Search

Pharyngoesophageal injury during anterior cervical spine surgery is a rare and potentially life-threatening complication; generally it is the result of intraoperative manipulation or hardware erosion and sometimes may be due to weakness of the pharyngoesophageal wall from pre-existing pathologic conditions, such as diabetes, gastritis, or obesity.We describe the management strategies in patients with an early postoperative hypopharyngeal perforation that occurred after anterior cervical spine surgery without failure of instrumentation, and we present a case treated endoscopically at our institution.Appropriate treatment for pharyngoesophageal perforations is controversial and not investigated in detail. There is a lack of prospective studies comparing initial conservative versus surgical approaches to treatment. In addition, endoscopic management is growing as a therapeutic option, but no consensus concerning the indications for an endoscopic approach in the treatment of pharyngoesophageal injury in anterior cervical spine surgery is currently reached. A common theme proposed in the literature is that early recognition and aggressive investigation and treatment are essential to ensure a good outcome. A customized interdisciplinary surgical approach is essential for successful treatment. Use of the transoral endoscopic approach is a useful noninvasive method to treat this rare but potentially devastating complication.

Objectives The endoscopic approach increasingly is used to treat third ventricular colloid cysts. Our objective was to assess the results of endoscopic resection of colloid cysts of the third ventricle. Methods A retrospective study was designed, and a series of 112 consecutive patients (76 male, 36 female) with third ventricular colloid cyst treated by endoscopic surgery was undertaken. Results We found that the most common clinical presentations in patients with third ventricular colloid cyst were headache, vomiting, and impaired vision. Complete resection was obtained in majority of patients (92%). Meningitis, hemiparesis, and memory deficits occurred most commonly as postoperative complications. Conclusions High rates of complete resection of third ventricular colloid cysts, with low morbidity and mortality, are possible with an endoscopic approach. The results of this study support the role of endoscopic resection in the treatment of patients with third ventricular colloid cysts as a safe and effective modality and show how endoscopic resection of third ventricular colloid cysts can produce favorable results.

Objective A modification of other reported endoscopic techniques for intracerebral clot evacuation is described and illustrated. Methods From January 2014 to December 2014, we operated on 6 patients harboring a spontaneous supratentorial intracerebral hemorrhage using a fully endoscopic freehand technique. Clinical chart and surgical videos were analyzed. Volumetric evaluation of the clot preoperatively and the residual hematoma postoperatively was performed. Clinical outcome was measured using the modified Rankin Scale and Glasgow Outcome Scale. Results The mean operative time was 96 minutes (range, 72–125 minutes). Clot evacuation was >90% in all patients. No patient experienced rebleeding after surgery. Two patients died. The Glasgow Outcome Scale score at 6 months was 4 in 2 patients, 3 in 2 patients, and 1 (death) in 2 patients. The modified Rankin Scale score at 6 months was 6 (death) in 2 patients, 4 in 2 patients, 3 in 1 patient and 2 in 1 patient. Conclusions The proposed minimally invasive technique allows a good rate of hematoma evacuation and intraoperative bleeding control. Further studies in large series are needed to confirm the role of this freehand endoscopic technique.

Objective Spontaneous cerebrospinal fluid leaks are most commonly located along the anterior skull base. Sphenoidal localization is less common, and clival localization is even rarer. We analyzed a group of patients with spontaneous leaks and selected patients with clival localization. This article discusses surgical management of these entities and provides a brief literature review regarding spontaneous clival leaks. Methods Of a cohort of 67 patients who presented to our departments with a spontaneous leak during the period 2005–2014, a retrospective data analysis was performed on 6 patients with clival localization of the defect. A skull base repair with a multilayered reconstruction was performed in 3 patients, and a single-layered reconstruction using a pedicled nasoseptal flap was performed in 3 patients. Results The patients included 6 women with a mean age of 60 years (range, 36–91 years). The mean length of the follow-up period was 69.5 months (range, 22–114 months). The overall success rate of the primary endoscopic repair was 83.3% (5 of 6 patients); this increased to 100% after revision surgery. Conclusions This series, although numerically limited, suggests that a minimally invasive endoscopic repair of idiopathic clival leaks may be accomplished with an acceptable rate of morbidity and excellent outcomes. Moreover, the pedicled nasoseptal flap has been confirmed to be the “workhorse” for the reconstruction of clival defects.

Objective The current approach for the diagnosis and repair of spontaneous and traumatic anterior skull-base defects is oulined, highlighting the controversies that exist in the field and describing the strategies required to access different segments of the anterior cranial fossa. Methods We reviewed the literature concerning endoscopic management of anterior skull-base defects. These publications have been combined with our own experience repairing cerebrospinal fluid (CSF) leaks and encephaloceles that developed spontaneously, traumatically, or intentionally as a result of endoscopic skull-base surgery. Results We present a systematic methodology for the repair of these defects. We have divided our surgical approach into four separate corridors. These are the transnasal, transsphenoidal, transethmoidal, and transmaxillary corridors. Dissection strategies vary for each corridor, but with a combination of approaches, all areas of the anterior skull base can be accessed. Skull-base defects are successfully repaired with a multilayered closure that often involves use of a vascularized pedicled mucosal flap. Adoption of this technique has decreased our rate of postoperative CSF leak from 5.9%–3.1%. Conclusions Endoscopic endonasal repair of CSF leaks and encephaloceles has evolved significantly during the past decade. The versatility of different endoscopic approaches through the four endonasal corridors allows for the endoscopic repair of almost all skull-base defects. The use of vascularized pedicled mucosal flaps has evolved to cover these defects as part of multilayered closure strategies.

Objectives Massive intracerebral and intraventricular hemorrhages require aggressive and rapid management to decrease intracranial hypertension. The amount of intraventricular blood is a strong prognostic predictor, and its fast removal is a priority. Neuroendoscopy may offer some advantages over more traditional surgical approaches. Methods All relevant data described in our experience and in publications about minimally invasive treatment of intraventricular and intracerebral hemorrhage found through MEDLINE searches and related references are reviewed. Results We described the technical details of neuroendoscopic management, highlighting the potential pitfalls and advantages of the techniques. Conclusion Early neuroendoscopic surgery is a feasible approach, allowing, in most instances, rapid clinical and radiological improvement.