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David Pitskhelauri, Department of Neuro-Oncology, Burdenko National Neurosurgical Medical Research Center, Ministry of Health of the Russian Federation, introduced the experience
of transatlanitipital fascial microsurgery in 15 patients with posterior fossa tumors without resecting any bone structure.
The results were published online in the July 2022 issue of J Neurosurg
.
- Excerpted from the article chapter
【Ref: Pitskhelauri D, et al.
J Neurosurg.
2022 July 22; 1-8.
doi: 1 10.
3171/2022.
5.
JNS22111.
[Epub ahead of print] 】
Research background
Minimally invasive surgery helps improve surgical outcomes
for a variety of intracranial diseases.
David Pitskhelauri, Department of Neuro-Oncology, National Neurosurgical Medical Research Center, Ministry of Health of the Russian Federation, introduced the experience
of microsurgery in 15 patients with posterior fossa tumors through atlanto-occipital membrane (AOM) without resecting any bone structure.
The results were published online in the July 2022 issue of J Neurosurg
.
Research methods
.
Among the 15 patients, the tumor was located in the brainstem in 8 cases and the fourth ventricle in 7 cases
.
In 2 cases, the tumor exceeded the line from the posterior edge of the foramen magnum to the lowest point of the slope (McRAE line).
Three patients had hydrocephalus before surgery, and none of them underwent cerebrospinal fluid shunt before and after surgery
.
The distance from the posterior atlantospinal arch to the posterior margin of the foramen magnum ranged from 9.
9 to 16.
5 mm (median 13 mm).
After head flexion and peeling of soft tissue, this distance increases by 0-7.
7 mm (median 3 mm).
MRI contrast scans are performed 12 days to 2 months after surgery to assess the extent
of tumor resection.
Visual analogue score (VAS) was used to assess the degree of
surgical wound pain.
After general anesthesia, the patient is placed in a prone position
.
The head is flexed so that the distance between the jaw and the sternum is 2-3 cm, and the head
is fixed with a Mayfield head frame.
The incision extends strictly upward along the midline 10 mm below the C2 spinous process and is about 3.
5-4 cm
long.
The skin incision dissects soft tissue in layers from bottom to up to posterior edge of foramen magnum along the white line; Peel off the posterior rectus minorus and rectus
majora with a single pole from about 1 cm from the posterior atlantovertebrae.
Cut the posterior AOM along the median line and turn it over to separate
it from the dura.
The posterior margin of the foramen magnum (width 15-20 mm)
is exposed symmetrically along the midline.
Then, a semi-oval or Y-shaped incision is made in the dura
.
The arachnoid membrane is sharply incised along the midline and the cerebrospinal fluid
is released from the occipital cisterie.
Using the side of the aspirator and microforceps or scissors, pull the cerebellar tonsils, transcribe the arachnoid trabecular in the Magendie foramen area, and cut the fourth ventricular tail and rhomboid fossa
.
If necessary, lateral separation can be continued to expose the tonsillar medullary fissure until the lateral foramen of the fourth ventricular ventricle
.
Depending on the relative position of the posterior edge of the foramen magnum and the dorsal side of the medulla oblongata, this approach can expose not only the caudal part of the fourth ventricle and the rhomboid fossa below the facial thalamus, but also the structure of the lower and lateral cerebellar medulla cisterns, as well as the midbrain aqueduct
.
During the incision of soft tissue and dura mater and manipulation in the area of the Magendie hole and latch, the surgeon is located in front of the patient's
head.
During the fourth ventricle and diamondial fossa, the surgeon is located on one side
of the patient's head.
Study results
All 15 patients had successful surgery, with a time from cutaneous incision to suture of 45-165 minutes, with a median of 95 minutes
.
There were 10 cases (66.
7%) of total tumor resection, 2 cases of brainstem diffuse glioma were biopsied, 1 case of dorsal pontine lymphoma was partially resected, and the other 2 cases were subtotal resection
.
Only one patient developed a postoperative complication, meningoencephalitis, treated with intravenous antibiotics
.
All surgical incisions healed well
.
Two patients developed pseudomyelomeningocele, which disappeared
spontaneously 2 months after surgery.
There was no cerebrospinal fluid leakage
after surgery or during follow-up.
After surgery, only 1 (6.
7%) patient had neck pain, with a VAS score of 3, and the remaining 14 (46.
7%) patients had pain that basically disappeared or disappeared
completely.
The follow-up period ranged from 2 to 12 months (median 7 months).
Five patients underwent radiotherapy and three received radiotherapy combined with chemotherapy
.
At the last follow-up, there was no tumor recurrence
.
One patient died
4 months after being discharged from the hospital due to new coronary pneumonia.
Conclusion of the study
The researchers believe that for suitable patients with posterior fossa tumors, the AOM boneless window minimally invasive surgical approach can fully expose the fourth ventricular tail and brainstem structure
.
