Extreme lateral transcondylar approach: technical improvements and lessons learned.

An extreme lateral transcondylar or extreme lateral transfacetal surgical approach was used to treat 22 patients with complex lesions over a 22-month period. The lesions included basilar invagination with vertebral artery pathology, giant aneurysm or arteriovenous fistula of the vertebral artery, meningioma, chordoma, chondrosarcoma, and paraganglioma. The approach was used alone or in combination with a presigmoid petrosal or subtemporal-infratemporal approach. Refinements of the operative technique, treatment strategies for complex lesions, and the avoidance of complications are discussed. Complications included cerebrospinal fluid leakage, meningitis, pseudomeningocele, hemiparesis or quadriparesis, lower cranial nerve deficits, and vertebral artery injury requiring repair. With treatment, major neurological deficits resolved completely in three patients and partially in two. There was no operative mortality, but four patients died during the follow-up period. For the 18 surviving patients, the mean preoperative and postoperative Karnofsky scores were 81 and 93, respectively. For the four who died, the mean preoperative Karnofsky score was 73 and the mean postoperative score was 63.