Tag: Posterior fossa surgery

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Contemporary analysis of the intraoperative and perioperative complications of neurosurgical procedures performed in the sitting position

J Neurosurg 127:182–188, 2017

Historically, performing neurosurgery with the patient in the sitting position offered advantages such as improved visualization and gravity-assisted retraction. However, this position fell out of favor at many centers due to the perceived risk of venous air embolism (VAE) and other position-related complications. Some neurosurgical centers continue to perform sitting-position cases in select patients, often using modern monitoring techniques that may improve procedural safety. Therefore, this paper reports the risks associated with neurosurgical procedures performed in the sitting position in a modern series.

METHODS The authors reviewed the anesthesia records for instances of clinically significant VAE and other complications for all neurosurgical procedures performed in the sitting position between January 1, 2000, and October 8, 2013. In addition, a prospectively maintained morbidity and mortality log of these procedures was reviewed for instances of subdural or intracerebral hemorrhage, tension pneumocephalus, and quadriplegia. Both overall and specific complication rates were calculated in relation to the specific type of procedure.

RESULTS In a series of 1792 procedures, the overall complication rate related to the sitting position was 1.45%, which included clinically significant VAE, tension pneumocephalus, and subdural hemorrhage. The rate of any detected VAE was 4.7%, but the rate of VAE requiring clinical intervention was 1.06%. The risk of clinically significant VAE was highest in patients undergoing suboccipital craniotomy/craniectomy with a rate of 2.7% and an odds ratio (OR) of 2.8 relative to deep brain stimulator cases (95% confidence interval [CI] 1.2–70, p = 0.04). Sitting cervical spine cases had a comparatively lower complication rate of 0.7% and an OR of 0.28 as compared with all cranial procedures (95% CI 0.12–0.67, p < 0.01). Sitting cervical cases were further subdivided into extradural and intradural procedures. The rate of complications in intradural cases was significantly higher (OR 7.3, 95% CI 1.4–39, p = 0.02) than for extradural cases. The risk of VAE in intradural spine procedures did not differ significantly from sitting suboccipital craniotomy/craniectomy cases (OR 0.69, 95% CI 0.09–5.4, p = 0.7). Two cases (0.1%) had to be aborted intraoperatively due to complications. There were no instances of intraoperative deaths, although there was a single death within 30 days of surgery.

CONCLUSIONS In this large, modern series of cases performed in the sitting position, the complication rate was low. Suboccipital craniotomy/craniectomy was associated with the highest risk of complications. When appropriately used with modern anesthesia techniques, the sitting position provides a safe means of surgical access.

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Telo-velar approach to fourth-ventricle tumours: how I do it

Telo-velar approach to fourth-ventricle tumours_how I do it

Acta Neurochir (2015) 157:607–610

The “telo-velar” approach is an alternative to cerebellar splitting to gain access to the fourth ventricle through the so-called cerebello-medullary fissure (CMF).

Method In this approach, the CMF is exposed and access to the ventricle is obtained by incising the tela choroidea and inferior medullary velum. This approach enables the exploration of the entire ventricle cavity from the obex to the aqueduct.

Conclusions The exposure of the fourth ventricle is satisfactory and the floor of the fourth ventricle can be visualised early and protected. The extent of resection and outcome are satisfactory in most patients, including those with large tumours or lesions attached to the lateral or superolateral recesses of the ventricle. The deep rostral tumour attachment is the main limitation of the telo-velar approach

Key Points

• Early exposure of the interface lesion-floor of the fourth ventricle favours a safer tumour dissection.

• We feel that resection of tonsils is not necessary in the surgical setting.

• The posterior arch of C1 should be removed only if the tonsils are below the level of the foramen magnum.

• The improved access to the lateral recess of the ventricle makes the telo-velar approach particularly effective in lesions attached to cerebellar peduncles.

• The wide dissection of the cerebello-medullary fissure and gentle tonsils retraction may prevent from the occurrence of cerebellar mutism or other major cerebellar dysfunctions.

• Even the bilateral opening of the CMF does not result in cerebellar mutism if wide and cautious dissection, avoiding retraction and vascular injuries, is obtained.

• The exposure of the fourth ventricle was satisfactory also in patients harbouring lesions attached to the lateral or even the superolateral recesses of the ventricle.

• A deep rostral tumour attachment seems to be, at least in our experience, the main specific limitation of the telo-velar approach.

• The risk of hydrocephalus can be reduced by opening of the fissure bilaterally, exposing the aqueduct, and by cisterna magna-fourth ventricle communication augmentation.

• The EVD is taken in place for 48-72 h to prevent possible abrupt increase of the intracranial pressure and to favour wound closure.

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Augmented Autologous Pericranium Duraplasty in 100 Posterior Fossa Surgeries—A Retrospective Case Series

Neurosurgery 71[ONS Suppl 2]:ons302–ons307, 2012

Primary closure of the dura in posterior fossa (p-fossa) surgeries is technically difficult and usually requires the use of a dural substitute. A variety of substitutes are currently available and data suggest that autologous materials are preferred in comparison with nonautologous substitutes.

OBJECTIVE: To report our experience using locally harvested autologous pericranium as a dural substitute in patients who underwent p-fossa surgeries.

METHODS: Retrospective analysis of patients who had undergone p-fossa craniotomies between 2005 and 2011. All patients received locally harvested autologous pericranium for duraplasty augmented with a dural sealant. Data were reviewed for complications including: surgical site infection, meningitis, cerebrospinal fluid leak, the radiographic formation of a pseudomeningocele, and any new neurological symptoms related to the incision or repair.

RESULTS: One hundred patients were identified. Indications for surgery included tumor, vascular lesions, or hemorrhage requiring surgical intervention, symptomatic Chiari I malformation, microvascular decompression for trigeminal neuralgia, and trauma requiring surgical decompression. The complication rate was 1% with 1 patient developing an nonsteroidal anti-inflammatory drug-induced aseptic meningitis and graft dehiscence requiring surgical revision.

CONCLUSION: Autologous pericranium with dural sealant augmentation is an effective way to repair the durotomy in p-fossa surgeries. To the best of our knowledge, this is currently the largest study using this technique in the adult neurosurgical literature. Our results report a much lower rate of complications in comparison with other duraplasty studies.

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