The posterior petrosal approach: technique and applications in pediatric neurosurgery

Clinical article

Restricted access

Object

Various lesions occur in deep locations or at the skull base in pediatric patients and require skull base approaches for resection. Skull base surgery confers the advantages of improved line of sight, a wider operative corridor, and reduced brain retraction. The posterior petrosal approach provides simultaneous access to lesions in the posterior middle fossa and posterior fossa from the top of the clivus to the level of the jugular foramen. It allows visualization of the ventrolateral brainstem and may be combined with various other supra- and infratentorial approaches, thus giving the surgeon a wide array of access routes to the lesion.

Methods

The authors conducted a retrospective review of all cases involving pediatric patients undergoing a posterior petrosal approach, either alone or in combination with other cranial approaches. Preoperative and postoperative data were collected, including presentation, neurological examination, imaging findings, pathological condition, operative details, perioperative complications, and postoperative outcomes.

Results

There were 13 patients (6 female, 7 male) with a mean age of 12.6 years (range 14 months–9 years). The posterior petrosal was the sole skull base cranial approach in 4 patients, whereas the posterior petrosal was combined with 1 or more other cranial approaches in 9. A gross-total resection was achieved in 7 patients, subtotal resection in 5, and a biopsy was performed in 1. Complications occurred in 9 patients, including 7 new or worsened cranial neuropathies. There was no perioperative mortality.

Conclusions

Although infrequently used in pediatric neurosurgery, the posterior petrosal approach is a highly versatile approach that can access intra- and extraaxial pathology centered on the petrous bone. The authors believe that patient outcomes are directly related to the degree of experience using this approach. Therefore, if this approach is to be used, they recommend collaboration with a skull base neurosurgeon.

Abbreviations used in this paper: CN = cranial nerve; SPS = superior petrosal sinus.

Article Information

Address correspondence to: William T. Couldwell, M.D., Ph.D., Department of Neurosurgery, University of Utah, 175 N. Medical Drive East, Salt Lake City, Utah 84132. email: neuropub@hsc.utah.edu.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Drawing showing patient in lateral decubitus position for petrosal approach.

  • View in gallery

    Schematic illustrations of the incision. Left: A periauricular incision starting just anterior to the tragus enables elevation of a combined suboccipital-posterior temporal bone flap). Two pairs of bur holes are placed straddling the transverse/sigmoid sinus region, the position of which can be precisely determined with the use of stereotaxy. The anterior extension of the bone flap with a fifth bur hole placed at the root of the zygoma is performed only if greater exposure of the middle fossa is required (for example, in a combined petrosal approach). Right: If a frontotemporal approach is required, then a curvilinear pterional scalp incision is added (dotted line). Modified from Liu JK, Couldwell WT: Petrosal approach for resection of petroclival meningiomas, in Badie B (ed): Neurosurgical Operative Color Atlas ed 2. New York: Thieme, 2007, pp 170–179, with permission.

  • View in gallery

    Artist's illustration of cosmetic mastoidectomy used in a combined petrosal approach. Upon elevation of the bone flap, a small triangle-shaped bone is left over the mastoid region. A cosmetic mastoidectomy is performed by cutting through the outer table of the bone using the zygomatic root, the external ear canal, and the lower mastoid margin as the limits of resection (dotted line). An oscillating saw or a high-speed fine-tipped cutting bur, as shown in the diagram, can be used. Reproduced from Liu JK, Couldwell WT: Petrosal approach for resection of petroclival meningiomas, in Badie B (ed): Neurosurgical Operative Color Atlas ed 2. New York: Thieme, 2007, pp 170–179, with permission.

  • View in gallery

    Artist's illustration of dural opening. The dura is first opened along the anterior border of the sigmoid sinus toward the SPS. The SPS usually drains into the sigmoid sinus just below the transverse-sigmoid junction, the usual site where the vein of Labbe drains. The SPS is clip or suture ligated and cut. The dura is then opened along the inferior temporal lobe toward the SPS, paying great attention to the position of the vein of Labbe. Reproduced from Liu JK, Couldwell WT: Petrosal approach for resection of petroclival meningiomas, in Badie B (ed): Neurosurgical Operative Color Atlas ed 2. New York: Thieme, 2007, pp 170–179, with permission.

  • View in gallery

    Artist's illustration of tumor exposure. Dissecting the vein of Labbe off the temporal lobe until its insertion into the sinus followed by application of retractors allows the posterior temporal lobe and the petrosal surface of the cerebellum to be retracted as a single unit. The tentorium can then be divided parallel to the SPS toward the incisura making sure that the cut ends posterior to the entrance of the trochlear nerve into the tentorium. Reproduced from Liu JK, Couldwell WT: Petrosal approach for resection of petroclival meningiomas, in Badie B (ed): Neurosurgical Operative Color Atlas ed 2. New York: Thieme, 2007, pp 170–179, with permission.

  • View in gallery

    Artist's illustration of tumor debulking. The tumor is exposed with cranial nerves draped over it. Internal debulking can then be carried out working between the nerves. Reproduced from Liu JK, Couldwell WT: Petrosal approach for resection of petroclival meningiomas, in Badie B (ed): Neurosurgical Operative Color Atlas ed 2. New York: Thieme, 2007, pp 170–179, with permission.

  • View in gallery

    Intraoperative photograph showing the fixation of the 2-piece bone flap with titanium plates and bur hole covers. The outer table of the mastoid buttresses the fat graft placed in the drilled mastoid cavity below. Reproduced from Couldwell WT, Fukushima T: Cosmetic mastoidectomy for the combined supra/infratentorial transtemporal approach. Technical note. J Neurosurg 79:460–461, 1993, with permission.

  • View in gallery

    Case 1. Left: Preoperative axial FLAIR (top row), and coronal (middle) and sagittal (bottom) T1-weighted contrast-enhanced MR images depicting the posterior mesial temporal mass extending into the basal cisterns both above and below the level of the incisura. Right: Postoperative axial (top row), coronal (middle), and sagittal (bottom) T1-weighted contrast-enhanced images show a small amount of residual tumor at the posterior ambient/quadrigeminal cistern junction.

  • View in gallery

    Case 2. Preoperative (A1–3) and postoperative (B1–3) MR images. The preoperative images show an irregular, lobulated, homogenously enhancing mass extending from the upper third of the clivus to the foramen magnum. Postoperatively, there was a small amount of residual tumor at the level of the foramen magnum.

References

  • 1

    Abdel Aziz KMSanan Avan Loveren HRTew JM JrKeller JTPensak ML: Petroclival meningiomas: predictive parameters for transpetrosal approaches. Neurosurgery 47:1391522000

    • Search Google Scholar
    • Export Citation
  • 2

    Al-Mefty OAyoubi SKadri PA: The petrosal approach for the total removal of giant retrochiasmatic craniopharyngiomas in children. J Neurosurg 106:87922007

    • Search Google Scholar
    • Export Citation
  • 3

    al-Mefty OAyoubi SSmith RR: The petrosal approach: indications, technique, and results. Acta Neurochir Suppl (Wien) 53:1661701991

    • Search Google Scholar
    • Export Citation
  • 4

    Al-Mefty OFox JLSmith RR: Petrosal approach for petroclival meningiomas. Neurosurgery 22:5105171988

  • 5

    Aoki KEsaki SMorikawa KKikuthi YHonda Y: [The size of the mastoid pneumatization and otitis media with effusion in children.]. Nippon Jibiinkoka Gakkai Kaiho 92:8938981989. (Jpn)

    • Search Google Scholar
    • Export Citation
  • 6

    Baldwin HZMiller CGvan Loveren HRKeller JTDaspit CPSpetzler RF: The far lateral/combined supra- and infratentorial approach. A human cadaveric prosection model for routes of access to the petroclival region and ventral brain stem. J Neurosurg 81:60681994

    • Search Google Scholar
    • Export Citation
  • 7

    Bochenek ZKukwa A: An extended approach through the middle cranial fossa to the internal auditory meatus and the cerebello-pontine angle. Acta Otolaryngol 80:4104141975

    • Search Google Scholar
    • Export Citation
  • 8

    Chatterjee DGhosh TBGhosh BB: Size variation of mastoid air cell system in Indian people at different age groups: a radiographic planimetric study. J Laryngol Otol 104:6036051990

    • Search Google Scholar
    • Export Citation
  • 9

    Cho CWAl-Mefty O: Combined petrosal approach to petroclival meningiomas. Neurosurgery 51:7087182002

  • 10

    Couldwell WTFukushima T: Cosmetic mastoidectomy for the combined supra/infratentorial transtemporal approach. Technical note. J Neurosurg 79:4604611993

    • Search Google Scholar
    • Export Citation
  • 11

    Eby TLNadol JB Jr: Postnatal growth of the human temporal bone. Implications for cochlear implants in children. Ann Otol Rhinol Laryngol 95:3563641986

    • Search Google Scholar
    • Export Citation
  • 12

    Erkmen KPravdenkova SAl-Mefty O: Surgical management of petroclival meningiomas: factors determining the choice of approach. Neurosurg Focus 19:2E72005

    • Search Google Scholar
    • Export Citation
  • 13

    Hakuba ANishimura S: Total removal of clivus meningiomas and the operative results. Neurol Med Chir (Tokyo) 21:59731981

  • 14

    Hakuba ANishimura STanaka KKishi HNakamura T: Clivus meningioma: six cases of total removal. Neurol Med Chir (Tokyo) 17:63771977

    • Search Google Scholar
    • Export Citation
  • 15

    Horgan MAAnderson GJKellogg JXSchwartz MSSpektor SMcMenomey SO: Classification and quantification of the petrosal approach to the petroclival region. J Neurosurg 93:1081122000

    • Search Google Scholar
    • Export Citation
  • 16

    Horgan MADelashaw JBSchwartz MSKellogg JXSpektor SMcMenomey SO: Transcrusal approach to the petroclival region with hearing preservation. Technical note and illustrative cases. J Neurosurg 94:6606662001

    • Search Google Scholar
    • Export Citation
  • 17

    House WFDe la Cruz AHitselberger WE: Surgery of the skull base: transcochlear approach to the petrous apex and clivus. Otolaryngology 86:ORL-770ORL-7791978

    • Search Google Scholar
    • Export Citation
  • 18

    Liu JKCouldwell WTPetrosal approach for resection of petroclival meningiomas. Badie B: Neurosurgical Operative Atlas: Neuro-Oncology ed 2New YorkThieme2006. 170179

    • Search Google Scholar
    • Export Citation
  • 19

    Nishimura SHakuba AJang BJInoue Y: Clivus and apicopetroclivus meningiomas—report of 24 cases. Neurol Med Chir (Tokyo) 29:100410111989

    • Search Google Scholar
    • Export Citation
  • 20

    O'Tuama LASwanson MS: Development of paranasal and mastoid sinuses: a computed tomographic pilot study. J Child Neurol 1:46491986

    • Search Google Scholar
    • Export Citation
  • 21

    Oghalai JSJackler RK: Anatomy of the combined retrolabyrinthine-middle fossa craniotomy. Neurosurg Focus 14:6e82003

  • 22

    Sincoff EHMcMenomey SODelashaw JB Jr: Posterior transpetrosal approach: less is more. Neurosurgery 60:2 Suppl 1ONS53ONS592007

  • 23

    Spetzler RFDaspit CPPappas CT: The combined supra- and infratentorial approach for lesions of the petrous and clival regions: experience with 46 cases. J Neurosurg 76:5885991992

    • Search Google Scholar
    • Export Citation

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 181 181 18
Full Text Views 109 109 1
PDF Downloads 86 86 2
EPUB Downloads 0 0 0

PubMed

Google Scholar