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Context Confirming a diagnosis of Cushing disease (CD) remains challenging, yet is critically important before recommending transsphenoidal surgery for adenoma resection. Objective To describe predictive performance of preoperative biochemical and imaging data relative to post-operative remission and clinical characteristics in patients with presumed CD. Design, Setting, Patients, Interventions Patients (n = 105; 86% female) who underwent surgery from 2007 through 2020 were classified into 3 groups: group A (n = 84) pathology-proven ACTH adenoma; group B (n = 6) pathology-unproven but with postoperative hypocortisolemia consistent with CD; and group C (n = 15) pathology-unproven, without postoperative hypocortisolemia. Group A + B were combined as confirmed CD and group C as unconfirmed CD. Main outcomes Group A + B was compared with group C regarding predictive performance of preoperative 24-hour urinary free cortisol (UFC), late night salivary cortisol (LNSC), 1-mg dexamethasone suppression test (DST), plasma ACTH, and pituitary magnetic resonance imaging (MRI). Results All groups had a similar clinical phenotype. Compared with group C, group A + B had higher mean UFC (P Conclusions Use of strict biochemical thresholds may help avoid offering transsphenoidal surgery to presumed CD patients with equivocal data and improve surgical remission rates. Patients with Cushingoid phenotype but equivocal biochemical data warrant additional rigorous testing.

Purpose To evaluate the impact of using consistent complication-avoidance protocols in patients undergoing endoscopic pituitary adenoma surgery including techniques for avoiding anosmia, epistaxis, carotid artery injury, hypopituitarism, cerebrospinal fluid leaks and meningitis. Methods All patients undergoing endoscopic adenoma resection from 2010 to 2020 were included. Primary outcomes included 90-day complication rates, gland function outcomes, reoperations, readmissions and length of stay. Secondary outcomes were extent of resection, short-term endocrine remission, vision recovery. Results Of 514 patients, (mean age 51 ± 16 years; 78% macroadenomas, 19% prior surgery) major complications occurred in 18(3.5%) patients, most commonly CSF leak (9, 1.7%) and meningitis (4, 0.8%). In 14 of 18 patients, complications were deemed preventable. Four (0.8%) had complications with permanent sequelae (3 before 2016): one unexplained mortality, one stroke, one oculomotor nerve palsy, one oculoparesis. There were no internal carotid artery injuries, permanent visual worsening or permanent anosmia. New hypopituitarism occurred in 23/485(4.7%). Partial or complete hypopituitarism resolution occurred in 102/193(52.8%) patients. Median LOS was 2 days; 98.3% of patients were discharged home. Comparing 18 patients with major complications versus 496 without, median LOS was 7 versus 2 days, respectively p Conclusion This study suggests that conformance to established protocols for endoscopic pituitary surgery may minimize complications, re-admissions and LOS while enhancing the likelihood of preserving gland function, although there remains opportunity for further improvements.

BACKGROUND With growing worldwide endoscopy experience, endonasal and supraorbital removal of tuberculum sellae meningiomas (TSM) has increased. OBJECTIVE To describe anatomic factors for guiding approach selection and outcomes. METHODS Retrospective analysis of patients undergoing endonasal or supraorbital TSM resection: approach criteria, clinical outcomes, acute magnetic resonance imaging (MRI) fluid-attenuated inversion-recovery (FLAIR)/T2 changes. RESULTS From 2008 to 2020, 33 patients (mean age 55 ± 11 yr) were identified: 20 (61%) had endonasal and 13 (39%) supraorbital removal. Comparing endonasal and supraorbital approaches, mean tumor volume (3.7 ± 3.5 cm3 vs 7.7 ± 8.5 cm3, P = .07); percent tumor above planum (42% vs 65%, P = .02), and lateral tumor beyond supraclinoid internal carotid arteries (1.4 ± 2.0 mm vs 4.0 ± 3.2 mm, P = .006) were greater for supraorbital route. Sellar depth was greater for endonasal route tumors (12.2 ± 2.6 mm vs 9.3 ± 2.4 mm, P = .003). Endoscopy, used in 10/13(77%) supraorbital cases, was helpful in additional tumor removal in 4/10(40%). Gross total removal and mean volumetric tumor resection were 16/20(80%) and 97.5% by endonasal, and 5/13(39%) and 96% by supraorbital route. Vision improved in 12/17 (71%) endonasal, 6/8 (75%) supraorbital operations, and worsened in 1 (3%) supraorbital case. Endonasal approach with optic canal decompression increased over study period: 15/20 (75%) endonasal patients vs 1/13(8%) supraorbital (P

Background Numerous randomized controlled trials (RCTs) relevant to the cerebrovascular field have been performed. The fragility index was recently developed to complement the P value and measure the robustness and reproducibility of clinical findings of RCTs. Objective In this study, we evaluate the fragility index for key surgical and endovascular cerebrovascular RCTs and propose a novel RCT classification system based on the fragility index. Methods Cerebrovascular RCTs reported between 2000 and 2018 were reviewed. Six key areas were specifically targeted in relation to stroke, carotid stenosis, cerebral aneurysms, and subarachnoid hemorrhage. The correlation between fragility index, number of patients lost to follow-up, and fragility quotient were evaluated to propose a classification system for the robustness of the studies. Results A total of 20 RCTs that reported significant differences between both study groups in terms of the primary outcome were included. The median fragility index for the trials was 5.5. An additional 30 randomly selected RCTs were added to propose a classification system with high reliability. The difference between the number of patients lost to follow-up and fragility index inversely correlated with the fragility quotient and was used to divide the robustness of the RCTs into 3 classes reflecting the reproducibility of the trial. Conclusions Neurosurgeons and neurointerventionalists should exercise caution with interpreting the results of cerebrovascular RCTs, especially when the sample size and events numbers are small and there is a high number of patients who were lost to follow-up, as quantitatively identified using the proposed classification system.

The concept of spinal cord injury has existed since the earliest human civilizations, with the earliest documented cases dating back to 3000 BC under the Egyptian Empire. Howevr, an understanding of this field developed slowly, with real advancements not emerging until the 20th century. Technological advancements including the dawn of modern warfare producing mass human casualties instigated revolutionary advancement in the field of spine injury and its management. Spine surgeons today encounter "Chance" and "Holdsworth" fractures commonly; however, neurosurgical literature has not explored the history of these physicians and their groundbreaking contributions to the modern understanding of spine injury. A literature search using a historical database, Cochrane, Google Scholar, and PubMed was performed. As needed, hospitals and native universities were contacted to add their original contributions to the literature. George Quentin Chance, a Manchester-based British physician, is well known to many as an eminent radiologist of his time who described the eponymous fracture in 1948. Sir Frank Wild Holdsworth (1904-1969), a renowned British orthopedic surgeon who laid a solid foundation for rehabilitation of spinal injuries under the aegis of the Miners' Welfare Commission, described in detail the management of thoraco-lumbar junctional rotational fracture. The work of these 2 men laid the foundation for today's understanding of spinal instability, which is central to modern spine injury classification and management algorithms. This historical vignette will explore the academic legacies of Sir Frank Wild Holdsworth and George Quentin Chance, and the evolution of spinal instability and spine injury classification systems that ensued from their work.

Purpose Minimally invasive meningioma removal through transcranial and endoscopic endonasal keyhole routes remain controversial. Herein we detail results of keyhole meningioma removal defined as use of a minimally invasive “retractorless” approach for which a traditional larger approach is often used instead. Methods Retrospective analysis from 2008-2021 of consecutive patients undergoing keyhole meningioma removal through one of six approaches: extent of resection, complications, endoscopy use, MRI FLAIR/T2 changes. Surgical goal was maximal safe removal including conservative(subtotal) removal for some invasive locations. Results Of 329 patients, keyhole approaches were utilized in 193(59%) patients (mean age 59±13; 30(15.5%) prior surgery) who underwent 213 operations; 205(96%) were skull base location. Approaches included: endoscopic endonasal(n=74,35%), supraorbital(n=73,34%), retromastoid(n=38,18%), mini-pterional(n=20,9%), suboccipital(n=4,2%), and contralateral transfalcine(n=4,2%). Primary outcomes: Gross total/near total(>90%) resection: 125(59%); (5% for petroclival, cavernous sinus/Meckel’s cave, spheno-cavernous locations vs 77% other locations). Complications included: permanent neurological worsening12(6%); CSF leak 2(1%); meningitis 2(1%); no patients sustained DVT, PE, MI, or 30-day mortality. Median LOS was 3 days with 94% discharged home and 96% with favorable 90-day KPS. Secondary outcomes: Small persistent FLAIR/T2 changes: 11(5.2%) patients. Endoscopy use: 87/139(63%) of craniotomies, facilitating additional tumor removal in 55%. Tumor progression was observed in 26(13%) patients(mean follow-up 42±36 months). Conclusion This analysis suggests keyhole meningioma removal can be associated with reasonable resection rates, low complication rates, short hospitalizations and high 90-day performance scores. Subtotal removal may be appropriate for invasive/adherent meningiomas to avoid complications. With careful patient selection and requisite experience, these approaches may be considered alternatives to traditional approaches.

In 1961, President John F. Kennedy declared that the United States would send a man to the moon and safely bring him home before the end of the decade. Astronaut Michael Collins was one of those men. He flew to the moon on the historic flight of Apollo 11 while Neil Armstrong and Buzz Aldrin walked on its surface. However, this was not supposed to be the case.Astronaut Collins was scheduled to fly on Apollo 8. While training, in 1968, he started developing symptoms of cervical myelopathy. He underwent evaluation at Wilford Hall Air Force Hospital in San Antonio and was noted to have a C5–6 disc herniation and posterior osteophyte on myelography. Air Force Lieutenant General (Dr.) Paul W. Myers performed an anterior cervical discectomy with placement of iliac bone graft. As a result, Astronaut James Lovell took his place on Apollo 8 flying the uncertain and daring first mission to the moon. This had a cascading effect on the rotation of astronauts, placing Michael Collins on the Apollo 11 flight that first landed men on the moon. It also placed Astronaut James Lovell in a rotation that exposed him to be the Commander of the fateful Apollo 13 flight.Here, the authors chronicle the history of Astronaut Collins’ anterior cervical surgery and the impact of his procedure on the rotation of astronaut flight selection, and they review the pivotal historic nature of the Apollo 8 spaceflight. The authors further discuss the ongoing issue of cervical disc herniation among astronauts.

The sellar and parasellar area is the site of many pituitary-related tumors and cysts including the most common pathologies pituitary adenomas, Rathke's cleft cysts, and craniopharyngiomas. For the great majority of these lesions, when symptomatic, surgery is considered first-line therapy. The transsphenoidal approach has evolved considerably and is considered the preferred route for most pathologies. However, despite accumulating worldwide experience and technological advances, including increasing use of an endoscopic approach, complications and suboptimal outcomes can and do occur. This chapter discusses the risks of surgery and strategies as well as clinical protocols from the preoperative to the postoperative phase to avoid complications and optimize outcomes while stressing the importance of teamwork in managing these complex patients.

Longer lifespan and newer imaging protocols have led to more older adults being diagnosed with pituitary adenomas. Herein, we describe outcomes of patients ≥ 65 years undergoing endoscopic adenoma removal. To address selection criteria, we also assess a conservatively managed cohort. A retrospective analysis of 90-day outcomes of patients undergoing endoscopic pituitary adenomectomy from 2010 to 2019 by a neurosurgical/ENT team was performed. Tumor subtype, cavernous sinus invasion, extent of resection/early remission, endocrinology outcomes, complications, re-operations and readmissions were analyzed. A comparator cohort ≥ 65 years undergoing clinical surveillance without surgery was also analyzed. Of 468 patients operated on for pituitary adenoma, 123 (26%) were ≥ 65 years (range 65–93 years); 106 (86.2%) had endocrine-inactive adenomas; 18 (14.6%) had prior surgery. Of 106 patients with endocrine-inactive adenomas, GTR was achieved in 70/106 (66%). Of 17 patients with endocrine-active adenomas, early biochemical remission was: Cushing’s 6/8; acromegaly 1/4; prolactinomas 1/5. Gland function recovery occurred in 28/58 (48.3%) patients with various degrees of preoperative hypopituitarism. New anterior hypopituitarism occurred in 3/110 (2.4%) patients; permanent DI in none. Major complications in 123 patients were: CSF leak 2 (1.6%), meningitis 1 (0.8%), vision decline 1 (0.8%). There were no vascular injuries, operative hematomas, anosmia, deaths, MIs, or thromboembolic events. Median length of stay was 2 days. Readmissions occurred in 14/123 (11.3%) patients, 57% for delayed hyponatremia. Intra-cohort analysis by age (65–69, 70–74, 75–79, ≥ 80 years) revealed no outcome differences. Cavernous sinus invasion (OR 7.7, CI 1.37–44.8; p = 0.02) and redo-surgery (OR 8.5, CI 1.7–42.8; p = 0.009) were negative predictors for GTR/NTR. Of 105 patients evaluated for presumed pituitary adenoma beginning in 2015, 72 (69%) underwent surgery, 8 (7%) had prolactinomas treated with cabergoline and 25 (24%) continue clinical surveillance without surgery, including two on new hormone replacement. This study suggests that elderly patients carefully selected for endoscopic adenoma removal can have excellent short-term outcomes including high resection rates, low complication rates and short length of stay. Our experience supports a multidisciplinary approach and the concept of pituitary centers of excellence. Based on our observations, approximately 25% of elderly patients with pituitary adenomas referred for possible surgery can be monitored closely without surgery.

Background Complications arising from cerebral venous occlusion/sacrifice during neurosurgical procedures have received comparatively less attention in the neurosurgical literature. Consequently, cerebral venous complications are not given due recognition, even though most practicing neurosurgeons would agree that they are not uncommon. We present a review of complications arising from venous sacrifice/occlusion during neurosurgery and discuss strategies described in the literature to prevent such occurrences. Methods We conducted a systematic review of the literature to provide a synopsis of the current evidence regarding cerebral venous injury after a neurosurgical procedure. The objectives of this review were to assess the incidence of venous injuries after a neurosurgical procedure with their clinical outcome and to evaluate current strategies and technical advances for their prevention. Complications related to dural venous sinuses were not considered in this review. Results Twenty-six relevant articles were identified and reviewed. Complications from cerebral venous occlusion/sacrifice are being increasingly recognized, and venous preservation strategies are being promoted in the neurosurgical literature. Based on our review of literature, the incidence of venous injury can range from 2.6% to 30%. We discuss the pathophysiology after venous injury and factors affecting outcome after cerebral venous injury. An overview of surgical techniques described to prevent or manage venous injury during neurosurgical procedures is presented. Conclusions The unpredictable response of the brain to venous injury causes catastrophic complications in a few patients. To avoid these complications, meticulous venous preservation should be a goal in all neurosurgical procedures. Increased recognition of cerebral venous complications over the last 2 decades has resulted in the increasing recognition among neurosurgeons that venous preservation is an essential tenet of neurosurgery.

Objective Natalizumab, a selective adhesion molecule inhibitor binding to an α-4 subunit of integrin, has emerged to be an effective immunomodulator, especially in the treatment of relapsing-remitting multiple sclerosis and Crohn disease. Recent reports documenting the development of primary central nervous system lymphoma (PCNSL) as a result of its administration have been concerning, and they trigger a debate about a possible causal association. In our report, we provide a comprehensive review of the literature on lymphoma development after natalizumab use, and we report an additional case of PCNSL development in a young woman who received natalizumab for her Crohn disease. Methods A systematic (qualitative) review of literature on lymphoma development after natalizumab therapy was performed by use of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data on patient characteristics, indication for drug therapy, dosages, radiologic findings, potential risk factors for PCNSL, and tumor markers were synthesized. Additionally, we present the findings from the case of a young woman who received natalizumab therapy (4 doses, 300 mg each) for Crohn disease and in whom PCNSL developed. Results Overall, 8 reports including our index case document lymphoma development after natalizumab use. Our case finding revisits the debate suggesting a remote possibility of association that warrants further evaluation and validation. Conclusions Evidence documenting a causal association of natalizumab and PCNSL is weak. Considering the potential benefits of using natalizumab for current indications, we recommend vigilant monitoring of patients receiving the drug for PCNSL outlook.

Limited information exists evaluating the impact of hospital caseload and elective admission on outcomes after patients have undergone extracranial-intracranial (ECIC) bypass surgery. Using the Nationwide Inpatient Sample (NIS) for 2001-2014, we evaluated the impact of hospital caseload and elective admission on outcomes after bypass.In an observational cohort study, weighted estimates were used to investigate the association of hospital caseload and elective admission on short-term outcomes after bypass surgery using multivariable regression techniques.Overall, 10,679 patients (mean age, 43.39 ± 19.63 years; 59% female) underwent bypass across 495 nonfederal U.S. hospitals. In multivariable models, patients undergoing bypass at high-volume centers were associated with decreased probability of mortality (odds ratio [OR], 0.39; 95% confidence interval [CI], 0.22-0.70; P 0.001), length of stay (OR, 0.86; 95% CI, 0.82-0.90; P 0.001), postbypass neurologic complications (OR, 0.66; 95% CI, 0.49-0.89; P = 0.007), venous thromboembolism (OR, 0.69; 95% CI, 0.49-0.97; P = 0.033), and acute renal failure (OR, 0.45; 95% CI, 0.26-0.80; P = 0.007), and higher hospitalization cost (26.3% higher) compared with low-volume centers. Likewise, patients undergoing elective bypass were associated with decreased likelihood of mortality (OR, 0.38; 95% CI, 0.25-0.59; P0.001), unfavorable discharge (OR, 0.57; 95% CI, 0.43-0.76; P0.001), length of stay (OR, 0.62; 95% CI, 0.59-0.64; P0.001), venous thromboembolism (OR, 0.61; 95% CI, 0.49-0.77; P 0.001), acute renal failure (OR, 0.64; 95% CI, 0.43-0.94; P = 0.022), wound complications (OR, 0.71; 95% CI, 0.53-0.96; P = 0.028), and lower hospitalization cost (34.5% lower) compared with nonelective admissions.Our findings serve as a framework for strengthening referral networks for complex cases to centers performing high volumes of cerebral bypass. Also, our study supports improved outcomes in select patients undergoing elective bypass procedures.

Evidence-based consensus on timing to surgical decompression following symptom onset in patients with cauda equina syndrome (CES) is limited or widely debated.This study aimed to investigate whether timing to intervention in the management of patients with CES has an impact on outcomes.This is a retrospective cohort study.The patient sample included 4,066 adult patients with CES registered in the Nationwide Inpatient Sample database (2005-2011) and undergoing elective decompression surgery.The outcome measures are inpatient mortality, unfavorable discharge (discharge to rehabilitation), prolonged length of stay (LOS75th percentile), and high hospital charges in patients undergoing decompression for CES.The patients were stratified into three categories based on timing to surgical intervention: (1) within 24 hours (n=1,846, 45.6%); (2) between 24 and 48 hours (n=1,080, 26.6%), and (3) beyond 48 hours (n=1,130, 27.8%). Multivariable logistic regression fitted with generalized estimating equations using the sandwich variance-covariance matrix estimator to account for the clustering of similar outcomes within hospitals was used to examine the association of timing to surgical intervention categories with binary primary end points. For metric end points (charges), we used the ordinary least squares model to test the effect of timing to intervention.The mean age of the cohort was 50.19±17.55 years and 41% were female. In comparison to patients operated within 24 hours, increased likelihood of inpatient mortality (odds ratio [OR]: 3.61, 95% confidence interval [CI]: 1.32-9.85, p=.012), unfavorable discharge (OR: 2.23, 95% CI: 1.87-2.66, p.001), prolonged postsurgical LOS (OR: 1.76, 95% CI: 1.44-2.14, p.001), and high hospital charges (OR:1.92, 95% CI: 1.81-2.05, p.001) were observed in patients operated on over 48 hours since admission. Likewise, patients with incomplete CES with intervention beyond 48 hours had higher odds for unfavorable discharge (OR: 2.51, 95% CI: 1.99-3.17, p.001), prolonged postsurgical LOS (OR: 1.73, 95% CI: 1.35-2.20, p.001), and high hospital charges (OR: 1.94, 95% CI: 1.79-2.10, p.001). Likewise, patients with complete CES with interventions beyond 48 hours had higher odds for unfavorable discharge (OR: 1.86, 95% CI: 1.41-2.45, p.001), prolonged postsurgical LOS (OR: 2.06, 95% CI: 1.53-2.77, p.001), and high hospital charges (OR: 1.39, 95% CI: 1.15-1.68, p.001).Early intervention in CES, regardless of the subtype (complete or incomplete), has higher likelihood of improved inpatient outcomes. The odds of getting better were higher, however, with incomplete CES. The timing of intervention did not seem to matter in traumatic CES as compared with degenerative etiology. Prospective randomized controlled trials may further help elucidate the impact of early intervention on outcomes in patients with CES.

OBJECTIVEIncreased lifespan has led to more elderly patients being diagnosed with meningiomas. In this study, the authors sought to analyze and compare patients ≥ 65 years old with those < 65 years old who underwent minimally invasive surgery for meningioma. To address surgical selection criteria, the authors also assessed a cohort of patients managed without surgery.METHODSIn a retrospective analysis, consecutive patients with meningiomas who underwent minimally invasive (endonasal, supraorbital, minipterional, transfalcine, or retromastoid) and conventional surgical treatment approaches during the period from 2008 to 2019 were dichotomized into those ≥ 65 and those < 65 years old to compare resection rates, endoscopy use, complications, and length of hospital stay (LOS). A comparator meningioma cohort of patients ≥ 65 years old who were observed without surgery during the period from 2015 to 2019 was also analyzed.RESULTSOf 291 patients (median age 60 years, 71.5% females, mean follow-up 36 months) undergoing meningioma resection, 118 (40.5%) were aged ≥ 65 years and underwent 126 surgeries, including 20% redo operations, as follows: age 65–69 years, 46 operations; 70–74 years, 40 operations; 75–79 years, 17 operations; and ≥ 80 years, 23 operations. During 2015–2019, of 98 patients referred for meningioma, 67 (68%) had surgery, 1 (1%) had radiosurgery, and 31 (32%) were observed. In the 11-year surgical cohort, comparing 173 patients < 65 years versus 118 patients ≥ 65 years old, there were no significant differences in tumor location, size, or outcomes. Of 126 cases of surgery in 118 elderly patients, the approach was a minimally invasive approach to skull base meningioma (SBM) in 64 cases (51%) as follows: endonasal 18, supraorbital 28, minipterional 6, and retrosigmoid 12. Endoscope-assisted surgery was performed in 59.5% of patients. A conventional approach to SBM was performed in 15 cases (12%) (endoscope-assisted 13.3%), and convexity craniotomy for non–skull base meningioma (NSBM) in 47 cases (37%) (endoscope-assisted 17%). In these three cohorts (minimally invasive SBM, conventional SBM, and NSBM), the gross-total/near-total resection rates were 59.5%, 60%, and 91.5%, respectively, and an improved or stable Karnofsky Performance Status score occurred in 88.6%, 86.7%, and 87.2% of cases, respectively. For these 118 elderly patients, the median LOS was 3 days, and major complications occurred in 10 patients (8%) as follows: stroke 4%, vision decline 3%, systemic complications 0.7%, and wound infection or death 0. Eighty-three percent of patients were discharged home, and readmissions occurred in 5 patients (4%). Meningioma recurrence occurred in 4 patients (3%) and progression in 11 (9%). Multivariate regression analysis showed no significance of American Society of Anesthesiologists physical status score, comorbidities, or age subgroups on outcomes; patients aged ≥ 80 years showed a trend of longer hospitalization.CONCLUSIONSThis analysis suggests that elderly patients with meningiomas, when carefully selected, generally have excellent surgical outcomes and tumor control. When applied appropriately, use of minimally invasive approaches and endoscopy may be helpful in achieving maximal safe resection, reducing complications, and promoting short hospitalizations. Notably, one-third of our elderly meningioma patients referred for possible surgery from 2015 to 2019 were managed nonoperatively.

OBJECTIVEWalter E. Dandy described for the first time the anatomical course of the superior petrosal vein (SPV) and its significance during surgery for trigeminal neuralgia. The patient’s safety after sacrifice of this vein is a challenging question, with conflicting views in current literature. The aim of this systematic review was to analyze the current surgical considerations regarding Dandy’s vein, as well as provide a concise review of the complications after its obliteration.METHODSA systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A thorough literature search was conducted on PubMed, Web of Science, and the Cochrane database; articles were selected systematically based on the PRISMA protocol and reviewed completely, and then relevant data were summarized and discussed.RESULTSA total of 35 publications pertaining to the SPV were included and reviewed. Although certain studies report almost negligible complications of SPV sectioning, there are reports demonstrating the deleterious effects of SPV obliteration when achieving adequate exposure in surgical pathologies like trigeminal neuralgia, vestibular schwannoma, and petroclival meningioma. The incidence of complications after SPV sacrifice (32/50 cases in the authors’ series) is 2/32 (6.2%), and that reported in various case series varies from 0.01% to 31%. It includes hemorrhagic and nonhemorrhagic venous infarction of the cerebellum, sigmoid thrombosis, cerebellar hemorrhage, midbrain and pontine infarct, intracerebral hematoma, cerebellar and brainstem edema, acute hydrocephalus, peduncular hallucinosis, hearing loss, facial nerve palsy, coma, and even death. In many studies, the difference in incidence of complications between the SPV-sacrificed group and the SPV-preserved group was significant.CONCLUSIONSThe preservation of Dandy’s vein is a neurosurgical dilemma. Literature review and experiences from large series suggest that obliterating the vein of Dandy while approaching the superior cerebellopontine angle corridor may be associated with negligible complications. However, the counterview cannot be neglected in light of some series showing an up to 30% complication rate from SPV sacrifice. This review provides the insight that although the incidence of complications due to SPV obliteration is low, they can happen, and the sequelae might be worse than the natural history of the existing pathology. Therefore, SPV preservation should be attempted to optimize patient outcome.

OBJECTIVETotal tumor excision with the preservation of neurological function and quality of life is the goal of modern-day vestibular schwannoma (VS) surgery. Postoperative facial nerve (FN) paralysis is a devastating complication of VS surgery. Determining the course of the FN in relation to a VS preoperatively is invaluable to the neurosurgeon and is likely to enhance surgical safety with respect to FN function. Diffusion tensor imaging–fiber tracking (DTI-FT) technology is slowly gaining traction as a viable tool for preoperative FN visualization in patients with VS.METHODSA systematic review of the literature in the PubMed, Cochrane Library, and Web of Science databases was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and those studies that preoperatively localized the FN in relation to a VS using the DTI-FT technique and verified those preoperative FN tracking results by using microscopic observation and electrophysiological monitoring during microsurgery were included. A pooled analysis of studies was performed to calculate the surgical concordance rate (accuracy) of DTI-FT technology for FN localization.RESULTSFourteen studies included 234 VS patients (male/female ratio 1:1.4, age range 17–75 years) who had undergone preoperative DTI-FT for FN identification. The mean tumor size among the studies ranged from 29 to 41.3 mm. Preoperative DTI-FT could not visualize the FN tract in 8 patients (3.4%) and its findings could not be verified in 3 patients (1.2%), were verified but discordant in 18 patients (7.6%), and were verified and concordant in 205 patients (87.1%).CONCLUSIONSPreoperative DTI-FT for FN identification is a useful adjunct in the surgical planning for large VSs (> 2.5 cm). A pooled analysis showed that DTI-FT successfully identifies the complete FN course in 96.6% of VSs (226 of 234 cases) and that FN identification by DTI-FT is accurate in 90.6% of cases (205 of 226 cases). Larger studies with DTI-FT–integrated neuronavigation are required to look at the direct benefit offered by this specific technique in preserving postoperative FN function.

Traumatic injuries to the thoracolumbar spine result in a high incidence of unstable fractures. The goal of the surgical management is to achieve an adequate decompression and stabilization. We have analyzed operative and postoperative features of anterior surgical approaches.We retrospectively analyzed the medical records of 45 patients that presented with traumatic unstable thoracolumbar fractures who underwent anterior corpectomy with stabilization from January 1999 to January 2009. The neurological status of the patient was defined using the American Spinal Injury Association (ASIA) impairment scale.The average age of the patients was 37.6 years (range: 13-70), with a male-to-female ratio of 1.5:1. Retroperitoneal approach was used in 64.4%, transthoracic in 13.3%, and transthoracic transdiaghragmatic in 22.2%. The average operation time, estimated blood loss (EBL), and length of stay after surgery was 412.3 min, 1098 ml and 9.1 days, respectively. A BMI25 was associated with longer operative times (p0.02) and higher EBL (p0.006). Perioperative complications occurred in 37.7%, (7 major, 10 minor). The mean sagittal angulation improved from 15.5 degree preoperatively to 8.7 degree postoperatively (p0.001). Postoperative neurological status remained intact in all patients having preoperative ASIA-E status (n=18), improved in 7 of 14 patients with ASIA-D, and improved in 1 of 5 patients with ASIA-B preoperative neurological deficit. There were no cases of neurological deterioration postoperatively, and majority of the patient (84.4%) of the patients were discharged home. At latest follow-up (mean 27.2 months) there were no new cases of neurological deficits, and 9 patients had a further improvement of neurological status.Based on our findings, anterior surgical approach appears to be a safe and effective technique for managing traumatic thoracic and lumbar unstable burst fractures. This is also evident that anterior decompression and stabilization achieves a significant correction of kyphotic deformity with a lower risk of neurological deterioration and pseudoarthrosis.

Objective and Importance. To illustrate the development of spontaneous subdural hematoma secondary to aplastic anemia resulting from the administration of trimethoprim-sulfamethoxazole. This is the first report of trimethoprim-sulfamethoxazole potentiating coagulopathy leading to any form of intracranial hematoma.Clinical Presentation. A 62-year-old female developed a bone marrow biopsy confirmed diagnosis of aplastic anemia secondary to administration of trimethoprim-sulfamethoxazole following a canine bite. She then developed a course of waxing and waning mental status combined with headache and balance related falls. CT imaging of the head illustrated a 3.7 cm×6.6 mm left frontal subdural hematoma combined with a 7.0 mm×1.7 cm left temporal epidural hematoma.Conclusion. Aplastic anemia is a rare complication of the administration of trimethoprim-sulfamethoxazole. Thrombocytopenia, regardless of cause, is a risk factor for the development of spontaneous subdural hematoma. Given the lack of a significant traumatic mechanism, this subset of subdural hematoma is more suitable to conservative management.

Background To analyze the differences in tumor progression patterns and histopathologic characteristics between skull base meningiomas (SBMs) and non–skull base meningiomas (NSBMs). Methods Retrospective data of 382 patients with SBMs and 200 patients with NSBMs who underwent primary microsurgical resection between January 1995 and December 2016 were analyzed. Data related to clinical history, neuroimaging, surgical technique, and follow-up were reviewed. A separate prospective cohort of 78 meningiomas operated on from June 2016 to July 2017 was analyzed (World Health Organization [WHO] grade and Ki-67 proliferation index) for biologic comparison. Results Skull base location, WHO grade II tumor, and subtotal resection were independent predictors of unfavorable outcome. The overall tumor progression rate in the SBM group (33%) was higher than in the NSBM group (19.7%) (P = 0.006) (mean follow-up period, 51 months). The 3-year, 5-year, and 10-year progression-free survival (PFS) was 78%, 60%, and 45% in the SBM group, whereas it was 90%, 80%, and 53% in the NSBM group, respectively. Interestingly, there was no difference in the median PFS after 10 years of follow-up (SBMs 210 months vs. NSBM 212 months, P = 0.93). In the prospective cohort of 78 meningiomas, there was no statistically significant difference in the proportion of WHO grade I tumors and in the mean Ki-67 index of WHO grade I meningiomas between the 2 groups. Conclusion There is a divergent tumor progression pattern for surgically treated SBMs vis-a-vis NSBMs. Differences in tumor biology and the proportion of Simpson grade I resections are likely attributable factors.

Sinus cavernosi, or the cavernous sinus, was coined by Jacques Bénigne Winslow in the 18th century. Among the neurosurgeons and the modern-day neuroanatomists, Winslow is mainly known for erroneously using the term cavernous sinus. As the anatomical understanding of the parasellar space advanced during the next 200 years, it was unclear as to why Winslow compared this space in the brain with that of a male reproductive organ (corpus cavernosum). Our primary objective was to study the historical treatise on anatomy written by Winslow in the 18th century and analyze his anatomical dissections and nomenclature for the parasellar compartment. In addition, his pertinent contributions to neuroscience are highlighted in this vignette.

The anatomical description of the fifth cranial nerve ganglion lacked detail before the work of Antonius Balthazar Raymundus Hirsch (1744–1778). Hirsch used new dissection techniques that resulted in the most meticulous report of the trigeminal ganglion (the gasserian ganglion) to have been reported. In 1765, the 21-year-old published these findings in a thesis, Paris Quinti Nervorum Encephali Disquisitio Anatomica In Quantum Ad Ganglion Sibi Proprium, Semilunare, Et Ad Originem Nervi Intercostalis Pertinet [An anatomical inquiry of the fifth pair of the nerves of the brain, so far as it relates to the ganglion unto itself, the semilunar, and to the source of the intercostal nerve]. Hirsch wrote his thesis as a paean to his ailing teacher, Johann Lorenz Gasser, but Gasser died before Hirsch was able to defend his thesis. Thereafter, Hirsch applied to teach anatomy at his alma mater, the University of Vienna, but the university did not consider his application, deeming him too young for the position. Oddly, Hirsch died at the young age of 35. For the present paper, the library at the University of Vienna (Universität Wien), Austria, was contacted, and Anton Hirsch's thesis was digitized and subsequently translated from Latin into English. The authors here attempt to place the recognition of the fifth cranial nerve ganglion within a historical perspective and trace the trajectory of its anatomical descriptions.

Object Transforaminal lumbar interbody fusion (TLIF) has been increasingly used to treat degenerative spine disease, including that in patients in whom earlier decompressive procedures have failed. Reexploration in these cases is always challenging and is thought to pose a higher risk of complications. To the best of the authors' knowledge, there are no current studies specifically analyzing the effects of previous lumbar decompressive surgeries on the complication rates of open TLIF. Methods The authors performed a retrospective study of surgeries performed by a single surgeon. A total of 187 consecutive patients, in whom the senior author (A.N.) had performed open TLIF between January 2007 and January 2011, met the inclusion criteria. The patients were divided into two groups (primary and revision TLIF) for the comparison of perioperative complications. Results Overall, the average age of the patients was 49.7 years (range 18–80 years). Of the 187 patients, 73 patients had no history of lumbar surgery and 114 were undergoing revision surgery. Fifty-four patients (28.9%) had a documented complication intraoperatively or postoperatively. There was no difference in the rate on perioperative complications between the two groups (overall, medical, wound related, inadvertent dural tears [DTs], or neural injury). Patients who had undergone more than one previous lumbar surgery were, however, more likely to have suffered from DTs (p = 0.054) and neural injuries (p = 0.007) compared with the rest. Conclusions In the hands of an experienced surgeon, revision open TLIF does not necessarily increase the risk of perioperative complications compared with primary TLIF. Two or more previous lumbar decompressive procedures, however, increase the risk of inadvertent DTs and neural injury.

Klippel-Feil syndrome, or brevicollis, is a complex congenital disorder caused by the improper segmentation of the cervical vertebrae. The authors present the very rare case of a patient with Klippel-Feil syndrome who presented with an intradural arachnoid cyst at the craniocervical junction. They also examine possible factors contributing to this association. A 46-year-old woman presented with complaints of progressively worsening headaches and dizziness of 18 months' duration. She also demonstrated mild bilateral upper-extremity weakness. Magnetic resonance imaging revealed fused cervical vertebrae and a dorsal intradural arachnoid cyst at the craniocervical junction, extending down to the fourth cervical level. Because of worsening myelopathy and the presence of brainstem compression, the patient underwent surgical excision of the arachnoid cyst, which was approached via a midline posterior suboccipital/upper cervical route. An endoscope was introduced through a gap between the occiput and fused upper cervical vertebrae, and the arachnoid cyst was widely fenestrated. Postoperatively, the patient has remained symptom free for more than 2 years with evidence of good radiological decompression. The authors report a unique association between craniocervical arachnoid cyst and Klippel-Feil syndrome. To their knowledge, no other cases of this association have been reported in the literature. Arachnoid cysts should be part of the differential diagnosis in the presence of worsening myelopathic symptoms or pain in patients with Klippel-Feil syndrome.

OBJECTIVEInsurance preauthorization is used as a third-party tool to reduce health care costs. Given the expansion of managed care, the impact of the insurance preauthorization process in delaying health care delivery warrants investigation through a diversified neurosurgery practice.METHODSData for 1985 patients were prospectively gathered over a 12-month period from July 1, 2014, until June 30, 2015. Information regarding attending, procedure, procedure type, insurance type, need for insurance approval, number of days for authorization, or insurance denial was obtained. Delay in authorization was defined as any wait period greater than 7 days. Some of the parameters were added retrospectively to enhance this study; hence, the total number of subjects may vary for different variables.RESULTSThe most common procedure was back surgery with instrumentation (28%). Most of the patients had commercial insurance (57%) while Medicaid was the least common (1%). Across all neurosurgery procedures, insurance authorization, on average, was delayed 9 days with commercial insurance, 10.7 days with Tricare insurance, 8.5 days with Medicare insurance, 11.5 days with Medicaid, and 14.4 days with workers' compensation. Two percent of all patients were denied insurance preauthorization without any statistical trend or association. Of the 1985 patients, 1045 (52.6%) patients had instrumentation procedures. Independent of insurance type, instrumentation procedures were more likely to have delays in authorization (p = 0.001). Independent of procedure type, patients with Tricare (military) insurance were more likely to have a delay in approval for surgery (p = 0.02). Predictably, Medicare insurance was protective against a delay in surgery (p = 0.001).CONCLUSIONSChoice of insurance provider and instrumentation procedures were independent risk factors for a delay in insurance preauthorization. Neurosurgeons, not just policy makers, must take ownership to analyze, investigate, and interpret these data to deliver the best and most efficient care to our patients.

OBJECTIVE Cavernous sinus meningiomas (CSMs) represent a cohort of challenging skull base tumors. Proper management requires achieving a balance between optimal resection, restoration of cranial nerve (CN) function, and maintaining or improving quality of life. The objective of this study was to assess the pre-, intra-, and postoperative factors related to clinical and neurological outcomes, morbidity, mortality, and tumor control in patients with CSM. METHODS A retrospective review of a single surgeon's experience with microsurgical removal of CSM in 65 patients between January 1996 and August 2013 was done. Sekhar's classification, modified Kobayashi grading, and the Karnofsky Performance Scale were used to define tumor extension, tumor removal, and clinical outcomes, respectively. RESULTS Preoperative CN dysfunction was evident in 64.6% of patients. CN II deficits were most common. The greatest improvement was seen for CN V deficits, whereas CN II and CN IV deficits showed the smallest degree of recovery. Complete resection was achieved in 41.5% of cases and was not significantly associated with functional CN recovery. Internal carotid artery encasement significantly limited the complete microscopic resection of CSM (p < 0.0001). Overall, 18.5% of patients showed symptomatic recurrence after their initial surgery (mean follow-up 60.8 months [range 3–199 months]). The use of adjuvant stereotactic radiosurgery (SRS) after microsurgery independently decreased the recurrence rate (p = 0.009; OR 0.036; 95% CI 0.003–0.430). CONCLUSIONS Modified Kobayashi tumor resection (Grades I–IIIB) was possible in 41.5% of patients. CN recovery and tumor control were independent of extent of tumor removal. The combination of resection and adjuvant SRS can achieve excellent tumor control. Furthermore, the use of adjuvant SRS independently decreases the recurrence rates of CSM.

Intrasellar plasmacytoma is a rare pituitary pathology. Pre-operative diagnosis remains a challenge as a sellar plasmacytoma mimics a pituitary adenoma in clinical and radiological features. We report a 45-year-old woman, known to have multiple myeloma, presenting to our clinic with a pituitary mass eventually diagnosed as a plasmacytoma. We review 26 similar cases reported in the literature and divide them into three categories, based on their presentation and follow-up data. Pitfalls in diagnosis and reported treatment modalities are also discussed. We conclude that presentation with cranial nerve palsies and an aggressive sellar mass on imaging, and without gross anterior hypophyseal hormonal imbalance, are featues of a pituitary plasmacytoma. The presentation and follow-up characteristics may help to determine the prognosis of such patients.

Inadvertent injury to eustachian tube leading to cerebrospinal fluid rhinorrhea is a known complication associated with drilling of Glasscock's triangle to expose the horizontal petrous internal carotid artery (ICA) for management of difficult tumors (especially malignant) or aneurysms at the cranial base. Contrary to the usual approach, we hypothesize that a “medial-to-lateral” approach to Glasscock's triangle drilling will minimize eustachian tube injury. Four formalin-fixed human cadaveric heads were dissected, and underwent appropriate morphometric analysis; yielding a total of eight datasets. The diameter of the horizontal petrous ICA exposed was 4.7 ± 0.9 mm (range, 3.8 to 5.6 mm).The mean distance from the medial carotid wall midpoint to the medial-most point on the eustachian tube was 6.35 ± 0.58 mm (range, 5.4 to 7.1 mm), yielding a “safety zone” for eustachian tube, ranging 0.2 to 1.9 mm lateral to the lateral carotid wall. With the medial-to-lateral approach, the eustachian tube remained preserved in all the specimens. The results of our study provide a practical, consistent, and safe method of maximizing horizontal petrous carotid artery exposure while minimizing the eustachian tube injury.

Several studies have shown that nonfixation of mesh in total extraperitoneal (TEP) inguinal hernia repair is safe and has no disadvantage compared to mesh fixation in terms of recurrence rate, pain scores, and other morbidity parameters. The aim of this study was to compare the effect of nonfixation of mesh with fixation in laparoscopic TEP inguinal hernia repair in a rural hospital in India. One hundred four patients were randomized to mesh nonfixation group or a fixation group during TEP. The postoperative pain scores on a visual analog scale (VAS) at 24 h, 1 week, 1 month, and 1 year, urinary retention, seroma formation, length of hospital stay, days taken to resume normal activities, and recurrence after 2 years were analyzed. The trial was registered at www.clinicaltrials.gov (ID: NCT01117337). One hundred four patients (194 hernias) were randomized to mesh nonfixation or fixation. The pain scores at 24 h were comparable (Fix, 1.31 ± 0.4; Nonfix, 1.42 ± 0.5, P = 0.23). The length of hospital stay (Fix, 1.12 ± 0.3 days; Nonfix, 1.15 ± 0.4 days, P = 0.7) and days taken to resume normal activities (Fix, 7.77 ± 1.3 days; Nonfix, 7.96 ± 1.15 days, P = 0.44) were also similar for both groups. The mean pain scores at 1 week (Fix, 1.25 ± 0.5; Nonfix, 1.34 ± 0.6, P = 0.42), 1 month (Fix, 1.06 ± 0.2; Nonfix, 1.17 ± 0.4, P = 0.12), 1 year (Fix, 1.04 ± 0.2; Nonfix, 1.13 ± 0.4, P = 0.11), and 2 years (Fix, 1.03 ± 0.2; Nonfix, 1.0, P = 0.17) were comparable for both groups. There was no recurrence in either group at a minimum follow-up of 2 years. There was no significant difference between fixation and nonfixation of mesh in TEP inguinal hernia repair with respect to postoperative pain, length of hospital stay, resumption of normal activities, seroma formation, and recurrence rate. Nonfixation of mesh is safe and recommended in TEP inguinal hernia repair when done by an experienced surgeon, even in a rural setting. The study highlights the potential for universal application of the procedure.

We describe a technique for the management of large benign ovarian cysts by single incision laparoscopic surgery (SILS) through the umbilicus. The paucity of intra-abdominal working space in large ovarian cysts poses a technical challenge. Moreover, difficult convergence of operating instruments and competition for operating space outside the abdomen during the SILS makes the procedure quite demanding, especially with the conventional instruments. The concept of providing traction by taking sutures from the abdominal wall, as done in SILS laparoscopic cholecystectomy, was applied for SILS cystectomy in large ovarian cysts. Two sutures taken through the abdominal wall and then through the cyst wall provide excellent traction and "hang" the cyst from the abdominal wall, making it convenient to dissect and operate. This technique demonstrates that SILS ovarian cystectomy is feasible, safe and technically unchallenging even in large benign ovarian cysts.

Creutzfeldt-Jakob disease (CJD) is a rare neurodegenerative condition with a rapid disease course and a mortality rate of 100%. Several forms of the disease have been described, and the most common is the sporadic type. The most challenging aspect of this disease is its diagnosis—the gold standard for definitive diagnosis is considered to be histopatho-logical confirmation—but newer tests are providing means for an antemortem diagnosis in ways less invasive than brain biopsy. Imaging studies, electroencephalography, and biomarkers are used in conjunction with the clinical picture to try to make the diagnosis of CJD without brain tissue samples, and all of these are reviewed in this article. The current diagnostic criteria are limited; test sensitivity and specificity varies with the genetics of the disease as well as the clinical stage. Physicians may be unsure of all diagnostic testing available, and may order outdated tests or prematurely request a brain biopsy when the diagnostic workup is incomplete. The authors review CJD, discuss the role of brain biopsy in this patient population, provide a diagnostic pathway for the patient presenting with rapidly progressive dementia, and propose newer diagnostic criteria.

Objective In this study, we validate the utility of navigation in intracranial meningioma excision and evaluate the effectiveness of image guidance surgery based on clinical outcome, extent of resection, and recurrence-free survival (RFS). Methods Information related to clinical history, use of neuronavigation, neuroimaging, microsurgical dissection, and outcomes of 517 consecutive cases with meningiomas between January 1995 and June 2015 was collected retrospectively. A Cox proportional hazards regression model was used to determine independent predictors of RFS. Results In this study, overall recurrence rate after tumor excision with or without neuronavigation was 17.7% and 31.2%, respectively ( P = 0.03). Based on neuronavigation use, RFS of the patients with meningiomas in different locations also varied significantly (skull base; with, 110 months vs. without, 157 months; P = 0.02). The median RFS for patients operated on with or without use of neuronavigation during resection of tumors was 167 and 97 months, respectively, (log-rank P =0.0001). In Cox regression multivariate analysis, use of neuronavigation ( P = 0.0001), gross total resection (Simpson grade I–II; P = 0.001), and World Health Organization grade I tumor ( P = 0.0001) were revealed as significant predictors of RFS. In addition, mean blood loss ( P = 0.005) and average length of stay ( P = 0.008) in the hospital were significantly reduced and performance status was improved using neuronavigation during resection of meningiomas. Conclusions Interactive surgical navigation is a useful tool in the operative management of intracranial meningiomas to decrease recurrence rate, blood loss, and length of stay, and to improve RFS and performance status. Therefore, use of neuronavigation should be ensured during resection of intracranial meningiomas.

Ayub Khan Ommaya (1930-2008) was a pioneering neurosurgeon of Pakistani origin who is widely known for inventing the Ommaya reservoir, a ventricular catheter with a mushroom-shaped dome for administration of intraventricular therapies. As a Rhodes Scholar at Oxford, Ommaya developed an early interest in studying traumatic brain injury. Over the course of his career, Ommaya employed subhuman primate models to better understand mechanisms underlying human cerebral concussion. His work on traumatic brain injury led to the creation of the National Center for Injury Prevention and Control, a center for injury prevention research at the Center for Disease Control. This historical paper visits Ommaya's life story and recounts his key contributions to neurosurgery.

Introduction Spinal intradural lipoma is a rare condition, accounting for

Prehospital helicopter use and its impact on outcomes in snowboarders and skiers incurring traumatic brain injury (TBI) is unknown. The present study investigates the association of helicopter transport with survival of snowboarders and skiers with TBI, in comparison with ground emergency medical services (EMS), by using data derived from the National Trauma Data Bank (2007-2014).Primary and secondary endpoints were defined as in-hospital survival and absolute risk reduction based upon number needed to transport (treat) respectively. Multivariable regression models including traditional logit model, model fitted with generalized estimating equations, and those incorporating results from propensity score matching methods were used to investigate the association of helicopter transport with survival compared with ground EMS.Of the 1018 snowboarders and skiers who met the criteria, 360 (35.4%) were transported via helicopters whereas 658 (64.6%) via ground EMS with a mortality rate of 1.7% and 1.5%, respectively. Multivariable log-binomial models demonstrated association of prehospital helicopter transport with increased survival (odds ratio 8.58; 95% confidence interval 1.09-67.64; P = 0.041; absolute risk reduction: 10.06%). This finding persisted after propensity score matching (odds ratio 24.73; 95% confidence interval 5.74-152.55; P0.001). The corresponding absolute risk reduction implies that approximately 10 patients need to be transported via helicopter to save 1 life.Based on our robust statistical analysis of retrospective data, our findings suggest prehospital helicopter transport improved survival in patients incurring TBI after snowboard- or ski-related falls compared with those transported via ground EMS. Policies directed at using helicopter services at remote winter resorts or ski or snowboarding locations should be implemented.