scholarly journals Resection of Foramen Magnum Meningioma through Modified Far Lateral Approach: Surgical Principles and Technical Nuances

2020 ◽  
Author(s):  
Vinayak Narayan ◽  
Fareed Jumah ◽  
Anil Nanda
Keyword(s):  
Spinal Cord ◽  
Tumor Resection ◽  
Cranial Nerves ◽  
Surgical Techniques ◽  
Foramen Magnum ◽  
Lateral Approach ◽  
Occipital Condyle ◽  
Far Lateral Approach ◽  
Far Lateral ◽  
Neurovascular Structures

Abstract Objectives Safe maximal resection is the basic principle of cranial base surgery and the grade of resection is an important factor influencing the prognostic outcome. This operative video highlights the surgical principles and technical nuances in the microsurgical resection of foramen magnum meningioma (FMM). Case Description The surgery was performed in a 45-year-old lady who presented with hoarseness of voice and spastic quadriparesis (grade 4/5). On imaging, FMM with mass effect on brainstem and spinal cord was identified. The tumor was gross totally resected through modified far lateral approach with minimal occipital condyle drilling. This video demonstrates the surgical techniques of tumor resection including early devascularization, operating in the arachnoid plane to dissect the neurovascular structures, piecemeal decompression, sharp dissection to separate tumor from lower cranial nerves (LCN), identifying the brainstem veins, and resecting the lesion from tumor–brainstem interface. Postoperatively, she had significant neurological improvement and the magnetic resonance imaging revealed excellent radiological outcome (Figs. 1 and 2). Conclusion The surgery of FMM is challenging due to the deep surgical corridor, critical location, close proximity with various neurovascular structures, firm consistency, and high vascularity of the tumor. The modified far lateral approach by preserving the occipital condyle may prevent the postoperative incidence of craniovertebral junction instability. The key operative principles to achieve the best surgical outcome include careful dissection along the arachnoid plane, gentle handling of cranial nerves, veins, and perforator vessels, avoidance of traction on brainstem and spinal cord, intraoperative neurophysiological monitoring, proper hemostasis, and meticulous dural closure.The link to the video can be found at: https://youtu.be/1qvAeUmNIUw.

Lateral Approach to Anterolateral Tumors at the Foramen Magnum: Factors Determining Surgical Procedure

2005 ◽  
Vol 56 (suppl_4) ◽  
pp. ONS-324-ONS-336 ◽  
Author(s):  
Nevo S. Margalit ◽  
Jonathan B. Lesser ◽  
Michael Singer ◽  
Chandranath Sen
Keyword(s):  
Vertebral Artery ◽  
Tumor Resection ◽  
Surgical Techniques ◽  
Foramen Magnum ◽  
Lateral Approach ◽  
Occipital Condyle ◽  
Transverse Foramen ◽  
Glomus Tumors ◽  
Far Lateral Approach ◽  
Operative Notes

Abstract OBJECTIVE: We discuss and evaluate surgical strategies and results in 42 patients with a variety of tumors involving the anterior and anterolateral foramen magnum and present factors affecting the degree of resection and patient outcomes. We describe our surgical techniques for resection of these tumors via the lateral approach, including consideration for occipital condylar resection and vertebral artery management. METHODS: A retrospective analysis was performed of 42 surgically treated patients with tumors involving the anterior and anterolateral foramen magnum. Patients received treatment between 1991 and 2002; patients’ files, operative notes, and pre- and postoperative imaging studies were used for the analysis. RESULTS: The female-to-male ratio was 28:14. Mean patient age was 47 years. Pathological entities comprised 18 meningiomas, 12 chordomas, 3 glomus tumors, 3 schwannomas, and 6 miscellaneous tumors. We mobilized the vertebral artery at the dural entry point in all patients with meningiomas. The vertebral artery was mobilized at the C1 transverse foramen for the majority of extradural tumors. Partial condyle resection was performed in eight meningiomas and five extradural tumors. Complete condyle resection was required in 12 cases, including 9 chordomas, 2 carcinomas, and 1 bone-invading pituitary adenoma. Thirteen patients required occipitocervical fusion after tumor resection. CONCLUSION: In anterior or anterolaterally located foramen magnum tumors, we think the extreme lateral or far lateral approach affords significant advantages. Vertebral artery mobilization and occipital condyle resection may be needed depending on the extent and location of the foramen magnum tumor and its specific pathological characteristics. Tumor invading the occipital condyle or significant condylar resection may cause occipitocervical instability and require fusion.

scholarly journals Foramen Magnum Meningioma: Far Lateral Approach

2019 ◽  
Vol 80 (S 04) ◽  
pp. S363-S364
Author(s):  
Ciro Vasquez ◽  
Alexander Yang ◽  
A. Samy Youssef
Keyword(s):  
Vertebral Artery ◽  
Cranial Nerves ◽  
Mass Effect ◽  
Craniocervical Junction ◽  
Foramen Magnum ◽  
Lateral Approach ◽  
Neurological Deficits ◽  
Occipital Condyle ◽  
Far Lateral Approach ◽  
Far Lateral

We present a case of a foramen magnum meningioma in a 42-year-old female who presented with headaches for 2 years, associated with decreased sensation and overall feeling of “heaviness” of the right arm. The tumor posed significant mass effect on the brainstem, and given the location of the tumor in the anterolateral region of the foramen magnum, a right far lateral approach was chosen. The approach incorporates the interfascial dissection technique to safely expose and preserve the vertebral artery in the suboccipital triangle. After drilling the posteromedial portion of the occipital condyle and opening the dura, the tumor can be entirely exposed with minimal retraction on the cerebellum. The working space offered by the far lateral approach allows careful dissection at the lateral craniocervical junction, and preservation of the V4 segment of the vertebral artery and the lower cranial nerves. Simpson's grade-2 resection was achieved with coagulation of the dural base around the vertebral artery. The postoperative course was unremarkable for any neurological deficits. At the 2-year follow-up, imaging identified no recurrence of tumor and the patient remains asymptomatic.The link to the video can be found at: https://youtu.be/IMN1O7vO5B0.

The far-lateral approach for foramen magnum meningiomas

2013 ◽  
Vol 35 (6) ◽  
pp. E12 ◽  
Author(s):  
Bruno C. Flores ◽  
Benjamin P. Boudreaux ◽  
Daniel R. Klinger ◽  
Bruce E. Mickey ◽  
Samuel L. Barnett
Keyword(s):  
Skull Base ◽  
Cervical Spinal Cord ◽  
Tumor Resection ◽  
Cranial Nerves ◽  
Foramen Magnum ◽  
Lateral Approach ◽  
Surgical Approaches ◽  
Confined Space ◽  
Far Lateral Approach ◽  
Far Lateral

Foramen magnum meningiomas (FMMs) are slow growing, most often intradural and extramedullary tumors that pose significant challenges to the skull base neurosurgeon. The indolent clinical course of FMMs and their insidious onset of symptoms are important factors that contribute to delayed diagnosis and relative large size at the time of presentation. Symptoms are often produced by compression of surrounding structures (such as the medulla oblongata, upper cervical spinal cord, lower cranial nerves, and vertebral artery) within a critically confined space. Since the initial pathological description of a FMM in 1872, various surgical approaches have been described with the aim of achieving radical tumor resection. The surgical treatment of FMMs has evolved considerably over the last 4 decades due to the progress in microsurgical techniques and development of a multitude of skull base approaches. Posterior and posterolateral FMMs can be safely resected via a standard midline suboccipital approach. However, controversy still exits regarding the optimal management of anterior or anterolateral lesions. Independently of technical variations and the degree of bone removal, all modern surgical approaches to the lower clivus and anterior foramen magnum derive from the posterolateral (or far-lateral) craniotomy originally described by Roberto Heros and Bernard George. This paper is a review of the surgical management of FMMs, with emphasis on the far-lateral approach and its variations. Clinical presentation, imaging findings, important neuroanatomical correlations, recurrence rates, and outcomes are discussed.

scholarly journals Technical strategies to approach aneurysms of the vertebral and posterior inferior cerebellar arteries

2005 ◽  
Vol 19 (2) ◽  
pp. 1-5 ◽  
Author(s):  
Niklaus Krayenbühl ◽  
Carlos A. Guerrero ◽  
Ali F. Krisht
Keyword(s):  
Posterior Inferior Cerebellar Artery ◽  
Cranial Nerves ◽  
Foramen Magnum ◽  
Lateral Approach ◽  
Anatomical Location ◽  
Microsurgical Anatomy ◽  
Far Lateral Approach ◽  
Far Lateral ◽  
Pica Aneurysms ◽  
Lower Cranial Nerves

Object Aneurysms of the vertebral artery (VA) and proximal posterior inferior cerebellar artery (PICA) are rare and challenging lesions, as they are located in front of the brainstem and surrounded by the lower cranial nerves. Many different approaches have been described for their treatment, and have yielded different results. With the use of different examples of lesions, the authors describe their surgical strategy in the management of VA and PICA aneurysms. Methods The far-lateral approach was used, and the potential of its different extensions according to the specific anatomical location and configuration of different types of aneurysms is emphasized. Conclusions With the present knowledge of the microsurgical anatomy in the region of the foramen magnum, the far-lateral approach can be tailored to the specific anatomical and morphological configuration of an aneurysm in this region with good surgical results.

Endoscope-Assisted Resection of Extra-Axial Premedullary Neurenteric Cyst via Far Lateral-Supracondylar Approach: 2-Dimensional Operative Video

2021 ◽  
Author(s):  
Kunal V Vakharia ◽  
Ryan M Naylor ◽  
Jamie J Van Gompel
Keyword(s):  
Posterior Inferior Cerebellar Artery ◽  
Cranial Nerves ◽  
Craniocervical Junction ◽  
Foramen Magnum ◽  
Lateral Approach ◽  
Neurenteric Cyst ◽  
En Bloc ◽  
Icg Angiography ◽  
Far Lateral Approach ◽  
Far Lateral

Abstract Neurenteric cysts are rare congenital lesions that may compress the ventral brainstem.1-9 In this operative video, we illustrate the surgical treatment of an intradural extra-axial neurenteric cyst extending from the lower pons to the craniocervical junction. The patient, an asymptomatic 52-yr-old female, underwent surveillance imaging of the premedullary lesion for 14 yr without progression. However, after developing progressive strain-induced headaches, imaging revealed a significant enlargement of the lesion with brainstem compression and partial obstruction of the foramen magnum. Therefore, surgical resection was pursued. The patient consented to the procedure. The patient underwent a lateral suboccipital craniotomy and C1 laminectomy through a far lateral approach. The lesion was immediately visualized upon opening the dura. After identifying the cranial nerves, we resected the tumor while taking care to preserve the neurovascular elements of the cerebellopontine angle and foramen magnum. During the resection, we unexpectedly encountered a firm nodule that was adherent to the right posterior inferior cerebellar artery. This was meticulously dissected and removed en bloc using intraoperative indocyanine green (ICG) angiography. The cavity was inspected with 0-degree and 30-degree endoscopes to ensure complete resection of the lesion. Gross total resection was confirmed on postoperative magnetic resonance imaging. The patient was neurologically intact with no cranial nerve abnormalities and discharged home on postoperative day 3. This case demonstrates that the far lateral-supracondylar approach affords safe access to the ventral pontomedullary and craniocervical junctions and that intraoperative adjuncts, including ICG angiography and endoscopic visualization, can facilitate complete lesion resection with excellent clinical outcomes.

scholarly journals Tailored Surgical Approaches for Foramem Magnum Tumors

2019 ◽  
Vol 39 (02) ◽  
pp. 061-067
Author(s):  
Jose Carlos Lynch ◽  
Celestino Esteves Pereira ◽  
Leonardo C. Weling ◽  
Mariangela Gonçalves
Keyword(s):  
Surgical Techniques ◽  
Foramen Magnum ◽  
Lateral Approach ◽  
Surgical Approaches ◽  
Lower Cranial Nerve ◽  
Suboccipital Craniotomy ◽  
Anatomic Location ◽  
Cranial Nerve Dysfunction ◽  
Far Lateral Approach ◽  
Far Lateral

Objective To describe our surgical techniques, analyze their safety and their postoperative outcomes for foramen magnum tumors (FMTs). Methods From 1986 to 2014, 34 patients with FMTs underwent surgeries using either the lateral suboccipital approach, standard midline suboccipital craniotomy, or the far lateral approach, depending on the anatomic location of the lesions. Results In the present series, there were 22 (64.7%) female and 12 (35.2%) male patients. The age of the patients ranged from 12 to 63 years old. We observed 1 operative mortality (2.9%). A total of 28 patients (82.3%) achieved a score of 4 or 5 in the Glasgow Outcome Scale (GOS). Gross total resection (GTR) was obtained in 22 (64.7%) patients. After the surgery, 9 (26%) patients developed lower cranial nerve dysfunction (LCNd) weakness. The follow-up varied from 1 to 24 years (mean: 13.2 years). Conclusion The majority of tumors located in the FM can be safely and efficiently removed using either the lateral sub occipital approach, standard middle line sub occipital craniotomy, or the far lateral approach, depending on the anatomic location of the lesions.

Far-lateral approach to intradural lesions of the foramen magnum without resection of the occipital condyle

2002 ◽  
Vol 96 (2) ◽  
pp. 302-309 ◽  
Author(s):  
Anil Nanda ◽  
David A. Vincent ◽  
Prasad S. S. V. Vannemreddy ◽  
Mustafa K. Baskaya ◽  
Amitabha Chanda
Keyword(s):  
Craniocervical Junction ◽  
Foramen Magnum ◽  
Lateral Approach ◽  
Additional Patient ◽  
Occipital Condyle ◽  
Rheumatoid Disease ◽  
Content Type ◽  
Far Lateral Approach ◽  
Far Lateral ◽  
Fine Print

Object. The goal of this study was to determine whether drilling out the occipital condyle facilitates surgery via the far-lateral approach by comparing data from 10 clinical cases with that from studies of eight cadaver heads. Methods. During the last 6 years at Louisiana State University Health Sciences Center—Shreveport, 10 patients underwent surgery via the far-lateral approach to the foramen magnum. Six of these patients harbored anterior foramen magnum meningiomas, one patient a dermoid cyst, two patients vertebral artery (VA) aneurysms, and an additional patient suffered from rheumatoid disease of the craniocervical junction. The surgical approach consisted of retromastoid craniectomy and C-1 laminectomy. The seven tumors and the pannus of rheumatoid disease were completely excised, and the two aneurysms were clipped without drilling the occipital condyle. In one patient a chronic subdural hematoma was found 3 months after surgery, but no patient displayed any complication associated with surgery. It is significant that in no patient was a cerebrospinal fluid leak present. All patients experienced improved neurological function postoperatively. To compare surgical visibility, eight cadaveric specimens (16 sides) were studied, including delineation of the VA and its segments around the craniocervical junction. Increase in visibility as a function of fractional removal of the occipital condyle was quantified by measuring the degrees of visibility gained by removing one third and one half of the occipital condyle. Removal of one third of the occipital condyle produced a mean increase of 15.9° visibility, and removal of one half produced a mean increase of 19.9°. Conclusions. On the basis of their findings the authors conclude that removal of the occipital condyle is not necessary for the safe and complete resection of anterior intradural foramen magnum tumors.

scholarly journals Far Lateral Transcondylar Transtubercular Approach for Microsurgical Resection of Foramen Magnum Meningioma: Operative Video and Technical Nuances

2020 ◽  
Author(s):  
James K. Liu ◽  
Vincent N. Dodson ◽  
Ali T. Meybodi
Keyword(s):  
Vertebral Artery ◽  
Cranial Nerve ◽  
Cranial Nerves ◽  
Foramen Magnum ◽  
Lateral Approach ◽  
Neurological Deficits ◽  
Endoscopic Endonasal ◽  
Surgical Access ◽  
Far Lateral Approach ◽  
Far Lateral

AbstractSurgical access to the ventral foramen magnum remains a technical challenge. With large lesions in this region compressing the brainstem and distorting the regional neurovascular relationships, formulating a surgical plan and its appropriate execution have crucial importance in achieving favorable outcomes. While the endoscopic endonasal approaches have gained increasing attention to access the clivus and the ventral brainstem, foramen magnum meningiomas are still preferred to be removed via an approach that obviates a trajectory through the nasopharyngeal mucosa. Therefore, the far lateral approach remains one of the most practical approaches for these challenging lesions. This operative video demonstrates the use of the far lateral transcondylar transtubercular approach to remove a large meningioma in the ventral foramen magnum in a 63-year-old male with progressive cervical myelopathy, presenting as spastic quadriparesis without any cranial nerve abnormality. Using a right-sided far lateral transcondylar transtubercular approach, the meningioma was exposed within the cerebellomedullary gutter engulfing the vertebral artery and distorting the course of the adjacent cranial nerves. Using the different corridors identified between the vertebral artery, spinal accessory, vagus, and hypoglossal nerves, multiple angles of attacks to the tumor were established and utilized to resect the lesion. A gross total resection was achieved and the patient was neurologically intact without any neurological deficits. This video demonstrates the importance of understanding the intricacies of neurovascular anatomy of the cervicomedullary region (i.e., the various triangles formed between these structures), and the effective use of these corridors to safely and efficiently remove a challenging ventral foramen magnum meningioma with neurovascular involvement, while preserving cranial nerve function. The surgical technique and nuances are described in a step-by-step fashion in this illustrative operative video.The link to the video can be found at: https://youtu.be/s1dFhuaRSt8.

The far lateral/combined supra- and infratentorial approach

1994 ◽  
Vol 81 (1) ◽  
pp. 60-68 ◽  
Author(s):  
Hillel Z. Baldwin ◽  
Christopher G. Miller ◽  
Harry R. van Loveren ◽  
Jeffrey T. Keller ◽  
C. Phillip Daspit ◽  
...  
Keyword(s):  
Brain Stem ◽  
Craniovertebral Junction ◽  
Foramen Magnum ◽  
Lateral Approach ◽  
Direct Access ◽  
Content Type ◽  
Far Lateral Approach ◽  
Far Lateral ◽  
Lower Clivus ◽  
Neurovascular Structures

✓ A far lateral approach to the ventral brain stem, lower clivus, and anterior foramen magnum is described. Methods for further exposure of the superior petroclival region by incorporating a subtemporal craniotomy and posterior petrosectomy are also demonstrated. Eight sequentially illustrated steps depict this technique. The far lateral/combined supra- and infratentorial exposure is a comprehensive surgical approach that provides direct access to the entire anterior and lateral brain stem and craniovertebral junction. It minimizes brain-stem retraction and maximizes visualization of the neurovascular structures.

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