Antegrade Concorde position for leveraging the lateral supracerebellar infratentorial approach

The lateral supracerebellar infratentorial (SCIT) approach is an established corridor for lesions of the pineal region, posterior thalamus, and dorsolateral brainstem. However, the classic Concorde position may result in unfavorable surgeon ergonomics and less intuitive anatomical orientation during lateral SCIT procedures.

Can a modified Concorde positioning technique improve surgeon ergonomics and provide a more natural anatomical orientation during lateral SCIT surgery while preserving the advantages of the classic Concorde position?

This retrospective cohort study included patients who underwent the lateral SCIT approach in Antegrade Concorde position 04/2020-10/2024. The modified head fixation aligns the surgical trajectory of the lateral approach nearly vertically, allowing the surgeon to operate while standing at the level of the patient's pelvis. Surgical techniques and outcomes were systematically documented, and all perioperative complications were recorded.

Twenty-eight patients (40 ± 18 years) with cavernous malformations, metastases, pilocytic astrocytomas, and meningiomas being the most common pathologies were included. Lesions involved the thalamus, pineal region, pons, midbrain, and cerebellum and were all successfully accessed. Postoperative complications occurred in 13 patients (46%), mainly transient neurological deficits related to lesion location, including diplopia (25%), sensory disturbances (14%), and gait instability (11%). Three patients (11%) required external ventricular drainage. No positioning-related complications occurred. Mild bilateral pneumocephalus without clinical relevance was observed in 8 patients (29%).

The Antegrade Concorde position improves ergonomics and feasibility of the lateral SCIT approach by restoring natural anatomical orientation and enabling a vertical surgical trajectory from a comfortable stance at the patient's pelvis.