Extreme Lateral Approach to the Craniovertebral Junction: An Update

  • Nabeel S. Alshafai
  • Tomasz Klepinowski
Part of the Acta Neurochirurgica Supplement book series (NEUROCHIRURGICA, volume 125)


Introduction:The term ‘extreme lateral approach’ (ELA) was first introduced by Sen and Sekhar relatively recently (in 1990). Its definition varies and remains controversial, but it generally entails more aggressive bony removal than the far lateral approach (FLA).

Goal: In this paper we review the relevant literature and weigh up the advantages and disadvantages of this approach. We propose methods to manage the complications resulting from the more invasive character of the ELA. Some modern trends regarding how to definitely distinguish the ELA from the FLA are also presented.

Methods: Using the PubMed database, literature was collected on the relevant topics and subsequently reviewed. All up-to-date tips and tricks were carefully gathered, and current morbidity and mortality rates were obtained, as well as further perspectives.

Results and Conclusion: The morbidity associated with the ELA remains higher than that associated with the FLA, but the mortality nowadays is comparable. The ELA undoubtedly is a challenging procedure requiring deep insight into the relevant anatomy and its normal variants.


Extreme lateral approach Meningiomas ELITE Vertebral artery transposition Craniovertebral junction 


  1. 1.
    Sen CN, Sekhar LN. An extreme lateral approach to intradural lesions of the cervical spine and foramen magnum. Neurosurgery. 1990;27(2):197–204.PubMedPubMedCentralCrossRefGoogle Scholar
  2. 2.
    Abla A, Lawton M. Midbasilar and vertebrobasilar junction aneurysms: extended retrosigmoid approach. Atlas Neurosurg Tech. 2015;1:247–52.Google Scholar
  3. 3.
    Salas E, Sekhar LN, Ziyal IM, Caputy AJ, Wright DC. Variations of the extreme-lateral craniocervical approach: anatomical study and clinical analysis of 69 patients. J Neurosurg. 1999;90(2 Suppl):206–19.PubMedGoogle Scholar
  4. 4.
    Ziyal IM, Salas E, Sekhar LN. The surgical anatomy of six variations. Turk Neurosurg. 1999;9:105–12.Google Scholar
  5. 5.
    Kawashima M, Tanriover N, Rhoton AL, et al. 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(3):662–75.PubMedCrossRefGoogle Scholar
  6. 6.
    Komotar RJ, Zacharia BE, McGovern RA, Sisti MB, Bruce JN, D’Ambrosio AL. Approaches to anterior and anterolateral foramen magnum lesions: a critical review. J Craniovertebral Junction Spine. 2010;1(2):86–99.CrossRefGoogle Scholar
  7. 7.
    Suhardja A, Agur AMR, Cusimano MD. Anatomical basis of approaches to foramen magnum and lower clival meningiomas: comparison of retrosigmoid and transcondylar approaches. Neurosurg Focus. 2003;14(6):e9.PubMedGoogle Scholar
  8. 8.
    Abhishek A, Anushree A, Patir R, Sehgal AD. Extreme lateral approach in a case of acute-onset quadriplegia due to high cervical neurenteric cyst. Pediatr Neurosurg. 2007;43(2):134–6.PubMedCrossRefGoogle Scholar
  9. 9.
    Crossman JE, David K, Hayward R, Crockard HA. Open reduction of pediatric atlantoaxial rotatory fixation: long-term outcome study with functional measurements. J Neurosurg Spine. 2004;100(3 Suppl):235–40.CrossRefGoogle Scholar
  10. 10.
    El-Sissy MH, Mahmoud M. C2 root nerve sheath tumors management. Acta Neurochir. 2013;155(5):779–84.PubMedCrossRefGoogle Scholar
  11. 11.
    Jia G, Wang Z, Zhang J. Diagnosis and treatment of hypoglossal neurinoma. Zhonghua Yi Xue Za Zhi. 2001;81(20):1264–5.PubMedGoogle Scholar
  12. 12.
    Krishnan P, Behari S, Banerji D, Mehrotra N, Chhabra DK, Jain VK. Surgical approach to C1–C2 nerve sheath tumors. Neurol India. 2004;52(3):319–24.PubMedGoogle Scholar
  13. 13.
    Kubota H, Tanikawa R, Katsuno M, et al. Vertebral artery-to-vertebral artery bypass with interposed radial artery or occipital artery grafts: surgical technique and report of three cases. World Neurosurg. 2014;81(1):202.e1–8.CrossRefGoogle Scholar
  14. 14.
    Kumar CV, Satyanarayana S, Rao BR, Palur RS. Extreme lateral approach to ventral and ventrolaterally situated lesions of the lower brainstem and upper cervical cord. Skull Base. 2001;11(4):265–75.PubMedPubMedCentralCrossRefGoogle Scholar
  15. 15.
    Liu JK. Extreme lateral transcondylar approach for resection of ventrally based meningioma of the craniovertebral junction and upper cervical spine. Neurosurg Focus. 2012;33(Suppl 1):1.PubMedGoogle Scholar
  16. 16.
    López-Flores G, Cruz-García O, Fernández-Melo R, Fernández-Alban M, Alfonzo-Sabatier C, Bouza-Molina W, Fermín-Hernández E, Castillo-Hernández JE. Osteochondroma of the atlantooccipital joint. Extreme lateral transcondylar approach. A case description. Rev Neurol. 2003;36(2):133–6.PubMedGoogle Scholar
  17. 17.
    Marhx-Bracho A, Rueda-Franco F, Ibarra-de la Torre A, García-González O, Bornstein-Quevedo L, León-Bogorge B. Chordoid meningioma of the foramen magnum in a child: a case report and review of the literature. Childs Nerv Syst. 2008;24(5):623–7.PubMedCrossRefGoogle Scholar
  18. 18.
    Nath PC, Mishra SS, Deo RC, Mahanta I. Congenital malrotation of the atlas with unilateral hypertrophy of the atlanto-occipital joint—a rare anomaly of the craniovertebral junction and its management. World Neurosurg. 2016;88:689.e9–689.e12.CrossRefGoogle Scholar
  19. 19.
    Pulido Rivas P, Villoria Medina F, Fortea Gil F, Sola RG. Dural fistula in the craniocervical junction. A case report and review of the literature. Rev Neurol. 2004;38(5):438–42.PubMedGoogle Scholar
  20. 20.
    Türe U, Pamir MN. Extreme lateral-transatlas approach for resection of the dens of the axis. J Neurosurg. 2002;96(1 Suppl):73–82.PubMedGoogle Scholar
  21. 21.
    Zozulya YP, Slynko YI, Al-Qashqish II. Surgical treatment of ventral and ventrolateral intradural extramedullary tumors of craniovertebral and upper cervical localization. Asian J Neurosurg. 2010;6(1):18–25.Google Scholar
  22. 22.
    Park HH, Lee K-S, Hong C-K. Vertebral artery transposition via an extreme-lateral approach for anterior foramen magnum meningioma or craniocervical junction tumors. World Neurosurg. 2016;88:154–65.PubMedCrossRefGoogle Scholar
  23. 23.
    Wanibuchi M, Fukushima T, Zenga F, Friedman AH. Simple identification of the third segment of the extracranial vertebral artery by extreme lateral inferior transcondylar–transtubercular exposure (ELITE). Acta Neurochir. 2009;151(11):1499–503.PubMedCrossRefGoogle Scholar
  24. 24.
    Mintelis A, Sameshima T, Bulsara KR, Gray L, Friedman AH, Fukushima T. Jugular tubercle: morphometric analysis and surgical significance. J Neurosurg. 2006;105(5):753–7.PubMedCrossRefGoogle Scholar
  25. 25.
    Calayag M, Gabel BC, Hong DS, Hatefi D, Gonda DD, Meltzer HS, Levy ML. 197 considerations in relationship to the approach for the treatment of lateralized posterior fossa tumors in children. Neurosurgery. 2016;63:177–8.CrossRefGoogle Scholar
  26. 26.
    Chandra PS, Jaiswal AK, Mehta VS. Foramen magnum tumors: a series of 30 cases. Neurol India. 2003;51(2):193–6.Google Scholar
  27. 27.
    Margalit NS, Lesser JB, Singer M, Sen C. Lateral approach to anterolateral tumors at the foramen magnum: factors determining surgical procedure. Neurosurgery. 2005;56(4 Suppl):324–36.PubMedGoogle Scholar
  28. 28.
    Shiban E, Török E, Wostrack M, Meyer B, Lehmberg J. The far-lateral approach: destruction of the condyle does not necessarily result in clinically evident craniovertebral junction instability. J Neurosurg. 2016;125:196–201.PubMedCrossRefGoogle Scholar
  29. 29.
    Calzada G, Isaacson B, Yoshor D, Oghalai J. Surgical approaches to the hypoglossal canal. Skull Base. 2007;17(3):187–96.PubMedPubMedCentralCrossRefGoogle Scholar
  30. 30.
    Avci E, Acevedo C, Fossett D. Extreme lateral approach. New York: Thieme; 2002. p. 90–9.Google Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2019

Authors and Affiliations

  • Nabeel S. Alshafai
    • 1
  • Tomasz Klepinowski
    • 1
    • 2
  1. 1.Alshafai Neurosurgical Academy (ANA)TorontoCanada
  2. 2.Department of NeurosurgeryCollegium Medicum Jagiellonian UniversityKrakówPoland

Personalised recommendations