Frameless stereotaxy for anterior spinal procedures.

OBJECT: Intraoperative image guidance provides real-time three-dimensional visualization and has been successfully applied in many posterior spinal procedures. The feasibility of applying these techniques to anterior spinal surgery has not been studied systematically because the anterior spine, in contrast to the posterior spine, lacks distinct anatomical landmarks for registration. The authors sought to evaluate the practicality of performing stereotaxy in the anterior spine in a cadaveric model. METHODS: Unilateral C4-L4 pedicle screws were placed posteriorly in three cadaveric specimens to serve as unknown markers within each vertebral body. The specimens then underwent computerized tomography (CT) scanning, and the CT data were transferred to an optical tracking system. The anterior surface of the spine was registered for use with the stereotactic system by using a paired point-matching technique. Attached to a surgical drill, K-wires were placed under stereotactic guidance in a tip-to-tip orientation with the posterior pedicle screws. A second postoperative CT scan was obtained, and accuracy was determined by measuring the distance between the tips of the K-wire and pedicle screw. The K-wires were placed tip to tip with pedicle screw markers in 57 vertebral levels. The mean registration error was 1.47+/-0.04 mm, and when combined with the universal instrument registration error of 0.7 mm yielded an overall registration error of 2.17+/-0.04 mm. The mean tip-to-tip distance for all K-wires placed was 2.46+/-0.23 mm. The difference between the mean tip-to-tip distance and overall registration error was not statistically significant (p > 0.05), indicating that the K-wires were placed within the expected range of error. CONCLUSIONS: The results of this study confirmed the feasibility of performing anterior stereotactic procedures throughout the spine. The accuracy of the findings in this study indicates that anterior stereotaxy should be applicable in clinical practice.

Effect of frameless stereotaxy on the accuracy of C1-2 transarticular screw placement.

OBJECT: In recent studies some authors have indicated that 20% of patients have at least one ectatic vertebral artery (VA) that, based on previous criteria in which preoperative computerized tomography (CT) and standard intraoperative fluoroscopic techniques were used. may prevent the safe placement of C1-2 transarticular screws. The authors conducted this study to determine whether frameless stereotaxy would improve the accuracy of C1-2 transarticular screw placement in healthy patients, particularly those whom previous criteria would have excluded. METHODS: The authors assessed the accuracy of frameless stereotaxy for C1-2 transarticular screw placement in 17 cadaveric cervical spines. Preoperatively obtained CT scans of the C-2 vertebra were registered on a stereotactic workstation. The dimensions of the C-2 pars articularis were measured on the workstation, and a 3.5-mm screw was stereotactically placed if the height and width of the pars interarticularis was greater than 4 mm. The specimens were evaluated with postoperative CT scanning and visual inspection. Screw placement was considered acceptable if the screw was contained within the C-2 pars interarticularis, traversed the C 1-2 joint, and the screw tip was shown to be within the anterior cortex of the C-1 lateral mass. Transarticular screws were accurately placed in 16 cadaveric specimens, and only one specimen (5.9%) was excluded because of anomalous VA anatomy. In contrast, a total of four specimens (23.5%) showed significant narrowing of the C-2 pars interarticularis due to vascular anatomy that would have precluded atlantoaxial transarticular screw placement had previous nonimage-guided criteria been used. CONCLUSIONS: Frameless stereotaxy provides precise image guidance that improves the safety of C1-2 transarticular screw placement and potentially allows this procedure to be performed in patients previously excluded because of the inaccuracy of nonimage-guided techniques.

Effects of propofol on hippocampal synaptic transmission in behaving rats.

BACKGROUND: The action of propofol has been studied in vitro and in vivo, but the effects of intravenously administered propofol on synaptic transmission in freely behaving rats have not been studied before. METHODS: Rats were implanted with recording electrodes in the dentate gyrus and with stimulation electrodes in the medial perforant path (MPP). Paired pulses at different interpulse intervals (IPIs) were delivered to the MPP, and average evoked potentials were recorded in the dentate gyrus before and after a bolus of propofol (10 or 20 mg/kg administered intravenously) or control vehicle was injected via femoral vein cannula. Because of the layered structure of the hippocampus, population excitatory postsynaptic potentials and population spikes could be distinguished and analyzed. RESULTS: Propofol has no significant effect on the population excitatory postsynaptic potentials or population spike evoked by a single MPP stimulus pulse. However, paired-pulse inhibition of the dentate population spikes was increased at IPI of 20 and 30 ms. Paired-pulse inhibition of the population spike was most prominent when tail pinch response was lost (deep and moderate anesthesia), but it persisted during light anesthesia. At 200 ms IPI, paired-pulse facilitation of population spikes was observed during moderate anesthesia in most rats. CONCLUSIONS: In freely behaving rats, intravenous propofol enhanced paired-pulse inhibition at < 50 ms IPI, likely by enhancing gamma-aminobutyric acid A receptor-mediated inhibition. Propofol also increased paired-pulse facilitation at 200 ms IPI through an unknown mechanism, which may contribute to the neuroexcitatory effect of propofol.

Endoscopic thoracic sympathectomy.

OBJECT: Thoracic sympathectomy has evolved as a treatment option for patients with hyperhidrosis and pain disorders. In the past, surgical procedures were highly invasive and caused significant morbidity, but the minimally invasive thoracoscopic procedure provides detailed visualization of the sympathetic ganglia and is associated with minimal postoperative morbidity. METHODS: The authors performed 112 thoracoscopic sympathectomy procedures in 65 patients, and the outcomes were equivalent to those previously established for open surgical techniques; however, the rate of surgery-related morbidity, length of hospital stay, and time until return to normal activity were substantially reduced. Complications and recurrence of symptoms were comparable with those demonstrated in previous reports. Overall patient satisfaction and willingness to undergo a repeated operative procedure ranged from 66 to 99%. Postoperatively, higher satisfaction rates were observed in patients with hyperhidrosis whereas in those with pain syndromes, satisfaction rates were lower. CONCLUSIONS: Minimally invasive thoracoscopic sympathectomy procedures are useful in treating sympathetically mediated disorders, and the results indicate that the procedure is associated with reduced morbidity and similar outcome when compared with results obtained after open surgery. Hyperhidrosis is well treated, but patients with pain syndromes have significantly poorer outcomes.