Neurovascular Structures Research Articles

Anatomical Step-by-Step Dissection of Complex Skull Base Approaches for Trainees: Surgical Anatomy of the Translabyrinthine and Transcochlear Approaches

Abstract Introduction Skull base neuroanatomy is traditionally learned through two-dimensional anatomical atlases, which while are of unquestionable value, lack the nuanced association of three-dimensional relationships between fundamental anatomical structures relevant to surgical approaches. Surgically focused step-by-step anatomical dissections can augment trainee learning of complex skull base techniques, particularly multistep and nuanced techniques such as translabyrinthine and transcochlear approaches. Methods Translabyrinthine and transcochlear approaches were performed on six sides of three formalin-fixed latex-injected specimens. The study objective was the completion and photo documentation of the steps involved in the approach in order to provide a comprehensive, intelligible, and anatomically oriented resource for multilevel trainees. Illustrative case examples were prepared to supplement approach dissections. Results The translabyrinthine and transcochlear approaches offer unique lateral windows through the temporal bone into the posterior fossa, providing excellent access to pathology at the petrous apex, internal auditory canal, Meckel's cave, and anterolateral brainstem. The transcochlear approach, which is an anterior extension of the translabyrinthine, particularly provides excellent exposure of the prepontine region and clivus. Important surgical considerations include patient position, temporal bone drilling and identification of critical landmarks, dural opening and identification of neurovascular structures, and reconstruction/closure techniques. Conclusion The translabyrinthine and transcochlear approaches are fundamental techniques for lateral skull base and posterior fossa pathologies. Both approaches are hearing-sacrificing but often require minimal to no cerebellar retraction and deliver unique visualization of prepontine neurovascular structures. This step-by-step approach guide provides a unique practical and high-yield surgically oriented learning resource for neurosurgery and otolaryngology trainees.

Contemporary Surgical Management of Craniofacial Fibrous Dysplasia Using Computer-Assisted Surgery and Intraoperative Navigation.

Craniofacial fibrous dysplasia (CFD) is a rare developmental disease of bone, which typically presents as a painless, expansile mass causing deformity of the craniofacial skeleton. In rare circumstances, compression of neurovascular structures may arise, causing symptoms such as pain, visual impairment, and hearing loss. Traditionally, CFD debulking has been performed with "freehand" techniques using preoperative imaging and anthropometric norms to determine the ideal amount of tissue removal. The advent of computer-assisted surgery, computer-aided design, and computer-aided manufacturing (CAD/CAM) has revolutionized the management of CFD. Surgeons can now fabricate patient-specific osteotomy/ostectomy guides, allowing for increased accuracy in bone removal and improved cosmetic outcomes. This series of 3 cases describe our institution's technique using patient-specific ostectomy "depth guides", which allow for maximum removal of fibro-osseous tissue while sparing deep and adjacent critical structures. These techniques can be widely applied to the craniofacial skeleton to assist in the surgical management of CFD.

Glomus jugulotympanicum tumor treated with radiation therapy: A case report with review of literature

Glomus tumors (or paragangliomas) are rare, benign tumors of neuroendocrine origin that appear in tissues of paraganglionic origin. This clinical entity poses a significant treatment challenge due to its proximity to critical neurovascular structures, thus the potential of morbid functional damage caused by disease progression and/or treatment approach. While surgery remains the standard of care for such cases, there has been an increasing trend toward management with radiotherapy or close observation. Here, we present a case of a large and irregularly shaped glomus jugulotympanicum tumor that was treated with volumetric arc radiotherapy. Given the risk of cranial neuropathy with surgery, radiation was the preferred treatment modality. This case demonstrated the safety and efficacy of volumetric arc radiotherapy in the management of a large glomus tumor with a complex shape.

Refraining from closed reduction of displaced distal radius fractures in the emergency department—in short: the RECORDED trial

BackgroundWith roughly 45,000 adult patients each year, distal radius fractures are one of the most common fractures in the emergency department. Approximately 60% of all these fractures are displaced and require surgery. The current guidelines advise to perform closed reduction of these fractures awaiting surgery, as it may lead to post-reduction pain relief and release tension of the surrounding neurovascular structures. Recent studies have shown that successful reduction does not warrant conservative treatment, while patients find it painful or even traumatizing. The aim of this study is to determine whether closed reduction can be safely abandoned in these patients.MethodsIn this multicenter randomized clinical trial, we will randomize between closed reduction followed by plaster casting and only plaster casting. Patients aged 18 to 75 years, presenting at the emergency department with a displaced distal radial fracture and requiring surgery according to the attending surgeon, are eligible for inclusion. Primary outcome is pain assessed with daily VAS scores from the visit to the emergency department until surgery. Secondary outcomes are function assessed by PRWHE, length of stay at the emergency department, length of surgery, return to work, patient satisfaction, and complications. A total of 134 patients will be included in this study with follow-up of 1 year.DiscussionIf our study shows that patients who did not receive closed reduction experience no significant drawbacks, we might be able to reorganize the initial care for distal radial fractures in the emergency department. If surgery is warranted, the patient can be sent home with a plaster cast to await the call for admission, decreasing the time spend in the emergency room drastically.Trial registrationThis trial was registered on January 27, 2023.

Anatomical determinants of occipitocervical fusion in skull base chordoma resection: a systematic review of the literature with illustrative cases.

Skull base chordomas are rare, locally osseo-destructive lesions that present unique surgical challenges due to their involvement of critical neurovascular and bony structures at the craniovertebral junction (CVJ). Radical cytoreductive surgery improves survival but also carries significant morbidity, including the potential for occipitocervical (OC) destabilization requiring instrumented fusion. The published experience on OC fusion after CVJ chordoma resection is limited, and the anatomical predictors of OC instability in this context remain unclear. PubMed and Embase were systematically searched according to the PRISMA guidelines for studies describing skull base chordoma resection and OC fusion. The search strategy was predefined in the authors' PROSPERO protocol (CRD42024496158). The systematic review identified 11 surgical case series describing 209 skull base chordoma patients and 116 (55.5%) who underwent OC instrumented fusion. Most patients underwent lateral approaches (n = 82) for chordoma resection, followed by midline (n = 48) and combined (n = 6) approaches. OC fusion was most often performed as a second-stage procedure (n = 53), followed by single-stage resection and fusion (n = 38). The degree of occipital condyle resection associated with OC fusion was described in 9 studies: total unilateral condylectomy reliably predicted OC fusion regardless of surgical approach. After lateral transcranial approaches, 4 studies cited at least 50%-70% unilateral condylectomy as necessitating OC fusion. After midline approaches-most frequently the endoscopic endonasal approach (EEA)-at least 75% unilateral condylectomy (or 50% bilateral condylectomy) led to OC fusion. Additionally, resection of the medial atlantoaxial joint elements (the C1 anterior arch and tip of the dens), usually via EEA, reliably necessitated OC fusion. Two illustrative cases are subsequently presented, further exemplifying how the extent of CVJ bony elements removed via EEA to achieve complete chordoma resection predicts the need for OC fusion. Unilateral total condylectomy, 50% bilateral condylectomy, and resection of the medial atlantoaxial joint elements were the most frequently described independent predictors of OC fusion in skull base chordoma resection. Additionally, consistent with the occipital condyle harboring a significantly thicker joint capsule at its posterolateral aspect, an anterior midline approach seems to tolerate a greater degree of condylar resection (75%) than a lateral transcranial approach (50%-70%) prior to generating OC instability.

Transpalpebral transorbital endoscopic lateral approach to the middle cranial fossa: anatomical study in cadaver

Transorbital expanded endoscopic approaches allow different areas of the skull base to be approached. The aim of our study is to analyse the main anatomical bone and neurovascular structures of the middle cranial fossa by means of a transpalpebral transorbital lateral endoscopic approach (TTLEA). An anatomical study was performed on 12 orbital cavities corresponding to 6 cadaver heads. All specimens were previously injected with colored latex through both carotid systems. The mean distance from the orbital rim to the zygomatic-facial foramen and to the zygomatic-temporal foramen was 11 mm and 16 mm respectively. In all cases the meningo-orbital foramen was found at a mean distance from the orbital rim of 34 mm. The superior orbital fissure (SOF) was located posterior to the meningo-orbital foramen at 39 mm. The foramen rotundum and foramen ovale were located separated from each other by 10 mm on average. Anterior to the foramen ovale a bony prominence was observed in all cases. In 11 cases (92%) the entrance of the accessory meningeal artery into the foramen ovale was evident and in one case an accessory foramen was observed. The middle meningeal artery was located in all dissections within the foramen spinosum. The TTLEA offers a wide and direct exposure of the middle cranial fossa. It should be considered as an alternative to transcranial approaches in certain lesions invading the lateral region of the middle cranial fossa, the lateral wall of the cavernous sinus or the infratemporal fossa.

Optic nerve head neurovascular assessments in patients with schizophrenia: A cross‐sectional study

AbstractObjectiveThe retina is a protrusion of the brain, so researchers have recently proposed retinal changes as a new marker for studying central nervous system diseases. To investigate optic nerve head neurovascular structure assessed by optical coherence tomography angiography (OCTA) in schizophrenia compared to healthy subjects.MethodsThe study was conducted from 2019 to 2021 at the Ibn Sina Psychiatric Hospital in Mashhad, Iran. We enrolled 22 hospitalized known cases of schizophrenia, treated with risperidone as an antipsychotic drug, and 22 healthy subjects. The two groups were matched in age and gender. In the schizophrenic group, the positive and negative syndrome scale test was used to assess the illness severity. All subjects underwent complete ophthalmic evaluations and OCTA imaging.ResultsWe found that the cup/disc area ratio, vertical cup/disc ratio, and horizontal cup/disc ratio are significantly higher in patients with schizophrenia than in healthy subjects (with p‐values of 0.019, 0.015, and 0.022, respectively). No statistically significant difference in the peripapillary retinal nerve fiber layer and vascular parameters of the optic nerve head was observed between schizophrenia and healthy groups.ConclusionWe found evidence regarding the difference in the optic nerve head tomographic properties in schizophrenia compared to healthy subjects. However, ONH vascular parameters showed no significant difference. More studies are needed for a definite conclusion.

Open Approach for Repair of Tibial PCL Avulsion

Background: Tibial avulsion of the posterior cruciate ligament (PCL) often requires operative fixation, which frequently results in successful outcomes if identified acutely. Open or arthroscopic techniques are most commonly used. Indications: Primary surgical indications for open fixation include acute tibial avulsion of the PCL. Secondary indications include grade 2 to grade 3 posterior drawer test and radiographic posterior subluxation of the tibia. Ideally, the joint space and articular cartilage should be well preserved. Technique Description: In the simplified approach initially described by Burks and Schaffer, the patient is placed prone, and an inverted L-shaped incision is made over the posteromedial corner of the knee. A plane is developed between the medial head of the gastrocnemius and the semimembranosus down to the knee joint capsule. The gastrocnemius is retracted laterally to protect neurovascular structures and a vertical capsulotomy is performed. The tibial attachment of the PCL is reduced and held with K (Kirschner) wires and then fixated with screw and washer. Results: Six months post operation, our patient achieved full active and passive range of motion with a stable posterior drawer test. He returned to work without difficulty. Multiple studies have shown success with open PCL fixation and decreased rates of arthrofibrosis when compared with arthroscopic approach. In this case, the patient did not develop arthrofibrosis. Discussion/Conclusion: PCL tibial avulsions can be safely treated with an open approach. Contrary to other ligaments that favor reconstruction over repair, PCL avulsions may be better treated with early repair, so it is important to avoid delay in intervention. The most common complication in both open and arthroscopic approaches is arthrofibrosis, which is less common in the open approach. Early range of motion is encouraged to prevent arthrofibrosis. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Novel classification of foramen magnum meningiomas predicted by topographic position relative to neurovascular bundle.

Proximity to critical neurovascular structures can create significant obstacles during surgical resection of foramen magnum meningiomas (FMMs) to the detriment of treatment outcomes. We propose a new classification that defines the tumor's relationship to neurovascular structures and assess correlation with postoperative outcomes. In this retrospective review, 41 consecutive patients underwent primary resection of FMMs through a far lateral approach. Groups defined based on tumor-neurovascular bundle configuration included Type 1, bundle ventral to tumor; Type 2a-c, bundle superior, inferior, or splayed, respectively; Type 3, bundle dorsal; and Type 4, nerves and/or vertebral artery encased by tumor. The 41 patients (range 29-81years old) had maximal tumor diameter averaging 30.1mm (range 12.7-56mm). Preoperatively, 17 (41%) patients had cranial nerve (CN) dysfunction, 12 (29%) had motor weakness and/or myelopathy, and 9 (22%) had sensory deficits. Tumor type was relevant to surgical outcomes: specifically, Type 4 demonstrated lower rates of gross total resection (65%) and worse immediate postoperative CN outcomes. Long-term findings showed Types 2, 3, and 4 demonstrated higher rates of permanent cranial neuropathy. Although patients with Type 4 tumors had overall higher ICU and hospital length of stay, there was no difference in tumor configuration and rates of postoperative complications or 30-day readmission. The four main types of FMMs in this proposed classification reflected a gradual increase in surgical difficulty and worse outcomes. Further studies are warranted in larger cohorts to confirm its reliability in predicting postoperative outcomes and possibly directing management decisions.

Successful salvage of upper extremity following severe crush injury associated with vascular compromise using a supra thin free anterolateral thigh flap

Traumatic injuries of the upper limbs can often result in serious and challenging wounds involving multiple compartments such as skin, bone, tendons and neurovascular structures. These type of injuries of the upper extremity pose several challenges to the plastic surgeon. The main difficulty is to provide a stable, long lasting and aesthetically acceptable coverage that enables joints excursion so that patient can return to work at the earliest. Here, we present a case of 45 years old gentlemen who sustained severe crush injury associated with avulsed radial and ulnar artery of left upper limb following road traffic accident. At presentation, there was no pin prick in his hand and hand was pale. At first surgery, hand was revascularized using a vein graft in radial artery and skin grafting was done over the forearm defect as a temporary cover. After 12 hours, when the viability of hand was reassured, the defect was covered with free supra thin anterolateral thigh (ALT) flap. Patient’s hand and flap both survived and he was discharged in a satisfactory condition.

Image-guided navigation in posterior orbital tumour surgery: a comparative cohort study

ABSTRACT Purpose The posterior orbit is a confined space, harbouring neurovascular structures, frequently distorted by tumours. Image-guided navigation (IGN) has the potential to allow accurate localisation of these lesions and structures, reducing collateral damage whilst achieving surgical objectives. Methods We assessed the feasibility, effectiveness and safety of using an electromagnetic IGN for posterior orbital tumour surgery via a comparative cohort study. Outcomes from cases performed with IGN were compared with a retrospective cohort of similar cases performed without IGN, presenting a descriptive and statistical comparative analysis. Results Both groups were similar in mean age, gender and tumour characteristics. IGN set-up and registration were consistently achieved without significant workflow disruption. In the IGN group, fewer lateral orbitotomies (6.7% IGN, 46% non-IGN), and more transcutaneous lid and transconjunctival incisions (93% IGN, 53% non-IGN) were performed (p = .009). The surgical objective was achieved in 100% of IGN cases, with no need for revision surgery (vs 23% revision surgery in non-IGN, p = .005). There was no statistically significant difference in surgical complications. Conclusion The use of IGN was feasible and integrated into the orbital surgery workflow to achieve surgical objectives more consistently and allowed the use of minimal access approaches. Future multicentre comparative studies are needed to explore the potential of this technology further.

Partial Sacrectomy in the Management of Sacral Chordoma: Case Report and Literature Review

AbstractChordomas are rare neoplasms of low to intermediate grades, which arise from ectopic remnants of notochordal tissue, presenting a slow growth pattern and locally aggressive behavior. Due to their insidious course, the diagnosis is late, requiring immediate therapeutic intervention. The main prognostic factor is total surgical resection with wide margins. This therapeutic objective is only achieved in 40% to 55.6% of the cases, since chordoma tends to present an aggressive behavior, invading adjacent tissues and neurovascular structures. Currently, the main challenge of sacrectomy is to balance a wide resection with the preservation of the neurological function of the patient. Despite cases of successful gross total resection, local recurrence is an inevitable reality, and the overall survival is relatively low. The indication of adjuvant therapies is not well stablished in the literature, since the response to radiotherapy is not satisfactory for these tumors. The aim of the present study is to present a report the case of a patient with sacral chordoma (SC) who underwent partial sacrectomy and to carry out a brief review of the literature on sacrococcygeal chordomas.

The importance of the palatine bone for endoscopic endonasal skull base surgery.

Endoscopic endonasal skull base surgery is increasingly prevalent, with its scope expanding from pathogens in the midline region to those in the paramedian region. Maximizing anterior sphenoidectomy is important for the median approach, and lateralizing the pterygopalatine fossa is crucial for the paramedian approach. Maximizing the surgical corridor in the nasal cavity and minimizing damage to neurovascular structures are vital for establishing a surgical field with minimal bleeding, ensuring safe, precise, and gentle procedures. However, the relationship between the maxillofacial and skull base bones in endoscopic endonasal skull base surgery is difficult to understand because these bones are intricately articulated, making it challenging to visualize each bone's outline. Understanding important bones and their related neurovascular structures is essential for all skull base surgeons to maximize the surgical corridor and minimize iatrogenic injury to neurovascular structures. This study aimed to elucidate the role of the palatine bone from a microsurgical anatomical perspective. Three dry skulls were used to demonstrate the structure of the palatine bone and its relationship with surrounding bones. A formalin-perfused cadaveric head was dissected to show the related neurovascular structures. The arteries and veins of the cadaveric heads were injected with red- and blue-colored silicon. Dissection was performed using a surgical microscope and endoscope. In addition, the utilization of the palatine bone as a landmark to identify neurovascular structures, which aids in creating a wider surgical field with less bleeding, was shown in two representative cases. The palatine bone consists of unique complex structures, including the sphenoidal process, ethmoidal crest, pterygopalatine canal, and sphenopalatine notch, which are closely related to the sphenopalatine artery, maxillary nerve, and its branches. The ethmoidal crest of the palatine bone is a well-known structure that is useful for identifying the sphenopalatine foramen, controlling the sphenopalatine artery and nerve, and safely opening the pterygopalatine fossa. The sphenoidal process of the palatine bone is a valuable landmark for identifying the palatovaginal artery, which is a landmark used to safely and efficiently expose the vidian canal. The sphenoidal process is easily cracked with an osteotome and removed to expose the palatovaginal artery, which runs along the pharyngeal groove, just medial to the vidian canal. By opening the pterygopalatine canal (also known as the greater palatine canal), further lateralization of the periosteum-covered pterygopalatine fossa contents can be achieved. Overall, the sphenoidal process and ethmoidal crest can be used as important landmarks to maximize the surgical corridor and minimize unnecessary injury to neurovascular structures.

Soft-tissue origin joint contractures treated with the Ilizarov fixation method

Introduction Soft-tissue origin joint contractures are a common orthopedic problem. It could be due to various etiologies. Treatment options are available from conservative to surgical methods. These joint contractures slowly become irreversible causing impairment in activities of daily routine. The Ilizarov method is a well established and time-tested method used for management of bone pathologies, but its use in the management of soft-tissue origin contractures is also possible. It has an established role in neoosteogenesis and histogenesis. Fixator assisted soft-tissue stretching done at sustained slow pace leads to histoneogenesis that avoids stretching of neurovascular structures and reduces the possibility of recurrence.Aims To determine usefulness of the Ilizarov method in management of joint contractures of soft tissue origin; to meet functional requirements of patients; to study complications of Ilizarov method in management joint contractures due to soft tissue origin.Material and methods A total of 6 cases of soft-tissue origin joint contractures due to tuberculosis, post‑traumatic stiffness, post-burn contracture, deformity due to a snake bite in the age group from 3 to 55 years were treated with gradual distraction of joint with the Ilizarov method from January 22 to October 23. Two cases were of triple knee deformity, two were post-traumatic elbow stiffness, one was post-burn great toe contracture and one was post snake bite valgus foot contracture. All cases were operated with transarticular Ilizarov frame application and gradual distraction of joints and soft tissue with the help of hinge- and rod distractor assembly done. All cases completed follow up of 1 year. Aggressive physiotherapy was given postoperatively.Results All cases obtained a reasonable functional outcome, with no recurrence of deformity. All patients walk independently.Conclusion The Ilizarov method can be used for treating joint contractures due to traumatic and non‑traumatic pathologies.

Pictorial Essay on Ultrasound and Magnetic Resonance Imaging of Paraspinal Muscles for Myofascial Pain Syndrome.

The paraspinal muscles of the cervical, thoracic, and lumbar spine are important pain generators because muscle strains or myofascial pain syndrome caused by trigger points are common during clinical practice. Ultrasonography is the most convenient imaging tool for evaluating these muscles due to its advantages, such as providing good delineation of soft tissues, easy accessibility, and zero radiation. Additionally, ultrasound can serve as a useful guiding tool for paraspinal muscle intervention to prevent inadvertent injuries to vital axial neurovascular structures. This pictorial essay presents ultrasound scanning protocols for the paraspinal and other associated muscles as well as a discussion of their clinical relevance. Axial magnetic resonance imaging has also been used to elucidate reciprocal anatomy. In conclusion, ultrasound imaging proves to be a valuable tool that facilitates the differentiation of individual paraspinal muscles. This capability significantly enhances the precision of interventions designed to address myofascial pain syndrome.

Intraoperative computed tomography for the management of traumatic complex facial fractures: a narrative review

Successful facial reconstruction requires accurate restoration of the concealed three-dimensional facial skeleton. The key rationale for intraoperative computed tomography (iCT) is that it facilitates the most comprehensive assessment of fracture reduction. Real-time visual feedback is now considered an essential component in hand, spine and general orthopaedic surgery. Frequently proposed as the new gold standard of care, iCT has been widely adopted in maxillofacial surgery, especially internationally. In contrast, our Australian experience is that access to iCT and therefore uptake is relatively lacking. The craniofacial skeleton is a complex structure owing to its various convexities and concavities, sinonasal elements, biomechanical buttresses, visceral and occlusal components and neurovascular structures. Classic approaches to open reduction internal fixation aim to reduce incisions to prevent complications such as ectropion, salivary leak or nerve damage. However, intraoperative assessment of fractures in minimally-invasive techniques are hindered by the limited extent of exposure, especially in the setting of complex fracture patterns or those that involve dynamic or functional endpoints. With iCT, surgeons may visualise, adjust and revise fixation without wide exposure while the patient is on the operating table. This obviates an additional operation that may be required due to an unsatisfactory fixation. iCT is cost-effective and reduces radiation exposure. Challenges in integrating iCT include competing for availability with other specialties, training staff and lack of awareness about the benefits this technology offers. This narrative review discusses the role of iCT in the modern Australian operating theatre.

Morphological study of the popliteus muscle-tendon complex in formalin embalmed adult cadavers

Background The dimensions of popliteus muscle and its tendon are subjected to variability in the origin, mode of insertion, innervation patterns and vascular supply. The aim of this study was to measure the length, thickness and width of the popliteus muscle and its tendon at its different parts. The objectives were to study the topographic anatomy of the neurovascular structures of the popliteus and also to determine the dimensions of the popliteo-fibular ligament. Methods This descriptive cross sectional institutional based study included 50 formalin embalmed adult lower limb specimens. The measurements were performed by using the digital Vernier caliper. Results The length of the popliteus muscle belly along the upper and lower border were 44.2±6.63 mm and 89.26±14.41 mm, width of the muscle belly at midpoint, musculotendinous junction and insertion were 28.45±6.85 mm, 11.7±3.5 mm and 75.95±10.7 mm. The thickness of muscle belly at the midpoint was 2.55±0.55 mm. The length of popliteal tendon, width at origin and at musculotendinous junction were 24.85±2.15 mm, 7.55±1.55 mm and 8.5±1.15 mm. The thickness of tendon of popliteus was 2.6±0.75 mm. The length of nerve to popliteus was 50.44±8.66 mm and its origin was located 27.54±6.18 mm from the intercondylar line. The distance of origin of medial and lateral geniculate arteries from the intercondylar line were 26.26±10.47 mm and 20.76±5.19 mm. The distance of division of popliteal artery was 49.44±16.26 mm from the intercondylar line. The length and width of the popliteo-fibular ligament was 17.84±3.43 mm and 7.36±1.9 mm individually. Conclusions This study offered detailed morphometric data of the popliteus and it is believed that the data of this anatomical research is enlightening to orthopedic surgeons particularly in the field of arthroscopic and plastic surgery. The data can be considered as the database from our population.

Retrosigmoid Suprameatal Approach for the Resection of a Petrotentorial and a Petroclival Meningioma: 3-Dimensional Operative Video

Posterior skull base meningiomas pose a formidable surgical challenge because of their proximity to critical neurovascular structures and the narrow corridor available for their resection. While radiosurgery may be an effective treatment alternative, 1 microsurgery remains superior in addressing associated compressive symptoms. 2 Several approaches have been described to access these lesions, with varying degrees of exposure to the petroclival region. 3-7 The choice of the optimal approach depends on different factors related to the tumor morphological features and the surgeon's preference and experience. The retrosigmoid approach is a straightforward procedure compared with other more laborious skull base approaches to the petroclival region. Its described intradural extensions contribute to its high versatility for posterior skull base tumors. One of these extensions involves drilling the suprameatal tubercle, significantly increasing exposure and maneuverability for tumors located medial to the internal acoustic canal. 8 The semisitting position adds further value as it allows for a gravity-assisted clearance of blood and debris, achieving a clear surgical field. 9 We present 2 patients suffering from trigeminal neuralgia secondary to a petrotentorial and a petroclival meningioma. Given the location of both tumors predominantly medial and superior to the internal acoustic canal, resection was carried out through a retrosigmoid suprameatal approach with the patient in a semisitting position. Relevant anatomic and surgical considerations are discussed and illustrated in this 3-dimensional operative video. Gross total resection was achieved, and both patients remained neurologically intact and pain-free at long-term follow-up. Both patients consented to the procedure and to the publication of their image.

Close Reduction of Supracondylar fracture of humerus in children by Gravity Method

Objective: To evaluate the outcomes of employing a new technique, the gravity method, for the closed reduction of supracondylar humerus fractures (Gartland’s type II and III) in pediatric patients treated at the Trauma Center of Aziz Bhatti Shaheed Hospital Gujrat. Methodology: This descriptive cross-sectional study was conducted at Aziz Bhatti Shaheed Hospital's Trauma Center from August 2022 to April 2023. Children under 12 years old, presenting within 48 hours of injury with closed supracondylar humerus fractures (Gartland’s Extension type II and III), were included. All patients underwent closed reduction and percutaneous pinning. Data analysis was performed using SPSS, employing means and standard deviations for quantitative variables, and frequency and percentage for qualitative variables. Results: The mean age was 5.5 years (±1.5). Among 65 patients, there were 45 males and 20 females, with a male-to-female ratio of 1:0.4. The right humerus was affected in 28 patients (43%), while the left humerus was affected in 37 patients (57%). The gravity method successfully reduced 90% of fractures without the need for an assistant surgeon, resulting in a zero percent incidence of iatrogenic neurovascular injury. The average surgical duration was 20 minutes (ranging from 16 to 24 minutes), with an average of 7 images captured using the image intensifier. In cases where the gravity method failed, alternative closed reduction methods were employed for 10% of fractures; no open reduction was necessary. Conclusion: The gravity method demonstrates safety and efficacy by providing accurate traction for reducing displaced supracondylar fractures without causing damage to the overlying skin or neurovascular structures around the elbow. Its applicability is particularly noteworthy in settings with a shortage of trained medical personnel and limited expertise in managing neurovascular complications.

Anatomical Safety Area for Periarticular Analgesic Infiltration through the Posterior Capsule in Total Knee Arthroplasty: Radiological Study in Magnetic Resonance.

Background: One of the main challenges of orthopedic surgery is adequate pain management after total knee arthroplasty. This work aimed to determine the anatomical safety area for infiltration through the posterior capsule of the knee in prosthetic surgery using Magnetic Resonance Imaging (MRI). Methods: A descriptive, observational, cross-sectional study was performed on 126 knee MRIs. The variables studied were age, sex, and distance between different neurovascular structures of the popliteal fossa (tibial nerve, common peroneal nerve, and vascular bundle). Data were analyzed for normality (Kolmogorov-Smirnov) and variance homogeneity (Levène). A value of p < 0.05 and a confidence interval of 9% were considered statistically significant for all comparisons. Student's t-test was used to compare the means between independent samples. Results: We observed statistically significant differences between the sexes regarding EP-EPS (external plateau-external popliteal sciatic nerve (common peroneal)), EP-IPS (external plateau-internal popliteal sciatic nerve (tibial)), and IP-PA (internal plateau-popliteal artery) measurements. The average distance between both nerves, EPS-IPS (external popliteal sciatic nerve and internal popliteal sciatic nerve), was 25.96 mm in females, while the value obtained in males was 29.93 mm, but this difference was not statistically significant. Conclusions: The average distance from the posterior capsule to the EPS and IPS nerves is greater in males than in females, despite no statistical differences. The presence of a lateralized arteriovenous bundle reduces the infiltration area of the external compartment. Regarding the safety area, infiltration of the internal compartment is safe since the volume diffuses into the muscle mass of the internal gastrocnemius upon injection. To infiltrate the external compartment, the needle must move at least 2 cm from the midline toward the external side (to exceed the maximum displacement of the neurovascular bundle established at 1.82 cm), and not advance beyond 0.76 cm (minimum distance at which we located the common peroneal nerve in the external compartment).