Hunterian Ligation With Distal Revascularization for Management of a Previously Coiled Giant Internal Cerebral Artery Aneurysm: 2-Dimensional Operative Video

Unclippable giant aneurysms pose a significant microsurgical challenge. Options for management are highly dependent on the aneurysm characteristics and cerebrovascular anatomy. Hunterian (proximal) ligation with either high-flow or low-flow distal revascularization is an option for the treatment of aneurysms of the internal carotid artery (ICA). This patient had a multiply recurrent supraclinoid ICA aneurysm following endovascular treatment and progressive ipsilateral homonymous hemianopsia. In preparation for the clip occlusion of the proximal ICA, the patient underwent a balloon test occlusion of the ICA, which had a negative result, indicative of tolerance. A pterional craniotomy was used to perform a low-flow bypass, superficial temporal artery to M2, and clip occlusion of the proximal ICA. The patient tolerated the procedure well with some pressure-dependent contralateral symptoms, which resolved. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

The Development of Trigger Thumb in the Contralateral Thumb in Pediatric Patients Presenting Initially With Unilateral Involvement

Background: Pediatric trigger thumb is a common condition that can occur bilaterally. There have been reports of a metachronous relationship between trigger thumbs developing in both extremities. Surgeons might consider delaying operative treatment of unilateral trigger thumb due to the concern that contralateral symptoms may develop later in childhood, requiring a second procedure and anesthetic event. Methods: We retrospectively reviewed patients diagnosed with pediatric trigger thumb from 2008 to 2016 at a large pediatric hospital. Data collected included age at presentation and onset, laterality, age and timing of onset of contralateral symptoms, time of index procedure and subsequent procedure (if any), severity of symptoms, previous treatments, range of motion, and birth history. Results: There were 198 patients with pediatric trigger thumb, with 55 patients (28%) presenting with or developing bilateral involvement. Fifty patients (25%) had bilateral involvement upon initial presentation. Five patients (3%) were subsequently diagnosed with contralateral trigger thumb after initial presentation of unilateral trigger thumb. Average time to contralateral trigger thumb development was 12 months after presentation in unilateral patients. Most patients presented with locked flexion contracture with palpable Notta’s nodule. Of the 5 patients who developed contralateral trigger thumbs, three required a second surgery after the index procedure. Conclusions: The vast majority of patients with bilateral trigger thumbs had bilateral involvement upon initial presentation to the pediatric hand clinic. Given the rarity of bilateral symptoms after initial unilateral presentation, we do not recommend delayed surgical intervention for patients with unilateral disease in children over 3 years of age.

Effect of combination of lateral recess decompression by Tessys technique and PTED in patients suffering from contralateral symptoms of lumbar disc herniation

The aim was to explore the effect of lateral recess decompression by percutaneous transforaminal endoscopic spine system (Tessys) technique combined with percutaneous transforaminal endoscopic discectomy (PTED) on pain medium, nerve function and stress response in patients suffering from contralateral symptoms of lumbar disc herniation. A total of 96 patients with contralateral symptoms of lumbar disc herniation treated in our hospital from February 2015 to April 2017 were randomly divided into control group and study group, with 48 cases in each group. The control group underwent PTED, and the study group underwent lateral recess decompression by Tessys technique combined with PTED. The visual analogue scale (VSA) score and Japanese Orthopaedic Association (JOA) score before surgery and 3 months after surgery were compared between the two groups. The levels of serum pain medium (prostaglandin E2 (PGE2), histamine (HA), 5-hydroxytryptamine (5-HT)) and oxidative stress indexes (malondialdehyde (MDA), myeloperoxidase (MPO), superoxide dismutase (SOD), total antioxidant capacity (TAC)) before surgery and 7 days after surgery were compared. The clinical efficacy of the two groups was compared at 1 month after treatment. One month after treatment, the excellent and good rate in the study group was significantly higher than that in the control group (85.4% vs 56.3%; P < 0.05). There was no significant difference between VAS and JOA score in the two groups preoperatively ( P > 0.05). At 3 months after surgery, the VAS score in the study group was significantly lower than that in the control group ( P < 0.05), and the JOA score in the study group was significantly higher than that in the control group ( P < 0.05). There was no significant difference in serum PGE2, HA and 5-HT levels between the two groups preoperatively ( P > 0.05). At 7 days after surgery, the serum PGE2, HA and 5-HT levels in the study group were significantly lower than those in the control group ( P < 0.05). Preoperatively, the levels of serum MDA, MPO, SOD and TAC were not significantly different between the two groups ( P > 0.05). On the seventh day after surgery, the levels of serum MDA and MPO in the study group were significantly lower than those in the control group ( P < 0.05), and the levels of SOD and TAC were significantly higher than those in the control group ( P < 0.05). In conclusion, the combined therapy of lateral recess decompression by Tessys technique and PTED in patients suffering from contralateral symptoms of lumbar disc herniation has a definite clinical effect, which can significantly alleviate the symptoms of low back pain and motor nerve function and reduce the contents of serum pain medium and the levels of oxidative stress. It is worthy of clinical promotion.

Lumbar Disc Herniation with Contralateral Radiculopathy: Do We Neglect the Epidural Fat?

Lumbar disc herniation (LDH) is the most common cause of radiculopathy, whose pathological entity underlying nerve root compression is usually on the same side as the symptoms. However, LDH causing contralateral radiculopathy are sometimes encountered by pain physicians. There have been tremendous developmens in the treatment options for LDH; the situation of LDH causing contralateral radiculopathy is indeed a dilemma for some pain physicians. We will report a case of a patient with a L4-5 disc herniation whose left herniated disc caused radiculopathy on the right side. After a percutaneous lumbar endoscopic discectomy via the side ipsilateral to the symptomatic side, this case obtained a significant symptom remission. The migrated epidural fat is discussed as a cause of associated contralateral neurological deficit. Only via a surgical approach ipsilateral to the herniated side, could there be a clinical improvement postoperatively. Key words: Contralateral symptoms, lumbar disc herniation, radiculopathy, epidural fat