Technical refinements in retraction for middle fossa surgery.

This report describes an alternative technique for exposure of the floor of the middle fossa.Descriptive review of alternative middle fossa retraction techniques on a retrospective case series.Tertiary referral center.Patients undergoing middle fossa or combined petrosal craniotomy were studied.Dural elevation was carried anteriorly past the middle meningeal artery to permit separation of the dura from connective tissue over the Gasserian ganglion. With the dural release, flexible spatula retractors (Fukushima) can be used.The advantages of this technique are 1) this system is "low profile," with the back of the retractor posing no obstruction to vision or angle of instrument manipulation; 2) the anterior dural release permits extensive exposure with less force than is necessary when dural attachments to the trigeminal nerve remain intact; and 3) anterior exposure of the clivus and petrous apex is achieved without the need for transection of V3 (3rd division fifth cranial nerve).The authors find these refinements of practical benefit for breadth of exposure, visibility, and room for instrumentation during middle fossa surgery.