Hae-Dong Jho

Transnasal‐Transsphenoidal Endoscopic Surgery of the Pituitary Gland

In 1907, Schloffer performed the first successful removal of a pituitary tumor using a nasoethmoidal transsphenoidal approach.1 Two years later, Hirsch employed an endonasal approach for transsphenoidal pituitary surgery.1 A variety of approaches were advocated, with mixed results, until 1910, when Cushing reported on the use of the sublabial-transseptaltranssphenoidal approach.2 The transsphenoidal route for pituitary surgery, via either sublabial or septal incision, became the standard treatment for pitui taryaden~mas.~.~

Endoscopic pituitary surgery: An early experience

BACKGROUND As an element of a minimally invasive management approach, we had developed an endonasal endoscopic transsphenoidal technique for the treatment of pituitary tumors. Initially, four patients were operated on via a sublabial, transseptal approach using a fiberoptic rigid endoscope in conjunction with the operating microscope. Encouraged by that experience, our subsequent 11 patients had undergone endonasal endoscopic transsphenoidal surgery without the use of a retractor or speculum. METHODS Our group of patients included nine females and six males, with an age range of 17-88 years (median: 43 years). There were four microadenomas, four intrasellar macroadenomas, three macroadenomas with suprasellar extension, three invasive macroadenomas involving the cavernous sinus with suprasellar extension, and one metastatic adenocarcinoma. RESULTS Thirteen patients with pituitary adenomas experienced resolution of their symptoms postoperatively. One patient with a recurrent prolactinoma responded partially following surgery and subsequently underwent gamma knife radiosurgery. Two patients were treated with postoperative fractionated radiation therapy, one for residual pituitary adenoma in the cavernous sinus, and the other for metastatic adenocarcinoma, respectively. The first patient, treated via an endonasal endoscopic approach for biopsy of the metastatic adenocarcinoma, developed postoperative cerebrospinal fluid (CSF) leak that was successfully managed with endoscopic packing of a fat graft. CONCLUSIONS The endonasal endoscopic transsphenoidal approach facilitates faster postoperative recovery by the avoidance of traditional incision and postoperative nasal packing. It offers a panoramic view of the sphenoid sinus and excellent visualization of the sellar and suprasellar structures with increased illumination and magnification. Such visualization provides the potential for more complete tumor resection, as well as a better chance of preserving pituitary function and avoiding neurovascular injury.

Endoscopic endonasal approach to the ventral cranio-cervical junction: anatomical study.

Summary.Summary. Objective: In order to develop an endoscopic endonasal approach to the ventral cranio-cervical junction and odontoid process under the concept of a minimally invasive surgical strategy, a cadaver study was performed. Methods: Sixteen artery-injected adult head specimens were used. Endonasal endoscopic approach was made through one- or two-nostril routes following the Jhos endonasal paraseptal technique. Rod-lens endoscopes, which were 2.7 or 4 mm in diameter, 18 cm in length with 0-, 30-, and 70-degree lenses, were used. Results: Surgical landmarks leading to the craniocervical junction were the inferior margin of the middle turbinate, nasopharynx and Eustachian tube. The nasopharynx was readily identified following the inferior margin of the middle turbinate. The line drawn between the Eustachian tubes indicated the juncture between the clivus and atlas. With a midline mucosal incision, the ventral cranio-cervical junction was exposed. Odontoid resection was performed with removal of the anterior arch of the atlas. Clival resection can be performed as much rostral as required. Manoeuverability of the surgical instruments was better with a two-nostril technique than with a one-nostril. Although the entire midline clivus was accessible rostrally, C-2 was the caudal limit through this endonasal route. A suturing device needed to be developed for mucosal or dural closure for live operations. Conclusion: This cadaver study demonstrates that an endoscopic endonasal approach to the ventral cranio-cervical junction and odontoid process can be a valid alternative to the conventional transoral approach.

Endoscopic endonasal cavernous sinus surgery: an anatomic study.

OBJECTIVEThe endoscopic surgical anatomy of the cavernous sinus was studied to establish an anatomic basis for endoscopic endonasal cavernous sinus surgery. METHODSFive adult cadaveric heads were studied with 0-, 30-, and 70-degree 4-mm rod-lens endoscopes. The posterior wall of the sphenoidal sinus was approached via a paraseptal, middle turbinectomy, or middle meatal approach. RESULTSThe posterior bony wall of the sphenoidal sinus is subdivided into five vertical compartments: midline, bilateral paramedian, and bilateral lateral. The midline vertical compartment consists of the planum sphenoidale, tuberculum sellae, sella, and clival indentation. The paramedian vertical compartment is composed of the medial third of the optic canal and the carotid artery protuberance. The lateral vertical compartment contains four bony protuberances (optic, cavernous sinus apex, maxillary, and mandibular) and three depressions (carotico-optic, ophthalmomaxillary [V1–V2], and maxillomandibular [V2–V3]). The three depressions form anatomic triangles at the lateral vertical compartment: the optic strut triangle, which is bordered by the optic nerve, carotid artery, and oculomotor nerve (IIIrd cranial nerve); the V1–V2 triangle; and the V2–V3 triangle. The internal carotid artery at the posterior wall of the sphenoidal sinus can be subdivided into two main segments: the parasellar and the paraclival. The vidian canal is a landmark that leads to the foramen lacerum, the mandibular nerve, and the pterygopalatine fossa. CONCLUSIONEndoscopic anatomy of the cavernous sinus has been studied via an endonasal route in cadaveric specimens to provide an anatomic basis for endoscopic endonasal cavernous sinus surgery.

Endoscopic endonasal approaches to the cavernous sinus: surgical approaches.

OBJECTIVEAfter completion of an earlier endoscopic transsphenoidal anatomic study, we studied various endoscopic transsphenoidal approaches using cadaveric specimens to develop endoscopic endonasal surgical approaches to the cavernous sinus. METHODSTen cavernous sinuses in five artery-injected adult cadaveric heads were studied with 0-, 30-, and 70-degree angled 4-mm rod-lens endoscopes. The extent of the surgical exposure, the skewed endoscopic anatomic view, and the maneuverability of surgical instruments through their relative operating spaces were studied after various endoscopic endonasal approaches via one nostril. RESULTSThe paraseptal approach was used between the nasal septum and the middle turbinate and provided exposure at the anteromedial portion of the cavernous sinus. The contralateral paraseptal approach rendered a slightly more medial view at the cavernous sinus than did the ipsilateral approach. This approach offered limited surgical access to the lateral vertical compartment. The middle turbinectomy approach allowed surgical access to the lateral wall of the cavernous sinus, except for the superior orbital fissure and the orbital apex. The middle meatal approach, which was made between the middle turbinate and the lateral nasal wall, revealed the entire lateral vertical compartment of the cavernous sinus, including the orbital apex and the superior orbital fissure. However, its lateral tangential surgical trajectory and the absence of dedicated surgical tools limited the surgeon’s surgical maneuverability. A combination of the middle turbinectomy and middle meatal approaches increased the operating space. CONCLUSIONVarious endoscopic endonasal surgical approaches to the cavernous sinus were studied using adult cadaveric head specimens.

Microvascular decompression of the eighth nerve in patients with disabling positional vertigo: Selection criteria and operative results in 207 patients

SummaryTwo-hundred seven patients who were operated on consecutively between January 1983 and December 1990 to relieve disabling positional vertigo (DPV) using the microvascular decompression (MVD) procedure were studied. Selection of the patients for MVD operations was based on both case history and the results of otoneurological tests. Of the 177 patients with unilateral symptoms, 8 were excluded because of previous vestibular nerve section, and 6 did not return for follow-up; of the remaining 163 patients, 129 (79%) were free of symptoms or markedly improved following MVD, and none became worse. Thirty patients had symptoms and signs of bilateral DPV, and of these 1 was excluded because of previous vestibular nerve section and 3 because of multiple operations. Of the remaining 26 patients, 20 (77%) were free of symptoms or markedly improved following MVD. Eleven of these patients had more than 2 operations. The follow-up time was an average of 38 months, ranging from 3 months to 10 years.The cure rate (about 80%) of MVD for DPV is similar to that reported for MVD for trigeminal neuralgia and hemifacial spasm. The cure rate of MVD for DPV was not related to gender or to the duration of the symptoms.Following a total of 254 operations that these 207 patients underwent, 4 patients (1.6%) lost hearing and 4 (1.6%) suffered marked hearing loss. Three patients suffered temporary deficits of other cranial nerves. There were no other complications to these operations.

Endoscopic transsphenoidal resection of a large chordoma in the posterior fossa

SummaryEncouraged by an experience with endoscopic transsphenoidal pituitary surgery, an endoscopic transsphenoidal technique was applied in a patient with a large chordoma in the posterior fossa. The patient was a 40-year-old man with a two-year history of progressive ataxia, a memory disorder and emotional instability. A magnetic resonance (MR) scan of the brain revealed a midline posterior fossa mass measuring 4 cm in diameter located between the clivus and the brainstem. The basilar artery and its bifurcation were encased by the tumor and the brainstem was also distorted by the tumor. Obstructive hydrocephalus was treated previously with a ventriculoperitoneal shunt and fractionated external beam radiation treatment was given without histological diagnosis at another hospital. Subtotal resection of the tumor was achieved utilizing an endoscopic transsphenoidal technique through the patients nostril. The portion of the tumor located behind the basilar artery was not resected in order to protect the brainstem perforating arteries. The patient showed dramatic improvement of his symptoms postoperatively. Residual tumor located behind the basilar artery was treated by stereotactic gamma-knife surgery. This is the first reported case of a large posterior fossa chordoma being treated by an endoscopic transsphenoidal technique.

Anterior microforaminotomy for treatment of cervical radiculopathy: part 1--disc-preserving "functional cervical disc surgery".

OBJECTIVE Anterior cervical microforaminotomy was developed by the senior author (H-DJ) under the concept of “functional spine surgery,” which directly eliminates compressive pathological factors while preserving functional anatomic features. The surgical results are reported. METHODS Among approximately 400 patients who underwent anterior cervical microforaminotomy at the University of Pittsburgh between March 1993 and May 1999, 104 patients met the inclusion criteria for this study. Forty-five patients were men and 59 were women. Patient ages ranged from 26 to 74 years (median, 46 yr). Compressive pathological lesions included spondylotic spurs in 44 cases (42.3%), soft disc herniation in 54 cases (51.9%), and a combination of the two in 6 cases (5.8%). RESULTS Eighty-three patients (79.8%) experienced excellent results, 20 patients (19.2%) experienced good results, and 1 patient experienced fair results. No patient demonstrated a poor or unchanged outcome. All patients demonstrated excellent decompression in their postoperative magnetic resonance imaging scans, and all patients except one with discitis maintained their motion segments well, as indicated in postoperative dynamic roentgenograms. Two patients developed transient Horner’s syndrome, one patient developed transient hemiparesis, and one patient developed discitis, resulting in spontaneous bone fusion. CONCLUSION Anterior microforaminotomy provided good or excellent outcomes, with minimal morbidities, for 98% of 104 patients with cervical discogenic radiculopathy. The functional anatomic features were well preserved for 99% of the patients.

Microvascular decompression for spasmodic torticollis

SummaryTwenty patients with spasmodic torticollis (ST) were treated by microvascular decompression (MVD) of the spinal accessory nerves, the upper cervical nerve roots and the brainstem. Thirteen were female and seven male. Median age was 47 years (range 39 to 70 years). Median duration of symptoms was 5 years (range 4 months to 17 years). Ten had right horizontal; nine, left horizontal; and one, retrocollis ST. Twenty-two operations were performed on twenty patients, suboccipital craniectomy and C1 laminectomy in 18 and retromastoid craniectomy in 4 operations.The most common compressing blood vessels were the vertebral artery and/or the posterior inferior cerebellar artery. No nerve section was performed. Three patients died of unrelated conditions, 3, 5 1/2, and 6 years postoperatively, respectively. Minimum follow-up period in the rest of the cases is 5 years (range 5 to 10 years). Thirteen (65%) were cured, four (20%) improved with minimal spasm, one (5%) improved with moderate spasm, and two (10%) improved minimally or unchanged. In most cases the cure or improvement was noticed gradually over 6 months to two years following the operation.There was no operative mortality. Postoperative morbidities included transient cerebrospinal fluid leakage through the surgical incision in one case and an apparent multiple small vessel stroke involving periventricular white matter in one reoperation case with full recovery.MVD for ST is a nondestructive benign procedure with high probability of cure or significant improvement.

Endoscopic transpedicular thoracic discectomy

OBJECT To minimize the invasiveness and maximize the adequacy of the decompressive procedure in thoracic discectomy, a 70 degrees endoscope was adapted to perform transpedicular thoracic discectomy. METHODS A posterior transpedicular approach was performed via a 2-cm transverse skin incision, aided by an operating microscope or a 0 degrees lens endoscope. Using a 70 degrees lens endoscope, discectomy was performed after obtaining direct visualization of the ventral aspect of the spinal cord dura mater. This surgical technique has been used in 25 patients. There were 12 men and 13 women whose ages ranged from 29 to 74 years (median 46 years). Thirteen patients experienced myelopathy, with or without radiculopathy, 10 presented with radiculopathy, and two patients suffered from segmental pain. The follow-up period ranged from 4 to 60 months (median 27 months). In 12 of 13 patients with myelopathy, excellent improvement was shown postoperatively. In the remaining patient, symptoms recurred after she was injured in a motor vehicle accident 3 months postsurgery. In nine of 10 patients with radiculopathy, pain resolved completely. In the one patient with right-sided hypochondral pain and in the two patients with segmental pain, no relief was obtained despite excellent discectomy results demonstrated on postoperative magnetic resonance images. The average length of hospital stay was overnight. CONCLUSIONS The use of a 70 degrees lens endoscope through a transpedicular route has made thoracic discectomy comparable with cervical or lumbar discectomy in terms of minimal surgical invasiveness, recovery time, and complexity of the procedure.