Risk Of Cerebrospinal Fluid Leak Research Articles

Janus orthogonal nanofiber membrane containing CPP@PDA for skull base reconstruction

In neurosurgery procedures, cerebrospinal fluid leakage is a commonly encountered complication. Reconstructing skull base defects with patch materials can reduce the risk of cerebrospinal fluid leakage which can lead to serious issues such as infection, meningitis, arachnoiditis, and delayed wound healing. An ideal skull base reconstruction material should not only serve as a leak-proof barrier but also promote skull base bone regeneration. To fulfill this challenge, this research designed and fabricated a Janus orthogonal bilayer nanofiber membrane (OPCL/PG-PCPP). The aligned PCL (APCL) nanofibers were constituted as the top layer to resist cerebrospinal fluid leakage, while the perpendicular PCL/gelatin (APG) fibers with calcium polyphosphate encapsulated polydopamine nanoparticles (CPP@PDA, labeled as PCPP) were designed as the bottom layer (APG-PCPP) to facilitate osteoblast migration and osteogenic differentiation. Among these, APG-1%PCPP nanofibers demonstrated the most effective induction of osteogenic differentiation in bone marrow mesenchymal stem cells (rBMSCs). Subsequent in vivo animal experiments revealed that the bone surface area (BS), bone volume fraction (BV/TV), and number of trabeculae (Tb.N) in the APG-1%PCPP group were twice as high as those in the control group, which confirmed the good osteogenic potentials. Therefore, due to its unique leak-proof and osteoinductive properties, the OPCL/PG-PCPP membrane holds promise as an applicable skull base reconstruction material in the field of neurosurgery.

Does Early Mobilization Following Resection of Spinal Intra-Dural Pathology Increase the Risk of Cerebrospinal Fluid Leaks?-A Dual-Center Comparative Effectiveness Research.

Background and Objectives: Prolonged bed rest after the resection of spinal intradural tumors is postulated to mitigate the development of cerebrospinal fluid leaks (CSFLs), which is one of the feared postoperative complications. Nonetheless, the empirical evidence supporting this conjecture remains limited and requires further investigation. The goal of the study was to investigate whether prolonged bed rest lowers the risk of CSFL after the resection of spinal intradural tumors. The primary outcome was the rate of CSFL in each cohort. Materials and Methods: To validate this hypothesis, we conducted a comparative effectiveness research (CER) study at two distinct academic neurosurgical centers, wherein diverse postoperative treatment protocols were employed. Specifically, one center adopted a prolonged bed rest regimen lasting for three days, while the other implemented early postoperative mobilization. For statistical analysis, case-control matching was performed. Results: Out of an overall 451 cases, we matched 101 patients from each center. We analyzed clinical records and images from each case. In the bed rest center, two patients developed a CSFL (n = 2, 1.98%) compared to four patients (n = 4, 3.96%) in the early mobilization center (p = 0.683). Accordingly, CSFL development was not associated with early mobilization (OR 2.041, 95% CI 0.365-11.403; p = 0.416). Univariate and multivariate analysis identified expansion duraplasty as an independent risk factor for CSFL (OR 60.33, 95% CI: 0.015-0.447; p < 0.001). Conclusions: In this CER, we demonstrate that early mobilization following the resection of spinal intradural tumors does not confer an increased risk of the development of CSFL.

Multiple skull base defects in the setting of spontaneous cerebrospinal fluid rhinorrhea; a dual institution view

PurposeIdiopathic intracranial hypertension (IIH) is a condition of high cerebrospinal fluid (CSF) pressure that presents with CSF leak. The implications of multiple skull base defects (SBD) and associated synchronous CSF leaks have not been previously explored. Materials and methodsA dual institutional case-control study examined multiple SBD's and encephaloceles on the risk of CSF leak and postoperative failures post-repair. IIH patients with CSF leaks and IIH controls without leaks were selected retrospectively. Chi square analysis evaluated for statistically significant alterations in probability with CSF leak development. Results192 patients were selected with 108 IIH controls and 84 spontaneous CSF leak cases. Signs and symptoms for IIH controls and CSF leak cases respectively were pulsatile tinnitus (60.2 % and 29.8 %), headaches (96.3 % and 63.1 %), papilledema (74.1 % and 12.5 %), visual field defects (60.8 % and 13 %) (p < 0.001). Encephalocele formation in controls was 3.7 % compared to cases at 91.6 % (p < 0.001). Multiple SBD's in controls compared cases was 0.9 % and 46.4 % respectively (p < 0.001). Subgroup analysis of CSF leak cases showed 15 patients with two CSF leak repairs due to a recurrence. 27 (39.1 %) single leak cases had multiple SDB's while 12 (80 %) recurrent leaks had multiple SDB's (p = 0.004). ConclusionsPatients with radiographic evidence of multiple SBD's and encephaloceles represent a high-risk population with a propensity for CSF leaks. Secondary SBD's are common in patients with spontaneous CSF rhinorrhea and higher in patients with a recurrence.

Assessment of the distribution and volume of air chambers around the inner auditory canal on high-resolution computed tomography scans of the temporal bone.

Assessment of the distribution and volume of air chambers around the inner auditory canal on high-resolution computed tomography scans of the temporal bone.

How I do it: lateral approach for craniocervical junction tumors.

The far lateral approach has been developed to access lesions at the craniocervical junction and upper cervical spinal canal. Associated morbidity triggered the development of less invasive tailored approaches. In this lateral approach to the craniocervical junction, the occipital condyle is kept intact, vertebral artery manipulation is minimized, and the sigmoid sinus is not skeletonized. A linear incision through skin and muscles and use of an abdominal wall fat graft minimize the risk of cerebrospinal fluid leakage. The exposure provided is sufficient for the majority of tumors in this region and allows for low complication rates.

Unilateral Supraorbital Keyhole Craniotomy Avoiding the Frontal Sinus for Large and Giant Olfactory-Groove Meningiomas: A Case Series

There are several different approaches to large and giant olfactory-groove meningiomas (OGMs). Each approach has advantages and disadvantages. We present our series using a unilateral supraorbital keyhole approach avoiding the frontal sinus for the resection of large and giant OGMs without the use of fixed brain retractors or orbital rim removal. All consecutive patients operated on for large (>3 cm in largest diameter) and giant (>5 cm) OGMs by the senior author from 2016 to 2021 were prospectively identified and retrospectively reviewed. Patients who were operated on using an endoscopic endonasal approach were excluded. No fixed retraction was used. In total, 14 consecutive patients (11 with large, 3 with giant) were included. All patients were female, with an average age ± standard deviation of 59.7 ± 11.5 years. The median [interquartile range] preoperative Karnofsky Performance Status score was 80 [80-88]. The median preoperative tumor diameter and volume were 3.8 [3.2-4.2] cm and 22.2 [10.5-25.2] cm3, respectively. All patients underwent gross total resection. The median hospital stay was 2.7 [2-3] days, with all patients being discharged to home. No patients incurred any postoperative medical and/or surgical complications. Of the 9 patients who had subjective smell preoperatively, 5 stated they had subjective olfaction after surgery. We demonstrate the utility of a unilateral supraorbital keyhole approach avoiding the frontal sinus for large and giant OGMs. The potential advantages of this approach are minimizing bilateral brain manipulation, avoiding the frontal sinus and potential mucoceles, and reducing the risk of cerebrospinal fluid leaks.

Neuroendoscopic Third Ventriculostomy

Endoscopy is essential in less invasive surgery and its use has widely expanded in almost all surgical specialties. This procedure has also been adopted for neurosurgery. It is now introduced in skull base surgery, expanded from endoscopic transsphenoidal surgery, to remove pituitary tumors, assisting tumor removal or removing a tumor only with the endoscope; spine surgery; and endoscopic third ventriculostomy(ETV). ETV is now accepted as a standard technique for treating noncommunicating hydrocephalus. Currently, 1067 neurosurgeons are certified by the Japan Society for Neuroendoscopy, and endoscopic surgery is recognized as a typical treatment option. This article describes the surgical procedure for ETV, a basic procedure for pediatric hydrocephalus. It is important to master intraventricular manipulation using the endoscope. Also, certain tips must be implemented before and after the endoscopic procedure to avoid complications. It is also necessary to emphasize the difference between adult cases, such as high risk of cerebrospinal fluid leakage in child cases. So that every single effort must be done to avoid this leak.

Positional relationship between lacrimal sac and skull base: implication of risk of cerebrospinal fluid leakage during dacryocystorhinostomy

Cerebrospinal fluid (CSF) leakage is a rare but severe complication during dacryocystorhinostomy (DCR). Understanding the details of the anatomy of the lacrimal drainage system and skull base is essential to avoid this complication. We examined the positional relationship between the lacrimal sac and skull base using 16 cadavers (22 sides) and using computed tomographic images taken in 81 patients (81 sides). Consequently, the frontal sinus intervened between the lacrimal sac and skull base in 81.8–90.1% of cases. The lacrimal sac fundus and posterior lacrimal crest were far from the skull base/cribriform plate, and the skull base above the lacrimal sac was considerably thick. These results indicate that the risk of skull base injury and consequent CSF leakage during DCR is extremely low. However, surgeons should be cautious of this complication by indirect injury due to a twisting movement of a bone rongeur applied to the maxillary bone during creation of a bony window in patients with no interposition of the frontal and ethmoid sinuses between the lacrimal sac and skull base.

Imaging analysis of dural exposure in cholesteatomas with a skull base defect.

Dural exposure during cholesteatoma surgery can pose a risk of cerebrospinal fluid leakage or residual disease. Therefore, delicate handling of the area surrounding the bone defect in the cranial fossa is required. However, in small-sized defects, preoperative prediction of dural exposure can be challenging. This study aimed to evaluate the diagnostic value of computed tomography (CT) for preoperative prediction of cholesteatoma-related dural exposure in bone discontinuities in the skull base. We evaluated serial high-resolution CT images showing bone density discontinuities in the middle cranial fossa (MCF) requiring mastoidectomy for cholesteatoma. The CT and intraoperative findings were analyzed retrospectively. We evaluated the length between the superior margins of the bone density discontinuities using coronal CT planes. Receiveroperatingcharacteristic (ROC) curves were constructed to determine the optimal cut-off values. We extracted data from 107 bone density discontinuities, among which 54 (50.5%) showed dural exposure intraoperatively. Discontinuities with dural exposure (n = 54) had significantly greater lengths than did those without (n = 53) (p < 0.001, Wilcoxon rank-sum test). The area under the curve was 0.9780 according to the ROC analysis, and the optimal cut-off value was determined to be 2.99mm (sensitivity 92.59%; specificity 94.34%). A bone density discontinuity length of > 2.99mm in the MCF on coronal CT plane is a reliable diagnostic marker for cholesteatoma-related dural exposure. Thus, preoperative high-resolution CT analysis can inform optimal surgical preparation and planning before manipulating the area surrounding the osteolytic lesion in the MCF.

Early postoperative complications and their measures after skull base reconstruction: A study from the standpoint of plastic and reconstructive surgeons

ObjectiveIn skull base surgery, postoperative complications may be lethal and it is important to know how to deal with these. There are several reports on complications after skull base reconstruction, but it is difficult to understand which are important for plastic surgeons in charge of reconstruction. The objective of this study is to clarify the early postoperative survival-related complications after skull base reconstruction of which plastic surgeons should participate in treatment. MethodsOne hundred and seventy-seven patients who underwent skull base reconstruction at our department over the last 12 years were retrospectively surveyed. The cases of early complications in which plastic surgeons were actively involved in treatment were investigated and the preventive measures actually taken at our facility are examined in addition to treatment methods after development. ResultsPlastic surgical complications were wound infection in seven patients, impaired blood flow in transplanted tissue in two patients, cerebrospinal fluid leakage in five patients, and intracranial compression in three patients. Total number of postoperative complications were seventeen and the total complication rate was 9.6%. Complication rates tended to be higher in anterior-middle skull base cases than in anterior or middle alone cases and higher with free tissue transfer than with locoregional flap. Multivariate analysis revealed that operation time was a significantly higher risk factor (p=0.012) and preoperative chemotherapy was a significantly lower risk factor (p=0.033) for the development of complications. It was also found that the hospitalization length was significantly longer when complications occurred (p<0.0001). Wound infection was treated with removal of the cause, sufficient drainage, and irrigation. Regarding preventive measures, it is necessary to pay attention especially to intracranial contamination with epithelial components. Rapid surgical measures were necessary when blood flow of the transplanted tissue was impaired. For pedicle flaps, conservation of the feeding vessel is needed, and for free flaps, reliable vascular anastomosis is needed as preventive measures. Plastic surgeons play a role in reducing the risk of cerebrospinal fluid leakage through covering the repaired dura mater with tissue with favorable blood flow, especially in reoperation after development of leakage. Skull base reconstruction with soft tissue may cause intracranial compression, and sometimes, it is not resolved by conservative treatment and reoperation is selected. ConclusionPlastic surgical postoperative complications were clarified, and treatment methods and preventive measures for them were examined. Careful consideration of blood flow, placement, and volume of the transplanted flap is important to prevent complications.

Association study of the pneumatization degree of mastoid air cells and postoperative complications after microvascular decompression in hemifacial spasm.

This study aimed to analyse the association between the degree of pneumatization of mastoid air cells (MACs) and postoperative complications after microvascular decompression in hemifacial spasm. We retrospectively reviewed 308 patients with hemifacial spasm who underwent surgery at our institute between January 2017 and March 2021. The degree of pneumatization of MACs was classified into four grades (grades 1, 2, 3, and 4) according to method of Han et al. The clinical data of the four grades were analysed and statistically examined. There were no statistically significant differences between the four grades in terms of the operative time, intraoperative blood loss, and postoperative hospital stay (all, P > 0.05). The incidence of hearing loss was higher in grade 4 MACs (26.56%) than in grades 1 and 2 MACs (5.41% and 2.89%, respectively; P < 0.05). The incidence of facial paralysis was higher in grade 4 MACs (28.13%) than in grades 1 and 2 MACs (5.41% and 9.18%, respectively; P < 0.001). The incidence of intracranial infection was higher in grade 3 MACs (17.65%) than in grade 2 MACs (3.89%) (P < 0.05). All four patients with cerebrospinal fluid leakage belonged to grade 4 MACs. The incidence of cerebrospinal fluid leakage was higher in grade 4 MACs (5.13%) than in grade 2 MACs (P < 0.05). This study found that the degree of pneumatization of MACs was closely related to the postoperative complications after MVD surgeries. Well-pneumatized MACs increase the risk of cerebrospinal fluid leakage and intracranial infection. However, insufficient exposure increases the risk of facial paralysis and hearing loss. For patients with well-pneumatized MACs, sufficient surgical exposure is the top priority when locating the bone hole. For those who may have a latent MAC opening, preventive occlusion should be considered.

Surgical Resection of Dorsal Spinal Meningiomas with the Inner Dura Layer—An Improved Preservation Technique of Spinal Dura in 40 Cases

Spinal meningiomas are the common benign tumors in intradural extramedullary spinal tumors. Simpson grade I resection is recommended to avoid tumor recurrence. However, the dura reconstruction increases a risk of cerebrospinal fluid leakage after this surgical resection. To address this concern, the inner dura layer resection and long-term surgical outcomes of this technique were designed and examined after total tumor resection to preserve the outer dura layer. This study included 40 spinal meningioma patients undergoing the outer dura layer resection between 2002 and 2019. Clinical characteristics, radiologic features, preoperative and postoperative functional states, tumor recurrence, and perioperative complications were described and evaluated. A total of 40 spinal meningioma cases with the median age of 63 years (36-81 years) were enrolled in this study. The median postoperative follow-up period of all 40 cases was 96 months (34-193 months). About 82.5% of cases were located in the thoracic spine, while 16.5% of cases were located in the cervical spine. Of the symptomatic cases, 87.5% of cases follow with satisfactory outcomes and 12.5% of cases follow with unexpected outcomes. The local spinal meningioma recurrence rate was 2.5% (1 of 40 cases). No postoperative cerebrospinal fluid leak occurred in the 40 spinal meningioma cases. A long-term postoperative follow-up indicated that this modified spinal dura preservation technique caused good neurologic improvement with rare recurrence. Therefore we recommend this improved technique may be an alternative surgical option for total resection of spinal meningiomas with favorable prognosis.

Fully endoscopic endonasal approach for the treatment of intrasellar arachnoid cysts.

To report our experience of endoscopic endonasal obliteration of symptomatic sellar arachnoid cyst (SAC). From 2002 to 2019, we retrospectively reported the data of 17 cases of SAC operated in Timone University Hospital, Marseille, France. Preoperative clinical findings were collected including main symptoms, visual function and endocrinological assessment. Surgical procedure was homogeneous and consisted in endonasal fully endoscopic surgical obliteration of the cyst cavity with fat graft. Post-operative outcomes, complication and follow-up was reported. Visual disorders and/or headaches were the main symptoms. Our technique provided improvement for 83.3% of the patients suffering from visual disturbance and for 87.5% of those suffering from headaches. We reported 2 cases of cerebrospinal fluid (CSF) leakage (11.8%), but no meningitis. One case of definitive diabetes insipidus occurred and one case of postoperative syndrome of inappropriate antidiuretic hormone secretion was temporary. There was one case of recurrence reported. The mean follow-up was 39months. Patients with symptomatic SAC can be treated successfully by endoscopic endonasal obliteration of the cyst. This simple technique offers true benefits for the patients without craniotomy, but the complication rate remains high especially with the risk of CSF leakage. Special attention to skull base opening and closing could reduce this risk.

Olfactory Preservation in Craniofacial Resection of Tumor Invading Hemianterior Skull Base: Operative Video.

In traditional craniofacial resection of tumors invading the anterior skull base, the bilateral olfactory apparatus is resected. Recently, transnasal endoscopy has been used for olfactory preservation in resections of unilateral low-grade malignancies. However, for tumors that invade the orbita or for high-grade malignancies, the transnasal endoscopic skull base surgery has been controversial. This video demonstrates the surgical techniques of olfactory preservation during craniofacial resection of a high-grade malignancy invading the hemianterior skull base and orbita. We present the case of a 32-year-old woman with osteosarcoma in the right ethmoid sinus. The tumor invaded the ipsilateral cribriform plate, dura menta, and orbital periosteum; however, the nasal septum and crista galli were intact ( Fig. 1A, B ). Because the tumor was a high-grade malignancy and the orbita had been invaded, we performed craniofacial resection instead of endoscopic resection ( Fig. C2A ). We drilled into the right side of the crista galli, midline of the cribriform plate, and perpendicular plate of the ethmoid bone via craniotomy. As a result, we accessed the nasal cavity directly ( Fig. 2B ). To preserve the nasal septum, we detached the remaining right septal mucosa through the transfacial approach ( Fig. 2C ). Because of the high risk of cerebrospinal fluid leakage as a result of previous irradiation, we performed vascularized free flap reconstruction of the skull base instead of pericranial flap. Postoperative computed tomography revealed no evidence of tumor ( Fig. 1C, D ). The patient's sense of smell returned after 1 postoperative day, and she was discharged on the postoperative day 14. The link to the video can be found at: https://youtu.be/XzPABYwzkjs .

New Tools and Techniques to Prevent CSF Leak in Cranial and Spinal Surgery.

Cerebro-spinal fluid (CSF) leak in cranial and spinal surgery seriously threatens the clinical prognosis of surgical cases exposing the patients to higher risk of infection, prolonged hospital stay, and need of reoperation. Ultimately, this cascade of events may lead to life-threatening complications, as in cases of meningitis/encephalitis, spondylodiscitis, subdural hematomas, and severe pneumocephalus. Moreover, CSF leak causes a consistent rise in healthcare-related costs which are nearly doubled in CSF leak cases after craniotomy or in spinal surgery. The risk of CSF leak tends to be higher in patients undergoing transnasal endoscopic surgery, posterior fossa craniotomies, and spinal surgery, while being considered a quite rare finding in supratentorial brain surgery. Here we analyzed the different implications of this issue focusing on the usefulness of new technologies and surgical strategies to prevent it. CSF leak rate may vary from 4% in transsphenoidal procedures to 32% in posterior fossa craniotomies. In spinal surgery, CSF leak may be a consequence of elective intradural surgery, accounting for 18% of the procedures, or being a result of incidental durotomies, ranging from 1 to 17% in different surgical series. Dural closure's reinforcement using different new dural sealants plays an important role in preventing these events. Moreover, the use of neuronavigation systems in skull base and posterior fossa surgery can help to minimize the size of approach and reduce the incidence of CSF leak. New minimally invasive spinal approaches, such as minimally invasive decompression for spinal degenerative disorders or performing selective laminotomies over laminectomies for intradural spinal pathology are very useful techniques to prevent CSF leak in this kind of surgery. In conclusion, although CSF leak remains a risky complication in neurosurgery, its prevention and treatment significantly benefited from advances in biomaterials and surgical technique.

Petrosal Approach for Giant Retrochiasmatic Craniopharyngioma: 2-Dimensional Operative Video.

Microsurgical resection of craniopharyngiomas poses significant challenges, which are amplified with tumors in the retrochiasmatic location and larger size. Traditional pterional trans-sylvian, subfrontal translamia terminalis, or interhemispheric approaches provide narrow surgical corridors with obstructed visualization of the tumor by the prefixed chiasm and slit optic carotid window.1-5 The superior extension of the tumor compressing the hypothalamus and third ventricle are likewise inaccessible. Dissection through these approaches requires crossing and manipulation of the already compromised optic apparatus with surgical instruments. Finally, the basilar artery and its perforating branches are often adherent to the posterior aspect of the tumor, and are invisible. Endonasal endoscopic techniques have been utilized as a surgical approach that accesses the tumor without crossing the optic apparatus; however, these approaches have a significant risk of cerebrospinal fluid leakage and require dissection of the basilar artery and hypothalamus from long distances with lengthy instruments.6-9 Frequently, the surgeon achieves only partial removal. The petrosal approach is ideal for tumors in the retrochiasmatic location.10-13 Advantages include unhindered access to the retrochiasmatic space without crossing the optic nerve and chiasm. The angle of approach allows visualization superiorly to the hypothalamus. Additionally, the approach shortens the distance to the tumor, allowing for delicate bimanual dissection of the tumor, especially at the basilar artery and hypothalamic interfaces. This video demonstrates three cases of retrochiasmatic craniopharyngioma resection through the petrosal approach, highlighting these advantages to optimize patient outcome. The patients and guardians consented for the surgery, photography, and publication of the patient's image. Figures from Al-Mefty et al11 used with permission from the Journal of Neurosurgery Publishing Group. Additional figures republished from Al-Mefty et al.12 "The petrosal approach for the resection of retrochiasmatic craniopharyngiomas," Neurosurgery, 2008, volume 62, issue 5 Suppl 2 (ONS), ONS331-ONS336, by permission of the Congress of Neurological Surgeons.

Preliminary report of modified expansive laminoplasty in the treatment of thoracic ossification of the ligamentum flavum.

ObjectiveThis study was performed to evaluate the role of posterior suspension of the laminae–ossification of the ligamentum flavum complex combined with miniplate fixation (modified expansive thoracic laminoplasty) in treating thoracic ossification of the ligamentum flavum (TOLF).MethodsEight patients with TOLF treated by modified expansive thoracic laminoplasty were retrospectively analyzed. Their general information, operative time, intraoperative blood loss, and postoperative complications were recorded. Neurological functional recovery was evaluated by the modified Japanese Orthopaedic Association (mJOA) score and Hirabayashi recovery rate preoperatively, postoperatively, and at the final follow-up. Preoperative and postoperative imaging was performed, and the decompression range and internal fixation positioning were evaluated.ResultsThe mJOA score significantly improved from 4.63 points preoperatively to 9.0 points at the final follow-up (Hirabayashi recovery rate of 77.75%). Postoperative computed tomography and magnetic resonance imaging revealed sufficient decompression of the surgical segment. At the final follow-up, the internal implants were well-placed, the lamina–ligamentum flavum complex showed no significant displacement, and neurological functional recovery was satisfactory.ConclusionSurgical treatment of TOLF is complicated and high-risk. Characterized by simplicity and sufficient decompression, modified expansive thoracic laminoplasty can reduce the risk of cerebrospinal fluid leakage and nerve injury with satisfactory neurological functional recovery.

Chronic rhinosinusitis due to cyano-acrylic glue after endoscopic transsphenoidal pituitary surgery

BackgroundTo reduce the risk of cerebrospinal fluid leak, clinicians utilize a filling material placed in the sella followed by floor reconstruction with various materials, including glue sealing. Cyano-acrylic glue Glubran®2 glue is commercially available and is generally used as embolizing agent and for the prevention of cerebrospinal fluid leakage.Case DescriptionA 25-year-old woman underwent endoscopic endonasal transsphenoidal surgery for pituitary adenoma. After tumor resection, sellar floor reconstruction was performed by mucosal graft and Glubran®2 glue. The early post-operative period was uneventful. However, 2 months after surgery, the patient complained of headache, facial pain and greenish foul-smelling nasal discharge with solid particles dripping from the nose. Medical treatment was unsuccessful. Brain MRI showed inflammation and thickening of the sphenoidal and para-sphenoidal mucosa. The patient underwent endoscopic endonasal surgery and a solid glass-like mass surrounded by inflamed infected mucosa was seen in the inferior and lateral aspects of the sphenoid sinus. Efforts were made to erupt and de-crust the solid mass until total resection was achieved. Early post-operative period was uneventful, and a course of antibiotics was continued until total disappearance of the discharge.ConclusionTo the best of our knowledge, this is the first case reporting of acrylic glue (Glubran®2)-related sinusitis. Surgeon should be aware about similar side effects for the glue material that would complicate the surgery.

Giant calcified thoracic disk herniations: ossification of PLL or autonomous entity?

Giant calcified thoracic disk herniation (GCTD) is an uncommon event, which requires surgical treatment in less than 1% of patients. GCDTs are a specific subgroup of herniated thoracic disks occupying more than 40% of the spinal canal showing calcifications associated with a certain degree of ossification. In this paper, we are reporting our whole experience in the surgical management of GCTDs through anterior approaches. We believe that they present characteristics that associate them to the circumscribed type of ossified posterior longitudinal ligament (OPLL) with a possible common pathophysiology consisting in the dural violation. Twenty-three consecutive patients with GCDTs were managed through anterior approaches during the period 1996-2019 at the Niguarda Hospital, Milan, Italy. Clinical data, radiological features, surgical reports, histological findings, and outcomes were reviewed. There was no mortality, whereas permanent morbidity consisted of 1 case of worsened paraparesis due to accidental spinal cord contusion. One patient required reoperation to repair a postoperative cerebrospinal fluid (CSF) leakage. All patients underwent postoperative MRI which showed excellent decompression of cord and dural sac in all cases. Histological study of en-bloc removed GCTD showed typical calcification patterns of the PLL. GCDTs may be assimilated to the so-called "circumscribed type" of OPLL. The GCDTs may show the same radiological CT and MRI pattern of OPLL. The anterior accesses now represent the standard of care for GCTDs. The use of operative microscope and intraoperative monitoring is mandatory. The risk of CSF leakage can be markedly reduced by meticulous reconstruction of the dura and the placement of spinal drainage. Adequate exposition may sometimes require one or two levels of corpectomy with consequent vertebral body reconstruction and fixation of anterior column of the spine.

A Revised Surgical Approach to Induce Endolymphatic Hydrops in the Guinea Pig.

Endolymphatic hydrops is an enlargement of scala media that is most often associated with Meniere's disease, though the pathophysiologic mechanism(s) remain unclear. In order to adequately study the attributes of endolymphatic hydrops, such as the origins of low-frequency hearing loss, a reliable model is needed. The guinea pig is agood model because it hears in the low-frequency regions that are putatively affected by endolymphatic hydrops. Previous research has demonstrated that endolymphatic hydrops can be induced surgically via intradural or extradural approaches that involve drilling on the endolymphatic duct and sac. However, whether it was possible to create an endolymphatic hydrops model using an extradural approach that avoided dangerous drilling on the endolymphatic duct and sac was unknown. The objective of this study was to demonstrate a revised extradural approach to induce experimental endolymphatic hydrops at 30 days post-operatively by obliterating the endolymphatic sac and injuring the endolymphatic duct with a fine pick. The sample size consisted of seven guinea pigs. Functional measurements of hearing were made and temporal bones were subsequently harvested for histologic analysis. The approach had a success rate of 86% in achieving endolymphatic hydrops. The risk of cerebrospinal fluid leak was minimal. No perioperative deaths or injuries to the posterior semicircular canal occurred in the sample. The presented method demonstrates a safe and reliable way to induce endolymphatic hydrops at a relatively quick time point of 30 days. The clinical implications are that the presented method provides a reliable model to further explore the origins of low-frequency hearing loss that can be associated endolymphatic hydrops.