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Neurosurgical management of petrous bone lesions: classification system and selection of surgical approaches

  • Original Article - Brain Tumors
  • Published:
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Abstract

Background

Surgery of petrous bone lesions (PBLs) is challenging for neurosurgeons. Selection of the surgical approach is an important key for success. In this study, the authors present an anatomical classification for PBLs that has been used by our group for over the past 26 years. The objective of this study is to investigate the benefits and applicability of this classification.

Methods

Between 1994 and 2019, 117 patients treated for PBLs were retrospectively reviewed. Using the V3 and arcuate eminence as reference points, the petrous bone is segmented into 3 parts: petrous apex, rhomboid, and posterior. The pathological diagnoses, selection of the operative approach, and the extent of resection (EOR) were analyzed and correlated using this classification.

Results

This series included 22 facial nerve schwannomas (18.8%), 22 cholesterol granulomas (18.8%), 39 chordomas/chondrosarcomas (33.3%), 6 trigeminal schwannomas (5.1%), 13 epidermoids/dermoids (11.1%), and 15 other pathologies (12.8%). PBLs were most often involved with the petrous apex and rhomboid areas (46.2%). The extradural subtemporal approach (ESTA) was most frequently used (57.3%). Gross total resection was achieved in 58.4%. Symptomatic improvement occurred in 92 patients (78.6%). Our results demonstrated a correlation between this classification with each type of pathology (p < .001), selection of surgical approaches (p < 0.001), and EOR (p = 0.008). Chordoma/chondrosarcoma, redo operations, and lesions located medially were less likely to have total resection. Temporary complications occurred in 8 cases (6.8%), persistent morbidity in 5 cases (4.3%), and mortality in 1 case.

Conclusion

In this study, we proposed a simple classification of PBLs. Using landmarks on the superior petrosal surface, the petrous bone is divided into 3 parts, apex, rhomboid, and posterior. Our results demonstrated that chordoma/chondrosarcoma, redo operations, and lesions involving the tip of the petrous apex or far medial locations were more difficult to achieve total resection. This classification could help surgeons understand surgical anatomy framework, predict possible structures at risk, and select the most appropriate approach for each patient.

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Abbreviations

AE:

Arcuate eminence

C6:

Petrous carotid artery

CN:

Cranial nerve

CPA:

Cerebellopontine angle

CSF:

Cerebrospinal fluid

ECA:

External carotid artery

EOR:

Extent of resection

ESTA:

Extradural subtemporal approach

FNS:

Facial nerve schwannoma

GCT:

Giant cell tumor

GE:

Geniculate ganglion

GG:

Gasserian ganglion

GSPN:

Greater superficial petrosal nerve

GTR:

Gross total resection

HB Gr:

House-Brackmann grading

IAC:

Internal auditory canal

ICA:

Internal carotid artery

ITFA:

Infratemporal fossa approach

M2:

M2 segment of the middle cerebral artery

MMA:

Middle meningeal artery

NTR:

Near total resection

PB:

Petrous bone

PBE:

Petrous bone epidermoid

PBL:

Petrous bone lesion

PTR:

Partial tumor resection

SSC:

Superior semicircular canal

STA:

Superficial temporal artery

STR:

Subtotal tumor resection

V3:

The mandibular nerve (third division of fifth cranial nerve)

TgF:

Trigeminal fibrous ring

TMJ:

Temporomandibular joint

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Acknowledgements

For patient follow-up data, we express our gratitude to Drs. Tsutomu Masuda, Takuro Inoue, and Hiromi Goto. In addition, we would like to express our gratitude to Lori Radcliffe and James Carter, PA-C for data collection and editorial assistance.

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Authors and Affiliations

  1. Division of Neurosurgery, Duke University Medical Center, Durham, NC, USA

    Udom Bawornvaraporn, Ali R. Zomorodi, Allan H. Friedman & Takanori Fukushima

  2. Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, 10330, Thailand

    Udom Bawornvaraporn

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  1. Udom Bawornvaraporn
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Contributions

Conception and design: Udom, Fukushima. Acquisition of data: Udom, Fukushima. Analysis and interpretation of data: Udom. Drafting the article: Udom, Fukushima. Critically revising the article: Udom, Fukushima, Friedman, Zomorodi. Reviewed submitted version of manuscript: Udom, Fukushima, Friedman, Zomorodi. Approved the final version of the manuscript on behalf of all authors: Fukushima. Statistical analysis: Udom. Administrative/technical/material support: Udom. Study supervision: Fukushima.

Corresponding author

Correspondence to Udom Bawornvaraporn.

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Ethics approval

All procedures performed in this study were in accordance with the ethical standards of Duke University Medical Center and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

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For this retrospective type of study, individual formal consent is not required.

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All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements) or nonfinancial interest (such as personal or professional relationships, affiliations, knowledge, or beliefs) in the subject matter or materials discussed in this manuscript.

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Bawornvaraporn, U., Zomorodi, A.R., Friedman, A.H. et al. Neurosurgical management of petrous bone lesions: classification system and selection of surgical approaches. Acta Neurochir 163, 2895–2907 (2021). https://doi.org/10.1007/s00701-021-04934-9

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