The posterior petrosal approach: technique and applications in pediatric neurosurgery

Object Various lesions occur in deep locations or at the skull base in pediatric patients and require skull base approaches for resection. Skull base surgery confers the advantages of improved line of sight, a wider operative corridor, and reduced brain retraction. The posterior petrosal approach provides simultaneous access to lesions in the posterior middle fossa and posterior fossa from the top of the clivus to the level of the jugular foramen. It allows visualization of the ventrolateral brainstem and may be combined with various other supra- and infratentorial approaches, thus giving the surgeon a wide array of access routes to the lesion. Methods The authors conducted a retrospective review of all cases involving pediatric patients undergoing a posterior petrosal approach, either alone or in combination with other cranial approaches. Preoperative and postoperative data were collected, including presentation, neurological examination, imaging findings, pathological condition, operative details, perioperative complications, and postoperative outcomes. Results There were 13 patients (6 female, 7 male) with a mean age of 12.6 years (range 14 months–9 years). The posterior petrosal was the sole skull base cranial approach in 4 patients, whereas the posterior petrosal was combined with 1 or more other cranial approaches in 9. A gross-total resection was achieved in 7 patients, subtotal resection in 5, and a biopsy was performed in 1. Complications occurred in 9 patients, including 7 new or worsened cranial neuropathies. There was no perioperative mortality. Conclusions Although infrequently used in pediatric neurosurgery, the posterior petrosal approach is a highly versatile approach that can access intra- and extraaxial pathology centered on the petrous bone. The authors believe that patient outcomes are directly related to the degree of experience using this approach. Therefore, if this approach is to be used, they recommend collaboration with a skull base neurosurgeon.