Posterolateral Sulcus Approach for Intramedullary Hemorrhage Associated With Cavernous Malformation of High Cervical Spine: Operative Technique and Outcomes.

Objective: Intramedullary hemorrhage (IH) associated with cavernous malformation (CM) of the high cervical spine remains a significant challenge for neurosurgeons. This study aimed to evaluate the efficacy and safety of the posterolateral sulcus (PLS) approach in managing these complex cases.

Methods: This single-center retrospective study included 58 cases of spinal intramedullary tumors treated surgically over the past 4 years. The PLS approach on the side of the IH was applied for the removal of CM. Neurological function was assessed using the modified McCormick functional scale (MMCS) before surgery, one week after surgery, and at the most recent follow-up.

Results: Six patients with IH associated with CM above the C3 level were identified from the database. The mean age was 31.2 years, and 4 of the 6 patients were female. Symptom duration prior to surgery ranged from 0 to 48 months. Total removal of the CM was achieved in all 6 cases without any serious adverse events including respiratory complications. The average follow-up duration was 21.7 months. The mean MMCS score was 3.0 before surgery, maintained at 2.5 in the early postoperative period, and improved further to 2.2 at the most recent follow-up. One patient of ventral-type CM experienced recurrent hemorrhage at the same level 30 months after the initial surgery. This patient subsequently underwent a second surgery using the anterolateral sulcus approach, which was well tolerated.

Conclusion: The PLS approach enables safe removal of CM even in the high cervical spine. However, ventral-type CMs remain a major surgical concern.