Search

IntroductionSurgery can be an effective treatment for epilepsy if the seizure onset is adequately localized. Invasive monitoring is used if noninvasive methods are inconclusive. Initial invasive monitoring may fail if the pre-surgical hypothesis regarding location of epileptic foci is wrong. At this point, a decision must be made whether to remove all electrodes without a clearly defined location of onset or to implant additional electrodes with the aim of achieving localization by expanding coverage.MethodsElectrodes were placed according to a hypothesis derived from noninvasive monitoring techniques in adult patients with long term epilepsy. Seizure onset was not clearly localized at the end of the invasive monitoring period in ten patients, and additional electrodes were placed based on a new hypothesis that incorporated data from the invasive monitoring period.ResultsSuccessful localization was achieved in nine patients. There were no complications with adding additional electrodes. At final follow up, four patients were seizure free while four others had at least a 50% reduction in seizures after undergoing surgical intervention.ConclusionSeizure foci were localized safely in 90% of adult patients with long term epilepsy after implanting additional electrodes and expanding coverage. Patients undergoing invasive monitoring without clear localization should have additional electrodes placed to expand monitoring coverage as it is safe and effective.

BackgroundThe costs of cervical spine surgery have steadily increased. We performed a 5-year propensity scoring-matched analysis of 276 patients undergoing anterior versus posterior cervical surgery at one institution.MethodsWe performed propensity score matching on financial data from 276 patients undergoing 1-3 level anterior versus posterior cervical fusions for degenerative disease (2015-2019).ResultsWe found no significant difference between anterior versus posterior approaches for hospital costs ($42,529.63 vs. $45,110.52), net revenue ($40,877.25 vs. $34,036.01), or contribution margins ($14,230.19 vs. $6,312.54). Multivariate regression analysis showed variables significantly associated with the lower contribution margins included age (β = -392.3) and length of stay (LOS; β = -1151). Removing age/LOS from the analysis, contribution margins were significantly higher for the anterior versus posterior approach ($17,824.16 vs. $6,312.54, P = 0.01).ConclusionAnterior cervical surgery produced higher contribution margins compared to posterior approaches, most likely because posterior surgery was typically performed in older patients requiring longer LOS.

BackgroundIncidental or intentional durotomy in spine surgery is associated with a risk of cerebrospinal fluid (CSF) leakage and reoperation. Several strategies have been introduced, but the incomplete closure is still relatively frequent and troublesome. In this study, we review current evidence on spinal dural repair strategies and evaluate their efficacy.MethodsPubMed, Web of Science, and Scopus were used to search primary studies about the repair of the spinal dura with different techniques. Of 265 articles found, 11 studies, which specified repair techniques and postoperative outcomes, were included for qualitative and quantitative analysis. The primary outcomes were CSF leakage and postoperative infection.ResultsThe outcomes of different dural repair techniques were available in 776 cases. Pooled analysis of 11 studies demonstrated that the most commonly used technique was a combination of primary closure, patch or graft, and sealant (22.7%, 176/776). A combination of primary closure and patch or graft resulted in the lowest rate of CSF leakage (5.5%, 7/128). In this study, sealants as an adjunct to primary closure (13.7%, 18/131) did not significantly reduce the rate of CSF leakage compared with primary closure alone (17.6%, 18/102). The rates of infection and postoperative neurologic deficit were similar regardless of the repair techniques.ConclusionsAlthough the use of sealants has become prevalent, available sealants as an adjunct to primary closure did not reduce the rate of CSF leakage compared with primary closure. The combination of primary closure and patches or grafts could be effective in decreasing postoperative CSF leakage.

ObjectiveCervical spondylotic myelopathy (CSM) is a degenerative disorder leading to progressive decline in spinal cord function. Cervical laminoplasty (CLP) and cervical laminectomy with fusion (CLF) are standard treatments for multilevel CSM. However, it is still unclear whether one procedure over the other provides better outcomes. Here, we performed a comprehensive review of published articles that compare the clinical outcomes and costs between CLP and CLF for CSM.MethodsA literature search was performed using PubMed, Web of Science, and Cochrane databases. Strict exclusion criteria were applied, and included articles were then assessed for publication year, study design, and significant differences in outcome variables.ResultsFrom 519 studies identified with search terms, 38 studies were included for the qualitative analysis. Statistically significant differences in the clinical outcomes and costs were found in 18 studies. Eleven studies were prospective or retrospective, and 8 studies were meta-analyses. For the outcome variables of interest, results were reported by classifying into prospective studies, retrospective studies, and meta-analyses.ConclusionCLP and CLF are 2 of the most commonly performed surgical procedures for the treatment of CSM. Although CLP and CLF each provide satisfactory clinical outcomes for patients with CMS, CLP may result in better cervical range of motion and less cost, length of stay, operation time, blood loss, paraspinal muscular atrophy, and rate of nerve palsies as compared to CLF. The major limitation of CLP versus CLF comparison studies includes the heterogeneity in techniques and preoperative criteria. Thus, further validation and investigations in larger cohorts will be required.

BackgroundAs a growing number of patients seek consultations for increasingly complex and costly spinal surgery, it is of both clinical and economic value to investigate the role for second opinions (SOs). Here, we summarized and focused on the shortcomings of 14 studies regarding the role and value of SOs before proceeding with spine surgery.MethodsUtilizing PubMed, Google Scholar, and Scopus, we identified 14 studies that met the inclusion criteria that included: English, primary articles, and studies published in the past 20 years.ResultsWe identified the following findings regarding SO for spine surgery: (1) about 40.6% of spine consultations are SO cases; (2) 61.3% of those received a discordant SO; (3) 75% of discordant SOs recommended conservative management; and (4) SO discordance applied to a variety of procedures.ConclusionThe 14 studies reviewed regarding SOs in spine surgery showed that half of the SOs differed from those given in the initial consultation and that SOs in spine surgery can have a substantial impact on patient care. Absent are prospective studies investigating the impact of following a first versus second opinion. These studies are needed to inform the potential benefit of universal implementation of SOs before major spine operations to potentially reduce the frequency and type/extent of surgery.

ObjectiveCorpus callosotomy is a palliative surgery for drug-resistant epilepsy that reduces the severity and frequency of generalized seizures by disconnecting the two cerebral hemispheres. Unlike with resection, seizure outcomes remain poorly understood. The authors systematically reviewed the literature and performed a meta-analysis to investigate rates and predictors of complete seizure freedom and freedom from drop attacks after corpus callosotomy.MethodsPubMed, Web of Science, and Scopus were queried for primary studies examining seizure outcomes after corpus callosotomy published over 30 years. Rates of complete seizure freedom or drop attack freedom were recorded. Variables showing a potential relationship to seizure outcome on preliminary analysis were subjected to formal meta-analysis.ResultsThe authors identified 1742 eligible patients from 58 included studies. Overall, the rates of complete seizure freedom and drop attack freedom after corpus callosotomy were 18.8% and 55.3%, respectively. Complete seizure freedom was significantly predicted by the presence of infantile spasms (OR 3.86, 95% CI 1.13-13.23), normal MRI findings (OR 4.63, 95% CI 1.75-12.25), and shorter epilepsy duration (OR 2.57, 95% CI 1.23-5.38). Freedom from drop attacks was predicted by complete over partial callosotomy (OR 2.90, 95% CI 1.07-7.83) and idiopathic over known epilepsy etiology (OR 2.84, 95% CI 1.35-5.99).ConclusionsThe authors report the first systematic review and meta-analysis of seizure outcomes in both adults and children after corpus callosotomy for epilepsy. Approximately one-half of patients become free from drop attacks, and one-fifth achieve complete seizure freedom after surgery. Some predictors of favorable outcome differ from those in resective epilepsy surgery.

Epilepsy is a common, debilitating neurological disorder characterized by recurrent seizures. Mood disorders and cognitive deficits are common comorbidities in epilepsy that, like seizures, profoundly influence quality of life and can be difficult to treat. For patients with refractory epilepsy who are not candidates for resection, neurostimulation, the electrical modulation of epileptogenic brain tissue, is an emerging treatment alternative. Several forms of neurostimulation are currently available, and therapy selection hinges on relative efficacy for seizure control and amelioration of neuropsychiatric comorbidities. Here, we review the current evidence for how invasive and noninvasive neurostimulation therapies affect mood and cognition in persons with epilepsy. Invasive therapies include vagus nerve stimulation (VNS), deep brain stimulation (DBS), and responsive neurostimulation (RNS). Noninvasive therapies include trigeminal nerve stimulation (TNS), repetitive transcranial magnetic stimulation (rTMS), and transcranial direct current stimulation (tDCS). Overall, current evidence supports stable cognition and mood with all neurostimulation therapies, although there is some evidence that cognition and mood may improve with invasive forms of neurostimulation. More research is required to optimize the effects of neurostimulation for improvements in cognition and mood.

Neurons expressing agouti-related protein (AgRP) are essential for feeding. The majority of these neurons are located outside the blood-brain barrier (BBB), allowing them to directly sense circulating metabolic factors. Here, we show that, in adult mice, AgRP neurons outside the BBB (AgRPOBBB) were rapidly ablated by peripheral administration of monosodium glutamate (MSG), whereas AgRP neurons inside the BBB and most proopiomelanocortin (POMC) neurons were spared. MSG treatment induced proliferation of tanycytes, the putative hypothalamic neural progenitor cells, but the newly proliferated tanycytes did not become neurons. Intriguingly, AgRPOBBB neuronal number increased within a week after MSG treatment, and newly emerging AgRP neurons were derived from post-mitotic cells, including some from the Pomc-expressing cell lineage. Our study reveals that the lack of protection by the BBB renders AgRPOBBB vulnerable to lesioning by circulating toxins but that the rapid re-emergence of AgRPOBBB is part of a reparative process to maintain energy balance.

BackgroundElectrode implantation for deep brain stimulation (DBS) can be performed in numerous ways, but the current "gold standard" is the use of frame-based systems for accuracy. Robotic stereotactic procedures, however, have gained increased interest because of their ease of use and reliability, but there could be concern about their safety in the United States as the result of recent lawsuits (e.g., the da Vinci Surgical System). We report the first DBS implantation performed using a robot (ROSA robotic device) approved by Food and Drug Administration for use in North America.Case descriptionA 56-year-old, right-handed woman with a 12-year history of Parkinson disease is described. She was offered bilateral subthalamic nucleus DBS placement to address motor fluctuations and dyskinesias. DBS electrode implantation was implemented successfully with ROSA robotic stereotactic assistance. Using preoperative magnetic resonance imaging scan acquisitions, we targeted the patient's subthalamic nucleus bilaterally. Bone fiducials were placed and intraoperative computed tomography (CT) imaging was obtained. The magnetic resonance imaging and CT were fused, and the patient was registered to the ROSA software. Trajectories were obtained and a microdrive device was fixed to the robotic arm to advance the electrode to the correct location. Electrodes were then placed bilaterally. Intraoperative CT showed good placement with no complications encountered.ConclusionsThe advantages of robotic assistance in stereotactic procedures are as follows: 1) improved accuracy, 2) "arc-less" approach, and 3) minor adjustments can be made in multiple planes to the entry point without adjustment of a frame. The case demonstrates robotic stereotactic assistance viability as an alternative to traditional frame-based or frameless systems in U.S. hospitals.

BackgroundElectrode implantation for deep brain stimulation (DBS) can be performed in numerous ways, but the current "gold standard" is the use of frame-based systems for accuracy. Robotic stereotactic procedures, however, have gained increased interest because of their ease of use and reliability, but there could be concern about their safety in the United States as the result of recent lawsuits (e.g., the da Vinci Surgical System). We report the first DBS implantation performed using a robot (ROSA robotic device) approved by Food and Drug Administration for use in North America.Case descriptionA 56-year-old, right-handed woman with a 12-year history of Parkinson disease is described. She was offered bilateral subthalamic nucleus DBS placement to address motor fluctuations and dyskinesias. DBS electrode implantation was implemented successfully with ROSA robotic stereotactic assistance. Using preoperative magnetic resonance imaging scan acquisitions, we targeted the patient's subthalamic nucleus bilaterally. Bone fiducials were placed and intraoperative computed tomography (CT) imaging was obtained. The magnetic resonance imaging and CT were fused, and the patient was registered to the ROSA software. Trajectories were obtained and a microdrive device was fixed to the robotic arm to advance the electrode to the correct location. Electrodes were then placed bilaterally. Intraoperative CT showed good placement with no complications encountered.ConclusionsThe advantages of robotic assistance in stereotactic procedures are as follows: 1) improved accuracy, 2) "arc-less" approach, and 3) minor adjustments can be made in multiple planes to the entry point without adjustment of a frame. The case demonstrates robotic stereotactic assistance viability as an alternative to traditional frame-based or frameless systems in U.S. hospitals.

Laser interstitial thermal therapy (LITT) is a minimally invasive procedure used to treat a variety of intracranial lesions. Utilization of robotic assistance with stereotactic procedures has gained attention due to potential for advantages over conventional techniques. The authors report the first case in which robot-assisted MRI-guided LITT was used to treat radiation necrosis in the posterior fossa, specifically within the cerebellar peduncle. The use of a stereotactic robot allowed the surgeon to perform LITT using a trajectory that would be extremely difficult with conventional arc-based techniques. A 60-year-old man presented with facial weakness and brainstem symptoms consistent with radiation necrosis. He had a history of anaplastic astrocytoma that was treated with CyberKnife radiosurgery 1 year prior to presentation, and he did well for 11 months until his symptoms recurred. The location and form of the lesion precluded excision but made the patient a suitable candidate for LITT. The location and configuration of the lesion required a trajectory for LITT that was too low for arc-based stereotactic navigation, and thus the ROSA robot (Medtech) was used. Using preoperative MRI acquisitions, the lesion in the posterior fossa was targeted. Bone fiducials were used to improve accuracy in registration, and the authors obtained an intraoperative CT image that was then fused with the MR image by the ROSA robot. They placed the laser applicator and then ablated the lesion under real-time MR thermometry. There were no complications, and the patient tolerated the procedure well. Postoperative 2-month MRI showed complete resolution of the lesion, and the patient had some improvement in symptoms.

Laser interstitial thermal therapy (LITT) is a minimally invasive procedure used to treat a variety of intracranial lesions. Utilization of robotic assistance with stereotactic procedures has gained attention due to potential for advantages over conventional techniques. The authors report the first case in which robot-assisted MRI-guided LITT was used to treat radiation necrosis in the posterior fossa, specifically within the cerebellar peduncle. The use of a stereotactic robot allowed the surgeon to perform LITT using a trajectory that would be extremely difficult with conventional arc-based techniques. A 60-year-old man presented with facial weakness and brainstem symptoms consistent with radiation necrosis. He had a history of anaplastic astrocytoma that was treated with CyberKnife radiosurgery 1 year prior to presentation, and he did well for 11 months until his symptoms recurred. The location and form of the lesion precluded excision but made the patient a suitable candidate for LITT. The location and configuration of the lesion required a trajectory for LITT that was too low for arc-based stereotactic navigation, and thus the ROSA robot (Medtech) was used. Using preoperative MRI acquisitions, the lesion in the posterior fossa was targeted. Bone fiducials were used to improve accuracy in registration, and the authors obtained an intraoperative CT image that was then fused with the MR image by the ROSA robot. They placed the laser applicator and then ablated the lesion under real-time MR thermometry. There were no complications, and the patient tolerated the procedure well. Postoperative 2-month MRI showed complete resolution of the lesion, and the patient had some improvement in symptoms.