Optic Nerve Decompression through a Supraorbital Approach

Objective We propose a stepwise decompression of the optic nerve (ON) through a supraorbital minicraniotomy and describe the surgical anatomy of the ON as seen through this approach. We also discuss the clinical applications of this approach. Methods Supraorbital approaches were performed on 10 preserved cadaveric heads (20 sides). First, 3.5-cm skin incisions were made along the supraciliary arch from the medial third of the orbit and extended laterally. A 2 × 3-cm bone flap was fashioned and extradural dissections were completed. A 180-degree unroofing of the ON was achieved, and the length and width of the proximal and distal portions of the optic canal (OC) were measured. Results The supraorbital minicraniotomy allowed for identification of the anterior clinoid process and other surgical landmarks and adequate drilling of the roof of the OC with a comfortable working angle. A 25-degree contralateral head rotation facilitated visualization of the ON. Conclusion The supraorbital approach is a minimally invasive and cosmetically favorable alternative to more extended approaches with longer operative times used for the management of ON decompression in posttraumatic or compressive optic neuropathy from skull base pathologies extending into the OC. The relative ease of this approach provides a relatively short learning curve for developing neurosurgeons.     

Respective Indications for Orbital Rim, Zygomatic Arch and Orbito-Zygomatic Osteotomies in the Surgical Approach to Central Skull Base Lesions. Critical, Retrospective Review in 146 Cases

BACKGROUND: Orbital Rim (ORo) Zygomatic Arch (ZAo) and Orbito-Zygomatic (OZo) osteotomies can be useful adjuncts to the classical Fronto-Pteriono-Temporal craniotomy in facilitating the exposure of deep seated skull base lesions, sparing brain retraction injuries. Based on a review of 146 "operated" cases, the authors suggest their guidelines for patient selection for each of these osteotomies. METHOD: 146 lesions (100 central skull base tumors, 29 deep vascular lesions and 17 mesial temporal epileptogenic foci) were surgically treated by the senior author between 1988-1999 using ORo (59 cases), ZAo (12 cases) and OZo (75 cases). The lesion were radically cured in 85% of the cases. A retrospective critical analysis of patients' records by an independent observer evaluated: 1)--the usefulness and the appropriateness of the performed osteotomy for obtaining an optimal approach to the lesion and 2)--morbidity related to the osteotomy and to brain retraction. FINDINGS: In only one case, the osteotomy (ORo) was found not to be useful. An other 17 patients who underwent OZo would have benefited from a reduced osteotomy (ORo in 15 cases, ZAo in 2 cases). In another case an ORo was found insufficient for an effective exposure of the lesion. Osteotomy-related morbidity rate was 10.2% (15 patients), mostly due to transient Temporo Mandibular Joint dysfunction. In spite of an appropriate approach, 12 patients (8.2%) showed neurological deficits (temporary) and/or CT manifestations attributable to brain retraction. INTERPRETATION: The additional osteotomies were found useful and relatively safe in facilitating the exposure of most of the lesions in this series. A target (rather than pathology) and surgical axis oriented list of indications for ORo, ZAo and OZo is given.     

Minilaparotomy Approach for the Resection of Laterally Spreading Tumors of the Colon

Purpose We report our experience of using the minimally invasive minilaparotomy approach to resect colonic laterally spreading tumors (LSTs) that could not be removed by colonoscopic snare polypectomy.Methods We prospectively examined 17 patients who underwent a minilaparotomy, defined as an incision less than 7cm long, between 1997 and 2001, for a collective 19 colonic LSTs.Results Complete en bloc resection of the LSTs was successfully performed in all 17 patients. The resections included colotomy and polypectomy in four patients (four LSTs), limited colectomy in seven patients (nine LSTs), and colectomy with regional lymph node dissection in six patients (six LSTs). There was no mortality or morbidity. The mean ± standard deviation (SD) length of the minilaparotomy was 6.7 (±0.8) cm, and the mean (±SD) operating time and blood loss were 139 (±39) min and 27 (±15) ml, respectively. Histology revealed 2 adenomas, 16 Tis carcinomas, and 1 T1 carcinoma. None of the patients had lymph node metastasis or positive resection margins. There have been no signs of tumor recurrence after a median follow-up period of 30.4 months.Conclusions The minilaparotomy approach is appropriate for resecting LSTs that cannot be removed by colonoscopic snare polypectomy, and provides a minimally invasive alternative to conventional laparotomy.     

Resection of Inferior Pubic Ramus Tumors through a Femoribus Internus–Perineal Approach

An operative approach to the inferior pubic ramus that was utilized in four patients with various bone tumors in the inferior pubic ramus is described here. These patients were successfully managed though a femoribus internus (inner thigh)–perineal approach. Data concerning preoperative and postoperative symptoms, surgical procedures, and outcomes are presented. There was no recurrence in the four cases and the pain associated with an initial pelvic floor had completely resolved except one case. The slight limitation in range of motion of the left hip joint and pain were performed in the same case postoperatively. The Musculoskeletal Tumor Society scores were 28, 15, 25, and 18 at the final follow‐up. A typical case is described in full and our experience concerning surgical indications, and intraoperative issues in tumor patients discussed. The purpose of this paper is to recommend that the femoribus internus–perineal approach be used to resect the inferior pubic ramus, whether affected by osteomyelitis, bone tumor, or tuberculosis, but especially in patients with tumors.     

Transsacral Approach to Resect a Gastrointestinal Stromal Tumor in the Rectum: Report of Two Cases

Gastrointestinal stromal tumors (GISTs) rarely arise in the rectum. Whereas a local resection with negative margins is generally considered adequate for resectable GISTs, a wide resection is usually indicated for rectal lesions because of the technical impossibility of local resection. We report the cases of two patients who underwent resection of a rectal GIST using a transsacral approach. Both patients had an uneventful postoperative course, and no evidence of recurrence has been identified. The transsacral approach appears to be less invasive and should be considered as the treatment of choice for a rectal GIST.     

Piezoelectric tools versus traditional oscillating saw for distal linear osteotomy in hallux valgus correction: Triple-blinded,randomized controlled study

BackgroundThe main goal of the surgical correction of the hallux valgus is the morphological correction associated with the functional rebalancing of the first ray. The aim of this triple-blinded, randomized controlled study was to show the efficacy of piezosurgery in performing distal linear osteotomy of the first metatarsal bone in HV correction, in terms of clinical and radiological outcomes at 1-year final follow up.Methods and materialsThis study was performed collecting prospectively pre-operative and post-operative data for all patients. 34 patients were included in the trial and were randomly allocated (1:1) in a Piezoelectric Group (PG) that involved the use of piezoelectric tools and in a Control Group (CG) that provided for the use of a traditional oscillating saw. In both groups, all patients were treated with a distal linear osteotomy of the first metatarsal bone. Clinical and radiographic assessments were performed.ResultsThe AOFAS score between the two groups was similar pre-operatively and during the follow-up period, with a slight superiority in the PG at each evaluation. The osteotomy surgical time was registered for both groups. Among the endpoints of the study, the radiological bone healing time was independently assessed by a radiologist that reported a lower mean value in the piezoelectric group compared with the control group.ConclusionsThis trial has shown that piezoelectric surgery is not inferior to traditional methods from the clinical-functional point of view, but can even lead to an evident reduction of bone healing time with a statistical significance.Level of evidenceLevel I.     

Modified oblique high tibial osteotomy with minimal fixation for correction of adolescent tibia vara: a prospective case series study

PurposeTo assess the reliability and efficacy of the modified oblique high tibial osteotomy for correction of complex deformity in adolescent tibia vara.MethodsA total of 19 patients (25 legs) with adolescent tibia vara were enrolled in this study. There were 16 male (84.2%) and three female (15.8%) patients who had modified Rab oblique osteotomy with minimal fixation performed. The age of the patients at time of surgery ranged from 12 years to 30 years (mean 17.23 (sd 5.27)). The body mass index ranged from 22 kg/m² to 42 kg/m² (mean 32.05 (sd 6.13)). All patients were followed up for over two years (mean 3.4; 2 to 5).ResultsThe femoro-tibial angle was improved from -34° to -12° (mean -20.04° (sd 5.24°) preoperatively and from -12° to 7°, postoperatively (mean 2.04° (sd 4.07)). Medial deviation of the mechanical axis corrected from 38 mm to 125 mm (mean 76.13 (sd 23.29)) preoperatively to 0 mm to 36 mm (mean 5.74 (sd 7.3)) postoperatively. The time needed to achieve union ranged from eight weeks to 16 weeks (mean 10.2 (sd 2.42)). According to the Lysholm functional knee score scale, there were 15 excellent (78.9%), two good (10.5%), one fair (5.2%) and one poor (5.2%) after correction of the deformity.ConclusionModified Rab osteotomy with minimal fixation by two or three screws shows promising results with good correction of varus deformity (coronal plane), internal torsion (axial plane) and procurvatum (sagittal plane), in management of adolescent tibia vara with minimal morbidity and complications.Level of evidenceIV     

经尺骨鹰嘴截骨入路与肱三头肌舌状瓣入路治疗肱骨髁间骨折的对比研究

目的对比经尺骨鹰嘴截骨入路与经肱三头肌舌状瓣入路治疗肱骨髁间骨折的临床效果。方法 2002年5月至2009年2月,手术切开复位内固定治疗62例肱骨髁间骨折患者。其中33例采用尺骨鹰嘴入路。按Riseborough-Radin分型,Ⅲ型18例,Ⅳ型15例。29例采用肱三头肌舌状瓣入路。左侧16例,右侧13例。按Riseborough-Radin分型,Ⅲ型18例,Ⅳ型11例。比较两组手术时间、出血量、术后并发症及愈合时间等,用Mayo评分来评价术后肘关节功能的改善程度。结果术后随访12～36个月,平均16.7个月。所有患者切口均Ⅰ期愈合。手术时间、出血量及愈合时间两组比较差异无统计学意义。术后尺骨鹰嘴截骨入路组肘部疼痛发生率低于肱三头肌舌状瓣入路组,肘关节活动度。采用尺骨鹰嘴入路组（优良率为87.88%）优于采用肱三头肌舌状瓣入路组（优良率为65.51%）。结论采用尺骨鹰嘴入路组的术后并发症的发生率少于采用肱三头肌舌状瓣入路组,术后肘关节活动度的满意率高于采用肱三头肌舌状瓣入路组采用肱三头肌舌状瓣入路组。     

A “Two‐incision” Approach for En Bloc Resection of Periacetabular Tumors with Illustrations from a Cadaver

A “two‐incision” approach for en bloc resection of periacetabular tumors and prosthesis reconstruction is described. The first incision begins in the middle of the iliac crest, continues over the inguinal ligament, extends to the symphysis pubis and then turns down to ischial tuberosity. The muscles attached to the iliac crest are only separated from its internal side. All the attachments of the abductor muscles to the iliac crest are left intact. The second incision runs from the sacroiliac joint to the greater trochanter and is curved in shape, providing external exposure of the sciatic notch and ischial tuberosity. Communication between the two approaches is possible inside and outside under the abductor muscles or through the sciatic notch. En bloc resection of the tumor is performed by cutting the pubic symphysis and iliac as planned preoperatively. The iliac osteotomy is performed by using a Gigli saw that has been led through the sciatic notch and under the abductor muscles. This “two‐incision” approach not only provides enough exposure to perform en bloc resection of periacetabular tumors, but also protects the continuity of the abductor muscles between the pelvis and greater trochanter, thus preventing prosthesis dislocation.     

Endoscopic Transnasal Interseptal Approach for Invasive Clival Tumors: Development of an Approach Method Regarding Maximal Preservation of the Nasal Anatomy

Asian people frequently show small noses, narrow nasal apertures, and congestive mucosa on the turbinates and septum. To reduce the risk of nasal morbidity with increased radicality for skull base tumors in these patients, we developed endoscopic transnasal interseptal approach (ETISA) in transsphenoidal surgery for invasive clival tumors (ICTs). Indication for ETISA is radical resection for tumors occupying deep ventral skull base regions, confined posterior to the level of the middle turbinates. After removing ethmoidal air cells, the middle turbinates are laterally deflected. A linear incision is made vertically on each side of the septal mucosa, which is separated from the bony septum as far as the sphenoid rostrum. The blades of an adjustable speculum are inserted submucosally, and the bony septum is temporarily displaced. The surgical pathway is widely maintained from the entrance to the deep surgical field without sacrificing the nasal mucosa and turbinates. Thirty-two consecutive patients with clival tumors (18 chordomas, 11 chondrosarcomas, 3 others) were treated. Bilateral middle turbinectomy was routinely performed in the initial 3 patients, but in only 4 of the remaining 29 (3 unilaterally, 1 bilaterally). Tumor was sufficiently resected in 29 patients (90.6%; gross total removal n = 25, subtotal resection n = 4). As complications, 6 patients showed mild and transient worsening of cranial nerve symptoms. Nasal complications arose in 3 patients, persisting > 3 months in 2 (5.7%). This approach allows fine bimanual handling and swift delivery of surgical equipment while reasonably preserving the nasal anatomy, which is useful in endoscopic transsphenoidal surgery for ICT.     

颈椎管肿瘤Asazuma分型对手术入路选择的意义

目的探讨颈椎管哑铃形神经鞘瘤的手术治疗方法及Asazuma分型在手术入路选择中的临床价值。方法总结我院2004年2月至2007年3月收治的13例颈椎管哑铃形肿瘤患者的临床表现、影像学特征、手术方式及手术前后患者脊髓神经功能改善情况,术前按照Asazuma分型进行评估,选择合适的手术入路,观察临床疗效,评估其临床应用价值。结果13例患者术前均经CT和MRI检查作出临床诊断,2例Ⅰ型,1例Ⅱa型,2例Ⅲa型,2例Ⅲb型,1例Ⅴ型,1例Ⅵ型采用后方入路,2例Ⅱc型采用前方入路,2例型采用前后联合入路。其中肿瘤完全切除11例（84.6%）,大部切除2例（15.4%）。3例患者术中同时切除宿主神经根。10例行内固定和植骨融合术。13例随访3个月至3年,平均16个月。所有患者术后临床症状及神经功能均有明显恢复。结论颈椎哑铃形椎管内肿瘤有较高的误诊、漏诊率,MRI检查对明确病变性质和位置有重要意义。Asazuma分型对颈椎管哑铃形神经鞘瘤的手术入路选择具有指导意义。     

Bilateral Orbital Metastases as the Presenting Finding in a Male Patient with Breast Cancer: A Case Report and Review of the Literature

Abstract: Breast cancer in men has traditionally been thought to be substantially different from that in women. As more becomes known about this relatively rare entity, the similarities between genders become more striking than the differences. Carcinoma of the male breast is an uncommon disease occurring in less than 1% of all breast cancers. Male breast carcinoma is staged similarly to female breast cancer using the American Joint Committee Clinical Staging System. As in women, axillary nodal status is the strongest predictor of outcome. Distant metastasis to bones, soft tissue, lungs, and liver have been widely reported in men with breast cancer. This case report provides a rather rare presentation of a man with breast carcinoma with bilateral orbital metastasis as an initial clinical presentation.     

Combined Transoral and Endoscopic Approach for Total Maxillectomy: A Pioneering Report

Total maxillectomy is sometimes necessary especially for malignant tumors originating from the maxillary sinus. Here we describe a combined transoral and endoscopic approach for total maxillectomy for the treatment of malignant maxillary sinus tumors and evaluate its short-term outcome. This approach was evaluated in terms of the physiological function, aesthetic outcome, and complications. Six patients underwent the above-mentioned approach for resection of malignant maxillary sinus tumors from May 2010 to June 2011. This combined transoral and endoscopic approach includes five basic steps: total sphenoethmoidectomy, sublabial incision, incision of the frontal process of the maxilla, incision of the zygomaticomaxillary fissure, and hard palate osteotomy. All patients with malignant maxillary sinus tumors successfully underwent the planned total endoscopic maxillectomy without the need for facial incision or transfixion of the nasal septum; there were no significant complications. Five patients received preoperative radiation therapy. All patients were well and had no recurrence at follow-up from 13 to 27 months. The combined approach is feasible and can be performed in carefully selected patients. The benefit of the absence of facial incisions or transfixion of the nasal septum, potential improvement in hemostasis, and visual magnification may help to decrease the morbidity of traditional open approaches.     

Efficacy of One‐stage Paravertebral Approach using a Micro‐Tubular Technique in Treating Thoracic Dumbbell Tumors

ObjectiveThe aim of the present study was to investigate the feasibility and efficacy of one‐stage surgical resection of thoracic dumbbell tumors using a paravertebral approach and a micro‐tubular technique.MethodsClinical data of thoracic dumbbell tumors resected using a paravertebral approach and a micro‐tubular technique (14 mm, non‐expandable type) in the Department of Neurosurgery at our hospital from July 2014 to July 2019 were retrospectively analyzed. Tumors were found between T1 and T12 vertebrae. Operation time, blood loss, hospitalization, recovery of neurological function, complications, the Japanese Orthopaedic Association (JOA) score, and the visual analogue scale (VAS) score were used to evaluate clinical efficacy.ResultsIn all 31 cases, tumors were completely resected in one operation, with a mean blood loss of 53.23 ± 33.08 mL (20–150 mL) and a mean operation time of 95.16 ± 20.31 min (60–180 min). According to the Eden classification, there were four type II cases, 16 type III cases, and 11 type IV cases. The incidence of tumors in the lower thoracic segment (T8–T12) was 51.6% (16/31 cases), while the incidences in the upper thoracic segment (T1–T4) and middle segment (T5–T8) were 25.8% (8/31 cases) and 22.6% (7/31 cases), respectively. Pathological diagnoses were schwannoma (n = 22), gangliocytoma (n = 4), metastatic tumor (n = 2), neurofibroma (n = 1), granuloma (n = 1), and lipoma (n = 1). After surgery, symptoms were relieved in all patients. VAS and JOA scores significantly improved (P < 0.001). There was no pleural or lung injury, and there were no complications, such as cerebrospinal fluid leakage. The average follow‐up duration was 29 months (13–59 months), during which time no tumor recurrence or spinal instability occurred. The group of Eden type II tumors had lower JOA scores at 12 months postoperatively, longer operation times, and more estimated blood loss compared with other groups (P < 0.05). There were no significant influences on VAS scores at 12 months postoperatively and postoperative hospital stay from the different types of tumors.ConclusionThe paravertebral approach with a micro‐tubular technique is a safe and effective minimally invasive surgical approach for thoracic dumbbell tumors that allows one‐stage tumor resection using a single incision. Using this approach significantly reduces intraoperative blood loss and postoperative complications, shortens hospital stay, and reduces the rates of postoperative spinal instability.     

Posterior Laminoplastic Laminotomy Combined with a Paraspinal Transmuscular Approach for Removing a Lumbar Dumbbell-shaped Schwannoma: A Technical Note

The surgical strategies and methods used to treat dumbbell-shaped tumors located in the lumbar-foraminal region are controversial. Although a total facetectomy and combined intra- and extraspinal canal approach provide a wide operative field, facet fusion is required, which can be rather invasive. Here, we report a successful removal of a lumbar dumbbell-shaped schwannoma using a combined laminoplastic laminotomy with Wiltse’s paraspinal surgical approach. This was performed under an operating microscope without a complete facetectomy, fusion, and posterior fixation. Briefly, we treated two patients with lumbar foraminal tumors, both dumbbell-shaped schwannomas located in the intra- and extradural portion. After a laminoplastic laminotomy, the intradural tumor was removed. The tumor located at the extracanalicular site was removed after drilling the pars interarticularis of the lamina, which was performed to enlarge the intervertebral foramen via Wiltse’s paraspinal surgical approach. During surgery, facetectomy with posterior fixation was not needed to remove the intraforaminal component. There was no lumbar instability or complication after surgery. Our results suggest that a combined posterior laminoplastic laminotomy and Wiltse’s paraspinal surgical approach is useful and less invasive for treating patients with lumbar foraminal tumors.     

A Modified Combined Transseptal/Transnasal Binostril Approach for Pituitary Lesions in Patients with a Narrow Nasal Space: Technical Note

We describe a modification of the combined transseptal/transnasal binostril approach using a two-surgeon, four-handed technique (modified Stamm''s approach) for pituitary lesions in patients with narrow nasal spaces. This approach comprises of a transseptal route through one nostril and a transnasal route without harvesting a pedicled nasoseptal flap (NSF) through the other. On the transseptal side, the nasal septum was removed using an endoscopic septoplasty technique. On the transnasal side, the mucosa containing the septal branch of the sphenopalatine artery over the face of the sphenoid and nasal septum was preserved for harvesting the NSF if an intraoperative cerebrospinal fluid leak was encountered. This approach was performed in six patients with pituitary lesions, including four nonfunctioning macroadenomas, one growth hormone-producing macroadenoma, and one Rathke''s cleft cyst, all of which were associated with a severe deviation of the nasal septum and/or narrow nasal space. The meticulous and comfortable manipulation of an endoscope and instruments were achieved in all six patients without surgical complications. Our findings, although obtained in a limited number of cases, suggest that the modified Stamm''s approach may be useful for selected patients, particularly those with a severe deviation of the nasal septum, without considerable damage to the nasal passages.