The combined transpetrosal approach: Anatomic study and literature review

The combined petrosal approach is an essential technique for the skull base neurosurgeon. In this manuscript, the authors provide a brief history of the development of this approach, technical instruction with consideration of important landmarks, and a literature review of the broad range of clinical applications for this approach. The combined petrosal approach was performed bilaterally in 6 cadaveric injected specimens. The relationship of middle and posterior fossa dura, venous sinuses, cranial nerves (CNs), and the vascular anatomy were studied. Additionally, the authors performed a systematic review of the literature to elucidate the clinical applications, technical considerations, outcomes, and complications associated with the combined petrosal approach. Several critical details of the approach are outlined. The approach offers a magnified view of this region and inflicts minimal damage to the temporal bridging veins while entering the transverse sinus no more than 5mm anterior to Citelli's angle. The approach allows for visualization of CN IV as an important anatomical landmark, while preserving the venous integrity of posterior cavernous sinus. The literature review surveys 11 studies that provide a range of clinical applications for the approach. The authors conclude that the combined petrosal approach is one of the most versatile skull base approaches to the middle and posterior fossa, and it can be used to address complex pathologies of the petroclival region. Detailed knowledge of its technical nuances and applications is essential for any skull base surgeon.