Spare parts neoumbilicoplasty.

Umbilical preservation can be challenging, particularly in complex cases involving simultaneous ventral hernia repair and abdominoplasty. Although the umbilicus serves no functional purpose, removal of the umbilicus can draw unwanted attention to the abdominal area and can cause emotional distress to patients. There are several well documented options for umbilical reconstruction. We present a new umbilical reconstruction technique relevant for such cases. This neoumbilicoplasty allows for preservation of the original umbilicus with relocation and reconstruction using local flaps. The technique is relatively simple and the time needed is minimal. The result is a natural, well positioned umbilicus using the principles of spare part surgery.

Avoiding Complications in Gigantomastia.

Gigantomastia is a disabling condition for patients and presents unique challenges to plastic surgeons. Presentation can occur throughout different phases of life, and treatment often begins with nonoperative measures; however, the most effective way to relieve symptoms is surgical breast reduction. Because of the large amount of tissue removed, surgeons can encounter different intraoperative and postoperative complications. By understanding this disease process and these complications, surgeons can attempt to minimize their occurrences. The authors present an overview of the cause, preoperative evaluation, techniques, and outcomes. Additionally, they present outcomes data from their center on 40 patients.

Current Status and Challenges of Laparoscopy in Ventral Hernia Repair.

Laparoscopic repair of ventral hernias gained strong popularity in the late nineties with some of the early enthusiasm lost later in time. We review the current status and challenges of laparoscopy in ventral hernia repair and best practices in this area. We specifically looked at patient and hernia defect factors, technical considerations that have contributed to the successes, and some of the failures of laparoscopic ventral hernia repair (LVHR). Patients best suited for a laparoscopic repair are those who are obese and diabetic with a total defect size not to exceed 10 cm in width or a "Swiss cheese" defect. Overlap of mesh to healthy fascia of at least 5 cm in every direction, with closure of the defect, is essential to prevent recurrence or bulging over time. Complications specifically related to surgical site occurrence favor the laparoscopic approach. Recurrence rates, satisfaction, and health-related quality of life results are similar to open repairs, but long-term data are lacking. There is still conflicting data regarding ways of fixating the mesh. The science of prosthetic material appropriate for intraperitoneal placement continues to evolve. The field continues to be plagued by single author, single institution, and small nonrandomized observational studies with short-term follow-up. The recent development of large prospective databases might allow for pragmatic and point-of-care studies with long-term follow-up. We conclude that LVHR has evolved since its inception, has overcome many challenges, but still needs better long-term studies to evaluate evolving practices.

Segmental and global lordosis changes with two-level axial lumbar interbody fusion and posterior instrumentation.

BACKGROUND: Loss of lumbar lordosis has been reported after lumbar interbody fusion surgery and may portend poor clinical and radiographic outcome. The objective of this research was to measure changes in segmental and global lumbar lordosis in patients treated with presacral axial L4-S1 interbody fusion and posterior instrumentation and to determine if these changes influenced patient outcomes. METHODS: We performed a retrospective, multi-center review of prospectively collected data in 58 consecutive patients with disabling lumbar pain and radiculopathy unresponsive to nonsurgical treatment who underwent L4-S1 interbody fusion with the AxiaLIF two-level system (Baxano Surgical, Raleigh NC). Main outcomes included back pain severity, Oswestry Disability Index (ODI), Odom's outcome criteria, and fusion status using flexion and extension radiographs and computed tomography scans. Segmental (L4-S1) and global (L1-S1) lumbar lordosis measurements were made using standing lateral radiographs. All patients were followed for at least 24 months (mean: 29 months, range 24-56 months). RESULTS: There was no bowel injury, vascular injury, deep infection, neurologic complication or implant failure. Mean back pain severity improved from 7.8±1.7 at baseline to 3.3±2.6 at 2 years (p < 0.001). Mean ODI scores improved from 60±15% at baseline to 34±27% at 2 years (p < 0.001). At final follow-up, 83% of patients were rated as good or excellent using Odom's criteria. Interbody fusion was observed in 111 (96%) of 116 treated interspaces. Maintenance of lordosis, defined as a change in Cobb angle ≤ 5°, was identified in 84% of patients at L4-S1 and 81% of patients at L1-S1. Patients with loss or gain in segmental or global lordosis experienced similar 2-year outcomes versus those with less than a 5° change. CONCLUSIONS/CLINICAL RELEVANCE: Two-level axial interbody fusion supplemented with posterior fixation does not alter segmental or global lordosis in most patients. Patients with postoperative change in lordosis greater than 5° have similarly favorable long-term clinical outcomes and fusion rates compared to patients with less than 5° lordosis change.

Clinical and radiographic outcomes with L4-S1 axial lumbar interbody fusion (AxiaLIF) and posterior instrumentation: a multicenter study.

INTRODUCTION: Previous studies have confirmed the benefits and limitations of the presacral retroperitoneal approach for L5-S1 interbody fusion. The purpose of this study was to determine the safety and effectiveness of the minimally invasive axial lumbar interbody approach (AxiaLIF) for L4-S1 fusion. METHODS: In this retrospective series, 52 patients from four clinical sites underwent L4-S1 interbody fusion with the AxiaLIF two-level system with minimum 2-year clinical and radiographic follow-up (range: 24-51 months). Outcomes included back pain severity (on a 10-point scale), the Oswestry Disability Index (ODI), and Odom's criteria. Flexion and extension radiographs, as well as computed tomography scans, were evaluated to determine fusion status. Longitudinal outcomes were assessed with repeated measures analysis of variance. RESULTS: Mean subject age was 52 ± 11 years and the male:female ratio was 1:1. Patients sustained no intraoperative bowel or vascular injury, deep infection, or neurologic complication. Median procedural blood loss was 220 cc and median length of hospital stay was 3 days. At 2-year follow-up, mean back pain had improved 56%, from 7.7 ± 1.6 at baseline to 3.4 ± 2.7 (P < 0.001). Back pain clinical success (ie, ≥30% improvement from baseline) was achieved in 39 (75%) patients at 2 years. Mean ODI scores improved 42%, from 60% ± 16% at baseline to 35% ± 27% at 2 years (P < 0.001). ODI clinical success (ie, ≥30% improvement from baseline) was achieved in 26 (50%) patients. At final follow-up, 45 (87%) patients were rated as good or excellent, five as fair, and two as poor by Odom's criteria. Interbody fusion observed on imaging was achieved in 97 (93%) of 104 treated interspaces. During follow-up, five patients underwent reoperation on the lumbar spine, including facet screw removal (two), laminectomy (two), and transforaminal lumbar interbody fusion (one). CONCLUSION: The AxiaLIF two-level device is a safe, effective treatment adjunct for patients with L4-S1 disc pathology resistant to conservative treatments.

Chest X-ray after tracheostomy is not necessary unless clinically indicated.

BACKGROUND: Chest radiography is routinely used post-tracheostomy to evaluate for complications. Often, the chest X-ray findings do not change clinical management. The present study was conducted to evaluate the utility of post-tracheostomy X-rays. METHOD: This retrospective review of 255 patients was performed at a single-center, university, level I trauma center. All patients underwent tracheostomy and were evaluated for postprocedure complications. RESULTS: Of the 255 patients, 95.7% had no change in postprocedure chest X-ray findings. New significant chest X-ray findings were found in 4.3% of patients, including subcutaneous emphysema, pneumothorax, and new significant consolidation. Only three of these patients required change in clinical management, and all changes were based on clinical presentation alone. CONCLUSIONS: Routine chest X-ray following tracheostomy fails to provide additional information beyond clinical examination. Therefore radiographic examination should be performed only after technically difficult procedures or if the patient experiences clinical deterioration. Significant cost savings and minimization of radiation exposure can be achieved when chest radiography after tracheostomy is performed exclusively for clinical indications.

Anatomic variation of the optic strut: classification schema, radiologic evaluation, and surgical relevance.

Objective Anatomic variability of the optic strut in location, orientation, and dimensions is relevant in approaching ophthalmic artery aneurysms and tumors of the anterior cavernous sinus, medial sphenoid wing, and optic canal. Methods In 84 dry human skulls, imaging studies were performed (64-slice computed tomography [CT] scanner, axial view, aligned with the zygomatic arch). Optic strut location related to the prechiasmatic sulcus was classified as presulcal, sulcal, postsulcal, and asymmetric. Morphometric analysis was performed. Results The optic strut was presulcal in 11.9% specimens (posteromedial margin bilaterally anterior to limbus sphenoidale), sulcal in 44% (posteromedial part adjacent to the sulcus's anterior two thirds bilaterally), postsulcal in 29.8% (posteromedial margin posterior to the sulcus's anterior two thirds), and asymmetric (left/right) in 14.3%. Optic strut length, width, and thickness measured 6.54 ± 1.69 mm, 4.23 ± 0.69 mm, and 3.01 ± 0.79 mm, respectively. Optic canal diameter was 5.14 ± 0.47 mm anteriorly and 4.79 ± 0.64 mm posteriorly. Angulation was flat (>45 degrees) in 13% or acute (<45 degrees) in 87% specimens. Conclusions Anatomical variations in the optic strut are significant in planning for anterior clinoidectomy and optic-canal decompression. Our optic strut classification considers these variations relative to the prechiasmatic sulcus on preoperative imaging.

Endovascular repair of a blunt abdominal aortic injury.

Blunt abdominal aortic injury is an uncommon traumatic finding. In the past, treatment options have traditionally consisted of open operative repair; however, the development of endovascular surgery has created new interventional possibilities. This case is presented to demonstrate the applications of endovascular abdominal aortic repair for a blunt traumatic injury.

Retrospective analysis of L5-S1 axial lumbar interbody fusion (AxiaLIF): a comparison with and without the use of recombinant human bone morphogenetic protein-2.

BACKGROUND CONTEXT: Since approval by the Food and Drug Administration in 2002, use of recombinant human bone morphogenetic protein-2 (rhBMP-2) to promote spinal fusion is increasing. PURPOSE: In this comparative analysis, the authors assess fusion rates and clinical outcomes of patients who underwent a presacral axial lumbar interbody fusion (AxiaLIF) (TranS1 Inc., Wilmington, NC, USA) at L5-S1 with posterior instrumentation, with or without rhBMP-2. STUDY DESIGN: Retrospective case-matched chart review. PATIENT SAMPLE: A matched cohort of 99 patients underwent fusion performed by two surgeons at two institutions (2005-2007): Specifically, 45 patients at The Christ Hospital received rhBMP-2 and 54 patients at the University of Pittsburgh had no rhBMP-2. OUTCOME MEASURES: Pre- and postoperative visual analog scale (VAS) scores were recorded, as was physiologic data on fusion rates, blood loss, and length of stay. Preoperative and postoperative Oswestry Disability Index (ODI) scores were obtained for patients treated with rhBMP-2. Odom's outcome criteria were obtained at 2-year follow-up for patients without rhBMP-2. METHODS: Data were collected prospectively. Demographic data, including sex and age, were matched. RESULTS: During the 2-year follow-up period, patients noted reduction in back pain and improved functional outcome measures. The most rapid reduction in VAS pain scores and improvement in ODI occurred within the first 3 months after surgery. Mean pre- and postoperative VAS scores improved 59% from 72.9 to 30.1 with rhBMP-2 and 72% from 81.3 to 22.6 without rhBMP-2. In rhBMP-2-treated patients, mean ODI scores were 54.4% preoperatively and 23.7% postoperatively, a 56.4% improvement at 2 years. In the non-rhBMP-2 patients, 80% reported excellent to good results using Odom criteria. Fusion rates were 96% with rhBMP-2 and 93% without rhBMP-2. Operative blood loss averaged 82 cm(3) with and less than 50 cm(3) without rhBMP-2. No differences in hospital length of stay were noted between the two groups or in the fusion rates with pedicle screws or facet screws. No major complications occurred with or without rhBMP-2. CONCLUSIONS: In our case-matched series, clinical outcomes were similar for patients who underwent an AxiaLIF L5-S1 interbody fusion with or without rhBMP-2. The data strongly suggest that there is a high confidence for no effect on fusion rate by using rhBMP-2.

Minimally invasive axial presacral L5-S1 interbody fusion: two-year clinical and radiographic outcomes.

STUDY DESIGN: Retrospective case series. OBJECTIVE: The primary aim of this study was to evaluate and report the 2-year clinical and radiographic outcomes associated with a L5-S1 interbody fusion procedure that employs an axial presacral surgical approach. SUMMARY OF BACKGROUND DATA: There are a number of lumbar interbody fusion procedures used to treat painful, degenerated discs. However, despite their procedural differences (e.g., anterior vs. posterior), all of the current surgical approaches are undertaken in the same anatomical plane that requires disruption of musculoligamentous and osseous support structures as well as vascular and neurologic tissue to gain access the intervertebral disc space. The presacral procedure is distinct in that it uses an approach along an axis essentially perpendicular to the anatomical plane of traditional fusion procedures. METHODS: One hundred fifty-six patients from four clinical sites were selected for inclusion if they underwent a L5-S1 interbody fusion via the presacral approach with the AxiaLIF system (TranS1, Wilmington, NC) and had both presurgical and 2-year radiographic or clinical follow-up. Back pain and functional impairment were evaluated with an 11-point numeric scale and the Oswestry Disability Index (ODI), respectively, preoperatively and at 2 years. Standard radiographic imaging techniques were used to determine fusion status. RESULTS: Marked clinical improvements were realized in back pain severity and functional impairment through 2 years of follow-up. Mean pain scores improved from 7.7 ± 1.6 (n = 155) preoperatively to 2.7 ± 2.4 (n = 148) at 24 months, reflecting an approximate 63% overall improvement (P < 0.001). Mean ODI scores improved from 36.6 ± 14.6% (n = 86) preoperatively to 19.0 ± 19.2% (n = 78) at 24 months, or approximately 54% (P < 0.001). Two-year clinical success rates on the basis of change relative to baseline of at least 30% were 86% (127 of 147) and 74% (57 of 77) for pain and function, respectively. The overall radiographic fusion rate at 2 years was 94% (145 of 155). CONCLUSION: Findings from this clinical series of patients treated with a presacral interbody fusion procedure, stabilized with the AxiaLIF rod, reflect favorable and durable outcomes through 2 years of follow-up.

Case Report: Successful non-operative management of spontaneous splenic rupture in a patient with babesiosis.

BACKGROUND: Babesiosis is a zoonotic disease transmitted by the Ixodes tick species. Infection often results in sub-clinical manifestations; however, patients with this disease can become critically ill. Splenic rupture has been a previously reported complication of babesiosis, but treatment has always led to splenectomy. Asplenia places a patient at greater risk for overwhelming post-splenectomy infection from encapsulated bacteria, Lyme disease, Ehrlichia as well as Babesia microti. Therefore, avoiding splenectomy in these patients must be considered by the physician; particularly, if the patient is at risk for re-infection by living in an endemic area. CASE PRESENTATION: A 54 year-old male from the northeast United States presented with left upper quadrant abdominal pain associated with fever, chills, night sweats and nausea. A full evaluation revealed active infection with Babesia microti and multiple splenic lacerations. This patient was successfully treated with appropriate pharmacological therapy and non-operative observation for the splenic injury. CONCLUSION: Patients diagnosed with Babesia microti infection are becoming more common, especially in endemic areas. Although clinical manifestations are usually minimal, this infection can present with significant injuries leading to critical illness. We present the successful non-operative treatment of a patient with splenic rupture due to babesiosis infection.

Anatomic study of the prechiasmatic sulcus and its surgical implications.

To address a lack of anatomical descriptions in the literature regarding the prechiasmatic sulcus, we conducted an anatomical study of this sulcal region and discuss its clinical relevance to cranial base surgery. Our systematic morphometric analysis includes the variable types of chiasmatic sulcus and a classification schema that has surgical implications. We examined the sulcal region in 100 dry skulls; bony relationships measured included the interoptic distance, sulcal length/width, planum sphenoidale length, and sulcal angle. The varied anatomy of the prechiasmatic sulcii was classified as four types in combinations of wide to narrow, steep to flat. Its anterior border is the limbus sphenoidale at the posterior aspect of the planum sphenoidale. The sulcus extends posteriorly to the tuberculum sellae and laterally to the posteromedial aspect of each optic strut. Averages included an interoptic distance (19.3 +/- 2.4 mm), sulcal length (7.45 +/- 1.27 mm), planum sphenoidale length (19 +/- 2.35 mm), and sulcal angle (31 +/- 14.2 degrees). Eighteen percent of skulls had a chiasmatic ridge, a bony projection over the chiasmatic sulcus. The four types of prechiasmatic sulcus in our classification hold potential surgical relevance. Near the chiasmatic ridge, meningiomas may be hidden from the surgeon's view during a subfrontal or pterional approach. Preoperative evaluation by thin-cut CT scans of this region can help detect this ridge.

Presacral retroperitoneal approach to axial lumbar interbody fusion: a new, minimally invasive technique at L5-S1: Clinical outcomes, complications, and fusion rates in 50 patients at 1-year follow-up.

BACKGROUND: The presacral retroperitoneal approach to an axial lumbar interbody fusion (ALIF) is a percutaneous, minimally invasive technique for interbody fusion at L5-S1 that has not been extensively studied, particularly with respect to long-term outcomes. OBJECTIVE: The authors describe clinical and radiographic outcomes at 1-year follow-up for 50 consecutive patients who underwent the presacral ALIF. METHODS: Our patients included 24 males and 26 females who underwent the presacral ALIF procedure for interbody fusion at L5-S1. Indications included mechanical back pain and radiculopathy. Thirty-seven patients had disc degeneration at L5-S1, 7 had previously undergone a discectomy, and 6 had spondylolisthesis. A 2-level L4-S1 fusion was performed with a transforaminal lumbar interbody fusion at L4-5 in 15 patients. AxiaLIF was performed as a stand-alone procedure in 5 patients and supplemented with pedicle screws in 45 patients. Pre- and postoperative visual analog scale (VAS) and Oswestry Disability Index (ODI) scores were evaluated and complications were tracked. Fusion was evaluated by an independent neuro-radiologist. RESULTS: At 1-year follow-up, VAS and ODI scores had significantly improved by 49% and 50%, respectively, versus preoperative scores. By high-resolution computer tomography (CT) scans, fusion was achieved in 44 (88%) patients, developing bone occurred in 5 (10%), and 1 (2%) patient had pseudoarthrosis. One patient suffered a major operative complication-a bowel perforation with a pre-sacral abscess that resolved with treatment. CONCLUSION: Our initial 50 patients who underwent presacral ALIF showed clinical improvement and fusion rates comparable with other interbody fusion techniques; its safety was reflected by low complication rates. Its efficacy in future patients will continue to be monitored, and will be reported in a 2-year follow-up study of fusion.

Extraforaminal lumbar disc herniations: microsurgical anatomy and surgical approach.

OBJECT: Familiarity with the microsurgical anatomy of the far-lateral compartment is essential for operating in patients with far-lateral discs. In this report the authors address the microsurgical anatomy studied in 24 extraforaminal lumbar disc spaces in three cadavers. METHODS: Cadaveric dissections confirmed the authors' operative experience in which they found an arterial arcade to be associated with the nerve trunk. The main trunk of the lumbar artery was located lateral to the exiting nerve root in the region of intervertebral foramen. The trunk of the lumbar spinal nerve descending from the level above was 7 mm (+/- 3 mm [standard deviation]) lateral to the lumbar artery. CONCLUSIONS: Clarification of the microsurgical anatomy of the far-lateral compartment confirmed the authors' clinical impression that the optimum approach to far-lateral discs is via the inferomedial quadrant of the extraforaminal compartment. In this quadrant, exposure of the main nerve root can be facilitated by dividing the posterior primary ramus and a newly described arterial arcade that envelops the nerve trunk. Once this arcade is divided, the nerve can be retracted with relative ease and safety, and the disc can be removed more easily.