A Practical Manual For Skull Base Approach

SKULL BASE SURGERY SOCIETY OF INDIA
NEUROSURGERY ACADEMY PUBLICATION
A PRACTICAL MANUAL FOR

SKULL BASE APPROACHES
ESSENTIALS FOR ASPIRING NEUROSURGEONS
NEUROSURGERY ACADEMY AND RESEARCH FOUNDATION (NARF) INITIATIVE

A Practical Manual for
Skull Base Approaches

Essentials for Aspiring Neurosurgeons

Essentials for Aspiring Neurosurgeons
Editors
Kodeeswaran M
Roopesh Kumar
Lokanayaki V
Priyadharshan KP
Neurosurgery Academy and Research Foundation Initiative

Editors: Kodeeswaran M, Roopesh Kumar VR,
Lokanayaki V, Priyadharshan KP
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Authors
Raghavendran R
Director and Professor, Institute of Neurosurgery, Madras Medical College and
Rajiv Gandhi Government Hospital, Chennai, India
Manas Panigrahi
Professor and Head of the Department, Department of Neurosurgery, KIMS
Hospital, Secunderabad, Telangana, India
Roopesh Kumar VR
Director of Neurosurgery and Senior Consultant Neurosurgeon,
MGM Healthcare, Chennai, India
Sivashanmugam Dhandapani
Professor of Neurosurgery, PGIMER, Chandigarh, India
Dwarakanath Srinivas
Professor of Neurosurgery, Department of Neurosurgery, National Institute of
Mental Health and Neuro Sciences (NIMHANS), Bengaluru, India
Ranganathan Jothi
Director, Institute of Neurosciences, Kauvery Hospital, Vadapalani & Alwarpet,
Chennai, India
Kodeeswaran M
Neurosurgery Academy and Research Foundation,
Professor and Head of the Department, Department of Neurosurgery,
Government Kilpauk Medical College and Hospital, Chennai, India
Lokanayaki V
Professor of Anatomy, Government Kilpauk Medical College and Hospital,
Chennai, India
Anil Kumar Sharma

Associate Professor and Head of the Department, Department of Neurosurgery,
AIIMS, Raipur, India
Kiruba Shankar
Fellowship in Skull Base Surgery (AIIMS) Senior Consultant,
Department of ENT, Head and Neck Surgery, Apollo Hospital, Chennai, India
Priyadharshan KP
Assistant Professor of Neurosurgery, Neurosurgery Academy & Research
Foundation, Department of Neurosurgery, Government Kilpauk Medical
College and Hospital, Chennai, India
Rajesh Menon M
Consultant Neurosurgeon, MGM Heathcare, Chennai, India
Mohamed Samiullah
Assistant Professor in Anatomy, Government Kilpauk Medical College and
Hospital, Chennai, India
Sushant Sahoo
PGIMER, Chandigarh, India
Rijuneeta Gupta
Chiragkumar Patel
Department of Neurosurgery, KIMS Hospital, Secunderabad, Telangana, India
Pratikkumar Koradia
Department of Neurosurgery, KIMS Hospital, Secunderabad, Telangana, India
Naveen Kumar M
Neurosurgery Academy & Research Foundation, Department of Neurosurgery,
Government Kilpauk Medical College and Hospital, Chennai, India
Editors
Kodeeswaran M, MRCS, MCh (Neurosurgery)
Professor & Head of the Department,
Department of Neurosurgery,
Government Kilpauk Medical College, Chennai, India.
Roopesh Kumar VR, MCh (Neurosurgery)

Director of Neurosurgery and Senior Consultant Neurosurgeon
MGM Heathcare, Chennai, India
Lokanayaki V, DO, MS (Anatomy)

Professor & Head of the Department of Anatomy,
Government Kilpauk Medical College, Chennai, India
Priyadharshan KP, MBBS, MS, MCh, DrNB (Neurosurgery)

Asst. Professor,
Department of Neurosurgery,
Government Kilpauk Medical College, Chennai, India
Foreword
“Teaching transforms the art of skull
base surgery into a dynamic journey of
discovery and improvement, where each
lesson learned and shared propels the
field forward.”
With immense pleasure and pride, I
pen this foreword for “A Practical Manual
for Skull Base Approaches: Essentials for
Aspiring Neurosurgeons.” This compre-
hensive guide, published by the Skull Base
Surgery Society of India in collaboration with the Neurosurgery Acad-
emy and Research Foundation represents a significant milestone in the
education and training of neurosurgeons worldwide.
The field of skull base surgery has evolved tremendously over the
past few decades, transforming from a highly specialized niche into
a fundamental component of neurosurgical practice. Advancements
in technology, surgical techniques, and our deepening understand-
ing of the complex anatomy and pathology of the skull base region
have driven this evolution. In this context, a manual that distills the
vast body of knowledge and experience into a practical, accessible
format is not just beneficial but essential.
This book is a testament to the dedication and expertise of the
Skull Base Surgery Society of India and Neurosurgery Academy
and Research Foundation. For aspiring neurosurgeons, this manual
offers a treasure trove of information that is both profound and
practical. I am confident that this book will serve as an invaluable
resource for neurosurgeons at all stages of their careers, fostering
excellence and inspiring the next generation of leaders in our field.
I extend my heartfelt congratulations to the editors, authors, and
all those involved in the publication of this manual. Your collective
efforts have resulted in a work that will undoubtedly leave a lasting
impact on the neurosurgical community.
Prof. Dr. Ashish Suri,

President, Skull Base Society of India
Skull base surgery has evolved over the
years and has become a passion for young
neurosurgeons who want to master the tech-
niques involved. There has been a paradigm
shift in the concepts of skull base surgery
from being maximally invasive to mini-
mally invasive, considering the quality of
survival, not just survival itself. Neurosur-
geons should be cautious about the techniques they use and strive to
avoid complications.
The Skull Base Surgery Society of India will be entering its
25th year in 2024, having been established in 1999. The country’s
pioneers have continued to inspire the younger generation to learn
these techniques, and hands-on cadaveric programs are regularly
conducted as a measure.
In addition, the society, under the auspices of the Neurosurgery
Academy at Kilpauk Medical College headed by Dr. Kodeeswaran,
has gone a step ahead by creating a manual to instruct beginners in
the basic steps before starting the dissection. I am certain that this
manual, written by various renowned skull base surgeons, will be a
valuable resource for the youngsters, and I thank them all profusely
for their contributions.
Dr. Roopesh Kumar

Secretary
Skull Base Surgery Society of India
Prof. Dr. Kodeeswaran M.
Founder – Neurosurgery Academy and
Research Foundation
It is with great enthusiasm and a

deep sense of purpose that I present
“A Practical Manual for Skull Base
Approaches: Essentials for Aspiring
Neurosurgeons.” This manual is the
product of extensive collaboration,
meticulous research, and the shared
expertise of many dedicated profession-
als within the field of skull base surgery.
Our primary aim is to equip the next generation of neurosurgeons
with the knowledge, skills, and confidence needed to excel in this
complex and demanding specialty.
The skull base is a region of remarkable anatomical complexity
and surgical challenge, requiring a high degree of precision, a thor-
ough understanding of anatomy, and a mastery of advanced tech-
niques. This book is designed to bridge the gap between theoretical
knowledge and practical application, providing a comprehensive
and accessible guide to skull base approaches.
The contributors to this manual are among the most respected
experts in their fields, and their collective experience and insights
are what make this book an invaluable resource. Each chapter has
been carefully crafted to offer detailed, step-by-step guidance on
various skull base approaches, combining theoretical foundations
with practical tips and techniques.
This manual also reflects the core values of the Skull Base
Surgery Society of India and the Neurosurgery Academy and
Research Foundation: a commitment to excellence, innovation, and
education. We believe that teaching and mentoring are integral to the
advancement of neurosurgery, and this book is a testament to that
belief. By sharing our knowledge and experience, we hope to inspire
continuous learning and foster a spirit of collaboration within the
neurosurgical community.
I am profoundly grateful to the Skull Base Surgery Society of
India for their unwavering support and to all the contributors whose
expertise and dedication have made this manual possible. Special
thanks also go to the reviewers who provided valuable feedback and
ensured the high quality of the content.
It is my sincere hope that “A Practical Manual for Skull Base
Approaches: Essentials for Aspiring Neurosurgeons” will serve as
a trusted companion for all those dedicated to mastering the art and
science of skull base surgery. May it guide you, inspire you, and
contribute to your journey of continuous improvement and excel-
lence in this noble field.
Table of Contents
Chapter 1: Overview of Skull Base Approaches . . . . . . . . . . 1

Lokanayaki V, Mohamed Samiullah, Priyadharshan KP
Chapter 2: Endoscopic Transsphenoidal Approaches:

Trans-Sellar, Transtuberculum, Transclival
Approach to Skull Base Lesions. . . . . . . . . . . . . . 9
Kiruba Shankar, Roopesh Kumar VR
Chapter 3: Endonasal Trans-Pterygoid Approach. . . . . . . . 27

Sivashanmugam Dhandapani, Sushant Sahoo,
Rijuneeta Gupta
Chapter 4: Expanded Endoscopic Endonasal Approach to

Occipital Condyle: Step-wise Dissection . . . . . . 39
Chapter 5: The Supraorbital “Keyhole”

Approach (SOKHA). . . . . . . . . . . . . . . . . . . . . . . 45
Anil Kumar Sharma
Chapter 6: Operative Corridors in Pterional

Craniotomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Raghavendran R
Chapter 7: Fronto Temporal Orbito Zygomatic
Craniotomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Roopesh Kumar VR, Rajesh Menon M
Chapter 8: Posterior Petrosectomy, Combined Presigmoid

and Subtemporal Approach: Step-by-Step
Surgical Approach . . . . . . . . . . . . . . . . . . . . . . . . 85
Chapter 9: Retro-Sigmoid Sub-Occipital (RSSO) Approach:

The Workhorse of the Cerebello-Pontine
Angle Surgeries. . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Priyadharshan KP, Kodeeswaran M, Ranganathan Jothi,
Naveen Kumar M
Chapter 10: Far Lateral Approach . . . . . . . . . . . . . . . . . . . 107

Manas Panigrahi, Chiragkumar Patel,
Pratikkumar Koradia
1
Overview of Skull Base
Anatomy and Surgery
Lokanayaki V,1 Mohamed Samiullah,2
Priyadharshan KP3
Prof. of Anatomy, Government Kilpauk
1
Medical College and Hospital, Chennai, India

2
Assistant Professor in Anatomy, Government Kilpauk
3
Neurosurgery Academy & Research Foundation,
Department of Neurosurgery, Government Kilpauk
“A comprehensive grasp of anatomical details is paramount in skull

base surgery. This knowledge underpins precise navigation through
intricate structures, ensuring surgeons can safely and effectively
address pathologies in this challenging area of the human body”
Prof. Dr. Lokanayaki V.
Introduction
The skull base connects the cranium and face, housing vital neu-
rovascular structures through channels and foramina.1,2 The base
of the cranial cavity is divided into 3 distinct fossae; the floor of
the anterior cranial fossa is at the highest level and the floor of the
posterior fossa is at the lowest.3
A Practical Manual for Skull Base Approaches 2
The anterior cranial fossa is formed by the frontal, ethmoidal,

and sphenoid bones and supports the frontal lobes of cerebral
hemispheres. Its floor is composed of the orbital plate of the fron-
tal bones, the cribriform plate and crista galli of the ethmoid bone
and lesser wings, jugum sphenoidal and pre-chiasmatic sulcus of
the sphenoid. The medial end of the lesser wing of the sphenoid
bone constitutes the anterior clinoid process. Thicker posterior root,
also known as optic strut separates the optic canal from the superior
orbital fissure. Each optic canal transmits the optic nerve and the
ophthalmic artery.3
The posterior cranial fossa is formed by the sphenoid, temporal,
and occipital bones and contains the cerebellum, pons, and medulla
oblongata. The most prominent feature in the floor of the posterior
cranial fossa is the foramen magnum in the occipital bone. The
clivus is a sloping surface that extends from the sella turcica to the
foramen magnum and is formed successively by the dorsum sellae,
the posterior part of the body of the sphenoid, and the basilar part of
the occipital bone.3
Advanced imaging such as CT and MRI are crucial for locat-
ing and assessing skull base lesions. They provide detailed views
of both bone and soft tissue structures, aiding in surgical planning
and understanding various conditions.1,2 Understanding the vascular
anatomy, including the cavernous sinus and craniocervical junction,
is essential for safe surgical procedures and interventions.
Evolution of Skull Base Surgery

The evolution of skull base surgery has been marked by significant
milestones and advancements, transforming from its early begin-
nings to the sophisticated procedures of today.4 This evolution can
be categorized into several key phases:
Early Developments (Pre-1940s)
Skull base surgery began as a rudimentary practice with a limited

understanding of the complex anatomy and minimal surgical tools.
Surgeons primarily focused on managing traumatic injuries to the
skull base and addressing superficial lesions accessible through
simple approaches.
3 Overview of Skull Base Anatomy and Surgery
Introduction of Microsurgery and

Cranial Techniques (1940s–1970s)
The mid-20th century saw the introduction of microsurgical tech-
niques, which revolutionized the field of neurosurgery. These tech-
niques allowed for finer dissection and manipulation of delicate
neurovascular structures within the skull base. The development of
cranial approaches, such as the pterional approach, provided better
access to deeper structures, including the anterior and middle fossa.5
Emergence of Endoscopic and Minimally Invasive

Techniques (1980s–2000s)
The late 20th century witnessed the advent of endoscopic and

minimally invasive approaches in skull base surgery. Endoscopy
enabled surgeons to access lesions through natural openings,
reducing the need for extensive craniotomies and minimizing sur-
gical trauma. This approach not only improved patient recovery
times but also expanded the scope of operable pathologies, partic-
ularly in the anterior skull base.6
Integration of Imaging and Navigation

Technologies (2000s-Present)
Advancements in imaging modalities such as CT, MRI, and angi-

ography have played a pivotal role in preoperative planning and
intraoperative navigation. Three-dimensional imaging and neuro-
navigation systems allow surgeons to precisely localize lesions, plan
optimal surgical paths, and monitor real-time progress during proce-
dures. These technologies have significantly enhanced surgical accu-
racy, minimized complications, and improved patient outcomes.7
Multidisciplinary Collaboration and

Comprehensive Care
In recent years, skull base surgery has increasingly become a mul-

tidisciplinary endeavor involving neurosurgeons, otolaryngologists
(ENT specialists), radiologists, and other healthcare professionals.
This collaborative approach ensures comprehensive preoperative
evaluation, patient-specific treatment planning, and integrated post-
operative care, leading to enhanced overall patient management.8
The Base for Skull Base Surgery
FIGURE 1 Bony anatomy – Sagittal section showing anterior middle and posterior
cranial fossa.
FIGURE 2 Bony anatomy – image demonstrating important landmarks for

trans-cranial surgeries; large circle – pterion, small circle – asterion.
There exists a lot of literature on numerous corridors, to approach

skull base lesions, and their modifications – anterior, anterolateral,
lateral, posterolateral, posterior, endonasal, and transventricular
corridors. In the current practice, with the advent of advanced imag-
ing systems, it is possible to individually cater to the incision, the
approach, endoscopic/microscopic, etc.
Any surgical plan needs a knowledge foundation, upon which
one can build to address various lesions. This chapter provides a
step-by-step practical surgical manual for the approaches that serve

as stepping stones in skull base surgery. Below are the pictorial
depictions of the approaches dealt with in this manual.
FIGURE 3 Mid-sagittal section of the craniofacial bones depicting the midline

endonasal corridors: anterior extended (yellow), trans-sellar (green), and posterior
extended (red) approaches.
FIGURE 4 Axial section showing the midline endonasal corridors (blue), extended
condylar corridor (green), and the trans-pterygoid corridor (purple).
FIGURE 5 Axial section showing various transcranial corridors. Blue: Supra-or-

bital; Purple: Fronto-temporo-orbito-zygomatic; Red: Pterional; Green: sub-tempo-
ral; Yellow: Retro-Sigmoid Sub-Occipital; Orange: Far lateral.
Future Directions
Comprehensive anatomical knowledge and advanced technologies
are crucial for successful skull base surgery. Evolving techniques
and interdisciplinary collaboration continue to drive improve-
ments in patient outcomes and surgical precision. Looking ahead,
the future of skull base surgery is likely to continue advancing
with further refinement of minimally invasive techniques, incor-
poration of robotics, and continued improvements in imaging and
navigation technologies.
References
1. Abhijit, A., Raut., Prashant, S, Naphade., Ashish, J, Chawla.
(2012). Imaging of skull base: Pictorial essay. Indian Journal
of Radiology and Imaging, doi: 10.4103/0971-3026.111485
2. Bernadine, Quirk., Steven, Connor. (2019). Skull base imag-

ing, anatomy, pathology and protocols. Practical Neurology,
doi: 10.1136/PRACTNEUROL-2019-002383
3. Gray’s Anatomy, The Anatomical Basisof Clinical Practice,
international Edition 42nd edition, Editor in Chief Susan Stan-
dring, Elsevier, pp. 580–581.
4. Akio, Morita. (2022). [History of Skull Base Surgery].
No shinkei geka. Neurological surgery, doi: 10.11477/
mf.1436204580
5. Thomas, N., Pajewski., David, E., Traul. (2012). Skull Base
Surgery. doi: 10.1007/978 1-4614-0308-1_24
6. Paul, J., Donald. (1991). History of skull base surgery. Skull
Base Surgery, doi: 10.1055/S-2008-1056983
7. Spetzger, U. (2011). Moderne Schädelbasischirurgie aus Sicht
des Neurochirurgen. Hno, doi: 10.1007/S00106-011-2282-3
8. Terry, Y., Shibuya., William, B., Armstrong., Jack, A., Shohet.
(2003). Skull Base Surgery. doi: 10.1016/B978-012239990-
9/50025-4
2
Endoscopic Transsphenoidal
Approaches: Trans-Sellar,
Transtuberculum, Transclival
Approach to Skull Base
Lesions
Kiruba Shankar,1 Roopesh Kumar VR2
Fellowship in Skull Base Surgery (AIIMS)

1
Senior Consultant, Department of ENT, Head and Neck

Surgery, Apollo Hospital, Chennai, India
Mail ID: drkiruba_s@apollohospitals.com
ORCID ID: 0000-0003-3339-5291
2
Director of Neurosurgery and Senior Consultant
Neurosurgeon, MGM Healthcare,
Chennai, India
Mail ID: roops1975@gmail.com
Introduction
Endoscopic Skull base surgery has evolved into a standard of care
for lesions involving the central skull base. Its obvious benefits are
improved visualization, avoidance of brain retraction, the ability to
directly access tumors with minimal damage to critical neurosur-
gical structures, and lack of external scars. The skull base is at the
anatomical boundary between the two surgical disciplines of neu-
rosurgery and otolaryngology. Surgery in this region is challenging
for both disciplines. The results of the team approach across the
globe between otolaryngologists and neurosurgeons, in approach-

ing these lesions have been very encouraging in terms of sino-nasal
morbidity and patient outcomes.
With increasing experience in the endonasal approaches,
expanded endonasal approaches have been used to target lesions
in the ventral skull base both in the sagittal plane and the coronal
plane. The chapter outlines the relevant anatomy, step-by-step tech-
niques, and operative nuances for these approaches.
Surgical Anatomy of the Transsphenoidal

Approach
The Nasal cavity is a vascular region, essential for various functions
like humidification and conditioning of the inhaled air. The nasal
cavity also functions to facilitate drainage of the secretions from the
adjacent paranasal sinuses. It also captures the odor-bearing parti-
cles and transmits them to the olfactory recesses, which are in the
superior portion of the nasal cavity, just medial to the superior turbi-
nates (1). They are lined by ciliated columnar epithelium with con-
tinuing mucociliary clearance. Any surgery in this region may lead
to dysfunction of these systems and result in a symptomatic patient.
Nasal Vestibule
The nasal vestibule is the first area encountered as you move pos-
teriorly through the anterior nares, also known as the nostrils or
external nasal valve. The first half of the vestibule has a covering
of keratinized stratified squamous epithelium that contains coarse
hairs called vibrissae. These hairs filter inhaled particles. The cov-
ering of the second half of the vestibule is respiratory epithelium,
pseudostratified ciliated columnar epithelium (2).
Boundaries
• Lateral: lateral crus of the lower lateral cartilage (LLC) and fibro-
fatty alar tissue
• Medial: medial crus of the LLC and septal cartilage
• Posterior: limen naris
During the surgical exposure, the Endoscope is lodged against this
region lifting the ala to make space for instruments to operate in the
surgical corridor.
11 Endoscopic Transsphenoidal Approaches
Nasal Cavity
Septum
The nasal septum partitions the nasal cavity into two separate com-
partments. It is covered by squamous epithelium, which differs from
the lateral walls of the nasal cavity. A portion of the anterior septum,
the vomeronasal organ is covered with erectile tissue which may
have functions in sexual health. It is composed of
Membranous septum: anterior most part of septum.
Cartilaginous Septum
• Quadrangular (septal) cartilage: forms the cartilaginous sep-
tum. It contains the Kiesselbach plexus (see blood supply) (3,4).
Bony Septum
• Perpendicular Plate of the Ethmoid:
• Vomer: Located inferior and slightly posterior to the perpendic-
ular plate of the ethmoid. It is attached inferiorly to the nasal
crest of the maxilla and palatine bone.
• Nasal Crest of the Maxilla and Palatine Bone: Together
these bones form the inferior support for the septal cartilage.
• Anterior Nasal Spine of the Maxilla: This is a bony projec-
tion formed by the paired maxillary bones. It is located anterior
to the piriform aperture and is palpable at the superior portion
of the philtrum of the upper lip.
• Rostrum of Sphenoid bone: Contributes to the posterior part of
the nasal septum.
Lateral Wall of the Nose

Prominent Landmarks
• Inferior turbinate: Separate bone

• Middle Turbinate: part of the ethmoid bone
• Superior Turbinate: part of the ethmoid bone
Recess and Meatus
• Inferior meatus: drains Nasolacrimal duct

• Middle meatus: drains maxillary sinus, frontal sinus, anteri-
or ethmoidal sinus
• Superior meatus: drains posterior ethmoidal sinus

• Sphenoethmoidal recess: drains Sphenoid sinus
During the Trans-sphenoidal approach, the surgical Landmarks to

be identified are
• Nasal septum (NS) / inferior turbinate/nasopharynx (Co).

• Middle turbinate (MT)
• Superior turbinate (ST)
• Sphenoid ostium (SO) at the Spheno-ethmoidal recess (SER).
The sphenoid ostium leads us to the sphenoid sinus which is the

workspace. It also is the landmark for the septal branch of the sphe-
nopalatine artery which serves as the pedicle for the Naso-septal flap.
A wide sphenoidotomy gives adequate visualization and instru-
mentation of the sella.
FIGURE 1 Intranasal landmarks: MT middle turbinate; SER sphenoethmoidal

recess; NS nasal septum; SO sphenoidal ostium; ST superior turbinate.
Anatomy of Skull Base Approach

Skull base craniotomy: It is the bone window created in the skull
base to access the skull base lesion.
External corridor: the path traversed by the endoscope and instru-

ments before skull base craniotomy is called the external corridor.
Internal corridor: the path traversed by the endoscope and instru-

ments between skull base craniotomy and the lesion is called the
internal corridor.
FIGURE 2 Anatomy of skull base approach.
Corners of consternation: the areas where the lesion is close to

critical vessel/nerve and meticulous bimanual dissection is required.
Know your Sphenoid Bone

The sphenoid bone contains its body, the pterygoid process, and the
greater and lesser wings. Medially, the lesser wings form the roof of
the optic canal and are continuous with the sphenoid planum.
The Sphenoid body contains a sinus, the Sphenoid sinus, which
can be classified based on its pneumatization.
Based on sagittal Pneumatization: (5,6).
The sellar type of sphenoid sinus is further classified into three
types based on coronal Pneumatization: (7) (Figure 4).
FIGURE 3 Classification of the sphenoid sinus.

The posterior root of the anterior clinoid process, also called the
optic strut, separates the optic canals above from the superior orbital
fissure below.
The chiasmatic sulcus is located posterior to the planum. Poste-
riorly, the chiasmatic sulcus is separated from the sellar cavity by
the tuberculum sellae. Endonasally, the Prechiasmatic sulcus corre-
sponds to the limbus sphenoidale.
The lateral wall of the sphenoid sinus has impressions formed
by the optic nerve and the Carotid, which form the Medial Optico-
carotid recess leading to the middle clinoid process and the Lateral
Optico-carotid recess leading to the anterior clinoid, it’s also a land-
mark for superior orbital fissure.
The Pterygoid Process is separated from the body of the sphe-
noid bone by the pterygoid-sphenoid suture line. The pterygoid-
sphenoid suture along with the Vidian canal serves as the landmark
for the laceral carotid. The other landmarks in the pterygoid pro-
cess are the Foramen Rotundum which transmits the maxillary
division of the trigeminal nerve, the palato-vaginal canal, and the
Key landmarks
Sphenoidal septum
Carotid impression
Clival recess
Limbus sphenoidale
Sellar bulge
Medial optico-carotid
recess
Lateral optico-carotid
recess
FIGURE 5 Sphenoid bone.

FIGURE 6 On wide sphenoidotomy: Sella, clival recess, superior orbital fissure,

vidian canal, and foramen rotundum can be seen.
vomero-vaginal canal. The lateral extent of the sphenoidotomy is

the palato-vaginal canal on both sides. The inferior extent of the
sphenoidotomy is the floor of the sphenoid sinus.
Navigation in Skull Base Surgery
The navigation system is essential in skull base surgeries, especially

in revision surgeries where normal anatomical landmarks are dis-
torted. Various navigation system that are available are
Medtronic Stealth-station S8 Navigation system
Stryker Nav 3i Navigation system
Healforce Excelin 04 Navigation system

Synaptive Modus plan Navigation system
NDI Polaris Vega Navigation system
Brain lab Kick Em Navigation system
The imaging is done under navigation protocol, loaded onto the
system, and the patient is registered after positioning.
Plan Your Exit Before Entry

A surgical plan on the required exposure and the appropriate recon-
struction is essentially discussed and planned ideally before the surgery.
• The Reconstruction should ensure a water-tight seal/separation

from the Sino-nasal tract.
• The exposure should address all corners of consternation.
Ideal nasal reconstruction
1. Should separate sino-nasal cavity and intracranial contents

2. Should be airtight and water-tight.
3. Robust enough to support the intracranial contents
4. Thin and pliable during surgical manipulation
5. Should not impede nasal function.
6. Should be able to withstand/ survive postoperative adjuvant ther-
apy like chemotherapy/radiotherapy/ Proton therapy.
Work-horse Plan for Skull Base Reconstruction
Nasal Lining and Vascularity

Local Flaps
• Naso-septal flap
• Lateral nasal flap
• Posterior pedicled inferior turbinate flap.
• Middle turbinate flap
• Sphenoid mucosal flap
• Anterior ethmoidal flap
Regional Flaps
• Galeo-pericranial flap
• Tempero parietal flap
Structural Support
• Bone graft
• Cartilage graft
• Implants like Medpore*, polypropylene implants
• Biocompsites like Stimulan*, Acrylic bone cements.
Dural Lining
• Fascia Lata
• Temporalis fascia
• Duragen*
• ReDura*
Patient Preparation
The patient is placed under general anesthesia in reverse Trende-
lenburg position with head turned 30 degrees to the right side and
tilt of 15 degrees towards the left shoulder. An indwelling Foley
catheter, invasive blood pressure monitoring, prophylactic antibi-
otics, and deep vein thrombosis (DVT) prophylaxis are used. The
right thigh is prepared for harvesting fat and fascia lata graft to
repair the surgical defect. As per protocol, no perioperative lumbar
drainage is placed.
Step by Step to Sella Exposure

Nasal Stage (External Corridor)
Step 1. The inferior turbinates are identified and lateralized.

Step 2. The middle turbinate is identified, right middle turbinate
lateralization is done & left middle turbinate is preserved
and lateralized. The Right middle turbinate if bulky may be
resected to improve exposure.
Step 3. Nasospetal flap/rescue flap harvested
Step 4. Bilateral superior turbinectomy and bilateral posterior eth-
moidectomy is done.
Step 5. The sphenoid ostium is identified and widened. The lateral
extent of the widening is until the vomero-vaginal Canal.
Step 6. The rostrum of the sphenoid is identified and resected.
Step 7. The vomer bone is resected and wide sphenoidotomy is done.
Key to creating a wide external corridor

1. Posterior septectomy
2. Lateralization of middle turbinate
3. Superior turbinectomy
4. Posterior ethmoidectomy
5. Wide sphenoidotomy
Sphenoidal Stage
Step 1. The sellar impression is identified. The landmarks on the
sphenoid sinus are identified.
Step 2. Sphenoid septations is drilled and reduced.
Step 3. The sellar floor is drilled and the underlying dura is
exposed between the four blues:
• the cavernous sinuses on the lateral aspect on both sides.
• anteriorly the anterior intercavernous sinus.
• posteriorly the posterior intercavernous sinus
Step 4. The sphenoid sinus is irrigated with Betadine Solution
Sellar Stage
Step 1. The Sella Dura is identified and opened with the cruciate
incision.
Step 2. The Dura is separated from the underlying tumor capsule
with a plate dissector.
Step 3. Bits of tumor are taken for sampling.
Step 4. The capsule is carefully dissected from the surrounding
structures, and the normal gland is identified. The tumor is
internally decompressed by curettage and suction. The tumor
is allowed to descend and be cleared from diaphragma sellae.
Step 5. The resection cavity is inspected for Residual tissue, Cere-
brospinal fluid leak, or bleeding. Haemostasis is secured.
Reconstruction Stage
The defect is reconstructed with fat, fascia, and a nasal septal flap.
The nasal cavity is packed with merocel after securing hemo-
stasis. It is essential to support the diaphragm sellae with fat graft/
duragen even if there is no clinical CSF leak during the surgery.
Trans-Tuberculum Trans-planum Approach

These sellar approaches can be extended to manage lesions in the
Supra-Sellar space, ex—Craniopharyngioma, Tuberculum Sella
Meningioma, dermoids, etc.
Modifications at the nasal stage:
1. The External corridor has to be wide enough to accommodate

hemostatic equipment and suction with free mobility (at least
4 degrees of movement) at the corners of consternation.
2. The nasoseptal flap is created large enough to cover the entire
defect
Sphenoidal Stage
This approach requires a skull base window with exposure

extending from planum sphenoidale to the Sella. The drilling is
extended into the tuberculum sellae and the planum sphenoidale
if required. The landmarks identified are the Limbus and medial
optico-carotid recess. The middle clinoid on both sides is drilled
and removed.
Management of Anterior Intercavernous Sinus
After identifying the anterior intracavernous sinus (AICS), a hor-

izontal cut is placed above and below the sinus, and the AICS is
coagulated between the two dural leaflets.
Care is taken to identify Vascular structures like the ophthalmic
artery and ophthalmic segment of the carotid and Neural structures
that may be close to the lesions are the pituitary stalk; optic nerves
and chiasma. The tumor is delivered by carefully dissecting follow-
ing the arachnoid planes.
Reconstruction Stage
The reconstruction in the Transplanum approach must be robust
as the defect may communicate with CSF cisterns like supra
sellar/sub chiasmatic cistern or have direct communication with
the third ventricle. The inner lining is placed with a dural sub-
stitute. A Gasket type closure is done for structural support. The
nasoseptal flap is placed on to the repair. It is essential to avoid
curl/folding of the flap and ensure bone contact for the flap all
around.
Trans Sphenoidal Trans Clival Approach

The clivus is surgically divided into upper, mid, and lower clivus.
The upper clivus exposure requires pituitary displacement/
transposition (either intra-dural/extradural).
Step-by-Step Approach
The patient is placed under general anesthesia in reverse Trendelen-
burg position with head turned 30 degrees to the right side and tilt
of 15 degrees towards the left shoulder. An indwelling Foley cathe-
ter, invasive blood pressure monitoring, prophylactic antibiotics, and
deep vein thrombosis (DVT) prophylaxis are used. The right thigh is
prepared for harvesting fat and fascia lata graft to repair the surgical
defect. As per protocol, no perioperative lumbar drainage is placed.
First Step: Nasal Stage
After preparing the nose with decongestion solution applied topi-
cally, a nasoseptal flap is harvested based on the right sphenopal-
atine vessels. A large middle meatal antrostomy is performed, and
the flap is placed into a wide middle meatal antrostomy, preserving
it from the surgical corridor.
Step 2: Sphenoidal Stage
Wide Sphenoidotomy is done by enlarging the sphenoid ostium.

After wide sphenoidotomy, the sellar floor and clival recess are iden-
tified and the sphenoid floor between the vidian nerves is drilled.
The clival carotid is demarcated at mid-clivus. The Pterygoid plates
are drilled after transposing the pterygopalatine contents to increase
the exposure in the sagittal.
Step 3: Trans-Clival Exposure
The paraclival carotid artery on each side is skeletonized using the

vidian canal as the landmark. The bone of the mid-clivus and the
inferior clivus is drilled. The clival bone is drilled exposing the
underlying dura. The arch of the first cervical vertebra is identified
and drilled. The odontoid process is identified and drilled to provide
access to the lower clivus where the tumor had invaded. The clival
tumor is seen completely resected up to the dural of the clivus. Bone
wax is applied to control the Bone bleeding.
Step 4: Resection of Intradural Component if Present
If an intradural invasion is identified; the clival dural is opened

by endoscopic scissors. The tumor is then resected using standard
neurosurgical bimanual techniques. The tumor is internally

debulked and carefully dissected from the surrounding nerves,
vertebra-basilar complex, and brainstem. The involved dura is
resected. Hemostasis is achieved with warm saline irrigation and
bipolar cautery.
Step 5: Multilayer Reconstruction
The 3-dimensional Clival defect is reconstructed at the level of

the laceral tissue using the Fascia fat and nasoseptal flap. In these
cases, it is essential to avoid overzealous packing to avoid contact of
reconstructive tissue with the brain stem.
The first layer is an intradural layer of dural substitute overlap-
ping the edges of the resected dura, followed by an interlay fascia
lata as Gasket type seal with composite septal bone/cartilage graft,
and a third layer of overlay fat and fascia to fill the dead space. The
nasoseptal flap is placed as the fourth and final layer of reconstruc-
tion. The nasoseptal flap is positioned in contact with bone at the
periphery of the defect to promote good seal and revascularization.
The repair is then supported with gel foam, oxidized cellulose, and
a size 10 Foley catheter, followed by nasal packing.
Postoperative Follow-up
Immediate postoperative care: the patients are carefully monitored
for GCS, temperature pulse rate, and fluid balance. A perioperative
steroid cover is placed. Intravenous Ceftriaxone at a dose of 2 gm
intravenously is continued. In cases of Increased Urine output sug-

gestive of postoperative Diabetes insipidus, is managed with Vaso-
pressin injection.
The nasal packs are removed on the third postoperative day as
per protocol. The patient is carefully monitored for any postopera-
tive CSF leakage. Suction clearance of the nasal secretions is done
on day 3, day 7, day 14, and day 21. The patient is placed on nasal
douching and steroid nasal spray for 3 weeks postoperatively.
Conclusion
1. The trans-sphenoidal approach gives excellent midline exposure
in the ventral skull base.
2. Gasket-type closure is essential for large defects to prevent CSF
leakage
3. Pterygopalatine translocation preserves the flap pedicle and other
lateral nasal wall structures
4. Meticulous post-operative suction clearance and nasal washing
reduces sino-nasal morbidity
References
1. Sobiesk JL, Munakomi S. Anatomy, Head and Neck, Nasal Cavity. StatPearls.
Treasure Island (FL) ineligible companies. Disclosure: Sunil Munakomi
declares no relevant financial relationships with ineligible companies.2024.
2. Park J, Suhk J, Nguyen AH. Nasal Analysis and Anatomy: Anthropometric
Proportional Assessment in Asians-Aesthetic Balance from Forehead to Chin,
Part II. Semin Plast Surg. 2015;29(4):226–31.
3. Converse JM, Holmes EM, Huffman WC. The deviated nose and septum: a
panel discussion. Trans Am Acad Ophthalmol Otolaryngol. 1954;58(5):741–9.
4. Converse JM. The cartilaginous structures of the nose. Ann Otol Rhinol Laryn-
gol. 1955;64(1):220–9.
5. Sethi KS, Choudhary S, Ganesan PK, Sood N, Ramalingum WBS, Basil R,
et al. Sphenoid sinus anatomical variants and pathologies: pictorial essay. Neu-
roradiology. 2023;65(8):1187–203.
6. Anusha B, Baharudin A, Philip R, Harvinder S, Shaffie BM, Ramiza RR. Ana-
tomical variants of surgically important landmarks in the sphenoid sinus: a radio-
logic study in Southeast Asian patients. Surg Radiol Anat. 2015;37(10):1183–90.
7. Vaezi A, Cardenas E, Pinheiro-Neto C, Paluzzi A, Branstetter BFt, Gardner PA,
et al. Classification of sphenoid sinus pneumatization: relevance for endoscopic
skull base surgery. Laryngoscope. 2015;125(3):577–81.
3
Endonasal Trans-Pterygoid
Approach
Sivashanmugam Dhandapani, Sushant Sahoo,
Rijuneeta Gupta
Introduction
The Endonasal Endoscopic Trans-Pterygoid approach provides
direct access for lesions in the maxillary sinus, pterygopalatine
fossa, infratemporal fossa, lateral sphenoid recess, petrous apex,
lateral cavernous sinus, parasellar area, and Meckel’s cave.
A better understanding of the skull base anatomy and surgical
expertise allows visualization and protection of important neuro-
vascular structures, thereby reducing post-operative complications.
Pituitary tumors with cavernous or parasellar extensions, clival
tumors such as chordoma, chondrosarcoma, trigeminal schwan-
noma, and angiofibroma are the common tumors that necessitate an
endonasal endoscopic trans pterygoid approach.
Operative Steps
Nasal Phase
Standard decongestion of the nasal mucosa should be done. A vas-

cularised nasoseptal pedicle flap from the opposite side is raised
whenever a CSF leak is likely. Posterior septectomy may be carried
out for complex lesions requiring bi-nostril handling. The middle
turbinate on the ipsilateral side is resected. The sphenoid ostium is
widened with Kerrison rongeurs and high-speed drill. The rostrum
of the sphenoid is drilled flush with the clival recess. The posterior
ethmoid sinus on the ipsilateral side is opened, and the mucosa of
the sinus is peeled off gently.
FIGURE 1 Access Offered by Trans Pterygoid Approach
Defining the Pterygopalatine Fossa
A wide middle meatus antrostomy is made around the hiatus semilu-

naris between the uncinate process and bulla ethmoidalis to expose
the posterior wall of the maxillary sinus.
FIGURE 2 Right Middle Meatus Antrostomy

29 Endonasal Trans-Pterygoid Approach
Sometimes, it is necessary to remove the inferior turbinate and

complete resection of the medial wall of the maxillary sinus to obtain
adequate exposure of the posterior and posterolateral portions of
the sinus wall. The sphenopalatine artery is identified, coagulated,
and cut at the medial border of the maxillary sinus, and the sphe-
nopalatine foramen is defined. The sphenopalatine foramen is pres-
ent between the orbital and sphenoid processes of the palatine bone
posterior to the middle turbinate. The bone behind this foramen is
formed by the orbital process of the palatine bone. Enlarging the
sphenopalatine foramen with a Kerrison micro punch and exposing
the periosteum of the pterygopalatine, zygomatic, and infratemporal
fossae are essential steps. The mucosa over the posterior wall and
roof of the maxillary sinus is removed gently. The posterior wall of
the maxillary sinus forms the anterior wall of the pterygopalatine
fossa. The amount of posterior wall bone to be removed depends on
the location and extent of the lesion as determined by preoperative
image studies or by information from the image-guided system at
the time of surgery. Then, the orbital process of the palatine bone
with the posteromedial wall of the maxillary sinus is drilled. This
exposes the pterygopalatine fossa.
The branches of the Vidian nerve, pterygopalatine ganglion and
its branches, maxillary nerve and artery, and their branches are the
FIGURE 3 Endonasal View after Right Medial Maxillectomy

important structures in the pterygopalatine fossa. It is important

to try to preserve the integrity of the periosteum and to avoid fat
protrusion into the operative field. If fat does protrude, it can be
reduced by bipolar electrocoagulation, which is also used to control
any bleeding.
Expansion Through Trans Pterygoid Corridor
The pterygopalatine fossa can be divided into two compart-

ments. The anterior compartment has the vascular structures
and the neural structures placed posteriorly. Careful dissection
of the overlying fat reveals the neurovascular structures. The
mouth of the pterygoid (vidian) canal harboring the Vidian nerve
FIGURE 4 Illustration of Right Pterygopalatine Fossa

and the foramen rotundum with maxillary nerve (V2) enclosed

in this space are important landmarks that guide further expan-
sion of the trans pterygoid corridor. The contents of the ptery-
gopalatine fossa are retracted laterally, and the sphenoid process
of the orbital bone and the medial pterygoid plate is defined.
FIGURE 5 Exposure of Right Pterygopalatine Fossa
FIGURE 6 Exposure of Right Vidian Foramen

FIGURE 7 Exposure & Drilling of Right Vidian Canal
The medial and sometimes lateral pterygoid processes may be

drilled out along with a wide sphenoidotomy to access the lateral
and pterygoid regions of the sphenoid sinus. The inferior portion
of the medial pterygoid plate is drilled in a controlled manner to
identify the Vidian nerve.
This nerve passes through the pterygoid canal into the pterygo-
palatine fossa and is identified at the junction of the medial pter-
ygoid plate and the floor of the sphenoid sinus. The genu of the
petrous internal carotid artery lies in relation to the Vidian nerve. So,
the inferior and the medial portions of the Vidian canal can be drilled
safely. This access allows the treatment of lesions that involve the
cavernous sinus and are lateral to the paraclival ICA.
Approach to the Cavernous Sinus

Entry into the cavernous sinus can be antero-inferior, medial, or lat-
eral to the cavernous carotid artery. While the posterior and superior
compartments of the cavernous sinus can be accessed better through
the medial wall of the cavernous sinus, the inferior compartment is
best accessed antero-inferiorly, and the lateral compartment through
the lateral trans cavernous approach.
FIGURE 8 Exposure of Right Cavernous Sinus
FIGURE 9 Entry into the Right Cavernous Sinus

FIGURE 10 Exposure of Right Paraclival ICA
FIGURE 11 Exposure of CN III at the Roof of the Posterior Compartment of

Cavernous Sinus
FIGURE 12 Exposure of Right Cavernous Sinus Compartments & CN VI
Approach to the Meckel Cave Area
Entry into the Meckel cave requires removing the pterygoid process,
posterior wall of the maxillary sinus, and lateral pterygoid plate.
The infraorbital nerve can be traced up to the foramen rotundum,
and the maxillary nerve can be followed, entering the Meckel cave.
The “quadrangular space,” bounded medially by the vertical carotid
and laterally by the maxillary nerve, can be opened to expose the
Meckel cave further completely. This allows the removal of tumors
like trigeminal schwannoma.
Approach to the Infratemporal Fossa
The infratemporal access adds a medial endoscopic maxillectomy,

which includes sectioning of the nasolacrimal duct (a dacryocysto-
rhinostomy is needed afterwards). In this surgical access, we resect
the posterior wall and sometimes the lateral wall of the maxillary
sinus, particularly in situations with lateral expansion of the lesion.
The second division of the trigeminal nerve can be identified at the
superior margin of the pterygopalatine fossa, travelling laterally
and superiorly towards the inferior orbital fissure. Posteriorly, it can
be traced up to the foramen of rotundum. Further drilling laterally

through the pterygomaxillary fissure gives access to the infratempo-
ral fossa, pterygoid canal, foramen rotundum, and superior orbital
fissure. Complete drilling of the posterior and lateral walls of the
maxillary sinus provides direct access to the infratemporal fossa.
Here, the V2/maxillary nerve and the infraorbital fissure form an
important landmark, dividing this area into medial pterygopalatine
and lateral infratemporal fossae.
References
1. Cárdenas Ruiz-Valdepeñas E, Simal Julián JA, Pérez Prat G, Arraez MA,
Ambrosiani J, Martin Schrader I, Soto Moreno A, Kaen A. The Quadrangular
Space, Endonasal Access to the Meckel Cave: Technical Considerations and
Clinical Series. World Neurosurg. 2022 Jul;163:e124–e136.
2. Dhandapani S, Sahoo S, Gupta R. The 10 Ds of Expanded Endonasal Endos-
copy for a Giant Tuberculum Sella Meningioma. Neurol India. 2023 Sep–
Oct;71(5):893–897.
3. Dhandapani S, Singh H, Negm HM, Cohen S, Anand VK, Schwartz TH.
Cavernous Sinus Invasion in Pituitary Adenomas: Systematic Review and
Pooled Data Meta-Analysis of Radiologic Criteria and Comparison of Endo-
scopic and Microscopic Surgery. World Neurosurgery 2016;96:36–46.
4. Fernandez-Miranda JC, Zwagerman NT, Abhinav K, Lieber S, Wang EW,
Snyderman CH, Gardner PA. Cavernous sinus compartments from the endo-
scopic endonasal approach: anatomical considerations and surgical relevance to
adenoma surgery. J Neurosurg. 2018;129(2):430–41.
5. Hardesty DA, Montaser AS, Carrau RL, Prevedello DM. Limits of endoscopic
endonasal transpterygoid approach to cavernous sinus and Meckel’s cave. J
Neurosurg. Sci. 2018;62(3):332–8.
6. Hofstetter CP, Singh A, Anand VK, Kacker A, Schwartz TH. The endoscopic,
endonasal, transmaxillary transpterygoid approach to the pterygopalatine fossa,
infratemporal fossa, petrous apex, and the Meckel cave. J Neurosurg. 2010
Nov;113(5):967–74.
7. Kaen A, Cárdenas Ruiz-Valdepeñas E, Di Somma A, Esteban F, Márquez
Rivas J, Ambrosiani Fernandez J. Refining the anatomic boundaries of the
endoscopic endonasal transpterygoid approach: the “VELPPHA area” concept.
J Neurosurg. 2018 Sep 21;131(3):911–919.
8. Martinez-Perez R, Silveira-Bertazzo G, Carrau RL, Prevedello DM. The impor-
tance of landmarks in endoscopic endonasal reinterventions: the transpterygoid
transcavernous approach. Acta Neurochir (Wien). 2020 Apr;162(4):875–880.
9. Negm HM, Singh H, Dhandapani S, Cohen S, Anand VK, Schwartz TH. Land-
marks to Identify Petrous Apex Through Endonasal Approach Without Trans-
gression of Sinus. J Neurol Surg B Skull Base. 2018 Apr;79(2):156–160.
10. Ouyang T, Zhang N, Xie S, et al. Outcomes and Complications of Aggressive

Resection Strategy for Pituitary Adenomas in Knosp Grade 4 With Transsphe-
noidal Endoscopy. Front. Oncol. 2021;11:693063.
11. Patil NR, Dhandapani S, Sahoo SK, et al. Differential independent impact of the
intraoperative use of navigation and angled endoscopes on the surgical outcome
of endonasal endoscopy for pituitary tumors: a prospective study. Neurosurg
Rev. 2021;44(4):2291–8.
12. Schwartz TH, Fraser JF, Brown S, Tabaee A, Kacker A, Anand VK. Endoscopic
cranial base surgery: classification of operative approaches. Neurosurgery 2008;
62(5):991–1002; discussion–5.
13. Singh AK, Patel BK, Darshan HR, Anand B, Singh A, Biradar H, George T,
Easwer HV, Nair P. Endoscopic Transpterygoid Corridor for Petroclival Tumors:
Case Series and Technical Nuances. Neurol India. 2023 Nov–Dec;71(6):
1159–1166.
4
Expanded Endoscopic
Endonasal Approach to
Occipital Condyle:
Step-wise Dissection
Department of Neurosurgery, National Institute of

Mental Health and Neuro Sciences (NIMHANS),
Bengaluru, India
Step 1 Standard Dissection and Exposure of

Nasopharynx
A standard middle as well as inferior turbinectomy is done (in
cadavers). As shown in Figure 1 right middle as well as inferior
turbinate are removed. A vascularized nasoseptal flap is raised by
subperiosteal dissection of the Nasal septum. The bony and cartilag-
inous parts of the nasal septum are exposed. Posterior Nasal septos-
tomy is performed and the keel of vomer is exposed.
Step 2 Wide Sphenoidotomy Performed to

Visualize the Sphenoid Sinus
After exposing both the sphenoid ostia the Vomer bone is removed
and both the sphenoid ostia are widened with the Kerrison’s punch.
The rest of the vomer bone is removed by passing the drill through
the palatovaginal canal bilaterally, then drilling inferior and supe-
rior to the vomer, and fracturing it off laterally. Anterior wall of
sphenoid sinus is removed, and the mucosa of the sphenoid sinus is
FIGURE 1 (A) Endoscopic view of the right middle turbinate (MT). (B) Right
Middle turbinatectomy is done and subperiosteal nasal flap is raised. (C) Right Nasal
septal (NS) Flap is raised with keel of vomer (KOV) and Bilateral sphenoid Ostium
(SO) in the view.
FIGURE 2 (A) Shows the appearance of Sphenoid Sinus after removing anterior
wall of the Sphenoid sinus. The Mucosa over the Left half of the sphenoid sinus
is removed while it is yet to be removed from the right half of the sphenoid sinus.
S – Sella, SphSp – Sphenoid Septum, SphS – Sphenoid sinus, Mu – Mucosa of
Sphenoid Sinus. (B) Shows the sphenoid septum being drilled.SphSp – Sphenoid
Septum.
removed completely (Figure 2A). The Sphenoid septum is drilled

and removed with the Kerrison’s punch and all the structures in the
posterior wall of sphenoid sinus are exposed (Figure 2B). Sellar
prominence, bilateral Opticocarotid recess (Medial and Lateral
OCRs), Parasellar ICA and Cavernous ICA impression are visual-
ised (Figure 3).
41 Extended Occipital Condyle Approach
FIGURE 3 Sphenoid Sinus appearance after drilling the sphenoid Septum. PS –

Planum sphenoidale, TS – Tuberculum Sella, OC – Optic Canal impression, CP –
Carotid Prominence, LOCR – Lateral optico carotid recess, MOCR – Medial Optico
carotid Recess, PCS – Paraclival ICA, CR – Clival Recess.
FIGURE 4 (A) Shows the Incision being placed in the Nasopharynx.After expos-
ing the lower clivus and the rim of foramen Magnum the challenge is to reach the
Occipital condyle and the hypoglossal canal. As described previously the opening
of the Eustachian tube overlies the Hypoglossal canal. SphS – Sphenoid Sinus,
ET – Eustachian tube, Nph – Nasopharynx. (B) Drilling of the remaining part of
Vomer and the inferior clivus.
Step 3 Nasopharyngectomy and Resection of

Basopharyngeal Fascia
The mucosa of the nasopharynx is incised and removed
(Figure 4A). (The authors recommend incising and reflecting
the mucosa of the nasopharynx after making an inverted “U”
shaped flap and replacing it back after the surgery in the patients).
Under the mucosa, the longus capitis muscle is exposed. The

Fibres of the longus capitis muscle are removed with scissors and
Kerrison’s punch. The attachment of Basopharyngeal fascia is
incised at the pharyngeal tubercle. After removing the attachment
of Basopharyngeal fascia, the posterior pharyngeal wall with the
mucosa of nasopharynx, longus capitis and Basopharyngeal fascia
can be reflected inferiorly as a single layer and later be replaced
back after the surgery. As a result the posterior pharyngeal wall is
dissected and reflected away from the lower clivus upto the level
of foramen Magnum.
Step 4 Removing the Rest of the Vomer Bone

Drill the remaining vomer while exposing the sphenoid sinus and
exposure of the lower clivus in midline (Figure 4B).
Step 5 Identification of the Medial Pterygoid

(MP) Plate
To dissect further in the coronal plane, mobilisation/resection of
Eustachian tube is essential. So, the next step is the exposure and
identification of Medial pterygoid plate.
To expose the pterygoid plates endoscopic medial maxillectomy
is performed upto the caudal aspect of lateral nasal wall. By wid-
ening the maxillary ostium using the Kerrison’s punch the medial
wall of the maxilla is completely opened. On opening the maxil-
lary sinus, the mucosa of maxillary sinus is removed. With this, the
medial pterygoid plate is exposed.
At this point, Vidian Nerve can be seen at the most anterior part
of the vidian canal. The most anterior part of Vidian canal can be
seen in the medial part of posterior wall of pterygopalatine fossa
at the Junction for the lateral wall of sphenoid sinus and the medial
pterygoid plate (Figure 5).
Step 6 Transection of the Parapharyngeal

Muscles
After the medial pterygoid plate is exposed, the attachment of the
tensor veli palatini at the base of medial pterygoid plate is dissected.
43 Extended Occipital Condyle Approach
FIGURE 5 Shows the medial maxillectomy has been performed on the Left
side with vidian canal visible at the junction of medial pterygoid plate and lateral
wall of sphenoid sinus.ET – Eustachain Tube (Left), MP – Medial Pterygoid plate
(Left), P. Max – Posterior wall of the Maxillary sinus (Left), SphS – Sphenoid Sinus,
VC – Vidian Canal with Vidian Nerve coming out of its anterior opening.
FIGURE 6 (A) Shows the exposed bilateral occipital condyles after removal of
muscles in the posterior wall of nasopharynx and removal of the cartilaginous part
of bilateral Eustachian tube (as described earlier, ET lies anterior to the hypoglossal
canal). OC – Occpital condyle, Nph – Nasopharynx, LC – Lower Clivus. (B) Shows
the Right Occipital condyle (ROC), Anterior end of Hypoglossal canal (aHG) and
Supracondylar groove (SOG), (C) Shows the Right Occipital condyle (LOC),
Anterior end of Hypoglossal canal (aHG) and Supracondylar groove (SOG).
FIGURE 7 (A) Shows the Dilling of the anterior part of the Left occpital con-
dyle (OC). The cancellous bone in the occipital condyle is seen. The anterior end of
the left hypoglossal canal (aHG) can be seen at the lateral end of occipital condyle.
(B) Shows the Left hypoglossal nerve (HG nerve) which is visible clearly after drill-
ing of the anterior part of occipital condyle, till the hypoglossal canal. PdOC – Post
drilling of the Occipital condyle.
The Eustachian tube is then mobilised from this attachment at

the lower part of Foramen Lacerum. The cartilaginous part of the
Eustachian tube is excised and the rest of the soft tissue in front of
the occipital condyle is dissected.
Step 7 Exposing the Occipital Condyles and

the Hypoglossal Canal
After excision of the cartilaginous part of the eustachian tube, the
fibres of longus capitis muscle and parapharyngeal muscles the
occipital condyles are exposed on either side. The anterior arch
of atlas is seen and traced laterally. The Atlantooccipital joint is
exposed. The Supracondylar groove is exposed by removal of the
soft tissue above the occipital condyle (Figure 6).
Hence on removal of the soft tissue on the lateral end of supra
condylar groove the hypoglossal nerve is seen. Following this step,
the anterior part of the occipital condyle is drilled till hypoglossal
canal is exposed and the hypoglossal nerve is exposed (Figure 7).
5
The Supraorbital “Keyhole”
Approach (SOKHA)
Anil Kumar Sharma
Associate Professor and Head, Department of

Neurosurgery, AIIMS, Raipur, Indiai
With advanced diagnostic and surgical tools, such as magnetic res-

onance imaging (MRI), advanced microscopy, and high-definition
endoscopy, it is much easier and safer to approach deep skull base
lesions through small incisions and keyhole craniotomy. Transcili-
ary supraorbital craniotomy for such lesions has become increas-
ingly popular worldwide. The supraorbital “keyhole” approach is
less invasive but still efficacious though proper patient selection is
the key to achieving best possible patient outcomes.
Indications
Lesions located around the sellar region and central skull base are
suitable for the application of supraorbital keyhole approach. A wide
and diverse group of pathologies can be addressed including tumors
(meningiomas, craniopharyngiomas, pituitary adenomas, etc.) and
vascular abnormalities (e.g., aneurysms, arteriovenous malforma-
tions, and cavernous hemangiomas).
Surgical Steps and Description

1. Patient Positioning
The patient is placed supine on the operating table; the head
is fixed in a three-pin Mayfield holder and the neck is kept
in extension with the head above the heart level to facilitate
venous drainage during surgery. After that, the head is rotated
to the contralateral side, the degree of rotation dependent on
the precise location of the lesion (15 degrees for ipsilateral

sylvian fissure, 20 degrees for lateral suprasellar, 30 degrees
for anterior suprasellar, and 60 degrees for olfactory groove/
cribriform plate regions). This will allow the frontal lobe to fall
away from the anterior fossa floor, therefore minimizing the
amount of frontal lobe retraction (Figure 1).
2. Incision
The eyebrows are not shaved. Usually, skin incision is placed
lateral to the supraorbital foramen running within the eyebrow
and extending to the area of the frontozygomatic suture.The
Incision should not extend medial to the supraorbital nerve to
avoid frontal numbness (Figure 1).
A 3–4 cm skin incision is made within the eyebrow, and the
subcutaneous tissue and frontal fascia are cut. The skin flaps
are retracted temporarily with stitches achieving optimal
exposure of the occipito-frontal, orbicular, and temporal mus-
cles. After exposure, the frontalis muscle is cut sharply paral-
lel to the orbital rim after which dissection of the orbicularis
and the frontotemporal insertion of the temporalis muscle are
also completed.
FIGURE 1 Intraoperative position and planning incision

47 The Supraorbital “Keyhole” Approach (SOKHA)
FIGURE 2 After eyebrow skin incision, the subcutaneous tissue dissection, and
craniotomy is completed
3. Craniotomy and Surgical Procedure

A small portion of temporalis muscle and fascia at the superior
temporal line is bluntly dissected. A single burr hole is made
behind the frontal bone zygomatic process (keyhole position)
to create a bone flap of approximately 2.0 cm × 2.5 cm.
It is important to ensure a craniotomy at least 1.5–2 cm in
width which is paramount in the manipulation of micro-
instruments. It is also crucial to recognize a breach of the frontal
sinus, as this can be a source of CSF leak post-operatively if
not adequately addressed. We use bone wax to seal off any
small breach of the frontal sinus and betadine-soaked gel foam
to seal off larger defects.
Any osseous extension of the orbital roof can also be levelled
with the high-speed drill. This not only improves visualization
but also allows greater access to instruments during the surgi-
cal procedure (Figures 3A,B).
The dura is opened in a “C”-shaped fashion with the base at the
orbital rim and reflected inferiorly with a stitch (Figure 3C).
The microscope is brought into the field, the frontal lobe is
gently lifted with a cottonoid, and the CSF cisterns are opened
to allow CSF egress to facilitate brain relaxation (Figure 3D).
Following brain relaxation, the primary procedure may be
performed safely with no or minimal use of fixed retractors
on the brain. Intradural lesion is resected with standard micro-
surgical technique (Figure 4).
Wound closure is straightforward. A watertight dural closure
is important and the dural leaflets are reapproximated with a
FIGURE 3 (A, B) After removal of the bone flap, the inner edge of the bone should
be removed. Drilling of the inner edge of the supraorbital rim after removal of the
bone flap allows excellent intracranial visualization, easy introduction and manoeu-
vring of micro-instruments to the site Small osseous extensions of the orbital roof
should also be removed extradurally. (C) The dura is opened with the base at the
orbital rim and reflected inferiorly with a stitch. (D) The CSF cisterns are opened to
allow CSF egress to facilitate brain relaxation.
FIGURE 4 4Ds-Consecutive steps of meningioma surgery, devascularisation,

detachment, debulking and dissection.
4–0 prolene in a running fashion. The craniotomy bone flap

is replaced with a burr hole cover and two titanium square
plates to improve the cosmetic result by restoring the supra-
orbital ridge. The pericranium and muscle flap are then closed
primarily. Final closure of the skin layer is done with a run-

ning subcuticular stitch. Superior cosmetic results can be
achieved while still achieving surgical efficacy and limiting
complications.
Use of Endoscopy
Endoscopes have facilitated in overcoming one of the main limita-
tions of the keyhole approach: illumination. The use of a rigid endo-
scope along with the operative microscope can provide a synergistic
effect with the supraorbital craniotomy and often aided in maximiz-
ing resection. A “second look” with the endoscope can also improve
the gross total resection of tumors despite the smaller craniotomy
with better visualization (Figure 5).
Shortcomings of SOKHA Approach and

Their Solutions
Supraorbital keyhole approaches have been criticized for their
restricted surgical freedom, narrow corridors, blind spots, and asso-
ciated learning curve.
FIGURE 5 A “second look” with the endoscope can also improve the gross
total resection of tumor with better visualization and feasibility to look at notable
blind-spots.
FIGURE 6 Cosmetic outcome at 3 months follow up.
FIGURE 7 Pre-operative and post operative MR images of olfactory groove

meningioma.
1. Narrow surgical corridor

Drilling of orbital ridge osseus extensions and drainage of cis-
ternal CSF provides extra space and improves degree of surgi-
cal freedom.
The use of special keyhole-adapted micro-instruments could
solve these problems.
FIGURE 8 Pre-operative and post-operative images of Planum Sphenoidale

meningioma.
FIGURE 9 Pre-operative and post operative Contrast enhanced MR images of

large ACF base meningioma.
2. The problem of lighting with the operating microscope

Endoscopic-assisted surgery is a common adjunct and allows
for safer dissection with better visualization through this smaller
incision than can often be achieved with the microscope alone.
3. Large and lateral frontal sinus
Avoidance of the frontal sinus will lower the risk of CSF leak
or postoperative infection. The use of neuronavigation can
help to localise frontal sinus during craniotomy and breach of
the frontal sinus can be avoided. A lateral frontal sinus may
even preclude use of this approach.
Comparison of SOKHA and Extended

Endoscopic Endonasal Approach for
ACF Base Meningiomas
SOKHA Extended Endonasal

Endoscopic Approach
A wider view of the lateral extent of the Early devascularization of the
tumor. tumor.
Avoidance of trauma to the nasal passages Better visualization of the medial
optic canal.
More suitable for tumors with extension Removal of all involved bone at
lateral to the carotid artery or optic nerve the skull base
and for tumors with vascular encasement.
Avoidance of an infected field Less manipulation of
neurovascular structures
Conclusions
The supraorbital craniotomy and keyhole approach through the eye-
brow permit access to a variety of lesions in the subfrontal corridor
with minimal brain retraction. All minimally invasive techniques
have a steep learning curve, and smaller, simpler lesions should be
performed first through this technique before moving on to larger,
more complicated lesions. Endoscopy can play an important role
in improving visualization through the keyhole corridor. The ideal
approach for the patient should be selected taking into account the
tumor anatomy with special attention to size, lateral extension and
surgeon experience.
Highlights
• The goal of “keyhole” surgery – not to perform a small inci-
sion and craniotomy but to permit adequate access to skull base
lesions.
• Take time in the preoperative planning and positioning of patient.
• The skin incision is placed within an eyebrow for better cosmetic
outcome.
• Attention should be focused on protecting the supraorbital nerve
to avoid the risk of frontal numbness.
• We should avoid opening the frontal sinus while designing the

craniotomy. However, when this occurs, a proper repair is needed.
• After opening the dura mater, open the chiasmatic and carotid
artery cisterns to further release CSF, thereby, relaxing the fron-
tal lobe and providing an optimal trajectory towards the lesion.
References
1. Robinow ZM, Peterson C, Riestenberg R, Waldau B, Yu N, Shahlaie K.
Cosmetic Outcomes of Supraorbital Keyhole Craniotomy Via Eyebrow Inci-
sion: A Systematic Review and Meta-Analysis. J Neurol Surg B Skull Base.
2022 Sep 15;84(5):470–498. doi: 10.1055/s-0042-1755575. PMID: 37671300;
PMCID: PMC10477017
2. Lan Q, Sughrue M, Hopf NJ, Mori K, Park J, Andrade-Barazarte H,
Balamurugan M, Cenzato M, Broggi G, Kang D, Kikuta K, Zhao Y, Zhang H,
Irie S, Li Y, Liew BS, Kato Y. International expert consensus statement
about methods and indications for keyhole microneurosurgery from Inter-
national Society on Minimally Invasive Neurosurgery. Neurosurg Rev. 2021
Feb;44(1):1–17. doi: 10.1007/s10143-019-01188-z. Epub 2019 Nov 21. PMID:
31754934; PMCID: PMC7851006.
3. Ormond DR, Hadjipanayis CG. The Supraorbital Keyhole Craniotomy
through an Eyebrow Incision: Its Origins and Evolution. Minim Invasive Surg.
2013;2013:296469. doi: 10.1155/2013/296469. Epub 2013 Jul 10. PMID:
23936644; PMCID: PMC3723243.
4. Shahid AH, Butler D, Dyess G, Bassett M, Harris L, Hummel U, Chason D,
Thakur JD. Supraorbital keyhole approaches in the first 3 years of practice: out-
comes and lessons learned. Patient series. J Neurosurg Case Lessons. 2024 Mar
25;7(13):CASE23744. doi: 10.3171/CASE23744. PMID: 38531085; PMCID:
PMC10971074.
6
Operative Corridors in
Pterional Craniotomy
Raghavendran R
Director and Professor, Institute of

Neurosurgery, Madras Medical College and
Rajiv Gandhi Government Hospital, Chennai, India
Overview
The frontotemporal craniotomy described by George Heuer in
1914, was further modified by pioneering neurosurgeons like
Kiliani, Krause and Dandy. Drake reported the sub-temporal
approach in the 1970s. The present-day pterional craniotomy and
trans-sylvian exposure, which gives the most straight and short-
est route to the chiasmatic and Interpeduncular fossa region was
described by Yasargil in 1975. Sano in 1980, further extended his
temporopolar approach by retraction of the temporal pole. Heros
described the “half-half” approach, a combination of trans-sylvian
and sub-temporal approaches. Later De Oliveira described the
Pre-temporal approach, which essentially combined the Lateral sub
frontal, Trans-sylvian, sub-temporal and the Temporopolar corri-
dors to the same region. The pterional craniotomy presents us with
many corridors and avenues, which can be selected as per the needs
of the surgical pathology. The basic dictum of maximal exposure
with minimal or no brain retraction, can be achieved by careful
selection of appropriate operative corridors
This approach is most suitable and provides safe and wide
access to aneurysms of anterior circulation, lesions of the ante-
rior and middle cranial base, sellar and suprasellar regions, mid
Basilar trunk up to its bifurcation, Proximal PCA, Proximal SCA
and tumours of Clival, Petroclival, Sphenopetroclival region, and

tumours traversing and involving the tentorial hiatus anterior and
anterolateral to the Brainstem. Optic chiasm and optic nerve, ICA,
ICA bifurcation, PCOM, oculomotor nerve and other critical neural
structures usually traverse between the surgeon and the lesion. Care-
ful selection, dissection and availability of multiple corridors and
the scope to further widen access through these corridors make it a
valuable, safe approach. Gravity facilitates safe falling away of the
frontal and temporal lobes, and egress of CSF by sequential opening
of the basal cisterns results in minimal or no brain retraction to get
the necessary wide access. The absence of major veins or venous
sinii is an added advantage of this approach.
Optic chiasm and optic nerve, ICA, ICA bifurcation, PCOM, ocu-
lomotor nerve, trochlear nerve, abducent nerve and other structures
are usually encountered in this approach and care must be taken to
avoid injury to these vital structures. Careful arachnoid dissection
along with an expectant look to protect these structures is important.
Injury to these structures while dissection is a major disadvantage of
this approach. Surgeon proposing to stop surgery when it is not too
late, cannot be over emphasised.
Approaches and Corridors

The standard pterional craniotomy can be further extended by
drilling away at selected bony structures and osteotomies, which
can provide wider access with lesser brain retraction like orbito-
zygomatic osteotomy, anterior and posterior clinoidectomy, etc…
The usual tracks available are the medial and lateral sub-frontal,
trans-sylvian, pre-temporal, temporo-polar and the anterior and pos-
terior sub-temporal. The above approaches can be used alone or can
be combined as per the needs. Once we expose the olfactory tract
and the optic Nerve sequentially, there are several corridors or trian-
gles between the vital neurovascular structures to reach the deeper
structures. These are essentially the corridor between both the optic
nerves, between the optic nerve and the ICA, between the ICA and
the III nerve, between the III Nerve and the tentorial edge and also
the space posterior to the optic Chiasm (retro chiasmatic).
57 Operative Corridors in Pterional Craniotomy
Major triangles. Optico carotid triangle (1), Carotid oculomotor triangle (2) and
supra carotid triangle (3). II is optic nerve, III is oculomotor nerve. ICA is internal
carotid artery, M1 is M1 segment of middle cerebral artery and A1 is A1 segment of
anterior cerebral artery.
Picture courtesy: Aakrithya Natchatra. R
The triangle between the ICA medially and the III nerve laterally. Careful dissection
will expose the vital structures and the basilar top. BA is basilar artery, comprehen-
sive is posterior communicating artery and T is tentorial edge.
Picture courtesy: Aadhitya Hirudhaya. R
The corridor medial and lateral to III nerve. High riding basilar aneurysms are seen
medial to III nerve. Low riding basilar aneurysms are seen lateral to III nerve and
medial to Tentorial edge. An is aneurysm.
Picture courtesy: Aadhitya Hirudhaya. R
Surgical Steps
1. Supine position with the head end of the table elevated to
30 degrees. The head is fixed with the 3-pin system and rotated
slightly to the opposite side by around 20 degrees. Neck exten-
sion is given such that on splitting the sylvian fissure the frontal
and temporal lobes along with the temporal pole fall away from
each other by gravity. Care should be taken during positioning
so as not to kink the major veins of the neck. Malar eminence
is placed as the topmost point.
2. A curvilinear incision is marked from the zygoma root to the
junction of the midline within the hairline. I prefer a free bone
flap. Bone removal is extended as needed. Durotomy is done
with the base to sylvian fissure. I do not use the lumbar CSF
drainage. Initially I use the medial sub frontal route to locate
the olfactory tract and the optic nerve. Then, I open the basal
cisterns sequentially and later proceed in the direction of the
selected corridor. Sylvian fissure is widely opened. Internal

carotid artery kinking must be avoided and flow in the vessel
must be maintained.
Surgical Steps
Case 1
1. (1) Optic nerve, (2) Optic chiasm. (3) Internal carotid artery
(4) Retro chiasmatic space arachnoid. Arachnoid dissection is
done gradually develops the space. The interface between the
cranial nerves and the lesion is handled via sharp arachnoid
dissection, at the same time preserving the arachnoid mem-
brane of the respective structures to avoid damage.
2. Sharp arachnoid dissection is done and the retro chiasmatic

space (4) is developed.
3. Sharp arachnoid dissection is done and the retro chias-

matic space is developed and the tumor (6) is exposed
and internal tumor debulking was done.
4. Sharp arachnoid dissection is done, the retro chiasmatic space

is developed and the tumor (6) is exposed, internal tumor
debulking is done and the tumor is mobilized into the space.
Tumour capsule is (6) dissected, mobilised and carefully excised.

After complete excision, the posterior arachnoid plane is left

intact. The A1 segment is seen. The dissection is done in the retro-
chiamatic space anterior to the A1 and ACOM complex.
Surgical Steps
Case 2
This was a case of ruptured basilar trunk aneurysm. The approach

was pterional trans sylvian combined with temporopolar.
The corridor selected was lateral to III nerve (3) and medial to ten-
torial edge (T). The basilar top and bifurcation were seen medial to
the III Nerve. The basilar trunk (B) is faintly seen through the CSF
filled cistern.
The III nerve (3) is seen with the arachnoid covering. Laterally
the basilar trunk (B) is seen and a small calibre superior cerebellar
artery (S) is seen arising from the basilar artery. An aberrant loop of
artery (A) was protruding from the posterior fossa, which was later
identified to be a large calibre anterior inferior cerebellar artery. A
fluffy sub-arachnoid bleed (SAH) is seen around the basilar.
Careful sharp dissection after fluffy SAH was removed, exposes the
aneurysm (A) arising from the basilar trunk (B). The neck of the
aneurysm (N) was delineated with care. The site of dome rupture
(R) was seen.
A permanent clip is applied at the neck of the aneurysm.

Surgical Steps
Case 3
This was a case of ruptured basilar top aneurysm. The approach was
right pterional trans sylvian. The corridor selected was between the
III nerve laterally and the ICA medially.
The Sylvian fissure is opened widely. Cisterns opened sequentially.

Sharp dissection was done. The optic nerve (2), ICA (I), the ICA
bifurcation into A 1 segment (A) and the M1 segment (M). The Lil-
liquist membrane (L) was opened. The III nerve (3) is seen laterally.
Careful dissection exposed the basilar artery (B), its bifurcation and the
ipsilateral Posterior Cerebral artery (P). A temporary clip was applied.
Temporary clip (T) and the basilar top aneurysm (A) are seen along
with the perforators (P).
The basilar top aneurysm clipped. The optic nerve (II), ICA, A1,
M1, basilar artery (B), clip (C), oculomotor nerve (III) and ipsilat-
eral PCA (P1) are seen.
Complication Avoidance
Supple Brain
After durotomy, opening sequentially the basal cisterns is done and

most importantly adequate time is spent for the CSF to egress. Care
should be applied to look for venous channels and the sylvian veins
from the brain into the skull base and all efforts should be made to
preserve them by doing parallel arachnoid dissection. The patient
should be positioned such that the frontal and temporal lobes along
with the temporal pole fall away from each other facilitated by grav-
ity, rather than retraction. Laxity of brain is of utmost importance.
Constant interaction with neuro-anaesthetists is done.
Arteries and Veins
Avoid kinking, undue traction or tear of arteries and veins, which

will compromise blood supply and venous drainage of the brain. It
is safe to do extended arachnoid dissection along the arteries and
veins to prevent traction and kinking, especially a complete opening
of the sylvian fissure should be done. Sharp dissection is preferable.
In case of vascular injury, in most occasions haemostasis can be
achieved with either a combination of properly constituted liquid
haemostatic material adequately, placement of gel foam and surgi-
cel or any one of the above alone. Coagulation of any vessel should
be the last resort. In essence every perforator and vascular twig from
all arteries and every tributary of veins should be preserved. Tear,
direct injury or avulsion of branches from a major vessel can cause
devastating damage and may result in an unsalvageable situation
and should be avoided by exercising patience.
Cranial Nerves
Cranial nerves I, II, III and IV are often encountered in this approach.
Olfactory tract and optic nerve when in their usual anatomical loca-
tions are easy to identify. Trochlear nerve is easily prone to damage
resulting in deficit, but at the same time recovery is usually good
and also does not produce major issues for the patients. Oculomotor
injury usually produces ptosis and extra ocular movement deficits
which can be profoundly disturbing to patients. Usually, oculomo-
tor apraxia recovers to a reasonable extent but can be a permanent
deficit also. An expectant approach towards locating these displaced

nerves and preserving them is needed.
Duroplasty
All necessary measures should be undertaken to prevent CSF leak

in the post-operative period. Bony margins should be adequately
waxed. Water tight dural closure with a graft if needed should be
done in all cases. Adequate measures should be taken to prevent
pneumocephalus.
Wisdom
• Go through the relevant literature before, the day of surgery.
• Aim of the surgery, registering the relevant three-dimensional
anatomy should be in our mind. Proper planning and method-
ology of safely executing the plan, complication avoidance and
measures to tackle complications if they occur should all be
discussed among the surgical team. Points at which the surgery
needs to be stopped should also be kept in mind before anaesthe-
sia induction of the patient. Availability and working condition
of all necessary equipment should be checked personally before
induction.
• Proper positioning of the patient as per the pre-operative plan
should be done without any compromise. As much as possible,
patient’s position should facilitate gravity assisted retraction.
Secure fixation of the 3-point fixator should be ensured.
• Neck extension and turning of head to the opposite side should
not cause kinking
• Osteoplastic bone flap will maintain the vascularity of the raised
bone flap. A major advantage of osteoplastic bone flap is har-
vesting the temporalis fascia for duroplasty. It avoids usage of
synthetic material as well as avoids another incision and scar for
harvesting fascia Lata. Bone flap elevation should be done with
care to avoid accidental tearing of duramater, especially in ex-
tremes of age, where duramater is usually adherent to the inner
table of bone flap.
• Dural tacking stitches are done all around, before durotomy.
It avoids extradural ooze which is usually seen when the brain
becomes lax.
• Dura is preferably opened with its base to the sylvian fissure in a

curvilinear fashion and is tacked with sutures to prevent it from
coming into the visual field of the microscope. Dural cross cuts
are provided such that the gravity facilitated fall away of frontal
and temporal lobes and temporal pole is unimpeded, and at the
same time holds the brain from falling away too much and pro-
ducing traction injury to underlying structures.
• Brain is gently and gradually mobilised and the olfactory tract and
optic nerve with its arachnoid covering are identified. Sequential
opening of the basal cisterns is done. Patiently wait for the brain
to become lax and supple. Then carefully do a complete sylvian
split to widely open it. Oculomotor nerve and the tentorium are
identified. Trochlear nerve is identified and secured before divi-
sion of tentorium is attempted.
• Continuous warm saline or Ringer Lactate irrigation is done
throughout the procedure to prevent vasoconstriction and
vasospasm of the vessels and also to prevent brain from
becoming dry.
• Meticulous closure of every tissue layer up to the skin is
mandatory.
Suggested Readings
1. Behari S, Rupant K Das, Awadhesh K Jaiswal,Vijendra K Jain. Fronto-temporo-
orbitozygomatic craniotomy and “half and half” approach for basilar apex aneu-
rysm. Neurology India, 2009,57:4;438–446.
2. Thomas A Kopitnik, H Hunt Batjer, Duke S Samson. Combined transylvian-
subtemporal exposure of cerebral aneurysms involving the basilar apex. Micro-
surgery, 1994,15:534–540.
3. Rice BJ, Peerless SJ, Drake CG. Surgical treatment of unruptured aneurysms of
posterior circulation. J Neurosurgery 1990,73:165–173.
7
Fronto Temporal Orbito
Zygomatic Craniotomy
Roopesh Kumar VR,1 Rajesh Menon M2
1
Director of Neurosurgery and Senior Consultant
Neurosurgeon, MGM Heathcare, Chennai, India
2
Consultant Neurosurgeon, MGM Heathcare,
Chennai, India
Introduction
The Fronto-temporal-orbito-zygomatic (FTOZ) approach is one of
the most versatile neurosurgical approaches for skull base lesions.
Even though originally described by Jane et al., in 1982, it was
popularized by Pellerin et al. (1984) and Hakuba et al. (1986) to
access lesions with limited retraction of the brain over parasellar and
interpeduncular regions. However, the approach has undergone var-
ious modifications ever since both technically and indication-wise
to suit individual needs.
It is an extension of the fronto-temporal approach with the addi-
tion of orbitozygomatic osteotomy through various sections of the
superiorolateral orbit and zygoma. This will allow wider exposure
of the subfrontal trajectory minimizing the need for retraction
when approaching anterior and middle skull base and upper retro-
clival regions.
It is a preferred approach for accessing lesions involving the
orbital apex, parasellar and para clinoid areas, tuberculum sella,
spheno orbital region, basilar apex, cavernous sinus, anterior and
middle fossa floor, paraclival, Meckel’s cave area, inter peduncular
cisterns and ventral brainstem.
Anatomical Considerations
A proper understanding of the skull, orbit, zygoma, other facial
bones and surrounding soft tissue layers is essential to carefully nav-
igate through the areas of exposure provided by the FTOZ approach.
The areas of exposure can be divided into various parts like antero-
lateral, intraorbital, and intracranial.
In the anterolateral region, one of the first bony landmarks

encountered is the frontozygomatic suture. The frontozygomatic
suture can be followed medially to identify the junction of the fron-
tozygomatic, sphenofrontal, and sphenozygomatic sutures. This
three-suture junction will be important for accurately placing the
MacCarty keyhole.
In addition, the sutures can be used to identify intraorbital land-
marks during the osteotomy like the inferior orbital fissure (IOF)
and superior orbital fissure (SOF). If the sphenozygomatic suture is
followed inferiorly from the three-suture junction we can reach the
IOF. Similarly, the frontozygomatic suture can be followed medially
73 Fronto Temporal Orbito Zygomatic Craniotomy
from an intraorbital perspective to reach the superolateral portion of

the SOF. The IOF can also be visualized extracranially through the
superior and medial portions of the infratemporal fossa.
The zygomaticofacial foramen is the anteroinferior limit of the
FTOZ osteotomy. This serves as a landmark for the cut across the
zygoma and to the lateral aspect of IOF. It is located on the lateral
surface of the zygomatic bone close to the orbital rim and transmits
the zygomaticofacial nerve, a branch of the maxillary nerve (V2).
However, this landmark may not be constant and may present as
multiple foramina.
When dissecting the zygoma, utmost care should be taken to
avoid injuring a branch of the superficial temporal artery, called
Transverse facial artery which courses laterally to the zygomatic
arch and then anteriorly to rim of orbit.
Diagrammatic representation of the extent of craniotomy in rela-

tion to bony structures nearby. The temporal, sphenoid wing and the
orbital bones may be additionally removed to expand the craniotomy
as required. (Blue, green and pink markings in the above picture.)
Steps in Ftoz Craniotomy

Patient Positioning
The patient is in supine position with the head secured to a Mayfield

three-point skull clamp. The trunk is elevated 20° to optimize
venous outflow. The head is translated 30° and extended 20° so that
the malar eminence is the highest point. The head is rotated to the
contralateral side ranges between 10° and 45° depending on area of
interest.
Schematic representation of the position of the head with tilt for

right FTOZ craniotomy. Head fixed on a 3-pin head clamp. Hair
need not be shaven completely.
Skin Incision and Soft-Tissue Dissection

The skin incision is made in a curvilinear fashion from 1 cm anterior
to the tragus to the opposite side midpupillary line behind the hair
line for cosmetic purposes. A receding hairline might require a full
bicoronal incision. See the picture below.
The skin flap is then reflected forward. Then the galea and peri-
osteum are incised together and reflected anteriorly. This galea-
pericranium vascularized flap can be used for reconstruction in the
case of the frontal sinus breech. Alternatively, pericranium can be
raised separately on either side of superior temporal line after rais-
ing skin flap along with galea. Then superficial and deep layers of
the superficial temporal fascia are incised together, 2.5 cm behind
the frontozygomatic suture and 2 cm below the superior temporal

line with temporalis muscle, leaving a myofascial cuff for recon-
struction. The temporalis muscle is exposed taking care not to
damage the posterior branch of the Superficial temporal artery and
zygomatic branch of the facial nerve. The cut is then taken poste-
riorly until the zygomatic process of the temporal bone is reached.
Subperiosteal detachment of the muscle can be carried out by adopt-
ing the Oikawa technique. Electrocauterization is ideally avoided
to preserve the blood supply and to prevent postoperative atrophy.
The periorbita is then dissected from the orbit for a depth of 3 cm
to visualize the lateral aspect of the superior orbital fissure (SOF).
Identification of Bony Landmarks
The supraorbital foramen and the supraorbital nerve are exposed

which grossly corresponds to the lateralmost limit of the air frontal
sinus. Identification of the coronal, sphenofrontal, sphenoparietal,
sphenosquamosal, and sphenozygomatic suture is then made and the
meeting point of these sutures forms the pterion. This also identifies
the lateral third of the greater sphenoid wing. The uppermost point
of the sphenosquamosal suture coincides with the superior limit of
the sphenoid wing and SOF. The sphenozygomatic suture labels the
midpoint of the lateral wall of the orbit. The frontozygomatic suture
corresponds to the roof of the orbit.
Craniotomy
The FTOZ involves the removal of the standard pterional bone flap,
followed by the orbitozygomatic bone flap.
The first burr hole should be placed at the MacCarty keyhole,
which has been described to be found at mean distances of 6.8 mm
superior and 4.5 mm posterior to the frontozygomatic suture. This
keyhole exposes the frontal lobe dura in the upper half and peri-
orbita in the lower half with the orbital roof in between. The next
burr hole is drilled superior to the zygomatic arch in the temporal
squamosal bone. The number of burr holes can vary depending on
the individual age and pathology of the patient. If required superior
frontal and superior medial temporal burr holes can be made for
ease of opening. The bone cut can also be extended to the fron-
tal region for anterior fossa lesions and inferiorly to the temporal
region for middle and posterior fossa lesions.
For the orbitozygomatic craniotomy, six bone cuts can be per-

formed using the IOF and SOF as landmarks.
The slightly oblique cut is made across the posterior root of the
zygomatic arch, arrow 3 in the diagram, just anterior to the articular
tubercle to avoid the risk of postoperative temporomandibular joint
dysfunction. Then another cut is made at the inferolateral margin of
the zygomatic bone, arrow 2 in the diagram. Subsequently, the next
cut is initiated in the anterolateral portion of the IOF and extends
posterolaterally to join the second cut above the malar eminence,
arrow 4 in the diagram. The IOF can be identified along the inferior
portion of the lateral orbital wall. In preparation for the next cut,
the dura is elevated from the superior and lateral walls of the orbit.
The fourth cut is made perpendicular to the superior orbital rim and
extends posteriorly across the orbital roof toward the SOF, arrow 1.
While the orbital rim is a thick bone, the orbital roof is relatively
thin and care must be taken to prevent the release of periorbital fat
and future enophthalmos. The fifth and sixth cuts (5 and 6 arrows)
are made starting from the IOF and SOF, respectively, to join these
structures and ultimately elevate the orbitozygomatic bone flap.
The orbital contents should be protected using retractors or sur-

gical patties. See picture.
Further exposure based on the target lesion
Removal of the orbital roof and the medial sphenoid wing. Once the
temporalis muscle is pushed inferiorly through the defect caused by
zygomatic bone removal, we will get better access to the anterolat-
eral aspect and floor of the middle fossa.
Exposure of the temporal floor, SOF and the ACP. By extradural

dissection, the anterior temporal lobe is elevated from the floor of
middle fossa. This also exposes the cavernous sinus region, superior
orbital fissure and the basal foramen.
Removal of the anterior clinoidal process and the optic strut

using high-speed diamond drills. This exposes the dura of the SOF
and reveals the optic strut which forms the inferior lateral wall of
the intracranial end of the optic canal.
The exposure after FTOZ craniotomy before durotomy. Here

the sphenoid bone is extensively drilled, and additionally temporo-
orbital craniotomy is done for wide exposure.
Dural Opening
The dura is opened parallel to the posterior ramus of the Sylvian

fissure, and if required two further curvilinear cuts are performed
on the frontal and temporal side. This type of opening decreases the
risk of damage to the Sylvian veins, especially in the case of swell-
ing of the brain. Care should be taken to protect the sylvian veins.
Intradural Corridors
The COZ approach enables four different corridors intradu-

rally: (1) sub-frontal, (2) trans-sylvian, (3) pre-temporal, and
(4) sub-temporal. Through the opening of the Lilliquist mem-
brane, the transsylvian and pretemporal corridors help to reach
deeper well-defined windows to the infratentorial region which are:
(1) optico-carotid, (2) carotid-oculomotor, (3) supracarotid, and
(4) oculomotor-tentorial.
Reconstruction
Duroplasty is done if the brain is not edematous depending on

the pathology addressed. The galea-pericranium can be used as a
double-layered autologous patch graft in the case of duroplasty or
if cranialization of the frontal air sinus is necessary. Care should be
taken to reconstruct the orbital roof to limit the risk of enophthal-
mos. Bone flap is replaced along with low-profile titanium mesh
to cover the bony defect arising out of additional bone removal
and secured in place using mini plates and 4 or 5 mm self-tapping
screws.
The temporalis muscle is reapproximated to the myofascial cuff

at the level of the superior temporal line. An interrupted suture with
2/0 vicryl stitches is used for the superficial temporal fascia and
galea. Subcutaneous drainage is left in place for 2 days to prevent
blood collection. Skin suture can be done with nylon stitches or skin
staplers.
Complications Avoidance
Complications of the FTOZ approach can be functional, aesthetic,
or both. Some of the most frequent ones are injury of the frontotem-
poral branch of the facial nerve, atrophy of the temporalis muscle,
masticatory imbalance, enophthalmos, diplopia, visual impairment,
and CSF leakage. The subfascial technique avoids the deficit of the
frontotemporal branch of the facial nerve. Blunt dissection and not
using electrocautery on the deep temporal fascia prevents postop-
erative atrophy of the temporalis muscle. Avoidance of detachment
of the masseter, along with functional preservation of the tempora-
lis muscle, prevents the risk of masticatory imbalance. Incidence
of diplopia, facial and orbital asymmetry is lessened by meticulous
osteosynthesis, which is generally performed using low-profile
mini-plates and screws. Protection of the periorbita is of utmost
importance to avoid enophthalmos and postoperative orbital hema-
toma. Risk of visual impairment or even blindness mainly comes
from anterior clinoidectomy, which is added to COZ craniotomy in
most cases. Risk of thermal damage to the optic nerve secondary to
overheating caused by the drill must be decreased by constant irri-
gation. Excessive downward displacement of the eyeball also needs
to be avoided to prevent visual morbidity. The need to expand the
subfrontal corridor can result in opening of the frontal sinus. Sphe-
noid sinus can be sometimes opened during anterior clinoidectomy
when ACP is highly pneumatized. Meticulous packing of both these
sites with autologous fat with or without galea-pericranium vascu-
larized flap is recommended to prevent cerebrospinal fluid leak and
infections in the future.
In Summary
Combining Orbito-zygomatic osteotomy along with Pterional crani-
otomy has three main advantages.
(1) It provides a wider working room allowing handling the
lesion at various angles, not previously possible. (2) Provides a
shorter working distance for deep neurovascular targets in the depth
of anterior and middle cranial base. (3) An increased subfrontal and
subtemporal angular exposure is possible with the additional bone
work. Many modifications can be attempted based on the target area
and structures involved.
Superolateral orbitotomy expands the subfrontal and transsyl-

vian corridor and raises surgical freedom to the basal forebrain,
hypothalamic region, interpeduncular fossa, and basilar apex. Zygo-
matic osteotomy shortens the working distance to the main targets
of the pre-temporal and subtemporal routes. Removal of the OZ bar
eliminates the need for brain retraction and allows for multiangled
trajectories. Moreover, FTOZ approach can be tailored based on the
location and extension of the lesion, thus optimizing target exposure
and decreasing the risk of complications.
References
1. Rodriguez Rubio R, Chae R, Kournoutas I, Abla A, McDermott M. Immersive
Surgical Anatomy of the Frontotemporal-Orbitozygomatic Approach. Cureus.
2019 Nov, 2;11(11):e6053. doi: 10.7759/cureus.6053. PMID: 31929953;
PMCID: PMC6945284.
2. Luzzi S, GiottaLucifero A, Spina A, Baldoncini M, Campero A, Elbabaa SK,
Galzio R. Cranio-Orbito-Zygomatic Approach: Core Techniques for Tailoring
Target Exposure and Surgical Freedom. Brain Sci. 2022 Mar;18;12(3):405. doi:
10.3390/brainsci12030405. PMID: 35326360; PMCID: PMC8946068.
3. El Ahmadieh, Tarek Y, Nuñez, Maximiliano, Vigo, Vera, Abou-Al-Shaar,
Hussam, Fernandez-Miranda, Juan C; Cohen-Gadol, Aaron A. Frontotemporal-
Orbitozygomatic Approach and Its Variants: Technical Nuances and Video
Illustration. Oper. Neurosurg. 2022 December;23(6):441–448.
4. Zabramski JM, Kiriş T, Sankhla SK, Cabiol J, Spetzler RF. Orbitozygo-
matic craniotomy. Technical note. J Neurosurg. 1998 Aug;89(2):336–41. doi:
10.3171/jns.1998.89.2.0336. PMID: 9688133.
5. Bilbao, CJ, Stofko, DL, & Dehdashti, AR. Cranio-orbitozygomatic approach:
Technique and modifications. Operative Techniques in Otolaryngology – Head
and Neck Surgery, 2013 December;24(4):229–234. https://doi.org/10.1016/j.
otot.2013.09.004
6. Youssef AS, Willard L, Downes A, Olivera R, Hall K, Agazzi S, van Loveren H.
The frontotemporal-orbitozygomatic approach: reconstructive technique and
outcome. Acta Neurochir (Wien). 2012 Jul;154(7):1275–83. doi: 10.1007/
s00701-012-1370-9. Epub 2012 May 11. PMID: 22576269.
Courtesy: Artist Loganathan for his medical illustrations

8
Posterior Petrosectomy,
Combined Presigmoid and
Subtemporal Approach:
Step-by-Step Surgical
Approach
Department of Neurosurgery, National Institute of

Mental Health and Neuro Sciences (NIMHANS),
Bengaluru, India
Positioning and Skin Incision

• General anesthesia, appropriate cranial nerve (CN) monitoring,
• Lateral decubitus position, head end elevated with an axillary
roll and hip roll.
• Three-point Mayfield fixation, in slight flexion, with the vertex
tilted slightly toward the floor.
• Principles: Bring the superior sagittal sinus roughly parallel to
the floor while minimizing compression of the contralateral in-
ternal jugular vein (IJV) and opening up the angle between the
ipsilateral shoulder and neck.
• Optional: lumbar drain for this operation, or release cerebro-
spinal fluid (CSF) from the cerebellopontine angle (CPA) upon
opening the pre-sigmoid dura.
• The location of the transverse sinus is approximated by connect-
ing an imaginary line between the inion and a point just above
the root of the ipsilateral zygoma
• The sigmoid sinus is projected along the digastric groove

extending from the mastoid tip up to the junction with the
transverse sinus.
• Skin incision as shown (Figure 1) Principles: The incision needs
to extend far enough posteriorly to allow a true retro-sigmoid
bony exposure as well as far enough inferiorly and anteriorly so
that the entire mastoid can be exposed up to the external audi-
tory canal (EAC). The scalp flap will maintain its blood supply
from a combination of the posterior limb of the superficial tem-
poral artery (STA), the posterior auricular artery, and the occipital
artery; care should be taken during exposure to protect the arteries
and their major branches.
• Scalp and Muscle Flaps: The myopericranial layers are elevated
in three segments
• The temporalis muscle is incised anteriorly and carried supe-
riorly to approximately 1 cm below the superior temporal line
(STL), leaving a cuff of muscle for closure, and posteriorly
along the posteroinferior aspect of the STL. The muscle is
dissected and retracted anteriorly and inferiorly.
• Posteriorly, the nuchal musculature is incised superiorly at
its attachment to the superior nuchal line, anteriorly parallel
and bisecting the mastoid, and posteriorly at the limit of the
scalp flap, paralleling the skin incision. The posterior flap is
reflected inferiorly at its pedicle, exposing the mastoid and
87 Posterior Petrosectomy Exposure
the occipital bone to just above the foramen magnum. The

arch of C1 can usually be palpated but does not need to be
exposed.
• The remaining tissue interposed between the anterior and pos-
terior muscle flaps is typically of poor quality for reconstruc-
tion but, where present, can be reflected toward the EAC with
the scalp flap.
Burr Holes
• At the anterior limit of the exposure, a temporal burr hole is
placed just above the root of the zygoma.
• Posterosuperiorly, a second hole is placed superiorly in the tem-
poral squamous bone just below the STL.
• Two burr holes on either side of the transverse sinus at the poste-
rior limit of the exposure. This burr hole exposes the dura mater
superior and inferior to the transverse sinus from which the dura
can safely be stripped superiorly and inferiorly
• The transverse–sigmoid sinus is then carefully unroofed with a
large diamond burr and copious irrigation. This drilling is contin-
ued superiorly until the middle fossa dura is uncovered.
• The angle between the superior aspect of the transverse–
sigmoid junction and the middle fossa dura can be quite acute and
therefore progressively smaller diamond burrs may need to be

employed to safely uncover this aspect of the sinus.
• Great care must be taken when separating the transverse–
sigmoid sinus junction from the bone at the anterior aspect of the
dissection, due to sizeable transosseous emissary veins.
Craniotomy and Bone Flap Elevation

If bleeding: Can be controlled with gel foam/Floseal@, a small
cotton patty, and moderate pressure. A figure-of-eight 6–0 monofila-
ment suture can then be placed to close the hole in the sinus. If there
is a larger tear in the sinus, additional sutures may be necessary.
Under such circumstances, it is helpful to increase the degree of
reverse Trendelenburg.
Mastoidectomy
• The general principles of mastoid dissection include proceed-
ing from lateral to medial and identifying peripheral anatomical
landmarks early in the procedure so that larger quantities of bone
can be safely and swiftly removed.
• Key boundaries include the sigmoid sinus and endolym-

phatic sac posteromedially, the middle fossa dura superiorly,
the jugular bulb inferiorly, and the fallopian and EACs
anterolaterally.
• The first step in this process is removal of the superficial mas-
toid cortex, which is completed using a 6- or 7-mm cutting bit
The mastoid is opened along its full superior–inferior extent and
carried anteriorly to the EAC wall. It is important to leave a thin
shell of bone along the posterior margin of the EAC as If this
bone is violated, the thin, adherent skin of the EAC is almost
always also violated as well, significantly increasing the risks of
CSF leak or wound infection.
• With the outer mastoid cortex removed, dissection proceeds
from superficial to deep as the air cells are removed with wide,
controlled sweeps.
• At the superomedial aspect of the mastoid, the air cells coalesce
into the antrum, typically located 1.5 cm deep to the spine of
Henle; this typically comes into view with a “pop” as the last
layer of medullary bone, known as Kerner’s septum, is removed.
• Exposure of the Horizontal and Posterior Semicircular Canal:
With the antrum exposed, the short process of the incus is
visualized in the fossa incudis—a confirmatory marker for the
antrum, and a key landmark for identifying the facial nerve, as

the short process of the incus effectively points to the nerve’s
mastoid genu
• The floor of the antrum contains the horizontal SCC, which is
easily distinguished from the surrounding medullary bone due
to the high-density, yellow-tinged, otic capsule Once the hori-
zontal SCC has been identified, any residual overlying bone can
be speedily removed, as the critical structures all lie deep to this
canal. Careful skeletonization of horizontal SCC is important, as
it is an important reference for many adjacent structures, includ-
ing the middle fossa dura superomedially which can be exposed
safely and quickly after the canal is identified, and the mastoid
genu of the facial nerve inferomedially, which travels just be-
yond the inferior wall of the horizontal SCC, making this a criti-
cal barrier to identify and respect.
• As the curvature of the horizontal canal becomes fully defined, it
should be followed posteriorly, where the posterior SCC will be
identified in a perpendicular orientation; this should be carefully
skeletonized along its inferior curvature to the middle fossa dura
superiorly, and the posterior fossa dura medially.
• The mastoid segment of the facial nerve can be identified here.
Copious irrigation should be used to help “see” through the bone,
remove bone particles and prevent heating which can result in
thermal injury to adjacent structures.
• Skeletonization of the Superior SCC and Decompression of
Presigmoid Dura (Trautmann’s Triangle)The superior SSC lies
much deeper in the exposure, beyond the curvature of the hori-

zontal canal, where it is encountered running orthogonally to the
other SCC.
• Trautman’s triangle: The presigmoid posterior fossa dura bound-
ed by jugular bulb inferiorly, the sigmoid sinus posteriorly, and
the superior petrosal sinus (SPS) superiorly
• If one SSC is inadvertently opened during drilling, the opening
should be occluded with bone wax immediately, and care must
be taken not to suction endolymph, in the hope that hearing and
balance function may be preserved.
Primary Presigmoid Dural Flap

The dura is opened in two stages. The primary dural flap is a rectan-
gle pedicled anteriorly, fashioned using three cuts
• The first cut (posterior) is made approximately 2 mm anterior to

the anterior margin of the sigmoid sinus and carried inferiorly
from just below the SPS in parallel to the sigmoid sinus until it
turns anteriorly to become the jugular bulb
• Thesecondcutismadeposteriortoanterior, just above the apex of
the jugular bulb. Completion of this cut provides ready access to
the inferior CPA cistern for CSF drainage, which, in turn, facili-
tates a safer and more expedited final exposure.
• The third (superior) cut is made along the inferior aspect of the
SPS out to the petrous apex dura.
• SPS Ligation and Sectioning of the SPS and Tentorium
• Vein of Labbe needs to be identified and preserved
• CSF release and then gently elevate the temporal lobe, revealing
the medial tentorial edge
• Once the medial tentorial edge is defined, the trajectory of the
incision in the tentorium becomes apparent. If the tentorial edge
is cut too far anteriorly, it will result in an inadvertent sacrifice
of CN IV.
Excellent visualization of CN III to XI is afforded by the approach,

which provides a broad, lateral-to-medial trajectory for resect-
ing lesions of the posterior fossa, in particular those seated at the
petrous apex or lateral clivus.
Key Surgical Steps

• Temporo-Suboccipitial Craniotomy
• Mastoldectomy and skeletonise the Sigmoid sinus
• Posterior petrosectomy with preservation of bony labyrinth
• Identification and preservation of Fallopian canal and internal
acoustic meatus
• Opening of the presigmoid and posterior subtemporal dura
• Ligation of the Superior petroal sinus, tentorial incision
• Internal debulking f/b capsular dissecton of the tumour from CN
IV to LCNs and the brainstem
• Closure with fat, pericranial graft, boneflap and temporalis muscle.
9
Retro-Sigmoid Sub-
Occipital (RSSO) Approach:
The Workhorse of the
Cerebello-Pontine Angle
Surgeries
Priyadharshan KP,1 Kodeeswaran M,1
Ranganathan Jothi,2 Naveen Kumar M1
Neurosurgery Academy & Research Foundation,

1
Department of Neurosurgery, Government Kilpauk

2
Director, Institute of Neurosciences,
Kauvery Hospital, Vadapalani & Alwarpet,
Chennai, India
• Introduction
• Neurosurgical Anatomy Essentials
• Myofascial anatomy
• Bony anatomy
• Superficial Vascular Anatomy
• Step-by-step RSSO guide:
• Patient Positioning
• Skin Incision
• Incision of the Skin
• Dissection of the Scalp Flap
• Dissection of the Muscles
• Craniotomy
Introduction
The retrosigmoid (RS) approach, derived from Fedor Krause’s 1903
unilateral cerebellopontine angle (CPA) technique, is the corner-
stone for treating CPA lesions/conditions. This method, refined by
neurosurgeons and neuro-otologists, provides excellent exposure of
CPA structures with minimal bone removal and offers a wide work-
ing area. It can be extended inferiorly via the far-lateral transcondy-
lar or retrocondylar approaches and anteriorly to the middle fossa
through intradural variations. Preoperative topographic and 3D
microanatomical studies are critical for the RS approach, enhancing
understanding of its soft tissue and bony structures.
The RS craniectomy is a standard approach to a variety of CPA
pathologies.1 A variety of methods have been described for the
approach including skin incisions, craniectomy versus craniotomy,
dural closure, and bone repair/cranioplasty.2–8 The anatomy of the
bony, vascular, and neural anatomy is well described.
To address the need for clear technical descriptions, this chapter
provides an in-depth description of the procedure, its modifications,
limitations, advantages, technical nuances, andcomplications.
Neurosurgical Anatomy Essentials

Myofascial Anatomy
Blood vessels and nerves in this region are predominantly located

within the subcutaneous adipose tissue, lying superficially above the
underlying musculatures. The most lateral and superior muscle in the
posterolateral region is the posterior auricular muscle (PAM), which
originates from the mastoid of the temporal bone at the superior nuchal
line (SNL) and inserts on the lower cranial surface of the concha, near
the external auditory meatus (EAM). Just inferior to the PAM is the
sternocleidomastoid muscle (SCM), which inserts on the lateral sur-
face of the mastoid at the lateral half of the SNL, while the trapezius
muscle lies medial to the SCM, originating from the medial third of
the SNL, external occipital protuberance, and the nuchal ligament.
The deep intrinsic muscles include the splenius capitis, which
inserts on the lateral portion of the mastoid and the lateral part of
the SNL, lying underneath the mastoid portion of the SCM. Below
the splenius capitis is the longissimus capitis, which inserts at the
95 Retro-Sigmoid Sub-Occipital (RSSO) Approach
posterior portion of the mastoid process. Medial to these muscles

is the semispinalis capitis, inserted below the trapezius at the SNL,
just superior to the inferior nuchal line (INL). This muscle’s lateral
insertion is partially covered by the splenius capitis, while its medial
insertion is covered by the trapezius.
Deeper muscles of the neck include the posterior belly of the digas-
tric muscle, originating from the digastric groove on the skull’s infe-
rior surface, medial to the mastoid process. The suboccipital muscles,
including the obliquus capitis superior, obliquus capitis inferior, rectus
capitis posterior major, and rectus capitis posterior minor, lie beneath
the semispinalis capitis. In the RS approach, two muscles are typically
exposed: the obliquus capitis superior, which inserts at the INL under
the lateral portion of the semispinalis capitis, and the rectus capitis
posterior major, which inserts on the lateral half of the INL, medial to
the obliquus capitis superior and posterolateral to the condyloid canal.
Bony Anatomy
Understanding the bony anatomy and natural boundaries is crucial

for identifying key landmarks for accessing the CPA via the RS
approach. The exposure is bordered anterolaterally by the EAM and
SS, superiorly by the SNL and TS, inferiorly by the craniocervi-
cal junction, and posteromedially by the median nuchal line. The
asterion, a significant landmark in this approach, helps estimate the
TSSJ before craniotomy. Defined by the junction of the lambdoid,
occipitomastoid, and parietomastoid sutures, its position can vary,
influencing its reliability as a TSSJ indicator. Other landmarks, such
as the zygoma-Inion line, can also aid in locating the TS, SS, and
TSSJ during the RS approach.
Superficial Vascular Anatomy
The posterior auricular artery (PAA), originating from the exter-

nal carotid artery (ECA) or occasionally the occipital artery (OA),
ascends posteriorly above the posterior belly of the digastric muscle.
It surfaces between the auricle and mastoid tip and runs superiorly
towards the vertex, providing branches that supply the postauricular
region and form anastomoses with nearby arteries. The PAA’s auric-
ular branch supplies the auricle and the posterior auricular muscle,
while the stylomastoid artery, also stemming from the PAA, supplies
the styloid process, mastoid process, and facial nerve. The PAA’s
length and diameter can vary, sometimes matching or exceeding the
size of the superior temporal artery (STA) or OA.
The occipital artery (OA) branches from the ECA below the PAA,
travelling below and then medial to the digastric muscle before
emerging from the occipital groove. It ascends superomedially, run-
ning above the obliquus capitis superior and semispinalis capitis,
covered by the sternocleidomastoid (SCM) and splenius capitis,
towards the superior nuchal line (SNL). The OA has ascending and
descending branches, with the superficial descending branch sup-
plying the neck muscles and the deep branch anastomosing with the
vertebral artery in the suboccipital triangle. The ascending branch
reaches the SNL and extends towards the vertex, forming anastomo-
ses with the STA and PAA.
Venous drainage in the posterolateral region involves the poste-
rior auricular vein (PAV),occipital vein (OV), mastoid emissary vein
(MEV), and occipital emissary vein (OEV). The PAV, arising from
a plexus with the OV and superficial temporal veins, drains into the
external jugular vein. The OV drains into various veins, including
the suboccipital and vertebral plexuses. The MEV is crucial in the
RS approach, often cauterized to prevent bleeding or air embolisms,
as it drains from the sigmoid sinus to the PAV and OV. The less
common OEV can form a confluence with the MEV and provides
venous drainage from the transverse sinus, posing operative risks
during surgeries performed in the sitting position
Superficial Nerve Anatomy
In the retroauricular region, the key sensory nerves for the RS approach
are the great auricular nerve (GAN) and the lesser occipital nerve
(LON). The GAN, originating from the ventral rami of C2 and C3
of the cervical plexus, wraps around the posterior border of the SCM
and emerges at Erb’s point. It ascends superficially across the SCM
towards the parotid gland, where it branches into the anterior branch
(serving the skin over the parotid gland and anteroinferior auricle),
the posterior branch (serving the skin over the mastoid process and
posterior auricle), and the lobular branch (serving the lobule).
The LON, arising from the ventral ramus of C2, sometimes also
C3, of the cervical plexus, curves lateral to cranial nerve XI and
emerges above Erb’s point. It ascends along the posterior border
of the SCM and pierces the deep cervical fascia near the cranium,
emerging posterior and superior to the GAN. The LON then fans
out into the anterior branch (which anastomoses with the GAN’s
posterior branch) and the posterior branch (which anastomoseswith
the greater occipital nerve medially).
During dissection, the posterior branch of the GAN and the LON
are particularly vulnerable due to their variable courses, so extra
care is needed to avoid damaging these nerves.
FIGURE 1 Image showing superficial muscles and neurovascular anatomy rele-

vant to the RSSO approach.
Step-by-Step Guide to RSSO

Patient Positioning
The optimal patient positioning for vestibular schwannoma (VS)

surgery using the retrosigmoid (RS) approach is a subject of ongo-
ing debate, particularly regarding facial nerve preservation, extent of
resection, and complications. Recent studies comparing two groups:
(1) Semi-sitting and Sitting positions, and (2) Lateral, supine with
extensive head rotation, lateral oblique (Fukushima/Three-quarter
prone), and park-bench positions, have shown that the semi-sitting
position significantly improved long-term facial nerve outcomes
without influencing the extent of resection, postoperative CSF
leaks, or hydrocephalus rates. However, venous air embolisms were
more frequent in the sitting position, while perioperative mortality
rates were similar across both groups. Both positioning groups are
deemed safe, but further multicentric prospective randomized trials

are needed to evaluate the risk-benefit ratio for each position in VS
surgery via the RS approach.
Skin Incision
The various incisions used are
• C-shaped
• Curvilinear incision
• Modified C or Sickle-shaped
• S-shaped
Linear and lazy S-shaped incisions are simpler and more adaptable,
but the use of retractors can cause bunching of the skin and muscles,
posing a risk to the occipital artery and nerves. The C-shaped inci-
sion allows for multilayer dissection and retraction of the skin and
muscle flaps, reducing the risk of postoperative CSF leaks; however,
the lower part of this incision may endanger neurovascular trunks.
The inverted U-shaped incision, which is based inferiorly, helps pre-
serve these neurovascular trunks but is limited to a single layer and
cannot be extended upwards. Given its advantages, the C-shaped
incision is favored by skull-base surgeons and will be detailed here.
FIGURE 2 Schematic diagram of the commonly used C- and S-shaped incisions

for RSSO.
Mark the Incision
• Use the zygoma-inion line and mastoid tip-asterion line to

approximate the TS,SS, and TSSJ.
• Draw a C-shaped incision from 2 cm superior to the middle of the
pinna to 1 cmmedial to the mastoid tip.
• Ensure the apex of the curve is 5 cm posterior to the postauricular

crease.
• Extend the incision inferiorly if necessary, depending on the case.
• The size of the incision can also be reduced based on the sur-
geon’s experienceand preference on a case-by-case basis.
Prepare the Surgical Area

• Prep and drape the surgical area.
• Apply lidocaine 1% with epinephrine to the incision area.
FIGURE 3 Patient in semi-sitting position.
Make the Skin Incision

• Incise the skin over the region of the temporalis muscle.
• Continue the incision towards the mastoid tip, ensuring to cut
through thesubcutaneous adipose tissue.
FIGURE 4 Lazy ‘S’ incision.
Avoid Nerve Damage

• Visualize and preserve the lesser occipital nerve, as it is more
superficial and enters the region at the posterior edge of the sub-
cutaneous tissue (approximately at the 4 o’clock position for the
left side and the 8 o’clock position for the right side).
• In case of an anteroinferior extension of the incision, avoid

injury to the GAN at McKinney’s point, located about 6.5 cm
inferior to the caudal edge of the EAM, representing the su-
perficial crossing of the nerve over the mid-transverse belly
of the SCM.
FIGURE 5 Incision deepened till the bone.
Dissection of the Scalp Flap
• Using sharp dissection sub-galeal flap is raised inferior to the SNL

• Care should be taken to ensure uniform flap thickness
• The flap is then elevated with the fascia of the PAM and SCM and
retractedanteriorly over the mastoid process.
FIGURE 6 Tissues retracted to expose the planned craniotomy site.

Dissection of the Muscles
• The muscles beneath can be cut similar to the skin incision and
retracted anteriorly or can be divided from the SNL and be re-
tracted inferiorly depending on the surgeon’s preference with
both techniques providing adequate exposure.
• The second method is however more anatomical dissection with
the musclesreflected based on their feeding vessels. The same is
described below.
Make the Vertical Incision

• Fascio-periosteal incision from the mastoid tip, up to the base of
the skin flap overthe mastoid process.
Dissect and Reflect Soft Tissues

• Elevate and retract the periosteum and soft tissues till the EAM
depression
Create Horizontal Incisions

• Make a horizontal incision along the SNL and the PAM
• Make a posterior incision to make a superior triangular occipital-
is flap (over the SNL) and an inferior triangular SCM flap (below
the SNL)
Dissect and Elevate Occipitalis Flap

• Elevate the occipitalis flap towards postero-superior direction
• Suture the flap with the drapes, avoid excessive force.
Dissect and Retract SCM Flap

• Elevate the SCM towards the postero-inferior/inferior direction
till the horizontalcrest of the sub-occipital bone.
• This should give adequate exposure to the planned craniotomy,
the asterion andthe emissary veins.
Handle Emissary Veins

• To reduce the risk of air embolisms the emissary veins should be
promptly dealt with
• Use bone wax/electrocautery to obliterate them. Avoid overpacking.
Determine Burr Holes

• Decide the number of burr holes based on the patient’s pathology
and age.
• Use more burr holes or a craniectomy for patients over 60 years
old, as their dura tends to be tightly adherent to the overlying bone.
FIGURE 7 Intra-operative picture showing identification of the asterion, the

digastrics groove and the mastoid tip.
Craniotomy Techniques
Standard RS Approach
• The Asterion marks the junction of the TS and SS and the primary
burrhole should be placed over or just below it.
• Proceed to craniotomy with the margins as below (size may be
adjusted ona case-by-case basis) – connect the outermost edge of
the initial burrhole to preserve the shape of the bone.
• From anterior-superior to posterior-superior along the TS.
• From posterior-superior to posterior-inferior over the cerebel-
lar hemisphere.
• From posterior-inferior to anterior-inferior
• Connect the anterior-inferior to anterior-superior just behind
the SS.
• Be cautious near the occipito-mastoid suture to avoid the occip-
ital arterytrunk.
Extended RS Approach
• Burr placement is similar to the standard approach
• Make cuts similar to the standard approach, and keep SS
skeletonization for the last
• Expose the jugular foramen by performing a limited posterior
mastoidectomy.
• Avoid beveling the bone flap. Ideally, the superficial exposure
should be adequately planned for the craniotomy, to allow for
adequate CPA exposure
• Seal exposed mastoid air cells with bone wax
Dural Opening
• Visualize the Dura
• Use magnification with an operating microscope
• Make the Incision: Use a medially based C-shaped incision along
the inferior edge of TS and posterior edge of SS, 3–5 mm away
from the sinuses.
FIGURE 8 RSSO done exposing the posterior fossa dura.
Retract the Dura

• Retract dura covering the sinuses after the extended RS approach
to increase thesurgical angle.
• Minor Dural injuries can be dealt with, with mild compression
with hemostatic agents. Be patient and open cautiously. Major
injuries can be disastrous.
FIGURE 9 Intra-operative picture showing C-shaped durotomy based on the

transverse and sigmoid sinus, and their junction.
Expose CPA Structures

• Arachnoid membrane dissected from the tumour
• In case of a tight posterior fossa, cut the arachnoid, to drain CSF
from the cisternamagna.
• Protect the cerebellum using dynamic retraction over cottonoids
or gel foam
• Perform CPA Microdissection as needed for the underlying
pathology – It is beyond the scope of this chapter to discuss
individual lesions
• Introperative facial nerve monitoring done along with CPA
dissection
FIGURE 10 CPA tumor being dissected of the brainstem medially.
Closure
• Carefully inspect the CPA and achieve hemostasis before closing
the dura.
• Watertight closure of the dura should be done. Fascial/synthetic

graft can be used.Fibrin glue can be used to reinforce the dura.
FIGURE 11 Water-tight dural closure.
Replace Bone Flap

• Replace the bone flap and secure it with titanium plates and screws
Suture Muscle and Skin Flaps

• Layered anatomical repair should be done in the reverse order of
the incision andexposure.
• Ensure hemostasis and water-tight closure at each step. Avoiding
CSF leak is ofgreat importance.
References
1. Lang J Jr, Samii A. Retrosigmoidal approach to the posterior cranial fossa. An
anatomical study. Acta Neurochir (Wien). 1991;111(3–4):147–153. doi:10.1007/
BF01400505
2. Das P, Borghei-Razavi H, Moore NZ, Recinos PF. Posterior Approach to Meckel’s
Cave: Retrosigmoid Craniectomy with Endoscopic Assistance. J Neurol Surg
Part B Skull Base. 2019;80(Suppl 3):S331–S332. doi:10.1055/s-0039- 1677851
3. Liu JK, Dodson VN. Retrosigmoid Suprameatal Approach for Resection of
Petrotentorial CerebellopontineAngle Meningioma: Operative Video and Tech-
nical Nuances. J Neurol Surg Part B Skull Base. 2019;80(Suppl 3):S290–S291.
doi:10.1055/s-0039-1685532
4. Elhammady MS, Telischi FF, Morcos JJ. Retrosigmoid approach: indica-
tions, techniques, and results. Otolaryngol Clin North Am. 2012;45(2):375-ix.
doi:10.1016/j.otc.2012.02.001
5. Mostafa BE, El Sharnoubi M, Youssef AM. The keyhole retrosigmoid approach
to the cerebello-pontine angle: indications, technical modifications, and
results. Skull Base Off J North Am Skull Base Soc Al. 2008;18(6):371–376.
doi:10.1055/s-0028-1087220
6. Yamashima T, Lee JH, Tobias S, Kim CH, Chang JH, Kwon JT. Surgical proce-
dure “simplified retrosigmoid approach” for C–P angle lesions. J Clin Neurosci.
2004;11(2):168-171. doi:10.1016/j.jocn.2003.06.004
7. Aldahak N, Dupre D, Ragaee M, Froelich S, Wilberger J, Aziz KM. Hydroxy-
apatite bone cement application for the reconstruction of retrosigmoid craniec-
tomy in the treatment of cranial nerves disorders. Surg Neurol Int. 2017;8:115.
doi:10.4103/sni.sni_29_17
8. Pabaney AH, Reinard KA, Asmaro K, Malik GM. Novel technique for cra-
nial reconstruction following retrosigmoid craniectomy using demineral-
ized bone matrix. Clin Neurol Neurosurg. 2015;136:66–70. doi:10.1016/j.
clineuro.2015.05.034
10
Far Lateral Approach
Manas Panigrahi, Chiragkumar Patel,
Pratikkumar Koradia
Department of Neurosurgery, KIMS Hospital,

Secunderabad, Telangana, India
The basic far lateral approach is used to reach lesions located along
the anterolateral margin of the foramen magnum. There were multiple
variants described in literature including transcondylar, supracondylar,
and paracondylar approaches.1,2 Each of the above variants is subclas-
sified into sub variants. The primary goal of the above approaches is
to access the space located anterior and lateral to the brainstem. The
standard transcondylar approach includes drilling of the condyle. The
extent of drilling of occipital condyle drilling is controversial. Litera-
ture suggests that 1/3 of occipital condyle drilling will not be associated
with postoperative instability. Previously published studies mentioned
following guidelines for amount of condyle drilling (Table 1).3,4
The anatomical landmark used during condyle drilling is hypo-
glossal canal. It divides the condyle in anterior two thirds and pos-
terior one third (Figure 1). The supracondylar approach is directed
above the occipital condyle to the hypoglossal canal or both above
and below the hypoglossal canal to the lateral side of the clivus.5
Trans-tubercular variants of the supracondylar approach include
drilling of jugular tubercles which obstruct the view in front of lower
cranial nerves. The paracondylar approach is directed through the
lateral to occipital condyle. Trans jugular variants of the paracon-
dylar approach include drilling of the jugular process which pro-
vides more anterior access to the foramen magnum in front of the
brainstem. Extreme far lateral approach is when the vertebral artery
mobilized medially from C1 foramen transversarium.6
The common indications of the transcondylar approach are
craniovertebral junction intradural tumor (e.g. meningioma, lower
Table 1 – Rationale for requirement and extent of condylar Resection3,4

Consideration Rationale
Consistency of tumor A firm tumor may require resection of the
condyle to facilitate a wider exposure.
Extent of attachment and If the attachment of tumor extends beyond
Encasement of vertebral artery the mid‑line, it may be advisable to
consider partial drilling of the condyle
Size of tumor and the displacement En plaque tumors and smaller tumors
of medulla which do not displace the medulla may not
require condylar resection.
FIGURE 1 Anatomical landmarks of occipital bone.
cranial schwannomas), vascular lesion of vertebral artery and

posterior inferior cerebral artery (eg. Aneurysms) and brain stem (e.g
cavernomas), extradural lesions of the occipital bone and jugular
foramen (e.g chordomas, glomus jugulare tumor etc.)
In this chapter we describe technical nuances of the basic far
lateral approach. The Far lateral approach is described in the present
chapter in the following headings-preoperative clinical examination
and detailed study of imaging, positioning of the patient, skin inci-
sion and muscle dissections, craniotomy and condyle drilling, dural
opening and surgical corridor, lesion excision and dural closure.
1. Pre-operative Clinical Examination and

Imaging Analysis
It is essential to perform a complete examination of patients with
special attention to lower cranial nerves and brain stem. Patients
with pre-operative lower cranial nerve deficits may need post-
operative ventilation, tracheotomy and prolonged tube feeding.
Imaging gadolinium enhanced MRI provides details of the character
109 Far Lateral Approach
of the lesion, location and extension of the lesion in the vertical and
horizontal direction, calcification, vascular and neural encroach-
ment. We routinely use DTI of the corticospinal tract in preoperative
workup. It provides information on the displacement of the tract and
helps in selecting the approach. CT angiogram helps in localising,
and analysing characteristics of vascular lesions, anatomical vari-
ants of vessels and their relation to bony anatomy.
Here, we present a 33-year-female, who presented with occipitial
Headache for 3 months. It was associated with numbness of the right
upper and lower limbs for 20 days with normal lower cranial nerves
examination and without motor deficit. Imaging features are described
in Figure 1. Contrast enhanced MRI Brain plain and contrast (Figures
2A,C,D) showed of a well-defined brilliant contrast-enhancing lesion
in the posterior fossa predominantly on the left compressing and
indenting cervico-medullary junction and encroaching the left verte-
bral artery (left vertebral artery not separately visible). There was no
dural tail or dural enhancement with contrast. CT angiography was
done to rule out an aneurysm and know the course of the left verte-
bral artery. MRS showed reduced NAA with increased choline levels.
MRI DTI of the corticospinal tract (Figures 2B,E) was suggestive of
displacement of the left corticospinal tract posteromedially and the
right Corticospinal tract posterolaterally.
Bilateral tracts showed normal FA values i.e no infiltration. Hence,
left side far lateral approach was selected for excision of the lesion.
FIGURE 2 Imaging features of present case.

2. Positioning of Patient and Intraoperative

Monitoring
Commonly used positions for far lateral approach were park bench
and lateral position. The main intention of adequate positioning
is to get adequate working space at the lateral part of the foramen
magnum. As described in Figure 3, we opted for lateral positioning
with head fixation with Sugita’s head frame. Strapping of patients
was done with plaster strips and all pressure points were cushioned.
We tend to tilt the table during surgery which provides a direct view
of the surgical field. Intraoperative monitoring of brainstem audi-
tory evoked responses (BAERs), somatosensory evoked potentials
(SSEPs), and as well as electromyography monitoring of cranial
nerves VII, X, XI, and XII were recommended.
FIGURE 3 Demonstration of lateral position.

3. Skin Incision and Muscle Dissections

Different types of skin incisions are described in literature: hockey
stick, lazy S, and horseshoe-shaped incision. As shown in Figure 4,
we prefer a hockey stick incision which begin in the midline from
A–Skin incision
landmarks:
Star-mastoid
process tip, Plus-
inion, Round-C4
spinous process)
B–Skin incision
and muscle
dissection
C–Muscle retrac-
tion toward lateral
and extent of
craniotomy
1. Extent of
craniotomy
2. C1 posterior
arch
3. C2 lamina
FIGURE 4 Skin incision and myocutaneous flap.

the C4 or C5 spinous process directed upward to just above the

external occipital protuberance, turning laterally just above the
superior nuchal line, and reaching the mastoid tip. The advantage
of a hockey stick incision is it will minimize dissection through the
neck muscles and mobilize the myocutaneous flap laterally out of the
operating zone. Subperiosteal elevation of suboccipital muscles is
done to expose occipital bone, posterior margin of foramen magnum
and C1 posterior arch extending up to lateral mass (Figure 4B). We
recommend blunt dissection technique while dissecting at the lat-
eral margin of the C1 arch to avoid vertebral artery injury. At this
step, we identify the vertebral artery (V3 segment) position over the
posterior arch of C1 and enter the dura. This exposes the posterior
margin of the occipital condyle and occipital atlantal joint.
4. Craniotomy and Occipital Condyle Drilling

Important landmarks to identify for suboccipital craniotomy are
asterion and inion. Asterion is at the junction of the transverse and
sigmoid sinus. Inion represents the external landmark of the torcula.
The standard burr hole site is inferior to the asterion. We preferred
thinning of occipital bone followed by craniectomy with the use of
rongeur. This is followed by C1 hemi-laminectomy and opening of
the posterior bony ridge of the foramen magnum (Figure 5A). Sub-
periosteal dissection is done along the lateral border of the C1 pos-
terior arch and exposure of lateral mass of C1 and occipital atlantal
joint. At this point, the vertebral artery should be identified at the
upper border of the C1 arch. Occipital condyle drilling has a basic
anatomical landmark – the hypoglossal canal. Cranial opening of
hypoglossal canal is located 5 mm above the junction of the poste-
rior and middle third of the occipital condyle. Ideally, drilling of the
occipital condyle up the condylar fossa is advocated.3,4 Literature
suggestive of more than 50% removal of condyle associated with
instability and needs fusion. As shown in Figure 4B, drilling of the
condyle is done up to the condylar fossa with high-speed conical
or round burr followed by thin edge removal by Kerrison rongeur.
Posterior to the occipital condyle, a depression, the condylar fossa,
may be pierced by the condylar canal, which transmits the poste-
rior condylar emissary vein. Communication between the vertebral
venous plexus and the sigmoid sinus may cause troublesome bleed-
ing which can be controlled with bone wax.
A–Showing anatomical
landmark before condyle
drilling
1. Occipital condyle
(white circle).
2. C1 posterior arch mar-
gin after laminectomy
3. Foramen magnum
bony margin
B–Occipital Condyle drill-

ing by high speed drill.
C–After drilling of the

condyle, removal of
margin by Kerrison
rongeur.
FIGURE 5 Occipital condyle drilling.

5. Dural Opening and Surgical Corridor

The Curvilinear dural opening starts behind the sigmoid sinus and
extends through the foramen magnum up to the C1 arch leaving
a cuff of the dura adjacent to the vertebral artery which will help
in dural closure (Figure 6A). Possible sources of bleeding during
the dural opening are the marginal sinus that encircles the foramen
magnum and dural arteries. Dura is reflected towards the lateral
side. After opening the dura, identification of the intradural course
of the vertebral artery, spinal accessory nerve, lower cranial nerves
and hypoglossal nerves is most important (Figure 6D). The vertebral
artery is located in front of the dentate ligament at the level of the
foramen magnum (Figure 6C). Lower cranial nerves and hypoglos-
sal rootlets are located anterior to vertebral arteries. Sectioning of
the dentate ligament helps in the mobilization of the vertebral arter-
ies and provides a surgical corridor between the rootlets of nerves
and the lateral margin of the foramen magnum.
6. Lesion Excision
After opening the dura, generous devascularization of the dural
supply is important. Due to narrow corridors, intra-lesional debulking
and dissection help in safe removal of the lesions. Avoidance of stretch-
ing of nerves or brainstem minimizes the neurological complications.
Intra-operative use of CUSA and LASER for debulking helps in reduc-
ing time and minimal blood loss (Figure 7B). In this case, the tumor
was extensively vascular and the use of thallium LASER helped in
minimising blood loss.8 The tumor was arising from the wall of the left
vertebral artery which was separated by LASER (Figure 7C). Histopa-
thology of the tumor came as malignant hemangiopericytoma (WHO
grade 3). Adequate haemostasis is quite important after resection.
7. Dural Closure
Watertight dural closure is recommended. Fat graft can be placed
underlying the dural edge while closures which helps in plugging
the small defects and prevents CSF leak.9
Post Operative Care and Complications
Post-operatively, the patient was kept in ICU with continued monitor-

ing of vitals. In the present case, we did not encounter post-operative
complications. Many authors recommend electively ventilating the
A–Opening of dura from the level of C1 arch to cerebellar dura.

(Black line indicates the direction of dural opening)
B–Reflection of the dura towords the lateral side and tied with silk stitch to
adjacent muscle.
(White arrow shows direction of dural reflection)
C–Cutting of first dentate ligament
(Black arrow pointing at dentate ligament identified as triangular shape)
D–Two corridors for surgical removal of tumor. Medial and lateral to Spinal
rootlets of spinal accessory nerves.
1. Spinal roots of spinal accessory nerve.
2. C1 dorsal root
3. Medulla
4. Tumor
5. Cervicomedullary vein
FIGURE 6 Dural opening and surgical corridor.
patients overnight. Possible early postoperative complications will be

posterior fossa hematoma, cerebellar edema, brainstem infarct, sleep
apnea and respiratory distress (due to lower cranial nerve palsy). Later
complications would be CSF leak, meningitis, respiratory infection etc.
FIGURE 7 (Continue)
A–Relation of the tumour with the vertebral artery Black arrow showing course
of vertebral artery.
B–Tumor debulking with LASER
(Black arrow tip showing LASER tip)
C–Tumor separation from vertebral artery by LASER
1. vertebral artery
2. course of vertebral artery
D–Completely separated from left vertebral artery
1. Left vertebral artery
2. Course of left vertebral artery
3. Right vertebral artery
4. Course of right vertebral artery
E–Dissection of lower pole of tumor
F–Separation of superior pole of tumor from lower cranial nerve rootlets.
Black arrows-rootles of lower cranial nerves.
G–Tumor delivered out after circumferential dissection.
H–Post-tumor-resection cavity and haemostasis.
FIGURE 7 Excision of tumor.
A-Dural closure with keeping fat graft under the margin of edge of the dura.
B-Complete watertight dural closure with prolene 4-0 stitch.
FIGURE 8 Dural closure.
Pearls of Far Lateral Approach

• Far lateral approach provides generous space in the anterolateral
part of the medulla and foramen magnum.
• The selection of approach depends on the location and extent of
the lesion (Table 2).
Table 2 – Suggested variants of far lateral approaches according to lesion.

Variants of far lateral approach Location of lesion
1 Extreme lateral Lower Clivus
2 Transjugular process Jugular Foramen tumors
3 Transtubercular Vertebral artery Engulfed
4 Transcondylar (partial) Ventral Foramen Magnum tumors
5 Retrocondylar Anterolateral foramen magnum
tumors
• Minimal condyle drilling prevents the need for fixation.

• Choosing a surgical corridor between the various neurovascular
structures is tobased on the lesion anatomy and its extension.
• Aggressive debulking helps in complete removal of the tumor
without adjacent structure damage.
• Intra-operative use of LASER helps in reducing time and mini-
mal blood loss.
• Watertight dural closure with fat graft helps in decreasing the risk
of CSF leak.
References
1. Babu RP, Sekhar LN, Wright DC: Extreme lateral transcon-
dylar approach: Technical improvements and lessons learned.
J Neurosurg 1994;81:49–59.
2. Baldwin HZ, Miller CG, van Loveren HR, Keller JT, Daspit
CP, Spetzler RF: The far lateral/combined supra- and infra-
tentorial approach: A human cadaveric prosection model for
routes of access to the petroclival region and ventral brainstem.
J Neurosurg 1994;81:60–68.
3. Panigrahi M, Vooturi S: Foramen magnum meningiomas –
Understanding the requirement and extent of condylar resec-
tion. Neurol India 2019;67:65–6.
4. Mohammad HU, Vooturi S, Panigrahi M. Far lateral approach:
Is condylar resection required? Neurol India 2016;64:455–6.
5. Lang DA, Neil-Dwyer G, Iannotti F: The suboccipital transcon-
dylar approach to the clivus and craniocervical junction for
ventrally placed pathology at and above the foramen magnum.
Acta Neurochir (Wien) 1993;125:132–137.
6. Sen CN, Sekhar LN: Surgical management of anteriorly

placed lesions at the cranio-cervical junction: An alternative
approach. Acta Neurochir (Wien) 1991;108:70–77.
7. Schramm J, Watanabe E, Strauss C, Fahlbusch R: Neurophysi-
ologic monitoring in posterior fossa surgery. I. Technical prin-
ciples, applicability and limitations. Acta Neurochir (Wien).
1989;98(1–2):9–18.
8. Evgenii Belykh, Kaan Yagmurlu, Nikolay L Martirosyan, Ting
Lei, Mohammadhassan Izadyyazdanabadi, Kashif M Malik,
Vadim A Byvaltsev, Peter Nakaji, Mark C Preul: Laser appli-
cation in neurosurgery. Surg Neurol Int. 2017;8:274.
9. Saigal R, Benet A, Hoffman W, et al.: Rotational Pericranial
Flap for Repair of Refractory Posterior Foss Pseudomeningo-
cele. Cureus 2014;6(1):e153.
A PRACTICAL MANUAL FOR
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SKULL BASE SURGERY SOCIETY OF INDIA

NEUROSURGERY ACADEMY PUBLICATION

A PRACTICAL MANUAL FOR

NEUROSURGERY ACADEMY AND RESEARCH FOUNDATION (NARF) INITIATIVE

A Practical Manual for

Skull Base Approaches

NEUROSURGERY ACADEMY PUBLICATION

A Practical Manual for

Neurosurgery Academy and Research Foundation Initiative

©2024 BOHR Publishers

Typeset and Cover designed by

Printed by Thoorigai Prints, Royapettah, Chennai, India

Anil Kumar Sharma

Roopesh Kumar VR, MCh (Neurosurgery)

Lokanayaki V, DO, MS (Anatomy)

Priyadharshan KP, MBBS, MS, MCh, DrNB (Neurosurgery)

Prof. Dr. Ashish Suri,

Dr. Roopesh Kumar

It is with great enthusiasm and a

Chapter 1: Overview of Skull Base Approaches . . . . . . . . . . 1

Chapter 2: Endoscopic Transsphenoidal Approaches:

Chapter 3: Endonasal Trans-Pterygoid Approach. . . . . . . . 27

Chapter 4: Expanded Endoscopic Endonasal Approach to

Chapter 5: The Supraorbital “Keyhole”

Chapter 6: Operative Corridors in Pterional

Chapter 8: Posterior Petrosectomy, Combined Presigmoid

Chapter 9: Retro-Sigmoid Sub-Occipital (RSSO) Approach:

Chapter 10: Far Lateral Approach . . . . . . . . . . . . . . . . . . . 107

Medical College and Hospital, Chennai, India

“A comprehensive grasp of anatomical details is paramount in skull

Prof. Dr. Lokanayaki V.

The anterior cranial fossa is formed by the frontal, ethmoidal,

Evolution of Skull Base Surgery

Early Developments (Pre-1940s)

Skull base surgery began as a rudimentary practice with a limited

Introduction of Microsurgery and

Emergence of Endoscopic and Minimally Invasive

The late 20th century witnessed the advent of endoscopic and

Integration of Imaging and Navigation

Advancements in imaging modalities such as CT, MRI, and angi-

Multidisciplinary Collaboration and

In recent years, skull base surgery has increasingly become a mul-

The Base for Skull Base Surgery

FIGURE 2 Bony anatomy – image demonstrating important landmarks for

There exists a lot of literature on numerous corridors, to approach

step-by-step practical surgical manual for the approaches that serve

FIGURE 3 Mid-sagittal section of the craniofacial bones depicting the midline

FIGURE 5 Axial section showing various transcranial corridors. Blue: Supra-or-

2. Bernadine, Quirk., Steven, Connor. (2019). Skull base imag-

Fellowship in Skull Base Surgery (AIIMS)

Senior Consultant, Department of ENT, Head and Neck

globe between otolaryngologists and neurosurgeons, in approach-

Surgical Anatomy of the Transsphenoidal

Lateral Wall of the Nose

• Inferior turbinate: Separate bone

• Inferior meatus: drains Nasolacrimal duct

• Superior meatus: drains posterior ethmoidal sinus

During the Trans-sphenoidal approach, the surgical Landmarks to

• Nasal septum (NS) / inferior turbinate/nasopharynx (Co).

Chapter 1: Overview of Skull Base Approaches . . . . . . . . . . 1

Chapter 2: Endoscopic Transsphenoidal Approaches:

Chapter 3: Endonasal Trans-Pterygoid Approach. . . . . . . . 27

Chapter 4: Expanded Endoscopic Endonasal Approach to

Chapter 5: The Supraorbital “Keyhole”

Chapter 6: Operative Corridors in Pterional

Chapter 8: Posterior Petrosectomy, Combined Presigmoid

Chapter 9: Retro-Sigmoid Sub-Occipital (RSSO) Approach: