The Posterior Cranial Fossa: Microsurgical Anatomy and Surgical Approaches

This work has grown out of my personal desire to improve the care of my patients. It represents a lifelong attempt to gain an understanding of the anatomy and intricacies of the brain that would improve the safety, gentleness, and accuracy of surgery for my patients. During college, I planned to pursue a career in social work but, during a course on psychology and the brain, I became captivated by the possibility of serving humanity through a career in neurosurgery. During medical school, I began working in a neuroscience laboratory in my spare time and, at the end of my residency, I completed a fellowship in neuroanatomy. It was during this fellowship that I realized the potential for greater knowledge about microneurosurgical anatomy to improve the care of my patients. This volume, a distillation of our studies of the posterior fossa, represents nearly 40 years of work and study in which more than 50 residents and fellows have participated, resulting in several hundred publications. It has been gratifying to view the role of our fellows and trainees in spreading this knowledge to other countries and around the world and to see the benefits of neurosurgeons applying this knowledge to improve surgery for their patients (Table 1). Especially gratifying has been the association with Drs. Katsutoshi Kitamura, Masashi Fukui, and Toshio Matsushima in Fukuoka, Japan, and Drs. Evandro de Oliveira, Helder Tedeschi, and Hung Wen in São Paulo, Brazil. It is to the fellows and associates in the microsurgery laboratory that this volume is dedicated. Special thanks go to our medical illustrators, David Peace and Robin Barry, who have worked with us for 2 decades; to Ron Smith, who has directed the microsurgery laboratory for many years; and to Laura Dickinson and Fran Johnson, who have labored over these and earlier manuscripts. Table 1: Residents and Fellows Who Have Worked in Dr. Rhoton’s Microsurgery LaboratoryIn the beginning, nearly 40 years ago, even with microsurgical techniques, our dissections were crude by current standards, with photographs needing to be retouched to bring out the facets of anatomy important in achieving a satisfactory outcome at surgery. Over the years, as we have learned to expose fine neural structures, the display of microsurgical anatomy has become more vividly accurate and beautiful than we had imagined at the onset, and it has enhanced the accuracy and beauty of our surgery. We hope that it will do the same for our readers. We plan to produce a second issue on the cerebrum and supratentorial areas in 2002 for the 25th anniversary of Neurosurgery, which I had some role in birthing, as President of the Congress of Neurological Surgeons 22 years ago. In the early development of neurosurgery, approaches to the posterior fossa were directed largely via the occipital squama and less frequently via the subtemporal transtentorial route. With the development of microsurgery and cranial base surgery, it became possible to work in long, narrow exposures, thus setting the stage for opening virtually all of the cranial base through carefully placed windows exposing small and selective parts of the posterior fossa. These developments led to approaches to the posterior fossa via the temporal bone as well as set the stage for approaches directed via the anterior and middle cranial base. In this volume, we have attempted not only to display the brain and cranial base in the best views for understanding the anatomy, but also to show the anatomy as exposed in opening multiple surgical routes to the posterior fossa. For those wanting even greater detail than displayed in this volume, our prior works, published largely in Neurosurgery and the Journal of Neurosurgery, can be consulted. This work has been sustained by numerous private contributions to our department and the University of Florida. Most prominent among these has been the R.D. Keene family, who made the first $1 million gift to the University of Florida, a gift that has supported our work for many years. Their gift was followed by additional endowments, totaling $16 million, which support many aspects of education and research in neurosurgery at the University of Florida. These gifts have endowed the following chairs and professorships: the R.D. Keene Family Chair, the C.M. and K.E. Overstreet Chair, the Mark Overstreet Chair, the Albert E. and Birdie W. Einstein Chair, the James and Newton Eblen Chair, the Dunspaugh-Dalton Chair, the Edward Shed Wells Chair, the Robert Z. and Nancy J. Greene Chair, the L.D. Hupp Chair, the William Merz Professorship, and the Albert L. Rhoton, Jr. Chairman’s Professorship. The most recent of these is the $4 million gift establishing the Albert L. Rhoton, Jr. Neurosurgery Professorship, held by William A. Friedman, who has followed me as Chairman of Neurosurgery. The efforts of the numerous clinicians and scientists recruited, as a result of the Endowed Chairs, contributed greatly to the founding of the University of Florida Brain Institute, where our studies of microsurgical anatomy are being completed. With this volume, we join our donors in their aspiration to improve the lives of those undergoing brain surgery throughout the world.