The Enhanced Recovery After Surgery protocol for the perioperative management of pituitary neuroendocrine tumors/pituitary adenomas.

OBJECTIVE: Enhanced Recovery After Surgery (ERAS) is a multimodal perioperative care pathway that has radically modified the management of patients in multiple surgical specialties. Until now, no ERAS Society guidelines have been formulated for the management of cranial pathologies. During the process of ERAS certification for their neurosurgical department, the authors formulated an ERAS protocol for the perioperative care of patients with pituitary neuroendocrine tumors (PitNET), along with a compliance checklist to monitor the adherence to it and its feasibility. The authors describe the protocol and checklist and report the results, including a cost-minimization analysis, with the application of the ERAS philosophy. METHODS: The steps that led to the development of this ERAS protocol, including items concerning the preoperative, intraoperative, and postoperative period, are detailed. The authors report their preliminary results through the comparison of the care practice of a historical cohort with a consecutive surgical cohort of patients with PitNET who underwent operation after the implementation of this ERAS protocol. A compliance checklist with key performance indicators was useful to monitor the adherence to the protocol and the changes in the perioperative management. RESULTS: Following the introduction of this ERAS protocol, the authors significantly shortened the duration of the antibiotic therapy (p < 0.00001) and increased the use of mechanical (p < 0.00001) and pharmacological measures to prevent deep venous thrombosis (p = 0.002). The median length of hospital stay was significantly shorter for the ERAS group (p = 0.00014), and there was no increase in readmission rate or postoperative complications. The documentation and data tracking strongly improved in the ERAS cohort and the authors were more attentive in pain evaluation (p = 0.001), postoperative hormonal supplementation (p = 0.001) and early feeding and mobilization (p = 0.0008 and p < 0.00001, respectively). More patients were discharged on day 3 after surgery in the ERAS group (p < 0.00001). The compliance to the whole process increased from 64.2% to 89.5% (p = 0.016), and the compliance per patient was also found to have significantly increased (p < 0.00001). CONCLUSIONS: The introduction of a standardized ERAS protocol for the perioperative management of patients with PitNET allowed the authors to improve the multidisciplinary management of these patients. With the application of simple cost-effective interventions and with the avoidance of unnecessary measures, gains were made in terms of early mobilization and feeding, thereby resulting in a shorter in-hospital stay.

The Enhanced Recovery After Surgery protocol for the surgical management of craniosynostosis: Lausanne experience.

OBJECTIVE: Over the past decade, the Enhanced Recovery After Surgery (ERAS) program has demonstrated its effectiveness and efficiency in improving postoperative care and enhancing recovery across various surgical fields. Preliminary results of ERAS protocol implementation in craniosynostosis surgery are presented. METHODS: An ERAS protocol was developed and implemented for cranial pediatric neurosurgery, focusing on craniosynostosis repair. The study incorporated a pre-ERAS group consisting of a consecutive series of patients who underwent craniosynostosis repair surgery prior to the implementation of the ERAS protocol; the results were compared with a consecutive group of patients who had been prospectively collected since the introduction of the ERAS for craniosynostosis protocol. The safety, feasibility, and efficiency of the ERAS protocol in pediatric neurosurgery was evaluated, through the collection of clinical data from the pre-, intra-, and postoperative phase. Surgery-related complications were evaluated according to the Clavien-Dindo classification. Costs of the stays were obtained using a microcosting approach. RESULTS: A total of 35 pre-ERAS patients and 10 ERAS patients were included. Scaphocephaly was the most common pathology in both groups. The overall compliance with the pre-, intra-, and postoperative criteria significantly increased-from 35.5%, 64.4%, and 54.7%, respectively, in each phase to 94%, 90%, and 84% (p < 0.001). The authors noticed a reduction in the average opioid dose used per patient in the ERAS group (p = 0.004), and they observed a trend toward a decreased mean length of stay from 5.2 days in the pre-ERAS group to 4.6 days in the ERAS group, without an increase of the rate of readmission within 30 days of surgery. The rate of complications decreased but this difference was not statistically significant. The hospital costs lowered significantly: from 21,958 Confederatio Helvetica Francs (CHF) in the pre-ERAS group to 18,936 CHF in the ERAS group (p = 0.02). CONCLUSIONS: The ERAS protocol represents a safe and cost-effective tool for the perioperative management of craniosynostosis. It showed its positive impact on the analgesia provided and on the reduction of in-hospital costs for these patients. ERAS protocols may thus be interesting options in the pediatric neurosurgical field.

Implementation of the Enhanced Recovery After Surgery (ERAS®) program in neurosurgery.

BACKGROUND: Over the past decade, Enhanced Recovery After Surgery (ERAS®) guidelines have been proven to simplify postoperative care and improve recovery in several surgical disciplines. The authors set out to create and launch an ERAS® program for cranial neurosurgery that meets official ERAS® Society standards. The authors summarize the successive steps taken to achieve this goal in two specific neurosurgical conditions and describe the challenges they faced. METHODS: Pituitary neuroendocrine tumors (Pit-NET) resected by a transsphenoidal approach and craniosynostosis (Cs) repair were selected as appropriate targets for the implementation of ERAS® program in the Department of Neurosurgery. A multidisciplinary team with experience in managing these pathologies was created. A specialized ERAS® nurse coordinator was hired. An ERAS® certification process was performed involving 4 seminars separated by 3 active phases under the supervision of an ERAS® coach. RESULTS: The ERAS® Pit-NET team included 8 active members. The ERAS® Cs team included 12 active members. Through the ERAS® certification process, areas for improvement were identified, local protocols were written, and the ERAS® program was implemented. Patient-centered strategies were developed to increase compliance with the ERAS® protocols. A prospective database was designed for ongoing program evaluation. Certification was achieved in 18 months. Direct costs and time requirements are reported. CONCLUSION: Successful ERAS® certification requires a committed multidisciplinary team, an ERAS® coach, and a dedicated nurse coordinator.

Aesthetic results in children with single suture craniosynostosis: proposal for a modified Whitaker classification.

OBJECTIVE: Aesthetic assessment after surgery for non-syndromic single suture craniosynostosis (SSC) is crucial. Surgeons' evaluation is generally based on Whitaker classification, while parental impression is generally neglected. The aim of this paper is to compare aesthetic perceptions of parents and surgeons after surgery for SSC, expressed by a 10-item questionnaire that complement Whitaker's classification. METHODS: The authors submitted a 10-item questionnaire integrating Whitaker's classification in order to evaluate the degree of satisfaction, the detailed aesthetics results and the need for surgical revision, to surgeons and parents of a consecutive series of patients operated for SSC between January 2007 and December 2018. The results were collected blindly. RESULTS: A total of 70 patients were included in the study. Scaphocephaly and trigonocephaly were the two most frequent craniosynostosis. Parents and surgeons general aesthetics evaluation and average rating for Whitaker's classification were 1.86 vs 1.67 (p = 0.69) and 1.19 vs 1.1 (p = 0.45) respectively. Parents' evaluation for scar perception and alopecia (p < 0.00001), the presence of bony crest (0.002), bony bump (p < 0.00001), or other bone irregularities (p = 0.02) are significantly worse when compared to surgeons' perception. CONCLUSIONS: Parents seem to be more sensitive to the detection of some aesthetic anomalies and their opinion should not be neglected. The authors propose a modified Whitaker classification based on their results to better stratify the aesthetic outcome after surgery for SSC.

Atlanto-occipital dislocation in a child: a challenging diagnosis. Illustrative case.

BACKGROUND: Atlanto-occipital dislocation (AOD) is a highly unstable injury of the osseoligamentous complex at the craniocervical junction that is more common in children. Its diagnosis remains a challenging process that must integrate clinical presentation and radiological criteria. OBSERVATIONS: A 9-year-old child presented with severe craniocervical trauma (Glasgow Coma Scale score 6) and cardiorespiratory arrest on-site. Prompt resuscitation on-site and transfer to the university hospital were performed, and a computed tomography (CT) scan showed a subarachnoid hemorrhage around the brainstem and a retroclival hematoma. Most of the radiological criteria on CT scans for AOD were negative, except for the occipital condyle-C1 interval, and further imaging with magnetic resonance imaging permitted the diagnosis of AOD with rupture of both the tectorial membrane and the transverse ligament. Occipital-cervical Oc-C1-2 fixation was performed. The neurological outcome was excellent, with full recovery 6 months after the trauma. LESSONS: AOD should be suspected in all high-intensity trauma in children, especially if the clinical presentation includes cardiorespiratory arrest and other brainstem and/or upper cervical cord symptoms along with premedullary subarachnoid hemorrhage. Understanding the ligamentous nature of the injury resulting in "normal" radiographs or CT scans is important to avoid underdiagnosing AOD, which can have detrimental consequences.

Transtubular image-guided surgery for spinal intradural lesions: techniques, results, and complications in a consecutive series of 60 patients.

OBJECTIVE: The authors previously described the image merge tailored access resection (IMTAR) technique for resection of spinal intradural lesions (SIDLs). The authors reported their updated experience with the IMTAR technique and compared surgical results between patients who underwent operations with 2D or 3D fluoroscopic guidance. METHODS: The authors reviewed 60 patients who underwent SIDL resection with transtubular techniques over a 14-year period. The earlier patients in the series underwent operations with 2D fluoroscopic image guidance. The latter patients underwent operations with the IMTAR technique based on 3D image guidance. The results of both techniques were analyzed. RESULTS: Sixty patients were included: 27 females (45%) and 33 males (55%). The median (range) age was 50.5 (19-92) years. Gross-total resection (GTR) was achieved in 52 patients (86.7%). Subtotal resection was accomplished in 5 patients (8.3%). Neurological complications occurred in 3 patients (5%), and tumor recurrence occurred in 1 patient (1.7%). The non-IMTAR and IMTAR cohorts showed similar postoperative Nurick scale scores and rates of neurological complications and GTR. The median (interquartile range) bone resection surface area at the index level was 89.5 (51-147) mm2 in the non-IMTAR cohort and 35.5 (11-71) mm2 in the IMTAR cohort, with a statistically significant difference (p = 0.0112). CONCLUSIONS: Surgery for SIDLs may be challenging, and meticulous surgical planning is crucial to optimize tumor access, maximize resection, and minimize risk of complications. Image-guided transtubular resection is an additional surgical technique for SIDLs and facilitates microsurgical tumor removal of ventrally located lesions with a posterolateral approach, without requiring potentially destabilizing bone resection.

Extreme lateral supracerebellar infratentorial approach for tentorial arteriovenous fistula associated with a giant venous ectasia: how I do it.

BACKGROUND: Surgery of tentorial dural arteriovenous fistulas (DAVF) associated with large ectatic vein remains challenging due to the intimate neurovascular relationships in the incisural space. Interruption of the arterialized vein requires a good knowledge of the regional anatomy and a precise preoperative evaluation. METHODS: We describe the key steps extreme lateral supracerebellar infratentorial (ELSI) approach for tentorial DAVF with a video illustration. The surgical anatomy is described along with the advantages and limitations of this approach. CONCLUSIONS: In cases of tentorial DAVF where the foot of the arterialized vein is located in the infratentorial compartment, ELSI offers good surgical exposure and outcomes.

Surgical outcome of tuberculum sellae and planum sphenoidale meningiomas based on Sekhar-Mortazavi Tumor Classification.

BACKGROUND: Results from surgical series of tuberculum and planum sphenoidale meningiomas tends to be heterogeneous. Sekhar-Mortazavi tumor classification system has been recently proposed in order to predict the surgical risk and outcome. METHODS: We retrospectively reviewed a consecutive series of tuberculum and planum sphenoidale meningioma operated at our institution between 2009 and 2016. Sekhar-Mortazavi Tumor Classification was applied to classify these tumors and evaluate the outcome. RESULTS: Twenty-seven patients were included in the study. There were 22 females (81%) and 5 males (19%). The mean age was 54 years (range 33-78). According to Sekhar-Mortazavi Tumor Classification: 14 patients (51.85%) were class I, 11 (40.74%) patients were in class II and 2 patients (7.41%) were in class III. Twenty-one patients (77.7%) presented with visual symptoms and deficits at preoperative neuro-ophthalmological examination. Sekhar-Mortazavi class I tumors had a postoperative visual improvement in 77.7% of cases while patients in Sekhar-Mortazavi class II-III had a postoperative visual improvement in 66.6% of cases (P=0.5). No patient had deterioration of optic nerve/chiasmal function following surgery. Gross total resection was obtained in 25 patients (92.5%) without any significative difference between class I and Class II-III tumors. Permanent endocrine dysfunction was observed only in one patient in SM Class II tumor. 3 patients (11%) showed a postoperative persistent cranial nerve deficit (2 patients were anosmic and one patient had a trochlear nerve deficit). None of the patients showed postoperative CSF leak. No onset of new seizures was observed postoperatively. There was no mortality or major morbidity in this series. CONCLUSIONS: Transcranial surgery provided very satisfying results with respect to visual and endocrine outcomes with very low surgical morbidity. The Sekhar-Mortazavi classification showed a trend towards better visual outcomes in Class I tumors. The classification system is easy to apply and could therefore prove useful to compare results between studies reported in literature, especially when comparisons are made between transcranial and endonasal surgery.

Surgery for diaphragma sellae meningioma: how I do it.

BACKGROUND: Surgery for diaphragma sellae meningiomas (DSM) remains challenging due to the intimate neurovascular relationships of the tumor. Excision of DSM along with a decompression of the optic apparatus requires a good knowledge of the skull base anatomy and a precise preoperative evaluation of the tumor extensions. METHOD: We describe the key steps of transcranial approach for DSM with a video illustration. The surgical anatomy is described along with the advantages and limitations of this approach. CONCLUSIONS: The transcranial approach allows a safe tumor excision with an early and adequate control of the neurovascular structures, while minimizing postoperative CSF rhinorrhea.

Spinal angiolipomas in pregnancy: Natural history and surgical treatment.

Spinal angiolipomas (SALs) are rare extradural tumors frequently located at the level of the thoracic spine and they are associated with spinal cord compromise that might result in severe myelopathy. While the first macroscopic description dates 1890, histologically these tumors where not described as angiolipomas until 1986 by Haddad et al. Occurrence in pregnancy is even more infrequent. Since their first macroscopic description, spinal angiolipomas were reported anecdotally in pregnant women. We present a case of spinal angiolipoma in pregnancy with confirmed histologic diagnosis. In the present paper, we reviewed the literature regarding spinal angiolipomas in order to characterize their clinical manifestation, natural history, radiologic and histologic appearance. We add also a further case of spinal angiolipoma in a pregnant woman. Finally, we provide suggestions for the management of such rare tumors in pregnancy.