title: Comparison of different infratentorial-supracerebellar approaches to the posterior and middle incisural space: a cadaveric study.
abstract: OBJECTIVE
  The purpose of this investigation was to describe and compare through cadaveric dissection the microsurgical exposure afforded by the median, paramedian, and extreme-lateral infratentorial-supracerebellar approaches to the posterior and middle incisural space.
  
  
  METHODS
  The median, paramedian, and extreme-lateral infratentorial-supracerebellar approaches were performed in 10 embalmed cadaveric heads by using standard microneurosurgical methods; each approach was executed a minimum of five times. The dissections were performed in a stepwise fashion, comparing the exposure afforded by each surgical route and highlighting the relationships among the targeted neurovascular structures. Exposure of the dural sinuses and transection of the tentorium were also evaluated in relation to the degree of exposure achieved. The median infratentorial-supracerebellar route provides direct exposure of the posterior incisural space, although the culmen represents a relative obstacle to exposure of the lower quadrigeminal plate. The paramedian variant allows a more lateral perspective on the posterolateral brainstem surface at the level of the middle incisural space, in addition to exposing the homolateral collicular plate. The extreme-lateral corridor widens the exposure of the paramedian approach to include the anterolateral brainstem surface, offering a complete view of the cisternal space surrounding the middle incisural space. Complete, constant exposure and retraction of the dural sinuses facilitated the surgical exposure.
  
  
  CONCLUSIONS
  The infratentorial-supracerebellar approaches allow safe circumferential exposure of the posterior and middle incisural space. Choosing among different variants allows the surgeon to reach selected areas, with the midline variant being best for exposure of the posterior incisural space, and the paramedian and extreme-lateral variants being best for reaching the posterior and the anterior part of the middle incisural space, respectively. The more lateral the approach, the more anterior and multiangled the exposure gained. Complete, constant exposure and retraction of the dural sinuses improves the exposure. Accurate knowledge of the regional anatomy is mandatory.
authors.affiliation: Division of Neurosurgery, Albert Einstein Medical Center, Philadelphia, Pennsylvania 19141, USA. lemoko60@hotmail.com
authors.forename: Mario
authors.initials: M
authors.lastname: Ammirati
authors.forename: Antonio
authors.initials: A
authors.lastname: Bernardo
authors.forename: Angelo
authors.initials: A
authors.lastname: Musumeci
authors.forename: Albino
authors.initials: A
authors.lastname: Bricolo
mesh_terms: D002102:Cadaver; D002531:Cerebellum / Q000033:anatomy & histology* / Q000601:surgery; D003388:Cranial Fossa, Posterior / Q000033:anatomy & histology* / Q000601:surgery; D003391:Cranial Nerves / Q000033:anatomy & histology / Q000601:surgery; D003399:Craniotomy / Q000379:methods*; D006801:Humans; D008636:Mesencephalon / Q000033:anatomy & histology* / Q000601:surgery