Retraction Injury Research Articles

Endoport-Guided Endoscopic Excision of Intraaxial Brain Tumors.

Transcortical approaches using a spatula-based retraction system have traditionally been used for the microsurgical resection of deep-seated intraventricular and parenchymal brain tumors. Recently, transparent cylindrical or tubular retractors have been developed to provide a stable corridor to access deeper brain lesions and perform bimanual microsurgical resection. The flexible endoports minimize brain retraction injury during surgery and, along with the superior vision of endoscopes, offer several advantages over standard microsurgery. In this chapter, we describe the surgical technique of the endoport-guided endoscopic excision of deep-seated intraaxial brain tumors. The endoscopic endoport technique that we use at our institution for the surgical management of intraventricular and intraparenchymal brain tumors has been described in detail with illustrative cases. Results from the literature review of intraventricular and intraparenchymal port surgery were analyzed, and the feasibility and safety of this technique were discussed. Surgical complication avoidance and management were highlighted. The port technique offers numerous potential advantages, including (1) reducing focal brain injury by distributing retraction forces homogenously, (2) minimizing white matter disruption and the risk of fascicle injury during cannulation, (3) ensuring the stability of the surgical corridor during the procedure, (4) preventing inadvertent expansion of the corticectomy and white fiber tract dissection throughout surgery, and (5) protecting the surrounding tissues against iatrogenic injuries caused by instrument entry and reentry. The endoport-assisted endoscopic technique is safe and offers an effective alternative option for the resection of intraventricular and intraparenchymal lesions.

Endoscopic Cylinder Surgery for Ventricular Lesions.

Cylinder retractors have been developed to reduce the risk of brain retraction injury during surgery by dispersing retraction pressure on the brain. In recent years, various types of cylinder retractors have been developed and widely used in neurosurgery. The ventricles, being deep structures within the brain, present an effective area for cylinder retractor utilization. Endoscopy provides a bright, wide field of view in the deep surgical field, even through narrow corridors.This chapter introduces surgical techniques using an endoscope through a cylinder. Given the deep and complex shapes of the ventricles, preoperative planning is paramount. Two main surgical techniques are employed in endoscopic cylinder surgery. The wet-field technique involves the continuous irrigation of artificial cerebrospinal fluid (CSF) during the procedure, maintaining ventricle shape with natural water pressure, facilitating tumor border identification, and achieving spontaneous hemostasis. Conversely, the dry-field technique involves CSF drainage, providing a clear visual field even during hemorrhage encounters. In intraventricular surgery, both techniques are used and switched as needed.Specific approaches for lateral, third, and fourth ventricular tumors are discussed, considering their locations and surrounding anatomical structures. Detailed intraoperative findings and strategies for tumor removal and hemostasis are presented.Endoscopic cylinder surgery offers a versatile and minimally invasive option for intraventricular tumors, leading to improved surgical outcomes. Overall, this technique enhances surgical precision and patient outcomes in intraventricular tumor cases.

Retractorless Surgery for Tuberculum Sellae Meningiomas via the Frontolateral Approach: A Single Institution's Experience

Although technologic advances have improved the surgical outcomes of tuberculum sellae meningiomas (TSMs), the treatment of these tumors remains challenging given important neurovascular structures involvement. In this article, the authors retrospectively reviewed the effectiveness of retractorless surgery for TSMs via the frontolateral approach (FLA). Between 2015 and 2022, 36 patients with TSMs underwent retractorless surgery via the FLA. The gross total resection (GTR) rates, visual outcomes, and complications were evaluated as the main outcome parameters. GTR was achieved in 34 patients (94.4%). Visual acuity improved in 93.9% (n= 31) of the 33 patients with visual deficits and remained unchanged in 6.1% (n= 2). No patients suffered from visual deterioration, brain retraction injury, mortality, and tumor recurrence in the mean follow-up duration of 33 months. Retractorless surgery via the FLA is a reliable transcranial option for the treatment of TSMs. High rates of GTR, excellent visual outcomes, and the low incidence of complications could be achieved if the surgical strategy mentioned in the article is adopted.

Surgical Resection of Deep-Seated Arteriovenous Malformations Through Stereotactically Guided Tubular Retractor Systems: A Case Series.

Arteriovenous malformations (AVMs) in the subcortical and/or periventricular regions can cause significant intraventricular and intracranial hemorrhage. These AVMs can pose a unique surgical challenge because traditional, open approaches to the periventricular region require significant cortical/white matter retraction to establish sufficient operative corridors, which may result in risk of neurological injury. Minimally invasive tubular retractor systems represent a novel, feasible surgical option for treating deep-seated AVMs. To explore 5 cases of NICO BrainPath-assisted resection of subcortical/periventricular AVMs. Five patients from a single institution were operated on for deep-seated AVMs using tubular retractor systems. Collected data included demographics, AVM specifications, preoperative neurological status, postoperative neurological status, and postoperative/intraoperative angiogram results. Five patients, ranging from age 10 to 45 years, underwent mini-craniotomy for stereotactically guided tubular retractor-assisted AVM resection using neuronavigation for selecting a safe operative corridor. No preoperative embolization was necessary. Mean maximum AVM nidal diameter was 8.2 mm. All deep-seated AVMs were completely resected without complications. All AVMs demonstrated complete obliteration on intraoperative angiogram and on 6-month follow-up angiogram. Minimally invasive tubular retractors are safe and present a promising surgical option for well-selected deep-seated AVMs. Furthermore, study may elucidate whether tubular retractors improve outcomes after microsurgical AVM resection secondary to mitigation of iatrogenic retraction injury risk.

Identification of Deep Cervical Fascial Layers During Anterior Cervical Spine Exposure.

Anterior approaches to the cervical spine are among the most common exposures by which neurosurgeons and orthopedic surgeons access the prevertebral space and ultimately the cervical disk and vertebral bodies. There is a paucity of literature describing the microanatomic fascial planes of the neck with respect to anterior cervical approaches. To delineate the microanatomic connections of the cervical fascial planes pertinent to anterior cervical exposure. Using a cadaveric model, original illustrations, the Visible Human Project, and an original surgical video, we demonstrate a stepwise method for identifying the correct planes for anterior cervical exposure. A step-by-step method for identifying the anterior cervical fascial planes intraoperatively is demonstrated. A comprehensive understanding of anterior cervical microsurgical anatomy is vital for performing a methodical yet efficient approach to the prevertebral space while minimizing retraction and iatrogenic injury to the surrounding neurovascular structures.

How effective is occipital transtentorial approach for pineal region lesions? An assessment of occipital lobe functions & surgical outcome

Background and objectivesThe occipital transtentorial approach (OT) is a useful surgical approach for the treatment of lesions of the pineal region. Because the approach provides wide operative views of superior cerebellar, splenium, quadrigeminal regions can also be operated using this technique. However it may be associated with complications due to damage to the occipital lobe, which can be caused by brain retraction injury. The study evaluates the effectiveness of the OT approach in terms of surgical outcome with special emphasis on occipital lobe functions which may be affected using this approach. MethodologySeventeen patients of pineal region lesions were operated by OT approach, and preoperative evaluation of the anatomy of the tentorial angle was performed and its significance was studied. Various occipital lobe functions were evaluated postoperatively and compared with preoperative status. Surgical outcome was evaluated in terms of extent of tumour resection, postoperative occipital lobe functions and modified Rankin scale. ResultsThe mean angle between the tentorium and occipital surface of cerebellum (tentorial angle) was 62.08 ± 7.17 degrees. The maximum and minimum tentorial angle was 83 and 51 degrees respectively. Out of 13 patients in which the postoperative functional assessment of occipital lobe functions was possible, 2 patients developed homonymous hemianopia (one transient, one permanent). Other functions remain unaffected. Near and gross total resection was possible in 4 (23.5 %) and 8 (47.1 %) patients respectively. The mean modified Rankin scale score was 1.8 indicating slight post-operative disability. ConclusionsAmongst the various occipital lobe functions, the visual field defects are the most common functions affected postoperatively in the occipital transtentorial approach. The OT approach is an appropriate and reasonable approach for the surgical management of pineal region lesions where high resectability rates can be achieved irrespective of the status of anatomical factors like tentorial angle; with slight postoperative morbidity with respect to occipital lobe functions.

Tentorial peeling during combined petrosal approach: a cadaveric dissection.

The combined petrosal approach is an excellent method to access the petroclival region but has the inherent risk of injury to the temporal lobe and Vein of Labbé. Tentorial peeling has the potential to largely eliminate these risks during the classic combined transpetrosal approach. Anatomical dissection of three adult injected non-formalin fixed cadaveric heads was performed. Combined petrosal approach with tentorial peeling was completed. A tentorial incision just superior and parallel to the superior petrosal sinus was made to enable peeling of the tentorium into two layers, the posterior fossa tentorial leaf (PFTL), and the temporal tentorial leaf (TTL). Tentorial peeling clearly exposed the continuity betweenthe temporal dura and the TTL as well as the continuity betweenthe presigmoid dura and the PFTL.This enabled the creation of a large dural flap extending to the tentorial incisura, providing wide access to the petroclival region without any exposure of the temporal lobe and/or basal temporal veins.Techniques to create the dural flap without trochlear nerve injury were also explored. The technique of tentorial peeling into two distinct layers has the potential to reduce the morbidity associated with temporal lobe retraction and venous injury. Further cadaveric studies and surgical case series are needed to validate this important surgical nuance in transpetrosal approaches.

Critical appraisal of minimally invasive keyhole surgery for intracranial meningioma in a large case series.

Meningioma surgery has evolved over the last 20 years with increased use of minimally invasive approaches including the endoscopic endonasal route and endoscope-assisted and gravity-assisted transcranial approaches. As the "keyhole" concept remains controversial, we present detailed outcomes in a cohort series. Retrospective analysis was done for all patients undergoing meningioma removal at a tertiary brain tumor referral center from 2008-2021. Keyhole approaches were defined as: use of a minimally invasive "retractorless" approach for a given meningioma in which a traditional larger approach is often used instead. The surgical goal was maximal safe removal including conservative (subtotal) removal for some invasive locations. Primary outcomes were resection rates, complications, length of stay and Karnofsky Performance Scale (KPS). Secondary outcomes were endoscopy use, perioperative treatments, tumor control and acute MRI FLAIR/T2 changes to assess for brain manipulation and retraction injury. Of 329 patients, keyhole approaches were utilized in 193(59%) patients (mean age 59±13; 30 (15.5%) had prior surgery) who underwent 213 operations; 205(96%) were skull base location. Approaches included: endoscopic endonasal (n = 74,35%), supraorbital (n = 73,34%), retromastoid (n = 38,18%), mini-pterional (n = 20,9%), suboccipital (n = 4,2%), and contralateral transfalcine (n = 4,2%). Primary outcomes: Gross total/near total (>90%) resection was achieved in 125(59%) (5% for petroclival, cavernous sinus/Meckel's cave, spheno-cavernous locations vs 77% for all other locations). Major complications included: permanent neurological worsening 12(6%), CSF leak 2(1%) meningitis 2(1%). There were no DVTs, PEs, MIs or 30-day mortality. Median LOS decreased from 3 to 2 days in the last 2 years; 94% were discharged to home with favorable 90-day KPS in 176(96%) patients. Secondary outcomes: Increased FLAIR/T2 changes were noted on POD#1/2 MRI in 36/213(17%) cases, resolving in all but 11 (5.2%). Endoscopy was used in 87/139(63%) craniotomies, facilitating additional tumor removal in 55%. Tumor progression occurred in 26(13%) patients, mean follow-up 42±36 months. Our experience suggests minimally invasive keyhole transcranial and endoscopic endonasal meningioma removal is associated with comparable resection rates and low complication rates, short hospitalizations and high 90-day performance scores in comparison to prior reports using traditional skull base approaches. Subtotal removal may be appropriate for invasive/adherent meningiomas to avoid neurological deficits and other post-operative complications, although longer follow-up is needed. With careful patient selection and requisite experience, these approaches may be considered reasonable alternatives to traditional transcranial approaches.

Brain retraction injury after elective aneurysm clipping: a retrospective single-center cohort study

BackgroundBRI is estimated to occur in 10% of skull-base surgery and 5% of aneurysm surgery. These estimates are based on a few studies with unclear methodology. The purpose of this study is to assess the rate of BRI occurrence, its risk factors, and the association between BRI and postoperative focal neurological deficit in patients that underwent elective aneurysm surgery in a single institution.MethodsAll patients that underwent elective aneurysm surgery in a single tertiary center in the Netherlands were included. BRI was defined as cortical hypodensities in the surgical trajectory not matching areas of large arterial infarction. Risk ratios were calculated between BRI and (a) the use of temporary parent artery occlusion during clipping, (b) anterior communicating artery (ACom), and (c) middle cerebral artery (MCA) location of the aneurysm, (d) presence of mentioned CVA risk factors, (e) the clipping of > 1 aneurysm during the same procedure, and (f) new focal neurological deficit. Statistical analysis further included t-tests and binary logistical regression analysis on the correlation between age and BRI.ResultsBRI was identified postoperatively in 42 of the 94 patients included in this study. A new focal neurological deficit was found in 7 patients in the BRI group. A total of 5 patients had persisting symptoms at 3-month follow-up, of which 2 were caused by BRI. Increasing age is a risk factor for developing BRI.ConclusionsThe high rate of BRI and significant risk of new postoperative focal neurological deficit in our patients should be considered when counseling patients for elective aneurysm surgery.

Intraoperative overlay of optic radiation tractography during anteromesial temporal resection: a prospective validation study.

Anteromesial temporal lobe resection (ATLR) results in long-term seizure freedom in patients with drug-resistant focal mesial temporal lobe epilepsy (MTLE). There is significant anatomical variation in the anterior projection of the optic radiation (OR), known as Meyer's loop, between individuals and between hemispheres in the same individual. Damage to the OR results in contralateral superior temporal quadrantanopia that may preclude driving in 33%-66% of patients who achieve seizure freedom. Tractography of the OR has been shown to prevent visual field deficit (VFD) when surgery is performed in an interventional MRI (iMRI) suite. Because access to iMRI is limited at most centers, the authors investigated whether use of a neuronavigation system with a microscope overlay in a conventional theater is sufficient to prevent significant VFD during ATLR. Twenty patients with drug-resistant MTLE who underwent ATLR (9 underwent right-side ATLR, and 9 were male) were recruited to participate in this single-center prospective cohort study. Tractography of the OR was performed with preoperative 3-T multishell diffusion data that were overlaid onto the surgical field by using a conventional neuronavigation system linked to a surgical microscope. Phantom testing confirmed overlay projection errors of < 1 mm. VFD was quantified preoperatively and 3 to 12 months postoperatively by using Humphrey and Esterman perimetry. Perimetry results were available for all patients postoperatively, but for only 11/20 (55%) patients preoperatively. In 1/20 (5%) patients, a significant VFD occurred that would prevent driving in the UK on the basis of the results on Esterman perimetry. The VFD was identified early in the series, despite the surgical approach not transgressing OR tractography, and was subsequently found to be due to retraction injury. Tractography was also used from this point onward to inform retractor placement, and no further significant VFDs occurred. Use of OR tractography with overlay outside of an iMRI suite, with application of an appropriate error margin, can be used during approach to the temporal horn of the lateral ventricle and carries a 5% risk of VFD that is significant enough to preclude driving postoperatively. OR tractography can also be used to inform retractor placement. These results warrant a larger prospective comparative study of the use of OR tractography-guided mesial temporal resection.

The Turtle Neck Sign: Identification of Severe Retracted Distal Biceps Tendon Rupture.

Background:Chronic tendon retraction subsequent to distal biceps tendon rupture significantly increases repair difficulty and potential for tendon grafting. Biceps tendons that appear short or absent with magnetic resonance imaging (MRI) or that cannot be readily identified at surgery may erroneously be classified as irreparable. These apparent “absent” biceps tendons may actually be retracted and curled up inside the muscle, visually resembling the head-neck of a turtle retracted inside its shell (the “turtle neck sign”). When located, these tendons could be unfolded and repaired primarily. This type of tendon retraction seems to be associated with high-degree ruptures and larcertus fibrosus tears.Purpose:To test the hypothesis that tendon retractions with a turtle neck sign on MRI are more associated with high-degree ruptures and larcertus fibrosus tears versus tendon tears with simple linear retraction.Study Design:Cross-sectional study; Level of evidence, 3.Methods:Retracted distal biceps tendon ruptures on sagittal MRI were categorized as linear retraction or curled-up (turtle neck) retraction. Retraction length, injury severity, and lacertus fibrosus tears were analyzed.Results:The authors retrospectively analyzed the patient records of 85 consecutive traumatic distal biceps tendon ruptures from 2003 to 2019; the final study cohort was 37 patients. Injury-to-surgery timing was as follows: <3 weeks, 43% (16 cases); 3 weeks to 3 months, 32% (12 cases); and >3 months, 24% (9 cases). Overall, 19 patients had linear retraction <7 cm (mean, 3.3 ± 1.9 cm) and 18 patients had a turtle neck retraction ≥7 cm (mean, 9.1 ± 1.6 cm). The injury-to-surgery time (median [± interquartile range]) was 27 days (±90 days) in the linear retraction group and 23 days (±65 days) in the turtle neck retraction group. The turtle neck retraction group had a significantly higher occurrence of abnormal hook test findings, complete distal biceps tendon rupture, and lacertus fibrosus tears compared with the linear retraction group (100% vs 58%, 100% vs 68%, and 100% vs 37%, respectively; P ≤ .02). However, significant repairability differences were not found.Conclusion:Highly retracted distal biceps turtle neck sign tendon ruptures occur frequently in association with high-degree ruptures and lacertus fibrosus tears. The presence of a turtle neck retraction did not affect reparability. Surgeons should be aware of this curled-up retraction to avoid mistaking it for an absent tendon or a muscle-tendon disruption.

Resection of intra- and paraventricular malignant brain tumors using fluorescein sodium-guided neuroendoscopic transtubular approach

BackgroundThe requirement of brain retraction and difficulty in distinguishing the tumor demarcation are challenging in conventional approaches to intra- and paraventricular malignant tumors (IV-PVMTs). Tubular retractors can minimize the retraction injury, and fluorescein-guided (FG) surgery may promote the resection of tumors. Our aim is to evaluate the feasibility, safety, and effectiveness of fluorescein-guided endoscopic transtubular surgery for the resection of IV-PVMTs. MethodsTwenty patients with IV-PVMTs underwent FG endoscopic transtubular tumor resection. Fluorescein sodium was administered before the dural opening. The intraoperative fluorescence staining was classified as “helpful” and “unhelpful” based on surgical observation. Extent of resection was assessed using postoperative magnetic resonance imaging. Karnofsky Performance Status (KPS) score was used to evaluate the general physical condition of patients. ResultsThere were 9 glioblastomas, 4 anaplastic astrocytomas and 7 metastatic tumors. “Helpful” fluorescence staining was observed in 16(80%) of 20 patients. Gross total resection was achieved in 16(80%) cases, near-total in 3(15%) cases, and subtotal in 1 (5%) case. No intra- or postoperative complications related to the fluorescein sodium occurred. The median preoperative KPS score was 83, and the median KPS score 3-month after surgery was 88. ConclusionFG endoscopic transtubular surgery is a feasible technique for the resection of IV-PVMTs. It may be a safe and effective option for patients with these tumors. Future prospective randomized studies with larger samples are needed to confirm these preliminary data.

The Novel Technique of Uniportal Endoscopic Interlaminar Contralateral Approach for Coexisting L5-S1 Lateral Recess, Foraminal, and Extraforaminal Stenosis and Its Clinical Outcomes

Background: Multifocal intra-and-extraspinal lumbar stenotic lesions could be decompressed with one endoscopic surgical approach, which has the advantages of functional structure preservation, technical efficacy, and safety. Methods: A retrospective study was performed on 48 patients who underwent uniportal endoscopic contralateral approach due to coexisting lateral recess, foraminal, and extraforaminal stenosis at the L5-S1 level. Foraminal stenosis grade and postoperative dysesthesia (POD) were analyzed. Visual analog scale (VAS) pain scores, modified Oswestry Disability Index (ODI) scores, and MacNab criteria for evaluating pain disability and response were analyzed. Results: The foraminal stenosis grade of the treated spinal levels was grade 1 (n = 16, 33%), grade 2 (n = 20, 42%), and grade 3 (n = 12, 25%). The rate of occurrence of POD grade 2 and above, which may be related to intraoperative dorsal root ganglion (DRG) retraction injury, was revealed to be 4.2% (two with grade 2, none with grade 3). The patients showed favorable clinical outcomes. Conclusions: Uniportal endoscopic interlaminar contralateral approach is an effective procedure to resolve combined stenosis (lateral recess, foraminal, and extraforaminal region) with one surgical approach at the L5-S1 level. It may be a minimal DRG retracting and facet joint preserving procedure in foraminal and extraforaminal decompression.

Navigated Endoport in the Purely Endoscopic Microsurgery of Intraventricular and Other Deep-Seated Brain Lesions: A Case Report

&lt;p&gt;&lt;strong&gt;Objective. &lt;/strong&gt;Brain parenchyma retraction is often necessary to reach various deep brain lesions during surgery. In order to minimise the incidence of the brain retraction injury, an endoport system may be employed. We present a report of a navigated endoport system in conjunction with an purely endoscopic microsurgery that was used in a patient with a deep-seated subependymoma.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Case Report. &lt;/strong&gt;A navigated endoport with purely endoscopic microsurgery were used in a patient with a tumour&lt;/p&gt;&lt;p&gt;located in the frontal horn of the left lateral ventricle. The endoport channel was made of a polyvinyl sheet that was cut into a 7 cm square, rolled into a tubular structure that was wrapped around the neuronavigational probe, and inserted in the access trajectory to the tumour. The endoport tube was then expanded with a balloon to a diameter of 7 mm and a surgical corridor was thus formed. During the purely endoscopic microsurgical lesionectomy, the tumour was completely removed from the frontal horn. The foramen of Monro was released and the septum pellucidum was perforated for better cerebrospinal fluid circulation. Histopathological examination confirmed the tumour as subependymoma. The recovery of the patient was unremarkable.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusion. &lt;/strong&gt;The expandable endoport system supplemented with neuronavigation is a safe and efficient option for deep-seated tumour removal. The tubular shape of the retractor enables standard microsurgical techniques through minimally invasive approaches and offers an excellent visualization of the underlying lesion.&lt;/p&gt;

Brain retraction injury

This review is devoted to various techniques for reduction of brain damage during retraction. Searching for reports was carried out in Russian and English languages using the PubMed database (n=721) without restrictions on language, date and study design according to the following keywords: «brain retraction injury», «spatula brain retractors», «tubular brain retractors», «retractorless neurosurgery». Primary screening and exclusion of duplicate manuscripts allowed us to single out the main group of articles (n=121). Some reports were excluded due to non-compliance with inclusion criteria (no description of methods, few references and insufficient data). The final list included 32 studies which were represented by cohort studies, retrospective analyses of surgical interventions, as well as experimental and laboratory studies. Small number of publications did not allow us to obtain unambiguous conclusions. Further research is required to reduce brain retraction trauma.

Cottonoid Sliders: A Simple and Cost-Effective Tool for Retractorless Intracranial Surgery.

Retraction injury can result in significant complications during intracranial operations. Alternative surgical techniques to minimize retraction pressure and duration of retraction can minimize the risk of retraction injury. We describe the use of a cottonoid "slider," which is a simple, cost-effective modification of a commonly used cottonoid, in multiple applications. The cottonoid sliders are constructed preoperatively by overlaying an adhesive plastic incision drape on one side of a dry cottonoid patty and trimming the edges to fit the form of the cottonoid. Intraoperatively, the sliders can slide across the parenchymal surface atraumatically and are used for gentle retraction to expose desired areas. In addition, suction may be placed on the slider to clear fluid from the operative view. The plastic side of the slider prevents adherence to the parenchymal surface. Retractorless surgical techniques have been developed to minimize risk of retractor associated injury in intracranial surgery by reducing retraction pressure and duration. Given that the cottonoid sliders glide along the parenchyma, do not stick, and are used for dynamic retraction, the main objectives to minimize retraction injury can be met while not compromising operative efficiency. Cottonoid sliders are a simple and cost-effective method of providing gentle exposure during intracranial surgery. This technique represents a valuable and cost-effective addition to the neurosurgical armamentarium.

Self-care promotion of the intact (non-circumcised) patient: A review of available recommendations.

With routine infant circumcision ratesdeclining in the United States, nurses are likely to encounter more intact (non-circumcised) male patients requiring genital hygiene, nursing interventions, and education accessing the health system. To date, a little emphasis has been placed on the care of the intact male patient in the nursing literature, resulting in ambiguity in care recommendations. The vagueness is problematic, as improper intact care, particularly in the pediatric patient, can result in forced retraction injuries, bleeding, scarring, and unnecessary intervention. In addition, with nurses conducting many of the tasks of hygiene and education for self-care, there is potential for impaired patient self-care and harm if nurses are not knowledgeable in intact care. Utilizing Orem's self-care theory as a framework, the aim of this effort is to perform a review of current recommendations on intact care to inform nursing practice with this population. As no evidence was found in the scientific literature, readily available consumer website resources were reviewed. Themes of hygiene and age of retraction emerged. While recommendations for hygiene practices were variable, all review sources (n = 12) were clear in advising against the premature retraction of the intact foreskin and identified this as a route for injury. With no current literature available to summarize current nursing clinical or educational practices, dissemination of these recommendations is necessary to prevent patient injury and promote appropriate patient self-care.

Interbody Fusions in the Lumbar Spine: A Review.

Lumbar interbody fusion is among themost common types of spinal surgery performed. Over time, the term has evolved to encompass a number of different approaches to the intervertebral space, as well as differing implant materials. Questions remain over which approaches and materials are best for achieving fusion and restoring disc height. We reviewed the literature on the advantages and disadvantages of various methods and devices used to achieve and augment fusion between the disc spaces in the lumbar spine. Using search terms specific to lumbar interbody fusion, we searched PubMed and Google Scholar and identified 4993 articles. We excluded those that did not report clinical outcomes, involved cervical interbody devices, were animal studies, or were not in English. After exclusions, 68 articles were included for review. Posterior approaches have advantages, such as providing 360° support through a single incision, but can result in retraction injury and do not always restore lordosis or correct deformity. Anterior approaches allow for the largest implants and good correction of deformities but can result in vascular, urinary, psoas muscle, or lumbar plexus injury and may require a second posterior procedure to supplement fixation. Titanium cages produce improved osteointegration and fusion rates but also increase subsidence caused by the stiffness of titanium relative to bone. Polyetheretherketone (PEEK) has an elasticity closer to that of bone and shows less subsidence than titanium cages, but as an inert compound PEEK results in lower fusion rates and greater osteolysis. Combination PEEK-titanium coating has not yet achieved better results. Expandable cages were developed to increase disc height and restore lumbar lordosis, but the data on their effectiveness have been inconclusive. Three-dimensionally (3D)-printed cages have shown promise in biomechanical and animal studies at increasing fusion rates and reducing subsidence, but additive manufacturing options are still in their infancy and require more investigation. All of the approaches to spinal fusion have plusses and minuses that must be considered when determining which to use, and newer-technology implants, such as PEEK with titanium coating, expandable, and 3D-printed cages, have tried to improve upon the limitations of existing grafts but require further study.

Percutaneous Endoscopic Transforaminal Approach for Far Lateral Lumbar Discectomy: 2-Dimensional Operative Video.

The conventional surgical approach to far lateral lumbar disk herniations is a paraspinal Wiltse approach. During the Wiltse approach, it is sometimes necessary to resect some of the facet or pars interarticularis to achieve an adequate exposure. The endoscopic transforaminal route can be of benefit in far lateral disk herniations due to direct access to the epidural space through Kambin's triangle, without the need for any bony removal or nerve retraction. In this video, we describe a percutaneous endoscopic transforaminal approach for far lateral discectomy in a patient presenting with a left L4 radiculopathy due to a far lateral L4-5 disk herniation. We describe Kambin's triangle anatomy and its relevance to the transforaminal route. The steps of the procedure are then described: dissection of soft tissue and removal of free disk fragments on the inferior aspect of the foramen far from the compressed exiting nerve route above to decrease the risk of retraction injury, gentle maneuvering of endoscope superiorly with removal of further compressive disk fragments, exposure of the exiting nerve root superiorly after adequate decompression is achieved and removal of any remaining fragments in close proximity to the nerve, and finally evaluation of traversing nerve root for any compressive lesions. The presentation ends with postoperative imaging confirming decompression of the far lateral disk herniation.

Stereotactic-Guided Dilatable Endoscopic Port Surgery for Deep-Seated Brain Tumors: Technical Report with Comparative Case Series Analysis

Deep-seated brain tumors are often best treated by primary surgical excision. Traditional microsurgical techniques can cause retraction injury and require extensive brain dissection. To mitigate this risk, stereotactic-guided tubular retractors were developed; however, the risk of shear injury remains. We created a stereotactic-guided dilatable port system to create a corridor for deep brain tumor surgery along the trajectory of a brain needle to minimize iatrogenic brain injury. Of the 8 included patients (6 colloid cysts, 1 metastasis, 1 intraventricular meningioma), 5 had undergone frameless and 3 frame-based stereotactic targeting. We used a tans-sulcal trajectory and a 2.6-mm stereotactic needle. At the target depth, the cannula was removed and the balloon inflated to 14 mm. The balloon was deflated and removed before placing the port. Pre- and 3-month postoperative magnetic resonance imaging scans were used to measure the T2-weighted signal change and residual cannulation defect. These patients were compared with a case-matched standard endoscopic port surgery cohort. All patients had undergone total lesional resection without new neurologic deficits. Patients undergoing dilatable endoscopic port surgery (DEPS) had significantly smaller residual cannulation defects (P < 0.05) but no significant differences in postoperative T2-weighted signal changes or diffusion restriction volumes at 3 months postoperatively (P > 0.05). DEPS might be a safe alternative to standard endoscopic port surgery or microsurgery for deep-seated brain tumors. The degree of iatrogenic injury using DEPS, as determined by magnetic resonance imaging analysis, might be equivalent to or less than that with standard port surgery techniques, although larger sample sizes are needed for validation.