Tag: Intradural

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Surgical management and outcomes in spinal intradural arachnoid cysts

Acta Neurochirurgica (2022) 164:1217–1228

Evaluation of the presentation and outcomes of different surgical treatment approaches for spinal intradural arachnoid cysts (SIAC).

Methods Cases were identified from electronic records of two major neurosurgical centres in London over the last 10 years (October 2009–October 2019) that have been surgically treated in both institutions. Clinical findings, surgical technique, and recurrence by procedure were statistically analysed. Statistical analysis was performed with STATA 13.1 Software.

Results A total of 42 patients with SIAC were identified for this study with a mean age at the time of surgery of 53.6 years and a male:female ratio of 8:13. There were 31 patients with primary SIACs and 11 with secondary SIACs. The most common presenting symptom was paraesthesia (n = 27). The most common location of the cyst was in the thoracic region (n = 33). Syrinx was present in 26.2% of SIACs (n = 11). Resection was associated with significantly better postoperative pain compared to other surgical techniques (p = 0.01), significantly poorer postoperative urinary function (p = 0.029), and lower rates of sensory recovery in patients who presented preoperatively with sensory deficit (p = 0.041). No significant difference was seen in symptomatic outcomes between patients with primary and secondary SIACs.

Conclusion Resection and drainage are both effective methods of managing SIACs. In this observational study, resection was associated with significantly reduced pain postoperatively when compared with drainage, however also with significantly less improvement in postoperative urinary function. Therefore, resection should be the gold standard management option for SIACs, with drainage as an option where resection is unsafe, and drainage should also be considered in patients presenting with urinary dysfunction.

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Surgical treatment of pontine cavernous malformations via subtemporal transtentorial and intradural anterior transpetrosal approaches

Neurosurgical Review (2020) 43:1179–1189

The aim of this study was to report our surgical experience on resection of the pontine cavernous malformations (CMs) via subtemporal transtentorial approach (STTA) and intradural anterior transpetrosal approach (ATPA).

Clinical data were retrospectively reviewed in 61 patients with pontine CMs that were surgically treated by the STTA and the intradural ATPA. The surgical procedures, complications, and outcomes were analyzed.

The study consists of 61 patients with a total of 61 pontine CMs. Other than 4 lesions located medially in the pons, all CMs were in the lateral pons with a left or right lateral epicenter (the left/right ratio was 22/35). Totally, 11 patients (18.0%) with lesions located in the upper pons were treated by the STTA, and 50 patients (82.0%) with lesions involving the lower pons were treated by the intradural ATPA. Postoperatively, the complete resection was achieved in 58 patients (95.1%) and incomplete resection in 3 patients (4.9%). Twenty-seven patients (44.3%) suffered from a new or worsened neurological deficit in the immediate postoperative period, and 8 patients (13.1%) encountered a non-neural complication, including rebleeding, cerebrospinal fluid leak, intracranial infection, and pulmonary infection, and 3 patients had contusion of temporal lobe. With a mean follow-up of 54.2 months, the patients’ neurological condition had improved in 43 cases (71.6%), not changed in 10 cases (16.7%), and worsened in 7 cases (11.7%), respectively. The Karnofsky Performance Scale (KPS) score evaluated at the last time for per patient was significantly better than their baseline status (t = 6.677, p < 0.001). However, 21 patients (35.0%) suffered from a new or worsened persistent postoperative deficit.

The lateral and anterolateral pons can be exposed well by the subtemporal transtentorial and intradural anterior transpetrosal approaches. Lesions of CMs located in the lateral pons, including ventrolateral and dorsolateral pons, could be totally removed by these two lateral approaches with an acceptable surgical morbidity.

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Lateral Supraorbital Approach Applied to Tuberculum Sellae Meningiomas

Neurosurgery 70:1504–1519, 2012 DOI: 10.1227/NEU.0b013e31824a36e8

Various surgical approaches for the removal of tuberculum sellae meningiomas (TSMs) have previously been described.

OBJECTIVE: To assess the reliability and safety of the lateral supraorbital (LSO) approach to remove TSMs.

METHODS: We identified all TSM patients operated on at the Department of Neurosurgery at Helsinki University Central Hospital, Finland, by the senior author (J.H.) using the LSO approach between September 1997 and August 2010. We retrospectively analyzed the clinical data, radiological findings, surgical treatment, histology, and outcome of patients and discuss the operative technique.

RESULTS: Apparent complete tumor removal was achieved in 45 patients (87%). Of 42 patients, preexisting visual deficit improved in 22, remained the same in 13, and worsened in 7, and de novo visual deficit occurred in 1 patient. At 3 months postdischarge, 47 patients (90%) had a good recovery, 4 (8%) were moderately disabled, and 1 (2%) died 40 days after surgery of unexplained cardiac arrest. Seven patients (13%) had minimal residual tumors, 2 of which required reoperation. During the median follow-up of 59 months (range, 1-133 months), tumor recurred in 1 of the patients who had undergone a second operation.

CONCLUSION: TSMs of all sizes can be removed via the LSO approach with minimal morbidity and mortality. Low-power or no coagulation is recommended near the optic nerves and the optic chiasm to preserve their vascular support from the internal carotid artery perforators. Our results are comparable to those obtained using more extensive and time-consuming approaches. We recommend the LSO approach to remove TSMs.

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Intradural spinal metastases: a surgical series of 15 patients

Acta Neurochir (2012) 154:871–877. DOI 10.1007/s00701-012-1313-5

Intradural spinal metastases are rare, and little is known regarding surgical indications and outcomes.

Methods A retrospective search identified adults with intradural spinal metastases operated on at the Mayo Clinic from 1994-2011. Data were collected regarding demographics, tumor type and location, and outcomes.

Results Fifteen patients with intradural spinal metastases were investigated. The age range was 38-74 years (mean= 55 years; ±SD=11.1). Predominant tumor location and type were lumbosacral and adenocarcinoma, respectively: 3 intramedullary and 12 extramedullary. Patients were operated on to relieve or prevent progressive/intractable neurological sequelae and/or pain. Of 13 who underwent resection, gross total removal was reported in 10; simple biopsy was performed in 2. There was one surgical complication, no medical complications, and no surgical mortality. At median follow-up of 1 month postoperatively, 10 of 15 patients were stable or improved. Of 13 patients who underwent resection, 10 were stable or improved. Of two patients who underwent biopsy, neither was stable or improved at follow-up. Using the Modified McCormick Scale, 11 of 15 patients were “functional” preoperatively and 4 went from “functional” preoperatively to “non-functional” postoperatively. Three of those four died within 60 days of surgery from systemic disease progression. Median hospital stay was 8 days. Ten of 15 patients died by the end of the study period, and the median survival of 15 patients was 5 months.

Conclusions With improved outcomes in metastatic cancer, more patients are encountered in practice. An aggressive surgical approach is warranted for extramedullary lesions, whereas caution is advised for intramedullary lesions. Postoperative functional decline is more likely due to systemic disease progression rather than surgery.

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Lateral Supraorbital Approach Applied to Anterior Clinoidal Meningiomas: Experience With 73 Consecutive Patients

Neurosurgery 68:1632–1647, 2011 DOI: 10.1227/NEU.0b013e318214a840

Anterior clinoidal meningiomas (ACMs) are a subgroup of meningiomas accounting for less than 10% of supratentorial meningiomas.

OBJECTIVE: To assess the reliability and safeness of the lateral supraorbital approach (LSO) to remove ACMs.

METHODS: Between September 1997 and October 2009, a total of 73 ACM patients were operated on at the Department of Neurosurgery, Helsinki University Central Hospital, by the senior author (J.H.). We retrospectively analyzed the clinical data, radiological findings, surgical treatment, histology, and outcome of patients, and discuss the operative technique.

RESULTS: Seventy-three patients were operated on by applying the LSO approach. Apparently complete removal was achieved in 57 patients (78%). Anterior clinoidectomy was performed in 21 cases. Preexisting visual deficit improved in 11 of 39 patients and worsened in 4; 3 had de novo visual deficit. At 3 months after discharge, 60 (82%) patients had a good recovery, 9 (12%) patients were moderately disabled, 1 presented with severe disability, and 3 (4%) patients died of surgery-related causes. Sixteen (22%) patients had residual tumors, 6 of which required reoperation. During the median followup of 36 months (range, 3-146), tumor recurred in 3 patients: 2 were followed-up and 1 was reoperated on.

CONCLUSION: ACMs can be removed via the LSO approach with relatively low morbidity and mortality. Anterior clinoidectomy is required only in selected cases, and we prefer the intradural approach during the LSO approach. High-power coagulation should be avoided in proximity of the optic nerve.

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