Objective Posterior apophyseal ring fracture (PARF) is an uncommon disorder that is usually accompanied by lumbar disc herniation (LDH). The aim of this study to describe the 8-year experience of performing minimally invasive treatment of PARF, giving particular attention to surgical technique and clinical outcome.
Methods We reviewed 1,324 consecutive patients with LDH seen in our department between 2013 and 2020. Forty-eight patients (3.63%) were enrolled who were diagnosed with PARF associated with LDH and underwent transforminal endoscopic lumbar discectomy (TELD). Mean duration of the final postoperative follow-up was 5.1 years. The control group was comprised of 50 patients diagnosed with LDH without PARF at the same facility. Data on clinical outcomes were analyzed.
Results The mean operation time in the PARF group was 105.4 minutes, which was longer than the mean operation time of the control group (83.9 minutes) (p = 0.001). Surgical complications, including dural tears (6.3%) and surgical instrument rupture (4.2%) were more common in the PARF group (p = 0.025). However, there was no significant difference in the proportion of excellent and good results and recurrence rates between the LDH patients with and those without PARF, respectively.
Conclusion TELD is a safe and effective minimally invasive approach for the treatment of PARF. However, minimally invasive techniques may require longer operation time and steeper learning curve for inexperienced surgeons. The separation and removal of bone fragments, a key step in the procedure, requires patience and care to prevent rupture, residual surgical instruments, and leakage of cerebrospinal fluid.
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Objective Considering the adverse natural history of spinal dural arteriovenous fistula (sDAVF), clinical outcomes may be worsened if the initial occlusive trial does not achieve complete fistula occlusion. We aimed to analyze the initial success rate of microsurgery and embolization and confirm the effects of initial treatment success on the clinical outcomes of sDAVF patients. In addition, we investigated the factors associated with initial treatment failure.
Methods A total of 38 patients treated for sDAVF at a single institution over a 14-year period were retrospectively reviewed. Clinical outcomes according to the initial treatment modality were quantitatively analyzed. Demographic characteristics and angioarchitecture data were evaluated to identify factors associated with initial treatment failure.
Results In the study population, 34 patients underwent embolization as the initial treatment, and complete occlusion of the fistula was achieved in 13 patients (38%). However, all patients who underwent microsurgery showed complete fistula occlusion. Among patients with initial treatment success, gait and micturition were improved with statistical significance (p < 0.001 each). However, in cases of initial treatment failure, only mild improvements in gait and micturition were observed, which were not statistically significant (p = 0.097 and p = 0.375, respectively). A narrow feeding artery diameter (p = 0.007) and embolization of the artery only (p = 0.002) were identified as factors associated with initial treatment failure.
Conclusion To achieve symptomatic improvement and prevent neurological deterioration due to recurrence, the initial definite occlusion of the fistula is important. Despite advances in endovascular techniques, microsurgical occlusion is still superior in terms of initial complete obliteration.
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Objective To date, applications of 3-dimensional (3D) printing in neurosurgery have been limited to the creation of anatomical models for training and simulation, fabrication of customized implants, and production of patient-specific surgical tool guides. We aim to demonstrate a new application of this technology for the online dissemination of novel surgical instrument designs across the world.
Methods A link to a 3D printing file and instructions for assembly of a spine localizer are included in this article. This device was used to determine the optimal location of skin incision in lumbar microsurgery in 43 consecutive patients. Data regarding the accuracy of the surgeon's initial estimate of the target site based on palpation of anatomical landmarks and the accuracy of the localizer device in locating the target spine segment were prospectively collected.
Results In 35 cases (81%), the surgeon’s initial estimate of the target site was correct. In the remaining 8 cases (19%), the initial estimate was off by 1 motion segment. Inaccuracy of the surgeon’s estimate was found to be associated with a higher body mass index and the presence of transitional lumbosacral anatomy, but not with age, sex, or location of the target segment. In all patients, the location of the incision guided by the localizer was found to overlie the target segment, yielding a device accuracy of 100%. There was no need to extend the incision or modify the surgical trajectory.
Conclusion This 3D-printable localizer serves as an example of a device that can be disseminated online and printed at the point of use, thus promoting online tool-sharing by neurosurgeons.
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Three-Dimensional Printed Model for Surgical Simulation of Combined Transpetrosal Approach Kosuke Kondo, Masaaki Nemoto, Naoyuki Harada, Hiroyuki Masuda, Syunpei Ando, Shuuhei Kubota, Nobuo Sugo World Neurosurgery.2019; 127: e609. CrossRef
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