Surgery for craniovertebral junction pathologies: minimally invasive anterior submandibular retropharyngeal key-hole approach.

BACKGROUND: Our objective was to develop a new, minimally invasive surgical technique for the resolution of craniovertebral junction pathologies, which can eliminate the complications of the previous methods, like liquor-leakage, velopharyngeal insufficiency and wound-dehiscence associated with the transoral or lateral approaches. METHODS: During the first stage of the operation, three patients underwent occipito-cervical dorsal fusion, while the fourth patient received C1-C2 fusion according to Harms. C1-C2 decompressive laminectomy was performed in all four cases. Ventral C1-C2 decompression with microscope assisted minimally invasive anterior submandibular retropharyngeal key-hole approach (MIS ASR) method was performed in the second stage. The MIS ASR-similarly to the traditional anterior retropharyngeal surgery-preserves the hard and soft palates, yet can be performed through a 25 mm wide incision with the use of only one retractor. RESULTS: The MIS ASR approach was a success in all four cases, there were no intra- and postoperative complications. This method, compared to the transoral approach, provided on average 23% (4.56 cm2/6.05 cm2) smaller dural decompression area; nonetheless, the entire pathology could be removed in all cases. After the surgery, all patients have shown significant neurological improvement. CONCLUSION: Based on the outcome of these four cases we think that the MIS ASR approach is a safe alternative to the traditional methods while improving patient safety by reducing the risk of complications.

Supraorbital subfrontal trans-laminar endoscope-assisted approach for tumors of the posterior third ventricle.

BACKGROUND: Different surgical approaches have been developed for dealing with third ventricle lesions, all aimed at obtaining a safe removal minimizing brain manipulation. The supraorbital subfrontal trans-lamina terminalis route, commonly employed only for the anterior third ventricle, could represent, in selected cases with endoscopic assistance, an alternative approach to posterior third ventricular lesions. METHODS: Seven patients underwent a supraorbital subfrontal trans-laminar endoscope-assisted approach to posterior third ventricle tumors (two craniopharyngiomas, one papillary tumor of the pineal region, one pineocytoma, two neurocytomas, one glioblastoma). Moreover, a conventional third ventriculostomy was performed via the same trans-laminar approach in four cases. RESULTS: Complete tumor removal was accomplished in four cases, subtotal removal in two cases, and a simple biopsy in one case. Adjuvant radiotherapy and/or chemotherapy was administered, if required, on the basis of the histologic diagnosis. No major complications occurred after surgery except for an intratumoral hemorrhage in a patient undergoing a biopsy for a glioblastoma, which simply delayed the beginning of adjuvant radiochemotherapy. No ventriculoperitoneal shunt placement was needed in these patients at the most recent clinical and radiologic session (average 39.57 months, range 13-85 months). Two illustrative cases are presented. CONCLUSIONS: The supraorbital subfrontal trans-laminar endoscope-assisted approach may provide, in selected cases, an efficient and safe route for dealing with posterior third ventricular tumors.

Clinical application of the supraorbital key-hole approach to the treatment of unilateral-dominant bilateral frontal contusions.

We compared the surgical efficacy of the supraorbital key-hole approach (SKA) to conventional unilateral frontotemporal craniotomy (UFTC) for the treatment of patients with unilateral-dominant bilateral frontal contusions (BFCs). A retrospective analysis of 62 patients with unilateral-dominant BFCs who underwent surgery at our institute between 2014 and 2017 was performed. There were 26 patients who underwent SKA (group A) and 36 who underwent UFTC (group B). Postoperative computed tomography scans showed satisfactory evacuation of the frontal cerebral contusions in both groups (p > 0.05). There was less intraoperative blood loss in group A than group B (17.1 ± 4.55 vs. 67.6 ± 10.28 mL, p < 0.05). The operative time was also shorter in group A (82.7 ± 13.73 vs. 132.4 ± 9.17 min, p < 0.05). Postoperative bleeding occurred in three cases in group A and in only one case in group B (p > 0.05). The average length of hospitalization was shorter in group A than group B (7.3 ± 1.09 vs. 12.9 ± 1.71 days, p < 0.05). No differences in the Glasgow Outcome Scale were observed between the two groups after 6 months of follow-up (p > 0.05). Thus, compared to UFTC, SKA is associated with shorter operation times and less trauma to the surrounding brain tissue.

Minimally invasive key-hole approach for the surgical treatment of single and multiple brain metastases.

The role of surgical management in the setting of multiple brain metastases is controversial. Although the role of surgical resection in single brain metastases is well stated, in multiple brain metastases whole brain radiation therapy remains a mainstay of treatment. In this series, the authors evaluate the efficacy of minimally invasive neurosurgical techniques in the resection of brain metastases with a particular focus on multiple metastases. 57 patients who underwent surgical resection of brain metastases with a key-hole approach, were analyzed for surgical success, complications, neurological deficits, functional outcome and overall survival. 187 brain metastases were detected. The majority of patients improved in KPS postoperatively at 6 weeks (80.6%) and 3 months follow up (62.5%). Mean overall survival was 14.2 months with a 1 year survival rate of 44%. According to univariate analysis, poor systemic control of cancer, tumor extending to both lobar and deep brain, lower extent of resection and symptomatic tumor resection were found to be associated with poorer survival. With the use of minimally invasive neurosurgery, aggressive management of multiple metastases leads to minimal postoperative stay, improvement in quality of life and overall survival. Patient overall survival is dependent on recursive partitioning analysis (RPA) class, and should be used to guide management.

Application of Lumber continued drainage of cerebrospinal fluid after Key-hole approach operation on hypertensive intracerebral hemorrhage / 中国综合临床

Objective To evaluate the therapeutic effects of Lumber continued drainage of cerebrospinal fluid after Key-hole approach operation and craniotomic hematoma elimination on the prognosis of hypertensive in-tracerebral hemorrhage patients. Methods Lumber continued drainage of cerebrospinal fluid after Key-hole ap-proach operation was conducted on 38 hypertensive intracerebral hemorrhage patients. At the 1st month and 6th month after operation, Glasgow coma scale (GCS), Glasgow outcome scale (GOS), Barthel index, language barrier degree evaluation and sports function barrier degree evaluation were measured. The therapeutic effects were observed and compared with 34 patients who were operated by craniotomic hematoma elimination. Results GCS was 6.8± 2.1,6.6±2.3 before operation and 10.5±2.5,8.7±2.2 one week after operation in experimental group and con-trol group respectively; GOS was 3.4±0.3,2.8±0.2 one month after operation and 4.1±0.6,3.2±0.4 six month after operation in experimental group and control group respectively; Bartherl index, language barrier degree and sports function barrier degree were 63.15±11.64,51.76±12.81 and 1.7±0.3,2.3±0.2,2.0±0.3, and 2.6± 0.4 (P<0.05 or P<0.01). Conclusion Lumber continued drainage of cerebrospinal fluid after Key-hole approach operation offers greater help in improving the patients' quality of existence, by which the neurological function recov-ers faster and the patients recover well.

Microneurosurgery for pituitary adenoma by supraorbital keyhole or endonasal transsphenoidal approaches / 中华神经医学杂志

Objective To compare the clinical effects of microneurosurgery by supraorbital key-hole or endonasal transsphenoidal approaches in the treatment of pituitary adenoma and investigate their complications. Methods We retrospectively analyzed the data of 87 patients with pituitary adenoma of which the anteroposterior diameter was less than 3 cm. These patients, admitted to our hospital from May, 2006 to June, 2008, were operated in an endoscope-assisted microsurgical manner via a supraorbital key-hole approach (n=42) or an endonasal transsphenoidal approach (n=45). The efficacy of these two approaches was compared and their complications were observed. Results The excision rate of the pituitary adenoma developing on or around the sella turcica operated through the supraorbital key-hole approach was significantly higher than that through the endonasal transsphenoidal approach(P< 0.05); while that of microadenoma or adenoma developing towards the sphenoid sinus operated through the supraorbital keyhole approach was statistically lower than that through the endonasal transsphenoidal approach (P<0.05). No obvious differences on the improvement of endocrine secretion, visual acuity and field was noted in these two approaches (P>0.05). The incidence rate of epistaxis and unilateral dysosphresia in the supraorbital key-hole approach was significantly lower as compared with that in the endonasal transsphenoidal approach (P<0.05). Conclusion Rarely having such complications as dysosphresia, epistaxis and sphenoiditis, neuroendoscopic surgery through supraorbital key-hole approach is the best way of treating the pituitary adenoma developing on or around the sella turcica and worth to promote in clinic.

Microsurgical anti endoscopic anatomy of sellar region related to key hole approach / 中华显微外科杂志

Objective To study the endoscopic anatomy of operative fissures in the sellar region related to pterional key-hole approach and to provide the anatomic basis for endoscope-assisted microneuro-surgery in the region. Methods Fifteen cadaver heads were dissected via pterional key-hole approach and the five operative fissures(Ⅰ、Ⅱ、Ⅲ、Ⅳ、Ⅴ) were studied with both microscope and endoscope, by which the outcomes observed were recorded and compared. Results The basic information obtained by the pterio-nalkeyhole approach was comparable to that of the classic ptefional approach. According to the anatomic guideposts under neuroendoscope, the microstructures of the five fissures and Willis' circle would be well demonstrated. It is better to display the various anatomic structures in sellar region by neuroendoscope rather than microscope, particularly some important microstructures. Angled endoscope can be used to inspec thidden but important structure behind the arteries and nerves. Conclusion According to the anatomic guideposts, an endoscopy can be used to enhance the visible field of an operative microscope related to pterional key-hole approach. The endoscope-assisted microsurgery can reduce complications and injury of the important structures and increase the curative effect on the lesions in the sellar region.