Category: Endoscopy

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Endoscopic lumbar discectomy: choosing the corridor around the pathology

Neurosurgical Focus. 2026;61(4):E10

The choice between interlaminar and transforaminal endoscopic discectomy depends on the relationship between the surgical corridor and the compressive pathology. This study describes how one experienced surgeon selected these complementary approaches, highlighting the importance of disc level, fragment location, cranial migration, and associated dorsal stenosis. Its principal contribution is an anatomical framework for planning rather than evidence that either technique produces superior outcomes.

Study and key findings

This retrospective series included 426 adults undergoing 438 single-level procedures between 2019 and 2025: 233 interlaminar and 205 transforaminal discectomies. Of the interlaminar procedures, 86.3% were performed at L5–S1; 95.6% of transforaminal procedures were performed at L4–5 or above.

In a matched analysis restricted to L4–5 and higher levels, involving 32 interlaminar and 64 transforaminal procedures, herniation within the canal, cranial migration, and dorsal stenosis were independently associated with selection of the interlaminar approach. The corresponding odds ratios were 19.69, 17.82, and 5.15. These estimates describe approach selection, not the probability of surgical success.

Disability and pain improved in both groups. Mean Oswestry Disability Index scores decreased from 45.2 to 20.8 after interlaminar surgery and from 46.6 to 23.4 after transforaminal surgery. Mean follow-up was 329 days; 41 procedures (9.4%) were followed by additional surgery at the index level.

Interpretation and limitations

At L5–S1, the interlaminar window and potential iliac crest obstruction help explain the predominant posterior route. Nevertheless, foraminal or extraforaminal pathology can favor transforaminal access even at this level. Cranially migrated intracanal fragments and dorsal compression may instead favor interlaminar access, which also permits posterior decompression.

The retrospective, single-surgeon design reflects individual expertise and selection preferences. The small matched sample and wide confidence intervals limit precision. Improvements in both groups cannot establish equivalence, superiority, or a validated selection algorithm.

Clinical takeaway

Plan the approach around the fragment and all relevant sources of compression. Assess migration, foraminal involvement, dorsal stenosis, iliac crest anatomy, and previous surgical scarring alongside the surgeon’s expertise. Disc level is a useful starting point, but should not determine the corridor alone.

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Resection versus fenestration for Rathke’s cleft cysts

J Neurosurg 145:92–102, 2026

In patients undergoing transsphenoidal surgery for a symptomatic Rathke’s cleft cyst, does cyst-wall resection reduce recurrence sufficiently to justify its potentially greater endocrine morbidity, or is simple fenestration the preferable strategy?

Objective

To compare the long-term clinical and radiological outcomes of cyst-wall resection and fenestration in patients undergoing transsphenoidal surgery for Rathke’s cleft cysts.

Methods

This retrospective, single-center study included 278 patients treated between 2000 and 2023:

  • 122 underwent cyst-wall resection.
  • 156 underwent fenestration and drainage.
  • Mean follow-up was 68 months.
  • A propensity-matched cohort of 242 patients was used for the principal comparison.

The authors analyzed headache, visual and endocrine outcomes, postoperative complications and cyst recurrence.

Main results

Fenestration and resection achieved similar improvement in visual and endocrine symptoms. However, headache resolution was significantly better after fenestration:

  • Gross-total resection: 43%
  • Subtotal resection: 34%
  • Fenestration: 59%

New growth-hormone deficiency was less frequent after fenestration:

  • Gross-total resection: 10%
  • Subtotal resection: 16%
  • Fenestration: 3.2%

The overall recurrence rate was 24%:

  • Gross-total resection: 18%
  • Subtotal resection: 39%
  • Fenestration: 25%

Recurrence-free survival was comparable between fenestration and gross-total resection. Subtotal resection showed the least favorable results.

A residual cyst on postoperative MRI was the strongest independent predictor of recurrence (HR 4.01; 95% CI 2.41–6.65).

Interpretation

The findings question the need for routine aggressive cyst-wall removal. Fenestration provided equivalent visual and endocrine improvement, better headache relief and fewer new hormonal deficits without increasing recurrence compared with gross-total resection.

Attempting cyst-wall resection without achieving complete removal may offer little benefit: subtotal resection combines greater pituitary manipulation with a relatively high recurrence rate.

Limitations

The study was retrospective and conducted at a single institution. Treatment selection was not randomized, surgical practice evolved during the 23-year study period, and follow-up was longer in the fenestration group.

Clinical takeaway

Wide fenestration appears to offer the best balance between decompression, symptom relief, endocrine preservation and recurrence control. Aggressive cyst-wall removal should not be pursued when the wall is firmly adherent to the pituitary gland or stalk.

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Fully Endoscopic Microvascular Decompression for Hemifacial Spasm Using 2-Dimensional/3-Dimensional Endoscopy

Operative Neurosurgery 30:870–879, 2026

This clinical case series reports outcomes of 204 patients who underwent fully endoscopic microvascular decompression (MVD) for hemifacial spasm (HFS), comparing 2D and preliminary 3D endoscopic techniques and analyzing learning-curve effects. Detailed methods, operative technique, intraoperative monitoring (LSR), and complication rates are presented alongside imaging and intraoperative findings.

Results show a 97.1% overall effectiveness with low long-term complication rates and improving outcomes over time; the 3D endoscope afforded improved stereoscopic perception though with higher cost and minor drawbacks, and the authors recommend further study of 3D endoscopy in MVD.

Study scope Retrospective analysis of 204 hemifacial spasm patients treated with fully endoscopic microvascular decompression using 2D (191) or 3D (13) endoscopy (July 2017–Oct 2024); mean follow-up 20.4 months.

Surgical approach Procedures used a retrosigmoid infrafloccular route with LSR monitoring; polytetrafluoroethylene (Teflon) pledgets placed between facial nerve REZ and offending vessels, with further exploration if LSR persisted.

Effectiveness At last follow-up, 198/204 (97.1%) had cessation or significant reduction of spasms (excellent 86.8%, good 10.3%).

Complications Immediate postoperative complications included facial weakness (7), hearing loss (11), tinnitus (1), infection (1), dysphagia (1), and CSF leak (1); 10 patients had persistent complications at last follow-up (6 hearing loss, 3 facial weakness, 1 tinnitus).

Learning curve Outcomes improved over time: effectiveness 95.6% → 97.1% → 98.5% (early/middle/late), while complication rates decreased 5.9% → 5.9% → 2.9%.

Offending vessels Most common offending vessel was AICA (43.1%), with multiple vessels in 33.3% of cases (including combinations with VA and PICA).

3D endoscopy pros/cons 3D endoscope provided subjectively better stereoscopic vision/depth perception aiding surgery, but had drawbacks including slight vertigo and high cost.

Overall conclusion Fully endoscopic MVD offers wide visualization of the neurovascular conflict region and helps minimize brain injury from retraction; favorable outcomes and low complications once technical proficiency is achieved, with more research needed on 3D’s role.

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Pineal cyst surgery beyond morphology: a critical evaluation of a consecutive surgical series

Acta Neurochirurgica (2026) 168:85

This study evaluates surgical management of symptomatic pineal cysts in a consecutive single-center cohort, comparing microsurgical, endoscopic, and stereotactic techniques. Radiological measures — notably aqueduct diameter and predominant cyst expansion — were analyzed alongside clinical outcomes using the Chicago Chiari Outcome Scale, showing durable benefit when surgery is guided by clinicoradiological criteria.

Findings indicate aqueduct narrowing and anterior expansion better predict positive postoperative outcomes than cyst size alone. Each surgical approach demonstrated specific indications: microsurgery for suspicious lesions, endoscopy for hydrocephalus/anterior compression, and stereotactic drainage for deep or high-risk cases, with overall high rates of sustained improvement.

Clinical problem: Surgical management of pineal cysts is especially controversial in non-hydrocephalic symptomatic patients because clinical–radiological correlations are inconsistent and many studies rely mainly on size/morphology for decisions.

Study design: Retrospective single-center cohort of 46 symptomatic pineal cyst patients (2008–2024), comparing surgical (n=18) vs non-surgical (n=28) groups and analyzing radiological markers (e.g., cyst dimensions, aqueduct diameter, predominant expansion) alongside outcomes measured by CCOS over time.

Key differentiators for surgery: Compared with non-surgical patients, surgical patients had larger cysts, narrower aqueducts (0.9 vs 1.6 mm, p<0.001), and much more frequent predominant anterior expansion (67% vs 7%, p<0.001).

Overall outcomes: After surgery, 94% achieved good/excellent CCOS (≥12) at 12 months, and 93% maintained good/excellent outcomes at long-term follow-up (mean 62 months).

Predictors: Aqueduct diameter was more closely associated with outcome than pineal cyst size; neither cyst volume nor hydrocephalus consistently predicted postoperative outcome.

Technique comparison: Microsurgical resection (n=12) had favorable long-term outcomes (mean CCOS 14.9) but the highest complication rate (3 patients) and the highest recurrence of headache despite total excision.

Endoscopic approach: Endoscopic fenestration + ventriculostomy (n=3) produced the best long-term outcomes (mean CCOS 15.7) with no recurrences reported.

Stereotactic option: Stereotactic drainage + Rickham reservoir (n=3) achieved stable decompression but lower long-term CCOS (mean 13.0) than other approaches.

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Operative Microscope In-Field Visualization of Confocal Laser Endomicroscopy Interface (Zeiss CONVIVO )

Operative Neurosurgery 29:860–864, 2025

This study evaluates integrating the Zeiss CONVIVO confocal laser endomicroscopy interface into the operative microscope heads-up display to allow simultaneous visualization of the surgical field and real-time confocal laser endomicroscopy (CLE) images. A randomized cohort of 22 intra-axial tumor surgeries showed shorter CLE usage times, fewer total captures, and a trend toward higher usable-image proportion with heads-up integration.

The integration improved intraoperative ergonomics by reducing probe motion artifacts and image noninterpretability, streamlining workflow, and decreasing operative time while preserving diagnostic utility of CLE for margin assessment in gliomas and other brain lesions.

Confocal Laser Endomicroscopy (CLE): Provides real-time, in vivo microscopic imaging of brain tumors during neurosurgery, enabling identification of tumor margins without the need for traditional tissue extraction or frozen section analysis.

Zeiss CONVIVO® System: A CLE device recently introduced in neurosurgery, proven reliable for both ex vivo and in vivo applications, and undergoing further clinical refinement.

Technical Challenge: Standard CLE use requires the surgeon to shift attention from the operative field to a separate screen to assess image quality, potentially causing motion artifacts, prolonging surgery, and increasing the number of unusable images.

Heads-Up Display Integration: Visualization of the CONVIVO® interface was integrated as a picture-in-picture display inside the operative microscope, allowing simultaneous monitoring of the surgical field and CLE images without diverting gaze.

Study Findings: Use of the heads-up display significantly reduced CLE employment time (mean 61.1 vs. 201.6 seconds; P = .01), decreased the total number of images acquired, and increased the proportion of usable images, though the latter was not statistically significant (P = .06).

Workflow Efficiency: Direct intraoperative feedback enabled by the heads-up display led to fewer motion artifacts, more efficient image acquisition, and reduced overall operative time.

Clinical Implications: The integration supports more efficient and accurate intraoperative tumor assessment, potentially improving the extent of resection, especially in gliomas, and reducing reliance on frozen sections.

Limitations and Future Directions: Further refinement is needed for effortless image acquisition; artificial intelligence for artifact reduction and real-time interpretation by neurosurgeons are potential future improvements.

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Institutional experience using the endoscopic endonasal approach for the treatment of 40 intracranial aneurysms: indications, outcomes, and technical considerations

J Neurosurg 143:1575–1587, 2025

This clinical series reviews 40 intracranial aneurysms treated via the endoscopic endonasal approach (EEA) over 20 years, outlining patient selection, operative techniques, reconstruction evolution, and outcomes. It emphasizes indications where EEA provides superior ventral access for paraclinoid and selected posterior circulation aneurysms, especially when endovascular therapy is unsuitable.

The report details complication rates—notably CSF leaks—and their temporal improvement, intraoperative adjuncts, follow-up imaging, illustrative cases, and statistical correlations identifying posterior location, age, and SAH as risk factors.

Endoscopic Endonasal Approach (EEA) Indications: EEA is reserved for carefully selected intracranial aneurysms—primarily medially projecting paraclinoidal/cavernous internal carotid artery (ICA) and posterior circulation aneurysms—especially when endovascular treatment is unsuitable and open surgery would risk cranial nerve or brain injury.

Advantages of EEA: Provides a direct ventral surgical corridor, enabling superior proximal/distal vascular control, avoiding brain retraction and cranial nerve manipulation, and facilitating treatment of concomitant sellar pathologies or multiple lesions in a single procedure.

Patient Selection and Outcomes: Out of 34 patients (40 aneurysms) over 20 years, most aneurysms treated were in the paraclinoid/cavernous ICA or posterior circulation; EEA was only used if it was considered safer than open or endovascular approaches, with less than 1% of aneurysm patients treated annually by EEA.

Complication Profile: The main complication was cerebrospinal fluid (CSF) leak (8 cases), particularly in posterior circulation or post-subarachnoid hemorrhage (SAH) cases; other complications included meningitis, clip exposure, lacunar infarcts, and transient cranial nerve palsies. No permanent cranial nerve deficits, visual loss, or procedure-related mortalities occurred since 2019.

Technical Evolution: Advancements in reconstruction techniques and instrumentation (e.g., dedicated endonasal clip appliers, multilayer closure) have reduced complications such as clip exposure and improved overall safety and outcomes over time.

Limitations of EEA: Not suitable for most anterior communicating artery (AcomA) aneurysms due to limited exposure and control; not feasible for revascularization procedures; requires a highly experienced, multidisciplinary team for optimal results.

Comparative Morbidity: EEA appears to reduce the risk of cranial nerve deficits and parenchymal injury compared to lateral (open) approaches, especially for midline lesions, but CSF leak remains the main limitation.

Clinical Recommendation: EEA should be considered only for selected cases where endovascular and open approaches are suboptimal, and only by experienced teams aware of the risks and reconstruction challenges, with all treatment options discussed in a multidisciplinary setting.

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Does Transforaminal Endoscopic Lumbar Discectomy Provide More Value than Microdiscectomy?

Operative Neurosurgery 29:209–218, 2025

Microdiscectomy (MD) provided greater value than transforaminal endoscopic discectomy (TED) for lumbar disc herniations at this institution, with higher improvement in patient-reported outcomes per dollar spent and shorter operative times. TED had higher costs and a steeper learning curve, but similar reoperation rates.

• This study compares the value of transforaminal endoscopic lumbar discectomy (TED) and microdiscectomy (MD) for lumbar disc herniation using a novel Operative Value Index (OVI).

• OVI measures percent change in Oswestry Disability Index (ODI) per $1000 spent intraoperatively, integrating patient outcomes and time-driven activity-based costing.

• MD had a significantly higher OVI, lower operative times, and lower intraoperative costs than TED; no significant difference in length of stay or reoperation rates was found.

• Only 43.5% of TED cases achieved clinically important improvement (MCID), compared to 66.3% for MD.

• TED was mainly used for foraminal herniations and had a higher proportion of older patients and comorbidities.

• Longer OR setup times and higher costs for TED may relate to the learning curve and surgeon experience.

• Authors suggest OVI is a practical, real-time value metric but note limitations including small TED sample size and retrospective design.

• Future studies should assess long-term outcomes, total episode costs, and track OVI as surgeons gain TED experience.

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Management of intracavitary bleeding during ultra-early minimally invasive intracerebral hemorrhage evacuation

J Neurosurg 142:1003–1013, 2025

Ultra-early minimally invasive endoscopic evacuation of intracerebral hemorrhage within 5 hours increases intraoperative bleeding but does not elevate risks of postoperative rebleeding or worsen long-term outcomes, suggesting safe exploration of its clinical benefits with proper techniques.

• Objective: The study examines the management of intracavitary bleeding during ultra-early minimally invasive intracerebral hemorrhage evacuation.

• Methodology: Patients with spontaneous supratentorial ICH were triaged for surgical evacuation using a 5-point intraoperative bleeding scale.

• Findings: Ultra-early evacuation within 5 hours is associated with increased intraoperative bleeding but not with postoperative rebleeding or worse long-term outcomes.

• Bleeding Scale: A score of 1 indicates no active bleeding, while a score of 5 indicates severe bleeding requiring extensive irrigation and cauterization.

• Results: Ultra-early evacuation had a mean bleeding score of 4.9, compared to 2.3 for evacuations conducted 5 to 10 hours after ictus.

• Conclusion: The benefits of ultra-early evacuation can be explored without increased risk of postoperative rebleeding using minimally invasive endoscopic techniques.

• Significance: The study supports the safety and feasibility of early evacuation strategies in improving functional outcomes for ICH patients.

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The oculomotor cistern and pituitary adenomas: anatomical and clinical study

J Neurosurg 142:766–776, 2025

• Study Focus: The research investigates the oculomotor cistern (OMC) and its involvement with pituitary adenomas (PitNETs), aiming to provide a histomorphological description and analyze its clinical impact.

• Methods: Ten hemisellae from formalin-fixed specimens were studied, and clinical data from patients undergoing endoscopic transsphenoidal surgery for PitNETs between 2014 and 2021 were analyzed.

• Results: OMC involvement was graded as not compressed, compressed, and invaded. Significant associations were found between OMC involvement and PitNET dimensions, Knosp grade, and preoperative oculomotor palsy.

• OMC Shape and Measurements: The OMC is elliptical with an average area of 3.1 mm² and a length of 5.5 mm. No points of weakness were identified in the histomorphological study.

• Clinical Findings: OMC compression and invasion were recorded in 43.1% and 9.3% of patients, respectively. Preoperative CN III palsy was documented in compressed (11.3%) and invasive (26.1%) OMCs.

• Surgical Implications: Endoscopic transsphenoidal surgery is effective in treating PitNETs with OMC involvement, though the choice between transcranial and endoscopic approaches remains debated.

• Histological Observations: The study confirmed the OMC’s extension ends before the anterior clinoid process (ACP), with potential points of weakness at the CS roof and MWCS.

• Conclusion: OMC involvement is significant in PitNETs, affecting patient outcomes. Detailed preoperative evaluation and postoperative follow-up are crucial for managing these cases.

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Lateral compartment of the cavernous sinus from the endoscopic endonasal approach: anatomical considerations and surgical relevance to adenoma surgery

• Objective: The study investigates the lateral compartment of the cavernous sinus (CS) and its surgical relevance in adenoma surgery using the endoscopic endonasal approach.

• Methods: Dissection was performed on 22 colored silicone-injected specimens to identify anatomical landmarks and techniques for mobilizing the internal carotid artery (ICA).

• Findings: The lateral compartment is divided into two subcompartments, with the upper housing the lateral parasellar ligament (LPL) and inferolateral trunk (ILT), and the lower containing sympathetic nerve branches.

• LPL and ILT: The LPL was identified in 86% of hemispheres, with varying configurations, and the ILT was found in 93%, primarily originating from the horizontal ICA segment.

• Techniques: Transection of the LPL, ILT, and COM facilitates medial ICA mobilization, enhancing access to the lateral compartment.

• Conclusions: The study underscores the anatomical intricacies of the lateral compartment and the potential benefits of the lateral transcavernous approach.

• Limitations: The study’s findings are based on cadaveric dissections, which may not fully replicate live surgical conditions.

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How Do the True Intraoperative Costs of Endoscopic Diskectomy Compare With Microdiskectomy for Lumbar Disk Herniations?

Operative Neurosurgery 27:690–697, 2024

Endoscopic lumbar diskectomy (ED) is a minimally invasive option for addressing lumbar disk herniations. With the introduction of value-based care systems, assessing the true cost of certain procedures is critical when creating reimbursement models and comparing procedures. Here, we compared the costs of performing a microdiskectomy (MD) and ED using time-driven activity-based costing.

METHODS: Total cost for the intraoperative episode was calculated using time-driven activity-based costing methodology. Individual costs were obtained by direct observation and electronic medical records and through querying multiple departments (business operations, sterile processing, plant operations, and pharmacy). Timestamps for all involved personnel and material resources were documented. A retrospective analysis was performed on 202 patients who underwent lumbar diskectomy through either MD (n = 167) or ED (n = 35) from 2018 to 2022. Personnel cost was calculated by multiplying the cost per unit time for each personnel type by the length of time spent in the operating room. Supply cost was calculated by aggregating the cost of all individual supplies, from medications to consumables to surgical trays, used during the case. Univariate and multivariable regression analyses were performed comparing the costs between these procedures.

RESULTS: The average intraoperative cost per case for ED and MD was $3915 ± $1025 and $3162 ± $954, respectively. Multivariable regression analysis revealed that ED had higher total cost ( β -coefficient: $912 ± $281, P = <.01) and supply cost ( β -coefficient: $474 ± $155, P = <.01) than MD. When accounting for surgeon as a covariate, however, total cost (P = .478) and supply cost (P = .468) differences between ED and MD were negligible.

CONCLUSION: ED has shown to be a better value option in addressing lumbar disk herniations, mostly because of advantages in perioperative care. Here, we show that when correcting for surgeon-level effects, the cost between the two procedures is statistically insignificant, reaffirming the value provided by ED.

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Analysis of the Efficacy of Neuroendoscopic Hematoma Removal Combined With Ventricular Lavage in Severe Intraventricular Hemorrhage—A Prospective Randomized Controlled Study

Neurosurgery 95:1297–1306, 2024

The current widely utilized clinical approach for severe intraventricular hemorrhage involves ventriculostomy with supportive drainage. The aim of our study was to evaluate the overall efficacy of neuroendoscopic hematoma removal combined with ventricular lavage as a treatment approach for severe intraventricular hemorrhage.

METHODS: A prospective randomized controlled study was conducted, selecting a total of 98 patients with severe intraventricular hemorrhage at our hospital from February 2021 to November 2022. The patients were randomly distributed into 2 groups using a randomized number table method: the neuroendoscopic group (undergoing neuroendoscopic hematoma removal combined with ventricular lavage) and the control group (undergoing intraventricular trepanation and drainage), with 49 patients in each group.

RESULTS: The neuroendoscopic group had significantly higher intraoperative blood loss than that of the control group (P = .037), while the drainage tube indwelling time and hospital stay in the neuroendoscopic group were significantly shorter (P < .001). At 6 hours (P = .021), 1 day (P = .002), 3 days (P < .001) and 7 days (P = .007) following surgery, the neuroendoscopic group exhibited evidently higher hematoma clearance rates compared with the control group. At 1 day and 3 days after surgery, the cerebrospinal fluid drainage volume in the neuroendoscopic group was significantly higher than that in the control group (P < .001), whereas at 7 days after surgery, it was significantly lower in the neuroendoscopic group compared with the control group (P < .001). Moreover, significantly lower incidence of intracranial infection (P = .045) and increased intracranial pressure (P = .008) was observed in the neuroendoscopic group compared with the control group.

CONCLUSION: Neuroendoscopic hematoma removal combined with ventricle lavage emerged as an effective treatment strategy for severe intraventricular hemorrhage, yielding significant therapeutic benefits. Therefore, this approach holds promise for broader clinical application and promotion.

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Endoscopic Retrolabyrinthine Craniotomy for Exposure of the Trigeminal Nerve Root Entry Zone

Operative Neurosurgery 27:464–470, 2024

Exposure of the root entry zone (REZ) of the trigeminal nerve (TN) for microvascular decompression is commonly obtained with a retrosigmoid approach, with or without endoscopic assistance. We hypothesized that adequate exposure of the TN REZ could be obtained through an endoscopic retrolabyrinthine (RL) approach. We aim to quantify exposure of the REZ of the TN using endoscopic RL approach, with and without drilling of the suprameatal tubercle of the internal auditory canal.

METHODS: Surgical dissection was performed bilaterally on 3 embalmed cadaveric human heads at the anatomy laboratory of the House Institute. Heads were scanned for volumetric analysis using 3D Slicer software both before and after dissection. Extent of exposure was quantified in 2 ways: first, by assessment of the surgeon’s ability to visualize 16 predetermined anatomic landmarks with the endoscope and second, we estimated the “working” area by placing fiducials under the fully endoscopic view and calculating the resultant 3D volume.

RESULTS: Using the standard endoscopic RL approach, anaverageof 13.8 landmarks (range 12-16) was visualized. The estimated working volume exposed by the RL on each side of each head varied from 189.28 to 527.85 mm3 . Drilling of the suprameatal tubercle provided both increases in landmark visualization and, on average, an additional 55 mm 3 of working volume.

CONCLUSION: The endoscopic RL approach is a viable alternative to the standard retrosigmoid approach. Potential advantages of the RL include a more lateral trajectory that minimizes the need for cerebellar retraction and a shorter working distance and shallower angle to the cerebellopontine angle. Potential disadvantages include longer surgery time, increased technical difficulty of exposure, and potential for cerebrospinal fluid leak and or hearing loss.

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Standard operating procedure and surgical technique innovation in fully endoscopic microvascular decompression for trigeminal neuralgia

Acta Neurochirurgica (2024) 166:351

Microvascular decompression (MVD) is a well-established and effective treatment for primary trigeminal neuralgia (TN). Endoscopy has been implemented to provide a comprehensive view of neurovascular conflict and minimizes the damages of brain retraction during MVD.

Objectives To preliminarily evaluate the surgical safety and efficacy of fully endoscopic microvascular decompression (EMVD) for primary TN with surgeon performing two-hand manipulation and assistant holding endoscope.

Methods Retrospective clinical analysis of 189 patients with primary TN underwent EMVD between June 2019 and August 2022 was performed. By analyzing the intraoperative situation, the outcomes of postoperative symptoms and the main complications, we evaluated the reliability and effectivity of the operative technique in the treatment of primary TN.

Results We summarized the standard operating procedure of EMVD for primary TN with surgeon performing two-hand manipulation and assistant holding endoscope. In addition, acicular bipolar electrocoagulation technique was developed to handle venous compression. During the follow-up period, good pain relief was achieved in 178 patients (94.2%) and recurrence of pain was observed in 4 patients (2.1%). Postoperative temporary complications included trigeminal dysesthesias (7 patients, 4.8%), cerebrospinal fluid leak (2 patients, 1.1%), hearing difficulty (3 patient, 1.6%), facial paresis (2 patients, 1.1%) and vertigo (5 patients, 2.7%). There were no cases of intracranial hemorrhage, cerebellar swelling and death.

Conclusion This EMVD technique is reliable and effective, and can be used as a routine surgical procedure for primary TN.

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Comparison of biportal endoscopic and microscopic tubular paraspinal approach for foraminal and extraforaminal lumbar disc herniation

J Neurosurg Spine 41:473–482, 2024

Foraminal and extraforaminal lumbar disc herniation (FELDH) is an important pathological condition that can lead to lumbar radiculopathy. The paraspinal muscle–splitting approach introduced by Reulen and Wiltse is a reasonable surgical technique. Minimally invasive procedures using a tubular retractor system have also been introduced. However, surgical treatment is considered more challenging for FELDH than for central or subarticular lumbar disc herniations (LDHs). Some researchers have proposed uniportal extraforaminal endoscopic lumbar discectomy through a posterolateral approach as an alternative for FELDH, but heterogeneous clinical results have been reported. Recently, the biportal endoscopic (BE) paraspinal approach has been suggested as an alternative. The aim of this study was to compare the clinical outcomes of BE and microscopic tubular (MT) paraspinal approaches for decompressive foraminotomy and lumbar discectomy (paraLD) in patients with FELDH.

METHODS Ninety-one consecutive patients with unilateral lumbar radiculopathy and FELDH underwent paraLD. Demographic and perioperative data were collected. Clinical outcomes were evaluated using the visual analog scale (VAS) for back and leg pain, the Oswestry Disability Index (ODI) for spinal disability, and the modified Macnab criteria for patient satisfaction. Postoperative complications and reoperation rates were also evaluated.

RESULTS In total, 76 patients were included in the final analysis. Among them, 43 underwent BE paraLD (group A) and the remaining 33 underwent MT paraLD (group B). The demographic and preoperative data were not statistically different between the groups. All patients showed significant improvements in VAS back, VAS leg, and ODI scores compared with baseline values (p < 0.05). The improvement in VAS back scores was significantly better in group A than in group B on postoperative day 2 (p < 0.001). However, all clinical parameters were comparable between the two groups after postoperative year 1 (p > 0.05). According to the modified Macnab criteria, 86.1% and 72.7% of the patients had excellent or good outcomes in groups A and B, respectively. No intergroup differences were observed (p = 0.367). In addition, there were no differences in the total operation time or amount of surgical drainage. Postoperative complications were not significantly different between the two groups (p = 0.301); however, reoperation rates were significantly higher in group B (p = 0.035).

CONCLUSIONS BE paraLD is an effective treatment for FELDH and is an alternative to MT paraLD. In particular, BE paraLD has advantages of early improvement in postoperative back pain and low reoperation rates.

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Full-endoscopic lumbar discectomy for lumbar disc herniation in young adults: 199 consecutive cases treated by a single surgeon with a mean 3.7-year follow-up

J Neurosurg Spine 41:369–377, 2024

Lumbar disc herniation (LDH) is rare in young adults. The present study aimed to evaluate the clinical outcomes of full-endoscopic lumbar discectomy (FELD) for LDH in young adults and to determine the risk factors that predict unfavorable outcomes of FELD for LDH in young adults.

METHODS A retrospective two-center cohort study was performed between January 2015 and October 2021 at the authors’ institutions. Clinical outcomes were assessed using the visual analog scale (VAS) for low-back pain and leg pain and the Oswestry Disability Index (ODI). The modified Macnab criteria were used to evaluate clinical efficacy at the last follow-up, and the global outcomes were classified into 4 groups, namely excellent, good, fair, and poor. The fair and poor groups were defined as unfavorable outcomes.

RESULTS One hundred ninety-nine patients were analyzed in this study (mean age 18.5 years, mean BMI 25.1 kg/m 2 , male/female sex ratio 2.8). The duration from the onset of symptoms to the operation was in general prolonged with age. The VAS and ODI scores significantly improved after surgery. A total of 17 of 195 single-segment cases had unfavorable outcomes based on the modified Macnab criteria. Lateral disc herniation (OR 3.72, 95% CI 1.14–12.12, p = 0.029) and high preoperative VAS score (OR 1.98, 95% CI 1.13–3.46, p = 0.017) were identified as risk factors for unfavorable outcomes after FELD.

CONCLUSIONS FELD for LDH in young adults is safe and effective. Preoperative VAS score and lateral disc herniation are risk factors of nonfavorable outcomes after surgery and may be a useful index for surgical procedure selection.

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Efficacy of Biportal Endoscopic Decompression for Lumbar Spinal Stenosis: A Meta-Analysis With Single-Arm Analysis and Comparative Analysis With Microscopic Decompression and Uniportal Endoscopic Decompression

Operative Neurosurgery 27:158–173, 2024

Biportal endoscopic decompression is a minimally invasive surgical technique for lumbar spinal stenosis (LSS). This meta-analysis aimed to evaluate the efficacy and safety of biportal endoscopic decompression through both a single-arm analysis and a comparative analysis.

METHODS: A comprehensive literature search was conducted to identify eligible studies reporting the outcomes of biportal endoscopic decompression for LSS. Single-arm analysis and comparisons with microscopic and uniportal endoscopic decompression were performed. Evaluated outcomes included visual analog scale (VAS) scores for back pain and leg pain, Oswestry Disability Index (ODI) scores, operation time, estimated blood loss, duration of hospital stay, and adverse events.

RESULTS: Single-arm analysis demonstrated significant improvements in VAS back pain, VAS leg pain, and ODI scores after biportal endoscopic decompression at postoperative 1-day to 36-month follow-up (all P < .001), compared with preoperative levels. The pooled mean single-level operation time was 71.44 min, and the pooled mean hospital stay was 3.63 days. The overall adverse event rate was 4.0%, with dural tear being the most common complication (3.0%). Compared with microscopic decompression, biportal endoscopic decompression showed significantly lower VAS back pain at 1-month (P < .001) and 6-month (P < .001) follow-up; lower VAS leg pain at 1-month (P = .045) follow-up; lower ODI scores at 3-month (P < .001), 12-month (P = .017), and >12-month (P = .007) follow-up; lower estimated blood loss (P = .003); and shorter hospital stay (P < .001). Adverse event rates did not differ between the techniques. No significant differences were observed between biportal endoscopic and uniportal endoscopic decompression groups for most efficacy and safety outcomes.

CONCLUSION: Biportal endoscopic decompression emerges as a safe and effective alternative for LSS, presenting potential advantages over the microscopic technique and comparable efficacy with the uniportal endoscopic technique.

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Standard operating procedure and surgical technique innovation in fully endoscopic microvascular decompression for trigeminal neuralgia: technical note on 189 patients

Acta Neurochirurgica (2024) 166:351

Microvascular decompression (MVD) is a well-established and effective treatment for primary trigeminal neuralgia (TN). Endoscopy has been implemented to provide a comprehensive view of neurovascular conflict and minimizes the damages of brain retraction during MVD.

Objectives To preliminarily evaluate the surgical safety and efficacy of fully endoscopic microvascular decompression (EMVD) for primary TN with surgeon performing two-hand manipulation and assistant holding endoscope.

Methods Retrospective clinical analysis of 189 patients with primary TN underwent EMVD between June 2019 and August 2022 was performed. By analyzing the intraoperative situation, the outcomes of postoperative symptoms and the main complications, we evaluated the reliability and effectivity of the operative technique in the treatment of primary TN.

Results We summarized the standard operating procedure of EMVD for primary TN with surgeon performing two-hand manipulation and assistant holding endoscope. In addition, acicular bipolar electrocoagulation technique was developed to handle venous compression. During the follow-up period, good pain relief was achieved in 178 patients (94.2%) and recurrence of pain was observed in 4 patients (2.1%). Postoperative temporary complications included trigeminal dysesthesias (7 patients, 4.8%), cerebrospinal fluid leak (2 patients, 1.1%), hearing difficulty (3 patient, 1.6%), facial paresis (2 patients, 1.1%) and vertigo (5 patients, 2.7%). There were no cases of intracranial hemorrhage, cerebellar swelling and death.

Conclusion This EMVD technique is reliable and effective, and can be used as a routine surgical procedure for primary TN.

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Anterior clinoid meningiomas: surgical results and proposed scoring system to predict visual outcomes

J Neurosurg 140:1295–1304, 2024

The authors report a single-surgeon experience with anterior clinoid meningiomas (ACMs) and propose a novel scoring system to predict visual outcomes based on preoperative risk factors.

METHODS A cohort study of all ACMs that were surgically treated by a single surgeon between 2003 and 2021 was performed. Visual function was assessed by an ophthalmologist pre- and postoperatively. Based on the combination of visual fields and visual acuity, 4 visual grades were described. Favorable visual outcomes were defined as mild visual deficit or intact vision postoperatively. Unfavorable visual outcomes were defined as a severe or moderate visual deficit. Predictors of unfavorable visual outcomes were identified using multivariable logistic regression analysis. A scoring system was then created using the resulting β coefficient. A receiver operating characteristic curve analysis was performed to identify a cutoff point on the grading score for stratifying patients at risk for unfavorable visual outcomes.

RESULTS Fifty-two patients met all inclusion criteria. Twenty-five (48%) patients presented with intact vision, and 27 (51%) presented with some visual dysfunction. Postoperative favorable visual outcomes were achieved in 39 patients (75%). Among the 27 patients presenting with visual dysfunction, 14 (52%) experienced improvement after surgery. No new visual deficits were observed among the 25 patients with intact vision at baseline. Nine patients (17%) had a reversible complication. Multivariable analysis showed that severe preoperative visual deficit (OR 13.03, 95% CI 2.64–64.39; p = 0.002), radiographic evidence of optic nerve (ON) encasement (OR 4.20, 95% CI 1.06–16.61; p = 0.04), intraoperative evidence of ON invasion (OR 17.31, 95% CI 2.91–102.86; p = 0.002), an average ganglion cell layer thickness of ≤ 70 µm (OR 21.54, 95% CI 2.94–159.04; p = 0.003), and an average retinal nerve fiber layer thickness of ≤ 80 µm (OR 13.68, 95% CI 1.91–98.00; p = 0.009) were associated with unfavorable visual outcome. The predictive score included the following factors: abnormal optical coherence tomography (OCT) findings, radiographic evidence of ON encasement by the tumor, and severe preoperative visual deficit. A score ≥ 4 of 6 points was demonstrated to be the cutoff associated with unfavorable visual outcome, with a sensitivity of 80%, specificity of 88%, positive predictive value of 80%, negative predictive value of 88%, and area under the curve of 0.847 (95% CI 0.674–1.0; p = 0.003).

CONCLUSIONS The authors have designed a practical and novel scoring system to predict visual outcomes in patients with ACMs. This scoring system may guide preoperative discussions with patients and timely surgical intervention to yield optimal visual function outcomes. Although most patients have excellent neurosurgical outcomes, severe baseline visual deficits, ON encasement, and characteristic OCT abnormalities are associated with unfavorable visual function after ACM resection.

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Pain alleviation and functional improvement: ultra-early patient-reported outcome measures after full endoscopic spine surgery

J Neurosurg Spine 40:465–474, 2024

Questions regarding anticipated pain improvement and functional recovery postsurgery are frequently posed in preoperative consultations. However, a lack of data characterizing outcomes for the first postoperative days only allows for anecdotal answers. Hence, the assessment of ultra-early patient-reported outcome measures (PROMs) is essential for patient-provider communication and patient satisfaction. The aim of this study was to elucidate this research gap by assessing and characterizing PROMs for the first days after full endoscopic spine surgery (FESS).

METHODS This multicenter study included patients undergoing lumbar FESS from March 2021 to July 2023. After informed consent was provided, data were collected prospectively through a smartphone application. Patients underwent either discectomy or decompression. Analyzed parameters included demographics, surgical details, visual analog scale scores for both back and leg pain, and the Oswestry Disability Index (ODI) score. Data were acquired daily for the 1st postoperative week, as well as after 2 weeks, 3 months, and 6 months.

RESULTS A total of 182 patients were included, of whom 102 underwent FESS discectomy and 80 underwent FESS decompression. Significant differences between the discectomy and decompression groups were found for age (mean 50.45 ± 15.28 years and 63.85 ± 13.25 years, p < 0.001; respectively), sex (p = 0.007), and surgery duration (73.45 ± 45.23 minutes vs 98.05 ± 46.47 minutes, p < 0.001; respectively). Patients in both groups reported a significant amelioration of leg pain on the 1st postoperative day (discectomy group VAS score: 6.2 ± 2.6 vs 2.4 ± 2.9, p < 0.001; decompression group: 5.3 ± 2.8 vs 1.9 ± 2.2, p < 0.001) and of back pain within the 1st postoperative week (discectomy group VAS score: 5.5 ± 2.8 vs 2.8 ± 2.2, p < 0.001; decompression group: 5.2 ± 2.7 vs 3.1 ± 2.4, p < 0.001). ODI score improvement was most pronounced at the 3-month time point (discectomy group: 21.7 ± 9.1 vs 9.3 ± 9.1, p < 0.001; decompression group: 19.3 ± 7.8 vs 9.9 ± 8.3, p < 0.001). For both groups, pain improvement within the 1st week after surgery was highly predictive of later benefits.

CONCLUSIONS Ultra-early PROMs reveal an immediate pain improvement after FESS. While the benefits in pain reduction plateaued within the 1st postoperative week for both groups, functional improvements developed over a more extended period. These results illustrate a biphasic rehabilitation process wherein initial pain alleviation transitions into functional improvement over time.

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