Lana D. Christiano

Surgical nuances for removal of tuberculum sellae meningiomas with optic canal involvement using the endoscopic endonasal extended transsphenoidal transplanum transtuberculum approach

Tuberculum sellae meningiomas frequently extend into the optic canals. Radical tumor resection including the involved dural attachment, underlying hyperostotic bone, and intracanalicular tumor in the optic canal offers the best chance of a Simpson Grade I resection to minimize recurrence. Decompression of the optic canal with removal of the intracanalicular tumor also improves visual outcome since this portion of the tumor is usually the cause of asymmetrical visual loss. The purely endoscopic endonasal extended transsphenoidal approach offers a direct midline trajectory and immediate access to tuberculum sellae meningiomas without brain retraction and manipulation of neurovascular structures. Although the endoscopic approach has been previously criticized for its inability to remove tumor within the optic canals, complete Simpson Grade I tumor removal including intracanalicular tumor, dural attachment, and involved hyperostotic bone can be achieved in properly selected patients. Excellent visualization of the suprasellar region and the inferomedial aspects of both optic canals allows for extracapsular, extraarachnoid dissection of the tumor from the critical structures using bimanual microsurgical dissection. In this report, the authors describe the operative nuances for removal of tuberculum sellae meningiomas with optic canal involvement using a purely endoscopic endonasal extended transsphenoidal (transplanum transtuberculum) approach. They specifically highlight the technique for endonasal bilateral optic nerve decompression and removal of intracanalicular tumor to improve postoperative visual function, as demonstrated in 2 illustrative cases. Special attention is also given to cranial base reconstruction to prevent CSF leakage using the vascularized pedicled nasoseptal flap.

Surgical nuances for removal of retrochiasmatic craniopharyngioma via the endoscopic endonasal extended transsphenoidal transplanum transtuberculum approach

Retrochiasmatic craniopharyngiomas are challenging tumors to remove given their deep location and proximity to critical neurovascular structures. Complete surgical removal offers the best chance of cure and prevention of recurrence. The endoscopic endonasal extended transsphenoidal approach offers direct midline access to the retrochiasmatic space through a transplanum transtuberculum corridor. Excellent visualization of the undersurface of the optic chiasm and hypothalamus can be obtained to facilitate bimanual extracapsular dissection to permit complete removal of these formidable tumors. In this report the authors review the endoscopic endonasal extended transsphenoidal approach, with specific emphasis on technical operative nuances in removing retrochiasmatic craniopharyngiomas. An illustrative intraoperative video demonstrating the technique is also presented.

The historical evolution of transsphenoidal surgery: facilitation by technological advances

Over the past century, pituitary surgery has undergone multiple evolutions in surgical technique and technological advancements that have resulted in what practitioners now recognize as modern transsphenoidal surgery (TSS). Although the procedure is now well established in current neurosurgical literature, the historical maze that led to its development continues to be of interest because it allows a better appreciation of the unique contributions by the pioneers of the technique, and of the innovative spirit that continues to fuel neurosurgery. The early events in the history of TSS have already been well documented. This paper therefore summarizes the major early transitions along the timeline, and then further concentrates on some of the more recent advancements in TSS, such as the surgical microscope, fluoroscopy, endoscopy, intraoperative imaging, and frameless guidance. The account of each of these innovations is unique because they were each developed as a response to certain historical needs by the surgeon. An understanding of these more recent contributions, coupled with the early history, provides a more complete perspective on modern TSS.

Surgical nuances for removal of retrochiasmatic craniopharyngiomas via the transbasal subfrontal translamina terminalis approach.

Giant craniopharyngiomas in the retrochiasmatic space are challenging tumors, given the location and surrounding vital structures. Surgical removal remains the first line of therapy and offers the best chance of cure. For tumors with extension into the retrochiasmatic space, the authors use the translamina terminalis corridor via the transbasal subfrontal approach. Although the lamina terminalis can be accessed via anterolateral approaches (pterional or orbitozygomatic), the surgical view of the optic chiasm is oblique and prevents adequate visualization of the ipsilateral wall of the third ventricle. The transbasal subfrontal approach, on the other hand, offers the major advantage of direct midline orientation and access to the third ventricle through the lamina terminalis. This provides the significant advantage of visualization of both walls of the third ventricle and hypothalamus as well as inferior midline access to the interpeduncular cistern to permit safe neurovascular dissection and total tumor removal. In this report, the authors describe the transbasal subfrontal translamina terminalis approach, with specific emphasis on technical surgical nuances in removing retrochiasmatic craniopharyngiomas. An illustrative video demonstrating the technique is also presented.

Double flap technique for reconstruction of anterior skull base defects after craniofacial tumor resection: technical note.

Successful reconstruction of large anterior skull base (ASB) defects after craniofacial resection of malignant skull base tumors is paramount for preventing cerebrospinal fluid (CSF) fistulas. The vascularized pedicled pericranial flap (PCF) has been the gold standard for repairing ASB defects after transbasal transcranial approaches. However, flap necrosis and delayed CSF leaks can occur after adjuvant radiation therapy. We describe a “double flap” reconstruction technique in which the PCF is augmented inferiorly by a secondary vascularized pedicled nasoseptal flap (NSF) that is harvested and rotated using an endoscopic endonasal approach.

Bone morphogenetic protein-induced inflammatory cyst formation after lumbar fusion causing nerve root compression

Bone morphogenetic protein (BMP) has been reported to cause early inflammatory changes, ectopic bony formation, adjacent level fusion, radiculitis, and osteolysis. The authors describe the case of a patient who developed inflammatory fibroblastic cyst formation around the BMP sponge after a lumbar fusion, resulting in compressive lumbar radiculopathy. A 70-year-old woman presented with left L-4 and L-5 radiculopathy caused by a Grade I spondylolisthesis with a left herniated disc at L4-5. She underwent a minimally invasive transforaminal lumbar interbody fusion with BMP packed into the interbody cage at L4-5. Her neurological symptoms resolved immediately postoperatively. Six weeks later, the patient developed recurrence of radiculopathy. Radiological imaging demonstrated an intraspinal cyst with a fluid-fluid level causing compression of the left L-4 and L-5 nerve roots. Reexpoloration of the fusion was performed, and a cyst arising from the posterior aspect of the cage was found to compress the axilla of the left L-4 nerve root and the shoulder of the L-5 nerve root. The cyst was decompressed, and the wall was partially excised. A collagen BMP sponge was found within the cyst and was removed. Postoperatively, the patients radiculopathy resolved and she went on to achieve interbody fusion. Bone morphogenetic protein can be associated with inflammatory cyst formation resulting in neural compression. Spine surgeons should be aware of this complication in addition to the other reported BMP-related complications.

Late prevertebral abscess after anterior cervical fusion.

Study Design. We present a unique case of a 54-year-old woman who developed a prevertebral abscess 2 years after anterior cervical fusion in the absence of previously reported risk factors for late infection. The literature relevant to this topic is reviewed. Objective. To report a rare complication of a commonly performed surgery. Summary of Background Data. Anterior cervical discectomy and fusion (ACDF) is one of the most commonly performed spinal surgeries. The complication rate is relatively low; the risk of infection is only 0.1% to 1.6%. In the late postoperative setting, more than 6 months, wound infections are very rare and are often associated with an esophageal perforation secondary to hardware migration. Methods. We present a rare complication of a deep wound infection in a 54-year-old woman 2 years after an anterior cervical fusion. On serial radiograph imaging after surgery, the surgical level demonstrated progressive fusion. At 2 years, however, the patient presented with acute dysphagia. Computed tomography (CT) of the neck with contrast demonstrated a rim enhancing prevertebral mass, which was treated with wound exploration and debridement. Direct laryngoscopy at the time of surgery did not demonstrate a breach in the esophageal mucosa and inspection of the esophagus during surgery did not reveal a diverticulum, tear, or breach in the esophagus. Results. After surgical exploration and debridement the patient was placed on a 6-week course of antibiotics. Her dysphagia improved significantly after debridement of the prevertebral abscess. Conclusion. Late occurring, deep wound infections are a rare complication of anterior cervical fusion. Dysphagia in the late postoperative setting should be considered carefully and evaluated for esophageal perforation or deep wound infection.

Endovascular management of acute ischemic stroke.

The management of stroke has progressed significantly over the past 2 decades due to successful treatment protocols including intravenous and intraarterial options. The intravenous administration of tissue plasminogen activator within an established treatment window has been proven in large, well-designed studies. The evolution of endovascular strategies for acute stroke has been prompted by the limits of the intravenous treatment, as well as by the desire to demonstrate improved recanalization rates and improved long-term outcomes. The interventional treatment options available today are the intraarterial administration of tissue plasminogen activator and newer antiplatelet agents, mechanical thrombectomy with the MERCI device and the Penumbra system, and intracranial angioplasty and stent placement. In this review the authors outline the major studies that have defined the current field of acute stroke management and discuss the basic treatment paradigms that are commonly used today.

Reconstruction of pterional defects after frontotemporal and orbitozygomatic craniotomy using Medpor Titan implant: Cosmetic results in 98 patients

OBJECTIVE Reconstruction of pterional and temporal defects after frontotemporal (FT) and orbitozygomatic (OZ) craniotomy is important for avoidance of temporal hollowing, maintaining functional restoration, and achieving optimal cosmesis. The objective of this study is to describe our experience and cosmetic results with pterional reconstruction after FT and OZ craniotomy with the Medpor Titan implant. METHODS Ninety-eight consecutive patients underwent reconstruction of pterional and temporal defects after FT and OZ craniotomy using the Medpor Titan implant. The implant was shaped to recreate the pterion to provide coverage for the cranial defect and to bolster the temporalis muscle to prevent temporal hollowing. The implant was then secured to the bone flap with titanium screws. Cosmetic evaluation was performed from both surgeons and patients perspective. RESULTS Of 90 patients who underwent cosmetic assessment at the 3 month follow-up, temporalis asymmetry was noticed subjectively by three patients and noted in 7 patients by the surgeon. Orbital asymmetry was not noticed in any cases by either surgeon or patient. Overall patient satisfaction was found in 89 of 90 patients (98.9%). There were no cases of temporal hollowing. One patient had a delayed wound infection, and one had an inflammatory reaction that required removal of the implant. CONCLUSIONS Our technique using the Medpor Titan implant is a fast and effective method for pterional reconstruction after FT and OZ craniotomy with excellent cosmetic results and patient satisfaction. The implant combines the advantages of both porous polyethylene and titanium mesh, including easy custom-shaping without sharp edges, structural support and relatively lower cost.

Ossification of the ligamentum flavum: a unique report of a Hispanic woman.

Ossification of the ligamentum flavum (OLF) is a disease of ectopic bone formation within the ligamentum flavum, which may result in mass effect and neurological compromise. The low thoracic region is the most common region of occurrence, and this is followed by the cervical, then lumbar, spine. The prevalence of OLF is significantly higher in the Japanese population compared with other nationalities and has a male preponderance. Ossification of the ligamentum flavum has been reported in association with the more common ligamentous pathological entities--ossification of the posterior longitudinal ligament and diffuse idiopathic skeletal hyperostosis. These latter two conditions have been linked to several metabolic processes, and a possible genetic basis has been hypothesized. Here, the authors present a unique case of OLF of the cervical spine in a patient with idiopathic hypercalcemia.