A modified supraclavicular approach to scalenotomy without first rib resection for the treatment of neurogenic thoracic outlet syndrome

Background: Current approaches to scalenectomy for brachial plexus decompression can cause nerve injuries in patients with neurogenic thoracic outlet syndrome (nTOS), especially when first rib resection (FRR) is performed. We describe a modified supraclavicular approach for scalenotomy that reduces the postoperative morbidity of nTOS patients. Methods: The patient is placed in supine position with the neck slightly extended and turned to the opposite side of the procedure. The modified incision begins above the clavicle 2.5 cm lateral to its first third, extends in medial direction, and turns upwards along the lateral edge of the sternocleidomastoid muscle (SCM) 2.5 cm from the clavicle. Skin flaps are elevated. The external jugular vein is dissected and retracted. The supraclavicular nerves and omohyoid muscle are conserved if found. The phrenic nerve is identified, dissected, and retracted. The anterior scalene muscle is divided, and the brachial plexus is freed. The clinical data and postoperative outcomes of patients that underwent surgery over the last three years were retrieved. The functionality of the arm after surgery was evaluated using the Disabilities of the Arm, Shoulder, and Hand questionnaire in Spanish (DASHe). Results: Sixteen nTOS patients received surgery with one bilateral procedure (17 procedures). Seventy-five percent were females with a median age of 53 years. Obesity and smoking were observed in 43.75% and 37.5% of patients, respectively. No postoperative complications occurred, except for one partial phrenic nerve palsy. All patients reduced their DASHe scores after surgery (mean reduction 41.09 ± 18.37). Conclusion: Our modified supraclavicular approach for scalenotomy is safe and improves outcomes in patients with nTOS, reducing the need for FRR

Management of complex brain lesions arising at sellar, petroclival, and interpeduncular regions via the pretemporal approach: Technical note

Background: Lesions of sellar, interpeduncular, and petroclival regions represent surgical challenges due to the spatial limitations imposed by the temporal lobe. The pretemporal approach is rarely advocated for this kind of lesions even when it offers a wider operative field than other traditional techniques. Case presentation: Here, we share our experience with the use of the pretemporal approach in a small case series: a giant meningioma of the tentorial notch (case 1), an aneurysm of the left posterior cerebral artery (case 2), and a giant pituitary adenoma (case 3). A frontotemporal incision was made with patients in supine position, their heads turned to the opposite side, and the malar eminence as their upper point. The skin flap and the temporal muscle were retracted anteriorly and inferiorly, respectively. The frontotemporosphenoidal craniotomy was performed and the lesser sphenoid wing removed. For cases 2 and 3, an orbitozygomatic craniotomy was added. After an S-shaped dura matter opening, the access to the interpeduncular fossa was through the sylvian fissure by careful dissection of adhesions between frontal and temporal lobes. Conclusions: On experienced hands, the pretemporal approach is a safe procedure for the management of lesions located in deep brain areas with low postoperative morbidity

A retrospective comparison of simultaneous and staged surgery for degenerative cervico-lumbar tandem spinal stenosis

Background: Cervical and lumbar tandem spinal stenosis (CLTSS) is a major cause of morbidity secondary to compressive degeneration of the spine. Currently, there is a paucity of studies objectively addressing the best management for this condition in terms of efficacy and cost-effectiveness. Hence, we aimed to conduct a side-by-side retrospective analysis of surgical outcomes, clinical improvement, and cost of care in non-Caucasian Hispanic patients with moderate-to-severe CLTSS subjected to simultaneous or staged cervical and lumbar spine surgery. Methods: Retrospective review of clinical records and postoperative outcomes of adult patients subjected to cervical and lumbar spine surgery either simultaneously or in stages. The surgical pattern was selected based on clinical studies, physical examination, and radiological findings, with monthly follow-up through objective clinical scores for at least six months after the last surgery. Results: Twelve patients received simultaneous cervical and lumbar spine surgery and six staged operations, both groups with comparable baseline comorbidities, manifestations, radiological findings, and receiving similar surgical procedures and postoperative management. Anterior cervical discectomy and fusion and transforaminal lumbar interbody fusion were the standard procedures performed in the cohort. Three patients in the staged-operation group received cervical decompression first. There were no differences between the groups' surgical outcomes, functional recovery, and complication rates. Nonetheless, the total cost of care was significantly lower in patients receiving simultaneous operation, while the clinical improvement was equivalent in both groups. Conclusions: Simultaneous and staged decompression offer similar outcomes for patients with CLTSS, but the one-staged combined surgery has a better cost- effectiveness profile