Avoidance and Management of Complications in Retrosigmoid Approach to Vestibular Schwannomas

An experience with two rare complications during surgery of vestibular schwannomas (VSs) is presented, and measures to avoid and manage the complications are discussed.Case A: Spinal cord ischemia in semi-sitting position: A 47-year-old with a giant vestibular schwannoma (VS) underwent surgery through a retrosigmoid approach in the semi-sitting position. The intraoperative phase was uneventful, except for an episode of moderate hypotension. Postoperatively, the patient woke up with quadriparesis. MRI on the cervical spine revealed restricted diffusion from C4 to C7 suggestive of cord ischemia. Complete neurological recovery occurred over the following 3 months. Awareness of this potential complication, preoperative screening for degenerative spine disease, avoiding excessive intraoperative cervical flexion, using sensory & motor evoked potentials, and diligently avoiding intraoperative hypotension can prevent such occurrences.Case B: High-riding jugular bulb (HRJB) injury: A 42-year-old male patient underwent a retrosigmoid approach for a right-sided VS in the lateral position. During internal auditory canal (IAC) drilling, there was an injury to the HRJB, resulting in torrential bleeding. It was managed successfully with the sequential application of Gelfoam, fibrin glue, and Surgicel. The drilling was carefully continued by using a diamond drill, and the complete excision of VS was achieved with no injury to cranial nerve 7 (CN7) while maintaining normal facial symmetry. Awareness of an HRJB reduces the risk, and in case of injury, sequential hemostatic measures ensure adequate IAC drilling and the total excision of the tumor.