Petroclival and Upper Clival Meningiomas III: Combined Anterior and Posterior Approach

Neurosurgeons who trained or practiced in the 1980s will painfully recollect the difficulties encountered when attacking a petroclival meningioma through the only available neurosur-gical approach at that time, the suboccipital.^1,2 Although surgeons generally accepted the inevitable multiple cranial nerve palsies that resulted, the frequency and severity of paralysis caused by brain stem retraction precipitated a near moratorium on such surgery as well as ultimately stimulating the search for better surgical strategies. The search for the efficacious treatment of petroclival meningiomas culminated in the development of lateral approaches to the petroclival region, improvements in skull base surgery, and formation of a multi-disciplinary team.^3–7 While the two previous chapters expertly describe the anterior and posterior transpetrosal techniques, this chapter focuses on the treatment of tumors by a combined approach. The skull base literature can appear confusing with its myriad of overlapping approaches and nonstandardized nomenclature, which often varies according to specialty. Therefore, we favor a component-based nomenclature that lists the individual approaches from which a larger approach is built. Using a building block strategy to design the operative approach, we keep a complex operation as simple as possible, as small as possible, and as big as necessary. Our approaches are designed to be minimally neuroinvasive and externally cosmetic. Throughout the chapter, frequently asked questions (FAQs) of practical use at the time of surgery are interspersed to further assist the reader.