Kraniovertebral bileşkenin mikrocerrahi anatomisi: posterolateral yaklaşımla anatomik çalışma

Yıl 2023, , 534 - 539, 30.09.2023

Yahya Efe Güner , Emre Yağız Sayacı , Emre Bahir Mete , Ayhan Cömert , Ümit Eroglu

https://doi.org/10.18663/tjcl.1341550

Öz

Amaç: Kranioservikal posterolateral yaklaşım, klivusun alt üçte biri ile C2 gövdesinin üst kısmı arasındaki dentat ligamanın önünde yer alan lezyonlar için endikedir. Bu oldukça kalabalık anatomik bölgenin açığa çıkarılma seviyesini artırmak için bu yaklaşım modifiye edilmiş alt grupları da tanımlanmıştır. Bu makalede, kraniovertebral bileşkedeki lezyonlara erişim sağlayan posterolateral yaklaşımın uygulanabilirliğini gösteren anatomik ve klinik bir çalışma sunuyoruz.
Gereç ve Yöntemler: Bu çalışmada formalinle sabitlenmiş ve mumyalanmış dört yetişkin kadavra örneği kullanıldı. Cilt insizyonunu takiben çeşitli kas gruplarının dikkatli diseksiyonu suboksipital üçgeni açığa çıkardı. Vertebral arterin seyrini göstermek için C1 ve C2 arka arkusları çıkarıldı. Son olarak kraniovertebral bileşkeye ulaşmak için suboksipital kraniyektomi yapıldı ve ilişkili bölgesel anatomi açık bir şekilde ortaya kondu.
Bulgular: Geniş klinik öneme sahip çok sayıda anatomik yapı, bu bölgenin hassaslığını ve karmaşıklığını sağlamaktadır. Diseksiyon işlemi sırasında vertebral arter, hipoglossal sinir, spinal aksesuar sinir, dentat ligamanlar, birinci ve ikinci servikal nöral kökler ve beyin sapı dikkatlice açığa çıkarılıp tanımlandı.
Sonuç: Kranioservikal posterolateral yaklaşım, kraniovertebral bileşke ve üst servikal omurgada yer alan patolojilerin cerrahi hakimiyetini ve manevra kabiliyetini arttırır. Bu yaklaşımla anatomik bilgi ve teknik altyapının geliştirilmesi ile bölgenin cerrahi zorlukları aşılabilir.

Anahtar Kelimeler

kraniyovertebral bileşke, mikrocerrahi, anatomi, kadavra, posterolateral yaklaşım

Microsurgical anatomy of the craniovertebral junction: An anatomical study with far lateral approach

Öz

Aim: The far lateral approach is indicated for lesions located anterior to the dentate ligament between the lower third of the clivus and the upper part of the C2 body. Modified subgroups have also been described for increasing the exposure of level of this highly crowded anatomical region. We present an anatomical and clinical study demonstrating the feasibility of a far lateral approach that provides access to multiple lesions at the craniovertebral junction.
Material and Methods: Four formalin-fixed and mummified adult cadaver specimens were used in this study. Skin incision, followed by careful dissection of various muscle groups, exposed the suboccipital triangle. C1 and C2 posterior arches were removed to reveal the course of the vertebral artery. Finally, suboccipital craniectomy was performed to reach craniovertebral junction and associated regional anatomy was openly exposed.
Results: Numerous anatomical structures that have vast clinical significance provides the delicacy and complexity of this region. Vertebral artery, hypoglossal nerve, spinal accessory nerve, dentate ligaments, first and second cervical neural roots and brainstem were carefully exposed and identified during the dissection process.
Conclusion: Far lateral approach increases the surgical dominance and maneuverability of the pathologies located in craniovertebral junction and upper cervical spine. With this approach, surgical difficulties of the region can be overcome with the development of anatomical knowledge and technical infrastructure. Knowledge of the microtopographic surgical anatomy of this region is the fundamental element to achieve an effective surgery.

Anahtar Kelimeler

craniovertebral junction, microsurgery, anatomy, cadaver, far lateral approach

Kaynakça

• Hammon WM, Kempe LG. The posterior fossa approach to aneurysms of the vertebral and basilar arteries. J Neurosurg. 1972 Sep;37(3):339-47. doi:10.3171/jns.1972.37.3.0339. Cited in: Pubmed; PMID 5069379. Heros RC. Lateral suboccipital approach for vertebral and vertebrobasilar artery lesions. J Neurosurg. 1986 Apr;64(4):559-62. doi:10.3171/jns.1986.64.4.0559. Cited in: Pubmed; PMID 3950739.
• George B, Dematons C, Cophignon J. Lateral approach to the anterior portion of the foramen magnum. Application to surgical removal of 14 benign tumors: technical note. Surg Neurol. 1988 Jun;29(6):484-90. doi:10.1016/0090-3019(88)90145-0. Cited in: Pubmed; PMID 3375978.
• Baldwin HZ, Miller CG, van Loveren HR, Keller JT, Daspit CP, Spetzler RF. The far lateral/combined supra- and infratentorial approach. A human cadaveric prosection model for routes of access to the petroclival region and ventral brain stem. J Neurosurg. 1994 Jul;81(1):60-8. doi:10.3171/jns.1994.81.1.0060. Cited in: Pubmed; PMID 8207528.
• Sen CN, Sekhar LN. Surgical management of anteriorly placed lesions at the craniocervical junction--an alternative approach. Acta Neurochir (Wien). 1991;108(1-2):70-7. doi:10.1007/BF01407670. Cited in: Pubmed; PMID 2058431.
• Luzzi S, Giotta Lucifero A, Bruno N, Baldoncini M, Campero A, Galzio R. Far Lateral Approach. Acta Biomed. 2022 Mar 21;92(S4):e2021352. Epub 20220321. doi:10.23750/abm.v92iS4.12823. Cited in: Pubmed; PMID 35441601.
• Rhoton AL, Jr. The far-lateral approach and its transcondylar, supracondylar, and paracondylar extensions. Neurosurgery. 2000 Sep;47(3 Suppl):S195-209. doi:10.1097/00006123-200009001-00020. Cited in: Pubmed; PMID 10983309.
• Bruneau M, George B. Classification system of foramen magnum meningiomas. J Craniovertebr Junction Spine. 2010 Jan;1(1):10-7. Conflict of Interest: None declared. doi:10.4103/0974-8237.65476. Cited in: Pubmed; PMID 20890409.
• Liu JK, Couldwell WT. Far-lateral transcondylar approach: surgical technique and its application in neurenteric cysts of the cervicomedullary junction. Report of two cases. Neurosurg Focus. 2005 Aug 15;19(2):E9. Epub 20050815. doi:10.3171/foc.2005.19.2.10. Cited in: Pubmed; PMID 16122218.
• Lanzino G, Paolini S, Spetzler RF. Far-lateral approach to the craniocervical junction. Neurosurgery. 2005 Oct;57(4 Suppl):367-71; discussion 367-71. doi:10.1227/01.neu.0000176848.05925.80. Cited in: Pubmed; PMID 16234687.
• Wen HT, Rhoton AL, Jr., Katsuta T, de Oliveira E. Microsurgical anatomy of the transcondylar, supracondylar, and paracondylar extensions of the far-lateral approach. J Neurosurg. 1997 Oct;87(4):555-85. doi:10.3171/jns.1997.87.4.0555. Cited in: Pubmed; PMID 9322846.
• Visocchi M. New Trends in Craniovertebral Junction Surgery Experimental and Clinical Updates for a New State of Art: Experimental and Clinical Updates for a New State of Art. 2019. ISBN: 978-3-319-62514-0.
• Cacciola F, Boszczyk B, Perrini P, Gallina P, Di Lorenzo N. Realignment of Basilar Invagination by C1-C2 Joint Distraction: A Modified Approach to a Paradigm Shift. Acta Neurochir Suppl. 2019;125:273-277. eng. doi:10.1007/978-3-319-62515-7_39. Cited in: Pubmed; PMID 30610333.
• Goel A. Treatment of basilar invagination by atlantoaxial joint distraction and direct lateral mass fixation. J Neurosurg Spine. 2004 Oct;1(3):281-6. eng. doi:10.3171/spi.2004.1.3.0281. Cited in: Pubmed; PMID 15478366.
• Yamazaki M, Koda M, Aramomi MA, Hashimoto M, Masaki Y, Okawa A. Anomalous vertebral artery at the extraosseous and intraosseous regions of the craniovertebral junction: analysis by three-dimensional computed tomography angiography. Spine (Phila Pa 1976). 2005 Nov 1;30(21):2452-7. eng. doi:10.1097/01.brs.0000184306.19870.a8. Cited in: Pubmed; PMID 16261125.
• Cacciola F, Phalke U, Goel A. Vertebral artery in relationship to C1-C2 vertebrae: an anatomical study. Neurol India. 2004 Jun;52(2):178-84. eng. Cited in: Pubmed; PMID 15269464.