Transhiatal Approach Essay Example for Free

Transhiatal Approach EssayAbstract attach cord syndrome (TCS) is a stretch-induced functional disorder of the spinal anesthesia anaesthesia anesthesia cord, which is directly related to filum fixation. Classic functional approaches to the filum involve open surgery and include varying amounts of spinal bone removal. In an causa to reduce the morbidity and mortality of these procedures, we explored a less encroaching(a) method. We evaluated the ability, safety and feasibility for epidural endoscopic dissection of the filum terminale by performing upward orientated navigation in the sacral spinal canaliseise through the sacral hiatus victimization a besotted endoscope. Four self-aggrandizing, phenol-formalin embalmed stiffs were used for extradural endoscopic dissection of the filum at the tip of thecal sac.After preparing the anatomical argona of sacral hiatus, a rigid endoscope (Storz, of 3.8 mm external diameter with one working channel) was inserted into the sacral spinal canal and the filum was set and mown easily. In all cases, it was attainable to manipulate the rigid endoscope and inspect the full length of the extradural sacral spinal canal, especially at the S1-S2 level. Our results indicate that the tested transhiatal approach for upward orientated extradural endoscopy re dedicates a minimally invasive procedure that provides an appropriate and feasible route to the extradural sacral spinal canal. furthermore it is an attractive choice for filum dissection in cases where tethered cord syndrome is not accompanied by any(prenominal) other pathology.IntroductionPhysicians and scientists have explored the clinical usefulness of spinal endoscopy over six decades. Endoscopic spinal surgery represents a major advance in the treatment of spinal disorders. It involves the use of small incisions that wield normal tissues while allowing the spinal pathology to be fully treated. This technique carries interesting clinical benefits, and its utility continues to prosper as technology advances.Tethered cord syndrome (TCS) is a manifestation of spina bifida occulta and can make it as a complication of surgically closed spina bifida aperta. The mechanical cause of TCS is an inelastic structure anchoring the caudal end of the spinal cord and preventing cephalad movements of the lumbosacral cord. Stretching of the spinal cord occurs in patients either when the spinal column grows fast-breaking than the spinal cord or when the spinal cord undergoes forcible flexion and extension.Symptomatic TCS can occur in adults as well as in children, manifesting with various clinical symptoms (Dachling, 1982 Kaplan, 1980 Klekamp et al. 1994), such as pain, neurologic deficits, and bowel and bladder dysfunction. Further studies have shown that early surgical correction in adults is recommended because of the high seek for irreversible neurologic deficits (Bermans et al. 2001).In recent years, further research efforts of scientists h ave ranged from full-fledged neurosurgery to minimally invasive approaches and have involved the use of flexible and rigid endoscopes for diagnosis and treatment of certain pathological entities (Heavner et al. 1991 Sabreski Kitahata, 1995 1996 Warnke et al. 2001, I, II Warnke et al. 2003). Encouraging results from the performance of co-axial downward orientated thecaloscopic procedures, with flexible steerable endoscopes in the lumbar subarachnoid space in living humans (Warnke et al. 2003), prompted us to study further thecaloscopic procedures for filum terminale dissection by using a rigid endoscope.This procedure usually offers a better optical view of the studied anatomic structures. The aim of the present anatomic study was not only to determine if the tip of thecal sac could be clearly visualized. found on the fact that epidural endoscopy through sacral hiatus was proved to be safe and viable (Sabreski Kitahata, 1995 1996 Sabreski Gerens, 1998), it also sought to explo re the possibility of using a rigid endoscope to untether prefixed filum terminale.Materials and MethodsFor this study, four adult phenol-formalin embalmed male cadavers from the Anatomy Department of the Medical School of the University of Athens were dissected using microsurgical and endoscopic techniques.Neurosurgical techniqueFig.2Insertion-of-the-rigFig.1Sacral-HiatusCadavers were placed in the prone position. A midline skin incision was centered over the sacral hiatus fig. 1. After anatomical preparation, the rigid endoscope fig.2 was inserted through the sacral hiatus and directed into the sacral spinal canal cephalad. It was angled in that manner in order that it would face the tip of thecal sac.The filum, which was holding thecal sac, was identified and dissected fig.3. The rigid endoscope used was a Storz with a 3.8mm external diameter and one working channel. For the documentation, a video-tape (Fuji VHS) was used and digital photographs were taken using a Fuji AS-205.Res ultsWith the help of a rigid endoscope, it is possible to visualize directly the tip of thecal sac and to perform a dissection of the filum terminale. A rigid endoscope was inserted into the sacral spinal canal and, with the benefit of the visibility it granted, was advanced cephalad with relative ease. The rigid endoscope provided a large welkin of view, which enabled the anatomical structures to be seen. The filum can be easily identified in fine detail, as it is the only structure adherent to the tip of thecal sac at the S1-S2 level. This procedure represents a minimally invasive method for direct visualization of the tip of thecal sac and dissection of filum terminale.DiscussionDiseases of the branch line predispose persons to continuing complaints ranging from mild discomfort to intense pain. Endoscopy of the anatomic structures contained within the spine makes possible thorough examinations for existing pathology and advances the exertion of appropriate methods of therapy (Warnke et al. 2003 Sabreski Kitahata, 1996). Use of neuroendoscopy has become widespread in spinal surgery for conditions ranging from degenerative disease to dishonor correction (Heavner et al. 1991 Sabreski Gerens, 1998 Sabreski Kitahata, 1995 1996). The growth in the number of minimally invasive spine surgical procedures being performed has been spurred by both technical advances and by its associated reduction in operative morbidity (1998 1995 1996).However, minimally invasive techniques are primarily employed in extradural procedures. Transhiatal extradural filum untethering provides the ability to untether a prefixed filum in a minimally invasive way. When referred to a neurosurgical clinic, adult patients with tethered cord syndrome tend to show important progressive neurological deficits (Klekamp et al. 1994 Dachling, 1982). Some authors (van Leeuwen, et al. 2001) have advocated prophylactic surgical treatment for the prevention of progressive neurological symptoms, which is, in this case, related to low morbidity.As an alternative to the risky open surgical treatment procedure, we evaluated the extradural endoscopic procedure for untethering of filum in cadavers. Extradural filum untethering could be indicated in cases of prefixed filum without other accompanying pathology such as meningomyelocele, CSF fistula, or arachnoidal cysts. It could also be performed before a surgical intervention, which for the most part include dura opening and removal of various amounts of spinal bone.During inspection of the sacral spinal canal with the rigid endoscope, the declination of the sacral spinal canal did not bring difficulties for the upward manipulation of the endoscope. pastime the physical inclination of the sacral spinal canal, the filum could be approached and dissected before reaching the lumbosacral angle. In some instances, it was difficult to dissect the filum because of its elasticity. However, the minimally invasive nature of neuroendoscop y provided by this procedure, and by the employment of the rigid endoscope, allows for a larger field of view at the sacral spinal canal through a smaller incision. This access and the ability to perform extradural inspection and filum dissection using this transhiatal approach are comparable with other therapeutic interventions used in neurosurgery, such as the endoscopic epidural placement of catheters in anaesthesiology.ConclusionsThis method of extradural endoscopic dissection of the filum terminale minimizes surgical trauma and provides comminuted visualization of and access to the extradural sacral spinal canal. Furthermore, it enables the filum to be identified and thus provides a minimally invasive alternative to current open surgical procedures indicated for filum untethering.Utilization of this procedure could (1) facilitate untethering of prefixed filum terminale without opening the dura and (2) minimize patient morbidity thereby presenting an overall attractive alternat ive to current methods of filum dissection. At present, neuroendoscopy is most widely used in minimally invasive spine surgery, but novel uses continue to emerge in the literature. As technology evolves and more experience is obtained, neuroendoscopy leave alone likely achieve additional roles as a mainstay in spinal surgery.ReferencesHeavner JF, Cholkhavatia S, Kizelsheeyn G. (1991). Percutaneous paygrade of the epidural and subarachnoid space with flexible endoscope. Reg. Anesth. 15 S1 85.Iskandar BJ, Fulmer BB, Hadley MN, Oakes WJ. (2001). Congenital tethered spinal cord syndrome in adults. Neurosurg. cerebrate 10(1) Article 7.Kaplan JQ, Quencer RM. (1980) The occult tethered conus syndrome in the adult. Radiology 137387-391.Klekamp J, Raimpondi AJ, Samii M. (1994) Occult dysraphism in adulthood clinical tend and management. Child Nerv Syst 10312-320.van Leeuwen R, Notermans NC, Vandertop P. (2001). Surgery in adults with tethered cord syndrome outcome study with self-r eliant clinical review. J. Neurosurg. 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