Download PDF
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)

Also available at
    Permissions and Reprints

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.

Keywords

far-lateral approach - quantitative anatomical study - practical surgical working area
 

  • 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
    CrossrefPubMedSearch in Google Scholar
  • 2 Heros RC. Lateral suboccipital approach for vertebral and vertebrobasilar artery lesions. J Neurosurg 1986; 64 (4) 559-562
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    PubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    PubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    PubMedSearch in Google Scholar
  • 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
    CrossrefSearch in Google Scholar
  • 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
    PubMedSearch in Google Scholar
  • 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
    Search in Google Scholar
  • 12 Babu RP, Sekhar LN, Wright DC. Extreme lateral transcondylar approach: technical improvements and lessons learned. J Neurosurg 1994; 81 (1) 49-59
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    Thieme ConnectPubMedSearch in Google Scholar
  • 15 Gonzalez LF, Amin-Hanjani S, Bambakidis NC, Spetzler RF. Skull base approaches to the basilar artery. Neurosurg Focus 2005; 19 (2) E3
    PubMedSearch in Google Scholar
  • 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
    Search in Google Scholar
  • 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
    Thieme ConnectPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 19 Hillman J, Säveland H, Jakobsson KE , et al. Overall management outcome of ruptured posterior fossa aneurysms. J Neurosurg 1996; 85 (1) 33-38
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    Thieme ConnectPubMedSearch in Google Scholar
  • 22 Rhoton Jr AL. The cerebellar arteries. Neurosurgery 2000; 47 (3, Suppl): S29-S68
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 26 Samii M, Klekamp J, Carvalho G. Surgical results for meningiomas of the craniocervical junction. Neurosurgery 1996; 39 (6) 1086-1094 ; discussion 1094–1095
    CrossrefPubMedSearch in Google Scholar
  • 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
    Search in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 30 Abla AA, Turner JD, Mitha AP, Lekovic G, Spetzler RF. Surgical approaches to brainstem cavernous malformations. Neurosurg Focus 2010; 29 (3) E8
    PubMedSearch in Google Scholar
  • 31 Garrett M, Spetzler RF. Surgical treatment of brainstem cavernous malformations. Surg Neurol 2009; 72 (Suppl. 02) S3-S9 ; discussion S9–S10
    CrossrefPubMedSearch in Google Scholar
  • 32 Brown AP, Thompson BG, Spetzler RF. The two-point method: evaluating brain stem lesions. BNI Q 1996; 12 ( (1)) 20-24
    PubMedSearch in Google Scholar
  • 33 Rhoton Jr AL. The far-lateral approach and its transcondylar, supracondylar, and paracondylar extensions. Neurosurgery 2000; 47 (3, Suppl): S195-S209
    CrossrefPubMedSearch in Google Scholar
  • 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
    PubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar