Delimitation of the risk area of the vertebral artery during the paramedian suboccipital approach.

OBJECTIVE: The V3 segment of the vertebral artery (V3-VA) is at risk during diverse approaches to the craniovertebral junction. Our objective is to present a system of anatomic and topographic landmarks to identify the V3-VA during the paramedian suboccipital approach (PMSOA) with the help of minimal or basic tools. MATERIAL AND METHODS: The first was a retrospective analysis of the angiotomography (CTA) of 50 patients over 18-years old, and 9 anatomical dissections. A series of lines were defined between the different bony landmarks. Within this lines the risk area of the vertebral artery (RAsV3-VA) and the risk point of the vertebral artery (RPsV3-VA) were defined. The second stage was a prospective study, where the previously defined measurements were carried out by using neuronavigation in 10 patients (20 sides) operated with the PMSO approach in order to confirm the presence of the V3 segment in the RAsV3-VA and RPsV3-VA. RESULTS: In the first stage, the V3 segment was found in the middle third of the X line in 96,6% of the cases. The distance between the inion and the UCP (percentile 5) was 20 mm and to the LCP (percentile 95) was 40 mm. In the range between the UCP and the LCP, in the middle third of the inion-mastoid line (RAsV3-VA), we found 90% of the V3-VA. The measurements taken during the second stage revealed that the artery was in the middle third of the X line in 97% of the cases. 85% of the patients presented the total of the V3s-VA on the RAsV3-VA and in 85% there was a direct relationship with the V3 segment and the RPV3s-VA. CONCLUSION: We propose an easy-to-implement system to delimit the risk area of the V3-VA during the PMSOA. We believe that these landmarks provide a practical, reliable, costless and useful tool that could decrease the risk of lesion of the V3-VA during this approach without the need of using.

Experience in awake glioma surgery in a South American center. Correlation between intraoperative evaluation, extent of resection and functional outcomes.

Introduction: Gliomas are the second most frequent primary brain tumors. Surgical resection remains a crucial part of treatment, as well as maximum preservation of neurological function. For this reason awake surgery has an important role.The objectives of this article are to present our experience with awake surgery for gliomas in a South American center and to analyze how intraoperative functional findings may influence the extent of resection and neurological outcomes. Materials and methods: Retrospective single center study of a cohort of adult patients undergoing awake surgery for brain glioma, by the same neurosurgeon, between 2012 and 2022 in the city of Buenos Aires, Argentina. Results: A total of 71 patients were included (mean age 34 years, 62% males). Seventy seven percent of tumors were low grade, with average extent of resection reaching 94% of preoperative volumetric assessment. At six months follow up, 81.7% of patients presented no motor or language deficit.Further analysis showed that having a positive mapping did not have a negative impact in the extent of resection, but was associated with short term postoperative motor and language deficits, among other variables, with later improvement. Conclusion: Awake surgery for gliomas is a safe procedure, with the proper training. In this study it was observed that guiding the resection by negative mapping did not worsen the results and that positive subcortical mapping correlated with short term postoperative neurological deficits with posterior improvement within six months in most cases.

Transoperative Magnetic Resonance Imaging in Awake Glioma Surgery: Experience in a Latin American Tertiary-Level Center.

OBJECTIVE: Analyze the usefulness, efficacy, and safety of transoperative magnetic resonance imaging (tMRI) in glioma surgery in awake patients. METHODS: Retrospective, single-center, analytical study of a cohort of patients who underwent awake surgery for gliomas by the same surgeon in a third-level Argentine center, in the period between 2012 and 2022. Only patients with pathology-confirmed gliomas, with 6-month follow-up, who had preoperative and postoperative volumetric magnetic resonance imaging, were included in this sample. Subsequently, we analyzed which patients received surgery with the tMRI protocol and the results using multivariate regression analysis. RESULTS: A total of 71 patients were included. A tMRI study was performed on 22 (31%) of these patients. The use of tMRI increased the percentage of resection by 20% (P = 0.03), thereby increasing the possibility of gross total resection. However, using tMRI significantly extended surgical time by 84 minutes (P < 0.001). In 55% of the patients in whom tMRI was performed, the resection was continued after it. The use of tMRI did not increase the rate of infections or the development of surgically associated neurological deficits in the long term, despite the fact that 47% of the patients showed the development of a new deficit or worsening of a previous one during the intraoperative period. CONCLUSIONS: The use of tMRI in awake glioma surgery proved to be a safe tool that contributes to increasing the degree of tumor resection, compared to the use of neurophysiological mapping and neuronavigation, at the expense of increased surgical times and costs. We consider tMRI in awake glioma surgery should be used in properly selected cases.

Intradural extramedullary tumors. Retrospective cohort study assessing prognostic factors for functional outcome in adult patients.

OBJECTIVE: The purpose of this study is to analyze a series of patients with intradural extramedullary tumors (IDEM) and assess factors that may modify or determine the final long term outcome and management. MATERIALS AND METHODS: Single Center, retrospective study of a series of surgical patients with IDEM lesions from our Institution operated between 2010 and 2021. Patients with less than 6 months of follow up were excluded. Several preoperative demographics, clinical, imaging and surgical features, as well as histopathology, recurrence and adjuvancy were assessed. Patients' final clinical outcome was categorized using the McCormick scale. RESULTS: A total of 203 patients with a mean follow-up of 30.50 months (range 6-130) were included. 57.64% of the analyzed population was female and the mean age was 50.51 years. The most frequent location of the tumors was dorsal (34.98%) followed by the lumbar region (32.02%). Total resection was achieved in 84.24% of cases, and the most frequent histopathology was Schwannoma (36.45%), followed by Meningioma (30.05%). Pain was the most usual initial symptom (63.05%). In our analysis, functional outcome after surgery was associated with statistical significance with preoperative McCormick grade, tumor type, EOR and postoperative complications such as hematoma and sphincter involvement. CONCLUSION: The management of these lesions depends on many factors. It is worthy of mention that clinical presentation, EOR, histopathology and postoperative complications have shown significant prognostic value for the final outcome. Early treatment with the intention of achieving GTR when possible, using carefully tailored approaches, should be considered before the onset of significant symptoms.

[Endoscopic vs. microscopic techniques for the treatment of trigeminal neuralgia. Our experience at an Argentine care center]. / Descompresión microvascular endoscópica versus microscópica en neuralgia trigeminal en un Centro argentino.

INTRODUCTION: Trigeminal neuralgia is a highly invalidating pathology, whose natural course has been modified thanks to decompressive microvascular surgery. The intervention can be carried out either with a microscope or via an endoscopic technique. Our goal was to compare these two techniques for the treatment of this complex pathology. METHODS: Retrospective, analytical study of a cohort of patients treated by a single surgeon at our institution, in the period between 2015 and 2021. RESULTS: We identified 31 patients and divided them into two groups: 15 (49%) treated using the microscopic technique (group M), and 16 (51%) exclusively via an endoscopic one (group E). Differences were observed between the means of the size of the craniectomy in group M (3.7 cm) compared to group E (2.5 cm); The mean length of hospital stay for patients in group E was shorter (4.46 days compared to that of patients in group M, whose hospital stay averaged 2.43 days). There were no differences between the two groups regarding the length of the procedure. In both groups, the predominant compression was due to the superior cerebellar artery (SCA). Pain outcomes were equivalent, with every patient in both groups having an improved postoperative Barrow Neurological Institute Pain Intensity Score (BNI). DISCUSSION: Endoscopic microvascular decompression is an attractive option for the resolution of neurovascular conflict as it provides functional results similar to the microscope technique, without requiring an extensive craniectomy and associated to shorter in-hospital stay, which is beneficial for both the patient and the institution.

Introducción: La descompresión microvascular (DMV) en la neuralgia trigeminal es una técnica quirúrgica cuyo objetivo es revertir la compresión a la que se ve sometido un nervio por una estructura vascular. El objetivo de este estudio fue realizar una comparación directa entre la descompresión microvascular endoscópica (DMV-E) y la misma a través del uso del microscopio (DMV-M) en el tratamiento de la neuralgia del trigémino. Métodos: Se realizó un estudio de cohorte retrospectivo de pacientes operados de neuralgia de trigémino, por un mismo cirujano, entre 2015 y 2021 en nuestra institución, tanto por técnica microquirúrgica como endoscópica. Resultados: Se obtuvieron un total de 31 pacientes divididos en dos grupos: Grupo M correspondiente a 15 (49%) pacientes abordados con técnica microscópica y Grupo E, con 16 (51%) pacientes intervenidos con técnica endoscópica. Se identificaron diferencias en el tamaño de la craniectomía, más pequeña en el grupo E (2.50 cm vs 3.70 cm grupo M); y en el tiempo de internación, de 2.43 días en el grupo E vs. 4.46 días en el grupo M. El tiempo de cirugía fue similar para ambas técnicas quirúrgicas La principal compresión fue dada por la arteria cerebelosa superior (ACS) en ambos grupos. Todos los pacientes presentaron mejoría del Barrow Neurological Institute Pain Intensity Score (BNI) en el postoperatorio en ambos grupos. Discusión: La DMV-E constituye una alternativa quirúrgica interesante a la ya conocida DMV-M para el tratamiento de la neuralgia trigeminal, por requerir menores dimensiones en la incisión cutánea y tamaño de la craniectomía, acortando el tiempo de internación, lo cual no solo implica un beneficio para el paciente, sino que también representa menor costo de internación.

Descompresión microvascular endoscópica versus microscópica en neuralgia trigeminal en un centro Argentino / Endoscopic vs. microscopic techniques for the treatment of trigeminal neuralgia. Our experience at an Argentine care center

Resumen Introducción: La descompresión microvascular (DMV) en la neuralgia trigeminal es una técnica quirúrgica cuyo objetivo es revertir la compresión a la que se ve someti do un nervio por una estructura vascular. El objetivo de este estudio fue realizar una comparación directa entre la descompresión microvascular endoscópica (DMV-E) y la misma a través del uso del microscopio (DMV-M) en el tratamiento de la neuralgia del trigémino. Métodos: Se realizó un estudio de cohorte retrospec tivo de pacientes operados de neuralgia de trigémino, por un mismo cirujano, entre 2015 y 2021 en nuestra institución, tanto por técnica microquirúrgica como endoscópica. Resultados: Se obtuvieron un total de 31 pacientes divididos en dos grupos: Grupo M correspondiente a 15 (49%) pacientes abordados con técnica microscópica y Grupo E, con 16 (51%) pacientes intervenidos con técnica endoscópica. Se identificaron diferencias en el tamaño de la cra niectomía, más pequeña en el grupo E (2.50 cm vs 3.70 cm grupo M); y en el tiempo de internación, de 2.43 días en el grupo E vs. 4.46 días en el grupo M. El tiempo de cirugía fue similar para ambas técnicas quirúrgicas La principal compresión fue dada por la arteria ce rebelosa superior (ACS) en ambos grupos. Todos los pacientes presentaron mejoría del Barrow Neurological Institute Pain Intensity Score (BNI) en el postoperatorio en ambos grupos. Discusión: La DMV-E constituye una alternativa qui rúrgica interesante a la ya conocida DMV-M para el tratamiento de la neuralgia trigeminal, por requerir menores dimensiones en la incisión cutánea y tamaño de la craniectomía, acortando el tiempo de internación, lo cual no solo implica un beneficio para el paciente, sino que también representa menor costo de internación.

Abstract Introduction: Trigeminal neuralgia is a highly invali dating pathology, whose natural course has been modi fied thanks to decompressive microvascular surgery. The intervention can be carried out either with a microscope or via an endoscopic technique. Our goal was to compare these two techniques for the treatment of this complex pathology. Methods: Retrospective, analytical study of a cohort of patients treated by a single surgeon at our institution, in the period between 2015 and 2021. Results: We identified 31 patients and divided them into two groups: 15 (49%) treated using the microscopic technique (group M), and 16 (51%) exclusively via an endoscopic one (group E). Differences were observed between the means of the size of the craniectomy in group M (3.7 cm) compared to group E (2.5 cm); The mean length of hospital stay for patients in group E was shorter (4.46 days compared to that of patients in group M, whose hospital stay averaged 2.43 days). There were no differences between the two groups regarding the length of the procedure. In both groups, the predomi nant compression was due to the superior cerebellar artery (SCA). Pain outcomes were equivalent, with every patient in both groups having an improved postoperative Barrow Neurological Institute Pain Intensity Score (BNI). Discussion: Endoscopic microvascular decompression is an attractive option for the resolution of neurovas cular conflict as it provides functional results similar to the microscope technique, without requiring an exten sive craniectomy and associated to shorter in-hospital stay, which is beneficial for both the patient and the institution.

Postoperative Third Nerve Palsy after Endoscopic Endonasal Transsphenoidal Surgery for Pituitary Adenoma: Elucidating its Mechanism.

Third nerve palsy is a rare complication of transsphenoidal surgery and has been merely mentioned in different studies, but there is not any rigorous analysis focusing on this particular complication. The purpose of this study is to analyze this complication after transsphenoidal surgery for a pituitary adenoma to better understand its pathophysiology and outcome. The authors retrospectively analyzed 3 cases of third nerve palsy selected from the 377 patients operated via a transsphenoidal route between 2012 and 2021 at FLENI, a private tertiary neurology and neurosurgical medical center located in Buenos Aires, Argentina. The three patients who presented this complication were operated on via an endoscopic approach. It was observed that an extension into the cavernous sinus (Knosp grade 4) and to the oculomotor cistern was present in the three patients. The deficit was apparent immediately after surgery in two patients. For these two patients, the supposed mechanism of ophthalmoplegia was an intraoperative nerve lesion. The other patient became symptomatic in the 48 h following the surgery. The mechanism implied in this case was intracavernous hemorrhagic suffusion. The latter patient completely recovered the third nerve deficit in the 3 months that followed, while the other two recovered after 6 months postoperative. Oculomotor nerve palsy after transsphenoidal surgery is a very rare complication and appears to be transient in most cases. The invasion of both the cavernous sinus and the oculomotor cistern seems to be a major factor in its physiopathology and should be preoperatively analyzed on magnetic resonance imaging (MRI); recognizing such extension should play an important role in the surgeon's operative considerations.

Apoplejía pituitaria e infección por SARS-COV-2 (COVID-19) / Pituitary apoplexy and SARS-CoV-2 (COVID-19) infection

Resumen La infección por coronavirus (SARS-CoV-2/COVID-19) es responsable de un diverso rango de manifestaciones extrapulmonares entre las cuales se destaca el compromiso neurológico directo o indirecto. La apoplejía hipofisaria es una entidad médica y neuroquirúrgica de gravedad variable que suele asociarse a la presencia de un adenoma subyacente. Un escaso número de reportes han vinculado estas dos enfermedades entre sí. Este trabajo describe un caso de apoplejía hipofisaria manifestada clínicamente en for ma concomitante al diagnóstico de COVID 19, en un paciente con macroadenoma hipofisario desconocido y su manejo terapéutico, revisando los mecanismos potencialmente subyacentes al nexo entre ambas entidades.

Abstract Coronavirus disease (SARS-CoV-2/COVID-19) is responsible for a wide variety of extrapulmonary manifestations, among which direct or indirect neurological compromise stands out. Pituitary apoplexy is a clinical and neurosurgical entity of variable severity, usually associated with a pituitary adenoma. Literature is scarce regarding the association between these diseases. This paper reports a case of pituitary apoplexy, manifested concomitantly to the diagnosis of COVID 19 in a patient with unknown pituitary macroadenoma, and its therapeutic management, reviewing the mechanisms potentially underlying the link between both entities.

[Pituitary apoplexy and SARS-CoV-2 (COVID-19) infection]. / Apoplejía pituitaria e infección por SARS-CoV-2 (COVID-19).

Coronavirus disease (SARS-CoV-2/COVID-19) is responsible for a wide variety of extrapulmonary manifestations, among which direct or indirect neurological compromise stands out. Pituitary apoplexy is a clinical and neurosurgical entity of variable severity, usually associated with a pituitary adenoma. Literature is scarce regarding the association between these diseases. This paper reports a case of pituitary apoplexy, manifested concomitantly to the diagnosis of COVID 19 in a patient with unknown pituitary macroadenoma, and its therapeutic management, reviewing the mechanisms potentially underlying the link between both entities.

La infección por coronavirus (SARS-CoV-2/COVID-19) es responsable de un diverso rango de manifestaciones extrapulmonares entre las cuales se destaca el compromiso neurológico directo o indirecto. La apoplejía hipofisaria es una entidad médica y neuroquirúrgica de gravedad variable que suele asociarse a la presencia de un adenoma subyacente. Un escaso número de reportes han vinculado estas dos enfermedades entre sí. Este trabajo describe un caso de apoplejía hipofisaria manifestada clínicamente en forma concomitante al diagnóstico de COVID 19, en un paciente con macroadenoma hipofisario desconocido y su manejo terapéutico, revisando los mecanismos potencialmente subyacentes al nexo entre ambas entidades.

Posterior Fossa Calcifying Pseudoneoplasm of the Neuraxis (CAPNON): Presentation of Three Surgical Cases.

BACKGROUND: Calcifying pseudoneoplasm of the neuraxis (CAPNON) is an extremely rare entity with fewer than 150 cases reported in the literature and mostly with a supratentorial or spinal location. Posterior fossa CAPNON has been reported scarcely, and association with perilesional edema is a topic not yet approached which might play a significant role in treatment decision and clinical progression. Our objective is to report, to our knowledge, the first series of 3 posterior fossa CAPNON surgically treated in a single institution and assess features that help provide a systematic approach to diagnosis and timely treatment. METHODS: This was a monocentric, retrospective study of surgical patients diagnosed with a posterior fossa CAPNON in the last 5 years. A thorough bibliographic research was conducted. RESULTS: Three patients were included. Locations involved IV ventricle, right cerebellopontine angle with extension to foramen magnum, and cerebellar vermis. Two of them presented with symptoms linked to acute hydrocephalus, and the other one presented with progressive cranial nerve palsy and brainstem compression signs. The 3 of them showed radiological signs of perilesional edema on their preoperative magnetic resonance imaging. Gross total resection was accomplished in one case, with near and subtotal resections in the others. There were no complications. The outcome was favorable in all cases. CONCLUSIONS: It is essential to contemplate this infrequent diagnosis in cases of calcified lesions involving the posterior fossa. When symptoms manifest, surgery should be considered. Perilesional edema could be associated with symptomatic progression and hence a sign suggesting the need for surgical treatment.

Surgical Treatment of IV Ventricle Calcifying Pseudoneoplasm of the Neuraxis (CAPNON) Operative Nuances.

Calcifying pseudoneoplasm of the neuroaxis (CAPNON) is a rare, slow growing, and generally benign fibro osseous mass that can emerge throughout the entire central nervous system (CNS). When diagnosed, prompt surgical treatment can determine a good neurological outcome and possibly curative resolution. The objective of the present work is to present a step by step technical report with its video. We present a 37 year old female presented with occipital headache and cervical pain associated with dysphagia, nausea, and gait disturbances. Computed tomography (CT) scan showed a focal calcified lesion on the floor of the IV ventricle projecting toward the vermis with associated supratentorial hydrocephalus and transependymal edema. The telovelar approach was chosen for the procedure. The outcome was favorable, with no complications. Postoperative CT was performed, which revealed no residual lesion. A step by step report of a IV ventricle CAPNON that manifested with hydrocephalus is described.

Global Rostral Midbrain Syndrome (GRMS) and Corpus callosum infarction in the context of shunt overdrainage.

We report 3 cases of Global rostral midbrain syndrome (GRMS) and Corpus Callosum (CC) infarction, in the context of hydrocephalus followed by shunt dysfunction and slit ventricles. Prior shunt implantation had been indicated for adult-onset hydrocephalus secondary to aqueductal stenosis of varying causes. All three patients had been stable for months before developing repeated shunt dysfunctions, ultimately progressing to parkinsonism, Parinaud syndrome, akinetic mutism, pyramidal signs, cognitive impairment, CC infarction and slit ventricles, in the context of CSF overdrainage. Parkinsonism-related symptoms responded to dopa in all cases, but Parinaud syndrome and cognitive impairment persisted. Although GRMS has been described in the context of a transtentorial pressure gradient after shunt blockage, in these three cases with similar clinical presentation, reverse transtentorial pressure gradient and slit ventricles due to shunt overdrainage was the likely cause. The authors discuss the role of CC infarction and provide a detailed analysis after gathering previously described data, to unify information under a recognizable clinical entity and better understand the underlying pathophysiology, treatment options and outcome.

Cervical laminoplasty with unilateral C4-5 foraminotomy: Technical note and case series.

OBJECTIVE: The open-door laminoplasty technique is widely used in the treatment of multilevel cervical myelopathy. Despite the satisfactory functional and radiological results of this technique, postoperative C5 palsy is still a severe and disabling complication with a variable incidence in the literature. The objective of this article is to describe and demonstrate the surgical technique step by step with the addition of unilateral C4-5 foraminotomy and to evaluate the results obtained to date, with special emphasis on C5 palsy. MATERIAL AND METHODS: Retrospective study of 20 patients operated on for cervical myelopathy using the "extended" laminoplasty technique, which is described step by step. RESULTS: Between January 2013 and April 2019, 20 patients were operated on using the extended laminoplasty technique. Only one patient (5%) presented postoperative C5 palsy. The postoperative recovery rate of the modified JOA (Japanese Orthopaedic Association) score was 54.5%, similar to that observed in other series. CONCLUSION: The extended cervical laminoplasty technique with unilateral C4-5 foraminotomy was developed and demonstrated for the prevention of C5 palsy. The results were analysed and an incidence of C5 palsy coinciding with the lowest percentage reported in the literature was obtained. A prospective randomised study would be useful to assess the role of preventive unilateral C4-5 foraminotomy.

"Este caso me desorientó... " / "This case disoriented me..."

Paciente masculino de 66 años que se presentó al servi-cio de guardia y urgencias por cuadro clínico caracteriza-do por mareos de 3 meses de evolución e inestabilidad de la marcha de 24 hs de evolución. Como único signo positi-vo al examen físico se constató dismetría de miembros su-periores. Se decidió estudiar con TC de cerebro en donde se identificó, en topografía pineal y tercer ventrículo, una voluminosa lesión ocupante de espacio, sólida, de aproxi-madamente 27 x 21 mm de densidad heterogénea, con pro-bable relación a restos hemáticos en distintos estadios evo-lutivos asociada a calcificaciones periféricas

Endoscopic resection through a retrosigmoid transmeatal approach of a large-sized vestibular schwannoma: operative video and technical nuances.

Surgical management of vestibular schwannomas has improved over the last 30 years. Whereas in the past the primary goal was to preserve the patient's life, today neurological function safeguarding is the main objective, with numerous strategies involving single resection, staged resections, postoperative radiosurgery, or single radiosurgery. The retrosigmoid approach remains the primary pathway for surgical access to the cerebellopontine angle (CPA). The use of an endoscope has great advantages. It contributes to the visualization and resection of residual tumor and also reduces the need for cerebellar retraction. The authors present a fully endoscopic resection of a large-sized vestibular schwannoma with facial nerve preservation. The video can be found here: https://stream.cadmore.media/r10.3171/2021.7.FOCVID21106.

Results in the treatment of intracranial hemangiopericytomas. Case series. / Resultados en el tratamiento de los hemangiopericitomas intracraneanos. Serie de casos.

OBJECTIVE: Intracranial hemangiopericytoma (HPC) is a rare central nervous system tumor characterized by its low incidence, high rate of local recurrence and risk of metastasis. The main objectives of this paper are two: to show the results in the treatment of HPC in our institution in the last 20years and to make a review of the literature on this topic. METHODS: Retrospective review that includes patients diagnosed with intracranial solitary fibrous tumor/hemangiopericytoma (SFT/HPC) that have undergone surgery from 1997 to 2017. It includes patients that had nuclear expression of STAT-6 (detected by immunohistochemistry) and gradeII/III histopathological diagnosis (defined by the World Health Organization in 2016). We collected demographic data, tumor characteristics, treatment and survival of these patients. RESULTS: A total of 19 patients fulfilled inclusion criteria. The median follow up was 96 months (12-230). The mortality rate was 21% (n=4). 57.9% of patients presented at least one tumor recurrence (n=11) (recurrences of 6%, 67% y 90% at 1, 5 and 10years). Five patients presented extracranial metastasis. Patients with tumors <6cm had greater survival (P<.05). CONCLUSIONS: A series of patients undergoing SFT/HPC were presented according to the new WHO criteria. Size is a predictor of survival. Currently there are no validated criteria for surgical resection in this pathology. A classification with surgical guidance would be useful.

Cervical laminoplasty with unilateral C4-5 foraminotomy: Technical note and case series. / Laminoplastia cervical con foraminotomía unilateral C4-C5: nota técnica y serie de casos.

OBJECTIVE: The open-door laminoplasty technique is widely used in the treatment of multilevel cervical myelopathy. Despite the satisfactory functional and radiological results of this technique, postoperative C5 palsy is still a severe and disabling complication with a variable incidence in the literature. The objective of this article is to describe and demonstrate the surgical technique step by step with the addition of unilateral C4-5 foraminotomy and to evaluate the results obtained to date, with special emphasis on C5 palsy. MATERIAL AND METHODS: Retrospective study of 20 patients operated on for cervical myelopathy using the "extended" laminoplasty technique, which is described step by step. RESULTS: Between January 2013 and April 2019, 20 patients were operated on using the extended laminoplasty technique. Only one patient (5%) presented postoperative C5 palsy. The postoperative recovery rate of the modified JOA (Japanese Orthopaedic Association) score was 54.5%, similar to that observed in other series. CONCLUSION: The extended cervical laminoplasty technique with unilateral C4-5 foraminotomy was developed and demonstrated for the prevention of C5 palsy. The results were analysed and an incidence of C5 palsy coinciding with the lowest percentage reported in the literature was obtained. A prospective randomised study would be useful to assess the role of preventive unilateral C4-5 foraminotomy.

Hemihypoglossal-Facial Nerve Transfer: Technical Description and Key Points: 2-Dimensional Operative Video.

Irreversible facial palsy, generally post-traumatic or postsurgical, can have devastating consequences for the patient from a functional, aesthetic, and psychological point of view. Among all of the reconstructive techniques, the hemihypoglossal-facial nerve transfer, which avoids the complete section of the hypoglossal nerve, is preferred by senior authors because of its excellent results and very low morbidity.1-5 This technique can be carried out in any neurosurgical center because it requires only basic instruments of microsurgery and a high-speed drill. However, detailed knowledge of the anatomy of the facial nerve in both its intrapetrosal and extracranial segments and of the hypoglossal nerve in its cervical segment is essential.1,6,7 Thus, previous practice in a cadaveric laboratory is recommended. The purpose of this video is to describe the technical nuances and key points of hemihypoglossal-facial nerve transfer. It was made using the surgical videos of 5 patients with a complete and irreversible facial paralysis who were operated using this technique in our institution between May and September 2019, all of whom consented to the procedure and to use for scientific purposes. The footages were edited, making a film in which the surgical technique is described in a stepwise fashion, emphasizing its most important features. To conclude, we would like to emphasize that the timing of surgery is of utmost importance and that this technique is both effective and reliable. Figures in the video at 00:54 and 01:35 are reprinted by permission from CCC: Springer Nature, Acta Neurochirurgica, Treatment of complete facial palsy in adults: comparative study between direct hemihypoglossal-facial neurorrhaphy, hemihipoglossal-facial neurorrhaphy with grafts, and massater to facial nerve transfer. Socolovsky M, Martins RS, di Masi G, Bonilla G, Siqueira M, vol 158, 945-957, copyright 2016.

[Placement of ventricle peritoneal shunt in the adult patient. A new protocol]. / Implante de shunt ventrículo peritoneal en el paciente adulto. Un nuevo protocol.

INTRODUCTION: Ventriculoperitoneal shunting is considered a relatively straightforward procedure, though it might ensure multiple complications. Our surgical team developed and implemented a new protocol since June 2016. The objective of this paper is to describe and illustrate the surgical technique step by step and to demonstrate that the use of the "new protocol" significantly reduces the complications associated with the procedure. METHODS: A retrospective descriptive study of 184 patients related with cerebrospinal fluid derivation systems from June 2014 to November 2017. One hundred and fourteen patients complied with the inclusion criteria. They were divided into two groups according to the protocol involved, previous (n = 59) and new (n = 55). The technique was described by photographic archive and surgical protocols. RESULTS: The technique consisting in seven phases was described. With the used of the new protocol the complications decreased significantly. After the new protocol, no ventriculoperitoneal shunt associated infections were observed. CONCLUSION: The technique for ventriculoperitoneal shunt consisting in seven phases was described thoroughly. This technique as well as a series of rules constitutes the new protocol. The implementation of the latter lessened the number of complications associated with the procedure. The "zero infection" rate is not a utopia.