Subtonsillar approach to the foramen of Luschka: an anatomic and clinical study

Conventional approaches to tumors of the foramen of Luschka are limited because the foramen is viewed from either the fourth ventricle laterally (transvermian approach) or the cerebellopontine angle medially (suboccipital approach). The definitive approach is subtonsillar, because the foramen of Luschka is actually the end of the natural cleavage plane between the cerebellar tonsil and the medulla. We describe the microsurgical anatomic features of the foramen of Luschka region and the operative technique for the subtonsillar approach to this region.

In the anatomic study, five formalin-fixed, silicone-injected, cadaveric heads were used. In the clinical study, the records for five patients treated via the subtonsillar approach were examined; several illustrative cases are presented.

The foramen of Luschka is formed by the tela choroidea and the rhomboid lip and exists at the lateral end of the cerebellomedullary fissure, which is a natural cleavage plane between the cerebellar tonsil and the medulla. The subtonsillar approach is performed via a suboccipital craniotomy; the patient is positioned in the lateral decubitus position, with the tumor side down. After the cerebellar tonsil is freed from arachnoid adhesions, it can be retracted rostrodorsally from the medulla, to expose the cerebellomedullary fissure. Clinically, the tela choroidea and rhomboid lip are significantly attenuated by tumor expansion. Therefore, by dissecting in a subtonsillar manner around the tumor, one can reach the foramen of Luschka without traversing any neural tissue.

The subtonsillar approach yields a panoramic view to the foramen of Luschka laterally and up to the middle cerebellar peduncle superiorly. This approach minimizes the distance between the tumor and the surgeon, while maximizing neural preservation. We think this is the definitive approach to this difficult region of the posterior fossa.