Neurosurgery
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Intractable focal epilepsy is a devastating disorder with profound effects on cognition and quality of life. Epilepsy surgery can lead to seizure freedom in patients with focal epilepsy; however, sometimes it fails owing to an incomplete delineation of the epileptogenic zone (EZ). Brain networks in epilepsy can be studied with resting-state functional connectivity (RSFC) analysis, yet previous investigations using functional MRI or electrocorticography have produced inconsistent results. Magnetoencephalography (MEG) allows noninvasive whole-brain recordings, and can be used to study both long-range network disturbances in focal epilepsy and regional connectivity at the EZ. ⋯ Widespread global decreases in functional connectivity are observed in patients with focal epilepsy and may reflect deleterious long-term effects of recurrent seizures. Furthermore, enhanced regional functional connectivity at the area of resection may help predict seizure outcome and aid surgical planning.
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Both transforaminal lumbar interbody fusion (TLIF) and lateral lumbar interbody fusion (LLIF) are effective surgical interventions for patients with degenerative lumbar spondylosis. We sought to compare health care costs by calculating the incremental cost-effectiveness ratio and, thereby, the difference in the total cost per quality-adjusted life-year (QALY) gained for TLIF vs LLIF for the treatment of degenerative spondylosis. We further calculated the thresholds for minimum clinically important difference (MCID) and minimum cost-effective difference (MCED) for patient-reported outcome measures at 2-year follow-up. ⋯ TLIF and LLIF produced equivalent 2-year patient outcomes at an equivalent cost-effectiveness profile.
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Failed back surgery syndrome (FBSS) is a type of neuropathic pain where extremity symptoms persist despite structurally corrective spinal surgery. This implies more substantial nerve damage rather than simply dysfunction whereby correcting the inciting structural derangement does not provide for clinical resolution. What remains unclear is how to predict which patients are likely to derive benefit from surgical intervention, and whether specific pain characteristics are associated with different likelihoods of good outcome. ⋯ While FBSS was more common among younger and female patients, this occurred with low overall frequency. Higher neuropathic pain screening scores correlated strongly with the likelihood and severity of significant postoperative leg pain. Further work is required to develop more accurate prognostication tools for patients undergoing structural spinal surgery for lumbar radiculopathy.
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Ambulatory surgery centers (ASCs) have emerged as lower-cost options for many surgical therapies. While ASCs offer significant cost advantages over hospital-based surgery, concern over the safety of outpatient anterior cervical discectomy and fusion (ACDF) has slowed its adoption. To date, only a few published series, each underpowered at less than 100 patients, make up the evidence basis for the safety of outpatient ACDF surgery. ⋯ Analysis of 1000 consecutive patients undergoing ACDF in an outpatient setting demonstrated surgical complications occur at a low rate (<1%) and can be appropriately diagnosed and managed in 4-hour ASC PACU window. Comparison with inpatient ACDF surgery cohort demonstrated similar results, highlighting that ACDF can be safely performed in an outpatient ambulatory surgery setting without compromising surgical safety. To decrease cost of care, surgeons can safely consider performing 1- and 2-level ACDF in an ASC environment.
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Nonfunctioning pituitary macroadenomas frequently invade the cavernous sinus and many cannot be completely resected without undue risk. Gamma knife radiosurgery (GKRS) is highly effective for treating residual and recurrent adenomas. However, there is no consensus as to whether GKRS should be used early to treat residual adenoma or after a set period of clinical observation during which adenoma growth is demonstrated. Given the high incidence of adenoma progression after subtotal resection over time, the present study examines the potential utility of GKRS performed shortly after transsphenoidal surgery vs expectant management with delayed GKRS treatment. ⋯ Early treatment with GKRS appears to decrease the rate of radiographic and symptomatic progression of subtotally resected nonfunctioning pituitary macroadenomas compared with late GKRS treatment after a period of expectant management. Delaying radiosurgery may place patients at increased risk for adenoma progression and endocrinopathy.