Category: Surgical technique

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Trigeminal neurinomas: clinical features and surgical experience in 84 patients

Neurosurg Rev (2009) 32:435–444.DOI:10.1007/s10143-009-0210-8

Trigeminal neurinomas are the second most common intracranial neurinomas next to the vestibular neurinomas. Eighty-four patients with trigeminal neurinomas were treated between 2003 and 2007. There were 40 women and 44 men (mean age 43 years). The most frequent symptoms were headache or numbness of the ipsilateral hemiface. There were 24 type A, nine type B, 45 type C, and six type D tumors. Dextroscope virtual reality technology was used for preoperative planning in recent eight cases. Gross total resection was achieved in 63 patients. We found that the major impediments to complete removal were adherent to the brainstem and skull base vascular structure, the frontotemporal approach with zygomatic or orbitozygomatic osteotomy or subtemporal approach could offer excellent exposure of the middle fossa and access to the posterior fossa, and Dextroscope virtual reality technology was a very useful tool to identify surgical and anatomic nuances and enhance preoperative planning in trigeminal neurinomas resection.

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Tentorial meningiomas: operative nuances and perioperative management dilemmas

Acta Neurochir (2009) 151:1037–1051.DOI 10.1007/s00701-009-0421-3

Tentorial meningiomas (TM), comprising approximately 3–6% of all intracranial meningiomas, are complex entities with an intricate relationship to surrounding structures and require multiple surgical approaches. In the present study, the rationale for deciding the approaches for TMs and the perioperative management dilemmas were evaluated.
Methods  Thirty-seven patients (28 primary [supratentorial (2), infratentorial (20) and both (6)] and nine complex [cerebellopontine (CP) angle (5) and petroclival (4)] TM) underwent surgery using the occipital transtentorial, supracerebellar infratentorial, subtemporal transtentorial, bioccipital suboccipital, midline suboccipital, retrosigmoid, and combined pre and retrosigmoid approaches. The extent of excision was categorized according to Simpson’s grade.
Results  Simpson’s grade of excision was I in six, II in 11, III in nine and IV in 11 patients, respectively. Follow-up assessment (2 months to 9 years) in 27 patients (72.9%) showed that 23 patients returned to their previous activity level with either no or minimal symptoms, three returned to previous activity level with major cranial nerve palsy, and one patient required permanent assistance. One patient had recurrence and four others underwent resurgery for residual tumor. Two patients with petroclival lesions died due to aspiration pneumonitis and meningitis, respectively; one with CP angle TM presented in a poor general condition and expired following emergency ventriculoperitoneal shunt and subsequent definite surgery. Pseudomeningocele, cerebrospinal fluid leak, and cranial nerve palsy were the major morbidities.
Conclusions  Classifying TM into medial and lateral, supra and infratentorial groups helps in deciding an appropriate and safe approach. Meticulously preserving venous sinuses is important since the risk of venous infarction cannot be predicted even with radiological good venous collaterization and apparent venous sinus blockade by tumor. Laterally situated tumors carry a better prognosis when compared to the medially situated ones. Leaving a small residual tumor in an effort to preserve important neurovascular structures does not obviate the expectation of a good long-term prognosis with minimal morbidity and low recurrence rates.

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Comparative study of anterior versus posterior decompression in elderly patients of cervical myelopathy with co-morbid conditions

Eur J Orthop Surg Traumatol (2009) 19:397–401 DOI 10.1007/s00590-009-0444-8

Study design: Prospective.

Objective: To assess the results of laminectomy in patients suffering from multilevel multidirectional compressive cervical myelopathy with co-morbid conditions and to compare results of anterior and laminectomy clinically, radiologically and functionally.

Summary of background data: Cervical myelopathy or myeloradiculopathy is a progressive degenerative disorder that usually starts in the middle age. It leads to circumferential cord compression leading to a constellation of signs and symptoms.

Methods: Prospective study of 30 cases in which we had compared the results of anterior and posterior decompression surgery. Our follow-up ranged from 18 to 60 months with an average follow-up of 31.8 months.

Results: Eighteen patients underwent laminectomy by posterior midline approach in which lamina and if required, medial one-third of the facet was also removed. Diskectomy and bone grafting was done in eight patients by standard anterior approach with removal of disc at two or three levels. Corpectomy and diskectomy above and below with bone grafting was done in four patients. Out of these two were fused with tricortical iliac crest and two with fibula.

Conclusion: Anterior decompression is the gold standard. However, in medically unfit patients with multi-level circumferential compression, laminectomy is an equally rewarding option.

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Minimally Invasive Lumbar Discectomy Had Worse Outcome than Conventional Open Microdiscectomy. A Randomized Controlled Trial

JAMA. 2009;302(2):149-158.

Context Conventional microdiskectomy is the most frequently performed surgery for patients with sciatica due to lumbar disk herniation. Transmuscular tubular diskectomy has been introduced to increase the rate of recovery, although evidence is lacking of its efficacy.

Objective To determine outcomes and time to recovery in patients treated with tubular diskectomy compared with conventional microdiskectomy.

Design, Setting, and Patients The Sciatica Micro-Endoscopic Diskectomy randomized controlled trial was conducted among 328 patients aged 18 to 70 years who had persistent leg pain (>8 weeks) due to lumbar disk herniations at 7 general hospitals in the Netherlands from January 2005 to October 2006. Patients and observers were blinded during the follow-up, which ended 1 year after final enrollment.

Interventions Tubular diskectomy (n = 167) vs conventional microdiskectomy (n = 161).

Main Outcome Measures The primary outcome was functional assessment on the Roland-Morris Disability Questionnaire (RDQ) for sciatica (score range: 0-23, with higher scores indicating worse functional status) at 8 weeks and 1 year after randomization. Secondary outcomes were scores on the visual analog scale for leg pain and back pain (score range: 0-100 mm) and patient’s self-report of recovery (measured on a Likert 7-point scale).

Results Based on intention-to-treat analysis, the mean RDQ score during the first year after surgery was 6.2 (95% confidence interval [CI], 5.6 to 6.8) for tubular diskectomy and 5.4 (95% CI, 4.6 to 6.2) for conventional microdiskectomy (between-group mean difference, 0.8; 95% CI, –0.2 to 1.7). At 8 weeks after surgery, the RDQ mean (SE) score was 5.8 (0.4) for tubular diskectomy and 4.9 (0.5) for conventional microdiskectomy (between-group mean difference, 0.8; 95% CI, –0.4 to 2.1). At 1 year, the RDQ mean (SE) score was 4.7 (0.5) for tubular diskectomy and 3.4 (0.5) for conventional microdiskectomy (between-group mean difference, 1.3; 95% CI, 0.03 to 2.6) in favor of conventional microdiskectomy. On the visual analog scale, the 1-year between-group mean difference in improvement was 4.2 mm (95% CI, 0.9 to 7.5 mm) for leg pain and 3.5 mm (95% CI, 0.1 to 6.9 mm) for back pain in favor of conventional microdiskectomy. At 1 year, 107 of 156 patients (69%) assigned to tubular diskectomy reported a good recovery vs 120 of 151 patients (79%) assigned to conventional microdiskectomy (odds ratio, 0.59 [95% CI, 0.35 to 0.99]; P = .05).

Conclusions Use of tubular diskectomy compared with conventional microdiskectomy did not result in a statistically significant improvement in the Roland-Morris Disability Questionnaire score. Tubular diskectomy resulted in less favorable results for patient self-reported leg pain, back pain, and recovery.

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A Randomized, Double-blinded Comparison of Ondansetron, Granisetron, and Placebo for Prevention of Postoperative Nausea and Vomiting After Supratentorial Craniotomy

Journal of Neurosurgical Anesthesiology: July 2009 – Volume 21 – Issue 3 – pp 226-230. doi: 10.1097/ANA.0b013e3181a7beaa

Postoperative nausea and vomiting (PONV) are frequent and distressing complications after neurosurgical procedures. We evaluated the efficacy of ondansetron and granisetron to prevent PONV after supratentorial craniotomy. In a randomized double-blind, placebo controlled trial, 90 adult American Society of Anesthesiologists I, II patients were included in the study. A standard anesthesia technique was followed. Patients were divided into 3 groups to receive either placebo (saline), ondansetron 4 mg, or granisetron 1 mg intravenously at the time of dural closure. After extubation, episodes of nausea and vomiting were noted for 24 hours postoperatively. Statistical analysis was performed using χ2 test and 1-way analysis of variance. Demographic data, duration of surgery, intraoperative fluids and analgesic requirement, and postoperative pain (visual analog scale) scores were comparable in all 3 groups. It was observed that the incidence of vomiting in 24 hours, severe emetic episodes, and requirement of rescue antiemetics were less in ondansetron and granisetron groups as compared with placebo (P<0.001). Both the study drugs had comparable effect on vomiting. However, the incidence of nausea was comparable in all 3 groups (P=0.46). A favorable influence on the patient satisfaction scores, and number needed to prevent emesis was seen in the 2 drug groups. No significant correlation was found between neurosurgical factors (presence of midline shift, mass effect, pathologic diagnosis of tumor, site of tumor) and the occurrence of PONV. We conclude that ondansetron 4 mg and granisetron 1 mg are comparably effective at preventing emesis after supratentorial craniotomy. However, neither drugs prevented nausea effectively.

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Fronto-basal interhemispheric approach for tuberculum sellae meningiomas; long-term visual outcome

Ganna, Ahmed, Dehdashti, Amir R., Karabatsou, Konstantina and Gentili, Fred. British Journal of Neurosurgery,23:4,422-430, (2009).

URL: http://dx.doi.org/10.1080/02688690902968836

We report our experience with the treatment of tuberculum sellae meningiomas using the fronto-basal interhemispheric approach. A retrospective analysis was performed on a series of 24 patients with tuberculum sellae meningiomas who were operated between March 2000 and January 2007. Patients’ presenting symptoms, radiological images, operative reports, and clinical follow-up data were reviewed with special consideration for visual outcome. Visual deterioration was the presenting symptom in all patients, followed by headache in 9 patients (37.5%). The average duration of visual symptoms was 17.6 months. The average tumor diameter was 2.63 cm; encasement of the carotid artery was identified in 7 patients (29%). Complete tumor removal was achieved in 21 patients (87.5%). Mean follow-up period was 52 months. Vision improved in 19 patients (79%), remained stable in 4 (17%) and deteriorated in 1 patient (4%). The degree of tumor removal or visual outcome were both unrelated to the tumor size (p=0.2 and p=0.6 respectively). While the degree of preoperative visual deficit did not affect the visual improvement rate in the whole group (p=0.9), those patients with improvement to good functional vision (>20/40) after the surgery, had a less severe preoperative deficit (p<0.001). The most common complication was anosmia (29.1%) and there was no mortality. The frontobasal interhemispheric approach is safe and provides a direct anatomical approach to tuberculum sellae meningiomas with relatively low incidence of complications. Patients with improved vision to good functional level had a better preoperative visual status.

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Functional outcome after language mapping for insular WHO Grade II gliomas in the dominant hemisphere: experience with 24 patients

Neurosurg Focus 27 (2):E7, 2009
Despite the report of recent experiences of insular surgery in the past decade, there has been no series specifically dedicated to studying functional outcome following resection of insular WHO Grade II gliomas involving the dominant hemisphere, in patients with no or only mild preoperative language deficit. In this article, the authors analyze the contribution of awake mapping for preservation of brain function, especially language, in a homogeneous series of 24 patients who underwent surgery for insular Grade II gliomas within the dominant insular lobe.

Methods
Twenty-four patients underwent surgery for an insular Grade II glioma involving the dominant hemisphere (22 left, 2 right), revealed by seizures in all but 1 case. The preoperative neurological examination result was normal in 17 patients (71%), whereas 7 patients presented with language disorders detected using an accurate language assessment performed by a speech therapist. All surgeries were performed on awake patients utilizing intra-operative language mapping involving cortical and subcortical stimulation.

Results
There were no intrasurgical complications or postsurgical sensorimotor deficits. Despite an immediate postoperative language worsening in 12 cases (50%), all patients recovered to a normal status within 3 months, and 6 cases even improved in comparison with their preoperative examination results. The 24 patients returned to normal social and professional lives. Moreover, the surgery had a favorable impact on epilepsy in all but 4 cases (83%). On control MR imaging, 62.5% of resections were total or subtotal. Three patients underwent a second or third awake surgery, with no additional deficit. All but 2 patients (92%) are alive after a mean follow-up of 3 years (range 3–133 months).

Conclusions
Although insular surgery was long believed to be too risky, the present results show that the rate of permanent deficit, especially dysphasia, following resection of Grade II gliomas involving the dominant insula has been dramatically reduced (none in this patient series), thanks to the systematic use of intraoperative awake mapping, even in cases of repeated operations. Furthermore, patient quality of life may be improved due to a decrease of epilepsy after surgery. Thus, the authors suggest systematically considering resection when an insular Grade II glioma is diagnosed after seizures in a patient with no or mild deficit, even a glioma invading the dominant hemisphere.

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