Microsurgical Decompression Research Articles

An Update on Peroneal Nerve Entrapment and Neuropathy.

Peroneal neuropathy is the most common compressive neuropathy of the lower extremity. It should be included in the differential diagnosis for patients presenting with foot drop, the pain of the lower extremity, or numbness of the lower extremity. Symptoms of peroneal neuropathy may occur due to compression of the common peroneal nerve (CPN), superficial peroneal nerve (SPN), or deep peroneal nerve (DPN), each with different clinical presentations. The CPN is most commonly compressed by the bony prominence of the fibula, the SPN most commonly entrapped as it exits the lateral compartment of the leg, and the DPN as it crosses underneath the extensor retinaculum. Accurate and timely diagnosis of any peroneal neuropathy is important to avoid progression of nerve injury and permanent nerve damage. The diagnosis is often made with physical exam findings of decreased strength, altered sensation, and gait abnormalities. Motor nerve conduction studies, electromyography studies, and diagnostic nerve blocks can also assist in diagnosis and prognosis. First-line treatments include removing anything that may be causing external compression, providing stability to unstable joints, and reducing inflammation. Although many peroneal nerve entrapments will resolve with observation and activity modification, surgical treatment is often required when entrapment is refractory to these conservative management strategies. Recently, additional options including microsurgical decompression and percutaneous peripheral nerve stimulation have been reported; however, large studies reporting outcomes are lacking.

Effect of BMI on the clinical outcome following microsurgical decompression in over-the-top technique: bi-centric study with an analysis of 744 patients

Decompression is one of the most common interventions in spinal surgery. Obesity has become an increasing issue in surgical patients. Therefore, the aim of this study was to analyze the clinical outcome following lumbar microsurgical decompression in correlation with the patient's body mass index (BMI). A toal of 744 patients with spinal claudication that were seen at two specialized spine centers were included in this study. All patients underwent a bilateral microsurgical decompression in over-the-top technique. Patients were allocated in 4 groups based in their BMI category: 18.5-24.9 (n = 204), 25.0-29.9 (n = 318), 30.0-34.9 (n = 164) and ≥ 35 (n = 58). Clinical outcome data were recorded at baseline as well as 3, 12 and 24months thereafter within a prospective study framework. The minimum follow-up was 12months. For statistical analysis, data were adjusted for age, length of surgery and ASA and were analyzed by generalized linear gamma-based models. Postoperative changes in all outcome parameters were clearly dependent on BMI. Patients with higher BMI were characterized by inferior baseline values for VAS Back (p < 0.05). Over the follow-up period, the groups with BMI 30-34.9 and BMI ≥ 35 benefitted significantly less from the surgery than the two slimmer groups (p < 0.05). The data obtained from this large, homogenous cohort demonstrate that the quality of life improved substantially in all patients that were treated microsurgically for spinal stenosis. However, a BMI ≥ 30 may be considered as a negative predictor for a significantly inferior clinical outcome.

Long-term Outcomes after Microsurgical Decompression of Lumbar Foraminal Stenosis and Adverse Effects of Preoperative Scoliosis: A Prospective Cohort Study

Lumbar foraminal stenosis is a common disorder, with surgical treatment varying from simple decompression to interbody fusion. It is often associated with degenerative lumbar scoliosis, but the effects of scoliosis on outcomes are unclear. The objectives of this study were to clarify long-term outcomes after microsurgical decompression of lumbar foraminal stenosis through Wiltse’s approach and to determine the effects of scoliosis on these outcomes. A total of 86 consecutive patients with lumbar foraminal stenosis were prospectively followed after microsurgical decompression. They were categorized in multiple subcohorts with follow-up durations ranging from 6 months to 5 years. Outcomes were assessed using the Short Form 36 questionnaire (average physical scores and bodily pain scores). Local Cobb angle of the operative segment was measured preoperatively, and its effects on outcomes were analyzed. Average physical scores improved significantly from 33.8 (95% confidence interval [CI]: 29.1–38.5) preoperatively to 59.5 (95% CI: 54.6–64.3) at 6 months postoperatively and remained improved for 5 years. Bodily pain scores improved significantly from 23.7 (95% CI: 18.7–28.6) preoperatively to 56.3 (95% CI: 51.2–61.6) at 6 months postoperatively and remained improved for 5 years. Patients with preoperative scoliosis (local Cobb angle >10 degrees) had poorer outcomes: average physical scores were worse by 9.6 points (p = 0.07) and bodily pain scores were worse by 12.1 points (p = 0.02), compared with patients without scoliosis (local Cobb angle ≤10 degrees). Microsurgical foraminal decompression produced overall excellent outcomes in patients with lumbar foraminal stenosis. Preoperative scoliosis attenuated these beneficial effects.

Surgical treatment of patients with degenerative grade I lumbar spondylolisthesis combined with spinal stenosis using minimally invasive bilateral decompression

Objective. To analyze clinical and radiological outcomes of minimally invasive bilateral decompression through a unilateral approach in the treatment of patients with degenerative grade I spondylolisthesis combined with lumbar spinal stenosis. Material and Methods. A total of 28 patients with degenerative grade I lumbar spondylolisthesis combined with spinal stenosis at one or several levels with clinical manifestations of neurogenic intermittent claudication and low back pain were operated on using the method of bilateral microsurgical decompression through a unilateral approach. The minimum follow-up period was 1 year. Clinical outcomes was assessed using VAS, Oswestry and MacNab questionnaires. Central stenosis of the spinal canal was graded according to Shizas classification based on MRI data, and the degree of segment stability according to Hanley and progression of spondylolisthesis in a neutral position were assessed by a functional lumbar spondylograms before surgery and in the long-term period. Results. The average hospital stay was 3.07 ± 0.26 days. The average duration of the operation was 145.07 ± 44.67 minutes. When assessing pain by VAS questionnaire, a significant decrease in the median value of the intensity of pain was noted: in the leg – from 7.0 [7.0; 8.0] to 1.0 [1.0; 2.0], in the back – from 5.0 [4.0; 5.0] to 1.0 [1.0; 2.0]. The ODI questionnaire showed a decrease in the median indicator of disability from 60.0 [56.0; 64.0] to 15.0 [12.0; 19.0]. Assessment of radiological outcomes showed a slight increase in the parameters of anteroposterior translation (on average +0.42 mm) and segmental rotation (on average +1.03 degrees) of the operated segment during functional tests, and a slight increase in spondylolisthesis (on average by 1.42 %), which in general did not affect clinical outcomes. Conclusion. Retrospective analysis of minimally invasive bilateral decompression through unilateral approach in patients with degenerative grade I lumbar spondylolisthesis combined with spinal stenosis without segmental instability provided the evidence of significant clinical efficacy of the method with a low risk of iatrogenic segment instability in the late postoperative period.

Cost analysis comparison between conventional microsurgical decompression and full-endoscopic interlaminar decompression for lumbar spinal stenosis surgery.

Two of the most commonly used techniques for treatment of lumbar spinal stenosis (LSS) include full-endoscopic interlaminar decompression (MIS) and conventional microsurgical decompression (CD). Although these procedures have proven efficacy for relief of stenotic symptoms, in this age of increased concerns for healthcare cost, weighing the respective accumulative costs is essential for deciding which approach to adopt. The aim of this study is to perform a cost analysis comparison between MIS and CD for LSS. A decision analysis model comparing MIS and CD for patients with LSS over a 1-year time horizon was conducted. Relevant unit costs associated with each surgical procedure and each possible complication treatment were estimated. Regarding the respective complication rates for each procedure, data was retrieved from the literature. Reoperation was considered for epidural hematoma, inadequate decompression or iatrogenic instability requiring fusion. Nonoperative treatment for complications like infection was also considered. The average total costs for MIS and CD were found to be HKD$54,863 and HKD$52,748 respectively. Both procedures carried similar costs in terms of hospitalization, radiology and routine follow-up visits. A 3.9% (HKD$2,115) difference in total cost was largely due to the differences in cost of surgery and complications. MIS costs 5.7% more than CD for an operation but was 28.1% less costly than MIS for complications. Given the similar clinical effectiveness of either procedure and only a small difference in overall cost, our findings suggest that surgeons should perform the procedure that they are competent with which guarantees adequacy of decompression.

The 270° Circumferential Microsurgical Decompression of the Foramen Magnum in Adult Chiari Malformation Type I: Single Surgeon Series of 130 Patients with Syringomyelia, Neurologic, and Headache Outcomes

Chiari malformation type I (CM-I) is a craniocervical junction disorder associated with descent of the cerebellar tonsils >5 mm. The prevalence of CM-I is common, including 0.5%-3.5% in the general population, 0.56%-0.77% on magnetic resonance imaging, and 0.62% in anatomic dissection studies. We sought to measure our surgical outcomes related to resolution/improvement of headaches, neurologic outcomes, and syringomyelia compared with reported adult CM-I studies from 2000-2019. From December 2003 to June 2018, the first author (K.I.A.) performed 270° circumferential decompression on adult (>18 years) patients with CM-I. At admission and follow-up, all parameters were numerically evaluated; headaches were self-reported on the visual analog scale, neurologic condition was evaluated using Karnofsky Performance Status and European Myelopathy Score, and syrinx width (if present) was measured on magnetic resonance imaging by grades I-IV. All parameters were analyzed, compared, and statistically tested. We compared results with our previously reported and updated systematic review of operative adult CM-I studies (studies from 2000 to 2019). In our series, 118/121 (98%) experienced headache improvements and 100% experienced neurologic improvements. Complete syrinx resolution was experienced by 35/43 (81%); 8 (19%) showed significant improvement. In data from reported studies (2000-2019), only 79% experienced headache resolution, 77% improvement of neurologic status, and 74% resolution/improvement of syrinx (mean). Our modified 270° circumferential microsurgical foramen magnum decompression for adult CM-I appears to be beneficial in improvement of outcomes, namely in resolution of the syrinx, neurologic symptoms, and headaches. We also confirm the association of body mass index with CM-I. Further studies are needed to confirm our results.

Optic Nerve Decompression from Coil Mass Impingement and Adhesion Following Large Internal Cerebral Artery Aneurysm Coil Embolization: 2-Dimensional Operative Video.

Aneurysmal mass effect is a consideration for treatment modality selection, particularly in the setting of cranial neuropathy or obstructive hydrocephalus. However, the extent of consequences related to mass effect is not always apparent periprocedurally from the original treatment. This unique video highlights a patient who underwent previous coil occlusion of a supraclinoid internal carotid artery (ICA) aneurysm with subsequent occlusion of the ipsilateral ICA who presented 16 yr later with progressive worsening hemianopsia. The preoperative imaging was suggestive of coil mass impingement prompting operative intervention for decompression. Intraoperative inspection demonstrated that the coil mass was exerting mass effect on the optic nerve and had partially migrated out of the aneurysm dome into the optic nerve. The ICA was also transected and mobilized to further reduce mass effect. Careful microsurgical decompression was achieved and prevented further visual compromise. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Factors of Adjacent Segment Disease Onset After Microsurgical Decompression for Lumbar Spinal Canal Stenosis

Few studies have examined the underlying cause of adjacent segment disease (ASD) after decompression surgery for lumbar spinal stenosis. The goal of this study is to investigate factors related to the onset of ASD after decompression surgery based on the imaging results. We examined 95 patients who underwent single-level decompression for lumbar spinal stenosis (L3/4, L4/5) and follow-up for 5 or more years. Radiographic images were performed preoperatively and at each year of follow-up. We then examined image parameters by focusing on the level operated on and adjacent segments in relation to the postoperative onset of symptomatic ASD. During the mean observation period of 7.5 years, 39 of 95 patients developed symptomatic ASD. Patients with a high preoperative sagittal rotation angle in adjacent segments possibly developed postoperative ASD (P= 0.0006). Furthermore, postoperative ASD tended to be unlikely in patients who exhibited postoperative slip progression at the operated level (P= 0.025). Based on receiver operating characteristic analysis, ASD developed with a probability of 91.3% in patients with a preoperative sagittal rotation angle of ≥7.5° in adjacent segments when there was no postoperative slip progression at the operated level. However, ASD developed in only 16.7% of patients with a preoperative adjacent segment sagittal rotation angle of 7.5° or less when there was postoperative slip progression at the operated level. Biomechanical changes at the operated level and adjacent segments contribute to the onset of ASD after lumbar decompression. Preoperative high sagittal rotation angle of adjacent segments and negative postoperative slip progression at the operated level are risk factors of ASD.

Biportal endoscopic technique in the treatment of spinal stenosis: early clinical experiences and results

ABSTRACT Objective Minimally invasive procedures in spine surgery have undergone significant development in recent times. A demand emerged from both surgeons and patients to develop and perform these types of surgeries in order to prevent biomechanical and surgical complications. Our study aimed to present early clinical results of a biportal endoscopy technique in the treatment of degenerative spinal stenosis. Method We created a retrospective database of patients who underwent biportal spinal endoscopic decompression at the National Institute of Clinical Neuroscience, Department of Neurosurgery, Semmelweis University, Budapest, Hungary, in 2019. The surgical steps of technique is discussed in details. Results Retrospectively, we identified and collected 21 patients in our retrospective analysis. The early results after endoscopic decompression were excellent, 17 patients (81%) mentioned good general comfort which coincided with small incisions and the preservation of posterior spinal muscles. Three patients (14%) mentioned good condition and minor postoperative pain which could be controlled with analgesics. One patients (5%) mentioned postoperative discomfort. The patients were controlled at 3, 6 and 9 months. The mean follow-up time was 7 months. Discussion Biportal endoscopic technique was developed to fulfil the requirements of minimally invasive techniques. Our results indicate this method may be highly effective for the treatment of lumbar spinal stenosis and an alternative to conventional microsurgical decompression; however, our study limited by its retrospective manner and small population size

Indications and Contraindications of Full-Endoscopic Interlaminar Lumbar Decompression

Spinal stenosis is a common disease with an increasing incidence. Narrowing of the spinal canal is caused by bone and soft tissue degeneration, such as osteophyte formation, facet and ligamentum flavum hypertrophy, and disc herniation. Various surgical techniques have been used to treat spinal canal stenosis, including open, tubular, microsurgical decompression, and fusion surgery. This article presents the technique for full-endoscopic interlaminar bilateral decompression of the lumbar spine. Surgical approach, anatomy, pathology, indications, contraindications, and surgical equipment are described. With well-chosen endoscopic equipment, surgical time can be reduced with minimal collateral damage. Clear advantages of full-endoscopic decompression over open or other minimally invasive surgery methods are demonstrated in many clinical studies. The endoscopic technique has been shown to be effective in spinal canal decompression with good to excellent clinical results. The interlaminar endoscopic approach minimizes iatrogenic injury to the stabilizing anatomic structures while achieving full unilateral and bilateral decompression. A significant improvement in pain and functional outcome scores with low complication rates has been demonstrated. This technique is safe for lumbar spinal decompression and more minimally invasive than a microendoscopic approach. However, this technique should be performed by surgeons with advanced skills. Endoscopy could become the gold standard for treatment of canal stenosis in the near future.

Comparative analysis of minimally invasive surgical decompression and fusion surgery in the treatment of stable stage i lumbar degenerative spondylolisthesis complicated by spinal stenosis

Purpose: a comparative analysis of long-term clinical and radiological outcomes of bilateral microsurgical decompression from unilateral approach and open fusion surgery in the treatment of patients with stable stage I lumbar degenerative spondylolisthesis complicated by spinal stenosis. Materials and methods: this study included 83 patients with degenerative stage I lumbar spondylolisthesis, combined with spinal stenosis at one/several levels. Bilateral microsurgical decompression from unilateral approach was performed in group A (n = 41), in group B (n = 42) we used transforaminal lumbar interbody fusion. Results: intraoperative blood loss and operation time significantly prevailed in group B (P &lt; 0,05). Pain in the legs (VAS), Oswestry disability index significantly decreased in both groups in the long-term postoperative period. No statistical difference in these was found in groups A and B (P = 0,59; P = 0,10). Lower back pain in both groups at the follow-up period had a significant difference: in fusion group there was a significantly higher intensity, than in group А (P &lt; 0,001). Assessment of radiological outcomes in group A at the level of spondylolisthesis showed a slight decrease in segment stability: an increase in anteroposterior displacement of the vertebrae by an average of 0,44 mm, the angular difference by 0,77°, an increase in displacement of the vertebral body by 1,30 % (P &lt; 0,05). Conclusion: minimally bilateral microsurgical decompression from unilateral approach is an effective method for treatment of stable stage I degenerative lumbar spondylolisthesis, combined with spinal stenosis, allowing to achieve significant regression of leg pain and disability in the long-term postoperative period. And this method admits to significantly decrease of low back pain, then in fusion surgery, as well as a low risk of postoperative instability and reoperation with instrumentation.

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

This 50-yr-old man had a 15-yr history of presyncopal episodes that were precipitated by turning his head to the right, and had worsened recently. Cerebral angiogram demonstrated complete cessation of anterograde flow in left vertebral artery (VA) at the level of the C1 sulcus arteriosus while turning head to right, indicating dynamic compression at the C1 level. Patient underwent left extreme lateral retrocondylar approach, partial C1 laminectomy and opening of the C1 foramen with complete microsurgical decompression of the VA. After skin incision, meticulous muscle dissection was performed and superior and inferior oblique muscles were disconnected from the tubercle of C1. The VA was exposed, and three areas of constriction were visible, first at the atlanto-occipital membrane laterally; second, located more medially as the artery curved around the occipital condyle to enter the posterior fossa; and third, located anterior to C2 nerve root. The artery was dissected from all the surrounding tissues, preserving the C2 nerve root, and the Cl foramen was opened completely. The Cl lamina was also partially resected and grooved to allow free placement of the VA. The VA was also decompressed near the C2 foramen. Postoperative computed tomography angiogram of the head and neck showed complete decompression of VA. The patient had no episodes of presyncope or dizziness while turning head to right and his mRs was 0 at 8 mo follow up. This 3D video shows the technical nuances of decompression of V3 segment of VA in bow hunters's syndrome. Informed consent was obtained from the patient prior to the surgery that included videotaping of the procedure and its distribution for educational purposes. All relevant patient identifiers have also been removed from the video and accompanying radiology slides.

Are degenerative spondylolisthesis and further slippage postoperatively really issues in spinal stenosis surgery?

Background and aims Opinions diverge concerning the prognostic importance of preoperative degenerative spondylolisthesis in patients with lumbar spinal stenosis, as well as the significance of further slippage post-operatively following decompression alone. However, a slip is only one among several factors related to the topic, e.g. duration and intensity of back and leg pain, pre-operative walking ability, number of levels operated and not least the experience of the surgeon. Our aim was to take all of the above-mentioned factors into consideration when analysing the patients' clinical outcome, reported as Change in back pain, Change in leg pain, Overall satisfaction and Change in walking ability, with special emphasis on the possible importance of pre- and/or post-operative degenerative spondylolisthesis. Methods We studied 200 consecutive patients, mean follow-up time 81 months (range 62-108). Before treatment and on the follow-up occasion all patients answered the SF-36 questionnaire and assessed their back and leg pain on a visual analogue scale (VAS). At follow-up the patients were asked about possible changes in back and leg pain (completely free, much better, somewhat better, unchanged, somewhat worse, much worse) and whether they were; satisfied with the outcome, in doubt or not satisfied. Before treatment and at follow-up the presence or not of degenerative spondylolisthesis was determined in the lateral view on a plain X-ray or MRI. By use of a microsurgical technique decompression was achieved in all patients by bilateral laminotomy not sparing the midline ligaments, irrespective of a degenerative spondylolisthesis or not. Eight surgeons with different surgical experience performed the operations. Four separate multivariate analyses were conducted, one for each clinical outcome. The Lasso method was used for variable selection and multiple imputation was applied to handle missing values. Results At follow-up 78.5% of the patients were completely satisfied with the outcome. Minimal clinical important difference (MCID) was achieved for 69% of the patients. Before surgery 28 patients were able to walk more than 1 km compared to 111 at follow-up. The reoperation rate at 6.8 years was 12% further decompressions and 2.5% fusions at the index level. Post-operative slippage was equally common in patients with and without a preoperative slip (around 30%). There were no notable differences in outcome in patients with and without a preoperative slip and no effect of further slippage at the index or another level post-operatively. Nor could the statistical analysis show any of the other covariates (age, gender, duration and intensity of back and leg pain, pre-operative walking ability or number of levels operated) to be of statistically significant importance for predicting the outcome. In the univariate statistical analysis differences were found between the patients of individual surgeons regarding satisfaction, pain improvement, and reoperation rates in favour of surgical experience, which were, however, not statistically significant in the multivariate analysis. Conclusions None of the covariates, including pre-operative spondylolisthesis and further slippage post-operatively, were statistically significant for predicting the clinical outcome. Implication Our results provide no evidence for adding fusion to the decompression.

Transcranial microsurgical decompression of the optic canal in surgical treatment of meningiomas of the sellar region

Transcranial microsurgical decompression of the optic canal in surgical treatment of meningiomas of the sellar region

Redundant nerve roots in lumbar spinal stenosis: inter- and intra-rater reliability of an MRI-based classification

PurposePatients with central lumbar spinal stenosis (LSS) have a longer symptom history, more severe stenosis, and worse postoperative outcomes, when redundant nerve roots (RNRs) are evident in the preoperative MRI. The objective was to test the inter- and intra-rater reliability of an MRI-based classification for RNR.MethodsThis is a retrospective reliability study. A neuroradiologist, an orthopedic surgeon, a neurosurgeon, and three orthopedic surgeons in-training classified RNR on 126 preoperative MRIs of patients with LSS admitted for microsurgical decompression. On sagittal and axial T2-weighted images, the following four categories were classified: allocation (A) of the key stenotic level, shape (S), extension (E), and direction (D) of the RNR. A second read with cases ordered differently was performed 4 weeks later. Fleiss and Cohen’s kappa procedures were used to determine reliability.ResultsThe allocation, shape, extension, and direction (ASED) classification showed moderate to almost perfect inter-rater reliability, with kappa values (95% CI) of 0.86 (0.83, 0.90), 0.62 (0.57, 0.66), 0.56 (0.51, 0.60), and 0.66 (0.63, 0.70) for allocation, shape, extension, and direction, respectively. Intra-rater reliability was almost perfect, with kappa values of 0.90 (0.88, 0.92), 0.86 (0.84, 0.88), and 0.84 (0.81, 0.87) for shape, extension, and direction, respectively. Intra-rater kappa values were similar for junior and senior raters. Kappa values for inter-rater reliability were similar between the first and second reads (p = 0.06) among junior raters and improved among senior raters (p = 0.008).ConclusionsThe MRI-based classification of RNR showed moderate-to-almost perfect inter-rater and almost perfect intra-rater reliability.

A combination of pathologies - facet joint synovial cyst, epidural lipomatosis and conjoined nerve root anomaly in the lumbar spine of a 45-year-old patient. A case report

Facet joint synovial cysts are abnormal fluid-filled cystic formations that develop from a degenerative process of the facet joints. Spinal epidural lipomatosis is a process of excessive accumulation of fat in the epidural space. Conjoined nerve root (CNR) anomaly refers to an anatomical variation in which two adjacent nerve roots share a common dural sleeve. The aforementioned three rare pathologies cause the same pathological process of stenosis, therefore compressing the nervous structures. A 45-year-old female patient was admitted to the Department of Neurosurgery with severe low back and radicular pain, and numbness along her left leg. Antalgic posture, painful paravertebral muscle tenderness, L4 radiculopathy, and L5 and S1 dermatome hypoesthesia on the left as well as positive straight leg raising sign (Laseque) were present upon examination. CT and MRI scanning showed stenosis on L4-L5 level caused by bilateral synovial cyst formation. Microsurgical decompression by foraminotomy at L4-L5 level on the left with dissection of the synovial cyst and epidural lipomatosis was performed. In the course of the operation CNR anomaly was discovered. The complete decompression alleviated the symptoms and after 3 uneventful postoperative days the patient was discharged. Spinal stenosis causing compression upon nervous structures is a process that could be caused by a number of conditions. The incidence of rare pathologies and anomalies or even the more rarely occurring combination of them must be considered on daily basis in the clinical practice in order to make the correct diagnosis and plan the best possible treatment for the patient.

Styloidogenic Jugular Venous Compression Syndrome: Clinical Features and Case Series

Styloidogenic jugular venous compression syndrome (SJVCS) is a rare cause of idiopathic intracranial hypertension (IIH). To elucidate the pathophysiology and the hemodynamics of SJVCS. We conducted a retrospective review of medical records, clinical images, dynamic venography, and manometry for consecutive patients with SJVCS undergoing microsurgical decompression from April 2009 to October 2017. Patients with IIH with normal venography and manometry findings served as controls. Data were analyzed for 10 patients with SJVCS who presented with headaches. Neck flexion exacerbated headaches in 7 patients. Eleven patients with IIH provided control data for normal intracranial venous pressure and styloid process anatomy. Patients with SJVCS had bilateral osseous compression of venous outflow. The styloid processes were significantly longer in patients with SJVCS than in those with IIH (mean [standard deviation (SD)] distance, 31.0 [10.6] vs 19.0 [14.1] mm; P<.01). The styloid process-C1 lateral tubercle distance was shorter in patients with SJVCS than in those with IIH (mean [SD] distance, 2.9 [1.0] vs 9.9 [2.8] mm; P<.01). Patients with SJVCS had significantly higher global venous pressure and a higher pressure gradient across the stenosis site than controls (mean [SD] pressure, 2.86 [2.61] vs 0.13 [1.09] cm H2O; P=.09). All 10 patients with SJVCS experienced venous pressure elevation during contralateral neck turning (mean [SD] pressure, 4.29 [2.50] cm H2O). All 10 patients with SJVCS underwent transcervical microsurgical decompression, and 9 experienced postoperative improvement or resolution of symptoms. One patient had transient postoperative dysphagia and facial drooping, and another patient reported jaw numbness. SJVCS is a novel clinical entity causing IIH. Patients should be evaluated with dynamic venography with manometry. Surgical decompression with removal of osseous overgrowth is an effective treatment in select patients.

Microsurgical unilateral laminotomy for bilateral decompression of degenerative lumbar canal stenosis: a comparative study

BackgroundThe quest for better patient outcomes is driving to the development of minimally invasive spine surgical techniques. There are several evidences on the use of microsurgical decompression surgery for degenerative lumbar spine stenosis; however, few of these studies compared their outcomes with the traditional laminectomy technique.ObjectivesThe aim of our study was to compare outcomes following microsurgical decompression via unilateral laminotomy for bilateral decompression (ULBD) of the spinal canal to the standard open laminectomy for cases with lumbar spinal stenosis.Subjects and methodsCases were divided in two groups. Group (A) cases were operated by conventional full laminectomy; Group (B) cases were operated by (ULBD) technique. Results from both groups were compared regarding duration of surgery, blood loss, perioperative complication, and postoperative outcome and patient satisfaction.ResultsThere was no statistically significant difference between both groups regarding the improvement of visual pain analogue, while improvement of neurogenic claudication outcome score was significant in group (B) than group (A). Seventy-three percent of group (A) cases and 80% of group (B) stated that surgery met their expectations and were satisfied from the outcome.ConclusionComparing ULBD with traditional laminectomy showed the efficacy of the minimally invasive technique in obtaining good surgical outcome and patient satisfaction. There was no statistically significant difference between both groups regarding the occurrence of complications The ULBD technique was found to respect the posterior spinal integrity and musculature, accompanied with less blood loss, shorter hospital stays, and shorter recovery periods than the open laminectomy technique.

Unilateral approach for over the top bilateral lumbar decompression

The main goal is bilateral microsurgical decompression of the cauda equina using a unilateral over the top approach. The challenge is to achieve decompression with minimal iatrogenic trauma to anatomical structures in the approach region and in the target area. Degenerative spinal disorders including lumbar central stenosis, lumbar lateral recess spinal stenosis, and foraminal narrowing. This technique is performed in patients presenting primarily with neurogenic claudication, leg or buttock symptoms, heaviness in the legs with or without radicular symptoms, with or without neurological deficits, and comparable MRI findings. There are no limitations regarding number of affected segments or the extent of narrowing. All available conservative treatment modalities not exhausted. Lack of serious neurological deficit. Minimally invasive, muscle-sparing and facet-joint-sparing bilateral enlargement of the lumbar spinal canal through a unilateral microsurgical cross-over approach. Patients are mobilized early 4-6 h postoperatively. Light sports activities (e.g., ergometer cycling, swimming) are allowed after 2weeks. The same is true for the return to normal daily or work activities except for heavy physical work (usually 4weeks out of work). Soft lumbar brace for 4weeks (optional). The clinical outcomes are good to excellent. Meta-analyses and large case series report success rates for microsurgical decompression procedures of 73.5-95%. The reoperation rates are low (0.5-10%).

Microsurgical Strategies for the Treatment of Compression Neuropathies Secondary to Vertebrobasilar Dolichoectasia: From Simple Decompression to Sling Transposition

Vertebrobasilar artery dolichoectasia may result in neural element compression anywhere along its course within the cervical region, the craniocervical junction or in the posterior fossa. The clinical syndromes most often observed include cranial neuropathy, bulbar dysfunction, myelopathy and cervical radiculopathy. When indicated, the operative techniques utilized to address vertebrobasilar artery dolichoectasia must be individually tailored, can be technically challenging, and have been rarely expounded. To share selected cases that demonstrate the variety of pathological states caused by vertebrobasilar artery dolichoectasia as well as our experience in managing this condition. Here we review examples of pathological impingement of neural elements compressed by ectasia within the vertebrobasilar arterial system throughout its anatomic course. The surgical techniques we have employed to alleviate the compression, including simple decompression as well as sling-assisted arterial transposition, are described. The evolution and refinement of our transposition technique are detailed. A wide range of pathological conditions may result from compression of neural structures throughout the course of the vertebrobasilar system. Compression of cervical nerve roots, the spinal cord, brainstem, and cranial nerves can be seen. Microsurgical management may be indicated in selected cases with gratifying results. Pathological compression of neural structures throughout the course of the vertebrobasilar system should be recognized. When indicated, microsurgical decompression must be tailored to the individual symptomology and the unique anatomic relationship in each case with the potential to prevent neurological worsening and, in many cases, improve functional outcome.