Extreme lateral transcondylar approach: technical improvements and lessons learned

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✓ An extreme lateral transcondylar or extreme lateral transfacetal surgical approach was used to treat 22 patients with complex lesions over a 22-month period. The lesions included basilar invagination with vertebral artery pathology, giant aneurysm or arteriovenous fistula of the vertebral artery, meningioma, chordoma, chondrosarcoma, and paraganglioma. The approach was used alone or in combination with a presigmoid petrosal or subtemporal-infratemporal approach. Refinements of the operative technique, treatment strategies for complex lesions, and the avoidance of complications are discussed.

Complications included cerebrospinal fluid leakage, meningitis, pseudomeningocele, hemiparesis or quadriparesis, lower cranial nerve deficits, and vertebral artery injury requiring repair. With treatment, major neurological deficits resolved completely in three patients and partially in two. There was no operative mortality, but four patients died during the follow-up period. For the 18 surviving patients, the mean preoperative and postoperative Karnofsky scores were 81 and 93, respectively. For the four who died, the mean preoperative Karnofsky score was 73 and the mean postoperative score was 63.

Article Information

Address for Dr. Babu: Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.Address reprint requests to: Laligam N. Sekhar, M.D., Department of Neurological Surgery, George Washington University Medical Center, 2150 Pennsylvania Avenue NW, Washington, DC 20037.

© AANS, except where prohibited by US copyright law.

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Figures

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    Photographs of anatomical dissections illustrating the finer points of the transcondylar approach, from the left side. The cadaver was placed in the right lateral decubitus position, and an ∩-shaped skin and subcutaneous tissue flap was used. Upper Left: The sternomastoid, semispinal, splenius capitis, and the levator scapulae muscles have been elevated from the occipital bone and mastoid process. The occipital artery, the transverse process of C-1, and the attached oblique and recti muscles are visible. Upper Right: The muscles have been detached from the C-1 vertebra laterally and reflected medially. The C-1 and C-2 nerve roots (C1, C2) and the extradural vertebral artery from C-2 upward are visible. The vertebral venous plexus has been removed. Lower Left: The vertebral artery has been unroofed from C-2 through the dural entrance point. A low mastoidectomy and a retrosigmoid craniectomy have been performed. The lateral third of the C-1 lamina has been removed. Lower Right: The extradural vertebral artery is reflected medially and the posterior third of the occipital condyle and lateral mass have been resected. The black thread marks the initial dural incision; the remaining incision encircles the vertebral artery (see also Fig. 2 upper right).

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    Photographs of anatomical dissections with the same specifications as Fig. 1. Upper Left: The dura has been opened with a small cuff left around the vertebral artery. The intra- and extradural portions of the hypoglossal nerve, the posterior inferior cerebellar artery, the partially resected occipital condyle, and the anterior spinal artery are shown. CN XII = 12th cranial nerve. Lower: Photograph showing the vertebrobasilar junction. Upper Right: Photograph demonstrating dural closure. Also visible are the partially resected occipital condyle, the extradural portion of the hypoglossal nerve, and the jugular bulb.

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    Case 22. Left: Magnetic resonance T1-weighted image, axial view, of the high cervical area showing a right vertebral arteriovenous fistula and dilated paravertebral veins. Right: Arteriogram showing the site of the fistula (arrow).

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    Case 12. Left: Vertebral arteriogram, lateral view, with the patient's neck in a neutral position, showing the hemicentrum of the C-4 vertebral body and the abnormal alignment of the neck. Center: Nonenhanced computerized tomography scan using a bone window showing the occipitalization of the atlas. Right: Vertebral angiogram revealing arterial occlusion with neck extension.

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    Case 13. Magnetic resonance images, nonenhanced sagittal view (A and B), nonenhanced axial view (C), and contrast-enhanced axial view (D), showing a large lower clivus/foramen magnum chordoma.

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    Case 13. Postoperative magnetic resonance images, axial (left) and sagittal (right) views, showing complete resection of the tumor.

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    Case 2. Upper: Computerized tomography scan with sagittal reconstruction of the cervicomedullary area showing basilar invagination. Lower: Vertebral angiogram showing severe stretching and narrowing of the contralateral vertebral artery and occlusion of the ipsilateral artery.

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    Case 2. Left: Arteriogram showing normal appearance of the vertebral artery after reconstruction. Right: Arteriogram demonstrating a pseudoaneurysm that developed from the artery beyond the site of anastomosis. The aneurysm could be trapped because the other artery had normalized in position and considerably enlarged in caliber.

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