Endoscopic Endonasal Approach to the Ventral Petroclival Fissure: Anatomical Findings and Surgical Techniques.

Objective The endoscopic endonasal approach has emerged as an excellent option for the treatment of lesions involving the petroclival fissure (PCF). Here, we investigate the surgical anatomy of the ventral PCF and its application in endoscopic endonasal surgery. Methods Sixteen head specimens were used to investigate the anatomical features of PCF and relevant technical nuances in translacerum, extreme medial, and contralateral transmaxillary (CTM) approaches. Two representative endoscopic endonasal surgeries involving the PCF were selected to illustrate the clinical application. Results From the endoscopic endonasal view, the ventral PCF is presented as a lazy L sign, which is divided into two distinct segments: (1) upper (or petrosphenoidal) segment, which extends vertically from the foramen lacerum inferiorly to the junction of the petrosal process of sphenoid bone and petrous apex superiorly, and (2) lower (or petroclival) segment, which extends inferolaterally from the foramen lacerum to the ventral jugular foramen. Approaching both segments of the ventral PCF first requires full exposure of the foramen lacerum, followed either by exposure of the anterior wall of cavernous sinus and paraclival internal carotid artery for upper segment access, or transection of pterygosphenoidal fissure and Eustachian tube mobilization for lower segment access. Combined with a CTM approach, the lateral extension of the surgical access can be improved for both upper and lower segment PCF approaches. Conclusion This study provides a detailed investigation of the microsurgical anatomy of the ventral part of PCF, relevant surgical approaches, and technical nuances that may facilitate its safe exposure intraoperatively.

Standard Orbitozygomatic Craniotomy versus Mini Orbitozygomatic Craniotomy via an Eyebrow Incision for Microsurgical Treatment of Anterior Communicating Artery Aneurysms.

Background Skull base approaches are utilized to improve microsurgical treatment of cerebral aneurysms. Advantages include early proximal and distal control, increased visualization, and minimal brain retraction. Orbitozygomatic (OZ) craniotomies via pterional incision are commonly used for the treatment of anterior communicating artery (ACoA) aneurysms. A smaller, less invasive OZ craniotomy performed through an eyebrow incision may provide several advantages over a standard OZ approach. Objective We compare surgical outcomes of the standard and eyebrow OZ for the treatment of ACoA aneurysms. Design All patients who underwent microsurgical treatment for ACoA aneurysms by a single surgeon over an 8-year period were included in this retrospective analysis. Patient demographics and clinical data were collected. Participants Thirty-seven consecutive patients were identified, with 15 receiving eyebrow OZ and 22 receiving standard OZ. Main Outcome Measures Data were collected on patient demographics, pathology, intraoperative and perioperative data, and 30-day morbidity. Results A total of 100% of the eyebrow OZ group and 95.5% of the standard OZ group had complete aneurysmal occlusion. Four eyebrow OZ and six standard OZ patients had an intraoperative rupture. All were managed without complication. Two eyebrow OZ and one standard OZ patient died within 30 days of surgery. No patients in either group had aneurysm recurrence, required retreatment, or were limited intraoperatively by exposure. Conclusions The OZ approach via an eyebrow incision has similar outcomes to a standard OZ approach and is a safe option for the treatment of ACoA aneurysms.

The impact of the Woven EndoBridge device on the treatment of anterior circulation wide-neck bifurcation aneurysms: a single-center experience.

OBJECTIVE: The paucity of literature comparing Woven EndoBridge (WEB) embolization to microsurgical clipping for anterior circulation wide-neck bifurcation aneurysms (WNBAs) underscores the need for further investigation into the optimal management of this patient subpopulation. The objective of this study was to compare the rate of endovascular and microsurgical treatment of WNBAs before and after the introduction of the WEB device. In addition, the authors performed a comparison of demographics, aneurysm characteristics, and treatment outcomes in patients before and after the introduction of the WEB device. METHODS: This study was a retrospective review of the usage rate of different treatment modalities for WNBAs before and after the WEB device was approved by the US FDA on September 27, 2018. RESULTS: The study cohort comprised 235 patients with anterior circulation WNBAs treated at the authors' institution, including 127 aneurysms treated pre-WEB and 108 treated post-WEB. Generally, the rate of endovascular treatment of anterior circulation WNBAs was significantly higher post-WEB (86.1% vs 46.5%, p < 0.001), while the rate of clipping was significantly lower (13.9% vs 53.5%, p < 0.001). During follow-up, the rate of adequate aneurysm occlusion (Raymond-Roy occlusion classification [RROC] grades 1 and 2) was nonsignificantly higher in the post-WEB cohort (83.9% vs 78.5%, p = 0.34), while the rate of RROC grade 3 was nonsignificantly higher in the pre-WEB cohort (21.5% vs 16.1%, p = 0.34). Additionally, and although nonsignificant, the rates of recurrence (pre-WEB 25.3% vs post-WEB 14.9%, p = 0.12) and retreatment (pre-WEB 22.8% vs post-WEB 14.9%, p = 0.22) were higher in the pre-WEB cohort. Recurrence was assessed before retreatment. CONCLUSIONS: After the introduction of the WEB device, the rate of endovascular treatment of WNBAs increased while the rate of microsurgical clipping decreased. It is essential for neurointerventionalists to become familiar with the indications, advantages, and shortcomings of all these different techniques to be able to match the right patient with the right technique to produce the best outcome.

Estimating Cognitive Workload Using Task-Related Pupillary Responses in Simulated Drilling in Cochlear Implantation.

OBJECTIVES: Training of temporal bone drilling requires more than mastering technical skills with the drill. Skills such as visual imagery, bimanual dexterity, and stress management need to be mastered along with precise knowledge of anatomy. In otorhinolaryngology, these psychomotor skills underlie performance in the drilling of the temporal bone for access to the inner ear in cochlear implant surgery. However, little is known about how psychomotor skills and workload management impact the practitioners' continuous and overall performance. METHODS: To understand how the practitioner's workload and performance unfolds over time, we examine task-evoked pupillary responses (TEPR) of 22 medical students who performed transmastoid-posterior tympanotomy (TMPT) and removal of the bony overhang of the round window niche in a 3D-printed model of the temporal bone. We investigate how students' TEPR metrics (Average Pupil Size [APS], Index of Pupil Activity [IPA], and Low/High Index of Pupillary Activity [LHIPA]) and time spent in drilling phases correspond to the performance in key drilling phases. RESULTS: All TEPR measures revealed significant differences between key drilling phases that corresponded to the anticipated workload. Enlarging the facial recess lasted significantly longer than other phases. IPA captured significant increase of workload in thinning of the posterior canal wall, while APS revealed increased workload during the drilling of the bony overhang. CONCLUSION: Our findings contribute to the contemporary competency-based medical residency programs where objective and continuous monitoring of participants' progress allows to track progress in expertise acquisition. Laryngoscope, 2024.

Resection of the tumor in the trigone of the lateral ventricle via the contralateral posterior interhemispheric transfalcine transprecuneus approach with multi-modern neurosurgery technology: a case report.

Choroid plexus papilloma (CPP) is a rare benign intracranial tumor origin that predominantly manifests in the lateral ventricle in children, accounting for 0.3%-0.6% of all primary intracranial tumors. It is extremely rare to have the CPP in the trigone of the lateral ventricle through the contralateral posterior interhemispheric transfalcine transprecuneus approach (PITTA). Herein, we report this rare case. A 7-year-old girl presented with headache. Magnetic resonance imaging of the brain showed periatrial lesions, and histopathological examination confirmed CPP (WHO grade I). The contralateral PITTA is a safe, effective, reasonable, and appropriate for some lesions in the trigone of the lateral ventricle. It provides a wider surgical angle (especially for the lateral extension) and reduces the risk of disturbance of the optic radiation compared with the conventional approaches. The use of multiple modern neurosurgical techniques, including interventional embolization, intraoperative navigation, microscope, and electrophysiological monitoring, make the procedure much easier and more accurate, and the neuroendoscope adds to the visualization of the microscope and can reduce surgical complications.

Haemorrhagic Complications After Microsurgical Treatment for Intracranial Aneurysms Under Acetylsalicylic Acid: An Impact Analysis.

BACKGROUND: Patients with intracranial aneurysms often have comorbidities that require them to take acetylsalicylic acid (ASA). In recent years, many patients with aneurysms have been prescribed ASA to prevent aneurysm enlargement. ASA is also prescribed to patients with intracranial aneurysms in preparation for surgical revascularization. METHODS: From 2016 to 2021, 64 patients underwent microsurgical aneurysm clipping without revascularization, and an additional 20 patients underwent extracranial to intracranial (EC-IC) bypass. The following parameters were analysed: the frequency of hemorrhagic complications, the blood loss volume, the duration of surgery and inpatient treatment, the change in hemoglobin level (Hb), hematocrit (Ht), erythrocytes, and clinical outcomes according to the modified Rankin scale (mRS). RESULTS: At the time of surgery, laboratory-confirmed effect of the ASA was registered in 22 patients (main group). In 42 patients, the ASA was not functional on assay (control group). Hemorrhagic complications were noted in two patients in the ASA group. In both cases, the hemorrhagic component did not exceed 15 ml in volume and did not require additional surgical interventions. Statistical analysis showed no significant differences in hemorrhagic postoperative complications. CONCLUSION: Taking low doses of acetylsalicylic acid during planned microsurgical clipping of cerebral aneurysms does not affect intraoperative blood loss volume, risk of postoperative hemorrhagic complications, length of stay in the hospital, or functional outcomes.

Complex Hand Reconstruction using a Novel Two-stage Temporary Ectopic Implantation of the Contralateral Upper Limb.

Ectopic transplantation of the hand remains a rare, innovative yet valuable operation in select cases of trauma and amputation. We aim to describe a novel technique of complex hand reconstruction using a two-stage ectopic implantation of the contralateral upper limb. A male patient with a near complete avulsion amputation of the right upper limb at the level of the mid-forearm and a crushing injury to his left hand was admitted after a farming accident. The right palm was ectopically transplanted to the left lower limb and both upper limbs underwent debridement with vacuum assisted dressings (VACs). There was eventual dieback of the left thumb, ring and little finger with a large palmar soft tissue defect that was eventually reconstructed using segments of the ectopically transplanted limb in two separate operations. The patient made an uneventful postoperative recovery and managed to regain protective sensation and gross motor function of his reconstructed hand.

Tailoring fenestrated aneurysm clips intraoperatively: Instant solution for a difficult problem.

The anterior communicating artery (AcoA) aneurysms represent the most complex aneurysms of the anterior circulation. For years, surgical challenges including the intricate anatomy and narrow surgical corridor have been overcome using supplementary techniques including extended craniotomies, wide opening of the cisterns, gyrus rectus resection and special clips like fenestrated clips. However, imaginative solutions such as intraoperative clip modification may be inevitable in particular cases for safe clipping. We retrospectively analyzed clinical records of two patients who required clip modification intraoperatively. Case #1 underwent microsurgical clipping of a ruptured, 4-mm AcoA aneurysm. Unfortunately, given the short distance between the two A2s, it was not possible to clip the aneurysm without a compromise to the contralateral A2 with the available shortest 3mm-fenestrated clip. We then used the clip modification technique intraoperatively by shortening the clip tips with mesh-plaque cutter and smoothening the remaining sharp ends using cautery sanding. Eventually, the aneurysm was clipped successfully with the modified-fenestrated clip. Post-clipping imagings confirmed complete occlusion of the aneurysm and patency of parent arteries. Case 2# underwent microsurgical clipping for a ruptured, 1-mm AcoA aneurysm. Like Case 1#, the initial clipping attempt with the available shortest 4mm-fenestrated clip failed given the excessive length of the tips. The patient, thus, required clip modification as described above. The aneurysm was then clipped successfully using the modified-fenestrated clip, protecting bilateral A2s. Post-clipping imagings demonstrated patency of parent arteries with no residual aneurysm filling. Clip modification seems to be an effective option in clipping the AcoA aneurysms when available clips are too long to secure them safely.

Lower limb salvage in necrotizing burn wound infection: The role of fibular ostectomy and local flaps in a resource-limited setting - A case report and literature review.

INTRODUCTION: Necrotizing burn wound infections following burn injuries are rare. Literature on these cases is also scarce. These infections are life- and limb- threatening unless properly managed. They also pose significant reconstructive challenge, especially in settings lacking microvascular capability. This report describes a limb preservation strategy for limb-threatening necrotizing infection of the leg that complicated a burn injury. Innovative approach was used, utilizing proximal fibular ostectomy, bipedicled local advancement flap and split thickness skin graft. CASE PRESENTATION: A 26-year-old female patient presented to our burn unit after sustaining a contact burn injury from a burning charcoal to her right lateral leg within three days. On the second day of admission, the patient developed significant changes in the appearance of the wound, leading to the diagnosis of necrotizing myofacitis. Emergent debridements were done with the aim of preserving the limb. Subsequent successful, albeit sub-optimal, reconstruction was also achieved despite the lack of microvascular surgical capability in the burn unit. DISCUSSION: This case report and literature review describes a rare limb-threatening necrotizing burn wound infection. The significant reconstructive challenge posed by the defect was addressed using a simple but rarely described reconstructive technique. The importance of limb preservation in LMIC is also emphasized. CONCLUSION: The goal of preserving a limb can be met by using a simple reconstructive technique, despite the lack of microvascular capabilities.

Microsurgical clipping versus endovascular therapy for treating patients with middle cerebral artery aneurysms presenting with neurological ischemic symptoms.

Studies comparing different treatment methods in patients with middle cerebral artery (MCA) aneurysms in different subgroups of onset symptoms are lacking. It is necessary to explore the safety and efficacy of open surgical treatment and endovascular therapy in patients with MCA aneurysms in a specific population. This study aimed to compare microsurgical clipping versus endovascular therapy regarding complication rates and outcomes in patients with MCA aneurysms presenting with neurological ischemic symptoms. This was a retrospective cohort study in which 9656 patients with intracranial aneurysms were screened between January 2014 and July 2022. Further, 130 eligible patients were enrolled. The primary outcome was the incidence of serious adverse events (SAEs) within 30 days of treatment, whereas secondary outcomes included postprocedural target vessel-related stroke, disabling stroke or death, mortality, and aneurysm occlusion rate. Among the 130 included patients, 45 were treated with endovascular therapy and 85 with microsurgical clipping. The primary outcome of the incidence of SAEs within 30 days of treatment was significantly higher in the clipping group [clipping: 23.5%(20/85) vs endovascular: 8.9%(4/45), adjusted OR:4.05, 95% CI:1.20-13.70; P = 0.024]. The incidence of any neurological complications related to the treatment was significantly higher in the clipping group [clipping:32.9%(28/85) vs endovascular:15.6%(7/45); adjusted OR:3.49, 95%CI:1.18-10.26; P = 0.023]. Postprocedural target vessel-related stroke, disabling stroke or death, mortality rate, and complete occlusion rate did not differ significantly between the two groups. Endovascular therapy seemed to be safer in treating patients with MCA aneurysms presenting with neurological ischemic symptoms compared with microsurgical clipping, with a significantly lower incidence of SAEs within 30 days of treatment and any neurological complications related to the treatment during follow-up.

Clinical, anatomical, and histological features of the rhomboid lip and considerations for surgery using a retrosigmoid approach: a retrospective study.

OBJECTIVE: The rhomboid lip is a neural tissue encountered during cerebellopontine angle surgery, with differing shape and extent among individuals. This study aimed to investigate the variation of rhomboid lips during posterior fossa surgery. METHODS: In this retrospective study, we examined posterior cranial fossa surgeries performed using a retrosigmoid approach. Rhomboid lips were classified according to thickness, extent, and appearance, with some subjected to histological analysis. T2-weighted magnetic resonance imaging (MRI) of rhomboid lips was conducted. RESULTS: Among 304 surgeries, rhomboid lips were observed in 75 patients who underwent schwannoma or meningioma resection, facial spasm-related neurovascular decompression, and other surgeries (37, 2, 32, and 4 patients, respectively). Rhomboid lips were categorized based on apparent thickness: thin membranous type, resembling an arachnoid membrane, and thick parenchymal type. Rhomboid lip extension was classified by position relative to the choroid plexus: non-extension, lateral extension, and jugular foramen (41, 22, and 12 patients, respectively). Veins were observed on the rhomboid lip surface in 37 cases. The rhomboid lip was visible in only one case (parenchymal jugular foramen type) on MRI. Histologically, the rhomboid lip comprised an ependymal cell layer, a glial layer, and connecting tissue. The glial layer thickness determined the rhomboid lip thickness, which was greater in the parenchymal type than in the membrane type. In 42 patients, the rhomboid lip was dissected, with no complications observed. CONCLUSIONS: Morphological classification of the rhomboid lip and understanding of its anatomical details contribute to safe surgical field development for neurosurgeons.

Effect of Laterality in Microsurgery: Comparative Study of an Expert and a Novice.

Background: Hand laterality has an impact on surgical gestures. In this study, we sought to measure the multi-parameter variability of the microsurgical gesture depending on the hand used and the differences between expert microsurgeons and novices. Methods: Ten experienced microsurgeons and twenty medical students with no prior microsurgical experience performed arterial anastomosis on a chicken wing artery using dominant and non-dominant hands. We measured time and force using a homemade force-sensing microsurgical needle holder, heart rate variability with a Polar H10 chest strap, anxiety with the STAI-Y questionnaire and anastomosis quality using the MARS 10 scale. Results: In the microsurgeons' group, duration of anastomosis (p = 0.037), force applied to the needle holder (p = 0.047), anxiety (p = 0.05) and MARS10 (p = 0.291) were better with the dominant hand. For novices, there was no difference between the dominant and non-dominant hand pertaining to force, time and stress level. There were no differences between microsurgeons and novices pertaining to force and anxiety using the non-dominant hand. Conclusions: The study highlighted a marked laterality among microsurgical experts, a finding that may be explained by current learning methods. Surprisingly, no laterality is observed in students, suggesting that for a specific gesture completely different from everyday tasks, laterality is not predefined. Ambidexterity training in the residency curriculum seems relevant and may help microsurgeons improve performance and postoperative outcomes.

Utilizing tubular retractors in colloid cyst resection: A single surgeon experience.

Background: Colloid cysts are intracranial lesions originating from abnormalities in the primitive neuroepithelium folding of the third ventricle. Various surgical approaches have been explored for the management of colloid cysts, each carrying its own set of advantages and limitations. Tubular retractors developed recently alleviate retraction pressure through radial distribution, potentially offering benefits for colloid cyst resection. This study aims to introduce and assess a modified microsurgical method utilizing the tubular retractor for addressing colloid cysts. Methods: The study included a retrospective assessment of patients who had colloid cysts and who were treated between 2015 and 2023 by one experienced surgeon. The demographic, clinical, radiological, histological, and surgical data regarding these patients were evaluated. The patients were assessed using the colloid cyst risk score, indicating a risk for obstructive hydrocephalus. Results: The minimally invasive microsurgical approach was successfully applied to all 22 identified patients. No postoperative surgical complications were reported. Gross total resection was achieved in 21 (95.5%) patients. The early complication rate was 22.7% (n = 5). There were no postoperative seizures, permanent neurological deficits, or venous injuries. The average hospital stay was 3 days. There was no evidence of recurrence at an average follow-up length of 25.9 months. Conclusion: The transtubular approach is an effective, safe method for treating colloid cysts. It achieves complete cyst removal with minimal complications, offering the benefits of less invasiveness, improved visualization, and reduced tissue disruption, strengthening its role in colloid cyst surgery.

The safety of perioperative antiplatelet continuation without selection biases in microsurgical decompression surgery for single level lumbar spinal stenosis and lumbar disc herniotomy.

PURPOSE: Each institution or physician has to decide on an individual basis whether to continue or discontinue antiplatelet (AP) therapy before spinal surgery. The purpose of this study was to determine if perioperative AP continuation is safe during single-level microsurgical decompression (MSD) for treating lumbar spinal stenosis (LSS) and lumbar disc hernia (LDH) without selection bias. METHODS: Patients who underwent single-level MSD for LSS and LDH between April 2018 to December 2022 at our institute were included in this retrospective study. We collected data regarding baseline characteristics, medical history/comorbidities, epidural hematoma (EDH) volume, reoperation for EDH, differences between preoperative and one-day postoperative blood cell counts (ΔRBC), hemoglobin (ΔHGB), and hematocrits (ΔHCT), and perioperative thromboembolic complications. Patients were divided into two groups: the AP continuation group received AP treatment before surgery and the control group did not receive antiplatelet medication before surgery. Propensity scores for receiving AP agents were calculated, with one-to-one matching of estimated propensity scores to adjust for patient baseline characteristics and past histories. Reoperation for EDH, EDH volume, ΔRBC, ΔHGB, ΔHCT, and perioperative thromboembolic complications were compared between the groups. RESULTS: The 303 enrolled patients included 41 patients in the AP continuation group. After propensity score matching, the rate of reoperation for EDH, the EDH volume, ΔRBC, ΔHGB, ΔHCT, and perioperative thromboembolic complication rates were not significantly different between the groups. CONCLUSION: Perioperative AP continuation is safe for single-level lumbar MSD, even without biases.

The safety and clinical outcomes of endovascular treatment versus microsurgical clipping of ruptured anterior communicating artery aneurysms: a 2-year follow-up, multicenter, observational study.

Background and objective: Current data on the optimal treatment modality for ruptured anterior communicating artery (AComA) aneurysms are limited. We conducted this multicenter retrospective study to evaluate the safety and clinical outcomes of endovascular treatment (EVT) and microsurgical clipping (MC) for the treatment of ruptured AComA patients. Methods: Patients with ruptured AComA aneurysms were screened from the Chinese Multicenter Cerebral Aneurysm Database. Propensity score matching (PSM) was used to adjust for baseline characteristic imbalances between the EVT and MC groups. The safety outcomes included total procedural complications, procedure-related morbidity/death and remedial procedure for complication. The primary clinical outcome was 2-year functional independence measured by the modified Rankin scale (mRS) score. Results: The analysis included 893 patients with ruptured AComA aneurysms (EVT: 549; MC: 346). PSM yielded 275 pairs of patients in the EVT and MC cohorts for comparison. Decompressive craniectomy being more prevalent in the MC group (19.3% vs. 1.5%, p < 0.001). Safety data revealed a lower rate of total procedural complications (odds ratio [OR] = 0.62, 95% CI 0.39-0.99; p = 0.044) in the EVT group and similar rates of procedure-related morbidity/death (OR = 0.91, 95% CI 0.48-1.73; p = 0.880) and remedial procedure for complication (OR = 1.35, 95% CI 0.51-3.69, p = 0.657) between the groups. Compared with that of MC patients, EVT patients had a greater likelihood of functional independence (mRS score 0-2) at discharge (OR = 1.68, 95% CI 1.14-2.50; p = 0.008) and at 2 years (OR = 1.89, 95% CI 1.20-3.00; p = 0.005), a lower incidence of 2-year all-cause mortality (OR = 0.54, 95% CI 0.31-0.93; p = 0.023) and a similar rate of retreatment (OR = 1.00, 95% CI 0.23-4.40; p = 1.000). Conclusion: Clinical outcomes after treatment for ruptured AComA aneurysms appear to be superior to those after treatment with MC, with fewer overall procedure-related complications and no increase in the retreatment rate. Additional studies in other countries are needed to verify these findings.

Influence of the sagittal spinal profile type on the long-term outcome of patients with symptomatic lumbar spinal stenosis after microsurgical decompression.

OBJECTIVE: Microsurgical decompression for patients with symptomatic lumbar spinal stenosis (LSS) has demonstrated long-term improvement concerning pain and function. Nonetheless, a considerable proportion of these patients do not experience satisfactory alleviation of symptoms. Previous studies have not found a direct influence of single sagittal parameters on patient outcomes. However, recent research indicates that a composite of parameters, presented in specific sagittal profile types (SPTs) that were defined by Roussouly and colleagues, may affect these outcomes. This study aims to investigate the impact of SPT on long-term outcomes of patients with LSS following microsurgical decompression. METHODS: This study is a prospective clinical observation. Patients with symptomatic LSS, who underwent microsurgical treatment and had long-term follow-up data for at least 36 months, were included. Patients with spinal deformity, fractures, or significant instability were excluded. Outcomes were measured using the numeric rating scale for pain, 36-Item Short Form Health Survey for quality of life, walking distance, Oswestry Disability Index, Roland-Morris Disability Questionnaire, and Odom's criteria. SPT was determined in blinded fashion by using preoperative long standing radiographs. RESULTS: The initial population of this observational study consisted of 128 patients, with long-term results available for 87 individuals, including 24 patients with SPT1, 20 with SPT2, 27 with SPT3, and 16 with SPT4. The average age was 70 years, with a slight male majority (56.3%) and a mean BMI of 27.9 kg/m2. After a median follow-up of 48 months, all groups showed significant improvement in walking distance, leg pain, and disability. Overall, 75% reported satisfaction with the surgery. However, patients with SPT1, which is characterized by low sacral slope and specific spinal curvatures, experienced significantly less improvement in back pain (p = 0.018) and related disability (p = 0.030), and lower satisfaction compared to other SPT groups (p = 0.008). CONCLUSIONS: The sagittal spinal type is influencing the long-term outcome of patients suffering from symptomatic LSS. Patients with a combination of a flat sacral slope and a low overall lumbar lordosis with a high lordosis in the lower lumbar spine (i.e., spinal SPT1) showed worse outcome concerning back pain and had decreased satisfaction with surgery than comparable subjects from other SPT groups. Consequently, the authors recommend the assessment of sagittal spinal types in patients diagnosed with symptomatic spinal stenosis prior to decompression surgery. Inclusion of SPT in the preoperative consultation process can provide valuable insights, potentially guiding practitioners to more tailored patient counseling.

[Comparative analysis of the results of microdiscectomy and minimally invasive transforaminal lumbar interbody fusion in the treatment of adjacent-level intervertebral disc herniations with lumbosacral transitional vertebra in elderly patients.]

The purpose of the study was a comparative analysis the effectiveness of microsurgical discectomy and minimally invasive transforaminal lumbar interbody fusion in the treatment of disk herniation adjacent to the anomaly of the lumbosacral junction segment in elderly patients. The study included 80 elderly patients (over 60 years old), divided into two groups: the 1st-(n=39) who underwent microsurgical discectomy; the 2nd- patients (n=41) operated on using minimally invasive transforaminal interbody fusion and percutaneous transpedicular stabilization (MI-TLIF). For the comparative analysis, we used gender characteristics (gender, age), constitutional characteristics (BMI), degree of physical status according to ASA, intraoperative parameters of interventions and the specificity of postoperative patient management, clinical data, and the presence of complications. Long-term outcomes were assessed at a minimum follow-up of 3 years. As a result, it was found that the use of MI-TLIF allows achieving better long-term clinical outcomes, fewer major complications in comparison with the microsurgical discectomy technique in the treatment of disc herniation adjacent to the anomaly of the lumbosacral junction segment in elderly patients.

Totally extraperitoneal laparoscopy-assisted microsurgical vasovasostomy for the treatment of obstructive azoospermia caused by pediatric bilateral inguinal herniorrhaphy.

BACKGROUND: Pediatric inguinal hernia repair (IHR) is a common cause of obstructive azoospermia (OA). Yet, the surgical treatment for this kind of OA remains difficult with poor fertility outcome. OBJECTIVES: To evaluate the safety and effectiveness of totally extraperitoneal laparoscopy-assisted microsurgical vasovasostomy (VV) in the treatment of OA caused by pediatric bilateral IHR. MATERIALS AND METHODS: Totally, 37 patients with OA caused by pediatric bilateral IHR were enrolled in this study from March 2015 to December 2020 in Shanghai General Hospital. The clinical data and fertility outcomes were collected and analyzed. RESULTS: All patients enrolled had a history of bilateral IHR at the age of 1-10 years old. The mean age of patients was 27 ± 4.31 (range: 18-35) years. Totally extraperitoneal laparoscopy (TEP) was applied in 31 patients for the exploration and retrieval of pelvic vas deferens end, and 30 of them underwent microsurgical VV successfully. Among the six cases where TEP was not applied, five cases underwent microsurgical anastomosis. Intraoperative exploration revealed that the location of vas deferens injuries included scrotum (2.70%, 1/37), inguinal canal (5.41%, 2/37), pelvic cavity (78.37%, 29/37), and multiple sites (13.51%, 5/37). The mean operation time was 339 ± 96.73 min (range: 130-510 min). There were no surgical complications. Thirty-three cases were followed up for 5-48 months with four cases lost to follow-up. The overall patency rate, pregnancy rate, and natural pregnancy rate were 75.86% (22/29), 46.67% (14/30), and 36.84% (7/19, 3 patients without family planning), respectively. And seven couples conceived through the assisted reproductive technique, two of which using fresh sperm in the ejaculate. CONCLUSION: TEP laparoscopy-assisted microscopic VV is an effective treatment for patients with OA caused by pediatric bilateral IHR.

Anterior Choroidal Artery Aneurysm Clipping: Angiographic Diagnostics and Surgical Tactics Focused on Visualizing the Anterior Choroidal Artery Behind the Aneurysm.

OBJECTIVE: This study describes our experiences with anterior choroidal artery (AChA) aneurysm clipping with a focus on visualizing the AChA just behind the aneurysm to identify the risk factors for adhesion of the AChA or its branches to the posterior wall of the AChA aneurysm. METHODS: The initial segment of the AChA just behind the aneurysm was evaluated preoperatively using three-dimensional (3D) rotational angiography, and its course was designated as posteromedial, posterior, or posterolateral. The posterior aspect of the AChA aneurysm was inspected intraoperatively using an endoscope or micromirror. RESULTS: Based on 3D rotational angiography, the main trunk of the AChA showed a posteromedial (n = 47, 57.3%), posterior (n = 18, 22.0%), or posterolateral (n = 17, 20.7%) course just behind the aneurysm. Intraoperatively, 14.6% (12 of 82) of the clipped AChA aneurysms revealed an AChA branch adhered to the posterior wall of the aneurysm. A multivariate analysis revealed that the posterior or posterolateral course of the initial segment of the AChA was a statistically significant risk factor for adhesion of an AChA branch to the posterior wall of the aneurysm (odds ratio [OR] 21.083, 95% confidence interval [CI] 2.567-173.166, P = 0.005). CONCLUSIONS: The initial course of the AChA just behind an AChA aneurysm can be evaluated using 3D rotational angiography. In contrast to a posteromedial course, a posterior or posterolateral course of the AChA just behind an AChA aneurysm can be a significant risk factor for adhesion of an AChA branch to the posterior wall of an AChA aneurysm.