Presented by Owoicho Adogwa, MD, MPH, FAANS, this brief video highlights the methods used for coding a neurosurgical procedure. The video also serves as an example of the content offered in AANS coding products and resources.

Posterior intra-articular distraction with cage placement to treat congenital atlantoaxial dislocation associated with basilar invagination Wanru Duan, MD,1 Dean Chou, MD,2 Fengzeng Jian, MD, PhD,1 and Zan Chen, MD, PhD1 1Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; and 2Department of Neurological Surgery, University of California, San Francisco, California Congenital atlantoaxial dislocation (AAD) associated with basilar invagination (BI) is a complex congenital malalignment at the craniovertebral junction. The olisthesis, atlantoaxial facet joint arthropathy, and the contraction of the anterior soft tissue make the treatment challenging. Our video demonstrates the surgical technique for posterior intra-articular distraction with cage placement to treat congenital atlantoaxial dislocation associated with basilar invagination. 10.3171/2020.3.FocusVid.191001

Stereotactic radiofrequency ventral posterolateral thalamotomy for cancer pain

Satoshi Kiyofuji, MD,1 Harry J. Cloft, MD, PhD,2 Colin L. W. Driscoll, MD,3 and Michael J. Link, MD1 Departments of 1Neurologic Surgery, 2Radiology, and 3Otorhinolaryngology, Mayo Clinic, Rochester, Minnesota A 60-year-old man with a history of four prior operations for a left cerebellar/middle cerebellar peduncle hemangioblastoma presented with hearing loss, imbalance, and ataxia (de la Monte and Horowitz, 1989). Magnetic resonance imaging (MRI) demonstrated a 3-cm cystic mass with heterogeneous enhancement in the same location. We resected the mass via reopening of the retrosigmoid approach (Lee et al., 2014). Left cranial nerves IV, V, VII, VIII, IX, X, and XI were all well identified and preserved, and feeding arteries from the brainstem were meticulously coagulated and transected without violating the tumor-brainstem interface (Chen et al., 2013). Preoperative embolization greatly aided safe resection of the mass, whose pathology revealed recurrence of hemangioblastoma (Eskridge et al., 1996; Kim et al., 2006; Sakamoto et al., 2012).

Presented by Michael Martin, MD, FAANS, this brief video highlights the methods used for coding a neurosurgical procedure. The video also serves as an example of the content offered in AANS coding products and resources.

Atul Goel, MCh Department of Neurosurgery, K.E.M. Hospital and Seth G.S. Medical College, Parel, Mumbai, India The basic surgical steps in the Goel technique of atlantoaxial fixation involve exposure of the atlantoaxial articulation, denuding of the articular cartilage, stuffing of bone graft pieces within the articular cavity, and subsequent instrumentation. “High-riding” vertebral artery in relationship to the pedicle-facet of C2 has been widely recognized to be a factor that makes insertion of the C2 pedicle-facet screw difficult or impossible. In this video, a technique of exposure and mobilization of the high-riding vertebral artery to permit safe C2 screw insertion is shown. An alternative option in the presence of such a high -riding vertebral artery is to use either C2 laminar or inferior facetal screw insertion. 10.3171/2020.4.FocusVid.20172

Limited midline myelotomy for visceral pain M. Benjamin Larkin, MD, PharmD, Robert Y. North, MD, PhD, Aditya Vedantam, MD, and Ashwin Viswanathan, MD Department of Neurosurgery, Baylor College of Medicine, Houston, Texas The traditional commissural myelotomy consists of a sagittal cut in the midline and was originally described by Greenfield and performed by Armour in 1926. Today, myelotomy refers to the selective disruption of the ascending visceral pain pathway. The success of the procedure is incumbent on the correct identification of the midline. Limited midline open myelotomy for the treatment of medically intractable abdominal or pelvic visceral cancer pain, with the aid of somatosensory evoked potentials to identify midline, offers patients superior pain relief over similar percutaneous techniques. Multicenter registries are needed to better elucidate the best surgical technique for this procedure.

C1–2 facet disarticulation for correction of iatrogenic cervical kyphosis following occipital-cervical fusion Miki Katzir, MD, Aboubakr T. Amer, MD, Asad S. Akhter, MD, Stephanus V. Viljoen, MD, and Ehud Mendel, MD, MBA Department of Neurological Surgery and the James Cancer Hospital, Wexner Medical Center, The Ohio State University, Columbus, Ohio The patient is a 69-year-old woman with a history of atlantoaxial instability and cervical pain who underwent an occipital-cervical fusion at an outside hospital. Five days following the procedure she required a PEG tube due to progressive dysphagia. Compared with preoperative imaging, x-ray shows cervical spine hyperextension with a significant decrease in the occipital–C2 angle. A swallow test confirmed aspiration and pharyngeal phase functional impairment. Two-stage surgery consisted of hardware removal, drilling the fused right C1–2 facet, reinstrumentation, and halo placement. The swallowing test confirmed there is no aspiration. We proceeded with rod placement. The patient recovered completely. 10.3171/2020.4.FocusVid.20175

Modified dorsal root entry zone lesioning for pain relief in cervical root avulsion injury Keisuke Takai, MD, PhD, and Makoto Taniguchi, MD, PhD Department of Neurosurgery, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan Neuropathic pain in the upper extremity due to cervical root avulsion injury is refractory to medical treatments. Superficial layers in the posterior horn of spinal gray matter, including the substantia gelatinosa, are the main target of dorsal root entry zone (DREZ) lesioning, which has been the most effective surgical treatment for the relief of intractable pain; however, residual pain and a decrease in pain relief during the long-term follow-up period have been reported. Based on pain topography in the most recent basic studies, the conventional DREZ lesioning procedure was modified to improve clinical outcomes.

Ken Matsushima, MD,1,2 Michihiro Kohno, MD, PhD,1 and Helmut Bertalanffy, MD, PhD2 1Department of Neurosurgery, Tokyo Medical University, Tokyo, Japan; and 2Center for Vascular Neurosurgery, International Neuroscience Institute Hannover, Hannover, Germany Microsurgical resection of the medullary cavernoma is rare, comprising less than 15% of more than 250 surgeries of brainstem cavernoma performed by the senior author (H.B.).1 This video demonstrates a case of a cavernous malformation inside the lateral part of the medulla, which was surgically treated via the olivary zone by the retrosigmoid supracondylar approach in a half-sitting position. Osseous drilling of the lateral foramen magnum provided wide exposure of the cerebellomedullary cistern around the olive.2,3 The lesion was completely dissected at the appropriate cleavage plane from the normal parenchyma. The patient developed no new neurological deficits and had no recurrence during 3 years of follow-up after the operation.

Presented by Jeremy T. Phelps, MD, MBA, FAANS, this brief video highlights the methods used for coding a neurosurgical procedure. The video also serves as an example of the content offered in AANS coding products and resources.

Presented by Jeremy T. Phelps, MD, MBA, FAANS, this brief video highlights the methods used for coding a neurosurgical procedure. The video also serves as an example of the content offered in AANS coding products and resources.

Rômulo A. S. Marques, MD,1 Rodrigo A. C. Cavalcante, MD, PhD,1 and Lucas M. C. E. Pimenta2 1Department of Neurosurgery and 2School of Medicine, Federal University of Goiás, Goiânia, Goiás, Brazil A 52-year-old male was involved in a car accident 30 years ago. He presented with complete motor paralysis of the left upper limb. This evolved into severe neuropathic pain (mainly shocking and burning sensation) distributed from C5 to T1 dermatomes. He was first treated with spinal cord stimulation (SCS), which did not show efficacy for pain control, maintaining high visual analog scale (VAS) scores. He then received complementary treatment with left cervical DREZotomy to mitigate suffering and preserve SCS function to control “mirror pain.

Expanded endoscopic endonasal transpterygoid transmaxillary approach for a giant trigeminal schwannoma Rafael Martínez-Pérez, MD, PhD,1 Marcus Zachariah, MD, PhD,1 Ruychen Li, MD,1 Giuliano Silveira-Bertazzo, MD,1 Ricardo L. Carrau, MD, MBA,1,2 and Daniel M. Prevedello1,2 Departments of 1Neurosurgery and 2Head and Neck Surgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio Atypical trigeminal schwannomas (ATSs) are notorious for their ability to invade the skull base. An expanded endoscopic endonasal approach (eEEA) provides direct access to the tumor with no need for cerebral retraction or manipulation of neurovascular structures. Herein, we present a case of a large temporal fossa extradural lesion with secondary invasion of the sella, clivus, and temporal and infratemporal fossae in a 49-year-old male with severe vision loss. A transpterygoid transmaxillary approach was performed. Gross-total removal was achieved and pathology revealed the diagnosis of ATS. Visual function fully recovered in the right side and the patient has been uneventfully followed since surgery.

How do APPs contribute to neurosurgical practice? Listen in as Michael Y. Wang, MD, FAANS, interviews Cathy M Rosenberg, APRN, on working both in patient care and administration in a neurosurgery department.

Microvascular transposition using Teflon sling technique Mitchell W. Couldwell, MSc, Vance Mortimer, AS, and William T. Couldwell, MD, PhD Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah Microvascular decompression is a well-established technique used to relieve abnormal vascular compression of cranial nerves and associated pain. Here the authors describe three cases in which a sling technique was used in the treatment of cranial nerve pain syndromes: trigeminal neuralgia with predominant V2 distribution, hemifacial spasm, and geniculate neuralgia and right-sided ear pain. In each case, the artery was mobilized from the nerve and tethered with a sling. All three patients had reduction of symptoms within 6 weeks.

Presented by Clemens M. Schirmer, MD, PhD, FAANS, this brief video highlights the methods used for coding a neurosurgical procedure. The video also serves as an example of the content offered in AANS coding products and resources.

Dorsal root ganglion stimulation for treatment of complex regional pain syndrome of the foot Kevin Hines, MD, Fadi Al Saiegh, MD, Aria Mahtabfar, MD, Kavantissa M. Keppetipola, MD, Caio M. Matias, MD, PhD, Chengyuan Wu, MD, MSBmE, and Ashwini Sharan, MD Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania This is a case of a 54-year-old man presenting with complex regional pain syndrome (CRPS) type 1 of the right lower extremity, which was most debilitating in the plantar aspect of the right foot. The patient had prior treatment with thoracic spinal cord stimulation; however, the foot pain remained intractable. Given that his pain was predominantly in his foot and remained debilitating despite thoracic spinal cord stimulation, it was recommended that the patient undergo a trial of dorsal root ganglion (DRG) stimulation. The surgical technique for placement of dorsal root ganglion stimulators is demonstrated in this operative video.

What does it take to become a neurosurgical PA? Listen in as Michael Y. Wang, MD, FAANS, interviews Jaclyn Baloga, PA-C, on the pathway to becoming a physician assistant practicing in neurosurgery. Learn details on everything from training and credentialing to the day-to-day of a practicing PA.