Dural Incision Research Articles

Intraoperative Ultrasound and Contrast-Enhanced Ultrasound in Surgical Treatment of Intramedullary Spinal Tumors

Surgical resection of intramedullary tumors remains technically challenging. The role of intraoperative ultrasound and contrast-enhanced ultrasound (CEUS) in these surgeries has not yet been well defined. This study was aimed to evaluate the potential of intraoperative ultrasonography, especially CEUS, in visualizing intramedullary spinal cord tumors, and to assess the values for improving surgical outcomes. This prospective study recruited 14 patients with intramedullary spinal cord tumor. All patients underwent tumor resection with intraoperative ultrasound and CEUS. The first ultrasonographic scanning was performed before the dural incision. After the dural incision, further ultrasonographic scanning was performed over the surface of the spinal cord. During and after the tumor removal, repeat ultrasonographic scanning was conducted to assess the extent of surgical resection. Follow-up data were collected and analyzed. Seven patients had small tumors involving 1 or 2 spinal segments, and 7 patients showed relatively large tumors involving ≥3 spinal segments. Intraoperatively, ultrasonography was able to visualize the lesion clearly in all cases. Using intraoperative ultrasound with CEUS, the tumor boundaries were clearly defined. After an average follow-up period of 15.93 months, neurologic function improved in 10 cases (71.4%) and remained unchanged in 4 cases (28.6%); there was no deterioration in individual neurologic function. Intraoperative ultrasound is of great value for localizing lesions and determining the extent of dural opening and myelotomy, therefore reducing the invasiveness of spinal surgery for intramedullary tumors. CEUS helps to delineate the tumor margins and perfusion features.

Sphenopalatine ganglion block: Intranasal transmucosal approach for anterior scalp blockade - A prospective randomized comparative study.

Background and Aims:Peripheral nerve blocks in neurosurgical practice attenuate most stressful responses like pin insertion, skin, and dural incision. Scalp block is conventionally the blockade of choice. Further studies for less invasive techniques are required. Intranasal transmucosal block of the sphenopalatine ganglion has shown promising results in patients with chronic headache and facial pain. The primary objective of our study was to compare the gold standard scalp block and bilateral sphenopalatine ganglion block (nasal approach) for attenuation of hemodynamic response to pin insertion. Secondary objectives included hemodynamic response to skin and dural incision.Material and Methods:After IRB approval and informed consent, a prospective randomized comparative study was carried out on 50 adult patients undergoing elective supratentorial surgery. The hemodynamic response to pin insertion, skin incision, and dural incision was noted in both the groups. The data was analyzed with NCSS version 9.0 statistical software.Results:The HR and MAP were comparable between the groups. Following dural incision MAP was significantly lower at 1,2,3,4,5 and 10 min in group SPG whereas in group S it was significantly lower at 1 and 2min. (P = 0.02 at T1, P = 0.03 at T2).Conclusions:Concomitant use of bilateral SPG block with general anesthesia is an effective and safe alternative technique to scalp blockade for obtundation of hemodynamic responses due to noxious stimulus during craniotomy surgeries.

Superficial Siderosis With Verrucous Vegetation Around a Dural Defect Confirmed by Intraoperative Ultrasonography

Superficial siderosis (SS) of the central nervous system (CNS) is a rare disease caused by repeated hemorrhages in the subarachnoid space. We describe surgical treatment of an SS case in which a dural defect with verrucous vegetation in the spinal canal was detected by intraoperative ultrasonography (US). After laminectomy, intraoperative US imaging confirmed verrucous vegetation and epidural fluid collection around the ventral dural defect before incision of the posterior dura mater. As intraoperative US also showed a dural defect at the ventral and right sides of the spinal cord, the posterior dural incision was made in a manner that was slightly more right lateral than standard midline. The ventral dural defect was repaired by direct sutures. After repair, intraoperative US imaging confirmed dural hole closure, removal of vegetation and resolution of the collected fluid. Dural closure was successful and symptoms partially improved despite the patient’s long history of SS. Intraoperative US can help surgeons make decisions about precise dural incision before repair. Intraoperative US is useful for detecting the level of dural defect and verrucous vegetation before repair and confirming closure of the dural defect, successful removal of vegetation and resolution of fluid collection after repair.

Cisterna magna reconstruction with arachnoid suturing in brainstem surgery.

We present an effective and easily applied technique for cisterna magna reconstruction with arachnoid suturing in brainstem surgery. Suturing with 10-0 monofilament was done in a patient with a medulla oblongata hemangioblastoma (diagnosed von Hippel-Lindau disease). Seven years later, follow-up imaging revealed a new lesion close to the previous one and the patient underwent reoperation. The craniotomy and dural incision were repeated, and the intact arachnoid was visualized with no meningocerebral adhesions. This technique preserves normal anatomic landmarks and facilitates and shortens dissection in reoperations, almost like a virgin case. We propose this technique for every lower brainstem and fourth ventricle procedure.The video can be found here: https://youtu.be/RKMcSoK6ycY.

Comparison of dural closure alternatives: an experimental study

Introduction: Dural closure preference has been a topic of debate in contemporary neurosurgery. This study aims to compare different closure techniques using an in vitro model.Methods: Human cadaveric dura mater was attached to a cylindrical metal glass filled with blue dyed saline. A 1 cm dural incision was made. Dural closure was performed using three different techniques. Each group had six samples: Group I – interrupted simple 4-0 polyglactin suture (S) only, Group II – S plus on lay collagen graft, Group III – S plus fibrin sealant. In Group NS, a 1 cm × 1 cm dural window was made. An onlay collagen graft was used with no suturing for this group to serve as an overtly weak reconstruction reference. Primary and secondary leak pressures were recorded (PLP and SLP, respectively).Results: All groups (I–III) had significantly higher PLP and SLP than Group NS. PLP was significantly higher in Group III as compared to groups I and II. Groups I and II had similar PLP values. SLP was similar in all three groups.Conclusion: In this study, the use of fibrin sealant has proven to be the best option in preventing dural leak. However, no technique was superior in the case of SLP.

Perioperative hypertension associated neurohumoral stress response in craniotomy patients: Effects of β-blocker and angiotensin converting enzyme inhibitor

BackgroundDevelopment of perioperative hypertension in craniotomy procedures is commonly associated with activation of sympathetic events through renin-angiotensin-aldosterone system (RAAS). Preemptive therapy with β-blockers or angiotensin converting enzyme (ACE) inhibitors may attenuate this hypertensive response. We conducted a randomized, double blind; placebo controlled study to compare the effect of β-blocker (atenolol) and an ACE inhibitor (Lisinopril) on perioperative hypertension in patients undergoing for the craniotomy and also studied biochemical markers of these two systems. MethodsEighty five patients undergoing craniotomy for supratentorial tumor removal were screened and randomized into three groups to receive either (atenolol; lisinopril or placebo). Blood analysis of renin, aldosterone, norepinephrine and sodium levels was drawn 12 h prior to surgery, at the time of dural opening, and at the time of extubation. Differences in mean arterial pressure (MAP), hear rate (HR) and biochemical markers between three groups were analyzed using one-way ANOVA. ResultsPerioperative hemodynamic changes were highly associated with biochemical markers in all the three groups. Specifically, HR was significantly attenuated by atenolol in the immediate extubation period (p < 0.01) persisted till 12 h postoperatively and this was associated with low plasma renin levels at the extubation. MAP was lowered by lisinopril and both aldosterone and norepinephrine levels were significantly lower (p < 0.01) at dural incision and extubation periods. ConclusionsPretreatment with atenolol or lisinopril significantly attenuated perioperative hypertension in patients undergoing craniotomy procedures. Lisinopril was better in lowering perioperative MAP while atenolol attenuated HR changes. RAAS inhibition may be the possible mechanism responsible for this hypertension effect in craniotomy procedures.

Microneurosurgical Removal of a Cervical Intramedullary Tumor Via Hemilaminoplasty: 3-Dimensional Operative Video.

Intramedullary tumors of the spinal cord are rare and account for 2% to 8.5% of all central nervous system tumors. In adults, ependymomas are the most common intramedullary tumors. The primary choice of treatment should be radical surgical removal, as this is curative for most tumors. Adequate tumor exposure is crucial and mostly achieved through standard laminectomy followed by midline myelotomy. However, extensive removal of posterior spinal elements may lead to worsening kyphotic deformities. After obtaining patient consent, this 3-dimensional video publication was prepared to present microneurosurgical removal of a C3-C6 cervical intramedullary tumor using right-sided hemilaminoplasty. C3-C6 hemilaminae were lifted en bloc. After dural and arachnoid incision, midline myelotomy was performed. Using microneurosurgical technique, the tumor was removed totally. After the dural closure, C3-C6 hemilaminae were placed into the previous position and reconstructed with mini-plates and screws. Preserving contralateral paraspinal muscles, spinous processes, midline spinal ligaments and bilateral facet joints helped maintaining the alignment of the spinal column. Comparing to laminectomy, hemilaminoplasty, decreases the postoperative pain and the total blood loss as only one side muscle dissection is enough. In the presented case, postoperative MRI showed total removal of the tumor. The final histopathology report indicated an ependymoma (WHO-Grade 2). Successful bone healing was demonstrated by postoperative cervical radiographs and CT scans. The patient has no postoperative neurological deficit. In conclusion, hemilaminoplasty is an effective and a less-invasive method in removal of intradural-intramedullary tumors with its advantages such as preventing the instability and reduction of blood loss and postoperative pain.

Combined Transpetrosal Approach With Preservation of Superior Petrosal Vein Drainage for a Cerebellopontine Angle Epidermoid Cyst Extending Into Meckel's Cave: 3-Dimensional Operative Video.

The combined transpetrosal approach enables wide exposure around the petroclival region by cutting the tentorium and superior petrosal sinus. We often choose this approach for removal of tumors ventral to the facial and vestibulocochlear nerves, such as petroclival meningioma and epidermoid cyst, because complete removal of the tumor under direct visualization is required to prevent its later recurrence, especially in young patients. Recent reports revealed anatomical variations of the drainage of the superior petrosal sinus, and dural incision considering preservation of the superior petrosal vein was proposed.1-3 This 3-dimensional video shows a patient with an epidermoid cyst, which was surgically treated using the combined transpetrosal approach, with consideration of the variation of the superior petrosal sinus and preservation of the drainage route of the superior petrosal vein. The video was reproduced after informed consent of the patient. The patient is a 31-yr-old woman who presented with a left cerebellopontine angle epidermoid cyst extending into Meckel's cave. The superior petrosal sinus was of the lateral type, draining only laterally into the transverse-sigmoid junction without medial connection with the cavernous sinus.1 The combined transpetrosal approach was performed with cutting of the superior petrosal sinus medial to the entry point of the superior petrosal vein, in order to preserve its drainage into the transverse-sigmoid junction. Meckel' cave was opened along its lateral margin, and tumor removal was accomplished, leaving only a minute part of the capsule strongly adhering to the neurovascular structures. The patient had no new permanent neurological deficits during follow-up. The figures in the video were modified from Matsushima et al1 by permission of the Congress of Neurological Surgeons.

The Eustachian Tube as a Landmark for Early Identification of the Abducens Nerve During Endonasal Transclival Approaches.

Expanded endonasal approaches have the potential to injure the abducens nerve (cranial nerve [CN] VI). The nerve's root entry zone (REZ) and cisternal segment (CS) are particularly prone to injury during the clivus resection and dural incision of transclival approaches. To investigate the role of the eustachian tube (ET) as a surgical landmark for the REZ and CS of CN VI. Transclival expanded endonasal approaches were performed bilaterally in 6 fresh-frozen cadaveric specimens (12 sides). Anatomic relationships between ET and CN VI were documented with neuronavigation. The mean vertical distance from the inferior brainstem point to the horizontal projection of CN VI REZ, CS midpoint, and interdural segment (ID) were 26.38 mm (95% confidence interval [CI] 17.36-35.4), 38.61 mm (95% CI 25.61-51.61), and 42.68 mm (95% CI 30.14-55.22), respectively. The relative vertical distance from the ET to the horizontal projections of the REZ, CS midpoint, and its ID were 6.43 mm (95% CI 3.25-9.61), 18.66 mm (95% CI 11.52-25.8), and 22.72 mm (95% CI 16.02-29.42), respectively. In the axial plane the angles between the ET and (1) the REZ and its midline horizontal projection point, (2) the midpoint and its midline horizontal projection point, and (3) ID and its midline horizontal projection point were 9.81±SD 5.20°, 18.50±SD 4.87°, and 24.71±SD 6.21°, respectively. The ET may serve as a constant landmark to reliably predict the position of the REZ and CS of CN VI.

Importance of collateral venous circulation on indocyanine green videoangiography in intracranial meningioma resection: direct evidence for venous compression theory in peritumoral edema formation.

Indocyanine green videoangiography (ICGVA) has been used in many neurosurgical operations, including vascular and brain tumor fields. In this study, the authors applied ICGVA to intracranial meningioma surgery and evaluated it usefulness with attention to collateral venous flow. Forty-two patients with intracranial meningioma who underwent ICGVA during microsurgical resection were retrospectively analyzed. For ICGVA, the ICG was injected intravenously at the standard dose of 12.5 mg before and/or after tumor resection. Intravascular fluorescence from blood vessels was imaged through a microscope with a special filter and infrared excitation light to illuminate the operating field. The authors assessed the benefits of ICGVA and analyzed its findings with preoperative radiological findings on MRI. ICGVA allowed real-time assessment of the patency and flow direction in very small peritumoral vessels in all cases. A safe dural incision could also be done based on information from ICGVA. The collateral venous channel due to venous obstruction of tumoral compression was found in 10 cases, and venous flow restoration after tumor resection was observed promptly after tumor resection in 4 cases. Peritumoral brain edema (PTBE) was observed on preoperative T2-weighted MRI in 19 patients. The presence of collateral venous circulation or flow restoration was significantly related to PTBE formation in multivariate analysis (p = 0.001; HR 0.027, 95% CI 0.003-0.242). ICGVA, an excellent method for monitoring blood flow during meningioma resection, provides valuable information as to the presence of venous collaterals and flow restoration. Furthermore, the fact that the presence of venous collaterals was found to be associated with PTBE may directly support the venous theory as the pathogenesis of PTBE formation.

Bifrontal Interhemispheric Approach Involving Cutting the Superior Sagittal Sinus for Distal Anterior Cerebral Artery Aneurysms

The unilateral interhemispheric approach for distal anterior cerebral artery aneurysms presents several risks, such as postoperative venous infarction due to occasional sacrifice of parasagittal bridging vein and postoperative frontal lobe damage due to retraction force. To overcome these risks, we used a bifrontal craniotomy with straight dural incision and cutting of the superior sagittal sinus. We retrospectively reviewed 61 patients (42 unruptured and 19 ruptured A2 and A3 aneurysms) who under aneurysm clipping through bifrontal interhemispheric approach between March 2007 and December 2017. There were 35 A2 aneurysms and 27 A3 aneurysms, and mean size of aneurysms was 5.45 mm. The modified bifrontal interhemispheric approach involved 3 steps: bifrontal craniotomy of centrobasal portion of the frontal bone, ligation and division of anterior one third of the superior sagittal sinus, and approaching the aneurysm via the interhemispheric space. All patients underwent computed tomography on postoperative days 3 and 7 for evaluation of brain retraction damage or venous infarction. Among patients with ruptured aneurysms, 79% had a favorable outcome (Glasgow Outcome Scale score 4 or 5) 6 months after primary subarachnoid hemorrhage; all patients with unruptured aneurysms had favorable outcomes. Surgical outcome was strongly related to preoperative neurologic Hunt and Hess grade. Three patients had poor outcomes due to poor Hunt and Hess grade on admission (grade 3 in 2 patients, grade 4 in 1 patient). Follow-up CT showed that venous infarction did not occur in any of the patients. Modified bifrontal interhemispheric approach may be a safe and effective method for treating A2 and A3 aneurysms with relatively good clinical outcome and no surgery-related complications.

Microsurgical Resection of Thoracic Meningioma: 2-Dimensional Operative Video.

The primary goal of surgery with spinal meningioma is complete safe tumor removal and decompression of the spinal cord. For the surgical removal of spinal meningioma, internal debulking before dissection of the tumor capsule is essential. Intraoperative ultrasonography to localize the tumor is recommended by some authors, but we use indocyanine green (ICG) videography to visualize the localization of tumor before dural incision. ICG videography allows safe and complete delineation of intradural tumors before dural opening. This technique is quick, cost-effective, and simple to use, especially with its integration into the surgical microscope. Herein, we present a case of a 54-yr-old female patient presenting with a 1-yr history of numbness of the right lower limb. Neurological examinations demonstrated temperature pain disorder of right lower limb and slight dysuria. Magnetic resonance images demonstrated intradural extramedullary tumor at the level of Th6. Preoperative diagnosis was spinal meningioma. In this surgical video, we show ICG angiography before dural opening, in addition to the basic surgical procedure of the thoracic meningioma. We believe this operative video will be useful for those in training as well as practicing surgeons. We received written informed consent from the patient for this publication.

Pig as a large animal model for posterior fossa surgery in oto-neurosurgery: A cadaveric study.

This study proposes a practical model for a new approach to the posterior fossa in common domestic pigs. Several surgical procedures can be simulated in the nonliving pig model, including soft tissue dissection, drilling of temporal bone, dural incision, access to the cerebellopontine angle, exposure of cranial nerves and drilling of the internal auditory canal. The pig model perfectly simulates standard otological and neurosurgical procedures, and we highlight the feasibility of our approach for further experiments in a living pig model with the possibility of reproducing the model for research on cranial nerves in pigs to study their electrophysiological behavior.

Decompressive Craniotomy and Fast-Track Duraplasty in Acute Subdural Hematomas

Background: Traumatic subdural hematoma is one of the severe injuries to brain with high mortality rates. Dural opening is often associated with brain herniation against the dural edges due to associated edema that would lead to venous infarction. Aim: The objective of this study is to describe a technical note that would allow fast and effective closure of the dura after hematoma evacuation via duraplasty with analysis of the safety and competency of the technique. Subjects and Methods: The fast-track technique was implemented in 15 successive cases with acute subdural hematoma where the fascia lata flap was prepared and sutured to the planned dural incision before opening the dura, which allowed fast and effective closure of the dura before brain herniation. Subdural bridges were planned by using Gelfoam to prevent venous compression. Analysis of the technique effectiveness was performed by the operative detection of brain herniation, as well as clinical and radiological follow-up of patients. Results: All patients had a Glasgow coma score (GCS) below six before the operation. Mean time from trauma to surgery was five hours. The dura could be effectively closed with no brain herniation in all cases. Nine patients survived (60%), where five of them ended up in a vegetative state. Of these two recovered and three continued in a persistent vegetative state. The mortality rate was 40%. Post-operative infarction was detected in post-operative imaging of four patients. Conclusion: The fast-track duraplasty technique is fast and effective in prevention of brain herniation during surgery with favorable clinical outcome in comparison with the poor and severely deteriorated preoperative clinical presentation. More studies to evaluate the impact of the technique on the survival rate are warranted.

Intraoperative Ventriculostomy Using K Point in Surgical Management of Aneurysmal Subarachnoid Hemorrhage

Intraoperative ventriculostomy in the surgical management of aneurysmal subarachnoid hemorrhage (SAH) is frequently performed to reduce increased intracranial pressure. The previously suggested ventriculostomy points have some limitations because the dura mater must be opened to be accessed and it is difficult to measure the exact entry point in patients with brain edema. We propose a new intraoperative ventriculostomy point (Kpoint) for use in the surgical management of aneurysmal SAH patient with severe brain edema. We performed intraoperative ventriculostomy using the K point on 155 patients with aneurysmal SAH between January 2012 and August 2016. Before opening the dura mater following standard pterional craniotomy, we inserted the ventricular catheter through a small dural incision perpendicular to the middle frontal gyrus toward the ipsilateral medial epicanthus. We simulated the catheter trajectory using a commercial navigation system on 2 patients with brain tumor. Ventriculostomy related hemorrhage occurred in 12 patients (7.7%), but there were no large hemorrhages causing neurologic deterioration or requiring evacuation. No language impairment was observed in these patients. Analysis using the navigation system revealed that the trajectory of K point ventriculostomy avoided critical periventricular brain structures and passed through the space between the genu of the corpus callosum and head of the caudate nucleus. K point ventriculostomy allows for easy access to a target point and protects the brain during opening of the dura mater and drilling of the sphenoid bone.

U-shaped durotomy for midline posterior fossa tumor removal: technical note and evaluation of results.

The classical dura opening for midline posterior fossa tumors in and around the 4th ventricle and the craniocervical junction is a Y-shaped incision. Several potential problems are associated with this technique. We used a technical variant, the U-shaped durotomy, previously described by Rhoton, offering several advantages. We report on the surgical results of the technique in a consecutive series of posterior fossa cases in children and adolescents. In all midline posterior fossa approaches, a U-shaped dural incision is standard in our institution. All cases were retrospectively analyzed regarding hydrocephalus, placement of EVD or lumbar drain, need for ETV or shunting during follow-up, and frequency of duraplasty, of pseudomeningocele, of primary watertight dural closure, of CSF leakage, and of venous sinus hemorrhage at opening. Fifty pediatric patients were included. In all easy occipital sinus, control was achieved and no additional dural retraction for tumor exposure required. In 49/50 patients, a primary watertight dura closure without duraplasty was achieved, also in re-do cases with previous U-shaped opening. One patient received a small periostium graft after having had a duraplasty following Y-shaped opening beforehand. No CSF fistula ever occurred and no pseudomeningocele was detected in any follow-up MRI. The U-shaped durotomy for dorsal midline approach to the 4th ventricle and craniocervical junction provides wide exposure to all tumors and allows for primary and watertight dura closure. Compared to published results and complications of classic Y-shaped dural opening, this method of durotomy and closure seems most advantageous.

Minimally Invasive Surgical Approach to Filum Sectioning: Technical Note.

Filum terminale lipoma (FTL) is known to cause various spinal symptoms collectively referred to as tethered cord syndrome (TCS). With the increasing use of magnetic resonance imaging, there has been an increase in the identification of FTLs. The treatment for FTL is surgical untethering by sectioning the filum terminale, which can prevent symptom progression and often results in improvement of symptoms. We recently introduced a new surgical strategy for filum terminale sectioning named interlaminar approach (ILA). In this surgical video, we present a minimally invasive technique of ILA. The surgical approach and postoperative result are outlined. A minimal 2 cm length of midline skin incision was performed at the L5 vertebral level. After skin incision, dissection was extended to expose the ligamentum flavum. The ligamentum flavum was then incised and retracted medially to expose the dural sac. After dural incision, the filum terminale was identified and pulled out from the dural sac and then sectioned. The maximum diameter of the filum terminale was 3 mm in our series. The surgical time for children was about 1 h. Adult patients need a deeper surgical field, so the operation takes more time. Until now, 46 patients (11 mo to 27 yr) have undergone ILA and been followed for more than 5 yr. Surgical complication was seen in only one patient who developed a subcutaneous fluid collection. All patients remained stable or showed improvement in preoperative symptoms. This technique provides the advantage of reduced soft tissue injury and minimal intradural procedures. Thin FTL showing TCS are candidates for ILA. This article complies with the guideline for patient information confidentiality and privacy protection. All the patients in this study provided written, informed consent for the procedure. Watch now at https://academic.oup.com/ons/article-lookup/doi/10.1093/ons/opx127 {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Minimally Invasive Surgical Approach to Filum Sectioning: Technical Note","caption":"","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_kcc30hx5"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} Disclosure The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.

Effectiveness of modified dural incision to preserve the patency of the occipital sinus in foramen magnum decompression for a patient with Chiari malformation type I.

Background:Foramen magnum decompression (FMD) has been acknowledged as a standard surgical procedure for symptomatic patients with Chiari malformation type I (CM-I). However, even if dural incision is necessary during FMD, the procedure of cutting off the occipital sinus has not been regarded as a safe option.Case Description:A 27-year-old woman with intractable occipital headache was diagnosed with CM-I without syringomyelia. Preoperative examination revealed a large oblique occipital sinus on her right side. During the first FMD, the dura mater was not incised to preserve the occipital sinus. However, her headache was not relieved with painkillers and cerebellar tonsillar ectopia remained. During the second FMD, two dural incisions were made, while preserving the occipital sinus patency. The dural patch was made using an autologous fascia for both dural incisions. Postoperatively, headache was completely resolved immediately, and cerebellar tonsil was elevated without any complication.Conclusion:This dural incision, which is a modification of the method introduced by Pritz, would be a useful FMD option for patients of CM-I with dominant occipital sinus, which would lead to the serious neurological sequelae if the sinus flow is disturbed.

Minimally Invasive Surgical Approach to Filum Lipoma

Filum terminale lipoma (FTL) causes various spinal symptoms known as tethered cord syndrome. The treatment for FTL is surgical untethering by sectioning the FTL, which can prevent symptom progression and often results in improvement of symptoms. This report describes a minimally invasive surgical strategy that we have introduced for FTL sectioning. The pediatric patients with FTL since 2007 were treated using this minimally invasive surgical strategy, which we refer to as an interlaminar approach (ILA). In summary, the surgical technique involves: minimal skin incision to expose the unilateral ligamentum flavum in the lower lumbar region; ligamentum flavum incision to expose the dural sac, and dural incision followed by identification and sectioning of the filum. Postoperatively, no bed rest was required. Prior to introducing ILA, we had used standard one level laminectomy/laminotomy (LL) with more than 1 week of postsurgical bed rest until 2007, providing an adequate control group for the benefit of the ILA. A total of 49 consecutive patients were treated using ILA. While 37 patients were treated using LL. Surgical complications that need surgery were seen only in one patient, who developed cerebrospinal fluid (CSF) leak in LL patients. No retethering or additional neurological symptoms were seen during follow-up. All patients complained of minimal postsurgical back pain, but no patients required postoperative bed rest in ILA patients, while LL patients need postsurgical bed rest because of back pain. The ILA strategy provides the advantage of a minimal tissue injury, associated with minimal postoperative pain, blood loss, and bed rest.

Efficacy, Reliability, and Safety of Completely Autologous Fibrin Glue in Neurosurgical Procedures: Single-Center Retrospective Large-Number Case Study.

Commercially available fibrin glue (Com-FG), which is used commonly worldwide, is produced with pooled human plasma from multiple donors. However, it has added bovine aprotinin, which involves the risk of infection, allogenic immunity, and allergic reactions. We evaluate the efficacy, reliability, and safety of completely autologous fibrin glue (CAFG). From August 2014 to February 2016, prospective data were collected and analyzed from 153 patients. CAFG was prepared with the CryoSeal System using autologous blood and was applied during neurosurgical procedures. Using CAFG-soaked oxidized regenerated cellulose and/or polyglycolic acid sheets, we performed a pinpoint hemostasis, transposed the offending vessels in a microvascular decompression, and covered the dural incision to prevent cerebrospinal fluid leakage. The CryoSeal System had generated up to a mean of 4.51 mL (range, 3.0-8.4 mL) of CAFG from 400 mL autologous blood. Com-FG products were not used in our procedures. Only 6 patients required an additional allogeneic blood transfusion. The hemostatic effective rate was 96.1% (147 of 153 patients). Only 1 patient who received transsphenoidal surgery for a pituitary adenoma presented with the complication of delayed postoperative cerebrospinal fluid leakage (0.65%). No patient developed allergic reactions or systemic complications associated with the use of CAFG. CAFG effectively provides hemostatic, adhesive, and safety performance. The timing and three-dimensional shape of CAFG-soaked oxidized regenerated cellulose and/or polyglycolic acid sheets solidification can be controlled with slow fibrin formation. The cost to prepare CAFG is similar compared with Com-FG products, and it can therefore be easily used at most institutions.