PREOPERATIVE DIAGNOSIS: Hydrocephalus.

POSTOPERATIVE DIAGNOSIS: Hydrocephalus.

OPERATION PERFORMED:
1. Left external ventricular drain removal.
2. Right ventriculoperitoneal shunt placement in 5 kg infant.

SURGEON: John Doe, MD

ANESTHESIA: General endotracheal.

INDICATION FOR PROCEDURE: The patient is a (XX)-year-old boy with a complex medical history who presented with a ventriculoperitoneal shunt failure. The patient has now had more than a week of negative cultures and appropriate antibiotics.

The risks, benefits and alternatives of surgery were discussed with the family. The risks including, but not limited to, bleeding, infection, injury to the brain, injury to the peritoneal contents, allergic reaction to anesthesia or even death were discussed.

No guarantees were made or implied. Despite the above, they desired to proceed with the left external ventricular drain removal and right ventriculoperitoneal shunt placement.

FINDINGS AND PROCEDURE: The patient was brought to the operative suite and underwent general endotracheal anesthesia. The left frontal incision was then prepped, the staples removed and the external ventricular drain stay stitches cut. The external ventricular drain was removed and the exit site as well as the insertion site was oversewn using 4-0 Vicryl Rapide.

Attention was then turned to the right side of the patient. He was prepped and draped in the usual sterile fashion and his previous right frontal incision was reopened with blunt and sharp dissection down to the existing bur hole. A curette was used to widen the bur hole and Kerrison punch was used to make it larger as well. Shunt passer was then passed from the right frontal region to the right lateral cervical region just above his ECMO cutdown site. The Micro Codman shunt single pressure of 70 mmHg had the Bactiseal peritoneal catheter tied to the proximal end and been appropriately flushed.

It was then passed through the shunt passer and the shunt passer was passed from the right lateral cervical region to the right upper quadrant and the shunt again was passed likewise. The distal 20-30 cm of peritoneal catheter were cut off and discarded.

The dura was incised using monopolar electrocautery and the ventricular catheter was passed into a depth of approximately 16.5 cm. It was easily passed into the lateral ventricle with spontaneous flow of moderate pressure CSF. The ventricular catheter was then appropriately attached to the Rickham reservoir and sewn in place using 2-0 Vicryl. The valve system was appropriately seated in the scalp tissue and spontaneous flow of clear CSF was appreciated through the distal end of the peritoneal catheter.

With the assistance of anesthesia, getting a valve set up to 40, peritoneal trocar was passed in the peritoneal cavity. The distal end of the peritoneal catheter was then passed into the peritoneal cavity without difficulty.

Dr. Jane Doe had been on standby should entering the peritoneal cavity have caused any difficulty in this medically complicated patient with a history of a Nissen and G-tube.

The incisions were copiously irrigated with antibiotic irrigation and closed in anatomic layers using 4-0 Vicryl. The final layer of skin was closed using 4-0 Vicryl Rapide in the cranial incision and benzoin and Steri-Strips in the neck and abdominal incision.

The patient tolerated the left external ventricular drain removal and right ventriculoperitoneal shunt placement well and was sent to the PACU postoperatively.

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PREOPERATIVE DIAGNOSES:
1. Chiari I malformation.
2. Cervical syrinx.

POSTOPERATIVE DIAGNOSES:
1. Chiari I malformation.
2. Cervical syrinx.

PROCEDURES PERFORMED:
1. Suboccipital decompression.
2. C1 laminectomy.
3. Duraplasty.

SURGEON: John Doe, MD

ANESTHESIA: General.

COMPLICATIONS: None.

SPECIMEN: None.

INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old gentleman who has a history of headaches and neck pain, particularly after strain or any type of Valsalva maneuver.

On MRI, he was found to have a Chiari I malformation with associated cervical syrinx. The patient wanted to proceed with surgery.

He understands the risk of the procedure (suboccipital decompression, C1 laminectomy, duraplasty), which mainly consists of CSF leak, hematoma, reoperation, infection, stroke, paralysis and death. The patient signed consent to proceed with surgery.

DESCRIPTION OF PROCEDURE: The patient was intubated and placed in the prone position with his head in a Mayfield headrest. Then, midline incision was marked, and he was prepped and draped in a sterile fashion.

Incision was made with a 10-blade scalpel and Bovie coagulator and then the incision was gradually carried down from the scalp down to the midline fascia, separating the muscles.

Then, the suboccipital area was exposed along with the arch of C1 and C2. After prompt hemostasis was accomplished, the arch of C1 was completely removed posteriorly, and suboccipital craniectomy was performed with the use of the Midas Rex.

The extent of the suboccipital decompression was approximately 3 cm on each of the midline. The arch of C2 was slightly undermined and then the dura was opened in the midline, and after decompression of the cerebellar tonsils, the dura was patched with Dura-Guard, which was sutured in placed with 4-0 Nurolon.

Hemostasis was achieved. The area of the suture was reinforced with Tisseel and Duragen. Then, the incision was closed with 2-0 Vicryl, 3-0 Vicryl and 3-0 nylon for the skin.

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SUBJECTIVE: The patient is 10 days status post right L5-S1 laminoforaminotomy for a right L5-S1 herniated nucleus pulposus. He comes today for suture removal stating that he had some mild irritation. He denies any significant wound drainage, has had some mild serosanguineous drainage from the incisional site. He denies any fevers, chills or sweats. His leg pain is much improved. He has had occasional twinges. He has not taken any pain medication in the last week. He has returned to work. He has not done any heavy lifting. Overall, he feels quite well.

OBJECTIVE: Today, he is in no acute distress. There is some mild sanguineous drainage on the dressing. There is some erythema around the incisional site. All sutures were prepped with iodine and removed without difficulty. At the most superior aspect of the incision, there was some mild dehiscence of the wound. There was no purulent material present. There was no edema present. This area was palpated. There was no depth of the wound. This area was prepped at the depth with iodine, and 3 Steri-Strips were applied to reapproximate this area.

ASSESSMENT AND PLAN: The patient is 10 days status post diskectomy at the right L5-S1 level. Neurologically, he is doing quite well. In terms of the incision, we did recommend he keep the Steri-Strips that were reapproximating the most superior aspect of the wound clean and dry for the next 5 to 7 days. Then, he can get them wet in the shower and they should fall off on their own.

We encouraged him to call us with any changes to the incisional area. We have also given him a prescription for Keflex 500 mg p.o. q.i.d. for the next 7 days. This will be called in to his pharmacy. If he has any other questions or concerns, he should contact Neurosurgery. He should remain at the current level of activity at this time, avoiding heavy lifting greater than 5 pounds, bending or twisting. We will advance his activity at his next followup visit.

Sample #2

SUBJECTIVE: This is a pleasant (XX)-year-old female evaluated for complaints of neck and right arm pain. Since that time, she has been treated with a steroid taper as well as physical therapy treatment. She has nearly completed her course of physical therapy. She continues to have right arm pain and paresthesias. This in fact progressed since our initial visit. She has been taking naproxen and Flexeril for her symptoms. She states that her pain is somewhat improved; however, she does have persistent paresthesias in the arm. She does feel subjectively weak in the arm as well. She states that her symptoms come and go in the arm; however, when she hangs her arm forward, she does get paresthesias down the right lateral aspect of her deltoid into her forearm and into her thumb. She also has paresthesias at present in this distribution.

She states initially she was unable to sleep due to the severe pain. Now, she is able to sleep. Again, she is taking naproxen and Flexeril twice daily. She does feel that physical therapy is helping. She did also feel that the Medrol Dosepak was helpful. In addition, she also complains of increasing dysphagia in the last two weeks. She did have an MRI performed a few days ago, which she brings for review today. She denies any bowel or bladder incontinence. She denies any lower extremity symptoms.

OBJECTIVE: Today, the patient is moving upper and lower extremities with 5/5 strength. Sensation intact in the upper and lower extremities. Deep tendon reflexes were normoreflexic. There were no beats of clonus present.

DIAGNOSTIC DATA: Review of the patient’s cervical MRI does show evidence of a disk herniation present at the C5-C6 level pressing on the right C6 nerve root. This also has some mild cord encroachment without cord signal change. Incidentally noted on this scan was T2 hyperintensities measuring approximately 5 mm within the inferior pole of the left and right thyroid lobes, most likely representing cystic structures.

ASSESSMENT AND PLAN: The patient is a (XX)-year-old female with right C5-C6 disk herniation encroaching on the right C6 nerve. She does have associated radiculopathy symptoms that have been present for over 6 weeks. She has completed Medrol Dosepak and physical therapy and continues to have numbness and tingling and pain down the arm. We do feel that evaluation by his surgeon is warranted at this time.

We will give her a note to return to work on light duty until she is evaluated by her next available spine surgeon. In addition, given the incidental finding of a thyroid cyst and her recent dysphagia in the last two weeks, we will have her set up to see her primary care physician for further evaluation in regards to these findings.

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Neurosurgical Transcription Operative Sample Report #1

OPERATIONS PERFORMED:
1. Bilateral C6-C7-T1-T2-T3-T4-T5-T6 arthrodesis, posterolateral type.
2. Bilateral C6 through T6 segmental instrumentation with Vertex and Legacy titanium screw/rod fixation systems.
3. Bilateral C7-T1, T1-T2, T2-T3, T3-T4, and T4-T5 decompressive laminectomies, medial facetectomies, tumor resection.
4. Right T2 transpedicular corpectomy, tumor resection.
5. Right T3 transpedicular corpectomy, tumor resection.
6. Right T4 transpedicular corpectomy, tumor resection.
7. Intraoperative fluoroscopy and image interpretation.
8. Somatosensory evoked potential monitoring/motor evoked potential monitoring.
9. Stealth neuronavigation, frameless stereotaxy for preoperative planning and intraoperative hardware placement.

DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient was taken to the operating room where he was placed in the supine position upon a gurney and all pressure points padded. Adequate general anesthesia was induced and maintained with a combination of intravenous inhalational agents. Foley urinary catheter was placed. The patient was turned prone upon the padded laminectomy roll and the head secured with a Mayfield three-pin head holder. The head and neck were positioned in neutral position. All pressure points were meticulously padded. The cervicothoracic region was prepared with DuraPrep solution and draped in the usual sterile manner with an iodine-impregnated adhesive sheath placed over all regions of exposed skin. Intravenous cefazolin was administered for perioperative prophylactic antibiotic coverage. Intravenous dexamethasone was given as a neuroprotective agent.

The proposed linear midline skin incision was scribed on the skin with gentian violet extending between the C5 and T6; it was determined fluoroscopically. This region was infiltrated subcutaneously with 1% lidocaine with 1:100,000 units of epinephrine and skin incision created with #10 scalpel blade. The incision was carried through the skin and subcutaneous tissues till the cervicothoracic dorsal fascia was encountered. This was incised on either side of midline and the paraspinous musculature dissected from the spinous processes, laminae, and transverse processes from C6 through T6 bilaterally. Self-retaining retractors were placed.

The T3 transverse process had been completely destroyed by tumor, and a tumor was identified protruding into the paraspinous musculature at this level. Decompressive laminectomies were performed at C7-T1, T1-T2, T2-T3, T3-T4, and T4-T5 with medial facetectomies undertaken. Along the right side of the canal, from T2 through T4, a large amount of epidural tumor was identified. The T3 transverse process and pedicle had been completely destroyed by tumor, and aggressive tumor debulking undertaken in a transpedicular fashion at T3, with tumor resection extending into the upper chest. The tumor was debulked from the ventral surface of the cord and from the vertebral bodies at T3. Right-sided transpedicular corpectomies were also performed at T2 and T4, again with aggressive debulking of tumor from the ventrolateral surface of the spinal cord, cutting back to healthy-appearing bone along the left half of the vertebral bodies at T2, T3, and T4. The T3 nerve root on the right was found to be grossly infiltrated by tumor, and this root was sacrificed to afford tumor resection. Specimens were submitted for frozen and permanent section histopathology. The former demonstrated metastatic squamous cell carcinoma, consistent with lung primary.

Once spinal cord decompression had been accomplished, attention was turned to spinal reconstruction. Pedicle screws were placed bilaterally at T6 and T5 using fluoroscopic imaging to the extent possible, given the patient’s body habitus and scoliosis. Stealth neuronavigation frameless stereotaxy was also utilized to assist hardware placement. On the right, at T2, T3, and T4, no pedicles were available due to tumor involvement. On the left, however, at T3 and T4, pedicle screws were placed at these pedicles and the left half of the vertebral bodies were sound and uninvolved with tumor. Bilateral pedicle screws using the Vertex system were placed at T1. Bilateral and lateral screws were placed at C6 and C7 using standard 20 degree cephalad and 20 degree lateral angulation. Custom contoured titanium rods were created with a 5.5 rod utilized in the mid thoracic spine and a 3.2 mm diameter rod used for the Vertex screws in the cervical spine as well as at T1. A “domino” connector was utilized to connect the 2 rods on either side. All connections were secured using top-loading connectors ________ manufacturer’s recommendations using a counter-torque device. Excellent fixation was accomplished.

The posterolateral elements from C6 through T6 were decorticated with Midas Rex drill. Allograft cancellous bone was morselized and combined with demineralized bone matrix and bone graft grafted upon the decorticated posterolateral elements from C6 through T6 bilaterally.

The operative field was flooded with saline and an air leak noted from the cavitary lesion within the right upper lobe of the lung that was contiguous with the spine, as expected.

The wound was irrigated with copious normal saline irrigant, bacitracin solution, meticulous hemostasis achieved. The wound was closed in anatomical layers. The cervicothoracic dorsal fascia was closed with 0 Vicryl simple interrupted suture, subcutaneous tissues with 2-0 Vicryl simple interrupted inverted suture, and the skin with surgical staples. Sterile dressings were applied over the wound.

The operative drapes were taken down, the patient turned supine, general anesthesia reversed, and the patient was subsequently transported to the postanesthesia care unit, while intubated but spontaneously ventilating, for postoperative monitoring. Chest x-ray was obtained immediately upon arrival, and the patient’s pulmonologist notified prior to leaving the operating room regarding possible pneumothorax and need for possible tube thoracostomy.

The patient tolerated the procedure well, and there were no intraoperative complications. Throughout the procedure, somatosensory evoked potential monitoring was maintained continuously and exhibited no changes from baseline at any time. Motor evoked potentials were likewise performed throughout and again were stable throughout.

Neurosurgical Transcription Operative Sample Report #2

OPERATION: Anterior cervical disk excision, interbody fusion with right anterior iliac bone graft, and anterior plate fixation, C5-6.

DESCRIPTION OF OPERATION: Under adequate general anesthesia, the patient was placed in the supine position on the OR table. Cervical halter traction was applied with a 10 pound weight drawn in neutral direction. Anterior aspect of the neck and the right anterior iliac crest area was prepped and draped in a sterile manner. A transverse skin incision was made in the anterior aspect of the right side of the neck. The incision was deepened through the subcutaneous tissue and the bleeding points were coagulated. The platysma muscle was incised in the same line of skin incision. A blunt dissection was carried out in the anterior aspect of the neck between the two fascial planes, carotid sheath laterally and tracheoesophageal sheath anteriorly. The anterior aspect of the cervical spine was approached and exposed. A spinal needle was inserted into the distal space and the x-ray was taken to identify the correct level.

The osteophyte formation in front of the anterior C5-6 area was removed with the rongeurs and the drills. Then, disk was removed with pituitary rongeurs. Disk space was severely narrowed and disk was severely degenerated. The end plates were decorticated with the curettes. Then, disk space was distracted and end plates were decorticated. Foraminal entrance was enlarged with a curette on both sides. Then, another oblique incision was made in the anterior aspect of the pelvis. The incision was deepened through the subcutaneous tissue onto the fascia. The fascia was opened over the iliac crest, and outer table of the iliac crest was exposed subperiosteally by elevating the gluteus medius muscle, the fascial attachment on the ilium.

Then, approximately 1 x 1.5 cm cortical cancellous bone plug was removed with an oscillating saw and osteotomes from the other table of the ilium. The bone graft was prepared into the approximately 1 cm width, 8 mm height, and 1.4 cm depth of the cortical cancellous bone block was prepared and this bone graft was impacted into the prepared disk space of C5-6 while the cervical spine was held in the longitudinal direction. The bone graft was securely impacted into the disk space. Then, 14 mm length of the anterior cervical plate was applied. Stryker spine plate was used. Then, by using the drill guide and drills and the tappers, screws were inserted into the C5 and C6. The x-ray was taken, AP and lateral views, to check the satisfactory position of the plate and screws.

Both wounds were irrigated with antibiotic solution. The graft bed on the right side, anterior pelvis, was prepared with bone wax and Gelfoam for hemostasis. Then, gluteus medius muscle and muscle fascia was reattached over the ilium with interrupted #1 Vicryl sutures, and the subcutaneous tissue was closed with #2-0 Vicryl sutures. Skin was closed with #4-0 subcuticular sutures and Steri-Strips were applied. Sterile dressing was applied. On the anterior neck, the platysma muscle was closed with #2-0 Vicryl sutures. Skin was closed with #4-0 subcuticular sutures. Steri-Strips were applied and sterile dressings were applied. The patient tolerated the operation well and left the OR to the recovery room in good condition. Philadelphia cervical brace was applied to the neck.

Neurosurgical Transcription Operative Sample Report #3

OPERATION PERFORMED: Lumbar diskography at L2-3, L3-4, and L4-5 levels.

DESCRIPTION OF OPERATION: A right-sided two-needle technique was performed at L2-3, L3-4 and L4-5, as well as an attempt made at L5-S1. An 18-gauge spinal needle was utilized through which a 22-gauge 7-inch spinal needle was advanced. Transpedicular approach was utilized. Betadine prep was used for skin disinfection. Sedation was provided by Anesthesia for conscious intravenous sedation. Skin and subcutaneous infiltration was provided by 1% lidocaine plain preservative-free. Contrast material used was Isovue-M 300 which contained approximately 0.6 mg of clindamycin to each 3 mL of Isovue dye. Results were as follows: At L2-3 level, 1 mL of contrast material was administered to confirm endpoint. The patient had pressure symptoms only. Disk morphology revealed a normal globular appearance. At L3-4 level, 1 mL of contrast material was administered to firm endpoint. The patient had 8/10 concordant pain consistent with her lower back symptomatology. Disk morphology revealed annular fissuring, also with radial tears. There also appeared to be some posterior spread of contrast, evidence of leakage in the epidural space. At L4-5 level, the patient had concordant pain, 1 mL of contrast material was administered to firm endpoint. Annular and radial tears were identified. Her pain level was noted to be 10/10. At L5-S1 level, attempt was made to access the disk; however, we were unable to access this secondary to pain and paresthesias and the patient’s anatomy. Therefore, we were unable to perform diskography at the L5-S1 level. Results of three-level diskography indicate a diskogenic source for pain at the L3-4 and L4-5 levels performed consistent with findings on MRI. The patient will proceed to CT scanning and recommendation for intradiskal electrothermal therapy would be recommended at the L3-4 and L4-5 levels.

Neurosurgical Transcription Operative Sample Report #4

DATE OF OPERATION: MM/DD/YYYY

PREOPERATIVE DIAGNOSIS: Herniated cervical disk at C5-C6.

POSTOPERATIVE DIAGNOSIS: Herniated cervical disk at C5-C6.

OPERATION PERFORMED: Anterior cervical diskectomy and fusion at C5-C6.

SURGEON: John Doe, MD

ASSISTANT: Jane Doe, MD

ANESTHESIA: General endotracheal.

DESCRIPTION OF OPERATION: The patient was placed under general endotracheal anesthetic in the supine position with the head rotated to the left. The right side of the neck was prepped and draped. An incision on the right side of the neck was made following one of the skin creases. Skin, subcutaneous tissue, and platysma were incised. Dissection was then carried out towards the anterior aspect of the cervical spine by dissecting the carotid vessels laterally and the trachea and esophagus medially. The C-arm was used for localization. Following this, insertion of the longus colli muscle was detached anterolaterally, and the anterior ligament was removed from the bodies of the C5 and C6. The annulus was incised. The distractor post was placed in the body of the C5 and C6. The interspaces were distracted. The operative microscope was brought into place. With the aid of the flat curettes, the cartilaginous plate was detached and then removed. There was evidence of rupture of the posterior ligament with the midline disk herniation and several free fragments. After careful excision of the intervertebral disk and with the aid of the operative microscope, the inferior lip of C5 was removed. The posterior ligament was then opened and small free fragments were also removed. The posterior ligament was excised. The dural sac was totally decompressed. Following this, a small ledge was created in the body of the C6 to act as a stopper for the graft. An 8 mm cornerstone graft was selected and then topped gently into place. Following this, the fusion was completed using the Atlantis plates with the screws on the body of C5 and C6. The position of the screws and plates were confirmed by fluoroscopy. Following this and after careful hemostasis, the wound was closed in layers with Vicryl, and the skin was approximated with the 4-0 Vicryl and adhesive band. The patient tolerated the procedure well.

Neurosurgical Transcription Operative Sample Report #5

OPERATION:

1. Anterior cervical strut graft arthrodesis, C5-6.
2. Anterior cervical osteophytectomy, C5-6.
3. Anterior cervical decompressive foraminotomies, C5-6.
4. Anterior cervical plating, C5-6.
5. Microscope use for nerve root microdissection.

DESCRIPTION OF OPERATION: The patient was brought to the operating room, induced and intubated without difficulty. She had received IV antibiotics in the holding area. The C-arm fluoroscopy unit was set up and a right-sided transverse parasagittal incision was marked off at C5-6. This area was prepped and draped in a sterile fashion. It was infiltrated with 1% Xylocaine with epinephrine and opened with a #10 blade, sharp dissection through the platysma muscle up to the anterior border of the sternocleidomastoid. Sharp and blunt dissection medial to this structure led into the prevertebral space. A handheld Cloward was used to retract the midline structures. A spinal needle was placed at the ________ C5-6 disk space and this was confirmed with a C-arm fluoroscopy unit. At this point, a Bovie cautery was used to dissect the anterior longitudinal ligament of the inferior aspect of C5 and the superior aspect of C6. Medial and lateral Rainbow retractors were placed in the field. Posts were drilled into the bodies of C5 and C6 for axial distraction. Once applied, the microscope was brought in. Under microscopic guidance, the anterior osteophytic disease was drilled away with a Midas Rex drill and the AM-35 drill bit. The disk space was entered and curettes and pituitaries were used to remove loose disk material. The endplates were then drilled down with a Midas Rex drill. A #2 Kerrison was used to remove posterior osteophytes. Decompressive foraminotomies were performed bilaterally including removal of soft disk material from the left hand side at C5-6. Once this was completed, the defect was sized. A 7 mm titanium strut graft was packed with Osteofil and tapped into place under fluoroscopic guidance. At this point, posts were removed and post holes were waxed. A 23 mm anterior cervical titanium plate was selected and secured into the bodies of C5 and C6 with 12 mm variable screws. Locking screws were tightened. Copious irrigation was followed with closure. Bleeding sites were cauterized. FloSeal was placed in the dissection area. The platysma was closed with interrupted #3-0 Vicryl sutures. The skin was closed with #4-0 subcuticular stitch. Steri-Strips were applied, and a dressing was placed on the patient’s neck. She awoke in good neurologic condition and was taken to the recovery room.

Neurosurgical Transcription Operative Sample Report #6

OPERATION: Elective posterior fossa craniotomy and resection of right CP angle mass.

DESCRIPTION OF OPERATION: The patient was brought into the operative suite, maintained in supine position, and was endotracheally intubated by the anesthesiologist. Prophylactically, the patient received 8 mg of Decadron in addition to 1 gram of Ancef. Upon securing of the ET tube, a Foley catheter was then placed by the OR staff. After that, the patient was then rolled, left side down, onto the bean bag and placed in a 3-point Mayfield head fixation system for a lateral approach. A paramedian incision was made, right behind the mastoid, approximately 2-3 fingerbreadths behind the pinna and mastoid of the ear, straight line incision. Upon fixing of the head into this position and securing of all areas from pressure necrosis during the entire case, the patient was slightly raised approximately 10-15 degrees for preservation of venous drainage during the entire case. The area was shaved and prepped and draped in the usual sterile fashion. A midline incision in the paramedian area, described above, was marked out on the skin, and after being prepped and draped in the usual sterile fashion, infiltrated with local infiltrant consisting of approximately 15 mL of 1% lidocaine, 1:100,000 epinephrine. After draping the area, skin incision ensued with a 10-blade down to the level of the paravertebral musculature and bowing through that area down to the level of the periosteum. With the periosteal elevator, the periosteum was lifted off exposing the calvaria down almost to the level of the ring of C1 and superiorly up to the occipital bone. Self-retaining retractors were then introduced to hold back the skin edges and the muscle, and at the landmarks of the asterion, a 14-mm perforator was then used to bur down to the level of the dura. This was matured and then a small craniotomy performed, approximately 4 to 4.5 cm in diameter, with its superior margin at the asterion, transverse sinus extending down inferiorly along the lateral edge of the posterior fossa and then laterally out to the sigmoid sinus. This area was enlarged with use of the bur and drilled down in the mastoid, exposing some the air cells which were immediately waxed with bone wax for preservation of CSF contiguity and prevention of a CSF leak. At that point in time, once our bone flap was enlarged with the Midas Rex drill and in addition with small Leksell rongeurs, deep dura was opened up in a curvilinear fashion exposing the cerebellum and out to the CP angle.

At that time, the lateral medullary cistern was opened up allowing free egress of CSF. This facilitated a great amount of cerebellar relaxation. At that point in time, the Leyla retractor was then placed onto the OR table, and with the Leyla retractor blade and protection of the cerebellar hemisphere, a small retractor was then placed onto the cerebellum and lifted superomedially exposing the CP angle. Immediately, under evidence was a very large tumor adherent to the petrous ridge and to the skull base. The rest of the procedure was then performed under the microscope and with neural monitoring. Upon exposure of the tumor, the stimulation was then performed for areas along the tumor surface for rough entrance into the tumor to see where the facial nerve and trigeminal nerve are wrapped around the tumor. This did not appear to be a typical schwannoma. It seemed to be very gritty and very adherent to the neurovascular structures. Immediately evident was the PICA, which seemed to be engulfed by the tumor and running amongst the middle of it. In addition, superiorly was ICA, which was extremely adherent to the superior edge of the tumor. At that point in time, through stimulation, we found a pattern, which was nonstimulatory, and this was bipolared and small and opened and evacuated of some tumor contents with the suction dissection. This freed up some of the capsule and allowed further mobility until further dissection of the facial nerve was evident through stimulation. The facial nerve is quite splayed out over the superior and anterior extent of the tumor. We kept on debulking the tumor from within and reducing its blood supply, as it was very adherent to the skull base and to the petrous ridge margin.

At that point in time, several small biopsies were sent for frozen pathology, which came back as a meningioma with psammoma bodies. We continued debulking this tumor and decompressing it off the brainstem. Circumferentially, we surrounded it with cottonoids and continued in a superior-to-inferior direction with constant stimulation and guiding so as not to take any cranial nerves. Facial nerve has been splayed out, quite compressed, but still stimulates at approximately 0.3 mA at the brainstem. We continued debulking the tumor, now with a small CUSA as it entered into the porus. The porus is enlarged and widened out and is completely devoid of normal anatomy. There is no need to drill down a porus that is completely adherent to the facial nerve and would cause further damage to the facial nerve. We continued out in debulking the tumor and basically amputated as it enters the porus. The complete intracranial compartment has been completely devoid of tumor. The facial nerve appears intact in the field and actually has stimulation at approximately 0.3 mA at the brainstem. The trigeminal nerve has been compressed and pressed superiorly but is intact in stimulation and stimulatory. In addition, there has been no compression on IX-X-XI complex inferiorly. ICA has been freed and so has PICA from the substance of the tumor and is intact with multiple loops in the area. This may be representative because the tumor has pulled and compressed ICA at several areas. We have abandoned going into the porus and drilling out further tumor at this area. This should be followed up with radiosurgery.

At that point in time, all bleeding points were coagulated with the use of bipolar cautery. There was minimal blood loss in the intracranial compartment, and the dura was then closed partially with interrupted 4-0 Nurolon sutures. A small area, which had not come together, has a Dura-Guard patch of approximately 1 x 2 cm placed in the middle of it, and this was secured in place with 4-0 Nurolon sutures. This was tested for watertight closure with irrigation fluid into the posterior fossa compartment. At that point in time, fibrin glue was then placed over the suture line of the dura. The mastoid was waxed again for prevention of any air leaks and CSF leaks during this time. The bone was then secured back in place with three 2-hole Synthes self-drilling setscrews and 4 x 1.5 mm screws. Once the bone had been secured in place, the self-retaining retractors were then removed allowing the paravertebral muscle contents and the paracervical strap muscles to come fall back into the normal contour.

The fascia was closed with interrupted 2-0 Vicryl sutures. The superficial fascia was then closed with interrupted 3-0 Vicryl sutures, then subcutaneous closed with 3-0 Vicryl sutures, and the skin was closed with a running continuous Monocryl stitch for watertight closure. Dry sterile dressing was then placed. The patient was then removed from 3-point Mayfield head fixation system and allowed to roll back onto the OR stretcher at the side of the bed. Upon moving all of her extremities and opening and closing her eyes spontaneously, there was a slight lower facial droop noted from approximately jawline down. This seems to be somewhat worse than the preoperative status. However, her eyes are opening and closing uninhibitedly and the eyes pointing normally. In addition, the tongue was quite midline at the end of the procedure. The patient was then endotracheally extubated and transferred to the recovery room without incident.

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abasia

absence seizures

acalculia

acaudal

accessory nerve

acetylcholine

acoustic schwannoma

afebrile seizure

afferent nerves

Alzheimer dementia

Alzheimer disease

amplitude

amyotrophic lateral sclerosis (or ALS)

anencephaly

aneurysm

aphasia

apraxia

arachnoid foramen

arachnoid membrane

astasia

astrocyte

astrocytoma

ataxia

ataxic gait

atonic seizure

aura

autonomic nervous system

axon

axon reflex

Babinski reflex

Babinski sign

Babinski syndrome

bacterial meningitis

Bell palsy

blood-brain barrier

bradykinesia

brain stem OR brainstem

brain wave

brainstem astrocytoma

Broca aphasia

Broca convolution

Broca fissure

Brudzinski sign

bulldog response

cardioembolic stroke

carotid plexus

cauda equina

cephalalgia

cephalgia

cerebellar

cerebellopontine (or CP)

cerebellum

cerebral angiography

cerebral brucellosis

cerebral concussion

cerebral cortex

cerebral hemorrhage

cerebral palsy

cerebral poliomyelitis

cerebral ventricle

cerebrospinal fluid (or CSF)

cerebrospinal fluid analysis

cerebrovascular accident

cerebrum

cervical radiculopathy

clonic seizure

closed head injury

cognitive deficit

coma

comatose

community-acquired bacterial meningitis

convolution

corpus callosum

cranial nerves (I-XII)

craniostenosis

craniosynostosis

craniotomy

cystic encephalomalacia

delirium

delirium tremens (or DT)

dementia

demyelination

dendrite

dense hemiparesis

dense hemiplegia

diplegia

dopamine

dopamine agonist

dura mater

dyslexia

echoencephalography

efferent nerves

embolic stroke

embolism

encephalitis

encephalomalacia

encephalopathy

epidural hematoma

epilepsy

epileptic seizure

event recall

evoked seizure

expressive aphasia

festinating gait

fissure

flaccid paralysis

foramen

foraminal

fornix

fourth ventricle

frontal lobe

galea

galea aponeurotica

ganglia

ganglion

ganglionectomy

giant cell astrocytoma

glioblastoma multiforme

glioma

grand mal seizure

gray matter

Guillain-Barré polyneuritis

Guillain-Barré syndrome

gyri

gyrus

hemianencephaly

hemianopia

hemiparesis

hemiplegia

hemorrhagic stroke

Huntington chorea

hydrocephalus

hyperesthesia

hyperkinesis

hypophysis

hypothalamus

intrathecal

Jolly reaction

lacunar stroke

laminectomy

leptomeningitis

lumbar puncture

lumbosacral radiculopathy

median nerve

medulla oblongata

meningeal

meninges

meningioma

meningitis

meningomyelocele

microglial cell

mild dementia

monoplegia

motor impairment

MRA

MRI

multiinfarct dementia

multiple sclerosis (or MS)

myasthenia gravis

myasthenic reaction

myelin sheath

myelogram

narcolepsy

neuralgia

neurological deficit

neuron

neuropathy

neurotransmitter

new-onset seizure

normocephalic

occipital lobe

orthostatic syncope

palsy

paraplegia

paresis

paresthesia

parietal lobe

parietooccipital fissure

Parkinson disease

peripheral nervous system

petit mal seizures

pia mater

piloid astrocytoma

poliomyelitis

polyneuritis

pons

postictal paresis

quadriplegia

radiculitis

radiculopathy

residual hemiparesis

Romberg sign

Romberg test

schwannoma

sciatic nerve

secondary seizure

seizure activity

senile delirium

senile dementia

senile tremor

sensory ataxia

sensory evoked potential

sensory impairment

shearing injury

somatosensory aura

somatosensory evoked potential

spastic hemiparesis

spastic hemiplegia

spastic quadriplegia

spina bifida

staphylococcal meningitis

stellate astrocyte

stereotactic neurosurgery

stimulus

subclinical seizure

sulci

sulcus

sylvian fissure

sympathetic nerves

synapse

synapse loss

syncopal

syncope

tandem stance

TBI or traumatic brain injury

thalamic

thalamus

thecal

thecal sac

thrombosis

titubation

tonic-clonic seizures

t-PA (tissue plasminogen activator)

transient hemiparesis

transient ischemic attack or TIA

trephination

tuberculous meningitis

vagal

vagotomy

vagovagal

vasovagal epilepsy

vasovagal syncope

venous thrombosis

ventricle of brain

vestibular schwannoma

viral meningitis

visual reflex epilepsy

visuospatial

vocal cord paralysis

waddling gait

Wernicke aphasia

whiplash injury

white matter

wide-necked aneurysm

Wolf-Orton bodies

Wolman disease

woodcutter’s encephalitis

wormian bones

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