Abstract
Surgical approaches to the fourth ventricle and its surrounding brainstem regions have changed significantly in the previous 30 years, after the establishment of cerebellomedullary fissure (CMF) opening. With the development of CMF opening techniques, CMF opening surgeries have become widely used for the treatment of various pathologies and have contributed to the improvement of surgical results in posterior fossa surgeries. We here review the historical progress of CMF opening surgeries to help the future progression of neurosurgical treatments. The authors studied the available literature to clarify how CMF opening surgeries have developed and progressed, and how much the idea and development of CMF opening techniques have affected the advancement of posterior fossa surgeries. With the establishment of angiography, anatomical studies on CMF in the 1960s were performed mainly to clarify vascular anatomy on radiological images. After reporting the microsurgical anatomy of CMF in a cadaveric study in 1982, one of the authors (T.M.) first proposed the clinical usefulness of CMF opening in 1992. This new method enabled wide exposure of the fourth ventricle without causing vermian splitting syndrome, and it took the place of the standard approach instead of the conventional transvermian approach. Several authors reported their experiences using this method from the end of the twentieth century to the early twenty-first century, and the naming of the approach, “telovelar approach” by Mussi and Rhoton in 2000 contributed to the global spread of CMF opening surgeries. The approach has become widely applied not only for tumors but also for vascular and brainstem lesions, and has assisted in the development of their surgical treatments, and brought up the idea of various fissure dissection in the posterior fossa. Studies of microsurgical anatomy of the fourth ventricle, including the CMF, has led to new surgical approaches represented by the transCMF/telovelar approach. The CMF opening method caused a revolution in posterior fossa surgeries. The idea was developed based on the experience gained while dissecting the CMF (the roof of the fourth ventricle) in the laboratory. Anatomical studies using cadaveric specimens, particularly their dissection by surgeons themselves, together with a deep understanding of brain anatomy are essential for further advancements in neurosurgical treatments.
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References
Abe H, Miki K, Kobayashi H, Ogata T, Iwaasa M, Matsushima T, Inoue T (2017) Unilateral trans-cerebellomedullary fissure approach for occipital artery to posterior inferior cerebellar artery bypass during aneurysmal surgery. Neurol Med Chir (Tokyo) 57:284–291
Akiyama O, Matsushima K, Maximiliano N, Matsuo S, Kondo A, Arai H, Rhoton AL Jr, Matsushima T (2018) Microsurgical anatomy and approaches around the lateral recess special reference to the entry into the pons. J Neurosurg 129:740–751
Aydin I, Hanalioglu S, Peker HO, Turan Y, Kina H, Cikla U, Baskaya MK (2018) The tonsillouvular fissure approach: access to dorsal and lateral aspects of the fourth ventricle. World Neurosurg 114:e1107–e1119
Bertalanffy H, Tissira N, Krayenbühl N, Bozinov O, Sarnthein J (2011) Inter- and intra-patient variability of facial nerve response areas in the floor of the fourth ventricle. Neurosurgery 68(1 Suppl operative):23–31
Bozkurt B, Kalani MYS, Yagmurlu K, Belykh E, Preul MC, Nakaji P, Spetzler RF (2018) Low retrosigmoid infratonsillar approach to lateral medullary lesions. World Neurosurg 111:311–316
Cavalheiro S, Yagmurlu K, da Costa MDS, Nicacio JM, Rodrigues TP, Chaddad-Neto F, Rhoton AL (2015) Surgical approaches for brainstem tumors in pediatric patients. Childs Nerv Syst 31:1815–1840
Cohen AR (1996) Chapter 7; surgical approach to the fourth ventricle. In: Cohen AR (ed) Surgical disorders of the fourth ventricle. Blackwell Science, Cambridge, pp 147–160
Dandy WE. (1945) Brain tumors: general diagnosis and treatment. in Surgery of the brain. Hagerstown: W.F. Prior
Deshmukh VR, Figueiredo EG, Desmukh P, Crawford NR, Preul MC, Spetzler RF (2006) Quantification and comparison of telovelar and transvermian approaches to the fourth ventricle. Neurosurgery 58:ONS202–ONS207
Deshmukh VR, Rangel-Castilla L, Spetzler RF (2014) Lateral inferior cerebellar peduncle approach to dorsolateral medullary cavernous malformation. J Neurosurg 121:723–729
Eissa EM (2018) The role of the telovelar approach in fourth ventricular surgery: a new perspective. Turk Neurosurg 28:523–529
El-Bahy K (2005) Telovelar approach to the fourth ventricle: operative findings and results in 16 cases. Acta Neurochir 147:137–142
Ezer H, Banerjee AD, Bollam P, Guthikonda B, Nanda A (2012) The superior transvelar approach to the fourth ventricle and brainstem. J Neurol Surg B Skull Base 73:175–182
Ferrante L, Mastronardi L, Acqui M, Fortuna A (1990) Mutism after posterior fossa surgery in children. J Neurosurg 72:959–963
Gok A, Alptekin M, Erkutlu I (2004) Surgical approach to the fourth ventricle cavity through the cerebellum fissure. Neurosurg Rev 27:50–54
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
Huang YP, Wolf BS (1967) The vein of the lateral recess of the fourth ventricle and its tributaries: roentgen appearance and anatomic relationships. Am J Roentgenol 101:1–21
Inoue K, Matsushima T, Ohara S, Masuoka J, Abe T. (2020) Study of the anatomical features of the offending arteries involved in glossopharyngeal neuralgia. Oper Neurosurg:1–10
Inoue T, Matsushima T, Inamura T, Kawamura T, Ishihara S, Fukui M (1998) Surgical approach to the mesencephalic vascular malformation. Surg Cereb Stroke 26:287–291 (in Japanese)
Jean WC, Aziz KMA, Keller JT, van Loveren HR (2003) Subtonsillar approach to the foramen of Luschka: an anatomic and clinical study. Neurosurgery 52:860–866
Kawashima M, Matsushima T, Nakahara Y, Takase Y, Masuoka J, Ohata K (2009) Trans-cerebellomedullary fissure approach with special reference to lateral route. Neurosurg Rev 32:457–464
Kawashima M, Takase Y, Matsushima T (2013) Surgical treatment of vertebral artery–posterior inferior cerebellar artery aneurysms: special reference to the importance of the cerebellomedullary fissure dissection. J Neurosurg 118:460–464
Kellogg JX, Piatt JH Jr (1997) Resection of fourth ventricle tumors without splitting the vermis: the cerebellomedullary fissure approach. Pediatr Neurosurg 27:28–33
Kempe LG (1970) Operative neurosurgery, vol 2. Springer-Verlag, New York, pp 1–33
Larsell O (1937) The cerebellum. A review and interpretation. Arch Neurol Psychiatr 38:580–607
Lawton MT, Quiñones-Hinojosa A, Jun P (2006) The supratonsillar approach to the inferior cerebellar peduncle: anatomy, surgical technique, and clinical application to cavernous malformations. Neurosurgery 59(ONS Suppl 4):ONS244–ONS252
Matsushima K, Kohno M, Bertalanffy H (2019) Resection of brainstem cavernous malformation via perifacial zone through retrosigmoid supracondylar approach. Neurosurg Focus 1(Suppl1):V16
Matsushima K, Yagmurlu K, Kohno M, Rhoton AL (2016) Anatomy and approaches along the cerebellar-brainstem fissures. J Neurosurg 124:248–263
Matsushima T (2015) Microsurgical anatomy and surgeries of the posterior cranial fossa. Springer Japan, Tokyo
Matsushima T, Abe H, Kawashima M, Inoue T (2012) Exposure of the wide interior of the fourth ventricle without splitting the vermis: importance of cutting procedures for the tela choroidea. Neurosurg Rev 35:563–572
Matsushima T, Fukui M, Inoue T, Natori Y, Baba T, Fujii K (1992) Microsurgical and magnetic resonance imaging anatomy of the cerebellomedullary fissure and its application during fourth ventricle surgery. Neurosurgery 30:325–330
Matsushima T, Inoue T, Inamura T, Natori Y, Ikezaki K, Fukui M (2001) Transcerebellomedullary fissure approach with special reference to methods of dissecting the fissure. J Neurosurg 94:257–264
Matsushima T, Kawashima M, Inoue K, Matsushima K, Miki K (2014) Exposure of wide cerebellomedullary cisterns for vascular lesion surgeries in cerebellomedullary cisterns: opening of unilateral cerebellomedullary fissures combined with lateral foramen magnum approach. World Neurosurg 82:e615–e621
Matsushima T, Matsukado K, Inoue T, Fukui M (2000) Part 5: trans-cerebellomedullary fissure approach. Nervous System in Children 25:173–177 (in Japanese)
Matsushima T, Rhoton AL Jr (1996) 113: microsurgical anatomy of the fourth ventricle. In: Wilkins RH, Rengachary SS (eds) Neurosurgery, Second edn. McGraw-Hill Book Company, Chicago, pp 1155–1171
Matsushima T, Rhoton AL Jr, Lenkey C (1982) Microsurgery of the fourth ventricle: part 1, microsurgical anatomy. Neurosurgery 11:631–667
Mussi ACM, Rhoton AL Jr (2000) Telovelar approach to the fourth ventricle: microsurgical anatomy. J Neurosurg 92:812–823
Ohue S, Fukushima T, Friedman AH, Kumon Y, Ohnishi T (2010) Retrosigmoid suprafloccular transhorizontal fissure approach for resection of brainstem cavernous malformation. Neurosurgery 66(6 Suppl operative):306–313
Rajesh BJ, Rao BRM, Menon G, Abraham M, Easwer HV, Nair S (2007) Telovelar approach: technical issues for large fourth ventricle tumors. Childs Nerv Syst 23:555–558
Tanriover N, Ulm AJ, Rhoton AL Jr, Yasuda A (2004) Comparison of the transvermian and telovelar approaches to the fourth ventricle. J Neurosurg 101:484–498
Tomasello F, Conti A, Cardali S, Torre DL, Angileri FF (2015) Telovelar approach to fourth ventricle tumors: highlights and limitations. World Neurosurg 83:1141–1147
Yang L, Zhang H, Wang X, Yan Z, Chen L, Ji X, Dong J (2017) Midline suboccipital endoscopic transcerebellomedullary fissure keyhole approach. J Craniofac Surg 28:1603–1606
Yang Y, van Niftrik B, Ma X, Velz J, Wang S, Regli L, Bozinov O (2019) Analysis of safe entry zones into the brainstem. Neurosurg Rev 42:721–729
Yasargil MG. (1996) Chapter 19. Median inferior suboccipital transfissual approach, Microneurosurgery IVB. Microneurosurgery of CNS Tumors. Georg Thieme Verlag, Stuttgart, New York, pp 315
Zaheer SN, Wood M (2010) Experiences with the telovelar approach to fourth ventricular tumors in children. Pediatr Neurosurg 46:340–343
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
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We would like to thank Mrs. Sumiko Matsushima for her valuable secretarial assistance in the preparation of this manuscript.
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Matsushima, T., Rutka, J. & Matsushima, K. Evolution of cerebellomedullary fissure opening: its effects on posterior fossa surgeries from the fourth ventricle to the brainstem. Neurosurg Rev 44, 699–708 (2021). https://doi.org/10.1007/s10143-020-01295-2
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DOI: https://doi.org/10.1007/s10143-020-01295-2