Anteroposterior Approach Research Articles

Surgical Results of Cochlear Implantation in Malformed Cochlea

To report the surgical aspects of cochlear implantation in malformed cochlea. Tertiary care center. Retrospective case review. Between November 1997 and October 2004, 20 patients with inner ear malformations were implanted in our department. The age range was between 2 and 37 years (average, 8.8 yr). The anomalies were classified according to Sennaroglu and Saatci classification. There were two patients with common cavity deformity, four cases of incomplete partition (IP) type I (cystic cochleovestibular malformation), four cases of IP type II (classical Mondini's deformity), nine patients with large vestibular aqueduct (LVA) syndrome, and one patient with X-linked deafness. Standard transmastoid facial recess approach was used in 17 patients (three patients with IP I, four patients with IP II, and nine patients with LVA syndrome). In the remaining patient with IP I, because of the dehiscent and anteriorly located facial nerve, the surgical approach had to be modified, and an anteroposterior approach was used. After elevating the tympanomeatal flap, the electrode was inserted through the ear canal and then transferred to the mastoid through a full-length cut produced in the ear canal. The flap then returned to its place. In the patients with common cavity deformity, the electrode was inserted by the transmastoid labyrinthotomy approach. Facial nerve had an abnormal course in four patients, but no patient had facial weakness postoperatively. Cerebrospinal fluid gusher was encountered in four patients, whereas oozing was present in five patients. It seems that a slightly larger cochleostomy may reduce postoperative rhinorrhea. The patient with common cavity deformity showed abnormal vestibular stimulation which decreased and was totally abolished during a 3-month period. Based on these findings, cochlear implantation is surgically feasible in patients with common cavity, IP types I and II, and LVA. The surgeon should be ready to make modifications in the surgical approach because of the abnormal course of the facial nerve and be ready to produce special precautions to cerebrospinal fluid gusher.

Neuromuscular Scoliosis Treated by Segmental Third-Generation Instrumented Spinal Fusion

We aimed to investigate whether the outcome and complications of surgical treatment of neuromuscular curves with segmental third-generation instrumentation could compare with those reported with standard second-generation instrumentation. The clinical and radiologic data of a single surgeon's consecutive series of patients with neuromuscular scoliosis treated with two types of newer-generation instrumentation and posterior or anteroposterior approaches were retrospectively and independently reviewed. The results of this study support the concept that third-generation instrumentation is able to provide at least as good results as second-generation instrumentation in the treatment of neuromuscular scoliosis patients, at the expense of a lower complication rate.

Operative Management of Sacral Chordoma

Sacrococcygeal chordoma presents a difficult diagnostic and therapeutic problem, with a high rate of local recurrence. The purpose of this report is to define the importance of adequate surgical treatment for optimum outcome and survival. Fifty-two patients underwent surgical treatment for sacrococcygeal chordoma between 1980 and 2001. The series included eighteen female patients and thirty-four male patients, with an average age of fifty-six years (range, thirteen to seventy-six years) at the time of the diagnosis. The surgical approach depended on the level and extent of the lesion, with a posterior approach performed in twenty-two patients and a combined anteroposterior approach used in thirty. A wide surgical margin was achieved in twenty-one patients. At an average of 7.8 years (range, 2.1 to twenty-three years) postoperatively, twenty-three patients were alive with no evidence of disease. Twenty-three patients (44%) had local recurrence. The rate of recurrence-free survival was 59% at five years and 46% at ten years. The overall survival rates were 74%, 52%, and 47% at five years, ten years, and fifteen years, respectively. The most important predictor of survival was a wide margin. All patients with a wide margin survived, and this survival rate was significantly different from that for patients who had had either marginal or intralesional excision (p = 0.0001). Of the twenty-one patients with a wide margin, seventeen (81%) had undergone a combined anteroposterior approach and only four had been treated with a posterior approach. A wide surgical margin is the most important predictor of survival and of local recurrence in patients with sacrococcygeal chordoma. Use of a combined anteroposterior approach increases the likelihood of obtaining a wide margin. Therapeutic Level IV.

Reconstruction after Total Sacrectomy

Nine patients had sacrectomy with ilio-lumbar arthrodesis for treatment of sacral malignancies at our institution between 2000 and 2004. Five patients had total sacrectomy, three had a sagittal hemisacrectomy, and one had an extended internal hemipelvectomy Type I-S. The average patient age was 39 years. Tumors were Stage IIB in seven patients and Stage IB in two patients. A combined anteroposterior approach was used and a wide surgical margin was attained in all seven patients. A new form of reconstruction using structural fibular grafts and pedicle screw-rod instrumentation was used to create a triangular construct along the anatomic force transmission vectors from the femoral heads to the lumbar spine. The average followup was 18 months. At latest followup, seven patients were alive with no evidence of disease, and two had died from disease. One patient suffered postoperative infection. Independent ambulation was noted in seven patients at last followup. Eight patients had stable reconstructions at latest followup (one patient, who died in December 2004, had a stable reconstruction and was walking with braces and a walker before her death). One patient had instrumentation failure twice and had additional revision instrumentation and bone grafting procedures. She eventually obtained a solid lumbopelvic fusion and walks with Canadian crutches and ankle-foot orthoses. The technique of reconstruction reported here offers promise in dealing with the challenges of reestablishing spinopelvic stability in this difficult anatomic location. Therapeutic study, Level IV-1 (case series). See the Guidelines for Authors for a complete description of levels of evidence.

Les complications du traitement chirurgical des déviations rachidiennes: Étude prospective multicentrique d’une cohorte de 3311 patients

Purpose of the study The incidence of complications secondary to surgical treatment of spinal deformations remains imprecise. The purpose of this prospective multicentric observational study was to assess the incidence of intra- and postoperative complications secondary to this type of surgery to detail the observed complications and to identify favoring factors. Material and methods For this study, we included 3311 patients who underwent surgery during a 12-month period for spinal deformation, defined as idiopathic or secondary scoliosis or kyphosis, irrespective of the localization, severity, or type of surgery performed. Four main categories of complications were studied: general, infectious, neurological, and mechanical. Pre- and intraoperative variables recorded were: epidemiological and morphological data, history of surgery for the same spinal deformation, co-morbid conditions, type of deformation treated (nature, anatomic localization, severity, reducibility), type of surgery performed (approach, duration of the operation), operative blood loss, extent and localization of the fusion, associated neurological release, vertebral osteotomy or not, type of graft used. Two types of analysis were performed. The first was a descriptive analysis to detail the overall incidence of complications and the incidence of each of the four main categories. The second was a multivariate analysis designed to determine factors significantly associated with complication occurrence. Results Mean age of the cohort was 27 ± 18 years; 6.8% of the patients had had a prior operation for the spinal deformation. The deformation was scoliosis in 90% (mean angle 56 ± 20̊) and kyphosis in 10% (mean angle 47 ± 23̊). An isolated posterior approach was used for 72.5% of patients, an isolated anterior approach for 6.4%, and a combined anteroposterior approach for 21.1%. Seven hundred four patients (21.3%) had one or more complications (850 complications) during or shortly after their operation. The incidences of general, infectious, mechanical and neurological complications were: 5.7%, 4.7%, 11.5%, and 1.8% respectively. Globally, considering all types of complications, the following factors were found to be significantly associated with complication occurrence: patient age, ASA score, extent of the fusion, presence of vertebral osteotomy, inclusion of the sacrum in the arthrodesis, and initial angle of the treated deformation. For patients with scoliosis, the following factors were significantly associated with a secondary central neurological disorder: initial angle of the deformation, use of vertebral osteotomy, type of curvature with greater risk for thoracic curvatures and double thoracic and lumbar curvatures. Conclusion This work enabled us to determine the overall rate of complications after surgical treatment of spinal deformations. Certain risk factors related with complication occurrence were identified, but the heterogeneous nature of the population and the methodology used to identify these factors only allowed detection of trends. A future study by etiological group or focusing on specific complications should allow a more precise analysis of these risk factors. This overall rate of complications should be used to better inform patients and their family about the risks of this type of surgery.

A new system for localization of nonpalpable breast lesions with adhesive marker plate

The objective of this article is to present a new method of preoperative localization of nonpalpable breast lesions by means of an adhesive marker plate that makes an anteroposterior approach to the thoracic wall possible. Between January 2000 and September 2002, 41 consecutive mammographic localizations were performed with the adhesive marker plate. In most cases ( n=34) the lesions were microcalcifications. The mean age of the patients was 54.7 years. The device used consists of a square plate made of highly flexible plastic with an adhesive film on the back for firm attachment to the area of the breast surface corresponding to the approximate location of the lesion. This plate contains a network of holes and a system of radiopaque coordinates. The technique for its use is described step by step. All 41 lesions were localized: to within 5 mm or by transfixation of the lesion in 95.1% of cases (39/41) and to within 1 cm in the remaining 2 cases. Surgical excision of the breast lesions was carried out successfully in all cases, and in 56% (23/41) it was possible to use a periareolar incision. Histological findings revealed 24 benign and 17 malignant lesions. This new technique permits the localization of nonpalpable breast lesions accurately, simply, and with very little discomfort to the patient. The anteroposterior approach simplifies the surgeon's task in the management of these lesions.

脊椎腫ように対するＨａｒｍｓ ｃａｇｅの使用経験

Six patients with spinal tumor were operated on using titanium mesh cages. Four patients were male and two were female. The average age of the patients was 54 years (range: 40 to 65 years). Three cases were of the cervical level and the others were thoracic. All patients had severe neck or back pain, and one patient had nerve pain. The follow-up ranged from 4 to 17 months (mean: 9.2 months). Four patients received the anteroposterior approach, and two the anterior approach.The operative time was 150 to 255 minutes (mean: 195 minutes). The mean intraoperative blood loss came to 330g (range: 70 to 750g). All patients reported that their pain decreased or disappeared. No cage failure or extrusion was observed.

Salvage Surgery for Recurrent Nasopharyngeal Carcinoma

To evaluate the efficacy of salvage surgery in the treatment of recurrent nasopharyngeal carcinoma (NPC) at the primary site. A retrospective investigation of the outcome of salvage surgery for 28 patients with recurrent NPC after definite radiation therapy. The nasopharynx was approached anteroposteriorly by the transmaxillary approach (maxillary swing, maxillectomy) or inferior approach (midline mandibulotomy or median labiomandibular glossotomy), or laterally by modified facial translocation or transpterygoid approach; intentional ligation of the internal carotid artery was performed after establishment of extracranial-intracranial (EC-IC) bypass in one patient; postoperative irradiation was given to the patients with positive pathological margins. Nine patients lived without disease for 20 to 93 months (mean interval, 52 mo) after surgery; among them, eight patients had T1 tumors that were resected totally by surgery via anteroposterior approaches and the other patient had postoperative irradiation to control the disease. Seven patients had local recurrence 8 to 21 months after treatment. Four patients developed distant metastases, including one patient with a T2b tumor that was totally resected through modified facial translocation approach with ligation of internal carotid artery. Eight patients died of other causes; internal carotid artery blowout was the cause of death in four of these eight patients. In most cases of recurrence, T1 nasopharyngeal tumors can be resected totally by anteroposterior approaches; for T2 or larger tumors, postoperative irradiation is usually necessary. Otherwise, facial translocation offers a better chance to completely resect the tumors. Internal carotid artery is better ligated if patients have received greater than 70 Gy irradiation or if the artery must be exposed during the surgery. We suggest that EC-IC bypass be used to avoid the possible complications (or cerebral ischemic stroke) caused by ligation of internal carotid artery. The transmaxillary approach is favored in the management of nasopharyngeal tumor recurrence with nasal cavity extension, and midline mandibulotomy is more suitable for resection of posterior margin of nasopharyngeal tumor recurrence. Facial translocation offers the widest operative field and is the most versatile approach for radical resection of nasopharyngeal tumor recurrence, but the surgeon should be skilled in the management of the facial nerves to reduce morbidity.

Diagnosis and treatment of giant cell tumor in the thoracic spine

A 23-year-old woman with incomplete paralysis was operated upon for a giant cell tumor in the thoracic spine. X-ray films revealed a destruction lesion in the vertebral body of the 12th thoracic vertebra. On the plain thoracic computed tomography scan, the finding was a soap-bubble appearance with a linear high density area in the mass lesion which destroyed the vertebral body. Preoperative angiography showed no apparent feeding artery to the tumor tissue; preoperative myelography showed incomplete block at the level of the 12th thoracic vertebra. A radical operation was carried out in one stage via a combined antero-posterior approach. In order to give radiotherapy immediately after operation, a vascular pedicled rib graft was made. This paper discusses the role of thoracic computed tomography scan in the diagnosis of giant cell tumor and the surgical techniques used in treatment.

Combined Use of Anterior and Posterior Surgery for Adult Scoliosis

The two-staged anteroposterior approach is the indicated surgical procedure for many patients with adult spine deformities as described in this article. These surgeries are not easily performed. The surgeon must have excellent knowledge of anatomy as well as expertise in performing these procedures in order to obtain maximum correction, stabilization of the spine, and minimize complications.

Simultaneous Anterior and Posterior Surgical Approach to the Thoracic and Lumbar Spine

A technique for the simultaneous anterior and posterior surgical approach to the thoracic and lumbar spine is presented. No intraoperative repositioning of the patient is required. The procedure requires a surgical team of two spinal surgeons and two assistant surgeons, as well as an anesthesiologist familiar with hypotensive techniques. The procedure as utilized in 14 cases has proven to be safe and expeditious. The simultaneous anteroposterior approach has proven to be especially useful in cases with combined anterior and posterior instability. The technique described provides the experienced spinal surgeon with the best solution to certain complex spinal problems.