Rarely Used Endoscopic Transnasal Transdiaphragmatic Technique in Patients with Suprasellar Extension: A Tertiary Center's Experience with Eleven Patient Cases

OBJECTIVE

As surgical techniques become less invasive, the use of endoscopy in brain surgery supports this trend. Numerous endoscopic surgical approaches have been defined, especially for skull base diseases. The current study summarizes our experience of using the rarely reported endoscopic transnasal transdiaphragmatic approach through the existing hole in the diaphragma sella to access lesions extending into the suprasellar region.

METHODS

Our surgical team performed 4876 endoscopic endonasal surgeries between August 1997 and December 2022 at the Department of Neurosurgery, Pituitary Research Center, Faculty of Medicine, Kocaeli University. The study retrospectively analyzed data from 11 patients who had undergone endoscopic transnasal transdiaphragmatic surgery since January 2020. Preoperative and postoperative magnetic resonance imaging, pituitary function examination, and clinical observation were carried out.

RESULTS

The mean age of the patients was 31.1 ± 10.7 years and the female/male ratio was 6:5. Pathologic subtypes observed included breast cancer metastasis (n = 1), adrenocorticotropic hormone-secreting adenoma (n = 4), growth hormone-secreting adenoma (n = 3), craniopharyngioma (n = 2), and Rathke cleft cyst (n = 1). The mean postoperative hospital stay was 4.7 ± 1.1 days and none of the patients showed cerebrospinal fluid leakage during this period.

CONCLUSIONS

The endoscopic transnasal transdiaphragmatic approach may be considered an alternative to the conventional extended endoscopic transnasal approach in patients with lesions extending into the suprasellar region. The main strength of this method is that it facilitates suprasellar region access through a small dural incision and bone defect in the base of the skull. As a result, it also reduces the risk of postoperative cerebrospinal fluid leakage and associated complications.

Salvage posterior atlantoaxial fixation techniques: A retrospective study

OBJECT

Since the atlantoaxial region have critical neurovascular anatomy and limited bone surface for fusion, the application and choice of salvage fixation techniques are highly important. To discuss alternative posterior atlantoaxial fixation surgery techniques.

METHODS

We retrospectively surgical records of 22 patients that posterior atlantoaxial fixation techniques were applied.

RESULTS

The patients included 11 males and 11 females (mean age: 65.7 years). The fracture type that caused instability is type 2 odontoid fractures (22). In six of these patients alternative stabilization techniques were applied due to anatomical variations, huge venous bleeding and iatrogenic trauma of the screw entry points during surgery.

CONCLUSIONS

Owing to anatomical variations, intraoperative challenges, and/or instrumentation failures, performing alternative surgical fixation technique is an important factor that affects the success of stabilization of the atlantoaxial region. Knowledge of salvage techniques especially during the learning curve is vitally important. Surgeons should adapt to intraoperative surgical challenges as required.

Effects of Modified Osteoplastic Pterional Craniotomy on Temporal Muscle Volume and Frontal Muscle Nerve Function

Introduction  Pterional craniotomy is a surgical approach frequently used in aneurysm and skull base surgery. Pterional craniotomy may lead to cosmetic and functional problems, such as eyebrow drop due to facial nerve frontal branch damage, temporal muscle atrophy, and temporomandibular joint pain. The aim was to compare the postoperative effects of our modified osteoplastic craniotomy with classical pterional craniotomy in terms of any change in volume of temporal muscle and in the degree of frontal muscle nerve damage. Materials and Methods  Aneurysm cases were operated with either modified osteoplastic pterional craniotomy or free bone flap pterional craniotomy according to the surgeon's preference. Outcomes were compared in terms of temporal muscle volume and frontal muscle nerve function 6 months postoperatively. Results  Preoperative temporal muscle volume in the modified osteoplastic pterional and free bone flap pterional craniotomy groups were not different ( p  > 0.05). However, significantly less atrophy was observed in the postoperative temporal muscle volume of the osteoplastic group compared with the classical craniotomy group ( p  < 0.001). In addition, when comparing frontal muscle nerve function there was less nerve damage in the modified osteoplastic pterional craniotomy group compared with the classical craniotomy group, although this did not reach significance ( p  > 0.05). Conclusion  Modified osteoplastic pterional craniotomy significantly reduced atrophy of temporal muscle and caused proportionally less frontal muscle nerve damage compared with pterional craniotomy, although this latter outcome was not significant. These findings suggest that osteoplastic craniotomy may be a more advantageous intervention in cosmetic and functional terms compared with classical pterional craniotomy.