prospective fashion, and portions have been reported in several publications. 1–3 , 5–10 , 15 , 17–21 , 23 , 25 In especially instructive or unusual cases, pre- and postoperative imaging studies, surgical videos, intraoperative photographs, and other appropriate data are also cataloged. We reviewed selective cases treated at different times to evaluate our methods, to share surgical pearls and surgical pitfalls, and to obtain an understanding of how our surgical approaches have evolved over time. Operative Techniques We have used 3 approaches to address HHs
Scott D. Wait, Adib A. Abla, Brendan D. Killory, Peter Nakaji and Harold L. Rekate
Roukoz Chamoun, Joel MacDonald, Clough Shelton and William T. Couldwell
S urgical removal remains one of the key treatment modalities for VSs. 3 A team approach between a neurotologist and a neurosurgeon offers the patient the expertise of both specialties and maximizes safety and the chances for an optimal outcome. Vestibular schwannomas can typically be resected through 1 of 3 main surgical approaches: the translabyrinthine, 2 the retrosigmoid, 4 or the middle fossa approaches. 1 In this article, we describe and illustrate our indications and surgical technique for the removal of these tumors. The Translabyrinthine
Shannon Hann, Nohra Chalouhi, Ravichandra Madineni, Alexander R. Vaccaro, Todd J. Albert, James Harrop and Joshua E. Heller
cervical spine's role in influencing global spinal alignment, maintaining horizontal gaze, and affecting a person's productivity and QOL. These studies review cervical alignment parameters and related outcome measures after deformity correction. 1 , 14 The decision-making process involved in choosing a surgical approach in cervical deformity, however, is not well summarized in literature. While there often is no single correct answer in spinal deformity surgery, we believe having a systematic algorithm for selecting a surgical approach may be of benefit and ultimately
Feng Xu, Ioannis Karampelas, Cliff A. Megerian, Warren R. Selman and Nicholas C. Bambakidis
-up, has also affected treatment algorithms. Nevertheless, many skull base surgeons continue to advocate for aggressive resection whenever possible. 15 In cases of smaller tumors, results typically are excellent, and often simple cranial approaches are adequate to ensure complete or near-total resection (NTR). 4 Larger tumors are much more difficult to treat and often require complex skull base approaches, many of which are rarely performed and are described using unclear terminology. Understanding the natural history, determining the surgical approach, and knowing the
Pierre-Hugues Roche, Vincent Lubrano, Rémy Noudel, Anthony Melot and Jean Régis
use in choosing the surgical approach. Posterior petrous bone meningiomas are lesions that develop in an area delineated by the superior petrosal sinus, the inferior petrosal sinus, and the sigmoid sinus. Despite early contact of the cranial nerves V, VII, and VIII with the meningioma, these nerves often remain protected in their own arachnoid sheath even in cases of large tumors. Therefore, if care is taken to avoid damaging these nerves during surgery, they can be preserved with excellent functional results. Before surgery is initiated, it is essential to predict
Alice Cherqui, Daniel H. Kim, Se-Hoon Kim, Hyung-Ki Park and David G. Kline
The goal of this study was to analyze the results of surgical treatment of paraspinal nerve sheath tumors (NSTs) and review the surgical approaches to paraspinal NSTs.
A retrospective review of the cases of paraspinal NSTs treated surgically by two senior authors during the period between 1970 and 2006 was undertaken. Surgical approaches that allow minimal disruption of normal anatomy and are aimed at complete resection of paraspinal lesions and preservation of spinal stability are reviewed according to the spinal level.
Eighty-eight paraspinal NSTs were treated surgically during the period: 56 schwannomas, seven solitary neurofibromas, 21 neurofibromas associated with neurofibromatosis Type 1 (NF1), and four malignant peripheral NSTs. Schwannomas tended to occur in the cervical and thoracic areas. Neurofibromas were usually associated with NF1 and tended to occur in the cervical area. Pain (79 patients, 90%) and paresthesia (81 patients, 92%) were the predominant clinical presenting symptoms; others included weakness (28 patients) and myelopathy (12 patients). Total resection of the tumor was achieved in 50 patients (89.3%) with schwannomas and 22 patients (78.6%) with neurofibromas. There was a large reduction of pain in 70 (88.6%) of 79 patients who had preoperative pain, and weakness improved in 18 (64.3%) of 28. Postoperative transient weakness occurred in 12 (42.9% ) of these patients, but in 85% of this group, the symptom improved over a 12-month period. Myelopathy was reduced in eight (66.7%) of 12 patients. The average follow-up period was 18 months.
Paraspinal NSTs present unique surgical challenges given their anatomical relationships to the spine, spinal cord, nerve roots, and major vasculature. The surgical technique should take into account the location of the lesion and its relationship to paraspinal anatomy, the extent of resection, sparing of normal anatomy, and spinal instability.
Adib A. Abla, Jay D. Turner, Alim P. Mitha, Gregory Lekovic and Robert F. Spetzler
hemorrhages and hemosiderin deposition in the brainstem. In 1928 Walter Dandy 4 reported the first case of a brainstem CM, which was surgically removed from the pontomedullary region in a 21-year-old patient. In the years since, our understanding of brainstem CMs has continued to evolve. Our knowledge is derived from a variety of publications that have reported on the pathophysiological characteristics of brainstem CMs, the natural history of the disease, and surgical approaches and outcomes. We review the natural history of brainstem CMs, prior reports of surgically
Richard K. Gurgel, Salim Dogru, Richard L. Amdur and Ashkan Monfared
have advocated partial resections, 2-stage resections, and combined partial resection with radiation therapy. 3 , 17 , 40 , 42 Moreover, questions remain regarding the surgical approach that provides the optimal facial nerve outcome. In this study, we systematically reviewed studies reporting postoperative outcomes of large VSs (≥ 2.5 cm of maximal or extrameatal diameter), with special attention to the facial nerve outcomes as a function of surgical approach and degree of tumor resection. Methods Search Criteria Following an Institutional Review Board
Norihiko Tamaki, Tatsuya Nagashima, Kazumasa Ehara, Yasuhiko Motooka and Kanak Kanti Barua
The management of chordomas involving the skull base continues to present a number of treatment-related problems. Recently, both radical resection and charged-particle irradiation or stereotactic radiosurgery have reportedly been found effective for tumor control and for promoting a better quality of life in patients. In this article the authors analyzed the outcomes in 17 patients with skull base chordomas who were surgically treated at Kobe University Hospital between 1972 and 2000.
Preoperative radiological examinations included magnetic resonance imaging, computerized tomography, angiography, and balloon occlusion test of the internal carotid artery. Among the various surgical approaches used to remove the tumor were the frontoorbitozygomatic, transmaxillary, transcondylar, transsphenoidal, and the transbasal. Total removal was achieved in two (12%), near-total removal in three (18%), subtotal removal in nine (52%), and partial removal in three patients (18%). Since 1990, chordomas have been radically resected via various skull base approaches; the combined total or near-total removal rate has been 80% in this period. Radical removal of the tumors has not led to an increased risk. At the final follow-up review (mean 59.5 month), 75% of the patients were still alive, and 25% had died of chordoma recurrence. The overall recurrence-free survival rate was 82% at 3 years and 51% at 5 years. The 5-year recurrence-free survival rate in the five patients who underwent the operation during the past decade was 77% (mean follow up of 5.2 years). In two patients with recurrent tumors who underwent radiosurgery, no evidence of tumor regrowth was demonstrated at 3 years posttreatment.
The authors suggest that for the treatment of skull base chordomas radical resection is a key factor for longer survival and improved quality of life. Patients with sufficiently small tumors, which show a favorable configuration and location, can be suitable candidates for stereotactic radiosurgery.
Wolfgang J. Weninger and Gerd B. Mülle
In this study the authors analyze the peculiarities of the parasellar anatomy and the topography of surgical approaches to the parasellar region (PSR) in human infants.
Forty-nine specimens of the PSR obtained at autopsy were studied using microdissection and histological analysis. Important distances between anatomical landmarks were measured with the aid of a dissecting microscope. One serially sectioned specimen was three-dimensionally reconstructed and analyzed on the computer screen by using the authors' new episcopic reconstruction technique.
The anatomy of the infant PSR differs distinctly from that of the adult. The parasellar portion of the internal carotid artery (ICA) does not form a siphon, but takes a straight course, and the venous pathways as well as the cranial and sympathetic nerves have different topographical relationships. Analyses of surgical approaches demonstrate that, in young children, the anterolateral approach can be used to reach the pterygopalatine compartment, the superior ophthalmic vein, and those pathological processes that extend from the orbit into the PSR. The approach via Parkinson's triangle can be used in 45% of cases to access the pathological processes that occur in the voluminous space above and behind the posterior flexure of the parasellar ICA. Taking this route, sympathetic nerve fibers passing through the PSR are not at risk, but some arterial branches that run within the lateral wall of the sinus can complicate this approach.
This study presents a guideline that can assist radiologists and neurosurgeons in the planning and performance of interventions within the PSR of neonates and young children.