Minimally invasive thoracic corpectomy and anterior fusion in a patient with metastatic disease: case report and review of the literature.

For patients with metastatic disease to the spine there are numerous surgical approaches for decompression of neural elements and maintenance of mechanical stability. The challenge is to accomplish this while minimizing patient morbidity. Here we report on the feasibility and utility of a minimally invasive extreme lateral approach to the mid to high thoracic spine for anterior decompression and fusion.

Percutaneous axial lumbar interbody fusion (AxiaLIF) of the L5-S1 segment: initial clinical and radiographic experience.

INTRODUCTION: Anterior access to the L5-S1 disc space for interbody fusion can be technically challenging, frequently requiring the use of an approach surgeon for adequate exposure. We reviewed our experience with a novel minimally invasive technique for L5-S1 interbody fusion that exploits the presacral space and its relative dearth of critical structures. METHODS: 35 patients (20 F:15 M, mean age 54 years) were included in this analysis. Average follow-up was 17.5 months. Back pain was secondary to lumbar degenerative disc disease (DDD), degenerative lumbar scoliosis, or lytic spondylolisthesis. All patients had radiographic evidence of L5-S1 degeneration and underwent percutaneous paracoccygeal axial fluoroscopically-guided interbody fusion (axiaLIF) with cage, local bone autograft, and rhBMP. RESULTS: Mean operative time for the L5-S1 axiaLIF procedure was 42 minutes. Twenty-one patients underwent axiaLIF followed by percutaneous L5-S1 pedicle screw-rod fixation. Two patients underwent axiaLIF followed by percutaneous L4-L5 extreme lateral interbody fusion (XLIF) and posterior instrumentation. Ten patients had a stand-alone procedure. Unfavorable anatomy precluded access to the L5-S1 disc space during open lumbar interbody fusion in 2 patients who subsequently underwent axiaLIF at this level as part of a large construct. Thirty-two patients (91%) had radiographic evidence of stable L5-S1 interbody cage placement and fusion at the last follow-up. CONCLUSIONS: The percutaneous paracoccygeal approach to the L5-S1 interspace provides a minimally invasive corridor through which discectomy and interbody fusion can safely be performed. It can be used alone or in combination with minimally invasive or traditional open fusion procedures. It may provide an alternative route of access to the L5-S1 interspace in those patients who may have unfavorable anatomy for or contraindications to the traditional open anterior approach to this level.

Multidirectional projectional rigid neuro-endoscopy: prototype and initial experience.

INTRODUCTION: The role of neuro-endoscopy is emerging. Traditional endoscopy is complicated by limited 2D views that make surgical interventions difficult. We have developed a rigid endoscope with a variable direction view that provides 3D visualization. MATERIALS AND METHODS: A prototype of the EndActive endoscope was used to examine 2 brain/intraventricular models. A 360-degree view is controlled via integrated joystick. Alternatively, the computer can volumetrically capture the ventricular surface. The captured video image can be viewed later or processed to create a flat projection map. The performance of this endoscope was compared to standard endoscopy with fixed directions of view. To simulate endoscopy, the center of the first brain model had eight labeled projections. The model was inspected with the multidirectional endoscope, standard rigid endoscopes (0-, 30- and 70-degree), and via a projection map. Ten neurosurgeons proficient in neuro-endoscopy were recruited for the experiments. The second brain model was labeled with 32 intraventricular tumors. RESULTS: With a 0-degree endoscope, only the number directly opposite the site of entry was visualized. With increasing angles, additional numbers were visualized. The 70-degree endoscope allowed 4 of 8 numbers to be visualized. Using the multidirectional endoscope, all 8 numbers were visualized. The multidirectional endoscope was more accurate in identifying markers compared to standard endoscopy (p = 0.031). The mean endoscopy times using the multidirectional endoscope and standard endoscopy were 143 and 117 seconds, respectively (p = 0.243). The best performance was obtained when the flat projection map was read (p < 0.01). Using the endoscope prototype, an average of 30.8 (96%) tumors was identified on the brain model. CONCLUSION: The EndActive endoscope is a rigid endoscope that provides complete visualization of a 3D space by controlling an adjustable viewing direction. In our study, the multidirectional endoscope provided superior visualization compared to standard endoscopy.

Gunshot wounds to the head: gang- and non-gang-related injuries and outcomes.

PRIMARY OBJECTIVE: This study examined the differences between gang and non-gang-related incidents of penetrative missile injuries in terms of demographics, motivation, intra-cranial pathology, transit time, injury time and clinical outcome. RESEARCH DESIGN: Retrospective and prospective chart review. METHODS AND PROCEDURES: Between 1985-1992, 349 patients with penetrating missile injuries to the brain presenting to LAC-USC were studied. EXPERIMENTAL INTERVENTIONS: Inclusion criteria were implemented to keep the cohort as homogenous as possible. Patients excluded were those with multiple gunshot wounds, non-penetrating gunshot wounds to the head, systemic injuries and cases in which the motivation for the incident was unknown. MAIN OUTCOMES AND RESULTS: Gang-related shooting slightly out-numbered non-gang-related incidents. Demographic analysis showed both a male and Hispanic predominance for both gang- and non-gang-related victims and significant differences in gender, race and age. Occipital entrance sites were more common in the gang-related vs temporal entrance sites in the non-gang-related. Mean transit time to the emergency department for gang-related shootings was less than non-gang-related shootings (24.4 vs 27.8 minutes). Most shooting incidents took place between 6pm and 3am. No difference between survival and outcome was noted between gang and non-gang victims. CONCLUSIONS: Significant differences were found between gang- and non-gang-related shooting victims in terms of demographics, entrance site and transit time. No difference was found between injury time, survival and outcome between gang and non-gang populations.

Improved patient outcome after surgical treatment for loculated empyema.

BACKGROUND: Empyemas complicate the hospital course of many patients. Advanced stages of empyema often require surgical intervention. METHODS: A retrospective review of 70 adult patients with empyema, hospitalized between the years of 1992 and 1997, was performed. Data on age, length of stay, comorbidities, diagnostic studies, and treatment was obtained. We compared patient outcome from patients with loculated empyemas who had surgical treatment and those who were managed nonsurgically. RESULTS: Seventy patient records were reviewed, 37 of which were of patients with loculated empyemas. Parapneumonic empyemas comprised 60% of all cases. Chest radiographs, computed tomography scan, and thoracentesis were the most common studies performed in both groups. Thirty-three patients with the radiographic finding of a loculated empyema were treated with either surgical decortication or tube thoracostomy. CONCLUSION: Empyemas at various stages of development require different forms of therapy; advanced empyemas treated early with decortication have a shorter duration of treatment, lower incidence of recurrence and fewer complications.

An early comparison between endoscopic ultrasound-guided fine-needle aspiration and mediastinoscopy for diagnosis of mediastinal malignancy.

Precise mediastinal lymph node staging is essential in non-small cell lung cancer for proper evaluation and treatment. In addition to CT, mediastinoscopy is routinely used for staging and diagnosis of mediastinal malignancy. Recently, endoscopic ultrasound (EUS) combined with fine-needle aspiration (FNA) biopsy has been used to evaluate mediastinal disease. The purpose of this study was to assess and compare mediastinoscopy with EUS/FNA in the evaluation of mediastinal masses. From August 1995 to July 1997, 21 patients with suspected mediastinal malignancy underwent cervical mediastinoscopy with biopsy. During this same period, seven patients with suspected mediastinal malignancy were evaluated using EUS/FNA. All patients were retrospectively studied. Both mediastinoscopy and EUS/FNA were highly sensitive in diagnosing mediastinal malignancy (100% and 86%, respectively). Specificity and positive predictive value were 100 per cent for both procedures. Mediastinoscopy and EUS/FNA are highly accurate methods of staging mediastinal malignancy. Mediastinoscopy provides better access to the upper and anterior mediastinum, whereas EUS/FNA can safely be used to biopsy subcarinal and posterior mediastinal masses. Mediastinoscopy and EUS/FNA target different areas of the mediastinum and may be complimentary in the evaluation of mediastinal malignancy and staging of bronchogenic carcinoma.