Guenther Christian Feigl

Background The most effective treatment for a typical trigeminal neuralgia is microvascular decompression of the trigeminal nerve. An approximately 3–5 cm in diameter retrosigmoid craniotomy with an approximately 12–14 cm long skin incision is considered the standard approach. Modern neurosurgery strives for minimally invasive surgical approaches, which in turn reduces both intraoperative and postoperative complications. The use of minimally invasive approaches in skull base neurosurgery and, in particular, in microvascular decompression of the trigeminal nerve can reduce the risk of complications such as cranial nerve and cerebellar injuries, cerebrospinal fluid (CSF) fistula and sinus thrombosis. The minimally invasive approach also provides a good cosmetic effect. Methods We conducted a retrospective study of 52 consecutive patients with trigeminal neuralgia. All patients underwent microvascular decompression of the trigeminal nerve via a minimally invasive retrosigmoid approach. The data were compared with date those of the largest published studies. The findings obtained in this patient population were consistent with those of large studies. Results Treatment efficacy was also in line, with 98.1% of patients showing improved symptoms of trigeminal neuralgia. No major permanent complications were observed. Transient complications included ipsilateral facial hypoesthesia (40.4%), mild facial nerve paresis (7.3%), hypoacusis (3.8%), and trochlear nerve paresis (1.9%), all resolving within three months post-surgery. Conclusion Minimally invasive retrosigmoid craniotomy result in as good surgical outcomes as standard craniotomy. The reduced size of a surgical approach does not affect the treatment efficacy. The reduced craniotomy size helps avoid traumatization of anatomical structures in the surgical field, reduce possible complications, and shorten postoperative follow-up.

There are two basic techniques to surgically reconstruct peripheral nerves for the recovery of function after traumatic nerve injuries. The end-to-end (EtE) neurorrhaphy, and in case of loss of the proximal stump, the end-to-side (EtS) neurorrhaphy, where the distal end of the acceptor nerve is connected to the side of a donor nerve. The current study was designed to further contribute to finding the best surgical technique for an EtS neurorrhaphy, comparing the functional outcome in a rat model. Using a rat sciatic nerve model, qualitative and quantitative analyses were performed to evaluate peripheral nerve regeneration after EtS. A total of 22 female Lewis rats (Charles River Wiga, 190 g, 8 weeks old) were used for this study. In one test group (E1/n = 6), an EtS was conducted without, and in the other (E2/n = 8) with performing a partial neurotomy (PN) through the epineurial partial flap (EPF). In the test groups (E1/E2), animals with EtS neurorrhaphy without PN reached the best mean functional score of 1.8 points according to our grading scale. Animals with EtS and PN scored with a mean of 2.2 points. These rats with EtS neurorrhaphy and PN had the poorest outcome. The control group C1 with EtE neurorraphies showed the best functional outcome with an average score of 1. The EtE represents the best surgical option for reconstruction of a nerve's anatomical continuity after transection if both ends are preserved. The EtS, on the other hand, represents a good alternative with almost equally good functional outcome in cases where the proximal nerve stump was lost. Results also indicate that an EPF should be created for optimal collateral axonal sprouting and the best possible results when performing an EtS. However, all other additional injuries of the donor nerve, such as a PN, should be avoided.

Cerebrospinal fluid (CSF) leakage is a common postoperative complication after suboccipital craniotomies and can develop into a potentially life-threatenin

Background and Clinical Significance: Traumatic brain injury (TBI) represents a major public health concern due to its profound neurological, psychological, and socioeconomic consequences. Effective management is essential to optimize patient outcomes and reduce healthcare burden. In cases involving extensive bone loss or complex fractures, particularly when decompressive craniectomy (DC) is considered, secondary cranial reconstruction is typically required. However, DC is associated with prolonged hospitalization, multiple surgical interventions, an increased risk of complications, and higher costs. Case Presentation: We present the case of a 59-year-old male involved in a high-energy bicycle accident, sustaining severe craniofacial trauma with multiple midface fractures, a multifragmented left cranial fracture, and a left-sided epidural hematoma with brain compression. Hematoma evacuation and immediate primary reconstruction of the fractured skull using autologous bone were successfully performed, avoiding the need for DC. The patient recovered under intensive care and was transferred to a neurorehabilitation center. Conclusions: Primary reconstruction of large skull fractures using autologous bone should remain the goal, whenever possible, in order to avoid additional costs, risks, and complications.

Minimally invasive spinal and cranial neurosurgery often requires tissue retraction. However, excessive tissue retraction is contrary to the principles of minimally invasive neurosurgery. Therefore, any retractor used should be small and atraumatic. Circular plastic retractors made from syringes of various sizes meet these requirements. We report a case series of patients with various cranial and spinal pathologies who underwent surgeries using “self-made” retractors made from plastic syringes of various sizes (2 mL, 5 mL, and 10 mL). All surgeries were performed via minimally invasive approaches. In all cases, the goals of surgical treatment were achieved with no neurological deficits. The use of “self-made” plastic retractors can be helpful in spinal and cranial minimally invasive neurosurgery. Making retractors from plastic syringes and using them is not labor-intensive. This method can extend the possibilities of the neurosurgeon, especially in the field of minimally invasive neurosurgery. Clinical trial number: Not applicable.

The endoscopic transsphenoidal approach is a common approach used in skull base neurosurgery to reach the sellar region. One of the intraoperative risks of this approach is intraoperative bleeding out of the carotid artery. Gentle drilling can prevent carotid artery injury. However, injury to smaller branches, such as the McConnell’s capsular artery, which is located within the surgical corridor, is more difficult to prevent. If such an injury is within the junction to the main trunk of the carotid artery, there will be a small circular defect in this area. This can result in massive blood loss and should be closed surgically immediately. We describe a clinical case of intraoperative bleeding from the McConnell’s artery originating from the carotid arterial segment (C4) in a 78-year-old female patient operated on for planum sphenoidale meningioma via endoscopic transsphenoidal approach, as well as provide a technical note on a possible technique for bleeding control in such cases. Pinpoint carotid bleeding as a result of intraoperative injury can be stopped by wedging a bone fragment in the carotid canal and fixing it in that position with histoacryl glue at the defect site.

BACKGROUND: Optic nerve schwannomas are an extremely rare pathology in neurosurgery. Their origin is rather debatable given the structure of the optic nerve, which does not typically have Schwann cells therein. However, a number of clinical cases of optic nerve tumors classified as schwannomas have been described in the literature. At present, there is no fundamental understanding of the etiology and pathogenesis of these tumors or treatment due to their rare incidence. OBSERVATIONS: The authors describe the clinical case of a 40-year-old female patient with blurred vision in the left eye for 6 months who was operated on for an optic nerve tumor via a minimally invasive supraorbital approach. Complete resection of the tumor was achieved. Histopathological examination revealed a schwannoma. The patient had no postoperative complaints or neurological deficits. The authors also performed a detailed review of the literature for cases with optic nerve schwannomas. Only 18 patient outcomes have been published so far. There are significant differences in the structure, localization, size, and surgical treatment of optic nerve schwannomas. LESSONS: Optic nerve schwannomas are extremely rare lesions. Hence, there is a need to accumulate knowledge in order to study the etiology, pathogenesis, and treatment of these tumors. The minimally invasive supraorbital approach can be successfully used in the surgical treatment of optic nerve schwannomas located in the optic canal. https://thejns.org/doi/10.3171/CASE24638

Objective : Reoperations are part of neurosurgical practice. In these cases, an already formed craniotomy seems the most logical and appropriate. However, reoperations via large approaches can be quite traumatic for the patient. Then minimally invasive approaches, being less traumatic, can be a good alternative.Methods : We describe seven consecutive patients who underwent reoperations using minimally invasive approaches in the areas of conventional craniotomies. Surgical Theater® visualization platform was used for preoperative planning. The study evaluated the size of surgical approach, surgical efficacy, and the presence of complications.Results : The size of a minimally invasive craniotomy was significantly smaller than that of a conventional approach. The preoperative goals were achieved in all described cases. There were no complications in the early postoperative period. Although the anatomy of the operated brain region in reoperations is altered, keyhole approaches can be successfully used with the support of preoperative planning and intraoperative neuronavigation. Given that the goals of reoperations may differ from those of the primary surgery, and a large approach is more traumatic for the patient, minimally invasive craniotomy can be considered as a good alternative. The successful use of minimally invasive approaches in areas of conventional craniotomies reinforces the philosophy of keyhole neurosurgery. In cases where goals can be achieved using small approaches, it makes no sense to use large conventional ones.Conclusion : Minimally invasive approaches can be successfully used during reoperations in patients after conventional craniotomies.

Background: Surgical treatment of therapy-resistant radiculopathy associated with lumbar herniated discs in patients with extreme obesity is a challenge for neurosurgeons. In addition to technical problems in surgery due to the abundant subcutaneous adipose tissue and perioperative risks, there are significant anesthetic risks when anesthesia is performed with a patient in the prone position. A surgical procedure should preferably be minimally traumatic and quick with minimal risks of complications. Large studies show good results with minimally invasive techniques, namely microsurgical and endoscopic ones. However, in the case of surgeries in patients with extreme obesity, an endoscopic approach seems to be preferable because the spinal canal is quickly reached through a small skin incision using this approach. Case Description: We describe in detail the successful surgical treatment of a 48-year-old patient with extreme obesity (body mass index 54.3 kg/m²) and therapy-resistant immobilizing radiculopathy at the L4 level on the left by minimally invasive endoscopic sequestrectomy. Following the surgery, the patient was rapidly mobilized and discharged on the 4th postoperative day. No complications were reported in the early and late postoperative periods. Conclusions: The endoscopic approach can be successfully used for the treatment of therapy-resistant radiculopathy in patients with extreme obesity and can be considered as the main technique of surgical treatment, being both quick and minimally traumatic.