Percutaneous endoscopic lumbar discectomy for L5-S1 disc herniation based on image analysis and clinical findings: A retrospective review of 345 cases.

The effect of spinal anatomical anomalies on the efficacy of percutaneous endoscopic lumbar discectomy (PELD) for disc herniation repair is unclear. This retrospective review aims to assess the safety and effectiveness of PELD for treating L5-S1 disc herniation with a range of characteristics and to determine the prevalence of lumbosacral transitional vertebrae (LSTV) anatomical anomalies to facilitate pre-surgical planning. From July 2005 to June 2019, 345 patients with L5-S1 disc herniations were treated with PELD. The primary outcome was 1-year postoperative visual analogue scale scores for low back and lower limb pain. The secondary outcomes included the surgical approach used, lumbosacral bony anomalies, presence of a ruptured disc or severely calcified disc, pediatric lumbar disc herniation, recurrent disc herniation management, and the long-term outcome. visual analogue scale scores for most patients were significantly improved after surgery. The prevalence of LSTVs was 4.05% (14/345 patients) in lumbar sacralization and 7.53% (26/345 patients) in sacral lumbarization. The prevalence of ruptured and severely calcified discs was 18.55% (64/345) and 5.79% (20/345), respectively. The prevalence of pediatric lumbar disc herniation was 2.02% (7/345). The recurrence rate was 4.34% (15/345). Two durotomy cases without sequelae and 8 cases of lower limb dysesthesia lasting longer than 3 months postoperatively were reported. PELD is safe and effective for treating L5-S1 disc herniation, including cases complicated by calcified lumbar disc herniation, disc rupture with migration, and the presence of LSTV. Appropriate imaging is essential to identify case-specific factors, including the prevalent LSTV anatomical anomalies, before surgery.

Palatal hybrid surgery for obstructive sleep apnea-state-of-the-art annotation of uvulopalatopharyngoplasty.

BACKGROUND: Surgery for obstructive sleep apnea (OSA) has changed in concept and technique that transformed from radical excision to functional reconstruction. The aim of this study was to investigate the safety and effectiveness of palatal hybrid surgery in OSA patients. METHODS: Palatal hybrid surgery is a tissue-specific technique (mucosa-preservation, tonsil-excision, fat-ablation, muscle-relocation/suspension) used in treating OSA patients with velopharyngeal obstruction. The study included 46 consecutive adults OSA patients. The palatal hybrid surgery annotates uvulopalatopharyngoplasty in stereoscopic reconstruction of tonsillar fossa (pharyngoplasty), omni-suspension of the soft palate (palatoplasty) and advancement of uvula (uvuloplasty). RESULTS: No patient experienced airway compromise, voice change or persistent nasal regurgitation following palatal hybrid surgery. One patient existed postoperative tonsillar fossa bleeding received conservative treatment. Postoperative pain in visual analogue scale (VAS) showed average score of 3, 3, 2, 0 at the 1st, 3rd, 7th, 14th day, respectively. Perioperative snoring severity (VAS) (8.7 vs 2.6) and daytime sleepiness (Epworth Sleepiness Scale) (11.3 vs 5.5) all improved significantly (p < 0.001). Posterior air space in retropalatal area increased from 8.4 to 11.1 mm (p < 0.001). Home sleep test showed that apnea-hypopnea index significantly reduced from 41.8 to 18.2 event/h and minimal oxygen saturation increased from 72.4 to 81.5% (p < 0.001). The success rate in individual Friedman stage was 100% (stage I), 63% (stage II) and 58% (stage III) with a total success rate of 63%. CONCLUSION: Palatal hybrid surgery using tissue-specific maneuver annotates UPPP in concept and technique. The results show that palatal hybrid surgery is mini-invasive with low morbid and is effective in improving subjective clinic symptoms, objective sleep parameters and success rate of OSA.

Prediction of Epiglottic Collapse in Obstructive Sleep Apnea Patients: Epiglottic Length.

OBJECTIVE: This study aims to explore the factors that contribute to epiglottic collapse (EC) in patients with obstructive sleep apnea (OSA). METHODS: This study enrolled 35 patients (34 males; median age, 39 years; median apnea-hypopnea index (AHI), 55.4 events/h; median body mass index (BMI), 26.9 kg/m2). EC (epiglottis attaching onto the posterior pharyngeal wall) was diagnosed by drug-induced sleep computed tomography (DI-SCT). Three dimensions were assessed for comparison between the EC and non-EC (NEC) groups that included anatomical measurement: epiglottic length and angle, endoscopic classification of epiglottis obstructing the glottis (Type I, none; Type II, partial; and Type III, total), and dynamic hyoid movement during DI-SCT (Δ hyoid = √(x2 + y2), maximal displacement of hyoid in x and y axes during sleep breathing cycle). RESULTS: EC was found in 12 patients (34%). No difference in age, gender, AHI, and BMI between the two groups was noted. The anatomical measurement revealed that epiglottis length was significantly different between the EC and NEC groups (21.2 vs 15.8 mm; p < 0.001), with a cutoff value of 16.6 mm (sensitivity, 100%; specificity, 65.2%). The EC group patients showed larger hyoid movement than the NEC group patients (Δ hyoid, 4.8 vs 3.0 mm; p = 0.027). By contrast, epiglottic angle and endoscopic classification revealed an insignificant difference between the two groups. CONCLUSION: Epiglottis is a potential collapse site among multilevel obstruction in moderate to severe OSA patients. Epiglottic length is highly sensitive in predicting EC, with the cutoff value of 16.6 mm. Hyoid movement plays a role in contributing to EC in OSA patients.

Idiopathic Sudden Sensorineural Hearing Loss in Patients with Obstructive Sleep Apnea.

PURPOSE: Obstructive sleep apnea (OSA) is characterized by recurring hypoxic-apneic events during sleep, and labyrinthine vascular compromise is a pathophysiologic hallmark of idiopathic sudden sensorineural hearing loss (ISSNHL). Some reports have discussed the relationship between OSA and hearing impairment; however, few have examined hearing prognosis in OSA and patients without OSA with ISSNHL. We aimed to investigate clinical manifestations of ISSNHL in patients with OSA, including severity of hearing loss and response to treatment. PATIENTS AND METHODS: A case-control study was conducted by extracting data from the sleep center and cochlea center databases of the Chang Gung Memorial Hospital. A retrospective chart review was performed to include confirmed adult OSA patients diagnosed with unilateral ISSNHL. Age and sex-matched patients without OSA with ISSNHL were enrolled as controls. Pure-tone average (PTA) thresholds were measured at specific frequencies. Changes in PTA before and after standard treatment with oral prednisolone (1mg/kg/day for 5 days, then tapered) and between participants with OSA and without OSA were compared. Standard treatment was given to all ISSNHL patients. RESULTS: Twenty-eight out of 8500 (0.33%) OSA patients experienced subsequent ISSNHL in 9 years. Patients with OSA (n=28) had poorer high-frequency perception in the unaffected ear than the patients without OSA (n=120), although the difference was not significant. Hearing in the affected ear among patients with OSA was comparable to that patients without OSA at individual frequencies and average, suggesting no difference in hearing loss in the affected ear between the two groups. In terms of high-frequencies (4000 and 8000 Hz) perception, patients with OSA had significantly poorer responses to steroid treatment than patients without OSA. CONCLUSION: ISSNHL may be one of the auditory complications associated with OSA. Patients with OSA had poorer prednisolone related hearing improvement in high frequencies than patients without OSA. Despite study limitations, OSA-related hypoxia and snoring noise is hazardous to hearing and standard treatments with CPAP is suggested in OSA patients for both holistic and auditory health.

How to manage continuous positive airway pressure (CPAP) failure -hybrid surgery and integrated treatment.

Obstructive sleep apnea (OSA) is a prevalent disease, which influences social relations and quality of life with major health impact. The etiology of OSA is multi-factorial involving both anatomical obstruction and physiological collapse of the upper airway during sleep with different proportion in individual patients. Continuous positive airway pressure (CPAP) is the gold standard and first-line treatment for OSA patients. The mechanism of CPAP is acting as air splint to avoid principal pharyngeal collapse during sleep. Consequently, extrapharyngeal collapse and significant pharyngeal obstructions can lower its compliance and lead to its failure. Adequate mask and pressure with thorough survey to eliminate side effects of CPAP from nasal, mask and flow-related problems are the prerequisite to improve CPAP compliance. For CPAP failure patients, multi-dimensional surgery is an alternative and salvage treatment that involves soft tissue surgery, skeletal surgery, and bariatric surgery. OSA patients with craniofacial anomaly are suggested to skeletal surgery. By contrast, OSA patients with pathological obesity are referred to bariatric surgery. Soft tissue surgery targets at the nose, soft palate, lateral pharyngeal wall, tongue and epiglottis that can be implemented by multi-level surgery with hybrid technique (mucosa-preservation, fat-ablation, muscle-suspension, tonsil-excision, cartilage-reconstruction) to maximize surgical outcomes and minimize complications. Some evolution in surgical concept and technique are noteworthy that include mini-invasive septoturbinoplasty, palatal suspension instead of excision, whole tongue treatment, and two-dimensional supraglottoplasty. Postoperative integrated treatment including myofunctional, positional therapy and body weight control reduces relapse of OSA and improves long-term treatment outcomes.

High elevation training mask as a respiratory muscle strength training tool for dysphagia.

BACKGROUND: Expiratory muscle strength training (EMST) is a treatment for swallowing dysfunction due to its activation of the suprahyoid muscles. Current EMST devices have numerous limitations. OBJECTIVE: The purpose was to evaluate the utility of elevation training mask as an alternative respiratory muscle strength training (RMST) device. METHODS: A closed system, simulating expiration was designed. Air was delivered through a pressure gauge with a measurement range of 0-15 psi. The EMST150TM and the Elevation Training Mask 2.0® (ETM) maximal resistance levels were measured and compared. RESULTS: EMST150 produced increasing expiratory resistance pressures of 0.3, 0.6, 1.2, 1.9 and 2.1 psi, which correspond to its indicator of 30, 60, 90, 120 and 150 cmH2O. The ETM resistance pressure produced expiratory resistance pressures of 0.1 and 0.2 psi at simulated altitudes of 3000 and 6000 feet, respectively. A stable expiratory resistance pressure of 0.25 psi was measured at simulated altitudes of 9000, 12,000, 15,000 and 18,000 feet. CONCLUSION: ETM provides adjustable expiratory muscle strength resistance pressures. Further investigation is necessary to evaluate safety, compliance and clinical efficacy in patients with swallowing dysfunction. SIGNIFICANCE: ETM can serve as an effective treatment modality for pulmonary dysfunction and swallowing disorders through RMST.

Long-Term Effects of Intracapsular Debulking and Adjuvant Somatostatin Analogs for Growth Hormone-Secreting Pituitary Macroadenoma: 10 Years of Experience in a Single Institute.

OBJECTIVE: Long-term effects of endoscopic endonasal transsphenoidal intracapsular debulking and adjuvant somatostatin analogs (SSAs) were evaluated in patients with growth hormone- (GH) secreting pituitary macroadenomas. METHODS: We retrospectively reviewed the medical records of 45 patients with acromegalic macroadenoma who underwent endonasal endoscopic transsphenoidal intracapsular debulking and received adjuvant SSAs (octreotide) between 2006 and 2015 who had >1 year of follow-up. To evaluate the predictive factors for 1 year and long-term biochemical outcomes, univariate and multivariate analyses were performed. RESULTS: Biochemical remission was achieved in 1 year in 20 of the 45 (44.4%) patients, and in 31 of the 45 patients after long-term adjuvant SSA treatment. Tumor control was achieved in 43 of the 45 (93.3%) patients. The univariate analysis showed age (≥55 years), tumor size (diameter ≤1.5 cm), premedication GH levels (≤2.8 ng/mL), premedication insulin-like growth factor 1 levels (≤2-fold of upper limit of normal range), cavernous sinus invasion (Knops grades 2, 3, and 4), and near-total tumor resection were associated with long-term outcomes. The multivariate analysis showed near-total resection was a significant predictor for long-term outcomes (P = 0.019). There were no new pituitary dysfunctions. The observed complications included one case of cerebrospinal fluid leakage and one case of epistaxis requiring intervention. CONCLUSIONS: Intracapsular debulking and adjuvant SSAs are a safe and viable treatment for patients with GH secreting pituitary macroadenoma to achieve biochemical remission and tumor control. Although adjuvant SSA treatment enhances residual tumor control, cavernous sinus invasion impedes the remission of endocrine tumors.

Treating cerebrovascular diseases in hybrid operating room equipped with a robotic angiographic fluoroscopy system: level of necessity and 5-year experiences.

BACKGROUND: A hybrid operating room (OR) equipped with robotic angiographic fluoroscopy system has become prevalent in neurosurgery. The level of necessity of the hybrid OR in treating cerebrovascular diseases (CVD) is rarely discussed. OBJECTIVE: The authors proposed a scoring and classification system to evaluate the cerebrovascular procedures according to the level of treatment necessity for CVD in a hybrid OR and shared our 5-year experiences. METHODS: From December 2009 to January 2016, the registry of cerebrovascular procedures performed in the hybrid OR was retrieved. A scoring system was used to evaluate the importance of the surgical and interventional components of a cerebrovascular procedure performed in the hybrid OR. The score of either component ranged from 1, 1.5, to 2 (1 = no role, 1.5 = supplementary or informative, 2 = important or therapeutic). The total score of a procedure was by multiplying two individual scores. Levels of necessity were classified into level A (important), level B (beneficial), and level C (replaceable). RESULTS: A total of 1027 cerebrovascular procedures were performed during this period: diagnostic angiography in 328, carotid artery stenting in 286, aneurysm coiling in 128, intra-operative DSA in 101, aspiration of ICH under image guidance in 79, intra-arterial thrombolysis/thrombectomy in 51, intracranial angioplasty/stenting in 30, hybrid surgery/serial procedures in 19, and rescue surgery during embolization in 5. According to the scoring system, hybrid surgery and serial procedures scored the highest points (2 × 2). The percentages distributed at each level: levels A (2.3%), B (17.5%), and C (80.2%). CONCLUSION: This study conveys a concept of what a hybrid OR equipped with robotic angiographic fluoroscopy system is capable of and its potential. For cerebrovascular diseases, hybrid OR exerts its value via hybrid surgery or avoiding patient transportation in serial procedures (level A), via providing real-time high-quality angiography and image guidance (level B), which constituted about 20% of the cases. The subspecialty of the group using the hybrid OR directly reflects on the number of procedures categorized in each level. In a hybrid OR, innovative treatment strategies for difficult-to-treat CVD can be developed.

High Resolution Manofluorographic Study in Patients With Multiple System Atrophy: Possible Early Detection of Upper Esophageal Sphincter and Proximal Esophageal Abnormality.

Introduction: Multiple system atrophy (MSA) has detrimental effects on swallowing function. The swallowing function of patients with MSA has not been systematically characterized and the underlying pathophysiological mechanisms of dysphagia remain poorly understood. Objectives: To investigate the characteristics of swallow function in MSA using high-resolution manofluorography (HRMF). Methods: We conducted a retrospective review of twenty-five MSA patients who underwent HRMF from 2016 to 2017. HRMF was utilized on patients with only oral diet (Functional Oral Intake Scale (FOIS) >3). Pharyngoesophageal and proximal esophageal pressure profiles were evaluated and compared to established normative data. The frequency and characteristics of upper esophageal sphincter (UES) and proximal esophageal abnormalities during rest and swallow were calculated. Results: The ages of patient cohort in our study ranged from 48-81 years (median 65 years) with male predominance (68%). We observed a distinct abnormal deglutitive proximal esophageal contraction (ADPEC) in 14 (56% of patients), which appears to reflect a discoordinated response of the striated muscle esophagus. Deficient UES relaxation duration, impaired UES relaxation, hypertensive resting UES pressure and hypotensive resting UES pressure were detected in 8 patients (32%), 3 patients (12%), 1 patient (4%), and 11 patients (44%) respectively. Conclusions: In patients with MSA, abnormal UES resting pressure is common. A discoordinated proximal esophageal pressure response was identified and may be a pathognomonic manometry finding for MSA. These findings may serve as indications of early stage swallowing dysfunction in patients with MSA.

Endoscope-assisted transsphenoidal puncture of the cavernous sinus for embolization of carotid-cavernous fistula in a neurosurgical hybrid operating suite.

Endovascular embolization is the treatment of choice for carotid-cavernous fistulas (CCFs), but failure to catheterize the cavernous sinus may occur as a result of vessel tortuosity, hypoplasia, or stenosis. In addition to conventional transvenous or transarterial routes, alternative approaches should be considered. The authors present a case in which a straightforward route to the CCF was accessed via transsphenoidal puncture of the cavernous sinus in a neurosurgical hybrid operating suite. This 82-year-old man presented with severe chemosis and proptosis of the right eye. Digital subtraction angiography revealed a Type B CCF with a feeding artery arising from the meningohypophyseal trunk of the right cavernous segment of the internal carotid artery. The CCF drained through a thrombosed right superior ophthalmic vein that ended deep in the orbit; there were no patent sinuses or venous plexuses connecting to the CCF. An endoscope-assisted transsphenoidal puncture created direct access to the nidus for embolization. Embolic agents were deployed through the puncture needle to achieve complete obliteration. Endoscope-assisted transsphenoidal puncture of the cavernous sinus is a feasible alternative to treat difficult-to-access CCFs in a neurosurgical hybrid operating suite.

Hybrid surgery for dural arteriovenous fistula in the neurosurgical hybrid operating suite.

Treatment of a dural arteriovenous fistula (AVF), which is difficult to access by either the surgical or endovascular approach, is challenging. A hybrid technique, combining a microsurgical approach and endovascular embolization, can provide less invasive management of dural AVFs in a modern neurosurgical hybrid operating suite. We present a case of intracerebral hemorrhage in the left cerebellum secondary to dural AVF, Cognard type IV with numerous tiny feeders from the ascending pharyngeal artery branches. No adequate arterial or venous route for endovascular embolization was found by neuroangiography. The hybrid technique, combining keyhole pterional craniotomy and embolization with n-butyl cyanoacrylate glue injection via direct cannulation of the periclival venous plexus, succeeded in obliterating the dural AVF. Intraoperative angiography showed successful embolization of the dural AVF without any complication. This report illustrates the usefulness of the neurosurgical hybrid operating suite for the treatment of difficult dural AVFs.

Temporary clamping of bilateral external carotid arteries for surgical excision of a complex dural arteriovenous fistula.

BACKGROUND: Some complex dural arteriovenous fistulas (DAVFs) are lesions that typically have numerous arterial feeders. Surgery, including resection of fistulas or skeletonization of the diseased sinus, is still one of the important treatments for these lesions. However, major blood loss is usually encountered during craniotomy because of abundant arterial feeders from the scalp and transosseous vessels. We present a novel approach for obliteration of the fistulas with less blood loss. METHODS: Our first case was a 52-year-old male who suffered from syncope and seizure. Cerebral digital subtraction angiography (DSA) revealed complex DAVFs with numerous arterial feeders from bilateral external carotid arteries (ECAs) and drainage into the superior sagittal sinus with cerebral venous reflux. The second case was a 48-year-old male presenting with chronic headache. His DSA also showed complex DAVFs along the superior sagittal sinus with cerebral venous reflux. In both cases, we performed the surgical procedure to obliterate the pathological fistulas after temporary clamping of bilateral ECAs and noted less blood loss than in the conventional surgery. RESULTS: The follow-up DSA showed successful obliteration of the complex DAVFs on the first case and partial improvement on the second case followed by transarterial embolization (TAE). The symptoms of the both patients were relieved after surgery with good recovery. CONCLUSION: Temporary clamping of bilateral ECAs can improve the safety and ease the surgical excision for complex DAVFs. By using this technique, neurosurgeons can deal with aggressive DAVFs more confidently and calmly.

Hybrid surgery for dural arteriovenous fistula in the neurosurgical hybrid operating suite.

Treatment of a dural arteriovenous fistula (AVF), which is difficult to access by either the surgical or endovascular approach, is challenging. A hybrid technique, combining a microsurgical approach and endovascular embolization, can provide less invasive management of dural AVFs in a modern neurosurgical hybrid operating suite. We present a case of intracerebral hemorrhage in the left cerebellum secondary to dural AVF, Cognard type IV with numerous tiny feeders from the ascending pharyngeal artery branches. No adequate arterial or venous route for endovascular embolization was found by neuroangiography. The hybrid technique, combining keyhole pterional craniotomy and embolization with n-butyl cyanoacrylate glue injection via direct cannulation of the periclival venous plexus, succeeded in obliterating the dural AVF. Intraoperative angiography showed successful embolization of the dural AVF without any complication. This report illustrates the usefulness of the neurosurgical hybrid operating suite for the treatment of difficult dural AVFs.