J Neurol Surg B Skull Base 2015; 76(01): 057-065
DOI: 10.1055/s-0034-1389373
Original Article
Georg Thieme Verlag KG Stuttgart · New York

Quantitative Anatomical Study of Tailored Far-Lateral Approach for the VA-PICA Regions

Young-Don Kim
1   Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
2   Department of Neurological Surgery, Daegu Catholic University Medical Center, Daegu, Korea
,
George A.C. Mendes
1   Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
,
Pablo Seoane
1   Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
,
Abhishek Agrawal
1   Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
,
Naveen Maramreddy
1   Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
,
Peter Nakaji
1   Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
,
Robert F. Spetzler
1   Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
,
Mark C. Preul
1   Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
› Author Affiliations
Further Information

Publication History

01 November 2013

14 June 2014

Publication Date:
21 September 2014 (online)

Abstract

Objective The extent of the far-lateral approach (FLA) has not yet been quantified for the region of the vertebral and posterior inferior cerebellar arteries (VA-PICA). We quantitatively analyzed six main sequential steps of the FLA.

Methods A modified small FLA (msFLA) and a classic large FLA (clFLA) were performed sequentially on both sides of five cadaveric heads. A frameless navigational system was used to quantify the angle of attack for the origin (T1) and lateral medullary segment (T2) of the PICA and the surgical area of exposure above and below the vagus nerve (cranial nerve [CN] X).

Results The total area of exposure above CN X increased significantly (p < 0.05) from the msFLA to the clFLA. However, the surgical exposure area below CN X did not change (p > 0.05). C1 hemilaminectomy increased (p < 0.05) the vertical angle of attack, and drilling the posteromedial third of the occipital condyle increased (p < 0.05) the horizontal angle of attack to the origin of the PICA.

Conclusions For the VA-PICA region, the msFLA offered a similar practical surgical working area and similar angles of attack when compared with the clFLA. The FLA should be tailored based on the location, size, and pathology of lesions and on the exposure required for effective surgical treatment.

 
  • References

  • 1 Bertalanffy H, Seeger W. The dorsolateral, suboccipital, transcondylar approach to the lower clivus and anterior portion of the craniocervical junction. Neurosurgery 1991; 29 (6) 815-821
  • 2 Heros RC. Lateral suboccipital approach for vertebral and vertebrobasilar artery lesions. J Neurosurg 1986; 64 (4) 559-562
  • 3 Spektor S, Anderson GJ, McMenomey SO, Horgan MA, Kellogg JX, Delashaw Jr JB. Quantitative description of the far-lateral transcondylar transtubercular approach to the foramen magnum and clivus. J Neurosurg 2000; 92 (5) 824-831
  • 4 Salas E, Sekhar LN, Ziyal IM, Caputy AJ, Wright DC. Variations of the extreme-lateral craniocervical approach: anatomical study and clinical analysis of 69 patients. J Neurosurg 1999; 90 (2, Suppl): 206-219
  • 5 Krayenbuhl N, Guerrero C, Krisht AF. Technical strategies to approach aneurysms of the vertebral and posterior inferior cerebellar arteries. Neurosurg Focus 2005; 19 (2) E4
  • 6 Bambakidis NC, Gonzalez LF, Amin-Hanjani S , et al. Combined skull base approaches to the posterior fossa. Technical note. Neurosurg Focus 2005; 19 (2) E8
  • 7 Matsushima T, Matsukado K, Natori Y, Inamura T, Hitotsumatsu T, Fukui M. Surgery on a saccular vertebral artery-posterior inferior cerebellar artery aneurysm via the transcondylar fossa (supracondylar transjugular tubercle) approach or the transcondylar approach: surgical results and indications for using two different lateral skull base approaches. J Neurosurg 2001; 95 (2) 268-274
  • 8 Wu A, Zabramski JM, Jittapiromsak P, Wallace RC, Spetzler RF, Preul MC. Quantitative analysis of variants of the far-lateral approach: condylar fossa and transcondylar exposures. Neurosurgery 2010; 66 (6, Suppl Operative): 191-198 ; discussion 198
  • 9 Perneczky A. The posterolateral approach to the foramen magnum. In: Samii M, , ed. Surgery In and Around the Brain Stem and the Third Ventricle: Anatomy, Pathology, Neurophysiology, Diagnosis, Treatment. Berlin, Germany: Springer-Verlag; 1986: 460-466
  • 10 Safavi-Abbasi S, de Oliveira JG, Deshmukh P , et al. The craniocaudal extension of posterolateral approaches and their combination: a quantitative anatomic and clinical analysis. Neurosurgery 2010; 66 (3, Suppl Operative): 54-64
  • 11 Thompson BG, Spetzler RF. Far-lateral suboccipital approach to the craniovertebral junction. In: Dickman CA, Spetzler RF, Sonntag VKH, , eds. Surgery of the Craniovertebral Junction. New York, NY: Thieme; 1997: 467-481
  • 12 Babu RP, Sekhar LN, Wright DC. Extreme lateral transcondylar approach: technical improvements and lessons learned. J Neurosurg 1994; 81 (1) 49-59
  • 13 D'Ambrosio AL, Kreiter KT, Bush CA , et al. Far lateral suboccipital approach for the treatment of proximal posteroinferior cerebellar artery aneurysms: surgical results and long-term outcome. Neurosurgery 2004; 55 (1) 39-50 ; discussion 50–54
  • 14 Matsushima T, Natori Y, Katsuta T, Ikezaki K, Fukui M, Rhoton AL. Microsurgical anatomy for lateral approaches to the foramen magnum with special reference to transcondylar fossa (supracondylar transjugular tubercle) approach. Skull Base Surg 1998; 8 (3) 119-125
  • 15 Gonzalez LF, Amin-Hanjani S, Bambakidis NC, Spetzler RF. Skull base approaches to the basilar artery. Neurosurg Focus 2005; 19 (2) E3
  • 16 Sanai N, Tarapore P, Lee AC, Lawton MT. The current role of microsurgery for posterior circulation aneurysms: a selective approach in the endovascular era. Neurosurgery 2008; 62 (6) 1236-1249 ; discussion 1249–1253
  • 17 Rohde V, Schaller C, Hassler W. The extreme lateral transcondylar approach to aneurysms of the vertebrobasilar junction, the vertebral artery, and the posterior inferior cerebellar artery. Skull Base Surg 1994; 4 (4) 177-180
  • 18 Al-khayat H, Al-Khayat H, Beshay J, Manner D, White J. Vertebral artery-posteroinferior cerebellar artery aneurysms: clinical and lower cranial nerve outcomes in 52 patients. Neurosurgery 2005; 56 (1) 2-10 ; discussion 11
  • 19 Hillman J, Säveland H, Jakobsson KE , et al. Overall management outcome of ruptured posterior fossa aneurysms. J Neurosurg 1996; 85 (1) 33-38
  • 20 Liew D, Ng PY, Ng I. Surgical management of ruptured and unruptured symptomatic posterior inferior cerebellar artery aneurysms. Br J Neurosurg 2004; 18 (6) 608-612
  • 21 Matsushima T, Kawashima M, Masuoka J, Mineta T, Inoue T. Transcondylar fossa (supracondylar transjugular tubercle) approach: anatomic basis for the approach, surgical procedures, and surgical experience. Skull Base 2010; 20 (2) 83-91
  • 22 Rhoton Jr AL. The cerebellar arteries. Neurosurgery 2000; 47 (3, Suppl): S29-S68
  • 23 al-Mefty O, Borba LA, Aoki N, Angtuaco E, Pait TG. The transcondylar approach to extradural nonneoplastic lesions of the craniovertebral junction. J Neurosurg 1996; 84 (1) 1-6
  • 24 Goel A, Desai K, Muzumdar D. Surgery on anterior foramen magnum meningiomas using a conventional posterior suboccipital approach: a report on an experience with 17 cases. Neurosurgery 2001; 49 (1) 102-106 ; discussion 106–107
  • 25 Nanda A, Vincent DA, Vannemreddy PS, Baskaya MK, Chanda A. Far-lateral approach to intradural lesions of the foramen magnum without resection of the occipital condyle. J Neurosurg 2002; 96 (2) 302-309
  • 26 Samii M, Klekamp J, Carvalho G. Surgical results for meningiomas of the craniocervical junction. Neurosurgery 1996; 39 (6) 1086-1094 ; discussion 1094–1095
  • 27 Day JD, Kellogg JX, Tschabitscher M, Fukushima T. Surface and superficial surgical anatomy of the posterolateral cranial base: significance for surgical planning and approach. Neurosurgery 1996; 38 (6) 1079-1083 ; discussion 1083–1084
  • 28 Sanai N, McDermott MW. A modified far-lateral approach for large or giant meningiomas of the posterior fossa. J Neurosurg 2010; 112 (5) 907-912
  • 29 Matsushima T, Goto Y, Natori Y, Matsukado K, Fukui M. Surgical treatment of glossopharyngeal neuralgia as vascular compression syndrome via transcondylar fossa (supracondylar transjugular tubercle) approach. Acta Neurochir (Wien) 2000; 142 (12) 1359-1363
  • 30 Abla AA, Turner JD, Mitha AP, Lekovic G, Spetzler RF. Surgical approaches to brainstem cavernous malformations. Neurosurg Focus 2010; 29 (3) E8
  • 31 Garrett M, Spetzler RF. Surgical treatment of brainstem cavernous malformations. Surg Neurol 2009; 72 (Suppl. 02) S3-S9 ; discussion S9–S10
  • 32 Brown AP, Thompson BG, Spetzler RF. The two-point method: evaluating brain stem lesions. BNI Q 1996; 12 ( (1)) 20-24
  • 33 Rhoton Jr AL. The far-lateral approach and its transcondylar, supracondylar, and paracondylar extensions. Neurosurgery 2000; 47 (3, Suppl): S195-S209
  • 34 Ciappetta P, Occhiogrosso G, Luzzi S, D'Urso PI, Garribba AP. Jugular tubercle and vertebral artery/posterior inferior cerebellar artery anatomic relationship: a 3-dimensional angiography computed tomography anthropometric study. Neurosurgery 2009; 64 (5) (Suppl. 02) 429-436 ; discussion 436
  • 35 Yamaguchi S, Eguchi K, Kiura Y, Takeda M, Kurisu K. Posterolateral protrusion of the vertebral artery over the posterior arch of the atlas: quantitative anatomical study using three-dimensional computed tomography angiography. J Neurosurg Spine 2008; 9 (2) 167-174