title: The midline suboccipital subtonsillar approach to the cerebellomedullary cistern and its structures: anatomical considerations, surgical technique and clinical application.
abstract: OBJECTIVE
  Lesions of the cerebellomedullary cistern lateral to the lower brainstem in an area extending from the foraminae of Luschka to the foramen magnum are rare and can be caused by various sources. There is no consensus on an ideal surgical approach. We describe the anatomical features and the surgical technique of the midline suboccipital subtonsillar (STA) approach to the cerebellomedullary cistern and its pathologies.
  
  
  METHODS
  The study was performed on three alcohol (ETOH)-fixed specimens (6 sides), and the technique of the approach was highlighted. The tonsillar retraction needed to view the important structures was measured. Additionally, the records of 31 patients who underwent the STA procedure were evaluated. We provide three clinical cases as examples.
  
  
  RESULTS
  Tonsillar retraction of 0.3cm (SD±0.1cm) exposed the PICA with its telo-velo-tonsillar and cortical branches. Retraction of 0.4cm (SD±0.2cm) exposed the spinal root of CN XI. Retraction of 0.9cm (SD±0.01cm) exposed the hypoglossal canal. Retraction of 1.3cm (SD±0.2cm) exposed the root exit zone of the glossopharyngeal nerve. Retraction of 1.6cm (SD±0.3cm) exposed the jugular foramen (JF), and retraction of 2.4cm (SD±0.2cm) exposed the inner auditory canal (IAC). In all of the selected cases, the pathology could be reached and exposed using the STA.
  
  
  CONCLUSIONS
  We recommend STA as a straightforward, easy-to-learn and therefore time-saving and safe procedure compared with other standard approaches to the cerebellomedullary cistern and its pathologies.
authors.affiliation: Department of Neurosurgery, Eberhard-Karls-University, Tübingen, Germany; Department of Clinical Anatomy, Eberhard-Karls-University, Tübingen, Germany. Electronic address: stephan.herlan@med.uni-tuebingen.de.
authors.forename: Stephan
authors.initials: S
authors.lastname: Herlan
authors.affiliation: Department of Neurosurgery, Eberhard-Karls-University, Tübingen, Germany.
authors.forename: Florian H
authors.initials: FH
authors.lastname: Ebner
authors.affiliation: Department of Neurosurgery, Eberhard-Karls-University, Tübingen, Germany.
authors.forename: Annika
authors.initials: A
authors.lastname: Nitz
authors.affiliation: Department of Clinical Anatomy, Eberhard-Karls-University, Tübingen, Germany.
authors.forename: Bernhard
authors.initials: B
authors.lastname: Hirt
authors.affiliation: Department of Neurosurgery, Eberhard-Karls-University, Tübingen, Germany.
authors.forename: Marcos
authors.initials: M
authors.lastname: Tatagiba
authors.affiliation: Department of Neurosurgery, Eberhard-Karls-University, Tübingen, Germany; Neurological Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates.
authors.forename: Florian
authors.initials: F
authors.lastname: Roser
mesh_terms: D002531:Cerebellum / Q000473:pathology* / Q000601:surgery*; D003391:Cranial Nerves / Q000473:pathology* / Q000601:surgery; D005539:Foramen Magnum / Q000473:pathology* / Q000601:surgery; D006801:Humans; D019635:Neurosurgical Procedures; D009777:Occipital Bone / Q000473:pathology* / Q000601:surgery; D016896:Treatment Outcome
keywords: Anatomy; Cerebellomedullary cistern; Lower cranial nerves; Suboccipital subtonsillar approach