Quality of life in Prolactinoma: A systematic review.

BACKGROUND: Prolactinomas are common tumours that significantly reduce quality-of-life (QOL) due to sellar mass effect, secondary hypogonadism, and the peripheral effects of prolactin. Understanding the factors that influence QOL would provide insights into therapeutic targets to optimise patient outcomes and improve wellbeing in prolactinoma. METHODS: A systematic review was performed in accordance with the PRISMA statement. Studies that reported patient QoL using validated metrics were included. Bias and methodological rigour were assessed using the MINORS criteria. RESULTS: A total of 18 studies were identified studies were available for review, comprising 877 patients. Most were small cross-sectional studies at high risk of bias. Prolactinoma exhibit worse QOL than healthy controls, particularly mental and psychosocial wellbeing. QOL is also worse than patients with non-functional adenomas, but better than those with Cushing's disease and acromegaly. QOL correlates with prolactin levels, and approaches population baseline with prolonged biochemical control. Dopamine agonists and surgery both improve overall QOL, however improvements are more rapid with surgery. CONCLUSION: Poor quality of life in prolactinoma is multifactorial, related to biochemical control, side effects of therapy, and sellar mass effect. Targeting persistent symptoms, reducing healthcare costs, and reducing side-effects of therapy are avenues to improving QOL in patients with prolactinoma.

Pituitary surgery and COVID.

An effect of the COVID-19 pandemic was the disruption of healthcare systems, especially surgical services provided to the community. Pituitary surgery was especially impacted, given the majority of cases were deemed non-urgent with very few exceptions, and the high risk of viral transmission conferred by the endoscopic endonasal transsphenoidal approach. Patients suffering from pituitary lesions with resultant endocrinopathy or visual symptoms saw their treatment delayed or altered, which had implications on their outcomes and care. This disruption extended to surgical training and the usual functioning of academic units, necessitating changes to curricula and implementation of novel methods of progressing surgical education. This review will explore the effect of the COVID pandemic on pituitary surgery, the experiences of various surgeons as well as the adaptations implemented on the frontlines. The lessons learned from the experience of the pandemic may assist specialists in gleaning insights regarding the care of patients in the future.

Glucocorticoids and Water Balance: Implications for Hyponatremia Management and Pituitary Surgery.

Water balance is fundamental to all homeostasis. The hypothalamic-pituitary-adrenal axis influences water balance through the effects of corticotropin-releasing hormone and cortisol on arginine vasopressin secretion and the peripheral effects of cortisol on hemodynamics and renal water handling. In this review, we explored the complex interplay of glucocorticoids with water balance, with particular attention to hyponatremia and pituitary surgery.

Surgical outcomes and quality of life in Rathke's cleft cysts undergoing endoscopic transsphenoidal resection: a multicentre study and systematic review of the literature.

OBJECTIVE: To establish the effect of endoscopic endonasal surgery (EES) on quality-of-life (QoL) in symptomatic Rathke cleft cyst (RCC). METHODS: Analysis of 38 patients with RCC treated by EES, with regular overall (ASBQ-35) and sinonasal-specific (SNOT-22) QoL assessment during the first postoperative year. A systematic literature review of large case series was performed with pooled analysis. RESULTS: In our series, mean age was 53.6 years with a female predominance (73.7%). Larger cysts were seen in males (p < 0.01), those with hypogonadism (p = 0.04), and visual dysfunction (p = 0.04). Complete normalisation of vision was seen in 83.3%. Persistence of visual dysfunction postoperatively was associated with diabetes (p = 0.005), hypertension (p = 0.02), suprasellar only location (p = 0.001), and monocular field cut (p = 0.02). Surgery did not significantly effect hormonal function. Sinonasal QoL transiently worsened after surgery, resolving within 3 weeks. A parallel transient worsening of overall QoL normalised by 6 weeks, and remained at preoperative baseline thereafter. These results were comparable to the literature, where 76.4% demonstrated improvement of vision and 13.1% had recurrence after treatment. There was no significant difference in outcomes between EES and microscopic approaches. CONCLUSIONS: We report longitudinal QoL outcomes in RCC for the first time. Vision commonly improves with surgery, but endocrinopathy is likely to persist. Microvascular risk-factors may compromise visual improvement. Surgery causes a transient worsening of sinonasal symptoms that resolves within 3-6 weeks, but patients may not experience significant improvement in QoL within the first postoperative year.

Transmantle and transvenous pressure gradients in cerebrospinal fluid disorders.

Hydrocephalus is the symptomatic endpoint of a variety of disease processes. Simple hydrodynamic models have failed to explain the entire spectrum of cerebrospinal fluid (CSF) disorders. Physical principles argue that for ventricles to expand, they must be driven by a force, Fishman's transmantle pressure gradient (TMPG). However, the literature to date, reviewed herein, is heterogenous and fails to consistently measure a TMPG. The venous system, like CSF, traverses the cerebral mantle, and thus analogous transparenchymal and transvenous pressure gradients have been described, reliant on the differential haemodynamics of the deep and superficial venous systems. Interpreting CSF disorders through these models provides new insights into the possible pathophysiological mechanisms underlying these diseases. However, until more sophisticated testing is performed, these models should remain heuristics.

Predictors of visual and endocrine outcomes after endoscopic transsphenoidal surgery for pituitary adenomas.

Surgery for pituitary adenoma is indicated for relief of mass effect and control of endocrinopathy. Setting benchmarks for visual and hormonal outcomes is important for monitoring performance of surgical centres, while understanding the preoperative factors that predict endocrine cure and visual improvement facilitates tailored counselling for patients prior to surgery. A prospective, consecutive cohort of surgically managed (endoscopic transsphenoidal) pituitary adenoma (n = 304) were analysed. Preoperative and postoperative endocrine and visual field assessments were performed and compared to demographic, imaging and pathological data. Larger adenomas tended to have preoperative endocrine deficiency (p < 0.001) and visual field defects (p < 0.001). The largest tumours did not experience normalisation of their endocrinopathy or visual fields with surgery. Of the adenomas with normal preoperative endocrine function, 92.0% (126/137) maintained this postoperatively; only 2 of the 11 patients with new hypopituitarism required long-term hormone replacement. Functional tumour cure was achieved in 65.2% (86/116) after surgery; 74.4% (32/43) of acromegalics and 70.0 (35/50) of Cushing's disease patients achieved hormonal control. All patients with isolated hyperprolactinaemia from stalk effect normalised with surgery, while only 15.9% (7/44) with hypopituitarism recovered normal endocrine function. New hypopituitarism was predicted by younger age and functional adenoma, particularly Cushing's disease. Resolution of endocrinopathy was less likely with reoperative cases and those with cavernous sinus invasion (Knosp grade > 2) or preoperative ophthalmoplegia. One-third of the cohort (102/304, 33.6%) had a preoperative field cut, most commonly an incomplete (51.0%) or complete (31.4%) bitemporal hemianopsia. Only two patients (2/304, 0.7%) had visual field worsening after surgery, while 71.6% (73/102) experienced partial or complete resolution of their field cut after surgery. Complete resolution of visual field defect was predicted by younger age and incomplete bitemporal hemianopsia. Surgery is a safe and effective therapy for pituitary adenomas. Nearly all patients experience improvement in visual fields, especially the young and those with incomplete bitemporal defects. Reoperative cases and those with cavernous sinus involvement (high Knosp grade/ophthalmoplegia) are less likely to have resolution of endocrinopathy. Visual worsening, new ophthalmoplegia or endocrinopathy were rare complications of surgery.

Validation of the anterior skull base questionnaire 35 in endoscopic pituitary adenoma surgery.

Patient quality of life (QOL) is an important metric of surgical success. To guide therapeutic advances in pituitary adenoma surgery, a validated, comprehensive instrument to quantify QOL is required. We aim to evaluate the validity of the 35 item anterior skull base questionnaire (ASBQ-35) in patients undergoing pituitary adenoma surgery. A total of 168 patients undergoing endoscopic resection of pituitary adenomas underwent longitudinal QOL assessment using the ASBQ-35 and the 22-item Sinonasal Outcomes Test (SNOT-22) over the first postoperative year. Validity of the ASBQ-35 was assessed by internal consistency, test-retest reliability, responsiveness to clinical change, and concurrent validity with the SNOT-22. Internal consistency of the ASBQ-35 was excellent, with a Cronbach's alpha > 0.95 across all timepoints. Test-retest reliability between 3 and 6 months (ICC = 0.82, p < 0.001) and 6 months and 12 months (ICC = 0.78, p < 0.001) was robust. Concurrent validity with SNOT-22 was strong across all timepoints (absolute Pearson r ≥ 0.63, p < 0.001). Mean ASBQ-35 scores were significantly worse at 3 weeks compared to preoperative baseline (mean difference - 0.28, p < 0.01); however, by 12 months, scores had significantly improved (mean difference + 0.24, p < 0.01), indicating that the scale is responsive to clinical change. Each of the 6 domains of the ASBQ, and all 35 component questions, contributed to the discriminative of the ASBQ to measure QOL during the first postoperative year. The ASBQ-35 is a valid, comprehensive tool for assessing QOL after endoscopic pituitary adenoma surgery. Each component of the ASBQ-35 contributed to the overall assessment of QOL during the first postoperative year.

Closure of skull base defects after endoscopic endonasal transsphenoidal surgery: the role of the local sphenoid mucosal flap for low flow leaks.

A local sphenoid mucosal flap (SMF) is naturally raised during endonasal exposure of the sella. Typically, these flaps are repositioned; however, they could be used in place of a nasoseptal flap (NSF) for closure of low-grade CSF leaks. In this study, we aim to establish the safety and efficacy of SMF closure for low-grade CSF leaks and to assess the impact on sinonasal quality of life (QoL) compared to NSF closure. In a consecutive, prospective cohort of anterior skull base pathology, data regarding sellar and suprasellar extension (Hardy grade), cavernous sinus invasion (Knosp grade), intraoperative (Kelly grade) and postoperative CSF leak, and sino-nasal QoL data (SNOT-22) were analysed. Of 187 patients with no/low flow (Kelly 0-1) intraoperative CSF leak, 127 (67.9%) received a SMF and 60 (32.1%) received a NSF. A total of 141/187 (75.4%) had no intraoperative leak, while 46/187 (24.6%) had grade-1 leaks. SMF were used in 70.9% (100/141) of cases without intraoperative leak, and 58.7% (27/46) of cases with Kelly grade-1 leaks. Hardy grade 4, grade E and Knosp grade 4 lesions were all more commonly closed with a NSF (p < 0.05). Two patients (1.1%) had postoperative CSF leaks, both in the SMF group, and both after no discernible intraoperative leak. Sinonasal QoL was below baseline for up to 3 months postoperatively. SMF cases tended to have better sinonasal QoL for up to 6 weeks after surgery. Thus, in the largest cohort to date, SMF are a safe alternative to NSF for closure low-grade skull base defects. Sinonasal QoL was better in the first 6 weeks after SMF closure than NSF closure.

Frailty does not preclude surgical success after endoscopic transsphenoidal surgery for pituitary adenomas.

INTRODUCTION: Frailty is a state of physiological vulnerability that negatively influences surgical outcomes. The effect of frailty on pituitary adenoma surgery, however, is not clear, and patients may be wrongly denied surgery because they are "too frail". We examined the effects of frailty on surgical outcome and quality-of-life (QoL) in patients undergoing endoscopic transsphenoidal resection of pituitary adenomas. METHODS: A prospective, consecutive cohort of surgically managed pituitary adenoma was analysed. Frailty was defined by the 5-factor modified Frailty Index (mFI-5) and the Charlson Comorbidity Index (CCI). QoL was measured by the anterior skull base questionnaire (ASBQ) and sinonasal outcomes test (SNOT). RESULTS: Of 304 patients with pituitary adenomas, 42 (13.8%) were frail (mFI5 of > 1). Frail patients tended to have smaller adenomas (p < 0.0001) with less suprasellar extension (p < 0.0001). Both overall (ASBQ) and sinonasal-specific (SNOT) QoL were not affected by frailty on multivariate analysis. Endocrine and visual outcomes were similarly not worsened by frailty. Overall, medical complications were uncommon, and perioperative morbidity or mortality was not significantly greater in the frail group. CONCLUSION: Frail patients experience the same QoL benefits from surgery as their non-frail counterparts, and have equivalently successful visual and endocrine outcomes. Frailty should not be seen as a barrier to successful surgical management of pituitary adenomas.

Diabetes insipidus after endoscopic transsphenoidal surgery: multicenter experience and development of the SALT score.

OBJECTIVE: To identify risk factors for the development of postoperative diabetes insipidus (DI) in a modern cohort of endoscopic endonasal transsphenoidal surgery. METHODS: Analysis of prospectively collected data of 449 consecutive patients operated on for anterior skull base pathology. DI was defined as a polyuria (> 250 ml/h for ≥ 2 consecutive hours) polydipsia syndrome associated with hypotonic urine with or without hypernatraemia. Multivariate logistic regression was used to identify predictors of postoperative DI. A simple scoring system was then created. RESULTS: Postoperative DI occurred in 46 (10.2%) patients. The development of DI did not affect quality of life. Predictors of DI on multivariate analysis included suprasellar extension (OR 2.2; p = 0.04), age < 50 years (OR 2.8; p = 0.003), craniopharyngioma histology (OR 6.7; p = 0.002), and Kelly grade 3 intraoperative CSF leak (OR 2.1; p = 0.04). The SALT score was created based on these characteristics, with one point awarded for each feature present, and predicted DI with fair to good predictive value in our cohort (AUROC 0.735 (95%CI 0.65-0.82)). The rates of postoperative DI were 4.0%, 6.5%, 15.0%. 36.8% and 85.7% for SALT scores of zero, one, two, three, and four, respectively. CONCLUSIONS: The SALT score predicts postoperative DI with fair to good accuracy, and now requires prospective external validation. Improved prediction of DI could optimize resource allocation and facilitate individualised preoperative patient counselling. We also provide our algorithm for diagnosis and treatment of DI.

Hyponatraemia and hypernatraemia: Disorders of Water Balance in Neurosurgery.

Disorders of tonicity, hyponatraemia and hypernatraemia, are common in neurosurgical patients. Tonicity is sensed by the circumventricular organs while the volume state is sensed by the kidney and peripheral baroreceptors; these two signals are integrated in the hypothalamus. Volume is maintained through the renin-angiotensin-aldosterone axis, while tonicity is defended by arginine vasopressin (antidiuretic hormone) and the thirst response. Edelman found that plasma sodium is dependent on the exchangeable sodium, potassium and free-water in the body. Thus, changes in tonicity must be due to disproportionate flux of these species in and out of the body. Sodium concentration may be measured by flame photometry and indirect, or direct, ion-sensitive electrodes. Only the latter method is not affected by changes in plasma composition. Classification of hyponatraemia by the volume state is imprecise. We compare the tonicity of the urine, given by the sodium potassium sum, to that of the plasma to determine the renal response to the dysnatraemia. We may then assess the activity of the renin-angiotensin-aldosterone axis using urinary sodium and fractional excretion of sodium, urate or urea. Together, with clinical context, these help us determine the aetiology of the dysnatraemia. Symptomatic individuals and those with intracranial catastrophes require prompt treatment and vigilant monitoring. Otherwise, in the absence of hypovolaemia, free-water restriction and correction of any reversible causes should be the mainstay of treatment for hyponatraemia. Hypernatraemia should be corrected with free-water, and concurrent disorders of volume should be addressed. Monitoring for overcorrection of hyponatraemia is necessary to avoid osmotic demyelination.

Intravenous milrinone for treatment of delayed cerebral ischaemia following subarachnoid haemorrhage: a pooled systematic review.

Small trials have demonstrated promising results utilising intravenous milrinone for the treatment of delayed cerebral ischaemia (DCI) after subarachnoid haemorrhage (SAH). Here we summarise and contextualise the literature and discuss the future directions of intravenous milrinone for DCI. A systematic, pooled analysis of literature was performed in accordance with the PRISMA statement. Methodological rigour was analysed using the MINORS criteria. Extracted data included patient population; treatment protocol; and clinical, radiological, and functional outcome. The primary outcome was clinical resolution of DCI. Eight hundred eighteen patients from 10 single-centre, observational studies were identified. Half (n = 5) of the studies were prospective and all were at high risk of bias. Mean age was 52 years, and females (69%) outnumbered males. There was a similar proportion of low-grade (WFNS 1-2) (49.7%) and high-grade (WFNS 3-5) (50.3%) SAH. Intravenous milrinone was administered to 523/818 (63.9%) participants. Clinical resolution of DCI was achieved in 375/424 (88%), with similar rates demonstrated with intravenous (291/330, 88%) and combined intra-arterial-intravenous (84/94, 89%) therapy. Angiographic response was seen in 165/234 (71%) receiving intravenous milrinone. Hypotension (70/303, 23%) and hypokalaemia (31/287, 11%) were common drug effects. Four cases (0.5%) of drug intolerance occurred. Good functional outcome was achieved in 271/364 (74%) patients. Cerebral infarction attributable to DCI occurred in 47/250 (19%), with lower rates in asymptomatic spasm. Intravenous milrinone is a safe and feasible therapy for DCI. A signal for efficacy is demonstrated in small, low-quality trials. Future research should endeavour to establish the optimal protocol and dose, prior to a phase-3 study.

Pyramidal weakness: Is it time to retire the term?

Pyramidal weakness, that is, the weakness that preferentially spares the antigravity muscles, is considered an integral part of the upper motor neuron syndrome. Despite its name, pyramidal weakness has very little to do with the pyramidal tract, and preeminent texts on neurology, neuroanatomy, and clinical examination differ considerably in their descriptions and localization of this enigmatic finding. Evidence from human and nonhuman primate studies demonstrates that lesions confined only to the corticospinal (pyramidal) tract cause significant deficits in fine motor control of the hand, but do not cause posturing or patterned weakness of the extremities. Lesioning of the corticofugal fibers, particularly the corticoreticular and corticopontine tracts, leads to dysbalanced output from reticulospinal, and vestibulospinal systems, which along with changes in rubrospinal tract output balance, probably accounts for the pyramidal weakness pattern. Importantly, this would delineate that pyramidal weakness could only be incited by lesions above the brainstem. It has also been suggested that the inherently greater strength of the antigravity musculature is the substrate for pyramidal weakness, independent of any preferential motor innervation. These hypotheses require further testing in myometric studies with carefully selected participants.

Twelve cases of pituitary metastasis: a case series and review of the literature.

PURPOSE: The pituitary gland is an unusual site for metastatic spread, but as patients with metastatic malignancy are living longer, it may become more prevalent. Compression of important anatomy adjacent to the sella may produce disabling symptoms and endocrine derangement, leading to significant morbidity. METHODS: An ambispective review of patient records between 2013 and 2017 from three neurosurgical centres was performed. After identifying cases, further investigation was performed to evaluate patient demographic, symptoms at presentation, radiological and histological findings, management, and outcome. RESULTS: Our investigation identified 12 patients with pituitary metastasis. The average age of the cases was 63.4 years, with breast (n = 4) and lung (n = 4) being the most common primary cancers. In half the cases there was a history of metastatic disease, while in one-quarter of cases, pituitary symptoms were the first sign of malignancy. Adenohypophyseal dysfunction (83%), diabetes insipidus (DI) (75%), headache (67%) and visual field defects (67%) were the most common findings at presentation. Glucocorticoid replacement increased the sensitivity for diagnosis of DI. All cases were contrast enhancing on MRI and the endoscopic trans-sphenoidal approach was preferred for biopsy and debulking. CONCLUSIONS: The pituitary should not be overlooked as a site of metastasis and sellar symptoms may be the first presentation of neoplastic disease. Any biochemical or clinical sign of pituitary pathology in a patient with known cancer should raise suspicion for sellar metastasis. Moreover, the development of DI or ophthalmoplegia from any pituitary lesion is suggestive of metastatic disease even in patients with no known primary.

Tension Pneumocephalus Secondary to Positive Pressure Ventilation Following Endoscopic Endonasal Skull Base Surgery: Three-Year Follow-Up After Implementation of an Institutional Protocol.

BACKGROUND: Tension pneumocephalus (PMC) is a rare and feared complication following the endonasal endoscopic approach (EEA) to skull base procedures. This is a neurosurgical emergency that requires urgent decompression to avoid catastrophic neurologic damage or death. An avoidable cause is the application of positive pressure ventilation (PPV) in EEA patients for postoperative hypoxia. Our institution implemented a hospital-wide protocol in response to this to identify and manage at-risk patients; this paper aims to identify if this protocol was effective in lowering the rates of tension PMC secondary to PPV. RESULTS: In the 3 years following the implementation of the protocol, 110 patients underwent EEAs, from which 1 case of tension PMC (found to be not secondary to PPV) was identified. This is compared with 2 cases of tension PMC secondary to PPV over the preceding 5 years, out of 406 EEA patients. This constitutes a quantifiable reduction in PPV-related tension PMC in both standard and extended approach EEAs, signifying the effective uptake of the protocol. CONCLUSIONS: We found no cases of tension PMC after PPV following EEA skull base surgery in our institution since the implementation of an institution-wide guideline. This underscores the utility of our simple and cost-effective preventative protocol in reducing the overall rates of tension PMC following the inadvertent postoperative application of PPV. Further research is needed to study the comparative risks and benefits of PPV in the post-EEA patient and thus inform future iterations of the protocol.

Vertebral Artery Mobilization During Transcondylar Extreme Far Lateral Approach for Excision of Large Foramen Magnum Meningioma: 2-Dimensional Operative Video.

Foramen magnum meningiomas are challenging lesions owing to their proximity to the lower brainstem, vertebrobasilar system, and lower cranial nerves.1,2 Tumor size, origin, morphology, relationship to neurovascular structures, and bony anatomy determine the optimal surgical approach.2,3 Classically, far lateral approaches have been the workhorse approach to the foramen magnum. Variations of the far lateral including transcondylar and extended transcondylar (paracondylar), with or without transposition of the vertebral artery, are sometimes used for a more lateral approach to the brainstem and clivus. Here, we present a 60-year-old male patient presenting with a large foramen magnum meningioma. Preoperative workup includes computed tomography and MRI with angiography to assess for posterior circulation dominance, anatomic variants including posterior inferior cerebellar artery origin, venous, and bony anatomy.1,4 An extreme far lateral provides access anterior to the vertebral artery to extend exposure beyond the standard far lateral approach. This comprised transcondylar drilling, bony mobilization of the V3 Vertebral artery from C1 foramen transversarium, and dural mobilization of vertebral artery with a dural cuff at its site of dural entry. The patient tolerated the procedure, gross total resection was achieved, and the patient was discharged home. This video demonstrates in detail the steps of exposure, condylar drilling, vertebral artery transposition, and dural opening. These maneuvers can be difficult to conceptualize yet are key to successful extended transcondylar exposure. The patient gave informed consent for surgery and video recording. Institutional Review Board approval was deemed unnecessary.

Subdural Versus Subgaleal Drain Placement After Minicraniotomy for Chronic Subdural Hematoma.

BACKGROUND AND OBJECTIVES: Surgical evacuation with placement of a postoperative drain is the standard treatment for symptomatic chronic subdural hematoma (cSDH). Subdural and subgaleal drains are equally effective after burrhole craniostomy, but the optimal location of the drain after craniotomy is not clear. We sought to compare the clinical and radiological outcomes of subdural and subgaleal drain placement in patients undergoing minicraniotomy for cSDH. METHODS: A retrospective review of 137 consecutive patients undergoing minicraniotomy for cSDH at a single institution was performed. Cases were stratified by location of postoperative drain. The primary outcome was change in functional status (modified Rankin Score, mRS) at 3 months from preoperative baseline. RESULTS: Among the patient cohort, 24.6% received subgaleal drain placement. After a median follow-up of 105 days, 79.4% (27/34) in the subgaleal group and 57.3% (59/103) in the subdural group (P = .02) had been discharged home. Worse premorbid mRS (P = .002), subdural drain location (P = .004), and decreased consciousness at presentation (Glasgow Coma Scale<15) (P < .002) were independent predictors of a discharge destination other than home. At the 3-month follow-up, the subgaleal group exhibited a mean improvement of 0.77 ± 1.2 points, while the subdural group had a deterioration of 0.14 ± 0.8 points (P < .01). Subgaleal drain location (P < .0001), better preoperative Glasgow Coma Scale (P = .01), and worse premorbid mRS (P = .0003) were independent predictors of improved mRS at 3 months. Recurrence requiring repeat surgery were more common in the subdural (13.6% (14/103) than the subgaleal 2.9% (1/34) group, P = .12), although the absolute incidence rates remained low. CONCLUSION: In patients undergoing minicraniotomy for cSDH, subgaleal drains are associated with shorter hospitalization, greater chance of discharge home, and better functional outcomes than subdural drains.

Preoperative coil localization for spinal surgery is accurate, safe and effective: a single-centre initial experience.

OBJECTIVE AND STUDY DESIGN: This is a retrospective, descriptive study of consecutive patients undergoing novel preoperative pushable coil localization for spinal surgery, in order to evaluate its feasibility, safety and accuracy. METHODS: Consecutive patients who underwent pre-operative coil marking for spinal surgery at our institution from May 2018 to July 2021 were included. Data were collected for coil placement, accuracy, complications and fluoroscopy usage. Patient demographic and relevant perioperative and procedural data were also collected. RESULTS: A total of 34 patients were identified of which 32 (94%) had complete data and imaging at last clinical follow up, with a mean duration of 13.9 months. There were no incorrect level surgeries performed. There were no coil-related complications found in our cohort. CONCLUSIONS: Preoperative coil placement is an accurate, safe and well-tolerated method for level localization in spinal surgeries.

Intraoperative Ultrasound and Findings of Lumbar Intradural Disk Herniation Causing Cauda Equina Syndrome.

Intradural lumbar disk herniation (ILDH) is a rare variant and accounts for 0.33%-1.5% of lumbar disk herniations. Although clues exist on preoperative imaging, they remain subtle and most cases of ILDH are diagnosed intraoperatively. Intraoperative ultrasound is a useful adjunct in diagnosing and managing ILDH. We present a case to demonstrate the features of an intradural herniated disk on ultrasound imaging and highlight the utility of intraoperative ultrasonography in establishing diagnosis, guiding dural opening, and confirming adequate nerve root decompression following diskectomy.

Quality of life and surgical outcomes in incidental pituitary adenomas undergoing endoscopic endonasal resection.

OBJECTIVE: Incidental, asymptomatic pituitary adenomas require nuanced, shared decision-making, which is limited by a poor understanding of their natural history and effects on quality of life (QOL). A greater understanding of the effects of surgery would inform evidence-based care. METHODS: A multicenter review of consecutive pituitary adenomas resected via an endoscopic endonasal approach (EEA) between late 2016 and mid-2021 was performed, with prospective, longitudinal QOL assessment (at 3 and 6 weeks and at 3, 6, and 12 months) postoperatively using the 35-item Anterior Skull Base Questionnaire. RESULTS: Of 366 adenomas resected during the study period, 52 (14.2%) were incidentally discovered, of which 51 (98.1%) were macroadenomas. Preoperative QOL in patients with these incidentalomas was better than in those with adenomas presenting with endocrinopathy (p < 0.01), visual failure (p = 0.02), or headache (p = 0.03). Surgery was performed due to visual field deficits (13.5%, n = 7); ophthalmoplegia (1.9%, n = 1); radiological compression or contact of the optic apparatus (63.5%, n = 33); functional status (growth hormone-secreting tumor) (5.8%, n = 3); and clinically significant growth (15.4%, n = 8). Surgical outcomes were excellent, with vision improved in 100% (7/7) and complete resection in 84.6% (44/52). There were 2 (3.8%) cases of new cortisol deficiency, 3 (5.8%) cases of transient postoperative diabetes insipidus, and 4 (7.7%) cases of postoperative hyponatremia. There were no perioperative complications and no cases of postoperative CSF leakage. QOL transiently decreased during the first 3 weeks after surgery, then improved to above baseline levels by 3 months (p = 0.03) and continued to improve throughout the first postoperative year (p = 0.03). All surgical indications demonstrated an overall mean improvement in QOL at 3 months. QOL benefits were not affected by age or tumor size. CONCLUSIONS: Resection of pituitary adenomas via the EEA provided a tangible benefit for patients within 3 months. Surgery via the EEA is safe, effective, and beneficial for patients with pituitary incidentalomas meeting accepted criteria for intervention.