A Combined Intra-extradural Approach to the Jugular Foramen for Complex Lesions with Transforaminal Extracranial Extension: A Technical Clinical Series

Background: Large complex lesions of the jugular foramen, namely, paragangliomas (glomus jugulare tumors) arising from the dome of the jugular bulb, as well as schwannomas and meningiomas of the lower cranial nerves involving the foramen magnum and neck, can extend from either an intracranial or extracranial origin through the jugular foramen. Surgical excision of these lesions is particularly difficult when they present with extensive intra- and extracranial involvement. We technically describe and review our extensive clinic experience using a modified combined approach to this region that combines a presigmoid infralabyrinthine approach, far lateral transcondylar exposure, and lateral upper cervical dissection.

Methods: Combined far lateral transpetrosal (infralabyrinthine) upper cervical approaches were performed on 70 patients as well as 5 cadaveric heads (10 sides). Patients were positioned in a modified park bench position, with the head rotated 45 degrees to the contralateral side, and with the mastoid process as the highest point. An upper cervical dissection was performed exposing the jugular vein and surrounding structures up to the base of the skull, followed by a conservative presigmoid infralabyrinthine mastoidectomy exposing the posterior fossa. A far lateral suboccipital craniotomy with partial extradural resection of the occipital condyle and C1 hemilaminotomy was performed, exposing the craniocervical junction, foramen magnum, and the lower cranial nerve. Surgical steps and techniques for safely mobilizing and accessing key neurovascular structures were identified and summarized.

Results: In all cases, the combined far lateral transpetrosal upper cervical approach provided extensive access to the jugular foramen region, both intracranially and extracranially, while preserving hearing. Gross total resection was achieved in 94% of cases. The most common sites of residual tumor were the brainstem and that adherent to or encasing the lower cranial nerves, especially cranial nerve IX due to its superior location in the extracranial compartment. Partial extradural resection of the occipital condyle improved exposure of the ventral aspect of the craniovertebral junction. C1 hemilaminotomy was useful in cases with lesions that extended inferiorly. This combined approach, while technically demanding, negates the need for multi-stage surgery, avoids facial nerve rerouting, facilitates access to the lower clivus and anterior foramen magnum, allows for careful dissection of tumor adjacent to the brainstem, and enables control of the vertebral artery and vertebrobasilar junction. Cadaveric dissections are shown ([Figs. 1] and [2]).

Conclusion: The combined far lateral transpetrosal upper cervical approach is a safe and highly effective approach for extensive intra-extradural lesions involving the jugular foramen that has proven to be an important component of the skull base neurosurgical armamentarium. Extensive surgical experience using this approach—the largest series to date—allowed us to identify key steps and techniques for maximizing resection of challenging tumors involving the jugular foramen. Understanding of the optimal surgical sequence, key surgical maneuvers, and anatomical relationships within the jugular foramen and its adjacent areas is requisite for application of this approach for complex intra-extradural lesions.

Fig. 1

Fig. 2

Publikationsverlauf

Artikel online veröffentlicht:
07. Februar 2025