Endoscopy and Fetoscopy Techniques for the Brain and Neuroaxis E-Book
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- Herausgeber: Bentham Science Publishers
- Kategorie: Fachliteratur
- Serie: Neuroendoscopy and Interventional Pain Medicines
- Sprache: Englisch
Neuroendoscopy and Interventional Pain Medicine is a clinically focused medical monograph series. With contributions from a team of internationally recognized neurosurgeons and spinal surgery specialists, the series aims to illuminate the latest advancements in minimally invasive neurosurgical techniques and pain management. Each volume offers invaluable insights into the future of minimally invasive treatments in this medical subspecialty.
Endoscopy and Fetoscopy Techniques for the Brain and Neuroaxis is the second of the monograph series. The book covers advanced endoscopic techniques for brain and spinal surgeries. Topics include visualization of the brain, endoscopic approaches to the sellar region, fetoscopy treatments for myelomeningocele, and methods for cancer pain relief. It also discusses endoscopic correction of craniosynostosis in children, complications like autonomic dysreflexia, and the importance of identifying the Adamkiewicz system in spinal procedures.
Key Features
- Covers a wide range of topics in neuroendoscopy and interventional pain medicine
- Emphasizes evidence-based approaches to treatment
- Offers clinical perspectives from expert surgeons
- Includes scientific references for researchers and advanced learners
It is an essential resource for readers who need to enhance their understanding of the latest technological advancements in neuroendoscopy and interventional pain medicine and apply these innovative techniques to improve patient outcomes.
Readership
This book is designed for a broad audience, including interventionalists, surgeons, medical students, healthcare professionals, and policy-makers involved in the care of patients with degenerative conditions of the neuroaxis.
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Seitenzahl: 284
Veröffentlichungsjahr: 2024
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PREFACE
Welcome to Neuroendoscopy and Interventional Pain Medicine, Vol. 2: Endoscopy and Fetoscopy Techniques for the Brain and Neuroaxis. This volume centers on sophisticated techniques and critical considerations in the rapidly developing field of advanced neuroendoscopy of the brain, anterior and posterior skull base, and spinal cord for pain, tumors, and seizures, mainly focusing on advanced intracranial, intradural, and fetoscopic procedures. It brings together the collective expertise of renowned specialists, offering an invaluable resource for clinicians and researchers dedicated to enhancing patient care through innovative surgical approaches.
The book begins with a comprehensive overview of the State-of-the-Art direct endoscopic visualization of the brain and neuroaxis, highlighting the latest advancements in imaging and visualization technologies that have revolutionized neurosurgical practices. One chapter sets the foundation for understanding the complex anatomy and pathological conditions that neuroendoscopy addresses. Trigeminal tractotomies and nucleotomies explore targeted endoscopic interventions for trigeminal neuralgia and other intractable facial pain syndromes. This chapter aims to improve outcomes for patients suffering from these debilitating conditions by providing detailed procedural insights. The endonasal endoscopic approaches to the sellar region and the anterior fossa chapter discuss minimally invasive techniques for accessing and treating pathologies in these critical regions. The authors present step-by-step methods and highlight the benefits of these approaches in reducing patient morbidity. Understanding the pathophysiology of myelomeningocele & modern surgical treatment is crucial for developing effective management strategies for this congenital condition. This chapter thoroughly examines the underlying mechanisms and contemporary fetoscopy options available to clinicians. Building on this knowledge, fetoscopy techniques for myelomeningocele outline the prenatal interventions that can be performed to mitigate the effects of myelomeningocele. The authors share cutting-edge fetoscopic techniques that hope for improved outcomes in affected fetuses. For the treatment of cancer pain, microendoscopic intradural cordotomy offers a minimally invasive option. This chapter details this approach's procedural aspects and efficacy, which targets the pain pathways within the spinal cord to provide relief for patients with intractable pain. The endoscopic anatomy of the transcallosal hemispherectomy based on a cadaver study with advanced 3D modeling provides a unique perspective on the anatomical intricacies of this procedure. Using advanced 3D modeling, the authors offer valuable insights into the endoscopic anatomy, facilitating better surgical planning and execution. Outcomes of endoscopic treatment for early correction of craniosynostosis in children present the benefits and results of early intervention for this congenital skull deformity. This chapter underscores timely surgical correction's importance in promoting normal brain development and growth. The chapter on autonomic dysreflexia with hypertension following durotomy-related intradural spread of irrigation fluid and air during routine spinal endoscopy addresses a severe but rare complication of spinal endoscopy. The authors discuss the pathophysiology, recognition, and management of autonomic dysreflexia to enhance patient safety. Finally, a commonly overlooked issue during thoracic spinal endoscopy is given credence in this volume's final chapter, highlighting the importance of preoperative identification of the Adamkiewicz System. A thorough preoperative workup is needed to avoid catastrophic complications during thoracic spinal endoscopy. By identifying Adamkiewicz's artery system, surgeons can better navigate the thoracic spine and reduce the risk of spinal cord ischemia.
Each chapter in this volume has been meticulously selected to reflect contemporary trends and innovations in neuroendoscopy of the brain, anterior and posterior fossa, brain stem, and relevant interventional pain management procedures. By addressing the need for safer, more efficient, and cost-effective solutions, this book aims to meet the demands of patients, healthcare providers, and policymakers. The editors hope that Vol. 2 of Neuroendoscopy and Interventional Pain Medicine: Intra- and Extradural Endoscopy & Fetoscopy Techniques of the Brain and Neuroaxis serves as an indispensable resource for clinicians and researchers committed to advancing the field and improving patient care.
List of Contributors
State-of-the-Art in Direct Endoscopic Visualization of the Brain and Neuroaxis
Ernesto Luis Carvallo Cruz1,William Omar Contreras López2,*,Kai-Uwe Lewandrowski3,4,5,Stefan Landgraeber6,Jorge Felipe Ramírez León7,8,9,Peter Winkler10,Benedikt Burkhardt11,Joachim Oertel12Abstract
Over the past two decades, the endoscopic endonasal approach has significantly expanded the armamentarium of minimally invasive skull base surgery. Initially developed for the treatment of pituitary adenomas, endoscopic endonasal skull base surgery (EESBS) has found increasing utility in managing a broad spectrum of skull base pathologies. Its application extends from the midline, encompassing the crista galli process to the occipitocervical junction, and laterally to the parasellar areas and petroclival apex. In recent years, there has been a notable shift from the exclusive use of endoscopic technology in endonasal pituitary surgery to other neuroendoscopic
procedures. This chapter aims to provide the reader with an up-to-date overview of clinical trials on endoscopic neurosurgery of the skull base, brain, and neuroaxis. Through a comprehensive review of the state-of-the-art published peer-reviewed literature, the authors strive to offer a concise summary of the current concepts in this rapidly advancing field.
INTRODUCTION
Technological advancements have played a pivotal role in the expansion of endoscopic visualization in the field of brain and neuroaxis. This innovative tool has emerged as a transformative technique, granting neurosurgeons unparalleled access during surgical procedures. Direct endoscopic visualization necessitates specialized endoscopes equipped with high-definition cameras and illumination systems. When combined with three-dimensional imaging systems, these high-definition cameras offer neurosurgeons an immersive and highly detailed view of the surgical field. This superior visualization facilitates the identification of critical structures and improves spatial orientation. Moreover, this technique provides a minimally invasive alternative to traditional open surgery, mitigating the risks associated with extensive tissue disruption while enhancing surgical precision and patient outcomes.
The boundaries of transnasal endoscopic surgery in the pituitary fossa have been surpassed, and its applications now extend from the midline, spanning from the crista galli process to the occipitocervical junction. It extends laterally to the parasellar areas and petroclival apex in the posterior skull base. The ability to directly visualize pathological structures, assess lesion extent, and precisely target treatment sites has made neuroendoscopy a competitive alternative to traditional open surgery for treating brain tumors, vascular malformations, hydrocephalus, and other conditions affecting the brain and neuroaxis. Furthermore, the applications of endoscopic surgery extend beyond conventional neurosurgery, finding utility in diagnostic biopsies, intracranial pressure monitoring, and cerebrospinal fluid management.
The advantages of direct endoscopic visualization are manifold. By utilizing smaller incisions or natural orifices, this technique minimizes tissue trauma and reduces the risk of complications such as infection, bleeding, and scarring. Additionally, endoscopes’ magnification and illumination capabilities enable surgeons to visualize structures with enhanced clarity and precision, thereby promoting optimal decision-making during surgery. Moreover, this technology contributes well to integrating augmented reality and virtual reality platforms, further improving surgical planning and intraoperative navigation, thereby fostering safer and more efficient procedures. Furthermore, the minimally invasive nature of neuroendoscopy often results in shorter hospital stays, faster recovery times, and improved patient satisfaction. In this chapter, the authors aim to provide an up-to-date overview of clinical trials on endoscopic neurosurgery of the skull base, brain, and neuroaxis.
Historical Perspectives
Since the dawn of the 20th century, endoscopic neurosurgical modalities have evolved significantly. Hermann Schloffer initiated the transsphenoidal access in 1906, innovatively accessing a pituitary neoplasm via the sphenoid bone. L'Espinasse, in 1910, employed a cystoscope for choroid plexus fulguration in two infants, heralding success in one [1]. Walter Dandy's 1922 endeavor for a choroid plexectomy found no success [2]; however, 1923 saw Mixter's landmark achievement with an endoscopic third ventriculostomy (ETV) using a urethroscope on a pediatric patient [3]. Scarff later introduced a state-of-the-art endoscope in 1935, playing a pivotal role in addressing hydrocephalus arising from benign aqueductal stenosis or periaqueductal masses [1, 4].
The paradigm shifted with Nulsen and Spitz's introduction of ventricular cerebrospinal fluid (CSF) shunting in 1952 [5]. Nevertheless, 1959 marked the ushering in of modern endoscopy through the rod-lens system developed by Harold Hopkins. By 1963, Gerard Guiot made noteworthy strides with a fiberoptic endoscopic transnasal transsphenoidal intervention. Yet, the operating microscope retained its supremacy, especially in skull base surgeries [5].
With the emergence of coupled-charge devices from Bell Laboratories in 1969, video-endoscopy found its footing, and was subsequently honed by Karl Storz. The subsequent decade observed an ETV renaissance for obstructive hydrocephalus, propelled by enhanced endoscopic visualization. In 1978, Vries delineated the ETV's potential using cutting-edge fiberoptic instruments [6]. Thereafter, Jones et al. highlighted evolving shunt-free success trajectories, peaking at 61% in a pool of 103 patients by 1994 [7] [8], with contemporary rates oscillating between 80% to 95% [1, 4-8]. In a further pioneering leap, 1992 saw Roger Jankowski et al. reporting the first endonasal pituitary excision via endoscopy [9], followed by Ricardo Carrau and Hae-Dong Jho's substantial series in 1997, encompassing 50 patients [10].
The Standards
Neuroendoscopy has evolved to encompass a plethora of conditions beyond traditional ventricular interventions. Now, its application extends to address intracranial cysts, intraventricular neoplasms, hypothalamic hamartomas, cranial base neoplasms, craniosynostosis, certain spine pathologies, specific hydrocephalus subtypes, among others. Modern neuroendoscopic suites, boasting high-definition endoscopic technologies, have exponentially enhanced surgical visualization and ergonomic efficiency, allowing seamless collaboration amongst multiple surgeons. In the following, the authors attempt to briefly touch on some of the current neuroendoscopic surgery standards without claiming complete description of the many protocol advances currently in various stages of clinical investigation in the fast moving field of neuroendoscopy.
Endoscopy in Hydrocephalus Management
Endoscopic third ventriculostomy (ETV) stands as the premier intervention for obstructive hydrocephalus, particularly in the context of aqueductal stenosis, with efficacy rates surpassing 60%. Additionally, ETV proves instrumental in managing hydrocephalus secondary to tectal plate lesions [1, 11]. Factors such as the hydrocephalus etiology and patient age play a pivotal role in ETV's success. While infants, especially those presenting with congenital hydrocephalus or myelomeningocele, may pose challenges, efficacy rates in older children and adolescents often eclipse 70% [12]. In instances of midline posterior fossa tumors precipitating acute hydrocephalus, a preoperative ETV can be contemplated, positioning it as a reliable substitute to shunt placement postoperatively [12]. Moreover, endoscopic techniques, including septostomy, septum pellucidotomy, fenestration of compartmentalized ventricles, and aqueductoplasty, address intricate hydrocephalus manifestations. Procedures like foraminoplasty at the foramina of Monro and Magendie, as well as endoscopic fourth ventriculostomy, further expand its applicability [1, 13, 14].
Endoscopic Management of Cysts and Intraventricular Neoplasms
Endoscopic techniques are indispensable in cyst fenestration, tumor biopsies, excisions, and biopsies of metastatic disease. Specifically, hydrocephalus stemming from suprasellar or quadrigeminal arachnoid cysts can be adeptly addressed via endoscopic fenestration. Given that a significant proportion of patients with intraventricular cysts or tumors manifest concomitant hydrocephalus, the endoscopic approach proffers the dual benefit of CSF redirection and neoplastic management [15, 16]. Current-day endoscopic tumor biopsies have gained substantial traction, boasting an impressive success rate (>90%) coupled with minimal risks (<3.5%) [17]. The methodology has rendered invaluable insights in the context of germ cell tumors, insidious hypothalamic/optic pathway gliomas, and Langerhans cell histiocytosis. For colloid cysts or pedunculated ependymal tumors, endoscopic excision stands as a viable strategy, barring instances of expansive cysts where risks associated with venous injury at the foramen of Monro elevate [14] (Fig. 1).
Fig. (1)) (a) Shown are endoscopic views of the right lateral ventricle with choroid plexus and foramen of Monro, (b) view into the foramen of Monro, (c) view onto the floor of the third ventricle, (d) view onto the pineal cyst, (d) fenestration of the cyst.Endoscopic techniques may proficiently address craniopharyngiomas, hypothalamic chiasmatic astrocytomas, as well as suprasellar and pineal germ cell tumors. However, complete resection of solid neoplasms is occasionally constrained due to instrumental limitations and hemostatic challenges. The efficacy of these endoscopic tumor excisions is contingent upon tumor dimensions, consistency, and vascularity [14, 17]. Additionally, endoscopic modalities have been effectively employed in the management of extraventricular arachnoid cysts located at sites such as the Sylvian and interhemispheric fissures and the posterior fossa, enabling safe fenestration from the cyst into the adjacent subarachnoid space [15].
Endoscopic-aided Craniosynostosis Management
Jimenez and associates were at the forefront of minimally invasive interventions for craniosynostosis [18, 19]. Optimal intervention using endoscopy-assisted craniosynostosis surgery (EACS) is feasible within the first six months of life, augmented with subsequent helmet molding therapy; the paradigm age being three months. This intervention, employing standard instruments alongside a 0° endoscope, is akin to those used in endoscopic facelift procedures. Concurrent blood aspiration is conducted using a dedicated aspirator. Documented outcomes highlight minimal complications and impressive success rates [19]. An ensuing section provides an in-depth discussion on EACS. For scaphocephaly, a meticulous craniectomy extending from anterior to posterior fontanelle is executed, and the removed bony strip measures roughly 4-5 cm in width and about 11 cm in length. Ancillary osteotomies can be orchestrated posterior to the coronal suture and anterior to the lambdoid sutures. Outcomes from this approach have been commendable, with only a fraction (9% of 139 subjects) necessitating transfusion [14, 18, 19]. Post-procedure, pediatric patients are advised a helmet for roughly ten months, initiated three weeks post-operatively, with vigilance towards potential dermal complications, which are infrequent.
Endoscopic Interventions for Hypothalamic Hamartoma (HH)
Hypothalamic Hamartomas (HHs), a cohort of uncommon non-malignant congenital anomalies emanating from the inferior hypothalamus, manifest with distinct clinical syndromes such as gelastic seizures, early-onset puberty, and cognitive disturbances. Aside from those presenting with premature puberty, surgical intervention is typically warranted. Depending on HH typology, varied or combined therapeutic strategies are employed. For expansive HHs, transcallosal craniotomies are favored, while smaller lesions are amenable to gamma knife surgery or stereotactic radiofrequency thermocoagulation. Endeavors involving endoscopic resection coupled with stereotactic navigation have been piloted for smaller HHs, albeit achieving only partial resections [20]. Owing to the typical ventricular dimensions in these patients, navigational aid is often indispensable [20]. Contemporary literature posits that endoscopic disconnection of HHs potentially surpasses other techniques in safety and efficacy.
Advancements in Neuroendoscopic Spinal Procedures
Over recent decades, there has been a marked ascendance in the adoption of neuroendoscopic techniques for managing both intra- and extradural spinal anomalies. The endoscopic fenestration of intradural arachnoid cysts has been streamlined, whereas the previously favored dissection of septations within multiloculated syringomyelia cavities during the 1990s yielded mediocre clinical and radiographic outcomes [21]. In modern minimally invasive spinal interventions, the neuroendoscope has carved out a pivotal niche. Its repertoire has burgeoned to incorporate diverse procedures like thoracoscopic sympathectomy [22], discectomies [23-28], lumbar laminotomies [29], anterior spinal reconstructive strategies [30-33], excisions of neoplasms [34, 35] and cystic formations [36-39]. The prevalence of endoscopic discectomy in the thoracic [40-44] and lumbar spine [45-48] has surged. While epiduroscopy has been employed in the treatment epidural fibrosis post-spinal interventions [49-52], its definitive efficaciousness warrants continued investigative scrutiny.
Intraparenchymal Neuroendoscopic Approaches
Endoscopic advancements, marked by enhanced illumination and visualization, have capacitated surgical endeavors within the brain parenchyma [17, 53]. The marriage of a keyhole craniotomy paradigm [54] with judiciously chosen trajectories facilitates endoscopic access to intraparenchymal lesions in conjunction with navigation [36]. The instrumentation, inclusive of suction apparatus, tumor forceps, microscissors, and coagulative implements, is introduced through a dedicated sheath. Impeccable intraoperative irrigation and drainage are imperative to ensure a lucid endoscopic vista. Resection goals—whether intralesional or excisional—hinge on the tumor's characteristics. While the scope of these endoscopic interventions is evolving, their current applicability extends to pathologies such as cavernous angiomas, cerebellar infarctions, intraparenchymal hematomas, and cerebral abscesses [14]. The endoscopic modality, celebrated for its precision and safety, harbors potential for broader indications for the treatment of intraparenchymal lesions [14].
Neuroendoscopic Augmentation in Microsurgical Interventions
Neurosurgeons are increasingly inclined towards leveraging neuroendoscopy in concert with traditional skull base microsurgical techniques. The endoscope, complementing the microscope's robust capabilities, provides unparalleled access to intricate recesses, minimizing the need for undue retraction and meticulous skull base access. Though the microscope remains the principal tool in endoscope-augmented microsurgery due to its unparalleled image integrity, endoscopic strategies are currently reserved for trained surgeons in specialized institutions. The endoscope excels in elucidating bony or dural detail and intricate neurovascular configurations. While typically manipulated freehand for inspection, it can also be anchored to a stabilizing apparatus, facilitating bimanual dissection and proffering the surgeon unhindered bilateral manual dexterity [14, 55]. This synergistic methodology has manifested its prowess in diverse skull base surgeries—including tumor resections (e.g., pituitary tumors, craniopharyngiomas, acoustic neuromas, and epidermoids), aneurysm occlusions, and trigeminal microvascular decompressions [14].
Endoscopic Innovations in Skull Base Surgery
The advent of neuroendoscopy has transformed the treatments for skull base neoplasms. Carrau et al. (1996) were pioneers in documenting their endeavors with endonasal transsphenoidal hypophysectomy [55], a legacy which was later expanded upon by de Divitiis et al. (1997) to encompass diverse sellar and parasellar pathologies [56]. Presently, the bilateral endonasal endoscopic stratagem facilitates comprehensive visualization from the anterior skull base's crista galli to the C2 vertebra. Notably, the endoscopic endonasal paradigm has showcased commendable efficacy and reduced morbidity in resecting pathologies such as pituitary adenomas and craniopharyngiomas. The choice of this modality for sellar or suprasellar lesions hinges on their extent, with supradiaphragmatic variants managed endonasally and suprasellar pre-chiasmatic infundibular abnormalities addressed via the trans-tuberculum-transplant sphenoidal technique [14].
Moreover, endoscopy has become instrumental in managing CSF rhinorrhea of diverse etiologies. Endoscopic interventions enable meticulous cranio-sinonasal space delineation, fostering multilayered reconstructions. While small bony defects are typically addressed with autologous fat or fascia accompanied by tissue sealant, sizable openings, especially with pronounced intraoperative CSF leaks, mandate a multi-tiered closure, amalgamating autologous fat grafts, fascia lata, bony buttresses, and tissue sealants. In scenarios of severe skull base abnormalities, the incorporation of a gasket seal closure becomes indispensable [14].
Endoscopic Skull Base Surgery (ESBS) has ascended to be a gold standard for several afflictions including pituitary macroadenomas, cerebrospinal fluid rhinorrhea, and anterior skull base meningiomas, among others. Beyond neurosurgery, otolaryngologists have embraced ESBS for a spectrum of pathologies, ranging from olfactory neuroblastoma (notably Kadish A and B types) to recurrent nasopharyngeal malignancies. The past triad of decades has witnessed a meteoric rise in ESBS adoption, with a significant proportion of nonfunctional pituitary adenomas now addressed via this modality. A meticulous survey revealed an overwhelming majority of skull base surgeons, encompassing both neurosurgeons and otolaryngologists, incorporating ESBS techniques in their armamentarium [57].
Advances in Transnasal Neuroendoscopic Interventions
Transnasal neuroendoscopic procedures epitomize minimally invasive endeavors targeting profound intracranial entities via the nasal conduit. An exhaustive analysis of extant literature has elucidated the multifaceted clinical applications, outcomes, merits, and limitations of this methodology. This exploration spanned a gamut of neurosurgical anomalies, from pituitary tumors to ventricular discrepancies. Accumulated evidence underscores the efficacy and safety profile of transnasal neuroendoscopic interventions, extolling their reduced morbidity, expedited recovery, and improved patient satisfaction [55], while ensuring surgical outcomes on par, if not surpassing, conventional methodologies [58]. Nonetheless, mastery of this technique presents a formidable learning curve, with its share of potential pitfalls. To nurture proficiency amongst the next generation, the lead author has instituted biannual cadaveric workshops in the postgraduate curriculum, focusing on hands-on exposure to this nuanced technique (Fig. 2).
Fig. (2)) Endoscopic views taking during the first author’s biannual cadaver training course organized for residents of his postgraduate training program: a) view of medial cornet at lateral view, b) septum medial, c) cutting the medial cornet, d) cutting middle turbine and creating flap, d) vomer and ostium sphenoidal, e) keel of vomer, ostium bilateral sphenoids.A comprehensive review of PubMed, MEDLINE, and Embase was undertaken to search for studies released exclusively between 2020 and 2023. The research strategy hinged on an amalgamation of specific terminologies: “transnasal neuroendoscopy,” “transnasal endoscopic surgery,” “skull base lesions,” “pituitary tumors,” “ventricular abnormalities,” and “hydrocephalus.” We centered our focus on investigations elaborating on clinical outcomes, surgical modalities, complications, and juxtapositions between transnasal neuroendoscopy and conventional open techniques. Literature spanning animal-based research, isolated case narrations, and non-anglophone compositions were systematically sidestepped. The task of data curation and integrity evaluation was spearheaded by a duo of independent examiners, anchoring their approach on the established PRISMA criteria. The preliminary exploration surfaced 20 manuscripts [59-78], of which a curated subset of 11 were deemed pertinent for this compendium [60-67, 76-78
