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The midline suboccipital subtonsillar approach to the cerebellomedullary cistern: how I do it

  • How I Do it -Neurosurgical Anatomy
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Abstract

Background

Lesions lateral to the lower brainstem in an area extending from the foraminae of Luschka to the foramen magnum are rare and include different pathologies. There is no consensus on an ideal surgical approach.

Method

To gain access to this area, we use the midline suboccipital subtonsillar approach (STA). This midline approach with unilateral retraction of the cerebellar tonsil enables entry into the cerebellomedullary cistern.

Conclusions

The STA offers excellent access with a panoramic view of the cerebellomedullary cistern and its structures and therefore can be useful for a number of different pathologies in the lower petroclival area.

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References

  1. D’Ambrosio AL, Kreiter KT, Bush CA, Sciacca RR, Mayer SA, Solomon RA, Connolly ES Jr (2004) Far lateral suboccipital approach for the treatment of proximal posteroinferior cerebellar artery aneurysms: surgical results and long-term outcome. Neurosurgery 55:39–54

    PubMed  Google Scholar 

  2. Han S, Wang Z, Wang Y, Wu A (2013) Transcerebellomedullary fissure approach to lesions of the fourth ventricle: less is more? Acta Neurochir 155:1011–1016

    Article  PubMed  Google Scholar 

  3. Herlan S, Ebner FH, Nitz A, Hirt B, Tatagiba M, Roser F (2014) The midline suboccipital subtonsillar approach to the cerebellomedullary cistern and its structures: anatomical considerations, surgical technique and clinical application. Clin Neurol Neurosurg 125:98–105

    Article  PubMed  Google Scholar 

  4. Jean WC, Abdel Aziz KM, Keller JT, van Loveren HR (2003) Subtonsillar approach to the foramen of Luschka: an anatomic and clinical study. Neurosurgery 52:860–866

    Article  PubMed  Google Scholar 

  5. Krayenbuhl N, Guerrero C, Krisht AF (2005) Technical strategies to approach aneurysms of the vertebral and posterior inferior cerebellar arteries. Neurosurg Focus 19:E4

    Article  PubMed  Google Scholar 

  6. Roser F, Ebner FH, Schuhmann MU, Tatagiba M (2013) Glossopharyngeal neuralgia treated with an endoscopic assisted midline suboccipital subtonsillar approach: technical note. J Neurol Surg A Cent Eur Neurosurg 74:318–320

    PubMed  Google Scholar 

  7. Roux A, Mohr G, Hardy J (1990) Vertebro-PICA aneurysms: midline suboccipital approach and laminectomy of the atlas. Br J Neurosurg 4:113–121

    Article  CAS  PubMed  Google Scholar 

  8. Tatagiba M, Koerbel A, Roser F (2006) The midline suboccipital subtonsillar approach to the hypoglossal canal: surgical anatomy and clinical application. Acta Neurochir 148:965–969

    Article  CAS  PubMed  Google Scholar 

  9. Wu A, Zabramski JM, Jittapiromsak P, Wallace RC, Spetzler RF, Preul MC (2010) Quantitative analysis of variants of the far-lateral approach: condylar fossa and transcondylar exposures. Neurosurgery 6(6 Suppl Operative):191–198

    Google Scholar 

  10. Ziyal IM, Sekhar LN, Salas E (1999) Subtonsillar-transcerebellomedullary approach to lesions involving the fourth ventricle, the cerebellomedullary fissure and the lateral brainstem. Br J Neurosurg 13:276–284

    Article  CAS  PubMed  Google Scholar 

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Author information

Authors and Affiliations

  1. Department of Neurosurgery, Eberhard Karls University Tübingen, Hoppe-Seyler-Straße 3, 72076, Tübingen, Germany

    Stephan Herlan, Florian H. Ebner & Marcos Tatagiba

  2. Institute of Clinical Anatomy and Cell Analysis, Eberhard Karls University Tübingen, Elfriede-Aulhorn-Str. 8, 72076, Tübingen, Germany

    Stephan Herlan

  3. Neurological Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates

    Florian Roser

Authors
  1. Stephan Herlan
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  2. Florian Roser
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  3. Florian H. Ebner
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  4. Marcos Tatagiba
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Corresponding author

Correspondence to Stephan Herlan.

Additional information

Key points

• The STA is a fast, straightforward and easy-to-perform approach to structures of the cerebellomedullary cistern

• Semi-sitting position and C1 laminotomy may improve the viewing angle, facilitating bimanual microsurgical dissection and avoiding tonsillar retraction

• Careful arachnoid dissection around the tonsils and cisterns enables panoramic view of the cerebellomedullary cistern

• Mild and intermittent tonsil retraction can be sufficient in the majority of the cases

• Endoscope assistance enhances the overview thus helping to achieve total tumour resection or aneurysm closure

• For distal PICA aneurysms the approach enables good proximal vessel control of the proximal intradural vertebral artery

• Electrophysiological monitoring of the lower cranial nerves is absolutely recommended

• Depending on pathology a temporary decrease of lower cranial nerve function may be expected

• Postoperative complications and risks are mainly dependent on pathology but not the approach

• Major limitations of the approach consist of pathologies expanding into the cerebellopontine and/or premedullary cistern as well as strong adhesions to the ventral parts of the brainstem

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Herlan, S., Roser, F., Ebner, F.H. et al. The midline suboccipital subtonsillar approach to the cerebellomedullary cistern: how I do it. Acta Neurochir 159, 1613–1617 (2017). https://doi.org/10.1007/s00701-017-3270-5

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  • DOI: https://doi.org/10.1007/s00701-017-3270-5

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