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World Neurosurgery Apr 2021The anatomy and spatial relationships of the dural sac comprising the Meckel cave (MC) and its ensheathed trigeminal ganglion (TG) are exceedingly intricate and complex....
BACKGROUND
The anatomy and spatial relationships of the dural sac comprising the Meckel cave (MC) and its ensheathed trigeminal ganglion (TG) are exceedingly intricate and complex. There are conflicting accounts in the literature regarding the dural configuration of the MC around the ganglion and the dual embryology of the MC and TG is still unclear.
METHODS
A combined systematic and narrative literature review was conducted to collate articles addressing MC and TG anatomy, in addition to their embryology, role in tumor spread, somatotopy, and association with trigeminal neuralgia.
RESULTS
Three key anatomic models by Paturet (1964), Lazorthes (1973), and Lang and Ferner (1983) have been put forward to show the arrangement of the MC around the TG. The TG is formed from both neural crest and placodal cells and drags the enveloping dura caudally to form the MC prolongation during development. Both a mediolateral and dorsoventral somatotopic arrangement of neurons exists in the TG, which corresponds to the 3 nerve divisions, of which V2 and V3 are prone to perineural tumor spread along their course.
CONCLUSIONS
Sound knowledge concerning the dural arrangement of the MC and the trigeminal divisions will be invaluable in optimally treating cancers in this region, and understanding TG somatotopy will immensely improve treatment of trigeminal neuralgia in terms of specificity, efficacy, and positive patient outcomes.
Topics: Cranial Fossa, Posterior; Dura Mater; Humans; Neurosurgical Procedures; Trigeminal Ganglion; Trigeminal Neuralgia
PubMed: 33516868
DOI: 10.1016/j.wneu.2021.01.081 -
World Neurosurgery Oct 2023Hemostasis is crucial in preventing hemorrhage during cranial neurosurgical procedures and maintaining visualization of the surgical field. There is significant... (Review)
Review
BACKGROUND
Hemostasis is crucial in preventing hemorrhage during cranial neurosurgical procedures and maintaining visualization of the surgical field. There is significant variation in the availability of hemostatic methods across different settings and hemostatic techniques are being continuously developed over the decades of practicing neurosurgery. The aim of this article is to provide an outline of the potential methods to achieve hemostasis based on the sequential operative anatomy of a cranial operation.
METHODS
A systematic review was conducted following the PRISMA guidelines. The PubMed database was searched from inception of the database to July 18, 2023. A total of 64 studies were identified fulfilling predefined inclusion criteria, and the risk of bias was assessed using the Joanna Briggs Institute checklists.
RESULTS
Seventy-one hemostatic agents, techniques, tools, and devices were identified, which were then categorized according to the operative phase for which they are indicated. Nine operative anatomic targets were addressed in the sequence in which they are involved during a cranial procedure. For each anatomic target, the following number of hemostatic techniques/agents were identified: 11 for scalp, 3 for periosteum, 10 for skull bone, 11 for dura mater, 9 for venous sinuses, 5 for arteries, 6 for veins, 12 for brain parenchyma, and 4 for cerebral ventricles.
CONCLUSIONS
Depending on the phase of the surgery and the anatomic structure involved, the selection of the appropriate hemostatic method is determined by the source of bleeding. Surgeon awareness of all the potential techniques that can be applied to achieve hemostasis is paramount, especially when faced with operative nuances and difficult-to-control bleeding during cranial neurosurgical procedures.
Topics: Humans; Neurosurgery; Hemostatics; Neurosurgical Procedures; Hemostasis; Skull; Hemostasis, Surgical
PubMed: 37586555
DOI: 10.1016/j.wneu.2023.08.030 -
European Spine Journal : Official... Dec 2022Hirayama syndrome is likely caused by a forward displacement of the posterior dura during cervical flexion leading to changes in the muscles of the fingers and wrist.... (Review)
Review
INTRODUCTION
Hirayama syndrome is likely caused by a forward displacement of the posterior dura during cervical flexion leading to changes in the muscles of the fingers and wrist. The aim of this systematic review was to document the number of reported cases, the necessity of dynamic MRI of the cervical spine and the subsequent treatment.
METHODS AND MATERIALS
A systematic review was conducted and the Pubmed/Medbase, Cochrane, Google, Embase and Ovid database were searched for (Hirayama) AND ((disease) OR (syndrome)). A total of 42 studies were included for analysis reporting 2311 patients.
RESULTS
The mean age was 20.2 ± 2.26 years and predominantly males (92.8%) were identified. On MRI the "snake eyes" appearance of the spinal cord was present in 27.8% and the typical time between onset of symptoms and diagnosis was 41.5 ± 16.4 months. A variety of different treatments have been reported, although there is no substantial evidence that any of them are superior to observation.
CONCLUSION
The delay in diagnosis from initial presentation of symptoms shows that this condition may be underdiagnosed in a variety of cases. Further, this study shows the necessity of either a dynamic MRI in flexion or a static MRI scan in neutral position and in flexion, to identify functional spinal and/or foraminal stenosis for a prompt diagnosis and subsequent treatment.
Topics: Male; Humans; Adolescent; Young Adult; Adult; Female; Spinal Muscular Atrophies of Childhood; Cervical Vertebrae; Neck; Dura Mater; Upper Extremity; Magnetic Resonance Imaging; Muscular Atrophy
PubMed: 35727373
DOI: 10.1007/s00586-022-07279-8 -
Neurosurgical Review Dec 2022Several complications have been reported after the use of grafts for duraplasty following posterior fossa decompression for the treatment of Chiari malformation type I.... (Meta-Analysis)
Meta-Analysis Review
Risk of meningitis after posterior fossa decompression with duraplasty using different graft types in patients with Chiari malformation type I and syringomyelia: a systematic review and meta-analysis.
Several complications have been reported after the use of grafts for duraplasty following posterior fossa decompression for the treatment of Chiari malformation type I. This study aims to investigate the rate of meningitis after posterior fossa decompression using different types of grafts in patients with Chiari malformation type I and associated syringomyelia. The search was conducted using multiple databases, including PubMed, Scopus, Web of Science, and Embase. Data on the rate of meningitis, syrinx change, and rate of reoperation were extracted and investigated. Quality of evidence was assessed using the Newcastle-Ottawa scale. Nineteen studies were included in the final meta-analysis, encompassing 1404 patients and investigating autografts, synthetic grafts, allografts, and xenografts (bovine collagen, bovine pericardium, and pig pericardium). Autografts were associated with the lowest rate of meningitis (1%) compared to allografts, synthetic grafts, and xenografts (2%, 5%, and 8% respectively). Autografts were also associated with the lowest rate of reoperation followed by xenografts, allografts, and synthetic grafts (4%, 5%, 9%, and 10% respectively). On the other hand, allografts were associated with the highest rate of syrinx improvement (83%) in comparison to autografts and synthetic grafts (77%, and 79% respectively). Autografts were associated with the lowest meningitis, reoperation, and syrinx improvement rates. Furthermore, synthetic grafts were associated with the highest reoperation and xenografts with the highest rate of meningitis, whereas allografts were associated with the best syrinx improvement rate and second-best meningitis rate. Future studies comparing autografts and allografts are warranted to determine which carries the best clinical outcome.
Topics: Humans; Animals; Cattle; Swine; Arnold-Chiari Malformation; Syringomyelia; Decompression, Surgical; Dura Mater; Treatment Outcome; Meningitis; Retrospective Studies
PubMed: 36180807
DOI: 10.1007/s10143-022-01873-6 -
Finite element modeling of the human cervical spinal cord and its applications: A systematic review.North American Spine Society Journal Sep 2023Finite element modeling (FEM) is an established tool to analyze the biomechanics of complex systems. Advances in computational techniques have led to the increasing use... (Review)
Review
BACKGROUND CONTEXT
Finite element modeling (FEM) is an established tool to analyze the biomechanics of complex systems. Advances in computational techniques have led to the increasing use of spinal cord FEMs to study cervical spinal cord pathology. There is considerable variability in the creation of cervical spinal cord FEMs and to date there has been no systematic review of the technique. The aim of this study was to review the uses, techniques, limitations, and applications of FEMs of the human cervical spinal cord.
METHODS
A literature search was performed through PubMed and Scopus using the words finite element analysis, spinal cord, and biomechanics. Studies were selected based on the following inclusion criteria: (1) use of human spinal cord modeling at the cervical level; (2) model the cervical spinal cord with or without the osteoligamentous spine; and (3) the study should describe an application of the spinal cord FEM.
RESULTS
Our search resulted in 369 total publications, 49 underwent reviews of the abstract and full text, and 23 were included in the study. Spinal cord FEMs are used to study spinal cord injury and trauma, pathologic processes, and spine surgery. Considerable variation exists in the derivation of spinal cord geometries, mathematical models, and material properties. Less than 50% of the FEMs incorporate the dura mater, cerebrospinal fluid, nerve roots, and denticulate ligaments. Von Mises stress, and strain of the spinal cord are the most common outputs studied. FEM offers the opportunity for dynamic simulation, but this has been used in only four studies.
CONCLUSIONS
Spinal cord FEM provides unique insight into the stress and strain of the cervical spinal cord in various pathological conditions and allows for the simulation of surgical procedures. Standardization of modeling parameters, anatomical structures and inclusion of patient-specific data are necessary to improve the clinical translation.
PubMed: 37636342
DOI: 10.1016/j.xnsj.2023.100246 -
Journal of Neurotrauma Jun 2021The meninges are membranous tissues that are pivotal in maintaining homeostasis of the central nervous system. Despite the importance of the cranial meninges in nervous...
The meninges are membranous tissues that are pivotal in maintaining homeostasis of the central nervous system. Despite the importance of the cranial meninges in nervous system physiology and in head injury mechanics, our knowledge of the tissues' mechanical behavior and structural composition is limited. This systematic review analyzes the existing literature on the mechanical properties of the meningeal tissues. Publications were identified from a search of Scopus, Academic Search Complete, and Web of Science and screened for eligibility according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The review details the wide range of testing techniques employed to date and the significant variability in the observed experimental findings. Our findings identify many gaps in the current literature that can serve as a guide for future work for meningeal mechanics investigators. The review identifies no peer-reviewed mechanical data on the falx and tentorium tissues, both of which have been identified as key structures in influencing brain injury mechanics. A dearth of mechanical data for the pia-arachnoid complex also was identified (no experimental mechanics studies on the human pia-arachnoid complex were identified), which is desirable for biofidelic modeling of human head injuries. Finally, this review provides recommendations on how experiments can be conducted to allow for standardization of test methodologies, enabling simplified comparisons and conclusions on meningeal mechanics.
Topics: Animals; Arachnoid; Biomechanical Phenomena; Brain; Dura Mater; Humans; Meninges; Pia Mater
PubMed: 33191848
DOI: 10.1089/neu.2020.7288 -
Neurosurgical Review Jun 2021Chiari malformation type I is a developmental abnormality with an array of surgical techniques introduced for the management of it. The most common technique is foramen... (Comparative Study)
Comparative Study Meta-Analysis
Chiari malformation type I is a developmental abnormality with an array of surgical techniques introduced for the management of it. The most common technique is foramen magnum decompression with duraplasty. Dura-splitting technique as one of the non-dura-opening techniques is a less known procedure that spares the internal layer of the dura and can theoretically result in fewer complications compared to duraplasty. So, we performed a review of literature and meta-analysis on different clinical and radiological aspects of this technique and compared its outcomes to duraplasty. MOOSE guidelines were followed. A systematic search of three databases based on predefined search strategy and inclusion/exclusion criteria was performed. After quality assessment and data extraction by two authors, summarized data were presented in form of tables, and meta-analysis results were illustrated in forest plots. A review of 10 included studies consisting of 370 patients revealed significantly shorter operation duration and less intraoperative blood loss in the dura-splitting technique compared to duraplasty. Interestingly, there was no significant difference between these two techniques in terms of clinical and radiological outcomes. Overall complication rate and incidence of CSF-related complications or infections were significantly in favor of the dura-splitting technique. Dura-splitting technique can be considered as a safe and effective surgical procedure for Chiari I malformation with comparable outcomes and fewer complications compared to duraplasty, although this interpretation is derived from retrospective observational studies and lack of a prospective clinical trial is evident.
Topics: Arnold-Chiari Malformation; Blood Loss, Surgical; Databases, Factual; Decompression, Surgical; Dura Mater; Foramen Magnum; Humans; Observational Studies as Topic; Plastic Surgery Procedures; Retrospective Studies; Treatment Outcome
PubMed: 32567026
DOI: 10.1007/s10143-020-01334-y -
World Neurosurgery Feb 2022Chronic subdural hematoma (CSDH) is a neurologic condition characterized as a hematoma in the subdural space with a period >3 weeks that primarily affects the elderly.... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Chronic subdural hematoma (CSDH) is a neurologic condition characterized as a hematoma in the subdural space with a period >3 weeks that primarily affects the elderly. Glucocorticoid, especially dexamethasone, either alone or combined with surgery, has been used to manage CSDH. We aimed to perform an updated systematic review and meta-analysis of the literature regarding the role of steroids in CSDH.
METHODS
We searched the electronic databases PubMed, PubMed Central, Scopus, and Embase for relevant articles until December 2020. Study characteristics, quality, and end points were extracted, and analysis was performed by RevMan 5.4.
RESULTS
The odds for subdural hematoma recurrence were decreased by 61% in the steroid group (odds ratio [OR], 0.39; confidence interval [CI], 0.19-0.79) compared with the control group. There was no significant difference in mortality during the study period (OR, 0.66; CI, 0.20-2.18), modified Rankin Scale score 0-3 (OR, 0.87; CI, 0.31-2.40), and modified Rankin Scale score 4-6 (OR, 1.15; CI, 0.42-3.18) between the 2 groups. However, pooling data from 3 studies showed 2.7 times higher odds of occurring adverse effects in steroid groups using the fixed-effect model (OR, 2.70; CI, 1.71-4.28). The treatment success was similar between the steroid and control groups (OR, 2.39; CI, 0.94-6.04).
CONCLUSIONS
Treatment with steroids was associated with a lesser recurrence of CSDH. However, there was no benefit of steroid treatment in CSDH compared with nonsteroid treatment in terms of mortality and treatment success and some but significantly increased risk of adverse events.
Topics: Aged; Glucocorticoids; Hematoma, Subdural, Chronic; Humans; Recurrence; Steroids; Subdural Space
PubMed: 34728401
DOI: 10.1016/j.wneu.2021.10.167 -
World Neurosurgery Mar 2021Surgery is the definitive treatment option for symptomatic Chiari malformation I (CMI), but there is no clear consensus as to the preferred surgical method. This study... (Comparative Study)
Comparative Study Meta-Analysis
Outcomes of Dura Splitting Decompression Versus Posterior Fossa Decompression With Duraplasty in the Treatment of Chiari I Malformation: A Systematic Review and Meta-analysis.
BACKGROUND
Surgery is the definitive treatment option for symptomatic Chiari malformation I (CMI), but there is no clear consensus as to the preferred surgical method. This study aimed to quantitatively assess and compare the effect and safety of dura splitting decompression (DSD) and posterior fossa decompression with duraplasty (PFDD) in treating patients with CMI.
METHODS
A literature search of EMBASE, MEDLINE, PubMed, Cochrane Library, and Web of Science databases was conducted. References from January 1990 to September 2020 were retrieved. We only included papers containing original data, comparing the use of DSD and PFDD in CMI patients.
RESULTS
Overall, 11 relevant studies were identified, wherein 443 patients treated for CMI by DSD were compared with 261 patients treated by PFDD. No difference was observed between PFDD and PFD in terms of clinical improvement (P = 0.69), syringomyelia improvement (P = 0.90), or reoperation (P = 0.22). DSD was associated with shorter operation durations (P = 0.0007), shorter length of stay (P = 0.0007), and shorter overall postoperative complications (P < 0.0001) (especially cerebrospinal fluid [CSF] leak [P = 0.005], meningitis [P = 0.002], and pseudomeningocele [P = 0.002]), as compared with PFDD.
CONCLUSIONS
This study confirmed that dura splitting decompression has clinical and syringomyelia improvement outcomes comparable to posterior fossa decompression with duraplasty. Compared with PFDD, DSD not only significantly shortened the operation time and length of stay, but also significantly reduced the overall complication rate, especially those related to incidence of CSF-related complications. More evidence from advanced multicenter studies are needed to require to validate the findings.
Topics: Arnold-Chiari Malformation; Cerebrospinal Fluid Leak; Cranial Fossa, Posterior; Decompression, Surgical; Dura Mater; Epidural Space; Humans; Length of Stay; Meningitis; Neurosurgical Procedures; Operative Time; Postoperative Complications; Reoperation; Surgical Wound Infection; Syringomyelia; Treatment Outcome
PubMed: 33290896
DOI: 10.1016/j.wneu.2020.11.163 -
Interventional Neuroradiology : Journal... Feb 2024Intracranial dural arteriovenous fistulas (dAVFs) are abnormal connections between arteries and veins within the dura mater. Various treatment modalities, such as... (Review)
Review
BACKGROUND
Intracranial dural arteriovenous fistulas (dAVFs) are abnormal connections between arteries and veins within the dura mater. Various treatment modalities, such as surgical ligation, endovascular intervention, and radiosurgery, aim to close the fistulous connection. Although transvenous embolization (TVE) is the preferred method for carotid-cavernous fistulas, its description and outcomes for noncavernous dAVFs vary. This has prompted a systematic review and meta-analysis to comprehensively assess the effectiveness of TVE in treating noncavernous dAVFs, addressing variations in outcomes and techniques.
METHODS
We searched PubMed and Embase, spanning from the earliest records to December 2022, to identify pertinent English-language articles detailing the utilization of TVE. We focused on specific procedural details, outcomes, and complications in patients older than 18 years. The data collected and analyzed comprised the sample size, number of fistulas, publication specifics, presenting symptoms, fistula grades, and pooled rates of embolizations, outcomes, follow-up information, and complications.
RESULTS
From a total of 565 screened articles, 15 retrospective articles encompassing 166 patients spanning across seven countries met the inclusion criteria. Their Newcastle-Ottawa scores ranged from 6 to 8. Intraprocedural complication rate was 10% (95% confidence interval [CI] = 5.9-17.1) and in-hospital postprocedural complication rate was 5.4% (95% CI = 2.8-10.6). Prevalence of in-hospital mortality was 5.5% (95% CI = 2.9-10.6). Complication rate during follow-up was 8.6% (95% CI = 4.7-15.7) with fistula rupture occurring in 5.5% (95% CI = 2.6-11.6) of patients. Complete obliteration rate at final angiographic follow-up was 94.9% (95% CI = 90.3-99.9). Symptoms improved in 95% (95% CI = 89.8-100) of patients at final follow-up.
CONCLUSION
To our knowledge, we present the first meta-analysis assessing obliteration rates, outcomes, and complications of TVE for dAVFs. Our analysis highlights the higher (>90%) complete obliteration rates. Large prospective multicenter studies are needed to better define the utility of TVE for noncavernous dAVFs.
PubMed: 38414437
DOI: 10.1177/15910199241234098