Single-surgeon approach in microvascular decompression for trigeminal neuralgia: Lessons from an Indonesian Tertiary-Level Neurological Center.

BACKGROUND: Microvascular decompression (MVD) is effective for refractory trigeminal neuralgia (TN), but its accessibility is often limited in lower-to-middle-income countries (LMICs). This study aims to assess the impact of implementing a single-surgeon policy on MVD for TN in LMICs. METHODS: A prospective cohort study was conducted from 2014 to 2020, comparing outcomes between multi-surgeon and single-surgeon policies. Residents were included in MVD procedures starting in 2019. The Barrow Neurological Institute (BNI) pain scale (P), numbness scale (N), and result conclusion scale (P + N) were used to evaluate outcomes (1 week, 1 month, 1 year, and yearly thereafter). Propensity score matching was performed before comparing the groups. Pain-free survival was assessed using Kaplan-Meier and Cox-regression analysis. RESULTS: We comprehensively analyzed data from 72 patients with a minimum one-year follow-up. The implementation of the single-surgeon policy had several notable impacts. Firstly, it led to an increased referral rate (p < 0.05) and a reduced duration to surgery (p < 0.05). During MVD, there was a significant increase in the identification of complex compression (p < 0.05) and a reduced frequency of internal neurolysis (p < 0.05). After surgery, the single-surgeon group exhibited a superior pain-control profile (RR 1.9, p < 0.001; ARR 26-36%), higher pain-free survival rate (p < 0.001), lower likelihood of pain recurrence (HR 0.2, p < 0.0001), and fewer additional surgical interventions compared to the multi-surgeon group. Moreover, the involvement of residents did not significantly impact surgical outcomes. CONCLUSIONS: Implementing a single-surgeon policy for MVD in LMICs has the potential to improve surgical outcomes, provide social benefits, and offer educational opportunities.

Analyzing the cost-effectiveness of microvascular decompression and percutaneous radiofrequency rhizotomy for trigeminal neuralgia: the role of clinical classification.

Trigeminal neuralgia (TN) is a neuropathic pain that can be treated with microvascular decompression (MVD) or percutaneous radiofrequency rhizotomy (PRR) when medications fail. However, the cost-effectiveness of these interventions is uncertain, and it is unclear whether TN should be considered as a single entity for cost-effectiveness analysis. To address these issues, a prospective cohort study was conducted between 2017 and 2020, documenting Burchiel et al.'s clinical classification, pain-free survival, complications, and costs. Two models of quality-adjusted life years (QALYs) were calculated: pain-specific (PQALY) and pain-complication-specific (PCQALY), based on pain-free survival and complications data, followed by cost-effectiveness analysis. The study included 112 patients, of whom 70 underwent MVD and 42 underwent PRR. Our findings revealed that MVD was less cost-effective in the PCQALY model than PRR, but more cost-effective in the PQALY model and had an incremental cost-effectiveness ratio (ICER) that met the World Health Organization cost-effectiveness threshold in both models. Further clinical classification analysis showed that MVD was only cost-effective in type 1 TN patients, with an ICER of 0.9 and 1.3 times the GDP/capita, based on PQALY and PCQALY, respectively, meeting the cost-effectiveness criteria. Conversely, MVD was economically dominated by PRR for type 2 TN patients based on PQALY. These findings indicate that PRR may be more cost-effective for type 2 TN patients, while MVD remains the cost-effective option for type 1 TN patients. Our study highlights the importance of clinical classification and complication in determining the cost-effectiveness of MVD and PRR for refractory TN.

Brain Tumor Programs in Asia and Africa: Current Status, Challenges, and Future Perspectives.

OBJECTIVE: To assess the status of brain tumor programs in Asia and Africa and propose comprehensive evidence-based short- and long-term measures for improving the existing systems. METHODS: A cross-sectional analytical study was conducted in June 2022 by the Asia-Africa Neurosurgery Collaborative. A 27-item questionnaire was designed and distributed to gain insight into the status and future directions of brain tumor programs in Asia and Africa. Six components of brain tumor programs were identified-surgery, oncology, neuropathology, research, training, and finances-and assigned scores of 0-14. The total scores allowed subclassification of each country into levels of brain tumor program from I to VI. RESULTS: A total of 110 responses from 92 countries were received. These were subdivided into 3 groups: group 1, countries with response from neurosurgeons (73 countries); group 2, countries with no neurosurgeons (19 countries); and group 3, countries without a neurosurgeon response (16 countries). The components associated with the highest level of brain tumor program were surgery, neuropathology, and oncology. Most countries in both continents had level III brain tumor programs with a mean surgical score of 2.24. The major lag between each group was with respect to the advances in neuropathology and financial support. CONCLUSIONS: There is an urgent need to improve and develop existing and nonexistent neuro-oncology infrastructure, personnel, and logistics in countries across the continents, especially for the countries with no neurosurgeons.

Case report: Teflon granuloma following microvascular decompression manifesting as light-triggered trigeminal neuralgia.

Trigeminal Neuralgia is commonly triggered by stimuli in the area of the trigeminal nerve innervation. We report an exceptionally rare case of a 61-year-old woman who complained of recurrent trigeminal neuralgia, which sole trigger was seeing a bright light. Teflon felt that was placed on the nerve root in the initial surgery was suspected of causing this rare type of trigeminal neuralgia. A reflex circuit linking luminance to trigeminal nerve activity may be implicated in activating a trigeminal nociceptive pathway by a bright light trigger.

Craniopharyngiomas: Challenges and Controversies.

Despite its benign histopathology, the treatment of craniopharyngioma remains one of the most formidable challenges faced by skull base surgeons. The technical challenges of tackling these complex central skull base lesions are paralleled by clinical challenges related to their unique tumor biology and the often-complex decision making required. In this article, we critically appraise the most recent literature to explore the challenges and controversies surrounding the management of these lesions. The role of curative resections and the shift in the surgical paradigm toward the multidisciplinary goal-directed management approach are discussed.

Current Results of Surgical Treatment of Craniopharyngiomas: The Impact of Endoscopic Endonasal Approaches.

Surgery is the main treatment option for the management of craniopharyngiomas. Transcranial microsurgical approaches, such as pterional and subfrontal approaches, have constituted the classic operative strategy for resection of these tumors. However, the development of endoscopic endonasal approaches has revolutionized the treatment of craniopharyngiomas in the last 15 years, and endoscopic resection is favored for most craniopharyngiomas. In this article, we discuss our experience with the management of craniopharyngiomas and review the current results of the surgical treatment of those tumors, including discussion of goals of surgery, complications, recurrences, and the role of adjuvant treatment.

Creative and Innovative Methods and Techniques for the Challenges in the Management of Adult Craniopharyngioma.

Craniopharyngioma remains a major challenge in daily clinical practice. The pathobiology of the tumor is still elusive, and there are no consensus or treatment guidelines on the optimal management strategy for this relatively rare tumor. However, recent technical and scientific advances, including genomic and radiomic profiling, innovation in surgical approaches, more precise radiotherapy protocols, targeted therapy, and restoration of lost functions all have the potential to significantly improve the outcome of patients with craniopharyngioma in the near future. Although many of these innovative tools in the new armamentarium of the clinician are still in their infancy, they could reduce craniopharyngioma-related morbidity and mortality and improve the patients' quality of life. In this article, we discuss these creative and innovative approaches that may offer solutions to the obstacles faced in treating craniopharyngioma and future possibilities in improving the care of these patients.

Surgical Anatomy Applied to the Resection of Craniopharyngiomas: Anatomic Compartments and Surgical Classifications.

BACKGROUND: Resective surgery remains the main treatment option for most patients with craniopharyngiomas. Understanding of the microsurgical anatomy of the sella and suprasellar region and its relationship with these tumors is necessary to achieve effective surgical treatment and minimize complications. In this article, we review the surgical anatomy related to craniopharyngiomas and divide it in 5 compartments according to tumor extension. METHODS: Endoscopic and microsurgical dissection were performed in 3 freshly injected cadaver heads at the Weill Cornell Surgical Innovations Laboratory (New York, New York, USA) and at the Surgical Skills Center at Mount Sinai Hospital (Toronto, Ontario, Canada). Tumor extension was classified as 1) inferomedial or sellar, 2) superomedial or suprasellar, 3) lateral or sylvian, 4) posterior or interpeduncular/prepontine, and 5) intraventricular. The selection of surgical approaches is discussed based on the anatomic nuances of each these regions. In addition, we reviewed the literature regarding previous anatomic classifications for resection of craniopharyngiomas. RESULTS: Different approaches should be considered according to tumor extension into different compartments. Purely sellar tumors are amenable to endoscopic transsellar approaches, whereas those with a suprasellar extension require an extended transtuberculum approach. In some of those patients, a narrow chiasm-pituitary window may block access to the tumor and a transcranial translamina terminalis approach may be favored. Tumors occupying the interpeduncular fossa may pose a significant challenge for an endoscopic endonasal approach and transcranial approaches. Transcavernous approaches and anterior and posterior clinoidectomies may be required for adequate exposure in such patients. Translamina terminalis and/or transcallosal approaches are recommended for resection of purely intraventricular tumors. Tumors extending into the lateral compartment should be considered for transcranial frontotemporal approaches. CONCLUSIONS: The understanding of such anatomic nuances aids in the selection of the most appropriate surgical approach and in the prevention of potential complications. Because most craniopharyngiomas are midline lesions, the endoscopic endonasal approach represents an excellent approach for most of those tumors. However, transcranial approaches should be considered for tumors with extension into the lateral compartment and for selected tumors involving the ventricular compartment (purely intraventricular tumors and those with extension to the foramen of Monro and/or lateral ventricles).

Long-term outcomes of transsphenoidal surgery for management of growth hormone-secreting adenomas: single-center results.

OBJECTIVE: Transsphenoidal surgery is advocated as the first-line management of growth hormone (GH)-secreting adenomas. Although disease control is defined by strict criteria for biochemical remission, the length of follow-up needed is not well defined in literature. In this report, the authors present their long-term remission rate and identify various predictive factors that might influence the clinical outcome. METHODS: The authors conducted a single-institute retrospective analysis of all transsphenoidal procedures for GH-secreting adenomas performed from January 2000 to June 2016. The primary outcome was defined as biochemical remission according to the 2010 consensus criteria and measured at the 1-year postoperative mark as well as on the last recorded follow-up appointment.Secondary variables included recurrence rate, patterns of clinical presentation, and outcome of adjuvant therapy (including repeat surgery). Subgroup analysis was performed for patients who had biochemical or radiological "discordance"-patients who achieved biochemical remission but with incongruent insulin-like growth factor 1 (IGF-1)/GH or residual tumor on MRI. Recurrence-free survival analysis was conducted for patients who achieved remission at 1 year after surgery. RESULTS: Eighty-one patients (45 female and 36 male) with confirmed acromegaly treated with transsphenoidal surgery were included. In 62 cases the patients were treated with a pure endoscopic approach and in 19 cases an endoscopically assisted microscopic approach was used.Primary biochemical remission after surgery was achieved in 59 cases (73%) at 1 year after surgery. However, only 41 patients (51%) remained in primary surgical remission (without any adjuvant treatment) at their last follow-up appointment, indicating a recurrence rate of 31% (18 of 59 patients) over the duration of follow-up (mean 100 ± 61 months). Long-term remission rates for pure endoscopic and endoscopically assisted cases were not significantly different (48% vs 52%, p = 0.6). Similarly, no significant difference in long-term remission was detected between primary surgery and repeat surgery (54% vs 33%, p = 0.22).Long-term remission was significantly influenced by extent of resection, cavernous sinus invasion (radiologically as well as surgically reported), and preoperative and early postoperative GH and IGF-1 levels (within 24-48 hours after surgery) as well as by clinical grade, with lower remission rates in patients with dysmorphic features and/or medical comorbidities (grade 2-3) compared to minimally symptomatic or silent cases (grade 1). CONCLUSIONS: The long-term surgical remission rate appears to be significantly less than "early" remission rates and is highly dependent on the extent of tumor resection. The authors advocate a long-term follow-up regimen and propose a clinical grading system that may aid in predicting long-term outcome in addition to the previously reported anatomical factors. The role of repeat surgery is highlighted.

Pituitary abscess following endoscopic endonasal drainage of a suprasellar arachnoid cyst: Case report and review of the literature.

BACKGROUND: Arachnoid cysts are uncommon lesions of the sellar region, and only rarely require decompressive surgery to treat symptoms. Pituitary abscesses are another rare lesion, and are an uncommon complication of pituitary surgery. A previously healthy 45 year old woman presented with a new finding of bitemporal hemianopsia. Magnetic resonance imaging (MRI) showed a cystic sellar lesion with suprasellar extension and compression of the optic chiasm. Endoscopic transphenoidal surgery was performed and the lesion was found to be an arachnoid cyst. She was well immediately after the operation, but 1 week later presented with headaches, fever and worsening visual acuity. MRI showed a homogenous collection in the sellar region that was compressing the chiasm. The patient was treated with antibiotics, and a second transphenoidal operation was performed, with frank pus found in the pituitary fossa. Cultures of the fluid found during the operation grew Escherichia coli and Staphylococcus lugdunensis. Her symptoms resolved after the second operation, and formal visual fields and a pituitary hormone panel were normal at this time. We report on a rare case of a pituitary abscess complicating surgery for a sellar arachnoid cyst, and discuss management of these conditions.

Awake Craniotomy in a Low- to Middle-Income Country: A Sustainability Analysis.

OBJECTIVE: This study evaluated the sustainability of teaching awake craniotomy in Indonesia. We explored the factors affecting how awake craniotomy can be taught in a low- to middle-income (LMIC) country and the factors affecting the utilization of awake craniotomy in Indonesia. METHODS: This is a prospective mixed-methods study in Indonesia. A questionnaire was administered to 100 neurosurgeons at a conference on their experience with neuro-oncology, awake craniotomy, and teaching missions. Thirty-three physicians participated in semi-structured interviews elaborating on these topics. Data on tumor caseload and resources were collected. RESULTS: Thirty-three of 88 respondents (41.3%) indicated that they still perform awake craniotomy. Although 87.3% felt that it was beneficial for patients and resource sparing, less than a quarter of them felt they had sufficient exposure/training in awake craniotomy. Almost all of them wanted further training and to maintain a relationship with international mentors. Four themes emerged about the factors that affect how we teach awake craniotomy in an LMIC: 1) the sustainability of a teaching mission is dependent on a culture of information sharing and 2) the support of multiple health care providers; 3) hospital structure affects how changes are implemented; and 4) health care professionals in Indonesia value opportunities for international training. Regarding the uptake of awake craniotomy in Indonesia, there are sociocultural factors that affect patients' receptiveness to surgery and the national insurance plan restricts the provision of neurosurgical care. CONCLUSIONS: Many factors need to be explored when planning a neurosurgical mission in LMICs to ensure its sustainability.