Quantification and comparison of telovelar and transvermian approaches to the fourth ventricle.
OBJECTIVE
To quantify the exposure to the fourth ventricle obtained with the telovelar and transvermian approaches.


METHODS
The telovelar, with and without C1 posterior arch removal, and transvermian approaches were performed on six cadaveric heads. The area of surgical exposure was calculated from triangles formed by defined anatomic points. A robotic microscope was used to determine the "angle of approach" for the same points.


RESULTS
The maximal allowable vertical angle of attack to the obex of the fourth ventricle was significantly greater with the telovelar approach than with the transvermian approach (P < 0.002), but there was no difference at the rostral fourth ventricle. The maximal allowable horizontal angle of attack at the level of the obex, Luschka, and rostral fourth ventricle was significantly greater with the telovelar than with the transvermian approach (P < 0.001). Removal of the C1 posterior arch with the telovelar approach significantly increased the vertical angle of approach to the obex (P < 0.001) and rostral aspect of the fourth ventricle (P = 0.005) compared with the telovelar alone. The telovelar approach with C1 arch removal offered a larger working area than the transvermian approach (P < 0.001).


CONCLUSIONS
Except for the vertical angle to the rostral aspect of the fourth ventricle, the telovelar approach provides greater angle of exposure in all planes than the transvermian approach. Removal of the C1 posterior arch obviates this sole advantage of the transvermian approach. The telovelar approach offers a corridor through noneloquent arachnoid planes and a safe and capacious working environment.
Deshmukh
Vivek R
VR
Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona 85013, USA.
Figueiredo
Eberval Gadelha
EG
Deshmukh
Puspha
P
Crawford
Neil R
NR
Preul
Mark C
MC
Spetzler
Robert F
RF
D002531:Cerebellum / Q000033:anatomy & histology / Q000601:surgery; D003399:Craniotomy / Q000379:methods*; D020546:Fourth Ventricle / Q000033:anatomy & histology / Q000601:surgery*; D006801:Humans; D008279:Magnetic Resonance Imaging / Q000379:methods; D038361:Neuronavigation / Q000379:methods; D019635:Neurosurgical Procedures / Q000379:methods*