INNOVATIVE SURGICAL TECHNIQUES / ADULTS
Persistent “unexplained” headache
A few months ago we assessed an 18-year-old patient complaining of headache and vomiting when standing upright. The inability to explain and treat the symptom had been detrimental to her quality of life.
We made the hypothesis that the possible cause was cerebrospinal fluid leakage (the fluid that normally surrounds the brain and spinal cord), but it was extremely difficult to locate the point of leakage. Following a brain and spine magnetic resonance imaging that did not prove helpful we subjected the patient to a special kind of examination (CT myelography) during which contrast is injected into the spine.
Two (!) leakage areas were revealed in the thoracic spine. An attempt was made to address the problem by CT-guided injection of a small amount of blood from the patient directly into the leakage points (epidural bloud patch) , but ultimately, due to only partial improvement, the patient was surgically treated with thoracic laminectomy and restoration of these points by microsurgery.
The patient now enjoys a normal life.
Revision of an unsuccessful fusion
We recently assessed a patient with severe back pain, no longer responding to medication, gait difficulty. The patient’s history included an extensive spinal fusion 7 years ago in another hospital, from the tenth thoracic to the first sacral vertebra. The imaging tests revealed spinal instability, fracture of the spinal fusion materials, screws were that was in close contact with large pelvic vessels. This last finding, in particular, which had never been diagnosed, put the patient’s life under constant threat, as it entailed the risk of future unexpected bleeding and death. After carefully studying the imaging scans, we proceeded to intentional obstruction (embolism) of these vessels in order to avoid any bleeding. We then surgically removed the materials of the previous spinal fusion and proceeded with a new modified spinal fusion.
The patient was mobilized on the first postoperative day and no longer needs medication, while his gait has also showed significant improvement.
Endoscopic pituitary adenoma removal without visible surgical incision
We assessed a patient with acromegaly, a condition characterized by gradual change of the facial features, edema of the hands and feet, heart disease, and diabetes mellitus. The reason was an overproduction of a hormone called growth hormone which is naturally responsible for height increase during puberty. We specifically identified a benign brain tumor (pituitary adenoma) and achieved complete surgical removal using an endoscope, through the patient’s nostril and without any visible surgical incisions. The recovery was rapid, with complete normalization of the growth hormone levels in the blood and subsequent normalization of the patient’s blood pressure and blood sugar.
Cervical spinal fusion with posterior access
We describe the case of a patient who was diagnosed with an invasive tumor that extended over three vertebrae (the last two cervical and the first thoracic). The result was the almost complete destruction of these vertebrae with subsequent instability and risk of quadriplegia (complete inability to move arms and legs). Posterior fusion was performed from the 2nd cervical to the 4th thoracic vertebra, a surgery with a high technical difficulty since it is performed in a region with very sensitive anatomical structures (the spinal cord, which is responsible for the movement of arms and legs, and the vertebral arteries, responsible for the perfusion of important brain structures).
The patient had an excellent post-operative course with full functional recovery. He has received appropriate oncology treatment, resulting in complete control of his condition.
It should be emphasized that the possibility of posterior access to the neck allows, in many cases, for the complete avoidance of spinal fusion (which is necessary when surgery is performed with the usual, anterior aproach).
Magnetic resonance imaging of the cervical spine where the tumor can be seen having invaded 3 vertebrae
Post-operative X-rays depicting posterior fusion from the 2nd cervical to the 4th thoracic vertebra.
Three-dimensional reconstruction of postoperative cervical and thoracic spine tomography, depicting posterior fusion from the 2nd cervical to the 4th thoracic vertebra.
Cervical spine neurinoma
We treated a patient with a large cervical spine neurinoma. This is a benign tumor that, due to its slow growth, had reached a very large size, causing it to “strangle” the spinal cord inside the spine and to further expand outside of it, coming in close contact with the exiting nerves. These nerves are responsible for arm movement and sensation. The size of the tumor, the pressure in the spinal cord and nerves, as well as its proximity to the vertebral artery, made surgical removal extremely dangerous. The tumor was successfully removed, and in order to restore spinal stability, a posterior cervicothoracic fusion was also performed.
Following surgery, the patient was completely cured and has no weakness at all.
Preoperative cervical magnetic resonance imaging showing the portion of the neurinoma that extends beyond the spine and comes in close contact with the outgoing nerves
Postoperative cervical magnetic resonance imaging depicting complete removal of the neurinoma
Vertebroplasty
We evaluated a patient with a history of osteoporosis and recent onset of intense low back pain with any movement. Lumbar spine magnetic resonance imaging revealed compressive fractures in the bodies of the first three lumbar vertebrae, a finding that is common in patients with osteoporosis even without injury. The patient was not relieved by medication and the healing process of the fractures was not satisfactory.
We therefore proposed treatment with vertebroplasty. This is a minimally invasive method that requires the patient to remain in the hospital for only a few hours, without general anesthesia and consists of a percutaneous (i.e. without incision, but simply using a needle) injection of bone cement into the fractured vertebrae. The result is fracture stabilization, while the local microscopic nerve endings responsible for the pain are destroyed by the heat produced locally during the solidification of the bone cement. The result is instant relief of the pain within a few minutes after completing the process.
Our patient was mobilized 2 hours later, with complete pain remission, and she no longer needs a brace.
Preoperative lumbar spine magnetic resonance imaging, showing lumbar vertebral fractures.
Intraoperative X-ray depicting the placement of the special needles inside fractured vertebral bodies. The special bone “cement” shall be injected through these needles.
Postoperative lumbar spine tomography, which depicts the correct injection of bone cement (strongly white material) inside the bodies of those lumbar vertebrae presenting with a fracture, thus offering spinal stability and pain relief.
Intraoperative photo depicting the imaging technologies used to ensure correct placement of the percutaneous needles inside the vertebral body and the subsequent safe injection of bone cement. This is achieved by using a special X-ray machine (C-arm) along with a CT-scan.
Awake craniotomy (with the patient collaborating)
“Awake craniotomy” is applied in recent years by neurosurgeons to safely remove brain tumors in regions of the brain that control movement or speech.
The procedure is based includes he patient being awake during the surgery, by means of a special anesthesia technique. We ask the patient to perform simple commands, such as moving his/her limbs or naming objects that are shown in pictures during surgery. The patient’s inability to execute any of these commands while the neurosurgeon painlessly stimulates specific areas of the brain, demonstrates these areas as functionally significant. The consequent removal of the tumor is performed without interfering with these areas. It is important to note that during the procedure, the patient feels no pain.
We applied this method to a 29-year-old patient with a history of seizures for months. She was subjected to brain magnetic resonance imaging, which showed a brain tumor in the left precentral region, the area responsible for the planning of right hand and right foot movements. During the awake phase, with the patient’s full co-operation and through direct brain stimulation, the motor cortex of the brain was defined, i.e. the area responsible for executing movement. Total tumor removal followed, while protecting the motor cortex.
The patient was awakened with an excellent level of communication and with fuctional right upper and lower extremity weakness as expected.
After 1 week, faster than even the most optimistic prediction, muscle strength of the right arm and right leg had returned to normal.
OR configuration prior to making a surgical incision. For precise surgical orientation, neuronavigation is used intraoperatively.
Snapshot of the awake craniotomy with the help of neuronavigation and brain mapping.
Minimally invasive spinal fusion
Transforaminal Lumbar Interbody Fusion (TLIF) is a minimally invasive surgical technique. It is applied in cases of spinal instability with degeneration of the intervertebral disc (the elastic tissue between the vertebrae allowing the mobility of the spine) and subsequent lumbar sciatica, a lower back pain that reflects on one or both legs.
Contrary to past spinal fusion surgeries that required large incisions and prolonged hospitalization, this new technique in properly selected patients allows for excellent results with very little inconvenience for the patients.
We have recently applied this technique to a 63-year-old patient with a history of spinal surgery in another hospital. Our patient was suffering from severe lower back pain that reflected on both legs and made it very difficult for her to ambulate.
She underwent a lumbar MRI (magnetic resonance imaging) which revealed significant degeneration of the intervertebral disc between the 5th lumbar and 1st sacral vertebra, resulting in the two vertebrae touching each other and subsequent compression of the exiting nerve roots.
Using a surgical microscope and guidance with a special x-ray machine (C-Arm), two small incisions were made, measuring a few centimeters each, and a special graft was placed between the vertebrae, restoring their correct position and releasing the compressed nerve roots. The vertebral spine was stabilized spinal fusion through these small incisions.
The patient was mobilized on the first postoperative day and had complete remission of pain in the lower back and lower extremities.
Intraoperative X-rays, which confirm the correct placement of the fusion materials.
One of the advantages of minimally invasive fusion is the very small size of the skin incisions, which minimizes postoperative pain and allows for fast recovery.
Urgent posterior cervical decompression and occipito-cervico-thoracic posterior instrumented fusion
We were called by the oncologists team of our hospital to evaluate an urgent case of a 63 year old male patient with a history of squamous cell lung cancer under chemotherapy and radiation therapy, with sudden onset of severe left shoulder pain and left arm weakness along with inability of keeping his head in the upright position. He underwent urgently cervical spine CT and MRI scan, which revealed pathologic fractures of the bodies C2, C3 and C4 due to secondary deposits, with fracture fragments compressing and posteriorly displacing the cervical spinal cord.
Treatment included immediate cervical spine stabilization with hard cervical collar followed by halo closed traction. The patient underwent a new cervical spine MRI after the closed traction, which revealed decrease of the posterior cervical spinal cord displacement, permitting us to avoid an additional anterior approach of anterior spinal cord decompression with multilevel cervical corpectomies.
The ultimate stage of treatment included the surgical procedure of posterior cervical spine decompression with laminectomies C1 to C7, followed by posterior occipito-cervico-thoracic instrumented fusion with occipital plate and screws, lateral mass C5 and C6 screws, transpedicular T1 and T2 screws, thoracic cross-link and 2 occipito-cervico-thoracic titanium rods.
Patient was discharged on the 4th post operative day, left shoulder pain free, with improved left arm strength
Dens fracture stabilization with posterior cervical instrumented fusion
We treated an urgent neurosurgical case of a 71 year old female patient, who presented with severe cervical spine region pain and tenderness after a fall from standing height resulting in head injury. On clinical examination she was neurologically intact. Her cervical spine CT scan revealed dens fracture II-III (Anderson and d’Alonzo classification)
Treatment included surgical procedure of posterior instrumented fusion C1/C2/C3 with free hand placement of lateral mass C1 and C3 titanium screws along with 2 titanium rods and synthetic bone graft, under continuous intraoperative neuromonitoring.
The patient was discharged home on the 3rd post operative day, with no neurologic deficit.
Posterior odontoidectomy with posterior fusion of upper cervical spine
We present the case of a 59 year-old female patient who visited our office due to persistent cervical spine pain along with left arm pain and numbness. Cervical spine CT scan revealed unstable type II dens fracture.
Picture «Pre operative C-spine CT scan»
Traditionally, treatment of this type of fractured included combined posterior and anterior approach, with initial stabilization through posterior instrumented fusion followed by anterior decompression with transoral (open or endoscopically assisted0 or transnasal endoscopically assisted odontoidectomy, basically a double procedure requiring long surgical time and intraoperative change of patient’s positioning on the surgical table from prone to supine.
In our case, odontoidectomy was performed though posterior endoscopically assisted approach followed by posterior instrumented fusion, with no need of the time wasting and even potentially harmful for the patient intraoperative change of positioning.
Our surgical technique consisted of posterior cervical decompression with C1, C2 and C3 laminectomies, resection of the medial portion of C2 lateral masses and partial odointectomy, endoscopically assisted with the 70 degrees endoscope.
Picture 2, «Post operative C-spine CT scan»
The procedure was concluded with posterior instrumented fusin C1/C2/C3 with 4 lateral mass (C1 and C3) screws and 2 titanium rods.
Picture «C1 lateral mass screws»
Picture «C3 lateral mass screws»
Modified segmental three level anterior cervical discectomy and fusion in a patient with severe cervical myelopathy
We present the case of a 74-year-old female patient, with inability of standing and walking due to severe bilateral lower extremities weakness. Clinical examination revealed severe balance problems, muscle strength of right lower extremity 3/5, left lower extremity 2/5, mainly in iliopsoas, quadriceps and anterior tibialis muscles. Also, bilateral upper extremities weakness 3/5 concerning intrinsic and forearm muscle groups as well as radicular pain radiating from right scapula to right palm. Cervical spine MRI and CT scan revealed severe cervical spinal stenosis C4/5/6/7 with myelopathic signal C6/7 due to C4/5 disc herniation, C5/C6 end plates posterior osteophytes and large extruded both rostral and caudal C6/7 disc herniation.
Traditionally, surgical treatment of these conditions consists of multilevel corpectomies (in this case C4/5/6/7 corpectomy would be required) followed by placement of long corpectomy cages, making the procedure extremely challenging for the surgeon and potentially harmful for the patient, with great risk of intraoperative complications along with high possibility of lack of adequate postoperative cervical lordosis, despite the use of new, expandable with adjustable lordosis corpectomy cages.
Instead of the traditional corpectomy technique, we performed in our patient 3-level segmental ACDF with interbody cages with integrated screws C4/C5/C6/C7 with supplementary partial posterior corpectomy of the inferior posterior quarter of C5 body and superior posterior quarter of C6 body with the use of curved high speed drill, under continuous intraoperative neuromonitoring.
The patient tolerated the procedure well and was discharged home on the second postoperative day, with no symptoms of right cervical radiculopathy, improved upper extremities muscle strength and stable lower extremities strength. After 2 months of physiotherapy program at home, the patient was able to walk alone, without the need of a cane.