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Ming-Ying Lan and Wei-Hsin Wang

This is a 37-year-old woman who presented with weight gain, a moon-shaped face, and muscle weakness for 4 months. Cushing’s disease was confirmed after a series of diagnostic tests. MRI demonstrated a pituitary macroadenoma with right cavernous sinus invasion and encasement of the right ICA. An endoscopic endonasal approach was performed, and gross-total resection could be achieved without injury of the cranial nerves. The Cushing’s syndrome improved gradually after the surgery. Histopathology revealed a corticotroph adenoma. In this surgical video, we demonstrate the strategies of tumor resection according to a surgical anatomy-based classification of the cavernous sinus from an endonasal perspective.

The video can be found here: https://youtu.be/aNXFRdGfjpI.

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Da Li, Yu-Ming Jiao, Liang Wang, Fu-Xin Lin, Jun Wu, Xian-Zeng Tong, Shuo Wang, and Yong Cao

OBJECTIVE

Surgical management of brainstem lesions is challenging due to the highly compact, eloquent anatomy of the brainstem. This study aimed to evaluate the safety and efficacy of preoperative diffusion tensor imaging (DTI) and diffusion tensor tractography (DTT) in brainstem cavernous malformations (CMs).

METHODS

A prospective randomized controlled clinical trial was performed by using stratified blocked randomization. The primary eligibility criterion of the study was being a surgical candidate for brainstem CMs (with informed consent). The study enrolled 23 patients who underwent preoperative DTI/DTT and 24 patients who did not (the control group). The pre- and postoperative muscle strength of both limbs and modified Rankin Scale (mRS) scores were evaluated. Muscle strength of any limb at 12 months after surgery at the clinic visit was the primary outcome; worsened muscle strength was considered to be a poor outcome. Outcome assessors were blinded to patient management. This study reports the preliminary results of the interim analysis.

RESULTS

The cohort included 47 patients (22 women) with a mean age of 35.7 years. The clinical baselines between these 2 groups were not significantly different. In the DTI/DTT group, the corticospinal tract was affected in 17 patients (73.9%): it was displaced, deformed/partially interrupted, or completely interrupted in 6, 7, and 4 patients, respectively. The surgical approach and brainstem entry point were adjusted in 3 patients (13.0%) based on DTI/DTT data. The surgical morbidity of the DTI/DTT group (7/23, 30.4%) was significantly lower than that of the control group (19/24, 79.2%, p = 0.001). At 12 months, the mean mRS score (1.1, p = 0.034) and percentage of patients with worsened motor deficits (4.3%, p = 0.006) were significantly lower in the DTI/DTT group than in the control group (1.7% and 37.5%). Multivariate logistic regression identified the absence of preoperative DTI/DTT (OR 0.06, 95% CI 0.01–0.73, p = 0.028) and use of the 2-point method (OR 4.15, 95% CI 1.38–12.49, p = 0.011) as independent adverse factors for a worsened motor deficit. The multivariate model found a significant correlation between poor mRS score and both an increased preoperative mRS score (t = 3.559, p = 0.001) and absence of preoperative DTI/DTT (t = −2.747, p = 0.009).

CONCLUSIONS

DTI/DTT noninvasively allowed for visualization of the anatomical relationship between vital tracts and pathologies as well as facilitated the brainstem surgical approach and entry-point decision making. The technique was valuable for complex neurosurgical planning to reduce morbidity. Nonetheless, DTI/DTT data should be interpreted cautiously.

■ CLASSIFICATION OF EVIDENCE Type of question: therapeutic; study design: randomized controlled trial; evidence: class I.

Clinical trial registration no.: NCT01758211 (ClinicalTrials.gov)

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Bing Zhou, Ming-Hua Li, Wu Wang, Hao-Wen Xu, Yong-De Cheng, and Jue Wang

Object

The authors conducted a study to evaluate the advantages of a 3D volume-rendering technique (VRT) in follow-up digital subtraction (DS) angiography of coil-embolized intracranial aneurysms.

Methods

One hundred nine patients with 121 intracranial aneurysms underwent endovascular coil embolization and at least 1 follow-up DS angiography session at the authors' institution. Two neuroradiologists independently evaluated the conventional 2D DS angiograms, rotational angiograms, and 3D VRT images obtained at the interventional procedures and DS angiography follow-up. If multiple follow-up sessions were performed, the final follow-up was mainly considered. The authors compared the 3 techniques for their ability to detect aneurysm remnants (including aneurysm neck and sac remnants) and parent artery stenosis based on the angiographic follow-up. The Kruskal-Wallis test was used for group comparisons, and the kappa test was used to measure interobserver agreement. Statistical analyses were performed using commercially available software.

Results

There was a high statistical significance among 2D DS angiography, rotational angiography, and 3D VRT results (X2 = 9.9613, p = 0.0069) when detecting an aneurysm remnant. Further comparisons disclosed a statistical significance between 3D VRT and rotational angiography (X2 = 4.9754, p = 0.0257); a high statistical significance between 3D VRT and 2D DS angiography (X2 = 8.9169, p = 0.0028); and no significant difference between rotational angiography and 2D DS angiography (X2 = 0.5648, p = 0.4523). There was no statistical significance among the 3 techniques when detecting parent artery stenosis (X2 = 2.5164, p = 0.2842). One case, in which parent artery stenosis was diagnosed by 2D DS angiography and rotational angiography, was excluded by 3D VRT following observations of multiple views. The kappa test showed good agreement between the 2 observers.

Conclusions

The 3D VRT is more sensitive in detecting aneurysm remnants than 2D DS angiography and rotational angiography and is helpful for identifying parent artery stenosis. The authors recommend this technique for the angiographic follow-up of patients with coil-embolized aneurysms.

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Ming Zhao, Xishan Li, Jianpeng Wang, Wang Li, and Zilin Huang

Retroperitoneal schwannomas (RSs) are particularly rare tumors, and resection is the first choice for symptomatic patients. However, some RSs with anatomical complexities pose great challenges for surgeons attempting radical resection without sacrificing the nearby critical structures, and subtotal resection leads to local recurrence, especially in refractory malignant RSs. The authors have successfully applied percutaneous CT-guided radiofrequency ablation in 2 cases of RSs, with favorable long-term progression-free survival.

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Ming Luo, Wengang Wang, Mingkui Shen, Xin Luo, and Lei Xia

OBJECTIVE

The radiographic and clinical outcomes of low-density (LD) versus high-density (HD) screw constructs in patients with adolescent idiopathic scoliosis (AIS) treated with all–pedicle screw constructs are still controversial. A systematic review and pooled analysis were performed to compare radiographic, perioperative, and quality-of-life (QOL) outcomes and complications in patients with moderate AIS treated with LD or HD screw constructs.

METHODS

The MEDLINE, Embase, and Web of Science databases were searched for English-language articles addressing LD versus HD screw constructs in AIS patients treated with all–pedicle screw constructs. The division of LD and HD groups was based on relative screw density and screw techniques. This systematic analysis strictly followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, and all articles included in the analysis met the criteria specified in the guidelines. Two reviewers independently assessed the quality of the studies using the Newcastle-Ottawa Scale. Date on radiographic, perioperative, and QOL outcomes and complications were extracted from the included studies.

RESULTS

Twelve studies, involving a total of 827 patients (480 treated with LD constructs, 347 with HD), were analyzed—1 randomized controlled trial, 1 quasi-randomized controlled trial, and 10 retrospective studies. The patients' age at surgery, preoperative Cobb angle of the major curve, amount of thoracic kyphosis, and major curve flexibility were reasonably distributed, and no statistically significant differences were found. Regarding the outcomes at most recent follow-up, there were no significant differences in the Cobb angle of the major curve (mean difference 0.96°, 95% CI −0.06° to 1.98°, p = 0.06, I2 = 1%), major curve correction (mean difference −0.72%, 95% CI −2.96% to 1.52%, p = 0.53, I2 = 0%), thoracic kyphosis (mean difference −1.67°, 95% CI −4.59° to 1.25°, p = 0.26, I2 = 79%), complications (odds ratio [OR] 0.66, 95% CI 0.31–1.42, p = 0.29, I2 = 0%), and QOL outcomes. Reduced operative time (mean difference −48.56 minutes, 95% CI −82.69 to −14.43 minutes, p = 0.005, I2 = 87%), blood loss (mean difference −77.85 ml, 95% CI −153.10 to −2.60 ml, p = 0.04, I2 = 0%), and hospital charges (mean difference −$5.92K, 95% CI −$6.59K to −$5.26K, p < 0.00001, I2 = 0%) were found in the LD group, compared with the HD group.

CONCLUSIONS

LD and HD screw constructs are both associated with satisfactory radiographic and QOL outcomes with few complications. This study supports the use of LD screw constructs for the treatment of moderate AIS, because they resulted in reduced operative time, blood loss, and hospital charges while maintaining radiographic and QOL outcomes and complication rates similar to those achieved with HD screw constructs.

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Ming-Xiang Zou, Jing Li, Xiao-Bin Wang, and Guo-Hua Lv

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Yeou-Chih Wang, Ming-Hsi Sun, Chi-Wen Lin, and Yen-Ju Chen

Object. Bilateral subaxillary transthoracic endoscopic sympathectomy (TES) is a popular procedure of upper thoracic sympathectomy. The anatomical locations of the T-2 and T-3 sympathetic trunks, as viewed under the endoscope, are varied in the rib head areas. In this study, the authors investigated the more visible anatomical locations of the T-2 and T-3 sympathetic trunks, the so-called nerves of Kuntz, and intercostal rami by performing transthoracic endoscopy.

Methods. Seventy patients with palmar hyperhidrosis undergoing bilateral TES (140 sides) via the anterior subaxillary approach were included in this study. The operative findings and video images of the T-2 and T-3 sympathetic trunks and ganglia were recorded and analyzed. The anatomical locations of the T-2 and T-3 sympathetic trunks along the horizontal axes of the rib heads were determined using a three-region system constructed by the authors. The area between the rib neck and the medial border of the rib head was equally divided into Region E (external half) and Region M (medial half). The area between the medial border of the rib head and the paravertebral ligament was defined as Region I.

The incidence of the T-2 and T-3 sympathetic trunks found in Regions E, M, and I were 31.4 to 42.9%, 50 to 57.1%, and 7.1 to 11.4%, respectively, on the left side, and 24.3 to 34.3%, 57.1 to 65.7%, and 8.6 to 10%, respectively, on the right side. One right (1.4%) and six left (8.6%) Kuntz nerves originating from the T-3 sympathetic trunk were found in seven patients (10%). The intercostal ramus was found around the T-2 rib neck in 24 patients (34.3%), with 18 cases (25.7%) for each side. The intercostal ramus around the T-3 rib neck was found in 17 patients (24.3%): 12 (17.1%) on the right and nine (12.9%) on the left.

Conclusions. These results indicate that approximately 90% of the T-2 or T-3 sympathetic trunks are located on the rib head. These findings may also be used to assist the surgeon in fluoroscopic guidance for locating the T-2 and T-3 sympathetic trunks during posterior percutaneous sympathectomy.

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King-Shun Chuang, Yeou-Chih Wang, Shin-Han Tsai, and Ming-Ying Liu

✓ The authors describe a case of a spinal intramedullary pseudocyst at T-1 that did not communicate with the surrounding spaces. The cystic wall was composed of dense connective tissue without epithelial or neoplastic cells. The patient's condition improved dramatically after surgical removal of the cyst. The literature on spinal intramedullary cystic lesions is reviewed and the etiology of pseudocysts is discussed. This case is believed to be the first in which a pseudocyst has been demonstrated within the spinal cord.

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Ming-Kai Hsieh, Fu-Cheng Kao, Wen-Jer Chen, I-Jung Chen, and Sheng-Fen Wang

OBJECTIVE

Spinopelvic parameters, such as the pelvic incidence (PI) angle, sacral slope angle, and pelvic tilt angle, are important anatomical indices for determining the sagittal curvature of the spine and the individual variability of the lumbar lordosis (LL) curve. The aim of this study was to investigate the influence of spinopelvic parameters and LL on adjacent-segment degeneration (ASD) after short lumbar and lumbosacral fusion for single-level degenerative spondylolisthesis.

METHODS

The authors retrospectively reviewed the records of all short lumbar and lumbosacral fusion surgeries performed between August 2003 and July 2010 for single-level degenerative spondylolisthesis in their orthopedic department.

RESULTS

A total of 30 patients (21 women and 9 men, mean age 64 years) with ASD after lower lumbar or lumbosacral fusion surgery comprised the study group. Thirty matched patients (21 women and 9 men, mean age 63 years) without ASD comprised the control group, according to the following matching criteria: same diagnosis on admission, similar pathologic level (≤ 1 level difference), similar sex, and age. The average follow-up was 6.8 years (range 5–8 years). The spinopelvic parameters had no significant influence on ASD after short spinal fusion.

CONCLUSIONS

Neither the spinopelvic parameters nor a mismatch of PI and LL were significant factors responsible for ASD after short spinal fusion due to single-level degenerative spondylolisthesis.