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Objectives Initially treating vestibular schwannomas (VSs) with subtotal resection (STR) followed by Gamma Knife radiosurgery (GKRS) for progression of tumor residual is a strategy that balances maximal tumor resection with preservation of neurological function. The effect of timing of GKRS for residual and recurrent VSs remains poorly defined. We developed a simple and practical treatment algorithm for the timing of GKRS after STR of VSs and reviewed our follow-up results to determine outcomes between patients treated with early vs. late GKRS. Patients and methods Patients that underwent STR between 1999 and 2017 for a VS at Tufts Medical Center were identified and included in the study cohort. Patients who received GKRS ≤ 12 months after STR were included in the early intervention group. Patients who received GKRS > 12 months after STR or did not have tumor progression on follow-up thus not requiring GKRS were included in the observation/delayed intervention group. Results STR of VSs was performed on 23 patients. Mean patient age at the time of STR was 53.0 years (range: 20–86.2). The mean follow-up was 4.2 years (range: 1 month-15.5 years). Patients most frequently presented with hearing loss. There were 5 patients (21.7 %) in the early intervention group and 18 (78.3 %) patients in the observation/delayed intervention group. Ten of 23 patients (43.5 %) required GKRS. Thirteen (56.5 %) did not receive GKRS. None of the patients in the early intervention group or the observation/delayed intervention group had changes in House-Brackmann (HB) Grade either after GKRS or at the end of the study period. Conclusions GKRS of residual or recurrent tumor is safe following STR of VS and appears to carry a low risk of worsening facial nerve function when performed for progressive tumor growth.

Introduction Cervical spinal cord herniation is a rare clinical entity. Reported after previous intradural surgery or surgery complicated by durotomy, patients return several months to years later with symptoms of worsening myelopathy. Herein is presented a case of a 51-year-old female patient with spinal cord herniation in the cervical spine after kyphosis deformity correction. Case Description A 51-year old female patient presented to the neurosurgery clinic with worsening cervical myelopathy due to cervical spinal cord tethering and adhesions from previous intradural surgery for Chiari malformation. Conservative treatment initially was recommended but ultimately unsuccessful, as her neurologic function continued to deteriorate. Follow-up imaging demonstrated progressive cervical kyphotic deformity with stability of the tethered spinal cord. The patient underwent cervical deformity correction to reduce tension on the spinal cord, after which her neurologic symptoms stabilized and began to improve with physical therapy. Four months after surgery, she returned to clinic with recurrence of cervical myelopathy. Repeat imaging demonstrated herniation of the cervical spinal cord through a dorsal defect, and the patient was treated successfully with a wide cervical duraplasty to recreate an intact thecal sac. Conclusions The inability of the spinal cord to compensate for changes in spinal alignment in cases of tethering makes it susceptible to increased pressure and tension at the point of tethering. Caution is urged when attempting deformity correction in the presence of spinal cord tethering, which may limit the capacity of the spinal cord and surrounding tissue to compensate for alterations in spinal alignment.