Antegrade Subperiosteal Temporalis Muscle Elevation and Posterior Retraction Technique Avoiding Muscle Incision for Pterional Craniotomy: A Technical Note.

Background: The current technique of pterional craniotomy involves temporalis muscle incision followed by retrograde elevation. Feasibility of antegrade temporalis muscle elevation without any direct incision over its bulk is evaluated. Objective: Incisionless "antegrade, subgaleal, subfascial, and subperiosteal elevation" of temporalis muscle preserves vascularity and muscle bulk. Posterior maneuvering of "bare" temporalis muscle bulk either above (out rolling) or under (in rolling) the scalp for pterional craniotomy is discussed. Material and Methods: Technique of antegrade, subfascial, subperiosteal elevation, and posterior rotation of temporalis muscle without incising in its bulk by "out rolling" or "in rolling" along the posterior aspect of the scalp incision was carried out in 15 cadavers and later in 50 surgical cases undergoing pterional craniotomy. Postoperatively, patients were evaluated for subgaleal collection and periorbital edema. Operated side cosmesis and temporalis muscle bulk was compared with nonoperated temporalis muscle at 6 months interval. Results: Antegrade subperiosteal dissection of temporalis muscle was possible in all cases. "In-rolling" or "out rolling" technique provided adequate surgical exposure during pterional craniotomy. Postoperative subgaleal collection and periorbital edema was prevented. Facial nerve paresis or temporalis muscle-related complications were avoided. Conclusion: Antegrade, subgaleal, subfascial, and subperiosteal dissection techniques of temporalis muscle elevation without any direct incision in its bulk enables neurovascular and muscle volume preservation. Posterior maneuvering of elevated temporalis muscle with "out rolling" or "in-rolling" technique is easy, quick, and provides adequate exposure during pterional craniotomy. Opening and closing of scalp layers without violating subgaleal space prevent postoperative subgaleal hematoma and periorbital edema.

Hangman's fracture: a clinical review based on surgical treatment of 15 cases.

This is a retrospective analysis of cases with hangman's fracture. The subject of 'hangman's fracture' has been elaborately evaluated in the literature. The authors propose an alternative format of surgical treatment that is based on modification of existing classification schemes. During the period 2015 to March 2020, 15 patients having hangman's fracture were identified and were surgically treated. The clinical condition was classified on the basis of American Spinal Injury Association scale (ASIA scale) and VAS parameters. The patients were classified into 4 groups depending on the presence (or absence) of atlantoaxial and/or C2-3 instability. Surgical decisions were guided by the proposed classification. Clinical evaluation and dynamic CT scan were done at follow-up visits. During the average follow-up of 26 months, all patients are essentially asymptomatic. There was marginal restriction of extent of neck movements in all cases. There was solid bone fusion in all cases. The proposed novel classification scheme based on the presence of atlantoaxial and C2-3 instability assisted in directing the treatment strategy of hangman's fracture.

"Interdural" Surgical Strategy for Lower Cranial Nerve Neurinomas-A Report of 14 Cases.

OBJECTIVE: We describe the dural relationships and its surgical implications for large lower cranial nerve (CN) neurinomas. The study is based on surgical experience with 14 cases. METHODS: During the period January 2014 to December 2019, 14 consecutive cases with large lower CN neurinomas were surgically treated with the aim of radical tumor resection. RESULTS: There were 9 males and 5 females, ranging in age from 17 to 65 years. All patients were operated in a single stage. The principal surgical observation was that the entire extent of tumor, which included intracranial, jugular fossa, and extracranial components, was within the "dural" confines and the tumor adjoining critical neural and vascular structures was displaced around the dome of the tumor. Radical surgical resection was achieved in all cases. During the follow-up period that ranged from 3 to 71 months (average 32 months), no symptomatic recurrence was observed and no patient needed reoperation. At the time of last clinical follow-up, the lower CN function in all patients was better than at the time of presentation. CONCLUSIONS: The "dural" cover of the lower CN neurinomas forms a strong and reliable plane of compartmentalization and allows safe tumor resection.