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Spinal cord

Core Procedures Myelotomy for intramedullary tumour Dorsal root entry zone lesioning for pain Selective dorsal rhizotomy for spasticity Cordotomy for pain Syringoperitoneal/syringopleural shunting The spinal cord lies within the upper two-thirds of the vertebral canal (spinal canal), which is formed by the vertebral bodies anteriorly, their pedicles and facet joints laterally and their laminae posteriorly. Although a discussion of the osseous anatomy of the spine is…

Brainstem and pineal region

Core Procedures Brainstem Midline suboccipital craniotomy to the cerebellum and fourth ventricle Retrosigmoid craniotomy to the lateral cerebellum and cerebellopontine angle Far lateral approach to the ventral brainstem Cranio-orbitozygomatic approach to the upper brainstem Pineal Gland Supracerebellar infratentorial approach Occipital interhemispheric transtentorial approach Posterior transcallosal approach Surgical approaches to the brainstem and pineal region are complex. The pineal gland is closely related to the confluence of…

Basal ganglia and thalamus

Core Procedures Stereotactic deep-brain stimulation electrode implantation (subthalamic nucleus, globus pallidus pars interna, Vim), radiofrequency lesioning (e.g. pallidotomy), biopsy or radiosurgery Management of any lesion (e.g. tumour, arteriovenous malformation, haematoma) partly or wholly involving the basal ganglia or thalamus Surface anatomy for frame-based stereotaxy Stereotaxy makes use of a three-dimensional coordinate system relative to a fixed frame of reference on the body to target deep lesions…

Cerebral vasculature

Core procedures Open approaches to the anterior circulation Open approaches to the posterior circulation Endovascular approaches to the anterior and posterior circulation Many vascular lesions (such as aneurysms) are approached via an endovascular route. Open surgery is more frequently performed for tumour resection, epilepsy and microvascular decompression of the trigeminal nerve rather than for aneurysm clipping. Embryology Embryological variants of cerebral vascular anatomy are commonly encountered…

Cerebral hemispheres and white matter tracts

Core procedures Treatment of medically refractory epilepsy. This chapter will address the key surgically relevant cortical and white matter anatomy of the brain and some of the principles underlying resection of limbic/paralimbic gliomas and removal of tumours in the eloquent cortex. Clinical anatomy Osseous anatomy and landmarks Sutures The cranial vault (calvaria) encloses the meninges and central nervous tissue. It consists of single frontal and occipital…

Ventricular system

Core Procedures Cannulation of the lateral ventricle Endoscopic third ventriculostomy Approaches to the third ventricle Approaches to the fourth ventricle An understanding of the three-dimensional anatomy of the ventricular system of the brain is critical to the safe and effective practice of neuro­surgery. An appreciation of the embryological development aids in comprehension of their neural and vascular relationships, and a sound three-dimensional grip on these relationships…

Foramen magnum and inferior clivus

Core Procedures Far-lateral approach and transcondylar extension Endoscopic endonasal approach to the inferior clivus and foramen magnum Surgical surface anatomy The C1 transverse process can often be palpated adjacent to the mastoid process; it acts as a reliable landmark for C1 and the location of the vertebral artery during muscular dissection. Clinical anatomy Multiple approaches are directed at the foramen magnum (FM) and inferior clivus from…

Cerebellopontine angle

Core Procedures Microvascular decompression of the trigeminal nerve Microvascular decompression of the facial nerve Microvascular decompression of the glossopharyngeal nerve Retrosigmoid approach to vestibular schwannomas and other cerebellopontine angle tumours Surgical access to the cerebellopontine angle (CPA) requires a detailed knowledge of surface anatomy to define the boundaries of safe surgical access, and an understanding of the variation of anatomy within the three neurovascular complexes that…

Suprasellar and paraclinoidal regions

Core Procedures Endoscopic endonasal suprasellar approaches Open transbasal subfrontal approach to anterior cranial fossa and lamina terminalis Anterior clinoidectomy With the increase in the application of endoscopic endonasal surgery to the skull base, it is feasible to access midline lesions in the rostrocaudal axis extending from the cribriform plate to the inferior clivus and the foramen magnum. The principles of standard sellar approaches both endonasally and…

Neurosurgical anatomy

This chapter contains an overview of the surgical anatomy of the brain that will be amplified in later chapters. The use of cisternal anatomy to guide microsurgical procedures in the supratentorial and infratentorial compartments is emphasized. The pterional, transcallosal and telovelar approaches are described because they are standard pro­cedures used to access a variety of intra-axial or intraventricular lesions. Surgical surface anatomy The pterion is the…

Root of the neck and tracheostomy

Root of the neck Core Procedures Percutaneous Access Subclavian vein access: Supraclavicular or infraclavicular approach – temporary central venous access Brachial plexus block: Interscalene approach – anaesthesia for shoulder and upper extremity Supraclavicular approach – anaesthesia for distal two-thirds of arm Infraclavicular approach – anaesthesia for distal two-thirds of arm Thoracic Outlet Syndrome Transaxillary approach – first rib resection for neurological and venous decompression Supraclavicular approach…

Thyroid and parathyroid glands

Core Procedures Thyroid lobectomy and isthmusectomy Total thyroidectomy/near-total thyroidectomy Sistrunk procedure (resection of a thyroglossal duct cyst) Parathyroidectomy Subtotal parathyroidectomy and transcervical thymectomy Parathyroid autotransplantation Parathyroid cryopreservation Central neck dissection The thyroid gland takes its name from the Greek words ‘ thyreos ’ (shield) and ‘ edido s’ (form) because of its shape and position in the anterior central neck. The parathyroid glands are named for…

Larynx

Core procedures Outpatient Transnasal flexible diagnostic endoscopy Transoral rigid diagnostic endoscopy Vocal fold medialization injection Vocal fold biopsy via channelled endoscope Inpatient Diagnostic ± therapeutic rigid laryngoscopy/pharyngoscopy Laryngeal framework surgery Total laryngectomy/pharyngolaryngectomy Partial laryngectomy Outline of voice production The primary function of the larynx is to act as a sphincter to prevent the entry of foreign material into the tracheobronchial tree. To achieve this, the vocal…

Pharynx

Core Procedures Tonsillectomy Transoral robotic surgery Adenoidectomy Nasopharyngectomy Embryology Lymphoid tissues develop at several sites around the oro- and nasopharynx. In each case the endodermal epithelium proliferates and grows into the surrounding neural crest mesenchyme as solid buds, which form fossae and crypts. Lymphoid cells accumulate around the crypts from the fifth month and become grouped into lymphoid follicles. Four pairs of invaginations form the tubal…

Neck

Core Procedures Neck dissection (selective (also called functional), modified radical and radical) Submandibular gland excision Branchial cyst excision Lymph node biopsy Access for microvascular anastomosis The anterior neck extends from the skull base (inferior surface of the clivus) above to the root of the neck below. From a surgical perspective, it may be divided into anterior and posterior triangles ( Fig. 15.1A ), which are further…

Temporal bone

Core procedures Tympanoplasty Stapedectomy Cochlear implantation Mastoidectomy Labyrinthectomy Endolymphatic sac surgery Facial nerve exploration/transposition/repair Congenital malformations Petrosectomy The temporal bone contains the organs of hearing and balance. The facial nerve, internal carotid artery, sigmoid sinus and jugular bulb passage through it or adjacent to it. These are all very important or vital structures and a thorough knowledge of temporal bone anatomy is necessary for those who…

External and middle ear

Core Procedures Surgical approaches Transcanal Endaural Retroauricular Canaloplasty Osteoma/exostosis Middle meatal stenosis Tympanic membrane Myringotomy tube Myringoplasty. Tympanoplasty: small, medium and large perforations Ossiculoplasty Basic situation one: malleus and stapes present, incus missing Basic situation two: incus and stapes missing; mobile versus fixed footplate Basic situation three: stapes only – mobile stapes; mobile footplate; fixed footplate Stapedotomy Mastoidectomy: canal wall up versus canal wall down A…

Salivary glands

Core Procedures Parotid gland: superficial parotidectomy, total parotidectomy Submandibular gland: excision of submandibular gland Sublingual gland: excision of sublingual gland, excision of ranula The salivary glands are exocrine glands that discharge saliva via a duct into the oral cavity. Grossly, these can be divided into three major pairs of glands, including the parotid, submandibular and sublingual glands, and over 400 minor glands, including those in the…

Mouth

Core Procedures Cleft lip and palate repair Submandibular calculi and sublingual gland removal Maxillary access for trauma or orthognathic surgery Mandibular orthognathic surgery and trauma surgery Anaesthesia for dentistry Embryology The oral cavity is demarcated as early as the fourteenth day of fetal development by the appearance of the prechordal plate. The endodermal thickening of the prechordal plate contributes to the oropharyngeal membrane, a temporary membrane…

Temporomandibular joint

Core Procedures Closed Procedures Arthrocentesis Arthroscopy Open Joint Procedures Discectomy Disc plication Eminoplasty Total joint replacement Open reduction and internal fixation of fractured condyle The temporomandibular joint (TMJ) is a bilateral diarthrodial, ginglymoid synovial joint, which is mobile independent of the motion of the contralateral joint. Upper and lower joint spaces within each joint are separated by an articular disc of fibrocartilage. The TMJ is unique…