Name: transtubular endoscopic posterolateral decompression for l5-s1 lumbar lateral disc herniation
Uploaded: 2022-10-14T13:00:00
Description: Watch this Scientific Journal Video about Transtubular Endoscopic Posterolateral Decompression for L5-S1 Lumbar Lateral Disc Herniation at JoVE.com

This study was supported by the Okayama Spine Group.

This study was approved by the ethics committee of Okayama Rosai Hospital (No. 305).
1. Patient history taking
<ol>
	<li>Ensure that the patient has a herniated disc that causes severe sciatica. Usually, the patient will have a history of some prodromal low back pain. They may correlate their symptoms with an episode of trauma.</li>
	<li>Ask the patient to describe their radiating leg pain, including its location. Also ask them about the activities that make it better or wor...

<ol>
	<li>Shawky, A. A., Babic, D., Siam, A. E., Ezzati, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Extraforaminal+microscopic+assisted+percutaneous+nucleotomy+for+foraminal+and+extraforaminal+lumbar+disc+herniations.">Extraforaminal microscopic assisted percutaneous nucleotomy for foraminal and extraforaminal lumbar disc herniations.</a> The Spine Journal. 18 (4), 620-625 (2018).</li><li>Mehta, R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transtubular+endoscopic+posterolateral+decompression+of+the+L5+root+under+navigation+and+O-arm:+A+technical+note.">Transtubular endoscopic posterolateral decompression of the L5 root under navigation and O-arm: A technical note.</a> Acta Medica Okayama. 75 (5), 637-640 (2021).</li><li>Pirris, S. M., Dhall, S., Mummaneni, P. V., Kanter, A. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Minimally+invasive+approach+to+extraforaminal+disc+herniations+at+the+lumbosacral+junction+using+an+operating+microscope:+Case+series+and+review+of+the+literature.">Minimally invasive approach to extraforaminal disc herniations at the lumbosacral junction using an operating microscope: Case series and review of the literature.</a> Neurosurgical Focus. 25 (2), 10 (2008).</li><li>Kotil, K., Akcetin, M., Bilge, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+minimally+invasive+transmuscular+approach+to+far-lateral+L5-S1+level+disc+herniations:+A+prospective+study.">A minimally invasive transmuscular approach to far-lateral L5-S1 level disc herniations: A prospective study.</a> Journal of Spinal Disorders and Techniques. 20 (2), 132-138 (2007).</li><li>Stavrinou, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Navigated+transtubular+extraforaminal+decompression+of+the+L5+nerve+root+at+the+lumbosacral+junction:+Clinical+data,+radiographic+features,+and+outcome+analysis.">Navigated transtubular extraforaminal decompression of the L5 nerve root at the lumbosacral junction: Clinical data, radiographic features, and outcome analysis.</a> BioMed Research International. 2016, 3487437 (2016).</li><li>Heo, D. H., Sharma, S., Park, C. K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopic+treatment+of+extraforaminal+entrapment+of+L5+nerve+root+(far+out+syndrome)+by+unilateral+biportal+endoscopic+approach:+Technical+report+and+preliminary+clinical+results.">Endoscopic treatment of extraforaminal entrapment of L5 nerve root (far out syndrome) by unilateral biportal endoscopic approach: Technical report and preliminary clinical results.</a> Neurospine. 16 (1), 130-137 (2019).</li><li>Watanabe, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Clinical+outcomes+of+posterior+lumbar+interbody+fusion+for+lumbar+foraminal+stenosis:+preoperative+diagnosis+and+surgical+strategy.">Clinical outcomes of posterior lumbar interbody fusion for lumbar foraminal stenosis: preoperative diagnosis and surgical strategy.</a> Journal of Spinal Disorders and Techniques. 24 (3), 137-141 (2011).</li><li>Fukui, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Japanese+Orthopaedic+Association+Back+Pain+Evaluation+Questionnaire.+Part+2.+Verification+of+its+reliability:+The+Subcommittee+on+Low+Back+Pain+and+Cervical+Myelopathy+Evaluation+of+the+Clinical+Outcome+Committee+of+the+Japanese+Orthopaedic+Association.">Japanese Orthopaedic Association Back Pain Evaluation Questionnaire. Part 2. Verification of its reliability: The Subcommittee on Low Back Pain and Cervical Myelopathy Evaluation of the Clinical Outcome Committee of the Japanese Orthopaedic Association.</a> Journal of Orthopaedic Science. 12 (6), 526-532 (2007).</li><li>Wiltse, L. L., Guyer, R. D., Spencer, C. W., Glenn, W. V., Porter, I. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Alar+transverse+process+impingement+of+the+L5+spinal+nerve:+The+far-out+syndrome.">Alar transverse process impingement of the L5 spinal nerve: The far-out syndrome.</a> Spine. 9 (1), 31-41 (1984).</li><li>Haher, T. R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+role+of+the+lumbar+facet+joints+in+spinal+stability.+Identification+of+alternative+paths+of+loading.">The role of the lumbar facet joints in spinal stability. Identification of alternative paths of loading.</a> Spine. 19 (23), 2667-2670 (1994).</li><li>Foley, K. T., Smith, M. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Microendoscopic+discectomy.">Microendoscopic discectomy.</a> Techniques in Neurosurgery. 3, 301-307 (1997).</li><li>Tanaka, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparison+of+navigated+expandable+vertebral+cage+with+conventional+expandable+vertebral+cage+for+minimally+invasive+lumbar/thoracolumbar+corpectomy.">Comparison of navigated expandable vertebral cage with conventional expandable vertebral cage for minimally invasive lumbar/thoracolumbar corpectomy.</a> Medicina. 58 (3), 364 (2022).</li><li>Zhang, W., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Accuracy+of+pedicle+screw+insertion+in+posterior+scoliosis+surgery:+A+comparison+between+intraoperative+navigation+and+preoperative+navigation+techniques.">Accuracy of pedicle screw insertion in posterior scoliosis surgery: A comparison between intraoperative navigation and preoperative navigation techniques.</a> European Spine Journal. 26 (6), 1756-1764 (2017).</li><li>Ikuta, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgical+complications+of+microendoscopic+procedures+for+lumbar+spinal+stenosis.">Surgical complications of microendoscopic procedures for lumbar spinal stenosis.</a> Minimally Invasive Neurosurgery. 50 (3), 145-149 (2007).</li><li>Frank, E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopically+assisted+open+removal+of+laterally+herniated+lumbar+discs.">Endoscopically assisted open removal of laterally herniated lumbar discs.</a> Surgical Neurology. 48 (5), 430-433 (1997).</li><li>Li, Y. Z., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Efficacy+and+safety+of+percutaneous+endoscopic+decompression+via+transforaminal+and+interlaminar+approaches+for+lumbar+spine+stenosis:+Protocol+for+a+systematic+review+and+meta-analysis.">Efficacy and safety of percutaneous endoscopic decompression via transforaminal and interlaminar approaches for lumbar spine stenosis: Protocol for a systematic review and meta-analysis.</a> Medicine. 99 (1), 18555 (2020).</li><li>Prod'homme, M., Sans-Merce, M., Pitteloud, N., Damet, J., Lascombes, P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Intraoperative+2D+C-arm+and+3D+O-arm+in+children:+A+comparative+phantom+study.">Intraoperative 2D C-arm and 3D O-arm in children: A comparative phantom study.</a> Journal of Children's Orthopaedics. 12 (5), 550-557 (2018).</li><li>Tanaka, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Percutaneous+C-arm+free+O-arm+navigated+biopsy+for+spinal+pathologies:+A+technical+note.">Percutaneous C-arm free O-arm navigated biopsy for spinal pathologies: A technical note.</a> Diagnostics. 11 (4), 636 (2021).</li></ol>

L5 radicular symptoms are caused mainly by L4-L5 disc herniation or stenosis. These symptoms may also occur due to L5 lumbar foraminal stenosis or L5-S1 lateral lumbar disc herniation (LLDH)9. Of all the symptomatic lumbar disc herniations, L5-S1 FLDH accounts for approximately 3%10. For L5-S1 foraminal lesions, a posterolateral or transforaminal approach is recommended. For this approach, there are three main techniques, such as the microscopic, tube with endoscopic, and f...

Diagnosis and surgeries for lumbar foraminal stenosis (LFS) and lumbar lateral disc herniation (LLDH) at the L5-S1 level are challenging for spine surgeons because of this level&#39;s unique structure1. The iliac crest, broad L5 transverse process (TP), small space between the sacral ala and the L5 TP, and osteophytes make the operating window very narrow2. If the bony resection is not enough, inadequate decompression to the L5 nerve root may lead to residual symptoms. Massive bony removal causes postoperative instability. These issues limit surgeons&#39; competencies with foraminal/extraforaminal L5 root decompression. Several reports have shown good results with minimally invasive spine surgeries, such as microscopic or endoscopic procedures in this area to decompress the L5 nerve root3,4. Recently, the use of navigation for foraminal decompression of the L5 root has been reported with good surgical outcomes5.
Fully endoscopic discectomy is becoming popular for removing lateral lumbar disc herniation6. Furthermore, microendoscopic procedures in combination with navigation can help the surgeon to decompress the L5 root with precision2. Usually, these techniques require intraoperative C-arm usage. The goal of this method is to decompress the L5 root precisely with minimum bony resection without a C-arm.
The indications for this technique are extraforaminal lumbar disc herniation and herniation/stenosis of the lateral half of the foraminal lumbar disc. The contraindications are herniation/stenosis of the medial one-third of the foraminal lumbar disc because the scope cannot reach the targeted area2.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>1488 HD 3-Chip camera system</td>
			<td>Stryker</td>
			<td>1000902487</td>
			<td></td>
		</tr>
		<tr>
			<td>16mm Endoscope Attachment, Sterile</td>
			<td>Medtronic</td>
			<td>9560160</td>
			<td></td>
		</tr>
		<tr>
			<td>18mm Endoscope Attachment, Sterile</td>
			<td>Medtronic</td>
			<td>9560180</td>
			<td></td>
		</tr>
		<tr>
			<td>4K 32&#34; surgical display</td>
			<td>Stryker</td>
			<td>0240-031-050</td>
			<td></td>
		</tr>
		<tr>
			<td>Adjustable hinged operating carbon table</td>
			<td>Mizuho OSI</td>
			<td>6988A-PV-ACP</td>
			<td>OSI Axis Jackson table</td>
		</tr>
		<tr>
			<td>L10 AIM light source</td>
			<td>Stryker</td>
			<td>1000902487</td>
			<td></td>
		</tr>
		<tr>
			<td>METRx MED System Endoscope, Long</td>
			<td>Medtronic</td>
			<td>9560102</td>
			<td></td>
		</tr>
		<tr>
			<td>METRx MED System Reusable Endoscope</td>
			<td>Medtronic</td>
			<td>9560101</td>
			<td>Metrx</td>
		</tr>
		<tr>
			<td>METRx MED System Reusable Endoscope</td>
			<td>Medtronic</td>
			<td>9560101 M</td>
			<td></td>
		</tr>
		<tr>
			<td>METRx MED System Reusable Endoscope, Long</td>
			<td>Medtronic</td>
			<td>9560102</td>
			<td></td>
		</tr>
		<tr>
			<td>Navigated high speed bur</td>
			<td>Medtronic</td>
			<td>EM200N</td>
			<td>Stelth&#160;</td>
		</tr>
		<tr>
			<td>Navigated passive pointer</td>
			<td>Medtronic</td>
			<td>960-559</td>
			<td></td>
		</tr>
		<tr>
			<td>NIM Eclipse system</td>
			<td>Medtronic</td>
			<td>ECLC</td>
			<td>Neuromonitouring</td>
		</tr>
		<tr>
			<td>O-arm</td>
			<td>Medtronic</td>
			<td>224ABBZX00042000</td>
			<td>Intraoperative CT</td>
		</tr>
		<tr>
			<td>Stealth station navigation system Spine 7R</td>
			<td>Medtronic</td>
			<td>9733990</td>
			<td>Navigation</td>
		</tr>
		<tr>
			<td>Surgical Carts</td>
			<td>Stryker</td>
			<td>F-NSK-006-00</td>
			<td></td>
		</tr>
		<tr>
			<td>Tubular Retractor, 16mm</td>
			<td>Medtronic</td>
			<td>955-524</td>
			<td></td>
		</tr>
		<tr>
			<td>Tubular Retractor, 16mm, Long</td>
			<td>Medtronic</td>
			<td>9560216</td>
			<td></td>
		</tr>
		<tr>
			<td>Tubular Retractor, 18mm</td>
			<td>Medtronic</td>
			<td>9560118</td>
			<td></td>
		</tr>
		<tr>
			<td>Tubular Retractor, 18mm, Long</td>
			<td>Medtronic</td>
			<td>9560218</td>
			<td></td>
		</tr>
	</tbody>
</table>

transtubular endoscopic posterolateral decompression for l5-s1 lumbar lateral disc herniation

We report a novel technique for C-arm free transtubular L5 nerve decompression under CT-based navigation to reduce the radiation hazard. This procedure is performed under general anesthesia and neuromonitoring. The patient is placed in a prone position on an operating carbon table. A navigation reference frame is placed percutaneously into the contralateral sacroiliac joint or spinous process. Then, CT scan images are obtained. After instrument registration, the L5-S1 foraminal level is confirmed with a navigated probe, and the entry point is marked. Using an approximately 2 cm skin incision, the subcutaneous tissue and muscles are dissected. The navigated first dilator is aimed at the L5-S1 Kambin&#39;s triangle, and sequential dilation is performed. The 18 mm tube is used and fixed to the frame. The bone around the Kambin&#39;s triangle is removed with a navigated burr. For lateral disc herniation, the L5 nerve root is identified and retracted, and the disc fragment is removed. The navigation-guided tubular endoscopic decompression is an effective procedure. There is no radiation hazard to the surgeon or the operating room staff.

Eight cases (four men, four women) underwent surgery using this new technique. The average age was 72.0 years, and the average follow-up period was 1.5 years. There were five patients with L5/S1 foraminal stenosis, two patients with L5/S foraminal disc herniation, and one patient with L3/4 foraminal disc herniation. We could perform all surgeries without a C-arm. The average surgical time and blood loss were 143 min &#177; 14 min and 134 &#177; 18 mL, respectively.
The average recovery percent...

Watch this Scientific Journal Video about Transtubular Endoscopic Posterolateral Decompression for L5-S1 Lumbar Lateral Disc Herniation at JoVE.com

Transtubular Endoscopic Posterolateral Decompression for L5-S1 Lumbar Lateral Disc Herniation

Presented here is a novel technique of C-arm free transtubular posterolateral decompression for lumbar foraminal stenosis and lateral disc herniation under O-arm navigation.

We report a novel technique for C-arm free transtubular L5 nerve decompression under CT-based navigation to reduce the radiation hazard. This procedure is ...

Diagnosis and surgery for lumbar foraminal stenosis and lumbar lateral disc herniation at L5-S1 level is challenging to spinal surgeon because of its unique structure. Iliac crest below L5 transverse process, small space between sacral alar and L5 transverse process, and osteophytes make the operating window very narrow. If the bone resection is not enough, inadequate decompression to the L5 nerve root made the residual symptom.Massive bone resection cause postoperative instability. These reason limit the surgeons familiarity with the extraforaminal L5 root decompression. Several reports supported good result with minimally invasive spine surgeries such as microscopic or endoscopic procedure at this area to decompress L5 nerve root.Recently, the use of navigation for foraminal decompression of L5 nerve root has been reported with good surgical results. Truly endoscopic discectomy is getting popular to remove natural disc herniation. Furthermore, microendoscopic procedure in combination with navigation, can help the surgeon to decompress L5 nerve root precisely.Usually, these techniques require intraoperative C-arm usage. The goal of this method is to decompress L5 root precisely with minimal bony resection without C-arm. This study was approved by the Ethics Committee of Okayama Rosai Hospital.This is a protocol of transtubular endoscopic posterolateral decompression for L5-S1 lumbar lateral disc herniation. Evaluation of radiograms and magnetic resonance imaging. Perform anterior, posterior, and lateral radiography in standing position to check lumbar deformity and spondylolisthesis.If the patient has severe deformity, spinal fusion is indicated. Perform functional radiography in standing position. Check functional radiograms to confirm lumbar instability by measuring vertebral abnormal movement.Perform MRI to accurately assess lumbar disc herniation showing where a herniation has occurred, and which nerves are affected. For lateral lumbar disc herniation, take coronal T2-weighted image to identify the location of the herniated disc. Evaluation of CT and MRI-CT fusion image.CT is important to check the herniated disc is calcified or to eliminate a nerve is compressed by the osteophyte. MRI-CT fusion image is very useful to understand the exact 3D location of herniated disc. Patient positioning and neuromonitoring.Provide general anesthesia to the patient. Ensure that the patient's eyes are not compressed with special face cover. Pay attention to the bolster position not to compress the abdomen of the patient.The neuromonitoring is preferable for this technique. Our system is a multimodality intraoperative motoring system, use to access spinal cord integrity and provide warning potential harm to critical neural pathways. Intraoperative CT and spinal navigation.This computer-controlled flexible full carbon frame is very useful. Transmit the CT 3D reconstructed images to the navigation system automatically by a cable. Navigated instrument registration.Register the navigated pointer director and high-speed burrs by tapping the tip of the different frame hold by manual. Incision and muscle dissection. With the help of a navigated pointer, confirm the location of L5-S1 foraminal level.Make an approximately 2 centimeter longitudinal skin incision. Then dissect the subcutaneous tissue, lumbar iliocostalis, and multifidus muscle along muscle fibers. Doctor navigated fast director at the base of the L5 transverse process using the navigation.Then insert the sequential dilators. Insert the final tube and fix it to the frame. Fix the final tube to the flexible arm assembly primary.Bone resection with navigated high-speed burr. Check the L5-S1 level with the navigated pointer in the navigation monitor. Remove the bone at the base of transverse process and the lateral part of the facet joint with the navigated high-speed burr.Endoscopic disc resection. Identify the L5 nerve root and retract cranially via nerve retractor. Then remove the disc fragment by pituitary forceps carefully.These are the postoperative CT and MRI. Herniated disc and osteophyte are completely removed. Representative results.There are eight cases, four men and four women of this new technique. Average age was 72 years old, and the average follow-up period was 1.5 years. Average surgical time and blood loss were 143 minutes and 134 milliliter, respectively.The average recovery rate of Japanese Association score was 72.3 percentage. There was no surgical complication. In conclusion, our new technique of navigating decompression is very useful to natural L5-S1 lesion.O-arm navigation gives the surgeons 3D image guidance and helps in accurate development of bony elements. Minimum facet resection avoids additional postoperative spinal instability, especially the use of navigated burr, helps real-time dynamic feedback during resection of bony spur. Thank you for your attention.

transtubular-endoscopic-posterolateral-decompression-for-l5-s1-lumbar

Research

JoVE Journal

Neuroscience

Lateral Diffusion and Exocytosis of Membrane Proteins in Cultured Neurons Assessed using Fluorescence Recovery and Fluorescence-loss Photobleaching

Membrane proteins such as receptors and ion channels undergo active trafficking in neurons, which are highly polarised and morphologically complex. This directed trafficking is of fundamental importance to deliver, maintain or remove synaptic proteins.
Super-ecliptic pHluorin (SEP) is a pH-sensitive derivative of eGFP that has been extensively used for live cell imaging of plasma membrane proteins1-2. At low pH, protonation of SEP decreases photon absorption and eliminates fluorescence emission. As most intracellular trafficking events occur in compartments with low pH, where SEP fluorescence is eclipsed, the fluorescence signal from SEP-tagged proteins is predominantly from the plasma membrane where the SEP is exposed to a neutral pH extracellular environment. When illuminated at high intensity SEP, like every fluorescent dye, is irreversibly photodamaged (photobleached)3-5. Importantly, because low pH quenches photon absorption, only surface expressed SEP can be photobleached whereas intracellular SEP is unaffected by the high intensity illumination6-10. 
FRAP (fluorescence recovery after photobleaching) of SEP-tagged proteins is a convenient and powerful technique for assessing protein dynamics at the plasma membrane. When fluorescently tagged proteins are photobleached in a region of interest (ROI) the recovery in fluorescence occurs due to the movement of unbleached SEP-tagged proteins into the bleached region. This can occur via lateral diffusion and/or from exocytosis of non-photobleached receptors supplied either by de novo synthesis or recycling (see Fig. 1). The fraction of immobile and mobile protein can be determined and the mobility and kinetics of the diffusible fraction can be interrogated under basal and stimulated conditions such as agonist application or neuronal activation stimuli such as NMDA or KCl application8,10. 
We describe photobleaching techniques designed to selectively visualize the recovery of fluorescence attributable to exocytosis. Briefly, an ROI is photobleached once as with standard FRAP protocols, followed, after a brief recovery, by repetitive bleaching of the flanking regions. This 'FRAP-FLIP' protocol, developed in our lab, has been used to characterize AMPA receptor trafficking at dendritic spines10, and is applicable to a wide range of trafficking studies to evaluate the intracellular trafficking and exocytosis.

This report describes the use of live cell imaging and photobleach techniques to determine the surface expression, transport pathways and trafficking kinetics of exogenously expressed, pH-sensitive GFP-tagged proteins at the plasma membrane of neurons.

Membrane proteins such as receptors and ion channels undergo active trafficking in neurons, which are highly polarised and morphologically complex. This ...

A Large Lateral Craniotomy Procedure for Mesoscale Wide-field Optical Imaging of Brain Activity

The craniotomy is a commonly performed procedure to expose the brain for in vivo experiments. In mouse research, most labs utilize a small craniotomy, typically 3 mm x 3 mm. This protocol introduces a method for creating a substantially larger 7 mm x 6 mm cranial window exposing most of a cerebral hemisphere over the mouse temporal and parietal cortices (e.g., bregma 2.5 - 4.5 mm, lateral 0 - 6 mm). To perform this surgery, the head must be tilted approximately 30&#176; and much of the temporal muscle must be retracted. Due to the large amount of bone removal, this procedure is intended only for acute experiments with the animal anesthetized throughout the surgery and experiment.
The main advantage of this innovative large lateral cranial window is to provide simultaneous access to both medial and lateral areas of the cortex. This large unilateral cranial window can be used to study the neural dynamics between cells, as well as between different cortical areas by combining multi-electrode electrophysiological recordings, imaging of neuronal activity (e.g., intrinsic or extrinsic imaging), and optogenetic stimulation. Additionally, this large craniotomy also exposes a large area of cortical blood vessels, allowing for direct manipulation of the lateral cortical vasculature.

This protocol presents a method for creating a large unilateral craniotomy over the temporal and parietal regions of the mouse cerebral cortex. This is especially useful for real time imaging over an expansive area of a cortical hemisphere.

The craniotomy is a commonly performed procedure to expose the brain for in vivo experiments. In mouse research, most labs utilize a small craniotomy, ...

Lateral Chronic Cranial Window Preparation Enables In Vivo Observation Following Distal Middle Cerebral Artery Occlusion in Mice

Focal cerebral ischemia (i.e., ischemic stroke) may cause major brain injury, leading to a severe loss of neuronal function and consequently to a host of motor and cognitive disabilities. Its high prevalence poses a serious health burden, as stroke is among the principal causes of long-term disability and death worldwide1. Recovery of neuronal function is, in most cases, only partial. So far, treatment options are very limited, in particular due to the narrow time window for thrombolysis2,3. Determining methods to accelerate recovery from stroke remains a prime medical goal; however, this has been hampered by insufficient mechanistic insights into the recovery process. Experimental stroke researchers frequently employ rodent models of focal cerebral ischemia. Beyond the acute phase, stroke research is increasingly focused on the sub-acute and chronic phase following cerebral ischemia. Most stroke researchers apply permanent or transient occlusion of the MCA in mice or rats. In patients, occlusions of the MCA are among the most frequent causes of ischemic stroke4. Besides proximal occlusion of the MCA using the filament model, surgical occlusion of the distal MCA is probably the most frequently used model in experimental stroke research5. Occlusion of a distal (to the branching of the lenticulo-striate arteries) MCA branch typically spares the striatum and primarily affects the neocortex. Vessel occlusion can be permanent or transient. High reproducibility of lesion volume and very low mortality rates with respect to the long-term outcome are the main advantages of this model. Here, we demonstrate how to perform a chronic cranial window (CW) preparation lateral to the sagittal sinus, and afterwards how to surgically induce a distal stroke underneath the window using a craniotomy approach. This approach can be applied for sequential imaging of acute and chronic changes following ischemia via epi-illuminating, confocal laser scanning, and two-photon intravital microscopy.

Lateral Chronic Cranial Window Preparation Enables In Vivo Observation Following Distal Middle Cerebral Artery Occlusion in Mice

Surgical occlusion of a distal middle cerebral artery branch (MCAo) is a frequently used model in experimental stroke research. This manuscript describes the basic technique of permanent MCAo, combined with the insertion of a lateral cranial window, which offers the opportunity for longitudinal intravital microscopy in mice.

Focal cerebral ischemia (i.e., ischemic stroke) may cause major brain injury, leading to a severe loss of neuronal function and consequently to a host of ...

Endoscopic Endonasal Trans-sphenoidal Approach: Minimally Invasive Surgery for Pituitary Adenomas

Endoscopic endonasal trans-sphenoidal surgery has become the gold standard for the surgical treatment of pituitary adenomas and many other pituitary lesions. Refinements in surgical techniques, technological advancements, and incorporation of neuronavigation have rendered this surgery minimally invasive. The complication rates of this surgery are very low while excellent results are consistently obtained through this approach.
This paper focuses on the step-by-step surgical approach to pituitary adenomas, which is based on personal experience, and details the results obtained with this minimally invasive surgery.

The aim of this paper is to describe the different steps of the endoscopic endonasal approach to the sella turcica.

Endoscopic endonasal trans-sphenoidal surgery has become the gold standard for the surgical treatment of pituitary adenomas and many other pituitary ...

Laminotomy for Lumbar Dorsal Root Ganglion Access and Injection in Swine

Dorsal root ganglia (DRG) are anatomically well defined structures that contain all primary sensory neurons below the head. This fact makes DRG attractive targets for injection of novel therapeutics aimed at treating chronic pain. In small animal models, laminectomy has been used to facilitate DRG injection because it involves surgical removal of the vertebral bone surrounding each DRG. We demonstrate a technique for intraganglionic injection of lumbar DRG in a large animal species, namely, swine. Laminotomy is performed to allow direct access to DRG using standard neurosurgical techniques, instruments, and materials. Compared with more extensive bone removal via laminectomy, we implement laminotomy to conserve spinal anatomy while achieving sufficient DRG access. Intraoperative progress of DRG injection is monitored using a non-toxic dye. Following euthanasia on post-operative day 21, the success of injection is determined by histology for intraganglionic distribution of 4&#39;,6-diamidino-2-phenylindole (DAPI). We inject a biologically inactive solution to demonstrate the protocol. This method could be applied in future preclinical studies to target therapeutic solutions to DRG. Our methodology should facilitate testing the translatability of intraganglionic small animal paradigms in a large animal species. Additionally, this protocol may serve as a key resource for those planning preclinical studies of DRG injection in swine.

We describe a method for laminotomy in swine that provides access to lumbar dorsal root ganglia (DRG) for intraganglionic injection. Injection progress is monitored intraoperatively and histologically confirmed up to 21 days after surgery. This protocol could be used for future preclinical studies involving DRG injection.

Dorsal root ganglia (DRG) are anatomically well defined structures that contain all primary sensory neurons below the head. This fact makes DRG attractive ...

Minimally Invasive Endoscopic Intracerebral Hemorrhage Evacuation

Intracerebral hemorrhage (ICH) is a subtype of stroke with high mortality and poor functional outcomes, largely because there are no evidence-based treatment options for this devastating disease process. In the past decade, a number of minimally invasive surgeries have emerged to address this issue, one of which is endoscopic evacuation. Stereotactic ICH Underwater Blood Aspiration (SCUBA) is a novel endoscopic evacuation technique performed in a fluid-filled cavity using an aspiration system to provide an additional degree of freedom during the procedure. The SCUBA procedure utilizes a suction device, endoscope, and sheath and is divided into two phases. The first phase involves maximal aspiration and minimal irrigation to decrease clot burden. The second phase involves increasing irrigation for visibility, decreasing aspiration strength for targeted aspiration without disturbing the cavity wall, and cauterizing any bleeding vessels. Using the endoscope and aspiration wand, this technique aims to maximize hematoma evacuation while minimizing collateral damage to the surrounding brain. Advantages of the SCUBA technique include the use of a low-profile endoscopic sheath minimizing brain disruption and improved visualization with a fluid-filled cavity rather than an air-filled one.

This paper details the surgical protocol for minimally invasive endoscopic intracerebral hemorrhage evacuation using the SCUBA technique.

Intracerebral hemorrhage (ICH) is a subtype of stroke with high mortality and poor functional outcomes, largely because there are no evidence-based ...

Role of Diffusion MRI Tractography in Endoscopic Endonasal Skull Base Surgery

Endoscopic endonasal surgery has gained a prominent role in the management of complex skull base tumors. It allows the resection of a large group of benign and malignant lesions through a natural anatomical extra-cranial pathway, represented by the nasal cavities, avoiding brain retraction and neurovascular manipulation. This is reflected by the patients' prompt clinical recovery and the low risk of permanent neurological sequelae, representing the main caveat of conventional skull base surgery. This surgery must be tailored to each specific case, considering its features and relationship with surrounding neural structures, mostly based on preoperative neuroimaging. Advanced MRI techniques, such as tractography, have been rarely adopted in skull base surgery due to technical issues: lengthy and complicated processes to generate reliable reconstructions for inclusion in the neuronavigation system. 
This paper aims to present the protocol implemented in the institution and highlights the synergistic collaboration and teamwork between neurosurgeons and the neuroimaging team (neurologists, neuroradiologists, neuropsychologists, physicists, and bioengineers) with the final goal of selecting the optimal treatment for each patient, improving the surgical results and pursuing the advancement of personalized medicine in this field.

We present a protocol to integrate diffusion MRI tractography in patient work-up to endoscopic endonasal surgery for a skull base tumor. The methods for adopting these neuroimaging studies in the pre- and intra-operative phases are described.

Endoscopic endonasal surgery has gained a prominent role in the management of complex skull base tumors. It allows the resection of a large group of ...

Activity of Posterior Lateral Line Afferent Neurons during Swimming in Zebrafish

Sensory systems gather cues essential for directing behavior, but animals must decipher what information is biologically relevant. Locomotion generates reafferent cues that animals must disentangle from relevant sensory cues of the surrounding environment. For example, when a fish swims, flow generated from body undulations is detected by the mechanoreceptive neuromasts, comprising hair cells, that compose the lateral line system. The hair cells then transmit fluid motion information from the sensor to the brain via the sensory afferent neurons. Concurrently, corollary discharge of the motor command is relayed to hair cells to prevent sensory overload. Accounting for the inhibitory effect of predictive motor signals during locomotion is, therefore, critical when evaluating the sensitivity of the lateral line system. We have developed an in vivo electrophysiological approach to simultaneously monitor posterior lateral line afferent neuron and ventral motor root activity in zebrafish larvae (4-7 days post fertilization) that can last for several hours. Extracellular recordings of afferent neurons are achieved using the loose patch clamp technique, which can detect activity from single or multiple neurons. Ventral root recordings are performed through the skin with glass electrodes to detect motor neuron activity. Our experimental protocol provides the potential to monitor endogenous or evoked changes in sensory input across motor behaviors in an intact, behaving vertebrate.

We describe a protocol to monitor changes in the afferent neuron activity during motor commands in a model vertebrate hair cell system.

Sensory systems gather cues essential for directing behavior, but animals must decipher what information is biologically relevant. Locomotion generates ...

Three-dimensional Navigation-guided, Prone, Single-position, Lateral Lumbar Interbody Fusion Technique

Lateral interbody fusion provides a significant biomechanical advantage over the traditional transforaminal lumbar interbody fusion due to the large implant size and optimal implant position. However, current methods for lateral interbody cage placement require either a two-staged procedure or a single lateral decubitus position that precludes surgeons from having either full access to the posterior spine for direct decompression or comfortable pedicle screw placement.
Herein is one institution's experience with 10 cases of a prone single-position approach for simultaneous access to the anterior and posterior lumbar spine. This allows both lateral lumbar interbody cage placement, direct posterior decompression, and pedicle screw placement, all in one position. Three-dimensional (3D) navigation is utilized for increased precision in both approaching the lateral spine and interbody cage placement. The traditional blind psoas muscle tubular dilation was also modified. Tubular retractors and lateral vertebral body retractor pins were used to minimize the risks to the lumbar plexus.

The single-position, prone, lateral approach allows for both lateral lumbar interbody placement and direct posterior decompression with pedicle screw placement in one position.

Lateral interbody fusion provides a significant biomechanical advantage over the traditional transforaminal lumbar interbody fusion due to the large ...

Primary Cultures of Rat Astrocytes and Microglia and Their Use in the Study of Amyotrophic Lateral Sclerosis

This protocol demonstrates how to prepare primary cultures of glial cells, astrocytes, and microglia from the cortices of Sprague Dawley rats and how to use these cells for the purpose of studying the pathophysiology of amyotrophic lateral sclerosis (ALS) in the rat hSOD1G93A model. First, the protocol shows how to isolate and culture astrocytes and microglia from postnatal rat cortices, and then how to characterize and test these cultures for purity by immunocytochemistry using the glial fibrillary acidic protein (GFAP) marker of astrocytes and the ionized calcium-binding adaptor molecule 1 (Iba1) microglial marker. In the next stage, methods are described for dye-loading (calcium-sensitive Fluo 4-AM) of cultured cells and the recordings of Ca2+ changes in video imaging experiments on live cells.
The examples of video recordings consist of: (1) cases of Ca2+ imaging of cultured astrocytes acutely exposed to immunoglobulin G (IgG) isolated from ALS patients, showing a characteristic and specific response compared to the response to ATP as demonstrated in the same experiment. Examples also show a more pronounced transient rise in intracellular calcium concentration evoked by ALS IgG in hSOD1G93A astrocytes compared to non-transgenic controls; (2) Ca2+ imaging of cultured astrocytes during a depletion of calcium stores by thapsigargin (Thg), a non-competitive inhibitor of the endoplasmic reticulum Ca2+ ATPase, followed by store-operated calcium entry elicited by the addition of calcium in the recording solution, which demonstrates the difference between Ca2+ store operation in hSOD1G93A and in non-transgenic astrocytes; (3) Ca2+ imaging of the cultured microglia showing predominantly a lack of response to ALS IgG, whereas ATP application elicited a Ca2+ change. This paper also emphasizes possible caveats and cautions regarding critical cell density and purity of cultures, choosing the correct concentration of the Ca2+ dye and dye-loading techniques.

We present here a protocol on how to prepare primary cultures of glial cells, astrocytes, and microglia from rat cortices for time-lapse video imaging of intracellular Ca2+ for research on pathophysiology of amyotrophic lateral sclerosis in the hSOD1G93A rat model.

This protocol demonstrates how to prepare primary cultures of glial cells, astrocytes, and microglia from the cortices of Sprague Dawley rats and how to ...