Operative Neurosurgery最新文献

Background and objectives: The medial parietooccipital and peritrigonal areas present challenges for neurosurgical procedures. Adjacency to the eloquent cortex-postcentral gyrus and cuneus, as well as crucial white matter tracts, such as optic radiation-makes the surgical approaches difficult. This study aims to describe the surgical technique and outcomes of treating lesions using the contralateral approach.

Methods: This study is a retrospective analysis of 19 surgical cases treated in the Department of Neurosurgery and Neurooncology, Copernicus Memorial Hospital, in Łódź between April 2021 and May 2024.

Results: Nineteen cases were treated with the contralateral posterior interhemispheric transfalcine transprecuneus approach. Six cases were vascular (all arteriovenous malformation) and 13 tumors (5 glioblastomas, 4 meningiomas, 4 metastasis, and 1 pilocytic astrocytoma). Twelve of them were in precuneus, 3 in the peritrigonal part of lateral ventricle, 2 in falx, and 2 in pulvinar. The mean surgery time was 4 hours 15 minutes ± 2 hours 21 minutes. The superior sagittal sinus was injured and managed using suture and hemostatic material in 2 cases. In 2 cases, a small anastomotic vein was sacrificed, and in none of cases, a venous infarction related to anastomotic veins was observed. A new neurologic deficit was present in 8 cases post-surgery improving after a few days. The mean hospitalization time was 11 ± 8.7 days.

Conclusion: The contralateral interhemispheric transfalcine approach is a valuable surgical technique for managing medial parietooccipital and peritrigonal lesions.

Background and objectives: The middle fossa approaches are tremendously versatile for treating small vestibular schwannomas, selected petroclival meningiomas, midbasilar trunk aneurysms, and lesions of the petrous bone. Our aim was to localize the internal acoustic canal and safely drill the petrous apex with these approaches. This study demonstrates a new method to locate the internal acoustic canal during surgery in the middle fossa.

Methods: The microsurgical anatomy of the middle fossa floor was studied in 11 formalin-fixed and silicone-injected cadaveric heads. Extradural dissection of the skull base was completed from the posterior to the anterior side. A zero-degree rigid endoscope was inserted perpendicularly into the external auditory canal. The light beam was first directed through the tympanic membrane, avoiding injury to the tympanic membrane. The room lights were dimmed to provide a clearer view of the transilluminated bony area. Drilling was performed with transillumination guidance.

Results: The transilluminated area included the tympanic and mastoid tegmen up to the arcuate eminence. The nonilluminated area was bounded posteriorly by the arcuate eminence, laterally by the greater superficial petrosal nerve, and posteromedially by the petrous ridge. In all specimens, drilling the transition line between the Kawase triangle and the transilluminated area unroofed the internal auditory canal (IAC). No transillumination of the carotid canal was seen after anterior petrosectomy in any of the specimens. The entire contents of the IAC were preserved in both anterior petrosectomy and unroofing of the IAC.

Conclusion: In this anatomical study, transillumination of the external auditory canal proved to be feasible, accurate, and safe in guiding the middle fossa approaches. The ease of implementation and cost-effectiveness of the technique may suggest a possible application in operative scenarios.

An anterior clinoidectomy is an important skull-base technique to have in the armamentarium when managing pathology of the paraclinoid region. Drilling the anterior clinoid (AC) provides access to the clinoidal internal carotid artery and early decompression of the optic nerve. This technique is essential in the management of central skull base tumors and aneurysms, especially from the opticocarotid region. The intricate neurovascular anatomy associated with the AC can be difficult to master. There are 2 main techniques for drilling the AC, intradural and extradural, although hybrid techniques have been described. The goal of this article was to provide an up-to-date technical report on performing an anterior clinoidectomy supplemented by high-quality original dissections and a 4K 2-dimensional video as a resource for trainees and junior neurosurgeons.

Background and objectives: To describe a novel technique of transorbital access to the lateral wall of the cavernous sinus (CS) after exenteration.

Methods: Cadaveric dissection study. Seven heads (13 orbits) were dissected after total orbital exenteration. The technique was centered on creation of an osteotomy within the greater wing of sphenoid, bordered by the superior and inferior orbital fissures to access the middle cranial fossa. V2 within the foramen rotundum was used as a guide to enter the interdural plane of the lateral CS wall. Results were expressed as the mean value ±1 SD.

Results: The lateral CS wall was precisely visualized with identification of cranial nerves III to V2 back to the anterior portion of the Gasserian ganglion. To enable this level of exposure, the osteotomy created within the greater wing of sphenoid was a triangular window with a height of 12.7 ± 1.5 mm (range 10.0-15.0 mm), bordered superiorly by the superior orbital fissure to a linear dimension of 12.8 ± 2.5 mm (range 8.0-18.0 mm), and inferiorly by the inferior orbital fissure to an extent of 12.1 ± 3.9 mm (range 0.9-15.0 mm). The distances from the orbital apex to the intracavernous cranial nerves V1 and V2, and V3 within the foramen ovale were 22.9 ± 3.6 mm (range 17.0-31.0 mm), 25.2 ± 5.0 mm (range 17.5-36.0 mm), and 27.8 ± 5.9 mm (range 18.0-41.0 mm), respectively. The distance between the orbital apex and anterior Gasserian ganglion approximated the maximum surgical corridor achieved with this technique, which was 31.8 ± 4.8 mm (range 26.0-44.0 mm).

Conclusion: The transorbital approach to the lateral CS wall is a feasible corridor of access after exenteration. It provides an alternative interdural pathway, thereby obviating the need for additional transcranial or endonasal access routes. Such a technique is in its infancy and surgical series are required to verify it in the clinical setting.

Background and objectives: Training in pedicle screw placement is crucial for neurosurgery residents, yet access to high-fidelity training models is often limited by cost and availability. This study introduces a novel, cost-effective barium-enhanced 3-dimensional (3D)-printed L4-5 spine model visible under fluoroscopy, aiming to validate its effectiveness as a training tool for novice residents in pedicle screw placement.

Methods: A barium-enhanced 3D-printed L4-5 spine model was developed to simulate human bone density and provide radiopacity under fluoroscopy. Ten neurosurgery residents with no prior experience in pedicle screw placement participated in a structured training program using this model. Each resident completed three training sessions, placing four pedicle screws per session, totaling 120 screw placements. Surgical duration, screw placement accuracy, and fluoroscopy usage were recorded. Screw placement accuracy was assessed by two independent blinded evaluators using both a visual grading method and the computed tomography-based Gertzbein-Robbins classification.

Results: The analysis demonstrated significant improvement in surgical time across sessions ( P < .0001), decreasing from 20:44 ± 4:32 minutes to 13:17 ± 4:04 minutes. The median number of fluoroscopic images decreased from 8.5 (range: 5-18) to 6.0 (range: 5-10), although not statistically significant ( P = .312). Visual assessment scores improved, with median breach scores decreasing from 0.25 (0.00-3.00) to 0.00 (0.00-0.25). Similarly, the median Gertzbein-Robins grades improved from 0.50 (0.12-2.88) to 0.12 (0.00-0.62). Visual and computed tomography-based assessments showed excellent correlation (intraclass correlation coefficients = 0.978, 95% CI: 0.953-0.989, P < .001).

Conclusion: The barium-enhanced 3D-printed spine model ($1.61/session) provides a highly cost-effective training tool for novice residents, demonstrating significant improvements in surgical efficiency. Although accuracy measures showed promising trends, more extensive studies may be needed to establish definitive improvements in placement precision. The model's radiopacity allows for realistic fluoroscopic imaging, bridging the gap between basic models and more expensive alternatives, which is particularly valuable in resource-limited settings.