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.

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.

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.

scholarly journals Unilateral extended suboccipital approach for a C1 dumbbell schwanoma

2015 ◽  
Vol 22 (1) ◽  
pp. 38-42
Author(s):  
R.M. Gorgan ◽  
Angela Neacşu ◽  
A. Giovani
Keyword(s):  
Vertebral Artery ◽  
Fibrous Tissue ◽  
Cranial Nerves ◽  
Gain Control ◽  
Complete Removal ◽  
Craniovertebral Junction ◽  
Lateral Approach ◽  
Far Lateral Approach ◽  
Far Lateral ◽  
Lower Cranial Nerves

Abstract Craniovertebral junction tumors represent a complex pathology carrying a high risk of injuring the vertebral artery and the lower cranial nerves. Dumbbell C1- C2 schannomas are very rare tumors in this location. We present a case of a 66 years old male accepted for left laterocervical localized pain, headache and vertigo, with a large C1 dumbbell schwannoma extending in lateral over the C1 arch and displacing the C3 segment of the vertebral artery superiorly and anteriorly. Complete removal of the tumor was achieved using a far lateral approach. The approach is discussed with focus on the vertebral artery anatomy as the approach should give enough space to gain control of the artery without creating instability. Safe removal of C1 nerve root schwanomas can be achieved even if they compress and displace the vertebral artery by entering a fibrous tissue plane between the tumor and the vertebral artery.

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.

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 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.

scholarly journals Resection of a Meningioma at Craniocervical Junction through Far Lateral Approach: Two-Dimensional Operative Video

2019 ◽  
Vol 80 (S 04) ◽  
pp. S358-S359
Author(s):  
Yong Yan ◽  
Hongxiang Wang ◽  
Tao Xu ◽  
Zhenyu Gong ◽  
Fan Hong ◽  
...  
Keyword(s):  
Vertebral Artery ◽  
Medulla Oblongata ◽  
Posterior Inferior Cerebellar Artery ◽  
Craniocervical Junction ◽  
Lateral Approach ◽  
World Health ◽  
Neurological Deficits ◽  
Who Grade ◽  
Far Lateral Approach ◽  
Far Lateral

Tumors located in the craniocervical junction region are significantly challenging for surgical resection. We shared our experience of a meningioma at craniocervical junction resected through far lateral approach in a 68-year-old female. The patient presented with intermittent headache with discomfort in the neck and shoulders for 3 years without any positive signs. Magnetic resonance imaging (MRI) revealed a tumor of 3.6 cm × 3.0 cm × 2.5 cm lying at the ventral side of medulla oblongata, with T1 hypointensity, T2 hyperintensity, and a significant enhancement on T1-contrast image. The far lateral approach on the right side was planned to resect the tumor with a park-bench position. The patient underwent a standard craniotomy using a lazy S-shaped incision. The transposition of vertebral artery was performed carefully therein, followed by removal of part of the arches of atlas and axis. After exposure of the tumor, vertebral artery (VA) and posterior inferior cerebellar artery (PICA) adhesive to the lesion could be seen operatively. Truncating the supplying blood vessels of the tumor was taken as the first step, followed by resecting the tumor mass in a piecemeal manner. While preserving VA, PICA, posterior nerves, medulla oblongata, and cervical cord, gross-total resection was achieved under the careful operation. The patient tolerated the procedure well without any neurological deficits. Histological examination confirmed the tumor as a meningioma (World Health Organization [WHO] grade I). Postoperative MRI scan depicted complete resection of the tumor. The patient remained symptom free without any evidence of recurrence during the follow-up period of 1 year. Informed consent was obtained from the patient.The link to the video can be found at: https://youtu.be/i9H-wS4fF10.

scholarly journals Muscular-stage Dissection during Far Lateral Approach and Its Transcondylar Extension

2018 ◽  
Vol 79 (S 04) ◽  
pp. S356-S361 ◽  
Author(s):  
Sakyo Hirai ◽  
Yoshiki Obata ◽  
Taketoshi Maehara ◽  
Masaru Aoyagi ◽  
Akihito Sato
Keyword(s):  
Vertebral Artery ◽  
Transverse Process ◽  
Foramen Magnum ◽  
Lateral Approach ◽  
Oblique Muscle ◽  
Occipital Condyle ◽  
Artery Dissection ◽  
Posterior Arch ◽  
Far Lateral Approach ◽  
Far Lateral

Background The far lateral approach includes exposure of the C1 transverse process, vertebral artery, posterior arch of the atlas, and occipital condyle. We designed a method for systematic muscular-stage dissection and present our experience with this approach. Operative Methods We used a horseshoe scalp flap that was reflected downward and medially. The lateral muscle layers were separated layer to layer to expose the suboccipital triangle. The medial muscle layers were separated in the midline and reflected in a single layer. At this stage, the midline of the C1 process and the foramen magnum were identified. The rectus capitis posterior major muscle was reflected to expose the posterior arch of the atlas. The C1 transverse process and vertebral artery were identified by reflection of the superior oblique muscle. The occipital condyle was separated accordingly. Results We used this method of muscular dissection in 10 patients (foramen magnum meningioma, n = 5; hypoglossal schwannoma, n = 2; others, n = 3). Systematic muscular-stage dissection facilitates identification of the anatomical landmarks with no vertebral artery injury. Gross total removal was obtained in all 9 patients with complex tumors. The patient with vertebral artery dissection successfully underwent proximal clipping. Conclusion Our muscular-stage dissection could contribute to safe and effective surgery for the far lateral approach.

Direct Lateral Approach to Pathology at the Craniocervical Junction: A Technical Note

2011 ◽  
Vol 70 (suppl_2) ◽  
pp. ons202-ons208 ◽  
Author(s):  
Kalil G. Abdullah ◽  
Richard S. Schlenk ◽  
Ajit Krishnaney ◽  
Michael P. Steinmetz ◽  
Edward C. Benzel ◽  
...  
Keyword(s):  
Craniocervical Junction ◽  
Foramen Magnum ◽  
Lateral Approach ◽  
Technical Note ◽  
Upper Cervical Spine ◽  
Endoscopic Endonasal ◽  
Far Lateral Approach ◽  
Upper Cervical ◽  
Direct Lateral Approach ◽  
Far Lateral

ABSTRACT BACKGROUND: Approaches to the foramen magnum and upper cervical spine traditionally include the posterior midline, far lateral, and endoscopic endonasal approaches. The far lateral approach is a well-established technique for the removal of pathology ventrolateral to the brainstem and the craniocervical junction, but it may be too extensive for lesions limited to areas far from the midline. OBJECTIVE: To present an alternative to the commonly used approaches to the foramen magnum and upper cervical. METHODS: We used an approach directly overlying ventral or lateral pathology. RESULTS: Two cases are presented in which the direct lateral approach followed by an occipitocervical fusion was successfully performed. CONCLUSION: This approach can be considered for patients in whom a ventral decompression is necessary but an endoscopic endonasal approach is undesirable or when a ventral, lateral, and ventrolateral resection of tumor, pannus, or infection is required.

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