HISTORY OF NEUROSURGERY IN JORDAN
Prof. Walid Maani, MD, FRCSed
Jordan University Hospital and Medical School
Jordan is a small country with big dreams, and many of its aspirations have become physical realities in our lifetime.
In order to be worthy of the global respect we currently enjoy, we must aspire to continue our progress and development.
§ The progress in medical care in Jordan was a translation of the concept that human power was the main asset of the country since it lacks natural resources.
§ Therefore emphases were placed on education and health.
§ Hence, primary health care indices & literacy rates are the best in the Arab world.
§ 25% of the population are students
§ 6% attend university and community colleges
To look at just 2 indices of health will tell the story of medical care progress in this country.
§ In 1950 the infant mortality rate was 63/1000,Today it is 17
§ In 1950 the expected age at birth was 47 years today it is 74.3
Not a single case of poliomyelitis was reported since 1993
The immunization rate in infants is above 98%
• The progress in medical care was across the board in all care levels; primary, secondary and tertiary.
• The advance in tertiary care covered all fields of medicine, so it was not a surprise that Jordan was the eighth country in the world to perform a cardiac transplant in 1984 at the KHMC by Dr. D.Hanania.
• The advancement in neurosurgery in Jordan is a part of this success story.
Management of unruptured brain AVM (bAVM) since ARUBA.
Professor Morgan is a cerebrovascular neurosurgeon.
Professor of Neurosurgery and Vice President, Health and Medical Development at Macquarie University,Australia.
ARUBA, a randomized control trial comparing medical management with or without interventional therapy for unruptured bAVM (ubAVM) recently concluded that “medical management alone is superior to medical management with inerventional therapy for the prevention of death or stroke in patients with [ubAVM] followed for 33 months.” This raises serious concerns for those that intend to continue to recommend treatment for ubAVM as well as anxiety that for those that have treated ubAVM that overall our care may have caused more harm than good. Therefore, this subject should be of importance to the neurosurgical community.
Comparing the outcomes for the 114 cases treated in ARUBA (via a variety of techniques) with our own experience with 368 cases treated or eligible for treatment by surgery for ubAVM. We compared this with the risk of haemorrhage before treatment. In contradistinction with ARUBA, we found that Spetzler Ponce Class (SPC) A ubAVM had a better outcome than conservative management (within 3 years) and there was a tendency for SPC B to be better than the natural history. The difference with ARUBA can be explained on the basis of the treatment modality and the ethical equipoise of ARUBA.
We conclude that the results of ARUBA are not generalizable. Furthermore, we suggest that surgery is the best treatment modality for SPC A ubAVM and may be better than other modalities for SPC B ubAVM. SPC C bAVM remain a formidable management problem.
Applications of Cerebral Bypass Surgery
Dr. Peter Horn
Several cerebrovascular diseases, such as the occlusion or stenosis of brain supplying arteries or complex cerebral aneurysms are amenable to the use of cerebral bypass surgery. In dependence form the underlying pathology several microsurgical procedures can be used either to restore insufficient cerebral blood circulation or to augment the regional cerebral blood flow, if the compensatory mechanisms fail. Typical applications for flow restoration that aims to prevent acute ischemic complications are – in dependence from the blood requirements – the establishment of high, intermediate – flow and standard extra cranial-intracranial arterial bypasses. Using these techniques the treatment of complex intracranial aneurysms either by surgical means (clipping) or in combination with endovascular procedures (coiling or stenting) that carry a high risk for vascular complications becomes possible. In these cases bypass surgery aims to prevent immediate an delayed ischemic complications after the treatment of these pathologies. A limited number of pediatric and adult patients suffer from rare steno-occlusive changes of the cerebral arteries. Although this condition develops slowly in most cases a hemodynamic failure occurs, ie. The compensatory mechanisms of the brain fail. Under these circumstances a significantly increased risk for recurrent ischemic stroke exists. Thus in carefully selected patients with either Moyamoya-disease and related conditions or vessel occlusion of other origin (atherosclerosis) direct (standard extracranial-intracranial bypass) or indirect (for instance encephalo-myo- synagiosis) help to minimize the risk for recurrent stroke. The presentation reviews the commonly used techniques for flow restoration and flow augmentation and depicts the current indications and practice using clinical cases.
Lamina Terminalis Approach for Craniopharyngiomas
Prof. Ibrahim Sbeih, MBCHB., FRCS., FRCSSN .
Third Ventricular tumors are the most difficult to expose and remove. Many neurosurgical approaches are being utilized.
I operated upon 161 third ventricular tumors using various surgical approaches. I used lamina terminalis approach in 102 patients in the period between 1990-2011. This includes 55 patients with craniopharyngiomas in addition to 47 patient with other various pathologies that include: Gliomas, Ependymomas, Hamartomas…etc.
We present here the result of surgical excision of 55 craniopharyngiomas using Lamina Terminalis Approach. 32/55 patients had tumor size of more than 4cm in diameter. 18/55 had solid lesion, 6/55 had cystic lesions and 31/55 had mixed solid/cystic lesions. Gross total resection was achieved in 43 out of 55 patients (76%) with recurrence in 6 cases (15%). There was one mortality in this group. Subtotal resection was achieved in 12 patients (22%) with recurrence in 10 patients (83%). We also encountered one mortality in this group. Endocrinological worsening and obesity were among the main morbidity issues but both usually improve within 2-3 years from surgery. We also encountered worsening of vision in two patients and confusional state in 5 patients, among other complications.
This approach has the advantages of allowing: radical excision of the lesion , neurovascular structures preservation , exposure of retroseller area , preservation of pituitary stalk and most importantly decreasing the misery associated with recurrence and its management, among other advantages. The factors that favor recurrence are large size of tumor, brain invasion, high Ki-67 index, adamantinoma histological type and incomplete surgical excision. We believe that incomplete resection is a virtual guarantee of recurrence. However this view should be taken on the background of risks of hypothalamic damage and other complication if total excision is pursued no matter what.
Utilization of multidisciplinary surgical techniques to successfully manage 20 brain abscesses in a child
Mohammed Al Barbarawi; Wail A. Hayajneh; Mohammad Y. Hiasat; Mohammed Z. Allouh
Childs Nervous System
Received: 22 January 2014 /Accepted: 20 February 2014
# Springer-Verlag Berlin Heidelberg 2014
Department of Neuroscience/ Division of Neurosurgery,
King Abdullah University Hospital
Jordan University of Science and Technology.
Purpose: This study describes a case of multiple brain abscesses in a four-year-old boy who presented with a history of fever and disorientation.
Methods: Medical investigations revealed severe leukocytosis and the presence of 20 hypodense lesions in the boy’s cerebrum. Initial medical treatment included intravenous antibiotics, antiepileptics, and dexamethasone. The boy underwent five surgical interventions within a period of 5 weeks that included frameless stereotactic craniotomies for aspiration and resection of the abscesses.
Results: At the 3-month follow-up, the boy displayed no neurological deficits and no lesions were detected in his brain.
Conclusions: This study reveals the importance of instituting a standardized protocol to determine the urgency of surgical intervention in cases of brain abscess so that surgical treatment can be applied in the appropriate time period. This case also shows that rewarding results can be obtained in treating brain abscesses in children when the proper treatment method is initiated in the appropriate amount of time.
Surgical management of bAVM without embolization.
Professor Morgan is a cerebrovascular neurosurgeon.
Professor of Neurosurgery and Vice President, Health and Medical Development at Macquarie University,Australia.
Embolisation as a preoperative procedure is widely adopted as a useful means of reducing the risks of surgery. However, since the introduction of ethylene vinyl alcohol copolymer (“onyx”) (EVACE) the application of embolisation has broadened to include more cases of attempted cure by EVACE as well as EVACE being employed more frequently for large bAVM prior to radiosurgery. However, the risks and benefits of EVACE have rarely been assessed. Furthermore, the costs incurred are considerable. After evaluating the benefits of EVACE in our practice we have abandoned preoperative embolisation since June 2008. We have made modification to our surgical technique, most notably strategies to get to the nose cone of the bAVM early, and believe that bAVM surgery can be performed without the need for embolisation. I will discuss these techniques.
New Aspects In The Management Of Brain Tumours
Dr. Peter Horn
The treatment of primary brain tumors remains one the most challenging tasks in neurosurgery. The results of systematic studies redefind the role of microneurosurgery during the last years. Today, the aim of surgery in high-grade glioma (HGG) consists in the achievement of gross-total resection (GTR) without secondary morbidity, that respresents an independent factor for survial in patients with glioma WHO IV that undergo neoadjuvant therapy. Thus surgery along with combined radiotherapy led to a signifacant improvment in outcome. Along with the introduction of new intraoperative imaging techniques such fluorescence – based resection (5ALA) and extended intraopertive neurophysiological monitoring and imaging the complications of glioma surgery were significantely reduced. Based on this, it became possible to safely resect intrinsic brain tumors even in highly eloquent brain regions. The availability of these novel technical achievments, along with the improved understandig of the natural history of low-grade glioma (LGG) led to a shift in the treatment in favour of surgery. Thus GTR in this entity, clearly improves outcome. The current presentation reviews and illustrates the current knowledge, possibilities and challenges in the surgical treatment of HGG and LGG.
Petroclival Meningiomas, personal experience.
Ibrahim Sbeih, MBCHB., FRCS., FRCSSN .
Petroclival Meningiomas which constitute 5% of all intracranial meningioma, are difficult lesions to treat.
I operated upon 61 cases of petroclival meningiomas in the period between 1990 – 2011. Seven patients were lost for follow up. We are presenting our experience with 54 cases (average age 43 years) which were followed up for a period ranging from 26 – 176 months. There were 36 females, and 18 males. None of our patients had previous surgeries for their meningiomas.
The main presenting manifestations were cranial nerve involvement, with abducent nerve deficits being the commonest. Other presentations included ataxia, hemiparesis, quadriparesis and features of raised intracranial pressure. Radiological diagnosis rested on the use of brain MRI, MRA, MRV and thin slice C-T scan of petrous bone and clivus. Surgical approaches utilized were retrosegmoid in 40 patients, petrosal in 9 patients and combined approaches in 5 patients. We achieved gross total resection in 38 patients and subtotal resection in 16 patients. Recurrence occurred in all 13 patients who had subtotal resection, and in 7 patients who had gross total resection. After a period of observation, Gamma radiosurgery was used in 11 patients, using 12 – 15 gray to the 50% isodose. Tumor control was achieved in 9 patients. Surgical results were: poor outcome in 4 patients, fair outcome in 10 patients and good outcome in 40 patients. Complications included new carinal nerve deficits in 15 patients, pyramidal weakness, CSF fistula and hydrocephalus. Mortality occurred in 2 patients.
Petroclival Meningiomas are formidable lesions to treat. Factors influencing surgical outcome include neurovascular relationship, bony invasion, multiple intracranial compartment involvement, among other factors. Every effort should be done to achieve gross radical excision. However this is not possible in some cases. For such residual tumors, Gamma radiosergurey should be used, after a period of observation.
Stereotactic & Functional Neurosurgery in Jordan
Mohammad Samaha ,M.D,FRCS, Consultant Neurosurgeon
Ibn Al-Haytham Hospital, Amman, Jordan.
The Stereotactic Neurosurgery was introduced at Ibn Al-Haytham Hospital in 1996 with the installment of the first Gamma Knife Center in the middle east and Arabic world. Since that time we treated more than 1300 cases; benign brain tumors,metastatic tumors, and trigeminal neuralgia, with a success rate comparable to the international figures. Then we performed more than one thousand stereotactic brain lesions biopsies and cysts drainage.
The functional neurosurgery was introduced in 1997 by stereotactic brain lesionings; pallidotomies and thalamotomies for intractable advanced parkinsonian cases, essential tremors, ischemic tremors and dystonia. We operated upon 600 cases of different types with a success rate exceeded 85%. With the advancement of the technology, we also introduced the deep brain stimulation in 1999, and we operated upon 62 cases of different indications with an excellent results.
In my presentation, we will present different video clips to show the results of our work.
Advanced MR Imaging of Brain Tumors
Asem Mansour, M.D.
Jordanian Board in Radiology,
fellowship of the Royal College of Radiologist (FRCR-London)
MR Neuroimaging plays an essential role in the primary diagnosis of intracranial tumors and for following the course and evaluating therapeutic effects. While conventional MR sequences provide high-resolution morphologic assessment of the tumor and its location and extent, MR spectroscopy can supply additional insights into metabolism and MR perfusion can better assess the vascularity of the tumor. These modalities combined can help identify tumor grade, invasive growth into neighboring tissue, and treatment-induced changes, as well as recurrences. Functional MR, on the other hand, can assess certain functional aspects of the brain and relate them to anatomy to ensure that the best surgical approach can be taken which usually translates into better outcome. Such simultaneous assessment of morphologic, functional, and metabolic aspects of the tumor can be very helpful in providing the best treatment options and patient care.
Constitutional Mismatch Repair-Deficiency (CMMR-D) Syndrome
Maysa Al-Hussaini MD FRCPath
Consultant Histopathologist/ Neuropathologist
King Hussein Cancer Center
Mismatch repair genes are involved in repair of mismatches that arise during replication. Heterologous germ-line mutations are associated with Lynch syndrome, an autosomal dominant cancer syndrome, in which affected individuals develop malignancies, notably colonic and endometrial carcinoma, in the 4th to 5th decades of life.
In contrast, CMMR-D syndrome is an autosomal recessive cancer syndrome caused by bi-allelic germ-line mutations in the mismatch repair genes. Affected individuals develop a variety of tumors, mostly hematological and brain tumors, usually in the 1st and 2nd decades of life. Some of those individuals live their first cancer and are prone to develop other tumors, many of which are Lynch syndrome-associated tumors.
Phenotypically; café au lait and skin hypo-pigmentations have been reported in majority of affected individuals.
Awareness of this increasingly recognized syndrome is needed for initiation of proper treatment as well as appropriate counseling of families.
Awake Craniotomy at King Abdullah University Hospital
Dr Moh’d Abrbarawi, Dr. Suleiman Daoud, Aymen Mousa Abu-Awad,
Department of Neuroscience/ Division of Neurosurgery,
King Abdullah University Hospital
Jordan University of Science and Technology.
10 cases underwent awake craniotomy for variable causes over past 10 years.
• 4 females and 6 males
• Age 27- 55.( average 35y)
• All cases had tumors and vascular lesions in the eloquent areas
• No awake craniotomy done for functional disorders
• 2 cases with low grade astrocytoma: left frontal
• 1 case with GBM left fronto-tempral
• 2 case with AVM grade 1 left upper temporal
• 3 case with cavernous hemangioma left temporal
• 2 cases with huge Meningioma and unfit for GA parasagittal
• All cases had successful awake craniotomy
The average real time of surgery was 2.30 hours from skin to skin.
• No intraoperative problems encountered in all cases, except in the patient with parasagittal meningioma who had a bleeding from the posterior part of the attached tumour to the saggittal sinus; that was expected and controlled instantly and given 1 unit of RBCs.
• 3 patients required shots of low dose of MDZ .
• No speech or motor disorder experienced in any during the clinical assessment.
• No epilepsy witnessed in all cases intra and post operatively .
Management of intracranial meningioma in Jordan
Abdullah Al-akayleh , Talal Ajarme
Department of Neurosurgery, King Hussein Medical Center, AMMAN-JORDAN
Background: Meningioma may range in presentation from incidental identified small lesions to large symptomatic tumors. Management options correspondingly vary and include careful observation, surgical excision, and palliative application of very limited therapeutic maneuvers in selected cases. This presentation discuss the options and difficulties in the management of meningiomas in a developing country.
Methods: This study is a retrospective analysis of prospectively recorded data of patients managed for intracranial meningioma between January 2010 and March 2013 at King Hssein Medical Center for Neurosurgery, Amman. Radiographic diagnosis of meningioma was based on computed tomography (CT) and or magnetic resonance imaging (MRI) criteria in all cases, but only patients who had surgery and a histological diagnosis were analyzed.
Results: sixty patients were radiographically diagnosed with intracranial meningioma over the period under review. The male to female ratio was 1:3.6 The peak age range for females was in the 6th decade and for males in the 5th decade. The locations were olfactory groove (7.1%), convexity (23.1%), parasagittal/falx (38.3%), sphenoid ridge (8.9%), tuberculum sellae (7.1%), tentorial(1.7%),intraventricular(1.7%) and posterior fossa (5.3%), orbital roof (5.3%), en-plaque (7.1%). The most common clinical presentation was headache in 67.3% followed by seizures (40.4%) and visual impairment (38.5%).
Conclusion: Histology was benign (World Health Organization [WHO] grade 1) in 55 patients. Four patients harbored an atypical and one had anaplastic tumors. Gross total resection of the tumor was achieved in 51 patients. Surgical mortality was 1.7%.
Validation of outcome measurements in surgically treated vestibular schwannomas
Corresponding Author: Abdulrahman AL-Shudifat
Surgical resection of benign skullbase tumors carries risk of post-operative morbidity. With decrease in morbidity and mortality, concerns and expectations for surgery have changed. In this scenario it is essential to assess risk of postoperative morbidity and incapacity. We have previously reported that work capacity after surgery of vestibular schwannomas was determined by age, gender and tumor size. In the present study we have validated different outcome tools with preoperative factors.
Patients and Methods:
167 patients from a retrospective and a prospective cohort who underwent microsurgical resection for vestibular schwannomas between 2001-2010 were surveyed. Preoperative variables as age, gender, tumor size and neurological symptoms where assayed against different outcome measures as QOL (EQ5D), work capacity/independency (actual work capacity, Karnovsky, independency), facial function (HB and SB), neurological score (patients and physicians score) in univariate and multivariate analysis.
All outcome measures except EQ5D showed a significant decrease postoperatively. Only HB grade differed significantly between the cohorts with a better score in the prospective cohort. Patient assessed neurological score correlated significantly to all other outcome measures. In multivariate analysis age was predictive for work capacity, gender and tumor diameter for patient assessed morbidity and diameter plus duration of surgery for HB facial score.
Standard QOL instruments may not be sensitive enough to measure outcome after surgery of benign skullbase tumors, work capacity is useful in younger patients but patient assessed morbidity may be more useful in all patients.
Dorsal Sympathectomy for Palmar Hyperhidrosis
Nasri J Sami Khoury MB, ChB, FRCSC, FACS.
Palmar Hyperhidrosis is a benign but very irritating condition where there is excessive sweating of the palms. This may be to such an extent that it becomes disabling. Wetting items the person handles such as paper may be most inconvenient and social interaction using the hands may be extremely embarrassing, especially for females.
The cause of Hyperhidrosis is not known but it involves over activity of the sympathetic discharge to the hands. A number of methods of treatment are used but the most effective is sympathectomy of the upper limbs. To minimize the potential consequences of facial sympathetic denervation, the second dorsal sympathetic ganglion is resected resulting in dry, warm and reddish hands.
The author has utilized this method of treatment for 10 patients with excellent results. Initially, bilateral costotransversectomy approaches were used but in the latter part of the series, bilateral sympathectomies was performed through a single midline upper thoracic incision.
The clinical syndrome is presented. The cases treated are reviewed and it is concluded that dorsal sympathectomy is an excellent method of treating Palmar Hyperhidrosis.
Surgery for lumber spinal sterosis with spondylo listhesis
Dr. John Christie
I’m putting together a talk on surgery for lumbar spinal stenosis associated with spondylolisthesis, looking at my results for decompression alone,without fusion. It might generate some controversy!
I’ll send you more when I get it a bit more together.
Surgical management of low grade isthmic spondylolisthesis; a randomized
controlled study of the surgical fixation with and without reduction
Dr. Zaid Audat
Background: spondylolisthesis is a condition in which a vertebra slips out of the proper position
onto the bone below it as a result of pars interarticularis defect. The slipped segment produces
abnormal positioning of the vertebrae in relation to each other along the spinal column and causes
mechanical back pain and neural breach .
Methods and materials: A randomized and double blinded study consisted of 41 patients aged 36-
69 years ( 18 females and 28 males) treated for symptomatic spondylolisthesis between
December,2006 and December ,2009. All patients were randomly distributed into two groups I and II.
Twenty patients were in Group I; they underwent reduction of the slipped vertebrae by using
Reduction-Screw Technique and posterior lumbar interbody fixation (PLIF). Group II consisted of
twenty one patients who underwent only surgical fixation (PLIF) without reduction . All patients in
this study had same pre and post operative management.
Results : only one case had broken rod in group I that required revision. Superficial wound
infection was experienced in two patients and one patient, from group II, developed wound
hematoma. The outcome in both groups was variable on the short term but was almost the same
on the long term follow up.
Conclusion: surgical management of symptomatic low grade spondylolisthesis should include neural
decompression and surgical fixation. Reduction of slipped vertebral bodies is unnecessary as the
ultimate outcome will be likely similar .
Surgical treatment of primary sacral tumors
Dr. Ziad Alzoubi
Primary tumors affecting the sacrum are rare in comparison with metastasis of the spine. The most common are chordomas, giant cell, chondrosarcomas, and Ewing sarcomas. The treatment is challenging, but although surgery is one of the best choices in many instances, but it is difficult to access, and brings high risk. In this lecture I will discuss my experience with 12 cases treated surgically, the indications, preoperative preparations and complications will be discussed.
Annular Closure Device our experience
Dr. Taraq Kanaan, Dr. Knosp, Dr. Dodier
Discectomy as a treatment for lumbar disc herniation is generally effective in the early post-operative period, but long-term outcomes may deteriorate due to recurrent herniation. The risk of recurrence is particularly increased in discs with large annular defects. Annular closure devices (ACDs) may allow for the benefits of limited nucleus removal, such as reduced back pain and better disc height maintenance, without the increased risk of reherniation. Significant complications with suturing techniques and devices that rely on annular integrity have been reported. Our purpose is to present the surgical technique associated with an ACD that is anchored into one of the adjacent vertebral bodies of the disc.
The implantation technique of an advanced ACD that is CE-marked and in clinical use is presented. This ACD consists of a flexible polymer mesh that blocks the annular defect and is fixed in place by a titanium bone anchor. After a standard lumbar discectomy, the height and width of the annular defect are assessed to determine the appropriate implant size. A sizing trial is then used to ensure that adequate access is available to deliver the implant at the proper angle relative to the disc space. Implantation is performed with the aid of fluoroscopy to ensure proper positioning of the delivery tool against the vertebral body. A hammer is used to drive the implant into its final position.
Surgical implantation of the device at the end of a standard microsurgical discectomy with minimal nucleus removal was fast and straightforward.
Preliminary effectiveness and safety data of this device have been reported elsewhere and are positive. Further evaluation of this device in a randomized trial is ongoing. Our experience has been that implantation of the device is intuitive, easy to perform, and does not substantially add to the length of surgery.
Evaluation and treatment of diastematomyelia
Dr. Nidal H. Khasawneh, M.D., FRCS NS, JBNS, JBGS
King Hussein Medical Centre
ABSTRACT: We reviewed the results for forty-three patients who had a diastematomyelia. All of the patients had been skeletally immature when the diagnosis was made, the mean age being six years (range, birth to thirteen years). Twenty-four patients (56 per cent) had a cutaneous lesion, such as a hairy patch, dimple, hemangioma, subcutaneous mass, or teratoma at or near the level of the diastematomyelia; thirty-four patients (79 per cent) had congenital scoliosis; and forty-two patients (98 per cent) had at least one associated musculoskeletal anomaly, such as spinal dysraphism, asymmetry of the lower extremities, club foot, or a cavus foot.
In twenty-seven patients (63 per cent), the diastematomyelia was located in the lumbar spine. Thirty-six patients had eighty-four neurological manifestations.
Resection of the spur was performed in all patients at a mean age of five years (range, three months to thirteen years). Thirty one patients who had a resection had no change in neurological condition, nine patients had improvement, and three patients had one symptom worsen after the operation.
Key words: diastematomyelia, dysraphism.
"Maximum-Minimal-Protocol": Towards New Neurosurgical Standards in Preoperative Planning and Informed Consent through Virtual 3D-Reconstruction and Simulation Using a Cost-Efficient DICOM Imaging Software
Philippe Dodier 1, Firas Hammadi 2, Tareq Kanaan 3, Prof. Engelbert Knosp 1
1. Dept. of Neurosurgery, Medical University Vienna, Austria
2. Dept. of Neurosurgery,
3. Dept. of Neurosurgery, Horst-Schmitt-Kliniken, Wiesbaden, Germany
Rapid advances in multimodal medical imaging techniques have led to significant improvements in 3D visualization technologies and supported the exact preoperative planning of keyhole approaches. Until now, these technologies are reserved to highly specialized centers with the necessary financial and personal resources. We present our experiences planning and simulating complex approaches to intracranial lesions with an affordable, cost-efficient and reliable 3D Imaging reconstruction software. The authors report no conflict of interest concerning the materials used in this study.
Using the 64-bit, FDA cleared version of the OsiriX software, an open source software DICOM viewer and PACS workstation, multimodal imaging data were processed, a 3-dimensional virtual reality model was reconstructed using the volume rendering method. We developed a simple 5-step algorithm (Maximum- Minimal Protocol „MMP“) aiming at acquiring following information:
. 3D reconstruction of intracranial lesions, angioarchitechture, geometrical and volumetrical evaluation, visualization of adjacent structures;
. analysis of superficial cortical anatomy;
. placement and size of planned craniotomy, if possible minimally invasive;
. skin incision in consideration of the course of important subcutaneous vessels;
. this information ultimately leading to the planning of the safest surgical trajectory and patient head positioning
105 preoperative 3D models were reconstructed. In all cases geometrical and volumetrical data were acquired. Our protocol was used to plan the approach for minimally invasive STA-MCA bypass surgery, tumor resection, electrode implantation.Time of planning could significantly be reduced after a development and training period of 5 weeks from more than 45min to less than 15min. Considerable intraoperative time savings due to better preparation were subjectively noticed, quantitative assessment is still ongoing.
Preoperative 3D VR models correlated to intraoperative anatomical landmarks, were used to plan skin incision and craniotomies. In cases of significant CSF shift and distortion of neuronavigation data, the simulations helped correcting trajectories and faster localisation of the lesion. 3D virtual imaging using OsiriX for surgical planning is simple, cost-efficient and considerably time saving, supporting intraoperative orientation, and is helpful for successful resection.
Endoscopic spine surgery with Easy GO: an analysis after 200 procedures with long term follow up
Joachim Oertel1, Benedikt Burkhard1, Sonja Vulcu1
1Klinik für Neurochirurgie, Universität des Saarlandes, Homburg / Saar, Germany
Objective: Minimally invasive spine surgery is under intense investigation. The Easy GO system combines bimanual surgical technique with minimal muscular trauma and skin incision. Here the authors report their experience with the endoscopic spine system after 232 procedures.
Material and Methods: The authors applied an endoscopic spine system in 232 procedures since August 2006. Here a detailed presentation of the results including advantages and disadvantages of the system is given.
Results: The 232 procedures consist of 189 surgeries for lumbar disc and spinal canal stenosis, 26 dorsal cervical decompression, 7 lateral transmuscular approaches to extraforaminal lumbar prolapses, 6 anterior cervical discectomies and 2 thoracic spinal canal stenoses. There was no emergency stopping of any procedure. In lumbar cases,there was an immediate pain relief in all patients. Three CSF leaks occurred, no root injury and no new postoperative neurological deficit. Four switches to microsurgery were performed for access problems to the prolapse (all 2006 and 2007) and one for CSF leak repair. In one case, the technique was abandoned for technical reasons. Long term success rate scored 88% at one-year-follow-up. Five reprolases were observed. Five patient were not satisfied with the results. In cervical cases, there was also an immediate pain relief in all cases. No CSF leaks occurred, no nerve root injuries were observed. Two switches to microsurgery were performed. One patient presented with worsening of his triceps paresis but the paresis completely recovered during a 3 months follow up. At one-year-follow-up, all patients were pain free. No recurrences were observed. One patient was unsatisfied with the results.
Conclusion: In all, the Easy GO system was easy and safe to handle with the standard bimanual microsurgical technique. Good postoperative results were achieved in various spinal indications. A randomized study has to be performed which compares endoscopic results with open microdiscectomy.
Cervical lateral mass screw-rod fixation. Surgical experience with 2500 consecutive screws. Analytical review and long term outcome.
Mohammad Al Barbarawi, Mohammed Allouh, Dr. Mounes Obeidat, Dr. Amer Jaradat, Dr, Tariq Harb, Dr. Hosam Abo Khdair,
Spine Journal .
Department of Neuroscience/ Division of Neurosurgery,
King Abdullah University Hospital
Jordan University of Science and Technology
This study reviews short and long term outcome and surgical complications of decompressive cervical Laminectomy with lateral mass screw instrumentation used to treat patients with variable cervical spine pathologies by a single surgeon.
To report short and long term outcome of patients undergoing posterior cervical stabilization with polyaxial screw-rod constructs and to investigate the safety and reliability of the technique with longest follow up of patients.
A retrospective study appraising clinical and radiological indicators in one of the largest consecutive series of 430 patients treated with this technique over the past eight years.
There were 430 patients treated with 2500 lateral mass polyaxial screws used for different cervical spine disorders. That included; degenerative disease, trauma, congenital anomalies, neoplasms and idiopathic disorders.
This study was carried out between Dec 2005 and January 2014 at King Abdullah University Hospital. Over eight years, 2500 lateral mass screws were placed in patients aged 14-75 years (150 females and 280 males) for variable cervical spine pathologies. All cases reviewed were conducted by same surgeon with a polyaxial screw-rod construct, modified Anderson-Sekhon entry point and projection was utilized for screw placement. Most patients had 12-14-mm length and 3.5 mm diameter screws placed for subaxial lateral mass and 28-30mm for C1 lateral mass. Intraoperative and post-operative plain x-ray and computed tomography scan were used to assess the screw position , besides that; the facet joint, nerve root foramen and foramen transversarium violation were also considered.
Follow-up was obtained in all cases ranging from 6 months and extended up to eight years. Clinical assessment parameteres included age, gender, pre-operative neurologic status, surgical indication and levels required stabilization. Incorporation of anterior instrumentation, Craniocervical or cervico-thoracic approaches were considered in some cases. Radiographic indicators included early postoperative cervical spine X-ray and computed tomography (CT) scan to check for screw location and plain radiographs at subsequent checks.
As a result, none developed neural or vascular injury. Twelve patients had wound infection, six of them were deep. Twenty patients had C5 radicular pain that subsided over time and two of them required C5 screw modification, another 3 patients required screw repositioning at different levels because of persistent radicular pain which subsided after surgery. Two patients had asymptomatic screw pull-out that was evident only on X-ray and CT scan that required no treatment. Iatrogenic CSF occurred in 12 cases with severe spondylosis while CSF leak from the wound was observed in only 3 patients. Symptomatic adjacent segment disease was noted on four cases within the period of follow up and were treated with surveillance
Decompressive cervical spine laminectomy with Lateral mass screw-rod arthrodesis is a unique surgical technique that can be applied safely and effectively not only for cervical spondylosis but for a wide variety of cervical spine diseases with low complications and durable short and long term outcome.
Minimally invasive spine surgery (MIS)
Dr. Darweesh khawaja
Consultant Neurosurgeon and spine surgeon.
Department of Neurosurgery
Nepean Hospital. Sydney/ Australia
Minimally invasive spine surgery (MIS) was first performed in the 1980s, but has recently seen rapid advances. Technological advances have enabled spine surgeons to expand patient selection and treat an evolving array of spinal disorders, such as degenerative disc disease, herniated disc, fractures, tumors, infections, instability, and deformity.
Endoscopic Assisted Transcranial Surgery of the Skull Base – Concepts and Surgical Technique
Joachim Oertel, Guilherme Ramina Montibeller
Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany
In skull base surgery, delicate structures frequently limit the microsurgical options in lesion removal or exposure of the operative field. Neuroendoscopy with its ability to “look around the corner” and its options in reducing craniotomy size and in reducing the extent of the approach may facilitate receiving additional information. Here, the authors focus on the description of the endoscopic technique in transcranial skull base surgery.
Material and Methods
A series of endoscope assisted skull base surgeries operated on by a single surgeon between 2003 and 2013 is presented. The endoscope was applied either for endoscopic inspection or endoscopic assistance in several skull base surgery cases. Surgical reports, diagnostic imaging and intraoperative video-recordings were retrospectively analyzed. Particular focus was given on the way of application, the ideal set up of the endoscopic equipment and the usefulness of the endoscope.
The usefulness of the endoscope for skull base meningiomas, vestibular schwannomas, trigeminal neurinomas, prepontine and parapontine arachnoid cysts, craniopharyngiomas aneurysms, hemifacial spasms, trigeminal neuralgias, and epidermoid tumors between other pathologies were analyzed. The endoscope was always applied together with the microscope to ensure intraoperative overview and 3D perception. In the most part of cases, the endoscope was used for inspection and in around 1/5 of the cases for endoscopic-assisted surgery. Some identified advantages of this technique were the reduction of retraction of structures and the option of better surgical field exposure when small craniotomies where performed. After microsurgical resection of intrameatal tumors, remnant tumor could be found in some cases during final endoscopic inspection. Endoscopic inspection and endoscopic-assisted tumor resection revealed to be of great support in epidermoid tumor surgeries finding remnant tumor and reaching difficult and delicate areas. The endoscope could also provide new information in some specific cases when the complete anatomy of aneurysms could not be exposed by the single use of the microscope.
The application of the endoscope in addition to the microscopic view revealed to be of great benefit for different pathologies of the skull base. After some training and respecting some safety rules the endoscope can be safely applied in this region. Neuroendoscopic visualization developed faster than microsurgical instruments and seeing does not necessarily means reaching in skull base surgery. The development of new instruments will certainly enhance the role of the endoscope in the near future.
Endoscopy Brain Surgery
Development of International Ethical Standards for Stem Cell-Based Therapy
Ziad AlZoubi1, Adeeb AlZoubi2,3, Emad Jafar1
1 Department of Neurorestoratology, Jordan Orthopedic and Spine Center, Amman, Jordan
2 Stem Cells of Arabia, Amman, Jordan
3 Department of Surgery, University of Illinois College of Medicine in Peoria, Peoria, IL, USA
Stem cell therapy (SCT) is a fast advancing field that is currently affecting most medical practices worldwide. Currently, there are vague guidelines that come short of governing the practice of SCT. The lack of such guidelines led to the emergence of uncontrolled practices that maimed the serious efforts in this very important field. These uncontrolled practices raised justified and serious considerations on the ethical, legal, religious issues surrounding SCT. The most critical question is whether the scientific community has enough data both on basic research and clinical arena to start implementing SCT on patients suffering from different illnesses. While patients suffering from illnesses as hematopoietic malignancies and immune deficiencies are currently covered by a world-wide acceptance for SCT to treat their diseases, patients suffering from other non-hematopoietic diseases are still waiting for such opportunity.
The ability of any SC research group to strike a balance between risk and benefit is of great importance towards establishing a high standard for SCT. However, to establish a solid base for such balance faces the challenge of translating the available scientific research findings to applicable clinical practice. This translational research requires conducting long and expensive clinical trials in order to collect enough data to justify SCT in clinical practice. Demands from patient advocate groups for availability of high quality SCT in shorter periods of time dictate streamlining efforts at international levels to guarantee the delivery of SCT without compromising patient safety and authenticity of results.
A reliable SCT approach should only be executed after obtaining an IRB approval from an accredited ethical committee for the intended work. The group should also define sources of funding such work, and methods or assessing and analyzing clinical outcomes. On the scientific side, the SCT team should define types, sources, methods of harvesting, purification and transplantation of the stem cells used in the therapy. We believe that a successful SCT team should be qualified and accredited to carry out SCT at an international standard and in accordance with local rules and guidelines in the country where the procedures are to be performed, where preparation and delivery of acceptable cellular products by authorized personnel in a licensed facility should be guaranteed.
Endoscopic transsphenoidal approach for pituitary adenoma
Ali Ayyad , Martin Glaser, Alf giese
Department of Neurosurgery, Johannes gutenberg university
The transsphenoidal route is a direct and rapid extra cerebral approach to the sellar region, and therefore, it is the most widely used technique for the processes involving this area.Since its introduction in 1907 it has been subjected to tremendous developments. The endoscope is the latest innovation in the field of optical instrumentation; it allows the ‘surgeon’s eye’ to penetrate the depth and width of the access route.
During 4 years between Dec.2003 till Dec.2011 we have operated 287 patients with pituitary macroadenoma, including 17 gaint adenoma. 145 males,142 females.76 had hormone active tumors (39 GH, 16 ACTH , 14 Prolactinoma, 5 GH+Prolc., 2 LH+FSH ), 124 with non functioning adenoma. Most patients presented with visual disturbances.
Total excision was achieved in 90% of patients.From 76 patients with active adenoma 75% were in remission postop.
85% of patients with visual disturbances showed improvement
No visual deterioration.
2 patients developed postoperative bleeding,
3 patients had postoperative CSF rhinorrhea.
46 hyposmia or anosmia
The minimum traumatization of the nasal cavitiy without nasal retractor, the optical advantages of the endoscopic visualization in anatomical orientation and tumor removal and the early postoperative improve of the patients without nasal packing are obvious advantages of the endoscopic binostril technique.
ENDOSCOPIC ASSISTED MICROVASCULAR DECOMPRESSION OF THE TRIGEMINAL AND FACIAL NERVE
Ali Ayyad , Martin Glaser, Alf giese
Department of Neurosurgery, Johannes gutenberg university
Microscopic vascular decompression became the gold standard for surgical treatment of neurovascular compression syndromes in the posterior fossa since it has been introduced By Jannetta .
The introduction of the endoscope in neurosurgical procedures has brought a further new dimension into the field of intraoperative visualization. It provides, in contrast to the microscope, a panoramic view of the cerebellopontine angle (CPA) anatomy (especially with angled endoscopes) and shows exactly the differences between the pathological and the normal anatomy.
during a 10 years from 2002 till 2012 We performed endoscopic assisted microvascular decompression in 77 patients with symptomatic trigeminal and facial nerve compression syndromes; 41 trigeminal neuralgia, 34 Hemifacial spasm and 2 patients with both syndromes. They were 40 females and 37 males.Surgery was performed in all cases under endoscope-assisted keyhole conditions. All 43 patients with trigeminal neuralgia received preoperative medication treatment and experienced failure with it. 20 patients out of 34 with hemifacial spasm had been previously treated with botulinum toxin injections.
75 of the 77 patients became symptom free after surgical treatment; one revision surgery was performed.
4 patients developed hearing deterioration, 2 facial palsies.
Conclusion: A precise planned keyhole craniotomy and the simultaneous use of the microscope and the endoscope render the procedure of the decompression less traumatic.
Neuroendoscopy, King Hussein Medical Centre Experience
Dr. Nidal Khasawneh, M.D.
Neurosurgery Department, King Hussein Medical Centre, Amman, Jordan.
OBJECTIVE: Neuroendoscopy is a corner stone in minimal invasive surgery in the field of neurosurgery. and an alternative to shunts in different types of cranial pathologies. In this paper we present our experience with neuroendoscope at King Hussein Medical Centre.
METHODS: During the last 8 years 218 cases were operated on using neuronendoscope, 174 cases of hydrocephalus and 41 cases of; arachnoid cyst (15 cases), tumour biopsies (17 cases), chronic subdural haematoma (5 cases), and craniopharyngioma (4 cases). Procedures and cases are described.
The 174 cases of hydrocephalus included the following aetiologies; 71 cases congenital aqueductal stenosis, 53 cases secondary to brain tumor,8 cases secondary to intraventricular bleeding, 19 cases with shunt failure (7 cases infection and 12 cases shunt obstruction), 23 cases of complicated hydrocephalus (9 loculated hydrocephalus, 11 septated hydrocephalus and 3 cases of isolated ventricle.).
RESULTS: The mean age for the 174 cases of hydrocephalus was 2.5 years (7 days to 66 years). Procedures included 163 cases of third ventriculostomy, 7 cases of aqueductoplasty, and 4 cases of lamina terminalis fenestration.
Procedure was successful in 59 cases (83%) of congenital aqueductal stenosis, 42 cases (80%) of brain tumour, 3 cases (37.5%) secondary to intraventricular bleeding, and 16 cases (68.4%) with shunt failure.
For complicated hydrocephalus unification of the ventricle and fenestration of loculation was achieved in all cases.
The four cases of craniopharyngioma were operated on as a recurrence and the cysts were aspirated, fenestrated and a reservoir inserted.
Tumour biopsies were diagnostic in 15 (88%) out of 17 cases.
CONCLUSION: The experience with neuronendoscope suggests a positive effect on reducing invasiveness of surgery and thus reducing complications rate, intensive care stay, hospitalisation, and operating time which indeed reflected on surgery outcome and patient’s morbidity.
Key words: neuronendoscope, hydrocephalus.
Endoscopic assisted microsurgical technique for management of anterior cranial fossa lesions using the key hole supraorbital approach
Dr. Ali Ayyad
The priority in contemporary neurosurgery is to achieve the greatest therapeutic effect while causing the least iatrogenic injury.
The concept of keyhole surgery is based on the careful preoperative study of diagnostic images to determine the anatomic windows that provide access to the pathological processes, taking into consideration the individual pathoanatomic situation of the patient.
The supraorbital subfrontal approach expose the suprasellar anatomic structures free for surgical dissection.
The endoscope is the latest innovation in the field of optical instrumentation; it allows the ‘surgeon’s eye’ to penetrate the depth and width of the access route
Using different angled endoscopes will be very helpful to extend further the surgical fields, visualize hidden parts and even control tumor removal which improves the surgical outcome.
Here we describe the endoscopic assisted micosurgical technique in combination with supraorbital key hole craniotomy, for management of ant. Cranial fossa lesions.
During a 17 year period between 1995 till 2012 we have performed endoscope assisted microsurgical procedures for ant.skull base lesions including:
Ant. Cranial fossa meningioma 137
Arachnoid cysts 42
Pituitary adenoma 58
The postoperative complications associated with approach were:
Supraorbital hypesthesia 17 patients
Permanent palsy of the frontal muscle 12 cases
Permanent hyposmia in 24 patients
Wound healing disturbances 3 cases
Subcutaneous CSF collection & leak in 11 patients
The supraorbital craniotomy allows a wide exposure for deep-seated intracranial areas, it offers equal surgical possibilities with less approach-related morbidity.
The optical advantages of the endoscopic visualization in anatomical orientation and tumor removal improve the surgical outcome.
All these factors contribute to improve the postoperative due to reduction in the complications with pleasing cosmetic outcome.
Penetrating head injury with a bullet outcome
Dr abdulrahman shdaifat
Department of neurosurgery
The university of Jordan
Our case is a 40 year-old male with history of penetrating head injury with falling bullet, which crossed midline twice (at time of injury and during spontaneous migration) with conscious patient at presentation and moderate visual field defect which showed gradual improvement after surgical intervention. Although reported morbidity and mortality is high in such injuries, our patient survived with less morbidity and a subjective visual improvement after surgical removal of the bullet.
Falling bullet injury, Penetrating brain injury, Migration, Surgical removal.