Quadriplegia in a patient who underwent posterior fossa surgery in the prone position

✓ Quadriplegia is a well-known complication of posterior fossa surgery performed while the patient is in the sitting position but is rarely associated with the prone position. A case of an 18-year-old man with a cerebellar medulloblastoma is described. There was no evidence of previous cervical disease. The patient suffered quadriplegia after undergoing surgery in the prone position. Postoperative magnetic resonance imaging demonstrated a long hyperintense C2—T1 lesion on T2-weighted sequences. The authors speculate that, during the prolonged period in which the neck was in hyperflexion, overstretching of the cervical spinal cord and compromise of its blood supply might have caused this devastating complication.

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Air embolism associated with wounds from a pin-type head-holder

Journal of Neurosurgery ◽

10.3171/jns.1982.57.5.0710 ◽

1982 ◽

Vol 57 (5) ◽

pp. 710-713 ◽

Cited By ~ 18

Author(s):

Dachling Pang

Keyword(s):

Posterior Fossa ◽

Air Embolism ◽

Posterior Fossa Surgery ◽

Sitting Position ◽

Entry Site ◽

Content Type ◽

Tension Pneumocephalus ◽

Head Holder ◽

Scalp Laceration ◽

Fine Print

✓ A case of intraoperative air embolism during posterior fossa surgery performed with the patient in the sitting position is reported. The entry site was through a comminuted fracture and scalp laceration resulting from faulty application of a pin-type head-holder. The possible role played by a large tension pneumocephalus in the ingress of venous air is also discussed. Simple precautions regarding the use of the pin-type head-holder are suggested to lessen the possibility of air embolism through the puncture wounds.

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Subdural tension pneumocephalos

Journal of Neurosurgery ◽

10.3171/jns.1979.50.4.0525 ◽

1979 ◽

Vol 50 (4) ◽

pp. 525-527 ◽

Cited By ~ 84

Author(s):

L. Dade Lunsford ◽

Joseph C. Maroon ◽

Peter E. Sheptak ◽

Maurice S. Albin

Keyword(s):

Posterior Fossa ◽

Air Bubbles ◽

Posterior Fossa Surgery ◽

Sitting Position ◽

Twist Drill ◽

Potential Complication ◽

Content Type ◽

Tension Pneumocephalus ◽

Prompt Diagnosis ◽

Fine Print

✓ Two patients developed subdural tension pneumocephalus after undergoing posterior fossa surgery performed in the sitting position. The mechanism for entry of air into the intracranial compartment is analogous to the entry of air into an inverted soda-pop bottle. As the fluid pours out, air bubbles to the top of the container. We have thus referred to this as the “inverted pop-bottle syndrome.” Computerized tomography provided prompt diagnosis and confirmed brain displacement. Twist-drill aspiration of the air resulted in improvement in both patients, although one patient subsequently died from an intracerebellar hemorrhage. Tension pneumocephalus appears to be another potential complication of posterior fossa surgery in the sitting position. This condition is easily diagnosed and treated, and should be considered whenever a patient fails to recover as expected following posterior fossa surgery.

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Air embolism from wounds from a pin-type head-holder as a complication of posterior fossa surgery in the sitting position

Journal of Neurosurgery ◽

10.3171/jns.1981.55.1.0147 ◽

1981 ◽

Vol 55 (1) ◽

pp. 147-148 ◽

Cited By ~ 24

Author(s):

José M. Cabezudo ◽

Fernando Gilsanz ◽

Jesús Vaquero ◽

Eduardo Areitio ◽

Roberto Martinez

Keyword(s):

Posterior Fossa ◽

Supine Position ◽

Unusual Case ◽

Air Embolism ◽

Posterior Fossa Surgery ◽

Sitting Position ◽

Fixation Device ◽

Content Type ◽

Head Holder ◽

Fine Print

✓ The authors report an unusual case of intraoperative air embolism during posterior fossa surgery in the sitting position. The source of air was one of the wounds made by the pin-type skull fixation device. We suggest that the patients should not be released from such device until they are in the supine position.

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EXTENSIVE SPINAL CORD INFARCTION AFTER POSTERIOR FOSSA SURGERY IN THE SITTING POSITION: CASE REPORT

Neurosurgery ◽

10.1227/01.neu.0000125008.93625.5e ◽

2004 ◽

Vol 54 (6) ◽

pp. 1512-1516 ◽

Cited By ~ 26

Author(s):

Xavier Morandi ◽

Laurent Riffaud ◽

Seyed F.A. Amlashi ◽

Gilles Brassier

Keyword(s):

Spinal Cord ◽

Case Report ◽

Posterior Fossa ◽

Spinal Cord Infarction ◽

Posterior Fossa Surgery ◽

Sitting Position

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Experiences with the Sitting Position in Posterior Fossa Surgery in 310 Patients

Journal of Neurological Disorders ◽

10.4172/2329-6895.s1-002 ◽

2015 ◽

Vol s1 ◽

Author(s):

Petridis AK

Keyword(s):

Posterior Fossa ◽

Posterior Fossa Surgery ◽

Sitting Position

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Neuroendoscopic Aspiration of Blood Clots in the Cerebral Aqueduct and Third Ventricle During Posterior Fossa Surgery in the Prone Position

Operative Neurosurgery ◽

10.1093/ons/opy324 ◽

2018 ◽

Vol 17 (2) ◽

pp. 143-148 ◽

Cited By ~ 1

Author(s):

Alberto Feletti ◽

Riccardo Stanzani ◽

Matteo Alicandri-Ciufelli ◽

Giuliano Giliberto ◽

Matteo Martinoni ◽

...

Keyword(s):

Prone Position ◽

Posterior Fossa ◽

Fourth Ventricle ◽

Blood Clot ◽

Third Ventricle ◽

Cerebral Aqueduct ◽

Posterior Fossa Surgery ◽

The Third ◽

Blood Clots ◽

Surgical Field

AbstractBACKGROUNDDuring surgery in the posterior fossa in the prone position, blood can sometimes fill the surgical field, due both to the less efficient venous drainage compared to the sitting position and the horizontally positioned surgical field itself. In some cases, blood clots can wedge into the cerebral aqueduct and the third ventricle, and potentially cause acute hydrocephalus during the postoperative course.OBJECTIVETo illustrate a technique that can be used in these cases: the use of a flexible scope introduced through the opened roof of the fourth ventricle with a freehand technique allows the navigation of the fourth ventricle, the cerebral aqueduct, and the third ventricle in order to explore the cerebrospinal fluid pathways and eventually aspirate blood clots and surgical debris.METHODSWe report on one patient affected by an ependymoma of the fourth ventricle, for whom we used a flexible neuroendoscope to explore and clear blood clots from the cerebral aqueduct and the third ventricle after the resection of the tumor in the prone position. Blood is aspirated with a syringe using the working channel of the scope as a sucker.RESULTSA large blood clot that was lying on the roof of the third ventricle was aspirated, setting the ventricle completely free. Other clots were aspirated from the right foramen of Monro and from the optic recess.CONCLUSIONWe describe this novel technique, which represents a safe and efficient way to clear the surgical field at the end of posterior fossa surgery in the prone position. The unusual endoscopic visual perspective and instrument maneuvers are easily handled with proper neuroendoscopic training.

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P06.05 The Sitting Position in the Very Young Pediatric Population: Pearls and Pitfalls of a 10-Years’ Experience

Neuro-Oncology ◽

10.1093/neuonc/noab180.083 ◽

2021 ◽

Vol 23 (Supplement_2) ◽

pp. ii25-ii25

Author(s):

S Linsler ◽

F Teping ◽

J Oertel

Keyword(s):

Posterior Fossa ◽

Pediatric Population ◽

Clinical Status ◽

Skull Fracture ◽

Special Focus ◽

Posterior Fossa Surgery ◽

Sitting Position ◽

Endoscopic Techniques ◽

Age At Surgery ◽

Persistent Foramen Ovale

Abstract BACKGROUND To investigate pearls and pitfalls of the sitting positioning in the pediatric population with special focus on related morbidity and surgical practicability. MATERIAL AND METHODS A retrospective analysis of a prospectively maintained internal database was performed. All pediatric patients younger than 18 years at date of surgery, who underwent procedures in sitting position between 01/2010 and 10/2020 were included into this analysis. RESULTS A total of 42 of posterior fossa surgeries were performed in 38 children between 01/2010 and 10/2020. Mean age at surgery was 8.9 years (13 months - 18 years). Mean height and weight were 134.4 (± 30.2) cm and 36.6 (± 21.7) kg respectively. Three children (7.9%) were diagnosed with persistent foramen ovale. Electrophysiologic monitoring was unremarkable during positioning in all cases. Mean time needed for anesthesiologic preparation and positioning was 84.5 (± 20.6) minutes. Perioperative blood transfusion was needed in 5 cases (11.9%). Incidence of VAE was 11.9%. There was no VAE related severe complication. One child (2.4%) showed postoperative skull fracture and epidural bleeding due to skull clamp application. Clinical status immediately after surgery was favorable or stable in 33 of the cases (78.6%). CONCLUSION Attentive performance and an experienced surgical team provided; the sitting position remains a safe variant for posterior fossa surgery in the pediatric population. Precautious skull clamp application and appropriate monitoring is highly recommended. Considering eloquent aspects, the sitting position offers excellent anatomical exposure and is ideal for combination with endoscopic techniques.

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Occurrence and management of postoperative pneumocephalus using the semi-sitting position in vestibular schwannoma surgery

Acta Neurochirurgica ◽

10.1007/s00701-020-04504-5 ◽

2020 ◽

Vol 162 (11) ◽

pp. 2629-2636

Author(s):

Kathrin Machetanz ◽

Felix Leuze ◽

Kristin Mounts ◽

Leonidas Trakolis ◽

Isabel Gugel ◽

...

Keyword(s):

Posterior Fossa ◽

Supine Position ◽

Tumor Size ◽

Clinical Symptoms ◽

Neurosurgical Procedures ◽

Posterior Fossa Surgery ◽

Sitting Position ◽

Tension Pneumocephalus ◽

Replacement Procedure ◽

Duration Of Surgery

Abstract Background The semi-sitting position in neurosurgical procedures is still under debate due to possible complications such as venous air embolism (VAE) or postoperative pneumocephalus (PP). Studies reporting a high frequency of the latter raise the question about the clinical relevance (i.e., the incidence of tension pneumocephalus) and the efficacy of a treatment by an air replacement procedure. Methods This retrospective study enrolled 540 patients harboring vestibular schwannomas who underwent posterior fossa surgery in a supine (n = 111) or semi-sitting (n = 429) position. The extent of the PP was evaluated by voxel-based volumetry (VBV) and related to clinical predictive factors (i.e., age, gender, position, duration of surgery, and tumor size). Results PP with a mean volume of 32 ± 33 ml (range: 0–179.1 ml) was detected in 517/540 (96%) patients. The semi-sitting position was associated with a significantly higher PP volume than the supine position (40.3 ± 33.0 ml [0–179.1] and 0.8 ± 1.4 [0–10.2], p < 0.001). Tension pneumocephalus was observed in only 14/429 (3.3%) of the semi-sitting cases, while no tension pneumocephalus occurred in the supine position. Positive predictors for PP were higher age, male gender, and longer surgery duration, while large (T4) tumor size was established as a negative predictor. Air exchange via a twist-drill was only necessary in 14 cases with an intracranial air volume > 60 ml. Air replacement procedures did not add any complications or prolong the ICU stay. Conclusion Although pneumocephalus is frequently observed following posterior fossa surgery in semi-sitting position, relevant clinical symptoms (i.e., a tension pneumocephalus) occur in only very few cases. These cases are well-treated by an air evacuation procedure. This study indicates that the risk of postoperative pneumocephalus is not a contraindication for semi-sitting positioning.

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Use of ligamentum nuchae graft for dural closure in posterior fossa surgery

Journal of Neurosurgery ◽

10.3171/jns.1998.89.1.0155 ◽

1998 ◽

Vol 89 (1) ◽

pp. 155-156 ◽

Cited By ~ 19

Author(s):

Edward J. Kosnik

Keyword(s):

Cerebrospinal Fluid ◽

Posterior Fossa ◽

Cerebrospinal Fluid Leakage ◽

Posterior Fossa Surgery ◽

Content Type ◽

Fluid Leakage ◽

Dural Closure ◽

Fine Print

✓ The technique of harvesting the ligamentum nuchae and its use in posterior fossa surgery are discussed. By using this technique the author has avoided postoperative cerebrospinal fluid leakage in more than 200 procedures.

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