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Open access

Julia Shawarba, Cand Med, Matthias Tomschik, and Karl Roessler

Facial and cochlear nerve preservation in large vestibular schwannomas is a major challenge. Bimanual pincers or plate-knife dissection techniques have been described as crucial for nerve preservation. The authors demonstrate a recently applied diamond knife dissection technique to peel the nerves from the tumor capsule. This technique minimizes the nerve trauma significantly, and complete resection of a large vestibular schwannoma without any facial nerve palsy and hearing preservation is possible. The authors illustrate this technique during surgery of a 2.6-cm vestibular schwannoma in a 27-year-old male patient resulting in normal facial function and preserved hearing postoperatively.

The video can be found here: https://stream.cadmore.media/r10.3171/2021.7.FOCVID21104

Open access

Gustavo S. Jung, Joel Fernando Sanabria Duarte, Afonso H. de Aragão, Ronaldo Pereira Vosgerau, and Ricardo Ramina

The course of the facial nerve (FN) has been extensively investigated in patients with vestibular schwannomas (VSs). FN running dorsally to the tumor capsule accounts for less than 3% of the cases. Diffusion tensor imaging (DTI)–based fiber tracking helps to preoperatively identify the FN. During surgery, a higher risk of injury is associated with the dorsal location of the FN. The authors demonstrate the nuances and tricks to identify and preserve a dorsal displaced FN during resection of a large VS, T3b according to the Hannover classification, through the retrosigmoid-transmeatal approach.

The video can be found here: https://stream.cadmore.media/r10.3171/2021.7.FOCVID2182

Restricted access

Sepideh Amin-Hanjani, Howard A. Riina, and Fred G. Barker II

Open access

Gang Song, Liyong Sun, Yuhai Bao, and Jiantao Liang

The main objectives of microsurgery for vestibular schwannoma are total tumor removal and preservation of facial and cochlear nerve function. For giant tumors, total tumor removal and facial nerve function preservation are challenging. The semisitting position has some advantages. In this video the authors show the removal of a giant vestibular schwannoma with the patient in a semisitting position. They demonstrate the advantages of the semisitting technique, such as the two-handed microsurgical dissection technique and a clear operative field. Finally, a small residual tumor in the internal auditory canal was removed by endoscopy. The patient’s facial function was House-Brackmann grade I at discharge.

The video can be found here: https://stream.cadmore.media/r10.3171/2021.7.FOCVID2176

Open access

Florian Roser, Tanmoy Maiti, and Mohamed Samy Elhammady

The present surgical video demonstrates safe opening of the internal auditory canal (IAC) during vestibular schwannoma surgery via a retrosigmoid approach in the sitting position. Resection of the intrameatal portion of a tumor is important for progression-free survival. Preoperative thin-sliced CT revealed a high-riding jugular bulb obscuring the trajectory. After dural opening, the IAC was approached anteriorly and superiorly. The posterior margin of IAC drilling was above the Tubingen line. Drilling was performed under continuous jugular compression. The vein was pushed down to augment visibility. An angled endoscope was helpful. IAC can be drilled safely in a high-riding jugular bulb with the technique mentioned in the video.

The video can be found here: https://stream.cadmore.media/r10.3171/2021.7.FOCVID2198

Open access

Sebastián J. M. Giovannini, Guido Caffaratti, Tomas Ries Centeno, Mauro Ruella, Facundo Villamil, Ricardo Marengo, and Andrés Cervio

Surgical management of vestibular schwannomas has improved over the last 30 years. Whereas in the past the primary goal was to preserve the patient’s life, today neurological function safeguarding is the main objective, with numerous strategies involving single resection, staged resections, postoperative radiosurgery, or single radiosurgery.

The retrosigmoid approach remains the primary pathway for surgical access to the cerebellopontine angle (CPA). The use of an endoscope has great advantages. It contributes to the visualization and resection of residual tumor and also reduces the need for cerebellar retraction.

The authors present a fully endoscopic resection of a large-sized vestibular schwannoma with facial nerve preservation.

The video can be found here: https://stream.cadmore.media/r10.3171/2021.7.FOCVID21106

Free access

George Hanna, Syed-Abdullah Uddin, Andrew Trontis, Lindsey Ross, Doniel Drazin, Terrence T. Kim, and J. Patrick Johnson

OBJECTIVE

Ankylosing spondylitis (AS) is a chronic inflammatory disease affecting the sacroiliac joints and axial spine that is closely linked with human leukocyte antigen–B27. There appears to be an increased frequency of associated epidural hematomas in spine fractures in patients with AS. The objective was to review the incidence within the literature and a single-institution experience of the occurrence of epidural hematoma in the context of patients with AS requiring spine surgery.

METHODS

Deep 6 AI software was used to search the entire database of patients at a single level I trauma center (since the advent of the institution’s modern electronic health record system) to look at all patients with AS who underwent spinal surgery and who had a diagnosis of epidural hematoma. Additionally, a systemic literature review was performed of all papers evaluating the incidence of epidural hematoma in patients with spine fractures.

RESULTS

A single-institution, retrospective review of records from 2009 to 2020 yielded a total of 164 patients with AS who underwent spine surgery. Of those patients, 17 (10.4%) had epidural hematomas on imaging, with the majority requiring surgical decompression. These spine fractures occurred close to the cervicothoracic or thoracolumbar junction. The patients ranged in age from 51 to 88 years, and there were 14 males and 3 females in the cohort. Eight patients were administered an antiplatelet and/or anticoagulant agent, and the rest were not. All patients required surgical stabilization, with 64.7% of patients also requiring decompressive laminectomies for evacuation of the hematoma and spinal cord decompression. Only 1 death was reported in the series. There was a tendency toward neurological improvement after surgical intervention.

CONCLUSIONS

AS has been a well-described pathologic process that leads to an increased risk of three-column injury in spine fracture, with an increased incidence of symptomatic epidural hematoma compared with patients without AS. Early recognition of this entity is important to ensure that appropriate surgical management includes addressing compression of the neural elements in addition to surgical stabilization.