Intraoperative imaging and navigation of the petrous apex by infralabyrinthine route.

Intraoperative imaging during skull-base surgery allows the operator to control surgical dissection and to tailor the approach, reducing morbidity due to inadequate resection or reintervention. The O-arm® (Medtronic, Fridley, MN, USA) navigation system is an intraoperative cone-beam CT device that was first designed for spinal surgery but now has applications in lateral skull-base surgery. In this technical note, we present a patient with petrous apex cholesterol granuloma located medial to the intrapetrous internal carotid artery and in the infralabyrinthine compartment. We report the possibility of natural drainage, using intraoperative imaging to guide resection, through a rapid, safe and minimally invasive approach.

Two level Anterior Lumbar Interbody Fusion (ALIF) in a patient with a rare vascular malformation, a duplication of the inferior vena cava.

BACKGROUND: Anterior Lumbar Interbody Fusion is now a well-established procedure to treat degenerative lumbar disease. This approach has its own risks and each spine surgeon must understand the pitfalls that can be encountered when dealing with an anatomy variation of the vessels in order to be able to perform the safest possible procedure. CASE DESCRIPTION: We report the case of a 48 years old man with a rare vascular anatomy variation undergoing a two-levels L4-L5 and L5-S1 ALIF procedure through a right-sided retroperitoneal approach. The preoperative imaging planning revealed a duplication of the Inferior Vena Cava (IVC) located on each side of the aorta. CONCLUSION: Preoperative Imaging evaluation and a detailed knowledge of the anatomy is the key of a safe and successful procedure as any variation can complicate the anterior approach. We believe that teaming up with a vascular surgeon for junior surgeons during the first anterior procedures and especially in the context of anatomical variation is recommended.

Assessment of the effectiveness of SFCR patient information sheets before scheduled spinal surgery.

INTRODUCTION: Patient information is an essential component of any surgical procedure as it allows the surgeon to collect informed consent. This is a legal obligation in the civil code and a professional obligation in the code of medical ethics. As a result, the French spinal surgery society (SFCR) decided to make a model information sheet available on the Internet. The goal of this prospective study was to evaluate the impact of this information sheet when given to patients before scheduled spinal surgery. METHODS: This was a single-centre prospective study performed between November 2014 and February 2015. Seventy patients filled out two questionnaires. The first was about the quality of the medical information given orally by the surgeon; it was administered to patients after the preoperative consultation. The second was about the quality of the medical information contained in the information sheet; it was administered after patients had read this sheet. For each of the questions, patients could either select "yes" if they found the information to be correct/useful (1 point) or "no" if not (0 point). RESULTS: The mean patient age was 56.7 years (range: 28-86). The average number of "yes" answers was 7.07 (out of 12) in the first questionnaire. The average number of "yes" answers was 10.3 (out of 12) after reading the information sheet. This indicates that patients were significantly better informed after reading the SFCR sheet. The written document was deemed to be understandable (mean: 8/10). It answered the patients' questions (mean: 6.7/10) and helped them understand how the surgical procedure would be carried out (mean: 7.3/10). The patients' level of education did not significantly alter these findings. CONCLUSION: Adding a written SFCR information sheet to the preoperative consultation improved patients' understanding before scheduled spine surgery. LEVEL OF EVIDENCE: Low-powered prospective study.

Acute isodense subdural hematoma on computed tomography scan--diagnostic and therapeutic trap: a case report.

BACKGROUND: Post-traumatic acute subdural hematomas generally appear hyperdense on a computed tomography scan. In the hyperacute stage, a subdural hematoma in rare cases appears heterogeneous with isodense images. This can pose a diagnostic problem and compromise patient care. Here we report a case of an isodense subdural hematoma and its management. CASE PRESENTATION: We report the case of a 59-year-old white European man who had a serious head injury with an acute subdural hematoma. The trauma was also responsible for blood loss and hemostasis disorders. A cerebral computed tomography scan revealed an isodense subdural hematoma. Our intervention confirmed that it was an acute hematoma. CONCLUSIONS: This unusual isodense appearance is due to anemia. It can be the cause of misdiagnosis and incorrect treatment choices.

Aim and indications of spinal angiography for spine and spinal cord surgery: Based on a retrospective series of 70 cases.

AIM: For spinal surgery, computerized tomography (CT scan) and magnetic resonance imaging (MRI) have clear indications and are easily accessible. In contrast, the indications and the use of spinal angiograms (SA) remain unclear, and many centres performing spinal surgery do not have an access to SA. Based on a retrospective study, the role of SA in spinal surgery is assessed and their indications are discussed. MATERIAL AND METHODS: A retrospective series of 72 SA in 70 patients is presented. No procedural accident occurred. SA was performed under general anaesthesia in 57 cases (82%). In 61 patients, locating the radiculomedullary arteries (RMA) was obligatory and performed in all cases: for 14 patients (21%), RMA were identified using the forecasted surgical approach (4 patients with degenerative disc disease out of 10 in the entire series were included), and modified. No ischaemic complications were observed in the series. Thirty-nine patients were treated for a tumour that was considered hypervascular (based on a histological hypothesis or the MRI data): 20 of them (51%) were preoperatively embolised and in only 8 cases was the operation considered "haemorrhagic" by the surgeon (among which, 3 intramedullary hemangioblastomas were included). No accident was observed during the embolisations. Thirteen patients presented with a vascular or haemorrhagic lesion (4 arteriovenous malformations, 6 dural arteriovenous fistulas, 3 intramedullary cavernomas): in all these cases, the SA was indispensable for the diagnosis and the decision-making process. Seven patients were treated by embolisation. In the last 8 cases, SA was considered for the diagnosis of a clinical worsening myelopathy with a non-contributive MRI, but it was not useful in providing a positive diagnosis. CONCLUSIONS: SAs were performed with different goals: (i) localization of RMA when a surgical approach between T4 and L2 involved the intervertebral foramen, or when an anterior approach was considered in order to avoid severe ischaemic complications (40% of the degenerative disc patients and 33% of the extramedullary tumour patients in this series); (ii) preoperative embolisation in cases of extramedullary tumours probably considered hypervascular (51% of the cases in the series) or in cases of arteriovenous shunt lesions (7 of 13 patients were treated by embolisation); (iii) as a diagnostic tool, SA is indispensable when MRI can reveal vascular abnormalities; it also provides information about the vascularisation as well as the endovascular possibilities in extramedullary tumours. In contrast, SA was not useful for intramedullary tumours because the RMA preoperative localisation is not mandatory (posterior approach), and embolisation seemed ineffective. SA was also not useful for the diagnosis of myelopathy with normal MRI. In the future, angiograms and MR angiography of the spinal cord may be useful in order to avoid general anaesthesia for a diagnostic procedure, but not practical to obtain access for endovascular treatment.