The authors wish to thank Carmina F. Angeles for her work on the previous edition’s version of this chapter. Procedure notes Instability of C1-2 may be due to trauma, infection, tumors, or rheumatoid arthritis. In deciding the appropriate management of unstable C1-2 injuries, the patient’s age, medical status, and compliance—along with the fracture pattern and whether ligamentous injury is involved—must be considered. One treatment modality that…

Indications Hydrocephalus, communicating or obstructive, that is not amenable to endoscopic third ventriculostomy (with or without choroid plexus coagulation) or treatment of primary etiology (i.e., removal of obstructing fourth ventricular neoplasm). Failure of previously placed shunt system. Contraindications Fevers or any evidence of active intracranial infection. Abnormal cerebrospinal fluid (CSF) rheology (high protein, pleocytosis, intraventricular hemorrhage). Body weight less than 2 kg (relative). You’re Reading a…

Indications Patients with late-onset (adolescent or adult) nontumoral obstructive hydrocephalus have the highest rate of success after endoscopic third ventriculostomy (close to 90%). The high success rate in this group is likely related to the presence of intact pathways for cerebrospinal fluid (CSF) absorption. Patients with obstructive hydrocephalus resulting from other etiologies also have high success rates after this procedure. These etiologies include CSF pathway obstruction…

Indications Fenestration of arachnoid cysts is indicated in cysts that show significant increase in size or associated clinical symptoms. The size of an arachnoid cyst typically remains stable or increases over time, and associated symptoms are unlikely to resolve spontaneously. Symptoms may include headaches, craniomegaly, developmental delay, and seizures. Surgical treatment of arachnoid cysts that are large enough to cause mass effect but that remain asymptomatic…

Indications The main indications for surgical intervention for craniosynostosis are the prevention of potential neurologic impairment and correction of deformity. Increased intracranial pressure, hydrocephalus, mental retardation, visual abnormalities, and learning disabilities all can be associated with craniosynostosis. Generally, the more sutures that are fused (as in the syndromic forms of craniosynostosis), the greater the likelihood of neurologic compromise. If there is any evidence of neurologic compromise,…

Indications The presence of an encephalocele is an indication for surgical repair. Encephaloceles are typically diagnosed at birth, although many are now identified in utero by ultrasound. Indications for the immediate repair of an encephalocele include open exposure to any meninges or brain, a ruptured encephalocele sac, and leakage of cerebrospinal fluid. Expeditious repair of the encephalocele in these circumstances minimizes the risk of a central…

Indications Symptomatic cysts. Symptoms may range from visual obscurations and loss of consciousness to positional headache, sensory disturbance, and short-term memory decline. Symptoms of hydrocephalus, such as urinary incontinence, dementia, and ataxia, may also be present. Secondary hydrocephalus or unilateral ventriculomegaly. Treatment is indicated whether or not symptoms are present. Incidental colloid cysts without secondary hydrocephalus. Incidental cysts are a controversial indication for surgical intervention. The…

Indications Indications for the transsphenoidal approach have significantly increased with the addition of the endoscope. Using a team approach with a skilled endoscopic rhinologist has rendered the endoscopic transsphenoidal approach a valid minimal-access method for exposing various midline skull base pathologies involving the planum sphenoidale, tuberculum sellae, medial cavernous sinus, pterygoid bone, and infrasellar clivus. The most common indication for the endoscopic transsphenoidal approach is a…

Additional videos for this topic are available online at . Indications In general, we prefer to use autologous calvarial bone grafts as the primary material for cranioplasty and skull reconstruction. Autogenous graft material typically has a low incidence of infection, grows with a child, and has highest rate of functional integration. It is usually obtainable in proximity to the defect site, and resorption tends to…

Indications Clinical confirmation of trigeminal neuralgia, hemifacial spasms, or glossopharyngeal neuralgia with an offending vessel seen on magnetic resonance imaging (MRI). MRI with FIESTA sequences are helpful in detailing the relationship of the brainstem vessels to the cranial nerves. You’re Reading a Preview Become a Clinical Tree membership for Full access and enjoy Unlimited articles Become membership If you are a member. Log in here

Indications Peripheral nerve stimulation (PNS) is indicated for patients with chronic, medically refractory, severe neuropathic pain that involves distribution of the nerve to be stimulated. Occipital nerve stimulation (ONS) is indicated primarily for treatment of occipital neuralgia, including posttraumatic and postsurgical pain in the occipital nerve distribution. Supraorbital nerve stimulation (SNS) is indicated for patients with trigeminal neuropathic pain, mainly secondary to posttraumatic or postsurgical supraorbital…

Indications Motor cortex stimulation (MCS) may be considered for patients with medically refractory deafferentation or neuropathic pain, including central pain syndromes related to stroke or, rarely, trauma or multiple sclerosis; trigeminal neuropathic pain (anesthesia dolorosa and postherpetic neuralgia); glossopharyngeal neuralgia; spinal cord injury; brachial plexus avulsion; and phantom limb or stump pain. Overall, efficacy is 40% to 70% for patients with refractory neuropathic pain, but identifying…

Indications Medically refractory, dopamine-responsive Parkinson disease. Medically refractory essential tremors. Medically refractory dystonia. Rare, off-label uses include treatment of chronic pain and of epilepsy. You’re Reading a Preview Become a Clinical Tree membership for Full access and enjoy Unlimited articles Become membership If you are a member. Log in here

Additional videos for this topic are available online at . Indications Pallidotomy Parkinson disease : Complications of advancing disease and medical therapy including tremor, wearing off, motor fluctuations, and dyskinesia in patients with a good response to levodopa therapy. Pallidotomy should preferably be unilateral in Parkinson’s disease patients. Dystonia : Disabling symptoms nonresponsive to medical therapy, including anticholinergics, benzodiazepines, and botulinum toxin. In certain cases,…

Additional videos for this topic are available online at . Indications Medically intractable, generalized atonic seizures. Secondarily generalized seizures without identifiable focus. Medically intractable, Lennox-Gastaut syndrome with multiple seizure types. Severe myoclonic absence seizures. You’re Reading a Preview Become a Clinical Tree membership for Full access and enjoy Unlimited articles Become membership If you are a member. Log in here

Indications When the planned resection site of a tumor is near essential language cortex, intraoperative language mapping is necessary. Occasionally, tumors in or near motor cortex are best removed with intraoperative testing of motor ability during surgery. You’re Reading a Preview Become a Clinical Tree membership for Full access and enjoy Unlimited articles Become membership If you are a member. Log in here

Indications Invasive monitoring of EEG in patients with medically refractory, focal-onset epilepsy can provide valuable information regarding an epileptogenic zone that is not clearly correlated with seizure symptoms and noninvasive studies, including scalp EEG, magnetic resonance imaging (MRI) of the brain, nuclear medicine studies, and magnetoencephalography (MEG). Invasive monitoring is indicated for the more precise identification of the epileptogenic zone in cases of “nonlesional” epilepsy, dual…

Indications Mesial temporal lobe epilepsy without evidence of neocortical involvement is an indication for selective amygdalohippocampectomy. The decision to proceed with surgery is usually made after medical intractability of epilepsy is established. In many institutions, a paradigm shift toward early consideration of surgery in mesial temporal lobe epilepsy has occurred because of the cognitive side effects of antiepileptic medications and the demonstration of superiority of resection…

Indications Medial temporal lobe epilepsy associated with mesial temporal sclerosis pathology consisting of neuronal cell loss, gliosis, and synaptic reorganization. Presumed mesial temporal sclerosis can be determined preoperatively as hippocampal atrophy or increased hippocampal fluid attenuated inversion recovery (FLAIR) signal on magnetic resonance imaging (MRI). Lesion-related temporal lobe epilepsy. Common lesions include vascular cavernous angiomas, focal developmental abnormalities, and low-grade neoplasms. Lesions may be associated with…

Indications Spontaneous intracerebral hemorrhage (ICH). Deep-seated and lobar hematomas with suspected underlying hypertension or cerebral amyloid angiopathy. Moderate-sized and large hematomas (> 20 mL). Normal coagulation parameters (international normalized ratio [INR] < 1.3, prothrombin time < 14, and partial thromboplastin time < 30–32 seconds or local normal range), platelet counts greater than 100,000/μL, and no evidence of platelet dysfunction other than aspirin effect (i.e., known use…