The midline suboccipital subtonsillar approach to the cerebellomedullary cistern and its structures: Anatomical considerations, surgical technique and clinical application

•We describe the anatomy, the surgical technique, and the clinical application of the STA.•The STA provides a straight and wide angle view of the cerebellomedullary cistern.•Many different types of pathologies are accessible using straight forward STA.•Approach related morbidity might be reduced using the STA.

ObjectiveLesions 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.MethodsThe 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.ResultsTonsillar retraction of 0.3 cm (SD ± 0.1 cm) exposed the PICA with its telo-velo-tonsillar and cortical branches. Retraction of 0.4 cm (SD ± 0.2 cm) exposed the spinal root of CN XI. Retraction of 0.9 cm (SD ± 0.01 cm) exposed the hypoglossal canal. Retraction of 1.3 cm (SD ± 0.2 cm) exposed the root exit zone of the glossopharyngeal nerve. Retraction of 1.6 cm (SD ± 0.3 cm) exposed the jugular foramen (JF), and retraction of 2.4 cm (SD ± 0.2 cm) exposed the inner auditory canal (IAC). In all of the selected cases, the pathology could be reached and exposed using the STA.ConclusionsWe 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.