Frederick A. Boop
Mark W. Kieran, Liliana C. Goumnerova, Michael Prados and Nalin Gupta
Daniel C. Lu, Nalin Gupta and Praveen V. Mummaneni
Surgical decompression of the vertebral artery (VA) between the suboccipital area and C-1 is typically performed via a large midline incision or a far-lateral approach. Such traditional open approaches are often associated with significant muscle dissection and blood loss. In this case, a 12-year-old boy suffered a stroke related to a VA rotational occlusion (bow hunter syndrome) and dissection due to a prominent suboccipital bone mass. Successful decompression of the VA was performed via a minimally invasive 22-mm tubular retractor. This is the first reported case report of a minimally invasive decompression of the VA between the skull base and C-1.
Matthew B. Potts, Jau-Ching Wu, Nalin Gupta and Praveen V. Mummaneni
Symptomatic tethered cord and associated anomalies such as diastematomyelia rarely present during adulthood but can cause significant pain as well as motor, sensory, and bladder dysfunction. As with children, studies have shown that surgical detethering may provide improvement in pain and neurological deficits. Typical surgical management involves an open laminectomy, sectioning of the filum terminale, and exploration of the split cord malformation. Such open approaches, however, cause significant paraspinous muscle trauma and scarring. Recent advances in minimally invasive techniques allow for access to the spine and thecal sac while minimizing associated muscular trauma. The authors present a comparison of open versus minimally invasive surgery to treat adult tethered cord syndrome.
Six adult patients underwent surgical release of a tethered spinal cord (2 of them also had diastematomyelia). The mean age of the patients was 47.78 years (range 31–64 years). All medical records and images were retrospectively reviewed. Three of the patients underwent traditional open laminectomies for detethering (open group) while the other 3 patients underwent minimally invasive (mini-open) spinal cord detethering. The length of the incision, length of stay, estimated blood loss, and complications were compared between the 2 groups.
All 6 patients had tethered spinal cords, and 1 patient in each group had diastematomyelia. The mean estimated blood loss during surgery (300 ml in the open group vs 167 ml in the mini-open group, p = 0.313) and the mean length of stay (7 days in the open group vs 6.3 days in the mini-open group, p = 0.718) were similar between the 2 groups. The incision length was half as long in the mini-open group versus the open group. However, 1 patient in the mini-open group developed a postoperative pseudomeningocele requiring surgical revision, whereas the open group had no revision surgeries.
Cases of symptomatic diastematomyelia and tethered cord in adults can be safely and effectively explored through a mini-open approach. In this small case series, the authors did find that the mini-open group had an incision that was 50% smaller than the open group, but they did not find a significant clinical difference between the groups.
Enrique C. G. Ventureyra
Paul Steinbok, Hugh J. L. Garton and Nalin Gupta
Tethered cord syndrome (TCS) is associated with a number of congenital anomalies involving early development of the spinal cord. These include myelomeningocele, spinal cord lipoma, low-lying conus medullaris, and a fibrofatty terminal filum. Occult TCS occurs in patients when clinical features indicate a TCS but the typical anatomical abnormalities are lacking. It is controversial whether surgical release of the terminal filum leads to clinical improvement in a patient who does not have a previously identified anatomical abnormality. To assess the clinical standard used by practicing pediatric neurosurgeons, a practice survey was conducted at the 2004 Annual Meeting of the Joint Section for Pediatric Neurological Surgery of the American Association of Neurological Surgeons/Congress of Neurological Surgeons.
The survey examined clinical decision making for a same-case scenario with differing appearance on imaging studies. There was a clear consensus regarding diagnosis and treatment in the patient with symptoms, a low-lying conus medullaris, and a fatty terminal filum. The vast majority of respondents (85%) favored surgical untethering for this patient. A majority of respondents (67%) also favored treatment for the patient having symptoms and a fatty terminal filum. There was, however, significant disagreement regarding the diagnosis and treatment of disease in one patient with symptoms and an inconclusive magnetic resonance imaging study. Some respondents clearly favored surgery, whereas others believed that this patient did not meet the diagnostic criteria for TCS.
The results of this survey support the development of a randomized clinical trial to address the benefit of surgery for occult TCS.