[Partial transcondylar approach - analysis of the surgical technique in cadaver simulation]. / Dostep przezklykciowy czesciowy - analiza techniki operacyjnej na podstawie symulacji na zwlokach.

The aim of the study was to present consecutive stages of the partial transcondylar approach. Six simulations of the partial transcondylar approach were performed on non-fixed human cadavers without any known pathologies in the head and neck. The consecutive stages of the procedure were documented with photographs and diagrams. The starting point for the partial transcondylar approach is a posterior repositioning of the suboccipital segment of the vertebral artery. The approach is achieved by partial removal of the occipital condyle and lateral mass of the atlas as well as by suboccipital craniectomy. Elevation of the cerebellar hemisphere presents an important supplement of the approach. The partial transcondylar approach is a reproducible technique, which provides surgical penetration of the anterior part of the cranio-cervical junction and related regions. This approach is particularly useful in the treatment of intradural tumours localized ventrally to the medulla.

Meningiomas of the anterior portion of the craniovertebral junction: immediate and late outcome following surgical removal using a partial transcondylar approach.

BACKGROUND AND PURPOSE: The partial transcondylar approach (PTA) is an alternative to the suboccipital approach in the surgical treatment of meningiomas of the anterior portion of the craniovertebral junction (APCVJ). The purpose of this study is to present our results of treatment of these meningiomas using PTA. MATERIAL AND METHODS: Fourteen patients (11 women, 3 men) with meningioma of the APCVJ were included in the study. Neurological status of the patients was assessed before and after surgery as well as at the conclusion of the treatment. The approximate volume of the operated tumour, its relation to large blood vessels, cranial nerves and brainstem, along with its consistency and vascularisation were assessed. RESULTS: The symptom duration ranged from 1 to 36 months (median: 11 months). In 79% of patients, motor deficits of the extremities were predominant symptoms. Less frequent symptoms included headache, cervical pain and sensory deficits of cervical nerves C2 to C5. Approximate volume of the tumours ranged from 2.5 mL to 22.1 mL (mean: 11.7 mL). Gross total or subtotal resection was achieved in 86% of patients. The postoperative performance status improved in 57%, did not change in 36% and deteriorated in 7% of the patients. CONCLUSIONS: The PTA is a useful technique for removal of meningiomas expanding intradurally of the APCVJ without significant compression of the medulla. The results of treatment were good in most patients.

Mucocoele and mucopyocoele of the frontal sinus penetrating to the cranial cavity and the orbit.

BACKGROUND AND PURPOSE: Mucocoele of the paranasal sinuses falls within the scope of interest for neurosurgery when erosion of the sinus wall and the osseous structures of the skull base develops and the lesion extends towards the cranial cavity, the orbit, the cavernous sinus or the sella turcica. The pa-per aims to present the method of treatment of extensive mucocoele which is used in our clinic. MATERIAL AND METHODS: We treated 7 patients (2 women and 5 men; age range: 27-68 years). Mucopyocoele was diagnosed in two cases, and mucocoele in the other five. In 5 cases, extension of the mucocoele to the cranial cavity and the orbit or to the ethmoid sinus and the orbit was observed. In the remaining 2 cases, mucopyocoele extended to the ethmoid sinus, the sphenoid and maxillary sinuses, cranial cavity and the orbit. The purpose of surgery was to remove the mucocoele or the mucopyocoele and to prevent recurrence. RESULTS: The postoperative course in all 7 patients was uneventful. All symptoms gradually receded. No relapse was observed in any patient during a follow-up period that varied from 10 months to 8 years; nor did incidents of inflammation of collateral sinuses occur. CONCLUSIONS: The treatment of mucocoele or mucopyocoele of the frontal sinus penetrating to the cranial cavity and the orbit consists of the following stages: cranialization of the frontal sinus, complete resection of the mucosa, tight closing of the frontal-nasal duct, and separating the air space of the opened collateral nasal sinuses from the cranial cavity with a large pedicled periosteal flap.

[Approach to the jugular foramen and related structures - an analysis of the surgical technique based on cadaver simulation]. / Dostep do otworu szyjnego i jego otoczenia - analiza techniki operacyjnej w oparciu o symulacje na zwlokach.

This study presents consecutive stages of the approach to the jugular foramen and related structures. Eleven simulations of the approach were performed on non-fixed human cadavers without any known pathologies in the head and neck. The consecutive stages of the procedure were documented with photographs and schematic diagrams. The starting point for the discussed approach is removal of the mastoid and petrosal parts of the temporal bone, as well as the jugular process and the jugular tuberculum. It allows penetration of the jugular foramen from the back. Widening of the approach enables penetration of the jugular foramen from above and the front. Approach to the jugular foramen is a reproducible technique, which provides surgical penetration of this foramen and related structures. This approach is particularly useful in the surgical treatment of tumours expanding in the petrous pyramid, surroundings of the petrosal part of the internal carotid artery, cerebellopontine angle, subtemporal fossa and nervous-vascular bundle of the neck.

Early and long-term results of the treatment of jugular paragangliomas using different ranges of surgical approach.

BACKGROUND AND PURPOSE: The applied approach to the jugular foramen is a combination of the juxtacondylar approach with the subtemporal fossa approach type A. The purpose of this study is to present our results of treatment of jugular paragangliomas using the aforementioned approach. MATERIAL AND METHODS: Twenty-one patients (15 women, 6 men) with jugular paragangliomas were included in the study. The neurological status of the patients was assessed before and after surgery as well as at the conclusion of treatment. The approximate volume of the tumour, its relation to large blood vessels, cranial nerves and brainstem, as well as consistency and vascularity were also assessed. RESULTS: The duration of symptoms ranged from 3 to 74 months. In 86% of patients hearing loss was the predominant symptom. The less frequent symptoms included pulsatile tinnitus in the head, dysphagia and dizziness. Approximate volume of the tumours ranged from 2 to 109 cm3. A gross total resection was achieved in 71.5% of patients. The postoperative performance status improved in 38% of patients, did not change in 38% and deteriorated in 24% of patients. CONCLUSIONS: A proper selection of the range of the approach to jugular foramen paragangliomas based on their topography and volume reduces perioperative injury without negative consequences for the radicality of the resection.

[Extended subtemporal approach to the subtemporal fossa and related structures - analysis of the surgical technique based on cadaver simulation]. / Dostep podskroniowy rozszerzony do dolu podskroniowego i jego otoczenia - analiza techniki operacyjnej na podstawie symulacji na zwlokach.

The aim of the study was to present consecutive stages of the extended subtemporal approach (ESA). Seven simulations of ESA were performed on non-fixed human cadavers without any known pathologies in the head and neck. The consecutive stages of the procedure were documented with photographs and schemes. The starting point for ESA is osteotomy of the zygomatic arch and craniectomy including the greater wing of the sphenoid bone. Dislocation or removal of subtemporal fossa contents allows one to penetrate its inside and related structures. Additional widening of inspection allows osteotomy of the condyloid process of the mandible. ESA is a reproducible technique which provides surgical penetration of the subtemporal fossa and related structures. This approach is particularly useful in the surgical treatment of tumours expanding in the orbit, maxillary sinus, pterygopalatine fossa, nasopharynx, sphenoid sinus, cavernous sinus, parapharyngeal space, retromandibular fossa and surroundings of the petrosal part of the internal carotid artery.

[Fronto-temporo-orbito-zygomatic approach - analysis of the surgical technique on cadaver simulations]. / Dostep czolowo-skroniowo-oczodolowo-jarzmowy - analiza techniki operacyjnej na podstawie symulacji na zwlokach.

This paper presents consecutive stages of the fronto-temporo-orbito-zygomatic approach (FTOZA). Two simulations of FTOZA were performed on non-fixed human cadavers without any known pathologies in the head and neck. The consecutive stages of the procedure were documented with photographs and schematic diagrams. The starting point for FTOZA is a pterional craniotomy and osteotomy including the orbital rim, body of the zygomatic bone and zygomatic arch. In justified cases it is also possible to temporarily remove the upper and lateral walls of the orbit. Wide drawing apart of the Sylvian fissure is an important supplement of the approach. The fronto-temporo-orbito-zygomatic approach is a reproducible technique, which provides surgical penetration of the middle cranial fossa and related regions. This approach is particularly useful in the treatment of tumours of the above-mentioned anatomical areas as well as vascular malformation of the posterior part of the arterial circle of the brain.

Direct and remote outcome after treatment of tumours involving the subtemporal fossa and related structures with the extended subtemporal approach.

BACKGROUND AND PURPOSE: The aim of the study was to present our results of the surgical treatment of subtemporal fossa tumours and surrounding regions using the extended subtemporal approach. MATERIAL AND METHODS: Twenty-five patients (10 women, 15 men) with subtemporal fossa tumours were included in the study. The neurological and performance status of the patients were assessed before and after surgery as well as at the conclu-sion of treatment. The approximate volume of the operated tumour, its relation to large blood vessels and cranial nerves, as well as consistency and vascularisation were assessed. RESULTS: The symptom duration ranged from 2 to 80 months (mean: 14 months). In 44% of patients, headache was the predominant symptom. Less frequent symptoms were: paralysis of the abducent nerve and disturbances of the trigeminal nerve. Approximate volume of the tumours ranged from 13 to 169 cm3 (mean: 66 cm3). The most frequent histological diagnosis was meningioma (16%), followed by angiofibroma, neurinoma and adenocystic carcinoma (12%). Total or subtotal resection was achieved in 80% of patients. CONCLUSIONS: The extended subtemporal approach allows for the removal of tumours of the subtemporal fossa and surrounding regions. This approach also allows one to remove tumours expanding in the regions surrounding the subtemporal fossa only. In such cases the subtemporal fossa constitutes the way of the surgical approach.

[Extended subfrontal approach to the central cranial base - analysis of the surgical technique in cadaver simulation]. / Dostep podczolowy rozszerzony do centralnej czesci podstawy czaszki - analiza techniki operacyjnej w oparciu o symulacje na zwlokach.

The aim of the study was to present consecutive stages of the extended subfrontal approach (ESA). Eight simulations of ESA were performed on non-fixed human cadavers without any known pathologies in the head and neck. The consecutive stages of the procedure were documented with photographs and schematic diagrams. The starting point for ESA is a bifrontal craniotomy and osteotomy including the base of the nose and superior parts of the orbits. If the anterior cranial base is not invaded by the tumour, an attempt to partially preserve olfaction is possible. Wound closure after removal of the tumour with ESA requires reconstruction of the tissue barrier between the cranial cavity, paranasal sinuses and nasopharynx. The extended subfrontal approach is a reproducible technique which provides surgical penetration of the central skull base. This approach is particularly useful in the surgical treatment of tumours expanding along the midline, superiorly and inferiorly to the skull base.

Direct and remote outcome after treatment of tumours involving the central skull base with the extended subfrontal approach.

BACKGROUND AND PURPOSE: To present our results of the surgical treatment of central skull base tumours using the extended subfrontal approach (ESA). MATERIAL AND METHODS: Twenty-six patients (8 women, 18 men) with central skull base tumours were included in the study. The neurological and performance status of the patients was assessed before and after surgery as well as at the conclusion of treatment. The approximate volume of the operated tumour, its relation to the large blood vessels, cranial nerves and brainstem, as well as consistency and vascularisation were assessed. RESULTS: The symptom duration ranged from 1.5 to 18 months (mean: 8.3 months). Loss of olfaction was the predominant symptom in 38% of patients. Less frequent symptoms were: paresis/paralysis of the 6th cranial nerve, psychoorganic syndrome, impaired visual acuity, nasal obstruction and headache. Approximate volume of the tumours ranged from 10 to 105 ml (mean: 54.3). The most frequent histological diagnosis was chordoma (19%), meningioma (15%), followed by haemangiopericytoma, fibroma and esthesioneuroblastoma (12%). Total or subtotal resection was achieved in 77% of patients. The postoperative performance status was improved in 39%, unchanged in 27% and impaired in 15% of patients. Five patients died after the surgery. CONCLUSIONS: Extended subfrontal approach is a useful technique for removal of benign tumours expanding along the midline, superiorly and inferiorly to the skull base. For removal of malignant tumours at the same location, ESA is an alternative to a combination of transcranial approach and one of the craniofacial approaches.

[Lateral approach to the cavernous sinus and its surroundings--analysis of surgical technique based on cadaver simulations]. / Dostep boczny do zatoki jamistej i jej otoczenia--analiza techniki operacyjnej w oparciu o symulacje na zwlokach.

BACKGROUND AND PURPOSE: The paper aims to present individual stages of a surgical approach to the cavernous sinus (CS) and its surroundings. MATERIAL AND METHODS: Twelve simulations of a surgical approach to the CS and its surroundings were performed in non-fixed cadavers. The subsequent stages of simulation were recorded in photographs and drawings. RESULTS: The starting point for the approach to the CS is a pterional craniotomy, as well as an osteotomy encompassing the anterior clinoid process and the surroundings of the superior orbital fissure, the optic canal, the foramen rotundum and the foramen ovale. The important phases of the approach include the delamination of the lateral CS wall and the mobilization of the dural rings of the internal carotid artery. Opening of the CS should be preceded with establishing proximal and distal control over the internal carotid artery. CONCLUSIONS: The surgical approach to the CS and its surroundings constitutes a repeatable method of penetration in this area of the cranial base, and it allows for limiting brain traction and preserving the anatomical integrity of the related vessel and nerve structures.

Direct and remote outcome after treatment of tumours involving the cavernous sinus and its surroundings.

BACKGROUND AND PURPOSE: The aim of this study was to present results obtained by the authors after surgical treatment of tumours involving the cavernous sinus (CS) and its surroundings. MATERIAL AND METHODS: Thirty-eight patients (23 females and 15 males) with tumours of the CS and its surroundings were included in the study. The neurological condition of patients and their ability to perform activities of daily living were evaluated prior to treatment, postoperatively and after completion of therapy. The following parameters were measured: approximate volume of the operated lesions; their relation to larger vessels, cranial nerves and the brainstem; consistency and vascularization. RESULTS: The medical history of the disease ranged from 1.5 to 48 months, mean 12 months. In 89.5% of cases impaired ocular motility on the side of the lesion was the symptom indicative of the condition. The second most common group of symptoms (29%) included impairments of trigeminal nerve function. The approximate volume of all resected tumours ranged from 0.6 to 60 mL (mean 12.2 mL). In 50% of cases the resected tumours were diagnosed as meningiomas. The remaining entities included: perithelioma, hypophyseal adenoma, adenoid cystic carcinoma, neuroendocrine carcinoma, trigeminal neurinoma, chordoma, cavernous angioma and lymphoma. In 63% resections were complete. Functional capacity of patients improved in 34% of cases, remained unchanged in 53%, deteriorated in 10.5%, and one patient died. CONCLUSIONS: Surgical intervention involving the CS and its surroundings enables resection of neoplastic tumours of this anatomical region with satisfactory clinical results and low mortality. Most patients suffer from temporary paresis or paralysis of the oculomotor, trochlear and abducent nerves. Reduction of completeness of resections of CS tumours decreases the number of postoperative neurological deficits without a significant increase in the rate of lesion regrowth.

[Operative treatment of the intramedullary tumors with the methylprednisolone usage--preliminary report]. / Leczenie operacyjne guzôw srodrdzeniowych z zastosowaniem methylprednizolonu - doniesienie wstepne.

UNLABELLED: The aim of the study was to assess the intermediate results of the intramedullary tumors treatment with neuroprotection including the methyvlprednisolone (MP) usage. MATERIAL AND METHOD: In the 1995-2003 period 33 patients with intramedullary tumors were operated on in Department of Neurosurgery in Sosnowiec. They were 10 females and 23 males in the age range of 11-61 years. Neuroprotection of the spinal cord in the course of treatment included: determining operational tactics on the basis of magnetic resonance imaging (MRI) performed in three planes, using MP according to NASCIS II and in maintenance dose in the 2-7 day after the operation, SSEP monitoring, myelotomy in the form of anatomical preparation of the posterior longitudinal fissure, sparing big transverse branches of the vasocorona of the posterior column, debulking of the tumor with an ultrasonic aspirator or CO2 laser, closure of the spinal cord after the removal of the tumor with pial sutures and sutures of the arachnoidea. RESULTS: Among the operated tumors 16 had a clear border, the remaining ones were 14 astrocytomas of varying malignancy and infiltration of the white matter of the spinal cord and 3 lipomas. Control MRI revealed a total removal of the lesion in 23 patients (70%), gross total removal in 7 patients (21%) partial removal in three patients (9%). The postoperative condition of the patients 2-3 weeks after the operation showed improvement in 12 cases (37%), no significant changes in 10 cases (30%) and deterioration in 11 cases (33%). CONCLUSION: Appropriate operative tactics together with the use of the MP make the acceptable morbidity rate after radical removal of intramedullary tumors .

Variability of the division of the cortical branches of the posterior cerebral artery.

This article presents a method of analysis of variation in the cortical branching of the posterior cerebral artery (PCA). The method takes account of previous observations and reflects various symptoms of such variation. Of 100 cerebral hemispheres into whose vessels a contrast medium was injected, 94 hemispheres have been qualified for further examination. In six hemispheres, there were anomalies of the PCA, which are not included in the present analysis of division. A general model of the division of the artery has been developed. On the basis of this model, principles of the analysis of the variation have been discussed. The model comprises of three elements. The first is the main trunk. The second is intermediate trunks. The third element may appear in two forms: proper cortical arteries and cortical arterial groups. The main trunk was defined as the vessels arising from the final division of the basilar artery with its end in the place of branching of the most peripheral proper cortical artery, that is, parieto-occipital artery. Intermediate trunks are these parts of the PCA that extend between the main trunk and proper cortical arteries or cortical arterial groups. The identification criterion for the intermediate trunks is its length, which is to be equal to or exceed the sum of the radius of the two vessels, which the intermediate trunk gives off. There have been distinguished primary and secondary intermediate trunks. Proper cortical arteries or cortical arterial groups are parts of the PCA by means of which blood is supplied directly to the cortex. Cortical branches of the PCA of a relatively constant topography and vascularization were termed proper cortical arteries. In some cases, cortical branches are accompanied by small vessels of varying number and size. They were named accessory cortical arteries. Proper cortical arteries together with accompanying accessory cortical arteries have been named cortical arterial groups. The number of the proper cortical arteries is considered to be constant and is six. The theory of combinations has been applied to establish all possible branching variants. There are 16 such variants. Eleven of them (68%) were represented in the analyzed material. In seven hemispheres (7.4%), intermediate trunks were not observed. In 87 hemispheres (92.6%), there were present primary intermediate trunks. In four hemispheres (4.2%), there were found primary and secondary intermediate trunks. Both proper cortical arteries and cortical arterial groups reached the first five cortical areas of the PCA. The last cortical area was reached by a cortical arterial group only.

[Occipitocervical fixation in the surgical treatment of pathologies of the craniovertebral junction]. / Stabilizacja szyjno-potyliczna w chirurgicznym leczeniu patologii pogranicza czaszkowo-kregoslupowego.

BACKGROUND AND PURPOSE: New surgical approaches to the tumors of the skull base necessitate removal of certain bone structures of the base. In the case of the transcondylar far-lateral approach, the whole occipital condyle and lateral mass of C1 are removed resulting in iatrogenic instability. Consequently, an occipitocervical fixation is needed. The aim of the study was to assess the usefulness of the CCD cervical system for the occipitocervical fixation in the surgery of the tumors of the craniovertebral junction. MATERIAL AND METHODS: The authors present the application of the CCD cervical system produced by Medtronic Sofamor-Danek in three patients who underwent surgery of tumors of the foramen magnum, clivus or craniovertebral junction. The system consists of two titanium rods, which adjusted to the curvature of the spine and the occiput, are fixed by laminar cervical and occipital hooks, fixed to the trepanation hole edge or the edge of the foramen magnum. It is also possible to use screws driven to the occipital bone if it is more than 7 mm thick. RESULTS: The system fixation is simple and relatively short. Good stabilization was achieved in all patients. No complications caused by the implants have been observed. CONCLUSIONS: The CCD cervical system can be successfully used for the occipitocervical fixation in a lateral transcondylar approach and in the cases of other non-traumatic craniocervical instability. It is especially recommended in cases of unusual thinning of the occipital bone or in osteoporotic states.

[Spontaneous spinal cord herniation: a rare cause of the Brown-Sequard syndrome]. / Samoistna przepuklina rdzenia kregowego -- rzadka przyczyna zespolu Brown-Sequarda.

Recent reports have shown that spontaneous spinal cord herniation in the thoracic segment of the spine may be one of the causes of the progressive spinal cord lesion. Although it was described for the first time by Wortzman in 1974, it was only in early 1990s that a growing number of publications on single cases of the condition started to be observed. In the relevant literature collected by us we found reports on 53 patients altogether. In a number of cases herniation was diagnosed only intraoperatively in spite of complex radiological diagnostics. The analysis of relevant literature shows that spontaneous or idiopathic spinal cord herniation has a very typical clinical picture and most cases share a number of features, such as the clinical condition, age and sex of the patient as well as the level and location of the entity and its radiological picture. We conclude that spontaneous herniation of the spinal cord may be not as rare as previously thought and that it should be always taken into account in differential diagnostics of progressive myelopathy in the thoracic segment in middle-aged patients, especially females.

[Results of the operative treatment of intramedullary gliomas]. / Wyniki leczenia operacyjnego glejaków sródrdzeniowych.

BACKGROUND AND PURPOSE: To assess the results of the operative treatment of intramedullary gliomas. MATERIAL AND METHODS: In 1995-2002, 30 patients with intramedullary tumors were treated surgically in the Department of Neurosurgery in Sosnowiec. Among them 23 intramedullary gliomas were recognized. There were 8 females and 15 males aged from 11 to 61. The condition of the patients before the operation was assessed according to a modified McCormick's scale. Only two patients were found to be in a good condition -- I degree, 17 patients (74%) -- II degree or III degree and 4 patients were in a serious condition -- IV degree. Among the operated tumors only 9 had a clear border. There were 5 ependymomas (grade I) and 4 anaplastic ependymomas (grade III). The remaining ones were astrocytomas of varying malignancy and infiltration of the white matter of the spinal cord: 8 cases of fibrillary astrocytoma, 3 cases of gemistocytic astrocytoma, but one anaplastic and one case of pilocytic astrocytoma, oligoastrocytoma mixtum and anaplastic oligoastrocytoma. RESULTS: Control MRI revealed a total removal of the lesion in 16 patients (70%), gross total removal in 5 patients (21%), partial removal in two patients (8%). Four patients died among those operated on: two in the perioperative period, the other two 9 months and 2 years after the surgery, respectively. In four patients there was observed regrowth of the lesion and one patient was re-operated on. In the second case fatal recurrence in region C2-Th6 was observed and the patient died, in the last two cases the patients were stable and thus it was decided to delay the re-operation. CONCLUSION: Low mortality, morbidity and recurrence rates recommend surgery as an effective treatment for intramedullary gliomas.

[An attempt to use Gore-Tex surgical membrane in lumbar disc surgery]. / Próba zastosowania blony przeciwzrostowej Gore-Tex w operacjach dyskopatii ledzwiowych.

BACKGROUND: Peridural fibrosis developing after lumbar discectomy may be responsible for as much as 20% of all Failed Back Surgery Syndrome. A variety of biological and non-biological materials have been used as a barrier to invasion of fibrous tissue into the vertebral canal. AIM: The purpose of this study was to evaluate the use of expanded polytetrafluoroethylene (ePTFE) surgical membrane (Gore-Tex membrane) to inhibit peridural fibrosis and reduce FBSS symptoms after lumbar discectomy. MATERIAL AND METHODS: In a prospective study we compared postoperative results in 20 patients who had an ePTFE membrane implanted during lumbar discectomy with the results in 20 patients in whom no material was implanted. The outcomes were evaluated using a questionnaire on activities of daily living according to the Low Back Outcome Score, pain grading scale -- Visual Analog Scale, assessment of Lasegue sign and MRI 18-24 months after the operation for all patients. RESULTS: The authors found no evident positive clinical and radiological effects of using ePTFE surgical membrane during lumbar discectomy. CONCLUSIONS: 1. It is impossible to prove that ePTFE membrane used during lumbar discectomy essentially prevents postoperative peridural scar formation. 2. The use of ePTFE membrane does not improve the outcome of the surgical treatment of lumbar disc herniation.

Intracranial subdural hematoma and pneumocephalus after spinal instrumentation of myelodysplastic scoliosis.

To report a case of acute intracranial subdural hematoma, pneumocephalus, and pneumorachis, which occurred because of cerebrospinal fluid (CSF) leak caused by a malpositioned transpedicular screw during spinal surgery for severe myelodysplastic scoliosis accompanied with hydrocephalus. Intracranial hemorrhage may occur as a consequence of dural sac penetration and CSF leakage after various medical procedures at the spinal level. The awareness of this severe complication is especially important during spinal instrumentation procedures in which inadvertent dural sac violation and CSF loss may be overlooked. A case report and literature review are presented here. A 12-year-old girl with a history of myelomeningocele and hydrocephalus underwent instrumentation for severe myelodysplastic scoliosis. Postoperatively, she became aphasic and increasingly somnolent. An urgent computed tomographic scan of the head and spine showed massive intracranial hematoma, pneumocephalus, pneumorachis, and a malpositioned pedicular screw that caused CSF leakage, intracranial hypotension, and bleeding remote from the surgical site. The patient needed neurosurgical cranial decompression and subsequent spinal reoperation with dural tear repair. The final outcome was an uneventful complete recovery. The increasing use of pedicular screws in spinal surgery carries a potential risk of occult dural sac violation with subsequent CSF leakage, intracranial hypotension, and the possibility of intracranial bleeding and pneumocephalus remote from the surgical site. This potentially fatal complication should always be considered after spinal surgery in the presence of early signs of neurological deterioration and necessitates an urgent cranial and spinal imaging to confirm the diagnosis and to make adequate treatment decisions.