Microsurgical Decompression Research Articles

Early Experience, Setup, Learning Curve, Benefits, and Complications Associated with Exoscope and Three-Dimensional 4K Hybrid Digital Visualizations in Minimally Invasive Spine Surgery.

Study DesignProspective observational study (n=74).PurposeTo evaluate the learning curve for exoscope and three-dimensional (3D) 4K hybrid visualization in terms of operating time, advantages, disadvantages, and surgical complications in tubular-access minimally invasive spine surgery (MISS) and to assess surgeon satisfaction with image quality, ergonomics, and ability to perform target site treatment.Overview of LiteratureWorking through tubular retractors poses a challenge. The extreme angulations during microsurgical decompression, especially contralateral decompression, require surgeons to work non-ergonomically. An exoscope allows surgeons to work ergonomically and independently of the microscope oculars as visualizations are now provided by large 3D 4K monitors. However, the value and efficacy of solely depending on an exoscope and 3D 4K monitors during microsurgical work are still unknown.MethodsSeventy-four patients (99 levels) underwent trans-tubular MISS between March 2018 and January 2019. Five patients were excluded: one had pyogenic discitis, two had revisions, and two were trans-tubular transoral. In total, we analyzed 69 for operating time, blood loss, and complications. The learning curve graph was plotted using the surgical time for each procedure. Surgeons were asked to rate their satisfaction with image quality, ability to maintain ergonomic posture, and efficient target site treatment.ResultsFor tubular microdiscectomy, the operating time plateaued after six cases, and for tubular decompression and minimally invasive transforaminal lumbar interbody fusion, the operating time plateaued after nine cases. Mean operating time was significantly reduced after the plateau. Complications included four cases of dural tear. All patients improved symptomatically, and there were no postoperative neurological deficits.ConclusionsUse of the exoscope has a short learning curve. Surgeons benefit from improved ergonomic posture during surgery, and resident teaching appears to be good. The only drawback is the need to rearrange the operating table setup. Complications were comparable to those when using the surgical microscope. An exoscope with hybrid digital visualization provides excellent visualization, depth perception, clarity, and precision target site treatment.

Retrospective single-centre series of 1300 consecutive cases of outpatient cervical spine surgery: complications, hospital readmissions, and reoperations

Background: Outpatient surgery is becoming more common and is more cost-effective than inpatient surgery. Nonetheless, many surgeons and health care administrators are still hesitant to accept outpatient surgery for cervical degenerative spinal disease (C-DSD). This study assesses the types and rates of complications, hospital admissions, and reoperations after outpatient surgery of C-DSD.Methods: Complications, hospital admissions within 90 days of surgery, and reoperations within one year of surgery were recorded retrospectively in 1300 outpatients undergoing microsurgical decompression for C-DSD at the Oslofjord Clinic from 2008 to 2017. The surgical procedures performed were anterior cervical decompression and fusion (ACDF) in 1083 patients and posterior cervical foraminotomy in 217 patients.Results: The surgical mortality rate was 0%. Sixteen major complications were recorded in 15/1300 (1.2%) patients. The complications were neurological deterioration in four patients, postoperative hematoma in two, dural lesions with cerebrospinal fluid leakage in one, deep surgical-site infection in one, persistent hoarseness in three, and persistent dysphagia in five. The two potentially life-threatening hematomas were detected within the planned six-hour observation period. Two (0.2%) patients were admitted to hospital within hours of surgery completion with stroke-like signs and symptoms, and four (0.3%) patients were admitted to hospital within 90 days due to surgery-related events. The rate of reoperations for cervical radiculopathy within 12 months was 25/1171 (2%); eight patients’ reoperations were due to inadequate primary decompression, one was due to recurrent disc herniation at the same level and side, and 16 were due to new-onset radiculopathy from an adjacent level or other side.Conclusions: Outpatient microsurgical decompression of the degenerative cervical spine in carefully selected patients appears to be safe and carries a low major complication rate, low hospital admission rate, and low one-year reoperation rate.

Corrigendum: Bow Hunter's Syndrome: Complete Microsurgical Decompression of Vertebral Artery by Far Lateral Retrocondylar Approach: 3-Dimensional Operative Video

Operative Neurosurgery: October 2019 - Volume 17 - Issue 4 - p 442 doi: 10.1093/ons/opz256

The Role of Stabilization-Free Microsurgical Decompression in the Surgical Treatment of Spinal Metastases

Symptomatic spine metastases are found in about 10% of patients with cancer. As the long-term survival of patients with carcinoma rises, the number of patients with symptomatic spine metastases is also increasing. In our tertiary referral center, patients usually present rapidly progressive neurologic disorders, which require an urgent treatment decision. Treatment options include extensive 360° stabilizations. These complex interventions are not always readily available. We examined the extent to which the patient population benefited from decompressive surgery without stabilization. We hypothesize that patients benefit from merely dorsal decompression, which preserves stability when they experience symptomatic spine metastases. We performed a retrospective analysis of electronic patient data from 19 patients, who were treated for symptomatic spine metastases by hemilaminectomy between 2009 and 2017. We evaluated the preoperative and postoperative neurologic functions using the American Spinal Injury Association (ASIA) Impairment Scale. A comparative literature analysis was carried out to assess the Spinal Neoplastic Instability Score, Tokuhashi score, and Tomita score. Nine participants had prostate cancer, 4 had mammary carcinoma, 3 had bronchial carcinoma, and 3 had other cancers. The median preoperative ASIA score was C, postoperatively, the score significantly improved to D (sign test P= 0.002). None of the patients needed stabilization within the follow-up period of up to 56 months. In our patient population, minimal intervention could significantly improve neurologic disorders. This outcome was seen over the whole study period. Even though different scoring systems suggest stabilization, our results show that spinal decompression alone might be indicated as well.

How I do it: bilateral lumbar spinal canal microsurgical decompression via unilateral approach.

Bilateral lumbar spinal canal decompression via unilateral approach is a surgical way to treat degenerative spinal canal stenosis. We report the treatment of degenerative lumbar spinal canal stenosis by removing overgrown ligaments, bone, and other compromising tissue on both sides of the spinal canal, using one side approach, avoiding surgical trauma of the counter side of the spine. This technique allows to achieve perfect results using common microsurgical instruments and Caspar distractor for one or multilevel surgery.

Endoscopic-Assisted Microvascular Decompression of Ectatic Vertebral Artery for Hemifacial Spasm: Operative Video and Technical Nuances

In this operative video atlas manuscript, the authors demonstrate the operative nuances and surgical technique for endoscopic-assisted microvascular decompression of a large ectatic vertebral artery causing hemifacial spasm. A retrosigmoid approach was performed and a large ectatic vertebral artery was transposed away from the root exit zone of cranial nerve VII ( Fig. 1 ). The lateral spread response disappeared, signifying adequate decompression of the facial nerve ( Fig. 2 ). The use of endoscopic-assistance during the microsurgical decompression was very useful to confirm the origin and also the resolution of neurovascular conflict. Postoperatively, the patient experienced immediate resolution of hemifacial spasm with normal facial nerve and hearing function. Written consent was obtained from the patient to publish videos, photographs, and images from the surgery. The link to the video can be found at: https://youtu.be/RlMz44uCDCw .

Submandibular Approach for Single-Stage Craniovertebral Junction Ventral Decompression and Stabilization: A Preliminary Cadaveric Study of Technical Feasibility

The craniovertebral junction (CVJ) may be affected by several diseases. It is an anatomically complex region, involving the osteoligamentous, vascular, and nervous structures, which makes surgery challenging. In a case of ventral compression, an anterior approach is preferable, although posterior fixation is often required. Anterior transmucosal approaches are associated with high rates of complications. However, decompression and fixation by the use of retropharyngeal extramucosal approaches may be challenging. To investigate the feasibility of a single-stage, anterior, extramucosal submandibular (SM) approach modification to the CVJ for simultaneous decompression and stabilization. This was a preliminary cadaveric feasibility study on 2 injected specimens. A variation of the SM approach with a short "boomerang" incision, microsurgical decompression of the ventral CVJ, and a new hybrid construct for an anterior atlantoaxial stabilization was investigated. The surgical approach, the decompression, and the instrumentation technique have been described. In addition, intraprocedural images and radiographs and also postprocedural computed tomographic images were collected. Furthermore, surgical exposure, working corridors and angles, and decompression grade were measured. The SM approach provided wide exposure of the ventral CVJ and the possibility for instrumentation and decompression by removing the anterior arch of C1 and the odontoid process. A single- stage anterior extramucosal SM approach for decompression and stabilization of the CVJ is feasible and could result in shorter surgical duration, avoiding the complications related to both the transmucosal approach and the prone position, although specific related risks exist. Mechanical investigation of this hybrid system and invivo studies are needed to confirm our results.

Imaging of Microhemodynamics in Peripheral Nerves by Contact Endoscope

Entrapment neuropathies include a wide field of locations. In most cases, the microsurgical decompression is still the therapy of choice. However, the role of venous stasis and ischemia is still discussed controversially. Here the authors evaluated the visualization of microvessels and the microperfusion at peripheral nerves with a contact endoscope during the surgical decompression for the first time. Eight patients were subjected to endoscopic or endoscopically assisted peripheral nerve decompression. In 3 patients with nerve tumors, the tumor carrying nerve was inspected endoscopically proximal and distal to the tumor site before and after resection. Microcirculation was assessed by a contact endoscope, allowing a 150-fold magnification, at superficial areas proximal and distal to the compression site. The electronically stored records were analyzed retrospectively using image processing software. Vessel diameter, red blood cell velocity, and blood flow, before and after decompression, were extracted. The contact endoscope was easy to handle intraoperatively without problems. All minimally invasive procedures were performed without complications. In the offline computer-assisted analysis, single arterioles and veins were visualized showing decreased red blood cell velocity prior to decompression. After surgical treatment, a statistically significant increase of blood flow was observed. Basically, the application of a contact endoscope for visualization of peripheral nerves' microcirculation is feasible. The observed effect of increased blood flow after decompression should be compared with the clinical outcome in a further prospective randomized study.

Surgical Outcomes in Idiopathic Recurrent Facial Nerve Paralysis: A Rare Clinical Entity.

To evaluate the postoperative facial nerve dysfunction, audiometric outcomes, and long-term quality-of-life outcomes of patients with idiopathic recurrent facial nerve paralysis (RFP) after middle cranial fossa (MCF) microsurgical decompression. Retrospective chart analysis of 11 (mean age 37.0 years, range 5 to 67) patients at an academic tertiary referral center who underwent MCF facial nerve decompression. Data analysis included evaluation of pre- and postoperative House-Brackmann (HB) score, pre- and postoperative pure-tone average (PTA), pre-and postoperative word recognition scores (WRS), and postoperative Facial Clinimetric Evaluation survey. Mean number of preoperative facial paralysis episodes was 3.5 (range 2 to 6), and preoperative HB score was 4.5 (range 1 to 6). Postoperatively, 0 patients had further episodes of facial nerve paralysis at an average of 6.5 years (range 0.1 to 17.6) (P = 0.005), and the average postoperative HB score was 2.1 (range 1 to 3) (P = 0.011). Postoperative audiometry was stably maintained as assessed with PTA and WRS scores. Microsurgical facial nerve decompression for idiopathic RFP may be a reliable therapeutic modality to prophylactically decrease the number of facial nerve paralysis episodes and may also help to improve facial nerve functional status. 4 Laryngoscope, 130:200-205, 2020.

Outcome and Prognosis of Microsurgical Decompression in Idiopathic Severe Common Fibular Nerve Entrapment: Prospective Clinical Study

Compression of the common fibular nerve at the level of the fibular neck is considered to be the most frequent lower limb entrapment syndrome, which can be either idiopathic or secondary. Decompressive surgery is indicated only after failure of conservative treatment and/or severe neurologic deficit. The effectiveness of microsurgical decompression has been established only for secondary entrapment syndrome. The aim of this study is to assess the results of microsurgical decompression and establish the prognosis of idiopathic severe common fibular nerve entrapment. Fifteen patients were included in this prospective clinical study and were followed at day 1 after surgery and later at 1, 6, and 12 months. More than half (64.3%) of patients had a total motor deficit (0/5). The median motor function preoperatively was 0/5. The average time of conservative treatment before surgery was 25.7 days (range 5-110 days). One patient refused surgical management. Thirteen out of 14 patients who underwent surgery showed significant motor function improvement. The median motor strength at 12 months was 4.5/5. Half of the patients regained normal motor function. The only patient who did not improve had the longest time to surgery interval (110 days). The patient who refused surgery showed no improvement (0/5 at 12 months). Microsurgical decompression should be considered early in the context of severe idiopathic common fibular nerve entrapment in order to get a favorable outcome.

Acute carpal tunnel syndrome regarding clinico-anatomical point of view in personified medicine

Carpal tunnel syndrome (CTS) requires special attention due to its different reasons and course. Knowledge about the variability of median nerve (MN) topography in carpal canal region, features of diagnosis and treatment extends outlooks on this pathology. Aggregating rare clinical cases from the Medline and Pubmed databases is useful to form personified approach. There are 3 types of topographic variations which should be considered to prevent false-positive diagnosis of pathology: recurrent branch location, early bi- and trifurcations of MN, anastomoses. Since acute CTS is treated only by surgery, every surgical approach is aimed at minimally invasiveness and fast recovery. Endoscopic decompression (ED) is more favorable regarding these aspects. However, this method cannot be considered as perfect due to available data about incomplete decompression and certain incidence of recurrences. The last ones are absent after microsurgical decompression as a rule. It can be concluded that only individual approach is advisable for complete release of CTS without iatrogenic damage and recurrences.

Large Retroperitoneal Hematoma and Lumbosacral Plexopathy Following Microsurgical Decompression via the Wiltse Paraspinal Approach: A Case Report

Journal of Minimally Invasive Spine Surgery & Technique (JMISST) is the official journal of the Korean Minimally Invasive Spine Surgery Society (KOMISS) for the publication of research results about minimally invasive spinal surgery (MISS), including studies in spinal endoscopic surgery, minimally invasive procedure for degenerative spine disease, pain intervention, and minimally invasive surgery for spinal fusion or spine trauma, neuroscience, neurology, molecular biology and biomechanics etc. Articles with helpful information for MISS such as reports of rare cases or technical review of special devices or equipment are also available

The trend towards full-endoscopic decompression : Current possibilities and limitations in disc herniation and spinal stenosis

The most frequent causes of degenerative constrictions of the spinal canal are disk herniations and spinal stenoses. The lumbar and cervical spine is the most affected. After conservative treatments have been exhausted, surgical intervention may be necessary. Today, microsurgical decompression is regarded as the standard procedure in the lumbar region, while in the cervical spine, microsurgical anterior decompression and fusion are standard. Full-endoscopic techniques for decompression are becoming increasingly widespread worldwide. The development of various surgically created approaches and appropriate instrument sets have made the full-endoscopic operation of disk herniations and spinal stenosis possible. This development has also permitted resection of soft disk herniations in the cervical spine. The use of the approaches depends on anatomical and pathological inclusion and exclusion criteria. The clinical results of standard procedures have been achieved, which must be regarded as aminimum criterion for the introduction of new technologies. On the basis of EBM criteria, it can be established that using the full-endoscopic techniques developed, adequate decompression is achieved in the defined indications with reduced traumatization, improved visibility conditions, and positive cost benefits. Today, full-endoscopic operations may be regarded as an expansion and alternative within the overall concept of spinal surgery.

The degree of invasiveness has no influence on the rate of incidental durotomies in surgery for lumbar spinal canal stenosis: data from the German spine registry.

Risk factors for incidental durotomies are good documented by some authors who consider the degree of invasiveness as a direct risk factor on this serious complication. We compared the rate of incidental durotomies and its dependence from the degree of invasiveness. The German Spine Registry could document 6016 surgeries for lumbar spinal canal stenosis, N.=2539 microsurgical decompression, and N.=2371 open decompression with stabilization. Both groups were identical concerning age and sex of patients, mean age: 77.1±1.60; females: 58%; males: 32%. There were 410 incidental durotomies, group 1: 209 (8.23%); group 2: 201 (8.47%). This difference is statistically not relevant (P=0,75). A surgical therapy is documented in 345 (84%) cases, suture with/without fibrin glue: group 1=162 and group 2=183. Fifty-nine patients had a persistent fistula that needed treatment with a lumbar drain, group 1: N.=30; and group 2: N.=29. The groups decompression vs. decompression plus fusion are statistically comparable. Although the stabilization with instrumentation is a more invasive procedure with longer operation times, trauma tissue and blood loss - in comparison with microsurgical decompression - showed no difference in the rate of incidental durotomies.

Treatment results for lumbar epidural lipomatosis: Does fat matter?

The lumbar epidural lipomatosis (LEL) is a rare disease that can cause sciatic pain syndrome or neurological deficits comparable to symptoms caused by a classical spinal canal stenosis. In severe cases surgical decompression was conducted. However, the outcome after decompressive surgery has only been investigated in small case series. In this study we compared the outcome of LEL patients after microsurgery with the outcome of patients with classical spinal stenosis (CSS). Patients with LEL (n = 38) and patients with CSS (n = 51), who received microsurgical decompression, were followed in a prospective observational study for 3years. The clinical results including the Oswestry Disability Index, Numeric Pain Rating Scale (NRS), Roland and Morris Disability Questionnaire, the Short Form-36 Score and the Walking Distance were analysed and compared between both groups. Patients with LEL improved significantly after microsurgical decompression in a 3-year follow-up concerning back pain, leg pain and pain-associated disability equal to patients with CSS (NRSback_LEL_preop. = 6.4; NRSback_CSS_preop. = 6.3; NRSback_LEL_3-years = 3.2; NRSback_CSS_3-years = 3.6; NRSleg_LEL_preop. = 6.3; NRSleg_CSS_preop. = 6.5; NRSleg_LEL_3-years = 2.5; NRSleg_CSS_3-years = 2.9; ODILEL_preop. = 52.7; ODICSS_preop = 51.8; ODILEL_3-years = 32.3; ODICSS_3-years = 27.6). The microsurgical decompression had a positive effect on the health-related quality of life, and patient satisfaction was high in both groups (LEL group-71%, CSS group-69%). LEL can influence the quality of life dramatically and cause a high degree of disability. A surgical decompression is a safe and effective procedure with a good clinical outcome comparable to the results in patients with an osteoligamentous spinal stenosis. Therefore, microsurgical decompression can be recommended in patients with LEL if conservative treatment fails. These slides can be retrieved under Electronic Supplementary Material.

Microsurgical Decompression of Trigeminal Neuralgia Caused by Simultaneous Double Arterial (SCA and AICA) and Petrosal Vein Complex Compression.

Trigeminal neuralgia is a chronic pain disorder affecting the face. In approximately 80% of cases, it is most commonly caused, when the root entry zone (REZ) of the trigeminal nerve is compressed by the superior cerebellar artery (SCA). The etiology of the remaining 20% of cases is distributed among venous, arteriovenous malformations, posterior fossa tumors, multiple sclerosis plaque compressions, and other pathologies. Combinations of those compressive factors are very rare. 1 2 3 4 Herein, we present a video clip of microvascular decompression (MVD) in a 73-year-old female, who has failed conservative treatment with 6 medications over 10 years. She was affected by a unique triple compression of the right REZ by the SCA, anterior inferior cerebellar artery (AICA), and petrosal vein complex ( Fig. 1A ). Right-sided microsurgical decompression of the REZ of the trigeminal nerve through standard retrosigmoid craniotomy was performed by the senior author (K.I.A.). The SCA and AICA were separated from the nerve using Teflon pledgets. The petrosal vein complex was coagulated and divided, freeing up the right trigeminal nerve ( Fig. 1B ). The patient was discharged home on the third postoperative day with complete resolution of trigeminal neuralgia. The link to the Video can be found at: https://youtu.be/PYVvImGW0yE .

Unilateral Laminotomy for Bilateral Microsurgical Decompression in Treating Multiple Spinal Stenosis

Multiple spinal stenosis with significant signs and symptoms is one of the complex problems in spine pathology. For a simple reason, many spine surgeons do conservative decompressions, such as decompressive laminectomy or bilateral laminotomy and flavectomy, with one incision (preservation of lamina). Unilateral laminotomy in the lumbar area for bilateral access in spinal canal is quite rare and is performed for the treatment of multiple spinal stenosis.With this technique, microsurgical decompression is done with partial resection of the ipsilateral facet, the medial part of the laminar arch, and the partial contralateral facet, with the complete removal of the ligamentum flavum. By this methods, the aim for complete bilateral flavectomy and partial bilateral facetectomy are the key for the success of clinical improvements in treating multiple spinal stenosis.

Unilateral Laminotomy for Bilateral Microsurgical Decompression in Treating Multiple Spinal Stenosis

Multiple spinal stenosis with significant signs and symptoms is one of the complex problems in spine pathology. For a simple reason, many spine surgeons do conservative decompressions, such as decompressive laminectomy or bilateral laminotomy and flavectomy, with one incision (preservation of lamina). Unilateral laminotomy in the lumbar area for bilateral access in spinal canal is quite rare and is performed for the treatment of multiple spinal stenosis.With this technique, microsurgical decompression is done with partial resection of the ipsilateral facet, the medial part of the laminar arch, and the partial contralateral facet, with the complete removal of the ligamentum flavum. By this methods, the aim for complete bilateral flavectomy and partial bilateral facetectomy are the key for the success of clinical improvements in treating multiple spinal stenosis.

Ganglion cyst of Guyon’s canal as a rare cause of compression neuropathy of the ulnar nerve (literature review and case report)

The study objectiveis to analyze the existing research literature devoted to this problem and to assess clinical characteristics and specific features of the diagnosis and rational neurosurgical treatment for ganglion cyst of Guyon’s canal (GCGC) that caused compression neuropathy of the ulnar nerve.Materials and methods.Since 1955, researchers reported only 19 cases of ganglion cysts located in the wrist area and associated with tunnel neuropathy of the ulnar nerve. Since this condition is extremely rare, we present our own clinical observations.Results.Using the literature data, we described various types of ulnar nerve compression according to individual nerve characteristics determining clinical manifestations of GCGC. We analyzed the prevalence of GCGC among patients of various age and gender, disease pathogenesis, and main diagnostic methods. A patient with GCGC-associated compression ischemic neuropathy of the ulnar nerve was treated in the neurological clinic of the I. M. Sechenov First Moscow State Medical University in 2016. Using visualization tools, we found a ganglion cyst located on the palmar surface at the level of the hook-shaped bone. The cyst caused medial displacement of the ulnar nerve and ulnar artery. We performed microsurgical decompression of the right ulnar nerve at the level of Guyon’s canal and removed the articular ganglion cyst using a standard procedure. In the postoperative period, we observed partial regression of neurological disorders.Conclusion.To identify the cause of ulnar nerve neuropathy in Guyon’s canal, a physician should consider both clinical and electrophysiological data and the results of ultrasound examination and/or magnetic resonance imaging. A detailed examination of these patients allows clarifying morphological characteristics of the lesion and identifying such a rare lesion as ganglion cyst.

Microsurgical Decompression in Trigeminal Neuralgia With or Without Vascular Compression: Illustrative Cases With 3-Dimensional Operative Video.

Microsurgical Decompression in Trigeminal Neuralgia With or Without Vascular Compression: Illustrative Cases With 3-Dimensional Operative Video.