Lumbar Endoscopic Microdiscectomy:Where Are We Now? An Updated Literature Review Focused on Clinical Outcome, Complications, and Rate of Recurrence

Endoscopic disc surgery (EDS) for lumbar spine disc herniation is a well-known but developing field, which is increasingly spreading in the last few years. Rate of recurrence/residual, complications, and outcomes, in comparison with standard microdiscectomy (MD), is still debated and need further data. We performed an extensive review based on the last 6 years of surgical series, systematic reviews, and meta-analyses reported in international, English-written literature. Articles regarding patients treated through endoscopic transforaminal or interlaminar approaches for microdiscectomy (MD) were included in the present review. Papers focused on endoscopic surgery for other spinal diseases were not included. From July 2009 to July 2015, we identified 51 surgical series, 5 systematic reviews, and one meta-analysis reported. In lumbar EDS, rate of complications, length of hospital staying, return to daily activities, and overall patients’ satisfaction seem comparable to standard MD. Rate of recurrence/residual seems higher in EDS, although data are nonhomogeneous among different series. Surgical indication and experience of the performing surgeon are crucial factors affecting the outcome. There is growing but still weak evidence that lumbar EDS is a valid and safe alternative to standard open microdiscectomy. Statistically reliable data obtained from randomized controlled trials (better if multicentric) are desirable to further confirm these results

Cavernous Malformations: Genetics Molecular Biology and Familial Forms

Cavernous malformations are compact lesions composed of sinusoidal vascular channels that resemble dilated capillaries. They are found throughout the central nervous system with an estimated incidence in the general population of about 0.4%. Cavernous malformations occur as a sporadic form in which lesions tend to be solitary and as a familial form characterized by multiple lesions and a strong family history of seizures. The familial forms of this disease are inherited in an autosomal dominant mode. Genetic studies have identified three distinct loci associated with the familial forms of this disease - which have been termed cerebral cavernous malformations (CCM): CCM1 located on the long arm of chromosome 7 (7q21 to 7q22), CCM2 on the short arm of chromosome 7 (7p13-p15), and CCM3 on the long arm of chromosome 3 (3q25 to 3q27). In the CCM population, 40% of families link to CCM1, 20% to CCM2, and 40% to CCM3. Further analysis has demonstrated that mutations in the KRIT1 gene are responsible for CCM1. KRIT1 is a binding protein that interacts with Krev-1/rap1a, a member of the Ras family of GTPases with tumor-suppressing activity for the Ras oncogenes. These findings, along with the evidence from magnetic resonance imaging (MRI) studies that the de novo appearance of new lesions is relatively common, suggest that cavernous malformations should be reclassified as benign vascular tumors. 2002, Elsevier Science (USA). All rights reserved

Anterolateral approach to the craniocervical junction

Abstract OBJECT: The authors present the surgical results obtained using the anterolateral approach to the craniocervical junction (CCJ) to resect a lesion with an extradural component located anterolateral to the foramen magnum and upper cervical spine. METHODS: The anterolateral approach, which is a presternomastoid retrojugular route to the CCJ, was performed in 14 patients. The skin incision follows the anterior edge of the sternomastoid muscle. The vertebral artery (VA) was exposed at C-1. This approach was extended either down to the cervical spine or anteriorly to the jugular foramen, according to specific requirements. Two patients had previously undergone other surgical procedures. The follow-up period ranged from 4 months to 6.2 years. The tumor resection was complete in 11 cases and subtotal in two. In a case of vertebral coiling, a vein graft was interposed between the V1 and the V3 segments of the VA, and the bypass was still patent at the 2-year follow-up examination. In two cases involving a glomus tumor, there was a transitory postoperative seventh cranial nerve deficit. CONCLUSIONS: The aforementioned technique allows for sufficient access to lesions located anterolateral to the CCJ. It is indicated in cases in which lesions exhibit a significant extradural component, and it provides good control of the VA, the cervical portion of the internal carotid artery, sigmoid-jugular complex, and lower cranial nerves. This approach can easily be combined with a posterolateral approach and can be extended anteriorly toward the jugular foramen and inferiorly toward the lower cervical spine

Intracranial Extra-axial Cavernous Angioma of the Cerebellar Falx

INTRODUCTION: Intracranial cavernous hemangiomas are benign vascular malformations that can be divided into intra-axial and extra-axial types. Extra-axial cavernous angiomas (or hemangiomas) are rare lesions; intracranially, they arise in relation to the dura mater or at a spinal level mimicking meningiomas. They are very rarely reported in the posterior cranial fossa. CASE REPORT: The authors report a case of a cavernous angioma that occurred in the cerebellar falx of a 58-year-old man. The lesion was discovered during cranial computed tomography (CT) and magnetic resonance imaging (MRI) examinations. The patient underwent surgery with en-bloc removal of the tumor. No significant intraoperative bleeding or complications occurred during the postoperative course. CONCLUSION: Intra-axial and extra-axial cavernous angiomas are histopathologically identical lesions, but by the radiological features, it is very difficult to distinguish the extra-axial cavernous angiomas from meningiomas, especially when dural tail sign and calcification are present

Spinal arachnoiditis ossificans: Report of three cases

Although the clinical and histological features of the pathological entity of spinal arachnoiditis ossificans (AO) have been established for some time, less attention has been paid to the treatment. We propose a classification of spinal AO evaluating the possibilities and indications for surgical or conservative treatment. Type III has a lumbar localization, presents with less neurological involvement, and usually requires conservative treatment. In Types I and II, which are usually thoracic, clinical worsening justifies surgical decompression or partial removal, whereas total removal is rarely achievable. The literature was reviewed, and the reports on three patients were added to the published cases. On the basis of a reappraisal of the computed tomographic and magnetic resonance imaging documentation and the surgical descriptions, the cases of AO were classified into three types: semicircular (Type I), circular (Type II), and englobing the caudal fibers (Type III). The indications for treatment were evaluated in terms of surgical possibilities and outcome

Assessment of the utility of the 2-μ thulium laser in surgical removal of intracranial meningiomas

Background and Objective Since the 1960s, lasers have been used in neurosurgery for surgical removal of intracranial tumors. Because of its limited penetration (2mm) through tissues and its wavelength, which is useful in water medium, the 2-mu thulium laser has been applied primarily in urology. Its features are attractive for application under microscope magnification during neurosurgical procedures. The aim of this study was to evaluate the usefulness of the 2-mu thulium laser during microsurgical removal of intracranial meningiomas. Materials and Methods Twenty patients with a diagnosis of intracranial meningiomas were treated with surgical intervention using a 2-mu thulium laser together with bipolar forceps, cavitron ultrasonic surgical aspirator (CUSA) and traditional microdissection instruments. Surgical removal was divided in four phases: (1) dissection from the external structures; (2) coagulation and debulking; (3) dissection from the deep structures; and (4) coagulation and removal of the basal implant. During all these steps, we evaluated the percentage of usage of the 2-mu thulium laser comparing them with bipolar forceps and ultrasonic aspirator and blunt dissection. Results Thulium laser was used mainly during phases 2 and 4 for 43% and 48.7% of the total removal, respectively. Although also useful during phases 1 and 3, it was only used for 2.2% and 31.3%, respectively: traditional dissection with scissors and forceps was preferred. Conclusions Thulium laser seems to be a useful aid in the surgery of intracranial meningiomas, especially to debulk, shrink, and coagulate the mass and the basal implant. Lasers Surg. Med. 45: 148154, 2013. (c) 2013 Wiley Periodicals, Inc