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Jan-Helge Klingler, Ulrich Hubbe, Christoph Scholz, Florian Volz, Marc Hohenhaus, Ioannis Vasilikos, Waseem Masalha, Ralf Watzlawick, and Yashar Naseri

OBJECTIVE

Intraoperative 3D imaging and navigation is increasingly used for minimally invasive spine surgery. A novel, noninvasive patient tracker that is adhered as a mask on the skin for 3D navigation necessitates a larger intraoperative 3D image set for appropriate referencing. This enlarged 3D image data set can be acquired by a state-of-the-art 3D C-arm device that is equipped with a large flat-panel detector. However, the presumably associated higher radiation exposure to the patient has essentially not yet been investigated and is therefore the objective of this study.

METHODS

Patients were retrospectively included if a thoracolumbar 3D scan was performed intraoperatively between 2016 and 2019 using a 3D C-arm with a large 30 × 30–cm flat-panel detector (3D scan volume 4096 cm3) or a 3D C-arm with a smaller 20 × 20–cm flat-panel detector (3D scan volume 2097 cm3), and the dose area product was available for the 3D scan. Additionally, the fluoroscopy time and the number of fluoroscopic images per 3D scan, as well as the BMI of the patients, were recorded.

RESULTS

The authors compared 62 intraoperative thoracolumbar 3D scans using the 3D C-arm with a large flat-panel detector and 12 3D scans using the 3D C-arm with a small flat-panel detector. Overall, the 3D C-arm with a large flat-panel detector required more fluoroscopic images per scan (mean 389.0 ± 8.4 vs 117.0 ± 4.6, p < 0.0001), leading to a significantly higher dose area product (mean 1028.6 ± 767.9 vs 457.1 ± 118.9 cGy × cm2, p = 0.0044).

CONCLUSIONS

The novel, noninvasive patient tracker mask facilitates intraoperative 3D navigation while eliminating the need for an additional skin incision with detachment of the autochthonous muscles. However, the use of this patient tracker mask requires a larger intraoperative 3D image data set for accurate registration, resulting in a 2.25 times higher radiation exposure to the patient. The use of the patient tracker mask should thus be based on an individual decision, especially taking into considering the radiation exposure and extent of instrumentation.

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Jürgen Beck, Ulrich Hubbe, Jan-Helge Klingler, Roland Roelz, Luisa Mona Kraus, Florian Volz, Niklas Lützen, Horst Urbach, Kristin Kieselbach, and Christian Fung

OBJECTIVE

Spinal CSF leaks cause spontaneous intracranial hypotension (SIH). Surgical closure of spinal CSF leaks is the treatment of choice for persisting leaks. Surgical approaches vary, and there are no studies in which minimally invasive techniques were used. In this study, the authors aimed to detail the safety and feasibility of minimally invasive microsurgical sealing of spinal CSF leaks using nonexpandable tubular retractors.

METHODS

Consecutive patients with SIH and a confirmed spinal CSF leak treated at a single institution between April 2019 and December 2020 were included in the study. Surgery was performed via a dorsal 2.5-cm skin incision using nonexpandable tubular retractors and a tailored interlaminar fenestration and, if needed, a transdural approach. The primary outcome was successful sealing of the dura, and the secondary outcome was the occurrence of complications.

RESULTS

Fifty-eight patients, 65.5% of whom were female (median age 46 years [IQR 36–55 years]), with 38 ventral leaks, 17 lateral leaks, and 2 CSF venous fistulas were included. In 56 (96.6%) patients, the leak could be closed, and in 2 (3.4%) patients the leak was missed because of misinterpretation of the imaging studies. One of these patients underwent successful reoperation, and the other patient decided to undergo surgery at another institution. Two other patients had to undergo reoperation because of insufficient closure and a persisting leak. The rate of permanent neurological deficit was 1.7%, the revision rate for a persisting or recurring leak was 3.4%, and the overall revision rate was 10.3%. The rate of successful sealing during the primary closure attempt was 96.6% and 3.4% patients needed a secondary attempt. Clinical short-term outcome at discharge was unchanged in 14 patients and improved in 25 patients, and 19 patients had signs of rebound intracranial hypertension.

CONCLUSIONS

Minimally invasive surgery with tubular retractors and a tailored interlaminar fenestration and, if needed, a transdural approach is safe and effective for the treatment of spinal CSF leaks. The authors suggest performing a minimally invasive closure of spinal CSF leaks in specialized centers.