Minimally Invasive Lateral Approach and Its Extension for the Craniocervical Region

Objective: A wide variety of craniocervical pathology traditionally has been treated from a midline posterior approach. However, it carries a risk of vascular problems and postoperative complications including CSF leakage, wound infection, and spinal instability. We describe concepts and surgical techniques of minimally invasive lateral approach. Methods: The location of the tumor, its area of attachment, and involvement of any vascular structures are noted and included in the decision-making process. The extent of drilling of the skull base and vertebral bone is not uniform and is tailored to the particular tumor or vascular lesion using the 3DCT for the preoperative simulation and the neuronavigation. The amount of the bone removal is decided based on the trajectory needed using an endoscopic assisted technique. The muscle dissection is preferably performed in anatomic layers. Results: Five high cervical neurinomas (intradural, extradural, and dumbbell type), three foramen magnum meningiomas, three high position carotid artery endarterectomies via retrojugular approach, three vertebral artery aneurysm (endoscopic-assisted clipping and trapping) were treated. Intradural jugular tuberclectomy is useful to remove the anterior part of bony eminence after the transcondylar fossa approach. The exposure was straightforward and provided relatively narrow but shallow operative field. Endoscopic assistance increased the anatomic exposure. There was no CSF leak, no infection, and no spinal instability associated with the initial surgery on follow-up. Conclusion: The selected craniocervical pathologies can be safely and effectively treated with minimally invasive techniques. Safe management of the vertebral artery and tailored surgical corridors after intrafascial muscle dissection are key considerations.