Letter: Intracranial Connections of the Vertebral Venous Plexus: Anatomical Study With Application to Neurosurgical and Endovascular Procedures at the Craniocervical Junction

Abstract BACKGROUND Descriptions of intracranial extensions of vertebral venous plexuses are lacking. OBJECTIVE To identify vertebral venous plexuses at the craniocervical junction in cadavers and describe them. METHODS The authors dissected 15 ink-injected, formalin-fixed, adult cadaveric heads and measured cranial extensions of the spinal venous plexuses. RESULTS All specimens had vertebral venous plexuses at the craniocervical junction composed of multiple interwoven vessels concentrated anteriorly (anterior vertebral plexuses), posteriorly (posterior vertebral venous plexuses), and laterally (lateral vertebral venous plexuses). Veins making up the plexus tended to be largest for the anterior internal vertebral venous plexus. On 33%, a previously unnamed lateral internal vertebral venous plexus was identified that connected to the lateral marginal sinus. The anterior external vertebral venous plexus connected to the basilar venous plexus via transclival emissary veins in 13%; remaining veins connected either intracranially via small perforating branches through the anterior atlanto-occipital membrane (33%) or had no direct gross connections inside the cranium (53%). The anterior internal vertebral plexus, which traveled between layers of the posterior longitudinal ligament, connected to the anterior half of the marginal sinus in 33% and anterolateral parts of the marginal sinus in 20%. The posterior internal venous plexus connected to the posterior aspect of the marginal sinus on 80% and into the occipital sinus in 13.3%. The posterior external venous plexus connected to veins of the hypoglossal canal in 20% and into the posterior aspect of the marginal sinus in 13.3%. CONCLUSION Knowledge of these connections is useful to neurosurgeons and interventional radiologists.

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In Reply: Intracranial Connections of the Vertebral Venous Plexus: Anatomic Study With Application to Neurosurgical and Endovascular Procedures at the Craniocervical Junction

Operative Neurosurgery ◽

10.1093/ons/opy069 ◽

2018 ◽

Vol 15 (3) ◽

pp. E27-E27

Author(s):

Aaron Cohen-Gadol

Keyword(s):

Endovascular Procedures ◽

Craniocervical Junction ◽

Anatomic Study ◽

Venous Plexus

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The Contralateral Transcaruncular Approach to the Parapharyngeal Space and Craniocervical Junction: An Anatomical Study

10.1055/s-0039-1679471 ◽

2019 ◽

Author(s):

Joao Alves-Belo ◽

Joao Mangussi-Gomes ◽

Salomon Cohen-Cohen ◽

Huy Truong ◽

Paul Gardner ◽

...

Keyword(s):

Parapharyngeal Space ◽

Anatomical Study ◽

Craniocervical Junction

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Anatomical analysis of transoral surgical approaches to the clivus

Journal of Neurosurgery ◽

10.3171/jns.2006.105.2.301 ◽

2006 ◽

Vol 105 (2) ◽

pp. 301-308 ◽

Cited By ~ 40

Author(s):

Vijayabalan Balasingam ◽

Gregory J. Anderson ◽

Neil D. Gross ◽

Cheng-Mao Cheng ◽

Akio Noguchi ◽

...

Keyword(s):

Mouth Opening ◽

Anatomical Study ◽

Craniocervical Junction ◽

Surgical Approaches ◽

Le Fort I Osteotomy ◽

Le Fort ◽

Anatomical Analysis ◽

Stereotactic Localization ◽

Good Exposure ◽

Le Fort I

Object The authors conducted a cadaveric anatomical study to quantify and compare the area of surgical exposure and the freedom available for instrument manipulation provided by the following four surgical approaches to the extracranial periclival region: simple transoral (STO), transoral with a palate split (TOPS), Le Fort I osteotomy (LFO), and median labioglossomandibulotomy (MLM). Methods Twelve unembalmed cadaveric heads with normal mouth opening capacity were serially dissected. For each approach, quantitation of extracranial periclival exposure and freedom for instrument manipulation (known here as surgical freedom) was accomplished by stereotactic localization. To quantify the extent of extracranial clival exposure obtained, anatomical measurements of the extracranial clivus were performed on 17 dry skull bases. The values (means ± standard deviations in mm2) for periclival exposure and surgical freedom, respectively, for the surgical approaches studied were as follows: STO = 492 ± 229 and 3164 ± 1900; TOPS = 743 ± 319 and 3478 ± 2363; LFO = 689 ± 248 and 2760 ± 1922; and MLM 1312 ± 384 and 8074 ± 6451. The extent of linear midline clival exposure and the percentage of linear midline clival exposure relative to the total linear midline exposure were as follows, respectively: STO = 0.6 ± 4.9 mm and 7.8 ± 11%; TOPS = 8.9 ± 5.5 mm and 24.2 ± 16.7%; LFO = 32.9 ± 10.2 mm and 85.0 ± 18.7%; and MLM = 2.1 ± 4.4 mm and 6.7 ± 11.1%. Conclusions The choice of approach and the resulting degree of complexity and associated morbidity depends on the location of the pathological entity. The authors found that the MLM approach, like the STO approach, provided good exposure of the craniocervical junction but limited exposure of the clivus. The TOPS approach, an approach attended by a lesser risk of morbidity, provided adequate exposure of the extracranial inferior clivus. Maximal exposure of the extracranial clivus proper was provided by the LFO approach.

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The intracranial denticulate ligament: anatomical study with neurosurgical significance

Journal of Neurosurgery ◽

10.3171/2010.9.jns10883 ◽

2011 ◽

Vol 114 (2) ◽

pp. 454-457 ◽

Cited By ~ 8

Author(s):

R. Shane Tubbs ◽

Martin M. Mortazavi ◽

Marios Loukas ◽

Mohammadali M. Shoja ◽

Aaron A. Cohen-Gadol

Keyword(s):

Vertebral Artery ◽

Dura Mater ◽

Hypoglossal Nerve ◽

Anatomical Study ◽

Craniocervical Junction ◽

Spinal Nerve ◽

Marginal Sinus ◽

Posterior Spinal Artery ◽

Before And After ◽

Ventral Roots

Object Knowledge of the detailed anatomy of the craniocervical junction is important to neurosurgeons. To the authors' knowledge, no study has addressed the detailed anatomy of the intracranial (first) denticulate ligament and its intracranial course and relationships. Methods In 10 embalmed and 5 unembalmed adult cadavers, the authors performed posterior dissection of the craniocervical junction to expose the intracranial denticulate ligament. Rotation of the spinomedullary junction was documented before and after transection of unilateral ligaments. Results The first denticulate ligament was found on all but one left side and attached to the dura of the marginal sinus superior to the vertebral artery as it pierced the dura mater. The ligament always traveled between the vertebral artery and spinal accessory nerve. On 20% of sides, it also attached to the intracranial vertebral artery and, histologically, blended with its adventitia. In general, this ligament tended to be thicker laterally and was often cribriform in nature medially. The hypoglossal nerve was always superior to the ligament, which always concealed the ventral roots of the C-1 spinal nerve. The posterior spinal artery traveled posterior to this ligament on 93% of sides. On one left side, the ascending branch of the posterior spinal artery traveled anterior to the ligament and the descending branch traveled posterior to it. Following unilateral transection of the intracranial denticulate ligament, rotation of the spinomedullary junction was increased by approximately 25%. Conclusions Knowledge of the relationships of the first denticulate ligament may prove useful to the neurosurgeon during procedures at the craniocervical junction.

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The full-endoscopic uniportal technique for decompression of the anterior craniocervical junction using the retropharyngeal approach: an anatomical feasibility study in human cadavers and review of the literature

Journal of Neurosurgery Spine ◽

10.3171/2018.4.spine171156 ◽

2018 ◽

Vol 29 (6) ◽

pp. 615-621 ◽

Cited By ~ 2

Author(s):

Sebastian Ruetten ◽

Patrick Hahn ◽

Semih Oezdemir ◽

Xenophon Baraliakos ◽

Harry Merk ◽

...

Keyword(s):

Anatomical Study ◽

Craniocervical Junction ◽

Alternative Methods ◽

Invasive Technique ◽

Viewing Angle ◽

Continuous Irrigation ◽

Anatomical Structures ◽

Target Region ◽

Advantages And Disadvantages ◽

Human Cadavers

OBJECTIVEAcute or progressive myelopathy may necessitate direct anterior decompression of the craniocervical junction and odontoidectomy. Different techniques with individual advantages and disadvantages can be used. In addition to the gold standard—the transoral approach—there is also increasing experience with the endoscopic transnasal technique. Other alternative methods are also being developed to reduce technical and perioperative problems. The aim of this anatomical study was to investigate the feasibility of the full-endoscopic uniportal technique with a retropharyngeal approach for decompression of the craniocervical junction, taking into consideration the specific advantages and disadvantages compared with conventional methods and the currently available data in the literature.METHODSFive fresh adult cadavers were operated on. The endoscope used has a shaft cross-section of 6.9 × 5.9 mm and a 25° viewing angle. It contains an eccentric intraendoscopic working channel with a diameter of 4.1 mm. An anterior retropharyngeal approach was used. The anatomical structures of the anterior craniocervical junction were dissected and the bulbomedullary junction was decompressed.RESULTSThe planned steps of the operation were performed in all cadavers. The retropharyngeal approach allowed the target region to be accessed easily. The anatomical structures of the anterior craniocervical junction could be identified and dissected. The bulbomedullary junction could be adequately decompressed. No resections of the anterior arch of the atlas were necessary in the odontoidectomy.CONCLUSIONSUsing the full-endoscopic uniportal technique with an anterior retropharyngeal approach, the craniocervical region can be adequately reached, dissected, and decompressed. This is a minimally invasive technique with the known advantages of an endoscopic procedure under continuous irrigation. The retropharyngeal approach allows direct, sterile access. The instruments are available for clinical use and have been established for years in other operations of the entire spine.

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Superficial surgical landmarks for the transverse sinus and torcular herophili

Journal of Neurosurgery ◽

10.3171/jns.2000.93.2.0279 ◽

2000 ◽

Vol 93 (2) ◽

pp. 279-281 ◽

Cited By ~ 31

Author(s):

R. Shane Tubbs ◽

George Salter ◽

W. Jerry Oakes

Keyword(s):

Anatomical Study ◽

Transverse Sinus ◽

Craniocervical Junction ◽

Anatomical Structures ◽

Content Type ◽

Medial Segment ◽

External Landmark ◽

Inferior Edge ◽

Formalin Fixed ◽

Fine Print

Object. The purpose of this anatomical study is to identify reliable external landmarks that can be used to determine accurately the lower border of the proximal segment of the transverse sinus (TS).Methods. The authors used 15 formalin-fixed cadaveric specimens for this project. Various anatomical structures were dissected and measurements of the distance between these structures and the proximal TS were obtained.The data collected in this study demonstrate that the inion is not always a reliable external landmark to use when determining the internal location of the very proximal TS and its drainage into the area of the torcular herophili. In addition, the authors found that the most accurate external landmark to use in reliably estimating the internal placement of the proximal TS is the point of insertion of the musculus semispinalis capitus and not the superior nuchal line. In the present study, this muscle never covered more than 5 mm of the inferior edge of the TS and was found to be a reliable anatomical structure for avoiding the medial segment of the TS.Conclusions. These findings could aid the surgeon in localizing the TS with various midline approaches to the posterior fossa and the craniocervical junction.

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Anatomical study of the third occipital nerve and its potential role in occipital headache/neck pain following midline dissections of the craniocervical junction

Journal of Neurosurgery Spine ◽

10.3171/2011.3.spine10854 ◽

2011 ◽

Vol 15 (1) ◽

pp. 71-75 ◽

Cited By ~ 16

Author(s):

R. Shane Tubbs ◽

Martin M. Mortazavi ◽

Marios Loukas ◽

Anthony V. D'Antoni ◽

Mohammadali M. Shoja ◽

...

Keyword(s):

Soft Tissues ◽

Facet Joint ◽

Anatomical Study ◽

Craniocervical Junction ◽

Surgical Approaches ◽

Potential Contribution ◽

Occipital Neuralgia ◽

Main Trunk ◽

Occipital Nerve ◽

The Third

Object Occipital neuralgia can be a debilitating disease and may occur following operative procedures near the occipital and nuchal regions. One nerve of this region, the third occipital nerve (TON), has received only scant attention, and its potential contribution to occipital neuralgia has not been appreciated. Therefore, in the present study the authors aimed to detail the anatomy of this nerve and its relationships to midline surgical approaches of the occiput and posterior neck. Methods Fifteen adult cadavers (30 sides) underwent dissection of the upper cervical and occipital regions. Special attention was given to identifying the course of the TON and its relationship to the soft tissues and other nerves of this region. Once identified superficially, the TON was followed deeply through the nuchal musculature to its origin in the dorsal ramus of C-3. Measurements were made of the length and diameter of the TON. Additionally, the distance from the external occipital protuberance was measured in each specimen. Following dissection of the TON, self-retaining retractors were placed in the midline and opened in standard fashion while observing for excess tension on the TON. Results Articular branches were noted arising from the deep surface of the nerve in 63.3% of sides. The authors found that the TON was, on average, 3 mm lateral to the external occipital protuberance, and small branches were found to cross the midline and communicate with the contralateral TON inferior to the external occipital protuberance in 66.7% of sides. The TON trunk became subcutaneous at a mean of 5 cm inferior to the external occipital protuberance. In all specimens, the cutaneous main trunk of the TON was intimately related to the nuchal ligament. Insertion of self-retaining retractors in the midline placed significant tension on the TON in all specimens, both superficially and more deeply at its adjacent facet joint. Conclusions Although damage to the TON may often be unavoidable in midline approaches to the craniocervical region, appreciation of its presence and knowledge of its position and relationships may be useful to the neurosurgeon who operates in this region and may assist in decreasing postoperative morbidity.

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