Surgical outcomes of intraoperative O-arm versus C-arm fluoroscopy in occipitocervical fixation: a retrospective analysis.

PURPOSE: This study aims to compare the effect of using O-arm and C-arm fluoroscopy on the surgical outcomes of occipitocervical fixation. METHODS: The study included patients who underwent occipitocervical fixation using O-arm or C-arm between 2005 and 2021. Of 56 patients, 34 underwent O-arm-assisted surgery (O-group) and 22 underwent C-arm-assisted surgery (C-group). We assessed surgical outcomes, including operative time, intraoperative blood loss, perioperative complications, and bone union. RESULTS: Almost half of the patients had rheumatoid arthritis-related disorders in both groups. Sixteen cases (47.1%) in the O-group and 12 cases (54.5%) in the C-group were fixed from occipito (Oc) to C3, 12 cases (38.2%) in the O-group and 7 cases (31.8%) in the C-group from Oc to C4-7, 5 cases (14.7%) in the O-group, and 3 cases (13.6%) in the C-group from Oc to T2 (p = 0.929). There was no significant difference in operative time (p = 0.239) and intraoperative blood loss (p = 0.595) between the two groups. Dysphagia was the most common complication in both groups (O-group vs. C-group, 11.7% vs. 9.1%). Regarding implant-related complications, occipital plate dislodgement was observed in four cases (18.2%) in the C-group (p = 0.02). The bone union rate was 96.3% in the O-group and 93.3% in the C-group (P = 1). CONCLUSIONS: O-arm use is associated with a reduced rate of occipital plate dislodgment and has a similar complication incidence compared with C-arm-assisted surgery and does not prolong operative time despite the time needed for setting and scanning. Accordingly, an O-arm is safe and useful for occipitocervical fixation surgery.

Robotic versus Open Surgery in Locally Advanced Non-Small Cell Lung Cancer: Evaluation of Surgical and Oncological Outcomes.

Locally advanced non-small cell lung cancer (NSCLC) consists of a heterogeneous group, with different pulmonary extension and lymph nodal involvement. Robotic surgery can play a key role in these tumours thanks to its technological features, although open surgery is still considered the gold-standard approach. Our study aims to evaluate the surgical and oncological outcomes of locally advanced NSCLC patients who underwent robotic surgery in a high-volume centre. Data from consecutive patients with locally advanced NSCLC who underwent robotic lobectomy were retrospectively analysed and compared with patients treated with open surgery. Clinical characteristics and surgical and oncological information were evaluated. From 2010 to 2020, 131 patients underwent anatomical lung resection for locally advanced NSCLC. A total of 61 patients were treated with robotic surgery (46.6%); the median hospitalization time was 5.9 days (range 2-27) and the postoperative complication rate was 18%. Open surgery was performed in 70 patients (53.4%); the median length of stay was 9 days (range 4-48) and the postoperative complication rate was 22.9%. The median follow-up time was 70 months. The 5-year overall survival was 34% in the robotic group and 31% in the thoracotomy group. Robotic surgery can be considered safe and feasible not only for early stages but also for the treatment of locally advanced NSCLC.

Long-term outcome after surgery for middle cluneal nerve entrapment neuropathy.

PURPOSE: Entrapment of the middle cluneal nerve (MCN-E) can elicit low back pain (LBP). Patients whose LBP responds only transiently to the analgesic effects of MCN blockage may be candidates for surgery. This study addresses its long-term efficacy. METHODS: We initially subjected 34 MCN-E patients (48 sides) to surgical release. Of these, 4 were excluded from this study because their follow-up was shorter than 24 months. The mean age of the 30 included patients was 71.5 years; the mean postoperative follow-up period was 40.4 months. Clinical outcomes were assessed on the Numerical Rating Scale (NRS) for LBP and the Roland Morris Disability Questionnaire (RDQ) before surgery and at the latest follow-up visit. RESULTS: The 30 patients (44 sides) reported severe LBP, leg symptoms were elicited by 32 sides. A mean of 1.4 MCN branches were surgically released, 32 sides were addressed by neurolysis, 7 by neurectomy, and 5 underwent both procedures due to the presence of 2 nerve branches. There were no complications. In the course of a mean follow-up of 26.3 months, MCN-E elicited recurrent symptoms on 6 sides; all had undergone neurolysis or neurectomy and a second operation improved the symptoms. All patients showed significant improvement at the last follow-up visit. Postoperatively both their NRS for LBP and their RDQ scores were improved (pre- vs. postoperative scores, p < 0.05). CONCLUSIONS: While surgical release of MCN-E is expected to yield long-term symptom relief, on 6 of 32 sides (18.8%) treated by neurolysis the patients reported pain recurrence. Whether neurectomy effectively prevents the recurrence of MCN-E in the long term requires further study.

Predictors and efficacy of surgical treatment for consecutive exotropia.

PURPOSE: To study the surgical outcomes of consecutive exotropia and predictive factors, and to compare the medial rectus (MR) advancement, lateral rectus (LR) recession, or a combination of both procedures. METHODS: A retrospective study of patients diagnosed with consecutive exotropia that were operated on (2000-2020) were included. The convergence was classified from 0 to +++, with good: ++/+++ and poor: 0/+. A good outcome was considered when the final horizontal deviation was < 10 prism diopters (pd). Follow-up since the surgery and the number of reoperations were registered. RESULTS: A total of 88 cases were analyzed, mean age: 33.98 ± 17.68 years (57.95%: women). The near and distance horizontal deviation mean (±SD) was 34.3 pd (±16.45) and 34.36 pd (±16.33), respectively. MR advancement was performed in 36.36%, LR recession in 27.27%, and a combination of both in 36.36%. Surgery was unilateral in 65.91% (bilateral in 34.09%). A good outcome was obtained in 69.32% and reoperations in 11.36%. The insufficiency convergence was associated with a bad outcome. The near horizontal deviation (P = .006), the vertical deviation (VD) association (P = .036) and the combination of both MR advancement and LR recession (P = .017) were predictors of a bad result. The mean follow-up was 56.5 months ± 57.65. CONCLUSION: A long-term good surgical result was obtained in most patients. The greatest near deviation, the VD association, and the combination of MR advancement and the LR recession were predictive factors for bad results.

Remission, complications, and overall survival in transsphenoidal pituitary surgery-a Swedish single-center experience of 578 patients.

BACKGROUND: Surgical treatment of pituitary lesions causing hormonal overproduction or mass effect is standard procedure. There are few reports on the results and complications related to these surgeries from Northern Europe. Our aim was to evaluate the outcome and complications of a single tertiary surgical center over more than a decade. METHODS: This was a retrospective study on all patients that underwent pituitary surgery from 1st of January 2005 to 31st of December 2017. The analysis included type of lesion, surgical method, pre- and postoperative need for hormonal substitution, hormonal outcome, complications to surgery, survival, need for revision surgery, or stereotactic radiation. Appropriate statistical analyses were made to evaluate surgical results, complications, and survival. RESULTS: Five hundred seventy-eight patients were included in the study. Remission was achieved in 58% of patients with GH-producing and 94% of ACTH-releasing adenomas. Sixty-six percent had no preoperative hormonal substitution compared to 39% postoperatively. Rhinosinusitis (10%) was the most commonly reported postoperative complication followed by leakage of cerebrospinal fluid (8%) and meningitis (4%). Standardized mortality rate for the study population was higher (p = 0.18) when compared to the general population. CONCLUSION: Our results regarding remission rates and complications are in comparison with previous studies. Surgery of pituitary lesion can be considered a safe and efficient surgery. We noted lower rates of CSF leakage in the later part of the study period and believe that this, in part, was an effect by the introduction of a multidisciplinary surgical skull base team and increased surgical experience.

Surgical complications and recurrence factors for asymptomatic meningiomas: a single-center retrospective study.

PURPOSE: Observation is the first management option in asymptomatic meningiomas, but when an enlargement or mass effect is observed, surgery is indicated. This study is aimed at exploring risk factors for complications and recurrence after surgery for asymptomatic meningioma. We also examined the impact of preoperative tumor embolization, which is considered controversial. METHODS: We retrospectively reviewed 109 patients with primary asymptomatic meningiomas surgically treated at our institute between April 2007 and March 2021. Patients who only had headaches as a nonspecific complaint were included in the asymptomatic group. Complications, time to recurrence, and Glasgow Outcome Scale (GOS) score were the endpoints of the study. Risk factors for complications and recurrence were explored. Moreover, the effect of the resection on nonspecific headaches was also explored. RESULTS: The permanent postoperative complication rate related to the surgical procedure was 1.8%. Of the total, 107 patients (98.2%) with asymptomatic meningiomas who were surgically treated achieved a GOS score of 5 1 year after the operation. Preoperative headache was present in 31 patients and improved postoperatively in 21 patients. Multivariate analysis using the Cox proportional hazard model showed that preoperative tumor embolization with > 80% resolution of tumor staining (p < 0.001) was negatively related to recurrence, whereas age (p = 0.046) and Simpson grade IV resection (p = 0.041) were positively related to recurrence. CONCLUSION: Although surgery for asymptomatic meningiomas can, in many cases, be safe, it is not free of complications Thus, surgical intervention for asymptomatic meningiomas should be considered cautiously. However, more than half the patients with headaches showed improvement. Simpson grade IV resection cases should be assessed for recurrence, and preoperative tumor embolization might be effective in controlling recurrence.

Effect of Preoperative Serum Transthyretin Levels on Postoperative Clinical Results and Morbidity in Patients Undergoing Spinal Surgery.

Introduction This study aims to investigate the effects of preoperative serum transthyretin (TTR) levels on surgical success, pain scores, and postoperative morbidity. Methods Note that, in our clinic, 188 patients who were operated for spinal pathologies between June 2010 and January 2011 were included in this study. Blood samples were drawn from all patients on the morning of surgery and then serum TTR measurements were made. Demographic data of all patients were collected, and then their preoperative and postoperative neurological examinations, Karnofsky scores, visual analog scale (VAS) scores, Oswestry Disability Index (ODI) scores, postoperative infection and wound healing status, hospital stay, and morbidity levels were recorded and TTR levels were compared. Results When preoperative TTR level of patients were low, their Karnofsky scores decreased, ODI scores increased, the early postoperative VAS and late postoperative VAS values increased, and the length of hospital stay was increased. Moreover, in patients with low TTR levels, postoperative Karnofsky scores were lower, postoperative ODI levels were higher, postoperative early and late VAS scores were higher, hospital stays were longer, peroperative complication rates were higher, wound infection rates were higher, the delay in wound site healing was higher, and the morbidity rate was higher. Conclusion Consequently, preoperative low TTR levels have been reported to be an effective parameter that can be used to predict surgical results, wound infection and wound site healing status, perioperative complications, and morbidity in spinal surgery.

Effect of Preoperative Serum Transthyretin Levels on Postoperative Clinical Results and Morbidity in Patients Undergoing Spinal Surgery.

INTRODUCTION: This study aims to investigate the effects of preoperative serum transthyretin (TTR) levels on surgical success, pain scores, and postoperative morbidity. METHODS: Note that, in our clinic, 188 patients who were operated for spinal pathologies between June 2010 and January 2011 were included in this study. Blood samples were drawn from all patients on the morning of surgery, and then, serum TTR measurements were made. Demographic data of all patients were collected, and then their preoperative and postoperative neurological examinations, Karnofsky scores, Visual Analog Scale (VAS) scores, Oswestry disability index (ODI) scores, postoperative infection and wound healing status, hospital stay, and morbidity levels were recorded, and TTR levels were compared. RESULTS: When preoperative TTR level of patients was low, their Karnofsky scores decreased, ODI scores increased, the early postoperative VAS and late postoperative VAS values increased, and the length of hospital stay was increased. Moreover, in patients with low TTR levels, postoperative Karnofsky scores were lower, postoperative ODI levels were higher, postoperative early and late VAS scores were higher, hospital stays were longer, peroperative complication rates were higher, wound infection rates were higher, the delay in wound site healing was higher, and the morbidity rate was higher. CONCLUSION: Consequently, preoperative low TTR levels have been reported to be an effective parameter that can be used to predict surgical results, wound infection and wound site healing status, perioperative complications, and morbidity in spinal surgery.

The Effect of Inferior Oblique Muscle Z-Myotomy in Patients with Primary Inferior Oblique Overaction.

Objectives: To investigate the surgical results of the inferior oblique muscle Z-myotomy in patients with inferior oblique muscle overaction (IOOA). Materials and Methods: The medical records of patients who had undergone inferior oblique muscle Z-myotomy for primary IOOA in a single center between 2017 and 2018 were retrospectively analyzed. All patients had mild IOOA (+1 and between +1 and +2). Preoperative and postoperative IOOA degrees and ocular motility examinations were evaluated. Inferior oblique muscle Z-myotomy is performed at 6 mm along the physiological muscle line after identifying the lower oblique muscle through an inferotemporal fornix incision. Results: Forty-seven eyes of 44 patients were included in the study. The patients were divided into those with +1 IOOA (n=37, 78.7%) and those with +1-2 IOOA (n=10, 21.3%). The mean age of the +1 group was 14.18±11.8 years and the mean age of the +1-2 group was 13.40±7.45 years. The mean follow-up time was 10.56±8.7 (6-17) months. Bilateral Z-myotomy was performed in 3 (6.8%) and unilateral in 41 (93.2%) of the patients. IOOA correction was observed in 43 (91.4%) of the 47 eyes after Z-myotomy, while 4 (8.6%) eyes still had preoperative levels of IOOA. There was no statistically significant difference in surgical success rate between the groups (p=0.849). When preoperative and postoperative IOOA values were compared, there was a statistically significant decrease in IOOA values in the postoperative period (p=0.001). No intraoperative or postoperative complications were observed. Conclusion: Inferior oblique Z-myotomy is a simple, fast, sutureless surgical procedure in which the original muscle insertion is preserved. Z-myotomy of the inferior oblique muscle can be used as a successful attenuation method in patients with minimal IOOA.

Surgical results of atypical femoral fractures in long-term bisphosphonate and glucocorticoid users - Relationship between fracture reduction and bone union.

Atypical femoral fracture (AFF) associated with bisphosphonate (BP) use is common, and its pathophysiology is considered to involve severely suppressed bone turnover. Surgical results following AFF fixation have not been optimal, with some cases resulting in delayed union or nonunion. Regarding bone healing, glucocorticoid (GC) has similar properties to BP. We investigated the surgical results of AFF fixation in both users of BP and GC, especially with regard to intraoperative fracture reduction. We included 12 AFFs in 11 patients with a follow-up over one year who all took GC for autoimmune disease and BP for management of GC-induced osteoporosis. Their mean age was 62 years and 10 patients were female. Six fractures were located in the subtrochanteric region of the femur and six were in the diaphysis. Intramedullary nails were used to treat all fractures. Union rate was recorded, and the status of the reduction immediately after the operation was analyzed. Four of the 12 cases developed nonunion, and three of them required additional surgery. The relationship between alignment, cortical continuity, fracture gap, and bone union was not significant. In the nonunion cases, cortical continuity on the anteroposterior and lateral views were never confirmed. Even if cortical continuity in either of the views was there, the two limbs resulted in nonunion. One third of the patients with AFF secondary to long-term BP and GC use developed nonunion despite their fracture reductions being acceptable. We consider strict reduction should be needed for these cases with disadvantage condition to bone union.

[Possibilities and perspectives of hyperspectral imaging in visceral surgery]. / Möglichkeiten und Perspektiven der Hyperspektralbildgebung in der Viszeralchirurgie.

HyperSpectral Imaging (HSI) technology enables quantitative tissue analyses beyond the limitations of the human eye. Thus, it serves as a new diagnostic tool for optical properties of diverse tissues. In contrast to other intraoperative imaging methods, HSI is contactless, noninvasive, and the administration of a contrast medium is not necessary. The duration of measurements takes only a few seconds and the surgical procedure is only marginally disturbed. Preliminary HSI applications in visceral surgery are promising with the potential of optimized outcomes. Current concepts, possibilities and new perspectives regarding HSI technology together with its limitations are discussed in this article.

The efficacy of OK-432 sclerotherapy on thyroglossal duct cyst and the influence on a subsequent surgical procedure.

Background: Although there are studies regarding the efficacy of OK-432 sclerotherapy on thyroglossal duct cyst (TDC), its effects on surgical procedure following this therapy have not been properly described. Objectives: The present study aimed to delineate the prognostic factors of OK-432 sclerotherapy in patients with TDC and investigate its influence on subsequent surgical procedure and the histological characteristics in patients with poor response to OK-432 sclerotherapy. Material and methods: We conducted a retrospective analysis of the medical records of 20 TDC patients treated with OK-432 sclerotherapy. Results: Of the 20 patients, OK-432 sclerotherapy was effective in 5 patients (25.0%). OK-432 showed a lower effective rate in multilocular cysts (9.1%) than in unilocular cysts (44.4%), although not significantly. Five cases were treated with surgery following OK-432 sclerotherapy. There was no significant difference in the operating time and the amount of bleeding between patients with and without OK-432 sclerotherapy. From the results of the histological examination of the cyst wall, two cases had stratified squamous epithelium and two cases showed the absence of lymphocyte infiltration. Conclusion and significance: OK-432 sclerotherapy is an acceptable initial treatment for TDC, especially in unilocular cysts, because of lack of influence on surgical procedure.

Gluteus medius muscle decompression for buttock pain: a case-series analysis.

BACKGROUND: The causes of low back and buttock pain are variable. Elsewhere, we presented a surgical technical note addressing the gluteus medius muscle (GMeM) pain that elicited buttock pain treatable by surgical decompression. Here, we report minimum 2-year surgical outcomes of GMeM decompression for intractable buttock pain. METHODS: Between January 2014 and December 2015, we surgically treated 55 consecutive patients with a GMeM pain. Of these, 39 were followed for at least 2 years; they were included in this study. Their average age was 69.2 years; 17 were men and 22 were women. The affected side was unilateral in 24 patients and bilateral in the other 15 (total 54 sites). The mean follow-up period was 40.0 months (range 25-50 months). The severity of pre- and post-treatment pain was recorded on the numerical rating scale (NRS) and the Roland-Morris Disability Questionnaire (RDQ). RESULTS: Of the 39 patients, 35 also presented with leg symptoms. They were exacerbated by walking in all 39 patients and by prolonged sitting in 33 patients; 19 had a past history of lumbar surgery and 4 manifested failed back surgery syndrome. Repeat surgery for wider decompression was performed in 5 patients due to pain recurrence 15.8 months after the first operation. At the last follow-up, the symptoms were significantly improved; the average NRS fell from 7.4 to 2.1 and the RDQ score from 10.5 to 3.3 (p < 0.05). CONCLUSIONS: When diagnostic criteria are met, GMeM decompression under local anesthesia is a useful treatment for intractable buttock pain.

Comparison between simple release and Z-plasty of retinaculum for de Quervain's disease: a retrospective study.

We compared two surgical procedures for de Quervain's disease that was not responsive to conservative treatment. Group A (simple release) consisted of 38 patients and group B (Z-plasty of the retinaculum) included 36 patients. The visual analogue scale score and the Disabilities of the Arm, Shoulder and Hand Score improved significantly after surgery; there were no statistical differences in outcome between the two groups. In group A, one patient required reoperation, two had subluxations of extensor tendons and two had temporary loss of sensation in the area of the radial nerve. In group B, two patients had temporary loss of sensation. The mean time to resolution of pain at the operative site was significantly shorter in group B. Both simple release and Z-plasty were effective surgical methods. Z-plasty allowed earlier return to activities of daily living but there was no statistical difference between the two groups in incidence of complication. Level of evidence: IV.

Surgical Outcomes of Modified Medial Rectus Resections in Recurrent Intermittent Exotropia

PURPOSE: To evaluate the outcomes of modified medial rectus (MR) resection using a lowered amount of MR resection for recurrent exotropia after bilateral lateral rectus (LR) recessions. METHODS: Fifty-six patients, who underwent MR resection from 2003 to 2017 for recurrent exotropia after bilateral LR recessions, were included. MR resection was performed using modified MR resection with a smaller amount of resection than the standard of 4 mm resection at 20 prism diopters (PD) of exotropia. Postoperative surgical results at 1 month, 6 months, 1 year and 2 years were classified as a success (5 PD esotropia [ET]-10 PD exotropia [XT]), overcorrection (>5 PD ET), and undercorrection (>10 PD XT). The clinical factors affecting surgical results at postoperative 6 month and 2 years were also evaluated. RESULTS: The success rate was 78.2% at postoperative 1 month and 87.5% at postoperative 6 months. The overcorrection rate was 21.8% and the undercorrection rate was 0% at postoperative 1 month. At postoperative 6 months, the overcorrection rate decreased to 0% and the undercorrection rate was 12.5%. The success rate was 85.7% at postoperative 1 year and 66.6% at postoperative 2 years. There was no clinical factor affecting the surgical outcomes except the ocular alignment at postoperative 1 month. The deviation at postoperative 1 month was more esotropic in patients with success at postoperative 6 months and 2 years than that in patients with undercorrection (p < 0.05). CONCLUSIONS: The modified MR resection showed favorable results of 87.5% at postoperative 6 months and 85.7% at 1 year. The angle of deviation at postoperative 1 month was an indicator of subsequent surgical outcomes.

Retrospective analysis of 79 patients with orbital floor fracture: outcomes and patient-reported satisfaction.

BACKGROUND: The aim of our retrospective study is to evaluate the management of isolated orbital floor fractures considering the clinical, functional and aesthetic results according to the surgical approach and the type of materials used. METHODS: Retrospectively, clinical, radiological, surgical, and ophthalmological data from 79 patients were collected from January 2010 to December 2016. Furthermore, included patients were interrogated on functional and aesthetic satisfaction. RESULTS: The main causes of trauma were physical aggression followed by accidents. The median time between trauma and surgery was 4 days. The most common surgical approaches were the subciliary and the transconjunctival ones. Alloplastic materials were used in 75 patients. In two patients, we used a combination of two grafts. Patients experienced minor immediate complications. On follow-ups, none of our patients suffered from ocular movement restrictions. Patients treated by subciliary approach had higher risk of retractile scaring compared to other surgical approaches. In our study, patients agreed to complete a questionnaire assessing functional and aesthetic outcomes with a high satisfaction score. No association between the implant material used and the results has been assessed. CONCLUSION: This study describes the results of orbital floor reconstructions. Despite a variety of materials used and surgical approaches performed, we believe that the transconjunctival approach is the most suitable option with a high satisfaction score.

Long-term follow-up of motor function deterioration following microsurgical resection of middle third parasagittal and falx meningioma.

BACKGROUND: Incidence of parasagittal meningioma varies in literature; it ranges from 16.8% to 25.6% of intracranial meningioma. Parafalcine meningioma accounts for about 8.5% of intracranial meningioma. Based on their relation to the superior Sagittal sinus and falx, these tumors had been classified into 3 groups; anterior third located between crista galli and coronal suture, middle third located between coronal and lambdoid sutures, and posterior third located posterior to lambdoid suture. METHODS: Seventeen cases of middle third parasagittal and falx meningioma operated between 2010 and 2014 were retrospectively reviewed; extent of resection was expressed according to Simpson's classification. Medical Research Council Grading System was used for assessment and evaluation of motor power during preoperative, postoperative, and long-term follow-up, and patients were divided into two groups: group A, no preoperative motor deficit, and group B, patients with preoperative motor deficit. Based on this grading system, we classified motor function into three categories as follows: no disability, partial disability but independent, and complete disability. Follow-up period ranged between 14 and 48 months with mean period 32 months. RESULTS: Total number of patients was 17, 10 females and 7 males. Age ranged between 38 and 63 with the mean age 47. Twelve cases were parasagittal meningioma and 5 cases were falx meningioma. All located at the middle one third. Family history was negative in all cases. Duration of presenting symptoms varied between 3 and 28 months; presenting symptoms were as follows: seizures 64.7% (11 patients), headache 52.9% (9 patients), motor weakness 47% (8 cases), and disturbed conscious level 5.9% (1 case). According to Simpson's classification, grade I resection was obtained in 4 patients and grade II in 13 patients. Intraoperative sinus invasion was present in 3 patients. In early postoperative outcome regarding motor function, 9 cases (53%) showed deterioration of motor function in group A: 4 patients out of 9, and group B: 4 patients out of 8. On long-term follow-up of patients with deteriorated motor function, 6 patients out of 9 improved (66%). CONCLUSIONS: Parasagittal and falx meningioma involving the middle third is associated with a higher incidence of motor function deterioration either as a presenting symptom or during postoperative period. Adobting the microsurgical techniques during surgical resection and preservation of integrity of the venous system and cerebral cortex, deterioration of motor function is transient in most of cases with a favorable outcome on long-term follow-up.

Surgical treatment of middle cluneal nerve entrapment neuropathy: technical note.

OBJECTIVE The etiology of low-back pain (LBP) is heterogeneous and is unknown in some patients with chronic pain. Superior cluneal nerve entrapment has been proposed as a causative factor, and some patients suffer severe symptoms. The middle cluneal nerve (MCN) is also implicated in the elicitation of LBP, and its clinical course and etiology remain unclear. The authors report the preliminary outcomes of a less invasive microsurgical release procedure to address MCN entrapment (MCN-E). METHODS The authors enrolled 11 patients (13 sites) with intractable LBP judged to be due to MCN-E. The group included 3 men and 8 women ranging in age from 52 to 86 years. Microscopic MCN neurolysis was performed under local anesthesia with the patient in the prone position. Postoperatively, all patients were allowed to walk freely with no restrictions. The mean follow-up period was 10.5 months. LBP severity was evaluated on the numerical rating scale (NRS) and by the Japanese Orthopaedic Association (JOA) and the Roland-Morris Disability Questionnaire (RDQ) scores. RESULTS All patients suffered buttock pain, and 9 also had leg symptoms. The symptoms were aggravated by standing, lumbar flexion, rolling over, prolonged sitting, and especially by walking. The numbers of nerve branches addressed during MCN neurolysis were 1 in 9 patients, 2 in 1 patient, and 3 in 1 patient. One patient required reoperation due to insufficient decompression originally. There were no local or systemic complications during or after surgery. Postoperatively, the symptoms of all patients improved statistically significantly; the mean NRS score fell from 7.0 to 1.4, the mean RDQ from 10.8 to 1.4, and the mean JOA score rose from 13.7 to 23.6. CONCLUSIONS Less invasive MCN neurolysis performed under local anesthesia is useful for LBP caused by MCN-E. In patients with intractable LBP, MCN-E should be considered.

Extended endoscopic endonasal approach for recurrent or residual symptomatic craniopharyngiomas.

OBJECTIVES: Removal of recurrent or residual symptomatic craniopharyngiomas is more challenging than the primary surgery. The extended endoscopic endonasal (EEE) approach has been proposed an alternative surgical route for removal of various suprasellar tumors including craniopharyngiomas currently. In this study, we summarized the operative experience and described the feasibility and advantages of this technique in recurrent or residual symptomatic craniopharyngiomas. PATIENTS AND METHODS: A retrospective review of 15 patients (9 males and 6 females) whom underwent EEE approach between April 2012 and February 2017, were included in this study. The lesions included 8 purely suprasellar craniopharyngiomas (2 extraventricular, 6 intraextraventricular), 3 both intra- and suprasellar craniopharyngiomas, and 4 intrasellar craniopharyngiomas. The mean preoperative (that is, EEE approach) tumor volume was 10.54 cm3. The mean follow-up period was 23.1 months (range, 8-54). All patients were analyzed in terms of the treatment effect, complictions and follow-up results. RESULTS: Total removal of tumors was achieved in 12 patients (80.0%) and subtotal removal in 3 cases (20.0%). The pituitary stalks were identified in 11 patients during operations and secured in 8 patients. Postoperative visual acuity was improved in 10 cases, and normalization of the impairment was achieved in 3 patients. There were no significant differences between pre and postoperative endocrine function, except in one patient with normal preoperative pituitary hormone function who suffered postoperative hypopituitarism. Postoperative diabetes insipidus (DI) occurred in 14 patients including 6 patients who had long-term DI and others reporting transient postoperative DI. No cerebrospinal fluid (CSF) leak was identified. There were no deaths or major complications. Obesity developed in 2 patients, with no deaths and recurrent cases during follow-up period. CONCLUSION: The pure EEE approach is a safe, effective alternative for treatment of recurrent or residual symptomatic craniopharyngiomas owing to its advantages including wide-angle view, close observation and elimination of brain retraction. Larger studies with further follow-up is needed to assess the long-term efficacy of this minimal access approach.

Microsurgical therapy of pituitary adenomas.

PURPOSE: We report the efficacy and safety of transsphenoidal microsurgery in a large and homogeneous cohort of patients with pituitary adenomas (PAs) treated at a single Institute by a single neurosurgeon. METHODS: A total of 2145 consecutive patients undergoing first surgery for a PA were included: 795 (37.1%) had a nonfunctioning pituitary adenoma (NFPA), 595 (27.7%) acromegaly, 496 (23.1%) Cushing's disease, 208 (9.7%) a PRL-secreting adenoma, and 51 patients (2.4%) a TSH-secreting adenoma. Remission was achieved when strict hormonal and radiological criteria were met. RESULTS: Early surgical remission was achieved in 66% of acromegalic patients, 79.6% of patients with Cushing's disease, 64.4% of prolactinomas, 74.5% of patients with a TSH-secreting adenoma, and 66.9% of NFPAs. The mean (±SE) follow-up was 60.1 ± 1.3 months. The recurrence-free survival at 10 years was 78.2% in acromegalic patients, 68.1% in prolactinomas, 74.3% in Cushing's disease, 70.3% in TSH-secreting adenomas, and 75.3% in NFPAs. Preoperative hypoadrenalism recovered in 35.3%, hypogonadism in 43.3% and hypothyroidism in 37.4% of patients with impaired function before surgery. The mortality rate was 0.2% and major morbidity 2.1%. New onset hypoadrenalism occurred after surgery in 2.5% of patients at risk, hypogonadism in 4.1%, and hypothyroidism in 1.8%. Permanent diabetes insipidus (DI) occurred in 0.9% of patients. CONCLUSIONS: In experienced hands, transsphenoidal microsurgery for PAs achieves remission in most patients with a low complication rate. Pituitary function is preserved in most cases and can recover in more than one-third of patients with preoperative hypopituitarism.