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The transpetrosal approach to the posterior cranial fossa, clivus, or foramen magnum is a surgical technique utilized primarily for accessing and treating conditions such as neoplastic tumors and vascular lesions located in these critical areas of the brain. This approach is characterized by its strategic incision and manipulation of surrounding anatomical structures to provide the surgeon with optimal visibility and access to the targeted region. The procedure begins with the immobilization of the patient's head, followed by a precise skin incision that initiates approximately 1 cm anterior to the tragus of the ear. The incision extends along the superior temporal line, curving posteriorly and caudally to reach about 6 cm behind the external auditory canal, ultimately terminating at the mastoid tip. Once the skin flap is elevated, the underlying temporalis muscle, pericranium, and suboccipital muscles are carefully retracted to expose the cranial bone. A flap may be harvested from the pericranium or temporalis fascia, which can be utilized later for dural closure. The surgical team then performs a temporo-suboccipital craniotomy, which involves creating multiple burr holes in the skull. These burr holes are interconnected using a drill or craniotome, allowing the bone flap to be lifted and providing access to the posterior fossa dura and the transverse sinus. To enhance visualization during the procedure, the squamous temporal bone may be flattened to align with the middle fossa floor. The middle fossa dura is elevated towards the petrous ridge, with careful attention to preserving vital blood vessels and nerves. The surgical dissection continues posteriorly toward the arcuate eminence, with the sigmoid sinus and presigmoid dura being alternately elevated off the mastoid bone. Bone resection is performed using cutting burrs and rongeurs, allowing for the identification of the posterior semicircular canal. The cortical bone is meticulously skeletonized while preserving the facial nerve, followed by the identification and skeletonization of the superior semicircular canal (SSC). The procedure culminates with the resection of the petrous ridge at the petrous apex, extending from the SSC to the trigeminal nerve. The posterior fossa is then opened along the anterior border of the sigmoid sinus, with the opening extended caudally to the superior petrosal sinus. Finally, the dura is opened through the trigeminal dural ring, retracted, and secured with stay sutures, providing a clear view of the petroclival region of the brain for further surgical intervention.
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The transpetrosal approach to the posterior cranial fossa, clivus, or foramen magnum is indicated for various surgical interventions, particularly in the context of the following conditions:
The transpetrosal approach involves several critical procedural steps that ensure effective access to the posterior cranial fossa. The first step is the immobilization of the patient's head to maintain stability throughout the surgery. Following this, a skin incision is made approximately 1 cm anterior to the tragus, extending along the superior temporal line. The incision curves posteriorly and caudally, reaching about 6 cm behind the external auditory canal and terminating at the mastoid tip. This incision allows for the elevation of a skin flap, which is carefully lifted off the temporalis muscle, pericranium, and suboccipital muscles.
Next, a flap may be harvested from the pericranium or temporalis fascia, which will be used later for dural closure. The muscles are then elevated and retracted to expose the underlying bone. A temporo-suboccipital craniotomy is performed by creating multiple burr holes in the skull. These burr holes are interconnected using a drill or craniotome, allowing the bone flap to be lifted, thereby exposing the posterior fossa dura and the transverse sinus. To enhance visualization, the squamous temporal bone may be flattened to align with the middle fossa floor.
Once the middle fossa dura is elevated toward the petrous ridge, care is taken to preserve surrounding blood vessels and nerves. The dissection continues posteriorly toward the arcuate eminence, with the sigmoid sinus and presigmoid dura being alternately elevated off the mastoid bone. Bone resection is performed using cutting burrs and rongeurs, which facilitates the identification of the posterior semicircular canal. The cortical bone is then skeletonized while ensuring the preservation of the facial nerve, followed by the identification and skeletonization of the superior semicircular canal (SSC).
The next step involves resecting the petrous ridge at the petrous apex, extending from the SSC to the trigeminal nerve. The posterior fossa is opened along the anterior border of the sigmoid sinus, with the opening extended caudally to the superior petrosal sinus. Finally, the dura is opened through the trigeminal dural ring, retracted, and secured with stay sutures, providing a clear view of the petroclival region of the brain for subsequent surgical procedures.
Post-procedure care following the transpetrosal approach includes monitoring for any complications such as bleeding, infection, or neurological deficits. Patients are typically observed in a recovery area before being transferred to a surgical ward for further monitoring. Pain management is an essential aspect of post-operative care, and patients may require analgesics to manage discomfort. Additionally, neurological assessments are performed regularly to evaluate the patient's recovery and to identify any potential complications early. The duration of recovery may vary depending on the extent of the surgery and the patient's overall health, with follow-up appointments scheduled to monitor healing and assess the need for any further interventions.
| Short Descr | TRANSPETROSAL APPROACH/SKULL | Medium Descr | TRANSPTRSAL POST CRNL FOSSA CLIVUS/FORAMN MAGNUM | Long Descr | Transpetrosal approach to posterior cranial fossa, clivus or foramen magnum, including ligation of superior petrosal sinus and/or sigmoid sinus | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 2 - Payment restriction for assistants at surgery does not apply to this procedure... | Co-Surgeons (62) | 1 - Co-surgeons could be paid, though supporting documentation is required... | Team Surgery (66) | 2 - Team surgeons permitted; pay by report. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Inpatient Procedures, not paid under OPPS | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P1G - Major procedure - Other | MUE | 1 | CCS Clinical Classification | 1 - Incision and excision of CNS |
This is a primary code that can be used with these additional add-on codes.
| 69990 | Addon Code MPFS Status: Restricted APC N ASC N1 PUB 100 CPT Assistant Article 1Microsurgical techniques, requiring use of operating microscope (List separately in addition to code for primary procedure) |
| 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 62 | Two surgeons: when 2 surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. each surgeon should report the co-surgery once using the same procedure code. if additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate code(s) may also be reported with modifier 62 added. note: if a co-surgeon acts as an assistant in the performance of additional procedure(s), other than those reported with the modifier 62, during the same surgical session, those services may be reported using separate procedure code(s) with modifier 80 or modifier 82 added, as appropriate. | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | GC | This service has been performed in part by a resident under the direction of a teaching physician | LT | Left side (used to identify procedures performed on the left side of the body) | RT | Right side (used to identify procedures performed on the right side of the body) |
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| 1994-01-01 | Added | First appearance in code book in 1994. |