Drilling the posterior wall of the petrous pyramid: a microneurosurgical anatomical study

Posterior approaches to the petroclival area requiring extensive drilling of the posterior pyramidal wall have been described in the last 10 years. If hearing is to be preserved, damage to the inner-ear structures must be avoided; however, the fine points of this pyramidal drilling technique have never been reported in detail. A microneurosurgical anatomical study was undertaken in 15 cadavers to determine the relationships between bone landmarks and labyrinthine structures that could be used to give some practical drilling guidelines. Drilling of the posterior pyramidal wall is facilitated on identification of the intersection of the petrous ridge with the most anterior portion of the bone ledge covering the sigmoid sinus (petrosigmoid intersection), the bony operculum of the endolymphatic sac, and the petrous ridge. Drilling may proceed rather safely at a minimum depth of 2.5 mm in an area 0.9 cm anterior and 1 cm inferior to the petrosigmoid intersection and petrous ridge, respectively. From there, identification of the vestibular aqueduct, genu, and horizontal portion is necessary to safely open the posterior wall of the internal auditory canal. The vestibular aqueduct represents the lateral and superior limits of drilling. The bone between these areas may then be safely drilled to a depth of at least 2.5 mm. A microneurosurgical dissection of the posterior pyramidal wall conducted in cadaveric material according to these guidelines did not violate any inner-ear structures.