Microvascular Decompression for Trigeminal Neuralgia: A Prospective, Multicenter Study

Neurosurgery 89:557–564, 2021

Microvascular decompression (MVD) is the most effective procedure for the long-term management of trigeminal neuralgia (TGN). However, retrospective and single-center studies are inherently biased, and there are currently no prospective, multi- center studies.

OBJECTIVE: To evaluate the short- and long-term outcomes and complications in patients with TGN who underwent MVD at specialized Japanese institutions.

METHODS: We enrolled patients with TGN who underwent MVD between April 2012 and March 2015. We recorded their facial pain grade and complications at 7 d (short term), 1 yr (mid-term), and 3 yr (long term) postoperatively.

RESULTS: There were 166 patients, comprising 60 men and 106 women (mean age 62.7 yr). Furthermore, 105 patients were aged over 60 yr. We conducted neuromonitoring in 84.3% of the cases. The complete pain relief, mortality, and complication rates at the short-term follow-up were 78.9%, 0%, and 16.3%, respectively. Overall, 155 patients (93.4%) completed the long-term follow-up, with the complete pain relief and complication rates of 80.0% and 5.2%, respectively.

CONCLUSION: In the hands of experienced neurosurgeons, MVD for TGN can achieve high long-term curative effects. In addition, complications are uncommon and usually transient. Our results indicate that MVD is an effective and safe treatment for patients with TGN, including elderly patients.

Is surgical resection useful in elderly newly diagnosed glioblastoma patients?

Acta Neurochirurgica (2018) 160:1779–1787

The incidence of glioblastoma among elderly patients is constantly increasing. The value of radiation therapy and concurrent/adjuvant chemotherapy has been widely assessed. So far, the role of surgery has not been thoroughly investigated. The study aimed to evaluate safety and impact of several entities of surgical resection on outcome of elderly patients with newly diagnosed glioblastoma treated by a multimodal approach.

Methods Patients ≥ 65 years, underwent surgery were included. The extent of surgical resection (EOR) was defined as complete resection (CR = 100%), gross total resection (GTR = 90–99%), sub-total resection (STR = 78–90%), partial resection (PR = 30– 78%), and biopsy. After surgery, all patients received adjuvant radiotherapy (60/2 Gy fraction) with concomitant/adjuvant temozolomide chemotherapy.

Results From March 2004 to December 2015, 178 elderly with a median age of 71 years (range 65–83 years) were treated. CR was obtained in 8 (4.5%), GTR in 63 (35.4%), STR in 46 (25.8%), PR in 16 (9.0%), and biopsy in 45 (25.3%). RTwas started in all patients, concurrent/adjuvant CHTin 149 (83.7%) and 132 (74.2%). The median follow-up time was 12.2 months (range 0.4– 50.4 months). The median, 1- and 2-year progression-free survival was 8.9 months (95%CI 7.8–100 months), 32.0 ± 3.5%, and 12.9 ± 2.6%. The median, 1- and 2-year overall survival were 12.2 (95%CI 11.3–13.1 months), 51.1 ± 3.7%, and 16.3 ± 2.9%. Tumor location, extent of resection, and neurological status after surgery statistically affected survival (p ≪ 0.01).

Conclusion Maximal surgical resection is safe and feasible in elderly patients with influence on survival. A preoperative evaluation has to be carried out.

Early Postoperative Complications for Elderly Patients Undergoing Single-Level Decompression for Lumbar Disc Herniation, Ligamentous Hypertrophy, or Neuroforaminal Stenosis

Neurosurgery 81:1005–1010, 2017

Lumbar decompression for disc herniation is frequently performed on elderly patients, and this trend will continue as the population ages. Clinical reports on the complications of lumbar discectomy show good results and cost effectiveness in young or middle-aged patients.

OBJECTIVE: To assess and compare the morbidity of single-level lumbar disc surgery for radicular pain in a cohort of patients greater than 80 yr of age to that of a middle-aged cohort.

METHODS: A total of 9451 patients who received a single-level lumbar decompression procedure for disc displacement without myelopathy were retrospectively selected from a multicenter validated surgical database from the American College of Surgeons National Surgical Quality Improvement Program. A cohort with 485 patients greater than 80 yr of age (80+) was compared with a middle-aged cohort with 8966 patients between 45 and 65 yr. Preoperative comorbidity and postoperative outcome variables observed included mortality, myocardial infarction, return to the operating room, sepsis, deep vein thrombosis, transfusions, cardiac arrest necessitating cardiopulmonary resuscitation, coma greater than 24 h, urinary tract infection, acute renal failure, use of ventilator greater than 24 h, pulmonary embolism, pneumonia, wound dehiscence, and postoperative infection.

RESULTS: The preoperative comorbidities and characteristics were significantly different between the middle-aged and the 80+ cohorts, with the older cohort having many more preoperative comorbidities. There was statistically significantly greater postoperative morbidity among the 80+ cohort regarding pulmonary embolism (0.8% vs 0.2%, P = .037), intra/postoperative transfusion requirement (1.9% vs 0.7%, P = .01), urinary tract infection (1.2% vs 0.3%, P = .011), and 30-d mortality (0.4% vs 0.1%, P = .046).

CONCLUSION: In this large sample of patients who received a single-level lumbar decompression procedure for disc displacement without myelopathy, elderly patients, particularly with American Society of Anesthesiologists class 3 and 4, had a statistically significant increase in morbidity and mortality, but the overall risk of complications remains low.

 

Endoscopic hematoma evacuation for acute and subacute subdural hematoma in elderly patients

Endoscopic hematoma evacuation for acute and subacute subdural hematoma in elderly patients

J Neurosurg 123:1065–1069, 2015

Endoscopic surgery was performed for acute or subacute subdural hematoma (SDH), and its effectiveness and safety in elderly patients were evaluated.

Methods Between September 2007 and November 2013, endoscopic surgery was performed in 11 elderly patients with acute SDH (8 patients) and subacute SDH (3 patients). The criteria for surgery were as follows: 1) the presence of clinical symptoms; 2) age older than 70 years; 3) no brain injury (intracerebral hematoma, brain contusion); 4) absence of an enlarging SDH; and 5) no high risk of bleeding. Hematoma evacuation was performed with a 4-mm rigid endoscope with a 0° lens and a malleable irrigation suction cannula.

Results Endoscopic surgery was performed under local anesthesia. The mean age of the patients was 82.6 years (range 73–91 years). There were 5 female and 6 male patients. The mean preoperative Glasgow Coma Scale score was 12, and 5 patients had been receiving antithrombotic drug therapy. The mean operation time was 85 minutes. Only 1 patient had rebleeding, and reoperation with the same technique was performed uneventfully in this individual. A total of 7 patients had a good recovery (modified Rankin Scale Score 0–2) at discharge.

Conclusions Endoscopic hematoma evacuation of acute and subacute SDH is a safe and effective method of clot removal that minimizes operative complications. This technique may be a less invasive method for treating elderly patients with acute and subacute SDHs.

Can Elderly Patients Recover Adequately After Laminoplasty?

Spine 2012 ; 37 : 667 – 671 

This was a prospective clinical comparative study of surgical outcomes for patients with cervical spondylotic myelopathy (CSM).

Objective. The purpose of this study was to compare the surgical outcomes between nonelderly and elderly patients with CSM who underwent laminoplasty.

Summary of Background Data. Age at the time of surgery influences the surgical outcome. We designed a large-scale study of the surgical outcome for CSM from a single operative procedure used exclusively in elderly patients.

Methods. A total of 520 consecutive patients with CSM (331 men; 189 women) who underwent double-door laminoplasty were included. Mean age was 62 years (range, 23–93), and mean duration of disease was 20.1 ± 32.0 months. Average postoperative followup period was 33.3 ± 15.7 months. Patients were divided into 3 groups by age: nonelderly ( < 65 years), young-old (65–74 years), and old-old ( ≥ 75 years). The number of patients in each group was 287, 143, and 90. Pre- and postoperative neurological status was evaluated using the Japanese Orthopaedic Association scoring system for cervical myelopathy (JOA score).

Results. Mean pre- and postoperative JOA scores in nonelderly, young-old, and old-old groups were 11.0 and 14.4, 10.2 and 13.2, and 8.7 and 11.8 points, respectively. The elderly group showed significantly low recovery rates of JOA scores compared with the nonelderly group ( P < 0.0001). However, mean achieved JOA scores (postoperative JOA score − preoperative JOA score) were 3.4, 3.0, and 3.1 in nonelderly, young-old, and old-old groups, respectively, with no significant difference among these groups ( P = 0.17).

Conclusion. Pre- and postoperative JOA scores were low in elderly patients. However, the achieved JOA score was almost similar among the 3 groups. Thus, elderly patients could obtain reasonable recovery after cervical laminoplasty.