Subfrontal Infrachiasmatic Approach

Subfrontal Infrachiasmatic Approach

In a video, Aldave et al., from the Division of Pediatric Neurosurgery, Texas Children’s Hospital, Department of Neurosurgery, Baylor College of Medicine, presented a case of a 6-yr-old girl with a large sellar-suprasellar craniopharyngioma.

The fact that the sphenoid was not pneumatized and the chiasm was elevated 1.2 cm from the planum sphenoidale were some of the reasons to choose a subfrontal infrachiasmatic approach as they discuss and show in the video. This approach has not been very well established in the literature but they demonstrated it can become a good alternative for a particular type of sellar-suprasellar tumors. Appropriate video authorization consent was obtained from the parent of the patient 1).

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Watch now at https://academic.oup.com/ons/article-lookup/doi/10.1093/ons/opy403

1)

Aldave G, Zinn P, Whitehead WE. Subfrontal Infrachiasmatic Approach to a Craniopharyngioma Resection: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown). 2019 Feb 5. doi: 10.1093/ons/opy403. [Epub ahead of print] PubMed PMID: 30726971.

Internal maxillary artery to middle cerebral artery bypass

Internal maxillary artery to middle cerebral artery bypass

The cervical carotid system has been used as a source of donor vessels for radial artery or saphenous vein grafts in cerebral bypassInternal maxillary artery to middle cerebral artery bypass has been described as an alternative, with reduction of graft length potentially correlating with improved potency.

The internal maxillary artery to middle cerebral artery “middle” flow bypass allows for shorter graft length with both the proximal and distal anastomoses within the same microsurgical field. These unique variable flow grafts represent an ideal opportunity for use of the cephalic vein of the forearm, which is more easily harvested than the wider saphenous vein graft and which has good match size to the M1/M2 segments of the middle cerebral artery. The vessel wall is supple, which facilitates handling during anastomosis. There is lower morbidity potential than utilization of the radial artery. Going forward, the cephalic vein will be the preferred choice for external carotid-internal carotid transplanted conduit bypass for Nossek et al. 1).

The internal maxillary artery (IMA) has been proposed as a donor to decrease invasiveness, but its length is insufficient for direct intra intracranial bypass surgery. Feng et al., reported interposition of a superficial temporal artery (STA) graft for high-flow IMA to middle cerebral artery (MCA) bypass using a middle fossa approach.

Twelve specimens were studied. A 7.5-cm STA graft was obtained starting 1.5 cm below the zygomatic arch. The calibers of STA were measured. After a pterional craniotomy, the IMA was isolated inside the infratemporal fossa through a craniectomy within the lateral triangle (lateral to the posterolateral triangle) in the middle fossa and transposed for proximal end-to-end anastomosis to the STA. The Sylvian fissure was split exposing the insular segment of the MCA, and an STA-M2 end-to-side anastomosis was completed. Finally, the length of graft vessel was measured.

Average diameters of the proximal and distal STA ends were 2.3 ± 0.2 and 2.0 ± 0.1 mm, respectively. At the anastomosis site, the diameter of the IMA was 2.4 ± 0.6 mm, and the MCA diameter was 2.3 ± 0.3 mm. The length of STA graft required was 56.0 ± 5.9 mm.

The STA can be used as an interposition graft for high-flow IMA-MCA bypass if the STA is obtained 1.5 cm below the zygomatic arch and the IMA is harvested through the proposed approach. This procedure may provide an efficient and less invasive alternative for high-flow EC-IC bypass 2).


The maxillary artery runs parallel to the frontal branch of the superficial temporal artery and is located on average 24.8 ± 3.8 mm inferior to the midpoint of the zygomatic arch. The pterygoid segment of the MaxA is most appropriate for bypass with a maximal diameter of 2.5 ± 0.4 mm. The pterygoid segment can be divided into a main trunk and terminal part based on anatomic features and use in the bypass procedure. The main trunk of the pterygoid segment can be reached extracranially, either by following the deep temporal arteries downward toward their origin from the MaxA or by following the sphenoid groove downward to the terminal part of the pterygoid segment, which can be followed proximally to expose the entire MaxA. In comparison, the prebifurcation diameter of the superficial temporal artery is 1.9 ± 0.5 mm. The average lengths of the mandibular and pterygoid MaxA segments are 6.3 ± 2.4 and 6.7 ± 3.3 mm, respectively.

The MaxA can be exposed without zygomatic osteotomies or resection of the middle fossa floor. Anatomic landmarks for exposing the MaxA include the anterior and posterior deep temporal arteries and the pterygomaxillary fissure 3).


Long Wang published all internal maxillary artery (IMA) bypasses performed between January 2010 and July 2018 in a single-center, single-surgeon practice.

In total, 12 patients (9 males, 3 females) with Complex middle cerebral artery aneurysms (CMCAAs) managed by high-flow IMA bypass were identified.

The mean size of CMCAAs was 23.7 mm (range 10–37 mm), and the patients had a mean age of 31.7 years (range 14–56 years). The aneurysms were proximally occluded in 8 cases, completely trapped in 3 cases, and completely resected in 1 case. The radial artery was used as the graft vessel in all cases. At discharge, the graft patency rate was 83.3% (n = 10), and all aneurysms were completely eliminated (83.3%, n = 10) or greatly diminished (16.7%, n = 2) from the circulation. Postoperative ischemia was detected in 2 patients as a result of graft occlusion, and 1 patient presenting with subarachnoid hemorrhage achieved improved modified Rankin Scale scores compared to the preoperative status but retained some neurological deficits. Therefore, neurological assessment at discharge showed that 9 of the 12 patients experienced unremarkable outcomes. The mean interval time from bypass to angiographic and clinical follow-up was 28.7 months (range 2–74 months) and 53.1 months (range 19–82 months), respectively. Although 2 grafts remained occluded, all aneurysms were isolated from the circulation, and no patient had an unfavorable outcome.

The satisfactory result in the present study demonstrated that IMA bypass is a promising method for the treatment of CMCAAs and should be maintained in the neurosurgical armamentarium. However, cases with intraoperative radical resection or inappropriate bypass recipient selection such as aneurysmal wall should be meticulously chosen with respect to the subtype of MCA aneurysm 4).


Wang L, Qian H, Shi X. The Reiteration of “Less Invasive” Way and Graft Selections for Internal Maxillary Bypass. World Neurosurg. 2018 Sep 8. pii: S1878-8750(18)32037-0. doi: 10.1016/j.wneu.2018.08.228. [Epub ahead of print] PubMed PMID: 30205227.

Videos

Internal Maxillary Artery to M2 Middle Cerebral Artery Bypass With Modified Superficial Temporal Artery Graft: 3-Dimensional Operative Video 5).


A video demonstrates a 37-year-old female who presented with a 1-month history of severe headache. Her complex middle cerebral artery (MCA) aneurysm was treated by IMaxA bypass with radial artery graft. Preoperative neuroimaging revealed a giant, fusiform, thrombosed aneurysm that extensively involved the sphenoidal (M1) and insular (M2) segments of the MCA. After a multidisciplinary discussion, the reversal high-flow IMaxA bypass was performed, followed by proximal MCA occlusion. We approached the aneurysm using a frontotemporal craniotomy with zygomatic osteotomy to expose the pterygoid segment of IMaxA (IM2), which is defined as the “SHI” IMaxA bypass method. Simultaneously, the radial artery graft was harvested and prepared before being anastomosed in an end-to-end fashion to the IM2 using No. 9-0 polypropylene. The free end of the RAG was then brought to the sylvian fissure and anastomosed to the M2 in an end-to-side manner. The proximal part of M1 after the bypass takeoff was then occluded with a permanent aneurysm clip (Aesculap Instruments Corp., Tuttlingen, Germany). Complete elimination of the aneurysm with a patent graft artery was observed postoperatively, and the patient was discharged with intact neurologic function (modified Rankin Scale score 0) 6).

References

1)

Nossek E, Costantino PD, Chalif DJ, Ortiz RA, Dehdashti AR, Langer DJ. Forearm Cephalic Vein Graft for Short, “Middle”-Flow, Internal Maxillary Artery to Middle Cerebral Artery Bypass. Neurosurgery. 2015 Sep 23. [Epub ahead of print] PubMed PMID: 26418874.
2)

Feng X, Meybodi AT, Rincon-Torroella J, El-Sayed IH, Lawton MT, Benet A. Surgical Technique for High-Flow Internal Maxillary Artery to Middle Cerebral Artery Bypass Using a Superficial Temporal Artery Interposition Graft. Oper Neurosurg (Hagerstown). 2017 Apr 1;13(2):246-257. doi: 10.1093/ons/opw006. PubMed PMID: 28927217.
3)

Yağmurlu K, Kalani MYS, Martirosyan NL, Safavi-Abbasi S, Belykh E, Laarakker AS, Nakaji P, Zabramski JM, Preul MC, Spetzler RF. Maxillary Artery to Middle Cerebral Artery Bypass: A Novel Technique for Exposure of the Maxillary Artery. World Neurosurg. 2017 Apr;100:540-550. doi: 10.1016/j.wneu.2016.12.130. Epub 2017 Jan 9. PubMed PMID: 28089839.
5)

Benet A, Meybodi AT, Feng X, Lawton MT. Internal Maxillary Artery to M2 Middle Cerebral Artery Bypass With Modified Superficial Temporal Artery Graft: 3-Dimensional Operative Video. Oper Neurosurg (Hagerstown). 2017 Apr 1;13(2):280. doi: 10.1093/ons/opw010. PubMed PMID: 28927219.
6)

Wang L, Qian H, Shi X. The “SHI” Internal Maxillary Bypass for 1 Giant Fusiform MCA bifurcation 2 Aneurysm: 2-Dimensional Operative Video. World Neurosurg. 2018 Oct 19. pii: S1878-8750(18)32360-X. doi: 10.1016/j.wneu.2018.10.063. [Epub ahead of print] PubMed PMID: 30347305.

Lumbar spinal stenosis case series

Lumbar spinal stenosis case series

Nine hundred and eighteen patients of the Acıbadem Fulya Hospital and Acıbadem Taksim Hospital were treated for single or multilevel lumbar spinal stenosis (LSS) by bilateral decompression via unilateral approach (BDUA) between January 2002 and January 2016. 180 patients of the 918 underwent microdiscectomy with decompression. They were then followed up postoperatively, at 6 and 12 months with radiological investigations, Oswestry Disability Index (ODI) and 36-item short-form health survey (SF-36) tests.

Four hundred and ninety-two patients were females (53,6%), four hundred and twenty six were males (46,4) whose mean age was 63,83±10,16 (range: 43-79 years). Duration of symptoms ranged from 4 to 49 months. Average follow-up time was 98 months (range 25-168 months) and the reoperation rate (RR) was 2,5%. The ODI scores decreased significantly (30.65± 7.82, to 11.32 ± 2.50 at six months and 11.30 ± 2.49 at first year) and the SF-36 parameter scores demonstrated a significant improvement in the early and late follow-up results.

BDUA for LSS allowed a sufficient and safe decompression of the neural structures, resulted in a highly significant reduction of the symptoms and disability, acceptable RR, and improved health-related quality of life 1).


A successive series of 102 patients with lumbar spinal stenosis from Aachen (with and without previous lumbar surgery) were treated with decompression alone during a 3-year period. Data on pre- and postoperative back pain and leg pain (numerical rating scale [NRS] scale) were retrospectively collected from questionnaires with a return rate of 65% (n = 66). The complete cohort as well as patients with first-time surgery and re-decompression were analyzed separately. Patients were dichotomized to short-term follow-up (< 100 weeks) and long-term follow-up (> 100 weeks) postsurgery.

Overall, both back pain (NRS 4.59 postoperative versus 7.89 preoperative; p < 0.0001) and leg pain (NRS 4.09 versus 6.75; p < 0.0001) improved postoperatively. The short-term follow-up subgroup (50%, n = 33) showed a significant reduction in back pain (NRS 4.0 versus 6.88; p < 0.0001) and leg pain (NRS 2.49 versus 6.91: p < 0.0001). Similar results could be observed for the long-term follow-up subgroup (50%, n = 33) with significantly less back pain (NRS 3.94 versus 7.0; p < 0.0001) and leg pain (visual analog scale 3.14 versus 5.39; p < 0.002) postoperatively. Patients with previous decompression surgery benefit significantly regarding back pain (NRS 4.82 versus 7.65; p < 0.0024), especially in the long-term follow-up subgroup (NRS 4.75 versus 7.67; p < 0.0148). There was also a clear trend in favor of leg pain in patients with previous surgery; however, it was not significant.

Decompression of lumbar spinal stenosis without fusion led to a significant and similar reduction of back pain and leg pain in a short-term and a long-term follow-up group. Patients without previous surgery benefited significantly better, whereas patients with previous decompression benefited regarding back pain, especially for long-term follow-up with a clear trend in favor of leg pain 2).


A total of 25 patients between May 2015 and June 2016 affected by radiologically demonstrated one-level lumbar spinal stenosis (LSS) with facet joint degeneration and grade I spondylolisthesis were included in this prospective study. All the patients underwent laminectomyforaminotomy, and one-level facet fixation (Facet-Link, Inc., Rockaway, New Jersey, United States). Pre- and postoperative clinical (Oswestry Disability Index[ODI], Short Form 36 [SF-36]) and radiologic (radiographs, magnetic resonance imaging, computed tomography) data were collected and analyzed.

Mean follow-up was 12 months. The L4L5 level was involved in 18 patients (72%) and L5S1 in 7 patients (28%); the average operative time was 80 minutes (range: 65-148 minutes), and the mean blood loss was 160 mL (range: 90-200 mL). ODI and SF-36 showed a statistically significant (p < 0.05) improvement at last follow-up.

Transfacet fixation is a safe and effective treatment option in patients with single-level LSS, facet joint degeneration, and mild instability 3).

2017

A retrospective matched-pair cohort study included a total of 144 patients who underwent surgery for bisegmental spinal stenosis at the levels L3-4 and L4-5 between 2008 and 2012. There were 72 matching pairs that corresponded in sex, year of birth, and width of the stenosed segments. The patients’ impairments were reported before, immediately after, and 6 and 12 months after surgery using the Oswestry Disability Questionnaire (ODQ-D) and the EuroQol-5D (EQ-5D). The data were evaluated statistically. Results The comparison of both surgical procedures regarding walking ability (walking a distance with and without a walking aid) revealed a significant difference. Patients who underwent hemilaminectomy had better postoperative results. The individual criteria of the ODQ-D and EQ-5D revealed no significant differences between 2-level fenestration and hemilaminectomy; however, there is always significant postoperative improvement in comparison with preoperative status. Age, sex, body mass index, comorbidities, smoking, and alcohol consumption had no influence on the surgical results. The reoperation rate was between 13% and 15% for both surgical techniques, not being significantly different. Conclusion Fenestration and hemilaminectomy are equivalent therapies for bisegmental lumbar spinal canal stenosis. Regarding walking, the study revealed better results for hemilaminectomy than for fenestration in this cohort of patients. Pain intensity, personal care, lifting and carrying of objects, sitting, social life, and travel all improved significantly postoperatively as compared with preoperatively. In both groups, health status as the decisive predictor improved considerably after surgery. We could show that both surgical methods result in significant postoperative improvement of all the individual criteria of the ODQ-D and the EQ-5D 4).

2016

726 patients with lumbar stenosis (without spondylolisthesis or scoliosis) and a baseline back pain score ≥ 5 of 10 who underwent surgical decompression only. No patient was reported to have significant spondylolisthesis, scoliosis, or sagittal malalignment. Standard demographic and surgical variables were collected, as well as patient outcomes including back and leg pain scores, Oswestry Disability Index (ODI), and EuroQoL 5D (EQ-5D) at baseline and 3 and 12 months postoperatively. RESULTS The mean age of the cohort was 65.6 years, and 407 (56%) patients were male. The mean body mass index was 30.2 kg/m2, and 40% of patients had 2-level decompression, 29% had 3-level decompression, 24% had 1-level decompression, and 6% had 4-level decompression. The mean estimated blood loss was 130 ml. The mean operative time was 100.85 minutes. The vast majority of discharges (88%) were routine home discharges. At 3 and 12 months postoperatively, there were significant improvements from baseline for back pain (7.62 to 3.19 to 3.66), leg pain (7.23 to 2.85 to 3.07), EQ-5D (0.55 to 0.76 to 0.75), and ODI (49.11 to 27.20 to 26.38). CONCLUSIONS Through the 1st postoperative year, patients with lumbar stenosis-without spondylolisthesis, scoliosis, or sagittal malalignment-and clinically significant back pain improved after decompression-only surgery 5).

2015

88 patients with LSS (47 men and 41 women) who ranged in age from 39 to 86 years (mean age 68.7 years). All patients had undergone microendoscopic laminotomy at Osaka City University Graduate School of Medicine from May 2008 through October 2012. The minimum duration of clinical and radiological follow-up was 6 months. All patients were evaluated by Japanese Orthopaedic Association (JOA) and visual analog scale (VAS) scores for low back painleg pain, and leg numbness before and after surgery.

The distance between the C7 plumb line and the posterior corner of the sacrum (sagittal vertical axis [SVA]) was measured on lateral standing radiographs of the entire spine obtained before surgery.

Radiological factors and clinical outcomes were compared between patients with a preoperative SVA ≥ 50 mm (forward-bending trunk [F] group) and patients with a preoperative SVA < 50 mm (control [C] group).

A total of 35 patients were allocated to the F group (19 male and 16 female) and 53 to the C group (28 male and 25 female).

The mean SVA was 81.0 mm for patients in the F group and 22.0 mm for those in the C group. At final follow-up evaluation, no significant differences between the groups were found for the JOA score improvement ratio (73.3% vs 77.1%) or the VAS score for leg numbness (23.6 vs 24.0 mm); the VAS score for low-back pain was significantly higher for those in the F group (21.1 mm) than for those in the C group (11.0 mm); and the VAS score for leg pain tended to be higher for those in the F group (18.9 ± 29.1 mm) than for those in the C group (9.4 ± 16.0 mm).

Preoperative alignment of the spine in the sagittal plane did not affect JOA scores after microendoscopic laminotomy in patients with LSS. However, low-back pain was worse for patients with preoperative anterior translation of the C-7 plumb line than for those without 6).

References

1)

Yüce İ, Kahyaoğlu O, Çavuşoğlu HA, Çavuşoğlu H, Aydın Y. Long term clinical outcome and reoperation rate for microsurgical bilateral decompression via unilateral approach of lumbar spinal stenosis. World Neurosurg. 2019 Jan 30. pii: S1878-8750(19)30203-7. doi: 10.1016/j.wneu.2019.01.105. [Epub ahead of print] PubMed PMID: 30710724.
2)

Geiger MF, Bongartz N, Blume C, Clusmann H, Müller CA. Improvement of Back and Leg Pain after Lumbar Spinal Decompression without Fusion. J Neurol Surg A Cent Eur Neurosurg. 2018 Dec 5. doi: 10.1055/s-0038-1669473. [Epub ahead of print] PubMed PMID: 30517963.
3)

Trungu S, Pietrantonio A, Forcato S, Tropeano MP, Martino L, Raco A. Transfacet Screw Fixation for the Treatment of Lumbar Spinal Stenosis with Mild Instability: A Preliminary Study. J Neurol Surg A Cent Eur Neurosurg. 2018 Sep;79(5):358-364. doi: 10.1055/s-0038-1655760. Epub 2018 Jul 16. PubMed PMID: 30011420.
4)

Schüppel J, Weber F. Retrospective Matched-Pair Cohort Study on Effect of Bisegmental Fenestration versus Hemilaminectomy for Bisegmental Spinal Canal Stenosis at L3-L4 and L4-L5. J Neurol Surg A Cent Eur Neurosurg. 2017 Jan 9. doi: 10.1055/s-0036-1597617. [Epub ahead of print] PubMed PMID: 28068753.
5)

Crawford CH 3rd, Glassman SD, Mummaneni PV, Knightly JJ, Asher AL. Back pain improvement after decompression without fusion or stabilization in patients with lumbar spinal stenosis and clinically significant preoperative back pain. J Neurosurg Spine. 2016 Nov;25(5):596-601. PubMed PMID: 27285666.
6)

Dohzono S, Toyoda H, Matsumoto T, Suzuki A, Terai H, Nakamura H. The influence of preoperative spinal sagittal balance on clinical outcomes after microendoscopic laminotomy in patients with lumbar spinal canal stenosis. J Neurosurg Spine. 2015 Jul;23(1):49-54. doi: 10.3171/2014.11.SPINE14452. Epub 2015 Apr 3. PubMed PMID: 25840041.
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