scholarly journals Long-term surgical outcomes following transsphenoidal surgery in patients with Rathke’s cleft cysts

2019 ◽  
Vol 130 (3) ◽  
pp. 831-837 ◽  
Author(s):  
Michelle Lin ◽  
Michelle A. Wedemeyer ◽  
Daniel Bradley ◽  
Daniel A. Donoho ◽  
Vance L. Fredrickson ◽  
...  
Keyword(s):  
Transsphenoidal Approach ◽  
Neurological Deficits ◽  
Csf Leak ◽  
Rathke's Cleft Cysts ◽  
The Mean ◽  
Rathke's Cleft ◽  
Cyst Fenestration ◽  
Csf Leaks

OBJECTIVERathke’s cleft cysts (RCCs) are benign epithelial lesions of the sellar region typically treated via a transsphenoidal approach with cyst fenestration and drainage. At present, there is limited evidence to guide patient selection for operative treatment. Furthermore, there is minimal literature describing factors contributing to cyst recurrence.METHODSThe authors conducted a retrospective analysis of 109 consecutive cases of pathology-confirmed RCCs treated via a transsphenoidal approach at a single center from 1995 to 2016. The majority of cases (86.2%) involved cyst fenestration, drainage, and partial wall resection. Long-term outcomes were analyzed.RESULTSA total of 109 surgeries in 100 patients were included, with a mean follow-up duration of 67 months (range 3–220 months). The mean patient age was 44.6 years (range 12–82 years), and 73% were women. The mean maximal cyst diameter was 14.7 mm. Eighty-eight cases (80.7%) were primary operations, and 21 (19.3%) were reoperations. Intraoperative CSF leak repair was performed in 53% of cases and was more common in reoperation cases (71% vs 48%, p < 0.001). There were no new neurological deficits or perioperative deaths. Two patients (1.8%) developed postoperative CSF leaks. Transient diabetes insipidus (DI) developed in 24 cases (22%) and permanent DI developed in 6 (5.5%). Seven cases (6.4%) developed delayed postoperative hyponatremia. Of the 66 patients with preoperative headache, 27 (44.3%) of 61 reported postoperative improvement and 31 (50.8%) reported no change. Of 31 patients with preoperative vision loss, 13 (48.1%) reported subjective improvement and 12 (44.4%) reported unchanged vision. Initial postoperative MRI showed a residual cyst in 25% of cases and no evidence of RCC in 75% of cases. Imaging revealed evidence of RCC recurrence or progression in 29 cases (26.6%), with an average latency of 28.8 months. Of these, only 10 (9.2% of the total 109 cases) were symptomatic and underwent reoperation.CONCLUSIONSTranssphenoidal fenestration and drainage of RCCs is a safe and effective intervention for symptomatic lesions, with many patients experiencing improvement of headaches and vision. RCCs show an appreciable (although usually asymptomatic) recurrence rate, thereby mandating serial follow-up. Despite this, full RCC excision is typically not recommended due to risk of hypopituitarism, DI, and CSF leaks.

Long-term outcomes of lumbar microdiscectomy in the pediatric population: a large single-institution case series

2019 ◽  
Vol 24 (5) ◽  
pp. 549-557
Author(s):  
Malia McAvoy ◽  
Heather J. McCrea ◽  
Vamsidhar Chavakula ◽  
Hoon Choi ◽  
Wenya Linda Bi ◽  
...  
Keyword(s):  
Conservative Management ◽  
Functional Outcomes ◽  
Pediatric Patients ◽  
Clinical Presentation ◽  
Case Series ◽  
Csf Leak ◽  
Single Institution ◽  
The Mean

OBJECTIVEFew studies describe long-term functional outcomes of pediatric patients who have undergone lumbar microdiscectomy (LMD) because of the rarity of pediatric disc herniation and the short follow-up periods. The authors analyzed risk factors, clinical presentation, complications, and functional outcomes of a single-institution series of LMD patients over a 19-year period.METHODSA retrospective case series was conducted of pediatric LMD patients at a large pediatric academic hospital from 1998 to 2017. The authors examined premorbid risk factors, clinical presentation, physical examination findings, type and duration of conservative management, indications for surgical intervention, complications, and postoperative outcomes.RESULTSOver the 19-year study period, 199 patients underwent LMD at the authors’ institution. The mean age at presentation was 16.0 years (range 12–18 years), and 55.8% were female. Of these patients, 70.9% participated in competitive sports, and among those who did not play sports, 65.0% had a body mass index greater than 25 kg/m2. Prior to surgery, conservative management had failed in 98.0% of the patients. Only 3 patients (1.5%) presented with cauda equina syndrome requiring emergent microdiscectomy. Complications included 4 cases of postoperative CSF leak (2.0%), 1 case of a noted intraoperative CSF leak, and 3 cases of wound infection (1.5%). At the first postoperative follow-up appointment, minimal or no pain was reported by 93.3% of patients. The mean time to return to sports was 9.8 weeks. During a mean follow-up duration of 8.2 years, 72.9% of patients did not present again after routine postoperative appointments. The total risk of reoperation was a rate of 7.5% (3.5% of patients underwent reoperation for the same level; 4.5% underwent adjacent-level decompression, and one patient [0.5%] ultimately underwent a fusion).CONCLUSIONSMicrodiscectomy is a safe and effective treatment for long-term relief of pain and return to daily activities among pediatric patients with symptomatic lumbar disc disease in whom conservative management has failed.

scholarly journals Outcome in surgically treated Rathke's cleft cysts: long-term monitoring needed

2011 ◽  
Vol 165 (1) ◽  
pp. 33-37 ◽  
Author(s):  
R Trifanescu ◽  
V Stavrinides ◽  
P Plaha ◽  
S Cudlip ◽  
J V Byrne ◽  
...  
Keyword(s):  
Visual Field ◽  
Visual Field Defects ◽  
Rathke's Cleft Cysts ◽  
Long Term Monitoring ◽  
Rathke's Cleft ◽  
Term Monitoring ◽  
Field Defects ◽  
Tsh Deficiency

ObjectiveTo clarify the outcome of all cases of Rathke's cleft cysts (RCC) treated surgically and followed up in Oxford during a long-term period.Subjects and methodsThe records of all patients with RCC seen in the Department of Endocrinology between January 1978 and June 2009 were reviewed.ResultsA total of 33 patients (20 females, median age 43 years) were identified. At presentation, major visual field defects were detected in 58% of patients and gonadotrophin, ACTH and TSH deficiency in 60, 36 and 36% of patients respectively. Desmopressin treatment was required in 18% of patients. Treatment consisted of cyst evacuation combined with or without biopsy/removal of the wall. Post-operatively, visual fields improved in 83% of patients with impairment, whereas there was no reversal of ACTH or TSH deficiency or of diabetes insipidus. All but one subject had imaging follow-up during a mean period of 48 months (range 2–267). Cyst relapse was detected in 22% of patients at a mean interval of 29 months (range 3–48 months); in 57% of them, the recurrence was symptomatic. Relapse-free rates were 88% at 24-months and 52% at 48-months follow-up. At last assessment, at least quadrantanopia was reported in 19% of patients, gonadotrophin, ACTH and TSH deficiency in 50, 42 and 47% of patients respectively. Desmopressin treatment was required in 39% of patients.ConclusionsIn this study of patients with RCC and long-term follow-up, we showed a considerable relapse rate necessitating long-term monitoring. Surgical intervention is of major importance for the restoration of visual field defects, but it does not improve endocrine morbidity, which in the long-term affects a substantial number of patients.

Preservation of olfaction in anterior craniofacial approaches

1993 ◽  
Vol 79 (1) ◽  
pp. 48-52 ◽  
Author(s):  
Robert F. Spetzler ◽  
James M. Herman ◽  
Stephen Beals ◽  
Edward Joganic ◽  
John Milligan
Keyword(s):  
Cribriform Plate ◽  
Csf Leak ◽  
En Bloc ◽  
Reconstructive Procedures ◽  
Content Type ◽  
The Mean ◽  
Ethmoid Sinuses ◽  
Fine Print ◽  
Csf Leaks

✓ Through the combined efforts of neurosurgeons, head and neck surgeons, and craniofacial surgeons, the standard transbasal approach to the frontal fossa has been modified to include removal of the orbital roofs, nasion, and ethmoid sinuses. This approach has been combined further with facial disassembly procedures to provide extensive midline exposure to the midface and clival region. Extended frontal approaches, however, necessitate removal of the crista galli and sectioning of the olfactory rootlets with the associated risk of anosmia, cerebrospinal fluid (CSF) leak, and the need for complex reconstruction of the frontal floor. To avoid these problems, the authors have modified the technique of handling the cribriform plate to preserve the olfactory unit. Circumferential osteotomy cuts are made around the cribriform plate to allow an en bloc removal with its attachment to both the dura and underlying mucosa. Opening of the dura is avoided and the cribriform bone is used to reconstruct the floor. Four patients underwent this approach, for treatment of an angiofibroma in three and a fibrosarcoma in one. The mean follow-up period was 7 months. No patients developed a CSF leak, and within 8 weeks olfaction had returned in all patients. There was no other associated morbidity. These data suggest that this modification of the transbasilar approach can alleviate extensive reconstructive procedures and CSF leaks while preserving olfaction.

Tethered cord syndrome in adults

2011 ◽  
Vol 15 (3) ◽  
pp. 258-270 ◽  
Author(s):  
Jörg Klekamp
Keyword(s):  
Spinal Cord ◽  
Tethered Cord ◽  
Tethered Cord Syndrome ◽  
Neurological Deficits ◽  
Short Term ◽  
Group A ◽  
The Mean ◽  
Group B

Object The treatment of tethered cord syndromes in adults is discussed regarding the natural history and surgical indications. The author analyzes data obtained in patients who were diagnosed with a tethered cord in adulthood and either underwent surgical or conservative therapy between 1991 and 2009. Methods Since 1991, data obtained in 2515 patients with spinal cord pathologies were entered into the spinal cord database, and prospective follow-up was performed through outpatient visits and questionnaires. Of the 2515 patients, 85 adults with a tethered cord syndrome formed the basis of this study. The tethering effect was caused either by a split cord malformation, a thick filum terminale, a conus medullaris lipoma with extradural extension, or various combinations of these mechanisms. The mean age of the patients was 46 ± 13 years (range 23–74 years) and the mean follow-up duration was 61 ± 62 months. Two groups were distinguished based on the absence (Group A, 43 patients) or presence (Group B, 42 patients) of an associated lipoma or dysraphic cyst (that is, dermoid, epidermoid, or neurenteric cyst). Surgery was recommended for patients with symptoms only. Short-term results were determined within 3 months of surgery, whereas long-term outcomes (clinical recurrences) were evaluated using Kaplan-Meier statistics. Results For all patients, pain was the most common major complaint. Severe neurological deficits were rare. In Group A, 20 of 43 patients underwent surgery, whereas in Group B 23 of 42 patients underwent surgery. Among individuals who did not undergo surgery, 17 patients refused surgery and 25 patients underwent recommended conservative treatment. Short-term postoperative results indicated a significant improvement of pain and a stabilization of neurological symptoms. Long-term results showed a good prognosis in patients in whom first-time (that is, nonrevision) surgery achieved successful untethering, with a 10-year rate of neurological stabilization in 89% of Group A and a 10-year rate of neurological stabilization in 81% of Group B patients. The benefit of secondary operations in Group B was limited, with eventual clinical deterioration occurring in all patients within 10 years. For patients treated conservatively, follow-up information could be obtained in 33 of 42 patients. Twenty-eight patients remained in stable clinical condition. Only 5 of the conservatively treated patients experienced clinical deterioration over time; in 4 of these individuals with deterioration, surgery had been recommended but was refused by the patient. The clinical recurrence rate in all conservatively treated patients was 21% after 10 years. With a recommendation for surgery this figure rose to 47% within 5 years. Conclusions Surgery in adult patients with a tethered cord syndrome should be reserved for those with symptoms. In surgically treated patients, pain relief can often be achieved, and long-term neurological stabilization tends to persist more often than it does in conservatively treated patients. A conservative approach is warranted, however, in adult patients without neurological deficits. Revision surgery in patients with complex dysraphic lesions should be performed in exceptional cases only.

Spondylolysis of C-2 in children 3 years of age or younger: clinical presentation, radiographic findings, management, and outcomes with a minimum 12-month follow-up

2014 ◽  
Vol 13 (2) ◽  
pp. 196-203 ◽  
Author(s):  
Loyola V. Gressot ◽  
Sudhakar Vadivelu ◽  
Steven W. Hwang ◽  
Daniel H. Fulkerson ◽  
Thomas G. Luerssen ◽  
...  
Keyword(s):  
Spinal Cord ◽  
Young Children ◽  
Neurological Deficits ◽  
Radiographic Findings ◽  
Children's Hospital ◽  
Very Young Children ◽  
The Mean ◽  
Neurologically Intact

Object Cervical spondylolysis is a rare condition that results from a pars interarticularis defect. The C-6 level is the most frequently involved site in the cervical spine. Its clinical presentations range from incidental radiographic findings to neck pain and, rarely, neurological deficits. Although 150 patients with subaxial cervical spondylolysis have been reported, a mere 24 adult and pediatric patients with C-2 spondylolysis have been described. The long-term outcomes of very young children with bilateral C-2 spondylolysis are of great interest, yet only a few longitudinal studies exist. Methods The authors retrospectively reviewed 5 cases of bilateral C-2 spondylolysis at Texas Children's Hospital and Riley Children's Hospital; these were combined with 5 other cases in the literature, yielding a total of 10 patients. Data regarding the patients' age, sex, C2–3 angulation and displacement, associated spine anomalies, neurological deficits, treatment, and most recent follow-up were recorded. Results The patients' ages ranged from 3 to 36 months (mean 12.9 months). There were 6 boys and 4 girls. The C2–3 angulation, displacement, and width of pars defect were measured when available. The mean C2–3 angulation was 9.5° (range 1–34°), the mean C2–3 displacement was 4.78 mm (range 1.1–10.8 mm), and the mean width of the pars defect was 4.16 mm (range 0.9–7 mm). One patient developed myelopathy and spinal cord injury. All 10 of the patients were treated initially with conservative therapy: 3 with close observation alone, 1 with a rigid cervical collar, 4 with a Minerva jacket, 1 with a sternal-occipital-mandibular immobilizer, and 1 with a halo vest. Three patients ultimately underwent surgery for internal fixation due to progressive instability or development of neurological symptoms. All patients were neurologically intact at the last follow-up (mean 44.3 months, range 14–120 months). Conclusions Based on the literature and the authors' own experience, they conclude that most very young children with C-2 spondylolysis remain neurologically intact and maintain stability in long-term follow-up despite the bony defect. This defect is often an asymptomatic incidental finding and may be managed conservatively. More aggressive therapy including surgery is indicated for those patients with a neurological deficit from spinal cord compromise secondary to stenosis and local C-2 kyphosis, progressive deformity, or worsening C2–3 instability.

Orbitozygomatic Craniotomy via an Eyebrow Incision: Management of the Opened Frontal Sinus

2020 ◽  
Author(s):  
David R. Peters ◽  
Caitlin Payne ◽  
Scott D. Wait
Keyword(s):  
Frontal Sinus ◽  
Analysis Data ◽  
Csf Leak ◽  
Invasive Approach ◽  
Perioperative Morbidity ◽  
Patient Demographics ◽  
Eyebrow Incision ◽  
Csf Leaks

Abstract Background The eyebrow orbitozygomatic craniotomy is a minimally invasive approach that can access a wide variety of lesions. Unintentional breach of the frontal sinus frequently occurs and has been cited as a reason to avoid this approach. Lack of access to a large pericranial graft and the inability to completely cranialize the sinus requires alternate techniques of sinus repair. We describe a technique for repairing an opened frontal sinus and retrospectively reviewed complications related to this approach. Methods All patients, who underwent an orbitozygomatic craniotomy via an eyebrow incision by a single surgeon from August 1, 2012 to August 31, 2018, were included in this retrospective analysis. Data were collected on patient demographics, pathology treated, operative details, and perioperative morbidity. Follow-up ranged from 6 weeks to 6 years. Results Total 50 patients with a wide variety of pathologies underwent analysis. Frontal sinus breach occurred in 21 patients. All were repaired by the described technique. One patient (ruptured aneurysm) had a suspected cerebrospinal fluid (CSF) leak postoperatively that resolved without any additional intervention. One patient developed a pneumomeningocele 4 years postoperatively that required reoperation. No patient suffered any infection or delayed CSF leak. Conclusion Breach of the frontal sinus is common during eyebrow craniotomies. Despite reduced options for local repair, these patients have experienced no CSF leaks requiring intervention and no infections in our series. Long-term mucocele risk is not reliably determined with our length of follow-up. Breach of the frontal sinus is not a contraindication to the eyebrow approach.

Long-term Risks of Persistent Ventral Spinal CSF Leaks in SIH: Superficial Siderosis and Bibrachial Amyotrophy

Neurology ◽  
2021 ◽  
pp. 10.1212/WNL.0000000000012786
Author(s):  
Wouter I. Schievink ◽  
Marcel Maya ◽  
Franklin Moser ◽  
Miriam Nuño
Keyword(s):  
Spinal Cord ◽  
Spontaneous Intracranial Hypotension ◽  
Csf Leak ◽  
Superficial Siderosis ◽  
Spinal Cord Herniation ◽  
Neurologic Disability ◽  
One Year ◽  
Csf Leaks

Background and Objectives:Superficial siderosis, bibrachial amyotropy, and spinal cord herniation are unusual but serious long-term sequelae of persistent spontaneous spinal CSF leaks in patients with spontaneous intracranial hypotension (SIH), particularly ventral spinal CSF leaks. However, the risk of developing such sequelae has not been established in this population. We undertook this study to determine the risk of these serious complications of persistent ventral spinal CSF leaks.Methods:This cohort study was conducted using data from a prospectively maintained data base of patients who meet the modified International Classification of Headache Disorders (ICHD)-III criteria for SIH. The patient population consisted of a consecutive group of patients with SIH and persistent ventral spinal CSF leaks, who were first seen within one year of onset of SIH symptoms and who had at least one year of follow-up.Results:Among 51 patients with SIH and a persistent ventral spinal CSF leak, superficial siderosis developed in six patients and bibrachial amyotropohy in two patients during 280 patient years of follow-up. The probability of these complications increased from 0% at 48 months, to 4.5% (95% confidence interval (CI): 1.0-28.0%) at 56 months, 10.5% (95% CI: 3.0-36.4%) at 96 months, 32.7% (95% CI: 15.0-62.8%) at 144 months, and 57.9% (95% CI: 30.2-87.6%) at 192 months. None of the patients developed spinal cord herniation.Discussion:Among patients with SIH and a persistent ventral spinal CSF leak, the risk of developing serious long-term sequelae is considerable. This study shows that early treatment of a ventral spinal CSF leak offers a unique opportunity to prevent neurologic disability from superficial siderosis and bibrachial amyotrophy.

scholarly journals Rathke’s cleft cysts following transsphenoidal surgery: long-term outcomes and development of an optimal follow-up strategy

2020 ◽  
Vol 162 (4) ◽  
pp. 853-861 ◽  
Author(s):  
Hani J. Marcus ◽  
Anouk Borg ◽  
Ziad Hussein ◽  
Zane Jaunmuktane ◽  
Stephanie E. Baldeweg ◽  
...  
Keyword(s):  
Transsphenoidal Surgery ◽  
Long Term Outcomes ◽  
Rathke's Cleft Cysts ◽  
Rathke's Cleft

Endonasal Endoscopic Fenestration of Rathke's Cleft Cysts: Whether to Leave the Fenestration Open or Closed?

2019 ◽  
Author(s):  
Leopold Arko ◽  
Jonathan C.M. Lee ◽  
Saniya Godil ◽  
Samuel Z. Hanz ◽  
Vijay K. Anand ◽  
...  
Keyword(s):  
Recurrence Rate ◽  
Open Group ◽  
Csf Leak ◽  
Closure Rate ◽  
Endoscopic Endonasal ◽  
Closed Group ◽  
Rathke's Cleft Cysts ◽  
Watertight Closure ◽  
Rathke's Cleft ◽  
Csf Leaks

Abstract Introduction Rathke's cleft cysts (RCC) are generally treated with transsphenoidal fenestration and cyst drainage. If no cerebrospinal fluid (CSF) leak is created, the fenestration can be left open. If CSF is encountered, a watertight closure must be created to prevent postoperative CSF leak, though sellar closure has theoretically been linked with higher recurrence rate. In this study, we investigate the relationship between sellar closure, rate of postoperative CSF leak, and RCC recurrence. Methods Retrospective review of a prospective database of all endoscopic endonasal RCC fenestrations and cases were divided based on closure. The “open” group included patients who underwent fenestration of the RCC, whereas the “closed” group included patients whose RCC was treated with fat and a rigid buttress ± a nasoseptal flap. The rate of intra- and postoperative CSF leak and radiographic recurrence was determined. Results The closed group had a higher rate of suprasellar extension (odds ratio [OR]: 8.0, p = 0.032) and intraoperative CSF leak (p ≤ 0.001). There were 54.8% intraoperative CSF leaks and no postoperative CSF leaks. Radiologic recurrence rate for the closed group (35.0%) was three times higher than the open group (9.1%; risk ratio [RR] = 3.85, p = 0.203), but not powered to show significance. None of the radiologic recurrences required reoperation. Conclusion Maintaining a patent fenestration between an RCC and the sphenoid sinus is important in reducing the rate of radiographic recurrence. Closure of the fenestration may be required to prevent CSF leak. While closure increases the rate of radiographic recurrence, reoperation for recurrent RCC is still an uncommon event.

scholarly journals The long-term recurrence of Rathke's cleft cysts as predicted by histology but not by surgical procedure

2016 ◽  
Vol 125 (4) ◽  
pp. 1002-1007 ◽  
Author(s):  
Yasuyuki Kinoshita ◽  
Atsushi Tominaga ◽  
Satoshi Usui ◽  
Kazunori Arita ◽  
Tetsuhiko Sakoguchi ◽  
...  
Keyword(s):  
Surgical Procedure ◽  
Squamous Metaplasia ◽  
Visual Disturbance ◽  
Initial Surgery ◽  
Long Term Follow Up ◽  
Rathke's Cleft Cysts ◽  
Rathke's Cleft ◽  
Term Monitoring

OBJECTIVE Patients with symptomatic Rathke's cleft cysts (RCCs) managed by surgical treatment often experience recurrence. The authors attempted to clarify the outcome of surgically treated RCCs over a long-term follow-up period. METHODS Ninety-one consecutive RCC patients with a follow-up period of more than 12 months (mean 80.2 months, range 12–297 months) were retrospectively studied. The authors examined the clinical features and postoperative course of patients who experienced a reaccumulation of cyst contents visible on MRI after the initial surgery, and they investigated data from the patients who underwent reoperation for symptomatic recurrent RCCs. RESULTS Reaccumulation of cyst contents occurred in 36 patients (39.6%). In 34 of these patients, a reaccumulation occurred in the first 5 years after surgery. The initial cysts in these patients were most often large, with squamous metaplasia in the cyst walls. Thirteen patients (14.3%) with recurrent symptoms underwent a reoperation, and 10 of the 13 patients had a reaccumulation of RCCs within the 1st year after surgery. The reoperations were performed in the 1st year (61.5%) or several years later (23.1%). Patients were likely to initially have had a visual disturbance and the cyst walls likely included squamous metaplasia. However, no association was observed between the incidence of reaccumulation/reoperation of RCCs and the surgical procedure for RCCs. CONCLUSIONS The reaccumulation rate of RCC is high in the long-term period, and it is associated with the histological findings but not with the surgical procedure. Long-term monitoring, for a period of at least 5 years, should therefore be conducted to identify and assess any RCC reaccumulation.

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