Indications

• •
  

  The suboccipital approach with C1 laminectomy provides adequate visualization of approximately 270 degrees of the circumference around the medulla. This approach does not provide safe access to the 90 degrees anterior to the medulla, however, because the visual angle needed to see this region is obscured by the occipital condyle, which must be drilled in most cases to allow access along this visual trajectory.

  
  
• •
  

  The muscular bulk in the midline approach performed in a conventional suboccipital craniectomy effectively limits the surgeon’s ability to dissect safely laterally enough to visualize the extracranial vertebral artery and to drill away the posterior occipital condyle.

Contraindications

• •
  

  The limits of this approach are the ventral clivus and brainstem above the pontomedullary junction.

Planning and positioning

• •
  

  Positioning for the far-lateral approach is perhaps the most complex of any common neurosurgical procedure.

  
  
• •
  

  After turning the table at least 120 degrees away from the anesthesia team, the patient is placed in a three-quarter prone position on the operating table, with the contralateral shoulder down. The superior (ipsilateral) shoulder is in mild flexion on an arm rest in mild flexion. The contralateral arm is draped off the edge of the bed and placed in a shoulder sling, which is secured to the edge of the bed with towel clamps.

  
  
• •
  

  The head is placed in a Mayfield head holder with two pins placed just behind the contralateral occiput. The single pin is placed in the ipsilateral frontal bone, above the superior temporal line. After pinning, the head is slightly flexed, rotated toward the contralateral shoulder, and elevated slightly. By positioning the patient three quarters prone, the appropriate head position is achieved.

  
  

  
  

  
  

  

  
  

  
  

  Positioning for far-lateral suboccipital approach.

  
  

Procedure

The skin incision is roughly hockey stick–shaped, consisting of three unequal-length limbs that are roughly perpendicular to each other. The long limb of the incision is midline and begins just below the spinous process of C3 and extends to just above the inion. The horizontal incision extends laterally from just above the inion to just above the mastoid tip. The short limb of the incision begins just below the mastoid tip and extends upward to meet the horizontal limb. This incision parallels the transverse and sigmoid sinuses and provides the ability to fold the myocutaneous flap laterally enough to expose the entire hemiocciput and the arch of C1 out to the tip of the transverse process.

Soft tissue elevation and identification of landmarks. Soft tissue dissection is performed with a combination of periosteal dissectors and monopolar cautery to expose three key landmarks in their entirety. The hemiocciput should be cleared of soft tissue down to the foramen magnum. Also, the mastoid process should be exposed down to the point where the mastoid tip begins to curve medially and anteriorly until the mastoid curves anteriorly. Finally, the lamina of C1 should be exposed laterally until the tip of the C1 transverse process can be palpated under the superior and inferior oblique muscles of the suboccipital triangle.

Only gold members can continue reading. Log In or Register to continue

Share this:

• Click to share on Twitter (Opens in new window)
• Click to share on Facebook (Opens in new window)

Related

Related posts:

Extended Retrosigmoid Craniotomy Paramedian Craniotomy and Unilateral Anterior Interhemispheric Approach for Clipping of Distal Anterior Cerebral Artery Aneurysm Selective Amygdalohippocampectomy Anterior C1-2 Fixation Costotransversectomy Open Carpal Tunnel Release

Stay updated, free articles. Join our Telegram channel

Join