Pharyngeal perforation and spontaneous extrusion of the cervical graft with its fixation device: a late complication of C2-C3 fusion via anterior approach.

Stabilisation of the fracture-dislocation of the cervical spine is achieved effectively by anterior or posterior or combined methods with attendant short and long term benefits, risks and complications associated with each procedure. Recently anterior methods have gained wider acceptance. A variety of preoperative and postoperative complications associated with anterior cervical fusion are well recognised. However, the delayed pharyngeal or oesophageal perforation is a rare, serious and life threatening complication of an anterior cervical internal fusion.The authors report a case of delayed pharyngeal perforation and spontaneous extrusion of the C2-C3 graft with its fixation device. After coughing out the entire gamet of the graft with the fixation pin, the patient was relieved of excruciating pain and dysphagia and had no significant morbidity thereafter over a 12-year follow up period. Relevant aspects are discussed with a review of the pertinent literature.

Possibility of the excision of aneurysms in the vertebrobasilar system followed by end-to-end anastomosis for the maintenance of circulation.

Microsurgical techniques have revolutionized the perspectives of neurosurgery. Vascular neurosurgery in particular has only shown real progress since the evolution of such techniques. The management of large fusiform aneurysms had always been more problematic than that of the usual aneurysms. Clipping was either insufficient to occlude the whole neck or too extensive to include a significant part of the parent vessel and its important branches. Several alternative methods were therefore developed to redress the problem and included proximal occlusion, coating and wrapping, induction of intralaminal thrombosis with a variety of substances, and balloon catheter occlusions; however, they have all proved to have limited success. Aneurysmorrhaphy (excision of the aneurysm and reconstruction of the vessel wall) has also been described. In 1978 Dolenc reported excision of a fusiform aneurysm along with the adjacent vessel wall and an end-to-end anastomosis, either directly or by interposing a short arterial graft, in two cases of peripheral middle cerebral aneurysms, and in one aneurysm arising from PICA. This communication deals with two cases of large fusiform aneurysms of the vertebrobasillar territory, one from PICA and another from P2P3 Segment of the posterior cerebral arteries. These aneurysms were excised and the parent vessel reanastomosed to restore its continuity as seen at surgery and on postoperative angiography. The results have been favourable. The technique is recommended for the elimination of a large fusiform aneurysm that cannot be safely or successfully clipped, provided the parent vessel is lax or mobile enough to permit direct reanastomosis despite the slight shortening of vessel length.

Management of seventh and eighth nerve involvement by cerebellopontine angle tumors.

Microsurgical techniques have made a significant contribution in the advancement of surgery. Since then, the field of neurosurgery has made great and rapid strides. Neurosurgeons now venture through the deep and delicate regions of the brain where they dared not venture only a few years ago. In particular, the morbidity and mortality of surgery in the CPA has seen a progressive decrease. This presentation deals with 200 consecutive tumors in the CPA operated on using microsurgical techniques during the last 6 years. One hundred sixty-seven (83.5%) of them were acoustic neuromas (which included 12 patients with bilateral tumors). Of the remaining 33, there were 21 meningiomas, 10 epidermoids, and 2 angioblastomas. Preoperative investigation has been aimed at arriving at a diagnosis which is as exact as possible in order to plan the operative strategy. All patients, ranging in age from 16 to 84, have been operated upon in the lounging position (with the necessary precautions) through a unilateral suboccipital craniectomy. The basic surgical technique, irrespective of the tumor, is to decompress it from within in order to relieve its tension and pressure on surrounding nerves, vessels, and the brain stem. The structures which are only compressed are spontaneously relieved of compression. This helps define their full anatomic course. Having been identified, they are protected from damage. The most adherent points between tumor and nerves are recognized and handled last under direct vision when there is sufficient space to allow manipulation of the tumor. In the rare event of the facial nerve being interrupted, nerve graft procedures are attempted during the same operation. Our experience with the technique of intracranial-intratemporal facial nerve grafting has yielded excellent results. The cochlear nerve lacks a Schwann cell cover in the CPA and is more prone to being affected, either by tumor processes or surgical manipulation. Of our 167 acoustic nerve tumors, 60% were larger than 3 cm in diameter. The two important factors with regard to predicting the preservation of the seventh and eighth cranial nerves are tumor size (less than 3 cm) and preoperative hearing loss (less than 40 dB). The preservation of facial nerve function after tumor removal was achieved in 87.8% of patients. The facial nerve was preserved in all patients with other tumors. With regard to hearing ability the overall result of preservation of function was achieved in 27.6%. However, when a low hearing loss (less than 40 dB) and small tumor size (less than 3 cm) are taken into account, the preservation was as high as 58%.(ABSTRACT TRUNCATED AT 400 WORDS)