High Anterior Cervical Approach to the Clivus and Foramen Magnum: A Microsurgical Anatomy Study

2011 ◽  
Vol 69 (suppl_1) ◽  
pp. ons103-ons116 ◽  
Author(s):  
Vittorio M. Russo ◽  
Francesca Graziano ◽  
Antonino Russo ◽  
Erminia Albanese ◽  
Arthur J. Ulm
Keyword(s):  
Skull Base ◽  
Cranial Nerves ◽  
Foramen Magnum ◽  
Microsurgical Anatomy ◽  
Lateral Skull Base ◽  
Cervical Approach ◽  
Anterior Cervical Approach ◽  
Vertebrobasilar Junction ◽  
Far Lateral ◽  
Lower Clivus

Abstract BACKGROUND: Surgical exposure of lesions located along the ventral foramen magnum (FM) and clivus poses a unique set of challenges to neurosurgeons. Several approaches have been developed to access these regions with varying degrees of exposure and approach-related morbidity. OBJECTIVE: To describe the microsurgical anatomy of the high anterior cervical approach to the clivus and foramen magnum, and describe novel skull base extensions of the approach. METHODS: Eight adult cadaveric specimens were included in this study. The high anterior cervical approach includes a minimal anterior clivectomy and its lateral skull base extensions: the extended anterior far-lateral clivectomy and the inferior petrosectomy. The microsurgical anatomy and exposure of the various extensions of the approach were analyzed. In addition, the capability of complementary endoscopy was evaluated. RESULTS: With proper positioning, the minimal anterior clivectomy exposed the vertebrobasilar junction, proximal basilar artery, anteroinferior cerebellar arteries, and 6th cranial nerve. The lateral skull base extensions provided access to the anterior FM, mid-lower clivus, and petroclival region, up to the Meckel cave, contralateral to the side of the surgical approach. CONCLUSION: The high anterior cervical approach with skull base extensions is an alternative to the classic approaches to the ventral FM and mid-lower clivus. A minimal anterior clivectomy provides access to the midline mid-lower clivus. The addition of an extended anterior far-lateral clivectomy and an inferior petrosectomy extends the exposure to the anterior FM and cerebellopontine angle lying anterior to the cranial nerves. The approach is also ideally suited for endoscopic-assisted techniques.

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.

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.

A Method for Cranial Nerve XI Silencing During Surgery of the Foramen Magnum Region: Technical Case Report

2018 ◽  
Vol 16 (4) ◽  
pp. E130-E133
Author(s):  
Derek G Southwell ◽  
Jonathan D Breshears ◽  
William R Lyon ◽  
Michael W McDermott
Keyword(s):  
Skull Base ◽  
Cranial Nerve ◽  
Clinical Presentation ◽  
Obstructive Hydrocephalus ◽  
Cranial Nerves ◽  
Foramen Magnum ◽  
Cerebellar Tonsil ◽  
Suboccipital Craniotomy ◽  
Far Lateral ◽  
The Right

Abstract BACKGROUND AND IMPORTANCE Skull base surgery involves the microdissection and intraoperative monitoring of cranial nerves, including cranial nerve XI (CN XI). Manipulation of CN XI can evoke brisk trapezius contraction, which in turn may disturb the surgical procedure and risk patient safety. Here we describe a method for temporarily silencing CN XI via direct intraoperative application of 1% lidocaine. CLINICAL PRESENTATION A 41-yr-old woman presented with symptoms of elevated intracranial pressure and obstructive hydrocephalus secondary to a hemangioblastoma of the right cerebellar tonsil. A far-lateral suboccipital craniotomy was performed for resection of the lesion. During the initial stages of microdissection, vigorous trapezius contraction compromised the course of the operation. Following exposure of the cranial and cervical portions of CN XI, lidocaine was applied to the course of the exposed nerve. Within 3 min, trapezius electromyography demonstrated neuromuscular silencing, and further manipulation of CN XI did not cause shoulder movements. Approximately 30 min after lidocaine application, trapezius contractions returned, and lidocaine was again applied to re-silence CN XI. Gross total resection of the hemangioblastoma was performed during periods of CN XI inactivation, when trapezius contractions were absent. CONCLUSION Direct application of lidocaine to CN XI temporarily silenced neuromuscular activity and prevented unwanted trapezius contraction during skull base microsurgery. This method improved operative safety and efficiency by significantly reducing patient movement due to the unavoidable manipulation of CN XI.

Microsurgical Anatomy of the Lateral Condylar Vein and Its Clinical Significance

2014 ◽  
Vol 11 (1) ◽  
pp. 135-146 ◽  
Author(s):  
Ken Matsushima ◽  
Takeshi Funaki ◽  
Noritaka Komune ◽  
Hiro Kiyosue ◽  
Masatou Kawashima ◽  
...  
Keyword(s):  
Skull Base ◽  
Clinical Significance ◽  
Internal Jugular Vein ◽  
Jugular Vein ◽  
Cranial Nerves ◽  
Average Diameter ◽  
Jugular Bulb ◽  
Foramen Magnum ◽  
Occipital Condyle ◽  
Microsurgical Anatomy

Abstract BACKGROUND Although the lateral condylar vein has been encountered in some skull base approaches and used as a route to access the anterior condylar venous confluence, few descriptions can be found in the literature regarding its morphology. OBJECTIVE To examine the anatomy of the lateral condylar vein and its clinical significance. METHODS The craniocervical junctions of 3 cadaveric heads, 15 dry bones, and 25 computed tomography venography images were examined. RESULTS The lateral condylar vein was identified in 88.0% of paracondylar areas, with an average diameter of 3.6 mm. This vein originated near the jugular bulb, descended along the lateral surface of the occipital condyle and medial to the internal jugular vein, cranial nerves IX to XI, and rectus capitis lateralis muscle to drain into the vertebral venous plexus surrounding the vertebral artery. The veins were classified according to their origin from either (1) the anterior condylar confluence or (2) the internal jugular vein. In some specimens, the lateral condylar vein courses within a small osseous canal lateral to the occipital condyle, the paracondylar canal, which was identified in 16.7% of paracondylar areas in the dry bones. CONCLUSION The lateral condylar vein may be encountered in exposing the jugular bulb, hypoglossal canal, or foramen magnum. This vein has been reported to be a main draining route of dural arteriovenous fistulas, in which case it can be utilized as a transvenous route for endovascular treatment, or obliterated. An understanding of the anatomy of this vein may prove useful in planning skull base and endovascular procedures.

Histology of the vertebral artery–dural junction: relevance to posterolateral approaches to the skull base

2019 ◽  
pp. 1-6
Author(s):  
Robert C. Rennert ◽  
Martin P. Powers ◽  
Jeffrey A. Steinberg ◽  
Takanori Fukushima ◽  
John D. Day ◽  
...  
Keyword(s):  
Connective Tissue ◽  
Vertebral Artery ◽  
Skull Base ◽  
Histological Analysis ◽  
Foramen Magnum ◽  
Entry Site ◽  
Microsurgical Technique ◽  
Vessel Injury ◽  
Far Lateral ◽  
Clear Delineation

OBJECTIVEThe far-lateral and extreme-lateral infrajugular transcondylar–transtubercular exposure (ELITE) and extreme-lateral transcondylar transodontoid (ELTO) approaches provide access to lesions of the foramen magnum, inferolateral to mid-clivus, and ventral pons and medulla. A subset of pathologies in this region require manipulation of the vertebral artery (VA)–dural interface. Although a cuff of dura is commonly left on the VA to avoid vessel injury during these approaches, there are varying descriptions of the degree of VA-dural separation that is safely achievable. In this paper the authors provide a detailed histological analysis of the VA-dural junction to guide microsurgical technique for posterolateral skull base approaches.METHODSAn ELITE approach was performed on 6 preserved adult cadaveric specimens. The VA-dural entry site was resected, processed for histological analysis, and qualitatively assessed by a neuropathologist.RESULTSHistological analysis demonstrated a clear delineation between the intima and media of the VA in all specimens. No clear plane was identified between the connective tissue of the dura and the connective tissue of the VA adventitia.CONCLUSIONSThe VA forms a contiguous plane with the connective tissue of the dura at its dural entry site. When performing posterolateral skull base approaches requiring manipulation of the VA-dural interface, maintenance of a dural cuff on the VA is critical to minimize the risk of vascular injury.

Revising the Indications of Transtemporal Surgical Approaches in the Modern Endoscopic Era of Skull Base Surgery: A Dying Art

2020 ◽  
Author(s):  
Ravi Sankar Manogaran ◽  
Raj Kumar ◽  
Arulalan Mathialagan ◽  
Anant Mehrotra ◽  
Amit Keshri ◽  
...  
Keyword(s):  
Skull Base ◽  
Surgical Approach ◽  
Nerve Palsy ◽  
Tertiary Care ◽  
Surgical Approaches ◽  
Microsurgical Anatomy ◽  
Complete Excision ◽  
Lateral Skull Base ◽  
The Individual ◽  
Selection Of

Abstract Objectives The aim of the study is to emphasize and explore the possible transtemporal approaches for spectrum of complicated lateral skull base pathologies. Design Retrospective analysis of complicated lateral skull base pathologies was managed in our institute between January 2017 and December 2019. Setting The study was conducted in a tertiary care referral center. Main Outcome Measures The study focused on the selection of approach based on site and extent of the pathology, the surgical nuances for each approach, and the associated complications. Results A total of 10 different pathologies of the lateral skull base were managed by different transtemporal approaches. The most common complication encountered was facial nerve palsy (43%, n = 6). Other complications included cerebrospinal fluid (CSF) collection (15%, n = 2), cosmetic deformity (24%, n = 4), petrous internal carotid artery injury (7%, n = 1), and hypoglossal nerve palsy (7%, n = 1). The cosmetic deformity included flap necrosis (n = 2) and postoperative bony defects leading to contour defects of the scalp (n = 2). Conclusion Surgical approach should be tailored based on the individual basis, to obtain adequate exposure and complete excision. Selection of appropriate surgical approach should also be based on the training and preference of the operating surgeon. Whenever necessary, combined surgical approaches facilitating full tumor exposure are recommended so that complete tumor excision is feasible. This requires a multidisciplinary team comprising neurosurgeons, neuro-otologist, neuroanesthetist, and plastic surgeons. The surgeon must know precise microsurgical anatomy to preserve the adjacent nerves and vessels, which is necessary for better surgical outcomes.

scholarly journals Far Lateral Craniotomy for Resection of Foramen Magnum Meningioma

2019 ◽  
Vol 80 (S 04) ◽  
pp. S355-S357
Author(s):  
Robert T. Wicks ◽  
Xiaochun Zhao ◽  
Celene B. Mulholland ◽  
Peter Nakaji
Keyword(s):  
Cranial Nerves ◽  
Craniocervical Junction ◽  
Foramen Magnum ◽  
Occipital Condyle ◽  
Formidable Challenge ◽  
Close Proximity ◽  
Vertebrobasilar Circulation ◽  
Far Lateral ◽  
Lower Cranial Nerves ◽  
Gain Access

Abstract Objective Foramen magnum meningiomas present a formidable challenge to resection due to frequent involvement of the lower cranial nerves and vertebrobasilar circulation. The video shows the use of a far lateral craniotomy to resect a foramen magnum meningioma. Design, Setting, and Participant A 49-year-old woman presented with neck pain and was found to have a large foramen magnum meningioma (Fig. 1A, B). Drilling of the posterior occipital condyle was required to gain access to the lateral aspect of the brain stem. The amount of occipital condyle resection varies by patient and pathology. Outcome/Result Maximal total resection of the tumor was achieved (Fig. 1B, C), and the patient was discharged on postoperative day 4 with no neurologic deficits. The technique for tumor microdissection (Fig. 2) is shown in the video. Conclusion Given the close proximity of foramen magnum meningiomas to vital structures at the craniocervical junction, surgical resection with careful microdissection and preservation of the overlying dura to prevent postoperative pseudomeningocele is necessary to successfully manage this pathology in those patients who are surgical candidates.The link to the video can be found at: https://youtu.be/Mds9N1x2zE0.

scholarly journals Resection of a Recurrent Cervicomedullary Junction Fibromyxoid Sarcoma through a Far Lateral Approach

2020 ◽  
Author(s):  
Vincent Nguyen ◽  
William Mangham ◽  
Jaafar Basma ◽  
Nickalus Khan ◽  
Jeffrey Sorenson ◽  
...  
Keyword(s):  
Cranial Nerves ◽  
Extent Of Resection ◽  
Craniocervical Junction ◽  
Lateral Approach ◽  
Senior Author ◽  
Microsurgical Anatomy ◽  
Dural Graft ◽  
Far Lateral Approach ◽  
Fibromyxoid Sarcoma ◽  
Far Lateral

Abstract Objectives This study describes a far lateral approach for the resection of a recurrent fibromyxoid sarcoma involving the ventrolateral brainstem, with emphasis on the microsurgical anatomy and technique. Design A far lateral craniotomy is performed in the lateral decubitus position and the transverse and sigmoid sinuses exposed. After opening the dura, sutures are placed to allow gentle mobilization of the sinuses. The recurrent tumor is immediately visible. The involved dura is resected and aggressive internal debulking is performed. Subarachnoid dissection gives access to the lower cranial nerves. The tumor is dissected off the affected portions of the brainstem. A dural graft is used to reconstitute the dura. 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 Dr. V.N. chart review, and literature review were performed by Drs. W.M. and J.B. Outcome measures Outcome was assessed with the extent of resection and postoperative neurological function. Results A near gross total resection of the lesion was achieved. The patient developed a left vocal cord paresis, but her voice was improving at 3-month follow-up. Conclusion Understanding the microsurgical anatomy of the craniocervical junction and ventrolateral brainstem and meticulous microneurosurgical technique are necessary to achieve adequate resection of lesions involving the ventrolateral brainstem. The far lateral approach provides an adequate corridor to this region.The link to the video can be found at: https://youtube/uYEhgPbgrTs.

The Asterion-to-Transverse Process of the Atlas Line as a Surgical Landmark

2021 ◽  
Author(s):  
Jaafar Basma ◽  
Dom E. Mahoney ◽  
Christos Anagnostopoulos ◽  
L. Madison Michael ◽  
Jeffrey M. Sorenson ◽  
...  
Keyword(s):  
Skull Base ◽  
Cranial Nerves ◽  
Three Dimensional ◽  
Transverse Process ◽  
Jugular Foramen ◽  
Foramen Magnum ◽  
Sigmoid Sinus ◽  
Cervical Region ◽  
Surgical Approaches ◽  
Anatomical Location

Abstract Introduction Proposed landmarks to predict the anatomical location and trajectory of the sigmoid sinus have varying degrees of reliability. Even with neuronavigation technology, landmarks are crucial in planning and performing complex approaches to the posterolateral skull base. By combining two major dependable structures—the asterion (A) and transverse process of the atlas (TPC1)—we investigate the A-TPC1 line in relation to the sigmoid sinus and in partitioning surgical approaches to the region. Methods We dissected six cadaveric heads (12 sides) to expose the posterolateral skull base, including the mastoid and suboccipital bone, TPC1 and suboccipital triangle, distal jugular vein and internal carotid artery, and lower cranial nerves in the distal cervical region. We inspected the A-TPC1 line before and after drilling the mastoid and occipital bones and studied the relationship of the sigmoid sinus trajectory and major muscular elements related to the line. We retrospectively reviewed 31 head and neck computed tomography (CT) angiograms (62 total sides), excluding posterior fossa or cervical pathologies. Bone and vessels were reconstructed using three-dimensional segmentation software. We measured the distance between the A-TPC1 line and sigmoid sinus at different levels: posterior digastric point (DP), and maximal distances above and below the digastric notch. Results A-TPC1 length averaged 65 mm and was posterior to the sigmoid sinus in all cadaver specimens, coming closest at the level of the DP. Using the transverse-asterion line as a rostrocaudal division and skull base as a horizontal plane, we divided the major surgical approaches into four quadrants: distal cervical/extreme lateral and jugular foramen (anteroinferior), presigmoid/petrosal (anterosuperior), retrosigmoid/suboccipital (posterosuperior), and far lateral/foramen magnum regions (posteroinferior). Radiographically, the A-TPC1 line was also posterior to the sigmoid sinus in all sides and came closest to the sinus at the level of DP (mean, 7 mm posterior; range, 0–18.7 mm). The maximal distance above the DP had a mean of 10.1 mm (range, 3.6–19.5 mm) and below the DP 5.2 mm (range, 0–20.7 mm). Conclusion The A-TPC1 line is a helpful landmark reliably found posterior to the sigmoid sinus in cadaveric specimens and radiographic CT scans. It can corroborate the accuracy of neuronavigation, assist in minimizing the risk of sigmoid sinus injury, and is a useful tool in planning surgical approaches to the posterolateral skull base, both preoperatively and intraoperatively.

Orbitomeningeal Band in Transcavernous Dissection and Anterior Clinoidectomy: 3-Dimensional Operative Video

2020 ◽  
Vol 19 (4) ◽  
pp. E414-E414
Author(s):  
Alvaro Campero ◽  
Matias Baldoncini ◽  
Juan F Villalonga ◽  
Amparo Sáenz
Keyword(s):  
Skull Base ◽  
Cranial Nerves ◽  
Lateral Wall ◽  
Senior Author ◽  
Microsurgical Anatomy ◽  
Resonance Imaging ◽  
Superior Orbital Fissure ◽  
3 Dimensional ◽  
Magnetic Resonance Imaging Mri ◽  
Base Lesion

Abstract The orbitomeningeal or meningo-orbital band (MOB) has been described as the most superficial dural band responsible for tethering the frontotemporal basal dura to the periorbita.1,2 The MBO usually interferes with the surgical approach to the most profound areas of the anterior and middle skull base. It is known that there are no cranial nerves on the lateral surface of the superior orbital fissure; therefore, the neurosurgeon can cut the MOB without causing any neurological deficit and, at the same time, achieving fully exposure of the anterior clinoid process1-4 and/or the lateral wall of the cavernous sinus.5 The purpose of this video is to describe the microsurgical anatomy of the MOB and illustrate the technique for its detachment, accompanied by 2 illustrative cases. To achieve this, we use 3-dimensional recordings of 2 cadaveric specimens’ dissections performed by the senior author. Case 1: 58-yr-old female with left blindness. Magnetic resonance imaging (MRI) shows an anterior and middle skull base lesion with orbital compression. Case 2: 32-yr-old male presenting with headache and trigeminal neuralgia. The MRI revealed an hourglass-shaped lesion in the posterior and middle fossa. Both patients signed an informed consent and agree with the use of their images for research purposes. We used a step-by-step approach for an adequate and secure dissection of the MOB highlighting the anatomic structures involved in the process. This approach allows safe and adequate access to the deeper structures of the anterior and middle skull base.

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