Exoscopic supraorbital approach for a tuberculum sellae meningioma.

Tuberculum sellae meningiomas are midline anterior skull base tumors and account for approximately 10-15% of all intracranial meningiomas. Clinical presentation of tuberculum sellae meningiomas is mainly characterized by visual deficits due to optic chiasm compression or optic canal invasion. Treatment options for TSM typically involve surgical resection of the tumor. The relevant microsurgical anatomy of the suprasellar region was discussed. (1,2). Tumor size, anatomical variations can affect the best approach for these tumors, with several approaches been described to access the suprasellar region as pterional, endoscopic endonasal and supraorbital approach that was the choice for this case (3). Besides the surgical corridor, minimally invasive techniques that preserve the surrounding tissue are becoming increasingly popular and are perfectly suited to deep seated lesions. In this article, we present a surgical video of an exoscopic supraorbital approach for resection of a tuberculum sellae meningioma. This is a case of a 42-year-old right-handed female who presented with headaches and progressive vision loss. Patient presented with tumor growth and surgery was indicated. We chose the minimally invasive supraorbital approach and then used the exoscope as magnification tool visualization tool. Gross total resection and decompression of the optic canals was achieved with improvement of visual field deficits.

Atrium meningioma: Transtubular posterior intraparietal sulcus approach.

Meningiomas that arise in the atria of the lateral ventricles are relatively rare lesions, that pose a unique challenge for surgery due to their deep-seated location and proximity to critical white matter tracts. Size and anatomical variations can affect the best approach for these tumors, with several approaches described to access the atrium including the interhemispheric trans-precuneus, trans-supramarginal gyrus, distal trans-sylvian, supracerebellar trans-collateral sulcus, and finally the trans-intraparietal sulcus approach, which was the choice for this case. Minimally invasive techniques that preserve the surrounding tissue are becoming increasingly popular and are perfectly suited to deep seated lesions. The relevant subcortical anatomy surrounding the atrium is discussed. The optic radiations form the lateral wall of the atrium, whereas commissural fibers of the tapetum form the roof of the atrium, and superficial to these fibers we have the superior longitudinal fasciculus that have vertical rami that communicate with the superior parietal lobule. Utilizing the posterior half of the intraparietal sulcus can preserve these fibers. The use of neuronavigation, brain magnetic resonance imaging with diffusion tensor imaging (DTI) tractography may be helpful in the surgical planning. In this article, we present a surgical video of a trans-tubular interparietal sulcus approach for resection of an atrium meningioma. A 43-year-old right-handed female who presented with progressive headaches and a diagnosis of idiopathic intracranial hypertension was found to have an atrial meningioma that grew in follow-up and surgery was recommended. We chose the posterior intraparietal sulcus approach as it provides a good angle of attack while preserving the optic radiations and most of the superior longitudinal fasciculus, using a tubular retractor to minimize tissue damage. Gross total resection of the tumor was achieved with complete preservation of patient neurological function.

The Current State of Visualization Techniques in Endoscopic Skull Base Surgery.

Skull base surgery has undergone significant progress following key technological developments. From early candle-lit devices to the modern endoscope, refinements in visualization techniques have made endoscopic skull base surgery (ESBS) a standard practice for treating a variety of conditions. The endoscope has also been integrated with other technologies to enhance visualization, including fluorescence agents, intraoperative neuronavigation with augmented reality, and the exoscope. Endoscopic approaches have allowed neurosurgeons to reevaluate skull base neuroanatomy from new perspectives. These advances now serve as the foundation for future developments in ESBS. In this narrative review, we discuss the history and development of ESBS, current visualization techniques, and future innovations.

Survival in patients with surgically treated spinal metastases.

BACKGROUND: Despite the various treatment protocols available, survival evaluation is a fundamental criterion for the definition of surgical management; there are still many inconsistencies in the literature on this topic, especially in terms of the value of surgery and its morbidity in patients with very short survival. OBJECTIVE: The objective was to analyze the association of clinical, oncological, and surgical factors in the survival of patients undergoing spinal surgery for spinal metastases (SM). MATERIALS AND METHODS: A retrospective cohort of forty patients who were surgically treated at our institution for SM between 2010 and 2018 were included in the study. We applied the prognostic scales of Tomita and Tokuhashi in each patient and evaluated the systemic status using Karnofsky Performance Scale (KPS) and Eastern Cooperative Oncology Group Performance Scale. Survival rate in months was estimated using the Kaplan-Meier curve, with death considered as primary outcome and, for the evaluation of the association between the variables, the Chi-square test, Fisher's exact test, or Fisher-Freeman-Halton test was applied for better survival. The level of statistical significance was considered as 5% (P ≤ 0.05). RESULTS: The mean survival was 8.4 months. Patients with KPS <70 had a mean survival of 6.36 months, while those with KPS >70 had a mean survival of 14.48 months (P = 0.04). The mean survival of patients classified as ECOG 2 was 7.05 months (95% confidence interval [CI]: 3.4-10.7), and that of patients classified as ECOG 3 and 4 was 1.24 months (95% CI: 0.8-1.59). The mean survival rate among the patients with unresectable metastases in other organs was 6.3 months (95% CI: 3.9-8.9), while the survival rate of those who did not have metastases was 13.8 months (95% CI: 10.0-17.68; P = 0.022). CONCLUSION: Survival was associated with the preoperative functional status defined by the KPS and ECOG scales and with the presence of nonresectable visceral metastases.

Neurological Outcome and Complications in Patients With Surgically Treated Spinal Metastases.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: Evaluate the epidemiology of surgical patients with spinal metastases, identify the complications, and evaluate their neurological prognoses. SUMMARY OF BACKGROUND DATA: The development of new oncological treatments and screening tests have increased the survival of oncologic patients, and consequently, the incidence of metastatic lesions of the spine. METHODS: Retrospective cohort of 40 patients surgically treated at the Hospital de Clínicas of UNICAMP for spinal metastases from January 2010 to September 2018, after diagnosis of symptomatic spinal cord compression and/or mechanical instability of the spine. Retrospectively analyzed patient charts applied the SINS score to evaluate the presence of mechanical instability. Neurological function was classified based on the Frankel index preoperative and postoperatively. To evaluate the association between variables, the Chi-square test, Fisher exact test, or Fisher-Freeman-Halton test was applied. For evaluating the improvement of neurological status between the Frankel scores before and after surgery, the McNemar test was applied for categorical and qualitative variables. In both the tests, variables with values of P > 0.05 were considered. RESULTS: Pain as the reason for the first visit presented an odds ratio (OR) = 2.44 (95% [CI]: 1.14-5.2) for instrumentation need (P = 0.024). A higher SINS score corresponded to the indication for instrumentation surgery due to the instability of the spine (P = 0.004). Within 30 days postoperative, five patients (11.1%) had complications. There was a statistically significant neurological improvement in patients who underwent surgery (P = 0.002). CONCLUSION: Pain as the first symptom was related to mechanical instability of the spine and surgical instrumentation. Patients treated with surgery presented improvement of the neurological function in the postoperative period. LEVEL OF EVIDENCE: 3.

Reliability of the New AOSpine Classification System for Upper Cervical Traumatic Injuries.

BACKGROUND: The new AOSpine Upper Cervical Classification System (UCCS) was recently proposed by the AOSpine Knowledge Forum Trauma team to standardize the treatment of upper cervical traumatic injuries (UCI). In this context, evaluating its reliability is paramount prior to clinical use. OBJECTIVE: To evaluate the reliability of the new AOSpine UCCS. METHODS: A total of 32 patients with UCI treated either nonoperatively or with surgery by one of the authors were included in the study. Injuries were classified based on the new AO UCCS according to site and injury type using computed tomography scan images in 3 planes by 8 researchers at 2 different times, with a minimum interval of 4 wk between assessments. Intra- and interobserver reliability was assessed using the kappa index (K). Treatment options suggested by the evaluators were also assessed. RESULTS: Intraobserver agreement for sites ranged from 0.830 to 0.999, 0.691 to 0.983 for types, and 0.679 to 0.982 for the recommended treatment. Interobserver analysis at the first assessment was 0.862 for injury sites, 0.660 for types, and 0.585 for the treatment, and at the second assessment, it was 0.883 for injury sites, 0.603 for types, and 0.580 for the treatment. These results correspond to a high level of agreement of answers for the site and type analysis and a moderate agreement for the recommended treatment. CONCLUSION: This study reported an acceptable reproducibility of the new AO UCCS and safety in recommending the treatment. Further clinical studies with a larger patient sample, multicenter and international, are necessary to sustain the universal and homogeneity quality of the new AO UCCS.

Using the keystone design perforator island flap in large myelomeningocele closure.

OBJECTIVE: Many repair techniques have been proposed to treat large myelomeningocele (MMC), and although effective in many cases, some of these techniques can be complex and time consuming, with complications such as cerebrospinal fluid (CSF) leakage, flap loss, tip necrosis, and wound dehiscence. The purpose of this study was to analyze cases of large skin defects and the methods applied and to report the outcomes of the keystone design perforator island flap (KDPIF) technique for large MMC closure. METHODS: The authors performed a retrospective review of all neonatal patients who had undergone KDPIF for MMC closure in the period from 2013 to 2018. All patients had a diagnosis of lumbosacral MMC based on obstetric ultrasound. The neurosurgeons and plastic surgeons had selected the cases after concluding that primary closure would be unlikely. The design of the flap is based on the randomly located vascular perforators, creating two identical opposing flaps to fashion a double keystone flap. During wound closure, V-Y advancement of each end of the double flap in the longitudinal axis creates redundancy in the central portion of the flap and reduces the horizontal tension. After discharge, both the neurosurgery and plastic surgery teams followed up all patients, tracking the results with photography. RESULTS: No skin flap dehiscence or necrosis, infection, or CSF leakage was detected, proving the reliability of the flap. One of the patients required further surgery for the large skin defects after insufficient intrauterine closure of the MMC and successfully underwent KDPIF treatment. Another patient (14.3%) had severe neonatal sepsis, which ultimately led to death. A ventriculoperitoneal shunt was required after the skin defect repair in 5 (83.3%) of the 6 surviving patients. Exceptional aesthetic results were achieved for all patients during the follow-up. CONCLUSIONS: The KDPIF technique is based on well-known vascular perforators of the intercostal, lumbar, and gluteal regions. Wound tension is widely distributed by the flap and, as a consequence, relevant tissue bulk, reliable vascularity, and important geometrical versatility are provided. In addition, most of the muscles and fascia are preserved, which is another advantage in terms of minimizing secondary morbidity to local tissue rearrangement. The use of KDPIF closure was successfully shown to be a viable alternative for more complex MMCs that present with large skin defects.