Cranial, Craniofacial and Skull Base Surgery (eBook)

Copyright Page 4
Foreword 5
Preface 6
Table of Contents 8
Contributors 11
Section 1 Cranial Neurosurgery 15
Introduction 16
History: The Past 16
Chronicles: The Present 17
Vision of the Next Step: The Future 18
References 18
1 Instruments 20
1.1 Introduction 20
1.2 Types of Instrument 20
1.3 Microscope 21
1.4 Endoscope 22
1.4.1 Video Camera and Monitor 23
1.4.2 Light Source 23
1.4.3 Video Documentation 24
1.5 Perforator and Craniotome 24
1.6 High-Speed Microdrill 24
1.7 Bleeding Control 25
1.8 Retraction Devices 25
1.9 MicroDoppler Probe 26
1.10 Neuronavigation System 26
1.11 Intraoperative MRI 26
1.12 Tumor Enucleation 26
1.13 Operating Room 27
References 27
2 Subfrontal Approaches 29
2.1 Historical Background 29
2.2 Subfrontal Unilateral Approach 29
2.2.1 Positioning and Skin Incision 29
2.2.2 Craniotomy 30
2.2.3 Dural Incision and Intradural Dissection 31
2.3 Subfrontal Bilateral Approach 33
2.3.1 Positioning and Skin Incision 33
2.3.2 Craniotomy 34
2.3.3 Dural Incision and Intradural Dissection 35
2.4 Complications 35
2.5 Final Considerations 35
References 37
3 Supraorbital Eyebrow Approach 38
3.1 Introduction 38
3.2 Indications 38
3.3 Patient Selection 39
3.4 Anatomical Studies 41
3.5 Application of Neuroendoscopy 42
3.6 Surgical Technique 42
3.7 Case Examples 44
3.7.1 Case 1 44
3.7.2 Case 2 45
3.7.3 Case 3 45
3.8 Complications and Complication Avoidance 46
3.8.1 Complications 46
3.8.2 Complication Avoidance 46
3.9 Criticisms of Supraorbital Eyebrow Craniotomy 47
3.10 Practical Advice: Getting Started with Supraorbital Eyebrow Craniotomy 48
3.11 Summary 48
References 48
4 Frontotemporal Approach 50
4.1 Introduction 50
4.2 Positioning 50
4.3 Skin Incision 51
4.4 Anatomical Basis for Preservation of the Superficial Temporal Artery and the Frontal Branch of the Facial Nerve 52
4.5 Anatomy of the Facial Nerve and Superficial Temporal Artery within the Temporal Region 52
4.6 Temporal Muscle DissectionMethods 54
4.6.1 Interfascial 54
4.6.2 Submuscular 54
4.6.3 Subfascial 54
4.7 Craniotomy 55
4.8 Dural Opening 56
4.9 Endoscope-Assisted Technique 57
4.10 Dura, Bone and Wound Closure 61
4.11 Extradural Anterior Clinoidectomy 63
4.12 Intradural Anterior Clinoidectomy 64
4.13 Posterior Clinoidectomy 65
4.14 General Considerations 66
4.14.1 Vascular Lesions 66
4.14.2 Meningiomas 67
4.14.3 Craniopharyngiomas 68
4.15 Special Considerations 69
References 70
5 Orbitozygomatic Approach 71
5.1 Introduction 71
5.2 Anatomy of the Anterolateral Cranial Region and Related Structures 72
5.3 Operative Technique 77
5.3.1 Frontotemporoorbitozygomatic Approach 77
5.3.2 Orbitopterional Approach 85
5.4 Indications 87
5.5 Complications and Complication Avoidance 94
References 95
6 Transcallosal Approaches to Intraventricular Tumors 97
6.1 History 97
6.2 Introduction 97
6.3 Surgical Technique 99
6.3.1 Anterior Transcallosal Approach 99
6.3.2 Middle Transcallosal Approach 103
6.3.3 Posterior Transcallosal Approach 103
6.3.4 Posterior Approach with Division of the Splenium 104
6.3.5 Posterior Paracallosal Transprecuneal Approach 106
6.4 Approaches to the Third Ventricles 106
6.4.1 Paraforniceal Approach 106
6.4.2 Interforniceal Approach 108
6.4.3 Suprachoroidal Approach 111
6.4.4 Subchoroidal Approach 111
6.4.5 Removal of the Lesion 111
6.5 Advantages of the Transcallosal Approach 111
6.6 Limits and Disadvantages of the Transcallosal Approach 113
6.7 Limits and Disadvantages of theApproaches to the Third Ventricles 114
6.7.1 Paraforniceal Route 114
6.7.2 Transchoroidal Routes 114
6.7.3 Interforniceal Approach 114
References 114
7 Subtemporal Approach 116
7.1 Introduction 116
7.2 Surgical Pathology 116
7.2.1 Meningiomas 116
7.2.2 Schwannomas 117
7.2.3 Cavernous Sinus Pathology 120
7.2.4 Pituitary Adenomas 120
7.2.5 Chordomas and Chondrosarcomas 122
7.2.6 Inflammatory Lesions 123
7.2.7 Aneurysms 124
7.3 Anterior Subtemporal Approach 125
7.3.1 Indications 125
7.3.2 Positioning 125
7.3.3 Skin Incision 125
7.3.4 Interfascial Dissection 126
7.3.5 Craniotomy 126
7.4 Extension of the Pretemporal Approach (Intra- and Extradural) with Orbitozygomatic Osteotomies 130
7.4.1 Positioning 130
7.4.2 Skin Incision 130
7.4.3 Interfascial Dissection 130
7.4.4 Craniotomy and Orbitozygomatic Osteotomy 130
7.5 Subtemporal Approach In Trigeminal Neurinomas 131
7.5.1 General Considerations 131
7.5.2 Subtemporal Interdural Approach 131
7.5.2.1 Surgical Technique 131
7.5.2.2 Dura Elevation and Peeling of the Meningeal Dura of the Middle Fossa 132
7.5.3 Extension into the Posterior Cranial Fossa with an Anterior Transpetrosal Approach 132
7.5.4 Extension into the Infratemporal Fossa 134
7.5.5 Subtemporal Interdural Approach in Other Skull-Base Tumors 134
7.6 Posterior Subtemporal Approach 136
7.6.1 Indications 136
7.6.2 Positioning 136
7.6.3 Skin Incision 137
7.6.4 Craniotomy 137
7.7 Transtemporal–Transchoroidal Fissure Approach 138
7.8 Subtemporal Approach In Posterior Circulation Aneurysms 140
7.8.1 Differences from the Pterional Approach 141
7.8.2 Role of the Pretemporal Approach 142
7.8.3 Role of th5e Anterior Transpetrosal Approach 143
7.8.4 Role of the Transtemporal– Transchoroidal Approach 143
References 144
8 Suboccipital Lateral Approaches (Presigmoid) 146
8.1 Introduction 146
8.2 Transpetrosal Approaches 146
8.2.1 Retrolabyrinthine Approach:Surgical Technique and “Tricks” 147
8.3 Conclusions 151
References 151
9 Suboccipital Lateral Approaches (Retrosigmoid) 152
9.1 Introduction 152
9.2 Positioning of the Patient 152
9.3 Craniotomy 153
9.4 Dural Closure and Reconstruction of the Posterior Skull Base 157
References 158
10 Suboccipital Median Approach 160
10.1 Patient Preparation and Positioning 160
10.1.1 Semisitting Position 160
10.1.2 Lateral Position 161
10.1.3 Prone Position 162
10.2 Surgical Approaches 162
10.2.1 Supracerebellar Infratentorial Approach 162
10.2.1.1 Indications 162
10.2.1.2 Technique 162
10.2.2 Inferior Suboccipital Median Approach 163
10.2.2.1 Indications 163
10.2.2.2 Technique 164
10.3 Illustrative Case 166
References 166
11 Middle Cranial Fossa Approach 167
11.1 Introduction 167
11.2 Description of Technique 167
11.3 Cadaver Head Study and Technical “Tricks” 171
11.4 Conclusions 172
References 172
12 Translabyrinthine and Transcochlear Petrosal Approaches 173
12.1 Introduction 173
12.2 Translabyrinthine Approach 173
12.2.1 Surgical Technique 173
12.2.1.1 Anatomical Landmarks 173
12.2.1.2 Patient Positioning 175
12.2.1.3 Incision 175
12.2.1.4 Superficial Bone Removal 175
12.2.1.5 Sigmoid Sinus Skeletonization 175
12.2.1.6 Middle Fossa Dura Exposure 176
12.2.1.7 Opening the Antrum 176
12.2.1.8 Labyrinth Exposure and Isolation 177
12.2.1.9 Identification of the Incus 177
12.2.1.10 Facial Nerve Dissection 177
12.2.1.11 Labyrinth Dissection 178
12.2.1.12 Dural Incision 179
12.2.1.13 Closure 179
12.3 Transcochlear Approach 179
12.3.1 Surgical Technique 180
References 182
13 Dorsolateral Approach to the Craniocervical Junction 183
13.1 Introduction 183
13.2 Review of the Literature 183
13.3 Microsurgical Anatomy 184
13.4 Clinical Application 186
13.4.1 General Considerations 186
13.4.2 Radiological Considerations 187
13.4.3 Goals of Surgery and Preoperative Planning 187
13.5 Surgical Technique 187
13.5.1 Anesthesia, Monitoring, Neuronavigation and Endoscopy 187
13.5.2 Patient Positioning 188
13.5.3 Skin Incision and Exposure of the Deep Suboccipital Region 188
13.5.4 Craniotomy and Extradural Exposure 189
13.5.5 The “C-Zero” (C0) Concept 190
13.5.6 Intradural Stage 194
13.5.7 Dural Closure, Cranioplasty and Wound Closure 195
13.6 Specific Considerations 195
13.6.1 Meningiomas 195
13.6.2 Neurinomas 196
13.6.3 Gliomas 199
13.6.4 Aneurysms 199
13.6.5 Cavernous Malformations 199
13.6.6 Extradural Lesions 199
13.7 Outcome and Complications 203
13.8 Lessons Learned 203
References 204
14Transsphenoidal Approaches: Endoscopic 205
14.1 Introduction 205
14.2 Surgical Anatomy 206
14.2.1 Endonasal Corridor 206
14.2.2 Sellar Region 208
14.2.3 Parasellar Area 209
14.3 Procedure 210
14.3.1 Preoperative Workup 210
14.3.2 Operating Room Set-up and Patient Positioning 211
14.3.3 Surgical Technique 211
14.3.3.1 Nasal Step 211
14.3.3.2 Sphenoidal Step 212
14.3.3.3 Sellar Step 212
14.3.3.4 Sellar Reconstruction 218
14.4 Pitfalls and Complication Avoidance 219
References 220
15 Endonasal Endoscope-Assisted Microscopic Approach 221
15.1 Introduction 221
15.2 Surgical Technique 221
15.2.1 Instrumentation 221
15.2.1.1 Modified Endonasal Specula 221
15.2.2 Patient Preparation, Positioning and Room Set-Up 223
15.2.3 Nasal Portion and Sphenoidotomy 223
15.2.4 Sellar Exposure 224
15.2.5 Cavernous Carotid Localization 224
15.2.6 Dural Opening 225
15.2.7 Adenoma Removal 225
15.2.8 Endoscopic Assistance to Maximize Tumor Removal 226
15.2.9 Extended Approach Modifications 226
15.2.9.1 Suprasellar and Planum Lesions 226
15.2.9.2 Clival Lesions and Cavernous Sinus Lesions 227
15.2.10 Intrasellar Hemostasis 227
15.2.11 Skull Base Reconstruction and CSF Leak Repair 227
15.2.12 Nasal Closure 229
15.2.13 Postoperative Care 229
15.3 Discussion 229
15.4 Conclusion 230
References 230
16 Transsphenoidal Approaches: Microscopic 233
16.1 Introduction 233
16.2 Special Considerations 233
16.3 Surgical Technique 234
16.3.1 General 234
16.3.2 Patient Positioning 235
16.3.3 Surgical Team Positioning 236
16.3.4 Patient Preparation 236
16.3.5 Adjunctive Navigation 236
16.3.5.1 Image Guidance 236
16.3.5.2 Doppler Probe 237
16.3.6 Surgical Approaches 237
16.3.6.1 Nasal Phase 237
16.3.6.2 Sphenoid Phase 241
16.3.6.3 Sellar Phase 241
16.3.6.4 Reconstruction/Closure 242
16.3.7 Summary of Conventional Approaches 242
16.3.7.1 Boundaries of the Microscopic Transsphenoidal Approaches: Extended Approaches 242
16.3.8 Special Surgical Considerations 243
16.3.8.1 Cushing’s Disease 243
16.3.8.2 Acromegaly 243
16.4 Complications 244
16.4.1 Complication Avoidance: Postoperative CSF Leakage and Vascular Injury 244
16.5 Summary 244
References 245
17 Expanded Endoscopic Endonasal Approaches to the Skull Base 247
17.1 Introduction 247
17.2 Endoscopic Endonasal Approach 248
17.2.1 Planning 248
17.2.2 Operating Room Setup 248
17.2.3 Surgical Exposure 248
17.3 Anatomical Modules 249
17.3.1 Sagittal Plane (Anterior to Posterior) 249
17.3.2 Coronal (Paramedian) Planes (Lateral to Carotid Arteries) 252
17.3.2.1 Anterior Coronal Plane (Anterior Fossa) 253
17.3.2.2 Midcoronal Plane (Middle Fossa) 253
17.3.2.3 Posterior Coronal Plane (Posterior Fossa) 255
17.4 Reconstruction Technique 257
17.5 Conclusion 258
References 258
Section 2 Maxillofacial Surgery 260
Introduction 261
Historical Notes 261
Introduction to Maxillofacial Approaches 261
References 263
18 Orbital Approaches 264
18.1 Introduction 264
18.2 Surgical Anatomy 264
18.3 Clinical Aspects 266
18.4 Orbital Imaging 267
18.5 Pathological Diagnosis 267
18.6 Indications for Surgical Intervention 268
18.7 Surgical Approaches to the Orbit 268
18.7.1 Lateral Orbitotomy 269
18.7.2 Inferior Orbitotomy 273
18.7.3 Superior Orbitotomy 276
18.7.4 Medial Orbitotomy 277
18.7.5 Craniofacial Approaches 282
18.8 “Special” Surgical Approaches 283
18.8.1 Optic Canal Decompression in Posttraumatic Optic Neuropathy 283
18.8.2 Optic Nerve Sheath Decompression in Pseudotumor Cerebri 283
18.8.3 Orbital Wall Decompression in Graves’ Ophthalmopathy 283
18.8.4 Transpalpebral Decompression of Graves’ Ophthalmopathy (Olivari’s Technique) 284
18.9 Complications 284
References 284
19 Transoral Approaches 286
19.1 Anatomy 286
19.1.1 Clivus 286
19.1.2 Foramen Magnum 286
19.1.3 Occipital bone 287
19.1.4 Atlas 288
19.1.5 Axis 288
19.1.6 Atlantoaxial Joints 289
19.1.7 Atlantooccipital Joints 289
19.1.8 Axis and Occipital Bone 289
19.2 Pathology 290
19.2.1 Congenital 290
19.2.2 Traumatic 290
19.2.3 Inflammatory 291
19.2.4 Neoplastic 291
19.2.5 Clinical Presentation 292
19.3 Radiological Assessment 292
19.4 Surgical Considerations 293
19.5 Surgical Technique 294
19.5.1 Patient Preparation 294
19.5.2 Surgical Procedure 295
19.5.3 Removal of C1 Arch and Odontoidectomy 297
19.5.4 Tumor Removal 297
19.5.5 Closure 297
19.5.6 Posterior Stabilization 297
19.6 Extended Transoral Approaches 298
19.6.1 Transmaxillary Approach (Le Fort I Maxillotomy) 298
19.6.1.1 Indications 299
19.6.1.2 Surgical Technique 299
19.6.2 Transmaxillary Palatal Split Approach (Extended Maxillotomy) 300
19.6.2.1 Indications 300
19.6.2.2 Surgical Technique 301
19.6.3 Transpalatal Approach 301
19.6.3.1 Indications 301
19.6.3.2 Surgical Technique 301
19.6.4 Transmandibular Approach (Median Labiomandibular Glossotomy) 302
19.6.4.1 Indications 303
19.6.4.2 Surgical Technique 303
References 303
20 Midfacial Approaches 305
20.1 History 305
20.2 Indications 305
20.3 Investigations 305
20.3.1 Radiography 305
20.3.2 Computed Tomography 305
20.3.3 Angiography 306
20.3.4 Magnetic Resonance Imaging 306
20.4 Surgical Technique 306
20.4.1 Skin Incision and Soft Tissue Dissection 306
20.4.2 Osteotomies 308
20.4.2.1 Ethmoidectomy and Medial Maxillectomy 308
20.4.2.3 Total Ethmoidomaxillectomy 308
20.5 Tumor Resection 309
20.6 Reconstruction 309
20.7 Closure 310
20.8 Postoperative Care 310
20.9 Complications 311
References 311
21 Midfacial Translocation Approach 312
21.1 Introduction 312
21.2 Anatomical Basis 312
21.3 Basic Principles 313
21.4 Indications 314
21.5 Surgical Technique 314
21.5.1 Patient positioning 315
21.5.2 Anesthetic Technique 315
21.5.3 Operative Techniques 315
21.5.3.1 Mini Facial Translocation (Central) 315
21.5.3.2 Minifacial Translocation (Lateral) 315
21.5.3.3 Standard Hemifacial Translocation 316
21.5.3.4 Extended Facial Translocation (Medial) 317
21.5.3.5 Extended Facial Translocation (Medial and Inferior) 317
21.5.3.6 Extended Facial Translocation (Posterior) 317
21.5.3.7 Bilateral Facial Translocation 317
21.6 Reconstruction 318
21.7 Complications and Disadvantages 320
References 321
22 Transmandibular Approaches 322
22.1 Introduction 322
22.2 History 322
22.3 Surgical Techniques 323
22.3.1 Anterior Approaches 323
22.3.1.1 Mandibular Swing 323
22.3.1.2 Transmandibular Approach Without Lip-Splitting 324
22.3.1.3 Bisagittal Transmandibular Approach 325
22.3.2 Lateral approaches 326
22.3.2.1 Transmandibular Approach According to Conley 326
22.3.2.2 Transmandibular Approach According to Obwegeser 327
22.3.2.3 Transmandibular Approach with Double Mandibular Osteotomy and Additional Coronoidectomy 328
22.3.2.4 Transmandibular Approach with Twofold Vertical Branch and Parasymphyseal Osteotomy 328
22.3.3 Combined Approaches 329
22.3.3.1 Lateral Combined Transmandibular Approach 329
22.3.4 Mandibular Subluxation 332
References 332
23 Anterior Cranial Base Reconstruction 333
23.1 Introduction 333
23.2 History 333
23.3 Grafts 334
23.4 Local flaps 338
23.5 Locoregional flaps 340
23.6 Microvascular flaps 340
References 343
Subject Index 345