title: Interfascial technique for vertebral artery exposure in the suboccipital triangle: the road map.
abstract: BACKGROUND
  The extradural portion of the vertebral artery (VA-V3) has a unique anatomy at the craniovertebral junction. The exposure of V3 can be accompanied by profuse bleeding from the venous plexus in addition to the potential risk of inadvertent injury of the VA during surgery at the craniovertebral junction. The natural tissue planes represent a road map to the safe exposure of the VA in the suboccipital triangle.
  
  
  OBJECTIVE
  To describe the microsurgical anatomy of the tissue planes in the suboccipital region.
  
  
  METHODS
  The suboccipital region was bilaterally dissected in 6 fresh silicone-injected cadaver heads. An interfascial technique was used to expose the VA-V3 following a tissue plane between the deep suboccipital muscular fascia dorsally and posterior atlantooccipital membrane, the C1 periosteal membrane, and the membrane covering the VA and venous plexus ventrally. The craniovertebral junction was harvested from 2 heads and prepared for histological sections. The same technique was applied in 25 operative cases.
  
  
  RESULTS
  The anatomic dissections confirmed the existence of an interfascial plane that can be dissected in a blunt fashion to reach as far lateral as the transverse processes of C1 and C2. Application of the dissection technique did not require diathermy coagulation in the operating room. In 25 cases, there was no injury of the VA or bleeding from the venous plexus.
  
  
  CONCLUSIONS
  Vertebral artery exposure in the suboccipital triangle (V3) can be achieved safely with minimal blood loss using a technique that follows the natural tissue plane between the deep suboccipital muscle fascia, the posterior atlantooccipital membrane, the membrane covering VA/venous plexus, and the periosteum of the C1 and C2 laminae.
authors.affiliation: Department of Neurosurgery, University of South Florida, Tampa, Florida, USA. ayoussef@hsc.usf.edu
authors.forename: A Samy
authors.initials: AS
authors.lastname: Youssef
authors.forename: Juan S
authors.initials: JS
authors.lastname: Uribe
authors.forename: Edwin
authors.initials: E
authors.lastname: Ramos
authors.forename: Rashid
authors.initials: R
authors.lastname: Janjua
authors.forename: L Brannon
authors.initials: LB
authors.lastname: Thomas
authors.forename: Harry
authors.initials: H
authors.lastname: van Loveren
mesh_terms: D001268:Atlanto-Axial Joint / Q000033:anatomy & histology / Q000601:surgery; D001269:Atlanto-Occipital Joint / Q000033:anatomy & histology / Q000601:surgery*; D001368:Axis, Cervical Vertebra / Q000033:anatomy & histology / Q000601:surgery; D001270:Cervical Atlas / Q000033:anatomy & histology / Q000601:surgery*; D004210:Dissection / Q000379:methods; D005205:Fascia / Q000033:anatomy & histology; D000071938:Fasciotomy; D005539:Foramen Magnum / Q000033:anatomy & histology / Q000601:surgery; D006801:Humans; D007431:Intraoperative Complications / Q000517:prevention & control; D008866:Microsurgery / Q000379:methods*; D018482:Muscle, Skeletal / Q000033:anatomy & histology / Q000601:surgery; D019635:Neurosurgical Procedures / Q000379:methods*; D009777:Occipital Bone / Q000033:anatomy & histology / Q000601:surgery; D014680:Veins / Q000033:anatomy & histology / Q000601:surgery; D014711:Vertebral Artery / Q000033:anatomy & histology / Q000601:surgery*