Neurosurgical focus最新文献

{"title":"Contribution of watertight dural closure to prevention of postoperative cerebrospinal fluid leakage in endoscopic transnasal surgery for intradural lesions.","authors":"Harisinh Parmar, Hirotaka Hasegawa, Yuki Shinya, Motoyuki Umekawa, Hironobu Nishijima, Kenji Kondo, Hideaki Ono, Shunya Hanakita, Nobuhito Saito","doi":"10.3171/2024.11.FOCUS24701","DOIUrl":"10.3171/2024.11.FOCUS24701","url":null,"abstract":"<p><strong>Objective: </strong>The goal of this study was to evaluate the efficacy of watertight dural closure (WTDC) in preventing postoperative CSF leakage during extended endoscopic transnasal surgery (ETS) for skull base tumors, while preserving sinonasal quality by omitting the routine use of a nasoseptal flap.</p><p><strong>Methods: </strong>This retrospective study included 28 patients who underwent ETS and experienced Esposito grade 3 CSF leakage at a single institution between June 2022 and June 2024. WTDC was performed using fascia lata grafts and various suturing techniques. Surgical videos and electronic medical records were reviewed to assess suturing times and postoperative outcomes. The efficacy of WTDC in preventing CSF leakage was evaluated, and the technical aspects of the procedure were analyzed.</p><p><strong>Results: </strong>Among the 28 patients (14 female, 14 male), WTDC was successfully achieved in 14 cases, with near-watertight closure in the remaining 14. The average suturing time decreased with experience, showing a trend of improved efficiency. No postoperative CSF leaks were observed, and 1 case of postoperative meningitis resolved without sequelae. Despite significant risk factors for CSF leakage, WTDC was effective in all patients without the routine use of lumbar drainage.</p><p><strong>Conclusions: </strong>WTDC in ETS is a reliable method for preventing postoperative CSF leakage, particularly in complex skull base surgeries with high-risk factors. This technique avoids the complications associated with nasoseptal flap use, preserves sinonasal quality, and reduces the need for lumbar drainage, making it a valuable option for skull base reconstruction.</p>","PeriodicalId":19187,"journal":{"name":"Neurosurgical focus","volume":"58 2","pages":"E5"},"PeriodicalIF":3.3,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143073652","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Trends in Medicare procedural and reimbursement rates for spinal CSF leak repair (2000-2021).","authors":"Muhammad I Jalal, Rohin Singh, Gabrielle Santangelo, Alex Schick, Aman Singh, Taylor Furst, Jonathan J Stone, G Edward Vates, David A Paul","doi":"10.3171/2024.11.FOCUS24699","DOIUrl":"10.3171/2024.11.FOCUS24699","url":null,"abstract":"<p><strong>Objective: </strong>CSF leaks are a common complication of spinal surgery, occurring in 3%-16% of elective cases and up to 12% of operatively managed traumatic spinal injuries. They can also occur following lumbar puncture. However, there are limited data on utilization and reimbursement trends within Medicare for CSF leak repairs. Characterizing the economic burden and market of spinal CSF leak repair has implications for optimizing effective management strategies. This study evaluates reimbursement and utilization trends for both surgical repair and epidural blood patch (EBP) management of spinal CSF leaks between the years 2000 and 2021.</p><p><strong>Methods: </strong>The 2000-2021 provider utilization and payment files from the Centers for Medicare & Medicaid Services was queried to identify all spinal CSF leak repair procedures billed to Medicare part B. For each management strategy, the number of procedures, total charges submitted by providers, and total Medicare reimbursements were extracted. Monetary data were adjusted to 2021 US dollars using changes to the Consumer Price Index. Spearman rank correlation coefficients were used to analyze trends in reimbursement and utilization.</p><p><strong>Results: </strong>From 2000 to 2021, 62,826 open surgical repairs were reported with $37,082,407 paid in reimbursement (45.9% repaired without additional laminectomy, 28.8% with laminectomy, and 25.3% requiring a spinal dural graft). An additional 63,227 EBPs were reported for CSF leak repair with $7,567,776 in reimbursement. Reimbursement for CSF leak repair without laminectomy totaled $15,707,094; repairs with laminectomy, $12,429,690; and use of spinal dural grafts, $8,945,444. Both a significant 162% increase in the utilization of spinal dural grafts (333 to 872, p < 0.001) and a decrease in reimbursement ($671 to $496, p = 0.02) was observed from 2000 to 2021. There was a significant 31% decrease in reimbursement for EBP ($148 to $102, p < 0.001).</p><p><strong>Conclusions: </strong>Significant variability exists in the management strategy and rates of utilization and reimbursement for treating spinal durotomy. Despite increasing utilization of spinal dural grafts, reimbursement has declined between the years 2000 and 2021. Further studies are required to optimize both the cost effectiveness and efficacy of spinal durotomy repair techniques.</p>","PeriodicalId":19187,"journal":{"name":"Neurosurgical focus","volume":"58 2","pages":"E15"},"PeriodicalIF":3.3,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143074973","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Multicenter study on 2-year outcomes of dual application of hydroxyapatite cranioplasty and a nasoseptal flap following endoscopic endonasal surgery for tuberculum sellae meningiomas or craniopharyngiomas.","authors":"Doo-Sik Kong, Yong Hwy Kim, Sang Duk Hong, Gwanghui Ryu, Ji Heui Kim, Chang-Ki Hong, Young-Hoon Kim","doi":"10.3171/2024.11.FOCUS24624","DOIUrl":"10.3171/2024.11.FOCUS24624","url":null,"abstract":"<p><strong>Objective: </strong>The authors evaluated the intermediate-term outcomes of a skull base reconstruction technique using hydroxyapatite cranioplasty combined with a nasoseptal flap following endoscopic endonasal surgery (EES) for suprasellar tumors. Specifically, the evaluation focused on the avoidance of lumbar CSF drainage, prevention of CSF leakage, and incidence of postoperative complications, including meningitis and nasoseptal flap necrosis, during a minimum follow-up of 2 years.</p><p><strong>Methods: </strong>This multicenter study included patients who met the following criteria: 1) underwent EES for tuberculum sellae meningiomas or craniopharyngiomas, 2) received dual application of hydroxyapatite cranioplasty and reconstruction using a nasoseptal flap, 3) had a follow-up duration of at least 2 years, and 4) did not undergo lumbar drainage of CSF postoperatively. The success rate of reconstruction was determined based on postoperative CSF leakage, associated complications, meningitis, postoperative hospital length of stay (LOS), and would dehiscence.</p><p><strong>Results: </strong>A total of 198 patients from three institutions diagnosed with tuberculum sellae meningioma (86 patients) or craniopharyngioma (112 patients) were included in this study. The median follow-up duration was 39 months. No patient underwent postoperative lumbar drainage of CSF. Postoperatively, only 3 patients (1.5%) experienced CSF leaks requiring reoperation. The median hospital LOS after surgery was 5 days. Other postoperative complications included atypical meningitis in 5 patients and wound dehiscence in 3 patients during the follow-up period. All patients with nonbacterial meningitis were treated with intravenous antibiotics and dexamethasone medication for 2 weeks.</p><p><strong>Conclusions: </strong>The combination of hydroxyapatite cranioplasty and a nasoseptal flap in reconstruction following EES decreased the requirement for postoperative lumbar CSF drainage and shortened hospital LOSs with minimal morbidities. Nevertheless, careful attention to the risks of meningitis and central necrosis of a nasoseptal flap is crucial for optimizing patient outcomes.</p>","PeriodicalId":19187,"journal":{"name":"Neurosurgical focus","volume":"58 2","pages":"E2"},"PeriodicalIF":3.3,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143075020","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Does the crafted abdominal fat grafting technique completely eliminate risk of postoperative CSF leak in endonasal pituitary surgery? Technical note and preliminary clinical outcome.","authors":"Nebojsa Lasica, Emal Lesha, Neal S Beckfort, Kenan I Arnautovic","doi":"10.3171/2024.11.FOCUS24665","DOIUrl":"10.3171/2024.11.FOCUS24665","url":null,"abstract":"<p><strong>Objective: </strong>The endonasal transsphenoidal approach (ETA) developed over the years has become the standard of care for sellar and parasellar lesions. However, because it necessitates the removal of the skull base bone, it is often accompanied by CSF leakage. The authors aimed to provide technical nuances and analyze the results of their routine fat grafting technique after ETA.</p><p><strong>Methods: </strong>A consecutive patient cohort (2004-2024) of 168 patients who underwent ETA for sellar and parasellar lesions and the modified fat grafting technique for skull base repair were retrospectively reviewed.</p><p><strong>Results: </strong>Overall, combined ETA and transcranial approach (TCA) was performed in 7 (4.2%) patients, and 4 (2.4%) patients had prior transsphenoidal surgery. The size of the lesion was < 10 mm in 24 (14.3%) patients, 10-30 mm in 93 (55.4%), and > 30 mm in 51 (30.4%). Histopathological diagnoses were as follows: 154 (91.7%) pituitary adenomas, of which 45 (26.8%) were secreting; 8 (4.8%) Rathke's cleft cysts; 2 (1.2%) inflammatory/autoimmune lesions; 2 (1.2%) craniopharyngiomas; 1 (0.6%) renal cell carcinoma metastasis; and 1 (0.6%) chordoma. Gross-total resection was achieved in 127 (75.6%) patients, near-total resection in 22 (13.1%), and subtotal resection/partial resection/biopsy in 19 (11.3%). Overall, 122 (72.6%) procedures had intraoperative CSF leakage. Postoperative CSF leakage was observed in 1 (0.6%) patient treated with a revision operation and regrafting with a slightly larger graft and lumbar drainage.</p><p><strong>Conclusions: </strong>Even slight modifications in contemporary surgical techniques and the addition of an innovative approach may improve the treatment of sellar and parasellar lesions via ETA and reduce the risk of CSF leakage. The authors have developed and described a modified fat grafting technique with gradual crafting and preprocessing of the abdominal fat tissue for skull base repair, and they have demonstrated its effectiveness in significantly reducing the CSF leak rate. This technique enables adequate reconstruction of skull base defects with low donor-site complication rates and obviates the need for external lumbar drainage.</p>","PeriodicalId":19187,"journal":{"name":"Neurosurgical focus","volume":"58 2","pages":"E3"},"PeriodicalIF":3.3,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143074188","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Which type of duraplasty is best for Chiari type I malformation surgery?","authors":"Laura Grazia Valentini, Veronica Saletti, Marco Moscatelli, Emma Ferrari, Mariangela Farinotti, Arianna Barbotti, Ignazio Gaspare Vetrano, Tommaso Francesco Galbiati","doi":"10.3171/2024.11.FOCUS24710","DOIUrl":"10.3171/2024.11.FOCUS24710","url":null,"abstract":"<p><strong>Objective: </strong>This study investigated whether the selection of different dural substitutes and distinct dural repair techniques correlates with the incidence rate of postoperative CSF leak in a mixed population of adults and children with Chiari type I malformation (CM-I) who underwent posterior fossa decompression with enlargement duraplasty (PFDD) as the first surgical approach.</p><p><strong>Methods: </strong>A retrospective analysis was conducted on all patients admitted to the authors' institution between 2006 and 2023 for PFDD to treat syringomyelia and/or symptoms due to CM-I. Clinical, radiological, and surgical data were extracted from a prospectively maintained database. Demographic information was collected from medical records. Surgical procedures were also scrutinized, specifically focusing on the type of dural graft used for duraplasty, alongside perioperative complications and the necessity for subsequent surgeries. Lastly, during follow-up, the occurrence of a CSF leak was assessed and analyzed in relation to the type of dural graft used during surgery. The type of dural substitute chosen changed over the years to reduce CSF fistulas, while the technique of PFDD remained the same. Consequently, large sequential homogeneous groups differing only by dural substitutes were available for comparison.</p><p><strong>Results: </strong>The data from 409 patients with CM-I undergoing PFDD were analyzed. A total of 368 cases had complete surgical data and were included. Thirty patients received autologous duraplasty. The remaining 338 cases with heterologous duraplasty from equine and bovine pericardium were considered for the comparative statistical analysis. The mean follow-up duration ranged from 39 months in adults to 45 months in children. The CSF complication rate requiring revision was 6.5% in the total cohort, with a higher incidence in children (10.5%) compared with adults (3.9%). There was no significant difference in adverse events (CSF leak, revision surgery, or ventriculoperitoneal shunt placement) between the different dural patches by univariate analysis if applied to the total cohort, although the trend neared significance (p = 0.06). In pediatric cases, this value was significant (p = 0.01) in favor of equine pericardium, particularly when combined with a collagen matrix inlay graft.</p><p><strong>Conclusions: </strong>This study on a large and homogeneous series of patients with CM-I undergoing PFDD with heterologous duraplasty demonstrated that CSF complications may be kept low. The dural substitutes derived from equine pericardium, particularly when combined with a collagen matrix inlay graft, exhibited a reduced rate of CSF leaks compared with substitutes derived from bovine pericardium.</p>","PeriodicalId":19187,"journal":{"name":"Neurosurgical focus","volume":"58 2","pages":"E13"},"PeriodicalIF":3.3,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143075024","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Modified graded skull base reconstruction for intraoperative CSF leak repair in endoscopic endonasal surgeries: a single-surgeon experience in initial years of practice and nuances in the early learning curve.","authors":"Mehdi Khaleghi, Adnan Hussain Shahid, Sudhir Suggala, Garrett Dyess, Ursula Noelle Hummel, Danielle N Chason, Danner Butler, Jai Deep Thakur","doi":"10.3171/2024.11.FOCUS24733","DOIUrl":"10.3171/2024.11.FOCUS24733","url":null,"abstract":"<p><strong>Objective: </strong>The purpose of this study was to evaluate the outcome of a modified graded reconstruction technique based on the size of intraoperative CSF leaks in patients undergoing endoscopic endonasal surgery performed by a single surgeon in the early years of his practice.</p><p><strong>Methods: </strong>The database of patients who underwent endoscopic endonasal approaches (EEAs) between September 2020 and August 2024 was included. Surgical complexity was categorized into levels II, III, and IV. Intraoperative CSF leak was categorized into 4 grades (0-3). Patients were divided into 2 timeline groups (those undergoing an EEA between 2020 and 2022 [group A] and between 2023 and 2024 [group B]) to assess the trends in surgical complexity and repair outcomes.</p><p><strong>Results: </strong>A total of 69 patients with a mean age of 56 ± 16.9 years (range 12-83 years) were identified; 34 (49.3%) were female. The median body mass index was 31 (> 25 in 82.6%). The most common pathology was nonsecretory macroadenoma (57.9%). The EEA at complexity levels II, III, and IV was performed in 36.2%, 46.4%, and 17.4% of the patients, respectively. Intraoperative CSF leaks grades 1, 2, and 3 were encountered in 39.1%, 7.2%, and 17.4% of the patients, whereas 36.2% did not develop leaks (grade 0). Fat grafts and collagen matrix were used for all patients with grades 1-3. Patients with complexity level II only developed grade 1 and 2 leaks, and none of level III developed grade 3. A nasoseptal flap was used in 4 patients (5.8%), with all having level IV surgery and grade 3 intraoperative leak. Only 1 patient (1.4%) developed a postoperative CSF leak, and a lumbar drain was only used for this patient (1.4%) at the revision surgery. The rate of grades 2 and 3 leaks in group B was significantly lower than in group A (8.3% vs 33.3%, p = 0.022). Temporary nasal packing usage was also significantly lower in group B (8.3%) than in group A (28.9%) (p = 0.049), whereas high-complexity EEA rates and pedicled flap usage were not correlated with the year of surgery.</p><p><strong>Conclusions: </strong>A graded endoscopic endonasal repair protocol, combined with the judicious use of lumbar drains and nasoseptal flaps rather than a reflexive approach, helps in minimizing postoperative CSF leak rates. Cross-training of neurosurgery graduates focusing on skull base practice is highly recommended for maximizing good outcomes in their early years of practice. With growing experience, intraoperative leak rates tend to decrease, and the reconstruction relies on a tailored multilayer strategy rather than bulky synthetic materials.</p>","PeriodicalId":19187,"journal":{"name":"Neurosurgical focus","volume":"58 2","pages":"E6"},"PeriodicalIF":3.3,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143074863","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Management of a large pseudomeningocele and cerebrospinal fluid fistula after microsurgical resection of recurrent lipomyelomeningocele in children.","authors":"Manina M Etter, Ladina Greuter, Raphael Guzman, Jehuda Soleman, Maria Licci","doi":"10.3171/2024.11.FOCUS24730","DOIUrl":"10.3171/2024.11.FOCUS24730","url":null,"abstract":"<p><strong>Objective: </strong>Symptomatic retethering in pediatric patients following complex spinal dysraphism surgery for lipomyelomeningocele (LMMC) repair occurs in approximately 20% of cases. Common complications after repeat surgery for retethering include infection, pseudomeningocele (PMC), and cerebrospinal fluid (CSF) fistula. The authors of this report aim to describe the treatment options for large PMCs or CSF fistulas in a series of patients who underwent repeat surgery for recurrent LMMC at their institution. Additionally, they review management strategies from the literature.</p><p><strong>Methods: </strong>This retrospective, descriptive case series includes patients with LMMC who required revision surgery for postoperative PMC or CSF fistula after recurrent untethering procedures at the authors' institution between 2013 and 2023. The surgical strategies for managing PMC and CSF fistula were examined. References for the narrative literature review were sourced from the PubMed and MEDLINE databases.</p><p><strong>Results: </strong>Eight patients underwent surgery for recurrent retethering due to worsening neurological deficits, including 2 (25.0%) patients who had undergone multiple previous untethering surgeries. The mean duration between symptom onset and repeat surgery was 11.30 ± 5.50 months. Of these 8 cases, 3 (37.5%) developed large postoperative PMCs and CSF fistulas. These patients required a mean of 4.7 ± 2.9 revision surgeries (range 3-8). Management often involved multiple techniques, including local wound revision, dural repair or sealing, mechanical coverage, tissue reconstruction, and external or internal fluid diversion. In all cases, PMCs and CSF fistulas were successfully treated, and at the final follow-up, all patients had stable neurological conditions compared to their preoperative status.</p><p><strong>Conclusions: </strong>Managing symptomatic retethering after LMMC repair is challenging, often complicated by PMC and CSF fistulas due to missing normal anatomical tissue layers, large defects, and poor dorsal support. Successful treatment typically requires a combination of techniques to address CSF-related issues. In the authors' experience, a multifaceted approach and familiarity with these methods are essential for achieving optimal outcomes.</p>","PeriodicalId":19187,"journal":{"name":"Neurosurgical focus","volume":"58 2","pages":"E17"},"PeriodicalIF":3.3,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143074777","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Results of a German national survey to assess early mobilization versus bed rest in the postoperative management of incidental durotomy during lumbar surgery and the need for a randomized clinical trial.","authors":"Tammam Abboud, Thomas Asendorf, Petros Evangelou, Bilal Younes, Dorothee Mielke, Veit Rohde","doi":"10.3171/2024.11.FOCUS24586","DOIUrl":"10.3171/2024.11.FOCUS24586","url":null,"abstract":"<p><strong>Objective: </strong>Incidental durotomy during degenerative lumbar spine surgeries poses a complex medical challenge. Despite its relatively common occurrence, consensus on its management remains elusive due to the absence of robust, high-level evidence, resulting in significant variations in practice across medical institutions. The aim of this survey was to assess the current practices in Germany regarding early mobilization versus bed rest in the postoperative management of incidental durotomy during lumbar surgery to estimate the need for a randomized clinical trial.</p><p><strong>Methods: </strong>A digital survey titled \"Postoperative management of incidental durotomy in lumbar spine surgery\" was conducted among 119 neurosurgical departments in Germany. Key questions included the use of bed rest postsurgery, timing of mobilization, and whether the practice depended on the complexity of the surgery or the quality of the dural tear repair. The survey also explored the role of lumbar drains in management and respondents' potential participation in a multicenter study on the benefits of bed rest.</p><p><strong>Results: </strong>Invitations were sent in November 2023, and responses were collected during November and December 2023. A total of 89 (75%) departments completed the survey. Among them, 75% reported using bed rest in the postoperative management of incidental durotomy. For 57%, this practice depends on the complexity of the surgical procedure or the quality of the surgical repair of the dural tear, while 18% apply it independently. Twenty-nine of the 89 departments (33%) answered that mobilization is allowed 24 hours after surgery, 13 departments (15%) allow mobilization after 48 hours, and 19 departments (21%) allow it after 72 hours. Additionally, 34% reported using a lumbar drain in cases of persistent postoperative CSF leakage, 36% use it for secondary surgical revision, and 30% do not use it in either case. Furthermore, 55 departments (62%) expressed potential interest in participating in a multicenter randomized trial addressing the postoperative management of incidental durotomy.</p><p><strong>Conclusions: </strong>The postoperative management of incidental durotomy during lumbar surgery exhibits significant variation across neurosurgical departments in Germany. Postoperative bed rest remains a common practice. To evaluate the true benefits of bed rest, a randomized multicenter study is recommended. A summary proposal for such a study is presented to address this need.</p>","PeriodicalId":19187,"journal":{"name":"Neurosurgical focus","volume":"58 2","pages":"E14"},"PeriodicalIF":3.3,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143074947","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Clival dural reconstruction via transnasal approaches: fat graft fixation technique.","authors":"Sabino Luzzi, Yücel Doğruel, Abuzer Güngör, Muhammet Enes Gurses, Serdar Rahmanov, Hatice Türe, Uğur Türe","doi":"10.3171/2024.11.FOCUS24560","DOIUrl":"10.3171/2024.11.FOCUS24560","url":null,"abstract":"<p><strong>Objective: </strong>CSF fistulas are the weak spots of transnasal endoscopic and microsurgical skull base approaches. An autologous fat graft is considered the best substrate for clival dural reconstruction via transnasal approaches. However, potential gravitational displacement of the graft may result in CSF leakage. The authors have developed and described herein the fat graft fixation (FGF) technique to secure the fat graft against dislocation after transclival resection of chordomas invading the dura.</p><p><strong>Methods: </strong>Seventy-five patients with cranial chordomas underwent surgical treatment at the authors' institution from September 2006 through June 2023. Of these, the authors collected demographic, clinical, radiological, surgical, and outcome data from 34 patients who underwent an endoscope-assisted microsurgical transclival approach via a transnasal, sublabial, or sublabial transmaxillary extended corridor. The FGF reconstruction technique was progressively implemented to improve clival reconstruction, with a focus on the results. With a custom-made 8-mm 3/8 round atraumatic surgical suture needle, a 4/0 Vicryl stitch was placed through the adjacent dural borders. An abdominal autologous fat graft was then placed over the dural defect. One triple knot was tied to secure the graft and prevent its delayed gravitational displacement. The primary outcome was to determine if the FGF group had a higher rate of early or late oronasal CSF fistula compared to the unlocked free graft group. Secondary outcomes included tension pneumocephalus, surgical site infection, and meningitis.</p><p><strong>Results: </strong>The fat graft was not used in 8 (23.5%) of the 34 patients because the dura was intraoperatively intact. The unlocked free graft and FGF techniques were used in 20 (58.8%) and 6 (17.6%) patients, respectively. Of the 34 patients, no fistulas were observed in the group treated with the FGF technique, while 4 fistulas were found in the unlocked free graft group (p < 0.05), with 2 of these cases involving meningitis. Patients with a CSF fistula underwent a total of 7 surgical procedures: 3 revision surgical procedures, 2 lumboperitoneal shunts, and 2 ventriculoperitoneal shunts.</p><p><strong>Conclusions: </strong>In the authors' preliminary experience, the FGF technique has shown promise in eliminating the risk of CSF fistula and other related complications after the transclival approach for clival chordomas involving the dura.</p>","PeriodicalId":19187,"journal":{"name":"Neurosurgical focus","volume":"58 2","pages":"E4"},"PeriodicalIF":3.3,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143075205","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Comprehensive craniometry for sagittal synostosis.","authors":"Jason A Ramsey, Phillip M Stevens, Brittany Coats, Timothy J Dixon, Sara C Chaker, Christopher M Bonfield, Michael S Golinko","doi":"10.3171/2024.10.FOCUS24466","DOIUrl":"https://doi.org/10.3171/2024.10.FOCUS24466","url":null,"abstract":"<p><strong>Objective: </strong>Sagittal synostosis is the most common type of craniosynostosis, resulting in deformity with distinctive morphological characteristics. These include occipital narrowing, parietal narrowing, anteriorly shifted vertex with parietal depression, and exaggerated frontal bossing. The traditional cephalic index affords limited reliability in quantifying initial severity and correction. The purpose of this study was to conceptualize and evaluate a set of novel metrics based on optical surface scanning (OSS) technology used for cranial remolding orthosis (CRO) treatment.</p><p><strong>Methods: </strong>The 25 most recent infants to receive CRO treatment for sagittal synostosis at a single center were reviewed retrospectively. All treated patients underwent the endoscope-assisted craniectomy technique without barrel staving. OSS representations of each patient's head were acquired perioperatively and at cessation of CRO treatment. A novel set of metrics were developed, comprising the occipital contour angle to assess severity of occipital narrowing; the vertex proportionality index to assess the anterior vertex relative to the depressed posterior anatomy; the parietal-temporal index to assess proximal cranial narrowing; and the sellion-frontal index as a measure of frontal bossing. The pre- and posttreatment results for all indices were compared against each other and against a control group of 33 nonsynostotic infants with grossly normal head shapes.</p><p><strong>Results: </strong>Initial treatment group means for all 4 indices demonstrated significant variance against both the final treatment group means and the control group means. No statistically significant differences were observed in the group means for occipital contour angle, parietal-temporal index, and sellion-frontal index between the posttreatment and control cohorts, which was suggestive of mean correction to normative levels for these morphological considerations. Despite an appreciable mean correction of parietal depression in the final treatment group, the mean vertex proportionality index values remained statistically different from the control group.</p><p><strong>Conclusions: </strong>Sagittal synostosis is characterized by several characteristic deviations from normocephaly. These are effectively improved by endoscope-assisted craniectomy with CRO intervention. Importantly, head shape abnormalities differ between patients, and the individual subject can present normatively for some deformational categories. Therefore, a multimetric approach is essential to quantify initial presentation and subsequent outcome. The introduction of novel OSS-enabled craniometry may facilitate more patient-centric management of this complex deformity. Specifically, features with the greatest deviation from normative standards can be identified, enabling creation of discrete treatment plans with respect to the focus and length of postoperative helmeting.</p>","PeriodicalId":19187,"journal":{"name":"Neurosurgical focus","volume":"58 1","pages":"E8"},"PeriodicalIF":3.3,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142915313","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}