Effect of Lower Extremity Nerve Decompression in Patients With Painful Diabetic Peripheral Neuropathy: The Diabetic Neuropathy Nerve Decompression Randomized, Observation Group and Placebo Surgery-Controlled Clinical Trial.

OBJECTIVE: To evaluate the effect of nerve decompression on pain in patients with lower extremity painful diabetic peripheral neuropathy (DPN). BACKGROUND: Currently, no treatment provides lasting relief for patients with DPN. The benefits of nerve decompression remain inconclusive. METHODS: This double-blinded, observation and same-patient sham surgery-controlled randomized trial enrolled patients aged 18 to 80 years with lower extremity painful DPN who failed 1 year of medical treatment. Patients were randomized to nerve decompression or observation group (2:1). Decompression-group patients were further randomized and blinded to nerve decompression in either the right or left leg and sham surgery in the opposite leg. Pain (11-point Likert score) was compared between decompression and observation groups and between decompressed versus sham legs at 12 and 56 months. RESULTS: Of 2987 screened patients, 78 were randomized. At 12 months, compared with controls (n=37), both the right-decompression group (n=22) and left-decompression group (n=18) reported lower pain (mean difference for both: -4.46; 95% CI: -6.34 to -2.58 and -6.48 to -2.45, respectively; P < 0.0001). Decompressed and sham legs equally improved. At 56 months, compared with controls (n=m 14), pain was lower in both the right-decompression group (n=20; mean difference: -7.65; 95% CI: -9.87 to -5.44; P < 0.0001) and left-decompression group (n=16; mean difference: -7.26; 95% CI: -9.60 to -4.91; P < 0.0001). The mean pain score was lower in decompressed versus sham legs (mean difference: 1.57 95% CI: 0.46 to 2.67; P =0.0002). CONCLUSIONS: Although nerve decompression was associated with reduced pain, the benefit of surgical decompression needs further investigation as a placebo effect may be responsible for part or all of these effects.

Decompression with or without Fusion in Degenerative Lumbar Spondylolisthesis.

BACKGROUND: In patients with lumbar spinal stenosis and degenerative spondylolisthesis, it is uncertain whether decompression surgery alone is noninferior to decompression with instrumented fusion. METHODS: We conducted an open-label, multicenter, noninferiority trial involving patients with symptomatic lumbar stenosis that had not responded to conservative management and who had single-level spondylolisthesis of 3 mm or more. Patients were randomly assigned in a 1:1 ratio to undergo decompression surgery (decompression-alone group) or decompression surgery with instrumented fusion (fusion group). The primary outcome was a reduction of at least 30% in the score on the Oswestry Disability Index (ODI; range, 0 to 100, with higher scores indicating more impairment) during the 2 years after surgery, with a noninferiority margin of -15 percentage points. Secondary outcomes included the mean change in the ODI score as well as scores on the Zurich Claudication Questionnaire, leg and back pain, the duration of surgery and length of hospital stay, and reoperation within 2 years. RESULTS: The mean age of patients was approximately 66 years. Approximately 75% of the patients had leg pain for more than a year, and more than 80% had back pain for more than a year. The mean change from baseline to 2 years in the ODI score was -20.6 in the decompression-alone group and -21.3 in the fusion group (mean difference, 0.7; 95% confidence interval [CI], -2.8 to 4.3). In the modified intention-to-treat analysis, 95 of 133 patients (71.4%) in the decompression-alone group and 94 of 129 patients (72.9%) in the fusion group had a reduction of at least 30% in the ODI score (difference, -1.4 percentage points; 95% CI, -12.2 to 9.4), showing the noninferiority of decompression alone. In the per-protocol analysis, 80 of 106 patients (75.5%) and 83 of 110 patients (75.5%), respectively, had a reduction of at least 30% in the ODI score (difference, 0.0 percentage points; 95% CI, -11.4 to 11.4), showing noninferiority. The results for the secondary outcomes were generally in the same direction as those for the primary outcome. Successful fusion was achieved with certainty in 86 of 100 patients (86.0%) who had imaging available at 2 years. Reoperation was performed in 15 of 120 patients (12.5%) in the decompression-alone group and in 11 of 121 patients (9.1%) in the fusion group. CONCLUSIONS: In this trial involving patients who underwent surgery for degenerative lumbar spondylolisthesis, most of whom had symptoms for more than a year, decompression alone was noninferior to decompression with instrumented fusion over a period of 2 years. Reoperation occurred somewhat more often in the decompression-alone group than in the fusion group. (NORDSTEN-DS ClinicalTrials.gov number, NCT02051374.).

The impact of competitive level of high school and collegiate athletes on outcomes of thoracic outlet syndrome.

OBJECTIVE: Thoracic outlet syndrome (TOS) has life-changing impacts on young athletes. As the level of competition increases between the high school (HS) and collegiate (CO) stage of athletics, the impact of TOS may differ. Our objective is to compare surgical outcomes of TOS in HS and CO athletes. METHODS: This was a retrospective review of HS and CO athletes within a prospective surgical TOS database. The primary outcome was postoperative return to sport. Secondary outcomes were resolution of symptoms assessed with somatic pain scale (SPS), QuickDASH, and Derkash scores. Categorical and continuous variables were compared using χ2 and analysis of variance, respectively. Significance was defined as P < .05. RESULTS: Thirty-two HS and 52 CO athletes were identified. Females comprised 82.9% HS and 61.5% CO athletes (P = .08). Primary diagnoses were similar between groups (venous TOS: HS 50.0% vs CO 42.3%; neurogenic TOS: 43.9% vs 57.7%; pectoralis minor syndrome: 6.3% vs 0.0%) (P = .12). Pectoralis minor syndrome was a secondary diagnosis in 3.1% and 3.8% of HS and CO athletes, respectively (P = 1.00). The most common sports were those with overhead motion, specifically baseball/softball (39.3%), volleyball (12.4%), and water polo (10.1%), and did not differ between groups (P = .145). Distribution of TOS operations were similar in HS and CO (First rib resection: 94.3% vs 98.1%; scalenectomy: 0.0% vs 1.9%, pectoralis minor tenotomy: 6.3% vs 0.0%) (P = .15). Operating room time was 90.0 vs 105.3 minutes for HS and CO athletes, respectively (P = .14). Mean length of stay was 2.0 vs 1.9 days for HS and CO athletes (P = .91). Mean follow-up was 6.9 months for HS athletes and 10.5 months for CO athletes (P = .39). The majority of patients experienced symptom resolution (HS 80.0% vs CO 77.8%; P = 1.00), as well as improvement in SPS, QuickDASH, and Derkash scores. Return to sport was similar between HS and CO athletes (72.4% vs 73.3%; P = .93). Medical disability was reported in 100% HS athletes and 58.3% CO athletes who did not return to sport (P = .035). CONCLUSIONS: Despite increased level of competition, HS and CO athletes demonstrate similar rates of symptom resolution and return to competition. Of those that did not return to their sport, HS athletes reported higher rates of medical disability as a reason for not returning to sport compared with CO athletes.

Contemporary outcomes of surgical decompression for functional popliteal entrapment syndrome.

BACKGROUND: Functional popliteal entrapment syndrome (FPES) is an under-recognized source of leg pain caused by dynamic compression of the popliteal vessels by surrounding musculature in the absence of anatomic abnormality. Late recognition and difficulty capturing this entity across imaging modalities can lead to significant morbidity in an often young and active patient population. Surgical outcomes and optimal diagnostic strategies remain uncertain. METHODS: We performed a retrospective cohort study of all patients undergoing surgical decompression for FPES at an academic medical center between 2018 and 2022. Preoperative symptoms, patient characteristics, imaging, operative details, and follow-up were captured. The primary outcome was symptomatic improvement at last clinic visit. Secondary outcomes included symptomatic improvement at 6 months and postoperative complications. RESULTS: A total of 24 extremities (16 patients) were included. The mean ± standard deviation age was 23.3 ± 6.4 years and 75.0% of patients were female. The median symptom duration before decompression was 27 months (interquartile range, 10.7-74.6 months). Preoperative symptom severity in the affected extremity was as follows: 33.3% limited from peak exercise, 25% unable to exercise, and 41.7% with debilitating symptoms that affected activities of daily living. Preoperative imaging with provocative maneuvers included duplex ultrasound (87.5%), magnetic resonance angiography (100%), and digital subtraction angiography (100%). Using digital subtraction angiography as the gold standard, the sensitivity for detection of FPES was 85.7% for duplex examination and 58.3% for magnetic resonance angiography. The median follow-up was 451 days (interquartile range, 281-635 days). Most patients demonstrated durable improvement in the affected extremity, with 29.2% realizing complete resolution of symptoms and 37.5% reporting symptomatic improvement at last clinic visit for a total of 66.7%; 20.8% had initial improvement, but developed recurrent symptoms and were found to have elevated compartment pressures consistent with chronic exertional compartment syndrome and were treated with formal fasciotomy. Repeat decompression was required in one extremity (4.2%) owing to recurrent symptoms. Two patients (8.3%) had minimal or no improvement in their affected extremity and workup for the cause of continued discomfort was ongoing. CONCLUSIONS: Delays in diagnosis of FPES are common. Provocative maneuvers until replication of symptoms across multiple imaging modalities may be necessary to reliably identify the disease process. Surgical decompression improved or completely resolved symptoms in two-thirds of extremities. Treating physicians should maintain suspicion for comorbid chronic exertional compartment syndrome, especially if symptoms recur or persist after decompression.

Management Strategies for Malignant Left-Sided Colonic Obstruction: A Systematic Review and Network Meta-analysis of Randomized Controlled Trials and Propensity Score Matching Studies.

BACKGROUND: The optimal treatment strategy for left-sided malignant colonic obstruction remains controversial. Emergency colonic resection has been the standard of care; however, self-expanding metallic stenting as a bridge to surgery may offer short-term advantages, although oncological concerns exist. Decompressing stoma may provide a valid alternative, with limited evidence. OBJECTIVE: To perform a systematic review and Bayesian arm random-effects model network meta-analysis comparing the approaches for management of malignant left-sided colonic obstruction. DATA SOURCES: A systematic review of PubMed, Embase, Cochrane Library, and Google Scholar databases was conducted from inception to August 22, 2023. STUDY SELECTION: Randomized controlled trials and propensity score-matched studies. INTERVENTIONS: Emergency colonic resection, self-expanding metallic stent, and decompressing stoma. MAIN OUTCOME MEASURES: Oncologic efficacy, morbidity, successful minimally invasive surgery, primary anastomosis, and permanent stoma rates. RESULTS: Nineteen of 5225 articles identified met our inclusion criteria. Stenting (risk ratio 0.57; 95% credible interval, 0.33-0.79) and decompressing stomas (risk ratio 0.46, 95% credible interval: 0.18-0.92) resulted in a significant reduction in the permanent stoma rate. Stenting facilitated minimally invasive surgery more frequently (risk ratio 4.10; 95% credible interval, 1.45-13.13) and had lower overall morbidity (risk ratio 0.58; 95% credible interval, 0.35-0.86). A pairwise analysis of primary anastomosis rates showed increased stenting (risk ratio 1.40; 95% credible interval, 1.31-1.49) compared with emergency resection. There was a significant decrease in the 90-day mortality with stenting (risk ratio 0.63; 95% credible interval, 0.41-0.95) compared with resection. There were no differences in disease-free and overall survival rates, respectively. LIMITATIONS: There is a lack of randomized controlled trials and propensity score matching data comparing short-term and long-term outcomes for diverting stomas compared to self-expanding metallic stents. Two trials compared self-expanding metallic stents and diverting stomas in left-sided malignant colonic obstruction. CONCLUSIONS: This study provides high-level evidence that a bridge-to-surgery strategy is safe for the management of left-sided malignant colonic obstruction and may facilitate minimally invasive surgery, increase primary anastomosis rates, and reduce permanent stoma rates and postoperative morbidity compared with emergency colonic resection.

Clinical Outcomes after Median Arcuate Ligament Release in Patients Responsive to Celiac Plexus Block.

PURPOSE: To determine if symptom relief with celiac plexus block (CPB) is associated with favorable clinical outcomes after median arcuate ligament release (MALR) surgery. MATERIALS AND METHODS: A retrospective review was performed from January 2000 to December 2021. Fifty-seven patients (42 women, 15 men; mean age, 43 years [range, 18-84 years]) with clinical and radiographic features suggestive of median arcuate ligament syndrome (MALS) underwent computed tomography (CT)-guided percutaneous CPB for suspected MALS. Clinical outcomes of CPB and MALR surgery were correlated. Adverse events were classified according to the Society of Interventional Radiology (SIR) guidelines. RESULTS: CT-guided percutaneous CPB was successfully performed in all 57 (100%) patients with suspected MALS. A cohort of 38 (67%) patients showed clinical improvement with CPB. A subset of 28 (74%) patients in this group subsequently underwent open MALR surgery; 27 (96%) responders to CPB showed favorable clinical outcomes with surgery. There was 1 (4%) CPB-related mild adverse event. There were no moderate, severe, or life-threatening adverse events. CONCLUSIONS: Patients who responded to CPB were selected to undergo surgery, and 96% of them improved after surgery.

Feasibility, safety, and efficacy of a new percutaneous interspinous device: a retrospective multicenter study.

PURPOSE: To evaluate safety and efficacy of the novel percutaneous interspinous device (PID) for the treatment of symptomatic degenerative lumbar spinal stenosis (DLSS) in 3 different centers. METHODS: From November 2016 to March 2020, 255 patients (male 125, mean age 71.2 years old range 49-91 years old) with neurogenic claudication, confirmed by electromyography, related to mono or bi-segmental lumbar central canal and/or foraminal stenosis were enrolled in the study. Magnetic resonance (MR) and/or computer tomography (CT), physical exam, and Visual Analogue Scale (VAS) and Zurich Claudication Questionnaire (ZCQ) were performed before and 6 months after the procedure. All treatments were performed under fluoroscopic guidance with local anesthesia and mild sedation. Technical success was defined as correct placement of the Lobster® (Demetrios Medical, Firenze, Italy) PID as demonstrated by computer tomography (CT) performed immediately after treatment; spinoplasty was performed in selected patients. RESULTS: PID placement was accomplished with a 99.6% success rate (257/258). The one device that was not implanted was due to a spinous process fracture. In 28 patients, more than 1 device was implanted in the same session (max 3 PIDs); 6 patients required a second implant in different session. A total of 172 prophylactic spinoplasties were performed (59.3%). No major complications occurred; 3 device misplacements were successfully treated with percutaneous retrieval and new device deployment. 99.6% of patients experienced clinical improvement. CONCLUSION: Lobster PID is an effective and safe minimally invasive decompression method for central canal and neural foraminal stenosis when patients are correctly selected.

Characterizing utilization patterns and reoperation risk factors of interspinous process devices: analysis of a national claims database.

INTRODUCTION: Interspinous process devices (IPDs) were developed as minimally invasive alternatives to open decompression surgery for spinal stenosis. However, given high treatment failure and reoperation rates, there has been minimal adoption by spine surgeons. This study leveraged a national claims database to characterize national IPD usage patterns and postoperative outcomes after IPD implantation. METHOD: Using the PearlDiver database, we identified all patients who underwent 1- or 2-level IPD implantation between 2010 and 2018. Univariate and multivariable logistic regression was performed to identify predictors of the number of IPD levels implanted and reoperation up to 3 years after the index surgery. Right-censored Kaplan-Meier curves were plotted for duration of reoperation-free survival and compared with log-rank tests. RESULTS: Patients (n = 4865) received 1-level (n = 3246) or 2-level (n = 1619) IPDs. Patients who were older (adjusted odds ratio [aOR] 1.02, 95% confidence interval [CI] 1.01-1.03, P < .001), male (aOR 1.31, 95% CI 116-1.50, P < .001), and obese (aOR 1.19, 95% CI 1.05-1.36, P < .01) were significantly more likely to receive a 2-level IPD than to receive a 1-level IPD. The 3-year reoperation rate was 9.3% of patients when mortality was accounted for during the follow-up period. Older age decreased (aOR 0.97, 95% CI 0.97-0.99, P = .0039) likelihood of reoperation, whereas 1-level IPD (aOR 1.37, 95% CI 1.01-1.89, P = .048), Charlson Comorbidity Index (aOR 1.07, 95% CI 1.01-1.14, P = .018), and performing concomitant open decompression increased the likelihood of reoperation (aOR 1.68, 95% CI 1.35-2.09, P = .0014). CONCLUSION: Compared with 1-level IPDs, 2-level IPDs were implanted more frequently in older, male, and obese patients. The 3-year reoperation rate was 9.3%. Concomitant open decompression with IPD placement was identified as a significant risk factor for subsequent reoperation and warrants future investigation.

Effectiveness of Corticosteroid Therapy in Enhancing Early Postoperative Recovery in Lumbar Spinal Stenosis Patients: A Retrospective Study.

BACKGROUND The degree of postoperative symptom improvement in patients with lumbar spinal stenosis (LSS) is crucial to their postoperative rehabilitation process and functional exercise. Corticosteroids have certain anti-inflammatory effects. This study aimed to explore whether small doses of corticosteroids would improve postoperative neurological symptoms in patients with lumbar spinal stenosis. MATERIAL AND METHODS Patients with lumbar spinal stenosis who underwent open surgery were divided into a corticosteroid therapy group (CTG) and a non-corticosteroid therapy group (NCTG). They were followed up for 24 months after surgery. The numeric rating scale (NRS) for leg pain (NRS-LP) and leg numbness (NRS-LN), Oswestry Disability Index (ODI) scores, and Short Form Health Survey (SF-36) scores of the 2 groups were compared at different time points to evaluate the therapeutic effect. RESULTS Of the 232 eligible patients enrolled, 128 received corticosteroids and 104 did not. At the 1-month postoperative follow-up, patients in the CTG had significantly lower NRS-LP and NRS-LN scores than those in the NCTG (P=0.017; P=0.043). At the 3-month follow-up, the NRS-LP and ODI scores of patients in the CTG were significantly lower than those of the NCTG (P=0.015; P=0.027), and SF-36 scores were significantly higher than that of the NCTG (P=0.012). At the 6-month follow-up, the SF-36 scores of patients in the CTG was significantly higher than that of the NCTG (P=0.008). CONCLUSIONS Small doses of corticosteroid therapy for postoperative lumbar spinal stenosis reduced symptoms and improved quality of life scores after surgery. However, it had little long-term impact on final patient outcomes.

Retrospective Study to Compare the Effectiveness of Minimally Invasive Microscopic Unilateral Laminotomy with Microscopic Bilateral Laminotomy for Bilateral Decompression in the Early Postoperative Period in 142 Patients with Single-Level Lumbar Spinal Stenosis.

BACKGROUND We aimed to compare the effectiveness of microscopic unilateral laminotomy for bilateral decompression (ULBD) and microscopic bilateral laminotomy for bilateral decompression (BLBD) in the early postoperative period among patients with single-level lumbar spinal stenosis (LSS). MATERIAL AND METHODS A retrospective cohort study was conducted on patients with LSS who underwent ULBD or BLBD between January 2020 and December 2023, including 94 patients who underwent ULBD and 58 who underwent BLBD. Patient demographics, comorbidities, smoking status, and data related to LSS were reviewed. Preoperative and postoperative assessments on day 10 included back pain visual analog scale (VAS), walking distance, and Odom criteria. Disability was evaluated using the self-assessment Oswestry Disability Index (ODI) preoperatively and on day 30. Additionally, wound infection, postoperative modified MacNab criteria, and pain (back, leg, and hip) were recorded. RESULTS Age and sex were similar in the 2 groups. Both surgeries significantly reduced low back pain, increased walking distance, and improved Odom category on day 10, compared with baseline (P<0.001 for all). A significant decrease in 30-day ODI, compared with baseline, was observed in both groups (P<0.001 for both). The ULBD group had a significantly higher percentage of patients with wound infection (P=0.014); however, the ODI score among ULBD recipients was significantly lower (better) on day 30 (P=0.047). CONCLUSIONS ULBD may represent a less invasive, more effective, and safer surgical alternative than BLBD and classical laminectomy in patients with single-level LSS, but precautions are essential concerning wound infection.

Comparison of surgical effect in active and inactive Dysthyroid Optic Neuropathy after Endoscopic Transnasal Medial Orbital Decompression.

PURPOSE: To evaluate and compare the changes in orbital soft tissue volume and visual function after endoscopic transnasal medial orbital decompression in patients with active and inactive dysthyroid optic neuropathy (DON). METHODS: This prospective, cohort study recruited 112 patients (112 eyes) with DON who were divided into an active and inactive DON group (56 eyes each) by clinical activity scores. All patients underwent endoscopic transnasal medial orbital decompression. The pre- and post-operative orbital soft tissue volumes were measured with high-resolution computed tomography (CT) using Mimics software. Visual function, including best-corrected visual acuity (BCVA), visual field (VF), and visual evoked potential (VEP), was recorded before and after surgery. RESULTS: Preoperatively, compared with the inactive DON group, the active DON group had greater extraocular muscle volume (EMV) and EMV/orbital volume (OV) ratio, but worse BCVA, VF, and exophthalmos. Postoperatively, although the EMV slightly increased, with the enlarged medial rectus muscle contributing dramatically, the EMV/OV ratio decreased in patients with DON. Besides, visual function including BCVA, VF, VEP and exophthalmos was also improved in both groups after surgery. There were no significant differences in postoperative OV; EMV; EMV/OV ratio; and the BCVA, VF, and VEP parameters between both groups (all P > 0.05). CONCLUSION: Patients with DON who did not respond well to steroids, regardless of disease activity, may benefit from orbital decompression via the decrease in the proportion of EMV in OV, especially patients with active DON, who showed more improved visual function than patients with inactive DON.

Peripheral nerve decompression for pain relief in the setting of previous obstetrical brachial plexus injury: a retrospective case series.

PURPOSE: In children with previous obstetrical brachial plexus injury (OBPI), upper extremity pain is present in 45 to 66% of patients. Recent literature reports this as musculoskeletal or neuropathic in nature. The purpose of the study is to demonstrate that peripheral nerve decompression, and neurolysis may be an effective treatment for patients with upper extremity pain in the context of previous OBPI. METHODS: A retrospective chart review was performed on patients undergoing peripheral nerve decompression and neurolysis after OBPI by senior author. The primary outcome assessed was pain, and secondary outcome measure was range of motion of the wrist and elbow. Outcome measures were assessed preoperatively as well as at their subsequent follow-up. RESULTS: Six patients were included, with a mean age of 14 years old at time of decompression. Three patients underwent median nerve, two patients underwent ulnar nerve, and one patient underwent posterior interosseous nerve decompression. There was a substantial improvement in pain post-operatively, demonstrated by reduction or resolution of subjective pain in all patients and resolution of Tinel's sign. There was a modest improvement in range of motion. CONCLUSION: This study demonstrates an improvement in subjective pain and range of motion after decompression and neurolysis in small subset of OBPI patients. It generates the hypothesis that peripheral nerve compression is a source of pain that can be addressed in this population. Future research should focus on confirming this hypothesis and assessing treatment options on a larger scale.

Neurological outcome following delayed traction and fixation in severe tetraparesis consecutive to posterior decompression for Chiari malformation: a case report.

BACKGROUND: Chiari malformation type 1 (CM1) is a congenital hindbrain malformation characterized by herniation of the cerebellar tonsils below the foramen magnum. The term Chiari type 1.5 is used when herniation of the brainstem under the McRae line and anomalies of the craniovertebral junction are also present. These conditions are associated with several symptoms and signs, including headache, neck pain, and spinal cord syndrome. For symptomatic patients, surgical decompression is recommended. When radiographic indicators of craniovertebral junction (CVJ) instability or symptoms related to ventral brainstem compression are present, CVJ fixation should also be considered. CASE DESCRIPTION: We report the case of a 13-year-old girl who presented with severe tetraparesis after posterior decompression for Chiari malformation type 1.5, followed 5 days later by partial C2 laminectomy. Several months after the initial surgery, she underwent two fixations, first without and then with intraoperative cervical traction, leading to significant neurological improvement. DISCUSSION AND CONCLUSION: This case report underscores the importance of meticulous radiological analysis before CM surgery. For CM 1.5 patients with basilar invagination, CVJ fixation is recommended, and C2 laminectomy should be avoided. In the event of significant clinical deterioration due to nonadherence to these guidelines, our findings highlight the importance of traction with increased extension before fixation, even years after initial destabilizing surgery.

Secondary metopic craniosynostosis after posterior cranial decompression in cloverleaf skull deformity.

Cloverleaf skull deformity or Kleeblattschadel syndrome is a severe condition where multiple cranial sutures are absent and prematurely fused, leading to a trilobate head shape. The remaining open sutures or fontanelles compensate for rapid brain expansion, while the constricted fused calvarium restricts brain growth and results in increased intracranial pressure. Recent data show that early posterior cranial and foramen magnum decompression positively affects infants with cloverleaf skulls. However, long-term sequelae are still rarely discussed. We hereby report a child who developed secondary metopic craniosynostosis after posterior cranial decompression, which required a front-orbital advancement and cranial remodelling as a definitive procedure.

Natural history of Chiari I malformation with syrinx and dilatation of the central canal in the pediatric population: the CHEO experience.

PURPOSE: Given that syrinx is often considered an indication of surgery in children with Chiari I malformation (CM1), understanding of the natural history of these patients is very challenging. In this study, we investigate the natural history of children with CM1 that have syrinx and/or prominence of the central canal on presentation. METHODS: All pediatric Chiari I patients who had syrinx and/or prominence of the central canal who underwent MR imaging of the head and spine from 2007 to 2020 were reviewed. Patients were divided into 3 groups (early surgery, delayed surgery, and conservative management). We focused on those patients who did not initially undergo surgery and had at least 1 year of clinical follow-up. We assessed if there were any radiological features that would correlate with need for delayed surgical intervention. RESULTS: Thirty-seven patients met the inclusion criteria. Twenty-one patients were female and 16 were male. The mean age at presentation was 8.7 (5.8 SD). Fourteen (38%) patients had early surgical intervention, with a mean of 2.5 months after initial presentation, 8 (16%) had delayed surgery due to new or progressive neurological symptoms and 46% of patients did not require intervention during follow-up. The length of tonsillar herniation and the position of the obex were associated with the need of surgery in patients who were initially treated conservatively. CONCLUSION: In pediatric patients with CM1 with syringomyelia and prominence of the central canal, conservative treatment is initially appropriate when symptoms are absent or mild. Close follow-up of patients with CM1 and dilatation of the central canal who have an obex position below the foramen magnum and greater tonsillar herniation is suggested, as these patients show a trend towards clinical deterioration over time and may require earlier surgical intervention.

Retroflexed dens in paediatric Chiari 1 patients and implications: Single centre retrospective study.

INTRODUCTION: Chiari 1 malformation and hind brain hernia can be associated with skull base and craniocervical anomalies. One of the more recently associated anomalies is a retroverted or retroflexed odontoid process or dens. We conducted a retrospective study of our operated symptomatic and conservatively managed asymptomatic Chiari cohort to assess the impact of dens retroflexion on rate of revision or cerebrospinal fluid diversion following primary foramen magnum decompression (FMD). METHODS: We undertook a retrospective study of all foramen magnum decompression (FMD) cases for Chiari type 1 malformation performed over a 15-year period in a single tertiary paediatric neurosurgical unit. For comparison, non-operated asymptomatic Chiari cases were considered as reference cohort. Information gathered included: demographics, age, sex, length of cerebellar tonsils below McRae's line, pB-C2 distance (a line drawn perpendicular to one drawn between the basion and the posterior aspect of the C2 body), angle of retroflexion (angle formed between a line drawn through the odontoid synchondrosis and its intersection with a line drawn from the tip of the odontoid process) and angle of retroversion (angle formed between the line drawn from the base of C2 and its intersection with a line drawn from the tip of the odontoid process). Grade of retroflexion was measured using pre-operative mid-sagittal MR images and classified as grade 0 (> 90°), grade 1 (85°-89°); grade 2 (80°-84°) and grade 3 (< 80°). The rates for redo surgery or need for cerebrospinal fluid (CSF) diversion were obtained from clinical records and compared in the operated and non-operated groups. RESULTS: One hundred twenty-six Chiari 1 patients were included in this study with adequate imaging. Sixty-five patients were in the non-operated asymptomatic cohort with 61 patients in the operated symptomatic cohort. Mean age of non-operated cohort was 10.2 years with M:F ratio (30:35). Mean cerebellar tonsillar length below McRae's line was 10.3 mm. 7.7% of this cohort had associated syrinx. Mean angles of retroversion and retroflexion were 76 and 78°, respectively. Retroflexion grades included (9.2% grade 1, 35% grade 2 and 52.3% grade 3). pB-C2 distance was 6.8 mm. Mean age of operated cohort was 11.3 years, with M:F ratio (21:40). Mean cerebellar tonsillar length below McRae's line was 15 mm. 45.9% of this cohort had associated syrinx. Mean angles of retroversion and retroflexion were 73 and 74.5°, respectively. Retroflexion grades included (4.9% grade 1, 16.5% grade 2 and 78.6% grade 3). pB-C2 distance was 6.9 mm. No association was identified between retroflexion grade and rate of revision or CSF diversion following primary foramen magnum decompression. CONCLUSION: The operated Chiari 1 cohort had more retroflexed dens, longer tonsils and associated syrinx compared to the non-operated asymptomatic cohort.

Ultrasound-guided needle aspiration of immediate postoperative symptomatic spinal epidural hematoma after lumbar stenosis surgical decompression in the elderly: a proof-of-concept case.

BACKGROUND: Symptomatic spinal epidural hematoma (SSEH) is one of the most feared complications and source of litigation in spine surgery. Its occurrence rises up to 2% in minimally invasive spine surgery. In parts of the world where the population is aging, more fragile patients are expected to undergo degenerative spine surgery. Management of the SSEH includes emergent spine MRI, though some experts advocate for direct second-look surgery without imaging. Then, an urgent revision surgery under general anesthesia for hematoma evacuation is warranted. We report the case of a threatening SSEH in an 88-year-old patient after lumbar spine stenosis surgery. In order to spare a second general anesthesia for this fragile patient, we opted for a percutaneous ultra-sound guided drainage of the hematoma under local anesthesia as a first line treatment. The procedure was successful, we report an instant relief of his neurological deficit while performing the procedure. CONCLUSION: Ultra-sound guided percutaneous drainage of hyperacute SSEH successfully avoided a revision surgery. It spared a second general anesthesia in a fragile patient. This procedure could be an alternative first-line treatment of SSEH for fragile patients.

Factors influencing discharge against medical advice (DAMA) in traumatic brain injury patients requiring decompressive surgery: a comprehensive analysis.

raumatic brain injury (TBI) is a significant global health concern, particularly affecting young individuals, and is a leading cause of mortality and morbidity worldwide. Despite improvements in treatment infrastructure, many TBI patients choose discharge against medical advice (DAMA), often declining necessary surgical interventions. We aimed to investigate the factors that can be associated with DAMA in TBI patients that were recommended to have surgical treatment. This study was conducted at single tertiary university center (2008-2018), by retrospectively reviewing 1510 TBI patients whom visited the emergency room. We analyzed 219 TBI surgical candidates, including 50 declining surgery (refused group) and the others whom agreed and underwent decompressive surgery. Retrospective analysis covered demographic characteristics, medical history, insurance types, laboratory results, CT scan findings, and GCS scores. Statistical analyses identified factors influencing DAMA. Among surgical candidates, 169 underwent surgery, while 50 declined. Age (60.8 ± 17.5 vs. 70.5 ± 13.8 years; p < 0.001), use of anticoagulating medication (p = 0.015), and initial GCS scores (9.0 ± 4.3 vs. 5.3 ± 3.2; p < 0.001) appeared to be associated with refusal of decompressive surgery. Based on our analysis, factors influencing DAMA for decompressive surgery included age, anticoagulant use, and initial GCS scores. Contrary to general expectations and some previous studies, our analysis revealed that the patients' medical conditions had a larger impact than socioeconomic status under the Korean insurance system, which fully covers treatment for TBI. This finding provides new insights into the factors affecting DAMA and could be valuable for future administrative plans involving national insurance.

Surgical Outcomes of Standardized Endoscopical Deep Medial Orbital Decompression in Dysthyroid Optic Neuropathy.

INTRODUCTION: The aim of the study was to standardize the endoscopic deep medial orbital decompression surgery for better relief of optic nerve compression in dysthyroid optic neuropathy (DON). METHODS: A total of 128 eyes from patients received the standardized endoscopic deep medial orbital decompression surgery were recruited in this study. The efficacy of the procedure was assessed at a 1-month follow-up by the best-corrected visual acuity (VA), visual field (VF), and visual evoked potential (VEP). Clinical data were collected to explore the factors that affected visual recovery. Oxygen saturation of retinal blood vessels, retinal thickness, and vessel density were measured to demonstrate the potential recovery mechanisms. RESULTS: After surgery, the ratio of extraocular muscle volume in the orbital apex to orbital apex volume significantly decreased from 44.32 ± 22.31% to 36.82 ± 12.02% (p < 0.001). 96.87% of eyes' final VA improved; average VA improved from 0.93 ± 0.73 to 0.50 ± 0.60 at 1 week (p < 0.001) and 0.40 ± 0.53 at 1 month (p < 0.001). Postoperatively, VF and VEP also improved, the oxygen saturation of retinal arteries increased, and the retinal thickness was reduced. Preoperative VA, visual impairment duration, and clinical activity score evaluation were associated with visual recovery. CONCLUSION: In this study, we standardized the endoscopic deep medial orbital decompression, of which key point was to relieve pressure in the orbital apex and achieved satisfactory visual recovery in DON patients.

The effect of C2 screw type on perioperative outcomes and long-term stability after C2-T2 posterior cervical decompression and fusion.

PURPOSE: To determine if C2 pedicle versus pars screw type predicts change in fusion status, C2 screw loosening, cervical alignment, and patient-reported outcomes measures (PROMs) after C2-T2 posterior cervical decompression and fusion (PDCF). METHODS: All adult patients who underwent C2-T2 PCDF for myelopathy or myeloradiculopathy between 2013-2020 were retrospectively identified. Patients were dichotomized by C2 screw type into bilateral C2 pedicle and bilateral C2 pars screw groups. Preoperative and short- and long-term postoperative radiographic outcomes and PROMs were collected. Univariate and multivariate analysis compared patient factors, fusion status, radiographic measures, and PROMs across groups. RESULTS: A total of 159 patients met the inclusion/exclusion criteria (76 bilateral pedicle screws, 83 bilateral pars screws). Patients in the C2 pars relative to C2 pedicle screw group were on average more likely to have bone morphogenic protein (p = 0.001) and four-millimeter diameter rods utilized intraoperatively (p = 0.033). There were no significant differences in total construct and C2-3 fusion rate, C2 screw loosening, or complication and revision rates between C2 screw groups in univariate and regression analysis. Changes in C2 tilt, C2-3 segmental lordosis, C0-2 Cobb angle, proximal junctional kyphosis, atlanto-dens interval, C1 lamina-occiput distance, C2 sagittal vertical axis, C2-7 lordosis, and PROMs at all follow-up intervals did not vary significantly by C2 screw type. CONCLUSION: There were no significant differences in fusion status, hardware complications, and radiographic and clinical outcomes based on C2 screw type following C2-T2 PCDF. Accordingly, intraoperative usage criteria can be flexible based on patient vertebral artery positioning and surgeon comfort level.