = 0.02). For the post-SRS DTI findings, ipsilateral trigeminal nerves with symptoms of <5 years demonstrated decrease in Cl, while those with symptoms ≧ 5 years demonstrated increase in Cl after SRS at the ipsilateral REZ (− 0.025 vs. 0.018, p = 0.04). At the cisternal segment of ipsilateral trigeminal nerve, symptoms of < 5 years were associated with decreased FA and increased λ2, while symptoms of ≧ 5 years were associated with increased FA and decreased λ2 after SRS (FA − 0.068 vs. 0.031, p = 0.04, λ2 0.0003 vs. − 0.0002, p = 0.02).

Conclusions SRS provides high rates of initial pain relief with moderate rates of facial hypoesthesia. Ipsilateral trigeminal nerve was associated with higher baseline REZ Cs, and baseline FAwas associated with duration of symptoms. There were significant associations between duration of symptoms and changes in ipsilateral REZ Cl, cisternal segment FA, and cisternal segment λ2 after SRS. These preliminary findings serve as comparisons for future studies investigating the use of DTI in radiosurgical planning for patients with TN.

Minimally Invasive Alternative Approaches to Pterional Craniotomy: A Systematic Review of the Literature

World Neurosurg. (2018) 113:163-179.

Minimally invasive alternatives to the pterional craniotomy include the minipterional and the supraorbital craniotomy (SOC). The latter is performed via either an eyebrow or an eyelid skin incision. The purpose of this systematic review was to analyze the type and the incidence of approachrelated complications of these so-called “keyhole craniotomies”.

METHODS: We review pertinent articles retrieved by search in the PubMed/ Medline database. Inclusion criteria were all full-text articles, abstracts, and posters in English, up to 2016, reporting clinical results.

RESULTS: A total of 105 articles containing data on 5837 surgeries performed via a minipterional or either of the 2 variants of the SOC met the eligibility criteria. Pain on mastication was the most commonly reported approach-related complication of the minipterional approach, and occurred in 7.5% of cases. Temporary palsy of the frontal branch of the facial nerve and temporary supraorbital hypesthesia were associated with the SOC eyebrow variant, and occurred in 6.5%, respectively in 3.6% of cases. Transient postoperative periorbital edema and transient ophthalmoparesis occurred in 36.8% and 17.4% of cases, respectively, when the SOC was performed via an eyelid skin incision. The risk of occurrence of the latter 2 complications was related to the removal of the orbital rim, which is an obligatory part of the SOC approach through the eyelid but optional with the SOC eyebrow variant.

CONCLUSIONS: Each of the 3 keyhole approaches has a specific set and incidence of approach-related complications. It is essential to be aware of these complications to make the safest individual choice.

Endoscopic endonasal odontoid resection with real-time intraoperative image-guided computed tomography

J Neurosurg 128:1486–1491, 2018

The authors present 4 cases in which they used intraoperative CT (iCT) scanning to provide real-time image guidance during endonasal odontoid resection. While intraoperative CT has previously been used as a confirmatory test after resection, to the authors’ knowledge this is the first time it has been used to provide real-time image guidance during endonasal odontoid resection. The operating room setup, as well as the advantages and pitfalls of this approach, are discussed.

A mobile intraoperative CT scanner was used in conjunction with real-time craniospinal neuronavigation in 4 patients who underwent endoscopic endonasal odontoidectomy for basilar invagination. All patients underwent a successful decompression.

In 3 of the 4 patients, real-time intraoperative CT image guidance was instrumental in achieving a comprehensive decompression. In 3 (75%) cases in which the right nostril was the predominant working channel, there was a tendency for asymmetrical decompression toward the right side, meaning that residual bone was seen on the left, which was subsequently removed prior to completion of the surgery.

Endoscopic endonasal odontoid resection with real-time intraoperative image-guided CT scanning is feasible and provides accurate intraoperative localization of pathology, thereby increasing the chance of a complete odontoidectomy. For right-handed surgeons operating predominantly through the right nostril, special attention should be paid to the contralateral side of the resection, where there is often a tendency for residual pathology.

“Birdlime” technique using TachoSil tissue sealing sheet soaked with fibrin glue for sutureless vessel transposition in microvascular decompression

J Neurosurg 128:1522–1529, 2018

Microvascular decompression (MVD) is effective for the treatment of trigeminal neuralgia (TN), hemifacial spasm (HFS), and glossopharyngeal neuralgia. The transposition technique is the standard procedure to avoid adhesions and granuloma around the decompression site but is more complex and difficult to perform than the interposition technique. The authors describe a simple and safe MVD transposition procedure they call the “birdlime” technique, which uses a tissue glue–coated collagen sponge soaked with fibrin glue, and the results of this technique.

METHODS The authors retrospectively reviewed the medical charts and radiographic findings of 27 consecutive patients with TN (8 patients) and HFS (19 patients) who, between January 2012 and December 2015, had undergone an MVD transposition procedure utilizing a tissue glue–coated collagen sponge (TachoSil tissue sealing sheet) soaked with fibrin glue (Tisseel 2-component fibrin sealant, vapor heated). Offending arteries among the patients with TN were the superior cerebellar artery (SCA) in 5 patients, the SCA and anterior inferior cerebellar artery (AICA) in 2, and the AICA in 1. Those among the patients with HFS were the vertebral artery (VA) in 3 patients, the VA and AICA in 4, the VA and posterior inferior cerebellar artery (PICA) in 3, the PICA in 4, the AICA in 1, the AICA-PICA in 3, and the PICA and AICA in 1. Operations were performed according to the Jannetta procedure. The offending artery was transposed and fixed to the dura mater of the petrous bone using TachoSil pieces soaked with fibrin glue. Postoperative constructive interference in steady-state MRI was performed to evaluate the change in the position of the offending artery.

RESULTS Transposition of the offending artery was easily and safely performed in all patients. All patients had total remission of symptoms directly after the procedure. No severe complications occurred. The postoperative course was uneventful. No recurrences, adhesions, or dysfunction of the cranial nerves was observed in any of the patients. Postoperative MRI showed that the offending vessels were displaced and fixed in the appropriate position.

CONCLUSIONS The described transposition technique provides an easy and adjustable way to perform MVD safely and effectively. In addition, this transposition and fixation technique is simple and avoids the risk of needle injury close to the cranial nerves and vessels. This simple sutureless technique is recommended for MVD to reduce the risk of intraoperative neurovascular injury.


Surgical Drains in Chronic Subdural Hematoma Surgery: From the Cheapest to the Most Expensive Drains

World Neurosurg. (2018) 112:284-286

Among the various neurosurgical techniques currently being used in chronic subdural hematoma (CSDH) surgery, bur hole craniostomy is the most popular worldwide. Recent studies have strongly recommended that a drain be placed after surgical evacuation of a hematoma, and a broad spectrum of preformed surgical drains is widely available for this purpose. If preformed drains are unavailable, a surgeon-made drain can be used and various methods are available to develop a drain in the operating room.

METHODS: Using a case report, we demonstrate how to develop a surgeon-made drain. Next, we retrospectively screened for subdural drain usage in consecutive patients undergoing bur hole drainage for CSDH at Adiyaman University Hospital between January 2017 and April 2017, and data from only those patients in whom a surgeon-made drain was used were included for analyses.

RESULTS: A 74-year-old male was operated with the diagnosis of CSDH. Assembly of a surgeon-made drain was explained step by step. Our review identified 6 unilateral and 2 bilateral cases in which 10 surgeon-made drains were used. Mean age of the patients was 72, and mean follow-up period was 7 months, 23 days. No instances of infection or drain-related complications had been recorded. The recurrence rate was 0%, and the average drainage period was 3.4 days.

CONCLUSIONS: In case of unavailability of a preformed drain, a surgeon-made drain can be used during CSDH surgery. Different methods are available and can be further diversified using various combinations of simple medical materials.

A Systematic Review of the Management of Trigeminal Neuralgia in Patients with Multiple Sclerosis

World Neurosurg. (2018) 111:291-306

Patients with trigeminal neuralgia (TN) and multiple sclerosis (MS) are often treated with medications or a surgical procedure. However, there is little evidence that such treatments result in 50% pain reduction and improvement in quality of life. The aim of this systematic review is to evaluate the clinical effectiveness of treatments in patients with MS and trigeminal neuralgia.

METHODS: We searched Medline, EMBASE, and the Cochrane Collaboration database from inception until October 2016. Two authors independently selected studies for inclusions, data extraction, and bias assessment.

RESULTS: All studies were of low quality using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. For medical management, 10 studies were included, of which one was a randomized controlled trial. Two studies were on the use of misopropol, unique to patients with MS. For surgical therapy, 26 studies with at least 10 patients and a minimum of 2 years follow-up were included. All types of surgical procedures are reported and the results are poorer for TN with MS, with 50% having a recurrence by 2 years. The main complication was sensory loss. Many patients had to undergo further procedures to become pain free and there were no agreed prognostic factors.

CONCLUSIONS: There was insufficient evidence to support any 1 medical therapy and so earlier surgery may be preferable. A patient with TN and MS has therefore to make a decision based on low-level evidence, beginning with standard drug therapy and then choosing a surgical procedure.

Endoscopic endonasal resection of the odontoid process

J Neurosurg 128:923–931, 2018

Treatment of odontoid disease from a ventral corridor has consisted of a transoral approach. More recently, the endoscopic endonasal approach (EEA) has been used to access odontoid pathology.

METHODS A retrospective review was conducted of patients who underwent an EEA for odontoid pathology from 2004 to 2013. During our analysis, the mean follow-up duration was 42.6 months (range 1–80 months). Patient outcomes, complications, and postoperative swallowing function were assessed either by clinic visit or phone contact.

RESULTS Thirty-four patients underwent an EEA for symptomatic odontoid pathology. The most common pathology treated was basilar invagination (n = 17). Other pathologies included odontoid fractures, os odontoideum, and metastatic carcinoma. The mean patient age was 71.5 years. Thirty-one patients underwent a posterior fusion. All 34 patients experienced stability or improvement in symptoms and all had successful radiographic decompression. The overall complication rate was 76%. Nearly all of these complications were transient (86%) and the overall complication rate excluding mild transient dysphagia was only 44%. Twenty-one patients (62%) suffered from transient postoperative dysphagia: 15 cases were mild, transient subjective dysphagia (6 of whom had documented preoperative dysphagia), whereas 6 other patients required tube feedings for decreased oral intake, malnutrition, and dysphagia in the perioperative setting (5 of these patients had documented preoperative dysphagia). Sixteen patients had documented preoperative dysphagia and 6 of these had lower cranial nerve dysfunction. Postoperatively, 6 (37.5%) of 16 patients with preoperative dysphagia and 4 (67%) of 6 with lower cranial nerve dysfunction had significant dysphagia/respiratory complications. Eighteen patients had no documented preoperative dysphagia and only 2 had significant postoperative dysphagia/respiratory complications (11%). The rates of these complications in patients without preoperative dysphagia were lower than in those with any preoperative dysphagia (p = 0.07) and especially those with preexisting lower cranial neuropathies (p = 0.007). Dysphagia was also significantly more common in patients who underwent occipitocervical fixation (19/26, 73%) than in patients who underwent cervical fusion alone or no fusion (2/8, 25%; p = 0.02). All patients with perioperative dysphagia had improved at follow-up and all patients were tolerating oral diets. No patient suffered from velopalatal insufficiency. Two patients had intraoperative CSF leaks. One of these patients underwent a negative exploratory surgery for a questionable postoperative CSF leak. One patient developed infection in the resection bed requiring debridement and antibiotics. One patient died 8 days following surgery from an unknown cause. The 90-day perioperative mortality rate was 2.9%.

CONCLUSIONS A completely EEA can be performed for compressive odontoid disease in all cases of neoplastic, degenerative, or invaginative atlantoaxial disease with satisfactory outcomes and low morbidity. Transient perioperative dysphagia and respiratory complications are common, usually as an exacerbation and reflection of underlying disease or occipitocervical fusion rather than the EEA, emphasizing the importance of avoiding transoral surgery.

Massive Brain Swelling and Death After Cranioplasty: A Systematic Review

World Neurosurg. (2018) 111:99-108.

Although cranioplasty is a common procedure, it may cause a variety of complications. Massive brain swelling after cranioplasty (MBSC) is an unusual complication that has been reported more frequently in recent years. Most of the existing information about this condition is speculative and the cause remains unclear.

METHODS: A PubMed and Scopus search adhering to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed to include studies reporting patients with MBSC. Different information was analyzed in these cases to describe the characteristics and identify risk factors for MBSC.

RESULTS: The search yielded 19 articles with a total of 26 patients. All studies were case reports and small case series. In most patients, preoperative intracranial hypotension and a considerable degree of sinking of skin flap were identified; this was the only constant finding observed in these cases. In addition, we propose a grading system to estimate the degree of preoperative sinking of skin flap and an algorithm with recommendations to decrease the incidence of MBSC.

CONCLUSIONS: MBSC is an unusual, highly lethal, and probably underreported condition. The information gathered in this review indicates that MBSC occurs secondary to a cascade of pathologic events triggered by the bone flap implantation. This evidence suggests that the primary pathologic change is a sudden increase in the intracranial pressure acting on a brain chronically exposed to intracranial hypotension.

Lumbar Disk Arthroplasty for Degenerative Disk Disease

World Neurosurg. (2018) 109:188-196.

Low back pain is the principal cause of long-term disability worldwide. We intend to address one of its main causes, degenerative disk disease, a spinal condition involving degradation of an intervertebral disk.

Following unsuccessful conservative treatment, patients may be recommended for surgery. The two main surgical treatments for lumbar degenerative disk disease are lumbar fusion: traditional standard surgical treatment and lumbar disk arthroplasty, also known as lumbar total disk replacement. Lumbar fusion aims to relieve pain by fusing vertebrae together to eliminate movement at the joint, but it has been criticized for problems involving insignificant pain relief, a reduced range of motion, and an increased risk of adjacent segment degeneration. This leads to development of the lumbar total disk replacement technique, which aims to relieve pain replacing a degenerated intervertebral disk with a moveable prosthesis, thus mimicking the functional anatomy and biomechanics of a native intervertebral disk. Over the years a large range of prosthetic disks has been developed.

The efficacy and current evidence for these prostheses are discussed in this review. The results of this study are intended to guide clinical practice and future lumbar total disk replacement device choice and design.

Season’s Greetings

Spine Navigation Based on 3-Dimensional Robotic Fluoroscopy for Accurate Percutaneous Pedicle Screw Placement

World Neurosurg. (2017) 108:76-83.

Minimally invasive spine surgery is associated with obstructed visibility of anatomic landmarks and increased radiation exposure, leading to higher incidence of pedicle screw mispositioning. To address these drawbacks, intraoperative 3-dimensional fluoroscopy (io3DF) and navigation are being increasingly used. We aimed to present our dedicated multifunctional hybrid operating room (HyOR) setup and evaluate the accuracy and safety of io3DF image-guided spinal navigation in transforaminal lumbar interbody fusion with percutaneous pedicle screw (PPS) placement.

METHODS: The HyOR includes a fixed 3D multiaxis robotic fluoroscopy arm that moves automatically to the preprogrammed position when needed. An initial io3DF assessment is performed to collect intraoperative images, which are automatically transferred into the navigation system. These data are used to calibrate the PPSs and insert them under computer-assisted navigation. A second io3DF is performed for verifying PPS position.

RESULTS: Between January 2014 and December 2016, 66 consecutive patients (age, 58.6  14.1 years) were treated for refractory lumbar degenerative pain. Seventy-three spinal levels were treated, and 276 screws were placed, with 4.2 ± 0.76 screws per patient. There was no measurable radiation to the HyOR staff, whereas the mean radiation dose per patient was 378.3  uGym2. The overall accuracy rate of PPS placement was 99.6%. There were no significant procedure-related complications.

CONCLUSIONS: Spine navigation based on io3DF images enabled us to avoid radiation exposure to the operating room team while delivering minimal but sufficient radiation doses to our patients. This approach achieved an accuracy rate of 99.6% for PPS placement in the safe zone, without significant complications.

The predictive value of T-tau and AB1-42 levels in idiopathic normal pressure hydrocephalus

Acta Neurochir (2017) 159:2293–2300

Idiopathic normal pressure hydrocephalus (INPH) has no reliable biomarker to assist in the selection of patients who could benefit from ventriculo-peritoneal (VP) shunt insertion. The neurodegenerative markers Ttau and Aβ1-42 have been found to successfully differentiate between Alzheimer’s disease (AD) and INPH and therefore are candidate biomarkers for prognosis and shunt response in INPH. The aim of this study was to test the predictive value of cerebrospinal fluid (CSF) T-tau and Aβ1-42 for shunt responsiveness. In particular, we pay attention to the subset of INPH patients with raised T-tau, who are often expected to be poor surgical candidates.

Methods: Single-centre retrospective analysis of probable INPH patients with CSF samples collected from 2006 to 2016. Index test: CSF levels of T-tau and Aβ1-42. Reference standard: postoperative outcome. ROC analysis assessed the predictive value.

Results: A total of 144 CSF samples from INPH patients were analysed. Lumbar T-tau was a good predictor of postoperative mobility (AUROC 0.80). The majority of patients with a co-existing neurodegenerative disease responded well, including those with high T-tau levels.

Conclusion: INPH patients tended to exhibit low levels of CSF T-tau, and this can be a good predictor outcome. However levels are highly variable between individuals. Raised T-tau and being shunt-responsive are not mutually exclusive, and such patients ought not necessarily be excluded from having a VP shunt.A combined panel of markers may be a more specific method for aiding selection of patients for VP shunt insertion. This is the most comprehensive presentation of CSF samples from INPH patients to date, thus providing further reference values to the current literature.

Interactive iBook-Based Patient Education in a NeuroTrauma Clinic

Neurosurgery 81:787–794, 2017

Traumatic brain injury (TBI) is a leading cause of death and disability in the United States. Educational interventions may alleviate the burden of TBI for patients and their families. Interactive modalities that involve engagement with the educational material may enhance patient knowledge acquisition when compared to static text-based educational material.

OBJECTIVE: To determine the effects of educational interventions in the outpatient setting on self-reported patient knowledge, with a focus on iPad-based (Apple, Cupertino, California) interactive modules.

METHODS: Patients and family members presenting to a NeuroTrauma clinic at a tertiary care academic medical center completed a presurvey assessing baseline knowledge of TBI or concussion, depending on the diagnosis. Subjects then received either an interactive iBook (Apple) on TBI or concussion, or an informative pamphlet with identical information in text format. Subjects then completed a postsurvey prior to seeing the neurosurgeon.

RESULTS: All subjects (n = 152) significantly improved on self-reported knowledge measures following administration of either an iBook (Apple) or pamphlet (P < .01, 95% confidence interval [CI]). Subjects receiving the iBook (n = 122) performed significantly better on the postsurvey (P < .01, 95% CI), despite equivalent presurvey scores, when compared to those receiving pamphlets (n = 30). Lastly, patients preferred the iBook to pamphlets (P < .01, 95% CI).

CONCLUSION: Educational interventions in the outpatient NeuroTrauma setting led to significant improvement in self-reported measures of patient and family knowledge. This improved understanding may increase compliance with the neurosurgeon’s recommendations and may help reduce the potential anxiety and complications that arise following a TBI.

Neurosurgery Department. “La Fe” University Hospital. Valencia, Spain


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