Surgical management of tethered spinal cord syndrome through biportal endoscopic approach: a novel technical note.

This video article explores a case of tethered cord release through a minimally invasive biportal endoscopic approach. A 24-year-old female with chronic back pain and thigh numbness underwent surgery. The chosen approach involved biportal endoscopic technique, demonstrating precision with minimal bone excision. Preoperative imaging revealed a midline fusion defect at L5 and abnormal conus medullaris termination. The surgical procedure involved one-sided hemilaminectomy, durotomy, and careful filum terminale separation. Postoperatively, radiological exams confirmed success with minimal bone defect. Emphasizing minimal invasiveness, reduced bone excision, and muscle sparing, this technique showcased successful outcomes, enabling the patient's rapid postoperative recovery without complications. The video can be found here: https://stream.cadmore.media/r10.3171/2024.1.FOCVID23228.

Comparison of lumbar microdiscectomy and unilateral biportal endoscopic discectomy outcomes: a single-center experience.

OBJECTIVE: Lumbar microdiscectomy (LMD) is still the gold-standard treatment for lumbar disc herniations with progressive neurological deficits that are refractory to conservative treatment. With improvement of endoscopic systems in recent years, endoscopic discectomy techniques have been developed as an alternative to LMD. The unilateral biportal endoscopic discectomy (UBE) technique is one of these endoscopic techniques, and its popularity has increased in recent years because it does not require high-cost specialized endoscopes, many microsurgical instruments are compatible with this system, and it is similar to LMD in terms of anatomical orientation. This study compared results between LMD and UBE techniques in patients with lumbar disc herniations performed by the same spine surgeons at a single center. METHODS: The data of patients with lumbar disc herniation who were operated on with LMD and UBE techniques were retrospectively reviewed. The data obtained were statistically evaluated. The operative video of one of the patients who underwent UBE was edited for demonstration. RESULTS: Between January 2021 and June 2022, 93 patients were operated on for lumbar disc herniation. LMD was performed in 39 patients, and UBE was performed in 54 patients. There were no significant differences in the complications, recurrence, postoperative back and leg pain, patient satisfaction rates, and quality of life index results of the patients in the two groups. The operation time was shorter in the LMD group. In the UBE group, estimated blood loss was lower and postoperative hospitalization was shorter. CONCLUSIONS: Although LMD is still the gold-standard treatment for lumbar disc herniation, the results of UBE are comparable to those of LMD, and it may be a good alternative for spine surgeons who prefer minimally invasive surgery.

Retrospective Evaluation of Neurosurgery Outpatient Services in 3 Different Tertiary Care Hospitals in Turkey.

BACKGROUND: Cascading of referrals to health institutions aims to increase the balanced distribution and quality of health services provided. Although health institutions in Turkey are divided into steps in terms of scope, there is no mandatory referral system for patient application. METHODS: Patients admitted to the neurosurgery outpatient clinic of 3 different hospitals in the first week of September 2023 were analyzed. The patients' complaints, reasons for referral to the outpatient clinic, by whom or by which system, the department to which they should have applied, and the necessity of the operation were examined to evaluate. RESULTS: There were 671 applications made to the neurosurgery outpatient clinic in 3 different health institutions. The average examination time per patient was 6 minutes. Surgical treatment was planned for only 14.8% of the patients. Most patients were referred to physical therapy and neurology departments from neurosurgery. Only 59% of the patients came to the examination by making an appointment, while 41% were examined without an appointment. The ratio of inappropriate admissions to total admissions in these 3 health institutions was 85.1%. CONCLUSIONS: Only a minority of patients admitted to the neurosurgery outpatient clinic at a public health institution in Turkey were found to require surgery, while the majority were referred to other outpatient clinics. This study underscores the significance of the referral chain in delivering high-quality health care services, particularly in the field of neurosurgery.

Microsurgical and fiber tract anatomy of the interthalamic adhesion.

OBJECTIVE: The authors of this study aimed to define the microanatomy of the interthalamic adhesion (ITA) using microfiber dissection, magnetic resonance (MR) tractography, and histological analysis. METHODS: Sagittal, coronal, and axial MR images from 160 healthy individuals 2-82 years of age were examined. The relationships between age range and ITA morphology as well as between gender and ITA morphology were evaluated statistically. Among these 160 individuals, 100 who had undergone MR tractography were examined. In this group, the presence of fiber tracts in the ITA and the relationship with ITA morphological types were examined. Thirty formalin-fixed human cadaveric brains were also examined endoscopically, and 6 hemispheres were dissected from the medial to lateral and superior to inferior directions under the microscope. Sections taken from one of the brains with an ITA type 2 with both thalami were examined histologically. Anti-neurofilament antibody was used in the histological examination. RESULTS: Four morphological types of ITA were observed. Type 1 had an adhesion/adherent appearance, type 2 had a bridge/commissure appearance, type 3 showed no adhesion, and type 4 had a double bridge. Tractographic examination revealed that 28% had no fiber tract transition in the ITA, 21% had a significant transition, and 51% had an indistinct transition. Statistically, the presence of the ITA was significantly higher in the pediatric (age) and female (gender) groups. In specimens with ITAs of a bridge/commissure appearance (type 2), fiber tracts showed clear transitions between thalami. In type 1 (adherent/adhesive appearance), fiber tracts were observed within the ITA, but a reciprocal transition was unclear. Dissection showed that these fiber tracts in the ITA reach the nucleus accumbens, caudate nucleus, and frontoorbital region anteriorly and the lateral habenula and posterior commissure posteriorly. Some fibers also joined the ansa peduncularis. In histological studies, axonal fibers moving in the ITA were observed with anti-neurofilament antibody staining. CONCLUSIONS: This is the first study to demonstrate fiber tracts of the ITA through fiber dissection and transillumination techniques as well as radiological and histological study. Statistical data were obtained by comparing the morphological group with age and gender groups. The anatomy of this structure, which has been neglected for many years, was reexamined. This study showed that the ITA has fibers connecting different parts of the brain, in contrast to previous studies suggesting that it was a simple massa.

Suprafloccular transhorizontal fissure approach to the cerebellopontine angle: an anatomical study with case series.

The suprafloccular transhorizontal fissure approach is a modified variant of the classical retrosigmoid approach option to be chosen for cerebellopontine angle lesions. In this study, we aimed to demonstrate a previously described but not widely used method, the suprafloccular transhorizontal fissure approach with anatomical dissection on the cadaver, accompanied by a case presentation with the largest clinical series in the literature. Klingler's protocol was used to prepare 8 silicone injected and 8 non-silicone injected human hemispheres. A total of 210 patients who underwent surgery in the cerebellopontine angle between 2019 and 2022 were evaluated in our clinic. Of these, the suprafloccular transhorizontal fissure approach was applied in 33 patient, and it was successful in 26 patient, but this approach could not be achieved in 7 patients. The transhorizontal fissure is a fissure in the cerebellum located between the superior semilunar lobule and the inferior semilunar lobule. In the 26 patients we operated with the suprafloccular transhorizontal fissure approach, there was no need for retraction and no complications developed. However, in 7 patients, this fissure could not be dissected due to adhesions. Suprafloccular approach is an alternative to the classical retrosigmoid approach in tumours smaller than 2 cm, medially localised with little cerebellar oedema and neurovascular compression syndrome. Because in this approach, no cerebellum retraction is required, vascular structures are better preserved and the surgical time is shortened. This approach can be applied in smaller tumours than 2 cm when the sulcal anatomy is appropriate.

Arterial Supply of the Basal Ganglia: A Fiber Dissection Study.

BACKGROUND: The basal ganglia, a group of subcortical nuclei located deep in the insular cortex, are responsible for many functions such as motor learning, emotion, and behavior control. Nowadays, because it has been shown that deep brain stimulation and insular tumor surgery can be performed by endovascular treatment, the importance of the vascular anatomy of the basal ganglia is being increasingly recognized. OBJECTIVE: To explain the arterial blood supply of the basal ganglia using white matter dissection. METHODS: The Klingler protocol was used to prepare 12 silicone-injected human hemispheres. The dissections were performed from lateral to medial with the fiber dissection technique to preserve arteries. RESULTS: The globus pallidus blood supply came from the medial lenticulostriate, lateral lenticulostriate, and anterior choroidal arteries; the substantia nigra and subthalamic nucleus were supplied by the branches of posterior cerebral artery; the putamen was supplied by the lateral and medial lenticulostriate arteries; and the caudate nucleus was supplied by the lateral lenticulostriate and medial lenticulostriate arteries and the recurrent artery of Heubner. CONCLUSION: Knowledge of the detailed anatomy of the basal ganglia and its vascular supply is essential for avoiding postoperative ischemic complications in surgeries related to the insula. In addition, knowledge of this anatomy and vascular relationship opens the doors to endovascular deep brain stimulation treatment. This study provides a 3-dimensional understanding of the blood supply to the basal ganglia by examining it using the fiber dissection technique. Further studies could use advanced imaging modalities to explore the vascular relationships with critical structures in the brain.

Microsurgical anatomy and insular connectivity of the cerebral opercula.

OBJECTIVE: Radiological, anatomical, and electrophysiological studies have shown the insula and cerebral opercula to have extremely high functionality. Because of this complexity, interventions in this region cause higher morbidity compared to those in other areas of the brain. In most early studies of the insula and white matter pathways, insular dissection was begun after the opercula were removed. In this study, the authors examined the insula and deep white matter pathways to evaluate the insula as a whole with the surrounding opercula. METHODS: Twenty formalin-fixed adult cerebral hemispheres were studied using fiber microdissection techniques and examination of sectional anatomy. Dissections were performed from lateral to medial, medial to lateral, inferior to superior, and superior to inferior. A silicone brain model was used to show the normal gyral anatomy. Sections and fibers found at every stage of dissection were photographed with a professional camera. MRI tractography studies were used to aid understanding of the dissections. RESULTS: The relationships between the insula and cerebral opercula were investigated in detail through multiple dissections and sections. The relationship of the extreme and external capsules with the surrounding opercula and the fronto-occipital fasciculus with the fronto-orbital operculum was demonstrated. These findings were correlated with the tractography studies. Fibers of the extreme capsule connect the medial aspect of the opercula with the insula through the peri-insular sulcus. Medial to lateral dissections were followed with the removal of the central core structures, and in the last step, the medial surface of the cerebral opercula was evaluated in detail. CONCLUSIONS: This anatomical study clarifies our understanding of the insula and cerebral opercula, which have complex anatomical and functional networks. This study also brings a new perspective to the connection of the insula and cerebral opercula via the extreme and external capsules.