R e t ro s i g m o i d A p p ro a c h :

Indications, Techniques, and Results

Mohamed Samy Elhammady, MDa,*, Fred F. Telischi, MEE, MD

b
,
Jacques J. Morcos, MD, FRCS (Eng.), FRCS (Ed)a

KEYWORDS
 Vestibular schwannoma  Acoustic neuroma  Retrosigmoid  Surgical technique

KEY POINTS
 The retrosigmoid or lateral suboccipital approach is the most commonly used approach
for vestibular schwannoma; indicated for tumors of all sizes, particularly when hearing
preservation is the goal.
 The excellent exposure of the brainstem and cranial nerves via the retrosigmoid approach
permits complete excision of small-to-medium-sized tumors when hearing preservation is
the goal and safe resection of larger tumors that compress the brainstem and adjacent
neurovascular structures.
 Expertise in retrosigmoid surgery is very much experience dependent, as one incremen-
tally learns new technical pearls in complication avoidance.

As in any other discipline, many of today’s accomplishments in the treatment of

acoustic neuromas owe their existence to the brilliance (or good fortune) of the
many pioneers who came before and paved an ever more refined path. The year
1777 seems to be the accepted time stamp that marks the recognition by Sandifort
during an autopsy of the entity of acoustic neuroma.1 Fast-forward to 1890, the
year that von Bergmann earned the distinct honor of attempting to become the first
to resect surgically an acoustic neuroma.1 The patient sadly succumbed before von
Bergmann’s localizing the tumor.

EARLY SURGICAL APPROACHES

In spite of reports by many authors, most today would recognize Krause as the archi-
tect of the suboccipital approach.2 It is quite amazing to realize that an early version of
the “translabyrinthine” approach was suggested by Panse in 19043; the tireless

a
Department of Neurological Surgery, University of Miami School of Medicine, Lois Pope LIFE
Center, 1095 NW 14th Terrace, 2nd Floor, (D4-6), Miami, FL 33136-1060, USA
b
Department of Otolaryngology, Neurological Surgery and Biomedical Engineering, University
of Miami School of Medicine, Clinical Research Building, 1120 NW 14th Street, 5th Floor,
Miami, FL 33136, USA
* Corresponding author.
E-mail address: [email protected]

Otolaryngol Clin N Am 45 (2012) 375–397

doi:10.1016/j.otc.2012.02.001 oto.theclinics.com
0030-6665/12/$ – see front matter Ó 2012 Published by Elsevier Inc.
376 Elhammady et al

debate between proponents of both approaches has been raging ever since. Cushing
criticized the translabyrinthine approach for its narrow confines, proximity of vascular
structures, risk of CSF leak, and unsuitability for large tumors.4 Remarkably, a hundred
years later, many modern neurosurgeons have similar reservations.
The advent of ventriculography, pneumoencephalography and angiography im-
proved the diagnostic accuracy of acoustic neuromas and Cairns is credited with
the first successful total resection of an acoustic neuroma with facial nerve preserva-
tion in 1931.5 While Cushing had advocated a bilateral suboccipital craniotomy in all
cases to prevent cerebellar herniation, and intentional subtotal resection, Dandy
much favored the small unilateral retrosigmoid flap and gross total resection, which
he first reported in 1917.6 McKenzie, Alexander7 and Olivecrona8 modified his tech-
nique, and popularized the shift from prone to sitting position, a trend that remained
significant for several decades, to be supplanted by the three-quarter prone and
supine positions in more recent years.

SURGICAL MICROSCOPE

The distinction of introducing the surgical microscope to the resection of acoustic

neuromas, undoubtedly, the most influential technical advance in this 120 year history
belongs to an otological surgeon, Bill House, although he used it to re-introduce
successfully the transtemporal approaches (translabyrinthine and middle fossa).9

EARLY SURGICAL OUTCOMES

Safety of surgery improved steadily through the century. Surgical mortality started in
the 80% range in the early days, and dropped to below 10% in House’s hands in the
1960s, and is today below 1%. Similarly, anatomic facial nerve preservation rates
started at 0% and today are virtually 100%.2

INDICATIONS

Treatment options for acoustic neuromas include observation, radiosurgery, and

microsurgery. The factors involved in decision-making are discussed in this issue in
the article by Sheth et al. Once a decision has been made to operate, the surgeon
must choose from among three main surgical approaches:

1. Middle fossa
2. Translabyrinthine
3. Retrosigmoid.

The choice of surgical approach is dependent on several factors including:

 Patient’s age
 Paitent’s hearing status
 Tumor size
 Surgeon preference.
The middle fossa approach is used for small tumors (z 1 cm) that are primarily intra-
canalicular and when hearing preservation is the goal.
The translabyrinthine approach is generally used for tumors of any size when
hearing preservation is not an issue.
The retrosigmoid or lateral suboccipital approach is the most commonly used
approach and is also indicated for tumors of all sizes, particularly when hearing preser-
vation is the goal. The retrosigmoid approach offers an excellent exposure of the
 Retrosigmoid Approach 377

brainstem and cranial nerves IV through XII. This permits complete excision of small-to-
medium-sized tumors when hearing preservation is the goal and safe resection of larger
tumors that compress the brainstem and adjacent neurovascular structures.

PREOPERATIVE ASSESSMENT

Preoperative evaluation includes:

 Standard preoperative labs

 Electrocardiogram
 Chest radiograph
 Assessment of the patient’s general health.

It is important to obtain a preoperative audiogram with pure tones and speech

discrimination to ascertain baseline hearing function.
Magnetic resonance imaging with and without gadolinium administration including
IAC views provides vital information regarding the soft tissue anatomy.
The tumor size, including its rostro-caudal and intracanalicular extensions, is
determined.
T2-weighted images provide details regarding tumor consistency (hyperintense
lesions are suggestive of softer and more suckable tumors), associated edema, and
the plane between the tumor and surrounding structures.
The location and size of the sigmoid sinus and jugular bulb should also be assessed,
particularly to be aware of a high jugular bulb that may hinder drilling of the caudal
posterior lip of the IAC.
Computed tomography of the temporal bone provides information regarding aera-
tion of the mastoid process and the location of the posterior semicircular canal in rela-
tion to the IAC.

ANESTHESIA FOR VESTIBULAR SCHWANNOMA

The anesthetic technique is similar to that of other brain tumors:

 After anesthesia is induced an arterial line is obtained and an indwelling Foley
catheter inserted.
 All pressure points are padded.
 Sequential compression devices are placed to prevent deep venous thrombosis.
 Preoperative antibiotics are administered one-half hour before skin incision and
10 mg of dexamethasone is given at the beginning of the operation. Antibiotics
are re-dosed as necessary based on the length of the procedure.
 At the time of skin incision, a 20% solution of mannitol in a dosage of 0.5 to 1 mg/kg
body weight is administered intravenously over a period of 15 to 20 minutes.
 The patient is hyperventilated to obtain an end-tidal CO2 of 28 mmHg.
 Although a lumbar drain can be inserted, we have found that, in most cases,
adequate brain relaxation can be obtained with corticosteroids, hyperventilation,
and cisterna magna drainage.
 It is important not to give paralytics to allow monitoring of facial nerve function.
However, once the tumor has been removed, inhalation anesthetics may be
administered to allow a rapid and smooth awakening from anesthesia.

MONITORING DURING SURGERY

Neurophysiologic monitoring during acoustic neuroma surgery allows continuous

assessment of brain stem, facial nerve, and auditory nerve function throughout the
378 Elhammady et al

procedure. Facial nerve function is monitored by inserting EMG electrodes into the
orbicularis oculi and oris muscles and placing a motion sensor on the patient’s
face. Brainstem auditory evoked potentials and electrocochleography using a trans-
tympanic electrode allows monitoring of auditory function in cases where hearing
preservation is attempted. We have been very satisfied with near-field direct cochlear
nerve recordings as a reliable measure of cochlear nerve functioning during dissec-
tion. More details about intraoperative monitoring are discussed in another Chapter.

SURGICAL TECHNIQUE
Position
The patient can be positioned sitting, supine, or in a lateral decubitus.
In the sitting position:
 The patient is placed upright on several cushions and hips and knees are bent
approximately 90 .
 The head is turned 30 toward the side of the lesion, flexed slightly in an antero-
posterior plane, and fixed in a 3-pin Mayfield head clamp.
The sitting position facilitates drainage of blood and cerebrospinal fluid out of the
wound and thus provides a bloodless and clear operative field. However, it carries
a higher risk of air embolism and spinal cord ischemia and, in our opinion is more
cumbersome and exhausting for the surgeon’s arms as compared with the other posi-
tions. For these reasons, we prefer either the supine or lateral decubitus position
based on the patient’s body habitus.
We used the supine position in our earlier experience, but more recently have adop-
ted the lateral decubitus position exclusively.
 In the supine position, the shoulder that is ipsilateral to the tumor is elevated with
a gel roll to allow turning of the head without excessive tension on the neck.
 In the lateral position, the patient is placed with the side of the lesion upward
while the dependant arm hangs off the bed and is cradled in a padded sling
between the table and edge of the Mayfield head holder.
 With the lateral position, it is important to retract the patient’s superior shoulder
toward the patient’s feet using adhesive tape, taking special care not to create
a brachial plexus stretch injury.
Regardless of the position used, the head is fixed in a 3-pin Mayfield clamp and
positioned with 3 movements:
1. Contralateral rotation so that the temple is parallel to the floor.
2. Contralateral bending so that the vertex is slightly tilted toward the floor.
3. Flexion in the anteroposterior plane until the chin is two finger breadths from the clavicle
to open the cervical-suboccipital angle. Over-flexion could compress the jugular veins.
The operating table is placed in slight reverse Trendelenberg so as to position the
patient’s head above the level of the heart to reduce cerebral venous congestion.

Incision and Exposure

The retroauricular region of the scalp is shaved. Several surface landmarks can be
identified and marked to plan the skin incision. We use 3 reference points:
1. External auditory canal (EAC)
2. Inion
3. Tip of the mastoid process.
 Retrosigmoid Approach 379

The course of the sigmoid sinus is represented by the posterior border of the
mastoid process. The EAC-inion line is generally parallel to and slightly lower than
the lower border of the transverse sinus.

 We mark a point along the EAC-inion line at which we start our drilling to expose
the transverse sigmoid junction. This point is placed 4 cm and 4.5 cm from the
external auditory canal in females and males, respectively.

Technical pearl
Although the asterion may be used to approximate the transverse-sigmoid junction,
it is frequently difficult to accurately identify intraoperatively. We have found that
these points are useful safe areas to start the drilling to expose the venous sinuses.
They are almost always medio-caudal to the actual TS junction.

 The size of the planned craniotomy is approximately 3.0 to 3.5 cm, immediately
posterior to the sigmoid sinus.
 A C-shaped retroauricular incision is then marked extending approximately 2 cm
below the tip of the mastoid to a point approximately 2 cm above the pinna. It is
crucial that the apex of the C-shaped incision extend beyond the medial edge of
the planned craniotomy because it is difficult to retract the skin posteriorly. It is
for this reason that we do not use a linear incision, which generally results in
the skin edges lifting up with traction and compromising the medial exposure.
 The scalp is prepped and draped in a standard fashion and the planned incision
infiltrated with 0.5% lidocaine with epinephrine 1:200,000.
 The scalp incision is elevated sparing the pericranium above the superior nuchal
line and the fascia overlying the suboccipital musculature.
 The suboccipital fascia and muscles are then incised in a T-shaped fashion.
 The horizontal limb is made leaving a small muscular cuff attached to the superior
nuchal line.
 The vertical limb is carried down caudally until the occipital bone changes orien-
tation from a horizontal to a more vertical plane (floor of the posterior fossa).

Technical pearl
Caution must be exercised during the lower end of the exposure. Overzealous use of
the Bovie in the region between the occipital bone and C1 may result in a vertebral
artery injury. In this region it is only necessary to incise the superficial muscle fibers.
Adequate exposure can then be achieved with several fishhooks retracting in an
upward direction, a maneuver that creates significant depth.

 Once the muscular incisions have been made, the muscles are elevated in a sub-
periosteal fashion to uncover the suboccipital bone and the base of the mastoid
process including the digastric groove. The exposure is maintained by retracting
the scalp flap and suboccipital muscles with fish hooks.
 The transverse and sigmoid sinuses are then exposed using a combination of 5
mm round cutting and diamond burrs.
 An initial burr hole is placed just medio-caudal to the presumed location of the
transverse-sigmoid junction based on the surface landmarks described above.
 Once the dura is identified, the drilling is continued in a superolateral direction
until the transverse-sigmoid junction is identified.
380 Elhammady et al

 Drilling is then continued in a caudal direction to expose the edge of the sigmoid
sinus. It should be noted that the outer wall of the sigmoid sinus is curved and
more adherent to the overlying bone than the transverse sinus.

Technical pearl
Bleeding from the mastoid emissary vein is frequently encountered during drilling.
This may be controlled with bone wax until its bony canal has been drilled, at which
point it may be coagulated and sectioned. The emissary vein may also be used as
a landmark and followed to the sinus.

 Once the sigmoid sinus has been exposed, the dura is carefully separated from
the overlying bone in the region of the transverse sinus and cerebellum.
 A craniotomy is then performed extending from the transverse sinus to the caudal
level of the sigmoid sinus where it curves anteriorly. Frequently, it is necessary to
remove additional bone inferiorly beyond the craniotomy flap to expose the floor
of the posterior fossa to gain access to the lateral cerebellomedullary cistern. Any
mastoid air cells that have been entered during the drilling are occluded now with
bone wax.
 At this stage of the procedure the operative microscope is used.
 The dura is opened in a C-shaped fashion based medially.
 Initially only a small horizontal dural opening at the caudal portion of the exposure
is made to avoid outward herniation of the cerebellum. It is helpful here for the
surgeon to position himself at the patient’s vertex, looking caudally with the
microscope.
 A 0.25  3 in telfa is placed over the cerebellum and the latter is depressed to
expose the lateral recess of the cisterna magna.
 The arachnoid membrane is then sharply incised under direct vision and cerebro-
spinal fluid is allowed to drain for several minutes.

Technical pearl
Occasionally there may be a small vein in this region which may be injured if the
cerebellum is excessively retracted or the arachnoid is blindly incised.

 Once the cerebellum is adequately relaxed, the remaining dura is opened

approximately 5 mm parallel to the sigmoid and transverse sinuses, and the dural
flap placed under tension medially to avoid it shrinking during the surgery. The
dural edge along the sigmoid and transverse sinuses is also retracted with 4–0
neurolon sutures.
Tumor Exposure and Removal
 The midportion of the cerebellum is covered with telfa patties and gently mobi-
lized to expose the cerebellopontine angle. A self-retaining retractor is never
used, no matter how small or large the tumor is.

Technical pearl
The key to exposure is not forceful cerebellar retraction, but rather thorough arach-
noidal lysis in the upper, middle and lower components of the CP angle cistern, as
well as the cerebellomedullary cistern. Working from caudally to rostrally is usually
the best strategy.
 Retrosigmoid Approach 381

 The next step is to open the arachnoid over the inferior tumor pole and the lower
cranial nerves and establish the appropriate plane of dissection.

Technical pearls
Acoustic neuromas are invested in two arachnoidal layers. The first of these
layers represents the peripheral arachnoidal layer of the posterior fossa whereas
the second layer comprises the arachnoid membrane that envelops the tumor
itself and was invaginated by it. Ideally the dissection should be performed
between these two layers so that cranial nerves and major arteries can be
shielded from the dissection. However, in the event that there is a poor arachnoi-
dal plane, it may be necessary to carry out the dissection between the tumor and
the deep arachnoidal layer.
Unless the tumor is very large and occupies all available space, the initial view
reveals the lateral portion of the tumor and the anterior inferior cerebellar artery
with its subarcuate branch. The lower cranial nerves and posterior inferior cerebellar
artery are identified caudally and the trigeminal and petrosal vein rostrally.
Occasionally, with small-to-medium-sized tumors the eighth nerve complex may
be identified entering the inferomedial side of the tumor with its fibers splayed over
the posterior surface of the capsule. In such cases the vestibular nerve remnant
proximal to the tumor is divided, enabling dissection of the tumor from the cochlear
and facial nerve.

 The AICA is dissected and mobilized off the capsule; branches to the tumor are
coagulated and sectioned.
 The subarcuate artery that arises from the AICA and enters the subarcuate fossa
(located superior and posterior to the IAC) is coagulated and divided.

Technical pearl
Rarely, a subarcuate variant of the AICA is identified in which the main vessel forms
a loop with the apex embedded in the dura and possibly the petrous bone just
posterior to the IAC. To free the AICA, the dura and bone surrounding the artery
must be carefully removed.

Technical pearl
At this stage in the procedure, the posterior surface of the tumor capsule is
inspected and stimulated to ensure that the facial nerve has not been displaced pos-
teriorly, a rare surgical variant that carries tremendous consequences if unrecog-
nized. In most cases the facial nerve can be found along the anterior or
anterosuperior surface of the tumor capsule as it courses laterally. However on
rare occasions, particularly in patients with recurrent tumors or those with neurofi-
bromatosis type 2, the facial nerve may be found on the inferior or even the posterior
aspect of the tumor. In small-to-medium-sized tumors, where the root entry zone of
the eighth cranial nerve may be visualized early in the procedure, the facial nerve is
identified or stimulated beneath and deep to the vestibulo-cochlear nerve. The facial
nerve can be differentiated from the eight cranial nerve and adjacent brainstem by
its characteristic color and of course by direct stimulation.
382 Elhammady et al

 After confirming that the facial nerve has not been displaced posteriorly, internal
decompression of the tumor is then performed to gain surgical space.
 The posterior surface of the capsule is entered and the intracapsular contents of
the lateral portion of the tumor are evacuated using a combination of suctioning,
bipolar coagulation, cup forceps, and ultrasonic aspiration. The goal should be to
thin the tumor to within a few millimeters from the remaining capsule. This creates
a space for delivery and subsequent internal decompression of the more medially
situated tumor. Furthermore, it reduces the tension on the VII/VIII nerve complex
during the dissection.

Technical pearl
Over-aggressive debulking should be avoided as it may breach the tumor capsule
and potentially injure the brainstem and adherent cranial nerves.

 Once adequate internal decompression has been achieved, the tumor capsule is
dissected along the double layer of arachnoid away from the surrounding neuro-
vascular structures. The dissection usually begins caudally separating the glos-
sopharyngeal and vagus nerves from the lower pole of the tumor capsule.

Technical pearl
Loops of the posterior and anterior inferior cerebellar arteries may be encountered
and need to be dissected from the tumor and protected.

 The dissection is continued medially along the medulla to the foramen of Luschka
and flocculus.
 After carefully elevating the inferiomedial capsule laterally and superiorly, the
facial and vestibulocochlear nerves are identified at their exit from the pons at
the pontomedullary sulcus.
 A useful landmark to identify the root entry zone of the VII/VIII complex is to trace
a line superiorly from the root entry zone of the glossopharyngeal and vagus
nerves. As previously mentioned the facial nerve is usually located just under
the vestibulocochlear nerve. These nerves are often splayed out and appear as
a thin membrane over the anterior surface of the tumor.
 The tumor capsule is sharply dissected away from the nerves using a combina-
tion of microscissors, a sharp nerve hook, or a Rhoton no. 3 dissector. Because
the cochlear nerve exits the IAC at the fundus through a “cribriform” plate, its
individual fibers are prone to be avulsed easily if retracted medially. There, Rho-
ton advocates using only medial-to-lateral traction of the tumor if hearing preser-
vation is the goal.10

Technical pearl
Dissection of these nerves beyond the point at which they become splayed,
thinned out, or enter through the porus acousticus is not advisable at this stage
in the procedure. The internal auditory (labyrinthine) branch of the AICA, which
frequently accompanies the eighth cranial nerve should be preserved if hearing
is to be saved.

 Next, the upper pole of the tumor capsule is separated from the trigeminal nerve
and petrosal vein. In most cases it is unnecessary to sacrifice the petrosal vein;
 Retrosigmoid Approach 383

however it may be coagulated and divided, if absolutely necessary, particularly

with larger tumors to facilitate dissection of the upper pole.
 The superior cerebellar artery is encountered and freely dissected.
 As the cranial, caudal, and medial portions of the tumor are dissected from the
surrounding neurovascular structures, the cleavage plane is maintained using
telfa patties.
 Redundant tumor capsule is excised and repeated internal decompression per-
formed to allow further centripetal mobilization of the tumor.

Technical pearl
Any maneuver that results in deterioration in the brainstem auditory evoked
responses or abnormal firing of the facial nerve require immediate cessation to allow
recovery. Irrigation with warm saline frequently quiets the facial nerve. Deterioration
secondary to surgically induced vasospasm may be managed by local application of
papaverine.

 When the porus is reached or when further dissection of the tumor from medial to
lateral becomes difficult, the posterior wall of the IAC is drilled and the intracana-
licular tumor removed.
 If the porus cannot be easily appreciated, a blunt microhook may be used to
probe the canal and delineate its superior and inferior margins.

Technical pearl
The tumor is frequently constricted by the thickened dura at the porus, which may
give a false impression as to the true caliber of the meatus and the amount of bone
removal required.

 Several landmarks on the posterior surface of the petrous bone provide orienta-
tion to the labyrinth and IAC:
1. The entrance of the subarcuate artery at the subarcuate fossa marks the
center of the superior semicircular canal.
2. The bony operculum which overlies the aperture of the vestibular aqueduct
approximates the floor of the internal auditory meatus.
3. The medial border of the endolymphatic sac can be used as a lateral boundary
to avoid the common crus and ampullated end of the superior semicircular
canal.
 Gelfoam sponges are placed in the subarachnoid space to prevent dissemination
of bone dust during drilling.
 The dura is excised along the axis of the IAC, extending no more that 1 cm lateral
to the porus acousticus. Alternatively, the dura may be incised in a C-shaped
fashion from the porus, elevated, and reflected over the posterior aspect of the
tumor, to be used later to cover the exposed perilabyrinthine air cells following
drilling.
 The posterior wall of the IAC is then drilled under constant suction and
irrigation until the posterior 180 to 270 of the canal circumference has been
removed.
 The dura lining the IAC is gradually exposed along its long axis from medial to
lateral using progressively smaller cutting then diamond burrs. The safe drilling
zone tapers as one reaches the fundus.
384 Elhammady et al

 An extensive bony removal as described is necessary to adequately expose the

tumor and facilitate its dissection.

Technical pearl
Caution should be exercised while drilling the superior aspect of the canal to avoid
injury to the facial nerve as it runs in the facial canal located in the antero-superior
quadrant of the IAC. Similarly, drilling of the inferior aspect of the canal should be
performed judiciously to avoid injury to a high jugular bulb.
The drilling should be carried as far laterally as the tumor extends without entering
the labyrinth.
A clue to the lateral extent of the tumor is the transition in color of the canal dura
from white to blue indicating presence and absence of tumor, respectively. Occa-
sionally the lateral exposure requires blue-lining of the common crus or ampullated
end of the superior semicircular canal.
In the event that a semicircular canal is entered, it should be immediately closed
with bone wax in hopes of preserving hearing. The endoscope may also be used to
visualize residual tumor in the lateral end of the canal.

 Once the drilling has been completed, the dura lining the IAC is opened to expose
the intracanalicular portion of the tumor.
 The tumor and/or superior vestibular nerve are displaced inferiorly to expose and
stimulate the facial nerve near the origin of the facial canal.
 The vestibular nerve remnant distal to the tumor is sectioned, whereas normal
vestibular fascicles are preserved.
 We also attempt to maintain continuity of the cochlear nerve, even if hearing
preservation is not a goal, because it provides support and limits movement
of the facial nerve. Furthermore it may reduce the risk of facial nerve
ischemia.
 The intracanalicular tumor is then removed and the facial nerve identified to the
porus. In most cases this part of the tumor has few adhesions to the nerves and
can be removed without difficulty. However, in some instances the tumor can
expand the porus irregularly and cause significant adhesions and displacement
of the nerves making identification of the nerves and tumor resection
challenging.

Technical pearl
The most difficult part of the tumor to dissect is the transitional or junctional zone.
This is a 1 cm long area along the ventrolateral portion of the tumor just proximal
to the porus acousticus. In this region the tumor capsule and nerves are extremely
adherent as a result of tumor invasion of the arachnoid. Facial nerve stimulation is
vital as it facilitates identification of the facial nerve fibers which may be difficult,
despite high magnification, to distinguish from arachnoidal adhesions or filaments
of the eighth cranial nerve.

 If the adhesions between the tumor and nerves prove to be extremely difficult to
dissect, a small piece of tumor may be left to avoid facial or cochlear nerve
injury.
 385
Case 1. Illustrates a typical case with hearing preservation. The surgical steps are
demonstrated in partial detail
35 year old woman who was diagnosed with a right acoustic neuroma in 2008. She was advised
conservative follow-up. The tumor grew from 9mm to 18mm in 3 years, with decline in hearing.
We first saw her in 2011 and recommended a retrosigmoid approach.
386 Elhammady et al
Retrosigmoid Approach 387
388 Elhammady et al

Case 2. Illustrates an unusual case (that must always be timely recognized intraoperatively)
where the facial nerve was draped on the posterior surface of the tumor, resulting in subtotal
resection
55 year old female with a left acoustic neuroma and Class A hearing, complaining of imbalance
and tinnitus.
Retrosigmoid Approach 389
390 Elhammady et al

 An efficient method to dissect tumor and identify simultaneously the nature of the
tissue being mobilized, is to use special dissecting-stimulating instruments.
 Prior to closure, the facial nerve is stimulated at its exit from the brainstem and, if
a current of 0.05 mA achieves stimulation, then long term normal facial nerve
function is almost guaranteed.
Closure
 After the tumor has been removed, the surgical bed is irrigated and is inspected
for hemostasis. Bleeding along the nerves generally stops spontaneously or with
Surgicel (Ethicon, Inc. Somerville, NJ, USA).
 The bony edges of the drilled internal auditory meatus are thoroughly waxed to
occlude any air cells.
 A fat graft, harvested from the abdomen, or a local piece of muscle is used to fill
loosely the IAC.
 A single layer of Surgicel is laid over the surface of the retracted cerebellum.
 The dura is closed in a watertight fashion either primarily or using a pericranial
graft or dural substitute.
 The bone flap is replaced and fixed with titanium plates.
 Bone loss is usually not excessive, because of the initial targeted opening, and
therefore cranioplasty is usually not needed.
 The wound is irrigated with copious amounts of antibiotic solution. The muscles
and skin are meticulously closed in layers.

POSTOPERATIVE CARE

The patient should be placed in an intensive care unit for hourly neurologic assessments
and continuous monitoring of vital signs. The patient’s head is elevated approximately
30 to minimize the incidence of a postoperative cerebrospinal fluid leakage through the
wound or development of a local pseudomeningocele. Assessment of lower cranial
nerve function should be performed before initiation of an oral diet. In patients with
House-Brackmann grade 4 to 6 facial paresis, exposure keratopathy is prevented by
instillation of saline eye drops every 2 hours during the day and use of an eye patch
and lubricant at night. A lateral tarsorrhaphy or placement of an upper eyelid gold
weight is performed if delayed or no recovery of facial function is expected. Postoper-
ative brain MRI with and without gadolinium including views of the internal auditory
canal and fat suppression sequences is obtained within 2 days of surgery to determine
the degree of resection and rule out postoperative hematoma or hydrocephalus.

SURGICAL RESULTS

There have been numerous series reporting surgical outcomes for acoustic neuromas.
A popular strategy has been to compare the results of radiosurgery versus open
surgery, as well as the results between the 3 different approaches: middle fossa, ret-
rosigmoid and translabyrinthine. The validity of most of these comparisons is generally
limited because of the retrospective nature of the studies, enrollment bias, heteroge-
neity of studied populations, skewed expertise within various institutions, and other
factors. Nonetheless, Table 1 is a snapshot summary of the most recent series (last
5 years) regarding outcomes and complications.

COMPLICATIONS AND THEIR MANAGEMENT

There are several complications unique to the retrosigmoid approach and resection of
acoustic neuromas. These include injury to the cerebellum, venous sinuses, posterior
 Retrosigmoid Approach 391

fossa vasculature, cranial nerves, and brain stem as well as postoperative cerebro-
spinal fluid leaks.

Cerebellar Injury
Cerebellar edema, hematoma, or contusion may occur. The causes are varied: Poor
positioning of the head and neck, careless elevation of the bone flap, opening the
dura in the face of a swollen brain and before obtaining CSF egress, excessive cere-
bellar retraction, venous sinus injury or compromise. Such complications can be
avoided by careful surgical technique and adequate cerebellar relaxation using corti-
costeroids, mannitol, hyperventilation and early release of cerebrospinal fluid from the
posterior fossa cisterns. In the event of a hematoma or contusion, surgical evacuation
of the clot or resection of the contused cerebellum is necessary. It should be noted
that approximately one third of the cerebellum can be resected without producing
a permanent cerebellar deficit. Cerebellar swelling secondary to compromise of
venous sinus drainage can be prevented by avoiding excessive head turning or flexion
during positioning. Management of venous sinus injury is discussed below. If the cere-
bellum remains swollen, it may be necessary to decompress the posterior fossa
including the foramen magnum.

Venous Sinus Injury

Transverse and sigmoid sinus injuries can occur during the craniotomy. Sharp tears
are easily repaired with 6–0 prolene. Other tears may be controlled by carefully layer-
ing (NOT packing) with Surgicel. Over-packing should be avoided as it may easily
occlude the sinus. If the tear is large, it is best to cover the bleeding with gelfoam
and a cottonoid, elevate the head of the bed to decrease venous pressure, and
then expose more of the sinus. The tear may then be repaired primarily with a 6–0
suture or using a small dural patch.

Cranial Nerve Deficits

Trigeminal nerve
Injury to the trigeminal nerve is rare and may occur in large acoustic neuromas during
dissection of the upper pole of the tumor. Deficits include diminished facial sensation
and loss of the corneal reflex. If there is an associated facial paralysis the potential for
exposure keratitis is high and thus preventive measures should be started early as
described above.

Facial nerve
Injury to the facial nerve may occur during drilling of the internal auditory canal or as
a result of transection or excessive traction on the nerve during tumor resection.
The facial nerve is particularly vulnerable to injury in large-sized lesions where it
may be thinned out over the tumor capsule and may be difficult to visualize or dissect.
The most vulnerable site is the junction between the cisternal and meatal segments.
Several options exist for facial nerve reconstruction in the event of transection or
persistent postoperative facial paralysis.
Primary repair of a transected nerve provides the best opportunity for functional
recovery. Prerequisites for primary repair include identification of both proximal and
distal stumps of the nerve and sufficient nerve length to allow trimming of the
damaged ends and approximation without any tension. This is frequently possible
because the nerve is often elongated by the tumor. The technique of primary repair
consists of direct end-to-end epineural or perineural anastomosis with a minimal
number of tension-free sutures.
 392
Elhammady et al
Table 1
Summary of surgical results of recent series as published since 2006

Extent of FP (Anatomic
Authors Year N Size Surgery Resection Preservation) FP (HB 1-2) HP Death Comments
Li et al11 2011 176 >3 cm RS 96% 82% 1.7%
Tringali 2010 278 Small RS N/A N/A 90% 41% N/A Degree of IAC filling
et al12 (subdivided correlates w HP and FP
into 4 groups
according to
the percentage
of IAC filling)
Phillips 2010 40 <1 cm in CPA MF 17 N/A N/A N/A Overall: 58% N/A Wave V intraop predicts
et al13 RS 23 RS: 48% HP. If yes, 78%, if no
MF: 71% 41%
Sughrue 2010 11,873 N/A All N/A N/A Overall regardless N/A N/A Literature review of
et al14 of size, approach, 79/296 studies on FP
or age: 74%
Approach:
MF: 85%
TL: 81%
RS: 78%
Size:
<2 cm: 90%
>2 cm: 67%
Age:
<65yrs: 71%
>65yrs: 84%
Sameshima 2010 125 <1.5 cm MF 43 GTR: 100% 100% Early (2 wk): MF: 77% 0% Prefer RS due to other
et al15 RS 82 MF: 95% RS: 73% factors (longer operative
RS: 100% time, more difficult
Late (8-12 mo): exposure, and a higher
MF: 100% incidence of temporal lobe
RS: 100% brain edema and temporary
facial weakness)
Sughrue 2010 998 N/A MF 286 N/A N/A N/A Overall: 52% N/A Review of 49/62 studies on HP.
et al16 RS 702 MF: 63% >1.5 cm and RS did worse
RS: 47% (independently) with HP
(on MVA)
Zhao 2010 89 Large RS GTR: 43% 93% Early: 40% N/A 0%
et al17 (>4 cm) NTR: 39% Late (1 y): 54%
Chen 2010 145 >3 cm: 119 RS GTR: 97% 91% 79% N/A 0%
et al18 <3 cm: 26
Hillman 2010 138 Average longest MF 88 N/A N/A MF: 88% MF: 59% N/A - FN recovers quicker in RS
et al19 diameter: RS 50 RS: 90% RS: 39% than MF
MF: 8 mm - HP more likely with MF
RS: 14 mm
Samii 2010 Group A Mean tumor size: RS GTR: Grp A: 92% Grp A: Grp A: 33% (3/9) Grp A: 0% Retrospective review of 50 pts
et al20 (>4 cm): 50 Grp A: 4.4 cm Grp A: 100% Grp: B: 98.8% 75% (HB I-III) Grp B: 60% Grp B: 0% with >4 cm (Grp A)
Group B Grp B: 2.3 cm Grp B: 97.6% Grp B: compared with a matched
(<3.9 cm): 167 91% (HB I-III) grp of 167 pts with VS <3.9
cm (Grp B).
Kameda 2010 242 Mean tumor RS N/A N/A N/A N/A N/A Study evaluating the effect of
et al21 size: 2.1 cm RS resection of VS on
tinnitus: 71% had it preop.
Postop: 25% gone, 33%
better, 32% no change, 10%
worse. No diff if 8th N cut or
not. New tinnitus in 9%.
Noudel 2009 843 Intracanalicular MF 529 N/A N/A At 1 y: MF: 38-100% MF: Review article comparing the
et al22 RS 314 MF: 72-100% RS: 13-100% RS: 0% HP and FP rates following
RS: 80-100% resection of intracanalicular
VS via MF (16 studies) and RS
(19 studies) approaches.

Retrosigmoid Approach
Yang 2008 110 <2 cm RS 100% 91% Early (1-2 mo): 81% Among pts 0%
et al23 Late (1-2 y): 91% with class
A or B
hearing
preop,
36% were
class A or B,
and 44% were
class A,B or
C postop

(continued on next page)

393
 394
Elhammady et al
Table 1
(continued )

Extent of FP (Anatomic
Authors Year N Size Surgery Resection Preservation) FP (HB 1-2) HP Death Comments
Cardoso 2007 240 Hanover tumor RS GTR: 99% 85% FP (HB I-III) in pts 40% (in tumors 1.6%
et al24 extension with preop facial up to 1.5 cm)
classification: function: 85%
T1: 12 <3 cm: 100%
T2: 41
T3a: 21
T3b: 24
T4a: 63
T4b: 79
Samii 2006 200 Hanover tumor RS GTR: 98% 98.5% Overall: Overall: 51% 0%
et al25 extension Early: 59% T1: 57%%
classification: At last f/u: 81% T2: 54%
T1: 22 T1, T2, T3: 100% T3a: 42%
T2: 18
T3a: 28
T3b: 40
T4a: 72
T4b: 20

Abbreviations: FP, facial nerve preservation; GTR, gross total resection rate; HP, hearing preservation; MF, middle fossa approach; MVA, multivariate analysis; N/A, not available; NTR, near
total resection rate; RS, retrosigmoid approach; VS, vestibular schwannoma.
The Hanover tumor extension classification system:
Class T1: intrameatal tumor
Class T2: intra- and extrameatal tumor
Class T3a: lesion filling the cerebello-pontine cistern
Class T3b: tumor reaching the brainstem
Class T4a: lesion compressing the brainstem
Class T4b: tumor severely dislocating the brainstem and compressing the fourth ventricle
 Retrosigmoid Approach 395

Interposition grafts are used if the two ends of the facial nerve can be found but there is
insufficient nerve length to allow tension-free primary anastomosis. Potential donors
include the sural or greater auricular nerves due to their well tolerated sensory deficits
and their comparable diameter to that of the facial nerve.
Complete hypoglossal-facial anastomosis is indicated after one year if there is no
return of facial function in an anatomically preserved nerve or failure of recovery
following primary repair or interposition grafting. The procedure may be performed
earlier in situations that preclude primary or interposition graft repair such as unavail-
ability of the proximal end of the facial nerve. Hypoglossal-facial anastomosis
improves facial tone and symmetry and provides reasonably good voluntary function
particularly around the mouth and midface with less satisfactory results around the
eye. However, patients must undergo biofeedback and motor re-education to learn
voluntary control, decrease synkinesis, and limit the facial grimacing that can occur
with mastication. The resulting unilateral hypoglossal paralysis can cause problems
with speech, mastication, and swallowing but is generally well tolerated. The tech-
nique consists of exposure of the extracranial facial and hypoglossal nerves. The facial
nerve is dissected from the stylomastoid foramen to its terminal branches (pes anser-
inus) in the parotid gland. The hypoglossal nerve along with the descendens hypo-
glossi and ansa cervicalis are dissected as far proximally and distally as possible to
maximize the length available for the anastomosis. The facial nerve is then sectioned
as close to the stylomastoid foramen as possible while the hypoglossal nerve and
descendens hypoglossi are divided as far distally as possible. A tension-free epineural
end-to-end anastomosis is then performed by suturing the hypoglossal nerve trunk to
the distal facial nerve stump. In an attempt to minimize the inevitable unilateral tongue
paralysis, the descendens hypoglossi can be anastomosed to the distal stump of the
hypoglossal nerve. Limitations of the complete hypoglossal-facial anastomosis
include the inability to perform the procedure in patients with preexisting uni- or bilat-
eral glossopharyngeal and vagal nerve or contralateral hypoglossal nerve injuries due
to the potentially severe disability that would ensue from the added effect of hypo-
glossal paralysis. Furthemore the procedure cannot be performed bilaterally in
patients with bilateral facial palsy. In these situations a partial hypoglossal-facial anas-
tomosis can be performed although the results are not as satisfactory as a complete
hypoglossal-facial anastomosis. The technique consists of splitting the hypoglossal
nerve to a thickness that is comparable to that of the facial nerve. Part of the hypo-
glossal nerve is then anastomosed to the distal facial nerve stump while maintaining
continuity of the remainder of the hypoglossal nerve.

Cochlear nerve
Injury to the cochlear function may occur during drilling if the labyrinth is violated or
during tumor dissection as a result of transection or excessive traction on the nerve.
Hearing loss may also occur if the internal auditory (labyrinthine) artery is sacrificed.
The BAHA (Bone Anchored Hearing Aid) could be considered in patients with such
unilateral complete deafness several months postop.

Lower cranial nerves

Inadvertent injury to the lower cranial nerves following resection of large tumors is
a major cause of morbidity. These cranial nerves are very sensitive to manipulation,
necessitating very gentle retraction and sharp dissection. Lower cranial nerve injury
may result in dysphagia, dysarthria, dysphonia, and inadequate airway protection.
Thus, patients should be started on an oral diet only after a formal evaluation of lower
cranial nerve function has been performed.
396 Elhammady et al

Brain Stem and Vascular Injury

Brain stem injuries may result from either excessive retraction or vascular injury. The
AICA lies in close relation to the VII/VIII nerve complex and is frequently incorporated in
the tumor capsule. AICA injuries may result in significant morbidity due to brainstem
and cranial nerve ischemia. Occlusion of the internal auditory (labyrinthine) branch
of the AICA may result in hearing loss. Although uncommon, compromise of the
PICA or its perforators may result in postoperative lateral medullary (Wallenberg)
syndrome.

Cerebrospinal Fluid Leak

Cerebrospinal fluid leakage may occur through the wound or may present as rhinor-
rhea by passing through the perilabyrinthine air cells to the middle ear cleft and eusta-
chian tube. Possible etiologies include inadequate wound or dural closure, an open air
cell in the bone, or postoperative hydrocephalus. A head CT should be obtained to rule
out hydrocephalus, pneumocephalus, or a pseudomeningocele. A thin-cut CT of the
temporal bone may demonstrate a large open air cell in the petrous bone or fluid within
the mastoid and give clues to a possible route of cerebrospinal fluid leakage. Initial
management with head elevation, a pressure bandage in the presence of a pseudome-
ningiocele, and spinal fluid drainage either through repeated lumbar punctures or
a lumbar drain may be sufficient for small leaks. On the other hand, large persistent
leaks or the presence of pneumocephalus requires surgical repair. This may consist
of waxing of any open air cells, possible packing of the middle ear if there is no hearing,
and meticulous water-tight closure of the dura and wound. Troublesome leaks may
require endoscopic obliteration of the eustachian tube as a last resort, with the inev-
itable subsequent conductive hearing loss. The presence of hydrocephalus requires
placement of a shunt after confirming the absence of meningitis.

CONCLUSIONS ON RETROSIGMOID APPROACH

The retrosigmoid approach, as performed by experienced surgeons today, is the most

versatile approach for the resection of acoustic neuromas. It is appropriate for small
and large tumors, as well as deaf and hearing ears. Expertise in this surgery is very
much experience dependent, as one incrementally learns new technical pearls in
complication avoidance. The next frontier will be in any new technology that might
facilitate facial and cochlear nerve preservation.

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