Retractorless CP Angle Surgery in Supine Position

Background: The cerebello-pontine angle hosts a variety of pathology. A suboccipital retrosigmoid approach enables to tackle such pathology by minimal invasive access. For this approach a variety of positions have been used. We describe a dissection technique that circumvents the use of any brain retraction by careful supine patient positioning and cisternal opening by combining well-known microneurosurgical principles.

Method: In a retrospectively evaluated transitory single surgeon series all consecutive 38 cases that were operated via a retractorless retrosigmoid approach during a 46-month period were screened for practicability of retractorless surgery. Principles and advantages of the applied technique are reported, and the transitional series is presented.

Results: Nineteen vestibular, 1 glossopharyngeal, 1 facial nerve schwannoma, 2 chondrosarcomas, 2 epidermoid recurrences, 4 petroclival, 3 petrosal meningiomas, 1 metastasis, 1 AVM, 1 DAVF, 1 branchiogenic cyst arising from CN IX/X, and 2 microvascular decompressions were operated. The sagittal extension of pathology ranged from the supra/ infratentorial transition to foramen magnum level. In no case secondary placement of a retractor was necessary nor found helpful for additional exposure. The applied principles of retractorless surgery enabled tissue sparing dissection. Other advantages are comfortable surgeon position, excellent field of view and substantially eased patient positioning. There is no congestion of CSF nor blood in this position.

Conclusion: We are quite satisfied with this supine and retractor free approach, and since long have completely adopted it.