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Minimally invasive foramen magnum durectomy and obexostomy for treatment of craniocervical junction–related syringomyelia in adults: case series and midterm follow-up

Mauricio Mandel, Igor Araújo Ferreira da Silva, Wellingson Paiva, Yiping Li, Gary K. Steinberg, and Manoel Jacobsen Teixeira

OBJECTIVE

Craniocervical junction–related syringomyelia (CCJS) is the most common form of syringomyelia. Approximately 30% of patients treated with foramen magnum decompression (FMD) will show persistence, recurrence, or progression of the syrinx. The authors present a pilot study with a new minimally invasive surgery technique targeting the pathophysiology of CCJS in adult patients.

METHODS

The authors retrospectively analyzed the clinical and radiological features of a consecutive series of patients treated for CCJS. An FMD and FM durectomy were performed through a 1.5- to 2-cm skin incision. Then arachnoid adhesions were cleared, creating a permanent communication from the fourth ventricle to the new paraspinal extradural cavity (obexostomy) and with the spinal subarachnoid space. The hypothesis was that the new CSF pouch acts like a pressure leak, interrupting the CCJS pathogenesis.

RESULTS

Twenty-four patients (13 female, 21–61 years old) were treated between 2014 and 2018. The etiology of CCJS was Chiari malformation type I (CM-I) in 20 patients (83.3%), Chiari malformation type 0 (CM-0) in 2 patients (8.3%), and CCJ arachnoiditis in 2 patients (8.3%). Two patients underwent reoperations after failed FMD for CM-I at other institutions. No major surgical complication occurred. One patient had postoperative meningitis with no CSF fistula. On postoperative MRI, shrinkage of the syrinx was seen in all patients. No patients experienced recurrence of the CCJS. No patient required a subsequent operation. The mean duration of surgery was 72 ± 11 minutes (mean ± SD), and blood loss was 35–80 ml (mean 51 ml). Follow-up ranged from 12 to 58 months. The average overall improvement in modified Japanese Orthopaedic Association scores was 10% (p < 0.001). The Odom scale showed that 19 patients (79.1%) were satisfied, 4 (16.7%) remained the same, and 1 (4.2%) reported a poor outcome. All patients experienced postoperative improvement in perception of quality of life (p < 0.001).

CONCLUSIONS

Minimally invasive FM durectomy and obexostomy is a safe and effective treatment for CCJS and for patients who have not responded to other treatment.

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Development and evaluation of a new pediatric mixed-reality model for neurosurgical training

Giselle Coelho, Eberval Gadelha Figueiredo, Nícollas Nunes Rabelo, Manoel Jacobsen Teixeira, and Nelci Zanon

OBJECTIVE

Craniosynostosis is a premature cranial suture junction and requires a craniectomy to decrease cranial compression and remodel the affected areas of the skull. However, mastering these neurosurgical procedures requires many years of supervised training. The use of surgical simulation can reduce the risk of intraoperative error. The authors propose a new instrument for neurosurgical education, which mixes reality with virtual and realistic simulation for repair of craniosynostosis (scaphocephaly type).

METHODS

This study tested reality simulators with a synthetic thermo-retractile/thermosensitive rubber joined with different polymers. To validate the model, 18 experienced surgeons participated in this study using 3D videos developed using 3DS Max software. Renier’s “H” technique for craniosynostosis correction was applied during the simulation. All participants completed questionnaires to evaluate the simulator.

RESULTS

An expert surgical team approved the craniosynostosis reality and virtual simulators. More than 94% of participants found the simulator relevant, considering aspects such as weight, surgical positioning, dissection by planes, and cranial reconstruction. The consistency and material resistance were also approved on average by more than 60% of the surgeons.

CONCLUSIONS

The virtual simulator demands a high degree of effectiveness with 3D perception in anatomy and operative strategies in neurosurgical training. Physical and virtual simulation with mixed reality required psychomotor and cognitive abilities otherwise acquired only during practical surgical training with supervision.

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Letter to the Editor. Decompressive craniectomy in TBI: What is beyond static evaluations in terms of prognosis?

Sergio Brasil, Wellingson Silva Paiva, Ricardo de Carvalho Nogueira, Angela Macedo Salinet, and Manoel Jacobsen Teixeira

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Letter to the Editor. Do bacteria contribute to formation and rupture of intracranial aneurysms?

Nícollas Nunes Rabelo, Renan Salomão Rodrigues, Arthur Araújo Massoud Salame, Paulo Henrique Braz-Silva, Manoel Jacobsen Teixeira, and Eberval Gadelha Figueiredo

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The nerve to the levator scapulae muscle as donor in brachial plexus surgery: an anatomical study and case series

Roberto Sergio Martins, Mario Gilberto Siqueira, Carlos Otto Heise, Luciano Foroni, Hugo Sterman Neto, and Manoel Jacobsen Teixeira

OBJECTIVE

Nerve transfers are commonly used in treating complete injuries of the brachial plexus, but donor nerves are limited and preferentially directed toward the recovery of elbow flexion and shoulder abduction. The aims of this study were to characterize the anatomical parameters for identifying the nerve to the levator scapulae muscle (LSN) in brachial plexus surgery, to evaluate the feasibility of transferring this branch to the suprascapular nerve (SSN) or lateral pectoral nerve (LPN), and to present the results from a surgical series.

METHODS

Supra- and infraclavicular exposure of the brachial plexus was performed on 20 fresh human cadavers in order to measure different anatomical parameters for identification of the LSN. Next, an anatomical and histomorphometric evaluation of the feasibility of transferring this branch to the SSN and LPN was made. Lastly, the effectiveness of the LSN-LPN transfer was evaluated among 10 patients by quantifying their arm adduction strength.

RESULTS

The LSN was identified in 95% of the cadaveric specimens. A direct coaptation of the LSN and SSN was possible in 45% of the specimens (n = 9) but not between the LSN and LPN in any of the specimens. Comparison of axonal counts among the three nerves did not show any significant difference. Good results from reinnervation of the major pectoral muscle (Medical Research Council grade ≥ 3) were observed in 70% (n = 7) of the patients who had undergone LSN to LPN transfer.

CONCLUSIONS

The LSN is consistently identified through a supraclavicular approach to the brachial plexus, and its transfer to supply the functions of the SSN and LPN is anatomically viable. Good results from an LSN-LPN transfer are observed in most patients, even if long nerve grafts need to be used.

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Letter to the Editor. The minipterional craniotomy: beyond the keyhole concept

Nícollas Nunes Rabelo, Manoel Jacobsen Teixeira, Robert F. Spetzler, and Eberval Gadelha Figueiredo

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The nerve to the levator scapulae muscle as donor in brachial plexus surgery: an anatomical study and case series

Roberto Sergio Martins, Mario Gilberto Siqueira, Carlos Otto Heise, Luciano Foroni, Hugo Sterman Neto, and Manoel Jacobsen Teixeira

OBJECTIVE

Nerve transfers are commonly used in treating complete injuries of the brachial plexus, but donor nerves are limited and preferentially directed toward the recovery of elbow flexion and shoulder abduction. The aims of this study were to characterize the anatomical parameters for identifying the nerve to the levator scapulae muscle (LSN) in brachial plexus surgery, to evaluate the feasibility of transferring this branch to the suprascapular nerve (SSN) or lateral pectoral nerve (LPN), and to present the results from a surgical series.

METHODS

Supra- and infraclavicular exposure of the brachial plexus was performed on 20 fresh human cadavers in order to measure different anatomical parameters for identification of the LSN. Next, an anatomical and histomorphometric evaluation of the feasibility of transferring this branch to the SSN and LPN was made. Lastly, the effectiveness of the LSN-LPN transfer was evaluated among 10 patients by quantifying their arm adduction strength.

RESULTS

The LSN was identified in 95% of the cadaveric specimens. A direct coaptation of the LSN and SSN was possible in 45% of the specimens (n = 9) but not between the LSN and LPN in any of the specimens. Comparison of axonal counts among the three nerves did not show any significant difference. Good results from reinnervation of the major pectoral muscle (Medical Research Council grade ≥ 3) were observed in 70% (n = 7) of the patients who had undergone LSN to LPN transfer.

CONCLUSIONS

The LSN is consistently identified through a supraclavicular approach to the brachial plexus, and its transfer to supply the functions of the SSN and LPN is anatomically viable. Good results from an LSN-LPN transfer are observed in most patients, even if long nerve grafts need to be used.

Free access

Letter to the Editor. The minipterional craniotomy: beyond the keyhole concept

Nícollas Nunes Rabelo, Manoel Jacobsen Teixeira, Robert F. Spetzler, and Eberval Gadelha Figueiredo

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Letter to the Editor. Minimally invasive techniques: the new frontier in neurosurgery

Nícollas Nunes Rabelo, Bruno Braga Sisnando da Costa, Manoel Jacobsen Teixeira, and Eberval Gadelha Figueiredo

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Letter to the Editor. PbtO₂ and prognosis after decompressive craniectomy

Marcelo de Lima Oliveira, Juliana R. Caldas, Manoel Jacobsen Teixeira, and Edson Bor-Seng-Shu