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The benefits of inferolateral transtubercular route on intradural surgical exposure using the endoscopic endonasal transclival approach

  • Original Article - Neurosurgical Anatomy
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Abstract

Background

Surgical access to the ventral pontomedullary junction (PMJ) can be achieved through various corridors depending on the location and extension of the lesion. The jugular tubercle (JT), a surgically challenging obstacle to access the PMJ, typically needs to be addressed in transcranial exposures. We describe the endoscopic endonasal transclival approach (EETCA) and its inferolateral transtubercular extension to assess the intradural surgical field gained through JT removal. We also complement the dissections with an illustrative case.

Methods

EETCA was surgically simulated, and the anatomical landmarks were assessed in eight cadaveric heads. Microsurgical dissections were additionally performed along the endoscopic surgical path. Lastly, we present an intraoperative video of the trans-JT approach in a patient with lower clival chordoma.

Results

The EETCA allowed adequate extracranial visualization and removal of the JT. The surgical bony window—obtained along the clivus and centered at the JT via the EETCA—measured 11 × 9 × 7 mm. Removal of the JT provided an improved intradural field within the lower third of the cerebellopontine cistern to expose an area bordered by the cranial nerves VII/VIII and flocculus superior and anterior margin of the lateral recess of the fourth ventricle and cranial nerves IX–XI inferiorly, centered on the foramen of Luschka.

Conclusions

Removal of the JT via EETCA improves exposure along the lower third of the cerebellopontine and upper cerebellomedullary cisterns. The inferolateral transtubercular extension of the EETCA provides access to the lateral recess of the fourth ventricle, in combination with the ventral midline pontomedullary region.

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Abbreviations

AICA:

Anterior inferior cerebellar artery

C1:

First cervical vertebra

C2:

Second cervical vertebra

CN:

Cranial nerve

CPA:

Cerebellopontine angle

EETCA:

Endoscopic endonasal transclival approach

ICA:

Internal carotid artery

JT:

Jugular tubercle

PICA:

Posterior inferior cerebellar artery

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Acknowledgements

We thank Gentek Medical and Technical Devices Trade and Industry Inc., Karl Storz’s country representation in Turkey, for their valuable contribution by providing the Storz Skull Base Endoscope system (Karl Storz SE & Co. KG, Tuttlingen, Germany) to the Microsurgical Neuroanatomy Laboratory in Istanbul University–Cerrahpasa, Turkey, Department of Neurosurgery.

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Authors and Affiliations

  1. Department of Neurosurgery, Tepecik Research and Training Hospital, Health Science University, Izmir, Turkey

    Ali Karadag

  2. Department of Neurosurgery, Microsurgical Neuroanatomy Laboratory, Cerrahpasa Medical Faculty, Istanbul University–Cerrahpasa, Istanbul, Turkey

    Ali Karadag, Pinar Gokdogan Kirgiz, Baran Bozkurt, Baris Kucukyuruk & Necmettin Tanriover

  3. Department of Neurosurgery, Sisli Etfal Research and Training Hospital, Health Science University, Istanbul, Turkey

    Pinar Gokdogan Kirgiz

  4. Department of Neurosurgery, Acibadem University, Istanbul, Turkey

    Baran Bozkurt

  5. Department of Neurosurgery, Cerrahpasa Faculty of Medicine, Istanbul University–Cerrahpasa, 34098, Istanbul, Turkey

    Baris Kucukyuruk & Necmettin Tanriover

  6. Department of Neurosurgery, Mayo Clinic, Jacksonville, FL, USA

    Karim ReFaey & Erik H. Middlebrooks

  7. Department of Radiology, Mayo Clinic, Jacksonville, FL, USA

    Erik H. Middlebrooks

  8. Department of Neurosurgery, KTO Karatay University, Medicana International Izmir Hospital, Izmir, Turkey

    Mehmet Senoglu

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  1. Ali Karadag
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Correspondence to Necmettin Tanriover.

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Karadag, A., Kirgiz, P.G., Bozkurt, B. et al. The benefits of inferolateral transtubercular route on intradural surgical exposure using the endoscopic endonasal transclival approach. Acta Neurochir 163, 2141–2154 (2021). https://doi.org/10.1007/s00701-021-04835-x

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