Quantitative Analysis of the Far-Lateral, Supra-Articular Transcondylar Transtubercular Approach Using Cadaveric Computed Tomography and Magnetic Resonance Imaging

2020 ◽  
Vol 19 (5) ◽  
pp. E498-E509
Author(s):  
Toshiaki Kodera ◽  
Ayumi Akazawa ◽  
Shinsuke Yamada ◽  
Hiroshi Arai ◽  
Takahiro Yamauchi ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Magnetic Resonance ◽  
Mr Imaging ◽  
Imaging Study ◽  
Lateral Approach ◽  
Working Space ◽  
Far Lateral Approach ◽  
Before And After ◽  
Fusion Images ◽  
Far Lateral

Abstract BACKGROUND Removing the jugular tubercle (JT) is regarded as an important step in the far-lateral approach; however, few cadaveric studies have objectively evaluated it. OBJECTIVE To quantitatively analyze the effect of JT removal in the far-lateral approach, using cadaveric computed tomography (CT) and magnetic resonance (MR) imaging. METHODS The far-lateral, supra-articular transcondylar transtubercular approach was employed on 23 sides of 13 formalin-fixed cadaveric heads. CT bone images were obtained before and after JT removal, and MR images were obtained before dissection and were merged with the CT bone images. The angles of attack used to approach the ventral region of the medulla, the distances between the medulla and the bony structure, and the volume of the paramedullary space were measured at the level of the JT on axial CT-MR fusion images. The values obtained after JT removal were compared with those obtained before JT removal. RESULTS All evaluated values were significantly increased after JT removal, including the angle of attack at the level of the JT (29.8 ± 7.4° vs 58.2 ± 15.5°, P < .001), the distance between the olive and the JT (6.4 ± 2.0 mm vs 9.5 ± 5.0 mm, P = .01), and the volume of the space around the medulla (0.28 ± 0.04 cm3 vs 0.47 ± 0.09 cm3, P < .001). CONCLUSION The paramedullary surgical working space widened by JT removal was quantitatively demonstrated in the cadaveric CT and MR imaging study. The measurement methods in this study can be applied to clinical cases and other skull base cadaveric studies.

“Lazy” far-lateral approach to the anterior foramen magnum and lower clivus

2015 ◽  
Vol 38 (4) ◽  
pp. E14 ◽  
Author(s):  
Samuel Moscovici ◽  
Felix Umansky ◽  
Sergey Spektor
Keyword(s):  
Foramen Magnum ◽  
Lateral Approach ◽  
Anatomical Structure ◽  
Lateral Mass ◽  
Surgical Mortality ◽  
Bone Removal ◽  
Working Space ◽  
Far Lateral Approach ◽  
Far Lateral ◽  
Lower Clivus

The far-lateral approach (FLA) has become a mainstay for skull base surgeries involving the anterior foramen magnum and lower clivus. The authors present a surgical technique using the FLA for the management of lesions of the anterior/ anterolateral foramen magnum and lower clivus. The authors consider this modification a “lazy” FLA. The vertebral artery (VA) is both a critical anatomical structure and a barrier that limits access to this region. The most important nuance of this FLA technique is the management of this critical vessel. When the lazy FLA is used, the VA is reflected laterally, encased in its periosteal sheath and wrapped in the dura, greatly minimizing the risk for vertebral injury while preserving a wide working space. To accomplish this step, drilling is performed lateral to the point where the VA pierces the dura. The dura is incised medial to the VA entry point by using a slightly curved longitudinal cut. Drilling of the condyle and the C-1 lateral mass is performed in a manner that preserves craniocervical stability. The lazy FLA is a true FLA that is based on manipulation of the VA and lateral bone removal to obtain excellent exposure ventral to the spinal cord and medulla, yet it is among the most conservative FLA techniques for management of the VA and provides a safer window for bone work and lesion management. Among 44 patients for whom this technique was used to resect 42 neoplasms and clip 2 posterior inferior cerebral artery aneurysms, there was no surgical mortality and no injury to the VA.

Microsurgical Excision of a Retro-odontoid Disc Hernia via a Far-lateral Approach: Successful Treatment of a Rare Cause of Myelopathy: Case Report

Neurosurgery ◽  
2004 ◽  
Vol 54 (4) ◽  
pp. 1015-1018 ◽  
Author(s):  
Akira Matsuno ◽  
Michi Nakashima ◽  
Mineko Murakami ◽  
Tadashi Nagashima
Keyword(s):  
Magnetic Resonance Imaging ◽  
Magnetic Resonance ◽  
Odontoid Process ◽  
Craniovertebral Junction ◽  
Lateral Approach ◽  
The Body ◽  
Cervical Cord ◽  
Resonance Imaging ◽  
Far Lateral Approach ◽  
Far Lateral

Abstract OBJECTIVE AND IMPORTANCE Among mass lesions causing myelopathy at the craniovertebral junction, retro-odontoid intervertebral disc hernias are very rare, with only four such cases reported in the literature. CLINICAL PRESENTATION A 77-year-old woman with this rare condition complained of motor and sensory disturbances in her extremities. Magnetic resonance imaging scans demonstrated an extradural mass lesion at the craniovertebral junction, compressing the lower medulla oblongata and the upper cervical cord posteriorly. INTERVENTION The lesion, which was partly mucinous cartilaginous and partly fatty and fibrous, was meticulously removed via a left far-lateral approach. The lesion was not neoplastic but was determined to be composed of fibrocartilaginous tissue, consistent with disc material. Postoperatively, the patient's sensory disturbances and motor weakness improved, and magnetic resonance imaging scans demonstrated marked shrinkage of the lesion. CONCLUSION Sagittal, T1-weighted, magnetic resonance imaging scans demonstrated a low-intensity band between the odontoid process and the body of the axis, which suggested a persistent cartilaginous band. Although upward migration of a herniated disc from the lower cervical spine and degeneration of retro-odontoid ligaments might be possible causes, a persistent cartilaginous band extending between the odontoid process and the body of the axis was considered to be the more likely origin of the retro-odontoid intervertebral disc hernia. Because the far-lateral surgical approach does not require retraction of the cervical cord and provides safe access to the lesion at the craniovertebral junction, it is a suitable surgical method for this condition.

scholarly journals Contralateral far-lateral approach for clipping of a ruptured vertebral artery–posterior inferior cerebellar artery aneurysm

2008 ◽  
Vol 25 (6) ◽  
pp. E9 ◽  
Author(s):  
Taryn McFadden Bragg ◽  
Edward A. M. Duckworth
Keyword(s):  
Computed Tomography ◽  
Vertebral Artery ◽  
Posterior Inferior Cerebellar Artery ◽  
Artery Aneurysm ◽  
Lateral Approach ◽  
Cerebellar Artery ◽  
Far Lateral Approach ◽  
Far Lateral ◽  
The Right ◽  
Pica Aneurysms

Numerous nuanced approaches have been used to access posterior inferior cerebellar artery (PICA) aneurysms for microsurgical clipping. The authors report the case of a patient with a right vertebral artery (VA)–PICA aneurysm that was reached via a contralateral far-lateral approach. The wide-necked saccular/fusiform aneurysm arose from the lateral aspect of the right V4 segment just proximal to the PICA origin, anterior to the jugular tubercle at the level of the hypoglossal canal. Computed tomography angiograms demonstrated the size and configuration of the aneurysm, and 3D reconstructions revealed the tortuosity of the right VA, defining its location just left of the midline adjacent to the lower clivus. A contralateral far-lateral approach to VA–PICA aneurysms should be considered when aneurysms cross the midline. Computed tomography angiography with volume rendering and interactive software capabilities can help identify the relationship of such an aneurysm to an individual's particular skull base osseous anatomy and is paramount in selecting the optimal microsurgical approach.

Sequential Extradural Release of the V3 Vertebral Artery to Facilitate Intradural V4 Vertebral Artery Reanastomosis: Feasibility of a Novel Revascularization Technique

2017 ◽  
Vol 13 (3) ◽  
pp. 345-351 ◽  
Author(s):  
Ali Tayebi Meybodi ◽  
Michael T. Lawton ◽  
Arnau Benet
Keyword(s):  
Vertebral Artery ◽  
Surgical Simulation ◽  
Average Length ◽  
Primary Anastomosis ◽  
Posterior Inferior Cerebellar Artery ◽  
Lateral Approach ◽  
Transverse Foramen ◽  
Far Lateral Approach ◽  
Before And After ◽  
Far Lateral

Abstract BACKGROUND: Revascularization of the intradural vertebral artery (VA) usually involves V3-V4 bypass using an interposition graft. The interposition of a graft increases surgical time, adds risks, and requires 2 suture lines. OBJECTIVE: To assess the feasibility of an excision-reanastomosis of V4 by sequentially releasing V3. METHODS: Twenty specimens were prepared for surgical simulation of a far-lateral approach. The third and fourth segments of the VA were exposed through the far-lateral approach bilaterally. The V3 segment was divided into three subsegments: (1) V3f: from entry to C1 transverse foramen to the point of exit from C1 transverse foramen; (2) V3s: from V3f to the distal point of V3 within the sulcus arteriosus; and (3) V3d: from point V3 leaves the sulcus arteriosus to its dural entrance. After transecting the VA 2 mm proximal to the posterior inferior cerebellar artery origin, each subsegment was released sequentially. We measured the lengths obtained before and after releasing each segment by pulling the VA along its main axis to recreate a V3-V4 excision-reanastomosis. RESULTS: The V3 could not be effectively mobilized without release. When totally released, an average length of 13.15 mm was available for completing V3-V4 reanastomosis. CONCLUSION: Complete release of V3 from all its adhesions in its extracranial course can provide an average length of 13.15 mm for excision-reanastomosis. The present study shows the anatomic feasibility of the use of V3 segment in primary anastomosis after excision of a diseased segment of the intradural VA, laying the basis for future clinical application.

Surgical Relevance of Pediatric Skull Base Maturation for the Far-Lateral Approach

2019 ◽  
Author(s):  
Robert Rennert ◽  
Reid Hoshide ◽  
Michael Brandel ◽  
Jeffrey Steinberg ◽  
Joel Martin ◽  
...  
Keyword(s):  
Skull Base ◽  
Lateral Approach ◽  
Far Lateral Approach ◽  
Far Lateral

Extended Transpterygoid Endonasal Far Lateral Approach: The Role of the Eustachian Tube Revised

Skull Base ◽  
2009 ◽  
Vol 19 (01) ◽  
Author(s):  
Paolo Battaglia ◽  
Guglielmo Romano ◽  
Iacopo Dallan ◽  
Maurizio Bignami ◽  
Luca Muscatello ◽  
...  
Keyword(s):  
Eustachian Tube ◽  
Lateral Approach ◽  
Far Lateral Approach ◽  
Far Lateral
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