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All Posts Tagged: Endoscope

Endoscope

With the endoscope we can use a special fiber optic microcamera to see inside the tissues and direct special tools for biopsies and to investigate anatomical abnormalities, opening new drainage channels of the cerebrospinal fluid (eg 3rd ventriculostomy), opening of brain cysts , removal of pituitary tumours, removal of cerebral hematomas, and even the surgical treatment of aneurysms. Special training of neurosurgeons is required as far as the techniques of the endoscope are concerned. The more the progress and development of the equipment, the more neurosurgical diseases are treated with endoscopic methods, in combination with other techniques, such as neuronavigation.

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Microsurgery

 

 

 

Just like other specialties, modern Neurosurgery often requires the use of a microscope to properly treat conditions such as slipped disk in the waist and neck, surgery for vascular lesions of the brain (aneurysms, vascular malformations, tumors), and spinal cord surgery. The use of a surgical microscope is now necessary in every neurosurgical unit and is combined with other infrastructures such as the endoscope, the neuronavigation and others. The use of the microscope in combination with percutaneous surgery, endoscopy and neuromonitoring, improves the effectiveness and safety of surgery. At the same time, blood loss, the risk of neurological damage, hospitalization time and recovery time after surgery are drastically reduced.

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Arachnoid cysts

 

 

These are congenital disorders formed by the pathological development of one of the membranes of the brain, namely the arachnoid mater. Normally this meninge is a thin membrane that covers the brain, leaving only minimal space, where the cerebrospinal fluid is located and circulating. If, due anatomical damage, this membrane allows for the accumulation of this fluid, this causes cysts to form, trapping fluid and exercising pressure on the brain. The diagnosis is possible via computed tomography and magnetic resonance imaging. There may be no clinical symptom, or there may be seizures, severe headaches, increased intracranial pressure, and other symptoms. These are benign conditions that may require a simple surgery, in which the fluid is drained towards its normal circulatory pathway, so that the brain can be decompressed.

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Hydrocephalus

 

 

Hydrocephalus is a condition of the brain characterized by abnormal concentration of cerebrospinal fluid (CSF). CSF is produced in special sacs in the brain called ventricles. The fluid circulates around the brain and the spinal cord, offering protection and support for the central nervous system. It is constantly produced and is reabsorbed at a rate of about half a liter per day. In pathological conditions, it may accumulate in the ventricles of the brain, or around the brain. This causes the ventricles to swell, which can be seen on a cerebral CT or MRI scan. Excessive CNS accumulation is called hydrocephalus, and can be accompanied by an increase in intracranial pressure; this is a condition that can be particularly threatening to health. Hydrocephalus can result from either an obstruction in the normal circulation of the fluid, or a disorder of its reabsorption, or in the event of overproduction.

Obstructive hydrocephalus

In obstructive hydrocephalus, there is an obstruction of the smooth circulation and drainage of the cerebrospinal fluid. This may be due to a stenosis (e.g. a stenosis of cerebral aqueduct) or pressure in the cavities that contribute to fluid accumulation due to a tumor or any other cause. In order to treat this, the obstruction must be resolved (for example, the tumor should be removed), or an alternative drainage must be found (valve placement or endoscopic surgery called a third ventriculostomy).

Non-obstructive (communicating) hydrocephalus

In this case, there is no obstruction in the circulation of the fluid, however, there is some problem involving its absorption at the areas where the fluid switches to the venous circulation (in the blood). The treatment is, again, to insert a valve and decompress the brain so that the fluid would be channeled to other cavities of the body (e.g. the peritoneal cavity, i.e. the patient’s abdomen.

Infantile hydrocephalus

The majority of cases of hydrocephalus occur in childhood, due to either a developmental disorder of the anatomical elements of the brain and skull, or due to a tumor or some other malformation. It is extremely important for the pediatrician to immediately diagnose hydrocephalus and refer the cases to the neurosurgeon for further investigation, treatment, and monitoring. Lack of the timely treatment for hydrocephalus can have devastating consequences for the health and development of a child. The increase in intracranial pressure may be life threatening and may require urgent neurosurgical treatment. Read more about infantile hydrocephalus.

Normal Pressure Hydrocephalus (NPH)

Normal pressure hydrocephalus is a syndrome that occurs mainly in elderly people. CSF accumulates in the ventricles of the brain and causes them to swell, but this is not necessarily accompanied by increased intracranial pressure. The syndrome includes 3 main symptoms: gait disturbance, mild dementia, and urinary incontinence. This type of hydrocephalus may occur following an injury or infection of the brain, although in most cases no cause is found.
In elderly patients, symptoms may include gait disturbances, dementia, memory disturbance, and urinary incontinence, as well as other medical conditions, such as Alzheimer’s disease, or stroke. Diagnosis can be challenging and requires the cooperation of specialists such as a neurologist, neurosurgeon, general practitioner, and psychologist.

Frequently asked questions

What can I expect after the surgery?

There is an improvement usually a few days after surgery. After being discharged from the hospital, the patient needs to be monitored. Postoperative valve reset may be needed, which is easily carried out at the doctor’s practice, without requiring any invasive or bloody operation. Although 100% effectiveness and improvement of symptoms could never be guaranteed, the benefits of surgery on patients requiring surgery are very important and impressive. Benefits clearly outweigh the risks and possible complications of surgery.

The use of the neurosurgical endoscope has provided us with new treatment possibilities, in many conditions such as hydrocephalus. Quite often, instead of inserting a valve, which is a foreign body into the brain and the body, therefore it could cause infections, malfunctioning, and other problems, we would first try to create alternative drainage of the fluid inside the brain. One of the methods for this is “third ventriculostomy”, which involves creating an opening on the bottom (lower part) of the third out of the four ventricles of the brain, i.e. in one of the 4 areas where cerebrospinal fluid is accumulated. This method would very often solve the problem, or at least it saves valuable time, by avoiding placing a valve in a very young child. The valve may need to be inserted later on at an older age, when the child’s body is stronger, or never. However, not all children are suitable candidates for this type of operation.

How do I know if I have normal pressure hydrocephalus?

Clinical examination and CT and MRI imaging are usually not enough. If there are the above symptoms and are gradually getting worse, an assessment by a specialist with experience in the diagnosis and treatment of this condition would be required. The general practitioner, internal medicine specialist or neurologist would first raise clinical suspicion for this. If the patient is referred to a neurosurgeon in a timely manner, the early diagnosis and treatment can have spectacular results in improving the patient’s quality of life and functionality.

How is infantile hydrocephalus diagnosed?

Hydrocephalus means an increased amount of cerebrospinal fluid inside the skull, i.e. around and inside the brain. The clinical diagnosis is usually made by the pediatrician treating the child. The most common finding, especially in newborns and infants, is the disproportionately large increase in the circumference of the child’s head.
In older children, the symptoms involve increased intracranial pressure. The child may complain of headaches, vomit frequently, especially in the morning, sleep excessively (although this is not always the case) and have slow psychomotor development. This is because the skull bones no longer leave gaps, or fontanelles, in the skull, so the size of the head cannot increase to the extent required so that the brain is not pressed by the excess cerebrospinal fluid. The diagnosis is documented by cerebral CT or MRI.
Newborn babies could also undergo a skull ultrasound.
An increase in intracranial pressure may also be noted by an ophthalmologist with an examination called a fundoscopy, which can reveal papilledema, meaning increased pressure at the point where the optic nerve passes from the brain to the fundus of the eye.

Can normal pressure hydrocephalus be treated?

Diagnosis may require special neurosurgical tests for the temporary drainage of the CSF. If the patient’s symptoms improve with these tests, then the diagnosis can be certain. A special internal permanent drainage tube could then be placed leading from the brain to another cavity in the body – usually the abdominal cavity. The surgery required is technically quite simple, although possible failure, obstruction of the tubule, or infection is always a risk. Usually a few days after valve placement, gait, memory, and urinary control are steadily improving, although some symptoms may persist for longer.

My child is diagnosed with hydrocephalus. Is surgery really necessary?

Not always. The cause and the degree of obstruction is the decisive factor. If hydrocephalus is obstructive, i.e. there is an obstruction that prevents the drainage of the excess fluid, as in the so-called aqueductal stenosis, then it may be necessary to open another alternative way to drain the fluid without any pressure phenomena on the brain. If the hydrocephalus is relatively limited and does not cause symptoms or an abnormal increase in head circumference, then it is characterized as “compensated” and the child should be monitored with regular MRI scans and investigation of the cerebrospinal fluid flow (examination performed together with the MRI) . However, hydrocephalus can have other causes, such as tumors or other anatomical abnormalities. In these cases, surgery is required not only to relieve hydrocephalus, but also to diagnose and treat the underlying condition.

 

 

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Minimally Invasive Neurosurgery

Neurosurgery techniques have been developed in order for operations to be performed with the least possible risk of body injury. Especially in Neurosurgery, where the object of treatment is the valuable nerve tissue, which if damaged can not be regenerated, the minimally invasive technique is really valuable for patients.

Minimally Invasive Methods utilize technologies such as Robotic Navigation, the Surgical Microscope and Endoscope , as well as a range of advanced surgical tools and equipment, such as the ultrasonic osteotomy. Surgeons who know these techniques are able to provide patients with modern surgical care in Greece, with the exact same quality characteristics as in the most advanced medical countries in the world.

Now even the most inaccessible anatomical areas can be operated on with minimal injury to sensitive nerve structures.

Minimally invasive spine surgery. Fashion or real progress?

In modern surgery, with the help of technology and the accumulation of experience, new methods have been developed, which help surgeons perform operations that in the past were particularly traumatic, with minimal risk of surgical trauma. In most surgical specialties, such as gynecology, urology, general surgery and others, the non-use of endoscopic and minimally invasive techniques for some surgeries tends to be considered bad medical practice (malpractice).

In many cases, all of these methods tend to replace open surgeries.

Minimally invasive spine surgery.

There is clear pressure coming from insurers, both private and public, as well as from the patients themselves for access to medical intervention which, while not lagging behind in terms of effectiveness, will be clearly more economical, and will restore the patients’ help, ensuring a better life overall.

The progress of spine surgery A typical example is spine surgeries, such as spinal fusion. Percutaneous spinal surgeries, for example, significantly reduce patients’ discomfort , pain, risk of complications, and hospitalization time. Even the largest spinal fusion does not mean that the patient is required to stay in bed. Patients with spondylolisthesis, spinal stenosis, lumbar spondylosis, and vertebral fractures after injury can move without pain within a few days and are discharged from the hospital in 2-3 days. The need for blood transfusions during spinal fusion surgeries is practically zero.

The purpose of minimally invasive techniques is to prevent injury of the muscles, blood vessels and nerves that supply them, which are caused by the conventional traditional open surgery technique. Many studies have shown that the traditional open posterior spinal fusion approach can be technically successful since X-rays show good results, but the results in terms of symptoms may be poorer than expected. The main symptoms of “Vertebral disease” are persistent back pain, the decrease in the strength of the back muscles and a feeling of fatigue or a heavy feeling in the back after performing activities. Therefore, if extensive incisions are avoided, this problem can be prevented.

Some patients who suffer from pain in the spine undergo all the necessary clinical and imaging tests (x-rays, magnetic resonance imaging, etc.) but no obvious cause of their pain is found. In order for these patients to be relieved, more specialized diagnostic and at the same time therapeutic mild invasive operations may be needed. For example nerve block, intervertebral disc herniation, joint vein denervation. All these methods are examples of minimally invasive treatments of the spine. Most of them are done using ultrasound and do not require hospitalization.

In the past, these patients would either not receive any invasive treatment and would suffer from consuming large amounts of drugs, with whatever morbidity and increase in medical costs this may cause, or they would undergo open surgery, with questionable end results and high costs.

All open vertebrae can be replaced by percutaneous, with the mere exception of surgeries to repair scoliosis. The time of full functional recovery is dramatically reduced by reducing the cost of health expenses.

Microdiscectomy becomes a matter of day care, while the incision in the skin is only 1.5 cm. The patients do not even have to spend the night in the hospital. Thus,recovery is accelated and they are able to return to their activities.

Kyphoplasty for the repair of vertebral fractures (e.g. from osteoporosis), is also done with daily hospitalization and immediate mobilization and relief of the patient.

Of course, we must be very careful in choosing the right methods. There is a risk that patients who need a normal discectomy (even in a minimally invasive way) to undergo, for example, a percutaneous disc coagulation operation, which will offer them nothing and will not avoid the discectomy. Patients are often seduced by attractive terminology (laser, robotics, bloodless, etc.). Not all cases of slipped disc are the same. Choosing the right method reduces the overall cost and inconvenience of a patient. Therefore, if minimally invasive methods are not used properly, they can harm the patient, delaying proper treatment.

Examples of Minimally Invasive Spine Surgery

Surgery

Duration of Hospitalization

Blood loss

Postoperative chronic pain

Type of Anesthesia

Duration of Intervention

Kyphoplasty 1 Day 10-15 cc 1-2 days Intoxication 30-60’
Endoscopic Microdiscectomy Daily 20-30 cc 1-2 Days total 60’
Nerve block Not required 0 0 Local 20’
Joint Denervation Not required 0 0 Local / Intoxication 20 ‘
Minimally Invasive Decompression 1 Day 20-40 cc 1-2 days Total 60-80 ‘
Percutaneous Spinal Cord 2-3 days 40-60 cc 2-3 days Total 40 ‘/ level
Average <1 day 25
cc
1-2
days
45 ‘

Comparison with Classical Invasive Methods

Surgery

Duration of Hospitalization

Blood loss

Postoperative Pain

Type of Anesthesia

Duration of the operation

Laminectomy 3-4 days 100-150 cc 7 days total 60-70 ‘
Microdiscectomy 1-2 days 150 cc 2-3 Days total 60′-90 ‘
Trimetectomy 2-3 days 200 cc 2-4 days total 60′-90 ‘
Open Spine 5 days 400-600 cc 7-10 days Total 60 ‘/ level
Average 3 days 250
cc
5, 2 5
days
75 ‘

 

Proper information of our patients contributes significantly to the selection of appropriate treatment. As surgeons, with respect to international clinical experience, we are constantly updating our techniques. Thus we harmonize with the rapidly evolving methods that improve the health of all, reducing the material and ethical costs of invasive treatment.

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