Surgical Strategies for Jugular Foramen Tumors

The jugular foramen is a complex anatomical structure that can vary considerably in size, shape, and dimensions. The most common tumors found within the jugular foramen are paragangliomas, followed by schwannomas, and less commonly, meningiomas, chordomas, chondrosarcomas, and plasmacytomas. It is important to have an extended knowledge of the anatomy of the jugular foramen and its surroundings, to understand each type of tumor growth pattern, and how it is related to the neurovascular structures that enclose them. The surgical removal of these tumors remains a challenge. Advances in neuroimaging, microsurgery, and modern cranial base surgery have allowed safe resection of these tumors with lower rates of morbidity and mortality. Total removal of these tumors increases the likelihood of achieving surgical cure and many approaches have been described to access this region. Although there are a variety of surgical approaches to the jugular foramen, it is important to individualize each case and tailor the approach for the patient to provide the appropriate necessary exposure to remove the most amount of tumor with the least amount of neurovascular morbidity. In this chapter, we describe the most common approaches to the jugular foramen with their indications, advantages, and disadvantages, as well a general perspective of the most important anatomic highlights that a neurosurgeon must have in order to attempt performing a jugular foramen approach. We also provide illustrative cases that have been performed over our experience and how each approach can be helpful in each situation. The jugular foramen can be exposed by several approaches depending on the type, size, and configuration of the lesion. We can divide the approaches based on anterolateral and posterolateral perspectives. The anterolateral approaches include the dissection of the structures located in front and lateral to the sigmoid sinus and jugular foramen, and posterolateral approaches area are accessed via dissection of structures behind and lateral to the sigmoid sinus and jugular foramen. Extensive knowledge of the anatomy and a multidisciplinary team is needed (neuro-otologist, head and neck surgeon, laryngologist, neuro-anesthesiologist, neurointerventionalist, radiation oncologist) to provide the patient the best optimal postoperative outcomes.