Intra-operative hypertension as a predictor of surgical outcomes in microvascular decompression surgery for trigeminal neuralgia.

PURPOSE: The trigeminocardiac reflex (TCR) has traditionally been characterized by a sudden decrease in heart rate, asystole, or hypotension during the manipulation of the trigeminal nerve (MTN) or its branches. While this classical TCR is well-documented, there is limited literature on alternative forms of TCR, such as the development of intraoperative hypertension (HTN) or tachycardia, and the underlying pathogenesis. Furthermore, a gap exists in understanding the correlation between intraoperative blood pressure readings and postoperative outcomes, particularly regarding pain relief in patients with trigeminal neuralgia (TN). Our study aims to examine intraoperative blood pressure trends during microvascular decompression (MVD) for TN and assess their impact on postoperative outcomes. METHODS: We selected 90 patients who underwent MVD for TN treatment. Blood pressure and heart rate were recorded both preoperatively and during the procedure, specifically during the MTN period, using an arterial line. The Barrow Neurological Institute (BNI) Pain Scale was calculated for all patients both pre- and post-operatively to evaluate pain relief after surgery. RESULTS: The mean age of the patients was 61.0 ± 12.35 years, with 64.4% being females. Classical TCR (hypotension) was observed in only 2.2% of patients, whereas 80% of patients developed hypertension (≥ 140/90) during MTN. The mean preoperative systolic blood pressure was 128 ± 22.25, and the mean intraoperative systolic blood pressure during MTN was 153.1 ± 20.2. An analysis of covariance, utilizing either preoperative BNI or duration of symptoms as covariate variables, revealed a statistically significant association between intraoperative HTN and postoperative BNI. A linear regression model demonstrated that intraoperative HTN following MTN significantly predicted a lower postoperative BNI score (p = 0.006). CONCLUSIONS: Intraoperative HTN during MTN, an observed yet underexplored phenomenon, demonstrated a correlation with improved postoperative outcomes. Furthermore, it is recommended to conduct additional investigations into potential neurovascular conflicts in patients not manifesting intraoperative HTN following MTN. A comprehensive understanding of TCR, encompassing its various forms, is vital for optimizing surgical management. This study underscores the imperative for further research to unravel the mechanisms linking intraoperative HTN to surgical outcomes in TN patients.

Microscope-Based Augmented Reality: A New Approach in Intraoperative 3D Visualization in Microvascular Decompression?

Neurovascular compression (NVC) syndromes such as trigeminal neuralgia (TN) are causally treated with microvascular decompression (MVD). Semiautomatic segmentation of high-resolution magnetic resonance imaging (MRI) data and constructive interference in steady state (CISS)/time-of-flight (TOF) sequences are utilized for the three-dimensional (3D) visualization of underlying causative vessels at the root entry zones of the relevant cranial nerves. Augmented reality (AR) of neurovascular structures was introduced especially in the resection of brain tumors or aneurysmatic operations. In this report, the potential feasibility of the implementation of microscope-based AR into the intraoperative microsurgical set-up of MVD was investigated. This article recommends the preoperative evaluation of 3D visualization besides the microscopical view of the surgeon. The implementation of multiple imaging data by AR into the operating microscope may afflict the experienced surgeon's view, which should be examined prospectively.

Comparative analysis of patients undergoing microvascular decompression for trigeminal neuralgia caused by solely arterial or solely venous compression.

OBJECTIVE: Trigeminal neuralgia (TN) due to venous compression is far less common than that due to arterial compression, and its pathogenesis is less clear. We investigated the clinical and imaging features of TN caused by solely venous compression by measuring the morphologies of the posterior cranial fossa (PCF) and the trigeminal nerve. METHODS: We retrospectively reviewed records of TN patients who underwent microvascular decompression at our institution and extracted cases with solely arterial or solely venous compression. Preoperative magnetic resonance imaging was used to find the length (Y), width (X), height (Z), and volume (V) of the PCF, the angle between the trigeminal nerve and pons (TPA), and the distance between Meckel's cave and the root entry zone (REZ) of the trigeminal nerve. RESULTS: Of 152 patients, 24 had TN caused solely by venous compression. The value of Y was significantly smaller in the venous group than the arterial group (P<0.01). The TPA was significantly smaller in the venous group (P<0.01). We hypothesized that TN patients with solely venous compression had a characteristic PCF morphology with a short anteroposterior diameter (Y), such that age-related changes in brain morphology could alter the course of the trigeminal nerve and cause compression by a vein. CONCLUSIONS: The morphological features of the PCF differed between patients with TN of venous and those with TN of arterial etiology. Age-related changes in brain morphology and changes of course of the trigeminal nerve may also add to the possibility of developing TN, especially of venous etiology.

Endoscopic Microvascular Decompression.

Microvascular decompression is a widely accepted surgical treatment for compressive cranial nerve pathologies such as trigeminal neuralgia, hemifacial spasm, glossopharyngeal neuralgia, and other craniofacial pain syndromes. Endoscopy has risen as a safe and effective minimally invasive tool to optimize microvascular decompression. Endoscopy offers improved visualization, minimizes retraction, and allows for smaller surgical openings compared to traditional microscopic approaches. There are several reports of improved neuralgia outcomes and reduced post-operative complications after endoscopic microvascular decompression. In skilled surgical hands, endoscopy is an excellent option for microvascular decompression as stand-alone tool or adjunct to the microscope. An overview of the history, operative considerations, and techniques is provided in this chapter.

Efficacy of early versus delayed spinal cord decompression in neurological recovery after traumatic spinal cord injury: Systematic review and meta-analysis. / Eficacia de la descompresión medular precoz versus tardía en la recuperación neurológica tras lesión medular traumática. Revisión sistemática y metaanálisis.

STUDY DESIGN: Systematic review and meta-analysis. OBJECTIVE: To compare early (<24 h) versus late (>24 h) spinal cord decompression on neurological recovery in patients with acute spinal cord injury. METHODS: A systematic review was performed according to the PRISMA protocol to identify studies published up to December 2022. PROSPECTIVE: cohort studies and controlled trials comparing early versus delayed decompression on neurological recovery were included. Variables included number of patients, level of injury, treatment time, ASIA grade, neurological recovery, use of corticosteroids, and complications. For the meta-analysis, the «forest plot¼ graph was developed. The risk of bias of the included studies was assessed using the ROBINS-I22 and Rob223 tools. RESULTS: Six of the seven studies selected for our review were included in the meta-analysis, with a total of 1188 patients (592 patients in the early decompression group and 596 in the delayed decompression group), the mean follow-up was 8 months, in 5 studies used methylprednisolone, the most reported complications were thromboembolic cardiopulmonary events.Five studies showed significant differences in favour of early decompression (risk difference 0.10, 95% confidence interval 0.07-0.14, heterogeneity 46%). The benefit was greatest in cervical and incomplete injuries. CONCLUSION: There is scientific evidence to recommend early decompression in the first 24 h after traumatic spinal cord injury, as it improves final neurological recovery, and it should be recommended whenever the patient and hospital conditions allow it to be safely done.

Graves-Basedow ophthalmopathy surgical approaches: Open vs Endoscopic.

Graves-Basedow's disease (GBD) is an autoimmune pathology that affects the thyroid and is characterized by the presence of goiter, hyperthyroidism, ophthalmopathy, and dermopathy. Graves-Basedow ophthalmopathy (GBO) is a set of inflammatory and infiltrative alterations of the orbital tissue that affects 40-90% of subjects suffering from GBD. Our study aims to investigate the differences in the clinical outcomes of patients treated with two different techniques: the classic open and the more modern endoscopic. A retrospective clinical study was carried out from the year 2011 until the year 2020 to evaluate the clinical outcomes of two different surgical techniques for the treatment of GBO. Eighteen patients were given surgical indications, 12 males and 6 females aged between 37 and 69 years (average age 48.5 years), for a total of 36 orbits. From the year 2011 to the year 2014, all patients were treated with the open orbital decompression technique; from 2015 onwards, patients were subjected to orbital decompression with the endoscopic transnasal approach. Pre- and postoperative ophthalmometry, reduction of proptosis, and reduction of oculo-orbital index were compared for the two techniques. As evidenced by the statistical analysis carried out on the sample before and after surgical treatment, there is a statistically significant difference between ophthalmometry and the Oculo-Orbital Index (IOO) values; this indicates that surgical orbital decompression with two walls (floor and medial wall) is effective in reducing exophthalmos. The positive result is also confirmed by the reduction of proptosis, measured in millimeters, averaging 1.7 mm. In the analysis of data relating to the two different patient groups, treated respectively with endoscopic orbital decompression (Technique 1) and classical open orbital decompression (Technique 2), the results obtained show that there is no statistically significant difference between the results of the two techniques. Therefore, the choice of surgical approach is at the discretion of the surgeon. It is our opinion that orbital decompression with the endoscopic transnasal technique should be an absolute indication in all patients who have clinical and radiographic signs of involvement of the optic nerve at the orbital apex (crowded apex syndrome) thanks to the ability of this technique to add and decompress the optical channel at the apex. For all other patients with GBO, the endoscopic technique of orbital decompression can be indicated as a first-line surgical approach considering the absence of skin scars and the best aesthetic results.

The selection of a surgical strategy for the treatment of adult degenerative scoliosis with "pear-shaped" decompression under open spinal endoscopy.

The prognoses of patients who undergo open spinal endoscopy (OSE) decompression significantly differ by scoliosis type and symptom despite the use of uniform standards and procedures for the decompression surgery. These differences may be directly related to the selection and formulation of surgical strategies but their cause remains unclear. The aim of this study was to verify and evaluate the efficacy of the "Symptom, Stenosis and Segment classification (SSS classification)" in determining an appropriate surgical strategy and to analyze the differences in the outcomes of different patients after receiving the selected surgical strategy. The results of this study ultimately provide a theoretical basis for the specific optimization of surgical strategies guided by the "SSS classification". This work was a retrospective study. We reviewed 55 patients with scoliosis and spinal stenosis who underwent "pear-shaped" decompression under OSE from May 2021 to June 2023 treated by our surgical team. To classify different types of patients, we defined the "SSS classification" system. The permutation and combination of subtypes in Symptom (including three subtypes: Convex = v, Concave = c and Bilateral = b), Stenosis (including three subtypes: Convex = v, Concave = c and Bilateral = b), and Segment (including two subtypes: Edge = e and Inside = i) yields 18 possible types (details in Table 1) in this classification system. To classify different types of surgeries, we also defined the operation system. The VAS Back and VAS Leg scores after surgical treatment were significantly lower in all patients 3 months after surgery than before surgery. (**P < 0.05). The Svve type accounted for the greatest proportion of patients (62.50%) in the VAS back remission group, and the Scce type accounted for the greatest proportion (57.14%) in the VAS back ineffective group. According to the VAS leg score, the percentage of patients in whom Svve was detected in the VAS leg remission group reached 60.87%, and the percentage of patients in whom Svve was detected in the VAS leg ineffective group reached 44.44%. Svve accounted for the greatest proportion of cases (61.22%) in the JOA-effective group, and Scce accounted for the greatest proportion of cases (50.00%) in the JOA-ineffective group. In the JOA-effective group, the Ovv type accounted for the greatest proportion (up to 79.59%), while in the JOA-ineffective group, Occ and Ovv accounted for 50.00% of the cases each. The proportions of Svve type were the highest in the healthy group (up to 60.00%) and the ODI-effective group (up to 50.00%). The Ovv type accounted for the greatest proportion of patients in the ODI-effective group (up to 80.00%), and the Occ type accounted for the greatest proportion of patients in the ODI-ineffective group (up to 60.00%). Most of the surgical plans formulated by the "SSS classification" method were considered appropriate, and only when the symptoms of patients were located on the concave side did the endoscopic decompression plan used in the present study have a limited ability to alleviate symptoms.

Preliminarily exploring the intraoperative ultrasonography characteristics of patients with degenerative cervical myelopathy.

BACKGROUND: How to quickly read and interpret intraoperative ultrasound (IOUS) images of patients with degenerative cervical myelopathy (DCM) to obtain meaningful information? Few studies have systematically explored this topic. PURPOSE: To systematically and comprehensively explore the IOUS characteristics of patients with DCM. MATERIALS AND METHODS: This single-center study retrospectively included patients with DCM who underwent French-door laminoplasty (FDL) with IOUS guidance from October 2019 to March 2022. One-way ANOVA and Pearson's /Spearman's correlation analysis were used to analyze the correlations between the cross-sectional area of the spinal cord (SC) and individual characteristics; the relationships between the morphology, echogenicity, pulsation, decompression statuses, compression types of SC, location of the spinal cord central echo complex (SCCEC) and the disease severity (the preoperative Japanese Orthopedic Association score, preJOA score); the difference of the spinal cord pulsation amplitude(SCPA) and the SCCEC forward movement rate (FMR) between the compressed areas(CAs) and the non-compressed areas (NCAs). RESULTS: A total of 38 patients were successfully enrolled (30 males and 8 females), and the mean age was 57.05 ± 10.29 (27-75) years. The cross-sectional area of the SC was negatively correlated with age (r = - 0.441, p = 0.006). The preJOA score was significantly lower in the heterogeneous group than in the homogeneous group (P < 0.05, p = 0.005). The hyperechoic area (HEA) was negatively while the SCCEC FMR was positively correlated with the preJOA score (r = - 0.334, p = 0.020; r = 0.286, p = 0.041). The SCCEC FMR and SCPA in CAs were significantly greater than those in NCAs (p < 0.05, p = 0.007; P < 0.001, P = 0.000). CONCLUSION: The cross-sectional area of the SC decreases with age in adults. More changes in intramedullary echogenicity and less moving forward of the SCCEC often indicate poor SC status, and the SCCEC FMR and SCPA are more pronounced in CAs.

[The otolaryngologist's role in evaluating diving fitness]. / Beurteilung einer Tauchtauglichkeit als HNO-Arzt.

Scuba diving and other modes of device-supported diving are popular activities that can be especially demanding and hazardous for people with preexisting physical conditions. Due to the high ambient pressure, the temperature differences, and potential unpredictable events, which have manifold effects on the organism, diving carries a high risk of life-threatening disease. A special risk is present if the body does not readily equalize air pressure changes. Therefore, prior to diving, all divers should undergo detailed education regarding the physical principles of the sport as well as specific physical examination. Consultation of an otolaryngologist is of exceptional relevance because many otorhinolaryngologic diseases can lead to (usually temporary) unfitness to dive. The role of the modern otorhinolaryngologist trained in diving medicine is to correctly advise the patient and restore fitness for diving via conservative or invasive methods.

Comparing opioid utilization and costs for surgical management of single-level spondylolisthesis: A national claims database analysis.

Introduction: The rise in degenerative lumbar spondylolisthesis (DLS) cases has led to a significant increase in fusion surgeries, which incur substantial hospitalization costs and often necessitate chronic opioid use for pain management. Recent evidence suggests that single-level low-grade DLS outcomes are comparable whether a fusion procedure or decompression alone is performed, sparking debate over the cost-effectiveness of these procedures, particularly with the advent of minimally invasive techniques reducing the morbidity of fusion. This study aims to compare chronic opioid utilization and associated costs between decompression alone and decompression with instrumented fusion for single-level degenerative lumbar spondylolisthesis. Material and methods: Using data from the PearlDiver database, a retrospective database analysis was conducted. We analyzed records of Medicare and Medicaid patients undergoing lumbar fusion or decompression from 2010 to 2022. Patient cohorts were divided into decompression alone (DA) and decompression with instrumented fusion (DIF). Chronic opioid use, pain clinic visits, and total costs were compared between the two groups at 90 days, 1 year, and 2 years post-surgery. Theory: Does DIF offer a more cost-effective approach to managing DLS in terms of chronic opioid use in single-level DLS patients. Results: The study revealed comparable chronic opioid use and pain clinic visits between DA and DIF groups at 90 days and 1 year. However, total costs associated with opioid prescriptions as well as surgical aftercare were significantly higher in the DIF group at 90 days (p < 0.05), 1 year (p < 0.05), and 2 years (p < 0.05) post-surgery compared to the DA group. Conclusions: This study highlights the higher costs associated with DIF up to 2 years post-surgery despite comparable symptom improvement when compared to DA and DIF at the 1-year interval. DA emerges as a more financially favorable option, challenging the notion of fusion's cost-offsetting benefits. While further investigation is needed to understand underlying cost drivers and optimize outcomes, our findings emphasize the necessity of integrating clinical and economic factors in the management of single-level DLS.

Microvascular Decompression versus Radiofrequency Ablation in Trigeminal Neuralgia of the Maxillary and Mandibular Divisions.

Background Although medical treatment is the mainstay of therapy, in trigeminal neuralgia (TN), patients failing to respond to it make them candidates to ablative or nonablative procedures. Objective The aim of this study was to compare the outcome of Microvascular decompression (MVD) and radiofrequency (RF) thermocoagulation in the management of TN affecting the mandibular and maxillary divisions. Materials and Methods Retrospective analysis of the data of 40 patients suffering from intractable classical TN affecting the maxillary or mandibular divisions or both was carried out. Twenty patients were operated upon by MVD of the trigeminal nerve; and 20 had RF ablation of the maxillary or mandibular divisions of the trigeminal nerve or both. Results In MVD the overall successful outcome was achieved in 16 patients (80%), while the failure was in 4 patients (20%) of which 3 had a fair outcome and 1 patient had a poor outcome. Whereas in RF the overall successful outcome was achieved in 17 patients (85%), while the failure was in 3 patients (15%) of which 2 had a fair outcome and 1 patient had a poor outcome. Outcome was insignificantly different between both groups ( p -value 0.806). Conclusion MVD and RF ablation represent safe and efficacious surgical choices for addressing TN that encompasses both the mandibular and maxillary divisions. Long-term follow-up studies demonstrate that MVD consistently yields favorable outcomes, establishing it as the preferred primary surgical technique, unless contraindicated by the patient's general health and specific needs.

Awake neurosurgery: Advancements in microvascular decompression for trigeminal neuralgia.

Background: The treatment landscape for trigeminal neuralgia (TN) involves various surgical interventions, among which microvascular decompression (MVD) stands out as highly effective. While MVD offers significant benefits, its success relies on precise surgical techniques and patient selection. In addition, the emergence of awake surgery techniques presents new opportunities to improve outcomes and minimize complications associated with MVD for TN. Methods: A thorough review of the literature was conducted to explore the effectiveness and challenges of MVD for TN, as well as the impact of awake surgery on its outcomes. PubMed and Medline databases were searched from inception to March 2024 using specific keywords "Awake Neurosurgery," "Microvascular Decompression," AND "Trigeminal Neuralgia." Studies reporting original research on human subjects or preclinical investigations were included in the study. Results: This review highlighted that MVD emerges as a highly effective treatment for TN, offering long-term pain relief with relatively low rates of recurrence and complications. Awake surgery techniques, including awake craniotomy, have revolutionized the approach to MVD, providing benefits such as reduced postoperative monitoring, shorter hospital stays, and improved neurological outcomes. Furthermore, awake MVD procedures offer opportunities for precise mapping and preservation of critical brain functions, enhancing surgical precision and patient outcomes. Conclusion: The integration of awake surgery techniques, particularly awake MVD, represents a significant advancement in the treatment of TN. Future research should focus on refining awake surgery techniques and exploring new approaches to optimize outcomes in MVD for TN.

A Case With Twists and Turns: A Report of Vertebrobasilar Dolichoectasia.

Vertebrobasilar dolichoectasia (VBD) is a rare anatomical abnormality of the vertebral artery system, defined as irregular expansion, elongation, and tortuosity of vertebral arteries. Anomalies of the vertebrobasilar artery can have a wide variety of clinical presentations, ranging from simple headaches to debilitating strokes. We present the case of an atypical presentation of VBD which mimicked trigeminal neuralgia by compressing the trigeminal nerve. There are currently no guidelines concerning the management of VBD, nor is there evidence of a definitive cure. This case invoked discussions among the medical team as to whether management should be medically or surgically focused, as well as long-term outcomes for patients with VBD. The superiority of medical versus surgical treatment of this issue is still a debated topic. This patient trialed medical management with dexamethasone and carbamazepine with no improvement in symptoms. He then underwent surgical gamma knife treatment but even this invasive measure was unsuccessful at relieving his symptoms. We hope that by presenting this case, we can display how the therapies available for VBD are limited and often unsuccessful in relieving the disease burden in patients with VBD.

Endoscopic endonasal optic nerve decompression in children younger than 2 years old with congenital optic canal stenosis: illustrative cases.

BACKGROUND: Congenital optic canal stenosis causing compressive optic neuropathy is a rare disorder that presents unique diagnostic and treatment challenges. Endoscopic endonasal optic nerve decompression (EOND) has been described for optic nerve compression in adults and adolescents but has never been reported for young children without pneumatized sphenoid sinuses. The authors describe preoperative and intraoperative considerations for three patients younger than 2 years of age with congenital optic canal stenosis due to genetically confirmed osteopetrosis or chondrodysplasia. OBSERVATIONS: Serial ophthalmological examinations, with a particular focus on object tracking ability, fundoscopic examination, and visual evoked potential trends in preverbal children, are important for detecting progressive optic neuropathy. The lack of pneumatization of the sphenoid sinus presents unique challenges and requires the surgical creation of a sphenoid sinus with the use of neuronavigation to determine the limits of bony exposure given the lack of easily identifiable anatomical landmarks such as the opticocarotid recess. There were no perioperative complications. LESSONS: EOND for congenital optic canal stenosis is safe and technically feasible even given the lack of pneumatization of the sphenoid sinus in young patients. The key operative step is surgically creating the sphenoid sinus through careful bony removal with the aid of neuronavigation. https://thejns.org/doi/10.3171/CASE23559.

Optic nerve decompression through pterional and supraorbital approaches in the treatment of severe traumatic optic neuropathy.

To investigate the effectiveness of optic nerve decompression (OND) in the treatment of severe traumatic optic neuropathy (TON) through pterional and supraorbital approaches, and to identify the prognostic factor for postoperative visual acuity (VA) following OND. Patients with severe TON treated with OND through either pterional or supraorbital approach in our institute from September 2019 to June 2022 were retrospectively reviewed in this study. Demographic information, trauma factors, the interval between trauma and complete blindness, the interval between trauma and surgery, and the associated craniofacial traumas were recorded. Hospitalization days and the postoperative VA of patients in two groups were compared. There were 54 severe TON patients with NLP included in this study; 21 patients underwent OND through the pterional approach, and the other 33 underwent the supraorbital approach. Respectively, in groups of pterional and supraorbital approaches, the average hospitalization days were 9.8 ± 3.2 and 10.7 ± 2.9 days (p = 0.58), the mean durations of follow-up were 18.9 ± 4.3 and 20.8 ± 3.7 months (p = 0.09), and the average circumference of OND were 53.14 ± 15.89 ◦ (range 220 ◦ -278◦) and 181.70 ± 6.56◦ (range 173 ◦ -193◦) (p<0.001). The overall improvement rates of pterional and supraorbital approaches are 57.1% and 45.5% (p = 0.40), respectively. Optic canal fracture (OCF) was revealed to be significantly associated with postoperative VA in the supraorbital approach (Binary: p = 0.014, CI: 1.573-57.087; Ordinal: p = 0.003, CI: 1.517-5.503), but not in the pterional approach. In the group of supraorbital approach, patients with OFC had a higher rate of a better outcome (78.6%) than those without (21.4%). Patients with severe traumatic TON may benefit from OND through either the pterional or supraorbital approach. OCF is a potential prognostic factor for postoperative VA following OND through the supraorbital approach.

Optimal Timing in Cervical Spinal Cord Injury: A Comprehensive Meta-Analysis of Ultra-Early Surgical Intervention Within Five Hours.

The optimal timing of surgery for cervical spinal cord injuries (SCI) and its impact on neurological recovery continue to be subjects of debate. This systematic review and meta-analysis aims to consolidate and assess the existing evidence regarding the efficacy of ultra-early decompression surgery in improving clinical outcomes after cervical SCI. A search was conducted in PubMed, Embase, Cochrane, and CINAHL databases from inception until September 18, 2023, focusing on human studies. The groups were categorized into ultra-early decompression (decompression surgery ≤ 5 hours post-injury) and a control group (decompression surgery between 5-24 hours post-injury). A random effects meta-analysis was performed on all studies using R Studio. Outcomes were reported as effect size (OR, treatment effect, and 95% CI. Of the 140 patients, 63 (45%) underwent decompression ≤ 5 hours, while 77 (55%) underwent decompression > 5 hours post-injury. Analysis using the OR model showed no statistically significant difference in the odds of neurological improvement between the ultra-early group and the early group (OR = 1.33, 95% CI: 0.22-8.18, p = 0.761). This study did not observe significant neurological improvement among cervical SCI patients who underwent decompression within five hours. Due to the scarcity of literature on the ultra-early decompression of cervical SCI, this study underscores the necessity for additional investigation into the potential benefits of earlier interventions for cervical SCI to enhance patient outcomes.

[ZHANG Weihua's experience in treatment of cervical spondylotic radiculopathy with ulna-tibia needling therapy combined with decompression-loosening manual manipulation].

The paper introduces professor ZHANG Weihua's experience in treatment of cervical spondylotic radiculopathy (CSR) with ulna-tibia needling therapy combined with decompression-loosening manual manipulation. Using "palpating, detecting and imaging observing", professor ZHANG Weihua gives the accurate diagnosis for the location, the stage and the severity of the disease. According to the nature of the disease, CSR is treated in three stages. He proposes the academic thought, "taking the tendons as the outline, regarding the meridians as the essential, rooting at qi and blood, co-regulating tendons and bones". The ulna-tibia needling therapy and decompression-loosening manual manipulation are combined in treatment. In the ulna-tibia needling therapy, the acupuncture is delivered at the lower 1/3 of the cutaneous regions of taiyang and shaoyang meridians, on the ulnar region (belt-like distribution). The decompression-loosening manual manipulation is operated in 3 steps, i.e. relaxing the nape region, decompressing and relaxing (includes positioning rotational wrenching, upward and backward elevation) and supination wrenching, and analgesia and regulating tendons; and the manipulation for analgesia and regulating tendons is supplemented to enhance the effect.

The surgical strategy "CSF decompression" facilitates outcomes of adults with Chiari malformation type I: An observational, real-world, single center study of 528 patients.

OBJECTIVES: We designed this study to introduce the surgical strategy "CSF decompression" in treating Chiari malformation type I (CMI), and compared the "CSF decompression" strategy with other surgical strategies to provide a solid basis for patient counseling. METHODS: A total of 528 consecutive CMI patients who underwent surgical interventions from 2012 to 2022 were enrolled. The surgical strategy for these patients was bony and dural decompression (BDD), anatomical reduction of herniated tonsils (AR) or CSF decompression (CSFD). Short-term results were determined after 3 months; long-term outcomes were evaluated at last follow-up and at least 18 months. RESULTS: The CSFD strategy was independently associated with better long- or short-term primary outcomes than AR or BDD (P < 0.001). Compared with short-term, the long-term outcomes were better in CSFD patients (P = 0.035), but were worse in BDD patients (P = 0.03). Specific surgical techniques cannot affect the long- and short-term outcomes of CMI patients. CSFD provided better long-term syringomyelia improvement than short-term (181/218, 83% vs 169/218, 77.5%; P < 0.001). CONCLUSION: The "CSF decompression" surgical strategy, but not a specific surgical technique or operative method, was associated with favorable neurological outcomes in adult CMI patients. The surgical technique and operative method should be selected according to the characteristics of each patient and the intraoperative condition to normalized CSF circulation at CVJ. The intraoperative target maybe smoothly CSF flow, out from the fourth ventricle and in to the bilateral Luschka foramina, could be observed.