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Blue R, Yang AI, Ajmera S, Spadola M, Howard S, Saylany A, Kvint S, Harber A, Daly M, Shekhtman E, Nair A, Deshpande R, Lee JY. Pain Outcomes Following Endoscopic Microvascular Decompression for Trigeminal Neuralgia Based on Vascular Compression Type. J Neurol Surg B Skull Base 2024; 85:287-294. [PMID: 38721365 PMCID: PMC11076079 DOI: 10.1055/a-2065-9650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 03/23/2023] [Indexed: 04/03/2023] Open
Abstract
Background Arterial compression of the trigeminal nerve at the root entry zone has been the long-attributed cause of compressive trigeminal neuralgia despite numerous studies reporting distal and/or venous compression. The impact of compression type on patient outcomes has not been fully elucidated. Objective We categorized vascular compression (VC) based on vessel and location of compression to correlate pain outcomes based on compression type. Methods A retrospective video review of 217 patients undergoing endoscopic microvascular decompression for trigeminal neuralgia categorizing VC into five distinct types, proximal arterial compression (VC1), proximal venous compression (VC2), distal arterial compression (VC3), distal venous compression (VC4), and no VC (VC5). VC type was correlated with postoperative pain outcomes at 1 month ( n = 179) and last follow-up (mean = 42.9 mo, n = 134). Results At 1 month and longest follow-up, respectively, pain was rated as "much improved" or "very much improved" in 89 69% of patients with VC1, 86.6 and 62.5% of patients with VC2, 100 and 87.5% of patients with VC3, 83 and 62.5% of patients with VC4, and 100 and 100% of patients with VC5. Multivariate analysis demonstrated VC4 as a significant negative of predictor pain outcomes at 1 month, but not longest follow-up, and advanced age as a significant positive predictor. Conclusion The degree of clinical improvement in all types of VC was excellent, but at longest follow-up VC type was not a significant predictor out outcome. However distal venous compression was significantly associated with worse outcomes at 1 month.
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Affiliation(s)
- Rachel Blue
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Andrew I. Yang
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Sonia Ajmera
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Michael Spadola
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Susanna Howard
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Anissa Saylany
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Svetlana Kvint
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Alexander Harber
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Megan Daly
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Emily Shekhtman
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Anjana Nair
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Riddhi Deshpande
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - John Y.K. Lee
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States
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Valente JP, Bento RF, Brito R. The endoscopic transcanal approach to the internal auditory canal: an anatomic study. Eur Arch Otorhinolaryngol 2024:10.1007/s00405-024-08739-1. [PMID: 38780628 DOI: 10.1007/s00405-024-08739-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 05/13/2024] [Indexed: 05/25/2024]
Abstract
PURPOSE The internal auditory canal (IAC) plays a key role in lateral skull base surgery. Although several approaches to the IAC have been proposed, endoscope-assisted transcanal corridors to the IAC have rarely been studied. We sought to provide a step-by-step description of the transcanal transpromontorial approach to the IAC and analyze anatomic relationships that might enhance predictability and safety of this approach. METHODS Ten cadaveric specimens were dissected and the extended transcanal transpromontorial approach to the IAC was established. Various morphometric measurements and anatomic landmarks were reviewed and analyzed. RESULTS The proposed technique proved feasible and safe in all specimens. There was no inadvertent injury to the jugular bulb or internal carotid artery. The chorda tympani, a key landmark for the mastoid segment of the facial nerve, was identified in all dissections. The spherical recess of the vestibule and middle turn of cochlea are important landmarks for identification of the labyrinthine segment of the facial nerve. Identification of all boundaries of the working area is also essential for safe access. Among various morphometric measurements, the modiolus-IAC angle (≈ 150°) proved particularly consistent; given its ease of use and low variability, we believe it could serve as a landmark for identification and subsequent dissection of the IAC. CONCLUSIONS The extended transcanal transpromontorial approach to the IAC is feasible and safe. Relying on anatomic landmarks to ensure preservation of the involved neurovascular structures is essential for a successful approach. The modiolus-IAC angle is a consistent, reproducible landmark for IAC identification and dissection.
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Affiliation(s)
- João Paulo Valente
- Department of Otorhinolaryngology, Hospital da PUC-Campinas, Campinas, Brazil.
| | | | - Rubens Brito
- Department of Otorhinolaryngology, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil
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Agosti E, De Maria L, Mattogno PP, Della Pepa GM, D’Onofrio GF, Fiorindi A, Lauretti L, Olivi A, Fontanella MM, Doglietto F. Quantitative Anatomical Studies in Neurosurgery: A Systematic and Critical Review of Research Methods. Life (Basel) 2023; 13:1822. [PMID: 37763226 PMCID: PMC10532642 DOI: 10.3390/life13091822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 08/17/2023] [Accepted: 08/25/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND The anatomy laboratory can provide the ideal setting for the preclinical phase of neurosurgical research. Our purpose is to comprehensively and critically review the preclinical anatomical quantification methods used in cranial neurosurgery. METHODS A systematic review was conducted following the PRISMA guidelines. The PubMed, Ovid MEDLINE, and Ovid EMBASE databases were searched, yielding 1667 papers. A statistical analysis was performed using R. RESULTS The included studies were published from 1996 to 2023. The risk of bias assessment indicated high-quality studies. Target exposure was the most studied feature (81.7%), mainly with area quantification (64.9%). The surgical corridor was quantified in 60.9% of studies, more commonly with the quantification of the angle of view (60%). Neuronavigation-based methods benefit from quantifying the surgical pyramid features that define a cranial neurosurgical approach and allowing post-dissection data analyses. Direct measurements might diminish the error that is inherent to navigation methods and are useful to collect a small amount of data. CONCLUSION Quantifying neurosurgical approaches in the anatomy laboratory provides an objective assessment of the surgical corridor and target exposure. There is currently limited comparability among quantitative neurosurgical anatomy studies; sharing common research methods will provide comparable data that might also be investigated with artificial intelligence methods.
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Affiliation(s)
- Edoardo Agosti
- Division of Neurosurgery, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Piazzale Spedali Civili 1, 25121 Brescia, Italy; (E.A.); (A.F.); (M.M.F.)
| | - Lucio De Maria
- Division of Neurosurgery, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Piazzale Spedali Civili 1, 25121 Brescia, Italy; (E.A.); (A.F.); (M.M.F.)
- Division of Neurosurgery, Department of Clinical Neuroscience, Geneva University Hospitals (HUG), 1205 Geneva, Switzerland
| | - Pier Paolo Mattogno
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy; (P.P.M.); (G.M.D.P.); (L.L.); (A.O.); (F.D.)
| | - Giuseppe Maria Della Pepa
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy; (P.P.M.); (G.M.D.P.); (L.L.); (A.O.); (F.D.)
| | | | - Alessandro Fiorindi
- Division of Neurosurgery, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Piazzale Spedali Civili 1, 25121 Brescia, Italy; (E.A.); (A.F.); (M.M.F.)
| | - Liverana Lauretti
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy; (P.P.M.); (G.M.D.P.); (L.L.); (A.O.); (F.D.)
- Department of Neurosurgery, Università Cattolica del Sacro Cuore, 20123 Rome, Italy;
| | - Alessandro Olivi
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy; (P.P.M.); (G.M.D.P.); (L.L.); (A.O.); (F.D.)
- Department of Neurosurgery, Università Cattolica del Sacro Cuore, 20123 Rome, Italy;
| | - Marco Maria Fontanella
- Division of Neurosurgery, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Piazzale Spedali Civili 1, 25121 Brescia, Italy; (E.A.); (A.F.); (M.M.F.)
| | - Francesco Doglietto
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy; (P.P.M.); (G.M.D.P.); (L.L.); (A.O.); (F.D.)
- Department of Neurosurgery, Università Cattolica del Sacro Cuore, 20123 Rome, Italy;
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Stebnev VS, Zhuravlev AV. Traditional analogue vs. three-dimensional digital visualization used in ophthalmic surgery. RUSSIAN OPHTHALMOLOGICAL JOURNAL 2023. [DOI: 10.21516/2072-0076-2023-16-1-168-174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/22/2023]
Abstract
The visualization of the surgical process remains a topical issue in cataract surgery. The review presents the history of visualization technique in ophthalmic surgery and compares the main current analogue and 3D digital technologies. The advent of 3D imaging systems in clinical practice has helped solve many issues associated with the use of standard analogue microscopes. These issues include limited focus and field of vision, the need to use a large amount of light, which increases the risk of iatrogenic retinal phototoxicity, the surgeon's attachment to the microscope and, consequently, a high load on the surgeon's visual apparatus when using eyepieces, as well as on their back and neck muscles.
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Affiliation(s)
- V. S. Stebnev
- Samara State Medical University, Institute of Vocational Education; “Eye Surgery” Ophthalmological Clinic
| | - A. V. Zhuravlev
- Samara State Medical University, Institute of Vocational Education; Kinel Central Regional Hospital
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5
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Serioli S, Agosti E, Buffoli B, Raffetti E, Alexander AY, Salgado-López L, Hirtler L, Rezzani R, Maroldi R, Draghi R, Borghesi I, Calbucci F, Peris-Celda M, Fontanella MM, Doglietto F. Microsurgical transcranial approaches to the posterior surface of petrosal portion of the temporal bone: quantitative analysis of surgical volumes and exposed areas. Neurosurg Rev 2023; 46:48. [PMID: 36745228 DOI: 10.1007/s10143-023-01956-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 01/12/2023] [Accepted: 01/24/2023] [Indexed: 02/07/2023]
Abstract
Different microsurgical transcranial approaches (MTAs) have been described to expose the posterior surface of the petrous bone (PPB). A quantitative, anatomical comparison of the most used MTAs, for specific areas of the PPB, is not available. Anatomical dissections were performed on five formalin-fixed, latex-injected cadaver heads (10 sides). Six MTAs were analyzed: Kawase approach (KWA), retrosigmoid approach (RSA), retrosigmoid approach with suprameatal extension (RSAS), retrolabyrinthine approach (RLA), translabyrinthine approach (TLA), and transcochlear approach (TCA). Surgical volumes and exposed areas of each approach were quantified with a dedicated neuronavigation system (ApproachViewer, part of GTx-Eyes II, University Health Network, Toronto, Canada) and adjuvant software (ITK-SNAP and Autodesk Meshmixer 3.5). Areas and volumes were compared using linear mixed models. TCA provided the best exposure of Trautmann's triangle and the retromeatal, suprameatal, meatal, and premeatal regions. RSAs provided the best exposure of the inframeatal region, with RSAS gaining significant exposure of the suprameatal region. KWA had the highest surgical volume, and RLA the lowest. Transpetrosal approaches offer the widest exposure of PPB proportionally to their invasiveness. Retrosigmoid approaches, which get to the studied region through a postero-lateral path, are paramount for the exposure of the inframeatal and suprameatal region and, given the adequate exposure of the remaining PPB, represent an effective approach for the cerebellopontine angle (CPA). These anatomical findings must be considered with approach-related morbidity and the pathological features in order to choose the most appropriate approach in clinical practice.
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Affiliation(s)
- Simona Serioli
- Division of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Piazza Spedali Civili 1, Spedali Civili of Brescia, 25123, Brescia, Italy
- Unit of Neurosurgery, GVM Care&Research, Maria Cecilia Hospital, Cotignola, Ravenna, Italy
| | - Edoardo Agosti
- Division of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Piazza Spedali Civili 1, Spedali Civili of Brescia, 25123, Brescia, Italy.
| | - Barbara Buffoli
- Section of Anatomy and Physiopathology, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Elena Raffetti
- Department of Public Health Sciences, Karolinska Institute, Stockholm, Sweden
| | | | | | - Lena Hirtler
- Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | - Rita Rezzani
- Section of Anatomy and Physiopathology, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Roberto Maroldi
- Division of Radiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Riccardo Draghi
- Unit of Neurosurgery, GVM Care&Research, Maria Cecilia Hospital, Cotignola, Ravenna, Italy
| | - Ignazio Borghesi
- Unit of Neurosurgery, GVM Care&Research, Maria Cecilia Hospital, Cotignola, Ravenna, Italy
| | - Fabio Calbucci
- Unit of Neurosurgery, GVM Care&Research, Maria Cecilia Hospital, Cotignola, Ravenna, Italy
| | | | - Marco Maria Fontanella
- Division of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Piazza Spedali Civili 1, Spedali Civili of Brescia, 25123, Brescia, Italy
| | - Francesco Doglietto
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Catholic University School of Medicine, Rome, Italy
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Tentorial peeling during combined petrosal approach: a cadaveric dissection. Acta Neurochir (Wien) 2022; 164:2833-2839. [PMID: 36163381 DOI: 10.1007/s00701-022-05370-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 09/15/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND The combined petrosal approach is an excellent method to access the petroclival region but has the inherent risk of injury to the temporal lobe and Vein of Labbé. Tentorial peeling has the potential to largely eliminate these risks during the classic combined transpetrosal approach. METHODS Anatomical dissection of three adult injected non-formalin fixed cadaveric heads was performed. Combined petrosal approach with tentorial peeling was completed. A tentorial incision just superior and parallel to the superior petrosal sinus was made to enable peeling of the tentorium into two layers, the posterior fossa tentorial leaf (PFTL), and the temporal tentorial leaf (TTL). RESULTS Tentorial peeling clearly exposed the continuity between the temporal dura and the TTL as well as the continuity between the presigmoid dura and the PFTL. This enabled the creation of a large dural flap extending to the tentorial incisura, providing wide access to the petroclival region without any exposure of the temporal lobe and/or basal temporal veins. Techniques to create the dural flap without trochlear nerve injury were also explored. CONCLUSION The technique of tentorial peeling into two distinct layers has the potential to reduce the morbidity associated with temporal lobe retraction and venous injury. Further cadaveric studies and surgical case series are needed to validate this important surgical nuance in transpetrosal approaches.
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Kalaiarasan K, Prathap L, Ayyadurai M, Subhashini P, Tamilselvi T, Avudaiappan T, Infant Raj I, Alemayehu Mamo S, Mezni A. Clinical Application of Augmented Reality in Computerized Skull Base Surgery. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE : ECAM 2022; 2022:1335820. [PMID: 35600956 PMCID: PMC9117015 DOI: 10.1155/2022/1335820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 04/19/2022] [Indexed: 12/02/2022]
Abstract
Cranial base tactics comprise the regulation of tiny and complicated structures in the domains of otology, rhinology, neurosurgery, and maxillofacial medical procedure. Basic nerves and veins are in the nearness of these buildings. Increased the truth is a coming innovation that may reform the cerebral basis approach by supplying vital physical and navigational facts brought together in a solitary presentation. In any case, the awareness and acknowledgment of prospective results of expanding reality frameworks in the cerebral base region are really poor. This article targets examining the handiness of expanded reality frameworks in cranial foundation medical procedures and emphasizes the obstacles that present innovation encounters and their prospective adjustments. A specialized perspective on distinct strategies used being produced of an improved realty framework is furthermore offered. The newest item offers an expansion in interest in expanded reality frameworks that may motivate more secure and practical procedures. In any case, a couple of concerns have to be cared to before that can be for the vast part fused into normal practice.
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Affiliation(s)
- K. Kalaiarasan
- Department of Information Technology, M. Kumarasamy College of Engineering, Karur, India
| | - Lavanya Prathap
- Department of Anatomy, Saveetha Dental College and Hospital, Saveetha Institute of Medical and Technical Sciences, Chennai, Tamil Nadu 600077, India
| | - M. Ayyadurai
- SG, Institute of ECE, Saveetha School of Engineering, SIMATS, Chennai, Tamil Nadu 600077, India
| | - P. Subhashini
- Department of Computer Science and Engineering, J.N.N Institute of Engineering, Kannigaipair, Tamil Nadu 601102, India
| | - T. Tamilselvi
- Department of Computer Science and Engineering, Panimalar Institute of Technology, Varadarajapuram, Tamil Nadu 600123, India
| | - T. Avudaiappan
- Computer Science and Engineering, K. Ramakrishnan College of Technology, Trichy 621112, India
| | - I. Infant Raj
- Department of Computer Science and Engineering, K. Ramakrishnan College of Engineering, Trichy, India
| | - Samson Alemayehu Mamo
- Department of Electrical and Computer Engineering, Faculty of Electrical and Biomedical Engineering, Institute of Technology, Hawassa University, Awasa, Ethiopia
| | - Amine Mezni
- Department of Chemistry, College of Science, Taif University, P.O. Box 11099, Taif 21944, Saudi Arabia
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8
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Ma L, Fei B. Comprehensive review of surgical microscopes: technology development and medical applications. JOURNAL OF BIOMEDICAL OPTICS 2021; 26:JBO-200292VRR. [PMID: 33398948 PMCID: PMC7780882 DOI: 10.1117/1.jbo.26.1.010901] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 12/04/2020] [Indexed: 05/06/2023]
Abstract
SIGNIFICANCE Surgical microscopes provide adjustable magnification, bright illumination, and clear visualization of the surgical field and have been increasingly used in operating rooms. State-of-the-art surgical microscopes are integrated with various imaging modalities, such as optical coherence tomography (OCT), fluorescence imaging, and augmented reality (AR) for image-guided surgery. AIM This comprehensive review is based on the literature of over 500 papers that cover the technology development and applications of surgical microscopy over the past century. The aim of this review is threefold: (i) providing a comprehensive technical overview of surgical microscopes, (ii) providing critical references for microscope selection and system development, and (iii) providing an overview of various medical applications. APPROACH More than 500 references were collected and reviewed. A timeline of important milestones during the evolution of surgical microscope is provided in this study. An in-depth technical overview of the optical system, mechanical system, illumination, visualization, and integration with advanced imaging modalities is provided. Various medical applications of surgical microscopes in neurosurgery and spine surgery, ophthalmic surgery, ear-nose-throat (ENT) surgery, endodontics, and plastic and reconstructive surgery are described. RESULTS Surgical microscopy has been significantly advanced in the technical aspects of high-end optics, bright and shadow-free illumination, stable and flexible mechanical design, and versatile visualization. New imaging modalities, such as hyperspectral imaging, OCT, fluorescence imaging, photoacoustic microscopy, and laser speckle contrast imaging, are being integrated with surgical microscopes. Advanced visualization and AR are being added to surgical microscopes as new features that are changing clinical practices in the operating room. CONCLUSIONS The combination of new imaging technologies and surgical microscopy will enable surgeons to perform challenging procedures and improve surgical outcomes. With advanced visualization and improved ergonomics, the surgical microscope has become a powerful tool in neurosurgery, spinal, ENT, ophthalmic, plastic and reconstructive surgeries.
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Affiliation(s)
- Ling Ma
- University of Texas at Dallas, Department of Bioengineering, Richardson, Texas, United States
| | - Baowei Fei
- University of Texas at Dallas, Department of Bioengineering, Richardson, Texas, United States
- University of Texas Southwestern Medical Center, Department of Radiology, Dallas, Texas, United States
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Aljuboori Z, Alhourani A, Nuru M, Nguyen C, Yeo H, Williams B, Andaluz N. Morphometric Study of the Posterior Fossa: Identification of Practical Parameters for Tailored Selection of Surgical Routes to the Petroclival Region. J Neurol Surg B Skull Base 2020; 83:37-43. [DOI: 10.1055/s-0040-1716691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 07/25/2020] [Indexed: 10/23/2022] Open
Abstract
Abstract
Introduction The petroclival region is an integral part of the skull base. It can harbor different pathologies and provides access to the petroclival junction and cerebellopontine angle. We present the results of the morphometric analysis of the posterior fossa and a prediction model to enable skull base surgeons to choose an optimal surgical corridor considering patient's bony anatomy.
Methods Ninety patients (14 to assess interobserver reliability) with temporal bone computed tomography were selected. Exclusion criteria included patients <18 years of age, radiographic evidence of trauma, infection, or previous surgery. The images were analyzed using OsiriX MD (Bernex, Switzerland). We recorded clival length, vertical angle, and surface area, and petroclival angle, petrous apex, and translabyrinthine corridors volume.
Results The average age was 49.5 years (55%) for males. The mean clival length and surface areas were 44.2 mm (standard deviation [SD] ± 4.1) and 8.1 cm2 (SD ± 1.3). The mean petrous apex and translabyrinthine corridors volumes were 2.2 cm3 (SD ± 0.6) and 10.1 cm3 (SD ± 3.7). The mean petroclival angle at the internal auditory canal (IAC) was 154.9 degrees (SD ± 9). The clival length correlated positively with clival surface area (rho = 0.6, p <0.05), petrous apex volume (rho = 0.3, p < 0.05), and translabyrinthine volume (rho = 0.3, p < 0.05).
Conclusion The petroclival region is complex and with high variability of surgical significance. The use of preoperative measurements of the clival length and petroclival angle as part of surgical planning that could help the surgeon to choose an optimal surgical corridor by overcoming the anatomical variability elements.
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Affiliation(s)
- Zaid Aljuboori
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky, United States
| | - Ahmad Alhourani
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky, United States
| | - Mohammed Nuru
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky, United States
| | - Candice Nguyen
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky, United States
| | - Heegook Yeo
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky, United States
| | - Brian Williams
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky, United States
| | - Norberto Andaluz
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky, United States
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Blue R, Li C, Spadola M, Saylany A, McShane B, Lee JYK. Complication Rates During Endoscopic Microvascular Decompression Surgery Are Low With or Without Petrosal Vein Sacrifice. World Neurosurg 2020; 138:e420-e425. [PMID: 32145425 DOI: 10.1016/j.wneu.2020.02.142] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 02/21/2020] [Accepted: 02/22/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Endoscopic-microvascular decompression (E-MVD) is a well-described treatment for trigeminal neuralgia (TGN), but there has been debate on the safety of intraoperative sacrifice of the petrosal vein (PV) due to concern for subsequent venous insufficiency. Our objective was to investigate the risk of PV sacrifice during E-MVD in TGN and subsequent postoperative complications and pain outcomes. METHODS 5 five-year review yielded 201 patients who underwent MVD for TGN. PV sacrifice, vascular compressive anatomy, and postoperative complications attributable to venous insufficiency were analyzed. Preoperative and postoperative pain outcomes were analyzed. RESULTS PV was sacrificed in 118 of 201 (59%) of patients, with 43 of 201 (21%) patients undergoing partial sacrifice versus 75 of 201 (37%) with complete sacrifice. No cases of venous infarction, cerebellar swelling, or fatal complications were noted in either cohort. Non-neurologic complications occurred in 1.69% (2 of 118) of patients with PV sacrifice and 0% (0 of 83) of patients with PV preservation. Neurologic deficits (facial palsy, conductive hearing loss, gait instability, memory deficit) occurred in equal proportions in PV preservation and sacrifice groups (2.41% vs. 1.69%) Overall, 87.3% (145 of 166) patients reported their pain as "very much improved" or "much improved" at 1 month, and no difference between groups was identified. CONCLUSIONS This study did not find higher complication rates in patients undergoing petrosal vein sacrifice during E-MVD for trigeminal neuralgia. In this series where petrosal vein was sacrificed only 59% of the time, it appears to be a safe technique, but larger studies will be needed to determine true incidence of complications after PV sacrifice.
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Affiliation(s)
- Rachel Blue
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Carrie Li
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael Spadola
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Anissa Saylany
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Brendan McShane
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - John Y K Lee
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Yacoub A, Wimmer W, Molinari G, Alicandri-Ciufelli M, Presutti L, Caversaccio M, Anschuetz L. Transcanal Transpromontorial Approach to Lateral Skull Base: Maximal Area of Exposure and Surgical Extensions. World Neurosurg 2019; 135:e181-e186. [PMID: 31778835 DOI: 10.1016/j.wneu.2019.11.102] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 11/18/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To determine the possible surgical extensions and maximal area of exposure (AOE) achievable through the transcanal transpromontorial approach (TTA) to the internal auditory canal (IAC) and cerebellopontine angle. We hypothesize a possible extension of indication for this minimally invasive approach to the lateral skull base. METHODS In this experimental anatomic study, the expanded TTA was first carried out in 4 temporal bones to define the anatomic boundaries of the maximal exposure, from 2 perspectives, the middle ear and the porus of the IAC. Consecutively, these identified boundaries were translated on segmented 3-dimensional (3D) surface models of 32 temporal bone high-resolution computed tomography scans. RESULTS The dissections performed were the basis followed during the determination of the AOE on the 3D surface models. The measurements revealed that the AOE at the middle ear was 152.9 ± 33.6 mm2, whereas it was 151.9 ± 24.8 mm2 at the porus of the IAC. The mean superoinferior and anteroposterior extensions at the middle ear were 14.7 ± 2.5 mm and 16.9 ± 2.5 mm, respectively. On the other hand, the mean superoinferior and anteroposterior extensions at the IAC porus were 10.3 ± 1.3 mm and 18.5 ± 1.9 mm, respectively. CONCLUSIONS Consistent with the minimally invasive approaches, the AOE is limited; however, if compared with traditional approaches, it appears of considerable size. Our results may assist the surgeon in the selection process of the appropriate candidates for the TTA and to tailor the approach to the disease.
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Affiliation(s)
- Abraam Yacoub
- Department of Otolaryngology Head and Neck Surgery, Inselspital University Hospital and University of Bern, Bern, Switzerland; Hearing Research Laboratory, ARTORG Center for Biomedical Engineering, University of Bern, Bern, Switzerland; Department of Otolaryngology Head and Neck Surgery, Faculty of Medicine, Ain Shams University, Cairo, Egypt.
| | - Wilhelm Wimmer
- Department of Otolaryngology Head and Neck Surgery, Inselspital University Hospital and University of Bern, Bern, Switzerland; Hearing Research Laboratory, ARTORG Center for Biomedical Engineering, University of Bern, Bern, Switzerland
| | - Giulia Molinari
- Department of Otolaryngology Head and Neck Surgery, Inselspital University Hospital and University of Bern, Bern, Switzerland; Department of Otolaryngology Head and Neck Surgery, University Hospital of Modena, Modena, Italy
| | | | - Livio Presutti
- Department of Otolaryngology Head and Neck Surgery, University Hospital of Modena, Modena, Italy
| | - Marco Caversaccio
- Department of Otolaryngology Head and Neck Surgery, Inselspital University Hospital and University of Bern, Bern, Switzerland; Hearing Research Laboratory, ARTORG Center for Biomedical Engineering, University of Bern, Bern, Switzerland
| | - Lukas Anschuetz
- Department of Otolaryngology Head and Neck Surgery, Inselspital University Hospital and University of Bern, Bern, Switzerland; Hearing Research Laboratory, ARTORG Center for Biomedical Engineering, University of Bern, Bern, Switzerland
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Quantitative Analysis of Surgical Freedom and Area of Exposure in Minimal-Invasive Transcanal Approaches to the Lateral Skull Base. Otol Neurotol 2019; 39:785-790. [PMID: 29879089 DOI: 10.1097/mao.0000000000001827] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
HYPOTHESIS We aim to provide objective data regarding the area of exposure (AOE) and the surgical freedom (SF) offered by the transcanal approaches to the lateral skull base. BACKGROUND Minimal-invasive transcanal lateral skull base procedures have been recently developed and their clinical feasibility demonstrated. The reduced access size requires careful analysis and selection of suitable cases, qualifying for a minimal-invasive approach. METHODS We performed the mentioned approaches in standardized dissection using human whole heads. Surgical freedom is defined as the degree of movement liberty of the surgical instrument at predefined landmarks. We assessed SF at anatomical landmarks throughout the lateral skull base. Moreover, we measured the AOE, defined as the surface on the lateral skull base reached by every approach. RESULTS We performed a total of 48 dissections under stereotactic image guidance in a total of 12 sides. The mean SF was assessed for the inferior petrous apex 602 mm, for the geniculate ganglion 1,916 mm, and for the fundus of internal auditory canal 1,337 mm. The AOE was measured for the infracochlear approach 55 mm, suprageniculate approach 67 mm, transpromontorial approach 11 mm, and for the expanded transpromontorial approach 93 mm at the fundus and 108 mm at the porus of the internal auditory canal. CONCLUSION This study provides a quantitative description of minimal-invasive transcanal approaches to the lateral skull base. The AOE offered by the expanded transcanal transpromontorial approach is inferior but comparable to the reported AOE of transmastoidal approaches. The reported objective measurements may provide important information for future preoperative planning and patient counseling.
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Arıcıgil M, Arbağ H, Dündar MA, Aziz SK, Yılmaz MT. Minimally Invasive Endoscopic Retrosigmoid Approach to the Cerebellopontine Angle Using a Novel Surgical Instrument: A Cadaveric Study. J Int Adv Otol 2019; 14:472-477. [PMID: 30644376 DOI: 10.5152/iao.2018.4474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES In this study, we aimed to describe how endoscopes show the neural and vascular structures at the cerebellopontine angle (CPA) through a minimal craniotomy in a well-described anatomic point in the retrosigmoid region and at the same time, evaluate the endoscopic anatomic exposure and maneuverability. We planned to use the new surgical instrument (endoscope cannula), which we designed on fresh frozen cadavers to simulate a real surgical procedure. MATERIALS AND METHODS The surgical procedure was planned to be performed on 20 sides of 10 fresh cadaver heads. The distance between the asterion and mastoid process was determined, and the midpoint was then marked. From this midpoint, a craniotomy 2 cm in size was posteriorly made. The endoscope cannula together with 0° or 30° endoscopes was inserted to capture the panoramic views of the neurovascular structures in CPA. Endoscopic anatomic exposure and maneuverability were evaluated using 0° and 30° endoscopes with/without the endoscope cannula. RESULTS The surgeon could easily use both hands during the surgical simulation, and maneuverability was seen to increase in CPA with the use of the endoscope cannula. CONCLUSION The surgeon can work actively with both hands when the endoscopes and the endoscope cannula are used together. We believe that owing to this, the surgeon's maneuverability would increase and a more effective minimally invasive endoscopic retrosigmoid surgery would ensue.
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Affiliation(s)
- Mitat Arıcıgil
- Department of Otorhinolaryngology, Head and Neck Surgery, Necmettin Erbakan University School of Medicine, Konya, Turkey
| | - Hamdi Arbağ
- Department of Otorhinolaryngology, Head and Neck Surgery, Necmettin Erbakan University School of Medicine, Konya, Turkey
| | - Mehmet Akif Dündar
- Department of Otorhinolaryngology, Head and Neck Surgery, Necmettin Erbakan University School of Medicine, Konya, Turkey
| | - Suhayb Kuria Aziz
- Department of Otorhinolaryngology, Head and Neck Surgery, Necmettin Erbakan University School of Medicine, Konya, Turkey
| | - Mehmet Tuğrul Yılmaz
- Department of Anatomy, Necmettin Erbakan University School of Medicine, Konya, Turkey
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Hussain R, Lalande A, Guigou C, Bozorg Grayeli A. Contribution of Augmented Reality to Minimally Invasive Computer-Assisted Cranial Base Surgery. IEEE J Biomed Health Inform 2019; 24:2093-2106. [DOI: 10.1109/jbhi.2019.2954003] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Belykh EG, Zhao X, Cavallo C, Bohl MA, Yagmurlu K, Aklinski JL, Byvaltsev VA, Sanai N, Spetzler RF, Lawton MT, Nakaji P, Preul MC. Laboratory Evaluation of a Robotic Operative Microscope - Visualization Platform for Neurosurgery. Cureus 2018; 10:e3072. [PMID: 30280067 PMCID: PMC6166902 DOI: 10.7759/cureus.3072] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background We assessed a new robotic visualization platform with novel user-control features and compared its performance to the previous model of operative microscope. Methods In a neurosurgery research laboratory, we performed anatomical dissections and assessed robotic, exoscopic, endoscopic, fluorescence functionality. Usability and functionality were tested in the operating room over 1 year. Results The robotic microscope showed higher sensitivity for fluorescein sodium, higher detail in non-fluorescent background, and recorded/presented pictures with color quality similar to observation through the oculars. PpIX visualization was comparable to the previous microscope. Near-infrared indocyanine green imaging 3-step replay allowed for more convenient accurate assessment of blood flow. Point lock and pivot point functions were used in dissections to create 3D virtual reality microsurgical anatomy demonstrations. Pivot point control was particularly useful in deep surgical corridors with dynamic retraction. 3D exoscopic function was successfully used in brain tumor and spine cases. Endoscopic assistance was used for around-the-corner views in minimally invasive approaches. We present illustrative cases highlighting utility and new ways to control the operative microscope. Conclusion Improvements of the robotic visualization platform include intraoperative fluorescence visualization using FNa, integrated micro-inspection tool, improved ocular imaging clarity, and exoscopic mode. New robotic movements positively assist the surgeon and provide improved ergonomics and a greater level of intraoperative comfort, with the potential to increase the viewing quality. New operational modes also allow significant impact for anatomy instruction. With the increasing number and complexity of functions, surgeons should receive additional training in order to avail themselves of the advantages of the numerous novel features.
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Affiliation(s)
- Evgenii G Belykh
- Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, USA
| | - Xiaochun Zhao
- Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, USA
| | - Claudio Cavallo
- Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, USA
| | - Michael A Bohl
- Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, USA
| | - Kaan Yagmurlu
- Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix , USA
| | - Joseph L Aklinski
- Neurosurgery, Barrow Neurological Institute/St. Joseph's Hospital and Medical Center, Phoenix, USA
| | | | - Nader Sanai
- Neurosurgery, Barrow Neurological Institute/St. Joseph's Hospital and Medical Center, Phoenix, USA
| | - Robert F Spetzler
- Neurosurgery, Barrow Neurological Institute/St. Joseph's Hospital and Medical Center, Phoenix, USA
| | - Michael T Lawton
- Neurosurgery, Barrow Neurological Institute/St. Joseph's Hospital and Medical Center, Phoenix, USA
| | - Peter Nakaji
- Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, USA
| | - Mark C Preul
- Neurosurgery, Barrow Neurological Institute/St. Joseph's Hospital and Medical Center, Phoenix, USA
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Jägersberg M, Brodard J, Qiu J, Mansouri A, Doglietto F, Gentili F, Kucharczyk W, Fasel J, Schaller K, Radovanovic I. Quantification of Working Volumes, Exposure, and Target-Specific Maneuverability of the Pterional Craniotomy and Its Minimally Invasive Variants. World Neurosurg 2017; 101:710-717.e2. [PMID: 28254536 DOI: 10.1016/j.wneu.2017.02.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 01/31/2017] [Accepted: 02/02/2017] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Quantitative comparison of minimally invasive and standard cranial approaches remains a methodologic challenge. The aim of this study was to apply a new digital, navigation-based method to quantify multiple parameters of the pterional, supraorbital, lateral supraorbital and mini-pterional approaches and to describe a target-specific maneuverability score. METHODS Supraorbital, lateral supraorbital, mini-pterional, and standard pterional craniotomies were performed on 8 sides in 4 cadaver heads. The limits of superficial and deep exposure and surgical target points were registered with image-guidance (Medtronic Stealth). A custom software (Guided Therapeutics Eyes II Software [GTxEyesII]) calculated superficial and deep surface areas, working volumes, and target distances. Volumes were reconstructed digitally and visualized with GTxEyesII. Finally, we defined for each approach a target-specific maneuverability score based on surface exposure, target distance, target position, and anatomical obstacles. RESULTS Surface exposure and volumes were significantly smaller for keyhole approaches compared with standard pterional craniotomy (P < 0.01). Maneuverability index scores showed the greatest values for standard pterional craniotomies, but nearly equally high scores could be achieved by one or several of the less-invasive approaches for most of the targets. CONCLUSIONS The combination of a navigation-based measurement method with custom software (GTxEyesII) provides a powerful tool for visualization and quantification of surgical approaches. Compared with standard pterional craniotomy, alternative keyhole craniotomies offer comparable deep exposure with smaller working volumes and relatively high maneuverability for specific targets.
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Affiliation(s)
- Max Jägersberg
- Division of Neurosurgery, Geneva University Hospitals and University of Geneva, Geneva, Switzerland.
| | - Jerermy Brodard
- Division of Neurosurgery, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Jimmy Qiu
- Department of Medical Imaging, Toronto General Hospital, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Alireza Mansouri
- Division of Neurosurgery, Toronto Western Hospital, University Health Network and Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | | | - Fred Gentili
- Division of Neurosurgery, Toronto Western Hospital, University Health Network and Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Walter Kucharczyk
- Department of Medical Imaging, Toronto General Hospital, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Jean Fasel
- Clinical Anatomy Research Group, Department of Cellular Physiology and Metabolism, University Medical Center, Geneva, Switzerland
| | - Karl Schaller
- Division of Neurosurgery, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Ivan Radovanovic
- Division of Neurosurgery, Toronto Western Hospital, University Health Network and Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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Lee JS, Scerrati A, Zhang J, Ammirati M. Quantitative analysis of surgical exposure and surgical freedom to the anterosuperior pons: comparison of pterional transtentorial, orbitozygomatic, and anterior petrosal approaches. Neurosurg Rev 2016; 39:599-605. [PMID: 27075862 DOI: 10.1007/s10143-016-0710-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 03/06/2016] [Indexed: 01/02/2023]
Abstract
Surgical approaches to the pons lump together different areas of the pons, such as the anterosuperior and the anteroinferior pons. These areas are topographically different, and different approaches may be best suited for one or the other area. We evaluated the exposure of the anterosuperior pons using different surgical approaches. We quantify the surgical exposure and surgical freedom to the anterosuperior pons afforded by the pterional transtentorial (PT), the orbitozygomatic with anterior clinoidectomy (OZ), and the anterior petrosal (AP) approaches. Five embalmed cadaver heads were used. The three approaches were executed on each side, for a total of 30 approaches. The area of maximal exposure of the anterosuperior pons was measured with the aid of neuronavigation. We also evaluated the feasible angles of approach in the vertical and horizontal planes. We were able to successfully expose the anterosuperior pons using all the selected approaches. In the PT and OZ approaches, mobilization of the sphenoparietal sinus can prevent over-retraction of the temporal bridging veins, while use of the endoscope can help in preserving the integrity of the fourth nerve while cutting the tentorium. The mean exposure area was largest for the AP and smallest for the PT; the surgical freedom was similar among all the approaches. However, there was no statistically significant difference among all the approaches in the exposure area or in the surgical freedom. There is no significant difference among the three evaluated approaches in exposure of the anterosuperior pons.
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Affiliation(s)
- Jung-Shun Lee
- Section of Neurosurgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Dardinger Microneurosurgical Skull Base Laboratory, Department of Neurological Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Alba Scerrati
- Institute of Neurosurgery, Catholic University of Rome, Rome, Italy.,Dardinger Microneurosurgical Skull Base Laboratory, Department of Neurological Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Jun Zhang
- Department of Radiology and Wright Center of Innovation in Biomedical Imaging, Wexner Medical Center, The Ohio State University, N1025 Doan Hall, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - Mario Ammirati
- Dardinger Microneurosurgical Skull Base Laboratory, Department of Neurological Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA.
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Yang J, Zhang F, Xu A, Li H, Ding Z. Comparison of surgical exposure and maneuverability associated with microscopy and endoscopy in the retrolabyrinthine and transcrusal approaches to the retrochiasmatic region: a cadaveric study. Acta Neurochir (Wien) 2016; 158:703-710. [PMID: 26860600 DOI: 10.1007/s00701-016-2733-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 02/02/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND The retrolabyrinthine and transcrusal approaches (RLA and TCA, respectively) are the two most often used posterior transpetrosal approaches that are used to treat lesions in the retrochiasmatic region. Endoscopes are increasingly used in neurosurgical practice. To determine whether a difference exists between the two transpetrosal approaches in the retrochiasmatic region, we evaluated and compared the exposure and maneuverability associated with the microscope and the endoscope in these approaches. METHODS Seven formalin-fixed cadaveric heads were dissected bilaterally through the two approaches: four for evaluation and three injected with colored latex for photography. The retrochiasmatic region was divided into four sub-compartments: the compartment before the infundibulum, which was further divided into two parts, (1) the ipsilateral and (2) the contralateral compartments; (3) the retroinfundibulum compartment; (4) the third ventricle. After each approach, exposure and maneuverability of the structures in these four compartments obtained by microscopy and endoscopy were scored under a guidance of a numerical grading system for further comparison. RESULTS The TCA provided better exposure and maneuverability at the retrochiasmatic region than the RLA in both the microscopy model [scores of 39.75 ± 2.12 and 32.38 ± 2.56 respectively (p < 0.05)] and the endoscopy model [scores of 82.13 ± 3.40 and 43.75 ± 1.67 respectively (p < 0.05)]. CONCLUSIONS The TCA is better than the RLA at offering exposure and manipulation to structures in the retrochiasmatic region, especially in patients whose lesion is located high into the third ventricle and/or expanded into the contralateral part. Endoscopes may be helpful in TCA in terms of exposing and maneuvering structures in the contralateral and interpeduncle fossa areas. However, in RLA, not enough room is available for simultaneously maneuvering an endoscope and a surgical instrument.
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Quantification and comparison of neurosurgical approaches in the preclinical setting: literature review. Neurosurg Rev 2016; 39:357-68. [PMID: 26782812 DOI: 10.1007/s10143-015-0694-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Revised: 03/25/2015] [Accepted: 06/27/2015] [Indexed: 12/14/2022]
Abstract
There is a growing awareness of the need for evidence-based surgery and of the issues that are specific to research in surgery. Well-conducted anatomical studies can represent the first, preclinical step for evidence-based surgical innovation and evaluation. In the last two decades, various reports have quantified and compared neurosurgical approaches in the anatomy laboratory using different methods and technology. The aim of this study was to critically review these papers. A PubMed and Scopus search was performed to select articles that quantified and compared different neurosurgical approaches in the preclinical setting. The basic characteristics that anatomically define a surgical approach were defined. Each study was analyzed for measured features and quantification method and technique. Ninety-nine papers, published from 1990 to 2013, were included in this review. A heterogeneous use of terms to define the features of a surgical approach was evident. Different methods to study these features have been reported; they are generally based on quantification of distances, angles, and areas. Measuring tools have evolved from the simple ruler to frameless stereotactic devices. The reported methods have each specific advantages and limits; a common limitation is the lack of 3D visualization and surgical volume quantification. There is a need for a uniform nomenclature in anatomical studies. Frameless stereotactic devices provide a powerful tool for anatomical studies. Volume quantification and 3D visualization of the surgical approach is not provided with most available methods.
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Elhadi AM, Almefty KK, Mendes GAC, Kalani MYS, Nakaji P, Dru A, Preul MC, Little AS. Comparison of surgical freedom and area of exposure in three endoscopic transmaxillary approaches to the anterolateral cranial base. J Neurol Surg B Skull Base 2014; 75:346-53. [PMID: 25276600 DOI: 10.1055/s-0034-1372467] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Accepted: 02/07/2014] [Indexed: 10/25/2022] Open
Abstract
Objective Endoscopic ipsilateral endonasal transmaxillary, contralateral endonasal transseptal transmaxillary, and Caldwell-Luc approaches can access lesions within the retromaxillary space and pterygopalatine fossa. We compared the exposure and surgical freedom of these transmaxillary approaches to assist with surgical decision making. Design Four cadaveric heads were dissected bilaterally using the three approaches just described. Prior to dissection, stereotactic computed tomography (CT) scans were obtained on each head to obtain anatomical measurements. Surgical freedom and area of exposure were determined by stereotaxis. Main Outcome Measures Area of exposure was calculated as the extent of the orbital floor, maxillary sinus floor, nasal floor, and mandibular ramus exposed through each approach. Surgical freedom was the area through which the proximal end of the endoscope could be freely moved while moving the tip of the endoscope to the edges of the exposed area. Results The mean exposed area was similar: 9.9 ± 2.5 cm(2) (Caldwell-Luc), 10.4 ± 2.6 cm(2) (ipsilateral endonasal), and 10.1 ± 2.1 cm(2) (contralateral transseptal) (p > 0.05). The surgical freedom of the Caldwell-Luc approach (113 ± 7 cm(2)) was greater than for either endonasal approach, 76 cm(2 )± 15 (p = 0.001) (ipsilateral endonasal) and 83 cm(2) ± 15 (p = 0.003) contralateral transseptal. Conclusions Our work demonstrates that the Caldwell-Luc endonasal approach offers greater surgical freedom than either approach for anterolateral skull base targets, although these approaches offer similar exposure.
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Affiliation(s)
- Ali M Elhadi
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States ; Interdisciplinary Graduate Program in Neuroscience, Arizona State University, Tempe, Arizona, United States
| | - Kaith K Almefty
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
| | - George A C Mendes
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
| | - M Yashar S Kalani
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
| | - Peter Nakaji
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
| | - Alexander Dru
- Neurosurgical Research Laboratory, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
| | - Mark C Preul
- Neurosurgical Research Laboratory, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
| | - Andrew S Little
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
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Mason E, Van Rompaey J, Carrau R, Panizza B, Solares CA. Anatomical and computed tomographic analysis of the transcochlear and endoscopic transclival approaches to the petroclival region. Laryngoscope 2013; 124:628-36. [PMID: 24105807 DOI: 10.1002/lary.24378] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 07/31/2013] [Accepted: 07/31/2013] [Indexed: 11/11/2022]
Abstract
OBJECTIVES/HYPOTHESIS Advances in the field of skull base surgery aim to maximize anatomical exposure while minimizing patient morbidity. The petroclival region of the skull base presents numerous challenges for surgical access due to the complex anatomy. The transcochlear approach to the region provides adequate access; however, the resection involved sacrifices hearing and results in at least a grade 3 facial palsy. An endoscopic endonasal approach could potentially avoid negative patient outcomes while providing a desirable surgical window in a select patient population. STUDY DESIGN Cadaveric study. METHODS Endoscopic access to the petroclival region was achieved through an endonasal approach. For comparison, a transcochlear approach to the clivus was performed. Different facets of the dissections, such as bone removal volume and exposed surface area, were computed using computed tomography analysis. RESULTS The endoscopic endonasal approach provided a sufficient corridor to the petroclival region with significantly less bone removal and nearly equivalent exposure of the surgical target, thus facilitating the identification of the relevant anatomy. The lateral approach allowed for better exposure from a posterolateral direction until the inferior petrosal sinus; however, the endonasal approach avoided labyrinthine/cochlear destruction and facial nerve manipulation while providing an anteromedial viewpoint. The endonasal approach also avoided external incisions and cosmetic deficits. The endonasal approach required significant sinonasal resection. CONCLUSIONS Endoscopic access to the petroclival region is a feasible approach. It potentially avoids hearing loss, facial nerve manipulation, and cosmetic damage.
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Affiliation(s)
- Eric Mason
- Department of Otolaryngology, Center for Cranial Base Surgery, Georgia Regents University, Augusta, Georgia, U.S.A
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