J Neurol Surg B Skull Base 2020; 81(03): 223-231
DOI: 10.1055/s-0039-1685536
Original Article
Georg Thieme Verlag KG Stuttgart · New York

Retrosigmoid Approach: A Simple and Safe Way to Resect Intrinsic Pontomedullary Lesions

José M. González-Darder
1  Department of Neurosurgery, Hospital Clínico Universitario, Valencia, Spain
Pau Capilla-Guasch
1  Department of Neurosurgery, Hospital Clínico Universitario, Valencia, Spain
Luis Real-Peña
1  Department of Neurosurgery, Hospital Clínico Universitario, Valencia, Spain
› Author Affiliations
Further Information

Publication History

06 December 2018

02 March 2019

Publication Date:
23 April 2019 (online)


Objectives The main objective of this article is to describe a simple and safe protocol for the microsurgical management of ventrally located intrinsic pontomedullary lesions based on the retrosigmoid approach, cortectomy performed utilizing safe entry zones of the pons and medulla, and a delicate microsurgical resection. The intraoperative protocol includes redundant procedures that provide security in decision-making during surgery.

Design A prospective series of 11 cases is presented. All patients were studied following the same clinical and imaging workup. A regular retrosigmoid craniotomy surgical approach was utilized. The peritrigeminal area in the pons and the olivary area in the medulla were considered as the safe entry zones. Neuronavigation of the white fiber tracts and electrophysiological monitoring were used as intraoperative aids to locate the lesions, the safe entry zones, and the placement of the cortectomy.

Results Six lesions were pontine, two medullary, and the remaining six pontomedullary. Eight lesions were cavernomas, while the remaining three tumors. Overall, we obtained a postoperative functional improvement in the affected cranial nerves in 90.1% of the patients and a total or partial recovery of long ascending or descending pathway symptoms in 72.3% of the patients. All the patients were satisfied with the procedure and the results.

Conclusions Radical resection of ventral intrinsic pontomedullary lesions displays a high degree of intraoperative reliability, and a good clinical result is possible using simple surgical procedures. The anatomical references are the first element in the decision-making process during surgery.