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Adesh Tandon, Sid Chandela, David Langer, and Chandranath Sen

C ervical radiculopathy secondary to compression from anomalous VAs is a known entity. Treatment options for extracranial tortuous VAs include conservative observation or some form of surgical MVD. The authors describe a novel sling technique that was successfully utilized for mobilization of the VA away from a compressed exiting cervical nerve root. To the authors' knowledge, this is the first MVD described utilizing this technique. Case Report History and Presentation This 52-year-old woman presented with several months of debilitating neck

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Mitchell W. Couldwell, Vance Mortimer, AS, and William T. Couldwell

Microvascular decompression is a well-established technique used to relieve abnormal vascular compression of cranial nerves and associated pain. Here the authors describe three cases in which a sling technique was used in the treatment of cranial nerve pain syndromes: trigeminal neuralgia with predominant V2 distribution, hemifacial spasm, and geniculate neuralgia and right-sided ear pain. In each case, the artery was mobilized from the nerve and tethered with a sling. All three patients had reduction of symptoms within 6 weeks.

The video can be found here: https://youtu.be/iM7gukvPz6E

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James K. Liu, Smruti K. Patel, Amanda J. Podolski, and Robert W. Jyung

initial fat layer is used to occlude any areas of CSF egress, and care is taken not to overpack the defect so as to avoid compression of the facial nerve. Continuous facial nerve monitoring is used during the reconstruction to detect any nerve irritation. Fibrin glue is placed over this initial fat graft followed by another layer of Surgicel ( Fig. 2E ). F ig . 1. Illustrations demonstrating the fascial sling technique for translabyrinthine reconstruction using a left-sided approach. A: The tumor (T) is exposed after a T-shaped presigmoid dural incision. B

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Jeffrey A. Steinberg, Jayson Sack, Bayard Wilson, David Weingarten, Bob Carter, Alexander Khalessi, Sharona Ben-Haim, and John Alksne

away from the trigeminal nerve. The first report of this method was described by Fukushima in 1982, in which a Dacron sling technique was used. 7 Other case reports and small case series describe similar methods, with various sling materials used to transpose the offending vessel away from the nerve. These studies have predominantly used foreign materials for sling creation, including Dacron, suture, Gore-Tex tape, aneurysm clips, and gelatin sponge. 9 , 13 However, Melvill and Baxter described the use of an autologous dural sling created from the underside of the

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Jeffrey A. Steinberg, Jayson Sack, Bayard Wilson, David Weingarten, Bob Carter, Alexander Khalessi, Sharona Ben-Haim, and John Alksne

away from the trigeminal nerve. The first report of this method was described by Fukushima in 1982, in which a Dacron sling technique was used. 7 Other case reports and small case series describe similar methods, with various sling materials used to transpose the offending vessel away from the nerve. These studies have predominantly used foreign materials for sling creation, including Dacron, suture, Gore-Tex tape, aneurysm clips, and gelatin sponge. 9 , 13 However, Melvill and Baxter described the use of an autologous dural sling created from the underside of the

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James K. Liu and Asif Shafiq

In this illustrative operative video, the authors demonstrate a Teflon bridge technique to achieve safe transposition of a large, tortuous ectatic basilar artery (BA) and anterior inferior cerebellar artery (AICA) complex to decompress the root entry zone (REZ) of the trigeminal nerve in a 61-year-old woman with refractory trigeminal neuralgia via an endoscopic-assisted retractorless microvascular decompression. Postoperatively, the patient experienced immediate facial pain relief without requiring further medications. The Teflon bridge technique can be a safe alternative to sling techniques when working in narrow surgical corridors between delicate nerves and vessels. The operative technique and surgical nuances are demonstrated.

The video can be found here: https://youtu.be/hIHX7EvZc1c

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James K. Liu and Robert W. Jyung

Large acoustic neuromas, greater than 3 cm, can be technically challenging tumors to remove because of their intimate relationship with the brainstem and surrounding cranial nerves. Successful tumor resection involves functional preservation of the facial nerve and neurovascular structures. The translabyrinthine approach is useful for surgical resection of acoustic neuromas of various sizes in patients with poor preoperative hearing. The presigmoid surgical corridor allows direct exposure of the tumor in the cerebellopontine angle without any fixed cerebellar retraction. Early identification of the facial nerve at the fundus facilitates facial nerve preservation. Large acoustic tumors can be readily removed with a retractorless translabyrinthine approach using dynamic mobilization of the sigmoid sinus. In this operative video atlas report, the authors demonstrate their operative nuances for resection of a large acoustic neuroma via a translabyrinthine approach using a retractorless technique. Facial nerve preservation is achieved by maintaining a plane of dissection between the tumor capsule and the tumor arachnoid so that a layer of arachnoid protects the blood supply to the facial nerve. Multilayered closure is achieved with a fascial sling technique in which an autologous fascia lata graft is sutured to the dural defect to suspend the fat graft in the mastoidectomy defect. We describe the step-by-step technique and illustrate the operative nuances and surgical pearls to safely and efficiently perform the retractorless translabyrinthine approach, tumor resection, facial nerve preservation, and multi-layered reconstruction of the skull base dural defect to prevent postoperative cerebrospinal fluid leakage.

The video can be found here: http://youtu.be/ros98UxqVMw.

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Najmedden Attabib and Anthony M. Kaufmann

, however, maintenance of vessel transposition may require additional surgical maneuvers, and a variety of sling techniques have been described. 3 , 7 , 8 , 12–15 We have also recognized the need for a sling technique in recent cases and adopted the use of fenestrated aneurysm clips that, to our knowledge, has not been previously described. The technique as well as the results of this series are reported, and the technique's potential merits are discussed. Clinical Material and Methods Patient Population The case series was drawn from a consecutive series of

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James K. Liu, Derald E. Brackmann, and Johnny B. Delashaw Jr.

closure techniques. DeMonte and Gidley review their experience with the middle fossa approach for intracanalicular tumors with excellent hearing preservation rates. In addition, Liu et al. introduce a novel fascial sling technique for dural reconstruction after translabyrinthine approaches to minimize postoperative cerebrospinal fluid leak rates. Lastly, Ginat and Martuza provide an excellent comprehensive review of the interpretation of postoperative neuroimaging after resection of acoustic neuromas. This edition of Neurosurgical Focus covers a wide range of topics

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Neurosurgical Forum: Letters to the Editor To The Editor A. Giancarlo Vishteh , M.D. , Robert F. Spetzler , M.D. Barrow Neurological Institute, Phoenix, Arizona 502 503 We read with great interest the article by Bejjani and Sekhar (Bejjani GK, Sekhar LN: Repositioning of the vertebral artery as treatment for neurovascular compression syndromes. Technical note. J Neurosurg 86: 728–832, April, 1997). The “suture slingtechnique of repositioning the vertebral artery (VA) is a helpful adjunct