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How I do it: lateral approach for craniocervical junction tumors

  • How I Do it - Neurosurgical technique evaluation
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Abstract

Background

The far lateral approach has been developed to access lesions at the craniocervical junction and upper cervical spinal canal. Associated morbidity triggered the development of less invasive tailored approaches.

Method

In this lateral approach to the craniocervical junction, the occipital condyle is kept intact, vertebral artery manipulation is minimized, and the sigmoid sinus is not skeletonized. A linear incision through skin and muscles and use of an abdominal wall fat graft minimize the risk of cerebrospinal fluid leakage.

Conclusions

The exposure provided is sufficient for the majority of tumors in this region and allows for low complication rates.

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Abbreviations

CSF:

Cerebrospinal fluid

FLA:

Far lateral approach

GTR:

Gross total resection

OC:

Occipital condyle

STR:

Subtotal resection

VA:

Vertebral artery

References

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Funding

No financial or material support has been received related to this study, and the authors have no relevant financial or non-financial interests to disclose.

Author information

Authors and Affiliations

  1. Department of Neurosurgery, Helsinki University Hospital, University of Helsinki, Topeliuksenkatu 5, 00260, Helsinki, Finland

    Tobias Rossmann, Michael Veldeman, Ville Nurminen & Martin Lehecka

  2. Department of Neurosurgery, Neuromed Campus, Kepler University Hospital, Linz, Austria

    Tobias Rossmann

  3. Department of Neurosurgery, RWTH Aachen University Hospital, Aachen, Germany

    Michael Veldeman

Authors
  1. Tobias Rossmann
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  2. Michael Veldeman
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  3. Ville Nurminen
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  4. Martin Lehecka
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Contributions

All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by Tobias Rossmann, Michael Veldeman, and Ville Nurminen. The first draft of the manuscript was written by Tobias Rossmann and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Tobias Rossmann.

Ethics declarations

Ethics approval and consent to participate

The research project was conducted following the principles outlined in the Declaration of Helsinki and was approved by the local university hospital review board. Informed consent was waived due to the retrospective nature of data.

Conflict of interest

The authors declare no competing interests.

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Key points

1. This lateral approach differs from classic FLA versions as the vertebral artery is not transposed, the sigmoid sinus is not skeletonized, and the occipital condyle is not drilled.

2. Keeping the occipital condyle intact prevents access to the hypoglossal canal and the jugular tubercle, with the latter potentially limiting access to the clivus and the space anterior to lower cranial nerves.

3. A straight skin incision is sufficient to achieve the desired exposure.

4. Hemilaminectomies of C1 and C2 can be added using the same approach.

5. Severe venous bleeding may be expected from the posterior condylar canal, other emissary veins, and the venous plexus surrounding vertebral artery and foramen magnum. Adequate preparation is key.

6. Use of an exoscope may increase the degree of surgical freedom as more extreme angles of view may be achieved.

7. We prefer to leave residual tumor close to vessels and cranial nerves to prevent injury.

8. Even transient lower cranial nerve dysfunctions may have severe sequelae and need to be avoided.

9. We suggest using a fat graft to augment dural closure, preventing CSF-leaks and covering mastoid air cells.

10. Reattach occipital bone and cervical laminae whenever possible, to provide a solid and protective landmark for re-do cases.

This article is part of the Topical Collection on Neurosurgical technique evaluation

Supplementary information

Below is the link to the electronic supplementary material.

Operative Video. Exoscopic resection of a right tonsillar hemangioblastoma using the lateral approach. (MP4 82737 KB)

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Rossmann, T., Veldeman, M., Nurminen, V. et al. How I do it: lateral approach for craniocervical junction tumors. Acta Neurochir 165, 1315–1322 (2023). https://doi.org/10.1007/s00701-022-05426-0

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  • DOI: https://doi.org/10.1007/s00701-022-05426-0

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