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Cerebellar Tumors

Indications The suboccipital craniotomy is used for most lesions in the posterior fossa. Its indications are: Brain tumors such as meningiomas, ependymomas, gliomas, medulloblastomas, acoustic neuromas and metastatic lesions. Vascular lesions such as aneurysms, cavernous malformations, arteriovenous malformations and intraparenchymal hemorrhages. Developmental anomalies such as Chiari malformations. Posterior fossa infections. Contraindications Cervical spine pathology that would oppose flexion and reduction of the neck. The sitting positioning…

Brainstem Tumors

Indications In general, surgical resection is preferred for accessible, symptomatic lesions with a focal growth pattern, while stereotactic biopsy is typically reserved for tumors with a diffuse growth pattern. If obstructive hydrocephalus is present, it is treated with a CSF diversion technique. In pediatric cases, and selective adult cases, an endoscopic third ventriculostomy (ETV) is preferred over ventriculoperitoneal shunt (VPS) placement. Contraindications Diffuse pontine glioma (brain…

Deep Intra-Axial Tumors

Indications and Preoperative Considerations Selective deep-seated intra-axial tumors can be surgically resected with the use of a tubular retractor system that creates a controlled surgical corridor with minimal brain retraction and damage to surrounding brain tissue. This controlled surgical corridor can be used for most intra-axial lesions, including lesions involving: Basal ganglia. Insular cortex. Lateral and/or third ventricle. Pineal region. Pulvinar/posterior thalamus. Contraindications Infiltrative lesions that…

Trans-Sulcal Versus Transcortical Resection of Subcortical Metastases

Introduction Metastatic lesions account for over 50% of intracranial lesions in adults. The most common primary locations of these metastases are lung, breast, skin and large intestine. The majority of intracranial metastases occur at the grey–white matter junction in the supratentorial space. Multiple metastases (>3 distinct lesions) are not uncommon. The goals of treating brain metastases are to relieve mass effect, improve neurologic symptoms, establish a…

Cortical/Subcortical Motor Mapping for Gliomas

Indications Intra-axial lesions are located in close proximity to the motor cortex (rolandic and perirolandic regions including the supplementary motor area). The infiltrative rather displacing nature of gliomas makes this approach suitable for low-grade gliomas (astrocytoma, oligoastrocytoma or oligodendrogliomas) and high-grade gliomas. Contraindications Non-cooperative patient because of disease or psychosocial issues. Inability to follow commands or to reproduce the motor tests in the preoperative training, including…

Awake Craniotomy and Speech Mapping for Gliomas

Indications Intra-axial lesions invading, or located in, eloquent areas related to the language cortex, especially in the dominant hemisphere. The infiltrative rather displacing nature of gliomas makes this approach very suitable for low-grade gliomas (astrocytoma, oligoastrocytoma or oligodendrogliomas) and high-grade gliomas. The goal of intraoperative speech mapping is: to determine the limits of the resection and the best surgical corridor to approach the lesion. to allow…

Robotics in Neurosurgery: Applications, Techniques, and Clinical Benefits

Introduction Improving safety and efficiency in the operating room has been the driving force behind technological advancements within the surgical suite. Development of minimally invasive surgical techniques has played a large role in this endeavor, with the first minimally invasive surgery being a laparoscopic cholecystectomy performed in 1987. The benefits of decreased surgical infection rates, shorter hospital stays, and lower postoperative opioid usage were soon realized.…

Nerve Reconstruction in Brachial Plexus Birth Injuries

Synopsis The vast majority of brachial plexus birth injuries (BPBIs) are caused by traction to the brachial plexus during labor. The incidence of BPBI is about 1 to 2 per 1000 births. Typically, the C5 and C6 spinal nerves are affected. The prognosis is generally considered to be good, but the percentage of children with residual deficits may be as high as 20% to 30%. The…

Management of Thoracic Outlet Syndrome

Thoracic outlet syndrome (TOS) refers to a group of complex symptoms in the upper extremity caused by compression of the brachial plexus, the subclavian artery, and the subclavian vein between the interscalene triangle and the inferior border of the axilla. Although a treatable disorder, TOS often remains undiagnosed in patients complaining of diffuse numbness, chronic pain of the head and neck, and pain and weakness of…

Management of Cranial Nerve Injuries

The incidence of traumatic cranial nerve injury is approximately 5% to 23%. Nontraumatic and iatrogenic injuries are not uncommon. Cranial nerve injuries are caused by direct impact or indirect transference of energy from the skull base and/or bony elements surrounding the cranial nerves. Neuroimaging studies are crucial for diagnosis; however, the clinician must rely on accurate history and the neurologic examination to confirm the appropriate diagnosis…

Nerve Sheath Tumors Involving the Spine

Introduction In 1887, Sir Victor Horsley performed the first successful surgical excision of a spinal intradural extramedullary (IDEM) tumor, which was diagnosed by William Gower. Since then, advances in imaging, anesthesia, surgical techniques, and monitoring have made surgical resection of these tumors one of the more gratifying experiences for both neurosurgeons and patients. The true incidence of intradural spinal tumors is unknown, as most hospital-based studies…

Management of Entrapment Neuropathies

Nerve compression is a common cause of spontaneous neurologic dysfunction. The term “entrapment neuropathy” should be used only to describe situations in which a small addition to the content of an already crowded osteomuscular channel causes compression, constriction, or distortion of peripheral nerves, or indeed causes interference with the gliding properties of the nerve. Stewart defines entrapment neuropathies as “compression neuropathies that occur at specific places…

Management of Median Nerve Compression

Introduction to Median Nerve Compression Due to their superficial locations, close relationship to neighboring muscles and tendons, and often long and meandering courses, peripheral nerves are frequently subject to physical forces that may result, if applied chronically, in functional impairment or neuropathy. When a nerve is exposed to repetitive stretch, compression, or friction, progressive internal injury may occur and sometimes debilitating symptoms of weakness, paresthesias, or…

Management of Adult Brachial Plexus Injuries

Brachial plexus injuries comprise approximately one-third of all peripheral nerve injuries and are seen in just more than 1% of patients presenting to a trauma facility. They usually affect younger patients, with a median age of 34. Because of the association of such injuries with violent trauma and contact sports, males are affected more frequently than females. By the same line of reasoning, they are also…

Imaging for Peripheral Nerve Disorders

Introduction Nerves can be seen in computed tomography (CT) scans and in routine magnetic resonance imaging (MRI) scans. However, because they are similar in size, shape, and location to other structures such as blood vessels and lymphatics, they cannot be identified reliably at all locations along their length unless specialized tissue-specific imaging strategies are applied. The optimal strategies provide both definitive identification of a nerve at…

Peripheral Nerve Injury

Introduction Little was known about peripheral nerve repair until the American Civil War. That conflict inflicted wounds on thousands of soldiers who received care at institutions throughout the states. Many with severe trauma were admitted to Turner Lane’s Hospital in Philadelphia. Dr. Silas Weir Mitchell, a neurologist interested in the peripheral nervous system, oversaw the neurologic wards at the center. Throughout his tenure, Mitchell systematically documented…

Surgical Management of Cerebrospinal Fluid Leakage After Spinal Surgery

A cerebrospinal fluid (CSF) leak can occur after trauma, after surgery, or idiopathically. With respect to spine surgery, any dural opening has the potential for a CSF leak. CSF leakage can be seen with anterior or posterior approaches. While some CSF leaks are encountered intraoperatively, others may become apparent postoperatively. For the patient, these leaks can manifest asymptomatically or as persistent headaches, and have a risk…