Quantitative Analysis of Variants of the Far-Lateral Approach

2010 ◽  
Vol 66 (suppl_2) ◽  
pp. ons191-ons198 ◽  
Author(s):  
Anhua Wu ◽  
Joseph M. Zabramski ◽  
Pakrit Jittapiromsak ◽  
Robert C. Wallace ◽  
Robert F. Spetzler ◽  
...  
Keyword(s):  
Angle Of Attack ◽  
Lateral Approach ◽  
Occipital Condyle ◽  
3 Dimensional ◽  
Hypoglossal Canal ◽  
Computed Tomographic ◽  
Transcondylar Approach ◽  
Surgical Exposure ◽  
Far Lateral Approach ◽  
Far Lateral

Abstract BACKGROUND The rationale for choosing between the condylar fossa and transcondylar variations of the far-lateral approach requires understanding of the relationships between the occipital condyle, jugular tubercle, and hypoglossal canal. OBJECTIVE We examined the anatomic relationship of these 3 structures and analyzed the effect that changes in these relationships have on the surgical exposure and angle of attack for these 2 approaches. METHODS Anatomic measurements of 5 cadaveric heads from 3-dimensional computed tomographic scans were compared with direct measurements of the same specimens. The condylar fossa and transcondylar approach were performed sequentially in 8 of 10 sides. Surgical exposure and angle of attack were measured after each exposure. RESULTS The jugular tubercle (JT) angle (JTA) measures the angle formed by reference points on the condyle, hypoglossal canal, and JT. When the JT and occipital condyle are not prominent (JTA > 180°), the transcondylar approach does not significantly increase petroclival or brainstem exposure compared with the condylar fossa approach; however, it does significantly increase the angle of attack to the junction of the posterior inferior cerebellar and vertebral arteries and the surgical angle for the medial part of the JT (P < .05). CONCLUSION The condylar fossa and transcondylar approaches provide similar exposures of the petroclivus and brainstem when the JT and occipital condyle are not prominent (JTA > 180° on 3-dimensional computed tomographic). However, for lesions below the hypoglossal canal, the transcondylar approach is preferred because it significantly increases the angle of attack.

Microsurgical anatomy of the transcondylar, supracondylar, and paracondylar extensions of the far-lateral approach

1997 ◽  
Vol 87 (4) ◽  
pp. 555-585 ◽  
Author(s):  
Hung T. Wen ◽  
Albert L. Rhoton ◽  
Toshiro Katsuta ◽  
Evandro de Oliveira
Keyword(s):  
Jugular Foramen ◽  
Lateral Approach ◽  
Occipital Bone ◽  
Occipital Condyle ◽  
Microsurgical Anatomy ◽  
Posterior Portion ◽  
Hypoglossal Canal ◽  
Transcondylar Approach ◽  
Far Lateral Approach ◽  
Far Lateral

✓ Despite a large number of reports of the use of the far-lateral approach, some of the basic detail that is important in safely completing this exposure has not been defined or remains poorly understood. The basic far-lateral exposure provides access for the following approaches: 1) the transcondylar approach directed through the occipital condyle or the adjoining portions of the occipital and atlantal condyles; 2) the supracondylar approach directed through the area above the occipital condyle; and 3) the paracondylar exposure directed through the area lateral to the occipital condyle. The transcondylar approach provides access to the lower clivus and premedullary area. The supracondylar approach provides access to the region of, and medial to, the hypoglossal canal and jugular tubercle. The paracondylar approach, which includes drilling of the jugular process of the occipital bone in the area lateral to the occipital condyle, provides access to the posterior portion of the jugular foramen and to the mastoid on the lateral side of the jugular foramen. In this study, the anatomy important to completing the far-lateral approach and these modifications was examined in 12 cadaveric specimens. In the standard posterior and posterolateral approaches, an understanding of the individual suboccipital muscles is not essential. However, these muscles provide important landmarks for the far-lateral approach and its modifications. Other important considerations include the relationship of the occipital condyle to the foramen magnum, hypoglossal canal, jugular tubercle, the jugular process of the occipital bone, the mastoid, and the facial canal. These and other relationships important to completing these exposures were examined in this study.

Delayed Occipitocervical Instability With Cranial Settling After Far-Lateral Transcondylar Surgery for Invasive Skull Base Tumor

2018 ◽  
Vol 16 (2) ◽  
pp. 250-255 ◽  
Author(s):  
Marcus D Mazur ◽  
Andrew T Dailey ◽  
Lubdha Shah ◽  
Jonathan P Scoville ◽  
William T Couldwell
Keyword(s):  
Skull Base ◽  
Lateral Approach ◽  
Occipital Condyle ◽  
Skull Base Tumor ◽  
Pathological Fractures ◽  
Hypoglossal Canal ◽  
Far Lateral Approach ◽  
Tumor Involvement ◽  
Far Lateral ◽  
Clinically Significant

Abstract BACKGROUND Occipitocervical instability is a rare but potentially severe complication of a far-lateral transcondylar surgical approach to the skull base. OBJECTIVE To investigate the incidence of clinically significant occipitocervical instability after transcondylar surgery via a far-lateral approach and to determine whether the extent of occipital condyle resection relative to the hypoglossal canal was associated with the development of occipitocervical instability. METHODS A retrospective review of patients undergoing far-lateral transcondylar surgery was performed at our institution to identify patients who developed postoperative occipitocervical instability. RESULTS Of the 61 far-lateral transcondylar operations performed, the authors identified 2 cases of delayed occipitocervical instability after surgery. In each case, the patient had tumor invading into the occipital condyle and supracondylar region and a resection extending anterior to the hypoglossal canal was performed. Both patients presented with pathological fractures and a severe occipitocervical deformity. CONCLUSION Patients who have tumor involvement of the occipital condyle and supracondylar region and undergo partial unilateral condylar resection are at risk for occipitocervical instability and should be considered for occipitocervical fusion.

scholarly journals Far Lateral Approaches: Far Lateral Approach With Minimal Condylectomy for C2 Schwannoma: 3-Dimensional Operative Video

2021 ◽  
Vol 22 (1) ◽  
pp. e49-e49
Author(s):  
Karol P. Budohoski ◽  
Damiano G. Barone ◽  
Ramez W. Kirollos ◽  
Thomas Santarius ◽  
Rikin A. Trivedi
Keyword(s):  
Lateral Approach ◽  
3 Dimensional ◽  
Far Lateral Approach ◽  
Far Lateral

Far Lateral Craniotomy Closure Technique for Preservation of Suboccipital Musculature

2020 ◽  
Author(s):  
Muhammad Salman Ali ◽  
Stephen T. Magill ◽  
Michael W. McDermott
Keyword(s):  
Muscle Atrophy ◽  
Craniovertebral Junction ◽  
Contralateral Side ◽  
Lateral Approach ◽  
Senior Author ◽  
Occipital Condyle ◽  
Closure Technique ◽  
Far Lateral Approach ◽  
Far Lateral ◽  
Initial Results

AbstractThe far lateral approach is used for accessing pathology at the craniovertebral junction but can be complicated by postoperative suboccipital muscle atrophy. In addition to significant cosmetic deformity, this atrophy can lead to head and neck pain and potentially could contribute to cranio-cervical instability. To address this issue, the senior author began using a single myocutaneous flap without a muscle cuff and securing it directly to the bone using predrilled holes in the bone that resemble a chevron. The method is described and illustrated with an example case. Results from seven consecutive cases are reported since the technique was adopted. Muscle atrophy was measured by calculating area at the level of the occipital condyle and compared with the contralateral side. No significant differences were noted. In conclusion, we have found this to be an excellent closure technique and wanted to present our initial results for consideration by other skull base surgeons.

Microsurgical anatomy of the posterior spinal artery via a far-lateral transcondylar approach

2009 ◽  
Vol 10 (3) ◽  
pp. 228-233 ◽  
Author(s):  
Hakan Seçkin ◽  
Özkan Ateş ◽  
Andrew M. Bauer ◽  
Mustafa K. Başkaya
Keyword(s):  
Posterior Inferior Cerebellar Artery ◽  
Lateral Approach ◽  
Microsurgical Anatomy ◽  
Posterior Spinal Artery ◽  
Transcondylar Approach ◽  
Cerebellar Artery ◽  
Far Lateral Approach ◽  
Close Proximity ◽  
Far Lateral ◽  
Clinically Significant

Object The posterior spinal artery (PSA) is a clinically significant vessel that may frequently be encountered during the far-lateral transcondylar approach. There have been a limited number of reports on the specific origin of the PSA in the literature. The aim of this study was to demonstrate the origin of the PSA. Methods Thirteen cadaveric heads (26 sides) were injected with colored silicon. A bilateral far-lateral transcondylar approach was performed on each side. In every specimen the site of the origin of the PSAs, as well as their course, branching pattern and anastomoses, external diameters, and neighboring vascular and nervous structures were recorded. Microanatomical dissections were performed using the surgical microscope. In addition, 8 surgical cases in which the far-lateral approach was used were collected prospectively to record the course and origin of the PSA. Altogether, a total of 34 sides were analyzed for their PSA origin and course. Results In the cadaveric specimens, the PSA was found to originate from the vertebral artery (VA) in 25 sides (96%). In 13 specimens (50%) the PSA originated from the V4 segment of the VA intradurally. In 12 specimens (46%) the PSA originated from the V3 segment of the VA extradurally. In 1 specimen (4%), in whom the posterior inferior cerebellar artery (PICA) had an early origin from the VA extradurally at the C-1 level, the PSA originated from the PICA. Of the 8 surgical cases, 2 patients had extradural origin of the PSA from the V3 segment of the VA, whereas 6 patients had intradural origin of the PSA from the V4 segment. Conclusions Although the usual origin of the PSA is from the VA either intra- or extradurally, its origin is closely related to the origin of the PICA. The PSA originates from the PICA in cases in which the PICA originates extradurally from the VA. In the far-lateral transcondylar approach, the dura is opened in close proximity to the VA. Knowledge of the origin and course of the PSA is critically important when executing the far-lateral approach to avoid its injury.

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.

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 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.

Far-lateral Approach to the Craniocervical Junction

2005 ◽  
Vol 57 (suppl_4) ◽  
pp. ONS-367-ONS-371 ◽  
Author(s):  
Giuseppe Lanzino ◽  
Sergio Paolini ◽  
Robert F. Spetzler
Keyword(s):  
Craniocervical Junction ◽  
Lateral Approach ◽  
Occipital Condyle ◽  
Lateral Part ◽  
Posterior Arch ◽  
Bone Removal ◽  
Far Lateral Approach ◽  
Cranial Base Surgery ◽  
Far Lateral ◽  
Angle Of View

Abstract THE FAR-LATERAL APPROACH is an extension of the standard suboccipital approach, designed to maximize exposure of the lateroventral craniocervical junction. Following a basic principle of cranial base surgery, the angle of view is increased by bone removal. Bone removal involves the most lateral part of the inferior occipital squama and the posterior arch of C1. Drilling of various portions of the occipital condyle further increases the exposure. Transposition of the vertebral artery is seldom required. The far-lateral approach allows a tangential, unobstructed view of the lateroventral cervicomedullary area and can be applied effectively to manage with a heterogeneous spectrum of pathological lesions involving this area. The technical aspects of the procedure are briefly illustrated in this report.

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