A Combined Far Lateral, Sublabyrinthine, Transpetrosal, Transcervical Approach to the Jugular Foramen, Anterior Brainstem, and Clivus

Introduction: A variety of lesions may occur in the jugular foramen, arising from the structures normally found within the jugular foramen or from contiguous structures. Surgical exposure is particularly difficult when these lesions present with extensive intra- and extracranial involvement. We describe a modified approach to this region that combines a presigmoid sublabyrinthine approach with a far lateral transcondylar exposure and upper cervical dissection. Material and Method: We performed a combined far lateral sublabyrinthine. Transpetrosal, transcervical exposure in 10 silicon-injected cadaveric heads (20 sides). An upper cervical dissection was performed exposing the jugular vein and surrounding structures up to the base of the skull. A presigmoid mastoidectomy was performed exposing the presigmoid posterior fossa and preserving the labyrinthine structures (sublabyrinthine). The exposure was completed by a far lateral suboccipital craniotomy with partial extradural resection of the condyle and hemilaminectomy of C1. After the dura was opened, the exposed surgical targets were evaluated with neuronavigational instruments. Results: Our anatomical evaluation confirmed that a far lateral exposure with extensive upper cervical dissection complete with conservative (functional sparing) petrous bone removal provides excellent exposure of the jugular foramen and surrounding intra- and extradural structures. Extradural resection of the occipital condyle improves exposure of the ventral aspect of the craniovertebral junction. Conclusion: A combined far lateral sublabyrinthine, transpetrosal, transcervical route that spares the function of the seventh and eighth cranial nerve complex is a valid alternative to more traditional approaches. It enables adequate exposure of the anterior brainstem and jugular foramen region without causing additional neurological deficits.