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Retrosigmoid Infralabyrinthine (Suprajugular) Approach to the Jugular Foramen: Indications, Limitations, and Surgical Nuances.

BACKGROUND
Among the several approaches described to the jugular foramen (JF), the retrosigmoid infralabyrinthine (suprajugular) approach was one of the most recently described.


OBJECTIVE
To describe the indications, limitations, and operative nuances of the suprajugular approach.


METHODS
We provided a pertinent review of the anatomy, indications, preoperative evaluation, surgical steps and nuances, and postoperative management.


RESULTS
The suprajugular approach is suitable for tumors occupying the intracranial compartment with limited extension into the JF. Volume, width, and configuration of the foramen dictate the feasibility of the approach. Tumors invading the venous system are not suitable for this approach. Preoperative 3-dimensional MRI and computed tomography are used to evaluate intrajugular extension, relationship between the tumor and the jugular bulb (JB), venous system invasion, and shape of the JF. During surgery, exposition of the entire posterior border of the sigmoid sinus is needed and removing the bone over the JB. After identification of the JF, the jugular notch and intrajugular process of the roof of the foramen are removed and intrajugular resection is completed. In cases of high-riding JB, it may be gently pushed down to allow visualization of the anterior foramen. In cases of JB laceration, it may be repaired using a muscle patch and usually does preclude further resection.


CONCLUSION
The suprajugular approach is variation of the retrosigmoid approach that, when properly indicated, provides excellent exposure of the medial JF, with most anatomical variations and intraoperative complications predicted by a comprehensive preoperative evaluation.