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Selective dorsal rhizotomy (SDR) is a treatment for lower-extremity spasticity in disorders such as cerebral palsy (CP). “Selective” refers to sectioning nerve rootlets with the most abnormal responses on electromyography (EMG) upon intraoperative stimulation. EMG abnormalities can be classified by waveform appearance or by degree of spread throughout lower extremity muscles. We examine the relationship between different EMG waveforms and grades of spread. Intraoperative SDR EMG records from November 2009 through December 2021 were analyzed for waveform types and degrees of spread. Irregular, incremental, multiphasic, sustained, and clonic waveform patterns were considered more abnormal. Decremental, squared decremental, and squared waveforms were less abnormal. Degrees of spread were graded 0–4+, 4+ signifying the most abnormal spread. Distribution of grades of spread was compared between waveform patterns using pairwise Cochran-Armitage tests with Holm-Bonferroni correction. We hypothesized that more abnormal EMG waveform patterns would correlate with higher grades of spread. Sixty-three patients were included, with an average age of 8 years. Most had cerebral palsy (86%, n = 54). The remainder had brain malformations (8%, n = 5) and other etiologies (6%, n = 4). Higher grades of spread significantly increased the likelihood of multiphasic, sustained, or clonic patterns, compared to decremental, irregular, and squared patterns (p < .05). Squared waveforms decreased with higher grades of spread relative to other patterns (p < .05). Different EMG waveform patterns are associated with varying grades of spread in SDR, suggesting that evaluating both waveform pattern and degree of spread together can be useful in guiding rootlet sectioning. [ABSTRACT FROM AUTHOR]

Purpose: Laryngoscopy and endotracheal intubation are known to increase activity of the sympathetic nervous system, and are usually associated with perioperative hypertension, cardiac arrhythmia, and tachycardia. The aim of this study was to determine the effect-site concentrations of remifentanil to inhibit the tracheal intubation response during etomidate anesthesia in elderly patients. Methods: American Society of Anesthesiologists physical status I-III patients aged 65 or older and scheduled for general anesthesia for elective surgery were enrolled in the study. Anesthesia induction was applied with etomidate 0.3 mg/kg, rocuronium 0.6 mg/kg, and target controlled infusion of remifentanil under the Minto pharmacokinetic model. Invasive continuous arterial blood pressure monitoring was used throughout the operation. A positive response was defined if the maximal mean arterial pressure (MAP) or heart rate (HR) within 3 min after tracheal intubation was 20% higher than the baseline value. The Dixon sequential method was used for the test, and the initial effect-site concentrations of remifentanil was 6 ng/ml. The EC50 and EC95 for the suppression of endotracheal intubation response by remifentanil were calculated by the probit method. Results: The EC50 for inhibiting tracheal intubation response by remifentanil in elderly patients was 6.53 ng/ml (95% CI:6.01–7.05 ng/ml) and EC95 was 8.05 ng/ml (95% CI:7.32–8.78 ng/ml) when combined with etomidate anesthesia. The changes of MAP, HR and BIS in positive group were significantly higher than those of negative group (P < 0.05). There were no episodes of hypoxemia, muscular tremor, chest wall rigidity or choking cough in both groups. Conclusions: Target controlled infusion of remifentanil in combination with etomidate is effective preventing hemodynamic instability in elderly patients during the anesthesia induction and endotracheal intubation. Clinical trial registration: This article was registered at Chinese Clinical Trial Registry (www.chictr.org.cn registration number: ChiCTR2300076261, date of registration: 28/09/2023). [ABSTRACT FROM AUTHOR]

Background: We aimed to determine the diagnostic accuracy of intraoperative muscle motor evoked potentials (mMEPs) in predicting postoperative motor deficits in individual muscles of patients with benign intramedullary spinal cord tumors (IMSCTs), and to correlate them with long-term functional outcome. Methods: A retrospective study of patients operated for benign IMSCTs from 2009 to 2021 was performed. Sixty-nine patients in whom baseline mMEP recordings were obtained from at least one muscle were included for analysis. A persistent drop of the baseline mMEP by ≥ 50% from baseline was considered significant. Results: The mean age of the patients was 33.2 ± 15.8 years and 47 (68.1%) of them were male. The most common tumor was ependymoma (56.5%). Baseline mMEPs were obtained in 400/1011 muscles that were monitored. Postoperative worsening of motor power was noted in 109/400 (27.3%) muscles with baseline mMEP recordings compared to 213/611 (34.9%) muscles with no baseline recordings (p = 0.01). Patients who had deterioration of mMEPs had a significantly higher rate of worsening of muscle power postoperatively compared to those who had no deterioration of mMEPs (100% vs. 30.2%, p < 0.001). The sensitivity of mMEPs in predicting postoperative motor function in monitored muscles was 53.1% (95% CI 43.5–62.6), specificity was 97.9% (95% CI 95.5–99.2), PPV was 90.9% (95% CI 81.6–95.7) and NPV was 84.1% (95% CI 81.3–86.6). At median follow-up of 18.5 (IQR 13–40) months, there was no significant difference in Nurick grade between patients who had intraoperative deterioration of mMEPs and those who did not. Conclusions: Intraoperative mMEP reduction had high specificity and low sensitivity for predicting immediate postoperative neurological deficits following IMSCT resection. However, the majority of patients who had worsening of mMEPs, recovered to their preoperative functional status or a better status at follow-up and there was no significant difference in long-term functional outcome between patients with and without intraoperative mMEP changes. [ABSTRACT FROM AUTHOR]

Background: Bronchial stenosis associated with bronchial anastomosis dehiscence after lung transplantation is a catastrophic complication following lung transplantation with a paucity of therapeutic solutions. Purpose: To describe an adaptation of the parallel stent grafting technique in the pulmonary arterial territory to treat this challenging situation. Research Design: This is a case report of a 52-year-old patient who presented bronchus stenosis and bronchial anastomosis dehiscence after lung transplantion. Bronchial stenting and lung retransplantation were contraindicated. Therefore, an endovascular approach using pulmonary artery endograft placement to prevent bleeding during repeated right bronchial balloon dilation was propposed. The technique consists of the deployment of an aortic extender endoprosthesis in the right main pulmonary artery and a balloon expandable stent in the upper lobe pulmonary artery (using a parallel graft configuration) through the common femoral and right internal jugular veins, respectively. Intraoperative transesophageal echocardiogram and one-lung ventilatory ventilation are needed. Results: The patient underwent a new bronchoscopy 16 days after the procedure, that showed epithelization at the previous eroded zone, enabling bronchocopic balloon dialtion to be safely performed. A post-operative contrast-enhanced CT scan revealed an adequate positioning of the stent grafts. Despite all eforts, the patient succumbed to ventilator associated pneumonia on postoperative day 108. Data Analysis: The technique's advantages include its feasibility even in situations in which other techniques may be contraindicated and its potential use in emergencies. Its limitations include the need for experienced interventionists to perform it, and the potential risk of acute tricuspid regurgitation. Conclusion: This study illustrates the early feasibility of the parallel stent grafting technique applied to the pulmonary artery territory. However, it's safety profile regarding infectious risk was not demontrated. [ABSTRACT FROM AUTHOR]

Background: Although total intravenous anesthesia (TIVA) with propofol and remifentanil is frequently used to optimize intraoperative neurophysiological monitoring (IONM), the exact effect of remimazolam on IONM remains unknown. Here, we compared the effects of propofol and remimazolam along with remifentanil on IONM during TIVA. Methods: In this prospective, double-blind, randomized controlled trial, 64 patients requiring IONM during cervical spine surgery were administered either propofol (Group P) or remimazolam (Group R). The preoperative latencies of the somatosensory-evoked potentials (SEP; N20 for the median nerve and P37 for the tibial nerve) were measured. SEP latencies and amplitudes and motor-evoked potential (MEP) amplitudes were measured 30 min after anesthetic induction (T1), 30 min after surgical incision (T2), after laminectomy or discectomy (T3), immediately after plate insertion or pedicle screw fixation (T4), and before surgical wound closure (T5). The primary outcome was the between-group difference in the N20 latency changes measured at T1 and preoperatively. Results: The change in SEP latencies including N20 and P37 at T1 compared with preoperative time was not significantly different between Groups P and R. Except for the amplitude of the right abductor brevis, there was no significant group-by-time interaction effect for intraoperative MEP amplitudes or SEP latencies and amplitudes. Conclusions: TIVA with remimazolam and remifentanil for cervical spine surgery yielded stable IONM, comparable to those observed with conventional TIVA with propofol and remifentanil. Further clinical trials are needed in other surgical contexts and with more diverse patient populations to determine the effects of remimazolam on IONM. [ABSTRACT FROM AUTHOR]

Concerns regarding residual neuromuscular block (RNMB) have persisted since the introduction of neuromuscular blocking agents, with reported incidences in the 21st century up to 50%. Advances in neuromuscular transmission (NMT) monitoring and the introduction of sugammadex have addressed this issue, but the impact of these developments remains unclear. This prospective observational study evaluated RNMB in 500 surgical patients in a large Dutch teaching hospital with readily available quantitative NMT monitoring and reversal agents. The anaesthetic technique and intraoperative NMT monitoring were independently chosen by the attending anaesthesiologist. Acceleromyography was performed upon arrival in the PACU for patients who received nondepolarising neuromuscular blocking agents. RNMB was defined as a train-of-four ratio (TOFR) <0.9. A systematic review was conducted to analyse trends in RNMB in contemporary practice. Out of 500 patients, 11 (2.2%) had a TOFR <0.9. Intraoperative NMT monitoring was performed in 77.6% of patients, and sugammadex was administered to 38% of patients. No patient received neostigmine. The only difference was an automatically recorded TOFR ≥0.9 at the end of surgery in 61.1% in the non-RNMB group compared with 18.2% in the RNMB group (P =0.009). Our systematic review identified incidences ranging from 3.5% to 53.3% since 2000, with a decreasing trend in Europe and North America. The incidence of residual neuromuscular block in the PACU was 2.2%. This suggests significant improvement in the prevention of residual neuromuscular block and stresses the importance of rigorous neuromuscular transmission monitoring and adequate use of reversal agents. [ABSTRACT FROM AUTHOR]

During infant aortic arch reconstruction, traditional electroencephalography (EEG) provides only qualitative data limiting neuromonitoring efficacy. Interhemispheric differences in the alpha:delta ratio (ADR) and suppression ratio (SR) measured using quantitative EEG generate numerical trends that may suggest cerebral ischemia. We hypothesized that the ADR and SR during cardiopulmonary bypass (CPB) would correlate with hemodynamics, and that ADR and SR interhemispheric differences would precede neurological injury from infants requiring aortic arch reconstruction. During aortic arch reconstruction, bilateral hemispheric ADRs and SRs were recorded every five minutes in conjunction with mean arterial pressure, temperature, CPB flow, and cerebral oximetry. Data were grouped into the cooling, antegrade cerebral perfusion (ACP), and rewarming periods of CPB. Correlation analysis determined relationships between the ADR, SR, and hemodynamic data. The cumulative interhemispheric ADR and SR differences were calculated during CPB. Neurological injury was defined as clinical/subclinical seizure or stroke. Among 79 infants, the ADRs decreased significantly during rewarming, whereas SRs were significantly greatest during ACP. There was a direct correlation between the ADR and cerebral oximetry (R2 = 0.734; P < 0.001) and an inverse correlation between the SR and temperature (R2 = 0.882; P < 0.001). Eight infants developed neurological injury that was more often preceded by an interhemispheric ADR difference >0.1 (50% vs 7.8%; P = 0.01) or SR difference >18% (41.7% vs 4.8%; P = 0.008). The ADR and SR correlate with cerebral oximetry and temperature, respectively, and significant interhemispheric differences often preceded neurological injury, suggesting the importance of quantitative EEG monitoring during infant aortic arch reconstruction. [ABSTRACT FROM AUTHOR]

Objectives: Intraoperative parathyroid hormone (IOPTH) monitoring has become routine in parathyroid surgery to facilitate less invasive techniques to treat hyperparathyroidism. Despite this, little is known about in vivo IOPTH kinetics, which can greatly affect the reliability of its interpretation. Methods: A prospective cohort of patients undergoing routine parathyroidectomy was studied. During each case, IOPTH was measured frequently, during all key perioperative events. Qualitative, univariate, and multivariate analysis was performed to better understand the patterns of in vivo IOPTH kinetics. Results: The IOPTH increased from preoperative baseline in every case, but some patients had a rapid spike after gland manipulation while others had a more gradual increase. The IOPTH peak occurred prior to excision in almost every case. The IOPTH began to fall prior to excision, typically returning to preoperative baseline levels just before excision. The average in vivo half-life of parathyroid hormone (PTH) was 5.2 minutes. Conclusion: There is substantial variation in the in vivo IOPTH kinetics and more research is needed to understand predictors of kinetic patterns and PTH half-life during parathyroidectomy. [ABSTRACT FROM AUTHOR]

A 24-year-old male with a history of a 1 year left side headache and left CN III palsy. After all examinations, an endoscopic endonasal approach was considered. Surgery was performed with neuronavigation and intraoperative neurophysiological monitoring. CSF diversion with external lumbar drain for 3 days was used. After surgery, CN III recovered and new CN VI palsy developed. Fortunately, it was transient and completely resolved 3 months later. No other complications were observed.By Bakhtiyar Pashaev and Arseniy PichuginReported by Author; Author [Extracted from the article]

The article discusses the surgical treatment of giant vestibular schwannomas, focusing on the goal of radical tumor removal while preserving facial nerve function. The study analyzed 30 patients with large VS, with most patients experiencing complete hearing loss on the tumor side. Results showed that total resection was achieved in 16% of patients, with 54% having good postoperative outcomes for facial nerve function. The use of modern neurosurgical technology and monitoring was highlighted as crucial for successful outcomes in treating these complex tumors. [Extracted from the article]

The article "Breaking the Impenetrable Fortress: The Infratrigeminal-Suprafloccular Approach to Pontine Lesions" published in the Journal of Neurological Surgery explores a new surgical approach for treating intrapontine lesions in the brainstem. Through the analysis of twenty cadaveric brainstem specimens, the authors identified a safe entry zone for microsurgical procedures, reducing the risk of post-operative complications and preserving critical structures. This study provides valuable insights into the microsurgical anatomy of the pontine region, offering a potential solution for addressing complex pathologies in a previously challenging area of the brain. [Extracted from the article]

This scoping review from the Journal of Neurological Surgery. Part B. Skull Base examines the use of intraoperative neuromonitoring (IONM) for cranial nerves III, IV, and VI during cranial base surgeries. The review found that the literature on this topic is limited, with no consensus on the optimal monitoring strategy. Results suggest that electromyography (EMG) monitoring may be associated with a higher risk of post-operative deficits compared to electrooculography (EOG) monitoring. Further research with larger patient cohorts is needed to better understand the implications of these monitoring techniques. [Extracted from the article]

The article "Cranial Nerve Function Preservation in Surgical Resection of Tumors with Jugular Foramen Extension: A Systematic Review" explores the challenges and techniques involved in preserving cranial nerve function during surgical resection of tumors extending into the jugular foramen. The study reviewed 265 patients, predominantly female, with Schwannoma being the most common pathology. Different surgical approaches were utilized, with the petro-occipital trans-sigmoid approach showing better preservation of lower cranial nerve function. The study emphasizes the importance of surgical planning and expertise in reducing cranial nerve morbidity during these procedures. [Extracted from the article]

The article explores the long-term cranial nerve outcomes following cerebellopontine angle meningioma resection, focusing on the effects of surgical and clinical characteristics on immediate and long-term outcomes. The study included 48 patients, predominantly female, with common deficits in cranial nerves 3/4/6, 5, and 8 pre-operatively. Significant reductions in deficits were observed post-operatively, with female sex and gross total resection associated with improved outcomes. The study emphasizes the importance of early intervention and consistent follow-up for enhancing long-term cranial nerve function. [Extracted from the article]

The article discusses the value of using Visual Evoked Potentials (VEPs) for intraoperative monitoring during neurosurgical procedures at King Saud University Medical City in Saudi Arabia. The study included 42 patients, with most experiencing preoperative visual symptoms. Results showed that VEP monitoring correlated with postoperative visual outcomes, with a high sensitivity and positive predictive value. The authors suggest that incorporating VEP monitoring, along with other modalities, can help optimize clinical outcomes and reduce visual impairment morbidity. [Extracted from the article]

Objectives: Posterior fossa decompression is currently an operative treatment of choice for Chiari Malformation I (CM1). However, there is controversy surrounding the possible benefits of employing intraoperative neuromonitoring (INM) for this type of procedure. In addition to presenting our single-center experience on the use of INM, we analyze the cost associated with INM in Chiari Malformation (CM) decompression surgery using the Healthcare Cost and Utilization Project (HCUP) database and discuss the legal implications of somatosensory evoked potentials (SSEP) monitoring during decompression for CM1. Methods: We conducted a retrospective review of all patients undergoing CM1 decompression with SSEP neuromonitoring from 2011 to 2018. We collected patient characteristics, hospital charges, and surgical cost data from the HCUP database for patients undergoing CM decompression. Finally, we performed a review within the Thompson Reuters Westlaw Edge database for reported litigation involving INM for CM decompression. Results: None of the 110 patients submitted to surgery for CM1 at our institution had any significant SSEP changes intraoperatively or developed post-operative neurological deterioration. There were higher mean total hospital charges and surgical costs associated with INM ($31,272) for patients who received INM compared to patients who did not receive INM ($24,112). A careful review of the Westlaw database with multiple-word search strategies revealed no reported medical malpractice claims regarding the absence of SSEP neuromonitoring in a CM decompression procedure. Conclusion: Using data collected at our institution and the HCUP national database, we showed that intraoperative neuromonitoring did not affect surgical planning and decision-making or post operative care, while adding unnecessary costs to CM decompression procedures. The absence of reported malpractice claims targeting the lack of neuromonitoring in CM cases suggests that SSEP neuromonitoring during CM may be unnecessary. We propose that neuromonitoring should not be used for routine CM decompression. [ABSTRACT FROM AUTHOR]

Lumbar foraminal stenosis can be surgically treated by foraminal decompression or facet joint resection and fusion (transforaminal lumbar interbody fusion, TLIF). While conventional foraminal decompression poses a risk of segmental instability, the endoscopic approach (extended endoscopic lumbar foraminotomy, EELF) resects only the ventral part of the facet joint with a horizontal surgical trajectory. A prospective observational study was performed to analyze the cost-effectiveness of EELF versus TLIF. Patients with dominant unilateral radicular pain from lumbar foraminal stenosis at or above L4-5, without severe central stenosis or instability, were included from January 2021 to February 2023. EELF involved sufficient foraminal widening using a reamer, followed by an endoscopic procedure. The primary outcome was the cost per quality-adjusted life year (QALY) gain at postoperative 12 months. Among 26 patients in each group, the primary analysis included 23 EELF patients (mean age: 72 ± 8 years) and 22 TLIF patients (mean age: 70 ± 8 years). EELF was significantly more cost-effective (EELF: $15,536.0 ± 4,190.0/QALY vs. TLIF: $32,869.4 ± 5,429.3/QALY, p <.001) and demonstrated shorter operating times, less blood loss, and shorter length of stay (p <.05), with no significant difference in clinical outcomes. Thus, EELF could be a cost-effective and less invasive alternative for treating lumbar foraminal stenosis. [ABSTRACT FROM AUTHOR]

Purpose: To investigate the technique for dorsal median sulcus (DMS) mapping and assess its application value in preserving dorsal columnn (DC) function during intramedullary space occupying surgery based on a single-center experience. Methods: A retrospective analysis was conducted on 41 cases of intramedullary spinal cord tumor admitted to the Department of Neurosurgery at the First Affiliated Hospital of Xiamen University from March 2017 to August 2023. All included cases underwent intraoperative electrophysiological monitoring, and were divided into a study group (n = 18) and a control group (n = 23), based on whether DMS mapping technique was utilized. The general and clinical data, intraoperative electrophysiological monitoring data, and changes in patients' deep sensory function before and after surgery were collected. The postoperative neurological function protection of the two groups of patients with intramedullary spinal cord tumor was compared. Results: The present study introduces a technique for DMS mapping through the dorsal region stimulation. The amplitude and waveform of somatosensory evoked potentials (SEPs) recorded by the nerve stimulation probe consistently exhibited patterns relative to the dorsal column. This method demonstrated stable localization of the DMS during surgical procedures in all cases (18/18). Furthermore, compared to the double fork bipolar neurostimulator, the concentric bipolar neurostimulator induced SEPs with higher amplitudes in the dorsal column. There was no significant difference in tumor resection duration between the two groups, while postoperative hospitalization duration was shorter in the study group than in control group. During incision of dorsal column, SEP deterioration rate was 0/18 in study group and 4/23 in control group. During the procedure of tumor resection, the rate of deterioration in SEP was 5/18 in the study group and 9/23 in the control group. One week and three months post-surgery, the rate of decline in deep sensation in lower limbs was 4/18 and 3/18 respectively for the study group, while it was 8/23 and 9/23 for the control group. Conclusion: The technique of DMS mapping is both stable and feasible, can assist the surgeon in accurately identifying the position of the posterior median sulci of the spinal cord and performing a precise dorsal columnotomy along the electrophysiological midline. This method holds great potential in enhancing the preservation of deep sensory function in patients' lower limbs post-surgery, thereby enabling them to benefit from the technique. Additionally, SEP Mapping of dorsal column aids in comprehending their function and facilitating rapid localization. Consequently, this approach introduces a novel neuroprotective measure for multimodal electrophysiological monitoring during intramedullary space occupying surgery. [ABSTRACT FROM AUTHOR]

Objective: The primary goal was to investigate whether the presence of preoperative lacunar infarcts (LACI) was associated with postoperative delirium (POD) in elderly patients undergoing elective major abdominal surgery. Design: A prospective cohort study. Setting and participants: Patients aged ≥ 65 years from a tertiary level A hospital in China. Methods: The POD was assessed once daily within the first postoperative 3 days using the Confusion Assessment Method. Neurocognitive tests using the Mini-mental State Examination (MMSE) and the Beijing version of the Montreal Cognitive Assessment scales were carried out within 3 days before surgery and 4–7 days after surgery. Regional cerebral oxygen saturation (rScO2) was recorded in the operating room. Logistic regression analysis was used to evaluate the impact of preoperative LACI on POD and to explore the risk factors for POD. Results: A total of 369 participants were analyzed, 161 in the preoperative LACI-positive group (P group), and 208 in the preoperative LACI-negative group (N group), respectively. The incidence of POD was 32.7% in our study. The incidence of POD was significantly higher in the P group than in the N group (39.1 vs 27.9%, risk ratio, 1.66; 95% CI 1.07–2.58; P = 0.022). Furthermore, the P group exhibited lower mean rScO2 values during the procedure (P < 0.001). In exploratory analysis, the advanced age (P = 0.005), sex (P = 0.038), and lower preoperative MMSE score (P = 0.019) were independent risk factors for POD in patients undergoing major abdominal surgery. Conclusions and implications: Preoperative LACI was common, and constituted a risk factor for POD in older patients undergoing abdominal surgery. Despite the frequent subclinical nature, the preoperative LACI led to lower mean rScO2 during the procedure. These findings could help early identification of high-risk POD patients. [ABSTRACT FROM AUTHOR]

Background: Patients undergoing general anesthesia are more frequently monitored for depth of anesthesia using processed electroencephalography. Opioid-free anesthesia is nowadays an accepted modality for general anesthesia, however it is unclear how to interpret data from processed electroencephalography when using a mixture of non-opioid anesthetic drugs. Our objective was to describe density spectral array patterns and compare processed encephalographic data indices between opioid-free and routine opioid based anesthesia. Methods: This prospective observational cohort study was conducted on 30 adult patients undergoing laparoscopic surgery in a non-tertiary regional hospital. The patients underwent general anesthesia with three different methods and were monitored for anesthesia depth using processed encephalography and density spectral array. Primary outcome is a group-derived mean difference in patient state index and spectral edge frequency. As a secondary outcome a descriptive comparison of the spectral power, derived from the density spectral array, was done between groups. Results: The opioid-free anesthesia group had significantly higher patient state index and spectral edge frequency compared to routine anesthesia. Density spectral array patterns were also different, most notably lacking the high power in alpha frequency spectrum seen in the other routine anesthesia methods. Conclusions: Processed electroencephalography monitoring can be used in opioid-free anesthesia, however clinicians should expect higher values in monitoring indices. The density spectral array pattern using a common protocol for opioid-free anesthesia, with mainly sevoflurane combined with low doses of dexmedetomidine and esketamine, differs from well described opioid and GABA-ergic anesthesia methods. These findings should be further validated using other protocols for opioid-free anesthesia in order to safely monitor anesthesia depth. Trial registration: Clinicaltrials.gov registration number NCT06227143, registration date; 26th of January 2024. [ABSTRACT FROM AUTHOR]

Background: Limited information is available regarding the application of lung-protective ventilation strategies during one-lung ventilation (OLV) across mainland China. A nationwide questionnaire survey was conducted to investigate this issue in current clinical practice. Methods: The survey covered various aspects, including respondent demographics, the establishment and maintenance of OLV, intraoperative monitoring standards, and complications associated with OLV. Results: Five hundred forty-three valid responses were collected from all provinces in mainland China. Volume control ventilation mode, 4 to 6 mL per kilogram of predictive body weight, pure oxygen inspiration, and a low-level positive end-expiratory pressure ≤ 5 cm H2O were the most popular ventilation parameters. The most common thresholds of intraoperative respiration monitoring were peripheral oxygen saturation (SpO2) of 90–94%, end-tidal CO2 of 45 to 55 mm Hg, and an airway pressure of 30 to 34 cm H2O. Recruitment maneuvers were traditionally performed by 94% of the respondents. Intraoperative hypoxemia and laryngeal injury were experienced by 75% and 51% of the respondents, respectively. The proportions of anesthesiologists who frequently experienced hypoxemia during OLV were 19%, 24%, and 7% for lung, cardiovascular, and esophageal surgeries, respectively. Up to 32% of respondents were reluctant to perform lung-protective ventilation strategies during OLV. Multiple regression analysis revealed that the volume-control ventilation mode and an SpO2 intervention threshold of < 85% were independent risk factors for hypoxemia during OLV in lung and cardiovascular surgeries. In esophageal surgery, working in a tier 2 hospital and using traditional ventilation strategies were independent risk factors for hypoxemia during OLV. Subgroup analysis revealed no significant difference in intraoperative hypoxemia during OLV between respondents who performed lung-protective ventilation strategies and those who did not. Conclusions: Lung-protective ventilation strategies during OLV have been widely accepted in mainland China and are strongly recommended for esophageal surgery, particularly in tier 2 hospitals. Implementing volume control ventilation mode and early management of oxygen desaturation might prevent hypoxemia during OLV. [ABSTRACT FROM AUTHOR]

Thyroid cancer is a common malignancy that requires comprehensive clinical evaluation prior to adequate surgical management. Over the last three decades thyroid surgery has tripled and is considered one of the most commonly performed procedures in general surgery. These procedures are associated with potential postoperative complications with significant deterioration in the patient's quality of life. While the current rates of recurrent laryngeal nerve injury following thyroidectomy have decreased secondary to intraoperative neuromonitoring, thyroid surgery remains the leading cause of iatrogenic injury. The authors herein present a case of a thyroid nodule with cervical lymph node involvement undergoing total thyroidectomy guided by near-ultraviolet (NUV) imaging nerve auto-fluorescent technology to visualize, identify and protect vital structures. [ABSTRACT FROM AUTHOR]

Introduction: Penetrating spinal cord injuries present unique clinical scenarios with high variability in presentation and management. These injuries are rare, accounting for 0.8% of annual penetrating spine injuries in the United States, with knives being the most common penetrating object. Retention of the knife blade further complicates management, with greater risk of infection and progressive neurologic injury. Given the rarity and variability of such injuries, preferred management for penetrating-knife spinal cord injuries (PKSCI), especially those with retained knife blades, remains contested. Furthermore, the management of PKSCI with concurrent lung injury is poorly described within the literature. Case Report: Here we discuss a unique case of a neurologically intact adult male who suffered a large lower thoracic PKSCI with complete dural transection and lung involvement. The patient arrived with the blade in situ while maintaining full neurologic function. Emergent imaging revealed the blade trajectory passing through the T8 lamina exiting the spinal canal at the costovertebral junction with involvement of the lung parenchyma and associated pneumorrhachis and pneumothorax. The patient was brought to the operating room where the blade was removed under direct visualization, the dura was repaired, and pneumothorax was stabilized. Conclusion: We describe in this case the choice of imaging, method of blade removal, cerebrospinal fluid leak management, dural repair, and concurrent lung injury management that afforded a favorable, ASIA class E outcome with complete preservation of neurologic function. [ABSTRACT FROM AUTHOR]

Sensory evoked potentials (EPs), namely, somatosensory, visual, and brainstem acoustic EPs, are used in neurosurgery to monitor the corresponding functions with the aim of preventing iatrogenic neurological complications. Functional deficiency usually precedes structural defect, being initially reversible, and prompt alarms may help surgeons achieve this aim. However, sensory EP registration requires presenting multiple stimuli and averaging of responses, which significantly lengthen this procedure. As delays can make intraoperative neuromonitoring (IONM) ineffective, it is important to reduce EP recording time. The possibility of speeding up EP recording relies on differences between IONM and outpatient clinical neurophysiology (CN). Namely, in IONM, the patient is her/his own control, and the neurophysiologist is less constrained by norms and standards than in outpatient CN. Therefore, neurophysiologists can perform a personalized selection of optimal locations of recording electrodes, frequency filter passbands, and stimulation rates. Varying some or all of these parameters, it is often possible to significantly improve the signal-to-noise ratio (SNR) for EPs and accelerate EP recording by up to several times. The aim of this paper is to review how this personalized approach is or may be applied during IONM for recording sensory EPs of each of the abovementioned modalities. Also, the problems hindering the implementation and dissemination of this approach and options for overcoming them are discussed here, as well as possible future developments. [ABSTRACT FROM AUTHOR]

Background: Posterior spinal instrumentation and fusion is an established surgical procedure for the correction of adolescent idiopathic scoliosis. Intraoperative neurophysiological monitoring is standard practice for this procedure. Anesthetic agents can have different, but significant, effects on neurophysiological monitoring outcomes. Aim: To determine if intravenous lidocaine infusion therapy has an impact on the intraoperative neurophysiological monitoring during posterior spinal instrumentation and fusion for adolescent idiopathic scoliosis. Methods: Following ethical approval, we conducted a retrospective review of charts and the archived intraoperative neurophysiological data of adolescents undergoing posterior spinal instrumentation and fusion for adolescent idiopathic scoliosis. Intraoperative neurophysiological monitoring data included the amplitude of motor evoked potentials and the amplitude and latency of somatosensory evoked potentials. A cohort who received intraoperative lidocaine infusion were compared to those who did not. Results: Eighty‐one patients were included in this analysis, who had surgery between February 4, 2016 and April 22, 2021: 39 had intraoperative intravenous lidocaine infusion and 42 did not. Based on hourly snapshot data, there was no evidence that lidocaine infusion had a detrimental effect on the measured change from baseline for MEP amplitudes in either lower (mean difference 41.9; 95% confidence interval −304.5 to 388.3; p =.182) or upper limbs (MD −279.0; 95% CI −562.5 to 4.4; p =.054). There was also no evidence of any effect on the measured change from baseline for SSEP amplitudes in either lower (MD 16.4; 95% CI −17.7 to 50.5; p =.345) or upper limbs (MD −2.4; 95% CI −14.5 to 9.8; p =.701). Finally, there was no evidence of a difference in time to first reportable neurophysiological event (hazard ratio 1.13; 95% CI 0.61 to 2.09; p =.680). Conclusions: Data from these two cohorts provide preliminary evidence that intravenous lidocaine infusion has no negative impact on intraoperative neurophysiological monitoring during PSIF for adolescent idiopathic scoliosis. [ABSTRACT FROM AUTHOR]

• Electrical stimulation in white matter induces delays in the evoked response due to slow conduction velocity. • The waveforms from white matter and cortical stimulation remain generally identical. • Responses to white matter and cortical stimulation differ on response times. • The relaxation of the N1 component is longer during cortical stimulations. • There is probable activation of intra-cortical axons during cortical stimulation. Direct cortical responses (DCR) and axono-cortical evoked potentials (ACEP) are generated by electrically stimulating the cortex either directly or indirectly through white matter pathways, potentially leading to different electrogenic processes. For ACEP, the slow conduction velocity of axons (median ≈ 4 m.s−1) is anticipated to induce a delay. For DCR, direct electrical stimulation (DES) of the cortex is expected to elicit additional cortical activity involving smaller and slower non-myelinated axons. We tried to validate these hypotheses. DES was administered either directly on the cortex or to white matter fascicles within the resection cavity, while recording DCR or ACEP at the cortical level in nine patients. Short but significant delays (≈ 2 ms) were measurable for ACEP immediately following the initial component (≈ 7 ms). Subsequent activities (≈ 40 ms) exhibited notable differences between DCR and ACEP, suggesting the presence of additional cortical activities for DCR. Distinctions between ACEPs and DCRs can be made based on a delay at the onset of early components and the dissimilarity in the shape of the later components (>40 ms after the DES artifact). The comparison of different types of evoked potentials allows to better understand the effects of DES. [ABSTRACT FROM AUTHOR]

Background In recent years, transcarotid artery revascularization (TCAR) has emerged as a safe and effective alternative to carotid artery stenting. While intraoperative neuromonitoring (IONM) techniques such as electroencephalogram (EEG) and somatosensory evoked potentials (SSEPs) are often employed during TCAR, there is limited research on their diagnostic accuracy. Methods The authors retrospectively reviewed a multi-institutional IONM database of TCAR procedures performed with EEG and SSEP monitoring. A total of 516 TCAR procedures were included in this study. Significant changes in EEG and/or SSEPs, surgeon's interventions, resolution of significant changes, and immediate postoperative neurological outcome were documented. Sensitivity, specificity, positive and negative predictive values were calculated. Results The incidence of intraoperative onset new neurologic deficit was 0.4%. Significant changes in EEG and/or SSEPs occurred in 5.4% of the cases. Of the cases with IONM alerts, 78.5% returned to baseline with a surgical or hemodynamic intervention. From the cases with unresolved IONM alerts, 33.3% woke up with a new neurological deficit. The overall sensitivity and specificity for IONM was 100% and 99.2%, respectively. The positive predictive value was 33.3% and the negative predictive value was 100%. Conclusions IONM during TCAR offers high sensitivity and specificity in predicting postoperative outcome. Patients with resolved IONM alerts had immediate neurological outcomes that were comparable to those who had no IONM alerts. [ABSTRACT FROM AUTHOR]

Evoked potentials can be used as an intraoperative monitoring measure in neurological surgery. Auditory evoked potentials (AEPs), or specifically brainstem auditory evoked responses (BAERs), are known for being minimally affected by anesthetics, while visually evoked potentials (VEPs) are presumed to be unreliable and easily affected by anesthetics. While many anesthesia trials or intraoperative recordings have provided evidence in support of these hypotheses, the comparisons were always made between AEPs and VEPs recorded sequentially, rather than recorded at the same time. Although the logistics of improving data comparability of AEPs and VEPs may be a challenge in clinical settings, it is much more approachable in animal models to measure AEPs and VEPs as simultaneously as possible. Five cats under dexmedetomidine sedation received five, 10-min blocks of isoflurane with varying concentrations while click-evoked AEPs and flash-evoked VEPs were recorded from subdermal electrodes. We found that, in terms of their waveforms, (1) short-latency AEPs (BAERs) were the least affected while middle-latency AEPs were dramatically altered by isoflurane, and (2) short-latency VEPs was less persistent than that of short-latency AEPs, while both middle- and long-latency VEPs were largely suppressed by isoflurane and, in some cases, completely diminished. In addition, the signal strength in all but the middle-latency AEPs was significantly suppressed by isoflurane. We identified multiple AEP or VEP peak components demonstrating suppressed amplitudes and/or changed latencies by isoflurane. Overall, we confirmed that both cat AEPs and VEPs are affected during isoflurane anesthesia, as in humans. [ABSTRACT FROM AUTHOR]

Background: Craniocervical junction (CCJ) dural arteriovenous fistulas (DAVFs) represent a rare yet critical vascular anomaly that may result in significant neurological impairments. Method: We report the case of a 52-year-old male with a history of medullary hemorrhage who underwent surgical intervention for a left CCJ DAVF. Through comprehensive surgical planning and meticulous intraoperative monitoring, multiple feeders of the DAVF were safely coagulated and transected, with successful DAVF obliteration confirmed by intraoperative angiography. Conclusion: The patient demonstrated full recovery, underscoring the efficacy of surgical management in complex cases facilitated by advanced techniques in a hybrid operating theatre. [ABSTRACT FROM AUTHOR]

Objective: Due to the absence of studies supporting the role of intraoperative neurophysiological monitoring (IONM) in intradural spinal tumors, this study evaluates the clinical outcome after these surgeries in relation to the use of the advanced intraoperative neurophysiological techniques. Methods: This is an observational, descriptive and retrospective study of two cohort groups in relation to the presence or absence of IONM during the intervention and the subsequent evaluation of the clinical and functional results in the short and medium terms. Ninety-six patients with extra- or intramedullary intradural spinal tumors operated on by the neurosurgery team of our center completed the current study. Results: We observed improvements in the Prolo, Brice and McKissock and McCormick scales scores in the monitored patients. These results examine the usefulness of IONM to preserve neurological functions and, therefore, its impact on quality of life. The rate of neurological deficits in the unmonitored patients was 14.5%, whereas it was 8.3% of the patients whose treatment included IONM. Conclusions: It is important to emphasize the importance of implementing IONM for early recognition of possible neurological damage, the improvement of postoperative functional outcomes, and for decreasing the rate of neurological complications. Significance: This study provides reliable results on the importance of IONM in intradural spinal tumor surgeries. [ABSTRACT FROM AUTHOR]

Background/Objectives: Cerebral arteriovenous malformations (AVMs) are rare but complex vascular anomalies, particularly challenging when located in eloquent regions such as the corpus callosum and post-central gyrus. This report aims to highlight the management and outcomes of a 41-year-old female patient with a hemorrhagic AVM in these critical areas, emphasizing the importance of early surgical intervention and advanced imaging techniques. Methods: The patient presented with a right-sided tonic–clonic seizure and expressive aphasia, prompting imaging that revealed a complex AVM with deep venous drainage and arterial supply from the anterior cerebral artery. A multidisciplinary team performed microsurgical resection via a left parasagittal fronto-parietal craniotomy. The surgical approach prioritized hematoma evacuation followed by a stepwise dissection of the AVM nidus under intraoperative monitoring. Results: Complete resection of the AVM was confirmed through postoperative angiographic and CT imaging. The patient showed stable recovery over 15 months, with no recurrence or new neurological deficits. This case demonstrates the critical role of advanced imaging, intraoperative strategies, and a multidisciplinary approach in achieving successful outcomes. Conclusions: Microsurgical resection remains the gold standard for AVMs in eloquent and deep-seated brain regions. Early diagnosis and tailored surgical interventions are crucial for managing these high-risk cases. This case underscores the importance of integrating advanced imaging, strategic surgical planning, and intraoperative monitoring to minimize complications and optimize long-term recovery. [ABSTRACT FROM AUTHOR]

Purpose: Anorectal and urogenital dysfunctions are common after rectal surgery and have a significant impact on quality of life. Intraoperative pelvic autonomic nerve monitoring (pIONM) has been proposed as a tool to identify patients at risk of these functional sequelae. This systematic review aims to evaluate the diagnostic accuracy of pIONM in detecting anorectal and urogenital dysfunction following rectal surgery. Methods: A systematic review of articles published since 1990 was conducted using MEDLINE, Embase, CINAHL, Google Scholar, Scopus, and Web of Science. Studies describing pIONM for rectal surgery and reporting anorectal or urogenital functional outcomes were included. The risk of bias was assessed using the QUADS-2 tool. The diagnostic accuracy of pIONM was established with pooled sensitivity and specificity alongside summary receiver-operating characteristic curves. Results: Twenty studies including 686 patients undergoing pIONM were identified, with seven of these studies including a control group. There was heterogeneity in the pIONM technique and reported outcome measures used. Results from five studies indicate pIONM may be able to predict postoperative anorectal (sensitivity 1.00 [95% CI 0.03–1.00], specificity 0.98 [0.91–0.99]) and urinary (sensitivity 1.00 [95% CI 0.03–1.00], specificity 0.99 [0.92–0.99]) dysfunction. Conclusions: This review identifies the diagnostic accuracy of pIONM in detecting postoperative anorectal and urogenital dysfunction following rectal surgery. Further research is necessary before pIONM can be routinely used in clinical practice. PROSPERO Registration Details: CRD42022313934. [ABSTRACT FROM AUTHOR]

Background: Biventricular pacing (BIV) is the gold standard for cardiac resynchronization therapy (CRT). Thirty percent of patients do not respond to CRT. Conduction system pacing (CSP) represents a viable alternative. Interventricular conduction delay (IVCD), as electrical desynchrony marker, is a CRT response predictor. The aim of this study was to determine the incidence of CRT responders by selecting the best approach between BIV and CPS based on intraoperative IVCD measurement in patients with HFrEF and LBBB. Methods: Ninety‐six patients were randomly assigned in a 1:1 ratio to either a standard BIV group(control group, CG) or a group where the CRT approach was determined based on IVCD evaluation(study group, SG). If the right ventricular sensed electrogram (RVs)–left ventricular sensed electrogram (LVs) interval was ≥100 ms, the lead was left in its original position; otherwise, the LV lead was removed, and CSP was performed instead. Clinical, EKG, and echocardiographic features have been assessed pre‐ and 6 months post‐implant. Echocardiographic and clinical responder were evaluated. Results: Thirty‐seven percent of patients in the SG underwent CSP, as the operative algorithm. The incidence of CRT responders was significantly higher in the SG (echocardiographic criterion: 92.5% vs. 69.8%, p:.009; clinical criterion 87.5% vs. 62.8%, p:.014). The SG showed a significantly greater difference in EF between pre‐ and post‐implant as well as reduced end‐diastolic and systolic volumes. Univariate and multivariate regression analysis indicated that enrollment in the SG was the only factor associated with CRT response. Conclusion: Intraoperative assessment of IVCD could help determine the optimal CRT approach between BIV and CSP, leading to a significant improvement in the rate of CRT responders. The aim of this study was to assess the optimal approach to CRT, comparing BIV and CPS based on intraoperative interventricular conduction delay (IVCD) in patients with HFrEF and LBBB. All patients initially underwent CRT using BIV. If the interval between the right ventricular sensed electrogram (RVs) and left ventricular sensed electrogram (LVs) was ≤100 ms, the LV lead was removed and CSP was performed. Twenty‐four percent of patients in the study group (SG) transitioned to CSP. The incidence of CRT responders was significantly higher in the SG compared to the control group. IVCD may serve as a guide in selecting the optimal CRT approach between BIV and CSP, resulting in a significant improvement in the rate of CRT responders. [ABSTRACT FROM AUTHOR]

Pulmonary alveolar proteinosis (PAP) is a rare pulmonary disorder characterized by the accumulation of surfactant/lipoprotein material in the alveoli and subsequent hypoxemic respiratory failure. Whole lung lavage (WLL), a procedure used to physically remove the lipoprotein material from the alveoli, is the first-line treatment for this disease process. Anesthesia providers may infrequently encounter the management of the WLL procedure due to the rarity of the underlying disease process. Pertinent anesthesia considerations for WLL are covered in the following case report. A review of the literature examines the pathophysiology of PAP, the various approaches to WLL, and the physiologic implications of WLL. [ABSTRACT FROM AUTHOR]

Opioid-free anaesthesia (OFA) is gaining recognition for its potential to mitigate opioid-related complications in surgical patients. This prospective observational study evaluates the outcomes of OFA in comparison to standard Opioid-based Anaesthesia (OA) in patients undergoing ENT surgery. Sixty patients were allocated equally into the OFA and OA groups. The primary outcomes assessed were postoperative pain scores and analgesia requirements. Secondary outcomes included the incidence of Postoperative Nausea and Vomiting (PONV), oxygen desaturation, and cardiovascular stability. The baseline demographics, laboratory parameters, and intraoperative haemodynamic monitoring indicated no significant differences between the groups, thereby confirming that the baseline conditions were comparable. Following the surgical procedure, patients who underwent OFA exhibited markedly lower pain scores and a decreased requirement for rescue analgesia. The average VNS pain scores recorded were 3.4 and 2.7 at 1 and 6 hours post-extubation, respectively, in contrast to the OA group, which reported scores of 5.1 and 4.9. Furthermore, the incidence of oxygen desaturation episodes and postoperative nausea and vomiting (PONV) was significantly reduced in the OFA group, with rates of 5.4% compared to 15.2% and 13.2% versus 27.9%, respectively. The OFA group exhibited enhanced cardiovascular stability, characterised by a reduction in the occurrences of bradycardia and hypotension. OFA demonstrates effective analgesic properties and minimises opioid-related adverse effects, indicating its potential as a safer alternative to OA in the context of ENT surgery. Additional research is necessary to validate these results and enhance OFA protocols within clinical settings. [ABSTRACT FROM AUTHOR]

Study Objective: We sought to assess the factors that are associated with ovarian preservation in the setting of surgically confirmed ovarian torsion, specifically focusing on the time to surgery after the emergency department (ED) presentation. Methods: We conducted a retrospective cohort study at a single tertiary care academic hospital from 2008 to 2021. Patients aged 12–40 with ovarian torsion were identified using diagnosis codes. We compared the outcome of ovarian preservation versus removal based on time to surgery after ED presentation, age, parity, Doppler flow, presence of ovarian mass, detorsion attempt, intraoperative suspicion of necrosis, and time of day. Results: We identified 60 surgical cases of ovarian torsion, with 25 undergoing oophorectomy (58.3% preserved). The median time from ED presentation to surgery was 8.6 hours, and only six surgeries occurred in <4 hours, which was not associated with ovarian preservation. Preservation was associated with Doppler flow (60% vs. 27%, p = 0.019) and was less likely when necrosis was suspected (20% vs. 84%, p < 0.001) and age ≥25 years (34% vs. 68%, p = 0.010). Detorsion attempts resulted in the preservation of 25% of ovaries with suspected necrosis. Parity and presentation time of day were not associated with preservation. Discussion: Time to surgery was not associated with ovarian preservation, possibly because few cases occurred in <4 hours. Setting goal times might improve outcomes. Ovaries are more likely to be preserved when detorsion is attempted despite necrotic appearance and when Doppler flow is present on sonographic exam. The surgical decision for oophorectomy may be based on factors unrelated to functional loss of the ovary. [ABSTRACT FROM AUTHOR]

Persistent spinal pain syndrome (PSPS) poses a significant medical challenge, often leading to diminished quality of life for affected individuals. In response to this clinical dilemma, spinal cord stimulation (SCS) has emerged as a promising intervention aimed at improving the functional outcomes and overall well-being of patients suffering from this debilitating syndrome. In case a therapy with percutaneous lead fails (e.g., due to a dislocation), surgical lead can be used as a stable alternative. This results in a more invasive procedure and does not allow for intraoperative monitoring. The aim of this study is to investigate the efficacy and safety of the use of surgical leads, as there have been only a few case series published so far. We included PSPS patients that gave consent to a SCS therapy and were treated with surgical leads. Outcome scores concerning the quality of life (Short Form Health Survey [SF-36]), pain related disability (Oswestry disability index [ODI]), sleeping quality (Pittsburgh Sleep Quality Index [PSQI]), and pain intensity (numeric rating scale [NRS]) were obtained prior to surgery and at outpatient visits after permanent implantation. In this study, 36 patients were implanted with a surgical lead SCS system. One patient developed a new neurologic deficit characterized by left-sided leg paresis attributable to postoperative hemorrhage, and another patient experienced a wound infection. These complications contributed to an overall morbidity rate of 5.6%. In 5 patients (20.8%), the electrodes were explanted within the first month. Follow-up data of 24 patients with a median follow-up time of 21 (interquartile range [IQR] 15–47) months were available. The mean pain intensity at rest and in motion was reduced. Further pain depending disability improved from a median ODI preop = 38% [IQR 30%–57%] to ODI follow-up = 21% [IQR 9%–35%] (P < 0.01). Additionally, the Sleeping Quality and the Quality of Life improved concerning the physical (median PCS preop = 22.5 [IQR 20.4–30.4] vs. PCS follow-up = 41.8 [IQR 35.2–47.0], P < 0.01) and mental (median MCS preop = 45.4 [IQR 31.1–55.5] vs. MCS follow-up = 58.1 [IQR 47.6–59.8], P = 0.018) component. SCS with surgical leads is a safe secondary technique to treat PSPS, where treatment with percutaneous leads fail. The results show a promising long-term effect concerning pain intensity and functional outcome. [ABSTRACT FROM AUTHOR]

Intracranial pressure (ICP) is a well-established measure in managing not only traumatic brain injury but also nontraumatic intracranial bleeding or edema. When ICP increases despite nursing or medical management, ICP may be reduced via surgical measures. Deciding whether to perform a craniotomy vs. craniectomy (whether the bone flap is replaced or not, respectively) is commonly made intraoperatively following preoperative planning. While ICP monitoring (ICPm) is standard pre- and postoperatively, its intraoperative utility remains understudied. We conducted a study utilizing prospectively gathered and retrospectively analyzed data from 25 traumatic brain injury surgical decompression cases at a single center. All cases had intraoperative ICPm throughout surgery. Our findings indicate that ICPm significantly influenced real-time intraoperative decision-making, diverging from preoperative. These results bring forward the potential pivotal role of intraoperative ICPm in guiding surgical strategies for elevated ICP, suggesting a novel data-driven approach to intraoperative management of decompression surgery. [ABSTRACT FROM AUTHOR]

Japanese neurosurgery faces challenges such as a declining number of neurosurgeons and their concentration in urban areas. Particularly in rural areas, access to neurosurgical care for patients with conditions, such as stroke, is limited, raising concerns about the collapse of regional healthcare. Robot-assisted surgical technologies have advanced in recent years, contributing to the improved precision and safety of deep brain surgery. This study proposes the "Artificial Intelligence (AI) and Robot-Assisted Surgery Moonshot Plan" for Japan, comprising 5 pillars: 1) establishment of regional medical centers, 2) development of remote surgery systems, 3) enhancement of robotic-assisted surgery training programs, 4) integration of AI technologies, and 5) promotion of industry-academia-government collaboration. In addition, strengthening the approach to spinal surgery is expected to revitalize regional medical centers, optimize the number of neurosurgeons, improve surgical skills, and promote minimally invasive surgery. This study analyzed the current status and challenges of Japanese neurosurgery through a literature review and statistical analysis. AI is used in various aspects of neurosurgery, including diagnostic support, surgical planning and navigation, treatment outcome prediction, intraoperative monitoring, robot-assisted surgery, and rehabilitation. However, challenges, such as data bias, ethical issues, costs, and regulations, remain. In Japan, issues such as the uneven distribution and decline of neurosurgeons, collapse of regional healthcare, and increase in the number of patients with spinal disorders due to aging have been highlighted. The "AI and Robot-Assisted Surgery Moonshot Plan" serves as a guide to overcome the challenges of neurosurgery in Japan and establish a sustainable medical system. [ABSTRACT FROM AUTHOR]

Septate uterus is one of the most common uterine malformations. Recent studies suggest that uterine septa may negatively affect fertility. In cases of recurrent pregnancy loss (RPL) or infertility, hysteroscopic metroplasty has been considered the primary treatment for septate uterus. This systematic review and meta-analysis aims to evaluate whether intraoperative ultrasound monitoring may improve the efficacy of hysteroscopic metroplasty compared to other types of intraoperative monitoring or to unguided resections. An electronic database search was performed to identify articles published until June 15, 2023. Five studies (two randomized clinical trials, two prospective studies and one retrospective cohort study) fulfilled the inclusion criteria. The primary outcome was the rate of residual septum > 10 mm after hysteroscopic metroplasty in the ultrasound (US) monitoring group compared to the rate of residual septum using other types of intraoperative monitoring/no monitoring (control group). The secondary outcomes were any residual septa, surgical time, complications, uterine perforations and reproductive outcomes. Intraoperative ultrasound for uterine septum resection significantly reduced the rate of residual septum > 10 mm and the rate of any residual septa compared to the control group. There was no statistically significant difference in the procedure time between women undergoing intraoperative US monitoring versus the control group. A trend toward reduction of surgical complications was observed in the intraoperative US group compared to the control group. In conclusion, intraoperative ultrasound during metroplasty may reduce the rate of the residual septum with no surgical time differences. Further studies are warranted to understand how this may improve reproductive outcomes. [ABSTRACT FROM AUTHOR]

The aim of this study was to verify the possibility of obtaining vital sign information using a laser and radar sensor in a manner that is non-invasive and painless for test animals. A dataset was obtained from respiratory movement of anaesthetized male F344 rats, signals of laser and radar sensors were recorded simultaneously with vital data acquired with an integrated multiple-channel intraoperative monitor. In addition, respiratory movements were also video recorded, and used as reference data of respiration rate (RR; ref-RR). Reference data for heart rate (HR; ref-HR) were obtained from the R wave of electrocardiogram data for each epoch. Signals recorded from the radar sensor (I- and Q-signals) were input to a computer, and HR (radar-HR) and RR (radar-RR) were estimated using the frequency analysis method. Among the six positions where respiratory movements were measured by the laser sensor, the number of peak counts matched the visual counts of respiratory movements in the video records. The respiratory movements were significantly the greatest over the most caudal rib in the dorsal (p < 0.001). The average radar-RR and ref-RR values showed correspondence (ref-RR, 69 ± 6.2 breaths/min; radar-RR, 68 ± 5.7 breaths/min (p = 0.04–1.00); equivalence ratio, 86%). The radar-HR data showed slight variability; however, there was 80% homology compared with the ref-HR values (ref-HR, 336 ± 19.6 beats/min; radar-HR, 348 ± 34.1 (p = 0.10–0.95)). Although comparison of the data under noradrenaline administration failed to track drug-induced changes in some cases, the HR and RR data of anesthetized rats measured from the radar sensor system showed comparable accuracy to other conventional methods. [ABSTRACT FROM AUTHOR]

• In high-cervical intramedullary spinal cord tumor surgery, unimpaired D-wave reliably predicts preserved gross-motor function for all covered spinal levels. • D-wave fails to predict the occurrence of mild permanent postoperative deficits affecting the fine-motor and compex hand function. • Only the combination of D-wave, mMEPs, EMG and SSEPs is able to provide a viable power for monitoring the complex hand function. D-wave can safely monitor the corticospinal-tract (CST)-function regarding gross-motor outcome of lower extremities, but it is still unknown whether i)D-wave can also safely monitor the gross-motor outcome of distal upper extremities in those patients undergoing high-cervical intramedullary-spinal-cord-tumor (IMSCT)-resection (enabling epidural D-wave-placement below C5) and ii)multimodal IONM can also predict fine-motor/complex hand function. We prospectively assessed 20 patients undergoing IMSCT-surgery above the C4/5-level with multimodal IONM (D-wave/mMEPs/EMG/SSEPs). Detailed gross-/fine-motor and complex hand function was assessed pre- and postoperatively and during long-term follow-up (mean:29.5 ± 18.8 months) and correlated with IONM-findings. D-wave monitoring was without intraoperative critical changes in all patients and none had any permanent postoperative gross-motor deficits. However, D-wave did not allow to predict the occurrence of mild permanent postoperative deficits affecting fine-motor function which was the case in 8% for distal upper extremities. The complex distal upper extremities' function assessed by Nine-Hole-Peg-Test (reflecting the complex motor/sensory interaction for hand-usability) was permanently deteriorated in 15% postoperatively and only the combination of D-wave/mMEPs/EMG/SSEPs was able to provide a viable predictive power (specificity:79%/sensitivity:43%). In high-cervical IMSCT-surgery, unimpaired D-wave reliably predicts preserved gross-motor function, but fails to sufficiently cover distal upper extremities' fine-motor/complex function. Our study underlines the importance of multimodal IONM for fine-motor/complex hand function. [ABSTRACT FROM AUTHOR]

Background/Objectives: Spinal astrocytomas (SA) represent 30–40% of all intramedullary spinal cord tumors (IMSCTs) and present significant clinical challenges due to their aggressive behavior and potential for recurrence. We aimed to pool the evidence on SA and investigate predictors of regrowth or recurrence after surgical resection. Methods: A systematic review and meta-analysis were conducted on peer-reviewed human studies from several databases covering the field of SA. Data were collected including sex, age, tumor location, extent of resection, histopathological diagnosis, and adjuvant therapy to identify predictors of SA recurrence. Recurrence was defined as failure of local tumor control or regrowth after treatment. Results: A total of 53 studies with 1365 patients were included in the meta-analysis. A postoperative deterioration in neurological outcomes, as assessed by the modified McCormick scale, was noted in most of the patients. The overall recurrence rate amounted to 41%. On meta-analysis, high-grade WHO tumors were associated with higher odds of recurrence (OR = 2.65; 95% CI: 1.87, 3.76; p = 0.001). Similarly, GTR was associated with lower odds of recurrence compared to STR (OR = 0.33; 95% CI: 0.18, 0.60; p = 0.0003). Sex (p = 0.5848) and tumor location (p = 0.3693) did not show any significant differences in the odds of recurrence. Intraoperative neurophysiological monitoring was described in 8 studies and adjuvant radiotherapy in 41 studies. Conclusions: The results highlight the significant importance of tumor grade and extent of resection in patient prognosis. The role of adjuvant radiotherapy remains unclear, with most studies suggesting no differences in outcomes, with limitations due to potential confounders. [ABSTRACT FROM AUTHOR]

Recurrent laryngeal nerve (RLN) injury during neck surgery can cause significant morbidity related to vocal cord (VC) dysfunction. VC electromyography (EMG) is used to aid in the identification of the RLN and can reduce the probability of inadvertent surgical injury. Errors in the placement of specialized EMG endotracheal tubes (ETT) can result in unreliable signals, false-negative responses, or no response when stimulating the RLN. We describe a novel educational protocol developed to optimize uniformity in the placement of ETTs to improve the reliability of RLN monitoring. An intraoperative neuromonitoring database was queried for all neck surgeries requiring RLN monitoring. Data points extracted for all cases requiring EMG monitoring for neck procedures. Free running and stimulated EMG were monitored and continuously recorded by a certified technologist. Alerts were compared between 2013–14 and 2015–18 using a two-sample test of proportions. Significant reductions in alerts were demonstrated after protocol implementation (7.5% pre-implementation to 2.1% post). Alerts were compared between 2013–14 (overall alert rate of 1.8%, pre-implementation period) and 2015–18 (overall alert rate of 2.8%, post-implementation period). Protocolization for placement of EMG-ETT improved accuracy in EMG monitoring. In the follow-up cohort of 1,080 patients, use of this protocol continued to reduce the rate of alerts related to ETT malposition, confirming the sustainability of this intervention through routine education. The risk of nerve injury is reduced when the rate of alerts is minimized. Scheduled or continuous protocol education of anesthesia personnel should continue to ensure compliance with protocol. [ABSTRACT FROM AUTHOR]

Background: Studies show that the two peak heights of electroencephalographic bicoherence (pBIC-high, pBIC-low) decrease after incision and are restored by fentanyl administration. We investigated whether pBICs are good indicators for adequacy of analgesia during surgery. Methods: After local ethical committee approval, we enrolled 50 patients (27–65 years, ASA-PS I or II) who were scheduled elective surgery. Besides standard anesthesia monitors, to assess pBICs, we used a BIS monitor and freeware Bispectrum Analyzer for A2000. Fentanyl 5 µg/kg was completely administered before incision, and anesthesia was maintained with sevoflurane. After skin incision, when the peak of pBIC-high or pBIC-low decreased by 10% in absolute value (named LT10-high and LT10-low groups in order) or when either peak decreased to below 20% (BL20-high and BL20-low groups), an additional 1 g/kg of fentanyl was administered to examine its effect on the peak that showed a decrease. Results: The mean values and standard deviation for pBIC-high 5 min before fentanyl administration, at the time of fentanyl administration, and 5 min after fentanyl administration for LT10-high group were 39.8% (10.9%), 26.9% (10.5%), and 35.7% (12.5%). And those for pBIC-low for LT10-low group were 39.5% (6.0%), 26.8% (6.4%) and 35.0% (7.0%). Those for pBIC-high for BL20-high group were 26.3% (5.6%), 16.5% (2.6%), and 25.7% (7.0%). And those for pBIC-low for BL20-low group were 26.7% (4.8%), 17.4% (1.8%) and 26.9% (5.7%), respectively. Meanwhile, at these trigger points, hemodynamic parameters didn't show significant changes. Conclusion: Superior to standard anesthesia monitoring, pBICs are better indicators of analgesia during surgery. Trial registry: Clinical trial Number and registry URL: UMIN ID: UMIN000042843 https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr%5fview.cgi?recptno = R000048907 [ABSTRACT FROM AUTHOR]

Microwave ablation therapy is frequently used to treat liver malignancies. To ensure proper tumor treatment, intraoperative feedback regarding ablation performance and lesion size is required. By employing an electrode array around the ablation needle, changes in electrical impedance of ex vivo liver are measured in real time. Time-series trends of magnitude and phase are measured for 90 °C and 110 °C ablation temperatures. A finite element model is additionally configured to simulate the underlying biological processes. Gradients in the magnitude and phase trends can indicate the growth of the ablation zone. In combination with a preoperative simulation, impedance-based ablation monitoring can be a possible tool to improve future treatments. [ABSTRACT FROM AUTHOR]

Minimally invasive parathyroidectomy is the treatment of choice in patients with primary hyperparathyroidism (PHP), but it needs a reliable preoperative localization method to detect hyperfunctioning parathyroid tissue. Higher sensitivity and lower radiation exposure was demonstrated for [18F]fluorocholine PET/CT (FCh-PET/CT) in comparison to [99mTc]sestamibi (MIBI) scintigraphy. However, data of its efficiency in resource use and patient outcomes is lacking. The aim of our study was to determine the resource efficiency and patient outcomes of FCh-PET/CT in comparison to conventional MIBI scintigraphy. A group of 234 patients who underwent surgery after MIBI scintigraphy was compared to a group of 163 patients who underwent surgery after FCh-PET/CT. The whole working process from the implementation of imaging to the completion of surgical treatment was analyzed. The economic burden was expressed in the time needed for the required procedures. The time needed to perform imaging was reduced by 83% after FCh-PET/CT in comparison to MIBI scintigraphy. The time needed to perform surgery was reduced by 41% when intraoperative parathyroid hormone monitoring was not used. There was no significant difference in the time of surgery between FCh-PET/CT and MIBI scintigraphy. FCh-PET/CT reduces the time of imaging, the time of surgery and potentially reduces the number of reoperations for persistent disease. [ABSTRACT FROM AUTHOR]