Background. Many tumors of different histologic structure originate from the anterior skull base. These lesions may be highly vascularized leading to limited resection and severe intraoperative blood loss. Midline tumors are primarily supplied by ethmoidal arteries, which are not subject to endovascular embolization. Aim of this study was comparative experimental analysis of different surgical approaches to the ethmoidal arteries.
Materials and methods. The anatomical study was performed on 12 fresh human cadavers without diseases involving the anterior skull base, orbits, and paranasal sinuses (24 sides). In all specimens internal and external carotid arteries were injected by silicone dye. Anatomical dissection was carried on investigating four different minimally invasive endoscopic approaches to the ethmoidal arteries: 1) transorbital approach to the ethmoidal arteries via bicoronal incision; 2) pre/trans/retrocaruncular approach to the ethmoidal arteries; 3) endoscopic endonasal transethmoidal approach to the canals of ethmoidal arteries; 4) endoscopic endonasal transethmoidal-transorbital approach to the ethmoidal arteries in the orbit.
Results. Surgical technique of the mentioned approaches was described, and their advantages and disadvantages were analyzed. We propose the algorithm for selection of direct endoscopic ligation of ethmoidal arteries based on selected surgical approach for tumor resection and its extracranial extension.
Conclusion. Decision making for tumor devascularization must be substantiated by visualization of vasculature (CT or MR angiography). The study has demonstrated advantages and disadvantages of different endoscopic approaches to the ethmoidal arteries for their ligation aiming at early devascularization of anterior skull base lesions. All four are minimally invasive and provide good functional outcome and cosmesis.
The article presents the literature data on the structural variability and age-related features of the midline anatomical structures of the anterior skull base (frontal sinus, ethmoid bone, anterior parasellar region, and medial orbital wall). This is the area of surgical interests of neurosurgeons and rhinosurgeons. The study objective is to analyze the literature data on the individual variability and age-related anatomy of these structures. The work is illustrated with original images from the authors’ personal archive. The individual anatomical features of eloquent structures in the surgical area (structures within the surgical corridor, key anatomical landmarks, optic tract, internal carotid and ethmoidal arteries, etc.) should be considered in planning surgery in patients of all age groups because they can limit the view and the amount of safe manipulations or increase the risk of complications. The presented data may be useful for neurosurgeons and otolaryngologists whose surgical interests are focused on the midline structures of the anterior skull base.
Objective - to determine the effect of various methods of perioperative analgesia on the rate of failed back surgery syndrome in patients operated on for spinal stenosis. Materials and methods. A total of 122 patients were operated on for spinal stenosis in 2010-2016. The patients were assigned to groups according to the type of received analgesia: Group K (n=19) underwent analgesia on-demand. Patients in the PMA group (n=21) received preventive multimodal analgesia (PMA) with ketoprofen, paracetamol and morphine. Patients in the PMA+PG (n=20) and PMA+N (n=20) groups additionally received pregabalin and nefopam, respectively. Patients in the PMA+E group (n=22) received continuous epidural analgesia with a combination of ropivacaine and morphine. In patients in the PMA+I group (n=20), the wound was infiltrated with ropivacaine and ketorolac. Results and conclusions. In Group K, analgesia was not adequate during five postoperative days. Analgesia with PMA resulted in significant pain reduction during three postoperative days compared to Group K. Wound infiltration in addition to PMA was followed by more significant pain relief during six postoperative hours (compared to the PMA group). Administration of pregabalin or nefopam, as well as epidural analgesia, did not improve quality of postoperative analgesia. Five to seven months after the surgery, 66% (57; 75%) of patients had low back and/or leg pain; 41% (32; 50%) of patients had leg pain. Among patients suffering from pain, 32-41% patients had the severe chronic pain syndrome that resulted in sleep disorder, disability and significant deterioration of quality of life. The rate of failed back surgery syndrome did not depend on the perioperative analgesia regimen.
The risk factors for acute pain as well as chronic pain syndrome (CPS) in spine surgery have not been defined to date. Purpose — to define the prognostic parameters of acute pain severity and the risk of CPS in patients operated on for spinal diseases and injuries. Material and methods. The study included 291 patients operated on for degenerative diseases and injuries of the spine at the Sklifosovsky Research Institute of Emergency Medicine in 2010―2016. Sociodemographic and clinical data and the psychological status of patients were evaluated. A mechanical algometer was used to measure the pain threshold (PT) and pain tolerance. The movement pain intensity was assessed by using a visual analog scale (VAS) on the day of surgery. Pain was considered minor at a median score of 0―4 cm and severe at a median score of 5―10 cm. The presence of CPS was assessed during a telephone survey 5―7 months after surgery. Results. The gender, PT, dynamic pain intensity before surgery, and expectation of postoperative pain are risk factors for severe acute postoperative pain. A multinomial logit regression model (Hosmer—Lemeshow test ― 4.322; p=0.827) predicts minor dynamic pain on the 1postoperative day with an accuracy of 70% (95% CI 63—76). The age and dynamic pain intensity on the 1postoperative are the risk factors for CPS; the multinomial logit regression model (Hosmer—Lemeshow test ― 3.1; p=0.928) predicts CPS with an accuracy of 65% (95% CI 59—71) 5―7 months after surgery. Conclusion. The developed software in the form of MS Excel calculators provides a particular patient with preoperative assessment of the risk for minor acute dynamic pain on the 1postoperative day and CPS 5―7 months after surgery.