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Background: In the endovascular era, most of vertebral artery (VA) and posterior inferior cerebellar artery (PICA) aneurysms were mainly treated with endovascular procedures. This study aimed to demonstrate the microsurgical treatment via the far-lateral approach without C1 laminectomy and its clinical outcomes. Methods: Forty-eight patients with VA and proximal PICA aneurysms treated by microsurgery through the far-lateral approach without C1 laminectomy, between January 2016 and June 2021, were retrospectively evaluated. Results: Most patients (87.5%) presented with subarachnoid hemorrhage. Grading at presentation was poor in 41.7%. The rates of VA dissecting aneurysms, saccular aneurysms of the VA-PICA junction, and true PICA saccular aneurysms were 54.2, 18.7, and 14.6%, respectively. All aneurysms were located above the lower margin of the foramen magnum. The far-lateral approach without C1 laminectomy was successfully used in all patients without residual aneurysms. Various surgical strategies were applied depending on the characteristics of the aneurysm. Good outcomes 3 months postoperatively were achieved in 77.1% and 89.3% for the overall and good-grade groups, respectively. Conclusions: Microsurgery is a safe and effective treatment of VA and proximal PICA aneurysms. Moreover, the far-lateral approach without C1 laminectomy was adequate and effective for aneurysms located above the lower border of the foramen magnum.
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Objective: Recurrent laryngeal nerve (RLN) injury is common complication after anterior cervical discectomy and fusion (ACDF). In the present study, we evaluated RLN function during ACDF surgery using intraoperative RLN monitoring with an electromyography-endotracheal tube (EMG-ET). Methods: In the present study, we retrospectively compared the postoperative RLN injury outcomes between patients who had undergone ACDF with and without an EMG-ET at Vajira Hospital from March 2017 to March 2022. Results: The analysis included 85 patients, 58 (68.2%) of whom had undergone surgery without an EMG-ET and 27 (31.8%) with an EMG-ET. Of the no EMG-ET group, 8 (13.8%) and 1 (1.7%) patient had developed immediate postoperative dysphagia and hoarseness, respectively, with complete recovery within 12 months. In the EMG-ET group, 2 (7.4%) and 1 (3.7%) patient had developed dysphagia and hoarseness, respectively, with complete recovery within 3 months for all 3 patients. Persistent postoperative RLN palsy had occurred in 5 patients (8.6%) without the EMG-ET but in none of the patients with the EMG-ET. The sensitivity and specificity for the use of intraoperative EMG-ET to detect a potential RLN injury were 67.0% and 96.0%, respectively. The use of an EMG-ET reduced the retractor time (P = 0.003), and a retractor time of <70 minutes was associated with a decreased incidence of postoperative RLN injury (odds ratio, 0.122; 95% confidence interval, 0.015-0.981; P = 0.048). Conclusions: The use of an EMG-ET for RLN monitoring during ACDF surgery was helpful in detecting postoperative RLN injury with fair sensitivity and high specificity and resulted in a shorter retractor time, thereby significantly reducing the risk of postoperative RLN injury.
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Background: The third segment of the vertebral artery (V3) is vulnerable during far lateral and retrosigmoid approaches. Although the suboccipital triangle (SOT) is a useful anatomical landmark, the relationship between V3 and the muscles forming the triangle is not well-described. We aimed to demonstrate the relationship between the V3, surrounding muscles, and SOT in clinical cases. Methods: Operative videos of patients with the vertebral artery (VA) and posterior inferior cerebellar artery (PICA) aneurysms treated with occipital artery-PICA bypass through the far lateral approach were examined. Videos from January 2015 to October 2021 were retrospectively reviewed to determine anatomy of the V3 and the SOT. Results: Fourteen patients were included in this study. The ipsilateral V3 was identified without injury in all patients using the bipolar cutting technique. The lateral 68.2% of the horizontal V3 segment, including the V3 bulge, was covered by the inferomedial part of the superior oblique muscle (SO). The medial 23.9% was covered by the inferolateral part of the rectus capitis posterior major muscle. The inferomedial part of the horizontal V3 segment is located within the SOT. Conclusion: Most of the V3, including the V3 bulge, were located beneath the SO and the inferomedial part of V3 located within the SOT. Elevation of the SO should be performed carefully using the bipolar cutting technique to avoid injury to the V3. To the best of our knowledge, this is the first description of the V3 relative to the SOT in the clinical setting.