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Volume 2
Volume 2




Professor and Chief
Section of Neurological Surgery
University of Missouri at Kansas City
Kansas City, Missouri


Professor and Chief
Division of Neurosurgery
Duke University Medical Center
Durham, North Carolina


Editor: Carol-Lynn Brown
Associate Editor: Marjorie Kidd Keating
Copy Editor: Janet Krejci
Designer: Dan Pfisterer
Illustration Planner: Wayne Hubbel
Production Coordinator: Raymond E. Reter

Copyright © 1992

The American Association of Neurological Surgeons

Chicago, Illinois

All rights reserved. This book is protected by copyright. No part of

this book may be reproduced in any form or by any means, in-
cluding photocopying, or utilized by any information storage and
retrieval system without written permission from the copyright

This publication is published under the auspices of the Publica-

tions Committee of the American Association of Neurological Sur-
geons (AANS). However, this should not be construed as indicat-
ing endorsement or approval of the views presented, by the AANS,
or by its committees, commissions, affiliates, or staff.

Printed in the United States of America

Library of Congress Cataloging-in-Publication Data

Neurosurgical operative atlas / AANS Publications Committee ;
editors, Setti S. Rengachary, Robert H. Wilkins.

p. cm.
Includes index.
ISBN 0-683-07234-X (v. 1)
I. Nervous system—Surgery—Atlases.
I. Rengachary, Setti S.
II. Wilkins, Robert H. II. AANS Publications Committee.
[DNLM: I. Nervous System—Surgery—Atlases. WL
17 N494]
RD593.N43 1991
for Library of Congress 90-14551

91 92 93 94 95
1 2 3 4 5 6 7 8 9 10

I am honored to write this foreword to The American Asso- James Greenwood of Houston, Texas (2), who pioneered
ciation of Neurological Surgeons’ Neurosurgical Opera- the complete removal of ependymomas in the cervical
tive Atlas. The list of operations is impressive and covers spinal cord and developed unique bipolar Bovie for-
almost every detail of neurosurgery. The authors selected ceps with suction at the tips. Use of his Bovie forceps
to present these operations are even more impressive, rep- enabled him to carry out detailed dissections with mag-
resenting, as they do, outstanding individuals in the United nifying lenses before the advent of the operating micro-
States and Canada who are respected and admired by ev- scope. Figure 1 shows the spinal cord split, the tumor
eryone in the medical profession. being removed, and a line of cleavage being developed;
This is not the first effort the former Harvey Cushing Figure 2 shows a further removal with the suction bipo-
Society has made in this field—more than 25 years ago lar forceps in the field.
the Board of Editors of the Journal of Neurosurgery Figure 3 shows a cervical fusion technique (3) and is
agreed that it was important to publish a section, entitled published to give due credit to Mr. George Lynch, the
Neurosurgical Techniques, of select operative drawings artist who approved of and often redrew illustrations that
with brief explanatory text that would be published as were published in Neurosurgical Techniques. Figure 3
fascicles over the ensuing years. illustrates the final stages of cervical fusion for disloca-
Most of us in neurosurgery at that time had depended tion of C-3, C-4, using bone and wire for the fusion pro-
on the volume devoted to the nervous system in Bancroft cess. This technique was used before the development of
and Pilcher’s Surgical Treatment, the responsibility for the acrylic fusion technique, which came to replace the
which had been that of Cobb Pilcher, then at Vanderbilt. bone grafting procedure.
Although Surgical Treatment was not specifically a “tech- As was expressed in the final paragraph of the intro-
niques” book, it had much technique in it and was widely duction to Neurosurgical Techniques (4), neurosurgery was
used. The editorial board of the Journal of Neurosurgery evolving rapidly, and often the procedure described had not
hoped that Neurosurgical Techniques would serve as a originated with the person who wrote about it. Then, as now,
more up-to-date version of that volume of Surgical Treat- surgery was a combination of new knowledge with old. Since
ment. knowledge is freely shared among surgeons nationally and
Emphasis in Neurosurgical Techniques was given to internationally, original techniques and ideas are passed
the artists’ depictions of established, safe techniques. The from teacher to student, from surgeon to surgeon, and
editors of the Journal realized that a procedure might be
done successfully in more than one way, but at least one
good and safe technique was to be described, and it was
assumed that the more skilled and experienced surgeons
would utilize other methods they found suitable.
The basis of the decision to focus on the drawings
and to have relatively little associated text was a previ-
ous atlas, the Atlas of Surgical Operations (1). Many of
the editors of the Journal had become familiar with this
atlas during their general surgical training. Mildred
Codding, who had been the artist for Harvey Cushing,
had developed an effective technique of drawing the
stages of operative procedures that had been and remains
an effective teaching aid.
The fascicles of Neurosurgical Techniques in the Jour-
nal of Neurosurgery were to be bound together but, due
to changes in publishers, this was never done. Fortunately,
some of the plates were preserved and given to me, as
editor of the fascicles. Three of these are shown to provide
© 1992 The American Association of Neurological Surgeons
a historical perspective.
The first two figures illustrate a technique by Dr. Figure 1.

© 1992 The American Association of Neurological Surgeons

Figure 2.

© 1992 The American Association of Neurological Surgeons

altered with changing developments and experience. A Figure 3.

procedure well-established today may seem naive or use-
less a few years hence. One can make valid judgments
only on the basis of data that become available. Thus, it
1. Cutler EC, Zollinger R. Atlas of surgical operations. Illustrated
is my great pleasure to introduce this ambitious project by Mildred B. Codding. New York: Macmillan, 1939.
by Dr. Wilkins and Dr. Rengachary. Not only will it up- 2. Greenwood J, Jr. Surgical removal of intramedullary tumors. J
date neurosurgical techniques, but it is also a further de- Neurosurg 1967;26:275-282.
velopment of the effort made by the editors of the Jour- 3. Alexander E, Jr, Davis CH, Jr, Forsyth HF. Reduction and
nal of Neurosurgery 25 years ago. We hope it will surpass fusion of fracture dislocations of the cervical spine. J Neurosurg
that effort. 1967;27:587-591.
4. Alexander E, Jr. Neurosurgical techniques introduction. J
EBEN ALEXANDER, JR. Neurosurg 1966;24:817-819.

Man has always had an innate urge to depict his activi- thority on it. Many illustrations are depicted in full color
ties in drawings, as the paintings of cave dwellers would despite the high costs involved in preparing the artwork
attest. Surgical atlases perhaps represent a formalized ver- and printing. In many instances where there is more than
sion of such an urge; the atlases, in addition to docu- one way to approach a problem, two different authors
menting the work, have instructional value as well—be- have been requested to write on the same subject so that
ing able to teach generations of trainees the craft of the reader will benefit from knowing alternative surgical
surgery as practiced by the masters of the trade. Although techniques.
electronic images have greatly advanced the instructional The atlas has been possible in large measure due to
process, printed artwork remains the backbone of the the efforts and sacrifices of the contributing authors. In
media for teaching. addition to sharing their knowledge and expertise, they
There has been a perception among all neurosur- have incurred large expenses in getting the artwork done;
geons for some time that a contemporary atlas in neuro- they have spent long hours with their illustrators to
surgery is due. To fill this void, the Publications Com- achieve the accurate and esthetically pleasing depiction
mittee of The American Association of Neurological of the procedures. One can also see the spectrum of artis-
Surgeons has undertaken the task of producing a com- tic talent that made this work possible.
prehensive atlas. The atlas will be published at bimonthly We thank George T. Tindall, M.D., for forming the
intervals in the form of fascicles containing up to six Publications Committee; Eben Alexander, Jr., M.D., for
operations each. To allow timely publication, topics are preparing the Foreword; Carol-Lynn Brown and Marjorie
included in a random fashion. Kidd Keating of the Williams & Wilkins Company, and
The Neurosurgical Operative Atlas, we believe, is Carl H. Hauber and Gabrielle J. Loring of The American
unique in several respects. It is comprehensive. When Association of Neurological Surgeons for coordinating
completed, it will contain descriptions of up to two hun- various phases of the project; Sherylyn Cockroft and
dred operative procedures. It is multiauthored. Given the Gloria K. Wilkins for secretarial help; members of the
complexity of the field and the explosive advances in Publications Committee for innumerable suggestions;
techniques, it is impossible for any one individual to be and Diane Abeloff for overseeing the entire artwork.
skilled enough to describe the entire spectrum of tech-
niques authoritatively. In many instances, the chosen au-
thors are those who developed a technique originally or SETTI S. RENGACHARY
have used the technique so extensively as to be an au- ROBERT H. WILKINS


Clinical Instructor of Neurosurgery Associate Professor
School of Medicine and Biomedical Sciences Department of Neurological Surgery
State University of New York University of Texas Southwestern Medical Center
Buffalo, New York Dallas, Texas


Assistant Professor Assistant Professor of Neurosurgery
Division of Neurosurgery School of Medicine and Biomedical Sciences
University of California at Los Angeles State University of New York
Los Angeles, California Buffalo, New York


Professor of Neurosurgery Chief Resident
Division of Neurological Surgery Department of Surgery (Neurosurgery)
University of Utah Medical Center University of Colorado Health Sciences Center
Salt Lake City, Utah Denver, Colorado


Department of Plastic and Reconstructive Surgery Department of Neurosurgery
Albert Einstein College of Medicine University of Saarland
Montefiore Medical Center Homberg/Saar, Germany
Bronx, New York
ISSAM A. AWAD, M.D., M.S. Associate Clinical Professor
Head, Section of Epilepsy Surgery Division of Neurosurgery
Head, Section of Cerebrovascular Surgery University of California at Los Angeles
The Cleveland Clinic Foundation Los Angeles, California
Cleveland, Ohio
ROY A. E. BAKAY, M.D. Clinical Professor of Neurosurgery
Departments of Neurosurgery and Neurology John A. Burns School of Medicine
Atlanta Veterans Administration Medical Center University of Hawaii
Decatur, Georgia Honolulu, Hawaii
Emory University
Atlanta, Georgia ALAN R. COHEN, M.D.
Assistant Professor
CONSTANCE M. BARONE, M.D. Department of Neurosurgery
Department of Plastic and Reconstructive Surgery New England Medical Center
Albert Einstein College of Medicine Boston, Massachusetts
Montefiore Medical Center
Bronx, New York EDWARD S. CONNOLLY, M.D.
Department of Neurosurgery
DANIEL L. BARROW, M.D. Ochsner Clinic and Alton Ochsner Medical
Associate Professor Foundation
Department of Neurosurgery New Orleans, Louisiana
Emory University School of Medicine
Atlanta, Georgia


Professor Professor
James and Newton Ebeen Scholar Department of Neurological Surgery
Department of Neurological Surgery University of California School of Medicine
University of Florida San Francisco, California
Gainesville, Florida
Departments of Neurosurgery and Neurology Division of Surgery
Atlanta Veterans Administration Medical Center The Cleveland Clinic Foundation
Decatur, Georgia Cleveland, Ohio
Emory University
Atlanta, Georgia CRAIG D. HALL, M.D.
Institute of Plastic and Reconstructive Surgery
LAWRENCE W. DESANTO, M.D. Albert Einstein College of Medicine
Professor and Chairman Montefiore Medical Center
Department of Otorhinolaryngology Bronx, New York
Mayo Clinic Scottsdale
Scottsdale, Arizona H. LOUIS HARKEY, M.D.
Department of Neurosurgery
MAGDY EL-KALLINY, M.D. University of Mississippi
Department of Neurosurgery Jackson, Mississippi
University of Cincinnati College of Medicine
Mayfield Neurological Institute LEO N. HOPKINS, M.D.
Cincinnati, Ohio Professor of Neurosurgery and Radiology
School of Medicine and Biomedical Sciences
AMR O. EL-NAGGAR, M.D. State University of New York
Assistant Professor Buffalo, New York
Department of Neurosurgery
University of Kentucky College of Medicine DAVID F. JIMENEZ, M.D.
Lexington, Kentucky Division of Pediatric Neurosurgery
Leo Davidoff Department of Neurological Surgery
KEVIN T. FOLEY, M.D. Albert Einstein College of Medicine
Chief of Neurosurgery Montefiore Medical Center
Walter Reed Army Medical Center Bronx, New York
Washington, D.C.
ATUL GOEL, M.CH. Department of Neurosurgery
Fellow University of Cincinnati College of Medicine
Center for Cranial Base Surgery Mayfield Neurological Institute
Department of Neurosurgery Cincinnati, Ohio
University of Pittsburgh School of Medicine
Pittsburgh, Pennsylvania PETER M. KLARA, M.D., PH.D.
Assistant Professor of Neurosurgery
JAMES T. GOODRICH, M.D., PH.D. Eastern Virginia Medical School
Director, Division of Pediatric Neurosurgery Norfolk, Virginia
Leo Davidoff Department of Neurological Surgery F. Edward Hebert School of Medicine
Albert Einstein College of Medicine Uniformed Services University of the Health
Montefiore Medical Center Sciences
Bronx, New York Bethesda, Maryland


Clinical Instructor of Neurosurgery Resident in Neurological Surgery
School of Medicine and Biomedical Sciences Emory University School of Medicine
State University of New York Atlanta, Georgia
Buffalo, New York


Professor and Chairman Professor
Department of Neurosurgery Division of Neurosurgery
Medical College of Wisconsin Duke University Medical Center
Milwaukee, Wisconsin Durham, North Carolina


Clinical Instructor of Neurosurgery Virginia Mason Medical Center
School of Medicine and Biomedical Sciences Seattle, Washington
State University of New York
Buffalo, New York W. JERRY OAKES, M.D.
Associate Professor
CHRISTOPHER M. LOFTUS, M.D. Division of Neurosurgery
Division of Neurosurgery Department of Surgery
Department of Surgery Assistant Professor
University of Iowa College of Medicine and Department of Pediatrics
Veterans Affairs Medical Center Duke University Medical Center
Iowa City, Iowa Durham, North Carolina


Clinical Assistant Professor Assistant Professor
Department of Surgery (Otolaryngology) Department of Radiology
University of Missouri Medical School University of Florida
Columbia, Missouri Gainesville, Florida
Associate Clinical Professor
University of Missouri School of Medicine PREM K. PILLAY, M.D.
Kansas City, Missouri Fellow
Preceptor and Instructor Department of Neurological Surgery
Department of Otorhinolaryngology The Cleveland Clinic Foundation
University of Kansas Medical Center Cleveland, Ohio
Kansas City, Kansas
DENNIS J. MAIMAN, M.D., PH.D. Professor
Associate Professor of Neurosurgery Department of Radiology
Medical College of Wisconsin University of Florida
Chief, Spinal Cord Injury Center Gainesville, Florida
Veterans Administration Medical Center
Medical Director, Spinal Cord Injury Center SETTI S. RENGACHARY, M.D.
Froedtert Memorial Lutheran Hospital Professor and Chief
Milwaukee, Wisconsin Section of Neurological Surgery
University of Missouri at Kansas City
PAUL KURT MAURER, M.D. Kansas City, Missouri
Division of Neurosurgery
University of Rochester Medical Center TIMOTHY C. RYKEN, M.D.
Rochester. New York Division of Neurosurgery
Department of Surgery
JEFFREY D. McDONALD, M.D., PH.D. University of Iowa College of Medicine and
Resident Veterans Affairs Medical Center
Department of Neurological Surgery Iowa City, Iowa
University of California School of Medicine
San Francisco, California DUKE SAMSON, M.D.
Clark Professor and Chairman
J. PARKER MICKLE, M.D. Department of Neurological Surgery
Professor University of Texas Southwestern Medical Center
Department of Neurological Surgery Dallas, Texas
University of Florida
Gainesville, Florida


Associate Professor Departments of Neurosurgery and Neurology
Department of Neurosurgery Atlanta Veterans Administration Medical Center
University of Pittsburgh School of Medicine Decatur, Georgia
Pittsburgh, Pennsylvania Emory University
Atlanta, Georgia
Assistant Professor MARION L. WALKER, M.D.
Department of Neurosurgery Primary Children’s Medical Center
The Mount Sinai Medical Center University of Utah
New York, New York Salt Lake City, Utah


Department of Neurosurgery Vice-Chairman
University of Saarland Department of Neurosurgery
Homberg/Saar, Germany Director of Neurotrauma
Allegheny General Hospital
JOHN M. TEW, JR., M.D. Associate Professor of Surgery (Neurosurgery)
Department of Neurosurgery Medical College of Pennsylvania
University of Cincinnati College of Medicine Pittsburgh, Pennsylvania
Mayfield Neurological Institute
Cincinnati, Ohio CHARLES B. WILSON, M.D.
Tong-Po Kan Professor and Chairman
SUZIE C. TINDALL, M.D. Department of Neurological Surgery
Associate Professor of Surgery (Neurosurgery) School of Medicine
Assistant Professor of Neurology University of California, San Francisco
Emory University School of Medicine San Francisco, California
Atlanta. Georgia
SUMIO UEMATSU, M.D. Assistant Professor
Associate Professor Department of Surgery (Neurosurgery)
Department of Neurosurgery University of Colorado Health Sciences Center
Johns Hopkins University School of Medicine Denver, Colorado
Baltimore, Maryland
LIEUTENANT COLONEL BRUCE E. Primary Children’s Medical Center
van DAM, M.D. University of Utah
Director of Spine Surgery Salt Lake City, Utah
Orthopaedic Surgery Service
Walter Reed Army Medical Center RONALD F. YOUNG, M.D.
Washington, D.C. Professor and Chief
Assistant Professor of Surgery Division of Neurological Surgery
Uniformed Services University of the University of California
Health Sciences Irvine, California
Bethesda, Maryland


Department of Neurosurgery
University of Cincinnati College of Medicine
Mayfield Neurological Institute
Cincinnati, Ohio

Foreword / v
Preface / vii
Contributors / ix

Volume 2


Ken R. Winston, M.D.
Michael J. Burke, D.V.M., M.D.


Blaine S. Nashold, M.D.
Amr O. El-Naggar, M.D.


Arthur L. Day, M.D.


James E. Wilberger, Jr., M.D.


Issam A. Awad, M.D., M.S.
Joseph F. Hahn, M.D.


Suzie C. Tindall, M.D.
Ali Krisht, M.D.


J. Parker Mickle, M.D.
Ronald G. Quisling, M.D.
Keith Peters, M.D.


Sumio Uematsu, M.D.


Issam A. Awad, M.D., M.S.
Prem K. Pillay, M.D.


Charles M. Luetje, M.D.


Chandranath Sen, M.D.
Laligam N. Sekhar, M.D.


James T. Goodrich, M.D., PH.D.
Craig D. Hall, M.D.


H. Hunt Batjer, M.D.
Duke Samson, M.D.


W. Jerry Oakes, M.D.


Jeffrey D. McDonald, M.D., PH.D.
Philip H. Gutin, M.D.


Dennis J. Maiman, M.D., PH.D.
Sanford J. Larson, M.D., PH.D.


Chandranath Sen, M.D.
Laligam N. Sekhar, M.D.


Charles M. Luetje, M.D.


Ronald F. Young, M.D.


Ronald I. Apfelbaum, M.D.


Setti S. Rengachary, M.D.


Lawrence W. DeSanto, M.D.


Laligam N. Sekhar, M.D.
Atul Goel, M.Ch.
Chandranath Sen, M.D.


Gregory J. Bennett, M.D.


Ralph B. Cloward, M.D.


Setti S. Rengachary, M.D.


H. Louis Harkey, M.D.
Wolfhard Caspar, M.D.
Yaghoub Tarassoli, M.D.


Timothy C. Ryken, M.D.
Chistopher M. Loftus, M.D.


H. Hunt Batjer, M.D.
Duke S. Samson, M.D.


Roy A. E. Bakay, M.D.
Jerrold L. Vitek, M.D., PH.D.
Mahlon R. Delong, M.D.


Arvind Ahuja, M.D.
Lee R. Guterman, PH.D., M.D.
Kimberly Livingston, M.D.
Leo N. Hopkins, M.D.


Chandranath Sen. M.D.
Laligam N. Sekhar, M.D.


Daniel L. Barrow, M.D.


Setti S. Rengachary, M.D.


Harry van Loveren, M.D.
Magdy El-Kalliny, M.D.
Jeffrey Keller, PH.D.
John M. Tew, Jr., M.D.


Alan R. Cohen, M.D.


Bruce E. van Dam, M.D.


Edward S. Connolly, M.D.


Constance M. Barone, M.D.
Ravelo V. Argamaso, M.D.
David F. Jimenez, M.D.
James T. Goodrich. M.D., PH.D.


Setti S. Rengachary, M.D.


Lyn C. Wright, M.D.
Marion L. Walker, M.D.


Mario Ammirati, M.D.
Melvin Cheatham, M.D.


Setti S. Rengachary, M.D.


Constance M. Barone, M.D.
David F. Jimenez, M.D.
Ravelo V. Argamaso, M.D.
James T. Goodrich, M.D., PH.D.


Sumio Uematsu, M.D.


Charles B. Wilson, M.D.


Paul Kurt Maurer, M.D.
Charles Nussbaum, M.D.


Peter M. Klara, M.D., PH.D.
Kevin T. Foley, M.D.

Index /


The metopic suture is functional for approximately the Surgery for trigonocephaly is cosmetic. Most parents of
first two years of life. Premature fusion of this suture is children with trigonocephaly find the dysmorphia to be
typically associated with a specific cranial dysmorphia, very noticeable and extremely undesirable. The defect does
termed trigonocephaly. While associated brain deformi- not improve with time; there is no reason to delay the
ties have been reported (i.e., holoprosencephaly and corrective procedure. We strongly prefer surgical repair
arhinencephaly), trigonocephaly is most commonly an iso- by four to six weeks of age but there is no upper age limit.
lated type of cranial dysmorphia in a neurologically nor-
mal child. RISKS
Risks associated with this procedure include blood loss
DESCRIPTION OF THE DEFECT and the need for transfusion. Dural lacerations, if not rec-
The dysmorphia is apparent at birth. When the head is ognized and repaired, can lead to enlarging skull defects
viewed from the vertex, the frontal area has a wedge or with cerebral herniation and brain injury. The osteoto-
triangular shape. A keel of bone extends vertically across mies may fuse too early or, conversely, reossification may
the forehead and may appear to continue below the be incomplete. Additional surgical procedures may be re-
frontonasal suture. The keel does not necessarily extend quired to achieve a desired satisfactory cosmetic result.
posteriorly to the bregma. Very characteristic of trigono- Injury to an eye or to periocular structures is possible,
cephaly is the severely retropositioned lateral parts of the with resulting damage to the visual system. Although rare,
supraorbital ridges. The bifrontal cranial dimension is ab- it is possible for the brain to be injured.
normally narrow, with a widening of the biparietal diam- Parents should also be informed that, while most chil-
eter which accommodates normal brain volume but ac- dren have an excellent cosmetic result, a perfectly shaped
centuates the cosmetic defect. skull is not likely to be achieved. A good result is one in
Although the eyes often appear hyperteloric, mea- which the child’s resulting craniofacial morphology will
surement of the orbits may show hypotelorism. The lat- not adversely affect normal psychosocial development.
eral canthal angles and therefore the lateral eyebrows may After surgery, the region of the forehead and orbits is usu-
appear elevated, but extraocular muscle functions are nor- ally normal in appearance to all but the most detailed ex-
mal. The term “startled coon” has been applied to the fa- amination.
cies of these children.
The diagnosis is made by inspection of the head. If the PREPARATION FOR SURGERY
characteristic abnormality cannot be identified, then either Preoperative laboratory evaluation generally consists of
there is no trigonocephaly or it is clinically insignificant. routine complete blood counts, electrolyte determinations,
Skull films will show the suture to be absent anteriorly and urinalysis. A prothrombin time, partial thromboplas-
(lower portion). Computed tomography scanning should tin time, and platelet count are also usually obtained. A
be done on patients with other congenital malformations shampoo with a chlorhexidine solution is done 8-24 hours
(i.e., palatal defects). These patients with trigonocephaly before surgery. Prophylactic antibiotics are started in the
are at higher risk for forebrain abnormalities. operating room and continued for 24 hours.


© 1992 The American Association of Neurological Surgeons Children under six months of age, and perhaps up to


age nine months, are repaired by the “floating forehead” and is the starting point for the osteotomies. If the ante-
procedure. This method corrects the almond shape of the rior fontanelle is closed, a small oval hole just anterior to
orbits and midline ridge and takes advantage of the pro- the coronal suture can be made with the craniotome.
gressively expanding brain to correct any remaining ab- The frontal convexity bone is removed first. An os-
normality. Children who are one year of age or older and teotomy is made just anterior to each coronal suture. The
some children under this age are best repaired by the osteotomy is continued anteriorly across the forehead
“tongue-in-groove” procedure. In older children, the brain approximately 1.5 cm superior to the supraorbital rims
is expanding more slowly and it is necessary to make a (Fig. 1). The resulting triangular piece of bone is sepa-
more rigidly structured repair. Also, it is not safe to leave rated from the underlying dura. and removed from the
large bony defects because they occasionally do not field. The only firm dural attachment to the frontal bone
reossify satisfactorily. is at the midline along the area of the superior sagittal
sinus. A wide periosteal elevator will usually disrupt this
DESCRIPTION OF FLOATING attachment with safety. Bleeding from the dura. is con-
FOREHEAD OPERATION trolled with bipolar coagulation and microfibrillar col-
lagen (Avitene). Bleeding from bone is controlled with
Position, Preparation of Scalp, and Draping microfibrillar collagen. Bone wax is used only if the above
The patient is placed in the supine position with the shoul- measures fail to control a point of active bleeding.
ders elevated by a transverse roll and the neck slightly Both supraorbital ridges are removed with a frontal
extended. An arterial line (usually a radial artery), a single bar en bloc, using osteotomes (Fig. 2). The frontal dura is
peripheral venous line, and a Foley catheter are placed. retracted superiorly and posteriorly. This necessitates sepa-
We do not shave or clip the hair, although this is com- ration of the dura. from the midline of the frontal fossa
monly done by most neurosurgeons. Using a sterile comb anterior to the crista galli. An osteotomy is made across the
or hemostat, the hair is parted along the proposed inci- floor of the frontal fossa (i.e., across each orbital roof) and
sion line. The scalp, including the ears and cheeks, are extended laterally across the sphenoid wings (Fig. 2). This
scrubbed with a chlorhexidine solution and the head is osteotomy is approximately 1-1.5 cm posterior to the su-
draped for a transcoronal incision. praorbital rims. The zygomaticofrontal suture is divided
vertically with an osteotome. A vertical osteotomy is made
Chemical Hemostasis in the sphenoid bones down to the level of the
The skin is infiltrated with 0.5% lidocaine with epineph- frontozygomatic suture. When necessary, a horizontal os-
rine (1/400,000) along the planned incision line. teotomy is made to connect the above two osteotomies.
An inverted “V”-shaped osteotomy is made through
Initial Soft Tissue Dissection the region of the frontonasal suture to free the supraor-
A coronal incision is made, beginning about 5 mm above bital rim. If an abnormal nasal ridge exists, it is removed
the insertion of each pinna and crossing the midline near with a high-speed burr.
the anterior fontanelle (Fig. 1). Skin edges are retracted
and clips (preferably children’s or Cone clips) are applied Remodeling of the Supraorbital Rims, Frontal Bar, and
to the scalp edge for hemostasis. Periosteal elevators are Forehead
used to free the pericranium anteriorly to the level of the The supraorbital bar is straightened. This almost always
supraorbital rims. The periorbita are then dissected from requires division in the midline. Posterior reinforcement
the superior half of each orbit. Medially this dissection is with a strip of bone taken from the frontal convexity may
continued well below the frontonasal suture and laterally be required. Straightening of the bar causes the lateral
below the frontozygomatic sutures. The supraorbital orbital margins to swing medially. A large Leksell rongeur
nerves can be preserved by using a thin osteotome to open is used to resect this protrusion and also to remodel the
the supraorbital foramen and reflecting the nerve anteri- superior orbit (Fig. 3).
orly with the skin. Remodeling of the forehead first involves division
of the frontal bone in its midline (Fig. 1). Switching right
Osteotomies for left and rotating the two fragments 90° often achieves
The frontal convexity and supraorbital rims are removed an acceptable appearance but sometimes other incisions
separately. A high-speed craniotome (e.g., Midas Rex) is in the frontal fragments are performed as needed to mold
used for all osteotomies in the frontal convexity. No burr them into an acceptable cosmetic appearance.
holes are made. Blunt dissection in the anterior fonta- Prior to replacing the above remodeled bones, the
nelle is used to separate the dura from the frontal bone narrow anterior biparietal diameter is addressed.


© 1992 The American Association of Neurological Surgeons

Figure 1. Removal and remodeling of the forehead bone. A, a coronal rim (inset). B, the forehead bone is removed and divided in its midline. C
incision is made. The dura is bluntly separated from bone at the anterior and D, switching right for left and rotating the fragments 90° will often
fontanelle and is the starting point for osteotomies. Osteotomies are made give a satisfactory shape. E, other osteotomies and smoothing of the fron-
just anterior to the coronal sutures and 1.5 cm superior to the supraorbital tal bone are performed as needed to improve the shape of the forehead.


© 1992 The American Association of Neurological Surgeons

Figure 2. Removal of the supraorbital bar. The supraorbital ridges and a is divided. An inverted V-shaped osteotomy through the frontonasal suture
1.5-cm frontal bar are removed en bloc. This necessitates separation of the is made. If the tongue-in-groove technique is required, osteotomies are made
dura from the frontal fossa anterior to the crista galli. Osteotomies across posteriorly to form a 2-4 × 1.5-cm “tongue” of bone which is continuous
the frontal fossa (orbital roofs) are indicated. The zygomaticofrontal suture with the frontal bar.


© 1992 The American Association of Neurological Surgeons

Figure 3. Remodeling of the supraorbital bar. A and B, the supraorbital osteotomies from glabella to nasion; using a large Leksell rongeur, the
bar is straightened by division in the midline. B, straightening of the bar superior orbital margin is rounded. D and E, osteotomies are made in the
causes the lateral orbital margins to protrude antermedially and may in- bone of the frontal fossa, facilitating a more natural curve to each su-
crease the distance between the orbits. C, on each side, the lateral orbital praorbital margin. F, the supraorbital bar is reinforced posteriorly with a
protrusion is resected and the interorbital distance is narrowed by vertical strip of bone (generally obtained from the remodeled forehead bone).


Using the high-speed craniotome, the anterior 1-2 cm with 2-0 Vicryl (Figs. 1 and 4). The forehead is then
of the parietal bone is morcellated and the resulting attached to the supraorbital bar with 2-0 Vicryl sutures
two to four fragments are left attached to the dura (Figs. (Fig. 4). Only rarely do we use a few wires and then
5 and 6). only in children over one year of age. The entire rigid
complex is then replaced and anchored with a single 3-
Replacement of Remodeled Forehead 0 Vicryl suture in the frontonasal region (Fig. 4). The
The frontal bones are sutured together at the midline result is a “floating forehead” (Fig. 5).

© 1992 The American Association of Neurological Surgeons

Figure 4. Replacement of remodeled bone. The forehead bone is able suture in the frontonasal region. Wire is occasionally used to
attached to the supraorbital bar using 2-0 absorbable sutures. The attach the forehead to the supraorbital bar in children over one year
entire rigid complex is replaced and anchored with a 3-0 absorb- of age.


Closure and Dressing frontal bar (Fig. 6). This tongue should be at least 1.5 cm
If the upper face has been prepared and draped appropri- wide and about 2-4 cm in length. This tongue always ex-
ately, the scalp should be returned to its normal position, tends posteriorly into the squamous portion of the tem-
temporarily at first, so that the appearance of the upper poral bone beyond the coronal suture. The osteotomies
face and orbits can be assessed. It may be necessary to along the lateral orbits are the same as described above.
make some corrective adjustments in the forehead and The remodeling of the supraorbital rim and frontal
orbits at that time. After the surgeon is satisfied with the bar should include all the steps described above. As a re-
appearance, the galea and underlying pericranium are sult, the tongue of bone will rotate outward on each side
sutured (single layer) with 3-0 Vicryl sutures (interrupted when the midline angle in the frontal bar is corrected.
or continuous technique). Skin edges are approximated Therefore, the sphenoid ridges will need to be notched on
with staples. Drains are occasionally required. Postop- their inner (medial) surfaces and the lateral bony frag-
eratively the head is wrapped snugly but never tightly. ments bent (green stick fracture) inward. It is very impor-
tant that the fragment to which the tongue is attached re-
DESCRIPTION OF TONGUE-IN-GROOVE main firmly continuous with the whole frontal bar.
OPERATION The remodeled forehead is returned to the operative
This procedure is identical to that described above for the field and sewed in the middle with one or two 3-0 Vicryl
first three steps. The removal of the convexity of the frontal sutures. The posteriorly directed tongues of bone are re-
bone and the osteotomy in the orbital roofs (floor of fron- turned to their respective grooves and secured 11.5 cm
tal fossa) are the same as in Step 4 above. The lateral anterior to their original location to give the desired cor-
osteotomies are, however, totally different. The high- rection. The tongues are sewed in place with wire and/or
torque craniotome is used to outline a posteriorly directed 2-0 Vicryl (Fig. 6). The closure and application of the
“tongue” of bone which remains in continuity with the dressing are accomplished as described above.

© 1992 The American Association of Neurological Surgeons

Figure 5. The floating forehead operation. This technique is used in chil- complex then floats over the growing brain. Morcellation of the anterior
dren under nine months of age. The remodeled forehead is replaced and parietal bones, leaving the fragments attached to the dura, corrects the nar-
anchored with an absorbable suture at the frontonasal region. The entire row anterior biparietal diameter.


© 1992 The American Association of Neurological Surgeons

Figure 6. The tongue-in-groove operation. This technique is used in older bone medially. The tongue must remain attached to the supraorbital bar.
children where a more rigid reconstruction is required. A posteriorly di- The forehead bone is replaced and secured in the frontonasal region. The
rected tongue of bone which is continuous with the frontal bar is created tongues of bone are secured 1-1.5 cm anterior to their previous location,
while the lateral osteotomies are performed. The tongue is 1.5 cm wide and thereby rigidly fixing the supraorbital bone in an advanced position. Bipa-
2-4 cm long. Upon straightening the supraorbital bar the tongue protrudes rietal morcellation is performed to correct the narrow anterior biparietal
laterally. Notching of the sphenoid wing facilitates moving the tongue of diameter.


The head of the patient’s bed is elevated. A hematocrit is The child is usually seen five to seven days postopera-
checked in the immediate postoperative period and twice tively for staple removal. Examinations are at about
daily for the first 48 hours. We transfuse packed red cells the six-week, six-month, and one-year anniversaries.
when the hematocrit drops to 22 or below. The dressing should Follow-up radiographs are not necessary unless the cos-
be monitored at approximately 4-hour intervals for the first metic result is questionable or clearly unsatisfactory.
24 hours to ensure that it is not too tight. Facial swelling An enlarging skull defect should alert the surgeon to
reaches its maximum at around 48 hours. The worst of the the presence of a dural tear and is an indication for
periorbital and facial edema resolves over the next 24 hours immediate surgical attention. No clinically significant
and the child is generally discharged at about the time both defects in bone should be palpable at a one-year post-
eyes are clearly open (usually the third to fifth postoperative operative follow-up.
day). A helmet is not used unless the child is a toddler.


INTRODUCTION sions are successful in the treatment of intractable facial

The dorsal root entry zone (DREZ) operation was origi- pain secondary to postherpetic neuralgia or anesthesia
nally reported in 1976 as a focal destruction of the sub- dolorosa, as well as in patients with trigeminal dysesthe-
stantia gelatinosa of Rolando. It was done on a patient sia for whom all other surgical treatments have failed.
with intractable arm pain following a brachial plexus avul- Combined nucleus caudalis-nucleus solitarius lesions in
sion injury. Since then it has been performed at the Duke the floor of the fourth ventricle are performed for the treat-
University Medical Center in over 500 patients with in- ment of intractable visceral pain of pharyngeal origin. The
tractable pain of various etiologies. Pain due to deaffer- nucleus solitarius contains the second-order neurons en-
entation responds best to the DREZ operation, which in- coding pain from cranial nerves IX and X from the tongue,
volves the creation of lesions in the dorsal root entry zone pharynx, larynx, and esophagus.
areas, destroying Rexed layers I through V using a
radiofrequency current delivered through a specially de- PREOPERATIVE EVALUATION
signed thermocouple electrode. These lesions are mainly A thorough evaluation of the patient’s pain is thus essen-
targeted toward the cells of origin of the second-order tial, especially for patients who have undergone previous
neurons in Rexed layers II and V which give rise to the multiple surgical procedures. Plain roentgenograms are
spinothalamic and spinoreticular tracts. The dorsal root obtained routinely to study the details of the bone anatomy,
entry zone extends from the upper cervical cord to the which is especially helpful in patients who have had pre-
conus medullaris deep to the intermediolateral sulcus. It vious operative interventions. Other preoperative radio-
intermingles cephalad with the trigeminal nucleus caudalis logical studies are essential in most cases to confirm the
which is the caudal portion of the trigeminal nucleus. The diagnosis (as in cases of brachial plexus or sacral plexus
nucleus caudalis receives the major pain afferents from avulsion injuries where myelography and magnetic reso-
the trigeminal system. Radiofrequency (RF) lesions in the nance imaging (MRI) usually show evidence of
nucleus caudalis have the same functional effect as the pseudomeningoceles along the avulsed roots (Fig. 1)) as
dorsal root entry zone lesions, and are performed to treat well as to visualize the spinal cord at the proposed opera-
intractable pain of head and facial origin, especially pain tive site for evidence of scar tissue or traumatic syringo-
caused by deafferentation. myelia (Fig. 2). All patients are given 10 mg of dexa-
methasone by mouth the evening prior to surgery. We do
PATIENT SELECTION not use perioperative antibiotics.
Careful patient selection is the key to the success of any
operative procedure. Patients with deafferentation pain OPERATIVE PROCEDURE
syndromes, especially brachial and sacral plexus avulsion All DREZ operations are performed under general an-
pains, benefit the most from this operation. The DREZ esthesia with appropriate physiologic monitoring as de-
operation is also very successful in paraplegic patients termined by the patient’s general condition; however, a
with intractable pain, including central pain and radicu- Foley catheter and an arterial line are essential. The
lar pain, in postamputation phantom pain, and in patient is then placed in the prone position. Patients
postherpetic neuralgia. Trigeminal nucleus caudalis le- undergoing nucleus caudalis lesions as well as patients
undergoing cervical DREZ lesions or lesions involv-
ing the upper four thoracic segments require immobi-
© 1992 The American Association of Neurological Surgeons lization of their head in a Mayf ield head holder


© 1992 The American Association of Neurological Surgeons

Figure 1. A, a cervical myelogram showing traumatic pseudo- pseudomeningoceles along the L5 and S1 nerve roots in a case of sacral
meningoceles along several cervical nerve roots in a case of brachial plexus avulsion injury.
plexus avulsion injury. B, a lumbar myelogram showing traumatic

to ensure anatomical alignment. Full flexion and elevation

of the head is also essential in nucleus caudalis cases as
well as in cases involving the uppermost cervical levels. A
reverse Trendelenburg position is then used to position the
operative site horizontally (Fig. 3). Patients undergoing le-
sions below T4 are placed in the prone position with the
head turned to one side. Adequate cushioning by placing
soft rolls under the chest, hips, arms, and legs will prevent
pressure injuries (Fig. 4). Particular care should be taken
to avoid injury to the ulnar and peroneal nerves. Intraop-
erative steroids are given in the form of intravenous 1-2
mg/kg/hr Solu-Medrol throughout the procedure along with
50 mg of ranitidine intravenously every eight hours. Muscle
relaxants are used in cases where intraoperative evoked
potential monitoring is used.
The level and extent of the surgical exposure re-
lates directly to the level and number of dermatomes
affected. Patients undergoing cervical DREZ lesions
require laminectomies extending one level rostral to
the highest dermatome affected, whereas those under-
© 1992 The American Association of Neurological Surgeons
going thoracic DREZ lesions require laminectomies
Figure 2. A cervical MRI showing a traumatic syrinx in a patient with
cervical spinal cord injury.
two levels higher. The number of laminectomies per-


© 1992 The American Association of Neurological Surgeons

Figure 3. Positioning of a patient undergoing nucleus caudalis DREZ lesions or cervical DREZ lesions.

© 1992 The American Association of Neurological Surgeons

Figure 4. Positioning of a patient undergoing thoracic or conus medullaris DREZ lesions.


formed is based directly, in a one-to-one ratio, upon the avulsed area on the spinal cord at the level of the conus is
number of painful dermatomes. For patients undergoing often hidden by these superficial sensory rootlets from
a conus medullaris DREZ lesioning for intractable lower higher levels and the surgeon must carefully retract these
extremity pain, as in patients with phantom pain, T10 roots to expose the avulsed area. Anatomical identifica-
through L1 laminectomies are performed. For trigeminal tion of the sacral sensory roots is often difficult. The S1
nucleus caudalis lesions a small suboccipital craniectomy dorsal root is the largest, and the best way to identify it
and C1-C2 laminectomies are performed (Fig. 11, upper visually is for the surgeon to find the last sacral root, which
left). Determination of the level is based on palpation of is extremely small, and count up from that point to the
the spinous processes and is confirmed by obtaining an largest dorsal root which should be the level of S1. The
intraoperative radiograph as necessary. most accurate method of dorsal root localization is the
The anatomy of the spinal roots varies according to use of somatosensory evoked potentials. Electrical stimu-
the level of their origin from the spinal cord. The lation over the femoral triangle, stimulating the femoral
cervicodorsal roots are made up of five to eight individual nerve, will give a good L1 localization. With the record-
rootlets that form the main sensory branch and exit via ing electrodes placed on the spinal cord while stimulat-
the intervertebral foramen at the level of origin from the ing over the popliteal fossa (posterior tibial or sciatic
spinal cord. In contrast, the thoracic dorsal roots are made nerve) and recording on the conus will give good S1 lo-
up of two to four rootlets which are much smaller in di- calization. Where there is an area of unilateral avulsion
ameter that form the main dorsal root and they exit at on the conus or loss of a leg from trauma, the intact leg
least two to three vertebral levels below their origin from can be used for somatosensory localization (Fig. 5).
the spinal cord. Whereas the cervical sensory rootlets The thoracic dorsal roots are the most difficult to
originate close together, the thoracic roots often are sepa- identify precisely at their origin on the spinal cord. We
rated by several millimeters with a distance of 5 mm be- use the “rule of two”: the origin of the dorsal root from
tween successive thoracic dorsal roots. This so-called the spinal cord is approximately two vertebral levels
blank space between the thoracic roots should also be in- above its exit at the intervertebral foramen. In patients
cluded in the DREZ lesioning. with postherpetic pain involving the thoracic or abdomi-
At the level of the conus medullaris, the lower lum- nal areas, the surgeon may note after opening the dura
bar and sacral roots are close to each other and may over- that certain of the dorsal roots appear abnormal. This
lap the conus and hide the lower sacral sensory roots. The is a good indication that the proper roots for

© 1992 The American Association of Neurological Surgeons

Figure 5. Localization by somatosensory evoked potential most positive wave recorded when stimulating the affected der-
monitoring. The site for DREZ lesioning is determined by the matome.


the DREZ lesion have been localized. These involved and rongeurs or using the Midas Rex M-3 bit as a perfo-
herpetic dorsal roots usually appear thin, dull, and gray- rator followed by a suboccipital craniotomy and removal
ish-red in color. A biopsy of the dorsal root reveals loss of the bone in one piece. Care should be taken during
of the large myelinated fibers. dissection of the paraspinal muscles at the C1-2 area due
The advantage of the DREZ lesion is that the clinical to the presence of large veins in that location. Careful
effect can be localized to specific dermatomes or der- dissection of the periosteum above and underneath the
matomal levels. As we have indicated above, precise ana- posterior arch of C1 should be performed prior to the use
tomical localization is important to restrict the lesion just of rongeurs or the drill. The craniectomy needs to extend
to the painful areas of the body. about one-third to one-half the distance from the fora-
Following a thorough skin preparation and draping, men magnum to the inion and extend bilaterally just short
a midline incision is made down to the subcutaneous tis- of the mastoid processes. The rim of the foramen mag-
sue, and using electrocautery the midline cervical or num is carefully dissected and preferably removed piece-
lumbodorsal fascia is incised. In most instances a stan- meal. The atlanto-occipital membrane is then dissected
dard multilevel bilateral laminectomy is done following a and cut using Dandy scissors. Bone wax and Surgicel are
subperiosteal dissection of the paraspinous muscles from used to control bleeding as mentioned above and the dura
the spinous processes and laminae. After adequate con- is then opened.
firmation of the desired levels, bilateral laminectomies The dural opening is accomplished with or without
are performed in almost all patients. Hemilaminectomies the aid of the operative microscope. Either way a 2-mm
are performed in patients with thoracic postherpetic neu- opening in the midline is made with a small-blade scal-
ralgia and in patients with unilateral intractable radicular pel, sparing the arachnoid. The dura is then opened
pain secondary to spinal cord injury. Postoperative recov- sharply in the midline along the entire extent of the bony
ery is faster and incisional pain is less in patients under- exposure (Fig. 6B). Using 4-0 silk sutures placed ap-
going hemilaminectomy. proximately 1 cm apart, the dural edges are retracted
We prefer to use the Midas Rex drill to perform the laterally, thus maximizing the exposure. In patients with
laminectomies to save operative time and for its safety when trauma or prior operative procedures, the dura and arach-
used by an experienced surgeon. We use the S-1 drill bits noid may be adherent and scarred down to the spinal
for lumbar and thoracic laminectomies and hemilaminec- cord. Gentle and blunt dissection using the microscope
tomies, and the B-1 drill bits for the cervical region. We is required to separate them. In nucleus caudalis DREZ
first use the AM-8 drill bit to drill the lower portion of the operations, care should be taken when opening the dura
most caudal lamina to expose the ligamentum flavum bi- across the area of the foramen magnum due to the fre-
laterally. The S-1 or B-1 bit is then used to cut through the quent presence of a circular sinus. Control of bleeding,
laminae one after the other, rostrally (Fig. 6A). This is per- from the sinus is achieved using hemostatic clips until
formed on both sides. The supraspinous and interspinous the dura is opened followed by replacing the clips with
ligaments above and below are cut with Mayo scissors and a running 4-0 silk suture. Once the dura is opened be-
the laminae and spinous processes are removed en toto. yond this point the incision is then curved laterally to-
The AM-8 bit is then used to widen the laminectomy as ward the side of the pain.
necessary. The use of the Midas Rex drill is not essential If the microscope was not used for the dural opening
and the laminectomies can be performed the conventional it is then brought into the field to open the arachnoid. The
way using rongeurs. A hemilaminectomy is used to expose arachnoid is opened directly over the dorsal root entry
the dorsal roots in the thoracic region in patients with zone in patients undergoing unilateral DREZ lesions. The
postherpetic pain. The dorsal roots are well visualized us- arachnoid is first opened in the middle of the exposure by
ing the microscope. Lesser postoperative pain and early the use of a sharp hook and scissors and then its edges are
mobility are advantages in this group of patients who are secured to the dural edges using small hemostatic clips
often elderly. We do not use the Midas Rex drill in cases (Fig. 6C). It is then opened caudally and rostrally using a
where epidural scarring is suspected from previous sur- microbayonet forceps and sharp microscissors. It is im-
gery, trauma, or infection. Bone bleeding is controlled by portant to keep the arachnoid edge secured to the dural
applying bone wax to the edges of the laminae. Epidural edge with hemostatic clips so that when the dura is closed
venous bleeding is controlled with bipolar cautery and small the subarachnoid space is maintained and adhesion of the
pieces of Surgicel. Cottonoid strips are placed over the sides dura to the spinal cord is prevented. In patients undergo-
of the wound and the dura is then opened. ing nucleus caudalis lesions, the posterior inferior cer-
In patients undergoing nucleus caudalis lesions, the ebellar artery is almost always encountered and care
suboccipital craniectomy is performed using a perforator should be taken to avoid injury to this impor-


© 1992 The American Association of Neurological Surgeons

Figure 6. A, a laminectomy performed using the Midas Rex AM-8 and S-1 drills. B, opening of the dura. C, opening of the arachnoid.


tant vessel. This is especially important in patients who placed at each end of the dural exposure between the su-
have undergone a previous retromastoid craniectomy for ture line and the adjoining supraspinous or interspinous
microvascular decompression of the fifth cranial nerve ligament. Central tack-up stitches are also used: two in
for tic douloureux, in whom scarring and thickening of four-level laminectomies and three in five-level laminec-
the arachnoid can obscure the vessel. tomies. These are placed between the dural suture line
Once the arachnoid is satisfactorily opened, any ad- and the connective tissue overlying the adjoining joint
herent structures over the dorsal root entry zone should capsule in the lumbar and thoracic regions, or to the cer-
be dissected and retracted. Commonly, multiple serpen- vical fascia and nuchal ligament in the cervical region.
tine vessels located along the intermediolateral sulcus We prefer to place tack-up stitches in all cases, whether
must be mobilized to allow for the introduction of the bilateral laminectomies or hemilaminectomies are per-
DREZ electrode. If bleeding is encountered, a small piece formed. Copious amounts of bacitracin irrigation are used
of Surgicel placed on the vessel is almost always suffi- after each layer of the wound is closed. The paraspinal
cient for hemostasis; if the bleeding is significant, bipo- muscles are sutured with 2-0 Vicryl sutures, followed by
lar coagulation at a low setting is used. The description closure of the subcutaneous tissue in two or three layers
of the DREZ electrodes as well as the specifics of the of 2-0 Vicryl sutures depending on its thickness. The skin
operation for various indications are mentioned later. In is then sutured using 4-0 continuous nylon sutures. We
general, the DREZ electrode is placed first into the most ordinarily do not use epidural drains. If drains are used
caudal aspect of the region to be lesioned, and is then they are preferably removed on the first postoperative day
moved stepwise in cephalad direction. This allows the to avoid infection and the development of a cerebrospinal
neurosurgeon to visualize the upper dorsal rootlets as a fluid (CSF) fistula.
guide. The electrode is placed into the entry zone at the
same angle as the dorsal root, i.e., approximately 45°. ELECTRODES AND LESION PARAMETERS
The electrode is placed into the spinal cord to a depth of The three types of DREZ electrodes in use at Duke are
2 mm, at which point the insulating collar prevents fur- manufactured by Radionics who also make the RF lesion
ther ingress. Lesions are made at 75°C for 15 seconds generator used in the DREZ operation (Fig. 7). The stan-
using the radiofrequency generator. The lesions are made dard DREZ electrode has a lesion tip of 2 mm and is 0.25
at 1-mm intervals along the entire affected dorsal root mm in diameter (Fig. 7A). The caudalis nucleus electrode
entry zone. The spinal region to be lesioned can be mea- has a tip length of 3 mm, a diameter of 0. 25 mm, a 1-mm
sured, and if the distance is 10 mm then 10 lesions should proximal insulation, and a 2-mm lesion tip (Fig. 7B). The
be made. A comparison of the improvement in pain af- proximal 1-mm insulation at the base is designed to pre-
ter DREZ procedures between the earlier patients oper- vent lesioning the ascending spinocerebellar tract which
ated on in the late 1970s and the more recent cases re- lies superficial to the trigeminal nucleus caudalis. A new
veal improved results with a greater number of DREZ type of caudalis electrode is made with a 90° angle at the
lesions. Blood vessels which are encountered are gently tip to facilitate its use at the higher levels of the
retracted and the electrode slipped into the entry zone cervicomedullary junction (Fig. 7C). The electrodes are
avoiding the coagulation of all except the smallest ves- made of a hollow stainless steel tube tapered and pointed
sels adherent to the DREZ area. The laser has been used at the end with an internal thermister at the tip to measure
by some neurosurgeons to create DREZ lesions, and the the temperature of the lesion. The RF lesions are made at
early clinical reports regarding relief of pain and com- 75°C for 15 seconds and this results in a lesion (2 × 4-5
plications appear to be satisfactory. We believe the laser mm) which will destroy the upper 5 or 6 Rexed layers in
lesion may be more difficult to control because of the the dorsal horn. Two postmortem studies have confirmed
lack of detailed laboratory studies, but this may be cor- the focal nature of the lesions of the Rexed layers. The heat
rected in the future. produced at the tip of the electrode is produced by the
After all lesions are made, total hemostasis is ob- radiofrequency current generator. Spinal cordotomy-type
tained within the thecal sac and all residual blood is electrodes are not satisfactory to make DREZ lesions.
gently irrigated away. The dura and arachnoid are
reapproximated in a single layer of continuous 4-0 Vicryl BRACHIAL PLEXUS AVULSION INJURY
suture, removing the silver clips gradually as the suture A laminectomy usually extending from C5 to T1 is per-
approaches the site of the clip to avoid any gaps in the formed, although it is imperative that at least a portion
arachnoid closure. Dural tack-up sutures are placed to of the healthy roots above and below the avulsion be
avoid compression in the event of the development of a visualized to avoid any residual postoperative pain.
postoperative epidural hematoma. A tack-up suture is The intermediolateral sulcus marking the entry


© 1992 The American Association of Neurological Surgeons

Figure 7. The various DREZ electrodes: A, standard DREZ electrode. B, nucleus caudalis DREZ electrode. C, El-Naggar-
Nashold right-angled nucleus caudalis DREZ electrode.

zone of the avulsed rootlets is readily identified in most cases sponsible dorsal rootlets as shown below; we find this to
and is easily seen along an imaginary line connecting the be crucial to avoid incomplete pain relief. Both soma-
entry zone of the first attached root above and the first at- tosensory evoked potential (SEP) and motor evoked po-
tached root below the avulsed area. Also, identification of tential (MEP) studies are carried out intraoperatively.
the DREZ area on the normal contralateral side helps in iden- Anatomic localization is most difficult with the thora-
tifying the overall anatomy of the area. DREZ lesions are columbar dorsal roots and those dorsal roots originating
then placed 1 mm apart extending between the healthy root- from the conus medullaris. Careful SEP studies from the
lets above and below as described above (Fig. 8). painful areas of the body give a precise dorsal root local-
ization, allowing the neurosurgeon to confine the DREZ
CONUS MEDULLARIS ROOT AVULSIONS lesions to the involved painful area of the body.
Avulsion injuries of the conus medullaris differ from those We now routinely monitor somatosensory evoked
in the cervical region in that usually only one or two lum- potentials intraoperatively. The potential recorded is pro-
bosacral roots are avulsed (L5 or S1). When the conus is duced by simultaneous firing of dorsal horn neurons, the
exposed at operation, the lumbosacral dorsal roots on ei- maximal discharge being in the spinal cord segment(s) of
ther side can be seen along with the avulsed area on the entry of the nerve stimulated (Fig. 5). This allows for pre-
conus. The dorsal roots on the side of the avulsion must cise localization of the level for lesion production. Stimu-
be carefully retracted laterally until the avulsed root level lating electrodes are placed bilaterally near affected nerves
is visualized (Fig. 9). as determined from the preoperative sensory exam, and
also on the contralateral side near the comparable intact
PARAPLEGIA WITH INTRACTABLE PAIN nerves. This allows for a comparison of normal with ab-
Meticulous dissection of the arachnoidal scarring and normal signals.
adhesions commonly found in these cases is necessary to For stimulating the body or the extremities, we use
identify the DREZ area. Intraoperative ultrasound is also subcutaneous bipolar needle electrodes; bipolar gold discs
used whenever there is a suspicion of the presence of a are used when stimulating the face. The evoked poten-
traumatic syrinx either on clinical, radiological, or surgi- tials are recorded from the surface of the spinal cord or
cal grounds. If present, the syrinx should be drained by the cervicomedullary junction using platinum-irridium
placement of a syringo-subarachnoid or syringo-perito- multicontact disc electrodes and also from the depth us-
neal shunt in addition to the DREZ lesions (Fig. 10). ing the lesion-generating electrode.
The largest amplitude negativity is determined af-
POSTHERPETIC NEURALGIA ter stimulation of the intact side. The negativity is usu-
Evoked potentials are very helpful in localizing the re- ally comparatively much reduced or otherwise ab-

© 1992 The American Association of Neurological Surgeons

Figure 8. DREZ lesions in brachial plexus avulsion injuries.


© 1992 The American Association of Neurological Surgeons

Figure 9. DREZ lesions in conus medullaris sacral avulsion injuries.


first and wired or plated into position (labeled C in

Fig. 6). The nasal bone and cribriform plate are usu-
ally the most solid structures to work with. The medial
canthal ligament also has to be reattached, which can
be done easily through a small drill hole. Next, a piece
of bone is fashioned to form the orbital roof. This is an
important structure which must be solidly placed (Fig.

© 1992 The American Association of Neurological Surgeons

Figure 10. DREZ lesions and drainage of a traumatic spinal cyst in cases with intractable pain due to spinal cord injury.


normal on the affected side. We have found that in many trigeminal tubercle between the border of the cuneate
instances after DREZ lesions are produced, the negative tubercle and the emerging cranial roots of the accessory
wave is replaced by a positive one. This positive potential nerve (Fig. 13C). Only one row of lesions is made. Fa-
generally signals the volume-conducted approach toward miliarity with the bilateral exposure of the nucleus
the electrode of neural activity, but without neuronal dis- caudalis is advised prior to performing the unilateral
charge at the electrode site. This positivity, then, provides exposure.
for an immediate feedback on the technical success of
NUCLEUS CAUDALIS DREZ LESIONING The exposure is the same as for nucleus caudalis DREZ
The DREZ lesions are made using the special caudalis lesioning. After arachnoid dissection, standard nucleus
electrodes described above. The special design of these caudalis DREZ lesions are made; then two lesions are
electrodes takes into account that the caudalis nucleus lies made to destroy the nucleus solitarius in the floor of the
beneath the surface of the cervicomedullary junction. fourth ventricle 1 mm above the obex and 1 mm lateral to
Therefore, the electrode tip is 3 mm in length and 0.25 the midline on the side of the pain (Fig. 11, middle). The
mm in diameter, with a proximal 1 mm insulated area and RF lesions are made using the straight nucleus caudalis
a distal 2-mm lesion tip. The RF lesions are made along electrode, thereby avoiding injury to the overlying cra-
the same line as the cervical dorsal root entry zones over nial nerve nuclei. Transient bradycardia and a slight drop
a distance of 15-20 mm from the level of the C2 dorsal of the blood pressure may occur during lesioning. The
rootlets to the tuberculum cinereum of the medulla at a use of 0.5-1 mg of atropine intravenously will prevent the
level slightly above the obex. Due to the larger cross-sec- vascular changes which are due to the proximity of the
tional diameter of the nucleus caudalis, two rows of RF afferent input from the carotid body into the ventral por-
lesions are made 1 mm apart using the same parameters tion of the nucleus solitarius. The combined nucleus
of 75°C for 15 seconds. The first row of lesions begins at caudalis and solitarius lesions give good pain relief in
the level of the dorsal rootlets of C2 and is extended ceph- patients with head and neck cancer, especially those with
alad to 5 mm above the obex. The second row begins at posterior pharyngeal and esophageal pain.
C2 but just dorsal to the exit of the rootlets of the spinal
accessory nerve (Fig. 11, middle and lower left). POSTOPERATIVE CARE
Currently, we perform a unilateral limited exposure Postoperative care is the same as for laminectomy patients.
of the nucleus caudalis. This is associated with less post- We prefer, however, progressive ambulation of the patients
operative pain and earlier ambulation. It involves a para- depending upon the clinical condition. Patients who un-
median skin incision (Fig. 12A). The incision is carried dergo conus medullaris DREZ lesioning or lower thoracic
down to the subcutaneous tissue, cervical fascia, and procedures are nursed in the flat position for three to four
trapezium muscle using electrocautery. The semispina- days followed by progressive ambulation. Patients with
lis capitis muscle is then split at the point of emergence upper thoracic, cervical, and caudalis DREZ surgery are
of the greater occipital nerve (Fig. 12B). The rectus capi- kept with the head of the bed up 30° for three days fol-
tis posterior minor muscles are divided at their insertion lowed by progressive ambulation. Steroids are continued
on the posterior tubercle of C1 and reflected upward. in the postoperative period for three days followed by rapid
The rectus capitis posterior major is retracted downward tapering over three to four days to avoid the deleterious
and laterally using a Leyla retractor (Fig. 12C). A uni- effect of steroids on wound healing. Analgesics are lim-
lateral suboccipital craniectomy with removal of the ip- ited to those necessary to control postoperative pain.
silateral half of the arch and whole tubercle of C1 is Parenteral narcotics for 24-48 hours are used followed by
then performed. The ligamentum flavum between C1 and oral codeine or oxycodone for a few days. We prefer not
C2 is also removed (Fig. 12D). The C2 lamina and the to give narcotics in high doses for extended periods of
muscles attached to C2 are left intact. The dura and arach- time to be able to assess the results of surgery.
noid are then opened as discussed previously. The le-
sions are made using the right-angled nucleus caudalis COMPLICATIONS
DREZ electrode (Fig. 13A), which provides a better angle Postoperative complications are in the order of 3-5%,
to target the lesion on the nucleus caudalis (Fig. 13B). including CSF leakage and postoperative epidural he-
The lesions are made starting above the C2 rootlets in matoma formation, in addition to ipsilateral lower ex-
line with the DREZ area of the spinal cord in the inter- tremity weakness or incoordination, especially follow-
mediolateral sulcus proceeding upward until the C1 root- ing DREZ lesions in the thoracic cord. Nucleus
lets are encountered. The lesions are then made into the caudalis DREZ lesioning can be especially compli-


© 1992 The American Association of Neurological Surgeons

Figure 11. Nucleus caudalis DREZ lesions using a bilateral exposure. Nucleus solitarius lesions are also shown.


© 1992 The American Association of Neurological Surgeons

Figure 12. Unilateral exposure of the nucleus caudalis.


© 1992 The American Association of Neurological Surgeons

Figure 13. Precise location of lesions of the nucleus caudalis.


cated by upper and/or lower extremity ataxia, usually tine antibiotics are not used; however, if signs of infec-
resolving in a few days. Cerebrospinal fluid leakage can tion develop, we obtain blood cultures as well as wound
be prevented by having a tight dural closure and nursing cultures followed by the administration of broad spec-
the patient in the appropriate position postoperatively. trum antibiotics until the final results of the cultures are
In nucleus caudalis DREZ operations we almost invari- obtained. Neurologic deficits in the form of ipsilateral
ably place a dural graft at the time of closure to avoid or bilateral upper and lower extremity weakness can be
undue tension on the dura, which in turn allows for a avoided by careful monitoring of evoked potentials as
better, tighter closure. Epidural hematomas can be pre- well as downstream electromyographic recording in ad-
vented by having a dry field prior to closure in addition dition to thorough adherence to the above mentioned
to the use of tackup stitches as mentioned above. Rou- principles of lesion making.


PERTINENT ANATOMY Other aneurysms originating within this segment in-

The ophthalmic segment (OphSeg) is the longest sub- variably incorporate the perforating branches to the hy-
arachnoid portion of the internal carotid artery (ICA). It pophysis and are herein called SupHypArt aneurysms
begins below the level of the anterior clinoid process at (Fig. 3). Small SupHypArt aneurysms usually arise from
the point where the ICA penetrates the dura to enter the the inferior or inferomedial surface of the ICA just oppo-
subarachnoid space and ends at the origin of the posterior site and slightly distal to the origin of the OphArt. These
communicating artery (PComArt) (Fig. 1). Removal of lesions may remain lateral to the sella, burrowing beneath
the anterior clinoid process (AC) to expose the proximal and medial to the ICA under the anterior clinoid process.
portion of the OphSeg reveals an ICA segment that lies Because the space beneath the carotid is limited, how-
beneath the subarachnoid space and outside the cavern- ever, most larger lesions will eventually expand medially
ous sinus. This portion, known as the clinoidal segment or superomedially above the diaphragma sellae into the
(ClinSeg), is limited superiorly by the dural reflections suprasellar space.
from the medial roof of the anterior clinoid process to-
ward the optic nerve and canal that mark ICA entry into PATIENT SELECTION
the subarachnoid space, a point known as the dural ring The typical patient harboring an OphSeg aneurysm is a
(DR). Inferiorly, the clinoid segment is bordered by a thin female in her mid-fifties who presents with a subarach-
layer of periosteum, bridging from the ICA to the oculo- noid hemorrhage (SAH) or visual changes, or whose an-
motor nerve (carotid-oculomotor membrane (COM) or eurysm is discovered incidentally. If bleeding has oc-
membranous ring), that separates this segment from the curred, surgery is performed on the earliest day possible
venous wall of the cavernous sinus. following the hemorrhage, as long as the patient is not a
Two named branches arise from the OphSeg, both of poor medical risk or has not sustained significant and ir-
which typically originate just above the dural ring. The reversible brain injury.
ophthalmic artery (OphArt) usually arises from the dor- Approximately one-half of symptomatic OphSeg
sal or dorsomedial ICA surface. Several perforating ves- aneurysms are giant lesions presenting with visual loss.
sels also arise from this segment, the largest of which has The high frequency of OphSeg lesions reaching large or
been named the superior hypophyseal artery (SupHypArt). giant proportions without bleeding is probably explained
These perforators typically arise from the medial or ven- by their reinforcement by adjacent structures, such as the
tromedial ICA surface. Their ventromedial origin, together optic nerve or dura of the lateral sellar wall and cavern-
with the gentle downward slope of the dural ring posteri- ous sinus. Lesions presenting with mass-related symp-
orly, often places the SupHypArt origins on a horizontal toms are often much larger on computed tomography than
plane below the level of both the anterior clinoid process the angiographically apparent lumen size would suggest,
and OphArt. indicating a significant incidence of partial luminal throm-
Ophthalmic segment aneurysms are divided herein bosis.
into two large categories, depending on association of the Because 40-50% of patients with one OphSeg lesion
aneurysm neck with the named arterial branches within also have at least one other intracranial aneurysm, the
the segment. Aneurysms arising in clear relation to the surgeon often must decide which lesion bled. Small
ophthalmic artery are termed OphArt aneurysms (Fig. 2). SupHypArt lesions that remain purely paraclinoid have a
These lesions arise from the ICA just distal to the origin very low rate of hemorrhage compared with those at other
of the ophthalmic artery, and initially project dorsally or locations, and asymptomatic lesions are often best treated
dorsomedially from the carotid surface toward the lateral conservatively unless intervention is planned for other
half of the optic nerve. reasons. Larger aneurysms, or those with medial supra-
sellar extension, appear to bleed with higher frequency.
© 1992 The American Association of Neurological Surgeons If intervention is planned, the ideal treatment of


© 1992 The American Association of Neurological Surgeons


Figure 1. Paraclinoid anatomy. A, lateral view (schematic) with the and reflecting from the medial surface of the AC delineates the
clinoid intact. The three paraclnoid segments of the ICA can be iden- paraclinoid segments. DR = dural ring; COM = carotid-oculomotor
tified, including the intracavernous segment (CavSeg), the clinoidal membrane (also called membranous ring); OSt = optic strut. In most
segment (ClinSeg), covered by the anterior clinoid process (AC), and instances, the OphArt and SupHypArt arise from the OphSeg, above
the ophthalmic segment (OphSeg). The OphSeg begins just proximal the dural ring. C, dorsal view (schematic) with the anterior clinoid
to the OphArt origin and ends at PComArt. Note the posterior bend of intact. Note the medial-to-lateral curve of the ICA that actually begins
the ICA just beyond the ophthalmic artery (OphArt) origin, which is just beyond the anterior bend of the CavSeg. The SupHypArt perfora-
usually obscured by the AC. ON = optic nerve; SupHypArt = superior tors usually arise from the inferomedial surface of the OphSeg as the
hypophyseal artery; PComArt = posterior communicating artery; ICA curves laterally. The right ON has been retracted superiorly to
AChorArt = anterior choroidal artery; CavSin = cavernous sinus. B, expose the OphArt origin. Occasionally, both or either branch may
lateral view (schematic) with the clinoid removed. The dura overlying arise from the ClinSeg, beneath the dural ring. Pit = pituitary gland.


© 1992 The American Association of Neurological Surgeons

© 1992 The American Association of Neurological Surgeons


Figure 2. Typical anatomy of ophthalmic artery aneurysms. A, a large placement of the lateral aspect of the optic nerve. The ON often creates a
ophthalmic artery aneurysm (schematic, lateral view, clinoid intact). Note groove in the superomedial surface of the aneurysm, and its position re-
the position of the optic nerve (ON) and the sharp angulation of its supe- stricts medial extension of the AN across the midline until late in the
rior surface (arrow) against the edge of the falciform ligament. Note also clinical course. FalcLig = falciform ligament. C, a lateral arteriogram of
that the anterior clinoid process (AC) limits the view of the proximal an- a typical large OphArt aneurysm. Note that the lesion originates just be-
eurysm neck and the origin of the ophthalmic artery (OphArt). DR = du- yond the OphArt takeoff and projects largely dorsally, above the bend of
ral ring; OphSeg = ophthalmic segment; AN = aneurysm. B, a large OphArt the carotid artery. As the lesion expands, the superior restriction imposed
aneurysm (schematic, dorsal view, clinoid intact). Note the medial dis- by the overlying optic nerve tends to close the carotid siphon.


© 1992 The American Association of Neurological Surgeons


© 1992 The American Association of Neurological Surgeons

Figure 3. Typical anatomy of superior hypophyseal artery aneurysms. A, the aneurysm neck. Note also that the AN does not sharply angulate the
a small superior hypophyseal artery aneurysm. 1, lateral view (schematic). optic nerve at the falciform ligament. 2, AP view (schematic). Note the
The aneurysm (AN) arises ventromedially above the dural ring (DR), op- two bulges at the aneurysm, one ventrally at the site of aneurysm origin.
posite the ophthalmic artery (OphArt) origin, and appears to project into and the second into the suprasellar space. To totally obliterate this lesion,
the cavernous sinus. The AN lies partly below the level of the anterior the ventral bulge (arrow) lateral to the sella must be incorporated in the
clinoid process (AC) but is still within the subarachnoid space. ON = op- clip down to the dural ring. C, a giant superior hypophyseal aneurysm,
tic nerve. 2, anteroposterior (AP) view (schematic). The AN projects ven- dorsal view (schematic). Note the suprasellar extension beneath the chi-
tromedially above the DR toward the lateral sellar wall. SupHypArt = asm, with the pituitary stalk (PitSt) displaced and allowing extension across
superior hypophyseal artery; Pit = pituitary gland. B, a larger superior the midline. D, a lateral arteriogram of a typical large SupHypArt aneu-
hypophyseal artery aneurysm. The lesion size now exceeds its ventral rysm. In this projection, the AN balloons both above and below the pro-
confines and expands into the suprasellar space below the optic nerves jected course of the ICA, which appears to run through the aneurysm
and chiasm. 1, lateral view (schematic). Note that the AN projects both lumen. The part of the aneurysm below the ICA represents the initial
dorsal and ventral to the OphSeg of the ICA, and its lumen is widely ventral origin, whereas the suprasellar extension lies superior. The ca-
splayed. The SupHypArt drape over the aneurysm’s superior surface, while rotid siphon appears to open as the lesion enlarges, due to the bulge be-
the posterior communicating artery (PComArt) is displaced posteriorly neath and medial to the ICA. Note that the region of the typical OphArt
and laterally. The AC limits the view of the ventral and medial aspects of origin is independent of the aneurysm.


OphSeg aneurysms is clipping, with preservation of the provides key knowledge to the surgeon about the anatomy
internal carotid artery and its branches. Major risks of likely to be encountered in the operating room.
surgery include blindness, stroke, or inability to com-
pletely secure the aneurysm neck. With proper exposure SURGICAL TECHNIQUE
and a firm understanding of parasellar and vascular
anatomy, however, most of these lesions are clippable, with Anesthesia and Monitoring
low risks to the brain or visual apparatus. Carotid ligation The ispilateral cervical carotid region should be unen-
should be considered a secondary alternative, as the risks cumbered by any anesthetic equipment. If temporary clip-
of stroke are higher from parent vessel sacrifice, the vi- ping of the ICA is anticipated, intravenous barbiturates
sual system is not as effectively decompressed, and com- are administered until burst suppression is achieved on
plete thrombosis of the aneurysm is not ensured. electroencephalography (EEG) and are continued until
patency in the carotid system is restored. Blood pressure,
PREOPERATIVE PREPARATION monitored with an indwelling radial artery catheter, is
Bleeding from OphSeg aneurysms is managed in the same generally maintained at normal levels. Continuous evoked
fashion as SAE from aneurysms in other locations, using potential and EEG monitoring is also utilized, and the
such measures as bedrest, calcium channel blockers, hy- blood pressure is elevated during ICA clipping if focal
dration, ventricular drainage (when indicated), steroids, changes are noted. Spinal drainage is not utilized rou-
and anticonvulsants. Prophylactic antibiotics are given to tinely.
all patients when they enter the operating suite and are
continued for 24 hours. Operative Positioning and Draping
Preoperative bedside testing of visual fields is often The patient is placed in the supine position, with the head
overlooked in the SAH patient, but should be dutifully elevated above the heart to promote good venous drain-
performed in those harboring large or giant OphSeg an- age (Fig. 4). The patient’s head is turned 45° toward the
eurysms. The early visual sign of an OphArt aneurysm opposite side, with the vertex lowered, to allow gravita-
(an inferior nasal field cut) is often not noted by the pa- tional distraction of the frontal and temporal lobes from
tient. Establishment of this visual field loss pattern not the skull base. A shoulder roll is used to minimize distor-
only documents the deterioration preoperatively, but also tion of the cervical carotid bifurcation.

© 1992 The American Association of Neurological Surgeons

Figure 4. Operative position and craniotomy exposure (schematic). The noid ridge. The carotid incision is draped into the operative field but is
arrow points to the “keyhole,” marking the external surface of the sphe- not opened in most instances.


The head is draped to permit visualization of the fron- able size (usually <5 mm) that houses an ICA segment
tal and temporal regions from the midline to below the (clinoidal segment) below the dural ring but outside the
zygoma. For giant lesions, especially those with calcifi- main venous channels of the cavernous sinus. Although
cations or luminal thrombosis, the cervical region is also covered by thin reflections of periosteum and small venous
draped to allow sterile access to the carotid bifurcation channels, the ClinSeg can be freed up from its loose at-
for proximal control or bypass source as desired. tachments, thus providing proximal exposure for tempo-
rary clipping if required.
Operative Procedure The dura is then opened and reflected to expose the
The skin incision for craniotomy extends from the mid- proximal portions of the sylvian fissure. The fissure is
line to the zygoma, one finger’s breadth behind the hair- split widely to allow an unobstructed view of the optic
line (Fig. 4). An incision is also marked over the cervical nerve, ICA, and aneurysm with minimal retraction.
carotid bifurcation, paralleling the anterior margin of the If indicated and not already performed, the clinoid
sternocleidomastoid muscle, but is not opened in most process is now removed intradurally (Fig. 6). After cau-
instances. terization, a cruciate incision is made into the dura cover-
The temporalis fascia is sectioned 1 cm below its skull ing the anterior clinoid process and the optic canal roof.
attachment superiorly, and just posterior to the fat pad The clinoid process is then carefully thinned and removed
containing the frontal branch of the facial nerve. The with small rongeurs and a highspeed drill. The removal
temporalis muscle with its remaining fascial covering is should extend laterally to include the medial roof of the
reflected inferiorly and posteriorly to expose the pterion. superior orbital fissure, inferomedially to trim the optic
A frontotemporal free bone flap is elevated, opening low strut, and superomedially to unroof the optic canal.
enough anteriorly so that 2-3 cm of the posterior frontal Optic nerve displacement, if not already done by the
fossa floor is exposed. The sphenoid ridge is removed aneurysm, is often necessary to visualize the proximal
extensively, and a temporal craniectomy is enlarged to neck. The falciform ligament should be sectioned before
allow an unobstructed view of the anterior aspect of the any aneurysm dissection is undertaken. This structure
middle cranial fossa. forms a knife-like edge against the superior aspect of the
Proximal visualization of the carotid and ophthalmic optic nerve, and mobilization of the nerve against it may
arteries is mandatory for both aneurysm types (OphArt further increase visual morbidity.
and SupHypArt), and, at this point, a decision is made The neck of the aneurysm is now ready to be de-
whether to remove the anterior clinoid process fined. Before beginning the dissection, the ClinSeg should
extradurally. While not always necessary for smaller le- be prepared to receive a temporary clip if the need is an-
sions, clinoidal removal is frequently required for safe ticipated. Extradural clinoidal removal requires that the
and accurate clipping of large or giant lesions. With clinoidal dura now be opened from within, thereby delin-
unruptured aneurysms, extradural clinoid removal can eating clearly the dural ring and the clinoidal ICA seg-
usually be done quite safely, without exposing the sub- ment. The dural ring is thicker laterally but thins on its
arachnoid space to bone debris. Generally, and especially medial surface. Its circumferential section allows mobili-
following SAH, the clinoidal tip is removed intradurally zation of the ICA and accurate identification of the OphArt
while the surgeon simultaneously visualizes the aneurysm, and aneurysm neck. Cervical carotid exposure is a rea-
thereby avoiding inadvertent rupture during extradural sonable alternative to proximal control within the clinoidal
manipulation. space, but neither is a substitute for extensive clinoidal
If done extradurally, the posterior roof of the orbit and optic strut removal.
and the lesser wing of the sphenoid bone covering the The proximal neck of OphArt aneurysms originates
superior and medial surface of the superior orbital fis- just distal to the OphArt and can be separated with gentle
sure are removed with a rongeur (Fig. 5). As the base of retraction of the aneurysm base and spreading dissection
the clinoid process and optic nerve are approached, a high- with micro-bayonetted forceps (Fig. 7). The distal neck is
speed diamond drill is utilized to thin the bone, which is usually unencumbered by major branch attachments, but
then fractured away with microcurettes. After the dura any perforators to the optic nerves, chiasm, or hypophy-
has been stripped away from the remaining clinoid tip, sis should be dissected free. Straight or side-angled clips,
the process is grasped with a hemostat, gently rocked free closed down parallel to the course of the ICA and sparing
of any remaining attachments, and removed. Bleeding is the OphArt, satisfactorily secure most OphArt lesions.
quite easily controlled with bone wax, Gelfoam, and Clips placed perpendicular to the ICA are often ineffec-
Surgicel. This extensive bone removal exposes the extra- tive in collapsing larger lesions and risk avulsion of the
dural optic nerve and the clinoidal space, a pocket of vari- proximal aneurysm neck.


© 1992 The American Association of Neurological Surgeons

Figure 5. Extradural clinoid removal (schematic). A, the extent of the thin shell remains, which is then fractured off the optic strut and detached
osseous removal is outlined in the crosshatched area. OC = optic canal; from the dura. The superior, lateral, and inferior walls of the extradural
AC = anterior clinoid process; SOF = superior orbital fissure; OSt = optic portion of the ON are removed carefully. 3, the completed exposure re-
strut. B, the operative view. 1, the right frontal and temporal lobes are veals the clinoidal segment (ClinSeg) of the carotid artery, and the optic
retracted extradurally to expose and permit removal of the posterior por- strut (OSt). The cavernous sinus lies posterior, inferior, and lateral to the
tions of the orbital roof back to the sphenoid ridge. The SOF is unroofed, ClinSeg and is covered by the inferior projection of dura from the AC
advancing toward the AC and the extradural portion of the optic nerve known as the carotid-oculomotor membrane (COM). DR = dural ring, the
(ON). 2, the AC is removed with a high-speed irrigating drill until only a point where the ICA penetrates the dura to enter the subarachnoid space.


© 1992 The American Association of Neurological Surgeons

Figure 6. Intradural clinoid removal, operative view (schematic). A, the roof have been removed. The clinoidal segment (ClinSeg) has been ex-
dural incision (right pterional frontotemporal craniotomy). The sylvian fis- posed, covered by the thin dura medial to the AC. The dural ring (DR)
sure has been opened widely, and the frontal and temporal lobes retracted. surrounds the ICA and marks its entrance into the subarachnoid space. The
The dotted lines mark a cruciate dural incision overlying the anterior cli- carotid-oculornotor membrane (COM) covers the cavernous sinus (CavSin).
noid process (AC), with an additional limb sectioning the falciform liga- The oculomotor nerve (III) can be seen through the COM, in the wall of the
ment (FalcLig) to untether the optic nerve (ON). OphArt = ophthalmic ar- CavSin. Bleeding is usually due to small venous tributaries that traverse the
tery; SupHypArt = superior hypophyseal artery; ICA = internal carotid artery; area and is easily controlled with pledgets of Gelfoam and gentle suction.
ACA = anterior cerebral artery; PComArt = posterior communicating ar- Extensive removal of the optic strut (OSt) provides enough exposure of
tery. B, the AC, roof, and lateral wall of the optic canal, and adjacent orbital the ClinSeg to permit temporary ICA clipping if necessary.


© 1992 The American Association of Neurological Surgeons


SupHypArt aneurysms project medially and inferi- distally on the neck and in the same direction as the first,
orly, just distal to the dural ring (Fig. 8). Small SupHypArt is often helpful in keeping the neck and aneurysm col-
aneurysms may be initially hidden from the surgeon by lapsed. If placement of the first two clips results in a com-
the overlying ICA and anterior clinoid process. In large promised ICA lumen, a third clip is applied distal to the
and giant varieties, the ICA is displaced slightly laterally second, and the original clip is removed. This process is
and superiorly toward the surgeon, and the neck of the repeated until wide carotid patency is ensured. The aneu-
lesion often appears so wide and long that the entire ca- rysm is then opened and its contents evacuated without
rotid wall appears incorporated into the aneurysm. As bleeding. The entire aneurysm wall does not need to be
SupHypArt aneurysms enlarge, their walls become ad- removed, but the visual apparatus must be thoroughly
herent to the dura of the sella, diaphragma, and lateral decompressed.
cavernous sinus wall. Although the arteriogram may sug- Some OphSeg lesions may be judged “unclippable”
gest otherwise, these lesions rarely if ever project into the because of marked calcification within their walls. Using
cavernous sinus, and the walls of the two structures can barbiturate anesthesia and temporary ICA clipping, the
be separated. By carefully adhering to the dural ring sur- laminated calcific walls are removed through an incision
face, the part of the aneurysm wall that bulges beneath into the aneurysm interior. The resultant neck is much more
the clinoid process is separated from the clinoidal dura, pliable and accepting of the clip, with less risk of parent
thus freeing up the proximal neck. vessel compromise by fractured or displaced calcification
The hypophyseal stalk may be adherent to the poste- or atheroma. A hemostat may occasionally be used to fa-
rior and medial surface of larger SupHypArt lesions. The cilitate creation of a surgical neck, but this instrument must
posterior communicating artery or its thallamoperforating be applied distal enough so as not to injure the parent ves-
branches are often draped over the distal end of the aneu- sel. Debris should be irrigated thoroughly from the parent
rysm, and these vessels must be carefully identified, sepa- vessel before final clip placement.
rated, and preserved. Because of their superior or medial projection, small
SupHypArt lesions are usually best obliterated with OphSeg aneurysms can often be clipped from a contralat-
a fenestrated clip whose blades pass over and then run eral approach between or behind the optic nerves. OphArt
parallel to the ICA, spanning the distance between the aneurysms are much easier to clip from a contralateral
PComArt and the dural ring. Although the OphSeg per- approach than are SupHypArt lesions. This capability may
forators (superior hypophyseal arteries) do not generally be quite important when deciding which side to treat first
supply brain parenchyma, some reach the optic chiasm, in a patient harboring bilateral lesions, one of which is an
and every attempt should be made to spare them from the OphSeg type. In general, the craniotomy should be done
surgical clip. Visual loss, either unimproved or somewhat on the side of the symptomatic aneurysm. The surgeon
worsened following surgery, can perhaps be caused by may then choose to explore the opposite carotid artery,
interruption of these vessels. The pituitary stalk receives with plans to obliterate the contralateral lesion if feasible.
blood supply from both sides, however, and endocrine Attempted clipping of large or giant OphSeg lesions from
deficits secondary to unilateral interruption of these a contralateral approach should be avoided except in emer-
branches are rarely noted. gent situations.
When large, both types of lesions (OphArt and Once the aneurysm is clipped and aspirated, the
SupHypArt) tend to be associated with arteriosclerosis in dura is closed, including the opening over the anterior
the carotid artery and/or adjacent aneurysm neck. Broad clinoid process. The clinoid often incorporates an ex-
necks are commonplace and are best secured by placing tension of the sphenoid sinus, and the residual bone
the clip parallel to the parent (ICA) vessel. The bulk of edges must be inspected and carefully sealed with
these aneurysms and the thickness of their necks often muscle, bone wax, or acrylic to prevent cerebrospinal
cause the initial clip to slip downward and partially ob- fluid leakage. A drain is left in the epidural space, and
struct the parent artery lumen. A second clip, applied more brought out posterior to the skin incision through a

Figure 7. Ophthalmic artery aneurysm clipping (right side, sche- ophthalmic segment; DR = dural ring; OSt = optic strut. B, defining
matic). A, exposure (see also Fig. 6B). The falciform ligament the proximal neck with microforceps dissection and suction-retrac-
(FalcLig) is sectioned before any aneurysm manipulation is under- tion. C, defining the distal neck. D, clip application. A side-angled
taken. AN = aneurysm; ON = optic nerve; OphArt = ophthalmic ar- clip has been placed parallel to the long axis of the ICA. The AN is
tery; SupHypArt = superior hypophyseal artery; PComArt = poste- then aspirated and carotid artery patency inspected.
rior communicating artery; ClinSeg = clinoidal segment; OphSeg =


© 1992 The American Association of Neurological Surgeons


Figure 8. Superior hypophyseal artery aneurysm clipping (right side, the dura alongside the ring. C, defining the distal neck. D, clip appli-
schematic). A, exposure (see also Fig. 6B). AN = aneurysm; ON = cation. A right-angled fenestrated clip is passed over the broadened
optic nerve; OphArt = ophthalmic artery; SupHypArt = superior hypo- carotid wall and carefully placed parallel to the ICA, with the fenes-
physeal artery; PComArt = posterior communicating artery; ClinSeg tration reconstructing the parent vessel lumen. The butt of the clip
= clinoidal segment; OphSeg = ophthalmic segment; DR = dural ring; must spare the PComArt, while the tips are advanced to the ventral
OSt = optic strut. B, defining the proximal neck with microforceps border (arrow) of the DR. The AN is then aspirated, and carotid pa-
and suction-retraction. Separation of the ventral AN bulge from the tency confirmed. If possible, the SupHypArt should also be spared, as
dura adjacent to the DR is often aided by circumferential section of they may provide critical blood supply to the ON or chiasm.


© 1992 The American Association of Neurological Surgeons

Figure 9. Clinoidal segment aneurysm (schematic). A, AP view. The able for proximal arterial control, and cervical exposure may be very
aneurysm (AN) arises below the dural ring (DR) and erodes through useful. Circumferential section of the DR is required to allow pas-
this membrane to enter the subarachnoid space medial and usually sage of a fenestrated clip around the ICA. The clip tips are then ad-
anterior to the ICA. AC = anterior clinoid process; ON = optic nerve; vanced as far proximally as to obliterate the neck, using great care to
COM = carotid-oculomotor membrane. B, operative view, right side. avoid injury to the cranial nerves within the cavernous sinus. Bleed-
Removal of the optic strut (OSt) is essential to gain access to the ing can be easily controlled with gentle Gelfoam or Surgicel pack-
aneurysm neck, which usually originates just above the COM ing and suction. III = oculomotor nerve within cavernous sinus wall;
anteromedially. Note that the clinoidal segment (ClinSeg) is not avail- OSt = optic strut.


separate stab wound. When the frontal sinus is violated blood supply of the optic nerve and chiasm.
by the craniotomy, the mucosa should be removed, and Postoperative diplopia may be due to either an ab-
the space packed with Gelfoam soaked with an antibi- ducens or oculomotor nerve paresis. When the dural ring
otic. The sinus is then obliterated with acrylic and in ques- is opened, these nerves lie in a relatively superficial posi-
tionable cases is oversewn with periosteum. The bone flap tion within the wall of the clinoidal space. They may be
is then anchored in position, and the temporalis muscle disturbed within the cavernous sinus either by clinoid re-
and skin are closed in traditional fashion. moval or by the clip blades as they are advanced proxi-
mally beyond the aneurysm neck.
POSTOPERATIVE CARE Aneurysms may arise from the clinoidal segment
Patients are thereafter managed according to their pre- and may be quite difficult to differentiate from OphSeg
senting symptoms. Patients with an unruptured aneurysm lesions (Fig. 9). These aneurysms probably account for
are mobilized the following day, with rapid normaliza- some lesions formerly termed ophthalmic aneurysms
tion of medications and fluid intake. SAH patients with which at surgery were “unclippable” or ruptured cata-
high vasospasm potential are hydrated aggressively for strophically. ClinSeg aneurysms probably represent cases
the duration of their risks. in which the OphArt or SupHypArt arises from the
clinoidal rather than the ophthalmic segment of the ca-
COMPLICATIONS AND THEIR rotid artery. As the space beneath the dural ring is lim-
MANAGEMENT ited, these lesions may eventually erupt through the dura
Transient or fixed postoperative hemibody deficits may into the subarachnoid space, where they appear along-
be an indication of carotid compromise and occur with side the ICA and resemble OphSeg aneurysms. Proxi-
higher frequency in patients with a calcified or partially mal exposure is much more difficult to obtain in these
thrombosed aneurysm with atherosclerosis within the ICA lesions, as the dural ring does not define its proximal
wall. Digital subtraction arteriography can be useful in extent. Clinoidal segment aneurysms are often adherent
the operating room or immediately postoperatively when to the undersurface of the anterior clinoid process and
parent vessel patency or embolization is questioned. optic strut, and extradural clinoidal removal may cause
Visual deterioration after surgery may occur if the premature aneurysm rupture before proximal or distal
optic nerve, already distorted medially and superiorly by vascular control has been established. If this type of an-
the underlying aneurysm, is further manipulated against eurysm is anticipated, proximal ICA exposure in the
the falciform ligament. Perforator sacrifice may harm the cervical region is essential.


INTRODUCTION impaired consciousness, but headache may be a very

Since first described by Virchow in 1875 as pachymenin- prominent complaint.
gitis haemorrhagica interna, the pathophysiology and In the era before computed tomography (CT), the
treatment of chronic subdural hematoma (SDH) has been diagnosis of chronic SDH was not made until postmor-
a controversial neurosurgical topic. Through the years, tem examination in over one-third of patients. Presently,
concepts on the pathophysiology of chronic SDH have CT is rarely incorrect in confirming or establishing the
been reviewed and revised. Similarly, a variety of treat- diagnosis. The typical finding is a focal hypodense len-
ments have been advocated—observation for spontane- tiform lesion over the surface of the hemisphere. Occa-
ous resolution, steroid and osmotic therapy, manipulation sionally, the CT may be unreliable if the SDH is isodense
of intracranial pressure, radical calvariectomy to collapse with the brain. In such situations, use of intravenous
the subdural space, shunting procedures, and exterioriza- contrast may result in visualization of the vascularized
tion of the subdural space. Currently, the favored surgical subdural membranes, giving indirect evidence of the
treatments for chronic SDH are twist drill or burr hole hematoma’s existence. Magnetic resonance imaging
craniostomy with or without closed system external drain- (MRI) can also assist in diagnosis when the CT is “nor-
age of the subdural space. More extensive procedures are mal” or equivocal. An acute subdural hematoma is
now usually reserved for the 10-25% of patients who do slightly hypointense on T1 weighted images and mark-
not respond clinically to these treatments. This chapter edly hypointense on T2 images. The hypointense signal
will focus on the techniques of twist drill and burr hole is due to the presence of deoxyhemoglobin, a strong
craniostomy for chronic SDH. paramagnetic substance. As the deoxyhemoglobin is
converted to methemoglobin, the T2 image becomes very
DIAGNOSIS intense. When the subdural hematoma becomes chronic,
The incidence of chronic SDH has been estimated to be and the conversion to methemoglobin is complete, the
1-2 per 100,000 population per year with an increasing hematoma will appear intense on both T1 and T2 im-
occurrence as age advances. Over 50% of patients may ages (Fig. 1).
have no history of trauma and, even in those that do, the When considering radiographic imaging for chronic
inciting incident is often mild and poorly remembered. SDH, it should be borne in mind that there is no clear
Predisposing factors have been shown to include advanced correlation between hematoma size and clinical symp-
age, chronic alcoholism, epilepsy, coagulopathy, and in- toms and signs. Thus, selection of patients for surgical
tracranial shunting procedures. treatment should rely more on clinical than on radio-
Chronic SDH may present in a variety of ways, mak- graphic criteria. In addition, a significant finding in many
ing the clinical diagnosis difficult. A frequent misdiag- chronic SDH treatment series has been that remission of
nosis is “dementia” because the patient is often elderly, a the clinical syndrome may significantly precede radio-
history of trauma is missing, and symptoms such as graphic resolution of the SDH—an important consider-
memory loss and personality change may be prominent ation in evaluating treatment results and the need for fur-
and slowly progressive. Chronic SDH can present with ther intervention.
acute or slowly progressing focal neurologic signs, mim-
icking a stroke or tumor. Other infrequent but well de- PATHOPHYSIOLOGY
scribed presentations include meningismus, seizures, and The initial stages in the formation of a chronic SDH in-
ataxia. Chronic SDH is not commonly associated with volve a proliferative response to blood in the subdural space.
Fibroblasts from the dura invade the area to form both an
outer and an inner membrane to “encapsulate” the SDH
© 1992 The American Association of Neurological Surgeons within approximately three weeks of its initial presence.


The surgical treatment for chronic SDH has evolved from
craniotomy for radical membranectomy to burr hole and
twist drill drainage of the fluid collection. Given the fact
that chronic SDH may resolve spontaneously with com-
plete and lasting recovery, it is not unreasonable to treat
alert patients who have few signs of cerebral dysfunction
with repeated clinical and CT follow-up. In those patients
whose clinical symptoms and signs from the subdural fluid
collection warrant intervention, burr hole or twist drill
craniostomy with or without closed system external drain-
age has become the preferred initial treatment option.

Twist Drill Craniostomy with External Closed System

This treatment approach should be considered when CT
and/or MRI demonstrates subdural fluid of homogenous
liquid character without septations and with sufficient
thickness (>1 cm) to ensure safety of blind dural perfora-
tion. This procedure maybe performed at the bedside un-
© 1992 The American Association of Neurological Surgeons der aseptic conditions using local anesthesia supplemented
Figure 1. MRI appearance of a chronic subdural hematoma. by intravenous sedation if necessary (Fig. 2).
The site for drainage is selected based on CT find-
ings—placement of the twist drill hole is over the maxi-
mal thickness of the SDH. The scalp in this area is shaved
to cover an area 3-4 cm in diameter from the selected
twist drill hole site. After skin preparation with Betadine
Theories about the subsequent enlargement of the or other antiseptic solutions, sterile drapes are placed about
hematoma have been numerous. For years, it was held the site. Xylocaine (0.5% with 1:100,000 epinephrine)
that an osmotic gradient developed across the membranes infiltration of the surrounding skin is accomplished, a No.
and that fluid was drawn into the subdural hematoma. 15 scalpel blade is used to nick the skin, a 5/8-inch twist
Others have held that fragile neocapillaries within the drill bit attached to a hand-powered drill is placed per-
membranes rupture repeatedly and fill the subdural cav- pendicular to the skull’s outer table, and drilling is begun
ity with recurrent hemorrhage. (Fig. 2A). Drilling may be continued in a perpendicular
Recent research has focused on disordered hemostatic direction or may then be slanted obliquely. Perforation of
mechanisms with increased fibrinolytic activity within the the outer table is appreciated by a lessening of tension on
membranes. Following the initial hemorrhage, abundant the drill bit; engagement of the inner table results in a
tissue thromboplastin is released into the subdural space, binding of the drill bit and should lead to caution as only
activating local clotting mechanisms. Thrombin is gener- one to two more turns on the drill are usually needed to
ated and crossed-linked fibrin is formed from fibrinogen. break through into the epidural space. The dura and outer
Clotting activation leads to mobilization of the intrinsic SDH membrane are then blindly perforated with a sharp
fibrinolytic system. Fibrin is split into fibrin degradation trocar or a 14- or 16-gauge needle to enter the subdural
products which affect further clot formation. Defective clot space. Only rarely does a significant amount of subdural
formation causes recurrent hemorrhage. As this process is fluid escape spontaneously at this point.
repeated, the dura reacts to fibrin nonspecifically to gradu- A standard ventriculostomy catheter may be used
ally form the vascularized outer membrane. As this mem- as the subdural drain. This catheter is modified by cut-
brane proliferates, the extrinsic fibrinolytic system is acti- ting off the blunt end and adding several side holes
vated and a self-perpetuating vicious cycle is repeated. It along the shaft to facilitate fluid and particulate drain-
has been postulated that the primary effect of surgical drain- age. The stylet is left in the catheter as it is passed
age procedures is to remove such self-perpetuating factors through the twist drill hole and is removed as soon as
from the subdural space and to allow restoration of normal the catheter is in the subdural space to prevent intra-
hemostatic mechanisms. cerebral penetration. The catheter is then directed


© 1992 The American Association of Neurological Surgeons

Figure 2. Twist drill craniostomy with external closed system drain- introduction of the subdural drainage catheter. C, tunneling of the
age. A, placement of the twist drill hole after the injection of a local drainage catheter. D, connection of the catheter to an external drain-
anesthetic and the creation of a small stab wound in the scalp. B, age system.


anteriorly or posteriorly for approximately 10 cm depend- ments should be able to be converted to a full craniotomy
ing on the location of the hole in relation to the SDH cav- without compromise of the vascular supply of the scalp
ity (Fig. 2B). The catheter is then checked for patency by (Fig. 4A).
allowing spontaneous gravity drainage of fluid or by as- Once the site is selected, the scalp is shaved for 3-
pirating 15-20 ml of the hematoma. Subcutaneous tun- 4 cm around the area; antiseptic skin preparation is ac-
nelling of the catheter is accomplished after first anes- complished and local anesthesia is induced with
thetizing the skin for 2-3 cm lateral to the twist drill site Xylocaine (0.5% with 1:100,000 epinephrine). A
(Fig. 2C). A trocar is used to guide the catheter to an exit 2.53.0-cm skin incision is made to accommodate an
site 2-3 cm away from the twist drill site. The catheter is airpowered cranial perforator and the periosteum is
rechecked for patency before connecting to a sterile closed stripped away from the area. A small mastoid retractor
drainage system (Fig. 2D). All wounds are sutured closed can be used to retract the skin edges. After the burr
with 3-0 nylon sutures. hole is made, the inner table is removed with a small
Postoperatively, prophylactic antibiotics—nafcillin curette or a Penfield No. 1 dissector. Bipolar coagula-
and cefotaxime—are given during the time the subdural tion of the dura is accomplished and a No. 11 scalpel
drain is left in place. Anticonvulsants are not given rou- blade is used to incise the dura in a cruciate fashion.
tinely unless there is a seizure history. The collection bag The outer subdural membrane is also coagulated and
of the drainage system is positioned 10-15 cm below head opened sharply. The subdural fluid often runs out or
level to promote gravity drainage of the subdural fluid. gushes out spontaneously at this point. A small red rub-
The patient is kept in bed with the head elevated no more ber catheter (7 or 9 French) can then be directed into
than 30°. Hydration, intravenous and oral, is encouraged the subdural space. Warm saline irrigation is carefully
to promote brain reexpansion. flushed through the subdural space until the effluent is
Within 24 hours, a follow-up CT scan is obtained clear and the inner membrane brain surface is visual-
(Fig. 3). If the patient’s initial symptoms and signs have ized (Fig. 4B). A subdural catheter and closed external
resolved, the CT scan shows substantial reduction (>50%) drainage system can then be left in place as described
in the size of the fluid collection, and/or output from the previously. Careful hemostatic closure of the skin in-
subdural catheter is minimal or clear, the catheter is re- cision with galeal and subcutaneous sutures should be
moved. If these criteria are not met, the catheter may be performed to avoid any bleeding that may gain access
left in place for several more days, and CT scans obtained to the subdural space and cause an acute reaccumulation
daily. Subdural fluid samples are sent daily and on re- of the hematoma. If the subdural fluid is too thick to
moval of the catheter for Gram stains, cultures, and sen- evacuate through the burr hole, or septations are en-
sitivity determinations. If the clinical symptoms and signs countered which prevent effective drainage of the sub-
are not satisfactorily resolved after two to three days and dural space, conversion to a full craniotomy is possible
the CT scan shows persistence of a significant SDH, al- for stripping of the inner and outer membranes and
ternative treatment approaches should be considered. complete evacuation of the hematoma (Fig. 4C).
The postoperative management of patients with burr
Burr Hole Craniostomy hole craniostomy is not significantly different from that
Burr hole craniostomy holds several advantages over the described for twist drill craniostomy.
twist drill technique: burr holes permit wider visualiza-
tion of the subdural space and of the outer and inner sub- COMPLICATIONS AND TREATMENT
dural membranes; hemostatic control of the vascularized RESULTS
outer membrane can be accomplished; the larger opening The outcome of surgical treatment of patients with chronic
permits freer drainage of thicker blood collections and SDH is quite variable. A compilation of treatment results
particulate matter; the subdural space may be cross-irri- over the past 30 years yields a cure rate ranging from 39
gated between burr holes for more complete emptying of to 100%, a recurrence rate of 1-37%, a rate of neurologic
the hematoma; brain reexpansion may be directly visual- sequelae of 7-32%, and a mortality rate of 0-28%. Such
ized; and, if necessary, the burr holes can be converted to variation could not be explained adequately by a differ-
a full craniotomy for further treatment as indicated. ence in surgical techniques alone, but more likely it re-
Burr hole craniostomy can be accomplished with lo- flects varying trends in patient selection and the means
cal anesthesia supplemented by intravenous sedation. Sit- and mechanisms of follow-up.
ing of the burr holes should be done with two factors in Comparison of burr hole versus twist drill tech-
mind: they should relate to the location of the maximal niques yields somewhat more consistent results, yet 10-
subdural fluid collection, but skin incisions and hole place- 25% of patients usually require some form of addi-


© 1992 The American Association of Neurological Surgeons

Figure 3. A, CT scans of a chronic SDH immediately after twist C, 4 weeks later showing substantial resolution of the SDH.
drill drainage. B, 24 hours later with the subdural drain still in place.


© 1992 The American Association of Neurological Surgeons

Figure 4. Burr hole craniostomy. A, siting of the burr holes. B, cross-irrigation of the subdural space
between holes. C, conversion of burr holes to a full craniotomy.


tional treatment. When evaluating results of treatment in cation rate from burr hole or twist drill drainage is
any given patient, however, as noted previously, it must quite low. Infection rates range from 1.5% to 4.2%;
be borne in mind that remission of the clinical syndrome subdural empyema has been reported in approximately
of chronic SDH does not necessarily require radiographic 2% of treated patients. Richter reported two epidural
resolution of the fluid collection. Camel et al. found in hematomas in a series of 120 patients after burr hole
their series of twist drill craniostomy treatment that 41 of SDH evacuation. Several authors have reported ten-
45 patients (91%) having residual SDH on follow-up CT sion pneumocephalus after drainage of the subdural
scan had complete or nearly complete resolution of symp- space.
toms. Similarly, CT scans did not normalize following Burr hole or twist drill craniostomy thus appears to
burr hole treatment until after three weeks in 92% of cases be a safe and reliable method of dealing with a clinically
reported by Richter and after 40 days in 84% of cases symptomatic chronic SDH. Other more invasive and ex-
described by Markwalder. Thus “recurrence” of the SDH tensive procedures, however, may be necessary in the few
after twist drill or burr hole treatment must be considered patients who are not appropriate candidates for these pro-
in light of such findings. cedures or who have recurrent or residual clinical prob-
Excluding the need for reoperation, the compli- lems in spite of this mode of treatment.


PATIENT SELECTION oxacillin, vancomycin, etc.) are administered at the time

Patients with intractable epilepsy where noninvasive tech- of skin incision for electrode implantation and are con-
niques do not clearly define the zone of epileptogenicity tinued prophylactically until electrode removal and re-
to the mesial temporal lobe structures need further delin- section of the epileptogenic tissue. The patient would
eation of the epileptic zone prior to resective surgery. In have donated autologous blood two to three weeks prior
these cases, noninvasive electroencephalographic (EEG) to surgery and/or would have been typed and screened
recording or the presence of a structural lesion may sug- for possible blood transfusion. Partial thromboplastin
gest basal frontal or lateral temporal epileptogenicity. time, prothrombin time, and bleeding time are checked
Especially on the dominant side, these regions cannot be preoperatively to rule out coagulopathy which may be
resected safely without tailored mapping. related to chronic anticonvulsant use.
In the following illustrated text, we describe the tech-
nique of insertion of subdural electrodes in the circum-
stance where surface recording alone suggests left fron- SURGICAL TECHNIQUE
totemporal epileptogenicity (interictal epileptiform
activity and seizure-onset EEG data) but does not define Operative Positioning
it further to the mesial temporal structures. The strategy The patient is placed in the supine position on the operat-
for electrode implantation is designed to allow coverage ing table; the head is extended 45° and rotated 60° away
of basal frontal areas, lateral frontotemporal structures, from the operative side (Fig. 1). It is helpful to place the
and basal temporal structures. The electrodes are subse- head at the “foot” of the operating table to provide more
quently used to map interictal and ictal-onset epileptiform knee room for the sitting surgeon and to allow the anes-
activity. Subsequent extraoperative stimulation using these thetist or nurse to raise or lower the operating table at the
electrodes defines areas of cortex involved in speech func- request of the operating team. The head is fixed in the
tion (zones of Broca and Wernicke). A tailored temporal desired position using a Mayfield head clamp or other
resection is then designed to accomplish maximal resec- skull fixation device. The whole head is shaved because
tion of epileptogenic tissue, while sparing eloquent re- meticulous scalp hygiene will be required in view of the
gions of brain involved in speech function. exiting electrode cables. The presence of hair near the
The general techniques of subdural electrode inser- electrode exit sites will invariably interfere with proper
tion and brain mapping may also be used in extratemporal care and hygiene at these sites.
regions of the brain, or in cases where a structural lesion
(i.e., neoplasm, vascular malformation, etc.) is located Draping and Skin Incision
adjacent to eloquent brain. A skin incision is marked to allow wide exposure of po-
tential areas of brain resection. Because the precise ex-
PREOPERATIVE PREPARATION tent of the zone of resection is not known at this time, a
Anticonvulsant therapy is titrated to levels near the toxic large frontotemporal incision is generally performed.
range prior to the insertion of subdural electrodes. In- Draping should allow exposure of not only the skin inci-
travenous antibiotics aimed to cover the skin flora (i.e., sion but also sites of potential cable exit. Because of this,
the scalp is prepared in a wide area beyond the proposed
incision. Otherwise, draping is performed as for a routine
© 1992 The American Association of Neurological Surgeons craniotomy.


© 1992 The American Association of Neurological Surgeons

Figure 1. Patient positioning for frontotemporal insertion of subdural electrodes.

Implantation of Subdural Electrodes intravenous mannitol is administered in the dose of 1 g/

The skin is incised through the galea aponeurotica, and kg, in addition to ensuring hyperventilation to a pCO2 of
Raney clips are applied to both edges of the scalp. The 25-30 mm Hg. The dural opening should allow exposure
scalp is reflected in the subgaleal plane, preserving at- of the inferior frontal regions and the lateral temporal lobe.
tachment of the underlying temporalis muscle to the cra- The selection of subdural grids, including size and
nial bone for subsequent osteoplastic craniotomy. Osteo- number of electrodes, is dictated by the areas of the brain
plastic bone removal (with a muscle nutrient pedicle to be covered. Subdural electrode grids consist of stain-
attached) is thought to minimize the risk of flap infection less steel (or platinum for magnetic resonance imaging
in the setting of chronically implanted subdural electrodes. compatibility) discs embedded in a sheet of Silastic, typi-
If a free bone flap is elevated, consideration must be given cally 1 cm apart. These are available through several com-
to maintaining this bone in a sterile fashion in a freezer mercial manufacturers. In the particular instance being
until removal of the subdural electrodes and final replace- described, a 4 × 4 grid is used to cover the basal frontal
ment of the bone. region (orbitofrontal cortex). A large 8 × 8 grid is used
The scalp is reflected in the subgaleal plane and is to cover the lateral frontotemporal neocortex, and this
held anteriorly and inferiorly using fishhooks (Fig. 2). is folded inferiorly to cover the inferior temporal and
The temporalis muscle is then incised in the line of the fusiform gyri. Another two 1 × 4 strips of electrodes are
proposed osteoplastic flap, making sure to preserve a vi- inserted transversely under the temporal lobe to cover
able vascularized muscle pedicle inferiorly. Three burr the anterior and posterior basal temporal areas (Fig. 3).
holes are placed, one at the pterion, one in the posterior
temporal area, and one in the posterior frontal area. These Wound Closure
are connected using a power craniotome, except inferi- Additional mannitol may be infused intravenously to
orly where the bone is rongeured under the preserved ensure continued brain relaxation prior to dural clo-
muscle pedicle (Fig. 2). This facilitates elevation of the sure. The dura mater is closed in a watertight fashion
osteoplastic flap and its reflection inferiorly along the around the electrode cables using 4-0 Nurolon sutures
temporalis muscle pedicle. (Fig. 4). The suture is passed in purse-string fashion
The dura mater is tacked to the edges of the surround- around the electrode cables for maximal watertight ef-
ing craniotomy using 4-0 Nurolon sutures. The dura mater fect. A piece of Gelfoam is placed around the site of
is opened in a C-shaped fashion and flapped anteriorly cable exit from the dura mater. The osteoplastic flap is
(Fig. 3). Prior to dural opening, if the brain appears tense, replaced and kept free-floating or fixed loosely using


© 1992 The American Association of Neurological Surgeons

Figure 2. Elevation of an osteoplastic bone flap.


© 1992 The American Association of Neurological Surgeons

Figure 3. Insertion of subdural electrodes. The choice of size and num- frontal regions (orbital frontal cortex), an 8 × 8 grid is used over the
ber of electrode grids depends on the areas of the brain to be covered. In lateral frontotemporal convexity, and two 1 × 4 strips are placed trans-
this particular instance, a 4 × 4 electrode grid is used to cover the basal versely to cover the basal temporal area.

© 1992 The American Association of Neurological Surgeons

Figure 4. Wound closure including watertight dural closure around the cable exit sites. The cables are tunneled subcutaneously and
are brought out via a separate scalp incision.


temporalis muscle sutures. The cables are brought out via ally increasing amperage. If there are no symptoms or
the posterior burr hole and are tunneled subcutaneously signs with stimulation at a maximum of 15 mA or at am-
to a separate stab scalp incision from which they exit. At perage just below the afterdischarge threshold, then test-
the site of skin cable exit, 3-0 Nurolon sutures are used ing is repeated for reading or speech interference.
once again in a purse-string fashion to ensure a water- Information gathered from recording and electrical
tight closure. The scalp is then closed in two layers using stimulation will consist of delineation of zones of maxi-
inverted interrupted 2-0 Vicryl sutures for the galea apo- mal interictal epileptiform activity, seizure-onset epilep-
neurotica and interrupted 3-0 Nurolon sutures for the skin tiform activity, and eloquent cortical regions (Fig. 5). A
(Fig. 4). plan of resection is then designed to excise a maximal
extent of epileptogenic brain, while staying at least 1 cm
BRAIN MAPPING away from eloquent brain regions.
Following electrode implantation, the patient is nursed in In the particular case illustrated here, epileptiform
a critical care unit for 24-48 hours. Throughout this pe- regions are noted in lateral and basal temporal areas. These
riod, close attention is paid to the serum electrolyte val- can be resected just close to but not including the tempo-
ues, ensuring a sodium level greater than 140 mEq/dl. ral speech area (Wernicke’s area). Electrical stimulation
Frequent infusions of mannitol or other diuretics and strict may induce speech interference near the temporal tip and
fluid restriction are adopted. Inappropriate antidiuretic in the fusiform gyrus (basal temporal speech area). Re-
hormone secretion and other factors may induce signifi- section of these areas (non-Broca, non-Wernicke) has not
cant brain edema during this critical period, necessitating been associated with any untoward sequelae.
removal of the subdural electrodes. We have not encoun- In addition to cortical stimulation, evoked potential
tered the need to remove electrodes because of brain studies of the lateral cortical plate may be performed to
edema in any patient maintained on strict fluid restriction define the rolandic fissure (as per standard neuro-
and where the serum sodium concentrations were main- physiologic techniques). Other specialized studies of
tained in an elevated range. Intravenous dexamethasone
is also administered at a dose of 4 mg every six hours.
Two to three days following electrode implantation, fluid
restriction may be eased as tolerated, and the steroids are
tapered. The patient is transferred to a special epilepsy
monitoring unit where the anticonvulsant medications are
gradually tapered for the first phase of brain mapping.
This first phase of brain mapping will consist of
interictal and ictal-onset monitoring of epileptiform ac-
tivity. The special monitoring unit is equipped with video-
EEG capabilities for real-time correlation of seizure symp-
tomatology with EEG phenomena. Monitoring of
epileptiform activities is continued until sufficient
interictal abnormalities are recorded and mapped and until
several of the patient’s typical seizures have been recorded.
This phase of the monitoring typically lasts 5-10 days.
Following this, the serum anticonvulsant levels are
gradually titrated once again to near-toxic ranges, in prepa-
ration for cortical stimulation. The second phase of brain
mapping will consist of stimulation of each of the subdu-
ral electrodes in a systematic fashion, to map eloquent
brain regions. This is performed in the epilepsy monitor-
ing unit in an unhurried fashion, with retesting performed
as needed to ensure accurate localization of frontal and © 1992 The American Association of Neurological Surgeons
temporal speech areas. The location of the electrodes is
correlated closely with surface landmarks as noted intra-
operatively and as documented by intraoperative draw- Figure 5. Results of cortical mapping in a hypothetical case. Frontal
ings and photographs. Each electrode is stimulated dur- and temporal speech areas have been delineated by cortical stimulation.
Prolonged monitoring has revealed a zone of interictal epileptiform ac-
ing wakefulness starting initially with a current intensity tivity, and another zone of seizure-onset epileptiform activity. The
of 1 mA. As long as there are no clinical symptoms or planned resection (dashed line) will include maximal excision of these
EEG afterdischarge, subsequent trials are used with gradu- epileptogenic areas while sparing mapped eloquent brain regions.


© 1992 The American Association of Neurological Surgeons

Figure 6. Tailored temporal lobectomy. At the second operation, the resection line. This will extend posteriorly to (but not include) the mapped
wound is reopened and the subdural plate is used to guide the planned temporal lobe speech area (Wernicke’s area).

© 1992 The American Association of Neurological Surgeons

Figure 7. Temporal lobectomy is performed along the planned resec- sions. The diagram illustrates the extent of temporal lobectomy as guided
tion line using bipolar electrocautery and suction. The Cavitron ultra- by extraoperative brain mapping.
sonic aspirator used at low settings is very helpful for such brain inci-


speech and memory and of movement-induced potentials the multiple cultures obtained during wound opening. The
can be performed as per institutional protocols. The whole subdural plates themselves are sent for cultures. The cable
period of brain mapping (recording of epileptiform activ- exit site is debrided and closed in a single layer. Sterile
ity and electrode stimulation) usually does not exceed three dressings are applied.
weeks (mean, 10 days). Throughout this time, prophylac-
tic antibiotic coverage is continued and meticulous scalp POSTOPERATIVE CARE
hygiene is maintained. Leakage at the cable exit sites is Postoperatively, anticonvulsants are continued at or near
not infrequent during this time. If it becomes excessive, toxic levels, and intravenous antibiotics are maintained
additional purse-string sutures at the cable exit sites may until final intraoperative culture results. Frequently (one-
be placed at the bedside. third of cases), these cultures reveal bacterial coloniza-
tion of at least one layer of the wound or the subdural
REMOVAL OF SUBDURAL ELECTRODES AND plates. In this case, intravenous antibiotics are continued
TAILORED TEMPORAL LOBECTOMY for 14 days following surgery and are followed by one
The patient is returned to the operating room following month of oral antibiotics, all aimed against the cultured
the period of brain mapping and is placed once again un- organism. This is done even in the absence of any clinical
der endotracheal anesthesia. The head is fixed in the same evidence of wound infection. In the circumstance of a
position and the areas of previous scalp incision and cable positive bone culture, intravenous antibiotics are contin-
exit sites are prepared and draped according to routine ued for four weeks even in the absence of clinical evi-
neurosurgical procedures (Fig. 6). The wound is reopened dence of wound infection.
with cultures taken from every layer prior to copious an- The above aggressive regimen of antibiotic treat-
tibiotic irrigation. At this time, the cable is cut and re- ment of bacterial colonization of the wound has elimi-
moved (by pulling out) prior to dural opening. The dura nated frank wound infections (purulence or meningitis)
mater is opened and the cortical surface is once again in the last 80 consecutive cases of subdural electrode
examined through the subdural grids, and correlations are insertion. Prior to this, wound purulence in the setting
made with previous photographs and diagrams. The pro- of implantation of subdural electrodes was not infrequent
posed line of resection is then marked on the cortical sur- at our institution.
face prior to removal of the subdural electrodes (Fig. 6).
Basal electrodes are left in place until completion of the OUTCOME AND COMPLICATIONS
basal resection, for they can be quite helpful in delineat- Using the above precautions, infection should not be more
ing the extent of such resection. frequent with this procedure than with any other neuro-
Cortical resection is performed along the proposed line surgical operation. Other complications are related to the
using bipolar electrocautery and suction (Fig. 7). The area of cortical resection. As long as the zone of resection
Cavitron ultrasonic aspirator used at low setting is particu- is at least 1 cm away from mapped eloquent areas, we
larly helpful in this regard. Following excision of the de- have not encountered any instances of permanent neuro-
sired portion of the temporal lobe, a decision must be made logic deficit related to focal cortical function.
whether to also excise mesial temporal structures. Favorable seizure outcome is accomplished in nearly
Meticulous hemostasis is ensured. The wound is two-thirds of patients undergoing this operation. This is
closed in layers, including watertight dural closure. A piece highly dependent on patient selection and other factors
of the osteoplastic bone flap is sent for culture along with related to the etiology and severity of the epilepsy.


PATIENT SELECTION head completes the preoperative radiological evaluation.

Most patients with gunshot wounds to the head require
surgery. Any depressed fracture due to a penetrating mis- SURGICAL PROCEDURE
sile is an open fracture and requires exploration, debride- The goals of surgery in patients with gunshot wounds to
ment, and elevation in order to prevent complications such the head are to remove all devitalized tissue, debris, and
as infection or cerebrospinal fluid (CSF) leakage. As pa- hematoma, to control hemorrhage, and to provide dural
tients reach the more serious end of the injury spectrum, closure and scalp coverage.
decisions regarding surgical intervention become more General endotracheal anesthesia is induced and the
difficult, as surgery may have little to offer. We list some pCO2 is maintained between 28 and 32 torr. Mannitol and
criteria for and against surgical intervention, realizing that furosemide are used if increased intracranial pressure is
each situation will need individual assessment. believed to be a potential problem. The head is widely
shaved. Hair and debris are removed from the irregular
Criteria in favor of surgical intervention: edges of the scalp defect. The head is positioned to facili-
Glasgow coma scale (GCS) 8 or above; tate extension of the scalp incision if necessary. For un-
GCS 5-8 with good response to cerebral resuscitation; complicated superficial wounds, the head may rest softly
Limited nondominant hemisphere injury; on a foam headrest, but for more complicated deep wounds
Tangential wounds;
in which brain retractors will be needed a three-point head
Young age.
Criteria against surgical intervention: fixation device is used. The scalp is prepared with a gentle
GCS 3-5; scrub of Betadine soap followed by painting with Betadine
GCS 5-8 with no response to cerebral resuscitation; solution. Sterile towels are secured circumferentially with
Extensive dominant hemisphere injury; a surgical stapler and cranial drapes are positioned.
Brain stem injury; Three major objectives are kept in mind when plan-
Injuries crossing the midline; ning the scalp incision:
Old age;
Associated major multisystem injuries. 1. To preserve blood supply to the scalp edges;
2. To incorporate the entry and/or exit wounds into the inci-
Patients with cerebral gunshot wounds are evaluated upon 3. To establish adequate exposure of the limits of fractured
arrival into the emergency facility. In addition to routine bone and any adjacent structures that might need repair.
trauma evaluation and care, coma grade and neurological
function are assessed, and measures for cerebral resuscita- We find the simple linear or modified linear inci-
tion (intubation, hyperventilation, and mannitol) are insti- sions (Fig. 1A) to be adequate in most injuries involving
tuted if indicated. Entrance and exit wounds are evaluated the hair-bearing scalp. For injuries of the forehead, a
and temporary dressings applied. All patients receive teta- bicoronal scalp incision is used (Fig. 1B). The anterior
nus prophylaxis and broad spectrum antibiotics. branch of the superficial temporal artery should be pre-
Anticonvulsants are administered if there has been obvi- served. Such a scalp incision facilitates adequate expo-
ous cortical damage. Plain anteroposterior and lateral skull sure of the frontal cranial base and avoids cosmetically
radiography followed by noncontrasted CT scanning of the unacceptable scars about the face. Raney clips are used
on healthy scalp edges, but clips are avoided on scalp edges
macerated or injured at the entrance or exit sites.
© 1992 The American Association of Neurological Surgeons After completing the scalp incision, the bony defect


© 1992 The American Association of Neurological Surgeons

Figure 1. A, for wounds within the hair-bearing scalp, the best scalp bicoronal scalp incision is used. The incision is located behind the hair-
incision is usually a linear or curvilinear incision centered over the en- line and positioned so as to preserve the anterior branch of the superfi-
try or exit wound. B, for injuries of the face or forehead in which wide cial temporal artery if there is potential disruption of the supraorbital
exposure of the frontal or anterior temporal fossa may be required, a blood supply from the injury.

is widened to expose all edges of the torn dura (Fig. 2A). son and because bullet fragments usually travel to much
This can be achieved by craniectomy or craniotomy. Large greater depth, we often leave bullet fragments behind.
pieces of bone are kept and soaked in Betadine solution. Necrotic brain, readily identified by its purple color
The dura is opened back to healthy brain all around. and soft fragile texture is removed with suction. Hemo-
Control of active bleeding is accomplished using bi- stasis is achieved with bipolar coagulation and gentle tam-
polar cautery or clips for very large vessels. Torn venous ponade with Gelfoam. We try not to leave foreign hemo-
sinuses are oversewn or patched with pericranium and static agents in the wound, as we think that they might
Gelfoam. serve to increase the incidence of cerebritis and brain
The missile track is then explored and debrided. One abscess. Once all bleeding has been controlled, hemosta-
helpful technique is illustrated in Figure 2B. The tip of an sis is checked by asking the anesthesiologist to increase
Asepto syringe is introduced into the depth of the track, the patient’s intrathoracic pressure as in Valsalva’s ma-
and the wound is irrigated with saline under moderate neuver.
pressure while the syringe is gently withdrawn. This ma- At this stage, the wound is ready to be closed. A peri-
neuver will deliver debris and small indriven pieces of cranial patch is used to close the dura (Fig. 2E). Water-
bone. tight dural closure helps to prevent CSF leakage or fun-
Pieces of bone or bullet fragments still embedded in gus cerebri. Sometimes taking a pericranial graft may
the wound may be localized using intraoperative ultra- prove difficult because of a lack of exposure; in certain
sound (Fig. 2C). In removing these fragments, the gelati- circumstances, attempts at harvesting a graft may further
nous pedicle should be coagulated, cut, and allowed to threaten an already tenuous blood supply to the injured
slip back in the wound as it frequently contains a small scalp edges. Under such circumstances, graft material may
blood vessel that has been previously tamponaded by the be taken from fascia lata or other body fascia through a
bone fragment (Fig. 2D). separate incision.
If the track is very deep, it is a good idea to set up a Whether or not to replace the bone remains a con-
self-retaining retractor system to aid in maintaining ex- troversial issue. If the wound is extremely dirty and
posure. This helps to keep the track well defined and aids contaminated, the bone is left out and the patient
in obtaining hemostasis deep in the wound. brought back for cranioplasty in six months; if the
Bacterial contamination of metallic bullet fragments wound is relatively clean, large (cleansed) fragments
is much lower than that of bone fragments. For this rea- of bone or a craniotomy bone flap is replaced and an-


© 1992 The American Association of Neurological Surgeons

Figure 2. A, adequate exposure of the injured area is essential. Bone localizing residual bone or bullet fragments. D, the gelatinous strand
removal by craniectomy or craniotomy back to normal dural edges is adherent to an extracted bone fragment is best coagulated before it is
desirable. B, an excellent technique for removing indriven bone frag- divided as it often contains a small vascular pedicle. E, watertight dural
ments and other debris is with gentle warm saline irrigation with an closure helps to prevent CSF leakage and fungus cerebri.
Asepto syringe. C, intraoperative ultrasound is occasionally useful for


chored with nonabsorbable, monofilament, synthetic su- age. Foreign and avascular materials should be avoided
tures. in attempts to reconstruct the bony floor.
Scalp closure or scalp coverage is critical in prevent- Wounds involving the temporal bone area are asso-
ing later complications. Routinely, the scalp is closed in a ciated with a high incidence of vascular injury. Hemor-
single layer with interrupted vertical mattress sutures us- rhage may be controlled with packing of the external ear
ing 3-0 nylon. This prevents placing foreign suture mate- canal or indirect balloon occlusion of the involved vessel
rial in the galeal layer and brings galea and epidermis or sinus.
into anatomical alignment. The closure should not be
under excessive tension. If simple closure of this type is COMPLICATIONS
not possible, arrangements should be made to adequately Disseminated intravascular coagulation may develop at
cover the injured area by use of rotational scalp flaps or a the time of operation. It is usually first recognized by
free vascularized flap. noting diffuse oozing of blood at the operative site which
is difficult to control with the usual methods. Laboratory
SPECIAL SURGICAL SITUATIONS evaluation will document elevated coagulation times and
Injuries of the major dural venous sinuses may be diffi- fibrin split products in conjunction with reduced platelet
cult to repair. In most cases, a sinus laceration may be counts and fibrinogen levels. The condition is treated with
simply oversewn. Generous exposure of the injured sinus infusions of fresh blood products, including frozen plasma
is mandatory for more severe sinus injuries, where sacri- and platelets.
fice of the sinus would prove potentially detrimental to CSF leakage may occur in the form of a cutaneous
the patient. In such cases, the sinus can be patched with fistula, otorrhea, or rhinorrhea. Hydrocephalus must be
pericranium or temporalis muscle. Bleeding can be con- ruled out, and the leak may stop with temporary placement
trolled temporarily by digital pressure or occlusion with of a spinal or ventricular drain. If the leak persists, the wound
a No. 7 Fogarty catheter. should be reexplored with adequate dural closure.
Gunshot wounds of the frontal area frequently prove Meningitis, abscess, and empyema are possible in-
to be very challenging. The face, orbits, and frontal and fectious complications. All are treated with appropriate
temporal fossae may be involved. A generous frontal, and antibiotics, and surgical drainage is frequently necessary
sometimes bifrontal, exposure is required for adequate with abscess or empyema.
debridement and repair. The involved sinuses should be Subarachnoid hemorrhage from a traumatic aneu-
exenterated. Intradural graft repair using pericranium or rysm may occur occasionally. Under these circumstances,
fascia is very important for preventing eventual CSF leak- a cerebral angiogram should demonstrate the lesion.


INTRODUCTION Our enthusiasm, because of the initial successes, be-

The transvenous therapy for vascular malformations in- came tempered after a review of 24 patients treated in a
volving high- and low-flow shunts is nothing new. Sean similar fashion revealed many of the problems with this
Mullan and others have been advocates for the incorpo- new therapy. However, the overall statistics, especially in
ration of this route of therapy for various lesions for many the neonate, have prompted continued interest in this tech-
years. The concept that the arterial side of high-flow fis- nique as an adjunct of therapy for the elimination of cen-
tulas needed to be attended to first in the obliteration of tral high-flow fistulas. Of the nine neonates we have
these lesions virtually eliminated the discussion and use treated with the transtorcular approach, five are alive and
of the transvenous approach to these lesions for decades. three are virtually normal except for mild spasticity in
The great risk of venous outlet obstruction and therefore the lower extremities. The 15 infants and older children
marked increased pressure in the thinly walled veins just treated with the transtorcular approach have fared very
distal to the shunts could very easily result in massive well, with a 50% cure rate angiographically and one death.
hemorrhage, producing major neurologic deficit or death. This death was secondary to an acute shunt malfunction
This threat and potential outcome has been demonstrated three months after transtorcular embolization of the vein
graphically to occur with transarterial endovascular of Galen malformation.
therapy for certain malformations when the embolic ma-
terial, principally glue, escaped into the venous outlets, TREATMENT CONCEPTS
solidifying the egress and resulting in major venous out- The general concepts which are important to the under-
let occlusion with hemorrhage. However, Mullan’s excel- standing of the utility of the transvenous treatment of vein
lent results with the transvenous approach to carotid cav- of Galen malformations remain fairly simple. First, in all
ernous fistulas continued to stimulate interest in a patients the goal is to gradually occlude and thereby elimi-
transvenous approach to various vascular malformations, nate the fistula or fistulae such that acute thrombosis with
especially those lesions such as vein of Galen malforma- acute venous outlet obstruction does not occur. Various
tions which carry high mortality and morbidity statistics guidelines and experiences obtained from our series will
with the standard surgical and transarterial approaches. be discussed below as to how this goal can be attained.
As the burgeoning subspecialty of interventional Second, the goal for transvenous therapy in the neo-
neuroradiology continued to grow, various technologies nate is to produce a cardiac survivor while maintain-
including new thrombolytic agents and particles have ing neurologic integrity. This goal has often resulted
made possible the approach to lesions heretofore unreach- in converting the neonate into a surviving infant with a
able. The combined interventional and neurosurgical ap- persistent fistula. There seems to be a delicate balance
proach to vein of Galen malformations as reported by for the neonate: the therapist should produce a cardiac
Berenstein and Epstein demonstrated the utility of this survivor but not eliminate the fistula completely be-
combined approach in improving morbidity and mortal- cause of the major risk of venous outlet obstruction,
ity statistics. We reported in 1986 the use of the trans- hemorrhage, and death. Again, how this is attained will
torcular approach for the endovascular treatment of vein be discussed below.
of Galen malformations. The third concept of major importance in the use
of this therapy revolves around the potential for con-
tinued, slow, progressive thrombosis after one or more
© 1992 The American Association of Neurological Surgeons therapies with the transtorcular route. We have been


tempted in our 15 infants and older patients to consider ment of choice for this very difficult group of malforma-
other therapies to rid the patient of the fistula completely tions. The transarterial approach requires the cooperation
(stereotactic radiosurgery or direct surgery). In two in- of an interventionlist trained in microcatheter manipula-
stances, we have admitted patients to the hospital for tion both on the transarterial and transvenous sides. In
prestereotactic radiosurgery angiograms and have found the neonate, access is often difficult from the transarterial
in one of these the total obliteration of the fistula since side, whereas the transvenous route, especially the
the child’s previous angiogram three months prior to that transtorcular route, is quick and easy. Of course, it is es-
admission and a substantial reduction in the flow in the sential to obtain high-quality pretherapy angiograms to
other patient which allowed us to wait to see if continued assess the extent of the lesion and the flow characteristics
thrombosis would occur. We have therefore treated no necessitating the therapy. Also, computed tomography
patients with adjunctive therapy including surgery or ste- (CT) scans and magnetic resonance imaging (MRI) of
reotactic radiosurgery and have had no patients hemor- the brain and ventricular spaces are essential before
rhage or develop other progressive symptomologies ne- therapy. Many of these individuals, especially in the neo-
cessitating further therapy. The bottom line, however, is natal group, have pretherapy lesions which can be exten-
that, as pointed out by Hoffman and others, the prognosis sive at times and can preclude therapy. Massive encepha-
of untreated or persistent vein of Galen malformations lomalacia is a relative contraindication to any form of
tends to be poor. Therefore, once therapy for these mal- therapy in this disease. Many of these patients have pre-
formations is undertaken by whatever route, continued treatment hydrocephalus and this often necessitates shunt-
perseverance and careful follow-up are essential for opti- ing procedures as a major form of therapy in the vein of
mum outcome. Galen malformations. Once the transtorcular route for
therapy has been decided upon, the steps as outlined be-
TECHNICAL ASPECTS low and in the accompanying figures can be carried out
The key steps in the transtorcular approach to vein of rapidly and in repeated sessions to obtain optimum out-
Galen malformations will be discussed. This simple op- comes in the neonate, infant, and older child.
eration is rapid and utilizes common materials and in-
struments found in all operating rooms and radiology Equipment and Technique
suites. Various embolic materials such as coils can be The initial surgical therapy is carried out in the operating
delivered to the vein of Galen malformation complex not room, and therefore a standard craniotomy set is neces-
only through the torcular approach but through a direct sary. A C-arm. imaging system is necessary during the
jugular puncture or through the femoral route if access procedure for placement of wires and also during the
can be obtained. The neurosurgeon, usually the primary venography (Fig. 1). Newer real-time subtraction units
care physician in this disorder, has control over which are available and make following the course of therapy
route is chosen for the treatment of these malformations. much easier and more accurate.
Today, transarterial endovascular therapy combined with A large burr hole is placed over the area of the tor-
transvenous occlusive therapy would seem to be the treat- cular herophili as identified on the angiogram. The ul-

Figure 1. An efficient arrangement of personnel and equipment dur-

ing a transtorcular embolization for a vein of Galen malformation is
shown. The surgeon and assistant (A and C) are seated, with the nurse
(B) and equipment directly behind the patient’s head. The patient is
positioned such that the occiput is close to the edge of the table so
that manipulations with various catheters entering the torcular are
unimpeded. The gantry for the C-arm fluoroscopic unit (D) can be
moved easily in and out to obtain high-quality real-time fluoroscopic
images during manipulation and deposition of coils during the proce-
dure. It is very important to have the visual monitor (E) directly across
from the surgeon so that all fluoroscopic manipulations can be seen
easily during the procedure. © 1992 The American Association of Neurological Surgeons


© 1992 The American Association of Neurological Surgeons

Figure 2. These drawings depict the patient positioning (A), location of tion. The ultrasonic scanner can be used to identify the torcular, straight
the incision (×), and the appearance of the torcular through the burr hole sinus, and aneurysm through this burr hole. Bleeding during the place-
(B). The small roll under the right shoulder allows the midline occiput ment of the incision and burr hole is minimal, and the dura forming the
to be parallel with the floor. This makes the approach through the torcu- outer surface of the torcular is thick and resistant to injury. It is not
lar with the various catheters quite simple. If the torcular is not identi- necessary to place a purse-string suture through the outer layer of dura
fied clearly after the burr hole is completed, then the craniectomy can and this will result in bleeding.
be enlarged with rongeurs to better expose the structure for emboliza-

trasound probe is very useful in defining the torcular (Fig. 3, B-D). Under fluoroscopy, an angiography cath-
herophili, straight sinus, and aneurysm (Fig. 2). The eter or sheath with an attached Tuohy-Borst adapter
area of the torcular herophili is tapped with a 25-gauge is advanced over the wire into the area of the aneu-
needle to ensure free return of arterialized blood (Fig. rysm (Fig. 3F). The guidewire is removed and a veno-
3A). A 16-gauge Angiocath is passed through this punc- gram performed through the indwelling angiography
ture and the soft end of the Angiocath is left in place catheter to assess location and flow characteristics.
through which a short, soft guidewire is advanced un- Various methods of measuring pressures and flows can
der fluoroscopic control into the area of the aneurysm be utilized at this point in the procedure to


© 1992 The American Association of Neurological Surgeons

Figure 3. These drawings (A through K) represent the essential steps in with an occluding finger placed over the hub of the sheath. A standard
the deposition of thrombogenic wires through the torcular via the straight soft guidewire is then placed through the sheath and advanced into the
sinus into a vein of Galen aneurysm. The area of the torcular is tapped aneurysm under fluoroscopic control (D). The Angiocath sheath is then
with a 25-gauge needle (A), and brisk bleeding results. Contrast agents removed while maintaining the position of the guidewire with the aid of
can be injected through this 25-gauge needle if there is any question fluoroscopy. The assistant holds the guidewire in place after the sheath
about the location of the penetrating needle. This needle is removed and has been removed (E) and then the surgeon advances a short angiographic
a standard 16-gauge Angiocath (B) is placed through the same hole into catheter or sheath with an attached Tuohy-Borst adapter over the
the straight sinus. The sharp inner needle of the Angiocath is removed, indwelling guidewire into the aneurysm (F). It is extremely important
and then the soft outer sheath can be advanced further into the straight to maintain the position of the guidewire safely within the confines of
sinus (C). Bleeding can be vigorous at this point but is controlled nicely the aneurysm during the placement of this catheter.


© 1992 The American Association of Neurological Surgeons

Figure 3. (Continued) The floppy guidewire is then removed and a sizes can be deposited on this basket lattice (J) to further reduce the
venogram can now be performed through the indwelling angiographic flow and to encourage thrombosis (J and K). An occluding finger is
catheter (G). A 90-145-cm floppy guidewire (the mandrel was removed used to control bleeding over the torcular once the angiographic cath-
prior to surgery) is now advanced through the Tuohy-Borst angiographic eter has been removed. A piece of Gelfoam is placed over this area and
catheter into the aneurysm (H and I). The venogram is performed after the skin is closed in a standard fashion (K).
deposition of this basket (I) and, if needed, Gianturco coils of various


help outline the therapeutic goal (Fig. 3G). A long floppy ternate routes of approach may have to be chosen. This
guidewire is passed into the aneurysm very carefully in poses no great problem, and these routes of entry can be
order to create a basket onto which various sizes of throm- easily identified on the preoperative angiogram.
bolytic Gianturco coils are deposited (Fig. 3, H-K); all Once the torcular is identified, a 16-gauge Angiocath
this is done under fluoroscopic control. Without the in- is passed into the hole previously made by the 25-gauge
dwelling basket the potential for embolization of the coils needle (Fig. 3B). Brisk bleeding will be obtained through
into the general venous circulation is a real threat. At the the Angiocath and the sharp needle from it can be re-
termination of the procedure, the catheter is removed and moved easily with advancement of the soft outer portion.
a piece of Gelfoam is placed over the bleeding hole in the Bleeding is brisk but easily controlled with an occluding
torcular herophili and held for 5 minutes. The skin is closed finger over the hub of the catheter. Under fluoroscopic
in layers and the patient is returned to the intensive care control, a soft guidewire is advanced through the catheter
unit for observation. into the aneurysm (Fig. 3D). This distance ranges from 6
to 9 cm from the surface of the dura to the anterior sur-
Individual Steps face of the aneurysm. Care must be taken not to advance
The positioning of the patient on the operating table is even the soft guidewire forcefully into the area of the most
shown in Figure 1. The head is placed in a position with anterior part of the aneurysm and malformation.
the sagittal suture parallel to the floor. The right shoulder Once the wire is in place, the 16-gauge Angiocath
is usually elevated slightly with a roll. The area of the sheath is removed. The assistant holds the wire in place
torcular herophili should be very close to the edge of the at the level of the dura and bleeding can be brisk at this
table so that the table itself is not obstructing the surgeons’ point while the angiographic sheath or catheter is placed
hands in their approach. The C-arm gantry and the visual over the wire and advanced through the dura and into
monitor are brought in from above and in front, respec- the area of the aneurysm (Fig. 3F). The tip of the wire
tively. The surgeon and assistant are operating as if an is carefully observed and maintained in its original po-
occipital approach is being utilized in the placement of a sition during the passage of this catheter so that force-
ventriculoperitoneal shunt. Angiographic localization of ful impingement does not occur on the anterior face of
the torcular herophili on the skull is estimated and a 3-4- the malformation. Once the catheter is in the aneurysm,
cm midline vertical incision is marked. Preparation and the guidewire is removed and the angiographic cath-
draping are standard for a burr hole. A small adjacent eter system is flushed with heparinized saline through
table is draped in a sterile fashion with all the necessary a side port. A Tuohy-Borst adapter is placed on the end
equipment ready so that when embolization is begun this of the catheter so that various therapeutic embolic
table can be rolled to the juncture of the operating table agents can be placed through the catheter without sig-
just below the position of the child’s head. This instru- nificant bleeding.
ment table is very useful in stabilizing the indwelling cath- At this point, the assistant and surgeon can rest be-
eter during evaluation and therapy. cause the catheter is in place and there is no further bleed-
The incision is made down to the skull and the peri- ing. This is a good point in the procedure to perform pres-
osteum is elevated. Bleeding is minimal. A burr hole is sure measurements through the side port of the
placed over the torcular and enlarged to 2-3 cm in diam- angiographic catheter and to look at the venous flow pat-
eter (Fig. 2). Again, bleeding is minimal. The red dilated terns produced in the malformation with venography. Our
torcular is easily identified from directly over the struc- initial procedure consisted of placing Gianturco coils di-
ture. If ultrasound equipment is available, ultrasonic iden- rectly into the aneurysm to produce thrombosis. This
tification of the torcular, straight sinus, and aneurysm is worked in certain individuals, but in others the flow char-
very useful in helping the surgeon to decide on the angle acteristics were so great that the coils themselves
of approach to the aneurysm through the torcular. If iden- embolized peripherally into the sigmoid sinus and, in one
tification of the torcular is not certain, then a 25-gauge instance, into the lung. Therefore, we have modified our
needle can be passed easily into the area suspected of being procedure by placing within the aneurysm a
the torcular. If bright red blood returns then one can be nonthrombogenic stainless steel basket constructed from
confident that this is the area of entry. If no blood is ob- a long stainless steel guidewire with the indwelling man-
tained then a further craniectomy should be carried out in drel removed (Fig. 3I). This is accomplished easily by
an effort to identify the torcular. It is important to realize cutting off the weld on the end and removing the stout
that a true torcular may not exist and an accessory straight thin wire with a clamp. This results in the production of
sinus may have to be utilized in approaching these le- a very floppy wire capable of forming a basket when
sions. In many of the patients, venous outlet obstruction placed within the aneurysm. Through the Tuohy-Borst
is already a part of the disease process and therefore al- adapter we advance this guidewire, which may


range from 90 to 145 cm in length, carefully into the deposited within the basket both to produce a change
aneurysm. This often results in a major change in the in the flow pattern and to induce thrombosis in a graded
venous flow pattern within the aneurysm, and in sev- fashion (Fig. 3J).
eral instances we stopped the procedure at this point At the termination of the procedure, the angiographic
and elected to return later to deposit thrombogenic catheter is removed and an occluding finger is placed over
wires onto this basket. If a major change in the meta- the egress site in the torcular. A small pledget of Gelfoam
bolic needs of the patient occurs with this deposition, is placed here and pressure applied for 5 minutes. No su-
such as a reduction or elimination of blood pressure tures are required to obtain hemostasis and the skin is
support, then we suggest that the procedure be termi- closed over the Gelfoam pledget in a standard fashion
nated and further therapy considered later. The philoso- (Fig. 3K). The child is returned to the intensive care unit
phy is to do as little as is needed to get a therapeutic for careful observation.
response, knowing that returning later for more therapy Repeat embolizations can be performed in the
is always possible. If we elect to deposit thrombogenic neuroradiology suite transcutaneously if needed. In this
material within the aneurysm we use Gianturco coils setting the procedure takes only a few minutes after anes-
of various sizes and have found that these are easily thesia is administered.


INTRODUCTION areas of the cortical convexity as well as the basal hemi-

The goal of epilepsy surgery is to remove the epilepto- spheric regions and the interhemispheric fissure. In addi-
genic parts of the brain while sparing critical functions. tion to widespread coverage of the cortical surfaces, the
To achieve this goal, two criteria are essential: precise subdural electrodes allow direct, systematic cortical stimu-
localization of the epileptogenic focus and identification lation to be performed over a period of days.
of areas with critical functions. However, as the number of electrode contacts required
To meet these criteria, electroencephalography (EEG) in the subdural grid increases for widespread coverage,
performed directly on the surgically exposed brain the cable may become so bulky that skin incision and
(electrocorticography (ECOG)) has been used intraopera- undermining of the subcutaneous tissue become neces-
tively. However, the ECOG technique has obvious limita- sary, which raises concerns about potential cerebrospinal
tions: it must be performed in a limited time and it does fluid (CSF) leakage and infection of the subdural space.
not allow EEG recording during epileptic attacks (ictal Therefore, a variation of the subdural grid technique that
recording). Accumulated evidence indicates that the most uses a finer, multiple cable (multi-minicable) was devel-
reliable information for localization of an epileptogenic oped. The minicable has a 2-mm diameter and can be
focus is obtained from the ictal recording. Epileptiform brought out through the skin using guiding needle punc-
discharges not associated with the patient’s habitual sei- tures. CSF leakage and grid infection have been mini-
zures (interictal discharges) alone are not sufficient. To mized by sealing the burr holes with glue and placing
catch and record these habitual seizures, at least several purse-string sutures at the site where the cable exits from
days of continuous EEG and video monitoring are needed. the scalp.
Furthermore, the physician has to determine that the re- Technical details include planning the craniotomy,
corded attack is typical of the patient’s habitual seizures. placing the grid, closing the dura, and closing the crani-
This is best achieved by analyzing video-recorded attacks otomy wound. The techniques described here for implan-
in combination with the simultaneously recorded EEG tation and use of the multi-minicable subdural grid al-
(Fig. 1). low localization of epileptogenic areas and mapping of
Once the epileptogenic area has been localized, the cortical function.
next task is to identify the functions of the area—most
importantly, speech and sensorimotor function—since re- PATIENT SELECTION
section of critical areas may result in significant func- The indications for grid implantation include:
tional impairment postoperatively. Critical functions, par-
ticularly speech and language, can be tested for only on 1. Incapacitating epileptic attacks;
fully awake patients. Intraoperative stimulation has been 2. Failure of medical management of the attacks;
used for this purpose also, but it is restricted by the lim- 3. Attacks originating from one cerebral hemisphere;
ited time available and by patient discomfort, particularly 4. EEG abnormalities adjacent to or within function-
in children. To overcome the limitations of intraoperative ally critical cortex;
studies, a technique for subdural implantation of elec- 5. Discrepancy of location of EEG abnormality and
trodes was developed. abnormality seen on magnetic resonance imaging.
The approach allows, if needed, coverage of broad
Contraindications to implantation are:

© 1992 The American Association of Neurological Surgeons 1. Presence of active local or systemic infection;


© 1992 The American Association of Neurological Surgeons

Figure 1. Diagram of the epilepsy monitoring system: the video camera ior and brain activity. Electrical stimulation for cortical mapping is car-
and the computerized EEG simultaneously record the patient’s behav- ried out through the implanted grid.

2. Uncorrectable bleeding tendency; Anesthesia and Positioning

3. Uncooperative or violent behavior of the patient. Endotracheal general anesthesia is used. The vertex of
the patient’s head extends out 3 cm from the headboard of
Age alone is not a contraindication to grid implantation. the operating table. The vertex is tilted down slightly to
The potential risks of the procedure are common to any facilitate drainage of blood out of the surgical field and
craniotomy, such as CSF leakage, infection, or hematoma to aid in opening of the base of the temporal subdural
formation. Every preventive precaution should be taken space. The head, neck, and chest are elevated by tilting up
during selection of candidates for implantation. the upper half of the operating table about 15°, so that the
vertex of the head is above heart level (Fig. 2).
To illustrate the subdural grid technique, the operative Grid and Operative Plan
details of grid implantation for a study of the language- The patient’s entire head is shaved. The rolandic line is
dominant left hemisphere are described. drawn on the scalp (details are shown in Fig. 3A). The
simplified midpoint to meatal (M-M) line, extending from
Preoperative Preparation the external auditory meatus to the midpoint between the
nasion and inion, may also be used (Fig. 3A). After deter-
Bleeding Time and Premedication mination of the amount of grid needed to encompass the
Bleeding time must be checked for all patients and should entire suspected epileptogenic area, including critical sen-
be within normal limits. Prophylactic broad-spectrum sorimotor cortex and language areas, the appropriate num-
antibiotics are given intravenously just prior to the skin ber (i.e., one or more) of multi-minicable electrode grids
incision and are administered daily until the removal of (Ad-Tech Medical Instrument Corp., Racine, WI) are au-
the grid. The serum level of anticonvulsant(s) should be toclaved at 270°F (132°C) for 10 minutes just prior to
checked 24 hours prior to surgery and should be kept at implantation.
the therapeutic level to avoid major tonic-clonic convul- For study over the language-dominant hemisphere,
sions in the immediate postoperative period. Double doses a 6 × 8 contact grid is placed over the lateral convexity
of the usual daily anticonvulsant may be given the night of the temporal lobe and cortex superior to the sylvian
before surgery to make up for anticipated loss of drugs fissure (Fig. 3C). The 6 × 8 contact grid is 9 cm long
during intraoperative depletion of body fluid. Dexametha- from anterior to posterior and 7 cm wide. Accordingly,
sone and other antiinflammatory drugs are avoided. the scalp incision and craniotomy opening should be


© 1992 The American Association of Neurological Surgeons

Figure 2. A, artist’s view of positioning of a patient for subdural grid board of the operating table to provide access for subcutaneous tunnel-
implantation over the left hemisphere. The vertex of the patient’s head ling using the Angiocath. C, the vertex is tilted down to allow gravita-
extends out 3 cm from the headboard of the operating table. The upper tional pull to aid in opening the subdural space at the temporal base. The
part of the operating table is elevated so that the patient’s vertex is higher tilted-down position of the vertex also facilitates drainage of blood from
than heart level. B, the vertex of the head must extend out from the head- the surgical field.

10 × 8 cm. The extra length (1 cm) allowance around the Burr Holes and Craniotomy
grid plate prevents buckling of the Silastic plate. Burr holes are made at each of the four corner points, and
two additional burr holes are also made; one at the mid-
Surgical Procedures point between the frontal and parietal points and the other
halfway between the parietal and mastoid points (Fig. 3B).
Skin Incision The multiple burr holes are connected by cuts made with
After the M-M line has been drawn on the head, four points the Gigli saw. The temporalis muscle should not be de-
are determined: the pterion; the base of the mastoid, 10 tached from the bone flap. The flap is turned outward us-
cm posterior to the pterion; the parietal point, 8 cm supe- ing the muscle as a hinge (Fig. 4E).
rior to the mastoid base; and, finally, the frontal point, 8 The dura is opened at the base of the craniotomy
cm superior to the pterion (Fig. 3B). A line connecting over the temporal lobe. The incision is extended an-
the four points is drawn, beginning at the pterion and ex- teriorly and posteriorly and is swung superiorly to-
tending to the frontal point, the parietal point, and toward ward the vertex; finally, the dura is reflected toward
the base of the mastoid, and ending by curving above and the midline.
in front the ear. The connecting line forms the so-called The arachnoid, vessels, and cortex are inspected. The
Falconer’s question-mark incision for temporal lobectomy. sylvian vein and the vein of Labbé are identified. The
During the incision, the superficial temporal artery is sylvian vein, which drains into the sphenopalatine sinus
carefully preserved to maintain the blood supply to the around the tip of the temporal lobe, and the vein of Labbé,
skin flap. Local anesthetic with 1/200,000 epinephrine is which drains into the transverse sinus at the posterior part
infiltrated along the outer margin of the incisional out- of the lobe, are examined by gentle retraction of the lobe.
line and around the superficial temporal artery at the neck The location of the vein of Labbé is measured from the
of the skin flap. tip of the temporal lobe.


© 1992 The American Association of Neurological Surgeons


Placement of Grid normal saline before placement of the last sutures to com-
First the 2 × 8 strip-grid is inserted into the temporal base plete dural closure.
(see the inset, Fig. 3C). While the anterior quarter of the
strip is held with a bayonet forceps, the wet grid is slipped Bone Flap and Cable Placement
into the subdural space as the mid-temporal base is slightly After retaining sutures are placed to anchor the dura to
lifted with a brain spatula. The grid is advanced with gentle the periosteum, the bone flap is secured with sutures tied
force mesially and toward the tip of the temporal lobe. to the skull through the drill holes. The cables emerge
The first (anterior) two electrode contacts reach the tem- through the craniotomy gap or multiple burr holes (Fig.
poral tip, and the remaining majority of electrodes cover 5). An epidural Hemovac drain is placed in the anterior-
the fusiform and parahippocampal gyri. The tail end of most frontal burr hole, sufficiently remote from the cable.
the strip emerges from the middle fossa posterior to the Gelfoam is packed in each burr hole. Medical adhesive is
tympanic prominence, crossing the fusiform and inferior used to fill in the bone gaps created by the craniotomy
temporal gyri. The strip is anchored to the dural sleeve at and burr holes, with care taken to ensure that the adhe-
the cross-point with a single fine suture. The 6 × 8 grid is sive does not contact the dura or brain or the epidural
placed over the lateral convexity of the temporal and drain tube, since the adhesive binds with the tubing and
frontoparietal lobes. A slit 2 cm long made between the would make its subsequent withdrawal difficult.
third and fourth rows of the grid allows the upper half of In cases with a space-occupying brain lesion, where
the grid-leaf to be angled toward the inferior orbital gy- brain may be herniated by the mass or edema, we have
rus and the lower half toward superior temporal gyrus. used a Raimondi peritoneal catheter or Raney scalp clip
The grid leaflets straddle the sylvian vein and sphenoid placed around the craniotomy flap (Fig. 6A) to elevate
wing. The multi-minicables are directed toward the pos- the bone flap off the cortical surface and avoid compres-
terior margin of the craniotomy (Fig. 3C). A few loosely sion of the edematous brain (Fig. 6B).
placed stitches are used to anchor the grid to the dura.
Before closure, detailed drawings are made and color Percutaneous Cabling
photographs are taken, with attention paid to the relation Before the skin flap is replaced, each cable is passed sub-
of the electrodes to the major cortical sulci and vessels. cutaneously using an Angiocath 10GA (3.4 mm), 3 inches
The sequential relation of the color-coded cables and elec- (7.6 cm). The Angiocath needle puncture is made as far
trode array is confirmed and recorded. away as possible from the craniotomy margin—typically
2-3 cm is sufficient (Fig. 5).
Dural Closure
Dural closure begins with suturing at the posterior tem- Purse-string Suture and Skin Closures
poral base. The running suture goes around the individual After completion of the scalp closure, a purse-string su-
cables and secures the cable with the dural closure. The ture is placed around the exit point of each cable (Fig. 7).
anterior and inferior or superior dural gap created by the
posterior dural approximation is closed with a dehydrated Postoperative Measures
human dural patch (Fig. 4). The closure again starts from
the temporal base and proceeds toward the lower vertex. Surgical Dressing
This facilitates drainage of subdural blood through the The cable exits are painted with antibiotic ointment. A
dural opening, which is lower with the head tilted down- bundle of a few cables is passed through the opening of
ward. The subdural space is irrigated a final time with a thick, soft pad (ABD-pad) that is used to cover the

Figure 3. A, estimation of the rolandic and sylvian lines on the scalp, line can also be used. The line is derived by simply connecting the
based on cranial landmarks, is shown. First, the halfway point (50%) midpoint to meatus, as depicted in the diagram. B, a question-mark
between the nasion and inion along the sagittal midline of the skull is incision extends from the pterion to the zygoma just in front of the ear.
determined; the point 19 mm posterior to the halfway point is the up- The superficial temporal artery is preserved to maintain the blood sup-
per rolandic point. A line is drawn from the upper rolandic point to the ply to the skin flap. Extra burr holes are needed for multi-minicable
lower rolandic point on the sylvian fissure. The lower rolandic point exits. C, the upper three rows of the electrode contact (3 × 8) ventral
is found by constructing a line from the perpendicular point to Reed’s to the sylvian fissure cover Broca’s speech area and the motor-sen-
line (a line formed by connecting the lower ridge of the orbit to the sory cortex; the lower three rows cover the lateral convexity of the
preauricular point (Preaur. pt.). The rolandic line is then formed by temporal lobe. The second grid (2 × 8) covers the fusiform and
connecting the upper and lower rolandic points. The simplified M-M parahippocampal gyri.


© 1992 The American Association of Neurological Surgeons

Figure 4. The dura is closed with a continuous running suture, similar Eight to ten minicables are individually passed through the dura, burr
to the technique used for closure of an arteriotomy (E). Note the dural holes, and subcutaneous tunnels that traverse the midline of the vertex.
patch, which allows the subdural space to expand, thereby minimizing An Angiocath is used for the passage of each cable through its subcuta-
compression of the arachnoid vessels and fluid space over the cortex. neous tunnel (A-D).


© 1992 The American Association of Neurological Surgeons

Figure 5. Sealing the craniotomy opening and burr holes using Silastic medical adhesive. Note the
temporalis muscle on the bone flap.


© 1992 The American Association of Neurological Surgeons

Figure 6. A and B, application of a Raimondi catheter or Raney scalp clip elevates the bone flap off the cortical surface and prevents com-
clips around the bone flap is shown. In patients with a space-occupy- pression of the swollen brain underneath the grid.
ing lesion or edema, the grid may compress the brain. The catheter or


Without cushioning, the bone flap collapses, put-

ting presure on the cerebral cortex.

Raimondi catheter technique for cushioning the bone


Scalp clip technique for cushioning the bone flap.

B © 1992 The American Association of Neurological Surgeons


© 1992 The American Association of Neurological Surgeons

Figure 7. This diagram depicts the path of the cable from the grid over burr hole is sealed with Gelfoam and Silastic adhesive. The Gelfoam pre-
the cortex and through the dura, skull (burr hole), galea, and scalp. The vents direct contact between the adhesive and the dura.


surgical wound. Another pad with a slit is used to cover part of surgical field is left open until the end of the dural
around the ear, including the area in front of the ear. As closure. These measures allow blood-tinged CSF to drain
the cable is held up out of the dressing by an assistant, an out through the dural opening. Placement of an active epi-
adhesive elastic bandage is applied over the skin flap and dural drain equipped with a suctioning reservoir (Hemovac)
cable exit area. The tails of the cables are then covered also helps to clear the fluid around the grid.
with 3 × 3-inch dressing sponges. The pressure dressing using the elastic adhesive ban-
dage minimizes subcutaneous bleeding. Shielding the
Sitting Position and Restraint craniotomy opening and burr holes with Gelfoam and
Certain precautions are unique to this procedure. As soon Silastic medical adhesive minimizes the escape of
as the patient recovers from the general anesthesia and subgaleal blood into the cranial space. Watertight closure
vital signs and neurologic condition are stabilized, the of the dural opening prevents the blood from running into
patient is placed in a sitting position, tilted at 45°. Both the subdural space and thus prevents formation of a sub-
hands are restrained by the use of mittens until the patient dural hematoma membrane. These wound-closure mea-
is transferred to the epilepsy monitoring unit. Routine skull sures for the scalp, skull, and dura minimize CSF leakage
x-rays are taken in the recovery room. The epidural drain and prevent grid infection.
is withdrawn on the first postoperative day, and EEG re- The dressing is changed and the drainage tube is re-
cording begins immediately. Stimulation studies are typi- moved 24 hours after surgery. Thereafter, the dressing must
cally begun on the third postoperative day. be changed once a week for routine wound inspection
and suture line care.
Postoperative Medications
The same anticonvulsants that the patient took prior to Intraoperative Technique
surgery are administered postoperatively. No steroid or The proper positioning unique to this procedure is impor-
anti-inflammatory medications are given. Moderate an- tant. The vertex of the head must extend out from the
algesics are given. The patient is given nothing by mouth, headboard of the operating table to provide access for
with fluid intake restricted for 24 hours. Prophylactic an- subcutaneous tunnelling using the Angiocath. I prefer not
tibiotics are continued until the grid is removed. to use a head fixation device, because the metal arms and
pins around the skull make the tunnelling procedure more
The success of the approach described here is heavily Our work has shown that motor and sensory areas
dependent on pre- and postoperative management as well have considerable individual variation and cover a much
as intraoperative technique. The discussion is divided ac- broader area than is conventionally believed. Using the
cording to these two concerns. rolandic line (R line) for outlining the craniotomy for grid
implantation (Fig. 3A) helps to ensure that the grid cov-
Preoperative and Postoperative Management ers the broadest possible cortical area for functional map-
The use of prophylactic antibiotics has been a subject of ping and localization of the epileptogenic area. We call
controversy. However, we administer a prophylactic anti- the modified R-line that we use the “midpoint to meatal
biotic (Ancef) until the subdural grid is removed. line” (M-M line). The midpoint is the halfway point be-
CSF leakage along a subcutaneously placed cable tween the nasion and inion, and the line is drawn from the
could be a major cause of grid infection. Every possible midpoint to the external auditory meatus.
measure is taken to prevent this. In particular, the postop- Autoclaving the grid is probably safer than gas ster-
erative sitting position discourages CSF leakage along the ilization because of the potential for residual chemicals
subcutaneous cables. The cable should be thin and should (ethylene oxide) accidentally remaining after sterilization
travel an extended distance in a deep subcutaneous tun- to cause cortical irritation. Every effort should be made
nel. Use of the finer, multicable system instead of a single, to reduce surgical blood loss, because the grid procedure
bulky cable system also reduces the chance of CSF leak- involves two stages, one for grid implantation and an-
age. other for grid removal, within a short period of time. In-
Because even a millimeter-thin hematoma membrane filtration of the epinephrine/local anesthetic combination
between the electrode and the cortex could interfere with around the skin incision is an effective hemostatic mea-
effective cortical stimulation and EEG recording, every sure. Use of every available hemostatic measure means
effort is made to prevent a hematoma membrane: bleeding that blood transfusion can be avoided.
time is checked preoperatively, the head is tilted down dur- The superficial temporal artery should not be ligated
ing the grid implant, and the dural opening at the lower or coagulated and the temporal muscle should


not be detached from the bone flap, in order to keep these point between the parietal and mastoid, are necessary ex-
tissues vital, which helps to minimize surgical wound in- its for the multi-minicable.
fection. Furthermore, in the event of an infection, maxi-
mum antibiotic irrigation of the wound can be achieved CONCLUSION
by the rich blood flow throughout the tissues. A nonsurgical setting, as opposed to the intraoperative
Although the grid currently available is only a milli- environment, provides comfort and support for the pa-
meter thick, it can buckle, and buckling will compress tient and allows EEG recording during the patient’s ha-
the cortical veins and the cortex. To prevent buckling, the bitual attacks. Complex speech and language testing can
craniotomy opening should be 1 cm wider than the grid be carried out with maximal cooperation of the patient.
plate. Use of the dural patch also provides an ample sub- The potential for infection is a serious concern with
dural space and prevents compression. any implanted device that has external leads. The surgi-
Craniotomy using the Gigli saw instead of a high- cal technique described here is intended to minimize CSF
speed craniotome is preferable. The Gigli saw allows a leakage, thereby reducing the risk of infection. How-
beveled-edge craniotomy, which prevents the bone flap ever, it should be emphasized that careful, complete,
from sinking and compressing the cerebral structures be- routine pre- and postoperative antiseptic measures, not
neath. The two extra burr holes, one halfway between the just intraoperative technique, are needed for ultimate re-
frontal and parietal burr holes and another at the halfway duction of the risk of infection and for surgical success.


PATIENT SELECTION sual memory in patients with suspected right temporal

Temporal lobectomy is an accepted surgical treatment of epileptogenicity). Intracarotid injection of amobarbital
intractable complex partial seizures for patients in whom (Wada test) is performed to confirm laterality of speech
the temporal lobe has been implicated as the site of and memory and to demonstrate that the contralateral tem-
electroencephalographic (EEG) seizure onset. In these poral lobe is able to support memory function.
patients, mesial temporal structures are the commonest Patients with unilateral or predominantly unilateral
site of abnormal epileptiform EEG activity. Postopera- EEG epileptiform abnormalities arising from the ante-
tive pathologic specimens from epileptic patients com- rior or anteromedial temporal lobe are selected for the
monly reveal histological abnormalities in the amygdalo- operation of anterior temporal lobectomy and microsur-
hippocampal region. The extent of mesiobasal resection gical resection of mesial structures. This operation is con-
in temporal lobectomy has been correlated directly with traindicated in patients with significant contralateral tem-
seizure outcome, with higher rates of seizure control poral pathology and in patients with epileptiform activity
achieved with more extensive resections of mesiobasal arising primarily from lateral temporal lobe structures.
temporal lobe structures. In this chapter, we describe a Patients with mesiotemporal epileptogenicity and an ad-
modified technique of temporal lobectomy with limited jacent temporal lobe lesion should undergo this described
lateral temporal resection and extensive microsurgical operation in addition to resection of the structural lesion
resection of mesial temporal structures. This operation (i.e., neoplasm, vascular malformation, etc.).
may be performed on the left or right temporal lobe with-
out mapping of speech areas, since the procedure is de- PREOPERATIVE PREPARATION
signed to spare all but the most anterior portion of lateral Anticonvulsant therapy is continued through the periop-
temporal lobe cortex. erative period at or near toxic concentrations. Preopera-
Candidates for this operation suffer from complex tive prothrombin time, partial thromboplastin time, and
partial seizures despite optimal medical therapy. The sei- bleeding time measurements are performed in all patients
zures are thought to be “intractable,” thereby interfering in view of possible coagulopathy from prolonged anti-
with psychosocial function and having a significant im- convulsant therapy. The patient would have donated two
pact on the patient’s life. Preoperative diagnostic studies units of autogenous blood two to three weeks prior to sur-
should include magnetic resonance imaging (MRI) of the gery, and/or would have been typed and screened for pos-
brain, including coronal views, to delineate any structural sible blood transfusion.
abnormalities in the temporal lobe. Other diagnostic in-
formation should include prolonged EEG monitoring of SURGICAL TECHNIQUE
interictal epileptiform abnormalities and seizure onset.
Detailed neuropsychological studies should be performed Operative Positioning
to define baseline preoperative cognitive and memory The patient is placed in the supine position on the op-
function. Any modality-specific impairment should be erating table with the head toward the “foot” of a typi-
noted (such as impaired verbal memory in patients with cal table to provide greater room for the knees of a
suspected left temporal epileptogenicity or impaired vi- sitting surgeon and to allow the anesthetist or nurse to
raise and lower the operating table without disturbing
the operating team. The frontotemporal area is shaved
© 1992 The American Association of Neurological Surgeons and the hair is combed away from the field. The pa-


tient’s head is extended 45° and turned 60° away from the other burr hole should be located at the most poste-
side of surgery (Fig. 1), and it is fixed in that position rior aspect of the incision. These are connected via a
using a Mayfield head clamp or other skull fixation sys- power craniotome to elevate a frontotemporal bone
tem. flap (Fig. 4). This free bone flap should not expose
The incision is marked as a question mark starting more than one or two finger breadths of the frontal
just in front of the tragus, extending posteriorly above the lobe but should allow as much of a temporal expo-
tip of the ear and anteriorly just above the superior tem- sure as possible. The key to further steps of this op-
poral line. The incision is extended inferiorly and anteri- eration will consist of subsequent removal of the
orly (along the forehead) enough to clearly expose the pterional ridge to allow a very anterior exposure of
pterion when flapped forward (Fig. 2). In most patients, the middle (temporal) fossa.
the incision will not extend anterior to the hairline more Rongeurs are used to remove the remaining portion
than 2 or 3 cm. The proposed incision is marked and the of the inferior squamous temporal bone down to the zy-
operative area is prepared and draped according to rou- gomatic root. This should allow exposure nearly flush with
tine craniotomy techniques. the floor of the middle fossa. Mastoid air cells are fre-
quently entered and should be thoroughly waxed. Anteri-
Operative Procedure orly, rongeurs are used to remove the thin temporal bone
covering the anterior temporal lobe dura. The pterional
Myocutaneous Flap ridge is thoroughly rongeured and subsequently drilled
The scalp is incised through the galea aponeurotica, and medially as far as the superior orbital fissure. At this point,
Raney clips are applied on both sides of the incision. The the tip of the temporal lobe should be seen extradurally.
temporalis muscle is opened along the line of the incision. Further intradural portions of the operation cannot be
The scalp and underlying temporalis muscle are turned carried out without this extensive bony removal of the
forward as a unit in the subperiosteal plane (Fig. 3). The pterional ridge (Fig. 5).
myocutaneous flap is dissected anteriorly to expose the
orbital zygomatic ridge and inferiorly to expose the zygo- Lateral Temporal Resection
matic root. The myocutaneous flap is held in this position Following the administration of intravenous mannitol
using multiple fine fishhooks tethered tensely with rubber (1 g/kg body weight) and insuring that the arterial pCO2
bands to a Yasargil Leyla bar attached to the operating table. tension is in the range of 25 to 30 mm Hg, the dura
Such tense holding forward of the flap is essential for sub- mater is tacked to the edges of the surrounding craniotomy
sequent bony exposure and intradural visualization. and is opened in a C-shaped fashion based anteriorly
(Fig. 6). The dural flap is elevated anteriorly and tensed
Bony Opening using 4-0 silk sutures allowing a full exposure of the
A burr hole should be placed on the pterion and an- temporal lobe tip and the sylvian veins. Any

© 1992 The American Association of Neurological Surgeons

Figure 1. Patient positioning. The head is extended 45° and rotated

60° away from the operative side. The head is fixed in this position
using a Mayfield head clamp or other skull fixation device.


© 1992 The American Association of Neurological Surgeons

Figure 2. Scalp incision. The pterion is marked (two finger breadths the tip of the ear and anteriorly just above the superior temporal line.
above the zygoma (B) and one thumb breadth behind the lateral orbital The anterior extent of the incision (on the forehead) should allow ad-
rim (A)). A question-mark skin incision is marked extending just ante- equate exposure of the pterion upon anterior flapping of the scalp and
rior to the tragus at the level of the zygoma, swinging posteriorly above muscle.


© 1992 The American Association of Neurological Surgeons


Figure 3. (Top) Myocutaneous flap. The scalp and temporalis muscle are Figure 5. (Lower middle) Resection of the pterional ridge. The lesser
flapped anteriorly and inferiorly as a single layer in the subperiosteal plane. wing of the sphenoid is resected using rongeurs and then a power drill
The myocutaneous flap is extended anteriorly to expose the orbital zygo- medially to the superior orbital fissure. This is essential for subsequent
matic ridge and inferiorly to expose the root of the zygoma. intradural portions of the operation.

Figure 4. (Upper middle) Free bone flap. The myocutaneous flap is Figure 6. (Bottom) Dural opening. The previous pterional resection
held anteriorly using multiple fishhooks which are tethered tensely with should allow extradural visualization of the temporal tip. The dural open-
rubber bands to a Leyla bar. One burr hole is placed at the pterion and a ing is performed in a C-shaped fashion and is flapped anteriorly.
second one at the posterior aspect of the incision. These are connected
using a power craniotome to elevate a frontotemporal bone flap.


temporal lobe tip draining veins should be visualized at in the subpial plane from the choroidal fissure to the tento-
this time, coagulated, and divided. rial incisura under direct microsurgical visualization. This
The lateral temporal lobe resection is accomplished cut traverses the hippocampal sulcus which separates the
by connecting three separate corticectomies (Fig. 7). The parahippocampal gyrus from the dentate gyrus. The arte-
first or “posterior” cut extends obliquely across the lat- rial feeders of the hippocampus (Ammon’s horn arteries)
eral temporal surface traversing the middle temporal gy- traverse the hippocampal sulcus after arising from the P2
rus 3.5 cm posterior to the temporal tip. The incision slants segment of the posterior cerebral artery; these arterial feed-
slightly anteriorly across the superior temporal gyrus and ers are coagulated and divided. The leptomeninges cover-
posteriorly across the inferior temporal gyrus, and con- ing the perimesencephalic cisterns are not violated. The
tinues transversely on the basal surface of the temporal medial and lateral cuts are extended posteriorly to the point
lobe to the collateral sulcus (which separates the fusiform where the tentorial edge curves medially. A third or “pos-
gyrus from the parahippocampal gyrus). This posterior terior” cut joins the lateral and medial cuts posteriorly to
cut spans across four gyri: the superior, middle, and infe- disconnect the hippocampal formation and allow its removal
rior temporal gyri and the fusiform gyrus. The second or in one piece. At this point, the tentorial edge should be
“superior” cut extends anteromedially below the sylvian seen curving medially behind the collicular plate on the
veins just inferior and parallel to the free edge of the lesser posterior aspect of the mesencephalon. During this micro-
wing of the sphenoid. It extends medially to the anterior surgical resection of mesiobasal structures, care should be
clinoid process which should be easily visualized (given taken not to use bipolar electrocautery at or near the tento-
the adequate bony exposure). These two cortical incisions rial incisura (where the 4th cranial nerve may be injured)
are then joined by a third or “inferior” cut across the basal or near the petrous apex (where the intratemporal portion
surface of the temporal lobe. This should totally discon- of the facial nerve may be injured).
nect the temporal pole which is removed in one piece.
This portion of the operation is performed with a head- Wound Closure
light. It does not involve any violation of important sylvian After securing meticulous hemostasis, thorough irriga-
structures (superiorly) or incisural structures (medially). tion of the resection cavity is performed. No pieces of
Surgicel or Gelfoam are left intradurally. The operating
microscope is removed and intraoperative electrocorti-
cography may be performed if this is a part of institu-
Resection of Mesial Structures tional epilepsy protocols. The value of intraoperative
The operating microscope is brought in at this point. A electrocorticography and further tailoring of the resec-
Greenberg or other self-retaining retractor system is set up, tion has not been proven.
and a narrow long blade is chosen. Under the operating The dura mater is closed in a watertight fashion us-
microscope, the stump of the temporal lobe is gently ex- ing running 4-0 Nurolon sutures. The bone flap is fixed
plored to locate the tip of the temporal horn of the lateral in place using 2-0 Nurolon sutures. The wound is irri-
ventricle. This is opened gently using bipolar coagulation, gated thoroughly and the temporalis muscle is approxi-
and a long cottonoid patty is slipped into the temporal horn mated using interrupted 2-0 Vicryl sutures. The galea
of the lateral ventricle. The long narrow blade of the self- aponeurotica is closed using inverted interrupted 2-0
retaining retractor is then inserted over the cottonoid patty Vicryl sutures. The skin is closed using interrupted 3-0
within the temporal horn. This retractor blade is used to Nurolon sutures behind the hairline and 4-0 nylon sutures
elevate the choroid plexus, thus opening the temporal horn in a plastic fashion for any portion of the incision extend-
like a fish’s mouth. This allows identification of the chor- ing anterior to the hairline. Antibiotic ointment is used to
oidal fissure medially and the hippocampal formation in cover the incision and a sterile head dressing is applied.
the floor of the temporal horn. Upon orientation in relation The anesthetic is reversed. The patient is allowed to awaken
to the pes hippocampus, the remaining portion of the and is examined in the operating room.
amygdala is removed by suction, making sure not to ex-
tend this resection superiorly above the plane of the sylvian OUTCOME AND COMPLICATIONS
fissure (into the caudate nucleus). Perioperative antibiotics are administered at the time
Mesial basal resection is completed through three sub- of the skin incision and are continued for 24 hours
sequent incisions into the mesiobasal temporal structures postoperatively. These are geared at our institution
(Fig. 8). The first or “lateral” cut extends from the lateral against the narrow spectrum of staphylococci (van-
edge of the floor of the temporal horn (terminal sulcus) to comycin or oxacillin). The patient is observed for 24
the collateral sulcus. The second or “medial” cut extends hours in a critical care unit. Fluid restriction, dex-


© 1992 The American Association of Neurological Surgeons

Figure 7. Resection of the temporal pole. This is carried out through three cortical incisions labeled 1, 2, and 3.


© 1992 The American Association of Neurological Surgeons

Figure 8. Resection of mesial structures. A narrow self-retaining fully protected using a cottonoid patty inserted under the retractor
retractor blade is used to open the temporal horn of the lateral ven- blade (in the temporal horn itself). Mesial structures at the floor of
tricle, allowing adequate exposure of mesial temporal structures at the temporal horn are then resected using three incisions labeled 1,
the floor of the temporal horn. The roof of the temporal horn is care- 2, and 3.


amethasone, and intermittent mannitol are used as pro- and are monitored closely in the perioperative period.
phylaxis against brain edema. Not uncommonly, follow- Early postoperative seizures not associated with electro-
ing left temporal resections, the patient may awaken with lyte abnormalities or low anticonvulsant levels are a
normal speech function but may develop transient dys- marker for future recurrent seizures. Otherwise, complete
phasia several hours after surgery, which may last for one control of seizures (on anticonvulsants) is expected in 70-
or two days. Permanent dysphasia is rare following this 80% of the patients. This rate may be affected by preop-
operation. Visual field abnormalities are encountered in erative selection protocols and other patient-related fac-
less than one-fourth of the patients, and these consist of tors. Patients who are seizure-free for one year following
incomplete homonomous quadrantic field defects; they surgery are likely to remain seizure-free thereafter; sub-
have been shown to be less frequent and less dense than sequent seizure recurrence may be related to tapering or
following more extensive temporal lobectomies. Other fo- lack of compliance with anticonvulsant therapy, and is
cal neurologic deficits are rare. It is extremely important rarely intractable.
to protect structures at the roof of the temporal horn to Postoperative radiographic verification of the extent
avoid homonomous hemianopia (optic tract) or hemipare- of resection (Fig. 9) is performed routinely at our institu-
sis (internal capsule). It is also important to avoid injury tion. Patients with retained temporal mesial structures are
to any structures within the perimesencephalic cistern to more likely to have seizure recurrence and may be helped
avoid cranial nerve or major vascular injuries. by reoperation aimed at resection of these residual mesial
Anticonvulsants are maintained at near toxic levels structures.

© 1992 The American Association of Neurological Surgeons

Figure 9. Postoperative T1-weighted MRI performed in the axial plane fissure). This reveals the extent of resection of the temporal pole and of
of the temporal lobe (axial cuts angled along the plane of the sylvian mesial structures to the collicular level.




INTRODUCTION the chorda tympani nerve and posteriorly by the VIIth

The potential for interruption of the VIIth cranial nerve nerve) is opened, the incus is removed, and the eustachian
during acoustic tumor removal is present for any sized tube and middle ear are filled with periosteum, fascia,
tumor. It is incumbent upon the surgeon(s) to be pre- and muscle to prevent postoperative cerebrospinal fluid
pared for this event and to be ready to implement an (CSF) leakage. The sigmoid sinus is skeletonized and re-
immediate plan of action should it occur. The immedi- tracted posteriorly with the Silverstein retractor. The ves-
ate plan should be that of direct VII-VII tibular bony otic capsule is removed and the internal au-
neuroanastomosis or autogenous cable graft interposi- ditory canal skeletonized in an arc of 180°. The area of
tion VII-VII neuroanastomosis. The plan should not be Bill’s bar separating the VIIth nerve from the superior
one of delay, or “inaction,” waiting for a time to per- vestibular nerve is identified and the superior vestibular
form a substitution cranial nerve anastomosis. nerve is avulsed from its canal; positive identification of
the VIIth nerve is made at this point in the operation.
OVERVIEW OF SURGICAL PROCEDURE Once this is accomplished, certain key anatomic
The author’s experience has been primarily with the op- points have been established. These include: 1) bone re-
eration of posterolateral craniectomy with translabyrin- moval from the superior petrosal sinus and middle fossa
thine exposure of the cerebellopontine angle (CPA). The dural plate superiorly to the jugular bulb inferiorly; 2)
details of the operative procedure will be highlighted for posterior retraction of the sigmoid sinus; 3) opening of
a clearer understanding of the VII-VII neuroanastomosis. the cochlear aqueduct to allow egress of CSF and reduc-
It must be clearly understood that this procedure allows tion of intracranial pressure; 4) skeletonization of the VIIth
for the removal of an acoustic tumor of any size. nerve from the posterior aspect through its mastoid por-
The patient is supine on the operating table with the tion, lateral to the vestibule, toward the geniculate gan-
head lying flat on a sheepskin and turned away from the glion, and at its entrance into the lateral end of the inter-
surgeon. The anesthesiologist is on the same side of the nal auditory canal (IAC); and 5) complete exposure of
operating table as the surgeon, with a 5-foot anesthesia the posterior fossa dura as outlined above.
tubing running along the other side of the patient, cross- If the cochlea is removed as in the case of tumors
ing over to the machine at the pelvis. Appropriate moni- with extension forward and into the tentorial notch, this
toring equipment is used for the assessment of VIIth nerve step is accomplished first and simultaneously with
function and the maintenance of anesthesia. skeletonization of the VIIth nerve. In essence, the ear ca-
A large postauricular incision is made just in the hair- nal skin and ossicles are removed, the bony posterior ear
line, the ear is rotated forward, and if bone removal is to canal wall is removed, and the cochlea is drilled away to
involve removal of the cochlea, the external ear canal is expose the carotid artery below the floor of the eusta-
transected and sewn shut. Bone removal is accomplished chian tube. The VIIth nerve can be skeletonized in an arc
with the air-driven Ototome drill. The mastoid is opened of 360° and the dural exposure extended medial to the
and saucerized widely posteriorly behind the sigmoid si- VIIth nerve, above the jugular bulb, to the carotid artery,
nus to the dura. The facial recess (bounded anteriorly by anteromedially, inferior to the IAC.
This exposure takes from a little less than two
© 1992 The American Association of Neurological Surgeons hours to three hours, depending upon the extent of


Figure 1. Lifting the divided VIIth nerve out of its bony canal.

Figure 2. Suture anastomosis of the VIIth nerve. Left inset, abdominal

fat is used to support the suture anastomosis of the VIIth nerve. Lower
inset, an autogenous cable graft is interposed between the proximal and
distal VIIth nerve stumps.


aeration of the temporal bone. From the induction of an- moval can be accomplished without damage to this laby-
esthesia to the operation starting time is approximately rinthine segment, allowing removal of the VIIth nerve out
30 minutes. of its bony canal (Fig. 1). Brisk bleeding occurs from the
The dura is opened in an apron-shaped fashion and vessels in the canal of the greater superficial petrosal
an “extradural” retraction with cottonoids only over the nerve. The angled neurotologic scissors can be helpful in
cerebellum is accomplished. The pCO2 is maintained at separating the nerve from the ganglion, and Avitene can
23 mm Hg and the patient is not paralyzed. be used for immediate hemostasis.
Tumor removal is posterior first in larger tumors us- Once the nerve is mobilized, a 7-0 silk suture is first
ing the House-Urban rotary dissector to gut the interior passed through the proximal stump of the VIIth nerve at
of the tumor, allowing for the development of arachnoid the brain stem. The suture is then passed through the dis-
planes and for the capsule of the tumor to be moved away tal end of the nerve which is gently brought into approxi-
from cranial nerves, vessels, cerebellum, and brain stem. mation with the proximal stump (Fig. 2). The first knot
Once the tumor is gutted, removed partially, and reduced should be a double (“surgeon’s”) knot so the second will
to smaller size, attention is turned to the lateral end of the hold fast. A piece of abdominal fat (taken for wound clo-
IAC. Here, previous identification of the VIIth nerve has sure) and Avitene are used to support the neuroanastomosis
been made. The tumor is then carefully dissected away (Fig. 2, left inset). The neuroanastomosis can be some-
from the VIIth nerve using continuous suction and irriga- what tenuous, and because the root exit area of the VIIth
tion via the Brackmann multifenestrated suction-irriga- nerve may be pushed into the brain stem, this support is
tor, the neurotologic scissors, and the insulated Crabtree helpful and is easy to place.
dissector, both designed for us, the latter of which is at- Rarely is it necessary to obtain an autologous cuta-
tached to the Xomed Nerve Integrity Monitor. neous nerve for cable grafting because the length gained
The problem of VIIth nerve preservation occurs dur- from the technique just described is ordinarily sufficient.
ing the dissection of the VIIth nerve at its anterior angu- If it is necessary, a segment of sural nerve from the area
lation out of the IAC. Many tumors spread the VIIth nerve just behind the lateral malleolus of the ankle is obtained.
so thinly over the anterior tumor surface that the plane of While grossly this nerve may look small, under the mi-
dissection can be lost in spite of lateral VIIth nerve iden- croscope it is always much larger than the root exit seg-
tification in the IAC and identification of its zone of exit ment of the VIIth nerve. In this instance, the proximal
from the brain stem. In fact, a histological plane between neuroanastomosis is accomplished first with the technique
tumor and VIIth nerve may not exist. It is at this site where just described, followed by the distal neuroanastomosis
the VIIth nerve is most commonly interrupted both ana- (Fig. 2, lower inset).
tomically and electrically, intentionally or unintentionally,
during total tumor removal. RESULTS
Our patients have exhibited better facial animation re-
VII-VII NEUROANASTOMOSIS sults with direct VII-VII neuroanastomosis than with a
Upon recognition of interruption of the VIIth nerve or delayed XII-VII neuroanastomosis. The results produce
the likelihood of little if any chance of regeneration spontaneous simultaneous facial movement, do not re-
through thin strands of tissue that resemble arachnoid, quire a second operation, and shorten the time of recov-
one must be ready to perform a VII-VII neuroanastomosis. ery compared with a second substitute cranial nerve
Previous skeletonization of the VIIth nerve during earlier neuroanastomosis. The results with an interposition au-
bone removal stages of the operation now becomes an togenous cable graft are not as good as those with direct
advantage of the posterolateral craniectomy and end-to-end VII-VII neuroanastomosis but are preferable
translabyrinthine operation. when compared with paralysis or XII-VII substitution.
The proximal end of the VIIth nerve is marked with If a patient has undergone a retrosigmoid, standard
a cottonoid at its root exit zone. The CPA is sealed off suboccipital craniectomy, the VIIth nerve can still be
with cottonoids to prevent scattering of bone dust through- mobilized and a VII-VII neuroanastomosis performed. The
out. Bone removal is completed along the thin bone cov- length of nerve gained from the rerouting described is
ering the VIIth nerve from the stylomastoid foramen to not changed because of the surgical exposure. I believe
the geniculate ganglion using a diamond drill. The sharp that any surgeon who performs acoustic tumor surgery
angulation of the VIIth nerve from the geniculate gan- should be prepared for the unfortunate situation of VIIth
glion into the IAC does not allow for 180° of bone re- nerve interruption, intentional or unintentional, and should
moval. However, careful diamond drilling techniques can either perform the VII-VII neuroanastomosis or call in
satisfactorily skeletonize the VIIth nerve, and bone re- someone who can.



The extended subfrontal approach is a modification of the THIS APPROACH
transbasal approach described by Derome. In addition to a 1. Intra- and extradural tumors of the anterior cranial
low bifrontal craniotomy, the supraorbital rims along with fossa (e.g., meningioma, esthesioneuroblastoma. na-
the anterior portions of the orbital roofs are removed, the sopharyngeal carcinoma, etc.);
extradural optic nerves are decompressed up to the orbital 2. Predominantly extradural tumors of the clivus that
apices, and the posterior ethmoid and sphenoid sinuses are may extend as low as the foramen magnum (e.g., chor-
widely opened. This approach provides access to the entire doma, chondrosarcoma);
anterior cranial fossa and to the portion of the middle and a. Extradural tumors of the clivus may occasionally
posterior cranial base between the cavernous and petrous penetrate and have a small intradural extension.
portions of the internal carotid artery (ICA) on each side These may also be removed by this approach.
down to the foramen magnum. It is useful for all intra- and b. When there is a major intradural extension of the
extradural lesions involving the anterior cranial fossa and tumor, only the extradural portion should be resected
predominantly extradural tumors involving the median re- by this approach because of the lack of control of
gion of the clivus and sphenoid bone. the vertebrobasilar system and cranial nerves and
the great depth of the working area. A separate ap-
PREOPERATIVE DIAGNOSTIC EVALUATION proach is advisable for the intradural tumor.
High resolution computed tomography (CT) scanning with c. The area of the posterior clinoid processes and
intravenous contrast enhancement in 1.5-mm slices is the dorsum sellae is not adequately accessed by
carried out in the axial and coronal planes. The finer de- this route. In our opinion this region is best ex-
tails of the bone destruction are best defined by the bone posed by an intradural subtemporal or trans-
algorithm. Opacification of the paranasal sinuses may sylvian approach.
occur due to tumor involvement, obstruction of the out-
flow, or mucosal thickening from inflammation, and this COMBINATION WITH OTHER APPROACHES
is differentiated by magnetic resonance imaging (MRI). 1. Tumors of the anterior cranial base frequently require
The MRI provides additional information and is specifi- combining a transfacial approach to access that part
cally useful for the soft tissue relations with regard to fat of the tumor extending into the nasal cavity and max-
planes, major vessels, cerebrospinal fluid (CSF) spaces, illa. This is performed most often in the same sitting
and the contents of the paranasal sinuses. Both T1- and so that en bloc removal of the tumor can be achieved
T2-weighted images and the appearance of the lesion af- with adequate reconstruction.
ter gadolinium administration are evaluated, especially 2. When the tumor extends lateral to the petrous and/or
noting the signal of the bone marrow in the area of bone cavernous ICA, a lateral extradural approach like the
destruction. subtemporal and infratemporal approach is also nec-
Arteriography is performed if the lesion is eccentric essary. Both approaches can be performed simulta-
and encroaches upon or surrounds the petrous or cavern- neously or at different stages.
ous ICA. Under such circumstances a balloon occlusion 3. Extensions into the cavernous sinus are dealt with in
test of the involved artery is recommended. Otherwise, a separate operation using an intradural approach.
magnetic resonance angiography provides adequate in-
formation regarding the disposition of the ICA in the vi- PREOPERATIVE PREPARATION
cinity of the tumor. The scalp is assessed for previous incisions which may


compromise the use of a pericranial flap for reconstruc- Incision

tion. If such a situation exists, alternative methods of re- A bicoronal incision is used, extending from the level of
construction using a vascularized free omental flap may one zygomatic arch to the other (Fig. 1B). The incision
be planned. must be placed as posteriorly as possible behind the coro-
Steroids are administered only if there is significant nal suture so that a long pericranial flap may be available.
mass effect and cerebral edema. Anticonvulsants are given Furthermore, the scalp incision can be made so that the
preoperatively if intradural anterior fossa tumor resection posterior scalp is undermined to harvest an additional
is planned. Intraoperative antibiotic coverage is routinely length of pericranium in continuation with the anterior
used and it consists of either a combination of vancomy- portion (Fig. 1C). The caudal ends of the incision should
cin and tobramycin or ceftriaxone and metronidazole. also be placed posteriorly, close to the ear, to avoid the
They are given at the beginning of the operation and con- frontal branch of the facial nerve.
tinued for 48 hours postoperatively or until the drains are
removed. Bony Exposure
The scalp flap is reflected along with the pericranium to
OPERATIVE PROCEDURE the level of the nasion and the orbit. The periorbita is
stripped from the roof and medial and lateral walls con-
Anesthetic Technique and tinuous with the pericranium. To avoid inadvertent injury,
Intraoperative Monitoring the pericranium is not elevated from the scalp until the time
General inhalation anesthesia is used and the endotracheal of reconstruction. If the supraorbital neurovascular bundle
tube is firmly secured with mandibular or interdental wires seems to emerge from a foramen, the anterior aspect of it is
to avoid dislodging the tube during intraoperative manipu- fractured with a small osteotome so that the vessel and nerve
lation of the head. Central venous and arterial catheters can be displaced caudally with the scalp and periorbita.
are inserted for fluid administration and hemodynamic Preservation of the artery is important since it supplies the
monitoring. An indwelling urinary catheter is used for pericranial flap. The temporalis muscle is elevated on ei-
accurate measurement of urine output. Sequential com- ther side from the temporal fossa to expose the pterion.
pression stockings are wrapped around the lower extremi- The bony exposure now consists of the frontal bones,
ties and are continued into the postoperative period to frontozygomatic sutures, supraorbital rims, and medial
reduce the chances of developing deep venous thrombo- walls of the orbits down to the level of the nasion (Fig. 2).
sis. A lumbar spinal drain is inserted after the induction
of anesthesia. CSF is aspirated in increments of 20 to 30 Craniotomy
ml as required to provide brain relaxation. If a significant A low bifrontal bone flap is elevated after making burr
intracranial mass is present, spinal fluid drainage is not holes at the “key hole” on either side and one placed 5 to
used and alternative means of brain relaxation like hyper- 6 cm superior to the nasion slightly on one side of the
ventilation and osmotic agents are used. Because cranial midline (Fig. 2). If the dura strips with difficulty, one-
nerve monitoring is usually not required, the use of neu- half of the bone flap may be elevated first, after which the
romuscular blockade is not a problem. Brain stem audi- dura can be separated from the opposite side under direct
tory evoked potentials may be monitored as an indicator vision and the other bone flap is elevated separately. This
for brain retraction. eliminates the need for a midline burr hole in the fore-
head. Small openings in the superior sagittal sinus, which
Positioning is small in this area, are easily controlled with Gelfoam
If it is anticipated that the patient’s head will be moved strips; larger rents need to be sutured. The dura is now
during the operation, the head is placed on a horseshoe tented up to the bone edges with sutures.
headrest; otherwise, a three-point pin fixation is preferred.
The patient lies supine and the head is slightly extended Fronto-orbital Osteotomy
to allow visualization along the floor of the anterior fossa CSF (20-40 ml) is removed through the drain and the
(Fig. 1A). The eyelids are sutured shut after instilling a subfrontal dura is separated from the orbital roofs
lubricating ointment. Unsterile electrophysiological moni- starting laterally and proceeding medially toward the
toring electrodes are inserted outside the surgical field. If crista galli. With a malleable retractor protecting the
additional ones are needed within the sterile field, sterile lateral orbit, a cut is made with the reciprocating saw
electrodes are inserted after preparation of the area. The at the frontozygomatic suture to the “key hole” burr
lateral thigh is also prepared for harvesting fat and fascia hole (Fig. 3A). A malleable retractor is now used to
lata if needed. protect the subfrontal dura. and another over the or-


© 1992 The American Association of Neurological Surgeons

Figure 1. The patient is positioned supine with the head on a horseshoe evated at the beginning of the operation; to obtain a greater length some
head rest or in a pin fixation device (A and B). The pericranium is el- of it has also been taken from the area posterior to the scalp incision (C).

© 1992 The American Association of Neurological Surgeons

Figure 2. The pericranium is elevated with the periorbita, preserving the supraorbital vessels, and the scalp is peeled down low.


© 1992 The American Association of Neurological Surgeons

Figure 3. The steps of the osteotomy are shown (A-D). It is important cuts. If the olfactory nerves are divided early, the intracranial midline
to carefully protect the orbital contents and the dura during these bone cut can be made further posteriorly into the ethmoid sinus.


bital contents and the osteotomies are extended medi- of the Extradural Optic Nerves
ally over the orbital roofs to the crista galli using the Under the magnification of the surgical microscope, the
saw (Fig. 3B). The frontal sinuses may extend into the subfrontal dura is elevated after the olfactory nerves have
orbital roofs for a variable distance. A horizontal os- been divided. The dura may be invaginated into multiple
teotomy is now made at the nasion, level with and about crevices in the anterior fossa floor and these folds must
half as deep as the anterior ethmoidal artery after co- be carefully delivered to avoid tears. Dural tears should
agulating and dividing it (Fig. 3C). The midline cut may be repaired immediately to avoid overlooking them in the
have to be repeated from intracranially to connect with end. The subfrontal dissection is facilitated further by
the external cut at the nasion. If during these cuts the aspirating CSF from the spinal drain. The extradural por-
periorbita is accidentally torn it is covered with cottonoid tions of the optic nerves are identified and the dura is
strips to prevent extrusion of the orbital fat. The fronto- elevated carefully since it is thin in this area and dural
orbital bone piece is now removed in one piece (Fig. tears are difficult to repair. Maintaining proper orienta-
3D). After this, the procedure differs depending on tion with the midline is helpful during this procedure.
whether the tumor involves the anterior cranial base or
the clivus, as described below. Decompression of the Extradural Optic Nerves
and Removal of the Planum Sphenoidale and
Tumors Involving the Anterior Cranial Base Posterior Ethmoidal Air Cells
In the case of an esthesioneuroblastoma, a nasopharyn- The frontal lobes are gently elevated extradurally with a
geal malignancy with dural involvement, or a meningioma self-retaining retractor and the optic nerves are carefully
with basal bony involvement, the dura is opened at the unroofed on their superior and medial aspects using a 3-
frontal pole on either side of the midline and the superior or 4-mm diamond burr on a high-speed drill operated by
sagittal sinus is doubly ligated and divided. The surgical the foot of the surgeon. Drilling should be done in a gentle
microscope is used for the intracranial portion of the op- stroking motion with minimal downward pressure under
eration. The frontal lobes are elevated while the surgeon constant irrigation. The optic canals diverge in a down-
carefully separates the olfactory tracts which are divided ward and outward angle of 45° and the bone which is
near the olfactory trigone in case of malignant tumors, very thin posteriorly gets rapidly thicker toward the or-
taking into consideration perineural invasion by these tu- bital apex. Another clue to the direction of the nerves can
mors. A wide margin of dura is coagulated and incised be obtained from the orbit which has been partly exposed
around the tumor and the high-speed drill is used to make by the supraorbital osteotomy (Fig. 4).
the bone cuts in the anterior fossa floor. Prior to the bone After both optic nerves have been unroofed to the
cuts, the optic nerves are unroofed extradurally on their orbits (about 2 cm), the planum sphenoidale is completely
superior and medial aspects, out to the orbital apices if removed with the drill and further anteriorly, the poste-
the tumor comes near the nerves (see below). This proce- rior ethmoidal air cells are also drilled away. The mucosa
dure is facilitated by using the medial wall of the orbit, of the sphenoid and ethmoid sinuses is removed thor-
which has already been unroofed, as a landmark. After oughly and if there is tumor within the sphenoid sinus a
the superior portion of the tumor has been mobilized and specimen can be sent for frozen section examination and
detached, the inferior and lateral portions are freed through the rest removed with the pituitary forceps, ring curettes,
a separate transfacial approach, after which the tumor is and suction.
delivered en bloc inferiorly.
In the case of a meningioma, standard microsurgical Delineation of the Lateral Margins
principles are utilized and the main intracranial tumor of the Exposure by Definition of the
mass is separated from the skull base to devascularize it Cavernous and Petrous ICA
from its ethmoidal arterial blood supply. The tumor mass The microscope is angled in from the contralateral side
is then debulked and separated from critical structures along the anterior fossa floor. Using a diamond burr
and removed. After the main tumor mass has been re- (3-4 mm), the bone on the undersurface and the medial
moved, the basal dura is excised and the bony involve- wall of the orbit is drilled away to expose the medial
ment is drilled away; the ethmoid and frontal sinuses are surface of the anterior portion of the cavernous ICA
entered in the process. (Fig. 5). Drilling is continued along the medial surface
of the artery; the ICA can be exposed up to the point
Extradural Tumors of the Clivus where the petrous ICA turns up into the cavernous.
segment (Fig. 6). The periosteal layer of dura separates
Division of the Olfactory Nerves, Elevation the ICA and the cavernous sinus from the surgical
of the Subfrontal Dura, and Exposure f ield, and venous bleeding if present is con-


© 1992 The American Association of Neurological Surgeons

Figure 4. (Top) The optic nerves are unroofed initially using the dia- Figure 5. (Bottom) The optic nerves have been unroofed along with the
mond burr; then the planum sphenoidale and the ethmoid sinuses are orbits. On each side the bone medial and inferior to the optic nerve has
entered with a cutting burr. been removed to uncover the medial aspect of the anterior cavernous ICA.


© 1992 The American Association of Neurological Surgeons

Figure 6. The cavernous ICA has been unroofed posteriorly up to its and the pituitary gland capsule (PIT) is exposed. The arrows indicate
entry into the cavernous sinus from the petrous bone. Looking under the area where the petrous ICA enters the cavernous sinus.
the left optic nerve (ON) the anterior intracavernous carotid (IC) is seen

trolled with Surgicel packing. The sellar floor is also limited laterally by the cavernous ICA, Dorello’s canal, and
drilled away to expose the dura; however, it will be noted the hypoglossal canal. Lesions placed further laterally can
that the dorsum sellae is hidden from the surgeon’s view not be accessed by this approach alone and it may have to be
by the pituitary gland in front (Fig. 6). Similarly, the op- combined with other approaches as mentioned above.
posite ICA is exposed with the microscope angled in from The fronto-orbital osteotomy adds some advantage
the other side. Tumor lying between the ICAs can be safely in reducing brain retraction when only tumors of the an-
removed and bleeding from the clival venous plexuses terior cranial fossa are concerned. However, for more
controlled with Surgicel packing. posteriorly situated tumors, the osteotomy and wide open-
After the tumor has been removed, the clival bone is ing of the sphenoid and ethmoid sinuses provide increased
drilled away until healthy marrow spaces are seen. The room for manipulating instruments and a better angle of
hypoglossal canal and Dorello’s canal are in the lateral visibility without increased brain retraction which is es-
limits of the exposure on each side and vigilance is nec- sential for working in the depths (Fig. 7B). The dorsum
essary to avoid injury to the nerves within these canals. sellae and the posterior clinoid processes remain a blind
Small intradural tumor extensions are carefully removed. spot because of the sellar contents in front.
The relative depth and narrow confines of the exposure
make more involved intradural dissection hazardous. Reconstruction
The crux of the reconstruction is a healthy pericranial
Extent of Exposure of the Skull Base flap based on the supraorbital vessels. The galeal layer
The entire anterior cranial base is exposed including the or- may also be included in this flap. The flap can be raised
bits and the frontal and ethmoid sinuses. Exposure posterior in the beginning of the operation or after tumor resec-
to this is restricted to the median and paramedian areas as tion has been completed. Tenotomy dissecting scissors
far back as the foramen magnum (Fig. 7A). The access is are used for elevating the flap, being careful to


© 1992 The American Association of Neurological Surgeons

Figure 7. A, the sphenoidal and clival exposure is limited by the ICA, visibility and the working area without the fronto-orbital and ethmoidal
Dorello’s canal, and the hypoglossal canal on either side. B, the angle of osteotomy (B), and with the osteotomy (A).


avoid creating holes or making the flap too thin. All dural dura up at two or three places. The fronto-orbital piece is
openings in the anterior fossa are closed primarily or patched. then replaced. The inferior surface of the fronto-orbital
For those along the clivus, a piece of fascia lata or temporalis bone is trimmed so that it does not strangulate the peri-
fascia is laid against the opening(s). Fat, harvested from the cranial flap. This piece of bone is anchored to the bifrontal
abdomen or thigh, is then lightly packed in the frontal, eth- bone flap and at the frontozygomatic sutures. All the con-
moid, and sphenoid sinuses after the mucosa is removed thor- vexity bone pieces are held with 2-0 Nurolon sutures or
oughly. The pericranial flap is carefully passed between the occasionally titanium miniplates and screws. Two drain-
optic nerves and laid against the clival dura (Fig. 8). This age catheters are placed in the subgaleal plane, connected
requires some manipulation; overpacking the sinuses with to a gravity drainage system, and brought out through
fat can be a hindrance. The ultimate success of the repair separate openings prior to closure of the temporalis muscle
depends on adequate revascularization of the fat from the and fascia and the scalp.
surrounding tissues. It will also be noted that removing the
fronto-orbital piece of bone gives added length to the peri- POSTOPERATIVE CARE
cranial flap, allowing it to reach further posteriorly. If healthy Continuation of the spinal drain is not required in the
pericranium is not available, a free omental flap connected postoperative period if a good dural repair has been
to the superficial temporal artery may also be used for a achieved. However, if this is continued, specific nursing
satisfactory reconstruction. instructions must be written to drain no more than 30-50
The clival bone is not reconstructed. If the medial ml of CSF every 8 hours. This is important to prevent
orbital walls have been completely removed, split calva- problems related to overdrainage, such as transtentorial
rial grafts are used, anchored with wires or titanium mini- herniation and epidural pneumocephalus.
or microplates. Bony reconstruction is not essential for A CT scan is performed on the first postoperative
the midline anterior cranial fossa floor after a craniofa- day as a routine to check for air, contusion, or edema to
cial resection if a healthy pericranial flap is available. direct specific therapy if required before there is a sig-
However, if desired, a piece of split calvarial bone can be nificant clinical problem. The subgaleal drains are con-
laid between the pericranial flap and the dura to bridge tinued for about 48 hours or until the drainage return is
the gap in the anterior fossa floor. minimal. Antibiotics are continued until the drains are
The bifrontal bone flap is replaced after tenting the removed.

© 1992 The American Association of Neurological Surgeons

Figure 8. Reconstruction of the cranial base with fat and pericranium. Note the additional length of pericranium
obtained by the fronto-orbital osteotomy.


PREVENTION AND MANAGEMENT rum or single donor serum, may also be used during re-
OF COMPLICATIONS construction with the fascia, fat, and pericranium.
Cerebral Edema
This is seldom encountered because of the generous bone Epidural Pneumocephalus
removal which greatly reduces brain retraction. It is usu- This is most often seen as a result of overzealous use of
ally seen when a large intracranial tumor has been re- the lumbar drain in the postoperative period. The patient
moved and sometimes when frontal veins draining into usually presents with mental status changes and has a
the superior sagittal sinus have been sacrificed or in- nonlocalizing neurologic exam. A CT scan confirms the
jured. Medical management with steroids and osmotic presence of air. This is managed by removal of the drain
agents suffices. Close monitoring of fluid and electro- and the patient is maintained flat in bed.
lyte balance is necessary because the syndrome of inap-
propriate secretion of antidiuretic hormone is quite com- Epidural Infection
mon in this setting and can further complicate the Because of the wide bifrontal exposure and inadequate
situation. tenting of the dura, epidural fluid collections may occur.
Contamination of this fluid with the sinus contents can
Cerebrospinal Fluid Leakage lead to an infection in this space. If infection is confirmed,
This problem is best avoided by performing a meticulous the surgical wound must be debrided and the bone flap
reconstruction. If the leak noted in the postoperative pe- has to be removed. Removal of the fronto-orbital os-
riod is small, a lumbar spinal drain is inserted. When the teotomy is not always necessary; because the bone piece
leak is large or persists after 4 or 5 days of spinal fluid is thin, it vascularizes early and can survive the infection.
drainage, surgical reexploration of the craniotomy is nec- Infections are more common in patients who have received
essary. Fibrin glue, prepared from the patient’s own se- radiation in the past.


INTRODUCTION The decision to operate is a joint one among the pe-

Children born with severe pansynostosis are usually di- diatricians (including neonatologists and intensive care
agnosed at birth or very shortly thereafter. The craniofa- personnel), the anesthesiologists, the patient’s family, and
cial team should be notified of the child’s condition very the craniofacial team. The potential risks to the very young
early and should be involved in the surgical planning as child are associated with the significant blood loss; al-
soon as possible. The most important factor in timing the most all of these children will require blood transfusions.
surgery is the presence of increased intracranial pressure In addition, the surgical team is operating on a child with
(ICP). In our experience, almost all children (greater than residual fetal hemoglobin and, in many cases, associated
90%) born with pansynostosis have increased intracra- congenital anomalies. Ideally, in children with
nial pressure. The most difficult child to diagnose is the pansynostosis, the preoperative evaluation includes a thor-
one with pansynostosis secondary to microcephaly. For- ough evaluation for any cardiac, renal, or other associ-
tunately, a good pediatric workup and genetic screen can ated anomalies, which are not at all uncommon. Abso-
identify this. The typical pansynostotic child has all the lutely essential is a full radiographic workup including
signs of increased ICP, including severe “beaten metal” standard computed tomography (CT) and magnetic reso-
appearance or “thumbprinting” of the skull. There are nance imaging (MRI) scans. Congenital anomalies such
usually associated signs of lethargy, increased irritability, as holoprosencephaly and other underlying maldevelop-
early signs of developmental delay, etc. In some cases mental problems of the brain should all be identified prior
these signs or symptoms can occur so early that the sur- to surgery. In many cases we ask our bioethics team to be
gery has to be scheduled within the first month of life. involved to make sure the child is a reasonable candidate
for surgery and to make the family aware of future devel-
TIMING OF SURGERY AND OTHER PREOPERA- opmental problems. Included in the radiologic studies
TIVE CONSIDERATIONS should be an evaluation of the ventricular system, a high
Children with pansynostosis are typically diagnosed percentage of these children develop hydrocephalus be-
within the first two or three weeks of life, if not at birth. cause of the severe cranial base anomalies. Because of
For craniofacial surgery, the ideal time in elective cases unusual positioning problems in these children (i.e., it is
is five to six months of age. This growth period allows not uncommon to have the child in hyperextension), the
for an ideal surgical weight plus a fully developed hema- skull base and cervicomedullary junction need full evalu-
tologic system. In children with severe pansynostosis and ation. A Chiari malformation, a bony anomaly, and a nar-
associated constricted calvarial growth, the luxury of row or distorted foramen magnum can all be seen in this
waiting six months is very rarely, if ever, possible. Typi- population. To prevent a child from awakening from sur-
cally, the surgery will have to be scheduled within the gery quadriplegic, it is important to sort out these details
first six weeks to prevent damage to the developing brain. first. If, for example, a Chiari malformation is detected,
The longer the surgical team can wait the safer the sur- then the surgeon will appropriately modify the position-
gery will be. ing to avoid hyperextension.
All of these children are placed on prophylactic
© 1992 The American Association of Neurological Surgeons anticonvulsants preoperatively. The appropriate loading


dose should be given at least 24 hours in advance of the be carefully waxed or coagulated. In addition, the venous
surgery and continued for 30 days after surgery. Because sinuses can be violated as part of the elevation of the bone
these children typically have severe skull base anoma- units and this can lead to a rather rapid and dramatic loss
lies, we complete a full endocrine workup to rule out any of blood and subsequent air embolism.
hypothalmic-pituitary dysfunction. A routine coagulation To monitor ICP during the operation, we often place
profile is done prior to surgery. As mentioned earlier, a an intraventricular drain and attach it to a transducer. This
full and complete medical workup is done to rule out any drain can also be used for the removal of CSF in an effort
cardiac, hepatic, or renal dysfunction. If any of these are to reduce the ICP and to relax the brain.
detected, the surgical management plan includes the ap- Perioperative antibiotics are used. Typically, only the
propriate treatment. It cannot be overemphasized how skin organisms are covered (e.g., Staphylococcus and
thorough this preoperative workup should be. It is not at Streptococcus). The drug of choice is oxacillin (or van-
all unusual to find one or more system abnormalities in comycin if the child is allergic to oxacillin). If the child
the preoperative workup. has another source of infection such as an otitis media or
an upper respiratory infection, these are treated preop-
SURGICAL TECHNIQUE eratively and cleared prior to the start of any surgery.

Anesthesia and Monitoring Positioning

Surgical correction of a pansynostosis is a long and tech- The typical child with pansynostosis requires remodel-
nically complex procedure. Our anesthesia team manages ing and repositioning of almost the entire calvarium (Figs.
these children as if they all have increased ICP so that 1-6). As a result, the entire calvarium must be exposed in
inhalation agents which increase ICP are avoided. The the operative field. This surgical field extends from the
use of paralytic agents is encouraged to prevent any move- level of the orbits to the level of the foramen magnum. To
ment during the operation and also to assist in reducing do this we place the child in the prone position with the
ICP. All the children are started on a dehydration agent head hyperextended (after radiologic evaluation has shown
(e.g., mannitol, 0.5 g/kg) prior to induction. A Foley cath- no abnormalities of the cervicomedullary junction). The
eter must always be placed to monitor urine output and to chin rests on a horseshoe head rest that is well padded
avoid a bladder rupture. A temperature probe is placed (Figs. 1, A and B, and 4A). The draping is done with two
either in the esophagus or rectum to monitor the body split sheets going in opposite directions, keeping the or-
temperature closely. Heating blankets are placed both bits and entire calvarium in the operative field. Bilateral
below and on top of the patient to prevent hypothermia. tarsorrhaphies are performed at the beginning of the op-
There is almost always a significant blood loss asso- eration to protect the eyes. We no longer do a full head
ciated with these cases; therefore, at least two large-bore shave; the hair is trimmed for approximately 2 cm where
intravenous lines should be placed. If vascular access is the skin incision is to be made.
difficult, then a subclavian or jugular line can be placed. Figure 7 shows the operating room layout. The table
Arterial monitoring is essential for evaluation of blood is usually reversed head to foot so that the surgeon’s legs
pressure, electrolytes, and blood gases. The child is kept fit comfortably under the table. The operator works at the
hypotensive with a mean arterial pressure of 50-60 mm head end of the table with the assistant to the right. The
Hg to help reduce blood loss. We now routinely use an nurse with the instrumentation is placed to the right of
oxygen saturation monitor which can be placed on the the assistant. A Mayo stand is placed over the table and
child’s finger. The normal position of the patient is in on this the nurse places the instruments directly in use.
hyperextension with the head well above the heart. For Behind the nurse is a larger table that holds the main in-
this reason, air embolism is a significant risk and must strument groups. A Mayo stand is placed to the left of the
also be monitored. Our anesthesiologists now routinely operating surgeon and directly to the side of the child’s
place a jugular line and a pre-cordial Doppler device to head. When the drapes are placed, this allows the anes-
monitor for air embolism. With meticulous skin incisions thesiologist an access tunnel to the child’s airway and to
and careful coagulation of all bleeding sites, plus waxing the child’s peripheral lines. All the suction tubes, cautery
of the bone edges, the risk of air embolism can be mark- lines, etc. are run off the opposite end of the table. This
edly reduced. It has been our experience that these chil- allows the surgeon and the assistant to sit and not have
dren, because of increased ICP, can have dilated scalp their chairs run over the various tubes and cables. The
veins and in addition large diploic venous channels. These only item at the foot of the surgeon should be the cautery
can be treacherous sites of venous air embolism and must pedals and the pedals to run the air drills when necessary.


© 1992 The American Association of Neurological Surgeons

Figure 1. A, operative positioning, lateral view. The child is placed number of soft spots could be palpated secondary to brain “escaping”
prone in a hyperextended position. The child (face down) rests on a through the skull. The lambdoid sutures were so tightly fused the child
well-padded horseshoe head rest. The electrocautery grounding pad is did not develop the usual inion point. The head assumed the typical
placed on the child’s back. B, a frontal intraoperative view of a child early “cloverleaf” appearance that occurs when all the sutures fuse. C,
with severe pansynostosis and an early cloverleaf deformity of the skull. an intraoperative view of the forehead (corresponds with the view in B)
This child was diagnosed at birth and by three weeks of age had stopped after the skin flaps and pericranium have been elevated. Methylene blue
all head growth. It is important to appreciate the number of deformities has been used to mark out the osteotomy sites. The orbital bandeau will
in the skull. Because of fusion of the coronal and squamosal sutures be harvested from just behind the coronal suture. The new forehead unit
there is a severe dimpling to the temporal region. Over the calvarium a will come from the child’s left temporoparietal region (see Fig. 3A).


© 1992 The American Association of Neurological Surgeons

Figure 2. A, the unit of bone that came from the area labeled B in Fig- ate from the photograph that severe pocketing and erosion of bone have
ure 3B. The view is of the underside of the bone, i.e., the inner table. occurred. With the advancement necessary to decompress the brain, there
One can appreciate the severe “thumbprinting” that can occur in these is a lack of sufficient bone available to cover the calvarium. Two impor-
cases. The dura is pushing through these areas, and in addition there are tant pieces of bone are those struts that will be placed over the convex-
points where the bone has been completely eroded through with dura ity to prevent a turricephaly from occurring. C, an intraoperative fore-
and brain exposed. The elevation of this bone has to be done very gen- head view of the child prior to closure. The wire basketweaving can be
tly and carefully to avoid injury to the sinuses and to the brain. B, once appreciated in the orbital bandeau. This view is the equivalent view of
the various bone units are harvested, they are taken to a separate table Figures 1, B and C, and 3B. D, the child at 10 months of age.
and positioned to see how they will fit on the child. It is easy to appreci-


© 1992 The American Association of Neurological Surgeons

Figure 3. A, an artistic reconstruction of Figure 1C showing the vari- on the right. The areas A and B will form the new forehead and
ous sites for osteotomies and harvesting. The bandeau is elevated posterior occipital unit. The bandeau is harvested and advanced for-
from just behind the coronal suture. The new forehead unit (area A) ward and positioned (right). A sagittal strip of bone is placed to hope-
is marked out with a Marchac template and elevated from the tem- fully prevent a turricephaly from developing. The blank areas are
poroparietal region. B, an artistic reconstruction of Figure 1C show- exposed dura mater, which is common due to lack of bone that oc-
ing the various osteotomies on the left and then their repositioning curs in the various advancements.


© 1992 The American Association of Neurological Surgeons

Figure 4. A, an intraoperative view of an eight-month-old child with with the various osteotomies marked out in methylene blue. The orbital
severe synostosis of all the calvarial sutures. The dimpling about the bandeau will be taken from just behind the coronal suture which can be
temporal region and the flattening and distortion over the right occipital seen in this view. The area over the child’s left occipitoparietal area was
region can be appreciated. In this child the frontal unit and orbital bandeau determined to have the best configuration to reconstruct a new occipital
are symmetrical and not distorted. The surgical team decided on a re- plate. D, a lateral view after reflection of the skin and periosteal flaps.
construction behind the coronal suture rather than a total calvarial re- Using methylene blue the osteostomies have been marked out. The
moval. B, an intraoperative view similar to A with more of an oblique bandeau will come from just behind the coronal suture. This will be
angle of the child’s head showing the severe distortion of the calvarium moved back and placed tongue-in-groove into the asterion step-off unit,
that has occurred over the posterior parietal and occipital regions. C, a which has also been marked out.
frontal view similar to A, after reflection of the skin and periosteal flaps,


© 1992 The American Association of Neurological Surgeons

Figure 5. A, an intraoperative view (equivalent to Fig. 4, A and B) after into position. D, a posterior view (i.e., looking at the occipital region)
the various units have been repositioned. The new bandeau has been showing the “fan cuts” made in the occipital unit to help it mold. In the
attached to the asterion, and the various bone units have been mounted older child the bone is not as malleable and this is a useful technique to
on the bandeau unit. In this view the surgeon has laid the bone out to help the brain remodel the bone as it grows. E, an intraoperative view at
show which units are being placed. B, an intraoperative view equiva- the completion of the operation, equivalent to Figure 4, A-C. The im-
lent to A with the bone laid into position and just prior to wiring. C, an mediate correction that occurs with this type of technique can be appre-
intraoperative view equivalent to A and B with the bone units wired ciated here.


© 1992 The American Association of Neurological Surgeons

Figure 6. A, an artist’s reconstruction of Figure 4A showing the vari- which the rest of the calvarial reconstruction will take place. D, an
ous osteotomies. B, an artist’s reconstruction of Figure 4D showing artist’s reconstruction of Figure 5C, from the child’s right side, show-
the various osteotomies from the child’s right side (opposite side ing the various units in their new positions. E, an artist’s reconstruc-
from Fig. 4D). The asterion step-off can be seen here and this is tion of Figure 5C showing the bone units wired into position. The
where the bandeau will be anchored. C, an artist’s reconstruction of units have been labeled and are equivalent to the schematic in A.
Figure 4D (opposite side view) showing the harvesting and direc- The donor sites and their eventual location can be appreciated better
tion of the new bandeau unit. This unit acts as the framework upon here in this schematic.


© 1992 The American Association of Neurological Surgeons

Figure 7. Operating room schematic. The surgeon typically sits at the gist to view the child and the respiratory apparatus. The anesthesia ma-
head of the child with the assistant to the right. The nurse is positioned chinery is placed behind the anesthesiologist. A large table is placed
to the right of the assistant. A Mayo stand is brought over the child at behind the nurse where most of the instruments are placed. The Mayo
the buttock level. Another Mayo stand is placed to the left of the child stand is used only for the immediate instrumentation.
and parallel with the child. This provides a tunnel for the anesthesiolo-

An additional point to consider in the draping is the use ear to ear and normally follows a midpoint between the
of waterproof drapes. As these cases require considerable nasion and inion. This incision will easily allow the op-
bone removal, the saline irrigation used can be copious. It is erator to expose from the level of the orbits and nasion,
important that the drapes in contact with the body not get over the convexity, to a point below the nuchal line. By
wet during the case. In addition, we place heating blankets this approach the entire calvarium can be visualized. Dur-
both below and on top of the child. Because these are small ing the skin incision, the temporalis fascia should not be
children, the heat loss can be considerable and rapid so hy- cut. The pericranium is elevated as a separate layer, and it
pothermia must be carefully monitored and avoided. is incised where it merges with the temporalis fascia. The
temporalis muscle is then elevated as a separate layer and
Skin Incision hinged to its base. By doing this, the temporalis is avail-
These cases require a large and wide exposure of the cal- able to be laid down intact at the end of the case and sewn
varium. The simplest and most cosmetically efficient in- back to the pericranial layer. If the exposure is carried
cision is the bicoronal incision. This incision is carried down to the foramen magnum, the nuchal muscles can be


elevated as a flap in continuity with the periosteal layer. reconstruct the calvarium in the fashion best suited to give
This technique allows the nuchal muscles to be laid down an advancement, keeping in mind the amount of bone avail-
at the end of the case when the periosteum is laid back. able. As shown in Figure 2, B and C, we have reconstructed
When the frontal periosteal membrane is elevated, the su- the new calvarium using the forehead unit and new orbital
praorbital nerve and artery complex on each side can be bandeau. To give an adequate advancement one can appre-
easily elevated with it. This will allow preservation of these ciate the “lack” of bone that occurs when the reconstruc-
important structures that run through the supraorbital tion is done. Important points to remember are a good fore-
notch on each side. Occasionally the notch will need to head and bandeau unit first. Bone has to be placed over the
be opened, especially in older children. It can be opened calvarium along the sagittal sinus to prevent a turricephaly.
with either a small osteotome or a 2-mm Kerrison punch. We have found that if the convexity/apex region is left open
the brain will go the path of least resistance and a turri-
Operative Technique cephaly can occur. With proper attention to strut placement,
To illustrate the operative technique used in this type of the brain (i.e., frontal lobes) will expand forward and not
craniofacial reconstruction we have selected two cases. upward. Struts placed along the convexity help orient this
Each case was done with a different technique. direction of growth. The other pieces of bone are then placed
in a mosaic fashion, attempting to cover as much of the
Case One brain as possible. In this particular child there was such a
severe constriction of the head that after the calvarium was
History: A six-week-old child presents with severe remodeled with the available bone only 60-70% of the
pansynostosis involving all the sutures, resulting in a se- brain was covered with bone. In young children, particu-
vere thumbprinting appearance of the skull. Craniofacial larly under one year of age, reossification will occur eas-
reconstruction here is going to require complete disas- ily and quickly.
sembly of the calvarium from the orbit to the posterior In children with severe pouching of the dura caused
fossa (Figs. 1-3). by thumbprinting, it is sometimes necessary to relax these
dural bands. This can be done by incising the dura. and
The patient is positioned with the head extended as not incising the arachnoid. This will allow relaxation with-
shown in Figure 1, A and B. After the bicoronal incision is out cerebrospinal fluid (CSF) leakage. CSF leaks can be
made and the periosteum is elevated, the entire calvarium very troublesome days later (causing subgaleal collec-
is exposed in the field. Because this child’s forehead and tions), so it is important to repair any CSF leaks or dural
orbital rims are going to be advanced, a new bandeau and tears resulting from the opening.
forehead unit need to be marked out. Figure 1C shows the Figure 2C shows the calvarial unit after placement
intraoperative view after methylene blue has been used to (28-gauge wire is used for stabilization of the forehead
mark the plates to be harvested. The bandeau will come units). In this child the bandeau was so flimsy that wire
from an area just anterior to the coronal suture. The only was woven through the bandeau. to give it additional sup-
area where a normal forehead unit can be located is over port. Wire is usually required wherever structural support
the left temporoparietal region. The rest of the osteoto- is needed. In those cases where support is not needed,
mies are designed to provide large pieces of bone for the softer suture material (we use either Nurolon or Vicryl) is
reconstruction after the bandeau and forehead have been more than adequate.
As this child has severe molding and thumbprinting Case Two
of the inner table, the bone elevation has to be done with
great care to avoid tearing the dura or entering a sinus History: An eight-month-old child was noted to have se-
(Fig. 2, A and B). Using a high-speed footed drill and vere pansynostosis with lack of head growth from five
“walking” the footplate along the grooves and digital months of age. After careful workup for microcephaly,
markings, these units can be elevated safely. Areas that which was ruled out, the craniofacial team determined
are particularly treacherous are over the sinuses and be- that the child had severe synostosis of all the calvarial
tween the orbits. On the CT scans the surgical team noted sutures. However, in this child the orbital units and fore-
this child to have a tongue of brain coming in deep be- head were not severely affected so the reconstruction was
tween the orbits. Early appreciation of such anatomy pre- based on the units behind the coronal sutures.
vents an unacceptable situation of tissue damage to the
frontal lobes. In many cases the sphenoid wings are se- The positioning techniques and preliminary steps
verely sclerosed (giving the harlequin eyes) and in these were the same as in Case One. The significance of
cases the sphenoid wings are removed bilaterally. this child’s synostosis can be appreciated in Figure 4,
Once the bone plates have been elevated, they are taken A and B, which shows the anterior and superior views.
off the field to another sterile table; here the surgeons can In this child, all the calvarial sutures were noted to be


closed or sclerosed on x-ray examination. However, the inspected for any bleeding points. Gelfoam placed over
aesthetic examination showed the orbits and forehead to the bleeding points is usually adequate. The surface is
be symmetrical. On the basis of this, instead of performing then copiously irrigated with warm physiological saline
a complete calvariectomy, we kept the forehead and orbital solution. As this is a long operation, with a long exposure
unit intact and reconstructed the rest of the calvarium. time, copious irrigation is essential to remove any debris
In Figure 4, C and D, the child’s head is shown from and bacterial contaminants. The pericranium is elevated
superior and lateral views to demonstrate the methylene and carefully stretched out over the calvarium. Particular
blue markings where the osteotomies will be performed attention is paid to the wires as these will snag the peric-
(Fig. 6, A and B, shows the artistic schematic). To cor- ranium and restrict the amount of spreading. The nuchal
rect the deformity over the occipital region and to allow muscles should come up easily with the posterior peri-
growth and advancement, a new bandeau is constructed. cranial layer. The frontal layer is then brought up and
This will act as the base unit for reconstruction. To an- retention sutures are placed between the front and back
chor this bandeau down, a “step-off ” has been marked layers. These layers will not meet, due both to shrinkage
out over the asterion region (Fig. 4D). The entire occipi- and to the advancement. However, they can be kept in
tal region and posterior fossa bone will be removed in position by retention sutures. Next, the temporalis muscles
two units and these pieces will be used in the recon- have to be reattached to the pericranium or sometimes
struction. The piece over the right occipital region (la- they can be sewn to the sutures in the bone units.
beled “A” in Fig. 6A) was determined to have the clos- A drain is placed in the subgaleal space to collect the
est symmetry to a new occipital plate and this was marked blood (which can be extensive) that arises from the skin
out using a preformed template. Because the sagittal si- flap. However, prior to closure of the skin flap, a careful
nus lies under the sagittal suture, it is sometimes useful search for bleeding points should be conducted to mini-
to make an additional osteotomy lateral to each side of mize such bleeding. In addition, the gutters must be irri-
the suture. Then the plate of bone over the sagittal sinus gated copiously again. When the flap is curled over, bone
is elevated last as a unit when full control is available to dust, old blood, and debris will collect—this must be irri-
handle any sagittal sinus bleeding. In children under one gated out!
year of age it is relatively easy to elevate bone off the Remembering that the reconstruction unit is very
sinuses, both sagittal and lateral. fragile, the surgeon places a soft “fluffy” dressing over
Once the bone has been harvested, the bandeau is the wound. Tight wraps or constricting dressings should
placed into position, tongue-in-groove to the asterion unit. be avoided because they will tend to collapse the bony
On this bandeau the new occipital unit, which had been construct. A stretched fishnet stocking is most useful to
previously fashioned, is placed. This acts as the frame- place over the head and keep the fluffy dressing in place.
work upon which to build the rest of the calvarium in a
mosaic unit. In Figure 5A we show the various bone units Specialized Instrumentation
winged out to show their location and position prior to These operations are done with a standard craniotomy
wiring them into position. In the older child with firmer set. It is recommend that a high-speed drill system with a
bone, it is occasionally useful to “fan cut” the bone to craniotome (e.g., Midas Rex) be used for harvesting the
allow the expanding brain to spread out (this can be seen calvarial bone. These children typically have a thin skull
in Fig. 5D). Figure 6C is a lateral schematic view show- with severe inner table erosion; to prevent injury to the
ing the bandeau in position. With the new occipital unit brain and dura the operator will need a well controlled
in position around this framework, the calvarium is re- high-speed drill system with a fine foot plate to separate
constructed in a mosaic pattern using the remaining bone bone and dura.
(Figs. 5, C and D, and 6, D and E). As in Case One, it is To mark out the forehead unit we have been using
important to remember to cover the sagittal sinus first the Marchac forehead templates. These templates are quite
with bone, to act as a strut and subsequently to prevent a useful in locating a unit of bone on the calvarium that
turricephalic pattern from developing. Again, wire is used most closely approximates the normal forehead.
in those parts that need the additional support. Suture
material is used where wire is not necessary.
Closure Technique There are a number of known complications associ-
After the calvarial bone units have been placed, the clo- ated with these complex craniofacial procedures. It
sure is done in a reverse fashion of the opening. The dura has been our experience that if the surgical team
is inspected for any CSF leaks. The venous sinuses are thinks of them as they go through the preoperative,


intraoperative, and postoperative steps, many of them can Abnormalities at the cervicomedullary junction are com-
be avoided. mon in these children. Before a child is hyperextended,
the surgeon must rule out any evidence of a Chiari mal-
Hemorrhage formation, bony anomaly, or narrowing of the foramen
magnum. If any of these is noted, the positioning has to
This can and will occur as a normal part of this operation. be corrected to allow for it.
Because of the extensive nature of the craniectomies and
the amount of flap exposure and osteotomies, the loss of Cerebrospinal Fluid Leakage
blood can be great. To assist in reducing this blood loss, All CSF leaks must be repaired and no evidence of a CSF
our team uses a number of techniques. Since these are leak can be present at the completion of the operation. If
children and there is an extended family, we request that necessary, the surgeon can have the anesthesiologist pro-
the family arrange for pedigree blood to be given a week vide a positive-pressure Valsalva maneuver at the end of
in advance. This reduces the risk of hepatitis, AIDS, and the case. In those cases where there is severe pansynostosis
other infectious diseases that can be carried in blood. The with dural pouches that need to be released, this can be
anesthesiologist keeps the child at a hypotensive blood done if the surgeon stays within the subdural space and
pressure range (mean arterial pressure of 50 mm Hg) dur- does not violate the arachnoid membrane. Keeping this
ing the procedure. Blood transfusion is done only when technique in mind will prevent arachnoid tears and CSF
the hematocrit drops below 28 or the child becomes clini- leaks.
cally symptomatic. We routinely plan on transfusing at
least one unit of blood, and in approximately 20% of the Wire Extrusion
cases a second unit will be needed. It goes without saying Although wires are necessary to provide strength and
that meticulous attention to technique can reduce the loss stability to the reconstruction, they can erode through
of blood dramatically. Use of epinephrine infiltration dur- the skin. It is imperative that the wires be turned under
ing the skin incision, skin clips, cautery, etc. all can help so that no sharp edges are present. At the completion of
reduce blood loss. the operation the surgeon should run a finger over the
scalp, feeling for any unusually prominent wires before
Infection closure. If a wire does erode through the skin later, it
Preoperatively, each child is started on an antibiotic for must be removed as soon as possible to prevent a local
skin organisms (usually oxacillin) which is continued for osteomyelitis. This can be done in the office with local
24 hours postoperatively. The rate of infection is quite anesthesia.
low in these cases if there is adequate attention to surgi-
cal technique. It cannot be overemphasized how impor- Hydrocephalus
tant it is to irrigate at the completion of each case to re- There is a very high incidence of hydrocephalus in chil-
move the debris that accumulates. These children typically dren with severe pansynostosis. There are also many dif-
will develop fevers in the first postoperative week. Rou- ferent opinions as to when to treat the hydrocephalus, i.e.,
tine fever workups are done but rarely is a source found. before or after the craniofacial reconstruction. It has been
We attribute these fevers to the resorption of blood that our policy to do the craniofacial procedure first and the
collects under the skin flap. In the case of an extensive shunt second. We have found that in some cases the treat-
advancement it is not uncommon to leave a large “dead ment of the pansynostosis alleviates the need to treat the
space.” These spaces have the highest incidence of infec- hydrocephalus (as was the situation in the first case). Also,
tion, and if a child develops evidence of sepsis these spaces the early correction of hydrocephalus can cause a dra-
may need to be tapped for a bacteriological culture. The matic collapse of the brain which will work against the
incidence of this happening is very low but always must reconstruction. However, if the child is very sick from
be considered in the differential diagnosis of postopera- increased intracranial pressure, the shunt can be placed
tive fever. first to relieve the elevated ICP and prevent the serious
sequelae due to this high pressure. Another factor to con-
Patient Positioning sider in a secondary placement of the shunt is the increased
Because of the need to place the child in hyperextension, risk of infection due to the shunt being present during a
it is important to get preoperative CT and MRI scans. lengthy reconstruction.


INTRODUCTION lar aneurysms. Infectious emboli from cardiac vegetations

Aneurysms occurring along the anterior cerebral artery tend to lodge in the distal anterior cerebral or middle ce-
and its major branches distal to the anterior communicat- rebral branches and the resulting inflammatory process
ing artery form a relatively uncommon and unique group. may break down the arterial wall, giving rise to a bacte-
Although only about 5% of patients with intracranial an- rial or mycotic aneurysm. In addition, the distal anterior
eurysms have lesions affecting these vessels, this rela- cerebral artery may be the site of a traumatic aneurysm.
tively small group of aneurysms is quite heterogeneous. The falx provides a buttress against which the cerebral
Typical saccular aneurysms most commonly arise at hemispheres impact during severe closed head trauma as
the major branching points of the anterior cerebral artery, transient brain shift occurs. The anterior cerebral artery
namely at the origin of small orbital branches arising along and its branches are vulnerable to varying severities of
the first 1-2 cm of the A2 segment, at the origin of the injury during this process. The intima and internal elas-
frontopolar artery, and at the origin of the callosomarginal tica may be disrupted, leading to dissection or true aneu-
artery. The latter location is by far the most common. As rysm formation, or the injury may be more severe, ex-
at other anatomical sites, saccular aneurysms not infre- tending through the muscular media and resulting in a
quently develop in conjunction with local arterial anoma- true aneurysm with intact adventitia or frank arterial lac-
lies. Occasional patients suspected of having a distal an- eration in which the hematoma is contained only by arach-
terior cerebral aneurysm will be found to have multiple noid or brain parenchyma (false aneurysm). The poten-
anterior communicating branches, and the aneurysm may tial for distal anterior cerebral artery aneurysms to be
be found to relate to the most distal communicating ves- infectious or traumatic must be kept in mind. Because
sel. Azygous A2 segments are not rare in these patients these disease processes may extend over a wide circum-
and the aneurysm may develop at the point of division of ference of the small anterior cerebral artery, intraopera-
this vessel into the bilateral callosomarginal and tive rupture is common and the potential requirement for
pericallosal arteries. An occasional patient with triplica- temporary arterial occlusion or even permanent vessel
tion of the A2 segments will be found to harbor a distal sacrifice is high.
aneurysm. It is vital to determine the presence of this Another unique feature of aneurysms of the distal
anomaly by preoperative angiography. Its origin is usu- anterior cerebral artery concerns their tendency to occur
ally posteriorly directed from the anterior communicat- with other intracranial aneurysms. Approximately 35-50%
ing artery, and the third A2 segment may be inadvertently of patients will be found to harbor multiple aneurysms,
included in a clip placement if the anomaly is not recog- and this feature significantly complicates operative plan-
nized. Finally, patients with an arteriovenous malforma- ning and occasionally makes it difficult to determine
tion fed by the pericallosal artery may develop unusual which lesion actually bled. Due to the unique location of
distal aneurysms, presumably due to the hemodynamic these aneurysms and the tendency for the sac to be em-
stress imposed by the malformation. bedded in a cingulate gyrus, rupture may result in diffuse
Important subgroups of these lesions are not saccu- subarachnoid hemorrhage (SAH), focal interhemispheric
SAH, interhemispheric subdural hematoma formation,
intraventricular hemorrhage, corpus callosal hemorrhage,
© 1992 The American Association of Neurological Surgeons or frontal lobe parenchymal hematoma formation.


PATIENT SELECTION has been associated with transient impairment of endog-

Patients found to harbor an incidental aneurysm of the enous cortisol production. We use a standard dose of dex-
distal anterior cerebral artery pose a potential dilemma to amethasone, 4 mg intravenously, every 6 hours. Appro-
the surgeon required to give advice. We remain relatively priate gastric prophylaxis is given throughout the steroid
aggressive in recommending surgical treatment for pa- course.
tients in good health under the age of 60 because even Although the value of anticonvulsant prophylaxis is
very small aneurysms have proven to produce SAH. It is questionable in terms of seizure prevention, the hazards
also our impression that patients who bleed from a pri- of a generalized seizure in the acute SAH period is very
mary aneurysm who have an incidental anterior cerebral significant due to the risk of precipitating rebleeding or
aneurysm may have a somewhat more virulent disease aspiration. It is our routine to administer a loading dose
process and we routinely recommend securing both le- of Dilantin intravenously followed by 100 mg every eight
sions, usually in the acute phase after SAH to permit more hours. We also administer perioperative antibiotic cover-
aggressive therapy for delayed ischemic complications age consisting of nafcillin, or vancomycin in the penicil-
from vasospasm should they occur. lin-allergic patient. Antibiotics are given on call to the
Patients presenting with SAH from a distal anterior operating room and are continued for 24 hours postop-
cerebral artery aneurysm are managed in the same fash- eratively. Antifibrinolytic therapy has been shown to de-
ion as our other aneurysm patients. Those in good clini- crease the incidence of early aneurysmal rebleeding but
cal grade (alert or only slightly drowsy) are operated upon to increase the incidence of ischemic deficits from va-
on the first elective operative day to minimize the risk of sospasm. We prefer to use E-aminocaproic acid only in
rebleeding and to permit maximal therapy for vasospasm. patients who are in poor neurologic grade or unstable
Those patients in poor grade (obtunded or comatose) are medical condition in whom a significant delay in aneu-
treated medically until their neurological status improves. rysm clipping is anticipated. For those patients in whom
An exception to this general strategy occurs in the patient early operation is planned, we usually do not initiate this
whose depressed level of consciousness is attributable to type of therapy.
an intraparenchymal or intraventricular hematoma. We
recommend early craniotomy with aneurysm clipping and SURGICAL TECHNIQUE
hematoma evacuation in that setting.
PREOPERATIVE PREPARATION Anesthetic management of patients with distal anterior
Patients being prepared for a craniotomy for a distal ante- cerebral aneurysms is similar to that used for patients with
rior cerebral aneurysm undergo the same regimen as that aneurysms at other sites. In addition to the vascular ac-
used for a patient with any other aneurysm. If SAH has cess provided by the use of a CVP or Swan-Ganz cath-
occurred, normovolemia and normotension are supported eter, as discussed above, at least one other 16-gauge
by placing a central venous catheter in patients with a venous catheter and one 14-gauge catheter are placed
healthy cardiovascular system and by placing a Swan- peripherally. A radial arterial catheter is also placed. If
Ganz catheter in those with significant cardiac dysfunc- CSF evacuation is thought to be mandatory due to known
tion. Crystalloid and colloid solutions are administered brain edema or hydrocephalus, a ventriculostomy or spi-
with a target central venous pressure (CVP) of 10-12 torr nal drain is placed. When a pterional craniotomy is to be
in the former group and a pulmonary capillary wedge used for a proximal anterior cerebral aneurysm or for an
pressure (PCWP) of approximately 10-15 torr in the lat- associated lesion, we prefer to puncture the ventricle us-
ter group. If acute hydrocephalus is present and well tol- ing landmarks as follows: an equilateral right triangle with
erated neurologically, it is left untreated to avoid the risk sides of 2.5 cm is constructed with one edge at the sphe-
of destabilizing the transmural gradient. If the patient noid ridge and the other edge resting on the distal sylvian
deteriorates due to the hydrocephalus, a ventriculostomy fissure. The hypotenuse of this triangle therefore rests on
is placed contralateral to the planned craniotomy and cere- the sylvian fissure. The frontal lobe is punctured perpen-
brospinal fluid (CSF) is allowed to drip off at a drainage dicularly at a site identified by the vertex of this triangle.
height of 15-20 cm. When pterional exposure is not contemplated, a contralat-
Corticosteroids are administered as standard prophy- eral frontal ventriculostomy or spinal drain is placed.
laxis for potential cerebral retraction injury and are con- Electroencephalographic (EEG) activity is monitored bi-
tinued for three to five days postoperatively, particularly laterally by needle scalp electrodes with a frontal elec-
if temporary arterial occlusion is used and etomidate has trode placed above the brow and a posterior lead in the
been used for cerebral metabolic suppression. This agent mastoid region.


We prefer a normotensive, normovolemic balanced tion of the distal anterior cerebral artery on which the an-
anesthetic with sodium thiopental (3-5 mg/kg) induction. eurysm resides. The primary goal of the initial craniotomy
If significant cardiovascular disease is present we use in a SAH case is to secure the ruptured lesion. However,
etomidate (0.3 mg/kg) intravenously for induction. Muscle subsequent hyperdynamic therapy, if it becomes necessary
relaxation is accomplished with vecuronium followed by due to developing ischemia from vasospasm, can jeopar-
curare/pancuronium for maintenance. Maintenance an- dize unclipped lesions. As a general rule, we attempt to
esthesia consists of isoflurane (0.5-2.5%), nitrous oxide secure as many of the aneurysms as possible at the primary
(65%), and oxygen (35%). Mannitol (1.0 g/kg) is infused procedure. Regrettably, most aneurysms associated with
rapidly intravenously at the time of scalp incision to as- distal anterior cerebral artery lesions involve the middle
sist with brain relaxation. cerebral artery or the internal carotid artery and therefore
If temporary arterial occlusion becomes necessary, usually require a separate microsurgical exposure. In gen-
etomidate (1.0 mg/kg) is administered to achieve EEG- eral, we position the patient optimally for securing the rup-
documented burst-suppression. This medication is then tured lesion and then manipulate the head holder to opti-
continued at a rate of 10 µg/kg/min until arterial flow is mize exposure of secondary lesions. When an anterior
restored. During this interval isoflurane is continued at a communicating artery aneurysm occurs with a more distal
dose of 0.4%, and 100% O2 is administered. Mannitol anterior cerebral lesion, both aneurysms are approached
(0.25 g/kg) is infused rapidly immediately prior to arte- interhemispherically. Although we usually prefer a right-
rial occlusion. Additionally, the pCO2 is normalized and sided approach (nondominant), the presence of associated
the blood glucose level is monitored carefully and kept in aneurysms requiring a left pterional craniotomy mandate
the 90-100 mg % range by insulin drip if necessary. Strict the performance of a second left parasagittal craniotomy
normotension is assured during this time to maximize to approach the distal anterior cerebral lesion.
collateral flow. Aneurysms arising from the first 1.0-1.5 cm of
the A2 segment can be very reasonably approached
Positioning through a pterional exposure which simply extends
Specific aspects of patient positioning are critically depen- the gyrus rectus resection used in the typical approach
dent on two major concerns: 1) other associated aneurysms to the anterior communicating artery (Fig. 1). As a
and the determination of which lesion bled; and 2) the por- r ule we place a small shoulder roll under the

© 1992 The American Association of Neurological Surgeons

Figure 1. Aneurysms of the distal anterior cerebral artery arising within teriorly to the midline and remains immediately posterior (if possible)
1.5 cm of the A2 origin may be approached by a conventional pterional to the normal hairline. The craniotomy is performed with three burr
craniotomy with the head rotated 45-60° as in the exposure of the ante- holes: 1) a burr hole at the “key” or just superior to the frontozygomatic
rior communicating region. The scalp incision (dashed line) begins 5- suture, 2) an inferior temporal burr hole, and 3) a posterior temporal
10 mm anterior to the tragus and extends superiorly, curving gently an- burr hole just inferior to the superior temporal line.


ipsilateral shoulder of the supine patient and rotate the spheric exposure of the callosal cistern in the region of
head to the left side by 45-60°. The neck is then slightly the genu.
flexed, bringing the chin toward the contralateral clavicle For unusual aneurysms arising posterior to the genu
to orient the plane of the floor of the anterior cranial fossa involving the horizontal segment of the anterior cere-
perpendicular to the long axis of the patient’s body. This bral artery, the patient is positioned supine and the neck
subtle maneuver allows the seated surgeon easier visual- is flexed slightly to optimize the surgeon’s exposure of
ization of the basal subarachnoid space without forcing the aneurysm (Fig. 4). This subtle alteration increases
him or her to encroach on the patient’s elevated shoulder. the susceptibility of the patient to venous air embo-
The head is then extended (tilted) so that the maxillary lism and mandates anesthetic monitoring and central
eminence rises superior to the brow. venous access.
An aneurysm arising from the origin of the
frontopolar or callosomarginal artery which lies inferior Skin Incision and Craniotomy
to the genu of the corpus callosum is optimally exposed Performance of appropriate scalp and bone incisions must
through a low right frontal parasagittal craniotomy. The take into consideration several concerns: associated aneu-
patient is positioned supine and the head placed in a neu- rysms, the location of the distal anterior cerebral aneurysm
tral position. The neck is then extended about 15° to pro- relative to the genu of the corpus callosum, and the posi-
vide the seated surgeon with a comfortable interhemi- tion of the ascending frontal bridging veins entering the
spheric approach parallel to the floor of the anterior cranial superior sagittal sinus. While a “vein-free” exposure of 2.0-
fossa (Fig. 2). 2.5 cm is probably ideal for interhemispheric exposures,
When the distal anterior cerebral artery aneurysm the exact position of the bone flap should be adjusted to
arises from the origin of the callosomarginal artery and is minimize the risk that large veins may be injured during
in close relationship to the genu of the corpus callosum, retraction. The presence of an associated aneurysm of
the patient is positioned supine with the head exactly neu- the internal carotid or middle cerebral artery with an
tral (Fig. 3). This position, when used with a slightly higher anterior cerebral aneurysm requiring interhemispheric
parasagittal craniotomy (centered halfway between the exposure would necessitate two separate bone flaps. Our
nasion and bregma), allows a comfortable interhemi- preference is to position the patient optimally for

Figure 2. Aneurysms arising from the frontopolar or callosomarginal

artery origin which reside inferior to the genu of the corpus callosum
may be approached through a 4.0 × 4.0-cm parasagittal craniotomy cen-
tered one-third of the way between the nasion and bregma. Optimal
patient positioning is accomplished by extending the neck by about 15°.
The preferred scalp incision (dashed line) is either a traditional bicoronal
incision (zygoma to zygoma) or it may be terminated 2.0-2.5 cm supe-
rior to the contralateral zygoma.
© 1992 The American Association of Neurological Surgeons


Figure 3. Aneurysms arising in the region of the genu of the corpus

callosum (usually from the origin of the callosomarginal artery) are
optimally exposed by positioning the patient supine with the head truly
neutral and the nasion to inion line perpendicular to the long axis of
the patient’s body. The preferred scalp incision is a modified bicoronal
incision (dashed line) extending from the ipstlateral zygoma across
the midline to the contralateral superior temporal line. The craniotomy
© 1992 The American Association of Neurological Surgeons
is roughly 4.0 × 4.0 cm and is centered midway between the nasion
and bregma.

Figure 4. Unusual distal anterior cerebral artery aneurysms arising pos-

terior to the genu involving the horizontal segment of the vessel are
optimally exposed by positioning the patient supine with the head
unrotated but with approximately 15° of neck flexion. The scalp inci-
sion (dashed line) is tailored to the exact aneurysm site but we prefer a
broad-based parasagittal flap hinged laterally and crossing the midline.
The craniotomy is parasagittal such that the tissue retraction is anterior
to the motor cortex.
© 1992 The American Association of Neurological Surgeons


the ruptured aneurysm and to perform both craniotomies holes should be placed with hand instruments and care-
but only open the dura at the primary site. After the rup- fully connected with a Gigli saw.
tured lesion is treated, the assistant adjusts the head posi- Distal pericallosal artery aneurysms occurring poste-
tion and the secondary aneurysm is approached. Specific rior to the genu are also best approached interhemispherically
details of the skin incision and craniotomy will focus on (Fig. 4). The exact site of the scalp incision and craniotomy
the four anatomical sites illustrated in Figures 1-4. is determined by the specific site of the aneurysm and the
For approaching those proximal A2 aneurysms aris- details of the venous anatomy. Every attempt should be made
ing from the orbital branch origins as shown in Figure 1, to avoid retraction on the motor cortex. In general, we prefer
we utilize a standard frontotemporal scalp incision be- a broad-based parasagittal scalp flap hinged laterally and
ginning 5-10 mm anterior to the tragus at the level of the crossing the midline. Since many of the aneurysms in this
zygoma. The incision extends superiorly and anteriorly, site are traumatic, any fractures in the region should man-
remaining posterior to the hairline whenever possible and date a craniotomy flap crossing the midline so that any asso-
terminating at the midline. Recent experience with the ciated superior sagittal sinus injury can be controlled. In more
interfascial opening as described by Yasargil appears to routine cases, a parasagittal craniotomy extending to the
be yielding superior cosmetic results and seems to mini- midline is preferred with the usual precautions to avoid si-
mize temporalis atrophy. The craniotomy is performed nus injury.
with three burr holes: 1) the first hole is placed at the
“key” or just superior to the frontozygomatic suture, 2) Microsurgical Procedure
the second hole is placed inferiorly on the temporal The microsurgical steps involved in treating distal ante-
squama, and 3) the third hole is placed temporally at the rior cerebral artery aneurysms may be divided by target
posterior aspect of the exposure just inferior to the supe- location into those requiring pterional exposure and those
rior temporal line. This final burr hole can later be cov- requiring interhemispheric exposure. Due to the similar-
ered well by closing the temporalis muscle and fascia. ity of dissection techniques used interhemispherically
Power instruments are then used to cut a generous fronto- regardless of how the aneurysm relates to the genu, the
temporal craniotomy with care to extend the anterior as- technical discussion will be illustrated by those aneurysms
pect of the bony removal to the brow at the midpupillary in proximity to the genu.
line (Fig. 1). The sphenoid ridge is then resected with
rongeurs and the posterior table of the frontal bone is re- Pterional Approach
moved with a high-speed drill to maximize access to the The initial exposure of those aneurysms involving the
skull base (Fig. 5A). proximal 1.5 cm of the A2 segment is identical to that
In treating aneurysms arising from the infracallosal well known for the anterior communicating complex with
portion of the distal anterior cerebral artery (Fig. 2) our the exception that our preference is to expose the lesion
preferred scalp incision is either a true bicoronal incision from the left side if it arises from the left anterior cerebral
or one that terminates 2.0-2.5 cm above the zygoma on the artery. This discussion will illustrate a right proximal A2
contralateral side. The parasagittal craniotomy is centered aneurysm.
about one-third of the way between the nasion and bregma Under microscopic visualization, a self-retaining
and is approximately 4.0 × 4.0 cm in size. The hand perfo- brain retractor is gently inserted along the orbital surface
rators are used to perform the two midline burr holes and a of the frontal lobe just anterior to the sylvian fissure. The
Gigli saw is used to connect them to avoid risk to the supe- retraction is deepened while the surgeon has clear visual-
rior sagittal sinus. When a particularly “tight” brain is an- ization of the bony sphenoid ridge. This bony landmark
ticipated due to an underlying parenchymal hematoma or ensures that the surgeon will arrive at the carotid cistern
edema, a somewhat larger bone flap should be used and and not inadvertently stray too far anterior. Once the re-
the flap can be extended across the midline. tractor is advanced to the point of visualization of the
Aneurysms arising from the callosomarginal artery optic nerve, it is stabilized just lateral to the nerve and
origin in the region of the genu are the most common gently depressed, placing the arachnoidal tissue of the
distal anterior cerebral aneurysms (Fig. 3). We prefer to medial sylvian fissure and carotid cistern on stretch. The
use a modified bicoronal scalp incision extending from fibers of the medial fissure are then opened sharply and
the ipsilateral zygoma across the midline to the contralat- this incision is directed medially, opening the carotid
eral superior temporal line, remaining behind the hairline cistern, severing the adhesions binding the optic nerve
in its entirety. The craniotomy is roughly 4.0 × 4.0 cm to the gyrus rectus, and opening the prechiasmatic cis-
and is centered midway between the nasion and bregma. tern in sequence (Fig. 5B). This maneuver drains addi-
As in all parasagittal craniotomy flaps, the midline burr tional CSF and should accomplish adequate brain re-


© 1992 The American Association of Neurological Surgeons

Figure 5. Pterional approach to the proximal A2 aneurysm. A, after the prechiasmatic cistern are opened sharply. C, progressive elevation
pterional craniotomy is performed, the sphenoid ridge and the inner of the gyrus rectus from the optic nerve will expose the ipsilateral A1
table of the frontal bone are resected with rongeurs and drills. B, after segment and the recurrent artery of Heubner. The A1 segment should
the orbital surface of the frontal lobe has been elevated to expose the be prepared for temporary clipping should such become necessary.
parasellar cisterns, the medial sylvian fissure, the carotid cistern, and


© 1992 The American Association of Neurological Surgeons

Figure 5. (Continued) D, after the right A1 segment enters the inter- often angiographically inapparent orbital branches. The aneurysms in
hemispheric fissure, the arachnoid binding the left optic nerve to the this region usually arise just distal to the involved branch. Once the
left gyrus rectus is opened. Exploration of this cistern will reveal the proximal neck is seen, the healthy portion of the A2 wall is followed
left A1 segment. E' and E", the retractor blade is withdrawn to the level distally to the point of its departure from the aneurysm, ensuring com-
of the olfactory tract allowing “herniation” of the gyrus rectus over the plete anatomical control of the aneurysm. G, for small aneurysms of the
tip of the retractor. This tissue is opened and aggressively resected down proximal A2, a conventional direct clipping may be performed perpen-
to the pia-arachnoid of the interhemispheric fissure. The anterior com- dicular to the parent vessel. For broad-based or large aneurysms, how-
municating complex and ipsilateral A2 can be seen through this tissue ever, temporary trapping should be performed with a more parallel clip
layer. F, dissection is carried distally on the A2 segment, exposing the application to avoid shearing or clip-induced stenosis.


laxation. The retractor is then moved slightly medially line of sight for passage of a straight or curved clip per-
and the gyrus rectus is elevated from the optic nerve. The pendicular to the parent vessel. For small aneurysms this
stretched arachnoidal adhesions are then severed and pro- is an acceptable alternative (Fig. 5G) but in broad-based
gressive deepening of this dissection medially will ex- or large aneurysms the resulting “gathering” of the A2
pose the ipsilateral Al segment. Once this key landmark segment as the clip closes may place undue shearing
is exposed it is circumferentially dissected as a prepara- stresses on the neck itself and may foreshorten the artery,
tory measure for the placement of a temporary clip in the producing a true stenosis. If this appears likely, tempo-
event of early operative rupture (Fig. 5C). The recurrent rary clips may be applied proximal and distal to the aneu-
artery of Heubner will be found superior and posterior to rysm under metabolic brain protection. The aneurysm can
the Al segment and this fragile vessel should be protected then be deflated and mobilized out of the interhemispheric
carefully. The Al segment is then carefully followed me- fissure, permitting a clip placement parallel with the long
dially and anteriorly along its course toward the interhemi- axis of the parent vessel.
spheric fissure. The A1 segment is left when it is seen to
curve sharply superiorly into the interhemispheric fissure. Interhemispheric Approach
The arachnoid binding the left optic nerve to the con- For aneurysms arising more distally on the anterior cere-
tralateral gyrus rectus is then severed sharply and the sub- bral artery, an interhemispheric approach is mandatory.
arachnoid space explored until the contralateral A1 seg- Regardless of the relationship of the target aneurysm to
ment is seen (Fig. 5D). At this point, proximal control is the genu, the lesions approached interhemispherically rep-
achieved. resent exceptions to classical vascular principles of early
The retractor is then withdrawn to the level of the acquisition of proximal arterial control. In general, the
olfactory tract, allowing a 4-5-mm width of gyrus rec- distal parent artery is dissected first followed by careful
tus to “herniate” over the retractor blade, obscuring the dissection past the aneurysm to the proximal vessel. In
anterior communicating region. A generous portion of addition, these lesions have a tendency to be small in di-
the medial gyrus rectus is then cauterized, opened, and ameter yet relatively broad-based with some involvement
subpially resected (Fig. 5E). This tissue is resected some- of the wall of the branch of origin. These anatomical char-
what more anteriorly and superiorly than normally acteristics make it frequently difficult to achieve the ideal
resected for exposure of an anterior communicating ar- goals of perfect aneurysm clipping without stenosis of
tery aneurysm. The pia-arachnoid is then sharply any afferent or efferent branch.
resected, exposing the ipsilateral Al-A2 junction, the an- After a parasagittal craniotomy is performed as de-
terior communicating artery and the origin of the re- scribed above (Fig. 3), the dura is opened in a stellate
current artery of Heubner (usually from the lateral as- fashion so that the medial dural flap may be reflected over
pect of the proximal A2 segment). The thorough the superior sagittal sinus with care not to induce steno-
dissection of the ipsilateral A2 segment provides defini- sis. This maneuver optimally exposes the medial aspect
tive proximal control and should be used in the event of of the frontal lobe as it plunges into the interhemispheric
hemorrhage to preserve flow in the contralateral ante- fissure (Fig. 6A). Under microscopic visualization, the
rior cerebral territory. The retractor is then gently de- lobe is gently dissected from the falx so that the surgeon
pressed to expose the gyrus rectus and arachnoid ob- can investigate the status of medially bridging veins. Ide-
scuring the A2 as it progresses anterosuperiorly. ally, a working space of 2 cm should be developed be-
Additional gyrus rectus is resected if necessary as the tween bridging veins and care should be taken to pre-
vessel is followed distally. The origin of the orbital serve all sizable veins. Vein sacrifice either purposeful or
branches should be treated carefully as the aneurysm by aggressive retraction can set the stage for postopera-
typically arises immediately distal to this origin. Once tive venous hemorrhagic infarction.
the proximal neck is isolated, the dissection follows the The self-retaining retractor is gently inserted medial to
healthy portion of the A2 segment until it emerges from the frontal cortex, initially using the falx as a guide. The falx
the aneurysmal segment (Fig. 5F). At this moment, proxi- has a variable depth anteriorly and soon the surgeon will
mal and distal control of the aneurysm has been achieved reach the inferior edge (Fig. 6B). Acquisition of this refer-
and the vessel should be widely dissected for placement ence point is frequently misinterpreted as heralding the iden-
of a distal temporary clip if needed. The interhemispheric tification of the corpus callosum. This costly error may lead
fissure is then explored to isolate the left A2 segment so the surgeon to aggressively manipulate the cingulate gyri
that it will not be inadvertently caught by a clip. which are usually densely adherent. Due to the fact that the
The aneurysms in this region usually project anteri- aneurysms in this region are often embedded in one or
orly and therefore usually present the surgeon with a clear both cingulate gyri, aggressive manipulation or re-


© 1992 The American Association of Neurological Surgeons

Figure 6. Interhemispheric approach to distal anterior cerebral artery an- falx serves as an excellent early landmark. Discovery of its inferior edge
eurysm. A, following a parasagittal craniotomy, the dura is opened and does not herald the region of the corpus callosum. The cingulate gyri are
the medial flap is sutured over the superior sagittal sinus. The resulting usually densely adherent beneath this point. C, meticulous sharp dissec-
exposure allows the surgeon to inspect the medial frontal cortex for bridg- tion should be used to divide the adhesions and occasionally small veins
ing veins. A working space of 2.0 cm should be developed between bridg- obscuring the potential space between the two cingulate gyri. Great care
ing veins. B, as the brain retractor is inserted medial to the frontal lobe the should be exercised to avoid the subpial plane of dissection.


© 1992 The American Association of Neurological Surgeons

Figure 6. (Continued) D, identification of the transverse arachnoidal bands and this landmark usually signals acquisition of proximal control. F, dis-
of the cistern of the corpus callosurn marks the initial entrance into the section from proximal to distal along the anterior surface of the anterior
subarachnoid space. The efferent pericallosal vessels will be seen within cerebral artery will disclose the origin of the callosomarginal artery. This
this cistern. E, sharp microdissection from distal to proximal along both vessel defines the proximal neck of the aneurysm and should be carefully
pericallosal arteries should be confined to the inferior aspect of the vessel mobilized from the neck. G, the medial aspect of the aneurysm neck is
as the aneurysm and callosomarginal origins are usually located superi- defined by gently sectioning arachnoidal bands between the healthy
orly. The pericallosal arteries will be seen to dive inferiorly at the genu pericallosal artery and the aneurysm sac.


© 1992 The American Association of Neurological Surgeons

Figure 6. (Continued) H, the distal neck is then defined from the effer- is excessively broad-based, a clip reconstruction in parallel to the
ent pericallosal artery and explored to ensure that no vessels are in the pericallosal artery is more physiologic and minimizes shearing stresses
potential path of the clip blade. I, due to the broad-based nature of many during clip closure as well as avoids the risk of stenosis. K, for complex
distal anterior cerebral artery aneurysms and the small size of the parent aneurysms of the distal anterior cerebral artery we recommend tempo-
artery, perpendicular clipping not infrequently produces stenosis of the rary trapping of the A2, callosomarginal, and pericallosal arteries with
pericallosal artery due to an “accordion effect.” J, when the aneurysm aneurysm deflation to allow safe reconstruction.


traction may avulse the underlying aneurysm. Rather than trunks are seen bilaterally, the vessel associated with the
move aggressively at this point, the surgeon is better ad- aneurysm should be carefully prepared for temporary
vised to meticulously divide the multitudinous arachnoi- occlusion should this become necessary.
dal adhesions between the cingulate gyri. Frequently, nu- The progressive delineation of the aneurysm com-
merous small veins similarly obscure the development of plex can now be accomplished by following the anterior
this potential space and often appear to bridge the hemi- surface of the proximal anterior cerebral as it proceeds
spheres. When necessary, these small veins maybe sacri- distally along the genu. The aneurysms at this site almost
ficed to ensure that the surgeon remains within the inter- invariably arise distal to the origin of the callosomarginal
hemispheric fissure and does not enter the potentially artery and the first anatomical detail noted on the ante-
disastrous subpial plane (Fig. 6C). Methodical expansion rior vessel wall will be the callosomarginal artery (Fig.
of the anterior to posterior working space available be- 6F). Successful dissection of this vessel must be done
tween the cingulate gyri will be rewarded by dramatically concurrently with dissection of the proximal aneurysmal
increased visibility in subsequent phases of the dissec- neck. Once this plane is established, the margin of the
tion. aneurysm from the parent pericallosal artery is followed
The appearance of transversely coursing dense arach- from proximal to distal, keeping the demarcation in mind
noidal bands at the inferior aspect of the cingulate gyrus between healthy and unhealthy tissue (Fig. 6G). This plane
marks the initial identification of the cistern of the cor- of dissection will ultimately free the distal aspect of the
pus callosum (Fig. 6D). Once this cistern is identified, aneurysm neck (Fig. 6H).
gentle suction removal of subarachnoid clot will reveal Once final neck dissection is performed several de-
the pericallosal vessels. A common mistake is to dissect cisions must be made. The surgeon must determine
only one vessel and assume it is the ipsilateral pericallosal whether clip placement should be perpendicular or paral-
artery, only to discover later that the apparent A2 repre- lel to the pericallosal artery and whether or not tempo-
senting proximal control does nothing to abate hemor- rary clipping would be beneficial. The fact that many of
rhage when temporarily occluded in the event of intraop- these lesions are small and broad-based and that the
erative aneurysm rupture. This error can be avoided by pericallosal artery is quite small suggests that not infre-
meticulously identifying both pericallosal arteries. quently a perpendicular clipping will “accordion” the
At this point, if substantial frontal lobe or ventricu- parent trunk, inducing significant stenosis. (Fig. 6I). When
lar hematoma is causing the exposure to be confining, a the vessel appears compromised, it is. Microvascular
small cortical incision may be made to partially decom- Doppler measurements are very sensitive in detecting criti-
press the brain. The goal of this maneuver is only to in- cal stenosis and should be used if the surgeon contem-
crease working space and not to totally evacuate the he- plates leaving the clip in place. If it is apparent that this
matoma. It should never be forgotten that the ruptured type of clip placement will be unsatisfactory, a more physi-
part of the sac is encased by the apex of the hematoma. ologic approach is to reconstruct the parent artery in par-
The goal of the dissection at this point is to assure allel. Additional dissection along the lateral aspect of the
proximal arterial control while manipulating the aneurysm aneurysm neck is required to mobilize the lesion into the
as little as possible. As the dissection proceeds proximally interhemispheric fissure (Fig. 6J). There is little reason
on the pericallosal vessels it is important to expand the to avoid the use of temporary arterial occlusion for brief
exposure so that the course of both right- and left-sided intervals in this anatomic site, particularly if pharmaco-
vessels is seen and understood. This knowledge will pre- logic brain protective regimens and normotensive anes-
vent disaster should urgent clipping become necessary. thesia are being used. This maneuver can allow orderly
Inadvertent clipping of a fragile anterior cerebral artery deflation of the aneurysm with final dissection and de-
with a permanent clip even if recognized and corrected finitive clipping and represents the most secure means of
will often fracture the intima and lead to thrombosis. For avoiding rupture during clip application (Fig. 6K). We
lesions arising at the genu of the corpus callosum, a help- strongly recommend complete temporary trapping by clip-
ful dissection technique is to remain on the inferior sur- ping the A2, callosomarginal, and pericallosal vessels with
face of the pericallosal vessels as the dissection pushes aneurysm aspiration as opposed to simple proximal clip-
proximally. The aneurysm and callosomarginal artery typi- ping of the A2. Should bleeding develop in the latter cir-
cally arise from the anterior or superior aspect of the ves- cumstance, the surgeon suctions retrograde collateral sup-
sel wall and remaining inferiorly will allow safe access to ply through the surgical tubing as the wound is cleared.
the vessel proximal to the aneurysm as the anterior sur- The distal anterior cerebral vessels are particularly
face of the genu is reached (Fig. 6E). Once the proximal vulnerable to reactive spasm due to manipulation. Af-


ter aneurysm clipping generous application of papaver- follow-up CT scan within 24 hours of the procedure in all
ine should be used to reverse this process. patients to look for edema or venous infarction.
Vasospasm remains the leading cause of morbidity
Closure following SAH. Fortunately, patients with distal anterior
The closure of both types of distal anterior cerebral cerebral artery aneurysms usually do not have diffuse thick
wounds should not differ from standard neurosurgical clot in the basal cisterns which would predispose to life-
practice. We routinely close the dura in a watertight fash- threatening vasospasm. Rather, the clot is either focally
ion and replace the bone flap. The temporalis muscle and interhemispheric or within the brain parenchyma or ven-
fascia are closed in the pterional procedures and the galea tricle. Therefore, the chief ischemic risk is to the distal.
is closed as a separate layer in all patients. We routinely anterior cerebral territory. Hyperdynamic therapy to date
use scalp staples now and have been pleased with the he- remains the most reliable means of medically palliating
mostatic and cosmetic results. Epidural drains are used this condition. When hypervolemia and hypertension fail,
when any question of hemostasis is present. the interventional radiologist may have some success in
these distal vessels but in our experience, they have been
COMPLICATIONS much more successful in the proximal subarachnoid ves-
The degree of brain retraction necessary to treat distal sels. Perhaps early operation, clot removal, and subarach-
anterior cerebral aneurysms is not insignificant and the noid thrombolytic therapy will minimize this complica-
risk to frontal bridging veins is constant. We advocate a tion in the future.


INTRODUCTION of a flat capillary hemangioma or a small dermal append-

Progressive dysfunction of the spinal cord may be caused age. When one of these cutaneous findings is present, it
by fixation or by distortion from a neoplasm. This chap- demands further investigation. Occasional patients may
ter focuses on three congenital entities that cause symp- have a flat capillary hemangioma with normal intradural
toms by different mechanisms. The patient with a teth- anatomy; however, a significant percent will have a teth-
ered spinal cord develops symptoms from tension of a ered spinal cord. Waiting for the patient to demonstrate
thickened and taut filum terminale on the distal cord. In- clinical findings of a neurogenic bladder is likely to re-
tramedullary spinal lipomas distort the surrounding cord sult in a fixed neurogenic deficit which is not reversible
but do not have a component of fixation that causes the with surgical intervention. Prevention of further bladder
neurologic deterioration. The lipomyelomeningocele has dysfunction by early investigation and prophylactic sur-
components of both cord fixation and distortion, which gery is warranted.
is thought to be the underlying explanation for the pro- Commonly, the initial clinical symptom in patients
gressive loss of neurologic function associated with this with the tethered cord syndrome is the gradual and pro-
lesion. Because the surgical approaches to these lesions gressive loss of coordinated bladder activity. This may
are quite different they will be discussed separately. become manifest as repeated bouts of urinary infection
or primary or secondary urinary incontinence. These uri-
TETHERED SPINAL CORD nary symptoms may be combined with evidence of spas-
The concept that fixation of the distal spinal cord by a ticity of the lower extremities. The lower extremity in-
thickened filum terminale can cause progressive spinal volvement is frequently a combination of hyperactive deep
cord dysfunction has become accepted during the last 40 tendon reflexes with upgoing toes and muscle wasting,
years. Surgical procedures to section the filum have only fasciculations, and shortened foot or leg length. The com-
become common in the past 20 years. The dysfunction of bination of upper and lower motor neuron disturbance in
the cord occurs from a combination of repeated small in- the lower extremities is the signature of this problem. Even
juries or contusions as the cord is put under tension with though the tension could be thought to be relatively sym-
movement (especially spinal flexion) and by vascular com- metric on the distal cord, the leg findings are typically
promise. The change in the superficial vasculature of the asymmetrical. Rectal incontinence is usually delayed un-
cord as well as its disturbed ability to metabolize oxygen til late in the course. Nonradicular pain in the back and
have been demonstrated both in laboratory animals and legs may be the primary cause of presentation in the adult
in humans. The vascular changes which occur with ten- population. Occasional precipitous deterioration has been
sion of the cord seem to improve following release of the recognized. Sudden lower spinal flexion as in patients
tension. assuming the lithotomy position under anesthesia has re-
Patients may present for clinical attention with a va- sulted in dramatic worsening and even abrupt onset of
riety of complaints. One group of patients will present paraplegia in occasional patients.
for clinical attention only as a result of cutaneous evi- In 10-20% of patients with congenital anorectal
dence of occult spinal dysraphism. This may take the form atresia, a tethered spinal cord will also be found. This
group of patients clearly warrants early investigation
in an effort to prevent the development of a neurogenic
© 1992 The American Association of Neurological Surgeons bladder and to improve the neurologic input into the


dysmorphic rectal sphincter. Many patients with a thick- toms and classical MRI changes are easily counseled to
ened filum terminale are seen to have some other form of accept operation in an attempt to prevent further loss of
neural tube abnormality. This may range from an obvious function. Asymptomatic patients can be approached in a
myelomeningocele to the combination of intact normal risk versus benefit analysis depending on the strength of
skin and an occult diastematomyelia or terminal the radiographic abnormalities and other evidence of
syringohydromyelia. dysmorphism, i.e., anorectal atresia, hemivertebrae, etc.
The suspicion of a tethered spinal cord is confirmed Once a decision to operate has been offered and ac-
with magnetic resonance imaging (MRI) or computed to- cepted, the patient is positioned prone with bolsters placed
mographic (CT) myelography. In general, three criteria under the iliac crest and thorax to allow free excursion of
are necessary to radiographically confirm the clinical the abdomen (Fig. 1A). It is generally recommended that
impression of a tethered spinal cord: caudal descent of intraoperative monitoring of rectal and/or urethral elec-
the conus, fatty infiltration and thickening of the filum tromyography (EMG) or manometry be available. This
terminale, and a drawn out or “funnel-like” appearance physiologic testing goes a long way to evaluate structures
of the distal conus. Normally the conus should not de- prior to their sacrifice. Ultra short-acting muscle paraly-
scend below the L1-2 disc space. The conus progressively sis is necessary to allow appropriate interpretation of these
ascends within the spine throughout embryologic devel- electrical parameters. An incision is made from the spinous
opment and early infancy. It normally attains its “adult” process of the tip of the L5 vertebra to the midsacrum
position by three to six months of age and maintains this (Fig. 1B). The dorsal bony elements of S1 and S2 are re-
position throughout adult life. In patients with the teth- moved by standard laminectomy technique and the sacral
ered cord syndrome, the thin delicate structure of the nor- cul-de-sac is exposed. There is rarely need to expose more
mal filum terminale is lost. It becomes thickened (usu- than the distal 2 to 3 cm of the subarachnoid space to
ally more than 3 mm in diameter) and is typically allow adequate visualization of the distal filum termi-
infiltrated by fat which is easily appreciated with current
imaging techniques. This thickening results in tension on
the conus and a loss of the normal bulbar lumbar enlarge-
ment of the distal cord. The cord assumes a funnel-like
appearance, dorsally displaced within the subarachnoid
space and under tension. When all radiographic findings
occur in a patient with an appropriate clinical setting, the
diagnosis is secure. Unfortunately, there are occasions
when patients present with progressive clinical symptoms
which could easily be attributable to a tethered cord but
the radiographic findings may be confusing. The conus
may be in a normal position but the filum may be thick,
infiltrated by fat, and dorsally displaced under tension.
As with many clinical situations, judgment in analyzing
the clinical and radiographic findings is essential to ar-
rive at an appropriate decision for the patient.
The natural history of the condition is not well un-
derstood. Many believe that the constant small trauma
associated with tension on the distal cord by the thick-
ened filum is associated with the relentless loss of neuro-
logic function in most patients. This loss may occur within
the first few months of life or more typically over a much
longer time. Occasional adult patients will demonstrate
many decades of symptom-free survival only to come to
© 1992 The American Association of Neurological Surgeons
clinical attention with irreversible bladder dysfunction.
Pain-free adolescents and adults with normal neurologic
Figure 1. A, prone position of an infant undergoing sectioning of the
function but clear radiographic abnormalities attest to the filum terminale. B, the typical skin incision for exposure of the sacral
incomplete ability of the clinician to predict the natural cul-de-sac. The skin incision extends from the spinous process of L5 to
history of this condition. Patients with progressive symp- the midsacrum.


nale. The dura is opened in the midline and the arachnoid of the dura and the superficial soft tissues. Patients are rou-
opened somewhat off the midline. The arachnoid is then tinely nursed flat for five days to allow adequate dural heal-
clipped to the opened dura. The thickened filum can be ing without the additional tension of orthostatic force of
recognized by the infiltration of fat within it, by its midline the cerebrospinal fluid (CSF).
dorsal position, and by the size differential between this Results with regard to blunting of the previous rate
structure and the surrounding thin delicate roots which exit of loss of neurologic function are quite favorable. The
in a ventrolateral direction. Once the filum is identified it ability to restore lost function, particularly bladder syn-
is carefully separated from all adherent nerve roots, par- ergy, is poor. Relief of pain and sensory loss is gratifying.
ticularly those on the ventral surface (Fig. 2A). One must Progressive moderate scoliosis may be arrested. Restora-
rotate the cord to visualize the undersurface and to ensure tion of motor function is less likely than sensory improve-
that no small roots are left adherent to the capsule of the ment or the relief of pain. Urologic dysfunction, which is
filum. Once inspected, the filum is electrically probed with the most common cause of clinical presentation, remains
insulated stimulating hooks to ensure that there is no neu- the least likely to improve once it is firmly established.
ral structure influencing urethral or rectal function con- The likelihood of adherence of the cut ends of the
tained within its structure (Fig. 2B). When this is confirmed filum is extremely small. Long-term complications are
the filum is coagulated and cut (Fig. 2C). This is done at rarely seen.
two levels to allow the excision of a section of 5 to 8 mm
which can be sent for histologic analysis and to ensure that INTRAMEDULLARY SPINAL LIPOMA
the two ends of the filum will not adhere to one another. Intramedullary fat which accumulates under the pia of
The amount of recoil of the proximal filum is frequently the spinal cord may cause the patient to present for
unimpressive. Care is taken to ensure a watertight closure clinical attention with chronic myelopathy or pain.

© 1992 The American Association of Neurological Surgeons

Figure 2. A, axial views through the sacrum before and after the adher- exclude the presence of neural tissue important to urethral or rectal func-
ent roots ventral to the thickened filum terminale have been dissected. tion prior to the planned sectioning. C, the initial section through the
B, intraoperative stimulation of the distal filum is being performed to filum terminale showing fat in the center of the filum.


These are rare congenital lesions which may lay dormant myelography. Additional useful information can be ob-
for many years or decades. They are not associated with tained from urodynamic testing and occasionally from
spina bifida occulta and are relatively evenly distributed in electromyography of the lower extremities.
the cord. There is a predilection for involvement of the dorsal The natural history of patients with a lipomyelomen-
aspect of the cord but the fat is not connected with a defect ingocele is a progressive loss of neurologic function. Oc-
of the arachnoid, dura, laminae, or skin. When symptom- casional exceptions to this natural history can be demon-
atic, these lesions are approached as any other intramedul- strated but the vast majority of infants followed
lary tumor with a laminectomy over the involved area. Us- prospectively without operative treatment will develop
ing an ultrasonic aspirator or a CO2 laser at very low progressive and relentless deterioration. Few would doubt
wattage, the fat can be removed and the fibrous septa be- that prophylactic surgery in early infancy is justified. If
tween the various compartments of fat can be disrupted. If there is any hope of preventing the development of a fixed
significant septation is present, the ultrasonic aspirator will urodynamic deficit it lies in early intervention. Surgical
prove to be much less effective than the carbon dioxide exploration should include release of the traction on the
laser. The cord may be reconstructed into a tube following cord and resection of a significant amount of the in-
the resection of the fat and the redundant dura is closed tramedullary lipoma. Reversal of bladder dysfunction is
primarily and tented dorsally in an effort to prevent adhe- unlikely once it is established and for that reason alone
sion from the resection site to the undersurface of the dura. early aggressive surgery is logical and justified. It should
The outlook for these patients is a function of the be mentioned that there is no place for a superficial exci-
degree of neurologic disability prior to surgery and the sion of the subcutaneous lipoma without disturbing the
success of the resection. intradural contents. A superficial excision seriously com-
plicates the eventual intradural procedure by the devel-
LIPOMYELOMENINGOCELE opment of excessive adhesions.
Subcutaneous fatty tumors over the midline lumbosacral A patient chosen for exploration of the lesion is po-
region usually emerge through a fascial, bony, or dural sitioned prone with soft supports under the iliac crest
defect and ultimately involve the caudal spinal cord. These and chest to allow free excursion of the abdomen. This
lesions are best described by where they grow into the significantly lessens epidural bleeding. The hips are
cord (dorsal or caudal). Lipomyelomeningoceles are part flexed and, again, intraoperative rectal and urethral moni-
of the larger group of conditions termed occult spinal toring are quite helpful. The skin incision is made in the
dysraphism and may be found in conjunction with di- midline directly over the subcutaneous mass and extends
astematomyelia, tethered spinal cord, or other forms of both above and below the mass (Fig. 3A). A common
this broader group. They do seem to have an enhanced error is not to allow sufficient distal room for adequate
genetic predisposition and may be associated with a Chiari exposure of the lesion. For routine lesions it is neces-
I malformation or occasionally hydrocephalus. The spe- sary to have access from the lower sacrum to two seg-
cial circumstance of a fatty mass associated with a termi- ments above the level of the fascial defect. The subcuta-
nal syringohydromyelia will be discussed later. neous lipoma is almost always easily separable from the
Symptoms related to these lesions range from a cos- lumbodorsal fascia and the skin. As the neck of the le-
metic presentation at birth with a significant subcutane- sion is circumferentially developed, large amounts of su-
ous fatty mass in the midline over the lumbosacral region perficial lipoma may be excised, reducing the bulk of
to a subtle subcutaneous lipoma associated with primary the lesion. The neck of fat coursing through the fascial
or secondary urinary incontinence. It is unusual today to defect is retained at this point (Fig. 3B). The soft tissues
have children present primarily with evidence of pain or and muscle adherent to the last intact spinous process
motor disturbance involving the lower extremities. In large and laminae are reflected laterally (Fig. 3C). The muscles
part this is due to an increased awareness of the progres- and other soft tissues circumferentially adherent to the
sive natural history of this lesion and the ease of confir- rudimentary laminae surrounding the neck of the lesion
mation of spinal cord involvement by MRI. Decreased or are also dissected. Immediately caudal to the last intact
absent rectal tone combined with a neurogenic bladder is laminae a band of fibrous tissue corresponding to the
a clinical indication of lower sacral root involvement from periosteum of an incompletely formed bony element will
a neurogenic cause and should be investigated further. commonly be encountered. With section of this band the
Today the procedures of choice to confirm the patho- dura may expand significantly into the area. This band
logic anatomy are MRI and x-ray films of the lumbar spine. may be associated with acute angulation of the mal-
These two modalities have almost totally replaced CT formed cord as it is drawn dorsally toward the


© 1992 The American Association of Neurological Surgeons

Figure 3. A, a typical skin incision over the dome of a lipomyelomen- (dashed lines). C, with excessive circumferential fat removed, the
ingocele. B, with the subcutaneous aspects of the lipoma dissected, the paraspinal muscles are then dissected off the last intact lamina. The
neck of the lesion coursing through the fascial defect is fully developed. constricting periosteal band immediately cephalad to the neck of the
Excessive lipoma can be removed safely to allow additional exposure lipoma can then be sectioned.


subcutaneous lipoma. Sectioning this band may signifi- care must be given at this point to appreciate the rela-
cantly relieve the tension on the cord and reduce its pos- tionship of the dorsal roots which have been displaced
terior angulation (Fig. 3C). laterally by the lipoma and the duralipoma complex
With adequate exposure of the dural tube cephalad (Fig. 4A). Obviously, no roots should be sacrificed
to the lipoma it is opened in the midline. Asymmetrical and yet the dura needs to be circumferentially dis-
exiting roots can then be seen. The junction of the dura sected away from the dorsally displaced cord (Fig.
to the neck of the lipoma as it emerges through the dural 4B). The asymmetrical arrangement of exiting roots
defect is a key landmark for further dissection. Special combined with rotation of the cord may further

© 1992 The American Association of Neurological Surgeons

Figure 4. A, a three-dimensional view of a lipomyelomeningocele dem- hooked knife being used to open the dura while the cord is rotated slightly
onstrating the dura-lipoma complex and the position of the exiting dor- for better exposure of the dorsal roots. The upper part of the lipoma is
sal roots. This relationship varies somewhat from patient to patient and also being excised by the CO2 laser.
with the degree of rotation of the cord. B, a surgical view showing a


complicate this maneuver. Once this critical maneuver is Numerous variations on this anatomic theme exist.
complete and the cord has moved into a relaxed ventral One which deserves special comment occurs when the
position within the dura, attention is returned to the in- subcutaneous lipoma is asymmetrically situated off the
tramedullary component of the lipoma. With the ultra- midline and opposite to it is a cleft of grayish blue thin
sonic aspirator or the CO2 laser the lipoma is progres- epithelium. The thinned epithelium is seen to be blue from
sively thinned until a small layer of fat remains against an underlying CSF cyst being formed by a terminal
the neural tissue. Dense septa coursing through the li- syringohydromyelia (Fig. 6, A and B).
poma limit the usefulness of the ultrasonic aspirator. This Operatively, this lesion is approached in a similar man-
is especially true in older children and adults. No attempt ner, with circumferential dissection of the subcutaneous
is made to completely excise all fat, but the bulk of the lipoma and cyst. With the last intact lamina removed, the
lesion is removed which then allows reconstitution of a dura is opened to expose the caudally displaced spinal cord.
neural tube. This is done with fine inverted nonreactive The plane between the dura-lipoma complex and the fatty
suture (Fig. 5). Attention is then directed to the filum infiltrated cord is again key. The cord may be quite ex-
terminale which may be thickened. Again, it is separated panded by the combination of fatty infiltration and enlarge-
from surrounding exiting roots and sectioned. ment of the central canal. Draining the cyst at this point
The dura is reapproximated, allowing a capacious may facilitate the circumferential dissection around the
CSF space dorsal to the newly formed neural tube. The dural attachment to the neck of the lipoma. The dura, too,
superficial soft tissues are reapproximated but not at the may be infiltrated by fat. This makes adequate dural clo-
expense of the dorsal CSF space. sure technically demanding. With careful dissection and

© 1992 The American Association of Neurological Surgeons

Figure 5. Following resection of the bulk of the intramedullary li- pacious CSF space dorsal to the newly formed neural tube is created
poma, the distal cord is reconstituted into a neural tube with inverted (lower inset). This lessens the likelihood of readherence at the op-
fine nonreactive sutures (upper inset). The dura is closed and a ca- erative site.


© 1992 The American Association of Neurological Surgeons

Figure 6. A, surface landmarks of a cystolipomyelomeningocele. Asym- caudal lipoma and its infiltrative nature with respect to the dura and
metric position of the lipoma to the right of midline and a thin epithelial terminal cord. Expansion of the distal central canal (terminal ventricle)
veil over the terminal syringohydromyelia on the left are apparent. B, into a syringohydromyelia. is easily appreciated.
anatomical relationships demonstrating the explosive expansion of the


constant changing of perspective, eventually the circum- the intradural contents are not constricted and, therefore,
ferential opening of the dura-fat interface can be accom- are less likely to become adherent.
plished. The dorsal roots may be seen to be adherent to Long-term results following aggressive resection and
the undersurface of the dura, and prior to each maneuver repair of lipomyelomeningoceles are still being accumu-
they should be sought. These roots are laterally displaced lated. What does seem clear is that the risk of a serious
and will be seen to exit in an asymmetric fashion. Exces- permanent injury from the operative manipulation is low
sive fat growing into the neural tissue will then be ex- in experienced hands and should be much less than 10%.
cised. Prior to section, each area is isolated and electri- The risks of spontaneous worsening without operation is
cally probed for neurologic function. The very caudal high, probably greater than 90% within the first two de-
portion of the conus can be reconstructed into a neural cades of life. The likelihood of 5 to 10 years of clinical
tube. If a large roughened surface not covered by pia is stability without further loss of neurologic function fol-
left following the resection of the lipoma and reconstruc- lowing surgery is also high. If these are the representative
tion of the neural tube, consideration should be given to risks and benefits, then early surgical intervention is rea-
placement of a thin sheet of nonreactive plastic between sonable and appropriate for this lesion. There are many
the reformed distal cord and the inner surface of the dura. anatomic variations with this category of congenital le-
This may lessen the likelihood of secondary readherence sions. The experience and judgment necessary in the suc-
at the site of separation. At times, a dural graft may be cessful operative manipulation of this lesion are signifi-
necessary. This can usually be harvested from the two- cant. This particular lesion should not be operated on by
ply lumbodorsal fascia. Again, watertight dural closure the surgeon who only deals with it occasionally. Serious
with preservation of a capacious CSF space around the loss of bladder and/or bowel function will occur with the
reformed neural tube is ideal. The soft tissue closure su- inadverent sacrifice of functioning nerve roots by the sur-
perficial to the dura is performed in such a manner that geon who does not perform this procedure regularly.



PATIENT SELECTION ticular attention is given to the anticonvulsant level; if the

Candidates for interstitial brachytherapy using implant- level is subtherapeutic, additional medication is adminis-
able radioactive 125I seed catheters are patients with a re- tered either intravenously or orally on the day of the pro-
current highly anaplastic astrocytoma or glioblastoma cedure. Beginning at midnight on the preceding day, the
multiforme and those with a single metastatic nodule (Fig. patient is kept from eating or drinking except for his or
1). An interstitial implant performed after external beam her usual medications. Lorazepam (0.5-1.0 mg) is admin-
radiotherapy in the initial treatment of patients with glio- istered orally for patient comfort before placement of the
blastoma multiforme has also recently been proven effec- stereotactic frame and is repeated orally or intravenously
tive. Patients selected for brachytherapy must have a tu- as needed throughout the day.
mor that is clearly visible on contrast-enhanced computed
tomography (CT) scans and the tumor must be less than APPLICATION OF THE FRAME
4.5 cm in its greatest dimension. Those who have dif- On the morning of operation, the scalp is shaved at least
fusely infiltrative tumors, are significantly impaired neu- in the region of the tumor, and a peripheral intravenous
rologically (Karnofsky performance score less than 70), line is inserted. The Brown-Roberts-Wells base ring
or have a life expectancy of less than three months are (BRW-HR) is applied using sterile technique. Local an-
excluded. In patients with a metastatic tumor, systemic esthesia (0.5% lidocaine with 1:200,000 epinephrine) is
disease must be stable. Other exclusion criteria are evi- used in adult patients, whereas general anesthesia is re-
dence of subependymal tumor spread or involvement of quired in children. The ring is secured to the outer table
the corpus callosum, tumor location in or immediately of the skull with four pins: one in each lateral frontal re-
adjacent to the cerebellum or brain stem, and multifocal gion approximately 2 cm above the eyebrow, and one in
tumors. Tumors with a prominent cystic component are each posterior-inferior parietal region. Pin sites are cho-
not ideal for interstitial brachytherapy because loss of cyst sen so that none is placed in the region of the tumor and
fluid during seed implantation may cause significant and so that the base ring itself is inferior to the lowermost
unpredictable changes in tumor geometry. If patients with tumor margin. For low-lying tumors, extenders are used
such tumors are to be treated with brachytherapy, cyst as side bars to make lower fixation of the ring possible,
fluid must be drained before implantation.
Most of the patient who have undergone TARGET ACQUISITION
brachytherapy at our institution have had a malignant In the CT suite, the localizer ring apparatus (BRW-LR) is
glioma that recurred after initial therapy with surgery, placed over the patient’s head and attached to the base ring;
external beam irradiation, and sometimes chemotherapy. the entire ring assembly is then secured to a ring attach-
Brachytherapy of primary glioblastoma used as a boost ment on the CT table. A contrast-enhanced axial CT scan,
after surgical resection and external beam radiation 3 mm in thickness, is then made. The asymmetrically posi-
therapy also seems to be effective in significantly pro- tioned radiopaque graphite rods on the localizer ring allow
longing patient survival. the tumor margins to be localized relative to the base ring.
Information from this scan is analyzed with a VAX 11-780
PREOPERATIVE PREPARATION computer, using the BRAIN program developed at the
Twenty-four to forty-eight hours before operation, the University of California, San Francisco. The three-dimen-
patient undergoes routine preoperative assessment. Par- sional tumor volume is determined on the basis of the outer
margin of enhancement on the CT scans. A radiation
© 1992 The American Association of Neurological Surgeons physicist selects the number and positions of cathe-


© 1992 The American Association of Neurological Surgeons

Figure 1. Implantable 125I radioactive seed catheters are stereotactically elements (bottom left). The catheters are secured in place by means of a
localized within the tumor bed (top). Typically, between one and three collar that is sutured onto the scalp (bottom right).
catheters are each loaded with one to five radioactive seeds and spacer


ters to be used and the number of 125I seeds loaded in remain awake, alert, and cooperative so that the neuro-
each, attempting to match the predicted volume of radi- surgeon can continuously assess neurologic status as seeds
ated tissue closely with the tumor volume and to mini- are implanted. A local anesthetic is used for analgesia in
mize the number of catheters inserted. Graphic represen- the region of catheter insertion.
tation of isodose radiation curves with the catheters in a
given position can be superimposed over a scan showing Positioning, Preparation, and Draping
the tumor volume in any plane (Fig. 2). The positions and The patient is placed in a semi-sitting position on the op-
number of catheters and seeds are varied in an interactive erating table. The BRW ring adaptor (BRW-MA) is used
manner until an ideal combination is determined for the to secure the base ring, attached to the patient’s head, to
tumor. Between one and three catheters loaded with one the Mayfield-Kees table attachment (Fig. 3). The scalp is
to five seeds each are commonly used for optimal tumor scrubbed in the region of the tumor with povidone-iodine
volume coverage. After the neurosurgeon and the radia- solution and then draped with lodoban plastic. Nafcillin
tion oncologist examine and approve the final treatment (2 g) or vancomycin (1 g) is administered intravenously
plan, the BRAIN program determines the target point for before the first skin incision.
the tip of each catheter relative to the BRW frame and
calculates the trajectory, including the BRW azimuth and Operative Procedure
declination angles. This pre-implant planning process After the arc-ring assembly (BRW-AS) is placed over the
takes a total of one to two hours. patient’s head onto the base ring, the entry point for the
first catheter is determined on the basis of the calculated
SURGICAL TECHNIQUE azimuth and declination angles. The skin in the area of
this entry point is anesthetized, a 4-5 mm incision is made,
Anesthesia and Monitoring and a twist drill hole 3.4 mm in diameter is made in the
The patient’s blood pressure, electrocardiogram, and oxy- skull (Fig. 4). For catheters to be inserted near the major
gen saturation are monitored continuously while he or vessels in the region of the sylvian fissure or midline, a
she is in the operating room. An anesthesiologist or nurse burr hole rather than a twist drill hole is made so that
practitioner is present throughout the procedure and ad- placement of the catheter can be visualized directly. A 2-0
ministers lorazepam and/or morphine as needed for pa- purse-string suture is placed in the scalp, to be used later
tient comfort. It is important, however, that adult patients in closing the skin around the catheter.

© 1992 The American Association of Neurological Surgeons

Figure 2. A patient with an anaplastic astrocytoma in the right tential catheter trajectories and isodose radiation curves are su-
frontal lobe undergoes analysis with the BRAIN computer pro- perimposed graphically over the tumor on a coronal contrast-en-
gram at UCSF before placement of catheters containing 125I. Po- hanced CT image.


© 1992 The American Association of Neurological Surgeons

Figure 3. The patient, in the Brown-Roberts-Wells base ring, has been tom). The BRW ring adaptor (top) secures the base ring to the Mayfield-
placed in a semi-sitting position for stereotactic seed implantation (bot- Kees table attachment.

© 1992 The American Association of Neurological Surgeons

Figure 4. A twist drill is used to make a 3.4-mm diameter cranial opening. The twist drill trajectory and location are determined by
the stereotactic coordinates for catheter placement.


At the twist drill hole, the dura is punctured with a cured together with cyanoacrylate adhesive. The arc-ring
K-wire and then dilated with a blunt probe. The arc ring is removed from the patient and returned to the phan-
is removed from the base ring and placed onto the phan- tom base, and the Silastic collar is attached to the scalp
tom base (BRW-PB) so that the required catheter length with several 5-0 nylon sutures. This procedure is repeated
to the first target site can be determined. The outer for each catheter in turn.
Silastic catheter (1.57 mm inside diameter, 2.16 mm During catheter placement, the radiation physicist
outside diameter) is loaded onto a stylet (Fig. 5) and prepares the radioactive seeds for implantation. The 125I
passed through the trajectory guide of the arc ring until high-activity seeds are each approximately 4 mm in length
it reaches the phantom base target, preset to the coordi- by 0.8 mm in diameter. These are loaded into inner nylon
nates determined by the BRAIN program (Fig. 6). A catheters (1.04 mm inside diameter, 1.47 mm outside di-
safety cuff is screwed onto the stylet to mark the proper ameter; see Fig. 5) with intervening spacer elements, if
length, and the catheter and stylet are withdrawn. The required, so that they will be arranged in the proper posi-
arc-ring assembly is returned to the patient and attached tions as determined by the BRAIN program.
to the base ring. The outer Silastic catheter and stylet After all outer Silastic catheters have been im-
are lubricated lightly with sterile mineral oil and then, planted, the operating room personnel don appropriate
using the arc-ring trajectory guide, carefully advanced radiation-protective attire. The inner nylon catheters
to the predetermined depth through a Silastic collar (Fig. containing the radioactive seeds are delivered to the
5) held at the skin surface (Fig. 7). After the stylet is operating room in a lightweight lead pig by the radia-
withdrawn, the outer Silastic catheter and collar are se- tion physicist. Each is inserted into the corre-

© 1992 The American Association of Neurological Surgeons

Figure 5. A stylet (far left) is used for passage of the outer Silastic
catheter (second from left) through the cranial opening. The outer cath-
eter is secured to a Silastic collar (far right) by means of cyanoacrylate © 1992 The American Association of Neurological Surgeons
adhesive, then the collar is sutured to the scalp surface. An inner nylon
catheter (second from right) is loaded with radioactive seeds and spacer
Figure 6. The outer Silastic catheter, loaded onto a stylet, is passed
elements, then inserted into the stereotactically placed outer catheter.
through the trajectory guide of the arc ring to the target of the phantom
base, preset to the coordinates for the catheter tip as determined by the
BRAIN computer program.


© 1992 The American Association of Neurological Surgeons

Figure 7. The outer Silastic catheter and stylet are inserted through the silastic collar held at the skin surface, then advanced carefully
to the predetermined brain depth using the arc-ring trajectory guide.

sponding outer catheter (Fig. 8) and then secured with a 60 Gy. The typical duration of therapy, at a dose rate of
hemostatic clip (Fig. 9). The purse-string scalp sutures 0.4-0.6 Gy per hour, is five to seven days.
are tied, and the final array of catheters (Fig. 10) is cov-
ered with a gauze dressing. A cloth cap, insewn with lead Removal of Catheters
plates 0.5 mm thick in the operative region, is placed on The neurosurgeon and radiation oncologist wear appropri-
the patient for shielding. The time taken in the operating ate radiation-protective attire while removing the seeds and
room for implantation is usually less than one hour. catheters; this is done in the patient’s hospital room unless
a burr hole was required for insertion. Catheters inserted
Dosimetry into a burr hole are removed in the operating room. After
A fiducial localizer box (Fig. 11) is placed over the removal of the overlying dressing, the area of the catheters
patient’s head and attached to the base ring, and antero- is cleansed with Betadine solution and infiltrated with lo-
posterior and lateral plain skull radiographs are taken. cal anesthetic. The hemostatic clips are removed from the
Each face of the localizer box has radiopaque marks that ends of the catheters, and each inner nylon catheter in turn
allow determination of the final seed positions relative to is carefully withdrawn and immediately placed in a lead
the BRW frame. These data are entered into the BRAIN pig. After all radioactive elements are removed, the outer
program, and actual isodose radiation curves are gener- catheters, attached to the collars, are slowly withdrawn from
ated. These curves, in turn, determine the duration of the the tumor bed. The scalp openings at the catheter entry
implantation therapy. For boost therapy to a primary glio- sites are quickly closed with single 4-0 nylon sutures. The
blastoma, the outer enhancing margin of the tumor is wound and catheters are inspected for evidence of celluli-
treated with 50 Gy; recurrent or metastatic lesions receive tis or epidural infection, and a simple dressing


© 1992 The American Association of Neurological Surgeons

Figure 8. The inner nylon catheters, preloaded with the radioactive of the protective clothing worn by all operating room personnel for
seeds and spacer elements, are inserted into the corresponding outer this stage of the procedure.
catheters. Note that the surgeon is wearing leaded vinyl gloves as part

© 1992 The American Association of Neurological Surgeons

Figure 9. The inner and outer catheter assembly is secured with a he- collar neck. (See also Fig. 1, bottom right, for another view of the final
mostatic clip placed across the outer catheter at the level of the Silastic catheter assembly.)


© 1992 The American Association of Neurological Surgeons

Figure 10. The final array of catheters (six in this case) in a patient 2-0 purse-string sutures for closure of the skin around the catheters at
undergoing treatment of a right parietal lobe tumor. The 5-0 nylon skin the scalp entry sites.
sutures for securing the Silastic collars to the scalp are visible, as are the

© 1992 The American Association of Neurological Surgeons

Figure 11. A fiducial localizer box is placed over the patient’s head onto manner, the final 125I seed positions are determined for the calculation of
the BRW base ring before plain skull radiographs are obtained. In this actual isodose radiation curves and the duration of implantation therapy.


is applied. The time required for removal of the seeds and sion, or both at a median time of 29 weeks after implanta-
catheters is typically 10 to 15 minutes. tion. Reoperation after boost therapy for primary glio-
The patient is allowed to go home after overnight blastomas was performed in 40% of patients at a median
observation. The sutures are left in place for 14 days be- time of 42 weeks after implantation.
cause of delayed healing of the heavily irradiated scalp
The decay of 125I occurs by electron capture resulting in
COMPLICATIONS emission of gamma-rays, x-rays, and electrons. In the high-
During interstitial brachytherapy, an increase in activity seeds, the 125I is absorbed onto resin balls and
peritumoral edema is not unusual. Headache, the most coated with a titanium capsule; therefore, only the gamma-
common symptom, occurs in perhaps one-half of patients rays and K-characteristic x-rays are emitted into the sur-
and is treated symptomatically. A decline in neurologic rounding tissue. The energy of the emitted gamma-rays is
status is not typical; such an occurrence demands aggres- relatively low, in the range of 27 to 35 keV.
sive evaluation, including CT scanning if needed. Al- During insertion and removal of the loaded inner cath-
though the onset of new seizures is distinctly rare, the eters, all personnel in the operating suite or the patient’s
risk of seizures may increase during therapy in patients private room wear lead aprons and radiation exposure
prone to such activity. The anticonvulsant level is moni- badges. Leaded vinyl rubber gloves, leaded eye glasses,
tored closely during the week of treatment, and high thera- and a thyroid shield are worn by the radiation physicist
peutic levels are maintained. Occasionally a patient’s ste- while preparing the inner catheters for implantation and by
roid dose is increased, but this can usually be readjusted the neurosurgeon while inserting and removing catheters.
at discharge to the pre-treatment level. The radioactive seeds, when not in the patient, are kept
Our experience with our first 406 implant patients inside a lightweight lead pig at all times. The patient wears
involved the following complications: Five patients ex- the leaded cloth cap while ambulating in the hospital dur-
perienced a mild cerebrospinal fluid leak that either was ing treatment and when others are present in the hospital
self-limited or responded to placement of additional skin room. Readings are taken with a radiation meter 1 meter
sutures in a procedure performed at the patient’s bedside. from the patient in all directions, both with and without the
Two patients had aseptic meningitis, two had bacterial cap, in the operating room and in the patient’s hospital room;
meningitis (fatal in one), and two developed cerebritis these values are posted on the door to the patient’s room.
that responded to antibiotic therapy. Four patients had an Visitors and staff wear leaded aprons when in the
intracerebral hemorrhage associated with catheter place- presence of the patient. For prolonged visits, visitors are
ment; two of these required operative evacuation. While required to remain more than 1 meter from the patient
undergoing treatment, five patients had a pulmonary em- and to position themselves on the side of the patient op-
bolus, one of which was fatal. Two patients developed posite the catheters. Patients are placed in private rooms,
wound breakdown associated with irradiation, and one of which are arranged so that the catheters are closest to the
these required skin grafting for closure. window and away from the hallway door while the pa-
Patients undergo routine CT scanning six to eight tient is in bed. Patients use disposable eating utensils, and
weeks after brachytherapy, and thereafter at intervals of linen and garbage are monitored daily for radiation lev-
two months. At our institution, the incidence of radiation els. There are no precautions regarding human waste. A
necrosis after brachytherapy is significant. For distinguish- lead pig, instrument tray, and radiation counter are kept
ing between radiation necrosis and tumor progression, in the patient’s room at all times.
positron emission tomography (PET) scanning is required These precautions are extensive in proportion to the
because both of these entities appear as enhancing tissue potential level of radiation to which the seed catheters
on contrast-enhanced CT scans. Diagnostic PET scanning may expose staff and visitors. Even in the absence of the
is performed if the patient is neurologically stable. How- lead-shielded cap, staff giving routine care would be ex-
ever, in patients experiencing neurologic decline, crani- posed to radiation on the order of less than 10 mrem per
otomy is performed for resection of the new enhancing month, and exposure at distances of 1 meter or greater
tissue. After interstitial brachytherapy of recurrent glio- would be negligible. To date, no mishaps or instances of
mas, approximately 50% of our patients required radioactive contamination have occurred in the intersti-
reoperation because of radiation necrosis, tumor progres- tial brachytherapy program at our institution.


INDICATIONS ment as well as the extent of spinal cord or cauda equina

The extracavitary approach to the thoracic or lumbar spine compression. This may include, but should not be limited
is indicated for the removal of extradural mass lesions to, positive contrast myelography because accurate bone
anterior and/or lateral to the spinal cord or cauda equina, imaging is of critical importance in defining the status of
followed by anterior vertebral fusion. In the presence of the pedicles and posterior elements, as well as the verte-
spinal instability or deformity, posterior surgical tech- bral bodies. Currently, we favor plain spine radiography,
niques such as spinal instrumentation, fusion, and, oc- computed tomography (CT) scanning with intrathecal
casionally, laminectomy can easily be incorporated in a logical contrast, and often magnetic resonance imaging (MRI).
sequence, with spinal cord or cauda equina decompres- Spinal angiography is commonly used in studying lesions
sion preceding spinal fixation. In the rare instance of a between T6 and L2 to identify the radiculomedullary ar-
lesion encircling the dural sac, the procedure can be per- tery of Adamkiewicz, which arises most commonly be-
formed bilaterally, providing circumferential decompres- tween T6 and T12, and provides a significant amount of
sion and bilateral anterior fusion. Although the procedure the blood supply to the middle and lower thoracic spinal
may be utilized throughout the thoracic and lumbar spine, cord. Angiography need not be considered for lesions at
it may be difficult above the level of T2 because of the or below L3. If the artery is found at the level of the le-
presence of the scapula, and below the level of L4 be- sion or at levels immediately proximal or distal to the le-
cause of the presence of the iliac crest (although this can sion, we recommend approaching the spine from the op-
be removed, providing bone for grafting). posite side.
The extracavitary approach is useful in the manage- In spite of many strongly worded opinions to the con-
ment of thoracic disc herniation, upper lumbar disc her- trary, there is no good evidence that early surgery is of
niation, trauma, tumors, and inflammatory diseases involv- benefit in the neurologically stable patient. Therefore, our
ing up to three and sometimes four vertebral levels. practice is to operate on most patients with spinal trauma
Excellent exposure of the vertebrae is offered, with early electively, i.e., within 5-10 days after injury, depending
and direct visualization of the dural sac (Figs. 1 and 2). on the medical status and associated trauma. However, in
Particularly at the thoracolumbar junction, the use of the the patient with rapidly deteriorating neurologic function,
extracavitary approach obviates the need for takedown of the procedure becomes an emergency. In such patients,
the diaphragm with its associated morbidity. However, with dexamethasone can be used as a temporizing measure.
lesions extending more than three levels, transthoracic or Dexamethasone, however, is not useful in patients with
transabdominal approaches may be more helpful. spinal cord injury. In patients with significant metastatic
disease, alternative surgical approaches of lesser magni-
PREOPERATIVE EVALUATION AND tude should be considered, including a more confined cos-
PREPARATION totransversectomy or transpedicular approach in associa-
Preoperative evaluation should include adequate radio- tion with spinal instrumentation.
graphic studies to determine the extent of bone involve- Preoperative preparation is minimal. It is impera-
tive that the determination of spinal stability be made
prior to the surgical procedure, so that the patient and
© 1992 The American Association of Neurological Surgeons operating room personnel can be properly advised. In


© 1992 The American Association of Neurological Surgeons

Figure 1. Extent of anterior thoracic decompression possible for vari- versectomy; orange, anterior transthoracic decompression; yellow,
ous surgical procedures, based on cadaver studies. Brown, costotrans- extracavitary approach as described in this chapter.

© 1992 The American Association of Neurological Surgeons

Figure 2. Extent of anterior lumbar decompression possible for various transpedicular approach; orange, anterior transabdominal decompres-
surgical procedures, based on cadaver studies. Brown. laminectomy/ sion; yellow, extracavitary approach as described in this chapter.


obtaining informed consent, the risks of worsened neuro- The decision to operate from the left or the right side
logic status, superficial or deep wound infection, pneu- is often determined by the pathology: if the lesion is more
mothorax, extensive hemorrhage, nonunion of the bone significant on the left, for example, the ideal approach
grafts, and failure of the instrumentation devices (if used) will also be from the left. As mentioned earlier, we avoid
need to be discussed. operating on the side of the artery of Adamkiewicz when-
In addition to ensuring acceptable physical status, ever possible. However, if the lesion is laterally placed on
prophylactic antibiotics are used although they are of un- the same side of the spine as the artery, we will approach
proven utility. The patient’s legs should be wrapped in from that side, taking great care to avoid arterial injury. If
compression bandages or anti-embolism stockings with the lesion is primarily central and the artery is irrelevant,
intermittent pneumatic compression. A Foley catheter and the side of the approach is determined by the surgeon’s
large-bore peripheral and central venous catheters are personal preference.
used. The vertical portion of the incision is made down the
In our institution, balanced anesthesia techniques midline, about three vertebral levels above and three lev-
using both narcotics and inhalation agents are favored. els below the lesion (Figs. 3 and 4). The lateral curved
Full physiologic monitoring, including direct arterial pres- portion generally extends 12-14 cm. If the lateral portion
sure and oxygenation measurements as well as cardiac is much longer (which does not improve exposure) re-
status checks, are important. We do not currently use in- traction later in the procedure may be difficult. The inci-
traoperative evoked potentials because decompression is sion is then carried through the subcutaneous tissue and
done under direct vision and the results of the neurophysi- the thoracodorsal fascia. If spinal instrumentation is to
ologic technique have been inconsistent. Hemodilution be performed, a subperiosteal dissection, cleanly expos-
and hypotension have been recommended for major spi- ing the laminae, facets, and spinous processes is accom-
nal surgery to decrease blood loss. However, we think that plished in the usual manner. Blunt and sharp dissection
the potential for sudden hemorrhage from epidural ves- are then used to elevate the thoracodorsal fascia off the
sels makes this technique unsafe. Instead, cell-savers underlying musculature, working from the midline dis-
(autotransfusion devices) are routinely used and are section. When the fascia has been freed over the entire
strongly recommended. Through the use of these devices, extent of the vertical incision, it is incised along the angled
our blood use has decreased from an average of 14 to 3 portion of the incision. The thin muscles superficial to
units per patient. the fascia remain attached to it. The entire skin, subcuta-
neous tissue, muscle, and fascia flap are then elevated
SURGICAL TECHNIQUE and retracted laterally. A plane is defined at the lateral
aspect of the erector spinae group, and these muscles are
Patient Positioning elevated as a layer off the ribs and are retracted medially.
The patient is positioned prone on chest rolls or on a spi- The more lateral muscles, including the remnants of the
nal frame, with the abdomen and chest free of the table. latissimus dorsi, are dissected free from the ribs.
Arms can either be above the head or carefully tucked at The number of ribs to be removed is dependent on
the sides. In either instance, it is important to position the the exposure needed for anterior decompression. For ex-
arms so that pressure on peripheral nerves is avoided, and ample, in surgery for thoracic disc herniation, one rib is
no stretch is applied to the brachial plexus. All pressure detached. For a single level fracture or tumor, we typi-
points are padded. cally remove two ribs, and for two-level disease, three
ribs. After all muscles and attached ligaments are cleaned
Operative Technique from the ribs circumferentially, with care taken to protect
Correct placement of the skin incision is absolutely criti- the intercostal arteries, the rib is transected 7-10 cm lat-
cal. The skin incision is marked after the patient has been eral to the costovertebral junction. The capsule of the cos-
positioned and portable x-ray films have defined the level tovertebral joint is incised with a scalpel, and the joint
of the lesion. The curved hockey-stick-shaped incision opened, using great care to avoid tearing the pleura. The
(Figs. 3 and 4) offers the best access to both the posterior rib is then elevated out of the field, and saved for later use
midline and the anterior vertebral body through the lateral as a graft. It is important to remove the rib and transverse
approach. In the thoracic or upper lumbar region, we typi- process at the articulation to ensure full exposure.
cally use ribs for bone grafts since one or more are removed In approaching lesions at L1 or L2, the 12th rib will
during the approach. If, however, the lesion is below L2 or typically need to be removed. Generally, the transverse
the rib is involved with tumor, is fractured, or is otherwise process of L2 is at approximately the same position as
unsuitable, iliac crest bone will be needed for grafting. the twelfth rib. Thus, rib removal offers bone graft,


© 1992 The American Association of Neurological Surgeons

Figure 3. The thoracic skin incision is made approximately three levels cephalad and three levels caudal to
the lesion, with a gently curved lateral portion.

© 1992 The American Association of Neurological Surgeons

Figure 4. The lumbar skin incision is made approximately three levels cephalad and three levels caudal to the lesion, with a gently
curved lateral portion. Here, the incision for an L2 fracture is shown.

surgical exposure, and localization, as discussed below. In using this approach for lower lumbar lesions, the iliac
For additional graft material, a portion of the 11th rib can crest will need to be resected to allow appropriate exposure.
easily be resected. This should be accomplished following careful dissection
Following rib removal at each level, the intercostal of the periosteum and muscle off the crest. Osteotomes are
neurovascular bundle is identified, the intercostal artery is then used to cleanly resect the obscuring portion, taking care
ligated and divided, and the intercostal nerve is isolated. to stay medial in the crest to avoid nerve injury. In addition,
The intercostal nerves are followed into the region of the the sacroiliac joint should not be violated to avoid long-term
neural foramina at the level of the lesion (Fig. 5). In Fig- pain. The bone edges are carefully waxed.
ures 6 and 7, the intercostal nerves are shown being re- Over most of the lumbar spine, anatomic localiza-
tracted for the purposes of exposure. However, it is more tion of vertebral levels is hampered by the lack of ribs.
commonly our practice to divide the intercostal nerves dis- Here, the transverse process assumes similar impor-
tally and to take advantage of the completely freed nerve to tance. The transverse processes located at the level of
safely gain access to the neural foramen. The band of hy- anterior pathology are identified and dissected free, as
pesthesia that results is rarely problematic and usually re- are those immediately cephalad and caudad. They are
solves over time, but the risk of a dysesthetic pain syn- then removed with a rongeur, often exposing the proxi-
drome resulting from a stretch injury of the nerve is high. mal portion of the nerve root from the more cephalad

© 1992 The American Association of Neurological Surgeons

Figure 5. Following removal of the rib segments, the intercostal nerves pedicle. As is explained in the text, distal ligation of one or more inter-
are followed proximal to their foramina, thus identifying the relevant costal nerves may simplify the approach.


© 1992 The American Association of Neurological Surgeons

Figure 6. The disc spaces on either side of the involved body(ies) are entered, and drilled out across the vertebral bodies.


© 1992 The American Association of Neurological Surgeons

Figure 7. Following spinal instrumentation, if indicated, the rib bone grafts are impacted into the previously made troughs.


spinal level. If not, the lumbar roots must be exposed by face can be helpful to break up adhesions, as well as de-
dissecting through the muscle masses lateral to the spine. fine spicules, etc. which may be stuck to the sac. Back-
Once found, they should be mobilized until they dive deep ward-angled curettes are then used to push this cortical
into the muscle or join into a plexus and retracted care- plate away from the dural sac, thus completing the de-
fully with nerve tapes. In contrast to the intercostal nerves, compression. Ideally, the entire plate will be fractured suc-
the lumbar nerves are not divided. cessfully, in a single piece, into the vertebral defect by
At this point, the periosteum (attached to the pleura, working primarily at the junctions of the intervertebral
diaphragm, and retroperitoneal tissues) of the appropri- discs, thus avoiding trauma at the point of cord or cauda
ate vertebrae is bluntly dissected away from the ventro- equina compression. Again, it is imperative that the plate
lateral aspect of the vertebral body and pedicle. It may be removal be extended across the spinal canal. A dental
necessary to carefully dissect a prefixed lumbar plexus mirror immersed in warm saline and held into the verte-
off the lateral aspect of the vertebral column. bral defect is helpful in visualizing the anterior aspect of
Unless the vertebrectomy is being performed for tu- the dural sac and the adequacy of decompression.
mor, there is no reason to dissect to the anterior midline Slots are then carved into the vertebral bodies adja-
of the body. Indeed, major blood loss may occur if the cent to the decompression to prepare a bed for the bone
anterior-lying segmental arteries are encountered. Follow- grafts to be placed later. The rib or iliac crest bone grafts
ing visual identification of the spinal lesion, blunted are prepared for grafting by cutting them 10-15% longer
needles or hemostats are placed into the discs at the mar- than the defect to be spanned. The ends are trimmed to
gins of the lesion, and an anteroposterior radiograph is 45° angles, with the shorter length being the leading edge.
obtained to ensure appropriate localization. At this point Ideally, at least two pieces of rib, or one bi- or tricortical
it may be advantageous to turn the table so that the iliac crest graft, are impacted into position, at least 1 cm
surgeon’s side is up approximately 15 to 20°. away from the dural sac to prevent cord or cauda equina
Dissection of the margins of the appropriate neural compression if full correction is not maintained (Fig. 7).
foramina is performed with a nerve hook; they are then If an intercostal nerve has been divided, a silver clip is
enlarged using small Kerrison rongeurs and curettes. The placed proximal to the dorsal root ganglion, and the nerve
pedicle is thinned and removed between the pertinent fo- is resected.
ramina. We often remove portions of the pedicles adja- In the presence of spinal instability or abnormal an-
cent to the affected levels to offer visualization of more gulation of the spine the bone grafts are placed after spi-
normal anatomic relationships between the dural sac and nal instrumentation. Bone wax and cellulose hemostatic
the spinal canal. Although some epidural bleeding may materials are used to cover exposed cancellous bone, lap-
occur as a result of this step, full removal of the pedicle arotomy sponges are packed for hemostasis, and the re-
affords lateral visualization of the dural sac which is im- tractors are removed. Because the subperiosteal dissec-
perative in this procedure. tion was performed earlier, following the placement of
With the removal of the pedicle and visualization of retractors the laminae are immediately available for prepa-
the dural sac, the dissection of the periosteum, and the in- ration. Spinal instrumentation is placed at this time; the
terpretation of the localizing radiograph, the disc spaces devices used depend on the pathology and the experience
above and below the level of the lesion should be well- of the surgeon. However, because the dural sac has been
defined. The discs are partially removed, and the disc spaces fully decompressed, realignment of even severe deformi-
drilled out using a brace and bit or a high-speed drill, at- ties can be performed without a high degree of risk to the
tempting to go through at least three-fourths of the way spinal contents. The midline muscles are reapproximated
across the body, thus ensuring that the surgeon is across using nonabsorbable sutures.
the spinal canal (Fig. 6). The intervening vertebral bone is Attention is again turned anteriorly. The erector spinae
then removed using a rongeur or a high-speed drill, again muscles are again retracted medially using self-retaining
being careful to go deep enough through the vertebra. If a retractors, and the lateral aspect of the dural sac is visual-
drill is used, care must be taken to avoid pushing the bit ized, as well as the bone defect created by the decompres-
through fractured bone or tumor toward the dural sac. At sion. Bone grafts are placed as discussed above.
this point, there should be at least 1 to 2 cm of bone left The wound is then carefully closed in layers. A large
anteriorly and a thin dorsal shelf posteriorly. surgical drain is left in the paravertebral region, with
Removal of the thin dorsal plate should be accom- one or two drain holes extending underneath the flap,
plished with great care, but rapidly, since epidural bleed- for approximately 48 hours. If the pleura has been en-
ing may result. Careful dissection of the dura-bone inter- tered inadvertently, a No. 32 chest tube should be


placed in the pleural space. The paravertebral muscle layer In instances where the pleura has scarred to the rib
and the thoracodorsal fascia are tightly closed using in- or vertebra, rents may occur. This tends to occur most
terrupted nonabsorbable sutures. The subcutaneous layer frequently in patients undergoing surgery more than three
is closed with interrupted synthetic absorbable sutures, weeks after injury. In these cases, a large chest tube should
and the skin with staples. be placed intraoperatively directly into the pleural rent,
to drain both air and blood. Occasionally, the pleural vio-
POSTOPERATIVE CARE lation will not be recognized until the patient is in the
The patient is usually maintained in the intensive care recovery room or ICU, and the chest tube will need to be
unit (ICU) for one to two days postoperatively. Surgical placed there.
drains are typically removed at 24 to 48 hours. Monitor- Infection rates are surprisingly low, considering the
ing of pulmonary, hemodynamic, and fluid status is im- length of the surgical wound and the duration of the pro-
portant. Therapies required for any neurologic deficit are cedure. Superficial skin infections occur in about 5% of
reinstated on the first postoperative day. cases; deep infections are rare. Other serious complica-
If an external orthosis was fabricated prior to sur- tions, including deep vein thrombosis and sepsis, have an
gery, the patient can be mobilized on the fourth or fifth incidence of less than 1%.
day. Otherwise, we generally manufacture the bivalved Longer term complications include nonunion of
cast on the seventh day and then get the patient up when bone grafts, development of deformity, and/or failure
the jacket is ready. Skin sutures or staples are also re- of the spinal instrumentation systems. All of these are
moved at this time. uncommon: we have seen three nonunions in a series
of over 800 patients treated for thoracic (>460 patients)
COMPLICATIONS or lumbar (>340 patients) trauma. Spinal instrumenta-
The most common complications of the procedure are tion devices, however, can fail, particularly if poor
systemic: pulmonary atelectasis due to splinting produced bone-metal interfaces exist, as is true for nonsublaminar
by pain, and hypovolemia and/or low hematocrit related wired Harrington distraction rods. Some loss of cor-
to continuing low-volume blood loss. In cases with sub- rection inevitably follows spinal instrumentation, and
stantial blood loss, now unusual because of the use of some graft collapse may occur. However, as a conse-
autotransfusion devices, consumptive coagulopathies oc- quence of the wide decompression afforded by the
cur frequently and must be treated aggressively with re- extracavitary decompression and the anterior interbody
placement of clotting factors. Ileus may be present for fusion, recurrence of neurologic symptoms or major
two to three days after a lumbar operation. deformity is unlikely.




INTRODUCTION communication of the transverse sinuses at the torcular.

The extreme lateral transcondylar approach is useful for Embolization carries a higher risk because of the over-
both intra- and extradural tumors in the region of the lower lapping blood supply of the tumor and spinal cord itself.
clivus, foramen magnum, and cervical spine situated ven- However, if an external carotid blood supply through the
tral to the neuraxis. The approach, in principle, relies on ascending pharyngeal artery can be identified, this can
removal of bone in the area of the mastoid process and be embolized.
the craniospinal articulation to provide a more lateral per-
spective, enabling the surgeon to visualize the anterior COMBINATION WITH OTHER PROCEDURES
aspect of the spinal canal and foramen magnum without When tumors involving the clivus appear to involve the
additional retraction or manipulation of the brain stem or petrous portion of the internal carotid artery (ICA), the
spinal cord. In addition, this approach allows complete extreme lateral approach may be combined with the
control of the vertebral artery on one side through its ex- subtemporal and infratemporal approach to allow removal
tra- and intradural course beginning at the level of C2 so of all the tumor under direct vision and also to permit the
that it can be safely dissected from the tumor. surgeon to maintain control of the ICA. If disruption of
the entire atlanto-occipital joint is considered because of
PREOPERATIVE DIAGNOSTIC EVALUATION its involvement by tumor, a fusion procedure can be car-
Magnetic resonance imaging (MRI) in multiple axes, par- ried out either some time before the tumor resection or
ticularly in the axial and sagittal planes, is considered es- after the tumor removal at the same setting. Similarly with
sential in the surgical planning. Exquisite detail of the the cervical spine, if a tumor like a chordoma is removed,
relation of the tumor to the vertebrobasilar system is seen a separate approach from the front or back may also be
as is the plane between the tumor and the brain stem and necessary to accomplish removal of the entire tumor.
spinal cord. In the cases where the tumor has extended
outside the canal, the extent of invasion of the PREOPERATIVE PREPARATION
extravertebral tissues can also be well appreciated. Intravenous administration of steroids is started the day
High-resolution computed tomography (CT) scan- before the operation and is continued into the early post-
ning is also performed because the bony relations to the operative period. Baseline somatosensory evoked re-
articular processes are best seen in this study. Intrathecal sponses are obtained for comparison with intraoperative
contrast agents do not seem to add to the information recordings. If lower cranial nerve deficits are suspected,
obtained from the combination of the MRI and CT. laryngoscopic examination is carried out for proper docu-
Angiography includes the study of both vertebral ar- mentation. A thorough discussion with the patient is im-
teries and the carotid system, to assess the status of the portant regarding the potential for developing lower cra-
jugular bulb on the side in question and also the cross- nial nerve palsies as a result of the operation and the
possible need for a temporary tracheostomy and/or gas-
© 1992 The American Association of Neurological Surgeons trostomy in the postoperative period.



The patient is placed in a full lateral decubitus position
Anesthesia and Intraoperative Monitoring on a foam mattress with the involved side up. The head is
General anesthesia with orotracheal intubation is stan- secured in a neutral position relative to the shoulders in a
dard procedure. The agents used will depend on the ex- three-point pin head rest and the thigh is left exposed to
tent and type of intraoperative monitoring to be used. harvest fat and fascia. If a simultaneous fusion procedure
Somatosensory evoked potential (SEP) monitoring is cur- is planned, the ipsilateral iliac crest is also included in the
rently used as an indicator of spinal cord distortion dur- field. A soft roll is placed under the lower aspect of the
ing the operation. The tenth, eleventh, and twelfth cranial chest to prevent pressure injury to the brachial plexus. If
nerves can be monitored by inserting needle electrodes a long operation time is anticipated, the lower shoulder is
into the vocal cord, trapezius muscle, and tongue, respec- allowed to project beyond the table and is supported by
tively, and the evoked responses to intraoperative stimu- rolls of foam sponge placed between it and the head clamp
lation can be recorded on an electromyographic monitor. attachment. This prevents both a brachial plexus injury
If such motor cranial nerve monitoring is used, muscle and pressure sores on the side of the chest wall. The pa-
relaxants will have to be avoided. However, an excessive tient is securely taped to the table, taking into account
amount of an inhalation agent will interfere with the SEP that the table may be rolled during the operation. Pres-
recording. An active dialogue between the anesthetist, the sure points are carefully padded.
neurophysiologist, and the surgeon will have to be main-
tained to determine what type of monitoring will be re- Operative Procedure
quired at each stage of the operation.
Central venous and arterial catheters are used for fluid Incision and Muscle Dissection
administration and hemodynamic monitoring. An indwell- If most of the tumor is above the foramen magnum, a
ing urinary catheter is used for accurate urine output mea- “U”-shaped skin flap is raised based on the neck and
surement. Sequential compression stockings are wrapped the top of the incision extends above the ear (Fig. 1).
around the lower extremities to reduce the incidence of For a tumor below the foramen magnum, a vertical
deep venous thrombosis during these lengthy operative incision is made on the side of the neck at the level of
procedures. the mastoid process and an “L”-shaped posterior ex-

© 1992 The American Association of Neurological Surgeons

Figure 1. The patient is placed in a full lateral decubitus position dally placed. A gentle “C”-shaped Incision may also be used if
with the head kept neutral in pin fixation. An alternate incision is more extensive temporal bone work is anticipated and the external
an inverted “L” on the side of the neck if the tumor is more cau- ear canal is divided.


tension is made from the top end of this, not quite back to be redundant to a variable degree. The ventral ramus of
the midline. The skin flaps are raised separately, and care the C2 root crosses the superficial surface of the artery
must be taken to identify the accessory nerve as it exits and is also a useful landmark; it is lifted up by a redun-
the sternomastoid muscle to enter the trapezius. It is lo- dant artery. The artery may also be identified distal to the
cated in the subcutaneous tissues of the posterior triangle transverse foramen of C1 by detaching the oblique muscles
and can be positively identified with a stimulator, thus from the lateral and inferior surface of the C1 transverse
eliminating confusion with nerves of the cervical plexus. process and visualizing the artery on the upper surface of
The muscles are elevated from the suboccipital area and the posterior arch. The artery is followed right up to its
the mastoid process. In the cervical region the surgeon dural entry, freeing it up from the joint capsule of the
dissects the muscle in layers, identifying the specific articulation between the occiput and the atlas. The isola-
muscles and dividing them near their lateral attachment tion of the vertebral artery should be carried out under
on the transverse processes of the vertebrae. This type of magnification to prevent injury to the vessel; it is also
dissection allows their reapproximation in anatomic lay- very helpful in controlling venous bleeding from the abun-
ers and also reduces postoperative pain. dant surrounding venous plexus.

Identification and Isolation of the Extradural Bone Exposure

Vertebral Artery For posterior fossa tumors extending down to the fora-
The deepest muscle layer consists of the superior and in- men magnum, the bony exposure consists of the suboc-
ferior oblique muscles and the upper portion of the leva- cipital region, the mastoid process anteriorly to the exter-
tor scapulae attached to the transverse process of the at- nal ear canal, the foramen magnum, the transverse process
las. The transverse process of the atlas is an important and posterior arch of C1, and the occiput-C1 articulation.
landmark. Between the inferior oblique muscle and the For predominantly spinal tumors reaching up to the fora-
transverse process of C2 is an area filled with areolar tis- men magnum, the exposure includes the lateral aspects
sue. Blunt dissection in this area under magnification will of the vertebral arches (starting with the articular pillars
lead to the identification of the vertebral artery as it pro- and extending back to the spinous processes) and the lower
ceeds from the foramen transversarium of C2 to the fora- suboccipital region including the foramen magnum and
men transversarium of C1. This segment of the artery may the tip of the mastoid process (Fig. 2).

Figure 2. The bone is exposed as described in the text. Note that the
laterally placed incision prevents the bulk of muscle on the side from
obscuring the surgeon’s line of vision.
© 1992 The American Association of Neurological Surgeons


Bone Removal situated ventrally or ventrolaterally, surrounding or dis-

A suboccipital craniectomy and mastoidectomy (the facial placing the vertebral artery on one side. The dura is opened
nerve and the labyrinth are not unroofed) are carried out. posterior to the sigmoid sinus and the opening is carried
The sigmoid sinus is unroofed up to the jugular bulb, and caudally posterior to the vertebral artery at the foramen
the rim of the foramen magnum is removed up to the occipi- magnum. The dural flap is retracted anteriorly, and the
tal condyle (Fig. 3). Under the magnification of the micro- dura is carefully opened completely around the vertebral
scope, the atlanto-occipital joint capsule is completely ex- artery with the surgeon being aware that the vessel may
cised after it has been carefully freed from the vertebral artery. be surrounded by tumor in this area (Fig. 4C). Once the
The posterior one-half or two-thirds of the occipital condyle artery is completely mobilized, tumor in front of the ves-
and upper articular facet of the C1 lateral mass are drilled sel can be removed with relative safety, and injuries to
away with a high-speed drill (Fig. 4A). Removal of the ar- the vessel can be managed adequately. Standard micro-
ticular pillars not only allows a more direct access to the surgical techniques are used to dissect the tumor from the
ventral lip of the foramen magnum but also allows the sur- brain stem and cranial nerves after adequate debulking.
geon to get completely around the vertebral artery at its du- As the tumor capsule is being dissected away, the oppo-
ral entry point, facilitating its mobilization from the tumor site vertebral artery comes into view. The tumor often
(Fig. 4B). For spinal tumors, a mastoidectomy is not required extends to the opposite vertebral artery entry site but sel-
and the bone removal mainly involves the suboccipital area, dom involves it intimately on both sides. A nerve stimu-
the foramen magnum, and the occipital condyle. From here, lator may be used for positive identification of the cranial
the procedure varies depending on the intra- or extradural nerves during dissection from the tumor. The dural base
location of the tumor and will be described separately. of the tumor is easily excised from this exposure because
the surgeon is working in front of the vertebral artery. If a
Intradural Tumors at the Craniocervical significant portion of the tumor is inside the jugular fora-
Junction men or the tumor is a jugular foramen neurinoma, the
The most common tumor in this location is a meningioma extracranial portion of the tumor may be excised at

© 1992 The American Association of Neurological Surgeons

Figure 3. The craniectomy exposes the sigmoid sinus and extends bral artery in this area and has to be carefully excised under magnifi-
from the foramen magnum to the occipital condyle. Note that the cation prior to removing the condyle.
atlanto-occipital joint capsule is intimately approximated to the verte-

Figure 4. A and B, complete resection of the occipital condyle and

unroofing of the extradural hypoglossal nerve. The vertebral artery is
displaced from the foramen transversarium of C1. C, exposure of the
extradural jugular foramen nerves requires obliteration of the jugular
bulb; the dura is opened to permit the surgeon to follow the nerves
from an intra- to extradural course.

© 1992 The American Association of Neurological Surgeons


the same setting after removal of the entire occipital approaches may be considered as discussed earlier. If the
condyle and obliteration of the jugular bulb as described patient has no hearing, the labyrinth may be drilled away,
below (Fig. 4C). However, this will necessitate a fusion unroofing the internal auditory canal to provide a further
operation. Another option is to remove the extracranial cephalad access.
portion of the tumor through a preauricular subtemporal-
infratemporal approach along with a transcervical route Spinal Tumors
at a separate stage and avoid a fusion. Dural closure is Intradural tumors situated ventrally include meningiomas
accomplished with a graft but watertight closure around and schwannomas. Some of the latter may extend in a
the vertebral artery is not possible. A piece of fat har- dumbbell fashion outside the spinal canal. The approach
vested from the abdomen or thigh is placed in the mas- for spinal tumors located caudal to C2 is carried out by
toidectomy defect and the muscles are reapproximated. drilling the posterior one-half to two-thirds of the articu-
Partial condylar excision does not necessitate a fusion. lar facets and the adjacent laminae as far back as the
spinous processes (Fig. 5A). If there is a dumbbell exten-
Extradural Tumors at the Craniocervical Junction sion of the tumor, the adjacent facets are completely drilled
Tumors most frequently found in this location include away to unroof the neural foramen and the extracanalicular
chordomas and chondrosarcomas. These are primarily ex- portion of the tumor is removed (Fig. 5, B-D). It must be
tradural tumors but may invade the dura and can occupy noted that the vertebral artery anterior to the tumor is usu-
both the intra- and extradural space. The goal of the op- ally not adherent to it and can be carefully dissected off.
eration is not only removal of the soft portion of the tu- For the purely intradural tumors, the dura is opened
mor but also the involved dura and the infiltrated bone. immediately posterior to the nerve roots after packing
Complete condylar resection renders this region unstable off the epidural bleeding with Surgicel strips. Because
and the fusion procedure which is necessary can be per- the dural opening is laterally placed on the thecal sac,
formed either at a separate operation or at the same sit- the spinal cord does not herniate out from the pressure
ting as the tumor resection. The status of the jugular bulb of the ventrally placed lesion. Usually through this ap-
and cross-communication at the torcular must be evalu- proach, the lesion comes into full view as soon as the
ated preoperatively; however, in most instances the jugu- dura is opened and the cord is barely seen. The tumor
lar bulb is obliterated by the tumor. After completing the is then progressively debulked with bipolar co-
bone removal described earlier, the bone removal is con-
tinued inferior to the labyrinth. The occipital condyle is
completely removed, thus exposing the extradural por-
tion of the hypoglossal nerve in its bony canal (Fig. 4B).
This part of the bone removal does not necessitate oblit-
eration of the jugular bulb. If there is involvement of the
lateral mass of C1, the vertebral artery is completely re-
moved from the foramen transversarium of C1 by dis-
secting subperiosteally along the artery and unroofing the
foramen with a high-speed drill or fine ronguers. The ar-
tery is then displaced laterally and all the involved bone
is removed with a high-speed drill.
When the tumor extends higher than the hypoglossal
foramen, the jugular bulb is entered after ligating the sig-
moid sinus and unroofing the bone over the bulb. In addi-
tion to the hypoglossal emissary vein, there may be a few
others that can cause troublesome bleeding in this area;
they are controlled with Surgicel packing. Once the jugu- © 1992 The American Association of Neurological Surgeons

lar and hypoglossal foramina have been unroofed, the Figure 5. A, the area of bone removal includes the posterior one-half to
nerves are best followed starting intradurally so that their two-thirds of the articular facets, depicted on this lateral view of the
spine. B, a dumbbell tumor with its extraspinal extension is shown. The
course may be plotted from the normal to the abnormal
green area shows the area of bone removal including the adjacent ar-
area (Fig. 4C). The nerves are completely skeletonized ticular facets above and below the tumor. The tumor before (C) and
by drilling the bone around them until healthy bone is after (D) removal and the view of the ventral aspect of the spinal cord
seen. When the petrous ICA is also involved, additional across the midline are shown from a completely lateral perspective.


agulation and suction or using the ultrasonic aspirator or In the case of a meningioma, the dural base is excised with-
the laser. While using the laser, care must be taken to avoid out much difficulty and a fascial graft is sutured in under
excessive heating of the neural tissues and copious irriga- magnification. Extradural tumors like chordomas can also
tion must be used. Dissecting the tumor capsule from the be removed by this approach, especially if they involve the
nerve rootlets and spinal cord is undertaken only after the pedicles and lateral masses and encircle the vertebral ar-
center of the tumor has been sufficiently debulked; radicu- tery. If there is intradural extension, this can also be dealt
lar vessels must be preserved. The approach provides ex- with and the dura adequately repaired. Additional ap-
cellent visualization of the tumor-cord interface to allow proaches may be necessary to remove portions of the tu-
safe dissection along this plane, and the entire ventral sur- mor extending into the vertebral body and the opposite side,
face up to the opposite nerve roots can be seen (Fig. 5D). and if instrumentation is needed for stabilization.

© 1992 The American Association of Neurological Surgeons

Figure 5, B-D.


EXTENT OF EXPOSURE tradural visibility beyond the ventral midline is extremely

The clival exposure extends from the level of the internal difficult because the thecal sac curves around and hides the
auditory canal to the foramen magnum. Laterally, the sur- bone. The entire lateral aspect of C1 and C2 is accessible up
geon can access the entire ventral aspect of the foramen to the midline. The vertebral artery is completely controlled
magnum intradurally from one hypoglossal canal to the other. so that it can be separated from the tumor, or repaired or
The bony exposure includes the bone inferior to the laby- grafted if necessary. Immediate stabilization through the same
rinth and the ipsilateral occipital condyle extending anteri- approach can also be carried out if the atlanto-occipital ar-
orly and posteriorly up to the midline (Fig. 6, A and B). Ex- ticulation is completely disrupted (Fig. 7).

© 1992 The American Association of Neurological Surgeons

Figure 6. The working area and viewing angle are seen from intracranially (A) and extracranially
(B), with and without exclusion of the jugular bulb. CN, cranial nerves.


© 1992 The American Association of Neurological Surgeons

Figure 7. The view obtained after removal of an extradural neoplasm and occipitocervical fixation with a titanium plate.

POTENTIAL COMPLICATIONS prevent their injury during surgical manipulation. In the

The spinal accessory nerve may be injured during the postoperative period special vigilance must be maintained
subcutaneous dissection. The nerve can be differentiated to detect dysfunction of the glossopharyngeal and vagus
from the cutaneous nerves by intraoperative stimulation nerves. In such instances, an early tracheostomy and/or
and if inadvertently transected should be directly sutured gastrostomy is important to avoid further complications
(with good results). from aspiration and malnutrition.
Injury to the vertebral artery can occur during the Cerebrospinal fluid leaks can occur because of the
extradural or intradural dissection and is repaired after difficulty of obtaining a watertight dural closure. It is
temporary occlusion. This is facilitated by carefully iso- important to close the wound in as many layers as pos-
lating the vessel and achieving proximal control in a nor- sible. If a leak does occur through the incision, a lumbar
mal area prior to manipulation within the tumor. spinal drain is left in for three or four days. If the leak
Although intraoperative monitoring helps to identify persists, the wound must be reexplored and a better dural
the cranial nerves in the distorted anatomy, it does not reconstruction carried out using a graft material.


INTRODUCTION The mastoid air cells are removed from the supe-
Ménière’s disease is an end-organ vestibular malady, the rior petrosal sinus to the jugular bulb (Fig. 1). Bone re-
symptoms of which (vertigo, nausea, and vomiting) can moval is carried above the posterior semicircular canal
be eliminated by vestibular nerve section. Hearing need and forward toward the superior semicircular canal so
not be destroyed nor does one have to enter the that the superior and posterior semicircular canals are
cerebellopontine angle (CPA) from behind the sigmoid the limits of the dissection anteriorly and superiorly.
sinus. Extradural temporal lobe retraction and opening of Inferiorly, the retrofacial air cells inferior to the poste-
the internal auditory canal (IAC) from above is not the rior semicircular canal are opened and the anterior limit
only alternative. The antesigmoid (presigmoid) mastoid of the dissection becomes the bone-covered facial nerve
craniectomy provides an effective and safe alternative in its mastoid portion. Air cells are removed then, infe-
approach. riorly to the jugular bulb.
The key features of the dissection to this point are: 1)
SURGICAL PROCEDURE retraction of the sigmoid sinus posteriorly; 2)
The patient is supine on the operating table with the face skeletonization of the vestibular otic capsule; 3) exten-
turned away from the surgeon. The head is at the foot of sion of bone removal into the retrofacial area; 4) exten-
the operating table and 5-foot anesthesia tubing crosses sion of bone removal to the junction of the superior and
over the pelvis to the anesthesia machine. The left abdo- posterior semicircular canals (the crus commune); and,
men is prepared for obtaining abdominal fat to be incor- 5) dural exposure of the entire posterior fossa in this area.
porated later in the dural closure to prevent postoperative The posterior semicircular canal must be thoroughly skel-
cerebrospinal fluid (CSF) leakage. The surgeon is seated etonized to allow for maximal forward dural flap eleva-
at the head of the table, the scrub nurse is across from the tion, but it must not be entered.
surgeon, and the microscope is brought in from the top of The dura is opened in an apron-shaped fashion from
the head. The television monitor is behind the surgeon, in the crus commune, along the superior petrosal sinus pos-
front of the scrub nurse and easily seen by the anesthesi- teriorly to the sigmoid sinus, inferiorly along the sigmoid
ologist. sinus posterior to the endolymphatic sac, and anteriorly
A large postauricular incision is made just within the into the retrofacial air cells toward and above the jugular
hairline, and the mastoid periosteum is elevated forward bulb. Silk sutures are used to hold this dural flap forward
to the external auditory canal. The mastoid air cells are over the posterior bony semicircular canal, weighted by
removed with the air-driven Ototome drill and the sig- hemostats (Fig. 2).
moid sinus is skeletonized. Bone behind the sigmoid si- It is at this point that patience becomes a virtue! It
nus is removed to expose the posterior fossa dura, the appears that there is insufficient exposure for the op-
sigmoid sinus is retracted with the Silverstein retractor, eration. The pCO2 must have been at 23 mm Hg for
and the vestibular otic capsule is skeletonized. Bone of some time. Incising the thin arachnoid with the
the otic capsule is hard and easily differentiated from the neurotologic scissors allows CSF to escape. The arach-
mastoid air cells. noid is between the cerebellum and the posterior pe-
trous face. The lowered pCO2, the escape of CSF, and
time allow for the cerebellum to fall away. The floccu-
© 1992 The American Association of Neurological Surgeons lus is usually the main structure in the way of seeing the


© 1992 The American Association of Neurological Surgeons

Figure 2. A, antesigmoid posterior fossa dural reflection exposing nerve; VIIth nerve is in view. D, cutting the vestibular division of
the VIIIth nerve. B, creating a cleavage plane between the vestibu- the VIIIth nerve with the neurotologic scissors. E, the retracted ends
lar and cochlear divisions of the VIIIth nerve. C, cleavage plane of the cut vestibular nerve, the intact cochlear nerve, and the facial
created between the vestibular and cochlear divisions of the VIIIth nerve are shown.


VIIIth nerve. Taking down the thin arachnoid carefully The dura is then approximated with sutures, and ab-
here allows visualization of the VIIIth nerve. Raising the dominal fat is incorporated into the suture line to gain a
operating table helps to bring the visual angle up almost watertight dural closure. Strips of abdominal fat are then
to the horizontal. used to fill the craniectomy defect. Filling the defect does
A piece of Telfa is placed over the cerebellum and not interfere with hearing. The postauricular incision is
retracted with the multifenestrated Brackmann sucker. closed. The patient is extubated and returned to the re-
Eventually, the VIIIth nerve comes into direct view. It is covery room.
directly in a plane that bisects the posterior semicircular
canal and angled slightly inferiorly from that plane. The COMPLICATIONS AND RESULTS
VIIth nerve can be seen along the inferior (cochlear divi- We have not experienced any complications with this pro-
sion) edge of the VIIIth nerve (Fig. 2A). The IXth and cedure regarding CSF leakage, meningitis, or wound in-
Xth nerves are sometimes seen as well as, more com- fection. We routinely use prophylactic antibiotics given
monly, the root entry zone of the Vth nerve. It is impor- at the induction of anesthesia and two doses after surgery.
tant not to hurry this stage. Simply, careful and delicate The duration of surgery is usually 2.5 to 3.5 hours. Head-
dissection of the arachnoid with time will provide the aches are not a problem. Most patients are discharged
exposure. Adhesions around an endolymphatic-CSF shunt within four to five days and are given no prescription an-
tube can be troublesome. algesics.
The vestibular and cochlear nerves are not clearly sepa- The one problem which has occurred has been hear-
rated by a cleft. Therefore, the tentorial 40-50% of the VIIIth ing loss. This can be caused by aggressive bone removal
nerve should be the guide for sectioning. The vestibular over the posterior semicircular canal with entry into the
nerve fibers tend to spiral anteriorly around the cochlear membranous canal, or interruption of microvascular cir-
division. The Rosen needle is used to gently probe the VIIIth culation to the cochlear nerve. We have not cut the co-
nerve at a level where there is almost invariably a tiny, lin- chlear nerve.
ear surface vessel on the VIIIth nerve (Fig. 2B). A plane of When a vestibular nerve section has been accom-
dissection either develops or is created by this maneuver plished as we have described, the effective complete re-
(Fig. 2C). The cephalad vestibular division is sectioned with lief of vertigo from Ménière’s disease has been greater
a 0.5-mm hook or with the neurotologic scissors (Fig. 2D). than 95%. We have not found it necessary to change our
As the ends of the vestibular division retract apart (Fig. approach to retrosigmoid because of exposure problems.
2E), the cochlear division becomes more definable and a We recognize that the postoperative morbidity of
little color differentiation develops, with the cochlear divi- retrosigmoid vestibular nerve sections is reportedly higher
sion appearing more yellowish. than we have experienced in our cases.
There should be no bleeding during any of these ma- Although we believe that this type of vestibular nerve
neuvers with careful and gentle dissection. A pia-arachnoid section is the procedure of choice, we realize there are
membrane often seems to separate the cochlear (inferior) many factors that determine the treatment for any patient
and vestibular (tentorial) divisions within the core of the for Ménière’s disease and that no one choice of treatment
VIIIth nerve, even if a surface cleft is not seen. is best for all patients.




INTRODUCTION with chronic intractable pain generally divide patients into

The role of stereotactic surgical ablative lesions for pain two groups. Patients with disease processes which acti-
relief is relatively small. In the armamentarium of the mod- vate intact pathways in the nervous system for the pro-
ern neurosurgeon, such procedures as intraspinal and in- cessing of pain information are thought to have pain of
traventricular infusion of opioids and electrical stimula- so-called nociceptive origin. Patients with injuries to the
tion procedures of the spinal cord and of deep brain sensory portion of the nervous system, including the pe-
structures have largely replaced stereotactic ablative lesions ripheral nerves, spinal cord, and brain, are considered to
for treating chronic intractable pain. Nevertheless, there have pain related to deafferentation. Some authors reserve
remains a small group of patients for whom the previously the term “deafferentation” for pain generated by injury to
mentioned techniques, and others available, are either un- peripheral nerves and reserve the term “central pain” for
suitable or unsuccessful and for whom stereotactic abla- pain related to lesions in the spinal cord or brain. Be-
tive procedures offer a suitable potential means for pain cause almost all of the lesions in the nervous system pro-
control. The primary brain targets for ablative stereotactic ducing pain result in various forms of deafferentation, it
procedures in the modern era are the medial thalamic nu- is thought suitable to use the terms deafferentation or cen-
clei (centrum medianum and parafascicularis intralaminar tral pain essentially synonymously. In general, all forms
nuclei) and the mesencephalon. A variety of other lesion of intervention including stereotactic ablative procedures
sites have been described in the past, including the ventral have higher success rates with nociceptive than with deaf-
posteromedial and ventral posterolateral specific sensory ferentation pain.
thalamic nuclei, the spinal thalamic pathway in the pons,
the pulvinar, and other thalamic nuclei such as the anterior PATIENT SELECTION
and medial nuclei, as well as targets in the frontal and tem- Patients with nociceptive pain often respond well to anal-
poral lobes. Lesions in the cingulum bundle which were gesics by a variety of routes, including opiates given by an
described some years ago for relief of chronic pain, but intraspinal or intraventricular route. These patients also
about which little has been written recently, have been sug- respond well to electrical stimulation, either of the spinal
gested again based on magnetic resonance imaging (MRI) cord or the brain, if analgesics and other pharmacologic
localization and recent positron emission tomography (PET) manipulations are unsuccessful. The role of adjunctive tech-
scan evidence that the cingulum bundle may be an impor- niques such as physical therapy, transcutaneous electrical
tant termination point for pain-related information. These stimulation, nerve blocks, biofeedback, psychiatric and psy-
new data have led to renewed interest in cingulumotomy as chological therapy, particularly when these modalities are
a potential therapeutic avenue. administered in the context of a comprehensive multidis-
Because the techniques for stereotactic surgical ab- ciplinary pain program, should not be overlooked in the
lation for pain require sophisticated electrophysiologic re- therapy of chronic pain. In general, stereotactic ablative
cording and stimulation methods to correctly locate the procedures should be considered only when other avenues
targets, it is recommended that they be performed only of therapy have been exhausted. In general, the author rec-
by neurosurgeons with considerable experience in func- ommends that all other available forms of therapy, includ-
tional stereotactic neurosurgery. Neurosurgeons dealing ing spinal and brain stimulation, be employed before ster-
eotactic ablative lesions are considered.
© 1992 The American Association of Neurological Surgeons Pain related to deafferentation is more difficult to


treat. Such pain is often unresponsive to oral pharmaco- the form of 1 g of cefadyl or 500 mg of vancomycin for
logic agents, including analgesics, anticonvulsants, and patients with penicillin allergies is administered
antidepressants. Electrical stimulation of either the spi- perioperatively beginning at approximately the time of
nal cord or the somatosensory thalamus relieves deaffer- placement of the stereotactic frame.
entation pain in about 50% of patients. In general, the An important part of preoperative preparation is se-
author recommends that these techniques be exhausted lection of the intended target. The author employs almost
before stereotactic ablative lesions are contemplated ex- exclusively the medial thalamus. This target encompasses
cept in one instance. This instance relates to the thalamic portions of the intralaminar nuclei (centrum medianum,
syndrome seen in patients who have experienced a tha- parafascicularis) and the medial dorsal nucleus (Figs. 1 and
lamic infarction with destruction of the ventral postero- 2). The lateral portion of the medial dorsal nucleus is usu-
lateral (VPL) and ventral posteromedial (VPM) soma- ally referred to as the central lateral nucleus in cats and
tosensory nuclei. In such patients, there is no available primates other than humans but stereotactic atlases gener-
thalamic target for stimulation, and stereotactic ablative ally do not assign a special designation to this region. This
procedures may be considered without prior testing of general medial thalamic area is believed to be the termina-
deep brain stimulation. For patients who experience pain tion of the multisynaptic paleospinothalamic pathway, with
of the “thalamic syndrome” in whom the infarction is lo- relays in the reticular formation, which is particularly in-
cated in the hemispheric white matter or cerebral cortex volved in the emotional response or suffering related to
rather than in the thalamus, a trial of thalamic somatosen- persistent pain rather than to the sensory-discriminative as-
sory stimulation is indicated prior to consideration of ste- pect of pain. Some recent animal studies, however, indi-
reotactic ablative lesions. cate more direct relays into the central lateral nucleus and
Patients who meet the criteria described earlier are the region called the nucleus submedius in animals, from
considered to be suitable candidates for consideration for both spinal and/or facial nociceptors. This general area can
stereotactic lesioning for relief of intractable pain. Such often be identified by recording abnormal bursting dis-
patients typically suffer pain related to anesthesia charges of neurons in patients with intractable pain. Be-
dolorosa, peripheral nerve injuries, postherpetic neural- cause axons of the neospinothalamic and trigeminothalamic
gia, spinal cord injury, and the thalamic syndrome. Other tracts terminate in the VPL and VPM thalamic nuclei, le-
indications include patients with invasion of the brachial sions in this location may induce loss of normal sensation
or lumbosacral plexus by cancer and patients with unsuc- and risk producing a deafferentation pain syndrome. There-
cessful spinal surgery who suffer intractable back and leg fore, the author does not utilize these targets. Although other
pain. The author considers a psychological assessment to thalamic targets have been employed by other surgeons,
be an important part of patient selection. Psychological the information available is so sparse and the basic science
test instruments such as the Minnesota Multiphasic Per- data linking other thalamic targets to pain perception so
sonality Inventory (MMPI) and psychological or psychi- tenuous, that the author has generally not employed them
atric interviews are considered extremely helpful in pa- clinically.
tient screening. Patients whose personality traits include The other major target for stereotactic ablative le-
hysteria, hypochondriasis, depression, and excessive fo- sions to treat pain is the periaqueductal gray matter of the
cus on somatic complaints are unlikely to respond to any mesencephalon. Lesions in this target are particularly
form of surgical intervention, including stereotactic useful for pain in the head and neck due to cancer, but the
lesioning. However, a relatively minor element of these relatively high incidence of complications, particularly
personality traits, particularly depression, is commonly interference with extraocular movements, relative to me-
seen in chronic pain patients and does not necessarily dial thalamotomy, has prompted the author to employ
contraindicate a stereotactic ablative lesion. mesencephalotomy rarely.
For unilateral pain, a single thalamic lesion contralat-
PREOPERATIVE PREPARATION eral to the side of the patient’s pain is generally adequate but
No special preoperative preparations are required. Gen- occasionally bilateral lesions may be required (Fig. 3). For
erally, a contrast-enhanced computed tomographic (CT) axial pain, including pain of the spine and abdominal or tho-
scan or MRI scan of the brain is recommended. Such stud- racic cavity, bilateral lesions are nearly always necessary. It
ies will identify any unexpected intracerebral lesions as is recommended that in all cases a unilateral lesion be cre-
well as any unusual anatomical variations. Such studies ated first and the patient observed for at least several weeks
are absolutely mandatory in patients whose pain emanates before a contralateral lesion is created. The purpose of wait-
from cerebrovascular lesions. Intravenous antibiotics in ing is to assess the effect of the single lesion and to allow


© 1992 The American Association of Neurological Surgeons

Figure 1. Axial (horizontal) section of the human brain at the level of parafascicularis (Pf) nuclei of the thalamus are shown on the left side.
AC and PC. The general location of the thalamus (Th) is shown on the (Modified from Schaltenbrand G, Wahren W: Atlas for Stereotaxy of
right side. The locations of the centrum medianum (CM) and the Human Brain. Stuttgart, Thieme, 1977, with permission).


© 1992 The American Association of Neurological Surgeons

Figure 2. A frontal (coronal) plane of the human brain 10 mm pos- VPM, ventral posteromedial thalamic nucleus; VPL, ventral poste-
terior to the midpoint of the AC-PC plane. The distance between rolateral thalamic nucleus. (Modified from Schaltenbrand G, Wahren
bars represents 10 mm. MD, medial dorsal thalamic nucleus; Pf, W: Atlas for Stereotaxy of the Human Brain. Stuttgart, Thieme, 1977,
parafascicular thalamic nucleus; Cent. Med., centrum medianum; with permission).


© 1992 The American Association of Neurological Surgeons

Figure 3. A frontal (coronal) plane of the human brain 7 mm posterior to mediate thalamic nucleus. See the legend to Figure 1 for additional abbre-
the midpoint of the AC-PC plane. The dotted line represents the location of viations. (Modified from Schaltenbrand G, Wahren W: Atlas for Stereotaxy
a thalamotomy lesion for the treatment of chronic pain. VIM, ventral inter- of the Human Brain. Stuttgart, Thieme, 1977, with permission).


any perilesional edema to subside as well as to assess any Positioning

interference with cognitive function before proceeding to The patient is usually placed supine in a semirecumbent
bilateral lesions. position. The Mayfield attachment to the operating room
table with an adaptor for attachment to the Leksell ster-
SURGICAL TECHNIQUE eotactic frame allows a variety of positioning options to
provide for patients of different age and degree of tho-
Anesthesia racic and cervical spinal curvature (Figs. 4 and 5). Be-
The procedures are performed under local anesthetic infil- cause the neurophysiologic portion of the operative pro-
tration of the scalp supplemented by intravenous sedation. cedure may be relatively lengthy, it is essential to provide
A 1% Xylocaine solution containing epinephrine in a con- the patient with the most comfortable position possible.
centration of 1:100,000 is infiltrated into the frontal and
occipital scalp at the points of stereotactic frame fixation. Draping
The same local anesthetic is also infiltrated into the scalp A plastic aperture drape such as used by ophthalmic sur-
overlying the intended burr hole opening. Sedation is pro- geons is ideal for providing exposure of the operative
vided by midazolam beginning with a test dose of approxi- site without excessively covering the patient. Excessive
mately 1 mg and fentanyl in an initial dose of approxi- draping of the patient’s body should be avoided in order
mately 50 µg. Supplementary doses are provided as required to allow observation of motor function as well as to per-
to produce mild sedation. Verbal response from the patient mit sensory stimulation and testing during the proce-
is essential during the electrophysiological portion of the dure. Observation of the patient’s face is also essential,
procedure in which the exact target is identified. The ideal particularly in instances where the procedure is intended
anesthetic situation is that in which the patient remains in a to treat intractable facial pain. In addition, the draping
light sleep but can be easily aroused by verbal stimulation. should allow for observation of the patient’s eyes in or-
Routine monitoring of the electrocardiogram and of blood der to observe changes in pupillary size and extraocular
oxygen values via a pulse oximeter is recommended. movements.

© 1992 The American Association of Neurological Surgeons

© 1992 The American Association of Neurological Surgeons

Figure 4. Vertex view of patient positioning in the Leksell Model G Figure 5. Lateral view of a patient in the Leksell Model G stereotactic
stereotactic frame. Stabilization of the frame by an adaptor attachment frame. Note the orientation of the frame base parallel to the orbital meatal
to the Mayfield head rest is shown. plane. The arc is positioned for right precoronal twist drill placement.


Skin Incision probe or electrode. More lateral burr hole placements re-
The author recommends a precoronal burr hole or twist sult in the needle passing from lateral to medial as it is
drill opening for all surgical ablation procedures to treat advanced, requiring reference not only to different axial
pain (Figs. 5 and 6). This allows access to the thalamus as and coronal plane stereotactic atlas diagrams but also to
well as the upper brain stem in a safe and relatively direct different sagittal plane diagrams which complicates the
manner. A variety of other access routes have been em- anatomical identification of the target. Excessively me-
ployed, particularly the posterior parietal approach, but dial placements of the burr hole may result in accidental
the latter risks either accidental anterior placement with injury to bridging veins passing from the cerebral cortex
potential injury to the sensory motor cortex or a posterior to the superior sagittal sinus or to very vascular paccionian
placement resulting in visual field deficits. The coronal granulations with difficult-to-control hemorrhage, or in-
suture can be identified by palpation and, in most in- jury to the parasagittal portion of the cerebral hemisphere
stances, lies approximately 13.5 cm posterior to the na- with possible weakness of the contralateral leg.
sion. The center of the burr hole should be placed ap-
proximately 2 cm lateral to the midline of the skull. This Operative Technique
positioning allows a relatively parasagittal approach to The author’s current technique employs MRI or CT scan-
the thalamus and the upper brain stem, approximately ning for stereotactic anatomic target localization. Some ste-
parallel to the midline of the hemispheres. Thus, as the reotactic surgeons still employ positive contrast ventricu-
lesioning probe or recording or stimulating electrode is lography for target localization. This technique may lead
advanced, the primary movements will be to increase the to difficulty in ventricular cannulation in patients with small
posterior and depth positioning of the electrode tip, mini- cerebral ventricles, potential reactions to the contrast me-
mizing medial-lateral movement. In this way, one may dium including seizures, and shifts in brain targets due to
employ the sagittal diagrams from stereotactic atlases in brain movement as a result of cerebrospinal fluid loss. These
plotting the structures which will be encountered by the risks, although small, can be avoided with CT or MRI

© 1992 The American Association of Neurological Surgeons

Figure 6. Frontal view of a patient in the Leksell stereotactic frame. of the third ventricle. The arc angle is adjusted for placement of a twist
The X coordinate is adjusted for a target 10 mm to the right of the middle drill entry anterior to the coronal suture.


localizations. Functional corroboration of target localiza- Obviously, other stereotactic systems are also suitable.
tion with microelectrode recording and/or micro- or Correct frame placement is essential for functional stereo-
macrostimulation is considered essential for correct tar- tactic neurosurgery as opposed to situations when there
get localization. Dependence on anatomic target local- is an anatomically identifiable target such as a tumor.
ization alone will lead to a decrease in the success rate. Functional stereotactic neurosurgery requires the use of
Once the desired physiologic target has been identified, reference points, generally the anterior commissure (AC)
the author employs the radiofrequency electrode technique and posterior commissure (PC), for anatomic target lo-
for lesion production. calization. With the Leksell system, placement of the base
The Leksell Model G stereotactic system offers an of the frame parallel to the orbital-meatal plane ensures
ideal method for anatomic target localization. This stereo- that the plane of the CT or MRI sections will be as close
tactic frame system is both CT- and MRI-compatible. as possible to the AC-PC plane (Fig. 5). Rotation or an-
gulation of the patient’s head in the frame will increase
the stereotactic error because of the need to calculate tar-
gets from a central reference point. The General Electric
1.5 Tesla MRI scanner is easily adapted for the Leksell
frame (Figs. 7 and 8). MRI scanning offers easier loca-
tion of the anterior and posterior commissures, particu-
larly on the sagittal T1-weighted image. Sections may then
be obtained parallel to the AC-PC line. Although images
in other planes may be employed, the axial scan which
shows the anterior and posterior commissures is satisfac-
tory alone for anatomic target localization.
Electrophysiologic target localization is carried out us-
ing a concentric bipolar tungsten microelectrode (Fig. 9).
Unfortunately, there is no commercially available electrode
suitable for such recordings. We use an etched tungsten wire
electrode with tip diameter about 1 µm and impedance of
about 1 megohm. The outer sheath of the concentric sleeve
© 1992 The American Association of Neurological Surgeons of the electrode is insulated except at its distal end. This ring,
located about 500 µm from the electrode tip, is used for
Figure 7. An MRI scanner table with the cradle positioned for attach-
ment of the Leksell Model G stereotactic frame. The grommets and microstimulation. Although electrical stimulation through
threaded nuts allow frame positioning. the 1-µm tip is possible, repeated current passage will

Figure 8. Patient positioning on the MRI scanner

couch with the stereotactic frame attached to the
© 1992 The American Association of Neurological Surgeons
positioning cradle. The fiducials for sagittal and axial
coordinate determination are visible.


Figure 9. Diagrammatic representation of the microelectrode used for

recording single cell activity and for microstimulation. The recording
portion is an electrolytically etched 0.01-inch diameter tungsten wire
with a tip diameter of 1-2 µm which is insulated with an epoxy polymer
and covered with a 28-gauge polyamide sleeve. The stimulating portion
is a stainless steel tube insulated with a 21-gauge polyamide sleeve.
The distal end of the sleeve is uninsulated. The distance between the
recording tip and the stimulating ring is about 500 µm. The total length
of the recording electrode is about 25 cm.

© 1992 The American Association of Neurological Surgeons


© 1992 The American Association of Neurological Surgeons

Figure 10. Single cell recording of spontaneous activity from the in a pattern of bursts of 9-20 action potentials at a rate of 12-16 bursts
intralaminar thalamus in a patient with chronic pain. The cell discharges per second. Vertical bar, 50 mV; horizontal bar, 20 msec.

© 1992 The American Association of Neurological Surgeons

Figure 11. An axial T1-weighted MRI scan of the human brain in the stereotactic frame. The arrow points to a thalamotomy lesion
performed for the treatment of chronic pain.


damage the electrode tip so that single cell activity can- ization of targets for stereotactic mesencephalotomy have
not be recorded. Recording is carried out beginning ap- been described. Epileptic discharges identified by EEG
proximately 5-10 mm before the intended target and con- recording techniques have been reported from this area.
tinued as necessary beyond the intended target as In addition, responses to electrical stimulation in this area,
determined anatomically. Single and multiple unit record- including painful responses within 6.5 mm of the midline
ings are made using conventional amplification techniques in the mesencephalic region, warmth or cold at targets up
with audio and video monitoring of electrical activity in- from 9 to 16 mm lateral to the midline, and a burning
traoperatively. The microelectrode is advanced using a sensation from targets scattered across this same target
hydraulic microdrive which allows micron range control area have been noted. Stimulation in this general region
of electrode movement. Particular electrophysiologic sig- may elicit reports of pain similar in character, intensity,
natures of the various lesioning targets are obtained. Single and location to the patient’s original pain complaint in
or multiple unit activity which is somatotopically orga- patients with central pain but not in those with nocicep-
nized and which can be activated by light mechanical tive pain. Ocular responses, including conjugate eye de-
contact with receptive fields on the contralateral portion viation, convergence, pupillary constriction, lid retraction,
of the body serves as a reliable localization of the VPM and restriction of upward gaze, are also typical of this
and VPL nuclei. Electrical stimulation in these same tar- location. However, these responses alone can be obtained
gets generally produces a sensation of paresthesias in the from a variety of locations in this general area and do not
corresponding contralateral portion of the body and cor- serve as a reliable confirmation of electrode positioning
roborates correct target localization. In patients with pain prior to lesioning. They are only a general indication of
related to deafferentation, spontaneous neuronal hyper- the target area. Some other electrophysiologic signatures
activity and disorganization of receptive fields may also both by recording and stimulation have been reported in
be identified with microelectrode recording in VPL and isolated publications in this area but general confirma-
VPM. Some authors recommend routine neurophysiologic tion of these results has not been forthcoming.
identification of VPL/VPM to serve as a reference guide Once the intended target has been localized anatomi-
to the thalamic nuclei but we do not usually use this tech- cally and electrophysiologically, a radiofrequency
nique. Recording in the intralaminar thalamic nuclei, in- lesioning electrode with a thermistor tip for temperature
cluding centrum medianum and parafascicularis as well recording and with an uninsulated area measuring 5 mm
as centralis lateralis, generally fails to identify neurons in length and 2.1 mm in diameter is inserted into the de-
which can be activated by peripheral stimulation. Like- sired target. The lesion is usually made beginning at about
wise, electrical stimulation in these targets usually fails 60°C with continuous monitoring of the patient’s clinical
to produce detectable sensations. Occasionally, patients neurologic condition and with final lesion temperatures
with pain related to deafferentation experience an inten- in the range of 75-80°C. Each temperature is maintained
sification of their pain with stimulation in the intralaminar for 60 seconds. Once an initial lesion has been created,
region. We have also recently identified spontaneous neu- further electrophysiologic recording and stimulation and
ronal hyperactivity in the intralaminar thalamic region in a clinical assessment of the patient is carried out to deter-
patients with chronic pain, and such activity may serve as mine whether further lesions should be created. Our goal
a guide to localization of the correct target for a medial is to produce a relatively large lesion, about 1 cm in length
thalamotomy (Figs. 3 and 10). We have identified such and about 6-8 mm in diameter.
bursting neurons in the intralaminar region, centrum It has been my practice to carry out a CT scan imme-
medianum, parafascicularis, and the lateral portion of the diately postoperatively to evaluate the possibility of in-
medial dorsal nucleus which was referred to earlier as the tracerebral hemorrhage. If hemorrhage is not identified,
central lateral nucleus. The bursting neurons discharge at the patient is returned to the usual neurosurgical nursing
a rate of approximately 2-6 bursts per second. The bursts unit and not observed in an intensive care unit. Postop-
generally contain 2-8 action potentials per burst with a erative follow-up MRI scanning is suggested as a means
firing frequency within each burst of 200-300 Hz. Occa- of documenting the location, size, and shape of the lesion
sionally, bursting neurons are identified with up to 60-80 created (Fig. 11). This technique is particularly helpful if
action potentials per burst. Our current technique is to an initial stereotactic ablative procedure fails to provide
identify the locations of bursting neurons in the medial the desired pain relief.
thalamus and then to attempt to destroy all of the tissue
where such neurons are located. Closure
Electrophysiologic observations which allow local- Generally, an acrylic cranioplasty is carried out to oc-


clude the burr hole and prevent later cosmetic deformity 21-gauge polyamide sleeve except for a small ring at the
due to indentation of the scalp. The scalp is then closed in distal end which allows for microstimulation. Although
two layers. microelectrodes suitable for single unit recording are
manufactured in short lengths, the lengths necessary for
Monitoring human recording are unavailable. The electrodes utilized
As mentioned, electrophysiologic monitoring is essential for electrical recording for epilepsy monitoring are not
for correct target identification. Targets in the VPL or VPM suitably small to allow single units to be identified. For
thalamus can probably be localized satisfactorily by elec- stimulation, we use a gross physiologic stimulator and a
trical stimulation alone, although electrical recording im- PSIU-7 constant current isolation unit. For
proves the accuracy considerably. Microstimulation. as microstimulation via the uninsulated distal ring of our
opposed to large electrode stimulation will result in more electrode, monophasic square wave pulses of 50 to 1.5
accurate localization. Electrical stimulation alone will mA are used. For stimulation through the electrode tip,
generally not allow reliable identification of the medial currents of 8-70 mA are used. Stimulation may be car-
thalamic nuclei because electrical stimulation elicits no ried out in a bipolar manner between the electrode tip and
detectable sensory phenomena in most patients. Thus, ring or in a monopolar manner between either the tip or
microelectrode recording is essential for medial thalamo- ring and an indifferent electrode. Stimulation frequencies
tomy to identify the target accurately. The identification of 5-300 Hz are used but most commonly 50-100 Hz is
of neurons exhibiting an abnormal bursting pattern in this used. Single pulse, multipulse trains, or continuous stimu-
location is considered a possible guide to lesioning. The lation is used.
bursting pattern is characterized by intermittent single unit
discharges with the burst frequency in the range of 2 to 6 COMPLICATIONS
per second. Individual bursts may contain as few as 2 or Medial stereotactic thalamotomy is the safest of the ste-
as many as 60 to 80 individual action potentials. Our tech- reotactic ablative procedures. Correctly placed lesions
nique has included an attempt to identify the distribution provide pain relief without any detectable change in the
of these abnormally discharging neurons and then to use patient’s sensory function. Lesions placed too far poste-
this information as a guide to lesion planning. We try to riorly may encroach on the region of the posterior com-
destroy all tissue from which such abnormal activity can missure and produce transient or (rarely) permanent eye
be recorded. movement disorders such as diplopia and limitation of
For mesencephalotomy, microstimulation is probably upward gaze. Occasional transient effects on cognitive
suitable for target localization. Microelectrode recording function usually resolve quickly, although bilateral me-
and microstimulation combined will allow for more ac- dial thalamic lesions may produce more lasting cogni-
curate target localization. tive deficits. Lesions in the lateral somatosensory nu-
clei produce an alteration in contralateral sensory
SPECIALIZED INSTRUMENTATION function which may include tactile and/or pain sensa-
The Leksell Model G stereotactic frame offers a versatile tion. Interference with proprioceptive sensation may also
instrument which is compatible with CT and MRI scan- be identified. Such lesions run a small risk of producing
ning and can be used with conventional ventriculography a deafferentation pain syndrome from interference with
as well for anatomic target localization. It can be easily somatosensory pathways.
interfaced with the appropriate neurophysiologic moni- Medial mesencephalic tractotomy is associated with
toring electrode equipment and lesioning equipment pre- a high incidence of temporary disorders of ocular motil-
viously described. The equipment necessary for electro- ity, most of which clear with time. Nashold, however, re-
physiologic monitoring includes a suitable preamplifier, ported a permanent problem with ocular motility in 16%
amplifier, and oscilloscope, and a facility for magnetic of his patients and Frank, in 13%. A mortality rate of 1.8%
taping of neuronal activity for later playback. The elec- was also reported by Frank. My opinion is that mesen-
trodes are fabricated in our laboratory from 0.01-inch di- cephalic tractotomy is associated with a significantly
ameter tungsten wire. The electrode tips are etched elec- higher complication rate than medial thalamotomy.
trically. The concentric outer sheath is made from stainless The best results with mesencephalic tractotomy have
steel tubing, and the insulation between the inner record- been reported with unilateral pain in the head and neck or
ing electrode and the outer stimulating electrode is pro- arm, although bilateral pain is occasionally controlled as
vided with an epoxy polymer resin and a 28-gauge polya- well. Bilateral medial thalamic lesions may also be re-
mide sleeve. The outer cylinder is also insulated with a quired to control either unilateral or midline pain.




INTRODUCTION reliably predict the incidence of this complication.

The treatment of odontoid fractures in which the fracture The most commonly used surgical treatment, either
occurs across the base of the odontoid process at its junc- as initial therapy or when immobilization fails, is a poste-
tion with the body of C2 (Type II) remains controversial rior fusion between the arches of C1 and C2. Depending
(Fig. 1). Early operative intervention or a period of im- on the technique this may require an additional period of
mobilization with an external device such as a Minerva external immobilization to increase the likelihood of suc-
jacket or halo vest have both been advocated. Various cess. This approach, while stabilizing the spine well, re-
authors have attempted to define the parameters which sults in elimination of the normal rotation between C1
will predict nonunion rates when these fractures are treated and C2 which accounts for more than one-half of the nor-
by immobilization. Direction of displacement, degree of mal axial rotation of the cervical spine.
displacement, and the age of the patient have been shown In contradistinction, anterior screw fixation allows
to be predictors of nonunion but the various published direct fixation across the fracture site and achieves im-
studies do not agree on absolute parameters which will mediate stability while restoring and preserving

© 1992 The American Association of Neurological Surgeons

Figure 1. A, a Type II odontoid fracture with anterolisthesis of the lateral view. B, a transoral anteroposterior (AP) view shows a fracture
odontoid on the body of C2 of approximately 5 mm is noted on the at the base of the odontoid process.

© 1992 The American Association of Neurological Surgeons


normal biomechanics of the spine. The special instrumen- techniques that avoid neck extension such as “blind”
tation described in this chapter has been developed to al- nasotracheal intubation or fiberoptic-assisted intubation
low this procedure to be performed easily, quickly, and should be utilized. In the case of anterolisthesis of the
safely. The fixation screws are made of titanium and thus odontoid which reduces in extension, no special technique
do not impede future magnetic resonance imaging (MRI) is usually required.
studies. The patient is positioned on the operating table with
a folded blanket beneath the shoulders to increase neck
PATIENT SELECTION extension. If the fracture reduces in extension, a hyper-
We initially offered the procedure to patients only after extended position is chosen (Fig. 2). If the odontoid is
failure of “conservative” measures (i.e., halo vest immo- retrolisthesed and reduces in flexion, the head is elevated
bilization). However, its demonstrated success and low and the neck is kept in a neutral position. Light halter
morbidity have convinced us that not only should it be traction holds the head immobile. A radiolucent bite
considered the operative procedure of choice but a viable block is placed to keep the jaws open and two portable
alternative to nonoperative initial management in patients C-arm fluoroscopic units are positioned to provide lat-
who are at a higher risk for nonunion. In addition, it is an eral and anteroposterior (AP) (transoral) views of the
appropriate choice for patients who, after full discussion, odontoid. If only one unit is available, it needs to be
opt for earlier intervention. rotated back and forth from the AP to the lateral posi-
tion. Freedom to achieve this movement should be en-
SURGICAL TECHNIQUE sured before draping.

Endotracheal Intubation Operative Procedure

and Patient Positioning After routine preparation and draping, a unilateral hori-
If the patient’s neck is unstable in extension, intubation zontal incision is made along a natural skin crease

© 1992 The American Association of Neurological Surgeons

Figure 2. The patient is positioned for surgery. Note the elevated thorax fluoroscopic control to avoid spinal canal compromise. Two fluoroscopic
and hyperextended neck (the patient’s fracture reduced in extension). units are used for sequential intraoperative AP (transoral) and lateral
Positioning was achieved while monitoring spinal motion under lateral fluoroscopic monitoring. Halter traction secures the head.


(Fig. 3) at about the level of the fifth cervical vertebra. serted beneath the longus colli muscle bellies bilaterally
Prior skin infiltration with a 1:200,000 epinephrine solu- and secured in the lateral retractor. These blades rather
tion will help achieve hemostasis which is then secured than the small fine-toothed blades should be used to firmly
with bipolar cautery. The platysma muscle is elevated and anchor the retractor system. Blunt dissection with a “pea-
divided and the fascia of the sternocleidomastoid muscle nut” in the retropharyngeal space quickly and easily opens
is sharply incised along the medial border of that muscle. a tunnel in front of the vertebral bodies up to C2. An angled
Blunt finger dissection then easily exposes the anterior retractor of the appropriate size is then inserted into this
surface of the spinal column at the midcervical level by space. It is attached to the retractor blade holder which in
opening natural planes medial to the carotid sheath and turn inserts into one side of the previously placed lateral
lateral to the trachea and esophagus. The fascia of the retractor (Fig. 3). This device allows angulation of the
longus colli muscle is incised in the midline and the muscle blade as needed. Note that no inferior retractor is placed.
is elevated from the vertebral bodies at about the C5-6 It is not needed and it interferes with achieving the cor-
level. This is done to allow firm fixation of the retractor rect trajectory for the approach to C2.
blades, which is important because the cephalad retractor A K-wire is then inserted through the incision up
will pull against these blades and, unless firm fixation is to the inferior edge of C2 under fluoroscopic control
achieved, may dislocate them. and impacted into the inferior edge of C2 (Fig. 4A). If
The sharp, large-toothed Caspar blades are then in- a single screw is to be placed, a midline entry site is

© 1992 The American Association of Neurological Surgeons

© 1992 The American Association of Neurological Surgeons

Figure 3. The site of the incision in the midcervical region is shown (dashed line). The inset shows the retractor in place.
Note the lack of any retractor components inferiorly which would impede achieving a proper trajectory.


© 1992 The American Association of Neurological Surgeons

Figure 4. A K-wire is inserted into the anterior inferior edge of C2 a shallow groove in the face of C3 and into the C2-3 annulus (insets B
under fluoroscopic control (inset A). A hollow-core drill is then placed and D). This should not remove any bone from the inferior edge of C2
over the previously placed K-wire and is rotated by hand (inset C) to cut (arrow, inset D).


chosen. A paramedian position about 2 mm off the mid- placed over these and the spikes of the outer guide tube are
line is used if two screws will be placed. firmly set into the third cervical vertebra (Fig. 6). This is
A hollow 8-mm drill (Fig. 4, B and C) is placed over the monitored fluoroscopically. The inner drill guide is then ex-
K-wire and rotated by hand to create a shallow groove in the tended to contact the inferior edge of C2 (Fig. 6, inset A).
face of C3 and the C2-3 disc and annulus to the inferior This is important to prevent the drill from “walking” up onto
border of C2. The drill guide system, which consists of inner C2 rather than penetrating the vertebral body.
and outer drill guide tubes that are mated together, is then Once the guide tubes are secure, the K-wire is re-
placed over the K-wire (Fig. 5). A plastic impactor cover is moved and replaced with a drill bit which engages the

© 1992 The American Association of Neurological Surgeons

Figure 5. The drill guide system consists of inner and outer guide tubes. These are mated together,
placed over the K-wire, and secured to C3 (inset).


© 1992 The American Association of Neurological Surgeons

Figure 6. A plastic impactor sleeve is placed over the drill guide assem- into C3. The inner guide tube is then advanced in the previously created
bly and the assembly Is gently tapped into place, to impact the spike trough to contact the inferior edge of C2 (inset, arrow).


starter hole made by the K-wire (Fig. 7). A right-angle The drilled hole is then tapped (threaded) (Fig. 8) by
drive is used to clear the thoracic region and a hole is then removing the drill and the inner drill guide (Fig. 8, inset A)
drilled under careful biplane fluoroscopic control from and replacing them with the tap which is manipulated by
the inferior anterior edge of C2 through the body of C2 hand while monitoring its progress fluoroscopically. The tap
and into the odontoid to its apex. This requires a low tra- also has calibration marks to recheck the depth of penetra-
jectory and may require manipulation of the head and/or tion and a sliding sheath which covers the exposed cutting
upper vertebrae to optimize alignment of the fragment tip to prevent soft tissue entanglement (Fig. 8, inset B). When
before drilling the hole. The drill guide often will assist the tap is being removed, the operator should be sure that the
with this as it allows both gentle anterior and posterior sleeve slides back over the exposed cutting edges.
displacement of the C2-3 complex. When the drill is at The screw, selected according to the measured
the apex of the odontoid its depth can be read off the cali- depth, is placed through the outer guide tube and into
bration marks on the shaft of the drill where it extends the C2 body through the drilled and tapped hole (Fig.
out of the inner drill guide (Fig. 7). For this to be accu- 9A). It is a lag screw with a nonthreaded proximal shaft
rate, the inner guide tube must be positioned properly with to allow the distal fragment to be pulled down to the
its distal end touching the inferior surface of C2 (Figs. 5, body of C2. In an acute fracture, it is placed into the
inset, and 6, inset). odontoid and tightened f irmly, as its progress is

© 1992 The American Association of Neurological Surgeons

Figure 7. A pilot hole is drilled from the inferior edge of C2 to the tip of upper surface of the odontoid. The calibration on the remaining exposed
the odontoid under biplane fluoroscopic control (inset). The illustration drill shaft indicates the depth of drill penetration and hence the length of
shows this in progress, not the final position which should extend to the the fixation screw needed.


© 1992 The American Association of Neurological Surgeons

Figure 8. The tap is used to cut threads into the bone along the pilot tive sliding sheath which protects the soft tissues when the tap extends
hole shaft after removing the inner drill guide (inset A). Note the protec- from the outer drill guide tube (inset B).


© 1992 The American Association of Neurological Surgeons

Figure 9. A, the screw is initially placed through the guide tube (not used to seat the screw fully into the odontoid. D, final position of the
shown) and then is advanced to the fracture site. B, in the circumstance screw. Note reapproximation of the odontoid fragment which is usually
of chronic nonunion, curetting the fracture site with bifaced angled seen in acute fractures but not in chronic cases. The screw head is well
curettes may enhance healing. This is not done with acute fractures. C, seated in the inferior edge of C2.
the ball driver allows screw engagement at ± 15° from its axis and is


© 1992 The American Association of Neurological Surgeons

Figure 10. Lateral (A) and AP (B) postoperative radiographs showed good reapproximation of a fractured odontoid and ideal screw position.

© 1992 The American Association of Neurological Surgeons

Figure 11. Bony bridging is demonstrated on lateral tomographic x-ray films taken at two (A) and six (B) months.


monitored fluoroscopically. Usually the fragment will be guides, drills the hole, taps the hole, and places the screw.
seen to be drawn down and reapproximated to the body No further curetting is needed. The second screw can be
of C2. The head of the screw should recess into the C2-3 either a lag screw or a fully threaded one.
annulus/disc edge or into the inferior edge of C2 (Fig. Figure 10 shows ideal screw placement on AP and
9D). lateral radiographs. The neck should be stable immedi-
For chronic nonunited fractures, the screw is placed ately. Flexion and extension of the patient’s neck under
into the body of C2 until just below the fracture site (Fig. fluoroscopy will confirm this and exclude any other un-
9B). The drill guide is then removed and special bisurfaced, recognized injury such as transverse ligament rupture or
angled curettes are used to freshen the fracture site and unstable adjacent segments. The retractors are then re-
remove fibrous tissue. This is done by forcing the tip of moved, the wound checked for hemostasis, and closure
the smaller curette through the weak anterior longitudi- completed in layers. We use interrupted absorbable su-
nal ligament at the fracture site (as monitored fluoroscopi- tures in the sternocleidomastoid muscle fascia, platysma
cally) and rotating the handle. The curette, which is angled muscles, and subcutaneous tissues, and use sterile adhe-
slightly in a coronal plane, has cutting surfaces on both sive strips on the skin. Normally we do not use drains.
its top and bottom sides. It is then replaced with the sec-
ond small curette angled in the opposite direction, which POSTOPERATIVE CONSIDERATIONS
is manipulated similarly. Then the two larger curettes are No external orthosis is needed unless there is concern about
sequentially introduced and also manipulated in the same the patient’s bone strength (i.e., osteopenia) or there are
manner. This is done to try to enhance fusion. other associated injuries which require this. Patients are
The screw head can then be reengaged in the ball observed carefully in the first 12-24 hours for any signs of
driver, which can be inserted at an angle of ±15° to the neck swelling, airway compromise, infection, or vocal cord
long axis of the screw, and tightened fully (Fig. 9C). In dysfunction. They can usually resume oral alimentation
chronic cases the fragment may not reapproximate to the within a day or two and be discharged from the hospital in
body of C2. If the screw penetrates and extends beyond a few days. They are allowed to return to normal activities
the posterior cortex of the odontoid for 1 mm or more or and work as long as these are not strenuous.
beyond its apex by 2 mm or more, it can be removed and Bone bridging is observable in two to five months in
a shorter screw substituted. acute cases but can be delayed in chronic nonunion.
Placement of a second screw is accomplished in a Tomograms are helpful to evaluate this as the relative
similar manner, using a K-wire for guidance, and an 8 density of adjacent bony structures makes early bone
mm drill to cut a groove in the anterior surface of C3 and bridging hard to detect on plain x-ray films (Fig. 11).
the C2-3 disc. As before, the surgeon places the drill


INTRODUCTION ing. The syndrome may affect one or both hands, and if
The carpal tunnel syndrome is the most common entrap- both hands are affected, the dominant hand is quite often
ment neuropathy that a neurosurgeon encounters in daily more involved than the nondominant hand. However, it is
practice. This syndrome is also treated by plastic surgeons, not uncommon to see patients with worse symptoms on
hand surgeons, orthopaedic surgeons, and general sur- the nondominant side. Some elderly patients may present
geons. Although the technique of surgery may vary to with motor atrophy involving the thenar muscles without
some extent, depending upon the specialty of the surgeon, any significant wrist pain. These individuals generally do
to obtain optimal results, one should be careful in the se- poorly with regard to motor function compared to those
lection of patients, be knowledgeable about the anatomy presenting with pain alone.
of the region, pay attention to details in the operative tech- Typically, one finds a paucity of objective findings
nique, and provide optimal postoperative care. In spite of on initial neurologic evaluation. In well over 30% of my
all these efforts, it is inevitable that 5 to 10% of individu- patients, I find no evidence of sensory or motor abnor-
als fail to improve or present with some complication. malities on careful testing. In less than 5% of individuals
These will be discussed at the end of the chapter. The there is motor atrophy involving the thenar muscles. In
goal of the treating surgeon of this common disorder is to the remainder there are varying degrees of sensory loss,
maximize favorable operative results and minimize com- especially in the tips of the thumb and index finger and
plications. less frequently in the middle finger and the lateral half of
the ring finger. The sensory loss consists of blunting of
PATIENT SELECTION pinprick and light touch sensation and impairment of two-
Operative indications are discussed based upon the clini- point discrimination at the finger tips. It is seldom that
cal picture prevalent in contemporary neurosurgical prac- one finds sensory loss extending to the remainder of the
tice. Gone are the days when patients presented with ad- digits and never to the palm of the hand. If sensory loss is
vanced thenar atrophy. The more typical presentation in a present in the dorsum of the hand, obviously one is deal-
modern setting is for a middle aged woman to present ing with a syndrome other than median neuropathy at the
with intractable pain and paresthesia in the hand that wakes wrist. Some clinicians attach a great deal of importance
her up at night. The pain is generally confined to the hand to the presence of Tinel’s and Phalen’s signs, but in con-
and is worse on the radial aspect than on the ulnar side. temporary neurosurgical practice I find these two signs
Quite often the patient may complain of diffuse aching to be of little value in making a surgical decision.
pain in the whole hand. At times, the pain radiates to the The diagnostic workup is generally tailored to the clini-
proximal forearm and even to the shoulder. A distinguish- cal presentation and the risk factors that lead to this syn-
ing characteristic of pain originating from the median drome. In the majority of individuals the lesion is idio-
nerve in the wrist is its distal to proximal progression start- pathic and therefore the only diagnostic test that is
ing at the wrist and then extending to the forearm and the performed is a nerve conduction velocity study and needle
shoulder, in contrast to the shooting pain starting at the electromyography. Prolongation of sensory latency is the
neck and radiating to the thumb and index finger that is earliest and most constant finding. Prolongation of motor
seen in C6 cervical radiculopathy. The pain is dull, ach- latency occurs next and finally denervation potentials are
ing, and constant. It is aggravated by hand motion. It seen in median-innervated muscles. Most patients that I
worsens during repetitive motion, typically during daily encounter have only prolongation of sensory conduction
household chores or at occupations such as typing or driv- velocity with minimal if any changes in the motor conduc-
tion velocity. However, one should exercise caution in se-
© 1992 The American Association of Neurological Surgeons lecting patients purely on the basis of nerve conduc-


tion velocity studies, if the clinical history is very atypi- lier, pregnant women seen in the third trimester of preg-
cal or if the patient has underlying peripheral neuropathy. nancy with a typical carpal tunnel syndrome may be
In such instances, if a surgical decision is made based on treated with reassurance and a wrist splint until the deliv-
mere prolongation of sensory conduction velocity, the ery. However, if the pain disturbs sleep at night and if
outcome could be suboptimal. patients require a narcotic agent for relief, then section of
The ideal situation is one in which the patient gives a the carpal ligament under local anesthesia might be a sim-
very typical history and demonstrates prolongation of pler alternative. Manual laborers who have a history of
sensory latency as a confirmatory finding. An especially repeated work-related injuries, present with an atypical
difficult situation is an individual who does heavy, strenu- history, have inadequate objective findings, are unhappy
ous manual labor and has what can be described as an about their occupation, and are seeking financial com-
“overuse syndrome.” If such an individual has an atypi- pensation, do extremely poorly.
cal history, has symptoms primarily from work-related A paradoxical situation arises when the patient has a
overuse, and has prolonged sensory conduction latency very typical history that suggests carpal tunnel syndrome
as a sole diagnostic criterion, the likelihood of failure from but the electrodiagnostic test is entirely negative. Such a
a surgical procedure to relieve his symptoms is probably situation is rarely seen in clinical practice, but is encoun-
quite high. Patients with diabetic neuropathy or alcoholic tered on occasion. If the clinical history and findings are
peripheral neuropathy who present with an atypical his- very typical, and if a repeated electrodiagnostic test con-
tory and have delayed sensory conduction velocity as the tinues to be negative and conservative treatment fails, in
sole diagnostic criterion are borderline candidates for such instances it is justifiable to proceed with a surgical
surgery. They should be advised that median neuropathy section of the carpal ligament as both a diagnostic and a
may be part of a generalized process; compression of the therapeutic measure.
nerve probably plays a modest role and surgical therapy
may not offer complete relief. SURGICAL ANATOMY
Although most patients have carpal tunnel syndrome The carpal tunnel is situated in the proximal part of the
on an idiopathic basis, some underlying risk factors should palm of the hand, limited by the wrist crease proximally.
be carefully assessed. Women should be questioned about It is well to emphasize that the entire carpal tunnel lies
pregnancy. Because carpal tunnel syndrome is a transient distal to the wrist crease in the palm of the hand. Indeed,
event during third trimester pregnancy, surgical therapy one is surprised to see instances where patients have been
can generally be withheld until delivery occurs; symp- referred for “recurrent carpal tunnel syndrome” when in
toms then ordinarily resolve spontaneously. Patients on fact the operative scar lies entirely or nearly entirely proxi-
contraceptive pills may be prone to carpal tunnel syn- mal to the wrist crease in the distal forearm.
drome. Rheumatoid arthritis is the most common, most The carpal tunnel is bounded dorsally by the carpal
obvious primary factor that leads to entrapment of the me- bones and ventrally by the transverse carpal ligament. The
dian nerve at the wrist. One should make certain that the carpal bones form a shallow trough which is completed
affected individuals are adequately treated for their sys- into the tunnel by the carpal ligament. Recent studies,
temic disease before surgical therapy is undertaken. If an magnetic resonance imaging (MRI) and computed tomog-
obvious endocrinopathy such as myxedema or acromegaly raphy (CT) scans, have shown that individuals who are
is detected during the clinical examination, the underly- predisposed to be afflicted by the carpal tunnel syndrome
ing process should be addressed first before the carpal tend to have small carpal canals. The small size of the
tunnel syndrome is dealt with surgically. An orthopaedic carpal canal as evidenced by the decrease in its cross-
opinion should be sought if the patient has a malunited sectional diameter is a congenital or developmental phe-
fracture or excessive callus related to the carpal bones or nomenon. The smaller size in women may account for
the distal end of the radius. A conservative approach the higher incidence of carpal tunnel syndrome in them.
should be practiced in individuals in whom the carpal tun- Among individuals who pursue the same occupation such
nel syndrome is of short duration or is of mild and inter- as truck driving or electrical maintenance, only a small
mittent nature, or if there is a reversible pathology. Typi- percentage develop carpal tunnel syndrome. It is conceiv-
cally, individuals who are accustomed to a sedentary able that congenitally small size of the carpal canal pre-
occupation but do heavy manual labor through a long disposes them to have the median entrapment neuropathy
weekend may present with a typical carpal tunnel syn- even though they are exposed to the same risk factor. I do
drome the following week. Such individuals should be not recommend routinely measuring the cross-sectional
treated with rest, a wrist splint, and nonsteroidal anti-in- area of the carpal canal by computed tomography.
flammatory agents before any diagnostic workup or sur- The contents of the carpal tunnel are the median
gical therapy is undertaken. Similarly, as indicated ear- nerve and the long flexor tendons including their syn-


ovial sheaths. Any lesion affecting the tendons or their arm is prepared up to the elbow using a povidone iodine
synovial sheaths tends to compromise the carpal canal soap for 10 minutes followed by a 2-minute paint with
and may produce compressive neuropathy. In a similar povidone-iodine solution. Draping is carried out using
manner, old healed fractures of the carpal bones with waterproof sheets with a central opening. The hand is kept
exuberant callus may also produce the syndrome. The in the supine position with all the digits outstretched, and
ulnar nerve is outside of the carpal canal and thus is not an iodine-coated clear plastic adhesive drape is laid over
subject to compression by the carpal ligament. The same it. This adhesive drape maintains the hand in the out-
applies to the palmar cutaneous branch of the median stretched position and thus one does not require any spe-
nerve and the corresponding palmar cutaneous branch cial devices to keep the hand outstretched. The patient is
of the ulnar nerve. The most significant part of the monitored with an automatic blood pressure cuff, an elec-
anatomy is the motor branch of the median nerve which trocardiographic monitor, and a digital oximeter. The an-
arises immediately under the carpal ligament near its esthesiologist maintains conversation with the patient
distal broader and supplies the thenar muscles. Numer- throughout the procedure to assess the level of comfort
ous variations of the motor branch have been described; and make sure there are no untoward complications. Pa-
however, if one follows the technique described in this tients may request to observe the operation but this is not
chapter it is seldom that the motor branch of the median allowed.
nerve will be exposed. The less dissection of the nerve,
the less morbidity there is with regard to nerve injury.
Anesthetic Technique
PREOPERATIVE PREPARATION The administration of anesthesia for section of the carpal
Section of the carpal ligament is usually done as an ligament is an integral part of the operative procedure.
outpatient procedure. If the patient has bilateral carpal The anesthetic technique is therefore described in some
tunnel syndrome, a decision has to be made whether to detail. There are three choices of anesthesia. The first is
section both ligaments in the same sitting or in two sepa- local infiltration anesthesia, the second is a Bier block,
rate sittings. This is usually decided after discussion and the third is general anesthesia. Local anesthesia is
with the patient, taking into account her or his personal the technique I prefer because of its simplicity and rapid-
preference. If the patient is very anxious to return to ity. General anesthesia is reserved for individuals who
work and not miss any work days, has sufficient house- are extremely apprehensive and do not wish to go through
hold help, and wishes to have the bilateral procedure, any procedure under local anesthesia.
this request may be complied with. Elderly individuals
living alone with no household help ordinarily prefer
to have the operations done in two separate sittings. Local Anesthesia
The patient is asked not to eat or drink after mid- For local anesthesia, I use 1% lidocaine without epineph-
night preceding the day of surgery although the proce- rine. It is important not to use epinephrine because of the
dure is done with local anesthesia. The patient is in- potential of spasm of the digital arteries which may lead to
structed to scrub the hands with a detergent containing ischemia of the fingers, perhaps even to the point of gan-
either povidone-iodine or chlorohexidine for two con- grene. Using a small-gauge needle (25-gauge) and a 10-ml
secutive days before surgery and on the morning of syringe, the skin is penetrated at the middle of the pro-
surgery. This is particularly important in individuals posed incision, and utilizing the same skin puncture the
with dirty, greasy hands from their employment, such infiltration is started subcutaneously and extended up to
as gas station attendants, auto mechanics, painters, and the limits of the incision and for about 1 cm beyond the
construction workers. Two hours before surgery, the proposed incision line. The advantage of infiltration be-
patient is administered a tranquilizing agent as premedi- yond the proposed incision line is that when the self-re-
cation. Two milligrams of lorazepam with a sip of wa- taining refractors are applied, the edges of the wound un-
ter has worked well for this purpose. The patient is ac- dergo traction and this may be painful if the infiltration is
companied by a relative or friend who can drive the not carried out beyond the wound edges. Generous amounts
patient home after surgery. of the anesthetic agent are used, usually 10 to 12 ml of
lidocaine. The infiltration is carried to the level of the trans-
SURGICAL TECHNIQUE verse carpal ligament but not any deeper. If the infiltration is
carried deep to the transverse carpal ligament, the patient
Positioning and Draping will get anesthesia in the distribution of the median nerve
The patient is positioned in a supine position with the and may be alarmed postoperatively to find dense anesthe-
arm outstretched on a well-cushioned arm board. The sia in the distribution of the median nerve. Although this


has no untoward consequences, the patient may have to formation of a hematoma or retrograde leakage of the an-
be reassured that this a reversible process. algesic agent from the puncture. By the time the surgical
scrub is completed, the patient will have surgical analgesia
Bier Block in the part to be operated upon. The distal tourniquet is left
A Bier block is a simple, elegant, and effective technique on and the proximal tourniquet is released. Thus the pa-
if used properly. The patient is connected to appropriate tient should not feel any tourniquet pressure. At the comple-
monitoring devices, including a pulse oximeter, cardiac tion of the procedure, the distal tourniquet is released and
monitor, and automatic blood pressure cuff. He or she taken off. The patient should be observed carefully to make
receives oxygen through a nasal cannula. A 20-gauge plas- sure there are no adverse effects from absorption of the
tic cannula is inserted into one of the dorsal veins of the anesthetic agent such as seizures, tingling, perioral numb-
hand, well away from the proposed tourniquet applica- ness, ringing in the ears, etc.
tion site. The arm is first elevated and held up from 1 to 2
minutes to facilitate drainage of all venous blood. An elas- Operative Technique
tic rubber Esmarch bandage is then applied from a distal The skin incision extends generally from the wrist
to proximal direction to further facilitate exsanguination crease distally in a slightly curvilinear manner toward
of the extremity. A special double tourniquet is then ap- a point that is in line with fully abducted thumb (Fig.
plied over the mid-arm over a piece of felt. This double 1). If the incision is extended distal to this point, there
tourniquet is especially designed for the Bier block. The is a risk of injuring the superficial palmar arch. In
proximal tourniquet is inflated first, and after the injec-
tion of the anesthetic agent, the distal tourniquet is in-
flated which does not cause any discomfort because the
pressure is against an already anesthetized area. The proxi-
mal tourniquet is then deflated. The Esmarch bandage is
It is imperative to make sure that the upper tourni-
quet is inflated before injecting any anesthetic agent
through the plastic cannula; as a confirmatory sign, one
should not feel any radial pulse and the palm of the hand
should appear blanched. The patient may have a tight sen-
sation under the tourniquet but this is quite tolerable.
Before injecting any medication, one also has to make
sure that the distal tourniquet is released. The most com-
monly used anesthetic agent is 0.5% lidocaine without
epinephrine; 50 ml of 0.5% lidocaine is slowly injected
through the plastic cannula over a period of 2 minutes. If
the plastic cannula had been placed close to the elbow in
the cephalic or cubital vein and if the local anesthetic agent
is injected too rapidly, there is a risk that the anesthetic
agent may escape the tourniquet pressure and be absorbed
systemically. To avoid this systemic absorption, it is im-
perative that the plastic cannula be placed as far distal in
the extremity as possible and the injection must be car-
ried out as slowly as possible. It is important to keep in
touch with the patient to make sure there are no adverse © 1992 The American Association of Neurological Surgeons

symptoms from systemic absorption such as dizziness,

Figure 1. The skin incision extends from the wrist crease in the
perioral tingling, seizures, etc. midpalm to a point in line with the fully extended thumb (horizontal
It takes approximately 5 to 7 minutes for the analgesia dashed line). An optional extension may be carried into the distal fore-
to take effect after the injection of the lidocaine. Then the arm (curvilinear dotted line) to facilitate exposure of the proximal part
plastic cannula is removed and the surgical scrub is started. of the transverse carpal ligament and the distal part of the deep fascia
of the forearm. Note that the main skin incision is not in the palmar
A little pressure is applied over the injection site to prevent skin crease but just medial to it.


fact, there is no need to extend the incision beyond this As soon as the skin incision is completed, exuberant
point because the distal edge of the transverse carpal liga- subcutaneous fatty tissue protrudes through the incision
ment is well within this limit. Proximally, the skin inci- (Fig. 2). Multiple cutaneous and subcutaneous bleeders
sion stops at the wrist crease but an optional extension are coagulated with bipolar cautery. At this stage, digital
can be carried into the distal forearm in a curvilinear pressure on the margins of the wound also facilitates con-
manner to facilitate exposure of the most proximal part trol of the bleeding. Initially, hand-held small rake refrac-
of the transverse carpal ligament. If the extension across tors are used to retract the skin margins, and the subcuta-
the wrist is decided upon, it should not be extended in a neous tissue is carefully divided in the midline, exposing
straight line across the wrist crease because that may re- the palmar aponeurosis (Fig. 3). The palmar aponeurosis
sult in a scar crossing the wrist joint, resulting in a re- is a fanshaped expansion into the palm of the palmaris
striction of motion and wrist pain. If the incision is made longus tendon. It flares out into thin, silvery fibers which
close to the middle of the palm, then there is much less are generally transparent and sparse. The palmar aponeuro-
risk of injuring the palmar cutaneous branch of the me- sis divides into multiple slips coursing toward the digits;
dian nerve which is further lateral and the palmar cutane- thus, their fibers become further separated as they are
ous branch of the ulnar nerve which is further medial. traced distally. The palmar aponeurosis is divided in line
Also one should make every effort not to place the main with the skin incision and retracted laterally. This exposes
incision within the palmar skin crease itself. The skin the transverse carpal ligament (Fig. 4).
crease in the palm of the hand forms a natural hinge to The distal part of the transverse carpal ligament
the thumb which should not be interfered with. Also, an is more apparent and a faint edge of the transverse
incision made in the skin crease within the palm does not carpal ligament can be seen blending with the palmar
heal as readily as do incisions made elsewhere. fascia. Proximally, the transverse ligament is ob-

© 1992 The American Association of Neurological Surgeons

Figure 2. Protrusion of exuberant palmar subcutaneous fat after the skin incision is made.


© 1992 The American Association of Neurological Surgeons

Figure 3. Exposure of the palmar aponeurosis.


© 1992 The American Association of Neurological Surgeons

Figure 4. Exposure of the transverse carpal ligament after midline sec- is covered over by the hypothenar and thenar muscles. In many instances
tion and retraction of the palmar aponeurosis. The distal margin of the (not shown in this illustration) they may meet and interdigitate in the
transverse carpal ligament is faintly visualized blending with the deep midline, blocking the transverse carpal ligament from view.
fascia of the palm. The proximal part of the transverse carpal ligament


© 1992 The American Association of Neurological Surgeons

Figure 5. The distal 80% of the transverse carpal ligament has been divided, exposing the median nerve. Note the constant fat
globule superficial to the median nerve at the distal end of the exposure.


scured by the origins of the hypothenar and thenar muscles are divided. This exposes the epineurium of the median
from the ligament itself. Quite often these two muscles nerve which is smooth, broad, and unmistakable. The
interdigitate across the midline such that the transverse operation is not complete until the most proximal part of
carpal ligament itself is not visualized. Thus, during the the transverse carpal ligament is divided and the deep
process of sectioning the transverse carpal ligament in its fascia of the forearm is encountered and part of the latter
proximal part one may have to go through the origin of is divided as well. Exposure of the proximal part of the
these two muscles in the midline. The section is started transverse carpal ligament is facilitated by strong retrac-
distally with a No. 15 blade knife. The first structure en- tion of the proximal part of the wound and undermining
countered is a small but constant pad of fat which covers the skin and subcutaneous fat superficial to the transverse
the distal part of the median nerve (Fig. 5). The incision carpal ligament (Fig. 6). At this point, extension of the
is then carried proximally using a sharp scissors; the trans- skin incision can be made for about a distance of 1 cm
verse carpal ligament in its proximal part along with the into the forearm if necessary. The proximal part of the
muscular origins of the hypothenar and thenar muscles transverse carpal ligament is then divided as well as

© 1992 The American Association of Neurological Surgeons

Figure 6. Proximal skin is being undermined with retraction to facilitate exposure of the proximal part of the transverse carpal ligament.


the distal-most part of the deep fascia of the forearm (Fig. POSTOPERATIVE CARE
7). This will expose the median nerve from the distal fore- A fluffy dressing and a 4-inch gauze bandage are applied.
arm all the way to the distal part of the transverse carpal Additionally, a 4-inch Ace bandage is applied snugly. The
ligament. After ensuring that no part of the ligament has Ace bandage is kept on for 6 hours and then removed. The
been left uncut, further hemostasis is obtained by bipolar patient is encouraged to use the fingers within the limits of
coagulation. No attempt is made to dissect the epineu- pain. However, heavy lifting and vigorous movement are
rium of the median nerve because this tends to cause neu- avoided. Patients are instructed not to get the incision wet.
rological impairment. The subcutaneous tissue is closed Because the palmar skin is slow to heal, sealing of the inci-
with 2-0 polyglycolic acid sutures and the skin with in- sion does not occur for several days. If the patient gets the
terrupted 4-0 nylon sutures. No drain is used. incision wet, water may seep into the wound and may

© 1992 The American Association of Neurological Surgeons

Figure 7. Section of the most proximal part of the transverse carpal ligament and the distal deep fascia of the forearm.


cause infection. The dressings are changed at 1 week and wrist through their job are less likely to improve, although
sutures are removed anywhere from 10 to 14 days after they may have a genuine intention to return to work.
the surgery. In patients with thick, callused skin, sutures Two major complications that can occur are wound
may be left in for an additional period if necessary. If infection and wound dehiscence. Wound infections are
there is any question, additional sterile paper tape may be not generally related to interoperative contamination be-
applied across the incision after the sutures are removed. cause of the very short operative period. They are most
probably related to lack of preoperative cleanliness, fail-
COMPLICATIONS AND RESULTS ure to prepare the skin for 10 minutes, or poor postopera-
With proper patient selection and the technique described tive care. If wound infection does occur, it can be treated
above, favorable results with resolution of virtually all with appropriate antibiotics without opening the wound.
symptoms are to be expected in over 90% of the cases. If this does not resolve, the skin sutures alone may be
However, there is an irreducible minimum number of pa- removed and wet soaks may be applied. At a later date
tients in whom the results are suboptimal. This comes secondary closure may be done. Deep wound infections
about in several clinical settings. In elderly patients who are rare.
may have associated wrist arthropathy, the pain relief may Dehiscence of the wound is most likely to occur in
not be complete. The pain seems to originate from two individuals with very thick palmar skin with calluses.
sources; one from median nerve compression and the other In such instances, the sutures may be left in for much
from degenerative arthropathy of the wrist. The second longer than 2 weeks if necessary, and sterile paper strips
situation concerns patients with advanced diabetic or al- may be applied after the suture removal to facilitate fur-
coholic peripheral neuropathy. In such instances neuro- ther healing.
logic recovery may not be complete because compres- Painful neuromas of the palmar cutaneous branches
sion of the median nerve is only one element in the disease of the median nerve and the ulnar nerve should not occur
process. Patients who do heavy manual labor and return if the incision is placed precisely in the middle of the palm
to the same kind of work as they did before surgery, gen- as described. Such neuromas tend to occur with trans-
erally tend to have a less favorable outcome and less com- verse and oblique incisions. Injury to the motor branch of
plete relief than those who have a less strenuous job. Pa- the median nerve occurs only in situations where the
tients with job-related injuries with a potential for financial median nerve is exposed and all its branches are traced.
gain may not improve and their postoperative course may The less exploration that is done beneath the carpal liga-
be prolonged. Patients with “overuse” syndrome who do ment, the less is the likelihood of injury to the median
extremely strenuous work and continuously abuse their nerve or to its branches.




THE DISEASE to accommodate the globe to the increased tissue volume

Graves’ ophthalmopathy is usually related temporally to in the orbit. Only when the anterior protrusion reaches a
hyperthyroidism but can be seen in euthyroid or hypothy- point where there are other problems is there a need for
roid individuals. The diagnosis seldom presents a chal- treatment. Because the muscle myopathy is the basic pa-
lenge with classical orbital changes or overt hyperthy- thology, muscle dysfunction can be a problem if there is
roidism, but in clinically euthyroid patients with asymmetry in the muscle disease. The result is diplopia.
asymmetric proptosis the diagnosis can be elusive. The The extremes of the disease are optic neuropathy with
most helpful signs here are lid retraction or lid lag. We visual loss and visual field defects. The degree of both
have also noted a temporal flare of the upper lid which can vary from minimal to serious or even total loss of
seems characteristic of thyroid eye disease. Other features vision. Corneal exposure is listed as a common problem
of ophthalmopathy include orbital congestion (injection in Graves’ ophthalmopathy. In fact, this seems to be rare.
and chemosis of the conjunctiva and lid edema), myopa- Of over 450 patients treated by orbital decompression,
thy, and optic neuropathy with or without proptosis. None only a few had corneal exposure and ulceration.
of the eye signs is pathognomonic of thyroid eye disease. The visual loss and the degree of proptosis seem in-
At times the diagnosis is made or confirmed with the thy- versely related. That is, in patients with severe proptosis
roid-stimulating hormone (TSH) suppression test for sub- there is usually little or no visual loss. This illustrates the
clinical hyperthyroidism. Another newer laboratory test observation that exophthalmos is in fact a natural ante-
is the TSH serum analysis which more easily will give rior orbital decompression. In some patients there is ex-
the same information. treme proptosis with no congestion, diplopia, or visual
Orbital imaging (computed tomography (CT) scan) loss. To them the problem is cosmetic and practical. Their
usually shows enlarged extraocular muscles which are the eyes are too obvious and at times touch their glasses.
principle cause of proptosis. The inferior rectus is usually
the first muscle involved, followed in order by the medial THE ISSUES
rectus, superior rectus, and lateral rectus muscles. Because There is no consensus of opinion concerning: 1) whether
of congestion at the orbital apex, it is possible to image a the orbital space should be enlarged; 2) the indications
dilated superior ophthalmic vein in Graves’ ophthalmopa- for enlarging the space; 3) the sequence of therapy that is
thy. The muscle enlargement is fusiform with sparing of most successful in restoring the eyes to near-normal; 4)
the tendinous insertions. This finding in combination with the value of mechanical enlargement of the space; 5) the
the characteristic muscle enlargement distinguishes nonsurgical alternatives that are useful in seriously af-
Graves’ ophthalmopathy from other entities such as or- fected patients; and 6) who (what specialty) should en-
bital myositis. A bulging orbital septum from protruding large the space.
fat is another useful CT finding. With the variable clinical scenarios there can be no
The eye findings of Graves’ ophthalmopathy vary single treatment. The ideal treatment would be to identify
from mild protrusion, which may be attractive, to a stare. the process that causes the muscle enlargement and re-
The anterior protrusion of the eye is the only natural way verse it. This is not possible at this time. Current therapy
includes soothing words and lubricating eye drops, oral
© 1992 The American Association of Neurological Surgeons steroids, orbital radiation, and orbital decompression.


Graves’ ophthalmopathy is a bilateral disease. It may be Because of the perceived magnitude of a frontal cran-
asymmetric and appear to be unilateral. Both eyes are not iotomy, use of this operation has been restricted to the
affected equally at the same time. Careful measurements most extreme manifestations of Graves’ ophthalmopathy
of the exophthalmos almost always show that the normal- and it is not offered to patients with lesser symptoms and
appearing eye measurement exceeds the extreme of the signs or to those who need only cosmetic decompression.
range of normal in unaffected individuals. The normal-ap- The pterion can be exposed through an incision an-
pearing eye is unlikely to stay that way. This observation is terior to the ear in a hair-bearing area, and the fibers of
important when a patient with asymmetric disease is con- the temporalis muscle split to approach the anterior and
sidered for orbital decompression. It makes little practical middle cranial fossae to remove the superior and lateral
sense to decompress only the more involved eye in what is walls of the orbit. It is possible to do both sides at the
a bilateral process. In the 450 patients decompressed by same session but usually the procedure is done on one
the author, unilateral decompression was performed twice side only. The inferior approach is the most often used
and in both that decision was later regretted. today. This can be done either transantrally or
transorbitally. Removing bone inferiorly and medially is
ORBITAL DECOMPRESSION logical because the greatest area of bone can be accessed
The concept of orbital decompression is simple. There is through a single incision, both sides can be done at one
too much tissue in a bony space and either tissue must be session, and the morbidity is similar to that of sinus sur-
removed or the space made larger when the excessive tis- gery. The transantral approach enlarges the orbital space
sue causes problems. Removal of tissue is not practical, to use the actual space of the antrum and ethmoid sinuses,
so the space must be enlarged. There are as many ways to whereas the superior, lateral, and pterional approaches
enlarge the space as there are bony walls in the orbit. The decompress into potential spaces only.
superior wall is the orbital plate of the frontal bone which It is appreciated that ocular protrusion is only one
can be approached from the anterior cranial fossa and is manifestation of Graves’ ophthalmopathy. Enlarging the
the basis of the transfrontal decompression. The lesser orbit will correct and in some cases eliminate proptosis.
and greater sphenoid wings and the zygomatic bone form In the process, most patients will experience improve-
the lateral wall; the maxilla lies inferiorly; and the paper ment of vision and reduction or elimination of visual
plate of the ethmoid and the lacrimal bone lie medially. field defects (see below on vision). The muscle myopa-
The lateral approach was the first one used for or- thy is an unknown before decompression and will re-
bital decompression. Dollinger, in 1910, removed the lat- main so after decompression. All affected muscles may
eral wall, leaving the lateral rim intact. This is the same return to their pre-disease state, or only some, or none
procedure Kronlein used to remove orbital tumors, and at all. Recovery of the muscles depends on the duration
the approach has his name. The lateral approach has been and degree of the myopathy; all muscles do not recover,
favored by ophthalmologists. There is little published on or if they do they do not always do so to the same de-
this approach, reflecting its infrequent use. gree. For this reason muscle imbalance and diplopia may
The superior approach prototype is through the ante- remain after the eye returns to a more normal position,
rior cranial cavity and is called the Naffziger operation. and muscle surgery may be needed to restore balanced
Another superior approach is the pterion approach de- vision. It is not an uncommon experience to see postop-
scribed by Welti and Offret. A craniotomy to decompress erative diplopia where none existed before in patients
the orbit may seem at first glance to be excessive until with severe visual loss. As vision returns it is double;
one appreciates the natural progression of serious oph- this is looked on as a positive benefit as compared to no
thalmopathy and the limited options. There are several vision. However, for total rehabilitation, muscle balance
published series of transfrontal orbital decompression with should be restored.
significant numbers of cases. Naffziger reviewed his over- Retraction of upper, lower, or both lids is a near-uni-
all experience with 40 cases in 1954. Poppen reported on versal problem in Graves’ ophthalmopathy. After decom-
66 patients in 1950 and MacCarty and colleagues col- pression, this problem remains and the cosmetic appear-
lected data on 46 patients. The results of this operation ance is not satisfactory in all cases. This can be corrected
are generally good. Visual loss is stabilized or improved by appropriate lid lowering for the upper lids and lid rais-
and the appearance is satisfactory. There is usually pulsa- ing for the lower lids. After muscles and lids are restored,
tion of the eye from transmitted dural pulsations. There unsightly lid skin can remain. Rarely, upper and lower lid
are comments about morbidity in the published reports blepharoplasty is needed.
but no reported deaths following the operation. The logical sequence for total rehabilitation then


seems to be: 1) decompression, 2) extraocular muscle be rendered euthyroid. If urgent decompression is required,
surgery, 3) lid surgery, and 4) lid skin surgery. hyperthyroidism can be controlled with propranolol.
Eye studies should include both uncorrected and cor-
TREATMENT PLANNING rected acuity measurements, exophthalmometer readings,
The technical aspects of orbital transantral decompres- assessment of extraocular and levator muscle function,
sion are straightforward and well within the capability of palpebral fissure measurements, ocular tension measure-
the otolaryngologist who is comfortable with antral and ments, and a complete funduscopic examination. Patients
ethmoid surgery. There are a number of technical details with visual loss that is not correctable with lenses require
that seem to make the difference between a successful visual field assessment. The field measurements docu-
operation and a disappointing one. If the surgery was all ment the seriousness of the eye problem and provide an
that was required, the otolaryngologist’s role would be objective base line for determining the effectiveness of
simple: operating, supervising the convalescent period, the operation.
and then stepping aside. Patient and professional satis- X-ray films of the sinuses are not needed if there is
faction require more than this. no history of sinus disease. Sinus films are really not of
The patient with Graves’ ophthalmopathy who is a much help even when there is a history of sinus disease
candidate for orbital decompression requires considerable because the actual state of the cavities is determined at
counseling. He or she must be provided with the insight surgery. Membrane thickening and polypoid disease are
into the rationale, risks, and limitations of the procedure not contraindications for decompression as these can be
to attain a realistic feeling for the probability of benefit treated at the time of decompression. Computed tomog-
from decompression for the specific problem. The pa- raphy scans are interesting but are only useful when the
tient also needs to know that the operation does not solve diagnosis is not certain. Then the typical muscle changes
the basic problem, that simply enlarging the orbital space are observed and the diagnosis is secure. Another excep-
will not provide total rehabilitation, and that other efforts tion where the CT scan is helpful is in the asymmetric
with muscles, lids, and skin may be needed. If the patient’s exophthalmos patient who does not have a history of hy-
expectations for improvement exceed the potential of the perthyroidism and the less involved eye proptosis mea-
operation, this should be discovered preoperatively. surement falls within the range of normal.
The surgeon’s goals and those of the patient must be Patients who are receiving corticosteroids systemi-
compatible. For example, a young woman with disfigur- cally or who have taken these drugs during the previous
ing proptosis as well as vision-threatening effects of oph- nine months require special precautions during and after
thalmopathy must be aware that the purpose of the opera- the operation. It has been our policy to prepare these pa-
tion is vision preservation, not cosmetic improvement and tients with either an intramuscular injection of 200 mg of
that her appearance after a successful decompression may cortisone acetate the evening before surgery and the morn-
be less than perfect and may never be what it was before ing of surgery or at least 40 mg of prednisolone during
the disease began. When each party to this operation has surgery and tapering oral corticosteroids during the post-
different ideas of what constitutes success, both will be operative period, the dosage of which is related to the
disappointed. The patient needs to know that a neurosur- patient’s previous intake.
geon or an otolaryngologist operating for an eye disease
is not an eye doctor but is only serving a technical role. SURGICAL TECHNIQUE
The surgeon must also realize that he or she is function- Complete decompression is possible only if a complete
ing as a consultant to the ophthalmologist and endocri- ethmoidectomy is accomplished. This point cannot be over-
nologist. One who gets involved with the treatment of emphasized. The need for a complete ethmoidectomy is
Graves’ ophthalmopathy will encounter problems that are one concern we have about attempting to do a transantral-
beyond the scope of any one specialty. It is far better to ethmoidal orbital decompression through approaches more
approach these patients as a team where the ophthalmo- familiar to the ophthalmologic surgeon via the conjuncti-
logic experts will take over after the orbit is enlarged to val route. There is a belief that the same bone removal can
carry on whatever further rehabilitative efforts are needed. be accomplished this way as through the sinuses. This is
not true. In the cases that have been redecompressed after
PREOPERATIVE EVALUATION anterior orbital approaches it was obvious in each that there
The preoperative evaluation involves endocrine and oph- was an inability to do a proper posterior ethmoidectomy.
thalmologic studies. If time permits (if the eye situation is Perhaps this area cannot be reached or the inexperience in
not an emergency), patients with hyperthyroidism should this area leads to a timid approach. Unfortunately, a


few operations redone were nothing but little blow-out Incision

fractures of the medial orbital floor. This is not an orbital A standard sublabial incision for anterior antrostomy ex-
decompression. It is our opinion that the incidence of in- poses the face of the maxillary antrum (Fig. 1). Bone is
adequate decompression is higher with the anterior ap- removed anteriorly up to the infraorbital rim and neu-
proach than with the transantral operation. This has tem- rovascular bundle. The microscope is introduced and the
pered our enthusiasm for the anterior approach, and we ethmoid sinuses are entered with a punch instrument
select the transantral operation for patients who need or- (Fig. 2). The precise point of entry is one-half the dis-
bital decompression. tance from front to back at the junction of the superior
medial antral wall. The angle of entry is about 45° up-
Position ward, directed to the medial canthus of the opposite eye.
The patient is placed on the operating table in the supine The ethmoid cells are then gently crushed and removed
position with about 15° of reverse Trendelenburg (i.e., up to the cribriform plate and back to the sphenoid si-
sitting slightly up). This allows more comfort for the sur- nus with the ethmoid exenteration instrument (Fig. 3).
geon and the assistant in relationship to the operating One can estimate the angle between the cribriform area
microscope which is used in all cases (300-mm lens). and the roof of the ethmoid capsule from front to back,
remembering that with the head slightly up, the poste-
Operating Microscope rior cribriform is lower than the anterior cribriform. The
The microscope provides two benefits: 1) it permits the bone of the cribriform plate is easily visualized and can
assistant to observe directly through a side piece or tele- be protected by working away from it with the instru-
vision monitor, and 2) the brilliant light and magnifica- ments rather than toward it. The decompression is not
tion make the operation easier and safer. adequate unless the level bone of this structure is visu-
The eyelids are stitched together and the eye is left alized. The most anterior ethmoid cells are not visual-
undraped. ized directly and these must be removed to complete

© 1992 The American Association of Neurological Surgeons

Figure 1. The standard sublabial “Caldwell-Luc” incision. A preliminary knife will allow a relatively bloodless start. The incision is made down to
injection with Xylocaine-adrenaline solution and the use of the cautery the bone and the soft tissue is elevated up to the infraorbital nerve.


the ethmoidectomy. After observing many residents learn- If there is bleeding from the anterior or posterior
ing this procedure, we realize that this is the most often ethmoid arteries, the easiest thing to do is to pack this
neglected site of the ethmoidectomy. temporarily with a cottonoid pledget soaked in epi-
An adequate complete ethmoidectomy can be esti- nephrine solution and go on with something else. The
mated if the ethmoid capsule will easily accommodate bleeding will settle down or gentle cautery can be
three 0.75-inch cottonoid strips soaked in epinephrine applied.
solution. If the three strips do not fit easily in the ethmoid Cerebrospinal fluid (CSF) can be seen to flow occa-
capsule, the ethmoidectomy is not complete. This is an sionally. This is no cause for alarm. A patch of antral
important clue to the technique. mucosa can be laid over the site of CSF leakage and

© 1992 The American Association of Neurological Surgeons

Figure 2. Entering the ethmoid sinuses. The ethmoid sinuses are en- at the junction of the medial maxillary wall and the roof of the sinus.
tered by a puncture at the midpoint between the front and the back and The key to a successful decompression is a complete ethmoidectomy.


© 1992 The American Association of Neurological Surgeons

Figure 3. The relationship between the roof of the ethmoid and the up to the solid bone of its roof. Otherwise, vertical pieces of bone will
floor of the anterior fossa. The ethmoid labyrinth must be exenterated restrict the decompression.

held in place with a bit of Oxycel cotton to stop the leak. medial to it. If extreme proptosis is an issue, the orbital
To my knowledge only one patient in more than 400 re- fat can be teased out of the orbit to increase the decom-
quired repair of a CSF leak after decompression. pression. This can be done by looking at eye position while
teasing out the fat. If there is a lesser amount of exoph-
Removing the Paper Plate of the Ethmoid thalmos present this is not done. In other words, the op-
and Orbital Floor eration can be tailored to the patient’s needs.
After the ethmoidectomy is completed, the bone of the One of the major technical difficulties is retraction
orbital floor is fractured away with a small curette or chisel. of the sublabial incision to get proper exposure of the or-
The bone is usually very thin medial to the course of the bital floor and ethmoid. We have tried a number of the
infraorbital nerve and will come away without difficulty. available self-retaining retractors and we have designed a
The bone around the nerve and lateral to it should also be few ourselves. None work well for us, and the best we
removed. Lateral to the nerve the bone is much thicker, can recommend is a hand-held Army-Navy retractor and
and a sphenoid punch-type instrument is useful. Likewise, a patient and steady assistant.
the thicker bone just behind the infraorbital rim (the rim The same procedure is done on the other eye during
is not removed) is easier to remove with the sphenoid the same session. It is inadvisable to perform a unilateral
punch. After the bony floor is removed, the paper plate of decompression.
the ethmoid can be fractured into the ethmoid capsule Decompression should be immediate; if it is not,
after removing the pledget. After rinsing out the bits and something is wrong. In most instances, orbital fat fills
pieces of bone, the orbital fascia (Fig. 4) is slit (Fig. 4, the ethmoid completely and the antrum in the upper half.
inset). This is done by placing a long-handled knife as far Occasionally one can see very large muscles and less fat.
forward and as far up as possible in the ethmoid and in- These cases do not decompress as well.
cising the periorbita as far back as possible. Succeeding At termination of the procedure, bilateral inferior
cuts are made more laterally. By working from the eth- nasal antral windows are placed for drainage.
moid medially to the antrum one can maintain direct vi-
sion. Going the other way puts orbital fat in the way. Usu- POSTOPERATIVE CARE
ally the fascia is incised in two places medial to the If packing is placed in the nose after the operation, it can
infraorbital nerve and one slit is made lateral to the nerve. be removed the next day. The patient is usually hospital-
At times the nerve is far lateral and all the slits are made ized for two or three days.


© 1992 The American Association of Neurological Surgeons

Figure 4. The appearance of the periorbita prior to its incision. In- cross-hatching is elective depending on the degree of proptosis. The
set, the pattern of slits into the periorbita. The first slit begins poste- usual decompression fills the ethmoid completely and the antrum in
rior and high. Subsequent slits progress from medial to lateral. The its upper half.

If there is diplopia after surgery, a clip-on lens occluder that Because of the short hospital stay, few complica-
can be alternated from eye to eye is helpful. It is best to delay tions, and the high percentage of satisfied patients when
any muscle surgery for six weeks to two months because selection is careful, the transantral orbital decompres-
changes in muscle position may continue for that long. sion seems to be a conservative form of treatment and
not a treatment of last resort. For these specific prob-
CONCLUSIONS lems, decompression seems more conservative than long
term, high dose corticosteroid therapy. Today, we are less
Until the biochemical process that produces the orbital reluctant to decompress orbits early in the course of the
pathology in Graves’ ophthalmopathy is better understood disease process than we were when our experience be-
and can be prevented or reversed, there will be a need for gan in 1969.
orbital decompression in some patients. Enlargement of Assessment of the effectiveness of transantral decom-
the orbital space does not in itself cure the orbital pro- pression becomes more subjective as indications expand
cess, but it does allow more space for the process to work to include cosmetic goals and when the decompression is
itself out. The operations to enlarge the space are only done as a preliminary step to muscle surgery. In these
palliative or rehabilitative. Selection of the appropriate circumstances the decompression is only the first part of
patients is essential. a more complex rehabilitative sequence that includes ex-
The predictability of recession of the eyes following traocular muscle surgery, lid surgery, and occasionally
decompression depends on the patient’s problem. The op- facial skin surgery.
eration is most predictable in patients with congestive With an anterior approach to the orbit, which is more
signs and visual loss of recent onset. When unsuccessful familiar to the ophthalmologic surgeon, some of the bone
treatment has preceded the decompression, the operation that is removed through the transantral route can be re-
becomes less predictable. Muscle surgery before decom- moved, but there is an obvious timidity with respect to
pression and orbital radiation are the two forms of pre- the ethmoid cells when they are approached through eye-
liminary treatment that limit or at least create uncertainty lid incisions. A complete ethmoidectomy is the key to
as to the predictable value of decompression. successful orbital decompression.

INTRODUCTION All patients in whom the petrous ICA is involved by

Middle fossa approaches may be used to remove or assist the tumor, or in whom a significant manipulation of the
in the removal of tumors involving the following areas: ICA will be necessary, a balloon occlusion test (B0T) of
the sphenoid bone and sinus, the infratemporal and ptery- the ICA is performed, along with clinical evaluation and
gopalatine fossae, the petrous apex region, the internal xenon CT-cerebral blood flow (CBF) studies. An algo-
auditory canal, and the middle or lower clival area. Types rithm of management based on the BOT-ICA is shown in
of lesions which may involve this area include benign Table 1.
neoplasms such as epidermoid cyst, cholesterol granu-
loma, neurilemmoma, and meningioma; malignant neo-
plasms such as chordoma, chondrosarcoma, and adenoid SURGICAL TECHNIQUE
cystic carcinoma; developmental lesions such as menin-
goencephalocele, and laterally placed cerebrospinal fluid Anesthesia and Monitoring
leaks through the sphenoid sinus or the eustachian tube; Anesthesia is induced with intravenous thiopental sodium
vascular lesions such as aneurysms of the petrous inter- and maintained with nitrous oxide, oxygen, and isoflurane.
nal carotid artery (ICA); and postinflammatory lesions To allow the monitoring of cranial nerve function, only
such as sphenoid sinus mucocele. A zygomatic osteotomy short-acting muscle relaxants are used.
technique can also be used to achieve a low exposure and To minimize the need for high concentrations of
to minimize brain retraction for aneurysms of the upper isoflurane (which may cause brain swelling), a constant
basilar artery and other lesions of the tentorial notch area. infusion of low-dose thiopental (at 2 mg/kg of body weight/
hour) is used. When cranial nerve monitoring is no longer
PREOPERATIVE EVALUATION necessary, the barbiturate infusion is stopped and a bal-
In addition to a detailed history and neurologic examina- anced anesthetic technique may be used. During the sur-
tion, the preoperative evaluation includes a computed to- gery, peripheral and central venous lines are needed for the
mographic (CT) scan especially using bone algorithms, administration of fluids and medications and an intraarte-
and a magnetic resonance imaging (MRI) scan using a rial line is used for measuring the blood pressure and the
spin-echo technique, without and with gadolinium en- blood gases. The anesthesiologist administers crystalloids
hancement. Additional tests will be indicated by the loca- in maintenance amounts only, replacing the blood lost dur-
tion of the tumor. Thus, on a patient with a tumor which ing operation predominantly with colloids such as red cells,
extends toward the facial nerve or the cochlea, an audio- or salt-poor albumin. When the blood loss exceeds 4 units,
gram and facial electromyogram will be performed. Since other blood components such as fresh-frozen plasma, plate-
intraoperative monitoring of the brain stem evoked re- lets, fibrinogen (cryoprecipitate), and calcium may need to
sponse (BSER) and the somatosensory evoked response be replaced to prevent the development of a bleeding di-
(SSEP) is used, a preoperative test of these modalities athesis. A lumbar subarachnoid drain is used to achieve
will be useful. brain retraction during extradural operations provided that
there is no significant intracranial mass. Intravenous man-
nitol or furosemide may be used for brain relaxation, if
© 1992 The American Association of Neurological Surgeons necessary. If temporary ICA occlusion is needed in


patients with a compromised collateral circulation, in- below the zygomatic arch, it must be kept very close to
duced hypertension (20-40 torr above baseline) and bar- the tragus of the ear to avoid the upper branches of the
biturate- or etomidate-induced coma and/or moderate facial nerve which travel in the substance of the parotid
hypothermia between 30 and 32°C is used for brain pro- gland approximately 1 to 1.5 cm in front of the tragus of
tection. the ear. The incision can be taken down to the base of the
Intraoperatively, cranial nerve and certain brain func- ear lobe and by meticulous dissection in layers, the su-
tions are monitored. Cranial nerve monitoring includes perficial temporal artery can be preserved (Fig. 1B). The
facial electromyography and the electromyographic and dissection plane will be on the capsule of the temporo-
electroneuronographic assessment of other nerves III-XII, mandibular joint and the masseteric fascia. The facial tis-
as needed. For monitoring of brain functions, SSEPs, sues superficial to this plane are moved forward along
BSER evoked by contralateral ear stimulation, and the with the scalp, and the zygomatic arch is exposed from
electroencephalogram (EEG) may be utilized. the condylar fossa to the zygomaticomaxillary suture. The
frontal branches of the facial nerve are now well protected
Patient Position and Initial Exposure by this technique (Fig. 1C). The temporalis muscle is el-
The patient is usually placed in the supine position with a evated from the temporal fossa entirely, and care must be
roll under the shoulder to minimize neck stretch. Except taken not to open into the cartilaginous external ear canal
when the head has to be turned during the operation, or superiorly.
when the incision is far posterior, the patient can usually
be placed in three-point pin fixation, turning the two-pin Craniotomy
arch to the vertical position. The head is usually held The craniotomy is temporal or frontotemporal in loca-
slightly extended, elevated, and turned 45° to 60° away tion. The osteotomies will vary depending upon the le-
from the surgeon. sion. When the lesion extends more posteriorly, and into
The initial skin incision can be curvilinear or the petroclival bone, the craniotomy extends more poste-
bicoronal, but the latter is preferred (Fig. 1A). The inci- riorly, and the zygomatic osteotomy includes the temporo-
sion is taken down to the skull through the pericranium mandibular (TM) joint (Fig. 1D). When prolonged
above the superior temporal line. The pericranial layer subfrontal or intraorbital work is required, an orbital os-
blends with the superficial layer of temporal fascia, and, teotomy is added to the zygomatic osteotomy.
therefore, subsequent dissection is carried out between When a zygomatic osteotomy is performed, the an-
the superficial and deep layers of the temporal fascia in- terior cut is made just behind the rim of the orbit with a
feriorly to the zygoma, and the superior and lateral or- fine reciprocating saw or with Midas Rex instrumenta-
bital rims are defined anteriorly. As the incision extends tion. The posterior cut may or may not include the

© 1992 The American Association of Neurological Surgeons

Figure 1. A, the incision shown here is bicoronal with extension into detached from the zygomatic bone. Note the superficial temporal artery
the preauricular facial area. B, the scalp and facial tissues have been and the frontal branch of the facial nerve. D, a temporal craniotomy
reflected forward, and the rims of the orbit and zygomatic arch have (upper pink area) and zygomatic osteotomy (lower pink area) including
been exposed. Note the orbital soft tissue and the supraorbital nerve. C, the condylar fossa are shown. The area shaded blue represents the bone
the temporomandibular joint has been opened, and the muscle has been removed piecemeal.


condylar fossa. In the latter instance, the posterior cut is bone changes or when the neoplasm obscures the land-
made quite easily just anterior to the TM joint. When the marks, this segment of the artery may be difficult to find.
condylar fossa is included, the TM joint capsule is opened, V3 is the most reliable landmark in the presence of patho-
and the meniscus is dissected away from the condylar logical changes. The GSPN is divided to avoid traction
fossa. Superiorly, the middle fossa dura is dissected from on the geniculate ganglion. The horizontal segment of the
the condylar eminence. The bone cuts are then made just ICA can be exposed further with the aid of a high-speed
posterior and anterior to the condylar fossa. The medial drill and rongeurs. If the eustachian tube is to be preserved,
cut should be made at or medial to the margin of the TM the surgeon has to be careful while drilling lateral to the
joint, to avoid injury to the petrous internal carotid artery petrous ICA. The tensor tympani muscle is a constant land-
which lies just medial to the TM joint. mark which lies superior to the eustachian tube (Fig. 2B).
A part of the petrous apex region, which lies pos-
Condyle Resection teromedial to the horizontal petrous ICA and lateral to
When the condyle of the mandible needs to be excised, the trigeminal eminence, can be removed extradurally.
the neck of the mandible is completely denuded of soft However, it is more easily done intradurally, and to re-
tissues and the attachments of the pterygoid muscles are move the entire petrous apex one has to work through the
divided. Care is taken not to injure the superficial tempo- posterior cavernous sinus. Laterally, one is limited by the
ral artery laterally, or the internal maxillary artery medi- cochlea. The best landmarks pointing to the location of
ally. A reciprocating saw is used to make the osteotomy at the cochlea are the GSPN (the cochlea lies inferomedial
the level of the notch of the coronoid process and the to the geniculate ganglion) and the genu of the petrous
condyle is excised (Fig. 2A). Remaining soft tissues in ICA. The cochlea lies supermedial to the genu of the pe-
the condylar fossa are removed down to the inferior mar- trous ICA but the distance is variable and is best studied
gin of the tympanic bone. Unilateral loss of the mandibu- in the bone-windowed preoperative CT scan.
lar condyle is surprisingly well tolerated by the patient
when the other side is intact. The ultimate disability will Exposure of the Entire Petrous and Upper
include a malocclusion of the teeth and slight difficulty Cervical ICA
with chewing on the ipsilateral side. To remove neoplasms from the middle and lower clival
region and to remove extensive tumors from the petrous
Middle Fossa Exposure apex region, the entire petrous and upper cervical ICA
Extradural middle cranial fossa dissection is facilitated has to be exposed and displaced forward. The condyle of
by the drainage of cerebrospinal fluid, either through a the mandible has to be resected for this exposure. The
lumbar subarachnoid catheter or by opening the carotid optimal area to start the exposure of the petrous ICA is
or the sylvian cistern intradurally. This dissection is per- the portion of the artery not encased by tumor. The expo-
formed from a posterior to an anterior direction, and a sure of the genu of the petrous ICA can be performed by
lateral to a medial direction, starting just above the exter- removing the bone at the junction of the floor of the middle
nal ear canal. The following landmarks are dissected and cranial fossa and the TM joint fossa. This is the tympanic
identified sequentially: tegmen tympani, arcuate emi- bone, and it is removed with the aid of rongeurs and drills,
nence, lesser superficial petrosal nerve (LSPN), greater preferably under magnification. The eustachian tube and
superficial petrosal nerve (GSPN), middle meningeal ar- the tensor tympani muscle lie just lateral to the genu of
tery (MMA), mandibular nerve (V3), and the maxillary the petrous ICA. Both structures will have to be inter-
nerve (V2). The LSPN is not always identifiable and may rupted to obtain exposure of the artery. The petrous ICA
be confused with the GSPN. The LSPN extends from a can be traced proximally and distally from this point. The
foramen on the petrous bone to the foramen spinosum. vertical segment of the petrous ICA can be exposed by
Monopolar stimulation of the posterior end of the GSPN removal of the tympanic bone directly medial to the TM
usually produces facial muscle contraction by retrograde joint. The upper cervical ICA can be found just below the
stimulation of the geniculate ganglion. The two nerves tympanic bone and medial to the styloid process (Fig. 2C).
can be thus distinguished. Occasionally, the geniculate The petrous ICA is surrounded by a venous
ganglion may be without a bony covering; this has oc- plexus, the sympathetic nerve, and a layer of perios-
curred only twice in about 200 middle fossa exposures in teum. Except when neoplasms invade the periosteum,
our experience (about 1%). The horizontal segment of the it is dissected with the artery from the bony canal. At
petrous ICA usually lies partially uncovered by bone in- the entrance to the canal, the periosteum blends with
ferior to the GSPN. However, when there are hyperostotic a fibrocartilaginous ring and then continues as the


© 1992 The American Association of Neurological Surgeons

Figure 2. A, the condyle of the mandible has been resected. Landmarks C, the entire petrous ICA has been uncovered. The fibrocartilaginous
in the middle cranial fossa used for the identification of the petrous ICA ring is being opened. Note the tumor medial to the petrous ICA and in
are shown. CNs, cranial nerves; V2, second trigeminal division; V3, third the sphenoid sinus between V2 and V3. E.T., eustachian tube; GSPN,
trigeminal division. B, the horizontal segment and genu of the petrous greater superficial petrosal nerve; MMA, middle meningeal artery. D,
ICA have been exposed. The greater superficial petrosal nerve, the eus- the petrous ICA has been displaced forward and the tumor has been
tachian tube, and the tensor tympani muscle have been divided. The resected. Note the exposed petroclival dura, the dural sleeve of the hy-
middle meningeal artery has been ligated. V1, first trigeminal division. poglossal nerve, the jugular bulb, and cranial nerves IX and X.


periosteum of the inferior surface of the skull. The fibro- placing the petrous ICA forward. This will expose the
cartilaginous ring has to be excised laterally and the peri- clivus from the trigeminal root down to the hypoglossal
osteum detached from it in order to mobilize the ICA. In foramen (Fig. 2D).
addition, about 2-3 cm of the upper cervical ICA has to
be dissected free from surrounding soft tissue to allow Combination with Subtemporal Intradural Approach
the lower end of the petrous ICA to be mobilized. To When the preauricular infratemporal-extradural
mobilize the upper end, V3 has to be completely liberated subtemporal approach is combined with an intradural
from its bony canal, and the bone between it and the ICA subtemporal approach, the structures of the middle cra-
has to be removed. Furthermore, the bone and fibrocarti- nial fossa, the upper, middle, and lower clival region, and
lage anteromedial to the petrous ICA must be removed. the tentorial notch can be well exposed from an anterolat-
This is the best time to divide the cartilaginous eusta- eral direction.
chian tube just medial to V3, cauterize its inner lining,
pack its lumen with autologous fat, and close it with 4-0 General Principles of Tumor Resection
Nurolon sutures. The petrous ICA can be moved forward Highly malignant tumors (e.g., squamous cell carcinoma)
(Fig. 2D), and left in that position while working on tu- are preferably resected en bloc without actually enter-
mor, or sutures can be placed through the periosteal sheath ing the tumor. On the other hand, low-grade malignan-
and the ICA sutured forward. While drilling the petroclival cies (e.g., chordoma, chondrosarcoma) or benign lesions
bone, the ICA must be protected with a broad retractor, (e.g., meningioma) are removed piecemeal at the core,
taking care not to compress the artery. and then dissected at the periphery. The majority of the
The bone of the middle and lower clivus lies medial lesions removed by this approach will be of the latter
to the ICA. The surgeon has to work anterior, posterome- two types. For the actual removal of the tumor, instru-
dial, and medial to the artery to remove tumors from this ments such as the bipolar cautery, suction, pituitary for-
area. Cranial nerve XII exits through the hypoglossal ca- ceps, and various types of sharp dissectors are usually
nal medial to the vertical segment of the ICA and lies used. Blood vessels and cranial nerves are preferably
within the clival bone (Fig. 8). dissected from a normal to an abnormal area. After re-
The jugular bulb and pars nervosa of the jugular fo- moval of the core of the tumor, the peripheral part is
ramen lie posterior to the vertical segment of the petrous removed along with the margins. For meningiomas, this
ICA and the surgeon should be careful not to violate these means the removal of some surrounding apparently nor-
structures. Tumors involving the jugular bulb can be re- mal dura. With chordomas and chondrosarcomas, the
moved from this approach as well. surrounding bone has to be drilled away circum-
ferentially preferably for a margin of 1 cm, well beyond
Sphenoid Sinus and Cavernous Sinus what looks abnormal under the microscope.
The lateral aspect of the sphenoid sinus can be entered by
removing bone of the base of the pterygoid processes Reconstruction
between V2 and V3. The inferior or the anterolateral as- Reconstruction is important to avoid cerebrospinal fluid
pect of the cavernous sinus can be entered by following leakage and infection, and is done in layers. Any dural
the petrous ICA, behind V3, or between V2 and V3. defects are closed with a free pericranial or fascia lata
patch, although a watertight seal may not be possible.
Division of V3 Circumferentially placed microsutures and single-donor
To gain further exposure of the clivus and sphenoid bone fibrin glue (obtained from the blood bank) may be used
across the midline and the contralateral petrous apex, V3 for this purpose. The extradural dead space has to then
can be divided and the temporal lobe retracted up. This be filled with autologous tissues. When the nasophar-
also allows an improved access to the inferior aspect of ynx is not exposed, the sphenoid sinus can be filled with
the cavernous sinus. The contralateral petrous ICA can autologous fat, which becomes vascularized in time (Fig.
be skeletonized by this approach. However, there is no 3A). When the opening into the sphenoid sinus is large,
good landmark to find the contralateral ICA, except for it is preferable to close it with temporalis muscle in-
the fact that the petrous bone housing the ICA is denser serted laterally (Fig. 3B) and a galeopericranial flap
than the cancellous clival bone. Additionally, the surgeon and autologous fat inserted anteriorly (subfrontally).
lacks proximal and distal control of the vessel. When there is a large defect in the nasopharynx or
the oropharynx, it is preferable to close the defect
Intradural Exposure by means of a vascularized rectus abdominis or a
The dura of the petroclival area can be opened after dis- l a t i s s i m u s d o r s i f l a p a t t a c h e d by m i c r o -


© 1992 The American Association of Neurological Surgeons

Figure 3. A, reconstruction has been accomplished purely with autolo- is atrophic or avascular, a vascularized rectus abdomens muscle may be
gous fat. B, a temporalis muscle flap may be used to supplement the transferred by means of microvascular anastomosis. This muscle (or an
autologous fat. C, when the operative defect is very extensive, if there alternative free flap) is used to fill the defect and close the nasopharyn-
is a large opening into the nasopharynx, or when the temporalis muscle geal opening.


vascular anastomosis to the cervical vessels (Fig. 3C). postoperative infection, usually from the nasopharynx. In
Regional rotation flaps may also be used. approximately 200 petrous ICAs exposed operatively, this
occurred twice in our series, on both occasions due to
POSTOPERATIVE MANAGEMENT persistent nasopharyngeal contamination and postopera-
A spinal drain is not used routinely in the postoperative tive infection. One patient eventually died; another was
period, unless cerebrospinal fluid (CSF) leakage devel- successfully salvaged by balloon occlusion of the ICA,
ops. Excessive blood loss during the operation may re- removal of the bone flap, and treatment with antibiotics.
quire replacement of blood components during the op- CSF leakage may occur from the eustachian tube or
eration. As with other major intracranial operations, the sphenoid sinus and always requires reoperation. Cra-
careful attention to the pulmonary and metabolic param- nial nerve palsies are usually temporary, but permanent
eters and to early ambulation is essential. Drains are usu- palsies may occur because of tumor invasion or operative
ally removed by the second or third postoperative day and injuries. When intraoperative cranial nerve injury is rec-
intravenous antibiotics are stopped at that time. If there ognized, it is best to manage it by immediate resuture or
was considerable manipulation of the ICA during the op- graft reconstruction.
eration, a postoperative angiogram is performed prior to
discharge, to rule out ICA occlusion or a pseudoaneurysm. ILLUSTRATIVE CASES


Potential complications include cerebral contusion or he- A 47-year-old woman presented with involvement of cra-
matoma, ICA occlusion or rupture, postoperative infec- nial nerves V and VI and was thought to have a neurilem-
tion, cerebrospinal fluid leakage, and cranial nerve pal- moma or a cartilaginous tumor (Fig. 4). An operation was
sies. Cerebral contusions and/or hematomas are managed performed by a temporal craniotomy and zygomatic os-
in the usual manner. ICA occlusion is very rare and when teotomy anterior to the TM joint without resection of the
it occurs may even be asymptomatic. However, in a pa- mandible or the TM joint. The sphenoid sinus was en-
tient with a compromised collateral circulation, it may ne- tered between V2 and V3, and a mucocele was totally re-
cessitate emergency reexploration. Carotid pseudo- moved with complete resolution of symptoms. A postop-
aneurysm or rupture is always the result of serious erative paresis of the frontalis muscle was temporary.

© 1992 The American Association of Neurological Surgeons

Figure 4. A T2-weighted MRI scan demonstrates a lesion of the sphenoid bone (sphenoid mucocele) initially thought to
be a neurilemmoma or a cartilaginous tumor.


Juvenile Angiofibroma small frontoorbital osteotomy, and zygomatic osteotomy,

A 15-year-old boy presented with epistaxis, and a large without extensive petrous ICA exposure or condyle re-
juvenile angiofibroma was diagnosed by biopsy. It filled section. The sphenoid sinus was entered laterally and
the nasopharynx, infratemporal and pterygopalatine fos- medially (by a subfrontal route). A major portion of the
sae, superior orbital fissure, cavernous sinus, and sphe- temporalis muscle was used for reconstruction. The pa-
noid sinus (Fig. 5). The lesion was removed through a tient had no permanent postoperative deficits.

© 1992 The American Association of Neurological Surgeons

Figure 5. A large juvenile nasopharyngeal angiofibroma occupying the poral fossae, and orbital apex-anterior cavernous sinus area is seen in
nasal cavity, nasopharynx, sphenoid sinus, pterygopalatine and infratem- these preoperative coronal (A) and sagittal (B and C) MRI scans.


Petroclival Cholesterol Granuloma a temporal craniotomy, zygomatic osteotomy, and

A 46-year-old man presented with progressive symp- condyle resection approach. An alternative approach
toms of dysfunction of cranial nerves V and VI. An ex- would have been to drain the cyst into the sphenoid si-
tensive lesion of the petrous apex and clivus medial to nus, but complete resection would have been impossible.
the petrous ICA and sphenoid sinus was seen on the CT His symptoms resolved totally, and no recurrence has
images (Fig. 6). The lesion was totally excised through been observed for 5 years.

© 1992 The American Association of Neurological Surgeons

Figure 6. A preoperative CT scan demonstrates an extensive petroclival cholesterol granuloma.


Chondrosarcoma after a temporal craniotomy, zygomatic osteotomy, and

A 48-year-old man had undergone a previous partial ex- condyle resection, and the exposure of the petrous ICA.
cision of a petroclival chondrosarcoma at another institu- The facial nerve was reconstructed with an intracranial-
tion through a transtemporal approach, with a postopera- extracranial graft, and the patient eventually made a House
tive facial palsy. He presented with significant tumor Grade III functional recovery. A small remnant in the cav-
recurrence involving the middle fossa, petroclival area, ernous sinus required an intradural approach to achieve
and basal cavernous sinus (Fig. 7). The lesion was resected total resection.

© 1992 The American Association of Neurological Surgeons

Figure 7. Preoperative axial (A) and coronal (B) MRI scans reveal a petroclival chondrosarcoma which previously had
been removed partially by a transtemporal approach.


Meningioma ral craniotomy, zygomatic osteotomy, condyle resection,

A 39-year-old man presented with an extensive radiation- and exposure of the petrous ICA. The temporalis muscle
induced meningioma. growing out of the ear canal and was inadequate for reconstruction because of prior sur-
involving the petroclival bone, infratemporal fossa, orbit, gery. A pectoralis muscle and fat flap was used to recon-
cavernous sinus, and petroclival dura (Fig. 8). He had had struct the operative defect. A cavernous sinus remnant
two prior operations. Preoperative deficits involved cra- required a subsequent reoperation. The patient was noted
nial nerves III, IV, V, VI, and VII. Because of the chronic to have a good tumor resection postoperatively. However,
infection associated with the external ear canal lesion, it tumor recurred in the orbit and the cavernous sinus a year
was removed first, with antibiotic irrigation of the ear later. This required reoperation and further radiation
canal. The extradural lesion was removed after a tempo- therapy to control the tumor.

© 1992 The American Association of Neurological Surgeons

Figure 8. Axial (A) and coronal (B) CT scans show an extensive radiation-induced meningioma involving the cavernous sinus,
petroclival bone and dura, and infratemporal fossa, and growing through the external ear canal.


Transthoracic vertebral body resection is an excellent
method of treatment of selected patients with spinal meta-
static disease. The most appropriate patients for this ap-
proach are those with metastatic disease that is localized
to one or several contiguous segments of the thoracic spine
and in whom the primary disease is well controlled (Fig.
1). In such cases, the anterior exposure permits a gross
total removal of the vertebral body tumor with a gener-
ally easier and safer dissection than that offered by alter-
native approaches, such as posterior transpedicular and
lateral extracavitary (costotransversectomy) approaches.
Access to the pleura and aorta permits a dissection plane
that is usually outside the tumor, with less risk of indirect
vascular injury than that associated with other approaches.
Extensive unilateral chest wall involvement makes tumor
excision beyond the confines of the spine difficult, but it
does not contraindicate surgery by the transthoracic ap-
proach. Bilateral chest wall involvement is rare and is not
readily accessible via thoracotomy.
Patients with multifocal metastatic disease who have
previously received radiotherapy to the spine are some-
what less ideal candidates for this type of surgery, but
still appropriate in selected cases. Patients with a reason-
able life expectancy in whom the primary disease may be
responsive to chemotherapy, such as those with breast
cancer, are also good candidates.
Patients who have previously received radiotherapy
to the spine may develop a progressive deterioration in
neurologic function secondary to pathologic vertebral
body fracture, resulting in kyphosis. Retropulsed bone
and tumor may result in spinal cord deformity in the
sagittal plane with paraparesis, despite the presence
of contrast material ventral to the spinal cord on my-
© 1992 The American Association of Neurological Surgeons
elography and in the absence of a myelographic block.
Posterior and lateral approaches are associated
Figure 1. This 46-year-old woman has squamous cell carcinoma of the
uterine cervix and a solitary metastasis to T-6 with vertebral body col-
© 1992 The American Association of Neurological Surgeons lapse, spinal cord compression, paraparesis, and a neurogenic bladder.


with a high incidence of wound infection and dehiscence tient; in most cases, however, an anterior position is more
in previously radiated patients. In this setting, the trans- comfortable. For tumors at the thoracolumbar junction in
thoracic approach is preferable. which the predominant side of tumor involvement is the
The degree of kyphosis that can be corrected and sta- left, a left-sided approach risks injury to the radiculo-
bilized with an anterior exposure is less than the degree of medullary artery of Adamkiewicz, with possible spinal
kyphosis that can be successfully treated with a combined cord infarction. If a leftsided exposure is necessary to
anterior and posterior approach. Patients with moderate obtain sufficient tumor removal, spinal angiography
kyphotic deformities of 30° or less are readily handled with should be performed preoperatively with attention to the
an anterior approach alone. Patients with major deformi- segmental aortic branches from the left side in the low
ties (greater than 45°) are infrequently encountered among thoracic region to localize this important vessel. Once
cancer patients with spinal metastases, unless they have identified, the vessel can be excluded from the surgery
had a prior laminectomy. For the major deformities, site, avoided by approaching the tumor from the right side,
anterior-posterior stabilization should be considered. or carefully microdissected to preserve spinal cord blood
Thoracotomy is contraindicated in patients with supply. The posterior spinal approach may be used simul-
chronic lung disease or inadequate pulmonary function. taneously by a second surgical team for the application of
In patients with widespread metastatic disease for whom stabilizing rods and the removal of additional tumor-in-
no effective systemic therapy exists and with a very lim- volved bone and epidural tissue.
ited life expectancy, thoracotomy with resection and re-
construction is contraindicated. Alternate treatments for Surgical Procedure
these patients include radiotherapy and external bracing The thoracotomy skin incision should approximately par-
to prevent kyphosis, and, in selected tumors such as pros- allel the ribs, curving rostrally as the midline is approached
tate cancer, endocrine therapy or chemotherapy. and extending laterally to the midaxillary line (Fig. 2).
Removal of one or two contiguous ribs is tolerated well
PREOPERATIVE PREPARATION and provides excellent autograft material for bone fusion.
Preoperative evaluation of patients being considered for Additionally, the trauma of chest wall retraction is some-
thoracotomy for vertebral body resection should include what reduced, particularly in elderly patients, if the rib is
appropriate radiographic studies (including computed removed.
tomography scans of the brain, chest, and abdomen, bone After subcutaneous bleeding points are coagulated,
scans, and mammograms) to determine the primary site the rib removal proceeds to the transverse process medi-
and the stage of the malignancy. Pulmonary function tests ally. The ligamentous attachment to the rib head should
may be used to determine the risk of pulmonary morbid- be cut and the rib detached from the vertebral bodies. Next,
ity from thoracotomy. Decadron or methylprednisolone the parietal pleura can be opened and retracted, providing
may be used to decrease spinal cord edema and injury excellent visualization of the involved vertebral body. The
caused by surgical trauma. Antibiotics should be given to lung is retracted gently, protected by a large laparotomy
immunocompromised and previously radiated patients to sponge.
decrease the risk of wound infection. At the level of tumor involvement, the pleura is usu-
ally deformed, thickened, and hypervascular. The pleura
OPERATIVE TECHNIQUE is incised along the vertebral body margins; it should be
coagulated as it is removed. Segmental vessels will then
Anesthesia be identified coursing across the vertebral body from an-
Anesthetic techniques should include direct arterial cath- terior to posterior in the middle and caudal half of the
eter access for blood pressure monitoring and blood gas vertebral body. These can be clipped proximally or co-
determinations during and after surgery; however, appro- agulated with bipolar cautery over a long segment to per-
priate noninvasive alternatives can be considered. Double- mit their removal.
lumen endotracheal intubation is usually unnecessary, as Next, the adjacent disks are explored, and their
the lung can be retracted gently without deflation to pro- position is confirmed with a lateral x-ray film, if nec-
vide sufficient access to the posterior chest wall and ver- essary. The disks are then incised with a scalpel and
tebral bodies. removed with pituitary rongeurs and curettes (Fig. 3).
During this process, the margins of the adjacent ver-
Positioning tebral body endplates can be explored, orienting the
Patients are best placed in a lateral decubitus position with surgeon to the posterior limit of the vertebral body to
the side of the predominant tumor involvement up (Fig. be resected. The vertebral anatomy can be quite dis-
2). The surgeon can stand anterior or posterior to the pa- torted by tumor extensions and pathologic fractures.


© 1992 The American Association of Neurological Surgeons

Figure 2. The lateral position for thoracotomy; note the rib removal at the costovertebral articulation, shown in the lower two illustrations.


© 1992 The American Association of Neurological Surgeons

Figure 3. Metastatic tumor in a compressed vertebral body. Note the segmental arteries from the aorta and
note the adjacent discs which are not involved by the tumor (inset).


At this phase of the operation, it is important to avoid utilized. The grafts should be made progressively longer
misjudging the vertebral confines. as they are inserted sequentially to make up for cancel-
Once the relatively bloodless discectomy is per- lous bone that will be loosened during the insertion of
formed, the vertebral body resection follows. The bone previous grafts and lengthen effectively the distance be-
may require a high-speed drill for removal or, if suffi- tween the troughs.
ciently destroyed, may be removed simply with curettes In patients with widespread metastatic disease and
or the ultrasonic aspirator (Fig. 4). When the vertebral in those who have an anticipated life expectancy of less
body tumor is removed throughout its anterior and poste- than 12 to 24 months, or if radiotherapy has been deliv-
rior extent, the posterior longitudinal ligament will be en- ered to the spine, long-term stability from a bone fusion
countered. The ipsilateral pedicle may be removed to fa- is not necessary and may not be successful if attempted.
cilitate identification of the segmental spinal nerve, which For these patients, reconstruction with a vertebral body
serves as a guide to the ventral margins of the dura. The “spacer” of the bone cement, polymethyl methacrylate
contralateral pedicle cannot be removed from this ap- (PMMA), usually supplemented by metal fixation in the
proach due to inadequate exposure. Identification of the form of Steinmann pins, plates, or contoured rods, is pre-
caudal margin of the pedicle is quite helpful as it will ferred (Fig. 7). The pins should be 1 to 2 mm in diameter
mark the entry site of the segmental spinal nerve into the and contoured slightly to match the thoracic kyphosis.
spinal canal. The vertebral body endplates should first be cut or drilled
Fine dissectors and nerve hooks can be used at this to provide adequate space for maneuvering the pins and
point to identify the posterior longitudinal ligament or, cement. Using a curved or right-angled drill, a hole is
alternatively, the ligament may be retracted away from made in the end of each vertebral body to accommodate
the dura with a fine hook and directly incised anteriorly each pin. The pin is first advanced caudally to the full
(Fig. 5). This should be done to ensure that the ventral length of the adjacent vertebral body and, if possible,
aspect of the dura is decompressed well. The ligament is through the next adjacent endplate and disk. The pin is
frequently deformed because of chronic posterior dis- then positioned into the intervertebral defect and moved
placement from retropulsed pathologic bone. As the liga- rostrally into its matching drill hole. Once two or three
ment is incised progressively, the epidural space is dis- pins have been inserted, the PMMA is packed between
sected intermittently with a fine blunt dissector. Usually the pins, leaving adequate space (10-15 mm) between the
this plane is not adherent. It is, however, quite vascular dura and bone cement. The PMMA is irrigated continu-
secondary to epidural veins, and these should be coagu- ously and Gelfoam or cottonoid sponges should be posi-
lated with the bipolar forceps. tioned temporarily over the dura during the process. If
Once the posterior longitudinal ligament is entirely there is localized chest wall involvement affecting the
removed to the margins of the vertebral body resection adjacent rib heads and lateral vertebral segments, such as
cavity, decisions can be made about reconstruction. If the the transverse processes, some of this additional tumor
adjacent vertebral body endplates appear to be grossly can be removed to optimize local control.
free of tumor and there is a relatively good control of If a moderate kyphosis is present, this may be par-
systemic disease, then bone fusion should be attempted. tially corrected by using a distraction device anteriorly in
The adjacent vertebral bodies should be prepared to ac- the intervertebral defect prior to placing pins and PMMA
cept bone grafts by using the high-speed drill or or by gentle external manual pressure over the apex of
osteotomes to cut a trough to a depth of approximately 5 the curve posteriorly. A major kyphosis (greater than 45°)
to 10 mm in the middle third of the vertebral body will probably require posterior instrumentation for ad-
endplates. This should be a transverse bony defect which equate correction. For patients with widely metastatic
extends from the exposed lateral aspect of the vertebral cancer and limited activities of daily living, moderate re-
bodies to the contralateral cortical bone. The trough must sidual deformities will probably be well tolerated. Poste-
be well developed along the contralateral side to permit rior correction to an optimal sagittal plane alignment may
placement of the maximal number of grafts. not be necessary and may be prohibitively risky if an ad-
Next, rib grafts are cut approximately 2 to 3 mm ditional posterior procedure is required through previously
longer than the measured distance between troughs, and radiated tissue.
the segments are trimmed into a sharp configuration at
the ends to provide additional mechanical linkage between Closure
the grafts and the vertebral bodies. The grafts are then A layered thoracotomy closure over a closed suction
impacted into position with the convex surface anterior chest tube drain concludes the procedure. Spinal cord
(Fig. 6). There is usually space for three or four rib grafts monitoring is not essential but may be helpful if exten-
if the full transverse diameter of each vertebral body is sive correction of kyphosis is anticipated, to prevent


© 1992 The American Association of Neurological Surgeons

Figure 4. Tumor excision begins with discectomy. The vertebral body bodies. The posterior longitudinal ligament is deformed and may cause
resection is completed to the posterior margin of the adjacent vertebral spinal cord compression (inset).


© 1992 The American Association of Neurological Surgeons

Figure 5. The posterior longitudinal ligament is incised and dissected from the dura with a fine dissector.
It is excised to complete the anterior decompression (inset).


© 1992 The American Association of Neurological Surgeons

Figure 6. Spinal stabilization is shown with rib grafts placed into a 5-10- The ribs are then impacted into place for a total of three or four grafts. A
mm trough cut or drilled into the adjacent vertebral bodies (upper inset). space of about 10 mm is left between the grafts and the dura (lower inset).


© 1992 The American Association of Neurological Surgeons

Figure 7. Steinmann pins are inserted into the vertebral bodies by pen- acrylate (inset) is further stabilized by making a shallow trough in each
etrating the adjacent caudal endplate and disc and are then advanced vertebral body.
into matching holes in the rostral vertebral body. The polymethyl meth-


over-distraction. Intraoperative radiographs should be used POSTOPERATIVE TREATMENT

to confirm that satisfactory spinal alignment exists prior If not previously radiated, all patients with tumors that
to placement of bone cement and to verify the location are likely to respond should undergo postoperative radio-
and extent of the resection. therapy to improve local tumor control. Patients who have
undergone a bone fusion should have radiotherapy two to
COMPLICATIONS three months after surgery to permit some initial vascu-
The neural complications of this operation include inad- larization of the graft. Patients with PMMA and metal
vertent surgical trauma to the spinal cord and spinal cord implant reconstructions can be radiated three to four weeks
infarction related to interruption of the segmental arterial after surgery. All patients should be fitted with an exter-
supply, both of which are rare and largely preventable. nal orthosis. Those with rigid internal stabilization need
Incomplete tumor removal and early tumor recurrence at only a light orthosis to limit extreme activities, but pa-
the margins of the resection can result in fusion failure or tients in whom a fusion is anticipated should be placed in
implant loosening with resultant spinal instability. Wound a stiff thoracolumbar orthosis to diminish the likelihood
healing and soft tissue problems are less common after of early graft displacement.
thoracotomy than after extensive posterolateral exposures.


INTRODUCTION include the patient’s advanced age, one or more previous

The surgical procedure described in this article is recom- anterior cervical operations resulting in extensive scar-
mended for removal of cervical disc lesions at one or more ring, failure of a previous fusion or fusion with anterior
levels followed by an interbody fusion using a cylindrical angulation, previous postoperative wound infection, or
dowel bone graft. It is the original technique devised and postoperative neurologic deficit.
described by the author in 1956 and used since for the
surgical treatment of acute and chronic cervical disc le- OPERATIVE TECHNIQUE
sions. The author strongly urges that the procedure be
performed exactly as described to avoid complications. Identification
The level of the lesion is best identified by injecting me-
CASE SELECTION thylene blue dye into the disc under radiologic control,
The anterior surgical approach to the cervical spine is either the day before operation when the discogram is
designed to treat pathologic lesions that cause pain and done, or in the operating room using portable x-ray equip-
impair function of the cervical nerve roots and spinal cord ment and an intradiscal needle marker.
at one or more levels. These lesions include acute and
chronic degenerative disc disease, traumatic dislocations Position and Anesthesia
and compression fractures, space-occupying lesions of the The patient is placed in the supine position with the neck
vertebral bodies, and intraspinal lesions anterior to the extended over a thick sandbag or a block of balsa wood
spinal cord (including ossification of the posterior longi- padded with foam rubber. The latter is soft, but firm, and
tudinal ligament). radiographs can be taken through it.
The patient is given a single dose of intravenous an-
INDICATIONS AND CONTRAINDICATIONS tibiotic and a heavy sedative one hour before operation.
Nitrous oxide and/or a fluorinated inhalation agent are
Indications used for endotracheal general anesthesia. Care must be
The indications for surgery are intractable pain and pro- taken not to hyperextend the patient’s neck for intuba-
gressive neurologic deficit which fail to respond to an tion. Use of fiberoptic light or just flexion of the neck
adequate trial of conservative therapy. Accurate identifi- will prevent spinal cord injury (quadriparesis) in the pres-
cation and definition of the lesion by contemporary im- ence of intraspinal osteophytes and a stenotic canal. The
aging techniques are essential. head is turned to the left and secured to the table with a
two-inch adhesive band across the head (Fig. 1, A and B).
There are no absolute contraindications to an anterior Preparation
cervical operation if the surgeon is confident in his or her Two Mayo stands are placed transversely over the chest
own surgical ability, is willing to tackle a complicated and abdomen and another is positioned vertically over
and difficult surgical procedure, and if he or she thinks the left side of the face. A horizontal draping bar the length
that the patient has a chance of improvement or recovery. of the operating table is placed on the left side and se-
The relative contraindications, however, are many. They cured to an upright standard at the head and the foot with
Fisher clamps.
© 1992 The American Association of Neurological Surgeons The neck is prepared with Betadine soap, Betadine


sterile covered Mayo trays are placed on the Mayo stands

to secure the drapes.

Small gauze sponges used for this operation are prepared
from 2 × 2-inch gauze folded lengthwise into a 2 × 3/4-
inch size. These small gauzes are packaged and sterilized
in bundles of 10 along with 3/4-inch cottonoid with strings.
Gelfoam is cut in 3/4-inch squares.

Position of Operating Team

The surgeon (right-handed) stands on the patient’s right
side facing the right ear. The surgical assistant stands at
the upper end of the table facing the top of the patient’s
head; the assistant should stand on a low platform to be
able to see into the depth of the wound. The scrub nurse
stands at the surgeon’s right and controls the Bovie unit.
The suction tubing is placed over the draping bar on the
upper Mayo stand and the aspirator is controlled by the
surgical assistant.
© 1992 The American Association of Neurological Surgeons

Figure 1. Positioning of a patient for anterior cervical discectomy Incision

and fusion.
The incision is made through the depth of the skin only,
never including the platysma muscle (Fig. 2). The sub-
solution, and alcohol. The skin incision is marked with a cutaneous areolar tissue is spread and cut with
superficial scratch of a scalpel or a marking pen.
Xylocaine (0.5%) with adrenalin and Wydase is infiltrated
subcutaneously in the line of the incision and in the deep
tissues. Deep digital pressure is made medial to the ca-
rotid artery. The needle is inserted until it touches bone,
and then the injection is made into the cleavage plane as
the needle is slowly withdrawn.

Location of Incision
Location of the transverse skin incision is determined by
the level of the lesion, or lesions, and is always in a nor-
mal wrinkle of the neck if possible. The C5/6 disc lies
beneath the cricoid cartilage. The incision for one, two,
or three levels (C4/5, C5/6, C6/7) is made at this level;
for lesions at C3/4 a separate incision is made 1 cm above
the thyroid cartilage. At C1/2 and C2/3 (including
hangman’s fracture) the transverse incision is made 1 cm
below the angle of the jaw from the midline to the mas-
toid bone. A vertical or diagonal skin incision is cosmeti-
cally unacceptable to the patient and should not be used.
There is no cervical lesion which cannot be exposed by
the anterior approach through a transverse skin incision,
provided that the incision is undermined adequately and
retracted vertically (Fig. 2).

The round hole of a small plastic drape (3M No. 1020) is
© 1992 The American Association of Neurological Surgeons
placed over the incision and the adhesive stuck to the skin.
A long sterile sheet is draped over the Mayo stands, up Figure 2. Dissection of the skin and subcutaneous tissue from
and over the long bar, and secured with clamps. Three the platysma.


the scissors above and below the incision. The skin and gus and strong lateral retraction is made to the left. The
subcutaneous tissue are freed from the platysma the same carotid artery is gently retracted to the right by the assis-
distance vertically as the length of the transverse inci- tant. This exposes the bone.
sion. The skin is retracted vertically with a single-toothed For a single level operation, the cleavage plane is
self-retaining retractor (Fig. 3). The platysma is carefully opened only to expose one disc. To expose adjacent lev-
spread and opened along its normal vertical fibers with els, it is opened upward to C4/5 by cutting a small neu-
scissors, taking care not to cut the superficial jugular vein rovascular bundle located at the lower margin of the thy-
immediately beneath. roid cartilage. This can be safely cauterized and divided
with scissors.
Soft Tissue Dissection To expose lower levels (C6/7 or C7/T1) the inferior
The medial margins of the cut platysma muscle and the thyroid artery will be encountered. It is dissected free and
underlying vein are retracted to the left to identify the me- if sufficiently long may be placed behind the vertical re-
dial border of the sternomastoid muscle. By spreading and tractor blade. If the artery is short it should be ligated and
cutting with scissors, loose areolar tissue surrounding this divided to avoid avulsion by strong retraction. Two other
muscle is divided throughout the length of the exposure. structures may be injured by retraction at lower levels:
The muscle is retracted laterally with an angulated hand the recurrent laryngeal nerve and a high-lying dome of
retractor. The diagonally placed omohyoid muscle is thus the pleura, resulting in hoarseness or pneumothorax, re-
exposed and freed after cauterizing small vessels along its spectively. These complications can be prevented by tak-
superior margin. This muscle is retracted medially and ing necessary precautions.
downward (Fig. 4). The carotid-esophageal cleavage plane
can be identified by a small white neurovascular bundle Exposure of the Spine
visible in the loose areolar tissue and running up and down. The avascular prevertebral areolar tissue is incised in
By spreading this tissue medial to the small nerve, a cleav- the midline with scissors to expose the parallel medial
age plane is opened cautiously by the spreading scissors margins of the longus colli muscles. The anterior longi-
and the small nerve retracted laterally. The tissues of the tudinal ligament covers the vertebrae between these
cleavage plane should not be roughly opened with the fin- muscles and above and below the disc. The disc level
ger. A right-angle hand retractor with a wide blade is held is identified by the previously injected methylene blue
in the surgeon’s left hand and placed beneath the esopha- dye or by an intraoperative radiograph with a needle

© 1992 The American Association of Neurological Surgeons © 1992 The American Association of Neurological Surgeons

Figure 3. The skin edges are retracted vertically with a single-toothed Figure 4. Dissection along the carotid-esophageal cleavage plane.
self-retaining retractor.


marker (see Fig. 7). A self-retaining retractor with blunt to fit the exact depth of the wound on the left side so the
blades can be placed for vertical exposure of the wound at flange of the blade is flush with the skin. The blade of simi-
this stage and manual retraction used for lateral exposure, lar length or slightly longer inserted on the right will project
or manual exposure can be used alone. Adequate detach- above the skin level, but this assists in maintaining the mid-
ment of the longus colli muscles from the adjacent verte- line position of the retractors. Retractor blades with smooth
bral bodies and the discs is an important step in the opera- tips are inserted vertically; the inferior blade is attached to
tion. The medial margins of these muscles are cauterized the short handle and slipped under the legs of the long
to seal muscle bleeders, and then the muscle attachments handle of the lateral blades. The upper smooth-tipped blade
are detached from the vertebral bodies with a sharp peri- is slightly shorter. The small retractor handle is opened to
osteal elevator up to the medial part of the transverse pro- its maximum, and then the hinge is broken sharply so the
cesses. The muscle is retracted with a second periosteal handle hugs the right side of the neck. This will force the
elevator to expose the bone (Fig. 5). Muscle and bone bleed- toothed retractor blades to the left for maximum midline
ers are controlled by cauterizing the bone with the cutting exposure (Fig. 7).
current set at a high level and packing with Gelfoam and
thrombin. Ample detachment of these muscles ensures a Removal of the Disc
wide exposure of the spine and prevents the retractor blades A pointed scalpel blade on a long handle is inserted into
from slipping. These blades with sharp teeth are designed the disc about 1.5 cm deep and the disc is cut along the
to protect the esophagus and larynx on the left side and the vertebral margins above and below and as far lateral as
carotid artery on the right (Fig. 6). If the blades are prop- possible (Fig. 7). If the patient has large anterior
erly inserted deep beneath the detached muscles, they will osteophytes or an intercalary bone (ossified anterior lon-
not slip or come out. The blade should be checked during gitudinal ligament) it may be necessary to remove these
the operation to determine whether the teeth remain safely projections with a small osteotome or disc rongeur be-
secured beneath the muscle. If a blade should slip, it is fore the disc is incised.
because the muscle has not been adequately detached. The The incised disc is removed with a narrow disc
blade is removed and reinserted to prevent trauma to the rongeur, and then all loose disc material is withdrawn
esophagus. Blades of different lengths are available to ac- from the interspace. A cervical vertebra spreader is in-
commodate wounds of various depths. A blade is chosen serted into the disc space, placed laterally on one

© 1992 The American Association of Neurological Surgeons © 1992 The American Association of Neurological Surgeons

Figure 5. Dissection of the longus colli muscles away from the Figure 6. Application of self-retaining retractors.
vertebral bodies.


side, and the thumb screw is turned to force the disc space The anteroposterior measurement of the disc space
open (Fig. 8). The cartilage plates are stripped from the ver- is taken with the depth gauge. The foot of the gauge is
tebra with a sharp elevator and then all cartilage and remain- placed on the posterior longitudinal ligament and the L
ing disc are scraped from both vertebrae using straight bar on the anterior margin of the vertebra (Fig. 9).
curettes until the fibers of the posterior longitudinal liga- If the radiographs show large posterior marginal
ment are exposed. The vertebra spreader may be moved from osteophytes, the anteroposterior measurements may be
side to side to assist in the exposure for disc removal (Fig. 8). increased by 1 or 2 mm. The measured distance is se-
cured with the set-screw on the gauge.

Exposure of the Spinal Canal

Before the drill hole is made, the vertebra spreader must
be inserted into the interspace far lateral to give maxi-
mum transverse exposure of the disc space. A notch is
made with a small osteotome or an air drill where the
vertebral margin of the lower vertebra curves upward to
meet the point of the Luschka joint. This notch is approxi-
mately 1 cm deep. The points of the vertebra spreader are
inserted and forced downward the full length to secure
the spreader so it will not slip out or fracture the vertebra
Because of variation in the size of vertebral bodies
and the width of disc spaces, four sizes of fluted drills are
available in diameters of 10, 12, 14, and 16 mm. The drills
are interchangeable on two drill shafts. The shafts are ad-
justable in length and have a guard and guide to fit.
The disc space is spread open 3-4 mm or more
with the vertebra spreader and a drill is chosen which
is large enough to remove approximately 2 mm of ver-
© 1992 The American Association of Neurological Surgeons

© 1992 The American Association of Neurological Surgeons © 1992 The American Association of Neurological Surgeons

Figure 7. (Top) Excision of the anterior annulus with a No. 11 vertebral spreader. The cartilage plates are being removed with a
blade knife. Note that the disc is stained with methylene blue that sharp elevator.
was injected preoperatively.
Figure 9. (Bottom right) Measurement of the anteroposterior dimen-
Figure 8. (Bottom left) Distraction of the intervertebral space with a sion of the disc space using a depth gauge.


tebral body on each side of the disc space. The drill is

screwed into its shaft and passed through the guard (Fig.
10). The drill will extend through the guard to the exact
distance measured by the depth gauge. It is adjusted to
this position by turning the large knurled ring on the shaft
and secured by tightening the small knurled ring. The
stepped end of the guide is inserted into the disc space in
the midline or slightly to the right and the guard slipped
down over it with the pins down. This places the guard
pins at an equal distance on each side of the disc space.
The round cap is placed over the upper end of the guard
and the pins are driven into the vertebral bodies by three
or four sharp taps with a hammer. The cap is removed and
replaced with the cross bar. The Hudson drill handle is
attached to the drill shaft (Fig. 11). The assistant grasps
the cross bar, angles it slightly to correspond to the verti-
cal direction of the disc space, and holds it in this posi-
tion with strong downward pressure during the drilling
(Fig. 12). The drill is inserted into the guard and the tre-
phine or drill hole in the disc space is completed with a
single drilling, if the depth has been correctly measured. A
relief opening in the guard permits escape of bone dust and
prevents the drill from binding. When drilling is complete,
the guard and drill are removed and the drill hole immedi-
ately filled with a Gelfoam pad soaked in topical thrombin
and packed with a patty. This arrests bone oozing from the © 1992 The American Association of Neurological Surgeons
cancellous bone and the walls of the drill hole. After a
minute or two the drill hole is cleaned, the bone dust is
recovered from the grooves of the drill, from the relief open-
ing in the guard and from the disc space lateral to the drill

© 1992 The American Association of Neurological Surgeons

© 1992 The American Association of Neurological Surgeons

Figure 11. (Top) The Hudson handle-drill-drill guard assembly.

Figure 10. Adjustment of the length of the exposed drill using the Figure 12. (Bottom) Trephination of the disc space and adjacent verte-
depth gauge. bral bodies.


hole. This bone dust is placed in the guard cap and cov-
ered with a patty and saved for later use.
The wound is irrigated with water. If the half-circle
of bone at the bottom of the drill hole is thin cortical bone
and moves when palpated, drilling is complete. Persistent
bleeding from the walls of the drill hole or the guard pin
holes is arrested by pressing thrombin-soaked Gelfoam
firmly into the bone with a finger. Bone wax is never
The drill hole is usually placed slightly off-center to
the right of the midline, regardless of the lateralization of
the lesion. The drill will thus remove more bone on the
right side. This facilitates removal of the osteophytes and
exposure of the right nerve root. It is easier to decom-
press the left nerve root when operating from the right
side of the patient. Also, the offset drill hole leaves more
intact interspace on the left for insertion of the vertebra
If the half-circle of bone at the bottom of the drill
hole is covered with cancellous bone and does not move
when palpated, redrilling may be required. This can be © 1992 The American Association of Neurological Surgeons

accomplished by reinserting the drill into the drill hole,

with the guard, and advancing the drill 2 or 3 mm by a few Figure 13. Removal of the thin posterior shell of the cortical bone of
turns of the knurled rings on the guard. If the hole is the vertebral body with a sharp curette.
redrilled it should only be done once to prevent drilling
too deep. Or, rather than a second drilling, thick bone at
the bottom of the drill hole can be thinned with an air drill
using a medium-sized round burr. When the bone is completely removed above and
The thin upper half of the shell of bone is removed below the disc, there should be a hole on each side of the
with a straight curette. The cup of the curette is inserted drill hole almost as large as the drill hole itself (Fig. 16).
under the edge of the vertebral rim and the shaft against This gives maximum exposure of the spinal canal. The
the outer rim of the drill hole, as a fulcrum. The bone is osteophyte removal can be facilitated by widening the disc
removed using an upward prying action (Fig. 13). If pos- space with a vertebra spreader inserted on alternate sides
terior osteophytes are present, these should be released to the bone removal.
from their attachments to the posterior longitudinal liga-
ment with the osteophyte elevator before using the curette. Removal of an Intraspinal Herniated Disc
The half-moon shell of the lower vertebra is released with Through this large bilateral bony opening, the intraspinal
the osteophyte elevator and nibbled with the 40° upbiting herniated disc fragments can be visualized and removed
cervical disc rongeur. and the entire nerve root exposed and decompressed (Fig.
16). To explore the foramen with a probe for more disc
Osteophyte Removal fragments beyond this ample exposure is not only unnec-
The posterolateral margins of the vertebrae lateral to the essary but dangerous.
drill hole are removed with their osteophytes, using a small The posterior longitudinal ligament is not routinely
curved osteotome and the 3-mm upbiting rongeur. Start- removed as recommended by some neurosurgeons but
ing at the left side of the lower vertebra a thin layer of is left intact to protect the dura. Most intraspinal discs
cortex is chiseled off from above downward to the lower herniate posterolaterally and are located beyond the lat-
margin. This is pried loose and removed with a straight eral border of the posterior longitudinal ligament. A
rongeur. This bone removal may be done with an air drill. central disc fragment herniated through a rent in the
After thinning the margin, the lateral osteophytes are freed ligament is identified and visualized by preoperative
with the osteophyte elevator (Fig. 14); then a generous cervical discogram and stained with methylene blue
quantity of bone is nibbled away with the upbiting 3-mm dye. It is easily identified. The only time a ligament is
disc rongeur (Fig. 15). The anterior margin of the inter- removed is when it is adherent to or is part of a large
vertebral foramen and the inferior margin of the upper posterior osteophyte, or when it is ossified (OPLL).
vertebral body are similarly removed. The dura is rarely (if ever) adherent to the posterior


© 1992 The American Association of Neurological Surgeons

© 1992 The American Association of Neurological Surgeons © 1992 The American Association of Neurological Surgeons

Figure 14. (Top) Freeing of the osteophyte with an osteophyte elevator. Figure 16. (Bottom right) Removal of a herniated disc fragment. The
extent of lateral bone removal is depicted.
Figure 15. (Bottom left) Excision of the osteophyte with a Kerrison


ligament or the osteophyte so there is no danger of dam- from the upper margins of the ilium so that the cortex of
aging the dura during the osteophyte removal. the iliac crest will be included along the side of the dowel
(Fig. 18C, arrow). This binds the two cortical ends of the
Obtaining the Bone Graft graft together to form a strong dowel which will not frac-
The bone graft (either dowel or wedge) used for cervical ture or collapse.
interbody fusion is obtained from a bone bank or from the The shaft of the dowel cutter can be turned by hand
patient’s ilium. Iliac bone is more accessible and is the best with a Hudson drill handle or attached to a power-driven
quality bone for spinal fusions. Different sizes and shapes cranial drill. The graft or grafts are placed and stored in a
of grafts are available. The bone grafts are obtained from dry gauze. The drill holes in the ilium are waxed and the
the patient’s anterior iliac crest immediately prior to or in wound closed with absorbable sutures. A large needle is
conjunction with the cervical operation or they may be re- passed through the drill hole from inside out, suturing the
moved the day before. Local anesthesia is used in the latter muscles on both sides through the drill hole. The skin
instance. These bone grafts are sealed in a sterile jar and wound is closed with subcutaneous inverted sutures and
placed in the deep freeze until used. surgical adhesive tape. A Jackson-Pratt drain is inserted
The patient’s pelvis is rotated to the left by placing if more than one graft is taken.
the right knee over the left thigh and inserting a large
sandbag beneath the right buttock (Fig. 17). An 8-cm di-
agonal skin incision is made over the iliac crest, three
fingers lateral to the anterior superior spine and 3 cm down
the fascia lata. The periosteum over the crest and lateral
surface of the ilium is stripped with a sharp periosteal
elevator and retracted wide enough to insert the dowel
cutter (Fig. 18A). A dowel cutter 2 mm larger than the drill
hole is selected along with its corresponding center pin.
© 1992 The American Association of Neurological Surgeons
It is attached to the shaft, and the projected center pin is
inserted high up into the ilium only 2 or 3 mm below the Figure 17. Position of the hip for harvesting the bone from the
upper margin of the crest and at right angles to its lateral iliac crest.
surface (Fig. 18B). It is important to remove the dowel

Figure 18. A, a dowel cutter is applied against the iliac bone for
harvesting a bone dowel. B, note that the dowel cutter is positioned
very close to the iliac crest. C, the side of the bone graft includes
© 1992 The American Association of Neurological Surgeons
cortical bone from the iliac crest (arrow).


Interbody Fusion
A tip for the dowel impactor is selected to correspond to
the diameter of the dowel. It is attached to the impactor
handle and screwed into the center pin hole in the dowel.
The anteroposterior diameter of the vertebral body is
measured with a depth gauge which is then set 2 or 3 mm
less (Fig. 19). The length of the dowel is fashioned with a
high-speed air drill to correspond to the depth gauge mea-
surements (Fig. 20). The size and shape of the dowel may
also be changed to fit the drill hole, removing the corners
of the round hole to an oval shape for an oval dowel. With
the bone graft firmly secured to the impactor, it is placed
in the drill hole to determine the size relationship (Fig.
21). Then with a few turns of the thumb screw on the
vertebra spreader to increase the vertical diameter of the
hole, the dowel is driven in with a few gentle taps of the
hammer. Heavy pounding is neither required nor neces-
sary. Manual traction of the head or extension of the neck
by the anesthetist for insertion of the graft may be dan-
gerous; the vertebra spreader is safer. If there are
osteophytes and/or a stenotic canal at the adjacent level,
the spinal cord may be injured from heavy pounding on
the first graft. If two levels are to be operated upon, it
may be wise to first remove the osteophytes at both levels
before impacting the grafts.
With the impactor still attached to the dowel, the
vertebra spreader is released and removed. The verte-
bral bodies will spring back together, firmly locking © 1992 The American Association of Neurological Surgeons

© 1992 The American Association of Neurological Surgeons

© 1992 The American Association of Neurological Surgeons

Figure 19. (Top right) Use of the depth gauge for determining the op- Figure 21. (Bottom right) Impaction of the dowel graft into the tre-
timum length of the dowel graft. phine hole.

Figure 20. (Left) The length of the dowel graft is fashioned to corre-
spond precisely to the depth gauge measurement, after allowing for a
safety margin of 2 or 3 mm.


the dowel in place. The impactor is then unscrewed from strengthen the fusion (Fig. 22).
the dowel and removed. A small pad of Gelfoam is packed When the toothed retractor blades are removed, the
into the bottom of the hole on both sides of the dowel to longus colli muscles return to their normal position. The
cover the nerve root. The cortical end plates may be fur- muscle is checked for bleeding points. The wound is irri-
ther broken up with a small curved osteotome. The bone gated with saline and a 7-mm Jackson-Pratt drain is cut
dust saved from the drill is packed into the interspace to to cover the exposed bone and is brought out through the
end of the skin incision (Fig. 23). The vertical retractors
are then removed and all cervical muscles returned to their
normal position.

Wound Closure
No deep sutures are required in the wound. However, if the
longus colli muscles are large and redundant their medial
margins can be pulled together with two or three fine su-
tures to cover the bone graft. Interrupted fine absorbable
sutures are used for a separate closure of the platysma
muscle (Fig. 24), keeping in mind that a figure-of-eight
stitch gives two sutures for one knot. Closing the platysma
muscle separately from the subcutaneous tissue will result
in a more cosmetically acceptable scar. If the platysma and
skin are sutured in a single layer, an ugly, puckered mov-
able scar may result. An inverted interrupted fine ab-
sorbable suture is used to close the subcutaneous layer
(Fig. 25A). The skin is never punctured (violated) with the
needle. Micropore paper tape is used to approximate the
skin edges (Fig. 25B). A gauze dressing is applied. The
© 1992 The American Association of Neurological Surgeons

© 1992 The American Association of Neurological Surgeons © 1992 The American Association of Neurological Surgeons

Figure 22. (Top left) The cortical plates of the vertebral bodies are Figure 23. (Bottom left) Insertion of a flat Jackson-Pratt drain.
removed with an osteotome. Bone dust is packed into the intervertebral
space on either side of the dowel to facilitate fusion. Figure 24. (Right) Approximation of the platysma layer with inter-
rupted inverted figure-of-eight sutures.


Jackson-Pratt drain is brought out through the center or

the end of the wound. It can be secured either with a
platysma muscle suture or the Steri-strips placed on the
skin, or both. The bulb of the Jackson-Pratt drain is at-
tached. The patient is extubated and moved to the recov-
ery room.

Postoperative pain from this operation is minimal and can
be controlled with mild analgesics. Steroids are given rou-
tinely. Decadron is administered intramuscularly every 4
hours, every 6 hours, and every 8 hours on three succeed-
ing days. This eliminates fever, dysphagia, and pain in
the neck and arms. The patient is permitted out of bed on
the day of operation. Movements of the neck are not re-
stricted. A brace is not required, but a soft cervical collar
is advised in more active patients. The drain is removed
when less than 10 ml of serum are obtained in an 8-hour
period, usually on the second or third day.
There is little danger of wound infection from the
drain. Postoperative antibiotics are seldom necessary. The
patient is discharged from the hospital on the third or
fourth postoperative day. X-ray films are taken prior to
discharge to determine the position of the graft and for
comparison with subsequent follow-up films.
The surgical technique for removal and fusion of two
or more discs is described in the following publication:
Spine 1988;13:823-827.

© 1992 The American Association of Neurological Surgeons

Figure 25. A, approximation of subcutaneous and subcuticular tissue.

B, application of adhesive micropore paper strips and the use of a
grenade suction reservoir.


PATIENT PRESENTATION AND SELECTION Electromyography and nerve conduction velocities

Patients with the cubital tunnel syndrome generally present give an objective assessment of the degree of the impair-
with weakness and atrophy of the intrinsic muscles of the ment of the ulnar nerve across the elbow. The commonly
hand and tingling and numbness in the medial two fin- observed features are as follows. The conduction veloc-
gers. Motor atrophy sets in early compared to the atrophy ity of the ulnar nerve across the elbow is slowed com-
associated with the carpal tunnel syndrome. Once motor pared to the velocity in the forearm segment of the ulnar
atrophy sets in, reversal is seldom rapid or complete; there- nerve. The amplitude of motor response in the abductor
fore, conservative treatment is less likely to help patients digiti quinti is decreased and the duration of the response
with the cubital tunnel syndrome than those with the car- is prolonged with stimulation of the nerve above the el-
pal tunnel syndrome. In neurosurgical practice, no appar- bow compared with stimulation below the elbow. This
ent etiology can be determined that accounts for the cu- finding is especially helpful in patients who have normal
bital tunnel syndrome. When the syndrome was described conduction velocity across the elbow in spite of typical
in the last century, it was related to malunited fractures clinical symptoms. The sensory latency is prolonged.
around the elbow involving either the distal humerus or Needle examination of the ulnar-innervated muscles may
the medial epicondyle. The ulnar paralysis came on years show varying changes. An early finding is a reduction in
after the healing of the fracture with the formation of exu- the voluntary motor unit action potentials. When axonal
berant callus. Cases in contemporary practice are seldom degeneration sets in, positive waves and fibrillation po-
due to compression from a callus. Rather, they are thought tentials may be observed.
to be due to the compression of the ulnar nerve in the Ulnar neuropathy should be differentiated from lesions
cubital tunnel by the sharp fascia that spans the two heads in the cervical spinal cord, lower cervical nerve roots, or
of the flexor carpi ulnaris. This is discussed further in the brachial plexus. Intrinsic spinal cord lesions are generally
section on surgical anatomy. painless, produce bilateral symptoms and signs, may be
On objective testing, one finds atrophy of the intrin- associated with Homer’s syndrome, and produce sensory
sic muscles, especially the first dorsal interosseous muscle. and motor loss in a segmental rather than peripheral nerve
There is usually weakness of the ulnar-innervated muscles, distribution. Extradural lesions such as cervical disc her-
including the palmaris brevis muscle, the abductor, op- niation or spondylosis produce characteristic root pains and
ponens, and flexor digiti quinti muscles, the flexor pollicis produce sensory and motor loss in a root distribution with-
brevis and adductor pollicis muscles, the medial two out alteration in nerve conduction velocity. Brachial plexus
lumbricals, and all of the interossei. The flexor carpi lesions involving the C8 and T1 roots may produce intrin-
ulnaris muscle is not generally affected because the fi- sic atrophy but the anatomic distribution will be one of
bers that subserve motor innervation of this muscle are root or plexus rather than peripheral nerve.
thought to be deep within the nerve and thus less com-
pressed than the fibers to the intrinsic muscles which are SURGICAL ANATOMY
situated more superficially. One should make sure that OF THE CUBITAL TUNNEL
there is no underlying peripheral neuropathy, either from The ulnar nerve originates from the medial cord of
diabetes or alcohol. If present, it may be hard to deter- the brachial plexus and descends down medial to the
mine to what extent the dysfunction is from the underly- brachial artery to the midarm. In the midarm at about
ing neuropathy and to what extent from the mechanical the level of the insertion of the coracobrachialis muscle,
impingement at the elbow. it pierces the medial intermuscular septum and de-
scends immediately behind the septum but in front of
© 1992 The American Association of Neurological Surgeons the medial head of the triceps to a point behind the


medial epicondyle. It then enters a fibrous tunnel, the so- nerve paralysis was the presence of exuberant callus in
called cubital tunnel, the roof of which is formed by the the distal humerus from a malunited fracture. In the early
two heads of the flexor carpi ulnaris muscle and a dense days, surgeons did not have good means of resecting the
fibrous band that spans across the two heads. The floor of callus to decompress the nerve; instead of subjecting the
the cubital tunnel is formed by the capsule of the elbow patient to a tedious procedure of resecting the callus, they
joint. During flexion, because of the separation of the rather transposed the ulnar nerve in front of the callus
medial epicondyle and the olecranon process, the fibrous which was a much simpler procedure. Nowadays, callus
band that connects the two heads of the flexor carpi ulnaris is rarely seen as the etiology for ulnar nerve compression
becomes very taut and is more likely to compress the u1nar at the elbows. Thus, there is no justification to transpose
nerve. During extension the fibrous band is more relaxed the nerve in contemporary practice. Most studies have
and less likely to compress the ulnar nerve. Repetitive shown that the transposition operation does not offer re-
motion that involves repetitive flexion at the elbow and sults superior to those of the simple decompression op-
adduction at the wrist, as is entailed in shoveling, may eration. Indeed, the complications and morbidity are less
produce compression of the nerve because of the scissor- with simple decompression than transposition. For these
like approximation of the two heads of the flexor carpi reasons, I prefer a simple decompression operation.
ulnaris and the increase in tension in the fibrous band
that spans the two heads. SURGICAL TECHNIQUE
It is important to note that the ulnar nerve has the The operation can be performed either with a brachial
widest diameter near the elbow because of the higher pro- plexus block or with general anesthesia. I generally pre-
portion of interstitial connective tissue within the nerve fer general anesthesia because it is more comfortable for
at this point. Indeed, in many individuals there is a bul- the patient. Application of a tourniquet is optional and I
bous swelling of the ulnar nerve behind the elbow. This do not use it. The entire arm is scrubbed from the axilla to
should not be mistaken for a neuroma. the wrist for 10 minutes with povidone-iodine soap and
then painted with povidone-iodine solution. The skin in-
CHOICE OF SURGICAL PROCEDURES cision (Fig. 1) is about 8 cm long. It starts 3 cm above the
There are basically three operative procedures that are elbow immediately posterior to the medial intermuscular
commonly done for patients with the cubital tunnel syn- septum, swings gently over in front of the medial epi-
drome. These are simple decompression of the ulnar nerve, condyle, and then drops down again into the forearm for
decompression followed by transposition of the ulnar nerve, about 3 cm. At the distal end of the skin incision, the basilic
and medial epicondylectomy. Medial epicondylectomy is vein will be noticeable. It is best not to transect the basilic
rarely done now because of the morbidity involved after vein, so the incision should stop just short of it.
removal of the medial epicondyle. Therefore, the choice The dissection is carried out with 3.5 × loupe magnifi-
is really between simple decompression and transposi- cation. The skin and subcutaneous bleeders are coagulated
tion of the ulnar nerve. with bipolar coagulation. A skin flap is reflected on both
I prefer a simple decompression operation for the sides; the surgeon dissects in the plane between the subcuta-
following reasons. It is generally said that recurrent dislo- neous fat and the deep fascia of the forearm. During this
cation of the ulnar nerve out of its groove leads to ulnar dissection, it is important to identify and preserve the branches
neuropathy from repeated trauma. The justification for of the medial cutaneous nerve of the forearm which
anterior transposition in such instances is that it protects traverses the subcutaneous tissue. Section of the nerve will
the nerve from chronic damage by impingement against
the epicondyle. However, studies have shown that recur-
rent dislocation of the nerve occurs in about 16% of nor-
mal individuals who have no evidence whatsoever of ul-
nar neuropathy. Thus, it has not been proved conclusively
that recurrent dislocation of the ulnar nerve predisposes
to ulnar neuropathy. Another justification for the trans-
position is that it offers a more direct course for the nerve.
There is a fallacy in this statement; the course is direct
and shorter only during flexion of the elbow but not dur-
© 1992 The American Association of Neurological Surgeons
ing extension. One should note that the ulnar transposi-
tion operation, viewed with a historical perspective, got Figure 1. The skin incision for decompression of the ulnar nerve. Note
started at a time when the most common cause of ulnar that the incision stops short of the basilic vein.


result in an area of numbness in the forearm and when Self-retaining retractors are then inserted. The deep
the patient awakens he will be alarmed to notice that his fascia is grasped with Adson forceps and incised in
original numbness has extended further into the forearm line with the skin incision (Fig. 2, A and B). The next
and may believe that his neurologic status has deterio- step is to identify the ulnar nerve in the arm. The best
rated from injury to the u1nar nerve. landmark for this is the sharp edge of the medial

Figure 2. A, B, incision of the deep fascia of the arm and

forearm. C, digital palpation of the medial intermuscular
septum and the ulnar nerve in the arm. © 1992 The American Association of Neurological Surgeons


© 1992 The American Association of Neurological Surgeons

Figure 3. A, section of the fascia over the ulnar nerve. B, section of C, the cut edges of the fascia are sewn over the flexor muscle on
the dense fascia spanning the two heads of the flexor carpi either side to prevent reformation of the cubital tunnel.
u1naris; a bulbous enlargement of the ulnar nerve is noticeable.


intermuscular septum. This can be palpated digitally (Fig. the skin with subcuticular sutures. No drain is used. The
2C). Just behind the medial intermuscular septum but in dressing is removed on the second postoperative day and
front of the medial head of the triceps is the ulnar nerve. no special further care is necessary.
This can be rolled under the finger (Fig. 2C). Once the
nerve is felt, the deep fascia over the ulnar nerve is di- RESULTS AND COMPLICATIONS
vided and the triceps muscle is gently retracted (Fig. 3A), The symptoms improve in over 80% of the cases. In pa-
exposing the ulnar nerve in the arm. There is usually a tients with an underlying peripheral neuropathy, either
bulbous swelling of the ulnar nerve as it reaches the el- from diabetes or alcoholism, the symptoms are less likely
bow (Fig. 3B). At this point, the dense fascia spanning to resolve. Also patients who wake up from an operative
the two heads of the flexor carpi ulnaris is identified. It procedure with ulnar neuropathy from failure to pad the
extends from the medial epicondyle to the olecranon pro- elbow do not fare well with ulnar nerve decompression.
cess (Fig. 3B). The most important step is to divide this If simple ulnar decompression fails, transposition of the
dense fascia well into the forearm until the surgeon is nerve is not likely to relieve the symptoms. If recurrence
sure that there is no remaining compression of the ulnar of symptoms is noted after simple decompression, it im-
nerve. It is not necessary to circumferentially isolate the plies that there is an underlying neuropathy, that the de-
nerve. Such a maneuver is likely to interfere with the blood compression is incomplete, or that the clinical diagnosis
supply to the ulnar nerve. One has to make sure that there is incorrect.
is no compression of the ulnar nerve by any fibrous band Making a trough in the flexor muscles and transpos-
or muscle fibers. To prevent reconstitution of the cubital ing the nerve and burying the nerve deep within the flexor
tunnel, the edges of the fascia are then sewn over the flexor mass has been advocated by some for recurrent cases.
muscles on either side with interrupted absorbable su- This creates another fibrous tunnel and the patients in the
tures (Fig. 3C). The decompression is now complete. long term invariably have recurrence of symptoms. I do
Meticulous hemostasis is obtained and the subcutaneous not advocate creating such a muscular trough for burying
layer is closed with interrupted absorbable sutures and the nerve after transposition.



INTRODUCTION herniation associated with simple fracture-subluxation is

Most neurosurgeons are comfortable with the anterior more common than previously thought. Following the
approach to the cervical spine and are familiar with removal of displaced disc or bone fragments, anterior plat-
interbody arthrodesis techniques. The ease of patient po- ing provides immediate internal stabilization, obviating
sitioning and tissue dissection makes this a popular pro- the need for a second posterior stabilization procedure or
cedure while providing direct access to common patho- halo immobilization.
logic compression. A successful interbody arthrodesis Caspar plate stabilization is useful in other types of
results in a highly stable block fusion that maintains nor- cervical trauma as well. Some hangman’s fractures with
mal cervical lordosis and intervertebral distances. How- C2-C3 disc and posterior longitudinal ligament disrup-
ever, in the presence of middle or posterior column insta- tion are highly unstable and cannot be adequately treated
bility it can be difficult to restore and maintain adequate by external immobilization. These fractures can be re-
stability with an interbody graft alone. The addition of an duced and stabilized with a Caspar plate to avoid the
anterior plate reestablishes and sustains stability, enhanc- obligatory loss of C1-C2 segment function associated with
ing the rate of bone healing. posterior internal fixation.
Historically, the potential risk of spinal cord or nerve The decreased risk of supine positioning and the ease
root injury associated with placing screws through the of operative exposure afforded by the anterior approach
cervical vertebral body deterred widespread use of ante- make anterior cervical plate stabilization an increasingly
rior internal stabilization. In addition, the potential risk popular alternative to posterior stabilization techniques
of instrument failure and subsequent injury to the esopha- even when decompression is not necessary.
gus and trachea has been a major source of concern. The Most locked facets can be reduced after anterior de-
development of a comprehensive surgical technique rely- compression with a combination of distraction and gentle
ing on implants and instrumentation (Aesculap Instrument manipulation and therefore do not constitute an absolute
Co., Burlingame, California and Aesculap Werde AG, contraindication for anterior cervical plating. However,
Tuttlingen, Germany) designed specifically for the cervi- if a locked facet is disassociated from the vertebral body
cal spine has made anterior internal fixation a freely ap- by a fracture through the pedicle, reduction via an ante-
plicable technique for spinal surgery today. rior approach may not be possible. Locked facets not re-
quiring anterior decompression are still best treated by
PATIENT SELECTION posterior reduction and stabilization.
The Caspar osteosynthetic stabilization technique was The indications for Caspar plating are not limited to
originally developed as a one-stage procedure for the treat- traumatic lesions of the cervical spine but can also include
ment of cervical trauma requiring anterior decompres- the treatment of degenerative diseases, tumors, and other
sion. Cervical burst fractures associated with partial cord processes requiring stabilization. Degenerative subluxation
injuries and/or root lesions often require decompression. with associated osteophytic root or cord compression can
It has also become apparent from recent use of magnetic be decompressed, reduced, and stabilized with the Caspar
resonance imaging (MRI) in cervical trauma that disc plate. Ossification of the posterior longitudinal ligament,
severe multilevel cervical spondylosis, and tumors of the
© 1992 The American Association of Neurological Surgeons vertebral body or anterior spinal canal are increasingly


being treated with cervical corpectomy followed by strut The addition of high-dose steroids in the perioperative pe-
graft reconstruction. The major complication associated riod may provide some protection against neural injury sec-
with cervical corpectomy is graft extrusion. The addition ondary to minor trauma or edema.
of a Caspar plate provides an anterior tension band that
deters graft extrusion and enhances fusion. Likewise, the OPERATIVE TECHNIQUE
risk of pseudoarthrosis increases following multilevel
discectomies for cervical spondylosis as the number of Anesthetic Technique
levels of decompression increases. Caspar plating with As with any cervical spine surgery, care should be taken
fixation at each intervening vertebral body will decrease during intubation to avoid movement of an unstable spine
the chance of malunion. or excessive hyperextension of a stable spine. Nasal intu-
The holding power of a screw in bone is directly re- bation with the assistance of a bronchoscope is usually
lated to the density and quality of the bone. In addition, preferable. After positioning the endotracheal tube, gen-
the plate and screws merely act as an internal splint while eral anesthesia is rapidly induced with sodium pentothal
bony remodeling occurs. If fusion is not ultimately and maintained with volatile anesthetic agents. Muscle
achieved, repeated stress on the instrumentation will even- relaxation should be avoided because stimulation of a
tually lead to treatment failure. Young healthy bone, most nerve root will give instant feedback in the form of a
common in traumatic cervical spine injuries, is ideally muscle twitch, providing “poor man’s evoked potentials.”
suited for anterior cervical stabilization. It provides ex-
cellent screw purchase and rapid bone healing. On the Positioning
other hand, osteoporotic bone has decreased density and The patient is placed supine with the head of the table
heals more slowly; therefore, the risk of screw loosening elevated 10° to 15° relative to the feet (reverse Trendelen-
is greater and the stresses on the plate are prolonged. These burg position), providing a direct line of vision through
problems combine to increase the risk of instrumentation the plane of the disc space. The head should rest on a
failure and malunion. The spinal surgeon must augment narrow support, such as a horseshoe head holder, in order
the stabilization with external bracing in accordance with to facilitate fluoroscopy. The addition of an adjustable
the quality of the patient’s bone. neck support assists in restoring and maintaining the
proper cervical lordosis throughout the procedure. Trac-
PREOPERATIVE PREPARATION tion is applied to the skull (2 to 8 kg) and arms (1 to 2 kg/
An attempt should be made to restore normal alignment arm utilizing padded cuffs) to maintain cervical alignment
with external traction prior to surgical intervention for and improve fluoroscopic visualization. The C-arm fluo-
cervical trauma. Skull traction is also useful for main- roscopy unit is positioned to provide a true lateral view
taining alignment during surgery. with the X-ray tube on the operative side (Fig. 1). The
A thin slice computed tomography (CT) scan is help- surgeon and assistant stand on either side of the X-ray
ful in identifying fractures and displaced bone fragments tube which is draped into the sterile field with a C-arm or
that are not seen on plain X-ray films. MRI may demon- Mayo stand cover.
strate disc herniation or hematoma compressing neural The hip should be slightly elevated with padding to
elements and may also show intramedullary pathology. facilitate exposure of the iliac crest if a graft is to be har-
When dealing with nontraumatic problems, MRI and CT vested. Meticulous care should be taken during draping
myelography are both useful for demonstrating neural to ensure a sterile, waterproof field. This is best achieved
compression. using a layer of adhesive-backed plastic drape over the
Because of the increased risk of infection associated prepared skin, followed by cloth or paper drapes. A sec-
with foreign body implantation, preoperative antibiotics are ond plastic drape can be applied to secure the drape edges
recommended to reduce the risk of infection by the common as well as any wires and cables that cross the sterile field.
offending organisms. An antistaphylococcal antibiotic, such
as a first or second generation cephalosporin, should be ad- Surgical Procedure
ministered intravenously within 1 hour of the skin incision
and repeated as an equivalent dose at the termination of the Skin Incision and Exposure
procedure or after 4 hours, whichever occurs first. If Foley Debate on the preferred side for a cervical skin inci-
catheter drainage is used or other potential Gram-negative sion has centered around the increased risk of injury to
contamination is present, gentamicin or an equivalent anti- asymmetrical structures in the neck, such as the recur-
biotic should be added to each antibiotic dose. These antibi- rent laryngeal nerve. However, unless the patient’s pa-
otics should be continued for 36 to 48 hours postoperatively. thology dictates otherwise, the surgeon’s dominant


Figure 1. Surgical positioning. The back and

head are elevated 10° to 15° and the neck is
extended. Traction is applied to the arms with
soft wrist cuffs (1 to 2 kg/arm) and to the skull
with Gardner-Wells tongs (2 to 8 kg). The C-
arm fluoroscope is positioned to provide a true
lateral view of the cervical spine. The chin strap
helps to stabilize the head and hold the chin out
of the surgical field. The neck rest is adjusted
© 1992 The American Association of Neurological Surgeons
to establish a normal cervical lordosis.

handedness should determine the side of the incision with to produce a relaxed skin incision. The middle and deep
right-handed surgeons exposing from the right side and layers of the cervical fascia are dissected along the me-
vice versa for left-handed surgeons. dial border of the sternocleidomastoid muscle. The
The level of incision is determined by fluoroscopic esophagus, trachea, and strap muscles are retracted me-
visualization and should overlie the midpoint of the cer- dially, and the carotid sheath and sternocleidomastoid
vical fusion. A wide transverse neck incision is placed muscle are retracted laterally. The omohyoid muscle which
within a skin fold extending 1 or 2 cm beyond the mid- crosses the exposure obliquely at the C5-C6 level can be
line. When three or four motion segments are being sta- mobilized or, if necessary, transsected. If a thyroid artery
bilized, an oblique incision along the medial border of interferes with the exposure it can be ligated and
the sternocleidomastoid muscle may be preferable. transsected. The exposure required for stabilization is
Generous myocutaneous flaps incorporating skin and much greater than that required for a simple anterior
platysma muscle are developed superiorly and inferiorly discectomy and interbody arthrodesis. It is exceedingly im-


portant to adequately dissect the soft tissues of the neck pin hole is drilled after verifying the trajectory with fluo-
to provide ample exposure without injuring the fine neu- roscopy, and a distraction pin is inserted. This pin can
rovascular structures of the neck. Inadequate exposure then be used along with the immobile distractor arm,
leads to excessive swelling, dysphagia, and hoarseness drill guide assembly to position other distraction pins in
in the postoperative period. a parallel fashion. Each distraction pin should be inserted
The longus colli muscles are detached from the verte- fully so that the base plate is flush with the vertebral
bral bodies bilaterally and are elevated from the disc space body. If an abnormal curvature is present, individual
above to the disc space below the level of fusion. The lon- distraction pins may need to be placed freehand to posi-
gus colli muscles should be dissected widely while avoid- tion them parallel to the endplates of the vertebral bod-
ing maceration of the muscle bellies because they must ies. Distraction pins placed parallel to the endplates of
sustain powerful lateral retraction. Serrated blades which the vertebral bodies will allow the distractor to restore
readily retain their position are placed beneath the longus the normal curvature even in the presence of significant
colli muscles under direct vision and are attached to the deformities. The vertebral body distractor is placed over
self-retaining retractor (Fig. 2). Toothless blades are used the shafts of the distraction pins and distraction forces
for longitudinal countertraction. For extensive exposure, are applied gradually.
tandemly placed lateral retractor systems can be used. A complete discectomy is performed with care to
remove the cartilaginous endplates. Anterior
Decompression and Graft Site Preparation osteophytes, bony irregularities, and the anterior infe-
The operative level is verified with fluoroscopy, and a rior lip of the superior vertebral body can be removed
partial discectomy is performed. The uncovertebral junc- with a high-speed drill to facilitate the discectomy. If a
tion should be identified bilaterally to facilitate the iden- total or partial corpectomy is to be performed, the discs
tification of the vertebral midline. The distraction pin above and below the vertebral body are removed. The
drill guide is positioned over the center of the vertebral anterior portion of the corpectomy can be performed
body and directed parallel to the vertebral endplate. The using a rongeur, and the bone fragments can be saved

© 1992 The American Association of Neurological Surgeons

Figure 2. The intraoperative fluoroscopic image (A) and the matched draw- sualize instruments such as the blunt hook (h) which would otherwise be
ing (B) demonstrate the longitudinal retractor blades (a) and the radiolucent obscured. The distraction pins (p) are inserted into the center of the verte-
lateral retractor blades (b). The radiolucent blades allow the surgeon to vi- bral body as far as possible without penetrating into the canal.


as augmentation for allografts. After the decompression midline of the vertebral body from the posterior cortex to
has been completed, any persistent abnormal cervical cur- the anterior cortex. The height of the graft site (i.e., the
vature or locked facets can be corrected by gently ma- distance between the vertebral endplates) is measured in
nipulating the distractors and the neck rest. the maximally distracted condition. The average graft
The endplates are then prepared to accept a graft. It should measure 7 to 8 mm in height but should not be
is important that the underlying cancellous bone not be greater than 10 mm to avoid overdistraction when there is
exposed by complete removal of the endplates since this severe ligamentous disruption.
will decrease the intrinsic supporting capacity of the ver- A tricortical iliac crest bone graft is ideal for interbody
tebral body and predispose the sturdy graft to penetrate arthrodesis up to a two-level corpectomy. Larger decom-
the weakened vertebral bodies. Due to the different shape pressions may require a fibular graft. Iliac crest osteoto-
of the superior and inferior endplates, production of par- mies should be at right angles to the surface of the crest
allel surfaces for grafting requires selective drilling of and parallel to each other. A double-bladed oscillating saw
the anterior third and posterior third of the caudal endplate ensures parallel surfaces. When harvesting iliac crest strut
and the posterior third or half of the rostral endplate (Fig. grafts for subtotal and total body replacement, it is prudent
3). When performed correctly, the graft site has parallel to include several extra millimeters to allow for reshaping.
surfaces with sufficient cortical bone remaining to sup- The depth of the graft should measure 3 mm less than
port the graft. A common error is failure to remove enough the anteroposterior diameter of the prepared interspace
anterior and posterior bony lip, thus leaving a central gap (generally about 15 mm in depth). This allows a suffi-
between the bone graft and vertebral endplate. A more cient margin of safety anterior to the spinal cord once the
serious error is the “ramp effect” caused by excessive bone bone plug is seated into place. Contrary to standard ante-
removal from the anterior two-thirds of the lower verte- rior fusion techniques, the bone plug is not countersunk
bral body. This produces a graft site that is taller anteri- for plating but is left flush with the anterior surface of the
orly than it is posteriorly and fosters forward dislocation spine. The edges of the graft can be beveled slightly to
of the graft. facilitate insertion.
The fabricated graft is tamped into position with the
Grafting vertebral bodies distracted and should fit snugly without re-
A tight-fitting “gapless” graft requires an appropriately quiring excessive force or hammering. The position of the
sized, well-formed bone plug as well as a meticulously graft can be inspected with a blunt hook placed along the
prepared graft site. Using a micrometer and depth gauge side of the graft under fluoroscopic guidance. Once the graft
to measure the height and depth of the graft site accu- is ideally situated, the vertebral body distractor can be used
rately, the proper dimensions of the bone plug can be de- to compress the fusion while small bits of cancellous
termined. The depth of the graft site is measured in the bones are gently impacted to fill the gaps. Similarly, when a

Figure 3. This schematic drawing demonstrates the appropriate bony removal necessary for creation of a parallel graft site.


fibular graft is used, cancellous bone chips can be laid is appropriately shaped and adequate torque is obtained
along the sides of the graft to enhance the fusion. In ei- on the screws as they are tightened. It is important to re-
ther case, care must be taken to avoid compression of the store normal alignment to prevent further injury to the
neural structures with these smaller bits of bone. spinal cord and to reestablish normal biomechanical rela-
At this point the distraction pins can be removed and tionships in the remainder of the cervical spine.
a small piece of Gelfoam or bone wax used to stop the The plate should be positioned carefully prior to drill-
hemorrhage from the hole. Any bony irregularities of the ing the screw holes. Because the exposure is not truly
anterior vertebral bodies can be removed with a drill to midline, there is a tendency to position the plate slightly
ensure that the plate fits flush. Maximum plate-to-bone toward the side of the incision. The uncovertebral joints
contact enhances the structural stability of the construct. and longus colli muscle insertions are useful landmarks
for identifying the midline. A temporary plate fixitor has
been designed for use with the new titanium plates which
Plating should make the positioning process easier.
Two very important points regarding Caspar anterior cer- The dual drill guide is adjustable for depth and di-
vical plating cannot be overstated. First, plate stabiliza- rects the screw holes in a converging course toward the
tion cannot be properly or safely performed without us- posterior cortex of the vertebral body. The appropriate
ing fluoroscopy. Dispensing with X-ray guidance will very depth can be estimated from the previously measured
likely lead to faulty plate fixation and could lead to disas- depth of the interspace and adjustments made in the guide
trous complications. Second, the surgeon should never to safeguard against overpenetration with the drill bit.
plate across an infused disc space. One should keep in The ideal screw position should maximize bone con-
mind that plating merely provides a temporary internal tact and should engage both the anterior cortex and the
splint which enhances the fusion process. It is the ossifi- posterior cortex of the vertebral body (Fig. 4). There is
cation of the graft placed in the cleared disc space that ample room between the spinal cord and the posterior
provides the long-term stability. If the plate crosses an cortex of the midvertebral body to accommodate slight
intact disc space, screw loosening or fracture will eventu- penetration of the screw tip. The intact posterior longitu-
ally occur because of the micromotions that remain pos- dinal ligament protects the dura. The screws are prefer-
sible. ably placed within the central third of the vertebral body
The plate selected will bind the intact vertebral bod- in the sagittal plane but can be placed outside of this re-
ies above and below the level(s) of instability. For a single gion as long as they do not violate the vertebral endplate
level fracture-subluxation, the plate should span the disc (Fig. 5). The optimum screw trajectory is a slightly ob-
space plus the adjacent vertebral bodies. For multilevel lique, medially directed angle of approximately 15°, par-
instability or vertebral body replacement procedures, the allel to the vertebral endplates. However, screws can be
plate will span two or more disc spaces plus the intact angled cephalad or caudad but, again, should not violate
vertebral bodies above and below the levels of instability. the endplate. At least two screws should be placed into
After selecting the appropriate length of plate by inspect- each vertebral body, not only for the added holding power
ing its fit with the C-arm fluoroscope, the plate is bent in but to prevent rotation. A distraction pin hole should not
a convex fashion to achieve a normal lordotic posture af- be used as a screw hole, as it has been widened during the
ter fixing the plate to the spine. Generally speaking, the distraction process.
curve should be smoothly distributed along the length of With the plate in position over the vertebral bodies,
the plate; the treatment of C2-C3 instability requires an the drill-guide tips are inserted into the holes of the plate.
exception. In this instance, the upper edge of the plate Generally, the most easily accessible level is drilled first so
should be more sharply bent to conform to the ventral the plate can be fixed loosely with two screws. The drill is
shape of the C2 vertebral body. inserted into the guide and the final trajectory is verified
The bent plate should be positioned over the verte- with fluoroscopy. Holes should be drilled deliberately and
bral bodies and inspected with fluoroscopy. The fit is carefully, relying on the feel of the drill and frequent fluo-
judged appropriate when the ends of the plate rest ap- roscopic visualization. A blunt K-wire is inserted into the
proximately 2 mm from the upper and lower endplates freshly drilled hole under fluoroscopic vision. The K-wire
and 3 to 5 mm of space exists between the center of the is useful for palpating the posterior cortex and posterior
plate and the vertebral column. Tightening the screws with longitudinal ligament at the depth of the drill hole and tem-
this bowed configuration will tend to shift the vertebral porarily stabilizes the plate and drill-guide.
bodies into the appropriate lordotic curvature. Restora- The screw holes are measured using the depth
tion of cervical lordosis can only be achieved if the graft gauge with the plate in position. The appropriate


© 1992 The American Association of Neurological Surgeons

Figure 4. Illustration of proper screw placement. A, screws should be caudad, but they should not penetrate the vertebral endplate. B, the
inserted in the middle third of the vertebral body and should penetrate optimal transverse screw trajectory is an oblique, slightly medially
the posterior cortex. It is acceptable for screws to angle cephalad or directed angle.

Figure 5. Examples of suboptimal screw placement. Failure to pen-

etrate the posterior cortex allows the screw to toggle and ultimately
© 1992 The American Association of Neurological Surgeons
back out. Screws should not penetrate into the graft site or adjacent
disc space.


screw is selected and inserted but not tightened fully. Once can be engaged fully without penetrating into the canal.
all of the screws are in position they can be tightened se- If a hole is stripped or a screw fails to tighten ad-
quentially “two fingers” tight (Fig. 6). Ideally the screw tips equately, the screw should be removed. Several salvage
should completely penetrate the posterior cortex without techniques are available, including using an oversized
extending into the spinal canal (Figs. 7 and 8). Some pen- rescue screw, redirecting and drilling a new hole with the
etration beyond the posterior cortex is allowable but no single drill guide, or filling the stripped hole with acrylic.
more than the width of one thread. The new titanium screws Also, an additional screw that abuts a tenuous screw can
are manufactured with a flat tip so that the posterior cortex often increase overall holding power.

Figure 6. Intraoperative photograph

showing a single level titanium plate at
the completion of the reconstruction and
© 1992 The American Association of Neurological Surgeons plating.


© 1992 The American Association of Neurological Surgeons

Figure 7. A, a single level interbody reconstruction and plating. The subtotal body replacement and plating. Note that the screws penetrate
plate fits flush with the vertebral body and graft but does not extend the posterior cortex of the partially resected body. C, total body replace-
beyond the superior and inferior endplates of the vertebral bodies. B, ment and plating.


plied in other situations requiring corpectomy such as ossi-

fication of the posterior longitudinal ligament or vertebral
body destruction secondary to tumor.

Wound Closure
After irrigating the wound and obtaining hemostasis, the
deep fascia can be reapproximated over the plate with 3-
0 absorbable sutures. A 3/16-inch, closed system drain is
placed at the depth of the wound and the platysma muscle
layer is reapproximated with 3-0 absorbable sutures. The
subcutaneous tissue and skin can be closed with inverted,
interrupted, subcuticular stitches using 4-0 absorbable
suture material. Placement of Steri-strips over the skin
edges results in a cosmetically pleasing closure.
The iliac crest donor site can be waxed and, if deemed
necessary, a small drain inserted. The fascia is
reapproximated over the crest with 1-0 absorbable sutures
and the subcutaneous tissue closed with inverted stitches
using 2-0 absorbable sutures. The skin can then be closed
with staples.

The plate acts as an internal splint, reducing the need for
© 1992 The American Association of Neurological Surgeons
external bracing, but it does not necessarily obviate the
Figure 8. Lateral fluoroscopy after the plate has been secured and the need for external bracing. The brace should be tailored to
retractors removed. Note the slight bend in the plate that restores the the individual based on the quality and complexity of the
normal lordotic curvature. reconstruction. Young, healthy bone as commonly encoun-
tered in trauma heals rapidly and holds screws well, and
Subtotal and Total Body Replacement therefore a soft collar is usually sufficient. On the other
When teardrop fractures or anterior body compression hand, osteoporotic bone has diminished screw-holding
fractures accompany an unstable spine, the bone fragments power and is slower to heal. For patients with osteoporo-
can be removed along with discectomies above and be- sis, a supplementary hard collar is recommended. In fact,
low the fractured body. A “U-shaped” block graft is con- the need for a halo brace should not be considered as a
structed to span the distance between the adjacent intact failure of the plating. An anterior cervical plate and a halo
vertebral bodies and envelope the intervening partially can complement each other in difficult high-risk cases.
resected body (Fig. 7B). A plate is then applied with screws The patient should be followed with frequent X-ray ex-
through both the anterior and posterior cortices of the in- amination until fusion has occurred and external bracing
tact vertebral bodies. Screws are also placed at the center should be modified as needed.
of the plate through the strut graft and the posterior cor-
tex of the partially resected vertebral body. As the screws COMPLICATIONS
are tightened, any residual subluxation is usually reduced The surgical exposure and operative time required for
and the normal lordotic curvature can be restored. cervical plating is increased compared to that required
For severe compression fractures of the vertebral body, for decompression and interbody reconstruction alone.
particularly when bone fragments are retropulsed and com- If soft tissue dissection is inadequate, prolonged ex-
promising the spinal cord, a complete vertebral corpectomy cessive retraction forces increase the risk of injury to
may be necessary. A block graft is situated in the defect, the structures of the neck. The consequences of inad-
tightly abutting the adjacent vertebral endplates (Fig. 7C). equate soft tissue relaxation are vocal cord dysfunc-
The screws are applied through both the anterior and pos- tion and dysphagia. Retraction forces can be reduced
terior cortices of the intact vertebral bodies. However, the by securing the lateral retractor blades under the lon-
central graft-holding screws should penetrate only the an- gus colli muscles. Although the serrated edges of the
terior two-thirds of the graft, thereby preventing posterior retractor blades threaten esophageal injury, if appro-
displacement of the graft. This technique also can be ap- priately secured under the longus colli muscles


the toothed blades actually reduce the overall risk of soft There is a race between bony union and instrument
tissue injury. failure. Once fusion occurs, the tension on the screws and
The majority of instrumentation failures can be at- plate are relieved. Delayed screw loosening, screw break-
tributed to technical errors in reconstruction as well as to age, and plate migration are indicative of an incomplete
improper plate and screw installation. The foundation for fusion. Screw loosening of one or two threads usually re-
a sturdy fusion construct relies on a sound bony recon- mains asymptomatic and is tolerable so long as bony union
struction. The graft and graft site should be shaped to ultimately occurs. If fusion does not occur, screw loosen-
provide maximum bony contact and should attempt to ing can proceed to screw extrusion or fracture.
restore normal anatomic relationships. Meticulous atten- Multilevel fusions are more prone to failure because
tion to detail during the preparation of the graft site and the forces are increased by the longer lever arm of the
the shaping of the graft is essential for a gratifying result. plate. Because of the increased stress on the implant, the
Similarly, accurate plate and screw positioning requires quality of the reconstruction becomes even more impor-
careful attention to bony landmarks with direct vision and tant. Every attempt should be made to restore the normal
fluoroscopy. cervical alignment and achieve maximum screw torque.
The quality of the patient’s bone is of paramount In addition, these cases should be augmented by more
importance. Osteoporotic bone has diminished support- substantial external bracing.
ive structure. Mismatches between the density of the re- The addition of an anterior cervical plate is never a
maining vertebral bodies and the intervening graft can substitute for proficient surgery. The bony reconstruction
result in graft penetration and settling of the overall con- is the principal component of the overall construct and
struct. Settling in turn increases stress on the screws lead- forms the foundation for remodeling. Therefore, meticu-
ing to screw loosening and plate migration. Osteoporotic lous attention to detail during this portion of the opera-
bone has a decreased coefficient of friction which trans- tion is exceedingly important. If the bony reconstruction
lates to decreased screw-holding power. With all other is performed correctly, adding a plate is much easier and
traction and torsion forces remaining equal, osteoporotic more effective. Of course, satisfactory plating technique
bone has an increased risk of screw loosening. Finally, is also important and relies on appropriate plate selection
osteoporotic bone is slower to heal. During prolonged bony and shaping as well as accurate screw placement. Skillful
remodeling the fusion construct is subjected to continued craftsmanship throughout all the steps of the procedure
stresses, increasing the chance of failure. described will enhance the overall outcome.



Anterior communicating artery aneurysms comprise 25 to All patients with a suspected subarachnoid hemorrhage
30% of all intracranial aneurysms. The patients generally should undergo emergent computed tomography (CT) scan-
present following a subarachnoid hemorrhage with symp- ning to identify the presence of blood in the subarachnoid
toms ranging from headache and meningismus to coma. space (e.g., basal cisterns, interhemispheric fissure, sylvian
Infrequently, aneurysms in this location will reach giant fissures) or ventricular system (Fig. 1). A lumbar puncture
size and the patient will present with symptoms secondary may help to confirm the diagnosis if CT scanning is equivo-
to compression of adjacent structures. Hemorrhage in the cal, provided there is no evidence of increased intracranial
region of the anterior communicating artery generally pro- pressure. Frequently the location of the hemorrhage
duces symptoms referable to hypoperfusion or compres-
sion of adjacent structures: optic nerves and chiasm, hypo-
thalamus, forebrain limbic structures, anterior internal
capsule, or perforating vessels to the basal ganglia. Clini-
cal management of aneurysmal subarachnoid hemorrhage
is focused on preventing further rebleeding and minimiz-
ing the effects of the initial hemorrhage. We will focus on
the management and operative approach to aneurysms aris-
ing from the anterior communicating artery.

All patients with subarachnoid hemorrhage referable to
an angiographically verified intracranial aneurysm should
be considered for surgical obliteration of the aneurysm.
Patients who meet criteria for Hunt and Hess grades I and
II without evidence of cerebral vasospasm, either by an-
giography or transcranial Doppler measurements, should
undergo aneurysm surgery at the earliest reasonable op-
portunity. Surgery may be delayed in patients who are
grades III and IV with significant vasospasm to allow
medical conditions to stabilize, to allow subarachnoid
blood to clear (aiding surgical dissection), and to avoid
© 1992 The American Association of Neurological Surgeons
the potential of a poor outcome associated with early sur-
gery on poor grade patients. Figure 1. Axial computed tomography scan of a 56-year-old man
presenting with the acute onset of headache, meningismus, and pho-
tophobia. Subarachnoid hemorrhage is present in the anterior inter-
© 1992 The American Association of Neurological Surgeons hemispheric fissure, basilar cistern, and both sylvian fissures.


on CT suggests the source, which is especially helpful

when multiple aneurysms are present.
Routine preoperative laboratory studies including
electrolyte determinations, complete blood count, clot-
ting parameters, bleeding time (if the patient is on aspirin
products or nonsteroidal antiinflammatory medications),
and serum osmolality should be obtained. Baseline x-ray
films of the chest and an electrocardiogram are also part
of the initial assessment.
If the patient is symptomatic from hydrocephalus or
an intracranial hematoma, ventricular drainage or evacu-
ation of the hematoma is carried out expeditiously, de-
pending on the clinical status of the patient. If immediate
surgical intervention is not required, cerebral angiogra-
phy is performed urgently to locate the source of the sub-
arachnoid hemorrhage and to aid in subsequent manage-
ment. For completeness, this study should include bilateral
carotid and posterior circulation studies, which will also
detect the presence of multiple aneurysms (found in 10-
20% of patients with aneurysmal subarachnoid hemor-
rhage). Angiography must satisfactorily demonstrate the
aneurysm neck, the relationship of the parent vessels, and
© 1992 The American Association of Neurological Surgeons
the primary side of filling. In the case of anterior com-
municating artery aneurysms, angiography must delin- Figure 2. Transorbital view of a right carotid angiogram of the patient
eate the dominant Al segment if possible. This may re- In Figure 1 reveals a 1-cm anterior communicating artery aneurysm.
quire multiple attempts including transorbital views, The right-sided injection fills the ipsilateral Al segment and bilateral
cross-compression of the contralateral carotid artery, and A2 segments with no evidence of vasospasm.
subtraction techniques (Fig. 2). Magnetic resonance im-
aging angiography is a promising addition to the radio-
logic evaluation, but at present it does not replace direct
intracarotid injection.
The presence of significant cerebral vasospasm may 7. ε-Aminocaproic acid (5 g intravenous loading dose,
alter management decisions. A baseline transcranial Dop- then 36 g/24 hours);
pler ultrasound study of intracranial flow velocities to 8. A stool softener (docusate sodium 100 mg by mouth,
compare with the initial angiogram is useful to guide treat- 3 times/day);
ment, particularly in poor grade patients. 9. A Foley catheter to monitor urine output (especially
in grades III and IV patients);
PREOPERATIVE MEDICAL MANAGEMENT 10. A histamine-blocking agent (e.g., ranitidine, 50 mg,
Patients not requiring emergent surgical intervention are intravenously, every 8 hours);
placed on a standard subarachnoid hemorrhage protocol 11. Codeine, 30-60 mg, intravenously, every 4 hours as
in an attempt to minimize agitation, control blood pres- needed for headache;
sure, maximize cerebral perfusion, and prevent 12. An antihypertensive agent to maintain systolic blood
rehemorrhage. This will include: pressure at 160 mm Hg or below (hydralazine, 10
mg, intravenously, every 1-2 hours or labetalol, 5-10
1. Strict bedrest with minimal essential nursing inter- mg, intravenously, every 1-2 hours) as necessary de-
vention; pending on heart rate. Avoid the use of additional
2. Pneumatic compression devices with elastic calcium channel blocking agents if the patient is on
stockings; nimodipine.
3. Phenobarbital, 30-60 mg, intravenously, every 4-8
hours as needed for agitation; If clinical and/or radiologic evidence of cerebral va-
4. Dilantin, 100 mg, intravenously, every 8 hours after sospasm is present, a central venous pressure line is placed
an appropriate loading dose; and volume expansion with Plasmanate or Hespan is un-
5. Nimodipine, 60 mg by mouth every 4 hours; dertaken to maintain central venous pressure (CVP) in
6. Intravenous fluids to maintain euvolemia (unless the 10-12 mm Hg range. Careful monitoring of oxygen-
clinical and radiologic evidence of vasospasm is ation is required in patients with compromised cardiac
present); function to avoid congestive heart failure.



Prior to the planned operation, patients are maintained on Following local infiltration with 1% lidocaine (epineph-
nothing by mouth for 6-8 hours. Premedications include rine is not used), a curvilinear skin incision is marked
dexamethasone, 10 mg IV and perioperative antibiotics for as indicated in Figure 3. The incision curves from a point
48 hours (generally vancomycin, 1 g, and gentamicin, 70 1 cm anterior to the tragus to the midline and extends to
mg). Large-bore intravenous access, an arterial blood pres- the glabella. This allows excellent visualization of the
sure monitoring catheter, and central venous access (pref- frontal region and with careful skin closure does not re-
erably with a pulmonary artery catheter) are placed in all sult in an adverse cosmetic outcome. Alternatively, the
patients to facilitate the avoidance of wide alterations in incision may end at the hairline to avoid the forehead
blood pressure and volume status intraoperatively. incision. The incision should avoid the superficial tem-
We customarily approach anterior communicating poral artery if possible. Hemostatic clips are applied to
artery aneurysms via the pterional approach. The choice the wound edges.
of operative side is based on the arterial anatomy and the
anatomy of the aneurysmal fundus. Whereas others have Dissection
advocated a right-sided approach in all cases where the A standard frontotemporal (pterional) craniotomy is
surgeon is right-handed, we prefer to operate from the performed, taking the incision to the midline and low
side of the dominant A1 segment and/or on the side clos- so that the anterior burr hole can be placed low in the
est to the aneurysmal neck. In this respect, we do not hesi- forehead, allowing sufficient exposure along the floor
tate to come from the left side if the aneurysm clearly of the frontal fossa (Fig. 3). The scalp and temporalis
points to the right and the left A1 is dominant. The major- muscle are taken up as a single flap without subgaleal
ity of approaches, however, are right-sided. dissection, thus avoiding injury to the frontalis branch
of the facial nerve. Four burr holes are placed as shown
OPERATIVE TECHNIQUE (Fig. 3) and connected with the Midas Rex drill, plac-
ing a low cut over the orbital rim and along the floor of
Positioning the frontal fossa. The high-speed air drill is used to
Following the induction of anesthesia and the placement take down the sphenoid ridge radically as for aneurysms
of monitoring lines and a lumbar drain, the patient is po- on the internal carotid artery. Likewise, the inner table
sitioned supine with the ipsilateral shoulder elevated on a of the skull along the anterior portion of the bone edge
rolled sheet. A three-pin Mayfield head rest is placed for is drilled away, allowing a few millimeters additional
skull fixation with the single pin in the contralateral fore- exposure for the microscope beam. Prior to the dural
head (Fig. 3). The head is rotated contralaterally in slight incision, the spinal drainage catheter is opened and 50-
extension, placing the ipsilateral malar eminence most 100 ml of spinal fluid is allowed to drain. The dura is
superior. The hair is generously shaved to avoid contami- opened in a curvilinear fashion (Fig. 4) and retracted
nation and the operative site is prepared with two 10- over the base.
minute scrubs of Betadine solution and allowed to dry. The arachnoid over the sylvian fissure is cauter-
ized and incised as shown in Figure 5. Dissection pro-
Draping ceeds under the operating microscope with placement
Sterile plastic barrier drapes are placed 2 cm past the of a brain retractor on the frontal lobe over Telfa
midline, across the brow, and just anterior to the tragus pledgets. The surgeon identifies first the olfactory nerve
including the root of the zygomatic arch. An iodine-im- and subsequently the optic nerve and ipsilateral ca-
pregnated adhesive drape is placed over the operative site rotid artery. The frontal retractor is then affixed with a
and an additional two layers of adhesive-lined disposable Greenberg self-retaining apparatus. A second taper point
drapes are placed to create a watertight seal. retractor is used on the temporal lobe to spread the
arachnoid of the sylvian fissure, enabling wide open-
Aids to Exposure ing of the fissure, which we prefer (Fig. 5). Once the
To aid in operative exposure and reduce intracranial pres- fissure has been opened adequately, retraction is deep-
sure, intravenous mannitol (1 g/kg) is given shortly after ened on the frontal and temporal lobes. The arachnoid
the skin incision is made. Hyperventilation is utilized to along the floor of the frontal fossa is opened from the
maintain the PaCO2 in the 25-30 mm Hg range. In addi- medial side of the optic nerve to the region of the
tion, the lumbar drain is opened just prior to the dural inci- optic chiasm. With progressive retraction and arach-
sion. These measures are designed to minimize the amount noid dissection, we follow the carotid artery to the
of retraction necessary to gain adequate exposure. origin of the ipsilateral A1 segment. Many sur-


© 1992 The American Association of Neurological Surgeons

Figure 3. Operative positioning for a right pterional craniotomy. A three- rior. The location of the skin incision is indicated as are the burr hole
pin headrest is used, placing the ipsilateral malar eminence most supe- positions for a diamond-shaped craniotomy.


© 1992 The American Association of Neurological Surgeons

Figure 4. The dura is opened in curvilinear fashion as shown (dashed line), with a generous inferior margin to
allow retraction of the dural edge over the base of the bony margin.


© 1992 The American Association of Neurological Surgeons

Figure 5. The arachnoid over the sylvian fissure is cauterized and in-
cised as shown to allow placement of retractor blades over the frontal
and temporal lobes. The positions of the frontal and temporal lobe re-
tractor blades are indicated.

geons prefer to identify the A1 segment as it crosses the ture during dissection. When this has been achieved, the
optic nerve, but it has been our preference to identify the dissection proceeds in the region of the anterior communi-
carotid bifurcation, even though this entails a few milli- cating artery. At this point the dissection sequence depends
meters extra retraction. on the aneurysmal anatomy; the surgeon approaches the
When this has been achieved, the A1 segment is fol- neck of the aneurysm first and leaves the fundus untouched.
lowed across with progressive arachnoid dissection, taking The goal at this point of the operation is to identify both A2
care not to injure the recurrent artery of Heubner which is segments, and customarily a moderate amount of gyrus
often seen at this juncture. As the dissection proceeds across rectus resection is required to do this (Fig. 6, A and B). We
the A1 segment toward the communicating complex, it is perform a standard subpial dissection of the gyrus rectus
possible to open the arachnoid further, thus exposing the on the ipsilateral side.
contralateral A1 segment crossing the contralateral optic We cannot emphasize too strongly that before the
nerve. Thus, proximal control of both A1 branches is ob- aneurysm neck can be approached successfully, it is es-
tained before the aneurysmal packet is approached. Proxi- sential to have control of all four branches of the anterior
mal control is achieved at each point: first on the internal communicating complex. This facilitates the application
carotid and ipsilateral A1, and ultimately on the A1 and A2 of temporary clips and affords total control in case of
segments bilaterally in case of untoward aneurysmal rup- unexpected aneurysmal rupture during neck dissection.


© 1992 The American Association of Neurological Surgeons

Figure 6. A, following progressive retraction, the bifurcation of the corticectomy, identification of the anterior communicating
the internal carotid artery is identified, allowing the ipsilateral A1 artery complex and bilateral anterior cerebral A1 and A2 segments
segment to be traced as it crosses the optic nerve. Exposure of the allows placement of temporary clips if necessary to safely facili-
anterior communicating complex is facilitated by a small tate further dissection of the aneurysm neck.
corticectomy of the ipsilateral gyrus rectus, as indicated. B, after


© 1992 The American Association of Neurological Surgeons

Figure 7. A, the anatomy of the anterior communicating artery com- to completely cross the aneurysm neck. Care must be taken following
plex is subject to wide variation. Careful identification of all segments clip positioning to avoid torsion on the normal arterial anatomy and to
of the anterior communicating artery complex allows complete proxi- avoid occlusion of perforating arterial branches. Potential positions of
mal control prior to further dissection. B, the aneurysm clip is selected temporary clips are as indicated.

© 1992 The American Association of Neurological Surgeons

Figure 8. A, after acceptable clip placement, the microvascular Dop- residual flow is detected within the aneurysm, the dome of the aneu-
pler probe is placed on the dome of the aneurysm to assess residual rysm is punctured to ensure complete obliteration.
flow. Comparison is made to the adjacent arterial structures. B, if no


Intraoperative Aneurysm Rupture Where no signal can be identified with the Doppler
Preparation for intraoperative aneurysm rupture can mini- probe, the aneurysm is judged to be ready for needle as-
mize the difficulty in obtaining hemostatic control. One piration which is the ultimate proof of complete oblitera-
large and two fine-tipped suction devices must be avail- tion (Fig. 8B). The microvascular Doppler probe is then
able and functional at all times. If the bleeding point is used to check for patency in all four branches of the arte-
small, pressure and a hemostatic agent such as Surgicel rial tree. Once this has been ascertained, the wound is
or a small muscle plug may allow control. Occasionally, closed.
careful bipolar cauterization may control a small leak but
risks tearing the dome of the aneurysm. Closure
If proximal control has been obtained at all points in Following satisfactory hemostasis, the dura is closed with
the anterior communicating complex, temporary clips may simple interrupted sutures of 4-0 Nurolon, creating a
be applied to allow additional dissection if necessary. The watertight seal. Epidural tackup sutures are placed
temporary clips should be selected and set aside as each circumferentially and a Gelfoam pad is placed in the
arterial segment is dissected. Alternatively, if sufficient epidural space. The bone flap is replaced. The most an-
dissection has been performed, direct aneurysm clipping terior sutures are tied first to avoid noticeable defects
(with repositioning, if necessary) is undertaken. Again, over the brow. One or two central dural tackup sutures
several clips should be selected and set aside during the are placed and tied through the bone flap. The muscle
early dissection to be available quickly if aneurysm rup- and galea are reapproximated with absorbable sutures
ture occurs. and the skin closed using 4-0 or 5-0 nylon sutures over
the forehead.
Clip Application
After all four branches of the anterior communicating POSTOPERATIVE MANAGEMENT
complex have been identified (Fig. 7A), we often use tem- A mildly hypervolemic state, with the CVP in the 6-10
porary clips prior to final neck dissection and clip appli- mm Hg range, is maintained postoperatively with blood
cation (Fig. 7B). Clip application is done under normo- pressure preferably in the 150-170 mm Hg range, depend-
tensive conditions, and if necessary the blood pressure is ing on the patient’s preoperative baseline. Decadron is
raised from previous hypotensive levels before any con- continued for 48 hours postoperatively and tapered sub-
sideration to temporary clip application is given. We do sequently. Nimodipine and anticonvulsants are continued
not use cerebral protective agents during temporary clip as initiated preoperatively to help reduce the incidence of
application, but we have a strict limitation to 10 minutes vasospasm and postoperative seizures. Careful neurologic
and often need only 3 or 4 minutes of temporary clip ap- evaluation is essential in the immediate postoperative
plication to achieve definitive clipping. If a second pe- period in the event of epidural or subdural bleeding. Care-
riod of temporary clip application is necessary, a 5-10 ful attention to hemostasis with an adequate number of
minute reperfusion period is completed before the clips epidural tackup sutures minimizes the risk of postopera-
are reapplied. Final dissection of the neck either with or tive bleeding complications. Observation for the devel-
without temporary clips should be complete before a per- opment of cerebral vasospasm is undertaken with serial
manent occluding aneurysm clip is applied. It is essential transcranial Doppler studies. If symptomatic, the patient
to choose a clip large enough to completely cross the an- is considered for hypertensive-hypervolemic therapy as-
eurysmal neck, and no attempt should be made to use the suming the aneurysm has been obliterated.
final clip to dissect the neck. The aneurysm should be Despite Doppler evidence of complete obliteration
completely prepared before a clip is positioned in the field. and intraoperative needle aspiration, we customarily per-
The clipped aneurysm can be evaluated with a mi- form postoperative angiography in all cases. Although
crovascular Doppler probe (Titronics Medical Instruments, intraoperative angiography is available, the microvascu-
Iowa City, IA) (Fig. 8A) which will give a signal in cases lar Doppler probe has eliminated the necessity in the
where the fundus is incompletely obliterated. majority of cases.




INTRODUCTION posterior clinoid processes, and membrane of Liliequist

Aneurysms arising from the distal basilar artery and re- anteriorly, the medial temporal lobes and tentorial edge
lating to the origin of the superior cerebellar artery (SCA), laterally, the cerebral peduncles and interpeduncular fossa
posterior cerebral artery (PCA), or the basilar apex ac- posteriorly, and the mammillary bodies and posterior per-
count for more than one-half of all aneurysms occurring forated substance superiorly. The basilar apex normally
in the vertebrobasilar circulation. Of these lesions, those resides only 15-17 mm posterior to the internal carotid
involving the basilar bifurcation are by far the most com- arteries, an anatomical fact that provided a rationale for
mon. Historically, a number of factors delayed the surgi- the application of the anterior, transsylvian exposure to
cal conquest of aneurysms of this region and, as a result, the treatment of basilar aneurysms.
these lesions represent the most recent intracranial aneu- After penetrating the interpeduncular cistern, the basi-
rysm to be subjected to routine surgical management. One lar artery gives origin to the SCAs which may be dupli-
such factor relates to the development of vertebral an- cated unilaterally or bilaterally. These branches usually have
giography well after carotid angiography was routinely a distinctive appearance through the surgical microscope;
accomplished. Additional delay resulted from some con- they are typically thin-walled vessels which have an exter-
troversy regarding the natural history of posterior circu- nal diameter of 1-2 mm. These vessels give rise to variable
lation aneurysms. The fact that basilar artery aneurysms numbers of mesencephalic penetrating branches and dis-
bleed, bleed repetitively, and cause death is now well es- tally supply large portions of the cerebellar hemispheres
tablished. The most important factor delaying the devel- including the dentate nuclei. The PCAs arise immediately
opment of surgical access to these lesions, however, re- distal to the superior cerebellar arteries and in their supe-
lates to the anatomic complexity of the interpeduncular rior junction form the basilar apex. These vessels are vari-
cistern and the extreme neurologic eloquence of the tis- able in size depending on the degree to which the posterior
sue irrigated by its vascular contents. The interpeduncu- communicating branches involuted during fetal life. They
lar cistern is central within the cranial vault, and standard are usually 2-3 mm in diameter and are typically more
surgical exposures must traverse 6-8 cm of subarachnoid atheromatous and thick-walled than the SCAs. In patients
space to reach the distal basilar artery. This distance with a persistent fetal posterior cerebral artery, the P1
coupled with the very narrow spaces available to the sur- segment (that portion of the PCA proximal to its junc-
geon clearly mandated the capabilities of the modern sur- tion with the posterior communicating artery) may be
gical microscope in providing exquisite illumination and seen only as a small fibrous band. The PCAs distally
magnification before operative procedures could become supply the posterior, inferior aspects of the temporal
relatively safe. lobes and the bulk of the occipital lobes. Proximally,
The anatomic complexity of the interpeduncular cis- however, the PCAs give origin to thalamoperforating
tern is directly related to the dangers of surgical manipu- branches which are critical endarteries supplying the mes-
lation in this region and, as such, deserves a brief descrip- encephalon and the posterior aspect of the diencephalon. Due
tion. This subarachnoid cistern is bounded by the clivus, to the extreme importance of the brain tissue irrigated by
these penetrating arteries, their relationship to distal
© 1992 The American Association of Neurological Surgeons basilar aneurysms represents a major cause of morbidity in


procedures directed at these lesions. Although specific we are seeing more patients with incidental basilar aneu-
patterns of thalamoperforating arteries are infinitely vari- rysms. Although a yearly risk of hemorrhage from an in-
able, they usually originate from the posterior basilar cidental aneurysm of 3% is reasonably established, this
trunk, the proximal P1 segments, and the posterior com- risk must be contrasted with a surgical morbidity which
municating arteries and stream along the posterior and is somewhat higher than for the more common anterior
lateral aspects of basilar bifurcation aneurysms. circulation aneurysms. For a surgeon to be able to offer
The oculomotor nerves are occasionally distorted and the patient a procedure which is competitive with the natu-
damaged by large and giant basilar artery aneurysms and ral history risk, certain conditions must be met. The pa-
are frequently (although transiently) rendered dysfunc- tient must be in good general health and reasonably ex-
tional by surgical dissection in this region. They travel pect to survive at least 15-20 years. The exact age criteria
anteriorly from the mesencephalon through triangles will vary from case to case depending on physiological
formed by the basilar artery, PCAs, and SCAs. Each pro- age and family history of longevity. The size and con-
ceeds immediately inferior to the ipsilateral posterior com- figuration of the aneurysm are also very important in terms
municating artery and penetrates the roof of the cavern- of surgical risk. Large and giant size and posterior pro-
ous sinus. The anterior aspect of the interpeduncular jection of the sac clearly increase the risk during opera-
cistern is bordered by a thick arachnoidal veil, the mem- tion. Finally, the experience of the surgeon is critical as
brane of Liliequist. This structure spans the space between the safe exclusion of basilar bifurcation aneurysms re-
both mesial temporal lobes and often confines the spill- quires dedicated and repetitive experience.
age of blood from a minor subarachnoid hemorrhage Once SAH has developed, however, the untreated
(SAH). This membrane must be dissected widely during patient’s malignant natural history justifies aneurysm
anterior approaches to the interpeduncular cistern. obliteration in all but the most extreme anatomic circum-
Two basic surgical exposures have emerged as means stances provided that the patient has not been neurologi-
of successfully dealing with the gamut of vascular pa- cally devastated by the hemorrhage. Our general strategy
thology of the interpeduncular cistern: the subtemporal for managing SAH is based on the belief that early opera-
approach and the pterional or transsylvian approach. Each tion minimizes the risk of rebleeding and permits maxi-
of these operative concepts has been expanded and de- mum therapy for symptomatic vasospasm should it de-
veloped after years of experience and each possesses cer- velop. For patients suffering rupture of an anterior
tain strengths and weaknesses and unique complications circulation aneurysm, we operate on the first elective day
which require thoughtful consideration during the plan- if the patient is in a good clinical grade (alert or drowsy).
ning of a surgical attack on a basilar bifurcation aneu- For patients with an aneurysm that requires little dissec-
rysm. In our opinion, thorough familiarity with each pro- tion or brain retraction, we offer an early procedure to
cedure and the many potential modifications is a those patients in more marginal neurologic conditions with
prerequisite for offering the individual patient an optimal substantial alterations of consciousness or focal deficits.
chance for a successful outcome. This discussion will For those with a ruptured basilar bifurcation aneurysm,
focus on the pterional or transsylvian approach with its however, the amount of dissection and retraction required
major modification, the “half-and-half ” approach. This is substantial and we prefer to allow the patient to im-
general approach capitalizes on the frequent use of this prove to a normal or near-normal level of consciousness
exposure by all neurosurgeons in treating neurosurgical prior to surgical attack. One exception to this general rule
diseases in the parasellar cisterns and on the close prox- is the patient whose altered level of consciousness may
imity of the basilar artery apex to the posterior carotid be explainable by acute hydrocephalus. Because this is
wall. Within certain anatomic constraints, the distal basi- usually a reversible type of neurologic deficit, we gener-
lar trunk, the origins of the SCAs and PCAs, and the basi- ally proceed with early operation.
lar apex can be well exposed through this route in the A final consideration regarding patient selection
majority of patients. concerns the anatomic details of the aneurysm under
attack. The major source of morbidity in these patients
PATIENT SELECTION is the invariable presence of thalamoperforating ar-
Once a patient is found to harbor a basilar bifurcation teries posterior to the sac. Aneurysms with signifi-
aneurysm, the decisions regarding whether or not to offer cant projections posteriorly into the interpeduncular
a surgical procedure and, if so, which procedure to offer, fossa cannot usually be safely clipped from an anterior
are critically dependent on a multitude of clinical and ana- surgical approach because the surgeon cannot see the
tomical concerns. With the expanding use of magnetic clip closure behind the basilar artery and perforators
resonance imaging (MRI) into larger patient populations, cannot be seen well. In addition, the transsylvian ap-


proach is limited in exposure inferiorly by the cartilagi- perioperative antibiotic coverage consisting of nafcillin
nous and bony posterior clinoid process and the clivus. In (or vancomycin in the penicillin-allergic patient). Antibi-
our experience, aneurysms taking origin below the mid- otics are given on call in the operating room and are con-
sellar depth cannot be well exposed via the transsylvian tinued for 24 hours postoperatively. Antifibrinolytic
route, particularly if significant need is anticipated for therapy has been shown to decrease the incidence of early
temporary arterial occlusion. In these circumstances we aneurysmal rebleeding but to increase the incidence of
routinely proceed with a lateral subtemporal procedure. ischemic deficits from vasospasm. We prefer to use E-
In the future, endovascular procedures may find a aminocaproic acid only in patients who are in poor neu-
role in the primary treatment of some basilar bifurcation rologic grade or unstable medical condition and for whom
aneurysms provided that the long-term results prove du- a significant delay in aneurysm clipping is anticipated.
rable and the risks of the procedure become acceptable. For those patients in whom early operation is planned, we
In the short term, these procedures may well improve the usually do not initiate this type of therapy.
outlook for those patients in poor neurologic condition
whose risk of rebleeding may be minimized by OPERATIVE TECHNIQUE
endovascular occlusion, allowing treatment for subsequent
vasospasm and time for potential neurologic recovery.