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Altunyuva O, Kasab R, Fedakar R, Yilmazlar S. Intradural anatomy and mobilization techniques of oculomotor, trochlear and abducens nerve after microsurgical dissection: a cadaveric study. NEUROCIRUGIA (ENGLISH EDITION) 2024; 35:253-262. [PMID: 38906416 DOI: 10.1016/j.neucie.2024.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 05/08/2024] [Accepted: 05/30/2024] [Indexed: 06/23/2024]
Abstract
BACKGROUND This study investigates the mobilization of cranial nerves in the upper clival region to improve surgical approaches. Cadaveric specimens (n = 20) were dissected to examine the oculomotor, trochlear, and abducens nerves. Dissection techniques focused on the nerves' intradural course and their relationship to surrounding structures. METHODS Pre-dissection revealed the nerves' entry points into the clival dura and their proximity to each other. Measurements were taken to quantify these distances. Following intradural dissection, measurements were again obtained to assess the degree of nerve mobilization. RESULTS Dissection showed that the abducens nerve takes three folds during its course: at the dural foramen, towards the posterior cavernous sinus, and lastly within the cavernous sinus. The trochlear nerve enters the dura and makes two bends before entering the cavernous sinus. The oculomotor nerve enters the cavernous sinus directly and runs parallel to the trochlear nerve. Importantly, intradural dissection increased the space between the abducens nerves (by 4.21 mm) and between the oculomotor and trochlear nerves (by 3.09 mm on average). This indicates that nerve mobilization can create wider surgical corridors for approaching lesions in the upper clivus region. CONCLUSIONS This study provides a detailed anatomical analysis of the oculomotor, trochlear, and abducens nerves in the upper clivus. The cadaveric dissections and measurements demonstrate the feasibility of mobilizing these nerves to achieve wider surgical corridors. This information can be valuable for surgeons planning endoscopic or microscopic approaches to lesions in the upper clivus region.
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Affiliation(s)
- Oguz Altunyuva
- Bursa Uludag University, Faculty of Medicine, Department of Neurosurgery, Bursa, Türkiye
| | - Reyhan Kasab
- Bursa Uludag University, Faculty of Medicine, Department of Neurosurgery, Bursa, Türkiye
| | - Recep Fedakar
- Bursa Uludag University, Faculty of Medicine, Department of Forensic Medicine, Bursa, Türkiye
| | - Selcuk Yilmazlar
- Bursa Uludag University, Faculty of Medicine, Department of Neurosurgery, Bursa, Türkiye.
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Cheng Y, Cao J, Chen Z, Geng H, Wu X, Zhang L, Bai J, Xiao X. Anatomic Study of Petrous Bone and Its Surrounding Structures in the Extended Anterior Transpetrosal Approach. J Craniofac Surg 2023; 34:2536-2539. [PMID: 37639661 DOI: 10.1097/scs.0000000000009673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 06/25/2023] [Indexed: 08/31/2023] Open
Abstract
Extended anterior transpetrosal approach (ATPA) includes drilling the petrous bone to achieve maximal exposure of the petroclival region. Injuring of surrounding neurovascular structures, such as the internal carotid artery (ICA), during the procedure may result in severe complications. In this study, we aimed to use computer topographic images to provide comprehensive anatomic information on the petrous bone and surrounding structures to help surgeons during the extended ATPA. Computer topographic angiography images of 110 individuals were reviewed, and measurements were performed on coronal, sagittal, and axial planes following multiplanar reformation. The petrous apex and sagittal midline were used to locate the anterior, middle, and posterior parts of the petrous bone and petrosal segment of the ICA during the ATPA. The thicknesses of the petrous bone were 3.28±0.71, 3.53±0.88, and 7.02±1.11 mm at the petrous apex, trigeminal impression, and internal opening of internal auditory canal (IAC) positions, respectively. The distances between the petrous apex to the trigeminal impression, internal opening of the IAC, auris interna, and labyrinth were 7.39±1.62, 15.95±2.48, 17.39±2.39, and 29.00±3.18 mm, respectively. Furthermore, the petrosal segment of the ICA was located at the above landmarks on the petrous bone. Our findings provide anatomic information on the petrous bone and surrounding structures during the extended ATPA procedure based on fixed anatomic landmarks so as to achieve maximal exposure and reduce the number of complications.
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Affiliation(s)
- Ye Cheng
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing
| | - Jun Cao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing
- Department of Neurosurgery, People's Hospital of Rizhao, Rizhao
| | - Zhenlin Chen
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing
- Department of Neurosurgery, First Hospital of Shanxi Medical University, Shanxi, China
| | - Homing Geng
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing
| | - Xiaolong Wu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing
| | - Lei Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing
| | - Jie Bai
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing
| | - Xinru Xiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing
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Tang K, Feng X, XiaodongYuan, Li Y, XinyueChen. Volumetric comparative analysis of anatomy through far-lateral approach: surgical space and exposed tissues. Chin Neurosurg J 2022; 8:1. [PMID: 35012682 PMCID: PMC8744288 DOI: 10.1186/s41016-021-00268-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 12/15/2021] [Indexed: 11/24/2022] Open
Abstract
Background The three-dimensional (3D) visualization model has ability to quantify the surgical anatomy of far-lateral approach. This study was designed to disclose the relationship between surgical space and exposed tissues in the far-lateral approach by the volumetric analysis of 3D model. Methods The 3D skull base models were constructed using MRI and CT data of 15 patients (30 sides) with trigeminal neuralgia. Surgical corridors of the far-lateral approach were simulated by triangular pyramids to represent two surgical spaces exposing bony and neurovascular tissues. Volumetric comparison of surgical anatomy was performed using pair t test. Results The morphometric results were almost the same in the two surgical spaces except the vagus nerve (CN X) exposed only in one corridor, whereas the volumetric comparison represented the statistical significant differences of surgical space and bony and neurovascular tissues involved in the two corridors (P<0.001). The differences of bony and neurovascular tissues failed to equal the difference of surgical space. Conclusions For far-lateral approach, the increase of exposure for the bony and neurovascular tissues is not necessarily matched with the increase of surgical space. The volumetric comparative analysis is helpful to provide more detailed anatomical information in the surgical design.
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Affiliation(s)
- Ke Tang
- Institute of Neurosurgery, The First Medical Center of Chinese PLA General Hospital, Fuxing Road 28, Beijing, 100853, People's Republic of China.
| | - Xu Feng
- Department of Basic Medicine, Xiamen Medical College, Guan kou zhong Road 1999, Xiamen, Fujian Province, 361023, People's Republic of China
| | - XiaodongYuan
- Department of Radiology, The Eighth Medical Center of Chinese PLA General Hospital, Heishanhu Road 17, Beijing, 100091, People's Republic of China
| | - Yang Li
- Departmentof Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, Zhong guan cun South Road 22, Beijing, 100081, People's Republic of China
| | - XinyueChen
- Department of Basic Medicine, Xiamen Medical College, Guan kou zhong Road 1999, Xiamen, Fujian Province, 361023, People's Republic of China
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Anatomical Study of Ethmoidal Foramina and Optic Canal in Endoscopic Trans-Nasal Approach to Anterior Skull Base. J Craniofac Surg 2021; 33:945-948. [PMID: 34456280 DOI: 10.1097/scs.0000000000008094] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Surgery to anterior skull base is challenging since complex structures are involved. Injury of olfactory fila and optic nerve may result in postoperative complications. In our study, the authors aim to use computer topographic image to provide a comprehensive anatomical information of anterior skull base and set up a new classification of optic canal (OC) in ethmoid sinus by the degree of bony defect, so as to help surgeons in endoscopic transnasal approach to anterior skull base. METHOD Computer topographic angiography images of 112 individuals were reviewed, the measurement was performed on coronal, sagittal, and axis planes after the multiplanar reformation. Nostril and mid-sagittal lines were used to locate the anterior, middle, and posterior part of ethmoidal foramina and orbital opening of OC. Further, the authors classified OC in ethmoidal sinus into 4 types by the degree of the bony defect. RESULT Distance between nostril to anterior, middle, and posterior part of ethmoidal foramina and OC are 6.23 ± 0.21, 6.62 ± 0.26, 7.29 ± 0.25, and 7.76 ± 0.41 mm, respectively. Angle between line from nostril to ethmoidal foramina and horizontal plane are 47.50° ± 1.03°, 41.67° ± 1.33°, 37.20° ± 1.34°, respectively. For the 4 types of OC, the percentage is 15.6%, 11.6%, 31.3%, and 41.5%, respectively. CONCLUSIONS Our findings provide anatomical information of ethmoidal foramina and OC during endoscopic transnasal approach to anterior skull base, on the basis of some fixed anatomical landmarks. So as to enhance the surgical safety of this procedure and aid in the choice of the appropriate endoscopic equipment for the procedure.
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Wu X, Ding H, Yang L, Chu X, Xie S, Bao Y, Wu J, Yang Y, Zhou L, Li M, Li SY, Tang B, Xiao L, Zhong C, Liang L, Hong T. Invasive Corridor of Clivus Extension in Pituitary Adenoma: Bony Anatomic Consideration, Surgical Outcome and Technical Nuances. Front Oncol 2021; 11:689943. [PMID: 34249739 PMCID: PMC8270656 DOI: 10.3389/fonc.2021.689943] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 05/28/2021] [Indexed: 12/02/2022] Open
Abstract
Background It is well known that the clivus is composed of abundant cancellous bone and is often invaded by pituitary adenoma (PA), but the range of these cancellous bone corridors is unknown. In addition, we found that PA with clivus invasion is sometimes accompanied by petrous apex invasion, so we speculated that the petrous apex tumor originated from the clivus cancellous bone corridor. The aim of this study was to test this hypothesis by investigating the bony anatomy associated with PA with clival invasion and its clinical significance. Methods Twenty-two cadaveric heads were used in the anatomical study to research the bony architecture of the clivus and petrous apex, including six injected specimens for microsurgical dissection and sixteen cadavers for epoxy sheet plastination. The surgical videos and outcomes of PA with clival invasion in our single center were also retrospectively reviewed. Results The hypoglossal canal and internal acoustic meatus are composed of bone canals surrounded by cortical bone. The cancellous corridor within clivus starts from the sellar or sphenoid sinus floor and extends downward, bypassing the hypoglossal canal and finally reaching the occipital condyle and the medial edge of the jugular foramen. Interestingly, we found that the cancellous bone of the clivus was connected with that of the petrous apex through petroclival fissure extending to the medial margin of the internal acoustic meatus instead of a separating cortical bone between them as it should be. It is satisfactory that the anatomical outcomes of the cancellous corridor and the path of PA with clival invasion observed intraoperatively are completely consistent. In the retrospective cohort of 49 PA patients, the clival component was completely resected in 44 (89.8%), and only five (10.2%) patients in the early-stage had partial residual cases in the inferior clivus. Conclusion The petrous apex invasion of PA is caused by the tumor invading the clivus and crossing the petroclival fissure along the cancellous bone corridor. PA invade the clivus along the cancellous bone corridor and can also cross the hypoglossal canal to the occipital condyle. This clival invasion pattern presented here deepens our understanding of the invasive characteristics of PA.
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Affiliation(s)
- Xiao Wu
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Han Ding
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Le Yang
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xuan Chu
- Department of Anatomy, School of Basic Medical Sciences, Anhui Medical University, Hefei, China
| | - Shenhao Xie
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Youyuan Bao
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jie Wu
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Youqing Yang
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Lin Zhou
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Minde Li
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Shao Yang Li
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Bin Tang
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Limin Xiao
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Chunlong Zhong
- Department of Neurosurgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Liang Liang
- Department of Anatomy, School of Basic Medical Sciences, Anhui Medical University, Hefei, China
| | - Tao Hong
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
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Measurements and Clinical Application of Anatomical Space for Transfrontal Pituitary Surgery Through Magnetic Resonance Imaging Reconstruction. J Craniofac Surg 2019; 30:1289-1293. [PMID: 30908444 DOI: 10.1097/scs.0000000000005510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE This study aims to clarify the relative position of the normal important structures and anatomical spaces formed by the structures passed through during the transfrontal pituitary surgery, and discuss how to avoid some eloquent structures. METHODS A total of 120 cases of magnetic resonance imaging images from normal adult brains were selected as the object of study and divided into male and female groups. The important adjacent structures of the pituitary passed through during the transfrontal pituitary surgery were marked on the reconstructed images. In all planes of the spaces passing through successively during the pituitary surgery, the morphological parameters such as the size, boundary, structure, and spatial extent of the spaces were measured. RESULTS The size, boundary, structure, and spatial extent of the space between the 2 optic nerves, the space between the optic nerves and the pituitary stalk, and the space between the tuber cinereum and the interal carotid artery in the plane of the pituitary stalk were measured, the anterior part and the posterior part in male were shorter than those in female (P = 0.021; P = 0.029); no statistically significant difference was found in the measurements of the lengths and angles of these spaces. CONCLUSIONS The authors' findings provide the surgeons with the detailed anatomical data and help to provide a morphological basis for intraoperative protection of the pituitary and vital adjacent structures and surgical approach.
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Gridding Microsurgical Anatomy of Far Lateral Approach in the Three-Dimensional Model. J Craniofac Surg 2018; 30:87-90. [PMID: 30394967 DOI: 10.1097/scs.0000000000004849] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE The far lateral craniotomy involves osteotomy of various portions of occipital condyle. Intracranial operation exposing clivus encounters complicated neurovascular anatomy. The aim of the present study was to make refinement for the anatomy of far lateral approach by gridding route in the 3-dimensional model. METHODS Computed tomography and magnetic resonance imaging data were used to construct 3-dimensional model containing osseous and neurovascular structures of skull base. Then, far lateral approach was simulated by triangular prism and divided into gridding surgical route. The relationship of surgical route and osseous and neurovascular structures was observed. Measurement of volume was performed to evaluate surgical exposure. RESULTS Observation of 3-dimensional model showed bony drilling of far lateral approach started with the occipital condyle and passed through the lateral edge of foramen magnum. The cerebellum and medulla oblongata were exempted from the surgical route exposing clivus. The anatomy variances of operative space, osseous, and neurovascular structures in the gridding route were displayed clearly and compared objectively. CONCLUSION The gridding operative spaces for the far lateral approach are useful to disclose the detailed discrepancy in the different surgical region. The volumetric measurement provides quantified information to facilitate a better understanding of the anatomy variance.
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Essayed WI, Singh H, Lapadula G, Almodovar-Mercado GJ, Anand VK, Schwartz TH. Endoscopic endonasal approach to the ventral brainstem: anatomical feasibility and surgical limitations. J Neurosurg 2017; 127:1139-1146. [PMID: 28084906 DOI: 10.3171/2016.9.jns161503] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Sporadic cases of endonasal intraaxial brainstem surgery have been reported in the recent literature. The authors endeavored to assess the feasibility and limitations of endonasal endoscopic surgery for approaching lesions in the ventral portion of the brainstem. METHODS Five human cadaveric heads were used to assess the anatomy and to record various measurements. Extended transsphenoidal and transclival approaches were performed. After exposing the brainstem, white matter dissection was attempted through this endoscopic window, and additional key measurements were taken. RESULTS The rostral exposure of the brainstem was limited by the sella. The lateral limits of the exposure were the intracavernous carotid arteries at the level of the sellar floor, the intrapetrous carotid arteries at the level of the petrous apex, and the inferior petrosal sinuses toward the basion. Caudal extension necessitated partial resection of the anterior C-1 arch and the odontoid process. The midline pons and medulla were exposed in all specimens. Trigeminal nerves were barely visible without the use of angled endoscopes. Access to the peritrigeminal safe zone for gaining entry into the brainstem is medially limited by the pyramidal tract, with a mean lateral pyramidal distance (LPD) of 4.8 ± 0.8 mm. The mean interpyramidal distance was 3.6 ± 0.5 mm, and it progressively decreased toward the pontomedullary junction. The corticospinal tracts (CSTs) coursed from deep to superficial in a craniocaudal direction. The small caliber of the medulla with very superficial CSTs left no room for a safe ventral dissection. The mean pontobasilar midline index averaged at 0.44 ± 0.1. CONCLUSIONS Endoscopic endonasal approaches are best suited for pontine intraaxial tumors when they are close to the midline and strictly anterior to the CST, or for exophytic lesions. Approaching the medulla is anatomically feasible, but the superficiality of the eloquent tracts and interposed nerves limit the safe entry zones. Pituitary transposition after sellar opening is necessary to access the mesencephalon.
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Affiliation(s)
- Walid I Essayed
- Department of Neurological Surgery, NewYork-Presbyterian Hospital, Weill Cornell Medical College, New York, New York
| | - Harminder Singh
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Gennaro Lapadula
- Department of Neurological Surgery, NewYork-Presbyterian Hospital, Weill Cornell Medical College, New York, New York.,Departments of Neurology and Psychiatry, and Neurosurgery, "Sapienza," University of Rome, Rome, Italy
| | - Gustavo J Almodovar-Mercado
- Department of Otolaryngology, NewYork-Presbyterian Hospital, Weill Cornell Medical College, New York, New York
| | - Vijay K Anand
- Department of Otolaryngology, NewYork-Presbyterian Hospital, Weill Cornell Medical College, New York, New York
| | - Theodore H Schwartz
- Department of Neurological Surgery, NewYork-Presbyterian Hospital, Weill Cornell Medical College, New York, New York
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