The presigmoid retrolabyrinthine approach: Technical note

BackgroundThe retrolabyrinthine approach is classified among the posterior petrosectomies. Its goal is to achieve an enlarged mastoidectomy while sparing the intrapetrous neurotologic structures in order to offer maximal exposure of the posterior cerebellopontine angle compound.MethodsThe stages of the procedure are subsequently the skeletonization of the sigmoid sinus, wide opening of the mastoid antrum and exposure of the semicircular canals. We present herein the technique, indications and limitations of the retrolabyrinthine approach.ConclusionThe retrolabyrinthine approach is a demanding technique. Nowadays the retrolabyrinthine approach is routinely combined to additional resections of the petrous bone, so-called “combined petrosectomies”, to target the jugular foramen or the petroclival area.     

Transdiscal instrumentation in single-level lumbosacral fusion for high-grade isthmic pediatric spondylolisthesis: Technical note and review of the literature

Pediatric spondylolisthesis is a common cause of back pain in children, typically managed conservatively with bracing and non-steroidal anti-inflammatory drugs. When posterolateral fusion is performed for refractory pain, pseudarthrosis and implant failure may occur, necessitating reoperation. To improve patient outcomes, there is a need for alternative surgical techniques to effectively manage high-grade isthmic slips. Here, the authors report the case of a child with Meyerding grade III anterolisthesis of L5 on S1 who was treated with a single-level, instrumented fusion using bilateral S1-L5 transdiscal screws, supported with L5-S1 posterolateral instrumentation and arthrodesis. Postoperatively, there was improvement in the patient's symptoms with good clinical and radiographic outcomes. The patient continues to be symptom free with radiographic evidence of hardware stability and bony fusion across the segment. The authors detail a novel surgical technique in children as well as a review of lumbosacral transdiscal screw fixation. Further evidence is required to definitively establish the safety, outcomes, and biomechanical strength of this technique.     

Use of Second Window ICG in spinal cord biopsy of a mildly contrast-enhancing lesion: Technical note and review of the literature

IntroductionIndocyanine green (ICG) is commonly used to visualize cerebral vasculature, particularly in the management of cerebral aneurysms. There have also been attempts to use ICG for visualization of tumors. Injection of ICG followed by immediate fluorescence microscopy is limited by the short time window for imaging and administration and restricted depth of imaging. Second Window Indocyanine Green (SWIG) addresses these issues by allowing for longer contrast times and the imaging of deeper regions of brain tissue. Biopsy of spinal cord lesions is often difficult for a variety of reasons, including the delicate nature of the tissue and differentiating normal from lesional tissue visually, especially in lesions with heterogeneous enhancement.MethodsIn this case report, we describe the use of second window ICG to facilitate the visualization of a spinal cord lesion and subsequent biopsy of the lesion.ResultsThis patient is a 24-year-old female who had recurrence of a suprasellar germinoma. An MRI of the rest of the neuraxis was performed to assess for the presence of drop metastases. The spinal cord from C2-5 was expanded with areas of patchy enhancement; however, this lesion was asymptomatic. The patient's oncologist requested a biopsy of this lesion to help direct subsequent care of her recurrent germinoma. The day before surgery, the patient had an intravenous injection of ICG dye. She then underwent a C3-5 laminectomy for biopsy of her cervical intramedullary lesion. After opening of the dura, no visible abnormality of the spinal cord could be identified. A Stryker endoscope showed an area of ICG uptake in the cord at approximately the C3-4 level. A midline myelotomy was centered over the ICG demarcated area and several samples were taken for pathology. Final biopsy results determined the lesion to be spinal cord parenchyma with perivascular and intraparenchymal lymphocytes – not consistent with spinal cord tumor or germinoma.ConclusionSecond Window ICG is effective in visualizing otherwise visually unremarkable spinal cord lesions. This technology can facilitate biopsy of these lesions and possibly their surgical resection.     

Ministernotomy compared with right anterior minithoracotomy for aortic valve surgery

ObjectivesMinisternotomy and right anterior minithoracotomy are the 2 main techniques applied for minimally invasive aortic valve replacement. The goal of this study is to compare early and long-term outcomes of both techniques.MethodsThe data of 2419 patients undergoing isolated minimally invasive aortic valve replacement between 1999 and 2019 were prospectively collected. Retrospectively, patients were divided into the ministernotomy group (n = 1352) and the minithoracotomy group (n = 1067).ResultsAfter propensity score matching, 986 patients remained in each group. Operation time and rate of conversion to full sternotomy were significantly higher in the minithoracotomy group than in the ministernotomy group (184.6 ± 45.2 vs 241.3 ± 68.6, relative risk, 2.54, P = .005 and .09 vs .23, relative risk, 1.45, P = .013, respectively). The 30-day mortality, excluding cardiac death, was lower in the ministernotomy group than in the minithoracotomy group (0.012 vs 0.028, relative risk, 1.41, P = .011, respectively); the intensive care unit length of stay (12.4 vs 16.5, relative risk, 1.62, P = .037, respectively) and hospital length of stay (5.4 vs 8.7, relative risk, 1.74 P = .028, respectively) were significantly longer in the minithoracotomy group. The minithoracotomy surgical approach was the strongest independent predictor of early mortality (odds ratio, 4.24 [1.67-7.35], P = .002). The actuarial survival by Kaplan–Meier analysis at 1, 3, 5, 10, and 20 years was significantly better in the ministernotomy group than in the minithoracotomy group (P = .0001). Actuarial freedom from reoperation at 5 years was 97.3% ± 4.4% in the ministernotomy group versus 95.8% ± 5.2% in the minithoracotomy group (P = .087).ConclusionsMinimally invasive aortic valve replacement using ministernotomy is associated with reduced operative time, intensive care unit stay, hospital length of stay, and postoperative morbidities and incisional pain, and improves early and long-term mortality.     

Radiomics for classification of bone mineral loss: A machine learning study

PurposeThe purpose of this study was to develop predictive models to classify osteoporosis, osteopenia and normal patients using radiomics and machine learning approaches.Materials and methodsA total of 147 patients were included in this retrospective single-center study. There were 12 men and 135 women with a mean age of 56.88 ± 10.6 (SD) years (range: 28–87 years). For each patient, seven regions including four lumbar and three femoral including trochanteric, intertrochanteric and neck were segmented on bone mineral densitometry images and 54 texture features were extracted from the regions. The performance of four feature selection methods, including classifier attribute evaluation (CLAE), one rule attribute evaluation (ORAE), gain ratio attribute evaluation (GRAE) and principal components analysis (PRCA) along with four classification methods, including random forest (RF), random committee (RC), K-nearest neighbor (KN) and logit-boost (LB) were evaluated. Four classification categories, including osteopenia vs. normal, osteoporosis vs. normal, osteopenia vs. osteoporosis and osteoporosis + osteopenia vs. osteoporosis were examined for the defined seven regions. The classification model performances were evaluated using the area under the receiver operator characteristic curve (AUC).ResultsThe AUC values ranged from 0.50 to 0.78. The combination of methods RF + CLAE, RF + ORAE and RC + ORAE yielded highest performance (AUC = 0.78) in discriminating between osteoporosis and normal state in the trochanteric region. The combinations of RF + PRCA and LB + PRCA had the highest performance (AUC = 0.76) in discriminating between osteoporosis and normal state in the neck region.ConclusionThe machine learning radiomic approach can be considered as a new method for bone mineral deficiency disease classification using bone mineral densitometry image features.     

Impact of dose reduction and the use of an advanced model-based iterative reconstruction algorithm on spectral performance of a dual-source CT system: A task-based image quality assessment

PurposeTo assess the impact of dose reduction and the use of an advanced modeled iterative reconstruction algorithm (ADMIRE) on image quality in low-energy monochromatic images from a dual-source dual energy computed tomography CT (DSCT) platform.Materials and methodsAcquisitions on an image-quality phantom were performed using DSCT equipment with 100/Sn150 kVp for four dose levels (CTDI_vol: 20/11/8/5mGy). Raw data were reconstructed for six energy levels (40/50/60/70/80/100 keV) using filtered back projection and two levels of ADMIRE (A3/A5). Noise power spectrum (NPS) and task-based transfer function (TTF) were calculated on virtual monoenergetic images (VMIs). Detectability index (d′) was computed to model the detection task of two enhanced iodine lesions as function of keV.ResultsNoise-magnitude was significantly reduced between 40 to 70 keV by ?56 ± 0% (SD) (range: ?56%–?55%) with FBP; ?56 ± 0% (SD) (?56%–?56%) with A3; and ?57 ± 1% (SD) (range: ?57%–?56%) with A5. The average spatial frequency of the NPS peaked at 70 keV and decreased as ADMIRE level increased. TTF values at 50% were greatest at 40 keV and shifted towards lower frequencies as the keV increased. The detectability of both lesions increased with increasing dose level and ADMIRE level. For the simulated lesion with iodine at 2 mg/mL, d’ values peaked at 70 keV for all reconstruction types, except for A3 at 20 mGy and A5 at 11 and 20 mGy, where d’ peaked at 60 keV. For the other simulated lesion, d’ values were highest at 40 keV and decreased beyond.ConclusionAt low keV on VMIs, this study confirms that iterative reconstruction reduces the noise magnitude, improves the spatial resolution and increases the detectability of enhanced iodine lesions.     

Clinical application and outcomes of reconstructive microsurgery in Africa: A systematic review and meta-analysis

BackgroundReconstructive microsurgical free flap techniques are often the treatment of choice for a variety of complex tissue defects across multiple surgical specialties. However, the practice is underdeveloped in low- and middle-income countries. The aim of this systematic review was to evaluate the clinical application and outcomes of reconstructive microsurgery performed in Africa.MethodsSeven databases (PubMed, Web of Science, MEDLINE, CINAHL, Academic Search Complete, Embase, and Google Scholar) were searched for studies reporting microsurgical procedures performed in Africa. The risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal Tools and quality of evidence using the GRADE approach. Meta-analysis was performed using a random effects model to estimate the pooled proportion of events with 95% confidence intervals. The primary outcome was free flap success rate, and the secondary outcomes were the complication and flap salvage rates.ResultsNinety-two studies were included in the narrative synthesis and nine in the pooled meta-analysis. In total, 1376 free flaps in 1327 patients from 1976 to 2020 were analyzed. Head and neck oncologic reconstruction made up 30% of cases, while breast reconstruction comprised 2%. The pooled flap survival rate was 89% (95% CI: 0.84, 0.93), complication rate 51% (95% CI: 0.36, 0.65), and free flap salvage rate was 45% (95% CI: 0.08, 0.84).ConclusionThis meta-analysis showed that the free flap success rates in Africa are high and comparable to those reported in high-income countries. However, the comparatively higher complication rate and lower salvage rate suggest a need for improved perioperative care.Review registrationRegistered with the International Prospective Register of Systematic Reviews (PROSPERO) on 25th September 2020, ID: CRD42020192344.     

A new oncoplastic technique with immediate nipple reconstruction for central breast tumors using Würinger's septum-based flap

IntroductionCentrally located breast tumors represent a challenge for both oncological and reconstructive surgeons, mainly due to the necessity of nipple-areola complex (NAC) removal. We describe an original oncoplastic solution utilizing a displacement flap technique with immediate nipple reconstruction.MethodsSince 2008, we developed an oncoplastic technique using a septum-based island flap for the reconstruction of central breast defects, including the NAC. This technique is based on the Würinger's septum which is centered around the intercostal perforators. A retrospective study was performed collecting data on patient characteristics, oncological features, and outcomes. Patient satisfaction was reported using a Likert scale.ResultsReconstruction was successfully realized in 15 patients (14 immediate and one delayed post-lumpectomy correction). In immediate surgery, the excision margins were all free of tumor. Minor complications occurred in three patients; one small area of skin necrosis was managed by secondary intention, and two cases of partial nipple necrosis were treated by debridement under local anesthesia. Contralateral symmetrization surgery was performed on nine patients. Patient satisfaction scored high.ConclusionIn comparison with the previous oncoplastic techniques used for reconstructing central defects, the septum-based island flap has increased flexibility, provides better projection, and can be combined with immediate NAC reconstruction.     

Acute intracranial hypertension management in metastatic brain tumor: A French national survey

BackgroundBrain metastases occur in 15–30% of cancer patients and their frequency has increased over time. They can cause intracranial hypertension, even in the absence of hydrocephalus. Emergency surgical management of brain metastasis-related intracranial hypertension is not guided by specific recommendations.ObjectiveWe aimed to make a French national survey of emergency management of intracranial hypertension without hydrocephalus in the context of cerebral metastasis.MethodsA national online survey of French neurosurgeons from 16 centers was conducted, consisting of three clinical files, with multiple-choice questions on diagnostic and therapeutic management in different emergency situations.ResultsIn young patients without any previously known primary cancer, acute intracranial hypertension due to a seemingly metastatic single brain tumor indicated emergency surgery for all those interviewed; 61% aimed at complete resection; brain MRI was mandatory for 74%. When a primary cancer was known, 74% of respondents were more likely to propose surgery if an oncologist confirmed the possibility of adjuvant treatment; 27% were more likely to operate on an emergency basis when resection was scheduled after multi-disciplinary discussion, prior to acute degradation.ConclusionCurrently, there is no consensus on the emergency management of intracranial hypertension in metastatic brain tumor patients. In case of previously known primary cancer, a discussion with the oncology team seems necessary, even in emergency. Decision criteria emerge from our literature review, but require analysis in further studies.     

Outcomes and technical issues of transcorporeal anterior cervical microforaminotomy in patients with cervical brachialgia

IntroductionTranscorporeal anterior cervical microforaminotomy is a motion-preserving surgery. It addresses directly to the prolapsed disc in contrast to posterior laminoforaminotomy and does not affect facet joints; in the transuncal approach, there is a chance of vertebral artery injury and it also decreases disc height; hence, may alter the motion of that segment.ObjectiveAim is to assess the outcome of surgery and its effectiveness.MethodsA total of 40 patients were observed retrospectively of which 33 were male and 7 were female. A single study of transcorporeal anterior cervical microforaminotomy was analyzed in a private hospital (Comfort Hospital), Dhaka, Bangladesh. Patients having pure brachialgia who were not relieved by conservative treatment over 6–8 weeks in cervical disc prolapse were included in the study. Patients having more than one level of disease, features of myelopathy, or instability were excluded from the study.ResultsAll patients were pain-free postoperatively, although after one to two months 2 out of 40 patients developed brachialgia and required anterior cervical discectomy and fusion.ConclusionTranscorporeal microforaminotomy for brachialgia is a safe and effective approach that is motion preserving and minimally invasive as well.     

Prospective assessment of reproducibility of three-dimensional ultrasound for fetal biometry

PurposeTo compare fetal ultrasound measurements performed by two observers with different levels of experience and evaluate the potential contribution of the use of three-dimensional (3D) ultrasound on repeatability, reproducibility and agreement of two-dimensional (2D) and 3D-derived measurements.Materials and methodsTwo observers (one senior and one junior) measured head circumference (HC), abdominal circumference (AC) and femur length (FL) in 33 fetuses (20 to 40 weeks of gestation). Each observer performed two series of 2D measurements and two series of 3D measurements (i.e., measurements derived from triplane volume processing). Measurements were converted into Z-scores according to gestational age. Variability between the different series of measurements was studied using Bland–Altmann plots and intra-class correlation coefficients (ICC).ResultsAgreement with the 2D measurements of the senior observer was higher in 3D than in 2D for the junior observer (systematic differences of −0.4, −0.2 and −0.8 Z-score vs. −0.1, −0.1 and −0.6 for HC, AC and FL on 2D and 3D datasets, respectively). The use of 3D ultrasound improved junior observer repeatability (ICC = 0.94, 0.88, 0.90 vs. 0.94, 0.94 and 0.96 for HC, AC and FL in 2D and 3D, respectively). The reproducibility was greater using the junior observer 3D datasets (ICC = 0.75, 0.60 and 0.45 vs. 0.79, 0.89 and 0.63 for HC, AC and FL, respectively).ConclusionThe use of 3D ultrasound improves the consistency of the measurements performed by a junior observer and increases the overall repeatability and reproducibility of measurements performed by observers with different levels of experience.     

The anterior talofibular ligament: A thin-slice three-dimensional magnetic resonance imaging study

PurposeThe aim of this study was to provide an accurate and improved understanding of anterior talofibular ligament (ATFL) anatomy, and to determine the exact positioning and diameter of the bony tunnel during ATFL repair and/or reconstruction surgery.MethodA total of 58 healthy asymptomatic volunteers were examined, wherein 38 underwent bilateral ankle 3D MRI, and 20 underwent unilateral ankle 3D MRI (10 left and 10 right ankles). Data from a total of 96 MRI datasets were collected. The MRI data from these cases were exported into Mimics to enable reconstruction of 3D ATFL models. The resulting image quality was evaluated using a 5-point subjective scoring system. In addition, the length, width, thickness, and positioning of each ATFL and the area of the ATFL footprints were identified within the 3D model using Mimics and SolidWorks.ResultsThe image quality score was 4.48 ± 0.50. The ATFL formed one (65.6%), two (31.3%), or three (3.1%) bundles forms. The footprint area was 31.25 ± 6.29 mm² on the fibular side, and 17.48 ± 4.49 mm² on the talar side.ConclusionThin-slice 3D MRI aids in the reconstruction of the 3D ATFL model, and it provides reference for the accurate anatomy of the area and location of the ATFL. This technology will facilitate diagnosis of ATFL injuries and choice of surgical methods.Level of Evidencelevel IV.     

Complications of percutaneous image-guided screw fixation: An analysis of 94 consecutive patients

PurposeThe purpose of this study was to retrospectively assess the safety profile of percutaneous image-guided screw fixation (PIGSF) for insufficiency, impending or pathological fractures.Materials and methodsFrom July 2012 to April 2020, all consecutive patients who underwent PIGSF were retrospectively included in the study. Patient characteristics, fracture type, procedural data and complications were analyzed. Complications were divided into per-procedural, early (< 24 hours) and delayed (> 24 hours) and classified into minor (grade 1-2) and major complications (grade 3-5) according to Common Terminology Criteria for Adverse Events (CTCAE) v5.0.ResultsA total of 110 fractures (40 insufficiency [36%], 53 pathological [48.5%] and 17 impending [15.5%] fractures) in 94 patients (48 women, 46 men; mean age, 62.7 ± 12.7 [SD] years; age range: 32–88 years) were treated with PIGSF during 95 procedures. Twenty-four-hours follow-up was available for all patients, and > 24-hours follow-up was available for 79 (79/110; 71.8%) fractures in 69 (69/94; 73.4%) patients. Per-procedural complications occurred in 3/110 fractures (2.7%, all minor). Early complications were reported in 4/110 fractures (3.6%, 1 major and 3 minor) and delayed ones in 14/79 fractures (17.7%, 5 major and 9 minor). The most frequent major delayed complication was infection (3/79; 3.8%).ConclusionThe rate of per-procedural and early (within 24 hours) complications following PIGSF is extremely low with most complications being minor, with major complications being delayed ones (> 24 hours).     

Is anterior mitral valve leaflet length important in outcome of septal myectomy for obstructive hypertrophic cardiomyopathy?

ObjectivesElongation of mitral valve leaflets is a phenotypic feature of hypertrophic cardiomyopathy, and some surgeons advocate plication of the anterior leaflet at the time of septal myectomy. The present study investigates mitral valve leaflet length and outcomes of patients undergoing septal myectomy for obstructive hypertrophic cardiomyopathy.MethodsWe reviewed the records and echocardiograms of 564 patients who underwent transaortic septal myectomy for obstructive hypertrophic cardiomyopathy between February 2015 and April 2018. Extended septal myectomy without plication of the anterior leaflet was the standard procedure. From intraoperative prebypass transesophageal echocardiograms, we measured anterior and posterior mitral valve leaflets and their coaptation length. For comparison, we performed these mitral valve leaflet measurements in 90 patients who underwent isolated coronary artery bypass grafting and 92 patients undergoing aortic valve replacement in the same period. Among patients with hypertrophic cardiomyopathy undergoing septal myectomy, we assessed left ventricular outflow tract gradient relief and 1-year survival in relation to leaflet length.ResultsMedian patient age (interquartile range) was 60.3 (50.2-67.7) years, and 54.1% were male. Concomitant mitral valve repair was performed in 36 patients (6.4%), and mitral valve replacement was performed in 8 patients (1.4%), primarily for intrinsic mitral valve disease. Patients in the hypertrophic cardiomyopathy cohort had significantly longer mitral valve leaflet measurements compared with patients undergoing coronary artery bypass grafting or aortic valve replacement (P < .001 for all 3 measurements). Preoperative resting left ventricular outflow tract gradients were not related to leaflet length (<30 mm, median 49 [21, 81.5] mm Hg vs ≥30 mm, 50.5 [21, 77] mm Hg; P = .76). Further, gradient reduction after myectomy was not related to leaflet length; patients with less than 30 mm anterior leaflet length had a median gradient reduction of 33 (69, 6) mm Hg compared with 36.5 (62, 6) mm Hg for patients with leaflet length 30 mm or more (P = .36). Anterior mitral valve leaflet length was not associated with increased 1-year mortality (P = .758).ConclusionsOur study confirms previous findings that patients with hypertrophic cardiomyopathy have slight (5 mm) elongation of mitral valve leaflets. In contrast to other reports, increased anterior mitral valve leaflet length was not associated with higher left ventricular outflow tract gradients. Importantly, we found no significant relationship between anterior mitral valve leaflet length and postoperative left ventricular outflow tract resting gradients or gradient relief. Thus, in the absence of intrinsic mitral valve disease, transaortic septal myectomy with focus on extending the excision beyond the point of septal contact is sufficient for almost all patients.     

Awake spinal anesthesia facilitates spine surgery in poor surgical candidates: A case series

BackgroundAnnually, hundreds of thousands of patients undergo surgery for degenerative spine disease (DSD). This represents only a fraction of patients that present for surgical consideration. Procedures are often avoided due to comorbidities that make patients poor candidates for general anesthesia (GA) and its associated risks. With increasing interest in awake surgery under spinal anesthesia (SA), the authors have observed that SA may facilitate spine surgery in patients with relative contraindications to GA. With this in mind, the authors set out to summarize the outcomes of a series of highly comorbid patients who received surgery under SA.MethodsCase logs of a single surgeon were reviewed, and patients undergoing spine surgery under SA were identified. Within this group, patients were identified with relative contraindications to GA, such as advanced age and medical comorbidities. For these patients, for whom surgery was facilitated by SA, the medical records were consulted to report demographic information and patient outcomes.ResultsTen highly comorbid patients were identified who received lumbar spine surgery for DSD under SA. Comorbidities included octogenarian status, obesity, and chronic health conditions such as heart disease. The cohort had a mean age of 75.5 and a mean American Society of Anesthesiologists Physical Status (ASA-PS) score of 3.1. The patients were predicted to have a 2.74-fold increase of serious complications compared to the average patient. There were no adverse events.ConclusionFor patients with symptomatic, refractory DSD and relative contraindications to GA, SA may facilitate safe surgical intervention with excellent outcomes.     

Threshold for lateral meniscal body extrusion on MRI in middle-aged and elderly patients with symptomatic knee osteoarthritis

PurposeTo determine the MRI-based threshold of lateral meniscal body extrusion (LMBE) that are associated with meniscal damage, cartilage damage and radiological knee osteoarthritis (OA).Materials and methodsA total of 142 patients (59 men and 83 women) with a mean age of 57.2 ± 7.9 (SD) years (range: 41–77 years) with symptomatic knee OA were included. Radiological assessment was performed using the Kellgren-Lawrence scoring system. Meniscus and cartilage damage were assessed using the whole-organ magnetic resonance imaging score. Meniscal extrusion was quantified on coronal sections of intermediate-weighted MRI sequences. Differences between medial and lateral compartments in meniscal extrusion and incidence of tibiofemoral OA-related structural changes were assessed using Wilcoxon signed rank test and Bowker test. Receiver operating characteristic curves and Youden index were used for determining thresholds for meniscal extrusion.ResultsA total of 142 knees were assessed. Meniscal body extrusion distances between medial and lateral compartments were significantly different in the entire sample, and in subjects with and without radiological knee OA (P < 0.05 for all). The incidence of structural changes between medial and lateral compartments were significantly different (P = 0.003 for meniscal damage; P = 0.001 for femoral cartilage damage). Three mm and 2 mm were determined to be the optimal thresholds for medial and lateral meniscal body extrusion, respectively.ConclusionMedial and lateral meniscal body extrusion were associated with the incidence of OA-related knee structural changes in symptomatic patients with knee OA. A threshold of 2 mm for LMBE with respect to meniscal damage, cartilage damage and radiological knee OA was determined.