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Mehmet Arslan, Ayhan Cömert, Halil İbrahim Açar, Mevci Özdemir, Alaittin Elhan, İbrahim Tekdemir, R. Shane Tubbs, Ayhan Attar, and Hasan Çağlar Uğur

Object

Although infrequent, injury to adjacent neurovascular structures during posterior approaches to lumbar intervertebral discs can occur. A detailed anatomical knowledge of relationships may decrease surgical complications.

Methods

Ten formalin-fixed male cadavers were used for this study. Posterior exposure of the lumbar thecal sac, nerve roots, pedicles, and intervertebral discs was performed. To identify retroperitoneal structures at risk during posterior lumbar discectomy, a transabdominal retroperitoneal approach was performed, and observations were made. The distances between the posterior and anterior edges of the lumbar intervertebral discs were measured, and the relationships between the disc space, pedicle, and nerve root were evaluated.

Results

For right and left sides, the mean distance from the inferior pedicle to the disc gradually increased from L1–2 to L4–5 (range 2.7–3.8 mm and 2.9–4.5 mm for right and left side, respectively) and slightly decreased at L5–S1. For right and left sides, the mean distance from the superior pedicle to the disc was more or less the same for all disc spaces (range 9.3–11.6 mm and 8.2–10.5 mm for right and left, respectively). The right and left mean disc-to-root distance for the L3–4 to L5–S1 levels ranged from 8.3 to 22.1 mm and 7.2 to 20.6 mm, respectively. The root origin gradually increased from L-1 to L-5. The right and left nerve root–to-disc angle gradually decreased from L-3 to S-1 (range 105°–110.6° and 99°–108°). Disc heights gradually increased from L1–2 to L5–S1 (range 11.3–17.4 mm). The mean distance between the anterior and posterior borders of the intervertebral discs ranged from 39 to 46 mm for all levels.

Conclusions

To avoid neighboring neurovascular structures, instrumentation should not be inserted into the lumbar disc spaces more than 3 cm from their posterior edge. Accurate anatomical knowledge of the relationships of intervertebral discs to nerve roots is needed for spine surgeons.

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John D. Reynolds III

passed by using a slightly more rigid tubing, as suggested by Cowan and Allen. 2 Adequate caution must of course be taken. The potential complications of guide wire and catheter procedures have been reviewed by Cope 1 and Lang. 3 Attempts to force the wire should be avoided since vascular perforation with subintimal placement or cardiac tamponade can occur; this principle is particularly important when dealing with areas of complete occlusion. There has been no incident of vascular perforation associated with this technique. Aspiration or manometric determination

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Cameron G. McDougall, Van V. Halbach, Christopher F. Dowd, Randall T. Higashida, Donald W. Larsen, and Grant B. Hieshima

, most physicians would agree that these are offset by the increased risk of thromboembolism in patients who do not undergo anticoagulation during treatment. Clearly, prompt recognition of hemorrhage and immediate reversal of anticoagulation with protamine sulfate are essential. In a previously published work, 14 other principles of management were discussed for dealing with vascular perforations that occur during endovascular therapy. The cases described in this report serve as examples of the pitfalls involved in endovascular aneurysm therapy and provide lessons

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Gary M. Nesbit, Wayne M. Clark, Oisin R. O'Neill, and Stanley L. Barnwell

risk is not known. Although in our one patient with carotid dissection catheter navigation was straightforward, if the wire and catheter had instead entered the subintimal false lumen, difficulty may have been encountered, significantly raising the risk of perforation. One approach to avoid the embolic and cervical carotid perforation risk would be to cross the ACoA from the contralateral ICA to perform the thrombolysis. In our opinion, the risk of intracranial vascular perforation is much higher with this approach. Perforation of intracranial vessels is an

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Yusuke Egashira, Shinichi Yoshimura, Yukiko Enomoto, Mitsunori Ishiguro, Takahiko Asano, and Toru Iwama

vascular perforations, arterial dissections, thromboembolic occlusions, or any other complications related to the endovascular procedure. Routine Endovascular Procedure The treatment method was selected according to the results of the International Subarachnoid Aneurysm Trial, 11 and patients with very small or wide-necked aneurysms, MCA aneurysms, or large ICHs were mostly referred for craniotomy. Diagnostic digital subtraction angiography and embolization were performed in an angiography suite (Axiom Artis BA, Siemens). Three-dimensional rotational angiography

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Phillip D. Purdy, H. Hunt Batjer, and Duke Samson

complicated by the development of uncontrollable cerebral edema attributed to normal perfusion pressure breakthrough, unrelated to the embolization or its complication. Results The overall series is summarized in Table 1 . Two of the surgical interventions (in Cases 1 and 2) were for vascular perforations at the time of embolization. With current technology, we might manage these interventionally today, as in Case 7. Case 3 represents intraparenchymal hemorrhage following rupture of the middle cerebral artery during inflation of a detachable balloon. That patient

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Van V. Halbach, Randall T. Higashida, Christopher F. Dowd, Kenneth W. Fraser, Tony P. Smith, George P. Teitelbaum, Charles B. Wilson, and Grant B. Hieshima

entered the dissection site, producing rebleeding. Prompt recognition and closure of the bleeding site resulted in a good outcome; although the patient still suffers mild sensory deficits, the only residual effect is a partial Wallenberg syndrome related to closure of the PICA. Our experience with other vascular perforations occurring during neurointerventional procedures 21 has shown that prompt recognition and closure of the perforation results in good clinical outcome in the majority of patients. Surgical Therapy Current surgical recommendations for the

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Hitoshi Fukuda, Kosuke Hayashi, Takafumi Moriya, Satoru Nakashita, Benjamin W. Y. Lo, and Sen Yamagata

evaluation for symptomatic vasospasm (n = 11) and chronic hydrocephalus (n = 14) were excluded from these analyses. Procedure-related complications were defined as symptomatic postoperative hematoma formation or cerebral infarction in cases of surgical clipping, vascular perforation, hematoma growth unrelated to aneurysmal rebleeding, 5 or symptomatic thromboembolic event in cases of endovascular coiling. Symptomatic vasospasm was defined as clinical symptoms, such as confusion or decline in level of consciousness, or focal deficits not clinically or radiographically

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Kanji Nakai, Yuji Morimoto, Kojiro Wada, Hiroshi Nawashiro, Katsuji Shima, and Makoto Kikuchi

the intraluminal medium and then is transformed into a force that induces cavitation bubbles. The bubbles immediately collapse, forming shock or sonic waves that provoke vasodilation. 14 The delivery of excessive energy to the vascular wall causes endothelial denudation, intramural hemorrhage, dissection, aneurysm formation, or perforation. 17 Teramura and coworkers 24 reported that the required energy to induce vasodilation is close to the energy needed to cause vascular perforation. In contrast, the use of a low-intensity and continuous-wave UV laser may be

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Paul G. Matz, Stephen M. Massa, Philip R. Weinstein, Christopher Turner, S. Scott Panter, and Frank R. Sharp

between the lysed and whole blood groups is that, after a single injection into the subarachnoid space, a greater concentration of one or more substances is released into the subarachnoid space from the lysed blood than that released from the whole blood. Injection of lysed or whole blood does not physiologically resemble clinical SAH. Vascular perforation produces physiological changes similar to those observed after clinical SAH, 8 although the volume of hemorrhage cannot be controlled in this model. Following intracranial vascular perforation, stress gene