Safety and efficacy of stand-alone anterior lumbar interbody fusion in low-grade L5-S1 isthmic spondylolisthesis.

Introduction Surgical management of isthmic spondylolisthesis is controversial and reports on anterior approaches in the literature are scarce. Research question To evaluate the safety and efficacy of stand-alone anterior lumbar interbody fusion (ALIF) in patients with symptomatic low-grade L5-S1 isthmic spondylolisthesis. Material and methods All adult patients with isthmic spondylolisthesis of the lumbosacral junction treated in a single institution between 2008 and 2019 with stand-alone ALIF were screened. A titan cage was inserted at L5-S1 with vertebral anchoring screws. Prospectively collected surgical, clinical and radiographic data were analyzed retrospectively. Results 34 patients (19 men, 15 women, mean age 52.5 ​± ​11.5 years) with a mean follow-up of 3.2 (±2.5) years were analyzed. 91.2% (n ​= ​31) of patients had a low-grade spondylolisthesis and 8.8% (n ​= ​3) grade III according to Meyerding classification. Mean COMI and ODI scores improved significantly from 6.9 (±1.5) and 35.5 (±13.0) to 2.0 (±2.5) and 10.2 (±13.0), respectively after one year, and to 1.7 (±2.5) and 8.2 (±9.6), respectively, after two years. The COMI and ODI scores improved in 86.4% and 80%, respectively, after one year and 92.9% of patients after two years by at least the minimal clinically important difference. No intraoperative complications were recorded. 8.8% (n ​= ​3) of patients needed a reoperation. Discussion and conclusion After stand-alone ALIF for symptomatic isthmic spondylolisthesis, the patients improved clinically important after one and two years. Stand-alone ALIF is a safe and effective surgical treatment option for low-grade isthmic spondylolisthesis

Risk factors for postoperative cerebrospinal fluid leakage after intradural spine surgery.

OBJECTIVE Well-defined risk factors for cerebrospinal fluid leakage (CSFL) following intradural spine surgery are scarce in the literature. The aim of this study was to identify patient and surgery related risk factors and the incidence of CSFL. METHODS For this retrospective cohort study, we identified consecutive patients who underwent intradural spine surgery between 2009 and 2021 at our department. Primary endpoint was the incidence of clinically or radiologically proven CSFL. The impact of clinical and surgical factors on occurrence of CSFL was analyzed. RESULTS In total, 375 patients (60.3% female, mean age 54 ± 16.5 years) were included. Thirty patients (8%) had postoperative CSFL and thereby a significantly higher risk for wound healing disorders (OR 24.9, CI 9.3-66.7) and surgical site infections (SSIs; OR 8.4, CI 2.6-27.7) (p<0.01 for each). No patient-related factors were associated with CSFL. Previous surgery at the index level correlated significantly with postoperative CSFL (OR 2.76, CI 1.1-6.8, p=0.03) in multivariate analysis. Furthermore, patients with intradural tumors tended to have a higher risk for CSFL (OR 2.3, CI 0.9-5.8, p=0.07). Surgery related factors did not influence occurrence of CSFL. Surgery on the thoracic spine had a significantly lower postoperative CSFL rate than surgery on the cervical or lumbar spine (OR -2.5, CI 1.3-4.9, p=0.02). CONCLUSIONS Our study found no modifiable risk factors for preventing CSFL after intradural spine surgery. Patients with previous surgery at the index level were at higher risk for CSFL. CSFL resulted in significantly more wound healing disorders and SSIs necessitating further therapy

How much space is needed for decompressive surgery in malignant middle cerebral artery infarction: Enabling single-stage surgery.

INTRODUCTION Decompressive hemicraniectomy (DCE) is routinely performed for intracranial pressure control after malignant middle cerebral artery (MCA) infarction. Decompressed patients are at risk of traumatic brain injury and the syndrome of the trephined until cranioplasty. Cranioplasty after DCE is itself associated with high complication rates. Single-stage surgical strategies may eliminate the need for follow-up surgery while allowing for safe brain expansion and protection from environmental factors. RESEARCH QUESTION Assess the volume needed for safe expansion of the brain to enable single-stage surgery. MATERIALS AND METHODS We performed a retrospective radiological and volumetric analysis of all patients that had DCE in our clinic between January 2009 and December 2018 and met inclusion criteria. We investigated prognostic parameters in perioperative imaging and assessed clinical outcome. RESULTS Of 86 patients with DCE, 44 fulfilled the inclusion criteria. Median brain swelling was 75.35 mL (8.7-151.2 mL). Median bone flap volume was 113.3 mL (73.34-146.1 mL). Median brain swelling was 1.62 mm below the previous outer rim of the skull (5.3 mm to -2.19 mm). In 79.6% of the patients, the volume of removed bone alone was equivalent to or larger than the additional intracranial volume needed for brain swelling. DISCUSSION AND CONCLUSION The space provided by removal of the bone alone was sufficient to match the expansion of the injured brain after malignant MCA infarction in the vast majority of our patientsA subgaleal space-expanding flap with a minimal offset can provide protection from trauma and atmospheric pressure without compromising brain expansion

Outcome after surgical treatment of cerebrospinal fluid leaks in spontaneous intracranial hypotension-a matter of time.

OBJECTIVE Spinal cerebrospinal fluid (CSF) leaks cause spontaneous intracranial hypotension (SIH). Microsurgery can sufficiently seal spinal CSF leaks. Yet, some patients suffer from residual symptoms. Aim of the study was to assess predictors for favorable outcome after surgical treatment of SIH. METHODS We included consecutive patients with SIH treated surgically from January 2013 to May 2020. Subjects were surveyed by a questionnaire. Primary outcome was resolution of symptoms as rated by the patient. Secondary outcome was postoperative headache intensity on the numeric rating scale (NRS). Association between variables and outcome was assessed using univariate and multivariate regression. A cut-off value for continuous variables was calculated by a ROC analysis. RESULTS Sixty-nine out of 86 patients (80.2%) returned the questionnaire and were analyzed. Mean age was 46.7 years and 68.1% were female. A significant association with the primary and secondary outcome was found only for preoperative symptom duration (p = 0.001 and p < 0.001), whereby a shorter symptom duration was associated with a better outcome. Symptom duration remained a significant predictor in a multivariate model (p = 0.013). Neither sex, age, type of pathology, lumbar opening pressure, nor initial presentation were associated with the primary outcome. ROC analysis yielded treatment within 12 weeks as a cut-off for better outcome. CONCLUSION Shorter duration of preoperative symptoms is the most powerful predictor of favorable outcome after surgical treatment of SIH. While an initial attempt of conservative treatment is justified, we advocate early definitive treatment within 12 weeks in case of persisting symptoms

Idiopathic Ventral Spinal Cord Hernia—A Single-Center Case Series of 11 Patients

BACKGROUND: Idiopathic spinal cord herniations (ISCH) are rare defects of the ventromedial or mediolateral dura mater with herniation of the spinal cord through the defect with approximately 350 described cases worldwide. Patients usually become symptomatic with motor or sensory neurological deficits and gait disturbances. OBJECTIVE: To describe characteristic symptoms and clinical findings and to evaluate the postoperative course and outcomes of ISCH. METHODS: We present a single-center data analysis of a case series of 11 consecutive patients who were diagnosed with ISCH and underwent surgery in our department between 2009 and 2021. RESULTS: All herniations were located in the thoracic spine between T2 and T9. In most cases, gait ataxia and dysesthesia led to further workup and subsequently to the diagnosis of ISCH. A “far-enough” posterior-lateral surgical approach, hemilaminectomy or laminectomy with a transdural approach, was performed under intraoperative neurophysiological monitoring which was followed by adhesiolysis, repositioning of the spinal cord and sealing using a dura patch. After surgery, clinical symptoms improved in 9 of 11 patients (81.8%), while only 1 patient experienced deterioration of symptoms (9.1%) and 1 patient remained equal (9.1%). The median preoperative McCormick grade was 3 (±0.70), while the median postoperative grade was 2 (±0.98) (P = .0047). CONCLUSION: In our case series of ISCH, we found that in most patients, neurological deficits improved postoperatively. This indicates that surgery in ISCH should not be delayed in symptomatic patients

Epidural Blood Patching in Spontaneous Intracranial Hypotension-Do we Really Seal the Leak?

PURPOSE Epidural blood patch (EBP) is a minimally invasive treatment for spontaneous intracranial hypotension (SIH). Follow-up after EBP primarily relies on clinical presentation and data demonstrating successful sealing of the underlying spinal cerebrospinal fluid (CSF) leak are lacking. Our aim was to evaluate the rate of successfully sealed spinal CSF leaks in SIH patients after non-targeted EBP. METHODS Patients with SIH and a confirmed spinal CSF leak who had been treated with non-targeted EBP were retrospectively analyzed. Primary outcome was persistence of CSF leak on spine MRI or intraoperatively. Secondary outcome was change in clinical symptoms after EBP. RESULTS In this study 51 SIH patients (mean age, 47 ± 13 years; 33/51, 65% female) treated with non-targeted EBP (mean, 1.3 EBPs per person; range, 1-4) were analyzed. Overall, 36/51 (71%) patients had a persistent spinal CSF leak after EBP on postinterventional imaging and/or intraoperatively. In a best-case scenario accounting for missing data, the success rate of sealing a spinal CSF leak with an EBP was 29%. Complete or substantial symptom improvement in the short term was reported in 45/51 (88%), and in the long term in 17/51 (33%) patients. CONCLUSION Non-targeted EBP is an effective symptomatic treatment providing short-term relief in a substantial number of SIH patients; however, successful sealing of the underlying spinal CSF leak by EBP is rare, which might explain the high rate of delayed symptom recurrence. The potentially irreversible and severe morbidity associated with long-standing intracranial hypotension supports permanent closure of the leak

Diagnostic challenges and therapeutic possibilities in spontaneous intracranial hypotension

Spontaneous intracranial hypotension (SIH) has gained more attention in the eyes of clinicians in the past years and is now recognized as an important cause of headaches. While usually self-limiting and benign, some patients suffer from debilitating symptoms that interfere significantly with their social and professional life. Thus, recognition and adequate treatment of SIH is of paramount importance. Recent refinements in imaging techniques combined with modern microneurosurgical techniques offer many diagnostic and therapeutic possibilities today. The aim of this review is to give the reader an updated review on the state-of-the art in the challenging diagnosis and treatment of SIH as well as an insight into recent developments of pathophysiological concepts and affiliations with other enigmatic diseases

Assessing Spinal Cerebrospinal Fluid Leaks in Spontaneous Intracranial Hypotension With a Scoring System Based on Brain Magnetic Resonance Imaging Findings.

Importance Various signs may be observed on brain magnetic resonance imaging (MRI) in patients with spontaneous intracranial hypotension (SIH). However, the lack of a classification system integrating these findings limits decision making in clinical practice. Objective To develop a probability score based on the most relevant brain MRI findings to assess the likelihood of an underlying spinal cerebrospinal fluid (CSF) leak in patients with SIH. Design, Setting, and Participants This case-control study in consecutive patients investigated for SIH was conducted at a single hospital department from February 2013 to October 2017. Patients with missing brain MRI data were excluded. Three blinded readers retrospectively reviewed the brain MRI scans of patients with SIH and a spinal CSF leak, patients with orthostatic headache without a CSF leak, and healthy control participants, evaluating 9 quantitative and 7 qualitative signs. A predictive diagnostic score based on multivariable backward logistic regression analysis was then derived. Its performance was validated internally in a prospective cohort of patients who had clinical suspicion for SIH. Main Outcomes and Measures Likelihood of a spinal CSF leak based on the proposed diagnostic score. Results A total of 152 participants (101 female [66.4%]; mean [SD] age, 46.1 [14.3] years) were studied. These included 56 with SIH and a spinal CSF leak, 16 with orthostatic headache without a CSF leak, 60 control participants, and 20 patients in the validation cohort. Six imaging findings were included in the final scoring system. Three were weighted as major (2 points each): pachymeningeal enhancement, engorgement of venous sinus, and effacement of the suprasellar cistern of 4.0 mm or less. Three were considered minor (1 point each): subdural fluid collection, effacement of the prepontine cistern of 5.0 mm or less, and mamillopontine distance of 6.5 mm or less. Patients were classified into groups at low, intermediate, or high probability of having a spinal CSF leak, with total scores of 2 points or fewer, 3 to 4 points, and 5 points or more, respectively, on a scale of 9 points. The discriminatory ability of the proposed score could be demonstrated in the validation cohort. Conclusions and Relevance This 3-tier predictive scoring system is based on the 6 most relevant brain MRI findings and allows assessment of the likelihood (low, intermediate, or high) of a positive spinal imaging result in patients with SIH. It may be useful in identifying patients with SIH who are leak positive and in whom further invasive myelographic examinations are warranted before considering targeted therapy

Intrakranieller Druck

Überwachung und Therapie des erhöhten intrakraniellen Druckes sind fester Bestand­teil der intensivmedizinischen Behandlung diverser neurochirurgischer, neurologi­scher und internistischer Krankheitsbilder. Die Liquordynamik beim Gesunden, das Zusammenspiel mit vaskulären Faktoren und die pathophysiologischen Veränderun­gen beim Kranken sind äusserst komplex und immer noch unvollständig verstanden

Normaldruck-Hydrozephalus

Gangstörung, kognitive Defizite und Harninkontinenz sind die typischen Symptome des idiopathischen Normaldruck-Hydrozephalus. Die Inzidenz der Erkrankung nimmt mit höherem Alter zu und mit der operativen Einlage einer Liquorableitung besteht auch bei älteren Patienten eine effektive Therapieoption