Abstract
The trans-cerebellomedullary fissure (CMF) approach provides good exposure of the fourth ventricle without splitting the inferior vermis. The popularly utilized trans-CMF approach is performed in the midline suboccipital approach. However, the trans-CMF approach actually has two routes: medial and lateral. The lateral route is the trans-CMF approach through a lateral foramen magnum approach such as the transcondylar approach, opening the CMF from the lower unilateral side. We studied the surgical anatomy of the CMF and fourth ventricle. Based on the anatomic findings, we adopted the lateral route of the trans-CMF approach for four patients, each with a tumor near the jugular tubercle extending into the fourth ventricle through the CMF. Our study demonstrated that the lateral route of the trans-CMF approach enables sufficient exposure of not only unilateral cerebellopontine cistern but also of the lateral part of the fourth ventricle. A tumor is safely removed by this approach with easy feeder or tumor bed controls, especially if it is anchored at the lateral part of the CMF as is the jugular tubercle meningioma.
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Antonio Mussi, Florianópolis, Brazil
Evandro de Oliveira, São Paulo, Brazil
The authors report their experience with the lateral route of the trans-CMF approach to the fourth ventricle. The approach was used for tumors occupying the region of the jugular tubercle and extending to the lateral portion of the fourth ventricle. The transcondylar fossa approach was used to access the region of the jugular tubercle. The lateral recess was exposed by dissecting the cerebellomedullary fissure and opening the tela choroidea. The authors show that dissection of the CMF exposes the lateral recess from the flocculus to the inferior cerebellar peduncle with no need of resection or sacrifice of parts of the cerebellum. This study reinforces the usefulness of the CMF to gain access to the fourth ventricle as described by one of the authors (Toshio Matsushima) in previous publications.
Niklaus Krayenbühl, Zurich, Switzerland
Kawashima et al report their experience with the transcerebellomedullary fissure approach in treating four patients with tumors in the region of the lateral recess of the fourth ventricle. The transcerebellomedullary fissure approach is usually used in medial approaches to the fourth ventricle and has been well described in earlier publications by Toshio Matsushima, one of the Co-authors. This well written article with its description of the surgical anatomy and pictures of cadaver dissections illustrates nicely the advantages of this technique, when dealing with challenging lesions situated in the very lateral part of the fourth ventricle like meningiomas of the jugular tubercle, ependymomas or neurinomas.
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Kawashima, M., Matsushima, T., Nakahara, Y. et al. Trans-cerebellomedullary fissure approach with special reference to lateral route. Neurosurg Rev 32, 457–464 (2009). https://doi.org/10.1007/s10143-009-0211-7
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DOI: https://doi.org/10.1007/s10143-009-0211-7