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 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.

Antero-Lateral Approach To The V3 Segment Of The Vertebral Artery

2006 ◽  
Vol 58 (suppl_1) ◽  
pp. ONS-29-ONS-35 ◽  
Author(s):  
Michaël Bruneau ◽  
Jan Frederick Cornelius ◽  
Bernard George
Keyword(s):  
Surgical Technique ◽  
Vertebral Artery ◽  
Dura Mater ◽  
Transverse Process ◽  
Foramen Magnum ◽  
Lateral Approach ◽  
Occipital Condyle ◽  
Exposure Control ◽  
Transverse Foramen ◽  
Inferior Aspect

Abstract OBJECTIVE: We describe our surgical technique of exposure, control, and transposition of the third segment of the vertebral artery (VA V3 segment). METHODS: The VA V3 segment extends from the C2 transverse foramen to the dura mater of the foramen magnum. It initially courses vertically between the C2 and C1 transverse foramens, then runs horizontally over the atlas groove, and finally obliquely upwards before piercing the dura mater. Exposure of the VA V3 segment through an antero-lateral approach is performed by passing medially to the ster-nomastoid muscle. After exposure and protection of the spinal accessory nerve, the C1 transverse process is identified below and in front of the mastoid tip. The small muscles that insert on it are cut to expose the C1-C2 portion. The inferior aspect of the horizontal portion is safely separated from the atlas groove by elevating the subperiosteal plane and the superior aspect is freed by a cut a few millimeters above the VA on the occipital condyle. Complete unroofing of the C1 transverse foramen is achieved by resecting the bone while leaving intact the subperiosteal plane. The VA then can be transposed. Venous bleedings during the dissection from periosteal sheath tearing can be controlled by direct bipolar coagulation. RESULTS: The control of the VA V3 segment is essentially used for lesions in the VA vicinity and to improve the surgical exposure at the craniocervical junction level. Indications therefore are tumoral removal, VA decompression, and rarely, nowadays, VA revascularization. CONCLUSION: Perfect knowledge of the anatomy and the surgical technique permits a safe exposure, control, and transposition of the VA V3 segment. This is the first step of many surgical procedures.

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 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.

Far-Lateral Approach Without Drilling the Occipital Condyle for Vertebral Artery–Posterior Inferior Cerebellar Artery Aneurysms

Neurosurgery ◽  
2017 ◽  
Vol 81 (2) ◽  
pp. 268-274 ◽  
Author(s):  
Pablo Seoane ◽  
Samuel Kalb ◽  
Justin C. Clark ◽  
Juan C. Rivas ◽  
David S. Xu ◽  
...  
Keyword(s):  
Vertebral Artery ◽  
Glasgow Outcome Scale ◽  
Posterior Inferior Cerebellar Artery ◽  
Lateral Approach ◽  
Occipital Condyle ◽  
Cerebellar Artery ◽  
Far Lateral Approach ◽  
Scale Scores ◽  
Far Lateral ◽  
Pica Aneurysms

Abstract BACKGROUND: The far-lateral transcondylar surgical approach is often used to clip vertebral artery (VA) and posterior inferior cerebellar artery (PICA) aneurysms. The role of condyle resection during this approach is controversial. OBJECTIVE: To evaluate patient outcomes in patients with VA–PICA aneurysms in whom drilling the occipital condyle was not necessary. METHODS: Between May 2005 and December 2012, a total of 56 consecutive patients with incidental or ruptured VA–PICA aneurysms underwent surgery with a far-lateral approach without condylar resection. Clinical presentation, surgical reports, presurgery and postsurgery radiological examinations, and clinical follow-up reports were assessed. Anatomic aneurysm location was analyzed through angiography or computed tomography angiography. We compared postsurgical Glasgow Outcome Scale scores, modified Rankin Scale scores, and morbidity in 2 groups: those with aneurysms in the anterior medullary segment and those with aneurysms in the lateral medullary segment. RESULTS: The predominant presentation was subarachnoid hemorrhage in 34 patients (60.7%). Most aneurysms (n = 27 [48.2%]) were located in the lateral medullary segment of the PICA, followed by the anterior medullary segment (n = 25 [44.6%]). Total aneurysm occlusion was achieved in 100% of patients, and bypass techniques were necessary in 3 patients (5.4%). Fifty-two patients (92.8%) had Glasgow Outcome Scale scores of 4 or 5 postsurgery. CONCLUSIONS: A far-lateral approach that leaves the occipital condyle intact is adequate for treating most patients with VA–PICA aneurysms.

Primary Vertebral Artery Reanastomosis During Retrosigmoid Skull Base Approach Following Iatrogenic Near-Transection With Monopolar Electrocautery

2014 ◽  
Vol 10 (4) ◽  
pp. 631-639 ◽  
Author(s):  
Joseph A. Osorio ◽  
Arnau Benet ◽  
Christopher P. Hess ◽  
Michael W. McDermott ◽  
Adib A. Abla
Keyword(s):  
Vertebral Artery ◽  
Primary Repair ◽  
Rapid Assessment ◽  
Tumor Resection ◽  
Lateral Approach ◽  
Vertebral Artery Injury ◽  
Vertebrobasilar Insufficiency ◽  
Artery Injury ◽  
Far Lateral Approach ◽  
Neurologically Intact

Abstract BACKGROUND: Iatrogenic vertebral artery injury is a rare neurosurgical complication, but it is potentially fatal. The majority of vertebral artery injuries are encountered during cervical spine instrumentation, and craniotomy-related injuries have been encountered during the far-lateral approach. OBJECTIVE: To present the first reported case of iatrogenic vertebral artery injury occurring during retrosigmoid craniotomy, in the setting of an anomalous vertebral artery course within the suboccipital musculature. METHODS: A 70-year-old man underwent elective retrosigmoid craniotomy for meningioma resection. During exposure, iatrogenic injury to the third segment of the vertebral artery occurred above the craniocervical junction. His vertebral arteries were codominant. The artery was primarily repaired and the operation was aborted. He was treated with aspirin, remained neurologically intact, and was discharged the next day. RESULTS: Immediate and 5-week vascular imaging studies demonstrated vessel patency. After 5 weeks, the patient returned for elective tumor resection, which was uncomplicated, and he remained neurologically intact at 10-week follow-up. CONCLUSION: The rarity of vertebral artery injuries and lack of previous such complications involving retrosigmoid craniotomy highlight the need for vigilance during any suboccipital exposure. Complication avoidance is possible by using several preoperative and intraoperative checks. When an injury has occurred, rapid assessment and management of the event is necessary, while primary repair may be more difficult following electrocautery-mediated laceration. Successful treatment of iatrogenic vertebral arterial injuries has been described, but the most frequently reported management has been endovascular sacrifice of the injured vessel, which carries inherent risks of vertebrobasilar insufficiency in a dominant vertebral artery.

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.

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.

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.

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