安东de Haen(1704 - 1776)成为最我之一nfluential physicians in the Habsburg Empire as a reformer of clinical instruction at Vienna Citizen’s Hospital (Bürgerspital), where he introduced the bedside teaching method he had learned from Herman Boerhaave in Leyden, Holland. He also promoted the meticulous recording of clinical observations and the use of postmortem studies to identify the cause of death in hospitalized patients. Among the numerous clinicopathological reports compiled in his monumental 18-volume workRationis Medendi in Nosocomio Practico, published in 1761, was the first documented patient with amenorrhea caused by a pituitary tumor, appearing in the 6th volume. This 20-year-old amaurotic woman, who had suffered from chronic excruciating headache, died after the unsuccessful application of a cauterizing iron to her temporal bone. At the autopsy, a large solid-cystic and calcified tumor with gross characteristics typical of adamantinomatous craniopharyngioma was found encroaching on the infundibulum and third ventricle. This is the first known account of an infundibulo-tuberal lesion associated with the impairment of sexual functions, predating by 140 years the pathological evidence for a sexual brain center sited at the basal hypothalamus. In this paper, the authors analyze the historical importance and impact of de Haen’s foundational report on the fields of neuroendocrinology and neurosurgery.
José María Pascual, Ruth Prieto, Maria Rosdolsky, and Verena Hofecker
Karam Asmaro, Michael Zhang, Adrian J. Rodrigues, Ahmed Mohyeldin, Vera Vigo, Kerem Nernekli, Hannes Vogel, Donald E. Born, Laurence Katznelson, and Juan C. Fernandez-Miranda
OBJECTIVE
Pituitary tumors (PTs) continue to present unique challenges given their proximity to the cavernous sinus, whereby invasive behavior can limit the extent of resection and surgical outcome, especially in functional tumors. The aim of this study was to elucidate patterns of cavernoinvasive behavior by PT subtype.
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A total of 169 consecutive first-time surgeries for PTs were analyzed; 45% of the tumors were functional. There were 64 pituitary transcription factor–1 (PIT-1)–expressing, 62 steroidogenic factor–1 (SF-1)–expressing, 38 T-box transcription factor (TPIT)–expressing, and 5 nonstaining PTs. The gold standard for cavernous sinus invasion (CSI) was based on histopathological examination of the cavernous sinus medial wall and intraoperative exploration.
RESULTS
Cavernous sinus disease was present in 33% of patients. Of the Knosp grade 3 and 4 tumors, 12 (19%) expressed PIT-1, 7 (11%) expressed SF-1, 8 (21%) expressed TPIT, and 2 (40%), were nonstaining (p = 0.36). PIT-1 tumors had a significantly higher predilection for CSI: 53% versus 24% and 18% for TPIT and SF-1 tumors, respectively (OR 6.08, 95% CI 2.86–13.55; p < 0.001). Microscopic CSI—defined as Knosp grade 0–2 tumors with confirmed invasion—was present in 44% of PIT-1 tumors compared with 7% and 13% of TPIT and SF-1 tumors, respectively (OR 11.72, 95% CI 4.35–35.50; p < 0.001). Using the transcavernous approach to excise cavernous sinus disease, surgical biochemical remission rates for patients with acromegaly, prolactinoma, and Cushing disease were 88%, 87%, and 100%, respectively. The granule density of PIT-1 tumors and corticotroph functional status did not influence CSI.
CONCLUSIONS
The likelihood of CSI differed by transcription factor expression; PIT-1–expressing tumors had a higher predilection for invading the cavernous sinus, particularly microscopically, compared with the other tumor subtypes. This elucidates a unique cavernoinvasive behavior absent in cells from other lineages. Innovative surgical techniques, however, can mitigate tumor behavior and achieve robust, reproducible biochemical remission and gross-total resection rates. These findings can have considerable implications on the surgical management and study of PT biology and behavior.
Youxuan Wu, Fa Lin, Yang Bai, Fa Liang, Xinyan Wang, Bo Wang, Minyu Jian, Yunzhen Wang, Haiyang Liu, Anxin Wang, Xiaolin Chen, and Ruquan Han
OBJECTIVE
Stellate ganglion block (SGB) is a commonly used sympathetic nerve block technique that may have benefits for patients with aneurysmal subarachnoid hemorrhage (aSAH) in the early stage. Cerebral vasospasm (CVS), one of the most common complications of aSAH, is accompanied by an abnormal increase in cerebral blood flow velocity (CBFV) and neurological dysfunction. In this pilot study the authors sought to determine the feasibility of early SGB for CVS in aSAH patients by observing the incidence of symptomatic CVS.
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Prior to receiving surgical treatment, patients with aSAH were randomly assigned to the SGB group or the non-SGB group. The primary outcome was the incidence of symptomatic CVS within 14 ± 2 days after the onset of aSAH. As a higher CBFV is often associated with CVS and a poor prognosis, the mean CBFV of the middle cerebral artery was observed immediately after surgery and on postoperative days 1, 2, 3, 5, and 7. Other secondary outcomes included transcranial Doppler (TCD)/CTA-type CVS, delayed cerebral ischemia during hospitalization, new cerebral infarction within 3 months, adverse events (AEs), and clinical prognosis.
RESULTS
Symptomatic CVS occurred in 40% of patients in the non-SGB group and in 20% in the SGB group (RR 0.50, 95% CI 0.22–1.16). Continuous TCD sonography revealed that the postoperative mean CBFV was lower in the SGB group than in the non-SGB group (F = 3.608, p = 0.02). In addition, the percentages of patients with CVS evaluated by TCD (TCD-CVS) and total new infarctions within 3 months were also significantly lower than those in patients with CVS (TCD-CVS 36.7% vs 70%, RR 0.52, 95% CI 0.31–0.89, and total new infarctions 26.7% vs 53.3%, RR 0.50, 95% CI 0.25–0.99). In terms of AEs and mortality, there were no significant differences between the two groups.
CONCLUSIONS
This pilot study demonstrated for the first time, to the authors’ knowledge, that early SGB is feasible and has the potential to reduce the risk of CVS and improve the prognosis of aSAH. This method may be a new treatment for patients with aSAH that may have more advantages than traditional therapeutic drugs and is worth further study.
Clinical trial registration no.: NCT04691271 (ClinicalTrials.gov)
Fred G. Barker II and James T. Rutka
Smruti K. Patel, Sara Hartnett, Amber Gaulden, Mridula Bethi, Mounira A. Habli, David N. McKinney, Foong Y. Lim, Jose L. Peiro, and Charles B. Stevenson
OBJECTIVE
The aim of this study was to evaluate the incidence of spinal inclusion cyst (sIC) formation after open fetal myelomeningocele (fMMC) repair and the effect of dural patch closure.
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作者进行了retrospective review of patients who underwent open fMMC repair at their institution between March 2011 and June 2020. All patients met the criteria for intervention defined by the Management of Myelomeningocele Study (MOMS). The primary outcomes investigated were development of sIC and need for surgical intervention. Secondary outcomes included need for CSF diversion, extent of reversal of hindbrain herniation, and ambulatory status.
RESULTS
56个病人打开fMMC修复,52岁had adequate spinal imaging for review. Twelve of these patients (23%) developed sIC (95% CI 0.11–0.35). Six patients experienced symptoms and required surgical detethering with sIC resection. Six additional patients had evidence of sIC on surveillance MRI but remained asymptomatic. The authors found a statistically significant relationship between the use of a dural allograft patch and sIC formation (p = 0.05). In terms of sIC development, there was no statistically significant difference between patients who underwent primary closure and those who received an allograft at the level of the fascia (p = 0.34) or skin (p = 0.26). The rate of hydrocephalus requiring CSF diversion was 52%. Interestingly, 98% of patients had improvement in extent of hindbrain herniation. Dural patch closure did not have any effect on the rate of progressive hydrocephalus (p = 0.33) or degree of reversal of hindbrain herniation (p > 0.99).
CONCLUSIONS
This study suggested that children with prenatally repaired MMC are at higher risk for development of sIC and associated symptoms than those who undergo postnatal repair. The presentation of symptoms was also earlier in these patients than previously reported after postnatal repair. The use of a dural allograft patch appears to have a positive correlation with sIC formation. Future investigations evaluating the incidence of sIC after fetoscopic MMC repair, in which primary dural closure typically cannot be achieved and a dural patch is most often utilized, will be helpful in facilitating prenatal counseling for patients considering fetal intervention.
Nikolaos Tachatos, Sandra Fernandes Dias, Elisabeth Jehli, Dennis Lübben, Martin Ulrich Schuhmann, and Marianne Schmid Daners
OBJECTIVE
Infants and small children face changing boundary conditions when treated with a ventriculoperitoneal shunt (VPS) for hydrocephalus. There are no systematic data describing shunt drainage behavior and changes over time in a growing child. Using a child-adapted patient simulator, the authors investigated the drainage behaviors of fixed differential pressure (DP) valves and adjustable valves with devices for preventing overdrainage in children of different ages.
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Three miniNAV DP valves with a 10–cm H2O medium-pressure setting (MN10) and three adjustable proGAV2.0 valves with a 25–cm H2O gravitational unit (GU) at low 5–cm H2O opening pressure (PG5) and medium 10–cm H2O开启压力(PG10)设置都探讨了tigated with a hardware-in-the-loop test bed. This test bed consisted of a posture motion mechanism and two pressure compartments that mimicked intracranial and abdominal pressures and was used to test the VPS under realistic in vitro conditions. Body orientation and length were physically set according to the child’s age. The software simulated the physiological situations of children aged 1, 5, and 10 years. All valves were tested according to these specifications, with 5 runs for 1 hour each in the horizontal, vertical, and horizontal positions. Intracranial pressure (ICP) and VPS flow were measured, and the respective cerebrospinal fluid volume changes and ICP set value were computed.
RESULTS
The drainage parameters increased with age in all valves in the vertical position, with that of MN10 being pronounced in the 1-year-old simulation. The GU values in PG5 and PG10 substantially reduced drainage compared with MN10. PG10 prevented drainage in the 1-year-old and 5-year-old setups, but there was some drainage at physiological ICP in the 10-year-old setup. In contrast, MN10 produced the largest decreases in ICP across all ages and positions, and overdrainage resulted in insufficient ICP recovery in the subsequent horizontal position. ICP levels were mostly constant with PG10 at all ages.
CONCLUSIONS
This study shows that unprotected DP valves may lead to overdrainage in infants, whereas low-pressure GU valves can prevent overdrainage through 5 years and medium-pressure GU valves admit physiological ICP through at least 10 years. Therefore, devices for preventing overdrainage should be included in the first implanted shunt, and opening pressure should be adjusted as the child grows.
Ken Porche, Sandra C. Yan, Yusuf Mehkri, Sai Sriram, Andrew MacNeil, Kaitlyn Melnick, Cynthia Garvan, Sasha Vaziri, Christoph Seubert, Gregory Murad, Matthew Decker, Adam Polifka, Daniel J. Hoh, and Basma Mohamed
OBJECTIVE
The Enhanced Recovery After Surgery (ERAS) protocol is a comprehensive, multifaceted approach aimed at improving postoperative outcomes. It incorporates a range of strategies to promote early and more effective recovery, including reducing pain, complications, and length of stay, without increasing readmission rate. To date, ERAS for spine surgery patients has been primarily limited to lumbar surgery and anterior cervical decompression and fusion (ACDF). ERAS has not been previously studied for posterior cervical surgery, which may present a greater opportunity for improvement in patient outcomes with ERAS than ACDF. This single-institution, multi-surgeon study assessed the impact of an ERAS protocol in patients undergoing posterior cervical decompression surgery.
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This study included a retrospective consecutive patient cohort with controls that were propensity matched for age, body mass index, sex, home opioid use, surgical levels, Nurick grade, and smoking status. In addition, consecutive patients who underwent posterior cervical decompression surgery for degenerative disease from December 2014 to December 2021 were included. ERAS was implemented in December 2018. Demographic, perioperative, clinical, and radiographic information was gathered. Regression models were created to evaluate length of stay, physiological function, pain levels, and opioid use. The primary focus was length of stay, with secondary outcomes including timing of ambulation, bowel movement, and voiding; daily pain scores; opioid consumption; discharge status; 30-day readmission rates; and reoperation rates.
RESULTS
There were 366 patients included in the study, all of whom were included in multivariate models, and 254 (127 in each cohort) were included on the basis of matching. After propensity matching, patient characteristics, operative procedures, and operative duration were similar between groups. The ERAS cohort had a significantly improved length of stay (3.2 vs 4.7 days, p < 0.0001) and home discharge rate (80% vs 50%, p < 0.001) without an increase in readmission rate. The ERAS cohort had an earlier day of the first ambulation (p = 0.003), bowel movement (p = 0.014), and voiding (p = 0.001). ERAS demonstrated a significantly lower composite complication rate (1.1 vs 1.8, p < 0.0001). ERAS resulted in better maximum pain scores (p = 0.043) and trended toward improved mean pain scores (p = 0.072), although total opioid use was similar.
CONCLUSIONS
Implementing a novel ERAS protocol significantly improved length of stay, return of physiological function, home discharge, complications, and maximum pain score after posterior cervical surgery.
Weibo Yu, Xiaobing Jiang, Haiyan Zhang, Zhensong Yao, Yuanming Zhong, Fubo Tang, and Daozhang Cai
OBJECTIVE
Recompression of augmented vertebrae (RCAV) is often seen after percutaneous kyphoplasty (PKP), especially at the thoracolumbar junction. The authors aimed to develop and validate a risk prediction model (nomogram) for RCAV and to evaluate the efficacy of a modified puncture technique for RCAV prevention after PKP for thoracolumbar osteoporotic vertebral fractures (OVFs).
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Patients who underwent PKP for single thoracolumbar OVFs (T10–L2) between January 2016 and October 2020 were reviewed and followed up for at least 2 years. All patients were randomly divided into a training group (70%) and a validation group (30%). Relevant potential data affecting recompression were collected. Predictors were screened by using binary logistic regression analysis to construct the nomogram. Calibration and receiver operating characteristic curves were used to evaluate the consistency of the prediction models. Finally, the efficacy of the modified puncture technique for prevention of RCAV in OVF patients with a preoperative intravertebral cleft (IVC) was further demonstrated through binary logistic regression analysis.
RESULTS
Overall, 394 patients were included and 116 of them (29.4%) sustained RCAV. The independent risk factors included decreased bone mineral density, lower level of serum 25-hydroxy vitamin D3, larger C7–S1 sagittal vertical axis (SVA), preoperative IVC, and solid-lump cement distribution. The area under the curve (AUC) of the prediction model was 0.824 in the training group and 0.875 in the validation group patients. The calibration curve indicated the predictive power of this nomogram, with the preoperative IVC having the highest prediction accuracy (AUC 0.705). The modified puncture technique significantly reduced the incidence of RCAV by enhancing bone cement distribution into a sufficiently diffused distribution in OVF patients with preoperative IVC.
CONCLUSIONS
The nomogram prediction model had satisfactory accuracy and clinical utility for identification of patients at low and high risk of postoperative RCAV. Patients at high risk of postoperative RCAV might benefit from the target puncture technique and vitamin D supplementation as well as effective antiosteoporotic therapies.
Alejandro Enriquez-Marulanda, Michael M. Young, and Philipp Taussky
颅内动脉瘤治疗revolutionized over the last decade with the development of flow diversion technology. The use of this technology has evolved rapidly and has proven that cerebrovascular disease treatment remains one of the forefront innovation areas in neurosurgery. The good results on the treatment of internal carotid artery aneurysms up to the communicating segment have motivated the use of flow diversion beyond the circle of Willis and in the posterior circulation. Further advances and innovations of flow-diverting devices are underway and intended to improve the safety and efficacy of this therapy. This review article provides a detailed discussion about the origin, mechanism of action, initial experience, complications, types of devices, and future perspectives of flow diversion technology.
