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Open access

Decompression of the internal auditory canal via the retrosigmoid approach in a patient with Camurati-Engelmann disease: illustrative case

Salah-Eddine Achahbar, Thomas Somers, and Tony Van Havenbergh

BACKGROUND

Camurati-Engelmann disease (CED) is a rare condition characterized by hyperostosis of the long bones and skull base. Symptoms include contractures and pain in affected extremities but can also include manifestations of cranial hyperostosis such as intracranial hypertension, Chiari malformation, exophthalmia, frontal bossing, and several cranial neuropathies due to cranial foraminal stenosis.

OBSERVATIONS

This report describes a 27-year-old patient with suspected CED who developed progressive intermittent facial nerve paresis, hemifacial spasms, and a decrease in hearing. There were no symptoms of increased intracranial pressure or vertigo. Radiological evaluation showed a significant thickening of the skull base with serious bilateral internal auditory canal stenosis. Because of the progressive nature of the aforementioned cranial neuropathies in combination with the correlating severe radiological compression, a surgical decompression of the facial nerve and vestibulocochlear nerve was performed via a retrosigmoid approach with intraoperative monitoring. Postoperative facial nerve function was intact. Hearing and vestibular function were unchanged. There were no more episodes of facial nerve palsy or spasm.

LESSONS

To the authors’ knowledge, this is the first report to describe decompression of the internal auditory canal via a retrosigmoid approach for symptomatic facial and cochlear nerve compression in a patient with CED.

Open access

A modern multidisciplinary approach to a large cervicothoracic chordoma using staged en bloc resection with intraoperative image-guided navigation and 3D-printed modeling: illustrative case

Nathan J. Pertsch, Owen P. Leary, Joaquin Q. Camara-Quintana, David D. Liu, Tianyi Niu, Albert S. Woo, Thomas T. Ng, Adetokunbo A. Oyelese, Jared S. Fridley, and Ziya L. Gokaslan

BACKGROUND

Cervicothoracic junction chordomas are uncommon primary spinal tumors optimally treated with en bloc resection. Although en bloc resection is the gold standard for treatment of mobile spinal chordoma, tumor location, size, and extent of involvement frequently complicate the achievement of negative margins. In particular, chordoma involving the thoracic region can require a challenging anterior access, and en bloc resection can lead to a highly destabilized spine.

OBSERVATIONS

Modern technological advances make en bloc resection more technically feasible than ever before. In this case, the successful en bloc resection of a particularly complex cervicothoracic junction chordoma was facilitated by a multidisciplinary surgical approach that maximized the use of intraoperative computed tomography–guided spinal navigation and patient-specific three-dimensional–printed modeling.

LESSONS

The authors review the surgical planning and specific techniques that facilitated the successful en bloc resection of this right-sided chordoma via image-guided parasagittal osteotomy across 2 stages. The integration of emerging visualization technologies into complex spinal column tumor management may help to provide optimal oncological care for patients with challenging primary tumors of the mobile spine.

Open access

Anterior cervical transvertebral approach for resection of an intraspinal ventral lesion: illustrative case

Dongao Zhang, Tao Fan, Wayne Fan, and Xingang Zhao

BACKGROUND

The anterior cervical corpectomy and fusion approach has been reported for the removal of ventral cervical tumors. However, the normal cervical vertebral body and the adjacent intervertebral discs have to be sacrificed. In this paper, the authors describe a novel anterior cervical transvertebral approach for the resection of cervical intraspinal ventral lesions.

OBSERVATIONS

A patient presented with an anteriorly placed extramedullary cyst. An anterior cervical transvertebral open-window and close-window approach was designed and applied to resect an intraspinal ventral enterogenous cyst. With this novel technique, a square was cut through the whole vertebral body at the four sides. After the cyst resection, the bone block was restored and fixed with a titanium miniplate. The lesion was totally resected, and the compression of the spinal cord was relieved. The physiological function of the cervical spine was kept intact after the operation. There was no postsurgical complication. The cervical alignment was normal at the 1-year postoperative follow-up.

LESSONS

The anterior cervical transvertebral open-window and close-window approach was developed and confirmed to be effective for the resection of cervical intraspinal lesions. The cervical physiological structure and function can be restored with this new technique.

Open access

The utility of diffusion tractography for speech preservation in laser ablation of the dominant insula: illustrative case

Timothy J. Kaufmann, Vance T. Lehman, Lily C. Wong-Kisiel, Panagiotis Kerezoudis, and Kai J. Miller

BACKGROUND

Open surgical treatment of insular epilepsy holds particular risk of injury to middle cerebral artery branches, the operculum (through retraction), and adjacent language-related white matter tracts in the language-dominant hemisphere. Magnetic resonance imaging (MRI)-guided laser interstitial thermal therapy (LITT) is a surgical alternative that allows precise lesioning with potentially less operative risk. The authors presented the case of a 13-year-old girl with intractable, MRI-negative, left (dominant hemisphere) insular epilepsy that was treated with LITT. Diffusion tensor imaging (DTI) tractography was used to aid full posterior insular lesioning in the region of stereo electroencephalography–determined seizure onset while avoiding thermal injury to the language-related superior longitudinal fasciculus (SLF)/arcuate fasciculus (AF) and inferior fronto-occipital fasciculus (IFOF).

OBSERVATIONS

DTI tractography was used successfully in planning insular LITT and facilitated a robust insular ablation with sharp margins at the interfaces with the SLF/AF and IFOF. These tracts were spared, and no neurological deficits were induced through LITT.

LESSONS

Although it is technically demanding and has important limitations that must be understood, clinically available DTI tractography adds precision and confidence to insular laser ablation when used to protect important language-related white matter tracts.

Open access

Sublaminar bands in oncological spine surgery: illustrative cases

Godard C. W. de Ruiter, Valerio Pipola, Cristiana Griffoni, and Alessandro Gasbarrini

BACKGROUND

Sublaminar bands have been used in addition to pedicle screw placement in the correction of idiopathic scoliosis forming a so-called hybrid construct.

OBSERVATIONS

In this article, the authors present several cases that demonstrate the potential applications of sublaminar bands in oncological spine surgery. The potential applications are divided into three categories: (1) as an additional tool in salvage procedures, (2) to correct kyphosis in pathological fractures, and (3) for bone graft anchoring to the spine.

LESSONS

The cases presented in this article demonstrate the potential beneficial effects of the sublaminar bands in addition to pedicle screw placement.

Open access

Cloward’s approach for Pancoast neurogenic tumors: illustrative cases

Yi-Hsuan Kuo, Po-Kuei Hsu, Jau-Ching Wu, Wen-Cheng Huang, and Tsung-Hsi Tu

BACKGROUND

Pancoast tumors are a wide range of tumors located in the apex of the lung. Traditional surgery for Pancoast neurogenic tumors frequently involves extensive approaches, whether anterior or posterior or a combination, in which osteotomies are sometimes required. In this study, the authors proposed a less invasive surgical strategy using the standard Cloward’s approach for complete resection of a schwannoma arising from the T1 nerve root.

OBSERVATIONS

Two patients, each harboring a large T1 tumor, one on each side, underwent Cloward’s approach with and without thoracoscopic surgery. Both patients had complete resection of the tumor. Considering the benign and encapsulated nature of neurogenic tumors, Cloward’s approach under neuromonitoring, which is a common procedure for anterior cervical discectomy for most neurosurgeons, is a safe and less invasive alternative for Pancoast neurogenic tumors. For patients whose tumor cannot be removed completely via Cloward’s approach, video-assisted thoracoscopic surgery is a viable backup plan with minimal invasiveness.

LESSONS

Cloward’s approach is a viable option for Pancoast neurogenic tumors.

Open access

Concomitant central venous sinus thrombosis and subdural hematoma in acute promyelocytic leukemia: middle meningeal artery embolization enables safe anticoagulation. Illustrative case

Kushagra Maini, Feroze Afzal, Dan-Victor Giurgiutiu, Scott Y. Rahimi, Manan Shah, Jeffrey A. Switzer, Fernando L. Vale, and Klepper Alfredo Garcia

BACKGROUND

Acute promyelocytic leukemia (APL) has long been associated with coagulation disorders. The proposed mechanism is a combination of fibrinolysis, proteolysis, platelet dysfunction, thrombocytopenia, and possibly disseminated intravascular coagulation. Hemorrhagic complications are prominent.

OBSERVATIONS

In this case, a 25-year-old female with newly diagnosed APL developed extensive cerebral venous thrombosis (CVT) and was initiated on a protocol with idarubicin and all-trans retinoic acid. The general recommendation for treating CVT is anticoagulation to stabilize the existing thrombus and prevent propagation. The patient was initiated on a heparin drip, but her clinical course was complicated by subdural hemorrhage (SDH) and epidural hemorrhage in the setting of thrombocytopenia. Anticoagulation was held, and her CVT propagated on follow-up imaging. To restart anticoagulation for CVT with a limited risk of SDH, the authors pursued middle meningeal artery (MMA) embolization. The patient was transitioned to apixaban and discharged to home.

LESSONS

MMA embolization enables safe anticoagulation in patients with concomitant CVT and SDH. The authors report the complex clinical course and effective management of this rare clinical scenario.

Open access

Patient-specific virtual reality technology for complex neurosurgical cases: illustrative cases

Diana Anthony, Robert G. Louis, Yevgenia Shekhtman, Thomas Steineke, Anthony Frempong-Boadu, and Gary K. Steinberg

BACKGROUND

Virtual reality (VR) offers an interactive environment for visualizing the intimate three-dimensional (3D) relationship between a patient’s pathology and surrounding anatomy. The authors present a model for using personalized VR technology, applied across the neurosurgical treatment continuum from the initial consultation to preoperative surgical planning, then to intraoperative navigation, and finally to postoperative visits, for various tumor and vascular pathologies.

OBSERVATIONS

Five adult patients undergoing procedures for spinal cord cavernoma, clinoidal meningioma, anaplastic oligodendroglioma, giant aneurysm, and arteriovenous malformation were included. For each case, 360-degree VR (360°VR) environments developed using Surgical Theater were used for patient consultation, preoperative planning, and/or intraoperative 3D navigation. The custom 360°VR model was rendered from the patient’s preoperative imaging. For two cases, the plan changed after reviewing the patient’s 360°VR model from one based on conventional Digital Imaging and Communications in Medicine imaging.

LESSONS

Live 360° visualization with Surgical Theater in conjunction with surgical navigation helped validate the decisions made intraoperatively. The 360°VR models provided visualization to better understand the lesion’s 3D anatomy, as well as to plan and execute the safest patient-specific approach, rather than a less detailed, more standardized one. In all cases, preoperative planning using the patient’s 360°VR model had a significant impact on the surgical approach.

Open access

Ultrasound-assisted neuroendoscopic lavage for intraventricular hemorrhage in a newborn: illustrative case

Luca Sartori, Giulia Melinda Furlanis, Samuel Luciano Caliri, Elisa Garbin, Valentina Baro, and Luca Denaro

BACKGROUND

The optimal treatment for posthemorrhagic hydrocephalus in newborns has not been established yet. Moreover, despite many valid therapeutic alternatives, unfavorable neurodevelopmental outcomes are frequent. According to recent literature, these discouraging results could be related to secondary inflammatory damage of the white matter due to the gradual dissolution of the intraventricular hematoma, which should be removed.

OBSERVATIONS

Neuroendoscopic lavage (NEL) has proven to be a safe and reliable procedure, able to adequately remove the intraventricular clots and the products of blood degradation. To increase surgical control of the entire ventricular system, the authors illustrated a case in which they associated real-time transfontanellar ultrasound monitoring with NEL.

LESSONS

Coupling these two techniques, the authors performed a rapid ventricular wash and obtained intraoperative confirmation of complete and accurate clot removal.

Open access

Restoration of sagittal alignment in high-grade isthmic spondylolisthesis using the reverse Bohlman technique with anterior lumbar interbody fusion using a hyperlordotic cage at L4–5: illustrative case

Terrence Ishmael, Vincent Arlet, and Harvey Smith

BACKGROUND

Circumferential fusion with or without reduction is the preferred treatment for high-grade isthmic spondylolisthesis. Reduction presents significant risk of neurological injury. The authors present one case in which the “reverse Bohlman” technique was used with the addition of a hyperlordotic interbody cage at L4–5 as a means to correct sagittal malalignment while avoiding the reduction of L5 on S1.

OBSERVATIONS

The patient was a 22-year-old woman with a long-term history of lower back pain and bilateral L5 radiculopathy secondary to high-grade isthmic lumbar spondylolisthesis. She underwent anterior lumbar interbody fusion using the reverse Bohlman technique plus a hyperlordotic interbody cage at L4–5, followed by decompression and posterior spinal instrumentation and fusion from L4 to the pelvis. At 2-year follow-up, she was found to have complete resolution of symptoms with clinical and radiographic evidence of fusion. Her spinopelvic parameters had significantly improved.

LESSONS

The reverse Bohlman technique with the addition of a hyperlordotic interbody cage at L4–5 is a potential alternative treatment method to correct sagittal malalignment while avoiding possible injury to the L5 nerve roots that can be seen in the reduction of high-grade isthmic spondylolisthesis.