{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,11]],"date-time":"2026-07-11T12:51:29Z","timestamp":1783774289741,"version":"3.55.0"},"reference-count":23,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"3","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2019,9]]},"abstract":"<jats:sec><jats:title>OBJECTIVE<\/jats:title><jats:p>The endoscopic endonasal transpterygoid route has been widely evaluated in cadavers, and it is currently used during surgery for specific diseases involving the lateral skull base. Identification of the petrous segment of the internal carotid artery (ICA) is a key step during this approach, and the vidian nerve (VN) has been described as a principal landmark for safe endonasal localization of the petrous ICA at the level of the foramen lacerum. However, the relationship of the VN to the ICA at this level is complex as well as variable and has not been described in the pertinent literature. Accordingly, the authors undertook this purely anatomical study to detail and quantify the peri-lacerum anatomy as seen via an endoscopic endonasal transpterygoid pathway.<\/jats:p><\/jats:sec><jats:sec><jats:title>METHODS<\/jats:title><jats:p>Eight human anatomical specimens (16 sides) were dissected endonasally under direct endoscopic visualization. Anatomical landmarks of the VN and the posterior end of the vidian canal (VC) during the endoscopic endonasal transpterygoid approach were described, quantitative anatomical data were compiled, and a schematic classification of the most relevant structures encountered was proposed.<\/jats:p><\/jats:sec><jats:sec><jats:title>RESULTS<\/jats:title><jats:p>The endoscopic endonasal transpterygoid approach was used to describe the different anatomical structures surrounding the anterior genu of the petrous ICA. Five key anatomical structures were identified and described: the VN, the eustachian tube, the foramen lacerum, the petroclival fissure, and the pharyngobasilar fascia. These structures were specifically quantified and summarized in a schematic acronym\u2014VELPPHA\u2014to describe the area. The VELPPHA area is a dense fibrocartilaginous space around the inferior compartment of the foramen lacerum that can be reached by following the VC posteriorly; this area represents the posterior limits of the transpterygoid approach and, of utmost importance, no neurovascular structures were observed through the VELPPHA area in this study, indicating that it should be a safe zone for surgery in the posterior end of the endoscopic endonasal transpterygoid approach.<\/jats:p><\/jats:sec><jats:sec><jats:title>CONCLUSIONS<\/jats:title><jats:p>The VELPPHA area represents the posterior limits of the endoscopic endonasal transpterygoid approach. Early identification of this area can enhance the safety of the endoscopic endonasal transpterygoid approach expanded to the lateral aspect of the skull base, especially when treating patients with poorly pneumatized sphenoid sinuses.<\/jats:p><\/jats:sec>","DOI":"10.3171\/2018.4.jns173070","type":"journal-article","created":{"date-parts":[[2018,9,21]],"date-time":"2018-09-21T14:20:29Z","timestamp":1537539629000},"page":"911-919","source":"Crossref","is-referenced-by-count":15,"title":["Refining the anatomic boundaries of the endoscopic endonasal transpterygoid approach: the \u201cVELPPHA area\u201d concept"],"prefix":"10.3171","volume":"131","author":[{"given":"Ariel","family":"Kaen","sequence":"first","affiliation":[{"name":"Departments of Neurosurgery and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eugenio","family":"C\u00e1rdenas Ruiz-Valdepe\u00f1as","sequence":"additional","affiliation":[{"name":"Departments of Neurosurgery and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alberto","family":"Di Somma","sequence":"additional","affiliation":[{"name":"Division of Neurosurgery, School of Medicine and Surgery, Universit\u00e0 degli Studi di Napoli Federico II, Naples, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Francisco","family":"Esteban","sequence":"additional","affiliation":[{"name":"Otorhinolaryngology, Hospital Universitario Virgen del Roc\u00edo;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Javier","family":"M\u00e1rquez Rivas","sequence":"additional","affiliation":[{"name":"Departments of Neurosurgery and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jes\u00fas","family":"Ambrosiani Fernandez","sequence":"additional","affiliation":[{"name":"Department of Anatomy and Human Embryology, University of Sevilla, Sevilla, Spain; and"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1754","reference":[{"key":"b1","series-title":"Neurosurgery","first-page":"425","article-title":"Segments of the internal carotid artery: a new classification","volume":"38","author":"Bouthillier A","year":"1996","unstructured":"Bouthillier A, van Loveren HR, Keller JT: Segments of the internal carotid artery: a new classification. Neurosurgery 38:425\u2013433, 1996"},{"issue":"1","key":"b2","series-title":"Neurosurg Focus","first-page":"E5","article-title":"Extended endoscopic endonasal approach to the pterygopalatine fossa: anatomical study and clinical considerations","volume":"19","author":"Cavallo LM","year":"2005","unstructured":"Cavallo LM, Messina A, Gardner P, Esposito F, Kassam AB, Cappabianca P, : Extended endoscopic endonasal approach to the pterygopalatine fossa: anatomical study and clinical considerations. Neurosurg Focus 19(1):E5, 2005"},{"issue":"Suppl 1","key":"b3","series-title":"Head Neck","first-page":"E1680","article-title":"Endoscopic endonasal study of the cavernous sinus and quadrangular space: anatomic relationships","volume":"38","author":"Dolci RL","year":"2016","unstructured":"Dolci RL, Upadhyay S, Ditzel Filho LF, Fiore ME, Buohliqah L, Lazarini PR, : Endoscopic endonasal study of the cavernous sinus and quadrangular space: anatomic relationships. Head Neck 38 (Suppl 1):E1680\u2013E1687, 2016"},{"key":"b4","series-title":"Laryngoscope","first-page":"31","article-title":"Endoscopic endonasal dissection of the infratemporal fossa: anatomic relationships and importance of eustachian tube in the endoscopic skull base surgery","volume":"121","author":"Falcon RT","year":"2011","unstructured":"Falcon RT, Rivera-Serrano CM, Miranda JF, Prevedello DM, Snyderman CH, Kassam AB, : Endoscopic endonasal dissection of the infratemporal fossa: anatomic relationships and importance of eustachian tube in the endoscopic skull base surgery. Laryngoscope 121:31\u201341, 2011"},{"key":"b5","series-title":"Laryngoscope","first-page":"445","article-title":"Endonasal endoscopic exposure of the internal carotid artery: an anatomical study","volume":"122","author":"Fortes FS","year":"2012","unstructured":"Fortes FS, Pinheiro-Neto CD, Carrau RL, Brito RV, Prevedello DM, Sennes LU: Endonasal endoscopic exposure of the internal carotid artery: an anatomical study. Laryngoscope 122:445\u2013451, 2012"},{"key":"b6","series-title":"Laryngoscope","first-page":"44","article-title":"Endoscopic anatomy of the pterygopalatine fossa and the transpterygoid approach: development of a surgical instruction model","volume":"118","author":"Fortes FS","year":"2008","unstructured":"Fortes FS, Sennes LU, Carrau RL, Brito R, Ribas GC, Yasuda A, : Endoscopic anatomy of the pterygopalatine fossa and the transpterygoid approach: development of a surgical instruction model. Laryngoscope 118:44\u201349, 2008"},{"key":"b7","series-title":"J Neurosurg","first-page":"1855","article-title":"Expanding the endoscopic transpterygoid corridor to the petroclival region: anatomical study and volumetric comparative analysis","volume":"128","author":"Freeman JL","year":"2018","unstructured":"Freeman JL, Sampath R, Quattlebaum SC, Casey MA, Folzenlogen ZA, Ramakrishnan VR, : Expanding the endoscopic transpterygoid corridor to the petroclival region: anatomical study and volumetric comparative analysis. J Neurosurg 128:1855\u20131864, 2018"},{"key":"b8","series-title":"Head Neck","first-page":"313","article-title":"Endonasal transpterygoid approach to the infratemporal fossa: correlation of endoscopic and multiplanar CT anatomy","volume":"34","author":"Hosseini SM","year":"2012","unstructured":"Hosseini SM, Razfar A, Carrau RL, Prevedello DM, Fernandez-Miranda J, Zanation A, : Endonasal transpterygoid approach to the infratemporal fossa: correlation of endoscopic and multiplanar CT anatomy. Head Neck 34:313\u2013320, 2012"},{"key":"b9","series-title":"Laryngoscope","first-page":"811","article-title":"Endoscopic endonasal transpterygoid approaches: anatomical landmarks for planning the surgical corridor","volume":"123","author":"Kasemsiri P","year":"2013","unstructured":"Kasemsiri P, Solares CA, Carrau RL, Prosser JD, Prevedello DM, Otto BA, : Endoscopic endonasal transpterygoid approaches: anatomical landmarks for planning the surgical corridor. Laryngoscope 123:811\u2013815, 2013"},{"key":"b10","series-title":"J Neurosurg","first-page":"177","article-title":"Expanded endonasal approach: vidian canal as a landmark to the petrous internal carotid artery","volume":"108","author":"Kassam AB","year":"2008","unstructured":"Kassam AB, Vescan AD, Carrau RL, Prevedello DM, Gardner P, Mintz AH, : Expanded endonasal approach: vidian canal as a landmark to the petrous internal carotid artery. J Neurosurg 108:177\u2013183, 2008"},{"key":"b11","series-title":"Laryngoscope","first-page":"2655","article-title":"Eustachian tube and internal carotid artery in skull base surgery: an anatomical study","volume":"124","author":"Liu J","year":"2014","unstructured":"Liu J, Pinheiro-Neto CD, Fernandez-Miranda JC, Snyderman CH, Gardner PA, Hirsch BE, : Eustachian tube and internal carotid artery in skull base surgery: an anatomical study. Laryngoscope 124:2655\u20132664, 2014"},{"key":"b12","series-title":"Otolaryngol Head Neck Surg","first-page":"377","article-title":"Eustachian tube as a landmark to the internal carotid artery in endoscopic skull base surgery","volume":"154","author":"Liu J","year":"2016","unstructured":"Liu J, Sun X, Liu Q, Wang D, Wang H, Ma N: Eustachian tube as a landmark to the internal carotid artery in endoscopic skull base surgery. Otolaryngol Head Neck Surg 154:377\u2013382, 2016"},{"key":"b13","series-title":"J Neurosurg","first-page":"1171","article-title":"Comparative analysis of the anterior transpetrosal approach with the endoscopic endonasal approach to the petroclival region","volume":"125","author":"Muto J","year":"2016","unstructured":"Muto J, Prevedello DM, Ditzel Filho LF, Tang IP, Oyama K, Kerr EE, : Comparative analysis of the anterior transpetrosal approach with the endoscopic endonasal approach to the petroclival region. J Neurosurg 125:1171\u20131186, 2016"},{"key":"b14","series-title":"J Neurol Surg B","first-page":"361","article-title":"Finding the petroclival carotid artery: the vidian\u2013eustachian junction as a reliable landmark","volume":"79","author":"Oakley GM","year":"2018","unstructured":"Oakley GM, Ebenezer J, Hamizan A, Sacks PL, Rom D, Sacks R, : Finding the petroclival carotid artery: the vidian\u2013eustachian junction as a reliable landmark. J Neurol Surg B 79:361\u2013366, 2018"},{"issue":"5 Suppl 2","key":"b15","series-title":"Neurosurgery","first-page":"385","article-title":"Microsurgical and endoscopic anatomy of the vidian canal","volume":"64","author":"Osawa S","year":"2009","unstructured":"Osawa S, Rhoton AL Jr, Seker A, Shimizu S, Fujii K, Kassam AB: Microsurgical and endoscopic anatomy of the vidian canal. Neurosurgery 64 (5 Suppl 2):385\u2013412, 2009"},{"issue":"4 Suppl 2","key":"b16","series-title":"Neurosurgery","first-page":"210","article-title":"Microsurgical anatomy and surgical exposure of the petrous segment of the internal carotid artery","volume":"63","author":"Osawa S","year":"2008","unstructured":"Osawa S, Rhoton AL Jr, Tanriover N, Shimizu S, Fujii K: Microsurgical anatomy and surgical exposure of the petrous segment of the internal carotid artery. Neurosurgery 63 (4 Suppl 2):210\u2013239, 2008"},{"key":"b17","series-title":"J Neurol Surg B Skull Base","first-page":"266","article-title":"Transposition of the pterygopalatine fossa during endoscopic endonasal transpterygoid approaches","volume":"74","author":"Pinheiro-Neto CD","year":"2013","unstructured":"Pinheiro-Neto CD, Fernandez-Miranda JC, Prevedello DM, Carrau RL, Gardner PA, Snyderman CH: Transposition of the pterygopalatine fossa during endoscopic endonasal transpterygoid approaches. J Neurol Surg B Skull Base 74:266\u2013270, 2013"},{"key":"b18","series-title":"Laryngoscope","first-page":"6","article-title":"Endoscopic anatomy of the palatovaginal canal (palatosphenoidal canal): a landmark for dissection of the vidian nerve during endonasal transpterygoid approaches","volume":"122","author":"Pinheiro-Neto CD","year":"2012","unstructured":"Pinheiro-Neto CD, Fernandez-Miranda JC, Rivera-Serrano CM, Paluzzi A, Snyderman CH, Gardner PA, : Endoscopic anatomy of the palatovaginal canal (palatosphenoidal canal): a landmark for dissection of the vidian nerve during endonasal transpterygoid approaches. Laryngoscope 122:6\u201312, 2012"},{"issue":"2 Suppl Operative","key":"b19","series-title":"Neurosurgery","first-page":"478","article-title":"Vidian nerve transposition for endoscopic endonasal middle fossa approaches","volume":"67","author":"Prevedello DM","year":"2010","unstructured":"Prevedello DM, Pinheiro-Neto CD, Fernandez-Miranda JC, Carrau RL, Snyderman CH, Gardner PA, : Vidian nerve transposition for endoscopic endonasal middle fossa approaches. Neurosurgery 67 (2 Suppl Operative):478\u2013484, 2010"},{"issue":"Suppl 4","key":"b20","series-title":"Laryngoscope","first-page":"S244","article-title":"Endoscopic endonasal dissection of the pterygopalatine fossa, infratemporal fossa, and post-styloid compartment. Anatomical relationships and importance of eustachian tube in the endoscopic skull base surgery","volume":"120","author":"Rivera-Serrano CM","year":"2010","unstructured":"Rivera-Serrano CM, Terre-Falcon R, Fernandez-Miranda J, Prevedello D, Snyderman CH, Gardner P, : Endoscopic endonasal dissection of the pterygopalatine fossa, infratemporal fossa, and post-styloid compartment. Anatomical relationships and importance of eustachian tube in the endoscopic skull base surgery. Laryngoscope 120 (Suppl 4):S244, 2010 (Abstract)"},{"key":"b21","series-title":"J Neurosurg","first-page":"157","article-title":"Anatomical study of the pterygopalatine fossa using an endoscopic endonasal approach: spatial relations and distances between surgical landmarks","volume":"106","author":"Solari D","year":"2007","unstructured":"Solari D, Magro F, Cappabianca P, Cavallo LM, Samii A, Esposito F, : Anatomical study of the pterygopalatine fossa using an endoscopic endonasal approach: spatial relations and distances between surgical landmarks. J Neurosurg 106:157\u2013163, 2007"},{"key":"b22","series-title":"J Neurosurg","first-page":"1032","article-title":"Endoscopic endonasal translacerum approach to the inferior petrous apex","volume":"124","author":"Taniguchi M","year":"2016","unstructured":"Taniguchi M, Akutsu N, Mizukawa K, Kohta M, Kimura H, Kohmura E: Endoscopic endonasal translacerum approach to the inferior petrous apex. J Neurosurg 124:1032\u20131038, 2016"},{"key":"b23","series-title":"J Neurol Surg B Skull Base","first-page":"358","article-title":"Endoscopic versus open approach to the infratemporal fossa: a cadaver study","volume":"76","author":"Youssef A","year":"2015","unstructured":"Youssef A, Carrau RL, Tantawy A, Ibraheim A, Solares AC, Otto BA, : Endoscopic versus open approach to the infratemporal fossa: a cadaver study. 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