The foramen lacerum: surgical anatomy and relevance for endoscopic endonasal approaches

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OBJECTIVE

The foramen lacerum is a relevant skull base structure that has been neglected for many years. From the endoscopic endonasal perspective, the foramen lacerum is a key structure due to its location at the crossroad between the sagittal and coronal planes. The objective of this study was to provide a detailed investigation of the surgical anatomy of the foramen lacerum and its adjacent structures based on anatomical dissections and imaging studies, propose several relevant key surgical landmarks, and demonstrate the surgical technique for its full exposure with several illustrative cases.

METHODS

Ten colored silicone-injected anatomical specimens were dissected using a transpterygoid approach to the foramen lacerum region in a stepwise manner. Five similar specimens were used for a comparative transcranial approach. The osseous anatomy was examined in 32 high-resolution multislice CT studies and 1 disarticulated skull. Representative cases were selected to illustrate the application of the findings.

RESULTS

The pterygosphenoidal fissure is the synchondrosis between the lacerum process of the pterygoid bone and the floor of the sphenoid bone. It constantly converges with the posterior end of the vidian canal at a 45° angle, and its posterolateral end points directly to the lacerum foramen. The pterygoid tubercle separates the vidian canal from the pterygosphenoidal fissure, and forms the anterior wall of the lower part of the foramen lacerum. The lingual process, which forms the lateral wall of the foramen lacerum, was identified in 53 of 64 sides and featured an average height of 5 mm. The mandibular strut separates the foramen lacerum from the foramen ovale and had an average width of 5 mm.

CONCLUSIONS

This study provides relevant surgical landmarks and a systematic approach to the foramen lacerum by defining anterior, medial, lateral, and inferior walls that may facilitate its safe exposure for effective removal of lesions while minimizing the risk of injury to the internal carotid artery.

ABBREVIATIONS ICA = internal carotid artery; PLL = petrolingual ligament.
Article Information

Contributor Notes

Correspondence Juan C. Fernandez-Miranda: Stanford University, Palo Alto, CA. drjfm@stanford.edu.INCLUDE WHEN CITING Published online November 30, 2018; DOI: 10.3171/2018.6.JNS181117.Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
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  • 1

    Abhinav KPanczykowski DWang WHSynderman CHGardner PAWang EW: Endoscopic endonasal interdural middle fossa approach to the maxillary nerve: anatomic considerations and surgical relevance. Oper Neurosurg (Hagerstown) 13:5225282017

    • Search Google Scholar
    • Export Citation
  • 2

    Dolci RLLDitzel Filho LFSGoulart CRUpadhyay SBuohliqah LLazarini PR: Anatomical nuances of the internal carotid artery in relation to the quadrangular space. J Neurosurg 128:1741812018

    • Search Google Scholar
    • Export Citation
  • 3

    Fernandez-Miranda JC: Intracranial region in Standring S (ed): Gray’s Anatomy ed 41. Amsterdam: Elsevier2016 pp 429442

  • 4

    Gruber W: Beiträge zur Anatomie des Schadelgrundes. Mem Akad Imp Sci St Petersburgh 13 Suppl:S1S341869

  • 5

    Gupta NRay BGhosh S: Anatomic characteristics of foramen vesalius. Kathmandu Univ Med J (KUMJ) 3:1551582005

  • 6

    Kassam ABPrevedello DMCarrau RLSnyderman CHGardner POsawa S: The front door to Meckel’s cave: an anteromedial corridor via expanded endoscopic endonasal approach- technical considerations and clinical series. Neurosurgery 64 (3 Suppl):ons71ons832009

    • Search Google Scholar
    • Export Citation
  • 7

    Kassam ABVescan ADCarrau RLPrevedello DMGardner PMintz AH: Expanded endonasal approach: vidian canal as a landmark to the petrous internal carotid artery. J Neurosurg 108:1771832008

    • Search Google Scholar
    • Export Citation
  • 8

    Lanzieri CFDuchesneau PMRosenbloom SASmith ASRosenbaum AE: The significance of asymmetry of the foramen of Vesalius. AJNR Am J Neuroradiol 9:120112041988

    • Search Google Scholar
    • Export Citation
  • 9

    Liu JPinheiro-Neto CDFernandez-Miranda JCSnyderman CHGardner PAHirsch BE: Eustachian tube and internal carotid artery in skull base surgery: an anatomical study. Laryngoscope 124:265526642014

    • Search Google Scholar
    • Export Citation
  • 10

    Ozturk KSnyderman CHGardner PAFernandez-Miranda JC: The anatomical relationship between the eustachian tube and petrous internal carotid artery. Laryngoscope 122:265826622012

    • Search Google Scholar
    • Export Citation
  • 11

    Pinheiro-Neto CDFernandez-Miranda JCRivera-Serrano CMPaluzzi ASnyderman CHGardner PA: Endoscopic anatomy of the palatovaginal canal (palatosphenoidal canal): a landmark for dissection of the vidian nerve during endonasal transpterygoid approaches. Laryngoscope 122:6122012

    • Search Google Scholar
    • Export Citation
  • 12

    Raval BBSingh PRRajguru J: A morphologic and morphometric study of foramen Vesalius in dry adult human skulls of Gujarat region. J Clin Diagn Res 9:AC04AC072015

    • Search Google Scholar
    • Export Citation
  • 13

    Shinohara ALde Souza Melo CGSilveira EMLauris JRAndreo JCde Castro Rodrigues A: Incidence, morphology and morphometry of the foramen of Vesalius: complementary study for a safer planning and execution of the trigeminal rhizotomy technique. Surg Radiol Anat 32:1591642010

    • Search Google Scholar
    • Export Citation
  • 14

    Simal-Julián JAMiranda-Lloret PBeltrán-Giner APlaza-Ramirez EBotella-Asunción C: Full endoscopic endonasal extreme far-medial approach: Eustachian tube transposition. J Neurosurg Pediatr 11:5845902013

    • Search Google Scholar
    • Export Citation
  • 15

    Taniguchi MAkutsu NMizukawa KKohta MKimura HKohmura E: Endoscopic endonasal translacerum approach to the inferior petrous apex. J Neurosurg 124:103210382016

    • Search Google Scholar
    • Export Citation
  • 16

    Tauber Mvan Loveren HRJallo GRomano AKeller JT: The enigmatic foramen lacerum. Neurosurgery 44:3863931999

  • 17

    Vaz-Guimaraes FNakassa ACIGardner PAWang EWSnyderman CHFernandez-Miranda JC: Endoscopic endonasal approach to the ventral jugular foramen: anatomical basis, technical considerations, and clinical series. Oper Neurosurg (Hagerstown) 13:4824912017

    • Search Google Scholar
    • Export Citation
  • 18

    Vescan ADSnyderman CHCarrau RLMintz AGardner PBranstetter B IV: Vidian canal: analysis and relationship to the internal carotid artery. Laryngoscope 117:133813422007

    • Search Google Scholar
    • Export Citation
  • 19

    Yasuda ACampero AMartins CRhoton AL Jrde Oliveira ERibas GC: Microsurgical anatomy and approaches to the cavernous sinus. Neurosurgery 62 (6 Suppl 3):124012632008

    • Search Google Scholar
    • Export Citation
  • 20

    Ziyal IMSalas EWright DCSekhar LN: The petrolingual ligament: the anatomy and surgical exposure of the posterolateral landmark of the cavernous sinus. Acta Neurochir (Wien) 140:2012051998

    • Search Google Scholar
    • Export Citation
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