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H D Jho

Publications and source records attributed to H D Jho.

At least 19 recordsLinked to original sources
PubMed2001

Endoscopic endonasal cavernous sinus surgery: an anatomic study.

OBJECTIVE: The endoscopic surgical anatomy of the cavernous sinus was studied to establish an anatomic basis for endoscopic endonasal cavernous sinus surgery. METHODS: Five adult cadaveric heads were studied with 0-, 30-, and 70-degree 4-mm rod-lens endoscopes. The posterior wall of the sphenoidal sinus was approached via a paraseptal, middle turbinectomy, or middle meatal approach. RESULTS: The posterior bony wall of the sphenoidal sinus is subdivided into five vertical compartments: midline, bilateral paramedian, and bilateral lateral. The midline vertical compartment consists of the planum sphenoidale, tuberculum sellae, sella, and clival indentation. The paramedian vertical compartment is composed of the medial third of the optic canal and the carotid artery protuberance. The lateral vertical compartment contains four bony protuberances (optic, cavernous sinus apex, maxillary, and mandibular) and three depressions (carotico-optic, ophthalmomaxillary [V1-V2], and maxillomandibular [V2-V3]). The three depressions form anatomic triangles at the lateral vertical compartment: the optic strut triangle, which is bordered by the optic nerve, carotid artery, and oculomotor nerve (IIIrd cranial nerve); the V1-V2 triangle; and the V2-V3 triangle. The internal carotid artery at the posterior wall of the sphenoidal sinus can be subdivided into two main segments: the parasellar and the paraclival. The vidian canal is a landmark that leads to the foramen lacerum, the mandibular nerve, and the pterygopalatine fossa. CONCLUSION: Endoscopic anatomy of the cavernous sinus has been studied via an endonasal route in cadaveric specimens to provide an anatomic basis for endoscopic endonasal cavernous sinus surgery.

Adult↗
PubMed2000

Endoscopic transsphenoidal pituitary surgery: various surgical techniques and recommended steps for procedural transition.

Various techniques in pituitary endoscopy are reviewed in the attempt to assemble the transitional steps necessary to take a neurosurgeon from traditional microscopic transsphenoidal surgery to endoscopic endonasal pituitary surgery. The senior author's (HDJ) experiences of endonasal endoscopy in more than 200 operations as well as the reports in the literature on pituitary endoscopy are reviewed. Two distinct advantages that an endoscope has over an operating microscope are its ability to visualize through a narrow surgical corridor and its ability to provide angled, close-up views. An endoscope can be used to assist the operating microscope (endoscope-assisted microsurgery). Endoscopy can also be used for endonasal retractor placement when microscopic surgery is preferred (endoscopic sphenoidotomy). When endonasal endoscopy is chosen, the surgical approach can be made with a deep-transseptal, a paraseptal, a middle turbinectomy or a middle meatal approach (endonasal transsphenoidal endoscopy). Endonasal endoscopy can be performed via either one or two nostrils. Working-channel endoscopy can be performed for restricted purposes. When a neurosurgeon desires to adopt endoscopy into pituitary surgery, the author recommends endoscope-assisted microsurgery as the first step followed by endoscopic sphenoidotomy as a combined effort between an endoscopic rhinologist and the neurosurgeon as the next step leading finally to endonasal pituitary endoscopy. Various methods of transsphenoidal endoscopy and the authors' recommendations for transitional steps are reported based on the authors' personal experience and literature review.

Acromegaly↗
PubMed1999

Endoscopic pituitary surgery.

Endoscopy has been adopted for transsphenoidal pituitary surgery. A rigid rod-lens endoscope, 4-mm in diameter and 18 cm in length, is used in replacement of the operating microscope. This endoscopic technique utilizes the patient's natural nasal air passage as a surgical corridor without a sublabial or nasal mucosal incision. The use of a transsphenoidal retractor is not necessary. Postoperative nasal packing is not required. The average length of a patient's hospital stay is overnight. Postoperative discomfort is minimal. An angled lens endoscope enables the surgeon to operate on tumors located in the suprasellar region under direct visualization. When the adoption of endoscopy in transsphenoidal pituitary surgery had demonstrated obvious advantages over conventional microscopic surgery, the use of this endoscopic endonasal technique has been expanded to include other skull base lesions at the anterior fossa skull base, cavernous sinus, clivus and clival posterior fossa. In this chapter, the author describes the evolution of this endoscopic transsphenoidal surgery, the pertinent sinonasal anatomy related to transsphenoidal endoscopy, the details of endoscopic endonasal transsphenoidal pituitary surgery, surgical approaches to the other skull base lesions, surgical results, and potential complications and their avoidance.

Adenoma↗
PubMed1999

Anterolateral approach for cervical spinal cord tumors via an anterior microforaminotomy: technical note.

A cervical spinal cord tumor located anteriorly to the spinal cord is conventionally approached through an anterior vertebrectomy followed by bone-graft reconstruction. In order to make a surgical approach minimally invasive, an anterior microforaminotomy technique is used for removal of a tumor located anterior to the spinal cord. When the senior author's experience increased with anterior microforaminotomy for cervical radiculopathy and myelopathy, it was observed that intradural pathology could also be taken care of through the anterior microforaminotomy which did not require bone fusion or postoperative immobilization. For tumor resection, the anterior foraminotomy is made like a flask-shaped hole, with a smaller outer opening similar to that for radiculopathy but incorporating a larger inner opening to accommodate the extent of the tumor in a longitudinal and transverse dimension. The surgical technique is described with two illustrated patients. Postoperatively, the patients did not require a cervical brace. Although their postoperative discomfort was minimal, they were kept in the hospital overnight postoperatively. Spinal stability was well maintained 6 weeks postoperatively. Postoperative imaging of the spine confirmed resection of the tumors. Anterior microforaminotomy is a minimally invasive microsurgical technique which can provide safe and successful removal of tumors located anteriorly to the spinal cord.

Cervical Vertebrae↗
PubMed1999

Endoscopic transpedicular thoracic discectomy.

OBJECT: To minimize the invasiveness and maximize the adequacy of the decompressive procedure in thoracic discectomy, a 70 degrees endoscope was adapted to perform transpedicular thoracic discectomy. METHODS: A posterior transpedicular approach was performed via a 2-cm transverse skin incision, aided by an operating microscope or a 0 degrees lens endoscope. Using a 70 degrees lens endoscope, discectomy was performed after obtaining direct visualization of the ventral aspect of the spinal cord dura mater. This surgical technique has been used in 25 patients. There were 12 men and 13 women whose ages ranged from 29 to 74 years (median 46 years). Thirteen patients experienced myelopathy, with or without radiculopathy, 10 presented with radiculopathy, and two patients suffered from segmental pain. The follow-up period ranged from 4 to 60 months (median 27 months). In 12 of 13 patients with myelopathy, excellent improvement was shown postoperatively. In the remaining patient, symptoms recurred after she was injured in a motor vehicle accident 3 months postsurgery. In nine of 10 patients with radiculopathy, pain resolved completely. In the one patient with right-sided hypochondral pain and in the two patients with segmental pain, no relief was obtained despite excellent discectomy results demonstrated on postoperative magnetic resonance images. The average length of hospital stay was overnight. CONCLUSIONS: The use of a 70 degrees lens endoscope through a transpedicular route has made thoracic discectomy comparable with cervical or lumbar discectomy in terms of minimal surgical invasiveness, recovery time, and complexity of the procedure.

Adult↗
PubMed1998

Posterolateral approach for anteriorly located cervical spine tumors: technical note.

Cervical spinal cord tumors located anteriorly to the spinal cord often require an extensive anterior vertebrectomy approach for their removal followed by bone fusion and postoperative immobilization. To minimize the invasiveness of the conventional anterior approach for those tumors, the author has utilized the anterolateral approach which was originally developed for spondylotic disc disease. However, some of those tumors still can be removed by a less invasive posterior approach which violates spinal integrity to a much lesser degree. Anteriorly located tumors, in which the tumor-cord interface line extends posteriorly to a horizontal line drawn along the posterior margin of the vertebral body, can be removed by the posterolateral approach with a skin incision made at the point where the tumor-cord line intersects. Because the facet joint is thin and the pedicle is shallow in the cervical spine, only a hemilaminectomy bone window is required in this posterolateral approach for removal of such tumors. Surgical techniques of this posterolateral approach for removal of anteriorly located cervical cord tumors are described with two illustrated patients.

Cervical Vertebrae↗
PubMed1998

Death from a malignant cerebellopontine angle triton tumor despite stereotactic radiosurgery. Case report.

Malignant vestibular nerve tumors are rare: to date, only three cases have been reported in the literature. The authors report a case of an eighth cranial nerve tumor that progressed 5 years after stereotactic radiosurgery. The patient was a 44-year-old man who underwent stereotactic radiosurgery for a 27-mm cerebellopontine angle tumor that was discovered on investigation of tinnitus and hearing loss. He developed facial weakness after 5 years, and repeated imaging revealed tumor enlargement. Despite complete microsurgical excision, the tumor rapidly recurred locally and subsequently disseminated within the neuraxis. The patient died 1 year after tumor progression was detected. Histopathological analysis revealed a malignant spindle cell neoplasm with frequent mitotic figures. The presence of positive rhabdoid elements on immunohistochemical studies confirmed that it was a triton tumor. The authors review the relevant literature concerning the classification and management of malignant vestibular nerve tumors and discuss the implications of tumor progression after stereotactic radiosurgery.

Adult↗
PubMed1998

Case of the month: February 1998--82 year old man with progressive visual defects.

An 82 year old man with a recurrent prolactin-secreting pituitary adenoma had clinically asymptomaptic fungal growth in necrotic tissue adjacent to the tumor. This fungus was characterized by clumps of basophilic hyphae with pigment production. Ascus formation containing nucleated conidiopores was present. The asci had tapered and cylindrical beaks making Microascus sp. the most likely diagnosis, however, without cultures, Pseudoallesheria boydii could not eliminated. The patient was treated with Amphotericin B and there was no evidence of intracranial extension 4 months later.

Adenoma↗
PubMed1997

Endoscopic pituitary surgery: an early experience.

BACKGROUND: As an element of a minimally invasive management approach, we had developed an endonasal endoscopic transsphenoidal technique for the treatment of pituitary tumors. Initially, four patients were operated on via a sublabial, transseptal approach using a fiberoptic rigid endoscope in conjunction with the operating microscope. Encouraged by that experience, our subsequent 11 patients had undergone endonasal endoscopic transsphenoidal surgery without the use of a retractor or speculum. METHODS: Our group of patients included nine females and six males, with an age range of 17-88 years (median: 43 years). There were four microadenomas, four intrasellar macroadenomas, three macroadenomas with suprasellar extension, three invasive macroadenomas involving the cavernous sinus with suprasellar extension, and one metastatic adenocarcinoma. RESULTS: Thirteen patients with pituitary adenomas experienced resolution of their symptoms postoperatively. One patient with a recurrent prolactinoma responded partially following surgery and subsequently underwent gamma knife radiosurgery. Two patients were treated with postoperative fractionated radiation therapy, one for residual pituitary adenoma in the cavernous sinus, and the other for metastatic adenocarcinoma, respectively. The first patient, treated via an endonasal endoscopic approach for biopsy of the metastatic adenocarcinoma, developed postoperative cerebrospinal fluid (CSF) leak that was successfully managed with endoscopic packing of a fat graft. CONCLUSIONS: The endonasal endoscopic transsphenoidal approach facilitates faster postoperative recovery by the avoidance of traditional incision and postoperative nasal packing. It offers a panoramic view of the sphenoid sinus and excellent visualization of the sellar and suprasellar structures with increased illumination and magnification. Such visualization provides the potential for more complete tumor resection, as well as a better chance of preserving pituitary function and avoiding neurovascular injury.

Adenoma↗
PubMed1997

Glabellar approach: simplified midline anterior skull base approach.

As a simplified microsurgical technique for lesions at the midline anterior skull base, a glabellar approach through a small incision (5 cm) between the eyebrows crossing the nasion was developed in four cadaver dissections. To determine the ideal positioning of the patient, the angle of the surgical trajectory was measured in the sagittal plane. In an effort to make an operation simple and accurate through this limited exposure, measurements were made in distance from the midline nasion to various intradural structures. Average distance from the midline point of the nasion (MPNa) to the midline of the tuberculum sella was 6.37 +/- 0.29 cm, 6.98 +/- 0.26 cm to the midline of the optic chiasm, and 8.00 +/- 0.11 to the lamina terminalis. In addition, measurements to other various anatomical landmarks were made. The angle of the line drawn from the MPNa to the midline of the tuberculum sella was 5.2 +/- 1 degrees against a line drawn between the lateral canthus and the tragus (LC-T) in the sagittal plane. Based upon this study, the positioning of the patient's head would be better if the LC-T line is positioned at 25 degree extension when the operating microscope is set at 20 degree inclination. Within 6 to 8 cm in depth from the MPNa, important landmarks are exposed without brain retraction. If surgical instruments are marked with ruler calibration, the depth of the surgical instruments will suggest the anatomical location. This glabellar approach has been used in three patients successfully. A brain retractor was not necessary and not used during the operations. This technique provides key exposures to the midline anterior skull base.

Adult↗
PubMed1997

Orbital roof craniotomy via an eyebrow incision: a simplified anterior skull base approach.

Utilizing the conceptual combination of brain protective skull base surgery and minimalism, a conventional frontal craniotomy for tumors in the subfrontal and parasellar regions is modified to an orbital roof craniotomy. Through a 4 to 5 centimeter (cm) long eyebrow incision an orbital roof craniotomy (measuring 2 cm by 3 cm), including the supraorbital arch, is made as a single piece bone flap. The orbital roof is opened up to the supraorbital fissure and to the optic canal by additional removal of the bone in the orbital roof. This will expose the globe and the orbitofrontal dura mater. When the dural incision is made at the orbital portion of the dura mater, the orbital contents are retracted by tack-up sutures. The tumor is removed utilizing the orbital space rather than the intracranial space. Brain retractors are not necessary and are not used to execute the tumor resection. This technique has been used in three patients with craniopharyngiomas, seven patients with meningiomas, and one patient with a subfrontal teratoma. Gross total resection was achieved in three patients with craniopharyngiomas and in five patients with subfrontal or parasellar meningiomas. Subtotal resection of the tumor was achieved in two patients with recurrent meningiomas and in the patient with a subfrontal teratoma. The surgeon's operating space through this exposure was sufficiently ample to achieve the goals of the operation. The direct eyebrow incision provides an additional vital working space with a width of more than 1 cm at the skull base by eliminating the scalp flap which a coronal incision employs. The surgical technique is described with a report of 11 cases.

Adult↗
PubMed1997

Spinal cord decompression via microsurgical anterior foraminotomy for spondylotic cervical myelopathy.

A microsurgical anterior foraminotomy, as a direct decompressive and motion-segment preserving technique, has been developed by the author and used successfully in many patients with spondylotic cervical radiculopathy for the past several years. From the author's increasing experience with anterior foraminotomy for cervical radiculopathy, it was noted that the spinal cord canal could be effectively decompressed utilizing the holes of anterior foraminotomy. This new technique accomplishes widening of the spinal cord canal anteriorly to the spinal cord in the transverse and longitudinal axis by direct removal of the compressive lesions through the holes of unilateral anterior foraminotomies. This technique does not require bone fusion or postoperative immobilization. 14 patients with spondylotic cervical myelopathy have been treated by this technique. 9 were males and 5 were females, and all presented with cervical myelopathy with or without radiculopathy. Age ranged from 32 to 68 years (median 55 years). 6 patients had spinal cord compression at one level, six patients experienced it at two levels, and two patients had it at three levels. Postoperatively, all patients showed improvement in their myelopathic symptomatology as well as gaining relief of their radicular symptoms. Corresponding MR scans confirmed satisfactory anatomical decompression in all patients. Postoperative dynamic roentgenograms confirmed spinal stability in all patients as well. Patients stayed in the hospital overnight postoperatively, and cervical braces were not used. This new surgical technique has shown excellent clinical outcomes with fast recovery and adequate anatomical decompression in 14 patients with spondylotic cervical myelopathy.

Adult↗
PubMed1997

Trigeminal numbness and tic relief after microvascular decompression for typical trigeminal neuralgia.

OBJECTIVE: After most operative treatments for trigeminal neuralgia, long-term tic relief is closely correlated with postoperative numbness in the trigeminal distribution. Microvascular decompression (MVD) is proposed to relieve tic through a nontraumatic mechanism. We investigated the relationship between postoperative trigeminal numbness and tic relief in a large, prospectively followed cohort of patients treated with MVD for typical trigeminal neuralgia. METHODS: Of 1204 patients who underwent MVD for typical tic during a 20-year period, 522 had single MVDs on a single side, had not undergone ablative trigeminal procedures before or after MVD, and were still being followed in 1994. In 1994, patients graded facial numbness using a questionnaire (response rate, 92%) with a 5-point scale. Multivariate Cox and logistic regression methods were used. The analyses were adjusted for the time that had passed between the performance of MVD and the completion of the questionnaire (minimum, 2 yr). RESULTS: Seventeen percent of patients reported some degree of persistent facial numbness. Decompression of a vein at MVD (odds ratio, 2.5) and failure to find compression by the superior cerebellar artery (odds ratio, 2.0) independently predicted postoperative facial numbness, which in turn predicted postoperative burning and aching facial pain (odds ratio, 5.2-5.9). A trend toward worse outcome was noted in patients with numb faces (P = 0.3). Similar findings were noted in subgroups of patients in whom the superior cerebellar artery was decompressed at MVD (n = 381) and in whom a superior cerebellar artery with no vein was found (n = 120). In the latter subgroup, facial numbness (5.8% of patients) significantly predicted worse long-term outcome (P = 0.03). CONCLUSION: We found no evidence that postoperative trigeminal numbness predicts relief of typical tic after MVD. Trigeminal numbness was related to operative findings at MVD and predicted postoperative burning and aching facial pain. To minimize postoperative facial dysesthesia, trauma to the trigeminal root during MVD should be avoided when possible.

Decompression, Surgical↗
PubMed1997

Decompression via microsurgical anterior foraminotomy for cervical spondylotic myelopathy. Technical note.

Over the past few years, a microsurgical anterior foraminotomy technique has been developed by the author and used to achieve spinal cord decompression for the treatment of cervical spondylotic myelopathy. A 5 x 8-mm unilateral anterior foraminotomy is accomplished by resecting the uncovertebral joint via an anterior approach. Through the foraminotomy hole, the posterior osteophytes at the spinal cord canal are removed diagonally up to the beginning of the contralateral nerve root. To treat multilevel disease, a tunnel is made among the foraminotomy holes. This technique accomplishes widening of the spinal cord canal in the transverse and longitudinal axes by direct resection of the compressive lesions through the holes of unilateral anterior foraminotomies; however, it does not require bone fusion or postoperative immobilization. Postoperatively patients remain in the hospital overnight, and do not need to wear cervical braces. This new surgical technique has shown excellent clinical outcomes with fast recovery and adequate anatomical decompression in patients with cervical spondylotic myelopathy. The surgical technique is reported and illustrated by two of the author's cases.

Cervical Vertebrae↗
PubMed1997

Endoscopic endonasal transsphenoidal surgery: experience with 50 patients.

An endoscope was used in transsphenoidal surgery and eventually replaced the operating microscope as the tool for visualization. This study focuses on 50 patients (28 females and 22 males) with a median age of 38 years (range 14-88 years). Initially, four patients underwent operation via a sublabial-transseptal approach using a rigid endoscope in conjunction with an operating microscope. The 48 subsequent operations were performed through a nostril using only rigid endoscopes. Forty-four patients had pituitary adenomas and six had various other lesions. Thirteen patients had microadenomas, 16 had intrasellar macroadenomas, nine had macroadenomas with suprasellar extension, and six had invasive macroadenomas involving the cavernous sinus. Seven patients had recurrent pituitary adenomas and 25 had hormone-secreting adenomas (eight patients with Cushing's disease and 17 patients with prolactinomas). Among the eight patients with Cushing's disease, seven had resolution of hypercortisolism clinically and chemically. Of the 17 patients with prolactinomas, 10 improved clinically with normal serum prolactin levels, four improved clinically with elevated serum prolactin levels, and three had residual tumors in the cavernous sinus. Among the 19 patients with nonsecreting adenomas, 16 underwent total resection and three subtotal resection leaving residual tumor in the cavernous sinus. Postoperatively, all patients who had undergone endonasal endoscopic surgery had unobstructed nasal airways with minimal discomfort. More than half of the patients required only an overnight hospitalization.

Adenoma↗
PubMed1997

Endoscopic microscopic transpedicular thoracic discectomy. Technical note.

In an effort to make thoracic discectomy simple and less invasive while using direct visualization, a 70 degrees-angled lens endoscope has been adopted to visualize the ventral aspect of the spinal cord dura mater during microsurgical thoracic discectomy via a transpedicular approach. The patient is positioned in a 60 degrees forwardly inclined lateral position with the side of the lesion facing upward. After radiographic corroboration of the correct level, a transpedicular approach is made using a 1.5-cm-diameter tubular retractor through a 2-cm-long paramedian transverse skin incision. With the aid of an operating microscope, the ipsilateral facet joint, including the upper portion of the pedicle, is removed using a high-speed drill, thus exposing the neural foramen, intervertebral disc, and upper portion of the pedicle leading to the vertebral bodies. When the herniated disc and bone spur have been removed laterally in relation to the spinal cord, creating a cavity under the operating microscope, a 4-mm-diameter rigid endoscope with a 70 degrees-angled lens is mounted to an endoscope holder so that the ventral aspect of the spinal cord dura mater can be visualized directly. With the aid of direct endoscopic visualization, the disc and bone spur, which compress the spinal cord anteriorly, are pushed away toward a cavity created at the intervertebral space and are removed using a downward-biting long-armed curette. Patients with myelopathy are kept overnight in the hospital; however, those with radiculopathy are discharged home on the same day as their operation. The surgical technique and two illustrative cases are reported.

Adult↗
PubMed1997

Percutaneous retrogasserian glycerol rhizotomy. Current technique and results.

Despite the establishment of the vasculoneural compression as a frequent cause of trigeminal neuralgia, minimally invasive surgical techniques to treat medically refractory trigeminal neuralgia are needed in order to minimize the risks associated with craniotomy. Percutaneous retro gasserian glycerol rhizotomy (PRGR) is one of the alternative surgical treatments to microvascular decompression. Technical simplicity, less chance of trigeminal sensory loss, no need of intraoperative sensory testing, and no attempted deliberate destruction of the trigeminal nerve are advantages over other percutaneous trigeminal operations.

Female↗