Minimally Invasive Neurosurgery最新文献

Introduction: Surgical site infection (SSI) in the setting of lumbar fusion is associated with significant morbidity and medical resource utilization. To date, there have been no studies conducted with sufficient power to directly compare the incidence of SSI following minimally invasive (MIS) vs. open TLIF procedures. Furthermore, studies are lacking that quantify the direct medical cost of SSI following fusion procedures. We set out to determine the incidence of SSI in patients undergoing MIS vs. open TLIF reported in the literature and to determine the direct hospital cost associated with the treatment of SSI following TLIF at our institution.

Methods: A systematic Medline search was performed to identify all published studies assessing SSI after MIS or open TLIF. The cumulative incidence of SSI was calculated from all reported cohorts and compared between MIS vs. open TLIF. In order to determine the direct hospital costs associated with the treatment of SSI following TLIF, we retrospectively reviewed 120 consecutive TLIFs performed at our institution, assessed the incidence of SSI, and calculated the SSI-related hospital costs from accounting and billing records.

Results: To date, there have been 10 MIS-TLIF cohorts (362 patients) and 20 open-TLIF cohorts (1 133 patients) reporting incidences of SSI. The cumulative incidence of reported SSI was significantly lower for MIS vs. open-TLIF (0.6% vs. 4.0%, p=0.0005). In our experience with 120 open TLIF procedures, SSI occurred in 6 (5.0%) patients. The mean hospital cost associated with the treatment of SSI following TLIF was $ 29,110 in these 6 cases. The 3.4% decrease in reported incidence of SSI for MIS vs. open-TLIF corresponds to a direct cost savings of $ 98,974 per 100 MIS-TLIF procedures performed.

Conclusions: Post-operative wound infections following TLIF are costly complications. MIS vs. open TLIF is associated with a decreased reported incidence of SSI in the literature and may be a valuable tool in reducing hospital costs associated with spine care.

Background: The primary purpose of our stereotactic anatomic study was to determine the safest electrode trajectory for deep brain stimulation (DBS) of the human nucleus accumbens (NA). Considering NA DBS together with the complications related to surgical implantation and based on methods for assessing the electrode trajectory we tried to reveal the secret of a trajectory for targeting the NA with the highest possible level of safety.

Material and methods: Our material consisted of 30 cerebral hemispheres we have in our Department from cadaver donors for students' education. We identified the electrode's target point in coronal sections. As safe we considered a trajectory from the cerebral cortex to the NA, which traverses the anterior limb of the internal capsule (AIC) without passing through either the caudate nucleus or putamen. We measured the minimum, maximum and safest coronal angles of the electrode trajectory (between the trajectory and the midline), as well as the AIC angle and width of the trajectory angle. We also measured trajectory projection length from the cerebral surface to the superior (d1) and inferior (d2) margins of the NA.

Results: The safest trajectory angle for NA DBS was found to have a mean value of 29.10 degrees, ranging from 23.80 to 35.40 degrees. The mean AIC angle was 33.78 degrees. We found no statistically significant difference between right and left hemispheres and a strong statistical relation between the safest electrode trajectory and AIC angle. Mean values of d1 and d2 were found to be 53.57 mm and 60.86 mm respectively. The mean value of the length of the electrode trajectory in coronal projection within the NA (d2-d1) was found to be 7.29 mm.

Conclusion: The new knowledge that our stereotactic anatomic study offers is a definition of the safest electrode trajectory for NA DBS, its coronal angle width, as well as an estimation of its length.

Objective: The aim of this study was to present our experience with retrograde suction decompression in clipping of large and giant cerebral aneurysms and analyze its advantages and pitfalls.

Methods: A retrospective analysis of 27 patients with large and giant intracranial aneurysms treated by suction decompression assisted clipping between November 2005 and February 2010 was done. The surgical technique and the outcome of patients were reviewed.

Results: All aneurysms were successfully clipped, and postoperative 3-D CTA or DSA revealed no major branch occlusion or residual aneurysm. There was no surgical mortality in both giant and large aneurysm groups.

Conclusion: Retrograde suction decompression is a successful adjunct to clipping of large and giant cerebral aneurysms.

Background: The aim of this study was to assess the influence of minimal invasive techniques (MIT) on secondary brain collapse (BC) following a frontal inter-hemispheric approach to midline tumors with accentuated preoperative brain shift phenomena.

Methods: We reviewed the results obtained in our department during the last 10 years in 24 treated patients with such tumors. Some of these patients underwent traditional surgical approaches using brain retractors (BR) and more recently alternative MIT including the creation of a narrow surgical corridor without brain retractors and the reinforcement and reinsertion from bridging veins. The patient's postoperative condition (consciousness recovery, respirator dependence, ICU-patient's stay and outcome) as well as the volume of the postoperative skull/brain space as a measurable indicator of BC and the ventricular index were assessed in all cases. All data were compared using the Chi square test, the 2-tailed Pearson correlation and t-test.

Results: 24 patients (11 operated with BR and 13 with MIT) were analyzed. The comparison between both techniques revealed a significant reduction of the postoperatively assessed skull/brain space (P<0.001), time for consciousness recovery (P<0.05), respirator dependence (P<0.001) and intensive care unit stay (P<0.005) for patients treated with MIT. A significant correlation was observed between radiological and clinical data (respirator dependence, consciousness recovery and ICU stay) from P<0.01, P<0.05 and P<0.01 respectively.

Conclusions: In our study MIT allow the patients to recover consciousness in a shorter period of time, reducing the needs for prolonged mechanical ventilation and ICU stay. In these patients, such clinical advantages are related with a radiologically assessed postoperative reduced brain collapse.

Object: The Disc Dekompressor and Nucleoplasty are 2 different, minimally invasive, percutaneous methods in the therapy for chronic discogenic low back pain. The aim of this study is to compare the effectiveness of both methods concerning the outcome one year after surgery.

Methods: We included patients with MRI-proven disc protrusion suffering from low back pain and/or radiating pain in the lower extremities. The pain perception of the patients was documented using the visual analogue pain scale (VAS). Furthermore, the patients were queried about analgesic consumption, disability in daily life and ability to work. Percutaneous minimally invasive nucleotomy using the Nucleoplasty or the Disc Dekompressor was carried out under fluoroscopic and CT-guidance. We carried out a follow-up examination at 6 and 12 months after the operation.

Results: From April 2005 to November 2007 a total of 126 patients underwent percutaneous minimally invasive nucleotomy using Nucleoplasty (April 2005 - December 2006) or the Disk Dekompressor (February 2006 - November 2007) and were followed up after 6 and 12 months. In the Nucleoplasty group the mean age of the 27 females (39%) and 42 males (61%) was 42 years (range: 18-74). In the Disc Dekompressor group the mean age of the 22 females (39%) and 35 males (61%) was 44 years (range: 16-76). The mean duration of symptoms in the Nucleoplasty group was 30.5 months (range: 1-120), and in the Disc Dekompressor group 16.3 months (range: 1-72). Statistically significant postoperative improvement concerning the VAS score was evident in both groups. Whereas the VAS score slightly increased in the Nucleoplasty group comparing the early postoperative score and the score after 12 months, the VAS score stayed on a low level in the Disc Dekompressor group. A statistically significant reduction in analgesic consumption, disability and occupational incapacitation was observed in the Nuceloplasty group and the Disc Dekompressor group.

Conclusions: Both Nucleoplasty and Disc Dekompressor are effective therapies for chronic, discogenic back pain. Regardless of the different mechanism no significant differences in the outcomes were found. Both techniques result in significant reductions in levels of disability and incapacity for work as well as decreased analgesic consumption.

Background: The aim of this study was to assess the feasibility of an endoscopic approach to the parapharyngeal space through a transnasal route. For this purpose, an anatomic study was conducted.

Material and methods: The target area was studied separately on each side in 4 adult cadaver heads. To simulate actual endoscopic surgery, the dissection was performed thoroughly under the rigid endoscope. The surgical steps and extent of surrounding tissue resection necessary for the approach were evaluated.

Results: Both the pre- and poststyloid compartments could be exposed with restricted sacrifice of the surrounding tissue around the pterygoid process. Adding a wide sphenoidotomy and subpetrous bone resection, the surgical exposure could be extended at the medial temporal skull base including the medial infratemporal fossa.

Conclusion: Although its usefulness has to be further verified in the clinical setting, the present results of the anatomic dissection indicate the potential of the approach to become a novel technique for treatment of a lesion in the parapharyngeal space.

Background: We present our experience using a standardized transnasal transclival approach (TTA) for endoscopic removal of chordomas of the clivus.

Patients: 13 patients with clival chordoma (CC) underwent tumor resection. Patients were operated by a surgical team consisting of a rhinosurgeon and a neurosurgeon. All patients underwent postoperative proton radiotherapy. Residual tumor was left in situations where radical removal would have entailed an increased risk of neurological deficits.

Results: Radical or near total removal of CC was accomplished in 12/13 patients. Intraoperative MRI (IMRI) was used in 4/13 CC patients. A watertight dural seal presented as the main challenge specifically for tumor extensions resulting in large dural defects.

Conclusion: The TTA provides an elegant alternative to classical approaches to clival lesions especially for midline tumor locations. For large tumors iMRI is of significant help. Dural reconstruction of large defects emerged as the greatest challenge of this technique even for experienced endoscopic surgeons.

Introduction: Until recently, the treatment of intracranial atherosclerosis has remained limited. Due to advances in endovascular technology and technique, angioplasty and stenting has become an accepted treatment for medically-refractory intracranial atherosclerosis. Patients with intracranial atherosclerosis frequently have multiple lesions, however, the clinical significance of each individual lesion is not always evident. In these instances the treating physician must decide which lesions should be managed conservatively, and which should be treated.

Technique: Emphasizing decision-making, we describe a patient in whom 3 separate atherosclerotic lesions in the same vascular territory underwent endovascular treatment in one treatment session. Each of the lesions was treated with angioplasty and stent placement.

Conclusion: This may be a relatively safe and efficacious technique that allows for the treatment of multiple lesions without the risks associated with multiple cerebral angiograms.