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Endoscopic Endonasal Transclival Approach to the Jugular Tubercle

Fernandez-Miranda, Juan C. MD*; Morera, Victor A. MD*; Snyderman, Carl H. MD*,‡; Gardner, Paul MD*

doi: 10.1227/NEU.0b013e3182438915
Surgical Anatomy and Technique

BACKGROUND: The jugular tubercle is a rounded bony prominence that arises from the inferolateral margin of the clivus. In a previous publication, we described the surgical anatomy of the expanded endonasal approach to the jugular tubercle.

OBJECTIVE: To illustrate the translation of laboratory work to the operating room describing the anatomic and technical nuances of the endonasal approach to the jugular tubercle.

METHODS: We review the relevant surgical anatomy needed to perform an endonasal approach to the jugular tubercle, and we select 4 different lesions to illustrate the application of our laboratory findings.

RESULTS: In the first case, exposure and partial drilling of the jugular tubercle was critical to gain an adequate corridor to the meningioma, particularly to its inferolateral margin. This allowed for early devascularization, safe extracapsular dissection, and preservation of surrounding neurovascular structures. In addition, the jugular tubercle was hyperostotic and its resection, along with generous dural removal, provided a grade I Simpson tumor resection. In the second (chondrosarcoma) and third (chordoma) cases, the jugular tubercle was infiltrated by tumor, and consequently its complete resection was essential to achieve total tumor removal. In the last case, an unusual adrenocorticotropic hormone-secreting adenoma recurrence at the jugular tubercle region, the technical modification of the transclival approach presented here was successfully applied to achieve complete resection and Cushing disease remission.

CONCLUSION: The transjugular tubercle variant of the expanded endonasal transclival approach allows for direct access to ventrolateral lesions in the inferior clival/petroclival region with no cerebral or cerebellar retraction, or cranial nerve manipulation during the approach.

ABBREVIATIONS: ACTH, adrenocorticotropic hormone

CTA, computed tomography angiography

ICA, internal carotid artery

PICA, posterior inferior cerebellar artery

*Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania

Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania

Correspondence: Juan C. Fernandez-Miranda, MD, Department of Neurological Surgery, 200 Lothrop St, PUH B400, Pittsburgh, PA 15213. E-mail: fernandezmirandajc@upmc.edu

Received February 26, 2011

Accepted November 9, 2011

Copyright © by the Congress of Neurological Surgeons