Does recurrent laryngeal nerve anatomy condition the choice of the side for approaching the anterior cervical spine?

AIM: The anterior cervical presternocleidomastoid approach is a safe and standardized procedure. Nevertheless, in all the largest series presented in literature, a certain risk of injury to the recurrent laryngeal nerves (RLNs) is reported and the choice of the side of the approach seems to influence such risk. Our aim was to study the surgical anatomy of the RLNs and to understand whether the side of the approach can be a risk factor for their surgical damage. METHODS: We performed an anatomical dissection of 6 fresh cadavers, studying the origin and the course of both the RLNs, to assess their vulnerability in the anterior presternocleidomastoid approach to the cervical spine. RESULTS: The origin of the right RLN was at C7 in 2 cases and at T1 in 4 cases. In all cases it arose where vagus nerve crossed the subclavian artery and it was directed superiorly and transversely to the esophagotracheal groove. CONCLUSIONS: The right and left RLNs have different origin and course. Although the discussion about the best side for the anterior cervical approach is debated, in our opinion, both anatomical and surgical considerations, concerning RLNs, lead to the evidences that the left side approach, when possible, should be preferred below the level of C4.

Ghost lesions in patient with cerebral-isolated neurosarcoidosis. A case report.

We present a case of isolated cerebral neurosarcoidosis with remitting nodular lesions resembling intraventricular neoplasms. The patient, admitted at our Department for surgical treatment of a magnetic resonance imaging (MRI) demonstrated fourth ventricle lesion, presented acute intracranial hypertension. A second MRI performed before the scheduled operation showed the disappearance of the fourth ventricle lesion and a tetra-ventricular hydrocephalus. The patient has been treated with a third-ventriculostomy, followed, after 15 days, by ventriculoperitoneal shunt. High doses of steroids have been administered. Cerebrospinal fluid analysis has been conducted and a high concentration of ACE, specific marker of neurosarcoidosis, has been found. No biopsy was performed to avoid surgical complications. A systemic chemotherapy with azathioprine has been started, but the patient died six months later for worsening of the clinical conditions. The autopsy confirmed the diagnosis of neurosarcoidosis. This is the first MRI documented case of neurosarcoidosis with remitting lesions. Diagnosis of isolated neurosarcoidosis is difficult and it is based on clinical and radiological exclusion of other entities. CSF examination is useful for diagnosis, for the reported specificity and sensibility of ACE. Medical treatment is based on corticosteroids and chemotherapic agents. Neurosurgical intervention can be related to treat hydrocephalus due to ependymal and arachnoidal involvement or to remove large lesions. In our opinion biopsy should be limited only to ACE negative patients and to those who do not respond to chemotherapy.

Surgical approaches to the cervico-thoracic junction.

The cervico-thoracic junction (CTJ) extends between the 7th cervical and the 4th thoracic vertebrae and comprehends the inferior portion of the brachial plexus and the parenchymatous, vascular and nervous structures of the upper mediastinum. The posterior surgical approaches, as the laminectomy or the arthro-pediclectomy, fail to expose the anterior spinal elements. Thus, further surgical approaches have been proposed: postero-lateral, antero-lateral (thoracotomies) and purely anterior. The aim of this study was to discuss indications, key anatomical landmarks and risks of the main surgical approaches to the CTJ. Ten fresh cadavers from the Anatomical Laboratory of the University of Nantes (France) were used for the surgical dissection of the CTJ. The postero-lateral and the antero-lateral approaches were performed in 4 cadavers each and the anterior approaches were studied in 2. The postero-lateral extrapleural approach (PLEA) permits an excellent antero-lateral exposure of the T2-T4 segment, preserving the parascapular musculature integrity. The thoracotomies allow the exposure of the antero-lateral portion of the junctional vertebrae, with the limits of the intrapleural approaches. The anterior approaches, including the presternocleidomastoid cervicotomy eventually associated to the sterno-claviculotomy, expose the anterior portion of the cervical and the upper thoracic vertebrae up to T4. We believe that the PLEA performs the greater surgical exposure with minimal risk of vasculo-nervous damage. Among the anterior approaches, the simple cervicotomy is the most indicated procedure in case of patients with certain anatomical conditions.

Radiation-induced schwannomas of the nervous system. Report of five cases and review of the literature.

Radiation therapy has important delayed effects on the central nervous system. Prominent among these effects is radiation necrosis of nervous tissue, but an oncogenic effect is also recognized. Both benign and malignant intracranial tumors can develop in irradiated fields, particularly in children. Most of these tumors are sarcomas, meningiomas or gliomas and only occasionally schwannomas. We report 5 cases of postirradiation acoustic nerve schwannoma observed in our Department.

Ethylene oxide sterilization of autologous bone flaps following decompressive craniectomy.

INTRODUCTION: In patients undergoing decompressive craniectomy, the bone flap is temporarily preserved either in the subcutaneous tissue of the patient or frozen. However, there are some drawbacks related to these methods. MATERIAL AND METHODS: In 16 patients in whom the bone flap was removed for decompressive craniectomy, the bone was firstly washed in hydrogen peroxide and then placed in hermetically-sealed bags and sterilized using ethylene oxide. The bone was repositioned after an average period of 4.3 months. RESULTS: One patient sustained an infection of the surgical wound which required permanent exclusion of the bone flap. In all the others, esthetic and functional results were good after an average follow-up of 20 months. Control CT-scan of the bone flap demonstrated preservation of its structural features with fusion of the bone margins and revitalization of the flap. On MRI a subdural space was again visible. CONCLUSIONS: Sterilization of the bone flap with ethylene oxide in patients undergoing decompressive craniectomy avoids some of the drawbacks related to the techniques currently used. The easiness, low cost, good aesthetic and functional results of this procedure make it a valid alternative to other techniques for preservation of autologous bone in decompressive craniectomies.

Progressive quadriparesis in adolescent with stenosis of the cervical spine.

INTRODUCTION: Progressive quadriparesis in adolescents suffering from cervical stenosis is a very rare entity. Only three cases have been reported in the literature. CASE REPORT: We report our own case of progressive quadriparesis in a young patient suffering from cervical stenosis, the first to be documented with pre- and postoperative magnetic resonance imaging.

Surgical approaches to tumours of the lateral ventricles in the dominant hemisphere.

BACKGROUND: Intraventricular neoplasms are rare tumours (1% of the tumours of the central nervous system). The surgical approach sometimes is quite difficult, particularly in the dominant hemisphere. The best choice of surgical approach is discussed. METHODS: The authors describe a series of 25 patients who underwent surgical treatment for tumours situated in the lateral ventricles of the dominant hemisphere. They discuss the most influential factors in the choice of surgical approach, which must allow maximum exposure of the lesion and vascular feeding branches without damaging highly functional areas (motor, visual and language areas). In particular, they report their experience using a low transtemporal route, between the middle and inferior gyri, for removing tumours localized in the temporal horn and/or trigone which made it possible to keep postoperative visual and phasic deficits to a minimum. RESULTS: In 5 patients the approach was transfrontal, in 10 temporal, in 6 superior parieto-occipital and in 4 transcallosal. Three patients died. Only 5 patients presented permanent deficits (anomia, apraxia and visual fields alterations). CONCLUSIONS: The size, site, hemisphere and vascularization of intraventricular tumours influence the choice of surgical approach. The basal transtemporal approach is particularly indicated to remove tumours of the temporal horn and trigone and it seems to reduce the risk of speech disturbances and alterations of posture.

Intraparenchymal haemorrhage after evacuation of chronic subdural haematoma. Report of three cases and review of the literature.

Three cases of intracerebral haemorrhage following removal of a chronic subdural haematoma are reported and the literature on this topic reviewed. The possibility of an increase in cerebral blood flow following removal of CSH, makes slow, gradual decompression mandatory in all patients submitted to cranial trapanation.