Tag: minimally invasive

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Coronal balance with circumferential minimally invasive spinal deformity surgery for the treatment of degenerative scoliosis

J Neurosurg Spine 34:879–887, 2021

Coronal malalignment (CM) in adult spinal deformity is associated with poor outcomes and remains underappreciated in the literature. Recent attempts at classifying CM indicate that some coronal shifts may be more difficult to treat than others. To date, outcomes for circumferential minimally invasive surgery (cMIS) of the spine in the context of these new CM classifications are unreported.

METHODS A retrospective evaluation of patients with degenerative scoliosis (Cobb angle > 20 ) consecutively treated with cMIS at a single institution was performed. Preoperative and 1-year postoperative standing radiographs were used to make the comparisons. Clinical outcome measures were compared. Patients were subgrouped according to the preoperative distance between their C7 plumb line and central sacral vertical line (C7-CSVL) as either coronally aligned (type A, C7-CSVL < 3 cm); shifted ≥ 3 cm toward the concavity (type B); or shifted ≥ 3 cm toward the convexity (type C) of the main lumbar curve.

RESULTS Forty-two patients were included (mean age 67.7 years). Twenty-six patients (62%) were classified as type A, 5 patients (12%) as type B, and 11 patients (26%) as type C. An average of 4.9 segments were treated. No type A patients developed postoperative CM. All type B patients had CM correction. Six of the 11 type C patients had CM after surgery. Overall, there was an improvement in the C7-CSVL (from 2.4 to 1.8 cm, p = 0.04). Among subgroups, only type B patients improved (from 4.5 to 0.8 cm, p = 0.002); no difference was seen for type A patients (from 1.2 to 1.4 cm, p = 0.32) or type C patients (from 4.3 to 3.1 cm, p = 0.11). Comparing type C patients with postoperative CM versus those without postoperative CM, patients with CM had worse visual analog scale back scores at 1 year (5 vs 1, p = 0.01). Moreover, they had higher postoperative L4 tilt angles (11  vs 5 , p = 0.01), indicating inadequate correction of the lumbosacral fractional curve.

CONCLUSIONS cMIS improved coronal alignment, curve magnitudes, and clinical outcomes among patients with degenerative scoliosis. It did not result in CM in type A patients and was successful at improving the C7-CSVL in type B patients. Type C patients remain the most difficult to treat coronally, with worse visual analog scale back pain scores in those with postoperative CM. Regional coronal restoration of the lumbosacral fracture curve should be the focus of correction in cMIS for these patients.

 

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Minimally Invasive Intracerebral Hematoma Evacuation Using a Novel Cost-Effective Tubular Retractor

World Neurosurg. (2021) 150:42-53

Spontaneous intracerebral hematoma (ICH) is a common disease with a dismal overall prognosis. Recent development of minimally invasive ICH evacuation techniques has shown promising results. Commercially available tubular retractors are commonly used for minimally invasive ICH evacuation yet are globally unavailable.

METHODS: A novel U.S. $7 cost-effective, off-the-shelf, atraumatic tubular retractor for minimally invasive intracranial surgery is described. Patients with acute spontaneous ICH underwent microsurgical tubular retractor assisted minimally invasive ICH evacuation using the novel retractor. Patient outcome was retrospectively analyzed and compared with open surgery and with commercial tubular retractors.

RESULTS: Ten adult patients with spontaneous supratentorial ICH and median preoperative Glasgow Coma Scale score of 10 were included. ICH involved the frontal lobe, parietal lobe, occipitotemporal region, and solely basal ganglia in 3, 3, 2, and 2 patients, respectively. Mean preoperative ICH volume was 80 mL. Mean residual hematoma volume was 8.7 mL and mean volumetric hematoma reduction was 91% (median, 94%). Seven patients (70%) underwent >90% volumetric hematoma reduction. The total median length of hospitalization was 26 days. On discharge, the median Glasgow Coma Scale score was 12.5 (mean, 11.7). Thirty to 90 days’ follow-up data were available for 9 patients (90%). The mean follow-up modified Rankin Scale score was 3.7 and 5 patients (56%) had a modified Rankin Scale score of 3.

CONCLUSIONS: The novel cost-effective tubular retractor and microsurgical technique offer a safe and effective method for minimally invasive ICH evacuation. Cost-effective tubular retractors may continue to present a valid alternative to commercial tubular retractors.

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Comparative anatomical analysis between the minipterional and supraorbital approaches

J Neurosurg 134:1276–1284, 2021

Keyhole approaches, namely the minipterional approach (MPTa) and the supraorbital approach (SOa), are alternatives to the standard pterional approach to treat lesions located in the anterior and middle cranial fossae. Despite their increasing popularity and acceptance, the indications and limitations of these approaches require further assessment. The purpose of the present study was to determine the differences in the area of surgical exposure and surgical maneuverability provided by the MPTa and SOa.

METHODS The areas of surgical exposure afforded by the MPTa and SOa were analyzed in 12 sides of cadaver heads by using a microscope and a neuronavigation system. The area of exposure of the region of interest and surgical freedom (maneuverability) of each approach were calculated.

RESULTS The area of exposure was significantly larger in the MPTa than in the SOa (1250 ± 223 mm2 vs 939 ± 139 mm2, p = 0.002). The MPTa provided larger areas of exposure in the ipsilateral and midline compartments, whereas there was no significant difference in the area of exposure in the contralateral compartment. All targets in the anterior circulation had significantly larger areas of surgical freedom when treated via the MPTa versus the SOa.

CONCLUSIONS The MPTa provides greater surgical exposure and better maneuverability than that offered by the SOa. The SOa may be advantageous as a direct corridor for treating lesions located in the contralateral side or in the anterior cranial fossa, but the surgical exposure provided in the midline region is inferior to that exposed by the MPTa.

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Eyebrow supraorbital keyhole craniotomy for olfactory groove meningiomas with endoscope assistance

Acta Neurochirurgica (2021) 163:101–112

Olfactory groove meningiomas (OGMs) are commonly treated with open craniotomy. Endonasal approaches have also been described. Objective To present clinical and radiographic outcomes for the minimally invasive eyebrow incision supraorbital keyhole approach with endoscopic assistance for OGMs.

Methods We performed a retrospective single-center cohort study and a systematic literature review.

Results Fifteen patients were identified, all with Grade I meningiomas. Radiographic gross total resection of enhancing tumor was achieved in all patients. Mean frontal lobe fluid-attenuated inversion recovery volume decreased from 11.1 ± 18.3 cm3 preoperatively to 9.9 ± 11.4 cm3 immediately postoperatively, and there was minimal new restricted diffusion (3.2 ± 2.2 cm3; max 7.5 cm3). Median length of stay was 3 days (range 2–8). Vision was improved in 4 (80%) and stable in 1 (20%) of 5 patients with a preoperative deficit. New postoperative anosmia occurred in 3 (23%) of 13 patients with any preoperative olfaction. All patients were satisfied with their cosmetic result at 3 months. After a median follow-up of 32.2 months, there were 2 (13.3%) asymptomatic radiographic recurrences, 1 treated with radiosurgery and the other with endoscopic endonasal approach (EEA). No patients required further craniotomy. Systematic review revealed the present series to be the largest to date reporting disaggregated outcomes for the eyebrow approach to OGM.

Conclusion The eyebrow incision supraorbital keyhole craniotomy with endoscopic assistance is a safe and effective approach to OGM with tumor control rates similar to more invasive open approaches and better than the endonasal approach.Rates of frontal lobe injury, CSF leak and anosmia are comparatively low.

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Predictors of the Best Outcomes Following Minimally Invasive Surgery for Grade 1 Degenerative Lumbar Spondylolisthesis

Neurosurgery, 87 (6) 2020: 1130–1138

The factors driving the best outcomes following minimally invasive surgery (MIS) for grade 1 degenerative lumbar spondylolisthesis are not clearly elucidated.

OBJECTIVE: To investigate the factors that drive the best 24-mo patient-reported outcomes (PRO) following MIS surgery for grade 1 degenerative lumbar spondylolisthesis.

METHODS: A total of 259 patients from the Quality Outcomes Database lumbar spondylolisthesis module underwent single-level surgery for degenerative grade 1 lumbar spondylolisthesis with MIS techniques (188 fusions, 72.6%). Twenty-four-month follow-up PROs were collected and included the Oswestry disability index (ODI) change (ie, 24-mo minus baseline value), numeric rating scale (NRS) back pain change, NRS leg pain change, EuroQoL-5D (EQ-5D) questionnaire change, and North American Spine Society (NASS) satisfaction questionnaire. Multivariable models were constructed to identify predictors of PRO change.

RESULTS: The mean age was 64.2 ± 11.5 yr and consisted of 148 (57.1%) women and 111(42.9%) men. In multivariable analyses, employment was associated with superior postoperative ODI change (β-7.8; 95% CI [−12.9 to −2.6]; P = .003), NRS back pain change (β −1.2; 95% CI [−2.1 to −0.4]; P = .004), EQ-5D change (β 0.1; 95% CI [0.01-0.1]; P = .03), and NASS satisfaction (OR = 3.7; 95% CI [1.7-8.3]; P < .001). Increasing age was associated with superior NRS leg pain change (β −0.1; 95% CI [−0.1 to −0.01]; P= .03) and NASS satisfaction (OR=1.05; 95%CI [1.01-1.09]; P=.02). Fusion surgerieswere associated with superior ODI change (β −6.7; 95% CI [−12.7 to −0.7]; P= .03), NRS back pain change (β −1.1; 95% CI [−2.1 to −0.2]; P= .02), and NASS satisfaction (OR = 3.6; 95% CI [1.6-8.3]; P= .002).

CONCLUSION: Preoperative employment and surgeries, including a fusion, were predictors of superior outcomes across the domains of disease-specific disability, back pain, leg pain, quality of life, and patient satisfaction. Increasing age was predictive of superior outcomes for leg pain improvement and satisfaction.

 

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Minimally invasive posterior percutaneous transarticular C1–C2 screws: how I do it

Acta Neurochirurgica (2020) 162:2047–2050

Transarticular C1–C2 screw fixation, first described by Magerl, is a widely accepted used technique for C1–C2 instability with a good biomechanical stability and fusion rate.

Method We present a 69-year-old woman, who was diagnosed with a C2 Odontoid fracture type III and primarily treated with conservative treatment and collar. During first 2 weeks of follow-up, the patient developed cervical pain associated with C1–C2 instability. A minimally invasive posterior C1–C2 transarticular screw instrumentation with a percutaneus approach was performed.

Results and conclusion Minimally invasive approach with tubular transmuscular approach for C1–C2 transarticular screws instrumentation is safe and effective for C1–C2 instability.

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Anterior Column Realignment: Analysis of Neurological Risk and Radiographic Outcomes

Neurosurgery DOI:10.1093/neuros/nyaa064

Anterior column realignment (ACR) is a less invasive alternative to 3-column osteotomy for the correction of sagittal imbalance. We hypothesized that ACR would correct sagittal imbalance with an acceptable neurological risk. OBJECTIVE: To assess long-term neurological and radiographic outcomes after ACR.

METHODS: Patients ≥18 yr who underwent ACR from 2005 to 2013 were eligible. Standing scoliosis radiographs were studied at preoperation, postoperation (≤6 wk), and at minimum 2 yr of follow-up. Clinical/radiographic data were collected through a retrospective chart review, with thoracic 1 spino-pelvic inclination (T1SPi) used as the angular surrogate for sagittal vertical axis.

RESULTS: A total of 26 patients had complete data, with a mean follow-up of 2.8 yr (1.8- 7.4). Preoperative, sagittal parameters were lumbar lordosis (LL) of −16.1◦, pelvic incidence (PI)-LL of 41.7◦, T1SPi of 3.6◦, and pelvis tilt (PT) of 32.4◦. LL improved by 30.6◦ (P < .001) postoperation.Mean changes in PT (−8.3), sacral slope (8.9), T1SPi (−4.9), and PI-LL (−33.5) were all significant. The motion segment angle improved by 26.6◦, from 5.2◦ to −21.4◦ (P < .001). Neurological complications occurred in 32% patients postoperation (n = 8; 1 patient with both sensory and motor). New thigh numbness/paresthesia developed in 3 (13%) patients postoperation; only 1 (4%) persisted at latest follow-up. A total of 6 (24%) patients developed a new lower extremity motor deficit postoperation,with 4 (8%) having persistent new weakness at last follow-up. Out of 8 patients with preoperative motor deficit, half saw improvement postoperation and 75% improved by last follow-up.

CONCLUSION: There was net motor improvement, with 24% of patients improving and 16% having persistent new weakness at latest follow-up; 60% were unchanged. Radiographic results demonstrate that ACR is a useful tool to treat severe sagittal plane deformity.

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Intermediate-term clinical and radiographic outcomes with less invasive adult spinal deformity surgery

Acta Neurochirurgica (2020) 162:1393–1400

Little information exists regarding longer-term outcomes with minimally invasive spine surgery (MISS), particularly regarding long-segment and deformity procedures. We aimed to evaluate intermediate-term outcomes of MISS for adult spinal deformity (ASD).

Methods This retrospective review of a prospectively collected multicenter database examined outcomes at 4 or more years following circumferential MIS (cMIS) or hybrid (HYB) surgery for ASD. A total of 53 patients at 8 academic centers satisfied the following inclusion criteria: age > 18 years and coronal Cobb > 20°, pelvic incidence-lumbar lordosis (PI-LL) > 10°, or sagittal vertical axis (SVA) > 5 cm.

Results Radiographic outcomes demonstrated improvements of PI-LL from 16.8° preoperatively to 10.8° and coronal Cobb angle from38° preoperatively to 18.2° at 4 years. The incidence of complications over the follow-up periodwas 56.6%.A total of 21 (39.6%) patients underwent reoperation in the thoracolumbar spine, most commonly for adjacent level disease or proximal junctional kyphosis, which occurred in 11 (20.8%) patients. Mean Oswestry Disability Index (ODI) at baseline and years 1 through 4 were 49.9, 33.1, 30.2, 32.7, and 35.0, respectively. The percentage of patients meeting minimal clinically important difference (MCID) (defined as 12% or more from baseline) decreased over time, with leg pain reduction more durable than back pain reduction.

Conclusions Intermediate-term clinical and radiographic improvement following MISS for ASD is sustained, but extent of improvement lessens over time. Outcome variability exists within a subset of patients not meeting MCID, which increases over time after year two. Loss of improvement over time wasmore notable in back than leg pain. However, average ODI improvement meets MCID at 4 years after MIS ASD surgery.

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Kambin’s triangle: definition and new classification schema

J Neurosurg Spine 32:390–398, 2020

Kambin’s triangle is an anatomical corridor used to access critical structures in a variety of spinal procedures. It is considered a safe space because it is devoid of vascular and neural structures of importance. Nonetheless, there is currently significant variation in the literature regarding the exact dimensions and anatomical borders of Kambin’s triangle. This confusion was originally caused by leaving the superior articular process (SAP) unassigned in the description of the working triangle, despite Kambin identifying that structure in his original report. The SAP is the most relevant structure to consider when accessing the transforaminal corridor. Leaving the SAP unassigned has led to an open-handed application of the term “Kambin’s triangle.” That single eponym currently has two potential meanings, one meaning for endoscopic surgeons working through a corridor in the intact spine and a second meaning for surgeons accessing the disc space after a complete or partial facetectomy. Nevertheless, an anatomical corridor should have one consistent definition to clearly communicate techniques and use of instrumentation performed through that space. As such, the authors propose a new surgically relevant classification of this corridor. Assigning the SAP a border requires adding another dimension to the triangle, thereby transforming it into a prism. The term “Kambin’s prism” indicates the assignment of a border to all relevant anatomical structures, allowing for a uniform definition of the 3D space. From there, the classification scheme considers the expansion of the corridor and the extent of bone removal, with a particular focus on the SAP.

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Staged Laser Interstitial Thermal Therapy (LITT) Treatments to Left Insular Low-Grade Glioma

Neurosurgery 2019 DOI:10.1093/neuros/nyz120

Low-grade insular gliomas remain challenging tumors for aggressive resection because of the numerous functional and vascular structures surrounding them. Because of the potential morbidities associated with open surgical resection, less invasive techniques may confer a more optimal balance between cytoreduction and surgical complications. For this reason, we evaluated the use of laser interstitial thermal therapy (LITT) for resection of a dominant hemisphere oligodendroglioma World Health Organization (WHO) grade II in a 68-yr-old patient by use of multiple staged surgeries for its resection.

CLINICAL PRESENTATION: Patient KK was a 68-yr-old female who was found to have a large, left-sided insular mass that was shown to be an oligodendroglioma WHO grade II, positive for codeletion 1p/19q and IDH1 mutant on biopsy. Over the course of 3 mo, KK underwent 2 stages of LITT, targeting different areas of the 5-cmtumor. The 60-d magnetic resonance imaging (MRI) demonstrated a reduction in size of the tumor from5.2×3.3×2.4 cm to 3.6 × 1.9 × 1.4 cm. She returned for a second stage targeting the anterior portion of the tumor. KK did well postoperatively and went on to postsurgical chemoradiation. At the
2-yr follow-up, the lesion showed near resolution on MRI.

CONCLUSION: This case report demonstrates successful use of LITT for staged surgeries to treat a left hemisphere-dominant insular lesion. This establishes the use of LITT as a viable, minimally invasive option to treat tumors that are difficult to access or pose concerns for increased morbidity through an open surgery.

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Upfront Magnetic Resonance Imaging-Guided Stereotactic Laser-Ablation in Newly Diagnosed Glioblastoma: A Multicenter Review of Survival Outcomes Compared to a Matched Cohort of Biopsy-Only Patients

Neurosurgery. 2019 Dec 1;85(6):762-772

Laser ablation (LA) is used as an upfront treatment in patients with deep seated newly diagnosed Glioblastoma (nGBM).

OBJECTIVE: To evaluate the outcomes of LA in patients with nGBM and compare them with a matched biopsy-only cohort.

METHODS: Twenty-four nGBM patients underwent upfront LA at Cleveland clinic, Washington University in St. Louis, and Yale University (6/2011-12/2014) followed by chemo/radiotherapy. Also, 24 out of 171 nGBM patients with biopsy followed by chemo/radiotherapy were matched based on age (< 70 vs ≥ 70), gender, tumor location (deep vs lobar), and volume (<11 cc vs ≥11 cc). Progression-free survival (PFS), overall survival (OS), and disease-specific PFS and OS were outcome measures. Three prognostic groups were identified based on extent of tumor ablation by thermal-damage-threshold (TDT)-lines.

RESULTS: The median tumor volume in LA (n = 24) and biopsy only (n = 24) groups was 9.3 cm3 and 8.2 cm3 respectively. Overall, median estimate of OS and PFS in LA cohort was 14.4 and 4.3 mo compared to 15.8 mo and 5.9 mo for biopsy only cohort. On multivariate analysis, favorable TDT-line prognostic groups were associated with lower incidence of disease specific death (P = .03) and progression (P = .05) compared to other groups including biopsy only cohort. Only age (<70 yr, P=.02) and tumor volume (<11 cc, P=.03) were favorable prognostic factors for OS.

CONCLUSION: Themaximum tumor coverage by LA followed by radiation/chemotherapy is an effective treatment modality in patientswith nGBM, compared to biopsy only cohort. The TDT-line prognostic groups were independent predictor of disease specific death and progression after LA.

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Outcomes of endoscopic discectomy compared with open microdiscectomy and tubular microdiscectomy for lumbar disc herniations: a meta-analysis

J Neurosurg Spine 31:802–815, 2019

Endoscopic discectomy (ED) has been advocated as a less-invasive alternative to open microdiscectomy (OM) and tubular microdiscectomy (TM) for lumbar disc herniations, with the potential to decrease postoperative pain and shorten recovery times. Large-scale, objective comparisons of outcomes between ED, OM, and TM, however, are lacking. The authors’ objective in this study was to conduct a meta-analysis comparing outcomes of ED, OM, and TM.

METHODS The PubMed database was searched for articles published as of February 1, 2019, for comparative studies reporting outcomes of some combination of ED, OM, and TM. A meta-analysis of outcome parameters was performed assuming random effects.

RESULTS Twenty-six studies describing the outcomes of 2577 patients were included. Estimated blood loss was significantly higher with OM than with both TM (p = 0.01) and ED (p < 0.00001). Length of stay was significantly longer with OM than with ED (p < 0.00001). Return to work time was significantly longer in OM than with ED (p = 0.001). Postoperative leg (p = 0.02) and back (p = 0.01) VAS scores, and Oswestry Disability Index scores (p = 0.006) at latest follow-up were significantly higher for OM than for ED. Serum creatine phosphokinase (p = 0.02) and C-reactive protein (p < 0.00001) levels on postoperative day 1 were significantly higher with OM than with ED.

CONCLUSIONS Outcomes of TM and OM for lumbar disc herniations are largely equivalent. While this analysis demonstrated that several clinical variables were significantly improved in patients undergoing ED when compared with OM, the magnitude of many of these differences was small and of uncertain clinical relevance, and several of the included studies were retrospective and subject to a high risk of bias. Further high-quality prospective studies are needed before definitive conclusions can be drawn regarding the comparative efficacy of the various surgical treatments for lumbar disc herniations.

 

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Middle Meningeal Artery Embolization for Chronic Subdural Hematoma

Neurosurgery, Volume 85, Issue 6, December 2019, Pages 801–807

Chronic subdural hematoma (SDH) is a particularly challenging pathology due to high recurrence rates (2%-37%) and complex medical comorbidities that tend to afflict the patient population. Recently, there have been several case series published describing the use of middle meningeal artery (MMA) embolization as an alternative to surgery for treatment of new or recurrent chronic SDH.

OBJECTIVE: To describe our first 60 cases of MMA embolization for chronic SDH. METHODS: MMA embolization was performed using angiography, selective microcatheterization of the MMA, and infusion of polyvinyl alcohol particles. Outcomes were assessed clinically and with interval imaging studies at 1 d, 2 wk, and 6 wk postprocedure, and additional intervals as indicated.

RESULTS: MMA embolization was performed successfully on 60 total SDHs in 49 patients. This includes upfront treatment for new (notpreviously treated) SDH in 42, for recurrence in 8, and prophylaxis (soon after surgical evacuation) in 10. There were 3 mortalities (unrelated to the procedure),and no procedural complications.Of the 50 nonprophylactic cases,there were 4 (8.9%) cases of recurrence requiring surgical evacuation, and 31 (68.9%) that had resolution or reduction in size >50% of SDH at longest follow-up. Overall, 41 (91.1%) were stable or decreased in size and able to avoid surgery.

CONCLUSION: MMA embolization may represent a minimally-invasive alternative to surgery for new or recurrent chronic SDH, or as prophylaxis to reduce the risk of recurrence after surgery. Given our encouraging results with a 91% long-term success rate, a large scale clinical trial is warranted.

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Need for arthrodesis following facetectomy for spinal peripheral nerve sheath tumors

J Neurosurg Spine 31:112–122, 2019

Spinal peripheral nerve sheath tumors (PNSTs) are a group of rare tumors originating from the nerve and its supporting structures. Standard surgical management typically entails laminectomy with or without facetectomy to gain adequate tumor exposure. Arthrodesis is occasionally performed to maintain spinal stability and mitigate the risk of postoperative deformity, pain, or neurological deficit. However, the factors associated with the need for instrumentation in addition to PNST resection in the same setting remain unclear.

METHODS An institutional tumor registry at a tertiary care center was queried for patients treated surgically for a primary diagnosis of spinal PNST between 2002 and 2016. An analysis focused on patients in whom a facetectomy was performed during the resection. The addition of arthrodesis at the index procedure comprised the primary outcome. The authors also recorded baseline demographics, tumor characteristics, and surgery-related variables. Logistic regression was used to identify factors associated with increased risk of fusion surgery.

RESULTS A total of 163 patients were identified, of which 56 (32 had facetectomy with fusion, 24 had facetectomy alone) were analyzed. The median age was 48 years, and 50% of the cohort was female. Age, sex, and race, as well as tumor histology and size, were evenly distributed between patients who received facetectomy alone and those who had facetectomy and fusion. On univariate analysis, total versus subtotal facetectomy (OR 9.0, 95% CI 2.01–64.2; p = 0.009) and cervicothoracic versus other spinal region (OR 9.0, 95% CI 1.51–172.9; p = 0.048) were significantly associated with increased odds of performing immediate fusion. On multivariable analysis, only the effect of total facetectomy remained statistically significant (OR 6.75, 95% CI 1.47–48.8; p = 0.025).

CONCLUSIONS The authors found that total facetectomy and cervicothoracic involvement may be highly associated with the need for concomitant arthrodesis at the time of index surgery. These findings may help surgeons to determine the best surgical planning for patients with PNST.

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Complications for minimally invasive lateral interbody arthrodesis: a systematic review and meta-analysis comparing prepsoas and transpsoas approaches

J Neurosurg Spine 30:446–460, 2019

Minimally invasive anterolateral retroperitoneal approaches for lumbar interbody arthrodesis have distinct advantages attractive to spine surgeons. Prepsoas or transpsoas trajectories can be employed with differing complication profiles because of the inherent anatomical differences encountered in each approach. The evidence comparing them remains limited because of poor quality data. Here, the authors sought to systematically review the available literature and perform a meta-analysis comparing the two techniques.

METHODS A systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A database search was used to identify eligible studies. Prepsoas and transpsoas studies were compiled, and each study was assessed for inclusion criteria. Complication rates were recorded and compared between approach groups. Studies incorporating an analysis of postoperative subsidence and pseudarthrosis rates were also assessed and compared.

RESULTS For the prepsoas studies, 20 studies for the complications analysis and 8 studies for the pseudarthrosis outcomes analysis were included. For the transpsoas studies, 39 studies for the complications analysis and 19 studies for the pseudarthrosis outcomes analysis were included. For the complications analysis, 1874 patients treated via the prepsoas approach and 4607 treated with the transpsoas approach were included. In the transpsoas group, there was a higher rate of transient sensory symptoms (21.7% vs 8.7%, p = 0.002), transient hip flexor weakness (19.7% vs 5.7%, p < 0.001), and permanent neurological weakness (2.8% vs 1.0%, p = 0.005). A higher rate of sympathetic nerve injury was seen in the prepsoas group (5.4% vs 0.0%, p = 0.03). Of the nonneurological complications, major vascular injury was significantly higher in the prepsoas approach (1.8% vs 0.4%, p = 0.01). There was no difference in urological or peritoneal/bowel injury, postoperative ileus, or hematomas (all p > 0.05). A higher infection rate was noted for the trans-psoas group (3.1% vs 1.1%, p = 0.01). With regard to postoperative fusion outcomes, similar rates of subsidence (12.2% prepsoas vs 13.8% transpsoas, p = 0.78) and pseudarthrosis (9.9% vs 7.5%, respectively, p = 0.57) were seen between the groups at the last follow-up.

CONCLUSIONS Complication rates vary for the prepsoas and transpsoas approaches owing to the variable retroperitoneal anatomy encountered during surgical dissection. While the risks of a lasting motor deficit and transient sensory dis- turbances are higher for the transpsoas approach, there is a reciprocal reduction in the risks of major vascular injury and sympathetic nerve injury. These results can facilitate informed decision-making and tailored surgical planning regarding the choice of minimally invasive anterolateral access to the spine.

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Reduced Acute Care Costs With the ERAS ® Minimally Invasive Transforaminal Lumbar Interbody Fusion Compared With Conventional Minimally Invasive Transforaminal Lumbar Interbody Fusion

Neurosurgery 83:827–834, 2018

Enhancing Recovery After Surgery (ERAS (R)  ) programs have been widely adopted throughout the world, but not in spinal surgery. In this report, we review the implementation of a “fast track”surgery for lumbar fusion and its effect on acute care hospitalization costs.

OBJECTIVE: To determine if a “fast track” surgery methodology results in acute care cost savings.

METHODS: Thirty-eight consecutive ERAS patients were compared with patients undergoing conventional minimally invasive transforaminal lumbar interbody fusion. Differences between these groups included the use of endoscopic decompression, injections of liposomal bupivacaine, and performing the surgery under sedation in the ERAS R  group.

RESULTS: Patients had similar medical comorbidities (2.02 vs 2 for ERAS R  and comparator groups, respectively; P = .458). Body mass index was similar (26.5 vs 27.0; P = .329). ERAS R  patients were older (65 vs 59 yr, P= .031). Both groups had excellent clinical results with an improvement of 23% and 24%, respectively. Intraoperative blood loss was less (68±31 cc vs 231±73, P<0.001). Length of staywas also less with ERAS R  surgery, at ameanof 1.23±0.8 d vs 3.9 ± 1.1 d (P = 0.009). When comparing ERAS R  surgery to standard minimally invasive transforaminal lumbar interbody fusion, the total cost for the acute care hospitalization was $19212vs $22656, respectively(P<0.001). This reflected an average of $3444 in savings, which was a 15.2% reduction.

CONCLUSION: ERAS (R)  programs for spinal fusion surgery have the potential to reduce the costs of acute care. This is made possible by leveraging less invasive interventions to minimize soft tissue damage.

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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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Radiological adjacent-segment degeneration in L4–5 spondylolisthesis: comparison between dynamic stabilization and minimally invasive transforaminal lumbar interbody fusion

J Neurosurg Spine 29:250–258, 2018

Pedicle screw–based dynamic stabilization has been an alternative to conventional lumbar fusion for the surgical management of low-grade spondylolisthesis. However, the true effect of dynamic stabilization on adjacent segment degeneration (ASD) remains undetermined. Authors of this study aimed to investigate the incidence of ASD and to compare the clinical outcomes of dynamic stabilization and minimally invasive transforaminal lumbar interbody fusion (MI-TLIF).

METHODS The records of consecutive patients with Meyerding grade I degenerative spondylolisthesis who had undergone surgical management at L4–5 in the period from 2007 to 2014 were retrospectively reviewed. Patients were divided into two groups according to the surgery performed: Dynesys dynamic stabilization (DDS) group and MI-TLIF group. Pre- and postoperative radiological evaluations, including radiography, CT, and MRI studies, were compared. Adjacent discs were evaluated using 4 radiological parameters: instability (antero- or retrolisthesis), disc degeneration (Pfirrmann classification), endplate degeneration (Modic classification), and range of motion (ROM). Clinical outcomes, measured with the visual analog scale (VAS) for back and leg pain, the Oswestry Disability Index (ODI), and the Japanese Orthopaedic Association (JOA) scores, were also compared.

RESULTS A total of 79 patients with L4–5 degenerative spondylolisthesis were included in the analysis. During a mean follow-up of 35.2 months (range 24–89 months), there were 56 patients in the DDS group and 23 in the MI-TLIF group. Prior to surgery, both groups were very similar in demographic, radiological, and clinical data. Postoperation, both groups had similarly significant improvement in clinical outcomes (VAS, ODI, and JOA scores) at each time point of evaluation. There was a lower chance of disc degeneration (Pfirrmann classification) of the adjacent discs in the DDS group than in the MI-TLIF group (17% vs 37%, p = 0.01). However, the DDS and MI-TLIF groups had similar rates of instability (15.2% vs 17.4%, respectively, p = 0.92) and endplate degeneration (1.8% vs 6.5%, p = 0.30) at the cranial (L3–4) and caudal (L5–S1) adjacent levels after surgery. The mean ROM in the cranial and caudal levels was also similar in the two groups. None of the patients required secondary surgery for any ASD (defined by radiological criteria).

CONCLUSIONS The clinical improvements after DDS were similar to those following MI-TLIF for L4–5 Meyerding grade I degenerative spondylolisthesis at 3 years postoperation. According to radiological evaluations, there was a lower chance of disc degeneration in the adjacent levels of the patients who had undergone DDS. However, other radiological signs of ASD, including instability, endplate degeneration, and ROM, were similar between the two groups. Although none of the patients in the present series required secondary surgery, a longer follow-up and a larger number of patients would be necessary to corroborate the protective effect of DDS against ASD.

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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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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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