Anterior cervical discectomy and fusion (ACDF) is one of the most common spinal procedures, frequently used for the treatment of cervical spine degenerative diseases. It was first described in 1958. Interestingly, to our knowledge, 3-level ACDF has not been previously published as a peer-reviewed video case with a detailed description of intraoperative microsurgical anatomy. In this video, we present the case of a 33-year-old male who presented with a combination of myelopathy (hyperreflexia and long tract signs in the upper and lower extremities) and bilateral radiculopathy of the upper extremities. He had been previously treated conservatively with physical therapy and pain management for 6 months without success. We performed 3-level microsurgical ACDF from C4 to C7. All 3 levels were decompressed, and bone allografts were placed to achieve intervertebral body fusion. A titanium plate was utilized from C4 to C7 for internal fixation. The patient was discharged home on the first postoperative day. His pain, numbness and tingling resolved, as well as his myelopathy. No perioperative complications were encountered. Herein we present the surgical anatomy of our operative technique including certain technical tips. Written consent was obtained directly from the patient.

SUMMARY Myxopapillary ependymomas (MPE) of the spinal cord are slow-growing benign tumors most frequently found in adults between 30 and 50 years of age. They arise from the ependyma of the filum terminale and are located in the area of the medullary conus and cauda. The recommended treatment option is gross total resection, while patients undergoing subtotal resection usually require radiotherapy. Complete resection without capsular violation can be curative and is often accomplished by simple resection of the filum above and below the tumor mass. Nevertheless, dissemination and distant treatment failure may occur in approximately 30% of the cases. In this paper, we propose an original MPE classification, which is based upon our personal series report concerned with tumor location and its correlation with the extent of resection. We also provide literature review, discussing surgical technique, tumor recurrence rate and dissemination, and adjuvant treatment. In conclusion, our findings suggest that MPE management based on the proposed 5-type tumor classification is favorable when total surgical resection is performed in carefully selected patients. Yet, further studies on a much broader model is obligatory to confirm this.

Abstract Dumbbell schwannoma of the cervical spine is a known entity,1-5 and should be radically resected with the preservation or improvement of neurological function. However, to our knowledge, an operative video of a C1-C2 cervical dumbbell schwannoma with ventral extension and dorsal spinal cord compression has not been reported previously. This tumor resection video performed by the senior author (KIA) includes details of dural opening, and techniques for microsurgical resection and for postoperative closure to avoid cerebrospinal fluid (CSF) leak and pseudomeningocele formation. Fat grafting was performed through a small paraumbilical incision. The patient was prone in MAYFIELD 3-point pin fixation (Integra LifeSciences, Plainsboro Township, New Jersey). Intraoperative neurophysiological electrodes were placed for somatosensory evoked potential (SSEP) and motor evoked potential (MEP) monitoring. Stealth neuronavigation was used to aid in tumor localization. A small suboccipital craniectomy and C1 laminectomy were performed before opening the dura. Using a microsurgical technique, the dura was opened in the form of the letter “Y.” The right-sided dentate ligament was cut to aid in the mobilization of the tumor away from the spinal cord. After dividing the tumor at the dumbbell isthmus, the ventral tumor component was removed, with attention paid to the division of a perforator coming from the vertebral artery. Intraforaminal tumor debulking was performed with a cavitron ultrasonic surgical aspirator (CUSA) and resected. High cervical dumbbell schwannoma should be radically resected while preserving and improving preoperative neurological function. Avoidance of CSF leak and formation of pseudomeningocele should be planned at the beginning, utilizing fascia and fat graft to avoid this feared complication. The patient provided written consent and permission to publish her image.

Globally, the discipline of neurosurgery has evolved remarkably fast. Despite being one of the latest medical specialties, which appeared only around hundred years ago, it has witnessed innovations in the aspects of diagnostics methods, macro and micro surgical techniques, and treatment modalities. Unfortunately, this development is not evenly distributed between developed and developing countries. The same is the case with neurosurgical education and training, which developed from only traditional apprentice programs in the past to more structured, competence-based programs with various teaching methods being utilized, in recent times. A similar gap can be observed between developed and developing counties when it comes to neurosurgical education. Fortunately, most of the scholars working in this field do understand the coherent relationship between neurosurgical education and neurosurgical practice. In context to this understanding, a symposium was organized during the World Federation of Neurological Surgeons (WFNS) Special World Congress Beijing 2019. This symposium was the brain child of Prof. Yoko Kato—one of the eminent leaders in neurosurgery and an inspiration for female neurosurgeons. Invited speakers from different continents presented the stages of development of neurosurgical education in their respective countries. This paper summarizes the outcome of these presentations, with particular emphasis on and the challenges faced by developing countries in terms of neurosurgical education and strategies to cope with these challenges.

Background Neuroanatomists have long been fascinated by the complex topographic organization of the cerebrum. We examined historical and modern phylogenetic theories pertaining to microneurosurgical anatomy and intrinsic brain tumor development. Methods Literature and history related to the study of anatomy, evolution, and tumor predilection of the limbic and paralimbic regions were reviewed. We used vertebrate histological cross-sections, photographs from Albert Rhoton Jr.’s dissections, and original drawings to demonstrate the utility of evolutionary temporal causality in understanding anatomy. Results Phylogenetic neuroanatomy progressed from the substantial works of Alcmaeon, Herophilus, Galen, Vesalius, von Baer, Darwin, Felsenstein, Klingler, MacLean, and many others. We identified two major modern evolutionary theories: “triune brain” and topological phylogenetics. While the concept of “triune brain” is speculative and highly debated, it remains the most popular in the current neurosurgical literature. Phylogenetics inspired by mathematical topology utilizes computational, statistical, and embryological data to analyze the temporal transformations leading to three-dimensional topographic anatomy. These transformations have shaped well-defined surgical planes, which can be exploited by the neurosurgeon to access deep cerebral targets. The microsurgical anatomy of the cerebrum and the limbic system is redescribed by incorporating the dimension of temporal causality. Yasargil’s anatomical classification of glial tumors can be revisited in light of modern phylogenetic cortical categorization. Conclusion Historical and modern topological phylogenetic notions provide a deeper understanding of neurosurgical anatomy and approaches to the limbic and paralimbic regions. However, many questions remain unanswered and further research is needed to elucidate the anatomical pathology of intrinsic brain tumors.

On September 9-12, 2019, I traveled to Beijing, China for the World Congress of Neurosurgery. I was eager to attend the biggest event of my profession for two reasons. One was my nomination for second vice-president of the World Federation of Neurosurgical Societies (WFNS). The second reason was to learn about Chinese culture for the first time in my life. I was honored to be elected for an officer position of the WFNS and I tremendously enjoyed the grandiosity of the Great Wall of China (Figure 1), the Forbidden City, and Summer Palace; I also enjoyed trying authentic Chinese food.

No abstract available.

OBJECTIVE To describe the technical nuances of multimodal transseptal-transsphenoid surgery for pituitary tumors using a combination of microneurosurgery, neuroendoscopy, and electromagnetic neuronavigation. MATERIALS AND METHODS A transnasal approach to the sella is performed endoscopically and widely exposed by an otolaryngologic surgeon. Surgery is next performed by the neurosurgeon with microscope and neuronavigation for microsurgical resection of pituitary tumors. Neuroendoscope is also used at the end of surgery to confirm tumor resection and inspect operative site. During surgery, the patient's head, angle and height of the microscope, and position of the table are repositionable to allow for multiple angle views. Abdominal fat harvested prior to the procedure is used to ensure cerebrospinal fluid seal. RESULTS The senior author (KIA) has used the combined approach with 84 consecutive patients. Radical resection was achieved in 66 patients, subtotal in 11, and partial in 7. There were no perioperative complications. Six patients experienced postoperative transient diabetes insipidus. The pituitary gland and stalk were preserved in all cases. Visual symptoms were improved in 78% and endocrinological symptoms in 56% of cases. CONCLUSION This combined approach is safe and effective. It increases the efficacy and radicality of surgical resection, helps to preserve the pituitary gland, and improves and resolves preoperatively altered patient hormonal function and impaired vision. It also reduces complications, provides less postoperative pain and discomfort, reduces the surgery time, and enables a shorter hospital-stay.

Abstract In this video, we demonstrate microsurgical resection of IV ventricle subependymoma. To the best of our knowledge, this is the first video case report of a microsurgical resection of subependymoma of the IV ventricle in the peer-reviewed English literature. Subependymomas are benign central nervous system tumors, typically arising in ventricular spaces, mostly in the IV and lateral ventricles.1-3 They are isointense on T1 and hyperintense on T2-weighted magnetic resonance imaging (MRI) with minimal or no enhancement.4 Microsurgery remains the mainstay treatment. Complete tumor resection is possible and curative with excellent prognosis.1,5-7 Although the clinical course appears benign, the inability to diagnose them radiographically with certainty and the possibility of an alternative malignant lesion support a low threshold for early and safe resection.8 A 39-yr-old man presented with severe headache and balance problems. Pre- and postcontrast neuroaxis MRI revealed a centrally located IV ventricle lesion without hydrocephalus. The aim of the surgery was complete tumor resection. Surgery was performed in the prone position by the senior author (KIA) with intraoperative neurophysiology monitoring. A small suboccipital craniotomy and C1 posterior arch removal was done. After opening the dura and arachnoid membrane, the tumor was identified and meticulously dissected from the adjacent posterior inferior cerebellar artery and the floor of the fourth ventricle and from brain stem white matter at the tumor-neural tissue interface to avoid brainstem interference. Histological analysis revealed subependymoma (World Health Organization Grade I). Postoperative pre- and postcontrast MRI revealed complete resection. Headache and balance problems completely resolved; the patient was neurologically intact. The patient provided written consent and permission to publish his image.