• Masatou Kawashima, Albert L Rhoton, and Toshio Matsushima.
• Department of Neurological Surgery, University of Florida, Gainesville, Florida 32610-0265, USA. kawasm@neurosurgery.ufl.edu
• Neurosurgery. 2008 Jun 1; 62 (6 Suppl 3): 1136-49.

ObjectiveDirect surgical approaches to the posterior incisural space, including the pineal region, remain as challenges for neurosurgeons. The purposes of this study were 1) to compare the surgical views in the various posterior approaches to the posterior incisural space and 2) to propose a new approach, which is a modification of the occipital transtentorial approach.MethodsTen adult cadaveric specimens (20 sides) were studied, using x3 to x40 magnification, after perfusion of the arteries and veins with colored silicone. Intraoperative views in the posterior approaches to lesions were examined in stepwise dissections. In addition, the efficacy of the occipital bi-transtentorial/falcine approach was studied.ResultsThe posterior incisural space has a roof, a floor, and anterior and lateral walls and extends backward to the level of the tentorial apex. The operative views defined by each approach differ in the extent to which they allow observation of the anatomic structures in the posterior incisural space. The occipital bi-transtentorial/falcine approach permits better observation of the contralateral half of the quadrigeminal cistern.ConclusionPrecise surgical anatomic knowledge of each approach is required for the treatment of lesions in the posterior incisural space, because the operative fields obtained with different approaches differ significantly. The occipital bi-transtentorial/falcine approach provides greater contralateral exposure of the posterior incisural space than does the occipital transtentorial approach.

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