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Background Partial sensory rhizotomy (PSR) is an “ultima ratio” procedure for patients with therapy-refractory trigeminal neuralgia (TN). The treatment can be offered to patients without a neurovascular conflict or to patients who did not benefit either from previous microvascular decompression (MVD) or from other interventional procedures. This study presents our experience with PSR. Methods Our prospectively maintained database was searched for patients who underwent PSR. We conducted a retrospective analysis of all patients with PSR. Clinical data, MR imaging, surgical videos, and OR notes were evaluated and a telephone interview for the last follow-up was done. Results Our search revealed 48 patients treated with PSR between 2004 and 2023. The average age was 59.4 years. Mean history of symptoms was 7.81 years (1–30 years). All types of previous treatments were included. Fifteen patients suffered from multiple sclerosis. A total pain relief was observed in 42 patients immediately after PSR, two patients had a partial pain improvement, and four patients observed no difference. An expected, variable hypesthesia occurred in 37 patients. The most common procedure was a PSR of the lower third. The mean follow-up was 38 months (3–183 months), five patients were lost to follow-up. 28 patients still had complete, 13 partial pain relief. Ten patients still needed medications but were satisfied with a lower dose and generally improved or were even pain-free. Thirteen patients who had benefited from the PSR initially, reported recurrent TN. Five of them received a second PSR after 5–55 months with complete pain relief. Conclusion Early after surgery patient satisfaction regarding pain relief/improvement was 92.7% (44 of 48 patients). During follow-up we observed complete or partial pain relief in 31 of 43 patients (72.1%) without pain medication, another 23.3% were satisfied with on-going medication. However, the degree of sensitive deficits is not predictable. Because of our convincing results, patients should be informed about PSR as a therapeutic option for therapy-refractory or recurrent TN. It may be considered either instead of, or as an alternative to, percutaneous procedures or radiosurgery.

BackgroundThere is paucity of information about the frequency of hydrocephalus prior to and after posterior fossa tumor surgery in adult patients and about the best way it should be managed. The present study was conducted to determine the frequency of hydrocephalus prior to and after posterior fossa tumor surgery in adult patients as well as the value of an endoscopic third ventriculostomy (ETV) prior to posterior fossa tumor surgery with regard to the rate of perioperative complications and persistent hydrocephalus.MethodsA single-institution retrospective chart review of all posterior fossa tumor surgeries of our department in a 10-year period (2005 to 2014) has been done.ResultsFifty-two of 243 adult patients with posterior fossa tumors presented with hydrocephalus at the time of admission prior to tumor surgery. 39/52 received early tumor surgery, 11/52 an ETV prior to tumor surgery and in 2/52 an external ventricular drainage (EVD) was inserted prior to tumor surgery. 3/52 patients required a permanent cerebrospinal fluid (CSF) diverting procedure for persistent hydrocephalus after tumor removal. One hundred ninety-one patients did not demonstrate a hydrocephalus before surgical treatment and four of them developed a post-resection hydrocephalus.ConclusionThe frequency of hydrocephalus prior to posterior fossa tumor surgery in adult patients is 21.4% and therefore much lower than in respective reports of pediatric patients. The risk of persistent hydrocephalus and newly developed hydrocephalus after tumor surgery was very low, too (5.7 and 2.1%, respectively). An ETV is not justified in every adult patient prior to posterior fossa tumor surgery.

Purpose Prognostic significance of lateral spreads response (LSR) disappearance in microvascular decompression (MVD) for hemifacial spasm (HFS) remains controversial. Still the timing of LSR disappearance and its association with overall outcomes has not been sufficiently investigated. We evaluate the prognostic significance of the timing of LSR disappearance during MVD in HFS. Methods Prospective documentation of the LSR-Status during the procedural steps was performed alongside routinely collected data. Surgical steps were categorized into three phases: Opening phase (skin incision till cisternal opening), arachnoid dissection, and actual Decompression phase. Outcome assessment was conducted after a follow-up period of at least 12 months, with favorable outcome defined as at least 90% resolution of the spasms. Results 214 patients were included with a mean age (SD) of 54.9 ± 11.6 years and a follow-up duration (SD) of 25.8 ± 15.7 months. The male-to-female ratio was 1:1.6. LSR was \"not detected\" in 32 patients (15.0%), with a 93.8% favorable outcome. LSR \"persisted\" in 22 patients (10.3%), showing only 77.3% favorable outcome. In 16 patients (7.4%), LSR disappeared during the opening phase, yielding a 100% favorable outcome. LSR disappearance occurred during arachnoid dissection in 40 patients (18.7%), with a 91.1% favorable outcome. Finally, LSR disappearance following nerve decompression was observed in 104 patients (48.6%), showing a 78.9% favorable outcome. Earlier disappearance of the LSR was associated with long-term cure (P-value < 0.05). Conclusion LSR may serve as a valuable intraoperative indicator during MVD for HFS. Early intraoperative disappearance of the LSR may predict favorable long-term outcomes. However, the disappearance of the LSR in general does not consistently correlate with surgical success.

Purpose Despite being rarely reported, ischemic insults resulting from compromising small brainstem perforators following microvascular decompression (MVD) remain a potential devastating complication. To avoid this complication, we have been using indocyanine green (ICG) angiography intraoperatively to check the flow within the small brainstem perforators. We aim to evaluate the safety and usefulness of ICG videoangiography in MVD. Methods We extracted retrospective data of patients who received ICG videoangiography from our prospectively maintained database for microvascular decompression. We noted relevant data including demographics, offending vessels, operative technique, outcome, and complications. Results Out of the 438 patients, 15 patients with a mean age (SD) of 53 ± 10.5 years underwent intraoperative ICG angiography. Male:female was 1:1.14. The mean disease duration prior to surgery was 7.7 ± 5.3 years. The mean follow-up (SD) was 50.7 ± 42.0 months. In 14 patients, the offending vessel was an artery, and in one patient, a vein. Intraoperative readjustment of the Teflon pledget or sling was required in 20% (3/15) of the cases. No patient had any sort of brainstem ischemia. Eighty percent of the patients (12/15) experienced complete resolution of the spasms. 86.7% (13/15) of the patients reported a satisfactory outcome with marked improvement of the spasms. Three patients experienced slight hearing affection after surgery, which improved in two patients later. There was no facial or lower cranial nerve affection. Conclusion Intraoperative ICG is a safe tool for evaluating the flow within the brain stem perforators and avoiding brainstem ischemia in MVD for hemifacial spasm.

Purpose Currently available grading and classification systems for hemifacial spasm either rely on subjective assessments or are excessively intricate. Here, we make use of facial recognition and facial tracking technologies towards accurately grouping patients according to severity and characteristics of the spasms. Methods A retrospective review of our prospectively maintained preoperative videos database for hemifacial spasm was done. Videos were analyzed using an Apple AR kit-based App. A facial mesh is automatically allocated to specific biometric facial points. Videos are analyzed using Blender software for measuring the amplitude and frequency of the spasms. Classification of the patients into groups was done using both divisive k-means and agglomerative hierarchical clustering. Correlation-Analysis with preoperative quality of Life (Qol) using SF-36 questionnaire and HFS-8 score was performed. Additionally, correlation with postoperative outcome was calculated. Results 79 preoperative videos were included. Both up-bottom and bottom-up clustering approaches grouped the patients into 3 different clusters according to 4 variables (eye closure, mouth distance change, rate, and repetition of the spasms). Correlation of the groups with the Qol was done for 46/79 patients (58.2%). Spasms could be classified into mild, moderate clonic and severe tonic spasms. Patients with mild spasms showed better Qol scores. Moderate clonic spasms experienced best outcomes following microvascular decompression. Conclusion This novel classification using facial-tracking and augmented-reality is easy to use and apply. It quantifies the severity and type of the spasms and relates it to the quality of life of patients, postoperative outcome, and could guide our management strategy.

Abstract BACKGROUND Intraoperative monitoring of brainstem auditory evoked potentials (BAEPs) has been implemented to reduce the risk of hearing impairment during microvascular decompression for hemifacial spasm. OBJECTIVE To evaluate intraoperative monitoring of BAEPs during microvascular decompression in patients with hemifacial spasm for predicting the risk of hearing impairment after surgery. METHODS This prospective study included 100 patients. BAEPs were recorded for all patients. We established a scoring system for the changes in wave I amplitude, I-III interpeak latency, and wave V amplitude and latency. For each change, total points were calculated, and a score out of 6 was assigned to every patient. We classified the patients based on the points scored into 3 risk groups: low-risk (0-3), medium-risk (4-5), and high-risk (6). Further, the correlation between the score and the hearing outcome was evaluated to detect the incidence and degree of hearing impairment. RESULTS Eighty-seven patients scored 0 to 3, 10 scored 4 to 5, and 3 scored 6. The degree of hearing impairment was proportionate to the score recorded at the end of surgery, and patients in the low-risk group showed no impairment; medium-risk group, deterioration of maximum 2 grades according to World Health Organization classification of hearing impairment; and high-risk group, deterioration of 3 to 4 grades. CONCLUSION Intraoperative monitoring of BAEPs evaluated through our scoring system was valuable in predicting hearing impairment after surgery.

BACKGROUND:Prospective randomized data for comparison of endoscopic and open decompression methods are lacking. OBJECTIVE:To compare the long- and short-term results of endoscopic and open decompression in cubital tunnel syndrome. METHODS:In a prospective randomized double-blind study, 54 patients underwent ulnar nerve decompression for 56 cubital tunnel syndromes from October 2008 to April 2011. All patients presented with typical clinical and neurophysiological findings and underwent preoperative nerve ultrasonography. They were randomized for either endoscopic (n = 29) or open (n = 27) surgery. Both patients and the physician performing the follow-up examinations were blinded. The follow-up took place 3, 6, 12, and 24 months postoperatively. The severity of symptoms was measured by McGowan and Dellon Score, and the clinical outcome by modified Bishop Score. Additionally, the neurophysiological data were evaluated. RESULTS:No differences were found regarding clinical or neurophysiological outcome in both early and late follow-up between both groups. Hematomas were more frequent after endoscopic decompression (P = .05). The most frequent constrictions were found at the flexor carpi ulnaris (FCU) arch and the retrocondylar retinaculum. We found no compressing structures more than 4 cm distal from the sulcus in the endoscopic group. The outcome was classified as “good” or “excellent” in 46 out of 56 patients (82.1%). Eight patients did not improve sufficiently or had a relapse and underwent a second surgery. CONCLUSION:The endoscopic technique showed no additional benefits to open surgery. We could not detect relevant compressions distal to the FCU arch. Therefore, an extensive far distal endoscopic decompression is not routinely required. The open decompression remains the procedure of choice at our institution. ABBREVIATION:Dig, digitFCU, flexor carpi ulnarisNAS, numeric analog scale

Abstract BACKGROUND During the 1990s, endoscopic aqueductoplasty (AP) was considered to be a valuable alternative to endoscopic third ventriculostomy (ETV) in treating hydrocephalus related to idiopathic aqueductal stenosis (iAS), with promising short-term outcomes. OBJECTIVE To evaluate the long-term outcome of AP in the treatment of iAS. METHODS Long-term follow-up clinical examinations and magnetic resonance (MR) imaging were performed for patients treated by an AP for iAS in our department. RESULTS Twenty patients (14 female, 6 male, mean age 41.7 yr, range 0.5-67 yr) were treated between 1996 and 2002. Two patients were lost to long-term follow-up. One patient died 6 mo after AP, but death was not related to the procedure. The mean follow-up for the remaining 17 patients was 120 mo. Clinically relevant aqueductal reclosure was observed in 11/17 patients after a mean follow-up of 53.4 mo. These 11 patients underwent ETV, which has been successful during further follow-up. Four of the six remaining patients presented with no clinical symptoms, although aqueductal restenosis was observed on MR imaging. Thus, the overall failure rate of AP was 88.2%. The failures were homogeneously distributed over the entire follow-up period. CONCLUSION AP has a high risk of failure during long-term follow-up and is not recommended as the first choice of treatment in hydrocephalus caused by iAS. ETV should be done instead. AP may be reserved for a limited number of patients in whom ETV is not feasible but should be combined with stenting to avoid reclosure of the aqueduct.

PurposeControversies regarding venous compression and trigeminal neuralgia (TN) still exist. The study demonstrates our experience for microvascular decompression (MVD) in TN caused by purely venous compression. The goal was to identify prognostic anatomical or surgical factors that may influence the outcome.MethodsBetween 2004 and 2020, 49 patients were operated with purely venous compression. Average age was 58.4 years. Mean history of TN was 7.8 years. Microsurgical procedures included transposition or separation of the vein, coagulation, and division. Several features have been analyzed with respect to BNI scores.ResultsEvaluation on discharge revealed a complete pain relief in 39 (80%), partial improvement in 7 (14%), and no benefit in 3 (6%) patients. Facial hypesthesia was reported by 14 (28.6%) patients. Mean follow-up (FU) was 42.1 months. BNI pain intensity score on FU revealed 71.4% excellent to very good scores (score 1: 32 (65.3%); 2: 3 (6.1%)). BNI facial numbness score 2 could be detected in 13 patients (26.5%) during FU. There was no statistical relationship between immediate pain improvement or BNI pain intensity score on FU with respect to surgical procedure, size of trigeminal cistern, type of venous compression, venous caliber, trigeminal nerve indentation, or neurovascular adherence. BNI facial numbness score was dependent on type of venous compression (p < 0.05).ConclusionWe did not find typical anatomical features that could either predict or influence the outcome regarding pain improvement or resolution in any form. Neither classic microvascular decompression (interposition/transposition) nor sacrificing the offending vein made any difference in outcome.