Abstract
IntroductionLesions of the jugular foramen (JF) and postero-lateral skull base are difficult to expose and exhibit complex neurovascular relationships. Given their rarity and the increasing use of radiosurgery, neurosurgeons are becoming less experienced with their surgical management. Anatomical factors are crucial in designing the approach to achieve a maximal safe resection.Methods and methodsSix cadaveric heads (12 sides) were dissected via combined post-auricular infralabyrinthine and distal transcervical approach with additional anterior transstyloid and posterior far lateral exposures. Contiguous surgical triangles were measured, and contents were analyzed. Thirty-one patients (32 lesions) were treated surgically between 2000 and 2016 through different variations of the retro-auricular distal cervical transtemporal approaches.ResultsWe anatomically reviewed the carotid, stylodigastric, jugular, condylar, suboccipital, deep condylar, mastoid, suprajugular, suprahypoglossal (infrajugular), and infrahypoglossal triangles. Tumors included glomus jugulare, lower cranial nerve schwannomas or neurofibromas, meningiomas, chondrosarcoma, adenocystic carcinoma, plasmacytoma of the occipitocervical joint, and a sarcoid lesion. We classified tumors into extracranial, intradural, intraosseous, and dumbbell-shaped, and analyzed the approach selection for each.ConclusionJugular foramen and posterolateral skull base lesions can be safely resected through a retro-auricular distal cervical lateral skull base approach, which is customizable to anatomical location and tumor extension by tailoring the involved osteo-muscular triangles.
Highlights
Lesions of the jugular foramen (JF) and postero-lateral skull base are difficult to expose and exhibit complex neurovascular relationships. Given their rarity and the increasing use of radiosurgery, neurosurgeons are becoming less experienced with their surgical management
Anatomical factors are crucial in designing the approach to achieve a maximal safe resection
We review a clinical series of 32 lesions where a modification of the LDC-RATT was used by the senior author (JHR) for surgical resection of distal cervical and posterolateral skull base lesions, either extending to or in close proximity to the jugular foramen
Summary
Six cadaveric heads (12 sides) were dissected via combined post-auricular infralabyrinthine and distal transcervical approach with additional anterior transstyloid and posterior far lateral exposures. Thirty-one patients (32 lesions) were treated surgically between 2000 and 2016 through different variations of the retro-auricular distal cervical transtemporal approaches. Six preserved cadaveric heads (12 sides) were dissected at the Medical Education and Research Institute (MERI) microsurgical laboratory in Memphis, TN. All cadaver specimens had preserved distal necks proximally, at least to the level of the omohyoid muscle. The following superficial triangles were defined and identified as previously described (Figures 2 and 3): (i) mastoid triangle, between the asterion, mastoid tip, and the supra-meatal crest (Figure 2A) [12]; (ii) carotid triangle, limited by the omohyoid, the sternocleidomastoid (SCM), and the digastric muscles (Figure 2B) [13]; and (iii) stylodigastric triangle between the digastric and the stylo-hyoid muscles (Figure 2C) [12]
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