title: [Anatomical landmarks and surgical limits in the suboccipital transmeatal approach to the acoustic neuroma].
abstract: BACKGROUND
  To completely remove the intracanalicular portion of the acoustic neuroma through the retrosigmoid approach, we must open the posterior wall of the internal auditory canal (IAC). Therefore, drilling the IAC is one of the key steps we need to take in the transmeatal surgical approach. Nevertheless, there are no clear anatomical landmarks to identify structures such as the semicircular canals, the jugular bulb or air cells. The individual anatomical variations and those caused by the tumour itself make preoperative evaluation essential if we wish to avoid complications such as deafness, cerebrospinal fluid leakage, bleeding and air embolism.
  
  
  OBJECTIVE
  We describe here the personal experience of the senior author (EU) in drilling the posterior wall of the IAC, with special reference to the anatomical landmarks and surgical limits in the suboccipital approach to the intracanalicular portion of the acoustic neuromas.
  
  
  METHODS
  This work is based on anatomical data obtained from drilling human temporal bones obtained from cadavers, along with our experience with 20 patients who were operated on for acoustic neuroma using Samii's technique.
  
  
  RESULTS
  We did not operate on any purely intracanalicular neurinomas using this approach. Two tumors were grade II (up to 20mm in diameter), 12 were grade III and 6 were grade IV. We did not drill far enough in any of these cases to be able to see the fundus of the IAC, which was confirmed by postoperative CT. Despite this, the tumor was considered to be completely removed in 17 cases. There was no mortality and we has no major complications as a result of drilling the IAC such as cerebrospinal fluid leakage or air embolism. we cannot guarantee that hearing loss of postoperative deafness, which were the norm except in one case of grade II, were caused by nervous, ischemic or labyrinthine lesions.
  
  
  CONCLUSIONS
  In our material it was not possible to completely expose the IAC fundus using a retrosigmoid approach without injury to labyrinth. The areas in which the risk of secondary complications is greatest when drilling are the inferior wall and the IAC fundus. The medial extension of the suboccipital craniotomy makes drilling the intrameatal tumor exposure easier. There are no intraoperative landmarks to locate the petrous structures while drilling the IAC except for those provided by the surgeon's own experience.
authors.affiliation: Servicio de Neurocirugía y Sección de O.R.L. Hospital Donostia. San Sebastián, España.
authors.forename: E
authors.initials: E
authors.lastname: Urculo
authors.forename: R
authors.initials: R
authors.lastname: Alfaro
authors.forename: M
authors.initials: M
authors.lastname: Arrazola
authors.forename: G
authors.initials: G
authors.lastname: Rejas
authors.forename: J
authors.initials: J
authors.lastname: Proaño
authors.forename: J
authors.initials: J
authors.lastname: Igartua
mesh_terms: D046508:Culture Techniques; D007758:Ear, Inner; D008279:Magnetic Resonance Imaging; D009367:Neoplasm Staging; D009464:Neuroma, Acoustic / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D019635:Neurosurgical Procedures / Q000379:methods*; D009778:Occipital Lobe; D013701:Temporal Bone / Q000033:anatomy & histology*; D014057:Tomography, X-Ray Computed