Manfred Mühlbauer, Wolfgang Pfisterer, Richard Eyb, and Engelbert Knosp
Anterior decompressive surgery with spinal fusion is considered an effective treatment for thoracolumbar fractures and tumors. However, it is also known to be associated with considerable surgical approach–related trauma. The purpose of this study was to show that lumbar corpectomy and spinal reconstruction can be performed via a minimally invasive retroperitoneal (MIR) approach and therefore, the surgical approach–related trauma can be reduced.
The hospital records and radiological studies obtained in five patients (mean age 67.4 years, range 59-76 years) who underwent lumbar corpectomy and spinal fusion via an MIR approach were studied retrospectively. Four patients presented with osteoporotic compression fractures at L-2 and L-3 and one patient with metastatic disease at L-4 from prostate cancer. In all patients neurological deficits due to cauda equina compression were demonstrated.
The MIR approach provided excellent exposure to facilitate complete spinal decompression and reconstruction in all patients, as verified on follow-up x-ray studies. All patients improved clinically. A 1-year follow-up record, available for four patients, showed evidence of continuing clinical improvement and, radiographically, a solid fusion or a stable compound union and anatomically correct reconstruction.
The MIR approach allows anterior lumbar spine surgery to be performed less invasively. The efficacy and safety of this technique compared with the conventional retroperitoneal approach to lumbar spine surgery should be further investigated in a larger series.
Manfred Mühlbauer, Wolfgang Pfisterer, Richard Eyb, and Engelbert Knosp
✓ The anterior decompressive procedure in which spinal fusion is performed is considered an effective treatment for thoracolumbar fractures and tumors. However, it is also known to be associated with considerable surgery-related trauma. The purpose of this study was to show that lumbar corpectomy and anterior reconstruction can be performed via a minimally invasive retroperitoneal approach (MIRA) and therefore the surgical approach—related trauma can be reduced.
The authors studied retrospectively the hospital records and radiological studies obtained in five patients (mean age 67.4 years, range 59–76 years) who underwent lumbar corpectomy and spinal fusion via an MIRA followed by posterior fixation. Four patients presented with osteoporotic compression fractures at L-2 and L-3, and one patient presented with metastatic disease in L-4 from prostate cancer. Neurological deficits due to cauda equina compression were demonstrated in all patients.
The MIRA provided excellent exposure to facilitate complete decompression and anterior reconstruction in all patients, as verified on follow-up radiographic studies. All patients improved clinically. A 1-year follow-up record is available for four patients and a 6-month follow-up record for the fifth patient; continuing clinical improvement has been observed in all. Radiography demonstrated anatomically correct reconstruction in all patients, as well as a solid fusion or a stable compound union in the four patients for whom 1-year follow-up records were available.
The MIRA allows the surgeon to perform anterior lumbar spine surgery via a less invasive approach. The efficacy and safety of this technique and its potential to reduce perioperative morbidity compared with conventional retroperitoneal lumbar spine surgery should be further investigated in a larger series.
Govindaraju Lakshmi Prasad
Alexander S. G. Micko, Adelheid Wöhrer, Stefan Wolfsberger, and Engelbert Knosp
An important prognostic factor for the surgical outcome and recurrence of a pituitary adenoma is its invasiveness into parasellar tissue, particularly into the space of the cavernous sinus (CS). The aims of this study were to reevaluate the existing parasellar classifications using an endoscopic technique and to evaluate the clinical and radiological outcomes associated with each grade.
The authors investigated 137 pituitary macroadenomas classified radiologically at least on one side as Grade 1 or higher (parasellar extension) and correlated the surgical findings using an endoscopic technique, with special reference to the invasiveness of the tumor into the CS. In each case, postoperative MRI was performed to evaluate the gross-total resection (GTR) rate and the rate of endocrinological remission (ER) in functioning adenomas.
The authors found a 16% rate of CS invasion during surgery for these macroadenomas. Adenomas radiologically classified as Grade 1 were found to be invasive in 1.5%, and the GTR/ER rate was 83%/88%. For Grade 2 adenomas, the rate of invasion was 9.9%, and the GTR/ER rate was 71%/60%. For Grade 3 adenomas, the rate of invasion was 37.9%, and the GTR/ER rate was 75%/33%. When the superior compartment of the CS (Grade 3A) was involved, the authors found a rate of invasion that was lower (p < 0.001) than that when the inferior compartment was involved (Grade 3B). The rate of invasion in Grade 3A adenomas was 26.5% with a GTR/ER rate of 85%/67%, whereas for Grade 3B adenomas, the rate of surgically observed invasion was 70.6% with a GTR/ER rate of 64%/0%. All of the Grade 4 adenomas were invasive, and the GTR/ER rate was 0%.
A comparison of microscopic and endoscopic techniques revealed no difference in adenomas with Grade 1 or 4 parasellar extension. In Grade 2 adenomas, however, the CS was found by the endoscopic technique to be invaded in 9.9% and by microscopic evaluation to be invaded in 88% (p < 0.001); in Grade 3 adenomas, the difference was 37.9% versus 86%, respectively (p = 0.002). Grade 4 adenomas had a statistically significant lower rate of GTR than those of all the other grades. In case of ER only, Grade 1 adenomas had a statistically significant higher rate of remission than did Grade 3B and Grade 4 adenomas.
The proposed classification proved that with increasing grades, the likelihood of surgically observed invasion rises and the chance of GTR and ER decreases. The direct endoscopic view confirmed the low rate of invasion of Grade 1 adenomas but showed significantly lower rates of invasion in Grade 2 and 3 adenomas than those previously found using the microscopic technique. In cases in which the intracavernous internal carotid artery was encased (Grade 4), all the adenomas were invasive and the GTR/ER rate was 0%/0%. The authors suggest the addition of Grades 3A and 3B to distinguish the strikingly different outcomes of adenomas invading the superior CS compartments and those invading the inferior CS compartments.
Alexander Micko, Arthur Hosmann, Aygül Wurzer, Svenja Maschke, Wolfgang Marik, Engelbert Knosp, and Stefan Wolfsberger
The transsphenoidal route to pituitary adenomas challenges surgeons because of the highly variable sinunasal anatomy. Orientation may be improved if the appropriate information is provided intraoperatively by image guidance. The authors developed an advanced image guidance protocol dedicated to sinunasal surgery that extracts information from multiple modalities and forms it into a single image that includes fine sinunasal structures and arteries.
The aim of this study was to compare the advantages of this novel image guidance protocol with the authors’ previous series, with emphasis on anatomical structures visualized and complication rate.
This retrospective analysis comprised 200 patients who underwent surgery for pituitary adenoma via a transnasal transsphenoidal endoscopic approach. The authors’ standard image guidance protocol consisting of CT for solid bone, T1CEMRI for soft tissues, and MRA for the carotid artery was applied in 100 consecutive cases. The advanced image guidance protocol added a first-hit ray casting of the CT scan for visualization of fine sinunasal structures, and adjustments to the MRA to visualize the sphenopalatine artery (SPA) were applied in a subsequent 100 consecutive cases.
A patent sphenoid ostium—i.e., an ostium not covered by a mucosal layer—was visualized significantly more often by the advanced protocol than the standard protocol (89% vs 40%, p < 0.001) in primary surgeries. The SPA and its branches were only visualized by the advanced protocol (87% and 91% of cases in primary surgeries and reoperations, respectively) and not once by the standard protocol. The number of visualized complete and incomplete sphenoid septations matched significantly more commonly with the surgical view when using the advanced protocol than the standard protocol at primary operation (mean 1.9 vs 1.6, p < 0.001). However, in 25% of all cases a complex and not a simple sinus anatomy was present. In comparison with the intraoperative results, a complex sphenoid sinus anatomy was always detected by the advanced but not by the standard protocol (25% vs 8.5%, p = 0.001).
Furthermore, application of the advanced protocol reduced the cumulative rate of complications (25% vs 18% [standard vs advanced group]). Although an overall significant difference could not be determined (p = 0.228), a subgroup analysis of reoperations (35/200) revealed a significantly lower rate of complications in the advanced group (5% vs 30%, p = 0.028).
The data show that the advanced image guidance protocol could intraoperatively visualize the fine sinunasal sinus structures and small arteries with a high degree of detail. By improving intraoperative orientation, this may help to reduce the rate of complications in endoscopic transsphenoidal surgery, especially in reoperations.
Brigitte Gatterbauer, Sinan Gevsek, Romana Höftberger, Carola Lütgendorf-Caucig, Adolf Ertl, Ammar Mallouhi, Klaus Kitz, Engelbert Knosp, and Josa M. Frischer
Treatment of parasagittal meningiomas is still considered a challenge in modern microsurgery. The use of microsurgical resection, radiosurgery, or a microsurgery-radiosurgery combination treatment strategy is often debated. The aim of this study was to evaluate the treatment of parasagittal meningioma and provide evidence that a multimodal approach reduces complication rates and achieves good tumor control rates.
The authors retrospectively reviewed long-term follow-up data on 117 patients who had been treated for parasagittal meningiomas at their institution between 1993 and 2013. Treatment included microsurgery, Gamma Knife radiosurgery (GKRS), and radiotherapy.
The median tumor volume prior to the first microsurgical resection was largest in the microsurgery-radiosurgery combination treatment group. Invasion of the superior sagittal sinus was significantly associated with a Simpson Grade IV resection and subsequent radiosurgery treatment. The Simpson resection grade did not influence time to progression or recurrence in benign meningioma cases. Complete sinus occlusion was followed by microsurgical resection of the occluded sinus, by tumor resection without resection of the sinus, or by GKRS. Histopathology revealed WHO Grade I tumors in most patients. However, a high percentage (33%) of atypical or malignant meningiomas were diagnosed after the last microsurgical resection. The time to recurrence or progression after microsurgery was significantly longer in patients with WHO Grade I meningiomas than in those with Grade II or III meningiomas. At follow-up, tumor control rates after GKRS were 91% for presumed meningioma, 85% for benign meningioma, 71% for atypical meningioma, and 38% for malignant meningioma.
A multimodal treatment approach to parasagittal meningiomas reduces the rate of complications. Thus, microsurgery, radiotherapy, and radiosurgery are complementary treatment options. Gamma Knife radiosurgery is safe and effective in patients with meningiomas invading the superior sagittal sinus. The procedure can be part of a multimodal treatment plan or administered as a single treatment in well-selected patients.
Alexander Micko, Johannes Oberndorfer, Wolfgang J. Weninger, Greisa Vila, Romana Höftberger, Stefan Wolfsberger, and Engelbert Knosp
Parasellar growth is one of the most important prognostic variables of pituitary adenoma surgery, with adenomas regarded as not completely resectable if they invade the cavernous sinus (CS) but potentially curable if they displace CS structures. This study was conducted to correlate surgical treatment options and outcomes to the different biological behaviors (invasion vs displacement) of adenomas with parasellar extension into the superior or inferior CS compartments or completely encasing the carotid artery (Knosp high grades 3A, 3B, and 4).
This was a retrospective cohort analysis of 106 consecutive patients with Knosp high-grade pituitary adenomas with parasellar extension who underwent surgery via a primary endoscopic transsphenoidal approach between 2003 and 2017. Biological tumor characteristics (surgical status of invasiveness and tumor texture, 2017 WHO classification, proliferation rate), extent of resection, and complication rate were correlated with parasellar extension grades 3A, 3B, and 4 on preoperative MRI studies.
Invasiveness was significantly less common in grade 3A (44%) than in grade 3B (72%, p = 0.037) and grade 4 (100%, p < 0.001) adenomas. Fibrous tumor texture was significantly more common in grade 4 (52%) compared to grade 3A (20%, p = 0.002), but not compared to grade 3B (28%) adenomas. Functioning macroadenomas had a significantly higher rate of invasiveness than nonfunctioning adenomas (91% vs 55%, p = 0.002). Mean proliferation rate assessed by MIB-1 was > 3% in all groups but without significant difference between the groups (grade 3A, 3.2%; 3B, 3.9%; 4, 3.7%). Rates of endocrine remission/gross-total resection were significantly higher in grade 3A (64%) than in grade 3B (33%, p = 0.021) and grade 4 (0%, p < 0.001) adenomas. In terms of complication rates, no significant difference was observed between grades.
According to the authors’ data, the biological behavior of pituitary adenomas varies significantly between parasellar extension patterns. Adenomas with extension into the superior CS compartment have a lower rate of invasive growth than adenomas extending into the inferior CS compartment or encasing the carotid artery. Consequently, a significantly higher rate of remission can be achieved in grade 3A than in grade 3B and grade 4 adenomas. Therefore, the distinction into grades 3A, 3B, and 4 is of importance for prediction of adenoma invasion and surgical treatment considerations.
Walter F. Saringer, Brian Reddy, Iris Nöbauer-Huhmann, Rene Regatschnig, Marion Reddy, Manfred Tschabitscher, and Engelbert Knosp
Object. Cervical radiculopathy is typically caused by posterolateral disc herniation or spondylotic foraminal stenosis, either of which may compress the ventral aspect of the nerve root. The authors undertook a study to establish the feasibility of performing an endoscopic approach for anterior cervical foraminotomy (ACFor) in a clinical setting.
Methods. Application of this method on cadavers was conducted to verify the practicability of this technique. The clinical study included 16 patients (eight men and eight women; mean age 46.6 years) all presenting with unilateral radicular symptoms (one at two adjacent ipsilateral levels), which were associated with various degrees of neck pain. Disc herniations and/or uncovertebral osteophytes were confirmed on magnetic resonance imaging and high-resolution computerized tomography scanning. A total of 17 endoscopic ACFors (one two-level procedure) were performed using a rigid glass endoscope (25° angled, 3-mm diameter, 10-mm length) mounted on a tubular retractor.
No major surgery-related complications were encountered. During a mean follow-up period of 13.8 months an average absolute improvement of 44% (p > 0.05) in the neck disability index score and of 96% (p > 0.05) in the visual analog scale score for radicular pain (compared with the preoperative score) was observed. During the follow-up period strength improved to normal in 84% and sensory deficit in 80% of the patients. The overall subjective patient satisfaction rate was 87.6%; the return-to-work rate after 4 weeks was 81.4%.
Conclusions. The advantages of endoscopic ACFor include minimial surgical exposure, improved intraoperative visualization, direct decompression of the nerve root, and the preservation of the intervertebral disc and the motion segment.
Stefan Wolfsberger, Ahmed Ba-Ssalamah, Katja Pinker, Vladimír Mlynárik, Thomas Czech, Engelbert Knosp, and Siegfried Trattnig
The aim of this study was to determine the value of high-field magnetic resonance (MR) imaging for diagnosis and surgery of sellar lesions.
High-field MR images were obtained using a 3-tesla unit with emphasis on sellar and parasellar structures in 21 patients preoperatively to delineate endo-, supra-, and parasellar anatomical structures. Special attention was given to the medial border of the cavernous sinus and possible invasion of a sellar tumor therein, and to assessing the application of high-resolution images during intraoperative neuronavigation. The 3-tesla MR images were compared with the standard MR images already obtained and with intraoperative findings.
Anatomical structures were studied in all 42 cavernous sinuses; in 32 of them comparisons with intraoperative findings were possible. The medial cavernous sinus border was rated intact in 53% on standard MR images, in 72% on 3-tesla MR images, and in 81% intraoperatively. With a positive correlation to surgical findings on 84% of 3-tesla MR images compared with 59% of standard MR images, a sensitivity of 83% compared with 67%, and a specificity of 84% compared with 58% (p = 0.016, McNemar test), 3-tesla MR imaging was superior for predicting tumor invasion through the medial cavernous sinus border. Although no difference was noted in delineation of the medial, superior, and inferior compartments, there was a better delineation of the lateral cavernous sinus compartment with 3-tesla MR imaging. This compartment was clearly visible on 40 sides (95%) on 3-tesla MR images compared with 34 sides (81%) on standard MR images. Identification of the cavernous sinus segments of the third, fourth, fifth (V1 and V2), and sixth cranial nerves was improved using high-resolution 3-tesla imaging compared with standard MR imaging. A mean of four cranial nerves was found as hypo-intense spots (range two–five spots) on 3-tesla MR imaging compared with a mean of three (range zero–four spots) on standard MR imaging. After addition of contrast agents, the anterior pituitary gland was found to be highly intense on 78% of T1-weighted three-dimensional magnetization-prepared rapid acquisition gradient-echo (MPRAGE) 3-tesla MR images compared with 73% of standard T1-weighted MR images. The optochiasmatic system displayed increased intensity on pre-contrast T1-weighted MPRAGE 3-tesla compared with standard T1-weighted MR images; it was hyperintense on 76% of 3-tesla compared with 15% of standard MR images, which was helpful for its delineation from suprasellar pituitary and tumor structures. Intraoperative navigation guided by fusion of 3-tesla MR images and computerized tomography (CT) scans was performed in seven patients. Whereas CT scanning was used during the transsphenoidal approach to depict the nasal bone structures, 3-tesla MR imaging was particularly useful for the visualization of parasellar tumor extension during microsurgical and/or endoscopic resection.
Due to its higher resolution, 3-tesla MR imaging was found to be superior to standard MR imaging for the delineation of parasellar anatomy and tumor infiltration of the cavernous sinus, and this modality provided improved imaging for intraoperative navigation.