The far-lateral craniotomy: tips and
                    tricks

This article intends to describe in a didactical and practical manner the suboccipital far-lateral craniotomy. This is then basically a descriptive text, divided according to the main stages involved in this procedure, and that describes with details how the authors currently perform this craniotomy.

neurosurgery; craniotomy; microsurgery; far-lateral approach

Authorship

Feres Chaddad Neto

Departamento de Neurocirurgia Vascular, Universidade Federal de São Paulo, Sao Paulo SP BrazilUniversidade Federal de São PauloBrazilSao Paulo, SP, BrazilDepartamento de Neurocirurgia Vascular, Universidade Federal de São Paulo, Sao Paulo SP Brazil

Laboratório de Microcirurgia, Instituto de Ciências Neurológicas, Hospital Real e Benemérita Sociedade Portuguesa de Beneficência, Sao Paulo SP, BrazilHospital Real e Benemérita Sociedade Portuguesa de BeneficênciaBrazilSao Paulo, SP, BrazilLaboratório de Microcirurgia, Instituto de Ciências Neurológicas, Hospital Real e Benemérita Sociedade Portuguesa de Beneficência, Sao Paulo SP, Brazil

Departamento de Neurocirurgia Vascular, Sociedade Brasileira de Neurocirurgia, Sao Paulo SP, BrazilDepartamento de Neurocirurgia VascularBrazilSao Paulo, SP, BrazilDepartamento de Neurocirurgia Vascular, Sociedade Brasileira de Neurocirurgia, Sao Paulo SP, Brazil

Hugo Leonardo Doria-Netto

Departamento de Neurocirurgia Vascular, Hospital Brigadeiro, Sao Paulo SP, BrazilHospital BrigadeiroBrazilSao Paulo, SP, BrazilDepartamento de Neurocirurgia Vascular, Hospital Brigadeiro, Sao Paulo SP, Brazil

José Maria de Campos Filho

Mateus Reghin Neto

Albert L Rothon Jr

Department of Neurosurgery, University of Florida, Gainesville USA, United States of AmericaUniversity of FloridaUnited States of AmericaGainesville, United States of AmericaDepartment of Neurosurgery, University of Florida, Gainesville USA, United States of America

Evandro de Oliveira

Departamento de Neurologia, Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Campinas SP, BrazilUniversidade Estadual de CampinasBrazilCampinas, SP, BrazilDepartamento de Neurologia, Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Campinas SP, Brazil

Correspondence: Hugo Leonardo Dória-Netto; Praça Amadeu Amaral, 27 - 5° andar; 01327-010 São Paulo SP, Brasil; E-mail: hldoria@hotmail.com

Conflict of interest: There is no conflict of interest to declare.

SCIMAGO INSTITUTIONS RANKINGS

Figures

Figures (10)

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Figure 1
Appropriate patient semi-sitting positioning in order to perform the far lateral approach. Note the headboard tilted up until maximum sixty degrees. The operative table main body in trendelenburg and legs elevated in order to place the knees semi-flected. The complete ninety degrees sitting position may be avoided once long time procedures on this position might cause sciatic and fibular nerves palsy. The articular body edges should be protected, specially the knees, hips, elbows and ankles. The legs are dressed with antithrombotic socks.

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Figure 2
(A) Cadaverous specimen in a posterior view showing the appropriate cutaneous incision mark. (B) the same cadaverous specimen, in a lateral view, showing the cutaneous incision mark.

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Figure 3
(A) After cutaneous incision, the scalp flap is reflected downward and medially showing the most superficial muscle layers formed by sternocleidomastoid, laterally, and trapezius muscle, medially. The trapezius attaches to the medial superior nuchal line and external occipital protuberance, as well as the spinous processes of cervical and thoracic vertebrae. Laterally it attaches to the shoulder on the scapula and the lateral third of clavicle, covering the semispinalis capitis. In this picture it is cut in order to show the occipital artery. The sternocleidomastoid source is the superior nuchal line and the mastoid process running downward and medially across the lateral aspect of neck until attaching to the clavicle and sternum. It covers partially the splenius capitis muscle. (B) The same picture in a closer view. Note that the trapezius muscle and sternocleidomastoid muscle cover the second muscle layer composed by the splenius capitis and semispinalis capitis muscles. (C) A lateral view of the former muscles. Note the muscle fibers distinct paths what helps to distinguish the muscles during the surgical dissection. Trapezius fibers are vertical. Sternocleidomastoid muscle fibers are diagonal going from superior to inferior and posterior to anterior.

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Figure 4
Detaching the trapezius and sternocleidomastoid muscles, as the most superficial muscle layer, we can find the second muscle layer composed by the semispinialis capitis muscle, medially, and the splenius capitis muscle, laterally. The semispinalis capitis has its source in between the superior and inferior nuchal lines, beginning in the midline, at the external occipital crest, and extending laterally to the occipitomastoid suture.

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Figure 5
Detaching the trapezius and splenius capitis muscle and reflecting then medially and inferiorly exposes the longissimus capitis muscle, the deep lamina of deep cervical fascia and the occipital artery. The longissimus capitis muscle is attached to the posterior edge of mastoid process, deeply to the splenius capitis and sternocleidomastoid muscles.

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Figure 6
Afterwards the detachment of longissimus muscle, we can find the lateral mastoid cleft with the digastric posterior belly inside, and the medial mastoid cleft, with the occipital artery inside. Under the longissimus and splenius capitis muscle, we can find superior and inferior oblique muscles.

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Figure 7
(A) The suboccipital triangle is composed by the rectus capitis posterior major muscle, above and medially, by the superior oblique muscle above and laterally, and by the inferior oblique muscle below and laterally. (B) Cadaverous specimen after the dissection and detachment of suboccipital triangle muscles, in order to show closely the neurovascular structures inside the triangle. We can find the terminal extradural vertebral artery, its muscle branches and first and second cervical neural root.

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Figure 8
Surgical picture showing all the anatomical structures after the muscular stage. Note the appropriate exposition of the external occipital protuberance, asterium, mastoid process, atlas posterior arch, C2 and the third segment of vertebral artery, as anatomical main points necessary to perform a complete far lateral approach.

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Figure 9
(A) Cadaverous specimen after retro-sigmoid craniotomy in order to perform the far lateral approach. Note the exposition of the whole sigmoid sinus, the vertebral artery, C1 and C2 dorsal roots, the hypoglossus condyle and with its posterior two thirds drilled and the hypoglossus nerve into the hypoglossal canal. (B) A closer view of the cadaverous specimen dissection performed while a far lateral approach is intended. Enphasys has been given to the vertebral entrance into the dura mater, the sigmoid sinus, the condyle with its posterior two thirds drilled in order to expose the hypoglossal canal and hypoglossus nerve and the posterior condylar emissary vein. This vein connects the external vertebral venous plexus to the sigmoid sinus. It is located, generally, at the inferior edge of the condyle.

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Figure 10
(A) The far lateral approach performed in a cadaverous specimen. After opening of the dura mater, we can find the cerebellar suboccipital face, vertebral artery and its extra and intradural segments, hypoglossus nerve, hypoglossal canal, C1 dorsal root, the spinal root of accessory nerve, sigmoid sinus and posterior condylar emissary vein. (B) The final result of the far lateral approach in a surgical picture. Note the relevant enlargement of the magnum foramen space obtained after drilling of the posterior two thirds of the occipital condyle. Note the vertebral artery and its extradural (V3) and intradural (V4) segments. Observe the dorsal roots of C1 and C2, the spinal root of accessory nerve and the cerebellar suboccipital face. At the lateral edge, we can find the sigmoid sinus and the dura mater reflected over it. This maneuver has been done in order to give pathway to cerebellum-pontine angle and cerebellum-medular cisterns as lateral as it is possible.

Figure 1 Appropriate patient semi-sitting positioning in order to perform the far lateral approach. Note the headboard tilted up until maximum sixty degrees. The operative table main body in trendelenburg and legs elevated in order to place the knees semi-flected. The complete ninety degrees sitting position may be avoided once long time procedures on this position might cause sciatic and fibular nerves palsy. The articular body edges should be protected, specially the knees, hips, elbows and ankles. The legs are dressed with antithrombotic socks.

Figure 2 (A) Cadaverous specimen in a posterior view showing the appropriate cutaneous incision mark. (B) the same cadaverous specimen, in a lateral view, showing the cutaneous incision mark.

Figure 3 (A) After cutaneous incision, the scalp flap is reflected downward and medially showing the most superficial muscle layers formed by sternocleidomastoid, laterally, and trapezius muscle, medially. The trapezius attaches to the medial superior nuchal line and external occipital protuberance, as well as the spinous processes of cervical and thoracic vertebrae. Laterally it attaches to the shoulder on the scapula and the lateral third of clavicle, covering the semispinalis capitis. In this picture it is cut in order to show the occipital artery. The sternocleidomastoid source is the superior nuchal line and the mastoid process running downward and medially across the lateral aspect of neck until attaching to the clavicle and sternum. It covers partially the splenius capitis muscle. (B) The same picture in a closer view. Note that the trapezius muscle and sternocleidomastoid muscle cover the second muscle layer composed by the splenius capitis and semispinalis capitis muscles. (C) A lateral view of the former muscles. Note the muscle fibers distinct paths what helps to distinguish the muscles during the surgical dissection. Trapezius fibers are vertical. Sternocleidomastoid muscle fibers are diagonal going from superior to inferior and posterior to anterior.

Figure 4 Detaching the trapezius and sternocleidomastoid muscles, as the most superficial muscle layer, we can find the second muscle layer composed by the semispinialis capitis muscle, medially, and the splenius capitis muscle, laterally. The semispinalis capitis has its source in between the superior and inferior nuchal lines, beginning in the midline, at the external occipital crest, and extending laterally to the occipitomastoid suture.

Figure 5 Detaching the trapezius and splenius capitis muscle and reflecting then medially and inferiorly exposes the longissimus capitis muscle, the deep lamina of deep cervical fascia and the occipital artery. The longissimus capitis muscle is attached to the posterior edge of mastoid process, deeply to the splenius capitis and sternocleidomastoid muscles.

Figure 6 Afterwards the detachment of longissimus muscle, we can find the lateral mastoid cleft with the digastric posterior belly inside, and the medial mastoid cleft, with the occipital artery inside. Under the longissimus and splenius capitis muscle, we can find superior and inferior oblique muscles.

Figure 7 (A) The suboccipital triangle is composed by the rectus capitis posterior major muscle, above and medially, by the superior oblique muscle above and laterally, and by the inferior oblique muscle below and laterally. (B) Cadaverous specimen after the dissection and detachment of suboccipital triangle muscles, in order to show closely the neurovascular structures inside the triangle. We can find the terminal extradural vertebral artery, its muscle branches and first and second cervical neural root.

Figure 8 Surgical picture showing all the anatomical structures after the muscular stage. Note the appropriate exposition of the external occipital protuberance, asterium, mastoid process, atlas posterior arch, C2 and the third segment of vertebral artery, as anatomical main points necessary to perform a complete far lateral approach.

Figure 9 (A) Cadaverous specimen after retro-sigmoid craniotomy in order to perform the far lateral approach. Note the exposition of the whole sigmoid sinus, the vertebral artery, C1 and C2 dorsal roots, the hypoglossus condyle and with its posterior two thirds drilled and the hypoglossus nerve into the hypoglossal canal. (B) A closer view of the cadaverous specimen dissection performed while a far lateral approach is intended. Enphasys has been given to the vertebral entrance into the dura mater, the sigmoid sinus, the condyle with its posterior two thirds drilled in order to expose the hypoglossal canal and hypoglossus nerve and the posterior condylar emissary vein. This vein connects the external vertebral venous plexus to the sigmoid sinus. It is located, generally, at the inferior edge of the condyle.

Figure 10 (A) The far lateral approach performed in a cadaverous specimen. After opening of the dura mater, we can find the cerebellar suboccipital face, vertebral artery and its extra and intradural segments, hypoglossus nerve, hypoglossal canal, C1 dorsal root, the spinal root of accessory nerve, sigmoid sinus and posterior condylar emissary vein. (B) The final result of the far lateral approach in a surgical picture. Note the relevant enlargement of the magnum foramen space obtained after drilling of the posterior two thirds of the occipital condyle. Note the vertebral artery and its extradural (V3) and intradural (V4) segments. Observe the dorsal roots of C1 and C2, the spinal root of accessory nerve and the cerebellar suboccipital face. At the lateral edge, we can find the sigmoid sinus and the dura mater reflected over it. This maneuver has been done in order to give pathway to cerebellum-pontine angle and cerebellum-medular cisterns as lateral as it is possible.

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The far-lateral craniotomy: tips and tricks

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[1] Correspondence: Hugo Leonardo Dória-Netto; Praça Amadeu Amaral, 27 - 5° andar; 01327-010 São Paulo SP, Brasil; E-mail: hldoria@hotmail.com