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.

Broken rod

Broken rod

Imaging of the screw in contact with the internal iliac vessels

Imaging of the screw in contact with the internal iliac vessels


 

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.

Snapshot of endoscopic transnasal transsphenoidal pituitary adenoma removal, where the patient's nostril is used as entryway without incisions

Snapshot of endoscopic transnasal transsphenoidal pituitary adenoma removal, where the patient's nostril is used as entryway without incisions


 

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

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.

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.

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

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

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.

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.

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.

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.

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.

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.

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.

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.

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.