Minimally Invasive Neurosurgery最新文献

Background: Persistent trigeminal artery (PTA) is one of the carotid-basilar anastomoses and occasionally complicates vascular or neoplastic pathology. The aim of this study was to become more familiar with the anatomy associated with PTA using an endoscopic view.

Material and methods: PTA was incidentally encountered in a fresh cadaver. Purely endoscopic approaches via supraorbital (extradural and intradural routes), endonasal, and retrosigmoid routes were performed with 4-mm, 0- and 30-degree rigid endoscopes.

Results: The PTA belonged to Salas's lateral type and Saltzman's type 1. The supraorbital extradural approach allowed good visualization of the origin and the cavernous portion of the PTA through the infratrochlear triangle. Using the endonasal route, the cisternal portion of the PTA and its confluence to the basilar artery were demonstrated after opening the clival dura; however, the origin of the PTA and the cavernous portion of the PTA were not sufficiently exposed even using a direct approach to the cavernous sinus. The retrosigmoid approach revealed the anatomical relationship among the PTA, trigeminal nerve, and abducent nerve in the petroclival region.

Conclusion: These 3 endoscopic approaches provided a superb image of the PTA and contribute to the anatomical comprehension of PTA. Additionally, these approaches make us more familiar with an endoscopic view of PTA.

Microsuturing in a narrow and/or a deep operating space is technically challenging and classical microinstruments such as a bayonet microneedle-holder have their limitation, mainly related to their in-built rigidity. In this technical note, a new flexible and 360° rotating shaft microneedle-holder made from nitinol is presented.

Background: Transforaminal percutaneous endoscopic lumbar discectomy (PELD) has become a routine surgical procedure because it is minimally invasive. Perioperative complications such as dural injury, infection, nerve root irritation and recurrence can occur not only with PELD, but also with conventional open microsurgery. In contrast, post-operative dysesthesia (POD) due to existing dorsal root ganglion (DRG) injury is a unique complication of PELD. When POD occurs, even if the traversing root has been successfully decompressed, it hinders swift recovery and delays the return to daily routines. Thus, prevention of POD is the key to successful and widespread use of PELD.

Material and methods: From January 2006 to December 2008, 154 patients underwent percutaneous endoscopic discectomy by floating retraction technique at 160 disc levels under local anesthesia. This approach towards the superomedial border of the lower pedicle and the cannula can be placed by gentle retraction of the root with perineural fat instead of direct compression of dorsal root ganglion. The clinical outcomes were assessed using the Visual Analogue Scale (VAS, 0-10 point) for radicular pain and low back pain, and using the Oswestry Disability Index (ODI) for functional status. Perioperative complications and recurrence were reviewed.

Results: The mean age was 45 years, the mean operative time was 36 min and the mean follow-up period was 3.4 years. The mean hospital stay for endoscopic discectomy was 1.8 days. No patient underwent repeated PELD or convert microsurgery by incomplete removal of the ruptured particle. All patients experienced early relief of symptoms, as determined by VAS and ODI. No patient developed POD. 1 patient experienced dural injury. There was 1 case of discitis. The recurrence rate was 1.95% (3 patients).

Conclusion: Transforaminal percutaneous endoscopic lumbar discectomy for intracanalicular lumbar disc herniation is a safe and effective procedure. The floating retraction technique is recommended to avoid development of POD.

Background: We report on a dual percutaneous fixation in 2 patients with a double thoracic spine fracture. The advantages and limitations of this new approach for treating traumatic spinal fractures are reviewed.

Clinical presentation: A 67-year-old male was admitted following a fall from a height of 3 m. A neurological examination revealed sub-T11 motor and sensory paraparesis. There were a T6 vertical body and bi-articular fracture and a T11 vertebral burst fracture with > 75% posterior wall damage. A 40-year-old male was admitted after a suicide attempt. A neurological examination revealed sub-T11 paraplegia. There were a T7 vertebral body fracture with intact posterior wall and a T11 burst fracture with > 75% posterior wall damage.

Surgical technique: The same technique was used in both cases. 2 minimally invasive percutaneous fixations of the 2 fractures were performed. In a third step, we performed a T10-T12 open laminectomy. This technique helped to limit blood loss and avoid an over-long fixation. Pedicle screw targeting was optimal. 16 months later, the neurological status was normal in patient 1 and there was neurological improvement in patient 2. No secondary segmental kyphotic deformities appeared.Percutaneous fixation enables the treatment of an acute thoracic spine fracture. With appropriate presurgical planning, this technique can be applied to all thoracic vertebrae. Spinal cord injuries justify the use of laminectomy together with percutaneous fixation, in order to limit erector muscle injury and blood loss.

Background: Bony defects extending laterally or superiorly within the posterior wall of the frontal sinus are generally deemed too difficult for endoscopic repair in spite of significant progress in surgical endoscopic techniques.

Patients and methods: We describe a technique of endoscopic repair of posttraumatic cerebrospinal fluid (CSF) leak from the postero-superior aspect of the frontal sinus in a 40- and a 29-year-old male. In both cases after careful assessment of the surgical anatomy the sinus was widely opened transnasally (Draf IIB and Draf III approach, respectively). Angled (45 and 70°) optics and malleable, individually profiled instruments were used to fit specific anatomic variations encountered during the procedure.

Results: Endoscopic manipulation near the dome of the sinus proved to be very limited in spite of a wide surgical opening. In our cases the site of the leak could be identified and successfully sealed with gentle pressure on the dura mater. The bony defects were repaired with a 2-layer reconstruction technique. There were no signs of recurrence during 6 months follow-up.

Conclusion: With contemporary endoscopic instrumentation, endoscopic closure of CSF leaks in the supero-posterior wall of the frontal sinus is feasible, especially in patients with favourable anatomy of the frontal sinus.

We present a short anatomic report on the feasibility of an endoscopic resection of an Os odontoideum, with preservation of the anterior arch of the atlas.

Background: After completing a craniotomy, it is important to replace the removed bone flap in its natural position in order to guarantee brain protection as well as improve cosmesis. A skull defect can expose the brain to accidental damage, and in cases of larger defects it may also cause the patients psychosocial problems. The ideal fixation device should provide reliable attachment of the flap to the skull and promote fast bony healing to avoid possible pseudo-arthrosis and/or osteolytic changes.

Materials and methods: This is a pilot randomized clinical trial on a series of 16 patients undergoing different craniotomies for benign brain lesions in which the bone flaps were replaced using traditional sutures (Prolene 0.0) in 8 cases and with a new skull fixation device (Skull Grip) in the other 8 (randomly allocated). All patients underwent CT scans of the head with 3D reconstruction at day 1 and day 90 postoperatively to evaluate bone flap position and fusion. These scans were independently reviewed by a neuroradiologist. Cosmesis was also evaluated clinically by the surgeon and radiologically by the neuroradiologist in the 2 patient groups.

Results: The new "Skull Grip" device has shown stronger fixation qualities with optimal bone flap fusion and increased cosmetic healing features vs. traditional sutures.

Conclusion: The "Skull Grip" has shown to be a reliable, effective and stronger bone flap fixation device when compared to traditional sutures.

Background: The surgical treatment of lumbar stenosis traditionally includes laminectomy for direct decompression of the spinal canal. Selected patients with spinal stenosis may also require lumbar fusion. Minimally invasive lateral transpsoas interbody fusion has the ability of placing a large interbody cage that can increase disc height and distract the spinal level. The purpose of this study was to examine the concept of indirect decompression of the spinal canal in patients with co-existing lumbar spinal stenosis undergoing lateral transpsoas interbody fusion.

Materials and methods: We reviewed 25 consecutive spinal stenosis patients with instability undergoing lateral transpsoas interbody fusion without laminectomy. All patients had relevant symptoms of back pain, leg pain, and/or spinal claudication and met standard criteria for lumbar fusion. Patients were evaluated by outcome analysis scales (VAS scores, Oswestry disability index and treatment intensity scale). Postoperative MRI scans, when available, were evaluated for change in canal dimensions. Statistical significance was assessed by paired t-test, which compares the mean change. There were 25 patients in the study (mean age 61 years). 15 patients had grade I spondylolisthesis. VAS for back pain intensity improved from 7.74 to 2.07 and for frequency from 7.91 to 2.22. VAS for leg pain intensity improved from 7.24 to 1.87 and frequency from 7.41 to 2.35. All improvements were statistically significant (P<0.0001). The Oswestry disability index improved from 55.1 to 16.4 (P<0.0001), and treatment intensity scale improved from 14.6 to 3.7 (P<0.0001). Radiographic evaluation in 20 treated levels (15 patients) found an increase in dural sac dimension of 54% in the anterior-posterior plane and 48% in the medial-lateral plane (P<0.0001). The calculated area of the dural sac increased an average of 143% (range of - 10.4% to + 495%).

Conclusion: Indirect decompression of spinal stenosis can be achieved with lateral transpsoas interbody fusion with improved clinical outcomes. Pre-op and post-op MRI scans showed a significant increase in dural sac dimensions. The mechanism for this indirect decompression may relate to stretching and unbuckling of the spinal ligaments and a decrease in intervertebral disc bulging. Further studies are needed to determine which stenosis patients undergoing this surgery are most appropriate for indirect decompression alone over laminectomy.

In endoscopic neurosurgery problems with haemostasis due to poor access exist. We have developed a system which allows the delivery of a variety of haemostatic agents in a more efficacious manner. The system has been used successfully in endoscopic skull base surgery and endoscopic surgery within the parenchyma of the brain using tube systems.

Background: The trans-lamina terminalis approach has been described to remove third ventricular tumors. Various surgical corridors for this approach include anterior (via bifrontal craniotomy), anterolateral (via supra-orbital craniotomy), lateral (via pterional craniotomy) and trans-sphenoidal corridors. Supra-orbital craniotomy offers a minimally invasive access for resection of third ventricular tumors.

Material and methods: The trans-lamina terminalis technique through a supra-orbital craniotomy is described. Also, a literature review of clinical outcome data was performed for the comparison of different surgical corridors (anterior, antero-lateral, lateral, and trans-sphenoidal).

Results: The operative steps and anatomic landmarks for supra-orbital craniotomy are discussed, along with 3 representative cases and respective outcomes. Gross total resection was achieved in 2 patients, and one patient required reoperation for recurrence. Based on the current literature, the clinical outcomes after supra-orbital craniotomy for trans-lamina terminalis approach are comparable to other surgical corridors.

Conclusions: The supra-orbital craniotomy for trans-lamina terminalis approach is a valid surgical choice for third ventricular tumors. The major strengths of this approach include minimal brain retraction and direct end-on view; however, the long working distance is a major limitation. The clinical outcomes are comparable to other surgical corridors. Sound understanding of major strengths, limitations, and strategies for complication avoidance is necessary for its safe and effective application.