Neurosurg Focus
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Review
Traumatic thoracolumbar spinal injury: an algorithm for minimally invasive surgical management.
Minimally invasive spinal (MIS) surgery techniques have been used sporadically in thoracolumbar junction trauma cases in the past 5 years. A review of the literature on the treatment of thoracolumbar trauma treated with MIS surgery revealed no unifying algorithm to assist with treatment planning. Therefore, the authors formulated a treatment algorithm. ⋯ Cases involving thoracolumbar trauma can safely be treated with MIS surgery in select cases of burst fractures. The role of percutaneous nonfusion techniques remains very limited (primarily to treat thoracolumbar trauma in patients with a propensity for autofusion [for example, those with ankylosing spondylitis]).
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Fully endoscopicmicrovascular decompression (E-MVD) of the trigeminal nerve was initially described more than 1 decade ago, but has not yet gained wide acceptance. The authors present the experience of their first 47 consecutive E-MVDs for trigeminal neuralgia (TN). ⋯ In experienced hands, E-MVD offers superb visualization and illumination and is both safe and effective, at least in the short term. Further longer-term study is needed to compare E-MVD to traditional microscopic MVD.
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Cerebral edema and hemorrhagic conversion are common, potentially devastating complications of ischemic stroke and are associated with high rates of mortality and poor functional outcomes. Recent work exploring the molecular pathophysiology of the neurogliovascular unit in ischemic stroke suggests that deranged cellular ion homeostasis due to altered function and regulation of ion pumps, channels, and secondary active transporters plays an integral role in the development of cytotoxic and vasogenic edema and hemorrhagic conversion. ⋯ Several robust preclinical studies have demonstrated the efficacy of glibenclamide blockade of SUR1-TRPM4 activity in reducing edema and hemorrhagic conversion in rodent models of ischemic stroke, prompting the study of the potential protective effects of glibenclamide in humans in an ongoing prospective phase II clinical trial. Preliminary data suggest glibenclamide significantly reduces cerebral edema and lowers the rate of hemorrhagic conversion following ischemic stroke, suggesting the potential use of glibenclamide to improve outcomes in humans.
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Endoscopic skull base surgery continues to rapidly evolve, requiring comparable advances in reconstructive techniques. While smaller skull base defects with low intraoperative CSF flow have been successfully managed with a variety of avascular and/or noncellular techniques, larger defects with high CSF flow require more robust repairs often in the form of vascularized flaps, which confer excellent success rates in this setting. Despite these successful outcomes, a paucity of data describing specific patient and operative characteristics and their effects on repair exist. ⋯ No significant association was found between perioperative complication rates and radiation therapy (p = 0.634). However, a significant association was found between postoperative complication rates and radiation therapy, primarily accounted for by an increased risk for prolonged (> 6 months) skull base crusting (p = 0.025). It is clear that larger skull base defects with high intraoperative CSF flow require thoughtful approach and strong consideration for vascularized repair.
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Thoracolumbar spine injuries are commonly encountered in patients with trauma, accounting for almost 90% of all spinal fractures. Thoracolumbar burst fractures comprise a high percentage of these traumatic fractures (45%), and approximately half of the patients with this injury pattern are neurologically intact. However, a debate over complication rates associated with operative versus nonoperative management of various thoracolumbar fracture morphologies is ongoing, particularly concerning those patients presenting without a neurological deficit. ⋯ Due to the limited number of high-quality studies, conclusions related to complication rates of operative and nonoperative management of thoracolumbar traumatic injuries cannot be definitively made. Further prospective, randomized studies of operative versus nonoperative management of thoracolumbar and lumbar spine trauma, with standardized definitions of complications and matched patient cohorts, will aid in properly defining the risk-benefit ratio of surgery for thoracolumbar spine fractures.