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ACNS SURGICAL MANUAL

Edited by : Iype Cherian / Karuna Tamrakar Karki


Assistant editors : Alastair R. Nandhini R.
Patron : Yoko Kato
Edition : First
Design : Quill Design, Kathmandu, Nepal.
Ph: +977-01-5541161
Email : quilldestination@gmail.com

Asian Congress of Neurological Surgeons


www.asiancns.org
Preface
The gulf between the so called experienced neurosurgeon and the novice is an ever narrowing one these days. Age
does not necessarily mean experience these days...
Many times, I have been frustrated by just discussion on pure anatomy, when all I needed was the technique to do a
certain surgery...And when the technique was actually described, it was like one of those fast bowlers delivering a ball
with their hands covered with their other arm so as that one would not understand the way the seam is held and which
direction would the ball swing or cut...
The “ACNS surgical manual” is an attempt to teach and educate the neurosurgeons in Neurosurgical techniques using
the template of neuroanatomy that commonly encountered in clinical practice. It is my hope that the reader will use
this surgical manual to assist him/her in establishing specific neurosurgical technique and subsequently for optimal
management of the neurosurgical patients.
I have modeled the format of this surgical manual for advancing the knowledge of neurosurgical technique from basic
skills to advanced. Emphasis has been given on techniques of skull base surgical skills, microsurgical techniques in
clipping cerebral aneurysms, carotid artery stenting, microvascular anastomosis technique, cisternostomy, endoscopic
excision of pituitary tumors, epilepsy surgery, and various spinal approaches that include recent technology and
information in each chapter. We would want this to be an interactive effort and everybody is welcome to send their
suggestions as well as the need to add more content. The accompanying video is very helpful.
This book is written in such a way that it will definitely serve the professional need in every aspect. However, suggestions
are most welcome and we would want to model the future editions of this book based on suggestions from all of you.
We promise to price it in the comfort zone for the young Asian Neurosurgeons.

Iype Cherian
Contents

Vascular
Hidehito Kimura/Eiji Kohmura - Distal transsylvian approach for the cerebral aneurysm surgery 5
Kojiro Wada - Carotid Endarterectomy (CEA) 23
Katsumi Takizawa - STA to MCA bypass 31
Naoya Kuwayama - Carotid artery stenting Endovascular Therapy 49
Trauma
Iype Cherian - Cisternostomy: A paradigm shift in managing severe head trauma 65
Skull base
Tetsuro Sameshima - Part I: Transmastoid Surgery 73
- Part II: Middle Fossa Dissection 86
Yoshinobu Seo - Skull Base Surgery Transpetrosal approach 111
Kentaro Mori - Dolenc's Skull Base Approach Cadaveric Study 143
Tumor
Yasuhiko Hayashi - Pituitary Endoscopic Endonasal Transsphenoidal Surgery 155
Epilepsy
Roy Thomas Daniel - Peri Insular Hemispherotomy (PIH) Epilepsy Surgery 169
Spine
Salman Sharif - How I Do It? Spine Surgery 191
Distal transsylvian approach
for the cerebral aneurysm surgery

Cerebral aneurysms typically arise from bifurcation of cerebral


arteries which run in the basal cisterns. So fundamentally aneurysms
usually exist in the basal subarachnoid space. In order to perform
safe and reliable cerebral aneurysmal surgery, it is preferable for us to
confirm clearly not only the aneurysm but also all normal surrounded
structures as much as possible under the operative microscope. To
achieve this, we need to dissect arachnoid membrane and arachnoid
trabeculae atraumatically using sharp dissection technique to obtain
surgical corridor wide enough to execute surgery.

Most Cerebral aneurysms in the anterior circulation, except for the


distal anterior cerebral artery (ACA) aneurysm, and some originate
from the upper basilar artery, can be operated by well-known
pterional approach. In detail, the pterional approach includes two Hidehito Kimura M.D. Ph. D.
major approaches: the subfontal approach and the transslyvian Eiji Kohmura M.D.Ph. D.
approach(4). Which approach should be chosen for each aneurysm Department of Neurosurgery
finally depends on the surgeon’s experience and preference. In the Kobe University Graduate School of Medicine
transslyvian approach, the extent of area that has to be dissected 7-5-1 Kusunoki-cho, Chuo-ku, Kobe 650-0017, JAPAN
Tel: +81-78-382-5966
in the sylvian fissure is relatively larger than the one in the subfrontal
E-mail: hidekimusbs@gmail.com
approach. Owing to this manipulation, we can obtain the wider
surgical field through the broadened subarachnoid corridor without

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Distal transsylvian approach for the cerebral aneurysm surgery

excessive brain retraction. This maneuver requires the precise microsurgical technique with careful inspection
under the operative microscope while making bloodless surgical field. For a neurosurgeon, who performs
not only aneurysm clipping but also does other various kinds of intracranial microsurgery, this fundamental
technique should be mastered. So in this chapter, we explain about the technical steps of distal transslyvian
approach for safe aneurysm surgery.

Instruments and manipulation:


In aneurysm surgery, we need to perform arachoid dissection atraumatically. If we dissect arachnoid
membrane and trabeculae bluntly, it sometimes may cause pial injury because the adhesion of the arachnid
to the pia is said to be much stronger than the one of the pia to the brain tissue. To avoid this, we need to cut
the arachnoid sharply with a microscissor. For this purpose, we choose Kamiyama Micro Scissors (Mizuho
Ikakogyo Co., ltd, Japan) on the right hand. Furthermore, in order to perform the precise microsurgical
manipulation, careful observation of microanatomy under high, sometimes maximum, magnification is
essential in the bloodless and clean surgical field. For this purpose, we prefer neurosurgical irrigation sucker,
SUCTION PLUSR (Codman Johnson & Johnson Co., ltd, U.S.A.) on the left hand. The use of irrigation sucker
is effective to wash out the subarachonoid clot in the patient with subarachnoid hemorrhage (SAH).

Differences between the subfrontal approach and transsylvian approach:


First, we should recognize the technical differences between the subfrontal and transsylvian approaches.
Both are done through pterional approach(4). In the subfontal approach, surgeons first get into the basal

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Distal transsylvian approach for the cerebral aneurysm surgery

cisterns, for example carotid cistern, proximal sylvian fissure, and dissect arachnoid membrane gently by
retracting the frontal lobe after opening the dura. Followed this maneuver, additional arachnoid dissection
may be performed medially or laterally according to the location of the aneurysm. The merit of this approach
is that the length of arachnoid dissection is shorter and relatively limited, which may contribute to shorten the
operation time. However, it also means that we relatively gain the narrow surgical field and often encounter
some difficulty in confirming aneurysm and the surrounded normal structures. Under such situation, the extent
of frontal lobe retraction may sometimes be excessive. These factors may cause to unintentional intraoperative
and postoperative complications. On the other hand, in the distal transsylvian approach, we begin to dissect
arachnoid membrane from the distal sylvian fissure. Its point is usually 4-5 cm above the flattened surface of
sphenoid bone. By splitting the distal sylvian fissure between the frontal and the temporal lobes widely, we notice
the widened surgical corridor along the sylvian fissure with minimum retraction of frontal lobe.

Indications of the distal transsylvian approach:


Most Cerebral aneurysms in the anterior circulation, except for the distal anterior cerebral artery aneurysm, can
be treated by this approach. By performing anterior temporal approach, which is an advanced approach of
distal transsylvian approach, we can treat the posteriorly projecting internal carotid- posterior communicating
artery (IC-PC) aneurysms and the distal basilar artery (BA) aneurysms(3).

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Distal transsylvian approach for the cerebral aneurysm surgery

Surgical procedure:

1. Position and Skin incision:


The patient is placed in supine position and the head is rotated toward the opposite side 45 degrees to make the
plane of fronto-temporal lobe horizontal in the surgical field and the back is tilted about 10 degrees. Ipsilateral
shoulder is propped up with padding to avoid excessive neck rotation. A curvilinear skin incision is made along
the hairline from mid line toward the superior margin of zygomatic arch just anterior to the tragus (Fig.2A). The
scalp is reflected in a single layer with the temporal muscle. Note, in this approach it is preferred to expose the
temporal surface wider than the one in the subfrontal approach so as to expose the sylvian fissure sufficiently in
the surgical field. Mannitol of 200ml to 300ml is usually administered intravenously before craniotomy to obtain
slack brain.

2. Craniotomy:
Three burrs hole are made. As Yasargil MG mentioned(5), the first burr hole is made just superior to the frontal
zygomatic suture under the linea temporalis. The second one is on the parietal bone along the linea temporalis.
And the third is made in the squamous temporal bone behind the spheno-temporal suture. The dura underlying
bone flap is carefully separated with a small curved periosteal elevator and the fronto-temporal craniotomy is
carried out by using a high-speed drill.The temporal side of the bone window should be opened wide enough
intentionally to expose the surface of sylvian fissure. The squamous temporal and the greater wing of sphenoid
bones are rongeured further inferiorly and the lesser wing is also rongeured and drilled as mush as possible to
produce a smooth, flat sphenoid surface and to reach the superior orbital fissure. Epidural hemostasis should be
completed at this step. Bleeding sites on the dural surface were controlled using bipolar coagulation. Bleeding

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Distal transsylvian approach for the cerebral aneurysm surgery

from the epidural space beneath the edges of craniotomy is well controlled by tying the tenting suture by 3-0
silk sutures with a small piece of Surgicel inserted in between the epidural space. After complete epidural
hemostasis, the dura was incised in a semicircle fashion, facing the sphenoid surface. Note; the sylvian vein
should be sufficiently exposed.

Arachnoid dissection:
Under the operative microscope, the arachnoid dissection is started approximately 4-5cm distal to the temporal
tip. First incision in arachnoid membrane is made by 27G needle. At first, two microforceps are held by both
hands and later it is exchanged to a microscissor in the right hand. Arachnoid membrane is sharply separated
from the distal to the proximal portion under the appropriately controlled, sometimes using maximumly magnified,
operative microscope. Traditionally it is said that the arachnoid of the sylvian fissure should be opened between
the frontal lobe and the most frontal side of the veins(5).However, occasionally it is much easier to separate the
space between the superficial sylvian veins rather than the adhesion between the sylvian vein and the brain
surface (Fig.2D). Arachnoid dissection is basically performed sharply by cutting arachnoid membrane and
trabeculae. To execute this sharp dissection, appropriate tension in dissection plane is essential. At this step,
a retractor is used to fix the brain on the right side gently, which is equivalent to the frontal lobe in Fig. 2E. By
fixing the right side and picking the arachonoid membrane on the other side, we can make proper tension to
separate on the arachnoid plane and cut sharply. After separating the superficial sylvian fissure to some extent,
about 1cm in length, next we dissect toward the insular cistern to confirm M2 branches of the MCA. Once you
get into the insular cistern, the brain retractor can be advanced and the tip of the retractor can be inserted into
the opened sylvian fissure. The operative microscope is angled or a bit declined anteriorly to watch the proximal
dissection plane. By retracting the brain gently on the right side and compressing the focal brain softly on the left
side by the tip of the sucker, we can make out the plane and can be dissected without much difficulty (Fig.2E).

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Distal transsylvian approach for the cerebral aneurysm surgery

Whether the correct plane is made precisely or not is very important. Surgeons must frequently re-adjust the right-
sided retractor and the left-sided tip of the sucker to make this correct plane.Care should be taken not to injure
the frontal and temporal lobe, and also not to injure the vein even if it is tiny one. As long as we dissect sharply
at the right plane, we rarely need to sacrifice the vein. We should recognize the postoperative brain edema that
might occur even if it would be even a small vein sacrificed. By dissecting arachnoid membrane around the vein
carefully, it can be well mobilized. In the operative field, it may sometimes hamper surgical corridor. However,
it doesn’t make any problem to proceed further as far as the sylvian fissure is opened wide enough. If we dissect
correctly, we can expose MCA bifurcation, M1 portion and the arachnoid membrane overlying the proximal
sylvian fissure from inside (Fig. 3A) to outside. By cutting this arachnoid, we can reach the carotid cistern.

3. Aneurysm exposure:
The operative microscope is now angled in an anterosuperior direction to expose the arachonoid overlying
the carotid artery and the optic nerve. Arachnoidal adhesion is taken down and the carotid cistern is opened.
The carotid artery is isolated for proximal control. With further arachnoid dissection, as needed, the posterior
communicationg artery, anterior choroidal artery, carotid artery bifurcation, and both anterior cerebral arteries
(ACA) may be visualized. The ACA region is exposed by dissecting the interhemispheric fissure from the inferior
surface and gently lifting the frontal lobe. Unless the brain edema is so severe, for example in the patient with
severe SAH, there is no need for the resection of gyrus rectus, since the line of vision to this region is taken
from the lateral direction via temporal fossa. For the aneurysm arising from the middle cerebral artery (MCA)
bifurcation, the opening of the sylvian fissure is limited until the proximal middle cerebral artery has been
isolated. This approach also provides an adequate space for the resection of the anterior clinoid process
intradurally, whenever necessary, during the exposure of paraclinoid aneurysms. The isolation of the aneurysm
neck is carried out under temporary clipping of the feeding vessel. The duration of temporary clipping should

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Distal transsylvian approach for the cerebral aneurysm surgery

be within 5 minutes per time. The direction of the operating microscope may need to be readjusted during clip
application so the view of the aneurysm neck and the clip blades is well visualized. With the use of temporary
clips, the internal pressure of the aneurysm sac is well controlled to avoid premature rupture in closing the both
blade of the aneurysm clip. After application of the clips to the aneurysm appropriately, Indocyanine green (ICG)
video angiography is performed to confirm that the aneurysm has been occluded well and the every surrounded
normal vessel, involving small perforators, is patent. And confirmation of microvascular doppler untrasound for
the aneurysm and the vessels is also essential. Finally by dissecting aneurysm sac from the surrounded structure
sharply or directly incised the aneurysm sac, the opposite side of the sac can be well visualized. This final
maneuver is very important for the confirmation that the every structure is not influenced or occluded by the both
blades of the clip.

4. Advanced approach: Anterior temporal approach:


By advancing distal transsylvian approach, anterior temporal approach can be performed(3). This approach can
be applied for the IC-PC aneurysms projecting posteriorly and distal BA aneurysm. The operative nuances is
that the exposure of anteromedial area to the temporal lobe makes wide surgical corridor lateral to the internal
carotid artery to approach the distal basilar artery lesions. The key steps of this approach are as follows: (1)
Detachment of superficial sylvian vein from the temporal lobe, (2) Detachment of anterior temporal artery and its
branch from the medial temporal surface, (3) Detachment of oculomotor nerve from the uncus, (4) Detachment
of anterior choroidal artery from the uncus(3). The patient position and the skin incision is the same as the one in
the distal transslyvian approach. However, in anterior temporal approach, anterior half of middle cranial fossa
should be exposed more widely than in the transsylvian approach. So we can reflect the skin flap in interfascial
manner. The actual manipulation is described in the illustrative case 2&3.

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Distal transsylvian approach for the cerebral aneurysm surgery

Illustrative cases:
Case 1: 58-year-old man, Rt. IC-PC unruptured aneurysm
The patient had right IC-PC unruptured aneurysm of 6 mm in diameter with small bleb (Fig.1A, B). The skin
incision and the area of craniotomy was drawn on the scalp preoperatively (Fig. 2A). A curvilinear skin incision
was made along the hairline from midline toward the superior margin of zygomatic arch just anterior to the tragus.
After fronto-temporal craniotomy, complete epidural hemostasis was achieved (Fig. 2B). The dura was incised
in a rectangle fashion. The sylvian fissure should be exposed sufficiently (Fig. 2C). Using the appropriately re-
adjusted magnification of surgical microscope, sometimes under the highly magnified microscopic view, dissection
of superficial sylvian vein has to be carried out. The right-sided temporal lobe was fixed by the retractor and the left
sided frontal lobe was compressed focally by the tip of the sucker (Fig. 2D). Once we got into the insular cistern,
right sided brain retractor was advanced a little towards the insular cistern. By gently retracting the brain and
compressing the left sided brain softly by the tip of the sucker, we could make out the plane to be dissected (Fig. 2E).
After dissecting the correct plane, we could expose MCA bifurcation, M1 portion (Fig.3A, black asterisk) and the
arachnoid membrane (Fig3A, white asterisk) overlying the proximal sylvian fissure from the inside, cut later. Then we
obtained widely opened sylvian fissure. After carotid cistern was dissected, left IC-PC aneurysm was exposed. The
aneurysm sac was adhered tightly to the temporal lobe that was being sharply dissected (Fig. 3B). Aneurysm sac
was dissected completely (Fig. 3C). The furcation of anterior choroidal artery was detected and dissected (Fig.3C,
arrowheads) After the internal carotid artery was temporally occluded, the aneurysm clip was applied paying
attention to keep the outlet of posterior communicating artery intact (Fig. 3D). His postoperative clinical course was
uneventful. Postoperative CT angiography demonstrated the disappearance of the aneurysm and the patency of
internal carotid artery (Fig. 1C,D).

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Distal transsylvian approach for the cerebral aneurysm surgery

Case 2: 67-year-old female, Rt. BA-SCA AN


The patient had ruptured right BA-superior cerebellar artery (SCA) aneurysm (Fig. 4A). For this aneurysm, we
preformed anterior temporal approach. After fronto-temporal craniotomy, dura was incised in a semicircular
fashion and reflected anteriorly (Fig. 5A). Note; in anterior temporal approach, sylvian fissure should be centered
in the field. (Fig. 5 asterisk: the frontal lobe) The tributary of the anterior temporal artery was dissected from the
temporal lobe (Fig.5B). After further dissection of the arachnoid, the oculomotor nerve (asterisk) was also dissected
from the uncus (Fig. 5C). And Liliequest’s membrane was seen beyond the nerve. After this membrane was
incised, the aneurysm sac was exposed.We have found the small perforator (Fig.5D arrow heads) firmly adhered
to the aneurysm sac (Fig. 5D). The intra-aneurysmal pressure is decreased by placing the temporary clip onto
the BA. Adhesion was separated by using a sharp micro-dissector (Fig. 6A). After the adhesion was dissected,
we could confirm normal structures, involving small perforators, beyond the aneurysm sac (Fig. 6C). The first clip
was applied to the sac (Fig. 6C). The second fenestrated clip was applied in a reversed direction (Fig. 6D). Her
postoperative clinical course was uneventful. Postoperative CT angiography demonstrated disappearance of the
aneurysm and the patency of posterior cerebral artery (PCA), BA and SCA (Fig. 4B).

Case 3: 77-year-old female, Rt. BA-SCA AN H&K Grade III SAH


The patient was transferred to our hospital. CT scan revealed subarachnoid hemorrhage of H&K grade III. CT
angiography demonstrated ruptured small basilar tip aneurysm (Fig. 7A). Anterior temporal approach was chosen
to treat this aneurysm. The subarachnoid clot was irrigated and removed by the irrigation sucker to maintain the
clean surgical field. During the subarachonoid dissection, the oculomotor nerve and the anterior choroidal artery
(Fig. 7C arrowheads) was detached from the uncus in order to retract the temporal lobe postero-laterally. The PC
sometimes hinders the surgical corridor. In such case, it can be ligated and cut just proximal to the junction with

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Distal transsylvian approach for the cerebral aneurysm surgery

the PCA (Fig. 7D). After PC was incised, the aneurysmal sac (Fig. 7E: arrowheads) was exposed (Fig. 7E). Two
aneurysmal clips were applied to the neck. The perforators around the aneurysm were confirmed to be intact
(Fig. 7F). Postoperative CT angiography revealed complete occlusion of the aneurysm (Fig. 7B).

References:
1. Chehrazi BB (1993) A temporal transsylvian approach to anterior circulation aneurysms. Neurosurgery
33(1):172
2. Figueiredo EG, Deshmukh P, Zabramski JM, Preul MC, Crawford NR, Spetzler RF (2006) The pterional-
transsylvian approach: an analytical study. Neurosurgery 59 (4 Suppl 2):ONS263–9; discussion ONS269
3. Tanikawa R et al, Anterior temporal approach for basilar bifurcation aneurysms as a modified distal transsylvian
approach. Surg Cereb Stroke (Jpn) 26: 259-264, 1998
4. Tanikawa R et al, Surgery of internal carotid aneurysms in distal transsylvian approach: Defferences and
Advantages of Distal Transsylvian Approach. Surg Cereb Stroke (Jpn) 32: 19-24, 2004
5. Yasargil MG: Interfascial pterional (Frontotemporosphenoidal) craniotomy, Microneurosurgery. New York,
Thieme-Stratton, 1984, vol 1, 215-233

Surgical Manual 14
Distal transsylvian approach for the cerebral aneurysm surgery

Fig. 1

CT angiography demonstrates unruptured left internal


carotid – posterior communicating artery (IC-PC) aneurysm.
C,D: Postoperative CT angiography demonstrates
disappearance of the aneurysm and the patency of internal
carotid artery.

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Distal transsylvian approach for the cerebral aneurysm surgery

Fig. 2

A: Skin incision and the area of craniotomy are drawn on


the scalp preoperatively. A curvilinear skin incision is made
along the hairline from mid line toward the superior margin
of zygomatic arch just anterior to the tragus. B: After fronto-
temporal craniotomy, epidural hemostasis is achieved. C: The
dura is incised in a rectangle fashion with adequate exposure
of sylvian fissure D: Dissection of superficial sylvian vein is
being carried out. Temporal lobe in right side is fixed by the
retractor and the frontal lobe in the left side is compressed
focally by the tip of the sucker. E: After reaching the insular
cistern, right sided brain retractor is advanced a little more
towards the distal insular cistern. By retracting the brain gently
and compressing left side softly by the tip of the sucker,
surgucal plane is then dissected.

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Distal transsylvian approach for the cerebral aneurysm surgery

Fig. 3

After dissecting the correct plane, we expose MCA bifurcation,


M1 portion (black asterisk) and the arachnoid membrane (white
asterisk) overlying the proximal sylvian fissure from inside. B:
Lt. IC-PC aneurysm is exposed. The aneurysm sac is adhered
tightly to the temporal lobe that is being sharply dissected. C:
Aneurysm sac is dissected completely. (arrowheads: anterior
choroidal artery) D: After the temporary occlusion of internal
carotid artery, aneurysm clip is applied paying attention to
keep the outlet of posterior communicating artery intact.

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Distal transsylvian approach for the cerebral aneurysm surgery

Fig. 4

CT angiography demonstrating unruptured left basilar


artery (BA) – superior cerebellar artery (SCA) aneurysm. B:
Postoperative CT angiography revealing completely occluded
aneurysm with patent BA and SCA.

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Distal transsylvian approach for the cerebral aneurysm surgery

Fig. 5

After craniotomy, the dura was reflected anteriorly. In the


anterior temporal approach, the sylvian fissure should
be centered in the field. (asterisk: the frontal lobe) B: The
tributary of the anterior temporal artery is being dissected
from the temporal lobe. C: The oculomotor nerve (asterisk)
is also dissected from the uncus. (Double asterisk: Liliequest’s
membrane) D: After incision in Liliequest’s membrane, the
aneurysm sac is exposed and the small perforator (arrow
heads) is found to be firmly adhered in the aneurysm sac.

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Distal transsylvian approach for the cerebral aneurysm surgery

Fig. 6

The intra-aneurysmal pressure was decreased by placing


temporary clip onto the basilar artery. And the tight adhesion
is being separated by using a sharp micro-dissector. B: After
the adhesion is dissected, we confirm normal structure beyond
the aneurysm sac. C: The first clip is applied to the sac. D:
The second fenestrated clip is applied in a reversed direction.

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Distal transsylvian approach for the cerebral aneurysm surgery

Fig. 7

CT angiography demonstrates ruptured small basilar tip


aneurysm. B: Postoperative CT angiography revealing
complete occlusion of the aneurysm. C: The anterior
choroidal artery (arrowheads) is being dissected from the
uncus. D: The posterior communicating artery sometimes
hinders the surgical corridor. In such case, it can be ligated
and cut just proximal to the junction with the posterior cerebral
artery. E. After incision of PC, the aneurysmal sac (asterisk) is
exposed. F: Two aneurysmal clips are applied to the neck
and the perforators around the aneurysm are confirmed to be
intact.

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Surgical Manual 22
Carotid Endarterectomy
(CEA)

Indication of CEA; table 1-3

Severity of stenosis Medical treatment CEA P VALUE


NASCET >70%
= 26% 9% <0.01
NASCET 50-69% 22.2% 15.7% 0.045
ECST >70%
= <0.01

Severity of stenosis Medical treatment CEA P VALUE


NASCET >70%
= 26% 9% <0.01
NASCET 50-69% 22.2% 15.7% 0.045
ECST >70%
= <0.01 Kojiro Wada, MD, Dept. of Neurosurgery,
National Defense Medical College,
Saitama, Japan
Severity of stenosis Medical treatment CEA P VALUE
NASCET >70%
= 26% 9% <0.01
NASCET 50-69% 22.2% 15.7% 0.045
ECST >70%
= <0.01

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Carotid Endarterectomy (CEA)

Operation data

Operation time:
About 3 hours

Anesthesia:
General anesthesia, muscle relaxant can be used, but only during induction if motor evoked potential (MEP)
monitoring is used, trans-oral intubation is usual.

Patient posture:
Supine position, head slightly extended and turned 45 degrees away from the operated side, with use of
horseshoe pillow

Monitoring:
Superior limb somatosensory evoked potential, electroencephalography, near infrared regional saturation of
oxygen (NIRS), or transcranial MEP

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Carotid Endarterectomy (CEA)

Table No. 4
Monitoring in detecting cerebral ischemia during CEA
Positive findings Sensitivity % Specificity %
TCD min 25cm/s 100 69
TCD % 48% 100 86
NIRS min 59 100 47
NIRS % 20% 83 83
Stump pressure 40mmHg 100 75
SEP % 50% 82 57

Moritz et al. Anesthesiology 2007

Blood pressure:
Normal or slightly elevated

Operative profile
The procedure is generally divided into three phases:
Exposure of the carotid arteries, removal of carotid plaque under the operating microscope, and closure of the
carotid artery and surgical wound.

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Carotid Endarterectomy (CEA)

First phase:
Exposure of the carotid arteries
The skin incision extends along the anterior border of the
sternocleidomastoid muscle 2 cm above the clavicle to the
tip of the mastoid process (Fig.1). The platysma is divided
and sharp dissection is continued along the medial border
of the sternocleidomastoid muscle (Fig.2). The omohyoid
Parotid gland muscle is located at the proximal side and the posterior belly
of the digastric muscle at the distal side. The triangle made
Mastoid process
by the sternocleidomastoid, omohyoid, and digastric muscles
Great auricular nerve
is called the carotid triangle. The carotid sheath located in
this traingle is covered by fat, lymph nodes, and internal
jugular vein. These tissues are dissected together from the
Care of XII
anterior and superior sides and retracted posteriorly to avoid
injury to the internal jugular vein. The internal jugular vein
is identified and dissection is continued medial to the vein.
The common facial vein and other large bridging veins may
require division (Fig.3). The hypoglossal nerve courses near
the common facial vein. Careful attention to the hypoglossal
nerve is required to safely dissect the common facial vein

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Carotid Endarterectomy (CEA)

(Fig.4). The hypoglossal nerve is dissected to the union of the


ansa hypoglossi and freed. Dissection of the common carotid
artery (CCA) is performed in the distal direction, then the
carotid bifurcation is identified. Systemic anticoagulation is
XII
employed, using intravenous administration of heparin 3000
IU. Lidocaine 1% (0.1 ml) is injected into the region of the
carotid sinus nerve. The CCA is isolated and secured with
silastic tape passed through a rubber catheter. The external
carotid artery (ECA) is dissected distally and secured with a
silastic tourniquet. The superior thyroid artery is exposed for
a few millimeters at its origin from the ECA to make space
for temporary clipping. The internal carotid artery (ICA) is
dissected distally. The hypoglossal nerve that passes into the
styloid diaphragm is anchored by the sternocleidomastoid
artery and vein originating from the occipital artery. Division
of the sternocleidomastoid artery and ansa hypoglossi can
facilitate mobilization of the hypoglossal nerve. The ICA is
CCA
dissected free and secured with a silastic tourniquet (Fig.5). ICA

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Carotid Endarterectomy (CEA)

Second phase:
Removal of carotid plaque
The operating microscope is moved into position. The superior thyroid artery is occluded with an aneurysm clip,
the ICA is occluded with a vascular clamp, then CCA and the ECA are also occluded with a vascular clamp.
The arteriotomy is extended with an angled Pott’s scissors into the ICA and carried out through the involved area
into the region of relatively normal intima. A shunt tube is inserted into the distal ICA. The shunt is back-bled, then
placed in the CCA. Using a blunt dissector, the plane of dissection is usually extended distally from the CCA
into the ICA. If tack-up sutures are necessary, simple longitudinal 7-0 Pronova sutures (Ethicon, Inc.) extending
over the intima cuff are placed if the distal intima is not securely attached and thickened. After the plaque is
removed, the artery is irrigated with heparinized saline and carefully inspected for any loose fronds of tissue.

Third phase:
Closure of the carotid artery and surgical wound
The carotid artery is closed with a continuous 5-0 suture. Pronova suture is preferred. The arteriotomy is closed
with the proximal suture that begins at the distal ICA and ends at the carotid bifurcation. Another suture begins
at the proximal end of the CCA and ends at the carotid bifurcation. The internal shunt tube is clamped and

Surgical Manual 28
Carotid Endarterectomy (CEA)

removed from the ICA, then the ICA is back-bled and occluded. The internal shunt tube is removed from the CCA
and the CCA is occluded. The artery is irrigated with heparinized saline. The remainder of the arteriotomy is
sutured and tied up, which completes the closure. The aneurysm clip is removed from the superior thyroid artery.
The occluding clamp is removed from the ECA for 10 seconds and reapplied, then the clamp is removed from
ICA for 10 seconds and reapplied. The occluding clamps are removed from the ECA, followed by the CCA,
allowing any air and debris to be flushed into the ECA. Then the occluding clamp is removed from the ICA.
Sealing of the vessel with a 7-0 Pronova suture may be necessary. A soft silastic drain is inserted through an
inferior stab wound, platysma is approximated, and skin closure is completed.

29 Surgical Manual
Surgical Manual 30
Superficial Temporal Artery (STA) to
Middle Cerebral Artery (MCA) bypass

1. Introduction
The superficial temporal artery to middle cerebral artery (STA-MCA) bypass is
the most basic procedure to execute a low-flow revascularization for anterior
circulation. The first clinical case was performed by M. G. Yasargil in 1967.
The preventive effect for ischemic lesion was denied by two large randomized
studies (EC-IC bypass study, 1985; COSS trial, 2011), but the reasons why
those studies failed to indicate their superior effectiveness to internal therapy
could be a selection of patient and frequency of surgical complication. As
shown in the result of JET study (2000, Japan), it is said that a bypass procedure
could be an effective therapeutic technique for a patient with hemodynamic
compromise.

Katsumi Takizawa, M.D.


Department of Neurosurgery,
Asahikawa Red Cross Hospital

31 Surgical Manual
Superficial Temporal Artery (STA) to Middle Cerebral Artery (MCA) bypass

Fig. 1
It is however essential to complete the bypass operation
with lower surgical risk for its utmost effectiveness. In recent
years, the procedure becomes absolutely essential not only
for ischemic lesion but also for aneurysm with a difficult
preservation of parent vessel and for skull base tumor surgery
requiring vascular sacrifice; therefore, it is said that STA-MCA
bypass operation would be one of the necessary techniques
for neurosurgeon to master. Although this operation is a basic
technique, there are various styles in procedural details (e.g.
single or double bypass? M4 or M2 for recipient?) depending
on the facility and surgeon. Although it is performed in any
procedure, the most important aspect in bypass operation is
a long-term patency for the anastomosed vessel. To complete
an assured and accurate anastomosis within the permissible
time is another important factor of good bypass surgery.
In this article, we had outlined the basic procedures and
important points of STA-MCA (M2) bypass surgery.

Fig 1: clinical case. Lt. M1 occlusion.

Surgical Manual 32
Superficial Temporal Artery (STA) to Middle Cerebral Artery (MCA) bypass

2. Technical aspects
Many often consider a practice of vascular anastomosis as
a practice of bypass operation. There are various steps to
complete the bypass operation such as a preparation for
donor (e.g. exfoliation and trimming of vascular stump), a
setting for anastomotic surgical field, and dural closure to
avoid cerebrospinal fluid (CSF) leakage or vascular closure.
Therefore, steady performance of all the steps eventually
leads to a long-term patent bypass without complication. As
being different from a training practice of anastomosis, these
steps need to be learned from actual operative procedures.

a. Preparation for STA (donor a.)


<exfoliation> ( Video 1)
When performing a double bypass, STA exfoliation is
required. To exfoliate parietal and frontal branch from STA
trunk, normally, a skin incision from a region passing a linear
temporalis to midline along the line of STA parietal branch
from preauricular region is performed.

Fig 1: clinical case. Lt. M1 occlusion.

33 Surgical Manual
Superficial Temporal Artery (STA) to Middle Cerebral Artery (MCA) bypass

Fig. 2
Exfoliation is conducted from right above the skin incision
for parietal branch. Since STA is located within dermis right
above galea aponeurotica and supplies to muscle, epidermis,
and pericranium, many small branches exist at the same
location. Superficial temporal veins are often located side-
by-side around the trunk. Many text books have described to
conduct a STA exfoliation in connective tissue layer around
the blood vessels to avoid vascular damage and spasm, but
actually the area around the blood vessel is the most sparse
and easy to exfoliate. When we conduct an exfoliation at this
layer, it would be easy to verify small branches so that we
can avoid severing these branches. Since we perform STA
exfoliation with titanium-made bipolar forceps, this method
allows us to perform it in short period of time and almost no
blood loss occurs. An appropriate tension, diagonally upward
against the incised skin is required to conduct the exfoliation
procedure more easy.

Fig 2: skin incision

Surgical Manual 34
Superficial Temporal Artery (STA) to Middle Cerebral Artery (MCA) bypass

Fig. 3
However it also requires a cautious hand movement because
of much difficulty to control the exfoliation procedure with
excessive traction. When the exfoliation is conducted
following this method, it requires to pay great attention to
handle blood vessel in a protective way (not excessively/
Fig 3: Draping and preparation
directly grasp a blood vessel with forceps) and always try to
avoid thermal damage or avulsion injury to a vascular branch.

Fig. 4
When the exfoliation of parietal branch from the main STA
trunk is completed, skin incision is extended to midline and
reverse a skin flap at the subgaleal layer. Exfoliation of parietal
branch is conducted from the backside of reversed scalp
incision. In this case, since STA orientation was found right
below the galea, galeal incision was made right above the
blood vessel with the same technique, and expose/exfoliate
the layer around the blood vessel.

Fig 4

35 Surgical Manual
Superficial Temporal Artery (STA) to Middle Cerebral Artery (MCA) bypass

Fig. 5
During exfoliating the parietal branch till periphery, it is
required to pay attention to skin epilation and ischemia, since
STA becomes excessively thinner and a hair root runs in a
shallow layer. Furthermore, always pay attention to a possible
damage of facial nerve at the time of exfoliation depending
on the orientation of parietal branch.
Exfoliated STA should be maintained with good blood
circulation right before anastomosis until STA anastomosis is
completed. However, it might become obstacle for craniotomy
by STA orientation. Additionally STA damage may occur in
an attempt to maintain blood circulation patent. Therefore,
after proper dissection and isolation of either branch of STA,
heparin saline solution should be fully filled up in vascular
lumen.

Fig 5

Surgical Manual 36
Superficial Temporal Artery (STA) to Middle Cerebral Artery (MCA) bypass

Fig. 6
b. Craniotomy (Fig.6a)
When executing an anastomosis to M2, fronto-temporal
craniotomy is performed with its routine size. If smaller size
craniotomy is performed, operative feild would become a
narrow and deep like a mortar shape. Therefore, it should be
noted that anastomosis in such conditions tends to be more
difficult to perform.

c. Dural incision (Fig.6b)


Dural incision is given along with a large flap shape but a
dura mater on temporal side should be incised by the length
of 6-7mm from the bony margin.

d. Preparation of recipient a.(M2) (Video.2)


When M2 is considered as “recipient a.”, MCA is widely
exposed separating the sylvian fissure. Although we select an
appropriate region for anastomosis after carefully examining
the blood vessel orientation and arterial sclerosis level, we
make better selection to avoide overlapping of perfused
Fig 6: craniotomy and dural incision

37 Surgical Manual
Superficial Temporal Artery (STA) to Middle Cerebral Artery (MCA) bypass

area if double anastomosis is performed. Since the


operative field for anastomosis to M2 is usually deep and
anastomosis itself could be more difficult as compared
to the execution at brain surface. it is important to set
the anastomotic operative field carefully. For securing
operative field shallow and wide, a spacer of Ben Sheet
® in a rolled shape can be used. When deciding an
anastomotic region, insert a silicon sheet under blood
vessel and then insert appropriate amount of Gelform®
under the silicon sheet. Since MCA is slightly lifted up by
this procedure and made as a fixed structure under tension,
anastomosis can be performed more easily. Bleeding
into the operative field during the anastomosis should be
avoided by conducting hemostasis more rigorously.

Fig. 7
Because the anastomosis could be difficult in a wet
operative field by CSF. Moisture should be maintained
by consistently suctioning the CSF. This can be done
by setting up a suctioning system, connecting the infant
feeding tube at the lower site of operative field. Conversely,
Fig 7: The difficulty of the suture depends on surgical field condition

Surgical Manual 38
Superficial Temporal Artery (STA) to Middle Cerebral Artery (MCA) bypass

when the operative field becomes an excessive dry, a suture


thread would cause a trouble by sticking to the surrounding
tissue; therefore, it should be careful to avoid an excessive dry
operative field by using Gelfoam. Brain surface around the
anastomotic operative field is therefore protected by placing
the piece of Gelform®. In such situation, Ben Sheet® might
create obstacle for anastomosis due to its loose thread, hence
it should not be placed around the operative field.

e. Stump preparation in donor a. (STA) (Video.3)


STA stump preparation will be performed right before
anastomosis. Connective tissue around the stump should
be thoroughly removed. For enlarging an apertural area of
anastomosis, we incise the stump with an angle of 60 degrees.
For widening an apertural area as fish mouth, further incision
is given on one side as the same length as the diameter of the
trimmed-off distal end.

Fig. 8
The stump visibility is improved by applying pioctanin (violet
die) to outer membrane of stump margin. This method offers
Fig 8: Stump forming of donor a.

39 Surgical Manual
Superficial Temporal Artery (STA) to Middle Cerebral Artery (MCA) bypass

a high usability, particularly for narrow and thin blood vessel. 10.0 or 9.0 Nylon is used for anastomosis
but normally two strings with the length of 5.0cm should be used. Although zoom-in/out in microscope is
frequently done during the anastomosis, the thread length up to 5.0cm can be handled for better visualization
within the operational field. If the length is too long, it may take more time to check the needle and the
lengthy thread. If the length is too short, the anastomosis can not be completed with two strings; therefore,
approximately 5cm would be the appropriate length. After completing STA stump preparation, threading
two strings to STA in advance is required for “Stay- suture”.

f. Final check before anastomosis


Incision length of MCA is important to be matched with a stump length of STA. The incision marking should
be conducted while matching and measuring the MCA with a trimmed STA stump. Incision length for thin
wall blood vessel should be a little shorter if the wall thickness between STA and MCA has difference
(normally the wall of STA is often thicker). Since a release of temporary blockage or additional arteriotomy in
MCA cannot be performed until anastomosis is completed, (it means no turning back after the execution), it
is important to complete all the preparations before the temporary blockage from a viewpoint of shortening
the anastomosis time. Before performing the temporary blockage, the final confirmation should be carried
out for the surgical setting in the best condition as well. The anastomosis should never be started until the
satisfactory setting is made without any compromise.

Surgical Manual 40
Superficial Temporal Artery (STA) to Middle Cerebral Artery (MCA) bypass

Fig. 9
g. Anastomosis (Video.4)
Firstly, MCA (recipient a.) is temporarily blocked with
appropriate clips, but make sure whether the temporary
blockage works before MCA incision. It can be confirmed
by a feel provided by grasping the blocked portion of MCA
with tweezers. The incision line should not be dentilated in
arteriotomy of MCA. During anastomosis, a surgeon should
not attempt to move his hand faster due to the concern of
blockage time. It is important not to be in hurry and perform
the anastomosis. The most important procedure for vascular
anastomosis is to precisely match the inner membranes of
“donor a.” and “recipient a.” (eversion technique)

Fig 9: vsetting of anastomotic field

41 Surgical Manual
Superficial Temporal Artery (STA) to Middle Cerebral Artery (MCA) bypass

Fig. 10
To avoid the inner membrane damage, the inner membrane
should not be grasped strongly by the forceps. For the suturing
method, the suture insertion distance should be the same as
thickness of blood vessel and a suture interval should be twice
the blood vessel thickness

Fig. 11
Make sure to tie up three time by one suture to avoid loose
Fig 10: schematic drawing of everting technique
knots. If it is sutured with such needle interval, total 20 stitches
would be completed with “stay suture” in an ordinary M2
bypass, but the suturing can normally be completed within
20 minutes. If an appropriate suturing is performed, a
blood leakage should not be occurred from the suture site.
Anastomosed stump should favorably expand at the time of
release of the temporary clips without any stenosis.

Fig 11: schematic drawing of suture method

Surgical Manual 42
Superficial Temporal Artery (STA) to Middle Cerebral Artery (MCA) bypass

Fig. 12
h. Dural closure/Wound closure (Video.5)
When closing a region penetrated by STA with dura mater
mutually, a kinking would occur and the circulation would
be slower. Yet conversely a CSF leakage would occur when
dura is too loosely closed. To avoid this risk, we perform a
dural closure with the following method. Firstly, a dura mater
and temporal muscle will be sutured approximately 3cm at the
site of covering the bone margin where STA gets penetrated
(Fig.13a). Secondly, construct a caulescent of small pedicle
by using a deep layer of temporal muscle in the temporal side
as being reversed and incised in flap shape. Dura mater and
temporal muscle in a bony margin covering should be sutured
by wrapping the STA with a side of this pedicle. Then the
dura should be closed after suturing other sides of it.

Fig 12: Photograph of the suture site

43 Surgical Manual
Superficial Temporal Artery (STA) to Middle Cerebral Artery (MCA) bypass

Fig. 13b
By this method, vessel kinking and CSF leakage at the site
of dura mater penetrated by STA will be prevented. It should
also be careful to avoid an occurrence of vessel kinking at
the bony margin even at the time of replacing a bone flap.
Hence frequent checking by a Doppler rheometer is to be
done to make sure regarding the patency of STA until the final
wound closure is done.

3. Practice for vascular anastomosis (Video.6)


For performing a satisfactory bypass operation, it requires to
take a enough time for practice on vascular anastomosis so
before actual performance in patients, anastomosis practice
can be done using a blood vessel in a small animal such as
mouse. It has an optimal advantage that the finger-touch of
blood vessel will be approximately the same as in live human
vessel. In such case, a laboratory work is required and would
be difficult to practice at ordinary hospitals. In addition, the
preparation and suturing practice might be troublesome. We
have been practicing using an artificial blood vessel and
chicken wing for anastomosis practice. Although it would
Fig 13: Photographs of dural closure

Surgical Manual 44
Superficial Temporal Artery (STA) to Middle Cerebral Artery (MCA) bypass

have a different finger-touch experience as compared to that


of live vessel, it can conveniently offer “Off the job trainning”
at anywhere if you have your own table-microscope.

Fig. 14
Furthermore, since you might not be able to operate under
the table-microscope with zoom-in/out like during an actual
operation, it would be effective to practice with a microscope Fig 14: practice at desk

used in operation theatre. Yet an artificial blood vessel or


chicken wing can be taken into the operation room and
practice before the real show.

Fig. 15
4. Summary
It is considered that STA-MCA bypass operation is not a special
technique, but a necessary technique is to safely treat the
various difficult conditions to cure. For the safe performance,
anastomosis practice is very important, which requires
to comprehend various procedures/tips sufficiently for
the entire operation. Therefore, this part of execution must Fig 15: practice at the operation room
be experienced and learned from the actual operation.

45 Surgical Manual
Superficial Temporal Artery (STA) to Middle Cerebral Artery (MCA) bypass

Furthermore, there are various ways to perform the bypass surgery but it would not necessarily be performed
with the above-described explanation. However, our method includes many important points/tips which are
acquired through a number of clinical experiences to construct an assured/safe bypass with a long-term
patency. Hopefully our method will be able to assist you as a reference in future.

Surgical Manual 46
47 Surgical Manual
Surgical Manual 48
Carotid artery stenting
Endovascular Therapy

Carotid endoarterectomy (CEA) is the standard treatment for the patients


with carotid artery stenosis. Recently, there are several radomised clinical
trials of carotid artery stenting (CAS) to evaluate its safety and efficacy,
comparing with CEA. SAPPHIRE (2004) and CREST (2010) are the
positive study to reveal the non inferiority of CAS, while the EVA-3S
(2006), SPACE (2004), and ICSS (2010) are the negative study to
CAS. We have to think about the various bias of these studies and
evaluate them in a fare fashion. Recently, the major adverse events of
CAS have been decreasing gradually to 5% or less as its methods and
endovasbular devices improve. Several important points are discussed
to perform the safer and efficacious CAS.

Naoya Kuwayama, M.D.,Ph.D.


Division of Neuroendovascular Therapy
Department of Neurosurgery
University of Toyama, Japan

49 Surgical Manual
Carotid artery stenting Endovascular Therapy

CAS: clinical evidence

CAS CEA Result

EVA-3S 2004 9.9% 3.9% discon.

SAPPHIRE 2004 4.8% 9.8% not inf.

SPACE 2006 6.84 6.34 not no inf.

ICSS 2010 7.4% 4.0% CEA

CREST 2010 5.2% 4.5% even

JCAS 2008 3.5% 3.2% even

Surgical Manual 50
Carotid artery stenting Endovascular Therapy

Patient’s demography
Age and gender
Cervical carotid artery stenosis occurs more often in male patients.
High age was one of the risk factor of the CEA. SAPPHIRE trial demonstrated non-inferiority of CAS to CEA
in the high risk patients. On the contrary, CREST estimated the high incidence of the major adverse events in
the patients over 70 years of age treated with CAS. Thus this study recommended CEA for the patients over
70 years of age, and CAS under 70 years.
Symptomatology
Transient ischemic attack and minor stroke are very important clinical signs to suggest the cervical carotid
artery stenosis. These symptoms may be caused by “artery to artery embolism” from the carotid plaque.
Therefore, it is essential to check the cervical carotid arteries in patients with stroke. NASCET (1991) proved
25% re-stroke rate within 2 years in the patients with symptomatic carotid stenosis of 70% or more. ACAS
(1995) also proved 11% re-stroke rate within 5 years in the patients with asymptomatic carotid stenosis of
60% or more.
Associated risk factor
The coronary and peripheral artery diseases are often associated with the carotid artery stenosis on the
base of systemic atherosclerotic condition. Hypertension, diabetes, and hyperlipidemia are also systemic risk
factors of the carotid artery stenosis.

51 Surgical Manual
Carotid artery stenting Endovascular Therapy

Plaque diagnosis
The soft or fragile plaque is one of the major risk factors of stroke
after CAS. Find these dangerous plaques before treatment by
ultrasonography and /or MRI (T1WI, T2WI, TOF).
Plaque MRI and its interpretation The most simple method to detect the soft plaque is
ultrasonogram. Low echoic component means lipid rich
・T1-high + TOF-iso contents or hematomas. The most sensitive and reliable
lipid rich plaque method is MRI plaque image. The combination of “T1-high
and TOF-iso intensity” means lipid rich plaque and “T1-high
・T1-high + TOF-high and TOF-high intensity” means old liquid hematomas in the
plaque. These lesions should be identified as “very dangerous
liquid hematoma
plaques”.
・short lesion or long lesion The circumferential calcification in the plaque and the wall
of carotid artery is also a lesion resisting to dilatation with
balloons and stents. Detect it with plain axial CT.

Surgical Manual 52
Carotid artery stenting Endovascular Therapy

Plaque diagnosis by MRI


68M: symptomatic long stenosis: unstable lipid rich plaque

T1: high TOF: slight high T1: high

53 Surgical Manual
Carotid artery stenting Endovascular Therapy

Plaque diagnosis by MRI and echo


79 M:asymptomatic stenosis, unstable plaque with hematoma
low echoic plaque
Echo

MRI plaque image

DSA TOF: high T1: high

Surgical Manual 54
Carotid artery stenting Endovascular Therapy

Access routes
It is important to evaluate the vascular abnormalities including ASO, aortic aneurysm/dissection, types of the
aorta (type-I, II, III) in the access routes from the groin to the carotid arteries. Trans-brachial access can be
selected in patients with difficult trans-femoral access. CT angiogram or MR angiogram can effectively find
these vascular abnormalities.

Cerebral perfusion
Postoperative hemorrhagic complications caused by hyperperfusion syndrome is rare (1.4%, Ogasawara
K) but disabling or fatal events after carotid revascularization, so-called hemodynamic compromise is the
major cause of this condition and intracerebral, subarachnoid, or even subdural hematomas may develop
immediately or within 1 or 2 days after stenting unlike the cases treated with CEA.
To prevent this devastating complication, pretreatment evaluation of the cerebral blood flow (CBF) is essential.
A combination of ipsilateral hypoperfusion and poor response to the vasodilating agents like acetazolamide
is a highly predictive factor of the yperperfusion syndrome after treatment.
Evaluate the cerebral blod flow and hemodynamic compromise with single photon emmision CT, xenon CT,
or positron emmision CT.

55 Surgical Manual
Carotid artery stenting Endovascular Therapy

Cerebral Protection method


preserving the ICA flow
distal filter (Filterwire, Angioguard)!

Surgical Manual 56
Carotid artery stenting Endovascular Therapy

Approach routes
1) Transfemoral approach
2) Transbrachial approach
3) Transcarotid approach (with small skin incision, no precutaneous pucture should be done)

Cerebral protection devices


1) Distal filter (Spider, Filterwire, Angioguard, etc)
2) Distal balloon (Percuserge Guardwire, etc)
3) Proximal balloon (Parodi’s system, 9Fr balloon guiding catheter, etc)

Stents
1) Open cell stent (Precise, Protégé, etc): The basic structure is the longitudinal successions of the independent
metal rings.
2) Closed cell stent (Carotidwall, etc): The basic structure is the pipe braided with metal wires

57 Surgical Manual
Carotid artery stenting Endovascular Therapy

Precise stent Carotidwall stent Protege stent

Angioguard (filter)
Filterwire (filter) Spider (filter)

Surgical Manual 58
Carotid artery stenting Endovascular Therapy

Premedications
1) Dual antiplatelet therapy
Dual antiplatelet therapy with clopidogrel (75mg) and low dose aspirin (100-300mg) is essential to prevent
postoperative thromboembolic complications. This medication should be continued at least for 3 months after
treatment.
2) Statin and other medication
Statin is sometimes effective to stabilise the unstable lipid-rich plaque before treatment. Hypertension and
diabetes should be well controlled before treatment.

Method
Anesthesia
Local anesthesia is good enough to do CAS. In case of distal balloon protection and flow reversal method
(Parodi), general anesthesia is sometimes preferred considering the carotid occlusion intolerance.

Guiding catheters
In case of simple distal balloon or filter protection, 8 French guiding catheters are used. In case with flow
reversal method, 9 French balloon guiding catheters are used.

59 Surgical Manual
Carotid artery stenting Endovascular Therapy

Simple balloon/filter protected CAS


Give the patient intravenous heparin after puncture to prolong the active clotting time (ACT) to 200-300
seconds.
After placing the guiding catheter in the common carotid artery, a balloon or a filter is placed carefully in the
distal internal carotid artery, followed by inflation of the balloon or opening the filter.
A PTA catheter (3.0-5.0mm in diameter) is coaxially sent to the lesion and inflated. Transient or prolonged
bradicardia and/or hypotension may ocurr when the carotid artery is dilated. Atropin and/or vasopressors
may sometimes be needed.
After retrieving the PTA catheter, send the stent catheter coaxially to the lesion and deploy it. Remind the open
type stent like Precise cannnot be resheathed once opened. In case of balloon protection, aspirate the blood
with debris in the distal internal carotid artery.
Use a post-dilatation balloon catheter if necessary. Retrieve the balloon or filter.

Flow reversal method


Puncture both the femoral artery (9F) and vein (5-6F) and give intravenous heparin.
Send the 9F balloon guiding catheter to the common carotid artery and Percusurge Guardwire (occlusion
balloon) to the proximal external carotid artery.
Send the microguidwire to the distal internal carotid artery for the coaxial insertion of a PTA balloon and a stent
cathether.
Connect the 9F balloon catheter and the femoral venous sheath with a filter, making the shunting circuit from A
to V line. Thus, the blood in the internal cartid artery is going reversely into the guiding catheter and finally to
the femoral vein (flow reversal) through the filter.

Surgical Manual 60
Carotid artery stenting Endovascular Therapy

Dilate the lesion with a PTA balloon catheter and deploy a stent. Use a post PTA balloon, if necessary.
Monitor the patient neurologic condition to check the occlusion intolerance. Use anesthetic agents if necessary.
Occlusion intolerance may be more evident after the blood pressure declines following carotid dilatation.

Complications of CAS
Thromboembolic complications
The debris coming out of the ruptured unstable plaque is one of the most frequent reasons of post-stenting stroke.
The filter protection is not recommended in the unstable plaque, especially including liquid hematoma.
Subacute stent occlusion may sometimes occur due to the herniated plaque component from the stent mesh and
thrombosis.

Bradycardia and hypotension


The distortion and stretch of the carotid body (baro-receptor) by PTA manipulation causes bradycardia and
hypotension, which are sometimes prolonged for days or weeks. Use atropin and/or vasostrictor agents.

Hyperperfusion syndrome
The decreased hemodynamic reserve will cause the postoperative hyperperfusion syndrome, sometimes resulting
in intracranial hemorrhage. Treatment priority is to control the blood pressure to avoid hypertension after stenting.
Postoperative continuous propofol infusion or barbitulate come therapy is considered one of the most effective
treatment against the aggressive hyperperfusion syndrome.

61 Surgical Manual
Carotid artery stenting Endovascular Therapy

Cholesterin embolism
Ruture of the aortic plaques by catheters and cholesterin shower are the most frequent cause of cholesterin embolism.
The blood eosinophil count will be elevated and the patient shows blue toes and renal failure. The fatality rate is
over 50%.

Puncture site complications


Groin hematomas, retroperitoneal hematomas, pseudoaneurysms, arteriovenous shunts others Metal allergy

Nationwide survey of carotid revascularization in Japan


Japan Atherosclerosis Study (JCAS) is the prospective registry of patients with carotid artery stenosis, which was
conducted from 2002 to 2006. The patients with carotid stenosis of 50% or more were enrolled in a prospective
fashion from 53 centers. The patients were treated either by medical therapy (MT), carotid endarterectomy (CEA),
or carotid artery stenting (CAS) according to each center’s indication. Endpoint is either ipsilateral stroke, acute
myocardial infarction, or death. 1164 patients were enrolled between the initial 3 years. 87% of the patients
were men. Mean age was 69.8 years. 51% of the patients had a symptomatic and 49% had an asymptomatic
stenosis. 45% of the patients were treated by CEA, 34% by CAS, and 21% by MT. Major adverse events at 30
day occurred in 3.2% of CEA and 3.6% of CAS group (ns). 746 patients were followed-up for 847 days (mean).
Restenosis ratio was 10.7% in CEA and 5.4%(p=0.016) in CAS group. In the follow-up period, ipsilateral stroke
occurred in 0.54% of CEA, 0.39% of CAS, and 6.09% (p<0.001) of MT group. 4.8% of the patients in CEA
group, 5.8% in CAS, and 10.4% in MT died. Cardiovascular events occurred in 3.5% of the 746 patients.

Surgical Manual 62
63 Surgical Manual
Surgical Manual 64
Cisternostomy: A paradigm shift in
managing severe head trauma
A Technical note

Introduction
Cisternostomy is an emerging innovative neurosurgical technique for the
optimal management of moderate to severe head injury in modern era
(1,2,3). It has same indications as that of decompressive hemicraniectomy.

Time interval
It is very essential not to waste any time to allow cytotoxic brain edema
or hypoxic injury to occur which may not respond to cisternostomy. The
early decision making and transport to theatre should be as fast as
possible. Cisternostomy is usually attempted within 4 hours of injury for
better outcome.

Difference from current surgical management of head injuries Dr. Iype Cherian
Professor and Chairman
Cisternostomy incorporates skull base and microvascular techniques and
Department of Neurosurgery, COMS
is much more technically demanding compared to a decompressive Bharatpur, Chitwan,Nepal
hemicraniectomy. However, after somebody is trained in this surgery, it Email:drrajucherian@gmail.com
can be done within a time of 10-20 minutes from dural opening.
Dural opening
At times a T cut leading to the proximal and distal dural ring of the
carotid is helpful to mobilize the carotid, if one needs to avoid additional
maneuvers like drilling the posterior clinoid to get space.

65 Surgical Manual
The surgical technique of Cisternostomy

1. Positioning of patient
Patient’s head is not placed in any head fixation system other
than in head ring. However, Leyla retractors may sometimes
aid in retraction of frontal lobe. After induction of general
anesthesia, patient is positioned in supine and head end is
raised at 30 degrees. Head is then extended to 15 degrees
and turned another 15 degrees to opposite side. Head
extension helps to gain entry into the interoptic cistern without
much difficulty. To access the membrane of Liliequist, head
is returned back in neutral position and microscopic angle is
changed to visualizing the “basilar quad”.

Craniotomy
A pterional flap with or without frontotemporal orbitozygomatic
(FTOZ) extension is used as the craniotomy. Sometimes a mini
Fig1 FTOZ, with spheniod drilling,extradural anterior clinoidectomy,
The positioning is just like for an aneurysm with the head and dissection of dura propria of the cavernous sinus upto V2
fixed, extended to 15 degrees and turned to the contralateral is necessary in a very tight brain to go as basal as possible
side with the malar prominence facing upwards.. Kindly
between the frontal and temporal lobes and gain direct access
note that the head should not be fixed if there are fractures
into the supra sellar cistern.

Surgical Manual 66
The surgical technique of Cisternostomy

It is very important to go as basal as possible in a tight brain so as to open all the cisterns. For this, the frontal
aspect of theskinflap has to be reflected downexposing the superior orbital rim. Inferior orbital fissure (IOF) is
identified with a blunt dissector by passing it through the orbit into the IOF. A burr hole is made in keyhole
and another just above the root of the zygoma. From the keyhole the 1st cut is made into the burr hole above
the zygomatic root and then the 2nd cut is made from the keyhole to the IOF. After reaching the IOF, the
craniotomy is turned to 90 degrees and the cut is made across the zygoma. 3rd cut is made though the burr
above the zygomatic arch all the way to the orbit, lateral to the supraorbital notch. This cut is deepened
with a chisel or a reciprocating sagittal saw into the orbital roof and then extended laterally towards the
keyhole. A single piece limited FTOZ flap can be mobilized in this fashion. Bone is bitten off up to the SOF
and meningo-orbital band is cut. A partial or a complete anterior clinoidectomy can be done in a extradural
fashion to facilitate space in a very tight brain. Extradural dissection upto V2 by dissecting the dura propria
of the cavernous sinus helps in gaining direct access to the supra sellar cistern.

67 Surgical Manual
The surgical technique of Cisternostomy

2. Dural opening
Dural opening is made as basal as possible in a line about
2.5 cm long parallel to supraorbital bow. After clearance
of subdural hematoma, the surgeon usually has a “2 minute
window” to get into the interoptic cistern. If the brain is very
Figure 2 tight, a direct approach to the suprasellar cistern using a
The dura is opened as basal as possible, sometimes with
the help of a modified Dolencs approach (Mini FTOZ,
modified Dolenc approach can be done. The trajectory is
extradural anterior clinoidectomy and dissection of dural important and author feels easier getting into it from slightly
propria of the cavernous sinus up to V2) lateral sub frontal approach. There should be no delay in
this step since very severe brain swelling can occur at this
particular time if the surgeon delays.

3. Interoptic cistern
Interoptic cistern usually does not contain much CSF.
However, by opening it wide with the gentle suction followed
by sharp dissection into the interhemispheric cistern and along
the contralateral A1 is important. After this step, visualization
Figure 3
of both the A1 and anterior communicating artery becomes
The initial parts of cisternostomy opening the interoptic,
opticocarotid (1) and the lateral carotid (2) cisterns. There clearer.
usually is blood within these cisterns and constant irrigation
into these cisterns after they have been opened helps one
to go to the next step, opening the membrane of Liliequist

Surgical Manual 68
The surgical technique of Cisternostomy

After the above said dissection, arachnoid layer medial and


lateral to the carotid is opened. Internal carotid perforators,
posterior communicating artery and pituitary stalk are visualized
from opticocarotid window. Posterior clinoid process is seen
posteriorly and sometimes is large enough to block the
approach through the membrane of Lillequist, through the optic
carotid window. Either a carotid mobilization with a T cut of
the dura, with incision of the proximal and distal dural ring
can be done or a direct drilling of posterior clinoid process
may be done through the triangle between A1, carotid artery
and the optic nerve or this drilling may be done through the
space between the carotid and the third nerve.

4. PCP Drilling
At times, (1)a prominent posterior clinoid process (PCP) stands
in the way of the surgeon to open the membrane of Liliequist.
Although lateral carotid mobilisation could be done after
extradural anterior clinoidectomy and incision of proximal
and distal dural ring to make space, sometimes an intradural
PCP removal gives ample space. Usage of drill (2) and a
bone CUSA (3) is shown.
Figure 4

69 Surgical Manual
The surgical technique of Cisternostomy

5,6. Membrane of Liliequist


This layer is opened by sharp dissection using bayoneted
side curve micro-scissor (working length 90 mm). “Basilar
quad” comprising of two posterior cerebral arteries superior
cerebellar arteries and the 3rd cranial nerve in between is
Figure 5 visualized.
(1) Shows the basilar bifurcation (Babi) and both PCAs,
the contralateral superior cerebellar artery and (2) the 3rd
All the cisterns are irrigated with normal saline and the blood
nerve in between the PCA and the SCA.
is thoroughly washed out. Minor bleeding into the cisterns
is usually stopped with continuous irrigation. Brain which
was tight to begin with becomes lax and pulsatile, if no
gross ischemia is anticipated. CSF draining catheter (infant
feeding tube, 8F) is put into the prepontine cistern through the
opticocarotid window. Dura is simply approximated taking
one or two stitches. Bone is replaced and wound is closed in
layers under a subgaleal drain. Cisternal drain is kept at the
height of 15 cm above the level of foramen of Monro. CSF is
allowed to drain for 3 days. The postoperative scans show the
opening up of all the basal cisterns and this clinically manifests
Figure 6 as remarkable clinical improvement in terms of mortality,
Schematic representation of the completed cisternostomy,
showing the lax brain.
ventilator time, ICU time and GOS at 6 weeks.

Surgical Manual 70
The surgical technique of Cisternostomy

a= optic nerve , b= internal carotid artery , c= ipsilateral A1 , d= M1, e= posterior communicating artery
f=Basilar artery , g=Posterior cerebral artery , h=Superior cerebellar artery , i=contralateral A1
j= membrane of Liliequist , PCP= posterior clinioid process , BAbi= basilar artery bifurcation

References
1. Iype Cherian, Ghuo Yi, Sunil Munakomi. Cisternostomy-replacing the age old decompressive hemicraniectomy?
p. 781-790 in 2nd edition of Essential Practice of Neurosurgery (WFNS), 2009, Access, Nagoya-Japan.

2. Inglese M et al. Clinical significance of dilated Virchow Robin spaces in mild traumatic brain injury. Brain
Inj. 2006 Jan:20(1):15-21

3. Jeffrey J. Iliff, Ming huan Wang, Maiken Nedergaard et al. A Paravascular Pathway Facilitates CSF Flow
Through the Brain Parenchyma and the Clearance of Interstitial Solutes, including Amyloid B. Sci Transl Med.
2012 August 15; 4(147): 147ra111.

71 Surgical Manual
Surgical Manual 72
Part I: Transmastoid Surgery
for retrolabyrinthine and translabyrinthine Approach

The retrolabyrinthine approach exposes the posterior fossa dura between


the sigmoid sinus, posterior semicircular canal, jugular bulb, and superior
petrosal sinus. Retrolabyrinthine access to the cerebellopontine angle (CPA)
with hearing preservation can be accomplished; however, exposure is
generally limited. The most frequent indication for an isolated retrolabyrinthine
approach is selective vestibular nerve section. More frequently the
retrolabyrinthine approach is combined with a temporal craniotomy and
splitting of the tentorium to expose the lateral pons and basilar artery from
the confluence of the vertebral arteries to the dorsum sellae (the combined
petrosal approach).
When hearing preservation is not a consideration, the CPA can be more
widely exposed by removing the vestibular labyrinth and skeletonizing the Tetsuro Sameshima, M.D., Ph.D.
Department of Neurosurgery
internal auditory canal through the translabyrinthine approach. Advocates Hamamatsu University School of Medicine
of this approach cite early identification of the facial nerve in the IAC and University Hospital, Hamamatsu city, Japan
minimal brain retraction as factors for improved results in acoustic tumor tetsurosameshima@gmail.com

surgery. Either the retro-or translabyrinthine approaches can be combined


with other lateral skull base procedures to enhance exposure, depending
on the location and extent of the lesion being exposed and the status of the
patient’s hearing such as the total petrosectomy approach with facial nerve
translocation.

73 Surgical Manual
Surface Anatomy of the Temporal Bone & Mastoid Triangles

Surface Anatomy of the Temporal Bone & Mastoid Triangles

A. Fukushima’s outer mastoid triangle:


Asterion - Root of zygoma posterior point- Mastoid tip

B. Fukushima’s inner triangle:


Sinodural angle – Aditus - Digastric ridge
Trautman’s triangle:
Sinodural angle - Superior aspect of the posterior
Fig A Surface Anatomy of the Temporal Bone & Mastoid Triangles
semicircular canal
Jugular bulb

Skin Incision
“A” Small C-shaped transmastoid incision
Represents standard transmastoid,
retrolabyrinthine or translabyrinthine incision used
by neuro-otologists

C) MaCewen’s triangle, Suprameatal triangle (Mastoid antrum):


Flat or Depressive area
Fig B Skin Incision

Surgical Manual 74
Surface Anatomy of the Temporal Bone & Mastoid Triangles

“A” Small C-shaped transmastoid incision


Represents a combined transmastoid and suboccipital
(retrosigmoid) approach frequently used for the preservation of
hearing function in acoustic neuroma surgery

“C” Combined transpetrosal incision


Represents a question-mark (C1) or L-shaped incision (C2) used
in this skull base dissection for combined petrosal approach

A. Fukushima’s outer mastoid triangle:


Asterion - Root of zygoma posterior point- Mastoid tip

Step 1: Positioning, incision and bony Landmarks


The head is placed in the lateral position, facing away from
the surgeon. A postauricular incision through the galea is
made, one inch behind the postauricular crease. The incision
extends from the mastoid tip and curves forward to end just
above the pinna (or mid-point of supramastoid crest)

Fig 1A

75 Surgical Manual
Surface Anatomy of the Temporal Bone & Mastoid Triangles

Fig. 1B
The scalp is elevated by sharply dissecting the subgaleal
connective tissue, which spans the galea and the underlying
pericranium. The pericranium is contiguous with the temporalis
fascia above and the fascia overlying the sternocleidomastoid
muscle below. A second incision is made in this deep layer
composed of temporalis fascia and muscle, periosteum, and
sternocleidomastoid fascia to fashion a musculofascial flap
that is important in obtaining a water tight, cosmetic closure.
The two flaps are elevated anteriorly to reveal the posterior lip
Fig 1B of the external auditory canal, the spine of Henle, and the root
of the zygoma posterior point. Large blunt scalp hooks are
used to reflect these flaps. The bony landmarks which should
be visualized at this point are: the root of zygoma posterior
point, the spine of Henle, the squamosal suture, the asterion,
the supramastoid or temporal crest, the mastoid tip and the
digastric groove

Fig. 1A & 1C
Step 2: Mastoidectomy and Retrolabyrinthine Exposure
Fig 1C The second step is performance of a mastoidectomy. Using

Surgical Manual 76
Surface Anatomy of the Temporal Bone & Mastoid Triangles

the high-speed drill with a large cutting burr (5~6 mm) and
continuous suction irrigation, the cortex over the mastoid bone
is removed. It is helpful to first outline the boundaries of bone
to be removed using the drill. The anterior border is a slightly
curved line, extending from the top of the external auditory
meatus to the mastoid tip. The superior margin is along a line
roughly perpendicular to the first, extending from the root of
zygoma posteriorly to the region of the asterion. These two
lines form a skewed “T” that defines the anterior and superior
margins of the mastoidectomy

Figure. 2A
The junction of these two lines generally marks the surface
projection of the region of the mastoid antrum and the lateral
semicircular canal.
The bone cortex is removed within the boundaries of these
lines, working anterior to posterior and superior to inferior. As Fig 2A

the cortical bone is removed, air cells will be encountered.


Posteriorly, over the sigmoid sinus, the bone will remain
compact. In order to provide maximum exposure, wide cortical
removal with saucerization should be performed prior to

77 Surgical Manual
Surface Anatomy of the Temporal Bone & Mastoid Triangles

deeper penetration. Gentle, brush-like strokes with the drill will


reveal the compact bone of the sigmoid sinus. Bone removal
proceeds, 1 cm behind the sigmoid, maintaining a uniform
depth as the sigmoid is exposed. When the sigmoid has been
skeletonized, the mastoid air cells are removed anteriorly and
superiorly to expose the middle fossa dura (Temporal tegmen)

Fig. 2B
Moving anteriorly, the air cells will be removed to expose the
compact bone of the bony labyrinth, or the solid angle. The
key landmark in this area is the mastoid antrum

Fig. 2C-E
This open space defines the anterior limit of bony removal and
locates the lateral semicircular canal. Maintaining the same
relative depth, air cell removal proceeds inferiorly towards the
jugular bulb. As air cells are removed from the mastoid tip
region, the digastric ridge will be encountered. The digastric
groove is an important landmark for defining the exit of the
facial nerve from the fallopian canal through the stylomastoid
Fig 2B
foramen. The stylomastoid foramen lies just medial to the

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Surface Anatomy of the Temporal Bone & Mastoid Triangles

anterior limit of the digastric ridge. At this point, the middle


fossa dura, presigmoid dura, and the sinodural angle should
be skeletonized. Again, the technique of removing bone to
the point of leaving a thin shell, which may be removed with
a dissector, is practiced to avoid damage to the dura and the
venous structures. For maximal exposure in the retrolabyrinthine
approach, the posterolateral portion of the bony labyrinth must
be completely defined. With a medium diamond burr (2-3 mm),
Fig 2C
the small air cells surrounding the labyrinth are removed. The
ridge covering the lateral semicircular canal is first identified as
the antrum is opened. The facial nerve will be located parallel
and 1-2 mm anterior to the lateral semicircular canal at this
point. Moving posteriorly, the posterior semicircular canal will
be defined. Inferior to the posterior semicircular canal, towards
the jugular dome, lie the retrofacial air cells. These air cells
are removed to skeletonize the jugular bulb. The dura is then
incised parallel to the pre-sigmoid region and the superior
petrosal sinus. The dura is retracted anteriorly exposing cranial
nerve VII and VIII in the cerebellopontine angle. Frequently the
lower cranial nerves can also be visualized.
Anteriorly, approximately 12-15 mm medial to the external
Fig 2D

79 Surgical Manual
Surface Anatomy of the Temporal Bone & Mastoid Triangles

auditory meatus, lies the fallopian canal. Therefore, bone


removal in the anterior direction at this level must be done
with extreme care to avoid violating the fallopian canal. The
facial nerve, which lies anterior to the labyrinthine structures,
is carefully approached, again using the lateral semicircular
canal as a landmark. The facial nerve is skeletonized using
the diamond burr from the external genu inferiorly to the
stylomastoid foramen. Care is taken to preserve a thin shell
of bone around the facial nerve for protection. This maneuver
must be done under constant, copious irrigation to dissipate
heat from the drill.

At this stage certain goals of bone removal


should have been met:
1. Skeletonization of the sigmoid sinus and jugular bulb;
2. Exposure of the presigmoid dura and middle fossa dura;
3. Definition of the lateral bony labyrinth, clearly visualizing
the lateral and posterior semicircular canals
4. Skeletonization of the fallopian canal and the entire course of
the facial nerve through the mastoid bone.

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Surface Anatomy of the Temporal Bone & Mastoid Triangles

Step 3: Translabyrinthine Drilling / IAC


The lateral and posterior semicircular canals (PSC) are first
opened with the drill. The amputated, or anterior, end of the
lateral semicircular canal (LSC) is carefully removed, bearing
in mind the close relationship of the tympanic portion of the
facial nerve. Preservation of the anterior wall of the lateral
semicircular canal will protect the tympanic segment of the
facial nerve. Removal of the superior segment of the posterior
semicircular canal will expose the common crus, which it
shares with the superior semicircular canal. The superior
semicircular canal (SSC) is then also opened by drilling
superiorly and anteriorly. The amputated, or inferior, limb of
the posterior semicircular canal is followed to the vestibule.
Drilling in this area, lateral and inferior to the vestibule, will
expose the vestibular aqueduct as it courses laterally toward
the endolymphatic sac. The vestibule is now opened by
continually removing bone, following the common crus

81 Surgical Manual
Surface Anatomy of the Temporal Bone & Mastoid Triangles

Fig. 3A-C
The wall of the vestibule which separates it from the internal
auditory canal is only a thin shell of bone. The compact
bone surrounding the internal auditory canal is then defined
by removing bone superior and inferior to the canal. It is
important in terms of maximizing the exposure, to remove
bone around the canal such that a greater than one half of
the circumference of the canal is skeletonized. It is important
to remove bone superiorly and inferiorly so that the anterior
Fig 3A
most extent of the canal is accessible. Bone removal inferior to
the canal will in some cases expose the cochlear canaliculus
which communicates with the CSF and perilymphatic spaces.
The bone around the internal auditory canal is then carefully
removed. Beginning in the region of the porus acusticus, the
compact bone surrounding the canal is thinned with a small
diamond burr until only a thin, repressible shell remains. As the
drilling proceeds laterally, bear in mind that dura only covers
the canal contents for approximately two-thirds of the canal’s
length. As the bone is thinned at the lateral end of the canal,
the transverse crest will be identified as a thin septum of bone
separating the superior from inferior vestibular nerves. The
Fig 3B

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Surface Anatomy of the Temporal Bone & Mastoid Triangles

paper-thin shell of bone in the region of the porus acusticus


is removed first with a fine dissector, with the bone over the
lateral most end of the internal auditory canal saved for last.
The superior lip of the porus is generally the most difficult to
manage because of the very close proximity of the facial nerve

Fig. 3D-G
The dura is incised beginning just medial to the sigmoid sinus,
5-10 mm below the superior petrosal sinus, and continued in
Fig 3D Fig 3E
a line toward the midportion of the internal auditory canal. At
the region of the porus the dural incision is extended superiorly
and inferiorly. Using a #11 blade, the dura of the canal is
opened to expose the superior and inferior vestibular nerves.
Sectioning of the nerves and then reflecting them laterally,
will reveal the cochlear and facial nerves. The latter two are
separated from the superior and inferior vestibular nerves by
Bill’s bar at the lateral end (Figure 3H & 3I).
The wound is closed in the following manner. The incus is
removed and a piece of temporalis muscle is harvested and
placed carefully through the epitympanum occluding the Fig 3F Fig 3G

origin of the Eustachian tube. The removal of the incus and

83 Surgical Manual
Surface Anatomy of the Temporal Bone & Mastoid Triangles

obliteration of the Eustachian tube entrance by muscle reduces


the possibility of CSF leakage. The dural incision is closed
up to the internal auditory canal and strips of autologous
(abdominal) fat are placed in the gaps of the dura so as to seal
the CSF space. The previously fashioned musculofascial flap
is closed tightly over the adipose graft and the postauricular
incision is closed in two layers.

Fig 2H

Fig 2B

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Surface Anatomy of the Temporal Bone & Mastoid Triangles

Combined transpetrosal approach

85 Surgical Manual
Part II: Middle Fossa Dissection
For Extended Middle Fossa and Anterior Petrosectomy Approach

The extradural subtemporal approach through the middle fossa (MF)


has become one of the most frequently done operative procedures in
contemporary skull base surgery. This approach can be used to expose the
lateral wall of the cavernous sinus, to resect the anterior petrous bone or to
open the internal auditory canal. The MF surgery is also done for excision of
intracanalicular acoustic neuromas, petrous and infracavernous chordomas,
trigeminal neuromas and small to medium size petroclival meningiomas. Full
understanding of microanatomical structure of the cavernous sinus region,
middle fossa and the rhomboid construct are essential for this approach.
Through this exercise the surgeon will acquire operative techniques for
anterior petrosectomy as well as exposure of IAC through the middle fossa.

Surgical Manual 86
Part II: Standard Middle Fossa Approach

Step 1: Incision, Craniotomy and Dural Elevation


The cadaver head is placed in the lateral position, with the
surgeon at the vertex. The incision begins in the preauricular
crease at the level of the root of zygoma and continues in a
Preauricular sickle incision
curvilinear fashion above the level of the squamosal suture.
The incision extends through the skin and subcutaneous tissue Fig 1A
to the temporalis fascia

Fig. 1A
Blunt dissection and a self-retaining retractor expose the Subtemporal groove Root of zygoma
(merge the root of zygoma)
temporalis muscle. The temporalis muscle is split along
the posterior margin of the skin incision and retracted with
skin hooks to expose the temporal squama. A 5 cm by 5
cm temporal craniotomy is performed which is placed 2/3
Burr hole
anterior and 1/3 posterior to the root of zygoma with a high- 4mm EXC diamond
(10~20mm
speed drill and suction irrigation (Figure 1B). The inferior edge above squamosal suture)

of the craniotomy, especially the inner plate of the temporal


bone is drilled away to make this opening even with the floor Squamosal suture

of the middle cranial fossa level along the root of the zygoma.
Subtemporal inner plate at the middle fossa base must be 5mm EXC diamond

shaved entirely flat Fig 1B

87 Surgical Manual
Part II: Standard Middle Fossa Approach

Subtemporal groove (merge


the root of zygoma)
Root of zygoma
Fig. 1C
The temporal lobe dura is elevated along the middle fossa
4mm EXC diamond
floor in a posterior to anterior direction. Foramen spinosum
and foramen ovale are then skeletonized and the middle
Burr hole (10~20mm meningeal artery is coagulated and divided. The dura
above squamosal
suture) propria is elevated from the trigeminal 3rd branch (V3)
Squamosal suture
at the foramen ovale using #15 blade knife and a sharp
5mm EXC diamond dissector. The greater superficial petrosal nerve (GSPN) and
45o the location of the geniculate ganglion are confirmed. This
dural elevation is important as 15% of geniculate ganglion
lie under a dehiscence in the floor of the middle fossa. In
surgery, the position of the geniculate ganglion can be
confirmed by stimulation with the facial nerve stimulator.
The surgeon needs to assume the approximate location of
the cochlea in relation to the geniculate ganglion and the
petrous carotid artery (C6). The petrous ridge is identified
Maximum shave medially and the Fukushima middle fossa rigid tapered
inner plate
to make flat access retractor is positioned
to the middle fossa base

3~4mm EXC diamond


Fig 1C

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Part II: Standard Middle Fossa Approach

Superior
semicircular canal

Fig. 1D
The arcuate eminence overlying the superior semicircular
canal is identified (arcuate eminence). The bone of the
arcuate eminence is drilled until the “blue line” of the
EAC
superior semicircular canal is seen. Violating this canal will
usually lead to deafness. In the fixed specimen, the line is
not necessarily blue but green. Try to thin the denser cortical
bone that surrounds the membranous labyrinth using a smooth
diamond burr. Begin at the arcuate eminence, but the arcuate
Fig 1D Coronal CT
eminence is not always precisely overlies the canal.
Maximum shave inner
MF hemostasis must be done quick and complete using Root of zygoma plate to make flat

diamond drill heat, touch spring coagulation, bone wax, 3~4mm


MMA
bipolar and surgicel. EXC diamond
Mastoid
V3

Arcuate eminence

GSPN

MMA ICA

Cochlea

89 Surgical Manual
Part II: Standard Middle Fossa Approach

Geniculate
GSPN ganglion
MMA C6 IAC dura Step 2: IAC Drilling
Surface landmarks can be misleading. The surgeon must be
V3
oriented to approximate the location of the IAC before drilling
Clivus
commences. The orientation of the IAC is a direct medial
Arcuate eminence extension of the external ear canal (EAC). Identification of
Inferior
petrosalsinus
the GSPN provides a guide to the location of the geniculate
Trigeminal ganglion and arcuate eminence, which can be used to
fibrous ring
approximate the location of the IAC.
Cochlea 3~4mm
Superior
petrosalsinus coarse diamond Drilling starts anteriorly and medially near the porus trigeminus
Fig 2A
along the petrous ridge. To facilitate a wider angle to the
middle fossa for the microscope, we recommend a pair of 2
mm and 4 mm tapered tip rigid steel retractor blades with the
retractor tip wedged at the base between the petrous ridge
and the dura. In this way we can retract temporal basal dura
effectively to obtain maximum surgical exposure towards the
middle fossa. Gradual and gentle drilling is recommended
with constant irrigation.A power diamond drill bit is used
laterally towards the petrous carotid and posteriorly towards
the arcuate eminence to expose the IAC (Figure 2A-D).
Fig 2B

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Part II: Standard Middle Fossa Approach

Four techniques have been described for the identification


of the IAC in the middle fossa approach. The classic
technique described by William House, follows the greater
superficial petrosal nerve to the geniculate ganglion,
then to the labyrinthine segment of the facial nerve into
the fundus of the internal auditory canal. At this point, the
remainder of the internal auditory canal is skeletonized. The
technique popularized by Ugo Fisch is termed as the meatal
plane approach (Figure 2F). In this technique, the superior
semicircular canal is identified and “blue lined” (leaving a thin
lining of bone over the membranous labyrinth). At this point, a
60-degree angle from the amputated end of the superior canal
defines a safe zone for drilling the IAC. The third approach
popularized by Garcia-Ibanez, is a medial drilling technique
(Figure 2G). Once the arcuate eminence and geniculate
ganglion are identified, the surgeon begins drilling medially
on a line bisecting the angle between the arcuate eminence
and the GSPN. It is safest to find the IAC by drilling close to
the petrous ridge (Mario Sanna, Figure 2H). Near the porus,
the surgeon can skeletonize the IAC dura 270 degrees. As
the drill proceeds towards the fundus of the IAC only the roof

91 Surgical Manual
Part II: Standard Middle Fossa Approach

of the canal can be removed. Overly aggressive drilling


of the fundus of the IAC will disrupt the cochlea anteriorly
or the superior semicircular canal posteriorly. The latter
technique is advantageous because the initial drilling prior
to clear identification of the IAC is performed away from
the susceptible inner ear structures (cochlea and labyrinth).
While keeping in mind the location of the cochlea, final
drilling at the isthmus between the cochlea and arcuate
eminence is done reaching towards Bill’s Bar.

Fig 2D

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Part II: Standard Middle Fossa Approach

Fig 2E: William House Fig 2F: Ugo Fisch

Fig 2E: Mario Sanna

93 Surgical Manual
Part II: Standard Middle Fossa Approach

Step 3: IAC Dura incision and Tumor Removal


The dura should be maintained intact until the IAC exposure is
complete. Drilling after opening the IAC dura risks damage to
the IAC contents. After full skeletonization of the IAC

Fig. 3B
The dura will be incised in the inverted T fashion along the
petrous ridge and then along the IAC. With the dural incision,
care has to be taken to avoid the branches from the AICA
vessel

Fig 3A Fig. 3A
In acoustic tumor surgery, the dura is reflected anteriorly and
posteriorly to expose the intracanalicular acoustic tumor

Fig 3B

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Part II: Standard Middle Fossa Approach

Fig. 3C
After locating the thin facial nerve both anatomically by the
Cochlea Tumor
high magnification microscope and physiologically with 0.05
milliamps facial nerve monitor, we then start to dissect the
facial nerve from the tumor capsule using a sharp knife, sickle
knife and angled typed hooks. The surgeon always identifies
the meatal loop and eventually the labyrinthine artery. Almost
always the most important key, is the identification of the
remaining vestibular nerve which forms a pseudocapsule
tumor; and once the surgeon is able to identify this separation Fig 3C
plane, the tumor capsule will be easily elevated using various
super-micro CP angle instruments (See “CP Angle Instruments”).

Fig. 3D
Facial nerve
After piecemeal removal of the tumor’s center, the IAC tumor
can be elevated safely off from the thin facial nerve and then
farther ventral and in the deeper portion of the surgical site
from the cochlear nerve. The most important technical tip
is to maintain a bloodless, clean operative field with high
magnification to keep the microanatomy
Cochlear nerve
Meatal loop of AICA
Fig 3D

95 Surgical Manual
Part II: Standard Middle Fossa Approach

Basically, a standard middle fossa approach is performed.


Chordoma 49M
Additional exposure is created anteriorly. The petrous ridge
is followed more anteriorly to expose the porous trigeminus.
The dura propria is separated from the mandibular branch of
the trigeminal nerve. The rhomboid area between the internal
auditory canal and the ICAis drilled away, exposing the
ascending portion of the internal carotid, the entire course of
the sixth cranial nerve, and Dorello’s canal.

Step 1: Incision, scalp reflection and craniotomy


Place the cadaver head in the lateral position, and position
Trigeminal neurinoma 63M
yourself at the vertex. Make the skin incision in the shape of a
question mark concave anteriorly, as illustrated

Meningioma 52 M

Surgical Manual 96
Part II: Standard Middle Fossa Approach

Fig. 1A: Incision A or B


Incise the fascia overlying the root of the zygomatic process
and elevate it, using a periosteal dissector, from the lateral
and medial surfaces of this structure. The goal is to free the
temporalis muscle from the root of the zygomaticprocess, A

allowing the muscle to be pulled forward. This maneuver will B

help to provide an unobstructed view across the middle fossa A. Regular subtemporal incision
B. Posterior temporal incision
floor, without needing to perform a zygomatic osteotomy. Fig 1A
(Vascularized galeofascial pericranial flap)

Make a burr hole at superior to the Squamosal suture and drill


a groove in the bone above the root of the zygoma using 4
mm extracoarse (EXC) diamond drill. Using a craniotome cut
an approximately 5 cm x 5 cm rectangular bone flap, lying
one-third behind and two-thirds in front of the external auditory
canal

Fig. 1B
Step 2: Dural elevation and identification of “Rhomboid”
structure
Using a small periosteal dissector, separate the dura from the
bone along the inferior border of the craniotomy until the floor
Fig 1B

97 Surgical Manual
Part II: Standard Middle Fossa Approach

of the middle fossa is exposed. Using a cutting burr, or a rongeur, remove any remaining bone to the level
of the middle fossa floor. This will provide an unobstructed, flat view across the floor.
Elevate the dura along the petrous ridge. The petrous ridge is composed of 2 ridges (medial and lateral).
Identify the arcuate eminence as a primary landmark. After exposing the arcuate eminence, elevate the dura
moving anteromedially to uncover the greater superficial petrosal nerve (GSPN) and tegmen tympani. The
GSPN lies in the major petrosal groove and is covered by a layer of connective tissue. This connective tissue
is continuous with the periosteum, which makes identification of the nerve dependent upon removal of this
covering. Elevate the dura until the middle meningeal artery is identified exiting the foramen spinosum. Divide
the artery at its entrance into the cranial vault. Now expose the mandibular division of the trigeminal nerve
as it enters the foramen ovale.
Elevate the dura in the posterior direction towards the petrous ridge to expose the bone between the arcuate
eminence and the trigeminal impression. Place two self-retaining tapered retractors to hold the temporal dura
away from the middle fossa floor.
Sharply free the dura from the lateral trigeminal complex by developing the plane between the temporal dura
and the connective tissue sheath of the nerve. This maneuver will increase the width of the extradural corridor
through which the procedure is performed.
The middle fossa landmarks defining the ‘Rhomboid’ complex may now be identified

Surgical Manual 98
Part II: Standard Middle Fossa Approach

Fig. 2A & 2B
These points are:
1. Intersection of the GSPN with the trigeminal nerve;
2. Porus trigeminus;
3. Intersection of the arcuate eminence (AE) and petrous ridge;
and
4. Intersection of the lines projected along the axes of the
GSPN and AE.

This complex, projected obliquely towards the clivus


through the petrous pyramid, delimits the volume of bone Fig 2A
which will be removed.

Step 3: Extradural bone removal


The goal of this stage of the operation is to create a max-
imal window in the anteromedial petrous pyramid while
preserving the neural and vascular structures of the temporal
bone. This objective is best accomplished by proceeding

Fig 2B

99 Surgical Manual
Part II: Standard Middle Fossa Approach

with the extradural bone removal in a precise, step-wise fashion.


Begin by unroofing the medial two-thirds of the internal auditory canal (IAC). Bisect the angle between the
lines projected along the axes of the greater superficial petrosal nerve (GSPN) and the arcuate eminence.
Start drilling with a medium (3 or 4 mm coarse) diamond burr along the midpoint of this bisection axis.
The dura overlying the IAC will be identified once you have removed approximately 3 to 4 mm of bone.
Continue to expose the dura overlying the medial IAC towards the petrous ridge. The dura will flare at the
porus acousticus, which will signal the medial extent of the canal. Remove several millimeters of bone on the
anterior side of the IAC, in the direction of the trigeminal complex.

Next, the GSPN and geniculate ganglion are addressed. The GSPN exits its bony canal at the facial hiatus
to continue its medial course in the major petrosal groove. With the medium diamond burr, the GSPN is
gently uncoveredposteriorlytothefacialhiatus, moving toward the geniculate ganglion. Expose the geniculate
ganglion, using light strokes with the smooth diamond burr, preserving a thin shell of bone over the ganglion.
Uncover the entire IAC towards the geniculate ganglion. As you approach the fundus of the IAC, the opening
should be no more than the width of the canal. Remember that the facial nerve sweeps upward to join the
geniculate ganglion as it passes the cochlea. This moves the intracanalicular facial nerve more superficial as
the fundus of the IAC is exposed.

Two of the three key landmarks, which locate the cochlea, are now identified: the geniculate ganglion
and the porus acousticus. To identify the third important landmark used to avoid opening the cochlea (the
intrapetrous carotid artery genu), uncover the internal carotid artery in the posterolateral triangle close to

Surgical Manual 100


Part II: Standard Middle Fossa Approach

V3. Still using the medium diamond burr, expose the artery GSPN Malleus
by removing the bone between the GSPN and the foramen MMA
Incus

spinosum. Divide the GSPN near its intersection with the tri-
geminal complex and reflect it posteriorly. Expose the carotid Geniculate
ganglion
artery from where it crosses under the trigeminal nerve to the
lateral point where the tensor tympani muscle crosses over V3
Cochlea
V2
the artery. At the point where the tensor tympani muscle and V1 Arcuate

adjacent eustachian tube cross the artery lies the genu of the eminence

internal carotid artery. This completes the identifi cation of the


IAC
three defining landmarks of the premeatal triangle, where the Figure 3A

cochlear resides (Figure3A-D). Eustachian


GSPN
tube Tensor
C6
tympani
muscle

Cochlea

Posterior IAC
fossa dura Premeatal
triangle

Figure 3B

16

101 Surgical Manual


Part II: Standard Middle Fossa Approach

Tetsuro Sameshima

Remove the soft, porous bone between the IAC and the carotid artery, avoiding the posterior lateral volume of
bone housing the cochlea. The bone immediately surrounding the cochlea is identified by its compact, non-
porous nature. Expose the posterior fossa dura anterior and medial to the IAC by removing the wedge of bone
between the IAC and the superior semicircular canal (termed the ‘postmeatal triangle’) using a small or me-
dium diamond burr. It is often helpful to ‘blue-line’the superior semicircular canal, which usually lies under the
arcuate eminence, in order to precisely define the lateral border of the triangle. Removal of this volume of bone
will effectively unroof approximately 270 degrees of the circumference of the IAC at the meatus.

Root of
Remove the soft, porous bone between the IAC and the
zygoma TMJ capsule carotid artery, avoiding the posterior lateral volume of bone
MMA housing the cochlea. The bone immediately surrounding the
Geniculate
ganglion cochlea is identified by its compact, non- porous nature.
Tensor
tympani Arcuate
Expose the posterior fossa dura anterior and medial to the IAC
muscle eminence by removing the wedge of bone between the IAC and the
V3
IAC
superior semicircular canal (termed the ‘postmeatal triangle’)
GSPN

C6 Cochlea

Figure 3C

Facial nerve neurinoma 68F


PreOp MRI PostOp MRI

17

Surgical Manual 102


Part II: Standard Middle Fossa Approach

using a small or me- dium diamond burr. It is often helpful


to ‘blue-line’the superior semicircular canal, which usually MMA
Geniculate
lies under the arcuate eminence, in order to precisely define GSPN ganglion
TMJ
the lateral border of the triangle. Removal of this volume of
Arcuate
bone will effectively unroof approximately 270 degrees of the C7 eminence
(superior
circumference of the IAC at the meatus. V3
semicircular canal)
C6

Posterior
fossa dura Geniculate notch
Cochlea (Fukushima’s bar)
Bill’s bar
Figure 3D

Geniculate
MMA ganglion

C7 AE
V3
C6 IAC dura

Cochlea

Internal carotid artery (C6-C7) exposure

Figure 3E

103 Surgical Manual


Part II: Standard Middle Fossa Approach

Tetsuro Sameshima

Now the final stage of bone removal is performed. Expose the posterior fossa dura inferior to the IAC by
removing the bone between the IAC and the intrapetrous carotid artery. First work medially, then laterally. At
the lateral margin, the volume of bone containing the cochlea should be ‘undercut’ in order to maximize
Now the final stage of bone removal is performed. Expose
exposure of the posterior fossa dura. The cochlea, lying within the basal half of the ‘premeatal triangle’, is quite the posterior fossa dura inferior to the IAC by removing the
vulnerable to injury at this stage. Again, the change in the quality of the bone surrounding the cochlea must
be recognized. Also note that the facial nerve lies in the anterior aspect of the IAC so be especially bone between the IAC and the intrapetrous carotid artery.
careful removing bone from the posterior premeatal triangle. Expose the dura moving inferiorly to expose
the inferior petrosal sinus (IPS). Remove bone across this sinus until the cancellous bone of the clivus is First work medially, then laterally. At the lateral margin,
reached.
the volume of bone containing the cochlea should be
At the anterior end, remove the bone of the petrous apex by coring out the apical bone next to the foramen ‘undercut’ in order to maximize exposure of the posterior
lacerum. Staying within the cortical bone, thin the cortex until only a depressible shell remains. Dissect this shell
away from the dura using a small sharp dissector. When the apex has been removed, the foramen lacerum will fossa dura. The cochlea, lying within the basal half of
be opened posteriorly. Dissect the remaining tip of bone free with a microdissector and remove it with
microrongeurs. the ‘premeatal triangle’, is quite vulnerable to injury at
this stage. Again, the change in the quality of the bone
surrounding the cochlea must be recognized. Also note
that the facial nerve lies in the anterior aspect of the IAC
so be especially careful removing bone from the posterior
Superior
Vestibule
Lateral
premeatal triangle. Expose the dura moving inferiorly to
semicircular Cochlea semicircular expose the inferior petrosal sinus (IPS). Remove bone across
canal IAC canal

Figure 3E Figure 3F
Posterior
Post-rhomboid drilling and anterior petrosectomy (CT) semicircular
canal

Surgical Manual 104


19
Part II: Standard Middle Fossa Approach

this sinus until the cancellous bone of the clivus is reached. Geniculate
ganglion
At the anterior end, remove the bone of the petrous apex Arcuate
by coring out the apical bone next to the foramen lacerum. eminence

Staying within the cortical bone, thin the cortex until only a
Cochlea
depressible shell remains. Dissect this shell away from the C7

dura using a small sharp dissector. When the apex has been C6
V3 IAC dura
removed, the foramen lacerum will be opened posteriorly.
Dissect the remaining tip of bone free with a microdissector Inferior
petrosal
Superior
petrosal
and remove sinus (IPS) sinus (SPS)

it with microrongeurs. Internal carotid artery translocation & clivus exposure

Figure 3H

Pharyngo-basilar Clivus
membrane
C7
Facial nerve

C6 Arcuate
GG
V3 eminence
IPS

Superior
vestibular
Posterior
nerve
fossa dura

Facial nerve Figure 3I

105 Surgical Manual

20
Part II: Standard Middle Fossa Approach

Step 4: Dural opening


Opening the dura must be preceded by interruption of the superior petrosal sinus (SPS) at the porus trigeminus. Incise
the dura superior to the superior petrosal sinus from the porus trigeminus to the arcuate eminence. Make a second
incision, parallel to the first, inferior to the superior petrosal sinus in the posterior fossa dura. Ligate the sinus anteriorly
at the porus trigeminus. Make a sagittal incision in the medial tentorium, 8 to 10 mm in length. Place a stitch in the
lateral corner of the incised tentorium and retract this superiorly.

Open the dura surrounding the trigeminal root at the porus trigeminus. Now incise the posterior fossa dura, at the
medial and lateral margins of the exposure, towards the inferior petrosal sinus (IPS). Incise the dura along the margin
of the inferior petrosal sinus to completely excise this section of posterior fossa dura. Identify the basilar artery in the
depth of the exposure. The AICA origin should next be located and its course followed to the region of the porus
acusticus. The VIth cranial nerve will be seen crossing over the AICA as it ascends towards Dorello’s canal (tube).
Dorello’s tube is located inside the inferior petrosal sinus far anteriorly. Note the differences in exposure by rotating
the microscope through various angles from medial to lateral (Figure 4A-E).

The extended middle fossa approach provides surgical access for posterior fossa lesions that involve the CPA and
extend anteriorly into the cavernous sinus and inferiorly along the pre-pontine region of the clivus. Simultaneous
access is possible for transtentorial tumor extensions and hearing preservation. The major limitation of this technique
is the amount of temporal lobe retraction necessary which can be much more extensive than that required for a
standard middle fossa approach.

Surgical Manual 106


Part II: Standard Middle Fossa Approach

GSPN

Clivus Inferior
petrosal sinus (IPS)
VA
Meckel’s cave

PICA
Posterior C6
cavernous sinus Arcuate
eminence

IV Superior
vestibular
nerve
Trigeminal neurinoma17/M
PreOp MRI PCA SCA AICA VII Superior
VI
petrosal
Figure 4A sinus (SPS)

VI Dorello’s
canal (tube)

VI
C6 V
C5
Gruber’s
ligaments

Posterior
cavernous sinus
SCA
IV
Basilar
PostOp MRI artery Figure 4B

22
107 Surgical Manual
Part II: Standard Middle Fossa Approach

Tetsuro Sameshima

AICA
Meckel’s cave Arcuate
eminence

Posterior
cavernous sinus
Pons
V
III IV

Basilar SCA
artery
Figure 4C
PCA
Inferior Meningioma42F
petrosal
V3 PreOp MRI PostOp MRI
Clivus sinus Meningioma42F
PreOp MRI PostOp MRI
Pons VI
V

Clivus
Figure 4D

Inferior
Venous petrosal sinus
confluence

Trigeminal
anterior VI
translocation
V

Dorello’s Basilar trunk aneurysm 54/F


Gruber’s ligaments Figure 4E
canal (tube) PreOp
Basilar trunkMRI
aneurysm 54/F PostOp MRI
PreOp MRI PostOp MRI
23

Surgical Manual 108

24
109 Surgical Manual
Surgical Manual 110
Skull Base Surgery
Transpetrosal approach

Transpetrosal approach

Yoshinobu SEO, M.D.


Board Chair, Chief of Skull Base Surgery, WFNS
Skull Base Surgery
Committee Member: Nakamura Memorial
Hospital, South-1 West-14
Chuoku Sapporo, 060-8570Japan
Phone#: +81-11-231-8555,
Yoshinonbu Seo Fax#: +81-11-231-8387,
E-mail: yoshinobu_seo@yahoo.co.jp

Sapporo, Japan

111 Surgical Manual


Transpetrosal Apporach

ᵡᶐᶍᶑᶑᴾᶎᶐᶍᶒᶃᶁᶒᶇᶍᶌ ᶒᶃᶁᶆᶌᶇᶏᶓᶃ

• ᵲᶆᶐᶃᶃᴾᶄᶇᶌᶅᶃᶐᶑᴾᶆᶍᶊᶂᶇᶌᶅ
• ᵡᶐᶍᶑᶑᴾᶎᶐᶍᶒᶃᶁᶒᶇᶍᶌ
• ᵡᶊᶍᶁᶉᶕᶇᶑᶃᴾᶐᶍᶒᵿᶒᶇᶍᶌ
• ᵣᶅᶅᵋᶑᶆᶃᶊᶊᶇᶌᶅᴾᴾᶒᶃᶁᶆᶌᶇᶏᶓᶃ
• ᵡᶓᶒᶒᶇᶌᶅᴾᶀᶓᶐᶐ→ ᶃᶖᶒᶐᵿᴾᶁᶍᵿᶐᶑᶃ→ ᶁᶍᵿᶐᶑᶃ→
ᶑᶋᶍᶍᶒᶆᴾᶂᶇᵿᶋᶍᶌᶂ
• ᵳᶑᶃᴾᶊᵿᶐᶅᶃᶐᴾᶀᶓᶐᶐᶑ ᶂᶐᶇᶊᶊ
• ᵧᶌᶂᶐᵿᶄᶒᴾᶄᶐᶍᶋᴾᶑᶓᶐᶐᶍᶓᶌᶂᶇᶌᶅᶑ
→ᶓᶑᶃᴾᵥᶃᶊᶄᶍᶐᶋᵊᴾᶀᶍᶌᶃᴾᶕᵿᶖ
ᶑᶓᶁᶒᶇᶍᶌ You should move the drill as the red arrow
indicates, or drill will kick.

Selection of approach
Frontotemporal
orbitozygomatic approach
 㻳㼑㼘㼒㼛㼞㼙
Translabyrinthine
 㻿㼡㼞㼓㼕㼏㼑㼘 transcochlear transapical
approach
 㻮㼛㼚㼑㻌㼣㼍㼤㻌㼜㼘㼍㼠㼑

 㻭㼘㼡㼙㼕㼚㼡㼙㻌㼜㼘㼍㼠㼑
Posterior petrosal approach
 㻰㼛㻌㼚㼛㼠㻌㼡㼟㼑㻌㼞㼡㼎㼎㼑㼞㻌㼟㼔㼑㼑㼠 (retrolabyrinthine)

Anterior petrosal approach

Sanna, modified

Surgical Manual 112


Anterior Transpetrosal Apporach

ᵱᶉᶇᶌᴾᵧᶌᶁᶇᶑᶇᶍᶌ

㻾㼛㼛㼠㻌㼛㼒
㼆㼥㼓㼛㼙㼍

㻵㼚㼏㼕㼟㼕㼛㼚
㼘㼕㼚㼑

Red line skin incision for harvesting large vascularized flap

ᵱᶁᵿᶊᶎᴾᵣᶊᶃᶔᵿᶒᶇᶍᶌ ᵫᶇᶂᶂᶊᶃᴾᵤᶍᶑᶑᵿᴾᵣᶖᶎᶍᶑᶓᶐᶃ

ᵰᶍᶍᶒᴾᶍᶄ
ᵸᶗᶅᶍᶋᵿ
㻾㼛㼛㼠㻌㼛㼒
㼆㼥㼓㼛㼙㼍
ᵫᵫᵟ

ᵱᶓᶎᶃᶐᶇᶍᶐ ᵴᵑ
㻿㼝㼡㼍㼙㼛㼟㼍㼘㻌 ᶎᶃᶒᶐᶍᶑᵿᶊᴾ ᵴᵐ
㼟㼡㼠㼡㼞㼑 ᶑᶇᶌᶓ㼟

ᵮᶃᶒᶐᶍᶓᶑ ᵟᶐᶁᶓᵿᶒᶃᴾᵣᶋᶇᶌᶃᶌᶁᶃ ᵥᵮᵬ


ᵰᶇᶂᶅᶃ

113 Surgical Manual


Anterior Transpetrosal Apporach

ᵡᶐᵿᶌᶇᶍᶒᶍᶋᶗ
ᵫᶇᶂᶂᶊᶃᴾᵤᶍᶑᶑᵿᴾᵰᶆᶍᶋᶀᶍᶇᶂᴾᵣᶖᶎᶍᶑᶓᶐᶃ
D 7KHLQWHUVHFWLRQRI
WKHWULJHPLQDOWKLUG
EUDQFKZLWKWKH
*631
E
E *HQLFXODWHJDQJOLRQ
D
F $UFXDWHHPLQHQFH
SHWURXVULGJH
F
G 3RUXVWULJHPLQXV

G
&RFKOHD

㻮㼡㼞㼞㻌㼔㼛㼘㼑 㻿㼡㼎㼠㼑㼙㼜㼛㼞㼍㼘㻌㼓㼞㼛㼛㼢㼑㻌㼐㼞㼕㼘㼘㼕㼚㼓

Operative view is
from superior-lateral direction To identify the cochlea

GSPN
GG
ICA

SSC

axial image coronal image IAC

Calculating the distance Calculating the distance


between the posterior between the petrous bone
extended line of the IC surface and cochlea is
and cochlea is useful. useful.

Surgical Manual 114


Anterior Transpetrosal Apporach

ᵫᶇᶂᶂᶊᶃᴾᵤᶍᶑᶑᵿᴾᵰᶆᶍᶋᶀᶍᶇᶂᴾᶂᶐᶇᶊᶊᶇᶌᶅ

㻳㼑㼚㼕㼏㼡㼘㼍㼠㼑㻌
㻳㻼㻺
㼓㼍㼚㼓㼘㼕㼛㼚
㻔㻳㻳㻕
㻵㻯㻭㻌㻔㻯㻢㻕
㻯㼛㼏㼔㼘㼑㼍
㻔㼎㼘㼡㼑㻌㼘㼕㼚㼑㻕

㻵㻭㻯

115 Surgical Manual


Anterior Transpetrosal Apporach

The Various Methods of IAC Drilling

William House Ugo Fisch

AE is not important. AE is very important.


Risk of opening SSC!

Garcia-Ibanez Mario Sanna

AE is important. AE is important.

AE: arcuate eminence Mario Sanna et al., Atlas of Acoustic Neurinoma Microsurgery, 1998

Surgical Manual 116


Posterior Transpetrosal Apporach

Posterior transpetrosal approach has very


narrow corridor to posterior fossa

Day Day

Indication: tumor located at posterior to the semicircular canals, superior to jugular


foramen, posterior to the chiasm such as craniopharyngioma, V3-P2 bypass

117 Surgical Manual


Posterior Transpetrosal Apporach

Posterior transpetrosal approach alone

Surgical Manual 118


Posterior Transpetrosal Apporach

Posterior petrosal approach alone

119 Surgical Manual


Posterior Transpetrosal Apporach

Bone CT is useful

• Air cells
• Sigmoid sinus
• High jugular bulb

Surgical Manual 120


Posterior Transpetrosal Apporach

Combination with High jugular bulb


Posterior transpetrosal approach
• Transcrusal approach (partial labyrinthectomy)
• Translabyrinthine, Transcochlear, Transapical app.
• Transjugular, Infrajugular, High cervical approach
• Anterior transpetrosal approach
• Subtemporal approach
• Orbitozygomatic approach
• Etc.
Mastoidectomy is fundamental!
Sanna

Skin incision Combined transpetrosal approach:

Fukushima Preserving the parietal branch of STA

121 Surgical Manual


Posterior Transpetrosal Apporach

After skin flap elevation, Lt side


Surface Landmarks
Fascia of
sternocleidomastoid Fascia of temporal
muscle muscle

Vascularized flap
Parietomastoid suture

Posterior Temporal
fossa muscle
muscles

After vascularized flap elevation, Lt side Fukushima

Parietomastoid suture (Asterion)


vs. TS-SS

Fukushima

Surgical Manual 122


Posterior Transpetrosal Apporach

Mastoidectomy

Fukushima

!Mastoid antrum and Sigmoid sinus is good landmark


!L-shaped craniotomy first is faster
Fukushima

Jackler

Around emissary veins should be well


skeletonized .

• facial nerve is as deep as LSC


• Incus indicates facial nerve
• LSC is at 30°angle with temporal tegmen
• posterior crus of SSC is deeper than anterior crus
• white tissue at digastric ridge is round about facial nerve
• tiny bone at jugular spine can be left behind to prevent bleeding Fukushima

123 Surgical Manual


Posterior Transpetrosal Apporach

Fat grafting

Jackler

Sanna

Jackler Jackler

Surgical Manual 124


Posterior Transpetrosal Apporach

Closure with vascularized flap and


abdominal fat

Lumbar drainage for 3 days after operation

125 Surgical Manual


Posterior Transpetrosal Apporach

Too much fat! Occlusion of sigmoid sinus

Surgical Manual 126


Posterior Transpetrosal Apporach

ᵓᵒᵤᵊᴾᵪᶒᴾᶆᶃᵿᶐᶇᶌᶅᴾᶂᶇᶑᶒᶓᶐᶀᵿᶌᶁᶃᴾᵆᵥᵋᵰᴾᶁᶊᵿᶑᶑᴾᵏᵇᴾ

127 Surgical Manual


Posterior Transpetrosal Apporach

No petrosal vein is visible at the affected side.

ᵳᶌᵿᶄᶄᶃᶁᶒᶃᶂᴾᶑᶇᶂᶃᴾ
ᵮᶃᶒᶐᶍᶑᵿᶊᴾᶔᶃᶇᶌ

Surgical Manual 128


Posterior Transpetrosal Apporach

.elbiscan
You ivnicut
si nthe
iev SPS
lasorat
tepitsehposterior
t fi noitroportion
p roiretsifothe
p stpetrosal
i ta SPS vein
eht tu
iscinvisible.
nac uoY

㼚㼛㼕㼠㼏㼑㼟㼟㼕㻰㻌㼑㼟㼍㻮㻌㼘㼘㼡㼗㻿㻌㼒㼛㻌㼘㼍㼡㼚㼍㻹㻌㻘㻦㼍㼙㼕㼔㻲㼡㼗㼡㼟㼔㼕㼙㼍㻦㻘㻌㻹㼍㼚㼡㼍㼘㻌㼛㼒㻌㻿㼗㼡㼘㼘㻌㻮㼍㼟㼑㻌㻰㼕㼟㼟㼑㼏㼠㼕㼛㼚
㼟㼡㼗㼡㻲

129 Surgical Manual


Posterior Transpetrosal Apporach

ᶎᶍᶑᶒᶍᶎᵊᵌᴾᵓᵌᵓᶗᶐ

㻲㼕㼎㼞㼛㼡㼟㻌㼙㼑㼚㼕㼚㼓㼕㼛㼙㼍㻘㻌㻹㻵㻮㻙㻝㻦㻞㻙㻟㻑

Surgical Manual 130


Posterior Transpetrosal Apporach

131 Surgical Manual


Posterior Transpetrosal Apporach

㼀㻞㼃㻵

㻮㻭

㻳㼐㻙㻯㻵㻿㻿

Surgical Manual 132


Posterior Transpetrosal Apporach

㼀㻞㼃㻵

㻮㻭

㻳㼐㻙㻯㻵㻿㻿

133 Surgical Manual


Posterior Transpetrosal Apporach

Incision of dura and tentorium


with patency of the petrosal vein

FS
FO
GPN V3
Co
SS C6
SSC
Temporal lobe
SPS IV

Extended line of the V3 is good landmark for tentorial incision.

Surgical Manual 134


Translabyrinthin Approach

Labyrinthectomy

• vestibule is found at deep side of ampulla of LSC


• inferior wall of LSC should be left behind to protect facial nerve
• posterior part of vestibule is deep side of common crus
Fukushima Fukushima

DR: digastric ridge, LSC: lateral semicircular canal,


PSC: posterior semicircular canal,
MCF: middle cranial fossa, SS: sigmoid sinus

Fukushima Sanna

135 Surgical Manual


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FN(m): mastoid segment of the VII


FN(g): second genu of the VII
FN: facial nerve
SSC: superior semicircular canal V: vestibule
LB: jugular bulb *: superior canal ampulla
<: thin bony wall protecting FN

Sanna
Sanna

SA: superior ampullary nerve


HC: horizontal crest
IAC: internal auditory canal

Sanna MFD: Middle fossa dura


Sanna

Surgical Manual 136


Translabyrinthin Approach

Sanna

SAC: superior ampullary canal, HC: horizontal crest, IVN: inferior vestibular nerve

Sanna

DR: digastric ridge, LSC: lateral semicircular canal,


PSC: posterior semicircular canal,
MCF: middle cranial fossa, SS: sigmoid sinus

Sanna
Sanna

137 Surgical Manual


Translabyrinthin Approach

SCA: superior canal ampulla, LCA: lateral canal ampulla,


SCA: superior canal ampulla, LCA: lateral
FNG: canal
facial ampulla,
nerve genu, SVN: superior vestibular nerve Sanna
FNG: facial nerve genu, SVN: superior vestibular nerve Sanna Sanna

HC: horizontal canal, IV: inferior vestibular nerve, V: vestibule, HC: horizontal canal, BB: Bill’s bar
CN: cochlear nerve, SV: superior vestibular nerve, CN: cochlear nerve, FN: facial nerve
FN: facial nerve, D: dura of canal >: beginning of labyrinthine segment of VII

Sanna Sanna

Surgical Manual 138


Translabyrinthin Approach

139 Surgical Manual


 㻰㼡㼞㼍㼘㻌㼕㼚㼏㼕㼟㼕㼛㼚㻌㼣㼕㼠㼔㻌㼜㼞㼑㼟㼑㼞㼢㼍㼠㼕㼛㼚㻌㼛㼒㻌㼢㼑㼚㼛㼡㼟㻌
㼟㼥㼟㼠㼑㼙
 㻼㼞㼑㼢㼑㼚㼠㼕㼛㼚㻌㼛㼒㻌㻯㻿㻲㻌㼘㼑㼍㼗㻌㼡㼟㼕㼚㼓㻌㼢㼍㼟㼏㼡㼘㼍㼞㼕㼦㼑㼐㻌
㼒㼘㼍㼜
 㻼㼞㼑㼟㼑㼞㼢㼍㼠㼕㼛㼚㻌㼛㼒㻌㼜㼕㼍㻌㼙㼍㼠㼑㼞㻌㼍㼚㼐㻌㼍㼞㼍㼏㼔㼚㼛㼕㼐㻌
㼙㼑㼙㼎㼞㼍㼚㼑
 㻼㼞㼑㼟㼑㼞㼢㼍㼠㼕㼛㼚㻌㼛㼒㻌㼢㼑㼕㼚㼟㻌㼍㼚㼐㻌㼍㼞㼠㼑㼞㼕㼑㼟㻌㼠㼔㼑㻌㼠㼡㼙㼛㼞

 㻰㼛㻌㼚㼛㼠㻌㼜㼡㼘㼘㻌㼍㼚㼐㻌㼠㼛㼡㼏㼔㻌㼠㼔㼑㻌㼏㼞㼍㼚㼕㼍㼘㻌㼚㼑㼞㼢㼑㼟

Surgical Manual 140


141 Surgical Manual
Surgical Manual 142
Dolenc's Skull Base Approach
Cadaveric Study

1. Dolenc’s technique
It is a combined epidural and subdural approach (Dolenc’s procedures) that
was pioneered by Dolenc and Hakuba, which allows opening of the lateral
wall of the cavernous sinus to treat various pathologies such as tumors and Kentaro Mori, MD. PhD.
Professor and chairman, Department of
aneurysms in the cavernous, para-cavernous, and central skull base regions Neurosurgery, National Defense Medical College
(2,3).The extradural temporopolar approach is mainly based on Dolenc’s 3-2 Namiki, Tokorozawa, Saitama 359-8513, Japan
Tel: +81-4-2995-1511
technique but is more focused on retraction of the temporal lobe along
E-mail: kmori@ndmc.ac.jp
with the dura mater (1). This modified Dolenc’s technique allows extradural
retraction of the temporal lobe which reduces the necessity of sacrificing
temporal tip bridging veins and provides a wide surgical corridor to the retro-
carotid space and interpeduncular cistern through the opened anterior part of
the cavernous sinus.

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Fig. 1
Fig.1. Operative approach and view of the modified Dolenc’s
approach (three-dimensional skull base model).
A: Black arrow showing the operative corridor from the space
made by temporal lobe retraction extradurally.
B: Operative field of the retro-carotid space and interpeduncular
cistern through the opened cavernous sinus.
II: optic nerve, III: oculomotor nerve, IV: trochlear nerve, V1:
first branch of the trigeminal nerve, V2: second branch of the
trigeminal nerve, IC: internal carotid artery, BA: basilar artery

This chapter describes the surgical techniques for the Dolenc’s


technique. In particular, how to cut the meningo-orbital band
(MOB), how to peel off the dura propria from the lateral
wall of the cavernous sinus, and how to remove the anterior
clinoid process (ACP) epidurally. These are the essential
maneuvers of the approach which have been shown in a
cadaver for better understanding of the operative technique.

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Dolenc’s technique

2. Surgical techniques and tips


Left side of cadaveric head was dissected. The cadaver head was perfused with colored silicon and was fixed
in Mayfield’s tri-pin and turned to the right side by 30 degrees.

i. Extradural procedures
Semi-coronal skin incision and inter-fascial dissection of the temporalis fascia are then performed. The temporal
muscle is detached from the superior temporal line but not incised. The temporal muscle is subperiosteally
dissected and retracted posterioinferiorly using fish hooks. Standard frontotemporal craniotomy is performed with
the anterior border at the mid-point of the orbit, and the temporal squama is rongeured out until the floor of the
middle cranial fossa is exposed.

Fig. 2A
The frontal and the temporal dura are subperiosteally dissected until flush with the frontal and middle fossae. The
lesser wing of the sphenoid and the orbital apex are drilled off until the MOB is exposed (Fig.2B).

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Fig. 2
Dolenc’s procedures (cadaveric study)
A: Frontotemporal craniotomy.
B: Meningo-orbital band (arrow head) exposure after the sphenoid
wing drilling. Dissection of the middle fossa dura is continued
until the orifices of the SOF and foramen rotundum (FR) are
exposed.

Fig. 3A
The roof of the SOF (major wing of the sphenoid bone)
is opened a width of 2 mm so as to expose the junction
between the dura propria of the temporal lobe and inner
membrane of the SOF to the cavernous sinus which separates
the neurovascular structures and the venous plexus inside

Fig. 3B arrow heads. Skeletonization of the FR is not required


because this junction is mostly exposed. The MOB is pulled
proximally using a forceps or a stitch and cut with micro-
scissors for about 4 mm. The tip of the microscissors should be
pointed toward the exposed junction at the SOF.

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Fig. 3B
Peeling off the dura propria from the inner membrane can
be started anywhere, with the easiest point between the
SOF and FR, using a micro-dissector with a sharp edge. If
the dura propria and inner membrane are tightly attached,
sharp dissection using micro-scissors is recommended. The
peeling is continued until the entire ACP is exposed epidurally.
The trochlear nerve, and first and second branches of the
trigeminal nerve can be seen through the semi-transparent
inner membrane.

Fig. 3C Fig.3 Dolenc’s procedures (extradural part)


A: Superior orbital fissure (SOF) and foramen rotundum (FR)
exposure.
B: Drilling of roof of SOF and cutting of meningo-orbital band
(MOB). Arrow heads indicate the junction between the dura
propria of the temporal lobe and the inner membrane over the
SOF.
C: After peeling off of the dura propria from the lateral wall of
the cavernous sinus until the whole epidural exposure of the
anterior clinoid process (ACP).

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Care should be taken to keep the sphenoparietal sinus in the dura propria side and stop peeling off at the point
where the sphenoparietal sinus drains into the cavernous sinus so as to prevent problems with venous congestion.
Before drilling ACP, the ACP should be carefully dissected off from the surrounding tissue because the oculomotor
nerve usually passes along the inferolateral part of the ACP. Drilling of the ACP has to be started from the lateral
part of it using a high speed drill with continuous saline irrigation. Optic canal is then opened partially in the
medial part of the ACP.

Fig. 4A
The constant saline irrigation is extremely important to avoid heat injury to the neurovascular structures. The ACP is
hollowed like an egg shell, and the remaining ACP can be removed en bloc. The anterior loop of the ICA (C3:
clinoid segment) in the opened clinoid space (Dolenc’s triangle) can be seen through the thin carotico-oculomotor
membrane.

Fig. 4B
The partially opened optic canal can be enlarged using a micro-punch and the remainder of the optic strut
between the opened clinoid space and optic canal can be removed with either a small diamond drill or using
micro-punch. At this point, the temporal lobe with the temporal dura mater can be moved posteriorly by 25 to
30 mm from the tip of the middle cranial fossa.

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Dolenc’s technique

Fig.4 Dolenc’s procedures (extradural part), continued


A: Anterior clinoid process drilling.
B: After the opening of the clinoid space and optic canal.
Arrow indicating the C3 portion of the ICA in the Dolenc’s
triangle
C: Optic nerve

(ii) Intradural procedures


The dura is cut along the sylvian fissure as far as the optic
nerve. Falciform ligament is cut, and then the dural incision
is continued to the inferior frontal dura in a L-shaped
fashion over the distal dural ring (Fig. 5A). Before tentorial
incision, the sylvian fissure should be opened widely and
the arachnoid membrane around the oculomotor nerve
should be incised to free the nerve from the medial temporal
lobe. Looking at the cisternal and extradural parts of the
oculomotor nerve, the medial tentorial edge is shaved off
from the anterior petroclinoid ligament for separation from
the cavernous sinus around the oculomotor nerve (Fig.5B).
Following these procedures, the temporal lobe can be
retracted posteriorly with the temporal dura mater to complete

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the extradural temporopolar approach with the surgical


corridor of the opened anterior part of the middle fossa
and the cavernous sinus (Fig. 5C). Then, the approach to
the retrocarotid space (Fig.5C, arrow head) through the
opened cavernous sinus is possible. Incision of falciform
ligament and distal dural ring facilitate movement of the
optic nerve and ICA (Fig.6A). Opening of the oculomotor
foramen facilitates mobilization of the oculomotor nerve.
If the target pathology is located beneath the posterior
clinoid process, the latter can be drilled off to expose the
pontine cistern (Fig.6B). Finally, the BA is exposed in the
interpeduncular cistern (Fig.6C).

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Dolenc’s technique

Fig. 5 Dolenc’s procedures (intradural part)

A: After opening the dura along the sylvian fissure.


Extradural (C3) and intradural part of ICA is observed across
the distal dural ring (DR).
B: Shaving off the medial tentorial edge.
C: After temporal lobe retraction with the temporal dura (TD).
Arrow head indicating retro-carotid space via the opened
cavernous sinus

Fig. 6 Dolenc’s procedures (intradural part), continued


A: Cutting of the distal dural ring.
B: Exposing interpeduncular cistern through the retro-carotid
space.
PCP: posterior clinoid process, L- PCA: left posterior cerebral
artery
C: After posterior clinoidectomy. BA is exposed.

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References
1. Day JD, Giannotta SL, Fukushima T: Extradural temporopolar approach to lesions ofthe upper basilar artery and
infrachiasmatic region. J Neurosurg 81:230-235, 1994
2. Dolenc V: Direct microsurgical repair of intracavernous vascular lesions. J Neurosurg 58:824-831, 1983
3. Hakuba A, Tanaka K, Suzuki T, Nishimura S: A combined orbitozygomaticinfratemporal epidural and subdural
approach for the lesions involving the entire cavernous sinus. J Neurosurg 71:699-704, 1989

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153 Surgical Manual
Surgical Manual 154
Pituitary
Endoscopic Endonasal Transsphenoidal Surgery

The transsphenoidal approach is a well-established procedure for the


surgical removal of intrasellar lesions, such as pituitary adenoma, Rathke
cleft cyst and craniopharyngioma. Lesions located in the suprasellar
region, above the diaphragm sellae without involvement of the sella
turcica, have been traditionally treated with various transcranial
approaches. In 1987, Weiss first reported the surgical management of
a purely suprasellar lesion using a modified transsphenoidal approach
that required additional bone removal from the anterior cranial base.
On the basis of this experience, others began to expand the standard
approach and apply it to the pituitary fossa, tuberculum sellae, and
posterior portion of the sphenoidal planum.
Recent advancement of endoscope techniques and instruments enables
us to modify the transsphenoidal approach to extend the access to the Yasuhiko Hayashi, M.D., Ph.D.
Department of Neurosurgery
suprasellar region directly. The endoscope yields a wider visualization of Kanazawa University, Kanazawa, Japan
the anatomic landmarks on the posterior wall of the sphenoid sinus. The
feasibility of a purely endoscopic extended transsphenoidal approach
to remove suprasellar lesions has been reported previously, and recently
the review of this approach is increasingly described. The most relevant
benefit is that this median approach permits the exposure of suprasellar
lesions without the need of brain retraction.

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Recent progress in diagnostic imaging techniques and intraoperative neuronavigation systems combined with
the introduction of the endoscope for surgical visualization via an endonasal route have accelerated the rapid
development of this technique. The detailed knowledge of the topological view of the suprasellar neurovascular
structures influences surgical technique during the extended endonasal transsphenoidal approach.

1. Advantages of Endoscopic Endonasal Transsphenoidal Surgery


# The close-up and multiangled views provided by the endoscope allow the neurosurgeon to maintain constant
view on neurovascular structures during dissection, despite the depth of the surgical field.
# The endoscope we used is a rigid endoscope (Karl Storz, Tuttlengen, Germany) that is 4 mm in diameter and
18 cm in length, with 0-, 30- and 45-degree lenses.The holder to the operative table is Unitrac (B-Braun).
# The endoscope is connected to a light source via a fiber-optic cable and to a camera fitted with three charge-
couple device (CCD) sensors. The video camera that connected to a 21-inch monitor supports the high resolution
three-CCD technology. The intraoperative images are recorded with a digital video recorder system to obtain a
suitable anatomic images.

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Basic advantages of the endoscope are as follows;


a. Wide vision of the surgical field
b. Less traumatism of the nasal structure
c. Application for the supra-sellar and the para-sellar lesions

Disadvantages are;
a. Necessity of acquiring specific endoscopic skills
b. Necessity of endoscopic equipment and appropriate surgical instrumentation
c. Limited range of handling
d. Images displayed are 2 dimensional, not 3D

2. Pre-operative neuroradiological evaluation


a. Computed tomography scan to visualize bony images
i. Deviation of the nasal septum
ii. Width of the nasal meatus
iii. Septation in the sphenoid sinus
iv. Pneumatization of the sphenoid sinus (sellar, pre-sellar, conchal)
v. Location of the sphenoid sinus ostinum
vi. Sellar floor thickness, destruction

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Angiography
i. Relationship between tumor and ICA; location of carotid
prominence and optico-carotid recessus; running course of
the cavernous portion of the ICA; distance between ICA
adjacent to pituitary tumor
ii. Sphenopalatine artery (a branch of the maxillary artery);
running in the pterygopalatine fossa and through the
sphenopalatine foramen
iii.
Anterior communicating artery, posterior communicating
artery; collateral circulation in the case of ICA occlusion after
injury
b. Magnetic Resonance Imaging
Sequences: T1, T2, FLAIR, Diffusion, FIESTA (or CISS), T2*,
MRA
i. Characters of adenoma (soft or hard, intra-tumoral hemorrhage)
ii. Degree of the suprasellar extension (compression of optic
chiasma)
iii. Invasion into the cavernous sinus
iv. Location of the normal pituitary gland
v. Preservation of hyperintensity in the posterior lobe
vi. Existence of sphenoidits (thickening of sphenoid sinus mucosa)

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c. Endocrinological evaluation
free tri-iodothyronin (T3), free thyroxin (T4), thyroid stimulating hormone (TSH) luteinizing hormone (LH), follicle-
stimulating hormone (FSH), prolactin GH, IGF-1, ACTH, cortisol serum osmolarity
* if necessary, triple loading test (CRH, TRH, LH-RH) should be performed. Urine osmolarity, urine specific
gravity,urine volume per day to be done.

d. Preoperative evaluation

Opthalmological evaluation (visual acuity and field, eyeball movement)
Otolaryngological evaluation (sinusitis, nasal septum, olfactory function)

Anatomical Check Points on the Endonasal Transsphenoidal Approach


1. Anterior nasal cavity
(Landmarks) inferior and middle turbinate, nasal septum
a. Confirmation of inferior turbinate, middle turbinate, nasal septum
b. Lateralization of the middle turbinate to enlarge the corridor of the approach; If the nasal cavity is narrow so
as not to allow endoscope and other instruments to introduce through one nostril, a middle turbinectomy is
performed. Removal of the middle turbinate provides easier access to the posterior nasal cavity, where the
choana, sphenoethmoid recess, and the sphenoid ostium are located.

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2. Posterior nasal cavity (Landmarks) superior and/or supreme


turbinate, sphenoid ostium

a. Confirmation of sphenoid ostium (white arrows)


b. Removal of posterior portion of the nasal septum: Nasal septum
is elevated from the sphenoid ostium, and its posterior portion
is removed for approximately 2cm; It is important to avoid
removal of too long nasal septum in the anterior direction, to
avoid injury to the olfactory epithelium, in which the olfactory
nerves (yellow arrow) termination distributes or the cribriform
plate of the ethmoidal sinus.

3. Anterior wall of the sphenoid sinus


(Landmarks) sphenoid ostium, anterior wall, septum

0 1 2 3 a. Enlargement of the sphenoid ostium: The sphenoid ostium


should be enlarged to make a large access to the sphenoid
sinus and to the sella floor. Anterior wall around the sphenoid
ostium is required to remove with Kerrison punch as much as
possible.

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b. Confirmation of septum in the sphenoid sinus:


Septum in the sphenoid sinus could be found through the
enlarged sphenoid ostium. Vomer bone at the posterior
portion of the nasal septum is also need to be removed,
resulting in communication on both sides of the nasal cavity.
These septums in the sphenoid sinus is useful landmarks to
obtain the anatomical orientation, such as sella floor and its
surroundings.

c. Arterial injury in the nasal cavity


i. Sphenopalatine artery: a branch of the maxillar artery; it
passes through the pterygoid fossa and sphenopalatine
foramen. Injury to this artery may lead to massive bleeding
during and after the transsphenoidal surgery.
ii. Posterior ethmoidal artey: a branch of ophthalmic artery,
passes through a thin, bony channel along the ethmoidal
roof. The risk of injury of this artery is increased during the
extended transsphenoidal approach.
d. Wide sphenoidectomy: In order to make a large open
access to the sellar floor, tuberculum sellae, and the planum
sphenoidale, removal of the anterior wall of the sphenoid

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sinus is necessary. After a wide sphenoidectomy, all of the


septation within the sphenoid sinus are removed upto their
attachment on the posterior and superior wall of the sphenoid
sinus. This yields a panoramic view of the planum sphenoidale
and the tuberculum sellae

4. Sellar floor
(landmarks) sellar floor, septum, carotid prominence,
opticocarotid recess, optic prominence, clivus

a. septum attachment to the sellar floor: septum is a good marker


of the orientation in the sphenoid sinus. Usually, 0-3 pieces
of septum exist which are attached to the sellar floor and its
surroundings.
b. sellar floor and its surroundings: opticocarotid recess is divided
into two types, medial and lateral. The medial opticocarotid
recess (arrow) corresponds intracranially to the medial clinoid
process, and identified using the lateral opticocarotid recess
and the bony prominences of the carotid artery and the
optic nerve as landmarks. Bone removal at the level of the
medial opticocarotid recess on the both sides is important for

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Extended Application for Craniopharyngioma

obtaining wider views of the supraclinoid portion of the ICA


and the optic nerve.
Carotid prominence located just above the cavernous portion
of the ICA is a useful landmark to make a decision of lateral
margin in the bone window and dural incision in the sellar
floor for removing the tumor in the sella.
After removal of the sellar floor, dural incision is performed.
However, this method is different for each surgeon. For the
maximam exposure of the tumor in the sellar, H shape incision
is recommended. If CSF leakage occurrs during the removal of
the tumor, dural suture could be performed.

5. Removal of the tumor in the sella


(Landmark) adenoma, dura, pituitary gland, medial wall of
cavernous sinus, dorsum sellae, diaphragm sellae

a. Tumor removal
After dural incision, internal bulking of the tumor is the first
procedure (left), basically, in case of non-functioning pituitary
adenoma. Many of the tumors are soft, and the removal using
curette can easily be done.

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Non-functioning adenoma excision can be performed with


an intra-casupular manner. After the removal of the adenoma,
the pituitary gland (yellow arrow) and diaphragm sellae (blue
arrow) can be found in the superior direction (middle), and
the medial wall of the cavernous sinus in the lateral direction
(right).
Meanwhile, in the case of functioning adenoma, the
endocrinological normalization is the final goal of the
treatment. Therefore, the removal of the tumor was performed
with an extra capsular dissection. The cleavage of the tumor
capsule and the surrounding dura mater is required to find out
for the total removal of the adenoma, although it is not easy
procedure.
b. intraoperative CSF leakage: Endoscope is useful to find out
intraoperative CSF fistula (yellow arrow) and repair with some
sutologous materials (left). If fistula is found, fascia, muscle or
fat with fibrin glue are applied to close the fistula completely.
Fat graft with PGA is also useful to support the material over
the fistula (blue arrow) (middle). PGA sheet with fibrin glue
should be covered over the fat or fascia graft at the sellar
floor (right).

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Extended Application for Craniopharyngioma

6. Approach for the supraellar region (trans-tuberculum)


(Landmarks) sellar floor, tuberculum sellae, planum sphenoidale, optic prominence, opticocarotid recess

“Extended endonasal endoscopic transsphenoidal surgery”can provide the best surgical visualization of the origin
site of craniopharyngioma. The subchiasmal space is still blind- corner for craniotomy.
Type of the tumor extension
1.Pre-chiasmal (left), 2) Retro-chiasmal (right)
Pituitary stalk, optic chiasm, and ACoA are variable in locations depending on the tumor extension, which are the
key factors to determine the approach.

Approach to the subchiasmal cistern


 ICA distances are not widened by tumor (narrow working space)
 Tuberculum sellae is not thinned out (not compressed by the tumor)
 Intercavernous sinus is sometimes patent (hemostasis is frequently difficult) (sufficient coagulation of the
intercavernous sinus before dural incision)
 Arachnoid membrane (cistern) exists between dura and tumor (CSF leakage always occurs during tumor removal)
a. Bone; drilling extends bilaterally towards the medial opticocarotid recess, and then to the planum sphenoidale1.5-
2cm in a A-P direction under navigation
b. Dura; longuitudinal, midline, horizontal: optic canal, diaphragma sellae
c. Neurovascular structures in the suprasellar cistern; ICA, SHA, cranial nerves II and III

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They are not involved in tumor itself. Pituitary gland is usually located under the tumor.

Dissection the tumor in the extracapular surroundings


Anterior wall of the cyst is opened sharply to drain the cyst contents. Working on either side of the stalk, the
cyst wall and solid portions are carefully dissected free from the optic chiama, carotid arteries, AcomA and
perforators.

cadaveric study
After tumor capsule dissection, the superior hypophyseal artery and the perforating branches for the inferior
surface of the optic chiasm and nerves are apparent. Laterally, the origin of the ophthalmic artery below the optic
nerve is also visible. When the endoscope is advanced below the chiasm, a lateral view displays the ICA, its
bifurcation, and A1 segment before it reaches to superior surface of the optic chiasm. The superior surface of
the pituitary gland and the dorsum sellae are also well visualized.

7. Reconstruction of anterior skull base


a. Pedicled nasal mucosa flap from the nasal septum, This vasculaized flap remarkably reduces the risk of CSF
leakage from the subchiasmal cistern
b. Repair of the skull base (tuberculum sellae)“gasket seal procedure”
i. Fascia placed in the subdural space
ii. Bone flap placed in the epidural space
iii. Fibrin glue placed in the bone surface

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8. Complications of the Endonasal Transsphenoidal Approach

a. Hypopituitarism
i. Dysfunction of the anterior lobe
hypocortisolism (hyponatremia), hypothyroidism
ii. Dysfunction of the posterior lobe (diabetes insipidus)
postoperative poor secretion and production of the pitressin
b. Nasal Bleeding
i. Injury of the sphenopalatine artery
ii. Injury of the posterior ethmoidal artery
c. Intra-tumoral hemorrhage from residual tumor
d. CSF Leakage, Meningitis
e. Hyposomnia
f. Visual acuity loss, restricted eye ball movement
g. Injury to internal carotid artery is always Life-threatening

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Peri Insular Hemispherotomy (PIH)
Epilepsy Surgery

Indications
The indications for peri-insular hemispherotomy (PIH) concern a restricted
population of epileptic patients who suffer from pharmacoresistant seizures.
The brain insult has to be unilateral and widespread throughout the
hemisphere. The anatomical substrates in such conditions are relatively well
identified and classified as hemispheric syndrome “remediable by surgery”.
The hemispheric disease has, in most instances, already created a “clinical
hemispheric syndrome” characterized by hemiplegia and hemianopsia.
The surgical decision to proceed to hemispherotomy is based on the critical
evaluation of the following six parameters: seizures, neurological status,
etiologies, electroencephalography, imaging, neuropsychology.

Roy Thomas Daniel


Seizures Professor and vice Chairman of Neurosurgery;
PIH is indicated for the treatment of refractory hemispheric epilepsy. The Head of Skull base vascular and Pediatric
indication is the same, independent of the surgical method of hemispherectomy Neurosurgeon
University Hospital of Lausanna (CHUV),
utilized. The predominant seizure pattern is focal motor, but patients often suffer Switzerland
from many seizure patterns, i.e. focal motor, partial complex, generalized,
etc. The seizures have been documented to be pharmacoresistant, i.e.
without successful control despite numerous anticonvulsants. Seizures have a
frequency of a few per day to thousands per year. The seizures should have
a dramatic impact on the patient’s psychosocial development; frequentation

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of normal school is exceptional, learning disabilities are the rule. The seizure frequency and/or severity may
be such that regression on acquired development is noticed; this may be characterized by loss of speech
abilities and aggravation of concentration or memory faculties. Abnormal behavior, mainly hyperactivity and
aggressiveness may be major elements of the clinical picture. Whether these represent seizure manifestations
or the result of an epileptic encephalopathy are possibilities.

Neurological examination
Depending on the pathological substrate responsible for the seizures, the hemispheric syndrome may be
complete or incomplete and either stable or progressive. Classically, the patient harbors a complete and
stable hemispheric syndrome characterized by a hemiplegia and a hemianopsia. In certain conditions
such as Rasmussen’s chronic encephalitis or extensive Sturge–Weber at an early stage, there may be
incapacitating seizures and minimal, if any, objective neurological dysfunction. In these conditions, which
are on one hand progressive and on the other hand responsible for severe seizure disorder before maximal
deficits. The decision to proceed to PIH, in these instances, is based on the severity of the seizures, the
rapidity of evolution of the underlying condition and the lack of alternative medical treatments. Surgery, when
carried out before maximal deficit, will definitively aggravate the neurological status. Even though this is to be
avoided when possible, PIH may be necessary in these dynamic, naturally progressive conditions, which will
lead to severe hemispheric deficit with time. This management issue is a matter of experience and judgment
and requires from the parents, as well, a good comprehension of the underlying disease. When assessing
the motor function preoperatively to determine its postoperative outcome, we have found that the motor deficit
is usually not made worse when preoperatively, patients are unable to perform finger opposition to the thumb,

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even if they are able to open and close the hand. This is particularly observed in cases of early pathology, such
as infantile hemiplegia, where the lesion might have preceded the final cortical organization and allowed some
plasticity mechanism to develop. The same interpretation is given to the inability to perform repeated foot tapping.
Repeated alternating movement of foot taping and finger opposition to the thumb or individual finger movements
depend on cortical function. The presence of gross voluntary movement, such as major joint movements, walking,
gross movement of the hand, do not require cortical participation and results, in part, from subcortical structures
or ipsilateral motor participation.
We have found in those patients who preoperatively demonstrated preservation of their visual field on formal
testing that the loss of visual field after hemispherectomy did not have any clinical impact. We suspect that the
preserved field on formal testing in a severely damaged hemisphere is not necessarily useful in daily activities.
We consider that the aggravation of visual field by hemispherectomy, in someone who otherwise meet the other
criteria for surgery, is not, by itself, a contraindication to PIH. The sensory examination is most often close to
normal despite severe anatomical hemispheric damage. However, light to moderate deficits can de demonstrated
in most patients when testing discrimination.

Etiologies
The anatomical substrates responsible for seizures are either congenital or acquired. Acquired conditions are
trauma, infection, Rasmussen’s encephalitis; in these conditions, the brain has had a period of normal development
and normal functioning for various lengths of time. In acquired conditions, one can assume that the hemispheric
neurological deficit might be worse than in congenital lesion as the compensatory mechanisms, named plasticity,
did not intervene as early [3, 18, 55]. Congenital anatomical substrates consist in prenatal vascular insult

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resulting from carotid or middle cerebral artery occlusion characteristic of the infantile hemiplegia, and extensive
Sturge–Weber, hemimegalencephaly and non-hypertrophic diffuse hemispheric migrational disorder. Anatomical
substrates that are solely affecting one hemisphere are accompanied by better neurological function and seizure
outcome after PIH. Seizure outcome is also noted to be not as good in migrational disorder compared to other
aetiologies, either congenital or acquired such as trauma or Rasmussen’s chronic encephalitis.

Electroencephalography
The electroencephalographic abnormalities on the affected hemisphere are usually multifocal, diffuse and
independent, reflecting the extent of the hemispheric involvement and the severe epileptogenicity. Epileptic
abnormalities from the good hemisphere are often encountered; from a prognostic view, it is important to value
these and determine if they are secondary or independent. Their presence is not a contraindication to PIH, as they
may represent dependent or intermediate epileptogenicity, in which cases, the ultimate seizure outcome should
be excellent; their presence remains slightly unfavorable. However, the abnormalities on the “good hemisphere”
raise concern about an etiology which could affect the brain bilaterally, questions the nature of the anatomical
substrate and the presence of secondary epileptogenesis. It could be a contribution to understand the persistence
of seizures after hemispherectomy.

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Imaging
Magnetic resonance imaging, with the different sequences, i.e.
T1, T2, flair and contrast, is the imaging modality of choice.
It demonstrates the global anatomy, allows to determine the
degree of atrophy usually present and provides information
concerning the status of the white matter, which may show
abnormality before atrophy. Furthermore, it provides important
information about the integrity of the “normal” hemisphere. It
may show specific changes or show the evolution of lesions, Fig 1: a MRI axial T1, b coronal T2 large left porencephaly—infantile
confirming the diagnosis of infantile hemiplegia hemiplegia, from in utero vascular occlusion of left MCA

Fig. 1 Sturge–Weber, migrational disorder


Fig. 2 Rasmussen’s encephalitis
Fig. 3 Computed tomography (CT) scan can demonstrate atrophy
and some specific diagnostic features but has been replaced
by magnetic resonance imaging (MRI). Rarely, an angiogram
will add any significant information, and thus, is not part of
the routine imaging. The presence of atrophy demonstrated
radiologically at the level of the cerebral peduncle and
medullary pyramid is also indicative of a severe cortical motor Fig 2: MRI T2, a coronal, b axial enlarged right hemisphere, enlarged
problem which should not be worsened by surgery ventricle, abnormal gyration, abnormal grey–white matter
differentiation, characteristic of hemimegalencephaly

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Fig. 4
In instances of few MRI abnormalities, functional imaging with
positron emission tomography (PET) scan can be contributing
in demonstrating extensive abnormal hypometabolic areas

Fig. 5
The MRI is also useful for the preparation of the surgical
strategy. Ventricular size, configuration of the callosum,
Fig 3: Rasmussen’s chronic encephalitis a MRI, T1, coronal. Mild thickness of the brain, configuration of the insula–basal ganglia
enlargement of the frontal horn, and smaller right hemisphere, at an
early stage of the disease, b CT axial, with contrast. Severe atrophy complex should be understood before undertaking surgery.
of the left hemisphere in a late stage Good understanding of the three dimensional individual brain
anatomy will make PIH safer.

Neuropsychology
Neuropsychology determines the status of brain functioning
before surgery and documents cognitive functions which are
usually below average; we have, however, encountered
instances of normal IQ. Serial testings before surgery may
document a temporal profile of cognitive degradation
secondary to progressing brain pathology such as in
Fig 4: MRI, T1, axial (temporo-occipital). Severe atrophy of the left Rasmussen’s encephalitis or the deleterious effects of repeated
hemisphere. Note the severe atrophy of the left cerebral peduncle

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seizure and the development of an epileptic encephalopathy;


regression in development quotient (DQ) is not unusual.
In our experience, the demonstration of severe cognitive
deficits reflects the involvement of both hemisphere and raises
concerns about seizure outcome; persistent seizures have been
encountered more frequently in patients with severe mental
impairment, operated on the basis of clearly lateralizing
electroencephalograms and imaging. In these instances, the
objective of surgery may shift from curative to palliative but still
be very worthwhile. Fig 5: a MRI, T1, axial. Mild atrophy of the right hemisphere in the
early stage of Rasmussen’s chronic encephalitis, b FDG-PET in
the same patient demonstrating diffuse right hemispheric glucose
hypometabolism
Surgical method of peri-insular hemispherotomy
Peri-insular hemispherotomy is a surgical method of functional
hemispherectomy. It allows to disconnect the hemisphere
through a peri-insular approach requiring only removal of the
fronto–parieto–temporal opercular cortices
Figs. 6 and 7
a. skin and bone flap Fig 6: MRI
Fig. 8 a. coronal T2, observe the normal perisylvian anatomy, and the angle
for the callosotomy (almost horizontal to the callosum),
Surgery is carried out under general anaesthesia with the b. coronal T1, note the disturbed superficial anatomy and the possibility
to do a parasagittal callosotomy directly (vertical to the approach),
patient supine, a cushion under the ipsilateral shoulder and c. coronal T2, note the absence of insula and basal ganglia, which
will modify the surgical stages, and exclude the insular stage of PIH.

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the head turned contralateral to surgery and kept horizontal;


the head is either fixed in a pin clamp or rests on a soft
horseshoe headrest and is taped. The skin and craniotomy
flaps are planned to allow access around the insula. Taking
into account the atrophy and brain shift that may exist, the MRI
is useful in appreciating the projected skin and bone flaps.
Fig 7: Anatomical preparation.
The flaps should extend anteriorly from the level of the coronal
a. Coronal section illustrating the three surgical stages of peri-insular suture, go posteriorly 3–4 cm behind the external auditory
hemispherotomy,
b. lateral view illustrating the resected fronto– parieto–temporal canal, allowing them to reach the posterior insula. The flaps
opercular cortices, and the sylvian vessels
do not need to reach the floor of the middle fossa but should
reach the mid- convexity and be high enough to provide
comfortable access to the suprasylvian circular sulcus, and
eventually, once in the ventricle, the corpus callosum.
Preoperative analysis of the coronal and sagittal MRI helps in
defining the exact site and size of the flaps

Fig 8: Skin incision for PIH bone, b flap for PIH

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Fig. 9
The dura is reflected either rostrally or caudally. The brain
exposure should provide at least 2- to 2.5-cm exposure on
either side of the sylvian fissure. This can vary according
to the degree of atrophy and whether the intraventricular
portion of the operation will be done through an already
existing large porencephaly, such as in middle cerebral artery
(MCA) prenatal infarct; more exposure is useful in situation
where little atrophy is present, such as in early encephalitis or
hemimegalencephaly.

b. PIH has three major surgical stages, i.e. supra-insular


window, infra-insular window and insular. Each has technical
steps that are now detailed. Magnification with the operating
microscope is useful. The illustrations refer to a left PIH.

The supra-insular window stage


The aim of this stage is to transect the corona radiata from the
frontal to parietal region and reach the ventricle to access the
corpus callosum in its whole extent; this will allow to disconnect Fig 9: MRI, T1. a Coronal, and b sagittal, useful in planning surgery
the whole of the suprasylvian portion of the hemisphere (ventricular size, orientation of callosum, atrophy of sylvian region,
etc.)

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Fig. 10
Resection of the fronto-parietal opercular cortex The first step is
accomplished by resecting the frontal and parietal opercular
cortex using a subpial resection technique with suction and
biporal (SB) or ultrasonic aspirator (UA), depending on the
tissue consistency

Fig. 11
This needs to be done with preservation of arteries and
Fig 10: Suprasylvian window–lateral
veins reaching the convexity, which prevents infarct of the
disconnected brain. The resection of the fronto-parietal
operculum will allow the surgeon to visualize through layers
of pia, the insular cortex and the vessels in the sylvian fissure.
This exposure is extended rostrally to reach the circular sulcus
corresponding to the white matter of the corona radiata just
rostral to the insula. Once this has been carried out from
the most anterior frontal part to the mid-parietal region, the
suprasylvian insular cortex is completely exposed.
Transection of the corona radiate: The second step consists in
transecting the corona radiate aiming at opening the lateral
Fig 11: Suprasylvian – coronal ventricle from the frontal horn to the trigone
–opercular resection

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Fig. 12
Using SB or the UA, the white matter at the level of the circular
sulcus is transacted in a plane perpendicular to the insula until
the lateral ventricle is reached; thus, this incision is just rostral to
the basal ganglia and thalamus. The opening in the ventricle is
then extended anteriorly and posteriorly. One can, then, rely
on the identification of the choroid plexus and visualize the
foramen of Monroe for orientation.

Trans-ventricular parasagital callosotomy: The third step


Fig 12: Suprasylvian – coronal –section of corona radiate
consists in a transventricular parasagittal callosotomy

Fig. 13
A self-retaining retractor applied against the rostral part of the
hemispheric opening may be useful to keep the ventricle wide
opened. Before callosotomy, we have found it easier to identify
the callosum by first proceeding to a rostro–caudal incision on
the medial wall of the lateral ventricle, perpendicular to the
callosum

Fig 13: Suprasylvian – coronal –parasagittal callosotomy

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Fig. 14
SC is used to go through the ependyma, cingulate gyrus and
reach the medial pia; eventually, the falx will be recognized
through the pia; the anatomy of the cingulate gyrus running
across should be recognized as it is being transected on
the way to reach the pericallosal cistern. Identification of the
pericallosal vessels is an excellent anatomical landmark with,
Fig 14: Suprasylvian – lateral – medial vertical incision approaching the
corpus callosum, b per-operative microphotograph – transventricular caudally, the callosum that is recognized by its white colour.
parasagittal callosotomy incision at the level of the genu of the
corpus callosum corona radiate
A transventricular parasagittal callosotomy can then be carried
out consisting of transecting all tissue as it enters the callosum
from the medial wall of the ventricle. As the surgical approach
is not interhemispheric but performed from the ventricle, the
callosal section is slightly oblique and parasagittal (Fig. 13).
It must extend anteriorly toward and around the genu to
reach the rostrum, and posteriorly, go around thesplenium.
The callosotomy is done by visualizing the tissue in the
pericallosal cistern from within the ventricle; the thin layer of
parasagittal tissue is transected with SB, aiming at exposing
the parasagittal vessels or the falx, this being the evidence of
neural fiber interruption. In doing so, the contralateral cingulum,
frontal lobe, anteriorly, falx and medial pia, posteriorly, are

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visualized. At the level of the genu, as the callosum is thicker,


great care is necessary not to pass through the callosum and
end up contralaterally; visualizing the pericallosal vessels
confirms the exact location and orientation.

Posterior hippocampotomy: Once around the splenium,


extending the medial incision anteriorly to reach the choroidal
fissure interrupts the outflow of the hippocampus through the
Fig 15: Suprasylvian – lateral – site of posterior callosotomy, around the
fimbria–fornix splenium, and posterior hippocampotomy

Fig. 15
This posterior hippocampotomy does not allow the removal of
the hippocampus, thus, partly deefferented.

Fronto basal disconnection: (Fig. 21)
The fifth step aims at isolating the frontal lobe from ipsilateral
connections by incising just anterior to the basal ganglia in a
coronal plane. This is done working from the pterional area
toward the parasagittal callosal incision at the rostrum, in a
coronal plane from inside the frontal horn, aiming to the edge
of the sphenoid wing; the edge of the sphenoid wing, seen

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from the pterional area and also transpially, is a good visual


landmark for the posterior extent of this frontal incision. The
identification of the olfactory tract and gyrus rectus provides
good anatomical landmarks when reaching medially. Care is
necessary not to damage the optic nerve. Preserving the basal
pia adds safety to this step.

The infra-insular window stage


Fig 16: Infrasylvian – coronal –opercular resection The aim of this stage is to disconnect the whole temporal lobe.
There are four steps to the infra-insular stage. Here, also, major
cortical arteries and veins are to be preserved.
Resection of the temporal opercular cortex

The temporal operculum (T1) is removed in a subpial matter


exposing the insular cortex

Fig. 16
The extent of removal is as far back as the posterior insula.
At that site, the temporal opercular removal should reach
the suprasylvian opercular removal. T1 removal is extended
anteriorly and medially to reach the uncus. This is done using

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CS or UA. The insula is, thus, completely exposed which


allows access to the circular sulcus caudally.
Transsection of the temporal stem: At the level of the circular
sulcus, the white matter is transsected to reach the temporal
horn which is opened from its most anterior aspect to the
trigone

Fig. 17
At this moment, the whole lateral ventricle, infra- and Fig 17: Infrasylvian – coronal – section of corona radiata
(temporal stem)
suprasylvian are accessible around the insula.

Resection of the amygdala: The uncus and amygdala are


excised by subpial aspiration

Fig. 18
The extent of supero-medial removal of the amygdala does not
transgress an imaginary line between the roof of the temporal
horn and the medial temporal pial bed. There are no visible
anatomical boundaries outlining the supero-medial aspect of
the amygdala. The optic tract may be visualized in the cistern
Fig 18: Infrasylvian – coronal – resection of amygdala and
if the medial resection is maximal; this is a good anatomical anterior hippocampus

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landmark and represents the limit of supero-medial removal of


the amygdala. The risk of not recognizing this landmark is to
end up in a plane rostral to the choroidal fissure, medial to the
temporal horn; this is to say in the basal ganglia. We recognize
that the clinical consequence may not be the same when this
happens in PIH, unlike an anterior temporal lobectomy.

The anterior hippocampus: As the posterior hippocampotomy


has previously been carried out in the supra-insular window
Fig 19: Anatomical preparation illustrating the incision undermining the
insula (a) anatomical preparation—axial, (b) MRI axial T1
stage (step 4), the hippocampus does not need to be completely
resected but the disconnection completed; this is ensured by
removing the anterior hippocampus until the choroidal fissure
is reached; there remains, then, no hippocampal efferents.
The insular stage: The insula is potentially epileptogenic; this
stage aims at eliminating its influence

Fig. 19, Fig. 20 & Fig. 21


Fig 20: Postoperative MRI T1. a sagittal, illustrating the perisylvian incision, At this point, the insula is the only cortical epileptogenic
b sagittal, illustrating the parasagittal callosotomy and vertical structure still physiologically connected to the hemisphere. It
median incision
can either be resected by subpial aspiration or undermined by
incising at the level of the claustrum/extreme capsule, working

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from either side of the insula, i.e. supra- and infrasylvian, at a


depth of 5–7 mm. In both techniques, overlying arteries and
veins have to be preserved.

Following these three stages, the whole hemisphere is
disconnected from ipsilateral and contralateral neurological
structures and kept vascularized. Once the disconnection is
completed, inspection of the surgical sites is carried out to
insure perfect hemostasis. Drains are left in the lateral ventricle Fig 21: Lateral view illustrating the peri-insular incision and preservation of
cortical vessels
and in the subgaleal space. These drains are left to wash
out blood debris form the cerebrospinal fluid (CSF) space
and to prevent epidural and subgaleal collection. Careful
monitoring of the volume of CSF that is drained is mandatory,
as overdrainage may be associated with venous haemorrhage
occurring topographically at a distance from the surgical site.
Bone flap and wound closures are carried out according to
standard neurosurgical technique. The drains are removed
within 48 h. Antibiotics are not routinely administered, and

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there are no indications to use corticosteroids. Complications, technical pitfalls and their avoidance in
paediatric peri-insular hemispherotomy

Preservation of cortical vessels: In a situation where anatomically, the hemisphere exhibits little, if any, atrophy
despite the underlying pathology, great care is necessary to preserve as many arteries and veins as possible

Fig. 22
If this is not done properly, brain swelling and hemispheric infarct secondary to ischemia, from interfering
with the arterial supply or venous drainage, may occur, leading to intracranial hypertension, mass effect
and death. This may be the case in Rasmussen’s encephalitis before severe atrophy, in Sturge–Weber,
in hemimegalencephaly or non-hypertrophic diffuse hemispheric dysplasia where at the time of surgery,
there may be no or little atrophy or the volume of the hemisphere may even be larger than normal. We
have encountered one such instance in an early chronic encephalitis adult patient with hardly any atrophy,
where many perisylvian arteriesand veins were sacrificed; this patient deteriorated rapidly during the third
postoperative night and died of transtentorial herniation secondary to hemispheric swelling. The same
caution applies for any anatomical substrate with minimal or absent brain atrophy. In instances of severe
atrophy, however, such as in large porencephaly secondary to prenatal vascular insult or advanced cases
of Ramussen’s encephalitis, the issue is not of the same amplitude, as the enlarged ventricle which needs to
be widely opened acts as a mechanical buffer in case of any brain swelling. Nevertheless, even in these
instances, we make all efforts to preserve as many arteries and veins as possible.

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Volume of CSF drainage: Two of our patients who showed postoperative neurological deterioration were
documented to have suffered distant haemorrage from the surgical site. One patient did not wake up from
surgery, while the other deteriorated 48 h after surgery and was found to have remote haemorrhage in the
contralateral frontal lobe and in the cerebellum. This child made an uneventful recovery. In this latter instance,
the deterioration seems to have coincided with a sudden rapid drainage from the ventricular drain. We
postulate that the sudden drainage of a large volume of ventricular CSF modifies the intracranial dynamic,
may create traction on veins and is responsible for the parenchymal haemorrhage, and subsequently, for the
neurological deterioration. This phenomenon can be prevented by setting the ventricular drain at a slightly
positive pressure, without vacuum and avoiding sudden drainage of a large amount of CSF.

Hydrocephalus: The incidence of hydrocephalus following hemispherotomy is rare and much less than other
forms of hemispherectomy. The potential for hydrocephalus is present in any intracranial surgery especially with
intraventricular surgery. The risk for hydrocephalus after peri-insular hemispherotomy is theoretically increased
in cases of infection or trauma as both these aetiologies may affect the patency of the subarachnoid space,
which can be further altered by surgery.

Seizure outcome: Seizure outcome is usually defined based on Engel’s classification. Most major series
worldwide report an Engel’s class 1 outcome between 80 and 90%. Etiology of the epilepsy can influence
the outcome. The best results have been obtained in children suffering from infantile hemiplegia (93%),

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secondary to prenatal vascular occlusion of the carotid but most often middle cerebral artery territory. Surgical
outcome after PIH in Rasmussen’s encephalitis which also, in most instances, is strictly a unilateral condition
but acquired, is excellent (90%). Results obtained in unilateral hemispheric involvement where the anatomical
substrate is one of hypertrophic or non-hypertrophic migrational disorders are not as good (80%), likely
reflecting a different physiopathology of epileptogenicity; one could suspect the presence of migrational
abnormalities in the preserved hemisphere or the early development of an epileptic encephalopathy, already
in utero.

It appears that the earliest PIH is carried out, the maximum will the benefit be. Benefits manifest through
seizure control and should provide the best environment for the optimal psychosocial development of the
child. There remains a subcategory of potential candidates for PIH where surgery may not be carried out right
away, but delayed, due to the absence of maximal deficit and possible benefits from other medical therapy.
In Rasmussen’s encephalitis, a European consensus has defined some guidelines for the management of these
patients, with the use of immunotherapy before surgery in certain patients. In most instances, however, PIH
should be performed as soon as the situation for such surgery is met and brought to the attention of the epilepsy
surgeon. Among the different surgical methods of hemispherectomy, peri-insular hemispherotomy appears to

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provide the lowest complication rate. Critical patient selection, clear three-dimensional understanding of the
patients’ brain anatomy and constant perioperative anticipation are keys to successful surgery.

References:

3. Bernasconi A, Bernasconi N, Lassonde M, Toussaint PJ, Meyer E, Reutens DC, Gotman J, Andermann F,
Villemure JG (2000) Sensorimotor organization in patients who have undergone hemispherectomy: a study
with (15) O-water PET and somatosensory evoked potentials. Neuroreport 11(14):3085–3090

18. Graveline C, Mikulis D, Crawley AP, Hwang P (1998) Regionalized sensorimotor plasticity after
hemispherectomy fMRI evaluation. Pediatr Neurol

55. Wieser GH, Henke K, Zumsteg D, Taub E, Yonekawa Y, Buck A (1999) Activation of the left motor cortex
during left leg movements after right central resection. J Neurol Neurosurg Psychiatry 67:487–491

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Surgical Manual 190
How I Do It?
Transoral and Craniocervical Junction Exposures Spine Surgery
and Upper C-Spine Screw Fixation

Odontoid Screw Placement


Indications
An odontoid screw is indicated for the treatment of type II fractures,
resulting in direct fixation of injury. Contraindications for screw placement
are an oblique fracture, especially in a posterior superior to anterior
inferior orientation, significant osteoporosis, and an incompetent transverse
ligament. If the patient has significant cervical kyphosis or a barreled chest,
it may be not possible to obtain appropriate positioning.
Positioning
The patient is positioned supine on the operating room table using biplane
fluoroscopic guidance so that the fracture is reduced. If the fracture is not
reduced, an odontoid screw will not be possible. AP view may be the best Salman Sharif
shot through the mouth. Muhammad Aamir Saghir
Flexion is generally applied at the cervico-thoracic junction and extension Department of Neurosurgery
Liaquat National Hospital & Medical College
at the craniocervical junction. The procedure is difficult to perform in Karachi, Pakistan
obese individuals and barrel-chested individuals. Free passage of all
instrumentation must be able to obtain prior to proceeding. A very flat
trajectory is required for screw placement. The head may be fixed in a
rigid device or simply placed on a horse shoe or dough nut.

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Incision
A transverse incision is generally placed approximately at the level of C5-6. The area of the incision
may be ascertained with the use of fluoroscopy and holding a K-wire lateral to the patient in a line that
is satisfactory for screw placement. The point where the K-wire intersects the skin on fluoroscopy should
be the point of the incision. A transverse incision is made on the right side of the neck. The platysma is
cleared off the subcutaneous tissue and opened longitudinally. The point of dissection is created medial
to the sternocleidomastoid and great vessels of the neck and lateral to the trachea and the esophagus. An
avascular soft tissue plane is created into the retropharyngeal space up to the level of C2-3. The midline
prominence of the body of C2 is identified. Correct position is verified with fluoroscopy. A specialized set
of self-retaining retractors are available that allow satisfactory retraction for the purpose of visualization.
Note; the majority of the procedure is done under fluoroscopy and not by direct visualization. A variety
of screw systems are available with both cannulated and noncannulated screws that can be placed into
the odontoid. One or two screws may be used. Single screw fixation returns the strength of the odontoid
to approximately 50% of normal; therefore, most do not feel that the placement of 2 screws is warranted.

A portion of the anterior inferior midline body of C2 is removed to create a flat surface for placement
of the drill guide. A K-wire may be advanced using biplanar fluoroscopy along the proposed operative
screw placement. The screw is placed to the cortical aspect of the odontoid process. Once satisfactory
position is obtained, drilling and tapping are performed. A lag screw is then placed so that the threaded
portion resides within the fractured portion of the odontoid. This will allow drawing of the distal fragment
to the proximal fragments, as well as place to construct under compression.

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A second screw is placed if desired next to the first screw.


This screw may be fully threaded. Closure is performed in
a standard three-layer fashion.

Fig. a:
A: Properly placed odontoid screw. The threads are past
the fracture and a lag effect has compressed the fractured
ends.
B: An oblique fracture may be further displaced by
an odontoid fracture and is considered a relative
contraindication. Fig a

Fig. b:
Process of placing a cannulated odontoid screw. First,
a K-wire is passed through the fractured elements. After
taping, the screw is placed over the wire to the distal
cortex.
A properly sized screw (i.e., threads distal to the fracture)
will lag the two pieces together.

Fig b

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Transoral Approach and Odontoidectomy


Fig. 1
Indications
Primarily extradural pathology from the clivus through C2.

Positioning
The head is placed in a slightly extended position on a
horse shoe head holder or may fix in Mayfield tongs. A
pack of 4 x 4 sponges is secured together with a no. 1 silk
tie and placed into the pharynx. This prevents prep solution
as well as blood from going into the esophagus and helps
to prevent postoperative nausea.

Dissection
Spetzler-Sonntag retractor is a table-mounted retractor is
uses to expose oropharynx, otherwise standard mouth-gag
retractors can be used. Fluoroscopy or image guided system
provides valuable feedback throughout the procedure.
The soft palate must be retracted to visualize the posterior
Fig 1 The posterior pharyngeal wall is opened with a oro- and nasopharynx. There are a variety of techniques
needle-tip Bovie.
available to perform this step. The Spetzler-Sonntag retractor

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allows direct retraction of the palate via a specialized


blade. Alternative method includes splitting the soft palate
at beginning just lateral to the uvula to the midline at the
level of the hard palate. The leaves may then be held
in place with sutures. A second method is performed by
passing red rubber catheters through the nose and brought
out through the mouth. A suture may be placed through the
end of the catheter and uvula. By pulling the catheter back
out of the nose the uvula and soft palate will be elevated
out of the plane of view. This generally allows satisfactory
retraction of the palate. The endotracheal tube is held out
of place with a separate retractor blade. Some surgeons
perform a tracheostomy routinely with this procedure.

Fig. 2
The muscle and mucosa are dissected as a single flap from
the clivus, anterior arch of C1, odontoid process, and the
body of C2. Care must be taken when performing the
lateral portions of this dissection, as the eustachian tube, Figure 2
hypoglossal nerve, and vertebral arteries are at risk in the The anterior tubercle of C1 (white arrow) and C2 body
lateral portion of the exposure. Approximately 2.5 cm of (yellow arrow) are first exposed

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exposure can be obtained safely around the midline. The


neck of the odontoid process should be dissected free so
that it may be easily identified.

Fig. 3
This assists greatly in judging the extent of the resection.
The musculo-mucosal flaps may be held in place with
sutures or with specialized retractor blades available with
some retractor systems. Once exposure is completed, a
drill is used to remove a portion of the anterior arch of C1.
If possible, the ring should be left in continuity along its
superior margin. If not, it may be resected. The resection
should be to the medial aspects of the lateral mass.

Fig 3: The anterior ring of C1 has been removed to expose the


odontoid process (white arrow). The shoulders of the dens
have been identified (white circles).

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Transoral and Craniocervical Junction Exposures

Fig. 4
Next, the odontoid process is drilled to a thin cortical rim
throughout its length. The inferior extent of the dissection
should be checked periodically with fluoroscopy. Small
sharp curettes may then be used to separate the alar and
apical ligaments from the tip of the odontoid process. A
small Kerrison punch is then used to cut through the base
of the thinned odontoid, and the odontoid is removed,
exposing the transverse ligament.

Fig. 5
Pannus may also be present. Care should be taken with
the odontoid process so that it is not pulled down upon,
since vital structures may be adherent to the underlying
dura.
The transverse ligament should be resected, as well as the
underlying tectorial membrane until the dura is identified.
The extent of resection can be judged by placing a
contrast agent within the cavity created and obtaining a
lateral fluoroscopic image. Free fragments of pannus may
be removed. Complete pannus removal is unnecessary as Fig 4: The dens has been removed, the transverse ligament is exposed
it may cause CSF leak. (white arrow).

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Incision is irrigated with antibiotic solution. Closure is


performed by running a single layer of absorbable 3-0
suture in the posterior pharynx, which approximates both
the muscle and the mucosa. The soft palate is closed
in two layers with absorbable suture, nasopharyngeal
mucosa being the first and then soft palatal muscle and
mucosa as a second layer. A feeding tube is passed
under direct vision through the nares and down through
the posterior pharynx. This is left for 5 days and feed is
given via this for this duration.
Concomitant posterior fusion is performed. On some
occasions, a posterior fusion may not be required.
A CSF leak is an unwanted complication of this
procedure and can be dealt either by primary closure
by muscle, fascia or fat or by placing a lumbar drain.
Approximately 10 ml per hour of CSF is drained for five
to seven days. The patient is placed on antibiotics at
meningitis doses. A preoperative pharyngeal culture may
be obtained, and this may help to guide postoperative
antibiotic regimens. The patient is treated with antibiotics
Fig 5: The transverse ligament and tectorial membrane have been for three days.
removed to expose the dura matter (white arrow).

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Transoral and Craniocervical Junction Exposures

Lateral Cervical Extrapharyngeal Approach


Indications
The approach is indicated for pathology located between the
clivus and the upper cervical spine (C1 and C2). Intradural
pathology may be addressed with this technique. Visualization
is significantly better for pathology located in the intradural
compartment opposite to the side of the incision.

Positioning
The head may be fixed in a Mayfield head holder or
alternatively place in a horse shoe. The head is slightly
extended and turned 30 degrees to the contralateral side. The
incision begins approximately one finger breadth posterior
to the angle of the mandible and is carried parallel at a
distance of approximately one finger breadth anteriorly past
the midline. The incision may also be teed and carried down
the length of the anterior border of the sternocleidomastoid
to some extent so that the inferior portion of the exposure is
obtained.

Fig. 1 Dissection Fig 1: Planned incision for transcervical extrapharyngeal approach.

The dissection is to performed with wide opening of the

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fascial layer, with each layer having a particular landmark


which has to be identified within it and then freed. The
skin and underlying fat layer are dissected free from the
underlying platysma muscle.

Fig. 2
The platysma is then opened in the midline at the level
Fig 2: The platysma has been identified
of the superior thyroid cartilage and cranially as far as it
may be identified. The platysma is then underminded and
separated from its underlying fascia layer and split in a
transverse fashion.

Fig. 3
The submandibular gland is identified, and fascia is
cleared. The submandibular gland is either removed,
making sure to tie off the salivary duct, or is retracted
laterally. If the duct of the gland is inadvertently cut, it
may be found in the region of the myohyoid muscle. The
digastric muscle is then dissected along its course and
Fig 3: The platysma has been split. The submandibular gland has been
may be retracted superiorly or alternatively to be cut at its
identified and mobilized superiorly (white arrow). The digastric tendonous attachment to the hyoid bone.
muscle and attachment to the hyoid bone are visualized.

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Transoral and Craniocervical Junction Exposures

Fig. 4
The ends should have suture ligatures to mark their ends so
that the muscle may be reapproximated later. Just beneath
the digastric, in the next fascial layer, is the hypoglossal
nerve.

Fig. 5
This will be dissected free from its fascial investiture and
retracted superiorly out of the operative site. The hyoid bone
Fig 4: The digastric muscle is being dissected off its attachment to the
is then identified. The hyoid bone is then also cleared of hyoid bone.
fascial investiture. Great care should be taken at this point
to avoid vigorous dissection of the musculature attached to
the hyoid bone, as this may cause inadvertent entry into
the pharyngeal space. The retropharynx may be entered
by using blunt dissection anterior to the carotid artery and
posterior to the pharyngeal muscles attached to the hyoid.

Fig 5: The digastric muscle has been elevated superiorly and the hypoglossal
nerve has been identified (white arrow).

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Fig. 6
The superior laryngeal nerve should not be encountered in
the standard approach to the upper cervical spine. However,
at lower levels, particularly down to C3-4, that may be
encountered. This nerve innervates the cricothyroidius muscle.
The muscles attached to the anatomy are then cleared off from
the underlying bone and bony resection and reconstruction
are performed. Closure is performed on an anatomic basis.
Prolonged dysphagia postoperatively is common.

Far Lateral Transcondylar Approach


Indications
This posterior approach is used to address lesions of the
ventral or ventral-lateral foramen magnum and C2 and will
provide exposure to approximately the inferior third of the
clivus. The pathology consists of primarily neoplastic and
vascular lesions, including aneurysms of the posterior inferior
cerebral artery.
Fig 6: The retropharynx has been entered.

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Transoral and Craniocervical Junction Exposures

Positioning
A modified park-bench position is used with the head secured in a Mayfield head holder. The cervical spine
is flexed to the point that only two finger breadths are allowed between the chin and the sternum. The head
is then rotated approximately 45 degrees downward, placing the mastoid process at the highest point in
the operative field. The cervical spine is then flexed 30 degrees laterally to the opposite shoulder. The head
may be placed in a more horizontal position if it is to be combined with other approaches, such as the
subtemporal and transpetrosal approaches. The dependent arm is hanging independently from the end of
the bed. It is padded and held in place with tape and padding to the Mayfield head holder. The ipsilateral
shoulder is taped to draw it out of the operative field.

Operative Procedure
The incision is an inverted hockey-stick. It begins medial to the tip of the mastoid process and extends up
to the superior nuchal line. It then continues medially along the nuchal line to the midline where it turns
downward and is carried to the level of C3 or C4. The sub-occipital muscles are cut, leaving a 1 cm cuff
of tissue to re-attach them to at a later point. Soft tissue is cleared from the foramen magnum, as well as
from the lateral portions of C1 and C2. The subcutaneous flap is held in place with fish hooks attached to

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Transoral and Craniocervical Junction Exposures

a retractor.
The lateral tubercle of C1 is identified as well as the extensive venous plexus surrounding the vertebral
artery. The artery is identified along its path through C1, along the lamia towards its entry point in the dura.
The foramen transverarium may be opened with a diamond bit and high speed drill to mobilize the vertebral
artery for better visualization and bony removal.
Resection of the C1 lamina is performed. A retrosigmoid suboccipital craniectomy is performed next.
Depending on the pathology, the craniectomy may include exposure of the transverse and sigmoid sinuses.
The key aspect of the exposure is drilling of the occipital condyle, which should be exposed following the
craniectomy. With the vertebral artery identified and retracted laterally if required, the condyle may be
drilled with a high-speed drill. The twelfth cranial nerve lies within the anterior one-third of the occipital
condyle, therefore, up to two-thirds of the condyle may be removed. This bony removal is crucial and

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permits exposure of the ventral brainstem.


At beginning, dura is opened in the midline in the
cervical spine and carried up into the posterior fossa. The
opening curves towards the transverse sigmoid junction.
The cerebellar hemisphere and tonsil may be elevated
with a retractor system to expose the intradural vertebral
artery and ventro-lateral and ventral brainstem. Resection
as planned is performed. Water-tight drill closure should
be attempted. The possibility of instability remains and
should be assessed if fusion is required. It should be a
bilateral occipital cervical fusion.Fig 7

Fig 7: Positioning and incision for far lateral exposure. Boney removal
and exposure have been performed.

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Anterior Cervical Exposures

Anterior Cervical Exposures

Cervical Discectomy
Indications
Failure of conservative treatment
persistent cervical radiculopathy and myelopathy
to stabilize traumatic cervical spine injuries
This approach can be used to address discs from C2 toT1.

Positioning
Patient is positioned in supine position on the operating
table, with the neck slightly extended by placing a small
vertical roll between the scapulae. The head is placed on
a horse shoe head-holder or dough nut.

Operative Procedure
The placement of the incision is based upon the disc
space to be operated upon. The C3-4 disc space lies
approximately at the level of the upper margin of the
thyroid cartilage.

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Anterior Cervical Exposures

The C6 body is usually behind the cricoid cartilage. A vertical incision may be used if more than two levels
are being addressed. For single level horizontal incision is usually applied. The horizontal incision begins
just lateral to the sternocleidomatoid muscle and is continued to the midline. The skin incision is made down
through the subcutaneous fat. The skin is dissected from the platysma muscle which is then incised over the
anterior border of the sternocleidomastoid vertically or horizontally.
Dissection is carried along the anterior border of the sternocleidomastoid, medial to the carotid artery and
jugular vein. An avascular plane is generally identified which is followed down to the prevertebral fascia to
increase the exposure. Blunt dissection can be performed. Approaches above omohyoid muscle generally
lead to the C5-6 disc space. Below this muscle, the interspace generally tends to be C6-7. Carefully
dissect to avoid injury to the internal jugular vein and carotid artery laterally and the oesophagus medially.
The inferior thyroid artery, which is a branch of the costocervical trunk, crosses in the region of the C6-7
interspace. It is at risk in C6-7 exposures. The vessel may be ligated without significant consequence. When
operating from right side, care must be taken to avoid injury to the superior laryngeal nerve, which enters the
tracheoesophageal groove. It is more prone to injury in exposures above C4. After reaching the vertebral
bodies, longus colli muscle is dissected off medial to lateral with either bipolar or low current monopolar
(25Hz). Care should be taken as the sympathetic plexus lies along or within the longus colli muscles. The
aggressive lateral dissection may also be injured the vertebral artery. A cervical retractor system may be used
to maintain exposure. The teeth of the bladed may be placed under the longus colli muscles. Longer smooth
blades may be placed in a rostral/caudal fashion to assist in exposure.
The disc space of interest is identified and confirmed with the help of image intensifier. The exposed disc

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is incised with a scalpel blade. At this point, distractor


may be applied. Although, this may cause interscapular
pain post operatively. The disc material is removed with a
combination of curettes and rongeurs. Disc removal should
continue to the uncovertebral joints bilaterally.

Fig. 1
The endplates should be properly visualized and the
osteophyte obscuring the view needs to be removed
via rongeur or high-speed drill down to the dura. At this
point the endplates should be completely cleaned off
their cartilaginous endplate and squared off with the drill
to accept a bone graft. Attention should now be focused
on the posterior annulus and longitudinal ligament (PLL).
The removal of osteophyte is also necessary from the
dorsal inferior and superior endplates to achieve complete
decompression. This may be performed with Kerrison
rongeurs or a high-speed drill. This will expose of the
Fig 1: Oblique view of the cervical spine. The disc space is held open by annulus and PLL. The PLL and any remaining osteophyte
a Penfield #1 to expose the uncovertebral joint (large white arrow).
The exiting nerve root (yellow arrow) is visualized as well as its
are removed. The exit foramen are opened for nerve root
association to the vertebral artery. decompression.

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Anterior Cervical Exposures

Disc space may be covered with osteophytes which may require either drilling or nibble to remove. A 3mm
to 4mm Kerrison punch is used to remove overhanging osteophyte to visualize whole disc space.

Cervical Corpectomy
Indications
Cervical discitis
Osteomyelitis,
Vertebral body neoplasm,
Vertebral burst or compression fractures,
Lesions producing cervical radiculopathy or myelopathy with a significant component of compression
located behind the vertebral body.
Positioning
Same as for cervical discectomy. Tongs may be applied in fracture disclocation or other relevant pathology.
Operative Procedure
The exposure has been described for the anterior cervical discectomy in above lines. It may require a
slight larger dissection depending on the extent of corpectomy. After the identification of the level, vertebral
distractor may be applied into the body above and below the planned resection. First the disc above
and below the body should be completely removed down to the PLL then the concerned body is removed
down to the PLL, with the help of high-speed drill. The width of the corpectomy may be 15 mm to 20 mm
wide. Our lateral limit is uncinate process. Care must be taken in patient with fracture uncinate which may
lead to injury to the vertebral artery. All foramina should be opened widely, depending on the indications

209 Surgical Manual


Anterior Cervical Exposures

for the corpectomy. The PLL may or may not be opened.


Foramen should be opened for proper decompression.
After decompression; the endplates should be cleared of all
cartilage for the placement of the bone graft.

Anterior Cervical Fixation


Anterior Cervical Plating Techniques
The surgeon has the ability to choose between constrained
(static) Anterior and semi-constrained (dynamic) cervical
plates. There indications for use should be known by the
surgeon and applied in the appropriate clinical situation.
Generally, the small plate should be chosen. The screw holes
Illustration depicting an angle that may be taken if the exposure is should be placed in near to the endplates of the concerned
performed from one side of the patient. If
decompression is performed from both sides, an Erlenmyer flask
level. If the plate is too small, the screws may involve the graft
decompression may be obtained. in the disc interspace. Alternatively, a plate that is too big
may damage on the disc space above or below the surgical
level, this may be more importaa important important
important when using axially dynamic plates. This may result
in accelerated degeneration of these discs.

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Lateral Mass Wire and Occipital Cervical Fixation

Lateral Mass Wire and Occipital Cervical Fixation

Lateral Mass Fixation


Indications
Cervical Instability due to trauma
After multilevel corpectomies
Posterior laminectomies

Positioning
Procedure is performed in prone position with head stabilized in Mayfield head fixation system.The shoulders
are taped caudally. Care should be taken not to provide so much pressure to avoid brachial plexus injury.
The neck may need to be slightly flexed.

Dissection
The spine is exposed with a midline incision down to the cervical fascia and then to the spinous processes.
The surgeon should follow the avascular raphe which is usually found caudally towards C7 or T1 and
follows the dissection rostrally. The muscles are then reflected off the spinous processes and lamina to expose
the facets and lateral masses. The dissection should continue until the entire lateral mass is exposed. Care
should be taken while dissecting laterally as there are extensive venous plexus that may be encountered.

Lateral mass screws may be placed from C3 to C7. At C2 level pedicle or pars interarticularis screws can
be used. Lateral mass fixation systems may easily extend to the occipit and/or thoracic spine (may require
a connector to joint small cervical to large thoracic rod. These include plates and rod/screw systems.

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Lateral Mass Wire and Occipital Cervical Fixation

A variety of trajectories have been described to avoid injury


to the vertebral arteries and cervical nerve roots. Preoperative
assessment of vertebral artery is essential via imaging.
The vertebral artery is located along the medial half of the
facet joint, while the cervical nerve root passes underneath the
inferior lateral quadrant. Thus the superior lateral quadrant is
the safe zone for screw placement. Before drilling screw holes
the boundaries of the lateral mass should be defined, that is,
the superior and inferior facets make the lateral border and
the medial border which is the lamina-lateral mass junction.
This essentially forms a square which may be divided into four
quadrants.

Fig. 1
There are different techniques for the placement of screws. The
Roy-Camille technique has the starting point as the midpoint
of the facet. The screws trajectory is 10 degrees parallel
to the lateral mass in the sagittal plane. The resulting hole
Fig 1: The lateral mass of the cervical spine is outlined. The spinous results in a very short trajectory through the lateral mass and
processes are shown with white dots. The Penfield dissector defines
the lateral border of the lateral mass.
therefore only a short screw may be placed. The commonly
used Magerl technique uses an entry point that is 1mm medial

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Lateral Mass Wire and Occipital Cervical Fixation

and 1mm inferior to the midpoint of the facet. The trajectory


for the screw is then 20-30º laterally and 30º superiorly.

Fig. 2
The superior trajectory should be parallel to the facet joint in
the sagittal plane. The technique utilizes a starting point which
is 1 mm medial to the midpoint of the facet. The screw is then
aimed 20 to 30 degrees laterally and about 10 degrees
rostrally in the sagittal plane.

With the help of a drill a small hole is made in the lateral


mass. A drill guide and predetermined depth may be drilled
or bicortical purchase may be performed. It is preferable to Fig 2: The lateral mass is defined by the purple marker, while the spinous
drill bicortical for the placement of bicortical screws. A useful processes are marked by white dots. A pilot hole is being drilled for
technique for drilling the holes is to gently tap with the drill a lateral mass screw. This is via the Magarel technique. The trajectory
is approximately 30º rostral and lateral (essentially up and out). The
tip until a small amount of give is felt, as the opposite cortical safe quadrant is depicted by the white arrow.
surface is penetrated. To access length of the screw, a depth
gauge may then be used. After that the tap is used and the
screw of appropriate size is placed.

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Lateral Mass Wire and Occipital Cervical Fixation

Fig. 3
Pedicle screws can be inserted into C7, T1, and T2. The entry
point is 1 to 2 mm below the inferior facet of the cephalad
vertebra. Image guided navigation may be used for safety.
If needed a small laminotomy can be done to palpate the
pedicle. The medial-lateral angulation is approximately 25 to
30 degrees but it should be determined from a preoperative
imaging study. The width of the screw should also be decided
from the preoperative radiology.

The rostral, caudal, and medial borders are defined by purple


marker. The middle of the lateral mass is demonstrated by a
purple dot. The lamina and spinous process are shown by the
Fig 3: Lateral mass screw being placed following drilling of pilot hole.
white arrow.

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Lateral Mass Wire and Occipital Cervical Fixation

C2 Fixation
Fixation at C2 may either be transpedicular, translaminar, or
into the pars interarticularis. Insertion of pars interarticularis
screws into C2 may be performed under fluoroscopy,
alternatively computer navigation may be used. The point of
entry is generally 3mm rostral to the C2/3 facet and 2-3 mm
medial to the pars interarticularis which should be identified
and palpated.

Fig. 1
Fig 1: Planning for C2 pars interarticularis screw placement. The arrow-head
The point of entry is generally in the region of the junction of
depicts the C2-3 disc space, the larger white arrow the cut C2 nerve
the facet and lamina and the trajectory is should be parallel to root, the smaller white arrow is pointing at the C2 pars interarticularis.
the medial aspect of the pars intraarticularis. With the help of The white dot is on the C2 spinous process. The entry site for the
screw is marked by a purple dot.
image intensifier the screw should be aimed at the anterior C1
tubercle without violating the C1/2 joint. Always remember
that the vertebral artery lies anteriorly and can be injured if the
trajectory of the screw is not shallow enough.

Alternatively, a pedicle screw may be placed at C2 with the


help of fluoroscopy or image guided system.
The point of entry is slightly higher and lateral than the pars

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Lateral Mass Wire and Occipital Cervical Fixation

intraarticularis screw and is pointed approximately 30


degrees medially and 10 degrees caudally.

Fig. 2
C2 translaminar screw fixation is a safer option with less risk
of the vertebral artery injury. The entry point is at the junction
Fig 2: The entry site for the C2 pedicle screw is somewhat more lateral and of the C2 spinous process and lamina. One hole is drilled
rostral as compared to a transarticular screw (see figure one). The on both sides; one should be posterior and superior while the
pars (pedicle) is readily visualized and palpated (white arrow). The
trajectory is 10 degrees rostrally and 30 degrees medially. opposite hole is more anterior and inferior.

Fig. 3
This allows two screws to be inserted safely. The hole may
be palpated with a probe and then tapped. Check for any
breach and than a screw can be placed. Usually, a screw
greater than 20mm may be inserted, for safer placement of
screw. A Penfield #4 may be placed sublaminar during the
insertion to detect any ventral breach. A small lateral breach
will have no effect on the stability of the screw.

Fig 3: View from the top of the patient’s head. A translaminar C2 screw has
been placed on the left side and is still attached to the screw driver. A
hole is being probed on the right side for the second screw.

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Lateral Mass Wire and Occipital Cervical Fixation

Transarticular Screw Fixation


Indications
Pathology leading to instability at C1-2
For posterior fusion following transoral resection of odontoid

Positioning
The patient is placed in prone position and the head is flexed and fixed in a Mayfield head holder. The
military position is used. Under fluoroscopy, C1/2 is aligned as appropriate. If they cannot be aligned,
transarticular fixation may not be performed.

Dissection
After incision C1-2 complex is exposed. Dissection also involves the C2/3 joint and the pars interarticularis.
The medial pars is fully identified, the entry point is generally 3mm rostral to the C2/3 joint and 2-3mm
lateral to the lamina. (See Figure 1 above) Under fluoroscopic guidance and with the help of a K-wire, the
trajectory of the screw is identified. Another small incision at the level of T1 for passage of instruments to the
atlanta-axial complex and the exact location of the incision is confirmed by the insertion of a K-wire lateral
to the neck in line with the screw placement.

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Lateral Mass Wire and Occipital Cervical Fixation

Different canulated or non-canulated screw systems are available. The proper dissection of the atlanta-axial
complex should involve facet joint, as well as the medial margin of the pars interarticularis, which represents
the lateral margin of the spinal canal. Image guided system may also help in the proper insertion of screws.
Direct visualization and lateral fluoroscopy are quite satisfactory for screw placement. The screw is directed
at 10 degrees medially or straight in the medial-lateral plane. The appropriate trajectory will allow the screw
to be placed through the pars, with the tip placed at approximately the posterior aspect of the anterior arch
of C1. Direct fluoroscopy should be performed throughout the procedure. Dislodgement of the K-wire may
occur, but the K-wire may also be pushed through the anterior portion of the vertebral body. Great care must
be taken that this does not happen.

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Ventral and Lateral Thoracic and Lumbar Exposures

Ventral and Lateral Thoracic and Lumbar Exposures

Transmanubrial approach
Indications
Operations require exposure of the cervico-thoracic junction down to the T2 level. The exposure obtained
is in the midline to approximately the T2-3 interspace. Exposure down to T4 and possibly even T5 can be
obtained with this approach, but this is very rare, and other approaches, such as a trans-sternal approach
may be utilized for this exposure. Preoperative imaging studies should be evaluated to ascertain the position
of the great vessels, which may limit the caudal extent of exposure through a trans-manubrial and particularly
trans-sternal approach.

Positioning
The patient is placed in the supine position with the arms at the side. The neck may be extended slightly.
The positioning is essentially the same as for a standard ACDF.

Dissection
The two incisions can be made. The first utilizes a transverse incision 1 cm above the clavicle, with a second
limb passing down the midline of the manubrium. The second incision is made along the anterior border
of the left sternocleidomastoid carried into the sternal notch and then straight down the midline over the
manubrium and the sternum, if this will be split.

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Fig. 1
The left side is preferred for the deep soft tissue dissection
because of the location of the recurrent laryngeal nerve
which passes under the arch of the aorta and enters into
the groove between the trachea and esophagus at a much
lower point than it would be seen on the right side.

Fig 1: Incisions used for ventral exposure of the cervicothoracic junction.


Fig. 2
Other structures to be aware of from a left side approach are
the thoracic duct, which enters the junction of the subclavian
and internal jugular vein on its posterior aspect.

Fig 2: The recurrent laryngeal nerve (arrow) is visualized as it enters the


tracheoesophagel groove. It is somewhat more lateral as one moves
caudally.

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Fig. 3
Once the manubrium is cleared of soft tissue with Bovie
electrocautery, the soft tissues underneath it are freed.

Fig. 4
This is generally done with blunt dissection with a sponge
on a stick. A portion of the manubrium may be removed in
either a piecemeal fashion or with a Drill bit utilizing a foot
Fig 3: The thoracic duct is identified. A suture is around the duct. The
plate for replacement at a later time. thoracic duct travels right to left and enters the dorsal surface of the
junction of the jugular and subclavian veins.

Fig 4: The soft tissue is cleared from the surface and undersurface of the
manubrium and medial clavicle. The amount of bone to be removed
from the manubrium is outlined in purple. The sternoclavicluar joint is
also marked in purple

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Fig 5: The manubrial window has been created. The omohyoid is seen
crossing the incision. The clavicle is still intact. Fig. 5
The remainder of the exposure is similar to the cervical
exposure, with a plane of dissection created lateral to the
esophagus and trachea and medial to the great vessels of
the neck. The brachiocephalic vein will be encountered in
the upper mediastinum. It may be retracted inferiorly. If it
provides an obstruction to the pathology, it can be ligated
and divided.

Fig. 6 and 7
Fig 6: The brachiocephalic vein is visualized through the manubrial window
(white arrow), it limits the caudal extent of the exposure. The arrow
The brachiocephalic vein may be a single vein or on
head points to the omohyoid muscle. occasion may represents as several smaller veins. A
variation of this trans-manubrial approach was described
by Sunderesan, in which the manubrium and medial one-
third of the clavicle are removed.

Fig 7: The brachiocephalic vein may be ligated and divided to increase


the caudal exposure

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Fig. 8
Surprisingly, removal of the clavicle is relatively well
tolerated, and this may be used for a reconstructive bone
graft. A trans-sternal approach may also be performed
by extending the midline limb of the incision down to the
xiphoid process. The soft tissue is cleared from the under
surface of the sternum, and a sternal saw is used to split it.
This may allow exposure down to the level of T4 or T5.
Fig 8: The medial clavicle has been removed to increase exposure

Fig. 9
Once again, this is limited by the soft tissue structures within
the mediastinum.

Fig 9: The manubrial window has been created. The omohyoid is seen
crossing the incision. The clavicle is still intact.

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Supraclavicular Approach
Indications
The approach provides limited exposure of C7, T1.
Alternatively, the approach can be used to expose the
lower brachial plexus and can be used to treat thoracic
outlet syndrome. Moreover, it may be used for biopsy of the
lung apex tumors.

Positioning
The patient is positioned supine with the neck rotated away
from the side of the approach.

Incision
A transverse incision is made 1 to 2 cm superior to and
parallel to the clavicle. It extends from the midline to the lateral
margin of the sternocleidomastoid muscle. The platysma
is divided in line with the incision, and the anterior and
external jugular veins are ligated. The sternocleidomastoid
is divided after a finger is placed underneath its deep
border to protect the structures aligned to it. Omohyoid and
sternohyoid muscles are divided and blunt dissection

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is used to expose the anterior scalene muscle lateral to


the carotid sheath. The superficial fascia located over the
anterior scalene is continuous with the prevertebral fascia.
The phrenic nerve should be identified as it crosses over the
anterior scalene in a supralateral to inframedial direction.
The brachial plexus is at the lateral border of the anterior
scalene. The deep fascia of the anterior scalene is Simpson’s
fascia, which connects the transverse process of C7 to the
first rib and is continuous with the parietal pleura of the
lung. The anterior scalene may be divided, taking care to
preserve Simpson’s fascia, which is subsequently freed from
the transverse process of C7. The lung is retracted inferiorly,
exposing the upper thoracic transverse processes and rib
heads. Structures that need to be identified and protect
include (1) recurrent laryngeal nerve, which is reflected
medially. Others are (2) vertebral artery, which is identified

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as it enters the transverse foramen at C6, (3) subclavian


artery and vein at the inferior border of the field, and (4) the
internal jugular vein, which runs along the medial border
of the incision. When exposure is from the left, the thoracic
duct must be identified. If it is injured, it needs to be ligated
proximally and distally to avoid chylothorax. The sympathetic
chain lies anterior to the rib heads and should be preserved.

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Trans-facet Pedicle Sparing Approach


Indications and Dissection
Indications, incision, and positioning are similar to the
transpedicular approach. This is a microscopic technique
which spares the pedicle. It is performed by drilling a
window into the inferior facet of the superior vertebra and
the superior facet of the inferior vertebra directly over the
disc space to be addressed. This necessitates removal of a
larger portion of the inferior facet of the superior vertebra.
Bone is left medially and laterally. The nerve root may be
visualized within the soft tissue of the opening. Removal of Diagram illustrating the transfacet approach.
the pathologic process is as described above.

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Transpedicular Approach
Indications
This may be used for ventrolateral pathology in the thoracic
Fig 1: A curvilinear incision is planned for the costotransversectomy (white
arrow).
spine primarily. This includes soft discs, as well calcified
discs. Some authors do remove centrally placed pathology
with this approach.

Positioning
The patient is placed in the prone position. Localization
of the appropriate level is one of the more common
complications associated with approaches to the thoracic
spine.

An AP film will more accurately localize the disc space.


A film should be obtained preoperatively, as well as
intraoperatively. In general, the disc space is located at
the level of the caudal pedicle. That it, for the T9/10 disc
Fig 2: View from the patient’s head. The spine has been exposed. Spinous
space, the T10 pedicle is need to be resected.
process, lamina, and transverse process (white dot) have been
exposed. The corresponding rib (white arrow) and costotransverse
ligament (blue arrow) are exposed.

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Dissection
A midline dorsal incision is used. Soft tissue is cleared from
the spinal segment of interest. The lateral portion of the
lamina and facets are drilled. The authors often perform a
laminectomy at the involved levels to improved visualization. Fig 3: View from the ipsilateral side of surgery. The transverse process (blue
A medial facetectomy is performed to the level of the pedicle. arrow) and rib have been removed to expose the lateral pedicle wall
and exiting nerve root (white arrow). The Penfield #4 is in the caudal
The transverse process at the pedicle level is removed to
portion of the incision.
further identify the lateral border. The pedicle is then drilled
until flush to the vertebral body. The exiting nerve root should
be protected during removal. The pedicle at the appropriate
level is drilled until it is flush with the vertebral body. To
remove the pathology, a trough is drilled into the vertebral
body and curettes are used to push the pathology into
the trough which has been created. Alternatively, the disc
space is entered and disc material removed. Down pushing
curettes may be used to push a more centrally located disc
down away from the spinal cord. Closure is a standard
three-layer closure.

Fig 4: The endothoracic fascia and pleura are being reflected off the lateral
aspect of the vertebral body.

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The costo-transverse ligaments are separated. The head of


the rib is disarticulated by placing a Cobb elevator between
the vertebral body and the rib head and twisted gently. The
ligamentous attachments may need to be sharply incised.
Fig 5: The lateral vertebral body has been exposed (blue arrow). The
pedicle has been resected to expose the lateral dura (white arrow).
Fig. 3
The soft tissue is cleared from the lateral spine with a Kittner
dissector.

Fig. 4
Care should be taken to preserve the neurovascular
bundle. The rib head that lies adjacent to the disc space
to be addressed. The relationships of the rib heads to the
vertebral bodies must be known. For example, the eighth
rib articulates at the T7-T8 disc space. The neurovascular
bundle can be used to identify at the bottom side of the

Fig 6: Diagram illustrating the exposure that may be gained with this
approach.

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pedicle. The transverse process is also removed. Lamina


and pedicle are removed as necessary to address the
pathology, and a trough can be drilled into the vertebral
body or disc removed and the pathology process can
be pushed into the trough. When combined with a
transpedicular approach of the opposite side, the entire
anterior vertebral body can be removed.
Fig 5, 6 & 7

Lateral Extracavitary Approach


Indications
Fig 7: Drawing illustrating the exposure that may be gained with this approach.
This approach uses extrapleural extravisceral dissection for
circumferential neural decompression. It is for pathology
located ventral to the spinal cord and can be used for
virtually any anterior extradural mass, including fractures,
tumors, infections, and herniated discs. Bony interbody
fusion can also be performed after the decompression, and
posterior fixation can be applied in the same operative
procedure.

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The standard lateral extracavitary approach can be used from T3 to L2. The parascapular approach,
which is a modification of this, can be used as high as C7.

Positioning
The patient is positioned on chest rolls or in operating frame on a spinal table. The abdomen and chest
must be free of compression. The arms are usually tucked at the sides. The patient must be secured to the
frame or the table with tape and straps, lateral tilting of the table is necessary during the decompressive
portion of the operation. A useful technique is to use a Wilson frame, which is elevated on one side with
blanket rolls, and the table is tilted to a flat position during the initial exposure, and then when the table
is returned to the neutral position, the patient will be tilted laterally, facilitating visualization.

Incision
Hockey stick Incision is made in midline. The midline portion of the incision is extended approximately
three levels above and three levels below the pathological segments, while the lower portion of the
incision is usually curved in a hockey stick fashion over the ribs or flank. The incision needs to allow
mobilization of the musculature over the rib cage and allow visualization and removal of approximately
10-12cm of rib.
If the lesion is below L2, a portion of the ileac crest will have to be removed to allow visualization.

Dissection
The skin is incised. Subcutaneous tissue, fascia and muscles, are stripped from the spinous processes

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and lamina, to the level of the transverse processes. Next, a myocutaneous flap is created laterally to the
erector spine muscles. A plane is present laterally to the erector muscles that may be created bluntly.
The myocutaneous flap may then be rotated laterally to expose the rib cage and lateral aspect to the
transverse processes. Approximately 10-12 cm of the rib must be exposed. In the lumbar spine, the
transverse processes will be visible. The erector muscle, freed from its attachment to the lamina and spinous
processes 3 levels above and below the pathological level may then be manipulated. Place a Penrose
drain circumferentially around the muscle mass so it may be retracted medially during the intervertebral
work.

It is the key to remember the rib vertebral body articulation. For example, the T6 rib articulates at the T5/6
disc space. Once localization has been confirmed the appropriate rib for resection is identified (the T6
rib for a T5/6 disc space approach). The periostium of the rib is removed with cautery while periosteal
elevators are used to clear the superior and inferior borders of the rib.

The rib is cut laterally, about 7 to 10 cm from the costovetebral joint. The rib head may be disarticulated
from the vertebral body with a Cobb elevator and the entire rib segment removed for bone grafting.
The intercostal artery and segmental nerves are exposed and may be traced back to the neural foramen
and ligated. The nerve must be sectioned proximal to dorsal root ganglia to avoid anesthesia dolorosa.
This allows localization of the caudal pedicle as well (T6 pedicle in our example). The 12th rib may be
removed and permits adequate exposure of L1 and L2. Below these levels, the appropriate transverse
processes are dissected and removed as above. For lower lumbar region, portion of the ileac crest is

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removed with osteotome after subperiostial dissection of the overlying muscles. It is important to remove
the medial aspect of the ileac crest to avoid neural injury and avoid entering to sacroileac joint.
Once the foramen and pedicle are identified, decompression may proceed. The vertebral bodies and
disc space are cleared off their soft tissue attachments with blunt dissection. Care must be taken not to
enter the pleural cavity as the pleura and lung are retracted laterally. A wet sponge should be placed on
the endothroacic fascia and pleura and retraction maintained with a hand-held or table mounted retractor.
The authors prefer to remove the pedicle primarily. This permits early identification of the lateral dura. The
pedicle may be removed with the aid of a high-speed drill and/or Kerrison rongeurs. Decompression
may then be performed. If vertebrectomy (tumor or fracture) is to be performed, the superior and inferior
disc spaces are first identified and removed as previously described. The intervening vertebral body is
then removed with a high-speed drill or larger rongeurs. A shelf of bone should be left over the ventral
dura until the end of the decompression. The decompression should be continued to the contralateral
pedicle. Finally, the posterior cortex of the vertebral body is down fractured into the resection cavity.
Significant epidural bleeding may be encountered and may be controlled with bipolar cautery and
hemostatic agents. Following decompression, bone grafting or expandable cage placement may be
performed.

The erector muscle may then be mobilized laterally and posterior instrumentation is performed. Prior to
closure, the pleura should be inspected for tears. A chest tube may be necessary, but in the authors
experience this is exceedingly rare. It is not necessary to reapproximate the ribs, and the wound is
closed in layers.

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Mini-ALIF Approach
This is also called the perirectus retroperitoneal approach.
Indications
This approach is used for anterior lumbar interbody fusion,
spondylolisthesis, post discectomy kyphosis or collapse and
for correction of sagittal or coronal plane. The two most
common levels that this is used at are L4-5 and L5-S1. It
may be supplemented with fusion posteriorly. Confirm on
imaging that aorta ends at normal level and not below
L5S1 or no aberrant vessel present in front of the desired
level.

Positioning
The patient is placed in the supine position on the standard
operating table, with a small roll beneath the small of the
back to increase lumbar lordosis. The table may be placed
Fig 1: The incision for an anterior lumbar exposure is based upon the level to
in Trendelenberg and rotated to the right for the dissection.
be operated on. The distance from the umbilicus to the pubis can be
divided in thirds. The junction of the lower third and upper two-thirds is
Fig. 1 the line of incision for L5-S1. The junction of the upper third and lower
two-thirds is the incision line for L4-5. The umbilicus marks the incision
A transverse incision is recommended for a single-level for L3-4. A tangential line (angled dotted line) splitting the distance
procedure. For multi-level procedures or in obese patients, between the L4-5/L5/S1 incisions may be used for two levels. 

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an oblique or curvilinear incision is recommended.


The incision is placed on the left side of the patient. The
medial starting point is 2 to 3cm to the right of midline
and extends to the left. Incisions are 4 to 5 cm or typically
long enough to achieve easy access to the spine. Vertical
incisions are also placed 2 to 3 cm to the left of midline.
The working area is difficult if the incision is placed too
cephalad. Following the skin incision, dissection is carried
on to the rectus sheath. The rectus sheath is incised to expose
the rectus abdominis muscle.

Fig. 2
The midline raphe is identified between the two rectus muscles
Fig 2: An incision for L5/S1 has been opened and the anterior rectus
and small adhesions between them are divided sharply.
fascia cleared. The left rectus muscle is elevated with a handheld retractor
while the posterior aspect is cleared of its attachments.
The epigastric muscles should be swept up with the muscle
and the hand-held retractor is placed to provide greater
retraction. The transversalis fascia is noted to be overlying
the peritoneum. The transversalis fascia is opened with a
scalpel blade until the preperitoneal fat is identified. Kittner
wands are then used to bluntly dissect the peritoneum from

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the overlying muscular layers below the arcuate ligament.


Fig. 3
Small tears in the peritoneum may occur, and if they do,
they should be repaired with absorbable suture. As the
peritoneum is dissected, the psoas muscle will be identified.
The ureter is also identified. Working lateral to the ureter, Fig 3: The rectus muscles have been separated in the midline. The surgeon
the peritoneum is mobilized to the right to expose the left is working under the left rectus muscle to identify the arcuate ligament.
The recuts muscle is held with an army/navy rectractor. The scissors
iliac vein and artery. in mark the arcuate ligament.

Fig. 4
A small Deaver retractor may be used to increase the
mobilization of the peritoneal sac.
The genital femoral nerve will also be noted on the
anterior surface of the psoas muscle. As before, for an L5-
S1 approach, the surgeon will be working between the
iliac vessels. At L4-5, one should work from left lateral to a
medial position by retracting the great vessels to the right.
For L5/S1, the prevertebral tissues should be mobilized to
the left of the iliac vein the expose the disc space and a
small portion of the cranial and caudal vertebral bodies.
Small adhesions between the left iliac vein and prevertebral Fig 4: Blunt dissection with the surgeon’s hand or a sponge stick permits
tissues should entry into the retroperitoneal space.

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be divided sharply and the iliac vein mobilized superiorly


and slightly to the left. A self retraining retractor may then be
placed to expose the left side of the L5 vertebral body and
L5-S1 disc space. This is continued to the right with blunt
dissection to expose the right L5 vertebral body and disc
space and held with a self retaining retractor.

Fig 5: Once the retroperitoneum has been entered, the peritoneal contents Fig. 5 and 6
may be retracted superiorly and to the right to expose the spine.
A small malleable may be placed inferiorly and wedged
on the surface of the sacrum to maintain inferior retraction.
When working at L4-5, left iliac vessels, venal cava and
aorta is mobilized to the right. The iliolumbar vein typically
comes off the left common iliac and travels in a cephalad
posterolateral direction. It typically has a diameter of 4 to
8 mm. This vessel should be ligated and transected, as
it will restrict movement of the inferior vena cava to the
right side. Moreover, if is it torn significant bleeding may
be encountered. Occasionally at L4-5, the fourth and fifth
segmental vessels may also need to be ligated.
Fig 6: With continued blunt dissection with a sponge stick the retroperitoneum
Closure of the anterior rectus sheath is performed with a
is entered and swept up and to the right. Working between the right running or interrupted suture.
and left common iliac vessels, the L5/S1 disc space is identified.

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Ventral Thoracic and Lumbar Exposures and


Fixation Techniques and Minimally Invasive
Surgery

L1 Grafting and Plating Techniques


A staple is placed into the cranial and caudal vertebral
bodies. The staple should be sized for the vertebral body
(not too large or too small). It should be seated posterior on
the vertebral body with care not to impinge on the neural
foramen and exiting nerve root. Two screws are usually
placed in the staple depending on the system used. The
Fig 1: An L1 corpectomy has been completed. Staples have been placed
posterior screw is directly anteriorly away from the spinal into the T12 and L2 vertebral bodies.
canal approximately 10 degrees. The anterior screw is
directed directly into the vertebral body or slightly posterior.
Holes in the vertebral body may be made through the staple
with an awl to the distal cortex. The hole is tapped (usually
undersized) to the distal cortex. A slightly longer screw is
then chosen to breach the distal cortex to obtain bicortical
purchase.

After the screws are placed in the staples, distraction may


be placed across the construct to permit placement of the
strut graft (allograft, autograft, or cage). The appropriately
sized plate or rod system is placed across the staples and Fig 2: Screws have been placed bicortically into the staples. Distraction has
compression is applied and the plate secured. been placed across the screws and an appropriately sized cage has
been placed into the corpectomy defect.

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ALIF
Anterior lumbar discectomy from femoral ring allograft:
nearly all manufactures have instruments for use with their
femoral ring allograft. If a femoral ring graft is to be cut
Fig 3: The rods have been placed across the screws and compression
applied.
separately, it is sized for the disc space after the disc has
been completely removed. It is then tapped into place with
bone tabs. A 6.5 mm large fragment screw with a washer
is then placed into the vertebral body so that the washer
Fig 1: The entire intervertebral hangs over the bone graft and prevents graft migration.
disc may be removed. After
distraction is applied, a
ALIF with cages and dowels: a variety of systems is available
bone graft may be placed. for implantation of cages and dowels.

Dorsal Fixation
Pedicle Screw Placement

A variety of methods have been described for pedicle screw


placement. Frameless stereotaxis may also be used for
pedicle screw placement. The entry points for the pedicles
in the lumbar spine are located at the junction

Fig 2: Alternatively, a threaded interbody device may be placed anteriorly.

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VTLE and FTMIS

of the midpoint of the transverse process and the midpoint


of the superior facet. I remove the bone with a high-speed
drill in this area to expose the cancellus core of the pedicle.
The axial angulation is in general 0 to 5 degrees at L1 and
then increases 5 degrees per level down to the sacrum,
where the medial lateral angulation is approximately 30
degrees. The angle in the sagittal plane can be determined
Fig 1: The starting point for a lumbar pedicle screw is indicated with the
from plain radiographs taken intraoperatively. The pedicles pedicle probe and described in the text.
are probed with the appropriate device. The width of the
pedicle can be judged from preoperative imaging studies.
Screws are available in a variety of diameters and lengths,
and an appropriate length and width screw should be
placed. Once the pedicles are probed, markers may be
placed and an x-ray obtained. Some individuals prefer to
use fluoroscopy for screw placement.

In the thoracic spine the pedicle is at the rostral aspect of


the transverse process and the midportion of the superior
articulating process. The inferior articulating process may
be removed with an osteotome to aid in localization of the
entry point. A high-speed drill used to drill away a starting
Fig 2: L5 and S1 pedicle screws have been placed.

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hole for the pedicle screw. An intraoperative X-ray is used for the sagittal angle while the medial angle
varies depending on the location, becoming straighter up and down the more caudal one descends the
spine. A gearshift probe is then carefully pushed into the pedicle. The length is estimated by the depth of
a pedicle probe, the hole tapped and screw placed. The aforementioned is for the straight in technique.
A more cranial starting hole and steeper sagittal angle is used for the anatomic trajectory. Fluoroscopy
may be used as well as frameless stereotaxy for ease of placement.

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TLIF Technique
Indications
TLIF is used for Spondylolisthesis grade 1 or 2, degenerative
disc disease, recurrent disc herniation with foramina
stenosis or disc space collapse or lumbar deformity. It is
much more lateral and is generally a unilateral approach.
The approach is generally performed on the side of nerve
root compression.

The entire facet complex and pars interarticularis are


removed on the side of the TLIF either with drill or osteotome.
This provides complete unroofing of the neural foramen and
pedicle to pedicle decompression. That is, bone is removed
to the medial aspect and foraminal aspect of the pedicles.
Contralateral pedicle screws are placed. The disc space
is incised and removed exposing the vertebral surface of
endplate for fusion. Due to the laterality of the approach
the dura generally does not have to be retracted. The disc
space is prepared.

Fig 2:Distraction is the


Diagram illustrating placed against
placement the
of a pedicle contralateral pedicle
hook.

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screws to aid in the interbody work and grafting. The


trajectory is oblique in nature. A variety of cages and bone
grafts occur that may be placed in the interbody space. I
generally place an oblique device (allograft or PEEK) across
the disc space. Fluoroscopy is useful to judge the anterior
extent of the device. The device should be placed across
midline. Autograft is packed into the interbody space prior
to placement of the interbody device. Ipsilateral pedicle
screws are placed last and compression placed across
lordotic construct.

Minimally invasive TLIF


MIS TLIF theoretically reduces soft tissue injury, blood loss,
recovery time, length of hospital stay and postoperative
pain. MIS TLIF could be generally applied in all indications
of OPEN TLIF.
The patient is positioned prone on Jackson table or rolls.
Incision is marked with fluoroscopy with two paramedian
incisions 3 cm lateral to midline. Fascia is sharply cut to
allow blunt finger dissection between longissimus and
multifidus muscle. If the approach is unilateral, the most

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affected side is taken. Tubular dilator retractors are applied after ensuring level with flouro. Lateral part
of facet is cleared with Monopolar cautery. After confirming lateral aspect of pars, a high speed drill
is used to perform partial or complete facetectomy. Lateral aspect of dura is visualized after removing
ligamentum flavum. Decompression is tailored according to pathology and two ports may be used for
bipolar pathology.
After confirming caudal pedicle and both exiting and traversing roots, annulus is incised, aggressive
discectomy performed along with preparation of end plates. Cage placement in disc space follows.
Percutaneous pedicle screws are placed using flouro and rest of technique is same as open.

Percutaneous pedicle screws


Percutaneous pedicel screws can be implanted using en face targeting, image guidance or biplanar
flouro. All methods are reasonably reliable, if care is taken to avoid complications. AP flouro technique
is most commonly used and will be described.
Patient is positioned prone on spinal table with care taken to ensure image can be obtained without any
hindrances. An absolute AP image is obtained at the desired level. Either the flouro or table is rotated
with the surgeon compensating for the angle changed. Ideal trajectory would be when the Xray beam
is completely aligned with the sagittal plane of the pedicle. The skin is marked 1 to 2cm lateral to the
lateral border of the pedicle and a Jamshidi needle is docked at the junction of transverse process and
the facet joint.
This is inserted 2 cm inside the pedicle using the image and ensuring that at 2 cm medial wall of

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the pedicle is not breached. The inner stylet of needle is


removed and K wire is inserted into the vertebral body. This
is repeated at all other levels. Once K wires are in place,
lateral flouro is used to guide an awl and tap. Care in
controlling K-wires is essential to avoid anterior breach or
pull out prematurely. This can have very dire consequences.
Lumbosacral Pelvic Fixation
Indications
Fixation to the sacrum may be required for degenerative
disease at the L5-S1 disc space, pelvic obliquity, or for
providing a solid base for a long construct. Additionally,
tumor or infection in the lower lumbar spine may require
instrumentation to the pelvis.
Positioning
Patients are prone on the operating room table. Care is
taken that the patient is positioned with the hips extended.
Fusion to the pelvis with the hips in flexion may result in
sagittal imbalance post operatively.
Incision
The lumbar incision is carried down over the midline sacrum.

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S1 Pedicle Screws
The entry points for sacral pedicle screws are similar to
those placed in the lumbar Spine. These screws are angled
approximately 25º medial and caudal. The optimal
placement is into the sacral promontory. Bicortical purchase
is often desired, especially in the osteoportoic spine. I prefer
to probe the pedicle to the distal cortex and then lightly tap
the probe through this cortex. This length is measured and
a screw 5mm longer than this length is placed. It is critical
Fig 1: The PSIS (white arrow head) and sciatic notch (white arrow) have
that bicortical screws be placed medially. If they are lateral been dissected for illustration. The probe demonstrates the trajectory
they may impinge on the L5 nerve root. Fluoroscopy and/ of an iliac screw.

or image guidance are extremely useful for the optimal


placement of these screws.

Iliac Screw Placement


Make a fascial incision lateral to the paraspinal muscles
directly over the Posterior superior iliac spine. A tunnel may
then be created under the muscle for the connection of the
rod to the screw. Identify PSIS, clear muscular attachments,
Fig 2: A starting hole has been created with a roungoure. A probe is placed
the starting point is 1mm ventral and 1mm caudal to the into the iliac wing.
PSIS. A starting point for the screw should be made with a

247 Surgical Manual


high-speed drill.
In general, the head of the screws should be below or
ventral to the PSIS. Once the hole is made a pedicle probe
is placed down the iliac wing between its two cortices. The
ideal trajectory is above and beyond the sciatic notch. One
may probe above the iliac wing to help determine trajectory
and simply aim for the greater trochanter. Additionally,
fluoroscopy may be used to determine trajectory or dissection
may be made over the iliac wing and a finger placed in
the sciatic notch. The trajectory is probed to quite a depth.
It is not uncommon to place a 70 or 80mm screw. If hard
bone is reached at about 40mm, the trajectory should be
adjusted someone cranially, the probe is likely abutting the
Fig 2: A screw is placed into the hole. An example of an iliac screw is
hard bone of the sciatic notch. A probes eye view or even shown.
lateral fluoro may be useful to place the screw immediately
above the notch and ideally distal to the notch. The hole is
then tapped (if desired) and a screw placed. I use an iliac
screw which has an angled head. An offset connector may
then be placed into the screw to make connection to the rod
much easier.

Surgical Manual 248

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