How I do it: step-by-step BacJac™ posterior interspinous spacer placement.

BACKGROUND: BacJac™ is a posterior interspinous spacer for selected cases of degenerative lumbar spine diseases. It blocks the metameric vertebral segment in terminal extension, restoring foraminal heights. METHODS: The authors provide a detailed step-by-step description of the surgical technique, shedding light on surgical tips and pitfalls of this procedure. An accurate pre-operative patient selection is analyzed, defining meticulously surgical indications. A high-quality video of the surgical procedure is provided. CONCLUSION: BacJac™ interspinous device allows a safe, mini-invasive, and effective treatment of selected cases of degenerative lumbar spine disease.

How I do it: surgical clip reconstruction of a large, partially thrombosed, ruptured middle cerebral artery aneurysm.

BACKGROUND: Ruptured large and partially thrombosed aneurysms are challenging lesions to treat successfully. METHODS: We describe the surgical treatment of a large, ruptured partially thrombosed middle cerebral artery (MCA) aneurysm. Once the Sylvian fissure is dissected, temporary clips are placed, and the clot is evacuated with simple microsuction and ultrasonic aspiration. The aneurysm is then carefully clip reconstructed to avoid compromise of the parent vessels. CONCLUSION: In cases of surgical clipping of large, thrombosed aneurysms, it is important to be aware of a few, but critically important, pitfalls to ensure successful outcome.

S1 Sacrectomy for Re-recurrent Rectal Cancer: Our Experience with Reconstruction Using an Expandable Vertebral Body Replacement Device.

INTRODUCTION: R0 resection is achieved by high sacrectomy for local recurrence of colorectal cancer, but significant rates of perioperative complications and long-term patient morbidity are associated with this procedure. In this report, we outline our unique experience of using an expandable cage for vertebral body reconstruction following S1 sacrectomy in a 66-year-old patient with re-recurrent rectal cancer. We aim to highlight several key steps, with a view to improving postoperative outcomes. TECHNIQUE: A midline laparotomy was performed with the patient in supine Lloyd-Davies position, demonstrating recurrence of tumor at the S1 vertebral body. Subtotal vertebral body excision of S1 with sparing of the posterior wall and ventral foramina was completed by using an ultrasonic bone aspirator. Reconstruction was performed using an expandable corpectomy spacer system. The system was assembled and expanded in situ to optimally bridge the corpectomy. The device was secured into the L5 and S2 vertebrae by means of angled end plate screws superiorly and inferiorly. Bone grafts were positioned adjacent to the implant after this. RESULTS: Total operating time was 266 minutes with 350 mL of intraoperative blood loss. There were no immediate postoperative complications. The patient did not report any back pain at the time of discharge, and no neurological deficit was reported or identified. Postoperative CT scan showed excellent vertebral alignment and preservation of S1 height. CONCLUSION: We conclude that high sacrectomy with an expandable metal cage is feasible in the context of re-recurrent rectal cancer when consideration is given to the method of osteotomy and vertebral body replacement.

Surgical approach to posterior inferior cerebellar artery aneurysms.

BACKGROUND: The far-lateral is a standardised approach to clip aneurysms of the posterior inferior cerebellar artery (PICA). Different variants can be adopted to manage aneurysms that differ in morphology, topography, ruptured status, cerebellar swelling and surgeon preference. METHOD: We distinguished five paradigmatic approaches aimed to manage aneurysms that are: proximal unruptured; proximal ruptured requiring posterior fossa decompression (PFD); proximal ruptured not requiring PFD; distal unruptured; distal ruptured. CONCLUSIONS: Preoperative planning in the setting of PICA aneurysm surgery is of paramount importance to perform an effective and safe procedure, to ensure an adequate PFD and optimal proximal control before aneurysm manipulation.

A New Technique in Surgical Management of the Giant Cerebral Hydatid Cysts.

OBJECTIVES: In hydatid disease, the central nervous system is affected approximately in 2% to 3% of patients. Surgical management in these patients is important. To develop a surgical technique to avoid the formation of great volume of cavity after hydatid cyst removal and prevent complications associated with brain collapse and cortical convolution. PATIENTS AND METHODS: In 2 patients, hydatid cysts were delivered by this new technique. A balloon filled with 150 cc of sterile air/distilled water was placed in the cavity until the balloon filled the entire cavity. Air/distilled water evacuation was continued at a rate of 20 cc/d and, after a week, eventually, the balloons were removed RESULTS:: All cysts were delivered without rupture. Neurologic outcomes were good. No complications were observed related to usage of the system such as balloon rupture, evacuation problems, and infection. CONCLUSION: The authors believe that the balloon insertion technique may be a useful method to prevent brain collapse, cortical convolution, and complications associated with this condition. Further technical refinements of the system are needed for better results.

Intradiscal Expandable Balloon Distraction During Transforaminal Decompression for Lumbar Foraminal and Lateral Recess Stenosis.

Advanced videoendoscopic equipment (such as motorized drills, chisels, and rongeurs) facilitates the use of modern decompression tools through the inner working channel of the spinal endoscope using the transforaminal approach. Postoperative dysesthetic leg pain, however, is common because of irritation of the dorsal root ganglion. This article presents a novel surgical technique employing an expandable balloon placed into the hollow intervertebral space in patients without any functional disc tissue to distract the stenotic motion segment. This approach improves visualization, facilitates removal of bone during the decompression, and minimizes intraoperative manipulation of the exiting and traversing nerve roots. In a study of 52 targeted patients with symptomatic spinal stenosis at 60 levels (L2/3-1, L3/4-9, L4/5-28, and L5/S1-22) due to advanced degenerative changes of the intervertebral disc and facet joint complex contributing to both foraminal and lateral recess stenosis, only 2 of the 52 patients complained of postoperative dysesthetic leg pain (3.85%) after undergoing this novel procedure. At the final 2-year follow-up, 80.9% of patients showed Excellent and Good outcomes according to modified Macnab criteria.

Emerging Technologies in Flow Diverters and Stents for Cerebrovascular Diseases.

PURPOSE OF REVIEW: Stents and flow diverters have revolutionized the treatment of cerebrovascular disease. Guglielmi coils, flexible microcatheters, and first-generation intracranial stents, such as Neuroform (Stryker Neurovascular) and Enterprise stents (Codman/DePuy-Synthes), have paved the way for the development of the Pipeline Embolization Device (PED) (ev3/Covidien/Medtronic) and other endovascular approaches. RECENT FINDINGS: This review discusses the historical development of flow diverter technologies from the PED to similar devices, such as the Surpass stent (Stryker Neurovascular), the Flow-Redirection Endoluminal Device (FRED; MicroVention, Inc.), the SILK stent (Balt Extrusion), and the p64 Flow Modulation Device (Phenox). In addition, the potential use of drug-eluting stents and various bioresorbable scaffolds (e.g., poly-L-lactic acid, magnesium), new developments in stent material (e.g., thin-film nitinol), design (e.g., biocompatible polymers, embedded microcircuitry, flow models), and potential applications for flow diverters will be considered. Endovascular treatment of cerebrovascular disease is rapidly advancing via continued development of new technology.

Application of actuator-driven pulsed water jet in aneurysmal subarachnoid hemorrhage surgery: its effectiveness for dissection around ruptured aneurysmal walls and subarachnoid clot removal.

In clipping surgery for aneurysmal subarachnoid hemorrhage (aSAH), critical steps include clot removal and dissection of aneurysms without premature rupture or brain injuries. To pursue this goal, a piezo actuator-driven pulsed water jet (ADPJ) system was introduced in this study. This study included 42 patients, who suffered aSAH and underwent clipping surgery. Eleven patients underwent surgery with the assistance of the ADPJ system (ADPJ group). In the other 31 patients, surgery was performed without the ADPJ system (Control group). The ADPJ system was used for clot removal and aneurysmal dissection. The clinical impact of the ADPJ system was judged by comparing the rate of premature rupture, degree of clot removal, and clinical outcomes. Intraoperatively, a premature rupture was encountered in 18.2 and 25.8% of cases in the ADPJ and control groups, respectively. Although the differences were not statistically significant, intraoperative observation suggested that the ADPJ system was effective in clot removal and dissection of aneurysms in a safe manner. Computed tomography scans indicated the achievement of higher degrees of clot removal, especially when the ADPJ system was used for cases with preoperative clot volumes of more than 25 ml (p = 0.047, Mann-Whitney U test). Clinical outcomes, including incidence of postoperative brain injury or symptomatic vasospasm, were similar in both groups. We described our preliminary surgical results using the ADPJ system for aSAH. Although further study is needed, the ADPJ system was considered a safe and effective tool for clot removal and dissection of aneurysms.

Current applications of robotics in spine surgery: a systematic review of the literature.

OBJECTIVE Surgical robotics has demonstrated utility across the spectrum of surgery. Robotics in spine surgery, however, remains in its infancy. Here, the authors systematically review the evidence behind robotic applications in spinal instrumentation. METHODS This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Relevant studies (through October 2016) that reported the use of robotics in spinal instrumentation were identified from a search of the PubMed database. Data regarding the accuracy of screw placement, surgeon learning curve, radiation exposure, and reasons for robotic failure were extracted. RESULTS Twenty-five studies describing 2 unique robots met inclusion criteria. Of these, 22 studies evaluated accuracy of spinal instrumentation. Although grading of pedicle screw accuracy was variable, the most commonly used method was the Gertzbein and Robbins system of classification. In the studies using the Gertzbein and Robbins system, accuracy (Grades A and B) ranged from 85% to 100%. Ten studies evaluated radiation exposure during the procedure. In studies that detailed fluoroscopy usage, overall fluoroscopy times ranged from 1.3 to 34 seconds per screw. Nine studies examined the learning curve for the surgeon, and 12 studies described causes of robotic failure, which included registration failure, soft-tissue hindrance, and lateral skiving of the drill guide. CONCLUSIONS Robotics in spine surgery is an emerging technology that holds promise for future applications. Surgical accuracy in instrumentation implanted using robotics appears to be high. However, the impact of robotics on radiation exposure is not clear and seems to be dependent on technique and robot type.

Blood Flow Diversion as a Primary Treatment Method for Ruptured Brain Aneurysms-Concerns, Controversy, and Future Directions.

Flow diversion is a novel treatment for brain aneurysms that works by redirecting blood flow away from the aneurysm. Immediately after placement of the stent, blood flow stagnates within the aneurysm dome and it undergoes thrombosis. Over time, a new endothelium develops across the neck, thereby reconstructing the parent vessel and curing the aneurysm. The use of this treatment method for ruptured aneurysms has two specific concerns: 1) risk of hemorrhage from the aneurysm after treatment because of potential delayed aneurysm occlusion; and 2) hemorrhagic complications from antiplatelet use, which is required to prevent thromboembolic complications from the device. In this review, we explore these two concerns based on the emerging published literature. Optimal peri-procedural management of these issues in the neurocritical care setting is vital to improving outcomes. We also identify ongoing clinical trials of flow diversion for the treatment of ruptured aneurysms. Flow diversion is an alternative to clipping or coiling for many ruptured aneurysms and may be potentially more efficacious in certain aneurysm subtypes.

STN DBS for Parkinson's disease: results from a series of ten consecutive patients implanted under general anaesthesia with intraoperative use of 3D fluoroscopy to control lead placement.

BACKGROUND: Deep brain stimulation (DBS) of the sub-thalamic nucleus (STN) is a recognised treatment for advanced Parkinson's disease (PD). We present our results of 10 consecutive patients implanted under general anaesthesia (GA) using intraoperative robotic three-dimensional (3D) fluoroscopy (Artis Zeego; Siemens, Erlangen, Germany). METHOD: Ten patients (nine men, one woman) with a mean age of 57.6 (range, 41-67) years underwent surgery between October 2013 and January 2015. The mean duration of PD was 9.2 [1-10] year. The procedure was performed under GA: placement of the stereotactic frame, implantation of the electrodes (Lead 3389; Medtronic, Minnesota, MN, USA) and 3D intraoperative fluoroscopic control (Artis Zeego) with image fusion with the preoperative MRI scans. All patients were evaluated preoperatively and 6 months postoperatively. RESULTS: The mean operative time was 240.1 (185-325) min. The mean Unified Parkinson's Disease Rating Scale (UPDRS) II OFF medication decreased from 23.9 preoperatively to 15.7 postoperatively. The mean OFF medication UPDRS III decreased from 41 to 11.6 and the UPDRS IV decreased from 10.6 to 7. The mean preoperative and postoperative L-Dopa doses were 1,178.5 and 696.5 mg, respectively. Two complications were recorded: one episode of transient confusion (24 h) and one internal pulse generator (IPG) infection. CONCLUSIONS: With improvement in preoperative magnetic resonance imaging (MRI) and the ability to control the position of the leads intraoperatively using Artis Zeego, we now perform this procedure under GA. Our results are comparable to others reported. The significant decrease in the duration of surgery could be associated with a reduced rate of complications (infection, loss of patient collaboration). However, this observation needs to be confirmed.

The use of magnetically controlled growing rod device for pediatric scoliosis.

OBJECTIVE: To study the safety and efficacy of an innovative device using distraction-based magnetically controlled growing rods (MCGR) for the treatment of pediatric scoliosis. METHODS: This is an evidence-based systematic review of literature for the surgical management of patients with pediatric scoliosis using MCGR technique. Six clinical studies regarding the use of MCGR were included in this review, with a total of 68 patients, and mean age of 8.38 years. The dual-rod (DR) technique of rod construct with MCGR was used in 33.85% and the single-rod (SR) in 66.15% of the patients. RESULTS: The mean preoperative main coronal curve for the DR was 65.9°, and for the SR was 69.6° (p>0.05). At the latest follow-up, it was 36.8° for DR and 43.0 degrees for SR (p<0.05). The mean preoperative T1 - S1 spinal length was 298.7 mm for the DR and 303.5 mm for the SR group (p<0.05). According to the latest follow-up, using the DR construct, the spinal length increased to 347 mm with 13.92% of total lengthening; and using the SR construct, the average lengthening was 339 mm, with 10.48% of total lengthening (p<0.05). Postoperative complications were similar, 25% in DR and 31.57% in the SR group (p>0.05). CONCLUSION: Level IV of medical evidence supports the use of MCGR as a safe and effective alternative for the treatment of severe pediatric scoliosis. Recommendation Grade C supports the role of MCGR with DR construct as an option to achieve a better correction of the scoliotic curve and to maximize the postoperative T1 - S1 spinal length.

Preliminary results of recurrent cubital tunnel syndrome treated with neurolysis and porcine extracellular matrix nerve wrap.

PURPOSE: To evaluate the clinical results of revision neurolysis and wrapping with porcine extracellular matrix (AxoGuard Nerve Protector, AxoGen Inc., Alachua, FL) for cubital tunnel syndrome after one previous surgical decompression. METHODS: Twelve patients with recurrent cubital tunnel syndrome were treated with decompression, porcine extracellular matrix nerve wrap, and minimal medial epicondylectomy (if not previously performed). The average follow-up period was 41 months (range, 24-61 mo). All patients had recurrent symptoms after having previously undergone one surgical decompression. The mean patient age was 45 years (range, 30-58 y). All patients were evaluated subjectively and objectively (pain, satisfaction, static 2-point discrimination, grip strength, and pinch strength). RESULTS: A significant improvement was demonstrated in postoperative pain levels (from 8.5 to 1.7), grip strength (from 41% to 86% of the unaffected side), and pinch strength (from 64% to 83% of the unaffected side). Static 2-point discrimination improved from an average 10.4 mm preoperatively to 7.6 mm postoperatively. Eleven of 12 patients demonstrated 2 mm or more improvement in 2-point discrimination postoperatively. There were no complications related to the use of the porcine extracellular matrix for nerve wrapping. CONCLUSIONS: This study found that secondary decompression combined with porcine extracellular matrix nerve wrapping was an effective and safe treatment for patients with recurrent cubital tunnel syndrome. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

The posterior coronal incision.

BACKGROUND: The coronal incision is a standard surgical approach in craniofacial surgery. It has undergone many modifications during the years in an attempt to optimize the esthetic appearance of the scar, including the sawtooth "stealth incision" and the sinusoidal incision. METHODS: We describe an alternative coronal approach extending posteriorly from the postauricular region over the occiput, resulting in an axial scar. RESULTS AND DISCUSSION: The posterior coronal incision provides equivalent exposure of the craniofacial skeleton while placing the scar in an esthetically optimal location that is much more likely to be camouflaged by hair, especially in patients with thinning hair or male-pattern baldness. It avoids a vertical temporal scar that is prone to widening and also allows the incision to be placed remotely from any neurosurgical hardware in the frontotemporal region. It may be used in craniofacial or neurosurgical procedures requiring access to the posterior or anterior cranial vaults or the upper craniofacial skeleton down to the maxillary alveolar rim.

A handmade eye movement monitor using a piezoelectric device during transsphenoidal surgery.

We describe a handmade eye movement monitor featuring a piezoelectric device for use during transsphenoidal surgery (TSS). The sensor consists of a piezoelectric device, condensers, resistors, and several inexpensive parts. Eyeball movements elicited by surgical manipulations during TSS for cavernous sinus tumor are detected by small disc-shaped sensors taped to the eyelids. The responses could be monitored as sharp waves on an electroencephalograph. After we started using this monitor, both the incidence and the severity of cranial nerve injuries during TSS for cavernous sinus tumor decreased. Our device is especially useful at operations to remove functioning pituitary adenomas invading the cavernous sinus and contributes to their favorable endocrine outcomes. None of our patients manifested the postoperative swelling of the eyelids or conjunctival congestion generally seen in patients subjected to the insertion of needle sensors for the acquisition of electromyograms of the extraocular muscles, which is widely used during surgery to identify the cranial nerves responsible for eye movement. Our monitor is less expensive and easier to use than any commercially available sensor devices. As our method does not require the insertion of needle sensors, it is less invasive than electromyography of the extraocular muscles.

Robot-assisted triple neurectomy for iatrogenic inguinal pain: a technical note.

BACKGROUND: Painful neuromas are a relatively common complication of hernia and abdominal wall surgery. OBJECTIVE: Surgical neurectomy has the potential to to provide durable relief for chronic pain; however, current surgical approaches are not without morbidity or anatomical challenges.We sought a surgical alternative. METHODS: In the treatment of a case of incapacitating inguinal pain, we performed an anterior transperitoneal approach using a surgical robot. RESULTS: This approach was facile and provided elegant anatomical visualization. CONCLUSION: This case describes the first known robot-assisted laparoscopic triple neurectomy and details a simplified, transperitoneal approach.

Robotic-assisted thymectomy with Da Vinci II versus sternotomy in the surgical treatment of non-thymomatous myasthenia gravis: early results.

BACKGROUND: The role of thymectomy in myasthenia gravis remains controversial. The remission rate 5years after surgery varies from 13 to 51% in the literature. Sternotomy is the standard technique, though unacceptable by patients because of significant esthetic sequelae. Our objective was to demonstrate that the robot-assisted technique using the Da Vinci Surgical Robot II is at least as efficient and leaves fewer scars than the standard surgical technique. METHODS: We retrospectively reviewed the data of 31 consecutive patients suffering from myasthenia gravis who underwent surgery in our center from January 1998 to March 2010. Ten patients with thymoma were excluded from this study. Two groups were formed: group 1 corresponding to patients treated with sternotomy, group 2 patients with robot-assisted technique. The duration of the hospital stay, the pain on D1, the degree of improvement at 1year according to Myasthenia Gravis Foundation of America (MGFA) classification, the frequency of relapses, and perioperative treatment were studied. RESULTS: Our sample consisted of 14 women and seven men. The mean age was 31.3years. The mean delay before surgery was 24months. Group 1 included 15 patients and group 2 had six patients. The complete remission rate at 1year was 9.5% (n=2). Surgery decreased the frequency of relapses after surgery (P=0.08) equally in the two groups. The duration of hospital stay and the pain level on D1 in group 2 were significantly lower than those in group 1 (P=0.02 and P<0.001). The degree of postoperative improvement was not significantly different between the two groups (P=0.31). CONCLUSION: The results at 1year are fully comparable for sternotomy and the robot-assisted technique. The robot provides additional benefits of minimally invasive techniques: minimal esthetic sequelae in often young patients, less parietal morbidity (including pain), shorter hospital stays. Our complete remission rate, lower than those in the literature, must be considered taking into account the early nature of these results. The surgical robot, because of its many advantages, appears to be a promising technique and should facilitate the early management of these patients.

External ventricular drainage for intraventricular hemorrhage.

Hemorrhagic stroke accounts for only 10% to 15% of all strokes; however, it is associated with devastating outcomes. Extension of intracranial hemorrhage (ICH) into the ventricles or intraventricular hemorrhage (IVH) has been consistently demonstrated as an independent predictor of poor outcome. In most circumstances the increased intracranial pressure and acute hydrocephalus caused by ICH is managed by placement of an external ventricular drain (EVD). We present a systematic review of the literature on the topic of EVD in the setting of IVH hemorrhage, articulating the scope of the problem and prognostic factors, clinical indications, surgical adjuncts, and other management issues.

Corpus callosotomy with the CO2 laser suction device: a technical note.

INTRODUCTION: Patients with symptomatic generalized epilepsy who are not candidates for resections may be considered for corpus callosotomy. METHODS: The two patients who were followed in this series underwent resection of the corpus callosum utilizing the OmniGuide CO(2) Laser System. SURGICAL TECHNIQUE: The OmniGuide CO(2) Laser Systemcan be used in place of the bipolar electrocautery in a corpus callosotomy to improve midline dissection, decrease the likelihood of entering the ventricle, and improve visualization in the dissection. CONCLUSION: The OmniGuide CO(2) Laser System is a valuable option when performing a corpus callosotomy.