1
|
Villamil F, Caffaratti G, Ruella M, Laplace LD, Calandri I, Darakdjian M, Nuñez M, Mormandi R, Cervio A. Delimitation of the risk area of the vertebral artery during the paramedian suboccipital approach. Clin Neurol Neurosurg 2024; 240:108269. [PMID: 38593567 DOI: 10.1016/j.clineuro.2024.108269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 03/28/2024] [Indexed: 04/11/2024]
Abstract
OBJECTIVE The V3 segment of the vertebral artery (V3-VA) is at risk during diverse approaches to the craniovertebral junction. Our objective is to present a system of anatomic and topographic landmarks to identify the V3-VA during the paramedian suboccipital approach (PMSOA) with the help of minimal or basic tools. MATERIAL AND METHODS The first was a retrospective analysis of the angiotomography (CTA) of 50 patients over 18-years old, and 9 anatomical dissections. A series of lines were defined between the different bony landmarks. Within this lines the risk area of the vertebral artery (RAsV3-VA) and the risk point of the vertebral artery (RPsV3-VA) were defined. The second stage was a prospective study, where the previously defined measurements were carried out by using neuronavigation in 10 patients (20 sides) operated with the PMSO approach in order to confirm the presence of the V3 segment in the RAsV3-VA and RPsV3-VA. RESULTS In the first stage, the V3 segment was found in the middle third of the X line in 96,6% of the cases. The distance between the inion and the UCP (percentile 5) was 20 mm and to the LCP (percentile 95) was 40 mm. In the range between the UCP and the LCP, in the middle third of the inion-mastoid line (RAsV3-VA), we found 90% of the V3-VA. The measurements taken during the second stage revealed that the artery was in the middle third of the X line in 97% of the cases. 85% of the patients presented the total of the V3s-VA on the RAsV3-VA and in 85% there was a direct relationship with the V3 segment and the RPV3s-VA. CONCLUSION We propose an easy-to-implement system to delimit the risk area of the V3-VA during the PMSOA. We believe that these landmarks provide a practical, reliable, costless and useful tool that could decrease the risk of lesion of the V3-VA during this approach without the need of using.
Collapse
Affiliation(s)
- Facundo Villamil
- Department of Neurosurgery, Microsurgical Neuroanatomy Laboratory, FLENI, Buenos Aires. Argentina.
| | | | - Mauro Ruella
- Department of Neurosurgery, FLENI, Buenos Aires, Argentina
| | | | | | | | - Maximiliano Nuñez
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Ruben Mormandi
- Department of Neurosurgery, FLENI, Buenos Aires, Argentina
| | - Andrés Cervio
- Department of Neurosurgery, FLENI, Buenos Aires, Argentina
| |
Collapse
|
2
|
Haas P, Hauser TK, Kandilaris K, Skardelly M, Tatagiba M, Adib SD. Case Report: Posterolateral Epidural Supra-C2-Root Approach (PESCA) for Biopsy of a Retro-Odontoid Lesions in Same Sitting After Occipitocervical Fixation and Decompression in a Case of Crowned Dens Syndrome With Brainstem Compression and Displacement. Front Surg 2022; 9:797495. [PMID: 35558389 PMCID: PMC9086508 DOI: 10.3389/fsurg.2022.797495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 03/31/2022] [Indexed: 11/15/2022] Open
Abstract
Background ‘Crowned dens syndrome' (CDS) is a special form of calcium pyrophosphate dihydrate deposition disease which is characterized radiologically by a halo-like or crown-like distribution in the periodontoid region and clinically by cervical pain. Herein, we will describe our experience of posterolateral epidural supra-C2-root approach (PESCA) for biopsy of retro-odontoid lesions in one surgical session after occipitocervical fixation and decompression in a patient with CDS and massive brainstem compression. Case Presentation A 70-year-old woman presented to our department with a 4-week history of progressive walking impairment, neck pain, neck rigidity, fever, dizziness, slight palsy of the left hand, and multiple fall episodes. Magnetic resonance imaging (MRI) of the craniovertebral junction (CVJ) and cervical spine revealed a lesion of the odontoid process and the retro-odontoid region with mainly solid components, as well as small cystic components, and brainstem compression and displacement. In first step, fusion surgery of the CVJ C0–C4 was performed with occiptocervical decompression. After fusion and decompression the lower lateral part of the C1 arc and the lateral superior part of the left side of the C2 arc were removed. The entry point was located directly above the superior part of the C2 root. A biopsy of the lateral portions of the lesions was obtained by bioptic forceps under microscope guidance. Pathologic examination of the mass revealed deposition of birefringent crystals compatible with calcium pyrophosphate. In addition to the clinical symptoms (especially neck pain), the diagnosis of CDS was made. Non-steroidal inflammatory drugs (NSAIDs) and colchicine (and later magnesium) were started. At follow-up examination 6 months after surgery, an MRI scan of the cervical spine revealed regression of the pannus and the cyst with replacement of the brainstem, clinical improvement of walking, and increased strength of the left hand. Conclusions This study demonstrates that PESCA can be used to obtain tissue for pathological analysis in one surgical sitting after fusion and decompression and that fusion, decompression, and PESCA (in the same session) together with subsequent conservative management could be a good alternative for the treatment of CDS.
Collapse
Affiliation(s)
- Patrick Haas
- Department of Neurosurgery, University of Tübingen, Tübingen, Germany
| | - Till-Karsten Hauser
- Department of Diagnostic and Interventional Neuroradiology, University of Tübingen, Tübingen, Germany
| | - Kosmas Kandilaris
- Department of Neuropathology, University of Tübingen, Tübingen, Germany
| | - Marco Skardelly
- Department of Neurosurgery, University of Tübingen, Tübingen, Germany
| | - Marcos Tatagiba
- Department of Neurosurgery, University of Tübingen, Tübingen, Germany
| | - Sasan Darius Adib
- Department of Neurosurgery, University of Tübingen, Tübingen, Germany
- *Correspondence: Sasan Darius Adib
| |
Collapse
|
3
|
Ibn Essayed W, Al-Mefty O. Transcondylar Odontoid Resection and Stabilization for Craniovertebral Degenerative Compression: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2021; 21:E429-E430. [PMID: 34293159 DOI: 10.1093/ons/opab269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 04/29/2021] [Indexed: 11/14/2022] Open
Abstract
Non-neoplastic craniovertebral junction lesions are well known with various etiologies.1,2 They are frequently associated with craniovertebral junction instability. Many require only stabilization for their management.2 However, when significant irreducible anterior compression is present, surgical decompression becomes necessary.2-4 The traditional decompression route is direct anterior, such as the transoral, transmaxillary, or endoscopic endonasal approaches with a separate posterior stabilization.1,2 The transcondylar approach offers a wide and direct exposure to the anterolateral foramen magnum and atlantoaxial space, allowing extensive decompression, total resection of the odontoid, and associated pannus, even with large lateral extension, as well as fusion in the same surgical setting.5 The surgical manipulation is parallel to the dural sac in the sagittal plane, which could be safer than perpendicular dissection.5 Understanding the regional anatomy allows safe exposure and transposition of the vertebral artery with the surrounding alveolar and venous plexus (suboccipital cavernous sinus).5-7 We present this technique's details in a case of a 72-yr-old female who presented with progressively worsening bilateral upper extremity weakness and significant anterior compression due to irreducible odontoid degenerative changes. We demonstrate the steps necessary to achieve adequate exposure and decompression. The patient agreed to the surgical intervention. Images at 2:46, 3:00, and 3:25 reused from Al-Mefty et al,5 by permission from JNSPG. Images at 9:28 from Symonds et al,3 by permission of Oxford University Press. Image at 2:15, © Ossama Al-Mefty, used with permission.
Collapse
Affiliation(s)
- Walid Ibn Essayed
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ossama Al-Mefty
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
4
|
Visocchi M, Signorelli F, Parrilla C, Paludetti G, Rigante M. Multidisciplinary approach to the craniovertebral junction. Historical insights, current and future perspectives in the neurosurgical and otorhinolaryngological alliance. ACTA ACUST UNITED AC 2021; 41:S51-S58. [PMID: 34060520 PMCID: PMC8172108 DOI: 10.14639/0392-100x-suppl.1-41-2021-05] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 01/22/2021] [Indexed: 11/23/2022]
Abstract
Historically considered as a nobody’s land, craniovertebral junction (CVJ) surgery or specialty recently gained high consideration as symbol of challenging surgery as well as selective top level qualifying surgery. The alliance between Neurosurgeons and Otorhinolaringologists has become stronger in the time. CVJ has unique anatomical bone and neurovascular structures architecture. It not only separates from the subaxial cervical spine but it also provides a special cranial flexion, extension, and axial rotation pattern. Stability is provided by a complex combination of osseous and ligamentous supports which allows a large degree of motion. The perfect knowledge of CVJ anatomy and physiology allows to better understand surgical procedures of the occiput, atlas and axis and the specific diseases that affect the region. Although many years passed since the beginning of this pioneering surgery, managing lesions situated in the anterior aspect of the CVJ still remains a challenging neurosurgical problem. Many studies are available in the literature so far aiming to examine the microsurgical anatomy of both the anterior and posterior extradural and intradural aspects of the CVJ as well as the differences in all the possible surgical exposures obtained by 360° approach philosophy. Herein we provide a short but quite complete at glance tour across the personal experience and publications and the more recent literature available in order to highlight where this alliance between Neurosurgeon and Otorhinolaringologist is mandatory, strongly advisable or unnecessary.
Collapse
Affiliation(s)
- Massimiliano Visocchi
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Institute of Neurosurgery, Catholic University School of Medicine, Rome, Italy.,Craniovertebral Junction Operative Unit, Master II Degree, Cadaver Lab and Research Center on Craniocervical Junction Surgery, Catholic University School of Medicine, Rome, Italy
| | - Francesco Signorelli
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Claudio Parrilla
- Otorhinolaryngology, Head and Neck Surgery, "A. Gemelli" Hospital Foundation IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Gaetano Paludetti
- Otorhinolaryngology, Head and Neck Surgery, "A. Gemelli" Hospital Foundation IRCCS, Catholic University of the Sacred Heart, Rome, Italy.,Craniovertebral Junction Operative Unit, Master II Degree, Cadaver Lab and Research Center on Craniocervical Junction Surgery, Catholic University School of Medicine, Rome, Italy
| | - Mario Rigante
- Otorhinolaryngology, Head and Neck Surgery, "A. Gemelli" Hospital Foundation IRCCS, Catholic University of the Sacred Heart, Rome, Italy.,Craniovertebral Junction Operative Unit, Master II Degree, Cadaver Lab and Research Center on Craniocervical Junction Surgery, Catholic University School of Medicine, Rome, Italy
| |
Collapse
|
5
|
Cervical Oblique Corpectomy: Revitalizing the Underused Surgical Approach With Step-By-Step Simulation in Cadavers. J Craniofac Surg 2021; 33:337-343. [PMID: 34267143 DOI: 10.1097/scs.0000000000007909] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
ABSTRACT Recently, the World Federation of Neurosurgical Societies Spine committee recommended that additional research on cost-benefit analysis of various surgical approaches for cervical spondylotic myelopathy be carried out and their efficacy with long-term outcomes be compared. Unfortunately, it is highly probable that the oblique corpectomy (OC) will not be included in cost-benefit investigations due to its infrequent application by neurosurgeons dealing with the spine. In this cadaveric study, head and necks of 5 adult human cadavers stained with colored latex and preserved in 70% alcohol solution were dissected under a table-mounted surgical microscope using 3× to 40× magnifications. The OC approach was performed to simulate real surgery, and the neurovascular structures encountered during the procedure and their relations with each other were examined. Oblique corpectomy was performed unilaterally, although neck dissections were performed bilaterally on 10 sides in all 5 cadavers. At each stage of the dissection, multiple three-dimensional photographs were obtained from different angles and distances. For an optimal OC, both the anterior spinal cord must be sufficiently decompressed and sufficient bone must be left in place to prevent instability in the cervical spine. Oblique corpectomy is a valid and potentially low cost alternative to other anterior and posterior approaches in the surgical treatment of cervical spondylotic myelopathy. However, meticulous cadaver studies are essential before starting real surgical practice on patients in order to perform it effectively and to avoid the risks of the technique.
Collapse
|
6
|
Caton MT, Narsinh K, Baker A, Abla AA, Roland JL, Halbach VV, Fox CK, Fullerton HJ, Hetts SW. Asymptomatic rotational vertebral artery compression in a child due to head positioning for cranial surgery: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 1:CASE2085. [PMID: 36034509 PMCID: PMC9394159 DOI: 10.3171/case2085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 11/19/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND The authors recently reported a series of children with vertebral artery (VA) compression during head turning who presented with recurrent posterior circulation stroke. Whether VA compression occurs during head positioning for cranial surgery is unknown. OBSERVATIONS The authors report a case of a child with incidental rotational occlusion of the VA observed during surgical head positioning for treatment of an intracranial arteriovenous fistula. Intraoperative angiography showed dynamic V3 occlusion at the level of C2 with distal reconstitution via a muscular branch “jump” collateral, supplying reduced flow to the V4 segment. She had no clinical history or imaging suggesting acute or prior stroke. Sequential postoperative magnetic resonance imaging scans demonstrated signal abnormality of the left rectus capitus muscle, suggesting ischemic edema. LESSONS This report demonstrates that rotational VA compression during neurosurgical head positioning can occur in children but may be asymptomatic due to the presence of muscular VA–VA “jump” collaterals and contralateral VA flow. Although unilateral VA compression may be tolerated by children with codominant VAs, diligence when rotating the head away from a dominant VA is prudent during patient positioning to avoid posterior circulation ischemia or thromboembolism.
Collapse
Affiliation(s)
| | | | | | | | | | - Van V. Halbach
- Departments of Neurointerventional Radiology,
- Neurological Surgery, and
| | - Christine K. Fox
- Child Neurology, University of California, San Francisco, San Francisco, California
| | - Heather J. Fullerton
- Child Neurology, University of California, San Francisco, San Francisco, California
| | | |
Collapse
|
7
|
Haas P, Hauser TK, Kandilaris K, Schenk S, Tatagiba M, Adib SD. Posterolateral epidural supra-C2-root approach (PESCA) for biopsy of lesions of the odontoid process in same sitting after occipitocervical fixation and decompression-perioperative management and how to avoid vertebral artery injury. Neurosurg Rev 2021; 44:2947-2956. [PMID: 33428076 PMCID: PMC8490265 DOI: 10.1007/s10143-020-01468-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 10/29/2020] [Accepted: 12/28/2020] [Indexed: 12/02/2022]
Abstract
This study aims to describe the posterolateral epidural supra-C2-root approach (PESCA), which might be a good alternative to the transoral, anterolateral, and other posterolateral approaches for biopsy of lesions of the odontoid process (OP). The preoperative planning of PESCA included computerized tomography (CT), CT-angiography, and three-dimensional reconstruction (if possible, even with three-dimensional print) to analyze the angle of the trajectory and the anatomy of the vertebral artery (VA). For PESCA, the patient is positioned under general anesthesia in prone position. In case of an osteolytic lesion with fracture of the OP, an X-ray is performed after positioning to verify anatomic alignment. In the first step, in case of instability and compression of the spinal cord, a craniocervical fusion and decompression is performed (laminectomy of the middle part of the C1 arc and removal of the lower part of the lateral C1 arc). The trajectory is immediately above the C2 root (and under the upper rest of the lateral part of C1 arc). Even if the trajectory is narrowed, it is possible to perform PESCA without relevant traction of the spinal cord. The vertical segment of V3 of the VA at the level of C2 is protected by the vertebral foramen, and the horizontal part of V3 is protected by the remnant upper lateral part of the C1 arc (in case of normal variants). PESCA might be a good choice for biopsy of selected lesions of the OP in same sitting procedure after craniocervical stabilization and decompression.
Collapse
Affiliation(s)
- Patrick Haas
- Department of Neurosurgery, University of Tuebingen, Hoppe-Seyler-Str. 3, 72076, Tuebingen, Germany
| | - Till-Karsten Hauser
- Department of Neuroradiology, University of Tuebingen, Hoppe-Seyler-Str. 3, 72076, Tuebingen, Germany
| | - Kosmas Kandilaris
- Department of Neuropathology, University of Tuebingen, Hoppe-Seyler-Str. 3, 72076, Tuebingen, Germany
| | - Sebastian Schenk
- Department of Anesthesiology and Intensive Care Medicine, University of Tuebingen, Hoppe-Seyler-Str. 3, 72076, Tuebingen, Germany
| | - Marcos Tatagiba
- Department of Neurosurgery, University of Tuebingen, Hoppe-Seyler-Str. 3, 72076, Tuebingen, Germany
| | - Sasan Darius Adib
- Department of Neurosurgery, University of Tuebingen, Hoppe-Seyler-Str. 3, 72076, Tuebingen, Germany.
| |
Collapse
|
8
|
Signorelli F, Olivi A, De Giorgio F, Pascali VL, Visocchi M. A 360° Approach to the Craniovertebral Junction in a Cadaveric Laboratory Setting: Historical Insights, Current, and Future Perspectives in a Comparative Study. World Neurosurg 2020; 140:564-573. [PMID: 32797988 DOI: 10.1016/j.wneu.2020.04.058] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 04/07/2020] [Accepted: 04/09/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND We herein outline the experience matured in our equipped Cranio-Vertebral Junction Laboratory for anatomic dissection. METHODS An extreme lateral approach (ELA) was performed on 4 fresh cadavers and submandibular approach was performed on 5. An endoscope and navigation-assisted far lateral approach (FLA) was performed in 5 injected specimens. In these specimens, a transoral approach was also performed, as well as a neuronavigation-assisted comparison between transoral and transnasal explorable distances. RESULTS As calculated with neuronavigation, statistically significant differences both in the explored craniocaudal (P = 0.003) and lateral (P = 0.008) distances were observed between the transoral approach and endoscopic endonasal approach. In FLA, neuronavigation facilitated identification and partial removal of the occipital condyle; in one case, during endoscopic intradural exploration, tearing of the emerging roots of the 11th cranial nerve occurred. In ELA, the site where the accessory nerve pierces into the sternocleidomastoid muscle was found at a distance from the tip of the mastoid between 3 and 4 cm. CONCLUSIONS During dissections, as in the clinical setting, endoscope and image guidance give the surgeon a constant orientation, increasing the accuracy and the safety of the approach. Nonetheless, the encumbrance of the endoscope could represent a limit in deep and narrow corridors as those running across the craniovertebral junction, especially in "oblique" FLA and ELA, in which the surgical target is often hidden by a delicate tangle of nerves and vessels. Its use appears more suitable and safer in "straight" approaches as transoral and transnasal in which there are no neurovascular structures interposed.
Collapse
Affiliation(s)
- Francesco Signorelli
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
| | - Alessandro Olivi
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Institute of Neurosurgery, Catholic University School of Medicine, Rome, Italy
| | - Fabio De Giorgio
- Institute of Public Health, Section of Legal Medicine, Catholic University School of Medicine, Rome, Italy
| | - Vincenzo Lorenzo Pascali
- Institute of Public Health, Section of Legal Medicine, Catholic University School of Medicine, Rome, Italy
| | - Massimiliano Visocchi
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Institute of Neurosurgery, Catholic University School of Medicine, Rome, Italy; Craniovertebral Junction Operative Unit, Master II Degree and Research Center Craniocervical Junction Surgery, Catholic University School of Medicine, Rome, Italy
| |
Collapse
|
9
|
Luzzi S, Gragnaniello C, Marasco S, Lucifero AG, Del Maestro M, Bellantoni G, Galzio R. Subaxial Vertebral Artery Rotational Occlusion Syndrome: An Overview of Clinical Aspects, Diagnostic Work-Up, and Surgical Management. Asian Spine J 2020; 15:392-407. [PMID: 32898967 PMCID: PMC8217850 DOI: 10.31616/asj.2020.0275] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 07/01/2020] [Indexed: 12/14/2022] Open
Abstract
Extrinsic compression of the subaxial vertebral artery (VA) may cause rotational occlusion syndrome (ROS) and contribute to vertebrobasilar insufficiency potentially leading to symptoms and in severe cases, to posterior circulation strokes. The present literature review aimed to report the main clinical findings, diagnostic work-up, and surgical management of the subaxial VA-ROS, the diagnosis of which can be difficult and is often underestimated. An illustrative case is also presented. A thorough literature search was conducted to retrieve manuscripts that have discussed the etiology, diagnosis, and treatment of ROS. Total 41 articles were selected based on the best match and relevance and mainly involved case reports and small cases series. The male/female ratio and average age were 2.6 and 55.6±11 years, respectively. Dizziness, visual disturbances, and syncope were the most frequent symptoms in order of frequency, while C5 and C6 were the most affected levels. Osteophytes were the cause in >46.2% of cases. Dynamic VA catheter-based angiography was the gold standard for diagnosis along with computed tomography angiography. Except in older patients and those with prohibitive comorbidities, anterior decompressive surgery was always performed, mostly with complete recovery, and zero morbidity and mortality. A careful neurological evaluation and dynamic angiographic studies are crucial for the diagnosis of subaxial VA-ROS. Anterior decompression of the VA is the cure of this syndrome in almost all cases.
Collapse
Affiliation(s)
- Sabino Luzzi
- Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy.,Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Cristian Gragnaniello
- Department of Neurological Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Stefano Marasco
- Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Alice Giotta Lucifero
- Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Mattia Del Maestro
- Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.,PhD School in Experimental Medicine, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Giuseppe Bellantoni
- Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Renato Galzio
- Neurosurgery Unit, Maria Cecilia Hospital, Cotignola, Italy
| |
Collapse
|
10
|
Tayebi Meybodi A, Zhao X, Borba Moreira L, Lawton MT, Lang MJ, Labib M, Preul MC. The Inferior Nuchal Line as a Simple Landmark for Identifying the Vertebral Artery During the Retrosigmoid Approach. Oper Neurosurg (Hagerstown) 2020; 18:302-308. [PMID: 31214695 DOI: 10.1093/ons/opz152] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Accepted: 03/04/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The V3 segment of the vertebral artery (V3-VA) is at risk during various approaches to the craniovertebral junction. Several landmarks have been defined to identify V3-VA, but these landmarks are not routinely exposed during a retrosigmoid (RS) approach, where musculocutaneous dissection inferiorly towards the foramen magnum can threaten this arterial segment. OBJECTIVE To find a landmark that will identify the V3-VA during the RS approach, and analyze the inferior nuchal line (INL) as this novel landmark. METHODS The anatomic relationships between the INL and the V3-VA were assessed in 7 cadaveric heads through RS exposure in the lateral position. RESULTS The INL is an L-shaped bony ridge with horizontal (medial) and vertical (lateral) arms, with the vertical arm being more conspicuous in all specimens (INLV). The mean depths of the V3-VA relative to the medial and lateral ends of the INLV were (mean ± standard deviation) 24.9 ± 7.1 mm, and 8.3 ± 3.2 mm, respectively. In all specimens, the V3-VA was located inferior and anterior to the INLV. CONCLUSION The INL provides an important landmark during RS approach that can protect the V3-VA from inadvertent injury or identify it for use in an interpositional bypass. The INLV identifies the region of the suboccipital triangle where the V3-VA is embedded. INLV is routinely seen during the RS approach, making it more relevant than other classic landmarks such as the transverse process of C1, C1 posterior arch, and the atlantomastoid line that are not exposed during the RS approach.
Collapse
Affiliation(s)
- Ali Tayebi Meybodi
- Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Xiaochun Zhao
- Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
| | | | - Michael T Lawton
- Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Michael J Lang
- Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Mohamed Labib
- Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Mark C Preul
- Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
| |
Collapse
|
11
|
Tardivo V, Labidi M, Passeri T, Bernat AL, Zenga F, Voormolen E, Penet N, Froelich S. From the Occipital Condyle to the Sphenoid Sinus: Extradural Extension of the Far Lateral Transcondylar Approach with Endoscopic Assistance. World Neurosurg 2019; 134:e771-e782. [PMID: 31734422 DOI: 10.1016/j.wneu.2019.10.190] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 10/30/2019] [Accepted: 10/31/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Surgical management of extensive skull base tumors, such as chordoma and chondrosarcoma, remains very challenging. The need for gross total removal to improve survival must be weighed against the risk of injury to neurovascular structures and the loss of stability at the craniovertebral junction. In cases of tumors that are already compromising craniovertebral junction stability, the occipital condyle can be exploited as a deep keyhole to reach the clivus, petrous apex, and sphenoid sinus. METHODS We performed an anatomic study on 7 cadaveric specimens to describe the main landmarks and boundaries of the corridor. We also provide a clinical case to demonstrate the feasibility of the approach. RESULTS In all specimens, using the space provided by the condyle, it was possible to drill the petrous bone up to the posterior wall of the sphenoid sinus following the direction of the inferior petrosal sinus. To successfully complete the approach, after the hypoglossal canal was exposed, endoscopic assistance was needed to overcome the narrowing of the visual field provided by the microscope. CONCLUSIONS In cases of invasive skull base tumor involving the craniovertebral junction and affecting its stability, the occipital condyle can be exploited as a deep keyhole to the homolateral and contralateral petrous apex, clivus, and sphenoid sinus.
Collapse
Affiliation(s)
- Valentina Tardivo
- Department of Neurosurgery, Lariboisière Hospital, Paris VII-Diderot University, Paris, France; Department of Surgical Sciences, University of Torino, Torino, Italy.
| | - Moujahed Labidi
- Department of Neurosurgery, Lariboisière Hospital, Paris VII-Diderot University, Paris, France; Division of Neurosurgery, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Thibault Passeri
- Department of Neurosurgery, Lariboisière Hospital, Paris VII-Diderot University, Paris, France
| | - Anne Laure Bernat
- Department of Neurosurgery, Lariboisière Hospital, Paris VII-Diderot University, Paris, France
| | - Francesco Zenga
- Division of Neurosurgery, Department of Neurosciences, University of Torino, Torino, Italy
| | - Eduard Voormolen
- Department of Neurosurgery, Lariboisière Hospital, Paris VII-Diderot University, Paris, France
| | - Nicolas Penet
- Department of Neurosurgery, Lariboisière Hospital, Paris VII-Diderot University, Paris, France
| | - Sebastien Froelich
- Department of Neurosurgery, Lariboisière Hospital, Paris VII-Diderot University, Paris, France
| |
Collapse
|
12
|
Luzzi S, Giotta Lucifero A, Del Maestro M, Marfia G, Navone SE, Baldoncini M, Nuñez M, Campero A, Elbabaa SK, Galzio R. Anterolateral Approach for Retrostyloid Superior Parapharyngeal Space Schwannomas Involving the Jugular Foramen Area: A 20-Year Experience. World Neurosurg 2019; 132:e40-e52. [PMID: 31520759 DOI: 10.1016/j.wneu.2019.09.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 09/03/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND Schwannomas encompassing the superior parapharyngeal space are challenging lesions because of the anatomical complexity of this region and the frequent involvement of the neurovascular structures of the jugular foramen. The purpose of this study is to report the technical aspects and the advantages of the anterolateral approach, here proposed for schwannomas of this complex area. METHODS The main steps of the anterolateral approach are described in detail, along with the results of a consecutive series of 38 patients with a retrostyloid superior parapharyngeal schwannoma involving the jugular foramen operated on by means of this route between 1999 and 2019. RESULTS The supine position is generally preferred. The medial border of the sternocleidomastoid muscle, mastoid tip, and superior nuchal line are the landmarks for the hockey-stick skin incision. The accessory nerve is retrieved and mobilized cranially. Detachment of the sternocleidomastoid, digastric, and nuchal muscles allows for a 180° exposure of the extracranial side of the jugular foramen. Three working corridors, namely the pre-carotid, pre-jugular, and retro-jugular, allow access to the deeper part of the jugular foramen area and the superior parapharyngeal space. In the present series, a gross total resection was achieved in 89.4% of the patients. Three recurrences occurred after an average follow-up of 80.5 ± 51 months. CONCLUSIONS The anterolateral approach is highly effective in the treatment of retrostyloid superior parapharyngeal space schwannomas involving the jugular foramen. Its simplicity of execution, versatility, and very low morbidity are among its main strengths.
Collapse
Affiliation(s)
- Sabino Luzzi
- Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy; Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
| | - Alice Giotta Lucifero
- Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Mattia Del Maestro
- Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; PhD School in Experimental Medicine, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Giovanni Marfia
- Experimental Neurosurgery and Cell Therapy Laboratory, Neurosurgery Unit, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy; Institute of Aerospace Medicine, Italian Air Force, Milan, Italy
| | - Stefania Elena Navone
- Experimental Neurosurgery and Cell Therapy Laboratory, Neurosurgery Unit, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Matias Baldoncini
- Microsurgical Neuroanatomy Laboratory-LaNeMic- II Division of Anatomy, Medicine School, University of Buenos Aires, Buenos Aires, Argentina; Department of Neurological Surgery, San Fernando Hospital, Buenos Aires, Argentina
| | - Maximiliano Nuñez
- Department of Neurosurgery, Hospital El Cruce, Buenos Aires, Argentina
| | - Alvaro Campero
- Servicio de Neurocirugía, Universidad Nacional de Tucumán, Tucumán, Argentina; Department of Neurosurgery, Hospital Padilla, San Miguel de Tucumán, Tucumán, Argentina
| | - Samer K Elbabaa
- Pediatric Neurosurgery, Pediatric Neuroscience Center of Excellence, Arnold Palmer Hospital for Children, Orlando, Florida, USA
| | - Renato Galzio
- Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy; Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| |
Collapse
|
13
|
Abstract
BACKGROUND The extreme lateral approach is a direct lateral approach which allows a good control of the entire length of the vertebral artery (VA), the jugular foramen, the lowest cranial nerves, and the jugular-sigmoid complex. Herein we try to exploit the variants of the approach and we identify indications, advantages, and disadvantages. METHODS All phases of the study were conducted at the Institute of Public Health Section of Legal Medicine and Insurance of the University. We performed the extreme lateral approach in four subjects, who died between 24 and 48 h before in non-traumatic circumstances (three men and one woman). RESULTS The great auricular nerve, the spinal accessory, the branches of the first ventral spinal nerves, the jugular vein, and the vertebral artery were identified in all the cadavers. In all cases the right VA exited from the transverse foramen of C1. The site of SCM piercing the accessory nerve was at a distance from the tip of the mastoid between 3 and 4 cm (3.3 in one case, 3.4 in 2 cases, and 3.7 in one case). No vessels and nerves have been damaged after being identified and isolated. CONCLUSIONS Extradural lesions at the ventro-lateral aspect of the CVJ may require an extreme lateral approach, a procedure more aggressive comparing with far lateral approach, which represents a reasonable option for large anterior and anterolateral lesions when greater exposure is required.
Collapse
|
14
|
Balak N, Baran O, Denli Yalvac ES, Esen Aydin A, Tanriover N. Surgical technique for the protection of the cervical sympathetic trunk in anterolateral oblique corpectomy: A new cadaveric demonstration. J Clin Neurosci 2019; 63:267-271. [DOI: 10.1016/j.jocn.2019.01.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 11/15/2018] [Accepted: 01/18/2019] [Indexed: 10/27/2022]
|
15
|
Cornelius JF, Pop R, Fricia M, George B, Chibbaro S. Compression Syndromes of the Vertebral Artery at the Craniocervical Junction. ACTA NEUROCHIRURGICA. SUPPLEMENT 2019; 125:151-158. [PMID: 30610316 DOI: 10.1007/978-3-319-62515-7_22] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Compression syndromes of the vertebral artery that occur at the craniocervical junction are extremely rare causes of haemodynamic insufficiency of the posterior cerebral circulation. The aetiology of the compression syndrome may be a malformation, trauma, tumour, infection or degenerative pathology. This may lead to dynamic vertebral artery occlusion where the vessel courses around the atlas and the axis-the so-called V3 segment. This in turn may result in insufficient collateral flow to the posterior fossa. The clinical picture is a vertebrobasilar insufficiency syndrome of variable expression ranging from vertigo to posterior fossa stroke. The typical clinical presentation is syncope occurring during rotation of the head, also known as 'bow hunter's syndrome'. The workup is based on dynamic angiography and computed tomography angiography. The treatment of choice is surgical vascular decompression, resulting in a good clinical outcome. However, in some instances, atlantoaxial fusion may be indicated. Alternatively, conservative and endovascular options have to be considered in inoperable patients.
Collapse
Affiliation(s)
| | - Raoul Pop
- Service de neuroradiologie interventionnelle, CHU, Strasbourg, France
| | - Marco Fricia
- Neurosurgery Department, Cannizzaro Hospital, Catania, Italy
| | - Bernard George
- Service de neurochirurgie, CHU Lariboisiere, Paris, France
| | | |
Collapse
|
16
|
Tayebi Meybodi A, Gandhi S, Preul MC, Lawton MT. The subatlantic triangle: gateway to early localization of the atlantoaxial vertebral artery. J Neurosurg Spine 2018; 29:18-27. [PMID: 29701566 DOI: 10.3171/2017.11.spine171068] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Exposure of the vertebral artery (VA) between C-1 and C-2 vertebrae (atlantoaxial VA) may be necessary in a variety of pathologies of the craniovertebral junction. Current methods to expose this segment of the VA entail sharp dissection of muscles close to the internal jugular vein and the spinal accessory nerve. The present study assesses the technique of exposing the atlantoaxial VA through a newly defined muscular triangle at the craniovertebral junction. METHODS Five cadaveric heads were prepared for surgical simulation in prone position, turned 30°-45° toward the side of exposure. The atlantoaxial VA was exposed through the subatlantic triangle after reflecting the sternocleidomastoid and splenius capitis muscles inferiorly. The subatlantic triangle was formed by 3 groups of muscles: 1) the levator scapulae and splenius cervicis muscles inferiorly and laterally, 2) the longissimus capitis muscle inferiorly and medially, and 3) the inferior oblique capitis superiorly. The lengths of the VA exposed through the triangle before and after unroofing the C-2 transverse foramen were measured. RESULTS The subatlantic triangle consistently provided access to the whole length of atlantoaxial VA. The average length of the VA exposed via the subatlantic triangle was 19.5 mm. This average increased to 31.5 mm after the VA was released at the C-2 transverse foramen. CONCLUSIONS The subatlantic triangle provides a simple and straightforward pathway to expose the atlantoaxial VA. The proposed method may be useful during posterior approaches to the craniovertebral junction should early exposure and control of the atlantoaxial VA become necessary.
Collapse
|
17
|
Keser N, Avci E, Soylemez B, Karatas D, Baskaya MK. Occipital Artery and Its Segments in Vertebral Artery Revascularization Surgery: A Microsurgical Anatomic Study. World Neurosurg 2018; 112:e534-e539. [DOI: 10.1016/j.wneu.2018.01.073] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Revised: 01/08/2018] [Accepted: 01/11/2018] [Indexed: 10/18/2022]
|
18
|
Eissa EM, Eldin MM. Odontoidectomy through posterior midline approach followed by same sitting occipitocervical fixation: A cadaveric study. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2017; 8:58-63. [PMID: 28250638 PMCID: PMC5324362 DOI: 10.4103/0974-8237.199879] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECT Atlantoaxial instability with irreducible odontoid process is one of the challenges in spine surgery. These lesions are commonly treated through anterior transoral approach which is followed by posterior atlantoaxial fusion. However, there are still many limitations, especially cerebrospinal fluid fistula with subsequent life-threatening infection, difficulty in cases with limited opening of mouth due to temporomandibular arthritis or anomalies of naso-oropharynx. Türe et al. used the extreme lateral transatlas approach for the removal of odontoid. In this study, we applied the transatlas approach but through posterior midline incision aiming to evaluate its safety and feasibility. METHODS In four silicon injected, formalin-fixed cadaver heads, posterior removal of the odontoid was done through the familiar midline incision and subperiosteal muscle separation and elevation of muscles as on unit followed by microscopic exposure and mobilization of the vertebral artery after opening of the foramen transversarium of atlas followed by drilling of lateral mass and odontoidectomy. Occipitocervical stabilization was done between the occiput and C2, C3 (C1 lateral mass screw can be added in the contralateral side for better stabilization). RESULTS Unilateral excision of the lateral mass of atlas after mobilization of the vertebral artery provided safe and excellent exposure of the odontoid process in the four cadaver heads without injury to vertebral artery or retraction of the dura. CONCLUSION Posterior removal of the odontoid can be done safely through wide and sterile operative field, and occipitocervical fixation performed at the same sitting without need for another operation and hence avoids the risk of cord injury from repositioning.
Collapse
|
19
|
Kunert P, Prokopienko M, Czernicki T, Nowak A, Marchel A. Sensorimotor C5 and C6 radiculopathy caused by thrombosed vertebral artery dissection and successfully treated with limited oblique corpectomy - Case report. Neurol Neurochir Pol 2016; 50:48-51. [PMID: 26851690 DOI: 10.1016/j.pjnns.2015.10.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 10/14/2015] [Indexed: 11/25/2022]
Abstract
The authors report the case of an exceptional presentation of vertebral artery dissection. A 44-year-old man who presented with left shoulder weakness, radicular pain and numbness of the left forearm and thumb was admitted to our hospital with an initial diagnosis of cervical disc herniation. Due to the inconsistency between the levels of radiculopathy (C5 and C6) and discopathy (C6-C7), neuroimaging examinations were extended. Based on MRI, MRA, CTA and DSA, left vertebral artery dissection with intramural hematoma was diagnosed. The patient underwent surgical decompression of the affected nerve roots using the anterolateral approach described by Bernard George. The radicular pain resolved immediately and sensorimotor deficit completely disappeared within 4 months. MRI/MRA performed 6 months after surgery showed the normal image of the vertebral artery. There were no ischemic events within 2.5 years of follow-up.
Collapse
Affiliation(s)
- Przemysław Kunert
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
| | - Marek Prokopienko
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland.
| | - Tomasz Czernicki
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
| | - Arkadiusz Nowak
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
| | - Andrzej Marchel
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
| |
Collapse
|
20
|
Cornelius JF, George B, N'dri Oka D, Spiriev T, Steiger HJ, Hänggi D. Bow-hunter's syndrome caused by dynamic vertebral artery stenosis at the cranio-cervical junction--a management algorithm based on a systematic review and a clinical series. Neurosurg Rev 2012; 35:127-35; discussion 135. [PMID: 21789571 DOI: 10.1007/s10143-011-0343-4] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Revised: 05/16/2011] [Accepted: 05/17/2011] [Indexed: 12/12/2022]
Abstract
Bow hunter's syndrome (BHS) is defined as symptomatic, vertebro-basilar insufficiency caused by mechanical occlusion of the vertebral artery (VA) at the atlanto-axial level during head rotation. In the literature, about 40 cases have been reported. However, due to the rarity of this pathology, there are no guidelines for diagnosis and treatment. Conservative, surgical, and endovascular concepts have been proposed. In order to work out an algorithm, we performed a systematic review of the literature and a retrospective analysis of patients, which have been treated in our institutions over the last decade. The clinical series was comprised of five patients. The symptoms ranged from transient vertigo to posterior circulation stroke. Diagnosis was established by dynamic angiography. In all patients, the VA was decompressed; one patient required additional fusion. The clinical and radiological results were good, and the treatment-related morbidity was low. The literature review demonstrated that Bow hunter's syndrome is a rare pathology but associated with a pathognomonic and serious clinical presentation. The gold standard of diagnosis is dynamic angiography, and patients were well managed with tailored vertebral artery decompression. By this management, clinical and radiological results were excellent and the treatment-related morbidity was low.
Collapse
|
21
|
Mazzoni A, Sanna M. A posterolateral approach to the skull base: the petro-occipital transsigmoid approach. Skull Base Surg 2011; 5:157-67. [PMID: 17170942 PMCID: PMC1656487 DOI: 10.1055/s-2008-1058930] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
This posterolateral approach is directed to the petro-occipital skull base and is a combination of a suboccipital craniotomy, with an inferoposterior petrosectomy. The areas exposed are the jugular foramen, occipital condyle, lower clivus to the midline, petrous apex, tympanic cavity, the vertical portion of the intrapetrous carotid artery below the level of the eustachian tube, cerebellopontine angle, the jugulocarotid space in the upper neck. We evaluated 45 cases as follows: 13 chemodectomas, 14 lower cranial nerve schwannomas, 10 meningiomas, and 8 other lesions. The approach is indicated for extra-, intra-, and transdural lesions of the jugular foramen area. The transdural lesions could be extirpated in a single procedure without cerebrospinal fluid leak. This, in addition to preservation of the facial nerve, middle and inner ear functions, constituted the main advantages of this approach. Lower cranial nerve deficit formed the major morbidity in the present series and is still an unsolved problem in such cases.
Collapse
|
22
|
Cavalcanti DD, Agrawal A, Garcia-Gonzalez U, Crawford NR, Tavares PL, Theodore N, Sonntag VK, Preul MC. Anterolateral C1–C2 Transarticular Fixation for Atlantoaxial Arthrodesis: Landmarks, Working Area, and Angles of Approach. Oper Neurosurg (Hagerstown) 2010; 67:ons38-42. [DOI: 10.1227/01.neu.0000383134.47267.0f] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
AbstractBACKGROUND:An alternative route must be used for atlantoaxial arthrodesis to avoid the risks of transoral route or when posterior approaches are contraindicated.OBJECTIVE:To assess relevant quantitative anatomic parameters for C1–C2 anterolateral transarticular fixation and to demonstrate the nuances of an anterolateral approach to the upper cervical spine.METHODS:Five cadaveric necks were dissected bilaterally to demonstrate anatomic landmarks and surgical technique. The C2 pars interarticularis was used as the entry for inserting screws toward the C1 lateral mass. Ten computed tomography scans were analyzed to quantify working area and optimal angles of approach.RESULTS:The medial surface of sternocleidomastoid muscle was dissected extensively but not divided. The C2 transverse process was a landmark for guiding dissection posterior to the carotid sheath. In all specimens, the gray ramus communicans from the superior cervical ganglion to the C2 nerve was a landmark for locating the C2 pars. Slightly below that branch, the longus capitis muscle could be displaced medially to reach the C2 pars. The ideal angles for screw placement were 22.9 ± 5.7° medial to the sagittal plane and 25.3 ± 7.4° posterior to the coronal plane. The mean working area was 71.2 mm2 (range, 49–103 mm2).CONCLUSION:We propose a new anterolateral stabilization technique for atlantoaxial instability based on less traumatic dissection of the upper cervical region, different instrumentation, and guidance by reliable landmarks. For anterolateral transarticular C1–C2 screw fixation, the gray ramus communicans to the C2 nerve is a reliable landmark for locating the entry for a screw on the C2 pars.
Collapse
Affiliation(s)
- Daniel D. Cavalcanti
- Division of Neurological Surgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Abhishek Agrawal
- Division of Neurological Surgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Ulises Garcia-Gonzalez
- Division of Neurological Surgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Neil R. Crawford
- Spinal Biomechanics Laboratory, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Paulo L.M.S. Tavares
- Division of Neurological Surgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona; Current address: Department of Neurosurgery Bonsucesso General Hospital Rio de Janeiro, Brazil
| | - Nicholas Theodore
- Division of Neurological Surgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Volker K.H. Sonntag
- Division of Neurological Surgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Mark C. Preul
- Division of Neurological Surgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona
| |
Collapse
|
23
|
Endoscopic-Assisted Lateral Transatlantal Approach to Craniovertebral Junction. World Neurosurg 2010; 74:351-8. [DOI: 10.1016/j.wneu.2010.05.037] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2010] [Accepted: 05/15/2010] [Indexed: 11/20/2022]
|
24
|
Safavi-Abbasi S, de Oliveira JG, Deshmukh P, Reis CV, Brasiliense LBC, Crawford NR, Feiz-Erfan I, Spetzler RF, Preul MC. The craniocaudal extension of posterolateral approaches and their combination: a quantitative anatomic and clinical analysis. Oper Neurosurg (Hagerstown) 2010; 66:54-64. [PMID: 20173573 DOI: 10.1227/01.neu.0000354366.48105.fe] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The aim of this study was to describe quantitatively the properties of the posterolateral approaches and their combination. METHODS Six silicone-injected cadaveric heads were dissected bilaterally. Quantitative data were generated with the Optotrak 3020 system (Northern Digital, Waterloo, Canada) and Surgiscope (Elekta Instruments, Inc., Atlanta, GA), including key anatomic points on the skull base and brainstem. All parameters were measured after the basic retrosigmoid craniectomy and then after combination with a basic far-lateral extension. The clinical results of 20 patients who underwent a combined retrosigmoid and far-lateral approach were reviewed. RESULTS The change in accessibility to the lower clivus was greatest after the far-lateral extension (mean change, 43.62 +/- 10.98 mm2; P = .001). Accessibility to the constant landmarks, Meckel's cave, internal auditory meatus, and jugular foramen did not change significantly between the 2 approaches (P > .05). The greatest change in accessibility to soft tissue between the 2 approaches was to the lower brainstem (mean change, 33.88 +/- 5.25 mm2; P = .0001). Total removal was achieved in 75% of the cases. The average postoperative Glasgow Outcome Scale score of patients who underwent the combined retrosigmoid and far-lateral approach improved significantly, compared with the preoperative scores. CONCLUSION The combination of the far-lateral and simple retrosigmoid approaches significantly increases the petroclival working area and access to the cranial nerves. However, risk of injury to neurovascular structures and time needed to extend the craniotomy must be weighed against the increased working area and angles of attack.
Collapse
Affiliation(s)
- Sam Safavi-Abbasi
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona 85013, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
25
|
Symptomatic occlusion at the origin of the vertebral artery treated using external carotid artery–cervical vertebral artery bypass with interposed saphenous vein graft. ACTA ACUST UNITED AC 2008; 69:164-8; discussion 168. [DOI: 10.1016/j.surneu.2007.07.073] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2007] [Accepted: 07/18/2007] [Indexed: 11/15/2022]
|
26
|
Civelek E, Kiris T, Hepgul K, Canbolat A, Ersoy G, Cansever T. Anterolateral approach to the cervical spine: major anatomical structures and landmarks. Technical note. J Neurosurg Spine 2008; 7:669-78. [PMID: 18074695 DOI: 10.3171/spi-07/12/669] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The authors undertook a study to explore the topographic anatomical features seen during the anterolateral approach to cervical spine, anatomical variations, and certain landmarks related to the surgical procedure. METHODS The study was conducted in 30 fresh cadavers. RESULTS The common carotid artery bifurcation was mostly found at the level of C-4 (78%). The inferior belly of the omohyoid muscle was seen to cross the sternocleidomastoid muscle at the C5-6 disc level along the entire C-6 vertebral body. To reach the lower cervical region, the sacrifice of this muscle makes the procedure easier. The facial vein drained into the internal jugular vein mostly at the level of C3-4 (54%). The superior ganglion of the cervical sympathetic chain was located at the C-4 vertebra, but the location of the intermediate ganglion exhibited some variation. The vertebral artery entered the transverse foramen of C-6 in 27 cadavers (90%), the transverse foramen of C-7 in two cadavers (7%), and the transverse foramen of C-4 in one cadaver (3%). Because the inferior thyroid artery crossed the C6-7 interspace obliquely, the course of the inferior thyroid artery may complicate the procedure. The C-5 uncinate process was shortest and narrowest and had the greatest distance from the medial edge of the process to the anterior tubercle (p < 0.001). CONCLUSIONS Understanding the qualitative anatomy of this region not only improves the safety of anterior and anterolateral cervical spine surgery but also allows adequate decompression of neural elements and resolution of the other pathological processes of this region. In this fresh cadaveric study, our goal was to improve the approach and decrease the incidence of complications.
Collapse
Affiliation(s)
- Erdinc Civelek
- Department of Neurosurgery, Istanbul University, Turkey.
| | | | | | | | | | | |
Collapse
|
27
|
Abstract
OBJECTIVES To report the outcomes of surgical treatment of vagal paragangliomas and to define a management protocol. DESIGN A retrospective case series. PATIENTS AND METHODS Sixteen consecutive patients with vagal paragangliomas managed by surgical resection using a cervicoparotid approach and pericapsular dissection using microsurgical techniques between 1990 and 2003. RESULTS All patients either had or developed a vagal palsy. Additional cranial nerve deficits were sustained in 8 patients. No patients died as a result of surgery or from their disease. CONCLUSIONS The technique used and described in this article allowed adequate exposure of the retrostyloid parapharyngeal space for the safe removal of all vagal tumors in this series. Careful consideration must be given to the likely natural progression of these tumors before committing to surgical resection. This is particularly important in patients with multifocal disease.
Collapse
Affiliation(s)
- Elisabetta Zanoletti
- ENT Unit, Department of Neurological and Neurosurgical Sciences, Ospedali Riuniti, Bergamo, Italy
| | - Antonio Mazzoni
- ENT Unit, Department of Neurological and Neurosurgical Sciences, Ospedali Riuniti, Bergamo, Italy
- Gruppo Otologico, Casa di Cura Piacenza, Piacenza, Italy
| |
Collapse
|
28
|
Paolini S, Lanzino G. Anatomical relationships between the V2 segment of the vertebral artery and the cervical nerve roots. J Neurosurg Spine 2006; 5:440-2. [PMID: 17120894 DOI: 10.3171/spi.2006.5.5.440] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT During surgical procedures focused on the cervical nerve roots, the surgeon works in proximity to the V2 segment of the vertebral artery (VA). Depending on the specific surgical approach, it may be necessary to identify, expose, or mobilize the artery. In most cases, the artery may be left undisturbed. To reduce the risk of iatrogenic injury to the V2 segment during anterior and anterolateral approaches to the cervical spine, the authors analyzed the relationship between the V2 segment and the proximal segment of the C3-6 nerve roots. METHODS Six cadaveric cervical spines (12 sides) were fixed with formalin, injected with red and blue latex, and investigated intraoperatively using different magnifications (x 3-40). The VA rested on the anteromedial surface of the cervical nerve roots at the level of each intertransverse space. The exiting nerve roots intersected the VA at a distance ranging from 4.5 to 8.1 mm (mean 6.3 +/- 1.06 mm) from the dural sac. The distance was slightly shorter at cephalad levels, suggesting that the artery is more posteriorly and medially situated at those levels. Arterial pedicles anchored the VA to the cervical nerve roots at various levels. These arteries gave rise to purely radicular, ligamentous, and medullary branches without a predictable pattern. After reaching the nerve roots on their lower margin, the nonligamentous branches pierced the radicular dural sheath within the neural foramen at a distance of 2 to 4 mm from the VA. CONCLUSIONS Proximal-to-distal dissection of a cervical nerve root may proceed with relative safety for at least 4 mm. The V2 segment of the VA gives rise to at least one radicular arterial pedicle between C-4 and C-6. These trunks give rise to purely radicular, ligamentous, and medullary branches in an unpredictable pattern.
Collapse
Affiliation(s)
- Sergio Paolini
- Università degli Studi di Perugia, IRCCS Neuromed, Pozzilli, Italy
| | | |
Collapse
|
29
|
Tubbs RS, Shoja MM, Acakpo-Satchivi L, Wellons JC, Blount JP, Oakes WJ, Iskandar BJ. Exposure of the V1–V3 segments of the vertebral artery via the posterior cervical triangle: a cadaveric feasibility study. J Neurosurg Spine 2006; 5:320-3. [PMID: 17048768 DOI: 10.3171/spi.2006.5.4.320] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Surgical exposure of the extracranial part of the vertebral artery (VA) is occasionally necessary. Historically, the greater portion of the extracranial portion of the VA has been approached by traversing the anterior cervical triangle. The authors speculated that this entire segment of the VA could be reached with equal efficacy via the posterior cervical triangle (PCT).
Methods
Six adult cadavers underwent dissection of the left and right VAs via the PCT. The entire extracranial VA was easily exposed through this approach. Only three of 12 sides required the transection of the clavicular head of the sternocleidomastoid muscle for exposure of the most proximal segment of the VA as it originated from the subclavian artery. No gross injury to the VA or other regional vessels or nerves was noted.
Conclusions
The authors found that the extracranial VA can be exposed easily through the PCT. Following confirmation of this technique in vivo, this approach may be added to the surgeon’s armamentarium for exposing the extracranial segment of the VA.
Collapse
Affiliation(s)
- R Shane Tubbs
- Department of Cell Biology, University of Alabama at Birmingham, Alabama, USA.
| | | | | | | | | | | | | |
Collapse
|
30
|
Passacantilli E, Santoro A, Pichierri A, Delfini R, Cantore G. Anterolateral approach to the craniocervical junction. J Neurosurg Spine 2005; 3:123-8. [PMID: 16370301 DOI: 10.3171/spi.2005.3.2.0123] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The authors present the surgical results obtained using the anterolateral approach to the craniocervical junction (CCJ) to resect a lesion with an extradural component located anterolateral to the foramen magnum and upper cervical spine. METHODS The anterolateral approach, which is a presternomastoid retrojugular route to the CCJ, was performed in 14 patients. The skin incision follows the anterior edge of the sternomastoid muscle. The vertebral artery (VA) was exposed at C-1. This approach was extended either down to the cervical spine or anteriorly to the jugular foramen, according to specific requirements. Two patients had previously undergone other surgical procedures. The follow-up period ranged from 4 months to 6.2 years. The tumor resection was complete in 11 cases and subtotal in two. In a case of vertebral coiling, a vein graft was interposed between the V1 and the V3 segments of the VA, and the bypass was still patent at the 2-year follow-up examination. In two cases involving a glomus tumor, there was a transitory postoperative seventh cranial nerve deficit. CONCLUSIONS The aforementioned technique allows for sufficient access to lesions located anterolateral to the CCJ. It is indicated in cases in which lesions exhibit a significant extradural component, and it provides good control of the VA, the cervical portion of the internal carotid artery, sigmoid-jugular complex, and lower cranial nerves. This approach can easily be combined with a posterolateral approach and can be extended anteriorly toward the jugular foramen and inferiorly toward the lower cervical spine.
Collapse
Affiliation(s)
- Emiliano Passacantilli
- Department of Neuroscience, Division of Neurosurgery, University of Rome, La Sapienza, Rome, Italy
| | | | | | | | | |
Collapse
|
31
|
Kawashima M, Tanriover N, Rhoton AL, Ulm AJ, Matsushima T. Comparison of the far lateral and extreme lateral variants of the atlanto-occipital transarticular approach to anterior extradural lesions of the craniovertebral junction. Neurosurgery 2003; 53:662-74; discussion 674-5. [PMID: 12943582 DOI: 10.1227/01.neu.0000080070.16099.bb] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2002] [Accepted: 04/24/2003] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Managing lesions situated in the anterior aspect of the craniovertebral junction (CVJ) remains a challenging neurosurgical problem. The purposes of this study were to examine the microsurgical anatomy of the anterior extradural aspect of the CVJ and the differences in the exposure obtained by the far lateral and extreme lateral atlanto-occipital transarticular approaches. The far lateral approach, as originally described, is a lateral suboccipital approach directed behind the sternocleidomastoid muscle and the vertebral artery and just medial to the occipital and atlantal condyles and the atlanto-occipital joint. The extreme lateral approach, as originally described, is a direct lateral approach deep to the anterior part of the sternocleidomastoid muscle and behind the internal jugular vein along the front of the vertebral artery. Both approaches permit drilling of the condyles at the atlanto-occipital joint but provide a different exposure because of the differences in the direction of the approach. METHODS Fifteen adult cadaveric specimens were studied using a magnification of x3 to x40 after perfusion of the arteries and veins with colored silicone. The microsurgical anatomy of the extradural aspects of the CVJ and the two atlanto-occipital transarticular approaches were examined in stepwise dissections. RESULTS The far lateral atlanto-occipital transarticular approach provides excellent exposure of the extradural lesions located in the ipsilateral anterior and anterolateral aspects of the extradural region of the CVJ. The extreme lateral atlanto-occipital transarticular approach provides excellent exposure, not only on the side of the exposure, but also extending across the midline to the medial aspect of the contralateral atlanto-occipital joint and the lower clivus. CONCLUSION The far lateral and extreme lateral variants of the atlanto-occipital transarticular approach provide an alternative to the transoral approach to the anterior extradural structures at the CVJ. Compared with the transoral approach, both approaches provide a shorter operative route, avoid the contaminated nasopharynx, reduce the incidence of cerebrospinal fluid leak, and are not limited laterally by the atlanto-occipital joint.
Collapse
Affiliation(s)
- Masatou Kawashima
- Department of Neurological Surgery, University of Florida, Gainesville, Florida, USA
| | | | | | | | | |
Collapse
|
32
|
Song JK, Burkey BB, Konrad PE. Lateral approach to a neurenteric cyst of the cervical spine: case presentation and review of surgical technique. Spine (Phila Pa 1976) 2003; 28:E81-5. [PMID: 12590225 DOI: 10.1097/01.brs.0000049225.46912.ba] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN The lateral cervical spinal approach is illustrated by a case of neurenteric cyst. OBJECTIVES To present a case of a neurenteric cyst resected the lateral cervical approach, and to review the approach in detail. SUMMARY OF BACKGROUND DATA Intradural lesions located anterior to the high cervical spinal cord may present a difficult surgical problem. Neurenteric cysts are unusual lesions found in the brain and spinal cord. This report presents a case of cervical neurenteric cyst causing anterior cord compression that was resected using the lateral cervical approach. METHODS A 32-year-old woman presented with chronic headaches and worsening nausea, tinnitus, dizziness, and hyperreflexia and clonus in her lower extremities. Magnetic resonance imaging of the cervical spine showed a mass compressing the anterior spinal cord at C3. Pathology showed that this lesion was a neurenteric cyst. The lesion was resected using the lateral cervical approach. RESULTS At this writing, 36 months after surgery, the patient has continued resolution of her symptoms, and no cyst recurrence has been shown on repeat MRI imaging. She has no evidence of postlaminectomy kyphosis. CONCLUSIONS The lateral cervical approach is useful for surgeons attempting to resect lateral and anterior intradural lesions of the cervical spine. It also gives excellent cranial-to-caudal access to the thecal sac, spinal cord, and the lesion to be resected. The neck incision preserves cosmesis, and neuromuscular function is maintained. Spinal fusion was avoided in the reported case.
Collapse
Affiliation(s)
- John K Song
- Department of Neurosurgery, Vanderbilt University, Nashville, Tennessee, USA
| | | | | |
Collapse
|
33
|
Affiliation(s)
- B George
- Department of Neurosurgery, Hôpital Lariboisière, Paris, France
| |
Collapse
|
34
|
Abstract
OBJECT Various approaches have been described for resection of the dens of the axis, each of which has potential advantages and disadvantages. Anterior approaches such as the transoral route or its modifications are the most commonly used for resection of this structure. The transcondylar approach, however, which allows the surgeon to view the craniovertebral junction (CVJ) from a lateral perspective, has been introduced by Al-Mefty, et al., as an alternative approach. In this report, the authors describe the surgical technique of the extreme lateral-transatlas approach and their clinical experiences. METHODS The authors first examined the surgical approach to the dens from a lateral perspective in five cadaveric heads. They found that removal of the lateral mass of the atlas provided adequate exposure for resection of the dens. Following this cadaveric study, the extreme lateral-transatlas approach was successfully performed at the authors' institution over a 1-year period (September 1998-August 1999) in five patients with basilar invagination due to congenital anomaly of the CVJ and rheumatoid arthritis. Furthermore, during the same procedure, unilateral occipitocervical fusion was performed following resection of the dens. In all cases complete resection of the dens was achieved using the extreme-lateral transatlas approach. This procedure provides a sterile operative field and the ability to perform occipitocervical fusion immediately following the resection. No postoperative complications or craniocervical instability were observed. The mean follow-up period was 17.2 months (range 13-24 months). CONCLUSIONS The extreme lateral-transatlas approach for resection of the dens was found to be safe and effective. Knowledge of the anatomy of this region, especially of the V3 segment of the vertebral artery, is essential for the success of this procedure.
Collapse
Affiliation(s)
- Uğur Türe
- Department of Neurosurgery, Marmara University School of Medicine, Istanbul, Turkey.
| | | |
Collapse
|
35
|
Santoro A, Passacantilli E, Guidetti G, Dazzi M, Guglielmi G, Cantore G. Bypass combined with embolization via a venous graft in a patient with a giant aneurysm in the posterior communicating artery and bilateral idiopathic occlusion of the internal carotid artery in the neck. J Neurosurg 2002; 96:135-9. [PMID: 11794595 DOI: 10.3171/jns.2002.96.1.0135] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors describe the case of a patient with a symptomatic giant aneurysm of the posterior communicating artery (PCoA) associated with bilateral idiopathic occlusion of the internal carotid artery (ICA). The presence of severe tortuosity of the vertebral arteries (VAs), both at their origin from the subclavian artery and at the level of the third segment, impeded navigation of the catheter for embolization of the aneurysm with Guglielmi detachable coils (GDCs). A direct surgical approach was considered to be a high-risk procedure because of the bilateral occlusion of the ICAs and the size of the aneurysm. The following therapeutic strategy was therefore adopted: 1) balloon occlusion test of the left VA; 2) vertebro-vertebral bypass with saphenous vein graft to provide a pathway for subsequent embolization; 3) ICA-left middle cerebral artery bypass to ensure blood flow in the event that embolization resulted in closure of the PCoA; and 4) GDC embolization of the aneurysm via the posterior circulation graft to ensure complete exclusion of the lesion from the arterial circulation and preservation of the PCoA. At 3-month follow-up review the patient did not present with any neurological deficits; at 1-year control examination, magnetic resonance (MR) imaging and MR angiography both confirmed complete exclusion of the aneurysm and patency of the two bypasses.
Collapse
Affiliation(s)
- Antonio Santoro
- Dipartimento di Scienze Neurologiche, Neurochirurgia, Rome, Italy.
| | | | | | | | | | | |
Collapse
|
36
|
George B, Lot G, Boissonnet H. Meningioma of the foramen magnum: a series of 40 cases. SURGICAL NEUROLOGY 1997; 47:371-9. [PMID: 9122842 DOI: 10.1016/s0090-3019(96)00204-2] [Citation(s) in RCA: 100] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Surgical treatment of foramen magnum meningiomas (FM meningiomas) has been improved by the recently developed posterolateral and anterolateral approaches. The choice of these approaches and the extent of bone resection, however, need to be defined according to the tumor location. METHODS Over a short period (1980-1993), 40 cases of FM meningiomas were treated either by the posterolateral (N = 31), the anterolateral (N = 5), or the midline posterior approaches (N = 4). The choice of surgical technique (surgical approach, extent of bone drilling, and dural opening) was made according to the tumor location, which is defined by three parameters: the horizontal plane (anterior N = 18, lateral N = 21, and posterior N = 1); the vertebral artery (above N = 4, below N = 20, and on both sides N = 16); the dura mater (intradural N = 24, extradural N = 2, and intraextradural N = 4). RESULTS Intradural anterior and lateral FM meningiomas were operated by the posterolateral approach. The bone drilling was limited either to the occipital condyle or to the lateral mass of the atlas, depending on whether the tumor location is above or below the vertebral artery, respectively. Intradural posterior meningiomas were treated by the midline posterior approach. FM meningiomas with an extradural component were resected by the anterolateral approach alone or combined with a midline posterior approach. The rate of complete resection was 94% for intradural FM meningiomas and 50% for the extradural ones. FM meningiomas with an extradural component generally have aggressive features invading the adjacent bone and soft tissues; this explains the difficulty of performing a complete resection. The clinical condition improved in 90%, worsened in 7.5%, and did not change in 2.5%. The worsened group consisted of three deaths (one case of air embolism, one case of pulmonary embolism, and one case with preoperative coma and tetraplegia). Similar results were obtained in both anterior and lateral locations. CONCLUSION FM meningiomas can be completely and safely removed in most cases, using an appropriate surgical technique. The technique must be chosen after precise and correct analysis of the tumor location. The lateral approaches are very effective in the treatment of lateral and anterior FM meningiomas.
Collapse
Affiliation(s)
- B George
- Service de Neurochirurgie, Hôpital Lariboisiere, Paris, France
| | | | | |
Collapse
|
37
|
Abstract
A lesion is described on the body of C4 from the skeleton of an adult male recovered from a 15th century site in Gloucester. The most plausible explanation for the lesion is that it represents the negative image of an extracranial aneurysm of the vertebral artery and thus is the earliest case described.
Collapse
Affiliation(s)
- M Vaswani
- Institute of Archaeology, University College Hospital, London, UK
| | | |
Collapse
|
38
|
Abstract
The authors studied the microsurgical anatomy of the suboccipital region, concentrating on the third segment (V3) of the vertebral artery (VA), which extends from the transverse foramen of the axis to the dural penetration of the VA, paying particular attention to its loops, branches, supporting fibrous rings, adjacent nerves, and surrounding venous structures. Ten cadaver heads (20 sides) were fixed in formalin, their blood vessels were perfused with colored silicone rubber, and they were dissected under magnification. The authors subdivided the V3 into two parts, the horizontal (V3h) and the vertical (V3v), and studied the anatomical structures topographically, from the superficial to the deep tissues. In two additional specimens, serial histological sections were acquired through the V3 and its encircling elements to elucidate their cross-sectional anatomy. Measurements of surgically and clinically important features were obtained with the aid of an operating microscope. This study reveals an astonishing anatomical resemblance between the suboccipital complex and the cavernous sinus, as follows: venous cushioning; anatomical properties of the V3 and those of the petrous-cavernous internal carotid artery (ICA), namely their loops, branches, supporting fibrous rings, and periarterial autonomic neural plexus; adjacent nerves; and skull base locations. Likewise, a review of the literature showed a related embryological development and functional and pathological features, as well as similar transitional patterns in the arterial walls of the V3 and the petrous-cavernous ICA. Hence, due to its similarity to the cavernous sinus, this suboccipital complex is here named the "suboccipital cavernous sinus." Its role in physiological and pathological conditions as they pertain to various clinical and surgical implications is also discussed.
Collapse
Affiliation(s)
- K I Arnautović
- Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, USA
| | | | | | | | | |
Collapse
|
39
|
Arnautovic KI, Al-Mefty O, Pait TG, Krisht AF, Husain MM. The suboccipital cavernous sinus. Neurosurg Focus 1996. [DOI: 10.3171/foc.1996.1.6.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors studied the microsurgical anatomy of the suboccipital region, concentrating on the third segment (V3) of the vertebral artery (VA), which extends from the transverse foramen of the axis to the dural penetration of the VA, paying particular attention to its loops, branches, supporting fibrous rings, adjacent nerves, and surrounding venous structures.
Ten cadaver heads (20 sides) were fixed in formalin, their blood vessels were perfused with colored silicone rubber, and they were dissected under magnification. The authors subdivided the V3 into two parts, the horizontal (V3h) and the vertical (V3v), and studied the anatomical structures topographically, from the superficial to the deep tissues. In two additional specimens, serial histological sections were acquired through the V3 and its encircling elements to elucidate their cross-sectional anatomy. Measurements of surgically and clinically important features were obtained with the aid of an operating microscope.
This study reveals an astonishing anatomical resemblance between the suboccipital complex and the cavernous sinus, as follows: venous cushioning; anatomical properties of the V3 and those of the petrous-cavernous internal carotid artery (ICA), namely their loops, branches, supporting fibrous rings, and periarterial autonomic neural plexus; adjacent nerves; and skull base locations. Likewise, a review of the literature showed a related embryological development and functional and pathological features, as well as similar transitional patterns in the arterial walls of the V3 and the petrous-cavernous ICA. Hence, due to its similarity to the cavernous sinus, this suboccipital complex is here named the "suboccipital cavernous sinus." Its role in physiological and pathological conditions as they pertain to various clinical and surgical implications is also discussed.
Collapse
|
40
|
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; 84:1-6. [PMID: 8613814 DOI: 10.3171/jns.1996.84.1.0001] [Citation(s) in RCA: 157] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Ventral extradural lesions at the craniovertebral junction are commonly exposed through the transoral or transmaxillary approach. The disadvantages of these approaches include: 1) difficulty in reaching laterally located lesions; 2) ineligibility of patients with an intradental distance of less than 25 mm or severe macroglossia; 3) the need for a separate procedure for stabilization and fusion; and 4) the risk of infection from transgressing a contaminated field. In this report, the authors describe the use of the transcondylar approach to extradural nonneoplastic lesions of the anterior craniovertebral junction for decompression and stabilization. Advantages of this approach include: 1) a short distance to the lesion; 2) a wide surgical envelope; 3) direct visualization of the dural sac, eliminating manipulation of the brainstem or upper spinal cord; 4) easy identification and control of the ipsilateral vertebral artery; 5) direct visualization and preservation of the lower cranial nerves; and 6) a sterile field. In addition, occipitocervical fusion and instrumentation can be performed during the same procedure. The transcondylar approach, based on anatomical studies in cadavers, was used to treat eight patients with ventral nonneoplastic lesions at the craniocervical junction. The technique and results are described.
Collapse
Affiliation(s)
- O al-Mefty
- Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, USA
| | | | | | | | | |
Collapse
|
41
|
Abd el-Bary TH, Dujovny M, Ausman JI. Microsurgical anatomy of the atlantal part of the vertebral artery. SURGICAL NEUROLOGY 1995; 44:392-400; discussion 400-1. [PMID: 8553261 DOI: 10.1016/0090-3019(95)00033-x] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Microanatomy of the vertebral artery has been the subject of multiple studies. However, none of them has covered every aspect of microvascular anatomy of the atlantal part of the vertebral artery. MATERIALS AND METHODS Microsurgical anatomy of the atlantal part of the vertebral artery was studied in 14 cadaveric specimens. The artery was dissected using the standard microsurgical technique under operative microscope magnification. The atlantal part of the vertebral artery was divided into five segments: the foraminal, sagittal, transverse, medial condylar, and dural. The length of each segment was measured, as was the diameter of the artery. The branches of this part of the artery were identified and the distance between the point of dural entry of the artery and the midline of the atlanto-occipital dura was measured. Distance between the mastoid tip and the artery and the distance between the mastoid tip and the tip of C1 transverse process were measured. RESULTS Results of all measurements are summarized in tables and text. We discuss various anomalies, branches, and lesions of the vertebral artery and surgical approaches with new methods of managing diseases in this area.
Collapse
Affiliation(s)
- T H Abd el-Bary
- Department of Neurosurgery, University of Illinois at Chicago 60612-7329, USA
| | | | | |
Collapse
|
42
|
Management of the Vertebral Artery in Excision of Extradural Tumors of the Cervical Spine. Neurosurgery 1995. [DOI: 10.1097/00006123-199501000-00014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
|
43
|
Sen C, Eisenberg M, Casden AM, Sundaresan N, Catalano PJ. Management of the vertebral artery in excision of extradural tumors of the cervical spine. Neurosurgery 1995; 36:106-15; discussion 115-6. [PMID: 7708146 DOI: 10.1227/00006123-199501000-00014] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Extradural tumors of the cervical spine may involve the vertebral artery on one or both sides, posing one of the limiting factors toward the radical resection of such neoplasms. A standard anterior approach may be inadequate for the management of such tumors. An anterolateral approach allows the dissection and mobilization of the vessel, which can then be preserved, resected, or reconstructed with a vein graft. An anterior approach can be supplemented with this for tumor resection and stabilization. This management strategy is described in 10 patients with a variety of tumors.
Collapse
Affiliation(s)
- C Sen
- Department of Neurosurgery, Mount Sinai Medical Center, New York, New York
| | | | | | | | | |
Collapse
|
44
|
Seyfried DM, Rock JP. The transcondylar approach to the jugular foramen: a comparative anatomic study. SURGICAL NEUROLOGY 1994; 42:265-71. [PMID: 7940117 DOI: 10.1016/0090-3019(94)90275-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The standard neurosurgical approach to the jugular foramen involves suboccipital craniectomy with access along the petrous bone. However, even after wide removal of the foramen magnum, only limited access into the infratemporal fossa can be obtained. The neurootologic exposures provide excellent infratemporal access but limited exposure to the posterior fossa, resulting in hearing loss and facial paresis or paralysis. Using cadaver specimens, we exposed the jugular foramen region by the transcondylar approach. A retromastoid incision is extended into the neck. The transverse foramen of the atlas is opened and the vertebral artery transposed medially, thereby providing exposure into the infratemporal fossa. A suboccipital craniectomy extending anterior to the sigmoid sinus is performed, and the posterolateral occipital condyle is resected. After resection of the sigmoid sinus, cranial nerves 9 through 12 are easily identified extracranially in the infratemporal fossa and can be followed proximally through their foramina to the brain stem. We compared the transcondylar approach to three standard approaches, morphometrically and anatomically, and found that the transcondylar approach not only compares favorably but also offers advantages in that it preserves auditory and facial nerve function and is useful for one-stage tumor resection.
Collapse
Affiliation(s)
- D M Seyfried
- Department of Neurological Surgery, Henry Ford Health Sciences Center, Detroit, Michigan 48202
| | | |
Collapse
|
45
|
Mabuchi S, Kamiyama H, Abe H. Distal ligation and revascularization from external carotid to vertebral artery with radial artery graft for treatment of extracranial vertebral artery dissection. Report of a case. Acta Neurochir (Wien) 1993; 125:192-5. [PMID: 8122550 DOI: 10.1007/bf01401852] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
We present a case of dissection of the extracranial vertebral artery with prominent occipital pain and elements of the lateral medullary syndrome. Arteriography showed a string and pearl sign. Magnetic resonance imaging allowed visualization of an intramural thrombus associated with a narrow vascular lumen. The distal portion of the diseased artery was ligated and vascular reconstruction using an interposed radial artery graft was performed. Pathological studies confirmed the diagnosis. The diagnostic roles of angiography and magnetic resonance imaging, and therapeutic strategies are discussed.
Collapse
Affiliation(s)
- S Mabuchi
- Department of Neurosurgery, Kushiro Rosai Hospital, Hokkaido, Japan
| | | | | |
Collapse
|
46
|
Distal ligation and revascularization from external carotid to vertebral artery with radial artery graft for treatment of extracranial vertebral artery dissection. Report of a case. Acta Neurochir (Wien) 1993. [PMID: 8122550 DOI: 10.1007/bf01401852.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We present a case of dissection of the extracranial vertebral artery with prominent occipital pain and elements of the lateral medullary syndrome. Arteriography showed a string and pearl sign. Magnetic resonance imaging allowed visualization of an intramural thrombus associated with a narrow vascular lumen. The distal portion of the diseased artery was ligated and vascular reconstruction using an interposed radial artery graft was performed. Pathological studies confirmed the diagnosis. The diagnostic roles of angiography and magnetic resonance imaging, and therapeutic strategies are discussed.
Collapse
|
47
|
Miyamoto S, Kikuchi H, Nagata I, Akiyama Y, Itoh K, Yamagiwa O, Asahi S. Saphenous vein graft to the distal vertebral artery between C-1 and C-2 using a lateral-anterior approach. Technical note. J Neurosurg 1992; 77:812-5. [PMID: 1403130 DOI: 10.3171/jns.1992.77.5.0812] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The authors present a modified surgical procedure for extracranial vertebral artery reconstruction. The use of the proposed technique results in access to the V3 segment of the vertebral artery between the C-1 and C-2 vertebrae through the retrojugular space without requiring bone rongeuring. A saphenous vein bypass graft was placed between the common carotid artery and the V3 segment of the vertebral artery in three patients with bilateral occlusive lesions of the proximal vertebral arteries.
Collapse
Affiliation(s)
- S Miyamoto
- Department of Neurosurgery, Kyoto University Medical School, Japan
| | | | | | | | | | | | | |
Collapse
|
48
|
George B, Dematons C, Cophignon J. Lateral approach to the anterior portion of the foramen magnum. Application to surgical removal of 14 benign tumors: technical note. SURGICAL NEUROLOGY 1988; 29:484-90. [PMID: 3375978 DOI: 10.1016/0090-3019(88)90145-0] [Citation(s) in RCA: 194] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
In surgery, better access to the anterior part of the foramen magnum with less risk to the lower brainstem can be obtained by lateral enlargement of the usual posterior opening. This requires exposure and control of the vertebral artery (VA) and the sigmoid sinus (SS) and, for further enlargement, medial transposition of the VA and section of the SS with inferior petrosal resection. This technique has been applied fully or partially in 14 cases of anteriorly located tumors of the foramen magnum. It widens exposure on the anterior aspect of the neural axis and allows work in a nearly frontal plane.
Collapse
Affiliation(s)
- B George
- Département de Neuro-chirurgie, Hôpital Lariboisière Paris, France
| | | | | |
Collapse
|
49
|
Spetzler RF, Hadley MN, Martin NA, Hopkins LN, Carter LP, Budny J. Vertebrobasilar insufficiency. Part 1: Microsurgical treatment of extracranial vertebrobasilar disease. J Neurosurg 1987; 66:648-61. [PMID: 3553453 DOI: 10.3171/jns.1987.66.5.0648] [Citation(s) in RCA: 130] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Extracranial vertebrobasilar artery thrombo-occlusive disease may cause repetitive transient ischemic episodes and, less frequently, brain-stem or cerebellar infarction. This report describes 40 patients who experienced repetitive vertebrobasilar ischemic symptoms despite maximal medical therapy. The natural history, pathogenesis, and treatment options for each causative lesion are reviewed. The operative approaches to symptomatic disease of the proximal vertebral arteries, arterial compression by cervical osteophytes, traumatic lesions of the vertebral arteries, and thrombo-occlusive pathology of the distal extracranial vertebral arteries are outlined. Specific anesthetic and surgical techniques that have proved successful while achieving zero operative mortality and low perioperative morbidity rates are reported.
Collapse
|
50
|
Hadley MN, Spetzler RF, Masferrer R, Martin NA, Carter LP. Occipital artery to extradural vertebral artery bypass procedure. Case report. J Neurosurg 1985; 63:622-5. [PMID: 4032027 DOI: 10.3171/jns.1985.63.4.0622] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
A 17-year-old boy suffered blunt trauma to the posterior cervical spine and later developed vertebrobasilar transient ischemic attacks refractory to medical management. At angiography, a pseudoaneurysm of the distal left vertebral artery was found. By means of a posterior midline approach, an extradural occipital artery to vertebral artery anastomosis was performed and the affected vertebral artery was clipped distal to the pseudoaneurysm. The indications for this procedure, the operative approach, and the clinical outcome are described.
Collapse
|