The significance of intra-abdominal pressure in neurosurgery and neurological diseases : a narrative review and a conceptual proposal

Intra-abdominal pressure (IAP) is a physiological parameter that has gained considerable attention during the last few decades. The incidence of complications arising from increased IAP, known as intra-abdominal hypertension (IAH) or abdominal compartment syndrome in critically ill patients, is high and its impact is significant. The effects of IAP in neurological conditions and during surgical procedures are largely unexplored. IAP also appears to be relevant during neurosurgical procedures (spine and brain) in the prone position, and in selected cases, IAH may affect cerebrospinal fluid drainage after a ventriculoperitoneal shunt operation. Furthermore, raised IAP is one of the contributors to intracranial hypertension in patients with morbid obesity. In traumatic brain injury, case reports described how abdominal decompression lowers intracerebral pressure. The anatomical substrate for transmission of the IAP to the brain and venous system of the spine is the extradural neural axis compartment; the first reports of this phenomenon can be found in anatomical studies of the sixteenth century. In this review, we summarize the available knowledge on how IAP impacts the cerebrospinal venous system and the jugular venous system via two pathways, and we discuss the implications for neurosurgical procedures as well as the relevance of IAH in neurological disorders

Posterior transdural discectomy: a new approach for the removal of a central thoracic disc herniation

BACKGROUND: The optimal surgical approach for thoracic disc herniation remains a matter of debate, especially for central disc herniation. In this paper, we present a new technique to remove central thoracic disc herniation, the posterior transdural approach, and report a series of 13 cases operated on in this way at our institute. METHODS: Between September 2004 and October 2010, 13 patients with symptomatic central thoracic disc herniation were operated on, utilising this posterior transdural approach. All patients underwent magnetic resonance imaging (MRI) of the thoracic spine before surgery. All patients were followed at our outpatient department for at least 3 months. In addition, all patients were interviewed in April 2009 and February 2011 to evaluate the final results. A seven-point Likert scale was applied and the Frankel score was determined preoperatively and postoperatively. Additionally, a postoperative MRI was obtained for all but two patients. RESULTS: The most frequently involved levels were T10-11 and T12-L1. Median operative time was 210 min (range 140-360). Three patients experienced reversible complications. No patient required spinal fixation. The median duration of hospitalisation was 6 days (range 4-20 days). With a median follow-up of 18 months, symptoms improved in 12 patients (92%), including the three patients with complications. One patient was unchanged (8%), while none of the patients experienced worsening of symptoms. CONCLUSIONS: The posterior transdural approach is well tolerated by the patient and has a relatively high success rate. It is a relatively simple and safe procedure, suitable for the operative treatment of almost all types of thoracic disc herniation, but especially the centrally located disc herniation

Anterior or posterior approach in the surgical treatment of cervical radiculopathy; neurosurgeons’ preference in the Netherlands.

Abstract Background For cervical foraminal nerve root decompression, anterior cervical discectomy with fusion (ACDF) or posterior cervical foraminotomy (PCF) can be applied. Amongst neurosurgeons, there seems to be a tendency to prefer ACDF over PCF, even though there are some advantages in favor of PCF. The object of present study is to evaluate which factors determine the choice for an anterior or posterior surgical approach in patients with a cervical radicular syndrome based on foraminal pathology. Methods A web-based survey was sent to all 133 neurosurgeons in the Netherlands. The first part focused on general perceived (dis)advantages of ACDF and PCF. The second part concerned questions about the choice between the two procedures. Furthermore, it was analyzed if exposure during training, amount of performed surgeries, assumed reoperation and complication rates influenced the choice of procedure by conducting Chi-square tests with post-hoc analysis. Results A total of 56 neurosurgeons responded (42%). Of these, 77% performed more than 10 ACDF and 25% more than 10 PCF annually. An overall preference for ACDF was observed, even when differentiating for a pure disc prolapse, a spondylotic or a combined stenosis. The most relative important factors for motivating the preference for either ACDF or PCF were: the assumed best decompression of the nerve root (18%), perceived congruence with current literature (16%), exposure during residency (12%), personal comfort with the procedure (11%), and experience with the technique (11%). Conclusions In this survey, there was an overall preference for ACDF above PCF for the surgical treatment of a foraminal cervical radiculopathy. In addition to subjective factors as “experience” and “ comfort” with the procedure, the respondents often motivated their choice as “the best one according to literature”. As there is currently no evidence about the superiority of any of the procedures in literature, this assumption is remarkable.</jats:p

The significance of intra-abdominal pressure in neurosurgery and neurological diseases: a narrative review and a conceptual proposal

Intra-abdominal pressure (IAP) is a physiological parameter that has gained considerable attention during the last few decades. The incidence of complications arising from increased IAP, known as intra-abdominal hypertension (IAH) or abdominal compartment syndrome in critically ill patients, is high and its impact is significant. The effects of IAP in neurological conditions and during surgical procedures are largely unexplored. IAP also appears to be relevant during neurosurgical procedures (spine and brain) in the prone position, and in selected cases, IAH may affect cerebrospinal fluid drainage after a ventriculoperitoneal shunt operation. Furthermore, raised IAP is one of the contributors to intracranial hypertension in patients with morbid obesity. In traumatic brain injury, case reports described how abdominal decompression lowers intracerebral pressure. The anatomical substrate for transmission of the IAP to the brain and venous system of the spine is the extradural neural axis compartment; the first reports of this phenomenon can be found in anatomical studies of the sixteenth century. In this review, we summarize the available knowledge on how IAP impacts the cerebrospinal venous system and the jugular venous system via two pathways, and we discuss the implications for neurosurgical procedures as well as the relevance of IAH in neurological disorders.status: publishe

Fluorescent-guided Surgery for High-grade Glioma

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The 15q24/25 Susceptibility Variant for Lung Cancer and Chronic Obstructive Pulmonary Disease Is Associated with Emphysema

RATIONALE: Genome-wide association studies have identified genetic variants in the nicotinic acetylcholine receptor (nAChR) on chromosome 15q24/25 as a risk for nicotine dependence, lung cancer and chronic obstructive pulmonary disease (COPD). Assessment of bronchial obstruction by spirometry, typically used for diagnosing COPD, fails, however, to detect emphysema. OBJECTIVES: To determine the association of the 15q24/25 locus with emphysema. METHODS: The rs1051730 variant on 15q24/25 was genotyped in two independent Caucasian cohorts of 661 and 456 heavy smokers. Participants underwent pulmonary function tests, computed tomography (CT) of the chest and took questionnaires assessing smoking behaviour and health status. MEASUREMENTS AND MAIN RESULTS: The rs1051730 A-allele correlated with reduced forced expiratory volume in 1 second (FEV1) and with increased susceptibility for bronchial obstruction with a pooled odds ratio (OR) of 1.33 (95% confidence interval [CI]=1.11-1.61; P=0.0026). In both studies a correlation between the rs1051730 A-allele and lung diffusing capacity (DLCO) and diffusing capacity per unit alveolar volume (KCO) was observed. Consistently, the rs1051730 A-allele conferred increased risk for emphysema as assessed by CT (P=0.0097 and P=0.019), with a pooled OR of 1.39 (CI=1.15-1.68; P=0.00051). Visual emphysema scores and scores based on densities quantified on CT were more pronounced in A-allele carriers, indicating that rs1051730 correlates with the severity of emphysema. CONCLUSIONS: The 15q24/25 locus in nAChR is associated with the presence and severity of emphysema. This association was independent of pack-years smoking, suggesting that nAChR is causally involved in alveolar destruction, as a potentially shared pathogenic mechanism in lung cancer and COPD.status: publishe