“Lazy” far-lateral approach to the anterior foramen magnum and lower clivus

2015 ◽  
Vol 38 (4) ◽  
pp. E14 ◽  
Author(s):  
Samuel Moscovici ◽  
Felix Umansky ◽  
Sergey Spektor
Keyword(s):  
Foramen Magnum ◽  
Lateral Approach ◽  
Anatomical Structure ◽  
Lateral Mass ◽  
Surgical Mortality ◽  
Bone Removal ◽  
Working Space ◽  
Far Lateral Approach ◽  
Far Lateral ◽  
Lower Clivus

The far-lateral approach (FLA) has become a mainstay for skull base surgeries involving the anterior foramen magnum and lower clivus. The authors present a surgical technique using the FLA for the management of lesions of the anterior/ anterolateral foramen magnum and lower clivus. The authors consider this modification a “lazy” FLA. The vertebral artery (VA) is both a critical anatomical structure and a barrier that limits access to this region. The most important nuance of this FLA technique is the management of this critical vessel. When the lazy FLA is used, the VA is reflected laterally, encased in its periosteal sheath and wrapped in the dura, greatly minimizing the risk for vertebral injury while preserving a wide working space. To accomplish this step, drilling is performed lateral to the point where the VA pierces the dura. The dura is incised medial to the VA entry point by using a slightly curved longitudinal cut. Drilling of the condyle and the C-1 lateral mass is performed in a manner that preserves craniocervical stability. The lazy FLA is a true FLA that is based on manipulation of the VA and lateral bone removal to obtain excellent exposure ventral to the spinal cord and medulla, yet it is among the most conservative FLA techniques for management of the VA and provides a safer window for bone work and lesion management. Among 44 patients for whom this technique was used to resect 42 neoplasms and clip 2 posterior inferior cerebral artery aneurysms, there was no surgical mortality and no injury to the VA.

The far lateral/combined supra- and infratentorial approach

1994 ◽  
Vol 81 (1) ◽  
pp. 60-68 ◽  
Author(s):  
Hillel Z. Baldwin ◽  
Christopher G. Miller ◽  
Harry R. van Loveren ◽  
Jeffrey T. Keller ◽  
C. Phillip Daspit ◽  
...  
Keyword(s):  
Brain Stem ◽  
Craniovertebral Junction ◽  
Foramen Magnum ◽  
Lateral Approach ◽  
Direct Access ◽  
Content Type ◽  
Far Lateral Approach ◽  
Far Lateral ◽  
Lower Clivus ◽  
Neurovascular Structures

✓ A far lateral approach to the ventral brain stem, lower clivus, and anterior foramen magnum is described. Methods for further exposure of the superior petroclival region by incorporating a subtemporal craniotomy and posterior petrosectomy are also demonstrated. Eight sequentially illustrated steps depict this technique. The far lateral/combined supra- and infratentorial exposure is a comprehensive surgical approach that provides direct access to the entire anterior and lateral brain stem and craniovertebral junction. It minimizes brain-stem retraction and maximizes visualization of the neurovascular structures.

scholarly journals The role of alternative anastomosis sites in occipital artery–posterior inferior cerebellar artery bypass in the absence of the caudal loop using the far-lateral approach

2017 ◽  
Vol 126 (2) ◽  
pp. 634-644 ◽  
Author(s):  
Hitoshi Fukuda ◽  
Alexander I. Evins ◽  
Koichi Iwasaki ◽  
Itaro Hattori ◽  
Kenichi Murao ◽  
...  
Keyword(s):  
Posterior Fossa ◽  
Posterior Inferior Cerebellar Artery ◽  
Technical Difficulty ◽  
Foramen Magnum ◽  
Lateral Approach ◽  
Difficulty Level ◽  
Occipital Artery ◽  
Cerebellar Artery ◽  
Far Lateral Approach ◽  
Far Lateral

OBJECTIVE Occipital artery–posterior inferior cerebellar artery (OA-PICA) bypass is a technically challenging procedure for posterior fossa revascularization. The caudal loop of the PICA is considered the optimal site for OA-PICA anastomosis, however its absence can increase the technical difficulty associated with this procedure. The use of the far-lateral approach for accessing alternative anastomosis sites in OA-PICA bypass in patients with absent or unavailable caudal loops of PICA is evaluated. METHODS A morphometric analysis of OA-PICA bypass with anastomosis on each segment of the PICA was performed on 5 cadaveric specimens through the conventional midline foramen magnum and far-lateral approaches. The difficulty level associated with anastomoses at each segment was qualitatively assessed in each approach for exposure and maneuverability by multiple surgeons. A series of 8 patients who underwent OA-PICA bypass for hemodynamic ischemia or ruptured dissecting posterior fossa aneurysms are additionally reviewed and described, and the clinical significance of the caudal loop of PICA is discussed. RESULTS Anastomosis on the caudal loop could be performed more superficially than on any other segment (p < 0.001). A far-lateral approach up to the medial border of the posterior condylar canal provided a 13.5 ± 2.2–mm wider corridor than the conventional midline foramen magnum approach, facilitating access to alternative anastomosis sites. The far-lateral approach was successfully used for OA-PICA bypass in 3 clinical cases whose caudal loops were absent, whereas the midline foramen magnum approach provided sufficient exposure for caudal loop bypass in the remaining 5 cases. CONCLUSIONS The absence of the caudal loop of the PICA is a major contributing factor to the technical difficulty of OA-PICA bypass. The far-lateral approach is a useful surgical option for OA-PICA bypass when the caudal loop of the PICA is unavailable.

scholarly journals The far-lateral approach: destruction of the condyle does not necessarily result in clinically evident craniovertebral junction instability

2016 ◽  
Vol 125 (1) ◽  
pp. 196-201 ◽  
Author(s):  
Ehab Shiban ◽  
Elisabeth Török ◽  
Maria Wostrack ◽  
Bernhard Meyer ◽  
Jens Lehmberg
Keyword(s):  
Extent Of Resection ◽  
Craniovertebral Junction ◽  
Foramen Magnum ◽  
Lateral Approach ◽  
Occipitocervical Fusion ◽  
Anterior Portion ◽  
Far Lateral Approach ◽  
Clinical Instability ◽  
Craniocervical Instability ◽  
Far Lateral

OBJECT Far-lateral or extreme-lateral approaches to the skull base allow access to the lateral and anterior portion of the lower posterior fossa and foramen magnum. These approaches include a certain extent of resection of the condyle, which potentially results in craniocervical junction instability. However, it is debated what extent of condyle resection is safe and at what extent of condyle resection an occipitocervical fusion should be recommended. The authors reviewed cases of condyle resection/destruction with regard to necessity of occipitocervical fusion. METHODS The authors conducted a retrospective analysis of all patients in whom a far- or extreme-lateral approach including condyle resection of various extents was performed between January 2007 and December 2014. RESULTS Twenty-one consecutive patients who had undergone a unilateral far- or extreme-lateral approach including condyle resection were identified. There were 10 male and 11 female patients with a median age of 61 years (range 22–83 years). The extent of condyle resection was 25% or less in 15 cases, 50% in 1 case, and greater than 75% in 5 cases. None of the patients who underwent condyle resection of 50% or less was placed in a collar postoperatively or developed neck pain. Two of the patients with condyle resection of greater than 75% were placed in a semirigid collar for a period of 3 months postoperatively and remained free of pain after this period. At last follow-up none of the cases showed any clear sign of radiological or clinical instability. CONCLUSIONS The unilateral resection or destruction of the condyle does not necessarily result in craniocervical instability. No evident instability was encountered even in the 5 patients who underwent removal of more than 75% of the condyle. The far- or extreme-lateral approach may be safer than generally accepted with regard to craniocervical instability as generally considered and may not compel fusion in all cases with condylar resection of more than 75%.

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.

Quantitative Analysis of the Far-Lateral, Supra-Articular Transcondylar Transtubercular Approach Using Cadaveric Computed Tomography and Magnetic Resonance Imaging

2020 ◽  
Vol 19 (5) ◽  
pp. E498-E509
Author(s):  
Toshiaki Kodera ◽  
Ayumi Akazawa ◽  
Shinsuke Yamada ◽  
Hiroshi Arai ◽  
Takahiro Yamauchi ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Magnetic Resonance ◽  
Mr Imaging ◽  
Imaging Study ◽  
Lateral Approach ◽  
Working Space ◽  
Far Lateral Approach ◽  
Before And After ◽  
Fusion Images ◽  
Far Lateral

Abstract BACKGROUND Removing the jugular tubercle (JT) is regarded as an important step in the far-lateral approach; however, few cadaveric studies have objectively evaluated it. OBJECTIVE To quantitatively analyze the effect of JT removal in the far-lateral approach, using cadaveric computed tomography (CT) and magnetic resonance (MR) imaging. METHODS The far-lateral, supra-articular transcondylar transtubercular approach was employed on 23 sides of 13 formalin-fixed cadaveric heads. CT bone images were obtained before and after JT removal, and MR images were obtained before dissection and were merged with the CT bone images. The angles of attack used to approach the ventral region of the medulla, the distances between the medulla and the bony structure, and the volume of the paramedullary space were measured at the level of the JT on axial CT-MR fusion images. The values obtained after JT removal were compared with those obtained before JT removal. RESULTS All evaluated values were significantly increased after JT removal, including the angle of attack at the level of the JT (29.8 ± 7.4° vs 58.2 ± 15.5°, P &lt; .001), the distance between the olive and the JT (6.4 ± 2.0 mm vs 9.5 ± 5.0 mm, P = .01), and the volume of the space around the medulla (0.28 ± 0.04 cm3 vs 0.47 ± 0.09 cm3, P &lt; .001). CONCLUSION The paramedullary surgical working space widened by JT removal was quantitatively demonstrated in the cadaveric CT and MR imaging study. The measurement methods in this study can be applied to clinical cases and other skull base cadaveric studies.

Sign in / Sign up

Export Citation Format

Share Document