Temporopolar epidural transcavernous transpetrous approach. Technique and indications

BACKGROUND AND PURPOSE: Several selective approaches have been recommended for access to the petroclival region (PCR). However, locoregional extension of the tumor may necessitate more extensive procedures. Dissections from injected specimens allowed us to describe the different osteodural triangles that are exposed to provide an extensive access to the PCR. METHOD: The bony step included a temporopterional flap and exposure of the paraclinoid carotid after removal of the anterior clinoid process. The sphenoid wing was then extensively drilled, exposing the foramen rotundum and ovale. An anterior petrosectomy was subsequently performed. The dura propria of the cavernous sinus was elevated as far as the Meckel cave. The sylvian fissure was also opened. Then, the temporobasal dura and the dura from the posterior surface of the petrous bone were opened and the superior petrosal sinus was coagulated and divided. The tentorium was divided toward its free edge. RESULTS: Via this approach, cranial nerves from the olfactory tract to the acousticofacial bundle are exposed. In the same way, the ventral and lateral surface of the pons is identified. CONCLUSION: The epidural temporopolar transcavernous transpetrous approach is useful to expose during the same procedure, elements of the posterior and middle cranial fossa. It is of particular value when managing tumors simultaneously involving the PCR, the parasellar, and the suprasellar regions.     

Long term surgical results of 154 petroclival meningiomas: A retrospective multicenter study

BackgroundOutcomes of petroclival meningiomas (PCM) (morbidity, permanent cranial nerves deficit, tumor removal and recurrence) are inconsistent in the literature, making it a challenge to predict surgical morbidity.MethodsA multicenter study of patients with PCMs larger than 2.5 cm between 1984 and 2017 was conducted. The authors retrospectively reviewed the patients’ medical records, imaging studies and pathology reports to analyze presentation, surgical approach, neurological outcomes, complications, recurrence rates and predictive factors.ResultsThere were 154 patients. The follow-up was 76.8 months on average (range 8–380 months). Gross total resection (GTR) was achieved in 40 (26.0%) patients, subtotal resection (STR) in 101 (65.6%), and partial resection in 13 (8.3%). Six (2.6%) perioperative deaths occurred. The 5-year, 10-year and 15-year progression-free survival (PFS) of GTR and STR with radiation therapy (RT) was similar (100%, 90% and 75%). PFS of STR without adjuvant radiation was associated with progression in 71%, 51% and 31%, respectively. Anterior petrosectomy and combined petrosectomy were associated with higher postoperative CN V and CN VI deficits compared to the retrosigmoid approach. The latter had a significantly higher risk of CN VII, CN VIII and LCN deficit. Temporal lobe dysfunction (seizure and aphasia) were significantly associated with the anterior petrosectomy approach.ConclusionsOur study shows that optimal subtotal resection of PCMs associated with postoperative RT or stereotactic radiosurgery results in long-term tumor control to equivalent radical surgery. Case selection and appropriate intraoperative judgement are required to reduce the morbidity.     

Posterior approach (Kraske procedure) for surgical treatment of presacral tumors

Presacral tumors are rare,but can comprise a great variety of histological types.Congenital tumors are the most common.Once the diagnosis is established,surgical resection is essential because of the potential for malignancy or infection.Previous biopsy is not necessary or may be even harmful.To decide the best surgical approach(abdominal,sacral or combined) an individual and multidisciplinary analysis must be carried out.We report three cases of cystic presacral masses in which a posterior approach(Kraske procedure) enabled complete resection,the only way to decrease local recurrence.All patients had a satisfactory recovery.A brief overview of retrorectal tumors is presented,focusing on classification,clinical presentation,diagnosis and surgical management.     

改良部分迷路切除岩骨尖入路的显微解剖

目的应用锁孔理念,对部分迷路切除岩骨尖入路进行改良,并对改良后的入路进行显微解剖学研究。方法对15例30侧成人尸头采用改良部分迷路切除岩骨尖入路暴露岩斜区,测量磨除部分迷路和岩骨尖后增加的手术视野和视角,观察岩斜区解剖结构的暴露情况。结果在4cm×3cm大小的骨窗范围内可以完成所有的手术操作。磨除部分迷路和岩骨尖后,手术水平视野平均增加14·2mm,垂直视野平均增加12·5mm,手术水平视角平均增加58°,垂直视角平均增加46°,该入路可充分暴露岩斜区各解剖结构,与原入路相比无明显差别。结论改良部分迷路切除岩骨尖入路暴露充分,较原入路创伤小,脑牵拉轻,不容易损伤颈静脉球和面神经颅外段等重要结构,是一种良好的处理岩斜区病变的手术入路。     

Management of bone-invasive en-plaque petrosal meningiomas. Removal using tailored petrosectomy

BACKGROUND AND PURPOSE: The invasion of bone responsible for hyperostosis is a typical phenomenon associated with en-plaque meningiomas. Although the sphenoid wing and spheno-orbital region are most frequently affected, petrosal involvement is rare and its surgical treatment difficult. Hyperostosis is caused by bone invasion, is responsible for the clinical signs, and prompts the surgeon to use an à la carte drilling that has to be evaluated preoperatively and carried out depending on tumor extension and the treatment goals. METHODS: We report two cases of invasive and evolving en-plaque petrosal meningiomas. Hyperostosis, bony modifications, and intracranial portion of the lesion were responsible for cophosis, facial palsy, trigeminal neuralgia, dysphonia, and laryngeal palsy in one case, and were responsible for hearing loss and facial palsy in the other case. RESULTS: In both cases, the à la carte petrosectomy allowed us to achieve total removal of the lesion. In one case, we used a trans- and infralabyrinthine transjugular approach (to control the extension of the lesion in the jugular foramen, within the sinusojugular axis, and in the internal auditory canal), associated with an anterior petrosectomy (to control the invaded petrous apex, Meckel's cave, and a middle cranial fossa extension). In the other case, we used a retro- and infralabyrinthine transsigmoid transtentorial approach to control the venous axis, the posterior fossa dura, and the tentorium. Total removal of the tumor including bone invasion was achieved in both cases. Neurological deficits improved or remain unchanged. Transient postoperative facial palsy recovered in two months. CONCLUSIONS: An à la carte petrosectomy performed by a surgical team with great expertise in the field of petrous bone anatomy and segmentation should lead to total removal including exposure of the dural tail and intracranial portion of the tumor, while preserving all cranial nerve functions.     

The middle cranial fossa: morphometric study and surgical considerations.

The anatomical features of the temporal bone can vary significantly among different individuals. These variations affect the operative view in middle cranial fossa surgery. We performed 18 middle fossa approaches in 9 cadaveric heads, with detailed morphological analysis, to identify unfavorable situations and reliable systems to avoid complications during surgery. We recorded linear, angular measurements and calculated areas. We performed a computed tomography (CT) scan with analysis of the amount of bone to remove in two temporal bones. We found that the location of the internal auditory canal (IAC) is the keystone of bone removal. We also found accuracy in the system suggested by E. and J. L. Garcia-Ibanez for its identification and that there is a smaller surgical window in female patients (statistically significant) that can be predicted on preoperative imaging studies. Our study also confirms significant individual variability in the mutual relationships of different surgical landmarks. We concluded that surgery of the middle fossa requires detailed understanding of the complex temporal bone anatomy. The surgeon has to be aware of extreme variability of the more commonly used anatomical landmarks. The method to identify the position of the IAC described by E. and J. L. Garcia-Ibanez seems to be the simplest and most reliable. When the surgical strategy includes an anterior petrosectomy, interindividual variability can critically affect the working area, particularly in females. The working area can be estimated on preoperative CT scans through the petrous bone.     

Preauricular Infratemporal Fossa Surgical Approach: Modifications of the Technique and Surgical Indications

A retrospective clinical analysis was performed to evaluate the effectiveness of the preauricular infratemporal fossa (ITF) surgical approach using modifications based on tumor pathology and extension, without compromising outcomes. Patients were surgically treated for tumors involving the ITF via a preauricular surgical approach during 1990 to 2000. Their clinical charts were reviewed to determine the association among pathological variables, details of the surgical procedure, and outcomes. Tumors in 65 patients were categorized as "malignant" and "benign." The malignant group included 44 patients (mean age, 49.5 years). Squamous cell carcinoma was the most common pathology followed by sarcomas. To achieve complete tumor resection, the ITF approach and dissection were combined with other procedures in 74% of these patients. No surgical complications were encountered in 74.4%, and a clinical cure was obtained in 55% of patients (follow-up, 2 years). The benign group included 21 patients (mean age, 36.7 years). Juvenile angiofibromas and meningiomas constituted most of the tumors in this group. An ITF approach alone was sufficient to achieve complete tumor excision in 66.7% of these patients. A clinical cure was achieved in 85% of patients (follow-up, 2 years), and 76.2% had no surgical complications. Chi-square tests revealed significant correlations between tumor extensions and surgical treatment variables. These were more evident in the malignant group, indicating the use of wider surgical exposures and more aggressive, extirpative surgery. The preauricular surgical approach to the ITF can be used to achieve a complete resection of a variety of tumors arising from or extending into the ITF. This approach can be tailored to the nature of the tumor and its extensions.     

The posterior approach to pelvic ring injuries: A technique for minimizing soft tissue complications

Surgical techniques and fixation strategies for the treatment of unstable posterior pelvic ring injuries continue to evolve. The safety of the posterior surgical approach in particular has been questioned due to historically high rates of wound related complications. More contemporary studies have shown lower infection rates, however concern still persists. These concerns for infection and wound necrosis have led, in part, to increased interest in closed reduction and percutaneous fixation for treatment of these injuries but an open posterior approach remains the optimal strategy in some injury patterns. We describe herein a modified posterior approach to the pelvis designed to minimize wound related complications and present our clinical results demonstrating wound complication rates consistent with contemporary publications.     

改良乙状窦前经部分骨迷路入路的显微解剖

目的 目的 研究改良乙状窦前经部分骨迷路入路的显微解剖暴露,探讨其对岩斜区的显露及在手术处理该区域病变中的优势. 方法 2012年4月至10月,对15具尸头标本进行手术人路的改良研究,在传统乙状窦前入路的基础上切除部分半规管和岩尖,详细记录岩斜区重要结构的显露情况. 结果 该入路能够提供至岩斜区和海绵窦后部宽大的操作空间,在乙状窦前显露范围(水平方向)为(19.41±1.58) mm,在颞叶下方的显露范围(垂直方向)为(14.18±1.88) mm,斜坡中心凹陷的最大暴露角度为(60.54±6.93)°,手术操作深度(55.87 4.34) mm.椎-基底动脉、小脑前下动脉、小脑上动脉、同侧第Ⅲ～X对和对侧第Ⅵ对脑神经、三叉神经腔、海绵窦后部等均显露良好. 结论 改良乙状窦前经部分骨迷路入路能够获得岩斜区深面和海绵窦后部良好暴露,具有暴露范围大、观察角度多、保留面听神经功能、早期阻断肿瘤的血供等方面的优势.     

The transzygomatic approach: A long-term clinical review

Summary The transzygomatic approach has been utilised to improve access to the skull base, infratemporal fossa and orbit for a number of years. It provides a low anterolateral approach to the skull base, along the floor of the middle fossa. It allows both a transsylvian and subtemporal approach with a reduction in brain retraction and better exposure of adjacent neurovasculature structures. A long term review of 53 patients is presented highlighting outcome at two years post surgery and morbidity of the approach. It is concluded that the technique is versatile and can be used to improve exposure of a variety of anatomical locations. There is minimal long term morbidity attributable to the surgery of access and the majority of patients have had good outcomes.     

Transbasal approaches: surgical details,pitfalls and avoidances

Lesions involving the anterior skull base and sphenoclival region are difficult surgical problems. This paper presents surgical details, pitfalls, avoidances and our experiences in the surgical treatment of lesions of the anterior skull base using neuronavigation. Between 1999 and 2003, 33 patients with pathology of the anterior skull base were operated on via the traditional transbasal and the extended transbasal approach. A passive-marker-based neuronavigation system has been used for intraoperative image guidance since April 2000. The patients consisted of 11 men and 22 women. Their ages ranged from 3 to 76 years, with a mean of 41 years. The lesions for which the approach was used included 9 cerebrospinal fluid (CSF) fistulae and 24 neoplastic lesions including meningioma (16 cases), metastasis (3 cases), chordoma (3 cases), plasmacytoma (1 case), and osteoma (1 case). Gross total removal of the tumors was accomplished in 22 out of 24 patients with tumor (91.6%). Postoperative complications include CSF leakage (2 cases), infection (2 cases) and transient impaired vision (1 case). One patient (3%) died postoperatively from hypothalamic dysfunction after removal of a benign tumor extending to the anterior third ventricle. Despite the incidence of postoperative infection and the high rate of CSF leakage and death, it is possible to obtain long-term survival for patients with tumors previously considered challenging and difficult surgical problems.     

Surgical strategies for giant medial sphenoid wing meningiomas: a new scoring system for predicting extent of resection

Background  Surgical management of giant medial sphenoid meningiomas (≥5 cm in maximum dimension) is extremely challenging due to their intimate relationship with vital neural structures like the optic nerve, cranial nerves of the cavernous sinus and the cavernous internal carotid artery. Their surgical management is presented incorporating a radiological scoring system that predicts the grade of tumour excision. Materials and methods  20 patients of giant medial sphenoidal wing meningioma (maximum tumour dimension range: 5.2 to 9.5 cm; mean maximum dimension = 6.12 ± 1.06 cm) with mainly visual and extraocular movement deficits, and raised intracranial pressure, underwent surgery. A preoperative radiological scoring system (range 1–12) was proposed considering tumour volume (using Kawamoto’s method); extension into the surrounding surgical corridors; extent of cavernous sinus invasion (based on the tumour relationship to the cavernous internal carotid artery); associated hyperostosis and/or >50% calcification; and, associated brain oedema. Both the conventional frontotemporal craniotomy (n = 13) and its extension to orbitozygomatic osteotomy (n = 7) were utilized. The cavernous sinus was explored in 4 patients and the hyperostotic sphenoid ridge drilled in five patients. Findings  Total excision was achieved in nine patients; small tumour remnants within the cavernous sinus, interpeduncular fossa or suprasellar cistern were left in eight patients; and less than 10% of tumour was left in three patients. A patient with a completely calcified meningioma died due to myocardial infarction. When the preoperative radiological score was ≥7, there was considerable difficulty in achieving total tumour excision. A mean follow of 17.58 ± 15.05 months revealed improvement in visual acuity/field defects in three, stabilisation in 11, and deterioration of ipsilateral visual acuity in five patients. Symptoms of raised pressure, cognitive dysfunction, aphasia and proptosis showed improvement. Conclusion  A relatively conservative approach to these extensive lesions resulted in good outcome in a majority of our patients. Both the standard as well as skull base approaches may be utilized for successful removal of giant medial sphenoidal wing meningiomas. A preoperative radiological score of ≥7 predicts a greater degree of difficulty in achieving complete surgical extirpation.     

Endoscopic endonasal approach to the ethmoidal planum: anatomic study

The endoscopic endonasal technique is currently used by otolaryngologists for the management of different extradural lesions located below the ethmoidal planum. The cooperation between ENTs and neurosurgeons has recently pushed the use of such approach also in the removal of some intradural lesions, which has promoted the interest for an anatomic study to identify the anatomical landmarks and the dangerous points during the endoscopic approach to this area. In six fresh cadaver heads, unilateral and bilateral measurements between the main landmarks of the approach were performed by means of an endoscopic endonasal approach. A wide exposure of the midline anterior skull base was realized. The maximum of lateral extension was obtained between the two medial orbital walls, at the middle of the cribriform plate (mean distance 25,33 mm), while the mean distance between the anterior and posterior ethmoidal arteries at the level of the lamina papyracea was 16 mm. The endoscopic endonasal route can be considered a minimally invasive technique to approach the ethmoidal planum. It requires adequate anatomical knowledge and endoscopic skill for its realization. Due to the wide window realizable through this corridor, it could be considered in selected cases for the removal of intradural lesions such as meningiomas or estesioneuroblastomas.     

Extensive lower clivus chordomas. Removal using the unilateral transmandibular approach

BACKGROUND AND PURPOSE: Clival chordomas are rare skull-base tumors with local malignant behavior. Their control and removal remain difficult because of their anatomical location and because of their extensions. The goal of the treatment is complete surgical removal in a single stage if possible, with minimal deficits, followed by proton therapy. If the tumor remains extradural for a while, it finally progresses through the dura backwards to reach and displace the brain stem and upper cervical cord. Its anterior extension in the retropharyngeal space offers a logical opportunity and many advantages to use an anterior approach. METHODS: With three consecutive cases, we try to demonstrate that the unilateral transmandibular approach offers a large exposure of the lower clivus, the foramen magnum in its ventral part, the ipsilateral infratemporal fossa and C1 to C3. Surgical complications concern the lower cranial nerves, including the hypoglossal. Serous otitis media is possible in case of opened Eustachian tube. Tracheostomy is needed because of a transient tongue oedema. RESULTS: The unilateral transmandibular approach enabled to anatomical and physiological nasal preservation, large operative field facilitating dural closure and tumor removal, with acceptable cosmetic results and sequellae considering the natural course and prognosis of the tumor. CONCLUSIONS: This approach seems to be very useful to reach and removed extensive lower chordomas.     

The midline suboccipital subtonsillar approach to the hypoglossal canal: surgical anatomy and clinical application

Summary Primary lesions of the hypoglossal canal, such as hypoglossal schwannomas, are rare. No consensus exists with regard to the surgical approach of choice for treatment of these lesions. Usually, lateral transcondylar approaches have been used. The authors describe the surgical anatomy of the midline subtonsillar approach to the hypoglossal canal. This approach includes a midline suboccipital craniotomy, dorsal opening of the foramen magnum and elevation of ipsilateral cerebellar tonsil to expose the hypoglossal nerve and its canal. The midline subtonsillar approach permits a straight primary intradural view to the hypoglossal canal. There is no necessity of condylar resections. The surgical anatomy of the subtonsillar approach is described and illustrated by an example of a case.     

The indications, surgical techniques, and limitations of laparoscopic myomectomy.

OBJECTIVE: To assess the indications and limits of laparoscopic myomectomies (LM). METHODS: We conducted a retrospective analysis of 89 consecutive cases of LM. Our LM procedures were as follows: Diluted vasopressin was injected into the myoma capsule, and a transverse incision was made by fine monopolar electrode. Traction was applied to the myoma with a myoma screw. The uterine wall was sutured with a curved needle. Fibrin glue spray was applied to prevent adhesion formation. Enucleated myomas were removed via trocar by using an electric morcellator. RESULTS: We enucleated 195 nodules with diameters > 2 cm; the mean size of the dominant myomas was 5.3 cm. The mean number of myomas removed from each patient was 2. The uterine wall was sutured in all cases with a mean of 9 sutures. The mean blood loss was 102 mL, and the mean operating time was 111 minutes. No patients were converted to laparotomy. The average hospital stay was 2.4 days. When the myomas were larger than 10 cm, the blood loss and operating time were increased. However, the number of myomas did not correlate with blood loss. CONCLUSION: LM appears to offer a number of advantages if the myoma is not larger than 10 cm.     

额外侧锁孔入路的显微与神经内镜解剖

目的对比研究前颅底的显微解剖与神经内镜解剖，为额外侧锁孔手术入路处理前颅底、鞍区病变提供解剖基础。方法经额外侧锁孔手术入路对15具成人尸头进行显微解剖和神经内镜下解剖，比较两种解剖所暴露的范围。结果显微解剖在嗅沟、鞍区和外侧裂存在一定范围的视野盲区；内镜有充足的照明，可将手术视野放大，无视野盲区，清楚地显示周围的解剖结构，而且看得更远。但内镜的图像为二维图像，缺乏景深。神经内镜辅助显微手术可以互补各自不足。结论额外侧锁孔入路在神经内镜的辅助下显微手术切除前颅底和鞍区的病变安全、微创。