Faculty Bibliography

OBJECTIVE:Enhanced Recovery After Surgery (ERAS) has led to a paradigm shift in perioperative care through multimodal interventions. Still, ERAS remains a relatively new concept in neurosurgery, and there is no summary of evidence on ERAS applications in cranial neurosurgery. METHODS:The authors systematically reviewed the literature using the PubMed/MEDLINE, Embase, Scopus, and Cochrane Library databases for ERAS protocols and elements. Studies had to assess at least one pre-, peri-, or postoperative ERAS element and evaluate at least one of the following outcomes: 1) length of hospital stay, 2) length of ICU stay, 3) postoperative pain, 4) direct and indirect healthcare cost, 5) complication rate, 6) readmission rate, or 7) patient satisfaction. RESULTS:A final 27 articles were included in the qualitative analysis, with mixed quality of evidence ranging from high in 3 cases to very low in 1 case. Seventeen studies reported a complete ERAS protocol. Preoperative ERAS elements include patient selection through multidisciplinary team discussion, patient counseling and education to adjust expectations of the postoperative period, and mental state assessment; antimicrobial, steroidal, and antiepileptic prophylaxes; nutritional assessment, as well as preoperative oral carbohydrate loading; and postoperative nausea and vomiting (PONV) prophylaxis. Anesthesiology interventions included local anesthesia for pin sites, regional field block or scalp block, avoidance or minimization of the duration of invasive monitoring, and limitation of intraoperative mannitol. Other intraoperative elements include absorbable skin sutures and avoidance of wound drains. Postoperatively, the authors identified early extubation, observation in a step-down unit instead of routine ICU admission, early mobilization, early fluid de-escalation, early intake of solid food and liquids, early removal of invasive monitoring, professional nutritional assessment, PONV management, nonopioid rescue analgesia, and early postoperative imaging. Other postoperative interventions included discharge criteria standardization and home visits or progress monitoring by a nurse. CONCLUSIONS:A wide range of evidence-based interventions are available to improve recovery after elective craniotomy, although there are few published ERAS protocols. Patient-centered optimization of neurosurgical care spanning the pre-, intra-, and postoperative periods is feasible and has already provided positive results in terms of improved outcomes such as postoperative pain, patient satisfaction, reduced length of stay, and cost reduction with an excellent safety profile. Although fast-track recovery protocols and ERAS studies are gaining momentum for elective craniotomy, prospective trials are needed to provide stronger evidence.

BACKGROUND: Intraoperative angiography is routinely utilized for aneurysms and arteriovenous malformations (AVMs) to verify complete occlusion and resection. Surgery for spinal and posterior fossa neurovascular lesions is usually performed in prone position. Intraoperative angiography in the prone position is challenging and there is no standardized protocol for this procedure. OBJECTIVE: To describe our experience with intraoperative angiography in the prone and lateral positions, using upper extremity arterial access. METHODS: We reviewed our experience with intraoperative angiography in the prone position between 2014 and 2015, where vascular access was obtained via the upper extremity arteries. Patients were treated in a hybrid endovascular operating room. High cervical and intracranial lesions were studied via brachial or radial access. All accesses were obtained using ultrasonographic guidance and a small caliber arterial sheath (4F). RESULTS: Five patients were treated in the prone and lateral positions using brachial/radial artery access. Patients harbored cerebellar AVM, lateral medullary AVM, cervical arteriovenous fistula (AVF), tentorial dural AVF, and tentorial-incisural dural AVF. Patients were positioned prone (n = 2), semiprone (n = 2), and lateral (n = 1) for the surgery. Three patients were treated via right brachial artery access. Two patients were treated via radial arteries access. All patients tolerated the procedures without technical or clinical complications. Intraoperative angiography verified complete occlusion and resection in all cases prior to surgical closure. CONCLUSIONS: Intraoperative angiography in the prone and lateral positions using upper extremity access is an important adjunct. Brachial or radial access can be obtained safely and provides comfortable and quick approaches.

BACKGROUND: Previous reports have proposed an association between traumatic brain injury (TBI) and subsequent glioblastoma (GBM) formation. METHODS: We used literature searches and radiographic evidence from two patients to assess the possibility of a link between TBI and GBM. RESULTS: Epidemiological studies are equivocal on a possible link between brain trauma and increased risk of malignant glioma formation. We present two case reports of patients with GBM arising at the site of prior brain injury. CONCLUSION: The hypothesis that TBI may predispose to gliomagenesis is disputed by several large-scale epidemiological studies, but supported by some. Radiographic evidence from two cases presented here suggest that GBM formed at the site of brain injury. We propose a putative pathogenesis model that connects post-traumatic inflammation, stem and progenitor cell transformation, and gliomagenesis.

OBJECTIVE: To analyze qualitatively C2 nerve dysfunction after its transection in C1-2 posterolateral instrumented fusions. METHODS: From 2002-2010, 20 consecutive patients underwent posterolateral instrumented fusions using C1 lateral mass and C2 pars or pedicle screws, mainly for type 2 dens fractures. Screws were placed under lateral fluoroscopic guidance using standard techniques. Bilateral C2 nerve roots were coagulated and transected in all patients. Mean follow-up was 30.7 months and consisted of clinical and radiographic examinations, telephone interviews, and mailed visual analogue scale (VAS) questionnaires assessing C2 nerve dysfunction. RESULTS: One patient was lost to follow-up after the initial postoperative visit. Fusion was evident in all patients with 12 months of follow-up and two of three patients with <12 months of follow-up. There were no instances of unintended neurologic deficits, vascular injury, cerebrospinal fluid (CSF) leak, or hardware malfunction or malposition. By the 2-week or 6-week office visit, 4 of 20 patients complained of sensory disturbance, and 2 had paresthesias in the C2 distribution. After longer follow-up, one additional patient developed mild sensory symptoms. Quality of life was adversely affected in only one patient. No patient developed neuropathic pain at any time after C2 sectioning. CONCLUSIONS: This study is the first series to describe C2 nerve function after posterior atlantoaxial instrumented fusion in adults of all ages. Sacrifice of the C2 nerve root increases fusion surface, allows for better preparation and decortication of the atlantoaxial joint, improves visualization for screw placement, and decreases blood loss and operative time without major clinical consequences.

Anteriorly located Type IV thoracic arteriovenous malformations (AVMs) are difficult to treat surgically. Although high-flow fistula subtypes are amenable to treatment using endovascular techniques, low-flow fistulas should be treated surgically. There are few reports discussing the diagnosis, behavior, and treatment of these spinal fistulas due to their low incidence. Posterior surgical approaches to Type IV spinal AVMs reported in the literature have been associated with high morbidity rates or aborted procedures. The authors report the successful management of a T-12 Type IV spinal AVM with an emphasis on approach, interoperative angiography, and the use of modern instrumentation. To the authors' knowledge, this is also the first reported case of multiple arterial-side aneurysms in a Type IV AVM of the anterior spinal artery