NEUROSURGICAL

OPERATIVE ATLAS
Volume 2
 NEUROSURGICAL
OPERATIVE ATLAS
Volume 2

AANS PUBLICATIONS COMMITTEE

Editors

SETTI S. RENGACHARY, M.D.

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

ROBERT H. WILKINS, M.D.

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

THE AMERICAN ASSOCIATION OF NEUROLOGICAL SURGEONS

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
owner.

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
617.4’8’00222—dc20
DNLM/DLC
for Library of Congress 90-14551
CIP

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

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.
 FOREWORD
© 1992 The American Association of Neurological Surgeons
Figure 2.
altered with changing developments and experience. A
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
is my great pleasure to introduce this ambitious project
by Dr. Wilkins and Dr. Rengachary. Not only will it up-
date neurosurgical techniques, but it is also a further de-
velopment of the effort made by the editors of the Jour-
nal of Neurosurgery 25 years ago. We hope it will surpass
that effort.
EBEN ALEXANDER, JR.
© 1992 The American Association of Neurological Surgeons
Figure 3.
References
1. Cutler EC, Zollinger R. Atlas of surgical operations. Illustrated
by Mildred B. Codding. New York: Macmillan, 1939.
2. Greenwood J, Jr. Surgical removal of intramedullary tumors. J
Neurosurg 1967;26:275-282.
3. Alexander E, Jr, Davis CH, Jr, Forsyth HF. Reduction and
fusion of fracture dislocations of the cervical spine. J Neurosurg
1967;27:587-591.
4. Alexander E, Jr. Neurosurgical techniques introduction. J
Neurosurg 1966;24:817-819.
 Preface
Man has always had an innate urge to depict his activi-
ties in drawings, as the paintings of cave dwellers would
attest. Surgical atlases perhaps represent a formalized ver-
sion of such an urge; the atlases, in addition to docu-
menting the work, have instructional value as well—be-
ing able to teach generations of trainees the craft of
surgery as practiced by the masters of the trade. Although
electronic images have greatly advanced the instructional
process, printed artwork remains the backbone of the
media for teaching.
There has been a perception among all neurosur-
geons for some time that a contemporary atlas in neuro-
surgery is due. To fill this void, the Publications Com-
mittee of The American Association of Neurological
Surgeons has undertaken the task of producing a com-
prehensive atlas. The atlas will be published at bimonthly
intervals in the form of fascicles containing up to six
operations each. To allow timely publication, topics are
included in a random fashion.
The Neurosurgical Operative Atlas, we believe, is
unique in several respects. It is comprehensive. When
completed, it will contain descriptions of up to two hun-
dred operative procedures. It is multiauthored. Given the
complexity of the field and the explosive advances in
techniques, it is impossible for any one individual to be
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
have used the technique so extensively as to be an au-
thority on it. Many illustrations are depicted in full color
despite the high costs involved in preparing the artwork
and printing. In many instances where there is more than
one way to approach a problem, two different authors
have been requested to write on the same subject so that
the reader will benefit from knowing alternative surgical
techniques.
The atlas has been possible in large measure due to
the efforts and sacrifices of the contributing authors. In
addition to sharing their knowledge and expertise, they
have incurred large expenses in getting the artwork done;
they have spent long hours with their illustrators to
achieve the accurate and esthetically pleasing depiction
of the procedures. One can also see the spectrum of artis-
tic talent that made this work possible.
We thank George T. Tindall, M.D., for forming the
Publications Committee; Eben Alexander, Jr., M.D., for
preparing the Foreword; Carol-Lynn Brown and Marjorie
Kidd Keating of the Williams & Wilkins Company, and
Carl H. Hauber and Gabrielle J. Loring of The American
Association of Neurological Surgeons for coordinating
various phases of the project; Sherylyn Cockroft and
Gloria K. Wilkins for secretarial help; members of the
Publications Committee for innumerable suggestions;
and Diane Abeloff for overseeing the entire artwork.
SETTI S. RENGACHARY
ROBERT H. WILKINS
 Contributors

ARVIND AHUJA, M.D. H. HUNT BATJER, M.D.

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

MARIO AMMIRATI, M.D. GREGORY J. BENNETT, M.D.

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

RONALD I. APFELBAUM, M.D. MICHAEL J. BURKE, D.V.M., M.D.

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

RAVELO V. ARGAMASO, M.D. WOLFHARD CASPAR, M.D.

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
MELVIN CHEATHAM, M.D.
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
RALPH B. CLOWARD, M.D.
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
 CONTRIBUTORS

ARTHUR L. DAY, M.D. PHILIP H. GUTIN, M.D.

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
JOSEPH F. HAHN, M.D.
MAHLON R. DELONG, M.D. Chairman
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.
JEFFREY KELLER, PH.D.
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

LEE R. GUTERMAN, PH.D., M.D. ALI KRISHT, M.D.

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
 CONTRIBUTORS

SANFORD J. LARSON, M.D., PH.D. BLAINE S. NASHOLD, JR., M.D.

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

KIMBERLY LIVINGSTON, M.D. CHARLES NUSSBAUM, M.D.

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

CHARLES M. LUETJE, M.D. KEITH PETERS, M.D.

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
RONALD G. QUISLING, M.D.
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
 CONTRIBUTORS

LALIGAM N. SEKHAR, M.D. JERROLD L. VITEK, M.D., PH.D.

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
CHANDRANATH SEN, M.D.
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

YAGHOUB TARASSOLI, M.D. JAMES E. WILBERGER, JR., M.D.

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
KEN R. WINSTON, M.D.
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
LYN C. WRIGHT, M.D.
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

HARRY van LOVEREN, M.D.

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

Foreword / v
Preface / vii
Contributors / ix

Volume 2

SURGICAL REPAIR OF TRIGONOCEPHALY / 1

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

DORSAL ROOT ENTRY ZONE (DREZ) LESIONING / 9

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

OPHTHALMIC SEGMENT ANEURYSMS / 25

Arthur L. Day, M.D.

CHRONIC SUBDURAL HEMATOMA / 42

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

TAILORED TEMPORAL LOBECTOMY USING SUBDURAL ELECTRODE GRIDS / 49

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

GUNSHOT WOUNDS OF THE BRAIN / 56

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

TRANSTORCULAR OCCLUSION OF VEIN OF GALEN MALFORMATIONS / 60

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

DETECTION OF AN EPILEPTIC FOCUS AND CORTICAL MAPPING USING

A SUBDURAL GRID / 67
Sumio Uematsu, M.D.

ANTEROMESIAL TEMPORAL LOBECTOMY FOR EPILEPSY / 79

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

ANASTOMOSIS OF THE FACIAL NERVE AFTER RESECTION OF AN

ACOUSTIC NEUROMA / 88
Charles M. Luetje, M.D.

AN EXTENDED SUBFRONTAL APPROACH TO THE SKULL BASE / 91

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

PANSYNOSTOSIS: SURGICAL MANAGEMENT OF MULTIPLE PREMATURE

SUTURE CLOSURE / 101
James T. Goodrich, M.D., PH.D.
Craig D. Hall, M.D.

DISTAL ANTERIOR CEREBRAL ARTERY ANEURYSMS / 113

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

TETHERED SPINAL CORD, INTRAMEDULLARY SPINAL LIPOMA, AND

LIPOMYELOMENINGOCELE / 127
W. Jerry Oakes, M.D.

INTERSTITIAL BRACHYTHERAPY / 136

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

LATERAL EXTRACAVITARY APPROACH TO THE THORACIC AND

LUMBAR SPINE / 145
Dennis J. Maiman, M.D., PH.D.
Sanford J. Larson, M.D., PH.D.

AN EXTREME LATERAL TRANSCONDYLAR APPROACH TO THE FORAMEN MAGNUM

AND CERVICAL SPINE / 154
Chandranath Sen, M.D.
Laligam N. Sekhar, M.D.

RETROLABYRINTHINE, PRESIGMOID APPROACH FOR SECTIONING OF THE

VESTIBULAR NERVE FOR MÉNIÈRE’S DISEASE / 163
Charles M. Luetje, M.D.

STEREOTACTIC SURGICAL ABLATION FOR PAIN RELIEF / 166

Ronald F. Young, M.D.

ANTERIOR SCREW FIXATION OF ODONTOID FRACTURES / 178

Ronald I. Apfelbaum, M.D.

CARPAL TUNNEL SYNDROME / 189

Setti S. Rengachary, M.D.

TRANSANTRAL ETHMOIDAL ORBITAL DECOMPRESSION FOR GRAVES’

OPHTHALMOPATHY / 200
Lawrence W. DeSanto, M.D.
 CONTENTS

MIDDLE FOSSA APPROACHES FOR INVASIVE TUMORS INVOLVING

THE SKULL BASE / 207
Laligam N. Sekhar, M.D.
Atul Goel, M.Ch.
Chandranath Sen, M.D.

TRANSTHORACIC EXCISION OF A SPINAL METASTASIS WITH VERTEBRAL BODY

RECONSTRUCTION / 219
Gregory J. Bennett, M.D.

ANTERIOR CERVICAL DISCECTOMY AND FUSION—THE CLOWARD

TECHNIQUE / 229
Ralph B. Cloward, M.D.

CUBITAL TUNNEL SYNDROME / 241

Setti S. Rengachary, M.D.

CASPAR PLATING OF THE CERVICAL SPINE / 246

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

SURGICAL MANAGEMENT OF ANTERIOR COMMUNICATING

ARTERY ANEURYSMS / 257
Timothy C. Ryken, M.D.
Chistopher M. Loftus, M.D.

BASILAR BIFURCATION ANEURYSM: PTERIONAL (TRANSSYLVIAN) APPROACH / 266

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

THALAMOTOMY FOR TREMOR / 282

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

ENDOVASCULAR TREATMENT OF CAROTID CAVERNOUS FISTULAS / 296

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

COMBINED TRANSSYLVIAN AND MIDDLE FOSSA APPROACH

TO INTERPEDUNCULAR FOSSA LESIONS / 305
Chandranath Sen. M.D.
Laligam N. Sekhar, M.D.

ANEURYSMS OF THE OPHTHALMIC SEGMENT OF THE INTERNAL

CAROTID ARTERY / 312
Daniel L. Barrow, M.D.
 CONTENTS

LUMBAR-PERITONEAL SHUNTING / 323

Setti S. Rengachary, M.D.

SURGERY OF THE CAVERNOUS SINUS / 334

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

ENCEPHALOCELES OF THE ANTERIOR CRANIAL BASE / 345

Alan R. Cohen, M.D.

COTREL-DUBOUSSET INSTRUMENTATION: INTERNAL FIXATION FOR

THORACOLUMBAR FRACTURES AND TUMORS / 354
Bruce E. van Dam, M.D.

POSTERIOR-LATERAL LUMBAR SPINAL FUSION / 360

Edward S. Connolly, M.D.

CORRECTION OF EXORBITISM / 368

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

MERALGIA PARESTHETICA / 373

Setti S. Rengachary, M.D.

DEPRESSED SKULL FRACTURE IN INFANTS / 380

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

COMBINED PRESIGMOID-TRANSTRANSVERSARIUM INTRADURAL APPROACH TO THE

ENTIRE CLIVUS AND ANTERIOR CRANIOSPINAL REGION / 384
Mario Ammirati, M.D.
Melvin Cheatham, M.D.

PARTIAL MEDIAN CORPECTOMY WITH FIBULAR GRAFTING FOR CERVICAL

SPONDYLOTIC MYELOPATHY / 396
Setti S. Rengachary, M.D.

CORRECTION OF ORBITAL HYPERTELORISM AND ORBITAL DYSTOPIA / 410

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

PERCUTANEOUS RADIOFREQUENCY RHIZOTOMY FOR THE TREATMENT

OF PARAPLEGIC SPASMS / 417
Sumio Uematsu, M.D.

ENDOCRINE-INACTIVE PITUITARY ADENOMAS / 428

Charles B. Wilson, M.D.
 CONTENTS

POSTERIOR DECOMPRESSION AND FUSION FOR CERVICAL

SPONDYLOTIC MYELOPATHY / 438
Paul Kurt Maurer, M.D.
Charles Nussbaum, M.D.

SURGICAL CORRECTION OF SWAN NECK DEFORMITY / 448

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

Index /
 SURGICAL REPAIR
OF TRIGONOCEPHALY
KEN R. WINSTON, M.D.
MICHAEL J. BURKE, D.V.M., M.D.
INTRODUCTION
The metopic suture is functional for approximately the
first two years of life. Premature fusion of this suture is
typically associated with a specific cranial dysmorphia,
termed trigonocephaly. While associated brain deformi-
ties have been reported (i.e., holoprosencephaly and
arhinencephaly), trigonocephaly is most commonly an iso-
lated type of cranial dysmorphia in a neurologically nor-
mal child.
DESCRIPTION OF THE DEFECT
The dysmorphia is apparent at birth. When the head is
viewed from the vertex, the frontal area has a wedge or
triangular shape. A keel of bone extends vertically across
the forehead and may appear to continue below the
frontonasal suture. The keel does not necessarily extend
posteriorly to the bregma. Very characteristic of trigono-
cephaly is the severely retropositioned lateral parts of the
supraorbital ridges. The bifrontal cranial dimension is ab-
normally narrow, with a widening of the biparietal diam-
eter which accommodates normal brain volume but ac-
centuates the cosmetic defect.
Although the eyes often appear hyperteloric, mea-
surement of the orbits may show hypotelorism. The lat-
eral canthal angles and therefore the lateral eyebrows may
appear elevated, but extraocular muscle functions are nor-
mal. The term “startled coon” has been applied to the fa-
cies of these children.
The diagnosis is made by inspection of the head. If the
characteristic abnormality cannot be identified, then either
there is no trigonocephaly or it is clinically insignificant.
Skull films will show the suture to be absent anteriorly
(lower portion). Computed tomography scanning should
be done on patients with other congenital malformations
(i.e., palatal defects). These patients with trigonocephaly
are at higher risk for forebrain abnormalities.
© 1992 The American Association of Neurological Surgeons
1
INDICATIONS FOR SURGERY
Surgery for trigonocephaly is cosmetic. Most parents of
children with trigonocephaly find the dysmorphia to be
very noticeable and extremely undesirable. The defect does
not improve with time; there is no reason to delay the
corrective procedure. We strongly prefer surgical repair
by four to six weeks of age but there is no upper age limit.
RISKS
Risks associated with this procedure include blood loss
and the need for transfusion. Dural lacerations, if not rec-
ognized and repaired, can lead to enlarging skull defects
with cerebral herniation and brain injury. The osteoto-
mies may fuse too early or, conversely, reossification may
be incomplete. Additional surgical procedures may be re-
quired to achieve a desired satisfactory cosmetic result.
Injury to an eye or to periocular structures is possible,
with resulting damage to the visual system. Although rare,
it is possible for the brain to be injured.
Parents should also be informed that, while most chil-
dren have an excellent cosmetic result, a perfectly shaped
skull is not likely to be achieved. A good result is one in
which the child’s resulting craniofacial morphology will
not adversely affect normal psychosocial development.
After surgery, the region of the forehead and orbits is usu-
ally normal in appearance to all but the most detailed ex-
amination.
PREPARATION FOR SURGERY
Preoperative laboratory evaluation generally consists of
routine complete blood counts, electrolyte determinations,
and urinalysis. A prothrombin time, partial thromboplas-
tin time, and platelet count are also usually obtained. A
shampoo with a chlorhexidine solution is done 8-24 hours
before surgery. Prophylactic antibiotics are started in the
operating room and continued for 24 hours.
SELECTION OF SURGICAL REPAIR
Children under six months of age, and perhaps up to
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
age nine months, are repaired by the “floating forehead”
procedure. This method corrects the almond shape of the
orbits and midline ridge and takes advantage of the pro-
gressively expanding brain to correct any remaining ab-
normality. Children who are one year of age or older and
some children under this age are best repaired by the
“tongue-in-groove” procedure. In older children, the brain
is expanding more slowly and it is necessary to make a
more rigidly structured repair. Also, it is not safe to leave
large bony defects because they occasionally do not
reossify satisfactorily.
DESCRIPTION OF FLOATING
FOREHEAD OPERATION
Position, Preparation of Scalp, and Draping
The patient is placed in the supine position with the shoul-
ders elevated by a transverse roll and the neck slightly
extended. An arterial line (usually a radial artery), a single
peripheral venous line, and a Foley catheter are placed.
We do not shave or clip the hair, although this is com-
monly done by most neurosurgeons. Using a sterile comb
or hemostat, the hair is parted along the proposed inci-
sion line. The scalp, including the ears and cheeks, are
scrubbed with a chlorhexidine solution and the head is
draped for a transcoronal incision.
Chemical Hemostasis
The skin is infiltrated with 0.5% lidocaine with epineph-
rine (1/400,000) along the planned incision line.
Initial Soft Tissue Dissection
A coronal incision is made, beginning about 5 mm above
the insertion of each pinna and crossing the midline near
the anterior fontanelle (Fig. 1). Skin edges are retracted
and clips (preferably children’s or Cone clips) are applied
to the scalp edge for hemostasis. Periosteal elevators are
used to free the pericranium anteriorly to the level of the
supraorbital rims. The periorbita are then dissected from
the superior half of each orbit. Medially this dissection is
continued well below the frontonasal suture and laterally
below the frontozygomatic sutures. The supraorbital
nerves can be preserved by using a thin osteotome to open
the supraorbital foramen and reflecting the nerve anteri-
orly with the skin.
Osteotomies
The frontal convexity and supraorbital rims are removed
separately. A high-speed craniotome (e.g., Midas Rex) is
used for all osteotomies in the frontal convexity. No burr
holes are made. Blunt dissection in the anterior fonta-
nelle is used to separate the dura from the frontal bone
2
and is the starting point for the osteotomies. If the ante-
rior fontanelle is closed, a small oval hole just anterior to
the coronal suture can be made with the craniotome.
The frontal convexity bone is removed first. An os-
teotomy is made just anterior to each coronal suture. The
osteotomy is continued anteriorly across the forehead
approximately 1.5 cm superior to the supraorbital rims
(Fig. 1). The resulting triangular piece of bone is sepa-
rated from the underlying dura. and removed from the
field. The only firm dural attachment to the frontal bone
is at the midline along the area of the superior sagittal
sinus. A wide periosteal elevator will usually disrupt this
attachment with safety. Bleeding from the dura. is con-
trolled with bipolar coagulation and microfibrillar col-
lagen (Avitene). Bleeding from bone is controlled with
microfibrillar collagen. Bone wax is used only if the above
measures fail to control a point of active bleeding.
Both supraorbital ridges are removed with a frontal
bar en bloc, using osteotomes (Fig. 2). The frontal dura is
retracted superiorly and posteriorly. This necessitates sepa-
ration of the dura. from the midline of the frontal fossa
anterior to the crista galli. An osteotomy is made across the
floor of the frontal fossa (i.e., across each orbital roof) and
extended laterally across the sphenoid wings (Fig. 2). This
osteotomy is approximately 1-1.5 cm posterior to the su-
praorbital rims. The zygomaticofrontal suture is divided
vertically with an osteotome. A vertical osteotomy is made
in the sphenoid bones down to the level of the
frontozygomatic suture. When necessary, a horizontal os-
teotomy is made to connect the above two osteotomies.
An inverted “V”-shaped osteotomy is made through
the region of the frontonasal suture to free the supraor-
bital rim. If an abnormal nasal ridge exists, it is removed
with a high-speed burr.
Remodeling of the Supraorbital Rims, Frontal Bar, and
Forehead
The supraorbital bar is straightened. This almost always
requires division in the midline. Posterior reinforcement
with a strip of bone taken from the frontal convexity may
be required. Straightening of the bar causes the lateral
orbital margins to swing medially. A large Leksell rongeur
is used to resect this protrusion and also to remodel the
superior orbit (Fig. 3).
Remodeling of the forehead first involves division
of the frontal bone in its midline (Fig. 1). Switching right
for left and rotating the two fragments 90° often achieves
an acceptable appearance but sometimes other incisions
in the frontal fragments are performed as needed to mold
them into an acceptable cosmetic appearance.
Prior to replacing the above remodeled bones, the
narrow anterior biparietal diameter is addressed.
 WINSTON AND BURKE : SURGICAL REPAIR OF TRIGONOCEPHALY

© 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.

3
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

© 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.

4
 WINSTON AND BURKE : SURGICAL REPAIR OF TRIGONOCEPHALY

© 1992 The American Association of Neurological Surgeons

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

5
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
Using the high-speed craniotome, the anterior 1-2 cm
of the parietal bone is morcellated and the resulting
two to four fragments are left attached to the dura (Figs.
5 and 6).
Replacement of Remodeled Forehead
The frontal bones are sutured together at the midline
© 1992 The American Association of Neurological Surgeons
Figure 4. Replacement of remodeled bone. The forehead bone is
attached to the supraorbital bar using 2-0 absorbable sutures. The
entire rigid complex is replaced and anchored with a 3-0 absorb-
6
with 2-0 Vicryl (Figs. 1 and 4). The forehead is then
attached to the supraorbital bar with 2-0 Vicryl sutures
(Fig. 4). Only rarely do we use a few wires and then
only in children over one year of age. The entire rigid
complex is then replaced and anchored with a single 3-
0 Vicryl suture in the frontonasal region (Fig. 4). The
result is a “floating forehead” (Fig. 5).
able suture in the frontonasal region. Wire is occasionally used to
attach the forehead to the supraorbital bar in children over one year
of age.
 WINSTON AND BURKE : SURGICAL REPAIR OF TRIGONOCEPHALY
Closure and Dressing
If the upper face has been prepared and draped appropri-
ately, the scalp should be returned to its normal position,
temporarily at first, so that the appearance of the upper
face and orbits can be assessed. It may be necessary to
make some corrective adjustments in the forehead and
orbits at that time. After the surgeon is satisfied with the
appearance, the galea and underlying pericranium are
sutured (single layer) with 3-0 Vicryl sutures (interrupted
or continuous technique). Skin edges are approximated
with staples. Drains are occasionally required. Postop-
eratively the head is wrapped snugly but never tightly.
DESCRIPTION OF TONGUE-IN-GROOVE
OPERATION
This procedure is identical to that described above for the
first three steps. The removal of the convexity of the frontal
bone and the osteotomy in the orbital roofs (floor of fron-
tal fossa) are the same as in Step 4 above. The lateral
osteotomies are, however, totally different. The high-
torque craniotome is used to outline a posteriorly directed
“tongue” of bone which remains in continuity with the
© 1992 The American Association of Neurological Surgeons
Figure 5. The floating forehead operation. This technique is used in chil-
dren under nine months of age. The remodeled forehead is replaced and
anchored with an absorbable suture at the frontonasal region. The entire
7
frontal bar (Fig. 6). This tongue should be at least 1.5 cm
wide and about 2-4 cm in length. This tongue always ex-
tends posteriorly into the squamous portion of the tem-
poral bone beyond the coronal suture. The osteotomies
along the lateral orbits are the same as described above.
The remodeling of the supraorbital rim and frontal
bar should include all the steps described above. As a re-
sult, the tongue of bone will rotate outward on each side
when the midline angle in the frontal bar is corrected.
Therefore, the sphenoid ridges will need to be notched on
their inner (medial) surfaces and the lateral bony frag-
ments bent (green stick fracture) inward. It is very impor-
tant that the fragment to which the tongue is attached re-
main firmly continuous with the whole frontal bar.
The remodeled forehead is returned to the operative
field and sewed in the middle with one or two 3-0 Vicryl
sutures. The posteriorly directed tongues of bone are re-
turned to their respective grooves and secured 11.5 cm
anterior to their original location to give the desired cor-
rection. The tongues are sewed in place with wire and/or
2-0 Vicryl (Fig. 6). The closure and application of the
dressing are accomplished as described above.
complex then floats over the growing brain. Morcellation of the anterior
parietal bones, leaving the fragments attached to the dura, corrects the nar-
row anterior biparietal diameter.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
© 1992 The American Association of Neurological Surgeons
Figure 6. The tongue-in-groove operation. This technique is used in older
children where a more rigid reconstruction is required. A posteriorly di-
rected tongue of bone which is continuous with the frontal bar is created
while the lateral osteotomies are performed. The tongue is 1.5 cm wide and
2-4 cm long. Upon straightening the supraorbital bar the tongue protrudes
laterally. Notching of the sphenoid wing facilitates moving the tongue of
POSTOPERATIVE MANAGEMENT
The head of the patient’s bed is elevated. A hematocrit is
checked in the immediate postoperative period and twice
daily for the first 48 hours. We transfuse packed red cells
when the hematocrit drops to 22 or below. The dressing should
be monitored at approximately 4-hour intervals for the first
24 hours to ensure that it is not too tight. Facial swelling
reaches its maximum at around 48 hours. The worst of the
periorbital and facial edema resolves over the next 24 hours
and the child is generally discharged at about the time both
eyes are clearly open (usually the third to fifth postoperative
day). A helmet is not used unless the child is a toddler.
8
bone medially. The tongue must remain attached to the supraorbital bar.
The forehead bone is replaced and secured in the frontonasal region. The
tongues of bone are secured 1-1.5 cm anterior to their previous location,
thereby rigidly fixing the supraorbital bone in an advanced position. Bipa-
rietal morcellation is performed to correct the narrow anterior biparietal
diameter.
FOLLOW-UP AND EXPECTED OUTCOME
The child is usually seen five to seven days postopera-
tively for staple removal. Examinations are at about
the six-week, six-month, and one-year anniversaries.
Follow-up radiographs are not necessary unless the cos-
metic result is questionable or clearly unsatisfactory.
An enlarging skull defect should alert the surgeon to
the presence of a dural tear and is an indication for
immediate surgical attention. No clinically significant
defects in bone should be palpable at a one-year post-
operative follow-up.
 DORSAL ROOT ENTRY ZONE
(DREZ) LESIONING
BLAINE S. NASHOLD, JR., M.D.
AMR O. EL-NAGGAR, M.D.
INTRODUCTION
The dorsal root entry zone (DREZ) operation was origi-
nally reported in 1976 as a focal destruction of the sub-
stantia gelatinosa of Rolando. It was done on a patient
with intractable arm pain following a brachial plexus avul-
sion injury. Since then it has been performed at the Duke
University Medical Center in over 500 patients with in-
tractable pain of various etiologies. Pain due to deaffer-
entation responds best to the DREZ operation, which in-
volves the creation of lesions in the dorsal root entry zone
areas, destroying Rexed layers I through V using a
radiofrequency current delivered through a specially de-
signed thermocouple electrode. These lesions are mainly
targeted toward the cells of origin of the second-order
neurons in Rexed layers II and V which give rise to the
spinothalamic and spinoreticular tracts. The dorsal root
entry zone extends from the upper cervical cord to the
conus medullaris deep to the intermediolateral sulcus. It
intermingles cephalad with the trigeminal nucleus caudalis
which is the caudal portion of the trigeminal nucleus. The
nucleus caudalis receives the major pain afferents from
the trigeminal system. Radiofrequency (RF) lesions in the
nucleus caudalis have the same functional effect as the
dorsal root entry zone lesions, and are performed to treat
intractable pain of head and facial origin, especially pain
caused by deafferentation.
PATIENT SELECTION
Careful patient selection is the key to the success of any
operative procedure. Patients with deafferentation pain
syndromes, especially brachial and sacral plexus avulsion
pains, benefit the most from this operation. The DREZ
operation is also very successful in paraplegic patients
with intractable pain, including central pain and radicu-
lar pain, in postamputation phantom pain, and in
postherpetic neuralgia. Trigeminal nucleus caudalis le-
© 1992 The American Association of Neurological Surgeons
9
sions are successful in the treatment of intractable facial
pain secondary to postherpetic neuralgia or anesthesia
dolorosa, as well as in patients with trigeminal dysesthe-
sia for whom all other surgical treatments have failed.
Combined nucleus caudalis-nucleus solitarius lesions in
the floor of the fourth ventricle are performed for the treat-
ment of intractable visceral pain of pharyngeal origin. The
nucleus solitarius contains the second-order neurons en-
coding pain from cranial nerves IX and X from the tongue,
pharynx, larynx, and esophagus.
PREOPERATIVE EVALUATION
A thorough evaluation of the patient’s pain is thus essen-
tial, especially for patients who have undergone previous
multiple surgical procedures. Plain roentgenograms are
obtained routinely to study the details of the bone anatomy,
which is especially helpful in patients who have had pre-
vious operative interventions. Other preoperative radio-
logical studies are essential in most cases to confirm the
diagnosis (as in cases of brachial plexus or sacral plexus
avulsion injuries where myelography and magnetic reso-
nance imaging (MRI) usually show evidence of
pseudomeningoceles along the avulsed roots (Fig. 1)) as
well as to visualize the spinal cord at the proposed opera-
tive site for evidence of scar tissue or traumatic syringo-
myelia (Fig. 2). All patients are given 10 mg of dexa-
methasone by mouth the evening prior to surgery. We do
not use perioperative antibiotics.
OPERATIVE PROCEDURE
All DREZ operations are performed under general an-
esthesia with appropriate physiologic monitoring as de-
termined by the patient’s general condition; however, a
Foley catheter and an arterial line are essential. The
patient is then placed in the prone position. Patients
undergoing nucleus caudalis lesions as well as patients
undergoing cervical DREZ lesions or lesions involv-
ing the upper four thoracic segments require immobi-
lization of their head in a Mayf ield head holder
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

© 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-

10
 NASHOLD AND EL-NAGGAR : DORSAL ROOT ENTRY ZONE LESIONING

© 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.

11
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
formed is based directly, in a one-to-one ratio, upon the
number of painful dermatomes. For patients undergoing
a conus medullaris DREZ lesioning for intractable lower
extremity pain, as in patients with phantom pain, T10
through L1 laminectomies are performed. For trigeminal
nucleus caudalis lesions a small suboccipital craniectomy
and C1-C2 laminectomies are performed (Fig. 11, upper
left). Determination of the level is based on palpation of
the spinous processes and is confirmed by obtaining an
intraoperative radiograph as necessary.
The anatomy of the spinal roots varies according to
the level of their origin from the spinal cord. The
cervicodorsal roots are made up of five to eight individual
rootlets that form the main sensory branch and exit via
the intervertebral foramen at the level of origin from the
spinal cord. In contrast, the thoracic dorsal roots are made
up of two to four rootlets which are much smaller in di-
ameter that form the main dorsal root and they exit at
least two to three vertebral levels below their origin from
the spinal cord. Whereas the cervical sensory rootlets
originate close together, the thoracic roots often are sepa-
rated by several millimeters with a distance of 5 mm be-
tween successive thoracic dorsal roots. This so-called
blank space between the thoracic roots should also be in-
cluded in the DREZ lesioning.
At the level of the conus medullaris, the lower lum-
bar and sacral roots are close to each other and may over-
lap the conus and hide the lower sacral sensory roots. The
© 1992 The American Association of Neurological Surgeons
Figure 5. Localization by somatosensory evoked potential
monitoring. The site for DREZ lesioning is determined by the
12
avulsed area on the spinal cord at the level of the conus is
often hidden by these superficial sensory rootlets from
higher levels and the surgeon must carefully retract these
roots to expose the avulsed area. Anatomical identifica-
tion of the sacral sensory roots is often difficult. The S1
dorsal root is the largest, and the best way to identify it
visually is for the surgeon to find the last sacral root, which
is extremely small, and count up from that point to the
largest dorsal root which should be the level of S1. The
most accurate method of dorsal root localization is the
use of somatosensory evoked potentials. Electrical stimu-
lation over the femoral triangle, stimulating the femoral
nerve, will give a good L1 localization. With the record-
ing electrodes placed on the spinal cord while stimulat-
ing over the popliteal fossa (posterior tibial or sciatic
nerve) and recording on the conus will give good S1 lo-
calization. Where there is an area of unilateral avulsion
on the conus or loss of a leg from trauma, the intact leg
can be used for somatosensory localization (Fig. 5).
The thoracic dorsal roots are the most difficult to
identify precisely at their origin on the spinal cord. We
use the “rule of two”: the origin of the dorsal root from
the spinal cord is approximately two vertebral levels
above its exit at the intervertebral foramen. In patients
with postherpetic pain involving the thoracic or abdomi-
nal areas, the surgeon may note after opening the dura
that certain of the dorsal roots appear abnormal. This
is a good indication that the proper roots for
most positive wave recorded when stimulating the affected der-
matome.
 NASHOLD AND EL-NAGGAR : DORSAL ROOT ENTRY ZONE LESIONING
the DREZ lesion have been localized. These involved
herpetic dorsal roots usually appear thin, dull, and gray-
ish-red in color. A biopsy of the dorsal root reveals loss
of the large myelinated fibers.
The advantage of the DREZ lesion is that the clinical
effect can be localized to specific dermatomes or der-
matomal levels. As we have indicated above, precise ana-
tomical localization is important to restrict the lesion just
to the painful areas of the body.
Following a thorough skin preparation and draping,
a midline incision is made down to the subcutaneous tis-
sue, and using electrocautery the midline cervical or
lumbodorsal fascia is incised. In most instances a stan-
dard multilevel bilateral laminectomy is done following a
subperiosteal dissection of the paraspinous muscles from
the spinous processes and laminae. After adequate con-
firmation of the desired levels, bilateral laminectomies
are performed in almost all patients. Hemilaminectomies
are performed in patients with thoracic postherpetic neu-
ralgia and in patients with unilateral intractable radicular
pain secondary to spinal cord injury. Postoperative recov-
ery is faster and incisional pain is less in patients under-
going hemilaminectomy.
We prefer to use the Midas Rex drill to perform the
laminectomies to save operative time and for its safety when
used by an experienced surgeon. We use the S-1 drill bits
for lumbar and thoracic laminectomies and hemilaminec-
tomies, and the B-1 drill bits for the cervical region. We
first use the AM-8 drill bit to drill the lower portion of the
most caudal lamina to expose the ligamentum flavum bi-
laterally. The S-1 or B-1 bit is then used to cut through the
laminae one after the other, rostrally (Fig. 6A). This is per-
formed on both sides. The supraspinous and interspinous
ligaments above and below are cut with Mayo scissors and
the laminae and spinous processes are removed en toto.
The AM-8 bit is then used to widen the laminectomy as
necessary. The use of the Midas Rex drill is not essential
and the laminectomies can be performed the conventional
way using rongeurs. A hemilaminectomy is used to expose
the dorsal roots in the thoracic region in patients with
postherpetic pain. The dorsal roots are well visualized us-
ing the microscope. Lesser postoperative pain and early
mobility are advantages in this group of patients who are
often elderly. We do not use the Midas Rex drill in cases
where epidural scarring is suspected from previous sur-
gery, trauma, or infection. Bone bleeding is controlled by
applying bone wax to the edges of the laminae. Epidural
venous bleeding is controlled with bipolar cautery and small
pieces of Surgicel. Cottonoid strips are placed over the sides
of the wound and the dura is then opened.
In patients undergoing nucleus caudalis lesions, the
suboccipital craniectomy is performed using a perforator
13
and rongeurs or using the Midas Rex M-3 bit as a perfo-
rator followed by a suboccipital craniotomy and removal
of the bone in one piece. Care should be taken during
dissection of the paraspinal muscles at the C1-2 area due
to the presence of large veins in that location. Careful
dissection of the periosteum above and underneath the
posterior arch of C1 should be performed prior to the use
of rongeurs or the drill. The craniectomy needs to extend
about one-third to one-half the distance from the fora-
men magnum to the inion and extend bilaterally just short
of the mastoid processes. The rim of the foramen mag-
num is carefully dissected and preferably removed piece-
meal. The atlanto-occipital membrane is then dissected
and cut using Dandy scissors. Bone wax and Surgicel are
used to control bleeding as mentioned above and the dura
is then opened.
The dural opening is accomplished with or without
the aid of the operative microscope. Either way a 2-mm
opening in the midline is made with a small-blade scal-
pel, sparing the arachnoid. The dura is then opened
sharply in the midline along the entire extent of the bony
exposure (Fig. 6B). Using 4-0 silk sutures placed ap-
proximately 1 cm apart, the dural edges are retracted
laterally, thus maximizing the exposure. In patients with
trauma or prior operative procedures, the dura and arach-
noid may be adherent and scarred down to the spinal
cord. Gentle and blunt dissection using the microscope
is required to separate them. In nucleus caudalis DREZ
operations, care should be taken when opening the dura
across the area of the foramen magnum due to the fre-
quent presence of a circular sinus. Control of bleeding,
from the sinus is achieved using hemostatic clips until
the dura is opened followed by replacing the clips with
a running 4-0 silk suture. Once the dura is opened be-
yond this point the incision is then curved laterally to-
ward the side of the pain.
If the microscope was not used for the dural opening
it is then brought into the field to open the arachnoid. The
arachnoid is opened directly over the dorsal root entry
zone in patients undergoing unilateral DREZ lesions. The
arachnoid is first opened in the middle of the exposure by
the use of a sharp hook and scissors and then its edges are
secured to the dural edges using small hemostatic clips
(Fig. 6C). It is then opened caudally and rostrally using a
microbayonet forceps and sharp microscissors. It is im-
portant to keep the arachnoid edge secured to the dural
edge with hemostatic clips so that when the dura is closed
the subarachnoid space is maintained and adhesion of the
dura to the spinal cord is prevented. In patients undergo-
ing nucleus caudalis lesions, the posterior inferior cer-
ebellar artery is almost always encountered and care
should be taken to avoid injury to this impor-
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

© 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.

14
 NASHOLD AND EL-NAGGAR : DORSAL ROOT ENTRY ZONE LESIONING
tant vessel. This is especially important in patients who
have undergone a previous retromastoid craniectomy for
microvascular decompression of the fifth cranial nerve
for tic douloureux, in whom scarring and thickening of
the arachnoid can obscure the vessel.
Once the arachnoid is satisfactorily opened, any ad-
herent structures over the dorsal root entry zone should
be dissected and retracted. Commonly, multiple serpen-
tine vessels located along the intermediolateral sulcus
must be mobilized to allow for the introduction of the
DREZ electrode. If bleeding is encountered, a small piece
of Surgicel placed on the vessel is almost always suffi-
cient for hemostasis; if the bleeding is significant, bipo-
lar coagulation at a low setting is used. The description
of the DREZ electrodes as well as the specifics of the
operation for various indications are mentioned later. In
general, the DREZ electrode is placed first into the most
caudal aspect of the region to be lesioned, and is then
moved stepwise in cephalad direction. This allows the
neurosurgeon to visualize the upper dorsal rootlets as a
guide. The electrode is placed into the entry zone at the
same angle as the dorsal root, i.e., approximately 45°.
The electrode is placed into the spinal cord to a depth of
2 mm, at which point the insulating collar prevents fur-
ther ingress. Lesions are made at 75°C for 15 seconds
using the radiofrequency generator. The lesions are made
at 1-mm intervals along the entire affected dorsal root
entry zone. The spinal region to be lesioned can be mea-
sured, and if the distance is 10 mm then 10 lesions should
be made. A comparison of the improvement in pain af-
ter DREZ procedures between the earlier patients oper-
ated on in the late 1970s and the more recent cases re-
veal improved results with a greater number of DREZ
lesions. Blood vessels which are encountered are gently
retracted and the electrode slipped into the entry zone
avoiding the coagulation of all except the smallest ves-
sels adherent to the DREZ area. The laser has been used
by some neurosurgeons to create DREZ lesions, and the
early clinical reports regarding relief of pain and com-
plications appear to be satisfactory. We believe the laser
lesion may be more difficult to control because of the
lack of detailed laboratory studies, but this may be cor-
rected in the future.
After all lesions are made, total hemostasis is ob-
tained within the thecal sac and all residual blood is
gently irrigated away. The dura and arachnoid are
reapproximated in a single layer of continuous 4-0 Vicryl
suture, removing the silver clips gradually as the suture
approaches the site of the clip to avoid any gaps in the
arachnoid closure. Dural tack-up sutures are placed to
avoid compression in the event of the development of a
postoperative epidural hematoma. A tack-up suture is
15
placed at each end of the dural exposure between the su-
ture line and the adjoining supraspinous or interspinous
ligament. Central tack-up stitches are also used: two in
four-level laminectomies and three in five-level laminec-
tomies. These are placed between the dural suture line
and the connective tissue overlying the adjoining joint
capsule in the lumbar and thoracic regions, or to the cer-
vical fascia and nuchal ligament in the cervical region.
We prefer to place tack-up stitches in all cases, whether
bilateral laminectomies or hemilaminectomies are per-
formed. Copious amounts of bacitracin irrigation are used
after each layer of the wound is closed. The paraspinal
muscles are sutured with 2-0 Vicryl sutures, followed by
closure of the subcutaneous tissue in two or three layers
of 2-0 Vicryl sutures depending on its thickness. The skin
is then sutured using 4-0 continuous nylon sutures. We
ordinarily do not use epidural drains. If drains are used
they are preferably removed on the first postoperative day
to avoid infection and the development of a cerebrospinal
fluid (CSF) fistula.
ELECTRODES AND LESION PARAMETERS
The three types of DREZ electrodes in use at Duke are
manufactured by Radionics who also make the RF lesion
generator used in the DREZ operation (Fig. 7). The stan-
dard DREZ electrode has a lesion tip of 2 mm and is 0.25
mm in diameter (Fig. 7A). The caudalis nucleus electrode
has a tip length of 3 mm, a diameter of 0. 25 mm, a 1-mm
proximal insulation, and a 2-mm lesion tip (Fig. 7B). The
proximal 1-mm insulation at the base is designed to pre-
vent lesioning the ascending spinocerebellar tract which
lies superficial to the trigeminal nucleus caudalis. A new
type of caudalis electrode is made with a 90° angle at the
tip to facilitate its use at the higher levels of the
cervicomedullary junction (Fig. 7C). The electrodes are
made of a hollow stainless steel tube tapered and pointed
at the end with an internal thermister at the tip to measure
the temperature of the lesion. The RF lesions are made at
75°C for 15 seconds and this results in a lesion (2 × 4-5
mm) which will destroy the upper 5 or 6 Rexed layers in
the dorsal horn. Two postmortem studies have confirmed
the focal nature of the lesions of the Rexed layers. The heat
produced at the tip of the electrode is produced by the
radiofrequency current generator. Spinal cordotomy-type
electrodes are not satisfactory to make DREZ lesions.
BRACHIAL PLEXUS AVULSION INJURY
A laminectomy usually extending from C5 to T1 is per-
formed, although it is imperative that at least a portion
of the healthy roots above and below the avulsion be
visualized to avoid any residual postoperative pain.
The intermediolateral sulcus marking the entry
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
© 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
and is easily seen along an imaginary line connecting the
entry zone of the first attached root above and the first at-
tached root below the avulsed area. Also, identification of
the DREZ area on the normal contralateral side helps in iden-
tifying the overall anatomy of the area. DREZ lesions are
then placed 1 mm apart extending between the healthy root-
lets above and below as described above (Fig. 8).
CONUS MEDULLARIS ROOT AVULSIONS
Avulsion injuries of the conus medullaris differ from those
in the cervical region in that usually only one or two lum-
bosacral roots are avulsed (L5 or S1). When the conus is
exposed at operation, the lumbosacral dorsal roots on ei-
ther side can be seen along with the avulsed area on the
conus. The dorsal roots on the side of the avulsion must
be carefully retracted laterally until the avulsed root level
is visualized (Fig. 9).
PARAPLEGIA WITH INTRACTABLE PAIN
Meticulous dissection of the arachnoidal scarring and
adhesions commonly found in these cases is necessary to
identify the DREZ area. Intraoperative ultrasound is also
used whenever there is a suspicion of the presence of a
traumatic syrinx either on clinical, radiological, or surgi-
cal grounds. If present, the syrinx should be drained by
placement of a syringo-subarachnoid or syringo-perito-
neal shunt in addition to the DREZ lesions (Fig. 10).
POSTHERPETIC NEURALGIA
Evoked potentials are very helpful in localizing the re-
16
sponsible dorsal rootlets as shown below; we find this to
be crucial to avoid incomplete pain relief. Both soma-
tosensory evoked potential (SEP) and motor evoked po-
tential (MEP) studies are carried out intraoperatively.
Anatomic localization is most difficult with the thora-
columbar dorsal roots and those dorsal roots originating
from the conus medullaris. Careful SEP studies from the
painful areas of the body give a precise dorsal root local-
ization, allowing the neurosurgeon to confine the DREZ
lesions to the involved painful area of the body.
We now routinely monitor somatosensory evoked
potentials intraoperatively. The potential recorded is pro-
duced by simultaneous firing of dorsal horn neurons, the
maximal discharge being in the spinal cord segment(s) of
entry of the nerve stimulated (Fig. 5). This allows for pre-
cise localization of the level for lesion production. Stimu-
lating electrodes are placed bilaterally near affected nerves
as determined from the preoperative sensory exam, and
also on the contralateral side near the comparable intact
nerves. This allows for a comparison of normal with ab-
normal signals.
For stimulating the body or the extremities, we use
subcutaneous bipolar needle electrodes; bipolar gold discs
are used when stimulating the face. The evoked poten-
tials are recorded from the surface of the spinal cord or
the cervicomedullary junction using platinum-irridium
multicontact disc electrodes and also from the depth us-
ing the lesion-generating electrode.
The largest amplitude negativity is determined af-
ter stimulation of the intact side. The negativity is usu-
ally comparatively much reduced or otherwise ab-
NASHOLD AND EL-NAGGAR : DORSAL ROOT ENTRY ZONE LESIONING

© 1992 The American Association of Neurological Surgeons

Figure 8. DREZ lesions in brachial plexus avulsion injuries.

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© 1992 The American Association of Neurological Surgeons

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

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 NASHOLD AND EL-NAGGAR : DORSAL ROOT ENTRY ZONE LESIONING

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.

19
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
normal on the affected side. We have found that in many
instances after DREZ lesions are produced, the negative
wave is replaced by a positive one. This positive potential
generally signals the volume-conducted approach toward
the electrode of neural activity, but without neuronal dis-
charge at the electrode site. This positivity, then, provides
for an immediate feedback on the technical success of
the operation.
NUCLEUS CAUDALIS DREZ LESIONING
The DREZ lesions are made using the special caudalis
electrodes described above. The special design of these
electrodes takes into account that the caudalis nucleus lies
beneath the surface of the cervicomedullary junction.
Therefore, the electrode tip is 3 mm in length and 0.25
mm in diameter, with a proximal 1 mm insulated area and
a distal 2-mm lesion tip. The RF lesions are made along
the same line as the cervical dorsal root entry zones over
a distance of 15-20 mm from the level of the C2 dorsal
rootlets to the tuberculum cinereum of the medulla at a
level slightly above the obex. Due to the larger cross-sec-
tional diameter of the nucleus caudalis, two rows of RF
lesions are made 1 mm apart using the same parameters
of 75°C for 15 seconds. The first row of lesions begins at
the level of the dorsal rootlets of C2 and is extended ceph-
alad to 5 mm above the obex. The second row begins at
C2 but just dorsal to the exit of the rootlets of the spinal
accessory nerve (Fig. 11, middle and lower left).
Currently, we perform a unilateral limited exposure
of the nucleus caudalis. This is associated with less post-
operative pain and earlier ambulation. It involves a para-
median skin incision (Fig. 12A). The incision is carried
down to the subcutaneous tissue, cervical fascia, and
trapezium muscle using electrocautery. The semispina-
lis capitis muscle is then split at the point of emergence
of the greater occipital nerve (Fig. 12B). The rectus capi-
tis posterior minor muscles are divided at their insertion
on the posterior tubercle of C1 and reflected upward.
The rectus capitis posterior major is retracted downward
and laterally using a Leyla retractor (Fig. 12C). A uni-
lateral suboccipital craniectomy with removal of the ip-
silateral half of the arch and whole tubercle of C1 is
then performed. The ligamentum flavum between C1 and
C2 is also removed (Fig. 12D). The C2 lamina and the
muscles attached to C2 are left intact. The dura and arach-
noid are then opened as discussed previously. The le-
sions are made using the right-angled nucleus caudalis
DREZ electrode (Fig. 13A), which provides a better angle
to target the lesion on the nucleus caudalis (Fig. 13B).
The lesions are made starting above the C2 rootlets in
line with the DREZ area of the spinal cord in the inter-
mediolateral sulcus proceeding upward until the C1 root-
lets are encountered. The lesions are then made into the
20
trigeminal tubercle between the border of the cuneate
tubercle and the emerging cranial roots of the accessory
nerve (Fig. 13C). Only one row of lesions is made. Fa-
miliarity with the bilateral exposure of the nucleus
caudalis is advised prior to performing the unilateral
exposure.
COMBINED NUCLEUS CAUDALIS-NUCLEUS
SOLITARIUS DREZ LESIONING
The exposure is the same as for nucleus caudalis DREZ
lesioning. After arachnoid dissection, standard nucleus
caudalis DREZ lesions are made; then two lesions are
made to destroy the nucleus solitarius in the floor of the
fourth ventricle 1 mm above the obex and 1 mm lateral to
the midline on the side of the pain (Fig. 11, middle). The
RF lesions are made using the straight nucleus caudalis
electrode, thereby avoiding injury to the overlying cra-
nial nerve nuclei. Transient bradycardia and a slight drop
of the blood pressure may occur during lesioning. The
use of 0.5-1 mg of atropine intravenously will prevent the
vascular changes which are due to the proximity of the
afferent input from the carotid body into the ventral por-
tion of the nucleus solitarius. The combined nucleus
caudalis and solitarius lesions give good pain relief in
patients with head and neck cancer, especially those with
posterior pharyngeal and esophageal pain.
POSTOPERATIVE CARE
Postoperative care is the same as for laminectomy patients.
We prefer, however, progressive ambulation of the patients
depending upon the clinical condition. Patients who un-
dergo conus medullaris DREZ lesioning or lower thoracic
procedures are nursed in the flat position for three to four
days followed by progressive ambulation. Patients with
upper thoracic, cervical, and caudalis DREZ surgery are
kept with the head of the bed up 30° for three days fol-
lowed by progressive ambulation. Steroids are continued
in the postoperative period for three days followed by rapid
tapering over three to four days to avoid the deleterious
effect of steroids on wound healing. Analgesics are lim-
ited to those necessary to control postoperative pain.
Parenteral narcotics for 24-48 hours are used followed by
oral codeine or oxycodone for a few days. We prefer not
to give narcotics in high doses for extended periods of
time to be able to assess the results of surgery.
COMPLICATIONS
Postoperative complications are in the order of 3-5%,
including CSF leakage and postoperative epidural he-
matoma formation, in addition to ipsilateral lower ex-
tremity weakness or incoordination, especially follow-
ing DREZ lesions in the thoracic cord. Nucleus
caudalis DREZ lesioning can be especially compli-
 NASHOLD AND EL-NAGGAR : DORSAL ROOT ENTRY ZONE LESIONING

© 1992 The American Association of Neurological Surgeons

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

21
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© 1992 The American Association of Neurological Surgeons

Figure 12. Unilateral exposure of the nucleus caudalis.

22
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© 1992 The American Association of Neurological Surgeons

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

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 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
cated by upper and/or lower extremity ataxia, usually
resolving in a few days. Cerebrospinal fluid leakage can
be prevented by having a tight dural closure and nursing
the patient in the appropriate position postoperatively.
In nucleus caudalis DREZ operations we almost invari-
ably place a dural graft at the time of closure to avoid
undue tension on the dura, which in turn allows for a
better, tighter closure. Epidural hematomas can be pre-
vented by having a dry field prior to closure in addition
to the use of tackup stitches as mentioned above. Rou-
24
tine antibiotics are not used; however, if signs of infec-
tion develop, we obtain blood cultures as well as wound
cultures followed by the administration of broad spec-
trum antibiotics until the final results of the cultures are
obtained. Neurologic deficits in the form of ipsilateral
or bilateral upper and lower extremity weakness can be
avoided by careful monitoring of evoked potentials as
well as downstream electromyographic recording in ad-
dition to thorough adherence to the above mentioned
principles of lesion making.
 OPHTHALMIC SEGMENT ANEURYSMS
ARTHUR L. DAY, M.D.
PERTINENT ANATOMY
The ophthalmic segment (OphSeg) is the longest sub-
arachnoid portion of the internal carotid artery (ICA). It
begins below the level of the anterior clinoid process at
the point where the ICA penetrates the dura to enter the
subarachnoid space and ends at the origin of the posterior
communicating artery (PComArt) (Fig. 1). Removal of
the anterior clinoid process (AC) to expose the proximal
portion of the OphSeg reveals an ICA segment that lies
beneath the subarachnoid space and outside the cavern-
ous sinus. This portion, known as the clinoidal segment
(ClinSeg), is limited superiorly by the dural reflections
from the medial roof of the anterior clinoid process to-
ward the optic nerve and canal that mark ICA entry into
the subarachnoid space, a point known as the dural ring
(DR). Inferiorly, the clinoid segment is bordered by a thin
layer of periosteum, bridging from the ICA to the oculo-
motor nerve (carotid-oculomotor membrane (COM) or
membranous ring), that separates this segment from the
venous wall of the cavernous sinus.
Two named branches arise from the OphSeg, both of
which typically originate just above the dural ring. The
ophthalmic artery (OphArt) usually arises from the dor-
sal or dorsomedial ICA surface. Several perforating ves-
sels also arise from this segment, the largest of which has
been named the superior hypophyseal artery (SupHypArt).
These perforators typically arise from the medial or ven-
tromedial ICA surface. Their ventromedial origin, together
with the gentle downward slope of the dural ring posteri-
orly, often places the SupHypArt origins on a horizontal
plane below the level of both the anterior clinoid process
and OphArt.
Ophthalmic segment aneurysms are divided herein
into two large categories, depending on association of the
aneurysm neck with the named arterial branches within
the segment. Aneurysms arising in clear relation to the
ophthalmic artery are termed OphArt aneurysms (Fig. 2).
These lesions arise from the ICA just distal to the origin
of the ophthalmic artery, and initially project dorsally or
dorsomedially from the carotid surface toward the lateral
half of the optic nerve.
© 1992 The American Association of Neurological Surgeons
25
Other aneurysms originating within this segment in-
variably incorporate the perforating branches to the hy-
pophysis and are herein called SupHypArt aneurysms
(Fig. 3). Small SupHypArt aneurysms usually arise from
the inferior or inferomedial surface of the ICA just oppo-
site and slightly distal to the origin of the OphArt. These
lesions may remain lateral to the sella, burrowing beneath
and medial to the ICA under the anterior clinoid process.
Because the space beneath the carotid is limited, how-
ever, most larger lesions will eventually expand medially
or superomedially above the diaphragma sellae into the
suprasellar space.
PATIENT SELECTION
The typical patient harboring an OphSeg aneurysm is a
female in her mid-fifties who presents with a subarach-
noid hemorrhage (SAH) or visual changes, or whose an-
eurysm is discovered incidentally. If bleeding has oc-
curred, surgery is performed on the earliest day possible
following the hemorrhage, as long as the patient is not a
poor medical risk or has not sustained significant and ir-
reversible brain injury.
Approximately one-half of symptomatic OphSeg
aneurysms are giant lesions presenting with visual loss.
The high frequency of OphSeg lesions reaching large or
giant proportions without bleeding is probably explained
by their reinforcement by adjacent structures, such as the
optic nerve or dura of the lateral sellar wall and cavern-
ous sinus. Lesions presenting with mass-related symp-
toms are often much larger on computed tomography than
the angiographically apparent lumen size would suggest,
indicating a significant incidence of partial luminal throm-
bosis.
Because 40-50% of patients with one OphSeg lesion
also have at least one other intracranial aneurysm, the
surgeon often must decide which lesion bled. Small
SupHypArt lesions that remain purely paraclinoid have a
very low rate of hemorrhage compared with those at other
locations, and asymptomatic lesions are often best treated
conservatively unless intervention is planned for other
reasons. Larger aneurysms, or those with medial supra-
sellar extension, appear to bleed with higher frequency.
If intervention is planned, the ideal treatment of
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

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26
 DAY : OPHTHALMIC SEGMENT ANEURYSMS
Figure 1. Paraclinoid anatomy. A, lateral view (schematic) with the
clinoid intact. The three paraclnoid segments of the ICA can be iden-
tified, including the intracavernous segment (CavSeg), the clinoidal
segment (ClinSeg), covered by the anterior clinoid process (AC), and
the ophthalmic segment (OphSeg). The OphSeg begins just proximal
to the OphArt origin and ends at PComArt. Note the posterior bend of
the ICA just beyond the ophthalmic artery (OphArt) origin, which is
usually obscured by the AC. ON = optic nerve; SupHypArt = superior
hypophyseal artery; PComArt = posterior communicating artery;
AChorArt = anterior choroidal artery; CavSin = cavernous sinus. B,
lateral view (schematic) with the clinoid removed. The dura overlying
27
and reflecting from the medial surface of the AC delineates the
paraclinoid segments. DR = dural ring; COM = carotid-oculomotor
membrane (also called membranous ring); OSt = optic strut. In most
instances, the OphArt and SupHypArt arise from the OphSeg, above
the dural ring. C, dorsal view (schematic) with the anterior clinoid
intact. Note the medial-to-lateral curve of the ICA that actually begins
just beyond the anterior bend of the CavSeg. The SupHypArt perfora-
tors usually arise from the inferomedial surface of the OphSeg as the
ICA curves laterally. The right ON has been retracted superiorly to
expose the OphArt origin. Occasionally, both or either branch may
arise from the ClinSeg, beneath the dural ring. Pit = pituitary gland.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

© 1992 The American Association of Neurological Surgeons

© 1992 The American Association of Neurological Surgeons

28
 DAY : OPHTHALMIC SEGMENT ANEURYSMS
Figure 2. Typical anatomy of ophthalmic artery aneurysms. A, a large
ophthalmic artery aneurysm (schematic, lateral view, clinoid intact). Note
the position of the optic nerve (ON) and the sharp angulation of its supe-
rior surface (arrow) against the edge of the falciform ligament. Note also
that the anterior clinoid process (AC) limits the view of the proximal an-
eurysm neck and the origin of the ophthalmic artery (OphArt). DR = du-
ral ring; OphSeg = ophthalmic segment; AN = aneurysm. B, a large OphArt
aneurysm (schematic, dorsal view, clinoid intact). Note the medial dis-
29
placement of the lateral aspect of the optic nerve. The ON often creates a
groove in the superomedial surface of the aneurysm, and its position re-
stricts medial extension of the AN across the midline until late in the
clinical course. FalcLig = falciform ligament. C, a lateral arteriogram of
a typical large OphArt aneurysm. Note that the lesion originates just be-
yond the OphArt takeoff and projects largely dorsally, above the bend of
the carotid artery. As the lesion expands, the superior restriction imposed
by the overlying optic nerve tends to close the carotid siphon.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

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30
 DAY : OPHTHALMIC SEGMENT ANEURYSMS
© 1992 The American Association of Neurological Surgeons
Figure 3. Typical anatomy of superior hypophyseal artery aneurysms. A,
a small superior hypophyseal artery aneurysm. 1, lateral view (schematic).
The aneurysm (AN) arises ventromedially above the dural ring (DR), op-
posite the ophthalmic artery (OphArt) origin, and appears to project into
the cavernous sinus. The AN lies partly below the level of the anterior
clinoid process (AC) but is still within the subarachnoid space. ON = op-
tic nerve. 2, anteroposterior (AP) view (schematic). The AN projects ven-
tromedially above the DR toward the lateral sellar wall. SupHypArt =
superior hypophyseal artery; Pit = pituitary gland. B, a larger superior
hypophyseal artery aneurysm. The lesion size now exceeds its ventral
confines and expands into the suprasellar space below the optic nerves
and chiasm. 1, lateral view (schematic). Note that the AN projects both
dorsal and ventral to the OphSeg of the ICA, and its lumen is widely
splayed. The SupHypArt drape over the aneurysm’s superior surface, while
the posterior communicating artery (PComArt) is displaced posteriorly
and laterally. The AC limits the view of the ventral and medial aspects of
31
the aneurysm neck. Note also that the AN does not sharply angulate the
optic nerve at the falciform ligament. 2, AP view (schematic). Note the
two bulges at the aneurysm, one ventrally at the site of aneurysm origin.
and the second into the suprasellar space. To totally obliterate this lesion,
the ventral bulge (arrow) lateral to the sella must be incorporated in the
clip down to the dural ring. C, a giant superior hypophyseal aneurysm,
dorsal view (schematic). Note the suprasellar extension beneath the chi-
asm, with the pituitary stalk (PitSt) displaced and allowing extension across
the midline. D, a lateral arteriogram of a typical large SupHypArt aneu-
rysm. In this projection, the AN balloons both above and below the pro-
jected course of the ICA, which appears to run through the aneurysm
lumen. The part of the aneurysm below the ICA represents the initial
ventral origin, whereas the suprasellar extension lies superior. The ca-
rotid siphon appears to open as the lesion enlarges, due to the bulge be-
neath and medial to the ICA. Note that the region of the typical OphArt
origin is independent of the aneurysm.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
OphSeg aneurysms is clipping, with preservation of the
internal carotid artery and its branches. Major risks of
surgery include blindness, stroke, or inability to com-
pletely secure the aneurysm neck. With proper exposure
and a firm understanding of parasellar and vascular
anatomy, however, most of these lesions are clippable, with
low risks to the brain or visual apparatus. Carotid ligation
should be considered a secondary alternative, as the risks
of stroke are higher from parent vessel sacrifice, the vi-
sual system is not as effectively decompressed, and com-
plete thrombosis of the aneurysm is not ensured.
PREOPERATIVE PREPARATION
Bleeding from OphSeg aneurysms is managed in the same
fashion as SAE from aneurysms in other locations, using
such measures as bedrest, calcium channel blockers, hy-
dration, ventricular drainage (when indicated), steroids,
and anticonvulsants. Prophylactic antibiotics are given to
all patients when they enter the operating suite and are
continued for 24 hours.
Preoperative bedside testing of visual fields is often
overlooked in the SAH patient, but should be dutifully
performed in those harboring large or giant OphSeg an-
eurysms. The early visual sign of an OphArt aneurysm
(an inferior nasal field cut) is often not noted by the pa-
tient. Establishment of this visual field loss pattern not
only documents the deterioration preoperatively, but also
© 1992 The American Association of Neurological Surgeons
Figure 4. Operative position and craniotomy exposure (schematic). The
arrow points to the “keyhole,” marking the external surface of the sphe-
32
provides key knowledge to the surgeon about the anatomy
likely to be encountered in the operating room.
SURGICAL TECHNIQUE
Anesthesia and Monitoring
The ispilateral cervical carotid region should be unen-
cumbered by any anesthetic equipment. If temporary clip-
ping of the ICA is anticipated, intravenous barbiturates
are administered until burst suppression is achieved on
electroencephalography (EEG) and are continued until
patency in the carotid system is restored. Blood pressure,
monitored with an indwelling radial artery catheter, is
generally maintained at normal levels. Continuous evoked
potential and EEG monitoring is also utilized, and the
blood pressure is elevated during ICA clipping if focal
changes are noted. Spinal drainage is not utilized rou-
tinely.
Operative Positioning and Draping
The patient is placed in the supine position, with the head
elevated above the heart to promote good venous drain-
age (Fig. 4). The patient’s head is turned 45° toward the
opposite side, with the vertex lowered, to allow gravita-
tional distraction of the frontal and temporal lobes from
the skull base. A shoulder roll is used to minimize distor-
tion of the cervical carotid bifurcation.
noid ridge. The carotid incision is draped into the operative field but is
not opened in most instances.
 DAY : OPHTHALMIC SEGMENT ANEURYSMS
The head is draped to permit visualization of the fron-
tal and temporal regions from the midline to below the
zygoma. For giant lesions, especially those with calcifi-
cations or luminal thrombosis, the cervical region is also
draped to allow sterile access to the carotid bifurcation
for proximal control or bypass source as desired.
Operative Procedure
The skin incision for craniotomy extends from the mid-
line to the zygoma, one finger’s breadth behind the hair-
line (Fig. 4). An incision is also marked over the cervical
carotid bifurcation, paralleling the anterior margin of the
sternocleidomastoid muscle, but is not opened in most
instances.
The temporalis fascia is sectioned 1 cm below its skull
attachment superiorly, and just posterior to the fat pad
containing the frontal branch of the facial nerve. The
temporalis muscle with its remaining fascial covering is
reflected inferiorly and posteriorly to expose the pterion.
A frontotemporal free bone flap is elevated, opening low
enough anteriorly so that 2-3 cm of the posterior frontal
fossa floor is exposed. The sphenoid ridge is removed
extensively, and a temporal craniectomy is enlarged to
allow an unobstructed view of the anterior aspect of the
middle cranial fossa.
Proximal visualization of the carotid and ophthalmic
arteries is mandatory for both aneurysm types (OphArt
and SupHypArt), and, at this point, a decision is made
whether to remove the anterior clinoid process
extradurally. While not always necessary for smaller le-
sions, clinoidal removal is frequently required for safe
and accurate clipping of large or giant lesions. With
unruptured aneurysms, extradural clinoid removal can
usually be done quite safely, without exposing the sub-
arachnoid space to bone debris. Generally, and especially
following SAH, the clinoidal tip is removed intradurally
while the surgeon simultaneously visualizes the aneurysm,
thereby avoiding inadvertent rupture during extradural
manipulation.
If done extradurally, the posterior roof of the orbit
and the lesser wing of the sphenoid bone covering the
superior and medial surface of the superior orbital fis-
sure are removed with a rongeur (Fig. 5). As the base of
the clinoid process and optic nerve are approached, a high-
speed diamond drill is utilized to thin the bone, which is
then fractured away with microcurettes. After the dura
has been stripped away from the remaining clinoid tip,
the process is grasped with a hemostat, gently rocked free
of any remaining attachments, and removed. Bleeding is
quite easily controlled with bone wax, Gelfoam, and
Surgicel. This extensive bone removal exposes the extra-
dural optic nerve and the clinoidal space, a pocket of vari-
33
able size (usually <5 mm) that houses an ICA segment
(clinoidal segment) below the dural ring but outside the
main venous channels of the cavernous sinus. Although
covered by thin reflections of periosteum and small venous
channels, the ClinSeg can be freed up from its loose at-
tachments, thus providing proximal exposure for tempo-
rary clipping if required.
The dura is then opened and reflected to expose the
proximal portions of the sylvian fissure. The fissure is
split widely to allow an unobstructed view of the optic
nerve, ICA, and aneurysm with minimal retraction.
If indicated and not already performed, the clinoid
process is now removed intradurally (Fig. 6). After cau-
terization, a cruciate incision is made into the dura cover-
ing the anterior clinoid process and the optic canal roof.
The clinoid process is then carefully thinned and removed
with small rongeurs and a highspeed drill. The removal
should extend laterally to include the medial roof of the
superior orbital fissure, inferomedially to trim the optic
strut, and superomedially to unroof the optic canal.
Optic nerve displacement, if not already done by the
aneurysm, is often necessary to visualize the proximal
neck. The falciform ligament should be sectioned before
any aneurysm dissection is undertaken. This structure
forms a knife-like edge against the superior aspect of the
optic nerve, and mobilization of the nerve against it may
further increase visual morbidity.
The neck of the aneurysm is now ready to be de-
fined. Before beginning the dissection, the ClinSeg should
be prepared to receive a temporary clip if the need is an-
ticipated. Extradural clinoidal removal requires that the
clinoidal dura now be opened from within, thereby delin-
eating clearly the dural ring and the clinoidal ICA seg-
ment. The dural ring is thicker laterally but thins on its
medial surface. Its circumferential section allows mobili-
zation of the ICA and accurate identification of the OphArt
and aneurysm neck. Cervical carotid exposure is a rea-
sonable alternative to proximal control within the clinoidal
space, but neither is a substitute for extensive clinoidal
and optic strut removal.
The proximal neck of OphArt aneurysms originates
just distal to the OphArt and can be separated with gentle
retraction of the aneurysm base and spreading dissection
with micro-bayonetted forceps (Fig. 7). The distal neck is
usually unencumbered by major branch attachments, but
any perforators to the optic nerves, chiasm, or hypophy-
sis should be dissected free. Straight or side-angled clips,
closed down parallel to the course of the ICA and sparing
the OphArt, satisfactorily secure most OphArt lesions.
Clips placed perpendicular to the ICA are often ineffec-
tive in collapsing larger lesions and risk avulsion of the
proximal aneurysm neck.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
© 1992 The American Association of Neurological Surgeons
Figure 5. Extradural clinoid removal (schematic). A, the extent of the
osseous removal is outlined in the crosshatched area. OC = optic canal;
AC = anterior clinoid process; SOF = superior orbital fissure; OSt = optic
strut. B, the operative view. 1, the right frontal and temporal lobes are
retracted extradurally to expose and permit removal of the posterior por-
tions of the orbital roof back to the sphenoid ridge. The SOF is unroofed,
advancing toward the AC and the extradural portion of the optic nerve
(ON). 2, the AC is removed with a high-speed irrigating drill until only a
34
thin shell remains, which is then fractured off the optic strut and detached
from the dura. The superior, lateral, and inferior walls of the extradural
portion of the ON are removed carefully. 3, the completed exposure re-
veals the clinoidal segment (ClinSeg) of the carotid artery, and the optic
strut (OSt). The cavernous sinus lies posterior, inferior, and lateral to the
ClinSeg and is covered by the inferior projection of dura from the AC
known as the carotid-oculomotor membrane (COM). DR = dural ring, the
point where the ICA penetrates the dura to enter the subarachnoid space.
 DAY : OPHTHALMIC SEGMENT ANEURYSMS
© 1992 The American Association of Neurological Surgeons
Figure 6. Intradural clinoid removal, operative view (schematic). A, the
dural incision (right pterional frontotemporal craniotomy). The sylvian fis-
sure has been opened widely, and the frontal and temporal lobes retracted.
The dotted lines mark a cruciate dural incision overlying the anterior cli-
noid process (AC), with an additional limb sectioning the falciform liga-
ment (FalcLig) to untether the optic nerve (ON). OphArt = ophthalmic ar-
tery; SupHypArt = superior hypophyseal artery; ICA = internal carotid artery;
ACA = anterior cerebral artery; PComArt = posterior communicating ar-
tery. B, the AC, roof, and lateral wall of the optic canal, and adjacent orbital
35
roof have been removed. The clinoidal segment (ClinSeg) has been ex-
posed, covered by the thin dura medial to the AC. The dural ring (DR)
surrounds the ICA and marks its entrance into the subarachnoid space. The
carotid-oculornotor membrane (COM) covers the cavernous sinus (CavSin).
The oculomotor nerve (III) can be seen through the COM, in the wall of the
CavSin. Bleeding is usually due to small venous tributaries that traverse the
area and is easily controlled with pledgets of Gelfoam and gentle suction.
Extensive removal of the optic strut (OSt) provides enough exposure of
the ClinSeg to permit temporary ICA clipping if necessary.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

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36
 DAY : OPHTHALMIC SEGMENT ANEURYSMS
SupHypArt aneurysms project medially and inferi-
orly, just distal to the dural ring (Fig. 8). Small SupHypArt
aneurysms may be initially hidden from the surgeon by
the overlying ICA and anterior clinoid process. In large
and giant varieties, the ICA is displaced slightly laterally
and superiorly toward the surgeon, and the neck of the
lesion often appears so wide and long that the entire ca-
rotid wall appears incorporated into the aneurysm. As
SupHypArt aneurysms enlarge, their walls become ad-
herent to the dura of the sella, diaphragma, and lateral
cavernous sinus wall. Although the arteriogram may sug-
gest otherwise, these lesions rarely if ever project into the
cavernous sinus, and the walls of the two structures can
be separated. By carefully adhering to the dural ring sur-
face, the part of the aneurysm wall that bulges beneath
the clinoid process is separated from the clinoidal dura,
thus freeing up the proximal neck.
The hypophyseal stalk may be adherent to the poste-
rior and medial surface of larger SupHypArt lesions. The
posterior communicating artery or its thallamoperforating
branches are often draped over the distal end of the aneu-
rysm, and these vessels must be carefully identified, sepa-
rated, and preserved.
SupHypArt lesions are usually best obliterated with
a fenestrated clip whose blades pass over and then run
parallel to the ICA, spanning the distance between the
PComArt and the dural ring. Although the OphSeg per-
forators (superior hypophyseal arteries) do not generally
supply brain parenchyma, some reach the optic chiasm,
and every attempt should be made to spare them from the
surgical clip. Visual loss, either unimproved or somewhat
worsened following surgery, can perhaps be caused by
interruption of these vessels. The pituitary stalk receives
blood supply from both sides, however, and endocrine
deficits secondary to unilateral interruption of these
branches are rarely noted.
When large, both types of lesions (OphArt and
SupHypArt) tend to be associated with arteriosclerosis in
the carotid artery and/or adjacent aneurysm neck. Broad
necks are commonplace and are best secured by placing
the clip parallel to the parent (ICA) vessel. The bulk of
these aneurysms and the thickness of their necks often
cause the initial clip to slip downward and partially ob-
struct the parent artery lumen. A second clip, applied more
Figure 7. Ophthalmic artery aneurysm clipping (right side, sche-
matic). A, exposure (see also Fig. 6B). The falciform ligament
(FalcLig) is sectioned before any aneurysm manipulation is under-
taken. AN = aneurysm; ON = optic nerve; OphArt = ophthalmic ar-
tery; SupHypArt = superior hypophyseal artery; PComArt = poste-
rior communicating artery; ClinSeg = clinoidal segment; OphSeg =
37
distally on the neck and in the same direction as the first,
is often helpful in keeping the neck and aneurysm col-
lapsed. If placement of the first two clips results in a com-
promised ICA lumen, a third clip is applied distal to the
second, and the original clip is removed. This process is
repeated until wide carotid patency is ensured. The aneu-
rysm is then opened and its contents evacuated without
bleeding. The entire aneurysm wall does not need to be
removed, but the visual apparatus must be thoroughly
decompressed.
Some OphSeg lesions may be judged “unclippable”
because of marked calcification within their walls. Using
barbiturate anesthesia and temporary ICA clipping, the
laminated calcific walls are removed through an incision
into the aneurysm interior. The resultant neck is much more
pliable and accepting of the clip, with less risk of parent
vessel compromise by fractured or displaced calcification
or atheroma. A hemostat may occasionally be used to fa-
cilitate creation of a surgical neck, but this instrument must
be applied distal enough so as not to injure the parent ves-
sel. Debris should be irrigated thoroughly from the parent
vessel before final clip placement.
Because of their superior or medial projection, small
OphSeg aneurysms can often be clipped from a contralat-
eral approach between or behind the optic nerves. OphArt
aneurysms are much easier to clip from a contralateral
approach than are SupHypArt lesions. This capability may
be quite important when deciding which side to treat first
in a patient harboring bilateral lesions, one of which is an
OphSeg type. In general, the craniotomy should be done
on the side of the symptomatic aneurysm. The surgeon
may then choose to explore the opposite carotid artery,
with plans to obliterate the contralateral lesion if feasible.
Attempted clipping of large or giant OphSeg lesions from
a contralateral approach should be avoided except in emer-
gent situations.
Once the aneurysm is clipped and aspirated, the
dura is closed, including the opening over the anterior
clinoid process. The clinoid often incorporates an ex-
tension of the sphenoid sinus, and the residual bone
edges must be inspected and carefully sealed with
muscle, bone wax, or acrylic to prevent cerebrospinal
fluid leakage. A drain is left in the epidural space, and
brought out posterior to the skin incision through a
ophthalmic segment; DR = dural ring; OSt = optic strut. B, defining
the proximal neck with microforceps dissection and suction-retrac-
tion. C, defining the distal neck. D, clip application. A side-angled
clip has been placed parallel to the long axis of the ICA. The AN is
then aspirated and carotid artery patency inspected.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

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38
 DAY : OPHTHALMIC SEGMENT ANEURYSMS
Figure 8. Superior hypophyseal artery aneurysm clipping (right side,
schematic). A, exposure (see also Fig. 6B). AN = aneurysm; ON =
optic nerve; OphArt = ophthalmic artery; SupHypArt = superior hypo-
physeal artery; PComArt = posterior communicating artery; ClinSeg
= clinoidal segment; OphSeg = ophthalmic segment; DR = dural ring;
OSt = optic strut. B, defining the proximal neck with microforceps
and suction-retraction. Separation of the ventral AN bulge from the
dura adjacent to the DR is often aided by circumferential section of
39
the dura alongside the ring. C, defining the distal neck. D, clip appli-
cation. A right-angled fenestrated clip is passed over the broadened
carotid wall and carefully placed parallel to the ICA, with the fenes-
tration reconstructing the parent vessel lumen. The butt of the clip
must spare the PComArt, while the tips are advanced to the ventral
border (arrow) of the DR. The AN is then aspirated, and carotid pa-
tency confirmed. If possible, the SupHypArt should also be spared, as
they may provide critical blood supply to the ON or chiasm.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
© 1992 The American Association of Neurological Surgeons
Figure 9. Clinoidal segment aneurysm (schematic). A, AP view. The
aneurysm (AN) arises below the dural ring (DR) and erodes through
this membrane to enter the subarachnoid space medial and usually
anterior to the ICA. AC = anterior clinoid process; ON = optic nerve;
COM = carotid-oculomotor membrane. B, operative view, right side.
Removal of the optic strut (OSt) is essential to gain access to the
aneurysm neck, which usually originates just above the COM
anteromedially. Note that the clinoidal segment (ClinSeg) is not avail-
40
able for proximal arterial control, and cervical exposure may be very
useful. Circumferential section of the DR is required to allow pas-
sage of a fenestrated clip around the ICA. The clip tips are then ad-
vanced as far proximally as to obliterate the neck, using great care to
avoid injury to the cranial nerves within the cavernous sinus. Bleed-
ing can be easily controlled with gentle Gelfoam or Surgicel pack-
ing and suction. III = oculomotor nerve within cavernous sinus wall;
OSt = optic strut.
 DAY : OPHTHALMIC SEGMENT ANEURYSMS
separate stab wound. When the frontal sinus is violated
by the craniotomy, the mucosa should be removed, and
the space packed with Gelfoam soaked with an antibi-
otic. The sinus is then obliterated with acrylic and in ques-
tionable cases is oversewn with periosteum. The bone flap
is then anchored in position, and the temporalis muscle
and skin are closed in traditional fashion.
POSTOPERATIVE CARE
Patients are thereafter managed according to their pre-
senting symptoms. Patients with an unruptured aneurysm
are mobilized the following day, with rapid normaliza-
tion of medications and fluid intake. SAH patients with
high vasospasm potential are hydrated aggressively for
the duration of their risks.
COMPLICATIONS AND THEIR
MANAGEMENT
Transient or fixed postoperative hemibody deficits may
be an indication of carotid compromise and occur with
higher frequency in patients with a calcified or partially
thrombosed aneurysm with atherosclerosis within the ICA
wall. Digital subtraction arteriography can be useful in
the operating room or immediately postoperatively when
parent vessel patency or embolization is questioned.
Visual deterioration after surgery may occur if the
optic nerve, already distorted medially and superiorly by
the underlying aneurysm, is further manipulated against
the falciform ligament. Perforator sacrifice may harm the
41
blood supply of the optic nerve and chiasm.
Postoperative diplopia may be due to either an ab-
ducens or oculomotor nerve paresis. When the dural ring
is opened, these nerves lie in a relatively superficial posi-
tion within the wall of the clinoidal space. They may be
disturbed within the cavernous sinus either by clinoid re-
moval or by the clip blades as they are advanced proxi-
mally beyond the aneurysm neck.
Aneurysms may arise from the clinoidal segment
and may be quite difficult to differentiate from OphSeg
lesions (Fig. 9). These aneurysms probably account for
some lesions formerly termed ophthalmic aneurysms
which at surgery were “unclippable” or ruptured cata-
strophically. ClinSeg aneurysms probably represent cases
in which the OphArt or SupHypArt arises from the
clinoidal rather than the ophthalmic segment of the ca-
rotid artery. As the space beneath the dural ring is lim-
ited, these lesions may eventually erupt through the dura
into the subarachnoid space, where they appear along-
side the ICA and resemble OphSeg aneurysms. Proxi-
mal exposure is much more difficult to obtain in these
lesions, as the dural ring does not define its proximal
extent. Clinoidal segment aneurysms are often adherent
to the undersurface of the anterior clinoid process and
optic strut, and extradural clinoidal removal may cause
premature aneurysm rupture before proximal or distal
vascular control has been established. If this type of an-
eurysm is anticipated, proximal ICA exposure in the
cervical region is essential.
 CHRONIC SUBDURAL HEMATOMA
JAMES E. WILBERGER, JR., M.D.
INTRODUCTION
Since first described by Virchow in 1875 as pachymenin-
gitis haemorrhagica interna, the pathophysiology and
treatment of chronic subdural hematoma (SDH) has been
a controversial neurosurgical topic. Through the years,
concepts on the pathophysiology of chronic SDH have
been reviewed and revised. Similarly, a variety of treat-
ments have been advocated—observation for spontane-
ous resolution, steroid and osmotic therapy, manipulation
of intracranial pressure, radical calvariectomy to collapse
the subdural space, shunting procedures, and exterioriza-
tion of the subdural space. Currently, the favored surgical
treatments for chronic SDH are twist drill or burr hole
craniostomy with or without closed system external drain-
age of the subdural space. More extensive procedures are
now usually reserved for the 10-25% of patients who do
not respond clinically to these treatments. This chapter
will focus on the techniques of twist drill and burr hole
craniostomy for chronic SDH.
DIAGNOSIS
The incidence of chronic SDH has been estimated to be
1-2 per 100,000 population per year with an increasing
occurrence as age advances. Over 50% of patients may
have no history of trauma and, even in those that do, the
inciting incident is often mild and poorly remembered.
Predisposing factors have been shown to include advanced
age, chronic alcoholism, epilepsy, coagulopathy, and in-
tracranial shunting procedures.
Chronic SDH may present in a variety of ways, mak-
ing the clinical diagnosis difficult. A frequent misdiag-
nosis is “dementia” because the patient is often elderly, a
history of trauma is missing, and symptoms such as
memory loss and personality change may be prominent
and slowly progressive. Chronic SDH can present with
acute or slowly progressing focal neurologic signs, mim-
icking a stroke or tumor. Other infrequent but well de-
scribed presentations include meningismus, seizures, and
ataxia. Chronic SDH is not commonly associated with
© 1992 The American Association of Neurological Surgeons
42
impaired consciousness, but headache may be a very
prominent complaint.
In the era before computed tomography (CT), the
diagnosis of chronic SDH was not made until postmor-
tem examination in over one-third of patients. Presently,
CT is rarely incorrect in confirming or establishing the
diagnosis. The typical finding is a focal hypodense len-
tiform lesion over the surface of the hemisphere. Occa-
sionally, the CT may be unreliable if the SDH is isodense
with the brain. In such situations, use of intravenous
contrast may result in visualization of the vascularized
subdural membranes, giving indirect evidence of the
hematoma’s existence. Magnetic resonance imaging
(MRI) can also assist in diagnosis when the CT is “nor-
mal” or equivocal. An acute subdural hematoma is
slightly hypointense on T1 weighted images and mark-
edly hypointense on T2 images. The hypointense signal
is due to the presence of deoxyhemoglobin, a strong
paramagnetic substance. As the deoxyhemoglobin is
converted to methemoglobin, the T2 image becomes very
intense. When the subdural hematoma becomes chronic,
and the conversion to methemoglobin is complete, the
hematoma will appear intense on both T1 and T2 im-
ages (Fig. 1).
When considering radiographic imaging for chronic
SDH, it should be borne in mind that there is no clear
correlation between hematoma size and clinical symp-
toms and signs. Thus, selection of patients for surgical
treatment should rely more on clinical than on radio-
graphic criteria. In addition, a significant finding in many
chronic SDH treatment series has been that remission of
the clinical syndrome may significantly precede radio-
graphic resolution of the SDH—an important consider-
ation in evaluating treatment results and the need for fur-
ther intervention.
PATHOPHYSIOLOGY
The initial stages in the formation of a chronic SDH in-
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
within approximately three weeks of its initial presence.
 WILBERGER : CHRONIC SUBDURAL HEMATOMA
© 1992 The American Association of Neurological Surgeons
Figure 1. MRI appearance of a chronic subdural hematoma.
Theories about the subsequent enlargement of the
hematoma have been numerous. For years, it was held
that an osmotic gradient developed across the membranes
and that fluid was drawn into the subdural hematoma.
Others have held that fragile neocapillaries within the
membranes rupture repeatedly and fill the subdural cav-
ity with recurrent hemorrhage.
Recent research has focused on disordered hemostatic
mechanisms with increased fibrinolytic activity within the
membranes. Following the initial hemorrhage, abundant
tissue thromboplastin is released into the subdural space,
activating local clotting mechanisms. Thrombin is gener-
ated and crossed-linked fibrin is formed from fibrinogen.
Clotting activation leads to mobilization of the intrinsic
fibrinolytic system. Fibrin is split into fibrin degradation
products which affect further clot formation. Defective clot
formation causes recurrent hemorrhage. As this process is
repeated, the dura reacts to fibrin nonspecifically to gradu-
ally form the vascularized outer membrane. As this mem-
brane proliferates, the extrinsic fibrinolytic system is acti-
vated and a self-perpetuating vicious cycle is repeated. It
has been postulated that the primary effect of surgical drain-
age procedures is to remove such self-perpetuating factors
from the subdural space and to allow restoration of normal
hemostatic mechanisms.
43
SURGICAL TREATMENT
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
Drainage
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-
der aseptic conditions using local anesthesia supplemented
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
or other antiseptic solutions, sterile drapes are placed about
the site. Xylocaine (0.5% with 1:100,000 epinephrine)
infiltration of the surrounding skin is accomplished, a No.
15 scalpel blade is used to nick the skin, a 5/8-inch twist
drill bit attached to a hand-powered drill is placed per-
pendicular to the skull’s outer table, and drilling is begun
(Fig. 2A). Drilling may be continued in a perpendicular
direction or may then be slanted obliquely. Perforation of
the outer table is appreciated by a lessening of tension on
the drill bit; engagement of the inner table results in a
binding of the drill bit and should lead to caution as only
one to two more turns on the drill are usually needed to
break through into the epidural space. The dura and outer
SDH membrane are then blindly perforated with a sharp
trocar or a 14- or 16-gauge needle to enter the subdural
space. Only rarely does a significant amount of subdural
fluid escape spontaneously at this point.
A standard ventriculostomy catheter may be used
as the subdural drain. This catheter is modified by cut-
ting off the blunt end and adding several side holes
along the shaft to facilitate fluid and particulate drain-
age. The stylet is left in the catheter as it is passed
through the twist drill hole and is removed as soon as
the catheter is in the subdural space to prevent intra-
cerebral penetration. The catheter is then directed
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

© 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.

44
 WILBERGER : CHRONIC SUBDURAL HEMATOMA
anteriorly or posteriorly for approximately 10 cm depend-
ing on the location of the hole in relation to the SDH cav-
ity (Fig. 2B). The catheter is then checked for patency by
allowing spontaneous gravity drainage of fluid or by as-
pirating 15-20 ml of the hematoma. Subcutaneous tun-
nelling of the catheter is accomplished after first anes-
thetizing the skin for 2-3 cm lateral to the twist drill site
(Fig. 2C). A trocar is used to guide the catheter to an exit
site 2-3 cm away from the twist drill site. The catheter is
rechecked for patency before connecting to a sterile closed
drainage system (Fig. 2D). All wounds are sutured closed
with 3-0 nylon sutures.
Postoperatively, prophylactic antibiotics—nafcillin
and cefotaxime—are given during the time the subdural
drain is left in place. Anticonvulsants are not given rou-
tinely unless there is a seizure history. The collection bag
of the drainage system is positioned 10-15 cm below head
level to promote gravity drainage of the subdural fluid.
The patient is kept in bed with the head elevated no more
than 30°. Hydration, intravenous and oral, is encouraged
to promote brain reexpansion.
Within 24 hours, a follow-up CT scan is obtained
(Fig. 3). If the patient’s initial symptoms and signs have
resolved, the CT scan shows substantial reduction (>50%)
in the size of the fluid collection, and/or output from the
subdural catheter is minimal or clear, the catheter is re-
moved. If these criteria are not met, the catheter may be
left in place for several more days, and CT scans obtained
daily. Subdural fluid samples are sent daily and on re-
moval of the catheter for Gram stains, cultures, and sen-
sitivity determinations. If the clinical symptoms and signs
are not satisfactorily resolved after two to three days and
the CT scan shows persistence of a significant SDH, al-
ternative treatment approaches should be considered.
Burr Hole Craniostomy
Burr hole craniostomy holds several advantages over the
twist drill technique: burr holes permit wider visualiza-
tion of the subdural space and of the outer and inner sub-
dural membranes; hemostatic control of the vascularized
outer membrane can be accomplished; the larger opening
permits freer drainage of thicker blood collections and
particulate matter; the subdural space may be cross-irri-
gated between burr holes for more complete emptying of
the hematoma; brain reexpansion may be directly visual-
ized; and, if necessary, the burr holes can be converted to
a full craniotomy for further treatment as indicated.
Burr hole craniostomy can be accomplished with lo-
cal anesthesia supplemented by intravenous sedation. Sit-
ing of the burr holes should be done with two factors in
mind: they should relate to the location of the maximal
subdural fluid collection, but skin incisions and hole place-
45
ments should be able to be converted to a full craniotomy
without compromise of the vascular supply of the scalp
(Fig. 4A).
Once the site is selected, the scalp is shaved for 3-
4 cm around the area; antiseptic skin preparation is ac-
complished and local anesthesia is induced with
Xylocaine (0.5% with 1:100,000 epinephrine). A
2.53.0-cm skin incision is made to accommodate an
airpowered cranial perforator and the periosteum is
stripped away from the area. A small mastoid retractor
can be used to retract the skin edges. After the burr
hole is made, the inner table is removed with a small
curette or a Penfield No. 1 dissector. Bipolar coagula-
tion of the dura is accomplished and a No. 11 scalpel
blade is used to incise the dura in a cruciate fashion.
The outer subdural membrane is also coagulated and
opened sharply. The subdural fluid often runs out or
gushes out spontaneously at this point. A small red rub-
ber catheter (7 or 9 French) can then be directed into
the subdural space. Warm saline irrigation is carefully
flushed through the subdural space until the effluent is
clear and the inner membrane brain surface is visual-
ized (Fig. 4B). A subdural catheter and closed external
drainage system can then be left in place as described
previously. Careful hemostatic closure of the skin in-
cision with galeal and subcutaneous sutures should be
performed to avoid any bleeding that may gain access
to the subdural space and cause an acute reaccumulation
of the hematoma. If the subdural fluid is too thick to
evacuate through the burr hole, or septations are en-
countered which prevent effective drainage of the sub-
dural space, conversion to a full craniotomy is possible
for stripping of the inner and outer membranes and
complete evacuation of the hematoma (Fig. 4C).
The postoperative management of patients with burr
hole craniostomy is not significantly different from that
described for twist drill craniostomy.
COMPLICATIONS AND TREATMENT
RESULTS
The outcome of surgical treatment of patients with chronic
SDH is quite variable. A compilation of treatment results
over the past 30 years yields a cure rate ranging from 39
to 100%, a recurrence rate of 1-37%, a rate of neurologic
sequelae of 7-32%, and a mortality rate of 0-28%. Such
variation could not be explained adequately by a differ-
ence in surgical techniques alone, but more likely it re-
flects varying trends in patient selection and the means
and mechanisms of follow-up.
Comparison of burr hole versus twist drill tech-
niques yields somewhat more consistent results, yet 10-
25% of patients usually require some form of addi-
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

© 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.

46
 WILBERGER : CHRONIC SUBDURAL HEMATOMA

© 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.

47
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
tional treatment. When evaluating results of treatment in
any given patient, however, as noted previously, it must
be borne in mind that remission of the clinical syndrome
of chronic SDH does not necessarily require radiographic
resolution of the fluid collection. Camel et al. found in
their series of twist drill craniostomy treatment that 41 of
45 patients (91%) having residual SDH on follow-up CT
scan had complete or nearly complete resolution of symp-
toms. Similarly, CT scans did not normalize following
burr hole treatment until after three weeks in 92% of cases
reported by Richter and after 40 days in 84% of cases
described by Markwalder. Thus “recurrence” of the SDH
after twist drill or burr hole treatment must be considered
in light of such findings.
Excluding the need for reoperation, the compli-
48
cation rate from burr hole or twist drill drainage is
quite low. Infection rates range from 1.5% to 4.2%;
subdural empyema has been reported in approximately
2% of treated patients. Richter reported two epidural
hematomas in a series of 120 patients after burr hole
SDH evacuation. Several authors have reported ten-
sion pneumocephalus after drainage of the subdural
space.
Burr hole or twist drill craniostomy thus appears to
be a safe and reliable method of dealing with a clinically
symptomatic chronic SDH. Other more invasive and ex-
tensive procedures, however, may be necessary in the few
patients who are not appropriate candidates for these pro-
cedures or who have recurrent or residual clinical prob-
lems in spite of this mode of treatment.
 TAILORED TEMPORAL LOBECTOMY
USING SUBDURAL ELECTRODE GRIDS
ISSAM A. AWAD, M.D., M.S.
JOSEPH F. HAHN, M.D.
PATIENT SELECTION
Patients with intractable epilepsy where noninvasive tech-
niques do not clearly define the zone of epileptogenicity
to the mesial temporal lobe structures need further delin-
eation of the epileptic zone prior to resective surgery. In
these cases, noninvasive electroencephalographic (EEG)
recording or the presence of a structural lesion may sug-
gest basal frontal or lateral temporal epileptogenicity.
Especially on the dominant side, these regions cannot be
resected safely without tailored mapping.
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-
totemporal epileptogenicity (interictal epileptiform
activity and seizure-onset EEG data) but does not define
it further to the mesial temporal structures. The strategy
for electrode implantation is designed to allow coverage
of basal frontal areas, lateral frontotemporal structures,
and basal temporal structures. The electrodes are subse-
quently used to map interictal and ictal-onset epileptiform
activity. Subsequent extraoperative stimulation using these
electrodes defines areas of cortex involved in speech func-
tion (zones of Broca and Wernicke). A tailored temporal
resection is then designed to accomplish maximal resec-
tion of epileptogenic tissue, while sparing eloquent re-
gions of brain involved in speech function.
The general techniques of subdural electrode inser-
tion and brain mapping may also be used in extratemporal
regions of the brain, or in cases where a structural lesion
(i.e., neoplasm, vascular malformation, etc.) is located
adjacent to eloquent brain.
PREOPERATIVE PREPARATION
Anticonvulsant therapy is titrated to levels near the toxic
range prior to the insertion of subdural electrodes. In-
travenous antibiotics aimed to cover the skin flora (i.e.,
© 1992 The American Association of Neurological Surgeons
49
oxacillin, vancomycin, etc.) are administered at the time
of skin incision for electrode implantation and are con-
tinued prophylactically until electrode removal and re-
section of the epileptogenic tissue. The patient would
have donated autologous blood two to three weeks prior
to surgery and/or would have been typed and screened
for possible blood transfusion. Partial thromboplastin
time, prothrombin time, and bleeding time are checked
preoperatively to rule out coagulopathy which may be
related to chronic anticonvulsant use.
SURGICAL TECHNIQUE
Operative Positioning
The patient is placed in the supine position on the operat-
ing table; the head is extended 45° and rotated 60° away
from the operative side (Fig. 1). It is helpful to place the
head at the “foot” of the operating table to provide more
knee room for the sitting surgeon and to allow the anes-
thetist or nurse to raise or lower the operating table at the
request of the operating team. The head is fixed in the
desired position using a Mayfield head clamp or other
skull fixation device. The whole head is shaved because
meticulous scalp hygiene will be required in view of the
exiting electrode cables. The presence of hair near the
electrode exit sites will invariably interfere with proper
care and hygiene at these sites.
Draping and Skin Incision
A skin incision is marked to allow wide exposure of po-
tential areas of brain resection. Because the precise ex-
tent of the zone of resection is not known at this time, a
large frontotemporal incision is generally performed.
Draping should allow exposure of not only the skin inci-
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
craniotomy.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
© 1992 The American Association of Neurological Surgeons
Figure 1. Patient positioning for frontotemporal insertion of subdural electrodes.
Implantation of Subdural Electrodes
The skin is incised through the galea aponeurotica, and
Raney clips are applied to both edges of the scalp. The
scalp is reflected in the subgaleal plane, preserving at-
tachment of the underlying temporalis muscle to the cra-
nial bone for subsequent osteoplastic craniotomy. Osteo-
plastic bone removal (with a muscle nutrient pedicle
attached) is thought to minimize the risk of flap infection
in the setting of chronically implanted subdural electrodes.
If a free bone flap is elevated, consideration must be given
to maintaining this bone in a sterile fashion in a freezer
until removal of the subdural electrodes and final replace-
ment of the bone.
The scalp is reflected in the subgaleal plane and is
held anteriorly and inferiorly using fishhooks (Fig. 2).
The temporalis muscle is then incised in the line of the
proposed osteoplastic flap, making sure to preserve a vi-
able vascularized muscle pedicle inferiorly. Three burr
holes are placed, one at the pterion, one in the posterior
temporal area, and one in the posterior frontal area. These
are connected using a power craniotome, except inferi-
orly where the bone is rongeured under the preserved
muscle pedicle (Fig. 2). This facilitates elevation of the
osteoplastic flap and its reflection inferiorly along the
temporalis muscle pedicle.
The dura mater is tacked to the edges of the surround-
ing craniotomy using 4-0 Nurolon sutures. The dura mater
is opened in a C-shaped fashion and flapped anteriorly
(Fig. 3). Prior to dural opening, if the brain appears tense,
50
intravenous mannitol is administered in the dose of 1 g/
kg, in addition to ensuring hyperventilation to a pCO2 of
25-30 mm Hg. The dural opening should allow exposure
of the inferior frontal regions and the lateral temporal lobe.
The selection of subdural grids, including size and
number of electrodes, is dictated by the areas of the brain
to be covered. Subdural electrode grids consist of stain-
less steel (or platinum for magnetic resonance imaging
compatibility) discs embedded in a sheet of Silastic, typi-
cally 1 cm apart. These are available through several com-
mercial manufacturers. In the particular instance being
described, a 4 × 4 grid is used to cover the basal frontal
region (orbitofrontal cortex). A large 8 × 8 grid is used
to cover the lateral frontotemporal neocortex, and this
is folded inferiorly to cover the inferior temporal and
fusiform gyri. Another two 1 × 4 strips of electrodes are
inserted transversely under the temporal lobe to cover
the anterior and posterior basal temporal areas (Fig. 3).
Wound Closure
Additional mannitol may be infused intravenously to
ensure continued brain relaxation prior to dural clo-
sure. The dura mater is closed in a watertight fashion
around the electrode cables using 4-0 Nurolon sutures
(Fig. 4). The suture is passed in purse-string fashion
around the electrode cables for maximal watertight ef-
fect. A piece of Gelfoam is placed around the site of
cable exit from the dura mater. The osteoplastic flap is
replaced and kept free-floating or fixed loosely using
 AWAD AND HAHN : TAILORED TEMPORAL LOBECTOMY USING SUBDURAL ELECTRODE GRIDS

© 1992 The American Association of Neurological Surgeons

Figure 2. Elevation of an osteoplastic bone flap.

51
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

© 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.

52
 AWAD AND HAHN : TAILORED TEMPORAL LOBECTOMY USING SUBDURAL ELECTRODE GRIDS

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.

53
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

© 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-

54
 AWAD AND HAHN : TAILORED TEMPORAL LOBECTOMY USING SUBDURAL ELECTRODE GRIDS
speech and memory and of movement-induced potentials
can be performed as per institutional protocols. The whole
period of brain mapping (recording of epileptiform activ-
ity and electrode stimulation) usually does not exceed three
weeks (mean, 10 days). Throughout this time, prophylac-
tic antibiotic coverage is continued and meticulous scalp
hygiene is maintained. Leakage at the cable exit sites is
not infrequent during this time. If it becomes excessive,
additional purse-string sutures at the cable exit sites may
be placed at the bedside.
REMOVAL OF SUBDURAL ELECTRODES AND
TAILORED TEMPORAL LOBECTOMY
The patient is returned to the operating room following
the period of brain mapping and is placed once again un-
der endotracheal anesthesia. The head is fixed in the same
position and the areas of previous scalp incision and cable
exit sites are prepared and draped according to routine
neurosurgical procedures (Fig. 6). The wound is reopened
with cultures taken from every layer prior to copious an-
tibiotic irrigation. At this time, the cable is cut and re-
moved (by pulling out) prior to dural opening. The dura
mater is opened and the cortical surface is once again
examined through the subdural grids, and correlations are
made with previous photographs and diagrams. The pro-
posed line of resection is then marked on the cortical sur-
face prior to removal of the subdural electrodes (Fig. 6).
Basal electrodes are left in place until completion of the
basal resection, for they can be quite helpful in delineat-
ing the extent of such resection.
Cortical resection is performed along the proposed line
using bipolar electrocautery and suction (Fig. 7). The
Cavitron ultrasonic aspirator used at low setting is particu-
larly helpful in this regard. Following excision of the de-
sired portion of the temporal lobe, a decision must be made
whether to also excise mesial temporal structures.
Meticulous hemostasis is ensured. The wound is
closed in layers, including watertight dural closure. A piece
of the osteoplastic bone flap is sent for culture along with
55
the multiple cultures obtained during wound opening. The
subdural plates themselves are sent for cultures. The cable
exit site is debrided and closed in a single layer. Sterile
dressings are applied.
POSTOPERATIVE CARE
Postoperatively, anticonvulsants are continued at or near
toxic levels, and intravenous antibiotics are maintained
until final intraoperative culture results. Frequently (one-
third of cases), these cultures reveal bacterial coloniza-
tion of at least one layer of the wound or the subdural
plates. In this case, intravenous antibiotics are continued
for 14 days following surgery and are followed by one
month of oral antibiotics, all aimed against the cultured
organism. This is done even in the absence of any clinical
evidence of wound infection. In the circumstance of a
positive bone culture, intravenous antibiotics are contin-
ued for four weeks even in the absence of clinical evi-
dence of wound infection.
The above aggressive regimen of antibiotic treat-
ment of bacterial colonization of the wound has elimi-
nated frank wound infections (purulence or meningitis)
in the last 80 consecutive cases of subdural electrode
insertion. Prior to this, wound purulence in the setting
of implantation of subdural electrodes was not infrequent
at our institution.
OUTCOME AND COMPLICATIONS
Using the above precautions, infection should not be more
frequent with this procedure than with any other neuro-
surgical operation. Other complications are related to the
area of cortical resection. As long as the zone of resection
is at least 1 cm away from mapped eloquent areas, we
have not encountered any instances of permanent neuro-
logic deficit related to focal cortical function.
Favorable seizure outcome is accomplished in nearly
two-thirds of patients undergoing this operation. This is
highly dependent on patient selection and other factors
related to the etiology and severity of the epilepsy.
 GUNSHOT WOUNDS OF THE BRAIN
SUZIE C. TINDALL, M.D.
ALI KRISHT, M.D.
PATIENT SELECTION
Most patients with gunshot wounds to the head require
surgery. Any depressed fracture due to a penetrating mis-
sile is an open fracture and requires exploration, debride-
ment, and elevation in order to prevent complications such
as infection or cerebrospinal fluid (CSF) leakage. As pa-
tients reach the more serious end of the injury spectrum,
decisions regarding surgical intervention become more
difficult, as surgery may have little to offer. We list some
criteria for and against surgical intervention, realizing that
each situation will need individual assessment.
Criteria in favor of surgical intervention:
Glasgow coma scale (GCS) 8 or above;
GCS 5-8 with good response to cerebral resuscitation;
Limited nondominant hemisphere injury;
Tangential wounds;
Young age.
Criteria against surgical intervention:
GCS 3-5;
GCS 5-8 with no response to cerebral resuscitation;
Extensive dominant hemisphere injury;
Brain stem injury;
Injuries crossing the midline;
Old age;
Associated major multisystem injuries.
PREOPERATIVE PREPARATION
Patients with cerebral gunshot wounds are evaluated upon
arrival into the emergency facility. In addition to routine
trauma evaluation and care, coma grade and neurological
function are assessed, and measures for cerebral resuscita-
tion (intubation, hyperventilation, and mannitol) are insti-
tuted if indicated. Entrance and exit wounds are evaluated
and temporary dressings applied. All patients receive teta-
nus prophylaxis and broad spectrum antibiotics.
Anticonvulsants are administered if there has been obvi-
ous cortical damage. Plain anteroposterior and lateral skull
radiography followed by noncontrasted CT scanning of the
© 1992 The American Association of Neurological Surgeons
56
head completes the preoperative radiological evaluation.
SURGICAL PROCEDURE
The goals of surgery in patients with gunshot wounds to
the head are to remove all devitalized tissue, debris, and
hematoma, to control hemorrhage, and to provide dural
closure and scalp coverage.
General endotracheal anesthesia is induced and the
pCO2 is maintained between 28 and 32 torr. Mannitol and
furosemide are used if increased intracranial pressure is
believed to be a potential problem. The head is widely
shaved. Hair and debris are removed from the irregular
edges of the scalp defect. The head is positioned to facili-
tate extension of the scalp incision if necessary. For un-
complicated superficial wounds, the head may rest softly
on a foam headrest, but for more complicated deep wounds
in which brain retractors will be needed a three-point head
fixation device is used. The scalp is prepared with a gentle
scrub of Betadine soap followed by painting with Betadine
solution. Sterile towels are secured circumferentially with
a surgical stapler and cranial drapes are positioned.
Three major objectives are kept in mind when plan-
ning the scalp incision:
1. To preserve blood supply to the scalp edges;
2. To incorporate the entry and/or exit wounds into the inci-
sion;
3. To establish adequate exposure of the limits of fractured
bone and any adjacent structures that might need repair.
We find the simple linear or modified linear inci-
sions (Fig. 1A) to be adequate in most injuries involving
the hair-bearing scalp. For injuries of the forehead, a
bicoronal scalp incision is used (Fig. 1B). The anterior
branch of the superficial temporal artery should be pre-
served. Such a scalp incision facilitates adequate expo-
sure of the frontal cranial base and avoids cosmetically
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.
After completing the scalp incision, the bony defect
 TINDALL AND KRISHT : GUNSHOT WOUNDS OF THE BRAIN
© 1992 The American Association of Neurological Surgeons
Figure 1. A, for wounds within the hair-bearing scalp, the best scalp
incision is usually a linear or curvilinear incision centered over the en-
try or exit wound. B, for injuries of the face or forehead in which wide
exposure of the frontal or anterior temporal fossa may be required, a
is widened to expose all edges of the torn dura (Fig. 2A).
This can be achieved by craniectomy or craniotomy. Large
pieces of bone are kept and soaked in Betadine solution.
The dura is opened back to healthy brain all around.
Control of active bleeding is accomplished using bi-
polar cautery or clips for very large vessels. Torn venous
sinuses are oversewn or patched with pericranium and
Gelfoam.
The missile track is then explored and debrided. One
helpful technique is illustrated in Figure 2B. The tip of an
Asepto syringe is introduced into the depth of the track,
and the wound is irrigated with saline under moderate
pressure while the syringe is gently withdrawn. This ma-
neuver will deliver debris and small indriven pieces of
bone.
Pieces of bone or bullet fragments still embedded in
the wound may be localized using intraoperative ultra-
sound (Fig. 2C). In removing these fragments, the gelati-
nous pedicle should be coagulated, cut, and allowed to
slip back in the wound as it frequently contains a small
blood vessel that has been previously tamponaded by the
bone fragment (Fig. 2D).
If the track is very deep, it is a good idea to set up a
self-retaining retractor system to aid in maintaining ex-
posure. This helps to keep the track well defined and aids
in obtaining hemostasis deep in the wound.
Bacterial contamination of metallic bullet fragments
is much lower than that of bone fragments. For this rea-
57
bicoronal scalp incision is used. The incision is located behind the hair-
line and positioned so as to preserve the anterior branch of the superfi-
cial temporal artery if there is potential disruption of the supraorbital
blood supply from the injury.
son and because bullet fragments usually travel to much
greater depth, we often leave bullet fragments behind.
Necrotic brain, readily identified by its purple color
and soft fragile texture is removed with suction. Hemo-
stasis is achieved with bipolar coagulation and gentle tam-
ponade with Gelfoam. We try not to leave foreign hemo-
static agents in the wound, as we think that they might
serve to increase the incidence of cerebritis and brain
abscess. Once all bleeding has been controlled, hemosta-
sis is checked by asking the anesthesiologist to increase
the patient’s intrathoracic pressure as in Valsalva’s ma-
neuver.
At this stage, the wound is ready to be closed. A peri-
cranial patch is used to close the dura (Fig. 2E). Water-
tight dural closure helps to prevent CSF leakage or fun-
gus cerebri. Sometimes taking a pericranial graft may
prove difficult because of a lack of exposure; in certain
circumstances, attempts at harvesting a graft may further
threaten an already tenuous blood supply to the injured
scalp edges. Under such circumstances, graft material may
be taken from fascia lata or other body fascia through a
separate incision.
Whether or not to replace the bone remains a con-
troversial issue. If the wound is extremely dirty and
contaminated, the bone is left out and the patient
brought back for cranioplasty in six months; if the
wound is relatively clean, large (cleansed) fragments
of bone or a craniotomy bone flap is replaced and an-
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

© 1992 The American Association of Neurological Surgeons

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

58
 TINDALL AND KRISHT : GUNSHOT WOUNDS OF THE BRAIN
chored with nonabsorbable, monofilament, synthetic su-
tures.
Scalp closure or scalp coverage is critical in prevent-
ing later complications. Routinely, the scalp is closed in a
single layer with interrupted vertical mattress sutures us-
ing 3-0 nylon. This prevents placing foreign suture mate-
rial in the galeal layer and brings galea and epidermis
into anatomical alignment. The closure should not be
under excessive tension. If simple closure of this type is
not possible, arrangements should be made to adequately
cover the injured area by use of rotational scalp flaps or a
free vascularized flap.
SPECIAL SURGICAL SITUATIONS
Injuries of the major dural venous sinuses may be diffi-
cult to repair. In most cases, a sinus laceration may be
simply oversewn. Generous exposure of the injured sinus
is mandatory for more severe sinus injuries, where sacri-
fice of the sinus would prove potentially detrimental to
the patient. In such cases, the sinus can be patched with
pericranium or temporalis muscle. Bleeding can be con-
trolled temporarily by digital pressure or occlusion with
a No. 7 Fogarty catheter.
Gunshot wounds of the frontal area frequently prove
to be very challenging. The face, orbits, and frontal and
temporal fossae may be involved. A generous frontal, and
sometimes bifrontal, exposure is required for adequate
debridement and repair. The involved sinuses should be
exenterated. Intradural graft repair using pericranium or
fascia is very important for preventing eventual CSF leak-
59
age. Foreign and avascular materials should be avoided
in attempts to reconstruct the bony floor.
Wounds involving the temporal bone area are asso-
ciated with a high incidence of vascular injury. Hemor-
rhage may be controlled with packing of the external ear
canal or indirect balloon occlusion of the involved vessel
or sinus.
COMPLICATIONS
Disseminated intravascular coagulation may develop at
the time of operation. It is usually first recognized by
noting diffuse oozing of blood at the operative site which
is difficult to control with the usual methods. Laboratory
evaluation will document elevated coagulation times and
fibrin split products in conjunction with reduced platelet
counts and fibrinogen levels. The condition is treated with
infusions of fresh blood products, including frozen plasma
and platelets.
CSF leakage may occur in the form of a cutaneous
fistula, otorrhea, or rhinorrhea. Hydrocephalus must be
ruled out, and the leak may stop with temporary placement
of a spinal or ventricular drain. If the leak persists, the wound
should be reexplored with adequate dural closure.
Meningitis, abscess, and empyema are possible in-
fectious complications. All are treated with appropriate
antibiotics, and surgical drainage is frequently necessary
with abscess or empyema.
Subarachnoid hemorrhage from a traumatic aneu-
rysm may occur occasionally. Under these circumstances,
a cerebral angiogram should demonstrate the lesion.
 TRANSTORCULAR OCCLUSION OF
VEIN OF GALEN MALFORMATIONS
J. PARKER MICKLE, M.D.
RONALD G. QUISLING, M.D.
KEITH PETERS, M.D.
INTRODUCTION
The transvenous therapy for vascular malformations in-
volving high- and low-flow shunts is nothing new. Sean
Mullan and others have been advocates for the incorpo-
ration of this route of therapy for various lesions for many
years. The concept that the arterial side of high-flow fis-
tulas needed to be attended to first in the obliteration of
these lesions virtually eliminated the discussion and use
of the transvenous approach to these lesions for decades.
The great risk of venous outlet obstruction and therefore
marked increased pressure in the thinly walled veins just
distal to the shunts could very easily result in massive
hemorrhage, producing major neurologic deficit or death.
This threat and potential outcome has been demonstrated
graphically to occur with transarterial endovascular
therapy for certain malformations when the embolic ma-
terial, principally glue, escaped into the venous outlets,
solidifying the egress and resulting in major venous out-
let occlusion with hemorrhage. However, Mullan’s excel-
lent results with the transvenous approach to carotid cav-
ernous fistulas continued to stimulate interest in a
transvenous approach to various vascular malformations,
especially those lesions such as vein of Galen malforma-
tions which carry high mortality and morbidity statistics
with the standard surgical and transarterial approaches.
As the burgeoning subspecialty of interventional
neuroradiology continued to grow, various technologies
including new thrombolytic agents and particles have
made possible the approach to lesions heretofore unreach-
able. The combined interventional and neurosurgical ap-
proach to vein of Galen malformations as reported by
Berenstein and Epstein demonstrated the utility of this
combined approach in improving morbidity and mortal-
ity statistics. We reported in 1986 the use of the trans-
torcular approach for the endovascular treatment of vein
of Galen malformations.
© 1992 The American Association of Neurological Surgeons
60
Our enthusiasm, because of the initial successes, be-
came tempered after a review of 24 patients treated in a
similar fashion revealed many of the problems with this
new therapy. However, the overall statistics, especially in
the neonate, have prompted continued interest in this tech-
nique as an adjunct of therapy for the elimination of cen-
tral high-flow fistulas. Of the nine neonates we have
treated with the transtorcular approach, five are alive and
three are virtually normal except for mild spasticity in
the lower extremities. The 15 infants and older children
treated with the transtorcular approach have fared very
well, with a 50% cure rate angiographically and one death.
This death was secondary to an acute shunt malfunction
three months after transtorcular embolization of the vein
of Galen malformation.
TREATMENT CONCEPTS
The general concepts which are important to the under-
standing of the utility of the transvenous treatment of vein
of Galen malformations remain fairly simple. First, in all
patients the goal is to gradually occlude and thereby elimi-
nate the fistula or fistulae such that acute thrombosis with
acute venous outlet obstruction does not occur. Various
guidelines and experiences obtained from our series will
be discussed below as to how this goal can be attained.
Second, the goal for transvenous therapy in the neo-
nate is to produce a cardiac survivor while maintain-
ing neurologic integrity. This goal has often resulted
in converting the neonate into a surviving infant with a
persistent fistula. There seems to be a delicate balance
for the neonate: the therapist should produce a cardiac
survivor but not eliminate the fistula completely be-
cause of the major risk of venous outlet obstruction,
hemorrhage, and death. Again, how this is attained will
be discussed below.
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
therapies with the transtorcular route. We have been
 MICKLE ET AL. : TRANSTORCULAR OCCLUSION OF VEIN OF GALEN MALFORMATIONS
tempted in our 15 infants and older patients to consider
other therapies to rid the patient of the fistula completely
(stereotactic radiosurgery or direct surgery). In two in-
stances, we have admitted patients to the hospital for
prestereotactic radiosurgery angiograms and have found
in one of these the total obliteration of the fistula since
the child’s previous angiogram three months prior to that
admission and a substantial reduction in the flow in the
other patient which allowed us to wait to see if continued
thrombosis would occur. We have therefore treated no
patients with adjunctive therapy including surgery or ste-
reotactic radiosurgery and have had no patients hemor-
rhage or develop other progressive symptomologies ne-
cessitating further therapy. The bottom line, however, is
that, as pointed out by Hoffman and others, the prognosis
of untreated or persistent vein of Galen malformations
tends to be poor. Therefore, once therapy for these mal-
formations is undertaken by whatever route, continued
perseverance and careful follow-up are essential for opti-
mum outcome.
TECHNICAL ASPECTS
The key steps in the transtorcular approach to vein of
Galen malformations will be discussed. This simple op-
eration is rapid and utilizes common materials and in-
struments found in all operating rooms and radiology
suites. Various embolic materials such as coils can be
delivered to the vein of Galen malformation complex not
only through the torcular approach but through a direct
jugular puncture or through the femoral route if access
can be obtained. The neurosurgeon, usually the primary
care physician in this disorder, has control over which
route is chosen for the treatment of these malformations.
Today, transarterial endovascular therapy combined with
transvenous occlusive therapy would seem to be the treat-
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.
61
ment of choice for this very difficult group of malforma-
tions. The transarterial approach requires the cooperation
of an interventionlist trained in microcatheter manipula-
tion both on the transarterial and transvenous sides. In
the neonate, access is often difficult from the transarterial
side, whereas the transvenous route, especially the
transtorcular route, is quick and easy. Of course, it is es-
sential to obtain high-quality pretherapy angiograms to
assess the extent of the lesion and the flow characteristics
necessitating the therapy. Also, computed tomography
(CT) scans and magnetic resonance imaging (MRI) of
the brain and ventricular spaces are essential before
therapy. Many of these individuals, especially in the neo-
natal group, have pretherapy lesions which can be exten-
sive at times and can preclude therapy. Massive encepha-
lomalacia is a relative contraindication to any form of
therapy in this disease. Many of these patients have pre-
treatment hydrocephalus and this often necessitates shunt-
ing procedures as a major form of therapy in the vein of
Galen malformations. Once the transtorcular route for
therapy has been decided upon, the steps as outlined be-
low and in the accompanying figures can be carried out
rapidly and in repeated sessions to obtain optimum out-
comes in the neonate, infant, and older child.
Equipment and Technique
The initial surgical therapy is carried out in the operating
room, and therefore a standard craniotomy set is neces-
sary. A C-arm. imaging system is necessary during the
procedure for placement of wires and also during the
venography (Fig. 1). Newer real-time subtraction units
are available and make following the course of therapy
much easier and more accurate.
A large burr hole is placed over the area of the tor-
cular herophili as identified on the angiogram. The ul-
© 1992 The American Association of Neurological Surgeons
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
© 1992 The American Association of Neurological Surgeons
Figure 2. These drawings depict the patient positioning (A), location of
the incision (×), and the appearance of the torcular through the burr hole
(B). The small roll under the right shoulder allows the midline occiput
to be parallel with the floor. This makes the approach through the torcu-
lar with the various catheters quite simple. If the torcular is not identi-
fied clearly after the burr hole is completed, then the craniectomy can
be enlarged with rongeurs to better expose the structure for emboliza-
trasound probe is very useful in defining the torcular
herophili, straight sinus, and aneurysm (Fig. 2). The
area of the torcular herophili is tapped with a 25-gauge
needle to ensure free return of arterialized blood (Fig.
3A). A 16-gauge Angiocath is passed through this punc-
ture and the soft end of the Angiocath is left in place
through which a short, soft guidewire is advanced un-
der fluoroscopic control into the area of the aneurysm
62
tion. The ultrasonic scanner can be used to identify the torcular, straight
sinus, and aneurysm through this burr hole. Bleeding during the place-
ment of the incision and burr hole is minimal, and the dura forming the
outer surface of the torcular is thick and resistant to injury. It is not
necessary to place a purse-string suture through the outer layer of dura
and this will result in bleeding.
(Fig. 3, B-D). Under fluoroscopy, an angiography cath-
eter or sheath with an attached Tuohy-Borst adapter
is advanced over the wire into the area of the aneu-
rysm (Fig. 3F). The guidewire is removed and a veno-
gram performed through the indwelling angiography
catheter to assess location and flow characteristics.
Various methods of measuring pressures and flows can
be utilized at this point in the procedure to
 MICKLE ET AL. : TRANSTORCULAR OCCLUSION OF VEIN OF GALEN MALFORMATIONS
© 1992 The American Association of Neurological Surgeons
Figure 3. These drawings (A through K) represent the essential steps in
the deposition of thrombogenic wires through the torcular via the straight
sinus into a vein of Galen aneurysm. The area of the torcular is tapped
with a 25-gauge needle (A), and brisk bleeding results. Contrast agents
can be injected through this 25-gauge needle if there is any question
about the location of the penetrating needle. This needle is removed and
a standard 16-gauge Angiocath (B) is placed through the same hole into
the straight sinus. The sharp inner needle of the Angiocath is removed,
and then the soft outer sheath can be advanced further into the straight
sinus (C). Bleeding can be vigorous at this point but is controlled nicely
63
with an occluding finger placed over the hub of the sheath. A standard
soft guidewire is then placed through the sheath and advanced into the
aneurysm under fluoroscopic control (D). The Angiocath sheath is then
removed while maintaining the position of the guidewire with the aid of
fluoroscopy. The assistant holds the guidewire in place after the sheath
has been removed (E) and then the surgeon advances a short angiographic
catheter or sheath with an attached Tuohy-Borst adapter over the
indwelling guidewire into the aneurysm (F). It is extremely important
to maintain the position of the guidewire safely within the confines of
the aneurysm during the placement of this catheter.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

© 1992 The American Association of Neurological Surgeons

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

64
 MICKLE ET AL. : TRANSTORCULAR OCCLUSION OF VEIN OF GALEN MALFORMATIONS
help outline the therapeutic goal (Fig. 3G). A long floppy
guidewire is passed into the aneurysm very carefully in
order to create a basket onto which various sizes of throm-
bolytic Gianturco coils are deposited (Fig. 3, H-K); all
this is done under fluoroscopic control. Without the in-
dwelling basket the potential for embolization of the coils
into the general venous circulation is a real threat. At the
termination of the procedure, the catheter is removed and
a piece of Gelfoam is placed over the bleeding hole in the
torcular herophili and held for 5 minutes. The skin is closed
in layers and the patient is returned to the intensive care
unit for observation.
Individual Steps
The positioning of the patient on the operating table is
shown in Figure 1. The head is placed in a position with
the sagittal suture parallel to the floor. The right shoulder
is usually elevated slightly with a roll. The area of the
torcular herophili should be very close to the edge of the
table so that the table itself is not obstructing the surgeons’
hands in their approach. The C-arm gantry and the visual
monitor are brought in from above and in front, respec-
tively. The surgeon and assistant are operating as if an
occipital approach is being utilized in the placement of a
ventriculoperitoneal shunt. Angiographic localization of
the torcular herophili on the skull is estimated and a 3-4-
cm midline vertical incision is marked. Preparation and
draping are standard for a burr hole. A small adjacent
table is draped in a sterile fashion with all the necessary
equipment ready so that when embolization is begun this
table can be rolled to the juncture of the operating table
just below the position of the child’s head. This instru-
ment table is very useful in stabilizing the indwelling cath-
eter during evaluation and therapy.
The incision is made down to the skull and the peri-
osteum is elevated. Bleeding is minimal. A burr hole is
placed over the torcular and enlarged to 2-3 cm in diam-
eter (Fig. 2). Again, bleeding is minimal. The red dilated
torcular is easily identified from directly over the struc-
ture. If ultrasound equipment is available, ultrasonic iden-
tification of the torcular, straight sinus, and aneurysm is
very useful in helping the surgeon to decide on the angle
of approach to the aneurysm through the torcular. If iden-
tification of the torcular is not certain, then a 25-gauge
needle can be passed easily into the area suspected of being
the torcular. If bright red blood returns then one can be
confident that this is the area of entry. If no blood is ob-
tained then a further craniectomy should be carried out in
an effort to identify the torcular. It is important to realize
that a true torcular may not exist and an accessory straight
sinus may have to be utilized in approaching these le-
sions. In many of the patients, venous outlet obstruction
is already a part of the disease process and therefore al-
65
ternate routes of approach may have to be chosen. This
poses no great problem, and these routes of entry can be
easily identified on the preoperative angiogram.
Once the torcular is identified, a 16-gauge Angiocath
is passed into the hole previously made by the 25-gauge
needle (Fig. 3B). Brisk bleeding will be obtained through
the Angiocath and the sharp needle from it can be re-
moved easily with advancement of the soft outer portion.
Bleeding is brisk but easily controlled with an occluding
finger over the hub of the catheter. Under fluoroscopic
control, a soft guidewire is advanced through the catheter
into the aneurysm (Fig. 3D). This distance ranges from 6
to 9 cm from the surface of the dura to the anterior sur-
face of the aneurysm. Care must be taken not to advance
even the soft guidewire forcefully into the area of the most
anterior part of the aneurysm and malformation.
Once the wire is in place, the 16-gauge Angiocath
sheath is removed. The assistant holds the wire in place
at the level of the dura and bleeding can be brisk at this
point while the angiographic sheath or catheter is placed
over the wire and advanced through the dura and into
the area of the aneurysm (Fig. 3F). The tip of the wire
is carefully observed and maintained in its original po-
sition during the passage of this catheter so that force-
ful impingement does not occur on the anterior face of
the malformation. Once the catheter is in the aneurysm,
the guidewire is removed and the angiographic cath-
eter system is flushed with heparinized saline through
a side port. A Tuohy-Borst adapter is placed on the end
of the catheter so that various therapeutic embolic
agents can be placed through the catheter without sig-
nificant bleeding.
At this point, the assistant and surgeon can rest be-
cause the catheter is in place and there is no further bleed-
ing. This is a good point in the procedure to perform pres-
sure measurements through the side port of the
angiographic catheter and to look at the venous flow pat-
terns produced in the malformation with venography. Our
initial procedure consisted of placing Gianturco coils di-
rectly into the aneurysm to produce thrombosis. This
worked in certain individuals, but in others the flow char-
acteristics were so great that the coils themselves
embolized peripherally into the sigmoid sinus and, in one
instance, into the lung. Therefore, we have modified our
procedure by placing within the aneurysm a
nonthrombogenic stainless steel basket constructed from
a long stainless steel guidewire with the indwelling man-
drel removed (Fig. 3I). This is accomplished easily by
cutting off the weld on the end and removing the stout
thin wire with a clamp. This results in the production of
a very floppy wire capable of forming a basket when
placed within the aneurysm. Through the Tuohy-Borst
adapter we advance this guidewire, which may
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
range from 90 to 145 cm in length, carefully into the
aneurysm. This often results in a major change in the
venous flow pattern within the aneurysm, and in sev-
eral instances we stopped the procedure at this point
and elected to return later to deposit thrombogenic
wires onto this basket. If a major change in the meta-
bolic needs of the patient occurs with this deposition,
such as a reduction or elimination of blood pressure
support, then we suggest that the procedure be termi-
nated and further therapy considered later. The philoso-
phy is to do as little as is needed to get a therapeutic
response, knowing that returning later for more therapy
is always possible. If we elect to deposit thrombogenic
material within the aneurysm we use Gianturco coils
of various sizes and have found that these are easily
66
deposited within the basket both to produce a change
in the flow pattern and to induce thrombosis in a graded
fashion (Fig. 3J).
At the termination of the procedure, the angiographic
catheter is removed and an occluding finger is placed over
the egress site in the torcular. A small pledget of Gelfoam
is placed here and pressure applied for 5 minutes. No su-
tures are required to obtain hemostasis and the skin is
closed over the Gelfoam pledget in a standard fashion
(Fig. 3K). The child is returned to the intensive care unit
for careful observation.
Repeat embolizations can be performed in the
neuroradiology suite transcutaneously if needed. In this
setting the procedure takes only a few minutes after anes-
thesia is administered.
 DETECTION OF AN EPILEPTIC FOCUS
AND CORTICAL MAPPING USING A
SUBDURAL GRID
SUMIO UEMATSU, M.D.
INTRODUCTION
The goal of epilepsy surgery is to remove the epilepto-
genic parts of the brain while sparing critical functions.
To achieve this goal, two criteria are essential: precise
localization of the epileptogenic focus and identification
of areas with critical functions.
To meet these criteria, electroencephalography (EEG)
performed directly on the surgically exposed brain
(electrocorticography (ECOG)) has been used intraopera-
tively. However, the ECOG technique has obvious limita-
tions: it must be performed in a limited time and it does
not allow EEG recording during epileptic attacks (ictal
recording). Accumulated evidence indicates that the most
reliable information for localization of an epileptogenic
focus is obtained from the ictal recording. Epileptiform
discharges not associated with the patient’s habitual sei-
zures (interictal discharges) alone are not sufficient. To
catch and record these habitual seizures, at least several
days of continuous EEG and video monitoring are needed.
Furthermore, the physician has to determine that the re-
corded attack is typical of the patient’s habitual seizures.
This is best achieved by analyzing video-recorded attacks
in combination with the simultaneously recorded EEG
(Fig. 1).
Once the epileptogenic area has been localized, the
next task is to identify the functions of the area—most
importantly, speech and sensorimotor function—since re-
section of critical areas may result in significant func-
tional impairment postoperatively. Critical functions, par-
ticularly speech and language, can be tested for only on
fully awake patients. Intraoperative stimulation has been
used for this purpose also, but it is restricted by the lim-
ited time available and by patient discomfort, particularly
in children. To overcome the limitations of intraoperative
studies, a technique for subdural implantation of elec-
trodes was developed.
The approach allows, if needed, coverage of broad
© 1992 The American Association of Neurological Surgeons
67
areas of the cortical convexity as well as the basal hemi-
spheric regions and the interhemispheric fissure. In addi-
tion to widespread coverage of the cortical surfaces, the
subdural electrodes allow direct, systematic cortical stimu-
lation to be performed over a period of days.
However, as the number of electrode contacts required
in the subdural grid increases for widespread coverage,
the cable may become so bulky that skin incision and
undermining of the subcutaneous tissue become neces-
sary, which raises concerns about potential cerebrospinal
fluid (CSF) leakage and infection of the subdural space.
Therefore, a variation of the subdural grid technique that
uses a finer, multiple cable (multi-minicable) was devel-
oped. The minicable has a 2-mm diameter and can be
brought out through the skin using guiding needle punc-
tures. CSF leakage and grid infection have been mini-
mized by sealing the burr holes with glue and placing
purse-string sutures at the site where the cable exits from
the scalp.
Technical details include planning the craniotomy,
placing the grid, closing the dura, and closing the crani-
otomy wound. The techniques described here for implan-
tation and use of the multi-minicable subdural grid al-
low localization of epileptogenic areas and mapping of
cortical function.
PATIENT SELECTION
The indications for grid implantation include:
1. Incapacitating epileptic attacks;
2. Failure of medical management of the attacks;
3. Attacks originating from one cerebral hemisphere;
4. EEG abnormalities adjacent to or within function-
ally critical cortex;
5. Discrepancy of location of EEG abnormality and
abnormality seen on magnetic resonance imaging.
Contraindications to implantation are:
1. Presence of active local or systemic infection;
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
© 1992 The American Association of Neurological Surgeons
Figure 1. Diagram of the epilepsy monitoring system: the video camera
and the computerized EEG simultaneously record the patient’s behav-
2. Uncorrectable bleeding tendency;
3. Uncooperative or violent behavior of the patient.
Age alone is not a contraindication to grid implantation.
The potential risks of the procedure are common to any
craniotomy, such as CSF leakage, infection, or hematoma
formation. Every preventive precaution should be taken
during selection of candidates for implantation.
OPERATIVE METHODS
To illustrate the subdural grid technique, the operative
details of grid implantation for a study of the language-
dominant left hemisphere are described.
Preoperative Preparation
Bleeding Time and Premedication
Bleeding time must be checked for all patients and should
be within normal limits. Prophylactic broad-spectrum
antibiotics are given intravenously just prior to the skin
incision and are administered daily until the removal of
the grid. The serum level of anticonvulsant(s) should be
checked 24 hours prior to surgery and should be kept at
the therapeutic level to avoid major tonic-clonic convul-
sions in the immediate postoperative period. Double doses
of the usual daily anticonvulsant may be given the night
before surgery to make up for anticipated loss of drugs
during intraoperative depletion of body fluid. Dexametha-
sone and other antiinflammatory drugs are avoided.
68
ior and brain activity. Electrical stimulation for cortical mapping is car-
ried out through the implanted grid.
Anesthesia and Positioning
Endotracheal general anesthesia is used. The vertex of
the patient’s head extends out 3 cm from the headboard of
the operating table. The vertex is tilted down slightly to
facilitate drainage of blood out of the surgical field and
to aid in opening of the base of the temporal subdural
space. The head, neck, and chest are elevated by tilting up
the upper half of the operating table about 15°, so that the
vertex of the head is above heart level (Fig. 2).
Grid and Operative Plan
The patient’s entire head is shaved. The rolandic line is
drawn on the scalp (details are shown in Fig. 3A). The
simplified midpoint to meatal (M-M) line, extending from
the external auditory meatus to the midpoint between the
nasion and inion, may also be used (Fig. 3A). After deter-
mination of the amount of grid needed to encompass the
entire suspected epileptogenic area, including critical sen-
sorimotor cortex and language areas, the appropriate num-
ber (i.e., one or more) of multi-minicable electrode grids
(Ad-Tech Medical Instrument Corp., Racine, WI) are au-
toclaved at 270°F (132°C) for 10 minutes just prior to
implantation.
For study over the language-dominant hemisphere,
a 6 × 8 contact grid is placed over the lateral convexity
of the temporal lobe and cortex superior to the sylvian
fissure (Fig. 3C). The 6 × 8 contact grid is 9 cm long
from anterior to posterior and 7 cm wide. Accordingly,
the scalp incision and craniotomy opening should be
 UEMATSU : DETECTION OF EPILEPTIC FOCUS AND CORTICAL MAPPING
© 1992 The American Association of Neurological Surgeons
Figure 2. A, artist’s view of positioning of a patient for subdural grid
implantation over the left hemisphere. The vertex of the patient’s head
extends out 3 cm from the headboard of the operating table. The upper
part of the operating table is elevated so that the patient’s vertex is higher
than heart level. B, the vertex of the head must extend out from the head-
10 × 8 cm. The extra length (1 cm) allowance around the
grid plate prevents buckling of the Silastic plate.
Surgical Procedures
Skin Incision
After the M-M line has been drawn on the head, four points
are determined: the pterion; the base of the mastoid, 10
cm posterior to the pterion; the parietal point, 8 cm supe-
rior to the mastoid base; and, finally, the frontal point, 8
cm superior to the pterion (Fig. 3B). A line connecting
the four points is drawn, beginning at the pterion and ex-
tending to the frontal point, the parietal point, and toward
the base of the mastoid, and ending by curving above and
in front the ear. The connecting line forms the so-called
Falconer’s question-mark incision for temporal lobectomy.
During the incision, the superficial temporal artery is
carefully preserved to maintain the blood supply to the
skin flap. Local anesthetic with 1/200,000 epinephrine is
infiltrated along the outer margin of the incisional out-
line and around the superficial temporal artery at the neck
of the skin flap.
69
board of the operating table to provide access for subcutaneous tunnel-
ling using the Angiocath. C, the vertex is tilted down to allow gravita-
tional pull to aid in opening the subdural space at the temporal base. The
tilted-down position of the vertex also facilitates drainage of blood from
the surgical field.
Burr Holes and Craniotomy
Burr holes are made at each of the four corner points, and
two additional burr holes are also made; one at the mid-
point between the frontal and parietal points and the other
halfway between the parietal and mastoid points (Fig. 3B).
The multiple burr holes are connected by cuts made with
the Gigli saw. The temporalis muscle should not be de-
tached from the bone flap. The flap is turned outward us-
ing the muscle as a hinge (Fig. 4E).
The dura is opened at the base of the craniotomy
over the temporal lobe. The incision is extended an-
teriorly and posteriorly and is swung superiorly to-
ward the vertex; finally, the dura is reflected toward
the midline.
The arachnoid, vessels, and cortex are inspected. The
sylvian vein and the vein of Labbé are identified. The
sylvian vein, which drains into the sphenopalatine sinus
around the tip of the temporal lobe, and the vein of Labbé,
which drains into the transverse sinus at the posterior part
of the lobe, are examined by gentle retraction of the lobe.
The location of the vein of Labbé is measured from the
tip of the temporal lobe.
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 UEMATSU : DETECTION OF EPILEPTIC FOCUS AND CORTICAL MAPPING
Placement of Grid
First the 2 × 8 strip-grid is inserted into the temporal base
(see the inset, Fig. 3C). While the anterior quarter of the
strip is held with a bayonet forceps, the wet grid is slipped
into the subdural space as the mid-temporal base is slightly
lifted with a brain spatula. The grid is advanced with gentle
force mesially and toward the tip of the temporal lobe.
The first (anterior) two electrode contacts reach the tem-
poral tip, and the remaining majority of electrodes cover
the fusiform and parahippocampal gyri. The tail end of
the strip emerges from the middle fossa posterior to the
tympanic prominence, crossing the fusiform and inferior
temporal gyri. The strip is anchored to the dural sleeve at
the cross-point with a single fine suture. The 6 × 8 grid is
placed over the lateral convexity of the temporal and
frontoparietal lobes. A slit 2 cm long made between the
third and fourth rows of the grid allows the upper half of
the grid-leaf to be angled toward the inferior orbital gy-
rus and the lower half toward superior temporal gyrus.
The grid leaflets straddle the sylvian vein and sphenoid
wing. The multi-minicables are directed toward the pos-
terior margin of the craniotomy (Fig. 3C). A few loosely
placed stitches are used to anchor the grid to the dura.
Before closure, detailed drawings are made and color
photographs are taken, with attention paid to the relation
of the electrodes to the major cortical sulci and vessels.
The sequential relation of the color-coded cables and elec-
trode array is confirmed and recorded.
Dural Closure
Dural closure begins with suturing at the posterior tem-
poral base. The running suture goes around the individual
cables and secures the cable with the dural closure. The
anterior and inferior or superior dural gap created by the
posterior dural approximation is closed with a dehydrated
human dural patch (Fig. 4). The closure again starts from
the temporal base and proceeds toward the lower vertex.
This facilitates drainage of subdural blood through the
dural opening, which is lower with the head tilted down-
ward. The subdural space is irrigated a final time with
Figure 3. A, estimation of the rolandic and sylvian lines on the scalp,
based on cranial landmarks, is shown. First, the halfway point (50%)
between the nasion and inion along the sagittal midline of the skull is
determined; the point 19 mm posterior to the halfway point is the up-
per rolandic point. A line is drawn from the upper rolandic point to the
lower rolandic point on the sylvian fissure. The lower rolandic point
is found by constructing a line from the perpendicular point to Reed’s
line (a line formed by connecting the lower ridge of the orbit to the
preauricular point (Preaur. pt.). The rolandic line is then formed by
connecting the upper and lower rolandic points. The simplified M-M
71
normal saline before placement of the last sutures to com-
plete dural closure.
Bone Flap and Cable Placement
After retaining sutures are placed to anchor the dura to
the periosteum, the bone flap is secured with sutures tied
to the skull through the drill holes. The cables emerge
through the craniotomy gap or multiple burr holes (Fig.
5). An epidural Hemovac drain is placed in the anterior-
most frontal burr hole, sufficiently remote from the cable.
Gelfoam is packed in each burr hole. Medical adhesive is
used to fill in the bone gaps created by the craniotomy
and burr holes, with care taken to ensure that the adhe-
sive does not contact the dura or brain or the epidural
drain tube, since the adhesive binds with the tubing and
would make its subsequent withdrawal difficult.
In cases with a space-occupying brain lesion, where
brain may be herniated by the mass or edema, we have
used a Raimondi peritoneal catheter or Raney scalp clip
placed around the craniotomy flap (Fig. 6A) to elevate
the bone flap off the cortical surface and avoid compres-
sion of the edematous brain (Fig. 6B).
Percutaneous Cabling
Before the skin flap is replaced, each cable is passed sub-
cutaneously using an Angiocath 10GA (3.4 mm), 3 inches
(7.6 cm). The Angiocath needle puncture is made as far
away as possible from the craniotomy margin—typically
2-3 cm is sufficient (Fig. 5).
Purse-string Suture and Skin Closures
After completion of the scalp closure, a purse-string su-
ture is placed around the exit point of each cable (Fig. 7).
Postoperative Measures
Surgical Dressing
The cable exits are painted with antibiotic ointment. A
bundle of a few cables is passed through the opening of
a thick, soft pad (ABD-pad) that is used to cover the
line can also be used. The line is derived by simply connecting the
midpoint to meatus, as depicted in the diagram. B, a question-mark
incision extends from the pterion to the zygoma just in front of the ear.
The superficial temporal artery is preserved to maintain the blood sup-
ply to the skin flap. Extra burr holes are needed for multi-minicable
exits. C, the upper three rows of the electrode contact (3 × 8) ventral
to the sylvian fissure cover Broca’s speech area and the motor-sen-
sory cortex; the lower three rows cover the lateral convexity of the
temporal lobe. The second grid (2 × 8) covers the fusiform and
parahippocampal gyri.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

© 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).

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© 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.

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© 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

74
 UEMATSU : DETECTION OF EPILEPTIC FOCUS AND CORTICAL MAPPING

Without cushioning, the bone flap collapses, put-

ting presure on the cerebral cortex.

Raimondi catheter technique for cushioning the bone

flap.

Scalp clip technique for cushioning the bone flap.

B © 1992 The American Association of Neurological Surgeons

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 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

© 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.

76
 UEMATSU : DETECTION OF EPILEPTIC FOCUS AND CORTICAL MAPPING
surgical wound. Another pad with a slit is used to cover
around the ear, including the area in front of the ear. As
the cable is held up out of the dressing by an assistant, an
adhesive elastic bandage is applied over the skin flap and
cable exit area. The tails of the cables are then covered
with 3 × 3-inch dressing sponges.
Sitting Position and Restraint
Certain precautions are unique to this procedure. As soon
as the patient recovers from the general anesthesia and
vital signs and neurologic condition are stabilized, the
patient is placed in a sitting position, tilted at 45°. Both
hands are restrained by the use of mittens until the patient
is transferred to the epilepsy monitoring unit. Routine skull
x-rays are taken in the recovery room. The epidural drain
is withdrawn on the first postoperative day, and EEG re-
cording begins immediately. Stimulation studies are typi-
cally begun on the third postoperative day.
Postoperative Medications
The same anticonvulsants that the patient took prior to
surgery are administered postoperatively. No steroid or
anti-inflammatory medications are given. Moderate an-
algesics are given. The patient is given nothing by mouth,
with fluid intake restricted for 24 hours. Prophylactic an-
tibiotics are continued until the grid is removed.
COMPLICATIONS AND THEIR PREVENTION
The success of the approach described here is heavily
dependent on pre- and postoperative management as well
as intraoperative technique. The discussion is divided ac-
cording to these two concerns.
Preoperative and Postoperative Management
The use of prophylactic antibiotics has been a subject of
controversy. However, we administer a prophylactic anti-
biotic (Ancef) until the subdural grid is removed.
CSF leakage along a subcutaneously placed cable
could be a major cause of grid infection. Every possible
measure is taken to prevent this. In particular, the postop-
erative sitting position discourages CSF leakage along the
subcutaneous cables. The cable should be thin and should
travel an extended distance in a deep subcutaneous tun-
nel. Use of the finer, multicable system instead of a single,
bulky cable system also reduces the chance of CSF leak-
age.
Because even a millimeter-thin hematoma membrane
between the electrode and the cortex could interfere with
effective cortical stimulation and EEG recording, every
effort is made to prevent a hematoma membrane: bleeding
time is checked preoperatively, the head is tilted down dur-
ing the grid implant, and the dural opening at the lower
77
part of surgical field is left open until the end of the dural
closure. These measures allow blood-tinged CSF to drain
out through the dural opening. Placement of an active epi-
dural drain equipped with a suctioning reservoir (Hemovac)
also helps to clear the fluid around the grid.
The pressure dressing using the elastic adhesive ban-
dage minimizes subcutaneous bleeding. Shielding the
craniotomy opening and burr holes with Gelfoam and
Silastic medical adhesive minimizes the escape of
subgaleal blood into the cranial space. Watertight closure
of the dural opening prevents the blood from running into
the subdural space and thus prevents formation of a sub-
dural hematoma membrane. These wound-closure mea-
sures for the scalp, skull, and dura minimize CSF leakage
and prevent grid infection.
The dressing is changed and the drainage tube is re-
moved 24 hours after surgery. Thereafter, the dressing must
be changed once a week for routine wound inspection
and suture line care.
Intraoperative Technique
The proper positioning unique to this procedure is impor-
tant. The vertex of the head must extend out from the
headboard of the operating table to provide access for
subcutaneous tunnelling using the Angiocath. I prefer not
to use a head fixation device, because the metal arms and
pins around the skull make the tunnelling procedure more
difficult.
Our work has shown that motor and sensory areas
have considerable individual variation and cover a much
broader area than is conventionally believed. Using the
rolandic line (R line) for outlining the craniotomy for grid
implantation (Fig. 3A) helps to ensure that the grid cov-
ers the broadest possible cortical area for functional map-
ping and localization of the epileptogenic area. We call
the modified R-line that we use the “midpoint to meatal
line” (M-M line). The midpoint is the halfway point be-
tween the nasion and inion, and the line is drawn from the
midpoint to the external auditory meatus.
Autoclaving the grid is probably safer than gas ster-
ilization because of the potential for residual chemicals
(ethylene oxide) accidentally remaining after sterilization
to cause cortical irritation. Every effort should be made
to reduce surgical blood loss, because the grid procedure
involves two stages, one for grid implantation and an-
other for grid removal, within a short period of time. In-
filtration of the epinephrine/local anesthetic combination
around the skin incision is an effective hemostatic mea-
sure. Use of every available hemostatic measure means
that blood transfusion can be avoided.
The superficial temporal artery should not be ligated
or coagulated and the temporal muscle should
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
not be detached from the bone flap, in order to keep these
tissues vital, which helps to minimize surgical wound in-
fection. Furthermore, in the event of an infection, maxi-
mum antibiotic irrigation of the wound can be achieved
by the rich blood flow throughout the tissues.
Although the grid currently available is only a milli-
meter thick, it can buckle, and buckling will compress
the cortical veins and the cortex. To prevent buckling, the
craniotomy opening should be 1 cm wider than the grid
plate. Use of the dural patch also provides an ample sub-
dural space and prevents compression.
Craniotomy using the Gigli saw instead of a high-
speed craniotome is preferable. The Gigli saw allows a
beveled-edge craniotomy, which prevents the bone flap
from sinking and compressing the cerebral structures be-
neath. The two extra burr holes, one halfway between the
frontal and parietal burr holes and another at the halfway
78
point between the parietal and mastoid, are necessary ex-
its for the multi-minicable.
CONCLUSION
A nonsurgical setting, as opposed to the intraoperative
environment, provides comfort and support for the pa-
tient and allows EEG recording during the patient’s ha-
bitual attacks. Complex speech and language testing can
be carried out with maximal cooperation of the patient.
The potential for infection is a serious concern with
any implanted device that has external leads. The surgi-
cal technique described here is intended to minimize CSF
leakage, thereby reducing the risk of infection. How-
ever, it should be emphasized that careful, complete,
routine pre- and postoperative antiseptic measures, not
just intraoperative technique, are needed for ultimate re-
duction of the risk of infection and for surgical success.
 ANTEROMESIAL TEMPORAL
LOBECTOMY FOR EPILEPSY
ISAAM A. AWAD, M.D., MS
PREM K. PILLAY, M.D.
PATIENT SELECTION
Temporal lobectomy is an accepted surgical treatment of
intractable complex partial seizures for patients in whom
the temporal lobe has been implicated as the site of
electroencephalographic (EEG) seizure onset. In these
patients, mesial temporal structures are the commonest
site of abnormal epileptiform EEG activity. Postopera-
tive pathologic specimens from epileptic patients com-
monly reveal histological abnormalities in the amygdalo-
hippocampal region. The extent of mesiobasal resection
in temporal lobectomy has been correlated directly with
seizure outcome, with higher rates of seizure control
achieved with more extensive resections of mesiobasal
temporal lobe structures. In this chapter, we describe a
modified technique of temporal lobectomy with limited
lateral temporal resection and extensive microsurgical
resection of mesial temporal structures. This operation
may be performed on the left or right temporal lobe with-
out mapping of speech areas, since the procedure is de-
signed to spare all but the most anterior portion of lateral
temporal lobe cortex.
Candidates for this operation suffer from complex
partial seizures despite optimal medical therapy. The sei-
zures are thought to be “intractable,” thereby interfering
with psychosocial function and having a significant im-
pact on the patient’s life. Preoperative diagnostic studies
should include magnetic resonance imaging (MRI) of the
brain, including coronal views, to delineate any structural
abnormalities in the temporal lobe. Other diagnostic in-
formation should include prolonged EEG monitoring of
interictal epileptiform abnormalities and seizure onset.
Detailed neuropsychological studies should be performed
to define baseline preoperative cognitive and memory
function. Any modality-specific impairment should be
noted (such as impaired verbal memory in patients with
suspected left temporal epileptogenicity or impaired vi-
© 1992 The American Association of Neurological Surgeons
79
sual memory in patients with suspected right temporal
epileptogenicity). Intracarotid injection of amobarbital
(Wada test) is performed to confirm laterality of speech
and memory and to demonstrate that the contralateral tem-
poral lobe is able to support memory function.
Patients with unilateral or predominantly unilateral
EEG epileptiform abnormalities arising from the ante-
rior or anteromedial temporal lobe are selected for the
operation of anterior temporal lobectomy and microsur-
gical resection of mesial structures. This operation is con-
traindicated in patients with significant contralateral tem-
poral pathology and in patients with epileptiform activity
arising primarily from lateral temporal lobe structures.
Patients with mesiotemporal epileptogenicity and an ad-
jacent temporal lobe lesion should undergo this described
operation in addition to resection of the structural lesion
(i.e., neoplasm, vascular malformation, etc.).
PREOPERATIVE PREPARATION
Anticonvulsant therapy is continued through the periop-
erative period at or near toxic concentrations. Preopera-
tive prothrombin time, partial thromboplastin time, and
bleeding time measurements are performed in all patients
in view of possible coagulopathy from prolonged anti-
convulsant therapy. The patient would have donated two
units of autogenous blood two to three weeks prior to sur-
gery, and/or would have been typed and screened for pos-
sible blood transfusion.
SURGICAL TECHNIQUE
Operative Positioning
The patient is placed in the supine position on the op-
erating table with the head toward the “foot” of a typi-
cal table to provide greater room for the knees of a
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
and the hair is combed away from the field. The pa-
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
tient’s head is extended 45° and turned 60° away from the
side of surgery (Fig. 1), and it is fixed in that position
using a Mayfield head clamp or other skull fixation sys-
tem.
The incision is marked as a question mark starting
just in front of the tragus, extending posteriorly above the
tip of the ear and anteriorly just above the superior tem-
poral line. The incision is extended inferiorly and anteri-
orly (along the forehead) enough to clearly expose the
pterion when flapped forward (Fig. 2). In most patients,
the incision will not extend anterior to the hairline more
than 2 or 3 cm. The proposed incision is marked and the
operative area is prepared and draped according to rou-
tine craniotomy techniques.
Operative Procedure
Myocutaneous Flap
The scalp is incised through the galea aponeurotica, and
Raney clips are applied on both sides of the incision. The
temporalis muscle is opened along the line of the incision.
The scalp and underlying temporalis muscle are turned
forward as a unit in the subperiosteal plane (Fig. 3). The
myocutaneous flap is dissected anteriorly to expose the
orbital zygomatic ridge and inferiorly to expose the zygo-
matic root. The myocutaneous flap is held in this position
using multiple fine fishhooks tethered tensely with rubber
bands to a Yasargil Leyla bar attached to the operating table.
Such tense holding forward of the flap is essential for sub-
sequent bony exposure and intradural visualization.
Bony Opening
A burr hole should be placed on the pterion and an-
© 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.
80
other burr hole should be located at the most poste-
rior aspect of the incision. These are connected via a
power craniotome to elevate a frontotemporal bone
flap (Fig. 4). This free bone flap should not expose
more than one or two finger breadths of the frontal
lobe but should allow as much of a temporal expo-
sure as possible. The key to further steps of this op-
eration will consist of subsequent removal of the
pterional ridge to allow a very anterior exposure of
the middle (temporal) fossa.
Rongeurs are used to remove the remaining portion
of the inferior squamous temporal bone down to the zy-
gomatic root. This should allow exposure nearly flush with
the floor of the middle fossa. Mastoid air cells are fre-
quently entered and should be thoroughly waxed. Anteri-
orly, rongeurs are used to remove the thin temporal bone
covering the anterior temporal lobe dura. The pterional
ridge is thoroughly rongeured and subsequently drilled
medially as far as the superior orbital fissure. At this point,
the tip of the temporal lobe should be seen extradurally.
Further intradural portions of the operation cannot be
carried out without this extensive bony removal of the
pterional ridge (Fig. 5).
Lateral Temporal Resection
Following the administration of intravenous mannitol
(1 g/kg body weight) and insuring that the arterial pCO2
tension is in the range of 25 to 30 mm Hg, the dura
mater is tacked to the edges of the surrounding craniotomy
and is opened in a C-shaped fashion based anteriorly
(Fig. 6). The dural flap is elevated anteriorly and tensed
using 4-0 silk sutures allowing a full exposure of the
temporal lobe tip and the sylvian veins. Any
 AWAD AND PILLAY : ANTEROMESIAL TEMPORAL LOBECTOMY FOR EPILEPSY

© 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.

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 AWAD AND PILLAY : ANTEROMESIAL TEMPORAL LOBECTOMY FOR EPILEPSY
Figure 3. (Top) Myocutaneous flap. The scalp and temporalis muscle are
flapped anteriorly and inferiorly as a single layer in the subperiosteal plane.
The myocutaneous flap is extended anteriorly to expose the orbital zygo-
matic ridge and inferiorly to expose the root of the zygoma.
Figure 4. (Upper middle) Free bone flap. The myocutaneous flap is
held anteriorly using multiple fishhooks which are tethered tensely with
rubber bands to a Leyla bar. One burr hole is placed at the pterion and a
second one at the posterior aspect of the incision. These are connected
using a power craniotome to elevate a frontotemporal bone flap.
83
Figure 5. (Lower middle) Resection of the pterional ridge. The lesser
wing of the sphenoid is resected using rongeurs and then a power drill
medially to the superior orbital fissure. This is essential for subsequent
intradural portions of the operation.
Figure 6. (Bottom) Dural opening. The previous pterional resection
should allow extradural visualization of the temporal tip. The dural open-
ing is performed in a C-shaped fashion and is flapped anteriorly.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
temporal lobe tip draining veins should be visualized at
this time, coagulated, and divided.
The lateral temporal lobe resection is accomplished
by connecting three separate corticectomies (Fig. 7). The
first or “posterior” cut extends obliquely across the lat-
eral temporal surface traversing the middle temporal gy-
rus 3.5 cm posterior to the temporal tip. The incision slants
slightly anteriorly across the superior temporal gyrus and
posteriorly across the inferior temporal gyrus, and con-
tinues transversely on the basal surface of the temporal
lobe to the collateral sulcus (which separates the fusiform
gyrus from the parahippocampal gyrus). This posterior
cut spans across four gyri: the superior, middle, and infe-
rior temporal gyri and the fusiform gyrus. The second or
“superior” cut extends anteromedially below the sylvian
veins just inferior and parallel to the free edge of the lesser
wing of the sphenoid. It extends medially to the anterior
clinoid process which should be easily visualized (given
the adequate bony exposure). These two cortical incisions
are then joined by a third or “inferior” cut across the basal
surface of the temporal lobe. This should totally discon-
nect the temporal pole which is removed in one piece.
This portion of the operation is performed with a head-
light. It does not involve any violation of important sylvian
structures (superiorly) or incisural structures (medially).
Resection of Mesial Structures
The operating microscope is brought in at this point. A
Greenberg or other self-retaining retractor system is set up,
and a narrow long blade is chosen. Under the operating
microscope, the stump of the temporal lobe is gently ex-
plored to locate the tip of the temporal horn of the lateral
ventricle. This is opened gently using bipolar coagulation,
and a long cottonoid patty is slipped into the temporal horn
of the lateral ventricle. The long narrow blade of the self-
retaining retractor is then inserted over the cottonoid patty
within the temporal horn. This retractor blade is used to
elevate the choroid plexus, thus opening the temporal horn
like a fish’s mouth. This allows identification of the chor-
oidal fissure medially and the hippocampal formation in
the floor of the temporal horn. Upon orientation in relation
to the pes hippocampus, the remaining portion of the
amygdala is removed by suction, making sure not to ex-
tend this resection superiorly above the plane of the sylvian
fissure (into the caudate nucleus).
Mesial basal resection is completed through three sub-
sequent incisions into the mesiobasal temporal structures
(Fig. 8). The first or “lateral” cut extends from the lateral
edge of the floor of the temporal horn (terminal sulcus) to
the collateral sulcus. The second or “medial” cut extends
84
in the subpial plane from the choroidal fissure to the tento-
rial incisura under direct microsurgical visualization. This
cut traverses the hippocampal sulcus which separates the
parahippocampal gyrus from the dentate gyrus. The arte-
rial feeders of the hippocampus (Ammon’s horn arteries)
traverse the hippocampal sulcus after arising from the P2
segment of the posterior cerebral artery; these arterial feed-
ers are coagulated and divided. The leptomeninges cover-
ing the perimesencephalic cisterns are not violated. The
medial and lateral cuts are extended posteriorly to the point
where the tentorial edge curves medially. A third or “pos-
terior” cut joins the lateral and medial cuts posteriorly to
disconnect the hippocampal formation and allow its removal
in one piece. At this point, the tentorial edge should be
seen curving medially behind the collicular plate on the
posterior aspect of the mesencephalon. During this micro-
surgical resection of mesiobasal structures, care should be
taken not to use bipolar electrocautery at or near the tento-
rial incisura (where the 4th cranial nerve may be injured)
or near the petrous apex (where the intratemporal portion
of the facial nerve may be injured).
Wound Closure
After securing meticulous hemostasis, thorough irriga-
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-
tional epilepsy protocols. The value of intraoperative
electrocorticography and further tailoring of the resec-
tion has not been proven.
The dura mater is closed in a watertight fashion us-
ing running 4-0 Nurolon sutures. The bone flap is fixed
in place using 2-0 Nurolon sutures. The wound is irri-
gated thoroughly and the temporalis muscle is approxi-
mated using interrupted 2-0 Vicryl sutures. The galea
aponeurotica is closed using inverted interrupted 2-0
Vicryl sutures. The skin is closed using interrupted 3-0
Nurolon sutures behind the hairline and 4-0 nylon sutures
in a plastic fashion for any portion of the incision extend-
ing anterior to the hairline. Antibiotic ointment is used to
cover the incision and a sterile head dressing is applied.
The anesthetic is reversed. The patient is allowed to awaken
and is examined in the operating room.
OUTCOME AND COMPLICATIONS
Perioperative antibiotics are administered at the time
of the skin incision and are continued for 24 hours
postoperatively. These are geared at our institution
against the narrow spectrum of staphylococci (van-
comycin or oxacillin). The patient is observed for 24
hours in a critical care unit. Fluid restriction, dex-
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© 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.

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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.

86
 AWAD AND PILLAY : ANTEROMESIAL TEMPORAL LOBECTOMY FOR EPILEPSY
amethasone, and intermittent mannitol are used as pro-
phylaxis against brain edema. Not uncommonly, follow-
ing left temporal resections, the patient may awaken with
normal speech function but may develop transient dys-
phasia several hours after surgery, which may last for one
or two days. Permanent dysphasia is rare following this
operation. Visual field abnormalities are encountered in
less than one-fourth of the patients, and these consist of
incomplete homonomous quadrantic field defects; they
have been shown to be less frequent and less dense than
following more extensive temporal lobectomies. Other fo-
cal neurologic deficits are rare. It is extremely important
to protect structures at the roof of the temporal horn to
avoid homonomous hemianopia (optic tract) or hemipare-
sis (internal capsule). It is also important to avoid injury
to any structures within the perimesencephalic cistern to
avoid cranial nerve or major vascular injuries.
Anticonvulsants are maintained at near toxic levels
© 1992 The American Association of Neurological Surgeons
Figure 9. Postoperative T1-weighted MRI performed in the axial plane
of the temporal lobe (axial cuts angled along the plane of the sylvian
87
and are monitored closely in the perioperative period.
Early postoperative seizures not associated with electro-
lyte abnormalities or low anticonvulsant levels are a
marker for future recurrent seizures. Otherwise, complete
control of seizures (on anticonvulsants) is expected in 70-
80% of the patients. This rate may be affected by preop-
erative selection protocols and other patient-related fac-
tors. Patients who are seizure-free for one year following
surgery are likely to remain seizure-free thereafter; sub-
sequent seizure recurrence may be related to tapering or
lack of compliance with anticonvulsant therapy, and is
rarely intractable.
Postoperative radiographic verification of the extent
of resection (Fig. 9) is performed routinely at our institu-
tion. Patients with retained temporal mesial structures are
more likely to have seizure recurrence and may be helped
by reoperation aimed at resection of these residual mesial
structures.
fissure). This reveals the extent of resection of the temporal pole and of
mesial structures to the collicular level.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
ANASTOMOSIS OF THE FACIAL
NERVE AFTER RESECTION OF AN
ACOUSTIC NEUROMA
CHARLES M. LUETJE, M.D.
INTRODUCTION
The potential for interruption of the VIIth cranial nerve
during acoustic tumor removal is present for any sized
tumor. It is incumbent upon the surgeon(s) to be pre-
pared for this event and to be ready to implement an
immediate plan of action should it occur. The immedi-
ate plan should be that of direct VII-VII
neuroanastomosis or autogenous cable graft interposi-
tion VII-VII neuroanastomosis. The plan should not be
one of delay, or “inaction,” waiting for a time to per-
form a substitution cranial nerve anastomosis.
OVERVIEW OF SURGICAL PROCEDURE
The author’s experience has been primarily with the op-
eration of posterolateral craniectomy with translabyrin-
thine exposure of the cerebellopontine angle (CPA). The
details of the operative procedure will be highlighted for
a clearer understanding of the VII-VII neuroanastomosis.
It must be clearly understood that this procedure allows
for the removal of an acoustic tumor of any size.
The patient is supine on the operating table with the
head lying flat on a sheepskin and turned away from the
surgeon. The anesthesiologist is on the same side of the
operating table as the surgeon, with a 5-foot anesthesia
tubing running along the other side of the patient, cross-
ing over to the machine at the pelvis. Appropriate moni-
toring equipment is used for the assessment of VIIth nerve
function and the maintenance of anesthesia.
A large postauricular incision is made just in the hair-
line, the ear is rotated forward, and if bone removal is to
involve removal of the cochlea, the external ear canal is
transected and sewn shut. Bone removal is accomplished
with the air-driven Ototome drill. The mastoid is opened
and saucerized widely posteriorly behind the sigmoid si-
nus to the dura. The facial recess (bounded anteriorly by
© 1992 The American Association of Neurological Surgeons
88
the chorda tympani nerve and posteriorly by the VIIth
nerve) is opened, the incus is removed, and the eustachian
tube and middle ear are filled with periosteum, fascia,
and muscle to prevent postoperative cerebrospinal fluid
(CSF) leakage. The sigmoid sinus is skeletonized and re-
tracted posteriorly with the Silverstein retractor. The ves-
tibular bony otic capsule is removed and the internal au-
ditory canal skeletonized in an arc of 180°. The area of
Bill’s bar separating the VIIth nerve from the superior
vestibular nerve is identified and the superior vestibular
nerve is avulsed from its canal; positive identification of
the VIIth nerve is made at this point in the operation.
Once this is accomplished, certain key anatomic
points have been established. These include: 1) bone re-
moval from the superior petrosal sinus and middle fossa
dural plate superiorly to the jugular bulb inferiorly; 2)
posterior retraction of the sigmoid sinus; 3) opening of
the cochlear aqueduct to allow egress of CSF and reduc-
tion of intracranial pressure; 4) skeletonization of the VIIth
nerve from the posterior aspect through its mastoid por-
tion, lateral to the vestibule, toward the geniculate gan-
glion, and at its entrance into the lateral end of the inter-
nal auditory canal (IAC); and 5) complete exposure of
the posterior fossa dura as outlined above.
If the cochlea is removed as in the case of tumors
with extension forward and into the tentorial notch, this
step is accomplished first and simultaneously with
skeletonization of the VIIth nerve. In essence, the ear ca-
nal skin and ossicles are removed, the bony posterior ear
canal wall is removed, and the cochlea is drilled away to
expose the carotid artery below the floor of the eusta-
chian tube. The VIIth nerve can be skeletonized in an arc
of 360° and the dural exposure extended medial to the
VIIth nerve, above the jugular bulb, to the carotid artery,
anteromedially, inferior to the IAC.
This exposure takes from a little less than two
hours to three hours, depending upon the extent of
 AWAD AND PILLAY : ANTEROMESIAL TEMPORAL LOBECTOMY FOR EPILEPSY

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.

89
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
aeration of the temporal bone. From the induction of an-
esthesia to the operation starting time is approximately
30 minutes.
The dura is opened in an apron-shaped fashion and
an “extradural” retraction with cottonoids only over the
cerebellum is accomplished. The pCO2 is maintained at
23 mm Hg and the patient is not paralyzed.
Tumor removal is posterior first in larger tumors us-
ing the House-Urban rotary dissector to gut the interior
of the tumor, allowing for the development of arachnoid
planes and for the capsule of the tumor to be moved away
from cranial nerves, vessels, cerebellum, and brain stem.
Once the tumor is gutted, removed partially, and reduced
to smaller size, attention is turned to the lateral end of the
IAC. Here, previous identification of the VIIth nerve has
been made. The tumor is then carefully dissected away
from the VIIth nerve using continuous suction and irriga-
tion via the Brackmann multifenestrated suction-irriga-
tor, the neurotologic scissors, and the insulated Crabtree
dissector, both designed for us, the latter of which is at-
tached to the Xomed Nerve Integrity Monitor.
The problem of VIIth nerve preservation occurs dur-
ing the dissection of the VIIth nerve at its anterior angu-
lation out of the IAC. Many tumors spread the VIIth nerve
so thinly over the anterior tumor surface that the plane of
dissection can be lost in spite of lateral VIIth nerve iden-
tification in the IAC and identification of its zone of exit
from the brain stem. In fact, a histological plane between
tumor and VIIth nerve may not exist. It is at this site where
the VIIth nerve is most commonly interrupted both ana-
tomically and electrically, intentionally or unintentionally,
during total tumor removal.
VII-VII NEUROANASTOMOSIS
Upon recognition of interruption of the VIIth nerve or
the likelihood of little if any chance of regeneration
through thin strands of tissue that resemble arachnoid,
one must be ready to perform a VII-VII neuroanastomosis.
Previous skeletonization of the VIIth nerve during earlier
bone removal stages of the operation now becomes an
advantage of the posterolateral craniectomy and
translabyrinthine operation.
The proximal end of the VIIth nerve is marked with
a cottonoid at its root exit zone. The CPA is sealed off
with cottonoids to prevent scattering of bone dust through-
out. Bone removal is completed along the thin bone cov-
ering the VIIth nerve from the stylomastoid foramen to
the geniculate ganglion using a diamond drill. The sharp
angulation of the VIIth nerve from the geniculate gan-
glion into the IAC does not allow for 180° of bone re-
moval. However, careful diamond drilling techniques can
satisfactorily skeletonize the VIIth nerve, and bone re-
90
moval can be accomplished without damage to this laby-
rinthine segment, allowing removal of the VIIth nerve out
of its bony canal (Fig. 1). Brisk bleeding occurs from the
vessels in the canal of the greater superficial petrosal
nerve. The angled neurotologic scissors can be helpful in
separating the nerve from the ganglion, and Avitene can
be used for immediate hemostasis.
Once the nerve is mobilized, a 7-0 silk suture is first
passed through the proximal stump of the VIIth nerve at
the brain stem. The suture is then passed through the dis-
tal end of the nerve which is gently brought into approxi-
mation with the proximal stump (Fig. 2). The first knot
should be a double (“surgeon’s”) knot so the second will
hold fast. A piece of abdominal fat (taken for wound clo-
sure) and Avitene are used to support the neuroanastomosis
(Fig. 2, left inset). The neuroanastomosis can be some-
what tenuous, and because the root exit area of the VIIth
nerve may be pushed into the brain stem, this support is
helpful and is easy to place.
Rarely is it necessary to obtain an autologous cuta-
neous nerve for cable grafting because the length gained
from the technique just described is ordinarily sufficient.
If it is necessary, a segment of sural nerve from the area
just behind the lateral malleolus of the ankle is obtained.
While grossly this nerve may look small, under the mi-
croscope it is always much larger than the root exit seg-
ment of the VIIth nerve. In this instance, the proximal
neuroanastomosis is accomplished first with the technique
just described, followed by the distal neuroanastomosis
(Fig. 2, lower inset).
RESULTS
Our patients have exhibited better facial animation re-
sults with direct VII-VII neuroanastomosis than with a
delayed XII-VII neuroanastomosis. The results produce
spontaneous simultaneous facial movement, do not re-
quire a second operation, and shorten the time of recov-
ery compared with a second substitute cranial nerve
neuroanastomosis. The results with an interposition au-
togenous cable graft are not as good as those with direct
end-to-end VII-VII neuroanastomosis but are preferable
when compared with paralysis or XII-VII substitution.
If a patient has undergone a retrosigmoid, standard
suboccipital craniectomy, the VIIth nerve can still be
mobilized and a VII-VII neuroanastomosis performed. The
length of nerve gained from the rerouting described is
not changed because of the surgical exposure. I believe
that any surgeon who performs acoustic tumor surgery
should be prepared for the unfortunate situation of VIIth
nerve interruption, intentional or unintentional, and should
either perform the VII-VII neuroanastomosis or call in
someone who can.
 AN EXTENDED SUBFRONTAL
APPROACH TO THE SKULL BASE
CHANDRANATH SEN, M.D.
LALIGAM N. SEKHAR, M.D.
INTRODUCTION
The extended subfrontal approach is a modification of the
transbasal approach described by Derome. In addition to a
low bifrontal craniotomy, the supraorbital rims along with
the anterior portions of the orbital roofs are removed, the
extradural optic nerves are decompressed up to the orbital
apices, and the posterior ethmoid and sphenoid sinuses are
widely opened. This approach provides access to the entire
anterior cranial fossa and to the portion of the middle and
posterior cranial base between the cavernous and petrous
portions of the internal carotid artery (ICA) on each side
down to the foramen magnum. It is useful for all intra- and
extradural lesions involving the anterior cranial fossa and
predominantly extradural tumors involving the median re-
gion of the clivus and sphenoid bone.
PREOPERATIVE DIAGNOSTIC EVALUATION
High resolution computed tomography (CT) scanning with
intravenous contrast enhancement in 1.5-mm slices is
carried out in the axial and coronal planes. The finer de-
tails of the bone destruction are best defined by the bone
algorithm. Opacification of the paranasal sinuses may
occur due to tumor involvement, obstruction of the out-
flow, or mucosal thickening from inflammation, and this
is differentiated by magnetic resonance imaging (MRI).
The MRI provides additional information and is specifi-
cally useful for the soft tissue relations with regard to fat
planes, major vessels, cerebrospinal fluid (CSF) spaces,
and the contents of the paranasal sinuses. Both T1- and
T2-weighted images and the appearance of the lesion af-
ter gadolinium administration are evaluated, especially
noting the signal of the bone marrow in the area of bone
destruction.
Arteriography is performed if the lesion is eccentric
and encroaches upon or surrounds the petrous or cavern-
ous ICA. Under such circumstances a balloon occlusion
test of the involved artery is recommended. Otherwise,
magnetic resonance angiography provides adequate in-
formation regarding the disposition of the ICA in the vi-
cinity of the tumor.
91
INDICATIONS FOR THE USE OF
THIS APPROACH
1. Intra- and extradural tumors of the anterior cranial
fossa (e.g., meningioma, esthesioneuroblastoma. na-
sopharyngeal carcinoma, etc.);
2. Predominantly extradural tumors of the clivus that
may extend as low as the foramen magnum (e.g., chor-
doma, chondrosarcoma);
a. Extradural tumors of the clivus may occasionally
penetrate and have a small intradural extension.
These may also be removed by this approach.
b. When there is a major intradural extension of the
tumor, only the extradural portion should be resected
by this approach because of the lack of control of
the vertebrobasilar system and cranial nerves and
the great depth of the working area. A separate ap-
proach is advisable for the intradural tumor.
c. The area of the posterior clinoid processes and
the dorsum sellae is not adequately accessed by
this route. In our opinion this region is best ex-
posed by an intradural subtemporal or trans-
sylvian approach.
COMBINATION WITH OTHER APPROACHES
1. Tumors of the anterior cranial base frequently require
combining a transfacial approach to access that part
of the tumor extending into the nasal cavity and max-
illa. This is performed most often in the same sitting
so that en bloc removal of the tumor can be achieved
with adequate reconstruction.
2. When the tumor extends lateral to the petrous and/or
cavernous ICA, a lateral extradural approach like the
subtemporal and infratemporal approach is also nec-
essary. Both approaches can be performed simulta-
neously or at different stages.
3. Extensions into the cavernous sinus are dealt with in
a separate operation using an intradural approach.
PREOPERATIVE PREPARATION
The scalp is assessed for previous incisions which may
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
compromise the use of a pericranial flap for reconstruc-
tion. If such a situation exists, alternative methods of re-
construction using a vascularized free omental flap may
be planned.
Steroids are administered only if there is significant
mass effect and cerebral edema. Anticonvulsants are given
preoperatively if intradural anterior fossa tumor resection
is planned. Intraoperative antibiotic coverage is routinely
used and it consists of either a combination of vancomy-
cin and tobramycin or ceftriaxone and metronidazole.
They are given at the beginning of the operation and con-
tinued for 48 hours postoperatively or until the drains are
removed.
OPERATIVE PROCEDURE
Anesthetic Technique and
Intraoperative Monitoring
General inhalation anesthesia is used and the endotracheal
tube is firmly secured with mandibular or interdental wires
to avoid dislodging the tube during intraoperative manipu-
lation of the head. Central venous and arterial catheters
are inserted for fluid administration and hemodynamic
monitoring. An indwelling urinary catheter is used for
accurate measurement of urine output. Sequential com-
pression stockings are wrapped around the lower extremi-
ties and are continued into the postoperative period to
reduce the chances of developing deep venous thrombo-
sis. A lumbar spinal drain is inserted after the induction
of anesthesia. CSF is aspirated in increments of 20 to 30
ml as required to provide brain relaxation. If a significant
intracranial mass is present, spinal fluid drainage is not
used and alternative means of brain relaxation like hyper-
ventilation and osmotic agents are used. Because cranial
nerve monitoring is usually not required, the use of neu-
romuscular blockade is not a problem. Brain stem audi-
tory evoked potentials may be monitored as an indicator
for brain retraction.
Positioning
If it is anticipated that the patient’s head will be moved
during the operation, the head is placed on a horseshoe
headrest; otherwise, a three-point pin fixation is preferred.
The patient lies supine and the head is slightly extended
to allow visualization along the floor of the anterior fossa
(Fig. 1A). The eyelids are sutured shut after instilling a
lubricating ointment. Unsterile electrophysiological moni-
toring electrodes are inserted outside the surgical field. If
additional ones are needed within the sterile field, sterile
electrodes are inserted after preparation of the area. The
lateral thigh is also prepared for harvesting fat and fascia
lata if needed.
92
Incision
A bicoronal incision is used, extending from the level of
one zygomatic arch to the other (Fig. 1B). The incision
must be placed as posteriorly as possible behind the coro-
nal suture so that a long pericranial flap may be available.
Furthermore, the scalp incision can be made so that the
posterior scalp is undermined to harvest an additional
length of pericranium in continuation with the anterior
portion (Fig. 1C). The caudal ends of the incision should
also be placed posteriorly, close to the ear, to avoid the
frontal branch of the facial nerve.
Bony Exposure
The scalp flap is reflected along with the pericranium to
the level of the nasion and the orbit. The periorbita is
stripped from the roof and medial and lateral walls con-
tinuous with the pericranium. To avoid inadvertent injury,
the pericranium is not elevated from the scalp until the time
of reconstruction. If the supraorbital neurovascular bundle
seems to emerge from a foramen, the anterior aspect of it is
fractured with a small osteotome so that the vessel and nerve
can be displaced caudally with the scalp and periorbita.
Preservation of the artery is important since it supplies the
pericranial flap. The temporalis muscle is elevated on ei-
ther side from the temporal fossa to expose the pterion.
The bony exposure now consists of the frontal bones,
frontozygomatic sutures, supraorbital rims, and medial
walls of the orbits down to the level of the nasion (Fig. 2).
Craniotomy
A low bifrontal bone flap is elevated after making burr
holes at the “key hole” on either side and one placed 5 to
6 cm superior to the nasion slightly on one side of the
midline (Fig. 2). If the dura strips with difficulty, one-
half of the bone flap may be elevated first, after which the
dura can be separated from the opposite side under direct
vision and the other bone flap is elevated separately. This
eliminates the need for a midline burr hole in the fore-
head. Small openings in the superior sagittal sinus, which
is small in this area, are easily controlled with Gelfoam
strips; larger rents need to be sutured. The dura is now
tented up to the bone edges with sutures.
Fronto-orbital Osteotomy
CSF (20-40 ml) is removed through the drain and the
subfrontal dura is separated from the orbital roofs
starting laterally and proceeding medially toward the
crista galli. With a malleable retractor protecting the
lateral orbit, a cut is made with the reciprocating saw
at the frontozygomatic suture to the “key hole” burr
hole (Fig. 3A). A malleable retractor is now used to
protect the subfrontal dura. and another over the or-
 SEN AND SEKHAR : EXTENDED SUBFRONTAL APPROACH TO THE SKULL BASE

© 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.

93
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

© 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.

94
 SEN AND SEKHAR : EXTENDED SUBFRONTAL APPROACH TO THE SKULL BASE
bital contents and the osteotomies are extended medi-
ally over the orbital roofs to the crista galli using the
saw (Fig. 3B). The frontal sinuses may extend into the
orbital roofs for a variable distance. A horizontal os-
teotomy is now made at the nasion, level with and about
half as deep as the anterior ethmoidal artery after co-
agulating and dividing it (Fig. 3C). The midline cut may
have to be repeated from intracranially to connect with
the external cut at the nasion. If during these cuts the
periorbita is accidentally torn it is covered with cottonoid
strips to prevent extrusion of the orbital fat. The fronto-
orbital bone piece is now removed in one piece (Fig.
3D). After this, the procedure differs depending on
whether the tumor involves the anterior cranial base or
the clivus, as described below.
Tumors Involving the Anterior Cranial Base
In the case of an esthesioneuroblastoma, a nasopharyn-
geal malignancy with dural involvement, or a meningioma
with basal bony involvement, the dura is opened at the
frontal pole on either side of the midline and the superior
sagittal sinus is doubly ligated and divided. The surgical
microscope is used for the intracranial portion of the op-
eration. The frontal lobes are elevated while the surgeon
carefully separates the olfactory tracts which are divided
near the olfactory trigone in case of malignant tumors,
taking into consideration perineural invasion by these tu-
mors. A wide margin of dura is coagulated and incised
around the tumor and the high-speed drill is used to make
the bone cuts in the anterior fossa floor. Prior to the bone
cuts, the optic nerves are unroofed extradurally on their
superior and medial aspects, out to the orbital apices if
the tumor comes near the nerves (see below). This proce-
dure is facilitated by using the medial wall of the orbit,
which has already been unroofed, as a landmark. After
the superior portion of the tumor has been mobilized and
detached, the inferior and lateral portions are freed through
a separate transfacial approach, after which the tumor is
delivered en bloc inferiorly.
In the case of a meningioma, standard microsurgical
principles are utilized and the main intracranial tumor
mass is separated from the skull base to devascularize it
from its ethmoidal arterial blood supply. The tumor mass
is then debulked and separated from critical structures
and removed. After the main tumor mass has been re-
moved, the basal dura is excised and the bony involve-
ment is drilled away; the ethmoid and frontal sinuses are
entered in the process.
Extradural Tumors of the Clivus
Division of the Olfactory Nerves, Elevation
of the Subfrontal Dura, and Exposure
95
of the Extradural Optic Nerves
Under the magnification of the surgical microscope, the
subfrontal dura is elevated after the olfactory nerves have
been divided. The dura may be invaginated into multiple
crevices in the anterior fossa floor and these folds must
be carefully delivered to avoid tears. Dural tears should
be repaired immediately to avoid overlooking them in the
end. The subfrontal dissection is facilitated further by
aspirating CSF from the spinal drain. The extradural por-
tions of the optic nerves are identified and the dura is
elevated carefully since it is thin in this area and dural
tears are difficult to repair. Maintaining proper orienta-
tion with the midline is helpful during this procedure.
Decompression of the Extradural Optic Nerves
and Removal of the Planum Sphenoidale and
Posterior Ethmoidal Air Cells
The frontal lobes are gently elevated extradurally with a
self-retaining retractor and the optic nerves are carefully
unroofed on their superior and medial aspects using a 3-
or 4-mm diamond burr on a high-speed drill operated by
the foot of the surgeon. Drilling should be done in a gentle
stroking motion with minimal downward pressure under
constant irrigation. The optic canals diverge in a down-
ward and outward angle of 45° and the bone which is
very thin posteriorly gets rapidly thicker toward the or-
bital apex. Another clue to the direction of the nerves can
be obtained from the orbit which has been partly exposed
by the supraorbital osteotomy (Fig. 4).
After both optic nerves have been unroofed to the
orbits (about 2 cm), the planum sphenoidale is completely
removed with the drill and further anteriorly, the poste-
rior ethmoidal air cells are also drilled away. The mucosa
of the sphenoid and ethmoid sinuses is removed thor-
oughly and if there is tumor within the sphenoid sinus a
specimen can be sent for frozen section examination and
the rest removed with the pituitary forceps, ring curettes,
and suction.
Delineation of the Lateral Margins
of the Exposure by Definition of the
Cavernous and Petrous ICA
The microscope is angled in from the contralateral side
along the anterior fossa floor. Using a diamond burr
(3-4 mm), the bone on the undersurface and the medial
wall of the orbit is drilled away to expose the medial
surface of the anterior portion of the cavernous ICA
(Fig. 5). Drilling is continued along the medial surface
of the artery; the ICA can be exposed up to the point
where the petrous ICA turns up into the cavernous.
segment (Fig. 6). The periosteal layer of dura separates
the ICA and the cavernous sinus from the surgical
f ield, and venous bleeding if present is con-
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

© 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.

96
 SEN AND SEKHAR : EXTENDED SUBFRONTAL APPROACH TO THE SKULL BASE
© 1992 The American Association of Neurological Surgeons
Figure 6. The cavernous ICA has been unroofed posteriorly up to its
entry into the cavernous sinus from the petrous bone. Looking under
the left optic nerve (ON) the anterior intracavernous carotid (IC) is seen
trolled with Surgicel packing. The sellar floor is also
drilled away to expose the dura; however, it will be noted
that the dorsum sellae is hidden from the surgeon’s view
by the pituitary gland in front (Fig. 6). Similarly, the op-
posite ICA is exposed with the microscope angled in from
the other side. Tumor lying between the ICAs can be safely
removed and bleeding from the clival venous plexuses
controlled with Surgicel packing.
After the tumor has been removed, the clival bone is
drilled away until healthy marrow spaces are seen. The
hypoglossal canal and Dorello’s canal are in the lateral
limits of the exposure on each side and vigilance is nec-
essary to avoid injury to the nerves within these canals.
Small intradural tumor extensions are carefully removed.
The relative depth and narrow confines of the exposure
make more involved intradural dissection hazardous.
Extent of Exposure of the Skull Base
The entire anterior cranial base is exposed including the or-
bits and the frontal and ethmoid sinuses. Exposure posterior
to this is restricted to the median and paramedian areas as
far back as the foramen magnum (Fig. 7A). The access is
97
and the pituitary gland capsule (PIT) is exposed. The arrows indicate
the area where the petrous ICA enters the cavernous sinus.
limited laterally by the cavernous ICA, Dorello’s canal, and
the hypoglossal canal. Lesions placed further laterally can
not be accessed by this approach alone and it may have to be
combined with other approaches as mentioned above.
The fronto-orbital osteotomy adds some advantage
in reducing brain retraction when only tumors of the an-
terior cranial fossa are concerned. However, for more
posteriorly situated tumors, the osteotomy and wide open-
ing of the sphenoid and ethmoid sinuses provide increased
room for manipulating instruments and a better angle of
visibility without increased brain retraction which is es-
sential for working in the depths (Fig. 7B). The dorsum
sellae and the posterior clinoid processes remain a blind
spot because of the sellar contents in front.
Reconstruction
The crux of the reconstruction is a healthy pericranial
flap based on the supraorbital vessels. The galeal layer
may also be included in this flap. The flap can be raised
in the beginning of the operation or after tumor resec-
tion has been completed. Tenotomy dissecting scissors
are used for elevating the flap, being careful to
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

© 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).

98
 SEN AND SEKHAR : EXTENDED SUBFRONTAL APPROACH TO THE SKULL BASE
avoid creating holes or making the flap too thin. All dural
openings in the anterior fossa are closed primarily or patched.
For those along the clivus, a piece of fascia lata or temporalis
fascia is laid against the opening(s). Fat, harvested from the
abdomen or thigh, is then lightly packed in the frontal, eth-
moid, and sphenoid sinuses after the mucosa is removed thor-
oughly. The pericranial flap is carefully passed between the
optic nerves and laid against the clival dura (Fig. 8). This
requires some manipulation; overpacking the sinuses with
fat can be a hindrance. The ultimate success of the repair
depends on adequate revascularization of the fat from the
surrounding tissues. It will also be noted that removing the
fronto-orbital piece of bone gives added length to the peri-
cranial flap, allowing it to reach further posteriorly. If healthy
pericranium is not available, a free omental flap connected
to the superficial temporal artery may also be used for a
satisfactory reconstruction.
The clival bone is not reconstructed. If the medial
orbital walls have been completely removed, split calva-
rial grafts are used, anchored with wires or titanium mini-
or microplates. Bony reconstruction is not essential for
the midline anterior cranial fossa floor after a craniofa-
cial resection if a healthy pericranial flap is available.
However, if desired, a piece of split calvarial bone can be
laid between the pericranial flap and the dura to bridge
the gap in the anterior fossa floor.
The bifrontal bone flap is replaced after tenting the
© 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.
99
dura up at two or three places. The fronto-orbital piece is
then replaced. The inferior surface of the fronto-orbital
bone is trimmed so that it does not strangulate the peri-
cranial flap. This piece of bone is anchored to the bifrontal
bone flap and at the frontozygomatic sutures. All the con-
vexity bone pieces are held with 2-0 Nurolon sutures or
occasionally titanium miniplates and screws. Two drain-
age catheters are placed in the subgaleal plane, connected
to a gravity drainage system, and brought out through
separate openings prior to closure of the temporalis muscle
and fascia and the scalp.
POSTOPERATIVE CARE
Continuation of the spinal drain is not required in the
postoperative period if a good dural repair has been
achieved. However, if this is continued, specific nursing
instructions must be written to drain no more than 30-50
ml of CSF every 8 hours. This is important to prevent
problems related to overdrainage, such as transtentorial
herniation and epidural pneumocephalus.
A CT scan is performed on the first postoperative
day as a routine to check for air, contusion, or edema to
direct specific therapy if required before there is a sig-
nificant clinical problem. The subgaleal drains are con-
tinued for about 48 hours or until the drainage return is
minimal. Antibiotics are continued until the drains are
removed.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
PREVENTION AND MANAGEMENT
OF COMPLICATIONS
Cerebral Edema
This is seldom encountered because of the generous bone
removal which greatly reduces brain retraction. It is usu-
ally seen when a large intracranial tumor has been re-
moved and sometimes when frontal veins draining into
the superior sagittal sinus have been sacrificed or in-
jured. Medical management with steroids and osmotic
agents suffices. Close monitoring of fluid and electro-
lyte balance is necessary because the syndrome of inap-
propriate secretion of antidiuretic hormone is quite com-
mon in this setting and can further complicate the
situation.
Cerebrospinal Fluid Leakage
This problem is best avoided by performing a meticulous
reconstruction. If the leak noted in the postoperative pe-
riod is small, a lumbar spinal drain is inserted. When the
leak is large or persists after 4 or 5 days of spinal fluid
drainage, surgical reexploration of the craniotomy is nec-
essary. Fibrin glue, prepared from the patient’s own se-
100
rum or single donor serum, may also be used during re-
construction with the fascia, fat, and pericranium.
Epidural Pneumocephalus
This is most often seen as a result of overzealous use of
the lumbar drain in the postoperative period. The patient
usually presents with mental status changes and has a
nonlocalizing neurologic exam. A CT scan confirms the
presence of air. This is managed by removal of the drain
and the patient is maintained flat in bed.
Epidural Infection
Because of the wide bifrontal exposure and inadequate
tenting of the dura, epidural fluid collections may occur.
Contamination of this fluid with the sinus contents can
lead to an infection in this space. If infection is confirmed,
the surgical wound must be debrided and the bone flap
has to be removed. Removal of the fronto-orbital os-
teotomy is not always necessary; because the bone piece
is thin, it vascularizes early and can survive the infection.
Infections are more common in patients who have received
radiation in the past.
 PANSYNOSTOSIS: SURGICAL
MANAGEMENT OF MULTIPLE
PREMATURE SUTURE CLOSURE
JAMES T. GOODRICH, M.D., PH.D.
CRAIG D. HALL, M.D.
INTRODUCTION
Children born with severe pansynostosis are usually di-
agnosed at birth or very shortly thereafter. The craniofa-
cial team should be notified of the child’s condition very
early and should be involved in the surgical planning as
soon as possible. The most important factor in timing the
surgery is the presence of increased intracranial pressure
(ICP). In our experience, almost all children (greater than
90%) born with pansynostosis have increased intracra-
nial pressure. The most difficult child to diagnose is the
one with pansynostosis secondary to microcephaly. For-
tunately, a good pediatric workup and genetic screen can
identify this. The typical pansynostotic child has all the
signs of increased ICP, including severe “beaten metal”
appearance or “thumbprinting” of the skull. There are
usually associated signs of lethargy, increased irritability,
early signs of developmental delay, etc. In some cases
these signs or symptoms can occur so early that the sur-
gery has to be scheduled within the first month of life.
TIMING OF SURGERY AND OTHER PREOPERA-
TIVE CONSIDERATIONS
Children with pansynostosis are typically diagnosed
within the first two or three weeks of life, if not at birth.
For craniofacial surgery, the ideal time in elective cases
is five to six months of age. This growth period allows
for an ideal surgical weight plus a fully developed hema-
tologic system. In children with severe pansynostosis and
associated constricted calvarial growth, the luxury of
waiting six months is very rarely, if ever, possible. Typi-
cally, the surgery will have to be scheduled within the
first six weeks to prevent damage to the developing brain.
The longer the surgical team can wait the safer the sur-
gery will be.
© 1992 The American Association of Neurological Surgeons
101
The decision to operate is a joint one among the pe-
diatricians (including neonatologists and intensive care
personnel), the anesthesiologists, the patient’s family, and
the craniofacial team. The potential risks to the very young
child are associated with the significant blood loss; al-
most all of these children will require blood transfusions.
In addition, the surgical team is operating on a child with
residual fetal hemoglobin and, in many cases, associated
congenital anomalies. Ideally, in children with
pansynostosis, the preoperative evaluation includes a thor-
ough evaluation for any cardiac, renal, or other associ-
ated anomalies, which are not at all uncommon. Abso-
lutely essential is a full radiographic workup including
standard computed tomography (CT) and magnetic reso-
nance imaging (MRI) scans. Congenital anomalies such
as holoprosencephaly and other underlying maldevelop-
mental problems of the brain should all be identified prior
to surgery. In many cases we ask our bioethics team to be
involved to make sure the child is a reasonable candidate
for surgery and to make the family aware of future devel-
opmental problems. Included in the radiologic studies
should be an evaluation of the ventricular system, a high
percentage of these children develop hydrocephalus be-
cause of the severe cranial base anomalies. Because of
unusual positioning problems in these children (i.e., it is
not uncommon to have the child in hyperextension), the
skull base and cervicomedullary junction need full evalu-
ation. A Chiari malformation, a bony anomaly, and a nar-
row or distorted foramen magnum can all be seen in this
population. To prevent a child from awakening from sur-
gery quadriplegic, it is important to sort out these details
first. If, for example, a Chiari malformation is detected,
then the surgeon will appropriately modify the position-
ing to avoid hyperextension.
All of these children are placed on prophylactic
anticonvulsants preoperatively. The appropriate loading
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
dose should be given at least 24 hours in advance of the
surgery and continued for 30 days after surgery. Because
these children typically have severe skull base anoma-
lies, we complete a full endocrine workup to rule out any
hypothalmic-pituitary dysfunction. A routine coagulation
profile is done prior to surgery. As mentioned earlier, a
full and complete medical workup is done to rule out any
cardiac, hepatic, or renal dysfunction. If any of these are
detected, the surgical management plan includes the ap-
propriate treatment. It cannot be overemphasized how
thorough this preoperative workup should be. It is not at
all unusual to find one or more system abnormalities in
the preoperative workup.
SURGICAL TECHNIQUE
Anesthesia and Monitoring
Surgical correction of a pansynostosis is a long and tech-
nically complex procedure. Our anesthesia team manages
these children as if they all have increased ICP so that
inhalation agents which increase ICP are avoided. The
use of paralytic agents is encouraged to prevent any move-
ment during the operation and also to assist in reducing
ICP. All the children are started on a dehydration agent
(e.g., mannitol, 0.5 g/kg) prior to induction. A Foley cath-
eter must always be placed to monitor urine output and to
avoid a bladder rupture. A temperature probe is placed
either in the esophagus or rectum to monitor the body
temperature closely. Heating blankets are placed both
below and on top of the patient to prevent hypothermia.
There is almost always a significant blood loss asso-
ciated with these cases; therefore, at least two large-bore
intravenous lines should be placed. If vascular access is
difficult, then a subclavian or jugular line can be placed.
Arterial monitoring is essential for evaluation of blood
pressure, electrolytes, and blood gases. The child is kept
hypotensive with a mean arterial pressure of 50-60 mm
Hg to help reduce blood loss. We now routinely use an
oxygen saturation monitor which can be placed on the
child’s finger. The normal position of the patient is in
hyperextension with the head well above the heart. For
this reason, air embolism is a significant risk and must
also be monitored. Our anesthesiologists now routinely
place a jugular line and a pre-cordial Doppler device to
monitor for air embolism. With meticulous skin incisions
and careful coagulation of all bleeding sites, plus waxing
of the bone edges, the risk of air embolism can be mark-
edly reduced. It has been our experience that these chil-
dren, because of increased ICP, can have dilated scalp
veins and in addition large diploic venous channels. These
can be treacherous sites of venous air embolism and must
102
be carefully waxed or coagulated. In addition, the venous
sinuses can be violated as part of the elevation of the bone
units and this can lead to a rather rapid and dramatic loss
of blood and subsequent air embolism.
To monitor ICP during the operation, we often place
an intraventricular drain and attach it to a transducer. This
drain can also be used for the removal of CSF in an effort
to reduce the ICP and to relax the brain.
Perioperative antibiotics are used. Typically, only the
skin organisms are covered (e.g., Staphylococcus and
Streptococcus). The drug of choice is oxacillin (or van-
comycin if the child is allergic to oxacillin). If the child
has another source of infection such as an otitis media or
an upper respiratory infection, these are treated preop-
eratively and cleared prior to the start of any surgery.
Positioning
The typical child with pansynostosis requires remodel-
ing and repositioning of almost the entire calvarium (Figs.
1-6). As a result, the entire calvarium must be exposed in
the operative field. This surgical field extends from the
level of the orbits to the level of the foramen magnum. To
do this we place the child in the prone position with the
head hyperextended (after radiologic evaluation has shown
no abnormalities of the cervicomedullary junction). The
chin rests on a horseshoe head rest that is well padded
(Figs. 1, A and B, and 4A). The draping is done with two
split sheets going in opposite directions, keeping the or-
bits and entire calvarium in the operative field. Bilateral
tarsorrhaphies are performed at the beginning of the op-
eration to protect the eyes. We no longer do a full head
shave; the hair is trimmed for approximately 2 cm where
the skin incision is to be made.
Figure 7 shows the operating room layout. The table
is usually reversed head to foot so that the surgeon’s legs
fit comfortably under the table. The operator works at the
head end of the table with the assistant to the right. The
nurse with the instrumentation is placed to the right of
the assistant. A Mayo stand is placed over the table and
on this the nurse places the instruments directly in use.
Behind the nurse is a larger table that holds the main in-
strument groups. A Mayo stand is placed to the left of the
operating surgeon and directly to the side of the child’s
head. When the drapes are placed, this allows the anes-
thesiologist an access tunnel to the child’s airway and to
the child’s peripheral lines. All the suction tubes, cautery
lines, etc. are run off the opposite end of the table. This
allows the surgeon and the assistant to sit and not have
their chairs run over the various tubes and cables. The
only item at the foot of the surgeon should be the cautery
pedals and the pedals to run the air drills when necessary.
 GOODRICH AND HALL : SURGICAL MANAGEMENT OF MULTIPLE PREMATURE SUTURE CLOSURE
© 1992 The American Association of Neurological Surgeons
Figure 1. A, operative positioning, lateral view. The child is placed
prone in a hyperextended position. The child (face down) rests on a
well-padded horseshoe head rest. The electrocautery grounding pad is
placed on the child’s back. B, a frontal intraoperative view of a child
with severe pansynostosis and an early cloverleaf deformity of the skull.
This child was diagnosed at birth and by three weeks of age had stopped
all head growth. It is important to appreciate the number of deformities
in the skull. Because of fusion of the coronal and squamosal sutures
there is a severe dimpling to the temporal region. Over the calvarium a
103
number of soft spots could be palpated secondary to brain “escaping”
through the skull. The lambdoid sutures were so tightly fused the child
did not develop the usual inion point. The head assumed the typical
early “cloverleaf” appearance that occurs when all the sutures fuse. C,
an intraoperative view of the forehead (corresponds with the view in B)
after the skin flaps and pericranium have been elevated. Methylene blue
has been used to mark out the osteotomy sites. The orbital bandeau will
be harvested from just behind the coronal suture. The new forehead unit
will come from the child’s left temporoparietal region (see Fig. 3A).
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
© 1992 The American Association of Neurological Surgeons
Figure 2. A, the unit of bone that came from the area labeled B in Fig-
ure 3B. The view is of the underside of the bone, i.e., the inner table.
One can appreciate the severe “thumbprinting” that can occur in these
cases. The dura is pushing through these areas, and in addition there are
points where the bone has been completely eroded through with dura
and brain exposed. The elevation of this bone has to be done very gen-
tly and carefully to avoid injury to the sinuses and to the brain. B, once
the various bone units are harvested, they are taken to a separate table
and positioned to see how they will fit on the child. It is easy to appreci-
104
ate from the photograph that severe pocketing and erosion of bone have
occurred. With the advancement necessary to decompress the brain, there
is a lack of sufficient bone available to cover the calvarium. Two impor-
tant pieces of bone are those struts that will be placed over the convex-
ity to prevent a turricephaly from occurring. C, an intraoperative fore-
head view of the child prior to closure. The wire basketweaving can be
appreciated in the orbital bandeau. This view is the equivalent view of
Figures 1, B and C, and 3B. D, the child at 10 months of age.
 GOODRICH AND HALL : SURGICAL MANAGEMENT OF MULTIPLE PREMATURE SUTURE CLOSURE
© 1992 The American Association of Neurological Surgeons
Figure 3. A, an artistic reconstruction of Figure 1C showing the vari-
ous sites for osteotomies and harvesting. The bandeau is elevated
from just behind the coronal suture. The new forehead unit (area A)
is marked out with a Marchac template and elevated from the tem-
poroparietal region. B, an artistic reconstruction of Figure 1C show-
ing the various osteotomies on the left and then their repositioning
105
on the right. The areas A and B will form the new forehead and
posterior occipital unit. The bandeau is harvested and advanced for-
ward and positioned (right). A sagittal strip of bone is placed to hope-
fully prevent a turricephaly from developing. The blank areas are
exposed dura mater, which is common due to lack of bone that oc-
curs in the various advancements.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
© 1992 The American Association of Neurological Surgeons
Figure 4. A, an intraoperative view of an eight-month-old child with
severe synostosis of all the calvarial sutures. The dimpling about the
temporal region and the flattening and distortion over the right occipital
region can be appreciated. In this child the frontal unit and orbital bandeau
are symmetrical and not distorted. The surgical team decided on a re-
construction behind the coronal suture rather than a total calvarial re-
moval. B, an intraoperative view similar to A with more of an oblique
angle of the child’s head showing the severe distortion of the calvarium
that has occurred over the posterior parietal and occipital regions. C, a
frontal view similar to A, after reflection of the skin and periosteal flaps,
106
with the various osteotomies marked out in methylene blue. The orbital
bandeau will be taken from just behind the coronal suture which can be
seen in this view. The area over the child’s left occipitoparietal area was
determined to have the best configuration to reconstruct a new occipital
plate. D, a lateral view after reflection of the skin and periosteal flaps.
Using methylene blue the osteostomies have been marked out. The
bandeau will come from just behind the coronal suture. This will be
moved back and placed tongue-in-groove into the asterion step-off unit,
which has also been marked out.
 GOODRICH AND HALL : SURGICAL MANAGEMENT OF MULTIPLE PREMATURE SUTURE CLOSURE
© 1992 The American Association of Neurological Surgeons
Figure 5. A, an intraoperative view (equivalent to Fig. 4, A and B) after
the various units have been repositioned. The new bandeau has been
attached to the asterion, and the various bone units have been mounted
on the bandeau unit. In this view the surgeon has laid the bone out to
show which units are being placed. B, an intraoperative view equiva-
lent to A with the bone laid into position and just prior to wiring. C, an
intraoperative view equivalent to A and B with the bone units wired
107
into position. D, a posterior view (i.e., looking at the occipital region)
showing the “fan cuts” made in the occipital unit to help it mold. In the
older child the bone is not as malleable and this is a useful technique to
help the brain remodel the bone as it grows. E, an intraoperative view at
the completion of the operation, equivalent to Figure 4, A-C. The im-
mediate correction that occurs with this type of technique can be appre-
ciated here.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
Figure 6. A, an artist’s reconstruction of Figure 4A showing the vari-
ous osteotomies. B, an artist’s reconstruction of Figure 4D showing
the various osteotomies from the child’s right side (opposite side
from Fig. 4D). The asterion step-off can be seen here and this is
where the bandeau will be anchored. C, an artist’s reconstruction of
Figure 4D (opposite side view) showing the harvesting and direc-
tion of the new bandeau unit. This unit acts as the framework upon
108
© 1992 The American Association of Neurological Surgeons
which the rest of the calvarial reconstruction will take place. D, an
artist’s reconstruction of Figure 5C, from the child’s right side, show-
ing the various units in their new positions. E, an artist’s reconstruc-
tion of Figure 5C showing the bone units wired into position. The
units have been labeled and are equivalent to the schematic in A.
The donor sites and their eventual location can be appreciated better
here in this schematic.
 GOODRICH AND HALL : SURGICAL MANAGEMENT OF MULTIPLE PREMATURE SUTURE CLOSURE
© 1992 The American Association of Neurological Surgeons
Figure 7. Operating room schematic. The surgeon typically sits at the
head of the child with the assistant to the right. The nurse is positioned
to the right of the assistant. A Mayo stand is brought over the child at
the buttock level. Another Mayo stand is placed to the left of the child
and parallel with the child. This provides a tunnel for the anesthesiolo-
An additional point to consider in the draping is the use
of waterproof drapes. As these cases require considerable
bone removal, the saline irrigation used can be copious. It is
important that the drapes in contact with the body not get
wet during the case. In addition, we place heating blankets
both below and on top of the child. Because these are small
children, the heat loss can be considerable and rapid so hy-
pothermia must be carefully monitored and avoided.
Skin Incision
These cases require a large and wide exposure of the cal-
varium. The simplest and most cosmetically efficient in-
cision is the bicoronal incision. This incision is carried
109
gist to view the child and the respiratory apparatus. The anesthesia ma-
chinery is placed behind the anesthesiologist. A large table is placed
behind the nurse where most of the instruments are placed. The Mayo
stand is used only for the immediate instrumentation.
ear to ear and normally follows a midpoint between the
nasion and inion. This incision will easily allow the op-
erator to expose from the level of the orbits and nasion,
over the convexity, to a point below the nuchal line. By
this approach the entire calvarium can be visualized. Dur-
ing the skin incision, the temporalis fascia should not be
cut. The pericranium is elevated as a separate layer, and it
is incised where it merges with the temporalis fascia. The
temporalis muscle is then elevated as a separate layer and
hinged to its base. By doing this, the temporalis is avail-
able to be laid down intact at the end of the case and sewn
back to the pericranial layer. If the exposure is carried
down to the foramen magnum, the nuchal muscles can be
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
elevated as a flap in continuity with the periosteal layer.
This technique allows the nuchal muscles to be laid down
at the end of the case when the periosteum is laid back.
When the frontal periosteal membrane is elevated, the su-
praorbital nerve and artery complex on each side can be
easily elevated with it. This will allow preservation of these
important structures that run through the supraorbital
notch on each side. Occasionally the notch will need to
be opened, especially in older children. It can be opened
with either a small osteotome or a 2-mm Kerrison punch.
Operative Technique
To illustrate the operative technique used in this type of
craniofacial reconstruction we have selected two cases.
Each case was done with a different technique.
Case One
History: A six-week-old child presents with severe
pansynostosis involving all the sutures, resulting in a se-
vere thumbprinting appearance of the skull. Craniofacial
reconstruction here is going to require complete disas-
sembly of the calvarium from the orbit to the posterior
fossa (Figs. 1-3).
The patient is positioned with the head extended as
shown in Figure 1, A and B. After the bicoronal incision is
made and the periosteum is elevated, the entire calvarium
is exposed in the field. Because this child’s forehead and
orbital rims are going to be advanced, a new bandeau and
forehead unit need to be marked out. Figure 1C shows the
intraoperative view after methylene blue has been used to
mark the plates to be harvested. The bandeau will come
from an area just anterior to the coronal suture. The only
area where a normal forehead unit can be located is over
the left temporoparietal region. The rest of the osteoto-
mies are designed to provide large pieces of bone for the
reconstruction after the bandeau and forehead have been
advanced.
As this child has severe molding and thumbprinting
of the inner table, the bone elevation has to be done with
great care to avoid tearing the dura or entering a sinus
(Fig. 2, A and B). Using a high-speed footed drill and
“walking” the footplate along the grooves and digital
markings, these units can be elevated safely. Areas that
are particularly treacherous are over the sinuses and be-
tween the orbits. On the CT scans the surgical team noted
this child to have a tongue of brain coming in deep be-
tween the orbits. Early appreciation of such anatomy pre-
vents an unacceptable situation of tissue damage to the
frontal lobes. In many cases the sphenoid wings are se-
verely sclerosed (giving the harlequin eyes) and in these
cases the sphenoid wings are removed bilaterally.
Once the bone plates have been elevated, they are taken
off the field to another sterile table; here the surgeons can
110
reconstruct the calvarium in the fashion best suited to give
an advancement, keeping in mind the amount of bone avail-
able. As shown in Figure 2, B and C, we have reconstructed
the new calvarium using the forehead unit and new orbital
bandeau. To give an adequate advancement one can appre-
ciate the “lack” of bone that occurs when the reconstruc-
tion is done. Important points to remember are a good fore-
head and bandeau unit first. Bone has to be placed over the
calvarium along the sagittal sinus to prevent a turricephaly.
We have found that if the convexity/apex region is left open
the brain will go the path of least resistance and a turri-
cephaly can occur. With proper attention to strut placement,
the brain (i.e., frontal lobes) will expand forward and not
upward. Struts placed along the convexity help orient this
direction of growth. The other pieces of bone are then placed
in a mosaic fashion, attempting to cover as much of the
brain as possible. In this particular child there was such a
severe constriction of the head that after the calvarium was
remodeled with the available bone only 60-70% of the
brain was covered with bone. In young children, particu-
larly under one year of age, reossification will occur eas-
ily and quickly.
In children with severe pouching of the dura caused
by thumbprinting, it is sometimes necessary to relax these
dural bands. This can be done by incising the dura. and
not incising the arachnoid. This will allow relaxation with-
out cerebrospinal fluid (CSF) leakage. CSF leaks can be
very troublesome days later (causing subgaleal collec-
tions), so it is important to repair any CSF leaks or dural
tears resulting from the opening.
Figure 2C shows the calvarial unit after placement
(28-gauge wire is used for stabilization of the forehead
units). In this child the bandeau was so flimsy that wire
was woven through the bandeau. to give it additional sup-
port. Wire is usually required wherever structural support
is needed. In those cases where support is not needed,
softer suture material (we use either Nurolon or Vicryl) is
more than adequate.
Case Two
History: An eight-month-old child was noted to have se-
vere pansynostosis with lack of head growth from five
months of age. After careful workup for microcephaly,
which was ruled out, the craniofacial team determined
that the child had severe synostosis of all the calvarial
sutures. However, in this child the orbital units and fore-
head were not severely affected so the reconstruction was
based on the units behind the coronal sutures.
The positioning techniques and preliminary steps
were the same as in Case One. The significance of
this child’s synostosis can be appreciated in Figure 4,
A and B, which shows the anterior and superior views.
In this child, all the calvarial sutures were noted to be
 GOODRICH AND HALL : SURGICAL MANAGEMENT OF MULTIPLE PREMATURE SUTURE CLOSURE
closed or sclerosed on x-ray examination. However, the
aesthetic examination showed the orbits and forehead to
be symmetrical. On the basis of this, instead of performing
a complete calvariectomy, we kept the forehead and orbital
unit intact and reconstructed the rest of the calvarium.
In Figure 4, C and D, the child’s head is shown from
superior and lateral views to demonstrate the methylene
blue markings where the osteotomies will be performed
(Fig. 6, A and B, shows the artistic schematic). To cor-
rect the deformity over the occipital region and to allow
growth and advancement, a new bandeau is constructed.
This will act as the base unit for reconstruction. To an-
chor this bandeau down, a “step-off ” has been marked
out over the asterion region (Fig. 4D). The entire occipi-
tal region and posterior fossa bone will be removed in
two units and these pieces will be used in the recon-
struction. The piece over the right occipital region (la-
beled “A” in Fig. 6A) was determined to have the clos-
est symmetry to a new occipital plate and this was marked
out using a preformed template. Because the sagittal si-
nus lies under the sagittal suture, it is sometimes useful
to make an additional osteotomy lateral to each side of
the suture. Then the plate of bone over the sagittal sinus
is elevated last as a unit when full control is available to
handle any sagittal sinus bleeding. In children under one
year of age it is relatively easy to elevate bone off the
sinuses, both sagittal and lateral.
Once the bone has been harvested, the bandeau is
placed into position, tongue-in-groove to the asterion unit.
On this bandeau the new occipital unit, which had been
previously fashioned, is placed. This acts as the frame-
work upon which to build the rest of the calvarium in a
mosaic unit. In Figure 5A we show the various bone units
winged out to show their location and position prior to
wiring them into position. In the older child with firmer
bone, it is occasionally useful to “fan cut” the bone to
allow the expanding brain to spread out (this can be seen
in Fig. 5D). Figure 6C is a lateral schematic view show-
ing the bandeau in position. With the new occipital unit
in position around this framework, the calvarium is re-
constructed in a mosaic pattern using the remaining bone
(Figs. 5, C and D, and 6, D and E). As in Case One, it is
important to remember to cover the sagittal sinus first
with bone, to act as a strut and subsequently to prevent a
turricephalic pattern from developing. Again, wire is used
in those parts that need the additional support. Suture
material is used where wire is not necessary.
Closure Technique
After the calvarial bone units have been placed, the clo-
sure is done in a reverse fashion of the opening. The dura
is inspected for any CSF leaks. The venous sinuses are
111
inspected for any bleeding points. Gelfoam placed over
the bleeding points is usually adequate. The surface is
then copiously irrigated with warm physiological saline
solution. As this is a long operation, with a long exposure
time, copious irrigation is essential to remove any debris
and bacterial contaminants. The pericranium is elevated
and carefully stretched out over the calvarium. Particular
attention is paid to the wires as these will snag the peric-
ranium and restrict the amount of spreading. The nuchal
muscles should come up easily with the posterior peri-
cranial layer. The frontal layer is then brought up and
retention sutures are placed between the front and back
layers. These layers will not meet, due both to shrinkage
and to the advancement. However, they can be kept in
position by retention sutures. Next, the temporalis muscles
have to be reattached to the pericranium or sometimes
they can be sewn to the sutures in the bone units.
A drain is placed in the subgaleal space to collect the
blood (which can be extensive) that arises from the skin
flap. However, prior to closure of the skin flap, a careful
search for bleeding points should be conducted to mini-
mize such bleeding. In addition, the gutters must be irri-
gated copiously again. When the flap is curled over, bone
dust, old blood, and debris will collect—this must be irri-
gated out!
Remembering that the reconstruction unit is very
fragile, the surgeon places a soft “fluffy” dressing over
the wound. Tight wraps or constricting dressings should
be avoided because they will tend to collapse the bony
construct. A stretched fishnet stocking is most useful to
place over the head and keep the fluffy dressing in place.
Specialized Instrumentation
These operations are done with a standard craniotomy
set. It is recommend that a high-speed drill system with a
craniotome (e.g., Midas Rex) be used for harvesting the
calvarial bone. These children typically have a thin skull
with severe inner table erosion; to prevent injury to the
brain and dura the operator will need a well controlled
high-speed drill system with a fine foot plate to separate
bone and dura.
To mark out the forehead unit we have been using
the Marchac forehead templates. These templates are quite
useful in locating a unit of bone on the calvarium that
most closely approximates the normal forehead.
COMPLICATIONS
There are a number of known complications associ-
ated with these complex craniofacial procedures. It
has been our experience that if the surgical team
thinks of them as they go through the preoperative,
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
intraoperative, and postoperative steps, many of them can
be avoided.
Hemorrhage
This can and will occur as a normal part of this operation.
Because of the extensive nature of the craniectomies and
the amount of flap exposure and osteotomies, the loss of
blood can be great. To assist in reducing this blood loss,
our team uses a number of techniques. Since these are
children and there is an extended family, we request that
the family arrange for pedigree blood to be given a week
in advance. This reduces the risk of hepatitis, AIDS, and
other infectious diseases that can be carried in blood. The
anesthesiologist keeps the child at a hypotensive blood
pressure range (mean arterial pressure of 50 mm Hg) dur-
ing the procedure. Blood transfusion is done only when
the hematocrit drops below 28 or the child becomes clini-
cally symptomatic. We routinely plan on transfusing at
least one unit of blood, and in approximately 20% of the
cases a second unit will be needed. It goes without saying
that meticulous attention to technique can reduce the loss
of blood dramatically. Use of epinephrine infiltration dur-
ing the skin incision, skin clips, cautery, etc. all can help
reduce blood loss.
Infection
Preoperatively, each child is started on an antibiotic for
skin organisms (usually oxacillin) which is continued for
24 hours postoperatively. The rate of infection is quite
low in these cases if there is adequate attention to surgi-
cal technique. It cannot be overemphasized how impor-
tant it is to irrigate at the completion of each case to re-
move the debris that accumulates. These children typically
will develop fevers in the first postoperative week. Rou-
tine fever workups are done but rarely is a source found.
We attribute these fevers to the resorption of blood that
collects under the skin flap. In the case of an extensive
advancement it is not uncommon to leave a large “dead
space.” These spaces have the highest incidence of infec-
tion, and if a child develops evidence of sepsis these spaces
may need to be tapped for a bacteriological culture. The
incidence of this happening is very low but always must
be considered in the differential diagnosis of postopera-
tive fever.
Patient Positioning
Because of the need to place the child in hyperextension,
it is important to get preoperative CT and MRI scans.
112
Abnormalities at the cervicomedullary junction are com-
mon in these children. Before a child is hyperextended,
the surgeon must rule out any evidence of a Chiari mal-
formation, bony anomaly, or narrowing of the foramen
magnum. If any of these is noted, the positioning has to
be corrected to allow for it.
Cerebrospinal Fluid Leakage
All CSF leaks must be repaired and no evidence of a CSF
leak can be present at the completion of the operation. If
necessary, the surgeon can have the anesthesiologist pro-
vide a positive-pressure Valsalva maneuver at the end of
the case. In those cases where there is severe pansynostosis
with dural pouches that need to be released, this can be
done if the surgeon stays within the subdural space and
does not violate the arachnoid membrane. Keeping this
technique in mind will prevent arachnoid tears and CSF
leaks.
Wire Extrusion
Although wires are necessary to provide strength and
stability to the reconstruction, they can erode through
the skin. It is imperative that the wires be turned under
so that no sharp edges are present. At the completion of
the operation the surgeon should run a finger over the
scalp, feeling for any unusually prominent wires before
closure. If a wire does erode through the skin later, it
must be removed as soon as possible to prevent a local
osteomyelitis. This can be done in the office with local
anesthesia.
Hydrocephalus
There is a very high incidence of hydrocephalus in chil-
dren with severe pansynostosis. There are also many dif-
ferent opinions as to when to treat the hydrocephalus, i.e.,
before or after the craniofacial reconstruction. It has been
our policy to do the craniofacial procedure first and the
shunt second. We have found that in some cases the treat-
ment of the pansynostosis alleviates the need to treat the
hydrocephalus (as was the situation in the first case). Also,
the early correction of hydrocephalus can cause a dra-
matic collapse of the brain which will work against the
reconstruction. However, if the child is very sick from
increased intracranial pressure, the shunt can be placed
first to relieve the elevated ICP and prevent the serious
sequelae due to this high pressure. Another factor to con-
sider in a secondary placement of the shunt is the increased
risk of infection due to the shunt being present during a
lengthy reconstruction.
 DISTAL ANTERIOR CEREBRAL
ARTERY ANEURYSMS
H. HUNT BATJER, M.D.
DUKE SAMSON, M.D.
INTRODUCTION
Aneurysms occurring along the anterior cerebral artery
and its major branches distal to the anterior communicat-
ing artery form a relatively uncommon and unique group.
Although only about 5% of patients with intracranial an-
eurysms have lesions affecting these vessels, this rela-
tively small group of aneurysms is quite heterogeneous.
Typical saccular aneurysms most commonly arise at
the major branching points of the anterior cerebral artery,
namely at the origin of small orbital branches arising along
the first 1-2 cm of the A2 segment, at the origin of the
frontopolar artery, and at the origin of the callosomarginal
artery. The latter location is by far the most common. As
at other anatomical sites, saccular aneurysms not infre-
quently develop in conjunction with local arterial anoma-
lies. Occasional patients suspected of having a distal an-
terior cerebral aneurysm will be found to have multiple
anterior communicating branches, and the aneurysm may
be found to relate to the most distal communicating ves-
sel. Azygous A2 segments are not rare in these patients
and the aneurysm may develop at the point of division of
this vessel into the bilateral callosomarginal and
pericallosal arteries. An occasional patient with triplica-
tion of the A2 segments will be found to harbor a distal
aneurysm. It is vital to determine the presence of this
anomaly by preoperative angiography. Its origin is usu-
ally posteriorly directed from the anterior communicat-
ing artery, and the third A2 segment may be inadvertently
included in a clip placement if the anomaly is not recog-
nized. Finally, patients with an arteriovenous malforma-
tion fed by the pericallosal artery may develop unusual
distal aneurysms, presumably due to the hemodynamic
stress imposed by the malformation.
Important subgroups of these lesions are not saccu-
© 1992 The American Association of Neurological Surgeons
113
lar aneurysms. Infectious emboli from cardiac vegetations
tend to lodge in the distal anterior cerebral or middle ce-
rebral branches and the resulting inflammatory process
may break down the arterial wall, giving rise to a bacte-
rial or mycotic aneurysm. In addition, the distal anterior
cerebral artery may be the site of a traumatic aneurysm.
The falx provides a buttress against which the cerebral
hemispheres impact during severe closed head trauma as
transient brain shift occurs. The anterior cerebral artery
and its branches are vulnerable to varying severities of
injury during this process. The intima and internal elas-
tica may be disrupted, leading to dissection or true aneu-
rysm formation, or the injury may be more severe, ex-
tending through the muscular media and resulting in a
true aneurysm with intact adventitia or frank arterial lac-
eration in which the hematoma is contained only by arach-
noid or brain parenchyma (false aneurysm). The poten-
tial for distal anterior cerebral artery aneurysms to be
infectious or traumatic must be kept in mind. Because
these disease processes may extend over a wide circum-
ference of the small anterior cerebral artery, intraopera-
tive rupture is common and the potential requirement for
temporary arterial occlusion or even permanent vessel
sacrifice is high.
Another unique feature of aneurysms of the distal
anterior cerebral artery concerns their tendency to occur
with other intracranial aneurysms. Approximately 35-50%
of patients will be found to harbor multiple aneurysms,
and this feature significantly complicates operative plan-
ning and occasionally makes it difficult to determine
which lesion actually bled. Due to the unique location of
these aneurysms and the tendency for the sac to be em-
bedded in a cingulate gyrus, rupture may result in diffuse
subarachnoid hemorrhage (SAH), focal interhemispheric
SAH, interhemispheric subdural hematoma formation,
intraventricular hemorrhage, corpus callosal hemorrhage,
or frontal lobe parenchymal hematoma formation.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
PATIENT SELECTION
Patients found to harbor an incidental aneurysm of the
distal anterior cerebral artery pose a potential dilemma to
the surgeon required to give advice. We remain relatively
aggressive in recommending surgical treatment for pa-
tients in good health under the age of 60 because even
very small aneurysms have proven to produce SAH. It is
also our impression that patients who bleed from a pri-
mary aneurysm who have an incidental anterior cerebral
aneurysm may have a somewhat more virulent disease
process and we routinely recommend securing both le-
sions, usually in the acute phase after SAH to permit more
aggressive therapy for delayed ischemic complications
from vasospasm should they occur.
Patients presenting with SAH from a distal anterior
cerebral artery aneurysm are managed in the same fash-
ion as our other aneurysm patients. Those in good clini-
cal grade (alert or only slightly drowsy) are operated upon
on the first elective operative day to minimize the risk of
rebleeding and to permit maximal therapy for vasospasm.
Those patients in poor grade (obtunded or comatose) are
treated medically until their neurological status improves.
An exception to this general strategy occurs in the patient
whose depressed level of consciousness is attributable to
an intraparenchymal or intraventricular hematoma. We
recommend early craniotomy with aneurysm clipping and
hematoma evacuation in that setting.
PREOPERATIVE PREPARATION
Patients being prepared for a craniotomy for a distal ante-
rior cerebral aneurysm undergo the same regimen as that
used for a patient with any other aneurysm. If SAH has
occurred, normovolemia and normotension are supported
by placing a central venous catheter in patients with a
healthy cardiovascular system and by placing a Swan-
Ganz catheter in those with significant cardiac dysfunc-
tion. Crystalloid and colloid solutions are administered
with a target central venous pressure (CVP) of 10-12 torr
in the former group and a pulmonary capillary wedge
pressure (PCWP) of approximately 10-15 torr in the lat-
ter group. If acute hydrocephalus is present and well tol-
erated neurologically, it is left untreated to avoid the risk
of destabilizing the transmural gradient. If the patient
deteriorates due to the hydrocephalus, a ventriculostomy
is placed contralateral to the planned craniotomy and cere-
brospinal fluid (CSF) is allowed to drip off at a drainage
height of 15-20 cm.
Corticosteroids are administered as standard prophy-
laxis for potential cerebral retraction injury and are con-
tinued for three to five days postoperatively, particularly
if temporary arterial occlusion is used and etomidate has
been used for cerebral metabolic suppression. This agent
114
has been associated with transient impairment of endog-
enous cortisol production. We use a standard dose of dex-
amethasone, 4 mg intravenously, every 6 hours. Appro-
priate gastric prophylaxis is given throughout the steroid
course.
Although the value of anticonvulsant prophylaxis is
questionable in terms of seizure prevention, the hazards
of a generalized seizure in the acute SAH period is very
significant due to the risk of precipitating rebleeding or
aspiration. It is our routine to administer a loading dose
of Dilantin intravenously followed by 100 mg every eight
hours. We also administer perioperative antibiotic cover-
age consisting of nafcillin, or vancomycin in the penicil-
lin-allergic patient. Antibiotics are given on call to the
operating room and are continued for 24 hours postop-
eratively. Antifibrinolytic therapy has been shown to de-
crease the incidence of early aneurysmal rebleeding but
to increase the incidence of ischemic deficits from va-
sospasm. We prefer to use E-aminocaproic acid only in
patients who are in poor neurologic grade or unstable
medical condition in whom a significant delay in aneu-
rysm clipping is anticipated. For those patients in whom
early operation is planned, we usually do not initiate this
type of therapy.
SURGICAL TECHNIQUE
Anesthesia
Anesthetic management of patients with distal anterior
cerebral aneurysms is similar to that used for patients with
aneurysms at other sites. In addition to the vascular ac-
cess provided by the use of a CVP or Swan-Ganz cath-
eter, as discussed above, at least one other 16-gauge
venous catheter and one 14-gauge catheter are placed
peripherally. A radial arterial catheter is also placed. If
CSF evacuation is thought to be mandatory due to known
brain edema or hydrocephalus, a ventriculostomy or spi-
nal drain is placed. When a pterional craniotomy is to be
used for a proximal anterior cerebral aneurysm or for an
associated lesion, we prefer to puncture the ventricle us-
ing landmarks as follows: an equilateral right triangle with
sides of 2.5 cm is constructed with one edge at the sphe-
noid ridge and the other edge resting on the distal sylvian
fissure. The hypotenuse of this triangle therefore rests on
the sylvian fissure. The frontal lobe is punctured perpen-
dicularly at a site identified by the vertex of this triangle.
When pterional exposure is not contemplated, a contralat-
eral frontal ventriculostomy or spinal drain is placed.
Electroencephalographic (EEG) activity is monitored bi-
laterally by needle scalp electrodes with a frontal elec-
trode placed above the brow and a posterior lead in the
mastoid region.
 BATJER AND SAMSON : DISTAL ANTERIOR CEREBRAL ARTERY ANEURYSMS
We prefer a normotensive, normovolemic balanced
anesthetic with sodium thiopental (3-5 mg/kg) induction.
If significant cardiovascular disease is present we use
etomidate (0.3 mg/kg) intravenously for induction. Muscle
relaxation is accomplished with vecuronium followed by
curare/pancuronium for maintenance. Maintenance an-
esthesia consists of isoflurane (0.5-2.5%), nitrous oxide
(65%), and oxygen (35%). Mannitol (1.0 g/kg) is infused
rapidly intravenously at the time of scalp incision to as-
sist with brain relaxation.
If temporary arterial occlusion becomes necessary,
etomidate (1.0 mg/kg) is administered to achieve EEG-
documented burst-suppression. This medication is then
continued at a rate of 10 µg/kg/min until arterial flow is
restored. During this interval isoflurane is continued at a
dose of 0.4%, and 100% O2 is administered. Mannitol
(0.25 g/kg) is infused rapidly immediately prior to arte-
rial occlusion. Additionally, the pCO2 is normalized and
the blood glucose level is monitored carefully and kept in
the 90-100 mg % range by insulin drip if necessary. Strict
normotension is assured during this time to maximize
collateral flow.
Positioning
Specific aspects of patient positioning are critically depen-
dent on two major concerns: 1) other associated aneurysms
and the determination of which lesion bled; and 2) the por-
© 1992 The American Association of Neurological Surgeons
Figure 1. Aneurysms of the distal anterior cerebral artery arising within
1.5 cm of the A2 origin may be approached by a conventional pterional
craniotomy with the head rotated 45-60° as in the exposure of the ante-
rior communicating region. The scalp incision (dashed line) begins 5-
10 mm anterior to the tragus and extends superiorly, curving gently an-
115
tion of the distal anterior cerebral artery on which the an-
eurysm resides. The primary goal of the initial craniotomy
in a SAH case is to secure the ruptured lesion. However,
subsequent hyperdynamic therapy, if it becomes necessary
due to developing ischemia from vasospasm, can jeopar-
dize unclipped lesions. As a general rule, we attempt to
secure as many of the aneurysms as possible at the primary
procedure. Regrettably, most aneurysms associated with
distal anterior cerebral artery lesions involve the middle
cerebral artery or the internal carotid artery and therefore
usually require a separate microsurgical exposure. In gen-
eral, we position the patient optimally for securing the rup-
tured lesion and then manipulate the head holder to opti-
mize exposure of secondary lesions. When an anterior
communicating artery aneurysm occurs with a more distal
anterior cerebral lesion, both aneurysms are approached
interhemispherically. Although we usually prefer a right-
sided approach (nondominant), the presence of associated
aneurysms requiring a left pterional craniotomy mandate
the performance of a second left parasagittal craniotomy
to approach the distal anterior cerebral lesion.
Aneurysms arising from the first 1.0-1.5 cm of
the A2 segment can be very reasonably approached
through a pterional exposure which simply extends
the gyrus rectus resection used in the typical approach
to the anterior communicating artery (Fig. 1). As a
r ule we place a small shoulder roll under the
teriorly to the midline and remains immediately posterior (if possible)
to the normal hairline. The craniotomy is performed with three burr
holes: 1) a burr hole at the “key” or just superior to the frontozygomatic
suture, 2) an inferior temporal burr hole, and 3) a posterior temporal
burr hole just inferior to the superior temporal line.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
ipsilateral shoulder of the supine patient and rotate the
head to the left side by 45-60°. The neck is then slightly
flexed, bringing the chin toward the contralateral clavicle
to orient the plane of the floor of the anterior cranial fossa
perpendicular to the long axis of the patient’s body. This
subtle maneuver allows the seated surgeon easier visual-
ization of the basal subarachnoid space without forcing
him or her to encroach on the patient’s elevated shoulder.
The head is then extended (tilted) so that the maxillary
eminence rises superior to the brow.
An aneurysm arising from the origin of the
frontopolar or callosomarginal artery which lies inferior
to the genu of the corpus callosum is optimally exposed
through a low right frontal parasagittal craniotomy. The
patient is positioned supine and the head placed in a neu-
tral position. The neck is then extended about 15° to pro-
vide the seated surgeon with a comfortable interhemi-
spheric approach parallel to the floor of the anterior cranial
fossa (Fig. 2).
When the distal anterior cerebral artery aneurysm
arises from the origin of the callosomarginal artery and is
in close relationship to the genu of the corpus callosum,
the patient is positioned supine with the head exactly neu-
tral (Fig. 3). This position, when used with a slightly higher
parasagittal craniotomy (centered halfway between the
nasion and bregma), allows a comfortable interhemi-
© 1992 The American Association of Neurological Surgeons
116
spheric exposure of the callosal cistern in the region of
the genu.
For unusual aneurysms arising posterior to the genu
involving the horizontal segment of the anterior cere-
bral artery, the patient is positioned supine and the neck
is flexed slightly to optimize the surgeon’s exposure of
the aneurysm (Fig. 4). This subtle alteration increases
the susceptibility of the patient to venous air embo-
lism and mandates anesthetic monitoring and central
venous access.
Skin Incision and Craniotomy
Performance of appropriate scalp and bone incisions must
take into consideration several concerns: associated aneu-
rysms, the location of the distal anterior cerebral aneurysm
relative to the genu of the corpus callosum, and the posi-
tion of the ascending frontal bridging veins entering the
superior sagittal sinus. While a “vein-free” exposure of 2.0-
2.5 cm is probably ideal for interhemispheric exposures,
the exact position of the bone flap should be adjusted to
minimize the risk that large veins may be injured during
retraction. The presence of an associated aneurysm of
the internal carotid or middle cerebral artery with an
anterior cerebral aneurysm requiring interhemispheric
exposure would necessitate two separate bone flaps. Our
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.
 BATJER AND SAMSON : DISTAL ANTERIOR CEREBRAL ARTERY ANEURYSMS

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

117
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
the ruptured aneurysm and to perform both craniotomies
but only open the dura at the primary site. After the rup-
tured lesion is treated, the assistant adjusts the head posi-
tion and the secondary aneurysm is approached. Specific
details of the skin incision and craniotomy will focus on
the four anatomical sites illustrated in Figures 1-4.
For approaching those proximal A2 aneurysms aris-
ing from the orbital branch origins as shown in Figure 1,
we utilize a standard frontotemporal scalp incision be-
ginning 5-10 mm anterior to the tragus at the level of the
zygoma. The incision extends superiorly and anteriorly,
remaining posterior to the hairline whenever possible and
terminating at the midline. Recent experience with the
interfascial opening as described by Yasargil appears to
be yielding superior cosmetic results and seems to mini-
mize temporalis atrophy. The craniotomy is performed
with three burr holes: 1) the first hole is placed at the
“key” or just superior to the frontozygomatic suture, 2)
the second hole is placed inferiorly on the temporal
squama, and 3) the third hole is placed temporally at the
posterior aspect of the exposure just inferior to the supe-
rior temporal line. This final burr hole can later be cov-
ered well by closing the temporalis muscle and fascia.
Power instruments are then used to cut a generous fronto-
temporal craniotomy with care to extend the anterior as-
pect of the bony removal to the brow at the midpupillary
line (Fig. 1). The sphenoid ridge is then resected with
rongeurs and the posterior table of the frontal bone is re-
moved with a high-speed drill to maximize access to the
skull base (Fig. 5A).
In treating aneurysms arising from the infracallosal
portion of the distal anterior cerebral artery (Fig. 2) our
preferred scalp incision is either a true bicoronal incision
or one that terminates 2.0-2.5 cm above the zygoma on the
contralateral side. The parasagittal craniotomy is centered
about one-third of the way between the nasion and bregma
and is approximately 4.0 × 4.0 cm in size. The hand perfo-
rators are used to perform the two midline burr holes and a
Gigli saw is used to connect them to avoid risk to the supe-
rior sagittal sinus. When a particularly “tight” brain is an-
ticipated due to an underlying parenchymal hematoma or
edema, a somewhat larger bone flap should be used and
the flap can be extended across the midline.
Aneurysms arising from the callosomarginal artery
origin in the region of the genu are the most common
distal anterior cerebral aneurysms (Fig. 3). We prefer to
use a modified bicoronal scalp incision extending from
the ipsilateral zygoma across the midline to the contralat-
eral superior temporal line, remaining behind the hairline
in its entirety. The craniotomy is roughly 4.0 × 4.0 cm
and is centered midway between the nasion and bregma.
As in all parasagittal craniotomy flaps, the midline burr
118
holes should be placed with hand instruments and care-
fully connected with a Gigli saw.
Distal pericallosal artery aneurysms occurring poste-
rior to the genu are also best approached interhemispherically
(Fig. 4). The exact site of the scalp incision and craniotomy
is determined by the specific site of the aneurysm and the
details of the venous anatomy. Every attempt should be made
to avoid retraction on the motor cortex. In general, we prefer
a broad-based parasagittal scalp flap hinged laterally and
crossing the midline. Since many of the aneurysms in this
site are traumatic, any fractures in the region should man-
date a craniotomy flap crossing the midline so that any asso-
ciated superior sagittal sinus injury can be controlled. In more
routine cases, a parasagittal craniotomy extending to the
midline is preferred with the usual precautions to avoid si-
nus injury.
Microsurgical Procedure
The microsurgical steps involved in treating distal ante-
rior cerebral artery aneurysms may be divided by target
location into those requiring pterional exposure and those
requiring interhemispheric exposure. Due to the similar-
ity of dissection techniques used interhemispherically
regardless of how the aneurysm relates to the genu, the
technical discussion will be illustrated by those aneurysms
in proximity to the genu.
Pterional Approach
The initial exposure of those aneurysms involving the
proximal 1.5 cm of the A2 segment is identical to that
well known for the anterior communicating complex with
the exception that our preference is to expose the lesion
from the left side if it arises from the left anterior cerebral
artery. This discussion will illustrate a right proximal A2
aneurysm.
Under microscopic visualization, a self-retaining
brain retractor is gently inserted along the orbital surface
of the frontal lobe just anterior to the sylvian fissure. The
retraction is deepened while the surgeon has clear visual-
ization of the bony sphenoid ridge. This bony landmark
ensures that the surgeon will arrive at the carotid cistern
and not inadvertently stray too far anterior. Once the re-
tractor is advanced to the point of visualization of the
optic nerve, it is stabilized just lateral to the nerve and
gently depressed, placing the arachnoidal tissue of the
medial sylvian fissure and carotid cistern on stretch. The
fibers of the medial fissure are then opened sharply and
this incision is directed medially, opening the carotid
cistern, severing the adhesions binding the optic nerve
to the gyrus rectus, and opening the prechiasmatic cis-
tern in sequence (Fig. 5B). This maneuver drains addi-
tional CSF and should accomplish adequate brain re-
 BATJER AND SAMSON : DISTAL ANTERIOR CEREBRAL ARTERY ANEURYSMS

© 1992 The American Association of Neurological Surgeons

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

119
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
© 1992 The American Association of Neurological Surgeons
Figure 5. (Continued) D, after the right A1 segment enters the inter-
hemispheric fissure, the arachnoid binding the left optic nerve to the
left gyrus rectus is opened. Exploration of this cistern will reveal the
left A1 segment. E' and E", the retractor blade is withdrawn to the level
of the olfactory tract allowing “herniation” of the gyrus rectus over the
tip of the retractor. This tissue is opened and aggressively resected down
to the pia-arachnoid of the interhemispheric fissure. The anterior com-
municating complex and ipsilateral A2 can be seen through this tissue
layer. F, dissection is carried distally on the A2 segment, exposing the
120
often angiographically inapparent orbital branches. The aneurysms in
this region usually arise just distal to the involved branch. Once the
proximal neck is seen, the healthy portion of the A2 wall is followed
distally to the point of its departure from the aneurysm, ensuring com-
plete anatomical control of the aneurysm. G, for small aneurysms of the
proximal A2, a conventional direct clipping may be performed perpen-
dicular to the parent vessel. For broad-based or large aneurysms, how-
ever, temporary trapping should be performed with a more parallel clip
application to avoid shearing or clip-induced stenosis.
 BATJER AND SAMSON : DISTAL ANTERIOR CEREBRAL ARTERY ANEURYSMS
laxation. The retractor is then moved slightly medially
and the gyrus rectus is elevated from the optic nerve. The
stretched arachnoidal adhesions are then severed and pro-
gressive deepening of this dissection medially will ex-
pose the ipsilateral Al segment. Once this key landmark
is exposed it is circumferentially dissected as a prepara-
tory measure for the placement of a temporary clip in the
event of early operative rupture (Fig. 5C). The recurrent
artery of Heubner will be found superior and posterior to
the Al segment and this fragile vessel should be protected
carefully. The Al segment is then carefully followed me-
dially and anteriorly along its course toward the interhemi-
spheric fissure. The A1 segment is left when it is seen to
curve sharply superiorly into the interhemispheric fissure.
The arachnoid binding the left optic nerve to the con-
tralateral gyrus rectus is then severed sharply and the sub-
arachnoid space explored until the contralateral A1 seg-
ment is seen (Fig. 5D). At this point, proximal control is
achieved.
The retractor is then withdrawn to the level of the
olfactory tract, allowing a 4-5-mm width of gyrus rec-
tus to “herniate” over the retractor blade, obscuring the
anterior communicating region. A generous portion of
the medial gyrus rectus is then cauterized, opened, and
subpially resected (Fig. 5E). This tissue is resected some-
what more anteriorly and superiorly than normally
resected for exposure of an anterior communicating ar-
tery aneurysm. The pia-arachnoid is then sharply
resected, exposing the ipsilateral Al-A2 junction, the an-
terior communicating artery and the origin of the re-
current artery of Heubner (usually from the lateral as-
pect of the proximal A2 segment). The thorough
dissection of the ipsilateral A2 segment provides defini-
tive proximal control and should be used in the event of
hemorrhage to preserve flow in the contralateral ante-
rior cerebral territory. The retractor is then gently de-
pressed to expose the gyrus rectus and arachnoid ob-
scuring the A2 as it progresses anterosuperiorly.
Additional gyrus rectus is resected if necessary as the
vessel is followed distally. The origin of the orbital
branches should be treated carefully as the aneurysm
typically arises immediately distal to this origin. Once
the proximal neck is isolated, the dissection follows the
healthy portion of the A2 segment until it emerges from
the aneurysmal segment (Fig. 5F). At this moment, proxi-
mal and distal control of the aneurysm has been achieved
and the vessel should be widely dissected for placement
of a distal temporary clip if needed. The interhemispheric
fissure is then explored to isolate the left A2 segment so
that it will not be inadvertently caught by a clip.
The aneurysms in this region usually project anteri-
orly and therefore usually present the surgeon with a clear
121
line of sight for passage of a straight or curved clip per-
pendicular to the parent vessel. For small aneurysms this
is an acceptable alternative (Fig. 5G) but in broad-based
or large aneurysms the resulting “gathering” of the A2
segment as the clip closes may place undue shearing
stresses on the neck itself and may foreshorten the artery,
producing a true stenosis. If this appears likely, tempo-
rary clips may be applied proximal and distal to the aneu-
rysm under metabolic brain protection. The aneurysm can
then be deflated and mobilized out of the interhemispheric
fissure, permitting a clip placement parallel with the long
axis of the parent vessel.
Interhemispheric Approach
For aneurysms arising more distally on the anterior cere-
bral artery, an interhemispheric approach is mandatory.
Regardless of the relationship of the target aneurysm to
the genu, the lesions approached interhemispherically rep-
resent exceptions to classical vascular principles of early
acquisition of proximal arterial control. In general, the
distal parent artery is dissected first followed by careful
dissection past the aneurysm to the proximal vessel. In
addition, these lesions have a tendency to be small in di-
ameter yet relatively broad-based with some involvement
of the wall of the branch of origin. These anatomical char-
acteristics make it frequently difficult to achieve the ideal
goals of perfect aneurysm clipping without stenosis of
any afferent or efferent branch.
After a parasagittal craniotomy is performed as de-
scribed above (Fig. 3), the dura is opened in a stellate
fashion so that the medial dural flap may be reflected over
the superior sagittal sinus with care not to induce steno-
sis. This maneuver optimally exposes the medial aspect
of the frontal lobe as it plunges into the interhemispheric
fissure (Fig. 6A). Under microscopic visualization, the
lobe is gently dissected from the falx so that the surgeon
can investigate the status of medially bridging veins. Ide-
ally, a working space of 2 cm should be developed be-
tween bridging veins and care should be taken to pre-
serve all sizable veins. Vein sacrifice either purposeful or
by aggressive retraction can set the stage for postopera-
tive venous hemorrhagic infarction.
The self-retaining retractor is gently inserted medial to
the frontal cortex, initially using the falx as a guide. The falx
has a variable depth anteriorly and soon the surgeon will
reach the inferior edge (Fig. 6B). Acquisition of this refer-
ence point is frequently misinterpreted as heralding the iden-
tification of the corpus callosum. This costly error may lead
the surgeon to aggressively manipulate the cingulate gyri
which are usually densely adherent. Due to the fact that the
aneurysms in this region are often embedded in one or
both cingulate gyri, aggressive manipulation or re-
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
© 1992 The American Association of Neurological Surgeons
Figure 6. Interhemispheric approach to distal anterior cerebral artery an-
eurysm. A, following a parasagittal craniotomy, the dura is opened and
the medial flap is sutured over the superior sagittal sinus. The resulting
exposure allows the surgeon to inspect the medial frontal cortex for bridg-
ing veins. A working space of 2.0 cm should be developed between bridg-
ing veins. B, as the brain retractor is inserted medial to the frontal lobe the
122
falx serves as an excellent early landmark. Discovery of its inferior edge
does not herald the region of the corpus callosum. The cingulate gyri are
usually densely adherent beneath this point. C, meticulous sharp dissec-
tion should be used to divide the adhesions and occasionally small veins
obscuring the potential space between the two cingulate gyri. Great care
should be exercised to avoid the subpial plane of dissection.
 BATJER AND SAMSON : DISTAL ANTERIOR CEREBRAL ARTERY ANEURYSMS
© 1992 The American Association of Neurological Surgeons
Figure 6. (Continued) D, identification of the transverse arachnoidal bands
of the cistern of the corpus callosurn marks the initial entrance into the
subarachnoid space. The efferent pericallosal vessels will be seen within
this cistern. E, sharp microdissection from distal to proximal along both
pericallosal arteries should be confined to the inferior aspect of the vessel
as the aneurysm and callosomarginal origins are usually located superi-
orly. The pericallosal arteries will be seen to dive inferiorly at the genu
123
and this landmark usually signals acquisition of proximal control. F, dis-
section from proximal to distal along the anterior surface of the anterior
cerebral artery will disclose the origin of the callosomarginal artery. This
vessel defines the proximal neck of the aneurysm and should be carefully
mobilized from the neck. G, the medial aspect of the aneurysm neck is
defined by gently sectioning arachnoidal bands between the healthy
pericallosal artery and the aneurysm sac.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

© 1992 The American Association of Neurological Surgeons

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

124
 BATJER AND SAMSON : DISTAL ANTERIOR CEREBRAL ARTERY ANEURYSMS
traction may avulse the underlying aneurysm. Rather than
move aggressively at this point, the surgeon is better ad-
vised to meticulously divide the multitudinous arachnoi-
dal adhesions between the cingulate gyri. Frequently, nu-
merous small veins similarly obscure the development of
this potential space and often appear to bridge the hemi-
spheres. When necessary, these small veins maybe sacri-
ficed to ensure that the surgeon remains within the inter-
hemispheric fissure and does not enter the potentially
disastrous subpial plane (Fig. 6C). Methodical expansion
of the anterior to posterior working space available be-
tween the cingulate gyri will be rewarded by dramatically
increased visibility in subsequent phases of the dissec-
tion.
The appearance of transversely coursing dense arach-
noidal bands at the inferior aspect of the cingulate gyrus
marks the initial identification of the cistern of the cor-
pus callosum (Fig. 6D). Once this cistern is identified,
gentle suction removal of subarachnoid clot will reveal
the pericallosal vessels. A common mistake is to dissect
only one vessel and assume it is the ipsilateral pericallosal
artery, only to discover later that the apparent A2 repre-
senting proximal control does nothing to abate hemor-
rhage when temporarily occluded in the event of intraop-
erative aneurysm rupture. This error can be avoided by
meticulously identifying both pericallosal arteries.
At this point, if substantial frontal lobe or ventricu-
lar hematoma is causing the exposure to be confining, a
small cortical incision may be made to partially decom-
press the brain. The goal of this maneuver is only to in-
crease working space and not to totally evacuate the he-
matoma. It should never be forgotten that the ruptured
part of the sac is encased by the apex of the hematoma.
The goal of the dissection at this point is to assure
proximal arterial control while manipulating the aneurysm
as little as possible. As the dissection proceeds proximally
on the pericallosal vessels it is important to expand the
exposure so that the course of both right- and left-sided
vessels is seen and understood. This knowledge will pre-
vent disaster should urgent clipping become necessary.
Inadvertent clipping of a fragile anterior cerebral artery
with a permanent clip even if recognized and corrected
will often fracture the intima and lead to thrombosis. For
lesions arising at the genu of the corpus callosum, a help-
ful dissection technique is to remain on the inferior sur-
face of the pericallosal vessels as the dissection pushes
proximally. The aneurysm and callosomarginal artery typi-
cally arise from the anterior or superior aspect of the ves-
sel wall and remaining inferiorly will allow safe access to
the vessel proximal to the aneurysm as the anterior sur-
face of the genu is reached (Fig. 6E). Once the proximal
125
trunks are seen bilaterally, the vessel associated with the
aneurysm should be carefully prepared for temporary
occlusion should this become necessary.
The progressive delineation of the aneurysm com-
plex can now be accomplished by following the anterior
surface of the proximal anterior cerebral as it proceeds
distally along the genu. The aneurysms at this site almost
invariably arise distal to the origin of the callosomarginal
artery and the first anatomical detail noted on the ante-
rior vessel wall will be the callosomarginal artery (Fig.
6F). Successful dissection of this vessel must be done
concurrently with dissection of the proximal aneurysmal
neck. Once this plane is established, the margin of the
aneurysm from the parent pericallosal artery is followed
from proximal to distal, keeping the demarcation in mind
between healthy and unhealthy tissue (Fig. 6G). This plane
of dissection will ultimately free the distal aspect of the
aneurysm neck (Fig. 6H).
Once final neck dissection is performed several de-
cisions must be made. The surgeon must determine
whether clip placement should be perpendicular or paral-
lel to the pericallosal artery and whether or not tempo-
rary clipping would be beneficial. The fact that many of
these lesions are small and broad-based and that the
pericallosal artery is quite small suggests that not infre-
quently a perpendicular clipping will “accordion” the
parent trunk, inducing significant stenosis. (Fig. 6I). When
the vessel appears compromised, it is. Microvascular
Doppler measurements are very sensitive in detecting criti-
cal stenosis and should be used if the surgeon contem-
plates leaving the clip in place. If it is apparent that this
type of clip placement will be unsatisfactory, a more physi-
ologic approach is to reconstruct the parent artery in par-
allel. Additional dissection along the lateral aspect of the
aneurysm neck is required to mobilize the lesion into the
interhemispheric fissure (Fig. 6J). There is little reason
to avoid the use of temporary arterial occlusion for brief
intervals in this anatomic site, particularly if pharmaco-
logic brain protective regimens and normotensive anes-
thesia are being used. This maneuver can allow orderly
deflation of the aneurysm with final dissection and de-
finitive clipping and represents the most secure means of
avoiding rupture during clip application (Fig. 6K). We
strongly recommend complete temporary trapping by clip-
ping the A2, callosomarginal, and pericallosal vessels with
aneurysm aspiration as opposed to simple proximal clip-
ping of the A2. Should bleeding develop in the latter cir-
cumstance, the surgeon suctions retrograde collateral sup-
ply through the surgical tubing as the wound is cleared.
The distal anterior cerebral vessels are particularly
vulnerable to reactive spasm due to manipulation. Af-
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
ter aneurysm clipping generous application of papaver-
ine should be used to reverse this process.
Closure
The closure of both types of distal anterior cerebral
wounds should not differ from standard neurosurgical
practice. We routinely close the dura in a watertight fash-
ion and replace the bone flap. The temporalis muscle and
fascia are closed in the pterional procedures and the galea
is closed as a separate layer in all patients. We routinely
use scalp staples now and have been pleased with the he-
mostatic and cosmetic results. Epidural drains are used
when any question of hemostasis is present.
COMPLICATIONS
The degree of brain retraction necessary to treat distal
anterior cerebral aneurysms is not insignificant and the
risk to frontal bridging veins is constant. We advocate a
126
follow-up CT scan within 24 hours of the procedure in all
patients to look for edema or venous infarction.
Vasospasm remains the leading cause of morbidity
following SAH. Fortunately, patients with distal anterior
cerebral artery aneurysms usually do not have diffuse thick
clot in the basal cisterns which would predispose to life-
threatening vasospasm. Rather, the clot is either focally
interhemispheric or within the brain parenchyma or ven-
tricle. Therefore, the chief ischemic risk is to the distal.
anterior cerebral territory. Hyperdynamic therapy to date
remains the most reliable means of medically palliating
this condition. When hypervolemia and hypertension fail,
the interventional radiologist may have some success in
these distal vessels but in our experience, they have been
much more successful in the proximal subarachnoid ves-
sels. Perhaps early operation, clot removal, and subarach-
noid thrombolytic therapy will minimize this complica-
tion in the future.
 TETHERED SPINAL CORD,
INTRAMEDULLARY SPINAL LIPOMA,
AND LIPOMYELOMENINGOCELE
W. JERRY OAKES, M.D.
INTRODUCTION
Progressive dysfunction of the spinal cord may be caused
by fixation or by distortion from a neoplasm. This chap-
ter focuses on three congenital entities that cause symp-
toms by different mechanisms. The patient with a teth-
ered spinal cord develops symptoms from tension of a
thickened and taut filum terminale on the distal cord. In-
tramedullary spinal lipomas distort the surrounding cord
but do not have a component of fixation that causes the
neurologic deterioration. The lipomyelomeningocele has
components of both cord fixation and distortion, which
is thought to be the underlying explanation for the pro-
gressive loss of neurologic function associated with this
lesion. Because the surgical approaches to these lesions
are quite different they will be discussed separately.
TETHERED SPINAL CORD
The concept that fixation of the distal spinal cord by a
thickened filum terminale can cause progressive spinal
cord dysfunction has become accepted during the last 40
years. Surgical procedures to section the filum have only
become common in the past 20 years. The dysfunction of
the cord occurs from a combination of repeated small in-
juries or contusions as the cord is put under tension with
movement (especially spinal flexion) and by vascular com-
promise. The change in the superficial vasculature of the
cord as well as its disturbed ability to metabolize oxygen
have been demonstrated both in laboratory animals and
in humans. The vascular changes which occur with ten-
sion of the cord seem to improve following release of the
tension.
Patients may present for clinical attention with a va-
riety of complaints. One group of patients will present
for clinical attention only as a result of cutaneous evi-
dence of occult spinal dysraphism. This may take the form
© 1992 The American Association of Neurological Surgeons
127
of a flat capillary hemangioma or a small dermal append-
age. When one of these cutaneous findings is present, it
demands further investigation. Occasional patients may
have a flat capillary hemangioma with normal intradural
anatomy; however, a significant percent will have a teth-
ered spinal cord. Waiting for the patient to demonstrate
clinical findings of a neurogenic bladder is likely to re-
sult in a fixed neurogenic deficit which is not reversible
with surgical intervention. Prevention of further bladder
dysfunction by early investigation and prophylactic sur-
gery is warranted.
Commonly, the initial clinical symptom in patients
with the tethered cord syndrome is the gradual and pro-
gressive loss of coordinated bladder activity. This may
become manifest as repeated bouts of urinary infection
or primary or secondary urinary incontinence. These uri-
nary symptoms may be combined with evidence of spas-
ticity of the lower extremities. The lower extremity in-
volvement is frequently a combination of hyperactive deep
tendon reflexes with upgoing toes and muscle wasting,
fasciculations, and shortened foot or leg length. The com-
bination of upper and lower motor neuron disturbance in
the lower extremities is the signature of this problem. Even
though the tension could be thought to be relatively sym-
metric on the distal cord, the leg findings are typically
asymmetrical. Rectal incontinence is usually delayed un-
til late in the course. Nonradicular pain in the back and
legs may be the primary cause of presentation in the adult
population. Occasional precipitous deterioration has been
recognized. Sudden lower spinal flexion as in patients
assuming the lithotomy position under anesthesia has re-
sulted in dramatic worsening and even abrupt onset of
paraplegia in occasional patients.
In 10-20% of patients with congenital anorectal
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
bladder and to improve the neurologic input into the
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

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.

128
OAKES : TETHERED SPINAL CORD, INTRAMEDULLARY SPINAL LIPOMA, AND LIPOMYELOMENINGOCELE
nale. The dura is opened in the midline and the arachnoid
opened somewhat off the midline. The arachnoid is then
clipped to the opened dura. The thickened filum can be
recognized by the infiltration of fat within it, by its midline
dorsal position, and by the size differential between this
structure and the surrounding thin delicate roots which exit
in a ventrolateral direction. Once the filum is identified it
is carefully separated from all adherent nerve roots, par-
ticularly those on the ventral surface (Fig. 2A). One must
rotate the cord to visualize the undersurface and to ensure
that no small roots are left adherent to the capsule of the
filum. Once inspected, the filum is electrically probed with
insulated stimulating hooks to ensure that there is no neu-
ral structure influencing urethral or rectal function con-
tained within its structure (Fig. 2B). When this is confirmed
the filum is coagulated and cut (Fig. 2C). This is done at
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
the two ends of the filum will not adhere to one another.
The amount of recoil of the proximal filum is frequently
unimpressive. Care is taken to ensure a watertight closure
© 1992 The American Association of Neurological Surgeons
Figure 2. A, axial views through the sacrum before and after the adher-
ent roots ventral to the thickened filum terminale have been dissected.
B, intraoperative stimulation of the distal filum is being performed to
129
of the dura and the superficial soft tissues. Patients are rou-
tinely nursed flat for five days to allow adequate dural heal-
ing without the additional tension of orthostatic force of
the cerebrospinal fluid (CSF).
Results with regard to blunting of the previous rate
of loss of neurologic function are quite favorable. The
ability to restore lost function, particularly bladder syn-
ergy, is poor. Relief of pain and sensory loss is gratifying.
Progressive moderate scoliosis may be arrested. Restora-
tion of motor function is less likely than sensory improve-
ment or the relief of pain. Urologic dysfunction, which is
the most common cause of clinical presentation, remains
the least likely to improve once it is firmly established.
The likelihood of adherence of the cut ends of the
filum is extremely small. Long-term complications are
rarely seen.
INTRAMEDULLARY SPINAL LIPOMA
Intramedullary fat which accumulates under the pia of
the spinal cord may cause the patient to present for
clinical attention with chronic myelopathy or pain.
exclude the presence of neural tissue important to urethral or rectal func-
tion prior to the planned sectioning. C, the initial section through the
filum terminale showing fat in the center of the filum.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
These are rare congenital lesions which may lay dormant
for many years or decades. They are not associated with
spina bifida occulta and are relatively evenly distributed in
the cord. There is a predilection for involvement of the dorsal
aspect of the cord but the fat is not connected with a defect
of the arachnoid, dura, laminae, or skin. When symptom-
atic, these lesions are approached as any other intramedul-
lary tumor with a laminectomy over the involved area. Us-
ing an ultrasonic aspirator or a CO2 laser at very low
wattage, the fat can be removed and the fibrous septa be-
tween the various compartments of fat can be disrupted. If
significant septation is present, the ultrasonic aspirator will
prove to be much less effective than the carbon dioxide
laser. The cord may be reconstructed into a tube following
the resection of the fat and the redundant dura is closed
primarily and tented dorsally in an effort to prevent adhe-
sion from the resection site to the undersurface of the dura.
The outlook for these patients is a function of the
degree of neurologic disability prior to surgery and the
success of the resection.
LIPOMYELOMENINGOCELE
Subcutaneous fatty tumors over the midline lumbosacral
region usually emerge through a fascial, bony, or dural
defect and ultimately involve the caudal spinal cord. These
lesions are best described by where they grow into the
cord (dorsal or caudal). Lipomyelomeningoceles are part
of the larger group of conditions termed occult spinal
dysraphism and may be found in conjunction with di-
astematomyelia, tethered spinal cord, or other forms of
this broader group. They do seem to have an enhanced
genetic predisposition and may be associated with a Chiari
I malformation or occasionally hydrocephalus. The spe-
cial circumstance of a fatty mass associated with a termi-
nal syringohydromyelia will be discussed later.
Symptoms related to these lesions range from a cos-
metic presentation at birth with a significant subcutane-
ous fatty mass in the midline over the lumbosacral region
to a subtle subcutaneous lipoma associated with primary
or secondary urinary incontinence. It is unusual today to
have children present primarily with evidence of pain or
motor disturbance involving the lower extremities. In large
part this is due to an increased awareness of the progres-
sive natural history of this lesion and the ease of confir-
mation of spinal cord involvement by MRI. Decreased or
absent rectal tone combined with a neurogenic bladder is
a clinical indication of lower sacral root involvement from
a neurogenic cause and should be investigated further.
Today the procedures of choice to confirm the patho-
logic anatomy are MRI and x-ray films of the lumbar spine.
These two modalities have almost totally replaced CT
130
myelography. Additional useful information can be ob-
tained from urodynamic testing and occasionally from
electromyography of the lower extremities.
The natural history of patients with a lipomyelomen-
ingocele is a progressive loss of neurologic function. Oc-
casional exceptions to this natural history can be demon-
strated but the vast majority of infants followed
prospectively without operative treatment will develop
progressive and relentless deterioration. Few would doubt
that prophylactic surgery in early infancy is justified. If
there is any hope of preventing the development of a fixed
urodynamic deficit it lies in early intervention. Surgical
exploration should include release of the traction on the
cord and resection of a significant amount of the in-
tramedullary lipoma. Reversal of bladder dysfunction is
unlikely once it is established and for that reason alone
early aggressive surgery is logical and justified. It should
be mentioned that there is no place for a superficial exci-
sion of the subcutaneous lipoma without disturbing the
intradural contents. A superficial excision seriously com-
plicates the eventual intradural procedure by the devel-
opment of excessive adhesions.
A patient chosen for exploration of the lesion is po-
sitioned prone with soft supports under the iliac crest
and chest to allow free excursion of the abdomen. This
significantly lessens epidural bleeding. The hips are
flexed and, again, intraoperative rectal and urethral moni-
toring are quite helpful. The skin incision is made in the
midline directly over the subcutaneous mass and extends
both above and below the mass (Fig. 3A). A common
error is not to allow sufficient distal room for adequate
exposure of the lesion. For routine lesions it is neces-
sary to have access from the lower sacrum to two seg-
ments above the level of the fascial defect. The subcuta-
neous lipoma is almost always easily separable from the
lumbodorsal fascia and the skin. As the neck of the le-
sion is circumferentially developed, large amounts of su-
perficial lipoma may be excised, reducing the bulk of
the lesion. The neck of fat coursing through the fascial
defect is retained at this point (Fig. 3B). The soft tissues
and muscle adherent to the last intact spinous process
and laminae are reflected laterally (Fig. 3C). The muscles
and other soft tissues circumferentially adherent to the
rudimentary laminae surrounding the neck of the lesion
are also dissected. Immediately caudal to the last intact
laminae a band of fibrous tissue corresponding to the
periosteum of an incompletely formed bony element will
commonly be encountered. With section of this band the
dura may expand significantly into the area. This band
may be associated with acute angulation of the mal-
formed cord as it is drawn dorsally toward the
 OAKES : TETHERED SPINAL CORD, INTRAMEDULLARY SPINAL LIPOMA, AND LIPOMYELOMENINGOCELE

© 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.

131
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
subcutaneous lipoma. Sectioning this band may signifi-
cantly relieve the tension on the cord and reduce its pos-
terior angulation (Fig. 3C).
With adequate exposure of the dural tube cephalad
to the lipoma it is opened in the midline. Asymmetrical
exiting roots can then be seen. The junction of the dura
to the neck of the lipoma as it emerges through the dural
defect is a key landmark for further dissection. Special
© 1992 The American Association of Neurological Surgeons
Figure 4. A, a three-dimensional view of a lipomyelomeningocele dem-
onstrating the dura-lipoma complex and the position of the exiting dor-
sal roots. This relationship varies somewhat from patient to patient and
with the degree of rotation of the cord. B, a surgical view showing a
132
care must be given at this point to appreciate the rela-
tionship of the dorsal roots which have been displaced
laterally by the lipoma and the duralipoma complex
(Fig. 4A). Obviously, no roots should be sacrificed
and yet the dura needs to be circumferentially dis-
sected away from the dorsally displaced cord (Fig.
4B). The asymmetrical arrangement of exiting roots
combined with rotation of the cord may further
hooked knife being used to open the dura while the cord is rotated slightly
for better exposure of the dorsal roots. The upper part of the lipoma is
also being excised by the CO2 laser.
 OAKES : TETHERED SPINAL CORD, INTRAMEDULLARY SPINAL LIPOMA, AND LIPOMYELOMENINGOCELE
complicate this maneuver. Once this critical maneuver is
complete and the cord has moved into a relaxed ventral
position within the dura, attention is returned to the in-
tramedullary component of the lipoma. With the ultra-
sonic aspirator or the CO2 laser the lipoma is progres-
sively thinned until a small layer of fat remains against
the neural tissue. Dense septa coursing through the li-
poma limit the usefulness of the ultrasonic aspirator. This
is especially true in older children and adults. No attempt
is made to completely excise all fat, but the bulk of the
lesion is removed which then allows reconstitution of a
neural tube. This is done with fine inverted nonreactive
suture (Fig. 5). Attention is then directed to the filum
terminale which may be thickened. Again, it is separated
from surrounding exiting roots and sectioned.
The dura is reapproximated, allowing a capacious
CSF space dorsal to the newly formed neural tube. The
superficial soft tissues are reapproximated but not at the
expense of the dorsal CSF space.
© 1992 The American Association of Neurological Surgeons
Figure 5. Following resection of the bulk of the intramedullary li-
poma, the distal cord is reconstituted into a neural tube with inverted
fine nonreactive sutures (upper inset). The dura is closed and a ca-
133
Numerous variations on this anatomic theme exist.
One which deserves special comment occurs when the
subcutaneous lipoma is asymmetrically situated off the
midline and opposite to it is a cleft of grayish blue thin
epithelium. The thinned epithelium is seen to be blue from
an underlying CSF cyst being formed by a terminal
syringohydromyelia (Fig. 6, A and B).
Operatively, this lesion is approached in a similar man-
ner, with circumferential dissection of the subcutaneous
lipoma and cyst. With the last intact lamina removed, the
dura is opened to expose the caudally displaced spinal cord.
The plane between the dura-lipoma complex and the fatty
infiltrated cord is again key. The cord may be quite ex-
panded by the combination of fatty infiltration and enlarge-
ment of the central canal. Draining the cyst at this point
may facilitate the circumferential dissection around the
dural attachment to the neck of the lipoma. The dura, too,
may be infiltrated by fat. This makes adequate dural clo-
sure technically demanding. With careful dissection and
pacious CSF space dorsal to the newly formed neural tube is created
(lower inset). This lessens the likelihood of readherence at the op-
erative site.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

© 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

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OAKES : TETHERED SPINAL CORD, INTRAMEDULLARY SPINAL LIPOMA, AND LIPOMYELOMENINGOCELE
constant changing of perspective, eventually the circum-
ferential opening of the dura-fat interface can be accom-
plished. The dorsal roots may be seen to be adherent to
the undersurface of the dura, and prior to each maneuver
they should be sought. These roots are laterally displaced
and will be seen to exit in an asymmetric fashion. Exces-
sive fat growing into the neural tissue will then be ex-
cised. Prior to section, each area is isolated and electri-
cally probed for neurologic function. The very caudal
portion of the conus can be reconstructed into a neural
tube. If a large roughened surface not covered by pia is
left following the resection of the lipoma and reconstruc-
tion of the neural tube, consideration should be given to
placement of a thin sheet of nonreactive plastic between
the reformed distal cord and the inner surface of the dura.
This may lessen the likelihood of secondary readherence
at the site of separation. At times, a dural graft may be
necessary. This can usually be harvested from the two-
ply lumbodorsal fascia. Again, watertight dural closure
with preservation of a capacious CSF space around the
reformed neural tube is ideal. The soft tissue closure su-
perficial to the dura is performed in such a manner that
135
the intradural contents are not constricted and, therefore,
are less likely to become adherent.
Long-term results following aggressive resection and
repair of lipomyelomeningoceles are still being accumu-
lated. What does seem clear is that the risk of a serious
permanent injury from the operative manipulation is low
in experienced hands and should be much less than 10%.
The risks of spontaneous worsening without operation is
high, probably greater than 90% within the first two de-
cades of life. The likelihood of 5 to 10 years of clinical
stability without further loss of neurologic function fol-
lowing surgery is also high. If these are the representative
risks and benefits, then early surgical intervention is rea-
sonable and appropriate for this lesion. There are many
anatomic variations with this category of congenital le-
sions. The experience and judgment necessary in the suc-
cessful operative manipulation of this lesion are signifi-
cant. This particular lesion should not be operated on by
the surgeon who only deals with it occasionally. Serious
loss of bladder and/or bowel function will occur with the
inadverent sacrifice of functioning nerve roots by the sur-
geon who does not perform this procedure regularly.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
INTERSTITIAL BRACHYTHERAPY
JEFFREY D. McDONALD, M.D., PH.D.
PHILIP H. GUTIN, M.D.
PATIENT SELECTION
Candidates for interstitial brachytherapy using implant-
able radioactive 125I seed catheters are patients with a re-
current highly anaplastic astrocytoma or glioblastoma
multiforme and those with a single metastatic nodule (Fig.
1). An interstitial implant performed after external beam
radiotherapy in the initial treatment of patients with glio-
blastoma multiforme has also recently been proven effec-
tive. Patients selected for brachytherapy must have a tu-
mor that is clearly visible on contrast-enhanced computed
tomography (CT) scans and the tumor must be less than
4.5 cm in its greatest dimension. Those who have dif-
fusely infiltrative tumors, are significantly impaired neu-
rologically (Karnofsky performance score less than 70),
or have a life expectancy of less than three months are
excluded. In patients with a metastatic tumor, systemic
disease must be stable. Other exclusion criteria are evi-
dence of subependymal tumor spread or involvement of
the corpus callosum, tumor location in or immediately
adjacent to the cerebellum or brain stem, and multifocal
tumors. Tumors with a prominent cystic component are
not ideal for interstitial brachytherapy because loss of cyst
fluid during seed implantation may cause significant and
unpredictable changes in tumor geometry. If patients with
such tumors are to be treated with brachytherapy, cyst
fluid must be drained before implantation.
Most of the patient who have undergone
brachytherapy at our institution have had a malignant
glioma that recurred after initial therapy with surgery,
external beam irradiation, and sometimes chemotherapy.
Brachytherapy of primary glioblastoma used as a boost
after surgical resection and external beam radiation
therapy also seems to be effective in significantly pro-
longing patient survival.
PREOPERATIVE PREPARATION
Twenty-four to forty-eight hours before operation, the
patient undergoes routine preoperative assessment. Par-
© 1992 The American Association of Neurological Surgeons
136
ticular attention is given to the anticonvulsant level; if the
level is subtherapeutic, additional medication is adminis-
tered either intravenously or orally on the day of the pro-
cedure. Beginning at midnight on the preceding day, the
patient is kept from eating or drinking except for his or
her usual medications. Lorazepam (0.5-1.0 mg) is admin-
istered orally for patient comfort before placement of the
stereotactic frame and is repeated orally or intravenously
as needed throughout the day.
APPLICATION OF THE FRAME
On the morning of operation, the scalp is shaved at least
in the region of the tumor, and a peripheral intravenous
line is inserted. The Brown-Roberts-Wells base ring
(BRW-HR) is applied using sterile technique. Local an-
esthesia (0.5% lidocaine with 1:200,000 epinephrine) is
used in adult patients, whereas general anesthesia is re-
quired in children. The ring is secured to the outer table
of the skull with four pins: one in each lateral frontal re-
gion approximately 2 cm above the eyebrow, and one in
each posterior-inferior parietal region. Pin sites are cho-
sen so that none is placed in the region of the tumor and
so that the base ring itself is inferior to the lowermost
tumor margin. For low-lying tumors, extenders are used
as side bars to make lower fixation of the ring possible,
TARGET ACQUISITION
In the CT suite, the localizer ring apparatus (BRW-LR) is
placed over the patient’s head and attached to the base ring;
the entire ring assembly is then secured to a ring attach-
ment on the CT table. A contrast-enhanced axial CT scan,
3 mm in thickness, is then made. The asymmetrically posi-
tioned radiopaque graphite rods on the localizer ring allow
the tumor margins to be localized relative to the base ring.
Information from this scan is analyzed with a VAX 11-780
computer, using the BRAIN program developed at the
University of California, San Francisco. The three-dimen-
sional tumor volume is determined on the basis of the outer
margin of enhancement on the CT scans. A radiation
physicist selects the number and positions of cathe-
 McDONALD AND GUTIN : INTERSTITIAL BRACHYTHERAPY

© 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

137
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
ters to be used and the number of 125I seeds loaded in
each, attempting to match the predicted volume of radi-
ated tissue closely with the tumor volume and to mini-
mize the number of catheters inserted. Graphic represen-
tation of isodose radiation curves with the catheters in a
given position can be superimposed over a scan showing
the tumor volume in any plane (Fig. 2). The positions and
number of catheters and seeds are varied in an interactive
manner until an ideal combination is determined for the
tumor. Between one and three catheters loaded with one
to five seeds each are commonly used for optimal tumor
volume coverage. After the neurosurgeon and the radia-
tion oncologist examine and approve the final treatment
plan, the BRAIN program determines the target point for
the tip of each catheter relative to the BRW frame and
calculates the trajectory, including the BRW azimuth and
declination angles. This pre-implant planning process
takes a total of one to two hours.
SURGICAL TECHNIQUE
Anesthesia and Monitoring
The patient’s blood pressure, electrocardiogram, and oxy-
gen saturation are monitored continuously while he or
she is in the operating room. An anesthesiologist or nurse
practitioner is present throughout the procedure and ad-
ministers lorazepam and/or morphine as needed for pa-
tient comfort. It is important, however, that adult patients
© 1992 The American Association of Neurological Surgeons
Figure 2. A patient with an anaplastic astrocytoma in the right
frontal lobe undergoes analysis with the BRAIN computer pro-
gram at UCSF before placement of catheters containing 125I. Po-
138
remain awake, alert, and cooperative so that the neuro-
surgeon can continuously assess neurologic status as seeds
are implanted. A local anesthetic is used for analgesia in
the region of catheter insertion.
Positioning, Preparation, and Draping
The patient is placed in a semi-sitting position on the op-
erating table. The BRW ring adaptor (BRW-MA) is used
to secure the base ring, attached to the patient’s head, to
the Mayfield-Kees table attachment (Fig. 3). The scalp is
scrubbed in the region of the tumor with povidone-iodine
solution and then draped with lodoban plastic. Nafcillin
(2 g) or vancomycin (1 g) is administered intravenously
before the first skin incision.
Operative Procedure
After the arc-ring assembly (BRW-AS) is placed over the
patient’s head onto the base ring, the entry point for the
first catheter is determined on the basis of the calculated
azimuth and declination angles. The skin in the area of
this entry point is anesthetized, a 4-5 mm incision is made,
and a twist drill hole 3.4 mm in diameter is made in the
skull (Fig. 4). For catheters to be inserted near the major
vessels in the region of the sylvian fissure or midline, a
burr hole rather than a twist drill hole is made so that
placement of the catheter can be visualized directly. A 2-0
purse-string suture is placed in the scalp, to be used later
in closing the skin around the catheter.
tential catheter trajectories and isodose radiation curves are su-
perimposed graphically over the tumor on a coronal contrast-en-
hanced CT image.
 McDONALD AND GUTIN : INTERSTITIAL BRACHYTHERAPY

© 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.

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 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
At the twist drill hole, the dura is punctured with a
K-wire and then dilated with a blunt probe. The arc ring
is removed from the base ring and placed onto the phan-
tom base (BRW-PB) so that the required catheter length
to the first target site can be determined. The outer
Silastic catheter (1.57 mm inside diameter, 2.16 mm
outside diameter) is loaded onto a stylet (Fig. 5) and
passed through the trajectory guide of the arc ring until
it reaches the phantom base target, preset to the coordi-
nates determined by the BRAIN program (Fig. 6). A
safety cuff is screwed onto the stylet to mark the proper
length, and the catheter and stylet are withdrawn. The
arc-ring assembly is returned to the patient and attached
to the base ring. The outer Silastic catheter and stylet
are lubricated lightly with sterile mineral oil and then,
using the arc-ring trajectory guide, carefully advanced
to the predetermined depth through a Silastic collar (Fig.
5) held at the skin surface (Fig. 7). After the stylet is
withdrawn, the outer Silastic catheter and collar are se-
© 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
adhesive, then the collar is sutured to the scalp surface. An inner nylon
catheter (second from right) is loaded with radioactive seeds and spacer
elements, then inserted into the stereotactically placed outer catheter.
140
cured together with cyanoacrylate adhesive. The arc-ring
is removed from the patient and returned to the phan-
tom base, and the Silastic collar is attached to the scalp
with several 5-0 nylon sutures. This procedure is repeated
for each catheter in turn.
During catheter placement, the radiation physicist
prepares the radioactive seeds for implantation. The 125I
high-activity seeds are each approximately 4 mm in length
by 0.8 mm in diameter. These are loaded into inner nylon
catheters (1.04 mm inside diameter, 1.47 mm outside di-
ameter; see Fig. 5) with intervening spacer elements, if
required, so that they will be arranged in the proper posi-
tions as determined by the BRAIN program.
After all outer Silastic catheters have been im-
planted, the operating room personnel don appropriate
radiation-protective attire. The inner nylon catheters
containing the radioactive seeds are delivered to the
operating room in a lightweight lead pig by the radia-
tion physicist. Each is inserted into the corre-
© 1992 The American Association of Neurological Surgeons
Figure 6. The outer Silastic catheter, loaded onto a stylet, is passed
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.
 McDONALD AND GUTIN : INTERSTITIAL BRACHYTHERAPY

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

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© 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.)

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© 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.

143
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
is applied. The time required for removal of the seeds and
catheters is typically 10 to 15 minutes.
The patient is allowed to go home after overnight
observation. The sutures are left in place for 14 days be-
cause of delayed healing of the heavily irradiated scalp
tissue.
COMPLICATIONS
During interstitial brachytherapy, an increase in
peritumoral edema is not unusual. Headache, the most
common symptom, occurs in perhaps one-half of patients
and is treated symptomatically. A decline in neurologic
status is not typical; such an occurrence demands aggres-
sive evaluation, including CT scanning if needed. Al-
though the onset of new seizures is distinctly rare, the
risk of seizures may increase during therapy in patients
prone to such activity. The anticonvulsant level is moni-
tored closely during the week of treatment, and high thera-
peutic levels are maintained. Occasionally a patient’s ste-
roid dose is increased, but this can usually be readjusted
at discharge to the pre-treatment level.
Our experience with our first 406 implant patients
involved the following complications: Five patients ex-
perienced a mild cerebrospinal fluid leak that either was
self-limited or responded to placement of additional skin
sutures in a procedure performed at the patient’s bedside.
Two patients had aseptic meningitis, two had bacterial
meningitis (fatal in one), and two developed cerebritis
that responded to antibiotic therapy. Four patients had an
intracerebral hemorrhage associated with catheter place-
ment; two of these required operative evacuation. While
undergoing treatment, five patients had a pulmonary em-
bolus, one of which was fatal. Two patients developed
wound breakdown associated with irradiation, and one of
these required skin grafting for closure.
Patients undergo routine CT scanning six to eight
weeks after brachytherapy, and thereafter at intervals of
two months. At our institution, the incidence of radiation
necrosis after brachytherapy is significant. For distinguish-
ing between radiation necrosis and tumor progression,
positron emission tomography (PET) scanning is required
because both of these entities appear as enhancing tissue
on contrast-enhanced CT scans. Diagnostic PET scanning
is performed if the patient is neurologically stable. How-
ever, in patients experiencing neurologic decline, crani-
otomy is performed for resection of the new enhancing
tissue. After interstitial brachytherapy of recurrent glio-
mas, approximately 50% of our patients required
reoperation because of radiation necrosis, tumor progres-
144
sion, or both at a median time of 29 weeks after implanta-
tion. Reoperation after boost therapy for primary glio-
blastomas was performed in 40% of patients at a median
time of 42 weeks after implantation.
RADIATION PRECAUTIONS
The decay of 125I occurs by electron capture resulting in
emission of gamma-rays, x-rays, and electrons. In the high-
activity seeds, the 125I is absorbed onto resin balls and
coated with a titanium capsule; therefore, only the gamma-
rays and K-characteristic x-rays are emitted into the sur-
rounding tissue. The energy of the emitted gamma-rays is
relatively low, in the range of 27 to 35 keV.
During insertion and removal of the loaded inner cath-
eters, all personnel in the operating suite or the patient’s
private room wear lead aprons and radiation exposure
badges. Leaded vinyl rubber gloves, leaded eye glasses,
and a thyroid shield are worn by the radiation physicist
while preparing the inner catheters for implantation and by
the neurosurgeon while inserting and removing catheters.
The radioactive seeds, when not in the patient, are kept
inside a lightweight lead pig at all times. The patient wears
the leaded cloth cap while ambulating in the hospital dur-
ing treatment and when others are present in the hospital
room. Readings are taken with a radiation meter 1 meter
from the patient in all directions, both with and without the
cap, in the operating room and in the patient’s hospital room;
these values are posted on the door to the patient’s room.
Visitors and staff wear leaded aprons when in the
presence of the patient. For prolonged visits, visitors are
required to remain more than 1 meter from the patient
and to position themselves on the side of the patient op-
posite the catheters. Patients are placed in private rooms,
which are arranged so that the catheters are closest to the
window and away from the hallway door while the pa-
tient is in bed. Patients use disposable eating utensils, and
linen and garbage are monitored daily for radiation lev-
els. There are no precautions regarding human waste. A
lead pig, instrument tray, and radiation counter are kept
in the patient’s room at all times.
These precautions are extensive in proportion to the
potential level of radiation to which the seed catheters
may expose staff and visitors. Even in the absence of the
lead-shielded cap, staff giving routine care would be ex-
posed to radiation on the order of less than 10 mrem per
month, and exposure at distances of 1 meter or greater
would be negligible. To date, no mishaps or instances of
radioactive contamination have occurred in the intersti-
tial brachytherapy program at our institution.
 LATERAL EXTRACAVITARY APPROACH
TO THE THORACIC AND LUMBAR SPINE
DENNIS J. MAIMAN, M.D.
SANFORD J. LARSON, M.D.
INDICATIONS
The extracavitary approach to the thoracic or lumbar spine
is indicated for the removal of extradural mass lesions
anterior and/or lateral to the spinal cord or cauda equina,
followed by anterior vertebral fusion. In the presence of
spinal instability or deformity, posterior surgical tech-
niques such as spinal instrumentation, fusion, and, oc-
casionally, laminectomy can easily be incorporated in a logical
sequence, with spinal cord or cauda equina decompres-
sion preceding spinal fixation. In the rare instance of a
lesion encircling the dural sac, the procedure can be per-
formed bilaterally, providing circumferential decompres-
sion and bilateral anterior fusion. Although the procedure
may be utilized throughout the thoracic and lumbar spine,
it may be difficult above the level of T2 because of the
presence of the scapula, and below the level of L4 be-
cause of the presence of the iliac crest (although this can
be removed, providing bone for grafting).
The extracavitary approach is useful in the manage-
ment of thoracic disc herniation, upper lumbar disc her-
niation, trauma, tumors, and inflammatory diseases involv-
ing up to three and sometimes four vertebral levels.
Excellent exposure of the vertebrae is offered, with early
and direct visualization of the dural sac (Figs. 1 and 2).
Particularly at the thoracolumbar junction, the use of the
extracavitary approach obviates the need for takedown of
the diaphragm with its associated morbidity. However, with
lesions extending more than three levels, transthoracic or
transabdominal approaches may be more helpful.
PREOPERATIVE EVALUATION AND
PREPARATION
Preoperative evaluation should include adequate radio-
graphic studies to determine the extent of bone involve-
© 1992 The American Association of Neurological Surgeons
145
ment as well as the extent of spinal cord or cauda equina
compression. This may include, but should not be limited
to, positive contrast myelography because accurate bone
imaging is of critical importance in defining the status of
the pedicles and posterior elements, as well as the verte-
bral bodies. Currently, we favor plain spine radiography,
computed tomography (CT) scanning with intrathecal
contrast, and often magnetic resonance imaging (MRI).
Spinal angiography is commonly used in studying lesions
between T6 and L2 to identify the radiculomedullary ar-
tery of Adamkiewicz, which arises most commonly be-
tween T6 and T12, and provides a significant amount of
the blood supply to the middle and lower thoracic spinal
cord. Angiography need not be considered for lesions at
or below L3. If the artery is found at the level of the le-
sion or at levels immediately proximal or distal to the le-
sion, we recommend approaching the spine from the op-
posite side.
In spite of many strongly worded opinions to the con-
trary, there is no good evidence that early surgery is of
benefit in the neurologically stable patient. Therefore, our
practice is to operate on most patients with spinal trauma
electively, i.e., within 5-10 days after injury, depending
on the medical status and associated trauma. However, in
the patient with rapidly deteriorating neurologic function,
the procedure becomes an emergency. In such patients,
dexamethasone can be used as a temporizing measure.
Dexamethasone, however, is not useful in patients with
spinal cord injury. In patients with significant metastatic
disease, alternative surgical approaches of lesser magni-
tude should be considered, including a more confined cos-
totransversectomy or transpedicular approach in associa-
tion with spinal instrumentation.
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
operating room personnel can be properly advised. In
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

© 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.

146
MAIMAN AND LARSON : LATERAL EXTRACAVITARY APPROACH TO THORACIC AND LUMBAR SPINE
obtaining informed consent, the risks of worsened neuro-
logic status, superficial or deep wound infection, pneu-
mothorax, extensive hemorrhage, nonunion of the bone
grafts, and failure of the instrumentation devices (if used)
need to be discussed.
In addition to ensuring acceptable physical status,
prophylactic antibiotics are used although they are of un-
proven utility. The patient’s legs should be wrapped in
compression bandages or anti-embolism stockings with
intermittent pneumatic compression. A Foley catheter and
large-bore peripheral and central venous catheters are
used.
In our institution, balanced anesthesia techniques
using both narcotics and inhalation agents are favored.
Full physiologic monitoring, including direct arterial pres-
sure and oxygenation measurements as well as cardiac
status checks, are important. We do not currently use in-
traoperative evoked potentials because decompression is
done under direct vision and the results of the neurophysi-
ologic technique have been inconsistent. Hemodilution
and hypotension have been recommended for major spi-
nal surgery to decrease blood loss. However, we think that
the potential for sudden hemorrhage from epidural ves-
sels makes this technique unsafe. Instead, cell-savers
(autotransfusion devices) are routinely used and are
strongly recommended. Through the use of these devices,
our blood use has decreased from an average of 14 to 3
units per patient.
SURGICAL TECHNIQUE
Patient Positioning
The patient is positioned prone on chest rolls or on a spi-
nal frame, with the abdomen and chest free of the table.
Arms can either be above the head or carefully tucked at
the sides. In either instance, it is important to position the
arms so that pressure on peripheral nerves is avoided, and
no stretch is applied to the brachial plexus. All pressure
points are padded.
Operative Technique
Correct placement of the skin incision is absolutely criti-
cal. The skin incision is marked after the patient has been
positioned and portable x-ray films have defined the level
of the lesion. The curved hockey-stick-shaped incision
(Figs. 3 and 4) offers the best access to both the posterior
midline and the anterior vertebral body through the lateral
approach. In the thoracic or upper lumbar region, we typi-
cally use ribs for bone grafts since one or more are removed
during the approach. If, however, the lesion is below L2 or
the rib is involved with tumor, is fractured, or is otherwise
unsuitable, iliac crest bone will be needed for grafting.
147
The decision to operate from the left or the right side
is often determined by the pathology: if the lesion is more
significant on the left, for example, the ideal approach
will also be from the left. As mentioned earlier, we avoid
operating on the side of the artery of Adamkiewicz when-
ever possible. However, if the lesion is laterally placed on
the same side of the spine as the artery, we will approach
from that side, taking great care to avoid arterial injury. If
the lesion is primarily central and the artery is irrelevant,
the side of the approach is determined by the surgeon’s
personal preference.
The vertical portion of the incision is made down the
midline, about three vertebral levels above and three lev-
els below the lesion (Figs. 3 and 4). The lateral curved
portion generally extends 12-14 cm. If the lateral portion
is much longer (which does not improve exposure) re-
traction later in the procedure may be difficult. The inci-
sion is then carried through the subcutaneous tissue and
the thoracodorsal fascia. If spinal instrumentation is to
be performed, a subperiosteal dissection, cleanly expos-
ing the laminae, facets, and spinous processes is accom-
plished in the usual manner. Blunt and sharp dissection
are then used to elevate the thoracodorsal fascia off the
underlying musculature, working from the midline dis-
section. When the fascia has been freed over the entire
extent of the vertical incision, it is incised along the angled
portion of the incision. The thin muscles superficial to
the fascia remain attached to it. The entire skin, subcuta-
neous tissue, muscle, and fascia flap are then elevated
and retracted laterally. A plane is defined at the lateral
aspect of the erector spinae group, and these muscles are
elevated as a layer off the ribs and are retracted medially.
The more lateral muscles, including the remnants of the
latissimus dorsi, are dissected free from the ribs.
The number of ribs to be removed is dependent on
the exposure needed for anterior decompression. For ex-
ample, in surgery for thoracic disc herniation, one rib is
detached. For a single level fracture or tumor, we typi-
cally remove two ribs, and for two-level disease, three
ribs. After all muscles and attached ligaments are cleaned
from the ribs circumferentially, with care taken to protect
the intercostal arteries, the rib is transected 7-10 cm lat-
eral to the costovertebral junction. The capsule of the cos-
tovertebral joint is incised with a scalpel, and the joint
opened, using great care to avoid tearing the pleura. The
rib is then elevated out of the field, and saved for later use
as a graft. It is important to remove the rib and transverse
process at the articulation to ensure full exposure.
In approaching lesions at L1 or L2, the 12th rib will
typically need to be removed. Generally, the transverse
process of L2 is at approximately the same position as
the twelfth rib. Thus, rib removal offers bone graft,
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

© 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.
148
 MAIMAN AND LARSON : LATERAL EXTRACAVITARY APPROACH TO THORACIC AND LUMBAR SPINE
surgical exposure, and localization, as discussed below.
For additional graft material, a portion of the 11th rib can
easily be resected.
Following rib removal at each level, the intercostal
neurovascular bundle is identified, the intercostal artery is
ligated and divided, and the intercostal nerve is isolated.
The intercostal nerves are followed into the region of the
neural foramina at the level of the lesion (Fig. 5). In Fig-
ures 6 and 7, the intercostal nerves are shown being re-
tracted for the purposes of exposure. However, it is more
commonly our practice to divide the intercostal nerves dis-
tally and to take advantage of the completely freed nerve to
safely gain access to the neural foramen. The band of hy-
pesthesia that results is rarely problematic and usually re-
solves over time, but the risk of a dysesthetic pain syn-
drome resulting from a stretch injury of the nerve is high.
© 1992 The American Association of Neurological Surgeons
Figure 5. Following removal of the rib segments, the intercostal nerves
are followed proximal to their foramina, thus identifying the relevant
149
In using this approach for lower lumbar lesions, the iliac
crest will need to be resected to allow appropriate exposure.
This should be accomplished following careful dissection
of the periosteum and muscle off the crest. Osteotomes are
then used to cleanly resect the obscuring portion, taking care
to stay medial in the crest to avoid nerve injury. In addition,
the sacroiliac joint should not be violated to avoid long-term
pain. The bone edges are carefully waxed.
Over most of the lumbar spine, anatomic localiza-
tion of vertebral levels is hampered by the lack of ribs.
Here, the transverse process assumes similar impor-
tance. The transverse processes located at the level of
anterior pathology are identified and dissected free, as
are those immediately cephalad and caudad. They are
then removed with a rongeur, often exposing the proxi-
mal portion of the nerve root from the more cephalad
pedicle. As is explained in the text, distal ligation of one or more inter-
costal nerves may simplify the approach.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

© 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.

150
MAIMAN AND LARSON : LATERAL EXTRACAVITARY APPROACH TO THORACIC AND LUMBAR SPINE

© 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.

151
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
spinal level. If not, the lumbar roots must be exposed by
dissecting through the muscle masses lateral to the spine.
Once found, they should be mobilized until they dive deep
into the muscle or join into a plexus and retracted care-
fully with nerve tapes. In contrast to the intercostal nerves,
the lumbar nerves are not divided.
At this point, the periosteum (attached to the pleura,
diaphragm, and retroperitoneal tissues) of the appropri-
ate vertebrae is bluntly dissected away from the ventro-
lateral aspect of the vertebral body and pedicle. It may be
necessary to carefully dissect a prefixed lumbar plexus
off the lateral aspect of the vertebral column.
Unless the vertebrectomy is being performed for tu-
mor, there is no reason to dissect to the anterior midline
of the body. Indeed, major blood loss may occur if the
anterior-lying segmental arteries are encountered. Follow-
ing visual identification of the spinal lesion, blunted
needles or hemostats are placed into the discs at the mar-
gins of the lesion, and an anteroposterior radiograph is
obtained to ensure appropriate localization. At this point
it may be advantageous to turn the table so that the
surgeon’s side is up approximately 15 to 20°.
Dissection of the margins of the appropriate neural
foramina is performed with a nerve hook; they are then
enlarged using small Kerrison rongeurs and curettes. The
pedicle is thinned and removed between the pertinent fo-
ramina. We often remove portions of the pedicles adja-
cent to the affected levels to offer visualization of more
normal anatomic relationships between the dural sac and
the spinal canal. Although some epidural bleeding may
occur as a result of this step, full removal of the pedicle
affords lateral visualization of the dural sac which is im-
perative in this procedure.
With the removal of the pedicle and visualization of
the dural sac, the dissection of the periosteum, and the in-
terpretation of the localizing radiograph, the disc spaces
above and below the level of the lesion should be well-
defined. The discs are partially removed, and the disc spaces
drilled out using a brace and bit or a high-speed drill, at-
tempting to go through at least three-fourths of the way
across the body, thus ensuring that the surgeon is across
the spinal canal (Fig. 6). The intervening vertebral bone is
then removed using a rongeur or a high-speed drill, again
being careful to go deep enough through the vertebra. If a
drill is used, care must be taken to avoid pushing the bit
through fractured bone or tumor toward the dural sac. At
this point, there should be at least 1 to 2 cm of bone left
anteriorly and a thin dorsal shelf posteriorly.
Removal of the thin dorsal plate should be accom-
plished with great care, but rapidly, since epidural bleed-
ing may result. Careful dissection of the dura-bone inter-
152
face can be helpful to break up adhesions, as well as de-
fine spicules, etc. which may be stuck to the sac. Back-
ward-angled curettes are then used to push this cortical
plate away from the dural sac, thus completing the de-
compression. Ideally, the entire plate will be fractured suc-
cessfully, in a single piece, into the vertebral defect by
working primarily at the junctions of the intervertebral
discs, thus avoiding trauma at the point of cord or cauda
equina compression. Again, it is imperative that the plate
removal be extended across the spinal canal. A dental
mirror immersed in warm saline and held into the verte-
bral defect is helpful in visualizing the anterior aspect of
the dural sac and the adequacy of decompression.
Slots are then carved into the vertebral bodies adja-
cent to the decompression to prepare a bed for the bone
grafts to be placed later. The rib or iliac crest bone grafts
are prepared for grafting by cutting them 10-15% longer
than the defect to be spanned. The ends are trimmed to
45° angles, with the shorter length being the leading edge.
Ideally, at least two pieces of rib, or one bi- or tricortical
iliac crest graft, are impacted into position, at least 1 cm
away from the dural sac to prevent cord or cauda equina
compression if full correction is not maintained (Fig. 7).
If an intercostal nerve has been divided, a silver clip is
placed proximal to the dorsal root ganglion, and the nerve
is resected.
In the presence of spinal instability or abnormal an-
gulation of the spine the bone grafts are placed after spi-
nal instrumentation. Bone wax and cellulose hemostatic
materials are used to cover exposed cancellous bone, lap-
arotomy sponges are packed for hemostasis, and the re-
tractors are removed. Because the subperiosteal dissec-
tion was performed earlier, following the placement of
retractors the laminae are immediately available for prepa-
ration. Spinal instrumentation is placed at this time; the
devices used depend on the pathology and the experience
of the surgeon. However, because the dural sac has been
fully decompressed, realignment of even severe deformi-
ties can be performed without a high degree of risk to the
spinal contents. The midline muscles are reapproximated
using nonabsorbable sutures.
Attention is again turned anteriorly. The erector spinae
muscles are again retracted medially using self-retaining
retractors, and the lateral aspect of the dural sac is visual-
ized, as well as the bone defect created by the decompres-
sion. Bone grafts are placed as discussed above.
The wound is then carefully closed in layers. A large
surgical drain is left in the paravertebral region, with
one or two drain holes extending underneath the flap,
for approximately 48 hours. If the pleura has been en-
tered inadvertently, a No. 32 chest tube should be
MAIMAN AND LARSON : LATERAL EXTRACAVITARY APPROACH TO THORACIC AND LUMBAR SPINE
placed in the pleural space. The paravertebral muscle layer
and the thoracodorsal fascia are tightly closed using in-
terrupted nonabsorbable sutures. The subcutaneous layer
is closed with interrupted synthetic absorbable sutures,
and the skin with staples.
POSTOPERATIVE CARE
The patient is usually maintained in the intensive care
unit (ICU) for one to two days postoperatively. Surgical
drains are typically removed at 24 to 48 hours. Monitor-
ing of pulmonary, hemodynamic, and fluid status is im-
portant. Therapies required for any neurologic deficit are
reinstated on the first postoperative day.
If an external orthosis was fabricated prior to sur-
gery, the patient can be mobilized on the fourth or fifth
day. Otherwise, we generally manufacture the bivalved
cast on the seventh day and then get the patient up when
the jacket is ready. Skin sutures or staples are also re-
moved at this time.
COMPLICATIONS
The most common complications of the procedure are
systemic: pulmonary atelectasis due to splinting produced
by pain, and hypovolemia and/or low hematocrit related
to continuing low-volume blood loss. In cases with sub-
stantial blood loss, now unusual because of the use of
autotransfusion devices, consumptive coagulopathies oc-
cur frequently and must be treated aggressively with re-
placement of clotting factors. Ileus may be present for
two to three days after a lumbar operation.
153
In instances where the pleura has scarred to the rib
or vertebra, rents may occur. This tends to occur most
frequently in patients undergoing surgery more than three
weeks after injury. In these cases, a large chest tube should
be placed intraoperatively directly into the pleural rent,
to drain both air and blood. Occasionally, the pleural vio-
lation will not be recognized until the patient is in the
recovery room or ICU, and the chest tube will need to be
placed there.
Infection rates are surprisingly low, considering the
length of the surgical wound and the duration of the pro-
cedure. Superficial skin infections occur in about 5% of
cases; deep infections are rare. Other serious complica-
tions, including deep vein thrombosis and sepsis, have an
incidence of less than 1%.
Longer term complications include nonunion of
bone grafts, development of deformity, and/or failure
of the spinal instrumentation systems. All of these are
uncommon: we have seen three nonunions in a series
of over 800 patients treated for thoracic (>460 patients)
or lumbar (>340 patients) trauma. Spinal instrumenta-
tion devices, however, can fail, particularly if poor
bone-metal interfaces exist, as is true for nonsublaminar
wired Harrington distraction rods. Some loss of cor-
rection inevitably follows spinal instrumentation, and
some graft collapse may occur. However, as a conse-
quence of the wide decompression afforded by the
extracavitary decompression and the anterior interbody
fusion, recurrence of neurologic symptoms or major
deformity is unlikely.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
AN EXTREME LATERAL TRANSCONDYLAR
APPROACH TO THE FORAMEN MAGNUM
AND CERVICAL SPINE
CHANDRANATH SEN, M.D.
LALIGAM N. SEKHAR, D.V.M., M.D.
INTRODUCTION
The extreme lateral transcondylar approach is useful for
both intra- and extradural tumors in the region of the lower
clivus, foramen magnum, and cervical spine situated ven-
tral to the neuraxis. The approach, in principle, relies on
removal of bone in the area of the mastoid process and
the craniospinal articulation to provide a more lateral per-
spective, enabling the surgeon to visualize the anterior
aspect of the spinal canal and foramen magnum without
additional retraction or manipulation of the brain stem or
spinal cord. In addition, this approach allows complete
control of the vertebral artery on one side through its ex-
tra- and intradural course beginning at the level of C2 so
that it can be safely dissected from the tumor.
PREOPERATIVE DIAGNOSTIC EVALUATION
Magnetic resonance imaging (MRI) in multiple axes, par-
ticularly in the axial and sagittal planes, is considered es-
sential in the surgical planning. Exquisite detail of the
relation of the tumor to the vertebrobasilar system is seen
as is the plane between the tumor and the brain stem and
spinal cord. In the cases where the tumor has extended
outside the canal, the extent of invasion of the
extravertebral tissues can also be well appreciated.
High-resolution computed tomography (CT) scan-
ning is also performed because the bony relations to the
articular processes are best seen in this study. Intrathecal
contrast agents do not seem to add to the information
obtained from the combination of the MRI and CT.
Angiography includes the study of both vertebral ar-
teries and the carotid system, to assess the status of the
jugular bulb on the side in question and also the cross-
© 1992 The American Association of Neurological Surgeons
154
communication of the transverse sinuses at the torcular.
Embolization carries a higher risk because of the over-
lapping blood supply of the tumor and spinal cord itself.
However, if an external carotid blood supply through the
ascending pharyngeal artery can be identified, this can
be embolized.
COMBINATION WITH OTHER PROCEDURES
When tumors involving the clivus appear to involve the
petrous portion of the internal carotid artery (ICA), the
extreme lateral approach may be combined with the
subtemporal and infratemporal approach to allow removal
of all the tumor under direct vision and also to permit the
surgeon to maintain control of the ICA. If disruption of
the entire atlanto-occipital joint is considered because of
its involvement by tumor, a fusion procedure can be car-
ried out either some time before the tumor resection or
after the tumor removal at the same setting. Similarly with
the cervical spine, if a tumor like a chordoma is removed,
a separate approach from the front or back may also be
necessary to accomplish removal of the entire tumor.
PREOPERATIVE PREPARATION
Intravenous administration of steroids is started the day
before the operation and is continued into the early post-
operative period. Baseline somatosensory evoked re-
sponses are obtained for comparison with intraoperative
recordings. If lower cranial nerve deficits are suspected,
laryngoscopic examination is carried out for proper docu-
mentation. A thorough discussion with the patient is im-
portant regarding the potential for developing lower cra-
nial nerve palsies as a result of the operation and the
possible need for a temporary tracheostomy and/or gas-
trostomy in the postoperative period.
 SEN AND SEKHAR : EXTREME LATERAL TRANSCONDYLAR APPROACH
SURGICAL TECHNIQUE
Anesthesia and Intraoperative Monitoring
General anesthesia with orotracheal intubation is stan-
dard procedure. The agents used will depend on the ex-
tent and type of intraoperative monitoring to be used.
Somatosensory evoked potential (SEP) monitoring is cur-
rently used as an indicator of spinal cord distortion dur-
ing the operation. The tenth, eleventh, and twelfth cranial
nerves can be monitored by inserting needle electrodes
into the vocal cord, trapezius muscle, and tongue, respec-
tively, and the evoked responses to intraoperative stimu-
lation can be recorded on an electromyographic monitor.
If such motor cranial nerve monitoring is used, muscle
relaxants will have to be avoided. However, an excessive
amount of an inhalation agent will interfere with the SEP
recording. An active dialogue between the anesthetist, the
neurophysiologist, and the surgeon will have to be main-
tained to determine what type of monitoring will be re-
quired at each stage of the operation.
Central venous and arterial catheters are used for fluid
administration and hemodynamic monitoring. An indwell-
ing urinary catheter is used for accurate urine output mea-
surement. Sequential compression stockings are wrapped
around the lower extremities to reduce the incidence of
deep venous thrombosis during these lengthy operative
procedures.
© 1992 The American Association of Neurological Surgeons
Figure 1. The patient is placed in a full lateral decubitus position
with the head kept neutral in pin fixation. An alternate incision is
an inverted “L” on the side of the neck if the tumor is more cau-
155
Positioning
The patient is placed in a full lateral decubitus position
on a foam mattress with the involved side up. The head is
secured in a neutral position relative to the shoulders in a
three-point pin head rest and the thigh is left exposed to
harvest fat and fascia. If a simultaneous fusion procedure
is planned, the ipsilateral iliac crest is also included in the
field. A soft roll is placed under the lower aspect of the
chest to prevent pressure injury to the brachial plexus. If
a long operation time is anticipated, the lower shoulder is
allowed to project beyond the table and is supported by
rolls of foam sponge placed between it and the head clamp
attachment. This prevents both a brachial plexus injury
and pressure sores on the side of the chest wall. The pa-
tient is securely taped to the table, taking into account
that the table may be rolled during the operation. Pres-
sure points are carefully padded.
Operative Procedure
Incision and Muscle Dissection
If most of the tumor is above the foramen magnum, a
“U”-shaped skin flap is raised based on the neck and
the top of the incision extends above the ear (Fig. 1).
For a tumor below the foramen magnum, a vertical
incision is made on the side of the neck at the level of
the mastoid process and an “L”-shaped posterior ex-
dally placed. A gentle “C”-shaped Incision may also be used if
more extensive temporal bone work is anticipated and the external
ear canal is divided.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
tension is made from the top end of this, not quite back to
the midline. The skin flaps are raised separately, and care
must be taken to identify the accessory nerve as it exits
the sternomastoid muscle to enter the trapezius. It is lo-
cated in the subcutaneous tissues of the posterior triangle
and can be positively identified with a stimulator, thus
eliminating confusion with nerves of the cervical plexus.
The muscles are elevated from the suboccipital area and
the mastoid process. In the cervical region the surgeon
dissects the muscle in layers, identifying the specific
muscles and dividing them near their lateral attachment
on the transverse processes of the vertebrae. This type of
dissection allows their reapproximation in anatomic lay-
ers and also reduces postoperative pain.
Identification and Isolation of the Extradural
Vertebral Artery
The deepest muscle layer consists of the superior and in-
ferior oblique muscles and the upper portion of the leva-
tor scapulae attached to the transverse process of the at-
las. The transverse process of the atlas is an important
landmark. Between the inferior oblique muscle and the
transverse process of C2 is an area filled with areolar tis-
sue. Blunt dissection in this area under magnification will
lead to the identification of the vertebral artery as it pro-
ceeds from the foramen transversarium of C2 to the fora-
men transversarium of C1. This segment of the artery may
© 1992 The American Association of Neurological Surgeons
156
be redundant to a variable degree. The ventral ramus of
the C2 root crosses the superficial surface of the artery
and is also a useful landmark; it is lifted up by a redun-
dant artery. The artery may also be identified distal to the
transverse foramen of C1 by detaching the oblique muscles
from the lateral and inferior surface of the C1 transverse
process and visualizing the artery on the upper surface of
the posterior arch. The artery is followed right up to its
dural entry, freeing it up from the joint capsule of the
articulation between the occiput and the atlas. The isola-
tion of the vertebral artery should be carried out under
magnification to prevent injury to the vessel; it is also
very helpful in controlling venous bleeding from the abun-
dant surrounding venous plexus.
Bone Exposure
For posterior fossa tumors extending down to the fora-
men magnum, the bony exposure consists of the suboc-
cipital region, the mastoid process anteriorly to the exter-
nal ear canal, the foramen magnum, the transverse process
and posterior arch of C1, and the occiput-C1 articulation.
For predominantly spinal tumors reaching up to the fora-
men magnum, the exposure includes the lateral aspects
of the vertebral arches (starting with the articular pillars
and extending back to the spinous processes) and the lower
suboccipital region including the foramen magnum and
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.
 SEN AND SEKHAR : EXTREME LATERAL TRANSCONDYLAR APPROACH
Bone Removal
A suboccipital craniectomy and mastoidectomy (the facial
nerve and the labyrinth are not unroofed) are carried out.
The sigmoid sinus is unroofed up to the jugular bulb, and
the rim of the foramen magnum is removed up to the occipi-
tal condyle (Fig. 3). Under the magnification of the micro-
scope, the atlanto-occipital joint capsule is completely ex-
cised after it has been carefully freed from the vertebral artery.
The posterior one-half or two-thirds of the occipital condyle
and upper articular facet of the C1 lateral mass are drilled
away with a high-speed drill (Fig. 4A). Removal of the ar-
ticular pillars not only allows a more direct access to the
ventral lip of the foramen magnum but also allows the sur-
geon to get completely around the vertebral artery at its du-
ral entry point, facilitating its mobilization from the tumor
(Fig. 4B). For spinal tumors, a mastoidectomy is not required
and the bone removal mainly involves the suboccipital area,
the foramen magnum, and the occipital condyle. From here,
the procedure varies depending on the intra- or extradural
location of the tumor and will be described separately.
Intradural Tumors at the Craniocervical
Junction
The most common tumor in this location is a meningioma
© 1992 The American Association of Neurological Surgeons
Figure 3. The craniectomy exposes the sigmoid sinus and extends
from the foramen magnum to the occipital condyle. Note that the
atlanto-occipital joint capsule is intimately approximated to the verte-
157
situated ventrally or ventrolaterally, surrounding or dis-
placing the vertebral artery on one side. The dura is opened
posterior to the sigmoid sinus and the opening is carried
caudally posterior to the vertebral artery at the foramen
magnum. The dural flap is retracted anteriorly, and the
dura is carefully opened completely around the vertebral
artery with the surgeon being aware that the vessel may
be surrounded by tumor in this area (Fig. 4C). Once the
artery is completely mobilized, tumor in front of the ves-
sel can be removed with relative safety, and injuries to
the vessel can be managed adequately. Standard micro-
surgical techniques are used to dissect the tumor from the
brain stem and cranial nerves after adequate debulking.
As the tumor capsule is being dissected away, the oppo-
site vertebral artery comes into view. The tumor often
extends to the opposite vertebral artery entry site but sel-
dom involves it intimately on both sides. A nerve stimu-
lator may be used for positive identification of the cranial
nerves during dissection from the tumor. The dural base
of the tumor is easily excised from this exposure because
the surgeon is working in front of the vertebral artery. If a
significant portion of the tumor is inside the jugular fora-
men or the tumor is a jugular foramen neurinoma, the
extracranial portion of the tumor may be excised at
bral artery in this area and has to be carefully excised under magnifi-
cation prior to removing the condyle.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

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

158
 SEN AND SEKHAR : EXTREME LATERAL TRANSCONDYLAR APPROACH
the same setting after removal of the entire occipital
condyle and obliteration of the jugular bulb as described
below (Fig. 4C). However, this will necessitate a fusion
operation. Another option is to remove the extracranial
portion of the tumor through a preauricular subtemporal-
infratemporal approach along with a transcervical route
at a separate stage and avoid a fusion. Dural closure is
accomplished with a graft but watertight closure around
the vertebral artery is not possible. A piece of fat har-
vested from the abdomen or thigh is placed in the mas-
toidectomy defect and the muscles are reapproximated.
Partial condylar excision does not necessitate a fusion.
Extradural Tumors at the Craniocervical Junction
Tumors most frequently found in this location include
chordomas and chondrosarcomas. These are primarily ex-
tradural tumors but may invade the dura and can occupy
both the intra- and extradural space. The goal of the op-
eration is not only removal of the soft portion of the tu-
mor but also the involved dura and the infiltrated bone.
Complete condylar resection renders this region unstable
and the fusion procedure which is necessary can be per-
formed either at a separate operation or at the same sit-
ting as the tumor resection. The status of the jugular bulb
and cross-communication at the torcular must be evalu-
ated preoperatively; however, in most instances the jugu-
lar bulb is obliterated by the tumor. After completing the
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-
lar and hypoglossal foramina have been unroofed, the
nerves are best followed starting intradurally so that their
course may be plotted from the normal to the abnormal
area (Fig. 4C). The nerves are completely skeletonized
by drilling the bone around them until healthy bone is
seen. When the petrous ICA is also involved, additional
159
approaches may be considered as discussed earlier. If the
patient has no hearing, the labyrinth may be drilled away,
unroofing the internal auditory canal to provide a further
cephalad access.
Spinal Tumors
Intradural tumors situated ventrally include meningiomas
and schwannomas. Some of the latter may extend in a
dumbbell fashion outside the spinal canal. The approach
for spinal tumors located caudal to C2 is carried out by
drilling the posterior one-half to two-thirds of the articu-
lar facets and the adjacent laminae as far back as the
spinous processes (Fig. 5A). If there is a dumbbell exten-
sion of the tumor, the adjacent facets are completely drilled
away to unroof the neural foramen and the extracanalicular
portion of the tumor is removed (Fig. 5, B-D). It must be
noted that the vertebral artery anterior to the tumor is usu-
ally not adherent to it and can be carefully dissected off.
For the purely intradural tumors, the dura is opened
immediately posterior to the nerve roots after packing
off the epidural bleeding with Surgicel strips. Because
the dural opening is laterally placed on the thecal sac,
the spinal cord does not herniate out from the pressure
of the ventrally placed lesion. Usually through this ap-
proach, the lesion comes into full view as soon as the
dura is opened and the cord is barely seen. The tumor
is then progressively debulked with bipolar co-
© 1992 The American Association of Neurological Surgeons
Figure 5. A, the area of bone removal includes the posterior one-half to
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
green area shows the area of bone removal including the adjacent ar-
ticular facets above and below the tumor. The tumor before (C) and
after (D) removal and the view of the ventral aspect of the spinal cord
across the midline are shown from a completely lateral perspective.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

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

© 1992 The American Association of Neurological Surgeons

Figure 5, B-D.

160
 SEN AND SEKHAR : EXTREME LATERAL TRANSCONDYLAR APPROACH

EXTENT OF EXPOSURE tradural visibility beyond the ventral midline is extremely

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

161
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

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

162
 RETROLABYRINTHINE PRESIGMOID
APPROACH FOR SECTIONING OF
THE VESTIBULAR NERVE
FOR MÉNIÈRE’S DISEASE
CHARLES M. LUETJE, M.D.
INTRODUCTION
Ménière’s disease is an end-organ vestibular malady, the
symptoms of which (vertigo, nausea, and vomiting) can
be eliminated by vestibular nerve section. Hearing need
not be destroyed nor does one have to enter the
cerebellopontine angle (CPA) from behind the sigmoid
sinus. Extradural temporal lobe retraction and opening of
the internal auditory canal (IAC) from above is not the
only alternative. The antesigmoid (presigmoid) mastoid
craniectomy provides an effective and safe alternative
approach.
SURGICAL PROCEDURE
The patient is supine on the operating table with the face
turned away from the surgeon. The head is at the foot of
the operating table and 5-foot anesthesia tubing crosses
over the pelvis to the anesthesia machine. The left abdo-
men is prepared for obtaining abdominal fat to be incor-
porated later in the dural closure to prevent postoperative
cerebrospinal fluid (CSF) leakage. The surgeon is seated
at the head of the table, the scrub nurse is across from the
surgeon, and the microscope is brought in from the top of
the head. The television monitor is behind the surgeon, in
front of the scrub nurse and easily seen by the anesthesi-
ologist.
A large postauricular incision is made just within the
hairline, and the mastoid periosteum is elevated forward
to the external auditory canal. The mastoid air cells are
removed with the air-driven Ototome drill and the sig-
moid sinus is skeletonized. Bone behind the sigmoid si-
nus is removed to expose the posterior fossa dura, the
sigmoid sinus is retracted with the Silverstein retractor,
and the vestibular otic capsule is skeletonized. Bone of
the otic capsule is hard and easily differentiated from the
mastoid air cells.
© 1992 The American Association of Neurological Surgeons
163
The mastoid air cells are removed from the supe-
rior petrosal sinus to the jugular bulb (Fig. 1). Bone re-
moval is carried above the posterior semicircular canal
and forward toward the superior semicircular canal so
that the superior and posterior semicircular canals are
the limits of the dissection anteriorly and superiorly.
Inferiorly, the retrofacial air cells inferior to the poste-
rior semicircular canal are opened and the anterior limit
of the dissection becomes the bone-covered facial nerve
in its mastoid portion. Air cells are removed then, infe-
riorly to the jugular bulb.
The key features of the dissection to this point are: 1)
retraction of the sigmoid sinus posteriorly; 2)
skeletonization of the vestibular otic capsule; 3) exten-
sion of bone removal into the retrofacial area; 4) exten-
sion of bone removal to the junction of the superior and
posterior semicircular canals (the crus commune); and,
5) dural exposure of the entire posterior fossa in this area.
The posterior semicircular canal must be thoroughly skel-
etonized to allow for maximal forward dural flap eleva-
tion, but it must not be entered.
The dura is opened in an apron-shaped fashion from
the crus commune, along the superior petrosal sinus pos-
teriorly to the sigmoid sinus, inferiorly along the sigmoid
sinus posterior to the endolymphatic sac, and anteriorly
into the retrofacial air cells toward and above the jugular
bulb. Silk sutures are used to hold this dural flap forward
over the posterior bony semicircular canal, weighted by
hemostats (Fig. 2).
It is at this point that patience becomes a virtue! It
appears that there is insufficient exposure for the op-
eration. The pCO2 must have been at 23 mm Hg for
some time. Incising the thin arachnoid with the
neurotologic scissors allows CSF to escape. The arach-
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-
lus is usually the main structure in the way of seeing the
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

© 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.

164
 LUETJE : RETROLABYRINTHINE PRESIGMOID APPROACH FOR SECTIONING VESTIBULAR NERVE
VIIIth nerve. Taking down the thin arachnoid carefully
here allows visualization of the VIIIth nerve. Raising the
operating table helps to bring the visual angle up almost
to the horizontal.
A piece of Telfa is placed over the cerebellum and
retracted with the multifenestrated Brackmann sucker.
Eventually, the VIIIth nerve comes into direct view. It is
directly in a plane that bisects the posterior semicircular
canal and angled slightly inferiorly from that plane. The
VIIth nerve can be seen along the inferior (cochlear divi-
sion) edge of the VIIIth nerve (Fig. 2A). The IXth and
Xth nerves are sometimes seen as well as, more com-
monly, the root entry zone of the Vth nerve. It is impor-
tant not to hurry this stage. Simply, careful and delicate
dissection of the arachnoid with time will provide the
exposure. Adhesions around an endolymphatic-CSF shunt
tube can be troublesome.
The vestibular and cochlear nerves are not clearly sepa-
rated by a cleft. Therefore, the tentorial 40-50% of the VIIIth
nerve should be the guide for sectioning. The vestibular
nerve fibers tend to spiral anteriorly around the cochlear
division. The Rosen needle is used to gently probe the VIIIth
nerve at a level where there is almost invariably a tiny, lin-
ear surface vessel on the VIIIth nerve (Fig. 2B). A plane of
dissection either develops or is created by this maneuver
(Fig. 2C). The cephalad vestibular division is sectioned with
a 0.5-mm hook or with the neurotologic scissors (Fig. 2D).
As the ends of the vestibular division retract apart (Fig.
2E), the cochlear division becomes more definable and a
little color differentiation develops, with the cochlear divi-
sion appearing more yellowish.
There should be no bleeding during any of these ma-
neuvers with careful and gentle dissection. A pia-arachnoid
membrane often seems to separate the cochlear (inferior)
and vestibular (tentorial) divisions within the core of the
VIIIth nerve, even if a surface cleft is not seen.
165
The dura is then approximated with sutures, and ab-
dominal fat is incorporated into the suture line to gain a
watertight dural closure. Strips of abdominal fat are then
used to fill the craniectomy defect. Filling the defect does
not interfere with hearing. The postauricular incision is
closed. The patient is extubated and returned to the re-
covery room.
COMPLICATIONS AND RESULTS
We have not experienced any complications with this pro-
cedure regarding CSF leakage, meningitis, or wound in-
fection. We routinely use prophylactic antibiotics given
at the induction of anesthesia and two doses after surgery.
The duration of surgery is usually 2.5 to 3.5 hours. Head-
aches are not a problem. Most patients are discharged
within four to five days and are given no prescription an-
algesics.
The one problem which has occurred has been hear-
ing loss. This can be caused by aggressive bone removal
over the posterior semicircular canal with entry into the
membranous canal, or interruption of microvascular cir-
culation to the cochlear nerve. We have not cut the co-
chlear nerve.
When a vestibular nerve section has been accom-
plished as we have described, the effective complete re-
lief of vertigo from Ménière’s disease has been greater
than 95%. We have not found it necessary to change our
approach to retrosigmoid because of exposure problems.
We recognize that the postoperative morbidity of
retrosigmoid vestibular nerve sections is reportedly higher
than we have experienced in our cases.
Although we believe that this type of vestibular nerve
section is the procedure of choice, we realize there are
many factors that determine the treatment for any patient
for Ménière’s disease and that no one choice of treatment
is best for all patients.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
STEREOTACTIC SURGICAL ABLATION
FOR PAIN RELIEF
RONALD F. YOUNG, M.D.
INTRODUCTION
The role of stereotactic surgical ablative lesions for pain
relief is relatively small. In the armamentarium of the mod-
ern neurosurgeon, such procedures as intraspinal and in-
traventricular infusion of opioids and electrical stimula-
tion procedures of the spinal cord and of deep brain
structures have largely replaced stereotactic ablative lesions
for treating chronic intractable pain. Nevertheless, there
remains a small group of patients for whom the previously
mentioned techniques, and others available, are either un-
suitable or unsuccessful and for whom stereotactic abla-
tive procedures offer a suitable potential means for pain
control. The primary brain targets for ablative stereotactic
procedures in the modern era are the medial thalamic nu-
clei (centrum medianum and parafascicularis intralaminar
nuclei) and the mesencephalon. A variety of other lesion
sites have been described in the past, including the ventral
posteromedial and ventral posterolateral specific sensory
thalamic nuclei, the spinal thalamic pathway in the pons,
the pulvinar, and other thalamic nuclei such as the anterior
and medial nuclei, as well as targets in the frontal and tem-
poral lobes. Lesions in the cingulum bundle which were
described some years ago for relief of chronic pain, but
about which little has been written recently, have been sug-
gested again based on magnetic resonance imaging (MRI)
localization and recent positron emission tomography (PET)
scan evidence that the cingulum bundle may be an impor-
tant termination point for pain-related information. These
new data have led to renewed interest in cingulumotomy as
a potential therapeutic avenue.
Because the techniques for stereotactic surgical ab-
lation for pain require sophisticated electrophysiologic re-
cording and stimulation methods to correctly locate the
targets, it is recommended that they be performed only
by neurosurgeons with considerable experience in func-
tional stereotactic neurosurgery. Neurosurgeons dealing
© 1992 The American Association of Neurological Surgeons
166
with chronic intractable pain generally divide patients into
two groups. Patients with disease processes which acti-
vate intact pathways in the nervous system for the pro-
cessing of pain information are thought to have pain of
so-called nociceptive origin. Patients with injuries to the
sensory portion of the nervous system, including the pe-
ripheral nerves, spinal cord, and brain, are considered to
have pain related to deafferentation. Some authors reserve
the term “deafferentation” for pain generated by injury to
peripheral nerves and reserve the term “central pain” for
pain related to lesions in the spinal cord or brain. Be-
cause almost all of the lesions in the nervous system pro-
ducing pain result in various forms of deafferentation, it
is thought suitable to use the terms deafferentation or cen-
tral pain essentially synonymously. In general, all forms
of intervention including stereotactic ablative procedures
have higher success rates with nociceptive than with deaf-
ferentation pain.
PATIENT SELECTION
Patients with nociceptive pain often respond well to anal-
gesics by a variety of routes, including opiates given by an
intraspinal or intraventricular route. These patients also
respond well to electrical stimulation, either of the spinal
cord or the brain, if analgesics and other pharmacologic
manipulations are unsuccessful. The role of adjunctive tech-
niques such as physical therapy, transcutaneous electrical
stimulation, nerve blocks, biofeedback, psychiatric and psy-
chological therapy, particularly when these modalities are
administered in the context of a comprehensive multidis-
ciplinary pain program, should not be overlooked in the
therapy of chronic pain. In general, stereotactic ablative
procedures should be considered only when other avenues
of therapy have been exhausted. In general, the author rec-
ommends that all other available forms of therapy, includ-
ing spinal and brain stimulation, be employed before ster-
eotactic ablative lesions are considered.
Pain related to deafferentation is more difficult to
 YOUNG : STEREOTACTIC SURGICAL ABLATION FOR PAIN RELIEF
treat. Such pain is often unresponsive to oral pharmaco-
logic agents, including analgesics, anticonvulsants, and
antidepressants. Electrical stimulation of either the spi-
nal cord or the somatosensory thalamus relieves deaffer-
entation pain in about 50% of patients. In general, the
author recommends that these techniques be exhausted
before stereotactic ablative lesions are contemplated ex-
cept in one instance. This instance relates to the thalamic
syndrome seen in patients who have experienced a tha-
lamic infarction with destruction of the ventral postero-
lateral (VPL) and ventral posteromedial (VPM) soma-
tosensory nuclei. In such patients, there is no available
thalamic target for stimulation, and stereotactic ablative
procedures may be considered without prior testing of
deep brain stimulation. For patients who experience pain
of the “thalamic syndrome” in whom the infarction is lo-
cated in the hemispheric white matter or cerebral cortex
rather than in the thalamus, a trial of thalamic somatosen-
sory stimulation is indicated prior to consideration of ste-
reotactic ablative lesions.
Patients who meet the criteria described earlier are
considered to be suitable candidates for consideration for
stereotactic lesioning for relief of intractable pain. Such
patients typically suffer pain related to anesthesia
dolorosa, peripheral nerve injuries, postherpetic neural-
gia, spinal cord injury, and the thalamic syndrome. Other
indications include patients with invasion of the brachial
or lumbosacral plexus by cancer and patients with unsuc-
cessful spinal surgery who suffer intractable back and leg
pain. The author considers a psychological assessment to
be an important part of patient selection. Psychological
test instruments such as the Minnesota Multiphasic Per-
sonality Inventory (MMPI) and psychological or psychi-
atric interviews are considered extremely helpful in pa-
tient screening. Patients whose personality traits include
hysteria, hypochondriasis, depression, and excessive fo-
cus on somatic complaints are unlikely to respond to any
form of surgical intervention, including stereotactic
lesioning. However, a relatively minor element of these
personality traits, particularly depression, is commonly
seen in chronic pain patients and does not necessarily
contraindicate a stereotactic ablative lesion.
PREOPERATIVE PREPARATION
No special preoperative preparations are required. Gen-
erally, a contrast-enhanced computed tomographic (CT)
scan or MRI scan of the brain is recommended. Such stud-
ies will identify any unexpected intracerebral lesions as
well as any unusual anatomical variations. Such studies
are absolutely mandatory in patients whose pain emanates
from cerebrovascular lesions. Intravenous antibiotics in
167
the form of 1 g of cefadyl or 500 mg of vancomycin for
patients with penicillin allergies is administered
perioperatively beginning at approximately the time of
placement of the stereotactic frame.
An important part of preoperative preparation is se-
lection of the intended target. The author employs almost
exclusively the medial thalamus. This target encompasses
portions of the intralaminar nuclei (centrum medianum,
parafascicularis) and the medial dorsal nucleus (Figs. 1 and
2). The lateral portion of the medial dorsal nucleus is usu-
ally referred to as the central lateral nucleus in cats and
primates other than humans but stereotactic atlases gener-
ally do not assign a special designation to this region. This
general medial thalamic area is believed to be the termina-
tion of the multisynaptic paleospinothalamic pathway, with
relays in the reticular formation, which is particularly in-
volved in the emotional response or suffering related to
persistent pain rather than to the sensory-discriminative as-
pect of pain. Some recent animal studies, however, indi-
cate more direct relays into the central lateral nucleus and
the region called the nucleus submedius in animals, from
both spinal and/or facial nociceptors. This general area can
often be identified by recording abnormal bursting dis-
charges of neurons in patients with intractable pain. Be-
cause axons of the neospinothalamic and trigeminothalamic
tracts terminate in the VPL and VPM thalamic nuclei, le-
sions in this location may induce loss of normal sensation
and risk producing a deafferentation pain syndrome. There-
fore, the author does not utilize these targets. Although other
thalamic targets have been employed by other surgeons,
the information available is so sparse and the basic science
data linking other thalamic targets to pain perception so
tenuous, that the author has generally not employed them
clinically.
The other major target for stereotactic ablative le-
sions to treat pain is the periaqueductal gray matter of the
mesencephalon. Lesions in this target are particularly
useful for pain in the head and neck due to cancer, but the
relatively high incidence of complications, particularly
interference with extraocular movements, relative to me-
dial thalamotomy, has prompted the author to employ
mesencephalotomy rarely.
For unilateral pain, a single thalamic lesion contralat-
eral to the side of the patient’s pain is generally adequate but
occasionally bilateral lesions may be required (Fig. 3). For
axial pain, including pain of the spine and abdominal or tho-
racic cavity, bilateral lesions are nearly always necessary. It
is recommended that in all cases a unilateral lesion be cre-
ated first and the patient observed for at least several weeks
before a contralateral lesion is created. The purpose of wait-
ing is to assess the effect of the single lesion and to allow
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

© 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).

168
 YOUNG : STEREOTACTIC SURGICAL ABLATION FOR PAIN RELIEF

© 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).

169
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

© 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).

170
 YOUNG : STEREOTACTIC SURGICAL ABLATION FOR PAIN RELIEF
any perilesional edema to subside as well as to assess any
interference with cognitive function before proceeding to
bilateral lesions.
SURGICAL TECHNIQUE
Anesthesia
The procedures are performed under local anesthetic infil-
tration of the scalp supplemented by intravenous sedation.
A 1% Xylocaine solution containing epinephrine in a con-
centration of 1:100,000 is infiltrated into the frontal and
occipital scalp at the points of stereotactic frame fixation.
The same local anesthetic is also infiltrated into the scalp
overlying the intended burr hole opening. Sedation is pro-
vided by midazolam beginning with a test dose of approxi-
mately 1 mg and fentanyl in an initial dose of approxi-
mately 50 µg. Supplementary doses are provided as required
to produce mild sedation. Verbal response from the patient
is essential during the electrophysiological portion of the
procedure in which the exact target is identified. The ideal
anesthetic situation is that in which the patient remains in a
light sleep but can be easily aroused by verbal stimulation.
Routine monitoring of the electrocardiogram and of blood
oxygen values via a pulse oximeter is recommended.
© 1992 The American Association of Neurological Surgeons
Figure 4. Vertex view of patient positioning in the Leksell Model G
stereotactic frame. Stabilization of the frame by an adaptor attachment
to the Mayfield head rest is shown.
171
Positioning
The patient is usually placed supine in a semirecumbent
position. The Mayfield attachment to the operating room
table with an adaptor for attachment to the Leksell ster-
eotactic frame allows a variety of positioning options to
provide for patients of different age and degree of tho-
racic and cervical spinal curvature (Figs. 4 and 5). Be-
cause the neurophysiologic portion of the operative pro-
cedure may be relatively lengthy, it is essential to provide
the patient with the most comfortable position possible.
Draping
A plastic aperture drape such as used by ophthalmic sur-
geons is ideal for providing exposure of the operative
site without excessively covering the patient. Excessive
draping of the patient’s body should be avoided in order
to allow observation of motor function as well as to per-
mit sensory stimulation and testing during the proce-
dure. Observation of the patient’s face is also essential,
particularly in instances where the procedure is intended
to treat intractable facial pain. In addition, the draping
should allow for observation of the patient’s eyes in or-
der to observe changes in pupillary size and extraocular
movements.
© 1992 The American Association of Neurological Surgeons
Figure 5. Lateral view of a patient in the Leksell Model G stereotactic
frame. Note the orientation of the frame base parallel to the orbital meatal
plane. The arc is positioned for right precoronal twist drill placement.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
Skin Incision
The author recommends a precoronal burr hole or twist
drill opening for all surgical ablation procedures to treat
pain (Figs. 5 and 6). This allows access to the thalamus as
well as the upper brain stem in a safe and relatively direct
manner. A variety of other access routes have been em-
ployed, particularly the posterior parietal approach, but
the latter risks either accidental anterior placement with
potential injury to the sensory motor cortex or a posterior
placement resulting in visual field deficits. The coronal
suture can be identified by palpation and, in most in-
stances, lies approximately 13.5 cm posterior to the na-
sion. The center of the burr hole should be placed ap-
proximately 2 cm lateral to the midline of the skull. This
positioning allows a relatively parasagittal approach to
the thalamus and the upper brain stem, approximately
parallel to the midline of the hemispheres. Thus, as the
lesioning probe or recording or stimulating electrode is
advanced, the primary movements will be to increase the
posterior and depth positioning of the electrode tip, mini-
mizing medial-lateral movement. In this way, one may
employ the sagittal diagrams from stereotactic atlases in
plotting the structures which will be encountered by the
© 1992 The American Association of Neurological Surgeons
Figure 6. Frontal view of a patient in the Leksell stereotactic frame.
The X coordinate is adjusted for a target 10 mm to the right of the middle
172
probe or electrode. More lateral burr hole placements re-
sult in the needle passing from lateral to medial as it is
advanced, requiring reference not only to different axial
and coronal plane stereotactic atlas diagrams but also to
different sagittal plane diagrams which complicates the
anatomical identification of the target. Excessively me-
dial placements of the burr hole may result in accidental
injury to bridging veins passing from the cerebral cortex
to the superior sagittal sinus or to very vascular paccionian
granulations with difficult-to-control hemorrhage, or in-
jury to the parasagittal portion of the cerebral hemisphere
with possible weakness of the contralateral leg.
Operative Technique
The author’s current technique employs MRI or CT scan-
ning for stereotactic anatomic target localization. Some ste-
reotactic surgeons still employ positive contrast ventricu-
lography for target localization. This technique may lead
to difficulty in ventricular cannulation in patients with small
cerebral ventricles, potential reactions to the contrast me-
dium including seizures, and shifts in brain targets due to
brain movement as a result of cerebrospinal fluid loss. These
risks, although small, can be avoided with CT or MRI
of the third ventricle. The arc angle is adjusted for placement of a twist
drill entry anterior to the coronal suture.
 YOUNG : STEREOTACTIC SURGICAL ABLATION FOR PAIN RELIEF
localizations. Functional corroboration of target localiza-
tion with microelectrode recording and/or micro- or
macrostimulation is considered essential for correct tar-
get localization. Dependence on anatomic target local-
ization alone will lead to a decrease in the success rate.
Once the desired physiologic target has been identified,
the author employs the radiofrequency electrode technique
for lesion production.
The Leksell Model G stereotactic system offers an
ideal method for anatomic target localization. This stereo-
tactic frame system is both CT- and MRI-compatible.
© 1992 The American Association of Neurological Surgeons
Figure 7. An MRI scanner table with the cradle positioned for attach-
ment of the Leksell Model G stereotactic frame. The grommets and
threaded nuts allow frame positioning.
© 1992 The American Association of Neurological Surgeons
173
Obviously, other stereotactic systems are also suitable.
Correct frame placement is essential for functional stereo-
tactic neurosurgery as opposed to situations when there
is an anatomically identifiable target such as a tumor.
Functional stereotactic neurosurgery requires the use of
reference points, generally the anterior commissure (AC)
and posterior commissure (PC), for anatomic target lo-
calization. With the Leksell system, placement of the base
of the frame parallel to the orbital-meatal plane ensures
that the plane of the CT or MRI sections will be as close
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
of the electrode is insulated except at its distal end. This ring,
located about 500 µm from the electrode tip, is used for
microstimulation. Although electrical stimulation through
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
positioning cradle. The fiducials for sagittal and axial
coordinate determination are visible.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

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

174
 YOUNG : STEREOTACTIC SURGICAL ABLATION FOR PAIN RELIEF

© 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.

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 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
damage the electrode tip so that single cell activity can-
not be recorded. Recording is carried out beginning ap-
proximately 5-10 mm before the intended target and con-
tinued as necessary beyond the intended target as
determined anatomically. Single and multiple unit record-
ings are made using conventional amplification techniques
with audio and video monitoring of electrical activity in-
traoperatively. The microelectrode is advanced using a
hydraulic microdrive which allows micron range control
of electrode movement. Particular electrophysiologic sig-
natures of the various lesioning targets are obtained. Single
or multiple unit activity which is somatotopically orga-
nized and which can be activated by light mechanical
contact with receptive fields on the contralateral portion
of the body serves as a reliable localization of the VPM
and VPL nuclei. Electrical stimulation in these same tar-
gets generally produces a sensation of paresthesias in the
corresponding contralateral portion of the body and cor-
roborates correct target localization. In patients with pain
related to deafferentation, spontaneous neuronal hyper-
activity and disorganization of receptive fields may also
be identified with microelectrode recording in VPL and
VPM. Some authors recommend routine neurophysiologic
identification of VPL/VPM to serve as a reference guide
to the thalamic nuclei but we do not usually use this tech-
nique. Recording in the intralaminar thalamic nuclei, in-
cluding centrum medianum and parafascicularis as well
as centralis lateralis, generally fails to identify neurons
which can be activated by peripheral stimulation. Like-
wise, electrical stimulation in these targets usually fails
to produce detectable sensations. Occasionally, patients
with pain related to deafferentation experience an inten-
sification of their pain with stimulation in the intralaminar
region. We have also recently identified spontaneous neu-
ronal hyperactivity in the intralaminar thalamic region in
patients with chronic pain, and such activity may serve as
a guide to localization of the correct target for a medial
thalamotomy (Figs. 3 and 10). We have identified such
bursting neurons in the intralaminar region, centrum
medianum, parafascicularis, and the lateral portion of the
medial dorsal nucleus which was referred to earlier as the
central lateral nucleus. The bursting neurons discharge at
a rate of approximately 2-6 bursts per second. The bursts
generally contain 2-8 action potentials per burst with a
firing frequency within each burst of 200-300 Hz. Occa-
sionally, bursting neurons are identified with up to 60-80
action potentials per burst. Our current technique is to
identify the locations of bursting neurons in the medial
thalamus and then to attempt to destroy all of the tissue
where such neurons are located.
Electrophysiologic observations which allow local-
176
ization of targets for stereotactic mesencephalotomy have
been described. Epileptic discharges identified by EEG
recording techniques have been reported from this area.
In addition, responses to electrical stimulation in this area,
including painful responses within 6.5 mm of the midline
in the mesencephalic region, warmth or cold at targets up
from 9 to 16 mm lateral to the midline, and a burning
sensation from targets scattered across this same target
area have been noted. Stimulation in this general region
may elicit reports of pain similar in character, intensity,
and location to the patient’s original pain complaint in
patients with central pain but not in those with nocicep-
tive pain. Ocular responses, including conjugate eye de-
viation, convergence, pupillary constriction, lid retraction,
and restriction of upward gaze, are also typical of this
location. However, these responses alone can be obtained
from a variety of locations in this general area and do not
serve as a reliable confirmation of electrode positioning
prior to lesioning. They are only a general indication of
the target area. Some other electrophysiologic signatures
both by recording and stimulation have been reported in
isolated publications in this area but general confirma-
tion of these results has not been forthcoming.
Once the intended target has been localized anatomi-
cally and electrophysiologically, a radiofrequency
lesioning electrode with a thermistor tip for temperature
recording and with an uninsulated area measuring 5 mm
in length and 2.1 mm in diameter is inserted into the de-
sired target. The lesion is usually made beginning at about
60°C with continuous monitoring of the patient’s clinical
neurologic condition and with final lesion temperatures
in the range of 75-80°C. Each temperature is maintained
for 60 seconds. Once an initial lesion has been created,
further electrophysiologic recording and stimulation and
a clinical assessment of the patient is carried out to deter-
mine whether further lesions should be created. Our goal
is to produce a relatively large lesion, about 1 cm in length
and about 6-8 mm in diameter.
It has been my practice to carry out a CT scan imme-
diately postoperatively to evaluate the possibility of in-
tracerebral hemorrhage. If hemorrhage is not identified,
the patient is returned to the usual neurosurgical nursing
unit and not observed in an intensive care unit. Postop-
erative follow-up MRI scanning is suggested as a means
of documenting the location, size, and shape of the lesion
created (Fig. 11). This technique is particularly helpful if
an initial stereotactic ablative procedure fails to provide
the desired pain relief.
Closure
Generally, an acrylic cranioplasty is carried out to oc-
 YOUNG : STEREOTACTIC SURGICAL ABLATION FOR PAIN RELIEF
clude the burr hole and prevent later cosmetic deformity
due to indentation of the scalp. The scalp is then closed in
two layers.
Monitoring
As mentioned, electrophysiologic monitoring is essential
for correct target identification. Targets in the VPL or VPM
thalamus can probably be localized satisfactorily by elec-
trical stimulation alone, although electrical recording im-
proves the accuracy considerably. Microstimulation. as
opposed to large electrode stimulation will result in more
accurate localization. Electrical stimulation alone will
generally not allow reliable identification of the medial
thalamic nuclei because electrical stimulation elicits no
detectable sensory phenomena in most patients. Thus,
microelectrode recording is essential for medial thalamo-
tomy to identify the target accurately. The identification
of neurons exhibiting an abnormal bursting pattern in this
location is considered a possible guide to lesioning. The
bursting pattern is characterized by intermittent single unit
discharges with the burst frequency in the range of 2 to 6
per second. Individual bursts may contain as few as 2 or
as many as 60 to 80 individual action potentials. Our tech-
nique has included an attempt to identify the distribution
of these abnormally discharging neurons and then to use
this information as a guide to lesion planning. We try to
destroy all tissue from which such abnormal activity can
be recorded.
For mesencephalotomy, microstimulation is probably
suitable for target localization. Microelectrode recording
and microstimulation combined will allow for more ac-
curate target localization.
SPECIALIZED INSTRUMENTATION
The Leksell Model G stereotactic frame offers a versatile
instrument which is compatible with CT and MRI scan-
ning and can be used with conventional ventriculography
as well for anatomic target localization. It can be easily
interfaced with the appropriate neurophysiologic moni-
toring electrode equipment and lesioning equipment pre-
viously described. The equipment necessary for electro-
physiologic monitoring includes a suitable preamplifier,
amplifier, and oscilloscope, and a facility for magnetic
taping of neuronal activity for later playback. The elec-
trodes are fabricated in our laboratory from 0.01-inch di-
ameter tungsten wire. The electrode tips are etched elec-
trically. The concentric outer sheath is made from stainless
steel tubing, and the insulation between the inner record-
ing electrode and the outer stimulating electrode is pro-
vided with an epoxy polymer resin and a 28-gauge polya-
mide sleeve. The outer cylinder is also insulated with a
177
21-gauge polyamide sleeve except for a small ring at the
distal end which allows for microstimulation. Although
microelectrodes suitable for single unit recording are
manufactured in short lengths, the lengths necessary for
human recording are unavailable. The electrodes utilized
for electrical recording for epilepsy monitoring are not
suitably small to allow single units to be identified. For
stimulation, we use a gross physiologic stimulator and a
PSIU-7 constant current isolation unit. For
microstimulation via the uninsulated distal ring of our
electrode, monophasic square wave pulses of 50 to 1.5
mA are used. For stimulation through the electrode tip,
currents of 8-70 mA are used. Stimulation may be car-
ried out in a bipolar manner between the electrode tip and
ring or in a monopolar manner between either the tip or
ring and an indifferent electrode. Stimulation frequencies
of 5-300 Hz are used but most commonly 50-100 Hz is
used. Single pulse, multipulse trains, or continuous stimu-
lation is used.
COMPLICATIONS
Medial stereotactic thalamotomy is the safest of the ste-
reotactic ablative procedures. Correctly placed lesions
provide pain relief without any detectable change in the
patient’s sensory function. Lesions placed too far poste-
riorly may encroach on the region of the posterior com-
missure and produce transient or (rarely) permanent eye
movement disorders such as diplopia and limitation of
upward gaze. Occasional transient effects on cognitive
function usually resolve quickly, although bilateral me-
dial thalamic lesions may produce more lasting cogni-
tive deficits. Lesions in the lateral somatosensory nu-
clei produce an alteration in contralateral sensory
function which may include tactile and/or pain sensa-
tion. Interference with proprioceptive sensation may also
be identified. Such lesions run a small risk of producing
a deafferentation pain syndrome from interference with
somatosensory pathways.
Medial mesencephalic tractotomy is associated with
a high incidence of temporary disorders of ocular motil-
ity, most of which clear with time. Nashold, however, re-
ported a permanent problem with ocular motility in 16%
of his patients and Frank, in 13%. A mortality rate of 1.8%
was also reported by Frank. My opinion is that mesen-
cephalic tractotomy is associated with a significantly
higher complication rate than medial thalamotomy.
The best results with mesencephalic tractotomy have
been reported with unilateral pain in the head and neck or
arm, although bilateral pain is occasionally controlled as
well. Bilateral medial thalamic lesions may also be re-
quired to control either unilateral or midline pain.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
ANTERIOR SCREW FIXATION
OF ODONTOID FRACTURES
RONALD I. APFELBAUM, M.D.
INTRODUCTION
The treatment of odontoid fractures in which the fracture
occurs across the base of the odontoid process at its junc-
tion with the body of C2 (Type II) remains controversial
(Fig. 1). Early operative intervention or a period of im-
mobilization with an external device such as a Minerva
jacket or halo vest have both been advocated. Various
authors have attempted to define the parameters which
will predict nonunion rates when these fractures are treated
by immobilization. Direction of displacement, degree of
displacement, and the age of the patient have been shown
to be predictors of nonunion but the various published
studies do not agree on absolute parameters which will
© 1992 The American Association of Neurological Surgeons
Figure 1. A, a Type II odontoid fracture with anterolisthesis of the
odontoid on the body of C2 of approximately 5 mm is noted on the
© 1992 The American Association of Neurological Surgeons
178
reliably predict the incidence of this complication.
The most commonly used surgical treatment, either
as initial therapy or when immobilization fails, is a poste-
rior fusion between the arches of C1 and C2. Depending
on the technique this may require an additional period of
external immobilization to increase the likelihood of suc-
cess. This approach, while stabilizing the spine well, re-
sults in elimination of the normal rotation between C1
and C2 which accounts for more than one-half of the nor-
mal axial rotation of the cervical spine.
In contradistinction, anterior screw fixation allows
direct fixation across the fracture site and achieves im-
mediate stability while restoring and preserving
lateral view. B, a transoral anteroposterior (AP) view shows a fracture
at the base of the odontoid process.
 APFELBAUM : ANTERIOR SCREW FIXATION OF ODONTOID FRACTURES
normal biomechanics of the spine. The special instrumen-
tation described in this chapter has been developed to al-
low this procedure to be performed easily, quickly, and
safely. The fixation screws are made of titanium and thus
do not impede future magnetic resonance imaging (MRI)
studies.
PATIENT SELECTION
We initially offered the procedure to patients only after
failure of “conservative” measures (i.e., halo vest immo-
bilization). However, its demonstrated success and low
morbidity have convinced us that not only should it be
considered the operative procedure of choice but a viable
alternative to nonoperative initial management in patients
who are at a higher risk for nonunion. In addition, it is an
appropriate choice for patients who, after full discussion,
opt for earlier intervention.
SURGICAL TECHNIQUE
Endotracheal Intubation
and Patient Positioning
If the patient’s neck is unstable in extension, intubation
© 1992 The American Association of Neurological Surgeons
Figure 2. The patient is positioned for surgery. Note the elevated thorax
and hyperextended neck (the patient’s fracture reduced in extension).
Positioning was achieved while monitoring spinal motion under lateral
179
techniques that avoid neck extension such as “blind”
nasotracheal intubation or fiberoptic-assisted intubation
should be utilized. In the case of anterolisthesis of the
odontoid which reduces in extension, no special technique
is usually required.
The patient is positioned on the operating table with
a folded blanket beneath the shoulders to increase neck
extension. If the fracture reduces in extension, a hyper-
extended position is chosen (Fig. 2). If the odontoid is
retrolisthesed and reduces in flexion, the head is elevated
and the neck is kept in a neutral position. Light halter
traction holds the head immobile. A radiolucent bite
block is placed to keep the jaws open and two portable
C-arm fluoroscopic units are positioned to provide lat-
eral and anteroposterior (AP) (transoral) views of the
odontoid. If only one unit is available, it needs to be
rotated back and forth from the AP to the lateral posi-
tion. Freedom to achieve this movement should be en-
sured before draping.
Operative Procedure
After routine preparation and draping, a unilateral hori-
zontal incision is made along a natural skin crease
fluoroscopic control to avoid spinal canal compromise. Two fluoroscopic
units are used for sequential intraoperative AP (transoral) and lateral
fluoroscopic monitoring. Halter traction secures the head.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

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

180
 APFELBAUM : ANTERIOR SCREW FIXATION OF ODONTOID FRACTURES

© 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).

181
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

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

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 APFELBAUM : ANTERIOR SCREW FIXATION OF ODONTOID FRACTURES

© 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).

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 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
starter hole made by the K-wire (Fig. 7). A right-angle
drive is used to clear the thoracic region and a hole is then
drilled under careful biplane fluoroscopic control from
the inferior anterior edge of C2 through the body of C2
and into the odontoid to its apex. This requires a low tra-
jectory and may require manipulation of the head and/or
upper vertebrae to optimize alignment of the fragment
before drilling the hole. The drill guide often will assist
with this as it allows both gentle anterior and posterior
displacement of the C2-3 complex. When the drill is at
the apex of the odontoid its depth can be read off the cali-
bration marks on the shaft of the drill where it extends
out of the inner drill guide (Fig. 7). For this to be accu-
rate, the inner guide tube must be positioned properly with
its distal end touching the inferior surface of C2 (Figs. 5,
inset, and 6, inset).
© 1992 The American Association of Neurological Surgeons
Figure 7. A pilot hole is drilled from the inferior edge of C2 to the tip of
the odontoid under biplane fluoroscopic control (inset). The illustration
shows this in progress, not the final position which should extend to the
184
The drilled hole is then tapped (threaded) (Fig. 8) by
removing the drill and the inner drill guide (Fig. 8, inset A)
and replacing them with the tap which is manipulated by
hand while monitoring its progress fluoroscopically. The tap
also has calibration marks to recheck the depth of penetra-
tion and a sliding sheath which covers the exposed cutting
tip to prevent soft tissue entanglement (Fig. 8, inset B). When
the tap is being removed, the operator should be sure that the
sleeve slides back over the exposed cutting edges.
The screw, selected according to the measured
depth, is placed through the outer guide tube and into
the C2 body through the drilled and tapped hole (Fig.
9A). It is a lag screw with a nonthreaded proximal shaft
to allow the distal fragment to be pulled down to the
body of C2. In an acute fracture, it is placed into the
odontoid and tightened f irmly, as its progress is
upper surface of the odontoid. The calibration on the remaining exposed
drill shaft indicates the depth of drill penetration and hence the length of
the fixation screw needed.
 APFELBAUM : ANTERIOR SCREW FIXATION OF ODONTOID FRACTURES

© 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).

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© 1992 The American Association of Neurological Surgeons

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

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 APFELBAUM : ANTERIOR SCREW FIXATION OF ODONTOID FRACTURES

© 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.

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 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
monitored fluoroscopically. Usually the fragment will be
seen to be drawn down and reapproximated to the body
of C2. The head of the screw should recess into the C2-3
annulus/disc edge or into the inferior edge of C2 (Fig.
9D).
For chronic nonunited fractures, the screw is placed
into the body of C2 until just below the fracture site (Fig.
9B). The drill guide is then removed and special bisurfaced,
angled curettes are used to freshen the fracture site and
remove fibrous tissue. This is done by forcing the tip of
the smaller curette through the weak anterior longitudi-
nal ligament at the fracture site (as monitored fluoroscopi-
cally) and rotating the handle. The curette, which is angled
slightly in a coronal plane, has cutting surfaces on both
its top and bottom sides. It is then replaced with the sec-
ond small curette angled in the opposite direction, which
is manipulated similarly. Then the two larger curettes are
sequentially introduced and also manipulated in the same
manner. This is done to try to enhance fusion.
The screw head can then be reengaged in the ball
driver, which can be inserted at an angle of ±15° to the
long axis of the screw, and tightened fully (Fig. 9C). In
chronic cases the fragment may not reapproximate to the
body of C2. If the screw penetrates and extends beyond
the posterior cortex of the odontoid for 1 mm or more or
beyond its apex by 2 mm or more, it can be removed and
a shorter screw substituted.
Placement of a second screw is accomplished in a
similar manner, using a K-wire for guidance, and an 8
mm drill to cut a groove in the anterior surface of C3 and
the C2-3 disc. As before, the surgeon places the drill
188
guides, drills the hole, taps the hole, and places the screw.
No further curetting is needed. The second screw can be
either a lag screw or a fully threaded one.
Figure 10 shows ideal screw placement on AP and
lateral radiographs. The neck should be stable immedi-
ately. Flexion and extension of the patient’s neck under
fluoroscopy will confirm this and exclude any other un-
recognized injury such as transverse ligament rupture or
unstable adjacent segments. The retractors are then re-
moved, the wound checked for hemostasis, and closure
completed in layers. We use interrupted absorbable su-
tures in the sternocleidomastoid muscle fascia, platysma
muscles, and subcutaneous tissues, and use sterile adhe-
sive strips on the skin. Normally we do not use drains.
POSTOPERATIVE CONSIDERATIONS
No external orthosis is needed unless there is concern about
the patient’s bone strength (i.e., osteopenia) or there are
other associated injuries which require this. Patients are
observed carefully in the first 12-24 hours for any signs of
neck swelling, airway compromise, infection, or vocal cord
dysfunction. They can usually resume oral alimentation
within a day or two and be discharged from the hospital in
a few days. They are allowed to return to normal activities
and work as long as these are not strenuous.
Bone bridging is observable in two to five months in
acute cases but can be delayed in chronic nonunion.
Tomograms are helpful to evaluate this as the relative
density of adjacent bony structures makes early bone
bridging hard to detect on plain x-ray films (Fig. 11).
 CARPAL TUNNEL SYNDROME
SETTI S. RENGACHARY, M.D.
INTRODUCTION
The carpal tunnel syndrome is the most common entrap-
ment neuropathy that a neurosurgeon encounters in daily
practice. This syndrome is also treated by plastic surgeons,
hand surgeons, orthopaedic surgeons, and general sur-
geons. Although the technique of surgery may vary to
some extent, depending upon the specialty of the surgeon,
to obtain optimal results, one should be careful in the se-
lection of patients, be knowledgeable about the anatomy
of the region, pay attention to details in the operative tech-
nique, and provide optimal postoperative care. In spite of
all these efforts, it is inevitable that 5 to 10% of individu-
als fail to improve or present with some complication.
These will be discussed at the end of the chapter. The
goal of the treating surgeon of this common disorder is to
maximize favorable operative results and minimize com-
plications.
PATIENT SELECTION
Operative indications are discussed based upon the clini-
cal picture prevalent in contemporary neurosurgical prac-
tice. Gone are the days when patients presented with ad-
vanced thenar atrophy. The more typical presentation in a
modern setting is for a middle aged woman to present
with intractable pain and paresthesia in the hand that wakes
her up at night. The pain is generally confined to the hand
and is worse on the radial aspect than on the ulnar side.
Quite often the patient may complain of diffuse aching
pain in the whole hand. At times, the pain radiates to the
proximal forearm and even to the shoulder. A distinguish-
ing characteristic of pain originating from the median
nerve in the wrist is its distal to proximal progression start-
ing at the wrist and then extending to the forearm and the
shoulder, in contrast to the shooting pain starting at the
neck and radiating to the thumb and index finger that is
seen in C6 cervical radiculopathy. The pain is dull, ach-
ing, and constant. It is aggravated by hand motion. It
worsens during repetitive motion, typically during daily
household chores or at occupations such as typing or driv-
© 1992 The American Association of Neurological Surgeons
189
ing. The syndrome may affect one or both hands, and if
both hands are affected, the dominant hand is quite often
more involved than the nondominant hand. However, it is
not uncommon to see patients with worse symptoms on
the nondominant side. Some elderly patients may present
with motor atrophy involving the thenar muscles without
any significant wrist pain. These individuals generally do
poorly with regard to motor function compared to those
presenting with pain alone.
Typically, one finds a paucity of objective findings
on initial neurologic evaluation. In well over 30% of my
patients, I find no evidence of sensory or motor abnor-
malities on careful testing. In less than 5% of individuals
there is motor atrophy involving the thenar muscles. In
the remainder there are varying degrees of sensory loss,
especially in the tips of the thumb and index finger and
less frequently in the middle finger and the lateral half of
the ring finger. The sensory loss consists of blunting of
pinprick and light touch sensation and impairment of two-
point discrimination at the finger tips. It is seldom that
one finds sensory loss extending to the remainder of the
digits and never to the palm of the hand. If sensory loss is
present in the dorsum of the hand, obviously one is deal-
ing with a syndrome other than median neuropathy at the
wrist. Some clinicians attach a great deal of importance
to the presence of Tinel’s and Phalen’s signs, but in con-
temporary neurosurgical practice I find these two signs
to be of little value in making a surgical decision.
The diagnostic workup is generally tailored to the clini-
cal presentation and the risk factors that lead to this syn-
drome. In the majority of individuals the lesion is idio-
pathic and therefore the only diagnostic test that is
performed is a nerve conduction velocity study and needle
electromyography. Prolongation of sensory latency is the
earliest and most constant finding. Prolongation of motor
latency occurs next and finally denervation potentials are
seen in median-innervated muscles. Most patients that I
encounter have only prolongation of sensory conduction
velocity with minimal if any changes in the motor conduc-
tion velocity. However, one should exercise caution in se-
lecting patients purely on the basis of nerve conduc-
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
tion velocity studies, if the clinical history is very atypi-
cal or if the patient has underlying peripheral neuropathy.
In such instances, if a surgical decision is made based on
mere prolongation of sensory conduction velocity, the
outcome could be suboptimal.
The ideal situation is one in which the patient gives a
very typical history and demonstrates prolongation of
sensory latency as a confirmatory finding. An especially
difficult situation is an individual who does heavy, strenu-
ous manual labor and has what can be described as an
“overuse syndrome.” If such an individual has an atypi-
cal history, has symptoms primarily from work-related
overuse, and has prolonged sensory conduction latency
as a sole diagnostic criterion, the likelihood of failure from
a surgical procedure to relieve his symptoms is probably
quite high. Patients with diabetic neuropathy or alcoholic
peripheral neuropathy who present with an atypical his-
tory and have delayed sensory conduction velocity as the
sole diagnostic criterion are borderline candidates for
surgery. They should be advised that median neuropathy
may be part of a generalized process; compression of the
nerve probably plays a modest role and surgical therapy
may not offer complete relief.
Although most patients have carpal tunnel syndrome
on an idiopathic basis, some underlying risk factors should
be carefully assessed. Women should be questioned about
pregnancy. Because carpal tunnel syndrome is a transient
event during third trimester pregnancy, surgical therapy
can generally be withheld until delivery occurs; symp-
toms then ordinarily resolve spontaneously. Patients on
contraceptive pills may be prone to carpal tunnel syn-
drome. Rheumatoid arthritis is the most common, most
obvious primary factor that leads to entrapment of the me-
dian nerve at the wrist. One should make certain that the
affected individuals are adequately treated for their sys-
temic disease before surgical therapy is undertaken. If an
obvious endocrinopathy such as myxedema or acromegaly
is detected during the clinical examination, the underly-
ing process should be addressed first before the carpal
tunnel syndrome is dealt with surgically. An orthopaedic
opinion should be sought if the patient has a malunited
fracture or excessive callus related to the carpal bones or
the distal end of the radius. A conservative approach
should be practiced in individuals in whom the carpal tun-
nel syndrome is of short duration or is of mild and inter-
mittent nature, or if there is a reversible pathology. Typi-
cally, individuals who are accustomed to a sedentary
occupation but do heavy manual labor through a long
weekend may present with a typical carpal tunnel syn-
drome the following week. Such individuals should be
treated with rest, a wrist splint, and nonsteroidal anti-in-
flammatory agents before any diagnostic workup or sur-
gical therapy is undertaken. Similarly, as indicated ear-
190
lier, pregnant women seen in the third trimester of preg-
nancy with a typical carpal tunnel syndrome may be
treated with reassurance and a wrist splint until the deliv-
ery. However, if the pain disturbs sleep at night and if
patients require a narcotic agent for relief, then section of
the carpal ligament under local anesthesia might be a sim-
pler alternative. Manual laborers who have a history of
repeated work-related injuries, present with an atypical
history, have inadequate objective findings, are unhappy
about their occupation, and are seeking financial com-
pensation, do extremely poorly.
A paradoxical situation arises when the patient has a
very typical history that suggests carpal tunnel syndrome
but the electrodiagnostic test is entirely negative. Such a
situation is rarely seen in clinical practice, but is encoun-
tered on occasion. If the clinical history and findings are
very typical, and if a repeated electrodiagnostic test con-
tinues to be negative and conservative treatment fails, in
such instances it is justifiable to proceed with a surgical
section of the carpal ligament as both a diagnostic and a
therapeutic measure.
SURGICAL ANATOMY
The carpal tunnel is situated in the proximal part of the
palm of the hand, limited by the wrist crease proximally.
It is well to emphasize that the entire carpal tunnel lies
distal to the wrist crease in the palm of the hand. Indeed,
one is surprised to see instances where patients have been
referred for “recurrent carpal tunnel syndrome” when in
fact the operative scar lies entirely or nearly entirely proxi-
mal to the wrist crease in the distal forearm.
The carpal tunnel is bounded dorsally by the carpal
bones and ventrally by the transverse carpal ligament. The
carpal bones form a shallow trough which is completed
into the tunnel by the carpal ligament. Recent studies,
magnetic resonance imaging (MRI) and computed tomog-
raphy (CT) scans, have shown that individuals who are
predisposed to be afflicted by the carpal tunnel syndrome
tend to have small carpal canals. The small size of the
carpal canal as evidenced by the decrease in its cross-
sectional diameter is a congenital or developmental phe-
nomenon. The smaller size in women may account for
the higher incidence of carpal tunnel syndrome in them.
Among individuals who pursue the same occupation such
as truck driving or electrical maintenance, only a small
percentage develop carpal tunnel syndrome. It is conceiv-
able that congenitally small size of the carpal canal pre-
disposes them to have the median entrapment neuropathy
even though they are exposed to the same risk factor. I do
not recommend routinely measuring the cross-sectional
area of the carpal canal by computed tomography.
The contents of the carpal tunnel are the median
nerve and the long flexor tendons including their syn-
 RENGACHARY : CARPAL TUNNEL SYNDROME
ovial sheaths. Any lesion affecting the tendons or their
synovial sheaths tends to compromise the carpal canal
and may produce compressive neuropathy. In a similar
manner, old healed fractures of the carpal bones with
exuberant callus may also produce the syndrome. The
ulnar nerve is outside of the carpal canal and thus is not
subject to compression by the carpal ligament. The same
applies to the palmar cutaneous branch of the median
nerve and the corresponding palmar cutaneous branch
of the ulnar nerve. The most significant part of the
anatomy is the motor branch of the median nerve which
arises immediately under the carpal ligament near its
distal broader and supplies the thenar muscles. Numer-
ous variations of the motor branch have been described;
however, if one follows the technique described in this
chapter it is seldom that the motor branch of the median
nerve will be exposed. The less dissection of the nerve,
the less morbidity there is with regard to nerve injury.
PREOPERATIVE PREPARATION
Section of the carpal ligament is usually done as an
outpatient procedure. If the patient has bilateral carpal
tunnel syndrome, a decision has to be made whether to
section both ligaments in the same sitting or in two sepa-
rate sittings. This is usually decided after discussion
with the patient, taking into account her or his personal
preference. If the patient is very anxious to return to
work and not miss any work days, has sufficient house-
hold help, and wishes to have the bilateral procedure,
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.
The patient is asked not to eat or drink after mid-
night preceding the day of surgery although the proce-
dure is done with local anesthesia. The patient is in-
structed to scrub the hands with a detergent containing
either povidone-iodine or chlorohexidine for two con-
secutive days before surgery and on the morning of
surgery. This is particularly important in individuals
with dirty, greasy hands from their employment, such
as gas station attendants, auto mechanics, painters, and
construction workers. Two hours before surgery, the
patient is administered a tranquilizing agent as premedi-
cation. Two milligrams of lorazepam with a sip of wa-
ter has worked well for this purpose. The patient is ac-
companied by a relative or friend who can drive the
patient home after surgery.
SURGICAL TECHNIQUE
Positioning and Draping
The patient is positioned in a supine position with the
arm outstretched on a well-cushioned arm board. The
191
arm is prepared up to the elbow using a povidone iodine
soap for 10 minutes followed by a 2-minute paint with
povidone-iodine solution. Draping is carried out using
waterproof sheets with a central opening. The hand is kept
in the supine position with all the digits outstretched, and
an iodine-coated clear plastic adhesive drape is laid over
it. This adhesive drape maintains the hand in the out-
stretched position and thus one does not require any spe-
cial devices to keep the hand outstretched. The patient is
monitored with an automatic blood pressure cuff, an elec-
trocardiographic monitor, and a digital oximeter. The an-
esthesiologist maintains conversation with the patient
throughout the procedure to assess the level of comfort
and make sure there are no untoward complications. Pa-
tients may request to observe the operation but this is not
allowed.
Anesthetic Technique
The administration of anesthesia for section of the carpal
ligament is an integral part of the operative procedure.
The anesthetic technique is therefore described in some
detail. There are three choices of anesthesia. The first is
local infiltration anesthesia, the second is a Bier block,
and the third is general anesthesia. Local anesthesia is
the technique I prefer because of its simplicity and rapid-
ity. General anesthesia is reserved for individuals who
are extremely apprehensive and do not wish to go through
any procedure under local anesthesia.
Local Anesthesia
For local anesthesia, I use 1% lidocaine without epineph-
rine. It is important not to use epinephrine because of the
potential of spasm of the digital arteries which may lead to
ischemia of the fingers, perhaps even to the point of gan-
grene. Using a small-gauge needle (25-gauge) and a 10-ml
syringe, the skin is penetrated at the middle of the pro-
posed incision, and utilizing the same skin puncture the
infiltration is started subcutaneously and extended up to
the limits of the incision and for about 1 cm beyond the
proposed incision line. The advantage of infiltration be-
yond the proposed incision line is that when the self-re-
taining refractors are applied, the edges of the wound un-
dergo traction and this may be painful if the infiltration is
not carried out beyond the wound edges. Generous amounts
of the anesthetic agent are used, usually 10 to 12 ml of
lidocaine. The infiltration is carried to the level of the trans-
verse carpal ligament but not any deeper. If the infiltration is
carried deep to the transverse carpal ligament, the patient
will get anesthesia in the distribution of the median nerve
and may be alarmed postoperatively to find dense anesthe-
sia in the distribution of the median nerve. Although this
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

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
removed.
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,

perioral tingling, seizures, etc.
It takes approximately 5 to 7 minutes for the analgesia
to take effect after the injection of the lidocaine. Then the
plastic cannula is removed and the surgical scrub is started.
A little pressure is applied over the injection site to prevent
Figure 1. The skin incision extends from the wrist crease in the
midpalm to a point in line with the fully extended thumb (horizontal
dashed line). An optional extension may be carried into the distal fore-
arm (curvilinear dotted line) to facilitate exposure of the proximal part
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
skin crease but just medial to it.

192
 RENGACHARY : CARPAL TUNNEL SYNDROME
fact, there is no need to extend the incision beyond this
point because the distal edge of the transverse carpal liga-
ment is well within this limit. Proximally, the skin inci-
sion stops at the wrist crease but an optional extension
can be carried into the distal forearm in a curvilinear
manner to facilitate exposure of the most proximal part
of the transverse carpal ligament. If the extension across
the wrist is decided upon, it should not be extended in a
straight line across the wrist crease because that may re-
sult in a scar crossing the wrist joint, resulting in a re-
striction of motion and wrist pain. If the incision is made
close to the middle of the palm, then there is much less
risk of injuring the palmar cutaneous branch of the me-
dian nerve which is further lateral and the palmar cutane-
ous branch of the ulnar nerve which is further medial.
Also one should make every effort not to place the main
incision within the palmar skin crease itself. The skin
crease in the palm of the hand forms a natural hinge to
the thumb which should not be interfered with. Also, an
incision made in the skin crease within the palm does not
heal as readily as do incisions made elsewhere.
© 1992 The American Association of Neurological Surgeons
Figure 2. Protrusion of exuberant palmar subcutaneous fat after the skin incision is made.
193
As soon as the skin incision is completed, exuberant
subcutaneous fatty tissue protrudes through the incision
(Fig. 2). Multiple cutaneous and subcutaneous bleeders
are coagulated with bipolar cautery. At this stage, digital
pressure on the margins of the wound also facilitates con-
trol of the bleeding. Initially, hand-held small rake refrac-
tors are used to retract the skin margins, and the subcuta-
neous tissue is carefully divided in the midline, exposing
the palmar aponeurosis (Fig. 3). The palmar aponeurosis
is a fanshaped expansion into the palm of the palmaris
longus tendon. It flares out into thin, silvery fibers which
are generally transparent and sparse. The palmar aponeuro-
sis divides into multiple slips coursing toward the digits;
thus, their fibers become further separated as they are
traced distally. The palmar aponeurosis is divided in line
with the skin incision and retracted laterally. This exposes
the transverse carpal ligament (Fig. 4).
The distal part of the transverse carpal ligament
is more apparent and a faint edge of the transverse
carpal ligament can be seen blending with the palmar
fascia. Proximally, the transverse ligament is ob-
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

© 1992 The American Association of Neurological Surgeons

Figure 3. Exposure of the palmar aponeurosis.

194
 RENGACHARY : CARPAL TUNNEL SYNDROME

© 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

195
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

© 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.

196
 RENGACHARY : CARPAL TUNNEL SYNDROME

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

197
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

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

198
 RENGACHARY : CARPAL TUNNEL SYNDROME
cause infection. The dressings are changed at 1 week and
sutures are removed anywhere from 10 to 14 days after
the surgery. In patients with thick, callused skin, sutures
may be left in for an additional period if necessary. If
there is any question, additional sterile paper tape may be
applied across the incision after the sutures are removed.
COMPLICATIONS AND RESULTS
With proper patient selection and the technique described
above, favorable results with resolution of virtually all
symptoms are to be expected in over 90% of the cases.
However, there is an irreducible minimum number of pa-
tients in whom the results are suboptimal. This comes
about in several clinical settings. In elderly patients who
may have associated wrist arthropathy, the pain relief may
not be complete. The pain seems to originate from two
sources; one from median nerve compression and the other
from degenerative arthropathy of the wrist. The second
situation concerns patients with advanced diabetic or al-
coholic peripheral neuropathy. In such instances neuro-
logic recovery may not be complete because compres-
sion of the median nerve is only one element in the disease
process. Patients who do heavy manual labor and return
to the same kind of work as they did before surgery, gen-
erally tend to have a less favorable outcome and less com-
plete relief than those who have a less strenuous job. Pa-
tients with job-related injuries with a potential for financial
gain may not improve and their postoperative course may
be prolonged. Patients with “overuse” syndrome who do
extremely strenuous work and continuously abuse their
199
wrist through their job are less likely to improve, although
they may have a genuine intention to return to work.
Two major complications that can occur are wound
infection and wound dehiscence. Wound infections are
not generally related to interoperative contamination be-
cause of the very short operative period. They are most
probably related to lack of preoperative cleanliness, fail-
ure to prepare the skin for 10 minutes, or poor postopera-
tive care. If wound infection does occur, it can be treated
with appropriate antibiotics without opening the wound.
If this does not resolve, the skin sutures alone may be
removed and wet soaks may be applied. At a later date
secondary closure may be done. Deep wound infections
are rare.
Dehiscence of the wound is most likely to occur in
individuals with very thick palmar skin with calluses.
In such instances, the sutures may be left in for much
longer than 2 weeks if necessary, and sterile paper strips
may be applied after the suture removal to facilitate fur-
ther healing.
Painful neuromas of the palmar cutaneous branches
of the median nerve and the ulnar nerve should not occur
if the incision is placed precisely in the middle of the palm
as described. Such neuromas tend to occur with trans-
verse and oblique incisions. Injury to the motor branch of
the median nerve occurs only in situations where the
median nerve is exposed and all its branches are traced.
The less exploration that is done beneath the carpal liga-
ment, the less is the likelihood of injury to the median
nerve or to its branches.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
TRANSANTRAL ETHMOIDAL ORBITAL
DECOMPRESSION FOR GRAVES’
OPHTHALMOPATHY
LAWRENCE W. DeSANTO, M.D.
THE DISEASE
Graves’ ophthalmopathy is usually related temporally to
hyperthyroidism but can be seen in euthyroid or hypothy-
roid individuals. The diagnosis seldom presents a chal-
lenge with classical orbital changes or overt hyperthy-
roidism, but in clinically euthyroid patients with
asymmetric proptosis the diagnosis can be elusive. The
most helpful signs here are lid retraction or lid lag. We
have also noted a temporal flare of the upper lid which
seems characteristic of thyroid eye disease. Other features
of ophthalmopathy include orbital congestion (injection
and chemosis of the conjunctiva and lid edema), myopa-
thy, and optic neuropathy with or without proptosis. None
of the eye signs is pathognomonic of thyroid eye disease.
At times the diagnosis is made or confirmed with the thy-
roid-stimulating hormone (TSH) suppression test for sub-
clinical hyperthyroidism. Another newer laboratory test
is the TSH serum analysis which more easily will give
the same information.
Orbital imaging (computed tomography (CT) scan)
usually shows enlarged extraocular muscles which are the
principle cause of proptosis. The inferior rectus is usually
the first muscle involved, followed in order by the medial
rectus, superior rectus, and lateral rectus muscles. Because
of congestion at the orbital apex, it is possible to image a
dilated superior ophthalmic vein in Graves’ ophthalmopa-
thy. The muscle enlargement is fusiform with sparing of
the tendinous insertions. This finding in combination with
the characteristic muscle enlargement distinguishes
Graves’ ophthalmopathy from other entities such as or-
bital myositis. A bulging orbital septum from protruding
fat is another useful CT finding.
The eye findings of Graves’ ophthalmopathy vary
from mild protrusion, which may be attractive, to a stare.
The anterior protrusion of the eye is the only natural way
© 1992 The American Association of Neurological Surgeons
200
to accommodate the globe to the increased tissue volume
in the orbit. Only when the anterior protrusion reaches a
point where there are other problems is there a need for
treatment. Because the muscle myopathy is the basic pa-
thology, muscle dysfunction can be a problem if there is
asymmetry in the muscle disease. The result is diplopia.
The extremes of the disease are optic neuropathy with
visual loss and visual field defects. The degree of both
can vary from minimal to serious or even total loss of
vision. Corneal exposure is listed as a common problem
in Graves’ ophthalmopathy. In fact, this seems to be rare.
Of over 450 patients treated by orbital decompression,
only a few had corneal exposure and ulceration.
The visual loss and the degree of proptosis seem in-
versely related. That is, in patients with severe proptosis
there is usually little or no visual loss. This illustrates the
observation that exophthalmos is in fact a natural ante-
rior orbital decompression. In some patients there is ex-
treme proptosis with no congestion, diplopia, or visual
loss. To them the problem is cosmetic and practical. Their
eyes are too obvious and at times touch their glasses.
THE ISSUES
There is no consensus of opinion concerning: 1) whether
the orbital space should be enlarged; 2) the indications
for enlarging the space; 3) the sequence of therapy that is
most successful in restoring the eyes to near-normal; 4)
the value of mechanical enlargement of the space; 5) the
nonsurgical alternatives that are useful in seriously af-
fected patients; and 6) who (what specialty) should en-
large the space.
With the variable clinical scenarios there can be no
single treatment. The ideal treatment would be to identify
the process that causes the muscle enlargement and re-
verse it. This is not possible at this time. Current therapy
includes soothing words and lubricating eye drops, oral
steroids, orbital radiation, and orbital decompression.
 DESANTO : TRANSANTRAL ETHMOIDAL ORBITAL DECOMPRESSION FOR GRAVES’ OPHTHALMOPATHY
Graves’ ophthalmopathy is a bilateral disease. It may be
asymmetric and appear to be unilateral. Both eyes are not
affected equally at the same time. Careful measurements
of the exophthalmos almost always show that the normal-
appearing eye measurement exceeds the extreme of the
range of normal in unaffected individuals. The normal-ap-
pearing eye is unlikely to stay that way. This observation is
important when a patient with asymmetric disease is con-
sidered for orbital decompression. It makes little practical
sense to decompress only the more involved eye in what is
a bilateral process. In the 450 patients decompressed by
the author, unilateral decompression was performed twice
and in both that decision was later regretted.
ORBITAL DECOMPRESSION
The concept of orbital decompression is simple. There is
too much tissue in a bony space and either tissue must be
removed or the space made larger when the excessive tis-
sue causes problems. Removal of tissue is not practical,
so the space must be enlarged. There are as many ways to
enlarge the space as there are bony walls in the orbit. The
superior wall is the orbital plate of the frontal bone which
can be approached from the anterior cranial fossa and is
the basis of the transfrontal decompression. The lesser
and greater sphenoid wings and the zygomatic bone form
the lateral wall; the maxilla lies inferiorly; and the paper
plate of the ethmoid and the lacrimal bone lie medially.
The lateral approach was the first one used for or-
bital decompression. Dollinger, in 1910, removed the lat-
eral wall, leaving the lateral rim intact. This is the same
procedure Kronlein used to remove orbital tumors, and
the approach has his name. The lateral approach has been
favored by ophthalmologists. There is little published on
this approach, reflecting its infrequent use.
The superior approach prototype is through the ante-
rior cranial cavity and is called the Naffziger operation.
Another superior approach is the pterion approach de-
scribed by Welti and Offret. A craniotomy to decompress
the orbit may seem at first glance to be excessive until
one appreciates the natural progression of serious oph-
thalmopathy and the limited options. There are several
published series of transfrontal orbital decompression with
significant numbers of cases. Naffziger reviewed his over-
all experience with 40 cases in 1954. Poppen reported on
66 patients in 1950 and MacCarty and colleagues col-
lected data on 46 patients. The results of this operation
are generally good. Visual loss is stabilized or improved
and the appearance is satisfactory. There is usually pulsa-
tion of the eye from transmitted dural pulsations. There
are comments about morbidity in the published reports
but no reported deaths following the operation.
201
Because of the perceived magnitude of a frontal cran-
iotomy, use of this operation has been restricted to the
most extreme manifestations of Graves’ ophthalmopathy
and it is not offered to patients with lesser symptoms and
signs or to those who need only cosmetic decompression.
The pterion can be exposed through an incision an-
terior to the ear in a hair-bearing area, and the fibers of
the temporalis muscle split to approach the anterior and
middle cranial fossae to remove the superior and lateral
walls of the orbit. It is possible to do both sides at the
same session but usually the procedure is done on one
side only. The inferior approach is the most often used
today. This can be done either transantrally or
transorbitally. Removing bone inferiorly and medially is
logical because the greatest area of bone can be accessed
through a single incision, both sides can be done at one
session, and the morbidity is similar to that of sinus sur-
gery. The transantral approach enlarges the orbital space
to use the actual space of the antrum and ethmoid sinuses,
whereas the superior, lateral, and pterional approaches
decompress into potential spaces only.
It is appreciated that ocular protrusion is only one
manifestation of Graves’ ophthalmopathy. Enlarging the
orbit will correct and in some cases eliminate proptosis.
In the process, most patients will experience improve-
ment of vision and reduction or elimination of visual
field defects (see below on vision). The muscle myopa-
thy is an unknown before decompression and will re-
main so after decompression. All affected muscles may
return to their pre-disease state, or only some, or none
at all. Recovery of the muscles depends on the duration
and degree of the myopathy; all muscles do not recover,
or if they do they do not always do so to the same de-
gree. For this reason muscle imbalance and diplopia may
remain after the eye returns to a more normal position,
and muscle surgery may be needed to restore balanced
vision. It is not an uncommon experience to see postop-
erative diplopia where none existed before in patients
with severe visual loss. As vision returns it is double;
this is looked on as a positive benefit as compared to no
vision. However, for total rehabilitation, muscle balance
should be restored.
Retraction of upper, lower, or both lids is a near-uni-
versal problem in Graves’ ophthalmopathy. After decom-
pression, this problem remains and the cosmetic appear-
ance is not satisfactory in all cases. This can be corrected
by appropriate lid lowering for the upper lids and lid rais-
ing for the lower lids. After muscles and lids are restored,
unsightly lid skin can remain. Rarely, upper and lower lid
blepharoplasty is needed.
The logical sequence for total rehabilitation then
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
seems to be: 1) decompression, 2) extraocular muscle
surgery, 3) lid surgery, and 4) lid skin surgery.
TREATMENT PLANNING
The technical aspects of orbital transantral decompres-
sion are straightforward and well within the capability of
the otolaryngologist who is comfortable with antral and
ethmoid surgery. There are a number of technical details
that seem to make the difference between a successful
operation and a disappointing one. If the surgery was all
that was required, the otolaryngologist’s role would be
simple: operating, supervising the convalescent period,
and then stepping aside. Patient and professional satis-
faction require more than this.
The patient with Graves’ ophthalmopathy who is a
candidate for orbital decompression requires considerable
counseling. He or she must be provided with the insight
into the rationale, risks, and limitations of the procedure
to attain a realistic feeling for the probability of benefit
from decompression for the specific problem. The pa-
tient also needs to know that the operation does not solve
the basic problem, that simply enlarging the orbital space
will not provide total rehabilitation, and that other efforts
with muscles, lids, and skin may be needed. If the patient’s
expectations for improvement exceed the potential of the
operation, this should be discovered preoperatively.
The surgeon’s goals and those of the patient must be
compatible. For example, a young woman with disfigur-
ing proptosis as well as vision-threatening effects of oph-
thalmopathy must be aware that the purpose of the opera-
tion is vision preservation, not cosmetic improvement and
that her appearance after a successful decompression may
be less than perfect and may never be what it was before
the disease began. When each party to this operation has
different ideas of what constitutes success, both will be
disappointed. The patient needs to know that a neurosur-
geon or an otolaryngologist operating for an eye disease
is not an eye doctor but is only serving a technical role.
The surgeon must also realize that he or she is function-
ing as a consultant to the ophthalmologist and endocri-
nologist. One who gets involved with the treatment of
Graves’ ophthalmopathy will encounter problems that are
beyond the scope of any one specialty. It is far better to
approach these patients as a team where the ophthalmo-
logic experts will take over after the orbit is enlarged to
carry on whatever further rehabilitative efforts are needed.
PREOPERATIVE EVALUATION
The preoperative evaluation involves endocrine and oph-
thalmologic studies. If time permits (if the eye situation is
not an emergency), patients with hyperthyroidism should
202
be rendered euthyroid. If urgent decompression is required,
hyperthyroidism can be controlled with propranolol.
Eye studies should include both uncorrected and cor-
rected acuity measurements, exophthalmometer readings,
assessment of extraocular and levator muscle function,
palpebral fissure measurements, ocular tension measure-
ments, and a complete funduscopic examination. Patients
with visual loss that is not correctable with lenses require
visual field assessment. The field measurements docu-
ment the seriousness of the eye problem and provide an
objective base line for determining the effectiveness of
the operation.
X-ray films of the sinuses are not needed if there is
no history of sinus disease. Sinus films are really not of
much help even when there is a history of sinus disease
because the actual state of the cavities is determined at
surgery. Membrane thickening and polypoid disease are
not contraindications for decompression as these can be
treated at the time of decompression. Computed tomog-
raphy scans are interesting but are only useful when the
diagnosis is not certain. Then the typical muscle changes
are observed and the diagnosis is secure. Another excep-
tion where the CT scan is helpful is in the asymmetric
exophthalmos patient who does not have a history of hy-
perthyroidism and the less involved eye proptosis mea-
surement falls within the range of normal.
Patients who are receiving corticosteroids systemi-
cally or who have taken these drugs during the previous
nine months require special precautions during and after
the operation. It has been our policy to prepare these pa-
tients with either an intramuscular injection of 200 mg of
cortisone acetate the evening before surgery and the morn-
ing of surgery or at least 40 mg of prednisolone during
surgery and tapering oral corticosteroids during the post-
operative period, the dosage of which is related to the
patient’s previous intake.
SURGICAL TECHNIQUE
Complete decompression is possible only if a complete
ethmoidectomy is accomplished. This point cannot be over-
emphasized. The need for a complete ethmoidectomy is
one concern we have about attempting to do a transantral-
ethmoidal orbital decompression through approaches more
familiar to the ophthalmologic surgeon via the conjuncti-
val route. There is a belief that the same bone removal can
be accomplished this way as through the sinuses. This is
not true. In the cases that have been redecompressed after
anterior orbital approaches it was obvious in each that there
was an inability to do a proper posterior ethmoidectomy.
Perhaps this area cannot be reached or the inexperience in
this area leads to a timid approach. Unfortunately, a
DESANTO : TRANSANTRAL ETHMOIDAL ORBITAL DECOMPRESSION FOR GRAVES’ OPHTHALMOPATHY
few operations redone were nothing but little blow-out
fractures of the medial orbital floor. This is not an orbital
decompression. It is our opinion that the incidence of in-
adequate decompression is higher with the anterior ap-
proach than with the transantral operation. This has tem-
pered our enthusiasm for the anterior approach, and we
select the transantral operation for patients who need or-
bital decompression.
Position
The patient is placed on the operating table in the supine
position with about 15° of reverse Trendelenburg (i.e.,
sitting slightly up). This allows more comfort for the sur-
geon and the assistant in relationship to the operating
microscope which is used in all cases (300-mm lens).
Operating Microscope
The microscope provides two benefits: 1) it permits the
assistant to observe directly through a side piece or tele-
vision monitor, and 2) the brilliant light and magnifica-
tion make the operation easier and safer.
The eyelids are stitched together and the eye is left
undraped.
© 1992 The American Association of Neurological Surgeons
Figure 1. The standard sublabial “Caldwell-Luc” incision. A preliminary
injection with Xylocaine-adrenaline solution and the use of the cautery
203
Incision
A standard sublabial incision for anterior antrostomy ex-
poses the face of the maxillary antrum (Fig. 1). Bone is
removed anteriorly up to the infraorbital rim and neu-
rovascular bundle. The microscope is introduced and the
ethmoid sinuses are entered with a punch instrument
(Fig. 2). The precise point of entry is one-half the dis-
tance from front to back at the junction of the superior
medial antral wall. The angle of entry is about 45° up-
ward, directed to the medial canthus of the opposite eye.
The ethmoid cells are then gently crushed and removed
up to the cribriform plate and back to the sphenoid si-
nus with the ethmoid exenteration instrument (Fig. 3).
One can estimate the angle between the cribriform area
and the roof of the ethmoid capsule from front to back,
remembering that with the head slightly up, the poste-
rior cribriform is lower than the anterior cribriform. The
bone of the cribriform plate is easily visualized and can
be protected by working away from it with the instru-
ments rather than toward it. The decompression is not
adequate unless the level bone of this structure is visu-
alized. The most anterior ethmoid cells are not visual-
ized directly and these must be removed to complete
knife will allow a relatively bloodless start. The incision is made down to
the bone and the soft tissue is elevated up to the infraorbital nerve.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
the ethmoidectomy. After observing many residents learn-
ing this procedure, we realize that this is the most often
neglected site of the ethmoidectomy.
An adequate complete ethmoidectomy can be esti-
mated if the ethmoid capsule will easily accommodate
three 0.75-inch cottonoid strips soaked in epinephrine
solution. If the three strips do not fit easily in the ethmoid
capsule, the ethmoidectomy is not complete. This is an
important clue to the technique.
© 1992 The American Association of Neurological Surgeons
Figure 2. Entering the ethmoid sinuses. The ethmoid sinuses are en-
tered by a puncture at the midpoint between the front and the back and
204
If there is bleeding from the anterior or posterior
ethmoid arteries, the easiest thing to do is to pack this
temporarily with a cottonoid pledget soaked in epi-
nephrine solution and go on with something else. The
bleeding will settle down or gentle cautery can be
applied.
Cerebrospinal fluid (CSF) can be seen to flow occa-
sionally. This is no cause for alarm. A patch of antral
mucosa can be laid over the site of CSF leakage and
at the junction of the medial maxillary wall and the roof of the sinus.
The key to a successful decompression is a complete ethmoidectomy.
 DESANTO : TRANSANTRAL ETHMOIDAL ORBITAL DECOMPRESSION FOR GRAVES’ OPHTHALMOPATHY
© 1992 The American Association of Neurological Surgeons
Figure 3. The relationship between the roof of the ethmoid and the
floor of the anterior fossa. The ethmoid labyrinth must be exenterated
held in place with a bit of Oxycel cotton to stop the leak.
To my knowledge only one patient in more than 400 re-
quired repair of a CSF leak after decompression.
Removing the Paper Plate of the Ethmoid
and Orbital Floor
After the ethmoidectomy is completed, the bone of the
orbital floor is fractured away with a small curette or chisel.
The bone is usually very thin medial to the course of the
infraorbital nerve and will come away without difficulty.
The bone around the nerve and lateral to it should also be
removed. Lateral to the nerve the bone is much thicker,
and a sphenoid punch-type instrument is useful. Likewise,
the thicker bone just behind the infraorbital rim (the rim
is not removed) is easier to remove with the sphenoid
punch. After the bony floor is removed, the paper plate of
the ethmoid can be fractured into the ethmoid capsule
after removing the pledget. After rinsing out the bits and
pieces of bone, the orbital fascia (Fig. 4) is slit (Fig. 4,
inset). This is done by placing a long-handled knife as far
forward and as far up as possible in the ethmoid and in-
cising the periorbita as far back as possible. Succeeding
cuts are made more laterally. By working from the eth-
moid medially to the antrum one can maintain direct vi-
sion. Going the other way puts orbital fat in the way. Usu-
ally the fascia is incised in two places medial to the
infraorbital nerve and one slit is made lateral to the nerve.
At times the nerve is far lateral and all the slits are made
205
up to the solid bone of its roof. Otherwise, vertical pieces of bone will
restrict the decompression.
medial to it. If extreme proptosis is an issue, the orbital
fat can be teased out of the orbit to increase the decom-
pression. This can be done by looking at eye position while
teasing out the fat. If there is a lesser amount of exoph-
thalmos present this is not done. In other words, the op-
eration can be tailored to the patient’s needs.
One of the major technical difficulties is retraction
of the sublabial incision to get proper exposure of the or-
bital floor and ethmoid. We have tried a number of the
available self-retaining retractors and we have designed a
few ourselves. None work well for us, and the best we
can recommend is a hand-held Army-Navy retractor and
a patient and steady assistant.
The same procedure is done on the other eye during
the same session. It is inadvisable to perform a unilateral
decompression.
Decompression should be immediate; if it is not,
something is wrong. In most instances, orbital fat fills
the ethmoid completely and the antrum in the upper half.
Occasionally one can see very large muscles and less fat.
These cases do not decompress as well.
At termination of the procedure, bilateral inferior
nasal antral windows are placed for drainage.
POSTOPERATIVE CARE
If packing is placed in the nose after the operation, it can
be removed the next day. The patient is usually hospital-
ized for two or three days.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
© 1992 The American Association of Neurological Surgeons
Figure 4. The appearance of the periorbita prior to its incision. In-
set, the pattern of slits into the periorbita. The first slit begins poste-
rior and high. Subsequent slits progress from medial to lateral. The
If there is diplopia after surgery, a clip-on lens occluder that
can be alternated from eye to eye is helpful. It is best to delay
any muscle surgery for six weeks to two months because
changes in muscle position may continue for that long.
CONCLUSIONS
Until the biochemical process that produces the orbital
pathology in Graves’ ophthalmopathy is better understood
and can be prevented or reversed, there will be a need for
orbital decompression in some patients. Enlargement of
the orbital space does not in itself cure the orbital pro-
cess, but it does allow more space for the process to work
itself out. The operations to enlarge the space are only
palliative or rehabilitative. Selection of the appropriate
patients is essential.
The predictability of recession of the eyes following
decompression depends on the patient’s problem. The op-
eration is most predictable in patients with congestive
signs and visual loss of recent onset. When unsuccessful
treatment has preceded the decompression, the operation
becomes less predictable. Muscle surgery before decom-
pression and orbital radiation are the two forms of pre-
liminary treatment that limit or at least create uncertainty
as to the predictable value of decompression.
206
cross-hatching is elective depending on the degree of proptosis. The
usual decompression fills the ethmoid completely and the antrum in
its upper half.
Because of the short hospital stay, few complica-
tions, and the high percentage of satisfied patients when
selection is careful, the transantral orbital decompres-
sion seems to be a conservative form of treatment and
not a treatment of last resort. For these specific prob-
lems, decompression seems more conservative than long
term, high dose corticosteroid therapy. Today, we are less
reluctant to decompress orbits early in the course of the
disease process than we were when our experience be-
gan in 1969.
Assessment of the effectiveness of transantral decom-
pression becomes more subjective as indications expand
to include cosmetic goals and when the decompression is
done as a preliminary step to muscle surgery. In these
circumstances the decompression is only the first part of
a more complex rehabilitative sequence that includes ex-
traocular muscle surgery, lid surgery, and occasionally
facial skin surgery.
With an anterior approach to the orbit, which is more
familiar to the ophthalmologic surgeon, some of the bone
that is removed through the transantral route can be re-
moved, but there is an obvious timidity with respect to
the ethmoid cells when they are approached through eye-
lid incisions. A complete ethmoidectomy is the key to
successful orbital decompression.
 MIDDLE FOSSA APPROACHES
FOR INVASIVE TUMORS
INVOLVING THE SKULL BASE
LALIGAM N. SEKHAR, D.V.M., M.D.
ATUL GOEL, M.CH.
CHANDRANATH SEN, M.D.
INTRODUCTION
Middle fossa approaches may be used to remove or assist
in the removal of tumors involving the following areas:
the sphenoid bone and sinus, the infratemporal and ptery-
gopalatine fossae, the petrous apex region, the internal
auditory canal, and the middle or lower clival area. Types
of lesions which may involve this area include benign
neoplasms such as epidermoid cyst, cholesterol granu-
loma, neurilemmoma, and meningioma; malignant neo-
plasms such as chordoma, chondrosarcoma, and adenoid
cystic carcinoma; developmental lesions such as menin-
goencephalocele, and laterally placed cerebrospinal fluid
leaks through the sphenoid sinus or the eustachian tube;
vascular lesions such as aneurysms of the petrous inter-
nal carotid artery (ICA); and postinflammatory lesions
such as sphenoid sinus mucocele. A zygomatic osteotomy
technique can also be used to achieve a low exposure and
to minimize brain retraction for aneurysms of the upper
basilar artery and other lesions of the tentorial notch area.
PREOPERATIVE EVALUATION
In addition to a detailed history and neurologic examina-
tion, the preoperative evaluation includes a computed to-
mographic (CT) scan especially using bone algorithms,
and a magnetic resonance imaging (MRI) scan using a
spin-echo technique, without and with gadolinium en-
hancement. Additional tests will be indicated by the loca-
tion of the tumor. Thus, on a patient with a tumor which
extends toward the facial nerve or the cochlea, an audio-
gram and facial electromyogram will be performed. Since
intraoperative monitoring of the brain stem evoked re-
sponse (BSER) and the somatosensory evoked response
(SSEP) is used, a preoperative test of these modalities
will be useful.
© 1992 The American Association of Neurological Surgeons
207
All patients in whom the petrous ICA is involved by
the tumor, or in whom a significant manipulation of the
ICA will be necessary, a balloon occlusion test (B0T) of
the ICA is performed, along with clinical evaluation and
xenon CT-cerebral blood flow (CBF) studies. An algo-
rithm of management based on the BOT-ICA is shown in
Table 1.
SURGICAL TECHNIQUE
Anesthesia and Monitoring
Anesthesia is induced with intravenous thiopental sodium
and maintained with nitrous oxide, oxygen, and isoflurane.
To allow the monitoring of cranial nerve function, only
short-acting muscle relaxants are used.
To minimize the need for high concentrations of
isoflurane (which may cause brain swelling), a constant
infusion of low-dose thiopental (at 2 mg/kg of body weight/
hour) is used. When cranial nerve monitoring is no longer
necessary, the barbiturate infusion is stopped and a bal-
anced anesthetic technique may be used. During the sur-
gery, peripheral and central venous lines are needed for the
administration of fluids and medications and an intraarte-
rial line is used for measuring the blood pressure and the
blood gases. The anesthesiologist administers crystalloids
in maintenance amounts only, replacing the blood lost dur-
ing operation predominantly with colloids such as red cells,
or salt-poor albumin. When the blood loss exceeds 4 units,
other blood components such as fresh-frozen plasma, plate-
lets, fibrinogen (cryoprecipitate), and calcium may need to
be replaced to prevent the development of a bleeding di-
athesis. A lumbar subarachnoid drain is used to achieve
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
necessary. If temporary ICA occlusion is needed in
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
patients with a compromised collateral circulation, in-
duced hypertension (20-40 torr above baseline) and bar-
biturate- or etomidate-induced coma and/or moderate
hypothermia between 30 and 32°C is used for brain pro-
tection.
Intraoperatively, cranial nerve and certain brain func-
tions are monitored. Cranial nerve monitoring includes
facial electromyography and the electromyographic and
electroneuronographic assessment of other nerves III-XII,
as needed. For monitoring of brain functions, SSEPs,
BSER evoked by contralateral ear stimulation, and the
electroencephalogram (EEG) may be utilized.
Patient Position and Initial Exposure
The patient is usually placed in the supine position with a
roll under the shoulder to minimize neck stretch. Except
when the head has to be turned during the operation, or
when the incision is far posterior, the patient can usually
be placed in three-point pin fixation, turning the two-pin
arch to the vertical position. The head is usually held
slightly extended, elevated, and turned 45° to 60° away
from the surgeon.
The initial skin incision can be curvilinear or
bicoronal, but the latter is preferred (Fig. 1A). The inci-
sion is taken down to the skull through the pericranium
above the superior temporal line. The pericranial layer
blends with the superficial layer of temporal fascia, and,
therefore, subsequent dissection is carried out between
the superficial and deep layers of the temporal fascia in-
feriorly to the zygoma, and the superior and lateral or-
bital rims are defined anteriorly. As the incision extends
208
below the zygomatic arch, it must be kept very close to
the tragus of the ear to avoid the upper branches of the
facial nerve which travel in the substance of the parotid
gland approximately 1 to 1.5 cm in front of the tragus of
the ear. The incision can be taken down to the base of the
ear lobe and by meticulous dissection in layers, the su-
perficial temporal artery can be preserved (Fig. 1B). The
dissection plane will be on the capsule of the temporo-
mandibular joint and the masseteric fascia. The facial tis-
sues superficial to this plane are moved forward along
with the scalp, and the zygomatic arch is exposed from
the condylar fossa to the zygomaticomaxillary suture. The
frontal branches of the facial nerve are now well protected
by this technique (Fig. 1C). The temporalis muscle is el-
evated from the temporal fossa entirely, and care must be
taken not to open into the cartilaginous external ear canal
superiorly.
Craniotomy
The craniotomy is temporal or frontotemporal in loca-
tion. The osteotomies will vary depending upon the le-
sion. When the lesion extends more posteriorly, and into
the petroclival bone, the craniotomy extends more poste-
riorly, and the zygomatic osteotomy includes the temporo-
mandibular (TM) joint (Fig. 1D). When prolonged
subfrontal or intraorbital work is required, an orbital os-
teotomy is added to the zygomatic osteotomy.
When a zygomatic osteotomy is performed, the an-
terior cut is made just behind the rim of the orbit with a
fine reciprocating saw or with Midas Rex instrumenta-
tion. The posterior cut may or may not include the
 SEKHAR ET AL. : MIDDLE FOSSA APPROACHES FOR INVASIVE SKULL BASE TUMORS

© 1992 The American Association of Neurological Surgeons

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

209
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
condylar fossa. In the latter instance, the posterior cut is
made quite easily just anterior to the TM joint. When the
condylar fossa is included, the TM joint capsule is opened,
and the meniscus is dissected away from the condylar
fossa. Superiorly, the middle fossa dura is dissected from
the condylar eminence. The bone cuts are then made just
posterior and anterior to the condylar fossa. The medial
cut should be made at or medial to the margin of the TM
joint, to avoid injury to the petrous internal carotid artery
which lies just medial to the TM joint.
Condyle Resection
When the condyle of the mandible needs to be excised,
the neck of the mandible is completely denuded of soft
tissues and the attachments of the pterygoid muscles are
divided. Care is taken not to injure the superficial tempo-
ral artery laterally, or the internal maxillary artery medi-
ally. A reciprocating saw is used to make the osteotomy at
the level of the notch of the coronoid process and the
condyle is excised (Fig. 2A). Remaining soft tissues in
the condylar fossa are removed down to the inferior mar-
gin of the tympanic bone. Unilateral loss of the mandibu-
lar condyle is surprisingly well tolerated by the patient
when the other side is intact. The ultimate disability will
include a malocclusion of the teeth and slight difficulty
with chewing on the ipsilateral side.
Middle Fossa Exposure
Extradural middle cranial fossa dissection is facilitated
by the drainage of cerebrospinal fluid, either through a
lumbar subarachnoid catheter or by opening the carotid
or the sylvian cistern intradurally. This dissection is per-
formed from a posterior to an anterior direction, and a
lateral to a medial direction, starting just above the exter-
nal ear canal. The following landmarks are dissected and
identified sequentially: tegmen tympani, arcuate emi-
nence, lesser superficial petrosal nerve (LSPN), greater
superficial petrosal nerve (GSPN), middle meningeal ar-
tery (MMA), mandibular nerve (V3), and the maxillary
nerve (V2). The LSPN is not always identifiable and may
be confused with the GSPN. The LSPN extends from a
foramen on the petrous bone to the foramen spinosum.
Monopolar stimulation of the posterior end of the GSPN
usually produces facial muscle contraction by retrograde
stimulation of the geniculate ganglion. The two nerves
can be thus distinguished. Occasionally, the geniculate
ganglion may be without a bony covering; this has oc-
curred only twice in about 200 middle fossa exposures in
our experience (about 1%). The horizontal segment of the
petrous ICA usually lies partially uncovered by bone in-
ferior to the GSPN. However, when there are hyperostotic
210
bone changes or when the neoplasm obscures the land-
marks, this segment of the artery may be difficult to find.
V3 is the most reliable landmark in the presence of patho-
logical changes. The GSPN is divided to avoid traction
on the geniculate ganglion. The horizontal segment of the
ICA can be exposed further with the aid of a high-speed
drill and rongeurs. If the eustachian tube is to be preserved,
the surgeon has to be careful while drilling lateral to the
petrous ICA. The tensor tympani muscle is a constant land-
mark which lies superior to the eustachian tube (Fig. 2B).
A part of the petrous apex region, which lies pos-
teromedial to the horizontal petrous ICA and lateral to
the trigeminal eminence, can be removed extradurally.
However, it is more easily done intradurally, and to re-
move the entire petrous apex one has to work through the
posterior cavernous sinus. Laterally, one is limited by the
cochlea. The best landmarks pointing to the location of
the cochlea are the GSPN (the cochlea lies inferomedial
to the geniculate ganglion) and the genu of the petrous
ICA. The cochlea lies supermedial to the genu of the pe-
trous ICA but the distance is variable and is best studied
in the bone-windowed preoperative CT scan.
Exposure of the Entire Petrous and Upper
Cervical ICA
To remove neoplasms from the middle and lower clival
region and to remove extensive tumors from the petrous
apex region, the entire petrous and upper cervical ICA
has to be exposed and displaced forward. The condyle of
the mandible has to be resected for this exposure. The
optimal area to start the exposure of the petrous ICA is
the portion of the artery not encased by tumor. The expo-
sure of the genu of the petrous ICA can be performed by
removing the bone at the junction of the floor of the middle
cranial fossa and the TM joint fossa. This is the tympanic
bone, and it is removed with the aid of rongeurs and drills,
preferably under magnification. The eustachian tube and
the tensor tympani muscle lie just lateral to the genu of
the petrous ICA. Both structures will have to be inter-
rupted to obtain exposure of the artery. The petrous ICA
can be traced proximally and distally from this point. The
vertical segment of the petrous ICA can be exposed by
removal of the tympanic bone directly medial to the TM
joint. The upper cervical ICA can be found just below the
tympanic bone and medial to the styloid process (Fig. 2C).
The petrous ICA is surrounded by a venous
plexus, the sympathetic nerve, and a layer of perios-
teum. Except when neoplasms invade the periosteum,
it is dissected with the artery from the bony canal. At
the entrance to the canal, the periosteum blends with
a fibrocartilaginous ring and then continues as the
 SEKHAR ET AL. : MIDDLE FOSSA APPROACHES FOR INVASIVE SKULL BASE TUMORS
© 1992 The American Association of Neurological Surgeons
Figure 2. A, the condyle of the mandible has been resected. Landmarks
in the middle cranial fossa used for the identification of the petrous ICA
are shown. CNs, cranial nerves; V2, second trigeminal division; V3, third
trigeminal division. B, the horizontal segment and genu of the petrous
ICA have been exposed. The greater superficial petrosal nerve, the eus-
tachian tube, and the tensor tympani muscle have been divided. The
middle meningeal artery has been ligated. V1, first trigeminal division.
211
C, the entire petrous ICA has been uncovered. The fibrocartilaginous
ring is being opened. Note the tumor medial to the petrous ICA and in
the sphenoid sinus between V2 and V3. E.T., eustachian tube; GSPN,
greater superficial petrosal nerve; MMA, middle meningeal artery. D,
the petrous ICA has been displaced forward and the tumor has been
resected. Note the exposed petroclival dura, the dural sleeve of the hy-
poglossal nerve, the jugular bulb, and cranial nerves IX and X.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
periosteum of the inferior surface of the skull. The fibro-
cartilaginous ring has to be excised laterally and the peri-
osteum detached from it in order to mobilize the ICA. In
addition, about 2-3 cm of the upper cervical ICA has to
be dissected free from surrounding soft tissue to allow
the lower end of the petrous ICA to be mobilized. To
mobilize the upper end, V3 has to be completely liberated
from its bony canal, and the bone between it and the ICA
has to be removed. Furthermore, the bone and fibrocarti-
lage anteromedial to the petrous ICA must be removed.
This is the best time to divide the cartilaginous eusta-
chian tube just medial to V3, cauterize its inner lining,
pack its lumen with autologous fat, and close it with 4-0
Nurolon sutures. The petrous ICA can be moved forward
(Fig. 2D), and left in that position while working on tu-
mor, or sutures can be placed through the periosteal sheath
and the ICA sutured forward. While drilling the petroclival
bone, the ICA must be protected with a broad retractor,
taking care not to compress the artery.
The bone of the middle and lower clivus lies medial
to the ICA. The surgeon has to work anterior, posterome-
dial, and medial to the artery to remove tumors from this
area. Cranial nerve XII exits through the hypoglossal ca-
nal medial to the vertical segment of the ICA and lies
within the clival bone (Fig. 8).
The jugular bulb and pars nervosa of the jugular fo-
ramen lie posterior to the vertical segment of the petrous
ICA and the surgeon should be careful not to violate these
structures. Tumors involving the jugular bulb can be re-
moved from this approach as well.
Sphenoid Sinus and Cavernous Sinus
The lateral aspect of the sphenoid sinus can be entered by
removing bone of the base of the pterygoid processes
between V2 and V3. The inferior or the anterolateral as-
pect of the cavernous sinus can be entered by following
the petrous ICA, behind V3, or between V2 and V3.
Division of V3
To gain further exposure of the clivus and sphenoid bone
across the midline and the contralateral petrous apex, V3
can be divided and the temporal lobe retracted up. This
also allows an improved access to the inferior aspect of
the cavernous sinus. The contralateral petrous ICA can
be skeletonized by this approach. However, there is no
good landmark to find the contralateral ICA, except for
the fact that the petrous bone housing the ICA is denser
than the cancellous clival bone. Additionally, the surgeon
lacks proximal and distal control of the vessel.
Intradural Exposure
The dura of the petroclival area can be opened after dis-
212
placing the petrous ICA forward. This will expose the
clivus from the trigeminal root down to the hypoglossal
foramen (Fig. 2D).
Combination with Subtemporal Intradural Approach
When the preauricular infratemporal-extradural
subtemporal approach is combined with an intradural
subtemporal approach, the structures of the middle cra-
nial fossa, the upper, middle, and lower clival region, and
the tentorial notch can be well exposed from an anterolat-
eral direction.
General Principles of Tumor Resection
Highly malignant tumors (e.g., squamous cell carcinoma)
are preferably resected en bloc without actually enter-
ing the tumor. On the other hand, low-grade malignan-
cies (e.g., chordoma, chondrosarcoma) or benign lesions
(e.g., meningioma) are removed piecemeal at the core,
and then dissected at the periphery. The majority of the
lesions removed by this approach will be of the latter
two types. For the actual removal of the tumor, instru-
ments such as the bipolar cautery, suction, pituitary for-
ceps, and various types of sharp dissectors are usually
used. Blood vessels and cranial nerves are preferably
dissected from a normal to an abnormal area. After re-
moval of the core of the tumor, the peripheral part is
removed along with the margins. For meningiomas, this
means the removal of some surrounding apparently nor-
mal dura. With chordomas and chondrosarcomas, the
surrounding bone has to be drilled away circum-
ferentially preferably for a margin of 1 cm, well beyond
what looks abnormal under the microscope.
Reconstruction
Reconstruction is important to avoid cerebrospinal fluid
leakage and infection, and is done in layers. Any dural
defects are closed with a free pericranial or fascia lata
patch, although a watertight seal may not be possible.
Circumferentially placed microsutures and single-donor
fibrin glue (obtained from the blood bank) may be used
for this purpose. The extradural dead space has to then
be filled with autologous tissues. When the nasophar-
ynx is not exposed, the sphenoid sinus can be filled with
autologous fat, which becomes vascularized in time (Fig.
3A). When the opening into the sphenoid sinus is large,
it is preferable to close it with temporalis muscle in-
serted laterally (Fig. 3B) and a galeopericranial flap
and autologous fat inserted anteriorly (subfrontally).
When there is a large defect in the nasopharynx or
the oropharynx, it is preferable to close the defect
by means of a vascularized rectus abdominis or a
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 -
 SEKHAR ET AL. : MIDDLE FOSSA APPROACHES FOR INVASIVE SKULL BASE TUMORS

© 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.

213
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
vascular anastomosis to the cervical vessels (Fig. 3C).
Regional rotation flaps may also be used.
POSTOPERATIVE MANAGEMENT
A spinal drain is not used routinely in the postoperative
period, unless cerebrospinal fluid (CSF) leakage devel-
ops. Excessive blood loss during the operation may re-
quire replacement of blood components during the op-
eration. As with other major intracranial operations,
careful attention to the pulmonary and metabolic param-
eters and to early ambulation is essential. Drains are usu-
ally removed by the second or third postoperative day and
intravenous antibiotics are stopped at that time. If there
was considerable manipulation of the ICA during the op-
eration, a postoperative angiogram is performed prior to
discharge, to rule out ICA occlusion or a pseudoaneurysm.
COMPLICATIONS AND MANAGEMENT
Potential complications include cerebral contusion or he-
matoma, ICA occlusion or rupture, postoperative infec-
tion, cerebrospinal fluid leakage, and cranial nerve pal-
sies. Cerebral contusions and/or hematomas are managed
in the usual manner. ICA occlusion is very rare and when
it occurs may even be asymptomatic. However, in a pa-
tient with a compromised collateral circulation, it may ne-
cessitate emergency reexploration. Carotid pseudo-
aneurysm or rupture is always the result of serious
© 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.
214
postoperative infection, usually from the nasopharynx. In
approximately 200 petrous ICAs exposed operatively, this
occurred twice in our series, on both occasions due to
persistent nasopharyngeal contamination and postopera-
tive infection. One patient eventually died; another was
successfully salvaged by balloon occlusion of the ICA,
removal of the bone flap, and treatment with antibiotics.
CSF leakage may occur from the eustachian tube or
the sphenoid sinus and always requires reoperation. Cra-
nial nerve palsies are usually temporary, but permanent
palsies may occur because of tumor invasion or operative
injuries. When intraoperative cranial nerve injury is rec-
ognized, it is best to manage it by immediate resuture or
graft reconstruction.
ILLUSTRATIVE CASES
Sphenoid Mucocele
A 47-year-old woman presented with involvement of cra-
nial nerves V and VI and was thought to have a neurilem-
moma or a cartilaginous tumor (Fig. 4). An operation was
performed by a temporal craniotomy and zygomatic os-
teotomy anterior to the TM joint without resection of the
mandible or the TM joint. The sphenoid sinus was en-
tered between V2 and V3, and a mucocele was totally re-
moved with complete resolution of symptoms. A postop-
erative paresis of the frontalis muscle was temporary.
 SEKHAR ET AL. : MIDDLE FOSSA APPROACHES FOR INVASIVE SKULL BASE TUMORS

Juvenile Angiofibroma small frontoorbital osteotomy, and zygomatic osteotomy,

A 15-year-old boy presented with epistaxis, and a large
juvenile angiofibroma was diagnosed by biopsy. It filled
the nasopharynx, infratemporal and pterygopalatine fos-
sae, superior orbital fissure, cavernous sinus, and sphe-
noid sinus (Fig. 5). The lesion was removed through a
without extensive petrous ICA exposure or condyle re-
section. The sphenoid sinus was entered laterally and
medially (by a subfrontal route). A major portion of the
temporalis muscle was used for reconstruction. The pa-
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.

215
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

Petroclival Cholesterol Granuloma a temporal craniotomy, zygomatic osteotomy, and

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

© 1992 The American Association of Neurological Surgeons

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

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 SEKHAR ET AL. : MIDDLE FOSSA APPROACHES FOR INVASIVE SKULL BASE TUMORS

Chondrosarcoma after a temporal craniotomy, zygomatic osteotomy, and

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

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 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

Meningioma ral craniotomy, zygomatic osteotomy, condyle resection,

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

218
 TRANSTHORACIC EXCISION
OF A SPINAL METASTASIS WITH
VERTEBRAL BODY RECONSTRUCTION
GREGORY J. BENNETT, M.D.

PATIENT SELECTION
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.

219
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
with a high incidence of wound infection and dehiscence
in previously radiated patients. In this setting, the trans-
thoracic approach is preferable.
The degree of kyphosis that can be corrected and sta-
bilized with an anterior exposure is less than the degree of
kyphosis that can be successfully treated with a combined
anterior and posterior approach. Patients with moderate
kyphotic deformities of 30° or less are readily handled with
an anterior approach alone. Patients with major deformi-
ties (greater than 45°) are infrequently encountered among
cancer patients with spinal metastases, unless they have
had a prior laminectomy. For the major deformities,
anterior-posterior stabilization should be considered.
Thoracotomy is contraindicated in patients with
chronic lung disease or inadequate pulmonary function.
In patients with widespread metastatic disease for whom
no effective systemic therapy exists and with a very lim-
ited life expectancy, thoracotomy with resection and re-
construction is contraindicated. Alternate treatments for
these patients include radiotherapy and external bracing
to prevent kyphosis, and, in selected tumors such as pros-
tate cancer, endocrine therapy or chemotherapy.
PREOPERATIVE PREPARATION
Preoperative evaluation of patients being considered for
thoracotomy for vertebral body resection should include
appropriate radiographic studies (including computed
tomography scans of the brain, chest, and abdomen, bone
scans, and mammograms) to determine the primary site
and the stage of the malignancy. Pulmonary function tests
may be used to determine the risk of pulmonary morbid-
ity from thoracotomy. Decadron or methylprednisolone
may be used to decrease spinal cord edema and injury
caused by surgical trauma. Antibiotics should be given to
immunocompromised and previously radiated patients to
decrease the risk of wound infection.
OPERATIVE TECHNIQUE
Anesthesia
Anesthetic techniques should include direct arterial cath-
eter access for blood pressure monitoring and blood gas
determinations during and after surgery; however, appro-
priate noninvasive alternatives can be considered. Double-
lumen endotracheal intubation is usually unnecessary, as
the lung can be retracted gently without deflation to pro-
vide sufficient access to the posterior chest wall and ver-
tebral bodies.
Positioning
Patients are best placed in a lateral decubitus position with
the side of the predominant tumor involvement up (Fig.
2). The surgeon can stand anterior or posterior to the pa-
220
tient; in most cases, however, an anterior position is more
comfortable. For tumors at the thoracolumbar junction in
which the predominant side of tumor involvement is the
left, a left-sided approach risks injury to the radiculo-
medullary artery of Adamkiewicz, with possible spinal
cord infarction. If a leftsided exposure is necessary to
obtain sufficient tumor removal, spinal angiography
should be performed preoperatively with attention to the
segmental aortic branches from the left side in the low
thoracic region to localize this important vessel. Once
identified, the vessel can be excluded from the surgery
site, avoided by approaching the tumor from the right side,
or carefully microdissected to preserve spinal cord blood
supply. The posterior spinal approach may be used simul-
taneously by a second surgical team for the application of
stabilizing rods and the removal of additional tumor-in-
volved bone and epidural tissue.
Surgical Procedure
The thoracotomy skin incision should approximately par-
allel the ribs, curving rostrally as the midline is approached
and extending laterally to the midaxillary line (Fig. 2).
Removal of one or two contiguous ribs is tolerated well
and provides excellent autograft material for bone fusion.
Additionally, the trauma of chest wall retraction is some-
what reduced, particularly in elderly patients, if the rib is
removed.
After subcutaneous bleeding points are coagulated,
the rib removal proceeds to the transverse process medi-
ally. The ligamentous attachment to the rib head should
be cut and the rib detached from the vertebral bodies. Next,
the parietal pleura can be opened and retracted, providing
excellent visualization of the involved vertebral body. The
lung is retracted gently, protected by a large laparotomy
sponge.
At the level of tumor involvement, the pleura is usu-
ally deformed, thickened, and hypervascular. The pleura
is incised along the vertebral body margins; it should be
coagulated as it is removed. Segmental vessels will then
be identified coursing across the vertebral body from an-
terior to posterior in the middle and caudal half of the
vertebral body. These can be clipped proximally or co-
agulated with bipolar cautery over a long segment to per-
mit their removal.
Next, the adjacent disks are explored, and their
position is confirmed with a lateral x-ray film, if nec-
essary. The disks are then incised with a scalpel and
removed with pituitary rongeurs and curettes (Fig. 3).
During this process, the margins of the adjacent ver-
tebral body endplates can be explored, orienting the
surgeon to the posterior limit of the vertebral body to
be resected. The vertebral anatomy can be quite dis-
torted by tumor extensions and pathologic fractures.
 BENNETT : TRANSTHORACIC EXCISION OF A SPINAL METASTASIS

© 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.

221
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

© 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).

222
 BENNETT : TRANSTHORACIC EXCISION OF A SPINAL METASTASIS
At this phase of the operation, it is important to avoid
misjudging the vertebral confines.
Once the relatively bloodless discectomy is per-
formed, the vertebral body resection follows. The bone
may require a high-speed drill for removal or, if suffi-
ciently destroyed, may be removed simply with curettes
or the ultrasonic aspirator (Fig. 4). When the vertebral
body tumor is removed throughout its anterior and poste-
rior extent, the posterior longitudinal ligament will be en-
countered. The ipsilateral pedicle may be removed to fa-
cilitate identification of the segmental spinal nerve, which
serves as a guide to the ventral margins of the dura. The
contralateral pedicle cannot be removed from this ap-
proach due to inadequate exposure. Identification of the
caudal margin of the pedicle is quite helpful as it will
mark the entry site of the segmental spinal nerve into the
spinal canal.
Fine dissectors and nerve hooks can be used at this
point to identify the posterior longitudinal ligament or,
alternatively, the ligament may be retracted away from
the dura with a fine hook and directly incised anteriorly
(Fig. 5). This should be done to ensure that the ventral
aspect of the dura is decompressed well. The ligament is
frequently deformed because of chronic posterior dis-
placement from retropulsed pathologic bone. As the liga-
ment is incised progressively, the epidural space is dis-
sected intermittently with a fine blunt dissector. Usually
this plane is not adherent. It is, however, quite vascular
secondary to epidural veins, and these should be coagu-
lated with the bipolar forceps.
Once the posterior longitudinal ligament is entirely
removed to the margins of the vertebral body resection
cavity, decisions can be made about reconstruction. If the
adjacent vertebral body endplates appear to be grossly
free of tumor and there is a relatively good control of
systemic disease, then bone fusion should be attempted.
The adjacent vertebral bodies should be prepared to ac-
cept bone grafts by using the high-speed drill or
osteotomes to cut a trough to a depth of approximately 5
to 10 mm in the middle third of the vertebral body
endplates. This should be a transverse bony defect which
extends from the exposed lateral aspect of the vertebral
bodies to the contralateral cortical bone. The trough must
be well developed along the contralateral side to permit
placement of the maximal number of grafts.
Next, rib grafts are cut approximately 2 to 3 mm
longer than the measured distance between troughs, and
the segments are trimmed into a sharp configuration at
the ends to provide additional mechanical linkage between
the grafts and the vertebral bodies. The grafts are then
impacted into position with the convex surface anterior
(Fig. 6). There is usually space for three or four rib grafts
if the full transverse diameter of each vertebral body is
223
utilized. The grafts should be made progressively longer
as they are inserted sequentially to make up for cancel-
lous bone that will be loosened during the insertion of
previous grafts and lengthen effectively the distance be-
tween the troughs.
In patients with widespread metastatic disease and
in those who have an anticipated life expectancy of less
than 12 to 24 months, or if radiotherapy has been deliv-
ered to the spine, long-term stability from a bone fusion
is not necessary and may not be successful if attempted.
For these patients, reconstruction with a vertebral body
“spacer” of the bone cement, polymethyl methacrylate
(PMMA), usually supplemented by metal fixation in the
form of Steinmann pins, plates, or contoured rods, is pre-
ferred (Fig. 7). The pins should be 1 to 2 mm in diameter
and contoured slightly to match the thoracic kyphosis.
The vertebral body endplates should first be cut or drilled
to provide adequate space for maneuvering the pins and
cement. Using a curved or right-angled drill, a hole is
made in the end of each vertebral body to accommodate
each pin. The pin is first advanced caudally to the full
length of the adjacent vertebral body and, if possible,
through the next adjacent endplate and disk. The pin is
then positioned into the intervertebral defect and moved
rostrally into its matching drill hole. Once two or three
pins have been inserted, the PMMA is packed between
the pins, leaving adequate space (10-15 mm) between the
dura and bone cement. The PMMA is irrigated continu-
ously and Gelfoam or cottonoid sponges should be posi-
tioned temporarily over the dura during the process. If
there is localized chest wall involvement affecting the
adjacent rib heads and lateral vertebral segments, such as
the transverse processes, some of this additional tumor
can be removed to optimize local control.
If a moderate kyphosis is present, this may be par-
tially corrected by using a distraction device anteriorly in
the intervertebral defect prior to placing pins and PMMA
or by gentle external manual pressure over the apex of
the curve posteriorly. A major kyphosis (greater than 45°)
will probably require posterior instrumentation for ad-
equate correction. For patients with widely metastatic
cancer and limited activities of daily living, moderate re-
sidual deformities will probably be well tolerated. Poste-
rior correction to an optimal sagittal plane alignment may
not be necessary and may be prohibitively risky if an ad-
ditional posterior procedure is required through previously
radiated tissue.
Closure
A layered thoracotomy closure over a closed suction
chest tube drain concludes the procedure. Spinal cord
monitoring is not essential but may be helpful if exten-
sive correction of kyphosis is anticipated, to prevent
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

© 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).

224
 BENNETT : TRANSTHORACIC EXCISION OF A SPINAL METASTASIS

© 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).

225
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

© 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).

226
 BENNETT : TRANSTHORACIC EXCISION OF A SPINAL METASTASIS

© 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-

227
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
over-distraction. Intraoperative radiographs should be used
to confirm that satisfactory spinal alignment exists prior
to placement of bone cement and to verify the location
and extent of the resection.
COMPLICATIONS
The neural complications of this operation include inad-
vertent surgical trauma to the spinal cord and spinal cord
infarction related to interruption of the segmental arterial
supply, both of which are rare and largely preventable.
Incomplete tumor removal and early tumor recurrence at
the margins of the resection can result in fusion failure or
implant loosening with resultant spinal instability. Wound
healing and soft tissue problems are less common after
thoracotomy than after extensive posterolateral exposures.
228
POSTOPERATIVE TREATMENT
If not previously radiated, all patients with tumors that
are likely to respond should undergo postoperative radio-
therapy to improve local tumor control. Patients who have
undergone a bone fusion should have radiotherapy two to
three months after surgery to permit some initial vascu-
larization of the graft. Patients with PMMA and metal
implant reconstructions can be radiated three to four weeks
after surgery. All patients should be fitted with an exter-
nal orthosis. Those with rigid internal stabilization need
only a light orthosis to limit extreme activities, but pa-
tients in whom a fusion is anticipated should be placed in
a stiff thoracolumbar orthosis to diminish the likelihood
of early graft displacement.
 ANTERIOR CERVICAL DISCECTOMY
AND FUSION—THE CLOWARD
TECHNIQUE
RALPH B. CLOWARD, M.D.
INTRODUCTION
The surgical procedure described in this article is recom-
mended for removal of cervical disc lesions at one or more
levels followed by an interbody fusion using a cylindrical
dowel bone graft. It is the original technique devised and
described by the author in 1956 and used since for the
surgical treatment of acute and chronic cervical disc le-
sions. The author strongly urges that the procedure be
performed exactly as described to avoid complications.
CASE SELECTION
The anterior surgical approach to the cervical spine is
designed to treat pathologic lesions that cause pain and
impair function of the cervical nerve roots and spinal cord
at one or more levels. These lesions include acute and
chronic degenerative disc disease, traumatic dislocations
and compression fractures, space-occupying lesions of the
vertebral bodies, and intraspinal lesions anterior to the
spinal cord (including ossification of the posterior longi-
tudinal ligament).
INDICATIONS AND CONTRAINDICATIONS
Indications
The indications for surgery are intractable pain and pro-
gressive neurologic deficit which fail to respond to an
adequate trial of conservative therapy. Accurate identifi-
cation and definition of the lesion by contemporary im-
aging techniques are essential.
Contraindications
There are no absolute contraindications to an anterior
cervical operation if the surgeon is confident in his or her
own surgical ability, is willing to tackle a complicated
and difficult surgical procedure, and if he or she thinks
that the patient has a chance of improvement or recovery.
The relative contraindications, however, are many. They
© 1992 The American Association of Neurological Surgeons
229
include the patient’s advanced age, one or more previous
anterior cervical operations resulting in extensive scar-
ring, failure of a previous fusion or fusion with anterior
angulation, previous postoperative wound infection, or
postoperative neurologic deficit.
OPERATIVE TECHNIQUE
Identification
The level of the lesion is best identified by injecting me-
thylene blue dye into the disc under radiologic control,
either the day before operation when the discogram is
done, or in the operating room using portable x-ray equip-
ment and an intradiscal needle marker.
Position and Anesthesia
The patient is placed in the supine position with the neck
extended over a thick sandbag or a block of balsa wood
padded with foam rubber. The latter is soft, but firm, and
radiographs can be taken through it.
The patient is given a single dose of intravenous an-
tibiotic and a heavy sedative one hour before operation.
Nitrous oxide and/or a fluorinated inhalation agent are
used for endotracheal general anesthesia. Care must be
taken not to hyperextend the patient’s neck for intuba-
tion. Use of fiberoptic light or just flexion of the neck
will prevent spinal cord injury (quadriparesis) in the pres-
ence of intraspinal osteophytes and a stenotic canal. The
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).
Preparation
Two Mayo stands are placed transversely over the chest
and abdomen and another is positioned vertically over
the left side of the face. A horizontal draping bar the length
of the operating table is placed on the left side and se-
cured to an upright standard at the head and the foot with
Fisher clamps.
The neck is prepared with Betadine soap, Betadine
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

sterile covered Mayo trays are placed on the Mayo stands

to secure the drapes.

Sponges
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).

Draping
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.

230
 CLOWARD : ANTERIOR CERVICAL DISCECTOMY AND FUSION
the scissors above and below the incision. The skin and
subcutaneous tissue are freed from the platysma the same
distance vertically as the length of the transverse inci-
sion. The skin is retracted vertically with a single-toothed
self-retaining retractor (Fig. 3). The platysma is carefully
spread and opened along its normal vertical fibers with
scissors, taking care not to cut the superficial jugular vein
immediately beneath.
Soft Tissue Dissection
The medial margins of the cut platysma muscle and the
underlying vein are retracted to the left to identify the me-
dial border of the sternomastoid muscle. By spreading and
cutting with scissors, loose areolar tissue surrounding this
muscle is divided throughout the length of the exposure.
The muscle is retracted laterally with an angulated hand
retractor. The diagonally placed omohyoid muscle is thus
exposed and freed after cauterizing small vessels along its
superior margin. This muscle is retracted medially and
downward (Fig. 4). The carotid-esophageal cleavage plane
can be identified by a small white neurovascular bundle
visible in the loose areolar tissue and running up and down.
By spreading this tissue medial to the small nerve, a cleav-
age plane is opened cautiously by the spreading scissors
and the small nerve retracted laterally. The tissues of the
cleavage plane should not be roughly opened with the fin-
ger. A right-angle hand retractor with a wide blade is held
in the surgeon’s left hand and placed beneath the esopha-
© 1992 The American Association of Neurological Surgeons
Figure 3. The skin edges are retracted vertically with a single-toothed
self-retaining retractor.
231
gus and strong lateral retraction is made to the left. The
carotid artery is gently retracted to the right by the assis-
tant. This exposes the bone.
For a single level operation, the cleavage plane is
opened only to expose one disc. To expose adjacent lev-
els, it is opened upward to C4/5 by cutting a small neu-
rovascular bundle located at the lower margin of the thy-
roid cartilage. This can be safely cauterized and divided
with scissors.
To expose lower levels (C6/7 or C7/T1) the inferior
thyroid artery will be encountered. It is dissected free and
if sufficiently long may be placed behind the vertical re-
tractor blade. If the artery is short it should be ligated and
divided to avoid avulsion by strong retraction. Two other
structures may be injured by retraction at lower levels:
the recurrent laryngeal nerve and a high-lying dome of
the pleura, resulting in hoarseness or pneumothorax, re-
spectively. These complications can be prevented by tak-
ing necessary precautions.
Exposure of the Spine
The avascular prevertebral areolar tissue is incised in
the midline with scissors to expose the parallel medial
margins of the longus colli muscles. The anterior longi-
tudinal ligament covers the vertebrae between these
muscles and above and below the disc. The disc level
is identified by the previously injected methylene blue
dye or by an intraoperative radiograph with a needle
© 1992 The American Association of Neurological Surgeons
Figure 4. Dissection along the carotid-esophageal cleavage plane.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
marker (see Fig. 7). A self-retaining retractor with blunt
blades can be placed for vertical exposure of the wound at
this stage and manual retraction used for lateral exposure,
or manual exposure can be used alone. Adequate detach-
ment of the longus colli muscles from the adjacent verte-
bral bodies and the discs is an important step in the opera-
tion. The medial margins of these muscles are cauterized
to seal muscle bleeders, and then the muscle attachments
are detached from the vertebral bodies with a sharp peri-
osteal elevator up to the medial part of the transverse pro-
cesses. The muscle is retracted with a second periosteal
elevator to expose the bone (Fig. 5). Muscle and bone bleed-
ers are controlled by cauterizing the bone with the cutting
current set at a high level and packing with Gelfoam and
thrombin. Ample detachment of these muscles ensures a
wide exposure of the spine and prevents the retractor blades
from slipping. These blades with sharp teeth are designed
to protect the esophagus and larynx on the left side and the
carotid artery on the right (Fig. 6). If the blades are prop-
erly inserted deep beneath the detached muscles, they will
not slip or come out. The blade should be checked during
the operation to determine whether the teeth remain safely
secured beneath the muscle. If a blade should slip, it is
because the muscle has not been adequately detached. The
blade is removed and reinserted to prevent trauma to the
esophagus. Blades of different lengths are available to ac-
commodate wounds of various depths. A blade is chosen
© 1992 The American Association of Neurological Surgeons
Figure 5. Dissection of the longus colli muscles away from the
vertebral bodies.
232
to fit the exact depth of the wound on the left side so the
flange of the blade is flush with the skin. The blade of simi-
lar length or slightly longer inserted on the right will project
above the skin level, but this assists in maintaining the mid-
line position of the retractors. Retractor blades with smooth
tips are inserted vertically; the inferior blade is attached to
the short handle and slipped under the legs of the long
handle of the lateral blades. The upper smooth-tipped blade
is slightly shorter. The small retractor handle is opened to
its maximum, and then the hinge is broken sharply so the
handle hugs the right side of the neck. This will force the
toothed retractor blades to the left for maximum midline
exposure (Fig. 7).
Removal of the Disc
A pointed scalpel blade on a long handle is inserted into
the disc about 1.5 cm deep and the disc is cut along the
vertebral margins above and below and as far lateral as
possible (Fig. 7). If the patient has large anterior
osteophytes or an intercalary bone (ossified anterior lon-
gitudinal ligament) it may be necessary to remove these
projections with a small osteotome or disc rongeur be-
fore the disc is incised.
The incised disc is removed with a narrow disc
rongeur, and then all loose disc material is withdrawn
from the interspace. A cervical vertebra spreader is in-
serted into the disc space, placed laterally on one
© 1992 The American Association of Neurological Surgeons
Figure 6. Application of self-retaining retractors.
 CLOWARD : ANTERIOR CERVICAL DISCECTOMY AND FUSION
side, and the thumb screw is turned to force the disc space
open (Fig. 8). The cartilage plates are stripped from the ver-
tebra with a sharp elevator and then all cartilage and remain-
ing disc are scraped from both vertebrae using straight
curettes until the fibers of the posterior longitudinal liga-
ment are exposed. The vertebra spreader may be moved from
side to side to assist in the exposure for disc removal (Fig. 8).
© 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
blade knife. Note that the disc is stained with methylene blue that
was injected preoperatively.
Figure 8. (Bottom left) Distraction of the intervertebral space with a
233
The anteroposterior measurement of the disc space
is taken with the depth gauge. The foot of the gauge is
placed on the posterior longitudinal ligament and the L
bar on the anterior margin of the vertebra (Fig. 9).
If the radiographs show large posterior marginal
osteophytes, the anteroposterior measurements may be
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
margin.
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
vertebral spreader. The cartilage plates are being removed with a
sharp elevator.
Figure 9. (Bottom right) Measurement of the anteroposterior dimen-
sion of the disc space using a depth gauge.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

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.

234
 CLOWARD : ANTERIOR CERVICAL DISCECTOMY AND FUSION

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

235
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

© 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
rongeur.

236
 CLOWARD : ANTERIOR CERVICAL DISCECTOMY AND FUSION

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

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).

237
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

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.

238
 CLOWARD : ANTERIOR CERVICAL DISCECTOMY AND FUSION
the dowel in place. The impactor is then unscrewed from
the dowel and removed. A small pad of Gelfoam is packed
into the bottom of the hole on both sides of the dowel to
cover the nerve root. The cortical end plates may be fur-
ther broken up with a small curved osteotome. The bone
dust saved from the drill is packed into the interspace to
© 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
removed with an osteotome. Bone dust is packed into the intervertebral
space on either side of the dowel to facilitate fusion.
239
strengthen the fusion (Fig. 22).
When the toothed retractor blades are removed, the
longus colli muscles return to their normal position. The
muscle is checked for bleeding points. The wound is irri-
gated with saline and a 7-mm Jackson-Pratt drain is cut
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
Figure 23. (Bottom left) Insertion of a flat Jackson-Pratt drain.
Figure 24. (Right) Approximation of the platysma layer with inter-
rupted inverted figure-of-eight sutures.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

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 CARE
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.

240
 CUBITAL TUNNEL SYNDROME
SETTI S. RENGACHARY, M.D.
PATIENT PRESENTATION AND SELECTION
Patients with the cubital tunnel syndrome generally present
with weakness and atrophy of the intrinsic muscles of the
hand and tingling and numbness in the medial two fin-
gers. Motor atrophy sets in early compared to the atrophy
associated with the carpal tunnel syndrome. Once motor
atrophy sets in, reversal is seldom rapid or complete; there-
fore, conservative treatment is less likely to help patients
with the cubital tunnel syndrome than those with the car-
pal tunnel syndrome. In neurosurgical practice, no appar-
ent etiology can be determined that accounts for the cu-
bital tunnel syndrome. When the syndrome was described
in the last century, it was related to malunited fractures
around the elbow involving either the distal humerus or
the medial epicondyle. The ulnar paralysis came on years
after the healing of the fracture with the formation of exu-
berant callus. Cases in contemporary practice are seldom
due to compression from a callus. Rather, they are thought
to be due to the compression of the ulnar nerve in the
cubital tunnel by the sharp fascia that spans the two heads
of the flexor carpi ulnaris. This is discussed further in the
section on surgical anatomy.
On objective testing, one finds atrophy of the intrin-
sic muscles, especially the first dorsal interosseous muscle.
There is usually weakness of the ulnar-innervated muscles,
including the palmaris brevis muscle, the abductor, op-
ponens, and flexor digiti quinti muscles, the flexor pollicis
brevis and adductor pollicis muscles, the medial two
lumbricals, and all of the interossei. The flexor carpi
ulnaris muscle is not generally affected because the fi-
bers that subserve motor innervation of this muscle are
thought to be deep within the nerve and thus less com-
pressed than the fibers to the intrinsic muscles which are
situated more superficially. One should make sure that
there is no underlying peripheral neuropathy, either from
diabetes or alcohol. If present, it may be hard to deter-
mine to what extent the dysfunction is from the underly-
ing neuropathy and to what extent from the mechanical
impingement at the elbow.
© 1992 The American Association of Neurological Surgeons
241
Electromyography and nerve conduction velocities
give an objective assessment of the degree of the impair-
ment of the ulnar nerve across the elbow. The commonly
observed features are as follows. The conduction veloc-
ity of the ulnar nerve across the elbow is slowed com-
pared to the velocity in the forearm segment of the ulnar
nerve. The amplitude of motor response in the abductor
digiti quinti is decreased and the duration of the response
is prolonged with stimulation of the nerve above the el-
bow compared with stimulation below the elbow. This
finding is especially helpful in patients who have normal
conduction velocity across the elbow in spite of typical
clinical symptoms. The sensory latency is prolonged.
Needle examination of the ulnar-innervated muscles may
show varying changes. An early finding is a reduction in
the voluntary motor unit action potentials. When axonal
degeneration sets in, positive waves and fibrillation po-
tentials may be observed.
Ulnar neuropathy should be differentiated from lesions
in the cervical spinal cord, lower cervical nerve roots, or
brachial plexus. Intrinsic spinal cord lesions are generally
painless, produce bilateral symptoms and signs, may be
associated with Homer’s syndrome, and produce sensory
and motor loss in a segmental rather than peripheral nerve
distribution. Extradural lesions such as cervical disc her-
niation or spondylosis produce characteristic root pains and
produce sensory and motor loss in a root distribution with-
out alteration in nerve conduction velocity. Brachial plexus
lesions involving the C8 and T1 roots may produce intrin-
sic atrophy but the anatomic distribution will be one of
root or plexus rather than peripheral nerve.
SURGICAL ANATOMY
OF THE CUBITAL TUNNEL
The ulnar nerve originates from the medial cord of
the brachial plexus and descends down medial to the
brachial artery to the midarm. In the midarm at about
the level of the insertion of the coracobrachialis muscle,
it pierces the medial intermuscular septum and de-
scends immediately behind the septum but in front of
the medial head of the triceps to a point behind the
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
medial epicondyle. It then enters a fibrous tunnel, the so-
called cubital tunnel, the roof of which is formed by the
two heads of the flexor carpi ulnaris muscle and a dense
fibrous band that spans across the two heads. The floor of
the cubital tunnel is formed by the capsule of the elbow
joint. During flexion, because of the separation of the
medial epicondyle and the olecranon process, the fibrous
band that connects the two heads of the flexor carpi ulnaris
becomes very taut and is more likely to compress the u1nar
nerve. During extension the fibrous band is more relaxed
and less likely to compress the ulnar nerve. Repetitive
motion that involves repetitive flexion at the elbow and
adduction at the wrist, as is entailed in shoveling, may
produce compression of the nerve because of the scissor-
like approximation of the two heads of the flexor carpi
ulnaris and the increase in tension in the fibrous band
that spans the two heads.
It is important to note that the ulnar nerve has the
widest diameter near the elbow because of the higher pro-
portion of interstitial connective tissue within the nerve
at this point. Indeed, in many individuals there is a bul-
bous swelling of the ulnar nerve behind the elbow. This
should not be mistaken for a neuroma.
CHOICE OF SURGICAL PROCEDURES
There are basically three operative procedures that are
commonly done for patients with the cubital tunnel syn-
drome. These are simple decompression of the ulnar nerve,
decompression followed by transposition of the ulnar nerve,
and medial epicondylectomy. Medial epicondylectomy is
rarely done now because of the morbidity involved after
removal of the medial epicondyle. Therefore, the choice
is really between simple decompression and transposi-
tion of the ulnar nerve.
I prefer a simple decompression operation for the
following reasons. It is generally said that recurrent dislo-
cation of the ulnar nerve out of its groove leads to ulnar
neuropathy from repeated trauma. The justification for
anterior transposition in such instances is that it protects
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-
ing extension. One should note that the ulnar transposi-
tion operation, viewed with a historical perspective, got
started at a time when the most common cause of ulnar
242
nerve paralysis was the presence of exuberant callus in
the distal humerus from a malunited fracture. In the early
days, surgeons did not have good means of resecting the
callus to decompress the nerve; instead of subjecting the
patient to a tedious procedure of resecting the callus, they
rather transposed the ulnar nerve in front of the callus
which was a much simpler procedure. Nowadays, callus
is rarely seen as the etiology for ulnar nerve compression
at the elbows. Thus, there is no justification to transpose
the nerve in contemporary practice. Most studies have
shown that the transposition operation does not offer re-
sults superior to those of the simple decompression op-
eration. Indeed, the complications and morbidity are less
with simple decompression than transposition. For these
reasons, I prefer a simple decompression operation.
SURGICAL TECHNIQUE
The operation can be performed either with a brachial
plexus block or with general anesthesia. I generally pre-
fer general anesthesia because it is more comfortable for
the patient. Application of a tourniquet is optional and I
do not use it. The entire arm is scrubbed from the axilla to
the wrist for 10 minutes with povidone-iodine soap and
then painted with povidone-iodine solution. The skin in-
cision (Fig. 1) is about 8 cm long. It starts 3 cm above the
elbow immediately posterior to the medial intermuscular
septum, swings gently over in front of the medial epi-
condyle, and then drops down again into the forearm for
about 3 cm. At the distal end of the skin incision, the basilic
vein will be noticeable. It is best not to transect the basilic
vein, so the incision should stop just short of it.
The dissection is carried out with 3.5 × loupe magnifi-
cation. The skin and subcutaneous bleeders are coagulated
with bipolar coagulation. A skin flap is reflected on both
sides; the surgeon dissects in the plane between the subcuta-
neous fat and the deep fascia of the forearm. During this
dissection, it is important to identify and preserve the branches
of the medial cutaneous nerve of the forearm which
traverses the subcutaneous tissue. Section of the nerve will
© 1992 The American Association of Neurological Surgeons
Figure 1. The skin incision for decompression of the ulnar nerve. Note
that the incision stops short of the basilic vein.
 RENGACHARY : CUBITAL TUNNEL SYNDROME
result in an area of numbness in the forearm and when
the patient awakens he will be alarmed to notice that his
original numbness has extended further into the forearm
and may believe that his neurologic status has deterio-
rated from injury to the u1nar nerve.
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.
243
Self-retaining retractors are then inserted. The deep
fascia is grasped with Adson forceps and incised in
line with the skin incision (Fig. 2, A and B). The next
step is to identify the ulnar nerve in the arm. The best
landmark for this is the sharp edge of the medial
© 1992 The American Association of Neurological Surgeons
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

© 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.

244
 RENGACHARY : CUBITAL TUNNEL SYNDROME
intermuscular septum. This can be palpated digitally (Fig.
2C). Just behind the medial intermuscular septum but in
front of the medial head of the triceps is the ulnar nerve.
This can be rolled under the finger (Fig. 2C). Once the
nerve is felt, the deep fascia over the ulnar nerve is di-
vided and the triceps muscle is gently retracted (Fig. 3A),
exposing the ulnar nerve in the arm. There is usually a
bulbous swelling of the ulnar nerve as it reaches the el-
bow (Fig. 3B). At this point, the dense fascia spanning
the two heads of the flexor carpi ulnaris is identified. It
extends from the medial epicondyle to the olecranon pro-
cess (Fig. 3B). The most important step is to divide this
dense fascia well into the forearm until the surgeon is
sure that there is no remaining compression of the ulnar
nerve. It is not necessary to circumferentially isolate the
nerve. Such a maneuver is likely to interfere with the blood
supply to the ulnar nerve. One has to make sure that there
is no compression of the ulnar nerve by any fibrous band
or muscle fibers. To prevent reconstitution of the cubital
tunnel, the edges of the fascia are then sewn over the flexor
muscles on either side with interrupted absorbable su-
tures (Fig. 3C). The decompression is now complete.
Meticulous hemostasis is obtained and the subcutaneous
layer is closed with interrupted absorbable sutures and
245
the skin with subcuticular sutures. No drain is used. The
dressing is removed on the second postoperative day and
no special further care is necessary.
RESULTS AND COMPLICATIONS
The symptoms improve in over 80% of the cases. In pa-
tients with an underlying peripheral neuropathy, either
from diabetes or alcoholism, the symptoms are less likely
to resolve. Also patients who wake up from an operative
procedure with ulnar neuropathy from failure to pad the
elbow do not fare well with ulnar nerve decompression.
If simple ulnar decompression fails, transposition of the
nerve is not likely to relieve the symptoms. If recurrence
of symptoms is noted after simple decompression, it im-
plies that there is an underlying neuropathy, that the de-
compression is incomplete, or that the clinical diagnosis
is incorrect.
Making a trough in the flexor muscles and transpos-
ing the nerve and burying the nerve deep within the flexor
mass has been advocated by some for recurrent cases.
This creates another fibrous tunnel and the patients in the
long term invariably have recurrence of symptoms. I do
not advocate creating such a muscular trough for burying
the nerve after transposition.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
CASPAR PLATING
OF THE CERVICAL SPINE
H. LOUIS HARKEY, M.D.
WOLFHARD CASPAR, M.D.
YAGHOUB TARASSOLI, M.D.
INTRODUCTION
Most neurosurgeons are comfortable with the anterior
approach to the cervical spine and are familiar with
interbody arthrodesis techniques. The ease of patient po-
sitioning and tissue dissection makes this a popular pro-
cedure while providing direct access to common patho-
logic compression. A successful interbody arthrodesis
results in a highly stable block fusion that maintains nor-
mal cervical lordosis and intervertebral distances. How-
ever, in the presence of middle or posterior column insta-
bility it can be difficult to restore and maintain adequate
stability with an interbody graft alone. The addition of an
anterior plate reestablishes and sustains stability, enhanc-
ing the rate of bone healing.
Historically, the potential risk of spinal cord or nerve
root injury associated with placing screws through the
cervical vertebral body deterred widespread use of ante-
rior internal stabilization. In addition, the potential risk
of instrument failure and subsequent injury to the esopha-
gus and trachea has been a major source of concern. The
development of a comprehensive surgical technique rely-
ing on implants and instrumentation (Aesculap Instrument
Co., Burlingame, California and Aesculap Werde AG,
Tuttlingen, Germany) designed specifically for the cervi-
cal spine has made anterior internal fixation a freely ap-
plicable technique for spinal surgery today.
PATIENT SELECTION
The Caspar osteosynthetic stabilization technique was
originally developed as a one-stage procedure for the treat-
ment of cervical trauma requiring anterior decompres-
sion. Cervical burst fractures associated with partial cord
injuries and/or root lesions often require decompression.
It has also become apparent from recent use of magnetic
resonance imaging (MRI) in cervical trauma that disc
© 1992 The American Association of Neurological Surgeons
246
herniation associated with simple fracture-subluxation is
more common than previously thought. Following the
removal of displaced disc or bone fragments, anterior plat-
ing provides immediate internal stabilization, obviating
the need for a second posterior stabilization procedure or
halo immobilization.
Caspar plate stabilization is useful in other types of
cervical trauma as well. Some hangman’s fractures with
C2-C3 disc and posterior longitudinal ligament disrup-
tion are highly unstable and cannot be adequately treated
by external immobilization. These fractures can be re-
duced and stabilized with a Caspar plate to avoid the
obligatory loss of C1-C2 segment function associated with
posterior internal fixation.
The decreased risk of supine positioning and the ease
of operative exposure afforded by the anterior approach
make anterior cervical plate stabilization an increasingly
popular alternative to posterior stabilization techniques
even when decompression is not necessary.
Most locked facets can be reduced after anterior de-
compression with a combination of distraction and gentle
manipulation and therefore do not constitute an absolute
contraindication for anterior cervical plating. However,
if a locked facet is disassociated from the vertebral body
by a fracture through the pedicle, reduction via an ante-
rior approach may not be possible. Locked facets not re-
quiring anterior decompression are still best treated by
posterior reduction and stabilization.
The indications for Caspar plating are not limited to
traumatic lesions of the cervical spine but can also include
the treatment of degenerative diseases, tumors, and other
processes requiring stabilization. Degenerative subluxation
with associated osteophytic root or cord compression can
be decompressed, reduced, and stabilized with the Caspar
plate. Ossification of the posterior longitudinal ligament,
severe multilevel cervical spondylosis, and tumors of the
vertebral body or anterior spinal canal are increasingly
 HARKEY ET AL. : CASPAR PLATING OF THE CERVICAL SPINE
being treated with cervical corpectomy followed by strut
graft reconstruction. The major complication associated
with cervical corpectomy is graft extrusion. The addition
of a Caspar plate provides an anterior tension band that
deters graft extrusion and enhances fusion. Likewise, the
risk of pseudoarthrosis increases following multilevel
discectomies for cervical spondylosis as the number of
levels of decompression increases. Caspar plating with
fixation at each intervening vertebral body will decrease
the chance of malunion.
The holding power of a screw in bone is directly re-
lated to the density and quality of the bone. In addition,
the plate and screws merely act as an internal splint while
bony remodeling occurs. If fusion is not ultimately
achieved, repeated stress on the instrumentation will even-
tually lead to treatment failure. Young healthy bone, most
common in traumatic cervical spine injuries, is ideally
suited for anterior cervical stabilization. It provides ex-
cellent screw purchase and rapid bone healing. On the
other hand, osteoporotic bone has decreased density and
heals more slowly; therefore, the risk of screw loosening
is greater and the stresses on the plate are prolonged. These
problems combine to increase the risk of instrumentation
failure and malunion. The spinal surgeon must augment
the stabilization with external bracing in accordance with
the quality of the patient’s bone.
PREOPERATIVE PREPARATION
An attempt should be made to restore normal alignment
with external traction prior to surgical intervention for
cervical trauma. Skull traction is also useful for main-
taining alignment during surgery.
A thin slice computed tomography (CT) scan is help-
ful in identifying fractures and displaced bone fragments
that are not seen on plain X-ray films. MRI may demon-
strate disc herniation or hematoma compressing neural
elements and may also show intramedullary pathology.
When dealing with nontraumatic problems, MRI and CT
myelography are both useful for demonstrating neural
compression.
Because of the increased risk of infection associated
with foreign body implantation, preoperative antibiotics are
recommended to reduce the risk of infection by the common
offending organisms. An antistaphylococcal antibiotic, such
as a first or second generation cephalosporin, should be ad-
ministered intravenously within 1 hour of the skin incision
and repeated as an equivalent dose at the termination of the
procedure or after 4 hours, whichever occurs first. If Foley
catheter drainage is used or other potential Gram-negative
contamination is present, gentamicin or an equivalent anti-
biotic should be added to each antibiotic dose. These antibi-
otics should be continued for 36 to 48 hours postoperatively.
247
The addition of high-dose steroids in the perioperative pe-
riod may provide some protection against neural injury sec-
ondary to minor trauma or edema.
OPERATIVE TECHNIQUE
Anesthetic Technique
As with any cervical spine surgery, care should be taken
during intubation to avoid movement of an unstable spine
or excessive hyperextension of a stable spine. Nasal intu-
bation with the assistance of a bronchoscope is usually
preferable. After positioning the endotracheal tube, gen-
eral anesthesia is rapidly induced with sodium pentothal
and maintained with volatile anesthetic agents. Muscle
relaxation should be avoided because stimulation of a
nerve root will give instant feedback in the form of a
muscle twitch, providing “poor man’s evoked potentials.”
Positioning
The patient is placed supine with the head of the table
elevated 10° to 15° relative to the feet (reverse Trendelen-
burg position), providing a direct line of vision through
the plane of the disc space. The head should rest on a
narrow support, such as a horseshoe head holder, in order
to facilitate fluoroscopy. The addition of an adjustable
neck support assists in restoring and maintaining the
proper cervical lordosis throughout the procedure. Trac-
tion is applied to the skull (2 to 8 kg) and arms (1 to 2 kg/
arm utilizing padded cuffs) to maintain cervical alignment
and improve fluoroscopic visualization. The C-arm fluo-
roscopy unit is positioned to provide a true lateral view
with the X-ray tube on the operative side (Fig. 1). The
surgeon and assistant stand on either side of the X-ray
tube which is draped into the sterile field with a C-arm or
Mayo stand cover.
The hip should be slightly elevated with padding to
facilitate exposure of the iliac crest if a graft is to be har-
vested. Meticulous care should be taken during draping
to ensure a sterile, waterproof field. This is best achieved
using a layer of adhesive-backed plastic drape over the
prepared skin, followed by cloth or paper drapes. A sec-
ond plastic drape can be applied to secure the drape edges
as well as any wires and cables that cross the sterile field.
Surgical Procedure
Skin Incision and Exposure
Debate on the preferred side for a cervical skin inci-
sion has centered around the increased risk of injury to
asymmetrical structures in the neck, such as the recur-
rent laryngeal nerve. However, unless the patient’s pa-
thology dictates otherwise, the surgeon’s dominant
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
© 1992 The American Association of Neurological Surgeons
handedness should determine the side of the incision with
right-handed surgeons exposing from the right side and
vice versa for left-handed surgeons.
The level of incision is determined by fluoroscopic
visualization and should overlie the midpoint of the cer-
vical fusion. A wide transverse neck incision is placed
within a skin fold extending 1 or 2 cm beyond the mid-
line. When three or four motion segments are being sta-
bilized, an oblique incision along the medial border of
the sternocleidomastoid muscle may be preferable.
Generous myocutaneous flaps incorporating skin and
platysma muscle are developed superiorly and inferiorly
248
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
to establish a normal cervical lordosis.
to produce a relaxed skin incision. The middle and deep
layers of the cervical fascia are dissected along the me-
dial border of the sternocleidomastoid muscle. The
esophagus, trachea, and strap muscles are retracted me-
dially, and the carotid sheath and sternocleidomastoid
muscle are retracted laterally. The omohyoid muscle which
crosses the exposure obliquely at the C5-C6 level can be
mobilized or, if necessary, transsected. If a thyroid artery
interferes with the exposure it can be ligated and
transsected. The exposure required for stabilization is
much greater than that required for a simple anterior
discectomy and interbody arthrodesis. It is exceedingly im-
 HARKEY ET AL. : CASPAR PLATING OF THE CERVICAL SPINE
portant to adequately dissect the soft tissues of the neck
to provide ample exposure without injuring the fine neu-
rovascular structures of the neck. Inadequate exposure
leads to excessive swelling, dysphagia, and hoarseness
in the postoperative period.
The longus colli muscles are detached from the verte-
bral bodies bilaterally and are elevated from the disc space
above to the disc space below the level of fusion. The lon-
gus colli muscles should be dissected widely while avoid-
ing maceration of the muscle bellies because they must
sustain powerful lateral retraction. Serrated blades which
readily retain their position are placed beneath the longus
colli muscles under direct vision and are attached to the
self-retaining retractor (Fig. 2). Toothless blades are used
for longitudinal countertraction. For extensive exposure,
tandemly placed lateral retractor systems can be used.
Decompression and Graft Site Preparation
The operative level is verified with fluoroscopy, and a
partial discectomy is performed. The uncovertebral junc-
tion should be identified bilaterally to facilitate the iden-
tification of the vertebral midline. The distraction pin
drill guide is positioned over the center of the vertebral
body and directed parallel to the vertebral endplate. The
© 1992 The American Association of Neurological Surgeons
Figure 2. The intraoperative fluoroscopic image (A) and the matched draw-
ing (B) demonstrate the longitudinal retractor blades (a) and the radiolucent
lateral retractor blades (b). The radiolucent blades allow the surgeon to vi-
249
pin hole is drilled after verifying the trajectory with fluo-
roscopy, and a distraction pin is inserted. This pin can
then be used along with the immobile distractor arm,
drill guide assembly to position other distraction pins in
a parallel fashion. Each distraction pin should be inserted
fully so that the base plate is flush with the vertebral
body. If an abnormal curvature is present, individual
distraction pins may need to be placed freehand to posi-
tion them parallel to the endplates of the vertebral bod-
ies. Distraction pins placed parallel to the endplates of
the vertebral bodies will allow the distractor to restore
the normal curvature even in the presence of significant
deformities. The vertebral body distractor is placed over
the shafts of the distraction pins and distraction forces
are applied gradually.
A complete discectomy is performed with care to
remove the cartilaginous endplates. Anterior
osteophytes, bony irregularities, and the anterior infe-
rior lip of the superior vertebral body can be removed
with a high-speed drill to facilitate the discectomy. If a
total or partial corpectomy is to be performed, the discs
above and below the vertebral body are removed. The
anterior portion of the corpectomy can be performed
using a rongeur, and the bone fragments can be saved
sualize instruments such as the blunt hook (h) which would otherwise be
obscured. The distraction pins (p) are inserted into the center of the verte-
bral body as far as possible without penetrating into the canal.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
as augmentation for allografts. After the decompression
has been completed, any persistent abnormal cervical cur-
vature or locked facets can be corrected by gently ma-
nipulating the distractors and the neck rest.
The endplates are then prepared to accept a graft. It
is important that the underlying cancellous bone not be
exposed by complete removal of the endplates since this
will decrease the intrinsic supporting capacity of the ver-
tebral body and predispose the sturdy graft to penetrate
the weakened vertebral bodies. Due to the different shape
of the superior and inferior endplates, production of par-
allel surfaces for grafting requires selective drilling of
the anterior third and posterior third of the caudal endplate
and the posterior third or half of the rostral endplate (Fig.
3). When performed correctly, the graft site has parallel
surfaces with sufficient cortical bone remaining to sup-
port the graft. A common error is failure to remove enough
anterior and posterior bony lip, thus leaving a central gap
between the bone graft and vertebral endplate. A more
serious error is the “ramp effect” caused by excessive bone
removal from the anterior two-thirds of the lower verte-
bral body. This produces a graft site that is taller anteri-
orly than it is posteriorly and fosters forward dislocation
of the graft.
Grafting
A tight-fitting “gapless” graft requires an appropriately
sized, well-formed bone plug as well as a meticulously
prepared graft site. Using a micrometer and depth gauge
to measure the height and depth of the graft site accu-
rately, the proper dimensions of the bone plug can be de-
termined. The depth of the graft site is measured in the
Figure 3. This schematic drawing demonstrates the appropriate bony removal necessary for creation of a parallel graft site.
250
midline of the vertebral body from the posterior cortex to
the anterior cortex. The height of the graft site (i.e., the
distance between the vertebral endplates) is measured in
the maximally distracted condition. The average graft
should measure 7 to 8 mm in height but should not be
greater than 10 mm to avoid overdistraction when there is
severe ligamentous disruption.
A tricortical iliac crest bone graft is ideal for interbody
arthrodesis up to a two-level corpectomy. Larger decom-
pressions may require a fibular graft. Iliac crest osteoto-
mies should be at right angles to the surface of the crest
and parallel to each other. A double-bladed oscillating saw
ensures parallel surfaces. When harvesting iliac crest strut
grafts for subtotal and total body replacement, it is prudent
to include several extra millimeters to allow for reshaping.
The depth of the graft should measure 3 mm less than
the anteroposterior diameter of the prepared interspace
(generally about 15 mm in depth). This allows a suffi-
cient margin of safety anterior to the spinal cord once the
bone plug is seated into place. Contrary to standard ante-
rior fusion techniques, the bone plug is not countersunk
for plating but is left flush with the anterior surface of the
spine. The edges of the graft can be beveled slightly to
facilitate insertion.
The fabricated graft is tamped into position with the
vertebral bodies distracted and should fit snugly without re-
quiring excessive force or hammering. The position of the
graft can be inspected with a blunt hook placed along the
side of the graft under fluoroscopic guidance. Once the graft
is ideally situated, the vertebral body distractor can be used
to compress the fusion while small bits of cancellous
bones are gently impacted to fill the gaps. Similarly, when a
 HARKEY ET AL. : CASPAR PLATING OF THE CERVICAL SPINE
fibular graft is used, cancellous bone chips can be laid
along the sides of the graft to enhance the fusion. In ei-
ther case, care must be taken to avoid compression of the
neural structures with these smaller bits of bone.
At this point the distraction pins can be removed and
a small piece of Gelfoam or bone wax used to stop the
hemorrhage from the hole. Any bony irregularities of the
anterior vertebral bodies can be removed with a drill to
ensure that the plate fits flush. Maximum plate-to-bone
contact enhances the structural stability of the construct.
Plating
Two very important points regarding Caspar anterior cer-
vical plating cannot be overstated. First, plate stabiliza-
tion cannot be properly or safely performed without us-
ing fluoroscopy. Dispensing with X-ray guidance will very
likely lead to faulty plate fixation and could lead to disas-
trous complications. Second, the surgeon should never
plate across an infused disc space. One should keep in
mind that plating merely provides a temporary internal
splint which enhances the fusion process. It is the ossifi-
cation of the graft placed in the cleared disc space that
provides the long-term stability. If the plate crosses an
intact disc space, screw loosening or fracture will eventu-
ally occur because of the micromotions that remain pos-
sible.
The plate selected will bind the intact vertebral bod-
ies above and below the level(s) of instability. For a single
level fracture-subluxation, the plate should span the disc
space plus the adjacent vertebral bodies. For multilevel
instability or vertebral body replacement procedures, the
plate will span two or more disc spaces plus the intact
vertebral bodies above and below the levels of instability.
After selecting the appropriate length of plate by inspect-
ing its fit with the C-arm fluoroscope, the plate is bent in
a convex fashion to achieve a normal lordotic posture af-
ter fixing the plate to the spine. Generally speaking, the
curve should be smoothly distributed along the length of
the plate; the treatment of C2-C3 instability requires an
exception. In this instance, the upper edge of the plate
should be more sharply bent to conform to the ventral
shape of the C2 vertebral body.
The bent plate should be positioned over the verte-
bral bodies and inspected with fluoroscopy. The fit is
judged appropriate when the ends of the plate rest ap-
proximately 2 mm from the upper and lower endplates
and 3 to 5 mm of space exists between the center of the
plate and the vertebral column. Tightening the screws with
this bowed configuration will tend to shift the vertebral
bodies into the appropriate lordotic curvature. Restora-
tion of cervical lordosis can only be achieved if the graft
251
is appropriately shaped and adequate torque is obtained
on the screws as they are tightened. It is important to re-
store normal alignment to prevent further injury to the
spinal cord and to reestablish normal biomechanical rela-
tionships in the remainder of the cervical spine.
The plate should be positioned carefully prior to drill-
ing the screw holes. Because the exposure is not truly
midline, there is a tendency to position the plate slightly
toward the side of the incision. The uncovertebral joints
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
should make the positioning process easier.
The dual drill guide is adjustable for depth and di-
rects the screw holes in a converging course toward the
posterior cortex of the vertebral body. The appropriate
depth can be estimated from the previously measured
depth of the interspace and adjustments made in the guide
to safeguard against overpenetration with the drill bit.
The ideal screw position should maximize bone con-
tact and should engage both the anterior cortex and the
posterior cortex of the vertebral body (Fig. 4). There is
ample room between the spinal cord and the posterior
cortex of the midvertebral body to accommodate slight
penetration of the screw tip. The intact posterior longitu-
dinal ligament protects the dura. The screws are prefer-
ably placed within the central third of the vertebral body
in the sagittal plane but can be placed outside of this re-
gion as long as they do not violate the vertebral endplate
(Fig. 5). The optimum screw trajectory is a slightly ob-
lique, medially directed angle of approximately 15°, par-
allel to the vertebral endplates. However, screws can be
angled cephalad or caudad but, again, should not violate
the endplate. At least two screws should be placed into
each vertebral body, not only for the added holding power
but to prevent rotation. A distraction pin hole should not
be used as a screw hole, as it has been widened during the
distraction process.
With the plate in position over the vertebral bodies,
the drill-guide tips are inserted into the holes of the plate.
Generally, the most easily accessible level is drilled first so
the plate can be fixed loosely with two screws. The drill is
inserted into the guide and the final trajectory is verified
with fluoroscopy. Holes should be drilled deliberately and
carefully, relying on the feel of the drill and frequent fluo-
roscopic visualization. A blunt K-wire is inserted into the
freshly drilled hole under fluoroscopic vision. The K-wire
is useful for palpating the posterior cortex and posterior
longitudinal ligament at the depth of the drill hole and tem-
porarily stabilizes the plate and drill-guide.
The screw holes are measured using the depth
gauge with the plate in position. The appropriate
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

© 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.

252
 HARKEY ET AL. : CASPAR PLATING OF THE CERVICAL SPINE
screw is selected and inserted but not tightened fully. Once
all of the screws are in position they can be tightened se-
quentially “two fingers” tight (Fig. 6). Ideally the screw tips
should completely penetrate the posterior cortex without
extending into the spinal canal (Figs. 7 and 8). Some pen-
etration beyond the posterior cortex is allowable but no
more than the width of one thread. The new titanium screws
are manufactured with a flat tip so that the posterior cortex
© 1992 The American Association of Neurological Surgeons
253
can be engaged fully without penetrating into the canal.
If a hole is stripped or a screw fails to tighten ad-
equately, the screw should be removed. Several salvage
techniques are available, including using an oversized
rescue screw, redirecting and drilling a new hole with the
single drill guide, or filling the stripped hole with acrylic.
Also, an additional screw that abuts a tenuous screw can
often increase overall holding power.
Figure 6. Intraoperative photograph
showing a single level titanium plate at
the completion of the reconstruction and
plating.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

© 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.

254
 HARKEY ET AL. : CASPAR PLATING OF THE CERVICAL SPINE
© 1992 The American Association of Neurological Surgeons
Figure 8. Lateral fluoroscopy after the plate has been secured and the
retractors removed. Note the slight bend in the plate that restores the
normal lordotic curvature.
Subtotal and Total Body Replacement
When teardrop fractures or anterior body compression
fractures accompany an unstable spine, the bone fragments
can be removed along with discectomies above and be-
low the fractured body. A “U-shaped” block graft is con-
structed to span the distance between the adjacent intact
vertebral bodies and envelope the intervening partially
resected body (Fig. 7B). A plate is then applied with screws
through both the anterior and posterior cortices of the in-
tact vertebral bodies. Screws are also placed at the center
of the plate through the strut graft and the posterior cor-
tex of the partially resected vertebral body. As the screws
are tightened, any residual subluxation is usually reduced
and the normal lordotic curvature can be restored.
For severe compression fractures of the vertebral body,
particularly when bone fragments are retropulsed and com-
promising the spinal cord, a complete vertebral corpectomy
may be necessary. A block graft is situated in the defect,
tightly abutting the adjacent vertebral endplates (Fig. 7C).
The screws are applied through both the anterior and pos-
terior cortices of the intact vertebral bodies. However, the
central graft-holding screws should penetrate only the an-
terior two-thirds of the graft, thereby preventing posterior
displacement of the graft. This technique also can be ap-
255
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.
EXTERNAL BRACING
The plate acts as an internal splint, reducing the need for
external bracing, but it does not necessarily obviate the
need for external bracing. The brace should be tailored to
the individual based on the quality and complexity of the
reconstruction. Young, healthy bone as commonly encoun-
tered in trauma heals rapidly and holds screws well, and
therefore a soft collar is usually sufficient. On the other
hand, osteoporotic bone has diminished screw-holding
power and is slower to heal. For patients with osteoporo-
sis, a supplementary hard collar is recommended. In fact,
the need for a halo brace should not be considered as a
failure of the plating. An anterior cervical plate and a halo
can complement each other in difficult high-risk cases.
The patient should be followed with frequent X-ray ex-
amination until fusion has occurred and external bracing
should be modified as needed.
COMPLICATIONS
The surgical exposure and operative time required for
cervical plating is increased compared to that required
for decompression and interbody reconstruction alone.
If soft tissue dissection is inadequate, prolonged ex-
cessive retraction forces increase the risk of injury to
the structures of the neck. The consequences of inad-
equate soft tissue relaxation are vocal cord dysfunc-
tion and dysphagia. Retraction forces can be reduced
by securing the lateral retractor blades under the lon-
gus colli muscles. Although the serrated edges of the
retractor blades threaten esophageal injury, if appro-
priately secured under the longus colli muscles
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
the toothed blades actually reduce the overall risk of soft
tissue injury.
The majority of instrumentation failures can be at-
tributed to technical errors in reconstruction as well as to
improper plate and screw installation. The foundation for
a sturdy fusion construct relies on a sound bony recon-
struction. The graft and graft site should be shaped to
provide maximum bony contact and should attempt to
restore normal anatomic relationships. Meticulous atten-
tion to detail during the preparation of the graft site and
the shaping of the graft is essential for a gratifying result.
Similarly, accurate plate and screw positioning requires
careful attention to bony landmarks with direct vision and
fluoroscopy.
The quality of the patient’s bone is of paramount
importance. Osteoporotic bone has diminished support-
ive structure. Mismatches between the density of the re-
maining vertebral bodies and the intervening graft can
result in graft penetration and settling of the overall con-
struct. Settling in turn increases stress on the screws lead-
ing to screw loosening and plate migration. Osteoporotic
bone has a decreased coefficient of friction which trans-
lates to decreased screw-holding power. With all other
traction and torsion forces remaining equal, osteoporotic
bone has an increased risk of screw loosening. Finally,
osteoporotic bone is slower to heal. During prolonged bony
remodeling the fusion construct is subjected to continued
stresses, increasing the chance of failure.
256
There is a race between bony union and instrument
failure. Once fusion occurs, the tension on the screws and
plate are relieved. Delayed screw loosening, screw break-
age, and plate migration are indicative of an incomplete
fusion. Screw loosening of one or two threads usually re-
mains asymptomatic and is tolerable so long as bony union
ultimately occurs. If fusion does not occur, screw loosen-
ing can proceed to screw extrusion or fracture.
Multilevel fusions are more prone to failure because
the forces are increased by the longer lever arm of the
plate. Because of the increased stress on the implant, the
quality of the reconstruction becomes even more impor-
tant. Every attempt should be made to restore the normal
cervical alignment and achieve maximum screw torque.
In addition, these cases should be augmented by more
substantial external bracing.
The addition of an anterior cervical plate is never a
substitute for proficient surgery. The bony reconstruction
is the principal component of the overall construct and
forms the foundation for remodeling. Therefore, meticu-
lous attention to detail during this portion of the opera-
tion is exceedingly important. If the bony reconstruction
is performed correctly, adding a plate is much easier and
more effective. Of course, satisfactory plating technique
is also important and relies on appropriate plate selection
and shaping as well as accurate screw placement. Skillful
craftsmanship throughout all the steps of the procedure
described will enhance the overall outcome.
 SURGICAL MANAGEMENT
OF ANTERIOR COMMUNICATING
ARTERY ANEURYSMS
TIMOTHY C. RYKEN, M.D.
CHRISTOPHER M. LOFTUS, M.D.

INTRODUCTION INITIAL EVALUATION

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.

PATIENT SELECTION
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.

257
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

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.

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 RYKEN AND LOFTUS : ANTERIOR COMMUNICATING ARTERY ANEURYSMS
PREOPERATIVE PREPARATION
Prior to the planned operation, patients are maintained on
nothing by mouth for 6-8 hours. Premedications include
dexamethasone, 10 mg IV and perioperative antibiotics for
48 hours (generally vancomycin, 1 g, and gentamicin, 70
mg). Large-bore intravenous access, an arterial blood pres-
sure monitoring catheter, and central venous access (pref-
erably with a pulmonary artery catheter) are placed in all
patients to facilitate the avoidance of wide alterations in
blood pressure and volume status intraoperatively.
We customarily approach anterior communicating
artery aneurysms via the pterional approach. The choice
of operative side is based on the arterial anatomy and the
anatomy of the aneurysmal fundus. Whereas others have
advocated a right-sided approach in all cases where the
surgeon is right-handed, we prefer to operate from the
side of the dominant A1 segment and/or on the side clos-
est to the aneurysmal neck. In this respect, we do not hesi-
tate to come from the left side if the aneurysm clearly
points to the right and the left A1 is dominant. The major-
ity of approaches, however, are right-sided.
OPERATIVE TECHNIQUE
Positioning
Following the induction of anesthesia and the placement
of monitoring lines and a lumbar drain, the patient is po-
sitioned supine with the ipsilateral shoulder elevated on a
rolled sheet. A three-pin Mayfield head rest is placed for
skull fixation with the single pin in the contralateral fore-
head (Fig. 3). The head is rotated contralaterally in slight
extension, placing the ipsilateral malar eminence most
superior. The hair is generously shaved to avoid contami-
nation and the operative site is prepared with two 10-
minute scrubs of Betadine solution and allowed to dry.
Draping
Sterile plastic barrier drapes are placed 2 cm past the
midline, across the brow, and just anterior to the tragus
including the root of the zygomatic arch. An iodine-im-
pregnated adhesive drape is placed over the operative site
and an additional two layers of adhesive-lined disposable
drapes are placed to create a watertight seal.
Aids to Exposure
To aid in operative exposure and reduce intracranial pres-
sure, intravenous mannitol (1 g/kg) is given shortly after
the skin incision is made. Hyperventilation is utilized to
maintain the PaCO2 in the 25-30 mm Hg range. In addi-
tion, the lumbar drain is opened just prior to the dural inci-
sion. These measures are designed to minimize the amount
of retraction necessary to gain adequate exposure.
259
Skin Incision
Following local infiltration with 1% lidocaine (epineph-
rine is not used), a curvilinear skin incision is marked
as indicated in Figure 3. The incision curves from a point
1 cm anterior to the tragus to the midline and extends to
the glabella. This allows excellent visualization of the
frontal region and with careful skin closure does not re-
sult in an adverse cosmetic outcome. Alternatively, the
incision may end at the hairline to avoid the forehead
incision. The incision should avoid the superficial tem-
poral artery if possible. Hemostatic clips are applied to
the wound edges.
Dissection
A standard frontotemporal (pterional) craniotomy is
performed, taking the incision to the midline and low
so that the anterior burr hole can be placed low in the
forehead, allowing sufficient exposure along the floor
of the frontal fossa (Fig. 3). The scalp and temporalis
muscle are taken up as a single flap without subgaleal
dissection, thus avoiding injury to the frontalis branch
of the facial nerve. Four burr holes are placed as shown
(Fig. 3) and connected with the Midas Rex drill, plac-
ing a low cut over the orbital rim and along the floor of
the frontal fossa. The high-speed air drill is used to
take down the sphenoid ridge radically as for aneurysms
on the internal carotid artery. Likewise, the inner table
of the skull along the anterior portion of the bone edge
is drilled away, allowing a few millimeters additional
exposure for the microscope beam. Prior to the dural
incision, the spinal drainage catheter is opened and 50-
100 ml of spinal fluid is allowed to drain. The dura is
opened in a curvilinear fashion (Fig. 4) and retracted
over the base.
The arachnoid over the sylvian fissure is cauter-
ized and incised as shown in Figure 5. Dissection pro-
ceeds under the operating microscope with placement
of a brain retractor on the frontal lobe over Telfa
pledgets. The surgeon identifies first the olfactory nerve
and subsequently the optic nerve and ipsilateral ca-
rotid artery. The frontal retractor is then affixed with a
Greenberg self-retaining apparatus. A second taper point
retractor is used on the temporal lobe to spread the
arachnoid of the sylvian fissure, enabling wide open-
ing of the fissure, which we prefer (Fig. 5). Once the
fissure has been opened adequately, retraction is deep-
ened on the frontal and temporal lobes. The arachnoid
along the floor of the frontal fossa is opened from the
medial side of the optic nerve to the region of the
optic chiasm. With progressive retraction and arach-
noid dissection, we follow the carotid artery to the
origin of the ipsilateral A1 segment. Many sur-
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

© 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.

260
 RYKEN AND LOFTUS : ANTERIOR COMMUNICATING ARTERY ANEURYSMS

© 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.

261
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
© 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
optic nerve, but it has been our preference to identify the
carotid bifurcation, even though this entails a few milli-
meters extra retraction.
When this has been achieved, the A1 segment is fol-
lowed across with progressive arachnoid dissection, taking
care not to injure the recurrent artery of Heubner which is
often seen at this juncture. As the dissection proceeds across
the A1 segment toward the communicating complex, it is
possible to open the arachnoid further, thus exposing the
contralateral A1 segment crossing the contralateral optic
nerve. Thus, proximal control of both A1 branches is ob-
tained before the aneurysmal packet is approached. Proxi-
mal control is achieved at each point: first on the internal
carotid and ipsilateral A1, and ultimately on the A1 and A2
segments bilaterally in case of untoward aneurysmal rup-
262
ture during dissection. When this has been achieved, the
dissection proceeds in the region of the anterior communi-
cating artery. At this point the dissection sequence depends
on the aneurysmal anatomy; the surgeon approaches the
neck of the aneurysm first and leaves the fundus untouched.
The goal at this point of the operation is to identify both A2
segments, and customarily a moderate amount of gyrus
rectus resection is required to do this (Fig. 6, A and B). We
perform a standard subpial dissection of the gyrus rectus
on the ipsilateral side.
We cannot emphasize too strongly that before the
aneurysm neck can be approached successfully, it is es-
sential to have control of all four branches of the anterior
communicating complex. This facilitates the application
of temporary clips and affords total control in case of
unexpected aneurysmal rupture during neck dissection.
 RYKEN AND LOFTUS : ANTERIOR COMMUNICATING ARTERY ANEURYSMS

© 1992 The American Association of Neurological Surgeons

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

263
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

© 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

264
 RYKEN AND LOFTUS : ANTERIOR COMMUNICATING ARTERY ANEURYSMS
Intraoperative Aneurysm Rupture
Preparation for intraoperative aneurysm rupture can mini-
mize the difficulty in obtaining hemostatic control. One
large and two fine-tipped suction devices must be avail-
able and functional at all times. If the bleeding point is
small, pressure and a hemostatic agent such as Surgicel
or a small muscle plug may allow control. Occasionally,
careful bipolar cauterization may control a small leak but
risks tearing the dome of the aneurysm.
If proximal control has been obtained at all points in
the anterior communicating complex, temporary clips may
be applied to allow additional dissection if necessary. The
temporary clips should be selected and set aside as each
arterial segment is dissected. Alternatively, if sufficient
dissection has been performed, direct aneurysm clipping
(with repositioning, if necessary) is undertaken. Again,
several clips should be selected and set aside during the
early dissection to be available quickly if aneurysm rup-
ture occurs.
Clip Application
After all four branches of the anterior communicating
complex have been identified (Fig. 7A), we often use tem-
porary clips prior to final neck dissection and clip appli-
cation (Fig. 7B). Clip application is done under normo-
tensive conditions, and if necessary the blood pressure is
raised from previous hypotensive levels before any con-
sideration to temporary clip application is given. We do
not use cerebral protective agents during temporary clip
application, but we have a strict limitation to 10 minutes
and often need only 3 or 4 minutes of temporary clip ap-
plication to achieve definitive clipping. If a second pe-
riod of temporary clip application is necessary, a 5-10
minute reperfusion period is completed before the clips
are reapplied. Final dissection of the neck either with or
without temporary clips should be complete before a per-
manent occluding aneurysm clip is applied. It is essential
to choose a clip large enough to completely cross the an-
eurysmal neck, and no attempt should be made to use the
final clip to dissect the neck. The aneurysm should be
completely prepared before a clip is positioned in the field.
The clipped aneurysm can be evaluated with a mi-
crovascular Doppler probe (Titronics Medical Instruments,
Iowa City, IA) (Fig. 8A) which will give a signal in cases
where the fundus is incompletely obliterated.
265
Where no signal can be identified with the Doppler
probe, the aneurysm is judged to be ready for needle as-
piration which is the ultimate proof of complete oblitera-
tion (Fig. 8B). The microvascular Doppler probe is then
used to check for patency in all four branches of the arte-
rial tree. Once this has been ascertained, the wound is
closed.
Closure
Following satisfactory hemostasis, the dura is closed with
simple interrupted sutures of 4-0 Nurolon, creating a
watertight seal. Epidural tackup sutures are placed
circumferentially and a Gelfoam pad is placed in the
epidural space. The bone flap is replaced. The most an-
terior sutures are tied first to avoid noticeable defects
over the brow. One or two central dural tackup sutures
are placed and tied through the bone flap. The muscle
and galea are reapproximated with absorbable sutures
and the skin closed using 4-0 or 5-0 nylon sutures over
the forehead.
POSTOPERATIVE MANAGEMENT
A mildly hypervolemic state, with the CVP in the 6-10
mm Hg range, is maintained postoperatively with blood
pressure preferably in the 150-170 mm Hg range, depend-
ing on the patient’s preoperative baseline. Decadron is
continued for 48 hours postoperatively and tapered sub-
sequently. Nimodipine and anticonvulsants are continued
as initiated preoperatively to help reduce the incidence of
vasospasm and postoperative seizures. Careful neurologic
evaluation is essential in the immediate postoperative
period in the event of epidural or subdural bleeding. Care-
ful attention to hemostasis with an adequate number of
epidural tackup sutures minimizes the risk of postopera-
tive bleeding complications. Observation for the devel-
opment of cerebral vasospasm is undertaken with serial
transcranial Doppler studies. If symptomatic, the patient
is considered for hypertensive-hypervolemic therapy as-
suming the aneurysm has been obliterated.
Despite Doppler evidence of complete obliteration
and intraoperative needle aspiration, we customarily per-
form postoperative angiography in all cases. Although
intraoperative angiography is available, the microvascu-
lar Doppler probe has eliminated the necessity in the
majority of cases.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
BASILAR BIFURCATION ANEURYSM:
PTERIONAL (TRANSSYLVIAN) APPROACH
H. HUNT BATJER, M.D.
DUKE S. SAMSON, M.D.
INTRODUCTION
Aneurysms arising from the distal basilar artery and re-
lating to the origin of the superior cerebellar artery (SCA),
posterior cerebral artery (PCA), or the basilar apex ac-
count for more than one-half of all aneurysms occurring
in the vertebrobasilar circulation. Of these lesions, those
involving the basilar bifurcation are by far the most com-
mon. Historically, a number of factors delayed the surgi-
cal conquest of aneurysms of this region and, as a result,
these lesions represent the most recent intracranial aneu-
rysm to be subjected to routine surgical management. One
such factor relates to the development of vertebral an-
giography well after carotid angiography was routinely
accomplished. Additional delay resulted from some con-
troversy regarding the natural history of posterior circu-
lation aneurysms. The fact that basilar artery aneurysms
bleed, bleed repetitively, and cause death is now well es-
tablished. The most important factor delaying the devel-
opment of surgical access to these lesions, however, re-
lates to the anatomic complexity of the interpeduncular
cistern and the extreme neurologic eloquence of the tis-
sue irrigated by its vascular contents. The interpeduncu-
lar cistern is central within the cranial vault, and standard
surgical exposures must traverse 6-8 cm of subarachnoid
space to reach the distal basilar artery. This distance
coupled with the very narrow spaces available to the sur-
geon clearly mandated the capabilities of the modern sur-
gical microscope in providing exquisite illumination and
magnification before operative procedures could become
relatively safe.
The anatomic complexity of the interpeduncular cis-
tern is directly related to the dangers of surgical manipu-
lation in this region and, as such, deserves a brief descrip-
tion. This subarachnoid cistern is bounded by the clivus,
© 1992 The American Association of Neurological Surgeons
266
posterior clinoid processes, and membrane of Liliequist
anteriorly, the medial temporal lobes and tentorial edge
laterally, the cerebral peduncles and interpeduncular fossa
posteriorly, and the mammillary bodies and posterior per-
forated substance superiorly. The basilar apex normally
resides only 15-17 mm posterior to the internal carotid
arteries, an anatomical fact that provided a rationale for
the application of the anterior, transsylvian exposure to
the treatment of basilar aneurysms.
After penetrating the interpeduncular cistern, the basi-
lar artery gives origin to the SCAs which may be dupli-
cated unilaterally or bilaterally. These branches usually have
a distinctive appearance through the surgical microscope;
they are typically thin-walled vessels which have an exter-
nal diameter of 1-2 mm. These vessels give rise to variable
numbers of mesencephalic penetrating branches and dis-
tally supply large portions of the cerebellar hemispheres
including the dentate nuclei. The PCAs arise immediately
distal to the superior cerebellar arteries and in their supe-
rior junction form the basilar apex. These vessels are vari-
able in size depending on the degree to which the posterior
communicating branches involuted during fetal life. They
are usually 2-3 mm in diameter and are typically more
atheromatous and thick-walled than the SCAs. In patients
with a persistent fetal posterior cerebral artery, the P1
segment (that portion of the PCA proximal to its junc-
tion with the posterior communicating artery) may be
seen only as a small fibrous band. The PCAs distally
supply the posterior, inferior aspects of the temporal
lobes and the bulk of the occipital lobes. Proximally,
however, the PCAs give origin to thalamoperforating
branches which are critical endarteries supplying the mes-
encephalon and the posterior aspect of the diencephalon. Due
to the extreme importance of the brain tissue irrigated by
these penetrating arteries, their relationship to distal
basilar aneurysms represents a major cause of morbidity in
 BATJER AND SAMSON : BASILAR BIFURCATION ANEURYSM
procedures directed at these lesions. Although specific
patterns of thalamoperforating arteries are infinitely vari-
able, they usually originate from the posterior basilar
trunk, the proximal P1 segments, and the posterior com-
municating arteries and stream along the posterior and
lateral aspects of basilar bifurcation aneurysms.
The oculomotor nerves are occasionally distorted and
damaged by large and giant basilar artery aneurysms and
are frequently (although transiently) rendered dysfunc-
tional by surgical dissection in this region. They travel
anteriorly from the mesencephalon through triangles
formed by the basilar artery, PCAs, and SCAs. Each pro-
ceeds immediately inferior to the ipsilateral posterior com-
municating artery and penetrates the roof of the cavern-
ous sinus. The anterior aspect of the interpeduncular
cistern is bordered by a thick arachnoidal veil, the mem-
brane of Liliequist. This structure spans the space between
both mesial temporal lobes and often confines the spill-
age of blood from a minor subarachnoid hemorrhage
(SAH). This membrane must be dissected widely during
anterior approaches to the interpeduncular cistern.
Two basic surgical exposures have emerged as means
of successfully dealing with the gamut of vascular pa-
thology of the interpeduncular cistern: the subtemporal
approach and the pterional or transsylvian approach. Each
of these operative concepts has been expanded and de-
veloped after years of experience and each possesses cer-
tain strengths and weaknesses and unique complications
which require thoughtful consideration during the plan-
ning of a surgical attack on a basilar bifurcation aneu-
rysm. In our opinion, thorough familiarity with each pro-
cedure and the many potential modifications is a
prerequisite for offering the individual patient an optimal
chance for a successful outcome. This discussion will
focus on the pterional or transsylvian approach with its
major modification, the “half-and-half ” approach. This
general approach capitalizes on the frequent use of this
exposure by all neurosurgeons in treating neurosurgical
diseases in the parasellar cisterns and on the close prox-
imity of the basilar artery apex to the posterior carotid
wall. Within certain anatomic constraints, the distal basi-
lar trunk, the origins of the SCAs and PCAs, and the basi-
lar apex can be well exposed through this route in the
majority of patients.
PATIENT SELECTION
Once a patient is found to harbor a basilar bifurcation
aneurysm, the decisions regarding whether or not to offer
a surgical procedure and, if so, which procedure to offer,
are critically dependent on a multitude of clinical and ana-
tomical concerns. With the expanding use of magnetic
resonance imaging (MRI) into larger patient populations,
267
we are seeing more patients with incidental basilar aneu-
rysms. Although a yearly risk of hemorrhage from an in-
cidental aneurysm of 3% is reasonably established, this
risk must be contrasted with a surgical morbidity which
is somewhat higher than for the more common anterior
circulation aneurysms. For a surgeon to be able to offer
the patient a procedure which is competitive with the natu-
ral history risk, certain conditions must be met. The pa-
tient must be in good general health and reasonably ex-
pect to survive at least 15-20 years. The exact age criteria
will vary from case to case depending on physiological
age and family history of longevity. The size and con-
figuration of the aneurysm are also very important in terms
of surgical risk. Large and giant size and posterior pro-
jection of the sac clearly increase the risk during opera-
tion. Finally, the experience of the surgeon is critical as
the safe exclusion of basilar bifurcation aneurysms re-
quires dedicated and repetitive experience.
Once SAH has developed, however, the untreated
patient’s malignant natural history justifies aneurysm
obliteration in all but the most extreme anatomic circum-
stances provided that the patient has not been neurologi-
cally devastated by the hemorrhage. Our general strategy
for managing SAH is based on the belief that early opera-
tion minimizes the risk of rebleeding and permits maxi-
mum therapy for symptomatic vasospasm should it de-
velop. For patients suffering rupture of an anterior
circulation aneurysm, we operate on the first elective day
if the patient is in a good clinical grade (alert or drowsy).
For patients with an aneurysm that requires little dissec-
tion or brain retraction, we offer an early procedure to
those patients in more marginal neurologic conditions with
substantial alterations of consciousness or focal deficits.
For those with a ruptured basilar bifurcation aneurysm,
however, the amount of dissection and retraction required
is substantial and we prefer to allow the patient to im-
prove to a normal or near-normal level of consciousness
prior to surgical attack. One exception to this general rule
is the patient whose altered level of consciousness may
be explainable by acute hydrocephalus. Because this is
usually a reversible type of neurologic deficit, we gener-
ally proceed with early operation.
A final consideration regarding patient selection
concerns the anatomic details of the aneurysm under
attack. The major source of morbidity in these patients
is the invariable presence of thalamoperforating ar-
teries posterior to the sac. Aneurysms with signifi-
cant projections posteriorly into the interpeduncular
fossa cannot usually be safely clipped from an anterior
surgical approach because the surgeon cannot see the
clip closure behind the basilar artery and perforators
cannot be seen well. In addition, the transsylvian ap-
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
proach is limited in exposure inferiorly by the cartilagi-
nous and bony posterior clinoid process and the clivus. In
our experience, aneurysms taking origin below the mid-
sellar depth cannot be well exposed via the transsylvian
route, particularly if significant need is anticipated for
temporary arterial occlusion. In these circumstances we
routinely proceed with a lateral subtemporal procedure.
In the future, endovascular procedures may find a
role in the primary treatment of some basilar bifurcation
aneurysms provided that the long-term results prove du-
rable and the risks of the procedure become acceptable.
In the short term, these procedures may well improve the
outlook for those patients in poor neurologic condition
whose risk of rebleeding may be minimized by
endovascular occlusion, allowing treatment for subsequent
vasospasm and time for potential neurologic recovery.
PREOPERATIVE PREPARATION
Patients being prepared for craniotomy for a basilar bi-
furcation aneurysm undergo a medical regimen very simi-
lar to that for anterior circulation lesions. If SAH has oc-
curred, normovolemia and normotension are achieved and
maintained by placing a central venous catheter in pa-
tients with a healthy cardiovascular system and by plac-
ing a Swan-Ganz catheter in those with significant car-
diac dysfunction. Crystalloid and colloid solutions are
administered with a target central venous pressure (CVP)
of 10-12 torr in the former group and a pulmonary capil-
lary wedge pressure (PCWP) of approximately 10-15 torr
in the latter group. If acute hydrocephalus is present and
well tolerated neurologically it is left untreated to avoid
the risk of destabilizing the transmural gradient. If the
patient deteriorates due to hydrocephalus, a ventriculos-
tomy is placed contralateral to the planned craniotomy
and cerebrospinal fluid (CSF) is allowed to drip off at a
drainage height of 15-20 cm.
Corticosteroids are administered as standard prophy-
laxis for potential cerebral retraction injury and are con-
tinued for 3-5 days postoperatively, particularly if tempo-
rary arterial occlusion has been used and etomidate
employed for cerebral metabolic suppression. This agent
has been associated with transient impairment of endog-
enous cortisol production. We use a standard dose of dex-
amethasone (4 mg intravenously every 6 hours). Appro-
priate medication is given to avoid gastric ulceration
throughout the steroid course. Although the value of anti-
convulsant prophylaxis is questionable in terms of sei-
zure prevention, the hazards of a generalized seizure in
the acute SAH period are very significant due to the risk
of precipitating rebleeding or aspiration. It is our routine
to administer a loading dose of Dilantin intravenously
followed by 100 mg every 8 hours. We also administer
268
perioperative antibiotic coverage consisting of nafcillin
(or vancomycin in the penicillin-allergic patient). Antibi-
otics are given on call in the operating room and are con-
tinued for 24 hours postoperatively. Antifibrinolytic
therapy has been shown to decrease the incidence of early
aneurysmal rebleeding but to increase the incidence of
ischemic deficits from vasospasm. We prefer to use E-
aminocaproic acid only in patients who are in poor neu-
rologic grade or unstable medical condition and for whom
a significant delay in aneurysm clipping is anticipated.
For those patients in whom early operation is planned, we
usually do not initiate this type of therapy.
OPERATIVE TECHNIQUE
Anesthetic Management
Our anesthetic management of patients with basilar bi-
furcation aneurysms is similar to that of patients with an-
eurysms in other sites. In addition to the central venous
access discussed previously, at least one other 16-gauge
and one 14-gauge venous catheter are placed peripher-
ally. A radial arterial catheter is also positioned. We usu-
ally do not use spinal CSF drainage and prefer a cortical
ventricular puncture as will be described below.
Electroencephalographic (EEG) activity is monitored bi-
laterally by needle scalp electrodes with a frontal elec-
trode placed above the brow and a posterior lead in the
mastoid region.
We prefer a normotensive, normovolemic balanced
anesthetic with sodium thiopental (3-5 mg/kg) induction.
If significant cardiovascular disease is present, we use
etomidate (0.3 mg/kg) intravenously for induction. Muscle
relaxation is accomplished with vecuronium followed by
curare/pancuronium for maintenance. Maintenance an-
esthesia consists of isoflurane (0.5-2.5%), nitrous oxide
(65%), and oxygen (35%). Mannitol (1.0 g/kg)is infused
rapidly at the time of scalp incision to assist with brain
relaxation.
If temporary arterial occlusion becomes necessary,
etomidate (1.0 mg/kg) is administered to achieve documented
EEG burst-suppression. This drug is then continued at a rate
of 10 µg/kg/min until arterial flow is restored. During this
interval, isoflurane is continued at a dose of 0.4% and 100%
O2 is administered. Mannitol (0.25 g/kg) is infused rapidly
immediately prior to arterial occlusion. Additionally, the
pCO2 is normalized and the blood glucose level is moni-
tored carefully and kept in the 90-100 mg% range, by an
insulin drip if necessary. Strict normotension is ensured
during this period to maximize collateral flow.
Patient Positioning
We generally prefer a right-sided craniotomy for ap-
 BATJER AND SAMSON : BASILAR BIFURCATION ANEURYSM
proaching these midline aneurysms so that the
nondominant frontal and temporal lobes and internal ca-
rotid artery are retracted. The presence of a preoperative
third nerve palsy suggests that an operative approach
should be from the side of the deficit to avoid bilateral
ptosis postoperatively. These relative factors must be
weighed against specific anatomic details of the aneu-
rysm complex. The entire distal basilar artery may be dis-
placed to one side and it is often difficult to adequately
expose this type of lesion from a contralateral approach.
Additionally, an asymmetric tilt of the aneurysm to the
left side suggests that the most difficult aspect of the neck
dissection will be on the left side. In this circumstance
the critical sharp separation of thalamoperforators aris-
ing from the left P1 from the aneurysm neck can be most
safely done from the left. The presence of a particularly
large (or fetal) posterior communicating artery can pro-
duce some degree of obstruction during aneurysm dis-
section and it is of some benefit to avoid this side. Each
of these variables must be considered with the specific
anticipated microsurgical problems to be encountered, and
a judgment made about the optimal side of operation for
the individual patient. If difficulties arise at the time of
exploration from unanticipated anatomical problems, it
is far safer to close, reposition the head, and explore from
the other side than to force a clip placement or fail to
definitively dissect the neck of the aneurysm. For the
present discussion, a right pterional craniotomy for basi-
lar aneurysm will be described.
Precise head position is more critical in distal basilar
surgery than in most other aneurysm approaches because
of the extremely confining space available in the interpe-
duncular cistern and limited available options for alter-
ing lines of sight. We prefer to apply the Mayfield-Kees
three-point skull fixation device with the two pins anteri-
orly, and find that a flat unobtrusive operative field is
consistently encountered. The patient is positioned supine
with no shoulder roll (Fig. 1D). Three specific maneu-
vers are then performed to ensure optimal head position.
First, the head is rotated to the left by about 20° (Fig.
1A). This relatively upright position ensures that the tem-
poral lobe will not gravitationally fall into the microsur-
gical exposure and, in fact, after generous sylvian dissec-
tion the temporal lobe will migrate posteriorly which tends
to widen rather than narrow the exposure along the tento-
rial incisura. Excessive rotation also greatly restricts the
surgeon’s ability to utilize the space between the optic
nerve and internal carotid artery.
The next maneuver involves subtle flexion of the
neck, bringing the chin toward the contralateral clavicle
(Fig. 1B). This adjustment orients the floor of the anterior
cranial fossa perpendicular to the long axis of the body,
269
maximizing the flexibility of the subsequent exposure for
the seated surgeon.
The final maneuver is critical in the positioning of a
patient with a basilar bifurcation aneurysm and is accom-
plished by extending the vertex so that the maxillary emi-
nence rises above the superior orbital ridge (Fig. 1C). Al-
though this maneuver is used in all pterional craniotomies,
it is somewhat exaggerated when a basilar bifurcation
aneurysm is the target. When appropriately done, this
extension maximizes gravitational displacement of the
frontal and temporal lobes away from the skull base and
therefore minimizes the degree of retraction of the optic
tract and diencephalon during the final stages of interpe-
duncular exposure.
Scalp Incision and Craniotomy
Our preferred scalp incision for the pterional approach to
the distal basilar artery is only slightly different than that
employed for the more common anterior circulation an-
eurysms. This incision begins at the level of the zygoma,
about 5-10 mm anterior to the tragus. The incision is car-
ried straight superiorly for 8-10 cm and then is curved
gently anteriorly to reach the level of the normal hairline
at the midline (Fig. 1D). Optimally, we attempt to keep
the incision behind the hairline, but this is obviously not
possible in balding men. As the incision is deepened
through the galea, care is taken to preserve at least one
major branch of the superficial temporal artery to maxi-
mize scalp healing, particularly in diabetics. Disposable
scalp clips are then applied to secure hemostasis.
Reflection of the scalp flap has two specific goals in
basilar aneurysm surgery: 1) to maximize temporal expo-
sure to facilitate sylvian fissure dissection and temporal lobe
retraction and to ensure that conversion to a subtemporal
exposure will be possible if necessary, and 2) to optimize the
subsequent cosmetic appearance. We believe that these goals
are best met in this circumstance by the interfascial dissec-
tion described and popularized by Yasargil. Incision of the
temporalis fascia and muscle parallel to the skin incision
with reflection of the flap in a single layer is certainly ac-
ceptable but recent experience shows that an interfascial
opening seems superior. The temporalis fascia is opened
down to the muscle aponeurosis and this fascial layer (which
is continuous with the pericranium) is reflected with the
pericranium anteriorly. The frontalis branch of the facial
nerve is embedded in the fatty tissue that becomes appar-
ent as the scalp is mobilized to about the level of the pte-
rion. The fat is then sharply undermined and reflected
with the scalp flap, leaving the temporalis muscle intact. The
flap is secured with fishhooks so that the frontozygomatic
suture and “anatomical key” are widely exposed. An inci-
sion is then made in the temporalis muscle begin-
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

© 1992 The American Association of Neurological Surgeons

Figure 1. Patient positioning for a right pterional approach to the basi-

lar bifurcation. A, minimal (20%) head rotation is used to prevent gravi-
tational temporal lobe migration into the operative field. B, flexion of
the neck pulls the chin toward the contralateral clavicle, orienting the
floor of the anterior cranial fossa perpendicular to the long axis of the
body. C, extension of the vertex of the head is performed aggressively
to maximize gravitational brain displacement from the skull base and to
minimize the amount of diencephalic retraction ultimately necessary to
expose the contents of the interpeduncular cistern. D, the final supine
patient positioning with the Mayfield-Kees head holder oriented so that
the two pins are applied to the frontal bone. A generous standard pterional
scalp incision is outlined (dashed line).

270
 BATJER AND SAMSON : BASILAR BIFURCATION ANEURYSM
ning anterior to the frontozygomatic suture, extending
through the “key,” and curving posteriorly below the su-
perior temporal line so that a substantial cuff of muscle
insertion is left intact for later closure (Fig. 2A). Reflec-
tion of the temporalis anteriorly and laterally exposes a
wide area of the temporal squama, facilitating subsequent
temporal craniectomy. Once dissected, care should be
taken to avoid coagulation of the deep neurovascular
bundle of the temporalis muscle because substantial at-
rophy will result.
The craniotomy is performed with three burr holes:
1) the first hole is placed at the “key” or just superior to
the frontozygomatic suture; 2) the second hole is placed
inferiorly and posteriorly on the temporal squama; and 3)
the third hole is placed at the posterior aspect of the ex-
posure just inferior to the superior temporal line so that it
can later be covered by suturing the temporalis muscle
back in place (Fig. 2B). Power instruments are then used
to cut a generous frontotemporal craniotomy with care to
extend the flap medially to the mid-pupillary line (Fig.
2B). The sphenoid ridge and the bone overlying the ante-
rior temporal lobe are then removed aggressively with
rongeurs and a high-speed air drill with a cutting burr.
The sphenoid resection is continued to the lateral aspect
of the superior orbital fissure, exposing the meningo-or-
bital artery. The inner table of the frontal bone is then
drilled off if it is prominent, maximizing access to the
skull base without brain retraction (Fig. 2C). Bone wax
and oxidized cellulose are used to secure bony and extra-
dural hemostasis prior to dural opening.
The dura is opened in a semilunar fashion with me-
dial limb extending to the frontal bone anteriorly and
the lateral limb crossing the sylvian fissure and then
angling sharply anteriorly along the superior temporal
gyrus, crossing the anterior branch of the middle
271
meningeal artery (Fig. 2D). The remaining dura overly-
ing the temporal lobe is opened in stellate fashion, pro-
viding wide temporal exposure should subsequent tem-
poral lobe mobilization be required. Not uncommonly,
the underlying brain will be found to be full and dis-
tended despite adequate diuresis and hyperventilation.
This is especially true in our practice as we tend to oper-
ate early in the post-SAH period. A basilar bifurcation
aneurysm often ruptures into the ventricle, increasing
the degree of hydrocephalus. Although spinal drainage
is a time-honored means of achieving brain relaxation,
we prefer to rely on direct ventricular puncture. Paine’s
point may be identified as follows: a point on the frontal
cortex is defined as the vertex of an isosceles right tri-
angle whose hypotenuse overlies the sylvian fissure and
whose sides are 2.5 cm in length (Fig. 2D). A Silastic
ventricular catheter is then passed perpendicularly
through this point and into the frontal horn. The stylet is
removed and the catheter is sutured to the scalp posteri-
orly. This technique very reliably produces a favorable
slack brain which permits microsurgical access to the
basal cisterns. The remainder of the operative procedure
is performed with the surgical microscope.
Microsurgical Procedure
The cornerstone of the pterional approach to the interpe-
duncular cistern is the wide dissection of the sphenoidal
portion of the sylvian fissure. This dissection offers three
specific features that facilitate subsequent exposure. First,
the loculation of CSF commonly present after diffuse SAE
can be drained, increasing brain relaxation even if ventricu-
lar drainage is used. Second, the ultimate line of visualiza-
tion of the distal basilar artery, particularly the posterolat-
eral wall, is accomplished through the sylvian fissure and
would be obstructed if the frontal and temporal lobes were
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
© 1992 The American Association of Neurological Surgeons
Figure 2. Pterional craniotomy for a basilar bifurcation aneurysm. A,
the scalp flap is reflected in two layers for an interfascial opening as
described by Yasargil. The temporalis fascia and periosteum are re-
flected together, exposing the fatty tissue encasing the frontalis branch
of the facial nerve. This tissue is undermined and reflected from the
temporalis muscle. The muscle is then opened as shown (dashed line)
and reflected laterally and anteriorly. B, a three-hole craniotomy is
performed as follows: the first burr hole (1) is placed at the anatomical
key just superior to the frontozygomatic suture; the second hole (2) is
placed inferiorly on the temporal squama; and the third hole (3) is
placed posteriorly immediately below the superior temporal line. These
holes are then connected using a power saw as indicated by the dashed
line, with care taken to provide generous medial exposure to the mid-
pupillary line. C, access to the skull base and basal cisterns is facilitated
272
by aggressive resection of the sphenoid ridge, the anterior temporal
squama, and the inner table of the frontal bone. Rongeurs and a high-
speed air drill are used for this resection. The goal of the sphenoid ridge
resection should be to expose the lateral aspect of the superior orbital
fissure. D, the dura is opened in a semilunar style with the medial limb
extending to the frontal bone and the lateral limb crossing the sylvian
fissure and angling anteriorly to the bone edge. The rest of the dura
overlying the temporal lobe is opened in stellate fashion and retracted
with stay sutures. If the brain remains distended despite routine anes-
thetic maneuvers, Paine’s point may be punctured as follows: a point
on the frontal cortex is defined as the vertex of an isosceles right
triangle whose sides are 2.5 cm and whose hypotenuse overlies the
sylvian fissure. A perpendicular puncture will reliably enter the frontal
horn. A Silastic catheter may then be secured to the scalp posteriorly.
 BATJER AND SAMSON : BASILAR BIFURCATION ANEURYSM
still bound together medially. Third, the proximal middle
cerebral artery may be kinked by the dense arachnoidal
bands of the medial sylvian fissure during the aggressive
frontal lobe retraction necessary for basilar exposure.
To initiate this dissection, a subfrontal retractor is
inserted beneath the posterior aspect of the frontal lobe
just anterior to the middle cerebral vein to a depth of about
3 cm. The retractor is then used to stretch the sylvian arach-
noid from the lateral extent of the sphenoidal portion of
the fissure so that a sharp arachnoidal opening can be
made from the most lateral aspect of the fissure and car-
ried medially in a single incision including the carotid
cistern and the prechiasmatic cistern (Fig. 3A). This inci-
sion is then extended like the letter T to include the poste-
rior carotid cistern toward the dural insertion of the third
cranial nerve. The surgeon than redirects the microscope
to focus on the lateral sylvian fissure. This superficial
arachnoidal opening is methodically deepened by stretch-
ing the arachnoidal bands with the suction tip and sec-
tioning all exposed arachnoidal tissue. This subarachnoid
dissection is continued and pushed medially as first the
anterior temporal artery and finally the middle cerebral
trunk (M1 segment) are encountered (Fig. 3B). Once this
key landmark is identified, further lateral-to-medial dis-
section as well as progressive proximal-to-distal dissec-
tion within the carotid cistern exposes the carotid bifur-
cation (Fig. 3C). The resultant exposure completely
liberates the internal carotid artery, the M1 segment, and
the A1 segment of the anterior cerebral artery from any
traction during progressive frontal lobe elevation. The fi-
nal step in the initial dissection involves sectioning of the
arachnoidal fibers binding the gyrus rectus to the optic
nerve, which sets the stage for subsequent retraction of
the optic tract if necessary.
Many patients will be found to have significant her-
niation of the mesial temporal lobe over the tentorial in-
cisura after SAH. Preparation for the approach into the
interpeduncular cistern must include opening this poten-
273
tial space whether or not a true “half-and-half ” exposure
is planned. Traditional technique mandates placement of
a second self-retaining retractor along the posterior-me-
dial surface of the temporal lobe, elevating the uncus out
of the incisura so that the tentorial edge can be visualized
back to the level of the cerebral peduncle. Although oc-
casionally this maneuver is not necessary due to gravita-
tional migration of the temporal lobe posteriorly follow-
ing sylvian dissection or the ease of uncal retraction with
surgical instruments during subsequent dissection, some
expansion of the subarachnoid space laterally is advis-
able at this early point in the event that problems arise or
that multiple temporary clips are required. Another op-
tion for facilitation of this exposure is to perform a sub-
pial resection of the uncus. The resultant exposure, re-
gardless of which option is chosen, provides access to the
interpeduncular cistern by one or a combination of three
potential routes: 1) through the triangular space between
the optic nerve, internal carotid artery, and A1 segment,
2) through the retrocarotid space, and 3) superior to the
carotid bifurcation (Fig. 3D).
Unique features of the patient’s anatomy lend them-
selves to primary development of dissection planes in one
of the three routes of access. The presence of a second
aneurysm of the internal carotid artery either involving
the medial or posterolateral wall obviously restricts the
surgical field either by the mass of the aneurysm itself or
by the presence of an aneurysm clip. Elderly or hyperten-
sive patients may have a particularly calcific atheroscle-
rotic carotid artery which resists manipulation. If a ves-
sel of this type occupies a relatively horizontal
supraclinoid course, dissection primarily through the
opticocarotid triangle is preferred. If the carotid occupies
a vertical projection, the retrocarotid approach may be
least traumatic. For patients with either a very short
supraclinoid carotid artery or a very high basilar bifurca-
tion (> 1 cm above posterior clinoid), an approach supe-
rior to the carotid bifurcation may be preferable. Ideally,
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
© 1992 The American Association of Neurological Surgeons
Figure 3. Initial microsurgical dissection. A, a subfrontal retractor
gently elevates the orbital surface of the frontal lobe, stretching
the arachnoid of the entire sphenoidal portion of the sylvian fis-
sure. This stretched arachnoid is then opened sharply and the
incision deepened to include the carotid and prechiasmatic cistern
as shown by the dashed line. B, the lateral sylvian opening is
deepened sharply and extended medially so that subtle redirection
of the retractor will expose the internal carotid artery (ICA) and
the anterior temporal branch and the M1 segment of the middle
cerebral artery. C, progressive lateral-to-medial sylvian dissection
and proximal-to-distal carotid cistern opening will culminate in
the exposure of the carotid bifurcation with liberation of the inter-
274
nal carotid artery (ICA), the M1 segment of the middle cerebral
artery, and the A1 segment of the anterior cerebral artery from
arachnoidal bands. D, final initial exposure is accomplished by
placing a temporal lobe retractor such that the uncal gyrus is el-
evated out of the tentorial incisura thus demonstrating the tento-
rial edge as far posteriorly as the cerebral peduncle. It is helpful to
bend the retractor in a 90° angle so that it will lie against the
surface of the lateral temporal lobe and not obstruct bimanual
access to the wound. This exposure provides for the use of three
potential routes of access to the interpeduncular cistern: 1) through
the optic-carotid triangle, 2) through the retrocarotid space, and
3) superior to the carotid bifurcation (arrows).
 BATJER AND SAMSON : BASILAR BIFURCATION ANEURYSM
however, the dissection progresses smoothly and quickly
in all three planes, thus providing the surgeon with maxi-
mal three-dimensional appreciation of the anatomy as the
interpeduncular cistern is entered.
Without question, however, the safest approach, par-
ticularly when the cisterns are packed with blood, is the
orderly progression of dissection along the inferior aspect
of the posterior communicating artery. This key structure
should be kept in mind regardless of whether it is being
dissected lateral or medial to the internal carotid artery
because it serves as a road map to the interpeduncular vas-
cular contents. Dissection along the inferior aspect of the
posterior communicating artery allows the surgeon to avoid
traumatizing anterior thalamoperforating arteries which
arise from the superior and superomedial aspects of the
posterior communicating artery and allows early identifi-
cation of the inferior surface of the P1-P2 junction along
the posterior cerebral artery. Inadvertent dissection along
the superior aspect of this junction may lead to early en-
counters with the aneurysm fundus prior to the attainment
of proximal arterial control. As the posterior communicat-
ing artery is followed posteriorly, it is helpful to sever its
arachnoidal attachments to the third cranial nerve (Fig. 4A).
As the posterior communicating artery penetrates the mem-
brane of Liliequist, this thick arachnoidal plane is opened
widely; SAH from the distal basilar complex pushes this
membrane anteriorly away from underlying vascular pa-
thology (Fig. 4B). Particular attention is directed to divid-
ing the membrane medially and inferiorly. Radical dissec-
tion of this membrane allows the posterior communicating
artery to be followed to the inferior surface of the P1-P2
junction. Once this important landmark is identified, de-
velopment of the dissection from the medial aspect of the
internal carotid is helpful to clearly see the P1-P2 junction
from both sides of the carotid artery (Fig. 4C). The result-
ant exposure permits significantly more three-dimensional
perception and dramatically increases the amount of avail-
able lighting through the microscope.
At this point the surgeon must approach the basilar
trunk. The safest route of access in a typical superiorly
275
projecting basilar bifurcation aneurysm is by dissecting
the inferior surface of the P1 segment medially (Fig. 4D).
The arachnoid and hematoma are sharply divided until
the course of the vessel clearly changes to a more upright
position. This subtle change usually marks the initial iden-
tification of the basilar artery. Further dissection inferi-
orly should isolate the ipsilateral SCA. Gentle dissection
across the face of the basilar artery marks the attainment
of proximal arterial control (Fig. 4E). It is wise to dissect
both sides of the basilar trunk at this time superior to the
SCAs to provide access for a temporary clip. Attention is
then directed to the contralateral anatomy and first the
inferior then the superior surface of the left P1 segment
are seen. Isolation of the superior aspect of the right P1
segment then completes the achievement of isolation of
afferent and efferent circulation.
Untimely rupture of the aneurysm at this point in the
procedure should not precipitate early reflex attempts to
clip the aneurysm but rather every effort should be made
to place temporary clips first on the basilar artery then on
both P1 segments. Premature attempts to clip the lesion
def initively will invariably occlude posterior
thalamoperforators posterior to the sac.
Dissection of the aneurysm is approached under high
magnification with the goal of gaining complete expo-
sure of the posterior aspect of the neck. Less than this
degree of dissection is not consistent with acceptable basi-
lar surgery from any surgical approach. The dire conse-
quences of injury to thalamoperforators mandates their
complete dissection. We prefer to develop the contralat-
eral neck dissection first with progressive sharp dissec-
tion from lateral to medial along the superior surface of
the left P1 until the origin of P1 from the neck is identi-
fied. At this point dynamic mobilization of the aneurysm
is required to permit progressive deepening of the dissec-
tion with sequential elevation of perforating arteries from
the aneurysm in preparation for clip passage (Fig. 5A).
After the left-sided aneurysm neck is safely dissected,
attention is directed to the ipsilateral (right) side. The goal
of dissection of the superior aspect of the right P1
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
© 1992 The American Association of Neurological Surgeons
Figure 4. Dissection to achieve proximal and distal arterial con-
trol. A, the safest approach to the basilar artery is along the
inferior surface of the posterior communicating artery so that
anterior thalamoperforators are avoided and early encounters
with the aneurysmal fundus do not occur. This dissection is facili-
tated by division of arachnoidal adhesions between the communi-
cating artery and the third cranial nerve (CN III). B, once the
posterior communicating artery is seen to penetrate the mem-
brane of Liliequist, this membrane is divided extensively. C, the
276
posterior communicating artery is dissected further to the P1-P2
junction. It is helpful to see this landmark both lateral (left) and
medial (right) to the carotid. D, the inferior surface of the P1
segment is dissected medially to identify the basilar trunk. Both
surfaces of the basilar artery are then prepared for a temporary
clip, preferably above the SCAs. E, identification of the left P1
segment both superiorly and inferiorly and preparation of the
right P1 segment superiorly marks the point at which all afferent
and efferent flow can be controlled.
 BATJER AND SAMSON : BASILAR BIFURCATION ANEURYSM
segment and ultimate neck definition must be gentle mo-
bilization of the sac medially and slightly anteriorly. Due
to the angle of approach, the posterior reaches of the neck
are better appreciated from the ipsilateral side (Fig. 5B).
Although the aggressive dissection described above is pos-
sible in small unruptured aneurysms, it may be extremely
difficult and dangerous in particularly fragile or large, ath-
erosclerotic lesions. In these circumstances, the use of tem-
porary arterial occlusion may be life-saving. Following the
administration of a brain protective regimen such as that
discussed above, a temporary clip may be applied to the
basilar trunk, preferably distal to the SCAs (Fig. 5C). The
aneurysm is often surprisingly softened by this maneuver,
permitting more complete mobilization. If sufficient mo-
bilization is still not possible or if a giant, thrombotic sac is
being attacked, proximal and distal temporary clips are re-
quired with aspiration of the aneurysm before definition
dissection can be accomplished (Fig. 5D). The duration of
temporary arterial occlusion tolerable with modern
neuroanesthesia and brain protection is unknown; our im-
pression is that up to 15 minutes of normotensive basilar
artery occlusion is usually safe.
The technical act of clipping a basilar artery bifurca-
tion aneurysm is more complex than that involved in treat-
ing any other type of aneurysm. The addition of halogen
lighting and mouthpiece control of the surgical micro-
scope has allowed a number of subtle innovations that
have increased the safety of clip application in this very
confining region. At no other site is the absolute require-
ment for perfect visualization of the aneurysm clip blades
(as they are inserted posteriorly into the interpeduncular
fossa) more important. In no other site is the neurologic
toll of inserting a clip with excessive length to the hilt
more costly. In no other circumstance is the presence of
even a small amount of aneurysm bleeding more devas-
tating (because the vital perforators are obscured imme-
diately). These problems are magnified by the visual ob-
struction usually created by even slender clip appliers and
clips. The rule, not the exception, is that as a clip is in-
serted past the internal carotid artery, it is possible to fo-
cus the microscope on only one aspect of the neck at a
277
time. As the clip blade (which is seen) slides along the
neck and passes perforators, the surgeon must adjust the
microscope with either mouthpiece control or nondominant
hand control. The clip is held steady and open while the
focus is centered on the contralateral neck. This maneu-
ver is even more difficult in those lesions with particu-
larly broad necks. A number of techniques can help to
circumvent this problem.
We have been impressed that the bayonetted clip made
by Aesculap when applied upside down allows the sur-
geon to maintain visual contact with the tips of the clip as
they are advancing, with no obstruction by the clip applier.
Common sense would dictate that using the bayonetted
clip right side up would be a better solution, but the tight
confines of the exposure usually do not allow this orien-
tation to work successfully (Fig. 6A). Additional benefit
may be obtained by maximally utilizing all of the previ-
ously dissected exposure medial and lateral to the inter-
nal carotid artery. A right-handed surgeon can use the
retrocarotid exposure for both the microscope’s line of
sight and for insertion of the clip applier. The suction tip
can be inserted medial to the carotid, thereby eliminating
one instrument as a visual obstruction (Fig. 6B). In cer-
tain circumstances, the visual access medial to the ca-
rotid may prove superior. It is then possible for the right-
handed surgeon to navigate the clip and applier very
carefully through the retrocarotid space, which transiently
“blinds” the surgeon to the clip. With progressive advance-
ment, however, the clip will come into view and the sur-
geon has excellent visual access to both clip blades unim-
peded by the clip applier (Fig. 6C). A left-handed surgeon
can perform a similar maneuver by viewing the anatomy
through the retrocarotid exposure and inserting the clip and
applier medial to the carotid. Not infrequently, the breadth
of the aneurysm neck mandates that the surgeon select a
clip whose blades are much longer than the depth of pen-
etration required simply to span the neck prior to advance-
ment. The temptation to advance to the hilt must be avoided,
and the clip should simply be advanced until the surgeon
“feels” the blades pass the neck. At that point, the clip may
be partially closed and the tips of the blades inspected to
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
© 1992 The American Association of Neurological Surgeons
Figure 5. Final aneurysm dissection. A, the contralateral neck is dis-
sected first by following the superior surface of the P1 segment to the
neck of the aneurysm. Significant mobilization of the aneurysm is then
required as the neck dissection is deepened and all thalamoperforating
arteries present are freed from the aneurysm neck. B, the goal of dissec-
tion of the ipsilateral (right) aspect of the neck is to definitively identify
all perforators posterior to the aneurysm. The sac must be mobilized
278
both medially and somewhat anteriorly out of the interpeduncular fossa.
C, if the aneurysm is particularly fragile or turgid, application of a tem-
porary clip to the basilar trunk may soften the lesion adequately to per-
mit mobilization. D, when temporary proximal occlusion is inadequate
for final dissection, or when a giant thrombotic sac must be opened and
its contents evacuated, temporary clips should be applied to the basilar
artery and to both P1 segments, allowing deflation of the aneurysm.
 BATJER AND SAMSON : BASILAR BIFURCATION ANEURYSM
© 1992 The American Association of Neurological Surgeons
Figure 6. Aneurysm clipping. A, the narrow confines of the clip
trajectory greatly limit the type of clip which may be applied
with perfect visual contact. The bayonetted Yasargil clip when
applied upside down seems to optimally minimize obscuration by
the clip and clip applier, allowing the surgeon to see the tips of
the blades well. B, to avoid visual obstruction by the clip and
surgical instruments, it is helpful for the right-handed surgeon to
align the microscope for a retrocarotid exposure and insert the
clip applier through this same space. The suction tip, however, is
inserted medial to the carotid, therefore eliminating it as a source
of visual obstruction. C, another maneuver to improve visualiza-
279
tion for the right-handed surgeon is to gain visual exposure of the
aneurysm complex medial to the carotid and insert the clip applier
lateral to the carotid. The clip is obscured until the blades enter
the interpeduncular cistern, at which point the surgeon has im-
proved visualization of the relationship of the blades to the neck
of the aneurysm without obscuration by the clip applier. D, al-
though the use of a clip with excessively long blades may be
mandated by a broad neck, the clip cannot be advanced past the
aneurysm neck or the perforating vessels in the interpeduncular
fossa will be caught by the clip blades. The result is a virtually
certain severe neurological deficit.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
see if perforators are jeopardized or residual neck requires
further advancement. This process can be repeated as of-
ten as required and until perfect clip application is
achieved. The use of excessive clip length will virtually
always incorporate perforating arteries, with disastrous
neurologic consequences (Fig. 6D).
Brief mention should be made of certain maneuvers
which offer the possibility of expanding the working space
and increasing the potential for innovative clip solutions to
difficult basilar aneurysms. The most important of these is
the so-called “half-and-half ” approach popularized by
Drake. This exposure is essentially a middle ground, utiliz-
ing many of the benefits of both the pterional as well as the
subtemporal procedure. This exposure can be quickly de-
veloped after the previously described transsylvian expo-
© 1992 The American Association of Neurological Surgeons
Figure 7. Modification of the pterional exposure. A, the “half-
and-half” exposure is achieved by mobilizing the temporal lobe
posteriorly and superiorly and disengaging the uncus from the
incisura. B, when a P1 segment is clearly patent, the posterior
communicating artery may be sacrificed provided that this ma-
neuver will improve access to the aneurysm or facilitate its mo-
280
sure has been completed. To achieve this exposure, a tem-
poral lobe retractor is inserted over the anterior and infe-
rior aspect of the temporal lobe after all pertinent spheno-
parietal venous drainage has been disconnected. Once so
placed, the retractor is used to mobilize the temporal lobe
and uncus in a posterosuperior direction. As this is done,
the arachnoidal connections between the uncus and third
cranial nerve are divided. The microscope is then adjusted
so that the line of vision is posterior and lateral to the inter-
nal carotid artery. The resulting exposure displays anatomy
previously hidden by the posterior clinoid process and cli-
vus and allows substantial posterior exposure of the aneu-
rysm sac in the interpeduncular fossa (Fig. 7A). One sig-
nificant advantage of this exposure is the dramatic
improvement in lighting achieved.
bilization. C, when a posterior communicating artery is domi-
nant or fetal, a hypoplastic P1 segment may be sacrificed pro-
vided that no perforators are jeopardized. D, improved lateral
displacement of the internal carotid artery can be accomplished
by division of the Al segment If the anterior communicating
artery is patent. Microclips are usually required.
 BATJER AND SAMSON : BASILAR BIFURCATION ANEURYSM
Components of the circle of Willis may occasionally
be sacrificed to gain specific advantages in terms of an-
eurysm exposure or mobilization. In patients with a small
posterior communicating artery and a patent P1 segment,
the posterior communicating artery can be sacrificed pro-
vided that the anterior thalamoperforators are not jeopar-
dized (Fig. 7B). We have found that gentle bipolar cau-
tery is preferable to double clipping prior to sectioning
because the clips form obstacles themselves. Similarly, a
hypoplastic P1 segment may be divided to provide ante-
rior mobilization of the aneurysm complex if a dominant
or fetal posterior communicating segment is present. All
thalamoperforators must be avoided very carefully (Fig.
7C). Occasionally the ability to laterally displace the in-
ternal carotid is limited by tethering by the A1 segment.
In this setting, the A1 segment can be divided provided
that the anterior communicating artery is patent. This
maneuver usually requires the use of microclips (Fig. 7D).
Components of the circle of Willis should be sacrificed
with caution in the SAH patient because vasospasm may
develop, maximizing the need for all available sources of
collateral blood flow.
A final maneuver to improve inferior exposure has
been described by Yasargil. The posterior clinoid process
can be resected if it obscures access to the basilar artery
for proximal control or obscures the neck of the aneu-
rysm. This may be accomplished by a high-speed air drill
or by rongeurs. Due to the intimate proximity of the in-
struments with the internal carotid artery, perforators, and
281
aneurysm, we do not recommend this maneuver to the
inexperienced. It is far safer to convert to a “half-and-
half ” exposure or a true subtemporal exposure to gain
working space inferiorly.
Closure
The frontotemporal craniotomy is closed in standard fash-
ion with a watertight dural closure and replacement of
the bone flap. An epidural drain is left whenever hemo-
stasis is in question. The temporalis fascia is sutured to
the previously prepared cuff, covering all burr holes. The
scalp is closed in layers with a separate galeal closure.
COMPLICATIONS
Potential complications of basilar surgery have been men-
tioned above but brief discussion is appropriate for the
treatment of symptomatic vasospasm. Our experience is
similar to that of others who have had reasonable success
with reversing ischemic neurologic deficits by the stan-
dard therapy of hypervolemia, hemodilution, and induced
hypertension. When these measures are unsuccessful,
however, we believe that immediate angioplasty should
be undertaken, particularly if symptoms are due to
vertebrobasilar ischemia. The interventional radiologist
can access these vessels quickly and can immediately re-
store normal vascular caliber in the majority of patients.
We currently consult our neuroradiologist if deficits do
not respond within 15-30 minutes of the institution of
maximal medical therapy.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
THALAMOTOMY FOR TREMOR
ROY A. E. BAKAY, M.D.
JERROLD L. VITEK, M.D., PH.D.
MAHLON R. DELONG, M.D.
INTRODUCTION
Medical and surgical therapies for the treatment of move-
ment disorders are evolving rapidly. These therapies have
developed from our greater understanding of the functional
organization of the basal ganglia and thalamus gained
through a combination of excellent animal models and ad-
vances in anatomical and electrophysiological techniques.
Medical therapy is now available to help delay the onset of
disabling symptoms as are a variety of medications to treat
the symptoms when they do occur. Although medical
therapy remains the mainstay of treatment, there are sig-
nificant limitations even with the most effective medica-
tion. As a result, there has been a resurgence of interest in
the operative treatment of involuntary movement disor-
ders—namely, functional stereotactic surgery. Most of the
advances in stereotactic technology have been a refine-
ment in the surgical tools, improvement in identifying tar-
gets through intraoperative electrophysiologic testing, and
indirectly through the advancement in radiographic imag-
ing techniques. The targets, however, have not changed in
the last 20 years. As the functional interconnections be-
tween the basal ganglia, thalamus, and cerebellum are bet-
ter understood, the question of which target is most effec-
tive has again been raised.
Lesions in the pallidal-thalamic pathway can be effi-
cacious and are least likely to produce concomitant com-
plications. There are multiple potential targets, which in-
clude the cells of origin in the medial globus pallidus
(pallidotomy) or where the fibers cross the subthalamic
area in the fields of Forel (campotomy) or in the termina-
tion of the pathway in the ventrolateral thalamus (VL thala-
motomy). The focus of stereotactic surgeons in the past
was on tremor, especially parkinsonian tremor. Tremor,
however, is usually not the most disabling symptom of
Parkinson’s disease, and reevaluation of appropriate tar-
gets is underway (i.e., thalamus versus pallidum) for par-
kinsonian tremor.
© 1992 The American Association of Neurological Surgeons
282
Posteroventral pallidotomy may improve not only
tremor and rigidity but also the akinesia and bradykine-
sia which accompany parkinsonism. The pallidal fugal
pathways into the thalamus may be a superior target for
the symptoms of multiple movement disorders. Never-
theless, VL thalamotomy remains the standard lesioning
procedure for relief of tremor per se.
VL thalamotomy means different lesion sites to dif-
ferent surgeons, depending on whose nomenclature is used
and what the different authors think they are lesioning.
We will take the larger view which includes the nucleus
ventro-intermedius (Vim) in the ventrolateral (VL) nuclear
complex. We will also focus on Parkinson’s disease since
this is where there is the greatest understanding. How-
ever, it is important to remember that stereotactic func-
tional neurosurgery treats a particular set of symptoms
and not a particular disease. Vim thalamotomy is best for
treating the symptoms of tremor.
PATIENT SELECTION
The medical treatment of tremor has become so sophisti-
cated that patients should be referred to neurologists with
special expertise in movement disorders. Patients who are
truly refractive to medication should be evaluated by a
team of neurologists and neurosurgeons to determine
whether or not they are appropriate candidates for stereo-
tactic surgery. Therapeutic goals should be individualized
for each patient based on the particular symptom com-
plex and a realistic appraisal of the results that may be
achievable by stereotactic surgery. Thalamotomy is effec-
tive in the treatment of all forms of tremor, regardless of
the particular etiology.
Parkinson’s disease is the most common movement
disorder treated by functional stereotactic surgery. The
syndrome consists of three cardinal symptoms: tremor,
rigidity, and akinesia. Akinesia is the most disabling
feature of the disease and yet is least likely to be amelio-
rated by Vim thalamotomy. The characteristic rest-
ing or “pill rolling” tremor is dramatic but is
 BAKAY ET AL. : THALAMOTOMY FOR TREMOR
usually not a source of significant disability. Lower limb
tremors are less likely to be disabling and proximal trem-
ors do not respond as well to thalamotomy. The combina-
tion of both resting and intention tremors is not uncom-
mon in severely affected patients and is more likely to be
disabling. The best surgical candidates are those with a
tremor-dominant symptomatology who have failed medi-
cal management.
Essential or familiar tremor can be very disabling.
Patients with this type of tremor who do not respond to
medical therapy are excellent candidates for thalamo-
tomy. Likewise, intention or cerebellar tremor can be
extremely disabling. Unfortunately, there is no effective
medication for cerebellar tremor. Intention tremor from
a number of etiologies—including multiple sclerosis,
stroke, or head injury—may respond well to thalamo-
tomy. These patients must be evaluated very carefully
since damage to the brain may result in a less predict-
able surgical result. Surgical success is diminished and
the risk of complications increased in the presence of
severe generalized brain atrophy, ataxia, or significant
memory or speech abnormalities; involvement of the
dominant hemisphere may also significantly increase the
risk of postoperative complications.
If the tremor is unilateral, the evaluation is relatively
straightforward. Patients who do not respond adequately
to medication and who have a significant disability from
the tremor can be treated with thalamotomy with a high
likelihood of success. Even if surgery is not totally suc-
cessful in alleviating tremor, medical therapy is fre-
quently more effective postoperatively. If the tremor is
bilateral but asymmetrical, there is more uncertainty as
to the most effective method of treatment. Most stereo-
tactic neurosurgeons would prefer treating the more se-
verely affected side and hope postoperatively that re-
duced medications will optimize the effectiveness of the
medications to reverse any adverse effects. Others would
concentrate on the dominant side to allow maximum
rehabilitation from a unilateral procedure. In our opin-
ion, the best choice depends on the degree of asymme-
try. Patients with dramatic differences in side-to-side
tremor should be operated on the more severely affected
side. In those where the asymmetry is less marked, it
depends on the degree of disability present on the domi-
nant side. One could then justify lesioning the dominant
hemisphere in order to have a functional dominant side.
If the patient has symmetrical bilateral tremor, there is
again less controversy with the dominant side being
lesioned first to provide a unilateral procedure which
would be functionally beneficial. If at all possible, one
should avoid a second procedure. When a second-side
procedure is unavoidable due to the severity of symp-
283
toms, then a minimum of 3 to 6 months should elapse
before the second side is operated upon. Every attempt
should be made to make the lesions as small and/or asym-
metrical as possible to minimize the risk of adverse cog-
nitive or communicative injury. Various methods other
than a thalamotomy may accomplish this, for example
by performing a thalamotomy on one side and a
pallidotomy or campotomy on the other; or, more re-
cently, a thalamic stimulator has been placed contralat-
eral to a successful thalamotomy. In no case should bi-
lateral campotomies be performed due to the risk of
mutism. The presence of brain stem injury is also a con-
traindication for bilateral procedures.
If the patient’s primary problem is akinesia and
bradykinesia, thalamotomy should not be considered. The
beneficial effects are too small for bilateral lesioning and
the complications too great to recommend. The role of ste-
reotactic surgery in this situation is currently undergoing
reevaluation, especially in light of recent evidence that
posteroventral pallidotomy is effective in treating akinesia.
Successful surgical candidates are generally in good
general health and have not become debilitated by their
disease. Patients requiring full-time nursing care or who
are mentally disabled should not be considered for sur-
gery. Special attention should be directed to exclude those
patients who have significant cognitive, swallowing, or
speech difficulties, as these are most likely to result in a
postoperative complication. Surgery is most successful
in those patients under the age of 65, but success can be
achieved in older patients if they are in good general health
and retain good cognitive abilities.
Any potential surgical candidate should be seen and
evaluated on several occasions by the neurosurgeon to
view the spectrum of symptoms and to develop rapport
with the patient. By giving the patient a detailed explana-
tion of the procedure preoperatively and by discussing
each step of the procedure as it occurs intraoperatively,
the patient is provided with sufficient insight and famil-
iarity that excellent cooperation can be achieved during
the operation.
SURGICAL TECHNIQUE
Preparations for Surgery
The procedure is performed under local anesthesia. Care must
be taken to ensure that the anesthesia service does not write
“routine” preoperative orders for these patients. No preop-
erative medicines should be given to the patient. No lines
should be placed on the limb contralateral to the lesion. It is
probably even more useful to instruct the patient to refuse
placement of lines on the side of the body that needs to be
evaluated intraoperatively. The infection rate is so low that
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
prophylactic antibiotics are not needed. The use of ste-
roids is optional. Whether or not the parkinsonian patients
should take their medication prior to the procedure de-
pends entirely on the severity of symptoms. If the patient
has “on” times immediately following ingestion of medi-
cation when there is very little symptomatology, it is prob-
ably best to hold medications until after the procedure. If
it is quite clear, even during the best “on” performance,
that the symptomatic deficits remain clearly evident, then
there is no need to withhold medication. In preparation
for surgery, we prefer removal of all the hair. This is best
accomplished with clips and electric razor. For some fe-
male patients, we will leave hair on the posterior half of
the head, so that they can cover the front and give the
illusion of retaining a normal appearance.
The initial target coordinates for stereotactic proce-
dures have always been obtained by image-directed sur-
gical methodology. The more information contained
within the imaging technique, the more precise the initial
probe placement. There has been an evolution from stan-
dard x-ray films which require correction for parallax,
magnification, rotation, and tilt, to three-dimensional to-
mographic imaging techniques. The combination of three-
dimensional target imaging techniques with three-dimen-
sional placement techniques brings to stereotactic
neurosurgery a high degree of precision. Most of the cur-
rent generation of computed tomography (CT) scanning
units have software available for this type of procedure.
Magnetic resonance (MR) imaging permits multiplanar
viewing and trajectory determination without the need
for reformatting steps, but the accuracy of such techniques
is not as good as CT. MR slices must be thicker, the fidu-
ciaries are subject to multiple field distortions, and the
error in identification of the fiduciaries is much larger.
Any CT-compatible stereotactic frame can be used but
the Cosman-Roberts-Wells (CRW) and the Leksell frames
seem best suited for functional stereotactic work. These
are rectilinear systems with a semicircular arc fixed around
the target, which allow easy transposition in X, Y, or Z
coordinates, permit multiple areas to be tested without
the need for additional calculations, and minimize the need
for manipulations of the frame coordinates.
The stereotactic frame is placed with the patient
seated. The frame should be angled approximately 6° from
the horizontal so that the anterior half of the ring is higher
than the posterior half. This will frequently allow the CT
scan slices parallel to the base frame to lie parallel to the
anterior commissure-posterior commissure (AC-PC line).
The frame is secured after infiltrating the scalp down to
the periosteum with 1% lidocaine HCl with epinephrine. If
a particularly long operation is anticipated, a mixture of
284
1% lidocaine HCl with 0.5% bupivacaine HCl in equal vol-
umes can be used. The head should fit comfortably within
the frame, leaving more room anteriorly than posteriorly
so that the nose is not compressed by the localizer or arc
system.
The patient is taken to the CT scan suite, where the
head ring is affixed to the gantry of the scanner. A ven-
tricular catheter is placed in the frontal horn of the lateral
ventricle down to the foramen of Monro. If the location of
the catheter is uncertain (i.e., due to the small size of the
ventricles), the position can be confirmed prior to the in-
jection of contrast by scanning at the level of the catheter
tip determined from a scout view. There has also been an
evolution in the contrast material from air to water-insoluble
to water-soluble, and most recently to nonionic contrast
agents. A nonionic contrast medium is preferred, because
watersoluble contrast agents such as metrizamide occasion-
ally cause seizures or metabolic encephalopathy. We use 1-
2 ml of a nonionic contrast agent carefully introduced into
the ventricle by gentle back and forth barbotage. A few
gentle exchanges will allow excellent outlining of the third
ventricle on the axial scans. It may be possible to identify
the landmarks of the third ventricle without contrast, but in
our experience this is not always the case. The anterior com-
missure can be difficult to identify and there is a definite
potential for the introduction of errors, which can be avoided
by ventriculography. Upon completion of the contrast place-
ment, the ventricular catheter is removed and the scalp in-
cision sealed with a mattress stitch. Serial 1.5-mm over-
lapping scans are then performed through the entire third
ventricle. If the frame has been put on precisely, these sec-
tions will go through the AC-PC line and the exact slice
can be determined from a midline reconstruction (Fig. 1).
If not, the angle of the gantry can be changed based on
these reconstructs and the patient rescanned. The measure-
ment mode on the CT scanner can then be engaged and
multiple coordinates for initial and subsequent targeting
generated.
The Walker nomenclature of the VL thalamus is less
precise than the Hassler terminology. The VL nucleus is
roughly the equivalent of Hassler’s nucleus ventro-oralis
anterior (Voa), nucleus ventro-oralis posterior (Vop), and
probably includes nucleus ventro-intermedius (Vim). Vba
is considered the best target for control of rigidity and Vim
is the best target for control of tremor. The target coordi-
nates should be considered as only the initial starting point;
further physiologic conformation is required. Because the
initial target point for many surgeons will vary from Vop
to Vim, recommended target coordinates may vary from
1 to 7 mm posterior to the midpoint of the AC-PC line.
Similarly, the lateral coordinates from the midline
 BAKAY ET AL. : THALAMOTOMY FOR TREMOR
© 1992 The American Association of Neurological Surgeons
Figure 1. Using the multiplanar reconstructive ability of most CT scanners,
a midsagittal reconstruction allows identification of the anterior commis-
sure (A) and posterior commissure (B) as well as the section which should
contain these anatomical landmarks. By choosing the appropriate gantry
vary from 10 to 15 mm and the vertical coordinates above
the AC-PC line vary from 0 to 3 mm. In addition to dif-
ferences in target point, changes in the size of the third
ventricle can push the target further laterally and make
it appear more anterior. The AC-PC line is approximately
24 ± 3 mm in the majority of parkinsonian patients. Nev-
ertheless, individual variations can be great. Because of
this, neurosurgical stereotactic centers are increasingly
using a proportionate system in target determination. For
Vop, we have been using a starting point at 5/12 of the
intracommissure distance from the posterior commis-
sure, since this is the most readily identified structure
and it is closest to the target (Fig. 2). For Vim, we use
20% of the intracommissural distance from the poste-
rior commissure (Fig. 3). The lateral distance depends
entirely on the observed location of the internal cap-
sule. The internal capsule is 10-15 mm lateral to the
midline for Vop and 16-22 mm for Vim. The lateral co-
ordinate is selected as 2 mm from the edge of the inter-
nal capsule, and 1.5 mm above the AC-PC line. Once
the target coordinates are selected, the patient is trans-
ported to the anesthesia preparation room.
A sterile field must be maintained from the head ring
upward, but the patient’s body is best left uncovered and a
simple screen placed between the patient and the sterile
field (Fig. 4). It is very important to be able to see the
affected side to observe spontaneous tremor as well as to
test for strength and coordination. We prefer that the pa-
tient be able to see his/her body and the surrounding part
285
angle, all sections will be parallel to this plane. The measurement capability
of the CT scanner allows an accurate AC-PC determination (26.4 mm for
this patient). To enhance the anatomical accuracy of the reconstruction,
1.5-mm sections are used as well as intraventricular contrast.
of the room in order to provide orientation and reduce
stress levels as much as possible. The anesthesia team
should be on the side ipsilateral to the lesion. An arterial
line for continuous blood pressure monitoring and an in-
travenous line for administration of medications are es-
sential. Short-acting narcotics are administered only if
absolutely required for patient comfort. Individual small
boluses are preferred so the surgeon knows how much
medication is given. The use of continuous drips is to be
avoided since these are readily manipulated by the anes-
thesiologist without consultation with the surgeon. This
is in contrast to any antihypertensive medication which
needs continuous smooth delivery to ensure that the pa-
tient remains in a normotensive range. In the operating
room setting, even the patient who is normally hypoten-
sive may suddenly demonstrate remarkably increased sys-
tolic pressures; it is extremely important for the surgeon
to be aware of the patient’s blood pressure throughout the
procedure, and be assured that acute elevations have not
occurred. Systolic blood pressure should be kept under
140 mm Hg.
Operative Techniques
Preliminary Steps
A 3-cm incision centered 2 cm from the midline and
perpendicular to a point 12 cm posterior to the nasion is
used as a standard entry point. The calvarium is pen-
etrated by a pneumatic perforator or Hall drill to
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

Figure 2. The initial target coordinates can be obtained by selecting a

section just above that containing the anterior and posterior commis-
sures (1.5 mm above AC-PC). Reconstruction of the AC-PC line (A to
B) gives a measurement similar to that determined from the sagit-
tal reconstruction (Fig. 1). Using a proportionate system, the ap-
proximate level of the Vop can be approximated along the AC-PC
line (point D is 5/12th the distance from the posterior commis-
sure). The lateral distance can be determined by constructing a
perpendicular to the AC-PC line at the level of D and measuring
the distance to the border of the internal capsule (arrow). Coordi-
nates for the target and nine fiduciary rods can then be accurately
determined. The same type of procedure will be used to obtain the
proximate position of the Vim, which will be 20% of the distance
from B to A.

© 1992 The American Association of Neurological Surgeons

Figure 3. Knowing the entry point and the tar-

get, one can define a trajectory. The Phillips CT
scanner is equipped with a trajectory following
program that allows section-by-section tracing of
the pathway to the target. Simultaneous projec-
tions of the trajectory on horizontal, coronal, and
sagittal reconstructions, as well as simultaneous
projection on a periaxial plane along the trajec-
tory, allow an accurate three-dimensional follow-
ing of the proposed probe pathway. The proposed
trajectory to a Vim target along the horizontal
axis is shown, with available sagittal and coronal
sections along the cross-hairs to the trajectory at
this level. Distance to the target (box) is also indi-
cated at 0.7 mm. This program was designed by
Dr. Bakay in conjunction with Phillips/ Hitachi
primarily for biopsy purposes but it also works
well in trajectory following for other types of
stereotactic procedures.

© 1992 The American Association of Neurological Surgeons

286
 BAKAY ET AL. : THALAMOTOMY FOR TREMOR

Figure 4. A patient is shown in two views (A and B) undergoing a right

thalamotomy. The left arm is available for testing and the right arm has
an intravenous line and an arterial line for anesthesia monitoring. The
sterile field is maintained behind the base ring of the stereotactic frame,
and instruments are passed from the nurse who is behind and to the side
of the surgeon.

© 1992 The American Association of Neurological Surgeons

287
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
provide an adequate opening. A twist drill frequently does
not provide sufficient room for manipulation for target
testing, especially if the skull is thick. After the opening
is made, it is advisable to cauterize the exposed arach-
noid and create an opening where the probe will pass.
This prevents a rather dramatic distortion of the probe
and brain when an attempt is made to pass a blunt instru-
ment through what can be a thickened, tough arachnoid
surface.
The patient’s tremor (at rest and with intention),
strength, and vocalization should be tested when the pa-
tient first enters the operating suite. Retesting should oc-
cur periodically throughout the preparatory phase and
immediately prior to passage of the microelectrode probe.
This is performed by the neurologist and allows expert
evaluation while freeing the surgeon to attend to the sur-
gical aspects of the procedure.
Microelectrode Recording Technique for
Physiologic Localization of the Target Site
Tremor is best treated with a small, precisely placed le-
sion in Vim. There is evidence that Vim receives both
vestibulothalamic and cerebellothalamic afferents and
projects to the primary motor cortex (area 4) but not to
area 3a of the sensorimotor cortex as suggested by Hassler.
Neurons with rhythmic 5-7 Hz action potentials have been
recorded in Vim as well as Vop. Vop probably does not
receive cerebellothalamic afferents. Both Vop and Voa
receive fibers from the internal segment of the globus
pallidus, and project to the precentral motor cortex and
the supplementary motor cortex. A somewhat larger le-
sion is required in Vop to produce similar tremor abla-
tion. We believe that this is caused by extension of the
lesion into Vim. In the past, large lesions were made so
that Voa, Vop, and Vim were included. With contempo-
rary techniques, inclusion of Voa in the lesion is not nec-
essary and only increases the risk of complications. It is
even debatable if Vop needs to be included in the lesion
for tremor. The target is Vim.
Microelectrode recording techniques are used in con-
junction with radiographic methods to facilitate identifi-
cation and localization of tremor-related cells in the arm
area of ventral Vim and discrimination of the location of
the nucleus ventro-caudalis (Vc) and the internal capsule.
Because of the inherent variability in biological systems,
radiographically determined target sites for lesion place-
ment may be inaccurate, varying as much as several milli-
meters from physiologically determined sites. By com-
bining microelectrode recording and stimulation
techniques with conventional radiographic methods, ac-
curate localization of the optimal target site can be greatly
improved. Precise localization allows restriction of the
288
size of the lesion while maintaining its effectiveness and
minimizing potential complications.
Platinum-iridium glass-coated microelectrodes with
a tip diameter of 2-4 µm and impedance of 0.5-2.0 MV
(at 1000 Hz) are secured in a stainless steel carrier tube
and held in place protected within the carrier tube by a
lock screw at the proximal end of the tube. The micro-
electrode carrier tube assembly is then fixed to a modi-
fied hydraulic microdrive head stage, which allows ad-
vancement of the microelectrode over a total range of
25-30 mm. The microdrive is calibrated to allow moni-
toring of the electrode position in micrometer incre-
ments. The head stage incorporates a high impedance
preamplif ier, which is connected to standard
electrophysiologic equipment for amplification, filter-
ing, and discrimination of electrophysiologic signals. In
addition, the head stage contains a toggle switch which
allows switching between recording and stimulation
modes. The recorded single cell (or unit) activity is dis-
played on an oscilloscope and fed into an audioamplifier
for aural monitoring of the signal. Spike activity is stored
on videotape for subsequent analysis.
A stainless steel guide tube with a rigid obturator is
passed through the brain in a parasagittal plane proceed-
ing from anterodorsal to posteroventral, stopping approxi-
mately 10 mm short of the radiographically determined
target site in the thalamus. The obturator is then with-
drawn and replaced by the microelectrode-head stage as-
sembly. The lock screw securing the microelectrode in
the head stage carrier tube is released and the electrode
advanced using the hydraulic microdrive. The exact loca-
tion of the microelectrode tip can be determined from the
known position of the end of the guide tube and the read-
ing on the microdrive at which the microelectrode tip be-
gins to protrude from the guide tube. Single units are dis-
criminated throughout the tract. At 0.5-1.0-mm intervals,
neuronal responses to passive manipulation and active
movement of individual body parts are sought and
microstimulation is carried out at a maximum of 40 µA
with trains of symmetric biphasic pulse pairs at a fre-
quency of 300 Hz. The patient is instructed to report any
change in sensation that occurs with microstimulation,
describing its location, quality, and intensity. At each
stimulation site, sensory thresholds are determined by
progressively decreasing the current intensity until the
stimulus no longer elicits a sensory response. For each
electrode penetration, responses to microstimulation, sen-
sory thresholds, spontaneous activity pattern(s), and the
response of discriminated units to sensorimotor exami-
nation are plotted on computer-generated maps of the
human thalamus scaled to the patient’s AC-PC coordi-
nates (Figs. 5 and 6).
 BAKAY ET AL. : THALAMOTOMY FOR TREMOR
© 1992 The American Association of Neurological Surgeons
Figure 5. Three representative microelectrode tracks through the
ventrolateral thalamus. The labeled nuclei are ventro-oralis ante-
rior (Voa), ventro-oralis posterior (Vop), ventro-intermedius (Vim),
and ventro-caudalis (Vc). The electrode tracks are depicted by the
three straight lines entering the thalamus from the anterodorsal
border and proceeding in a caudoventral direction. Neurons were
isolated using standard electrophysiologic techniques, and the sen-
sory modality and somatotopic specificity were assessed for each
neuron. A, neuronal responses to somatosensory examination are
coded by letters depicting the body part and the color of the bar
along the right side of the electrode track which depicts the sen-
sory modality. Portions of the track in which tactile responses
were found are in green; those with deep proprioceptive responses
are colored yellow. Body regions are depicted by the letter along
the right side of the track: El, elbow; Fa, face; Fi, finger; H, hand;
L, leg; M, mouth; S, shoulder; Th, thumb; UL, upper lip; W, wrist. B,
289
along the left side of the track, the purple bar depicts the response
to microstimulation; the numbers are the thresholds in microamps
required to elicit a sensory response. In both A and B, the solid red
circles denote cells with a tremor-related firing pattern. The shaded
region denotes the lesion site. As demonstrated in A, penetrations
through the thalamus in this orientation in the parasagittal plane
generally proceed through the leg area into the arm area. Proximal
limb regions are encountered before distal limb regions; e.g., shoul-
der regions are encountered first, followed by progressively more
distal arm regions. Deep responses are found through Vim, giving
way to tactile responses as one proceeds into Vc. Responses to
microstimulation (B) are generally similar to those found on so-
matosensory examination; the thresholds decrease as one moves
closer toward Vc. (These figures were adapted from data collected
in collaboration with Dr. Fred Lenz, Department of Neurosurgery,
The Johns Hopkins Hospital, Baltimore, MD.)
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

© 1992 The American Association of Neurological Surgeons

Figure 6. Three microelectrode tracks in a plane 2 mm medial to that
in Figure 5 illustrating somatosensory responses (A) and microstimulation
responses (B). Abreviations and color coding are as in Figure 5. The
relatively greater number of neuronal responses related to the arm and
face area reflect the somatotopic organization in Vim (see also Fig. 7B)
with face, arm, and leg areas oriented in a medial-to-lateral direction.
The medial extent of a lesion made in the lateral plane represented in
Figure 5 is shown. Although the size of the lesion will be smaller in the
more medial plane, it may still encompass a number of tremor-related
cells found in the ventral portion of Vim. The lesion should always be
made at a site far enough away from the internal capsule and anterior
border of Vc to minimize potential complications.

290
 BAKAY ET AL. : THALAMOTOMY FOR TREMOR
Lateral and ventral boundaries of Vim and the ante-
rior border of Vc are determined based on microstimulation
effects and neuronal response properties. Because of the
lateral convexity of the thalamus, penetrations through its
more lateral border are characterized by neuronal responses
which occur at deeper locations and over shorter distances.
Furthermore, the lateral border of the thalamus is adjacent
to the internal capsule where microstimulation results in
intense short-latency muscle contractions which gener-
ally involve more than one limb. The anterior border of the
sensory thalamus (Vc) is characterized by low threshold
(5-10 µA), microstimulation-induced paresthesias, and the
presence of neurons with small, well-defined receptive
fields to tactile sensation in a body area in which the stimu-
lation-induced paresthesias occurred. Anterior sites are
characterized by a lack of microstimulation-induced
paresthesias, even at current intensities of 40 µA. There is
a gradation of cell responses to sensorimotor examination
as one moves rostrally from Vim to Vop and Vba; cells in
Vim respond readily to passive (somatosensory) manipu-
lation, whereas cells in Vop and Vba tend to respond more
selectively to voluntary movement and less to passive
(somatosensory) manipulation. Because of the somato-
topic arrangement of Vim and Vc, penetrations made too
medial or lateral are characterized by the microstimulation-
induced paresthesias or somatosensory responses pre-
dominantly restricted to the face or leg, respectively. No
motor responses are observed with microstimulation.
In parkinsonian patients with a resting tremor affect-
ing distal portions of the limb, the target site is defined as
the area in Vim having neurons bursting in synchrony with
the tremor and giving deep sensory responses to the af-
fected portion of the limb. Figure 7 illustrates the relative
location of the target site viewed in sagittal, coronal, and
horizontal planes. Microstimulation in this area may abol-
ish tremor or in some cases may actually drive the tremor.
Paresthesias should not be induced by low-intensity
microstimulation. The site(s) chosen for lesion placement
should be selected to avoid the internal capsule and the
anterior border of Vc.
Alternatively, bipolar concentric semimicroelectrodes
with a tip diameter of approximately 0.6 mm and an
interpole distance of 0.3-0.6 mm may be used for physi-
ologic localization of target sites. While the basic tech-
nique is essentially the same as described above for mi-
croelectrodes, there are significant differences in the kind
of information each provides. The effects of electrical
stimulation on tremor can be examined with both tech-
niques; however, the semimicroelectrode technique gives
a broader sampling of cellular activity and allows identi-
fication of brain structures based more on background
noise levels than on neuronal response properties. Due to
291
its lower spatial resolution, it is not as good as the micro-
electrode technique in identifying and isolating single
units in order to identify tremor-synchronous cellular ac-
tivity and/or specific response patterns to sensorimotor
examination. In summary, the semimicroelectrode tech-
nique is better suited to locate and differentiate thalamic
subnuclei, where the microelectrode technique is more
accurate and allows more precise location of the target
area within Vim.
Macroelectrode Techniques
and Lesion Generation
Successful lesions have been made with either cryo-
genic or thermal techniques. Technological advances
have been much more rapid with thermal techniques,
allowing a much smaller and more delicate probe to be
used. Radiofrequency lesions are preferred over those
made by direct current because of the ability to shape
and standardize lesions. We prefer to use the Radionics
Model RFG-313 for lesion generation. For a lesioning
probe, a thermistor electrode is strongly preferred. Elec-
trode tips of 1.1-1.6 mm diameter with electrode lengths
of 3-5 mm are most commonly used. The rigid guide
tube with an internal diameter that permits the passage
of both the recording probe and the lesioning probe is
highly desirable. Such a guide tube must fall short of
the target so that unwarranted damage does not occur
and adequate testing can be performed. The guide tube
will provide some reassurance that the lesioning probe
is going to the same area that was tested by the record-
ing probe.
The same electrode can be used to stimulate and
record impedances. As soon as the probe is started to-
ward the target, the impedance monitor can be turned on
to immediately provide a quick check of the circuit conti-
nuity. If the impedance is off-scale, there is a break in the
circuit and grounds and connections need to be checked.
If the impedance reads 0, there is a short in the cable or
electrode. Most often it is the cable, but checking both
the cable and the electrode is essential. Impedance moni-
toring toward the target can be quite useful to demon-
strate dramatic changes going from white to gray matter,
allowing boundary identification. The lesion generator can
then be turned on and the thermister should read body
temperature. Once the electrode is in the proper place,
electrostimulation is a highly useful technique to confirm
that the probe has been placed exactly.
In some centers, this is the only electrophysiologi-
cal confirmation technique used. We do not use the
stimulation generator on the lesion generator system
because voltage-dependent stimulation is not as de-
pendable as constant current stimulation. A Grass
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

© 1992 The American Association of Neurological Surgeons

Figure 7. The relative location of a lesion made in Vim is shown in GPe, globus pallidus, external segment; GPi, globus pallidus, inter-
three different planes; parasagittal (A), coronal (B), and horizontal (C). nal segment; LGN, lateral geniculate nucleus; Pt, Put, putamen; RN,
The lesion is superimposed on the homunculus in the coronal and hori- red nucleus; SN, substantia nigra; STN, subthalamic nucleus.
zontal planes. Ca, caudate nucleus; IC, internal capsule; II, optic tract;

292
 BAKAY ET AL. : THALAMOTOMY FOR TREMOR
generator with a constant current adaptor or the Ojemann
stimulator works well for this purpose. Stimulation pulses
can be used from 2 to 200 Hz at 1-8 mA for 1 msec dura-
tion. Most useful is testing at 5 Hz and then switching to 50
Hz. Frequencies at the lower end will cause contralateral
synchronous motor twitches when the target is too near the
internal capsule. Macroelectrode stimulation that produces
this type of motor response at low threshold (1-2 mA)
strongly suggests that the probe is too close to the internal
capsule, and a more medial location is advised. More tonic
motor responses occur at the higher frequencies. Sensory
responses generally occur at 50-100 Hz and, when they
occur at a low milliamp range (< 1 mA), this strongly sug-
gests that the probe is placed too far posteriorly. Paresthesias
in the contralateral lip or hand (especially the thumb) sug-
gest that the optimal lesion site is located just anterior to
this location. Caution must be used in interpreting results
of stimulation in the higher milliamp range due to current
spread. Respiratory inhibition suggests a placement that is
too medial, and visual, vestibular, auditory, oculomotor, or
fear responses suggest a subthalamic placement. The two
most useful responses indicating correct location are inhi-
bition of deep tendon reflexes and inhibition of tremor.
© 1992 The American Association of Neurological Surgeons
Figure 8. The relative location of a Vim lesion is shown in a combined cutaway view. The probe is entering from anterior in a parasagittal plane.
293
Observation of the patient’s tremor in response to stimula-
tion is generally made at 50 Hz and, if the electrode is in
Vim or Vop, tremor can be arrested. Macroelectrode stimu-
lation of Voa generally increases the amplitude of the tremor
of Parkinson’s disease, especially at low stimulation rates
(5 Hz), but at 50 Hz the rate of rapidly alternating move-
ments of the arm can be slowed and ocular movements can
be produced conjugately to the contralateral side. At this
frequency, occasionally tremor can be arrested although
this may be secondary to current spread into Vop. If
macroelectrode stimulation of a target point arrests tremor,
a lesion in the same site will uniformly result in improve-
ment. If macroelectrode stimulation facilitates or increases
tremor, a lesion in the same site will commonly but incon-
sistently improve the movement disorder. Dystonia is vir-
tually always driven by stimulation. Contralateral upper and
lower extremity deep tendon reflexes should be tested re-
petitively before and during stimulation. Care must be taken
to differentiate the loss of a reflex from a diminished re-
sponse due to increased muscle contraction.
Once the electrode is believed to be in the proper
position (Fig. 8), the lesion is made using an electrode
that is 1 mm in diameter with a 3-mm bare tip. A lesion
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
3 mm in diameter is anticipated. A temperature of 42°C
allows for a potentially reversible lesion. Testing over a
10-minute period of a patient’s strength, speech, and
tremor gives an initial assessment of the safety of the
lesion. The temperature is then raised to 75°C for 60
seconds. Throughout this time, careful monitoring and
continuous evaluation of speech, strength, and tremor
need to be performed. A suggestion of dysarthria, weak-
ness, or sensory loss should result in immediate termi-
nation of the procedure. In this case, a reevaluation is
made six months later to determine if the patient is a
suitable candidate for further surgery based on follow-
up imaging studies and the degree of the resultant neu-
rological deficit. A well-placed lesion should stop the
tremor without a deficit. In most cases, a 30-60-mm3
lesion is sufficient and no further lesioning should be
performed. If, after completion of the lesion and obser-
vation for 10-15 minutes, the tremor returns or is not
really abated, the temperature can be raised to 80°C for
60 seconds to slightly enlarge the lesion. Alternatively,
the electrode can be withdrawn 3-5 mm and a second
lesion made at 75°C for 30 seconds to extend the lesion
into the superior aspect of the Vim and Vop. If neither of
these strategies is completely successful, it is better to
terminate the procedure at this point than continue to
make increasingly larger lesions. The physiological
parameters are frequently lost due to lesioning and it is
unwise to probe the lesion area. Again, it is best to make
the lesion as small as possible and it is far better to come
back another day than to push on to larger and larger
lesions and increase the likelihood of complications.
Closure
After removing the probe, the burr hole is filled with
Gelfoam. A cranioplasty is only performed for cosmetic
reasons if a large burr hole has been used. Alternatively, a
plastic cover is acceptable, but a metal cover should be
avoided. A watertight closure of the galea and skin will
help prevent cerebrospinal fluid (CSF) leakage and in-
fection. The wound is covered for 2 days and kept dry
until suture removal in 5-7 days.
POSTOPERATIVE CONSIDERATIONS
Following completion of the thalamotomy, blood pres-
sure control must be maintained for 24-72 hours postop-
eratively. This involves admission to the intensive care
unit (ICU), with pressure monitoring through the arterial
line and titration of antihypertensives as necessary. Bedrest
is maintained and procedures which may increase arte-
rial pressure are avoided. Frequent careful neurological
examinations are required. We no longer perform routine
postoperative CT scanning unless there is evidence of
294
neurological deterioration and the CT scan can assist in
determining whether the deterioration is due to edema or
hemorrhage. High-dose steroids are of limited value. Opti-
mal management of intraparenchymal hemorrhage has not
been established. Aspiration procedures are of little value
and a ventriculostomy is placed only if CSF obstruction
occurs. The most common postoperative hemorrhage ob-
served on CT scanning is a “target” lesion with a small
high-contrast center and surrounding edema. A larger le-
sion consists of a solid or irregular high-density mass.
Unfortunately, the CT scan is not predictive of complica-
tions and since the most important aspect is to maintain
blood pressure control, routine postoperative scans are
probably of less value than continuous blood pressure
monitoring and treatment in the ICU.
Once the patient is ready to be transferred from the
ICU, consultation may be obtained with physical therapy
and occupational therapy to provide maximum rehabili-
tation. With large lesions, there is occasionally a tendency
in the immediate postoperative period for the patient not
to use the hand contralateral to the thalamic lesion, de-
spite the fact that tremor and rigidity are abolished and
the hand is more facile than the ipsilateral hand. This type
of neglect generally clears within several weeks. The same
may occur in the lower extremity, causing balance prob-
lems. By intervening early with physical therapy, it is likely
that functional relearning for the side contralateral to the
thalamotomy can be facilitated. The patient can be dis-
charged 5-10 days postoperatively.
RESULTS AND COMPLICATIONS
Vim thalamotomy can abolish contralateral tremor and
greatly diminish contralateral rigidity, especially if the
lesion is extended more anteriorly into Vop. Functional
quality of life is improved, and manual dexterity in par-
ticular can be significantly improved to the extent that it
was limited by tremor. Finally, dyskinesias caused by
levodopa therapy can be markedly reduced or eliminated
in the contralateral limb. It remains controversial whether
or not surgery is less effective in patients who have
been treated for a long time with levodopa, and it is
highly controversial whether or not thalamotomy de-
lays the progression of parkinsonism. It would appear
to us that neither of these are in fact the case, but oper-
ating on more severely affected patients is less likely
to produce success and the tremor-predominant patients
have a slower more benign course of the disease. Thala-
motomy does not significantly alter any underlying aki-
nesia, or any loss of manual dexterity which is predomi-
nantly the result of ataxia. Thalamotomy should not be
performed with the primary anticipation of improving
speech, gait, or vegetative or emotional function. Ip-
 BAKAY ET AL. : THALAMOTOMY FOR TREMOR
silateral tremor is occasionally but not reliably improved.
Intention tremor can be improved significantly. Ataxia,
however, does not respond to thalamotomy. Although uni-
lateral thalamotomy should be highly successful in im-
proving tremor in 70-90% of patients, bilateral thalamo-
tomy may be highly successful in only 50-75% of patients.
Although other aspects of the underlying disease may
progress, successful lesions retain tremor control in long-
term follow-up.
The correct complication rate is very difficult to de-
termine. The large volume of cases in the past were done
with techniques that are archaic by today’s standards, and
therefore the complication rates in the old literature are not
appropriate for discussion. Patients treated with modem
technology are unfortunately very few, even in the most
active centers, and valid complication rates are much more
difficult to obtain. Nevertheless, the general consensus
would indicate that mortality should be less than 0.5%. The
most common source of mortality and severe morbidity is
hemorrhage, which is an unavoidable complication from
thermal injury to the blood vessel wall at the time of the
295
lesion generation. Hemorrhage may occur immediately or
be delayed by 1 or 2 days. With current techniques, an in-
correctly placed lesion should not be a source for compli-
cations, but collateral damage from too large a lesion is
possible. Major complications include cognitive distur-
bances, paralysis, dysphagia, sensory loss, and speech dis-
turbances. The combined complication rate would be an-
ticipated to be 15-20% with permanent disability at
approximately 5%. These rates can double or triple when
high-risk patients are included or bilateral lesions are per-
formed. Dexamethasone may mask mild transient postop-
erative symptoms but it probably does not prevent perma-
nent complications. The infection rate is less than 0.5%
and seizures occur in the 1% range. Hemiballism is rarely
seen today, and certainly would be anticipated at less than
a 0.1% rate. Recurrence of tremor during the first month
after surgery is uncommon and suggests either too small a
lesion or an inappropriately placed lesion. In our experi-
ence, a second larger or better-placed lesion will almost al-
ways abolish the tremor permanently. The exceptions are
tremors from multiple sclerosis (cerebellar outflow tremors).
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
ENDOVASCULAR TREATMENT
OF CAROTID CAVERNOUS FISTULAS
ARVIND AHUJA, M.D.
LEE R. GUTERMAN, PH.D., M.D.
KIMBERLY LIVINGSTON, M.D.
LEO N. HOPKINS, M.D.
INTRODUCTION
Carotid cavernous fistulas (CCFs) are abnormal commu-
nications between the carotid artery and the cavernous
sinus. Direct CCFs are communications between the in-
ternal carotid artery (ICA) and the cavernous sinus (Fig.
1). These fistulas occur as a consequence of trauma, a
ruptured intracavernous carotid artery aneurysm, a col-
lagen deficiency syndrome, an arterial dissection, fibro-
muscular dysplasia, or iatrogenesis. Indirect (dural) CCFs
involve the dural branches of the external carotid artery
or ICA to the cavernous sinus and usually arise spontane-
ously, more often in women.
The clinical manifestations of CCF are related to the
degree of the arterial shunt and the local vascular anatomy.
Symptoms and signs include an orbital or cephalic bruit,
pulsating exophthalmos, chemosis, transient ischemic at-
tacks, diplopia (caused by paresis of cranial nerve III, IV,
or VI), diminished visual acuity, orbital pain, headache,
hemorrhage (intracerebral, subarachnoid, epistatic, or
otorrhagic), and consequences of increased intracranial
pressure.
Management depends upon the vascular anatomy and
the neurologic sequelae associated with the fistula. Pa-
tients suspected to have a CCF require angiography. An-
giography also helps to evaluate the presence of cortical
venous drainage or a varix within the subarachnoid space;
these findings have been associated with an increased risk
of intracranial hemorrhage and are indications for inter-
vention. Patients should have a baseline neuro-ophthal-
mologic evaluation of visual acuity and intraocular pres-
sure, with documentation of exophthalmos and any retinal
arterial or venous abnormality.
Indirect CCFs are slow flow lesions that can undergo
spontaneous thrombosis. Patients with indirect CCFs can
© 1992 The American Association of Neurological Surgeons
296
be managed conservatively if they have no neurologic
deficit and minimal symptoms, such as mild headache or
bruit. Daily manual compression of the ipsilateral carotid
artery leads to spontaneous thrombosis in 30% of indi-
rect CCFs. During carotid compression, the patient should
use the contralateral hand to apply pressure for 10 sec-
onds every 2 hours. The duration of compression can be
gradually increased to a maximum of 30 seconds at 5-10-
second intervals for a period of 2 days. If the patient re-
mains symptomatic, endovascular treatment with arterial
embolization alone, or in combination with venous oc-
clusion, is employed to occlude the fistula.
Direct CCFs, usually high flow lesions, rarely throm-
bose spontaneously and may require intervention more
acutely. Endovascular techniques are associated with lower
morbidity and mortality and are preferred to surgical in-
tervention as the first line of treatment. Surgery should
be reserved for lesions inaccessible by transarterial or
transvenous routes or in cases of incomplete endovascular
treatment. Surgical techniques can also be used to expose
percutaneously inaccessible vessels for endovascular
embolization or for direct surgical packing of the cavern-
ous sinus.
Endovascular methods employ various embolic
agents delivered through an arterial or venous route; ini-
tial attempts usually involve a transarterial approach.
Detachable balloons are the most widely used embolic
agent for CCFs because they can be directed into the fis-
tula by flow. Complete obliteration of the fistula with pres-
ervation of the ICA is possible in most cases.
An alternative endovascular approach involves the
transvenous route. The transvenous approach is tech-
nically more diff icult but is useful when the
transarterial approach is unsuccessful or infeasible
because of local vascular anatomy. Because balloons can
be difficult and dangerous to maneuver through the
 AHUJA ET AL. : ENDOVASCULAR TREATMENT OF CAROTID CAVERNOUS FISTULAS

© 1992 The American Association of Neurological Surgeons

Figure 1. A schematic lateral view of the cavernous sinus showing a tear in the internal carotid artery.
Blood flow through the carotid artery into injured vein(s) establishes a carotid cavernous fistula (CCF).

297
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
more circuitous venous pathways, coils are the most
widely used embolic agent for the transvenous approach.
We will discuss the endovascular treatment of a direct
CCF by the arterial approach using silicone balloons and
by the venous approach using coils.
MATERIALS
Balloons
Endovascular balloons are constructed of latex or silicone
polymers. Latex polymer undergoes photodegradation and
should be stored in the dark. Latex balloons can be de-
signed to mold to an individual vascular shape and, when
inflated intravascularly, resume the desired shape. The
latex balloon is anchored to the delivery catheter system
(e.g., 2.2 French Tracker®, Target Therapeutics, Inc., San
Jose, CA) with latex thread. The tension of this attach-
ment determines the force required to detach the balloon.
Silicone balloons have been used more extensively than
latex balloons in the United States. The silicone balloon is
made of a semipermeable membrane that is biocompatible
and nonbiodegradable. It has a miter valve for sealing and
rarely deflates, whereas a latex balloon will eventually de-
flate within weeks to months. The silicone balloon has prop-
erties that enhance elongation and expansion while main-
taining a soft, low tension shell, allowing the balloon to be
placed into restrained areas with minimal damage to ves-
sel walls. The compliance curve for silicone balloons is
bimodal. Pressure decreases initially with increasing vol-
ume until a critical volume is reached, beyond which pres-
sure increases linearly with increasing volume until the
balloon ruptures. Understanding this concept is therefore
important, not only to preclude balloon rupture, but also to
appreciate that beyond the critical volume, a submaximally
inflated balloon may exert excessive pressure on the sur-
rounding vessel, leading to vascular injury.
298
Silicone balloons are available in three different sizes
in both nondetachable and detachable forms (Table 1).
Nondetachable balloons (Interventional Therapeutics
Corporation, South San Francisco, CA) come mounted
onto a 2.2 French polyethylene catheter. Detachable bal-
loons can be mounted on a 2.2 French delivery catheter
(Interventional Therapeutics Corporation) or on a Tracker®
18 catheter (Target Therapeutics) for placement (Fig. 2).
They are available in different sizes and detachment
strengths. The detachment strength is determined by the
coefficient of friction between the miter valve and the
catheter. The tension of this attachment determines the
force required to detach the balloon. Medium or high de-
tachment strength balloons are used most often in the treat-
ment of a direct CCF.
Fluoroscopic visualization of the silicone balloon
during placement requires inflation of the balloon with a
radiopaque liquid, such as a metrizamide solution. The
balloon must be filled with an isosmotic to slightly
hyperosmotic contrast agent to avoid osmotic swelling or
deflation. Metrizamide powder can be diluted with nor-
mal saline to adjust the isosmolality of the solution prior
to introduction into the balloon cavity.
Coils
Platinum coils are made from fine strands of platinum
wire which can be coated with various agents, such as
Dacron, to increase their thrombogenicity. Available in
differing lengths and shapes, most coils are compat-
ible with magnetic resonance imaging (Fig. 3). Once
the microcatheter tip is maneuvered into the ideal loca-
tion, coils are delivered into the lesion until the desired
effect is achieved; their complex helical shape helps se-
cure their position. Technologic advances now allow re-
trievable coils of varying shapes and lengths to be de-
tached only after correct placement is confirmed.
© 1992 The American Association of Neurological Surgeons
Figure 2. Successive inflations of a medium-sized detachable balloon
mounted on a Tracker® 18 catheter.
 AHUJA ET AL. : ENDOVASCULAR TREATMENT OF CAROTID CAVERNOUS FISTULAS
© 1992 The American Association of Neurological Surgeons
Figure 3. Differing sizes and shapes of Dacron-coated platinum coils, ranging from a 5-mm straight to a 2 × 20-mm complex coil.
OPERATIVE PROCEDURE
Preoperative Considerations
The patient is admitted the evening before the procedure
for intravenous hydration. Measurements are made of the
complete blood count, serum electrolytes, total urea nitro-
gen, creatinine, prothrombin time, and activated partial tis-
sue thromboplastin time. A urinalysis, chest x-ray films,
and an electrocardiogram are obtained. A Foley catheter is
placed to avoid the discomfort and reflex hypertension of-
ten associated with a full bladder.
On call to the angiography suite, a combination of
atropine, Dilaudid, and Versed is administered intra-
muscularly. Additional Dilaudid or Versed is given to
the patient intravenously or intramuscularly as needed
during the procedure. The procedure is carried out in
the awake patient with moderate sedation under local
anesthesia.
The patient is positioned supine on the angiogra-
phy table and is prepared and draped in a sterile fash-
ion. He or she is monitored for blood pressure and car-
diac rhythm and is given supplemental oxygen by a
nasal cannula.
299
Arterial Access and Anticoagulation
Following a 2% local lidocaine injection, the femoral ar-
tery is cannulated with an 18-gauge needle using the
Seldinger technique. A guide wire is passed into the ves-
sel, and the needle is removed. An introducer sheath is
placed over the guide wire and is sutured in place. This
procedure is repeated on the contralateral side. The sheaths
are perfused with heparinized saline (1000 units of hep-
arin/1000 ml of normal saline).
Heparin is used to decrease the incidence of throm-
boembolic events. The patient is given an initial dose of
5000 units of heparin intravenously, with hourly assess-
ment of the activated clotting time (ACT) used to titrate
the anticoagulant during the procedure, maintaining the
ACT at 1.5-2.0 times the baseline value.
Baseline Angiography
Selective angiography of the symptomatic internal and
external carotid arteries is then performed using a 5.0
French catheter. This catheter is positioned using a
0.035- or 0.038-inch polymer-coated guide wire to opti-
mize the ease and safety of catheter positioning. Non-
ionic contrast material is used routinely for digital
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
subtraction angiography (DSA). In the case of a high-
flow fistula, rapid sequence DSA is used. If the opening
of the fistula is still undetectable angiographically because
of rapid arteriovenous shunting, carotid compression can
be used to impede the arterial flow velocity. Injection of
the contralateral carotid or dominant vertebral artery with
compression of the diseased carotid may help identify the
origin of the fistula angiographically. Information pro-
vided can be used to design a strategy for occlusion.
Placement of Nondetachable Balloon
A 7.3 French guide catheter (Interventional Therapeutics
Corporation) is introduced through one of the two femo-
ral sheaths and advanced into the symptomatic ICA. This
catheter is attached to a rotating hemostatic adapter and
heparinized saline flush pack for continuous irrigation
(Fig. 4). Through the opposite femoral sheath, a second
guide catheter is introduced and advanced into the same
ICA, slightly proximal to the first guide catheter, making
certain that flow through the carotid artery is not impeded.
A second rotating hemostatic adapter and heparinized
saline flush pack are similarly attached, and both guide
catheters are slowly perfused with heparinized saline to
prevent thrombotic complications.
The size of the fistula is approximated from the di-
agnostic angiograms; and an appropriate-sized, nondetach-
able silicone balloon coaxial system is introduced through
the more proximally placed guide catheter and advanced
into the ICA. A “road map” (subtracted angio-architec-
ture superimposed on the real-time fluoroscopic image) of
the ICA is created so that the anatomic location of the
fistula can be identified. The nondetachable balloon is
guided into the fistula and inflated to gain a better under-
standing of the exact size of balloon or balloons required
to completely occlude the lesion. Angiography is per-
formed through the guide catheter to demonstrate clo-
© 1992 The American Association of Neurological Surgeons
Figure 4. The catheterization system: catheter (A); rotating hemostatic adapter (B); three-way stopcock
(to which a heparinized saline flush pack is attached) (C).
300
sure of the fistula and patency of the parent vessel. The
nondetachable balloon is then deflated and removed from
the fistula and “parked” just distal to the fistula in the
ICA.
Placement of Detachable Balloon
An appropriate-sized detachable silicone balloon is now
selected and prepared for delivery by attaching it to a
Tracker® 18 microcatheter. This system is purged of air
with isosmotic metrizamide, then advanced through the
unused 7.3 French guide catheter into the ICA and subse-
quently maneuvered into the fistula and inflated (Fig. 5).
With very large fistulas, multiple balloons must be used,
whereas with smaller fistulas, a single balloon may suf-
fice to completely occlude the fistula. It is important to
note that submaximal inflation of each detachable bal-
loon is essential to minimize the chance of balloon rup-
ture. Extreme care is taken in an attempt to occlude the
fistula while preserving the parent carotid artery. It is very
important to use intermittent DSA to follow the progress
of the procedure.
The nondetachable balloon is strategically inflated
(angioplasty) to optimally position the detachable balloons
into the fistula (Fig. 6). After successful occlusion of the
fistula, the nondetachable balloon is removed. Three-ves-
sel angiography must then be carried out to ensure com-
plete and effective treatment with preservation of normal
cerebral vessels.
If two guide catheters cannot be placed, the tech-
nique is modified by using only one guide catheter.
First, the nondetachable balloon is introduced. Once
the size of the fistula is determined, the nondetachable
balloon is removed, and the detachable balloon is intro-
duced through the same guide catheter. The subsequent
steps for placement and detachment of balloons are as
previously described.
 AHUJA ET AL. : ENDOVASCULAR TREATMENT OF CAROTID CAVERNOUS FISTULAS

© 1992 The American Association of Neurological Surgeons

Figure 5. Two 7.3 French guide catheters have been placed in the catheter into the fistula opening. B, the balloon is inflated to fill
involved carotid artery through a transfemoral arterial approach the fistula. C, the detachable balloon has been detached with
with a balloon placed distal to the fistula (not shown). A, a me- complete occlusion of the fistula and patency of the internal
dium strength detachable balloon is placed through a second guide carotid artery.

301
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

© 1992 The American Association of Neurological Surgeons

Figure 6. Two 7.3 French guide catheters have been placed into the used to position the detachable balloon into place and preserve the
involved carotid artery through a transfemoral arterial approach. A, the carotid artery. C, after angiography demonstrates carotid patency
detachable balloon cannot be placed through the CCF opening. B, a with fistula closure, the balloon is detached; the nondetachable
nondetachable balloon is placed through a second guide catheter and is balloon is deflated and removed.

302
 AHUJA ET AL. : ENDOVASCULAR TREATMENT OF CAROTID CAVERNOUS FISTULAS
Occlusion of the Parent Artery
In some cases, with an extremely large fistula and major
disruption of the carotid artery, the parent vessel must be
occluded along with the fistula. Before occluding a carotid
artery, a test occlusion of the ICA is routinely carried out.
For this procedure, we routinely use a double-lumen, soft
balloon catheter. The double-lumen balloon catheter is
placed in the symptomatic ICA. The balloon is inflated
through one catheter lumen. The second lumen is flushed
continuously with heparinized saline (1000 units of hep-
arin/1000 ml of normal saline) distally. Occlusion of the ICA
is carried out in a fully heparinized patient to minimize throm-
botic complications. The patient is subjected to complete
occlusion of the ICA for 15 minutes with continuous neu-
rologic monitoring. If this portion of the procedure is well
tolerated, then the patient’s mean arterial pressure is re-
duced to approximately 70% of baseline using intravenous
sodium nitroprusside for a period of 10 minutes. Continu-
ous neurologic monitoring is critical. Any significant
change in neurologic status prompts immediate discontinu-
ation of the test. Ideally, cerebral blood flow measurements
can be made during ICA occlusion. A major decrease in
ipsilateral hemispheric flow indicates potential intolerance
to permanent ICA occlusion.
If the patient tolerates test occlusion of the ICA, we
Figure 7. The tip of a guide catheter is positioned in the jugular bulb
via a transfemoral approach (not shown). The tip of a Tracker® 18
catheter is positioned through the guide catheter into the cavernous
303
think it is safe to proceed to total occlusion of the ICA
along with the fistula if that is necessary. Great care must
be taken not to occlude the parent vessel without first
filling the fistula with balloons. Routinely, when a major
vessel such as the ICA is sacrificed with balloons, an ad-
ditional proximal “safety” balloon is placed to ensure
permanence.
Transvenous Approach
Alternatively, if the transarterial approach is not feasible, a
transvenous approach can be used. The major venous drain-
age from the fistula is identified and utilized for the
transvenous approach. When possible, the transfemoral vein
approach is used, and a 5.0 French guide catheter is posi-
tioned in the region of the jugular bulb. A rotating hemo-
static adaptor and heparinized saline flush pack are attached
to the guide catheter. A Tracker microcatheter with a flex-
ible tip wire is then maneuvered through the venous sys-
tem via the petrosal sinus into the cavernous sinus. Although
it is sometimes possible to maneuver a balloon through the
venous system, it is much easier, and probably safer, to use
coils in the transvenous approach. The Tracker® catheter is
placed as close to the fistula as possible within the cavern-
ous sinus, and coils (0.0018 or 0.0010 inch) are then used to
fill the fistula and occlude it from the venous side (Fig. 7).
sinus. After optimal placement of the Tracker® 18 tip, platinum coils
(0.0018 or 0.0010 inch thickness) are delivered until the fistula is
occluded.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
Extreme care must be used to avoid damage to any in-
tracranial veins, as rupture of these thin-walled vessels
could result in catastrophic intracerebral hemorrhage.
If the major venous drainage is through the oph-
thalmic venous system, it is sometimes possible through
a direct surgical approach to the superior ophthalmic vein
to catheterize the cavernous sinus for transvenous place-
ment of coils. However, this is extremely dangerous in
an acutely dilated fragile ophthalmic vein because of
the risk of orbital hemorrhage. This approach, therefore,
is usually reserved for the more chronic, long-standing
type of fistula.
Conclusion of the Procedure
After completion of the endovascular procedure, prota-
mine (1 mg/100 units of heparin) is used to reverse the
heparinization until the ACT is normalized. Subsequently
304
the groin sheaths are removed and pressure is applied until
hemostasis is complete. The patient’s neurologic status
and the vascular status of the lower extremities are care-
fully monitored in the intensive care unit for 24 hours.
Follow-up angiography is usually carried out before dis-
charge from the hospital.
RESULTS
Endovascular methods are used to occlude a CCF in 85 to
98% of cases. There are occasional recurrences (1.3 to
9%) that can usually be treated successfully with a sec-
ond endovascular approach. The carotid artery can be pre-
served in 60 to 70% of cases. Major complications of the
endovascular method include thromboembolic events, bal-
loon migration, and vessel damage resulting in hemor-
rhage or cerebral infarction. Endovascular treatment is the
method of choice for a direct CCF.
 COMBINED TRANSSYLVIAN AND
MIDDLE FOSSA APPROACH TO
INTERPEDUNCULAR FOSSA LESIONS
CHANDRANATH SEN, M.D.
LALIGAM N. SEKHAR, M.D.
INTRODUCTION
The interpeduncular fossa region includes the following
structures: the upper clivus, the dorsum sellae, the upper
basilar artery with its quadrification, the midbrain, and
the origin of the oculomotor nerves. For the purpose of
this paper the caudal limit of this region is the level of the
trigeminal root. Lesions in this area include upper basilar
aneurysms, meningiomas, chordomas, chondrosarcomas,
and, occasionally, large invasive pituitary adenomas. The
difficulty of approaching such lesions arises from their
depth, which requires considerable and prolonged brain
retraction. Frequently there is inadequate visualization and
suboptimal control of the surrounding structures such as
the proximal part of the basilar artery. The operation de-
scribed here uses the concept of removal of the orbital
rim and zygomatic arch to reduce brain retraction and an
approach to the area from an anterolateral direction by
entering the posterior aspect of the cavernous sinus and
drilling the petrous apex medial to the petrous carotid
artery.
PREOPERATIVE EVALUATION
High resolution computed tomography (CT) scanning and
magnetic resonance imaging (MRI) (before and after en-
hancement) in the axial and coronal planes provide
complementary information and allow the surgeon to as-
sess the bony and neurovascular relations of the lesion,
respectively. Sagittal MRI is also helpful because it com-
pletes the three-dimensional picture which is essential for
surgical planning.
In patients with an aneurysm of the upper basilar ar-
tery, the unsubtracted arteriograms should also be evalu-
ated to assess the relation of the aneurysm neck with the
dorsum sellae and clivus. Four-vessel arteriography is
carried out for tumors, and accessible feeding vessels to
© 1992 The American Association of Neurological Surgeons
305
the tumor can be embolized to facilitate the operation.
When it is expected that the petrous internal carotid ar-
tery (ICA) will be manipulated for the approach, we rec-
ommend the performance of a balloon occlusion test of
the vessel to evaluate the collaterals in the event that the
ICA must be temporarily occluded.
PREOPERATIVE PREPARATION
Steroids are administered (for tumors) for a day or two in
advance and tapered off rapidly after the operation. The
patient is given a loading dose of an anticonvulsant to
achieve a therapeutic level. Intraoperative antibiotic cov-
erage (consisting of vancomycin and tobramycin) begins
with the induction of anesthesia and is continued for 48
hours after the operation.
OPERATIVE PROCEDURE
Anesthesia
General inhalation anesthesia is used, with muscle relax-
ants as required because cranial nerve monitoring is usu-
ally not performed. Central venous and arterial catheters
are inserted for fluid administration and hemodynamic
monitoring. An indwelling urinary catheter is used with a
graduated chamber for accurate output measurement.
Sequential pneumatic compression stockings are wrapped
around the lower extremities to reduce the incidence of
deep venous thrombosis. Brain stem auditory and soma-
tosensory evoked potentials are monitored during the en-
tire operation to continually assess brain stem integrity
and the extent of temporal lobe retraction.
Positioning
The patient is placed in a supine position on an “egg
crate” mattress with the head turned to the side op-
posite the lesion about 45°, extended to bring the ma-
lar eminence higher than the cranium, and fixed in a
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
three-point pin head rest (Fig. 1, A and B). The thigh is
prepared in anticipation of a fascia lata graft if necessary.
Monitoring electrodes are placed outside the sterile field
and additional sterile electrodes are placed if needed af-
ter preparing the surgical area.
Incision
The beginning of the incision is placed at the level of the
ear lobule, well below the zygomatic arch and just in front
of the ear so that the normal crease will hide the scar. It is
then brought over the vertex as a bicoronal incision or to
the opposite forehead so that when the scalp flap is el-
evated, the superior and lateral rim of the orbit and the
whole zygomatic arch are easily exposed. While the scalp
flap is elevated, the frontal branch of the facial nerve is
preserved by staying deep to it and including the tempo-
ral fat pad with the scalp. The periorbita is elevated in
continuity with the pericranium (Fig. 2A).
Bony Exposure
The temporalis muscle is freed from its attachment to
the zygomatic arch, as is the masseter, and the temporo-
mandibular joint (TMJ) capsule is exposed. The
periorbita is stripped from the roof and lateral wall of
the orbit, exposing the inferior orbital fissure. The
temporalis muscle is elevated from the skull, exposing
the temporal region (Fig. 2B).
Craniotomy and Orbitozygomatic Osteotomy
Three burr holes are made: one at the “key hole,” another
© 1992 The American Association of Neurological Surgeons
Figure 1. The head is rotated about 45° to the side opposite the opera-
tion (A) and is slightly extended to bring the malar eminence to the
highest level (B). The incision is brought close to and in front of the ear
306
above the external ear canal, and the third above the su-
perior temporal line. A free bone flap is elevated. The
greater sphenoid wing is rongeured almost down to the
foramina ovale and spinosum and the dura is elevated from
the orbital roof, the temporal fossa, and the floor of the
middle fossa (Fig. 3C). The osteotomies are made while
the dura and periorbita are protected with malleable re-
tractors (Fig. 3A). The supraorbital osteotomy is made just
lateral to the supraorbital notch by placing the tip of the
reciprocating saw blade inside the orbit and extending the
cut into the anterior portion of the orbital roof. The infe-
rior cut is made at the zygomatico-maxillary junction by
placing the tip of the saw in the inferior orbital fissure
and cutting posterolaterally. The cuts are then connected
with the saw, starting at the roof and cutting laterally to
meet with the inferior osteotomy.
The posterior osteotomy “C” is normally used when
only a limited exposure of the petrous ICA is needed (Fig.
3A). If the entire petrous ICA needs to be exposed, the
osteotomy “C” is used instead (Fig. 3B). For the osteotomy
“C” the TMJ capsule is not opened and the reciprocating
saw is used to divide the root of the zygoma close to its
temporal origin. In the case of osteotomy “C” the TMJ
capsule is opened on the lateral aspect and the meniscus
and the mandibular condyle are dislocated inferiorly, with
care taken not to injure the external auditory canal which
is located immediately posteriorly. With the temporal dura
elevated, a "V” shaped osteotomy is made with the apex
of the “V” located just medial to the mandibular condyle.
The posterior limb of the “V” should be placed just
and to the level of the lobule of the ear. The relation of the incision to
the facial nerve is shown.
 SEN AND SEKHAR : INTERPEDUNCULAR FOSSA LESIONS
anterior to the external ear canal to avoid entering the middle
ear cavity. The osteotomy can be completed with the help
of a ¼-inch osteotome. The entire orbitozygomatic piece of
bone is removed in one piece. The bone in the posterior
part of the orbit is drilled down to unroof the superior or-
bital fissure (Fig. 3C). However, bone removal does not
have to be carried out further posteriorly to the anterior
© 1992 The American Association of Neurological Surgeons
Figure 2. A, the scalp is reflected with the pericranium to expose the
entire zygomatic arch, the superior and lateral rims of the orbit, and the
temporomandibular joint (TMJ). The frontal branch of the facial nerve
(CN VII) is carried up with the scalp and is adequately protected by
taking the temporal fat pad with it. The periorbita is freed from the roof
307
clinoid process unless the lesion in question extends into
the anterior cavernous sinus. When the lesion is confined
to the interpeduncular region and does not extend into the
cavernous sinus, only a zygomatic osteotomy can be per-
formed, without the orbital rim. The arch is divided anteri-
orly at its junction with the orbital rim and is displaced
inferiorly, attached to the masseter muscle.
and lateral wall of the orbit in continuity with the pericranium. B, the
temporalis muscle is fully mobilized from the temporal fossa and the
upper border of the zygomatic arch. The two important burr holes are
the one at the “key hole” and the one low on the temporal floor above
the external ear canal.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
© 1992 The American Association of Neurological Surgeons
Figure 3. A, The cut A is just lateral to the supraorbital notch and ex-
tends about 2 cm into the roof of the orbit. The cut B is made by placing
the tip of the reciprocating saw into the orbit at the inferior orbital fis-
sure and drawing it across the zygomaticomaxillary junction. The cuts
on the roof and lateral wall are connected from intracranially with the
saw. The cut C can be made simply at the root of the zygoma, flush with
the cranium without violating the temporomandibular joint. B, alterna-
tively, cut C' is made after stripping the TMJ capsule subperiosteally
308
from the glenoid fossa and making a V-shaped osteotomy with the saw
to include the glenoid fossa with the zygomatic arch. During the C'
osteotomy, care must be exercised so that the posterior cut does not
enter the middle ear and the apex of the cut must be clearly short of the
petrous portion of the internal carotid artery. C, the greater sphenoid
wing and the temporal squama are rongeured down close to the foramina
ovale and spinosum, and the lesser wing is drilled away to unroof the
superior orbital fissure, both from above and below.
 SEN AND SEKHAR : INTERPEDUNCULAR FOSSA LESIONS
Exposure of the Petrous ICA
and Removal of the Petrous Apex
The temporal lobe is elevated extradurally to expose
the foramina ovale and spinosum. If the brain is full at
this point, some cerebrospinal fluid may be drained
off by opening the dura and a cistern. If this is not
successful, osmotic agents can be used for brain relax-
ation. The middle meningeal artery is coagulated and
divided and the arcuate eminence of the petrous bone
is identified. The greater superficial petrosal nerve
(GSPN) is identif ied as it emerges from the
anteromedial aspect of the arcuate eminence and is
© 1992 The American Association of Neurological Surgeons
Figure 4. A, the relation of the horizontal petrous ICA to its surround-
ing structures is shown. B, after unroofing the horizontal segment all
the way back to its genu, the artery is dissected free circumferentially
from the bony canal and the bone medial to the vessel is drilled in the
triangular area which constitutes the petrous apex. C, the area of the
309
dissected free, coagulated, and divided to avoid trac-
tion on the geniculate ganglion of the facial nerve
while the temporal lobe is retracted. The horizontal
portion of the petrous ICA is located medial to the
third trigeminal division, along the course of the GSPN
and anteromedial to the arcuate eminence (Fig. 4A). It
may be partially or completely devoid of bony cover-
ing. Using the diamond burr, the artery is unroofed to
its genu posteriorly including some of its upper verti-
cal portion (Fig. 4B). It is important to remember that
the eustachian tube is immediately lateral to the ICA,
separated from it by only a thin layer of bone less than a
bone drilled is shown in relation to the ICA, cochlea, labyrinth, and
the IAC. It is just inferomedial to Meckel’s cave. IAC, internal audi-
tory canal; ICA, internal carotid artery; GSPN, greater superficial pet-
rosal nerve; MMA, middle meningeal artery; V3, third division of the
trigeminal nerve.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

© 1992 The American Association of Neurological Surgeons

Figure 5. A, the sylvian fissure is widely split, starting laterally,
to expose the ICA bifurcation, the tentorial edge, and the third
cranial nerve. B, the veins of the temporal tip are divided and the
temporal tip is elevated out of the middle fossa to provide an
anterior subtemporal perspective. The tentorium is divided start-
ing just posterior to the fourth cranial nerve and coming laterally
through the posterior cavernous sinus, over the trigeminal gan-
glion and lateral to it. The entire premesencephalic and prepon-
tine area is visualized through the opened posterior cavernous
sinus and the petrous apex, above and below the trigeminal root.
II, optic nerve; III, oculomotor nerve; V, trigeminal nerve; ICA,
internal carotid artery; MCA, middle cerebral artery.

310
 SEN AND SEKHAR : INTERPEDUNCULAR FOSSA LESIONS
millimeter in thickness, and that the geniculate ganglion
and cochlea are just posterior to the genu of the petrous
ICA. If a further caudal exposure of the artery is required,
the eustachian tube needs to be transected. Once the en-
tire circumference of the artery has been dissected free, a
small retractor is used to depress it and the bone medial
to the artery is drilled away, exposing the clival dura. Re-
moval of the petrous apex (Fig. 4C) that has thus been
carried out improves the exposure of the premesencephalic
and prepontine area from the intradural subtemporal route,
after the tentorium is divided and the posterior cavernous
sinus is entered.
Transcavernous, Transpetrous Apex
Approach to the Upper Clivus
The frontotemporal dura is opened and the sylvian fis-
sure is split widely by starting over the lateral convexity
and following the middle cerebral artery (MCA) branches
into the fissure (Fig. 5A). The draining veins at the tem-
poral tip are sacrificed and the temporal lobe is further
mobilized by opening the arachnoid on its medial aspect,
following the third cranial nerve toward the brain stem
(Fig. 5B). The anterior temporal branch of the MCA may
have to be divided to facilitate this. In a progressive man-
ner, the temporal tip is retracted laterally to give a wide
access to the middle cranial fossa, the tentorial notch, and
the premesencephalic area.
With a small hook, the edge of the tentorium is everted
to expose the entry point of the fourth cranial nerve and,
using a sickle-shaped knife, the tentorium is opened in a
lateral direction. Bleeding from the venous sinuses in the
tentorial leaves can be controlled with bipolar coagula-
tion to seal the edges, while the posterior cavernous sinus
is packed with Surgicel. The posterior vertical segment
of the cavernous ICA forms the anterior limit of the ac-
cess route to the upper clivus. The tentorial incision is
carried directly over the trigeminal ganglion, and the su-
perior petrosal sinus is cut across and packed with
Surgicel. This incision is taken lateral to the trigeminal
ganglion and root, thus allowing the surgeon to visualize
the premesencephalic and prepontine area above and be-
low the trigeminal nerve (Fig. 5B).
Extent of Exposure
The basilar artery is exposed from its summit to the level
of the anterior inferior cerebellar artery origin. The ven-
tral aspect of the midbrain and upper pons is seen, in-
cluding the origin of the oculomotor and trigeminal nerves.
The clivus is exposed from the level of the posterior cli-
noid processes to the level of the horizontal petrous ICA.
Further caudal exposure requires the use of other ap-
311
proaches such as the preauricular infratemporal approach
with displacement of the entire petrous ICA or the
presigmoid subtemporal approach.
Reconstruction
Prior to the closure, most of the Surgicel that was packed
into the cavernous sinus is removed so that undue com-
pression on the cranial nerves and intracavernous ICA is
avoided. The temporal lobe is closely inspected for con-
tusions; adequate debridement and hemostasis are essen-
tial prior to closure. The eustachian tube site is inspected
for any breach and the air cells of the petrous apex are
waxed. A piece of autologous fat is left over the petrous
ICA to plug the dural hole at the petrous apex, and the
dural opening in the tentorium is covered with a piece of
pericranium or fascia lata with a few circumferential su-
tures from intradurally. The convexity dura is closed and
the orbitozygomatic piece of bone is secured with 2-0
Nurolon sutures or titanium miniplates. The remainder of
the closure is carried out in a standard manner. A subgaleal
drain attached to a closed gravity drainage system is left
for 2 or 3 days.
POSTOPERATIVE CARE
Edema and contusion of the temporal lobe is potentially
the most dangerous postoperative complication. A CT scan
is recommended on the first postoperative day to act as a
baseline examination. If there is significant swelling, fol-
low-up scans are performed and the patient is treated in
an intensive care setting. Fluid balance and hydration are
monitored closely. Adequate anticonvulsant levels are
maintained to avoid any seizures complicating the post-
operative course.
Jaw opening and closing exercises are instituted early
to prevent occlusion problems from the muscles of mas-
tication or TMJ disruption. Meticulous eye care is essen-
tial if corneal sensation is impaired.
POTENTIAL COMPLICATIONS
Temporal lobe edema and contusion should be treated
aggressively, and early surgical debridement should be
performed if clinically indicated. Cerebrospinal fluid
leakage is infrequent unless the eustachian tube or the
sphenoid sinus has been violated. Small leaks are
treated with a period of lumbar spinal drainage. For
larger leaks, localization with a CT scan after intrathe-
cal contrast administration is recommended prior to
surgical intervention.
Palsies of the oculomotor, trochlear, trigeminal, and/
or abducens nerves can occur. These are usually tempo-
rary and result from the surgical manipulation.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
ANEURYSMS OF THE OPHTHALMIC
SEGMENT OF THE INTERNAL
CAROTID ARTERY
DANIEL L. BARROW, M.D.
INTRODUCTION
Intracranial aneurysms are usually named for the branch
of the parent vessel with which the sac has an intimate
anatomic relationship. The ophthalmic segment of the
internal carotid artery (ICA) is the longest subarachnoid
portion of this vessel, and many aneurysms in this region
have no direct relationship to the ophthalmic artery. As a
result, a complicated and confusing nomenclature has
evolved, which allows multiple names for similar aneu-
rysms and the same name for aneurysms with different
anatomy and surgical considerations.
Traditionally, neurosurgeons have classified proxi-
mal ICA aneurysms as supraclinoid or infraclinoid on the
basis of their relationship to the anterior clinoid process.
Infraclinoid aneurysms were assumed to reside within the
cavernous sinus and were regarded as having a more be-
nign natural history. Because of the low incidence of sub-
arachnoid hemorrhage and the risks of directly approach-
ing intracavernous aneurysms, infraclinoid aneurysms
were either left untreated or managed by indirect means
such as carotid ligation.
Day has provided a much clearer and surgically rel-
evant nomenclature for proximal ICA aneurysms through
a clinical and anatomical analysis of 80 patients with oph-
thalmic segment aneurysms. Based upon a better under-
standing of the regional anatomy, we now recognize that
aneurysms formerly regarded as supraclinoid may arise
in relation to either the ophthalmic artery or the superior
hypophyseal artery, and that they present different surgi-
cal challenges.
True intracavernous aneurysms arise below the ante-
rior clinoid process and ophthalmic artery. These aneu-
rysms are less likely to hemorrhage and more commonly
present with cranial neuropathy related to involvement of
the III, IV, V, or VI cranial nerves. However, aneurysms
© 1992 The American Association of Neurological Surgeons
312
arising from the anterior intracavernous ICA may expand
through the dura into the subarachnoid space and
supraclinoid region.
The clinoidal aneurysm, arising on the clinoidal seg-
ment of the ICA between the two carotid dural rings, is
frequently confused with an intracavernous aneurysm. In
reality, the clinoidal segment (or carotid cave) is neither
intradural nor intracavernous. An accurate knowledge of
anatomy and diagnostic imaging studies is required to
determine the precise location of these aneurysms preop-
eratively.
Although carotid cave and intracavernous aneurysms
may be confused with ophthalmic or superior hypophy-
seal aneurysms, the surgical approach is somewhat dif-
ferent. Only aneurysms of the ophthalmic and superior
hypophyseal arteries are addressed in this publication.
ANATOMY
The ophthalmic segment of the ICA extends from the point
where it penetrates the dura beneath the anterior clinoid
process to the origin of the posterior communicating ar-
tery. The entire segment is 1 to 1.5 cm in length and has
several arterial branches. The most proximal and largest
arterial branch is the ophthalmic artery, which originates
from the dorsal or dorsomedial surface of the ICA just
after the carotid artery enters the subarachnoid space (Fig.
1). The ophthalmic artery travels on the inferior aspect of
the optic nerve through the optic canal to the orbit.
Several perforating arteries also arise from the more
distal aspect of the ophthalmic segment. These perfora-
tors vary in size and supply the dura around the cavern-
ous sinus, the pituitary gland and stalk, and the optic
nerves and chiasm. These vessels typically arise from the
medial or inferomedial surface of the ICA, the largest
being the superior hypophyseal artery (Fig. 1).
Beneath the anterior clinoid process lies a short por-
tion of the ICA of variable length which is distal to
 BARROW : ANEURYSMS OF THE OPHTHALMIC SEGMENT OF THE ICA
© 1992 The American Association of Neurological Surgeons
Figure 1. A superolateral view of the ophthalmic segment of the ICA, illustrating pertinent regional anatomy.
the cavernous sinus and proximal to the artery’s entry into
the subarachnoid space. This segment, termed the clinoidal
segment of the ICA, is thus extracavernous and extradu-
ral (Fig. 1). The clinoidal segment is defined by the proxi-
mal and distal fibrous rings that correspond to the exit of
the carotid artery from the cavernous sinus and its entry
into the intradural space, respectively. Once the anterior
clinoid process is removed, the anatomic features of the
dural rings are appreciated. Exposure of the clinoidal seg-
ment of the ICA provides a site where the surgeon can
obtain proximal control of the ICA during surgery for
ophthalmic segment aneurysms.
PATIENT SELECTION
As with other intracranial aneurysms, carotid ophthalmic
aneurysms may present with subarachnoid hemorrhage
or as a result of mass effect. More rarely, a large, partially
thrombosed sac may be the source of distal embolization.
Some lesions are discovered incidentally on computed
313
tomography (CT) or magnetic resonance imaging (MRI)
during the evaluation of unrelated conditions. Because of
the proximity of the ophthalmic artery to the optic nerve,
a common presentation is unilateral optic neuropathy
manifested by unilateral visual loss and an afferent pupil-
lary defect. Larger, medially projecting lesions may com-
promise the optic chiasm, and thus present with a bitem-
poral visual field defect.
Surgery is generally recommended for all symp-
tomatic aneurysms. Patients presenting with subarach-
noid hemorrhage are generally taken to the operating
room as early as their medical condition permits. An-
eurysms presenting with visual loss are usually best
treated surgically because they present risk not only of
progressive visual loss but also of future hemorrhage.
Treatment recommendations for purely incidental an-
eurysms are individualized after consideration of the
patient’s age and health, and the size and configura-
tion of the aneurysm.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

PATIENT PREPARATION plex or giant aneurysms in whom prolonged tempo-

All patients with intracranial aneurysms undergo four-
vessel cerebral angiography to detect multiple aneu-
rysms. Various views are used to best illustrate the neck
of each aneurysm (Figs. 2 and 3). An assessment of
collateral circulation is carried out with an endovascular
balloon test occlusion in selected patients with com-
rary occlusion is anticipated or in whom direct clip-
ping is predicted to be difficult. This is performed by
inflating a nondetachable balloon within the ipsilateral
ICA and repeatedly examining the patient for 30 to 40
minutes to assess for neurologic def icits. If the
patient develops an ischemic neurologic def icit,

Figure 2. Anteroposterior (A) and lateral (B) views of a left carotid arteriogram demonstrate a small ophthalmic artery aneurysm (arrows).
Note that the aneurysm points superiorly and originates immediately distal to the ophthalmic artery (arrowheads).

© 1992 The American Association of Neurological Surgeons

Figure 3. Anteroposterior (A) and lateral (B) views of a left carotid in Figure 2, arises from the medial aspect of the carotid, and extends
arteriogram of a large superior hypophyseal artery aneurysm. Note that medially. An arrow points to a groove on the superior surface of the
the aneurysm arises more distally than the ophthalmic aneurysm shown aneurysm dome created by the optic nerve.

314
 BARROW : ANEURYSMS OF THE OPHTHALMIC SEGMENT OF THE ICA
the balloon is immediately deflated, and it is clear that
the patient has inadequate collateral perfusion. If the pa-
tient tolerates the test occlusion clinically, single photon
emission computed tomography (SPECT) is performed
to measure cerebral blood flow during the period of tem-
porary carotid occlusion. This is compared to a baseline
study. A drop in cerebral blood flow in the hemisphere
ipsilateral to the test occlusion suggests that the patient
has marginal collateral circulation and may not tolerate
extended or permanent occlusion of the ICA.
Knowledge of the status of collateral blood flow to
the cerebral hemisphere ipsilateral to the aneurysm is quite
helpful in determining the options for managing the an-
eurysm. The risk of surgical adjuncts such as temporary
clip application proximal and distal to the aneurysm dur-
ing dissection and clipping can be assessed. Furthermore,
if the aneurysm proves to be unclippable, prior knowl-
edge of potential collateral is important in determining
other treatment options such as sacrifice of the ICA, with
or without extracranial-to-intracranial bypass grafting, or
endovascular balloon occlusion of the aneurysm.
Patients presenting with a subarachnoid hemorrhage
are placed on a prophylactic anticonvulsant preoperatively,
usually phenytoin (Dilantin). Those presenting with an
aneurysmal mass effect and those with an incidental an-
eurysm are not routinely placed on anticonvulsants. On
the morning of the planned surgical procedure, the pa-
tient is given a broad spectrum antibiotic, such as a cepha-
losporin, intravenously.
In the preoperative anesthesia holding area, a Teflon
sheath is placed into one femoral artery to be used for
introduction of an angiography catheter for later intraop-
erative angiography. A lumbar subarachnoid needle for
cerebrospinal fluid drainage and brain relaxation may be
used in patients with a large or giant aneurysm, especially
those undergoing early surgery following a subarachnoid
hemorrhage when the brain is expected to be “tight.” In
this situation, the patient is placed on a split mattress in
the lateral decubitus position and a lumbar puncture is
performed. The patient is then turned supine with the lum-
bar puncture needle extending through the split mattress
and attached to a sterile drainage tube with a stopcock
and a sterile collection bag. Cerebral function is moni-
tored by somatosensory evoked potentials or
electroencephalography.
SURGICAL TECHNIQUE
Patient Positioning
After the induction of general anesthesia, the patient’s head
is turned to the opposite side and secured with a radiolu-
cent, three-point fixation head holder. The head should
315
be positioned so the surgeon has a direct lateral view of
the aneurysm neck. For ophthalmic artery aneurysms ex-
tending superiorly, the head is turned approximately 30
to 45°. For a medially projecting, superior hypophyseal
aneurysm, the head is turned only 10 to 20°, and the sur-
geon works in the space between the ICA and the ipsilat-
eral optic nerve to view the neck of the aneurysm.
Skin Incision and Exposure
Although proximal control of the ICA may be obtained
intracranially at the petrous segment in Glasscock’s tri-
angle or at the clinoidal segment, the neck is routinely
prepared and draped within the field should proximal
control of the cervical ICA be necessary. In the past, we
routinely exposed the cervical carotid artery for ruptured,
large, or complex aneurysms, but with further experience
we have achieved proximal control intracranially in most
cases. However, exposure of the cervical carotid is cer-
tainly an option if the surgeon is not experienced in ob-
taining proximal control at the clinoidal or petrous seg-
ment of the ICA.
A curvilinear scalp incision is made from the mid-
line to the ipsilateral zygomatic arch within the patient’s
hairline, and Raney clips are applied to the skin edges
(Fig. 4). The scalp flap is turned, preserving the posterior
branch of the superficial temporal artery in the event it is
needed for a vascular bypass. The temporalis muscle is
divided beneath the skin incision and elevated from the
skull. The skin flap and temporalis muscle are dissected
further to expose the underlying frontotemporal region
as far forward as the orbitofrontal angle and inferiorly to
the zygomatic arch. Wound exposure is maintained with
fishhooks attached to rubber bands and a self-retaining
retractor.
Craniotomy
Four or five burr holes are placed to form a generous fron-
totemporal (pterional) craniotomy (Fig. 4). The additional
frontal exposure is not necessary for exposure of the aneu-
rysm, but it allows more options in angling the aneurysm
clip applier. The burr holes are then connected with an air
craniotome after separation of the underlying dura with a
Penfield No. 3 dissector. The bone flap is fractured across
the sphenoid ridge and elevated. The anterior temporal and
frontal dura is separated from its overlying bone and the
lesser wing of the sphenoid. The bone overlying the tip of
the temporal lobe is removed with a rongeur and a high-
speed drill with a cutting burr. During the extradural re-
moval of the lesser wing of the sphenoid, orbital roof, and
anterior clinoid (Fig. 5A), drainage of cerebrospinal fluid
from the lumbar subarachnoid drain is helpful in minimiz-
ing retraction of the frontal and temporal lobes.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
© 1992 The American Association of Neurological Surgeons
Removal of the Sphenoid Bone and
Anterior Clinoid Process
The blades of a self-retaining retractor are used to protect
the frontal and temporal lobes extradurally (Fig. 5B). The
posterior roof of the orbit, the lesser wing of the sphenoid
bone covering the superior and medial surfaces of the su-
perior orbital fissure, the base of the clinoid process, and
the bony roof of the optic canal are all removed
extradurally with a highspeed drill (Fig. 5, A and B). Once
the periorbita is exposed back to the superior orbital fis-
sure and the anterior clinoid process, the operating mi-
croscope is brought into the field and a small diamond
burr is used to unroof the optic canal and core out the
interior of the anterior clinoid process. The roof of the
optic canal is removed under constant irrigation to pre-
vent thermal damage to the optic nerve. The anterior cli-
noid process is then connected to the skull base only by
the optic strut beneath the optic nerve. The anterior cli-
noid process may be entirely removed extradurally, or this
may be done after intradural exposure (Fig. 5C). If the
316
Figure 4. Illustration of the scalp incision, craniotomy flap, and du-
ral opening (dashed lines) for an approach to an ophthalmic seg-
ment aneurysm.
surgeon continues extradurally, by slowly coring out the
clinoid process with a diamond burr under irrigation, the
clinoid is disconnected from the skull base and remains
adherent only by its investing dura. After carefully sepa-
rating the dura with a small spatula microdissector, the
entire anterior clinoid process can be removed with small
pituitary rongeurs. Removal of the clinoid exposes the
clinoidal segment of the ICA extradurally. Upon remov-
ing the clinoid, there is frequently some venous bleeding,
which is easily controlled with small pieces of Surgicel.
In cases involving an unruptured aneurysm, the entire
anterior clinoid process is removed extradurally. With
some ruptured aneurysms or with CT evidence of fused
anterior and posterior clinoid processes, however, the cli-
noid is removed down to its tip and the remainder of the
clinoid is removed intradurally after direct visualization
of the aneurysm.
Intradural Dissection
The dura overlying the sylvian fissure is opened in a
 BARROW : ANEURYSMS OF THE OPHTHALMIC SEGMENT OF THE ICA

Figure 5. A, superior view of a portion of the skull base. The shaded
area outlined by dashed lines represents the region of extradural
bone removal. B, with the frontal and temporal lobes protected
extradurally by retractors, the anterior clinoid process and optic
roof are removed with a high-speed drill under constant irrigation.
The entire anterior clinoid process may be removed extradurally.
C, illustration of the intradural removal of the anterior clinoid
process. The dura over the clinoid is opened with a No. 11 knife
blade and elevated with a microcurette. The clinoid process is then
removed with a high-speed drill under constant irrigation.

317
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
curvilinear fashion and tacked rostrally to the temporalis
muscle with sutures. The dura is opened posteriorly over
the sylvian fissure and tacked back with sutures to ex-
pose the sylvian fissure and the floor of the anterior middle
fossa. The proximal sylvian fissure is opened sharply with
straight microscissors. The blades of a self-retaining re-
tractor are used to gently elevate the frontal lobe and to
depress the temporal lobe to expose the ipsilateral ICA
and optic nerve. With large or giant aneurysms, the dome
of the sac may be densely adherent to the undersurface of
the frontal lobe, and the surgeon must be careful not to
avulse the dome of the aneurysm when elevating the fron-
tal lobe.
If the anterior clinoid process has not been completely
removed extradurally, the dura overlying the tip of the
anterior clinoid is coagulated with a bipolar coagulator
and incised with a No. 11 knife blade (Fig. 5C). Using a
microcurette, the dura is gently separated from the tip of
the anterior clinoid, which is then drilled to a thin shelf of
bone with a small diamond burr under constant irriga-
tion. Complete removal of the anterior clinoid process
and prior removal of the optic canal roof and lateral wall
exposes the dural ring that fixes the ICA at the site (Fig.
6A). Sectioning this ring exposes the clinoidal segment
of the ICA, a short portion of the carotid artery that lies
below the dural ring but outside the cavernous sinus proper
(Fig. 6B).
Depending upon the size of the aneurysm and the
direction in which it points, the ipsilateral optic nerve may
or may not be displaced by the aneurysm. Most ophthalmic
aneurysms extend superiorly and elevate the inferior and
lateral aspects of the ipsilateral optic nerve. Superior hy-
pophyseal artery aneurysms more commonly extend me-
dially beneath the optic chiasm. In both instances, it is
useful to divide the falciform ligament with a dural knife
or microscissors so that one may mobilize the optic nerve
without compressing it further against the falciform liga-
ment (Fig. 6B). Mobilizing the optic nerve allows better
visualization of the ophthalmic artery.
Once the dural ring around the carotid artery is di-
vided, the clinoidal segment is visualized; this allows for
the placement of a temporary clip proximal to the aneu-
rysm, if necessary. If the clinoidal segment is too short to
accept a temporary clip, or if it is involved with the aneu-
rysm, proximal control must be obtained by exposing the
petrous segment of the ICA at Glasscock’s triangle or by
exposing the cervical ICA in the neck. In most instances,
however, proximal control at the clinoidal segment can
be achieved.
Clip Selection and Placement
Dissection of the neck of the aneurysm proceeds to iden-
tification of the proximal and distal aspects of the neck
318
for proper clip selection. In planning clip placement, one
must ensure that surrounding normal vessels such as the
ophthalmic, posterior communicating, and superior hy-
pophyseal arteries are not inadvertently included in the
clip. It is not always possible to spare the small superior
hypophyseal artery or arteries, but every attempt should
be made to do so. For an ophthalmic artery aneurysm that
extends superiorly (Fig. 7A), a straight or side-angled clip
placed parallel to the long axis of the ICA is usually ad-
equate (Fig. 7B). Occasionally, a fenestrated clip may be
used that includes the optic nerve within the fenestration.
For medially projecting superior hypophyseal aneurysms,
the ICA is usually lying dorsal to the aneurysm with the
aneurysm on the ventral surface (Fig. 7C). Here, a fenes-
trated clip is used to encircle and reconstruct the carotid
lumen with the blades running parallel to the ICA (Fig.
7D). The dome of the aneurysm is then punctured to en-
sure that it is no longer filling.
Intraoperative Angiography
Intraoperative angiography is performed to verify that
the aneurysm is completely obliterated and that perfu-
sion through the surrounding normal vasculature is main-
tained (Fig. 8). Any abnormalities identified on the in-
traoperative angiogram may be corrected immediately,
thus decreasing the risk of intraoperative complications
such as incomplete obliteration of the aneurysm or oc-
clusion or stenosis of the parent artery or surrounding
nutrient arteries.
Wound Closure
Once appropriate clip placement is verified, retractors
are removed and the dura is closed in a watertight fash-
ion using running 3-0 Vicryl sutures. The bone flap is
replaced using silk sutures. The temporalis muscle is
reapproximated using interrupted 2-0 Vicryl sutures,
and the galea is closed with running 3-0 Vicryl sutures.
The skin is closed with staples. Drains are not routinely
used postoperatively, and the lumbar subarachnoid
needle or catheter, if used, is removed prior to awaken-
ing the patient.
POSTOPERATIVE CARE
The patient is observed in the postanesthesia care unit
until fully recovered from the effects of general anesthe-
sia and then observed in an intensive care unit until stable.
Patients who have had a subarachnoid hemorrhage are
maintained in a hypervolemic, hypertensive, and
hemodiluted state to decrease the risk of delayed ischemia
from cerebral vasospasm.
COMPLICATIONS
The surgical management of intracranial aneurysms
 BARROW : ANEURYSMS OF THE OPHTHALMIC SEGMENT OF THE ICA

© 1992 The American Association of Neurological Surgeons

Figure 6. A, intradural exposure after removal of the anterior clinoid origin and the neck of the aneurysm. Division of the falciform ligament
process reveals the dural ring over the carotid artery and the falciform frees the optic nerve which has been kinked against this dural structure
ligament over the optic nerve. B, once the dural ring is divided, the by the underlying aneurysm.
clinoidal segment of the carotid is exposed as is the ophthalmic artery

319
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

© 1992 The American Association of Neurological Surgeons

Figure 7. A, B, the usual clip application for an ophthalmic artery superior hypophyseal aneurysm is illustrated. Because the aneu-
aneurysm is illustrated. A straight or 45° side-angled clip can usually rysm is on the medial surface of the carotid artery, a fenestrated
be used with the blades placed parallel to the carotid artery to avoid clip is used to reconstruct the lumen of the parent artery with the
kinking or distorting the parent artery. C, D, clip application for a clip blades parallel to the carotid.

320
 BARROW : ANEURYSMS OF THE OPHTHALMIC SEGMENT OF THE ICA
© 1992 The American Association of Neurological Surgeons
Figure 8. An intraoperative left carotid arteriogram, lateral view,
demonstrates complete obliteration of an ophthalmic artery aneu-
rysm with a straight clip (arrow) and normal filling of the ophthalmic
artery (arrowheads).
is associated with a large number of potential complica-
tions, including the sequelae of subarachnoid hemorrhage
and associated cerebral vasospasm. Discussion of many
of these complications is beyond the scope of this text.
However, some of the more common technical difficul-
ties encountered in the surgical management of ophthalmic
segment aneurysms deserve mention.
Intraoperative Aneurysm Rupture
The untimely intraoperative rupture of an aneurysm is a
potentially devastating complication, particularly if the
neck of the aneurysm has not been dissected and proxi-
mal and distal control of the parent artery obtained. One
of the distinct advantages of performing an extradural
removal of the medial sphenoid wing and anterior clinoid
process is that the surgeon obtains proximal control of
the parent artery at an early stage of the operation. As
mentioned earlier, for large or complex aneurysms, par-
ticularly those that have recently bled, it is acceptable to
expose the cervical ICA rather than completely removing
the anterior clinoid process extradurally.
Once the dura is opened, one must elevate the frontal
lobe cautiously because the dome of the aneurysm may
be adherent to the undersurface of the frontal lobe. Ex-
cessive retraction of the frontal lobe may result in avul-
sion of the dome from the aneurysm, precipitating an
untimely hemorrhage.
If the aneurysm ruptures after the parent artery and
neck have been exposed, management is much more
321
straightforward. Usually, the bleeding can be controlled with
careful suctioning, and temporary clips may be placed on
the clinoidal segment of the ICA and on the ICA distal to
the neck of the aneurysm. It is our practice to avoid hy-
potension in the event of an intraoperative rupture. Induced
hypertension, mannitol, and barbiturates (to achieve burst
suppression of the electroencephalogram) are used to pro-
tect the brain during the period of temporary focal ischemia.
Optic Nerve Injury
Several steps in the surgical management of ophthalmic
segment aneurysms have the potential to traumatize the
optic nerve. Importantly, a significant number of patients
presenting with ophthalmic segment aneurysms already
have compromised visual function due to compressive
and/or ischemic effects of the aneurysm dome upon the
undersurface of the optic nerve. Most often, this is due to
kinking of the elevated optic nerve against the falciform
ligament. In this situation, even minor trauma or manipu-
lation of the optic nerve may result in irreversible injury.
During the extradural removal of the optic roof, an-
terior clinoid process, and optic strut, the optic nerve may
be injured by direct mechanical trauma from the drill or
may be damaged by thermal injury. The use of the operat-
ing microscope and constant irrigation by an assistant will
minimize these risks.
Once the dura has been opened and the aneurysm
exposed, sectioning of the carotid ring and the falciform
ligament overlying the optic nerve will untether the optic
nerve and allow the surgeon to carefully manipulate this
structure with less risk.
In addition to these mechanical causes, visual wors-
ening may be the result of vascular injury to the optic nerve
and/or chiasm. One must be extremely careful in dissect-
ing the neck or dome of an ophthalmic segment aneurysm
on the undersurface of the optic nerve as its blood supply is
derived from a ventral direction. Avulsion of small perfo-
rating vessels may result in ischemic injury. Furthermore,
compromise or occlusion of the ophthalmic artery may re-
sult in ischemic injury and every attempt should be made
to spare this artery in clipping these aneurysms. In placing
a clip across the neck of an ophthalmic segment aneurysm,
one must be careful to avoid kinking or distorting the optic
nerve with the clip itself.
Occlusion of the Parent Artery
In clipping any aneurysm, one should avoid occlud-
ing, kinking, or otherwise compromising blood flow
through the parent artery. For aneurysms of the oph-
thalmic segment, careful clip selection can usually pre-
vent this complication. True ophthalmic artery aneu-
rysms are best occluded by placing a clip parallel to
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

the parent ICA rather than perpendicular, particularly if
there is a wide neck to the aneurysm (Fig. 7B). Fenes-
trated clips are best suited for superior hypophyseal an-
eurysms, as the fenestration allows reconstitution of the
lumen of the ICA (Fig. 7D).
We have found intraoperative angiography to be ex-
tremely useful in documenting the patency of the parent
artery after clip ligation of an intracranial aneurysm and
allowing for immediate replacement of the clip(s) if there
is any suggestion of compromised flow.

322
 LUMBAR-PERITONEAL SHUNTING
SETTU S. RENGACHARY, M.D.
INTRODUCTION
Two major classes of cerebrospinal fluid (CSF) diversion-
ary devices are used in contemporary neurosurgical prac-
tice, the ventriculoperitoneal shunt and the lumbar-peri-
toneal shunt. This chapter deals with lumbar-peritoneal
shunting.
Diversion of lumbar spinal fluid into the peritoneal
space was attempted as early as 1898 by Ferguson. Nu-
merous technical advances were necessary to devise a
shunt system that would function in a reliable manner with
minimal morbidity. Early attempts at diversion were he-
roic measures associated with very high mortality and
disastrous complications. One of the early procedures was
to drill a hole through the vertebral body and place a
metallic stent through the body to serve as a conduit, al-
lowing flow of the lumbar spinal fluid directly through
the conduit into the peritoneal space. Cushing attempted
twelve of these procedures with two deaths and numer-
ous complications. He wrote, “among the first of my pa-
tients—as will probably have been true of most young
men entering this particular field—were infants with what
is known as essential hydrocephalus, for which a greater
number of treatments have as yet been advocated (I have
been guilty of proposing one or two myself) than suc-
cesses recorded—if indeed there are any clear-cut suc-
cesses recorded.”
The next phase was the introduction of a polyethyl-
ene catheter as a conduit. Using such a catheter, Matson
standardized the technique of lumbar-ureteral shunting,
which required a nephrectomy. The major disadvantages
of the procedure were unregulated overdrainage of cere-
brospinal fluid, the need to resect one kidney, electrolyte
imbalance, diarrhea, bowel intusussception, and crack-
ing and kinking of the polyethylene tubes. Most of these
complications were overcome with the invention and in-
troduction of silicone elastomers in shunt manufacture.
The introduction of one-way valves that opened at prede-
termined pressures also signaled a major breakthrough.
I will discuss the use of a lumbar-peritoneal shunt
© 1992 The American Association of Neurological Surgeons
323
system utilizing a horizontal-vertical (HV) valve assembly.
The technical details of the shunt assembly are discussed
later.
PATIENT SELECTION
The general indication for a lumbar-peritoneal shunting
procedure is the presence of obstruction to the cerebrospi-
nal fluid absorptive mechanism with resultant increased
intracranial pressure, ventriculomegaly, or both. It is im-
perative for this procedure that a free communication ex-
ists between the ventricular system and the spinal sub-
arachnoid pathways. If an obstruction within the
ventricular system exists (“obstructive hydrocephalus”),
lumbar-peritoneal shunting is contraindicated because it
may result in disastrous caudal herniation of brain stem
structures.
Lumbar-peritoneal shunting may be used in the fol-
lowing classes of disorders that affect the cerebrospinal
fluid dynamics.
Pseudotumor Cerebri
Pseudotumor cerebri in the majority of instances is a self-
limited disease which responds to the use of steroids, aceta-
zolamide, repeated lumbar punctures, and elimination of
any obvious risk factors. However, in some cases the syn-
drome remains intractable to therapy. The two major symp-
toms that dictate surgical therapy are progressive visual
failure from papilledema due to increased intracranial pres-
sure and intractable generalized headaches. In this small
subset of patients who do not respond to conventional medi-
cal therapy, surgical options should be considered. There
are two options available. If the visual failure alone is the
predominant symptom without headaches, then optic
nerve decompression may be considered. The disadvan-
tages of the optic nerve decompression are: 1) it has to be
performed bilaterally in most instances; 2) it does not ad-
dress the underlying pathophysiology, namely increased
intracranial pressure, and it only symptomatically im-
proves one component of the ill effects of the elevated
intracranial pressure, namely visual failure; 3) there is
some risk of optic nerve damage during the decompression
procedure; and 4) if the patient has intractable headaches
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
in addition to visual failure, the decompression proce-
dure will still leave the patient symptomatic. The decom-
pression procedure should thus be reserved exclusively
for a very small subset of patients with pseudotumor
cerebri who have deteriorating visual function as the sole
clinical manifestation without headache, and who hesi-
tate to have an implanted foreign body. I prefer to use
lumbar-peritoneal shunting as a primary procedure even
in this subset of patients; in my experience and that of
others, visual failure never progresses in the presence of
a functioning shunt. It generally takes about a month for
the papilledema to subside.
Patients with intractable headaches and visual fail-
ure are excellent candidates for lumbar-peritoneal shunt-
ing. Although ventriculoperitoneal shunting is likely to
yield comparable results, the small size of the ventricles
may render ventricular access technically difficult. I re-
sort to ventriculoperitoneal shunting only in individuals
in whom a lumbar puncture is difficult because of mor-
bid obesity; in such instances I counsel the patient about
the contingency of a ventriculoperitoneal shunt, should
lumbar access fail. It is imperative that in all patients di-
agnosed as having pseudotumor cerebri, one or more
samples of lumbar spinal fluid be checked carefully for
chemistry, cell count, cytology, and culture to make sure
that the patient does not harbor chronic meningitis or
meningeal carcinomatosis.
Communicating Hydrocephalus
Communicating hydrocephalus results from failure of
adequate absorption of cerebrospinal fluid because of oc-
clusion of the arachnoid villi from previous acute or
chronic meningitis, or subarachnoid hemorrhage. The lat-
ter may be from any cause, such as head trauma, rupture
of an aneurysm or arteriovenous malformation, or an op-
erative procedure. Communicating hydrocephalus is a
primary indication for lumbar-peritoneal shunting.
However, several precautions have to be followed prior
to subjecting the patient to the shunting procedure. First,
one has to make sure, using imaging studies of the brain,
that there is no loculation within the ventricular system
from ventriculitis and that there is no obstruction at certain
strategic sites such as the foramen of Monro or the aque-
duct of Sylvius causing loculated hydrocephalus involving
either one or both lateral ventricles or their temporal or
occipital horns. It is also imperative to confirm that any
active infectious process has resolved; repeated negative
cultures and normalization of cell count should be docu-
mented. If the cerebrospinal fluid contains debris, a large
324
number of cells, or a high concentration of protein, lumbar-
peritoneal shunting should be delayed. In such instances,
it may be beneficial to install temporary ventricular or lum-
bar drainage for several days to allow clearing of the fluid;
occasionally this maneuver alone may eliminate the need
for a permanently implanted shunt.
Low or Normal Pressure Hydrocephalus
Low or normal pressure hydrocephalus is another good
indication for lumbar-peritoneal shunting, but stringent
criteria should be used in patient selection. There is a lot
of controversy about selection criteria. I follow the gen-
eral consensus in that the patient should have at least two
of the three components of the clinical triad of this syn-
drome, namely, dementia, gait disturbance, and urinary
incontinence. Magnetic resonance imaging (MRI) or com-
puted tomography (CT) should show ventriculomegaly
in the absence of significant cortical atrophy. An optional
diagnostic test is the radionuclide cisternogram to assess
the CSF dynamics. Although the predictive value of this
test has been questioned, I use this test and find it to be of
substantial value.
For the treatment of communicating, low pressure,
or normal pressure hydrocephalus, there are a few advan-
tages of lumbar-peritoneal shunting over ventriculoperi-
toneal shunting. Because the cortical mantle is not pen-
etrated, there is no risk of development of a seizure focus.
The risk of bleeding related to penetration of the cortex,
white matter, and deeper structures, although minimal, is
eliminated. Postoperative diagnostic imaging of the head
either by MRI or CT is not marred by the presence of a
foreign body within the cranial cavity.
Occlusion of Major Intracranial Venous Sinuses
Occlusion of major intracranial venous sinuses such as
the distal part of the superior sagittal sinus, the dominant
transverse sinus, or the jugular bulb may result in increased
venous pressure with a consequent increase in cerebrospi-
nal fluid pressure and ventriculomegaly. With the advent
of magnetic resonance angiography, this syndrome is be-
ing recognized more frequently. Patients using contracep-
tive pills are particularly prone to this disorder. Patients
with a hypercoagulative state from the presence of high
levels of C protein are also susceptible to this syndrome.
Although direct venous reconstruction is a possibility, the
procedure is often formidable and it is difficult to main-
tain the patency of a venous diversionary system. Lum-
bar-peritoneal shunting in such instances offers an attrac-
tive alternative.
 RENGACHARY : LUMBAR-PERITONEAL SHUNTING

CONTRAINDICATIONS TO LUMBAR Patients who have congenital anomalies in the lum-

PERITONEAL SHUNTING
The shunting procedure requires the introduction of a large
14-gauge Tuohy needle into the lumbar subarachnoid space.
This may not be feasible in some clinical situations. Pa-
tients with advanced lumbar degenerative arthropathy with
marked spinal stenosis have a very narrow spinal canal with
crowding of cauda equina roots, and a spinal tap or the
satisfactory advancement of the lumbar catheter may not
be technically possible. Patients with an advanced degree
of congenital kyphoscoliosis with rotational deformities
may also present a similar problem. Achondroplastic dwarfs
tend to have an extreme degree of narrowing of the spinal
canal, and in such individuals a ventriculoperitoneal shunt
may be the better alternative. Patients who have undergone
multiple previous lumbar laminectomies for disc disease
with documented evidence of adhesive arachnoiditis or with
radiologic evidence of an extensive posterior midline fu-
sion of the lumbar spine are not suitable candidates for
lumbar-peritoneal shunting. Very small infants will not ac-
commodate the 14-gauge needle that is required for the
introduction of the catheter.
bosacral region, such as meningomyelocele, tethered cord
syndrome, lipomeningocele, diastematomyelia, etc., are bet-
ter treated by ventriculoperitoneal shunting. Patients with
a Chiari malformation or aqueductal stenosis with hydro-
cephalus are also best treated by ventriculoperitoneal shunt-
ing. Patients with infection or skin breakdown in the lumbar
area, with chronic infection from any cause, or with verte-
bral osteomyelitis or discitis are not suitable candidates for
lumbar-peritoneal shunting.
DESCRIPTION OF THE SHUNT SYSTEM
The main components of the lumbar-peritoneal shunt sys-
tem are a lumbar catheter, a peritoneal catheter, a valve
unit, a “stepdown” connector between the lumbar cath-
eter and the valve unit, a straight connector between the
valve unit and the peritoneal catheter, and a suture clamp.
The Valve Unit
The valve unit (Fig. 1, inset) provides controlled drain-
age of the cerebrospinal fluid from the lumbar sub-
arachnoid space into the peritoneal cavity while main-

© 1992 The American Association of Neurological Surgeons

Figure 1. The lumbar-peritoneal shunt assembly in place. The valve unit is shown enlarged at the top (inset).

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 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
taining the intracranial pressure in the physiologic range.
The valve has a unique bimodal design to compensate for
varying hydrostatic pressures in the recumbent and up-
right positions. On the inlet side is the lower pressure
mechanism consisting of a spring actuated ball-in-cone
valve. The tension in the spring determines the valve open-
ing pressure. On the outlet side is the higher pressure,
gravity actuated mechanism consisting generally of three
freely rolling steel balls. The combined weight of the balls
determines the opening pressure.
In the horizontal position, only the lower pressure,
spring actuated, ball-in-cone valve is functional. The spi-
nal fluid, after it escapes out of the valve, simply flows by
the steel spheres which are free to move and do not block
the entry site into the high pressure mechanism. As the
patient assumes an upright position, however, the steel
balls gravitate down and block the entry site into the
mechanism. For the fluid to flow now, it has to lift up the
steel balls. In the upright position, both the spring actu-
ated and gravity actuated mechanisms are functional; thus
in the upright position, spinal fluid flow remains constant
despite the higher hydrostatic pressure.
The low and high pressure valves are housed in a
clear silicone elastomer casing. The inlet tubing into the
valve is clear and the outlet tubing is opaque. A color-
coded band at the lower waist of the silicone casing indi-
cates the pressure ranges of the horizontal and vertical
valves (Table 1).
An appropriate range of valve pressures should be
chosen based on the ventricular size and the height of the
patient (Table 1). The range of opening pressure for the
horizontal valve is chosen based on the ventricular size.
A lower opening pressure range (50-80 mm H2O) should
be chosen for patients with extreme ventricular enlarge-
ment and a standard opening pressure range (85-125 mm
H2O) for patients with moderate ventricular enlargement.
The opening pressure of the vertical valve is chosen ac-
cording to the patient’s height. Tall adults with moderate
ventricular enlargement will require valves with a higher
opening pressure range (325-445 mm H 2O). Average
adults or tall children with moderate ventricular enlarge-
326
ment will require a standard opening pressure range (265-
365 mm H2O).
Lumbar Catheter
The lumbar catheter is a narrow radiopaque silicone cath-
eter with multiple small perforations at its distal end. The
distal end is inserted into the lumbar subarachnoid space
through a Tuohy needle and the proximal end is connected
to the inlet side of the valve unit.
Peritoneal Catheter
The peritoneal catheter is of larger diameter than the lum-
bar catheter. It is also made of radiopaque silicone elas-
tomer. Its proximal end is connected to the outlet side of
the valve unit using a straight connector. The distal end
has several staggered rows of slits which provide mul-
tiple routes of drainage but do not function as valves.
“Stepdown” Connector
The stainless steel stepdown connector is used to attach
the lumbar catheter to the inlet side of the valve unit. The
smaller side connects to the catheter and the larger side
connects to the valve unit.
Straight Connector
The stainless steel straight connector is used to attach the
peritoneal catheter to the outlet side of the valve unit.
Suture Clamp
A butterfly suture clamp made of silicone is used to an-
chor the lumbar catheter to the lumbodorsal fascia near
the entry site of the catheter to prevent migration of the
catheter during movements of the back (Fig. 3E).
PREOPERATIVE PREPARATION
A diagnostic workup should include brain imaging
with an MRI or CT study to confirm the clinical di-
agnosis and to rule out obstruction within the ven-
tricular pathways. A plain roentgenogram of the lum-
bar spine in the anteroposterior projection will rule out
any local abnormalities that will contraindicate a lum-
 RENGACHARY : LUMBAR-PERITONEAL SHUNTING

bar puncture. In a patient who has undergone multiple OPERATIVE TECHNIQUE

previous abdominal procedures with significant abdomi-
nal adhesions, the help of a general surgeon may be sought
to assist in the laparotomy component of the procedure.
If the patient has had a recent diagnostic or therapeutic
lumbar puncture, the operation should be delayed for at
least three to five days so that during surgery the lumbar
catheter is more likely to enter the subarachnoid space
rather than the subdural space. If the clinical situation
permits, it is best to readmit the patient a week to 10 days
after the tap for the definitive surgical procedure.
Anesthetic Considerations and
Patient Positioning
I always use general anesthesia for this procedure. Good
muscle relaxation will help during the laparotomy.
The operation is always done in the lateral decubi-
tus position (Fig. 2A). It can be either the right or the
left lateral decubitus position depending on the
surgeon’s preference. I generally use the right lateral
decubitus position with the patient’s left side up. The

© 1992 The American Association of Neurological Surgeons

Figure 2. A, the lateral decubitus position used for lumbar-perito-

neal shunting. B, lumbar puncture with a Tuohy needle. C, rota-
tion of the needle by 90° to direct the bevel of the needle cephalad.

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 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
patient is rolled over a soft egg crate mattress in the lat-
eral decubitus position with the hip and knee flexed on
the down side and extended on the up side. All the pres-
sure points are additionally padded, especially those un-
der the greater trochanter and the right arm. A rolled sheet
is placed under the axilla to prevent compression of the
axillary artery and vein. The free left arm is held over in a
suspended arm rest as is generally used in thoracotomy
procedures. The patient may lay over an inflatable bean
bag mattress which helps to retain the lateral decubitus
position throughout the procedure. The head should be
supported on sheets or pillows to maintain its neutral po-
sition, in line with the spine. The chest and the knee are
flexed to maximize the interspinous space but there should
be sufficient room in front for laparotomy access. The
back, flank, and abdomen are shaved, prepared, and
draped. In patients in whom the CSF pressure is low, the
operating table may be tilted into a head up position to
promote good flow of CSF.
Checking the Valve for Patency and One-way Flow
Before implantation of the valve unit, the valve patency
and one-way flow mechanism should be checked, as fol-
lows.
Patency
The valve unit is temporarily connected to the lumbar and
peritoneal catheters. The inlet (lumbar) tubing is sub-
merged in a sterile saline solution. A syringe is attached
to the distal (peritoneal) end of the tubing through a blunt
18-gauge needle. Saline is slowly aspirated through the
system, purging out all of the air. The syringe is then dis-
connected, and the distal end is allowed to hang freely.
Patency is proven if saline drips from the distal end.
One-way Flow Mechanism
After the valve unit and the catheters have been filled
with saline in the manner described above, the valve is
held vertically (with the arrow pointing down) and the
distal end of the peritoneal catheter is elevated above the
valve unit. Absence of fluid return through the proximal
tubing for 80 seconds confirms an intact one-way flow
mechanism.
Introduction of the Lumbar Catheter
I generally do not make a lumbar incision before the in-
sertion of the needle. In the unlikely event that the lum-
bar puncture is not successful, then one may have to go to
a space higher or lower. Ordinarily, the lumbar puncture
is performed at the L3-L4 or L4-L5 space. Standard ana-
tomical landmarks are used (Fig. 2B). The top of the iliac
328
crest generally corresponds to the L4-L5 interspinous
space. One should be cognizant of the fact that in the lat-
eral decubitus position the spinous processes do not lie
exactly in the midline between the paraspinal muscle
masses. They tend to be at a slightly upper (lateral) level.
In difficult cases it may be necessary to use fluoroscopy
briefly to identify the appropriate interspace and the mid-
line with a marker.
A 14-gauge, thin-wall Tuohy needle is then passed
parallel to the plane of the floor and directed 10 to 15°
cephalad. The needle should be advanced slowly and cau-
tiously because the goal is to enter the subarachnoid space
in a single pass. The bevel of the needle is directed hori-
zontally until the dura is penetrated. In many instances, a
pop may be felt as the dura is penetrated. The needle is
advanced in small increments and the stylet is removed
periodically to ascertain whether the subarachnoid space
has been entered. This careful maneuver prevents going
past the ventral dura and thus hitting the ventral dural
venous plexus. Once the arachnoid has been pierced and
the stylet has been removed, a gush of spinal fluid es-
capes because of the size of the needle.
In some instances the fluid flows well initially but
then stops abruptly because of the tamponading of the tip
of the needle by a nerve root. In such instances, gently
turning the needle by 30 to 50° will change the direction
of the distal aperture of the needle and thus will facilitate
better flow. If one is in doubt whether the subarachnoid
space has been penetrated properly, a small quantity of a
water-soluble contrast agent may be injected through the
needle and an anteroposterior roentgenogram taken with
a lateral beam which will show the contrast agent in the
subarachnoid space.
After the placement of the needle into the lumbar
subarachnoid space, the bevel of the needle is turned ei-
ther cephalad or caudad to direct the catheter (Fig. 2C).
The stylet is removed and the thin radiopaque lumbar cath-
eter, which has multiple perforations at the end, is inserted
through the needle into the lumbar subarachnoid space
(Fig. 3A). The insertion is generally easy although the
catheter typically hesitates a bit as it maneuvers the curve
at the tip of the needle before passing on with relative
ease. In exceptional situations, a guidewire can be used to
stiffen the catheter and direct it into the lumbar subarach-
noid space. In no circumstance should the catheter be with-
drawn through the needle because the sharp end of the
needle may shear the catheter. If the catheter must be with-
drawn for any reason then the needle should be withdrawn
along with it. It is not necessary to insert more than 8 or 10
cm of the catheter tube into the lumbar subarachnoid space.
In fact, a catheter longer than this may tend to irritate the
 RENGACHARY : LUMBAR-PERITONEAL SHUNTING

© 1992 The American Association of Neurological Surgeons

Figure 3. A, insertion of the lumbar catheter through the Tuohy needle. blade. C, D, the lumbar catheter is brought to a flank incision with a
B, a skin incision is made on either side of the Tuohy needle. The pres- subcutaneous tunneler. E, the lumbar catheter is anchored to the
ence of the needle prevents the catheter from being nicked by the knife lumbodorsal fascia with a butterfly suture clamp (enlarged view).

329
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
cauda equina roots because of its entanglement within
the roots. If the CSF is bloody, the lumbar catheter must
not be inserted until the fluid is completely clear. During
the insertion of the catheter it is best to leave its other end
open to monitor free flow which will ensure that it is not
being kinked.
When the catheter has been passed to the desired
length, a lumbar skin incision is made for 1 cm on either
side of the needle (Fig. 3B). I prefer to make the incision
before the needle is withdrawn because incising the skin
after needle withdrawal carries the risk of nicking into
the lumbar catheter. The needle is then withdrawn over
the catheter; the surgeon should hold the catheter at the
skin puncture so it does not get pulled out. A small hemo-
stat protected with rubber sleeves is used to clamp the tip
of the catheter. Near the entry site of the lumbar catheter
into the spine, the catheter is anchored to the lumbodorsal
fascia with a butterfly suture clamp (Fig. 3E).
Flank Dissection
A horizontal 5-cm flank incision is made midway between
the costal margin and the top of the iliac crest. The inci-
sion is deepened through the subcutaneous fatty layer until
the fascia covering the external oblique muscle is exposed.
Self-retaining retractors are inserted. Using a tissue tun-
neler, the lumbar catheter is brought into the flank wound
from the lumbar area (Fig. 3C and D). The lumbar cath-
eter is again clamped.
Minilaparotomy
A horizontal incision is made about 2-4 cm above the
umbilical level, extending from the midline to the lateral
border of the rectus abdominis muscle (Fig. 4A). The skin,
subcutaneous tissue, and anterior rectus sheath are incised
horizontally, and self-retaining retractors are inserted (Fig.
4B). Subcutaneous bleeders are coagulated. The rectus
abdominis muscle is split using a hemostat or any other
appropriate blunt instrument (Fig. 4C). The posterior rec-
tus sheath is exposed and it is grasped with hemostats
and lifted up. Using a No. 15 blade knife or blunt-tipped
scissors, it is incised. I make sure that the peritoneum is
also incised. Fatty tissue extrudes out of the opening (Fig.
4D). Make sure that this represents omentum and not
preperitoneal fat. If the peritoneal cavity has indeed been
entered, one should be able to insert almost three-fourths
the length of a blunt Freer elevator (about 5 inches) easily
and without any resistance. The distal end of the perito-
neal catheter (which has a square tip) is inserted into the
peritoneal cavity using a bayonet forceps, and the cath-
eter is directed toward the subhepatic space (Fig. 4E).
The peritoneal catheter has two or three slits near the
330
end. These slits are designed to open in case the tip of the
catheter gets plugged. These slits do not function as slit
valves but merely as additional ports. The catheter then is
tunneled through the subcutaneous space and brought into
the flank wound (Fig. 5A).
Final Shunt Assembly
The valve unit should be filled with saline to remove the
air pocket from the valve, through a blunt needle attached
to the inlet side (clear) tubing. The lumbar tubing is
trimmed to the desired length and connected to the inlet
side of the valve unit with the stepdown connector. The
connection is secured with 3-0 silk ligatures. The clamp
on the lumbar catheter is released. If the valve is now
held in a horizontal position, the CSF will flow out of the
outlet side of the valve. The lumbar catheter is then
reclamped. The free end of the peritoneal catheter is
brought into the flank wound and excess length is cut off
(Fig. 5B). The peritoneal catheter is connected to the out-
let side (opaque tubing) of the valve unit using a straight
connector (Fig. 5C). For optimal functioning of the valve
unit, it should be oriented properly. A properly oriented
valve unit will have its long axis parallel to the long axis
of the trunk of the patient (Fig. 5D). The arrow on the
inlet valve should point toward the patient’s feet. The valve
is secured to the fascia overlying the external oblique
muscle by passing fine Nurolon sutures through the four
holes in the valve housing (Fig. 5D). The shunt assembly
is now complete. Lumbar, abdominal, and flank wounds
are closed in layers using absorbable sutures. Subcuticu-
lar skin sutures are used.
POSTOPERATIVE MANAGEMENT
The patient is maintained on intravenous fluids for about
24 hours until active bowel sounds are heard and bowel
activity is established. The patient is then started on clear
liquids, progressing to a regular diet. Adequate narcotic
analgesics are administered. To ensure that the patient gets
acclimatized to the shunt, the head of the bed is gradually
elevated in increments over a period of 24 hours and the
patient is generally allowed to sit on the side of the bed by
48 hours. The patient can then get out of bed in a chair for
a few hours at a time and is allowed to ambulate on the
third or fourth day. This cautious management facilitates
the patient getting used to the new CSF dynamics. Usu-
ally the patient is ready to be discharged on the fifth post-
operative day.
A follow-up CT or MRI study is obtained one
month postoperatively which will confirm normaliza-
tion of ventricular enlargement. Patients with pseudotumor
cerebri are monitored serially with visual f ield
 RENGACHARY : LUMBAR-PERITONEAL SHUNTING

© 1992 The American Association of Neurological Surgeons

Figure 4. A, the skin incision used for the minilaparotomy. B, incision peritoneum; a portion of the omentum extrudes out. E, insertion of the
of the anterior rectus sheath. C, longitudinal blunt separation of the rec- distal catheter into the peritoneal cavity.
tus abdominis fibers. D, incision of the posterior rectus sheath and the

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 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

© 1992 The American Association of Neurological Surgeons

Figure 5. A, a tunneler is used to bring the peritoneal catheter to the valve unit. D, the final orientation of the valve unit after the lumbar and
flank incision. B, the peritoneal catheter is brought into the flank wound peritoneal catheters have been attached to it. The valve unit is being
(note the clear tubing on the inlet side of the valve unit and the opaque anchored to the fascia over the external oblique muscle through the four
tubing on the outlet side). C, the peritoneal catheter is attached to the holes in the valve unit.

332
 RENGACHARY : LUMBAR-PERITONEAL SHUNTING
testing, visual acuity measurements, and fundus pho-
tography.
COMPLICATIONS OF SURGERY
Like any shunt, the lumbar-peritoneal shunt is suscep-
tible to infections. The incidence of infection is low be-
cause no component of the shunt is in the venous sys-
tem. If shunt blockage is suspected, it has to be confirmed
by a radionuclide study. The radionuclide is injected into
the lumbar subarachnoid space and the flow of the nu-
clide through the shunt into the peritoneal cavity is moni-
tored. If the shunt is patent, the radionuclide should es-
cape into the peritoneal cavity within minutes after
injection. If it is not functioning, the shunt will need to be
333
replaced. About 1 to 2% of the patients present with mani-
festations of cauda equina root irritation. In most instances
this is transient and resolves with time. If this persists, the
lumbar catheter will need to be replaced. Headaches are
uncommon but may occur if a proper valve with appropri-
ate pressure has not been chosen. Lack of precipitous
drainage of CSF in the upright position, attributable to
the unique shunt design, has kept the incidence of subdu-
ral hematoma very low. Even if a subdural hematoma
occurs, it is seldom of the massive degree that is seen
with the single pressure opening device. Migration of the
catheter from the spinal canal should not occur if the lum-
bar catheter has been properly anchored to the lumbar
fascia with the clamp.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
SURGERY OF THE CAVERNOUS SINUS
HARRY VAN LOVEREN, M.D.
MAGDY EL-KALLINY, M.D.
JEFFREY KELLER, PH.D.
JOHN M. TEW, JR., M.D.
INTRODUCTION
Using information from the works of Parkinson, Dolenc,
Hosobushi, Hakuba, and other pioneering investigators
as well as our own studies of the microsurgical anatomy
of the cavernous sinus (CS) region, we have attempted to
develop a comprehensive approach for treating lesions of
the CS. Because the CS is confined by bony and dural
structures, exploration of any CS lesion necessitates re-
moval of all or parts of these structures. The extent of this
removal depends on 1) the nature of the lesion (tumor
versus vascular lesion); 2) the location of the lesion (an-
terior, posterior, or both); 3) the features of the lesion (fi-
brous versus soft tumor); and 4) whether cure or decom-
pression of the contents of the CS is the goal of surgery.
Although the microsurgical anatomy of the CS and
its surrounding region is well known, the question remain-
ing is whether a radical resection of tumors of the CS is
possible. What are the indications, goals, and limitations
of CS surgery? We describe a technique to explore the
CS and the indications, applications, and limitations of
the technique for different types of tumors and vascular
lesions.
For lesions involving the entire CS, we use a fronto-
temporal craniotomy, which is combined with an
orbitozygomatic osteotomy in some cases. The approach
to surgical exploration of the CS is divided into an extra-
dural phase and an intradural phase; each phase is com-
posed of six steps. All extradural steps involve removing
bone from the anterior and middle cranial fossae. Removal
of these bony areas is the key that unlocks the neurovas-
cular structures for intradural exploration. Intradural steps
essentially unlock the neurovascular structures from du-
ral confinement while allowing the surgeon to remain
outside the venous compartment of the CS. This approach
also facilitates control of the arterial and venous circula-
© 1992 The American Association of Neurological Surgeons
334
tion. At the end, the intradural approach achieves a multi-
sided exposure of any CS lesion that fills the whole si-
nus. The addition of an orbitozygomatic osteotomy helps
multisided exposure by expanding the view to the CS re-
gion below the frontal lobe and medial to the temporal
lobe. When the lesion is localized in a single compart-
ment of the CS, the surgeon selects the most appropriate
approach to the involved compartment from among those
described below. Because the first three extradural steps
can be done from an intradural approach, we also describe
separately a method to explore the CS directly in the in-
tradural phase without a preceding extradural phase.
SURGICAL TECHNIQUE
Anesthesia
After the induction of general anesthesia and intubation,
a lumbar spinal catheter is placed for draining cerebrospi-
nal fluid (CSF) during the operation. Intraoperative CSF
aspiration helps retraction during the extradural phase of
the procedure. Osmotic diuretics also help to obtain maxi-
mal brain relaxation. If temporary occlusion of the inter-
nal carotid artery (ICA) is deemed necessary during the
procedure, the anesthesiologist should be prepared to put
the patient in pentobarbital coma to protect the brain.
Blood pressure should remain within a normal range dur-
ing the entire procedure and be elevated by 30% above
baseline pressure during temporary ICA occlusion.
Operative Positioning
The patient is placed in a supine position with the head ro-
tated 30° from the midline (Fig. 1A). The thorax is elevated
10-15° and the neck is extended. Adjustments in head rota-
tion will be necessary during the procedure, especially while
drilling the anterior clinoid process. The longitudinal axis
of the anterior clinoid process should be parallel to the
surgeon’s line of vision. The frontotemporal craniotomy used
extends anteriorly along the superior orbital rim to the
VAN LOVEREN ET AL. : SURGERY OF THE CAVERNOUS SINUS

© 1992 The American Association of Neurological Surgeons

Figure 1. A, the position of the patient is shown, as is the scalp incision (dashed line).
B-D, the initial two steps in the extradural exposure are depicted.

335
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
midpoint of the orbit and inferiorly to the zygoma
(Fig. 1B).
Extradural Phase
Step 1: Orbital Roof
The dura is separated from the floor of the anterior cra-
nial fossa. Because the roof of the orbit is quite thin cen-
trally, it opens readily with a small chisel or high-speed
drill. The periorbita is identified and dissected off the or-
bital roof. The posterior half of the orbital roof is removed
using conventional rongeurs (Fig. 1B). The medial por-
tion of the orbital roof, which slopes down toward the
cribriform plate, is preserved to avoid entry into the pos-
terior ethmoid and sphenoid sinuses. If these sinuses are
opened, they should be stuffed deeply with the mucosa
that is dissected free from the bone and kept intact, and
sealed with a piece of temporalis muscle and fibrin glue.
Another way to resect the posterior half of the orbital roof
is to resect the bone starting from the lower half of a “key-
hole” burr hole, which has exposed simultaneously the
periorbita and frontal lobe dura.
Step 1 includes unroofing and mobilizing the optic
nerve from the optic canal. When the bony roof of the
optic canal is removed with a diamond burr, the dura pro-
pria of the optic nerve is exposed (Fig. 1C). This removal
permits mobilization of the optic nerve, which is essen-
tial to avoid injury to the optic nerve during subsequent
dissection of the anterior clinoid process.
Step 2: Anterior Clinoid Process
Using a diamond burr, the surgeon cores the anterior cli-
noid process (ACP), leaving a thin shell of cortical bone
(Fig. 1C). When the medial lesser sphenoid wing and bony
strut beneath the optic nerve are removed, the anterior
clinoid process disconnects from the skull base. The re-
maining shell of bone is then teased and removed, leav-
ing intact the underlying dural layer (Fig. 1D). While drill-
ing the anterior clinoid process, there is the possibility
that an osseous bridge between the tip of the anterior and
middle clinoid process will form a complete or incom-
plete carotid-clinoid foramen. Also, the anterior clinoid
process is occasionally connected to the posterior clinoid
process by an osseous bridge; this connection not only
makes removing the tip of the anterior clinoid process
more difficult but increases the risk of extradural
clinoidectomy, especially if an aneurysm is present. If
extradural removal of the ACP is unusually difficult, the
residual ACP should be removed intradurally.
Extensive removal of the anterior clinoid process ex-
poses the clinoid space (carotid cave)—a pocket of vari-
able size (usually approximately 5 mm). The carotid cave
336
houses a segment of the carotid artery (clinoid segment)
below the dural ring where the carotid artery becomes intra-
dural. This extradural space is outside the main venous
channels of the CS. If the anteromedial surface of the ante-
rior loop should be revealed, more drilling of the optic strut
is carried out medially and as deeply as possible using a
small diamond burr. The optic strut separates the optic nerve
sheath from the anterior loop of the ICA covered with dura.
The posterior ethmoidal cells can be opened on the lateral
side of the optic nerve. These cells should be packed with a
piece of temporalis muscle and fibrin glue if entered to
prevent postoperative CSF leakage.
Step 3. Superior Orbital Fissure
By removing the medial portion of the lesser sphenoid
wing, the surgeon will reveal the dura overlying the supe-
rior orbital fissure (SOF). The lateral bony wall of the
superior orbital fissure is thinned, fractured, and removed
(Fig. 2A)
Step 4. Foramen Rotundum
A small island of bone separates the inferior aspect of the
superior orbital fissure from the foramen rotundum. By
removing the anterolateral rim of the foramen with a dia-
mond burr, the surgeon permits the mobilization of the
maxillary (V2) division of the trigeminal nerve (Fig. 2B).
Step 5. Foramen Ovale
As the elevation of the middle fossa dura continues to the
vertical inclination of the petrous pyramid, the surgeon
reveals both the foramen ovale and the foramen spinosum
(Fig. 2B). The middle meningeal artery traversing the fo-
ramen spinosum is coagulated and divided. The antero-
lateral boundaries of the foramen ovale are expanded, thus
enabling mobilization of the mandibular nerve (V3).
Step 6. Exposure of the Petrous Internal Carotid Artery
(Glasscock’s Triangle)
Glasscock’s triangle is bordered laterally by a line between
the foramen spinosum and the arcuate eminence, and
medially by the groove of the greater superficial petrosal
nerve (GSPN). The dorsal aspect of V3 forms the base of
the triangle (Fig. 2B). The GSPN is sacrificed to avoid
traction injury to the geniculate ganglion and facial nerve.
The bone of Glasscock’s triangle is removed with a dia-
mond burr to expose the horizontal segment of the pe-
trous ICA (between the lateral and posterior loops). Un-
roofing the petrous bone over the ICA should not proceed
posteriorly beyond the point where the ICA turns verti-
cally, if injury to the cochlea is to be avoided. Exposure
of the petrous ICA permits proximal arterial control and
offers a potential site for bypass vascular grafting.
 VAN LOVEREN ET AL. : SURGERY OF THE CAVERNOUS SINUS

© 1992 The American Association of Neurological Surgeons

Figure 2. The final four steps in the extradural exposure are demonstrated (A,B), as is the first step of the intradural exposure (C,D).

337
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
Intradural Phase
Step 1. Dural Opening
The dural opening begins along the line of the sylvian
fissure toward the ACP (Fig. 2, C and D). The incision
extends medially, perpendicular to the optic nerve and
laterally across the temporal lobe. When drilling the roof
of the optic canal, anterior clinoid process, and medial
lesser sphenoid wing from an intradural approach, we open
the dura as in a conventional pterional approach and then
tack the dura to the temporalis muscle.
If the ACP is not removed in the extradural phase it
can be removed in the intradural phase by the Hakuba
technique, as shown in Figures 5 and 6. To perform the
intradural removal of the roof of the optic canal, anterior
clinoid process, and medial lesser sphenoid wing, the sur-
geon secures a broad operative field after opening the
dura, the carotid and chiasmatic cisterns, and the sylvian
fissure. The temporal veins entering the lateral wall of
the CS are coagulated and cut. The dura overlying the
roof of the optic canal and the ACP and along the poste-
rior margin of the sphenoid wing is divided and the dural
leaf is reflected anteriorly. The surgeon opens the falci-
form fold with an arachnoid knife and then deroofs the
optic canal, performs an anterior clinoidectomy, and re-
moves the sphenoid wing as in the extradural phase.
Step 2. Carotid Rings
The ICA is fixed by two dural rings: the proximal ring is
the exit point of the ICA from the CS and the distal ring is
the point where the artery becomes intradural (Figs. 2D
and 3A). The clinoid segment of the ICA lies between
these two rings. By sharp dissection, the surgeon sections
the distal carotid dural ring surrounding the dorsolateral
wall of the ICA. Next, the dura propria covering the optic
nerve is incised along its lateral margin, and the dura is
reflected. As a result of both maneuvers, the clinoid seg-
ment is mobilized. When the optic nerve is retracted me-
dially, the ophthalmic artery can be exposed. Opening the
proximal ring will expose the anteroinferior compartment
of the CS.
Step 3. Oculomotor Nerve
The oculomotor nerve (III) penetrates the CS roof close
to the lateral wall and immediately courses in the lateral
wall along the inferior lateral margin of the clinoid bed.
To open widely the anterior part of the lateral wall, us-
ing an arachnoid knife, the surgeon incises the outer
layer from the oculomotor foramen of the third nerve
along its anterior margin until the incision crosses over
the anterior loop of the ICA (Fig. 3, B and C). This inci-
sion avoids injury to the trochlear nerve (IV) that crosses
over nerve III in the SOF.
338
The deep membranous layer of the lateral wall of the
CS separates these nerves from the venous channels of
the CS. If the inner layer is opened, then the interior of
the CS will be exposed. Control of venous bleeding can
be achieved by surgical packing of Surgicel into the CS.
To expose the anterior CS and the anterior loop and hori-
zontal portion of the intracavernous ICA, the surgeon
opens the CS roof (medial triangle of Hakuba) starting at
the entry point of nerve III toward the posterior clinoid
process; this incision extends toward the medial aspect of
the distal carotid ring (Fig. 3C).
Step 4. Trochlear Nerve
The surgeon identifies the trochlear nerve as it enters the
edge of the tentorial dura posterolateral to nerve III (Fig.
4A). Dissection of dura that overlies nerve IV continues
anteriorly into the SOF.
Step 5. Trigeminal Nerve
The ophthalmic division (V1) of the trigeminal nerve is
identified rostrally near the SOF; its dural covering is dis-
sected (Fig. 4B). When this dissection continues posteri-
orly, the surgeon reaches Meckel’s cave. At this stage, the
lateral wall of the CS is totally exposed and any of its
four compartments (i.e., lateral, anteroinferior, postero-
superior, medial) can be entered by opening the inner
membranous layer of the lateral wall. Meckel’s cave may
be exposed by further dissection of dura from the trigemi-
nal ganglion and its second (V2) and third (V3) divisions.
The trigeminal ganglion is separated from the ICA by the
bony floor of Meckel’s cave, which may be incompetent
(Fig. 4C).
Step 6. Abducens Nerve and the Interior of the
Cavernous Sinus
At this point the entire CS is unlocked from its bony and
dural confinements, while all nerve structures in its lat-
eral wall are kept intact. The nerve VI is the only cranial
nerve truly in the CS. This nerve enters the CS via
Dorello’s canal and lies lateral to the horizontal portion
of the intracavernous ICA (Fig. 4C).
TUMOR SURGERY
OF THE CAVERNOUS SINUS
When the entire CS is involved by a vascular lesion or
tumor, multisided exposure is achieved via the following
triangles: 1) the medial triangle of Hakuba; 2) the para-
median triangle between cranial nerves III and VI; 3)
Parkinson’s triangle; and 4) Mullan’s triangle (anterolat-
eral triangle) between the first and second divisions of
the trigeminal nerve (Fig. 4D). When the lesion is local-
ized to one portion of the CS, the appropriate triangle is
used to expose the lesion.
 VAN LOVEREN ET AL. : SURGERY OF THE CAVERNOUS SINUS

© 1992 The American Association of Neurological Surgeons

Figure 3. In steps 2 and 3 of the intradural exposure, the internal carotid artery rings are uncovered (A) and the
oculomotor nerve is dissected free (B,C).

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 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

© 1992 The American Association of Neurological Surgeons

Figure 4. A-C, the final three steps in the intradural exposure of the cavernous sinus are shown. D, surgical entry into the cavernous sinus can be
made through any of the five triangles shown.

340
 VAN LOVEREN ET AL. : SURGERY OF THE CAVERNOUS SINUS
Tumor Removal
In the space of the CS, the tumor is dissected using bipo-
lar coagulation, laser vaporization, and microsurgical tech-
niques. In cases of tumors involving the entire CS, sig-
nificant venous bleeding is not encountered because the
tumor itself compresses the venous pathways. In tumors
involving only part of the CS, venous hemorrhage is not
encountered until tumor removal is nearly complete.
Venous bleeding is controlled with Surgicel packing and
by elevating the patient’s head; however, excessive
Surgicel packing should be avoided to prevent cranial
nerve or vascular compression.
The abducens nerve running through the center of
the space lateral to the ICA must be carefully identified
and dissected to be preserved. In those cases in which the
adventitia of the ICA is not invaded by the tumor, a plane
of cleavage can be developed and the ICA can be pre-
served. In those cases with ICA adventitial invasion, there
are two options. First, sacrifice of the artery is an option
if it is thought that a cure or more radical resection will
be achieved. This option can be done without a bypass
graft for patients tolerating preoperative ICA occlusion
and with a bypass graft for those who do not. Second, if
cure is not an objective, tumor should be left attached to
the artery. If a tear occurs in the arterial wall, temporary
clips are applied to the proximal and distal ICA, and the
arterial injury is repaired with a fine microsuture.
Modification of Technique According to
Tumor Classification
We have classified CS tumors into types:
Type I (Intracavernous)
Intracavernous tumors fill and are confined to the CS (e.g.,
hemangiopericytoma and meningioma). These tumors are
rare. They require a comprehensive exposure and explo-
ration of the CS using all the steps described. Proximal
control of the precavernous artery can be obtained by
applying a temporary clip on the petrous ICA. Distal con-
trol is achieved by applying a temporary clip on the cli-
noid or supraclinoid ICA. Meningiomas are usually at-
tached to the adventitia of the intracavernous carotid
artery; cure cannot be achieved without sacrificing the
ICA. Cure will necessitate a bypass graft if the patient
fails to tolerate test occlusion.
Type II (Interdural)
Interdural tumors arise and/or are located between the su-
perficial and deep layers of the lateral wall of the CS (i.e.,
dura propria and inner membranous layers, respectively).
Trigeminal neurinomas arising from the ophthalmic divi-
sion of the trigeminal nerve remain interdural in their early
341
growth until they break through the inner membranous layer
and become intracavernous. Other tumors of this type are
epidermoid tumors and melanomas. To remove these tu-
mors, the extradural steps are not required.
If the tumor extends anteriorly, removal of the roof
of the optic canal, ACP, and medial sphenoid wing can be
achieved intradurally. Incision of the outer layer of the
lateral wall of the CS in Parkinson’s triangle is usually
sufficient. This incision can be expanded to include the
paramedian triangle and the roof (medial triangle) of the
CS. The tumor can be excised without entering the CS
because the inner membranous layer, which separates these
tumors from the venous channels of the CS, is intact in
most cases. These tumors do not require temporary vas-
cular control because they are outside the CS. Cranial
nerve palsies usually do not worsen after this type of re-
section and generally resolve in less than three months.
Type III (Invasive)
Invasive tumors enter the CS by infiltration along the
course of nerves, vascular structures, or fibrous layers, or
by invasion directly through dural planes. A trigeminal
neuroma is an example of a tumor that infiltrates the CS
along the course of the ophthalmic division of the trigemi-
nal nerve, penetrating the inner membranous layer late in
its growth. Examples of tumors that invade through dural
planes include invasive pituitary adenomas that penetrate
the medial wall of the CS and medial sphenoid wing men-
ingiomas that invade the lateral wall. Tumors that invade
a part of the CS can be removed by a modified approach
through one or more triangles appropriate to tumor loca-
tion. Tumors that either entirely fill or extend beyond the
CS require a comprehensive exploration of the CS when
indicated.
VASCULAR SURGERY
OF THE CAVERNOUS SINUS
Ophthalmic Segment Aneurysms
Most carotid ophthalmic aneurysms arise from the oph-
thalmic segment of the ICA. The ophthalmic segment
extends between the ophthalmic and the posterior com-
municating arteries. Because the ophthalmic artery usu-
ally arises from the ICA just beyond the distal dural ca-
rotid ring, most carotid ophthalmic aneurysms arise distal
to this ring. With large aneurysms or when there is a more
proximal origin of the ophthalmic artery, the neck of the
aneurysm may arise at the level of the dural ring or the
clinoid segment of the ICA. Although aneurysms arising
from the clinoid segment are rare, intracavernous aneurysms
extending into the clinoid segment are not uncommon.
Some carotid ophthalmic region aneurysms are not related
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

to the ophthalmic artery but instead arise at the branching
point of the superior hypophyseal artery. These aneurysms
usually point opposite the ophthalmic artery origin, usu-
ally medially or inferomedially.
Whether these aneurysms relate to the ophthalmic
artery or the superior hypophyseal artery, removal of
the ACP and the optic canal roof is important so that
the surgeon can visualize the clinoid segment and use
it for proximal control (Fig. 5). Also, removal aids vi-
sualization of the origin of the ophthalmic artery and
the neck of the aneurysm (Fig. 6A). Unroofing the op-
tic canal and opening the dura propria enables the sur-

© 1992 The American Association of Neurological Surgeons

Figure 5. A-C, intradural removal of the anterior clinoid process and the roof of the optic canal provides exposure of the
clinoid segment of the internal carotid artery.

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 VAN LOVEREN ET AL. : SURGERY OF THE CAVERNOUS SINUS

© 1992 The American Association of Neurological Surgeons

Figure 6. Completion of the exposure of the clinoid and intradural segments of the internal carotid artery and the origin of the
ophthalmic artery (A) permits clip ligation of an ophthalmic segment aneurysm (B).

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 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
geon to retract the optic nerve medially, thus further ex-
posing the aneurysm neck and the ophthalmic artery. Also,
exposing the extradural portion of the ICA (proximal to
the neck of the aneurysm) gives the surgeon more room
for appropriate clipping of the aneurysm neck in line with
the parent artery (Fig. 6B).
Cavernous Aneurysms
Cavernous aneurysms can be treated if they are symp-
tomatic by cranial nerve compression, embolic ischemic
events, or pain. Although cavernous aneurysms are most
amenable to endovascular balloon occlusion, on rare oc-
casion they should be approached directly. Trapping tech-
niques are considered if the patient’s tolerance to vascu-
lar occlusion has been established. Bypass grafting is
performed if cerebral collateral circulation is insufficient.
Direct clipping of a cavernous aneurysm is accomplished
by obtaining proximal vascular control in Glasscock’s tri-
344
angle and distal control at the paraclinoid or supraclinoid
carotid segment. The lateral wall is reflected without CS
entry. The aneurysm is isolated through the appropriate
triangle by brushing CS veins away from the aneurysm
with gentle Surgicel packing. The aneurysm neck is iden-
tified and clipped in the usual fashion.
Carotid-Cavernous Fistulae
Carotid-cavernous f istulae are best treated by
endovascular balloon occlusion with preservation of par-
ent artery patency, if possible. Indications for direct re-
pair include proximal carotid artery dissection and fail-
ure of the balloon technique. Only the appropriate triangle
localized over the exact site of fistula origin is opened.
Surgicel packing is forced around the artery until repeated
intraoperative angiograms demonstrate closure of the fis-
tula with preserved arterial patency. Temporary ocular
palsies will certainly occur.
 ENCEPHALOCELES OF THE ANTERIOR
CRANIAL BASE
ALAN R. COHEN, M.D.

INTRODUCTION are also seen. Anterior basal encephaloceles are some-

An encephalocele is literally a hernia of the brain. The times discovered incidentally during craniofacial recon-
term is used loosely to describe a congenital protrusion struction for hypertelorism.
of the cranial contents beyond the normal confines of the The encephalocele sac usually contains cerebrospinal
skull. Encephaloceles are rare malformations, occurring fluid (CSF) or gliotic brain; very infrequently such critical
with a worldwide incidence of about 1 per 5000 live births. structures as the hypothalamus, optic apparatus, or anterior
cerebral arteries may be encountered in large herniations.
DEFINITIONS AND EPIDEMIOLOGY Children with encephaloceles of the anterior cranial base
The terminology used to describe encephaloceles is often are usually neurologically normal, although hydrocephalus
confusing and inconsistent. Contributing to the confusion and epilepsy have been reported infrequently. Neurologic
are the following issues: the lesions are encountered in- dysfunction is seen much more often in association
frequently, the contents of the hernia sacs are variable,
and the sac locations may be described either in relation
to external landmarks or internal defects in the skull.
Encephaloceles which pass through the same internal skull
defect may project to different locations externally.
I prefer to use a simple scheme and divide
encephaloceles into two groups: those related to the cra-
nial vault and those related to the cranial base. Cranial
vault encephaloceles account for the vast majority of those
encountered in the Western Hemisphere. These all present
as visible external masses and usually occur along the
midline in the frontal, parietal, or occipital region. Rarely,
they may occur off the midline at the pterion. The occipi-
tal encephalocele is the most frequent variant seen in North
America.
Cranial base encephaloceles differ from those of the
cranial vault in that the herniation occurs internally, pro-
ducing no obvious visible external mass. For this reason,
the clinical presentation of these “basal” encephaloceles
is more often insidious. The most common site of hernia-
tion is through an enlarged foramen cecum in the floor of
the anterior cranial fossa (Fig. 1). These basal
encephaloceles usually come to attention because of a
nasal (or rarely pharyngeal) mass, or because of symp-
toms of nasal obstruction, cerebrospinal fluid (CSF) rhi-
norrhea, or recurrent meningitis. Occasionally midline © 1992 The American Association of Neurological Surgeons
facial anomalies such as cleft palate and hypertelorism
Figure 1. Encephalocele of the anterior cranial base. The stalk passes
through a defect in the floor of the anterior fossa at the site of the fora-
men cecum. The sac terminates in the nasal cavity between the septum
© 1992 The American Association of Neurological Surgeons medially and the middle turbinate laterally.

345
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

with the posteriorly located occipital encephaloceles of

the cranial vault than with those located anteriorly at the
cranial base.
There is a remarkable geographic distribution of
encephaloceles. Whereas posteriorly situated encepha-
loceles are more common in the Western Hemisphere,
anteriorly situated ones are more common in Southeast
Asia. In fact, the ratio of anterior to posterior
encephaloceles in Thailand is 9.5:1. Curiously, sex ratios
vary with encephalocele location, with a male to female
ratio of 1:2 for occipital encephaloceles, and almost 2:1
for lesions situated at the anterior skull base.
A peculiar type of encephalocele occurs at the junc-
tion of the cranial vault and cranial base. It is similar
to the anterior basal encephalocele in that there is an
internal skull defect in the floor of the frontal fossa
between the frontal and ethmoid bones, usually at the
site of the foramen cecum. However, unlike most ante-
rior basal encephaloceles which project downward into
the nasal cavity, this encephalocele projects anteriorly
as a visible defect on the face at the root of the nose.
This lesion has been variably described as a
frontoethmoidal or sincipital encephalocele. The term
sincipital is derived from Latin and refers broadly to
the anterior and upper part of the head. Literally speak-
ing, sincipital encephaloceles may occur somewhere
between the bregma and anterior aspect of the ethmoid
bone, but in fact most occur at the skull base in rela-
tion to the nasal root.
Although they are characterized by an obvious vis-
ible external projection, frontoethmoidal (sincipital)
encephaloceles are best thought of as cranial base le-
sions. There is an internal skull defect at the foramen
cecum, the same site implicated in the anterior basal
encephaloceles described above. The epidemiology is
also similar to these basal encephaloceles, with an inci-
dence rare in the Western Hemisphere and dispropor-
tionately frequent in Southeast Asia. Frontoethmoidal
encephaloceles occur with particular frequency in Ma-
laysia, Thailand, Burma, and Indonesia. These lesions
have been subdivided anatomically based upon the site
of the external skull defect opening into the face. There
are three types: nasofrontal, nasoethmoidal, and naso-
orbital. Nasofrontal encephaloceles project onto the face
at the nasion through an opening between the frontal
bone above and the nasal and ethmoid bones below (Fig.
2A). This is the site of the primitive fonticulus © 1992 The American Association of Neurological Surgeons

nasofrontalis, a fibrous membrane bridging the nasal
and frontal bones during embryologic development, serv-
ing to separate the dura from the developing skin.
Nasoethmoidal encephaloceles are long-necked and
project somewhat more inferiorly, between the frontal
and nasal bones above and the displaced ethmoid bone
Figure 2. Frontoethmoidal (sincipital) encephalocele variants, each
projecting externally to create a visible facial deformity at the root
of the nose: A, a nasofrontal encephalocele passing between the
frontal bone above and displaced nasal and ethmoid bones below; B,
a nasoethmoidal encephalocele passing between the frontal and na-
sal bones above and displaced ethmoid bone and nasal cartilage be-
low; C, a naso-orbital encephalocele projecting externally through
the medial wall of the orbit.

346
 COHEN : ENCEPHALOCELES OF THE ANTERIOR CRANIAL BASE
and nasal cartilage below (Fig. 2B). Naso-orbital
encephaloceles are rare and project through the
inferomedial wall of the orbit, passing between the fron-
tal process of the maxillary bone anteriorly and the lacri-
mal bone and lamina papyracea of the ethmoid bone pos-
teriorly (Fig. 2C).
PREOPERATIVE CONSIDERATIONS
The most common clinical presentation of an encephalo-
cele at the anterior cranial base is a mass producing symp-
toms of unilateral nasal obstruction in an infant. The en-
cephalocele sac terminates in the nasal cavity, lying
between the septum medially and the middle nasal turbi-
nate laterally. It may be visualized as a glistening pink or
blue intranasal mass. It often pulsates with the heartbeat
and may swell with crying or a Valsalva maneuver. A unique
feature of nasal encephaloceles is their tendency to en-
large with compression of the jugular veins (positive
Furstenberg test).
Basal encephaloceles must be differentiated from
other nasal masses. Nasal polyps are rare in infants and
are located lateral rather than medial to the middle turbi-
nate. Other congenital nasal lesions include dermoids, li-
pomas, fibromas, hemangiomas, and nasopharyngeal
cysts. In older individuals, basal encephaloceles must be
distinguished from a variety of benign and malignant skull
base tumors, as well as such inflammatory lesions as
mucoceles and granulomas of the nose and paranasal si-
nuses. Some authors distinguish the nasal encephalocele
from a related clinical entity, the so-called nasal glioma,
although these lesions appear to share a common embry-
ology. The presence of a stalk connecting the nasal mass
with the brain distinguishes the nasal encephalocele from
the nasal glioma. This distinction may be a difficult one to
make clinically. The only real issue in terms of manage-
ment is that nasal gliomas may be biopsied safely via a
transnasal approach whereas encephaloceles may not.
Radiographic demonstration of the anterior skull base
encephaloceles is best performed with magnetic resonance
imaging (MRI). The midsagittal image provides a beauti-
ful demonstration of the hernia sac passing through a de-
fect in the frontal floor to terminate in the nasal cavity.
MRI is useful for detecting the rare instance in which
important neurovascular structures pass into the encepha-
locele sac. Angiography is not routinely necessary but
may be considered if the MRI suggests involvement of
the anterior cerebral arteries in the herniation. Three-di-
mensional computed tomography can be helpful for plan-
ning more complex craniofacial repairs.
OPERATIVE ANATOMY
Most congenital encephaloceles of the anterior cranial base
347
pass through an enlarged foramen cecum ossis frontalis
(Fig. 1). The foramen cecum is an opening between the
frontal crest anteriorly and the crista galli posteriorly. It is
considered to be a blind opening but may sometimes trans-
mit a vein from the nasal cavity to the superior sagittal
sinus. In cases of nasal encephalocele the foramen cecum
may enlarge significantly. The crista galli (rooster’s comb)
is a triangular piece of bone projecting upward from the
cribriform plate of the ethmoid bone, giving attachment to
the anterior falx cerebri. Thus, most basal encephaloceles
pass through a defect in the frontal floor anterior to the
crista galli and project inferiorly into the nasal cavity.
OPERATIVE TECHNIQUE
This describes a simple operative technique for repairing
an anterior cranial base encephalocele. Historically, this
lesion has been approached both transnasally and
transcranially. The transnasal route is discouraged because
it has been associated with serious risks of bleeding, in-
fection, and CSF fistula formation. The transcranial ap-
proach was first described by Dandy in 1929, and varia-
tions of this are still used commonly.
The procedure described below involves an intracra-
nial extradural exposure in an infant. This approach is
designed for encephaloceles with a relatively narrow neck
and a sac which terminates in the nasal cavity.
Encephaloceles with a broad stalk or ones which include
critical neurovascular structures are best managed using
a combined extradural-intradural exploration. Encephalo-
celes associated with hypertelorism or those projecting
onto the face (frontoethmoidal encephaloceles) are more
complex and are best repaired in conjunction with a
craniofacial team.
Preoperative nasal cultures are obtained and the child
is begun on an anticonvulsant and antibiotics appropriate
for staphylococci and streptococci. The operation is per-
formed under general anesthesia with oral endotracheal
intubation. Arterial, venous, and Foley catheters are in-
serted. Although the procedure is not usually associated
with significant blood loss, even minor bleeding may have
serious consequences in young infants. Therefore, blood
is made available for transfusion. In older infants and
adults, a lumbar subarachnoid catheter is used for intra-
operative drainage of CSF.
The patient is positioned supine on a warming blan-
ket and covered with a regular blanket to minimize heat
loss. The head is supported by a doughnut cushion, el-
evated 20°, and extended with the brow up (Fig. 3). Adults
are positioned in a similar fashion using a Mayfield three-
pin head holder.
The scalp is shaved and cleansed with alcohol fol-
lowed by povidone-iodine soap and solution. A coronal
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

incision well behind the hairline is outlined with a mark-

ing pen. The operative field is walled off with towels
and covered with an iodoform-soaked adhesive drape.
The scalp is infiltrated with a solution of 0.1% lidocaine
with a 1:1,000,000 dilution of epinephrine. The incision
is made with a No. 10 blade and scalp hemostasis is
obtained using Raney clips and Dandy clamps. Alterna-
tively, in younger infants the scalp may be opened using
a Shaw hemostatic scalpel. The scalp is reflected anteri-
orly in the avascular loose areolar plane which lies deep
to the galea but superficial to the pericranium. Great
care is taken not to disturb the pericranium, which is
mobilized as a separate vascularized layer to reconstruct
the skull base at the close of the procedure. The pericra-
nium is incised with a knife and reflected anteriorly us-
ing square-ended periosteal elevators (Fig. 4). The peri-
cranial flap is based on a vascular pedicle supplied by
the frontal and supraorbital arteries. Any holes in the
pericranial flap are repaired at this point using 4-0
Nurolon sutures. The scalp and pericranial graft are cov-
ered with moist sponges.
A bifrontal free bone flap is fashioned. Burr holes
are placed in the keyhole region bilaterally, and a small
© 1992 The American Association of Neurological Surgeons
burr hole is placed in the low frontal midline using a
Figure 3. Patient positioned for bifrontal craniotomy. A coronal scalp
incision is outlined (dashed line).

© 1992 The American Association of Neurological Surgeons

Figure 4. A vascularized pericranial flap is reflected anteriorly.

348
 COHEN : ENCEPHALOCELES OF THE ANTERIOR CRANIAL BASE

high-speed drill (e.g., Midas Rex). The frontal sinus
does not present a problem in infants because it is not
yet pneumatized. A posterior midline burr hole can be
avoided by using a knife and dental instrument to cre-
ate “suturotomies” and separate dura from bone on ei-
ther side of the anterior fontanelle. The bone flap is
elevated using a Midas Rex drill and footplate system
to connect the holes, with cuts directed away from the
midline (Fig. 5). The dura is tented up to the posterior
margins of the craniotomy defect using 4-0 Nurolon
sutures.
The dura is dissected gently off the floor of the

Figure 5. A bifrontal bone flap is created (A) and removed (B). © 1992 The American Association of Neurological Surgeons

349
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

anterior cranial fossa bilaterally using a Freer elevator or
a bayonet forceps and cottonoid patties. The dissection is
usually not difficult, but can be troublesome medially in
the region of the cribriform plate. When necessary, the
dissection may be facilitated by the use of hyperventila-
tion, mannitol, and drainage of CSF to relax the brain.
The surgeon identifies the encephalocele stalk as it
enters the bony defect at the foramen cecum (Fig. 6). The
stalk is dissected circumferentially. If the stalk is narrow
and well seen, the entire dissection may be carried out
extradurally. A 4-0 Nurolon suture-ligature is placed through
and around the encephalocele stalk, and the stalk is then
divided with scissors just distal to the site of ligation (Fig.
7). The intracranial portion of the encephalocele is thereby
disconnected from the intranasal portion of the sac, which
may be grasped from below by an otolaryngologist and
delivered through the nose (Fig. 8). If the nasal sac is tena-
cious, it is left alone and will either shrivel up, requiring no
further treatment, or alternatively may be removed easily
after several weeks at a second sitting.
Hemostasis is secured and the ligated basal fron-
tal dura is covered with a piece of thrombin-soaked
Gelfoam, which may be infiltrated with fibrin glue.
Bony reconstruction of the skull base is usually not
necessary. The vascularized pericranial graft is brought
down to cover the skull base and is fixed to the
frontobasal dura with 4-0 Nurolon sutures (Fig. 9). The
bone flap is replaced (Fig. 10) and the scalp is closed in

© 1992 The American Association of Neurological Surgeons

Figure 6. The encephalocele stalk is identified and isolated.

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 COHEN : ENCEPHALOCELES OF THE ANTERIOR CRANIAL BASE

© 1992 The American Association of Neurological Surgeons

Figure 7. The stalk of the encephalocele is ligated with a suture ligature (A,B) and is transected (C,D).

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© 1992 The American Association of Neurological Surgeons

Figure 8. The sac of the encephalocele (A) is removed transnasally (B) after its stalk has been ligated and divided intracranially.

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 COHEN : ENCEPHALOCELES OF THE ANTERIOR CRANIAL BASE
© 1992 The American Association of Neurological Surgeons
Figure 9. Reconstruction of the anterior skull base. The pedicled
pericranial flap is sutured to the basal frontal dura and serves as a
barrier between the remnant of the encephalocele stalk above and
the bony defect opening into the nasal cavity below.
two layers. In older infants and adults, the lumbar sub-
arachnoid catheter is left in place for up to 5 days to pro-
tect the operative repair.
COMPLICATIONS
Complications are generally related to infection or the
formation of a CSF fistula. Both may occur as the re-
sult of communication between the subarachnoid space
and the nasal cavity. Measures to prevent such compli-
cations include the creation of a meticulous dural clo-
sure which is protected by a vascularized graft of peri-
cranium. Because of the potential for communication
between the intracranial compartment and the nasal
cavity, I avoid placing a subgaleal drain. A CSF fistula
353
Figure 10. The bone flap is replaced.
which does not respond to lumbar drainage should be
explored surgically.
SUMMARY
Encephaloceles of the anterior cranial base are rare mal-
formations which present insidiously. Although they are
more difficult to repair than the posteriorly situated oc-
cipital encephaloceles, basal encephaloceles are associ-
ated with a much better neurologic prognosis. Straight-
forward lesions may be approached intracranially with
an extradural dissection. More complex lesions may re-
quire intradural exploration. Goals of surgery should be
protection of neurovascular structures and prevention of
a CSF fistula.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

COTREL-DUBOUSSET
INSTRUMENTATION: INTERNAL
FIXATION FOR THORACOLUMBAR
FRACTURES AND TUMORS
BRUCE E. VAN DAM, M.D.

INTRODUCTION
Doctors Yves Cotrel and Jean Dubousset introduced a new
form of segmental spinal instrumentation in 1984. Al-
though initially intended for the surgical treatment of spi-
nal deformities such as scoliosis, it was immediately
adopted for use in other spinal disorders. The main ad-
vantages of Cotrel-Dubousset (C-D) instrumentation lie
in its adaptability to different clinical problems and the
secure internal fixation it provides. The latter advantage
usually allows rapid mobilization of the patient without
the need for external support, i.e., casts or braces.
Common to most fractures and tumors of the thora-
columbar region is the tendency to produce instability
leading to kyphosis. Consequent attempts at decompres-
sion of the neuraxis by laminectomy or pedicle excision © 1992 The American Association of Neurological Surgeons

may be further destabilizing. In these situations the ten-

Figure 1. A closed pedicle hook. Laminar hooks can also be closed.
dency toward progressive kyphosis and further neurologic Note the hex screw for securing the hook to the rod. The hex screw
injury must be resisted by secure internal fixation until must either be retracted or removed for the rod to slip through the body
bony healing in the form of a fusion takes place. Where of the hook. The small holes in the body accommodate the hook holder.
kyphosis already exists, it is desirable to use the same
internal fixation to reduce the deformity and to secure
the spine. C-D instrumentation excels on both counts.

SYSTEM COMPONENTS
An array of hooks and screws is available to use in the C-D
construct. However, one need only be familiar with a basic
few to successfully treat kyphosis-producing fractures or
tumors in the thoracolumbar region. Hooks are either closed
(Fig. 1) or open (Fig. 2). Open hooks allow the surgeon to
drop the rod in, whereas closed hooks require the rod to slide
through the bodies of the hooks. In general, it is desirable to
use closed hooks at the caudal and cephalic extents of the
© 1992 The American Association of Neurological Surgeons

Figure 2. An open pedicle hook. Laminar hooks can also be open. Open
hooks require a blocker to be secured to the rod. Open hooks should not
be used at the ends of the C-D construct. The small holes in the body
© 1992 The American Association of Neurological Surgeons accommodate the hook holder.

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 VAN DAM : COTREL-DUBOUSSET INSTRUMENTATION
construct to avoid rod dislodgement. Open hooks are used
in between to facilitate rod insertion.
Two rods are always used, and nearly always a sym-
metrical construct is formed bilaterally. The rods are tex-
tured with diamond-shaped asperities so that locking hex
screws can engage each hook to the rod. There are two
basic types of 7-mm rods (5-mm rods are used in pediat-
ric cases): a standard stainless steel rod and a more rigid
cold-rolled stainless steel rod. For purposes of reducing
and maintaining reduction of a thoracolumbar kyphosis,
the cold-rolled rod is preferred.
OPERATIVE TECHNIQUE
Following the induction of general anesthesia, the patient
is gently log-rolled to a prone position on a four-poster
frame or chest rolls (Fig. 3A). Use of a frame that encour-
ages flexion of the spine is inadvisable. Flexion, which
would otherwise facilitate access to the interlaminar space,
merely exacerbates the deformity. Furthermore, there is
also the tendency to fix the lumbar spine in a less lordotic
position unless the lumbar spine is allowed to extend pas-
sively. The back from T-1 to the gluteal cleft is prepared
in a sterile manner, keeping the iliac crests exposed for
autogenous iliac bone graft harvesting.
A straight midline incision is used from one level
cephalad to one level caudad to the proposed extent of
instrumentation. A radiographic marker film is taken to
ensure exposure at the correct levels. Subperiosteal ex-
posure of the posterior bony elements out to the trans-
verse processes in the thoracic region and to the superior
articular facets in the lumbar region is performed. Care is
taken to remove all soft tissue from the exposed bone. For
purposes of illustration it will be assumed that an insta-
bility exists at T-12. Therefore, the posterior elements of
T-9 to L-2 would be exposed.
Hook sites are prepared symmetrically. A “claw”
construct is needed bilaterally at T-9, which results in a
bracketing of the pedicle of T-9. The claw is created by
placing a closed lumbar laminar hook over the transverse
process and a closed pedicle hook in the facet joint (Figs.
3D and 4). A transverse process elevator is passed over
and around both T-9 processes to cut the costotransverse
ligaments and establish a path for the closed laminar hooks
(Fig. 3B). A pedicle finder is similarly used to establish a
path in the T9-10 facet joints (Fig. 3B). It is important
that the finder not be directed medially toward the spinal
canal and that it truly lie between the inferior and supe-
rior articular facets (i.e., in the joint). If the pedicle finder
penetrates the cortex of the inferior articular facet and
the pedicle hook subsequently lies in that position, then
pull-out of the hook is likely to occur. The laminar hooks
are placed over the transverse processes using a hook
355
holder to grasp the hooks and rotate them into position. A
hook holder and hook driver are then used to insert the
pedicle hooks within the facet joints. Again, care is taken
to direct the pedicle hooks directly cephalad. The pedicle
hooks should be gently tapped into place to engage the
pedicle with the teeth of the hooks. This is accomplished
by using a mallet against the end of the hook driver.
Hook sites are then prepared in a supralaminar posi-
tion at L-1. This is done by removing most of the spinous
process of T-12, excising the ligaments flava at T-12 to
L-1, and creating a suitably sized notch bilaterally to ac-
commodate open lumbar laminar hooks (Fig. 3B). It
should be noted that lumbar laminar hooks should not be
used in the thoracic region. The smaller thoracic laminar
hook should be used instead. The open lumbar laminar
hooks can then be placed in the notched supralaminar
position at L-1 with a hook holder. The body of the hook
will rest on the lamina but the hook will be unstable until
secured to the rod. So long as the hook is not forced ante-
riorly without resting on the lamina, it poses no potential
problem to neural tissue.
The most caudal hooks are closed lumbar laminar
hooks situated bilaterally in an infralaminar position at
L-2. It is not necessary to notch the lamina but the liga-
mentum flavum must be elevated from the L-2 lamina
caudally on each side to create a path for the hooks. This
is accomplished using a lamina elevator (Fig. 3B). Care
must be taken to pass the lamina elevator and the hook
around the bony cortex of the lamina and not to penetrate
the cortex. If the hook comes to lie between the cortices
of the lamina it will likely pull out. The closed lumbar
lamina hooks are inserted with the use of a hook holder.
A 7-mm cold-rolled rod of appropriate length is se-
lected and contoured into lordosis for the caudal hooks
and slight kyphosis for the cephalic hooks (Fig. 3C). It is
important to bend the rod to create an extension force
with the rod once it is secured to the hooks. After con-
touring, a hook blocker for the open laminar hook at L-1
is tentatively secured to the rod. Note that the blocker is
tapered and slides into the open hook in the direction in
which the hook points (Fig. 3D). The rod should be suffi-
ciently long to project 1 cm beyond the transverse pro-
cess hook at T-9 and the infralaminar hook at L-2.
A hook holder is used to grasp the T-9 transverse
process hook to prevent its dislodgement. The rod is
grasped with a rod holder and inserted through the
closed T-9 hooks, dropped into the open hook at L-1,
and inserted through the closed infralaminar hook at
L-2. It is necessary to hold the L-2 hook with a hook
holder to prevent dislodgement. This maneuver should
reduce any kyphosis at the level of instability unless
the rod has been contoured with too little lord-
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
© 1992 The American Association of Neurological Surgeons
Figure 3. A, the patient is positioned on a four-poster frame. Passive
extension of the lumbar spine is promoted as well as diminished
intraabdominal pressure. B, the transverse process elevator, pedicle
finder, and laminar elevator are seen on the right. A notch has been
established at L-1 in a supralaminar position. On the left the hooks are
in their prepared sites: a closed laminar hook over the T-9 transverse
process, a closed pedicle hook in the T9-10 facet joint, an open laminar
hook in the supralaminar position at L-1, and a closed laminar hook in
356
the infralaminar position at L-2. C, the rod bender is used to contour the
rods. D, the left rod is inserted into the hooks. The claw at T-9 is com-
pressed and secured. The interval from the claw to L-1 is distracted and
the L-1 hook is secured. The L-2 hook is compressed toward L-1 and is
secured. On the right, a pusher is guiding the hook blocker into the open
hook at L-1. The process of compressing, distracting, and securing the
hooks on the right will then be repeated. E, the finished construct is
shown, with the DTT devices in place.
 VAN DAM : COTREL-DUBOUSSET INSTRUMENTATION

transverse traction) devices (Fig. 3E). This step is impor-

tant to create a rigid quadrilateral frame. The DTT de-
vices are secured to the rods just caudal to the T-9 claws
and just cephalad to the supralaminar L-1 hooks. After
sufficient tightening of the nuts against the opposing small
hooks, the heads of the paired hooks should touch. Ex-
cess DTT rod length is cut off. After the Stagnara wake-
up test has confirmed that neurologic function has not
been impaired, all the hex screws are torqued off.
At this point a rigid construct applying an extension
and a distraction force has been created. Short-

© 1992 The American Association of Neurological Surgeons

Figure 4. A claw. The lumbar laminar hook (upper hook) passes

over the transverse process. The pedicle hook engages the pedicle
by insertion into the facet joint.

osis. If the rod has been contoured properly, insertion of

the rod will require that some force be exerted anteriorly
as it is inserted into the L-2 infralaminar hook.
The hooks are now on the rod but need to be secured
to it. In addition, some distraction force needs to be ap-
plied across the level of instability (in this case, T-12) to
provide tension to the spinal ligaments (ligamentotaxis).
First, the T-9 hooks are compressed together with the hook
compressor (Fig. 5) and their hex screws tightened to the
rod while compression is being applied. The hex screws
are tightened with a T-wrench. Care is taken not to torque
off the heads of the hex screws at this time.
© 1992 The American Association of Neurological Surgeons
The hook blocker is then passed into the open
supralaminar hook at L-1. The hook is held with a hook Figure 5. A hook compressor compressing the hooks of the claw to-
holder, and pushers for the tapered blocker are used to gether. The hex screws are tightened and the hooks are secured to the
slide the blocker into the open hook (Fig. 3D and 6). Un- rod while the hooks are under active compression.
til the blocker engages the open hook, the pusher with
extensions is used to control rotation of the blocker. Once
engaged, the blocker is firmly seated using the pusher
without extensions.
A distraction force is then applied between the claw
at T-9 and the supralaminar hook at L-1. The rod holder is
applied about 2 cm cephalad to the L-1 hook and a spreader
is placed between the rod holder and hook (Fig. 7). A
distraction force is applied and the hex screw tightened
but not torqued off. Care must be taken to ensure that the
supralaminar hook is resting on the lamina and is in its
notch before any distraction force is applied.
To complete the hook construct, the infralaminar hook
at L-2 is compressed toward the supralaminar hook at
L-1. By once again grasping the rod with a rod holder just
cephalad to the L-2 hook, a hook compressor can bracket
the rod holder and hook. Compression is applied and the
hex screw tightened. © 1992 The American Association of Neurological Surgeons

After the same procedures have been repeated on the Figure 6. Final seating of the blocker into the open hook using the pusher
contralateral side, the rods are joined by DTT (device for without extensions.

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 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
© 1992 The American Association of Neurological Surgeons
Figure 7. Distraction is achieved by grasping the rod 2 cm from the
hook and placing the hook distractor between the hook and rod holder.
term stability has been achieved. For long-term stability
a fusion must be performed. All facet joints not actually
holding a hook (in this case, T9-10) should be excised
and the articular cartilage curetted. Decortication of all
laminar surfaces from T-9 to L-2 is performed, usually
with a high-speed burr. This step does not require total
removal of the dorsal cortex but a “roughening” of the
surface. Copious amounts of cancellous or corticocan-
cellous autogenous iliac bone is applied over the decorti-
cated surface from T-9 to L-2.
No drain is placed deep to the fascia which is closed
with a running, locked absorbable suture. A drain is placed
beneath the subcutaneous tissue which is closed with a
running absorbable suture. The skin is closed with staples,
and a dry dressing is applied.
358
Distraction is maintained by tightening the hex screw on the hook while
active distraction is carried out.
POSTOPERATIVE CONSIDERATIONS
The drain is discontinued at 48 hours postoperatively as
are the antibiotics which were begun 30 minutes before
skin incision. The patient is encouraged to become active
on the second postoperative day, first by sitting up and
then by standing and walking in the room. If the patient’s
bone is not porotic, no postoperative brace is needed. If
there is a question about the quality of the bone and its
ability to hold the hooks, then use of an extension back
brace is recommended. In either case, the patient must
avoid any stooping or bending which might promote hook
dislodgement. Walking and everyday activities are encour-
aged but more vigorous activity (such as sports) are
avoided for six months. At that time, radiographs are taken
to assess the fusion.
 POSTERIOR-LATERAL LUMBAR
SPINAL FUSION
EDWARD S. CONNOLLY, M.D.
INTRODUCTION
Lumbar spinal fusion may be performed by the posterior,
posterior-lateral, posterior-interbody, or anterior-interbody
technique. Posterior-lateral fusion and posterior-interbody
fusion are the techniques most commonly employed. The
advantages of posterior-lateral fusion are a low risk of
neural injury and a high fusion rate. This technique also
may be used with various forms of instrumentation, and
additional levels may be incorporated easily.
PREOPERATIVE CONSIDERATIONS
Posterior-lateral lumbar spinal fusion may be associated
with considerable bleeding. Therefore, the patient should
donate two units of whole blood for autologous transfu-
sion at surgery. A cell saver suction device should be used
during surgery for added blood volume protection. Pneu-
matic hose, compression stockings, or Ace bandage wraps
reduce pooling of blood in the legs and reduce the risk of
phlebothrombosis. Perioperative antibiotic prophylaxis is
important to reduce the incidence of postoperative wound
infection. A thoracolumbar spinal orthosis is made for
the patient’s postoperative use.
OPERATIVE TECHNIQUE
The patient is initially placed in the supine position, gen-
eral anesthesia is induced, and the patient is intubated.
An intra-arterial line is inserted into the radial artery
and an indwelling Foley catheter is inserted into the blad-
der and attached to gravity drainage. The legs are
wrapped and placed in pneumatic stockings. The patient
is then placed in the prone position on an appropriate
frame or in the knee-chest position, to prevent compres-
sion of the abdomen. We prefer using the new Andrews
spinal surgery table, which allows the abdomen to be
completely free and allows use of the image intensifier
in the anteroposterior and lateral projections (Fig. 1).
Any abdominal compression will greatly increase blood
loss. The back is then prepared with a Betadine scrub
followed by the application of Betadine solution, and is
© 1992 The American Association of Neurological Surgeons
359
draped in a sterile manner.
A midline skin incision is made from one spinal seg-
ment above to one spinal segment below the segments to
be fused. The appropriate levels are confirmed with an
intraoperative lateral x-ray film. The deep fascia is in-
cised and the paraspinous muscles are dissected
subperiosteally from the spines and laminae, including
one segment above and one below the area of fusion, us-
ing electrosurgical cautery. The dissection is carried lat-
erally over the facet joints, and the transverse processes
are exposed at the levels to be fused. The muscles are
held laterally by self-retaining retractors.
If the sacrum has been exposed, a posterior iliac au-
tograft may be harvested by dissecting laterally between
the superficial fascia and the deep fascia until the poste-
rior iliac crest is encountered. The posterior muscle at-
tachment to the posterior iliac crest is detached with the
electrocautery, exposing a 6 × 6-cm area of the ilium. An
osteotome is used to split the exposed posterior iliac crest.
This will provide a piece of cortical cancellous bone ap-
proximately 6 × 6 cm in size. Gouges are then used to
obtain strips of cancellous bone (Fig. 2). As much bone
as possible is removed, as long as it does not pose the risk
of fracture to the anterior cortical aspect of the posterior
iliac crest. The bone is then placed in bacitracin solution.
The cut surface of the ilium is thoroughly waxed and
packed with an abdominal laparotomy sponge. At the end
of the fusion procedure, the laparotomy sponge is removed
and a Jackson-Pratt drain is inserted in the site. If the area
to fuse is positioned high in the lumbar spine, it may be
necessary to make a separate skin incision directly over
the posterior iliac crest to obtain the bone grafts.
After the bone grafts have been obtained, the
endplates are removed from the facet joints of the seg-
ments to be fused using an osteotome, curette, or high-
speed drill (Fig. 3). All soft tissue is removed from the
lateral masses and transverse processes. The cortical
surfaces of the lateral masses and transverse pro-
cesses are then roughened until they bleed (Fig. 4);
the burr of a high-speed drill can be used for this pur-
pose. Cancellous bone is impacted into the facet
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

© 1992 The American Association of Neurological Surgeons

Figure 1. Positioning for surgery. The prone knee-chest position prevents abdominal compression and allows anteroposterior and
lateral x-ray imaging of the lumbar spine.

360
 CONNOLLY : POSTERIOR-LATERAL LUMBAR SPINAL FUSION

© 1992 The American Association of Neurological Surgeons

Figure 2. A gouge is used to obtain strips of cancellous bone.

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 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

© 1992 The American Association of Neurological Surgeons

Figure 3. The facet joints of the segments to be fused have their cartilaginous endplates removed by osteotome, curette, or high-speed drill.
The inset shows curetting of a facet joint.

362
 CONNOLLY : POSTERIOR-LATERAL LUMBAR SPINAL FUSION

© 1992 The American Association of Neurological Surgeons

Figure 4. The cortical surfaces of the lateral masses and transverse processes are roughened until a bleeding surface is reached.

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 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

spaces (Fig. 5). The bone grafts are placed in a
“matchstick” fashion over the exposed transverse pro-
cesses, bridging the space between the transverse pro-
cesses and the lateral masses (Fig. 6). Donor cancellous
bone may be mixed with the autograft if more bone is
needed. The self-retaining retractors are removed, allow-
ing the muscles to cover the bone grafts.
If the wound is very wet, a Jackson-Pratt drain is
placed over the laminae and brought out through a stab
wound in the flank. The deep fascia is then closed
tightly with interrupted sutures of 0 Vicryl. The lap-
arotomy sponge is removed from the graft site and a
drain is inserted. The superficial fascia is closed with
interrupted inverted sutures of 2-0 Vicryl and the skin

© 1992 The American Association of Neurological Surgeons

Figure 5. Cancellous bone is impacted into the facet joints. The inset shows a magnified view.

364
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© 1992 The American Association of Neurological Surgeons

Figure 6. Bone grafts are placed in “matchstick” fashion over the lateral masses and from transverse process to transverse process on each side.

365
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
is approximated with interrupted mattress sutures of 3-0
nylon. A dry sterile dressing is applied to the wound.
If spinal instrumentation is to be used in conjunction
with the fusion, the spinal instrumentation is inserted and
postinstrumentation x-ray films are taken before the fu-
sion is performed.
POSTOPERATIVE CONSIDERATIONS
Postoperatively, the perioperative antibiotics are discontin-
366
ued after 48 hours and the drains are removed. Postopera-
tive pain is controlled with a parenteral central access pump
and intramuscular Toradol. The patient is then placed in
the preformed clamshell thoracolumbar standing orthosis
(TLSO) brace and ambulation begins at 48 hours. The pa-
tient is kept in elastic stockings for the first two weeks. The
patient is kept in the TLSO brace until bony fusion occurs
radiographically. This brace may be removed while in bed
and to shower but otherwise it is worn at all times.
 CORRECTION OF EXORBITISM
CONSTANCE M. BARONE, M.D.
RAVELO V. ARGAMASO, M.D.
DAVID F. JIMENEZ, M.D.
JAMES T. GOODRICH, M.D., PH.D.
INTRODUCTION
Exorbitism or proptotic eyes secondary to craniofacial
dysostosis is a consequence of shallow orbital sockets and
is not due to enlargement of the orbital contents. There-
fore, corrective surgery for this problem consists of in-
creasing the depth of the orbital cavities. This correction
may be undertaken in two operations: as a fronto-orbital
advancement done at three to six months of age, and later
midface advancement done after the age of four years,
preferably during adolescence. The midface operation
should not be performed in the very young because their
tooth buds are located high up in the maxilla and the os-
teotomies will disrupt them, leading to severe dental prob-
lems as the child grows. Some surgical teams have cho-
sen to perform both operations as a single step procedure,
i.e., the monobloc advancement. There is a much greater
© 1992 The American Association of Neurological Surgeons
© 1992 The American Association of Neurological Surgeons
Figure 1. A-C, three views of a patient with exorbitism.
367
risk of infection with the monobloc procedure and that,
along with the high incidence of tooth bud disruption,
has led us to perform a two-stage procedure.
Exorbitism and midface retrusion are commonly ob-
served in craniofacial dysostosis, e.g., Crouzon’s and
Apert’s syndromes. Exorbitism, however, may occur with-
out any midface deformity or dental malocclusion, as is
demonstrated in the patient presented here. Correction in
this particular case could be accomplished by orbitonasal
osteotomies through bicoronal, lower lid, and buccal in-
cisions. The principle in such surgical procedures is to
restore a satisfactory aesthetic balance by recontouring
the face with both advancements of bone units and onlay
grafts if necessary. Our craniofacial team has elected to
do our facial onlays and reconstructions with calvarial
bone. Because it is membranous, the use of this type of
graft lessens significantly the risk of graft resorption,
which occurs occasionally with rib (endochondral bone)
grafts. However, the techniques of both calvarial bone and
rib harvesting will be discussed.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
PREOPERATIVE EVALUATION
At the Montefiore Medical Center all patients with cranio-
facial disorders are evaluated at the Center for Craniofa-
cial Disorders. The patient is evaluated by specialists
from the fields of pediatrics, pediatric neurology, pedi-
atric neurosurgery, genetics, plastic surgery, ophthal-
mology, dentistry, dentofacial surgery, otolaryngology,
and speech therapy. All patients have plain x-ray films
of the face and skull as well as computed tomography
(CT) scanning with bone windows in axial and coronal
planes. We now routinely use three-dimensional CT
scan reconstruction preoperatively. With the software
programs available we can perform measurements and
surgical osteotomies on the reconstructed CT model
preoperatively. With this technique we are able to cal-
culate the amount of advancement as well as the amount
of bone to be harvested for the reconstruction. We have
not found magnetic resonance imaging to be helpful in
these cases.
OPERATIVE PREPARATION
We routinely start an antistaphylococcal antibiotic at the
start of the operation. Because the surgical manipulations
are all extradural, we do not routinely use anticonvulsant
medications or steroids.
Because there is considerable bone harvesting and
multiple osteotomies in these procedures, the surgical team
should be prepared for blood loss that is significant enough
to require transfusion. If the family is interested, we rou-
tinely plan for pedigree (donor directed) blood donations.
If available, a cell saver unit can rescue up to 50% of the
patient’s lost blood volume. Because of the risk of exten-
sive blood loss, all patients require at least two large-bore
intravenous lines of 16 gauge or larger. If there is any
history of cardiac or pulmonary problems, we routinely
put in a central venous pressure line. An arterial line is
mandatory for monitoring blood gases, hematocrit, elec-
trolytes, etc. during the procedure.
For an advancement of the orbital rims alone, 2 units
of packed red blood cells are made available. However, if
the midface is also included in the advancement (i.e., a
LeFort III disconnection), 4 units of packed cells are made
available. If a LeFort III disconnection is planned and the
patient is to be placed in intermaxillary fixation, then a
tracheostomy should be considered. If the orbital rims
alone are all that will be advanced, as in this case, then we
routinely use orotracheal intubation. Ideally, the endotra-
cheal tube should be sutured to the gingiva, around a tooth
using a heavy silk suture, to prevent inadvertent extuba-
tion during the operation.
To protect the eyes from corneal abrasions and expo-
sure during the procedure, all patients have bilateral tarsor-
rhaphies prior to formal draping. If corneal shields are
368
available. these may be used in place of the tarsorrhaphies.
OPERATIVE TECHNIQUE
Positioning
The patient is placed in the supine position with the
head resting on a cerebellar (horseshoe) head rest. The
head is placed in a slightly extended, brow-up posi-
tion. Rigid fixation devices like a Mayfield clamp are
specifically avoided because the surgeon will need to
move the head (although usually never more than 10 to
15°); this flexibility is essential during the operation
to provide various views of the facial region. Anesthe-
sia equipment is on the left side of the patient, placed
below the patient’s shoulder level. The operating sur-
geon is placed at the head of the patient with the assis-
tant to the right of the surgeon. The instrument tray
comes in over the patient’s abdomen but is positioned
no higher than the midthoracic region. The surgical
team therefore has access to both sides of the patient’s
head as well as intraoral access. For this reason we avoid
the use of bulky overhead tables which reduce access
and visualization of the face.
Draping
Because a bicoronal incision as well as intraoral and in-
fraorbital incisions will be used, the entire face and mouth
must be prepared in addition to the scalp. The mouth is
irrigated copiously with Betadine solution and the nares
are also cleansed with cotton swabs soaked in Betadine
solution. The head is shaved along the proposed bicoronal
incision for a width of about 1.5 cm. We no longer do full
head shaves. Patients (or their parents) are quite appre-
ciative of being able to comb the hair over the wound one
week later. We have had no increased incidence of wound
infections since starting this technique more than five
years ago. The head and entire face are then cleaned with
Betadine scrub, cleansed with alcohol, and painted with
Betadine solution.
In an adult, the bicoronal incision site is then in-
jected with 0.5% lidocaine and a 1:200,000 epinephrine
solution. In a child (less than seven years old) we use
0.25% lidocaine and a 1:400,000 epinephrine solution.
Sterile towels are placed below the posterior portion of
the bicoronal incision and are also stapled to the poste-
rior aspect of the scalp. A facial drape is then placed
over the lower lip, chin, and endotracheal tube. It is im-
portant that the drapes are loose so that the head can be
moved during the procedure.
We routinely run all our suction lines, cautery
cords, etc. toward the foot of the patient. Because the
surgical team sits, this allows easy mobility of the
 BARONE ET AL. : CORRECTION OF EXORBITISM
chairs (i.e., the chairs are not rolling over the cords and
tubes).
Because the operative site is heavily irrigated during
the procedure, it is important to have waterproof outer
drapes. Some of the newer drape designs have large plas-
tic bags for fluid collection; we have found these to be
quite useful.
Skin Incisions and Flap Elevation
To gain access to the frontal bone, the supraorbital rims,
and the nasal bridge, a bicoronal scalp incision is used.
This incision is carried from tragus to tragus, well behind
the hairline. A full thickness skin flap is elevated, leaving
the pericranium intact. The pericranial flap is then elevated
separately as a second layer. Frequently the supraorbital
nerve and artery are encased in a bony canal along the
supraorbital rim; they can be freed by removing the ante-
rior wall of the supraorbital canal with an osteotome or
small Kerrison punch. The temporalis muscles are left
intact and are elevated in a fan-shaped fashion from each
temporal fossa using a monopolar electrocautery.
The dissection is carried forward and over the su-
praorbital rims following the subperiosteal plane and ex-
tending into the orbits to a depth of about 1.5 cm. The
lateral portions of the orbit and the frontozygomatic pro-
cess are also exposed on each side. To gain access to the
inferior orbital rims, a lower eyelid incision is made on
each side at the junction between the lower lid skin and
the cheek skin. This incision is carried through the or-
bicularis oculi muscle onto the infraorbital rim.
Subperiosteally, the orbital contents are elevated off the
orbital floor to a depth of approximately 3 cm. The me-
dial orbital contents as well as the lateral inferior orbital
contents are elevated in a similar manner. Care is taken to
preserve the infraorbital nerve. As an alternative, a
subciliary incision can be used; however, this makes the
dissection somewhat more difficult and introduces the
possibility of an undesirable postoperative ectropion and/
or ciliary inversion. At this point, the entire orbital con-
tents are freed from their bony encasement in a subperi-
osteal plane.
Next an intraoral, transbuccal incision is performed
which extends across the midline of the pyriform aper-
ture. The pyriform aperture and maxilla are exposed fol-
lowing the subperiosteal plane. Once again, care must be
taken to protect the infraorbital nerves. Gentle retraction
of the globes should be observed at all times.
Calvarial Bone Harvesting
A large amount of calvarial bone is readily exposed via the
bicoronal incision. Calvarial bone can be harvested utilizing
one of two methods. The first method requires a craniotomy.
369
A full thickness piece of calvarial bone is removed and then
split along the diploic space using the Midas Rex drill with
a C-1 attachment and a reciprocating saw. The thickest bone
is found over the parietal region. Once the bone has been
split, the inner table is placed back in the donor site. The
outer table is then used for reconstruction (the outer table
has smoother contours, making it better for the aesthetic
reconstruction). A second technique for bone harvesting
does not require a craniotomy. A trough is developed around
the edges of the proposed piece of bone. The trough is
easily created with an olive tip drill. Curved osteotomes are
then used to split the calvarium along the diploic space,
thereby elevating the outer table. Care must be taken to
avoid getting too deep because the dura can be torn inad-
vertently. It is best to harvest a bone graft from the side of
the nondominant hemisphere.
Rib Graft Harvesting
Another technique for bone harvesting is the rib graft tech-
nique. This is easily done via an inframammary incision.
Through this incision, adjacent ribs can be removed; usu-
ally ribs 6 and 7 are selected. The ribs are dissected by
first incising the anterior periosteum and then using a Key
periosteal elevator to raise the anterior periosteum from
the rib. An Alexander elevator is used to strip the superior
and inferior borders of the rib free. A Doyen periosteal
elevator is then used to separate the posterior (or deep)
periosteum from the undersurface of the rib. Care must
be taken not to injure the underlying pleura.
Prior to closure, irrigation with saline is performed
while the anesthesiologist manually inflates the lungs to
check for bubbling, a sign of an air leak. If a leak is found,
the pleura has been entered inadvertently during the dis-
section. The tear should be repaired and a small red rub-
ber tube (No. 10F) placed into the pleural space. The tube
is then placed to low water-seal suction (approximately
20 ml water pressure). The donor site is closed in layers.
When the patient is in the recovery room, an x-ray film of
the chest is obtained. If there is no evidence of a pneu-
mothorax, the chest tube is removed and an occlusive
petroleum gauze dressing is applied.
The harvested ribs are split along the superior and
inferior borders using an osteotome and contoured using
a Tessier rib bender. This technique doubles the available
amount of rib bone for grafting.
Craniofacial Osteotomies
With a reciprocating saw, the osteotomy is initiated
across the nasal radix and extended to the medial or-
bital walls above the level of the lacrimal fossa. This
area is easily approached via the bicoronal incision.
Laterally, the osteotomy extends on the frontozygoma-
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

© 1992 The American Association of Neurological Surgeons

Figure 2. Artistic reconstruction showing the various osteotomies and bone onlays.

370
 BARONE ET AL. : CORRECTION OF EXORBITISM
tic process. This is done in a stepwise fashion, with the
assistant using a malleable retractor to protect and retract
the orbital contents. During this stage of the operation,
the anesthesiologist should monitor the vital signs closely;
if there is too much traction on the globe, the blood pres-
sure will increase and the heart rate will decrease.
An osteotomy is then made across the orbital floor,
back about 1.5 cm from the orbital rim. This osteotomy,
most easily done via the lower lid incision, is extended
across the medial orbital wall, finally connecting the os-
teotomy lines of the medial orbital walls together. During
this dissection it is mandatory to protect the orbital con-
tents with a malleable retractor. Outside the orbits the lat-
eral cut continues along the body of the zygoma and then
proceeds medially, below the infraorbital foramen and
toward the pyriform aperture of the nose. This osteotomy
is done through an intraoral approach. The process is re-
Figure 3. Artistic reconstruction showing the bone onlays
from a lateral view.
371
peated on the opposite side. The nasal septum is cut after
a submucosal dissection has been performed. All the os-
teotomy lines should now be connected.
The thin bones are easily fractured as the orbitonasal
unit is mobilized in a forward and slightly downward di-
rection. The spur that is developed in the inferior segment
is made to abut against the rim of the superior segment
after the lower part of the orbit is advanced. Autogenous
bone blocks obtained from the split calvaria (or split rib)
are impacted into the nasofrontal and zygomatic defects
and secured in place using miniplates, microplates, or wires.
Split rib grafts or split calvarial grafts are then laid over the
gaps created over the maxilla and orbital floors. Additional
strips of either rib grafts or calvarial grafts are placed and
either wired or lag screwed to the supraorbital rims. The
pericranial flap is then placed over the superior orbital rims
and the bone grafts in this area.
© 1992 The American Association of Neurological Surgeons
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
© 1992 The American Association of Neurological Surgeons
Figure 4. A-C, postoperative views of the patient one year after surgery.
Closure
It is especially important to use extreme care with the
globes and lacrimal system during the orbital dissection.
If not, a fistula can occur. If proper care is not taken with
the medial osteotomies, the surgeon may inadvertently
extend into the cribriform plate and thus enter the ante-
rior cranial fossa. If this happens, there is the possibility
of a dural tear and subsequently a cerebrospinal fluid
(CSF) leak. It is often useful at the end of the operation,
prior to elevating the skin flap, to have the anesthesiolo-
gist perform an extended Valsalva maneuver while the
surgeon looks for a CSF leak. If a CSF leak occurs in the
postoperative period, a lumbar spinal drain placed for five
to seven days usually corrects the problem. If not, the
patient has to be reexplored and the leak sealed.
Closure of the bicoronal incision begins with copi-
ous irrigation and hemostasis. Particular attention must
be paid to the skin folds and the gutter space that devel-
ops because debris collects here and offers the most po-
tential for infection. The temporalis muscles are then laid
back in their proper position and secured into place using
Vicryl sutures. These sutures are easily placed through
the holes of the microplates or through holes made in the
frontal bone. A drain is placed and attached to light suc-
tion for 48 hours. Scalp closure is accomplished using
both the galeal layer and the skin layer. The lower eyelid
skin incisions are closed in a single layer using fine nylon
372
(less than 5-0) which must be applied meticulously to re-
duce scarring. The mouth is again irrigated with Betadine
solution and the transbuccal incision closed using a single
layer of absorbable sutures. The tarsorrhaphy sutures are
then removed and the eyes irrigated with a balanced salt
solution. Lacri-Lube is placed in both eyes and a head
dressing is applied.
POSTOPERATIVE CARE
Intensive care monitoring for at least 48 hours postopera-
tively is highly recommended in these patients. Because
of the blood loss that can occur and the risk of epidural
hematoma formation, hemodynamic monitoring is man-
datory.
The patient is kept on antibiotics for three days post-
operatively. The patient takes a clear liquid diet for three
days and then advances to a soft diet, rinsing the mouth
with saline between meals throughout this period. After a
period of one to two weeks, the patient usually may resume
a regular diet. There will be significant postoperative peri-
orbital swelling, especially by the third postoperative day,
but this resolves gradually. It is often helpful to warn the
parents and patient of this swelling preoperatively.
The bone grafts may undergo resorption with time.
If this happens, the patient may require future contour-
ing. As mentioned previously, there is evidence that cal-
varial bone undergoes less resorption than rib grafts.
 MERALGIA PARESTHETICA
SETTI S. RENGACHARY, M.D.
Meralgia paresthetica is a syndrome caused by entrap-
ment of the lateral femoral cutaneous nerve of the thigh
in the inguinal region.
ANATOMY
The lateral femoral cutaneous nerve arises from the lum-
bar plexus from the primary rami of the second and third
lumbar nerves (Fig. 1). It is a pure sensory nerve which
emerges from the lateral border of the psoas major muscle
and courses downward and forward toward the iliacus
muscle and then obliquely toward the anterior superior iliac
spine. It lies deep to the iliacus fascia. It passes from the
pelvis into the thigh beneath the inguinal ligament 1 to 2
cm medial to the anterior superior iliac spine. The nerve
actually pierces the lateral attachment of the inguinal liga-
ment to the anterior superior spine. There is a complex mesh
of fascia in multiple planes beneath the lateral attachment
of the inguinal ligament. The mesh is formed by a
confluence of fascial structures consisting of the follow-
ing: 1) the deeper layer of the inguinal ligament; 2) the
fibroaponeurotic origin of the sartorius muscle; 3) fascial
connections between the inguinal ligament and fascia lata;
and 4) the fibrotendinous attachment of the internal ob-
lique muscle to the anterior superior iliac spine. It is more
accurate to state that the lateral femoral cutaneous nerve of
the thigh pierces this complex mesh of fascia rather than to
depict simplistically the nerve piercing the inguinal liga-
ment. After leaving the pelvis, the nerve descends under
the fascia lata for about 4-6 cm and then pierces through
the fascia. It divides into two or three anterior and poste-
rior branches (Fig. 2A).
The most common mechanism of compression of the
nerve is through downward traction by the fascia lata when
the patient is upright. When the hip is fully extended, the
traction seems to be the worst as is the compression on
the nerve; thus, patients are most symptomatic in the up-
right position but are comfortable in the recumbent posi-
tion because of the relaxation of the fascia lata. The lat-
eral femoral cutaneous nerve supplies an extensive area
© 1992 The American Association of Neurological Surgeons
373
in the anterolateral and posterior thigh and the gluteal
region (Fig. 2B). In patients with a compression syndrome,
only the anterolateral part of the thigh shows subjective
and objective sensory findings. This implies that the fi-
bers subserving the anterior thigh are immediately under
the ligament and thus are more prone to compression than
the posterior fibers.
PATIENT SELECTION
It is to be stressed that only a small fraction of patients
who present with typical symptoms of meralgia
paresthetica ever come to surgery. In most instances the
disease is self-limited and conservative treatment is suf-
ficient. Conservative treatment consists of the following
measures. Because these patients are generally obese, a
weight reduction program may be helpful, although most
of the time the patients are not compliant. Compressive
devices such as belts, trusses, or corsets should be avoided.
Infiltration with 3 to 5 ml of 0.5% Marcaine with epi-
nephrine and a steroid preparation may alleviate the symp-
toms temporarily. If the symptoms started because of un-
accustomed prolonged standing or running, these activities
should be curtailed temporarily to see whether the symp-
toms resolve. No surgery should be considered during
pregnancy because the phenomenon may be transient.
Patients generally come to surgery when the pain
becomes intractable and remains constant whether they
are standing or recumbent. A local anesthetic block not
only helps in the diagnosis but also confirms that there is
no anatomic variation in the nerve in relation to the ante-
rior superior iliac spine. If the patient does not benefit
from the block it may imply that there may be a higher
lesion such as a lesion of the lumbosacral plexus or cauda
equina. If there is no anesthesia demonstrated in the dis-
tribution of the lateral femoral cutaneous nerve after the
block, it may imply that there may be an anatomic varia-
tion of the nerve; for example, the nerve may be far more
medial than is usually described.
DIAGNOSTIC STUDIES
I depend entirely on the clinical features to establish
the diagnosis of meralgia paresthetica. Electromyogra-
phy and nerve conduction velocity studies are or-
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

© 1992 The American Association of Neurological Surgeons

Figure 1. The origin, course, and distribution of the lateral femoral cu- major muscle and the fascia have been removed. All branches of the
taneous nerve of the thigh. On the right side of the specimen, the psoas lumbar plexus are not shown.

374
 RENGACHARY : MERALGIA PARESTHETICA

© 1992 The American Association of Neurological Surgeons

Figure 2. A, the anatomy of the lateral femoral cutaneous nerve in the thigh. B, the sensory distribution of the lateral femoral cutaneous nerve.

375
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
dered primarily to rule out other lesions such as lesions of
the lumbosacral plexus or cauda equina roots. Sensory nerve
conduction studies of the lateral femoral cutaneous nerve,
especially in obese individuals, are technically difficult and
often unreliable. If the patient has any sensory loss outside
the distribution of the lateral femoral cutaneous nerve or has
motor weakness or reflex change, further diagnostic proce-
dures should be considered such as magnetic resonance im-
aging of the lumbar spine and of the retroperitoneal area.
OPERATIVE TECHNIQUE
Anesthesia
I always use general anesthesia. Local anesthesia is gen-
erally to be avoided because sometimes the exploration
of the nerve is tedious and may take longer than expected.
Also, in obese people, one may have to retract the ab-
© 1992 The American Association of Neurological Surgeons
Figure 3. A, the skin incision conventionally used to expose the lateral
femoral cutaneous nerve. B, the skin incision used by the author.
376
dominal panniculus considerably to expose the inguinal
area and this may be very uncomfortable for the patient.
Because one does not intend to use nerve stimulation
during the procedure, a muscle relaxant may be used to
allow easy retraction of the abdominal wall.
Positioning
The operation is done with the patient lying comfortably
in the supine position on a cushioned mattress on the op-
erating table. The lateral inguinal area is shaved, prepared,
and draped in a conventional manner.
Surgical Technique
The conventional incision often used is a horizontal in-
cision just below the inguinal ligament, extending from
below the anterior superior iliac spine for about 5 cm
parallel to the ligament (Fig. 3A). However, I find a
 RENGACHARY : MERALGIA PARESTHETICA

lazy S incision starting just above and medial to the ante-
rior superior iliac spine and descending down and across
the inguinal ligament toward the anterior thigh to be more
convenient, requiring less retraction and allowing easier
longitudinal exploration of the nerve without undue trac-
tion on the skin edges (Fig. 3B). This is of special consid-
eration in obese individuals.
Self-retaining Gelpi retractors are inserted. A
Richardson retractor may be used to retract the abdomi-
nal panniculus upward. The dissection is started at the
lower end of the exposure. The fascia lata is incised at
the anterior border of the sartorius muscle, and the inci-
sion in the fascia is carried cephalad up to the inguinal
ligament (Fig. 4A). The nerve can usually

© 1992 The American Association of Neurological Surgeons

Figure 4. A, sectioning of the fascia lata at the anterior border of the

sartorius muscle. B, sectioning of the superficial portion of the inguinal
ligament. C, sectioning of the fascial bands posterior to the nerve.

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 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

© 1992 The American Association of Neurological Surgeons

Figure 5. A, sectioning of the nerve distal to the inguinal ligament. B, twisting of the nerve around a hemostat under traction.
C, sectioning of the nerve just distal to the ligament.

378
 RENGACHARY : MERALGIA PARESTHETICA
be identified just at the anterior border of the sartorius
muscle, descending obliquely across the muscle. It is best
to identify the nerve under the deep fascia rather than
superficial to it because the fat globules may simulate the
nerve and it is harder to identify the nerve within the thick
subcutaneous layer of fat in the thigh. Magnifying loupes
(3.5 ×) are used to facilitate surgical dissection.
The nerve is then traced cephalad to the inguinal liga-
ment, and at this point the superficial portion of the in-
guinal ligament is divided, unroofing the canal in the in-
guinal ligament through which the nerve passes (Fig. 4B).
The nerve is retracted forward with a nerve hook, and the
mesh of fascial bands posterior to the nerve is divided
sharply (Fig. 4C). At the end of the decompression, the
surgeon should be able to easily pass an index finger all
around the nerve and feel only soft yielding tissue with-
out any sharp fascial bands.
If the nerve is not found in the usual location, the
subcutaneous dissection should be extended medially for
about 4 cm to the femoral area and laterally over the ante-
rior iliac spine. If after such mediolateral dissection the
nerve is still not identified, the inguinal ligament and all
the fascial bands extending from the inguinal ligament to
the sartorius fascia and the iliac fascia can be sectioned.
Merely reducing the tensile force in the inguinal ligament
ameliorates the symptoms, but of course this is done only
in exceptional circumstances where exhaustive explora-
tion is unsuccessful in finding the nerve.
I do not believe in transposing the nerve medially
because, as is well known, the nerve is bound by the iliac
fascia within the pelvis and simply moving the nerve
379
medially will not alter the course of the nerve in its proxi-
mal part within the pelvis. It may actually cause a kink
because the proximal part is bound by the iliac fascia and
is held tight against the iliacus muscle. At the end of the
procedure, I infiltrate 0.5% Marcaine with epinephrine
around the nerve so that the patient will not have dyses-
thesia in the nerve distribution in the immediate postop-
erative period.
Avulsion of the nerve is an older procedure and I do
not recommend it. It leaves an area of numbness in the
lateral part of the thigh, and there is risk of formation of a
neuroma, which causes persistent pain. The technique, if
one elects to do it, involves sectioning the nerve just
slightly distal to the inguinal ligament (Fig. 5A), grasping
the nerve with a hemostat, rotating it under tension (Fig.
5B), and sectioning the nerve just distal to the ligament
(Fig. 5C) so that it will retract upward from its site of
constriction. To reiterate, this is not a preferred method.
COMPLICATIONS
In some instances, the patient may wake up with transient
paresthesia in the immediate postoperative period. To
avoid this, I generally use Marcaine at the end of the pro-
cedure so that the patient will have complete relief. Per-
sistence of symptoms implies insufficient sectioning of
all the fascial connections beneath the inguinal ligament
and the iliac fascia. Other complications include wound
infection and hematoma formation, which can be avoided
by the use of meticulous surgical techniques. I have not
seen an occurrence of an inguinal hernia from sectioning
of the lateral attachments of the inguinal ligament.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
DEPRESSED SKULL FRACTURE
IN INFANTS
LYN C. WRIGHT, M.D.
MARION L. WALKER, M.D.
INTRODUCTION
The depressed skull fracture in infants under one year
of age differs from depressed fractures in the older age
groups. This is due to the relative plasticity of the skull
which is not yet fully ossified. These fractures, referred
to as “ping pong ball” fractures because of their re-
semblance to an indented ping pong ball (Fig. 1, A and
B), may be treated by a more conservative surgical pro-
cedure than the typical depressed skull fracture re-
quires. The surgery is generally nonemergent but should
be done within the first 72 hours before the bone be-
gins to heal, making the elevation of the fracture more
involved surgically.
It has been reported that in newborns the bone will
eventually remodel without any surgical intervention. This
may indeed occur, but signs of remodeling of the bone
should begin within a few days. It is our belief that pro-
longed pressure of the bone on the cortex may precipitate
a seizure focus, and the possibility of a dural laceration is
unknown; therefore, we believe that elevation of the frac-
ture is beneficial. The potential risks of the surgery are
infection, intracranial hematoma formation, and blood
loss. However, with good surgical technique the possibil-
ity of complications is extremely low.
ANESTHETIC CONSIDERATIONS
Anesthetic considerations are very important in this young
age group. Current studies suggest that the child should
have nothing by mouth for at least three hours after drink-
ing clear fluids and for four to six hours after ingesting
formula or milk. Good intravenous access is essential and
whole blood should be available. Preoperatively the child
is typed and screened for blood. After the induction of
anesthesia, prophylactic antibiotics are given; the child
also is given three doses of antibiotics postoperatively.
© 1992 The American Association of Neurological Surgeons
380
Increased intracranial pressure usually is not a prob-
lem, but if there is any concern regarding pressure, an
awake intubation would be the safest approach. Narcot-
ics should be avoided in this age group. It is recommended
that the arterial oxygen saturation levels be maintained at
90-93%.
The young infant has difficulty maintaining body
temperature due to decreased insulation and the large
amount of body surface area of the head. Heat loss should
be a major concern. The room must be kept warm. When
the child is exposed, warming lights should be used. A
heating blanket is always placed on the operating room
table. Warming the anesthetic gases also helps to prevent
hypothermia.
OPERATIVE TECHNIQUE
The child is positioned on the operating table with a roll
placed behind the back to create a 45° angle between the
patient and the table (Fig. 1C). The head is turned to lie
directly lateral. The partial lateral position of the body
relieves any potential stress to the cervical musculature
and ensures that there will be no obstruction of venous
return. The hair is then shaved in a pattern extensive
enough to encompass a scalp incision surrounding the
fracture should this become necessary. When the child is
draped, an area large enough to accommodate a larger
incision around the fracture site should be allowed.
The initial incision should be approximately 1.5 cm
in length along the suture line nearest to the depressed
fracture, generally the coronal suture, and at least 2 to 3
cm from the midline (Fig. 2A). The periosteum is opened
with a Bovie electric cautery. A periosteal elevator is used
to free the periosteum and delineate the bone edge at the
suture line (Fig. 2B). The periosteal elevator is then used
to strip the dura from the bone in a sweeping fashion until
the depression of the bone is reached (Fig. 2C). With con-
sistent gentle upward pressure, the periosteal elevator is
used to lever the bone from a concave to a convex posi-
tion (Fig. 3).
 WRIGHT AND WALKER : DEPRESSED SKULL FRACTURE IN INFANTS

© 1992 The American Association of Neurological Surgeons

Figure l. A and B, the depressed skull fracture in an infant resembles an placed supine, the shoulder is elevated 45°, and the head is turned to a
indentation in a ping pong ball. C, for operative treatment, the child is lateral position.

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© 1992 The American Association of Neurological Surgeons

Figure 2. A, a 1.5-cm incision is made along the suture line near- the epidural space beneath the fracture. C, the periosteal elevator
est the fracture (ordinarily the coronal suture) and a periosteal el- is used in a sweeping motion, with upward pressure to elevate the
evator is inserted. B, the elevator is passed through the suture into fracture.

382
 WRIGHT AND WALKER : DEPRESSED SKULL FRACTURE IN INFANTS
© 1992 The American Association of Neurological Surgeons
Figure 3. The periosteal elevator is passed through the suture (A),
is advanced into the epidural space beneath the fracture site (B),
In many cases, there will be a snap as the bone re-
sumes its normal contour. The bone can splinter, and gentle
sweeping motions while continuing upward elevation may
be necessary. Care should be taken not to push the instru-
ment through a fracture line if one is present. Counter
pressure is obtained by the surgeon placing the thumb or
index finger of the other hand over the defect as pressure
is exerted from below the fracture. This technique allows
for greater control.
Once the bone is elevated, the wound and epidural
space are irrigated to ensure hemostasis. The galea is
383
and is used to lever the depressed bone back into a normal convex
position (C).
closed with 4-0 absorbable sutures in a simple interrupted
fashion. After an adhesive substance has been placed on
the skin, it is approximated with sterile adhesive strips.
CONCLUSIONS
The depressed skull fracture in the infant under one year
of age can be treated safely and effectively by the method
described. The hospital stay is usually 48 to 72 hours. The
results are good and long-term sequelae are avoided. The
child is exposed to very little risk while undergoing this
procedure.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
COMBINED PRESIGMOID-
TRANSTRANSVERSARIUM
INTRADURAL APPROACH TO
THE ENTIRE CLIVUS AND ANTERIOR
CRANIOSPINAL REGION
MARIO AMMIRATI, M.D.
MELVIN CHEATHAM, M.D.
INTRODUCTION
The clivus and the anterior craniocervical junction can
be approached surgically in a variety of ways. Standard
retrosigmoid, suboccipital craniectomy approaches to the
clivus and to the craniocervical junction require retrac-
tion of the cerebellum and sometimes the brain stem. In
addition, it is sometimes necessary to amputate the lat-
eral one-third of the cerebellum in order to improve ac-
cess to this area. Even then, exposure along the clivus
and at the basilar tip may not be satisfactory.
The far lateral transcondylar approach also offers
excellent exposure of the upper cervical canal, the craniospi-
nal junction, and the lower and middle clivus, but access
to the upper clivus, to Meckel’s cave, and to the posterior
portion of the cavernous sinus is limited.
Transoral approaches to the clivus offer excellent
exposure of the upper, middle, and lower clivus, and, with
odontoidectomy, the upper cervical spinal canal can be
accessed. Lateral exposure is very limited in this expo-
sure due to the position of the carotid arteries.
Subtemporal and other middle cranial fossa
transpetrosal approaches to the petroclival area offer ex-
cellent exposure of the petrous ridge and the upper clivus
and basilar tip, as well as the tentorial notch and the pos-
terior cavernous sinus. However, access to the lower cli-
vus and upper cervical canal is not possible.
The transcochlear approach to the clivus with rerout-
ing of the facial nerve accesses the upper and middle cli-
vus. Lesions extending to the lower clivus or to the anterior
© 1992 The American Association of Neurological Surgeons
384
craniospinal region are visualized suboptimally. Hearing
is lost due to removal of the labyrinth and cochlea.
The combined supra-infratentorial presigmoid sinus
avenue to the petroclival region affords superb visualiza-
tion of the upper and middle clivus and bordering areas.
Still, access to the lower clivus or anterior craniospinal
region is confined or lacking.
The combined presigmoid-transtransversarium ap-
proach has been developed as a sound neuroanatomic
route to the entire length of the clivus. It is a newly de-
scribed modification, and union, of the far lateral approach
and the presigmoid approaches to this region. This new
approach can be utilized in surgery of neoplasms which
involve extensively the clivus and the craniocervical re-
gion, such as chordomas, meningiomas, and glomus tu-
mors. In addition, it may offer improved access to aneu-
rysms and arteriovenous malformations in this area.
SURGICAL PROCEDURE
This operative procedure is best done with the patient in
a semisitting position with the head immobilized in a
Gardner-Wells head holder. The head is turned 30° to-
ward the side of the lesion; 10 to 15° of flexion of the
head will improve dissection at the craniocervical level
(Fig. 1).
A curvilinear skin incision is started above the ear in
the posterior temporal region. It is extended suboccipitally
1 cm medial or posterior to the inner mastoid edge to the
level of C2-3 and then curved anteriorly toward the poste-
rior border of the sternocleidomastoid muscle (Fig. 2).
A scalp flap is developed, and the trapezius muscle
 AMMIRATI AND CHEATHAM : PRESIGMOID-TRANSTRANSVERSARIUM INTRADURAL APPROACH
Figure 1. The patient’s position.
is exposed, thus revealing the greater occipital nerve as it
pierces the trapezium muscle at its attachment to the oc-
ciput at the nuchal line. The trapezium muscle is then in-
cised and separated from the occiput with preservation of
the greater occipital nerve. The margins of the trapezium
muscle medially and the sternocleidomastoid muscle lat-
erally are developed and then separated off the underly-
ing muscle layer. This allows visualization of the semi-
spinalis capitis, splenius capitis, and splenius cervicis
muscles as they lie deep to the trapezium and sternocleido-
mastoid muscles (Fig. 3). The greater occipital nerve can
be identified as it passes through the semispinalis capitis
muscle near the occiput, and it is now possible to identify
the lesser occipital and greater auricular nerves in the slit
between the posterior border of the sternocleidomastoid
muscle and the splenius cervicis muscle.
The levator scapulae muscle lies along the floor of
this slit inferiorly as does the external branch of the ac-
cessory nerve. Care must be exercised to avoid injury to
the accessory nerve at this point (Fig. 3). The posterior
portion of the sternocleidomastoid muscle is then sepa-
rated from its mastoid attachment, allowing palpation
of the tip of the mastoid and the transverse processes of
C-1 and C-2. The splenius capitis muscle and the under-
lying longissimus capitis muscle are separated from the
mastoid and turned inferiorly to allow identification of
the greater occipital nerve in the semispinalis capitis
muscle (Fig. 4).
The semispinalis capitis muscle is then cut horizon-
tally just below this point and is reflected inferiorly while
the greater occipital nerve is protected. This exposes the
obliquus capitis inferior and superior muscles and the rec-
tus capitis posterior major and minor muscles (Fig. 5).
385
© 1992 The American Association of Neurological Surgeons
Next, the greater occipital nerve is followed proximally
as it circles the inferior border of the obliquus capitis in-
ferior muscle, to where it joins the C-2 nerve trunk. The
anterior (ventral) branch of the C-2 spinal nerve is identi-
fied and is followed anterolaterally as it crosses the ver-
tebral artery exiting the foramen transversarium of C-2
(Figs. 5 and 6).
The C1-2 joint is identified. The vertebral artery is
then exposed over the posterior arch of C-1, and the
obliquus and rectus muscles are freed from their bony
attachments, allowing exposure of the posterior elements
of C-1 and C-2 all the way to the midline (Fig. 6). The
foramen transversarium of C-1 is unroofed posteriorly
using a thin-plate Kerrison rongeur, exposing the verte-
bral artery which is then freed circumferentially from
above the foramen transversarium of C-2 to its point of
dural penetration medial to the atlanto-occipital joint (Fig.
6, inset).
Freeing the vertebral artery reveals a complex of
venous channels, and also one or more arterial branches
which require transection. The vertebral artery is now
ready to be retracted medially. At this point, attention is
shifted to the mastoid; the digastric incisura is identified
and the posterior belly of the digastric muscle is removed.
The facial nerve is then visualized as it exits the stylo-
mastoid foramen lateral to the digastric incisura, and the
proximal internal jugular vein is identified medial to the
incisura. (Fig. 7).
The posterior arch of C-1, the lamina of C-2, and
the medial portion of the C1-2 joint are removed and
the C-2 spinal nerve is transected close to its dural exit
point (Fig. 8). After careful medial retraction of the
fully mobilized vertebral artery, the medial portion of
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Figure 2. The skin incision and the superficial posterior cervical muscles.

386
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© 1992 The American Association of Neurological Surgeons

Figure 3. The initial stage of the dissection.

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© 1992 The American Association of Neurological Surgeons

Figure 4. The incision in the semispinalis capitis muscle is depicted (dashed line).

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© 1992 The American Association of Neurological Surgeons

Figure 5. The course of the greater occipital nerve is illustrated.

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© 1992 The American Association of Neurological Surgeons

Figure 6. The anterior ramus of the C-2 spinal nerve leads to the vertebral artery. The foramen transversarium of C-1 must be unroofed to
free the vertebral artery (inset).

© 1992 The American Association of Neurological Surgeons

Figure 7. Diagrammatic representation of the relationships among the vertebral artery, the internal jugular vein, and the facial nerve.

390
 AMMIRATI AND CHEATHAM : PRESIGMOID-TRANSTRANSVERSARIUM INTRADURAL APPROACH
the atlanto-occipital joint is drilled away. The drilling is
continued until there is enough space anterior to the ver-
tebral artery dural entry point, but usually not to the point
of entry into the hypoglossal canal. The purpose of the
drilling of this joint is to gain access to the dura anterior
to the vertebral artery dural entry point, which then al-
lows dural opening lateral, or anterior, to the vertebral
artery and medial to the atlanto-occipital joint. This, in
turn, exposes the lower clivus and the upper cervical spi-
nal canal. At this point the cranial and spinal dura should
be exposed in continuous fashion medial to the atlanto-
occipital joint. The lower dura that is exposed is the ante-
rolateral spinal dura, which offers a good view of the an-
terior portion of the spinal canal (Fig. 8).
A medially extended suboccipital craniectomy and a
presigmoid bony removal are then completed (Fig. 9). In
drilling the posterior pyramis, it is necessary to avoid en-
try into the posterior semicircular canal and the endolym-
phatic sac and duct to preserve hearing.
The dura is then opened horizontally above the trans-
Figure 8. Medial retraction of the vertebral artery allows controlled removal of the atlanto-occipital joint.
391
verse sinus on both sides of the petrous ridge (Fig. 9), and
the basal temporal lobe veins (e.g., the vein of Labbé) are
dissected free from their arachnoidal sleeves. The dura is
also cut anterior to the sigmoid sinus down to the jugular
bulb. The craniospinal dura is cut longitudinally, medial
to the sigmoid sinus and lateral, or anterior, to the verte-
bral artery dural entry point while the vertebral artery is
retracted medially.
The superior petrosal sinus is identified and the ten-
torium is transected just medial to it, all the way to the
incisura (Fig. 10). The tentorium is also cut in a
lateromedial direction to develop a tentorial flap, setting
the stage for gentle superior retraction of the
occipitotemporal portion of the brain.
The presigmoid dural opening gives full access to the
petrous apex and the upper and middle clivus. Cranial nerves
III through IX are now clearly visualized (Fig. 11). The
craniospinal dural opening exposes the lower clivus, the jugu-
lar foramen, and the upper cervical spinal cord from the front,
with full control of all neurovascular structures (Fig. 12).
© 1992 The American Association of Neurological Surgeons
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© 1992 The American Association of Neurological Surgeons

Figure 9. The dural incision lines are shown.

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© 1992 The American Association of Neurological Surgeons

Figure 10. The tentorial incision lines are demonstrated.

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© 1992 The American Association of Neurological Surgeons

Figure 11. Cranial nerves III through IX are exposed after a presigmoid dural opening. PICA, posterior
inferior cerebellar artery; AICA, anterior inferior cerebellar artery.

394
 AMMIRATI AND CHEATHAM : PRESIGMOID-TRANSTRANSVERSARIUM INTRADURAL APPROACH
© 1992 The American Association of Neurological Surgeons
Figure 12. The craniospinal dural opening anterior to the vertebral artery dural penetration point allows
excellent exposure of the jugular foramen area (anatomic preparation).
ADVANTAGES OF THIS APPROACH
Historically, neurosurgical approaches to the posterior
fossa skull base have revolved around the simple suboc-
cipital craniectomy. Exposure of the petroclival area, by
this approach, has been limited. The combination of the
presigmoid approach and the far lateral transcondylar ap-
proach, coupled with mobilization of the vertebral artery
(the combined presigmoid-transtransversarium approach),
offers superior access to the entire clivus. In addition, tu-
mors of the upper craniospinal junction can be approached
more safely.
The anterior limit of this approach is represented by
the posterior semicircular canal and the endolymphatic
sac. If these structures are removed, a partial petrosectomy
may be performed, extending to the internal auditory ca-
nal, with consequent improvement in the exposure ante-
rior to the brain stem.
395
POSSIBLE COMPLICATIONS
Extensive lateral bone removal in the upper cervical area
may cause instability, thus necessitating a posterior stabi-
lization procedure. Disturbance of the jugular bulb must
be avoided unless adequate contralateral venous drain-
age has been demonstrated. A total petrosectomy abol-
ishes hearing.
As with any operative procedure performed in the
semisitting position, placement of a central venous
catheter line and Doppler monitoring for air embolism
are indicated to identify and manage this possible com-
plication.
Any posterolateral approach necessitates dealing with
the cranial nerves and vessels which may be positioned
between the surgeon and the tumor that is to be removed.
Any traction on, or disturbance of, these structures can
result in a neurologic deficit.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
PARTIAL MEDIAN CORPECTOMY WITH
FIBULAR GRAFTING FOR CERVICAL
SPONDYLOTIC MYELOPATHY
SETTI S. RENGACHARY, M.D.
INTRODUCTION
Spondylotic myelopathy is a common spinal cord disor-
der encountered frequently by neurosurgeons. As late as
10 years ago, the major goal in the management of
spondylotic myelopathy was to arrest the progression of
the disease rather than to expect a major improvement in
the neurologic outcome. Myelopathy was thought to have
a vascular ischemic basis and thus it was considered to be
an irreversible phenomenon. Recent understanding of the
biomechanics of the cervical spine in patients affected
with spondylosis and autopsy study of the spinal cord in
patients affected with this symptomatology have empha-
sized the mechanical component of the syndrome which
lends itself to surgical correction. The vascular compo-
nent, although significant, occurs only in the end stages
of the disease, and if the myelopathy is detected and treated
early, significant improvement in the symptomatology
may be expected.
Mechanical elements that compress the spinal cord
are either static or dynamic. Static compression occurs
from spondylotic ridges and also from inherent stenosis
of the spinal canal; dynamic compression occurs from
intermittent subluxation of the vertebral segments from
ligamentous laxity and from infolding of the ligamentum
flavum. Any surgical procedure designed to alleviate the
mechanical symptoms should not only eliminate the static
compressive elements but should also stabilize the spine.
Merely decompressing without stabilizing the spine of-
fers no lasting relief of the neurologic symptoms.
Cervical laminectomy, a time-honored decompres-
sive procedure for spondylotic myelopathy, has given sub-
optimal results. The combination of multilevel discectomy,
osteophytectomy, and fusion gives better results than lami-
nectomy but does not expand the sagittal diameter of the
© 1992 The American Association of Neurological Surgeons
396
spinal canal; stenosis is a major underlying factor in pa-
tients with cervical spondylotic myelopathy, superimposed
on the spondylotic process. Although canal expansion with
a laminoplasty procedure seems to be ideally suited to
alleviate the symptoms, it has given varying results and
has not gained uniform popularity to warrant general adop-
tion. Published experience and my experience suggest that
partial median vertebrectomy with strut grafting offers
the best chance for improvement of the symptoms and
signs of cervical spondylotic myelopathy, although no
ideal operation exists for this disease.
PATIENT SELECTION
The most common indication for surgery is the presence
of cord disturbance as manifested by one of the myelopa-
thy syndromes. The spectrum of syndromes includes trans-
verse myelopathy, Brown-Séquard’s syndrome, anterior
cord syndrome, central cord syndrome, syndrome of the
posterior columns, and myeloradiculopathy. The most
common presentation is one of gait disturbance from a
transverse myelopathy in the cervical area. Occasionally,
a patient may present with a central cord contusion syn-
drome after an acute trauma. The rapidity with which the
gait disturbance occurs may vary. In some individuals it
may be slow and insidious over a period of years. In oth-
ers it may be insidious at the outset but rapidly progresses
at the time the patient seeks medical counsel, and in still
others it may be rapid from the very start. In some pa-
tients there may be polyradiculopathy superimposed on
cervical myelopathy. There is hardly a justification for a
vertebrectomy and strut grafting in patients who have pure
radiculopathy, although it may occur at multiple levels.
In some patients with tandem stenosis of the cervical spine
and the lumbar spine, the classical features of spasticity
and hyperreflexia in the lower extremities may be masked
by the presence of lower motor neuron disease because of
cauda equina involvement from lumbar stenosis. In such
 RENGACHARY : CERVICAL SPONDYLOTIC MYELOPATHY
patients, multilevel anterior cervical decompression may
have to be based on imaging studies, especially magnetic
resonance imaging (MRI). The same applies for patients
with preexisting paralysis of the lower extremities from
previous polio or a similar condition affecting the lower
motor neurons. One may be hesitant to offer surgical
therapy in patients with minimal radiologic manifesta-
tions of cervical spondylosis, with myelopathy out of pro-
portion to the changes seen in the imaging studies. Such
individuals may harbor two diseases, an intrinsic degen-
erative spinal cord disease and cervical spondylosis. Those
patients should be warned that they may have an underly-
ing intrinsic spinal cord disorder and the outcome may
not be satisfactory. Thoughtful deliberation and procras-
tination are justified in such a setting. Ossification of the
posterior longitudinal ligament, although rare among
Caucasians, is being recognized increasingly and may
contribute to or aggravate the stenosis from the
spondylotic process.
In selecting patients, an additional criterion is the
systemic condition of the patient. Patients past 75 years
of age who have an advanced degree of osteoporosis and
systemic conditions such as coronary sclerosis and fail-
ing renal function should be treated by extended conser-
vative therapy. In such individuals, a simple laminectomy
with some sort of posterior stabilization may be a simpler
alternative. Patients who have undergone prior decom-
pressive cervical laminectomy without any benefit from
surgery are also candidates for this procedure as long as
the myelopathy is not very advanced. They will certainly
require either halo stabilization after surgery or plate and
screw fixation of the graft. Patients with true congenital
stenosis involving the cervical spine with minimal or no
spondylotic disease but with progressive myelopathy are
also candidates for this operation, because in such indi-
viduals decompressive laminectomy alone offers only
transient relief. An advanced swan neck deformity result-
ing from prior trauma or an extensive decompressive lami-
nectomy may be corrected by multilevel partial median
vertebrectomy and strut grafting. The correction of such
a deformity is easier in individuals whose neck alignment
can be restored by a trial of cervical traction.
PREOPERATIVE PREPARATION
I generally obtain a medical consultation, especially if
the patient is past 70 years of age, to assess cardiac, renal,
and pulmonary functions. Plain x-ray films of the cervi-
cal spine and an MRI scan are the basic studies required
to confirm the diagnosis and plan the operative proce-
dure. Cervical myelography and computed tomography
are done less frequently with the use of MRI. The MRI
study carries additional advantages: intrinsic disorders of
397
the spinal cord such as tumor or syringomyelia may be
ruled out; in the advanced stages of cervical spondylotic
myelopathy, myelomalacia may be apparent which will
predict less favorable results. If an intrinsic disease of the
spinal cord such as amyotrophic lateral sclerosis is sus-
pected, then a neurologic consultation is in order. If there
are any atypical findings in the lower extremities, such as
lack of spasticity and hyperreflexia, the lumbar spine
should be evaluated to rule out the possibility of a tan-
dem stenosis. In patients with ossification of the poste-
rior longitudinal ligament, the entire spine should be stud-
ied radiographically to ascertain the extent of ossification.
In some instances, the ossification may extend well into
the thoracic spine; in such cases, resecting the cervical
vertebral bodies alone may provide inadequate decom-
pression.
SURGICAL CONSIDERATIONS
Anesthesia
General anesthesia is induced. The endotracheal tube is
brought to the left side of the mouth. In short, stocky in-
dividuals it may be necessary to do a nasal tracheal rather
than an oral tracheal intubation because this will facili-
tate closure of the mouth and thus increase the space avail-
able below the jaw. It may be worthwhile to consider fore-
going the use of an oral airway for the same reason. The
endotracheal tube is secured toward the left cheek so that
there is no tape in the right lower jaw close to the skin
incision. Somatosensory evoked potential monitoring is
particularly helpful during dissection close to the spinal
cord. In addition, an arterial line, a large-bore venous can-
nula, and a Foley catheter are inserted. Oxygen satura-
tion is continuously measured through a pulse oximeter.
Patient Positioning
The patient is positioned supine with a rolled sheet or a
1-liter plastic bag containing an intravenous solution be-
hind the neck and upper chest to support the neck and
extend it slightly (Fig. 1). One of the major advantages of
this position is that worsening of the neurologic condi-
tion does not occur from the positioning alone, in con-
trast to posterior decompressive procedures done in the
prone position. To my knowledge no case of worsening
of the neurologic deficit has occurred from slightly ex-
tending the neck. At this point it may be worthwhile to
secure a halo ring and apply a 5-pound traction. If one
anticipates using plate and screw fixation of the bone graft,
halo fixation may not be necessary. The neck and right
hip area are prepared for 10 minutes with povidone-io-
dine soap and painted with povidone-iodine solution for
2 minutes. Draping is routine.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
Skin Incision
There are two choices. A horizontal incision that is used
customarily for anterior discectomy and fusion can be used
if a one- or two-level vertebrectorny is planned (Fig. 2A).
This will provide adequate exposure. In individuals with
a thin, long neck, this incision may be adequate for more
than two vertebral levels if the incision is extended hori-
zontally well across the midline medially and across the
sternocleidomastoid muscle laterally. However, in short,
© 1992 The American Association of Neurological Surgeons
Figure 1. Operative position for a multilevel partial median vertebrec-
tomy with fibular grafting. The patient is positioned supine, with a rolled
sheet or a Miter plastic intravenous solution bag placed under the upper
© 1992 The American Association of Neurological Surgeons
Figure 2. Skin incision. A, for one- or two-level vertebrectomies, a
horizontal incision along one of the skin creases in the neck is suffi-
cient. For multilevel corpectomies in a thin individual with a long
neck, a similar incision may be used but is extended much longer
horizontally to facilitate the greater longitudinal exposure of the spine.
B, in a patient with a short neck or a kyphotic deformity of the cervi-
cal spine. the narrow interval between the mandible and manubrium
398
stocky individuals with chronic obstructive pulmonary
disease and a kyphotic deformity of the neck, a vertically
oriented curvilinear incision gives a more comfortable
exposure of the anterior cervical spine (Fig. 2B). The ver-
tical curvilinear incision starts just below the angle of the
jaw and is carried forward toward the hyoid bone, dropped
down to the sternocleidomastoid muscle, and then angled
forward to the suprasternal notch. The scar resulting from
this incision, however, is less acceptable cosmetically.
chest and neck to provide firm support and extend the neck. A halo ring
has been secured to the head and connected to a 5-pound traction. The
proposed skin incisions in the neck and right hip are shown (dashed lines).
sterni may not allow good longitudinal exposure through a horizon-
tal incision. In such a setting, a vertically oriented curvilinear inci-
sion starting below the angle of the mandible, extending forward
toward the hyoid bone, then dropping down over the sternocleido-
mastoid muscle, and ending in the suprasternal notch will provide
more comfortable exposure of the spine, although it may be less ac-
ceptable cosmetically.
 RENGACHARY : CERVICAL SPONDYLOTIC MYELOPATHY
Operative Technique
Subcutaneous fatty tissue and the platysma muscle
are divided along with the skin incision. It is not nec-
essary to undermine the skin considerably (Fig. 3A),
but the dissection should be carried extensively un-
der the platysma to facilitate extensive craniocaudad
exposure of the spine (Fig. 3B). The subcutaneous
bleeders are coagulated with a bipolar coagulator. A
Figure 3. A, after the skin incision is completed, it is undermined
slightly to define the platysma; extensive undermining in this layer is
unnecessary. B, the platysma is incised along the skin incision and
399
key landmark in the next step is the anterior border of
the sternocleidomastoid. After reflection of the
platysma muscle, the deep investing layer of the cer-
vical fascia is exposed and this fascia is divided along
the entire length of the anterior border of the sterno-
cleidomastoid muscle (Fig. 3C). This exposes the
structures in the carotid triangle. At this point the ster-
nocleidomastoid is retracted laterally. The inter-
© 1992 The American Association of Neurological Surgeons
extensive undermining is carried out under the platysma. C, the in-
vesting layer of deep fascia is divided along the anterior border of
sternocleidomastoid muscle.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

nal jugular vein is generally quite large and full and
drapes across the carotid artery. The major tributar-
ies of the jugular vein are doubly ligated and divided
(Fig. 4). This includes the lingual facial complex of
veins. The superior and inferior borders of the omo-
hyoid muscle are defined by dissecting the fascia
around it and it is then divided. The jugular vein is
retracted laterally, exposing the common carotid and
external and internal carotid arteries. In most instances
it may not be necessary to ligate the superior thyroid
artery, but if this is necessary to facilitate craniad
exposure, the artery can be ligated without hesitation.
The trachea and esophagus are retracted medially with
a hand-held retractor. This exposes the prevertebral fas-

© 1992 The American Association of Neurological Surgeons

Figure 4. The major tributaries of the jugular vein are doubly ligated and divided.

400
 RENGACHARY : CERVICAL SPONDYLOTIC MYELOPATHY
cia which is incised longitudinally (Fig. 5A). The su-
perior and inferior limits of the vertebrectomy are de-
fined by inserting spinal needles into appropriate disc
spaces and taking a lateral radiograph (Fig. 5B). After
confirming the limits of the vertebrectomy, the medial
borders of the longus colli muscle are coagulated us-
© 1992 The American Association of Neurological Surgeons
Figure 5. A, the prevertebral fascia is divided, exposing the vertebral
bodies and intervertebral discs. B, the cranial and caudal limits of the
401
ing electrocautery at a high setting. Then the muscles
are dissected off the vertebral bodies using sharp peri-
osteal elevators and electrocautery (Fig. 6A). Self-re-
taining retractors are then inserted, making sure that
the tips of the retractor blades are caught under the lon-
gus colli muscle, thus preventing any undue pres-
vertebrectomy are defined by inserting 18-gauge needles in the disc
spaces and taking a lateral radiograph.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
sure on the carotid artery. Two self-retaining retractors,
one above and one below, may be necessary for extensive
exposures.
The next step is to cut a core in the anterior longitu-
dinal ligament and the anterior annulus of each of the
intervening discs (Fig. 6B) and remove the nucleus
© 1992 The American Association of Neurological Surgeons
Figure 6. A, using a sharp periosteal elevator, the prevertebral muscles
are dissected off the vertebral bodies and self-retaining retractors are
inserted with the blade tips locked under the muscle edges so that the
402
pulposus of each disc using curettes and pituitary
rongeurs (Fig. 7, A and B). This provides enough room
to use a high-speed drill to remove the cortical endplates
of the vertebral bodies (Fig. 7C). Discectomy and re-
moval of cortical endplates entail minimal blood loss.
Following this the intervening cancellous bone of
carotid artery will not be compressed. B, using a No. 15 blade knife, a
core is cut out of the anterior longitudinal ligament and the anterior
annulus fibrosus at each level.
 RENGACHARY : CERVICAL SPONDYLOTIC MYELOPATHY
the vertebral body is removed quickly in large bites
using a large Leksell rongeur (Fig. 8A). Bleeding from
the cancellous bone, especially from a nutrient artery,
may be controlled by applying bone wax held on the
tip of a peanut gauze held in a hemostat. The bone
wax may be applied to the posterior surface of the
trough that is created but not along the sides, because
the posterior part of the vertebral bodies eventually
will be completely drilled out down to the posterior
longitudinal ligament. On the other hand, application
Figure 7. A and B, using curettes and pituitary rongeurs, the disc mate-
rial is cleared from each disc space. C, the cortical endplates are drilled
403
of wax to the side walls of the trough may interfere
with bone fusion. A high-speed drill with a cutting burr
is used to remove the posterior part of each vertebral
body (Fig. 8B). As the posterior longitudinal ligament
is reached, it may be safer to use a diamond burr (Fig.
8C). As one gains experience, the cutting burr may be
used all the way to the posterior longitudinal ligament.
The posterior longitudinal ligament is then defined
throughout the limits of the intended vertebrectomy.
At this point, a trough is made on the inferior surface
© 1992 The American Association of Neurological Surgeons
away using a high-speed cutting burr. Bone and disc dissection this far
is generally avascular.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
of the resected body above and the superior surface of the
resected vertebral body below, again using a high-speed
drill. This trough is generally placed in the anterior half
of the vertebral body so that the seated strut graft will not
migrate posteriorly (see Fig. 10A). The trough should be
made before the longitudinal ligament is excised, because
the posterior longitudinal ligament offers a strong barrier
against any accidental penetration.
© 1992 The American Association of Neurological Surgeons
Figure 8. A, the intervening cancellous bone of the vertebral bodies is
removed in large, quick bites using Leksell rongeurs to minimize blood
loss. B, the posterior corticocancellous plate is drilled away using a
404
Using a sharp nerve hook, the posterior longitudinal
ligament is picked up and then a No. 11 blade knife is used
to incise the ligament vertically. It is well to remember that
the posterior longitudinal ligament is in two layers—a very
tough anterior layer containing longitudinal fibers and a thin,
transparent posterior layer closely resembling dura. Some-
times the posterior layer may be mistaken for dura. One way
to avoid this mistake is to pass an instrument such as a Wood-
cutting burr. C, close to the posterior longitudinal ligament, it may be
safer to use a diamond burr, but with experience a cutting burr may be
used all the way to the ligament.
 RENGACHARY : CERVICAL SPONDYLOTIC MYELOPATHY
son elevator underneath this layer to see whether it will eas-
ily glide up and down. If it does not, it means that the true
dura has not been exposed. After the incision in the posterior
longitudinal ligament has been made, it is excised piece-
meal using a small Kerrison rongeur (Fig. 9). Any epidural
bleeding can be controlled by one of two maneuvers. One is
to elevate the head of the operating table such that the venous
bleeding will be minimal with low venous pressure. The other
© 1992 The American Association of Neurological Surgeons
Figure 9. A and B, the posterior longitudinal ligament is excised piecemeal using a Kerrison rongeur.
405
is to place a strip of Gelfoam soaked in topical thrombin
over the dura temporarily to stop the venous bleeding.
Attention is now directed to shaping the graft. I
generally use a fibular allograft. Although the fusion
is quicker with an autograft, there is significant mor-
bidity from harvesting a fibular graft from the patient.
The morbidity generally consists of pedal edema and
intractable, aching pain in the ankle. An autogenous
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
iliac crest graft can be used for shorter segments. The iliac
crest graft fuses faster but it will not stand axial stress with
multilevel corpectomies. Ideally, an iliac crest autograft is
used after resection of one or two vertebral bodies; a fibu-
lar allograft is used for three or more vertebrectomies. The
fibular allograft is fashioned in the upper and lower ends
to fit the trough made in the vertebral bodies (Fig. 10). The
cranial end is impacted into the trough and the caudal end
is gently tamped in place after the neck is placed in signifi-
cant traction either by weights or by the anesthesiologist
pulling on the head (Fig. 11A). After placement, the graft
stability can be checked by grasping it with a Kocher clamp
to see if there is any motion. Alternatively, the anesthesi-
ologist may flex the neck; the graft should be stable and
there should be no motion in the fused segment. The can-
cellous bone removed during the vertebrectomy can be
saved and packed on either side and in front of the fibular
graft (Fig. 11B). Alternatively, additional autogenous can-
cellous bone can be harvested through a separate incision
over the iliac crest. Because the small cancellous chips may
fall out of the area when the patient assumes an upright
posture, it may be worthwhile to sew a rectangular piece of
Vicryl mesh to the longus colli muscle (Fig. 12A).
Closure
Meticulous hemostasis is obtained and the wound is irri-
gated copiously with normal saline. Only a two-layer clo-
sure is made, one for the platysma and the other for the
subcuticular area. A drain should be used because of the
© 1992 The American Association of Neurological Surgeons
Figure 10. A, the author’s method. B, the conventional method
of seating a fibular graft. From Rengachary SS, Redford JB: Par-
tial median corpectomy for cervical spondylotic myelopathy. In
406
extensive dissection. Although the wound may look ab-
solutely dry at the time of closure, because of the large
raw area left in the bone there is a distinct risk of he-
matoma formation if a drain is not placed. A halo vest is
then applied (Fig. 12B). If one decides to use a plate and
screw fixation during the operation, this will obviate the
need for halo fixation.
POSTOPERATIVE FOLLOW-UP
A cervical spine film is taken at the end of the procedure
to confirm the optimal placement of the graft. Cervical
spine films are then repeated at the end of 3 months to
assess the progress of the fusion. I generally leave the
halo on for about 8 to 12 weeks. The patient is instructed
to care for the halo pin sites regularly.
COMPLICATIONS
A wound hematoma may occur from extensive dissec-
tion. It is important at the time of extubation that the pa-
tient does not cough vigorously. The head of the bed should
be elevated in the immediate postoperative period. A suc-
tion drain facilitates the removal of blood and serous fluid
and reduces the likelihood of hematoma formation. If a
hematoma does occur, depending upon its size, one may
treat it conservatively or may drain it. The presence of a
hematoma also increases the likelihood of infection.
There are a few neural structures that are at risk
of damage during neck dissection. The marginal man-
dibular branch of the facial nerve may be cut if the
Wilkins RH, Rengachary SS, eds. Neurosurgery Update II. New
York: McGraw-Hill, 1991, pp. 356-359. With permission of the
publisher.)
 RENGACHARY : CERVICAL SPONDYLOTIC MYELOPATHY

© 1992 The American Association of Neurological Surgeons

Figure 11. A, the fibular graft is tamped in place as the cervical spine
is distracted. B, small pieces of autogenous cancellous bone (harvested
either from the removed vertebral bodies or through a separate inci-
sion from the iliac crest) are packed on the sides and in front of the
fibular graft.

407
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

© 1992 The American Association of Neurological Surgeons

Figure 12. A, a woven Vicryl mesh is sewn to the longus colli muscles
to retain the cancellous chips. B, a halo vest is applied at the end of the
procedure.

408
 RENGACHARY : CERVICAL SPONDYLOTIC MYELOPATHY
incision is placed too high. The superior laryngeal nerve
is at risk during dissection of the superior thyroid artery
and the recurrent laryngeal nerve during dissection of the
lower part of the pharynx. Injuries to these nerves are
best avoided by meticulous attention to anatomic details.
The spinal cord itself is at risk during the drilling proce-
dures and also during maneuvers to seat the graft.
Graft migration is a serious potential problem. It most
often occurs from inadequate preparation of the host site
and suboptimal fashioning of the graft itself. There are
two ways of seating the graft. One is to make a clothes-
pin-like notch in the upper and lower ends of the graft
and place the notch against the anterior cortical bone of
409
the vertebral bodies (Fig. 10B). This tends to cause a frac-
ture of the anterior superior corner of the vertebral body
below and migration of the graft. I prefer a total inlay
graft as depicted in Figure 10A. With good seating of the
graft and immobilization in a halo, the incidence of graft
migration should be very low.
Restriction of neck mobility with an extensive fusion
is an expected side effect but patients seldom complain of
it if the myelopathy improves significantly. There is always
a potential risk of disc rupture at a level above or below the
fusion site because of accelerated degenerative changes
from increased mobility at these sites, but the exact inci-
dence of this complication is unknown at this time.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
CORRECTION OF ORBITAL
HYPERTELORISM AND
ORBITAL DYSTOPIA
CONSTANCE M. BARONE, M.D.
DAVID F. JIMENEZ, M.D.
RAVELO V. ARGAMASO, M.D.
JAMES T. GOODRICH, M.D., PH.D.
INTRODUCTION
Orbital hypertelorism is defined as true lateral displace-
ment of the orbits. Clinically, this is seen as an exagger-
ated distance between the orbits. Normal measurements
between the anterior lacrimal crests in Caucasian adults
range from 18.5 to 29.9 mm for females and from 19.5 to
30.7 mm for males. Orbital dystopia refers to the position
of the orbits aligned on the vertical axis. The four-year-
old girl presented here had craniofrontonasal dysplasia
with both orbital dystopia and orbital hypertelorism. Her
interorbital distance measured 34 mm preoperatively.
Normal interorbital distance for a four-year-old girl ranges
from 13 to 21 mm, with the 50th percentile being 17 mm.
PREOPERATIVE EVALUATION
At the Montefiore Medical Center, all patients with cranio-
facial disorders are evaluated at the Center for Craniofa-
cial Disorders. The patient is evaluated by individuals from
the disciplines of pediatrics, pediatric neurology, pediat-
ric neurosurgery, genetics, plastic surgery, ophthalmol-
ogy, dentistry, dentofacial surgery, otolaryngology, and
speech therapy. All patients have plain x-ray films of the
face and skull as well as computed tomography (CT) scan-
ning with bone windows in axial and coronal views. We
routinely use three-dimensional CT scan reconstruction
with a software program that allows us to perform mea-
surements and surgical osteotomies on the reconstructed
model preoperatively (Fig. 1).
In the patient presented here, the interorbital distance
between anterior lacrimal crests was 34 mm. The right
supraorbital rim was 8 mm lower than the left supraor-
bital rim, representing an orbital dystopia (Fig. 2). Mul-
© 1992 The American Association of Neurological Surgeons
410
tiple cranial defects were noted from a prior cranial op-
eration at another institution. In addition, the nose was
short, with the right nasal ala being higher than the left
nasal ala. Such clinical findings are typical of those seen
in children with craniofrontonasal dysplasia and require
a complex craniofacial reconstruction.
OPERATIVE PREPARATION
We routinely start antibiotic therapy (to cover for both
skin and nasal flora) at the time of anesthesia induction
in the operating room. Because all surgical manipulations
are extradural, anticonvulsant and steroid therapies are
not used routinely. With an extensive reconstruction in a
four-year-old child, two units of packed red blood cells
are made available (preferably donor-directed). If avail-
able, a cell saver unit can rescue up to 50% of the patient’s
lost blood volume. Because of the risk of extensive blood
loss, all patients require at least two large-bore intrave-
nous lines of 16 gauge or larger. An arterial line is placed
during induction to permit serial blood gas and hemat-
ocrit measurements, etc. during the procedure. For eye
protection, all patients have bilateral tarsorrhaphies per-
formed or corneal shields placed prior to formal draping.
The patient is intubated orotracheally.
OPERATIVE TECHNIQUE
Positioning
The patient is placed in the supine position with the
head on a cerebellar head rest. Rigid fixation devices
like a Mayfield head clamp are not used because the
surgeon will need to move the head (never more than
10 to 15°, however). Anesthesia equipment is on the
left side of the patient and the nurse’s Mayo stand is
 BARONE ET AL. : CORRECTION OF ORBITAL HYPERTELORISM AND ORBITAL DYSTOPIA

© 1992 The American Association of Neurological Surgeons

Figure 1. Three-dimensional CT reconstructions for preoperative plan- outlined. C, the orbital repositioning necessary has been calculated
ning. A, the preoperative reconstruction shows the bony detail of the and the bone units repositioned; the numbers generated by the com-
dystopia and orbital hypertelorism; from this image the amount of puter are very helpful in determining the requirements for adequate
orbital movement required can be calculated. B, the orbital units are positioning.

Figure 2. A child with craniofrontonasal dysplasia mani-

fested by orbital hypertelorism and orbital dystopia.

© 1992 The American Association of Neurological Surgeons

411
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

placed over the mid-abdomen. Overhead tables are not © 1992 The American Association of Neurological Surgeons
used because they restrict frontal access and visualiza-
tion of the patient’s head.

Draping
Because a bicoronal incision as well as bilateral infraor-
bital incisions will be used the head and the entire face
down to the nose must be prepared. The nares are
cleansed with cotton swabs soaked in Betadine solution.
The head is only shaved along the proposed bicoronal
incision for a width of about 1.5 cm. The face and head
are cleaned with Betadine scrub, cleansed with alcohol,
and painted with Betadine solution. In an adult, the
bicoronal incision site is then injected with 0.5%
lidocaine and a 1:200,000 epinephrine solution, In a child
(less than seven years old) we use 0.25% lidocaine and
a 1:400,000 epinephrine solution. Sterile towels are
placed below the posterior portion of the bicoronal inci-
sion and are also stapled to the posterior aspect of the
scalp. A facial drape is then placed just below the nose
and over the upper lip and endotracheal tube. It is im-
portant that the drapes are loose so that the head can be
moved during the procedure.
We routinely run all our suction lines, cautery cords,
etc. toward the foot of the patient. Because our surgical
team routinely sits, this allows easy mobility of the chairs
(i.e., the chairs are not rolling over the cords and tubes). Figure 3. An intraoperative view showing the V-Y correction to shorten
Because the operative site is often irrigated during the nasal bridge and correct the excessive nasal skin from a medial
the procedure, it is important to have waterproof outer movement of orbits.
drapes. Some of the newer drape designs have large plas-
tic bags for fluid collection: we have found these to be
quite useful.

Skin Incisions in nasal length, a midline incision is chosen. Particular

To gain access to the frontal bone, orbits, and nasal re-
gion, a bicoronal scalp incision is used. This incision is
carried from tragus to tragus, well behind the hairline,
both for a cosmetic closure and to allow for a large peri-
cranial flap that can be used in the subsequent repair.
Flap Elevation
A full thickness scalp flap is elevated following the stan-
dard subgaleal plane, leaving the pericranium intact. The
pericranium is then elevated as a second separate layer.
The flaps are carried forward to the orbital rims, to the
level of the supraorbital nerve and artery on each side.
These are frequently encased in a small notch of bone in
the supraorbital rim. This notch can be opened easily us-
ing a small osteotome or small Kerrison rongeur.
An inverted V-shaped skin incision is made on top of
the glabellar region (Fig. 3) to allow proper nasal length-
ening as well as resection of the excess skin after the or-
bits have been moved medially. If there is no asymmetry
care must be taken in elevating the scalp flap if the pa-
tient has had a prior operative cranial procedure (as did
the patient presented here), because multiple bony defects
may be present which cause the dura to be adherent to the
overlying pericranium and galea.
The scalp flap dissection must expose the belly of
the temporalis muscle and the zygomatic arch bilaterally.
In the central facial region, the nasal bones as well as the
medial orbital wall should be exposed fully. The temporalis
muscle is elevated as a unit using a monopolar needle tip
electrocautery. To gain access to the infraorbital region
as well as the maxilla, a lower eyelid incision is made
between the cheek skin and the periorbital skin. This in-
cision is made within a natural skin fold and usually is
located directly above the infraorbital rim. As an alterna-
tive, a subciliary incision can be performed and the skin
elevated as a skin-muscle flap. However, this sometimes
leads to an ectropion and/or to subciliary inversion, so we
are not as likely to use it.

412
 BARONE ET AL. : CORRECTION OF ORBITAL HYPERTELORISM AND ORBITAL DYSTOPIA
Craniofacial Osteotomies
A frontal craniotomy is performed about 2.5 cm above
the superior orbital rims (Fig. 4). The use of a high-
speed drill is preferred (e.g., Midas Rex drill with a B-
5 footplate) which allows speedy bone removal in a
single step and thus decreases blood loss. The frontal
lobes are then gently retracted extradurally, thus ex-
posing the orbital roof and anterior cranial fossa on
each side. Filaments from the olfactory bulbs are cut
and the dura is oversewn if cerebrospinal fluid (CSF)
© 1992 The American Association of Neurological Surgeons
413
leakage is noted. Subperiosteal elevation of the scalp
flap is continued over the orbital rims into the orbits to
a distance just past the equators of the globes. A hori-
zontal osteotomy is performed 1.5 cm above the supe-
rior orbital rims (Figs. 4 and 5). This leaves a horizon-
tal bar or bandeau of bone attached to the cranium. A
block of bone below the bandeau, consisting of the
crista galli, the nasal bones, and the ethmoid bones, is
removed en bloc using the Midas Rex drill with a C-1
attachment and an osteotome.
Figure 4. Artistic reconstruction showing the osteotomy lines
and resection of the midline nasal complex and sinuses.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

Figure 5. Artistic reconstruction outlining the osteotomy lines

along the orbital walls.
© 1992 The American Association of Neurological Surgeons

414
 BARONE ET AL. : CORRECTION OF ORBITAL HYPERTELORISM AND ORBITAL DYSTOPIA
The ethmoid sinuses are then exenterated carefully
using pituitary rongeurs. Care must be taken to remove
all mucosa so that a mucocele does not develop in the
future. The cartilaginous nasal septum is identified be-
tween the septal mucosa and is dissected free from the
mucosa. A septal resection is performed, with removal
of all of the septal cartilage between the medial orbital
walls. This creates room for the medial translocation
of the orbitonasal complex and maintains an open air-
way. Tears in the nasal mucosa are repaired with chro-
mic catgut sutures. A segment of the removed nasal
bone is then placed in the midline opening at the ante-
Figure 6. Artistic reconstruction showing the bone units repositioned.
Bone grafts have been placed laterally, to the side of each orbit. Be-
cause the right orbit had to be moved superiorly, a graft was placed in
415
rior cranial base, thus separating the cranial cavity from
the nasal cavity.
The periorbita is completely freed circumferentially
around each globe. Using an osteotome, the lateral os-
teotomies are performed anterior to the zygoma, as ap-
proached from the bicoronal incision. This osteotomy
is continued via the lower lid incision. In a four-year-
old girl, it is important to keep the osteotomy line above
the infraorbital foramen on each side to avoid destroy-
ing future tooth buds. The lower osteotomies are con-
tinued until they meet the medial osteotomies, which
were performed previously (Figs. 4 and 5). Be-
© 1992 The American Association of Neurological Surgeons
the defect inferior to the orbit. The medial canthal ligaments have been
reattached in this schematic.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
cause the right superior orbital rim was 8 mm lower than
the left in our patient, an 8-mm segment of bone is now
removed from the superior aspect of the right orbit to allow
a superiorly directed repositioning of the right eye (Fig. 4).
The osteotomy within the bony orbit is done
circumferentially for a 360° cut, approximately 2 cm in
from the orbital rim (Fig. 5). An assistant holds a mal-
leable retractor to protect and retract the globe. An os-
teotome is placed in the inferior lid incision to perform
the inferior and lower medial and lateral wall osteotomies.
The orbital roof and upper medial and lateral orbital walls
are divided through an intracranial approach with an as-
sistant placing gentle retraction on the frontal lobe and
another protecting and retracting the globe with a mal-
leable retractor (Fig. 5). A completed osteotomy is then
confirmed using a 2-mm osteotome.
Medial canthopexies are performed by first identify-
ing the medial canthal ligaments, passing a 26-gauge wire
through them, and then repositioning them through a new
hole that is drilled posterior and superior to the lacrimal
crest (Fig. 6). The wires are passed through these holes
and then anteriorly over the medial orbital wall. The wires
are tied together, bringing the orbits toward the midline.
In addition, the right orbit is repositioned superiorly by 8
mm. These bone units are secured to the bandeau using
microplates.
Using Joseph scissors, the overlying nasal skin is sepa-
rated from the underlying upper and lower lateral nasal
cartilages, creating a pocket for a cantilever bone graft.
The cantilever bone graft consists of a full thickness piece
of calvarial bone, 8 mm wide and 5 cm long. The bone
graft is then placed in the created nasal pocket and is se-
cured in place using a microplate to the bandeau. This can-
tilever technique stabilizes the bone graft to improve the
previously flat appearance of the nose. The distance be-
tween the medial orbital walls now measures 15 mm. We
usually overcorrect the medial approximation of the orbital
walls because the orbits tend to drift laterally with time.
The pericranial flap is then reflected between the nasal
and cranial cavities. The frontal bone plate is replaced
and secured into position using microplates. The
temporalis muscles are then rotated anteriorly and sutured
in place using Vicryl sutures placed through holes in the
microplates or through drill holes made in the bandeau
and frontal bone.
Closure
Prior to closure it is extremely important to check for any
416
CSF leaks. Undetected leaks can hinder postoperative
recovery. The critical area for examination is around the
cribriform plate region. Any dural tears during the cranio-
tomy have to be repaired. We often have the anesthesiolo-
gist perform an extended Valsalva maneuver to look for a
CSF leak.
Closure of the bicoronal scalp incision is performed
after copious irrigation with saline solution and meticu-
lous hemostasis. Debris commonly collects beneath the
scalp flap. These areas must be irrigated out thoroughly
because they are a potential source of infection. A drain
is attached to light suction for 48 hours. Scalp closure is a
standard two-layer closure with approximation of the
galeal and skin layers.
The lower eyelid incisions are closed in a single layer
using a 5-0 or 6-0 nylon suture. The excess nasal skin is
then removed along the prior inverted V incision (after a
V-Y lengthening of the right side of the nose in the present
case) (Fig. 3). This incision is closed in two layers. The
tarsorrhaphy sutures are removed. The pupils are checked
and the eyes irrigated with a balanced salt solution. Lacri-
Lube is then placed in each eye.
POSTOPERATIVE CARE
The patient is continued on antibiotics (selected to cover
both skin and nasal flora) for five days postoperatively
because the nasal cavity was entered which increases the
risk of infection. There is always significant periorbital
swelling postoperatively as well as strabismus. The pa-
tient and family should be forewarned of this in the pre-
operative counseling sessions. In most patients the stra-
bismus corrects to its original pattern. Any surgical
correction of a postoperative strabismus should be de-
layed for at least six months, and preferably for one year.
CSF leakage, meningitis, mucocele formation, bone
graft loss, epiphora from duct obstruction, visual loss,
and death have all been reported with these types of com-
plex craniofacial repairs. With proper attention to detail,
such complications can be reduced to the very minimum.
As mentioned above, dural tears must be repaired me-
ticulously during the operation. The use of the pericranial
flap to separate the nasal and cranial contents is also im-
portant in reducing the incidence of infection. These pa-
tients must be followed for the delayed development of
mucoceles and meningitis. Patients undergoing
canthopexies have the potential to develop lateral drift-
ing of the medial canthopexies and may require later sec-
ondary revisions.
 PERCUTANEOUS RADIOFREQUENCY
RHIZOTOMY FOR THE TREATMENT
OF PARAPLEGIC SPASMS
SUMIO UEMATSU, M.D.
INTRODUCTION
Our first percutaneous radiofrequency (RF) rhizotomy
was carried out in 1971 on an 18-year-old girl with
spastic paraplegia caused by spinal cord injury. Bilat-
eral L-1, L-2, and L-3 roots were denervated. The pro-
cedure achieved impressive relief of the painful spas-
modic attacks and reduced the flexor spasms in her hip
and knee joints. After the procedure, she was able to
sit in a wheelchair, and toileting and daily nursing and
hygienic care became possible. Other investigators have
now proven the percutaneous approach to be a safe and
effective palliative procedure.
Percutaneous RF rhizotomy allows selective destruc-
tion of a spinal nerve root at the posterior sensory gan-
glion or further central rootlet, thereby disrupting the spi-
nal reflex arc and alleviating the spasms (Fig. 1).
GENERAL CONSIDERATIONS
Patient Selection
Paraplegic patients suffering severe, painful spasms in the
hip and knee joints are candidates for percutaneous rhizo-
tomy. The spasms can be provoked by the slightest irrita-
tion of the skin or by passive or voluntary body shift. The
spastic attacks can be so severe that the patient is thrown
out of the wheelchair. Patients with neurogenic
hyperreflexic bladder also benefit from selective sacral
rhizotomy.
If the patient presents with complete loss of motor
and sensory function in the lower extremities (paraple-
gia) and has shown no clinical signs indicating functional
recovery for at least six months, the procedure should be
considered. However, if motor and/or sensory functions
are preserved or the patient is not completely paralyzed
(paraparetic), the procedure should be reserved until such
time as there has been no sign of further functional gain
for at least one year.
© 1992 The American Association of Neurological Surgeons
417
Facilities and Equipment
Fluoroscopy is essential for placement of the probe. The
procedure is best carried out in the operating room, with
an anesthesiologist readily available. A typical arrange-
ment is shown in Figure 2.
A Radionics RF lesion generator is used. The sur-
geon should study carefully the specifications of the de-
vice and should be fully familiar with its operation. Fur-
thermore, careful attention must be paid to electrical safety
with the device.
DIAGNOSTIC BLOCK
Indications
In the paraparetic patient, a diagnostic block is done to
assess the possible negative effects of rhizotomy, such as
loss of some motor and sensory functions, as well as the
possible positive effects, such as relief of the spasms. Use
of a longer lasting local anesthetic such as Marcaine hy-
drochloride provides sufficient time (six to nine hours)
for assessment of self-care, ambulation, use of a wheel-
chair, bowel and bladder control, sexual functions, and
even the ability to drive a specialized motor vehicle or
motorized wheelchair. Complete destruction of the sen-
sory root over a wide area may result in trophic gangrene
or decubiti. For this reason, partial denervation sufficient
to relieve the spasms, but preserving some nerve fibers,
is an important consideration.
Preparation
The patient should be informed about the purpose of the
diagnostic block. The ultimate decision about whether to
use the permanently destructive RF rhizotomy is heavily
dependent on the patient’s response to the block. Further-
more, advance explanation of the technical details often
minimizes the need for sedatives or analgesics. It is cru-
cial to have maximal cooperation from an alert patient
during the procedure.
Blood pressure and heart rate are recorded. The
degree of spasms is noted in a chart. Intravenous
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

© 1992 The American Association of Neurological Surgeons

Figure 1. Anatomical sketch showing the site of RF lesioning on the sensory ganglion used to disrupt the spinal reflex arc.

418
 UEMATSU : PERCUTANEOUS RADIOFREQUENCY RHIZOTOMY FOR PARAPLEGIC SPASMS
© 1992 The American Association of Neurological Surgeons
Figure 2. Artist’s view of the set-up for the procedure. Note the C-arm
fluoroscopic apparatus in the center. The fluoroscopy monitor is in the
access is secured. Emergency resuscitative and general
anesthetic equipment are readily available.
Procedure
The block is carried out under fluoroscopic control. The
patient is typically placed in a prone position (Fig. 3). A
rolled sheet is placed on each side of the abdomen to flex
the thoracolumbar junction and widen the intervertebral
foramina.
The thoracolumbar area is wiped with a standard sur-
gical preparation. The area is covered with an Ioband ad-
hesive drape. The fluoroscope is positioned for an antero-
posterior (AP) view. A long clamp (Peon) is used as a
pointer while the fluoroscopic examination is performed.
Skin marking is made just over the outer edge of the trans-
verse process one spinal level below the targeted spinal
root. The target point is located at the upper margin of the
disc level just caudal to the x-ray shadow of the pedicle
(Fig. 4, A and B).
A local anesthetic is infiltrated at the needle entry
site. A 20-gauge lumbar puncture needle is directed at the
target. When the needle is near the lamina level, the fluo-
roscope is positioned for a lateral view. The needle tip is
419
right upper corner, and the RF lesion generator and surgical instruments
are on the left.
advanced to the foramen under fluoroscopic control. It is
wise to inform the patient that a radiating pain to the leg
may be felt as the needle approaches the spinal root in the
foramen. For the diagnostic block, the needle need not
advance into the foramen. This avoids injection of the
anesthetic into the subarachnoid space, which not only
could decrease the effectiveness of the block by anesthe-
tizing other roots and the adjacent spinal cord, but also
could incur the risk of cardiorespiratory arrest if the an-
esthetic migrates to the level of the brain stem.
After appropriate needle placement is achieved, a lo-
cal anesthetic (0.5 ml) is injected using a tuberculin sy-
ringe. The anesthetic is injected only after it is confirmed
that no cerebrospinal fluid or blood can be aspirated into
the syringe. A total of 1.0 ml is injected at each level.
The patient should be observed for two hours in the
recovery room before discharge to home or to a hospital
room. It is our practice to give the patient a chart for hourly
rating of the relief of spasms over the next 24 hours. The
first column of the charts is used for the date and time,
the second column is for the rating of spasms (0 for no
spasms, 10 for maximum spasms), and the remaining
space is for hourly comments by the patient.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

© 1992 The American Association of Neurological Surgeons

Figure 3. The patient is usually prone. Rolled sheets are placed L1-2 spinous processes. Note that an electric ground pad and cable
on each side of the chest and abdomen, resulting in an arch in the are placed between the x-ray table and thigh, pressing firmly
thoracolumbar spine. The peak of the arch is at the level of the against the skin.

© 1992 The American Association of Neurological Surgeons

Figure 4. A, the needle penetrates the skin at the head of the transverse rected to the target foramen. B, the foramen is located at the base of the
process that is located one level below the target foramen and is di- transverse process, at the upper margin of the disc level.

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 UEMATSU : PERCUTANEOUS RADIOFREQUENCY RHIZOTOMY FOR PARAPLEGIC SPASMS
RADIOFREQUENCY RHIZOTOMY
There are three approaches for a RF rhizotomy. These are
a foraminal approach, a midline spinal approach, and a
sacral foraminal approach.
Foraminal Approach
In the foraminal approach, the RF lesion is made in the
posterior sensory ganglion in the intervertebral foramen.
Patient Selection
Patients with spasms of one lower extremity or paraparetic
patients are the best candidates for this approach. The risks
of the procedure are minimal. Destruction of no more than
two spinal roots may not result in a significant functional
deficit in the lower extremity. Coagulation or thrombotic
occlusion of the spinal radicular arteries (particularly the
artery of Adamkiewicz) is a potential risk. Other possible
complications include escape of the local anesthetic into
the blood circulation or subarachnoid cerebrospinal fluid.
Preparation and Anesthesia
It is important to explain the procedure to the patient in
detail in advance, with particular emphasis on what the
patient might experience and the need for accurate re-
sponses during the procedure. The patient must be alert,
because patient cooperation is essential in monitoring
motor and sensory functions during the procedure. The
patient should have nothing by mouth for at least six hours
prior to the procedure. Atropine (0.4 mg intramuscularly)
and Demerol (75 mg) may be given preoperatively. An
intravenous infusion in the arm is secured. Two or three
milliliters of 1% lidocaine is injected subcutaneously at
the needle entry point. During electrothermocoagulation,
Brevital sodium can be given intravenously by the anes-
thesiologist if pain is intolerable.
Operative Setting
The patient is placed in the prone position (Fig. 3). Rolls
of folded sheets are placed underneath the abdomen and
iliac crest. This position permits fluoroscopic examina-
tion of the lateral, oblique, and AP views of the spine.
Flexion of the spine opens the intervertebral foramina,
but some patients who have severe flexor spasms of the
hip and knee joints cannot lie in the face-down position.
In such cases it is best to place the patient in a lateral
recumbent position with the affected side up. The ground
pad is placed under the thigh opposite to the treated side
to avoid confusion that may be caused by stimulation of
the skin or muscle by the ground pad. The thoracolumbar
area of the back is wiped thoroughly with a surgical anti-
421
septic solution, and a sterile adhesive drape is placed to
cover a wide area of the back. The fluoroscopic unit is
brought over the surgical field. The needle entry point is
determined by fluoroscopic visualization. The foramina
are easily visualized in the lateral view.
Placement of the Electrode
The electrode used, a Radionics TIC-TM thermoelectrode,
is 1.1 mm in diameter, with a 5-mm exposed tip with a
thermistor. Its point of entry is usually 4 cm from the
midline and the target point in the intervertebral foramen
is located in the slightly rostral portion of the interverte-
bral disc space (Figs. 1, 4, A and B, and 5). The needle is
advanced into the dorsal one-third of the foramen. When
it is 10 mm away from the target, the fluoroscopic tube is
relocated for AP visualization during advancement of the
needle to the target. The target, in the AP view, is located
0-2 mm medial to the medial edge of the facet joint and
2-3 mm caudal to the caudal edge of the joint.
When the needle is placed in the target, an attempt is
always made to aspirate gently for spinal fluid or blood.
If cerebrospinal fluid is observed, the needle is withdrawn
1-2 mm.
Stimulation and Lesioning
Electrode stimulation is tried at 2/sec, with a pulse width
of 0.5 msec, at less than 1.0 volt. A muscle response should
be obtained in the specific appropriate myotome for each
spinal nerve (Table 1). After proper muscle contraction,
trial thermocoagulation is performed at 45°C for 15 sec-
onds. Paretic patients are asked to wiggle the toes on both
feet during the entire treatment. The treatment is increased
in increments of 4 to 5°C, reaching a maximum of 74°C
for 90 seconds each.
Precautions and Technical Pitfalls
It is essential to observe the motor response to stimula-
tion in specific muscles. Contraction should be limited
primarily to the muscles to be treated. Failure to obtain
apparent muscle contraction at less than 1.0 volt is an
indication to readjust the electrode. When RF lesioning
is made in the vicinity of the T-11 to L-1 levels, the RF
temperature should be kept at or below 74°C to avoid in-
juring the spinal cord or the artery of Adamkiewicz.
Cerebrospinal fluid is a good heat sink and thus re-
quires more RF current for heating. If an inordinate
amount of current is needed to achieve the appropriate
temperature (74°C), the electrode tip may be in the CSF
space or there may be a loss of current along the elec-
trode shaft due to abraded insulation.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

© 1992 The American Association of Neurological Surgeons

Figure 5. An artist’s view of the trajectory of the needle for introduc- fluid space filled with multiple lumbosacral roots (cauda equina). The
tion into the L2-3 intervertebral foramen. Note an ample cerebrospinal RF lesion site is deep over the ganglion.

Midline Spinal Approach

The midline spinal approach is essentially a spinal tap
approach. The electrode used for this procedure is the
Radionics RRE electrode, which is 1.6 mm in diameter,
with a 6-mm exposed tip with a thermistor.

Patient Selection
The midline approach is less cumbersome than the fo-
raminal approach. However, this approach is less se-
lective. Paraplegic (completely paralyzed) patients may
be treated with this approach. Loss of sensorimotor or
bowel and bladder functions is not a concern in these
patients, because they have already lost these functions.

Preparation and Anesthesia

The patient is usually placed in the prone position.
However, these patients frequently cannot lie in the
face-down position due to severe flexion contracture
of the hips and knees. In such cases, it is best to start
the procedure with the patient in the lateral recumbent
(fetal) position. The RF electrode nearly always pene-

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 UEMATSU : PERCUTANEOUS RADIOFREQUENCY RHIZOTOMY FOR PARAPLEGIC SPASMS
trates into the subarachnoid fluid space in this approach.
Mild sedation is sufficient for this procedure, because
most patients have totally lost sensation in the electrode
penetration area. However, a patient with painful spasms
may not tolerate the fetal position or may be unable to
cooperate for any length of time on the fluoroscopic table.
In such cases the procedure should be carried out under
general anesthesia.
The following routine preoperative measures are necessary:
1. Nothing by mouth (NPO) six hours prior to surgery;
2. Routine blood and urine analysis (and culture);
3. Biochemical profile including serum electrolyte values;
4. Electrocardiogram;
5. X-ray films of the chest and lumbar spine;
6. Arterial blood gas determinations;
7. Premedication: Atropine (0.4 mg intramuscularly) and
Demerol (100 mg intramuscularly) one hour prior to
surgery.
In patients with actively inflamed decubitus ulcers
or urinary tract infections, adequate antibiotic treatment
should be administered preoperatively until there are no
clinical signs of active infection at surgery.
Operative Setting
The patient is placed on an x-ray table equipped with fluo-
roscopy. The patient lies in the lateral recumbent (fetal)
position or prone position with as much flexion of the
thoracolumbar area as possible. Pillows are placed under
the head and axilla and between the thighs in the lateral
recumbent position. The skin over the thoracolumbar back
is prepared with Betadine solution. The surgical field is
fully covered with a sterile adhesive drape, leaving the
patient uncovered from the lower abdomen and the waist
down to allow inspection of motor responses of the abdo-
men, hips, knees, and ankles to the electrical stimulations.
An electric ground pad is inserted between the thigh and
the fluoroscopic table so that the skin of the thigh firmly
contacts the pad.
Placement of the Electrode
Three spinal roots, L-1, L-2, and L-3, can be destroyed
by a single electrode placement (Fig. 6, A and B). The
L-1 and L-2 spinous processes are identified by fluo-
roscopy. The electrode penetrates the skin at the L-2
spinous process in the midline. The electrode is ad-
vanced to bring its tip just cephalad to the T-12 to L-1
disc, just inferior to the caudal medial edge of the
pedicle of T-12 (Fig. 7, A and B).
Electrical Stimulation
Electrical stimulations (0.5-1.0 volt) are performed. If the
423
electrode is directly on a root, muscle contractions of the
appropriate muscles of the ipsilateral limb can be seen. If
not, the electrode is withdrawn or advanced slightly (1-2
mm) until only the specific muscle contractions appro-
priate to the root to be denervated are elicited. Contrac-
tion of the adductor muscles is expected upon stimula-
tion of the L-1 root. Extension of the ankle indicates that
the electrode is over L-4, and flexion indicates that the
electrode is over the S-1 root. Complete disruption of the
lower lumbar (L-4 and L-5) and upper sacral (S-1 and S-2)
roots results in flaccid palsy of the ankle joint and may
invite trophic decubiti in the gluteals or heel. After satis-
factory placement of the electrode with appropriate myo-
tome responses, the RF lesion is made.
RF Lesioning
The thermal treatment begins at 45°C for 15 seconds.
Careful inspection is made over the abdomen, thigh, and
calf. Myoclonic contractions may be seen over the muscles
being denervated. The contractions should be limited to
the adductor muscles and quadriceps of the thigh and
should not occur in the leg or hamstring muscles. The
temperature is increased incrementally, 5°C at a time. The
range of motion of the joints, starting with the ankle, knee,
and hip, is examined as frequently as possible during the
step-by-step increase in thermal treatment (at 50, 55, 60,
65, 70, and 74°C) to completion. The temperature should
not exceed 74°C.
After completion of the RF rhizotomies on one side,
the electrode is withdrawn halfway and directed toward
the opposite pedicle at L-1. After fluoroscopic confirma-
tion and stimulation studies, RF treatment is given as de-
scribed above.
Precautions and Warning
It should be remembered that direct contact of the RF
electrode with blood vessels (with a temperature over 74°C
may result in vascular occlusion, especially of the artery
of Adamkiewicz (the largest medullary artery at around
T-12 to L-4, more commonly found on the left). Tempera-
tures above 74°C should be avoided to prevent focal boil-
ing and thermal trauma to the spinal cord and/or further
medially located spinal roots.
Sacral Foraminal Approach
A neurogenic hyperreflexic urinary bladder can be treated
with a RF rhizotomy of sacral nerve roots.
Patient Selection
Candidates for this procedure have involuntary pre-
cipitous micturition and/or short intervals between
catheterization or voiding, due to neurogenic hyper-
reflexia. A patient with a fibrotic bladder that is not
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

© 1992 The American Association of Neurological Surgeons

Figure 6. A, a lateral view of a longitudinal section of the thoracolum- electrode placement. The three RF-treated roots are shown by broken
bar spine from T-12 to L-3, showing the relationship between the RF red lines. B, a lateral x-ray film of the same area of the spine as in A,
electrode, spinal roots, and spinal cord. RF thermal coagulation of the with the electrode in place.
three roots (L-1, L-2, and L-3) is achieved simultaneously with a single

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 UEMATSU : PERCUTANEOUS RADIOFREQUENCY RHIZOTOMY FOR PARAPLEGIC SPASMS

© 1992 The American Association of Neurological Surgeons

Figure 7. A, a posterior view of the spine at T-12 to L-3. (Note that the
spinal cord may extend down to the L-2 level in some patients.) The
RF-treated roots (L-1, L-2, L-3) are typically located laterally, and the
nontreated roots (L-4, L-5, and the sacral roots) are located around cen-
tral parts of the subarachnoid space, away from the laterally placed RF
electrode. The electrode penetrates the skin at the L-2 spinous process
(not shown) and extends to the target (the medial caudal margin of the
T-12 pedicle). B, an AP view of the thoracolumbar spine on x-ray film,
at the same levels as in A.

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 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

© 1992 The American Association of Neurological Surgeons

Figure 8. A, the relationship of the electrode to the first, second, third, and is inserted through the second sacral foramen to the second ganglion. B, an
fourth sacral foramina. Note that one probe is inserted through the sacral artist’s view of the cross-section at the level of the second sacral ganglion,
hiatus and its tip is in contact with the fifth and fourth roots. A second probe with the electrode inserted through the second sacral foramen.

426
 UEMATSU : PERCUTANEOUS RADIOFREQUENCY RHIZOTOMY FOR PARAPLEGIC SPASMS
distensible to a capacity of 200 ml is not considered for
sacral rhizotomy. Baseline urodynamic studies, includ-
ing cystometry, anal sphincter electromyography, and a
urethral pressure profile, are carried out along with a di-
agnostic sacral block.
Diagnostic Block
Under fluoroscopic control, various combinations of the
S-2, S-3, and S-4 nerve roots are anesthetized at the ante-
rior sacral foramina via the posterior sacral foramina. The
initial block is done with Marcaine, 1.0 ml at each of the
S-2, S-3, and S-4 nerve roots bilaterally, to ascertain the
bladder’s capacity to increase beyond 200 ml.
Urodynamometry is repeated within one hour of the sac-
ral block. During the next 12 hours, the following should
be recorded:
1. Intervals between voluntary voiding;
2. Amount of urine in voluntary voiding;
3. The intervals between catheterization;
4. The volume of urine obtained by catherization;
5. Frequency of involuntary micturition.
If bladder capacity is increased after the block to at
least 200 ml, serial blocks are performed on successive
days to determine the predominant roots innervating the
detrusor muscle. Permanent RF rhizotomy is performed
at the sacral roots providing the predominant bladder nerve
supply. When bladder capacity is not increased to at least
200 ml, additional roots need to be blocked.
Operative Setting
Preoperative preparations are identical to those described
in the previous sections. The procedure is carried out un-
427
der local anesthesia with sedation. An indwelling cath-
eter is placed and connected to the cystometrographic
device. The patient is placed in the prone position.
The TIC-TM thermoelectrode (1.1 mm in diameter,
with 5-mm tip exposure and thermistor) with stylet is
inserted into the selected sacral foramen with the aid of
AP and lateral fluoroscopy (Fig. 8, A and B). The elec-
trode is advanced through the guiding needle to the an-
terior foramen.
Lesioning and Precautions
The RF lesioning is performed up to a temperature of
74°C (starting at 45°C) at each preselected root level
at the anterior sacral foramen. Stimulation of the nerve
root and cystometric monitoring to confirm the accu-
racy of electrode placement before making the root le-
sion are used to physiologically confirm the position-
ing of the electrode. Particular care is taken to keep
the electrode tip within the foramen, to avoid burning
the adjacent rectal wall. The patient’s general condi-
tion is observed for two hours before discharge. Fol-
low-up urologic examinations are carried out regularly
as clinically indicated.
SUMMARY
Radiofrequency rhizotomy is described as an alternative
to surgical open rhizotomy or myelotomy. The use of ra-
diologic image intensification, electrical stimulation, and
temperature control makes the technique safe and accu-
rate. The procedure is best applied to patients who suffer
incapacitating spasms of the extremities or a neurogenic
hyperreflexic bladder. The therapeutic effect is usually
permanent; however, if symptoms recur, the procedure
can be repeated as needed.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
ENDOCRINE-INACTIVE
PITUITARY ADENOMASa
CHARLES B. WILSON, M.D.
INTRODUCTION
Unlike their endocrine-active counterparts, endocrine-
inactive pituitary adenomas become symptomatic through
their growth and expansion and often are not diagnosed
until they become very large. The clinical syndromes they
produce do not reflect hormonal imbalance, but rather
reflect damage to the anterior pituitary gland and com-
pression of suprasellar and parasellar structures.
Transfrontal approaches to the sella are effective for
removing large extrasellar tumors, but as many as 95% of
pituitary adenomas are now removed transsphenoidally,
with access to the sella obtained by use of a surgical mi-
croscope and fluoroscopic monitor. Most endocrine-in-
active adenomas are so large, however, that they present
daunting obstacles to total transsphenoidal removal. Still,
many, although certainly not all, of these tumors can be
removed completely with preservation of anterior pitu-
itary function and possibly even with recovery of lost
anterior pituitary function. With an appropriate surgical
strategy, the transsphenoidal removal of endocrine-inac-
tive tumors is both safe and effective. The primary treat-
ment of all endocrine-inactive adenomas should be
transsphenoidal removal with the objective of cure. When
removal is known to be incomplete, regrowth of the tu-
mor is inevitable, and for that reason, postoperative irra-
diation is indicated with few exceptions.
CLINICAL PRESENTATION
Impairment of vision and partial hypopituitarism are the
most common initial signs of endocrine-inactive pituitary
adenomas, after which are headaches that may be severe
and the involvement of extraocular muscle function. Im-
paired vision is by far the most frequent presenting sign.
Headache and impaired libido are the next most frequent
complaints, with impaired menses and diplopia, galac-
© 1992 The American Association of Neurological Surgeons
a
This chapter is adapted in part from Wilson CB: Endocrine-inactive
pituitary adenomas. Clin Neurosurg 1992; 38:10-27.
428
torrhea, and adrenal insufficiency occurring in fewer pa-
tients. Large adenomas frequently exhibit hemorrhage,
necrosis, and cyst formation, but only rarely do patients
develop the full clinical syndrome of pituitary apoplexy.
Signs of neural involvement within the cavernous sinus,
usually on only one side, nearly always indicate an abruptly
enlarging mass caused by necrosis or, less often, bleed-
ing within the tumor. Paradoxically, clinical signs are sel-
dom produced by a tumor invading the cavernous sinus
and engulfing those same cranial nerves.
LABORATORY EVALUATIONS
Patients with an endocrine-inactive adenoma may have
elevated serum levels of gonadotropins and a-subunit. In
males, the most frequent abnormality is an elevated se-
rum level of follicle-stimulating hormone (FSH). Females
may show an increased ratio of α-subunit to luteinizing
hormone (LH) and FSH, which may corroborate the di-
agnosis of endocrine-inactive adenoma and may be help-
ful in diagnosing a recurrence. In regard to menopausal
status, however, serum levels of both gonadotropins are
normal. Although there may be qualitative and quantita-
tive defects in gonadotropin synthesis by the gonadotro-
pin-secreting cells in both male and female patients, the
FSH is biologically active in those patients with elevated
serum FSH levels. The α-subunit levels in blood are el-
evated in 10% of all females and 38% of males who have
an endocrine-inactive adenoma, but there is no associ-
ated clinical activity. Adenomas that produce LH but not
FSH are extremely rare. Nearly all endocrine-inactive
adenomas can or do secrete coupled or uncoupled gona-
dotropins, but they have no clinical expression, either
because the product stimulates no endocrine syndrome
or because hormone biosynthesis and secretion are de-
fective.
Endocrine-inactive adenoma cells exhibit re-
sponses of gonadotropin secretion to gonadotropin-re-
leasing hormone (GnRH), thyrotropin-releasing hor-
mone (TRH), and bromocriptine which do not de-
 WILSON : ENDOCRINE-INACTIVE ADENOMAS

pend on baseline levels of hormone production. Gona-
dotropin-secreting adenomas treated with bromocriptine
show a prompt reduction in secretory activity. During
long-term bromocriptine therapy, more than 50% of pa-
tients with endocrine-inactive adenomas show a reduc-
tion in their serum levels of gonadotropins or subunits.
Serum levels of neuron-specific enolase, which is se-
creted by endocrine-inactive adenomas, are elevated in
a few patients.
A complete preoperative endocrine evaluation is ad-
visable, including sampling for LH, FSH, and the α-sub-
unit, because detailed preoperative and serial postop-
erative testing is the only way in which the effects and
effectiveness of therapy can be defined quantitatively.
RADIOLOGIC STUDIES
High-resolution magnetic resonance (MR) imaging is the
indispensable preoperative radiologic study. Imaging is
done without and then with gadolinium enhancement,
which defines the anterior lobe tissue. Dynamic MR imag-
ing provides rapid sequences after the injection of gado-
linium, in which the anterior lobe enhances quickly and
fades rapidly, whereas the tumor enhances later with a
more gradual loss of intensity.
INDICATIONS FOR SURGICAL APPROACHES
Craniotomy
A craniotomy may be safer and more effective than the
transsphenoidal approach in a few selected cases. The
indications that dictate a transfrontal approach in treating
pituitary adenomas are the presence of one or more of the
following:
4. Pituitary insufficiency, of which the earliest sign is a
blunting of growth hormone (GH) responsiveness; go-
nadotropin insufficiency is an even stronger indication.
When risks are weighed against benefits, such an
aggressive approach is warranted and appropriate, based
on the real potential for surgical cure and preservation of
anterior pituitary function.
SURGICAL TECHNIQUE
Certain technical surgical maneuvers are particularly help-
ful in meeting the objective of total removal of an endo-
crine-inactive adenoma. The sublabial-transseptal approach
to the sella is a standard procedure, during which septal
cartilage is obtained for recontructing the sella (Fig. 1).
Positioning
The patient remains in a semisitting position throughout
the procedure. Because of the risk of air embolism, the
surgeon must be prepared to modify the position intraop-
eratively if opened veins do not bleed.
Operative Technique
General anesthesia is induced, and a lumbar sub-
arachnoid catheter is introduced through a Tuohy
needle for later injection and withdrawal of fluid, to
provide absolute control of the suprasellar capsule.

1. A large suprasellar mass with minimal or dispropor-

tionately little sellar enlargement;
2. Extrasellar extension into the middle fossa of an
extrasellar mass that is greater in volume than the
intrasellar volume;
3. An unrelated intracranial lesion (e.g., parasellar aneu-
rysm) that may complicate a transsphenoidal operation;
4. A densely fibrous tumor that cannot be removed
transsphenoidally; the craniotomy is done as a second
procedure to relieve compression of a compromised op-
tic chiasm.

Transsphenoidal Approach
The indications dictating transsphenoidal removal of
symptomatic endocrine-inactive adenomas are the pres-
ence of one or more of the following:

1. Extrasellar tumor extension, including extension into Figure 1. The transsphenoidal approach to the sella is made with the
the sphenoid sinus; patient in a semisitting position, head rotated to face the surgeon, who
stands at the patient’s right side. (Rendered and reproduced in part with
2. Pituitary apoplexy;
permission from Wilson CB. Endocrine-inactive pituitary adenomas.
3. Intractable headaches; Clin Neurosurg 1992;38:10-27.)

429
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
Unless the anterior sellar wall is paper thin, the wall is
perforated with an air drill. The dura is then exposed by
use of punches until the grooves are visible along mar-
gins of both cavernous sinuses and the surgeon arrives at
the lower edge of the circular sinus at the tuberculum.
The most anterior portion of the sellar floor is removed
until the horizontal plane is reached (Fig. 2).
Using a No. 11 knife blade, the surgeon incises the
dura along a line 2 mm from the bone edges (Fig. 3). The
dural edges are sealed by use of a right-angled bipolar
coagulating forceps to close any opened dural venous si-
nus and to obtain wider exposure of the tumor by shrink-
age of the dural fringe. The dura is coagulated to the very
edge of the cavernous sinus. At the end of the procedure,
the surgeon is usually able to see much of the sinus wall,
or the compressed anterior lobe covering it, because nor-
mal venous pressure in the sinus serves to “float” the dis-
placed dura medially into the field.
The central portion of the tumor is removed with dis-
sectors, microrongeurs, ring curettes, and suction to en-
courage the tumor to retract from peripheral structures and
to provide space into which the shell of the tumor can be
displaced (Fig. 4). The most critical step in this procedure
is finding and developing the plane between the tumor and
the compressed residual anterior lobe, which is almost al-
ways found lying laterally on the wall of the cavernous si-
nus, usually (but not always) asymmetrically. The site of
the anterior lobe often can be identified preoperatively on
a high-resolution MR image made without and then with
gadolinium enhancement (Fig. 5). On the MR images of
very large tumors, however, neither a difference in attenu-
ation between the anterior lobe and the tumor nor the loca-
tion of the displaced pituitary stalk can be identified, and
in such a case the surgeon must work slowly until the ante-
rior lobe can be identified. Gentle dissection is used to find
the plane separating the smooth surface of the tumor from
the attenuated remnant of anterior lobe tissue (Fig. 6). At
times, the tumor behaves as if it has an invisible capsule
that facilitates clean separation of the tumor from com-
pressed and displaced normal tissues.
When the plane has been developed on the side of
the identifiable anterior lobe, two objectives have been
met: 1) sparing of the anterior lobe and 2) clean separa-
tion of the tumor from adjacent tissue. The plane is ex-
tended completely around the intrasellar tumor with the
use of microenucleators, dissectors, tiny cottonoid pat-
ties, and even the leading edge of a ring curette (Fig. 6).
In some cases, enhanced and unenhanced high-reso-
lution MR images do not delineate the site of the com-
pressed anterior pituitary gland. The extent of this prob-
lem depends on the degree of suprasellar extension,
430
because in many cases a large tumor inverts the pituitary
stalk—the most reliable indicator of the direction in which
the anterior lobe is displaced—into the anterior third ven-
tricle, and deviation of the floor of the third ventricle may
not be apparent. In such a case, the surgeon can reliably
identify the plane separating the tumor and displaced nor-
mal tissues by removing the central portion of the
intrasellar tumor (Fig. 4) and then proceeding across the
sella toward the dorsum sellae in a plane parallel to the
sellar floor. Advancing slowly as the dorsum is approached,
the surgeon will readily recognize the abrupt transition
between the thinly enveloped surface of the tumor and
the plane separating it from flattened anterior and poste-
rior pituitary remnants. An instrument such as a right-
angle ring curette or a microenucleator can be slipped
into this plane, and dissection of the tumor from normal
tissues can proceed (Fig. 6), the removal progressing for-
ward from the dorsum sellae rather than backward from
one side (Fig. 7).
It can be surprisingly easy to separate tumor from
the suprasellar capsule when a thin remnant of anterior
lobe forms a part of the capsule and when the suprasellar
extension is neither extremely large nor irregular and/or
markedly asymmetrical. When the suprasellar capsule
consists predominantly of unthickened arachnoid and
when the suprasellar surface of the tumor has irregular
nodules, however, this separation of the tumor is very dif-
ficult. Most difficult is the exposure and removal of tu-
mor nodules trapped in the folds of a suprasellar capsule
so extensive that it does not invert into the sella as a smooth
sheet, but rather collapses in folds. First, the bulk of the
suprasellar tumor is removed after being forced into the
field of vision by the subarachnoid injection of saline
(without preservative) by the anesthesiologist, as needed.
Great care is taken to guard against elevating intracranial
pressure (ICP) excessively and thereby literally bursting
the thin capsule. Dissection of the tumor from the cap-
sule can proceed from one or both sides by following the
previously defined intrasellar plane. It may be helpful to
exert countertraction by holding the capsule with a
cottonoid patty on a sucker tip (Fig. 8). Tumor trapped in
folds is located and separated by opening the folds with a
forceps speculum. Small tears in the arachnoid can be
sealed with the angled bipolar coagulating forceps.
A thorough inspection is made of the entire surface
previously in contact with tumor, and a dental mirror is
used, if necessary, to verify that all sites are free of tumor.
Then, with a dry field and no communication with the
subarachnoid space, the sella is filled with absolute alco-
hol. The alcohol is changed at least once and is left in
place for five minutes.
 WILSON : ENDOCRINE-INACTIVE ADENOMAS

Figure 2. The dura covering the sella is exposed to the edge of floor, which in some cases requires drilling through the interposed
the circular sinus at the tuberculum sellae and to the groove de- body of the sphenoid bone. (Rendered with permission from Wil-
lineating the medial border of the cavernous sinus on each side. son CB. Endocrine-inactive pituitary adenomas. Clin Neurosurg
Finally, bone is removed down to the horizontal plane of the sellar 1992;38:10-27.)

Figure 3. The dura is incised 1-2 mm from the bone edge to coagulating forceps. (Rendered with permission from Wilson
avoid opening into a major venous sinus. The dura can be CB. Endocrine-inactive pituitary adenomas. Clin Neurosurg
shrunk closer to the bone edge by using right-angle bipolar 1992;38:10-27.)

431
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

Figure 4. The interior of the tumor is removed to help define the plane (Rendered and reproduced in part with permission from Wilson CB.
separating the adenoma from the compressed anterior pituitary gland. Endocrine-inactive pituitary adenomas. Clin Neurosurg 1992;38:10-27.)

432
 WILSON : ENDOCRINE-INACTIVE ADENOMAS
Figure 5. The pituitary stalk is displaced with the major remnant of the
anterior pituitary gland, and in this case the surgeon would initially seek
the plane separating the adenoma from pituitary gland on the left side.
A, a T1-weighted MR image shows a large suprasellar component. B, a
gadolinium-enhanced MR image shows the compressed anterior lobe
433
and stalk, displaced to the left (right side of illustration). C, the stalk is
demonstrated more clearly in an image obtained 48 hours postopera-
tively that shows a central hypointense hematoma and a peripheral rim
of fat. (Reproduced with permission from Wilson CB. Endocrine-inac-
tive pituitary adenomas. Clin Neurosurg 1992:38:10-27.)
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

Figure 6. The critical plane between the adenoma and the anterior lobe has wise, from the top) a microenucleator, a fine cottonoid pledget, and the
been defined. Working from this initial plane of cleavage, the surgeon sepa- leading edge of a ring curette. (Rendered with permission from Wilson CB.
rates the adenoma from the compressed normal structures using (clock- Endocrine-inactive pituitary adenomas. Clin Neurosurg 1992;38:10-27.)

434
 WILSON : ENDOCRINE-INACTIVE ADENOMAS

Figure 7. Working toward the dorsum sellae through a partially as a dissector, the leading surface of a right-angle ring curette.
excavated tumor, the surgeon identifies the plane separating the (Rendered and reproduced in part with permission from Wilson
adenoma from compressed normal structures. Beginning at this CB. Endocrine-inactive pituitary adenomas. Clin Neurosurg
point, the plane of dissection is defined and is followed by using, 1992;38:10-27.)

435
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
Figure 8. Gentle countertraction can be applied with a sucker
tip protected by a small cottonoid pledget during the removal
of tumor loosely adherent to the suprasellar capsule. (Rendered
Closure
The sella is filled with subcutaneous fat, and the surgeon
must take care to avoid or minimize displacement of fat
above the sella. A septal cartilage graft is slipped beneath
the dural edges laterally so that it fits snugly, and the graft
is finally sealed in place with a layer of fibrin glue.
The lumbar subarachnoid catheter is left in place and
capped because its withdrawal can cause cerebrospinal fluid
(CSF) leakage at the puncture site and consequent depres-
sion of the ICP. Intracranial hypotension removes the tam-
ponade effect of normal ICP and encourages bleeding into
the tumor bed. The catheter can be removed safely after 24
hours, but if there is an opening into the subarachnoid space,
the catheter should be attached to a drainage bag main-
tained at heart level for 48 to 72 hours. After the lumbar
catheter is removed, the patient is permitted unrestricted
436
and reproduced in part with permission from Wilson CB. En-
docrine-inactive pituitary adenomas. Clin Neurosurg
1992;38:10-27.)
activity. A headache that develops after lumbar puncture is
treated promptly with an epidural blood patch.
POSTOPERATIVE INTERVENTION
CSF rhinorrhea that recurs after 72 hours of lumbar sub-
arachnoid drainage and progressive postoperative visual
deterioration caused by intracapsular hemorrhage which
occurs shortly after removal of a large adenoma are indi-
cations for early operative intervention. In a patient with
postoperative visual loss that is neither significant nor
rapidly progressive, an unenhanced computed tomogra-
phy (CT) scan should be obtained before operative inter-
vention is entertained because edema of the optic nerves
and chiasm may account for the deterioration. In such a
situation, the sella should not be explored without evi-
dence of a hematoma.
 WILSON : ENDOCRINE-INACTIVE ADENOMAS
POSTOPERATIVE CARE
If surgery has achieved curative removal of the tumor and
if the anterior pituitary gland is preserved, then postop-
erative irradiation is not needed and the patient may not
require full pituitary hormone replacement therapy on a
permanent basis. Compression of the anterior lobe usu-
ally impairs the secretion of hormones in the following
order: GH, gonadotropins, adenocorticotropic hormone
(ACTH), and TSH, although the production of ACTH may
be affected earlier than that of the other hormones in some
cases. There may be recovery of GH secretion, but this is
usually not the case. Because an untreated GH deficiency
has been implicated in decreased lean body mass and ver-
tebral bone density and increased adipose tissue mass in
normal elderly men, and in premature death from cardio-
vascular disease despite adequate hormone replacement
therapy in patients with hypopituitarism, GH replacement
therapy may be considered in patients whose GH secre-
tion is not restored by the operation.
A decision to recommend postoperative irradiation
presupposes incomplete removal of the adenoma. In
younger patients who have residual pituitary function and
a strong wish for parenthood, irradiation can be postponed
and the patient followed with serial observation. For frail
or elderly patients, in whom the tumor grows more slowly,
radiation therapy may not be appropriate. For patients with
massive infarction of the adenoma who present with pi-
tuitary apoplexy, irradiation should be deferred and their
course followed, because any remaining tumor cells may
not be viable.
DIAGNOSIS OF RECURRENCE
Pituitary adenomas in general have low proliferative ac-
tivity. Invasive pituitary tumors and adenomas in patients
younger than middle age tend to have a high labeling
index (LI), whereas recurrent pituitary tumors may re-
tain a low level of proliferative activity. Because they
have an LI of over 1%, endocrine-inactive adenomas are
in the kinetic range of well-differentiated astrocytomas.
Although the detection of a subunit is a promising marker
for tumor recurrence in patients with abnormal preop-
erative serum levels, the current follow-up evaluation
for all patients with endocrine-inactive tumors requires
serial high-resolution MR images made at six-month
intervals unless the tumor has been irradiated, in which
case a yearly MR image is adequate. Both clinical evalu-
ations and CT scans are relatively insensitive in detect-
437
ing early postoperative regrowth. The greater accuracy
of MR images should permit detection of almost all
recurrences with five years unless the tumor has been ir-
radiated, and even most of those recurrences may be de-
tected within five years.
ADJUVANT THERAPY
The option of reoperation or irradiation is offered to pa-
tients with adenoma regrowth who have not received ra-
diation therapy. Recurrence of a previously irradiated tu-
mor, depending on its size and clinical manifestations, is
treated by one therapy or a combination of therapies: op-
eration, reirradiation, or medical therapy which currently
is restricted to bromocriptine.
Radiation Therapy
The complications of radiation therapy provide an argu-
ment for an aggressive surgical approach. Nonetheless,
when radiation is necessary in treating an endocrine-in-
active adenoma, current techniques deliver a nearly uni-
form dose to a defined tumor volume with a rapid reduc-
tion in the irradiation of tissue outside of the target area
and a resultant sparing of adjacent normal tissues. Ex-
cept for the unusual case of a large tumor volume, the
preferred technique involves bilateral moving coronal arc
fields with reversing 30° wedge filters. In treating large
tumors, two lateral wedged fields are used with one supe-
rior (or vertex) field without a wedge. The linear accel-
erator has advantages over a cobalt source in both accu-
racy and sparing of normal tissues. Irradiation (1.8 Gy to
both fields) is continued daily for 5 days each week to a
total dose of 45 Gy. Irradiation to more than 50 Gy or
daily doses greater than 2 Gy increase complication rates
without providing improved control. This approach has
resulted in a recurrence-free survival rate of greater than
95%. An increased field size is significantly associated
with a reduced level of tumor control.
Medical Treatment
Bromocriptine may have an inhibitory effect on the growth
of some endocrine-inactive pituitary adenomas that is
time-dependent and increases with the duration of admin-
istration. A reduction in the size of adenomas after six
weeks of bromocriptine therapy has been reported, and
newer dopamine agonists may be even more effective.
Bromocriptine is generally ill-advised as the initial and
sole treatment of most endocrine-inactive tumors.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
POSTERIOR DECOMPRESSION
AND FUSION FOR CERVICAL
SPONDYLOTIC MYELOPATHY
PAUL KURT MAURER, M.D.
CHARLES NUSSBAUM, M.D.
INTRODUCTION
Cervical spondylotic myelopathy (CSM) results from two
synergistic variables: 1) narrowing of the diameter of
the cervical spinal canal by spondylotic spurs and hy-
pertrophic ligamenta flava; and 2) spinal cord traction
and repetitive trauma within this compromised canal
because of the inherent motion of the cervical spine (i.e.,
a dynamic component of CSM). To be successful, an
operative treatment of CSM must address both the static
compressive and the dynamic aspects. Posterior decom-
pression and stabilization offer an approach to both of-
fending variables. Multilevel decompression is readily
achieved and significant reduction of dynamic forces is
accomplished without the need for postoperative exter-
nal fixation devices.
PATIENT SELECTION
Patients with myelopathy from single or dual level disc/
spur complexes may be appropriately treated by simple
anterior cervical discectomy and fusion, or standard pos-
terior procedures with or without lateral mass plates, etc.
However, patients with cervical spondylotic myelopathy
often have multilevel disease spanning from C-3 to C-7.
The multiple level involvement is cumulative and good
long-term results are achieved by addressing the dynamic
aspects of all involved levels. Patients with myelopathy
from multilevel cervical spondylosis are, therefore, can-
didates for posterior decompression and stabilization.
Because of the multilevel nature of CSM and the impor-
tance of reduction of the dynamic component, we gener-
ally prefer C3-7 decompression and immobilization. This
prohibits moving the motion arc into other regions of the
cervical cord. The patient will still retain approximately
25° of flexion/extension postoperatively.
© 1992 The American Association of Neurological Surgeons
438
PREOPERATIVE PREPARATION
Although nearly all of our patients have had magnetic
resonance imaging of the cervical spine, the majority
undergo cervical intrathecal contrast-enhanced computed
tomography. The axial images with intrathecal contrast
are very useful in defining the severity of involvement at
various levels. Patients are given a perioperative dose of
an antibiotic (1 gram of nafcillin) intravenously. No ste-
roids are used. Somatosensory evoked potential monitor-
ing is used intraoperatively.
OPERATIVE TECHNIQUE
Anesthesia
The patients are intubated in a Philadelphia collar with
the surgeon acting as observer to ensure against flexion
or extension during intubation. Fiberoptic technique has
been used in many patients, but we do not routinely use
awake intubation techniques. A systemic arterial catheter
is placed as well as two intravenous peripheral lines. A
urinary catheter is placed prior to positioning.
Positioning
Proper positioning is very critical for two reasons: 1) the
compromised canal will not tolerate excessive flexion or
extension, which could lead to spinal cord injury; and 2)
the patient will have instrumentation placed which fixes
the patient approximately in the position used at surgery.
Although the patients retain approximately 25° of flex-
ion/extension postoperatively, improper positioning at
surgery could lead to an uncomfortable head stance post-
operatively (Fig. 1).
The patient is rolled from the stretcher into a prone
position on the operating table. The Philadelphia col-
lar is left on for this maneuver because it reduces the
risk of flexion or extension. A three-point head holder
is used with the neck fixed in a neutral to slightly ex-
tended position (Fig. 1). The head is shaved to just
 MAURER AND NUSSBAUM : POSTERIOR DECOMPRESSION AND FUSION FOR CSM
© 1992 The American Association of Neurological Surgeons
Figure 1. The patient is placed in a prone position. The neck should
be fixed in a neutral to slightly extended position. A neutral cervical
spine angle reduces compressive risks to the spinal cord intraopera-
tively and maximizes patient comfort postoperatively because the neck
below the inion. The iliac crest is draped to allow har-
vesting of the bone graft.
Surgical Technique
A generous skin incision is made from the low subocciput
to the region of the T3-4 interspace (Fig. 1). An appro-
priately long exposure is important to allow for the safe
passage of sublaminar wires or cables. A standard sub-
periosteal dissection is then completed from C-1 to T-2.
The subperiosteal dissection is carried well out to the
lateral facet to allow ample room for bone fusion and
the placement of spinal instrumentation. A high-speed
drill with a combination of cutting and diamond bits is
used to form a trough at the lamina-facet groove on ei-
ther side from C3-7 (Fig. 2A). A 4-mm diamond bit is
then used to finally “wafer” the bone layer at each level.
The laminae are carefully lifted away one or two levels
at a time. Care must be taken not to angle a lamina into
the cord. Leaving the spinous processes intact permits
gentle traction of the posterior arches away from the dura
while the ligamentum flavum is incised at each level.
Completion of the C3-7 laminectomy yields full cervi-
cal decompression (Fig. 2B). Foraminotomies may be
accomplished at this time if a mixed myeloradiculopa-
thy is present.
439
will be instrumented approximately in this position. Note the skin in-
cision extending from the low subocciput to T-4 to allow adequate
room for placement of a Luque ring above and below the proposed
decompression.
To prepare for the next stage of the procedure, i.e.,
instrumentation, care must be taken to be absolutely sure
a clear epidural zone is prepared between C1-2, T1-2, and
T2-3 (Fig. 2B). This can be accomplished easily by using
small Kerrison rongeurs and pituitary forceps to remove
the ligamentum flavum and epidural fat from these
interlaminar regions. The subarachnoid space at C-2 and
at T1-3 is relatively capacious even in the patient with
cervical spondylotic myelopathy and is ideal for passage
of sublaminar cables.
The next step of the procedure involves passage of
the sublaminar and facet cables. Although we used wire
in the past, we now use the Songer cable system (Danek
Medical, Memphis, TN). The Songer system comprises
two 49-strand stainless steel cables attached to a 19-gauge
“leader” (Fig. 3). The cables are very soft and pliable.
Once the “leader” is passed under the lamina, the soft
cables pass easily, thus making the cables easier and safer
to use than wire by standard techniques. Fatigue tests dem-
onstrate that the stainless steel cables are 6 to 22 times
more resistant to failure than stainless steel wires.
A total of f ive double cables are used (three
sublaminar, two facet), making ten cables available for
fixation. Due to the uniform tightening allowed with
the cable system, and the increased strength of the
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

© 1992 The American Association of Neurological Surgeons

Figure 2. The decompression phase of the procedure. A, a high-speed
drill with cutting and diamond bits is used to form a trough (gutter) on
each lamina-facet groove. A clamp may be placed on the intact spinous
processes and gentle traction applied. This greatly facilitates a safe
dissection of the underlying ligamenta flava and easy en bloc removal
of the laminae. Use of the drill eliminates instrument encroachment
on an already compromised cervical canal. B, a full decompression
has been achieved. Also, C1-2, T1-2, and T2-3 have been cleared of
ligamentum flavum and epidural fat. This is important to allow safe
passage of sublaminar cables from one clean epidural plane to the
next. A small laminotomy can be made, if needed, to provide adequate
space for cable passage.

440
 MAURER AND NUSSBAUM : POSTERIOR DECOMPRESSION AND FUSION FOR CSM
© 1992 The American Association of Neurological Surgeons
Figure 3. The Songer double cables are passed under the lamina at C-2,
T-1, and T-2. A gentle curve (inset) placed in the leader loop of the
cable facilitates the sublaminar pass. Once the double cable is under the
lamina, care is taken to observe the dura to ensure that compression is
cables, facet wires are not used. This reduces the risk of
the extra drill holes in the facets as well as decreasing
operative time.
The “leader” wire loop of the Songer double cable
is fashioned into a gentle curve (Figs. 3 and 4). It is
passed carefully under the C-2 lamina while the dura is
observed to prevent indentation and compression. If the
interlaminar areas are cleared properly, this is accom-
plished easily. As the leader loop comes into view above
the superior rim of C-2, it is grasped with a blunt nerve
hook (Fig. 3). The leader is pulled and the cable allowed
to follow passively. It is important not to push the cables
through, but to allow the nerve hook to simply pull the
cable under the lamina. This prevents an accumulation
of cable under the lamina which could compress the cord.
Once the soft cable is half of the way under the lamina,
the leader loop is cut with the wire cutter and the cables
are passed off to the sides (Fig. 3). Steri-strips or drape
tape can be used to hold the cables to the sides. Clamps
441
not occurring. The leader loop of the cable is grasped with a blunt nerve
hook, and the cables pulled under the lamina. The loop is cut and yields
six sublaminar cables (two each at C-2, T-1, and T-2). Four facet cables
will be placed.
should not be used to hold the cables because they can
damage the braided strands.
A double sublaminar cable is passed under T-1 and
another under T-2. Splitting the leader loop thus yields
four more sublaminar cables; two under T-1 and two un-
der T-2 (Fig. 3). Holes are drilled obliquely through the
inferior facets of C-3 and C-4 and a single cable is passed
at each facet. This completes placement of the cables
needed for instrument fixation.
The next step is formation of a Luque rectangle (Luque
ring) from a straight Luque rod (Figs. 4 and 5). As shown
in Figure 5, the straight 3/16-inch metal rod is bent with
the use of 3/16-inch Darek in situ rod benders. An 18-gauge
wire is placed in the wound and simply hand or clamp-bent
into a model template upon which the permanent rod will
be based (Fig. 4). The template should wrap over the C-2
spinous process and under the T-2 spinous process. A gentle
curve should be placed in the wire template so that it sits
relatively evenly on the facets and laminar surfaces.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
© 1992 The American Association of Neurological Surgeons
Figure 4. Instrumentation for the Luque ring/Songer cable system. 1,
a straight 3/16-inch Luque rod. This will be bent into a properly formed
Luque ring. 2, an 18-gauge wire template. Standard 18-gauge wire is
placed in the wound after decompression and is bent by hand or clamp
to serve as a template for the formation of the permanent Luque ring.
The top loop is seated just over the spinous process of C-2, the curve
allows load bearing on the facets and T1-2 laminae, and the lower
loop seats under the spinous process of T-2. 3, In situ rod benders
Based on this template, the straight Luque rod is bent at
appropriate intervals to form the completed ring (Fig. 5).
The curve is placed in the ring with a French rod bender
(Figs. 4 and 5). Excess rod is cut off with a rod cutter
(Figs. 4 and 5). The Luque ring is now ready to be fixed
in position as an internal immobilization device.
The Luque ring is passed into the wound and seated
over the spinous process of T-2 (Figs. 6 and 7). The loop
on the end of each cable is passed inside the Luque ring,
and the cut end of the leader is passed through the loop
(Fig. 6). This forms a noose around the Luque ring (Figs.
6 and 7). The leader is passed through the crimp (called
“top hat” because of its distinctive shape) which will
tighten and fix the cable noose in position (Figs. 4 and
442
which are used to bend the 3/16-inch straight Luque rod. 4, a French
rod bender, for placement of a curve in the Luque rod. 5, a rod cutter.
6, a Songer double cable (two 49-strand stainless steel cables attached
to a 19-gauge wire leader loop). The leader loop will be curved gently
to allow passage under the lamina. 7, a wire cutter. 8, Tensioner-crimper
pliers, used to tighten the cable system. 9, a torque wrench which at-
taches to the tensioner-crimper to allow uniform tightening of each
cable. 10, a cable cutter.
7). The crimp sits in the jaws of a special crimping pli-
ers, a tensioner-crimper (Figs. 4 and 6). The wire passes
through the top hat crimp (Fig. 6, inset) and then into a
spool at the end of the tensioner-crimper pliers. The
tensioner-crimper pliers is slid down onto the Luque
ring, thereby tightening the noose. A torque wrench is
applied to the tensioner-crimper pliers and turned un-
til the spool reaches 10 inch-pounds. This allows uni-
form tightening of each cable around the Luque ring.
Once 10 inch-pounds has been achieved, the tensioner-
crimper handles are squeezed tightly, which closes the
crimp on the cable, rigidly fixing the cable in position
(Fig. 7A). The cable is cut 2 mm above the crimp (Fig.
7B). Alternating cables are tightened to allow the Luque
 MAURER AND NUSSBAUM : POSTERIOR DECOMPRESSION AND FUSION FOR CSM

© 1992 The American Association of Neurological Surgeons

Figure 5. Formation of the Luque ring. A and B, a 3/16-inch straight section the rod. E, a French French rod bender is used to place a curve
Luque rod is bent based on the 18-gauge wire template. C, the inferior in the Luque ring, based on the 18-gauge template. F, the completed
loop is bent, using the in situ rod benders. D, a rod cutter is used to Luque ring.

443
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

© 1992 The American Association of Neurological Surgeons

Figure 6. The Luque ring is seated in the operative field with the
cephalad end over the spinous process of C-2 and the caudal end
under the spinous process of T-2. The free end of each cable is placed
around the Luque ring and through the cable loop, thus forming a
noose around the Luque ring (example: right cable at C-2). The cable
is passed through the crimp (“top hat”) which sits in the jaws of the
tensioner-crimper pliers (inset). The cable is then tightened to 10
inch-pounds using the torque wrench on the tensioner-crimper de-
vice. The crimper handles are squeezed, fixing the cable noose around
the Luque ring.

444
 MAURER AND NUSSBAUM : POSTERIOR DECOMPRESSION AND FUSION FOR CSM
© 1992 The American Association of Neurological Surgeons
Figure 7. A, the Luque instrumentation is held in its final position by
six sublaminar cables, two at C-2, two at T-1, and two at T-2, and four
ring to seat properly. Completion of cable tightening gives
six sublaminar and four facet cable fixation of the Luque
ring which allows for a very solid construct (Fig. 7). The
use of the torque wrench system allows for uniform tight-
ening which eliminates the wire twisting techniques that
lead to metal fatigue and breakage.
After the spinal cord is decompressed and immobilized
445
facet cables. B and C, the cable system allows uniform tightening and
fatigue-resistant fixation.
(i.e., both the compressive and dynamic aspects addressed),
bone “pâte” is used for bone grafting over the facets. The
facets are gently “buffed” with a cutting bit on a high-speed
drill to allow an adequate surface for bone fusion. Iliac crest
may be used as the bone donor site. Bone graft can be wedged
under the edge of the Luque ring (Fig. 8C).
The wound is irrigated and closed with 2-0 Vicryl
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

© 1992 The American Association of Neurological Surgeons

Figure 8. A, for closure, 2-0 absorbable sutures are used in the cervical tive (B) and postoperative (C) axial views. Note the bone graft material
fascia and subcutaneous tissue. The lower illustrations show preopera- packed around the rod at the facets (C).

446
 MAURER AND NUSSBAUM : POSTERIOR DECOMPRESSION AND FUSION FOR CSM
sutures in interrupted fashion in the cervical fascia (Fig.
8A). A tight fascia/muscle closure is required to reduce
dead space and eliminate seroma formation. The dura is
not covered with gelatin sponge. Inverted subcutaneous
Vicryl sutures are placed. Skin staples are used and a
simple dressing is applied. No drains are used. Care is
taken to control the head while the patient is rolled off the
operating table. A Philadelphia collar is used for approxi-
mately four weeks postoperatively. The duration of sur-
gery is generally 4 to 4.5 hours.
POSTOPERATIVE CARE
The patient is observed in the intensive care unit for 12 to
18 hours and is allowed to ambulate and begin a regular
diet on the second day. The patient is generally discharged
on the fifth postoperative day.
COMPLICATIONS
Multilevel decompression and instrumentation can be
447
a safe and expeditious procedure. Quadriplegia is a
potential complication of any procedure for CSM but
should be extraordinarily rare with proper attention
to detail. Transfusions have been required in less than
5% of the cases. Seroma formation can occur due to
the large dead space involved. Tight muscle closure
has eliminated this problem. Instrument breakage
should be rare and has not occurred to date with the
fatigue-resistant Songer cable system. Bone fusion
should be complete in approximately 12 weeks. No
external fixation devices are used and halo problems
are thereby eliminated. Although there is, appropri-
ately, a decrease in cervical motion, enough motion
is retained at the occiput-C-1 and C1-2 levels (ap-
proximately 25° of flexion/extension) to allow rea-
sonable movement. Lack of motion has not been a sig-
nificant postoperative complaint, and the significant
reduction of dynamic forces is important in the treat-
ment of this disease process.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
SURGICAL CORRECTION OF SWAN
NECK DEFORMITY
PETER M. KLARA, M.D., PH.D.
KEVIN T. FOLEY, M.D.
INTRODUCTION
Patients who have undergone cervical laminectomy are
at risk for postlaminectomy kyphosis, or “swan neck de-
formity.” Multilevel laminectomy or extensive laminec-
tomy with violation of the facet joints carries an increased
risk of instability and resultant deformity. Additionally,
removal of the musculature inserting on the C-2 lamina
and spinous process seems to significantly increase the
risk of subsequent deformity.
In adults, spondylotic myelopathy is the most com-
mon reason for multilevel laminectomy. In children, how-
ever, spinal cord tumors are the most common indication
for this procedure. The immature spine is much more sus-
ceptible to kyphotic deformity than is the adult spine.
Radiation to the pediatric spine also has been associated
with kyphotic deformity; however, a causal relationship
has not been established unequivocally.
Other causes of swan neck deformity include trauma,
syringomyelia, and congenital anomalies such as the
Klippel-Feil syndrome. These latter conditions may re-
sult in kyphotic deformity in either adults or children.
PRESENTATION
Pain is the most common presenting complaint in both
the adult and pediatric populations. The pain may be
radicular or referred, but an ill-defined, aching sensation
in the cervical or thoracic spine may be the sole symp-
tom. A full spectrum of neurologic deficits may be seen.
These range from typical radiculopathy to a full myelo-
pathic picture. The neurologic deficits depend upon the
degree of neural compression.
The illustrations in this article were reprinted with permission from
Aesculap.
© 1992 The American Association of Neurological Surgeons
448
EVALUATION
A high degree of suspicion should lead to further evalua-
tion in any persistently symptomatic patient who has un-
dergone cervical laminectomy or has had a history of cer-
vical problems. Plain cervical spine films which include
flexion and extension views are the basis for the diagnosis
of swan neck deformity. In patients who are neurologically
intact and present only with minimal pain, conservative
therapeutic measures should be instituted. These can con-
sist of physical therapy and bracing, with periodic radio-
graphic evaluation to determine whether instability is
present or there is progressive deformity.
In patients with neurologic deficit of a radicular or
myelopathic nature, further diagnostic studies are war-
ranted. Additionally, for patients whose pain is progres-
sive and significantly inhibits their activities of daily liv-
ing despite a trial of nonoperative management, further
evaluation should be pursued. In addition, patients who
demonstrate progressive kyphosis should be considered
for further evaluation. Magnetic resonance imaging
(MRI), with its overall excellent anatomic detail, is the
preferred study. Alternatively, a myelogram coupled with
postmyelogram computed tomography (CT) scanning can
be obtained. Underlying lesions, such as tumors or syrin-
gomyelia, must be excluded.
INDICATIONS FOR SURGERY
Progressive neurologic deficit associated with kyphosis
is a clear surgical indication. Demonstration of progres-
sive kyphosis or instability despite bracing and other thera-
peutic measures also is an indication for surgery. Finally,
pain that severely restricts activities of daily living and is
refractory to nonoperative management may be amelio-
rated by surgical intervention.
PREOPERATIVE PREPARATION
Most patients with swan neck deformity demonstrate
some degree of reduction when placed in traction (Fig.
1, A and B). Although halter traction may allow one
 KLARA AND FOLEY : SURGICAL CORRECTIONOF SWAN NECK DEFORMITY
Figure 1. A, a stylized representation of a young man with
postlaminectomy kyphosis (swan neck deformity). The drawing was made
from plain cervical radiographs (inset). This young man developed ven-
triculitis and required shunting following a craniotomy for tuberous scle-
rosis. After standard shunting procedures failed, he underwent a posterior
shunting procedure which included laminectomies of C-1 to C-3. The
449
patient ultimately presented with neck pain and the Lhermitte phenom-
enon as well as radiographic evidence of progressive cervical kyphosis.
B, application of skull traction resulted in significant reduction of kypho-
sis and decreased neck pain. C, representation of surgical correction with
anterior cervical discectomy and osteosynthesis using Caspar plates and
screws. A postoperative film is shown in the inset.
NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

Figure 1B.

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451
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
to gain intraoperative reduction, skull traction with
Gardner-Wells tongs is better tolerated by most patients
over longer times. After Gardner-Wells tongs have been
applied, 10 to 20 pounds may be added incrementally while
the patient is monitored with frequent neurologic assess-
ment and serial radiographs. Care must be taken to en-
sure that no cord compression exists prior to any attempts
at reduction. Such compression can be aggravated by re-
duction in traction and can lead to serious neurologic com-
promise. In most cases, a minimum of 24 to 48 hours in
traction is required for adequate reduction. Muscle relax-
ants and analgesics are employed to aid this process. If
significant reduction is achieved, all motion segments that
reduce significantly will require discectomy and fusion.
While it is desirable to limit the number of levels fused,
more reduction will be obtained and maintained with
multilevel fusions. At a minimum, one motion segment
above and below the apex of kyphosis must be fused to
obtain reasonable results.
ANESTHESIA AND POSITIONING
The patient is brought to the operating room in traction,
and intubation is done awake with fiberoptic bronchos-
copy. The patient is then positioned supine and neuro-
logic examination accomplished before the induction of
anesthesia (Fig. 2A). Prophylactic antibiotics are employed
and C-arm fluoroscopy is used throughout the procedure
to monitor reduction as well as hardware placement. Mag-
nification is beneficial, and this can be accomplished with
loupes or the operating microscope.
Intraoperative evoked potential monitoring is also
desirable. Traction on the shoulders and arms maybe nec-
essary to improve fluoroscopic visualization of lower cer-
vical levels. This may be accomplished by wrist restraints
or shoulder taping. A rolled sheet placed longitudinally
between the scapulae will allow the shoulders to fall pos-
teriorly and improve visualization of the lower levels.
OPERATIVE PROCEDURE
The neck is prepared and draped in the usual sterile
fashion for a standard anterior cervical approach. The
iliac crest may also be prepared and used as a source
of autograft bone. Alternatively, iliac allograft may be
used. A horizontal incision is usually adequate for a 3-
4 level fusion and instrumentation (Fig. 2B). The choice
of a right- or left-sided incision depends upon the
surgeon’s preference, recognizing fully the pros and
cons of each approach. The skin incision is made and
extended down to the platysma, which is incised hori-
zontally. A superior and inferior subplatysmal dissec-
tion is necessary for adequate exposure. The sterno-
cleidomastoid muscle must be released along its
452
anterior border by dividing the investing fascia gener-
ously (Fig. 2).
The trachea and esophagus are retracted medially and
the carotid artery is retracted laterally (Fig. 2C). The su-
perficial temporal artery pulse can be monitored to check
for excessive carotid artery retraction. The prevertebral
fascia is divided in longitudinal fashion to expose the
anterior aspect of the cervical spine. Hand-held retrac-
tors may be used for the initial exposure; however, self-
retaining retractors afford better exposure for instrumen-
tation. To place the self-retaining retractors safely, the
insertions of the longus colli muscles must be separated
from the vertebral body. Care must be taken to place the
teeth of the retractor blades beneath the longus colli
muscles so that pressure from the blades is directed to
these muscles and not to critical structures such as the
trachea, esophagus, or carotid artery. This also helps to
prevent the blades from dislodging. An additional retrac-
tor is placed along the long axis of the spine to assist in
longitudinal exposure (Fig. 3B).
Once the levels for fusion have been confirmed fluo-
roscopically, Caspar distraction screws can be placed, thus
facilitating discectomy and interbody graft placement
(Figs. 3B, 4-6). The annulus at each interspace is incised,
distraction applied, and a discectomy accomplished us-
ing curettes and rongeurs (Fig. 6, A and B). The posterior
longitudinal ligament may be incised to facilitate removal
of spondylotic spurs or to verify that no free fragments of
disc material have herniated.
After completion of discectomy, appropriately sized
bone grafts are fashioned and positioned (Fig. 7, A-C).
Care should be taken to remove the cartilaginous endplates
of the disc spaces and to make their surfaces parallel, thus
maximizing bone-to-bone contact with the graft. This
maneuver ensures removal of all soft tissue and optimizes
fusion (Fig. 6A).
Occasionally, cord compression from vertebral bod-
ies may necessitate corpectomy to accomplish decompres-
sion or reduction of kyphosis. This is more common in
posttraumatic kyphosis. In this entity, less preoperative
reduction is usually obtained and the kyphosis is frequently
fixed. In such cases, combined anterior and posterior pro-
cedures may be necessary.
An anterior cervical plate is then chosen to span the
operated motion segments without extension over intact
disc spaces above and below the fusion (Fig. 8A). Sev-
eral anterior cervical plating systems are now available
commercially. Some plates and screws are made of tita-
nium and allow for postoperative evaluation with MRI.
The surgeon should be familiar with the type of plate
used, as biomechanical properties vary. A critical por-
tion of the procedure is to contour the anterior
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KLARA AND FOLEY : SURGICAL CORRECTIONOF SWAN NECK DEFORMITY

Figure 2. A, patient positioning with fluoroscopy in place. Tong traction is maintained to improve radiographic localization as well as alignment. B,
C, topographical and cross-sectional representation of the operative approach; horizontal skin incision and standard anterior cervical approach.
454
NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

Figure 3. A and B, distraction screws are placed in the midportion of the

vertebral body. Penetration of the vertebral body is 12-16 mm, depend-
ing on the distraction screw chosen. The drill bit is self-stopping and
visibly different from the bit used for creating screw pilot holes.
455
Figure 4. A and B, the second distraction screw is placed parallel to the
first using a drill guide that slides over the immobile distractor arm.
KLARA AND FOLEY : SURGICAL CORRECTIONOF SWAN NECK DEFORMITY
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NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

Figure 5. A and B, distraction screws are placed in the vertebral bodies

above and below the discs to be removed. After incision of the annulus,
general distraction should be applied incrementally.
457
Figure 6. A and B, parallel distraction facilitates discectomy and pro-
vides an unimpeded view of the disc space. Furthermore, distraction in
this manner does not injure cortical endplates.
KLARA AND FOLEY : SURGICAL CORRECTIONOF SWAN NECK DEFORMITY
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NEUROSURGICAL OPERATIVE ATLAS, VOL. 2

Figure 7. A-C, either autograft or allograft can be shaped as desired. Careful

measurements result in a graft with maximal bone-to-bone contact. Attention to
this detail promotes fusion.
459
Figure 8. A, measurement of the midvertebral body diameter in the anteroposterior plane is
necessary for selection of an appropriate drill length. Micrometer adjustment of the drill guide
determines the length of the drill hole. An estimation of this AP diameter can be made on a
preoperative CT scan. Care should be taken not to measure the AP diameter at the disc space,
because osteophytic spurs may give an erroneous value. Penetration of the posterior cortex is
necessary to minimize screw toggle and screw backout. B, the screw should be placed in the
middle one-third of the vertebral body with a 10-20° medial angulation. C, the Caspar plate
KLARA AND FOLEY : SURGICAL CORRECTIONOF SWAN NECK DEFORMITY

should not encroach on a healthy disc space and should be appropriately contoured to reestablish
a more normal cervical lordosis.
 NEUROSURGICAL OPERATIVE ATLAS, VOL. 2
plate to assist in reestablishing cervical lordosis. Not all
plates lend themselves to contouring.
The following description applies to the Caspar ante-
rior cervical plating system, which has been our preferred
instrumentation for this procedure. Once an appropriately
sized plate has been selected and contoured, it must be se-
cured with screw fixation. One can approximate the neces-
sary length of the 3.5-mm diameter bicortical screw by
measuring the anteroposterior (AP) diameter of the cervi-
cal vertebral body on a preoperative CT scan. It is impor-
tant to measure this diameter on a CT slice through the
midportion of the body, because CT slices adjacent to the
disc spaces may include anterior and posterior osteophytes,
resulting in selection of screws that are too long. The mi-
crometer on the Caspar drill guide is then set to this mea-
surement and a pilot hole is drilled under fluoroscopic guid-
ance. Ideally, the pilot hole is placed in the middle third of
the vertebral body, parallel to the disc space in the sagittal
plane and angled 10-20° medially in the axial plane. Dif-
ferent angulation of the screw is sometimes required, how-
ever, and is acceptable as long as the posterior cortex is
engaged and the screw does not violate the disc space (Fig.
8, A-C). One should “feel” the drill bit just penetrate the
posterior vertebral body cortex. A blunt-tipped K-wire may
also be used to palpate for cortical penetration, again un-
der fluoroscopic guidance. If bone remains at the base of
the pilot hole, the micrometer is advanced 1 mm and drill-
ing is continued. This process is repeated until the poste-
rior cortex is just perforated. When the drill bit is replaced
within the pilot hole, this should be done manually (i.e.,
without applying the drill motor) to minimize inadvertent
widening of the pilot hole.
In general, the first pilot hole is drilled into the slot
at the base of the Caspar plate. A 3.5-mm screw that is 1-
2 mm longer than the final drill guide micrometer setting
is then selected (this compensates for the screw head and
plate thickness) and secured into the pilot hole, but not
tightened fully. Tapping of the pilot hole prior to screw
placement should include the anterior vertebral body cor-
tex only. The second pilot hole is drilled into the slot at
the apex of the Caspar plate, diagonal to the first hole.
Prior to drilling this hole, ensure that the plate is in its
proper final position (it can be rotated and translated about
the not yet fully tightened first screw). Screw length se-
lection follows the same process outlined above. These
first two screws are than tightened fully (utilizing the
thumb, index, and middle fingers only) and their partner
screws are placed. At this point, the plate has been se-
cured to the vertebral bodies at either end of the planned
fusion. The Caspar plate, which has been contoured pre-
viously (using a plate bender) into a lordotic curve, sits
460
somewhat above the intervening cervical vertebral bod-
ies. Appropriately sized bicortical screws are then placed
into these bodies sequentially, allowing for a gradual re-
duction of the swan neck deformity and reestablishment
of a cervical lordosis (Fig. 9, A and B).
If adequate screw purchase is not obtained (stripped
screws), screws of a larger diameter can be used to gain
additional torque (“rescue screws”). Alternatively, methyl
methacrylate can be used to secure “loose” screws.
The wound is irrigated and closed in the usual fash-
ion. A drain is optional. It is unusual for patients to re-
quire intensive care monitoring after this procedure, but
a neurologic examination immediately upon reversal of
anesthesia is mandatory. The patient is fitted with a Phila-
delphia collar and maintained on antibiotics for 24 hours.
Most patients are ambulatory on the first postoperative
day and able to tolerate liquids. In most instances, the
Philadelphia cervical collar is worn for 30 days with ac-
tivity restrictions. Patients with severely osteoporotic bone
may require additional external support. This may be ac-
complished with prolonged use of a Philadelphia collar
or application of a halo. White collar work may be re-
sumed in two to four weeks. Fusion is usually obtained
by 12 weeks.
COMPLICATIONS
The complications associated with the surgical correc-
tion of swan neck deformity include the well-known com-
plications of anterior cervical spine surgery. Additionally,
complications associated with hardware placement may
be encountered. These are discussed below.
Screw loosening can occur and is most likely within
the first six weeks after surgery. If this is limited to loos-
ening of a single screw by no more than two to three
threads, the patient should be maintained in a Philadel-
phia collar and followed radiographically at one-week
intervals. If screw loosening progresses to greater than
two to three threads or if more than one screw loosens,
revision may be required. Hardware revision may be as
simple as single screw tightening or may be more com-
plex and require screw replacement with a screw of larger
diameter (i.e., 4.5-mm rescue screws). If posterior corti-
cal purchase has not been obtained in the original proce-
dure, it should be accomplished at revision. Additional
screws also maybe inserted at a given vertebral level in
an attempt to gain additional purchase.
The risk of screw loosening is increased in os-
teoporotic bone or if posterior cortical purchase is not
obtained. In the case of osteoporotic bone, additional
screw purchase may be obtained by placing a small
amount of methyl methacrylate into the screw hole
 KLARA AND FOLEY : SURGICAL CORRECTIONOF SWAN NECK DEFORMITY
Figure 9. A, ideal screw and plate placement. Screws should
purchase the posterior cortex and two-finger torque tightness
should be accomplished. B, the relationship between plate,
and then inserting the screw. Care must be taken not to use
an excessive amount of methyl methacrylate when the pos-
terior cortex has been penetrated; this could possibly lead
to extravasation of methyl methacrylate and neural com-
pression. Dural penetration with cerebrospinal fluid leak
461
vertebral bodies, and grafts is represented. The plate should
not infringe on healthy disc spaces above or below the fused
segments.
or neural injury should be a very rare occurrence in the
hands of surgeons trained in the Caspar technique. The
potential for such injuries, however, exists and constant at-
tention to technical detail as well as intraoperative fluoro-
scopic monitoring should minimize these risks.