The Le Fort I-palatal split approach for skull base tumors: efficacy, complications, and outcome

The pterygomaxillary junction: An imaging study for surgical information of LeFort I osteotomy

Maxillary osteotomy is a common surgical procedure and often involves separation of the pterygomaxillary junction (PMJ), which is a “blinded” procedure with inherent risks. Knowledge of the PMJ structure is essential. It remains unclear whether patients with different facial types have different PMJ structures, or different surgical outcome. This study evaluated the computed tomographic images of 283 consecutive patients who received orthognathic surgery. Patients were classified into Angle class I, II, III and cleft lip/palate groups. The results showed that the PMJ was 5.1 ± 1.4 mm in thickness, 9.7 ± 1.7 mm in width, and 102.0 ± 4.0 degrees relative to the sagittal plane in the level of posterior nasal spine. There were no statistically significant differences in these measurements among the groups. The class III group demonstrated significantly smaller angle relative to the maxillary occlusal plane. The cleft group showed significantly longer vertical distance between the posterior nasal spine and the lower border of PMJ, shorter distance between the second molar and PMJ, and longer distance between the descending palatine artery and PMJ. With regard to postoperative outcome, the cleft group showed higher incidence of pterygoid plate fracture. The results in this study provide additional surgical anatomic information.

Solitary lesions of the clivus: what else besides chordomas? An extensive clinical outlook on rare pathologies

BACKGROUND

Solitary non-chordomatous lesions of the clivus are rare pathologies, which represent a diagnostic challenge. This study provides an overview of the clinical, radiological and prognostic characteristics of non-chordomatous clival lesions, highlighting current therapeutic options.

METHODS

Twenty-two non-chordomatous lesions of the clivus were collected. A retrospective analysis of clinical and radiological patterns as well as survival data was conducted.

RESULTS

Clinical presentation was a result of local mass effect. Imaging features, although mainly specific, were not always diagnostic. Extent of surgery was gross total in 45.5 % of cases. Depending on the histology, biological behaviour and presence of seeding, adjuvant treatment was performed, tailoring the treatment strategy to the single patient.

CONCLUSIONS

Solitary non-chordomatous lesions of the clival bone are more prevalent than expected. They should be approached with a correct differential diagnosis, considering specific epidemiological, radiological, and histopathological characteristics, to minimise diagnostic bias and allow the planning of the best treatment strategy.

Comparing operative exposures of the le fort I osteotomy and the expanded endoscopic endonasal approach to the clivus

Objectives We compare surgical exposures to the clivus by Le Fort I osteotomy (LFO) and the expanded endoscopic endonasal approach (EEEA). Methods Ten cadaveric specimens were imaged with 1.25-mm computed tomography. After stereotactic navigation, EEEA was performed followed by LFO. Clival measurements included lateral and vertical limits to the midline lower extent of exposure (t test). Results For EEFA and LFO, respectively, maximal lateral exposure in millimeters (mean ± standard deviation) was 24.5 ± 3.7 and 24.5 ±  - 3.8 (p = 0.99) at the opticocarotid recess (OCR) and 25.1 ±  - 4.1 and 24.1 ±  - 3.0 (p = 0.53) at the foramen lacerum level; lateral reach at the hypoglossal canals was 39.0 ±  - 5.88 and 56.1 ±   - 5.3 (p = 0.0004); and vertical extension was 56.0 ±  - 4.1 and 56.3 ±  - 3.4 (p = 0.78). Conclusions For clival exposures, LFO and EEEA were similar craniocaudally and laterally at the levels of the OCR and foramen lacerum. LFO achieved greater exposure at the level of the hypoglossal canal.

Morbidity profile and functional outcome of modified facial translocation approaches for skull base tumors

The primary objective of this study was to evaluate morbidity associated with facial translocation approaches for skull base and results of various technical modifications. Forty consecutive patients who underwent facial translocation approaches for accessing skull base tumors from July 2005 to June 2010 were included in this study. There were 25 patients who underwent standard facial translocation, 4 patients medial mini, and 11 patients underwent extended facial translocation. Thirteen patients had benign disease and 27 patients had malignant disease. Resection was R0 in 36 and R1 in 4 patients. Most patients had acceptable cosmetic results. None of the patients had problems related to occlusion or speech and swallowing. The commonest complication observed was nasal crusting in 16 patients. Grade 2 trismus and exposure of mini plate was seen in three patients. Two patients developed necrosis of translocated bone. Three patients developed palatal fistula before modification of palatal incision. Facial translocation provides a satisfactory access for adequate clearance of skull base tumors with satisfactory aesthetic and functional results. With modifications of the surgical technique and implementation of new surgical tools, the morbidity of facial translocation approaches will continue to decrease.

Life threatening epistaxis complicating extended maxillotomy for chordoma

Postoperative hemorrhagic complications of the "open-door" maxillotomy approach to the skull base and clivus are uncommon. We report a case of maxillary artery pseudoaneurysm and discuss the management of this condition.

Transoral approach and extended modifications for lesions of the ventral foramen magnum and craniovertebral junction

OBJECTIVES

To describe our method of performing the transoral approach and the extended approaches to the ventral foramen magnum and craniovertebral junction and review the technical aspects and operative nuances.

DESIGN

Review.

RESULTS

The transoral approach provides direct midline exposure to access extradural disease located at the craniovertebral junction and ventral foramen magnum. The corridor of exposure is generally limited by the extent to which the patient can open his or her mouth. The location of the hard palate relative to the craniovertebral junction limits superior exposure, whereas the mandible and base of the tongue limit the inferior exposure. In most cases, exposure can be obtained from the inferior clivus to the middle to lower C2 vertebral body. Extended transoral approaches can be performed to increase exposure if necessary. These approaches include transmaxillary (Le Fort I maxillotomy), transmaxillary with a midline palatal split (extended "open-door" maxillotomy), transpalatal, and median labiomandibular glossotomy (transmandibular split).

CONCLUSIONS

The transoral approach effectively provides direct access to extradural midline lesions of the craniovertebral junction. A specialized retractor system can expose the inferior clivus to the C2 body. Extended approaches as described can access lesions that extend beyond these limits.

A comprehensive analysis of intracranial chordoma and survival: a systematic review

OBJECTIVE

Despite the published information on cranial chordoma, most of the data regarding survival in these patients has come from a single institution. Here, we perform a systematic review of the literature to evaluate across multiple institutions the overall survival after treatment for intracranial chordoma.

MATERIALS AND METHODS

We systematically analysed every study published in English and found a total of over 2000 patients being treated for intracranial chordoma. The overall 5-year and 10-year survivals in these patients were stratified according to the age (<5 years vs. >5 years and  <40 years vs. >40 years), treatment (surgery and radiation vs. surgery alone) and histological findings (chondroid vs. typical). Data were analysed via Pearson chi-square test and student t-test when appropriate.

RESULTS

A total of 560 non-duplicated patients treated for cranial chordoma met inclusion criteria for this systematic analysis. The survival rate among these patients was 63% (299 patients) and 16% (176 patients) for 5-year and 10-year survivals, respectively. There was no difference in overall survival between the two groups when a cut-off age of 40 years was used (<40 years = 50% vs.  >40 years = 51% at 5-year survival; p = 0.1), but when 5 years was used as the cut-off age, then survival was better for patients in the group older than 5 years of age (<5 years = 14% vs.  >5 years = 66%; p = 0.001). There was no difference between 5-year survival in patients with chordoma with histological chondroid features and those with chordoma possessing typical histology (45% vs. 67%; p = 0.06). When patients who only received surgery were compared to those patients who were treated with surgical intervention in combination with adjuvant radiation treatment, no difference in survival rate was found (54% vs. 56% at 5 years; p = 0.8).

CONCLUSION

The results of our systematic study provide data to predict the survival of intracranial chordoma patients across multiple institutions. Our data suggest that patients younger than 5 years of age may be associated with a worse prognosis, and adjuvant radiation therapy and histological type were not associated with the improvement of survival rates.

Quantification of clival and paraclival exposure in the Le Fort I transmaxillary transpterygoid approach: a microanatomical study

OBJECT

The authors describe a modified Le Fort I maxillotomy with medial and posterior antrectomy and removal of the pterygoid plates, aimed at improving the lateral surgical exposure during open transmaxillary surgery for pathological conditions involving the clivus. A cadaveric microanatomical study was conducted to compare the planimetric exposures allowed by the transmaxillary transpterygoid (TMTP) approach and the standard Le Fort I maxillotomy (STM).

METHODS

Six cadaveric specimens that had been fixed with glutaraldehyde and injected with latex were dissected to obtain morphometric measurements after both TMTP and STM approaches. The anatomical areas exposed by the surgical approaches were calculated using ImageJ 1.37a software.

RESULTS

As expected, the TMTP approach allowed for a greater surgical exposure, with an incremental area exposed ranging from 4.9 to 7.6 cm(2) (mean ± standard deviation 6.4 ± 1.2 cm(2), 95% CI 5.4-7.4 cm(2)). The amount of additional anatomical area visualized, as recorded as a percentage increase after the TMTP approach when compared with the STM approach, ranged from 83 to 109% (mean 99%).

CONCLUSIONS

The lateral surgical exposure allowed by the STM approach is limited by the pterygoid plates. The TMTP approach significantly improves the exposure of the anatomical regions lateral to the clivus, allowing access to the pterygopalatine and medial infratemporal fossae. In comparison with the STM, the TMTP approach allows for a surgical exposure that is nearly double. The authors conclude that the TMTP approach provides a significant improvement in the surgical exposure of the lateral paraclival areas, when compared with the STM approach.

Adjuvant radiation therapy and chondroid chordoma subtype are associated with a lower tumor recurrence rate of cranial chordoma

Cranial chordomas are rare tumors that have been difficult to study given their low prevalence. Individual case series with decades of data collection provide some insight into the pathobiology of this tumor and its responses to treatment. This meta-analysis is an attempt to aggregate the sum experiences and present a comprehensive review of their findings. We performed a comprehensive review of studies published in English language literature and found a total of over 2,000 patients treated for cranial chordoma. Patient information was then extracted from each paper and aggregated into a comprehensive database. The tumor recurrences in these patients were then stratified according to age (<21 vs. >21 years), histological findings (chondroid vs. typical) and treatment (surgery and radiation vs. surgery only). Data was analyzed via Pearson chi-square and t-test. A total of 464 non-duplicated patients from 121 articles treated for cranial chordoma met the inclusion criteria. The recurrence rate among all patients was 68% (314 patients) with an average disease-free interval of 45 months (median, 23 months). The mean follow-up time was 39 months (median, 27 months). The patients in younger group, patients with chordoma with chondroid histologic type, and patients who received surgery and adjuvant radiotherapy had significantly lower recurrence rate than their respective counterparts. The results of our systematic analysis provide useful data for practitioners in objectively summarizing the tumor recurrence in patients with cranial chordomas. Our data suggests that younger patients with chondroid type cranial chordoma treated with both surgery and radiation may have improved rates of tumor recurrence in the treatment of these tumors.

Transmaxillary approach to the cranial base: an evaluation of 11 cases

Surgical access to the skull base is always difficult, especially because of the noble anatomic structures present there. Maxillary osteotomy provides direct view to the clivus region and the neck spine, and it also bears less morbidity when compared to the many other accesses described in the literature.

Aim

to assess 11 patients submitted to transmaxillary osteotomy, describing the surgical technique and postoperative results and complications.

Materials and Methods

A retrospective study involving eleven patients submitted to transmaxillary approach to the brainstem. We studied dental occlusion, trans and postoperative bleeding, bone necrosis and soft tissue alterations. All followed the same surgical protocol and were followed up for two years.

Results

after treatment, all the patients improved in their clinical status and had no neurological complication, trans and postoperative hemorrhage or major complications were seen. Among the complications, two patients had incomplete maxilla fracture, two had laceration of their nasal mucosa and one had, as late complication, an oral-sinusal fistula.

Conclusion

Transmaxillary osteotomy provided proper access to the clivus for brainstem decompression with low rate of complications in this series.

Midfacial translocation, a variation of the approach to the rhinopharynx, clivus and upper odontoid process

OBJECTIVE

A surgical variation of the technique of facial translocation procedure is proposed, which has been called midfacial translocation for approach to the entire medial and lateral region of the middle third of the face, including the rhinopharynx, sphenoid sinus, pterygomaxillary fossa, odontoid process, and clivus.

PATIENTS AND METHODS

The medical records of five treated patients accordingly were reviewed for an analysis of the surgical technique, the disease, the topography of the lesion, and the complications.

RESULTS

The approach permitted ventral decompression of the bulbomedullary junction with resection of the C1 arch and the odontoid process in four patients and resection of a chordoma of the clivus located along the midline and extending intradurally in the fifth patient. Only one patient presented with dehiscence of the posterior half of the soft palate, this being the only complication observed following surgery in these patients. Three months postoperatively, no patient presented any aesthetic alteration of the face. Functionally, there was only infraorbital hypoaesthesia on the side of flap rotation.

CONCLUSION

The technique of midfacial translocation provides both good surgical approach and access to the rhinopharynx, pterygomaxillary fossa, high odontoid process and clivus, with few adverse sequelae for the patient.

The Use of the Facial Translocation Technique in the Management of Tumors of the Paranasal Sinuses and Skull Base

OBJECTIVE: We sought to assess the efficacy of facial translocation in the management of tumors of the skull base and paranasal sinuses.

STUDY DESIGN AND SETTING: From July 1993 to December 1999, 75 patients, aged 3 to 102 years old, underwent facial translocation. Thirty-three (44%) patients also underwent a combined neurosurgical procedure. Nineteen (25%) had previous surgery. These patients were followed up to 6 years.

RESULTS: There were 21 benign and 54 malignant tumors. There were no perioperative deaths. The morbidity rate was 31%. Of the 54 patients with malignant tumors, the actuarial 3-year survival rate was 59%, whereas the local control rate was 54%.

CONCLUSION: The facial translocation technique offers favorable exposure of the critical zones of the anterior and middle cranial base, thus facilitating extensive resection and reconstruction.

SIGNIFICANCE: This study demonstrates that facial translocation is one of the best surgical approaches to the skull base.

Tratamiento quirúrgico de la impresión basilar mediante osteotomía tipo Le Fort I segmentada. A propósito de un caso

The expansive lesions, whether tumoral or not, originated at the level of the anatomical region of the skull base (SB), show a great histologic variety and clinicaly they cause a variable chronic neurological disfunction. Surgical treatment appears to be the best therapeutic option. An exhaustive knowledge of the topographic anatomy of this area is the mandatory in order to design an appropriate surgical strategy. In many cases, a narrow cooperation with specialists is necesary. As in any other surgical activity, a complete excision of the lesion and an optimal functional and aesthetic rehabilitation, without complications, is the challenge of the surgical team. The approach to the anatomical area of the SB is not single, but is based on a number of procedures, although none of them could be considered the best, or without technical difficulty or any complications. Within the group of transoral approaches, the Le Fort I-Palatal split (LFPS) technique has been considered by different authors an excellent way to approach the clivus and the occipito-vertebral joint. We report the case of a patient, treated in cooperation with the Department of Neurosurgery of our hospital. He was clinical and radiologically diagnosed of basilar impresion with bulbar compression, and the MRI revealed the presence of a located extradural fibrous injury above the odontoid apophysis. Therefore we chose the use of a LFPS to approach this lesion. With an optimal surgical field, a complete excision of the lesion was obtained. The postoperatory result in the subsequent follow-up was highly satisfactory.

Facial translocation approach to the skull base: the viability of translocated facial bone graft

OBJECTIVES

A retrospective review of 56 patients who were operated through a facial translocation approach was carried out to assess the viability of the translocated facial bone segment.

METHODS

Eleven patients had preoperative radiotherapy, and 26 had postoperative radiotherapy. In 14 patients the translocated bone segment was kept attached to the anterior cheek, and in 42 patients the bone segment was detached and then implanted. A vascularized flap was used to obliterate the defect in the paranasal sinuses in 15 patients.

RESULTS

Twelve (21.4%) patients had devitalized bone segment and required sequestrectomy. The incidence of devitalized bone segment was higher in the patients who received postoperative radiotherapy (P = 0.04) and lower in the patients in whom the defect in the paranasal sinuses was reconstructed with a vascularized flap (P = 0.006).

CONCLUSIONS

The translocated facial bone segment should be kept attached to the cheek soft tissue when possible, or the defect in the paranasal sinuses should be reconstructed with a vascularized flap.

The 2-piece Le Fort I osteotomy for cranial base access: an evaluation of 9 patients

PURPOSE

This article discusses the use of the 2-piece Le Fort I osteotomy to gain access to the cranial base and the authors' experiences with this technique.

METHODS

Medical records of patients who required surgical access to the cranial base were retrospectively reviewed, and demographic data, procedures done, postoperative results, and complications were recorded.

RESULTS

Nine patients underwent a 2-piece Le Fort I osteotomy. Complications included development of a pseudoaneurysm of the internal carotid artery in 1 patient, 2 cerebrospinal fluid leaks, both of which resolved, and 1 patient who lost 2 teeth and some associated bone.

CONCLUSION

The 2-piece Le Fort I osteotomy provides excellent access to the clival region of the cranial base with minimal complications.