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Neurosurgical Review Sep 2023Endoscopic transsphenoidal surgery is a novel surgical technique requiring specific training. Different models and simulators have been recently suggested for it, but no... (Review)
Review
Endoscopic transsphenoidal surgery is a novel surgical technique requiring specific training. Different models and simulators have been recently suggested for it, but no systematic review is available. To provide a systematic and critical literature review and up-to-date description of the training models or simulators dedicated to endoscopic transsphenoidal surgery. A search was performed on PubMed and Scopus databases for articles published until February 2023; Google was also searched to document commercially available. For each model, the following features were recorded: training performed, tumor/arachnoid reproduction, assessment and validation, and cost. Of the 1199 retrieved articles, 101 were included in the final analysis. The described models can be subdivided into 5 major categories: (1) enhanced cadaveric heads; (2) animal models; (3) training artificial solutions, with increasing complexity (from "box-trainers" to multi-material, ct-based models); (4) training simulators, based on virtual or augmented reality; (5) Pre-operative planning models and simulators. Each available training model has specific advantages and limitations. Costs are high for cadaver-based solutions and vary significantly for the other solutions. Cheaper solutions seem useful only for the first stages of training. Most models do not provide a simulation of the sellar tumor, and a realistic simulation of the suprasellar arachnoid. Most artificial models do not provide a realistic and cost-efficient simulation of the most delicate and relatively common phase of surgery, i.e., tumor removal with arachnoid preservation; current research should optimize this to train future neurosurgical generations efficiently and safely.
Topics: Humans; Animals; Endoscopy; Cadaver; Computer Simulation; Databases, Factual; Skull Base Neoplasms
PubMed: 37725193
DOI: 10.1007/s10143-023-02149-3 -
Surgical Neurology International 2023Chronic subdural hematoma (CSDH) is a condition characterized by the accumulation of fluid, blood, and blood breakdown products between the brain's arachnoid and dura...
BACKGROUND
Chronic subdural hematoma (CSDH) is a condition characterized by the accumulation of fluid, blood, and blood breakdown products between the brain's arachnoid and dura mater coverings. While steroids have been explored as a potential treatment option, their efficacy and safety remain uncertain. This meta-analysis and systematic review aimed to assess the impact of steroids on CSDH management, including mortality, recurrence, complications, and functional outcomes.
METHODS
We conducted a comprehensive literature search in major electronic databases up to June 2023, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and Cochrane Handbook for Systematic Reviews and Interventions. Inclusion criteria encompassed adult patients with CSDH, the use of steroids as monotherapy or adjuvant therapy, and clearly defined outcomes. Randomized controlled trials and cohort studies meeting these criteria were included in the study.
RESULTS
The initial search yielded 4315 articles, with 12 studies meeting the inclusion criteria. Our findings indicate a non-significant trend toward reduced mortality with steroids in combination with standard care (Odds ratios [OR] = 0.66, 95% confidence interval [CI] 0.20-2.18). However, substantial heterogeneity was observed (I = 70%). Sensitivity analysis, excluding influential studies, suggested a potential increased mortality risk associated with steroids (OR = 1.47, 95% CI 0.87-2.48). Steroids showed a possible benefit in reducing the recurrence of CSDH (OR = 0.58, 95% CI 0.20-1.67), but with significant heterogeneity (I = 89%). No clear advantage of steroids was observed in terms of functional outcomes at three months (modified Rankin scale scores). Furthermore, steroids were associated with a significantly higher incidence of adverse effects and complications (OR = 2.17, 95% CI 1.48-3.17).
CONCLUSION
Steroids may have a potential role in reducing CSDH recurrence but do not appear to confer significant advantages in terms of mortality or functional outcomes. However, their use is associated with a higher risk of adverse effects and complications. Given the limitations of existing studies, further research is needed to refine the role of steroids in CSDH management, considering patient-specific factors and treatment protocols.
PubMed: 38213424
DOI: 10.25259/SNI_771_2023 -
PloS One 2022This patient and public-involved systematic review originally focused on arachnoiditis, a supposedly rare "iatrogenic chronic meningitis" causing permanent neurologic... (Review)
Review
BACKGROUND & IMPORTANCE
This patient and public-involved systematic review originally focused on arachnoiditis, a supposedly rare "iatrogenic chronic meningitis" causing permanent neurologic damage and intractable pain. We sought to prove disease existence, causation, symptoms, and inform future directions. After 63 terms for the same pathology were found, the study was renamed Diseases of the Leptomeninges (DLMs). We present results that nullify traditional clinical thinking about DLMs, answer study questions, and create a unified path forward.
METHODS
The prospective PRISMA protocol is published at Arcsology.org. We used four platforms, 10 sources, extraction software, and critical review with ≥2 researchers at each phase. All human sources to 12/6/2020 were eligible for qualitative synthesis utilizing R. Weekly updates since cutoff strengthen conclusions.
RESULTS
Included were 887/14286 sources containing 12721 DLMs patients. Pathology involves the subarachnoid space (SAS) and pia. DLMs occurred in all countries as a contributor to the top 10 causes of disability-adjusted life years lost, with communicable diseases (CDs) predominating. In the USA, the ratio of CDs to iatrogenic causes is 2.4:1, contradicting arachnoiditis literature. Spinal fusion surgery comprised 54.7% of the iatrogenic category, with rhBMP-2 resulting in 2.4x more DLMs than no use (p<0.0001). Spinal injections and neuraxial anesthesia procedures cause 1.1%, and 0.2% permanent DLMs, respectively. Syringomyelia, hydrocephalus, and arachnoid cysts are complications caused by blocked CSF flow. CNS neuron death occurs due to insufficient arterial supply from compromised vasculature and nerves traversing the SAS. Contrast MRI is currently the diagnostic test of choice. Lack of radiologist recognition is problematic.
DISCUSSION & CONCLUSION
DLMs are common. The LM clinically functions as an organ with critical CNS-sustaining roles involving the SAS-pia structure, enclosed cells, lymphatics, and biologic pathways. Cases involve all specialties. Causes are numerous, symptoms predictable, and outcomes dependent on time to treatment and extent of residual SAS damage. An international disease classification and possible treatment trials are proposed.
Topics: Arachnoiditis; Biological Products; Humans; Iatrogenic Disease; Meningitis; Prospective Studies
PubMed: 36178925
DOI: 10.1371/journal.pone.0274634 -
World Neurosurgery Feb 2017Acquired Chiari malformations (ACM) and associated syringomyelia secondary to space-occupying lesions can cause neurologic deficits independent of or in combination with... (Review)
Review
BACKGROUND
Acquired Chiari malformations (ACM) and associated syringomyelia secondary to space-occupying lesions can cause neurologic deficits independent of or in combination with the offending mass. Although type I Chiari malformations are traditionally treated with posterior fossa decompression, optimal surgical management of ACM and associated syringomyelia remains unclear. The purpose of this study is to review the current literature surrounding the management of ACM.
METHODS
A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Using the relevant keywords, articles were identified through multiple databases from inception to April 2016. Our primary outcome was postoperative resolution of tonsillar herniation, syringomyelia, and clinical symptoms and signs.
RESULTS
Thirty studies (27 case reports and 3 case series), encompassing 44 patients, were included in the review. Meningiomas (36%) and arachnoid cysts (32%) were the lesions most commonly associated with ACM. Offending lesions were usually large (85%) and almost all were found in the posterior fossa (89%). Syringomyelia was present in 82% of cases. Overall, all but 1 patient had improvement or resolution of their syringomyelia after surgery and none required a syrinx shunt. Rates of tonsillar ascent, syrinx resolution, and neurologic recovery were similar in patients who underwent lesion removal alone versus those who underwent posterior fossa decompression and lesion removal.
CONCLUSIONS
Space-occupying lesions in the posterior fossa are a rare cause of ACM and syringomyelia. Surgical management of the underlying lesion improves ACM and associated syringomyelia without the need for syrinx shunting.
Topics: Adolescent; Adult; Arachnoid Cysts; Arnold-Chiari Malformation; Child; Child, Preschool; Female; Humans; Male; Meningioma; Middle Aged; Pharyngeal Diseases; Radiology; Syringomyelia; Treatment Outcome; Young Adult
PubMed: 27894943
DOI: 10.1016/j.wneu.2016.11.080 -
The Journal of Maternal-fetal &... 2016To conduct a literature review to assess the effectiveness of first trimester ultrasonographic markers of spina bifida (SB) integrating data with our prospective... (Review)
Review
OBJECTIVE
To conduct a literature review to assess the effectiveness of first trimester ultrasonographic markers of spina bifida (SB) integrating data with our prospective experience.
METHODS
The analysis of the SB cases that we prospectively detected in the first trimester, between January 2012 and February 2014, and a systematic review of all the papers evaluating the effectiveness of SB ultrasonographic markers at 11-14 weeks, namely brain stem diameter (BS), fourth ventricle/intracranial translucency (IT), cisterna magna (CM), brain stem/occipital bone distance (BSOB), the ratio between BS and BSOB. Some studies assess only the effectiveness of IT, others include more parameters, and few include them all.
RESULTS
We prospectively detected four SB cases, three open (OSB) and one closed (CSB), in a low risk population undergoing first trimester screening. In the three OSB, CM (in 2/3 cases) and BSOB (3/3) distance were below the 5th percentile, BS and BS/BSOB ratio (3/3) were above the 95th percentile. In the CSB, all the measurements were within normal limits.
CONCLUSION
The literature and our data agree that most fetuses with OSB demonstrate in the first trimester positive sonographic markers in the posterior fossa, but additional prospective studies are needed to establish the best protocol for OSB screening.
Topics: Adult; Brain Stem; Cisterna Magna; Female; Fourth Ventricle; Humans; Occipital Bone; Pregnancy; Pregnancy Trimester, First; Prospective Studies; Spinal Dysraphism; Ultrasonography, Prenatal
PubMed: 26381234
DOI: 10.3109/14767058.2015.1085967 -
Pain Physician 2009Post lumbar surgery syndrome or failed back surgery syndrome with persistent pain continues to increase over the years. The speculated causes of post lumbar laminectomy... (Review)
Review
BACKGROUND
Post lumbar surgery syndrome or failed back surgery syndrome with persistent pain continues to increase over the years. The speculated causes of post lumbar laminectomy syndrome include acquired stenosis, epidural fibrosis, arachnoiditis, radiculopathy, and recurrent disc herniation. Epidural fibrosis may account for as much as 20% to 36% of all cases of failed back surgery syndrome. Percutaneous epidural adhesiolysis has been employed in interventional pain management in the treatment of chronic, refractory low back and lower extremity pain after back surgery.
STUDY DESIGN
A systematic review of randomized trials and observational studies.
OBJECTIVE
To evaluate the effectiveness of percutaneous adhesiolysis in managing chronic low back and lower extremity pain due to post lumbar surgery syndrome.
METHODS
A comprehensive literature search was conducted utilizing electronic databases, as well as systematic reviews and cross references from 1966 through December 2008. The quality of individual articles used in this analysis was assessed by modified Cochrane review criteria for randomized trials and the Agency for Healthcare Research and Quality (AHRQ) criteria for assessment of observational studies. Clinical relevance was evaluated using 5 questions according to the criteria recommended by the Cochrane Review Back Group. Analysis was conducted using 5 levels of evidence, ranging from Level I to III, with 3 subcategories in Level II.
OUTCOME PARAMETERS
The primary outcome measure was pain relief (short-term relief of at least 6 months and long-term relief of more than 6 months). Secondary outcome measures were improvement in functional status, psychological status, return to work, and change in opioid intake.
RESULTS
Of the 13 studies considered for inclusion, 3 randomized trials and 4 observational studies met the inclusion criteria for methodologic quality assessment and evidence synthesis based on methodologic quality scores of 50 or more. Evidence of percutaneous adhesiolysis in the management of chronic low back pain in post-lumbar surgery syndrome is Level I to Level II-1, with evidence derived from 3 randomized trials.
LIMITATIONS
There is a paucity of efficacy and pragmatic trials. No trials have been published after 2006.
CONCLUSION
The indicated level of evidence for percutaneous adhesiolysis is Level I or II-1 based on the US Preventative Services Task Force (USPSTF) criteria.
Topics: Chronic Disease; Disability Evaluation; Epidural Space; Failed Back Surgery Syndrome; Humans; Low Back Pain; Lumbosacral Region; Postoperative Period; Tissue Adhesions; Treatment Outcome
PubMed: 19305485
DOI: No ID Found -
Surgical Neurology International 2022Idiopathic spinal epidural arachnoid cysts (SEACs) are rare and may cause myelopathy and cord compression. They typically arise from a congenital defect in the dura that... (Review)
Review
BACKGROUND
Idiopathic spinal epidural arachnoid cysts (SEACs) are rare and may cause myelopathy and cord compression. They typically arise from a congenital defect in the dura that communicates with the intrathecal subarachnoid space. Although the ideal treatment of SEACs is direct dural repair and cyst excision, there is as yet no clear standard of care for the management of these lesions.
METHODS
A 47-year-old female presented with myelopathy attributed to an magnetic resonance imaging-documented posterior epidural T12-L2 cyst (i.e., 1.1 × 6 × 3.3 cm) lesion. The patient underwent a direct dural repair of the fistulous communication between the subarachnoid space and the cyst, along with cyst drainage/ excision through a right-sided laminotomy. Postoperatively, the patient was asymptomatic. We additionally reviewed the literature regarding the management of SEACs.
RESULTS
Our review yielded 14 articles involving 18 patients with predominantly thoracolumbar (57%) SEACs that were either communicating (61%) or not communicating (39%) with the subarachnoid space. They averaged 35.5 years of age and exhibited a male preponderance (66%). Symptoms typically included pain (78%), followed by weakness/myelopathy (42%). Surgery frequently included bilateral laminectomies (57%) followed by unilateral laminectomies (50%) that typically resulted in symptom resolution.
CONCLUSION
SEACs are rare typically thoracolumbar lesions that may cause myelopathy which resolves following direct dural closure/subarachnoid fistulous occlusion.
PubMed: 36761263
DOI: 10.25259/SNI_928_2022 -
World Neurosurgery Aug 2016To review the literature and analyze the efficacy and safety of 3 surgical methods (neuroendoscopic fenestration, microsurgical fenestration, and cystoperitoneal... (Comparative Study)
Comparative Study Meta-Analysis Review
OBJECTIVE
To review the literature and analyze the efficacy and safety of 3 surgical methods (neuroendoscopic fenestration, microsurgical fenestration, and cystoperitoneal shunting) for middle cranial fossa arachnoid cysts (MCFACs).
METHODS
We searched MEDLINE, PubMed, and Cochrane Central electronic databases and collected studies of patients with MCFACs treated with 1 of 3 surgical methods. Eligible studies reported the rate of clinical symptoms improvement (RCSI), rate of cyst reduction (RCR), rate of total complications (RTC), rate of short-term complications (RSTC), rate of long-term complications (RLTC), and other parameters.
RESULTS
Eighteen studies met the criteria. MCFACs were divided into 3 groups on the basis of surgical method: RCSI in group I (237 patients, neuroendoscopic fenestration) was 90% (95% confidence interval [CI]: 83%-95%); RCR: 76% (95% CI: 67%-84%); RTC: 28% (95% CI: 22%-34%); RSTC: 23% (95% CI: 17%-30%); and RLTC: 6% (95% CI: 3%-11%). RCSI in group II (144 patients, microsurgical fenestration) was 87% (95% CI: 75%-96%); RCR: 87% (95% CI: 70%-97%); RTC: 49% (95% CI: 30%-68%); RSTC: 44% (95% CI: 21%-68%); RLTC: 3% (95% CI: 0%-12%). RCSI in group III (93 patients, cystoperitoneal shunting) was 93% (95% CI: 66%-99%); RCR: 93% (95% CI: 66%-99%); RTC: 20% (95% CI: 5%-42%); RSTC: 10% (95% CI: 0%-31%); RLTC: 15% (95% CI: 9%-23%). RLTC differed significantly between the 3 groups (P = 0.005); RTC and RSTC between group I and group II (P = 0.002).
CONCLUSIONS
All 3 surgical methods are effective for MCFACs, but considering safety, neuroendoscopic fenestration may be the best initial procedure.
Topics: Adolescent; Arachnoid Cysts; Child; Child, Preschool; Cranial Fossa, Middle; Female; Humans; Internationality; Male; Microsurgery; Neuroendoscopy; Postoperative Complications; Prevalence; Risk Factors; Treatment Outcome; Ventriculoperitoneal Shunt
PubMed: 27319312
DOI: 10.1016/j.wneu.2016.06.046 -
Frontiers in Bioengineering and... 2021Tumorous lesions developing in the cerebellopontine angle (CPA) get into close contact with the 1st (cisternal) and 2nd (meatal) intra-arachnoidal portion of the facial...
Clinical Studies and Pre-clinical Animal Models on Facial Nerve Preservation, Reconstruction, and Regeneration Following Cerebellopontine Angle Tumor Surgery-A Systematic Review and Future Perspectives.
Tumorous lesions developing in the cerebellopontine angle (CPA) get into close contact with the 1st (cisternal) and 2nd (meatal) intra-arachnoidal portion of the facial nerve (FN). When surgical damage occurs, commonly known reconstruction strategies are often associated with poor functional recovery. This article aims to provide a systematic overview for translational research by establishing the current evidence on available clinical studies and experimental models reporting on intracranial FN injury. A systematic literature search of several databases (PubMed, EMBASE, Medline) was performed prior to July 2020. Suitable articles were selected based on predefined eligibility criteria following the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guidelines. Included clinical studies were reviewed and categorized according to the pathology and surgical resection strategy, and experimental studies according to the animal. For anatomical study purposes, perfusion-fixed adult New Zealand white rabbits were used for radiological high-resolution imaging and anatomical dissection of the CPA and periotic skull base. One hundred forty four out of 166 included publications were clinical studies reporting on FN outcomes after CPA-tumor surgery in 19,136 patients. During CPA-tumor surgery, the specific vulnerability of the intracranial FN to stretching and compression more likely leads to neurapraxia or axonotmesis than neurotmesis. Severe FN palsy was reported in 7 to 15 % after vestibular schwannoma surgery, and 6% following the resection of CPA-meningioma. Twenty-two papers reported on experimental studies, out of which only 6 specifically used intracranial FN injury in a rodent ( = 4) or non-rodent model ( = 2). Rats and rabbits offer a feasible model for manipulation of the FN in the CPA, the latter was further confirmed in our study covering the radiological and anatomical analysis of perfusion fixed periotic bones. The particular anatomical and physiological features of the intracranial FN warrant a distinguishment of experimental models for intracranial FN injuries. New Zealand White rabbits might be a very cost-effective and valuable option to test new experimental approaches for intracranial FN regeneration. Flexible and bioactive biomaterials, commonly used in skull base surgery, endowed with trophic and topographical functions, should address the specific needs of intracranial FN injuries.
PubMed: 34239858
DOI: 10.3389/fbioe.2021.659413 -
Journal of Clinical Neuroscience :... Feb 2018Cervical intradural disc herniation (CIDH) is rare, and diagnosis and treatment are challenging. We conducted a systematic review and meta-analysis of the literature on... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Cervical intradural disc herniation (CIDH) is rare, and diagnosis and treatment are challenging. We conducted a systematic review and meta-analysis of the literature on the diagnosis and treatment of CIDH.
METHOD
The presentation, imaging manifestations, diagnosis, management, prognosis and possible pathogenesis were reviewed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. English-language studies and case reports published from inception to 2017 were retrieved. Data on presentation, imaging characteristics, diagnosis, management, outcomes and pathogenesis were extracted.
RESULTS
Twenty articles involving 23 patients were selected. The most common involved level was C5-6 (43.5%), followed by C6-7 (30.4%), C4-5 (13%), and C3-4 (13%). Spontaneous IDH occurred in 61% of the patients, and relevant cervical trauma was present in 39%. Brown-Sequard's syndrome (56.5%), quadriparesis (34.8%), and radiculopathy (8.7%) were the main presentations. Magnetic resonance imaging (MRI) was the most commonly used diagnostic technique, and the "halo" and "Y-sign" were strong indicators of CIDH. Three (13%) patients were diagnosed as having CIDH preoperatively, and 87% were confirmed intraoperatively. All patients underwent surgical intervention primarily (73.9%) through an anterior approach. Neurological function improved postoperatively in all patients but one. Dural and arachnoid mater tears were managed by direct suture or covering with a substitute, and only one patient sustained cerebrospinal fluid (CSF) leakage after surgery.
CONCLUSION
IDH mostly involves the lower cervical spine. More than half of the patients had spontaneous CIDH, and some had a relevant cervical trauma history. BSS was the main presentation. It is difficult to diagnose CIDH depending on clinical presentations and radiographic findings. Surgery was an effective treatment for CIDH and can provide a definitive diagnosis. With meticulous management of dural and arachnoid tears, the postoperative incidence of CSF leakage was found to be low.
Topics: Cerebrospinal Fluid Leak; Cervical Vertebrae; Humans; Intervertebral Disc Degeneration; Intervertebral Disc Displacement; Magnetic Resonance Imaging
PubMed: 29162303
DOI: 10.1016/j.jocn.2017.10.024