Superior Laryngeal Nerve Palsy After Anterior Cervical Diskectomy and Fusion: A Case Report and Cadaveric Description.

BACKGROUND AND IMPORTANCE: Superior laryngeal nerve (SLN) injury after high cervical dissection can result in changes in vocal pitch due to cricothyroid denervation and dysphagia with aspiration risk because of decreased sensation of the supraglottic larynx. CLINICAL PRESENTATION: We describe a 69-year-old singer with cervical spondylotic myelopathy who underwent elective C3/4 and C4/5 anterior cervical diskectomy and fusion. Postoperatively, the patient reported changes in his voice, most noticeable with higher registers. A number of studies confirmed severe right superior laryngeal neuropathy. A cadaveric description included to highlight anatomic relationships critical in minimizing risk of SLN injury during an anterior cervical diskectomy and fusion approach. CONCLUSION: The SLN is a critical structure vulnerable to iatrogenic injury during high cervical dissections for anterior approaches to the spine. Therefore, it is critical for spine surgeons to have a firm understanding of SLN anatomy for these approaches.

Retrosigmoid Craniectomy with a Layered Soft Tissue Dissection and Hydroxyapatite Reconstruction: Technical Note, Surgical Video, Regional Anatomy, and Outcomes.

Introduction There are many reported modifications to the retrosigmoid approach including variations in skin incisions, soft tissue dissection, bone removal/replacement, and closure. Objective The aim of this study was to report the technical nuances developed by two senior skull base surgeons for retrosigmoid craniectomy with reconstruction and provide anatomic dissections, surgical video, and outcomes. Methods The regional soft tissue and bony anatomy as well as the steps for our retrosigmoid craniectomy were recorded with photographs, anatomic dissections, and video. Records from 2017 to 2019 were reviewed to determine the incidence of complications after the authors began using the described approach. Results Dissections of the relevant soft tissue, vascular, and bony structures were performed. Key surgical steps are (1) a retroauricular C-shaped skin incision, (2) developing a skin and subgaleal tissue flap of equal thickness above the fascia over the temporalis and sub-occipital muscles, (3) creation of subperiosteal soft tissue planes over the top of the mastoid and along the superior nuchal line to expose the suboccipital region, (4) closure of the craniectomy defect with in-lay titanium mesh and overlay hydroxyapatite cranioplasty, and (5) reapproximation of the soft tissue edges during closure. Complications in 40 cases were pseudomeningocele requiring shunt ( n = 3, 7.5%), wound infection ( n = 1, 2.5%), and aseptic meningitis ( n = 1, 2.5%). There were no incisional cerebrospinal fluid leaks. Conclusion The relevant regional anatomy and a revised technique for retrosigmoid craniectomy with reconstruction have been presented with acceptable results. Readers can consider this technique when using the retrosigmoid approach for pathology in the cerebellopontine angle.

Endovascular embolization versus surgical clipping in a single surgeon series of basilar artery aneurysms: a complementary approach in the endovascular era.

BACKGROUND: Currently, most basilar artery aneurysms (BAAs) are treated endovascularly. Surgery remains an appropriate therapy for a subset of all intracranial aneurysms. Whether open microsurgery would be required or utilized, and to what extent, for BAAs treated by a surgeon who performs both endovascular and open procedures has not been reported. METHODS: Retrospective analysis of prospectively maintained, single-surgeon series of BAAs treated with endovascular or open surgery from the first 5 years of practice. RESULTS: Forty-two procedures were performed in 34 patients to treat BAAs-including aneurysms arising from basilar artery apex, trunk, and perforators. Unruptured BAAs accounted for 35/42 cases (83.3%), and the mean aneurysm diameter was 8.4 ± 5.4 mm. Endovascular coiling-including stent-assisted coiling-accounted for 26/42 (61.9%) treatments and led to complete obliteration in 76.9% of cases. Four patients in the endovascular cohort required re-treatment. Surgical clip reconstruction accounted for 16/42 (38.1%) treatments and led to complete obliteration in 88.5% of cases. Good neurologic outcome (mRS ≤ 2) was achieved in 88.5% and 75.0% of patients in endovascular and open surgical cohorts, respectively (p = 0.40). Univariate logistic regression analysis demonstrated that advanced age (OR 1.11[95% CI 1.01-1.23]) or peri-procedural adverse event (OR 85.0 [95% CI 6.5-118.9]), but not treatment modality (OR 0.39[95% CI 0.08-2.04]), was the predictor of poor neurologic outcome. CONCLUSIONS: Complementary implementation of both endovascular and open surgery facilitates individualized treatment planning of BAAs. By leveraging strengths of both techniques, equivalent clinical outcomes and technical proficiency may be achieved with both modalities.

Far-Lateral Transcondylar Approach to a Right Cervicomedullary Dural Arteriovenous Fistula of the Posterior Fossa.

Objectives Dural arteriovenous fistulas (DAVFs) at the cervicomedullary junction are uncommon and often accompanied by subarachnoid hemorrhage (SAH). We aim to illustrate in detail the microsurgical procedure for treating a DAVF located at the cervicomedullary junction. Design We present a two-dimensional operative video that includes clinical history, preoperative imaging, surgical strategy, still images with labels, clinical course, and postoperative imaging. Setting The microsurgery was performed at an academic medical center. Participant The patient is a 55-year-old female who presented with SAH, acute onset headache, nausea, and vomiting. Angiography demonstrated right vertebral artery vasospasm and a persistent arteriovenous shunt at the cervicomedullary junction supplied by small perforating arteries of the right vertebrobasilar junction ( Fig. 1 ). Main Outcome Measures The patient was placed in the park-bench position with the head turned to the contralateral side. A hockey stick incision was made, followed by a right-side far-lateral transcondylar approach. Indocynanine green videoangiography was performed to help identify the areas of arteriovenous shunting. Multiple clips were placed to interrupt vessels that corresponded to arterial feeders at the level of the C1 and C2 nerve root sleeves ( Fig. 2 ). The dura was closed in a water tight fashion and the posterior fossa was reconstructed with a titanium mesh. Results Postoperative imaging showed no evidence of continued arteriovenous shunting. The patient was discharged in good clinical condition with an uneventful postoperative course. Conclusion A deep understanding of the microsurgical vascular anatomy is necessary for successful occlusion of a cervicomedullary DAVF. The link to the video can be found at: https://youtu.be/-LfOcNB05BY .