A randomized controlled trial comparing conservative versus surgical treatment in patients with foot drop due to peroneal nerve entrapment: results of an internal feasibility pilot study.

BACKGROUND: Based on the lack of literature to support any treatment strategy in patients with foot drop due to peroneal nerve entrapment, a prospective study randomizing patients between surgery and conservative treatment is warranted. Since studies comparing surgery to no surgery are often challenging, we first examined the feasibility of such a randomized controlled trial. METHODS/DESIGN: An internal feasibility pilot study was conducted to assess several aspects of process, resource, management, and scientific feasibility. The main objective was the assessment of the recruitment rate. The criterion to embark on a full study was the recruitment of at least 14 patients in 6 participating centers within 6 months. Cross-over rate, blinding measures, training strategies, and trial assessments were evaluated. The trial was entirely funded by the KCE Trials public funding program of the Belgian Health Care Knowledge Centre (ID KCE19-1232). RESULTS: The initial duration was prolonged due to the COVID-19 pandemic. Between April 2021 and October 2022, we included 19 patients of which 15 were randomized. Fourteen patients were treated as randomized. One drop-out occurred after randomization, prior to surgery. We did not document any cross-over or accidental unblinding. Training strategies were successful. Patients perceived the quality of life questionnaire as the least relevant assessment. Assessment of ankle dorsiflexion range of motion was prone to interobserver variability. All other trial assessments were adequate. DISCUSSION: Recruitment of the anticipated 14 patients was feasible although slower than expected. The Short-Form Health Survey (SF-36) and assessment of ankle dorsiflexion range of motion will no longer be included in the full-scale FOOTDROP trial. CONCLUSION: The FOOTDROP study is feasible. TRIAL REGISTRATION: ClinicalTrials.gov, identifier NCT04695834 . Registered 4 January 2021.

Transnasal transsphenoidal pituitary surgery in a large tertiary hospital, a retrospective study.

OBJECTIVES: Pituitary adenomas (PAs), although being small tumours, can have quite an impact on patients' lives causing hormonal and visual disturbances, for which surgery must be performed. As a large peripheral hospital with specialists in pituitary surgery, an assessment of the efficacy and safety of transnasal transsphenoidal pituitary surgery was made. METHODS: A retrospective analysis of neurosurgical reports as well as pre and postoperative imaging was made to evaluate the presenting symptoms, tumoural variables, peri-operative morbidity, and long-term outcome. RESULTS: This cohort included 105 patients who were operated for PAs over a 9-year period, with a slight male predominance. Adenomas had a mean maximum diameter of almost 25 mm, with one-third of tumours presenting with a Knosp-grade 3 or 4. As expected, most patients presented with either visual (32.4%) or hormonal (40.0%) disturbances. After surgery, 85.3% had complete resolution of visual deficits, and 97.1% had normalisation of hormonal hypersecretion. Postoperative hormonal insufficiency requiring substitution was observed in 43.1% and was significantly more frequent in males and in non-functioning pituitary adenomas (NFAs). Postoperative cerebrospinal fluid (CSF) leakage was observed in 2.9%, and merely one patient developed meningitis. Tumour recurrence was significantly more frequent in patients with partial resection as compared to complete resection (25.6 vs. 7.9%). CONCLUSIONS: This study demonstrates that transnasal transsphenoidal pituitary surgery can be performed safely and effectively in a large non-university hospital, improving visual and/or hormonal disturbances as well as providing long-term tumour control. Patients with larger adenomas are at an increased risk to develop postoperative hypopituitarism.

Long-Term Outcome in Patients With Spinal Cord Stimulation for Failed Back Surgery Syndrome: A 20-Year Audit of a Single Center.

STUDY DESIGN: This is a retrospective, observational study. INTRODUCTION: Spinal cord stimulation (SCS) has found its application in chronic pain treatment, with failed back surgery syndrome (FBSS) as one of the most important indications. However, to date, little is known about the long-term effectiveness of the treatment. The aim of this study is to analyze retrospectively the long-term outcomes of SCS treatment in a single multidisciplinary pain center on predominant radicular pain, using devices of a single manufacturer. MATERIALS AND METHODS: Patient data on overall patient satisfaction, pain intensity, and adverse events were retrospectively collected in our clinical practice between January 1998 and January 2018, for 191 patients who received a permanent SCS implant. Secondary health measures included the influence of opioid and nicotine use on pain reduction after therapy. RESULTS: The trial-to-implant ratio was 93.6%. At a mean follow-up of 10.6 years, 78.5% of the patients were satisfied with the treatment outcome, with a significant pain reduction of an average three points on a Numeric Rating Scale. Opioid and nicotine usage did not have a significant link with the pain reduction one year after the treatment. Furthermore, devices had an average battery lifespan of 8.4 years. A total of 248 revisions were recorded. A total of 24 patients (11.7%) acquired an infection; 7 of 204 patients had an infection during the trial period, 2 of 191 patients had an infection in the first postoperative year, and 15 of 191 patients had an infection after the first year. The average time to infection, if not in the first year, was 10.1 years. CONCLUSIONS: A successful long-term outcome regarding pain relief in patients with predominant radicular pain due to FBSS is established with SCS therapy.

Conservative versus surgical treatment of foot drop in peroneal nerve entrapment: rationale and design of a prospective, multi-centre, randomized parallel-group controlled trial.

BACKGROUND: High-quality evidence is lacking to support one treatment strategy over another in patients with foot drop due to peroneal nerve entrapment. This leads to strong variation in daily practice. METHODS/DESIGN: The FOOTDROP (Follow-up and Outcome of Operative Treatment with Decompressive Release Of The Peroneal nerve) trial is a randomized, multi-centre study in which patients with peroneal nerve entrapment and persistent foot drop, despite initial conservative treatment, will be randomized 10 (± 4) weeks after onset between non-invasive treatment and surgical decompression. The primary endpoint is the difference in distance covered during the 6-min walk test between randomization and 9 months later. Time to recovery is the key secondary endpoint. Other secondary outcome measures encompass ankle dorsiflexion strength (MRC score and isometric dynamometry), gait assessment (10-m walk test, functional ambulation categories, Stanmore questionnaire), patient-reported outcome measures (EQ5D-5L), surgical complications, neurological deficits (sensory changes, motor scores for ankle eversion and hallux extension), health economic assessment (WPAI) and electrodiagnostic assessment. DISCUSSION: The results of this randomized trial may elucidate the role of surgical decompression of the peroneal nerve and aid in clinical decision-making. TRIAL REGISTRATION: ClinicalTrials.gov NCT04695834. Registered on 4 January 2021.

Ethical attitudes in neurosurgery at the height of the COVID-19 pandemic.

•Pandemic conditions imposed withholding or withdrawing neurosurgical treatment.•Variation exist in the management of intracranial haemorrhage or TBI during a pandemic.•Triaging guidelines for neurosurgical patients need to be established.

Evidence in peroneal nerve entrapment: A scoping review.

BACKGROUND AND PURPOSE: Daily management of patients with foot drop due to peroneal nerve entrapment varies between a purely conservative treatment and early surgery, with no high-quality evidence to guide current practice. Electrodiagnostic (EDX) prognostic features and the value of imaging in establishing and supplementing the diagnosis have not been clearly established. METHODS: We performed a literature search in the online databases MEDLINE, Embase, and the Cochrane Library. Of the 42 unique articles meeting the eligibility criteria, 10 discussed diagnostic performance of imaging, 11 reported EDX limits for abnormal values and/or the value of EDX in prognostication, and 26 focused on treatment outcome. RESULTS: Studies report high sensitivity and specificity of both ultrasound (varying respectively from 47.1% to 91% and from 53% to 100%) and magnetic resonance imaging (MRI; varying respectively from 31% to 100% and from 73% to 100%). One comparative trial favoured ultrasound over MRI. Variable criteria for a conduction block (>20%-≥50) were reported. A motor conduction block and any baseline compound motor action potential response were identified as predictors of good outcome. Based predominantly on case series, the percentage of patients with good outcome ranged 0%-100% after conservative treatment and 40%-100% after neurolysis. No study compared both treatments. CONCLUSIONS: Ultrasound and MRI have good accuracy, and introducing imaging in the standard diagnostic workup should be considered. Further research should focus on the role of EDX in prognostication. No recommendation on the optimal treatment strategy of peroneal nerve entrapment can be made, warranting future randomized controlled trials.

Intraneural ganglion cyst of the common peroneal nerve causing foot drop in a 12-year old child.

OBJECTIVES: Intraneural ganglia are benign fluid-filled cysts contained within the subepineurial space of peripheral nerves. The common peroneal nerve at the fibular neck is by far the most frequently involved, although other nerves can be affected as well. Although the differential diagnosis of foot drop in adults and children show some differences, clinical presentation, diagnostic workup, treatment and follow-up of intraneural ganglia are quite similar in both groups. The primary objective was to create an overview of intraneural ganglia in children, with an emphasis on diagnostic workup and potential pitfalls during neurosurgical intervention, based on all available literature concerning this topic and own center experiences. As a secondary objective, we tried to raise the awareness concerning this unique cause of foot drop in childhood. PATIENTS AND METHODS: We performed a review of the literature, in which children who developed foot drop secondary to an intraneural ganglion cyst of the common peroneal nerve were examined. A total of eleven articles obtained from MEDLINE were included. Search terms included: "pediatric", "children", "child", "intraneural ganglia", "intraneural ganglion cysts", "foot drop", "peroneal nerve" and "fibular nerve". Additional studies were identified by checking reference lists. Furthermore, we present the case of a 12-year old girl with foot drop caused by an intraneural ganglion cyst. She underwent cyst decompression with evacuation of intraneural cyst fluid and articular branch disconnection. PRISMA and CARE statement guidelines were followed. RESULTS: We hypothesize that minor injury caused a breach in the joint capsule, resulting in synovial fluid egression along the articular nerve branch, corroborating the unifying articular theory and emphasizing the need for ligation of said branch. Foot drop is a predominant characteristic, explained by the proximity of the anterior tibial muscle motor branch near the articular branch nerve. In children, satisfactory motor recovery after surgical decompression is to be expected. CONCLUSION: Sudden or progressive foot drop in children warrants an exhaustive neurophysiological and radiological workup. The management of intraneural ganglia is specific, consisting of nerve decompression, articular branch ligation and joint disarticulation, if deemed necessary. Our surgical results support the unifying articular theory and emphasize the importance of ligation and transection of the articular branch nerve, distally from the anterior tibial muscle branch, in order to prevent intraneural ganglia recurrence. This well-documented case adds depth to the current literature on this sparsely reported entity.

The external carotid artery as a rare feeder of a spinal dural arteriovenous fistula causing cervical myelopathy: A review of the literature.

Introduction: A causal relationship between SDAVF's and cervical myelopathy is exceedingly rare. 1-2% of these lesions are located at the craniocervical junction of which 12% are caused by arterial feeders from the external carotid artery. A correct diagnosis can be challenging with a high rate of initial misdiagnosis. Research question: Which aspects constitute the most important potential pitfalls in the diagnostic workup and treatment of SDAVF's with feeders from the external carotid artery causing cervical myelopathy? Material and methods: We performed a PRISMA-guided review of the literature in which fourteen articles were included. We illustrate the diagnostic hazards through one of our own cases. Results: SDAVF's at the cervical segment contain unique clinical and radiographic characteristics which differ from those elsewhere. Cervical myelopathy is caused by a SDAVF in 2.3% of cases. Pitfalls are numerous and diagnosis can be challenging, due to a broad differential diagnosis, potential isolated lower extremity involvement and absence of spinal cord edema on MRI. MR-alterations not always correlate with fistula localization. Discussion and conclusion: A SDAVF should be part of the differential diagnosis in patients with subacute tetraparesis. When MRI shows signal alterations in combination with enlarged perimedullary vessels, a SDAVF should be suspected. Spinal angiography should include the vertebrobasilar system, as well as the internal and external carotid arteries. Early and adequate occlusion by means of an endovascular or neurosurgical approach of the draining radicular veins should be pursued. A multidisciplinary approach is key in the diagnostic workup and treatment of these patients.

5-Aminolevulinic acid for recurrent malignant gliomas: A systematic review.

OBJECTIVES: Nowadays, several techniques have been developed in order to guide neurosurgeons during intended maximal safe resection of high-grade gliomas (HGG). Fluorescence-guided microsurgery using 5-aminolevulinic acid (5-ALA) is one of these. A large amount of studies have been performed evaluating benefits in newly diagnosed HGG. However, little is known about the safety, accuracy and efficacy in recurrent HGG. The primary objective of this thesis is to examine the value of 5-ALA in patients with recurrent HGG concerning diagnostic accuracy, extent of resection (EOR), safety and survival compared to white-light resection. As a secondary objective, we compared these results with current literature concerning 5-ALA in newly diagnosed HGG. PATIENTS AND METHODS: We performed a systematic review and included eighteen articles obtained from MEDLINE, EMBASE, Web of Science and TRIP database. Search terms include "glioma" and "aminolevulinic acid". Additional studies were identified through checking the reference lists. This study is in conformity with the PRISMA and BMJ guidelines. RESULTS: 5-ALA shows similar results regarding diagnostic accuracy in recurrent HGG compared to newly diagnosed HGG, although specificity and negative predictive value seem lower. It shows complementary value in identifying tumor boundaries compared to MRI-neuronavigation. Diagnostic accuracy is not influenced by previous chemo- or radiotherapy. New neurological deficits proved to be similar and were in general mainly temporary. However, adverse events overall were more common. Therefore, indications for repeat surgery should be followed strictly. 5-ALA might increase overall survival in recurrent gliomas, but has no clear impact on progression-free survival. CONCLUSION: 5-ALA should be regarded as a useful and safe intraoperative tool in recurrent glioma surgery.

External neurolysis as a treatment for foot drop secondary to weight loss: a retrospective analysis of 200 cases.

BACKGROUND: Peroneal nerve entrapment is the most common peripheral mononeuropathy of the lower limbs. Foot drop, a common presentation, leads to an impaired eversion and dorsiflexion of the foot. An intriguing observation is the occurrence of foot drop secondary to weight loss. METHODS: A retrospective study of patients surgically treated for peroneal nerve entrapment was performed between January 1, 1995 and December 31, 2016, at the Department of Neurosurgery, Genk, Belgium. Out of a total of 421 patients, 200 patients with foot drop secondary to weight loss were included. For each subject, motor and sensory outcomes after external neurolysis were investigated. As a primary objective, we examined the postoperative outcomes of external neurolysis as a treatment for foot drop in patients with peroneal nerve entrapment at the fibular head secondary to weight loss. As a secondary objective, we analyzed the correlation between patient characteristics and the success rate of external neurolysis. RESULTS: When defining success as a postoperative MRC score of 4 or 5, external neurolysis has a success rate of 85% in patients with foot drop secondary to weight loss. A significant difference (P = < 0.0001) between postoperative and preoperative MRC scores indicates that external neurolysis leads to significant improvement of motor function in patients with foot drop secondary to weight loss. A multiple logistic regression model showed that "preoperative MRC scores" and "duration of symptoms" were the only variables with an impact on postoperative MRC scores. Other variables such as "age," "gender," and "side of entrapment" had no significant impact on postoperative results. CONCLUSIONS: Statistical analysis emphasizes the important role of external neurolysis in the treatment of peripheral peroneal nerve entrapment. Therefore, external neurolysis at the fibular head should be regarded as a very effective and safe procedure in patients with foot drop secondary to weight loss.

Intermittent Feet Dorsiflexion as a Simple Trick to Improve Cervical Fluoroscopic Visualization.

BACKGROUND: Anterior cervical surgery is routinely performed using fluoroscopy. Visualizing the lower cervical levels can be challenging, particularly in obese, muscular, and broad-shouldered patients. We found that grabbing both feet of the patient at the level of the metatarsals and cranially pushing the feet, creating dorsiflexion at the ankle joints, seems to increase the number of fluoroscopically visualized cervical levels. We aimed to measure the average change in fluoroscopically visualized levels when performing this maneuver. METHODS: In 10 consecutive patients undergoing an anterior cervical discectomy and fusion procedure, we counted the number of fluoroscopically visualized cervical levels. Visible cervical levels in lateral fluoroscopic cervical images that were taken with and without the execution of the aforementioned maneuver were counted by 2 blinded observers. RESULTS: Performing this maneuver added on average almost 1 vertebral body height to the fluoroscopic image. The additional number of fluoroscopically visible cervical levels was significantly higher in patients <50 years old but was not affected by sex or body mass index. CONCLUSIONS: We propose a simple, convenient, and effective technique to increase the number of visualized cervical levels on lateral cervical fluoroscopy. This maneuver may have some advantages compared with other commonly used techniques.

A multicentre, prospective, randomized, controlled study to evaluate the use of a fibrin sealant as an adjunct to sutured dural repair.

BACKGROUND: Obtaining intra-operative watertight closure of the dura is considered important in reducing post-operative cerebrospinal fluid (CSF) leak. The purpose of this study was to evaluate a fibrin sealant as an adjunct to sutured dural repair to obtain intra-operative watertight closure in cranial neurosurgery. METHODS: This randomized, controlled multicenter study compared a fibrin sealant (EVICEL® Fibrin Sealant [Human]) to sutured dural closure (Control). Subjects underwent supratentorial or posterior fossa procedures. Following primary dural repair by sutures, the closure was evaluated for intra-operative CSF leak by moderately increasing the intracranial pressure. If present, subjects were randomized to EVICEL® or additional sutures (2:1 ratio), stratified by surgical approach. Following treatment, subjects were successful if no CSF leaks were present during provocative challenge. Safety was assessed to 30 days post-surgery, including incidence of CSF leakage. RESULTS: One hundred and thirty-nine subjects were randomized: 89 to EVICEL® and 50 to Control. Intra-operative watertight closure was achieved in 92.1% EVICEL®-treated subjects versus 38.0% controls; a treatment difference of 54.1% (p < 0.001). The treatment differences in the supratentorial and posterior fossa strata were 49.1% and 75.7%, respectively (p < 0.001). The incidence of adverse events was similar between treatment groups. No deaths or unexpected serious adverse drug reactions were reported. CSF leakage within 30 days post-operatively was 2.2% and 2.0% in EVICEL® and control groups, respectively. In addition, 2 cases of CSF rhinorrhoea were observed in the EVICEL® group. Although not associated with the suture line where EVICEL® was applied, when combined with the other CSF leaks, the observed leak rate in the EVICEL® group was 4.5%. CONCLUSIONS: These results indicate that EVICEL® is effective as an adjunct to dural sutures to provide watertight closure of the dura mater in cranial surgery. The study confirmed the safety profile of EVICEL®.

Migrating pseudomeningocele causing posterior fossa syndrome.

We present two cases of spontaneous intracerebellar migration of a pseudomeningocele. This is a rarely reported complication of posterior fossa surgery with possible life threatening cerebellar mass effect. The probable mechanism is a slow but progressive cerebrospinal fluid (CSF) movement (one-way valve mechanism) into the pseudomeningocele with secondary herniation or dissection through a weakened dura into the cerebellum causing progressive or acute cerebellar dysfunction. Evacuation and dural repair with or without CSF shunting or marsupialisation results in resolution of the symptoms.

Peroneal neuropathy after weight loss: a high-resolution ultrasonographic characterization of the common peroneal nerve.

OBJECTIVE: The objective of this study was to use in vivo ultrasonographic imaging to analyze the common peroneal nerve in controls and patients who were diagnosed with peroneal neuropathy (PN) due to significant weight loss. We also looked for a relationship between weight loss (magnitude) and the occurrence of PN. MATERIALS AND METHODS: Fifty controls and six patients who were diagnosed with PN after losing a significant amount of weight were examined by means of ultrasonography (US). On the US images, the structure and reflectivity of the nerve were analyzed. Correlations were made between the ultrasonographic measurements and the body mass index (BMI) of controls. In PN patients, these ultrasonographic parameters were compared between the normal and pathological legs. RESULTS: BMI was positively correlated with the transverse cross-sectional area of the nerve and fibular tunnel in controls. In controls with a high BMI, the peroneal nerve appeared thicker and the US reflectivity of the nerve was higher. A lower US reflectivity was observed in the pathological legs of the six patients who developed PN after weight loss. CONCLUSION: The transverse cross-sectional area and reflectivity of the peroneal nerve on the US images could be viable tools in the diagnosis of PN after weight loss.

Giant intracranial capillary hemangioma associated with enlarged head circumference in a newborn.

The authors describe the case of a patient with an intracranial capillary hemangioma, and they review the recent literature on intracranial capillary hemangiomas with special attention to their differential diagnosis and management. The only sign in this 7-week-old boy was head enlargement. There were no neurological deficits, and imaging revealed a large intracranial lesion in the right temporal fossa. The results of biopsy confirmed the diagnosis, and, after endovascular embolization, the entire lesion was resected. The incidence of intracranial capillary hemangioma is very low but may be underestimated. In the present case, the size of the tumor prompted surgical treatment. The natural behavior of extracranial capillary hemangiomas, however, suggests that a conservative approach with follow-up and steroid therapy may also be considered.

Foot drop as a complication of weight loss after bariatric surgery: is it preventable?

BACKGROUND: Although rare, the relationship between peroneal nerve palsy and weight loss has been well documented over the last decades. Of the 160 patients operated for persisting foot drop in our institution, weight loss was considered to be the major contributing factor for 78 patients (43.5%). METHODS: We compared patients who developed a foot drop after bariatric surgery with a control group of patients who underwent bariatric surgery (gastric banding) but did not develop peroneal neuropathy. RESULTS: 9 patients developed foot drop after bariatric surgery. The mean weight loss for these patients was 45 kg. Weight reduction took place during a mean period of 8.6 months. Our control group consists of 10 patients. The mean weight loss of these patients was 43.8 kg, and the weight reduction took place during a mean period of 21.7 months. CONCLUSION: In contrast to earlier studies, we demonstrated that significant weight loss is correlated with a higher risk to develop foot drop and that the time period in which the weight loss is achieved is important. A rapid reduction of body weight is correlated with a higher risk to develop foot drop.

Posterior fossa syndrome after a vermian stroke: a new case and review of the literature.

The posterior fossa syndrome (PFS) is a well-known clinical consequence of posterior fossa surgery that has only been reported in a limited number of cases with a nontumoral etiology. It consists of transient cerebellar mutism, behavioral abnormalities and personality changes. We describe a 12-year-old child who developed transient cerebellar mutism associated with behavioral and emotional symptoms following rupture of a vermis arteriovenous malformation (AVM). Following the stroke, the girl experienced a 24-hour symptom-free interval. After that, she became mute and her emotional state was characterized by severe anxiety, irritability and withdrawal. After 3 days, mutism resolved and dysarthria became apparent. Two weeks after stroke, the AVM was surgically removed and the postoperative course was uneventful. This case is the first reported in which the PFS occurred after focal nonsurgically induced cerebellar damage.