Category: Surgical technique

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Double-barrel STA to proximal MCA bypass and proximal parent artery occlusion for a fusiform superior clinoidal ICA aneurysm

Acta Neurochirurgica (2018) 160:1939–1943

Blood flow replacement and parent artery occlusion are alternative treatments of complex fusiform superior clinoidal ICA aneurysms. While double-barrel STA to proximal MCA bypass is a conventional approach among these reported bypass algorithms, its technical details remain underexplored.

Method We have applied the double-barrel STA to proximal MCA bypass and parent artery occlusion to treat a 45-year-old female patient with a right fusiform superior clinoidal ICA aneurysm. The technical nuances of this approach are reported.

Conclusion We show that double-barrel STA to proximal MCA bypass and proximal parent artery occlusion can be alternative treatments of complex fusiform superior clinoidal ICA aneurysms.

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Robot-assisted multi-level anterior lumbar interbody fusion: an anatomical study

Acta Neurochirurgica (2018) 160:1891–189

Minimally invasive surgical approaches still provide limited exposure. Access to the L2–L5 intervertebral discs during a single procedure is challenging and often requires repositioning of the patient and adopting an alternative approach.

Objectives Investigate the windows to the L2–L5 intervertebral discs to assess the dimensions of the interbody implants suitable for the procedure and evaluate the feasibility of multi-level lumbar intervertebral disc surgery in robot-assisted surgery (RAS)

Methods Sixteen fresh-frozen cadaveric specimens underwent a retroperitoneal approach to access the L2–L5 intervertebral discs. The L2–L3 to L4–L5 windows were defined as the distance between the left lateral border of the aorta (or nearest common iliac vessel) and the medial border of the psoas, measured in a static state and after gentle medial retraction of the vascular structures. Two living porcine specimens and one cadaveric specimen underwent da Vinci robot-assisted transperitoneal approach to expose the L2–L3 to L4–L5 intervertebral discs and perform multi-level discectomy and interbody implant placement.

Results The L2–L3 to L4–L5 intervertebral disc windows significantly increased from a static to a retracted state (p < 0.05). The mean L2–L3, L3–L4, and L4–L5 windows measured respectively 20.1, 21.6, and 19.6 mm in the static state, and 27.2, 30.9, and 30.3 mm after gentle vascular retraction. The intervertebral windows from L2–L3 to L4–L5 were successfully exposed through an anterior transperitoneal approach with the da Vinci robot on the cadaveric and living porcine specimens, and interbody implants were inserted.

Conclusion RAS appears to be feasible for a mini-invasive multi-level lumbar intervertebral disc surgery. The RAS procedure, longer and more expensive than conventional MIS approaches, should be reserved for elective patients.

 

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Randomized controlled study comparing 2 surgical techniques for decompressive craniectomy: with watertight duraplasty and without watertight duraplasty

J Neurosurg 129:1017–1023, 2018

Decompressive craniectomy (DC) is a widely used procedure in neurosurgery; however, few studies focus on the best surgical technique for the procedure. The authors’ objective was to conduct a prospective randomized controlled trial comparing 2 techniques for performing DC: with watertight duraplasty and without watertight duraplasty (rapid-closure DC).

METHODS The study population comprised patients ranging in age from 18 to 60 years who were admitted to the Neurotrauma Service of the Hospital da Restauração with a clinical indication for unilateral decompressive craniectomy. Patients were randomized by numbered envelopes into 2 groups: with watertight duraplasty (control group) and without watertight duraplasty (test group). After unilateral DC was completed, watertight duraplasty was performed in the control group, while in the test group, no watertight duraplasty was performed and the exposed parenchyma was covered with Surgicel and the remaining dura mater. Patients were then monitored daily from the date of surgery until hospital discharge or death. The primary end point was the incidence of surgical complications (CSF leak, wound infection, brain abscess, or subgaleal fluid collections). The following were analyzed as secondary end points: clinical outcome (analyzed using the Glasgow Outcome Scale [GOS]), surgical time, and hospital costs.

RESULTS Fifty-eight patients were enrolled, 29 in each group. Three patients were excluded, leaving 27 in the test group and 28 in the control group. There were no significant differences between groups regarding age, Glasgow Coma Scale score at the time of surgery, GOS score, and number of postoperative follow-up days. There were 9 surgical complications (5 in the control group and 4 in the test group), with no significant differences between the groups. The mean surgical time in the control group was 132 minutes, while in the test group the average surgical time was 101 minutes, a difference of 31 minutes (p = 0.001). The mean reduction in total cost was $420.00 USD (a 23.4% reduction) per procedure in the test group.

CONCLUSIONS Rapid-closure DC without watertight duraplasty is a safe procedure. It is not associated with a higher incidence of surgical complications (CSF leak, wound infection, brain abscess, or subgaleal fluid collections), and it decreased surgical time by 31 minutes on average. There was also a hospital cost reduction of $420.00 USD (23.4% reduction) per procedure. Clinical trial registration no.: NCT02594137 (clinicaltrials.gov)

 

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The eyebrow approach for anterior circle of Willis aneurysms

Acta Neurochirurgica (2018) 160:1749–1753

The eyebrow approach is a keyhole technique that gives a wide access to the anterior circle of Willis.

Methods A 4-cm linear incision is placed in the upper limit of the eyebrow and a small supraorbital bone flap is raised. A wide arachnoid dissection is essential to maximize the working space. One or multiple aneurysms may be treated by the same approach.

Conclusions The eyebrow approach is a safe technique for selected aneurysms of the anterior circle of Willis

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Minimally Invasive Brain Port Approach for Accessing Deep-Seated Lesions Using Simple Syringe

World Neurosurg. (2018) 117:54-61

Retraction-related injury is a recognized complication in neurosurgery. Use of tubular retractors that distribute the pressure on brain tissue was introduced to minimize brain injury. We developed a modified technique using a simple plastic syringe with a Foley catheter to achieve atraumatic cannulation in accessing deep lesions.
METHODS: A retrospective pilot study was conducted to assess safety of the syringe transtubular technique for accessing deep lesions as a cost-effective substitute for commercial brain port methods and to identify retractionrelated injury using diffusion-weighted magnetic resonance imaging postoperatively. Nine patients were operated on using the syringe technique. Lesions selected were intraparenchymal, deeply located in the supratentorial compartment. Lesions were located in the insula (n [ 2), thalamus or basal ganglia (n [ 5), subcortical frontoparietal (n [ 1) lobe, and right temporal lobe (n [ 1). Patients with hematomas, intraventricular lesions, superficially located lesions; pediatric patients less than 12 years old; and patients undergoing redo surgeries were excluded.
RESULTS: Surgical goals were achieved in 8 patients. Three patients had transient deficits; one patient had significant morbidity, which was diagnosed postoperatively as toxoplasmosis. Diffusion restriction was noted in all patients at the surgical cavity but not in the cannulation path.
CONCLUSIONS: Transtubular approaches have a good safety profile and can help achieve surgical goals. Larger studies are needed to compare this approach with other methods, including its effect on hospital stay and survival. The syringe technique is an alternative safe method that can be used in certain neurosurgical centers where commercial tube systems are unavailable.

 

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Contralateral anterior interhemispheric transcallosal- transrostral approach to the subcallosal region

J Neurosurg 129:508–514, 2018

The authors report a novel surgical route from a superior anatomical aspect—the contralateral anterior interhemispheric-transcallosal-transrostral approach—to a lesion located in the subcallosal region. The neurosurgical approach to the subcallosal region is challenging due to its deep location and close relationship with important vascular structures. Anterior and inferior routes to the subcallosal region have been described but risk damaging the branches of the anterior cerebral artery.

METHODS Three formalin-fixed and silicone-injected adult cadaveric heads were studied to demonstrate the relationships between the transventricular surgical approach and the subcallosal region. The surgical, clinical, and radiological history of a 39-year-old man with a subcallosal cavernous malformation was retrospectively used to document the neurological examination and radiographic parameters of such a case.

RESULTS The contralateral anterior interhemispheric-transcallosal-transrostral approach provides access to the subcallosal area that also includes the inferior portion of the pericallosal cistern, lamina terminalis cistern, the paraterminal and paraolfactory gyri, and the anterior surface of the optic chiasm. The approach avoids the neurocritical perforating branches of the anterior communicating artery.

CONCLUSIONS The contralateral anterior interhemispheric-transcallosal-transrostral approach may be an alternative route to subcallosal area lesions, with less risk to the branches of the anterior cerebral artery, particularly the anterior communicating artery perforators.

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Suprafloccular approach via the petrosal fissure and venous corridors for microvascular decompression of the trigeminal nerve

J Neurosurg 129:324–333, 2018

Surgical exposure and decompression of the entire trigeminal nerve in a conventional lateral supracerebellar approach can be challenging because of blockages from the superior petrosal vein complex, cerebellum, and vestibulocochlear nerve. The authors demonstrate a novel suprafloccular approach via the petrosal fissure and venous corridors that can be used as a substitute for the conventional route used to treat trigeminal neuralgia and present a consecutive series of patients and their clinical outcomes.

METHODS Preoperative and postoperative clinical data from 420 patients who underwent this modified approach at Hangzhou First People’s Hospital between March 2012 and May 2014 were reviewed. The technique expands the working space by opening the petrosal fissure and dissecting adhesions between the vein of the cerebellopontine fissure and the simple lobule as needed. Via 3 surgical corridors, the entire trigeminal nerve is exposed and decompressed thoroughly with minimal retraction of the surrounding vital structures.

RESULTS The medial one-third of the trigeminal nerve accounted for the majority (275 [65.5%] cases) of neurovascular conflict sites. The lateral corridor was used in 219 (52.1%) cases, the medial corridor was used in 175 (41.7%) cases, and the intermediate corridor was used in 26 (6.2%) cases. The entire trigeminal nerve in each patient was accessed directly and decompressed properly. At the end of the 24-month follow-up period, the rate of excellent results (Kondo score of T0 or T1) was stable at approximately 90.5%. No complications were related directly to petrosal vein or vestibulocochlear nerve injury.

CONCLUSIONS Based on data from the large patient series, the authors found this suprafloccular approach via the petrosal fissure and venous corridors provides full exposure and decompression of the entire trigeminal nerve, a high cure rate, and a low neurovascular morbidity rate.

trigeminal neuralgia,suprafloccular,petrosal fissure, cerebellopontine fissure,venous corridor, clinical outcome, functional neurosurgery, pain

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Total en-bloc spondylectomy through a posterior approach: technique and surgical outcome in thoracic metastases

Acta Neurochirurgica (2018) 160:1373–1376

In 1981, Roy-Camille et al. have firstly reported the total en-bloc spondylectomy (TES) through a posterior approach for cases of malignant spine tumors in order to reduce the local recurrence and to increase the patient’s survival. By then, this surgery has been increasingly gaining recognition. However, it requires a high level of technical ability and knowledge of spinal anatomy, physiology, and biomechanics.

Method Herein, we report the patient’s selection and technique to execute the TES for cases of thoracic metastasis.

Conclusion This surgery is technically demanding so the patient’s selection requires a careful pre-operative evaluation. However, it can be suggested for patients affected by intracompartmental lesions with a good prognosis since the tumor’s progression is “limited” by local barriers as demonstrated by histological studies.

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Electromagnetic neuronavigation for the percutaneous treatment of trigeminal neuralgia with balloon compression

Acta Neurochirurgica (2018) 160:1337–1341

Several techniques have been described for the percutaneous treatment of trigeminal neuralgia; however, each has significant drawbacks. We propose a new technique for percutaneous balloon compression of the trigeminal ganglion and distal trigeminal nerve using electromagnetic (EM) neuronavigation.

Methods The procedure was performed in 17 consecutive patients with trigeminal neuralgia. Patients were then followed up with telephone interview. We also performed a cadaveric validation study to further investigate the accuracy of the technique using dye.

Results Excellent clinical outcomes were achieved with a reduction in the median pain score from 10 out of 10 to 0 out of 10 following the procedure. The cadaveric study also demonstrated a high rate of foramen ovale cannulation.

Conclusion EM-based targeting of the foramen ovale and balloon inflation within Meckel’s cave is a quick, reproducible and straightforward technique for the percutaneous treatment of trigeminal neuralgia.

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Contralateral posterior interhemispheric approach to deep medial parietooccipital vascular malformations

J Neurosurg 129:198–204, 2018

Deep medial parietooccipital arteriovenous malformations (AVMs) and cerebral cavernous malformations (CCMs) are traditionally resected through an ipsilateral posterior interhemispheric approach (IPIA), which creates a deep, perpendicular perspective with limited access to the lateral margins of the lesion. The contralateral posterior interhemispheric approach (CPIA) flips the positioning, with the midline positioned horizontally for retraction due to gravity, but with the AVM on the upper side and the approach from the contralateral, lower side. The aim of this paper was to analyze whether the perpendicular angle of attack that is used in IPIA would convert to a parallel angle of attack with the CPIA, with less retraction, improved working angles, and no significant increase in risk.

METHODS A retrospective review of pre- and postoperative clinical and radiographic data was performed in 8 patients who underwent a CPIA.

RESULTS Three AVMs and 5 CCMs were resected using the CPIA, with an average nidus size of 2.3 cm and CCM diameter of 1.7 cm. All lesions were resected completely, as confirmed on postoperative catheter angiography or MRI. All patients had good neurological outcomes, with either stable or improved modified Rankin Scale scores at last follow-up.

CONCLUSIONS The CPIA is a safe alternative approach to the IPIA for deep medial parietooccipital vascular malformations that extend 2 cm or more off the midline. Contralaterality and retraction due to gravity optimize the interhemispheric corridor, the surgical trajectory to the lesion, and the visualization of the lateral margin, without resection or retraction of adjacent normal cortex. Although the falx is a physical barrier to accessing the lesion, it stabilizes the ipsilateral hemisphere while gravity delivers the dissected lesion through the transfalcine window. Patient positioning, CSF drainage, venous preservation, and meticulous dissection of the deep margins are critical to the safety of this approach.

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Syringe Port: A Convenient, Safe, and Cost-Effective Tubular Retractor for Transportal Removal of Deep-Seated Lesions of the Brain

World Neurosurg. (2018) 114:117-120

Minimally invasive transportal resection of deep intracranial lesions has become a widely accepted surgical technique. Many disposable, mountable port systems are available in the market for this purpose, like the ViewSite Brain Access System. The objective of this study was to find a cost-effective substitute for these systems.

METHODS: Deep-seated brain lesions were treated with a port system made from disposable syringes. The syringe port could be inserted through minicraniotomies placed and planned with navigation. All deep-seated lesions like ventricular tumours, colloid cysts, deep-seated gliomas, and basal ganglia hemorrhages were treated with this syringe port system and evaluated for safety, operative site hematomas, and blood loss.

RESULTS: 62 patients were operated on during the study period from January 2015 to July 2017, using this innovative syringe port system for deep-seated lesions of the brain. No operative site hematoma or contusions were seen along the port entry site and tract.

CONCLUSIONS: Syringe port is a cost-effective and safe alternative to the costly disposable brain port systems, especially for neurosurgical setups in developing countries for minimally invasive transportal resection of deep brain lesions.

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Supraorbital approach through eyebrow skin incision for aneurysm clipping

Acta Neurochirurgica (2018) 160:1155–1158

Surgery has been in a huge development where the aim is to achieve same or better results with less complication in a less invasive way; these minimal approaches can be applied in a very safe way to aneurysmal neurosurgery.

Method Images are studied to optimize the patient positioning and the surgical roadmap. After the positioning, the skin incision, craniotomy, and dura incision are performed and intradural lesion is reached. A watertight closure is performed under the microscope.

Conclusion The keyhole approach requires some adaption from the side of the surgeon and can be performed only in cases envisioned to have no increased risk for the patient.

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Surgical clipping of vertebrobasilar junction aneurysms through a far-lateral transcondylar approach

Acta Neurochirurgica (2018) 160:1149–1153

Vertebrobasilar junction aneurysms occur rarely, but have a higher rupture rate than supratentoral aneurysms, and higher morbidity and mortality. Their location ventral to the neuroaxis makes them a challenging surgical lesion.

Methods In this paper, we share our experience with the surgical technique for the management of these complex aneurysms.

Conclusion An in-depth understanding of the anatomy of these aneurysms, careful preoperative planning, and a meticulous surgical technique, including knowledge of every detail of the procedure—positioning, an advanced skull base technique, and careful aneurysm dissection and clipping—is essential for a successful outcome of the surgery.

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Minimally Invasive Alternative Approaches to Pterional Craniotomy: A Systematic Review of the Literature

World Neurosurg. (2018) 113:163-179.

Minimally invasive alternatives to the pterional craniotomy include the minipterional and the supraorbital craniotomy (SOC). The latter is performed via either an eyebrow or an eyelid skin incision. The purpose of this systematic review was to analyze the type and the incidence of approachrelated complications of these so-called “keyhole craniotomies”.

METHODS: We review pertinent articles retrieved by search in the PubMed/ Medline database. Inclusion criteria were all full-text articles, abstracts, and posters in English, up to 2016, reporting clinical results.

RESULTS: A total of 105 articles containing data on 5837 surgeries performed via a minipterional or either of the 2 variants of the SOC met the eligibility criteria. Pain on mastication was the most commonly reported approach-related complication of the minipterional approach, and occurred in 7.5% of cases. Temporary palsy of the frontal branch of the facial nerve and temporary supraorbital hypesthesia were associated with the SOC eyebrow variant, and occurred in 6.5%, respectively in 3.6% of cases. Transient postoperative periorbital edema and transient ophthalmoparesis occurred in 36.8% and 17.4% of cases, respectively, when the SOC was performed via an eyelid skin incision. The risk of occurrence of the latter 2 complications was related to the removal of the orbital rim, which is an obligatory part of the SOC approach through the eyelid but optional with the SOC eyebrow variant.

CONCLUSIONS: Each of the 3 keyhole approaches has a specific set and incidence of approach-related complications. It is essential to be aware of these complications to make the safest individual choice.

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Trans-Sulcal Endoport-Assisted Evacuation of Supratentorial Intracerebral Hemorrhage

Operative Neurosurgery 14:524–531, 2018

The surgical management of supratentorial intracerebral hemorrhages (ICH) remains controversial due to large trials failing to show clear benefits. Several minimally invasive techniques have emerged as an alternative to a conventional craniotomy with promising results.

OBJECTIVE: To report our experience with endoport-assisted surgery in the evacuation of supratentorial ICH and its effects on outcome compared to matched medical controls. METHODS: Retrospective data were gathered of patients who underwent endoportassisted evacuation between January 2014 and October 2016 by a single surgeon. Patients who were managed medically during the same period were matched to the surgical cohort. Previously published cohorts investigating the same technique were analyzed against the present cohort.

RESULTS: Sixteen patients were identified and matched to 16 patients treated medically. Location, hemorrhage volume, and initial Glasgow Coma Scale (GCS) score did not differ significantly between the 2 cohorts. Themean volume reduction in the surgical cohort was 92.05%±7.05%. The improvement in GCS in the surgical cohortwas statistically significant (7-13, P = .006). Compared to the medical cohort, endoport-assisted surgery resulted in a statistically significant difference in in-hospital mortality (6.25% vs 75.0%, P < .001) and 30-d mortality (6.25% vs 81.25%, P < .001). Compared to previously published cohorts, the present cohort had lower median preoperative GCS (7 vs 10, P = .02), but postoperative GCS did not differ significantly (13 vs 14, P = .28).

CONCLUSION : Endoport-assisted surgery is associated with high clot evacuation and decreases 30-d mortality compared to a similar medical group.

 

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Method for temporal keyhole lobectomies in resection of low- and high-grade gliomas

J Neurosurg 128:1388–1395, 2018

The purpose of this study was to describe a method of resecting temporal gliomas through a keyhole lobectomy and to share the results of using this technique.

METHODS The authors performed a retrospective review of data obtained in all patients in whom the senior author performed resection of temporal gliomas between 2012 and 2015. The authors describe their technique for resecting dominant and nondominant gliomas, using both awake and asleep keyhole craniotomy techniques.

RESULTS Fifty-two patients were included in the study. Twenty-six patients (50%) had not received prior surgery. Seventeen patients (33%) were diagnosed with WHO Grade II/III tumors, and 35 patients (67%) were diagnosed with a glioblastoma. Thirty tumors were left sided (58%). Thirty procedures (58%) were performed while the patient was awake. The median extent of resection was 95%, and at least 90% of the tumor was resected in 35 cases (67%). Five of 49 patients (10%) with clinical follow-up experienced permanent deficits, including 3 patients (6%) with hydrocephalus requiring placement of a ventriculoperitoneal shunt and 2 patients (4%) with weakness. Three patients experienced early postoperative anomia, but no patients had a new speech deficit at clinical follow-up.

CONCLUSIONS The authors provide their experience using a keyhole lobectomy for resecting temporal gliomas. Their data demonstrate the feasibility of using less invasive techniques to safely and aggressively treat these tumors.

 

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“Birdlime” technique using TachoSil tissue sealing sheet soaked with fibrin glue for sutureless vessel transposition in microvascular decompression

J Neurosurg 128:1522–1529, 2018

Microvascular decompression (MVD) is effective for the treatment of trigeminal neuralgia (TN), hemifacial spasm (HFS), and glossopharyngeal neuralgia. The transposition technique is the standard procedure to avoid adhesions and granuloma around the decompression site but is more complex and difficult to perform than the interposition technique. The authors describe a simple and safe MVD transposition procedure they call the “birdlime” technique, which uses a tissue glue–coated collagen sponge soaked with fibrin glue, and the results of this technique.

METHODS The authors retrospectively reviewed the medical charts and radiographic findings of 27 consecutive patients with TN (8 patients) and HFS (19 patients) who, between January 2012 and December 2015, had undergone an MVD transposition procedure utilizing a tissue glue–coated collagen sponge (TachoSil tissue sealing sheet) soaked with fibrin glue (Tisseel 2-component fibrin sealant, vapor heated). Offending arteries among the patients with TN were the superior cerebellar artery (SCA) in 5 patients, the SCA and anterior inferior cerebellar artery (AICA) in 2, and the AICA in 1. Those among the patients with HFS were the vertebral artery (VA) in 3 patients, the VA and AICA in 4, the VA and posterior inferior cerebellar artery (PICA) in 3, the PICA in 4, the AICA in 1, the AICA-PICA in 3, and the PICA and AICA in 1. Operations were performed according to the Jannetta procedure. The offending artery was transposed and fixed to the dura mater of the petrous bone using TachoSil pieces soaked with fibrin glue. Postoperative constructive interference in steady-state MRI was performed to evaluate the change in the position of the offending artery.

RESULTS Transposition of the offending artery was easily and safely performed in all patients. All patients had total remission of symptoms directly after the procedure. No severe complications occurred. The postoperative course was uneventful. No recurrences, adhesions, or dysfunction of the cranial nerves was observed in any of the patients. Postoperative MRI showed that the offending vessels were displaced and fixed in the appropriate position.

CONCLUSIONS The described transposition technique provides an easy and adjustable way to perform MVD safely and effectively. In addition, this transposition and fixation technique is simple and avoids the risk of needle injury close to the cranial nerves and vessels. This simple sutureless technique is recommended for MVD to reduce the risk of intraoperative neurovascular injury.

 

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Median Supraorbital Keyhole Approach for Clipping Ruptured Distal Anterior Cerebral Artery Aneurysm

World Neurosurg. (2018) 112:73-76

The minimally invasive approach to distal anterior cerebral artery (DACA) aneurysms has not gained much acceptance due to difficulties associated with the conventional frontal paramedian approach. The more proximal basal interhemispheric approach, however, necessitates extensive dissection of soft tissues. We describe a novel minimally invasive median supraorbital keyhole craniotomy with a basal interhemispheric approach for clipping a ruptured DACA aneurysm.

METHODS: A 62-year-old patient presented with subarachnoid hemorrhage. Computed tomography angiography revealed a DACA aneurysm. The surgical technique involved a keyhole craniotomy made via an eyebrow incision extending between the supraorbital notches, and flush with the anterior cranial fossa. The dura was opened at the anterior part, the falx was cut, an interhemispheric dissection was carried out, adequate proximal control was obtained, and the aneurysm neck was dissected and clipped. A relevant review of the literature was carried out.

RESULTS: The patient recovered well, with no residual aneurysm or forehead numbness, with good cosmesis. Compared with the previously described “keyhole unilateral interhemispheric” approaches, our technique has less likelihood of encountering bridging veins; easier cisternal cerebrospinal fluid release, making it feasible even in swollen brain; better proximal vascular control; and trajectory toward the neck rather than dome.

CONCLUSION: The median supraorbital keyhole approach is a minimally invasive technique sufficient for clipping most DACA aneurysms, with easier access, better proximal control, and good cosmesis.

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Endplate changes after lumbar discectomy with and without implantation of an annular closure device

Acta Neurochirurgica (2018) 160:855–862

The implantation of a bone-anchored annular closure device (ACD) might be associated with the developed new endplate changes (EPC) after surgery.

Methods A post hoc analysis has been done in patients from a prospective randomized multicenter study. All patients underwent limited lumbar discectomy with intraoperative randomization into the groups limited lumbar discectomy alone or additional ACD implantation. Low-dose lumbar computed tomography (CT) and clinical investigations were performed preoperatively and 12 months after the operation.

Results A total of 554 patients were randomized. After exclusion of dropouts, the per-protocol population included 493 patients (251 in the control group and 242 in the ACD group); the follow-up rate was ≥ 90%. The number of patients showing EPC at baseline was similar in both groups. The number of patients showing EPC and the total EPC lesion area significantly increased in both groups over time, but significantly increased more in the EPC group for the superior and inferior endplate (all P < 0.0001). There was no association of pre-existing number and size of EPC with sex, age, or smoking habits. Correlation of clinical variables showed no relation with number, size, and increase of EPC area after surgery.

Conclusions Patients with primary lumbar disc herniation show EPC in the corresponding segments. There is a significant increase of lesion number and size within 12 months after discectomy. This increase is significantly more pronounced in the ACD group. Presence and growth of EPC is not correlated with low-back pain or ODI.

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Surgical strategy to avoid ischemic complications of the pyramidal tract in resective epilepsy surgery of the insula

J Neurosurg 128:1173–1177, 2018

Surgical treatment of the insula is notorious for its high probability of motor complications, particularly when resecting the superoposterior part. Ischemic damage to the pyramidal tract in the corona radiata has been regarded as the cause of these complications, resulting from occlusion of the perforating arteries to the pyramidal tract through the insular cortex. The authors describe a strategy in which a small piece of gray matter is spared at the bottom of the periinsular sulcus, where the perforating arteries pass en route to the pyramidal tract, in order to avoid these complications.

This method was successfully applied in 3 patients harboring focal cortical dysplasia in the posterior insula and frontoparietal operculum surrounding the periinsular sulcus. None of the patients developed permanent postoperative motor deficits, and seizure control was achieved in all 3 cases.

The method described in this paper can be adopted for functional preservation of the pyramidal tract in the corona radiata when resecting epileptogenic pathologies involving insular and opercular regions.

 

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