Comparative Analysis of the Far Lateral, Far Medial, and Contralateral Transmaxillary Approaches to the Jugular Tubercle

BACKGROUND AND OBJECTIVES: The jugular tubercle (JT) is a bony prominence located between the basilar and condylar parts of the occipital bone, superior to the hypoglossal canal. This study compares the volume of the JT removed, the overall area of exposure and the surgical corridor among the far lateral approach (FLA), far medial approach (FMA), and contralateral transmaxillary (CTM) corridor. METHODS: Using image guidance, 10 cadaveric specimens were dissected: The JT was drilled through FMA and CTM in 10 sides, whereas FLA was performed on the opposite 10 sides. The surgical corridor and overall area of exposure were measured. A subanalysis was conducted to compare the angle of the surgical trajectory between FMA and CTM. Computed tomography scan volumetric measurements were used to compare the approaches. Five illustrative cases are presented. RESULTS: The angle of the surgical trajectory to the JT was significantly greater for CTM (33.8° ± 7.1°) compared with FMA (14.3° ± 2.6°, P < .001). The area of exposure was significantly larger with FLA (410.7 ± 78.1 mm 2 ) and CTM (436.8 ± 44.8 mm 2 ) compared with FMA (270.7 ± 21.9 mm 2 , P < .001). In addition, CTM (212.2 ± 32.2 mm 2 ) provided a significantly wider surgical corridor than FMA (82.7 ± 12.4 mm 2 , P < .001) and showed a trend toward greater exposure compared with FLA ( P = .05). The mean percentage of JT resected was 56.7% for FLA, 40.4% for FMA, and 94% for CTM ( P < .05). CONCLUSION: Open and endoscopic approaches are complementary for addressing lesions in the inferior clival and petroclival regions. The CTM approach represents a feasible extension of the standard endoscopic endonasal approach, increasing the surgical corridor angle and providing greater lateral exposure than the FMA. In addition, CTM enables a substantially greater volume of JT resection compared with both FLA and FMA.