The midline suboccipital subtonsillar approach to the cerebellomedullary cistern: how I do it

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Lesions lateral to the lower brainstem in an area extending from the foraminae of Luschka to the foramen magnum are rare and include different pathologies. There is no consensus on an ideal surgical approach.


To gain access to this area, we use the midline suboccipital subtonsillar approach (STA). This midline approach with unilateral retraction of the cerebellar tonsil enables entry into the cerebellomedullary cistern.


The STA offers excellent access with a panoramic view of the cerebellomedullary cistern and its structures and therefore can be useful for a number of different pathologies in the lower petroclival area.

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Author information

Correspondence to Stephan Herlan.

Additional information

Key points

• The STA is a fast, straightforward and easy-to-perform approach to structures of the cerebellomedullary cistern

• Semi-sitting position and C1 laminotomy may improve the viewing angle, facilitating bimanual microsurgical dissection and avoiding tonsillar retraction

• Careful arachnoid dissection around the tonsils and cisterns enables panoramic view of the cerebellomedullary cistern

• Mild and intermittent tonsil retraction can be sufficient in the majority of the cases

• Endoscope assistance enhances the overview thus helping to achieve total tumour resection or aneurysm closure

• For distal PICA aneurysms the approach enables good proximal vessel control of the proximal intradural vertebral artery

• Electrophysiological monitoring of the lower cranial nerves is absolutely recommended

• Depending on pathology a temporary decrease of lower cranial nerve function may be expected

• Postoperative complications and risks are mainly dependent on pathology but not the approach

• Major limitations of the approach consist of pathologies expanding into the cerebellopontine and/or premedullary cistern as well as strong adhesions to the ventral parts of the brainstem

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Herlan, S., Roser, F., Ebner, F.H. et al. The midline suboccipital subtonsillar approach to the cerebellomedullary cistern: how I do it. Acta Neurochir 159, 1613–1617 (2017).

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  • Cerebellomedullary cistern
  • Suboccipital subtonsillar approach
  • Lower cranial nerves