Bone Removal Research Articles

Evaluation of the Gross Total Resection Rate of Suprasellar Pituitary Macroadenomas with and without the Removal of the Tuberculum Sellae Bone

Improving the gross total resection (GTR) rate of suprasellar pituitary macroadenomas (SPMAs) using the pure endoscopic endonasal transsphenoidal approach (EETA) has been a long-standing focus of neurosurgeons. This study was aimed at evaluating the influences of the removal of the tuberculum sellae bone (TSB) without opening the dura of the tuberculum sellae on the GTR rate of SPMAs via the EETA. We retrospectively analyzed medical reports of patients with SPMAs who underwent EETA between February 2015 and November 2020. Data on clinical manifestations, endocrinologic types, imaging features (Hardy classification, morphology, and texture), clinical outcomes, and TSB removal status were collected. All patients were followed up for 6 months postoperatively. Seventy-eight patients were enrolled in our study. The GTR rates of the TSB removal group (45/78, 57.7%) and nonremoval group (33/78, 42.3%) were 80.0% (36/45) and 57.6% (19/33), respectively. Univariate logistic regression analysis found that the removal of TSB, rounded morphology, and low Hardy classification were correlated with higher GTR rates. Multiple logistic regression analysis indicated that even after adjusting for tumor types and imaging features, the removal of TSB had an independent effect on the GTR rate (odds ratio, 7.6; 95% confidence interval, 1.8-31.6; P= 0.005). The incidence rates of postoperative cerebrospinal fluid leakage and diabetes insipidus were not significantly different between the TSB removal group and TSB nonremoval group. TSB removal using EETA without opening the tuberculum sellae dura improves the GTR rate of SPMAs without increasing the incidence of postoperative complications.

Augmented Reality for Retrosigmoid Craniotomy Planning.

While medical imaging data have traditionally been viewed on two-dimensional (2D) displays, augmented reality (AR) allows physicians to project the medical imaging data on patient's bodies to locate important anatomy. We present a surgical AR application to plan the retrosigmoid craniotomy, a standard approach to access the posterior fossa and the internal auditory canal. As a simple and accurate alternative to surface landmarks and conventional surgical navigation systems, our AR application augments the surgeon's vision to guide the optimal location of cortical bone removal. In this work, two surgeons performed a retrosigmoid approach 14 times on eight cadaver heads. In each case, the surgeon manually aligned a computed tomography (CT)-derived virtual rendering of the sigmoid sinus on the real cadaveric heads using a see-through AR display, allowing the surgeon to plan and perform the craniotomy accordingly. Postprocedure CT scans were acquired to assess the accuracy of the retrosigmoid craniotomies with respect to their intended location relative to the dural sinuses. The two surgeons had a mean margin of d avg = 0.6 ± 4.7 mm and d avg = 3.7 ± 2.3 mm between the osteotomy border and the dural sinuses over all their cases, respectively, and only positive margins for 12 of the 14 cases. The intended surgical approach to the internal auditory canal was successfully achieved in all cases using the proposed method, and the relatively small and consistent margins suggest that our system has the potential to be a valuable tool to facilitate planning a variety of similar skull-base procedures.

Management of Urosymphyseal Fistula and Pelvic Osteomyelitis: A Comprehensive Institutional Experience and Improvements in Pain Control

BackgroundUrosymphyseal fistula (USF) is an uncommon but painful and devastating condition typically occurring after radiotherapy for pelvic malignancy, with a delayed diagnosis and a risk of opioid dependence. ObjectiveTo characterize our institutional experience and determine the impact of intervention for USF on pain control and opioid use. Design, setting, and participantsWe evaluated data for 33 adult patients diagnosed with USF and managed at a quaternary institution between 2009 and 2021. Outcome measurements and statistical analysisWe assessed chronic opioid use, pain scores, prior therapy for pelvic malignancy, prior endoscopic procedures, microbiology and histology congruence, and postoperative complications. For comparative analyses we used a χ2 test or Fisher’s exact test for categorical variables and a Wilcoxon signed-rank test for continuous variables. Results and limitationsNearly 94% of the patients had received prior pelvic radiotherapy and >80% occurred in 2016–2021 but were not diagnosed until a median of 10 mo (interquartile range [IQR] 3.5–19.5) following endoscopic procedure(s). Osteomyelitis was suspected in 78.8% of imaging reports and nearly 70% had a positive preoperative urine culture. Over 90% of patients underwent cystectomy, pubic bone debridement or resection, and a soft-tissue pedicle flap. Preoperative urine cultures were concordant with 60% of intraoperative tissue/bone cultures. Histologic osteomyelitis was identified in 85% and concordant with 80% of preoperative imaging. Clavien-Dindo grade ≥3 complications occurred in 15.6%. The median pain score decreased from 4 (IQR 0–8) preoperatively to 0 (IQR 0) postoperatively (p < 0.001). Chronic opioid use decreased from 39.4% to 21.2% (p = 0.02). ConclusionsPelvic osteomyelitis may complicate USF and commonly manifests with severe, persistent pain. USF incidence may be increasing or at least increasingly recognized, but diagnosis is delayed. Definitive management results in significant improvements in pain perception and a decrease in chronic opioid use. Patient summaryWe examined features of urinary fistulas, which are abnormal openings or connections between part of the urinary tract and another structure. Patients with a urinary fistula involving the pelvic bones can present with severe pain, but diagnosis of the condition is often delayed. Removal of some pelvic bone with bladder removal or repair can result in a decrease in long-term pain and in the use of opioid drugs for pain relief.

Surgical procedures for correcting vertical maxillary excess: A review.

IntroductionVertical maxillary excess, a common orthodontic problem that leads to long faces and open bites, can be repositioned with a Le Fort I osteotomy. However, the Le Fort I osteotomy poses the risk of a variety of complications including descending palatine artery (DPA) injury. Although several Le Fort I osteotomy modifications were reported to avoid complications associated with this osteotomy, only a few of such studies were conducted in Japan, and details remain scarce.Patients and methodsWe performed a literature review regarding modifications of Le Fort I osteotomies, including Le Fort I with a horseshoe osteotomy, modified horseshoe osteotomy, unilateral horseshoe osteotomy, pyramidal osteotomy, and U-shaped osteotomy. We identified eight relevant studies conducted in Japan; one study did not provide the number of patients examined. The 77 patients (seven studies) with vertical maxillary excess who underwent orthognathic surgery were ≥17 years old.DiscussionThere were no severe complications after the modified Le Fort I osteotomies. The postoperative maxillary changes obtained by the conventional horseshoe, modified horseshoe, unilateral type of horseshoe, pyramidal, and U-shaped osteotomies were nearly repositioned to the planned position and remained stable for ≥12 months post-surgery.ConclusionOur review indicates that preserving the DPA can lower the incidence of intra- and post-operative complications. Each modification of the Le Fort I osteotomy (i.e., conventional horseshoe, modified horseshoe, unilateral horseshoe, pyramidal, and U-shaped osteotomy) has its respective advantages and indications.

Achilles Tendon Allograft Preparation Technique for Anterior Cruciate Ligament Reconstruction: A Technical Note

Several factors associated with graft preparation for the surgery of the anterior cruciate ligament (ACL) like the wrong thawed, prophylaxis, bone cuts, excessive bone removal as well as positioning problems like a tunnels-graft mismatch, insufficient harvesting of the donor's tendon, size graft limitations (length and diameter), uncontrolled rotation of graft in their longitudinal axis, over or under tensioned graft, fixation mistakes, bone defects, secondary arthrofibrosis or morbidity of the donor site, and others factors importantly affect the outcomes of the ACL surgery. In this sense, the Achilles tendon Allograft is an advantageous technique where many of the previous limitation factors described can be controlled during an appropriate preparation. However, to obtain the maximum potentialities of the graft a detailed knowledge of the preparation is required. Hence, we aimed to describe how to prepare the Achilles tendon Allograft to control the graft's length and diameter, bone removal, and fixation requirements.

The Management of Transalevolar Surgery Teeth with Pulpal Polyps Condition

Background: The failure of intra-alveolar tooth extraction in cases of tooth extraction with complications is generally resolved by performing transalveolar tooth extraction. The open method of tooth extraction involves surgery by cutting the tooth or bone. Flap creation and partial removal of alveolar bone, refinement of alveolar bone, curettage, and suturing are the principles of this extraction method. The planning of the stages of the transalveolar extraction method must be made as carefully as possible to avoid complications of tooth extraction. Tooth extraction treatment in dental practice can be carried out due to various causes, including caries. Pulp polyps or also known as chronic hyperplastic pulpitis is another form of irreversible pulpitis in the chronically inflamed pulp so that the pulp tissue appears to the occlusal surface. Treatment in cases of pulp polyps varies widely depending on the remaining tooth crown wall. The usual treatments for polyps pulp patients are root canal treatment (RCT), pulpotomy to extraction. The transalveolar extraction method is performed by first taking a portion of the bone supporting the tooth. Objective: Knowing the treatment management of polyp pulp extraction with transalveolar surgery methods, indications and contraindications for transalveolar surgery and knowing the correct medical selection in cases of transalveolar surgical extraction of teeth with polyp pulp. Discussion: Chronic hyperplastic pulpitis or pulp polyp is a pathological condition that attacks vital pulp tissue so that it experiences a chronic inflammation as a defense response from the body to the pulp tissue against bacterial infection. The term use of the term chronic hyperplastic pulpitis occurs due to granulation of the pulp tissue covered with epithelial tissue due to chronic infection. The management of cases of pulp polyps for which restoration is no longer possible is to remove them. Extraction is the last step that can be done if restoration measures do not eliminate the source of infection. The transalveolar extraction procedure of the teeth located in the mandible is preceded by asepsis and anesthesia and removal of the polypoid tissue. Conclusion: In several cases of brittle teeth, extraction by intraalveolar method often failed so that it needs to be extracted by transalveolar method. Management of extraction with polyp pulp includes removal of the polypoid tissue first before extraction. The administration of medical therapy with the antibiotic amoxicillin 500 mg for 5 days, paracetamol for 5 days and dexamethasone for 3 days can control the patient's pain and help the healing process quickly.

Odontossecção intermediária em retenção atípica de caninos inferiores

Two lower canines horizontally situated in the anterior mental region were removed. In order to minimize bone loss during teeth extraction it was used an intermediate tooth section technique. Sectioning allows central, crown and apical portions of the tooth to be removed through a not too large opening provided by bone removal.

A Novel Instrument for Endoscopic Ear Surgery With a Steerable Flexible Tip: A Pediatric Anatomical Validation Study.

This study compares the reaching ability of two classes of transcanal endoscopic ear surgery (TEES) instruments when operating on difficult to access anatomical targets; two novel instruments with steerable flexible tips (SFT-A and SFT-B) and suction capability are compared with standard commercially available tools. TEES surgeons identified the need for a new surgical instrument that can enable accessibility of all areas visualized by the endoscope. This motivated the development of the two instrument prototypes. Six temporal bone models were 3D printed based on CT data from five cholesteatoma patients. Four anatomical targets were marked on each model. Using these targets, the reaching ability while using four standard TEES instruments were compared with the SFT-A and SFT-B prototypes by five surgeon participants. Results were analysed to compare success rates of contacting each target using each tool by fitting four Firth's logistic regression models. This calculated the statistically significant differences (p < 0.05) in tool success rate. Using SFT-A to contact the sinus tympani (100%) was significantly more successful than the Panetti suction dissector for atticus (PAT) (77%) and to contact the sinodural angle (0%) was less successful than the PAT (10%) and SFT-B (93%). Using SFT-B to contact the lateral semicircular canal (90%) was significantly more successful than all current tools and to contact the sinodural angle (93%) was significantly more successful than all tools. Using SFT-B enables enhanced accessibility of anatomical structures during TEES which may lead to less extensive bone removal to facilitate minimally invasive TEES.

Opioids Are Infrequently Required following Ambulatory Otologic Surgery.

To determine the frequency with which postoperative opioid prescriptions are required after ambulatory otologic surgery. Retrospective chart review. Tertiary otology-neurotology practice. Patients (n = 447) given over-the-counter acetaminophen and ibuprofen following ambulatory otologic surgery between July 1, 2018 and June 30, 2020. Opioid prescription upon request. Patient, disease, and surgical variables such as age, sex, past medical history, chronic pain condition, surgical procedure, primary versus (vs.) revision surgery, and endoscopic vs. microscopic approach were examined for relationship to ad hoc opioid prescription rate. Of 370 adult patients (mean age 49.0 yrs, range 18.0-88.5 yrs), 75 (20.3%) were prescribed opioids for postoperative pain, most commonly oxycodone-acetaminophen 5/325 mg. Of 77 pediatric patients (mean age 8.8 yrs, range 0.7-17.9 yrs), 5 (6.5%) were prescribed postoperative opioid analgesia. In the adult population, chronic pain condition, pain medication use at baseline, canal wall up mastoidectomy, tympanoplasty, tympanomeatal flap, bone removal of the mastoid, postauricular incision, and intraoperative microscopy were independent predictors of opioid pain prescription. When controlling for all significant variables, only chronic pain condition remained significant (odds ratio = 3.94; p = 0.0007). In the pediatric population, atresiaplasty, meatoplasty, and conchal cartilage removal were independently associated with opioid prescription, but none remained significant when analyzed in a multivariate linear model. Pain following ambulatory otologic surgery may be adequately managed with over-the-counter pain medications in the majority of cases. Opioids may be necessary in adults with preexisting pain conditions.

2021 Canadian Spine Society Abstracts.

# Abstract 45. Determining clinically important improvement following surgery for degenerative conditions of the spine: analysis of the Canadian Spine Outcomes and Research Network (CSORN) Registry {#article-title-2} There is significant variability in clinically important improvement (CII)

Transcanal Endoscopic Ear Surgery for Epitympanic Cholesteatoma With Obliteration Using Bioglass.

Transcanal Endoscopic Ear Surgery for Epitympanic Cholesteatoma With Obliteration Using Bioglass.

C7 Fracture as a Complication of C7 Dome-Like Laminectomy : Impact on Clinical and Radiological Outcomes and Evaluation of the Risk Factors.

ObjectiveCervical expansive laminoplasty is an effective surgical method to address multilevel cervical spinal stenosis. During surgery, the spinous processes of C2 and C7 are usually preserved to keep the insertion points of the cervical musculature and nuchal ligament intact. In this regard, dome-like laminectomy (undercutting of C7 lamina) instead of laminoplasty is performed on C7 in selected cases. However, resection of the lamina can weaken the C7 lamina, and stress fractures may occur, but this complication has not been characterized in the literature. The objective of the present study was to investigate the incidence and risk factors for C7 laminar fracture after C7 dome-like laminectomy and its impact on clinical and radiological outcomes. MethodsPatients who underwent cervical open-door laminoplasty combined with C7 dome-like laminectomy (n=123) were classified according to the presence of C7 laminar fracture. Clinical parameters (neck/arm pain score and neck disability index) and radiologic parameters (C2–7 angle, C2–7 sagittal vertical axis, and C7–T1 angle) were compared between the groups preoperatively and at postoperatively at 3, 6, 12, and 24 months. Risk factors for complications were evaluated, and a formula estimating C7 fracture risk was suggested. ResultsC7 lamina fracture occurred in 32/123 (26%) patients and occurred at the bilateral isthmus in 29 patients and at the spinolaminar junction in three patients. All fractures appeared on X-ray within 3 months postoperatively, but patients did not present any neurological deterioration. The fracture spontaneously healed in 27/32 (84%) patients at 1 year and in 29/32 (91%) at 2 years. During follow-up, clinical outcomes were not significantly different between the groups. However, patients with C7 fractures showed a more lordotic C2–7 angle and kyphotic C7–T1 angle than patients without C7 fractures. C7 fracture was significantly associated with the extent of bone removal. By incorporating significant factors, the probability of C7 laminar fracture could be assessed with the formula 'Risk score = 1.08 × depth (%) + 1.03 × length (%, of the posterior height of C7 vertebral body)', and a cut-off value of 167.9% demonstrated a sensitivity of 90.3% and a specificity of 65.1% (area under the curve, 0.81). ConclusionC7 laminar fracture can occur after C7 dome-like laminectomy when a substantial amount of lamina is resected. Although C7 fractures may not cause deleterious clinical outcomes, they can lead to an unharmonized cervical curvature. The chance of C7 fracture should be discussed in the shared decision-making process.

Piezoelectric canalplasty for exostoses and osteoma

ObjectiveTo evaluate the safety profile and surgical technique for removal of symptomatic exostoses and osteoma of the external auditory canal with a micro-oscillating piezoelectric device. MethodA chart review was conducted on patients undergoing piezoelectric canalplasty between 2019 and 2021 at tertiary referral hospital. Surgery was performed by two surgeons with varying experience. Bone removal was achieved using both osteotomy and osteoplasty. Postoperative complications, operative time and hearing outcome were evaluated. ResultsThe study comprised 16 patients (16 ears). No major complications occurred. The skin of the auditory canal was completely preserved in all patients without injury to the tympanic membrane. Except for one patient with known noise-induced hearing loss, there was no postoperative deterioration of the bone-conduction threshold more than 10 dB HL at any frequency. The difference of the bone-conduction threshold in pure-tone audiometry (average for 0.5, 1, 2 and 4 kHz) three weeks postoperatively had a median of 0.6 dB ± 5.7. One patient complained of temporary new tinnitus. One patient had prolonged wound healing. Mean operative time was comparable with literature data. ConclusionThe atraumatic characteristics of the piezoelectric instrument enable low-risk removal of external auditory canal exostoses and osteoma. Through the combination of precise osteotomy and osteoplasty, this novel instrument has the potential to become established in routine canalplasty.

Extradural anterior clinoidectomy through endoscopic transorbital approach: laboratory investigation for surgical perspective.

The endoscopic transorbital approach (eTOA) is a new mini-invasive procedure used to explore different areas of the skull base. Authors propose an extradural anterior clinoidectomy (AC) through this corridor, defining the anatomical landmarks of the anterior clinoid process (ACP) projection onto the posterior orbit wall and the technical feasibility of this approach. We describe the exposure of the opticocarotid region and the surgical freedom and the angles of attack obtained with this novel approach. Five cadaver heads underwent an eTOA at the Laboratory of Surgical Neuroanatomy of the University of Barcelona. A step-by-step description of the extradural endoscopic transorbital clinoidectomy was provided. A volumetric analysis of the morphometrics characteristics of the sphenoid wings was evaluated before and after dissection using CT scans. Pterional approach was performed to ascertain ACP removal. In all the specimens, it was possible to resect the ACP endo-orbitally aiming an optimal optic canal (OC) unroofing. The surface of the triangle corresponding to the ACP projection onto the posterior orbit wall was 0.42 ± 0.20 cm2. The drilled area to perform the extradural clinoidectomy via eTOA was 3.11 ± 2.27 cm2, and the volume of bone removal corresponding to the greater sphenoid wing (GSW) and lesser sphenoid wing (LSW) was 2.55 ± 1.41 and 0.26 ± 0.18 cm3 respectively. The area of surgical freedom provided by the eTOA was (3.11 ± 2.27cm2), and the angles of attack were 21.39 ± 9.13° in the horizontal axel and 30.63 ± 18.51° in the vertical. The described extradural anterior clinoidectomy by eTOA uses specific landmarks to localize the ACP on the posterior orbit wall. Resection of the ACP is a technically feasible approach, achieving the main goals of any clinoidectomy.

Differential effects of anti-RANKL monoclonal antibody and zoledronic acid on necrotic bone in a murine model of Staphylococcus aureus-induced osteomyelitis.

Osteomyelitis is characterized by progressive inflammatory bone destruction accompanied by severe pain and disability. However, with the exception of antibiotic therapies, there is no established therapy to protect the bone from infectious osteolysis. The anti-receptor activator of nuclear factor-kB ligand (RANKL) monoclonal antibody (anti-RANKL Ab) is a potential drug based on its proven effectiveness in preventing joint bone erosion in rheumatoid arthritis; however, the efficacy and adverse effects of anti-RANKL Ab in osteomyelitis remain to be investigated. In this study, we investigated the effects of anti-mouse RANKL Ab on acute osteomyelitis and compared them with those of zoledronic acid (ZA) using a murine model. Mice were inoculated with bioluminescent Staphylococcus aureus (Xen 29) on their left femur and then treated with ZA, anti-RANKL Ab, or phosphate-buffered saline as control. A 21-day longitudinal observational study using microcomputed tomography showed that both anti-RANKL Ab and ZA had an osteoprotective effect against infectious osteolysis. However, it was also demonstrated through bioluminescence imaging that ZA delayed the spontaneous reduction of bacterial load and through histology that it increased the amount of necrotic bone, while anti-RANKL Ab did not. Findings from histopathological and in vitro studies suggest that an intense inflammatory response around the necrotic bone could induce osteoclasts in a RANKL-independent manner, leading to the removal of necrotic bone, even after administration of the anti-RANKL Ab therapy. Collectively, anti-RANKL Ab may exert an osteoprotective effect without hampering the removal of the necrotic bone, which serves as a nidus for infection in osteomyelitis.

Modified transverse tibial bone transplantation and microcirculation reconstruction for the treatment of end-stage diabetic foot

To explore clinical effect of modified transverse tibial bone transfer microcirculation reconstruction in treating end-stage diabetic foot. From August 2016 to June 2018, 87 patients with diabetic foot treated with modified tibial transverse bone removal and microcirculation reconstruction, inclduing 54 males and 33 females;aged from 39 to 95 years old with an average of (68.9±11.3) years old;2 patients were grade 2, 37 patients were grade 3 and 50 patients were grade 4 according to Wagner's classification;the courses of diabetic were for 10 to 16 years with an average of (13.0±2.2) years;the courses of diabetic feet were for 21 to 48 days with an avergae of (34.2±8.6) days. Postoperative comlications were observed. Skin temperature, visual analogue scale(VAS) and ankle brachial index(ABI) and wound healing were recorded before and 3 months after operation. All patients were followed up for 4 to 19 months with an average of (12.6±2.8) months. Two patients occurred subcutaneous tissue liquefaction and seepage under needle passage during bone transfer, and scabed without special treatment. One patient was performed amputation above 5 cm of ankle joint because of severe infection, and 1 patient occurred re-ulceration at 1 year after wound healing, bone transfer was performed again at the same site, and was completely healed at 8 weeks after operation. The healing time of wound ranged from 3 to 24 weeks with an average of (11.9± 3.8) weeks. Foot skin temperature before operation was (28.9±0.91) ℃, and increased to (31.70±0.32)℃ at 3 months after operation(t=5.72 P=0.006);VAS score before opertaion was (7.80±0.72), and improved to (2.20±0.13) at 3 months after operation (t=25.38, P=0.000);ABI beforeoperation was(0.48±0.30), increased to(0.98±0.24) at 3 months after oeprtaion(t= 14.68, P=0.000). Modified lateral tibial bone transfer could effectively reconstruct microvascular network under lower leg, promote recovery of peripheral blood vessels, and promote wound healing of foot, reduce or avoid amputation. At the same time, the improved osteotomy is one of the effective methods for the treatment of diabetic foot which has advantags of less trauma, simple opertaion.

Virtual implantation technique to estimate endoprosthetic contact of percutaneous osseointegrated devices in the tibia

Percutaneous osseointegrated (OI) devices have an endoprosthesis attached to the residual bone of an amputated limb, then pass permanently through the skin to be connected to the distal prosthetic componentry outside of the body. Whether the bone-anchoring region of current OI endoprostheses are cylindrical, and/or conical, they require intimate bone-endoprosthesis contact to promote stabilizing bone attachment. However, removing too much cortical bone to achieve more contact leads to thinner and, subsequently, weaker cortical walls. Endoprostheses need to be designed to balance these factors, namely maximizing the contact, while minimizing the volume of bone removed. In this study, 27 human tibias were used to develop and validate a virtual implantation method. Then, 40 additional tibias were virtually implanted with mock cylindrical and conical bone-anchoring regions at seven residual limb lengths to measure resultant bone-endoprosthesis contact and bone removal. The ratio of bone-endoprosthesis contact to bone volume removed showed the conical geometry had more contact area per volume bone removed for all amputation levels (p ≤ 0.001). In both mock devices, cortical penetration of the endoprosthesis at 20% residual length occurred in 74% of cases evaluated, indicating that alternative endoprosthesis geometries may be needed for clinical success in that region of bone.

A new primate model of hypophyseal dysfunction

For pituitary regenerative medicine, the creation of a hypophyseal model in monkeys is necessary to conduct future preclinical studies; however, previous studies reported that hypophysectomy in monkeys is not always safe or satisfactory. This study aimed to create a hypophyseal dysfunction model in a cynomolgus monkey using a safer surgical technique and establish the protocol of pituitary hormone replacement therapy for this model. Surgical resection of the pituitary gland of a 7.8-year-old healthy adult cynomolgus male monkey weighing 5.45 kg was performed to create a hypophyseal dysfunction model for future regenerative studies. Endoscopic transoral transsphenoidal surgery was used to perform hypophysectomy under navigation support. These procedures were useful for confirming total removal of the pituitary gland without additional bone removal and preventing complications such as cerebrospinal fluid leakage. Total removal was confirmed by pathological examination and computed tomography. Hypopituitarism was verified with endocrinological examinations including stimulation tests. Postoperatively, the monkey’s general condition of hypopituitarism was treated with hormone replacement therapy, resulting in long-term survival. The success of a minimally invasive and safe surgical method and long-term survival indicate the creation of a hypophyseal dysfunction model in a cynomolgus monkey; hence, this protocol can be employed in the future.

Piezosurgery for safe and efficient petrous bone cutting in cerebellopontine angle and petroclival meningioma surgery

Intradural petrous bone drilling has become a widespread practice, providing extended exposure in the removal of cerebellopontine angle (CPA) or petroclival tumors. Adjacent neurovascular structures are at risk, however, when drilling is performed in this deep and narrow area. Hence, this study evaluates the use of Piezosurgery (PS) as a non-rotating tool for selective bone cutting in CPA surgery.A Piezosurgery® device was used in 36 patients who underwent microsurgery for extra-axial CPA or petroclival tumors in our Neurosurgical Department between 2013 and 2019. The clinical and radiological data were retrospectively analyzed. The use of PS was evaluated with respect to the intraoperative applicability and limitations as well as efficacy and safety of the procedure.Piezosurgical petrous bone cutting was successfully performed in the removal of meningiomas or extra-axial metastases arising from the dura of the petroclival region (21 patients) or petrous bone (15 patients). PS proved to be very helpful in the deep and narrow CPA region, considerably reducing the surgeon’s distress toward bone removal in close proximity to cranial nerves and vessels in comparison to common rotating drills. The use of PS was safe without injuries to neurovascular structures. Gross total resection was achieved in 67% of petroclival and 100% of petrous bone tumors.Piezosurgery proved to be an effective and safe method for selective petrous bone cutting in CPA surgery avoiding rotating power and associated risks. This technique can particularly be recommended for bone cutting in close vicinity to critical neurovascular structures.

Surgical management of the orbit in thyroid eye disease: lateral orbital decompression.

Lateral orbital wall decompression is one of many well established techniques available to surgeons in management of patients with clinically significant thyroid eye disease (TED). Several different surgical approaches have been described in the literature and are reviewed herein. Lateral orbital wall decompression remains a popular technique for surgical management of TED, with a recent American Society of Ophthalmic Plastic and Reconstructive Surgery survey showing that 22.6% of respondents preferred a single-wall procedure, with 36.8% of that subset preferring lateral wall decompression alone. Surgical techniques for lateral orbital wall decompression differ based on several steps, such as the incisional approach, whether to take an ab-interno versus ab-externo approach, and whether to remove orbital fat to achieve further decompression. In addition, technological advances have produced an array of tools available to the orbital surgeon to achieve efficient and accurate bone removal. Lateral orbital wall decompression for TED, despite being an older technique, remains a popular and well established procedure for orbital decompression. Though no randomized controlled clinical trial supports one decompression technique over another for TED, lateral orbital wall decompression offers many benefits such as its ease of access and visualization of the orbital space.