Eyebrow incision for combined orbital osteotomy and supraorbital minicraniotomy: application to aneurysms of the anterior circulation. Technical note.

A modification of the supraorbital keyhole approach, the eyebrow incision-minisupraorbital craniotomy with orbital osteotomy, is described. Unique to this approach is a one-piece supraorbital craniotomy, measuring 2.5 x 3.5 cm, that incorporates the orbital rim and roof and the frontal process of the zygomatic bone through an eyebrow incision. The orbital osteotomy facilitates view of the anterior and middle cranial fossa through the operating microscope, as well as the maneuverability of instruments through a small craniotomy. A pericranial flap is elevated with its base at the orbit and used for closure of the frontal sinus, if necessary. The approach was used successfully in elective surgery of 10 aneurysms of the anterior circulation. The mean aneurysm size was 5.9 mm, with a range of 4 to 10 mm. Advantages of this approach include minimal disruption and exposure of normal brain tissue, reduced frontal lobe retraction, and an excellent postoperative cosmetic result. The approach is performed quickly by virtue of a limited skin incision with minimal temporalis muscle dissection and a small bone flap. The neuroendoscope, although helpful at times, is not essential and no special instruments or intraoperative image guidance is required. Relative contraindications include the presence of a large frontal sinus, severe brain edema, and recent subarachnoid hemorrhage. In addition, this approach has not been used for the treatment of giant intracranial aneurysms.

Vertebroplasty: techniques to avoid complications.

BACKGROUND CONTEXT: The use of vertebroplasty for treatment of spinal fractures and spinal hemangiomas is increasing at a rapid pace. Although this is a minimally invasive procedure, complications have been reported. The most important of these is the unintentional migration of polymethylmethacrylate (PMMA). PURPOSE: The authors present methods, equipment, and principles that minimize occurrence of PMMA migration and other complications. STUDY DESIGN/SETTING: Patients in a private/university neurosurgery practice were studied retrospectively by chart review. PATIENT SAMPLE: During a 3-year period, 53 levels of vertebroplasty were performed on 35 patients presenting with indications of intractable pain resulting from vertebral body compression fractures. OUTCOME MEASURES: Pain assessment and outcome determination were made by the treating physician based on dialog with the patient, examination, and the patient's use of narcotics. The medical records of patients were reviewed for these factors as well as for signs of cerebrospinal fluid leak, PMMA migration, new radiculopathy, myelopathy, new fracture, pulmonary emboli, infection, or bleeding. METHODS: Criteria for inclusion consisted of disabling back pain corresponding to a recent fracture, pharmacotherapy, and medically stable for anesthesia. Vertebroplasty patients were followed up at 2 to 3 weeks and at 3 months after their procedure. RESULTS: Success rate for relief of pain was 89%. The overall complication rate was 6% per treated vertebral level. There were no deaths or delayed complications. Factors that reduce complications were identified and include the following: accurate needle placement, adequate barium radio-opacification of PMMA, viscous low pressure delivery of PMMA, and PMMA delivery under direct fluoroscopic visualization. CONCLUSION: Although vertebroplasty is considered a minimally invasive procedure, it can result in serious complications even without technical misadventures.