Does Cervical Cord Compression Preclude Lateral Suboccipital Positioning in Cerebellopontine Angle Tumor Excision?

Introduction:The lateral suboccipital position for cerebellopontine (CP) angle surgery offers many benefits to the neurosurgeon by increasing surgical exposure to the cranial nerve, brainstem, lateral cerebellum, and the vessels.However, placing the patient's head in this position may pose problems for patients who have an existing cervical myelopathy.The cervical myelopathy may be exacerbated and lead to a new neurological deficit intraoperatively or postoperatively.Utilizing neuromonitoring techniques such as somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs) can help identify injuries due to patient positioning as well as inadvertent surgical insults leading to neurological deficits postoperatively.We describe a case report of a patient posted for CP angle surgery utilizing neuro-monitoring as a technique to recognize neurological insult after positioning the patient in the lateral suboccipital position and prior to commencing the surgery.The objective of this case report is to demonstrate the clinical value of using multimodal intraoperative neuromonitoring (IONM) to prevent iatrogenic spinal cord injury in patients with pre-existing cervical myelopathy undergoing CP angle surgery.Case description: A 49-year-old female patient presented with neck pain, numbness in both hands and giddiness.Her magnetic resonance imaging (MRI) brain was suggestive of a right-sided CP angle meningioma.She was additionally evaluated for her symptoms prior to admission, and her MRI cervical spine showed cord compression at the C5-C6 and C6-C7 levels.Owing to her cervical cord compression and to safeguard against additional injury to the cervical spinal cord during intubation, video laryngoscopy was performed.Corticobulbar tract (CBT) monitoring, SSEP, and MEP were utilized to identify the integrity of the ascending and descending tracts at baseline, after intubation, after positioning in the lateral suboccipital position, during, and after the completion of surgery.The surgery was uneventful, and the tumor was excised successfully with the aid of the neuromonitoring techniques that also helped identify any possible injury to the ascending and descending tracts due to the precarious position for surgery.Conclusion: Patients presenting with overlapping symptoms of cervical cord compression and symptoms due to CP angle tumors will require a neurological screening for cervical myelopathy.Magnetic resonance imaging images of the patient require reviewing to identify any pathology that might confound the progress of the disease and surgery.An avoidance of extreme flexion is required to prevent any iatrogenic injury due to positioning.This case illustrates that for a 49-year-old patient with both a CP angle meningioma and multi-level cervical cord compression (C5-C7), the standard lateral suboccipital position can be safely utilized through a specific safety protocol.The successful outcome was made possible by preoperative cervical screening, the use of video laryngoscopy to limit neck extension, and real-time IONM (SSEP/MEP) to verify the integrity of the ascending and descending tracts during the critical post-positioning phase.We recommend this combined approach as a standard for patients with dual-pathology to avoid permanent neurological deficits.