Color Atlas of Brainstem Surgery

Spetzler RF, Kalani MYS, Nakaji P, Yagmurlu K. Color Atlas of Brainstem Surgery. Thieme; 2017; 416 pp; 850 ill; $249.99

cover of Spetzler

This recent publication is a unique work that emphasizes the structural and functional anatomy of the thalamus and brainstem and provides guidance for accessing these regions surgically for intrinsic lesions. The print atlas is accompanied by a large collection of online media, including animations and narrated surgical videos.

The book opens with an overview of anatomy, beginning with surface structures and perpendicular sections of whole fixed brains and progressing through focused dissections. To clarify specific relationships, it strategically incorporates diagrams of deep venous anatomy and cisterns around the brainstem. It summarizes the function and location of the long fiber tracts at the level of the cerebrum, midbrain, pons, medulla, and spinal cord, reviewing the clinically significant deficits incurred with lesions at each level. The discussion then integrates these concepts to introduce the safe entry zones of the brainstem, identifying both surface and deep structures that must be avoided. Fixed tissue dissections of varying depth demonstrate the three-dimensional relationships of adjacent tracts and nuclei. Full-color illustrations and dissection views of the associated vasculature are accompanied by axial slices depicting the territories of arterial supply. The combination of detailed sketches and meticulous dissections helps the reader bridge the conceptual gap between cross-sectional images and a surgeon’s view of the deeper structures that are imminently transgressed. The anatomy section finishes with a summary of the skull base foramina and traversing cranial nerves.

The next section of the book specifically describes the safe entry zones and nearby landmarks, with illustrations that depict the surface and cross-sectional anatomy of each zone. Some of this content is outlined in the preceding chapter, but this section provides a detailed rationale for the use of the safe entry zones based on adjacent and deep structures. The figures are intuitive, the labeling is easy to follow, and the legends provide thorough explanations of the concepts, but the inclusion of references for further information would have been valuable.

The third section of the book summarizes general principles of microsurgery and brainstem surgery, such as the use of dynamic retraction, the keyhole concept, and the 2-point method in choosing an operative approach to an intrinsic lesion. This leads to the fourth section, which reviews the steps to performing various skull base approaches, incorporating considerations for patient position, skin incision, and craniotomy flap. Each basic approach is described, followed by variations, and includes an explanation of how each module affects the final exposure achieved. Detailed illustrations accompany these discussions and are followed by step-by-step cadaveric dissections to demonstrate the stages of each procedure. These discussions provide a thorough review for surgeons with some familiarity with the procedures, although again, references are not included for readers wanting more detail. Anterior cranio-orbital, anterior petrosal, middle fossa, posterior petrosal, combined supra- and infratentorial, suboccipital, retrosigmoid, far-lateral, interhemispheric and pineal region approaches and variants are described. The online media animations demonstrate the location of safe entry zones accessible through each surgical approach.

The final and largest section of the book is an extensive collection of surgical cases. These are organized by brainstem region, from the thalamus to the cervical spinal cord, and encompass numerous cavernous malformations as well as arteriovenous malformations, various intra-axial tumors, and bypass procedures for complex aneurysms. Each case is introduced with a helpful bulleted list that includes the diagnosis, neurologic status, approach, position, and outcome. Illustrations reference the approach and brainstem safe entry zone as discussed previously in the book, and pertinent imaging is displayed. A series of intraoperative photographs arrayed side-by-side with labeled sketches guides the reader through the steps of the procedure, demonstrating the manner in which, for instance, a cavernous malformation is mobilized or an anastomosis sutured. The online operative videos, provided for all 51 cases, reiterate the teaching points and highlight the subtle differences between similar-looking cases and the technical keys to successful completion of each procedure.

This remarkable work makes the formidable undertaking of brainstem surgery comprehensible and feasible while demonstrating a safe and judicious approach to its application. A nuanced discussion of brainstem anatomy and a focused review of complex skull base approaches are integrated through the experience of a neurosurgical pioneer to create a resource distinct from works that cover these subjects singly. This atlas will be a valuable reference for all students and practitioners of cranial neurosurgery.

Color Atlas of Brainstem Surgery
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