World Neurosurg
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Spinal stenosis is a common disease with an increasing incidence. Narrowing of the spinal canal is caused by bone and soft tissue degeneration, such as osteophyte formation, facet and ligamentum flavum hypertrophy, and disc herniation. Various surgical techniques have been used to treat spinal canal stenosis, including open, tubular, microsurgical decompression, and fusion surgery. This article presents the technique for full-endoscopic interlaminar bilateral decompression of the lumbar spine. ⋯ This technique is safe for lumbar spinal decompression and more minimally invasive than a microendoscopic approach. However, this technique should be performed by surgeons with advanced skills. Endoscopy could become the gold standard for treatment of canal stenosis in the near future.
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Stigma is defined as a social process resulting in labeling, stereotyping, and separation that cause status loss, disapproval, rejection, exclusion, and discrimination of the labeled individuals. Stigma can be experienced by individuals or groups, can be real or perceived, and can include a wide array of characteristics (e.g., race/ethnicity, gender, and health conditions). It is well documented that stigma for health conditions is a barrier to treatment and leads to worse outcomes for vulnerable people. ⋯ This review provides an overview of stigma and its application in a neurosurgical setting, including diagnoses treated by neurosurgeons as well as diagnoses with impact on neurosurgical outcomes. Examples of stigmatizing diagnoses of relevance to neurosurgical practice include epilepsy, pain, smoking, obesity, and substance use disorder. This information is useful for the practicing neurosurgeon to understand the origins and higher-order effects of societal perceptions surrounding certain diagnoses, and the subsequent effects on health that those perceptions can create on a systemic level.
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Extradural anterior clinoidectomy is an important tool for neurovascular and skull base surgery. This technique is cardinal for expanding access to the proximal carotid artery, optic nerve, sella, and the central skull base. The goal of anterior clinoidectomy is to reveal the more proximal ophthalmic and clinoidal segments of the internal carotid artery (ICA) while skeletonizing the proximal optic nerve. This maneuver expands the opticocarotid and carotid-oculomotor windows and therefore the operative corridor to the interpeduncular cisterns; both the carotid artery and optic nerve are partially untethered or liberated and can be more safely mobilized.
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The ability of ultrasonography to safely penetrate deeply into the brain has made it an attractive technology for neurological applications for almost 1 century. Having recognized that converging ultrasound waves could deliver high levels of energy to a target and spare the overlying and surrounding brain, early applications used craniotomies to allow transducers to contact the brain or dural surface. The development of transducer arrays that could permit the transit of sufficient numbers of ultrasound waves to deliver high energies to a target, even with the loss of energy from the skull, has now resulted in clinical systems that can permit noninvasive focused ultrasound procedures that leave the skull intact. ⋯ The major clinical use of this technology, at present, has been limited to treatment of refractory essential tremor and parkinsonian tremor, although the first study of this approach had targeted sensory thalamus for refractory pain, and new targets and disease indications are under study. Finally, focused ultrasonography can also be used at a lower frequency and energy level when combined with intravenous microbubbles to create cavitations, which will open the blood-brain barrier rather than ablate tissue. In the present review, we have discussed the historical and scientific foundations and current clinical applications of magnetic resonance-guided focused ultrasonography and the genesis and background that led to the use of this technique for focal blood-brain barrier disruption.
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Magnetic resonance-guided focused ultrasound (MRgFUS) is a cutting-edge technology that is changing the practice of movement disorders surgery. Given the noninvasive and innovative nature of this technology, there is great interest in expanding the use of MRgFUS to additional diseases and applications. Current approved applications target the motor thalamus to treat tremor, but clinical trials are exploring or plan to study noninvasive lesions with MRgFUS to ablate tumor cells in the brain as well as novel targets for movement disorders and brain regions associated with pain and epilepsy. ⋯ This also provides a foundation for noninvasive intravenous delivery of therapeutic molecules to precise brain targets after transient disruption of the BBB. Certain chemotherapies for brain tumors, immunotherapies, gene, and cell therapies are all examples of therapeutic or even restorative agents that normally will not enter the brain without direct infusion but which have been shown in preclinical studies to effectively traverse the BBB after transient disruption with MRgFUS. Here we will review these novel applications of MRgFUS to provide an overview of the extraordinary potential of this technology to expand future neurosurgical treatments of brain diseases.