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Namath S. Hussain and Mick J. Perez-Cruet

Spine surgery as we know it has changed dramatically over the past 2 decades. More patients are undergoing minimally invasive procedures. Surgeons are becoming more comfortable with these procedures, and changes in technology have led to several new approaches and products to make surgery safer for patients and improve patient outcomes. As more patients undergo minimally invasive spine surgery, more long-term outcome and complications data have been collected. The authors describe the common complications associated with these minimally invasive surgical procedures and delineate management options for the spine surgeon.

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Matthew A. Adamo, Doniel Drazin and John B. Waldman

Object

Infants with severe traumatic brain injury represent a therapeutic challenge. The internal absence of open space within the infant cranial vault makes volume increases poorly tolerated. This report presents 7 cases of decompressive craniectomy in infants with cerebral edema.

Methods

The authors reviewed the medical charts of infants with brain injuries who presented to Albany Medical Center Hospital between January 2004 and July 2007. Variables that were examined included patient age, physical examination results at admission, positive imaging findings, surgery performed, complications, requirement of permanent CSF diversion, and physical examination results at discharge and outpatient follow-up using the King's Outcome Scale for Childhood Head Injury. Seven infants met the inclusion criteria for the study. Six infants experienced nonaccidental trauma, and 1 had a large infarction of the middle cerebral artery territory secondary to a carotid dissection. At admission, all patients were minimally responsive, 4 had equal and minimally reactive pupils, 3 had anisocoria with the enlarged pupil on the same side as the brain lesion, and all had right-sided hemiparesis. Six patients received a left hemicraniectomy, whereas 1 received a left frontal craniectomy. In all cases, bone was cultured and stored at the bone bank.

Results

Postoperatively, 3 patients who developed draining CSF fistulas needed insertions of external ventricular drains, with incisions oversewn using nylon sutures and a liquid bonding agent. After prolonged CSF drainage and wound care, these patients all developed epidural and subdural empyemas necessitating surgical drainage and debridement. Methicillin-resistant Staphylococcus aureus was found in 2 patients and Enterococcus in the third. All patients developed hydrocephalus necessitating the insertion of a ventriculoperitoneal shunt, and all had bone replaced within 1–6 months from the time of the original operation. Two patients required reoperation due to bone resorption. At outpatient follow-up visits, all had scores of 3 or 4 on the King's Outcome Scale for Childhood Head Injury. Each patient was awake, interactive, and could sit, as well as either crawl or walk with assistance. All had persistent, improving right-sided hemiparesis and spasticity.

Conclusions

Despite poor initial examination results, infants with severe traumatic brain injury can safely undergo decompressive craniectomy with reasonable neurological recovery. Postoperative complications must be anticipated and treated appropriately. Due to the high rate of CSF fistulas encountered in this study, it appears reasonable to recommend both the suturing in of a dural augmentation graft and the placement of either a subdural drain or a ventriculostomy catheter to relieve pressure on the healing surgical incision. Also, one might want to consider using a T-shaped incision as opposed to the traditional reverse question mark-shaped incision because wound healing may be compromised due to the potential interruption of the circulation to the posterior and inferior limb with this latter incision.

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Joachim Oertel, Stefan Linsler, Akos Csokonay, Henry W. S. Schroeder and Sebastian Senger

OBJECTIVE

The unexpected intraoperative intraventricular hemorrhage is a rare but feared and life-threatening complication in neuroendoscopic procedures because of loss of endoscopic vision. The authors present their experience with the so-called “dry field technique” (DFT) for the management of intraventricular hemorrhages during purely endoscopic procedures. This technique requires the aspiration of the entire intraventricular CSF to achieve clear visualization of the bleeding source.

METHODS

More than 500 neuroendoscopic intraventricular procedures were retrospectively analyzed over the last 24 years for documented severe hemorrhages, which were treated by the application of the DFT.

RESULTS

The technique was required in 6 cases, including tumor resection/biopsy, cyst resection, and intraventricular lavage. Additionally, the technique was applied as part of the planned strategy in 3 cases of endoscopic tumor removal. The hemorrhage was stopped in all cases and no associated postoperative deficits occurred.

CONCLUSIONS

Although severe hemorrhages are rare, the neurosurgeon needs to be aware of them and has to establish strategies for their management. Most hemorrhages can be stopped by constant irrigation and coagulation. In the other rare cases, the DFT is a safe, reliable technique and can be easily incorporated into endoscopic surgery.

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John R. Vender, Sydney Hester, Jennifer L. Waller, Andy Rekito and Mark R. Lee

of catheter w/ normal function 0.00 ± 0.00 0.02 ± 0.12  0 67 (100.00) 126 (98.44)  1 0 (0.00) 2 (1.56) The difference in total overall number of procedures (elective and complication related) was statistically significantly higher in the pediatric group. In addition, there was a statistically and significantly higher percentage of procedures for overall complication management and wound complication management in pediatric patients compared with adult patients. More surgeries were performed for catheter and pump-related complications

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Thomas C. Origitano, Guy J. Petruzzelli, Darl Vandevender and Bahman Emami

Object

Malignant tumors of the skull base represent a group of diverse and infrequent lesions. Comprehensive oncological management requires a multidisciplinary team of neurological surgeons, otolaryngologists, radiation oncologists, plastic surgeons, and medical oncologists. The authors describe an institutional experience in performing 54 combined anterior–anterolateral cranial base resections for malignant disease.

Methods

The technical considerations for preoperative workup, surgical approach, resection, and reconstruction are outlined and illustrated. Considerations for complication management and avoidance are detailed.

Conclusions

Overall mortality (0%) and morbidity rates (18%) are acceptable. The influence on the natural history of the disease process is an ongoing study.

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Akshay Sharma, Gabrielle E. Rieth, Joseph E. Tanenbaum, James S. Williams, Nakao Ota, Srikant Chakravarthi, Sunil Manjila, Amin Kassam and Bulent Yapicilar

OBJECTIVE

The middle clinoid process (MCP) is a bony projection that extends from the sphenoid bone near the lateral margin of the sella turcica. The varied prevalence and morphological features of the MCP in populations stratified by age, race, and sex are unknown; however, the knowledge of its anatomy and preoperative recognition on CT scans can aid greatly in complication avoidance and management. The aim of this study was to further illustrate the surgical anatomy of the parasellar region and to quantify the incidence of MCP and caroticoclinoid rings (CCRs) in dried preserved human anatomical specimens.

METHODS

The presence, dimensions, morphological classification (incomplete, contact, and CCR), and intracranial relations of the MCP were measured in 2726 dried skull specimens at the Hamann-Todd Osteological Collection at the Cleveland Museum of Natural History. Specific morphometric data points were recorded from each of these hemiskulls, and categorized based on age, sex, and ethnicity. Linear and logistic regressions were used to determine associations between explanatory variables and MCP morphology. Computed tomography scans of the skull specimens were obtained to explore radiological landmarks for different types of MCPs. Illustrative intraoperative videos were also analyzed in the light of these crucial surgical landmarks.

RESULTS

The sample included 2250 specimens from males and 476 from females. Specimens were classified as either “white” (60.5%) or “black” (39.2%). An MCP was found in 42% of specimens, with 60% of those specimens presenting bilaterally. Fully ossified CCR comprised 27% of all MCPs, and contact (defined as contact without ossification between MCP and anterior clinoid process) comprised 4% of all MCPs. White race (relative to black race) and increasing age were significant predictors of MCP presence (p < 0.001). White race was significantly associated with greater average MCP height (p < 0.001). Among skulls with CCR, both male sex and older age (> 70 years relative to < 50 years) were associated with increased CCR diameter (p < 0.001). No other significant predictors or associations were observed. The CT scans of skulls replicated and validated the authors’ morphometric observations on incomplete, contact, and CCR patterns adequately. The surgical strategies of clinoid bone removal are validated, with appropriate video illustrations.

CONCLUSIONS

Variations in the patterns of bony MCPs can pose a significant risk for injury to the internal carotid artery during parasellar procedures, especially those involving clinoidectomy and optic strut drilling. Understanding parasellar anatomy, especially on skull-base CT imaging, may be integral to surgical planning and preoperative risk counseling in both transcranial and extended endonasal procedures, as well as to preparing for complications management perioperatively.

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applicable, but I believe the exposure requirement is essentially comparable. References 1. Malis LI : Tentorial, torcular and paratorcular meningiomas , in Apuzzo MLJ (ed): Brain Surgery. Complication Management and Avoidance. New York : Churchill Livingstone , 1993 , Vol 1 , pp 231 – 247 Malis LI: Tentorial, torcular and paratorcular meningiomas, in Apuzzo MLJ (ed): Brain Surgery. Complication Management and Avoidance. New York: Churchill Livingstone, 1993, Vol 1, pp 231–247 2. Malis LI

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. Berlin : Springer-Verlag , 1990 , pp 89 – 219 Lasjaunias P, Berenstein A: Surgical Neuroangiography, Vol 3. Functional Vascular Anatomy of Brain, Spinal Cord, and Spine. Berlin: Springer-Verlag, 1990, pp 89–219 7. Mayer PL , Kier EL : The phylogenetic and ontogenetic basis of cerebrovascular anomalies and variants , in Apuzzo MLJ (ed): Brain Surgery: Complication Management and Avoidance. New York : Churchill Livingstone , 1992 (In press) Mayer PL, Kier EL: The phylogenetic and ontogenetic basis of

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Visish M. Srinivasan, Andrew P. Carlson, Maxim Mokin, Jacob Cherian, Stephen R. Chen, Ajit Puri and Peter Kan

Cerebrovascular Disease and Neurointerventional Technique , ed 2 . New York : Springer , 2013 14 Hauck EF , Natarajan SK , Langer DJ , Hopkins LN , Siddiqui AH , Levy EI : Retrograde trans-posterior communicating artery snare-assisted rescue of lost access to a foreshortened Pipeline Embolization Device: complication management . Neurosurgery 67 ( 2 Suppl Operative ): 495 – 502 , 2010 15 Jabbour P , Chalouhi N , Tjoumakaris S , Gonzalez LF , Dumont AS , Randazzo C , : The Pipeline Embolization Device: learning curve and predictors

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Jason P. Sheehan

transcended the AANS/Congress of Neurological Surgeons neurosurgical sections of tumors, pediatrics, vascular, and stereotactic and functional neurosurgery. Radiosurgical devices have become significantly more refined since the early work by Leksell and colleagues. Neurosurgeons now use radiosurgical principles to treat spinal diseases in addition to more traditional intracranial pathology. Similarly, the radiosurgical delivery techniques, indications, and complication management have become more fully defined. While performing radiosurgery, neurosurgeons now play a role