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.     

Superior interhemispheric approach for midline meningioma from the anterior cranial base

Background

For suprasellar meningioma, the fronto-basal exposure is considered the standard approach. The superior interhemispheric (IH) approach is less described in the literature.

Objective

To assess the surgical complications, functional outcome (visual, olfaction), morbidity and mortality rates and late recurrence, after resection by superior IH approach of midline skull base meningioma.

Methods

Between 1998 and 2008, 52 consecutive patients with midline meningioma on the anterior portion of the skull base (mean age: 63.8 ± 13.1; sex ratio F/M: 3.7) were operated on via the superior IH approach. After a mean follow-up of 56.9 ± 32.9 months, an independent neurosurgeon proposed a prospective examination of functional outcome to each patient, as well as a visual and olfactory function assessment.

Results

Fifty-two patients were divided into a group with olfactory groove meningioma (n = 34) and another with tuberculum sellae meningioma (n = 18). The outcome was characterized by postoperative complications in 13 patients (25%), mortality rate in two (3.8%) and long-term morbidity at in 17 (37%) of 50 surviving patients. Based on multivariate analysis, no prognosis factor was significant as regards the favorable outcome. The mean postoperative KPS score (86.6 ± 9.4) was significantly improved. However, dysexecutive syndrome was observed in four patients (8%), hyposmia-anosmia in 34 (68%) and visual acuity deteriorated in one (2%).

Conclusion

The superior IH approach could be considered a safe anteriorly orientated midline approach for removal OGM and TSM meningioma.     

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。     

Morphometric measurements of the anterior skull base for endoscopic transoral and transnasal approaches

The objective of this study is to determine the bony limits of the transnasal and transoral approaches to the anterior skull base. The data we present are meant to assist surgeons in preoperative planning for lesions of the sella, clivus, foramen magnum, and odontoid. Using precise measurements undertaken on 41 high-resolution computed tomography scans from patients at the University of Pennsylvania without any history of sinus or sellar pathology, we sought to define the bony limits of transoral and transnasal approaches. Direct measurements and calculated angles were used to assess the dimensions of the anterior skull base. Using our measurements, a transnasal approach can reach an average of 22.5 mm below the plane of the hard palate to the body of C2, and a transoral route can reach 38 mm above the basion along the length of the clivus. Analysis of variance demonstrated no significant differences when subjects were grouped based on race or gender. The measurements outlined within this article help to define the relative dimensions necessary for adapted transoral and transnasal skull base surgeries.     

3D-FIESTA MR images are useful in the evaluation of the endoscopic expanded endonasal approach for midline skull-base lesions

The endoscopic expanded endonasal approach (EEA) has been reported in literature as a useful tool to treat sellar, parasellar, suprasellar, and clival lesions. The endoscope permits a panoramic view rather than a narrow microscopic view, and this approach can reach the lesion without brain retraction and with minimal neurovascular manipulation. However, because of the narrow corridor, the preoperative evaluation of the lesions should be of high priority. 3D fast-imaging employing steady-state acquisition (3D-FIESTA) or constructive interference in steady state (CISS) MR imaging provides high spatial resolution in the small structures within the cisterns. Therefore, this technique may be useful for better preoperative planning in detecting optic nerve, oculomotor nerve, chiasma, infundibulum, pituitary stalk, and small vessels in sellar region. Here we used the 3D-FIESTA MR images to evaluate EEA for seven midline skull-base lesions. Our report showed that, when EEA was used to treat midline skull-base lesions, 3D-FIESTA MR images were valuable in the assessment of vital structures in and around the tumor-involved midline skull-base region. 3D-FIESTA MR images can help in making a better preoperative planning, locating the intraoperative structures, and reducing the surgical risks. Otherwise, this approach is helpful for the craniopharyngioma classification based on EEA.     

2种腔镜下甲状腺手术的比较

目的比较2种入路腔镜甲状腺手术的优缺点。方法乳晕入路腔镜下甲状腺腺瘤切除术10例(乳晕入路组),颈部小切口腔镜辅助甲状腺手术11例(颈部小切口组),比较2组手术时间、术中出血量、住院时间和并发症。结果21例均成功完成腔镜甲状腺手术。乳晕入路组手术时间(132.4±39.1 m in)明显长于颈部小切口组(89.2±16.8 m in,t=3.347,P=0.003)。乳晕入路组术中出血量(12.9±4.3 m l)明显少于颈部小切口组(18.2±5.5 m l,t=-2.442,P=0.025)。乳晕入路组术后住院时间(4.2±1.0 d)长于颈部小切口组(3.0±0.6 d,t=3.373,P=0.003)。21例随访6个月均未见甲状腺肿瘤复发或甲状腺功能减退。结论与颈部小切口腔镜辅助甲状腺手术相比,乳晕入路腔镜甲状腺手术手术时间较长,不易掌握,但暴露更充分,视野更清晰,术中出血少,美容效果好。     

Novel flexible forceps for endoscopic transsphenoidal resection of pituitary tumors: technical report

The endoscope has become an essential tool for transsphenoidal pituitary surgeries because of the panoramic view and the ability to visualize structures beyond the direct line of vision. However, the regular dedicated instruments for these surgeries sometimes do not reach the areas visualized by an angled endoscope, and instrument maneuverability is limited. To overcome or minimize these problems, we constructed a new flexible tumor forceps that can be manipulated to change shape after placing into the surgical fields via the endonasal or sublabial route, to reach any desirable location for tumor dissection and excision. We applied this newly developed instrument in endonasal endoscopic resection complementing microsurgical procedure in 20 cases of pituitary tumors. The flexible forceps was able to access sites where regular dedicated instruments for transsphenoidal pituitary surgeries could not readily reach despite endoscopic visualization. No complication was observed in the present series, confirming the safety of the newly designed flexible forceps. Our newly developed flexible forceps improves the instrument maneuverability of endoscopic transsphenoidal resection of pituitary tumors, especially those located laterally at the cavernous sinuses or with frontal extension. The use of this instrument makes the best use of endoscopic panoramic visualization for tumor removal.     

Surgical approaches for vertebro-basilar trunk aneurysms located in the midline

Summary Fourteen cases of midline vertebro-basilar trunk aneurysms were operated on by four routes of surgical approach: middle fossa anterior transpetrosal approach (ATP), presigmoid transpetrosal approach (PTP), conventional lateral suboccipital approach (LSO) or suboccipital transcondylar approach (STC). There was no mortality, but the morbitity was different depending on the surgical approach. In basilar trunk aneurysms located higher than the internal auditory canal, excellent results were obtainable by ATP, especially in the case of posteriorly projecting aneurysms. For midline vertebral aneurysms located lower than the internal auditory canal, STC resulted in less surgical complications than LSO. Extradural resection of the jugular tubercle was necessary for aneurysms located on the distal vertebral artery at or close to the vertebro-basilar junction. For vertebro-basilar junction aneurysms located at the level of the internal auditory canal, hearing was preserved by STC, but not by ATP or PTP. However, choice of the surgical approach may depend on the direction of the aneurysm and the technical accessibility of the skull base. All these skull base approaches reduced surgical complications of retraction damage to the cranial nerves and the brain stem. This holds true for all aneurysms arising from the midline vertebro-basilar trunk.     

扩大经蝶窦入路切除侵袭性垂体腺瘤

目的探讨采用扩大经蝶窦入路切除侵袭性垂体腺瘤的有效性和安全性。方法根据鞍区显微解剖学研究结果,采用扩大经蝶窦手术入路治疗64例侵袭性垂体腺瘤。结果肿瘤全部切除51例,次全切除13例。术后发生短暂性尿崩症26例,脑脊液鼻漏5例及急性腺垂体功能低下者1例,无死亡及颅内感染。8例患者术后给予放射治疗,6例予以溴隐亭治疗。随诊3个月至6年,未见肿瘤复发或继续生长。结论采用扩大经蝶窦入路切除巨大或不规则鞍外生长垂体腺瘤时,肿瘤显露满意,全切除率高,无明显手术并发症,是一种安全、有效的方法。对于那些肿瘤切除不彻底的患者,术后应密切随访,必要时给予放射或药物治疗。     

The Extended Transbasal Approach: Clinical Applications and Complications

Summary  Objectives. To describe in detail key technical aspects of the extended transbasal approach which involves en-bloc mobilisation of the supraorbital rim, the orbital roof and the nasoethmoidal complex. In some patients osteotomies were performed around the cribriform plate with a view to maintaining olfaction.  To review 18 patients with deep seated lesions located in the central skull base region (including 6 recurrences) to highlight patient selection, presentation, surgical morbidity and outcome.  Methods. Prospective data recording and clinical chart review.  Results. Outcome was assessed at a minimum of 1 year after operation using the Glasgow Outcome Score. Thirteen patients had made a good recovery, 1 was moderately disabled, 2 were severely disabled (both had been severely disabled before operation), and 2 died. By contrast, quality of life assessment indicated that only 7 of the surviving 14 adults had returned to normal levels of activity and perceived health; although 6 of the other 7 patients had resumed their former occupations, their follow up assessments showed a reduced quality of life. Of the 13 patients who had an olfaction preservation procedure, 6 showed appreciation of smell on formal testing.  Conclusions. In patients with progressive and extensive deep seated lesions this technique provides wide exposure in a shallow surgical field. Complication rates although acceptable were significantly higher in patients with intradural lesions. In some selected patients it was possible to preserve olfaction. Specific surgical outcome assessments pointed to satisfactory results, but failed to reflect the degree of patient disability. There is a need for outcome measures that take into account the patient's expectations and which address his quality of life in order to validate the benefits of these procedures.     

The Extended Transbasal Approach: A Quantitative Anatomical and Histological Study

Summary  Since its introduction in 1972 the transbasal approach to the anterior fossa and sphenoethmoidal region has undergone a number of modifications. The extended transbasal approach with preservation of olfaction not only improves exposure of the anterior fossa, but also provides access to the clivus as far inferiorly as the foramen magnum.  An anatomical study has been undertaken to photographically demonstrate and quantify the varying degrees of exposure that this technique provides. The pituitary stalk was used as an intracranial target. The amount of exposure was compared using a standard subfrontal approach, a transbasal approach and an extended transbasal with preservation of olfaction. In addition, a histological study was carried out to investigate the level to which identifiable olfactory nerves extended into the nasal mucosa.  The anatomical study demonstrates the area of the “external window of exposure” can be doubled using a transbasal approach and more than quadrupled using the extended transbasal approach, when gaining access to the pituitary stalk. In addition, the study highlights the exposure of other anatomical areas, such as the medial orbit, the cavernous sinus, the clivus and the vertebrobasilar complex. The histological study establishes that the olfactory nerves extend only 10mms below the cribriform plate.     

“Extended length” endoscopic harvest of the great saphenous vein for coronary artery bypass grafting

Introduction The endoscopically harvested vein from thigh usually falls short by half to one length in patients requiring multiple conduits. Increased risk of complications precludes routine endoscopic vein harvest from the leg and an extra incision for open technique is often required thereby nullifying the sole purpose of the former. We employed the endoscope to harvest this extra length of vein from the upper half of the leg with little or no extra risk. Methods From January 2006 to September 2006 we endoscopically harvested the vein in thigh as well as the leg using the same entry point incision over the medial epicondyle in 40 cases. The only exclusion criterion for the study was a superficial location and subcutaneous visibility of the vein in the leg. We made 3 incisions in each patient of average size 2.5 cm. Results Five patients required conversion to the open technique. The average harvest time was 59 minutes. Average length of the conduit was 48 cms. Complications included 1 minor wound infection, 1 case of superificial wound dehiscence, 1 haematoma requiring aspiration and minor erythema at the incision site in 2 patients. Most common complication observed was ecchymosis in 6 patients (5 high; 3 leg). None of the patient developed lymphoedema and none required re-hospitalization for vein harvest related wound complications. Conclusion “Extended endoscopic vein harvest” and avoidance of the open incision was possible in most patients with no additional risk and that the procedure could be routinely employed in patients requiring multiple conduits.     

腔镜下切除巨大甲状腺病变的手术经验

【摘要】 目的 探讨腔镜下切除巨大甲状腺病变的可行性。方法 选择15例甲状腺良性病变患者,病变最大直径10 cm。采用胸乳入路腔镜下切除甲状腺病变的手术方法。结果 全组均顺利完成手术,无中转开放手术。术中出血量为5~600(75±20)mL,1例因手术断面出血控制不佳,出血量较多。手术时间为55~180(88±21)min,术后住院天数为3~6(3.8±0.5)d。1例术后一周出现皮下积液,重新放置引流管治愈。无其它并发症。全组患者对手术美容效果均满意。结论 腔镜下采用分块切除的方法切除巨大甲状腺病变是可行的,但须选择良性病变。     

经皮内窥镜下腰椎间盘切除术治疗外侧型腰椎间盘突出症

目的:探讨腰椎后外侧入路经皮内窥镜下椎间盘切除术治疗外侧型腰椎间盘突出症的手术技术和临床疗效.方法:2006年3月～2007年3月共收治40例外侧型腰椎间盘突出症患者,男25例,女15例,平均年龄35岁(17～63岁),突出节段L5/S1 8例,L4/5 30例,L3/4 2例.采用局部浸润麻醉,C型臂X线透视引导下定位,后外侧入路经皮穿刺进入椎间孔,工作套管逐级扩张,显露突入椎管后外侧的椎间盘组织,在内窥镜直视下行突出髓核组织切除术.采用视觉模拟疼痛评分(visual analogue scale,VAS)和改良MacNab标准评定手术疗效.结果:本组无术中硬脊膜破裂和血管、神经损伤并发症.5例患者术后出现下肢一过性痛觉过敏,经保守治疗1周后症状缓解.平均手术时间70min(40～150min),出血5～20ml,平均术后下床时间36h(24～48h),平均住院时间5d(3～10d).随访时间12个月.下肢坐骨神经痛VAS评分术前为8.5±1.2分,术后3d时为3.5±1.4分,末次随访时为1.5±1.1分;术前、术后结果进行配对t检验有显著性差异(P<0.01).MacNab标准临床效果评定结果为优30例,良6例,可4例,优良率90%.结论:经皮内窥镜下椎间盘切除术创伤小、出血少、视野清晰、操作精细、术后恢复快、手术效果优良,是治疗外侧型腰椎间盘突出的优选术式.     

神经导航引导下内镜经蝶入路切除鞍上型巨大垂体瘤

目的探讨神经内镜及神经导航用于经鼻蝶入路治疗鞍区肿瘤的临床应用及手术技巧。方法对2007-03—2013-11间收治的32例鞍上型巨大垂体肿瘤实施神经内窥镜结合神经导航技术经鼻蝶手术切除。结果本组肿瘤全切除24倒,近全切除6倒,大部分切除2例。术后患者症状均有不同程度改善。2例患者出现一过性脑脊液漏,5例出现尿崩症,其中1例需长期口服弥凝,无其他严重并发症发生。结论内镜技术经鼻蝶手术治疗垂体肿瘤,具有对鼻腔正常结构损伤小、暴露清楚等特点,特别是对于传统显微镜手术不能暴露的鞍上结构显露满意。结合导航技术能提高肿瘤的全切率及手术的安全性。     

Extended lateral approach for elective hind foot surgery—A safe and versatile incision

Aim

The aim of our study was to review our experience of the extended lateral approach to the hind foot in treatment of non-traumatic foot disorders with particular reference to wound complications.

Materials and methods

We retrospectively reviewed 51 consecutive patients who under went extended lateral approach to the hind foot for treatment of various non traumatic foot disorders. We documented the indication for surgery, co-morbidity, quality of wound healing and other wound related problems.

Results

The mean age was 47.9. There were three superficial wound infections (5.8%). One had slight sensory loss close to the scar, one developed hypersensitivity over the scar. There was no wound break down or any deep infection. No sural nerve deficit was noted. Six patients had the calcaneal screw removed due to prominent metal work (11.7%).

Conclusion

The extended lateral approach to hind foot is safe in the surgical treatment of a wide variety of non-traumatic foot conditions. Despite the larger deep dissection, the arterial anatomy ensures reliable wound healing and a low incidence of wound complications.     

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.     

椎管内麻醉不同穿刺入路对膝关节镜手术的影响

目的：观察直入穿刺法与旁入穿刺法2种不同椎管内麻醉穿刺方法对膝关节镜手术患者的影响。方法：择期行膝关节镜手术120例,ASA Ⅰ～Ⅱ级,按随机数字表法随机分为直入法穿刺组和旁入法穿刺组。均采用一点法即针内针单间隙穿刺技术。观察每组患者的麻醉起效时间、穿刺成功率、神经异感、硬膜外置管困难发生率、硬膜外导管误入血管发生率、术后腰背痛发生情况,麻醉后1、5、10、30min无创血压、心率、脉搏血氧饱和度。结果：直法与旁入法腰麻硬膜外联合穿刺在麻醉起效时间（5．24±0．4）min vs（5．14±0．6）min、硬膜外置管困难发生率1．7％ vs 1．7％、硬膜外导管误入血管发生率3．4％ vs 1．7％、神经异感发生率3．4％ vs 3．4％无显著性差异（P〉0．05）。麻醉后1、5、10、30min SBP、DBP、HR、SpO2,2组间差异无统计学意义（P〉0．05）。旁入法术后腰背痛的发生率75．0％（45／60） vs 23．3％（14／60）及持续时间（2．44±0．8）d vs（2．04±0．7）d明显低于直入法组（x^2=32．042,P=0．000;t=2．195,P=0．004）。结论：2种麻醉穿刺方法均可安全有效地应用于膝关节镜手术;与直入法相比,旁入法腰麻硬膜外联合麻醉术后腰痛发生率低。     

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.