@Rita13 if this helps this is my complete surgical report with Dr. Liu. He really makes sure he covers all bases when it comes to decompressing and making sure it stays that way. You could even show Dr. Hackman and see what he thinks as well. Good luck!!!
FACILITY: Cooperman Barnabas/CBMC
REPORT NAME: OPERATIVE REPORT
DATE OF SERVICE: 6/29/2026
SURGEON: James K. Liu, MD
ASSISTANTS: Uchenna Peter-Okaka, MD
PREOPERATIVE DIAGNOSIS: Left atlanto-styloid jugular venous compression syndrome.(M89.8X8, I87.1)
POSTOPERATIVE DIAGNOSIS: Left atlanto-styloid jugular venous compression syndrome.(M89.8X8, I87.1)
OPERATION:
- Left extended far-lateral infralabyrinthine anterolateral approach to
the craniocervical junction.(61597-62) - Resection of extradural styloid process and C1 transverse process for internal jugular vein decompression.(61615)
- Cranioplasty greater than 5 cm.(62141)
- Use of intraoperative microscope.(69990)
- Use of intraoperative ICG angiography.(99240)
- Use of stereotactic image guidance.(61781)
COMPLICATIONS: None.
INTRAOPERATIVE FINDINGS: The left internal jugular vein (IJV) was exposed at the level of the skull base and craniocervical junction. The styloid process was about 2.4 cm and was removed with a high-speed drill and Kerrison rongeurs. We then drilled down the C1 transverse process until we fully decompressed the IJV. These maneuvers were required to get adequate circumferential decompression of the IJV. We also performed fasciotomy and lysis of connective tissue overlying the IJV to allow for vein expansion. The posterior belly of the digastric muscle was resected to expose the IJV and to ensure the IJV was fully decompressed. Post-decompression ICG angiography showed excellent anterograde filling of a more dilated IJV. Cranial nerves 7 and 10-12 MEPs remained intact.
INDICATIONS: This is a 39 year-old female who presented with jugular vein compression syndrome. Her symptoms are comprised of persistent brain fog, memory impairment, confusion, and dissociative sensations described as feeling detached. She also reports bilateral chronic head and facial pressure, daily headaches with intermittent migraines, and electric shock-like sensations in the head. Otologic symptoms include constant bilateral ear pressure, tinnitus (ringing), popping and crackling, intermittent whooshing sounds, and occasional perception of heartbeat in the ears (especially when laying flat). She reports intermittent stabbing ear pain and rare episodes of clear fluid drainage.
Visual symptoms include bilateral blurred vision, floaters, static-like visual disturbances especially when she looks up or outside, brighter lights trigger this and has pressure behind the eyes. She reports frequent dizziness and orthostatic symptoms, including near-syncope with tunnel vision and several prior syncopal episodes. Additional symptoms include jaw and neck pain, pain in back of the throat, throat discomfort with persistent globus sensation, dysphagia affecting both solids and liquids, hoarseness, and frequent throat clearing. She also reports generalized fatigue, weakness, palpitations with fluctuating blood pressure (cardiac workup reportedly normal), shortness of breath, gastrointestinal issues, and diffuse body pain. Neurologic symptoms include intermittent numbness, tingling, and weakness in the upper extremities, more pronounced on the left, as well as episodic facial twitching. Symptoms are predominantly localized to the head and neck, with bilateral involvement but slightly worse on the left side. When extending the neck, she gets TV static vision (visual snow), and bilateral tinnitus. Her symptoms are profoundly debilitating. As such, the patient is unable to work and reports significant impairment in daily functioning, including inability to participate in family life, social activities, or routine tasks. She reports difficulty with eating, speaking for extended periods, concentration, and mobility during symptomatic episodes.
CTA and CTV atlantostyloid jugular vein compression, left greater than the right. The left IJV was severely compressed between the styloid and C1 transverse process. There were also vertebral venous collateral engorgement formed as accessory venous pathways due to the chronic jugular venous compression. Preoperative dynamic angiogram with venous manometry showed that venous collaterals and engorgement of the vertebral venous plexus on the both sides. There was a venous pressure gradient of 3 mm Hg on the left (sigmoid sinus 15, IJ at C2 12 mm Hg) and a pressure gradient of 3 mm Hg on the left (sigmoid sinus 14, IJ at C2 11 mm Hg). The superior sagittal sinus pressure increased from 13 to 20 with head extension. It is my suspicion that the venous compression is contributing to venous hypertension and obstruction of venous outflow which can produce his debilitating symptoms. Because the symptoms are primarily on the left and the left IJV is more compressed, I have therefore recommended a left internal jugular vein decompression via a left infralabyrinthine far lateral (anterolateral) skull base approach to the craniocervical junction for resection of the bone at the skull base (styloid process and C1 tubercle), jugular vein fasciotomy to decompress the internal jugular vein.
We informed the patient all the risks of the operation, which included but not limited to bleeding, infection, CSF leak, transient or permanent neurological deficits including numbness or weakness, risk of vascular injury and all risks related to the anesthesia. We also informed the patient that there is also possibility that she could have persistent symptoms such as headaches, dizziness, and tinnitus after styloidectomy/C1 decompression which may be related to other conditions. She understands these risks and would like to proceed with surgery. Informed consent was obtained and all questions were answered.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed under general endotracheal anesthesia. A formal time-out was performed at the start of the case identifying name of the patient, name of the
procedure, and all known drug allergies. The patient was positioned in the
supine position with the head on horseshoe head holder. Head was turned towards the right, approximately 45 degrees, to expose the left neck and mastoid. A left shoulder role was placed to facilitate positioning. All pressure points were adequately padded and the patient was secured to the table with adhesive tape. A left craniocervcial incision that extended superiorly behind the mid-retroauricular region was marked that ran along the anterior border of the sternocleidomastoid muscle behind the angle of the jaw.
Stereotactic image guidance was used (61781) for intraoperative nagivation of the skull base and craniocervical junction region using CTA head and neck images. This allowed for accurate and precise anatomic localization and 3D reconstruction of the arterial and venous anatomy with the bony structures, demonstrating the severe point of atlanto-styloid venous compression. Using a 10 blade, the skin incision was made.
We then performed a left extended anterolateral (far lateral) infralabyrinthine approach to the craniocervical junction (61597). The skin incision was made with a 10 blade and we dissected along the medial border of the sternocleidomastoid muscle to identify the left internal jugular vein, the spinal accessory nerve and the posterior belly of the digastric muscle. We mobilized the sternocleidomastoid muscle posteriorly, detatching it from the subocciput and mobilized the posterior belly of the digastric muscle anteriorly with fish hooks. We removed lymph nodes that were obstructing the exposure to the jugular vein. The occipital artery was ligated with suture ligatures and divided sharply to access the C1 transverse process. We exposed the palpable C1 transverse process that was compressing the posterior aspect of the IJV. We then identified the styloid process after reflecting the posterior belly of the digastric muscle inferiorly from the scalp flap. The IJV was displaced anteriorly by the C1 transverse process and severely compressed at this level by the enlarged styloid process. The spinal accessory nerve (CN 11) was coursing along the posterior surface of the IJV superiorly, and coursed along the posterior surface of the IJV and turned posteriorly towards the sternocleidomastoid muscle at the level of C1 just anterior to the C1 transverse process.
We brought in the intraoperative microscope (69990) for magnification and illumination. We then performed the infralabyrinthine mastoidectomy and removal of the mastoid tip. This maneuver allowed us to mobilize the posterior belly of the digastric muscle more superiorly and anteriorly to get better exposure of the skull base while protecting the facial nerve.
I then performed removal of the extradural craniocervical junction bony processes that was compressing the IJV at the skull base, namely the styloid process and the C1 transverse process (61615). We dissected out and isolated the styloid process with a Fukushima A-dissector and upangled curette. The styloid was noted to be very thick and elongated, and fused to the skull base. We mobilized and dissected away the muscles attached to the styloid process. We used a high-speed curved tip 2mm diamond drill to remove the proximal end of the styloid and disconnect it from the skull base. We then grabbed the styloid with a tonsil clamp. The distal portion of the styloid was disconnected from the tendinous muscle attachments with a Kerrison rongeur and Metzenbaum scissors to complete the styloid process removal. The muscles attached to the styloid were disconnect sharply with the Metzenbaum scissors. We confirmed that the styloid was removed past the C1 transverse process superiorly near the level of the mastoid tip and skull base. We then resected the posterior belly of the digastric muscle to optimize the exposure of the upper IJV and to maximize the IJV decompression. We then dissected the muscles and fascia off the C1 transverse process and drilled off the tip of the C1 transverse process behind the IJV. The IJV was gently retracted anteriorly with microdissectors and the IJV and accessory nerve were protected during drilling of the C1 transverse process with a high-speed 2 mm diamond drill with irrigation. We removed the C1 until we reached the vertebral artery canal leaving an eggshell bone overlying the vertebral canal. We shaved off all protuberances that were compressing the IJV. This achieved circumferential 360-degree decompression of the IJV. We then performed fasciotomy of the IJV and lysed the soft tissue connective tissue to maximize the expansion of the IJV. At the end of our decompression, we could see clear expansion of the diameter of the IJV with better filling.
Post-decompression intraoperative ICG angiography (92240) showed excellent anterograde venous flow through the IJV. Meticulous hemostasis was achieved. The mastoid air cells were sealed off with bone wax. The wound was irrigated with antibiotic saline.
A cranioplasty greater than 5 cm (62141) was performed using the HydroSet cement to reconstruct the mastoid defect. Once the bone solidified, the wound was irrigated with antibiotic saline. Meticulous hemostasis was achieved and multilayer wound closure was performed with 2-0 Vicryl sutures to reattach the splenius capitis and sternocleidomastoid muscles to the muscle cuff. Multilayered wound closure was performed with 2-0 Vicryl sutures for the galea and dermis and staples for the skin. Wound dressings were applied. SSEP and MEPs were intact. Cranial nerve 11 stimulated well with the Prass probe. MEPs of cranial nerves 7, and 9-12 were intact. All counts of needles and sponges were correct. I was the attending of record and I was present and performed all critical portions of the procedure.
James K. Liu, MD
