Surgical relevance of pediatric skull base maturation for the far-lateral and extreme-lateral infrajugular transcondylar–transtubercular exposure approaches

2019 ◽  
Vol 24 (1) ◽  
pp. 85-91 ◽  
Author(s):  
Robert C. Rennert ◽  
Reid Hoshide ◽  
Michael G. Brandel ◽  
Jeffrey A. Steinberg ◽  
Joel R. Martin ◽  
...  
Keyword(s):  
Skull Base ◽  
Pediatric Population ◽  
Age Groups ◽  
Foramen Magnum ◽  
Occipital Condyle ◽  
Adult Size ◽  
Older Children ◽  
Base Parameters ◽  
Far Lateral ◽  
Skull Base Anatomy

OBJECTIVELesions of the foramen magnum, inferolateral-to-midclival areas, and ventral pons and medulla are often treated using a far-lateral or extreme-lateral infrajugular transcondylar–transtubercular exposure (ELITE) approach. The development and surgical relevance of critical posterior skull base bony structures encountered during these approaches, including the occipital condyle (OC), hypoglossal canal (HGC), and jugular tubercle (JT), are nonetheless poorly defined in the pediatric population.METHODSMeasurements from high-resolution CT scans were made of the relevant posterior skull base anatomy (HGC depth from posterior edge of the OC, OC and JT dimensions) from 60 patients (evenly distributed among ages 0–3, 4–7, 8–11, 12–15, 16–18, and > 18 years), and compared between laterality, sex, and age groups by using t-tests and linear regression.RESULTSThere were no significant differences in posterior skull base parameters by laterality, and HGC depth and JT size did not differ by sex. The OC area was significantly larger in males versus females (174.3 vs 152.2 mm2; p = 0.01). From ages 0–3 years to adult, the mean HGC depth increased 27% (from 9.0 to 11.4 mm) and the OC area increased 52% (from 121.4 to 184.0 mm2). The majority of growth for these parameters occurred between the 0–3 year and 4–7 year age groups. Conversely, JT volume increased nearly 3-fold (281%) from 97.4 to 370.9 mm3 from ages 0–3 years to adult, with two periods of substantial growth seen between the 0–3 to 4–7 year and the 12–15 to 16–18 year age groups. Overall, JT growth during pediatric development was significantly greater than increases in HGC depth and OC area (p < 0.05). JT volume remained < 65% of adult size up to age 16.CONCLUSIONSWhen considering a far-lateral or ELITE approach in pediatric patients, standard OC drilling is likely to be needed due to the relative stability of OC and HGC anatomy during development. The JT significantly increases in size with development, yet is only likely to need to be drilled in older children (> 16 years) and adults.

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.

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.

Corridor-Based Endonasal Endoscopic Surgery for Pediatric Skull Base Pathology With Detailed Radioanatomic Measurements

2013 ◽  
Vol 10 (2) ◽  
pp. 273-293 ◽  
Author(s):  
Matei A. Banu ◽  
Allison Rathman ◽  
Kunal S. Patel ◽  
Mark M. Souweidane ◽  
Vijay K. Anand ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Skull Base ◽  
Pediatric Population ◽  
Visual Fields ◽  
Age Groups ◽  
Cerebrospinal Fluid Leak ◽  
Gross Total Resection ◽  
Benign Tumors ◽  
Minimal Risk ◽  
Total Resection

Abstract BACKGROUND: Pediatric anatomy is more restricted, and the propagation of endonasal endoscopic approaches in the pediatric population has been limited. OBJECTIVE: To demonstrate the feasibility of the endonasal endoscopic approach in a variety of age groups and to perform measurements of the corridors and spaces available for surgery as a guide for case selection. METHODS: Only patients &lt;18 years were included. The choice of operative corridor/approach is described in relation to pathological entity and location. Preoperative/postoperative visual fields and endocrine panels, extent of resection, as well as postoperative long-term complications are described. Prospective magnetic resonance image-based anatomic measurements of key distances were performed to determine age-dependent surgical indications and limitations. RESULTS: Forty purely endoscopic procedures were performed in 33 pediatric patients (5-18 years of age) harboring a variety of skull base lesions, from benign tumors to congenital malformations. For the 20 patients in whom gross total resection was the intended goal of surgery, gross total resection was attained in 15 (75%). There were 2 infections (5%) and no cerebrospinal fluid leaks. Significant improvement was shown in 58.3% of patients with visual deficits. Hormone overproduction resolved in 75% of patients, while preoperative hormone insufficiency only improved in 29.2%. Wider intercarotid distance at the superior clivus (P = .01) and shorter nare-dens working distance (P = .001) predicted improved outcomes and fewer postoperative complications. CONCLUSION: Endonasal endoscopic skull base approaches are viable in the pediatric population, they are not impeded by sphenoid sinus aeration, and they have minimal risk of cerebrospinal fluid leak and meningitis. Outcomes and complications can be predicted based on specific radio anatomical skull base measurements rather than age.

Quantitative description of the far-lateral transcondylar transtubercular approach to the foramen magnum and clivus

2000 ◽  
Vol 92 (5) ◽  
pp. 824-831 ◽  
Author(s):  
Sergey Spektor ◽  
Gregory J. Anderson ◽  
Sean O. McMenomey ◽  
Michael A. Horgan ◽  
Jordi X. Kellogg ◽  
...  
Keyword(s):  
Pathological Condition ◽  
Quantitative Description ◽  
Foramen Magnum ◽  
Sigmoid Sinus ◽  
Occipital Condyle ◽  
Content Type ◽  
Suboccipital Craniectomy ◽  
Successive Step ◽  
Far Lateral ◽  
Fine Print

Object. The purpose of this study was to evaluate the far-lateral transcondylar transtubercular approach (complete FLA) based on quantitative measurements of the exposure of the foramen magnum and petroclival area obtained after each successive step of this approach.Methods. The complete FLA was reproduced in eight specially prepared cadaveric heads (a total of 15 sides). The approach was divided into six steps: 1) C-1 hemilaminectomy and suboccipital craniectomy with unroofing of the sigmoid sinus (basic FLA); 2) partial resection of the occipital condyle (up to the hypoglossal canal); 3) removal of the jugular tuberculum; 4) mastoidectomy (limited to the labyrinth and the fallopian canal) and retraction of the sigmoid sinus; 5) resection of the lateral mass of C-1 with mobilization of the vertebral artery; and 6) resection of the remaining portion of the occipital condyle. After each successive step, a standard set of measurements was obtained using a frameless stereotactic device. The measurements were used to estimate two parameters: the size of the exposed petroclival area and the size of a spatial cone directed toward the anterior rim of the foramen magnum, which depicts the amount of surgical freedom available for manipulation of instruments.The initial basic FLA provided exposure of only 21 ± 6% of the petroclival area that was exposed with the full, six-step maximally aggressive (complete) FLA. Likewise, only 18 ± 9% of the final surgical freedom was obtained after the basic FLA was performed. Each subsequent step of the approach increased both petroclival exposure and surgical freedom. The most dramatic increase in petroclival exposure was noted after removal of the jugular tuberculum (71 ± 12% of final exposure), whereas the least improvement in exposure occurred after the final step, which consisted of total condyle resection.Conclusions. The complete FLA provides wide and sufficient exposure of the foramen magnum and lower to middle clivus. The complete FLA consists of several steps, each of which contributes to increasing petroclival exposure and surgical freedom. However, the FLA may be limited to the less aggressive steps, while still achieving significant exposure and surgical freedom. The choice of complete or basic FLA thus depends on the underlying pathological condition and the degree of exposure required for effective surgical treatment.

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.

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 Microsurgical Gross Total Resection of Foramen Magnum Meningioma via Far Lateral Approach

2019 ◽  
Vol 80 (S 04) ◽  
pp. S360-S362
Author(s):  
Sima Sayyahmelli ◽  
Mustafa K. Başkaya
Keyword(s):  
Skull Base ◽  
Foramen Magnum ◽  
Lateral Approach ◽  
World Health ◽  
Gross Total Resection ◽  
Fine Motor ◽  
Total Resection ◽  
Postoperative Course ◽  
Far Lateral Approach ◽  
Far Lateral

Foramen magnum meningiomas are one of the most challenging tumors for skull base neurosurgeons due to their proximity to critical neurovascular structures. The far-lateral approach demonstrated here facilitates access to lesions involving the anterior portion of the foramen magnum.In this video, we present a 62-year-old woman with hand numbness and weakness. The patient had significant difficulty in fine motor movements of both hands. In the neurological examination, she had a significant right-hand intrinsic muscle weakness and mild quadriparesis.Magnetic resonance imaging (MRI) showed a dural-based homogeneously enhancing extra-axial mass in the anterior foramen magnum with a significant mass effect on the brain stem and the upper cervical cord. The decision was made to proceed with a far lateral transcondylar skull base approach including partial C1 laminectomy.The surgery and postoperative course were uneventful. The postoperative MRI showed gross total resection of the mass. The histopathology indicated a WHO (World health Organization) grade-I meningioma. The patient's postoperative course was uneventful. She improved to normal neurological function within several weeks and continues to do well without recurrence at 20 months' follow-up.In this video, we demonstrated important steps for the microsurgical resection of these challenging lesions.The link to the video can be found at: https://youtu.be/_nuX2Y7YU9w.

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 Tumors of the skull base in children: review of tumor types and management strategies

2002 ◽  
Vol 12 (5) ◽  
pp. 1-13 ◽  
Author(s):  
Eve C. Tsai ◽  
Stephen Santoreneos ◽  
James T. Rutka
Keyword(s):  
Skull Base ◽  
Pediatric Population ◽  
Management Strategies ◽  
Treatment Strategies ◽  
Surgical Approaches ◽  
Skull Base Tumors ◽  
Nasopharyngeal Angiofibroma ◽  
Review Management ◽  
Skull Base Lesions ◽  
Skull Base Anatomy

Although many treatment strategies for skull base tumors in adults have been reported, relatively little has been reported regarding such therapies in the pediatric population. Skull base tumors in children present a therapeutic challenge because of their unique pathological composition, the constraints of the maturing skull and brain, and the small size of the patients. In this review, the authors examine the pediatric skull base lesions that occur in the anterior, middle, and posterior cranial base, focusing on unique pediatric tumors such as encepahalocele, fibrous dysplasia, esthesioneuroblastoma, craniopharyngioma, juvenile nasopharyngeal angiofibroma, cholesteatoma, chordoma, chondrosarcoma, and Ewing sarcoma. They review management strategies that include radio- and chemotherapy, as well as surgical approaches with emphasis on the modifications and complications associated with the procedures as they apply in children. Evidence for the advantages and limitations of radiotherapy, chemotherapy, and surgery as it pertains to the pediatric population will be examined. With a working knowledge of skull base anatomy and special considerations of the developing craniofacial skeleton, neurosurgeons can treat skull base lesions in children with acceptable morbidity and mortality rates. Outcomes in this population may be better than those in adults, in part because of the benign histopathology that frequently affects the pediatric skull base, as well as the plasticity of the maturing nervous system.

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.

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