Three-dimensional computed tomography-guided excision of an intrathoracic giant thymoma with elongated thymic vessels

We report the case of an intrathoracic giant thymoma with elongated thymic vessels, which was successfully resected under three-dimensional computed tomography guidance. A large, left-sided intrathoracic mass was incidentally found in a 41-year-old woman during a routine work-up for uterine cancer. Six vessels were noted arising from the tumor, five of which were connected to the anterosuperior mediastinum. The vasculature suggested that the tumor originated from the thymus and grew into the left pleural cavity, which pulled and elongated the associated vessels. Preoperative computed tomography imaging demonstrated that these vessels were located behind the tumor, which increased the risk for catastrophic intraoperative bleeding. We created a detailed surgical plan using our preoperative computed tomography data and successfully excised the tumor using intraoperative three-dimensional computed tomography guidance. Histopathological examination revealed a type AB thymoma without capsular invasion. This case highlighted the role of preoperative planning and intraoperative imaging in resecting an intrathoracic giant thymoma safely. In the video, we demonstrate how we performed the procedure under three-dimensional navigation.

Computed tomography-guided transforaminal lumbar puncture using local anesthesia and a straight 22-gauge spinal needle for intrathecal nusinersen in adults: Findings in 77 procedures

Background Intrathecal nusinersen is the first Food and Drug Administration-approved treatment for spinal muscular atrophy. Reliable intrathecal access is critical for initial and maintenance therapy; however, this can be challenging in older patients with spinal muscular atrophy many of whom have had prior lumbar instrumentation and osseous fusion. Transforaminal lumbar punctures have emerged as a technique for intrathecal access that avoids the hazards of cervical punctures. We describe our technique for transforaminal lumbar punctures under computed tomography guidance using local anesthesia and a straight 22-gauge needle. Methods Following local institutional review board approval, medical records of all patients undergoing computed tomography-guided transforaminal lumbar puncture for intrathecal nusinersen injection were obtained and analyzed. The rate of technical success and immediate complications were recorded. Any delayed complications noted in a 3-day follow-up phone call and future office visit were also recorded. Data collation and analysis were performed using Excel. Results A total of 77 transforaminal lumbar punctures were performed with intrathecal administration of nusinersen, for a 100% technical success rate. Local anesthesia was used in 76 cases, with conscious sedation used in one case. General anesthesia was not used in any case. There were no major complications. One patient had a postdural puncture headache that resolved completely after a transforaminal epidural blood patch performed 4 days later. Conclusions Intrathecal administration of nusinersen is critical for treatment of patients with spinal muscular atrophy. Our described technique allows for reliable access to the intrathecal space using local anesthesia and a straight 22-gauge spinal needle under computed tomography guidance, and is easily reproducible.