OBJECTIVE:The aim of this report was to evaluate the long-term effectiveness and safety of mild lumbar decompression for the treatment of neurogenic claudication associated with lumbar spinal ...stenosis. This technique uses a percutaneous dorsal approach to remove small portions of ligament and lamina, thereby restoring space and decompressing the spinal canal.
MATERIALS AND METHODS:Two-year data are reported for 45 patients treated with mild decompression at 11 US sites. Outcome measures included the Visual Analog Scale (VAS), Oswestry Disability Index, and Zurich Claudication Questionnaire. Safety was monitored throughout the procedural and follow-up period for all patients. Interim data are included for these patients at 1 week, 6 months, and 1-year follow-up.
RESULTS:Seventy-one percent of patients reported improvement in VAS at the end of the reporting period. At 2 years, patients demonstrated a statistically significant reduction of pain as measured by VAS, and improvement in physical function and mobility was significant as measured by Zurich Claudication Questionnaire and Oswestry Disability Index. Tukey honestly significant different test found significant improvement in all outcome measures from baseline to each follow-up interval. Further, major improvement occurred by 1-week follow-up and showed no difference between each subsequent follow-up, signifying considerable stability and durability of the initial result over time. No major device or intraprocedural adverse events were reported.
DISCUSSION:In this report of 2-year follow-up on 45 patients treated with mild percutaneous lumbar decompression, patients experienced statistically significant pain relief and improved functionality.
Introduction:
External ventricular drain (EVD) catheters are a cornerstone of neurosurgical perioperative care. Catheter occlusion by blood clot, brain matter or other debris is unfortunately a ...common and frustrating problem, necessitating catheter exchange and hemorrhagic risk exposure due to the need for insertion of a new catheter. The author describes the use of commonly available neuroendovascular wires for catheter clearance.
Methods:
Two different neuroendovascular micro-guide wires, Chikai 0.014” (Asahi) and NeuroSynchro 0.014” (Stryker) were used. In each case, a preexisting EVD had ceased to flow, with occlusion from blood or tumor debris. Using sterile technique, the catheter was disconnected from the drainage tubing. After shaping a gentle “C” curve at the tip, the micro-guide wire was then inserted into the catheter. Flouroscopic imaging in the anterior-posterior view was used to follow the wire tip into the distal ventricular catheter, and then out the side inlets. A gentle back and forth motion of the wire was then used to dislodge the blockage, as well as rotation to allow wire entry into successive inlets. In both cases, flow was reestablished for a minimum of 24 hours.
Discussion:
Neuroendovascular micro-guide wires have multiple advantages as a tool to clear a clogged EVD. First, the tip is extremely soft and atraumatic, as these wires are designed to enter into ruptured cerebral aneursyms. Hence, if the wire contacts the ependymal wall, it will typically deform upon itself, as opposed to dissecting and entering into the brain. Second, the wires are highly radio-opaque, and thus can be easily tracked under even portable fluoroscopic units. Third, the wires are highly flexible, and will easily navigate through a looped catheter. Fourth, the wires are available at any hospital that has a neuroendovascular service line. If the wire technique is successful in relieving the clog, then the patient will be spared the risk of a new catheter insertion, which will ultimately decrease complication rates.
Introduction:
Large exophytic tumors can be technically challenging because of the bulky nature of the mass and potential blood loss. Absolute ethanol can be used in these scenarios to create an ...immediate sclerosis of the intratumoral vessels, allowing the surgeon to proceed with resection without delay.
History:
A 60-year-old female patient presented with a hemorrhagic, spherical exophytic mass originating from the right pinna, measuring approximately 8 cm in diameter. Outside needle biopsy demonstrated sarcoma, likely induced by prior radiation 6 years before treating a parotid tumor. The large external component subsumed the entire ear, and extended transtemporally to merge with a second intradural component within the middle and posterior fossae.
Intervention:
Transcatheter preoperative embolization was performed via middle meningeal and local branches of the external carotid artery using polyvinyl alcohol. The next day, under general anesthesia, the tumor was directly punctured at three separate sites with 18-guage spinal needles from the external surface. After performance of angiography to assess run-off, 2 mL of absolute ethanol was injected at each site. Within minutes, the tissue became wooden, firm, and avascular in a region for 2 to 3 cm surrounding the needle tip. Resection was easily performed by paring the tumor away with a number 11 blade.
Discussion:
Direct ethanol puncture can achieve rapid devascularization of bulky tumors. Extreme caution must be taken to limit the spread of the ethanol into areas containing potentially functional structures. A clear understanding of the estimated pattern of spread of the ethanol, as demonstrated in the image aforementioned during contrast injection, is essential to perform the technique safely.
Spondylytic degeneration of the axial lumbar spine is a major cause of pain and disability. Recent advances in spinal surgical instrumentation, including percutaneous access and fusion techniques, ...have made possible the performance of instrumented fusion through small incisions. By blending strategies of interventional pain management, neuroradiology, and conventional spine surgery, it is now feasible to treat spinal axial pain using permanent fixation techniques and local anesthesia in the setting of a fluoroscopy suite using mild sedation and local anesthesia.
The author presents a series of percutaneous thoracolumbar fusion procedures performed in a biplane neuroangiographic suite and without general anesthesia for the treatment of spondylytic pain. All procedures utilized pedicle screw fixation, harvesting of local bone autograft, and application of bone fusion material.
In this series of 13 patients, a statistically significant reduction of pain was seen at both the 2-week post-operative timepoint, as well as at the time of longest follow-up (mean 40 weeks).
The advanced and rapid imaging capabilities afforded by a neuroangiographic suite can be safely combined with percutaneous fusion techniques so as to allow for fusion therapies to be applied to patients where the avoidance of general anesthesia is desirable.
Background and Importance. Treatment of spinal column metastatic tumors is challenging, especially in the setting of progressive disease despite previous radiation and chemotherapy. Intra-arterial ...chemotherapy is an uncommonly used but established treatment for head and neck cancers, retinoblastoma, and glioblastoma. The author reports extension of the IAC concept to vertebral metastatic tumors. Clinical Presentation. Two patients with intractable spinal pain secondary to spinal metastatic involvement at T11-L1 segments were treated with intra-arterial injections of cisplatin, with simultaneous sodium thiosulfate chelation. The first patient, a 60-year old female with metastatic lung carcinoma underwent, three cycles of therapy over a 9-week period; the treated regions demonstrated bone remodeling and sclerosis. The second case was a 40-year old male with malignant pheochromocytoma, who underwent a single treatment and succumbed 5 weeks later from progressive widespread disease. Both patients reported significant pain relief and neither of them exhibited a decline in neurologic function. Conclusion. The intra-arterial delivery of cisplatin appeared to be well tolerated in the two cases. In the case with the longest survival, the treated vertebral segments became more sclerotic, consistent with biomechanical stabilization. Endovascular treatment of spinal metastases may hold promise, especially as newer categories of biologic agents become more widely available.
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FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, UL, UM, UPUK
Patients with spinal epidural abscesses (SEAs) may have a variable presentation. Such an infection has a typical appearance on magnetic resonance imaging (MRI) and enhances with gadolinium. We ...present a case that was a diagnostic challenge where pre- and intra-operative findings resulted in conflicting impressions. The mimicker was a spinal angiolipoma (SAL). The authors then provide a thorough review of this rare spinal neoplasm. A 55-year-old man presented with back pain, paresis, paresthesia, and urinary retention. MRI was indicative of a longitudinal epidural thoracic mass with a signal homogeneous to nearby fat, curvilinear vessels, and lack of enhancement. Although at emergent surgery, the lesion was found to contain abundant purulent material. Microbiology was positive for methicillin-resistant
and consistent with SEA without evidence of neoplasia. While the imaging features were suggestive of an angiolipoma, the findings at surgery made SEA more likely, which were validated histopathologically. The diagnosis of SEA is often clear-cut, and the literature has reported only a few instances in which it masqueraded as another process such as lymphoma or myelitis. The case highlights SEA masquerading as an angiolipoma, and further demonstrates to clinicians that obtaining tissue diagnosis plays a crucial role diagnostically and therapeutically. SALs, on the other hand, are slow-growing tumors that can be infiltrating or noninfiltrating. They typically present with chronic symptoms and T1-MRI shows an inhomogeneous picture. Complete surgical excision is standard of care and patients tend to do well afterward.
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
Lumbar spinal stenosis (LSS) functionally impacts significant numbers of Americans per year. Current estimates place the number of Americans suffering from senescent lumbar spinal stenosis at ...400,000. The prevalence of this disorder in patients ranging from 60 to 69 years of age is very high. Forty‐seven percent of this age group have mild to moderate stenosis, and 19.7% have severe stenosis. As the baby boomer generation gets older, 10,000 individuals attain the age of 65 years every day in United States. LSS is becoming very common and will be a major healthcare issue as the population ages. Although LSS is not life threatening, it can cause substantial disability with limitations to performing daily activities, and thus, the associated negative impact on quality of life (QOL). This article reviews the pathophysiology and current treatment options for LSS, focusing on evidence‐based treatment options.
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BFBNIB, DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, UILJ, UKNU, UL, UM, UPUK, VSZLJ
Introduction: Many orthopaedic procedures require drilling of bone, especially fracture repair cases. Bone drilling results in heat generation due to the friction between the bone and the drill bit. ...A high-level of heat generation kills bone cells. Bone cell death results in resorption of bone around bone screws.
Methods: We searched in the literature for data on parameters that influence drilling bone and could lead to thermal necrosis. The points of view of many orthopaedists and neurosurgeons based upon on previous practices and clinical experience are presented.
Results: Several potential complications that lead to thermal necrosis are discussed and highlighted.
Discussion: Even in the face of growing evidence as to the negative effects of heat induction during drilling, simple and effective methods for monitoring and cooling in real-time are not in widespread usage today. For that purpose, we propose some suggestions for the future of bone drilling, taking note of recent advances in autonomous robotics, intelligent systems and computer simulation techniques.
Conclusions: These advances in prevention of thermal necrosis during bone drilling surgery are expected to reduce the risk of patient injury and costs for the health service.
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