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Object Minimally invasive (MI) fusion and instrumentation techniques are playing a new role in the treatment of adult spinal deformity. The open pedicle subtraction osteotomy (PSO) and Smith-Petersen osteotomy (SPO) are proven segmental methods for improving regional lordosis and global sagittal parameters. Recently the MI anterior column release (ACR) was introduced as a segmental method for treating sagittal imbalance. There is a paucity of data in the literature evaluating the alternatives to PSO and SPO for sagittal balance correction. Thus, the authors conducted a preliminary retrospective radiographic review of prospectively collected data from 2009 to 2012 at a single institution. The objectives of this study were to: 1) investigate the radiographic effect of MI-ACR on spinopelvic parameters, 2) compare the radiographic effect of MI-ACR with PSO and SPO for treatment of adult spinal deformity, and 3) investigate the radiographic effect of percutaneous posterior spinal instrumentation on spinopelvic parameters when combined with MI transpsoas lateral interbody fusion (LIF) for adult spinal deformity. Methods: Patient demographics and radiographic data were collected for 36 patients (9 patients who underwent MI-ACR and 27 patients who did not undergo MI-ACR). Patients included in the study were those who had undergone at least a 2-level MI-LIF procedure; adequate preoperative and postoperative 36-inch radiographs of the scoliotic curvature; a separate second-stage procedure for the placement of posterior spinal instrumentation; and a diagnosis of degenerative scoliosis (coronal Cobb angle > 10° and/or sagittal vertebral axis > 5 cm). Statistical analysis was performed for normality and significance testing. Results Percutaneous transpedicular spinal instrumentation did not significantly alter any of the spinopelvic parameters in either the ACR group or the non-ACR group. Lateral MI-LIF alone significantly improved coronal Cobb angle by 16°, and the fractional curve significantly improved in a subgroup treated with L5–S1 transforaminal lumbar interbody fusion. Fifteen ACRs were performed in 9 patients and resulted in significant coronal Cobb angle correction, lumbar lordosis correction of 16.5°, and sagittal vertebral axis correction of 4.8 cm per patient. Segmental analysis revealed a 12° gain in segmental lumbar lordosis and a 3.1-cm correction of the sagittal vertebral axis per ACR level treated. Conclusions The lateral MI-LIF with ACR has the ability to powerfully restore lumbar lordosis and correct sagittal imbalance. This segmental MI surgical technique boasts equivalence to SPO correction of these global radiographic parameters while simultaneously creating additional disc height and correcting coronal imbalance. Addition of posterior percutaneous instrumentation without in situ manipulation or overcorrection does not alter radiographic parameters when combined with the lateral MI-LIF.

Patients with temporal lobe CCM should be offered resection for durable seizure control, prevention of secondary epileptogenic foci, and elimination of hemorrhage risk. The preoperative work-up should follow a team approach. Surgical intervention should include complete lesionectomy in all cases. Intra or extra-operative ECoG for neocortical lesions may be beneficial. Management of mesial temporal CCMs (archicortex) should consider resection of a well-defined epileptogenic zone (including mesial structures) due to high probability of pathologically proven MTS. The use of this treatment algorithm is useful for the education and treatment of these patients.

Since its revival in the early 1990s, neuroendoscopy has become an integral component of modern neurosurgery. 7,16,19 Various endoscopic techniques have been described and are frequently used for the treatment of CSF circulation disorders including third ventriculostomy, septostomy, lamina terminalis fenestration, temporal ventriculostomy, foraminoplasty of the foramen of Monro, and aqueductoplasty. 21 Endoscopic placement of indwelling stents, however, is a rarely performed, but nonetheless valuable, procedure. The best-studied stenting procedure is aqueductal stenting in the setting of triventricular hydrocephalus and in cases of isolated fourth ventricles in children, which is known to be technically feasible and has shown good results in long-term follow-up. 2,9,13,18,22 Limited reports exist, however, about the value and outcome of endoscopic stent placement in adults.We present the first series of neuroendoscopic stent placement in adults from a single center over 20 years. The aim of the present study was to identify favorable indications for neuroendoscopic stent placement in adults, including operative results, complications, and clinical outcomes data.abbreviatioNs AC = arachnoid cyst; ETV = endoscopic third ventriculostomy. results Of 526 endoscopic intraventricular procedures, stents were placed for treatment of CSF disorders in 25 cases (4.8%). The technique was used in the management of arachnoid cysts (ACs; n = 8), tumor-related CSF disorders (n = 13), and hydrocephalus due to stenosis of the foramen of Monro (n = 2) or aqueduct (n = 2). The mean follow-up was 87.1 months. No deaths or infections occurred that were related to endoscopic placement of intracranial stents. Late stent dislocation or migration was observed in 3 patients (12%). coNclusioNs Endoscopic intracranial stent placement in adults is rarely required but is a safe and helpful technique in select cases. It is indicated when reliable and long-lasting restoration of CSF pathway obstructions cannot be achieved with standard endoscopic techniques. In the treatment of tumor-related hydrocephalus, it is a good option to avoid reclosure of the restored CSF pathway by tumor growth. Currently, routine stent placement after endoscopic fenestration of ACs is not recommended. Stent placement for treatment of CSF disorders due to tumor is a good option for avoiding CSF shunting. To avoid stent migration and dislocation, and to allow for easy removal if needed, the device should be fixed to a bur hole reservoir.

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The present series confirms the feasibility and safety of ETV before posterior fossa tumor surgery in adult patients. If patients had symptomatic hydrocephalus before tumor surgery, an ETV can be performed, followed by early elective tumor surgery. A prophylactic ETV in asymptomatic patients is not advised. Early elective tumor surgery should be performed in these patients.

The SCIT is a powerful tool that the neuroendoscopist can use for visualization to achieve hemostasis when performing intraventricular endoscopic surgery.

Patients with increased intracranial pressure (ICP) caused by hydrocephalus or brain injury have poor brain compliance or increased brain stiffness. The condition is commonly treated by a surgical diversion of cerebrospinal fluid (CSF) through placement of a ventriculoperitoneal (VP) shunt. These inserted devices frequently fail and require replacement. Assessment of failed devices typically requires an invasive surgical procedure to implant an ICP sensor. Brain compliance can be determined non-invasively by comparing the intracranial pressure (ICP) waveform to the digital artery waveform. The ICP waveform is derived from a piezo sensor snugged into the external ear canal and worn as a headset. The digital artery waveform is derived from a stand pulse oximeter. Digital signal processing performed on sampled data from these two sensors shows a time-lag or phase relationship between the two waves which widens with worsening brain stiffness or compliance. An algorithm is presented that shows how these signals can be used to compute brain compliance. An instrument designed to calculate real-time brain compliance to aid healthcare professionals is described.