Characterizing mJOA-defined post-surgical recovery patterns in patients with degenerative cervical myelopathy.

Background: Degenerative cervical myelopathy is a spinal disorder resulting in progressive cord compression and neurological deficits that are assessed using the modified Japanese Orthopedic Association (mJOA) questionnaire. It is difficult to predict which patients will recover neurological function after surgery, making it challenging for clinicians to set postoperative patient expectations. In this study, we used mJOA subscores to identify patterns of recovery and recovery timelines in patients with moderate and severe myelopathy. Methods: Fifty-three myelopathy patients were enrolled and completed the mJOA questionnaire both pre-surgery, and six weeks and six months post-surgery. Pearson chi-square tests were performed to assess relationships of both recovery patterns and recovery timelines with severity of disease. Results: Moderate myelopathy patients were significantly more likely than severe myelopathy patients to experience full recovery of upper extremity, lower extremity, and sensory domains. Disease severity did not significantly impact the timeline during which recovery occurs. Overall, >90% of patients experienced at least partial recovery by six months post surgery, 80% of which demonstrated it within the first six weeks. Conclusions: This study shows the more severe the disease experienced by myelopathy patients, the more likely they will be left with permanent disabilities despite surgery. Early identification and treatment are therefore necessary to prevent worsening quality of life and increased costs of functional dependence. The recovery timelines for each subscore are similar and provide new values to guide patient expectations in their potential post-operative recovery. The overall recovery timeline is more generalizable though potentially lacking the specificity patients seek.

Reproducibility of 3D pH-weighted chemical exchange saturation transfer contrast in the healthy cervical spinal cord.

Spinal cord ischemia and hypoxia can be caused by compression, injury, and vascular alterations. Measuring ischemia and hypoxia directly in the spinal cord noninvasively remains challenging. Ischemia and hypoxia alter tissue pH, providing a physiologic parameter that may be more directly related to tissue viability. Chemical exchange saturation transfer (CEST) is an MRI contrast mechanism that can be made sensitive to pH. More specifically, amine/amide concentration independent detection (AACID) is a recently developed endogenous CEST contrast that has demonstrated sensitivity to intracellular pH at 9.4 T. The goal of this study was to evaluate the reproducibility of AACID CEST measurements at different levels of the healthy cervical spinal cord at 3.0 T incorporating B1 correction. Using a 3.0 T MRI scanner, two 3D CEST scans (saturation pulse train followed by a 3D snapshot gradient-echo readout) were performed on 12 healthy subjects approximately 10 days apart, with the CEST volume centered at the C4 level for all subjects. Scan-rescan reproducibility was evaluated by examining between and within-subject coefficients of variation (CVs) and absolute AACID value differences. The C4 level of the spinal cord demonstrated the lowest within-subject CVs (4.1%-4.3%), between-subject CVs (5.6%-6.3%), and absolute AACID percent difference (5.8-6.1%). The B1 correction scheme significantly improved reproducibility (adjusted p-value = 0.002) compared with the noncorrected data, suggesting that implementing B1 corrections in the spinal cord is beneficial. It was concluded that pH-weighted AACID measurements, incorporating B1-inhomogeneity correction, were reproducible within subjects along the healthy cervical spinal cord and that optimal image quality was achieved at the center of the 3D CEST volume.

The importance of measuring prolactin prior to surgical management of a pituitary lesion: An illustrative case.

The characterization of sellar and suprasellar lesions is reliant on patient presentation, medical imaging, and hormone profiling. Prolactinomas are the most common type of functional pituitary adenomas, accounting for up to 57%. Importantly, prolactinomas can present without clear symptoms and with doubtful or even normal imaging. A 41-year-old male patient was referred to neurosurgery for consideration for resection of a sellar lesion, as initial CT imaging suggested a large meningioma. Subsequent MRI of the sella favored macroadenoma, meningioma, and craniopharyngioma as the top differential considerations. These conditions all indicate a diagnosis that would require surgical management. Clinical evaluation of this patient did not elicit any obvious clinical features suggestive of hyperprolactinemia. Fortunately, we obtained a full hormone panel which revealed a significantly elevated prolactin level of 17,390 µg/L. Based on this elevated prolactin level, we diagnosed a pituitary giant prolactinoma. Treatment with a dopamine agonist therapy was initiated and the response confirmed this diagnosis. This case demonstrates the importance of obtaining a prolactin level prior to surgical management of a sellar lesion. Had a prolactin level not been obtained, this patient would have undergone surgical resection based on both the imaging and clinical judgment.

Chondroblastoma of the knee in a teenager.

Chondroblastoma is an uncommon osseous neoplasm that accounts for less than 1% of all bone tumors. Characteristically it arises in the epiphysis or apophysis of long bones in young patients and may extend into the metaphysis. A sixteen-year-old male presents with a 1-year history of left knee pain associated with joint stiffness and interfering with performing daily activities. Radiographic and contrast enhanced magnetic resonance imaging favored the diagnosis of chondroblastoma. This was then confirmed histologically. The clinical signs and symptoms of Chondroblastoma are usually nonspecific, pain is most often moderate and can be revealed as a result of a trauma. The definitive diagnosis is mainly pathological due to the lack of specificity of radiological findings consistent with the presented case.

Spinal cord compression is associated with brain plasticity in degenerative cervical myelopathy.

The impact of spinal cord compression severity on brain plasticity and prognostic determinates is not yet fully understood. We investigated the association between the severity of spinal cord compression in patients with degenerative cervical myelopathy, a progressive disease of the spine, and functional plasticity in the motor cortex and subcortical areas using functional magnetic resonance imaging. A 3.0 T MRI scanner was used to acquire functional images of the brain in 23 degenerative cervical myelopathy patients. Patients were instructed to perform a structured finger-tapping task to activate the motor cortex to assess the extent of cortical activation. T2-weighted images of the brain and spine were also acquired to quantify the severity of spinal cord compression. The observed blood oxygen level-dependent signal increase in the contralateral primary motor cortex was associated with spinal cord compression severity when patients tapped with their left hand (r = 0.49, P = 0.02) and right hand (r = 0.56, P = 0.005). The volume of activation in the contralateral primary motor cortex also increased with spinal cord compression severity when patients tapped with their left hand (r = 0.55, P = 0.006) and right hand (r = 0.45, P = 0.03). The subcortical areas (cerebellum, putamen, caudate and thalamus) also demonstrated a significant relationship with compression severity. It was concluded that degenerative cervical myelopathy patients with severe spinal cord compression recruit larger regions of the motor cortex to perform finger-tapping tasks, which suggests that this adaptation is a compensatory response to neurological injury and tissue damage in the spinal cord.

Pfeiffer syndrome in an adult with previous surgical correction: A case report of CT findings.

Pfeiffer syndrome, affecting roughly 1 in 100,000 individuals is characterized by acrocephalosyndactyly - the premature closure of skull sutures (craniosynostosis). These acrocephalosyndactyly syndromes which are often sporadic de novo but also autosomal dominant in inheritance can be characterized by the fact that they often involve FGFR and TWIST genes. In the presented case, a 27-year old male level three trauma admission displayed skull abnormalities on physical examination that history taking confirmed was the result of pediatric surgically corrected Pfeiffer syndrome. Noncontrast brain CT as part of his trauma work-up revealed characteristic Pfeiffer syndrome imaging pattern of midface hypoplasia, nonvisualization of coronal and sagittal sutures, and a degree of obstructive hydrocephalus. Pfeiffer syndrome requires extensive pediatric surgery often with poor adult follow up. The case presented provides good visualization of characteristic skull abnormalities in a surgically corrected adult. By virtue of imaging an adult, this provides readers with a unique look at the long-term viability and the body's resulting physiological adaptations of the extensive mandatory pediatric surgery these patients undergo.

Does the Neurological Examination Correlate with Patient-Perceived Outcomes in Degenerative Cervical Myelopathy?

BACKGROUND: In patients with neurological disorders, a divergence can exist between patients' perceptions regarding the outcomes and the objective neurological findings. Degenerative cervical myelopathy (DCM), a prevalent condition characterized by progressive compression of the cervical spinal cord, can produce debilitating symptoms and profound neurological findings. The purpose of the present study was to determine whether the physician-derived neurological examination findings, as recorded by American Spine Injury Association (ASIA) summary score, correlated with the patient-derived outcome measures for DCM. METHODS: A total of 78 patients underwent surgical management of DCM with completion of preoperative and 6-month follow-up assessments. Surgical management consisted of either anterior or posterior cervical decompression. All patients underwent a neurological evaluation, including an ASIA assessment before surgery and 6 months after surgery, and completed the modified Japanese Orthopaedic Association (mJOA), neck disability index (NDI), and Short-Form 36-item (SF-36) scales pre- and postoperatively to measure both disease-specific and general perceived outcomes. RESULTS: The objective physician-derived neurological testing (ASIA) did not correlate with the patient-derived scales (mJOA, NDI, and SF-36) pre- or postoperatively. Patients reported significant improvements (P < 0.001) at 6 months postoperatively in extremity functioning (mJOA), neck pain (NDI), overall physical health (SF-36), and objective strength and sensory functioning (ASIA). All patient-perceived outcome measures correlated with each other pre- and postoperatively (P < 0.01). CONCLUSIONS: Objective scoring of postoperative neurological function did not correlate with patient-perceived outcomes before and after surgery for DCM. Traditional testing of motor and sensory function as part of the neurological assessment may not be sensitive enough to assess the scope of neurological changes experienced by patients with DCM.

Differential effects of transcranial direct current stimulation on antiphase and inphase motor tasks: A pilot study.

Ageing is associated with a decline in motor function that critically interferes with activities of daily living involving manual dexterity. Transcranial direct current stimulation (tDCS) is a form of non-invasive brain stimulation that has been shown to enhance manual dexterity in healthy aging adults. The supplementary motor area (SMA) is involved in motor preparation and bimanual control; therefore, bihemispheric tDCS incorporating the SMA may preferentially enhance bimanual motor movements in healthy older adults. The aim of the current study was to determine if tDCS incorporating SMA could improve manual dexterity in older adults. Twenty-four adults, aged 67-84 participated in this double-blind, randomized, cross over design, pilot study. One group of participants (n = 17) were randomized to receive stimulation or sham on their first visit and received the contrary on their second visit, seven days later. A second group of participants (n = 10) received three consecutive days of tDCS while performing a motor task. Participants performed unimanual and bimanual hand movements while receiving 2 mA of tDCS. The total time for participants to complete three trials of each task was recorded. No significant differences in performance times were observed between single or tri session tDCS and sham conditions. However, tDCS had opposing effects on the motor consolidation of anti-phase and in-phase bimanual tasks. During the tri session paradigm, older adults improved performance learning of antiphase bimanual movements more quickly than inphase bimanual movements, suggesting a different mechanism of action of these two movements.

Biomechanical evaluation of the ProDisc-C stability following graded posterior cervical injury.

OBJECTIVEThere are limited data regarding the implications of revision posterior surgery in the setting of previous cervical arthroplasty (CA). The purpose of this study was to analyze segmental biomechanics in human cadaveric specimens with and without CA, in the context of graded posterior resection.METHODSFourteen human cadaveric cervical spines (C3-T1 or C2-7) were divided into arthroplasty (ProDisc-C, n = 7) and control (intact disc, n = 7) groups. Both groups underwent sequential posterior element resections: unilateral foraminotomy, laminoplasty, and finally laminectomy. Specimens were studied sequentially in two different loading apparatuses during the induction of flexion-extension, lateral bending, and axial rotation.RESULTSRange of motion (ROM) after artificial disc insertion was reduced relative to that in the control group during axial rotation and lateral bending (13% and 28%, respectively; p < 0.05) but was similar during flexion and extension. With sequential resections, ROM increased by a similar magnitude following foraminotomy and laminoplasty in both groups. Laminectomy had a much greater effect: mean (aggregate) ROM during flexion-extension, lateral bending, and axial rotation was increased by a magnitude of 52% following laminectomy in the setting of CA, compared to an 8% increase without arthroplasty. In particular, laminectomy in the setting of CA introduced significant instability in flexion-extension, characterized by a 90% increase in ROM from laminoplasty to laminectomy, compared to a 16% increase in ROM from laminoplasty to laminectomy without arthroplasty (p < 0.05).CONCLUSIONSForaminotomy and laminoplasty did not result in significant instability in the setting of CA, compared to controls. Laminectomy alone, however, resulted in a significant change in biomechanics, allowing for significantly increased flexion and extension. Laminectomy alone should be used with caution in the setting of previous CA.

1H MR spectroscopy of the motor cortex immediately following transcranial direct current stimulation at 7 Tesla.

Transcranial direct current stimulation (tDCS) is a form of non-invasive brain stimulation that may modulate cortical excitability, metabolite concentration, and human behaviour. The supplementary motor area (SMA) has been largely ignored as a potential target for tDCS neurorehabilitation but is an important region in motor compensation after brain injury with strong efferent connections to the primary motor cortex (M1). The objective of this work was to measure tissue metabolite changes in the human motor cortex immediately following tDCS. We hypothesized that bihemispheric tDCS would change levels of metabolites involved in neuromodulation including N-acetylaspartate (NAA), glutamate (Glu), and creatine (tCr). In this single-blind, randomized, cross-over study, fifteen healthy adults aged 21-60 participated in two 7T MRI sessions, to identify changes in metabolite concentrations by magnetic resonance spectroscopy. Immediately after 20 minutes of tDCS, there were no significant changes in metabolite levels or metabolite ratios comparing tDCS to sham. However there was a trend toward increased NAA/tCr concentration (p = 0.08) in M1 under the stimulating cathode. There was a strong, positive correlation between the change in the absolute concentration of NAA and the change in the absolute concentration of tCr (p<0.001) suggesting an effect of tDCS. Both NAA and creatine are important markers of neurometabolism. Our findings provide novel insight into the modulation of neural metabolites in the motor cortex immediately following application of bihemispheric tDCS.

Motor network recovery in patients with chronic spinal cord compression: a longitudinal study following decompression surgery.

OBJECTIVE The authors used functional MRI to assess cortical reorganization of the motor network after chronic spinal cord compression and to characterize the plasticity that occurs following surgical intervention. METHODS A 3-T MRI scanner was used to acquire functional images of the brain in 22 patients with reversible cervical spinal cord compression and 10 control subjects. Controls performed a finger-tapping task on 3 different occasions (baseline, 6-week follow-up, and 6-month follow-up), whereas patients performed the identical task before surgery and again 6 weeks and 6 months after spinal decompression surgery. RESULTS After surgical intervention, an increased percentage blood oxygen level-dependent signal and volume of activation was observed within the contralateral and ipsilateral motor network. The volume of activation of the contralateral primary motor cortex was associated with functional measures both at baseline (r = 0.55, p < 0.01) and 6 months after surgery (r = 0.55, p < 0.01). The percentage blood oxygen level-dependent signal of the ipsilateral supplementary motor area 6 months after surgery was associated with increased function 6 months after surgery (r = 0.48, p < 0.01). CONCLUSIONS Plasticity of the contralateral and ipsilateral motor network plays complementary roles in maintaining neurological function in patients with spinal cord compression and may be critical in the recovery phase following surgery.

Does design matter? Cervical disc replacements under review.

The present article reviews the design rationale of currently available cervical disc replacements. Recent prospective randomized control trials comparing cervical disc replacement and anterior fusion have demonstrated safety as well as equal or superior clinical results. Increasingly, more devices are becoming available on the market. Understanding design rationale will provide context for the surgeon to optimize decision making for the most appropriate prosthesis. Cervical arthroplasty is a technique that is undergoing rapid design refinement and development. Further improvements in device design will enable patient-specific device selection. Understanding the design rationale and complication profile of each device will improve clinical and radiographic outcomes.

Bilateral caudate nucleus infarcts: A case report of a rare complication following endoscopic resection of a tuberculum sellae meningioma.

BACKGROUND: We present a rare complication of bilateral caudate infarcts and necrosed nasoseptal flaps after endoscopic transsphenoidal resection of tuberculum sellae meningioma. This case highlights the importance of early and accurate diagnosis and treatment of a postoperative cerebrospinal fluid (CSF) leak and associated bacterial meningitis, and reviews any existing guidelines regarding its management. CASE DESCRIPTION: A 54-year-old otherwise healthy man presented with progressive bitemporal hemianopsia. Magnetic resonance imaging of the head revealed a large, homogeneously enhancing sellar and suprasellar mass consistent with a meningioma. An endoscopic endonasal transsphenoidal approach was performed to resect the tuberculum sellae meningioma. The patient developed basal bacterial meningitis secondary to a CSF leak, requiring repair on two separate occasions. At the time of both repairs, there was evidence of necrosis of the nasoseptal flaps used for the repairs. Soon after the diagnosis of meningitis, the patient developed bilateral caudate infarcts. CONCLUSION: This report discusses the possible underlying etiologies for the bilateral caudate infarcts and necrosed flaps including bacterial meningitis with associated local vasospasm of nearby vessels resulting in infarction. This case emphasizes the importance of concise management of postendoscopic CSF leak and discusses the guidelines regarding antimicrobial therapy and the management of lumbar drains.

Zinc oxide tetrapods inhibit herpes simplex virus infection of cultured corneas.

PURPOSE: Infection of the human cornea by herpes simplex virus type-1 (HSV-1) can cause significant vision loss. The purpose of this study was to develop an ex vivo model to visualize viral growth and spread in the cornea. The model was also used to analyze cytokine production and study the antiviral effects of zinc oxide tetrapods. METHODS: A ß-galactosidase-expressing recombinant virus, HSV-1(KOS)tk12, was used to demonstrate the ability of the virus to enter and develop blue plaques on human corneal epithelial (HCE) cells and corneal tissues. Freshly obtained porcine corneas were cultured and then scratched before infection with HSV-1(KOS)tk12. The blue plaques on the corneas were imaged using a stereomicroscope. Western blot analysis for HSV-1 proteins was performed to verify HSV-1 infection of the cornea. Using the ex vivo model, zinc oxide tetrapods were tested for their anti-HSV-1 potential, and a cytokine profile was developed to assess the effects of the treatment. RESULTS: Cultured corneas and the use of ß-galactosidase-expressing HSV-1(KOS)tk12 virus can provide an attractive ex vivo model to visualize and study HSV-1 entry and spread of the infection in tissues. We found that unlike cultured HCE cells, which demonstrated nearly 100% infectivity, HSV-1 infection of the cultured cornea was more restrictive and took longer to develop. We also found that the zinc oxide tetrapod-shaped nano- and microstructures inhibited HSV infection of the cultured cells, as well as the cultured corneas. The cytokine profile of the infected samples was consistent with previous studies of HSV-1 corneal infection. CONCLUSIONS: The ability to visualize HSV-1 growth and spread in corneal tissues can provide new details about HSV-1 infection of the cornea and the efficacy of new cornea-specific antiviral drug candidates. The ex vivo model also demonstrates antiviral effects of zinc oxide tetrapods and adequately portrays the drug delivery issues that cornea-specific treatments face.

Metabolite and functional profile of patients with cervical spondylotic myelopathy.

OBJECTIVE The goal of this study was to compare the recovery of neuronal metabolism and functional reorganization in the primary motor cortex (M1) between mild and moderate cervical spondylotic myelopathy (CSM) following surgical intervention. METHODS Twenty-eight patients with CSM underwent 3-T MRI scans that included spectroscopy and functional MRI, before surgery and 6 months postsurgery. The classification of severity was based on the modified Japanese Orthopaedic Association questionnaire. Mild and moderate myelopathy were defined by modified Japanese Orthopaedic Association scores > 12 of 18 (n = 15) and 9-12 (n = 13), respectively. Ten healthy control subjects underwent 2 MRI scans 6 months apart. Metabolite levels were measured in the M1 contralateral to the greater deficit side in patients with CSM and on both sides in the controls. Motor function was assessed using a right finger-tapping paradigm and analyzed with BrainVoyager QX. RESULTS Patients with mild CSM had a lower preoperative N-acetylaspartate to creatine (NAA/Cr) ratio compared with moderate CSM, suggesting mitochondrial dysfunction. Postsurgery, NAA/Cr in moderate CSM decreased to the levels observed in mild CSM. Preoperatively, patients with mild CSM had a larger volume of activation (VOA) in the M1 than those with moderate CSM. Postoperatively, the VOAs were comparable between the mild and moderate CSM groups and had shifted toward the primary sensory cortex. CONCLUSIONS The NAA/Cr ratio and VOA size in the M1 can be used to discriminate between mild and moderate CSM. Postsurgery, the metabolite profile of the M1 did not recover in either group, despite significant clinical improvement. The authors proposed that metabolic impairment in the M1 may trigger the recruitment of adjacent healthy cortex to achieve functional recovery.

Retrospective review of percutaneous synovial cyst ruptures: increased thickness of the T2 hypointense rim on post-rupture MRI may be associated with need for subsequent surgery.

OBJECTIVE: To analyze MRI characteristics of lumbar facet synovial cysts and distinguish those requiring subsequent surgical management for recurrence, after percutaneous synovial cyst rupture. METHODS AND MATERIALS: Retrospective chart review conducted in patients undergoing percutaneous synovial cyst rupture between February 2012 and April 2015. Pre- and post-percutaneous rupture procedure MRI spine studies were serially reviewed. Synovial cyst sizes, T1 and T2 signal characteristics and changes therein, T2 hypointense (or 'dark rim') thickness and change, and changes in the complexity of cyst signals were compared. Operative notes for patients who underwent subsequent surgical removal of recurrent synovial cysts were reviewed. RESULTS: 24 patients received 41 percutaneous synovial cyst rupture procedures, with a technical success rate of 82.9%. There was a significant difference in the mean increased thickness of the T2 hypointense rim on the first post-rupture MRI scan (p=0.0411) between patients requiring subsequent surgery and those who did not. There was a significant difference in the average sizes of synovial cysts before the procedure (p=0.0483) in those requiring subsequent surgery and those who did not. Five complications were noted (12.2%), mostly involving leg pain or weakness. Of the nine patients who underwent subsequent surgery post-synovial cyst rupture, six of the surgeries had recorded difficulty pertaining to scarring and/or adherence of the cyst to dura. CONCLUSIONS: A larger increase in thickness of the T2 hypointense rim on the first post-rupture MRI scan and a larger synovial cyst size were associated with the need for subsequent surgical resection.

Cervical Spondylotic Myelopathy: Metabolite Changes in the Primary Motor Cortex after Surgery.

Purpose To characterize longitudinal metabolite alterations in the motor cortex of patients with cervical spondylotic myelopathy (CSM) by using proton magnetic resonance (MR) spectroscopy and to evaluate white matter integrity with diffusion-tensor imaging in patients who are recovering neurologic function after decompression surgery. Materials and Methods Informed written consent was obtained for all procedures and the study was approved by Western University's Health Sciences Research Ethics Board. Twenty-eight patients with CSM and 10 healthy control subjects were prospectively recruited and underwent two separate 3-T MR imaging examinations 6 months apart. Patients with CSM underwent surgery after the first examination. N-acetylaspartate (NAA), an indicator of neuronal mitochondrial function, normalized to creatine (Cr) levels were measured from the motor cortex contralateral to the greater functional deficit side in the patient group and on both sides in the control group. Fractional anisotropy and mean diffusivity were measured by means of diffusion-tensor imaging in the white matter adjacent to the motor and sensory cortices of the hand and the entire cerebral white matter. Clinical data were analyzed by using Student t tests. Results In patients with CSM, NAA normalized to Cr (NAA/Cr) levels were significantly lower 6 months after surgery (1.48 ± 0.08; P < .03) compared with preoperative levels (1.73 ± 0.09), despite significant improvement in clinical questionnaire scores. Fractional anisotropy and mean diffusivity were the same (P > .05) between the patient and control groups in all measured regions at all time points. Conclusion NAA/Cr levels decreased in the motor cortex in patients with CSM 6 months after successful surgery. Intact white matter integrity with decreased NAA/Cr levels suggests that mitochondrial metabolic dysfunction persists after surgery. © RSNA, 2016 Online supplemental material is available for this article.

Quantitative evaluation of vision-related and health-related quality of life after endoscopic transsphenoidal surgery for pituitary adenoma.

OBJECTIVE Endoscopic resection of pituitary adenomas has been reported to improve vision function in up to 80%-90% of patients with visual impairment due to these adenomas. It is unclear how these reported rates translate into improvement in visual outcomes and general health as perceived by the patients. The authors evaluated self-assessed health-related quality of life (HR-QOL) and vision-related QOL (VR-QOL) in patients before and after endoscopic resection of pituitary adenomas. METHODS The authors prospectively collected data from 50 patients who underwent endoscopic resection of pituitary adenomas. This cohort included 32 patients (64%) with visual impairment preoperatively. Twenty-seven patients (54%) had pituitary dysfunction, including 17 (34%) with hormone-producing tumors. Patients completed the National Eye Institute Visual Functioning Questionnaire and the 36-Item Short Form Health Survey preoperatively and 6 weeks and 6 months after surgery. RESULTS Patients with preoperative visual impairment reported a significant impact of this condition on VR-QOL preoperatively, including general vision, near activities, and peripheral vision; they also noted vision-specific impacts on mental health, role difficulties, dependency, and driving. After endoscopic resection of adenomas, patients reported improvement across all these categories 6 weeks postoperatively, and this improvement was maintained by 6 months postoperatively. Patients with preoperative pituitary dysfunction, including hormone-producing tumors, perceived their general health and physical function as poorer, with some of these patients reporting improvement in perceived general health after the endoscopic surgery. All patients noted that their ability to work or perform activities of daily living was transiently reduced 6 weeks postoperatively, followed by significant improvement by 6 months after the surgery. CONCLUSIONS Both VR-QOL and patient's perceptions of their ability to do work and perform other daily activities as a result of their physical health significantly improved by 6 months after endoscopic resection of pituitary adenoma. The use of multidimensional QOL questionnaires provides a precise assessment of perceived outcomes after endoscopic surgery.