The Importance of Planning Ahead: A Three-Dimensional Analysis of the Novel Trans-Facet Corridor for Posterior Lumbar Interbody Fusion Using Segmentation Technology

BACKGROUND

The rise of minimally invasive lumbar fusions and advanced imaging technologies has facilitated the introduction of novel surgical techniques with the trans-facet approach being one of the newest additions. We aimed to quantify any pathology-driven anatomic changes to the trans-facet corridor, which could thereby alter the ideal laterality of approach to the disc space.

METHODS

In this retrospective cohort study, we measured the areas and maximum permissible cannula diameters of the trans-facet corridor using commercially available software (BrainLab, Munich, Germany). Exiting and traversing nerve roots, thecal sacs, and lumbar vertebrae were manually segmented on T2-SPACE magnetic resonance imaging. Spondylolisthesis, disc protrusions, and disc space heights were recorded.

RESULTS

A total of 118 trans-facet corridors were segmented bilaterally in 16 patients (65.6 ± 12.1 years, 43.8% female, body mass index 29.2 ± 5.1 kg/m2). The mean areas at L1-L2, L2-L3, L3-L4, and L4-L5 were 89.4 ± 24.9 mm2, 124 ± 39.4 mm2, 123 ± 26.6 mm2, and 159 ± 42.7 mm2, respectively. The mean permissible cannula diameter at the same levels were 7.85 ± 1.43 mm, 8.98 ± 1.72 mm, 8.93 ± 1.26 mm, and 10.2 ± 1.94 mm, respectively. Both parameters increased caudally. Higher degrees for spondylolisthesis were associated with larger areas and maximum cannula diameters on regression analysis (P < 0.001).

CONCLUSIONS

Our results illustrate that pathology, like spondylolisthesis, can increase the area of the trans-facet corridor. By understanding this effect, surgeons can better decide on the optimal approach to the disc while taking into consideration a patient's unique anatomy.

Outcome comparison of minimally invasive proximal and distal chevron Akin osteotomies in patients with severe hallux valgus deformity: A randomized prospective study

PURPOSE

To date, the surgical treatment of severe hallux valgus deformity remains challenging despite the various methods presented. This study aimed to compare the effectiveness of minimally invasive distal chevron Akin osteotomies (d-MICA) and minimally invasive proximal chevron Akin osteotomies (p-MICA) in correcting severe hallux valgus deformities.

METHODS

This prospective follow-up study included patients randomly assigned to undergo p-MICA or d-MICA for hallux valgus deformities with a preoperative hallux valgus angle (HVA) ≥ 40° and/or a first to second intermetatarsal angle (IMA) ≥ 16°. After a minimum follow-up period of two years, we compared various clinico-radiographic parameters of patients whose HVA exceeded 15° at the final follow-up.

RESULTS

In the p-MICA and d-MICA groups, seven of 40 cases (17.5%) and 16 of 41 cases (39.0%), respectively, exhibited HVA > 15° at the final follow-up (P = 0.048). The preoperative parameters showed no significant differences. However, at the first weight-bearing assessment, the HVA, IMA, and relative second metatarsal length were significantly smaller, and the distal metatarsal articular angle (DMAA) was greater in the p-MICA group (all P < 0.05) compared with the d-MICA group. Postoperatively, both groups exhibited significant decreases in HVA and IMA at the final follow-up (P < 0.001 for all parameters). The p-MICA group showed no significant changes in DMAA and the relative length of the second metatarsal (P = 0.253 and 0.185, respectively). However, the d-MICA group showed a significant decrease in DMAA (P < 0.001) and an increase in the relative length of the second metatarsal at the final follow-up (P = 0.01).

CONCLUSIONS

p-MICA and d-MICA procedures demonstrated effective correction potential for severe hallux valgus deformities; however, the d-MICA procedure exhibited a notably higher incidence of unsatisfactory correction at the final follow-up than p-MICA. Therefore, d-MICA may be less predictable in achieving successful outcomes than p-MICA in treating severe hallux valgus deformities.

Fluoroscopy-Guided Percutaneous Transthoracic Pleural Forceps Biopsy in Patients With Exudative Pleural Effusion

OBJECTIVE

This study aimed to evaluate the diagnostic performance and procedural characteristics of fluoroscopy-guided percutaneous transthoracic pleural forceps biopsy (PTPFB) in patients with exudative pleural effusion.

MATERIALS AND METHODS

Patients with exudative pleural effusion who underwent PTPFB between May 1, 2014, and February 28, 2023, were included in this retrospective study. The interval between percutaneous catheter drainage (PCD) and PTPFB, number of biopsies, procedural time, and procedure-related complications were evaluated. The sensitivity, specificity, and accuracy of diagnosing malignancy were computed for pleural cytology using PCD drainage, PTPFB, and combined PTPFB and pleural cytology.

RESULTS

Seventy-one patients, comprising 50 male and 21 female (mean age, 69.5 ± 15.3 years), were included in this study. The final diagnoses were benign lesions in 48 patients (67.6%) and malignant in 23 patients (32.4%). The overall interval between PCD and biopsy was 2.4 ± 3.7 days. The interval between PCD and biopsy in the group that underwent delayed PTPFB was 5.2 ± 3.9 days. The mean number of biopsies was 4.5 ± 1.3. The mean procedural time was 4.4 ± 2.1 minutes. Minor bleeding complications were reported in one patient (1.4%). The sensitivity, specificity, and accuracy for pleural cytology, PTPFB, and combined PTPFB and pleural cytology were 47.8% (11/23), 100% (48/48), and 83.1% (59/71), respectively; 65.2% (15/23), 100% (48/48), and 88.7% (63/71), respectively; and 78.3% (18/23), 100% (48/48), and 93.0% (66/71), respectively. The sensitivity and accuracy of cytology combined with PTPFB were significantly higher than those of cytological testing alone (P = 0.008 and 0.001, respectively).

CONCLUSION

Fluoroscopy-guided PTPFB is an accurate and safe diagnostic technique for patients with exudative pleural effusion, with acceptable diagnostic performance, low complication rates, and reasonable procedural times.

Impact of solvent dry down, phase change, vehicle pH and slowly reversible keratin binding on skin penetration of cosmetic relevant compounds: II. Solids

We extended a mechanistic, physics-based framework of the dry down process, previously developed for liquids and electrolytes, to solids and coded it into the latest UB/UC/P&G skin permeation model, herein renamed DigiSkin. The framework accounts for the phase change of the permeant from dissolved in a solvent (liquid) to precipitated on the skin surface (solid). The evaporation rate for the solid is reduced due to lower vapor pressure for the solid state versus subcooled liquid. These vapor pressures may differ by two orders of magnitude. The solid may gradually redissolve and penetrate the skin. The framework was tested by simulating the in vitro human skin permeation of the 38 cosmetically relevant solid compounds reported by Hewitt et al., J. Appl. Toxicol. 2019, 1-13. The more detailed handling of the evaporation process greatly improved DigiSkin evaporation predictions (r2 = 0.89). Further, we developed a model reliability prediction score classification using diverse protein reactivity data and identified that 15 of 38 compounds are out of model scope. Dermal delivery predictions for the remaining chemicals have excellent agreement with experimental data. The analysis highlighted the sensitivity of water solubility and equilibrium vapor pressure values on the DigiSkin predictions outcomes influencing agreement with the experimental observations.

Percutaneous transverse pinning for metacarpal fractures: a clinical trial

INTRODUCTION

Metacarpal fractures account for 25%-50% of all hand fractures and may negatively impact hand function and ability to work. Percutaneous transverse pinning of non-articular metacarpal fractures allows mobilisation immediately after the procedure.

METHODS

Between March 2017 and February 2022, 56 patients undergoing percutaneous transverse pinning for unstable metacarpal fractures were prospectively recruited. We investigated surgical outcomes in terms of Patient-rated Wrist/Hand Evaluation (PRWHE) and pre-and post-operative radiographic evaluation. The Student t-test was used to compare the means of PRWHE values after surgery. Statistical significance was set at p < 0.05.

RESULTS

The mean age was 40.21 ± 17.9 years (range of 16 to 86 years). The average operating time was 27.96 min. The mean follow-up period was 14.3 ± 6.4 months (from 2 to 41 months). The mean PRWHE score was 6.5 ± 1.8. None of the patients had clinically observable rotational deformities, and the functional outcomes were satisfactory.

CONCLUSION

Percutaneous transverse pinning for non-articular metacarpal fractures restores excellent function, and imaging results are satisfactory. Further high-quality clinical trials are required to validate these results on a larger scale.

LEVEL OF EVIDENCE

II, prospective cohort study.

Achilles Tendon Rupture

There are many high-level studies comparing nonoperative treatment, open repair, and minimally invasive repair for Achilles tendon ruptures. This article summarizes the most up-to-date literature comparing these treatment options. The authors' preferred protocol for nonoperative treatment is discussed. Preferred techniques for open repair and chronic Achilles repair are discussed with reference to the literature.

Delivery of minoxidil encapsulated in cyclodextrins with photoacoustic waves enhances hair growth

The current pharmacological management of androgenetic alopecia is inconvenient and requires a discipline that patients find difficult to follow. This reduces compliance with treatment and satisfaction with results. It is important to propose treatment regimens that increase patient compliance and reduce adverse effects. This work describes transdermal delivery of minoxidil partially encapsulated in β-cyclodextrin and assisted by photoacoustic waves. Photoacoustic waves transiently increase the permeability of the skin and allow for the delivery of encapsulated minoxidil. A minoxidil gel formulation was developed and the transdermal delivery was studied in vitro in the presence and absence of photoacoustic waves. A 5-min stimulus with photoacoustic waves generated by light-to-pressure transducers increases minoxidil transdermal delivery flux by approximately 3-fold. The flux of a 1% minoxidil formulation promoted by photoacoustic waves is similar to the passive flux of a 2% minoxidil commercial formulation. Release of minoxidil from β-cyclodextrin increases dermal exposure without increasing peak systemic exposure. This promotes hair growth with fewer treatments and reduced adverse effects. In vivo studies using encapsulated minoxidil and photoacoustic waves yielded 86% hair coat recovery (vs. 29% in the control group) and no changes in the blood pressure.

Multi-Center Two-Year Patency Outcomes of Endovascular Arteriovenous Fistulas (endoAVF) Created with a 4 French System

PURPOSE

To assess multicenter two-year patency outcomes of endovascular arteriovenous fistulas (endoAVF) created with the WavelinQ device.

MATERIALS AND METHODS

Patients who had fistulas created at three centers from January 2018 to December 2020 were included in this retrospective study. In total, 112 patients underwent endoAVF creation [40 females, 72 males; mean age 60 years (range 18-88)]. Data collected included patient demographics, location of fistula creation, interventions performed, and brachial artery flows pre- and post-creation. Two-year cumulative patency, functional patency, and primary patency were assessed with Kaplan-Meier methodology. Factors affecting patency and maturation were examined using the Cox proportional hazards model.

RESULTS

Technical success defined as angiographically successful endoAVF creation was 97.3% (109/112). In 11 patients the fistula did not mature for dialysis use. For 98 patients (87%) with endoAVF maturation, 12- and 24-month cumulative patency was 94.3% and 91.7%. Functional patency (two-needle cannulation) at 12 and 24 months was 95.7% and 92.7%, respectively. Median maturation time is 95 days (IQR 51-231 days). Male gender and brachial vein coiling at the time of endoAVF creation were predictive of maturation. There were 34 censored events (four patients undergoing renal transplantation; 30 patients deceased). Number of reinterventions per patient year was 0.73 where 43 were maturation procedures and 101 were maintenance procedures. One Grade 3 complication occurred of arterial access puncture site pseudoaneurysm.

CONCLUSION

A high two-year functional and cumulative patency following endoAVF creation with the WavelinQ device was observed in this multicenter real-world experience Level of Evidence: 3 Level of Evidence III.

Percutaneous distal chevron osteotomy is associated with lower immediate postoperative pain and a greater range of motion than the open technique: A prospective randomized study

PURPOSE

The results of past studies comparing percutaneous techniques with traditional open techniques for hallux valgus are controversial. Therefore, this study aimed to compare the radiologic and clinical outcomes of percutaneous and open distal chevron osteotomies.

METHODS

Seventy-one patients with mild to severe hallux valgus deformity were randomized to undergo percutaneous distal chevron osteotomy (percutaneous group, n = 36) or open distal chevron osteotomy (open group, n = 35) between October 2019 and September 2020. Radiological and clinical outcomes were assessed preoperatively and postoperatively. Outcome measures included the foot and ankle outcome score, foot functional index, visual analogue scale (VAS) scores for pain, range of motion (ROM) of the first metatarsophalangeal (MTP) joint, hallux valgus angle, intermetatarsal angle, and first metatarsal shortening. Additionally, the first metatarsal declination angle was measured to evaluate sagittal malunion.

RESULTS

The mean first metatarsal declination angle decreased significantly at 12 months postoperatively in both groups (p = 0.021 and p < 0.001 in the percutaneous and open groups, respectively), and the decrement was significantly greater in the open group (p = 0.033). The mean VAS score for pain on postoperative day one was 4.2 ± 1.9 and 5.3 ± 1.7 in the percutaneous and open groups, respectively (p = 0.019). The mean ROM of the first MTP joint did not change significantly after surgery, from 72.5 ± 7.5 preoperatively to 71.0 ± 9.5 at 12 months postoperatively in the percutaneous group (p = 0.215); however, it decreased significantly from 70.6 ± 7.3 preoperatively to 63.4 ± 10.4 at 12 months postoperatively in the open group (p < 0.001). There were no significant differences between the groups regarding other clinical outcomes.

CONCLUSION

The percutaneous group showed a lower immediate pain level at postoperative day 1 and better ROM of the first MTP joint at 12 months postoperatively.

What can go wrong when doing right? A pictorial review of iatrogenic genitourinary complications

A growing number of treatments for genitourinary diseases can result in various iatrogenic complications. Multimodality imaging in the post-procedural setting is essential for early and accurate diagnosis to limit morbidity and mortality. We review common and uncommon treatment-induced pathologies affecting the genitourinary system via a case-based approach. We illustrate notable complications affecting the kidneys, ureters, bladder, and urethra induced by percutaneous procedures, external beam radiation, immunotherapy, laparoscopic/robotic pelvic surgery, and intravesicular BCG. Finally, we provide guidance on optimal imaging techniques for diagnosis and highlight the role of image-guided interventions for mitigation of complications.

Neuronavigated percutaneous gasserian radiofrequency thermorhizotomy for trigeminal neuralgia: how I do it

BACKGROUND

Radiofrequency thermorhizotomy (TRZ) is an established treatment for trigeminal neuralgia (TN). TRZ can result risky and painful in a consistent subset of patients, due to the need to perform multiple trajectories, before a successful foramen ovale cannulation. Moreover, intraoperative x-rays are required.

METHOD

TRZ has been performed by using a neuronavigated stylet, before trajectory planning on a dedicated workstation.

CONCLUSION

Navigated-TRZ (N-TRZ) meets the expectations of a safer and more tolerable procedure due to the use of a single trajectory, avoiding critical structures. Moreover, N-TRZ is x-ray free. Efficacy outcomes are similar to those reported in literature.

Spinal Cord Stimulator Paddle Lead Revision and Replacement for Misplaced or Displaced Electrodes

OBJECTIVE

Spinal cord stimulators (SCSs) are commonly implanted via a laminotomy or laminectomy. Revision surgery may be necessary in instances of hardware failure or loss of efficacy. It is uncommon for leads to have been initially misplaced in a suboptimal position and revision in these cases necessitates additional dissection for appropriate repositioning. Accordingly, there is concern with a more extensive revision for a potentially higher risk of associated complications. This study aims to describe a series of patients with failed paddle SCS electrodes due to misplacement who underwent revision and replacement.

METHODS

Patients who underwent SCS paddle replacement for misplaced paddles between 2021 and 2023 were identified. Medical charts were reviewed for demographic data, operative details, and incidence of complications.

RESULTS

Sixteen patients underwent thoracic SCS paddle revision and replacement. The mean age was 59.6 ± 12.6 years, with 11 females and 5 males. Misplaced paddles were too lateral (n = 12), too high (n = 2), or incompletely within the epidural space (n = 2). The mean duration from initial implantation to revision surgery was 44.8 ± 47.5 months. The mean operative duration was 126.1 ± 26.9 minutes and all patients required a "skip" laminectomy or laminotomy. No complications were encountered. The mean length of follow-up was 18.4 ± 7.3 months. Mean preoperative pain intensity was 7.9 ± 1.5 and at last follow-up was 3.6 ± 1.7 (P < 0.001). All but 1 patient continued to use their device in follow-up.

CONCLUSIONS

The revision and replacement of misplaced paddle SCS electrodes is a feasible and durable revision strategy, even in long-term implants with extensive scarring.

Percutaneous femoral access: Stuck guide wire, decannulation difficulty due to unravelling and knotting

Percutaneous techniques for femoral arterial access are increasingly being performed due to advances in endovascular cerebral procedures, as they provide a less morbid and minimally invasive approach than open procedures. Common complications associated with this peripheral puncture include hematoma, bleeding, pseudoaneurysm, arteriovenous fistula, retroperitoneal bleeding, inadvertent venous puncture, dissection, etc. The retrograde femoral access is currently the most frequently used arterial access as it is technically straightforward, allows for the use of larger size sheaths and catheters, allows repeated attempts, etc. Although being technically less challenging, grave complications can occur due to hardware failure. Here, we present a case of unruptured posterior inferior cerebellar artery (PICA) aneurysm, who underwent uneventful diagnostic cerebral digital substraction angiography (DSA) via right femoral artery route on first attempt, but on second attempt for therapeutic intervention, landed up with stuck guide wire and faced decannulation difficulty due to unravelling of guide wire and multiple knot formation, which was finally removed after multiple attempts at pulling and improvised manoeuvres. Such cannulation and decannulation difficulties have been reported multiple times for central venous access, but extremely rarely for femoral routes, making this case a rarity and worth reporting.

Update on Percutaneous Ablation for Sarcoma

PURPOSE OF REVIEW

To provide an update on the current state of percutaneous thermal ablation in the treatment of sarcoma.

RECENT FINDINGS

Data continue to accrue in support of ablation for local control and palliation of specific sarcoma subtypes such as extra-abdominal desmoid fibromatosis and for broader indications such as the treatment of oligometastatic disease. The synergistic possibilities of various combination therapies such as cryoablation and immunotherapy represent intriguing areas of active investigation. Histotripsy is an emerging non-invasive, non-thermal ablative modality that may further expand the therapeutic arsenal for sarcoma treatment. Percutaneous thermal ablation is a valuable tool in the multidisciplinary management of sarcoma, offering a minimally invasive adjunct to surgery and radiation therapy. Although there remains a paucity of high-level evidence specific to sarcomas, ablation techniques are demonstrably safe and effective for achieving local tumor control and providing pain relief in select patients and are of particular benefit in those with metastatic disease or requiring palliative care.

Retrogasserian trigeminal radiofrequency-thermorhizotmoy for trigeminal neuralgia

Based on a personal experience of 4200 surgeries, radiofrequency thermocoagulation is useful lesional treatment for those trigeminal neuralgias (TNs) not amenable to microvascular decompression (idiopathic or secondary TNs). Introduced through the foramen ovale, behind the trigemnial ganglion in the triangular plexus, the needle is navigated by radiology and neurophysiological testing to target the retrogasserian fibers corresponding to the trigger zone. Heating to 55-75 °C can achieve hypoesthesia without anaesthesia dolorosa if properly controlled. Depth of anaesthesia varies dynamically sedation for cannulation and lesioning, and awareness during neurophysiologic navigation. Proper technique ensures long-lasting results in more than 75% of patients.

Dermal absorption of high molecular weight parent and alkylated polycyclic aromatic hydrocarbons from manufactured gas plant soils using in vitro assessment

An enhanced in vitro human dermal bioavailability method was developed to measure the release of twenty parent and seven alkylated high molecular weight (HMW) polycyclic aromatic hydrocarbons (PAHs) from contaminated soils collected from five former manufactured Gas Plants (MGP) in England. GC-MS/MS was used to quantify HMW PAHs in soil, Strat-M artificial membrane representing skin, and synthetic receptor solution (RS) representing systemic circulation at 1-h, 10-h, and 24-h timesteps. Fluoranthene and pyrene exhibited the highest fluxes from soils to membrane (ranging from 9.5 - 281 ng/cm2/h) and soil to RS ( Collapse

Key Words

• Bioavailability
• PAH
• Percutaneous
• Risk assessment

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MESH Headings

• Humans
• Polycyclic Aromatic Hydrocarbons/analysis
• Soil
• Tandem Mass Spectrometry
• Molecular Weight
• Soil Pollutants/analysis
• Pyrenes
• Environmental Monitoring/methods
• Fluorenes

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Grants Collapse

Comparative analysis of ultrasound-guided percutaneous biopsy of native kidneys in children and adults using the free-flank supine antero-lateral decubitus positioning

PURPOSE

Ultrasound-guided percutaneous biopsy (USPB) of the native kidneys is the preferred diagnostic method for several nephrological conditions in both adult and pediatric populations. Conventionally, native kidney biopsies are conducted with patients in the prone position (PP). However, an alternative approach involving the supine oblique antero-lateral position (SALP) has been explored, particularly for individuals who are obese, elderly, or critically ill.

METHODS

This study aimed to assess the feasibility and outcomes of USPB performed in SALP with a Free-Flank setting (FF-SALP) in pediatric patients (Group A) compared to adults (Group B). Data from kidney biopsies conducted between 2008 and 2021 were gathered. The study focused on the safety and the prevalence of biopsy samples containing a minimum of 10 glomeruli, histopathological yield in both groups.

RESULTS

Complication rates were low in both groups (5.6% vs. 3.7%; p = 0.454), without major complications noted. The pediatric group achieved a significantly higher mean number of glomeruli per biopsy compared to the adult group (20.6 ± 12.3 vs. 15.7 ± 9.4; p < 0.001). However, when evaluating the minimum threshold of 10 glomeruli (76.3% vs. 68.5%; p = 0.072) and histopathologic yield (95.3% vs. 93.5%; p = 0.408), no differences were observed between groups.

CONCLUSION

USPB of native kidneys in the FF-SALP position is a safe and effective method for tissue sampling in patients with parenchymal disease. It demonstrated comparable diagnostic yields and complication rates in the pediatric and adult populations, providing advantages in terms of airway management, making it particularly useful for pediatric patients that require general anesthesia.

Comparative analysis of combined spinal-epidural anesthesia and general anesthesia in percutaneous nephrolithotomy: a prospective study on surgical team and operating room personnel satisfaction

OBJECTIVE

We aimed to investigate the efficacy and complications of combined spinalepidural anesthesia and general anesthesia in percutaneous stone surgery prospectively.

MATERIALS AND METHODS

The study prospectively included patients who underwent percutaneous nephrolithotomy with general anesthesia (Group.1) or combined spinal-epidural anesthesia (Group.2) at the Department of Urology, Training and Research Hospital, Karabuk University. between December 2018 and December 2019. The effect of the anesthesia technique on the comfort and satisfaction of the operating room personnel, surgeon and anesthesia team were prospectively evaluated and recorded.

RESULTS

During the postoperative period, the spinal anesthesia group had a significantly lower visual analog score than the general anesthesia group. No patient in either group required narcotic analgesics during the postoperative period. In terms of overall satisfaction scores, the surgeon performing the surgical procedure had a significantly higher satisfaction score in the general anesthesia group than in the CSEA group. The score was considered good in the general anesthesia group and moderate in the CSEA group. Personnel satisfaction was higher in the patient group that underwent CSEA. In the general anesthesia group, the score was considered to be average. In the CSEA group, the satisfaction score was considered good, with a statistically significant difference (p < 0.05). The anesthesia team's satisfaction score was moderate, with no significant difference between the CSEA and general anesthesia groups (p > 0.05).

CONCLUSION

PCNL under CSEA can be performed safely in certain individuals. Different anesthetic techniques may have varied levels of satisfaction among the surgical team.

Symptomatic lumbar Tarlov cyst resolution after computed tomography-guided percutaneous trans-sacral fibrin glue intracystic injection: A case report and literature review

Background

Perineural Tarlov cysts are extrathecal cerebrospinal fluid-filled cavities in the perineural recesses around dorsal spinal nerve roots. They are mostly asymptomatic but may occasionally cause back pain, radiculopathy, neurological deficits, and idiopathic intracranial hypotension.

Case Description

A 40-year-old female presented with a partial left foot drop attributed to a symptomatic L5 Tarlov cyst with an extension anterior to the sacrum. Following a computed tomography (CT)-guided percutaneous trans-sacral fibrin glue intracystic injection, the cyst was markedly reduced in size, and the patient's symptoms resolved.

Conclusion

Rarely, patients may present with symptomatic lumbar Tarlov cysts located anterior to the sacrum. Here, we present a patient whose left-sided foot drop resolved following the percutaneous trans-sacral CT-guided L5 intracyst injection of fibrin glue.

Safety of tranexamic acid in surgically treated isolated spine trauma

BACKGROUND

Tranexamic acid (TXA), a synthetic antifibrinolytic drug, effectively reduces blood loss by inhibiting plasmin-induced fibrin breakdown. This is the first study in the United Kingdom to investigate the effectiveness of TXA in the surgical management of isolated spine trauma.

AIM

To assess the safety of TXA in isolated spine trauma. The primary and secondary outcomes are to assess the rate of thromboembolic events and to evaluate blood loss and the incidence of blood transfusion, respectively.

METHODS

This prospective observational study included patients aged ≥ 17 years with isolated spine trauma requiring surgical intervention over a 6-month period at two major trauma centers in the United Kingdom.

RESULTS

We identified 67 patients: 26 (39%) and 41 (61%) received and did not receive TXA, respectively. Both groups were matched in terms of age, gender, American Society of Anesthesiologists grade, and mechanism of injury. A higher proportion of patients who received TXA had a subaxial cervical spine injury classification or thoracolumbar injury classification score > 4 (74% vs 56%). All patients in the TXA group underwent an open approach with a mean of 5 spinal levels involved and an average operative time of 203 min, compared with 24 patients (58%) in the non-TXA group who underwent an open approach with an average of 3 spinal levels involved and a mean operative time of 159 min. Among patients who received TXA, blood loss was < 150 and 150-300 mL in 8 (31%) and 15 (58%) patients, respectively. There were no cases of thromboembolic events in any patient who received TXA.

CONCLUSION

Our study demonstrated that TXA is safe for isolated spine trauma. It is challenging to determine whether TXA effectively reduces blood loss because most surgeons prefer TXA for open or multilevel cases. Further, larger studies are necessary to explore the rate, dosage, and mode of administration of TXA.

Endoscopic-Guided Suture Lateralization for Bilateral Vocal Fold Paralysis: Surgical Tips for Better Outcome

OBJECTIVE

This study aims to describe a precise description of suture lateralization (SL) technique and evaluate its effectiveness and safety in management of bilateral vocal fold paralysis (BVFP).

METHOD

A preclinical cadaveric study followed by application on a case series of BVFP patients. After the preliminary study executed to precisely localize the optimal sites for needle insertion, a prospective interventional study was conducted on 19 subjects presenting with respiratory distress due to BVFP. Data collection included their clinical presentation and a detailed assessment including auditory perceptual assessment, laryngoscopy (rigid or flexible), and video fluoroscopic swallowing study.

RESULTS

Widening of the inter-glottic distance at the site of the sutures was statistically significant (P < 0.001). Decannulation was achieved in three out of four tracheotomized patients. The suturing led to a significant difference in loudness, jitter, and harmonic-to-noise ratio (P = 0.042, 0.004, and ≤0.001, respectively).

CONCLUSION

This study suggests that SL is a feasible and effective technique with low incidence of adverse events and the potential of reversibility. Optimal localization of the suture insertion points translated into less intraoperative manipulation of the cords and shorter operative time.

A Novel Approach to Grade 2 Closed Olecranon Fractures (Oestern and Tscherne Classification) Through Percutaneous Tension Band Wiring: A Case Report

Introduction

Olecranon fractures with compromised overlying skin such as superficial and deep abrasions and puncture wounds pose a challenge to manage as they are at a higher risk of wound and hardware-associated complications such as wound dehiscence, infection, gaping, and prominent hardware. Management of such fractures requires a holistic approach with special attention to the skin and soft tissues.

Case Report

This case highlights a 28-year-old male with a history of falls from a bike resulting in the right comminuted displaced olecranon fracture with multiple superficial abrasions which was managed with a thorough wound wash, antibiotics for 3 days after which percutaneous tension band wiring was performed through a 3 cm incision to prevent any wound complications. Rehabilitation and physical therapy were started immediately and the patient restored the complete range of motion at the elbow thus resuming his activities of daily living.

Conclusion

Utilizing a percutaneous technique for fixation in closed olecranon fractures with compromised overlying skin is considered an innovative, secure, dependable, and effective approach.

Could pain change position choice? Comparison of pain level, analgesic requirement and hospitalization time in supine and prone percutaneous nephrolithotomy

PURPOSE

Investigation of how position affects postoperative pain levels and hospitalization in patients undergoing percutaneous nephrolithotomy (PNL) surgery.

METHODS

Between August 2019 and December 2022, a total of 156 patients who underwent prone (pPNL) and supine percutaneous nephrolithotomy (sPNL) due to kidney stones were included in the study. Demographic data, preoperative CT scans, laboratory results, transfusion rates, operation durations, complication rates, stone-free rates, analgesic use, nephrostomy removal time, hospitalization duration, fluoroscopy time, hemoglobin decrease and postoperative Visual Analog Scale (VAS) scores were evaluated for all patients. By comparing these data between the sPNL and pPNL groups, the effect of position selection in PNL on pain control, analgesic requirement, and hospitalization duration was examined.

RESULTS

In the comparison of the pPNL and sPNL groups, there was a significant difference between the two groups in body mass index, hounsfield unit, complication rate, analgesic rate, nephrostomy remove time, hospitalization time, operation time, fluoroscopy time and VAS score (p = 0.025, p < 0.001, p = 0.012, p = 0.012, p < 0.001, p < 0.001, p < 0.001, p < 0.001 and p < 0.001, respectively).

CONCLUSION

The shorter operation and hospitalization time in the sPNL group could be attributed to performing surgeries in a physiological position. Additionally, sPNL seems advantageous in terms of patients' pain levels, hospitalization time and VAS scores. One reason for this could be the different areas of access in sPNL and pPNL, which may correspond to different dermatome regions. Considering the low level of pain and reduced analgesic usage, sPNL appears to be advantageous.

Percutaneous Image-Guided Cryoablation of Endophytic Renal Cell Carcinoma

PURPOSE

Endophytic renal cancer treatment is a challenge. Due to difficulties in endophytic tumor visualization during surgical extirpation, image-guided percutaneous cryoablation (PCA) is an attractive alternative. The minimally invasive nature of PCA makes it favorable for comorbid patients as well as patients in which surgery is contraindicated. Oncological outcomes and complications after PCA of endophytic biopsy-proven renal cell carcinoma (RCC) were reviewed in this study.

MATERIALS AND METHODS

Patients were included after a multidisciplinary team conference from January 2015 to November 2021. Inclusion criteria were endophytic biopsy-proven T1 RCC treated with PCA with one year of follow-up. Complications were reported according to the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) classification system and the Clavien-Dindo classification (CDC) system. Major complications were defined as a grade ≥ 3 according to the CDC.

RESULTS

Fifty-six patients were included with a total of 56 endophytic tumors treated during 61 PCA sessions. The median RENAL nephrometry score was 9 (IQR 2), and the mean tumor size was 25.7 mm (SD ± 8.9 mm). Mean hospitalization time was 0.39 (SD ± 1.1) days. At a mean follow-up of 996 days (SD ± 559), 86% of tumors were recurrence free after one PCA. No patients progressed to metastatic disease. According to the CIRSE classification, 10.7% (n = 6) had grade 3 complications, and 5.4% (n = 3) had CDC major complications.

CONCLUSION

This study demonstrates that PCA of endophytic biopsy-proven T1 RCC is safe with few major complications and excellent local tumor control rates at almost three-year mean follow-up. LEVEL OF EVIDENCE 3: Retrospective cohort study.

Xu D. A novel technique for decortication of the lumbar facet joints for posterolateral fusion with percutaneous exposure: A cadaveric feasibility study

Background

Percutaneous approaches to the spine have been explored recently for various procedures, including transforaminal lumbar interbody fusion. It is known that facet decortication leads to higher rates of fusion, but effective percutaneous approaches have not been well documented. There are a set of instruments used in the cervical spine for percutaneous decortication, the CORUS™ Spinal System-X (DI# 00852776006508), which may be useful in this setting. Our aim was to investigate the feasibility of decorticating the lumbar facet joints with these instruments in cadavers to aid in minimally invasive lumbar fusion.

Methods

We performed percutaneous facet joint decortication at each facet joint in the lumbar spine in two adult cadavers. We tested varying degrees of laterality for entry points and angulation for access at each level to optimize the innovative procedure.

Results

When using the CORUS™ Spinal System-X to obtain percutaneous access for facet decortication in the lumbar spine, we successfully dissected down to the facet joint without neurovascular injury. At the L1-L2 and L2-L3 levels, access was best obtained at 4 cm from midline with an angulation of 10°. At the L3-L4 and L4-L5 level, access was best obtained at 4 cm from midline with an angulation of 20°.

Conclusions

This study demonstrates that percutaneous lumbar facet joint decortication is feasible with the CORUS™ Spinal System-X instruments, and warrants further, comparative study in the clinical setting.