An in vitro evaluation of sagittal alignment in the cervical spine after insertion of supraphysiologic lordotic implants.

PURPOSE: Cervical spine malalignment can develop as a consequence of degenerative disc disease or following spinal surgery. When normal sagittal alignment of the spine is disrupted, further degeneration may occur adjacent to the deformity. The purpose of this study was to investigate changes in lordosis and sagittal alignment in the cervical spine after insertion of supraphysiologic lordotic implants. METHODS: Eight cadaveric cervical spines (Occiput-T1) were tested. The occiput was free to translate horizontally and vertically but constrained from angular rotation. The T1 vertebra was rigidly fixed with a T1 tilt of 23°. Implants with varying degrees of lordosis were inserted starting with single-level constructs (C5-C6), followed by two (C5-C7), and three-level (C4-C7) constructs. Changes in sagittal alignment, Occ-C2 angle, cervical lordosis (C2-7), and segmental lordosis were measured. RESULTS: Increasing cage lordosis led to global increases in cervical lordosis. As implanted segmental lordosis increased, the axial levels compensated by decreasing in lordosis to maintain horizontal gaze. An increase in cage lordosis also corresponded with larger changes in SVA. CONCLUSION: Reciprocal compensation was observed in the axial and sub-axial cervical spine, with the Occ-C2 segment undergoing the largest compensation. Adding more implant lordosis led to larger reciprocal changes and changes in SVA. Implants with supraphysiologic lordosis may allow for additional capabilities in correcting cervical sagittal plane deformity, following further clinical evaluation.

Safety, immediate and mid-term results of the newer generation of hydrogel coils in the treatment of ruptured aneurysms: a multicenter study.

OBJECTIVE: To assess the 'real-world' performance of the newer generation of hydrogel coils in ruptured aneurysms. METHODS: A multicenter retrospective study was carried out of angiographic and clinical outcome data on consecutive patients with ruptured aneurysms treated with at least 70% of the newer generation of hydrogel coils. Demographics and data on clinical grade, smoking, use of statins, aneurysm size, location, technique used, packing density, immediate angiographic result, angiographic follow-up, rebleeding and clinical outcome were obtained and analyzed. RESULTS: Eighty patients (54F; 26M) with an average age of 55.1 years were entered in the study. Forty-four presented good clinical grade (Hunt and Hess 1 or 2). Forty-two (52.5%) aneurysms were ≤5 mm. 56.7% of the aneurysms were treated with simple coil embolization and 39.6% with balloon-assisted coil. The packing density ranged from 9.3% to 92.6% (mean 48.5%). Immediate occlusion rates (Raymond-Roy Scale) were: complete occlusion (class I) in 57.5%, residual neck (class II) in 32.5% and residual aneurysm (class III) in 10%. Intraoperative rupture occurred in 3 cases (3.75%). Clinical follow-up, available in 73 patients, showed a good outcome (modified Rankin Scale 0-2) in 76.3%. Preliminary data on imaging follow-up were available in 54 patients (average 6.8 months) with complete occlusion in 77.8%, residual neck in 20.3% and residual aneurysm in 1.9%. There was no re-hemorrhage. CONCLUSIONS: Our data show that the use of the newer-generation hydrogel coils in the treatment of ruptured aneurysms is feasible, safe and effective with high immediate and mid-term occlusion rates and low morbidity.

The radical transbasal approach for resection of anterior and midline skull base lesions.

OBJECT: Craniofacial surgery can be performed to treat midline and anterior skull base lesions by creating a bicoronal scalp incision without the need for an additional transfacial procedure. Originally described as the transbasal approach, several modifications for further exposure of the skull base have been described. The authors present data on the application and outcomes of a modified transbasal approach. The radical transbasal approach consists of a bifrontal craniotomy and a frontoorbitonasal osteotomy. METHODS: Between 1992 and 2002, 41 patients (28 male and 13 female patients with a mean age of 38.3 years [range 7-77 years]) underwent 44 radical transbasal procedures. Twenty-three malignant and 18 benign lesions involving the midline skull base were treated. These cases were reviewed retrospectively. Gross-total resection of 30 lesions was achieved. Seven lesions were resected subtotally and six partially; one lesion was debulked. Complications occurred in 26 (59.1%) of the 44 operations and mostly consisted of cerebrospinal fluid leakage. The surgery-related mortality rate was 6.8% (three patients). Based on their pre- and postoperative Karnofsky Performance Scale scores, 86.4% of patients improved or remained the same. CONCLUSIONS: The radical transbasal approach increases the midline craniofacial corridor by allowing the globes to be safely retracted laterally. It also enhances exposure of the maxillary sinus from above. The morbidity and mortality rates associated with this procedure are high but consistent with the known rates for craniofacial surgery. This approach is best suited for the treatment of anterior skull base tumors that extend into the nasal cavity, orbit, ethmoid sinus, nasopharynx, and upper clivus. The approach may allow resection of tumors involving the maxillary sinus area without the need for an additional transfacial approach.

Preserving olfactory function in anterior craniofacial surgery through cribriform plate osteotomy applied in selected patients.

OBJECTIVE: Olfaction is often sacrificed to gain access to the cranial base in anterior craniofacial surgery. We describe the long-term results of olfactory function in patients who underwent anterior craniofacial surgery and a cribriform plate osteotomy to preserve olfaction. METHODS: Between 1992 and 2004, 28 patients underwent 29 cribriform plate osteotomies in an attempt to preserve olfaction during anterior craniofacial surgery performed through modified extended transbasal approaches. Patients' charts and office notes were reviewed retrospectively. Formal olfactory testing was available in 5 patients, but most data were based on patients' subjective reports of olfaction. Olfactory preservation was defined by the subjective ability to detect fumes such as coffee, chocolate, roses, and orange juice regardless of the intensity of the sensation. Follow-up was based on phone calls to patients. RESULTS: Four patients were lost to follow-up and excluded. Therefore, follow-up was available in 24 patients after 25 procedures. On the basis of patients' subjective reports, olfaction was spared in 22 patients after 23 procedures (92%) and was confirmed objectively in the five patients formally tested. After surgery, only two patients were anosmic. CONCLUSION: Olfaction can be preserved in selected patients undergoing anterior craniofacial surgery. At least 1 cm of nasal mucosa should remain attached to the cribriform plate, which can be achieved by including the nasal bone in the osteotomy of the orbital bar. A medial orbital canthopexy is therefore necessary after these procedures.

Exposure of midline cranial base without a facial incision through a combined craniofacial-transfacial procedure.

OBJECTIVE: A single-stage combined craniofacial-transfacial approach that exposes the midline cranial base without visible facial incisions is described. METHODS: Between 1992 and 1998, eight patients underwent surgery for five different anterior cranial base pathological findings: four angiofibromas, one mesenchymal chondrosarcoma, one esthesioneuroblastoma, one odontogenic myxoma, and one encephalocele. In all cases, the surgical exposure consisted of a bicoronal scalp incision with a bifrontal craniotomy and fronto-orbitonasal osteotomy, and then a sublabial incision for transmaxillary exposure. RESULTS: Gross total resection was achieved in five cases. The encephalocele was resected with complete reconstruction of the bony defect. Seven patients developed complications, primarily wound infections, cerebrospinal fluid leaks, and anemia. Postoperative Karnofsky Performance Scale scores ranged between 80 and 100 (mean, 92.5). Long-term follow-up information (mean, 56 mo; median, 59.5 mo; range, 5-108 mo) was available for all patients. CONCLUSION: Large anterior cranial base lesions can be resected and excellent cosmetic outcomes can be achieved with a single-stage combined transfacial-craniofacial approach that exposes the entire midline cranial base and requires no facial incisions.

Bilateral locked facets of the lumbosacral spine: treatment with open reduction and transpedicular fixation.

BACKGROUND: A 23-year-old man was involved in a motor vehicle crash and found to have bilateral locked facets at L5-S1. His neurologic examination, radiographic workup, surgical management, postoperative care, and the relevant literature are discussed. DESIGN: Case report and literature review. RESULTS: This patient underwent solid fusion with anatomic alignment following open reduction and internal fixation. He made a good neurologic recovery. CONCLUSION: Early surgery, consisting of open reduction, fixation, and fusion, provides the best results in patients with lumbosacral fracture-dislocations.

Comparison of routine and selective use of intraoperative angiography during aneurysm surgery: a prospective assessment.

OBJECT: Whether routine intraoperative angiography is necessary for cerebral aneurysm surgery is currently under debate. In this study the authors prospectively assessed the cerebrovascular surgeon's accuracy in predicting the need for intraoperative angiography. METHODS: Between January 2002 and January 2003, 200 consecutive patients (141 female and 59 male patients, mean age 52.8 years) with 235 aneurysms underwent routine intraoperative angiography. Before the operation, the surgeons indicated whether they believed that intraoperative angiography was necessary. Their responses were recorded as "intraoperative angiography necessary" or "intraoperative angiography unnecessary." Regardless of the response, all patients underwent intraoperative angiography after the aneurysm had been clipped. Changes in treatment resulting from intraoperative angiography were compared with surgeons' preoperative predictions of the need for intraoperative angiography. Intraoperative angiography was predicted to be necessary in 41 cases (20%) and unnecessary in 159 cases (80%). Its use altered treatment in 14 patients. Seven of these patients were among the group in which intraoperative angiography was deemed necessary and seven were in the group in which it was considered unnecessary. In the latter group, two patients had residual aneurysms, three had parent vessel occlusion, and two had previously undiagnosed aneurysms. Only one patient (0.5%) sustained a major intraoperative complication attributed to angiography. CONCLUSIONS: Given the frequency of significant disease that remains undetected if intraoperative angiography is used on a selective basis and the low complication rate associated with the procedure, the use of intraoperative angiography should be considered in the majority of aneurysm cases.

Anterior communicating artery aneurysm following radiation therapy for optic glioma: report of a case and review of the literature.

A 42-year-old female presented with subarachnoid hemorrhage (SAH), presumably from a radiation-induced anterior communicating artery aneurysm. Six years earlier, she had undergone radiation treatment for an optic glioma that was diagnosed based on imaging criteria. The aneurysm was successfully clipped, and the optic glioma was biopsied to verify the diagnosis histologically. Radiation-induced cerebral aneurysms often manifest with a fatal SAH. These aneurysms typically develop in the field of radiation and are diagnosed a mean of 8.52 years after radiation. Rarely, the aneurysm sac thromboses spontaneously. Clipping or coiling of the aneurysm can be an effective treatment.

Salvage of advanced squamous cell carcinomas of the head and neck: internal carotid artery sacrifice and extracranial-intracranial revascularization.

OBJECT: Squamous cell carcinoma (SCC) of the head and neck may involve the carotid artery (CA) in the neck or skull base. Whether tumor resection should be associated with sacrifice of the CA is debatable. METHODS: Records obtained in five consecutive patients (three men, and two women; mean age 58 years, range 47-69 years) treated for recurrent or progressive SCC involving the internal carotid artery (ICA) at the skull base were reviewed retrospectively. The ICA was sacrificed, an extracranial-intracranial (EC-IC) bypass was performed using a saphenous vein graft, and the tumor and involved ICA segment were resected. Gross-total resection of the SCC was achieved in four cases. One patient died of an acute postoperative stroke due to bypass occlusion and did not undergo tumor resection. No other permanent ischemic or neurological deficits were noted. The other four patients died of tumor progression (survival range 2-40 months, mean 14 months). One patient survived for more than 2 years (2-year overall survival rate 20%). Histological tumor invasion of the CA wall was verified in one of the three evaluated specimens. CONCLUSIONS: A high rate of morbidity and mortality is associated with cases in which skull base CA sacrifice and an EC-IC bypass are performed. Not all resected arteries are shown to have malignant infiltration on histological examination. Better preoperative imaging criteria are needed to define malignant infiltration of the ICA at the skull base. Chemotherapy and radiotherapy without aggressive tumor resection may be an option for these patients.

Thoracoscopic approaches to the thoracic spine: experience with 241 surgical procedures.

INTRODUCTION: Microsurgical thoracoscopic approaches to the thoracic spine allow access to the spinal cord, spinal nerves, disc spaces, vertebral bodies, paravertebral soft tissues, and sympathetic chain with minimal invasiveness. METHODS: Between January 1994 and January 2000, 241 thoracoscopic procedures were performed: 164 thoracic sympathectomies, 60 discectomies, 5 neurogenic tumor resections, 8 corpectomies and spinal reconstructions, 2 anterior releases, and 2 biopsies. Cases were reviewed to evaluate the efficacy, surgical results, and complications of the thoracoscopic procedures. RESULTS: An adequate sympathectomy was achieved in all 164 sympathectomies. There was 100% relief of palmar and 95% relief of axillary hyperhidrosis. Reflex sympathetic dystrophy responded poorly to sympathectomy with recurrent pain. Thoracoscopic discectomy achieved complete decompression in 98% of patients. Gross total tumor resection was achieved in all five paraspinal neurogenic tumors. There was no operative mortality. Morbidity compared favorably with open surgical approaches to the thoracic spine. CONCLUSION: Thoracoscopic spinal surgery is an effective technique that provides full, direct access to the ventral thoracic spine. Its morbidity rate appears to be lower than that associated with open thoracotomy. It improves patient comfort and cosmetic results and shortens recovery. This technique has become the authors' surgical approach of choice for removing benign intrathoracic paraspinal neurogenic tumors and central herniated thoracic discs and for performing biopsies and thoracic sympathectomies. The senior author still prefers open surgical approaches for most thoracic corpectomies and spinal reconstruction procedures.

Thoracoscopic resection of thoracic neurogenic tumors.

OBJECT: The authors describe the treatment and results of thoracoscopic resection performed in patients with neurogenic tumors. METHODS: Seven patients with large intrathoracic paraspinal neurogenic tumors underwent a thoracoscopic procedure to achieve gross-total resection. All tumors were entirely intrathoracic and treated thoracoscopically except in one patient whose tumor had an intraspinal extension. Gross-total resection was achieved in all cases. Postoperatively, one patient developed Homer syndrome. The only other complication, transient intercostal neuralgia, resolved in all patients. Clinical examination and magnetic resonance imaging follow-up examination in all patients demonstrated no evidence of recurrent disease (mean follow up 12.5 months). CONCLUSIONS: Endoscopic transthoracic approaches can reduce approach-related soft-tissue morbidity and facilitate a patient's recovery by preserving the normal tissues of the chest wall, by avoiding rib retraction and muscle transection, and by reducing postoperative pain.

Biportal thoracoscopic sympathectomy: surgical techniques and clinical results for the treatment of hyperhidrosis.

OBJECTIVE: To describe a bilateral thoracoscopic sympathectomy procedure, using a biportal approach, for the treatment of severe hyperhidrosis. METHODS: Between May 1996 and September 2000, 103 consecutive patients underwent thoracoscopic sympathectomy procedures to treat bilateral hyperhidrosis (206 procedures). Operative results, complications, and patient satisfaction were determined by reviews of hospital and office charts and by follow-up assessments in the outpatient clinic. Long-term results were determined with clinical examinations, follow-up office visits, and follow-up questionnaires. RESULTS: Ninety-three patients presented with primary palmar hyperhidrosis, eight with primary axillary hyperhidrosis, and two with primary craniofacial hyperhidrosis. Rates of complete resolution in the primary area affected were 100% in palmar and craniofacial cases and 75% in axillary cases. The average length of hospitalization was 1.06 days, and 96 patients (93.2%) were discharged on or before the end of the first postoperative day. Of 59 patients (57.3%) who developed compensatory hyperhidrosis, only 11 patients (10.7%) reported that it was bothersome and none considered it disabling. All postoperative complications were transient; five patients experienced unilateral Horner's syndrome, three patients experienced intercostal neuralgia, and two patients required a chest tube after surgery because of a pneumothorax. CONCLUSION: Thoracoscopic sympathectomy using a biportal approach effectively treats hyperhidrosis and is associated with short hospital stays, high patient satisfaction rates, and low rates of compensatory hyperhidrosis or other complications.