Traumatic carotid cavernous fistulas. Rare and life threatening.

Purpose: Carotid-cavernous fistulas (CCFs) are often underdiagnosed or misdiagnosed. In polytraumatized patients, the focus is primarily on treating potentially life-threatening conditions such as increased intracranial pressure and hemorrhages. This case report aims to identify common diagnostic mistakes in rare pathologies. Objective: We present a case of a young female patient who was admitted to the emergency room after a motorbike accident. The patient's vital parameters were successfully stabilized, and she spent approximately four weeks in the ICU and neurosurgical ward. The patient exhibited limited communication, ophthalmoplegia, and a swollen, red left eye. After four weeks, the patient's parents initiated admission to our department due to the suspicious red swollen eye. Angiography revealed a complete rupture of the internal carotid artery (ICA) into the cavernous sinus, and occlusion of the ICA showed significant improvement in the eye edema and the patient's mental state. Two days later, the patient was able to communicate with complex sentences. Three months after the occlusion, the patient showed positive progress, posting dancing videos on TikTok. Conclusion and Importance: A carotid-cavernous fistula presenting with a red swollen eye can be misdiagnosed as retrobulbar hematoma or conjunctivitis. Failure to recognize and treat it promptly can lead to severe morbidity.

Electrode placement for SEEG: Combining stereotactic technique with latest generation planning software for intraoperative visualization and postoperative evaluation of accuracy and accuracy predictors.

BACKGROUND: Intracranial recordings with stereoelectroencephalography (SEEG) aims at defining the epileptogenic zone in patients with pharmacoresistant epilepsy. Currently used techniques for depth electrode implantation include stereotactic frame-based and navigated frameless applications, both either conventional or robot-assisted. Safety and diagnostic effectiveness depend on accuracy of implantation. OBJECTIVE: To evaluate the planning experience, accuracy of stereotactic electrode placement as well as accuracy predictors with the use of latest generation planning software. METHODS: Retrospective study of 15 consecutive patients who received depth electrodes using the Leksell stereotactic frame, after planning with Elements (Brainlab, Munich, Germany). For each electrode, we calculated the entry point error (EPE) as lateral deviation and target point error (TPE) both as lateral deviation and distance to tip. Multivariate regression analysis and computation of 95% confidence intervals using the bootstrap method were applied for statistical analysis and evaluation of accuracy predictors. RESULTS: The mean EPE, lateral deviation at TP and distance to tip at TP were 0.6 ±0.5 mm, 1.1 ±0.7 mm and 1.5 ±0.8 mm respectively. Order of implantation (1-6 vs. >6) is predictor for distance to tip at TP and length of electrode predictor for the lateral deviation at TP. Localization of electrode generally did not correlate to error, but insular electrodes were significantly less accurate than lobar ones. CONCLUSION: Combination of frame-based stereotaxy with latest generation planning software may offer a better planning and implantation experience. Accuracy predictors should be analyzed and be considered for the improvement of accuracy and safety of SEEG implantation methods.

Multilobar Epilepsy Surgery in Childhood and Adolescence: Predictors of Long-Term Seizure Freedom.

BACKGROUND: Although multilobar resections correspond to one-fifth of pediatric epilepsy surgery, there are little data on long-term seizure control. OBJECTIVE: To investigate the long-term seizure outcomes of children and adolescents undergoing multilobar epilepsy surgery and identify their predictors. METHODS: In this retrospective study, we considered 69 consecutive patients that underwent multilobar epilepsy surgery at the age of 10.0 ± 5.0 yr (mean ± SD). The magnetic resonance imaging revealed a lesion in all but 2 cases. Resections were temporo-parieto(-occipital) in 30%, temporo-occipital in 41%, parieto-occipital in 16%, and fronto-(temporo)-parietal in 13% cases. Etiologies were determined as focal cortical dysplasia in 67%, perinatal or postnatal ischemic lesions in 23%, and benign tumors in 10% of cases. RESULTS: At last follow-up of median 9 yr (range 2.8-14.8), 48% patients were seizure free; 33% were off antiepileptic drugs. 10% of patients, all with dysplastic etiology, required reoperations: 4 of 7 achieved seizure freedom. Seizure recurrence occurred mostly (80%) within the first 6 mo. Among presurgical variables, only an epileptogenic zone far from eloquent cortex independently correlated with significantly higher rates of seizure arrest in multivariate analysis. Among postsurgical variables, the absence of residual lesion and of acute postsurgical seizures was independently associated with significantly higher rates of seizure freedom. CONCLUSION: Our study demonstrates that multilobar epilepsy surgery is effective regarding long-term seizure freedom and antiepileptic drug withdrawal in selected pediatric candidates. Epileptogenic zones-and lesions-localized distant from eloquent cortex and, thus, fully resectable predispose for seizure control. Acute postsurgical seizures are critical markers of seizure recurrence that should lead to prompt reevaluation.

How Safe Is Minimally Invasive Transforaminal Lumbar Interbody Fusion for Octogenarians?: A Perioperative Complication Analysis.

BACKGROUND: Technical advances in minimally invasive spine surgery have reduced blood loss, access trauma, and postoperative length of stay. However, operating on the susceptible group of octogenarians still poses a dilemma because of a plethora of age-related comorbidities. The aim of this study was to investigate the safety of minimally invasive surgery (MIS) transforaminal lumbar interbody fusion (TLIF) in octogenarians. METHODS: We conducted a retrospective single-center study of all patients over 80 years of age who, between March 2009 and February 2014, had undergone MIS TLIF. The primary outcome was recorded major and minor complications within 30 days of surgery. RESULTS: Twenty-one patients with an average age of 84.1 ± 2.7 years underwent MIS TLIF in 31 levels for degenerative lumbar disk disease with intolerable pain after failure of conservative treatment. Of the patients, 33.3% showed no perioperative complications. In the remaining 66.7%, 6 major complications and 24 minor complications occurred within 30 days of surgery. Two of these patients died within 30 days of surgery because of sepsis and pulmonary embolism (mortality rate 9.5%). CONCLUSIONS: Our study spotlighted the susceptible group of octogenarians and evaluated the safety of MIS TLIF. The perioperative morbidity for octogenarians undergoing MIS TLIF is substantial and even higher than for patients over 65 years of age. Two thirds of patients in this subgroup suffer at least 1 complication. The 30-day mortality rate was 9.5%. Therefore, it is advisable for these patients to exploit all available conservative options prior to surgery.

[Intracranial Meningiomas: A Neurosurgical Disease? Possibilities and Limitations of Surgery]. / Intrakranielle Meningeome: ein neurochirurgisches Krankheitsbild?

Intracranial Meningiomas: A Neurosurgical Disease? Possibilities and Limitations of Surgery Abstract. Meningiomas are the most common intracranial tumors. According to the WHO classification they are categorized as WHO I-III. Most meningiomas are WHO I and can be treated by complete microsurgical resection and thus cured. Imaging and controls should be performed using MRI. Asymptomatic meningiomas can be observed. Symptomatic meningiomas and meningiomas in proximity to neural and vascular structures should be resected microsurgically using modern techniques such as neuromonitoring, neuronavigation and minimally invasive techniques. The recurrence rate is determined by the extent of resection according to the Simpson classification and the histological grading of the tumor. With subtotal resection, complex tumors, recurrences and higher grade meningiomas the use of radiotherapy or radiosurgical treatment should be discussed in a tumor board.

Multilobar Resections for 3T MRI-Negative Epilepsy: Worth the Trouble?

OBJECTIVE: Multilobar resection in magnetic resonance imaging (MRI)-negative drug-resistant epilepsy warrants attention because they account for up to one third of MRI-negative epilepsy surgery. Despite their high prevalence, data are sparse, and the risk/benefit ratio continues to be debated. The present study investigated the postoperative seizure outcomes in this especially challenging subgroup. METHODS: We retrospectively analyzed the data of 4 consecutive patients with 3T MRI-negative findings and drug-resistant focal epilepsy who had undergone multilobar epilepsy surgery at our institution. RESULTS: The mean age at first surgery was 28.5 years (range, 14-48); 1 patient required 2 consecutive reoperations. The final resection was in the frontotemporal and temporo-parieto-occipital regions in 2 patients each. Histopathological examination revealed mild malformations of cortical development in 2 patients and focal cortical dysplasia type Ia and type IIa in 1 patient each. At the last follow-up examination (median, 3.3 years; range, 1-11), 2 patients were completely seizure free (Engel class Ia), 1 patient had experienced some disabling seizures after surgery but had been free of disabling seizures for 2 years at the last follow-up examination (Engel class Ic), and 1 patient had experienced worthwhile improvement (Engel class IIb) and had been seizure free for 1 year at the last follow-up examination. No surgical complications developed. CONCLUSIONS: Our results have demonstrated that multilobar epilepsy surgery is effective for lasting seizure control for selected 3T MRI-negative candidates, leading to favorable outcomes for all 4 of our patients. Comprehensive multimodal preoperative evaluation is a prerequisite for postoperative success. Reevaluation should be considered for patients with seizure recurrence, because reoperation could be especially beneficial for selected patients who have not responded to an initially limited resection.

Histopathology of 3 Tesla MRI-negative extratemporal focal epilepsies.

BACKGROUND: Information about the histopathology in 3 Tesla MRI negative extratemporal epilepsies is relatively limited. Most common histopathological findings in earlier (mixed 1.5 or 3 Tesla) MRI-negative series are focal cortical dysplasia (FCD), gliosis or normal findings. These series mostly use the older Palmini criteria for classification and grading. We focus on histopathology of only 3 Tesla MRI-negative extratemporal epilepsies according to the current ILAE criteria and investigate potential correlation to seizure outcome 1 year postoperatively. MATERIALS AND METHODS: Sixteen substrates of 3 Tesla MRI-negative extratemporal epilepsies were examined in two steps. Standard stains and immunohistochemical reactions and Palmini criteria were used prospectively during the initial examination. Retrospectively, all specimens were re-examined and re-evaluated. Phospho-6 and calretinin stains and ILAE criteria were used during the review examination. RESULTS: Initial examination revealed 5 FCDs Palmini 1b, two 1a, five 2a and 4 cases of gliosis. The review examination according to ILAE criteria revealed 6 FCDs type IIa, 2 FCDs Ib and 7 mild malformations of cortical development (mMCD) type II. None of our cases was labelled as isolated gliosis after the review examination. The incidence of FCD, after the review examination per ILAE criteria, was reduced to 56%; versus 75% per Palmini. CONCLUSIONS: In "true" 3 Tesla MRI-negative extratemporal epilepsies, incidence of FCD may be lower than in earlier MRI-negative series that included weaker MRI-field. Furthermore, consistent review examination may confirm the diagnosis of mMCD type II as substrate in cases diagnosed as "gliosis" or "normal" in the past.

The oxymoron of image-guided resection in 3 T MRI-negative extratemporal epilepsy: Technique and postoperative results.

OBJECTIVE: We share our experience with extratemporal MRI-negative epilepsies that received "image-guided" resection with the use of neuronavigation after invasive presurgical video-EEG monitoring. We describe and discuss our technique of image generation, navigation system registration, and surgical resection. In addition, we evaluate seizure outcome with respect to the preoperatively planned versus achieved resection. PATIENTS AND METHODS: Seven patients with 3 T MRI-negative extratemporal epilepsy received navigation-guided resective surgery. The resection plan was based on electrophysiological data from intracranial EEG recordings. For each case a resection segment was created in the neuronavigation device in a systematic manner. We compared the preoperatively planned segment to the achieved resection and looked for correlation with postoperative seizure outcome according to Engel classification, at last follow-up (mean 2.4 years, range 1-4 years). RESULTS: Mean volume of planned resections was 23.8 ±â€¯15.3 cm3 and of achieved resections 17 ±â€¯10.4 cm3. There was complete overlap with planned resection in 4 patients and partial overlap in 3. Postoperative seizure outcome was class I in 4 patients (57%), IIIA in 1 patient and IVB in 2 patients. Three patients reached seizure-freedom (Engel IA). Volume of planned resection, volume difference of planned versus achieved resection and level of overlap (complete versus partial) did not significantly correlate to seizure outcome. CONCLUSION: The use of neuronavigation for planning and executing a tailored resection in MRI-negative extratemporal epilepsy is elaborate but can be an effective procedure.

Histopathology of 3 Tesla MRI-negative temporal lobe epilepsies.

INTRODUCTION: Histopathology of MRI-negative temporal lobe epilepsies (TLE) shows heterogeneous findings. The use of either 1.5 or 3 Tesla MRI for the selection of MRI-negative cases and use of older classification systems instead of the current ILAE classification system may account for this heterogeneity. We focus on histopathology of 3 Tesla MRI-negative TLE according to ILAE criteria and investigate potential correlation to seizure outcome 1 year postoperatively. MATERIALS AND METHODS: Twenty specimens (9 neocortical, 11 hippocampal) from eleven 3 Tesla MRI-negative patients with TLE were examined in two steps. Standard stains and immunohistochemical reactions as well as Palmini and Wyler criteria were used prospectively during the initial examination. Retrospectively, all specimens were re-examined and re-evaluated. Phospho-6 and calretinin stains and the ILAE criteria were used during the review examination. RESULTS: Initial examination revealed 7 focal cortical dysplasias (FCDs) Palmini type 1, two cases of cortical gliosis, 4 cases of hippocampal sclerosis (HS) Wyler grade 1 and seven cases of hippocampal gliosis. The review examination according to ILAE criteria revealed 4 FCDs type I and 5 mild malformations of cortical development. All hippocampal specimens showed "no HS/gliosis only" after the review examination. Histopathology showed no correlation to seizure outcome. DISCUSSION: This is the first histopathological study to include only 3 Tesla MRI-negative cases. The use of ILAE criteria lead to the diagnosis of "no HS/gliosis only" of all hippocampal specimens, a finding not in line with previously reported series. The spectrum of diagnoses within neocortical specimens showed accordingly more mild findings.

3 Tesla MRI-negative focal epilepsies: Presurgical evaluation, postoperative outcome and predictive factors.

OBJECTIVE: To investigate presurgical diagnostic modalities, clinical and seizure outcome as well as predictive factors after resective epilepsy surgery in 3 Tesla MRI-negative focal epilepsies. PATIENTS AND METHODS: This retrospective study comprises 26 patients (11 males/15 females, mean age 34±12years, range 13-50 years) with 3 Tesla MRI-negative focal epilepsies who underwent resective epilepsy surgery. Non-invasive and invasive presurgical diagnostic modalities, type and localization of resection, clinical and epileptological outcome with a minimum follow-up of 1year (range 1-11 years, mean 2.5±2.3years) after surgery as well as outcome predictors were evaluated. RESULTS: All patients underwent invasive video-EEG monitoring after implantation of intracerebral depth and/or subdural electrodes. Ten patients received temporal and 16 extratemporal or multilobar (n=4) resections. There was no perioperative death or permanent morbidity. Overall, 12 of 26 patients (46%) were completely seizure-free (Engel IA) and 65% had a favorable outcome (Engel I-II). In particular, seizure-free ratio was 40% in the temporal and 50% in the extratemporal group. In the temporal group, long duration of epilepsy correlated with poor seizure outcome, whereas congruent unilateral FDG-PET hypometabolism correlated with a favorable outcome. CONCLUSIONS: In almost two thirds of temporal and extratemporal epilepsies defined as "non-lesional" by 3 Tesla MRI criteria, a favorable postoperative seizure outcome (Engel I-II) can be achieved with accurate multimodal presurgical evaluation including intracranial EEG recordings. In the temporal group, most favorable results were obtained when FDG-PET displayed congruent unilateral hypometabolism.

Incidental Durotomy in Open Versus Tubular Revision Microdiscectomy: A Retrospective Controlled Study on Incidence, Management, and Outcome.

STUDY DESIGN: Retrospective case-control study. OBJECTIVE: To compare the incidence, management, and outcome of incidental durotomy in revision microdiscectomy with open and minimal-access surgery. SUMMARY OF BACKGROUND DATA: Incidental durotomy occurs with a variable incidence of 3%-27% in spine surgery. The highest rate occurs in revision microdiscectomy. The intraoperative and postoperative management of dural tears varies in the literature and the definite impact on clinical outcome has to be clarified. METHODS: This is a retrospective study of medical records of 135 patients who underwent revision microdiscectomy, divided into 2 subgroups: OPEN (n=82) versus minimal-access surgery (MINI, n=53). Occurrence of intraoperative dural tears, intraoperative and postoperative management of durotomy, and clinical outcomes, according to MacNab criteria, were retrospectively examined. Statistical comparisons for categorical values between groups were accomplished using the 2-tailed Fisher exact test. P-values <0.05 were considered to be statistically significant. RESULTS: The incidence of durotomy in group OPEN was 19.5% (n=16/82) and in group MINI 17.0% (n=9/53) (P=0.822). The majority of durotomies (23/25) were repaired with an absorbable fibrin sealant patch alone. Postoperative cerebrospinal fluid fistula occurred only in 1 case of the OPEN group and was treated with lumbar drainage without the need for a reoperation. Patients with durotomy of the MINI group tended to have better outcome compared with those of the OPEN group without being statistically significant. CONCLUSIONS: The incidence of durotomy and postoperative cerebrospinal fluid fistula in lumbar revision microdiscectomy does not significantly differ between minimal-access and standard open procedures. The application of a fibrin sealant patch alone is an effective strategy for dural repair in revision lumbar microdiscectomy.

Functional hemispherectomy is safe and effective in adult patients with epilepsy.

INTRODUCTION: Functional hemispherectomy (FH) is a well-established therapeutic option for children with epilepsy with parenchymal damage confined to one hemisphere, yet its application in adults remains rare. The intention of our study was to investigate postoperative clinical and epileptological outcome in adults who received FH for intractable epilepsy. MATERIALS AND METHODS: We retrospectively analyzed 12 adult patients (18-56years) with intractable epilepsy due to unihemispheric pathology. All patients underwent FH. Postoperative neurological and cognitive outcome as well as seizure status were evaluated with a mean follow-up period of 4.9years. RESULTS: Ten patients (83%) were seizure-free (Engel I), and two (17%) had recurrent seizures at last follow-up. Apart from one patient requiring operative revision for bone flap infection, no perioperative morbidity or mortality occurred. Postoperative functional assessment revealed deterioration of motor function in 7 patients, whereas 5 remained unchanged. Language was unchanged in 8 patients. The absence of background slowing in preoperative electroencephalogram (EEG) as well as ictal and interictal EEG patterns located ipsilateral to the side of surgery was associated with favorable seizure outcome. CONCLUSION: Favorable seizure control and acceptable functional outcome can be achieved by FH in adults with intractable epilepsy. The risk of postoperative deficits is moderate and even older patients are able to manage postoperative motor impairment. Therefore, FH should be considered in case of unihemispheric lesions also in adults.

Visual field defects following different resective procedures for mesiotemporal lobe epilepsy.

INTRODUCTION: One of the most common side effects of mesiotemporal lobe resection in patients with medically intractable epilepsy are visual field defects (VFD). While peripheral defects usually remain unnoticed by patients, extended VFD influence daily life activities and can, in particular, affect driving regulations. This study had been designed to evaluate frequency and extent of VFD following different surgical approaches to the mesiotemporal area with respect to the ability to drive. MATERIALS AND METHODS: This study comprises a consecutive series of 366 patients operated at the Epilepsy Center in Freiburg for intractable mesiotemporal lobe epilepsy from 1998 to 2016. The following procedures were performed: standard anterior temporal lobectomy (ATL: n=134; 37%), anterior temporal or keyhole resection (KH: n=53; 15%), and selective amygdalohippocampectomy via the transsylvian (tsAHE: n=145; 40%) and the subtemporal (ssAHE: n=34; 9%) approach. Frequency and extent of postoperative VFD were evaluated in relation to different surgical procedures. According to the German driving guidelines, postoperative VFD were classified as driving-relevant VFD with the involvement of absolute, homonymous central scotoma within 20° and driving-irrelevant VFD with either none or exclusively minor VFD sparing the center. RESULTS: Postoperative visual field examinations were available in 276 of 366 cases. Postoperative VFD were observed in 202 of 276 patients (73%) and were found to be driving-relevant in 133 of 276 patients (48%), whereas 69 patients (25%) showed VFD irrelevant for driving. Visual field defects were significantly less likely following ssAHE compared with other temporal resections, and if present, they were less frequently driving-relevant (p<0.05), irrespective of the side of surgery. CONCLUSION: Subtemporal sAHE (ssAHE) caused significantly less frequently and less severely driving-relevant VFD compared with all other approaches to the temporal lobe, irrespective of the side of surgery.

Comparative Study of C-arms for Intraoperative 3-dimensional Imaging and Navigation in Minimally Invasive Spine Surgery Part I: Applicability and Image Quality.

STUDY DESIGN: This was a retrospective analysis. OBJECTIVE: This study compares 2 different 3-dimensional (3D) C-arm devices for intraoperative imaging and navigation with regard to clinical applicability and image quality. SUMMARY OF BACKGROUND DATA: Minimally invasive spine surgery requires intraoperative imaging techniques to adequately visualize the unexposed spine. For this purpose, mobile 3D C-arms became available along with the evolution of intraoperative navigation techniques. METHODS: The C-arm devices Siremobil Iso-C 3D (Siemens) and Vision FD Vario 3D (Ziehm) perform an automated orbital rotation around the patient acquiring a 3D image set out of multiple successive fluoroscopic images. We report on technical specifications of the C-arms and our daily experience regarding clinical applicability. Furthermore, 5 spine surgeons evaluated blinded triplanar planes of 40 cervical, thoracic, and lumbar 3D scans that were obtained during routine surgery regarding usability for navigation. We assessed the delineation of cortical bone, artifacts, and overall image quality using a 0-10 numeric rating scale. RESULTS: The Siremobil Iso-C 3D requires 128 seconds for its 190-degree scanning arc with equidistant isocenter. The Vision FD Vario 3D performs an elliptical scanning arc and completes its 135-degree scan in 64 seconds; furthermore, it features a flat panel detector and fully digital imaging. The smaller dimensions of the Vision FD Vario 3D made it easier to maneuver in the operating room compared with the more bulky Siremobil Iso-C 3D. With respect to image quality in cervical 3D scans, the Siremobil Iso-C 3D reached significantly higher scores in all categories. The Vision FD Vario 3D revealed less artifacts in lumbar 3D scans. CONCLUSIONS: The Siremobil Iso-C 3D provides high-quality 3D scans in slender spine regions (eg, cervical spine), whereas the Vision FD Vario 3D appears to have advantages in the lumbar spine. Further evolution and novel devices are needed to optimize image quality and handling.

Comparative Study of C-Arms for Intraoperative 3-dimensional Imaging and Navigation in Minimally Invasive Spine Surgery Part II: Radiation Exposure.

STUDY DESIGN: A radiation exposure study in vitro. OBJECTIVE: This study aimed to compare the radiation exposure of 2 different 3-dimensional (3D) C-arm devices on an anthropomorphic phantom. SUMMARY OF BACKGROUND DATA: Minimally invasive pedicle screw placement requires intraoperative imaging techniques for visualization of the unexposed spine. Mobile 3D C-arms compose a 3D image data set out of multiple successive fluoroscopic images. METHODS: We compared the 3D C-arm devices Siremobil Iso-C 3D (Siemens Sector Healthcare, Erlangen, Germany) and Vision FD Vario 3D (Ziehm Imaging, Nuremberg, Germany) regarding their radiation exposure. For this purpose, dosimeters were attached on an anthropomorphic phantom at various sites (eye lenses, thyroid gland, female, and male gonads). With each C-arm, 10 automated 3D scans as well as 400 fluoroscopic images were performed on the cervical and lumbar spine, respectively. RESULTS: The Vision FD Vario 3D generally causes higher radiation exposures than the Siremobil Iso-C 3D. Significantly higher radiation exposures were assessed at the eye lenses performing cervical (294.1 vs. 84.6 µSv) and lumbar 3D scans (22.5 vs. 11.2 µSv) as well as at the thyroid gland performing cervical 3D scans (4405.2 vs. 2761.9 µSv). Moreover, the Vision FD Vario 3D caused significantly higher radiation exposure at the eye lenses for standard cervical fluoroscopic images (3.2 vs. 0.4 µSv). CONCLUSIONS: 3D C-arms facilitate minimally invasive and accurate pedicle screw placement by providing 3D image datasets for intraoperative 3D imaging and navigation. However, the hereby potentially increased radiation exposure has to be considered. In particular, the Vision FD Vario 3D appears to generally evoke higher radiation exposures than the Siremobil Iso-C 3D. Well-indicated application of ionizing radiation and compliance with radiation protection principles remain mandatory to keep radiation exposure to patient and staff as low as reasonably achievable.

Minimally Invasive Posterior Cervical Foraminotomy: Freiburg Experience With 34 Patients.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: Assessment of outcome after minimally invasive posterior cervical foraminotomy (MI-PCF). SUMMARY OF BACKGROUND DATA: Surgical management of cervical radiculopathy represents a controversial area in spinal surgery. Preferred approaches include both anterior cervical discectomy and posterior cervical foraminotomy (PCF). Numerous studies showed comparable results. Employing PCF eliminates risks associated with anterior approach. PCF as originally described by Spurling and Scoville necessitates extensive stripping of cervical muscles to expose the cervical spine, resulting in muscle injury, impaired muscle function, prolonged postoperative neck pain, and increased use of narcotics. There are only few studies investigating outcome after employing MI-PCF. MATERIALS AND METHODS: Retrospective review of 34 patients who underwent MI-PCF for presenting complaints, postoperative and follow-up outcome. RESULTS: In the last follow-up the weakness resolved completely in 62.6% of patients, in 4.1% improved and in 16.5% remained unchanged. In the last follow-up 76.7% of patients originally presenting with pain reported complete resolution of pain and 10% reported partial improvement of pain. In total, 23.5% of patients were lost during follow-up as far as pain was concerned. In the last follow-up, 75% of patients achieved relative neck-pain-freedom (Visual Analog Scale≤3) at rest and 62.5% of patients under strain. The mean neck pain on Visual Analog Scale at rest was 2.13 (SD=2.42) and 3.34 (SD=3.01) under strain. In total, 93.8% (n=15) of patients would undergo the same procedure for the same achieved result. CONCLUSIONS: Minimally invasive cervical foraminotomy is an effective procedure for decompression of cervical nerve roots regardless the type of the stenosis. Even employing minimally invasive technique still causes neck pain in the long term affecting up to 25% of patients. More randomized control studies are required to clarify the benefits of minimally invasive PCF.

Microsurgical resection of juxtafacet cysts without concomitant fusion-Long-term follow-up of 74 patients.

OBJECT: We report on our experience with treating juxtafacet cysts focusing on clinical outcome, rate of recurrence and secondary surgery, especially fusion. METHODS: This retrospective study evaluates patients who underwent surgical resection of juxtafacet cysts without concomitant fusion from 2002 to 2013 with a minimum follow-up of one year. RESULTS: Complete follow-up is available in 74 patients. Mean follow-up in all 74 patients was 69±34months (range, 14-140 months). Mean ODI was 14.9%. 68 patients (91.9%) were pleased with the results and would undergo surgery again. Three patients (4.1%) underwent secondary resection because of cyst recurrence at the same site. Four patients (5.4%) needed secondary fusion. CONCLUSIONS: In patients without evident clinical and radiological criteria of instability we regard surgical resection of juxtafacet cysts without concomitant fusion as adequate primary treatment due to good outcome and low incidence of secondary symptomatic instability.

Minimally invasive tubular microdiscectomy for recurrent lumbar disc herniation.

OBJECTIVE: The aim of the study was to investigate the safety and efficacy of minimally invasive tubular microdiscectomy for the treatment of recurrent lumbar disc herniation (LDH). As opposed to endoscopic techniques, namely microendoscopic and endoscopic transforaminal discectomy, this microscopically assisted technique has never been used for the treatment of recurrent LDH. METHODS: Thirty consecutive patients who underwent minimally invasive tubular microdiscectomy for recurrent LDH were included in the study. The preoperative and postoperative visual analog scale (VAS) scores for pain, the clinical outcome according to modified Macnab criteria, and complications were analyzed retrospectively. The minimum follow-up was 1.5 years. Student t-test with paired samples was used for the statistical comparison of pre- and postoperative VAS scores. A p value < 0.05 was considered to be statistically significant. RESULTS: The mean operating time was 90 ± 35 minutes. The VAS score for leg pain was significantly reduced from 5.9 ± 2.1 preoperatively to 1.7 ± 1.3 postoperatively (p < 0.001). The overall success rate (excellent or good outcome according to Macnab criteria) was 90%. Incidental durotomy occurred in 5 patients (16.7%) without neurological consequences, CSF fistula, or negative influence to the clinical outcome. Instability occurred in 2 patients (6.7%). CONCLUSIONS: The clinical outcome of minimally invasive tubular microdiscectomy is comparable to the reported success rates of other minimally invasive techniques. The dural tear rate is not associated to higher morbidity or worse outcome. The technique is an equally effective and safe treatment option for recurrent LDH.

Minimally invasive redo discectomy for recurrent lumbar disc herniations.

The purpose of this systematic review is to investigate which minimally invasive techniques have been used for discectomy in recurrent lumbar disc herniation (LDH), to present the success and complication rates and to evaluate the advantages and limitations of each technique. Discectomy for recurrent LDH is accompanied by a higher morbidity rate compared with primary LDH. Because of the limited operating field, the majority of surgeons have been discouraged from utilising a minimally invasive approach for revision surgery. Minimally invasive techniques have gained ground in the treatment of primary LDH and an increasing number of patients are expressing interest in such techniques for the treatment of recurrent LDH. Microendoscopic discectomy (MED), endoscopic transforaminal and interlaminar discectomy (ETD and EID) have been used for treatment of recurrent LDH. The reported success rate is 60-95%. Full endoscopic techniques, especially ETD, showed favourable results concerning dural tear rates but have a demanding learning curve. The limitations of ETD include dislocated disc fragments or concomitant lateral recess stenosis, and MED is more effective in these instances. All three techniques have a low delayed instability rate. MED, ETD and EID are safe and efficient treatment options for surgical management of recurrent LDH with good success and low complication rates. At the same time, they offer the advantages of minimally invasive access.

Minimally invasive resection and vertebroplasty for an osteolytic C-1 metastasis of malignant meningioma: case report.

Malignant meningiomas are a rare but aggressive subset of intracranial meningiomas leading to a very limited life expectancy. The occurrence of spinal metastases in these tumors is an even rarer event. The described patient had an intracranial malignant meningioma and developed a symptomatic osteolytic contrast-enhancing lesion in the left C-1 lateral mass suspicious for metastasis. The authors performed a minimally invasive posterior resection of the lesion with vertebroplasty of C-1. Histopathology verified metastasis of the malignant meningioma. The surgical procedure resulted in prompt and permanent pain reduction until the patient died 18 months later. Given the very limited life expectancy in this case, the authors did not consider occipitocervical fusion because of their desire to preserve the range of motion of the head. Therefore, they suggest minimally invasive tumor resection and vertebroplasty in selected palliative tumor patients.