Evolution of Far-Lateral Approach: Single Surgeon Experience from Louisiana State University, Shreveport

Background: The far-lateral approach is an extension of the suboccipital approach and is used for accessing lesions in the anterolateral brainstem and craniovertebral junction.

Objective: To analyze the evolution of technique and outcome of patients who underwent surgery using a far-lateral approach and compare transcondylar and paracondylar modifications of the approach.

Methods: From 1994 to 2011, a total of 35 patients underwent surgery with a far-lateral approach. We retrospectively reviewed the records of these patients to analyze their clinical outcomes. We also reviewed the surgical technique used by the senior author.

Results: Of the 35 patients, 18 had aneurysms of the proximal PICA, proximal basilar artery, vertebrobasilar junction and AICA; and 17 patients had various tumors of which foramen magnum meningioma, C1-C2 neurofibroma, pontine cavernoma, and petroclival meningioma were predominant. Nine patients (26%) underwent partial resection of occipital condyle during surgery, whereas 26 patients (74%) underwent surgery without condyle resection. Complete resection was possible in all but one case; foramen magnum meningioma and adequate clipping of the aneurysm was possible in all cases. Follow-up data were available for 28 patients (80%), the mean duration of follow-up being 32 months. One patient died in the postoperative period due to systemic complications, and another died 6 years later due to an unrelated cause. At last follow-up, 15 patients (54%) had good recovery (GOS 5), 9 patients (32%) had moderate disability (GOS 4), and 4 patients (14%) remained in the same functional state (GOS 3). One patient had recurrence of foramen magnum meningioma. Three patients had persistent hydrocephalus after surgery and required ventriculoperitoneal shunting procedure. Patients who underwent occipital condyle resection had a higher incidence of developing new or worsening of preexisting lower cranial nerve paresis, although the difference was not significant (P > 0.05). There was no significant difference in outcome of patients who underwent surgery with and without condyle resection.

Conclusion: Far-lateral approach is an excellent approach to access lesions located in ventrolateral brainstem, ventrolateral and ventral foramen magnum and vertebrobasilar junction area. In many cases one can preserve the occipital condyle without compromising on the exposure to the lesion. However, every patient must be individualized and the surgical approach planned taking into consideration patient factors and tumor characteristics.