1
|
Capilla-Guasch P, Quilis-Quesada V, Pastor-Escartín F, Tabarés Palacín D, Valencia Salazar JP, González-Darder JM. Olivary body exposure through far lateral and lower retrosigmoid approaches. Comparative analysis of the exposed surface and angle of attack. Neurocirugia (Astur : Engl Ed) 2024; 35:152-163. [PMID: 38244925 DOI: 10.1016/j.neucie.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 08/27/2023] [Indexed: 01/22/2024]
Abstract
OBJECTIVES Throughout neurosurgical history, the treatment of intrinsic lesions located in the brainstem has been subject of much controversy. The brainstem is the anatomical structure of the central nervous system (CNS) that presents the highest concentration of nuclei and fibers, and its simple manipulation can lead to significant morbidity and mortality. Once one of the safe entry points at the medulla oblongata has been established, we wanted to evaluate the safest approach to the olivary body (the most used safe entry zone on the anterolateral surface of the medulla oblongata). The proposed objective was to evaluate the working channel from the surface of each of the far lateral and retrosigmoid approaches to the olivary body: distances, angles of attack and channel content. MATERIAL AND METHODS To complete this work, a total of 10 heads injected with red/blue silicone were used. A total of 40 approaches were made in the 10 heads used (20 retrosigmoid and 20 far lateral). After completing the anatomical study and obtaining the data referring to all the approaches performed, it was decided to expand the sample of this research study by using 30 high-definition magnetic resonance imaging of anonymous patients without cranial or cerebral pathology. The reference points used were the same ones defined in the anatomical study. After defining the working channels in each of the approaches, the working distances, angle of attack, exposed surface, and the number of neurovascular structures present in the central trajectory were analyzed. RESULTS The distances to the cranial and medial region of the olivary body were 52.71 mm (SD 3.59) from the retrosigmoid approach and 27.94 mm (SD 3.99) from the far lateral; to the most basal region of the olivary body, the distances were 49.93 (SD 3.72) from the retrosigmoid approach and 18.1 mm (SD 2.5) from the far lateral. The angle of attack to the caudal region was 19.44° (SD 1.3) for the retrosigmoid approach and 50.97° (SD 8.01) for the far lateral approach; the angle of attack to the cranial region was 20.3° (SD 1.22) for the retrosigmoid and 39.9° (SD 5.12) for the far lateral. Regarding neurovascular structures, the probability of finding an arterial structure is higher for the lateral far, whereas a neural structure will be more likely from a retrosigmoid approach. CONCLUSIONS As conclusions of this work, we can say that far lateral approach presents more favorable conditions for the microsurgical treatment of intrinsic bulbar and bulbomedullary lesions approached through the caudal half of the olivary body. In those cases of bulbar and pontine-bulbar lesions approached through the cranial half of the olivary body, the retrosigmoid approach can be considered for selected cases.
Collapse
Affiliation(s)
- Pau Capilla-Guasch
- Departamento de Neurocirugía, Hospital Clínico Universitario de Valencia, Valencia, Spain; Laboratorio de Microneurocirugía, Departamento de Anatomía y Embriología Humana, Universidad de Valencia, Valencia, Spain; Laboratorio de Microneurocirugía, Arkansas Neuroscience Institute (ANI), Arkansas, USA.
| | - Vicent Quilis-Quesada
- Departamento de Neurocirugía, Hospital Clínico Universitario de Valencia, Valencia, Spain; Laboratorio de Microneurocirugía, Departamento de Anatomía y Embriología Humana, Universidad de Valencia, Valencia, Spain; Laboratorio de Microneurocirugía, Arkansas Neuroscience Institute (ANI), Arkansas, USA; Clínica Mayo, Florida, USA
| | - Félix Pastor-Escartín
- Departamento de Neurocirugía, Hospital Clínico Universitario de Valencia, Valencia, Spain; Laboratorio de Microneurocirugía, Departamento de Anatomía y Embriología Humana, Universidad de Valencia, Valencia, Spain
| | - Diego Tabarés Palacín
- Departamento de Neurocirugía, Hospital Clínico Universitario de Valencia, Valencia, Spain; Laboratorio de Microneurocirugía, Departamento de Anatomía y Embriología Humana, Universidad de Valencia, Valencia, Spain
| | - Juan Pablo Valencia Salazar
- Departamento de Neurocirugía, Hospital Clínico Universitario de Valencia, Valencia, Spain; Laboratorio de Microneurocirugía, Departamento de Anatomía y Embriología Humana, Universidad de Valencia, Valencia, Spain
| | - José M González-Darder
- Departamento de Neurocirugía, Hospital Clínico Universitario de Valencia, Valencia, Spain; Laboratorio de Microneurocirugía, Departamento de Anatomía y Embriología Humana, Universidad de Valencia, Valencia, Spain
| |
Collapse
|
2
|
Inoue T, Goto Y, Inoue Y, Adidharma P, Prasetya M, Fukushima T. Potential reasons for failure and recurrence in microvascular decompression for hemifacial spasm. Acta Neurochir (Wien) 2023; 165:3845-3852. [PMID: 38012393 DOI: 10.1007/s00701-023-05861-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 10/22/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND To examine the factors contributing to persistent and recurrent hemifacial spasms (HFS) following a microvascular decompression (MVD) procedure and to suggest technical improvements to prevent such failures. METHODS A retrospective review was conducted on fifty-two cases of repeat surgery. The extent of the previous craniotomy and the location of neurovascular compression (NVC) were investigated. The operative findings were categorized into two groups: "Missing Compression" and "Teflon Contact". The analysis included long-term outcomes and operative complications after repeat MVD procedures. RESULTS Missing compression was identified in 29 patients (56%), while Teflon contact was observed in 23 patients (44%). Patients with missing compression were more likely to experience improper craniotomy (66%) compared to those with Teflon contact (48%). Medially located NVC was a frequent finding in both groups, mainly due to compression by the anterior inferior cerebellar artery. In the missing compression group, during the repeat MVD, Teflon sling retraction was utilized in 79% of cases, while in the Teflon contact group, the most common procedure involved removing the Teflon in contact (65%). After the repeat MVD procedure, immediate spasm relief was achieved in 42 patients (81%), with six (12%) experiencing delayed relief. After a median follow-up of 54 months, 96% of patients were free from spasms. Delayed facial palsy, facial weakness, and hearing impairment were more frequently observed in the Teflon contact group. CONCLUSIONS A proper craniotomy that provides adequate exposure around the REZ is crucial to prevent missing the culprit vessel during the initial MVD procedure. Teflon contact on the REZ should be avoided, as it poses a potential risk of procedure failure and recurrence.
Collapse
Affiliation(s)
- Takuro Inoue
- Department of Neurosurgery, Koto Memorial Hospital, Higashiomi, Shiga, Japan.
- Department of Neurosurgery, National Brain Center Hospital, Jakarta, Indonesia.
| | - Yukihiro Goto
- Department of Neurosurgery, Koto Memorial Hospital, Higashiomi, Shiga, Japan
| | - Yasuaki Inoue
- Department of Neurosurgery, Nadogaya Hospital, Chiba, Japan
| | - Peter Adidharma
- Department of Neurosurgery, National Brain Center Hospital, Jakarta, Indonesia
| | - Mustaqim Prasetya
- Department of Neurosurgery, National Brain Center Hospital, Jakarta, Indonesia
| | - Takanori Fukushima
- Division of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| |
Collapse
|
3
|
Benet A, Spetzler RF. Cavernous Malformations: What They Have Taught Us. Neurosurgery 2023; 69:9-21. [PMID: 36924486 DOI: 10.1227/neu.0000000000002400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 01/13/2023] [Indexed: 03/18/2023] Open
Affiliation(s)
- Arnau Benet
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | | |
Collapse
|
4
|
Sun L, Qi M, Shao X, Chen S, Fang X, Zhou W, Zhou W, Chen H, He G, Fan X, Sun Y, Di G, Jiang X. Modified Skin Incision and Location of Burr-Hole Surgery via a Retrosigmoid Approach: An Anatomical Study. Skull Base Surg 2022; 84:98-104. [PMID: 36743712 PMCID: PMC9897899 DOI: 10.1055/s-0041-1740971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 11/12/2021] [Indexed: 02/07/2023]
Abstract
Objective This study aims to reduce the tissue damage during craniotomy with retrosigmoid approach. A modified sickle-shaped skin incision was developed, and a new burr-hole positioning method was proposed. Methods Five adult cadaveric heads (10 sides) were used in this study. The sickle-shaped skin incision was performed during craniotomy. The nerves, blood vessels, and muscles were observed and measured under a microscope. Additionally, 62 dry adult skull specimens (left sided, n = 35; right sided, n = 27) were used to measure the distance between the most commonly used locating point (asterion [Ast] point) and the posteroinferior point of the transverse sigmoid sinus junction (PSTS) (Ast-PSTS), as well as the distance between the new locating O point and the PSTS (O-PSTS). Then, the reliability of the new locating O point was validated on the same five adult cadaveric heads (10 sides) used for the sickle-shaped skin incision. Results The sickle-shaped skin incision reduced the damage to the occipital nerves, blood vessels, and muscles during the surgery via a retrosigmoid approach. The dispersion and variability of O-PSTS were smaller than those of Ast-PSTS. Conclusion The sickle-shaped skin incision of the retrosigmoid approach can reduce the tissue damage and can completely expose the structures in the cerebellopontine angle. The modified O point is a more reliable locating point for a burr-hole surgery than the Ast point.
Collapse
Affiliation(s)
- Lean Sun
- Department of Neurosurgery, Yijishan Hospital, Wannan Medical College, Wuhu, China
| | - Min Qi
- Department of Neurosurgery, Yijishan Hospital, Wannan Medical College, Wuhu, China
| | - Xuefei Shao
- Department of Neurosurgery, Yijishan Hospital, Wannan Medical College, Wuhu, China
| | - Sansong Chen
- Department of Neurosurgery, Yijishan Hospital, Wannan Medical College, Wuhu, China
| | - Xinyun Fang
- Department of Neurosurgery, Yijishan Hospital, Wannan Medical College, Wuhu, China
| | - Wei Zhou
- Department of Neurosurgery, Yijishan Hospital, Wannan Medical College, Wuhu, China
| | - Wei Zhou
- Department of Neurosurgery, Yijishan Hospital, Wannan Medical College, Wuhu, China
| | - Hao Chen
- Department of Neurosurgery, Yijishan Hospital, Wannan Medical College, Wuhu, China
| | - Guoyuan He
- Department of Neurosurgery, Yijishan Hospital, Wannan Medical College, Wuhu, China
| | - Xiran Fan
- Department of Neurosurgery, Yijishan Hospital, Wannan Medical College, Wuhu, China
| | - Yongkang Sun
- Department of Neurosurgery, Yijishan Hospital, Wannan Medical College, Wuhu, China
| | - Guangfu Di
- Department of Neurosurgery, Yijishan Hospital, Wannan Medical College, Wuhu, China
| | - Xiaochun Jiang
- Department of Neurosurgery, Yijishan Hospital, Wannan Medical College, Wuhu, China,Address for correspondence Xiaochun Jiang Department of Neurosurgery, Yijishan Hospital, Wannan Medical College2 Wast Zheshan Road, Wuhu, Anhui 241001China
| |
Collapse
|
5
|
Di G, Zhou W, Fang X, Li Q, Sun L, Jiang X. Transmastoid Trautman's Triangle Combined Low Retrosigmoid Approach for Foramen Magnum Meningiomas: Surgical Anatomy and Technical Note. J Neurol Surg B Skull Base 2021; 82:659-667. [PMID: 34745834 DOI: 10.1055/s-0040-1713755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 04/15/2020] [Indexed: 10/22/2022] Open
Abstract
Objective This study was aimed to assess the potential of utilizing a transmastoid Trautman's triangle combined low retrosigmoid approach for ventral and ventrolateral foramen magnum meningiomas (FMMs) surgical treatment. Methods We simulated this transmastoid Trautman's triangle combined low retrosigmoid approach using five adult cadaveric heads to explore the associated anatomy in a step-by-step fashion, taking pictures of key positions as appropriate. We then employed this approach in a single overweight patient with a short neck who was suffering from large ventral FMMs and cerebellar tonsillar herniation. Results Through cadaver studies, we were able to confirm that this transmastoid Trautman's triangle combined with low retrosigmoid approach achieves satisfactory cranial nerve and vasculature visualization while also offering a wide view of the whole of the ventrolateral medulla oblongata. We, additionally, have successfully employed this approach to treat a single patient suffering from large ventral FMMs with cerebellar tonsillar herniation. Conclusion This transmastoid Trautman's triangle combined low retrosigmoid approach may represent a complement to treatment strategies for ventral and ventrolateral FMMs, particularly in patients with the potential for limited surgical positioning due to their being overweight, having a short neck and suffering from cerebellar tonsillar herniation.
Collapse
Affiliation(s)
- Guangfu Di
- Department of Neurosurgery, First Affiliated Hospital (Yijishan Hospital) of Wannan Medical College, Wuhu, China.,Department of Human Anatomy, School of Basic Medicine, Wannan Medical College, Wuhu, China
| | - Wei Zhou
- Department of Neurosurgery, First Affiliated Hospital (Yijishan Hospital) of Wannan Medical College, Wuhu, China
| | - Xinyun Fang
- Department of Neurosurgery, First Affiliated Hospital (Yijishan Hospital) of Wannan Medical College, Wuhu, China.,Department of Human Anatomy, School of Basic Medicine, Wannan Medical College, Wuhu, China
| | - Qiang Li
- Department of Human Anatomy, School of Basic Medicine, Wannan Medical College, Wuhu, China
| | - Lean Sun
- Department of Neurosurgery, First Affiliated Hospital (Yijishan Hospital) of Wannan Medical College, Wuhu, China
| | - Xiaochun Jiang
- Department of Neurosurgery, First Affiliated Hospital (Yijishan Hospital) of Wannan Medical College, Wuhu, China.,Department of Human Anatomy, School of Basic Medicine, Wannan Medical College, Wuhu, China
| |
Collapse
|
6
|
Matsushima T, Rutka J, Matsushima K. Evolution of cerebellomedullary fissure opening: its effects on posterior fossa surgeries from the fourth ventricle to the brainstem. Neurosurg Rev 2020; 44:699-708. [PMID: 32281017 DOI: 10.1007/s10143-020-01295-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 03/10/2020] [Accepted: 03/30/2020] [Indexed: 11/27/2022]
Abstract
Surgical approaches to the fourth ventricle and its surrounding brainstem regions have changed significantly in the previous 30 years, after the establishment of cerebellomedullary fissure (CMF) opening. With the development of CMF opening techniques, CMF opening surgeries have become widely used for the treatment of various pathologies and have contributed to the improvement of surgical results in posterior fossa surgeries. We here review the historical progress of CMF opening surgeries to help the future progression of neurosurgical treatments. The authors studied the available literature to clarify how CMF opening surgeries have developed and progressed, and how much the idea and development of CMF opening techniques have affected the advancement of posterior fossa surgeries. With the establishment of angiography, anatomical studies on CMF in the 1960s were performed mainly to clarify vascular anatomy on radiological images. After reporting the microsurgical anatomy of CMF in a cadaveric study in 1982, one of the authors (T.M.) first proposed the clinical usefulness of CMF opening in 1992. This new method enabled wide exposure of the fourth ventricle without causing vermian splitting syndrome, and it took the place of the standard approach instead of the conventional transvermian approach. Several authors reported their experiences using this method from the end of the twentieth century to the early twenty-first century, and the naming of the approach, "telovelar approach" by Mussi and Rhoton in 2000 contributed to the global spread of CMF opening surgeries. The approach has become widely applied not only for tumors but also for vascular and brainstem lesions, and has assisted in the development of their surgical treatments, and brought up the idea of various fissure dissection in the posterior fossa. Studies of microsurgical anatomy of the fourth ventricle, including the CMF, has led to new surgical approaches represented by the transCMF/telovelar approach. The CMF opening method caused a revolution in posterior fossa surgeries. The idea was developed based on the experience gained while dissecting the CMF (the roof of the fourth ventricle) in the laboratory. Anatomical studies using cadaveric specimens, particularly their dissection by surgeons themselves, together with a deep understanding of brain anatomy are essential for further advancements in neurosurgical treatments.
Collapse
Affiliation(s)
- Toshio Matsushima
- International University of Health and Welfare, Fukuoka, Japan. .,Neuroscience Center, Fukuoka Sanno Hospital, 3-6-45 Momochihama, Sawara-ku, Fukuoka, 814-0001, Japan.
| | - James Rutka
- Department of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ken Matsushima
- Department of Neurosurgery, Tokyo Medical University, Tokyo, Japan
| |
Collapse
|
7
|
Karadag A, Senoglu M, Middlebrooks EH, Kinali B, Guvencer M, Icke C, Sayhan S, Karabay N, Camlar M, Olomu OU, Tanriover N. Endoscopic endonasal transclival approach to the ventral brainstem: Radiologic, anatomic feasibility and nuances, surgical limitations and future directions. J Clin Neurosci 2020; 73:264-279. [PMID: 32005412 DOI: 10.1016/j.jocn.2020.01.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Accepted: 01/04/2020] [Indexed: 12/25/2022]
Abstract
The endoscopic endonasal transclival approach (EETA) is less invasive than traditional open approaches; however, there is currently limited data on the pre-operative features that may predict success of the EETA. Surgical landmarks and exposure of the EETA and expanded EETA are assessed. We retrospectively measured multiple anatomic features in 154 adult dry skulls, 22 C1 and C2 dry bone vertebrae, and 500 paranasal sinus computed tomography (CT) scans. We also dissected 13 formalin-fixed, silicone-injected adult cadaveric heads. Relevant qualitative and quantitative data were obtained with CT (n = 10) and cadaveric dissection (n = 13). They are expressed as mean (SD), as appropriate and compared with unpaired t tests. Categorical variables were compared with χ2 tests. We determined the prevalence of clival and sphenoid sinus anatomic variations and assessed potential exposure of the craniovertebral region, based on the relative position of the nasal bone tip, posterior point of the hard palate, and their relation to the position of C1 and C2. Depending on anatomic features, EETA should allow visualization of the ventral brainstem. The mean (SD) dimensions of the surgical window for EETA were 43.2 (5.1) × 18.3 (1.1) mm, in the craniocaudad and horizontal dimensions, respectively. The craniocaudad dimension enlarged to 60.2 (4.7) mm with expanded EETA. The EETA allowed satisfactory exposure for odontoid and C1 anterior arch resection (expanded EETA) in all specimens, regardless of the orientation of the palate. The combination of preoperative radiographic assessment and intraoperative considerations allows safe and effective application and facilitate selection of the most appropriate approach.
Collapse
Affiliation(s)
- Ali Karadag
- Department of Neurosurgery, Health Science University, Tepecik Research and Training Hospital, Izmir, Turkey
| | - Mehmet Senoglu
- Department of Neurosurgery, Health Science University, Tepecik Research and Training Hospital, Izmir, Turkey.
| | - Erik H Middlebrooks
- Division of Neuroradiology, Mayo Clinic, Jacksonville, FL, USA; Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Burak Kinali
- Department of Neurosurgery, Health Science University, Tepecik Research and Training Hospital, Izmir, Turkey
| | - Mustafa Guvencer
- Department of Anatomy, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Cigdem Icke
- Department of Anatomy, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Salih Sayhan
- Department of Anatomy, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Nuri Karabay
- Department of Radiology, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Mahmut Camlar
- Department of Neurosurgery, Health Science University, Tepecik Research and Training Hospital, Izmir, Turkey
| | - Osarenoma U Olomu
- Department of Otorhinolaryngology/Audiology, Mayo Clinic, Jacksonville, FL, USA
| | - Necmettin Tanriover
- Department of Neurosurgery, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul, Turkey
| |
Collapse
|
8
|
Tayebi Meybodi A, Lawton MT, Moreira LB, Zhao X, Lang MJ, Nakaji P, Preul MC. Retromastoid-transmuscular identification and harvest of the occipital artery during retrosigmoid craniotomy. J Neurosurg 2019; 133:1-8. [PMID: 31299653 DOI: 10.3171/2019.4.jns19323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 04/17/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Harvesting the occipital artery (OA) is challenging. The subcutaneous OA is usually found near the superior nuchal line and followed proximally, requiring a large incision and risking damage to the superficially located OA. The authors assessed the anatomical feasibility and safety of exposing the OA through a retromastoid-transmuscular approach. METHODS Using 10 cadaveric heads, 20 OAs were harvested though a 5-cm retroauricular incision placed 5 cm posterior to the external auditory meatus. The underlying muscle layers were sequentially cut and recorded before exposing the OA. Changes in the orientation of muscle fibers were used as a roadmap to expose the OA without damaging it. RESULTS The suboccipital segment of the OA was exposed without damage after incising two consecutive layers of muscles and their investing fasciae. These muscles displayed different fiber directions: the superficially located sternocleidomastoid muscle with vertically oriented fibers, and the underlying splenius capitis with anteroposteriorly (and mediolaterally) oriented fibers. The OA could be harvested along the entire length of the skin incision in all specimens. If needed, the incision can be extended proximally and/or distally to follow the OA and harvest greater lengths. CONCLUSIONS This transmuscular technique for identification of the OA is a reliable method and may facilitate exposure and protection of the OA during a retrosigmoid approach. This technique may obviate the need for larger incisions when planning a bypass to nearby arteries in the posterior circulation via a retrosigmoid craniotomy. Additionally, the small skin incision can be enlarged when a different craniotomy and/or bypass is planned or when a greater length of the OA is needed to be harvested.
Collapse
|
9
|
Yang Y, van Niftrik B, Ma X, Velz J, Wang S, Regli L, Bozinov O. Analysis of safe entry zones into the brainstem. Neurosurg Rev 2019; 42:721-729. [PMID: 30726522 DOI: 10.1007/s10143-019-01081-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 12/09/2018] [Accepted: 01/21/2019] [Indexed: 01/02/2023]
Abstract
Intra-axial brainstem surgeries are challenging. Many experience-based "safe entry zones (SEZs)" into brainstem lesions have been proposed in the existing literature. The evidence for each one seems limited. English-language publications were retrieved using PubMed/MEDLINE. Studies that focused only on cadaveric anatomy were also included, but the clinical case number was treated as zero. The clinical evidence level was defined as "case report" when the surgical case number was ≤ 5, "limited evidence" when there were more than 5 but less than 25 cases, and "credible evidence" when a publication presented more than 25 cases. Twenty-five out of 32 publications were included, and 21 different SEZs were found for the brainstem: six SEZs were located in the midbrain, 9 SEZs in the pons, and 6 SEZs in the medulla. Case report evidence was found for 10 SEZs, and limited evidence for 7 SEZs. Four SEZs were determined to be backed by credible evidence. The proposed SEZs came from initial cadaveric anatomy studies, followed by some published clinical experience. Only a few SEZs have elevated clinical evidence. The choice of the right approach into the brainstem remains a challenge in each case.
Collapse
Affiliation(s)
- Yang Yang
- Department of Neurosurgery, University Hospital of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Bas van Niftrik
- Department of Neurosurgery, University Hospital of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Xiangke Ma
- Department of Neurosurgery, University Hospital of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Julia Velz
- Department of Neurosurgery, University Hospital of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Sophie Wang
- Department of Neurosurgery, University Hospital of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Luca Regli
- Department of Neurosurgery, University Hospital of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Oliver Bozinov
- Department of Neurosurgery, University Hospital of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland.
| |
Collapse
|