Name:
10.3171/2024.1.FOCVID23209
Description:
10.3171/2024.1.FOCVID23209
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/40363f34-0427-4964-8749-2bbf6ffe43cb/videoscrubberimages/Scrubber_286.jpg
Duration:
T00H09M20S
Embed URL:
https://stream.cadmore.media/player/40363f34-0427-4964-8749-2bbf6ffe43cb
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/40363f34-0427-4964-8749-2bbf6ffe43cb/17. 23-209.mp4?sv=2019-02-02&sr=c&sig=enYuqHqefcgAyBuZSHlXvU0%2BWFL4y%2FSqeJVL%2FwWhRhI%3D&st=2026-03-31T20%3A37%3A58Z&se=2026-03-31T22%3A42%3A58Z&sp=r
Upload Date:
2024-03-04T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[MUSIC PLAYING]
SANJAY KONAKONDLA: This case demonstrates the application of full endoscopic unit portal spine techniques to safely remove a disc osteophyte complex and to repair a spontaneous cerebrospinal fluid leak in the thoracic spine. I'm Sanjay Konakondla, and I'll review the patient workup, technical nuances, and intraoperative considerations we made for a successful surgical result. The patient is a 43-year-old female, with a past medical history significant for anxiety and depression, who suffered from multiple years of longstanding headaches, dizziness, double vision, and generalized malaise.
SANJAY KONAKONDLA: Previous workup identified tonsillar ectopia. However, the clinical workup and questioning revealed symptoms more closely related to intracranial hypotension. She had significant exacerbation of her headaches with any amount of activity, which included sitting from a supine position or standing from a seated position. She also failed conservative management, which also included empiric epidural blood patch.
SANJAY KONAKONDLA: Imaging available for review included an MRI of the brain, as well as a cervical spine, which revealed a full sella and findings suggestive of intracranial hypotension. The cervical MRI revealed cerebellar ectopia, as well as extradural cerebrospinal fluid in the high thoracic spine. The thoracic spine MRI revealed a significant T7 to T8 disc osteophyte complex, with ventral compression of the spinal cord and findings of extradural cerebrospinal fluid.
SANJAY KONAKONDLA: A prone position CT myelogram revealed a fast cerebrospinal fluid leak at the level of the T7-8 disc osteophyte complex. The patient was deemed appropriate for an operative intervention for disc osteophyte removal and repair of the spinal fluid leak. A full endoscopic surgical procedure was chosen to optimize intraoperative visualization while minimizing surgical invasiveness and to avoid an open intradural approach, which may necessitate greater spinal cord manipulation.
SANJAY KONAKONDLA: After full informed consent, the patient was scheduled electively for this procedure. Intraoperative positioning included an open Jackson table with a Wilson frame. The patient was induced under general endotracheal anesthesia without complication and positioned prone onto the operating table. All pressure points were accounted for and padded. Intraoperative neuromonitoring was used throughout the case.
SANJAY KONAKONDLA: Screens were opposite to the surgeon for comfort. Surgery was completed from a right-sided approach, as the leak was slightly eccentric to the right side. Intraoperative fluoroscopy is used to identify specific landmarks. After the appropriate level is identified, lines are drawn at the midline and at the disc level. The C-arm on the AP view was used to mark the appropriate level,
SANJAY KONAKONDLA: and a spinal needle was placed on the caudal pedicle of the contralateral side. This static marker at the level of interest is our preferred technique when completing endoscopic approaches in the thoracic spine to create a reproducible and constant point of reference throughout the procedure. A spinal needle is advanced into Kambin's triangle. A K-wire is placed through the spinal needle,
SANJAY KONAKONDLA: the spinal needle is removed, and sequential dilators are placed over the K-wire. A tubular retractor is then advanced over the final dilators. The system used in this case was a joimax TESSYS set, which has a tubular retractor inner and outer diameter of 6.5 and 7.5 mm, respectively. This allows for the passage of an endoscope with a 3.7-mm working channel diameter and facilitates Kerrison instruments up to 3.5 mm and a round diamond drill of 3.5-mm in diameter.
SANJAY KONAKONDLA: The endoscope is introduced into the tubular retractor and a high-speed diamond tip drill is used to remove the partial inferior articulating process of T7 and partial superior articulating process of T8. After minimal drilling, the joint space can be identified and is labeled by the still image. Once the joint is identified, further drilling can be completed through the superior articulating process of T8 to enter the epidural space.
SANJAY KONAKONDLA: Once the epidural space is identified, drilling is continued to enlarge the opening to access the disc space in the epidural space. Epidural veins are identified once the medial superior articulating process is removed, and the distinction between the dura and the epidural veins and fibers of the epidural space is critical, and we stress the practice of, quote, "trusting the fat" to continue safely to identify the spinal cord dura.
SANJAY KONAKONDLA: Pituitary graspers are used to clear the epidural space and expose the spinal cord dura. This is where it is absolutely necessary to properly identify tissue planes. The disk herniation can be identified ventral to the spinal cord, as shown in the still image.
SANJAY KONAKONDLA: To facilitate safe entry ventral to the spinal cord, a high-speed drill is used to remove part of the dorsal vertebral body of T7 and T8 and further disc resection is completed. We recommend our vertebral body core technique to not only easily identify anatomy, but to avoid spinal cord manipulation. This also keeps a barrier between the drill bit and the spinal cord dura.
SANJAY KONAKONDLA: The disc space is then followed medially to identify any further disc herniations and to facilitate visualization directly ventral to the spinal cord dura. A curved ball-tip bipolar device can be passed ventral to the spinal cord dura and dorsal to the disc herniation. Additional disc herniation can be appreciated here as we have the vertebral bodies appropriately and clearly identified.
SANJAY KONAKONDLA: This is freed from the ventral dura and carefully removed with pituitary graspers, both straight and slightly up-angled. It is important to note here that the direction of release should always be directed ventrally into the space created and away from the spinal cord. This technique ensures the avoidance of spinal cord trauma when removing discs through an angled scope view.
SANJAY KONAKONDLA: After removal of the disc components, the spinal cord is now decompressed. Attention can now be placed on identification of the ventral dural defect. A curved instrument was used to identify this defect, which is shown with the blue arrow in the still image. Once identified, the defect was inspected thoroughly.
SANJAY KONAKONDLA: Small pieces of dural substitute were cut and used for repair of the dural defect. Dural substitute was placed as an inlay, followed by an inlay of various dural substitute pieces and sizes. During these maneuvers, the continuous irrigation was stopped intermittently to ensure proper placement of the dural substitute.
SANJAY KONAKONDLA: The laxity of the dura can be appreciated here due to the extradural spinal fluid leak. A dural sealant was subsequently applied. The scope and the tubular retractor were removed, and the incision was closed with absorbable sutures and glue. Surgery time was 148 minutes and estimated blood loss was about 10 cc. The patient was admitted to the hospital and observed closely.
SANJAY KONAKONDLA: She was laid flat overnight and gradually mobilized on postoperative day 1 to postoperative day 3, and was discharged on postoperative day 3, reporting immediate symptom relief. The patient was followed closely for rebound headaches and a CT of the head was completed, which revealed stable ventricle size. Postoperative MRI of the thoracic spine revealed a decompressed spinal cord with removal of the disc osteophyte complex and significant decrease in extradural cerebrospinal fluid.
SANJAY KONAKONDLA: It should be noted that these cases are challenging, and specific consideration should be given to preoperative planning. Comprehensive training and full endoscopic spine procedures, clinical experience, and surgical volume of endoscopic spine procedures are necessary for successful surgical outcome.
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