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  • ISSN: 2373-9479
    Volume 2, Issue 5
    Editorial
    Jorge E. Alvernia* and Marc Sindou
    Parasagittal meningiomas comprise 20/30% of all intracranial meningiomas. Because of their location and by definition involvement of the sagittal sinus and and/or surrounding bridging veins, radical surgery without potential morbidity is challenging. A subtotal resection is often recommended with the argument that meningiomas are benign and slowly growing tumors.
    Clinical Image
    Roland Roelz*, Jaroslaw Maciaczyk, and Ramazan Jabbarli
    A 90-year-old woman who had suffered a fall at home presented with mild confusion, retrograde amnesia and headaches to our emergency room. Clinical examination revealed soft biparietal tumescences without laceration of the overlying skin.
    Research Article
    Caroline E. Poorman, Peter G. Passias*, Kristina M. Bianco, Anthony Boniello, Sun Yang, and Michael C. Gerling
    Abstract:
    Background: Cervical drains have historically been used to avoid postoperative wound and respiratory complications such as excessive edema, hematoma, infection, re-intubation, delayed extubation, or respiratory distress. Recently, some surgeons have ceased using drains because they may prolong hospital stay, operative time, and patient discomfort.
    Objective: To investigate the effectiveness of postoperative drains following one- and two-level cervical fusions.
    Methods: A retrospective consecutive case series was conducted at a single institution from 2010-2013. Outcome measures included operative time, hospital stay, estimated blood loss and incidence of wound complications, respiratory complications, and overall complications. Statistical analyses used to compare patients who received a postoperative drain to those who did not included independent samples t-test, chi-square, analysis of covariance, and linear regression.
    Results: 39 patients who received a postoperative drain and 42 patients who did not were included. There were no differences in demographics between the two groups. Patients with drains showed increased operative time (100.1 vs 69.3 min, p<0.001), hospital stay (38.9 vs. 31.7 hrs, p=0.021), and blood loss (62.7 vs 29.1 mL, p<0.001) compared to patients without drains. The frequency of wound complications, respiratory complications, and overall complications did not vary significantly between groups.
    Conclusions: Cervical drains may not be necessary for patients undergoing one- and two-level cervical fusion. While there were no differences in incidence of complications between the two groups, the patients treated with drains had significantly longer operative time and length of hospital stay. This could contribute to excessive costs for patients treated with drains.
    Yukinori Takase, Masatou Kawashima*, Toshio Matsushima, Jun Masuoka, Yukiko Nakahara, and Kohei Inoue
    Abstract: Postoperative cerebellar swelling may cause severe clinical problems, particularly when the Superior Petrosal Veins (SPVs) are sacrificed during surgery of the posterior fossa. We investigated the relationship between abnormalities on Magnetic Resonance (MR) images and clinical symptoms after sacrificing the tributaries of the SPV during surgery in patients with trigeminal neuralgia. Thirty-four patients who underwent microvascular decompression surgery for trigeminal neuralgia underwent MR examinations within 3 days after surgery to elucidate the incidence of abnormal changes in the cerebellum. The tributaries of the SPV were divided anatomically into four groups according to the draining area. The number of sacrificed tributaries, imaging abnormalities, duration of surgical manipulation with a microscope, and clinical symptoms were evaluated in each group. At least one tributary of the SPV was sectioned in 30 patients. Hyperintense lesions were identified on both Diffusion-Weighted Images (DWIs) and Fluid-Attenuated Inversion Recovery (FLAIR) images in 6 patients (17.6%; type 1) and only on FLAIR images in 17 patients (50%; type 2). Only DWIs did not show hyperintense lesions in any patient (0%; type 3). No imaging abnormalities were observed in 11 patients (32.4%; type 4). The number of sacrificed tributaries was not significantly associated with the incidence of imaging abnormalities. Three type 1 patients developed transient clinical symptoms. Although imaging abnormalities were frequently observed, most of them were clinically silent, indicating that the tributaries of the SPV, with the exception of the petrosal fissure draining area group, may be sectioned without significant major complications during microvascular decompression.
    Kengo Suzuki, Yukinori Akiyama, Toshiya Sugino, Takeshi Mikami, Masahiko Wanibuchi, Toru Inagaki, Shinsuke Irie, Koji Saito, and Nobuhiro Mikuni*
    Abstract: Neuronavigation systems have become standard neurosurgical tool; however, there is a major concern to be solved. Brain shift occurs during surgery, which compromises the system's accurate anatomical representation. We developed and evaluated a convenient new method for a rapid intraoperative correction of brain shift during neuronavigation. We assessed four patients (4 females; mean age 61.0 years) that underwent a fronto-temporal craniotomy. Each voxel movements of CT images in the brain parenchyma are analyzed as displacement vector using neuronavigation system, and a new free-form deformation method was established among these patients and verified in another one. The shape concordance rate between the actual intraoperative CT image and CT image, which was corrected by our model, was 75.1%. On the basis of nonlinear geometric algorithms that involve intraoperative measurements of anatomical landmark positions, our model might beuseful especially in pterional craniotomy, which is one of the most common approaches employed in neurosurgery. Future improvements and further accumulation of patients' data will enable our model to be applied to a variety of surgeries.
    Gabriele P. Jasper, Gina M. Francisco, David B. Choi, Deus Cielo, Curtis E. Doberstein, and Albert E. Telfeian*
    Abstract:
    Background: The adverse effect of obesity on spine surgery outcomes has been postulated and reported multiple times but with some controversy. The impact of general anesthesia on patients with multiple medical comorbidities and the prolonged retraction times associated with thicker soft tissue have been implicated as potential factors in the higher complication rates seen in this population.
    Objectives: Transforaminal endoscopic discectomy and foraminotomy is an ultra-minimally invasive outpatient surgical option available to obese patients that does not require general anesthesia and does not necessitate additional retraction due to additional thicker soft tissue. The purpose of this study was to assess the benefit of tranforaminal endoscopic discectomy and foraminotomy in obese patients with single level lumbar disc herniations and lumbar radiculopathy.
    Methods: After Institutional Review Board Approval, charts from 82 consecutive patients with BMIs of at least 30 kg/m2 who had undergone single level endoscopic lumbar discectomies and foraminotomies were retrospectively identified and categorized according to BMI: Class I obesity, BMI 30.0-34.9 kg/m2; Class II obesity, BMI 35.0-39.9 kg/m2; or Class III obesity, BMI =40.0 kg/m2. Patients aged 40 and older (average age 61.8, 40% female) with complaints of lower back and radicular pain who underwent endoscopic procedures between 2007 and 2012 were reviewed.
    Results: The average pain relief 1 year postoperatively was reported to be 68.4% for Class I, 66.1% for Class II, and 43.5% for Class III. The average pre-operative VAS scores were 8.8 for Class I, 9.2 for Class II, and 9.0 for Class III, all as indicated in our questionnaire as describing severe and constant pain. The average 1 year postoperative VAS scores were 2.6 for Class I, 3.0 for Class II, and 3.2 for Class III, indicated in our questionnaire as mild and intermittent pain. There were no infections or other complications reported and the reherniation rate for the 1 year was 7.5% in Class I, 12.5% in Class II, and 0% in Class III.
    Conclusion: Endoscopic discectomy is a safe and effective alternative to open back surgery. The1 year follow-up data presented here appears to indicate that an ultra-minimally invasive approach to the obese spine patient that has a low complication rate, avoids general anesthesia, is performed in the lateral position, and is outpatient might be worth studying in a prospective, longer term way.
    Review Article
    Yad Ram Yadav*, Vijay Parihar, Shailendra Ratre, and Yatin Khare
    Abstract: Trigeminal neuralgia (TN) is a sudden, severe, brief, stabbing and recurrent pain within one or more branches of the trigeminal nerve. Although multiple mechanism involving peripheral pathologies at root (compression or traction), dysfunctions of brain stem, basal ganglion and cortical pain modulatory mechanisms could have role, neurovascular conflict (NCV) is most accepted theory. Patients with significant medical comorbidities, without NVC and multiple sclerosis are generally recommended to undergo gamma knife radiosurgery, percutaneous balloon compression, and glycerol rhizotomy and radiofrequency thermocoagulation procedures. Microvascular decompression (MVD) is surgical treatment of choice in TN resistant to medical management. There may be multiple NVC and entire course of root from pons to ganglion should be decompressed. Nerve combing or partial sensory root sectioning can be combined with MVD when no vascular conflict is detected intraoperative. Successful outcome after MVD in typical TN is 90-95%and 75% at 1and 5 years respectively. Immediate postoperative pain relief, shorter preoperative duration, older age, and typical features are good predictors of favorable outcome. Type 2 TN, presence of autonomic symptoms; multiple sclerosis is associated with poor prognosis. Compression or contact on the root by the prosthesis should be avoided to prevent recurrence. Endoscopic technique can be used alone for vascular decompression or as an adjuvant to microscope. It allows better visualization of vascular conflict including ventral aspect. Effectiveness and completeness of decompression can be assessed and new vascular conflicts that may be missed by microscope can be identified. It requires less brain retraction.
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