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Daily bibliographic review of the Neurosurgery Department. La Fe University Hospital. Valencia, Spain

The behavior of residual tumors and facial nerve outcomes after incomplete excision of vestibular schwannomas

 incomplete excision of vestibular schwannomas

J Neurosurg 120:1278–1287, 2014

The authors evaluated the behavior of residual tumors and facial nerve outcomes after incomplete excision of vestibular schwannomas (VSs).

Methods. The case records of all patients who underwent surgical treatment of VSs were analyzed. All patients in whom an incomplete excision had been performed were analyzed. Incomplete excision was defined as near-total resection (NTR), subtotal resection (STR), and partial resection (PR). Tumors in the NTR and STR categories were followed up with a wait-and-rescan approach, whereas the tumors in the PR category were subjected to a second- stage surgery and were excluded from this series. All patients included in the study underwent baseline MRI at the 3rd and 12th postoperative months, and repeat imaging was subsequently performed every year for 7–10 years postoperatively or as indicated clinically. Preoperative and postoperative facial function was noted.

Results. Of the 2368 patients who underwent surgery for VS, 111 patients who had incomplete excisions of VSs were included in the study. Of these patients, 73 (65.77%) had undergone NTR and 38 (34.23%) had undergone STR. Of the VSs, 62 (55.86%) were cystic and 44 (70.97%) of these cystic VSs underwent NTR. The residual tumor was left behind on the facial nerve alone in 62 patients (55.86%), on the facial nerve and vessels in 2 patients (1.80%), on the facial nerve and brainstem in 15 patients (13.51%), and on the brainstem alone in 25 patients (22.52%). In the 105 patients with normal preoperative facial nerve function, postoperative facial nerve function was House-Brackmann (HB) Grades I and II in 51 patients (48.57%), HB Grade III in 34 patients (32.38%), and HB Grades IV–VI in 20 pa- tients (19.05%). Seven patients (6.3%) showed evidence of tumor regrowth on follow-up MRI. All 7 patients (100%) who showed evidence of tumor regrowth had undergone STR. No patient in the NTR group exhibited regrowth. The Kaplan-Meier plot demonstrated a 5-year tumor regrowth-free survival of 92%, with a mean disease-free interval of 140 months (95% CI 127–151 months). The follow-up period ranged from 12 to 156 months (mean 45.4 months).

Conclusions. The authors’ report and review of the literature show that there is undoubtedly merit for NTR and STR for preservation of the facial nerve. On the basis of this they propose an algorithm for the management of incomplete VS excisions. Patients who undergo incomplete excisions must be subjected to follow-up MRI for a period of at least 7–10 years. When compared with STR, NTR via an enlarged translabyrinthine approach has shown to have a lower rate of regrowth of residual tumor, while having almost the same result in terms of facial nerve function.

 

 

Percutaneous trigeminal tractotomy–nucleotomy with use of intraoperative computed tomography and general anesthesia

Percutaneous trigeminal tractotomy–nucleotomy with use of

Neurosurg Focus 35 (3):E5, 2013

For confirming the correct location of the radiofrequency electrode before creation of a lesion, percutaneous CT-guided trigeminal tractotomy–nucleotomy is most commonly performed with the patient prone and awake. However, for patients whose facial pain and hypersensitivity are so severe that the patients are unable to rest their face on a support (as required with prone positioning), awake CT-guided tractotomy-nucleotomy might not be feasible.

The authors describe 2 such patients, for whom percutaneous intraoperative CT-guided tractotomy-nucleotomy under general anesthesia was successful. One patient was a 79-year-old man with profound left facial postherpetic neuralgia, who was unable to tolerate awake CT-guided tractotomy-nucleotomy, and the other was a 45-year-old woman with intractable hemicranial pain that developed after a right frontal lesionectomy for epilepsy. Each patient underwent a percutaneous intraoperative CT-guided tractotomy-nucleotomy under general anesthesia.

No complications occurred, and each patient reported excellent pain relief for up to 6 and 3 months after surgery, respectively. Percutaneous intraoperative CT-guided tractotomy-nucleotomy performed on anesthetized patients is effective for facial postherpetic neuralgia and postoperative hemicranial neuralgia

Flat-Panel Fluoroscopy O-arm–Guided Percutaneous Radiofrequency Cordotomy: A New Technique for the Treatment of Unilateral Cancer Pain

O-arm cordotomy

Neurosurgery 72[ONS Suppl 1]:ons27–ons34, 2013

Percutaneous radiofrequency cordotomy (PRFC) involves controlled ablation of the anterolateral quadrant of the spinal cord, thereby relieving pain. Evolving from a morbid open surgery, the procedure has been modernized through the application of physiological target confirmation, well-regulated thermal ablation, and improved intraoperative imaging.

OBJECTIVE: To evaluate the utility in PRFC of a new high-resolution, portable flatpanel fluoroscopic imaging technology, the O-arm Imaging System. The O-arm allows traditional 2-dimensional fluoroscopy in addition to axial and 3-dimensional reconstructed computed tomography imaging.

METHODS: PRFC was performed using the O-arm Imaging System in 6 patients with unilateral cancer pain.

RESULTS: Patients experienced 90% to 100% initial pain relief, with 50% to 100% sustained pain relief at the time of death at 2 to 12 months. There were no complications.

CONCLUSION: Portable flat-panel fluoroscopy allows high-resolution, readily updated computed tomography and fluoroscopic image guidance during PRFC. Use of this new technology may assist neurosurgeons in providing an important analgesic intervention at centers possessing the imaging technology.

KEY WORDS:

The Use of Intraoperative Navigation for Percutaneous Procedures at the Skull Base Including a Difficult-to-Access Foramen Ovale

Neurosurgery 70[ONS Suppl 2]:ons177–ons180, 2012 DOI: 10.1227/NEU.0b013e3182309448

We describe the use of an intraoperative CT scan obtained using the Medtronic O-arm (Littleton, Massachusetts) for image-guided cannulation of the foramen ovale not previously accessible with the use of fluoroscopy alone. Unlike previously described procedures, this technique does not require placement of an invasive head clamp and may be used with an awake patient.

OBJECTIVE: To describe the use of intraoperative neuronavigation for accessing skull base foramina and, specifically, cannulating of the foramen ovale during percutaneous rhizotomy procedures using an intraoperative image guidance CT scanner (Medtronic O-arm, Littleton, Massachusetts).

METHODS: A noninvasive Landmark Fess Strap attached to a spine reference frame was applied to the heads of 4 patients who harbored a difficult-to-access foramen ovale. An intraoperative HD3D skull base scan using a Medtronic O-arm was obtained, and Synergy Spine software was used to create 3D reconstructions of the skull base. Using image guidance, we navigated the needle to percutaneously access the foramen ovale by the use of a single tract for successful completion of balloon compression of the trigeminal nerve.

RESULTS: All 4 patients (3 females and 1 male; ages 65-75) underwent the procedure with no complications.

CONCLUSION: Based on our experience, neuronavigation with the use of intraoperative O-arm CT imaging is useful during these cases.

Neurosurgery Department. “La Fe” University Hospital. Valencia, Spain

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