History, Variations, and Extensions of the Retrosigmoid Approach: Anatomical and Literature Review

2021 ◽  
Author(s):  
Jaafar Basma ◽  
Christos Anagnostopoulos ◽  
Andrei Tudose ◽  
Mikhail Harty ◽  
L. Madison Michael ◽  
...  
Keyword(s):  
Cerebellopontine Angle ◽  
Jugular Foramen ◽  
Retrosigmoid Approach ◽  
Anatomical Landmarks ◽  
Posterior Fossa Surgery ◽  
Different Types ◽  
Microsurgical Techniques ◽  
Subarachnoid Spaces ◽  
Far Lateral ◽  
Suboccipital Approach

AbstractThe retrosigmoid approach is the workhorse for posterior fossa surgery. It gives a versatile corridor to tackle different types of lesions in and around the cerebellopontine angle. The term “extended” has been used interchangeably in the literature, sometimes creating confusion. Our aim was to present a thorough analysis of the approach, its history, and its potential extensions. Releasing cerebrospinal fluid from the subarachnoid spaces and meticulous microsurgical techniques allowed for the emergence of the retrosigmoid approach as a unilateral variation of the traditional suboccipital approach. Anatomical landmarks are helpful in localizing the venous sinuses and planning the craniotomy, and Rhoton's rule of three is the key to unlock difficult neurovascular relationships. Extensions of the approach include, among others, the transmastoid, supracerebellar, far-lateral, jugular foramen, and perimeatal approaches. The retrosigmoid approach applies to a broad range of pathologies and, with its extensions, can provide adequate exposure, obviating the need for extensive and complicated approaches.

scholarly journals Microvascular Decompression for Geniculate Neuralgia through a Retrosigmoid Approach

2018 ◽  
Vol 80 (S 03) ◽  
pp. S322-S322
Author(s):  
Vincent N. Nguyen ◽  
Jaafar Basma ◽  
Jeffrey Sorenson ◽  
L. Madison Michael
Keyword(s):  
Microvascular Decompression ◽  
Cerebellopontine Angle ◽  
Cranial Nerves ◽  
Senior Author ◽  
Retrosigmoid Approach ◽  
Microsurgical Anatomy ◽  
Pain Syndromes ◽  
Large Vein ◽  
Microsurgical Techniques ◽  
Nervus Intermedius

Objectives To describe a retrosigmoid approach for the microvascular sectioning of the nervus intermedius and decompression of the 5th and 9th cranial nerves, with emphasis on microsurgical anatomy and technique. Design A retrosigmoid craniectomy is performed in the lateral decubitus position. The dura is opened and cerebrospinal fluid (CSF) is released from the cisterna magna and cerebellopontine cistern. Dynamic retraction without rigid retractors is performed. Subarachnoid dissection of the cerebellopontine angle exposes the 7th to 8th nerve complex. A neuromonitoring probe is used with careful inspection of the microsurgical anatomy to identify the facial nerve and the nervus intermedius as they enter the internal auditory meatus. The nervus intermedius is severed. A large vein coursing superiorly across cranial 9th nerve was coagulated and cut. A Teflon pledget is inserted between a small vessel and the 5th nerve. Photographs of the region are borrowed from Dr. Rhoton's laboratory to illustrate the microsurgical anatomy. Participants The senior author performed the surgery. The video was edited by Drs. V.N. and J.B. Outcome Measures Outcome was assessed by postoperative neurological function. Results The nervus intermedius was successfully cut and the 5th and 9th nerves were decompressed. The patient's pain resolved after surgery and at later follow-up. Conclusions Understanding the microsurgical anatomy of the cerebellopontine angle is necessary to identify the cranial nerves involved in facial pain syndromes. Subarachnoid dissection and meticulous microsurgical techniques are key elements for a successful microvascular decompression.The link to the video can be found at: https://youtu.be/pV5Wip7WusE.

Three-Dimensional Computed Tomography Angiography Assisted Resection of Ventral Foramen Magnum and Jugular Foramen Tumours via Modified Far Lateral Suboccipital Approach

2019 ◽  
Vol 9 (2) ◽  
pp. 354-359
Author(s):  
Dongxue Li ◽  
Xuefei Deng ◽  
Shiying Ling ◽  
Nan Zhang ◽  
Dejun Bao ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Facial Paralysis ◽  
Computed Tomography Angiography ◽  
Three Dimensional ◽  
Jugular Foramen ◽  
Foramen Magnum ◽  
Lateral Suboccipital Approach ◽  
Far Lateral ◽  
Suboccipital Approach

Objective: The anatomical relationship of ventral foramen magnum and jugular foramen tumour is complex and the operation is very difficult. The aim of this study was to summarize the microsurgical experience of the removal of the ventral foramen magnum and jugular foramen tumours via the modified far lateral suboccipital approach assisted by three-dimensional computed tomography angiography (3D-CTA). Methods: The clinical data and follow-up results of 13 cases of 3D-CTA assisted suboccipital far lateral approach from July 2011 to September 2017 were analyzed retrospectively. There were 5 males and 8 females. Preoperative CT and MRI were used for routine imaging diagnosis, and the 3D-CTA simulated surgical approach was performed. The preoperative operation scheme was established, and the risk of operation was evaluated according simulated operation. After individualized exposure, the modified far lateral suboccipital approach was completed under the neuroelectrophysiological monitoring technique. Results: The preoperative images were completely consistent with the findings in the surgery. There were 9 cases of jugular foramen tumour and 4 cases of ventral foramen magnum tumour. Of the 13 cases, only 1 case of jugular glomus tumour had extra-cranial residual, while the whole intracranial tumour was removed. In other 12 cases, the tumours were completely removed under the microscope. After operation, the headache disappeared, and hearing loss was improved. There was no perioperative deaths, infection and cerebrospinal fluid leakage. The facial paralysis was occurred in 1 patient. After 3–39 months of follow-up, there was no recurrence of tumour, or new nerve function defect. Hoarseness, choking of drinking water and numbness of limbs were all improved at the end of the follow-up period. The symptoms of postoperative facial paralysis were also improved during the follow-up period. Conclusion: After the preoperative simulation and evaluation by 3D-CTA, the ventral foramen magnum and jugular foramen tumours can be rescted safely and effectively via far modified lateral suboccipital approach.

Suprajugular extension of the retrosigmoid approach: microsurgical anatomy

2014 ◽  
Vol 121 (2) ◽  
pp. 397-407 ◽  
Author(s):  
Ken Matsushima ◽  
Michihiro Kohno ◽  
Noritaka Komune ◽  
Koichi Miki ◽  
Toshio Matsushima ◽  
...  
Keyword(s):  
Skull Base ◽  
Cerebellopontine Angle ◽  
Jugular Foramen ◽  
Jugular Bulb ◽  
Glossopharyngeal Nerve ◽  
Retrosigmoid Approach ◽  
Illustrative Case ◽  
Microsurgical Anatomy ◽  
Total Removal ◽  
Skull Base Approach

Object Jugular foramen tumors often extend intra- and extracranially. The gross-total removal of tumors located both intracranially and intraforaminally is technically challenging and often requires a combined skull base approach. This study presents a suprajugular extension of the retrosigmoid approach directed through the osseous roof of the jugular foramen that allows the removal of tumors located in the cerebellopontine angle with extension into the upper part of the foramen, with demonstration of an illustrative case. Methods The cerebellopontine angles and jugular foramina were examined in dry skulls and cadaveric heads to clarify the microsurgical anatomy around the jugular foramen and to define the steps of the suprajugular exposure. Results The area drilled in the suprajugular approach is inferior to the acoustic meatus, medial to the endolymphatic depression and surrounding the superior half of the glossopharyngeal dural fold. Opening this area exposed the upper part of the jugular foramen and extended the exposure along the glossopharyngeal nerve below the roof of the jugular foramen. In the illustrative case, a schwannoma originating from the glossopharyngeal nerve in the cerebellopontine angle and extending below the roof of the jugular foramen and above the jugular bulb was totally removed without any postoperative complications. Conclusions The suprajugular extension of the retrosigmoid approach will permit removal of tumors located predominantly in the cerebellopontine angle but also extending into the upper part of the jugular foramen without any additional skull base approaches.

Translabyrinthine Approach for Acoustic Neuroma

Neurosurgery ◽  
2004 ◽  
Vol 54 (2) ◽  
pp. 391-396 ◽  
Author(s):  
John Diaz Day ◽  
Douglas A. Chen ◽  
Moises Arriaga
Keyword(s):  
Surgical Treatment ◽  
Acoustic Neuroma ◽  
Cerebellopontine Angle ◽  
Hearing Preservation ◽  
Retrosigmoid Approach ◽  
The Past ◽  
Translabyrinthine Approach ◽  
Acoustic Neuromas

Abstract THE TRANSLABYRINTHINE APPROACH has been popularized during the past 30 years for the surgical treatment of acoustic neuromas. It serves as an alternative to the retrosigmoid approach in patients when hearing preservation is not a primary consideration. Patients with a tumor of any size may be treated by the translabyrinthine approach. The corridor of access to the cerebellopontine angle is shifted anteriorly in contrast to the retrosigmoid approach, resulting in minimized retraction of the cerebellum. Successful use of the approach relies on a number of technical nuances that are outlined in this article.

scholarly journals Gross Total Resection of Large Cerebellopontine Angle Meningioma with a Supratentorial Extension via Retrosigmoid Approach with Suprameatal Drilling and Tentorial Sectioning

2018 ◽  
Vol 79 (S 05) ◽  
pp. S399-S401
Author(s):  
Sima Sayyahmelli ◽  
Adi Ahmetspahic ◽  
Mustafa Baskaya
Keyword(s):  
Surgical Resection ◽  
Cerebellopontine Angle ◽  
Surgical Techniques ◽  
Retrosigmoid Approach ◽  
World Health ◽  
Gross Total Resection ◽  
Total Resection ◽  
Facial Numbness ◽  
Magnetic Resonance Imaging Mri ◽  
Health Organization

Meningiomas are the second most common neoplasm in the cerebellopontine angle (CPA), and are challenging lesions to treat surgically. With significant refinements in surgical techniques, operative morbidity, and mortality have been substantially reduced. Total or near-total surgical resection can be accomplished in the majority of cases via appropriately selected approaches, and with acceptable morbidity. In this video, we present a 51-year-old woman, who had a 2-year history of vertigo with symptoms that progressed over time. She presented with blurry vision, sensorineural hearing loss, tinnitus, left-sided facial numbness, and double vision. Magnetic resonance imaging (MRI) showed a left-sided homogeneously enhancing mass at CPA with a supratentorial extension. MRI appearance was consistent with a CPA meningioma with supratentorial extension. The patient underwent surgical resection via a retrosigmoid approach. Suprameatal drilling and tentorial sectioning were necessary to achieve gross total resection. The surgery and postoperative course were uneventful. The histopathology was a WHO (world health organization) grade I meningioma. MRI showed gross total resection of the tumor. After a 1.5-year follow-up, the patient is continuing to do well with no residual or recurrent disease. In this video, microsurgical techniques and important steps for the resection of this challenging meningioma of the cerebellopontine angle are demonstrated.The link to the video can be found at: https://youtu.be/CDto52GxrG4.

scholarly journals Retrosigmoid transmeatal and suprajugular approach for cerebellopontine angle meningioma: operative video

2017 ◽  
Vol 43 (videosuppl2) ◽  
pp. V3 ◽  
Author(s):  
Ken Matsushima ◽  
Michihiro Kohno
Keyword(s):  
Vagus Nerve ◽  
Temporal Bone ◽  
Surgical Management ◽  
Cerebellopontine Angle ◽  
Jugular Foramen ◽  
Bone Drilling ◽  
Operative Field ◽  
Nerve Monitoring ◽  
Brainstem Surgery ◽  
Neurovascular Structures

Surgical management of cerebellopontine angle meningiomas is challenging due to the intricate neurovascular structures within the limited operative field and the compression of eloquent structures including the brainstem. Surgery on tumors extending into the temporal bone is especially difficult and demands complicated approaches. However, modifications to the retrosigmoid approach utilizing intradural temporal bone drilling enable access to such tumoral extensions without any additional invasive approaches. This video demonstrates the case of a cerebellopontine angle meningioma extending into the internal acoustic meatus and jugular foramen that was surgically treated through the retrosigmoid transmeatal and suprajugular approaches under continuous vagus nerve monitoring.The video can be found here: https://youtu.be/aUD1vr6TbOc.

Comparison of Endoscopic Endonasal Approach and Lateral Microsurgical Infratemporal Fossa Approach to the Jugular Foramen: An Anatomical Study

2021 ◽  
Author(s):  
Jianfeng Liu ◽  
Carlos D. Pinheiro-Neto ◽  
Dazhang Yang ◽  
Eric Wang ◽  
Paul A. Gardner ◽  
...  
Keyword(s):  
Facial Nerve ◽  
Infratemporal Fossa ◽  
Deep Understanding ◽  
Type A ◽  
Jugular Foramen ◽  
Anatomical Landmarks ◽  
Endoscopic Endonasal Approach ◽  
Endonasal Approach ◽  
Endoscopic Endonasal ◽  
Complex Anatomy

Abstract Objective The jugular foramen is one of the most challenging surgical regions in skull base surgery. With the development of endoscopic techniques, the endoscopic endonasal approach (EEA) has been undertaken to treat some lesions in this area independently or combined with open approaches. The purpose of the current study is to describe the anatomical steps and landmarks for the EEA to the jugular foramen and to compare it with the degree of exposure obtained with the lateral infratemporal fossa approach. Materials and Methods A total of 15 osseous structures related to the jugular foramen were measured in 33 adult dry skulls. Three silicone-injected adult cadaveric heads (six sides) were dissected for EEA and three heads (six sides) were used for a lateral infratemporal fossa approach (Fisch type A). The jugular foramen was exposed, relevant landmarks were demonstrated, and the distances between relevant landmarks and the jugular foramen were obtained. High-quality pictures were obtained. Results The jugular foramen was accessed in all dissections by using either approach. Important anatomical landmarks for EEA include internal carotid artery (ICA), petroclival fissure, inferior petrosal sinus, jugular tubercle, and hypoglossal canal. The EEA exposed the anterior and medial parts of the jugular foramen, while the lateral infratemporal fossa approach (Fisch type A) exposed the lateral and posterior parts of the jugular foramen. With EEA, dissection and transposition of the facial nerve was avoided, but the upper parapharyngeal and paraclival ICA may need to be mobilized to adequately expose the jugular foramen. Conclusion The EEA to the jugular foramen is anatomically feasible but requires mobilization of the ICA to provide access to the anterior and medial aspects of the jugular foramen. The lateral infratemporal approach requires facial nerve transposition to provide access to the lateral and posterior parts of the jugular foramen. A deep understanding of the complex anatomy of this region is paramount for safe and effective surgery of the jugular foramen. Both techniques may be complementary considering the different regions of the jugular foramen accessed with each approach.

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