Volume maximised glycerol rhizolysis for trigeminal neuralgia: a single centre analysis of outcomes.

OBJECTIVES: Glycerol rhizotomy is an established treatment for medically refractory trigeminal neuralgia in select cases where microvascular decompression is contraindicated or not preferred. The standard approach is to inject a fixed volume of glycerol using Hartel's technique into Meckel's cave. We discuss a 'volume-maximised' technique of measuring the volume of Meckel's cave using intra-operative fluoroscopy and injecting an equivalent volume of glycerol such that every patient receives a tailored quantity of glycerol dependent on the volume of Meckel's cave. The safety and efficacy of this approach is analysed. METHODS: A retrospective analysis of 53 procedures where volume-maximised glycerol rhizolysis was utilised over a 7-year period (2012 -2018) at a single centre by the senior author was carried out. The incidence and duration of pain freedom and complications incurred over a median follow-up period of 8 years were analysed. RESULTS: 37 procedures were carried out for typical trigeminal neuralgia, 13 for secondary trigeminal neuralgia, and 3 for atypical trigeminal neuralgia. Overall, pain freedom was achieved in 85% cases, and 92% in patients with typical trigeminal neuralgia. Median duration of pain freedom in patients with typical trigeminal neuralgia was 63 months, versus 6 months in those with secondary trigeminal neuralgia (p < 0.00001). 14 procedures (26.4%) resulted in mild and temporary complications. 54.7% of cases experienced hypoaesthesia in a distribution similar to or less extensive than the distribution of trigeminal neuralgia. The presence of hypoaesthesia post-procedure was highly predictive of longer pain freedom (95 months versus 8 months median pain freedom (p = 0.00003)). CONCLUSIONS: Volume-maximised glycerol injection is safe and effective when compared to literature-reported outcomes post-standard volume glycerol injections. The duration of pain freedom achieved exceeds most literature-reported studies, with hypoaesthesia outcomes being comparable with previous studies. Pain freedom outcomes are more favourable in those with post-procedure hypoaesthesia.

Endonasal skull base repair with a vascularised pedicled temporo-parietal myo-fascial flap.

Objective: Expanded endonasal approaches (EEAs) to the skull base have increased the scope and extent of pathologies that can be treated endoscopically. The trade-off is creation of large skull base bone defects requiring reconstruction to re-establish barriers between the sino-nasal mucosa and subarachnoid space to prevent CSF leak and infection. A popular reconstructive technique is the local vascularized pedicled naso-septal flap, an option that may not always be possible when there is disruption of the vascular pedicle from multiple previous surgeries, adjuvant radiotherapy or extensive tumor infiltration. An alternative is the regional temporo-parietal fascial flap (TPFF) transposed via the trans-pterygoid route. We implemented a modification of this technique incorporating contralateral temporalis muscle at the tip of this flap and deeper vascularised pericranial layers within the pedicle to provide a more robust flap in selected cases. Study design/methods: A retrospective review of two cases is presented with both patients having undergone multiple EEAs to resect skull base tumors with adjuvant radiotherapy, their postoperative courses complicated by recalcitrant CSF leaks resistant to multiple surgeries. Results: Our patients had their persistent CSF fistulae repaired using infra-temporal transposition of the TPFF modified to include some of the contralateral temporalis muscle with optimisation of a vascular pedicle: a temporo-parietal temporalis myo-fascial flap (TPTMFF). Both CSF leaks resolved without further complication. Conclusion: In situations where local flap repair to reconstruct skull-base defects following EEA may not be viable or has failed, a modified regional flap incorporating temporo-parietal fascia with a preserved vascular pedicle along with attached temporalis muscle plug may provide a robust alternative option.

The 'muscle wonton' repair - A case series of internal carotid artery injuries at a single Centre during its 10-year experience in endoscopic transsphenoidal pituitary surgery.

INTRODUCTION: Although rare, injury to the internal carotid artery (ICA) during pituitary surgery may result in serious morbidity such as stroke or death. This case series explores a single centre's incidence and outcomes of ICA injury during endoscopic transsphenoidal pituitary surgery, discusses the current management options, and introduces the 'muscle wonton' (morcellised muscle wrapped in a single sheet of Surgicel®) as being a viable repair option. METHODS: All patients undergoing pituitary operations from January 2010 to December 2019 at the Queen Elizabeth Hospital, Birmingham, UK were included. Primary outcome was number of internal carotid artery injuries during pituitary surgery. Secondary outcome measures included pre-operative (demographic, risk factors such as previous radiotherapy, number of previous operations, imaging available), operative (intra-operative image guidance, intra-operative doppler ultrasound, which side ICA was damaged, repair technique) and post-operative result (death, cranial nerve VI palsy, or stroke). RESULTS: 7 out of 893 patients (0.8%) were identified as having an ICA injury. Four of the injuries were left sided. Average age was 54 years old, five were male. In four of the ICA injuries intra-operative navigation imaging was used, and a further two concurrently used ultrasound doppler. Three of the seven cases resulted in permanent morbidity (stroke). There were no other consistent demographic, pre-operative, operative, or post-operative similarities. The two patients with muscle wonton repair suffered no permanent serious complication of ICA injury (i.e. death, abducens nerve palsy, stroke). DISCUSSION: Our findings resemble the current literature, with left sided ICA injury being more common. Different methods for repairing ICA injury exist, however morcellised muscle patches have shown significant promise in animal models, and the perforated Surgicel® helps create an easy delivery method. The muscle wonton is a viable surgical option for repairing ICA injuries during pituitary surgery.

Chordomas and chondrosarcomas of the skull base: treatment and outcome analysis in a consecutive case series of 24 patients.

BACKGROUND: We present our 9-year consecutive case series of skull base chordomas and chondrosarcomas from a UK tertiary referral centre, discussing treatments offered and outcomes. This was carried out to improve understanding around current treatment and to better inform the management of future patients. METHODS: Consecutive case series over a 9-year period (2007-2016). Retrospective data analysis from the electronic skull base multidisciplinary team database and the digital patient records at a UK tertiary referral centre RESULTS: Twenty-four patients were identified (11 chordomas, 13 chondrosarcomas, mean age 52). Nineteen had proton beam therapy (PBT) postoperatively; two had intensity-modulated radiotherapy; two had no further treatment. One patient was lost to follow-up. All chordomas were resected via a transnasal endoscopic approach. Of the 19 patients undergoing resection with PBT, 13 were disease free at latest follow-up, and six patients had local recurrence, of which two died (mean follow up 7.4 years). Of the three patients treated with surgery then IMRT/TomoTherapy, one died 4 years post-treatment, and the other two are alive after 4 and 5 years of follow-up respectively. Of the two patients treated with surgery alone, one was lost to follow-up, and the other is alive after more than 8 years. Chondrosarcoma 5-year survival was 91.6%, and chordoma 4-year survival was 75%. CONCLUSION: Skull base chordomas and chondrosarcomas can be challenging to resect, and most cases require adjuvant therapy to achieve control. Where complete resection is not possible, it is critical to undertake sufficient resection to permit high-dose radiation.

Novel Surgical Treatment of Recurrent CSF Leak by Temporoparietal Temporalis Myofascial Flap: A Series of 6 Cases.

BACKGROUND: With the advent of modern endoscopes and a better anatomic understanding of the skull base, the indications of endonasal approaches are increasing. These procedures may be complicated by high rates of postoperative cerebrospinal fluid (CSF) leak, and reconstruction of the defect remains challenging. In the anterior skull base, vascularized grafts have been reported as superior in preventing CSF leakage and infection. The Hadad-Bassagasteguy flap, being a pedicled flap, is our first line flap to reconstruct the skull base. When we were not successful with this flap, we resorted to different flaps. OBJECTIVE: We modified the originally described temporoparietal fascial flap by Fortes et al and applied clinically. The objective of this paper is to briefly describe the modification of the flap and to review the clinical outcome. METHODS: From 2014 to 2018, in 6 cases of CSF leak with the appropriate indication, we used the temporoparietal myofascial flap repair that is a modification of the temporoparietal fascial flap by Fortes et al. We took all the 6 patients in our study and followed them up. RESULTS: All of the 6 repairs were successful, and no CSF leak was found just after the operation in 6- to 48-month follow-up. CONCLUSION: We recommend our modified novel temporoparietal myofascial flap as a very good option in case of failed cases of postoperative CSF leak.

Surgical Approaches to the Orbit: A Neurosurgical Perspective.

Orbital pathologies can be complex to manage surgically. In this article, we describe some of the most common and relevant approaches to orbital tumours. For each approach we describe the appropriate indications, surgical technique, potential complications, and illustrate a case example.

Endoscopic endonasal surgery for Clival Chordomas - a single institution experience and short term outcomes.

Purpose: Clival Chordomas are locally aggressive tumours which pose a significant treatment challenge. Endoscopic endonasal approach for clival chordomas is correlated with higher resection rates and lower morbidity rates in comparison to open approaches. We present our initial single institution experience and short-term patient outcomes following endoscopic endonasal approach for resection of clival chordomas. Materials and methods: This is a retrospective analysis of ten patients undergoing endoscopic endonasal approach for clival chordomas in our neurosurgical unit over a 6 year period between August 2010 and September 2016. The procedures were performed using two surgeons, four hands, binostril endoscopic endonasal approach with a Karl Storz® endoscope and intraoperative BrainLab® image guidance. Results: Overall 15 endoscopic endonasal approach resections of clival chordoma were performed in 10 patients with median follow up period of 39.5 months (range 9-76). Gross total resection was achieved in 4 cases (40%), near total resection in 4 cases (40%) and subtotal resection in 2 cases (20%). 5 cases (50%) required revision resections. Cerebrospinal fluid leak occurred in 2 patients. 1 case of meningitis occurred in a patient with revision surgery. There were no new neurological deficits post operatively with 3 patients demonstrating resolution of diplopia post operatively. No recurrence occurred following gross total resection. 1 out of 4 cases of near total resection showed evidence of progression during the follow up period. Both cases of subtotal resection demonstrated evidence of progression with one dying of unrelated cause during the follow up period. Conclusion: Endoscopic endonasal approach represents a safe technique for debulking and resection of clival chordomas. Due to the rarity of clival chordomas, it is important that patients with this pathology are managed in high volume skull base centres where a multi-disciplinary team approach is available.

Outcome of Nonfunctioning Pituitary Adenomas That Regrow After Primary Treatment: A Study From Two Large UK Centers.

Context: Despite the major risk of regrowth of clinically nonfunctioning pituitary adenomas (CNFAs) after primary treatment, systematic data on the probability of further tumor progression and the effectiveness of management approaches are lacking. Objective: To assess the probability of further regrowth(s), predictive factors, and outcomes of management approaches in patients with CNFA diagnosed with adenoma regrowth after primary treatment. Patients, Design, and Setting: Retrospective cohort study of 237 patients with regrown CNFA managed in two UK centers. Results: Median follow-up was 5.9 years (range, 0.4 to 37.7 years). The 5-year second regrowth rate was 35.3% (36.2% after surgery; 12.5% after radiotherapy; 12.7% after surgery combined with radiotherapy; 63.4% with monitoring). Of those managed with monitoring, 34.8% eventually were offered intervention. Type of management and sex were risk factors for second regrowth. Among those with second adenoma regrowth, the 5-year third regrowth rate was 26.4% (24.4% after surgery; 0% after radiotherapy; 0% after surgery combined with radiotherapy; 48.3% with monitoring). Overall, patients with a CNFA regrowth had a 4.4% probability of a third regrowth at 5 years and a 10.0% probability at 10 years; type of management of the first regrowth was the only risk factor. Malignant transformation was diagnosed in two patients. Conclusions: Patients with regrown CNFA after primary treatment continue to carry considerable risk of tumor progression, necessitating long-term follow-up. Management approach to the regrowth was the major factor determining this risk; monitoring had >60% risk of progression at 5 years, and a substantial number of patients ultimately required intervention.

Epidemiology of acromegaly: review of population studies.

Acromegaly is a rare condition necessitating large population studies for the generation of reliable epidemiological data. In this review, we systematically analysed the epidemiological profile of this condition based on recently published population studies from various geographical areas. The total prevalence ranges between 2.8 and 13.7 cases per 100,000 people and the annual incidence rates range between 0.2 and 1.1 cases/100,000 people. The median age at diagnosis is in the fifth decade of life with a median diagnostic delay of 4.5-5 years. Acral enlargement and coarse facial features are the most commonly described clinical manifestations. At the time of detection, most of the tumors are macroadenomas possibly relating to diagnostic delays and posing challenges in the surgical management. Increased awareness of acromegaly amongst the medical community is of major importance aiming to reduce the adverse sequelae of late diagnosis and treatment, improve patient outcomes and, hopefully, reduce the burden on the health care system.

THERAPY OF ENDOCRINE DISEASE: Surgery in microprolactinomas: effectiveness and risks based on contemporary literature.

Microprolactinomas are the most common pituitary adenomas. In symptomatic patients, dopamine agonists are the first-line treatment of choice; when cabergoline is used, biochemical control rates between 85 and 93% have been reported. Long-term treatment is needed in most of the cases with compliance, patient convenience, and potential adverse effects representing areas requiring attention. Based on the literature published in the past 15 years, transsphenoidal surgery can lead to normal prolactin in the postoperative period in usually 71-100% of the cases with very low postoperative complication rates. Surgical expertise is the major determinant of the outcomes, and it may be a cost-effective option in young patients with life expectancy greater than 10 years (provided it is performed by experienced surgeons at high volume centers with confirmed optimal outcomes). Larger series of patients with adequate follow-up could further validate the place of transsphenoidal surgery (particularly through the endoscopic approach for which long-term results are currently limited) in the management algorithm of patients with microprolactinoma.

Diabetes Insipidus after Traumatic Brain Injury.

Traumatic brain injury (TBI) is a significant cause of morbidity and mortality in many age groups. Neuroendocrine dysfunction has been recognized as a consequence of TBI and consists of both anterior and posterior pituitary insufficiency; water and electrolyte abnormalities (diabetes insipidus (DI) and the syndrome of inappropriate antidiuretic hormone secretion (SIADH)) are amongst the most challenging sequelae. The acute head trauma can lead (directly or indirectly) to dysfunction of the hypothalamic neurons secreting antidiuretic hormone (ADH) or of the posterior pituitary gland causing post-traumatic DI (PTDI). PTDI is usually diagnosed in the first days after the trauma presenting with hypotonic polyuria. Frequently, the poor general status of most patients prevents adequate fluid intake to compensate the losses and severe dehydration and hypernatremia occur. Management consists of careful monitoring of fluid balance and hormonal replacement. PTDI is associated with high mortality, particularly when presenting very early following the injury. In many surviving patients, the PTDI is transient, lasting a few days to a few weeks and in a minority of cases, it is permanent requiring management similar to that offered to patients with non-traumatic central DI.

"Round-the-Clock" Surgical Access to the Orbit.

Objective To describe an algorithm to guide surgeons in choosing the most appropriate approach to orbital pathology. Methods A review of 12 selected illustrative cases operated on at the neurosurgical department of University of Pittsburgh Medical Center over 3 years from 2009 to 2011 was performed. Preoperative coronal magnetic resonance imaging and/or computed tomography views were compared using a "clock model" of the orbit with its center at the optic nerve. The rationale for choosing an external, endoscopic, or combined approach is discussed for each case. Results Using the right orbit for demonstration of the clock model, the medial transconjunctival approach provides access to the anterior orbit from 1 to 6 o'clock; endoscopic endonasal approaches provide access to the mid and posterior orbit and orbital apex from 1 to 7 o'clock. The lateral micro-orbitotomy gives access to the orbit from 8 to 10 o'clock. The frontotemporal craniotomy with orbital osteotomy accesses the orbit from 9 to 1 o'clock; addition of a zygomatic osteotomy to this extends access from 6 to 8 o'clock. Conclusions Combined, the approaches described provide 360 degrees of access to the entire orbit with the choice of the optimal approach guided primarily by the avoidance of crossing the plane of the optic nerve.

Classification of sphenoid sinus pneumatization: relevance for endoscopic skull base surgery.

OBJECTIVES/HYPOTHESIS: The goal of this study was to present a classification based on the degree of pneumatization of the sphenoid sinus in the coronal plane that can be used to instruct preoperative planning for endoscopic endonasal surgery (EES). STUDY DESIGN: Observational anatomical study. METHODS: The geometry of sphenoid sinus pneumatization was characterized (n = 204 hemisinus) on high-resolution computed tomography scans, and its associations with the location of the foramen rotundum (FR) and the vidian canal (VC) were measured. Based on these findings, we propose a simple classification of pneumatization of the sphenoid sinus relevant for EES. RESULTS: The lateral recess of the sphenoid sinus was pneumatized lateral to the FR in the coronal plane in 54% of patients. The distance separating the FR and the VC correlated strongly with the depth of the lateral recess. Based on these findings, we propose three types of pneumatization: type I, where the pneumatization extends from the midline to the medial edge of the VC (25%); type II, where the pneumatization reaches the medial edge of the FR (39%); and type III, where the pneumatization extends beyond the medial border of the FR (37%). CONCLUSIONS: The proposed sphenoid sinus pneumatization classification in the coronal plane is simple and reproducible. It predicts the distance between vidian and maxillary nerve, determines the size of the surgical window to access the middle cranial fossa transnasally, and instructs on the potential risk to neurovascular structures during surgery.

Endoscopic endonasal approach for pituitary adenomas: a series of 555 patients.

PURPOSE: To report the results of a consecutive series of patients who underwent an endoscopic endonasal approach (EEA) for resection of a pituitary adenoma and compare them to previous series of microscopic and endoscopic approaches. METHODS: A retrospective review of clinical and radiographic outcomes of a consecutive series of patients operated at our center between 2002 and 2011 was performed. RESULTS: 555 patients underwent an EEA for removal of a pituitary adenoma. The mean follow up was 3.1 years (range 3 months to 9.5 years); 36 were lost to follow up. Ninety-one (17.5%) harbored recurrent adenomas. An expanded approach to reach the supra-, para- and infra-sellar spaces was employed in 290 patients (55.9%). Reconstruction with a nasal septal flap was used in 238 cases (65.6%). The rate of gross total resection was 65.3% in the 359 patients with non-functioning adenomas. The remission rates with EEA alone were 82.5% in the 57 ACTH-secreting adenomas, 65.3% in the 49 GH-secreting adenomas and 54.7% in the 53 prolactinomas. Of the 237 patients presenting with visual loss, 190 (80.2%) improved or normalized, 41 (17.3%) remained unchanged and 4 (1.7%) experienced transient visual deterioration due to postoperative apoplexy. In addition, no patient without preexisting visual loss suffered new visual decline. The overall post-operative CSF leak rate was 5% and this decreased to 2.9% after the introduction of reconstruction with the naso-septal flap. Two patients (0.3%) had an ICA injury. CONCLUSIONS: The EEA is a safe and effective way to surgically approach pituitary adenomas, particularly in recurrent tumors, those with supra-sellar extension or cavernous sinus invasion. The remission and complication rates are comparable or favorable compared with those reported in previous series of microscopic and endoscopic approaches.

Endoscopic endonasal surgery for giant pituitary adenomas: advantages and limitations.

OBJECT: Giant pituitary adenomas (> 4 cm in maximum diameter) represent a significant surgical challenge. Endoscopic endonasal surgery (EES) has recently been introduced as a treatment option for these tumors. The authors present the results of EES for giant adenomas and analyze the advantages and limitations of this technique. METHODS: The authors retrospectively reviewed the medical files and imaging studies of 54 patients with giant pituitary adenomas who underwent EES and studied the factors affecting surgical outcome. RESULTS: Preoperative visual impairment was present in 45 patients (83%) and partial or complete pituitary deficiency in 28 cases (52%), and 7 patients (13%) presented with apoplexy. Near-total resection (> 90%) was achieved in 36 patients (66.7%). Vision was improved or normalized in 36 cases (80%) and worsened in 2 cases due to apoplexy of residual tumor. Significant factors that limited the degree of resection were a multilobular configuration of the adenoma (p = 0.002) and extension to the middle fossa (p = 0.045). Cavernous sinus invasion, tumor size, and intraventricular or posterior fossa extension did not influence the surgical outcome. Complications included apoplexy of residual adenoma (3.7%), permanent diabetes insipidus (9.6%), new pituitary insufficiency (16.7%), and CSF leak (16.7%, which was reduced to 7.4% in recent years). Fourteen patients underwent radiation therapy after EES for residual mass or, in a later stage, for recurrence, and 10 with functional pituitary adenomas received medical treatment. During a mean follow-up of 37.9 months (range 1-114 months), 7 patients were reoperated on for tumor recurrence. Three patients were lost to follow-up. CONCLUSIONS: Endoscopic endonasal surgery provides effective initial management of giant pituitary adenomas with favorable results compared with traditional microscopic transsphenoidal and transcranial approaches.

Emergency neurosurgical referrals in the North East of England - trends over four years 2008-2011.

AIMS: On-call referrals are a considerable part of the neurosurgical workload. Many neurosurgical centres in the UK have now adopted the practice of maintenance of electronic databases to keep records of on-call activity. We analysed the neurosurgical on-call referrals database maintained at the Newcastle General Hospital (NGH)/Royal Victoria Infirmary (RVI) to assess any trends in the nature of referrals. METHODS: Retrospective review and statistical analysis of a contemporaneously populated referrals database, maintained at the Regional Neurosciences Unit in Newcastle. Data were analysed from August 2008 to April 2011. A three point moving average was used to depict trend in the number of referrals. Descriptive statistics were used to display other trends. Analysis was conducted using JMP 8.0.2 (SAS Institute, Cary, NC, USA). RESULTS: Our analysis reveals that the number of emergency referrals to neurosurgery in the North East of England is increasing year-on-year. Mean number of referrals per day has increased by almost 5 over the study period (9.06 in 2008 compared to 13.93 in 2011). The major diagnoses that account for this increase are lumbar degenerative conditions, intracerebral haematomas, spinal trauma and subarachnoid haemorrhage. 50% of the patients are referred out of hours and approximately one-third are admitted. In contrast, 47% of all referrals to rule out a cauda equina syndrome, need admission for scanning. General practitioners (GP) are the single biggest source of referral outside of the parent NHS trust and 47% of the GP referrals are regarding lumbar degenerative conditions and cauda equina syndrome. CONCLUSIONS: Continuously increasing referrals have implications on cost, staffing and sustainability of the service. Alternative referral pathways, especially for referrals from primary care, must be considered to restore the on-call workload to 'true' neurosurgical emergencies.

Endoscopic endonasal approach for growth hormone secreting pituitary adenomas: outcomes in 53 patients using 2010 consensus criteria for remission.

We report the outcomes of the endoscopic endonasal approach (EEA) for resection of growth hormone secreting pituitary adenomas using 2010 consensus criteria. We also assess outcomes with additional medical therapy and radiosurgery (RS) for patients not achieving remission with EEA alone. A retrospective review of 53 patients who had follow up endocrinologic data at least 3 months post-surgery was performed among patients who were treated by EEA between 1998 and 2012. Data were analyzed for remission using GH and IGF-I levels based on 2010 consensus criteria. We also analyzed the outcomes using 2000 consensus criteria for ease in comparison to prior studies of outcomes of surgery for acromegaly. In this series of mostly large (88.2% macroadenomas), invasive (46.9% Hardy-Wilson C, D, E) adenomas, there were 27 patients (50.9%) who achieved remission after EEA only. For patients who had no remission with EEA alone, RS and/or medical therapy were used and 37 patients (69.8 %) achieved remission overall. Statistical analysis showed larger tumor size, Hardy Stages C, D, E and Knosp Scores 3, 4 to be predictive against remission for EEA only and EEA with other modalities. The volume of residual tumor after EEA was not found to be predictive of remission with additional therapies. We used stringent consensus criteria from 2010 in a series which included a high proportion of invasive GH secreting adenomas to show that EEA alone or combined with other modalities results in comparable remission rates to earlier studies which used less strict criteria, while retaining low complication rates.

Intraoperative computed tomography guidance to confirm decompression following endoscopic endonasal approach for cervicomedullary compression.

Introduction Cervicomedullary compression often requires an anterior approach to address the compressive vector. In certain cases an endoscopic endonasal approach (EEA) is ideal for decompression. It is essential that an adequate decompression be achieved and verified before the patient leaves the operating room. The purpose of this study was to evaluate the use intraoperative computed tomography (IO-CT) in assessing the adequacy of decompression. Methods A retrospective chart review revealed 11 cases of EEA odontoid resection IO-CT verification of decompression. Operative reports and review of imaging was used to determine if further decompression was performed following the intraoperative scan. Results Out of 11 EEA cases, 4 (36%) patients showed evidence of residual compression following an initial IO-CT. Further operative decompression was undertaken following the first scan in all cases. A second intraoperative scan was then used to confirm complete decompression. No patient left the operating room with residual compression. Discussion IO-CT provided valuable utility in 36% of the cases after the initial resection was incomplete. The standard fluoroscopic guidance may not provide adequate resolution and enhanced utility like IO-CT.