full-endoscopic-transforaminal-thoracic-discectomy-operative-technique

Full Endoscopic Transforaminal Thoracic Discectomy Operative Technique

Thoracic disc herniations are a degenerative pathology of the thoracic spine wherein a portion of nucleus pulposis herniates into the epidural space, ...

Houston Methodist Neurological Institute

The Medpor porous polyethylene implant provides benefits to perform sellar floor reconstruction when indicated. This material has been used for cranioplasty and reconstruction of skull base defects and facial fractures. We present the most extensive use of this implant for sellar floor reconstruction and document the safety and benefits provided by this unique implant.

Sellar Floor Reconstruction with the Medpor Implant Versus Autologous Bone After Transnasal Transsphenoidal Surgery: Outcome in 200 Consecutive Patients.

Spinal epidural hematoma (SEH) occurring after chiropractic spinal manipulation therapy (CSMT) is a rare clinical phenomenon. Our case is unique because the patient had an undiagnosed cervical spinal arteriovenous malformation (AVM) discovered on pathological analysis of the evacuated hematoma. Although the spinal manipulation likely contributed to the rupture of the AVM, there was no radiographic evidence of the use of excessive force, which was seen in another reported case. As such, patients with a known AVM who have not undergone surgical intervention should be cautioned against symptomatic treatment with CSMT, even if performed properly. Regardless of etiology, SEH is a surgical emergency and its favorable neurological recovery correlates inversely with time to surgical evacuation.

Cervical Epidural Hematoma after Chiropractic Spinal Manipulation Therapy in a Patient with an Undiagnosed Cervical Spinal Arteriovenous Malformation.

Primary central nervous system (CNS) vasculitis is an idiopathic inflammatory process that selectively affects CNS vasculature without a systemic inflammatory response, and causes luminal obstruction with resultant ischemia of recipient tissue. Its varying clinical symptoms and signs depend on the caliber of vessels involved and distribution and location of the affected structures. Granulomatous hypophysitis (GH) is an autoimmune inflammatory process typically affecting women, and usually presents with hypopituitarism, and at times, diabetes insipidus, and/or visual loss. Both entities are rare CNS diseases, which, to our knowledge, have never been previously reported in the same patient.

Primary central nervous system vasculitis preceded by granulomatous hypophysitis: Case report with a review of the literature.

Fetal brain perfusion is supplied by the primitive dorsal aorta anteriorly, longitudinal neural arteries posteriorly, and anastomotic transverse segmentals. Most notable of these connections are the primitive trigeminal, otic, hypoglossal, and proatlantal arteries. With cranial-cervical circulatory maturation and development of the posterior communicating segments and vertebro-basilar system, these primitive segmental anastomoses normally regress. Anomalous neurovascular development can result in persistence of these anastomoses. Due to its territory of perfusion, the persistent primitive hypoglossal artery (PPHA) is associated with vertebral artery and posterior communicating artery hypoplasia or aplasia. As a consequence, primary blood supply to the hindbrain comes chiefly from this single artery. Although usually clinically silent, PPHA is susceptible to common cerebrovascular disorders including athero-ischemic disease and saccular aneurysmal dilation to name a few. We present a case of transient ischemic attack in a patient with a PPHA and proximal atherosclerotic disease treated by endovascular stenting.

Transient Ischemic Attack in the Setting of Carotid Atheromatous Disease with a Persistent Primitive Hypoglossal Artery Successfully Treated with Stenting: A Case Report.

Spinal cord stimulation is an effective adjunct to the treatment of a variety of chronic pain syndromes. Complications are relatively low in morbidity and are most often secondary to hardware malfunction/malposition. Infection and undesired dysesthesias represent only a minority of complications. Neuropathic orchalgia and scrotalgia after placement of epidural spinal cord stimulator is a previously unreported morbidity. While alarming, this condition is physiologically benign, causing no neurological or urological dysfunction. The two cases we encountered both occurred during uncomplicated percutaneous trial stimulator placement. Corticosteroid treatment and stimulator activation facilitated resolution of the dysesthesia and allowed completion of the trial in one case, while the other case was refractory and resulted in termination of the trial.

Acute Neuropathic Orchalgia and Scrotalgia After Percutaneous Spinal Cord Stimulator Lead Placement: Two Cases with an Unusual Complication.

Image-guided approaches to spinal instrumentation and interbody fusion have been widely popularized in the last decade [1-5]. Navigated pedicle screws are significantly less likely to breach [2, 3, 5, 6]. Navigation otherwise remains a point reference tool because the projection is off-axis to the surgeon's inline loupe or microscope view. The Synaptive robotic brightmatter drive videoexoscope monitor system represents a new paradigm for off-axis high-definition (HD) surgical visualization. It has many advantages over the traditional microscope and loupes, which have already been demonstrated in a cadaveric study [7]. An auxiliary, but powerful capability of this system is projection of a second, modifiable image in a split-screen configuration. We hypothesized that integration of both Medtronic and Synaptive platforms could permit the visualization of reconstructed navigation and surgical field images simultaneously. By utilizing navigated instruments, this configuration has the ability to support live image-guided surgery or real-time navigation (RTN). Medtronic O-arm/Stealth S7 navigation, MetRx, NavLock, and SureTrak spinal systems were implemented on a prone cadaveric specimen with a stream output to the Synaptive Display. Surgical visualization was provided using a Storz Image S1 platform and camera mounted to the Synaptive robotic brightmatter drive. We were able to successfully technically co-adapt both platforms. A minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) and an open pedicle subtraction osteotomy (PSO) were performed using a navigated high-speed drill under RTN. Disc Shaver and Trials under RTN were implemented on the MIS TLIF. The synergy of Synaptive HD videoexoscope robotic drive and Medtronic Stealth platforms allow for live image-guided surgery or real-time navigation (RTN). Off-axis projection also allows upright neutral cervical spine operative ergonomics for the surgeons and improved surgical team visualization and education compared to traditional means. This technique has the potential to augment existing minimally invasive and open approaches, but will require long-term outcome measurements for efficacy.

Videoexoscopic real-time intraoperative navigation for spinal neurosurgery: a novel co-adaptation of two existing technology platforms, technical note.

The retrosigmoid approach is broadly applicable to many posterior fossa procedures. However, cerebellar retraction is often necessary for lesions in the cerebellopontine angle, which can lead to complications. An extended retrosigmoid approach skeletonizes the sigmoid sinus and allows a wider corridor with less retraction. This study investigated the differences in retraction pressure between the retrosigmoid and extended retrosigmoid approach in a cadaveric model.

A Comparison of Cerebellar Retraction Pressures in Posterior Fossa Surgery: Extended Retrosigmoid Versus Traditional Retrosigmoid Approach.

The off-label usage of amino-amide anesthetics in intrathecal drug delivery systems (IDDS) for the treatment of chronic non-malignant and malignant pain is supported in the polyanalgesic consensus guidelines as a second-line adjunctive therapy. Although strong evidence for its clinical efficacy is lacking, its clinical safety profile has been well established within established dosing parameters. Despite the rarity of neurological adverse reactions to intrathecal bupivacaine, whether given as regional anesthesia or intrathecal therapy, neurologic morbidity associated with its administration is well documented. The etiology of adverse reactions is often difficult to definitively identify, especially given the variabilities associated with compounding errors in the formulation, solvent contamination, and mechanical factors. We present a rare case of toxic myelitis and arachnoiditis resulting in paraplegia two months after the addition of bupivacaine to the intrathecal analgesic regimen and discuss possible etiological factors with a review of the literature.

Toxic Myelitis and Arachnoiditis After Intrathecal Delivery of Bupivacaine via an Implanted Drug Delivery System: Case Report and Review of the Literature.

Lateral lumbar interbody fusion (LLIF), first described in the literature in 2006 by Ozgur ., involves direct access to the lateral disc space via a retroperitoneal trans-psoas tubular approach. Neuromonitoring is vital during this approach since the surgical corridor traverses the psoas muscle where the lumbar plexus lies, risking injury to the lumbosacral plexus that could result in sensory or motor deficits. The risk of neurologic injury is especially higher at L4-5 due to the anatomy of the plexus at this level. Here we report our single-center clinical experience with L4-5 LLIF.

Complications associated with L4-5 anterior retroperitoneal trans-psoas interbody fusion: a single institution series.

Pyogenic spondylodiscitis diminishes spinal structural integrity via disruption of the anterior and middle column, sometimes further compounded by iatrogenic violation of the posterior tension band during initial posterior decompressive surgeries. Although medical management is typically sufficient, refractory infection or progressive deformity may require aggressive debridement and reconstructive arthrodesis. Although anterior debridement plus reconstruction with posterior stabilization is an effective treatment option, existing techniques have limited efficacy for correcting focal deformity, leaving patients at risk for long-term sagittal imbalance, pain, and disability.

Short lever arm, bipedicular handlebar construct for correction of acute angular kyphosis in spondylodiscitis-induced kyphotic deformity: illustrative case.

Lumbar drain placement is a common neurosurgical procedure, with several surgical and medical indications extending even beyond the specialty. One complication of placement is a fractured catheter fragment. In some circumstances, catheter retrieval is necessary which is classically performed through an open approach. Here, we present the only reported case of a retained lumbar drain catheter which was retrieved using a transforaminal endoscopic approach to the lumbar spine.

Fractured Lumbar Drain Catheter Retrieval Using an Endoscopic Transforaminal Approach to the Lumbar Spine.

Surgical treatment of extremely migrated caudal and rostral lumbar disc herniations is technically challenging. Traditional open technique often requires more bone resection which can lead to rare but significant complications such as pars fracture or instability requiring fusion surgery. Endoscopic discectomy is a safe alternative to traditional open surgery with acceptable complication rates. Endoscopic discectomy provides the advantage of excellent visualization and maneuverability while minimizing soft tissue trauma and bony resection which can result in less postoperative pain, opioid consumption, and quicker recovery. We present a surgical technique guide for endoscopic discectomy of two patients with very high rostral (grade 1) and caudal (grade 6) lumbar disc herniations as graded by Ahn's modification of the Lee-Kim grading classification. Risks, benefits and alternatives to surgery discussed with patients and the patients consented to the procedure. This video is not a replacement to hands on training.

Meng Huang

Department of Neurosurgery

Houston Methodist Neurological Institute

Full Endoscopic Transforaminal Thoracic Discectomy Operative Technique

Meng Huang

.css-o250i3{font-size:18px;font-family:Open Sans,sans-serif;line-height:21.6px;}Department of Neurosurgery

Houston Methodist Neurological Institute

Full Endoscopic Transforaminal Thoracic Discectomy Operative Technique

Department of Neurosurgery