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Exposure of the wide interior of the fourth ventricle without splitting the vermis: importance of cutting procedures for the tela choroidea

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Abstract

In recent years, new procedures for fourth ventricular surgeries have been developed with good results. In particular, the trans-cerebellomedullary fissure approach, which exposes the fourth ventricle without splitting the inferior vermis, has proven successful. For optimum results, specialized techniques should be employed in order to effectively open the roof of the fourth ventricle and obtain a wide exposure of its interior. These techniques include the following steps: (1) placement of an incision over the teania extending from the foramen of Magendie to the ventricular entrance of the lateral recess; (2) lateral extension of the incision to the roof of the lateral recess to facilitate its exposure; (3) implementation of the same procedure on the contralateral side. Upon completion of these steps, the bilateral cerebellar tonsils can be easily retracted superolaterally; this eventually exposes a wide interior of the ventricle. In order to ensure successful surgeries, explicit and accurate descriptions of technique are vital. In this article, we employ detailed illustrations to precisely demonstrate the operative procedures and techniques for fourth ventricular surgeries.

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Acknowledgements

We would like to express our gratitude to Prof. Rhoton, University of Florida, for giving us the opportunity to study the microsurgical anatomy of the fourth ventricle and for his sustained attention to our work. We also thank Mrs. Takako Shiga and Mrs. Sumiko Matsushima for preparing the manuscript and illustrations.

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Authors and Affiliations

  1. Department of Neurosurgery, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga-shi, Saga, 849-8501, Japan

    Toshio Matsushima & Masatou Kawashima

  2. Department of Neurosurgery, Faculty of Medicine, University of Fukuoka, Fukuoka, Japan

    Hiroshi Abe & Tooru Inoue

Authors
  1. Toshio Matsushima
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  2. Hiroshi Abe
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  3. Masatou Kawashima
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  4. Tooru Inoue
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Correspondence to Toshio Matsushima.

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Comments

Ulrich Sure, Essen, Germany

The present paper is a very nice Technical Note on the exposure of the fourth ventricle by incision of the tela choroidea. The paper is nicely written and highly relevant for microneurosurgeons, because it nicely explains and demonstrates the various types and extensions of the telovelomedullary approach. It offers very instructive figures with its possible variations. Personally, I recommend to read the discussion. Here, it is correctly pointed out that an incision of the velum medullare posterior (inferior) is not necessary for a wide exposure of the fourth ventricle, even in very large tumors with an extension up to the aqueduct.

According to my personal experience, there is nothing to add to the authors’ statements. In my opinion, the manuscript represented one of the rare occasions where even no further correction was necessary in its primary version. It deserved immediate publication. The authors have to be congratulated for this excellent and important contribution to the recent microsurgical literature.

Ernesto Coscarella, Miami, USA

My congratulations to the Dr. Matsushima and authors for this paper which shows well-done anatomical dissections and correct correlation to their surgical cases. I personally believe that detailed anatomical studies made in the skull base lab are very useful to better understand the anatomy we encounter in real surgery. It will improve our minimal surgical manipulations as well as we are going to achieve a better and safer exposure of the lesions.

As the authors admit in the introduction, the conceptual framework of these CMF approaches is well documented, but detailed anatomical studies of this complicated microsurgical anatomy is very important as well. Besides to improve our surgical manipulation techniques it will inspire the youngest neurosurgeons to use rigorous skull base lab experience in their daily practice as well.

Following my personal anatomy dissection experience in the lab, I agree that the cerebellar tonsils are mostly free structures and attached to the cerebellar biventral lobule only on the superior lateral surface of the upper pole. Therefore it is possible and intelligent to look for their mobilization in order to expose the floor of the IV ventricle.

Moreover, by looking straight at the tonsil and virtually removing it, we will expose on the same plane the lateral surface of the rhomboid fossa of the IV ventricle, particularly the junction of the superior (SCP), middle (MCP), and inferior (ICP) cerebellar peduncles. Therefore, their mobilization can definitely open small corridors to the surface entry points of these structures as well. A good example is for MCP cavernous malformations resection.

As the author mentioned, I agree that for high IV ventricle located lesions, like medulloblastomas or upper gliomas, limited vermis splitting is inevitable to better achieve total resection.

In conclusion, again my congratulations to Dr Matsushima and others for this well-done paper, hoping to see more similar works in the future as well.

Nils H. Ulrich, M.D., Zurich, Switzerland

This article probably comes from a group that to my research has one of the largest operative experiences of fourth ventricular surgeries. This is a well-written and documented technical note that precisely demonstrates the operative procedures in the fourth ventricular region. The group around Matsushima et al. illustrates an operative technique of the medial route for the trans-cerebellomedullary fissure approach. The authors distribute detailed illustrations about the operative procedures for this kind of fourth ventricular surgeries. Two very well-documented illustrative cases are included to visualize their very own methods. Neurosurgeons who are keen in fourth ventricular surgery, should gather this technical note as a must-have to learn from it. In my opinion, this technical note is a motivational framework to stimulate young neurosurgeons to participate in more lab time experience as well. At the end, this will help to improve surgical manipulation techniques to achieve superior resections in the fourth ventricular region.

In summary, again congratulations to Matsushima et al. for this convincing technical note, we hope to see related work in the near future.

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Matsushima, T., Abe, H., Kawashima, M. et al. Exposure of the wide interior of the fourth ventricle without splitting the vermis: importance of cutting procedures for the tela choroidea. Neurosurg Rev 35, 563–572 (2012). https://doi.org/10.1007/s10143-012-0384-3

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