The Combined Subtemporal-Suboccipital Approach: A Modified Surgical Access to the Clivus and Petrous Apex

Abstract

Objective: The surgical access to the clivus and the petrous apex is still a challenge. A combined approach is best fitted to lesions located in the middle and posterior cranial fossa. The approach described is centered on the petrous bone and requires an extensive bone resection; nevertheless, no osteoplastic bone flap is necessary. Methods: In contrast to approaches described before, the petrous bone is drilled away anterior to the sigmoid sinus more extensively, the sinus is unroofed. For exposure of the middle cranial fossa the petrous bone should be resected down to the roof of the external meatus, the total extent of the craniotomy is significantly smaller. Results and Conclusion: The surgical access as described above provides a wide operative field under preservation of important intracranial structures. This modified approach minimizes the cerebellar and temporal lobe retraction. The neural and vascular structures can be preserved under direct vision to the tumor. The blood supply is interrupted at the beginning of the operation.

Approach - Clivus - Cerbellopontine Angle - Subtemporal-Suboccipital

References

• 1 Spetzler R F, Daspit C P, Pappas C TE. The combined supra- and infratentorial approach for lesions of the petrous and clival regions: experience with 46 cases.  J Neurosurg. 1992;  76 588-599
• 2 Fraenkel J. Contribution to the surgery of neurofibroma of the acoustic nerve.  Ann Surg. 1904;  40 293-319
• 3 Borchardt M. Zur Operation der Tumoren des Kleinhirnbrückenwinkels [in German].  Berl Klein Wschr. 1905;  42 1033-1035
• 4 Naffziger H. Brain surgery with special reference to exposure of the brain stem and posterior fossa.  Surg Gyn Obst. 1928;  46 240-248
• 5 Fay T. The management of tumors of the posterior fossa by the transtentorial approach.  Surg Clin North Am. 1930;  10 1422-1499
• 6 Bailey P. Concerning the technique of operations for acoustic neuroma.  Zentralbl Neurochir. 1939;  4 1-5
• 7 Hitselberger W E, House W F. A combined approach to the cerebellopontine angle. A suboccipital-petrosal approach.  Arch Otolaryng. 1966;  84 267-285
• 8 Morrison A W, King T T. Experiences with a translabyrinthine-transtentorial approach to the cerebellopontine angle. Technical note.  J Neurosurg. 1973;  38 382-390
• 9 Hakuba A, Nishimura S, Tanaka K, Kishi H, Nakamura T. Clivus meningioma: six cases of total removal.  Neurol Med Chir (Tokyo). 1977;  17 63-77
• 10 Malis L I. Surgical resection of tumors of the skull base. In: Wilkins RH, Rengashary SS (eds). Neurosurgery Vol. 1. New York: McGraw Hill 1985: 1011-1021
• 11 Al-Mefty O, Fox J L, Smith R R. Petrosal approach for petroclival meningeoma.  Neurosurgery. 1988;  22 510-517
• 12 Al-Mefty O, Fox J L, Rifai A, Smith R R. A combined infratemporal and posterior fossa approach for the removal of giant glomus tumors and chondrosarcomas.  Surg Neurol. 1987;  28 423-431
• 13 Fukushima T. Combined supra- and infra-parapetrosal approach for petroclival lesions. In: Sekhar LN, Janecka IP (eds). Surgery of Skull Base Tumours. New York: Raven Press 1993: 661-670
• 14 Hakuba A, Nishimura S, Jang B J. A combined retroauricular and preauricular transpetrosal-transtentorial approach to clivus meningeomas.  Surg Neurol. 1988;  30 108-116
• 15 Miller C G, van Loveren H R, Keller J T, Pensak M, el-Kalliny M, Tew Jr J M. Transpetrosal approach: surgical anatomy and technique.  Neurosurgery. 1993;  33 461-469
• 16 Samii M, Ammirati M. The combined supra-infratentorial presigmoid-sinus-avenue to the petroclival region. Surgical technique and clinical applications.  Acta Neurochir. 1988;  95 6-12