By U. Umbrak. University of Idaho.
C: Typical sonogram of a lumbar interspace: midline hyperechoic structures represent the ligamentum flavum–dorsal dura unit (upper) and the ventral dura posterior longitudinal ligament–vertebral body complex (lower); bilateral symmetrical hyperechoic structures indicate articular and transverse processes with their acoustic shadows 20 mg erectafil for sale. Locating the epidural space in obstetric patients—ultrasound a useful tool: continuing professional development purchase erectafil 20mg with visa. Locating the epidural space in obstetric patients—ultrasound a useful tool: continuing professional development cheap erectafil 20mg without a prescription. This list includes both the supplies needed to perform the block and the emergency equipment required to treat rare, but potentially catastrophic complications. Subarachnoid anesthesia is usually induced in an operating room or nearby procedure room. Epidural anesthesia can be induced in a labor room or in the preoperative holding area. Positioning 2289 Most patients will either sit or lie on one side during induction of neuraxial anesthesia. Inserting a spinal needle with the patient in the prone jackknife position has been described, but is rarely used in contemporary practice. Still, a recent report describes a real-time ultrasound-guided approach to the L5–S1 interspace in prone patients. The choice between sitting and lateral position32 depends on the provider, the patient, and the procedure. You should be comfortable inserting spinal and epidural needles with patients in either position so you can choose the most suitable approach for each patient and procedure. When sitting, place the patient squarely on the operating table with back and buttocks at the near edge. Tilting the operating table may help flex the patient’s hips and lumbar spine, further opening the lumbar interspaces (Fig. Having obese patients, and those with poorly palpable36 landmarks, sitting can make it easier to identify the subarachnoid or epidural space. When positioned properly, a line from the C7 vertebral prominence to the gluteal cleft identifies the midline. Table 35-1 Suggested Contents for an Epidural Cart 2290 Figure 35-13 Sitting position for neuraxial block. Position the patient squarely on the bed or operating table with the buttocks at the edge near the operator. The patient’s legs can be supported by the table, a stool, or (in Labor and Delivery) flexed on the bed. When using the lateral position, bring the patient’s back to the edge of the table. An assistant can help the patient bend her knees and hips and flex her lumbar spine. The site of surgery and baricity of the local anesthetic will determine the choice of side. When inducing subarachnoid anesthesia for cesarean section using either hyperbaric or isobaric drug, place the patient on her right side, then turn supine, and provide left uterine displacement. Use blankets and pillows to make sure the patient is warm, comfortable, and appropriately covered. Patients with painful fractures may need deeper sedation to allow appropriate positioning. Although skilled pediatric anesthesiologists have a good record of safely inducing neuraxial anesthesia after induction of general anesthesia in children, this approach38 does not seem prudent in adults. Both chlorhexidine with alcohol42 and povidone–iodine with alcohol provide effective skin decontamination. Most anesthesiologists use thin (≤24-gauge) needles to limit the risk of headache. A shorter introducer needle helps puncture the skin and guide the flimsier spinal needle toward the subarachnoid space. This larger diameter improves the tactile feel as the needle advances through the ligamentum flavum and into the epidural space. Epidural needles usually 2293 have a curved tip to help guide the catheter in the epidural space. Curved tip epidural needles, as well as the straight-tipped Crawford needle, also can be used for caudal block. Combined subarachnoid epidural block can be performed sequentially with regular needles or as a needle-through-needle technique. The needle-through- needle technique can be done most simply with an extra long spinal needle and a regular epidural needle (Fig. Specialized needle-through-needle, or needle-beside-needle combinations are also available (Fig. Approach Lumbar neuraxial block can be performed with either a midline or paramedian approach (Fig. The thoracic spinous processes slope steeply and the thoracic spine does not flex as much as the lumbar spine. As a result, the thoracic epidural space is more easily entered using the paramedian approach. A: An 18-gauge, 90- mm Tuohy needle and 27-gauge, 127-mm Whitacre needle side by side. Technique Identifying the subarachnoid or epidural space is an exercise in applied 2294 anatomy. Recognize which part of the vertebrae (spinous process, lamina) and where (midline, right, or left) the needle is touching and make an informed choice to redirect the needle toward the target (Fig. After positioning the patient, identify the midline by palpating the spinous processes. In obese patients, estimate the midline by imagining a line between the C7 prominence and the intergluteal cleft. In patients with poor landmarks, insert the needle in the presumed midline and explore. If the needle strikes bone, assess your location (spinous process: intermediate or shallow depth; lamina: deeper) and adjust your approach accordingly. The midline approach requires anatomic projection in only two planes: sagittal and horizontal. The paramedian needle insertion site is 1 cm lateral and slightly below the cephalad edge of the more caudal spinous process. The needle is inserted 10 to 15 degrees off both sagittal and horizontal planes (inset). The insertion site is approximately 1 cm lateral to the superior edge of the inferior spinous process (Fig. Angle the needle slightly cephalad and slightly medial, aiming for the midline at the estimated depth of the epidural or subarachnoid space. A bony obstruction at the estimated depth of the subarachnoid or 2295 epidural space is usually lamina. Gradually walk the needle cephalad until you enter the epidural or subarachnoid space.
Endonasal transsphe- tuitary adenoma and a tuberculum sellae meningioma: technical noidal approach for pituitary adenomas and other sellar lesions: an case report 20mg erectafil amex. Neurosurgery 2007;60(4 cheap erectafil 20mg online, Suppl 2):E401 discount erectafil 20mg without a prescription, discussion assessment of efcacy, safety, and patient impressions. J Neurosurg E401 2003;98:350–358 Microscopic and Endoscopic 23 Transsphenoidal Pituitary Surgery: A Reasoned and Balanced Dialectic Nathan C. Oyesiku The transnasal or endonasal transsphenoidal approach to Both hands are free to handle instruments (yes, bimanual the sella, developed in the early 20th century, was a re- surgery is safer and more efective, but get an endoscope markably elegant solution to the problems that early driver or holder and you can free up the neurosurgeon to surgeons faced with intracranial access to the pituitary use both hands); enhanced illumination at the source ver- gland. More recently pituitary neurosurgeons have if adjuvant therapy is still needed); operating times are rediscovered the endoscope, deploying it in endoscopic- shorter or longer (that depends on whom one reads and assisted and endoscopic-based transsphenoidal operations his or her veracity). The litany of claims and counterclaims to refne illumination and visualization of the sella and para- goes on and on as protagonists are swept up in the tide and sellar regions during pituitary procedures. As experience with endoscopic vantages of both techniques allows the rational surgeon to sinus surgery increased, endoscopic endonasal techniques individualize the approach to each patient’s lesion. Not ev- were adapted and expanded for use in other conditions af- ery patient is best served by the exclusive use of either a fecting the paranasal sinuses and skull base. Surgeons need to be comfortable with all the avail- loceles and mucoceles were reported. Evangelism and surgeons must be carefully deployed; “a fool with a tool is proselytism now compete with cautious clinicians and still a fool, only a more dangerous fool. Opinion and bias now rival balanced con- No instrument or equipment can make one a surgeon. Surgeons achieve expertise by years of training and the ac- The arguments are by now familiar: “minimally inva- quisition of experience. Good judgment comes from experi- sive” (yet both are endonasal—endonasal microscopic or ence, whereas experience comes from bad judgment (Jim endonasal endoscopic); shorter length of stay (length of Horning). The critical question facing pituitary neurosur- stay has nothing to do with a microscope or an endoscope); geons today becomes when and how to deploy endoscopic nasal packing (packing has nothing to do with a microscope and microscopic techniques, based on available data and or an endoscope); the view is three-dimensional (3D) and experience. In this chapter, we present clinical decision- stereoscopic versus two-dimensional (2D) and somewhat making factors that should guide the discerning and dis- distorted (yes, but 3D endoscopes are now being devel- criminating neurosurgeon as to whether microscopy-based, oped); panoramic visibility and ability to see around cor- endoscopy-based, or a hybrid of the two techniques repre- ners (yes, but this provides little added advantage in cases sents the optimal procedure for successfully resolving pitu- where the lesion is small and straight ahead at 0 degrees). With both procedures, induc- tion of general anesthesia and placement of a lumbar drain The state of the literature surrounding this debate is at (if needed) are identical. Positioning of the head should be present polarized between traditional microscopists and fxed approximately 10 degrees toward the surgeon. For evangelical endoscopists, both arguing in favor of their pro- sellar lesions, the head is generally fexed approximately cedural biases. Most 20 degrees and even more so if the disease is clival in ori- descriptions of these techniques occur with little attempt to gin. That being said, some surgeons do not use a Mayfeld head holder in endoscopic approaches. If an endoscope will be Planning and Positioning used, typically the endoscope monitor is positioned behind the patient; the surgeon stands on the right, the assistant The diferential diagnosis of pathologies that may occupy stands on the left, and anesthesia is situated on the side op- the sella turcica includes tumors and nonneoplasms and is 20 posite the surgeon behind the assistant. Even the most common lesion, pituitary adeno- be used, this is an appropriate time to balance and drape mas, frequently have parasellar extensions (Fig. Also, intraoperative guidance systems, if any, should be the strategy of how microscopic and endoscopic techniques readied. Next, the nasal mucosa is prepared with a vasocon- are applied must begin at the planning stage, which should strictive agent, for example, 4% cocaine or oxymetazoline. In the endonasal transseptal microscopic-based procedure, Assistant surgeons, most commonly otorhinolaryngolo- the nasal mucosa may be injected with local anesthetic to gists, may be included if an endoscopic approach is under aid in the dissection of the rhinoseptal mucosa. This multidisciplinary approach, although endonasal microscopic approach there is no septal mucosal still institution-dependent, is a very common and reason- 21 dissection. In this scenario, the operating room should be accommo- Approach and Exposure dated to facilitate both teams. In the microscope-based tion is done, it is usually necessary to insert a nasal specu- transseptal (but not the direct endonasal procedure), a small lum to hold the nasal mucosa out of the line of sight and vertical buried incision is made within the nasal mucosa in to push the middle turbinate laterally. If a direct endonasal either nare but usually ipsilateral to the operating surgeon. A at the face of the sphenoid between the ostium and the handheld nasal speculum is inserted medial to the septum septum, subluxing the septum and exposing the face of and lateral to the rhinoseptal mucosa, taking care not to tear the sphenoid. Any remaining attachment of mucosa to the the nostril containing the nasal speculum. The perpendicular plate of the in endoscopic-based procedures, the procedure is typically ethmoid and the vomer between the surgeon and the sella multidisciplinary, with the otolaryngologist completing the are removed. The nasal speculum is then arranged in the endoscopic endonasal approach to the sphenoid sinus and newly formed submucosal cavity with the tips of the blades the neurosurgeon opening the sella and resecting the tu- nearly at the base of the sphenoid sinus. However, many neurosurgeons perform the approach is in good position, the blades are gently opened to keep the without an otolaryngologist. The use of a speculum is not necessary, as there croscopic procedure both obviate an initial nasal mucosal is no need for mucosal retraction and no “line-of-sight” incision. Moreover, a speculum would limit the nasal mucosal incision, a large bilateral sphenoidectomy the space available for the endoscope and surgical instru- and posterior one-third septectomy are created to provide ments. However, because no speculum is present, the en- for entry of the instruments and the endoscope into the doscope and instruments can abrade the mucosa and cause sphenoid sinus. This opening is invasive and indeed quite bleeding that can obstruct the endoscope lens. Because of so in that the mucosa and bone over the sphenoid sinus wall this, and due to the proximity of the lens to the operative are extensively debrided and approximately one third of the feld, during endoscopic-based procedures frequent and posterior septum is removed (fortunately this is not exter- repeated cleansing of the endoscope is often required. Upon entry of the endoscope into the As the endoscopic procedure commences, the camera nare, the camera is oriented with the following important and instruments are introduced parallel to one another landmarks identifed: (1) the inferior turbinate and eusta- through one or both nostrils. It is important not to lose chian tube in the lateral feld, (2) the nasal septum in the sight of the instruments in front of the endoscope to pre- medial feld, (3) the nasal cavity foor in the inferior feld, vent trauma to the mucosa or important neurovascular and (4) the middle turbinate head in the superior feld. The surgeon is ofered a wide viewing angle may sometimes be necessary to decongest and perhaps lat- with the endoscope that provides a panoramic view of the erally dislocate the middle turbinate head, which usually sphenoid sinus, the face of the pituitary gland, and the in- closely approximates the nasal septum. These are normally located is resected using the microscope, and the endoscope then approximately 1. The ostia initially may not be vis- est outside the view of the microscope, including the cav- ible, as the view can be obstructed by the superior turbinate. The surgeon should note, however, that the al24 quantifed the volume of space accessible under both lateral lamella of the cribriform plate is thin, which poses a microscopic and endoscopic guidance. At this point, the nasal septum may be 240 Endoscopic Pituitary Surgery detached from the sphenoid rostrum and the bone of the vo- posure to endoscopic techniques. In both procedures, tive and likely will facilitate the appropriate and judicious the sphenoid ostia are opened using a bone punch or mi- use of one or both techniques dictated by the anatomy of crodrill. Once the sphenoid sinus is opened, the midline is each patient’s tumor rather than by the surgeon’s comfort identifed. Surgeons should note the location of the septum with one particular technology over the other.
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