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Endoscopic far-lateral approach to the posterolateral craniovertebral junction: an anatomical study

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Abstract

Minimally invasive surgery to the posterolateral craniovertebral junction (CVJ) has not been sufficiently described. The aims of this study were to evaluate the feasibility of an endoscopic far-lateral approach to the posterolateral craniocervical junction and to better understand the related anatomy under distorted endoscopic view. Ten fresh cadavers were studied with 4-mm 0° and 30° endoscopes to develop the surgical approach and to identify surgical landmarks. After making a 3-cm straight incision behind the mastoid process, the superior oblique and rectus capitis posterior major muscles were partially exposed. An endoscope was then introduced and the two muscles were followed inferiorly until the posterior arch of the atlas appeared. The two muscles were removed to create ample working space without violating the posterior atlanto-occipital membrane. The vertebral artery was identified by the landmark of the posterior arch of the atlas, and the atlanto-occipital joint and foramen magnum were exposed. In addition to suboccipital craniectomy, transcondylar, supracondylar, and paracondylar extension by drilling were applicable through the narrow corridor under superb visualization. The intradural neurovascular structures from the acousticofacial bundle to the dorsal root of C2, anterolateral space of the foramen magnum, cerebellomedullary fissure, and fourth ventricle were clearly demonstrated. This endoscopic far-lateral approach offers excellent exposure of surgical landmarks around the posterolateral CVJ with minimal invasiveness. Endoscopic soft tissue dissection is key to creating the surgical corridor. This approach could offer an alternative to the conventional far-lateral approach in selected cases.

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Authors and Affiliations

  1. Center for Anatomy and Cell Biology, Department of Systematic Anatomy, Medical University of Vienna, Waehringer Strasse 13, 1090, Vienna, Austria

    Fuminari Komatsu, Mika Komatsu, Antonio Di Ieva & Manfred Tschabitscher

Authors
  1. Fuminari Komatsu
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  2. Mika Komatsu
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  3. Antonio Di Ieva
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  4. Manfred Tschabitscher
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Correspondence to Fuminari Komatsu.

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Comments

Michaël Bruneau, Brussels, Belgium

This article describes elegantly a minimally invasive endoscopic retromastoid transmuscular approach to the posterolateral craniovertebral junction based on the study of ten cadavers. The authors wished to perform a feasibility study and they achieved this goal very nicely, providing illustrative figures that detail all surgical steps and anatomical structures beautifully, including the fourth ventricle, the intradural structures around the foramen magnum, and the extradural lower cranial nerves. The concept of minimally invasive surgery to the posterolateral craniovertebral junction has been reported recently but pure endoscopic approach seems new. The supposed benefit regarding cervical muscle atrophy and postoperative discomfort of this minimally invasive approach over the conventional far-lateral approach has still to be studied as well as the benefit of endoscopic over microscopic approach, or a combination of both modalities. The advantage of the endoscope consists obviously in its ability to look around the corners.

Domenico Solari and Paolo Cappabianca, Naples, Italy

In this detailed anatomical study, the authors demonstrate the possibility to apply for a minimally invasive route to access a deep-located area of the skull base, i.e., the craniovertebral junction, and deal with different pathologies of this region. Besides, they highlight the contribution of the endoscopic technique that in the last decades has tremendously boosted the development of minimally invasive approaches, affording its extension among neurosurgeons on one hand and ENT and maxillofacial surgeons.

The authors move the attention toward the need for anatomic knowledge and surgical hand and mind skills, regardless of the tools or the technique, and confirm the utmost importance of preoperative planning, together with the outcome, which cannot be considered only a matter of surgical deed. They report an unbiased and well-balanced analysis of the approach, providing a true analytical perspective on the surgical strategies to access such complex skull base area. It should be kept in mind that surgery of this area could tremendously depend on several anatomical conditions and, as well, it is worth remembering that the access could be achieved by means of different routes in the attempt of improving the outcome while reducing the risk of morbidity. Treatment algorithms have been designed so that the morbidity associated with each procedure should have not exceeded the morbidity associated with the natural history of the disease. Lastly, we would like to underline that the widespread use of the endoscopic endonasal surgery in the management of different skull base pathologies provides a direct midline access to this area of the skull base, with minimal risk of damaging the adjacent important neurovascular structures.

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Komatsu, F., Komatsu, M., Di Ieva, A. et al. Endoscopic far-lateral approach to the posterolateral craniovertebral junction: an anatomical study. Neurosurg Rev 36, 239–247 (2013). https://doi.org/10.1007/s10143-012-0433-y

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