Far Lateral Approach—Modifications, Applications, Technique, and Results

Objective: To evaluate results of surgeries performed using several modifications of the far-lateral approach.

Methods: From 2000 to 2006, 40 patients ages 19 to 73 were operated with the far lateral approach (FLA). Patients presented with PICA aneurysms (3), meningiomas of the foramen magnum (21) or jugular tuberculum or jugular foramen (10), epidermoid tumors (4), and brainstem cavernomas (2). The approach included suboccipital/retrosigmoid craniotomy. The extent of drilling of the condyle, jugular tuberculum, and/or mastoid process, and vertebral artery manipulation were tailored to the pathology and its location. Patients were operated in the sitting or three-quarter prone position. In 6 patients the FLA was widened to provide transpetrosal access. These patients were placed on their backs with head rotation.

Results: Significant complications included CSF leak with meningitis (1 patient, 3.3%), new lower cranial nerve dysfunction (4 patients, 13.3%), pulmonary embolism (2 patients, 6.7%), cerebellar infarction (1 patient, 3.3%), and facial paresis (2 patients, 6.7%). The most convenient type of the FLA was that with partial mobilization of the vertebral artery, which provides good access to the ventral portion of the foramen magnum and jugular foramen.

Conclusion: FLA is an important route to the posterolateral skull base. Several modifications may be useful; the most convenient being partial mobilization of the vertebral artery, which demands relatively less extensive bone work and provides excellent access to the ventral portion of the foramen magnum and jugular foramen area.