General Neurosurgeons Research Articles

Prevalence of cervical myelomalacia in adult patients requiring a cervical magnetic resonance imaging.

A retrospective study. To determine the prevalence of cervical myelomalacia in patients requiring cervical magnetic resonance imaging. The presence of myelomalacia in the cervical spinal cord in has prognostic value after decompression surgery. Some surgeons consider operative treatment of all patients with myelomalacia based on the assumption that myelomalacia is a relatively uncommon finding. However, the prevalence of cervical myelomalacia in symptomatic patients has not been fully established. The sentences containing the key word "myelomalacia" were extracted from a large database of cervical magnetic resonance imaging reports and manually reviewed by an experienced neuroradiologist to determine whether the interpreting radiologists thought there was myelomalacia in the cervical spinal cord. The prevalence of myelomalacia was calculated for different age and sex groups, as well as for the medical specialties/subspecialties of the referring providers. A total of 964 of 23,139 patients who underwent magnetic resonance imaging findings consistent with cervical myelomalacia. The overall prevalence of myelomalacia in this population was 4.2%; 5.6% in males and 3.0% in females. The rates increased linearly with age until the eighth decade when it reached 7.6% overall, 9.2% for males and 6.2% for females, but dropped to 5.1% for patients older than 80. There were considerable variations in the prevalence of myelomalacia in patients referred by different specialties/subspecialties. Specialists in spinal cord injury had the highest rate (28.7%), followed by neurological (8.4%) and orthopedic (6.4%) spine surgeons, general neurosurgeons (5.5%), and neurologists (4.2%). Specialists who generally do not treat patients with spine problems had the lowest (1.2%) followed by nonspine orthopedists (1.6%) and primary care doctors (2.1%). The overall prevalence of cervical myelomalacia was relatively low in the studied population, and it was affected by age, sex, and the specialties/subspecialties of referring providers. These results may help direct treatment guidelines and allow for informed discussions with patients in terms of the risk versus the benefit of surgery. 1.

Treatment by specialist surgical neurooncologists improves survival times for patients with malignant glioma.

Surgeries for CNS tumors are frequently performed by general neurosurgeons and by those who specialize in surgical neurooncology. Subspecialization in neurosurgical practice has become common and may improve patient morbidity and mortality rates. However, the potential benefits for patients of having their surgeries performed by surgical neurooncologists remain unclear. Recently, a shift in patient care to those who practice predominantly surgical neurooncology has been promoted. Evidence for this practice is lacking and therefore requires fundamental investigation. The authors conducted a case-control study of neurooncology patients who underwent surgery for glioblastoma and anaplastic astrocytoma during 2006-2009. Outcomes were compared for patients whose surgery was performed by general neurosurgeons (generalists) or by specialist neurooncology neurosurgeons (specialists). An electronic record database and a picture archiving and communication system were used to collect data and assess the extent of tumor resection. Mortality rates and survival times were compared. Patient comorbidity and postoperative morbidity were assessed by using the Waterlow, patient handling, and falls risk assessment scores. Effects of case mix were adjusted for by using Cox regression and a hazards model. Outcomes for 135 patients (65 treated by generalists and 70 by specialists) were analyzed. Survival times were longer for patients whose surgery was performed by specialists (p=0.026) and after correction for case mix (p=0.019). Extent of tumor resection was greater when performed by specialists (p=0.005) and correlated with increased survival times (p=0.004). There was a trend toward reduced surgical deaths when surgery was performed by specialists (2.8%) versus generalists (7%) (p=0.102), and inpatient stays were significantly shorter when surgery was performed by specialists (p=0.008). The prognosis for glioblastoma multiforme remains dire, and improved treatments are urgently needed. This study provides evidence for a survival benefit when surgery is performed by specialist neurooncology neurosurgeons. The benefit might be attributable to increased tumor resection. Furthermore, specialist neurooncology surgical care may reduce the number of surgical patient deaths and length of inpatient stay. These findings support the recommendations for subspecialization within surgical neurooncology and advocate for care of these patients by specialists.

Alternatives to surgical tracheostomy: A critical review

Surgical tracheostomy (ST) is the oldest life-saving procedure in records, usually done by otolaryngologists and occasionally by general surgeons, thoracic surgeons, and neurosurgeons. It has been an important surgical skill for any given otolaryngology training program. On the contrary, retromolar, submental, submandibular endotracheal intubations, and their modifications are carried out by oral surgeons, maxillofacial surgeons, skull base surgeons, and plastic surgeons and are considered alternative to ST. Despite none are done in an emergency situation, it is suggested to be less invasive, simple, safe, with less surgical time, nearly unknown complications, has unsightly scar and cheaper in comparison to ST. It is thought that these techniques provide free surgical access in cases where oral and nasal intubations are often not suitable and require intermittent intraoperative dental occlusion to check alignment of fractured fragments. In the current report, PubMed has been reviewed for the reasons, indications, complications, techniques, and modifications of the above mentioned ST alternatives. The article critically discusses the surgical part of these innovative procedures and concludes that ST, in spite of its risks, remains the procedure of choice for surgical airway access when long-term intubation is not anticipated, especially in emergencies and difficult airways. A regular workshop of this highly in demand surgical skill is suggested.

Part I: The Application of the h-Index to Groups of Individuals and Departments in Academic Neurosurgery

The h-index was introduced as a means of quantifying the contribution a researcher makes to the scientific literature. We evaluated the h-index for academic neurosurgeons to assess the various methods of calculation and to determine whether the h-index can be used to differentiate groups of individuals by various classifications. The h-index was calculated for all neurosurgeons from 10 institutions ranked highly by 2012 U.S. News & World Report plus the authors' institution via Scopus. The h-index also was calculated manually to evaluate its accuracy. The average h-index was calculated for groups on the basis of sex, academic rank, years in practice, institution, and subspecialty. Cumulative and mean h-indices were calculated for each department. The median h-index for the 188 neurosurgeons was 16 (mean, 19.71; range, 0-61). There was a positive association between the h-index, academic rank, and years posttraining. There was a significant difference between the "manually calculated" and automated h-indices, particularly for more senior physicians. The difference in h-index between men and women was not statistically significant. Among subspecialties, vascular surgeons had the greatest average h-index and general neurosurgeons had the lowest. There were significant shifts in departmental rankings when the cumulative or mean departmental indices were compared with the U.S. News & World Report rankings. Application of the h-index as a bibliometric in neurosurgery can distinguish academic productivity on the basis of academic rank, years posttraining, and neurosurgical subspecialties. The application of the h-index to compare departments is problematic and, at this time, not reliable.

Editorial: Maintaining journal independence

The membership of the American Association of Neurological Surgeons (AANS) should be aware of a disagreement between myself and the AANS Executive Committee. In my view, the matter is straightforward and should not be controversial. The Editorial Board is the ruling body of the Journal of Neurosurgery and each Editor since 1944 has served at their pleasure. I had anticipated that the Editorial Board could feasibly elect a new Editor at the April meeting of the AANS. To this end, a search committee carefully identified four candidates (a pediatric neurosurgeon, spine surgeon, and two general neurosurgeons) and these candidates subsequently visited the Journal offices in Charlottesville. Each candidate has proposed detailed but quite different plans for the future direction and administration of the Journals. They and their proposals will be presented to the 32 member Editorial Board of the Journals at the annual afternoon Journals’ meeting at the AANS. At this two and one half hour meeting, the Editorial Board will listen to the presentations, ask questions, and discuss who should be elected the next Editor. I felt that this was insufficient time for the Board members to carefully consider each candidate’s interview and to evaluate these very different proposals for the future of the Journals. I also thought that forcing a vote at the April meeting would likely result in factions, not consensus. Although the candidates and their proposals should be presented at the Editorial Board Meeting, I suggested that putting off the final vote until June 8 at the Senior Society meeting would give our Advisory Board and our Editorial Board time to thoughtfully assess the interviews, to review the proposals, and to reach a wellreasoned and measured consensus regarding the future of the Journals. It is not possible to do this in one afternoon. After I made this recommendation, I received from the Executive Committee a reply which flatly rejected my effort to afford the Editorial Board a few weeks to reach consensus on the new Editor in Chief (EIC). Instead, the Executive Committee asserted that if the Editorial Board fails to elect a new EIC and submit that individual’s name to the AANS by May 1, the Executive Committee will, on May 2, unilaterally terminate the current EIC, assume the role of EIC, assume control of all operations of the JNS offices in Charlottesville, and dictate the process of selecting the next EIC. Specifically, the Executive Committee asserts that it will send a letter to all members of the Editorial Board on May 2 for a vote, and declare the candidate with the largest number of votes to immediately assume the role of EIC, apparently regardless of whether that candidate receives less than majority approval and regardless of the response rate from this mailing. The scholarly and executive independence of the Journal has often been challenged in the past but always without success. This attempt by the AANS to take on the role held by the Journals’ Board members, those most familiar with the Journals and the neurosurgical literature, represents a sea change for JNS publishing. This assertion of control endangers the future well-being of the journals, compromises the independence of the Editorial Board, improperly assumes that the Executive Committee has authority to terminate, without cause, the duly elected EIC and fundamentally denies the Editorial Board the opportunity to reach consensus on the future leadership of the Journals of Neurosurgery. If the AANS Executive Committee forces a vote at the meeting or takes over the Journals of Neurosurgery Board’s responsibilities—neither action being justified— every subsequent Editor will be beholden to the AANS Executive Committee, the critical importance of independence will be lost. The Journal will become the political voice of the AANS not the scholarly voice of the world neurosurgical community. (http://thejns.org/doi/abs/10.3171/2013.3.JNS13610)

Variation in Specialists' Reported Hospitalization Practices of Children Sustaining Blunt Head Trauma

IntroductionQuestions surround the appropriate emergency department (ED) disposition of children who have sustained blunt head trauma (BHT). Our objective was to identify physician disposition preferences of children with blunt head trauma (BHT) and varying computed tomography (CT) findings.Methods:We surveyed pediatric and general emergency physicians (EP), pediatric neurosurgeons (PNSurg), general neurosurgeons (GNSurg), pediatric surgeons (PSurg) and trauma surgeons regarding care of two hypothetical patients: Case 1: a 9-year-old who fell 10 feet and Case 2: an 11-month-old who fell 5 feet. We presented various CT findings and asked physicians about disposition preferences. We evaluated predictors of patient discharge using multivariable regression analysis adjusting for hospital and ED characteristics and clinician experience. Pediatric EPs served as the reference group.Results:Of 2,341 eligible surveyed, 715 (31%) responded. Most would discharge children with linear skull fractures (Case 1, 71%; Case 2, 62%). Neurosurgeons were more likely to discharge children with small subarachnoid hemorrhages (Case 1 PNSurg OR 6.87, 95% CI 3.60, 13.10; GNSurg OR 6.54, 95% CI 2.38, 17.98; Case 2 PNSurg OR 5.38, 95% CI 2.64, 10.99; GNSurg OR 6.07, 95% CI 2.08, 17.76). PSurg were least likely to discharge children with any CT finding, even linear skull fractures (Case 1 OR 0.14, 95% CI 0.08, 0.23; Case 2 OR 0.18, 95% CI 0.11, 0.30). Few respondents (<6%) would discharge children with small intraventricular, subdural, or epidural bleeds.Conclusion:Substantial variation exists between specialties in reported hospitalization practices of neurologically-normal children with BHT and traumatic CT findings.

1285 – Training of bosnia-herzegovina mental health professionals in group analysis as the factor of development of culture of dialogue in the aftermath ofthe 1992–1995 war

Aim The primary objective will focus the first of all on Group Analysis (GA) as the psychotherapy method and theory of group analysis applied particularly in post-war environments. It outlines in particular a Zagreb Institute for GA Training Programme that took place in Tuzla University Clinical Centre, Department of Psychiatry, in Bosnia-Herzegovina (BH) in response to 1992–1995 war, in helping to train mental health workers in GA to enable them to treat psychological trauma symptoms of war survivors. Method In the GA education in the period of 16 years mental health professionals employed in mental health services were involved as well as other care employees as General Practitioners, Family physicians, pediatricians, gynecologists and neurosurgeons, psychologists and special educators. Results Trainees in education were from greater part of BH, and from several towns from neighborhoods countries. In this way a new room for mutual exchanges of experiences and establishing of cooperation was created. Idea of group analytic treatment of persons with mental health problems spread out on the whole region of BH through this model of education. The future of GA application as a psychotherapy model in BH confirmed through established models of education which are employed inowadays in Tuzla, Sarajevo and Mostar. The future of GA is provided in activities focused on foundations of the Institute for Analysis in Tuzla. Conclusion Training of Bosnia-Herzegovina mental health workers to effectively use GA with enthusiastic help of GA trainers from Institute for GA Zagreb will develop dialogue culture in postwar BH.

Identification of Knowledge Gaps in Neurosurgery Using a Validated Self-Assessment Examination: Differences Between General and Spinal Neurosurgeons

The practice of neurosurgery requires fundamental knowledge base. Residency training programs and continuing medical education courses are designed to teach relevant neurosurgical principles. Nevertheless, knowledge gaps exist for neurosurgeons and may be different between cohorts of neurosurgeons. The Self-Assessment in Neurological Surgery (SANS) General Examination and Spine Examination are online educational tools for lifelong learning and maintenance of certification. This study examines the gaps in knowledge of spinal neurosurgeons and general neurosurgeons taking SANS. From 2008 to 2010, a total of 165 spinal neurosurgeons completed the 243 available questions of the SANS Spine Examination. Over that same time frame, 993 general neurosurgeons completed the SANS General Spine Examination. Mean scores were calculated and assessed according to 18 major neurosurgical knowledge disciplines. Statistical analysis was carried out to evaluate for significant knowledge gaps among all users and significant differences in performance between spinal neurosurgeons and their general neurosurgeon counterparts. The mean overall examination score was 87.4% ± 7.5% for spinal neurosurgeons and 71.5% ± 8.9% for general neurosurgeons (P < 0.001). Of the 18 major knowledge categories in SANS, spinal neurosurgeons (n = 165) answered questions incorrectly 15% or greater of the time in five of the categories. The categories of lower performance for spinal neurosurgeons were cerebrovascular, anesthesia and critical care, general clinical, tumor, and trauma. For general neurosurgeons (n = 993), the five knowledge categories with lowest performance were cerebrovascular, epilepsy, peripheral nerve, trauma, and radiosurgery. Although spinal neurosurgeons and general neurosurgeons shared some areas of decreased performance including trauma and cerebrovascular, spine neurosurgeons relatively underperformed in general clinical, anesthesia and critical care, and tumor. The SANS Spine Examination demonstrated knowledge gaps in specific categories for spinal surgeons. The knowledge areas of diminished performance differed between spinal and general neurosurgeons. Identification of specific areas of deficiency could prove useful in the design and implementation of educational programs and maintenance of certification.

Neurosurgery in Afghanistan during “Operation Enduring Freedom”: a 24-month experience

"Operation Enduring Freedom" is the US war effort in Afghanistan in its global war on terror. One US military neurosurgeon is deployed in support of Operation Enduring Freedom to provide care for both battlefield injuries and humanitarian work. Here, the authors analyze a 24-month neurosurgical caseload experience in Afghanistan. Operative logs were analyzed between October 2007 and September 2009. Operative cases were divided into minor procedures (for example, placement of an intracranial pressure monitor) and major procedures (for example, craniotomy) for both battle injuries and humanitarian work. Battle injuries were defined as injuries sustained by soldiers while in the line of duty or injuries to Afghan civilians from weapons of war. Humanitarian work consisted of providing medical care to Afghans. Six neurosurgeons covering a 24-month period performed 115 minor procedures and 210 major surgical procedures cases. Operations for battlefield injuries included 106 craniotomies, 25 spine surgeries, and 18 miscellaneous surgeries. Humanitarian work included 32 craniotomies (23 for trauma, 3 for tumor, 6 for other reasons, such as cyst fenestration), 27 spine surgeries (12 for degenerative conditions, 9 for trauma, 4 for myelomeningocele closure, and 2 for the treatment of infection), and 2 miscellaneous surgeries. Military neurosurgeons have provided surgical care at rates of 71% (149/210) for battlefield injuries and 29% (61/210) for humanitarian work. Of the operations for battle trauma, 50% (106/210) were cranial and 11% (25/210) spinal surgeries. Fifteen percent (32/210) and 13% (27/210) of operations were for humanitarian cranial and spine procedures, respectively. Overall, military neurosurgeons in Afghanistan are performing life-saving cranial and spine stabilization procedures for battlefield trauma and acting as general neurosurgeons for the Afghan community.

Grand Challenge: The Emerging Field of Neurohospitalist Medicine

Grand Challenge: The Emerging Field of Neurohospitalist Medicine

脳深部刺激療法(DBS)はどんな症例に有効か(&lt;特集&gt;一般脳神経外科医が知っておくべきsubspecialtyの知識)

脳深部刺激療法(DBS)はどんな症例に有効か(&lt;特集&gt;一般脳神経外科医が知っておくべきsubspecialtyの知識)

脳神経外科手術における電気生理学的モニタリングの要点とピットフォール(&lt;特集&gt;一般脳神経外科医が知っておくべきsubspecialtyの知識)

脳および脳神経の機能温存のために,脳神経外科手術において種々の電気生理学的モニタリングが広く施行されるようになってきた.最近では,脳機能としては,運動,感覚,言語,視覚,聴覚などのモニタリングが施行され,脳神経機能も第1〜12脳神経のモニタリングが可能である.本稿では,まず最初にモニタリングに共通する基本的事項として,記録電極,アーチファクト対策,フィルター,麻酔について述べた.次いで,正中神経刺激および後脛骨神経刺激体性感覚誘発電位(SEP),脳表直接電気刺激および経頭蓋電気刺激による筋電図記録の運動誘発電位(MEP),視覚誘発電位(VEP)の要点について概説し,最後にSEP,MEP,VEPモニタリングにおいて実際に経験したピットフォール症例を提示し,考察を加えた.

抗血栓療法の実際 : 周術期や出血時の対応を含めて(&lt;特集&gt;一般脳神経外科医が知っておくべきsubspecialtyの知識)

抗血栓療法の実際 : 周術期や出血時の対応を含めて(&lt;特集&gt;一般脳神経外科医が知っておくべきsubspecialtyの知識)

Slitlike Ventricle Syndrome

Severely increased intracranial pressure can be life-threatening in shunted children who do not experience ventricular enlargement. This condition is termed normal ventricular hydrocephalus and represents the most severe form of slit ventricle syndrome. A 7-year-old girl with a repaired lumbosacral myelomeningocele and shunted at birth who presented with headache, vomiting, seizure, and deterioration of level of consciousness was admitted to the pediatric intensive care unit. Because her ventricles were small to slitlike on cranial computed tomographic (CT) scan, the shunt was presumed to be working. Although the cerebrospinal fluid analysis was normal, she received initial empirical treatment of viral encephalitis. Twenty-four hours after admission, she evolved with apnea and bradycardia, requiring ventilatory support. Repeated CT scans were unchanged from one study to the next. After 48 hours, her condition worsened, and cerebrospinal pressure during lumbar puncture reached more than 30 mm Hg despite the serial CT scan disclosing no ventricular enlargement. She underwent a shunt revision that showed that the catheter was occluded and had adhered to the ventricular wall. The shunt was replaced, resulting in dramatic neurological improvement. This report highlights a life-threatening condition involving chronically shunted children who present severe intracranial hypertension without ventriculomegaly and may often be neglected or unrecognized by emergency physicians or general neurosurgeons.

Paediatric central nervous system tumours in a New Zealand population: A 10-year experience of epidemiology, management strategies and outcomes

We analysed 166 cases of paediatric central nervous system tumour presenting to Auckland City and Starship Children’s Hospital, New Zealand, between 1995 and 2004. The purpose of this study was to perform an audit of paediatric neurosurgical practice in the upper North Island of New Zealand with the objective of assessing patient presentation, demographics, and modality and efficacy of therapy. The overall incidence of central nervous system tumours was 3.42/100,000/year. The incidence rate of medulloblastoma for Maori was over double that for European New Zealanders. Tumour clearance was attempted in 81.3% of patients. Some type of adjunct therapy was received by 45.2% of patients. Overall, 60.8% of patients had satisfactory or good results. Survival rates for pilocytic astrocytoma and ependymoma were consistent with previous studies. Survival data for medulloblastoma demonstrate improved outcomes with complete resection of tumour and with a specialist paediatric neurosurgeon compared with general neurosurgeons. Recent management changes have led to improved outcomes.

Head and neck oncology: the UK experience. Who is publishing what?

Using the MEDLINE database (OVID), a retrospective review of the UK literature on head and neck oncology was performed for the period 1994-2000, each publication being categorised by department and first author. Tumours almost exclusively managed by general surgeons, cardiothoracic surgeons and neurosurgeons were excluded. In the years 1994 to 2000, there were a total of 120 UK publications, 72% of which came from non-academic NHS units; 23% of the publications were from ENT units, 23% from oral and maxillofacial (OMF) surgery units and 18% from plastic surgery units. The majority of plastic surgery publications described reconstructive techniques, whereas a wider range of topics was observed in the publications by ENT and OMP surgeons. Several irregularities in the MEDLINE database were discovered and are discussed. The findings of this study may be relevant to the future planning of head and neck oncology services.

Adults with Hydrocephalus Treated in Infancy and Childhood

This review considers the unique pathophysiologies and problems confronting adults who have been treated for hydrocephalus since infancy. Most of these patients will have to change the setting in which they receive care. Therefore, general neurosurgeons who will become the new caretakers for these adult patients must understand the challenges involved. Hydrocephalus in adults has a limited number of origins, and a limited number of points of obstruction can cause the condition. In contrast, congenital conditions that cause hydrocephalus can lead to multiple points of obstruction, making management of these infants difficult. Infants also have distensible heads, which can lead to unique causes of hydrocephalus. Intracranial venous hypertension causes pseudotumor cerebri in adults but it is a rather common cause of hydrocephalus in infants with distensible heads. The most common cause of infantile hydrocephalus is spina bifida associated with a Chiari II malformation. There are four different points of obstruction in these patients, each manifesting with a unique syndrome at the time of shunt failure. The concept of shunt dependency is being redefined as the popularity of endoscopic third ventriculostomy increases. Although the use of the technique in the context of spina bifida remains controversial, the procedure may allow more than 70% of children shunted in infancy whose ventricles expand at the time of shunt failure to live without a shunt. Unlike adults, 20% of infants who are still shunt dependent as adults will have very high intracranial pressure at the time of shunt failure even though the ventricles do not expand. A significant percentage of these patients will benefit from a valve-regulated lumboperitoneal shunt. Any adult who experiences ventricular dilatation at the time of shunt failure should be considered a candidate for endoscopic third ventriculostomy.

Paediatric neurosurgery in India.

In a vast country like India, with children constituting 40% of a total population of 900 million people, the need and scope for paediatric neurosurgery is enormous. Initial organised attempts to focus attention on the need for paediatric neurosurgery as a subspecialty were made in 1983 and 1987, respectively, by holding symposia on infections and tumours in children. However, when the Annual Conference of ISPN was held in Bombay this served as a great impetus to the development of paediatric neurosurgery as a subspecialty in this country. It led to the formation of the Indian Society for Paediatric Neurosurgery in the following year, which now has 90 neurosurgeons in full membership. It has held annual meetings ever since its inception and has held CME programmes with international faculty in 1992, 1994, 1996, 1997 and 1998. Half a dozen neurosurgeons have already devoted themselves mainly to the practice of paediatric neurosurgery. Paediatric neurosurgery is best developed in a large multi-disciplinary paediatric institute. We have been able to establish a neurosurgical service at Jerbai Wadia Hospital for Children, a paediatric institute of repute in Mumbai, and hope to have training programmes and fellowships in the near future for both general and paediatric neurosurgeons, as they will have to continue treating cases of spina bifida and hydrocephalus for several years to come.

Basal lateral subtemporal approach for trigeminal neurinomas: report of an experience with 18 cases.

Subtemporal craniotomy centred on the external ear canal was used to surgically treat 18 trigeminal neurinomas. The approach was found to be suitable to deal with either or both the middle fossa and the posterior cranial fossa components of the tumour. The basal extension of the exposure was achieved by resection of the roots of the zygomatic arch, roof of the external ear canal and superior third of the mastoid bone. The temporalis muscle was rotated anteriorly. The direction of the approach to the tumour was the shortest and perpendicular from the surface and avoided any neural or vascular exposure or manipulation. The basal exposure was horizontally wide and significantly low which reduced the operating distance, limited the extent of temporal lobe retraction and provided additional space for manipulation of instruments. The exposure was manoeuvreable with anterior, posterior and medial expansion being possible during or prior to tumour resection. The approach had the advantage of being simple and relatively quick and of its familiarity to general neurosurgeons. The experience with the approach with trigeminal neurinomas and its possible advantages over other available approaches to these lesions are analysed in this report.

Middle fossa sub-Gasserian ganglion approach to clivus chordomas.

A modified lateral subtemporal, transpetrous apex and sub-Gasserian ganglion approach was found to be most suitable for clival chordomas. The approach selection was based on the typical anatomical relationship of chordomas in terms of site of origin, pattern of growth and neural and vascular displacements. The approach was suitable to deal with tumour anterior and lateral to the brain stem, the clival part of the tumour and its sub-cavernous sinus extensions. The carotid artery was under control. The approach had the advantage of being simple and relatively quick and of its familiarity to general neurosurgeons. The tumour could be excised radically and extension of anterior, posterior and inferior exposure was possible.