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Far Lateral Craniotomy for Resection of Foramen Magnum Meningioma
Address for correspondence
01 April 2019
25 August 2019
22 October 2019 (online)
Objective Foramen magnum meningiomas present a formidable challenge to resection due to frequent involvement of the lower cranial nerves and vertebrobasilar circulation. The video shows the use of a far lateral craniotomy to resect a foramen magnum meningioma.
Design, Setting, and Participant A 49-year-old woman presented with neck pain and was found to have a large foramen magnum meningioma ([Fig. 1A, B]). Drilling of the posterior occipital condyle was required to gain access to the lateral aspect of the brain stem. The amount of occipital condyle resection varies by patient and pathology.
Outcome/Result Maximal total resection of the tumor was achieved ([Fig. 1B, C]), and the patient was discharged on postoperative day 4 with no neurologic deficits. The technique for tumor microdissection ([Fig. 2]) is shown in the video.
Conclusion Given the close proximity of foramen magnum meningiomas to vital structures at the craniocervical junction, surgical resection with careful microdissection and preservation of the overlying dura to prevent postoperative pseudomeningocele is necessary to successfully manage this pathology in those patients who are surgical candidates.
The link to the video can be found at: https://youtu.be/Mds9N1x2zE0.
This is a masterful demonstration of the “far lateral” approach to resect a left ventral foramen magnum meninigioma. This is absolutely the quintessential lesion that is best addressed with this approach. I strongly agree, there is rarely a reason, when addressing intradural pathology, to disrupt the articular surface between the occipital condyle and cervical 1 (C1). As the video demonstrates, I also often end up leaving a small plaque of tumor just ventral to the dural entry point of the ipsilateral vertebral artery. Early in my career, I would completely mobilize the vertebral artery out of the foramen transversarium of C1 and C2 to transpose it to allow access to this otherwise somewhat blind area, but I now think this is not a fruitful undertaking. It puts the artery at significant risk, takes a very long time, and by no means guarantees a surgical cure. Of note, I usually use an autologous fascia lata graft sewn in with a running 5–0 monofilament suture to get a watertight closure to avoid pseudomeningocele formation at the conclusion of tumor resection. I also prefer the “hockey-stick” incision rather than a C-shaped retroauricular incision. I feel this video will be a great primer for anyone planning to perform this approach. Congratulations to the authors on a great result.
Michael J. Link, MD
Mayo Clinic, Rochester
Conflict of Interest
The authors thank the staff of Neuroscience Publications at Barrow Neurological Institute for assistance with manuscript and video preparation.