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MRI Stealth Guided Suboccipital Craniotomy Sample Report


Brainstem cavernous malformation.

Brainstem cavernous malformation.

1.  MRI stealth-guided suboccipital craniotomy.
2.  Gross total resection of brainstem cavernous malformation.
3.  Microscope use for nerve root microdissection.

SURGEON:  John Doe, MD





DISPOSITION:  To the recovery room.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room, induced and intubated without difficulty.  A MRI stealth scan had been completed the night before.  This was registered as the patient had a Mayfield headholder attached to the head.  The patient was rolled prone on an operating room table with his head flexed.  The occipital and suboccipital regions were shaved and scrubbed with a Betadine scrub brush, registration.  This area was prepped and draped in sterile fashion.  It was infiltrated with 1% Xylocaine with epinephrine and opened with a 10 blade.  Bovie cautery to superficial fascial layers led down to the nuchal fascia.  Staying in the midline, the dissection continued down to the occipital bone and the arch of C1.  Dissection laterally was followed with placement of deep retractors in the field.

At this point, curettes were used to free up the posterior margin of the foramen magnum and the superior arch of C1.  The Midas Rex and the AM-35 drill bit was used to drill a trough in a suboccipital craniotomy position.  Once the bone was thinned, a #3 Kerrison was used to complete this craniotomy.  The bone was removed en bloc at this time.  The fascia superior to the C1 arch was removed, as was a small portion of the superior edge of C1.  The bony edges were waxed.  Copious irrigation was followed with placement of a stitch in the midline.  The dura was then opened, leaving the arachnoid intact.  Three dural tacking sutures were placed on either side.

At this point, the microscope was brought in.  Under microscopic guidance, the arachnoid was opened.  The underlying cervicomedullary junction was identified, as were the cerebellar tonsils.  Retraction of the cerebellar tonsils laterally led to identification of the obex and the inferior portion of the floor of the fourth ventricle.  On the right-hand side, as expected, a hemosiderin-stained bulge was seen.  A thin film of medullary tissue was seen with obvious cavernous malformation beneath.  A Beaver blade was used to make a linear incision overlying this abnormality and vascular sacs were immediately seen.  Tedious dissection with suction bipolar cautery, microscissors, and dissecting instruments to remove portions of the cavernous malformation piece by piece without injuring the surrounding tissue was carried out.  Slowly, the margins of the cavernous malformation were defined medially and laterally, inferiorly and superiorly.  Near the end of the resection, significant venous bleeding was seen from the depths of the resection bed.  This was controlled with Gelfoam.

Once the cavernous malformation had been completely removed, returning to this area, careful cautery of the floor of the resection area led to identification of a vein, which was subsequently cauterized.  The pressure was raised 20 points and no bleeding was identified.  This was returned to around a systolic of 100.  FloSeal was placed over the floor of the cavernous malformation resection area.

At this point, closure began.  The deep retractors were removed.  The Greenberg retractor system had been used to hold the cerebellar tonsils away from the midline.  The dura was closed with running 4-0 silk suture.  Tisseel was placed over the dural closure.  DuraGen was placed over that.  The bone flap was reattached with Synthes cranial plates.  The nuchal musculature and fascia were closed with interrupted 0 Vicryl sutures.  Superficial fascial layers were closed with interrupted 2-0 Vicryl sutures.  The skin was closed with a 3-0 nylon suture.  Betadine ointment and a Telfa dressing were applied.  The patient was returned to the supine position and taken to the recovery room intubated.

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