2026 Proffered Presentations
S235: JUGULAR TUBERCLE REMOVAL TECHNIQUE ENHANCES ACCESS TO MID-TO-LOWER CLIVUS: CADAVERIC STEP-BY-STEP DISSECTION
Xiaochun Zhao, MD; Beste Gulsuna; Panayiotis E Pelargos; Jeffrey A Zuccato; Ian F Dunn; University of Oklahoma Health Sciences Center
Introduction: In the access to specific posterior fossa pathologies, the jugular tubercle, located caudal and ventral to the jugular foramen and rostral to the hypoglossal canal, can be obstructive. Jugular tubercle removal has been described in the extreme lateral approach, but this technique can be applied as an additional maneuver t in other lateral suboccipital approaches including the retrosigmoid approach or far lateral transcondylar approach, to maximize access to middle and lower clivus. This note provides a step-by-step removal of the jugular tubercle in the example of an extended retrosigmoid approach.
Methods: The jugular tubercle removal technique was demonstrated with cadaveric dissection. The focus is that this technique can be applied as an individual technique in any lateral suboccipital approaches, including in retrosigmoid variants as demonstrated herein.
Results: A right sided retrosigmoid approach was demonstrated here. The soft tissue was mobilized and retracted medially and posteriorly, leaving minimal mass effect on the lateral side. The vertebral artery and C1 lateral tubercle were dissected for demonstration purposes. A craniotomy focusing on the inferior part of the sigmoid sinus was completed and the jugular bulb was exposed, along with the jugular tubercle and occipital condyle caudal to it. The rostral part of the condyle was removed until the hypoglossal canal to keep the condyle joint intact without affecting the stability. The condyle continues and becomes the jugular tubercle, which was subsequently debulked. The access becomes increasingly limited as the debulking deepens between the jugular tubercle and hypoglossal canal. The dura can be opened gradually as the drilling continues to release and mobilize the jugular bulb, following the curvature of the sigmoid sinus and jugular bulb. Intradural removal medial and deep to the spinal accessory nerve can be applied at depth. After removal, the space lateral to the spinal accessory nerve widens with good access to the middle to lower clivus and vertebrobasilar junction.
Conclusion: Removal of the jugular tubercle can be applied as an individual technique to enhance access to the middle and lower clivus, with neurovascular structures including the vertebrobasilar junction, anterior inferior cerebellar artery, posterior inferior cerebellar artery, and abducens nerve at midline. This study provides step-by-step dissection of this technique in a cadaver specimen.