[Domestic software, medical devices and materials in surgery for hyperostotic craniofacial meningiomas]. / Primenenie otechestvennogo programmnogo obespecheniya, meditsinskikh izdelii i materialov v khirurgii giperostoticheskikh kraniofatsial'nykh meningiom. (Klinicheskii sluchai i obzor literatury).

OBJECTIVE: The modern concept of resection of hyperostotic craniofacial meningiomas involves the desire for one-stage surgery with excision of tumor and simultaneous extensive skull defect closure. MATERIAL AND METHODS: The authors present skull defect closure with an individual implant after resection of cranioorbital meningioma in a 61-year-old man. The neoplasm was accompanied by exophthalmos and eyelid edema. The patient underwent simultaneous microsurgical resection and skull reconstruction with an individual implant. At discharge (7 days after surgery), exophthalmos regressed to 3 mm. After 3 months, ophthalmologist revealed complete regression of exophthalmos. RESULTS: Domestic software and 3D printers were used for implant modeling and preparing the necessary physical models and molds. We intraoperatively used domestic polymer and titanium fixation systems for manufacturing and fixation of implant. CONCLUSION: This clinical case confirms that resection of hyperostotic craniofacial meningioma with simultaneous bone defect closure using domestic analogues of software, technical equipment, materials and methods is possible at all stages of this procedure.

Clinical Characteristics and Prognostic Analysis of Osteolytic and Hyperostosis Sphenoid Orbital Meningiomas: A Single-Center Experience.

Reactive hyperostosis of spheno-orbital meningiomas (SOMs) often occurred in the sphenoid wing, while osteolytic SOMs (O-SOMs) were rarely discussed. This study preliminarily evaluated the clinical characteristics of O-SOMs and analyzed prognostic factors affecting the recurrence of SOMs. We retrospectively analyzed the medical records of consecutive patients who underwent surgery for a SOM between 2015 and 2020. According to the bone changes of sphenoid wing, SOMs were divided into O-SOMs and hyperostosis SOMs (H-SOMs). A total of 31 procedures were performed in 28 patients. All cases were treated by pterional-orbital approach. It was confirmed that 8 cases were O-SOMs and the other 20 cases were H-SOMs. Total tumor resection was performed in 21 cases. There were 19 cases with Ki 67 ≥3%. The patients were followed up for 3 to 87 months. Proptosis improved in all patients. All O-SOMs had no visual deterioration, while 4 H-SOMs cases had visual deterioration. There was no significant difference in clinical outcomes between the two types of SOM. The recurrence of SOM was related to the degree of resection, but not to the type of bone lesions, invasion of cavernous sinus and Ki 67.

Factors associated with favorable visual outcome after surgery of clinoidal meningiomas.

BACKGROUND: The anatomical relationship between clinoidal meningiomas and the optic nerve accounts for their frequent finding on visual disturbances. The goal of the surgery is to perform complete resection and obtain visual recovery. The aim of this study is to determine the factors associated with favorable visual outcome. METHODS: We recorded clinical (including ophthalmological), imaging and surgical data of all patients operated on for clinoidal meningiomas between 2010 and 2020 in 2 French neurosurgical departments and we analyzed their impact on visual outcome. RESULTS: A total of 34 patients were included. At 3-4 months after surgery, 23 patients (68%) had favorable visual outcome. Factors associated with favorable visual outcome were duration of ophthalmologic symptoms < 6 months, preoperative visual acuity > 0.5, absence of optic atrophy, meningioma in high signal intensity on T2-weighted or FLAIR MRI, absence of optic canal involvement and absence of bone hyperostosis on pre-operative CT scan. A soft tumor and a clear brain/tumor border were intra-operative factor associated with favorable ophthalmological outcome. CONCLUSIONS: In clinoidal meningiomas, an early surgery should be performed to optimize visual improvement. Hyperintense lesion on T2-weighted/FLAIR preoperative MRI is correlated with a soft consistency which allows an easier surgery associated with a favorable visual outcome. Invasion of the optic canal and bone hyperostosis should reserve the visual prognosis.

Giant Skull Tumor: A Benign Meningioma.

ABSTRACT: A 37-year-old male patient was complaining from painless forehead swelling, which started 5 years ago. Brain computed tomography scan and magnetic resonance imaging showed a large extradural mass compressing the both frontal lobes with skull bone infiltration, hyperostosis and enlargement. The patient was operated in 2 stages. In the first stage, the authors achieved separation for the tumor from the scalp and skull. In the second stage after 1 week, the authors continued with circumferential dural opening around the tumor and separation of the tumor from brain tissue. Duroplasty was performed by autologous fascia latta and skin flap was closed primarily. The specimen was received grossly as huge mass weighing 1530 g and measuring 39 × 16 × 12 cm. Histopathologic examination showed grade I meningioma extending beyond the skull to the surrounding soft tissue.

Hyperostosing sphenoid wing meningiomas.

Some sphenoid wing meningiomas are associated with a significant hyperostotic reaction of the adjacent sphenoid ridge that may even exceed the size of the intradural mass. The decision-making process and surgical planning based on neuroanatomic knowledge are the mainstays of management of this group of lesions. Given their natural history and biologic behavior, many hyperostosing meningiomas at this location require long-term management analogous to a chronic disease. This is particularly true when making initial decisions regarding treatment and planning surgical intervention, when it is important to take into consideration the possibility of further future interventions during the patient's life span.

Swallowed by the bone - Is skin reaction the "tip of the iceberg"?

The most frequent complications of osseointegrated implantation include implant-site infections, soft tissue overgrowth and failure of osseointegration. Bone overgrowth is also a complication at the abutment site and infrequently reported. We describe a rare case of difficult control and exuberant bone overgrowth, with total implant involvement, in a short period of time never before described in the literature. Bone growth around the implant is frequently underestimated and can be the cause of difficult control of skin reactions, that in some cases is just the "tip of the iceberg". Timely surgical review with removing excess bone may lead to implant preservation and control of skin reaction and healing.

Hyperostosing sphenoid wing meningiomas: surgical outcomes and strategy for bone resection and multidisciplinary orbital reconstruction.

OBJECTIVE: Hyperostosing sphenoid wing meningiomas cause bony hyperostosis that may extend into the orbit, resulting in proptosis, restriction of extraocular movements, and/or compressive optic neuropathy. The extent of bony removal necessary and the optimal reconstruction strategy to prevent enophthalmos is debated. Herein, the authors present their surgical outcomes and reconstruction results. METHODS: This is a retrospective review of 54 consecutive patients undergoing resection of sphenoid wing meningiomas associated with bony hyperostosis. The majority of cases were operated on by the senior author. Extent of tumor resection, volumetric bone resection, radiographic exophthalmos index, complications, and recurrence were analyzed. RESULTS: The median age of the cohort was 52.1 years, with women comprising 83% of patients. Proptosis was a presenting symptom in 74%, and 52% had decreased visual acuity. The WHO grade was I (85%) or II (15%). The median follow-up was 2.6 years. On volumetric analysis, a median 86% of hyperostotic bone was resected. Gross-total resection of the intracranial tumor was achieved in 43% and the orbital tumor in 27%, and of all intracranial and orbital components in 20%. Orbital reconstruction was performed in 96% of patients. Postoperative vision was stable or improved in 98% of patients and diplopia improved in 89%. Postoperative complications occurred in 44% of patients, and 26% of patients underwent additional surgery for complication management. The most frequent complications were medical complications and extraocular movement deficits. The median preoperative exophthalmos index was 1.26, which improved to 1.12 immediately postoperatively and to 1.09 at the 6-month follow-up (p < 0.001). Postoperatively, 18 patients (33%) underwent adjuvant radiotherapy after subtotal resection. Tumors recurred/progressed in 12 patients (22%). CONCLUSIONS: Resection of hyperostosing sphenoid wing meningiomas, particularly achieving gross-total resection of hyperostotic bone with a good aesthetic result, is challenging and associated with notable medical and ocular morbidity. Recurrence rates in this series are higher than previously reported. Nevertheless, the authors were able to attain improvement in proptosis and visual symptoms in the majority of patients by using a multidisciplinary approach.

Surgical nuances of the expanded endoscopic anterior skull base craniectomy for hyperostotic meningioma resection.

BACKGROUND: The rostral expanded endoscopic approach (EEA) to anterior cranial fossa (ACF) has several advantages over transcranial/craniofacial surgery, providing early access to the vascular supply of tumors and reducing morbidities of craniotomy especially that of brain retraction. This article presents endoscopic landmarks and nuances for a wide ACF corridor, with stepwise image-guided dissections highlighting surgical tricks and techniques to enhance surgical safety. METHODS: We describe an expanded endoscopic endonasal anterior skull base craniectomy for a recurrent large olfactory groove hyperostotic meningioma, with correlated cadaveric dissections. CONCLUSION: The widening of rostral EEA can provide a safe and feasible route to access ACF. This article highlights the specific landmarks in endoscopic anatomy with reference to the angle of visualization and bayonetted instruments.

Comparative Analysis of Endoscopic Transorbital Approach and Extended Mini-Pterional Approach for Sphenoid Wing Meningiomas with Osseous Involvement: Preliminary Surgical Results.

OBJECTIVE: Sphenoid wing meningiomas (SWMs) can be treated with complete surgical resection and the recently introduced endoscopic transorbital approach (ETOA) offers a minimally invasive alternative. In this study, the surgical outcome of ETOA and the extended mini-pterional approach (eMPTA) for SWMs with osseous involvement is compared. METHODS: From October 2015 to May 2019, 24 patients underwent surgery for SWMs with osseous involvement. Among them, tumor resection was performed by ETOA for 11 patients (45.8%) and eMPTA for 13 patients (54.2%). The tumor characteristics, surgical outcome and morbidity, and approach-related aesthetic outcome were analyzed and compared retrospectively between ETOA and eMPTA based on SWM classification. RESULTS: The location of SWMs was mostly the middle sphenoid ridge (group III) (45.8%), followed by the greater sphenoid wing (group IV) (29.2%). Simpson resection grades I/II were achieved in 9 of 11 patients (81.8%) with ETOA and 11 of 13 patients (84.6%) with eMPTA. There were no differences in tumor characteristics between the 2 approaches. Surgery time, surgical bleeding, and hospital length of stay were significantly shorter with ETOA. Three patients had transient surgical morbidities such as diplopia (n = 1), ptosis (n = 1), and cerebrospinal fluid leak (n = 1) after ETOA. No differences could be seen in surgical morbidities between ETOA and eMPTA. CONCLUSIONS: ETOA can provide direct access to the sphenoid bone and resectability with a more rapid and minimally invasive exposure than does eMPTA. Maximal subtotal resection with extensive sphenoid bone decompression for tumors with cavernous sinus infiltration is the key to a good clinical outcome, regardless of the surgical approach.

Novel Characteristic Skull Magnetic Resonance Imaging Features Associated With Meningioma.

OBJECTIVE: Meningioma-related skull magnetic resonance imaging findings other than hyperostosis are not widely recognized. We evaluated the novel findings of the skull adjacent to meningiomas. METHODS: Records from patients with meningiomas located adjacent to the skull on magnetic resonance imaging (n = 32) were included. Three skull findings (intramedullary prominent vessel, intramedullary enhancement, intramedullary T2-hyperintensity) and the widely known hyperostosis were retrospectively visually assessed. The frequency of these 3 findings and the relevance to each other, and their relationships with hyperostosis, size, length adjacent to the skull, and relative signal intensity of the meningioma were examined. RESULTS: The incidence of the three findings was 46.88%, 53.13%, and 62.5%, respectively, and that of hyperostosis was 46.88%. Each association involving the findings was strong, and they were significantly related to the size and length. CONCLUSIONS: Intramedullary prominent vessel, intramedullary enhancement, and intramedullary T2-hyperintensity may be novel characteristic skull findings associated with meningioma.

Endoscopic endo- and extra-orbital corridors for spheno-orbital region: anatomic study with illustrative case.

BACKGROUND AND OBJECTIVE: Management of selected spheno-orbital meningiomas via the endoscopic transorbital route has been reported. Surgical maneuverability in a narrow corridor as that offered by the orbit may be challenging. We investigate the additional use of an extra-orbital (EXO) path to be used in combination with the endo-orbital (EO) corridor. MATERIAL AND METHODS: Three human cadaveric heads (six orbits) were dissected at the Laboratory of Surgical Neuroanatomy at the University of Barcelona. The superior eyelid endoscopic transorbital approach was adopted, introducing surgical instruments via both corridors. Surgical freedom analysis was run to determine directionality of each corridor and to calculate the surgical maneuverability related to three anatomic targets: superior orbital fissure (SOF), foramen rotundum (FR), and foramen ovale (FO). We also reported of a 37-year-old woman with a spheno-orbital meningioma with hyperostosis of the lateral wall of the right orbit, treated with such combined endo-orbital and extra-orbital endoscopic approach. RESULTS: Combining both endo-orbital and extra-orbital corridors permitted a greater surgical freedom for all the targets compared with the surgical freedom of each corridor alone (EO + EXO to SOF: 3603.8 mm2 ± 2452.5 mm2; EO + EXO to FR: 1533.0 mm2 ± 892.2 mm2; EO + EXO to FO: 1193.9 mm2 ± 782.6 mm2). Analyzing the extra-orbital pathway, our results showed that the greatest surgical freedom was gained in the most medial portion of the considered area, namely the SOF (1180.5 mm2 ± 648.3 mm2). Regarding the surgical case, using both pathways, we gained enough maneuverability to nearly achieve total resection with no postoperative complications. CONCLUSION: An extra-orbital corridor may be useful to increase the instruments' maneuverability, during a pure endoscopic superior eyelid approach, and to reach the most medial portion of the surgical field from a lateral-to-medial trajectory. Further studies are needed to better define the proper indications for such strategy.

The Use of Bone Morphogenetic Protein in the Intervertebral Disk Space in Minimally Invasive Transforaminal Lumbar Interbody Fusion: 10-year Experience in 688 Patients.

STUDY DESIGN: Retrospective Cohort. OBJECTIVE: The objective of this study was to characterize one surgeon's experience over a 10-year period using rhBMP-2 in the disk space for minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). SUMMARY OF BACKGROUND DATA: MIS TLIF has been utilized as a technique for decreasing patients' immediate postoperative pain, decreasing blood loss, and shortened hospital stays. Effectiveness and complications of rhBMP-2's use in the disk space is limited because of its off-label status. METHODS: Retrospective analysis of consecutive MIS TLIFs performed by senior author between 2004 and 2014. rhBMP-2 was used in the disk space in all cases. Patients were stratified based on the dose of rhBMP-2 utilized. Patients had 9 to 12 month computerized tomography scan to evaluate for bony fusion and continued follow-up for 18 months. RESULTS: A total of 688 patients underwent a MIS TLIF. A medium kit of rhBMP-2 was utilized in 97 patients, and small kit was used in 591 patients. Fusion rate was 97.9% and this was not different between the 2 groups with 96/97 patients fusing in the medium kit group and 577/591 patients fusing in the small kit group. Five patients taken back to the operating room for symptomatic pseudoarthrosis, 4 reoperated for bony hyperostosis, and 10 radiographic pseudoarthroses that did not require reoperation. A statistically significant difference in the rate of foraminal hyperostosis was found when using a medium sized kit of rhBMP-2 was 4.12% (4/97 patients), compared with a small kit (0/591 patients, P=0.0004). CONCLUSIONS: Utilization of rhBMP-2 in an MIS TLIF leads to high fusion rate (97.9%), with an acceptable complication profile. The development of foraminal hyperostosis is a rare complication that only affected 0.6% of patients, and seems to be a dose related complication, as this complication was eliminated when a lower dose of rhBMP-2 was utilized. LEVEL OF EVIDENCE: Level IV.

Does the reduction of inferior turbinate affect lower airway functions? / A redução da concha nasal inferior afeta as funções das vias aéreas inferiores?

Abstract Introduction: Although the nose and lungs are separate organs, numerous studies have reported that the entire respiratory system can be considered as a single anatomical and functional unit. The upper and lower airways affect each other either directly or through reflex mechanisms. Objective: In this study, we aimed to evaluate the effects of the radiofrequency ablation of persistent inferior turbinate hypertrophy on nasal and pulmonary function. Methods: Twenty-seven patients with bilateral persistent inferior turbinate hypertrophy without septal deviation were included in this study. All of the patients were evaluated using anterior rhinoscopy, nasal endoscopy, acoustic rhinometry, a visual analogue scale, and flow-sensitive spirometry on the day before and 4 months after the radiofrequency ablation procedure. Results: The post-ablation measurements revealed that the inferior turbinate ablation caused an increase in the mean cross-sectional area and volume of the nose, as well as in the forced expiratory volume in 1 s, forced vital capacity, and peak expiratory flow of the patients. These differences between the pre- and post-ablation results were statistically significant. The post-ablation visual analogue scale scores were lower when compared with the pre-ablation scores, and this difference was also statistically significant. Conclusion: This study demonstrated that the widening of the nasal passage after the reduction of the inferior turbinate size had a favorable effect on the pulmonary function tests.

Resumo Introdução: Embora o nariz e os pulmões sejam órgãos separados, numerosos estudos relataram que todo o sistema respiratório pode ser considerado como uma única unidade anatômica e funcional. As vias aéreas superiores e inferiores afetam uma à outra diretamente ou através de mecanismos reflexos. Objetivo: Avaliar os efeitos da ablação por radiofrequência em conchas nasais inferiores com hipertrofia persistente sobre a função nasal e pulmonar. Método: Foram incluídos neste estudo 27 pacientes com hipertrofia persistente bilateral de conchas inferiores sem desvio septal. Todos os pacientes foram avaliados com rinoscopia anterior, endoscopia nasal, rinometria acústica, escala visual analógica e espirometria sensível ao fluxo no dia anterior e quatro meses após o procedimento de ablação por radiofrequência. Resultados: As medidas pós-ablação demonstraram que a ablação das conchas nasais inferiores resultou em um aumento da área transversal média e do volume do nariz, bem como do volume expiratório forçado em um segundo, da capacidade vital forçada e do fluxo expiratório máximo dos pacientes. Essas diferenças entre os resultados pré e pós-ablação foram estatisticamente significantes. Os escores da escala visual analógica pós-ablação foram menores quando comparados com os escores pré-ablação e essa diferença também foi estatisticamente significante. Conclusão: O alargamento da passagem nasal após a redução do tamanho das conchas nasais inferiores teve efeito favorável nos testes de função pulmonar.

Does the reduction of inferior turbinate affect lower airway functions?

INTRODUCTION: Although the nose and lungs are separate organs, numerous studies have reported that the entire respiratory system can be considered as a single anatomical and functional unit. The upper and lower airways affect each other either directly or through reflex mechanisms. OBJECTIVE: In this study, we aimed to evaluate the effects of the radiofrequency ablation of persistent inferior turbinate hypertrophy on nasal and pulmonary function. METHODS: Twenty-seven patients with bilateral persistent inferior turbinate hypertrophy without septal deviation were included in this study. All of the patients were evaluated using anterior rhinoscopy, nasal endoscopy, acoustic rhinometry, a visual analogue scale, and flow-sensitive spirometry on the day before and 4 months after the radiofrequency ablation procedure. RESULTS: The post-ablation measurements revealed that the inferior turbinate ablation caused an increase in the mean cross-sectional area and volume of the nose, as well as in the forced expiratory volume in 1s, forced vital capacity, and peak expiratory flow of the patients. These differences between the pre- and post-ablation results were statistically significant. The post-ablation visual analogue scale scores were lower when compared with the pre-ablation scores, and this difference was also statistically significant. CONCLUSION: This study demonstrated that the widening of the nasal passage after the reduction of the inferior turbinate size had a favorable effect on the pulmonary function tests.

Bone Overgrowth Causing Proximal Ventriculoperitoneal Shunt Malfunction.

BACKGROUND: Hydrocephalus is an international disease process that is commonly treated surgically with a ventriculoperitoneal shunt. This device may be prone to malfunction, most commonly from obstruction, disconnection, or infection. CASE DESCRIPTION: A 35-year-old female with hydrocephalus and a ventriculoperitoneal shunt presented with altered mental status and imaging concerning for a shunt malfunction. Intraoperatively, she was found to have bone growing over and compressing the proximal occluder of the shunt valve, causing a mechanical obstruction. Removal of the bone allowed for egress of cerebrospinal fluid and return of proper shunt function. The patient did well postoperatively. CONCLUSION: Hydrocephalus, ventriculoperitoneal shunts, and shunt revisions represent a significant health burden and cost. Here we present an unusual cause of a shunt malfunction caused by bony overgrowth.

Endoscopic Modified Medial Maxillectomy for Fungal Ball of the Hypoplastic Maxillary Sinus With Bony Hypertrophy.

Sinus fungal ball is defined as noninvasive chronic rhino-sinusitis with a clump of mold in the paranasal sinuses, typically affecting the maxillary sinus. Fairly good outcomes of endoscopic surgery have been reported where the ball is removed through the antrostomy. However, the affected sinus tends to have a smaller cavity and thicker bony walls. As such, it is often challenging to maintain a window size that is sufficient to control possible recurrence. The endoscopic modified medial maxillectomy procedure was applied to a 61-year old and a 70-year old female patient with maxillary sinus fungal ball. Using this method, we created a much larger inferior meatal antrostomy without difficulty. The window provided us with an endoscopic view of the whole sinus and complete eradication of the lesion. Endoscopic modified medial maxillectomy is useful as a surgical procedure for maxillary sinus fungal ball and should be considered for better outcomes.

Transorbital endoscopic eyelid approach for resection of sphenoorbital meningiomas with predominant hyperostosis: report of 2 cases.

Sphenoorbital meningiomas (SOMs) are slow-growing tumors that originate from the sphenoidal wing and are associated with visual deterioration, extrinsic ocular movement disorders, and proptosis caused by hyperostosis of the lateral wall of the orbit. In some cases, the intracranial component is quite small or "en plaque," and the majority of the symptoms arise from adjacent hyperostosis. Craniotomy has traditionally been the standard of care, but new minimally invasive multiportal endoscopic approaches offer an alternative. In the current study, the authors to present their experience with the transorbital endoscopic eyelid approach for the treatment of 2 patients with SOMs and sphenoid wing hyperostosis. Clinical and radiological data for patients with SOMs who underwent a transorbital endoscopic eyelid approach were retrospectively reviewed. Surgical technique and clinical and radiographic outcomes were analyzed. The authors report the cases of 2 patients with SOMs and proptosis due to sphenoid wing hyperostosis. One patient underwent prior craniotomy to debulk the intracranial portion of the tumor, and the other had a minimal intracranial component. Both patients were discharged 2 days after surgery. MR images and CT scans demonstrated a large debulking of the hyperostotic bone. Postoperative measurement of the proptosis with the aid of an exophthalmometer demonstrated significant reduction of the proptosis in one of the cases. Persistence of intraconal tumor in the orbital apex limited the efficacy of the procedure in the other case. A review of the literature revealed 1 publication with 3 reports of the transorbital eyelid approach for SOMs. No measure of relief of proptosis after this surgery had been previously reported. The transorbital endoscopic approach, combined with endonasal decompression of the medial orbit, may be a useful minimally invasive alternative to craniotomy in a subset of SOMs with a predominantly hyperostotic orbital wall and minimal intracranial bulky or merely en plaque disease. In these cases, relief of proptosis and optic nerve compression are the primary goals of surgery, rather than gross-total resection, which may have high morbidity or be unachievable. In cases with significant residual intraconal tumor, orbital bone removal alone may not be sufficient to reduce proptosis.

Radiofrequency turbinate volume reduction vs. radiofrequency-assisted turbinectomy for nasal obstruction caused by inferior turbinate hypertrophy.

Radiofrequency procedures are a well-accepted treatment for nasal obstruction. We conducted a randomized, noncontrolled study to compare the effectiveness of submucosal bipolar radiofrequency turbinate volume reduction (RFTVR) and bipolar radiofrequency-assisted turbinectomy (RFaT) in patients presenting with nasal obstruction caused by inferior turbinate hypertrophy. A total of 30 patients-15 males and 15 females, aged 15 to 60 years (mean: 32)-were randomly divided into one of the two homogeneous treatment groups. Outcomes were determined by comparisons of subjective symptom scores on a visual analog scale and by anterior active rhinomanometry at postoperative days 7, 14, and 28 and again at 6 months postoperatively. Both groups demonstrated significant and similar improvements in nasal airway function both subjectively and objectively. However, we noted that the incidence of adverse effects and postoperative morbidity was higher in the RFaT group. Therefore, we conclude that when surgery is indicated, RFTVR is the preferred treatment for nasal obstruction secondary to inferior turbinate hypertrophy. RFaT is equally effective, but it is associated with a slightly higher incidence of adverse effects.