Endoscopic Endonasal Transclival Transcondylar Approach for Foramen Magnum Meningiomas

2015 ◽  
Vol 12 (2) ◽  
pp. 153-162 ◽  
Author(s):  
Wei-Hsin Wang ◽  
Kumar Abhinav ◽  
Eric Wang ◽  
Carl Snyderman ◽  
Paul A Gardner ◽  
...  
Keyword(s):  
Odontoid Process ◽  
Human Head ◽  
Foramen Magnum ◽  
Surgical Anatomy ◽  
Occipital Condyle ◽  
Anatomical Landmarks ◽  
Endoscopic Endonasal ◽  
Medial Condyle ◽  
Anterior Arch ◽  
Surgical Corridor

Abstract BACKGROUND The endoscopic endonasal approach provides a direct route to ventral foramen magnum (FM) lesions like meningiomas, which are difficult to access. Endonasal access at the FM is limited laterally by the occipital condyles and inferiorly by the C1 anterior arch and the odontoid process, which may need partial resection. OBJECTIVE We investigated the surgical anatomy and technical nuances for endonasally increasing the surgical corridor at the FM region both laterally and inferiorly. Unique to our report, we quantified the amount of required medial condyle resection to obtain exposure of the lateral aspects of the FM. METHODS Five fresh human head silicone-injected specimens underwent endonasal inferior transclival, transcondylar approaches. The lateral limit of medial condyle resection was defined using a vertical line extending inferiorly from foramen lacerum and its intersection with the occipital condyle. The condylectomy was limited posteriorly by the cortical bone surrounding the hypoglossal canal. The volume of the resected condyle (cubic centimeters) for 10 sides was measured using the pre- and postdissection computed tomography-volumetric analysis. RESULTS The mean percentage condylar volume resected during a unilateral medial condylectomy was 18% (9.7%-28.3%). The surgical corridor was extended inferiorly in all specimens without violating the transverse ligament by drilling the superior aspects of C1 anterior arch and the exposed odontoid tip. These operative nuances were successfully applied in the operating room. CONCLUSION Anatomical landmarks can reliably guide an endonasal anteromedial condyle resection. Minimal condyle resection is required to widen lateral access at the FM, which minimizes the risk of craniocervical instability.

“Far-Medial” Expanded Endonasal Approach to the Inferior Third of the Clivus

2010 ◽  
Vol 66 (suppl_2) ◽  
pp. ons211-ons220 ◽  
Author(s):  
Victor A. Morera ◽  
Juan C. Fernandez-Miranda ◽  
Daniel M. Prevedello ◽  
Ricky Madhok ◽  
Juan Barges-Coll ◽  
...  
Keyword(s):  
Cranial Nerves ◽  
Foramen Magnum ◽  
Direct Access ◽  
Occipital Condyle ◽  
Endonasal Approach ◽  
Endoscopic Endonasal ◽  
Hypoglossal Canal ◽  
Expanded Endonasal Approach ◽  
Surgical Corridor ◽  
Lower Cranial Nerves

Abstract OBJECTIVE The endoscopic endonasal transclival approach is a valid alternative for treatment of lesions in the clivus. The major limitation of this approach is a significant lateral extension of the tumor. We aim to identify a safe corridor through the occipital condyle to provide more lateral exposure of the foramen magnum. METHODS Sixteen parameters were measured in 25 adult skulls to analyze the exact extension of a safe corridor through the condyle. Endonasal endoscopic anatomic dissections were carried out in nine colored latex–injected heads. RESULTS Drilling at the lateral inferior clival area exposed two compartments divided by the hypoglossal canal: the jugular tubercle (superior) and the condylar (inferior). Completion of a unilateral ventromedial condyle resection opens a 3.5 mm (transverse length) * 10 mm (vertical length) lateral surgical corridor, facilitating direct access to the vertebral artery at its dural entry point into the posterior fossa. The supracondylar groove is a reliable landmark for locating the hypoglossal canal in relation to the condyle. The hypoglossal canal is used as the posterior limit of the condyle removal to preserve more than half of the condylar mass. The transjugular tubercle approach is accomplished by drilling above the hypoglossal canal, and increases the vertical length of the lateral surgical corridor by 8 mm, allowing for visualization of the distal cisternal segment of the lower cranial nerves. CONCLUSION The transcondylar and transjugular tubercle “far medial” expansions of the endoscopic endonasal approach to the inferior third of the clivus provide a unique surgical corridor to the ventrolateral surface of the ponto- and cervicomedullary junctions.

scholarly journals Endoscopic endonasal transoculomotor triangle approach for adenomas invading the parapeduncular space: surgical anatomy, technical nuances, and case series

2019 ◽  
Vol 130 (4) ◽  
pp. 1304-1314 ◽  
Author(s):  
Cristian Ferrareze Nunes ◽  
Stefan Lieber ◽  
Huy Q. Truong ◽  
Georgios Zenonos ◽  
Eric W. Wang ◽  
...  
Keyword(s):  
Cavernous Sinus ◽  
Case Series ◽  
Surgical Anatomy ◽  
Oculomotor Nerve ◽  
Oculomotor Nerve Palsy ◽  
Tumor Extension ◽  
Endoscopic Endonasal ◽  
Transcranial Approach ◽  
Surgical Corridor ◽  
Dural Opening

OBJECTIVEPituitary adenomas may extend into the parapeduncular space by invading through the roof of the cavernous sinus. Currently, a transcranial approach is the preferred choice, with or without the combination of an endonasal approach. In this paper the authors present a novel surgical approach that takes advantage of the natural corridor provided by the tumor to further open the oculomotor triangle and resect tumor extension into the parapeduncular space.METHODSSix injected specimens were used to demonstrate in detail the surgical anatomy related to the approach. Four cases in which the proposed approach was used were retrospectively reviewed.RESULTSFrom a technical perspective, the first step involves accessing the superior compartment of the cavernous sinus. The interclinoid ligament should be identified and the dura forming the oculomotor triangle exposed. The oculomotor dural opening may be then extended posteriorly toward the posterior petroclinoidal ligament and inferolaterally toward the anterior petroclinoidal ligament. The oculomotor nerve should then be identified; in this series it was displaced superomedially in all 4 cases. The posterior communicating artery should also be identified to avoid its injury. In all 4 cases, the tumor invading the parapeduncular space was completely removed. There were no vascular injuries and only 1 patient had a partial oculomotor nerve palsy that completely resolved in 2 weeks.CONCLUSIONSThe endoscopic endonasal transoculomotor approach is an original alternative for removal of tumor extension into the parapeduncular space in a single procedure. The surgical corridor is increased by opening the dura of the oculomotor triangle and by working below and lateral to the cisternal segment of the oculomotor nerve.

Endoscopic Endonasal Approaches to the Clivus with No Violation of the Nasopharynx: Surgical Anatomy and Clinical Illustration

2021 ◽  
Author(s):  
Carlos D. Pinheiro-Neto ◽  
Laura Salgado-Lopez ◽  
Luciano C.P.C. Leonel ◽  
Serdar O. Aydin ◽  
Maria Peris-Celda
Keyword(s):  
Posterior Fossa ◽  
Cerebrospinal Fluid Leak ◽  
Craniovertebral Junction ◽  
Foramen Magnum ◽  
Surgical Anatomy ◽  
Csf Leak ◽  
Surgical Approaches ◽  
Endoscopic Endonasal Approach ◽  
Endonasal Approach ◽  
Endoscopic Endonasal

Abstract Background Despite the use of vascularized intranasal flaps, endoscopic endonasal posterior fossa defects remain surgically challenging with high rates of postoperative cerebrospinal fluid leak. Objective The aim of the study is to describe a novel surgical technique that allows complete drilling of the clivus and exposure of the craniovertebral junction with preservation of the nasopharynx. Methods Two formalin-fixed latex-injected anatomical specimens were used to confirm feasibility of the technique. Two surgical approaches were used: sole endoscopic endonasal approach and transnasion approach. The sole endonasal approach was used in a patient with a petroclival meningioma. Results In both anatomical dissections, the inferior clivectomy with exposure of the foramen magnum was achieved with a sole endoscopic endonasal approach. The addition of the transnasion approach helped to complete drilling of the inferior border of the foramen magnum and exposure of the arch of C1. Conclusion This study shows the anatomical feasibility of total clivectomy and exposure of the craniovertebral junction with preservation of the nasopharynx. A more favorable anatomical posterior fossa defect for the reconstruction is achieved with this technique. Further clinical studies are needed to assess if this change would impact the postoperative CSF leak rate.

Endoscopic endonasal transpterygoid approaches: Anatomical landmarks for planning the surgical corridor

2013 ◽  
Vol 123 (4) ◽  
pp. 811-815 ◽  
Author(s):  
Pornthep Kasemsiri ◽  
C. Arturo Solares ◽  
Ricardo L. Carrau ◽  
J. Drew Prosser ◽  
Daniel M. Prevedello ◽  
...  
Keyword(s):  
Anatomical Landmarks ◽  
Endoscopic Endonasal ◽  
Surgical Corridor

scholarly journals Fully Endoscopic Minimally Invasive Transrectus Capitis Posterior Muscle Triangle Approach to the Posterolateral Condyle and Jugular Tubercle

2017 ◽  
Vol 78 (05) ◽  
pp. 359-370 ◽  
Author(s):  
Wang Mingdong ◽  
Roger Mathias ◽  
Eric Wang ◽  
Paul Gardner ◽  
Hong Wang ◽  
...  
Keyword(s):  
Minimally Invasive ◽  
Fourth Ventricle ◽  
Jugular Foramen ◽  
Foramen Magnum ◽  
Endoscopic Approach ◽  
Occipital Condyle ◽  
Anatomical Landmarks ◽  
Bone Removal ◽  
Soft Tissue Dissection ◽  
Greater Occipital Nerve

Background We evaluated a transrectus capitis posterior muscle triangle approach to the posterolateral foramen magnum, occipital condyles, jugular tubercle, and the fourth ventricle. We also assessed factors that affect the amount of bone removal required. Objective To evaluate if the proposed approach is as effective as standard open approaches to expose the lateral portion of the foramen magnum. Methods The proposed minimally invasive fully endoscopic approach was performed in 15 cadaveric specimens using 4-mm (0- and 45-degree) endoscopes. Results Using a 5-cm straight paramedian incision, the rectus capitis posterior minor and major muscles were partially removed unilaterally, providing a corridor through the muscles to reach the foramen magnum region. After meticulous soft tissue dissection, key anatomical landmarks can be identified such as the greater occipital nerve, the vertebral artery that wraps around the atlanto-occipital joint, and the bony protuberance that heralds the occipital condyle. A suboccipital craniotomy associated with the transcondylar, supracondylar or paracondylar approach is performed depending on the amount of bone removal desired to maximize the surgical view. By doing so, the jugular foramen can be exposed laterally as well as the fourth ventricle medially. Conclusion The proposed endoscopic approach can provide access through the transrectus capitis posterior muscle triangle leading directly to the occipital condyle. A stepwise approach is critical to gain a surgical corridor to the inferolateral petroclival region and the fourth ventricle.

The Endoscopic Endonasal Approach to the Inferior Clivus and Foramen Magnum: Anatomical Landmarks in the Surgical Window

2015 ◽  
Vol 76 (S 01) ◽  
Author(s):  
Satyan Sreenath ◽  
Benjamin McClintock ◽  
Benjamin Huang ◽  
Kibwei McKinney ◽  
Brian Thorp ◽  
...  
Keyword(s):  
Foramen Magnum ◽  
Anatomical Landmarks ◽  
Endoscopic Endonasal Approach ◽  
Endonasal Approach ◽  
Endoscopic Endonasal

scholarly journals Endoscopic Endonasal Transclival Odontoidectomy for Basilar Invagination: Operative Video and Technical Nuances

2020 ◽  
Author(s):  
James K. Liu ◽  
Vincent N. Dodson ◽  
Kevin Zhao ◽  
Jean Anderson Eloy
Keyword(s):  
Odontoid Process ◽  
Craniovertebral Junction ◽  
Basilar Invagination ◽  
Foramen Magnum ◽  
Endoscopic Endonasal ◽  
Motor Weakness ◽  
Cervicomedullary Junction ◽  
Unsteady Gait ◽  
Cervical Traction ◽  
Motor Strength

AbstractBasilar invagination is a congenital or acquired craniovertebral junction abnormality where the tip of the odontoid process projects through the foramen magnum which can cause severe symptomatic compression of the brainstem and spinal cord. If left untreated, patients can develop progressive quadriparesis. Traditionally, basilar invagination can be treated with cervical traction and posterior stabilization. However, in irreducible cases, anterior decompression via a transoral or endonasal approach may be necessary. In this operative video, we demonstrate an endoscopic endonasal transclival approach for odontoidectomy to successfully treat a 37-year-old female with severe basilar invagination causing symptomatic compression on the cervicomedullary junction resulting in unsteady gait and motor weakness. The patient had Klippel–Feil syndrome where the C1 arch was assimilated to the foramen magnum and transclival drilling was needed to adequately access the odontoid process for removal. A second-stage posterior occipitocervical stabilization and fusion was performed the following day. Immediate postoperative imaging showed excellent decompression of the cervicomedullary junction. Postoperatively, the patient had significant improvement in gait and motor strength in all extremities, and was ambulating independently without assistance at 1 year after surgery. The endoscopic endonasal transclival odontoidectomy is a useful strategy to treat severe irreducible basilar invagination causing symptomatic neural compression. The surgical technique and nuances are described in a step-by-step fashion in this illustrative operative video.The link to the video can be found at: https://youtu.be/HL4K7KqJEJM.

scholarly journals Endoscopic endonasal atlantoaxial transarticular screw fixation technique: an anatomical feasibility and biomechanical study

2015 ◽  
Vol 22 (5) ◽  
pp. 470-477 ◽  
Author(s):  
George A. C. Mendes ◽  
Curtis A. Dickman ◽  
Nestor G. Rodriguez-Martinez ◽  
Samuel Kalb ◽  
Neil R. Crawford ◽  
...  
Keyword(s):  
Odontoid Process ◽  
Axial Rotation ◽  
Biomechanical Study ◽  
Entry Point ◽  
Biomechanical Analysis ◽  
Posterior Fixation ◽  
Anatomical Landmarks ◽  
Endoscopic Endonasal ◽  
Second Stage ◽  
Flexion Extension

OBJECT The primary disadvantage of the posterior cervical approach for atlantoaxial stabilization after odontoidectomy is that it is conducted as a second-stage procedure. The goal of the current study is to assess the surgical feasibility and biomechanical performance of an endoscopic endonasal surgical technique for C1–2 fixation that may eliminate the need for posterior fixation after odontoidectomy. METHODS The first step of the study was to perform endoscopic endonasal anatomical dissections of the craniovertebral junction in 10 silicone-injected fixed cadaveric heads to identify relevant anatomical landmarks. The second step was to perform a quantitative analysis using customized software in 10 reconstructed adult cervical spine CT scans to identify the optimal screw entry point and trajectory. The third step was biomechanical flexibility testing of the construct and comparison with the posterior C1–2 transarticular fixation in 14 human cadaveric specimens. RESULTS Adequate surgical exposure and identification of the key anatomical landmarks, such as C1–2 lateral masses, the C-1 anterior arch, and the odontoid process, were provided by the endonasal endoscopic approach in all specimens. Radiological analysis of anatomical detail suggested that the optimal screw entry point was on the anterior aspect of the C-1 lateral mass near the midpoint, and the screw trajectory was inferiorly and slightly laterally directed. The custommade angled instrumentation was crucial for screw placement. Biomechanical analysis suggested that anterior C1–2 fixation compared favorably to posterior fixation by limiting flexion-extension, axial rotation, and lateral bending (p > 0.3). CONCLUSIONS This is the first study that demonstrates the feasibility of an endoscopic endonasal technique for C1–2 fusion. This novel technique may have clinical utility by eliminating the need for a second-stage posterior fixation operation in certain patients undergoing odontoidectomy.

scholarly journals Deconstruction of the Surgical Approach to the Jugular Foramen Region: Anatomical Study

2018 ◽  
Vol 80 (05) ◽  
pp. 518-526
Author(s):  
Jaafar Basma ◽  
L. Madison Michael ◽  
Jeffrey M. Sorenson ◽  
Jon H. Robertson
Keyword(s):  
Surgical Approach ◽  
Styloid Process ◽  
Jugular Foramen ◽  
Surgical Anatomy ◽  
Cervical Region ◽  
Occipital Condyle ◽  
Digastric Muscle ◽  
Microsurgical Anatomy ◽  
Anatomical Landmarks ◽  
Transcervical Approach

Abstract Introduction The jugular foramen occupies a complex and deep location between the skull base and the distal-lateral-cervical region. We propose a morphometric anatomical model to deconstruct its surgical anatomy and offer various quantifiable target-guided exposures and angles-of-attack. Methods Six cadaveric heads (12 sides) were dissected using a combined postauricular infralabyrinthine and distal transcervical approach with additional anterior transstyloid and posterior far lateral exposures. We identified anatomical landmarks and combined new and previously described contiguous triangles to expose the region; we defined the jugular and deep condylar triangles. Angles-of-attack to the jugular foramen were measured after removing the digastric muscle, styloid process, rectus capitis lateralis, and occipital condyle. Results Removing the digastric muscle and styloid process allowed 86.4° laterally and 85.5° anteriorly, respectively. Resecting the rectus capitis lateralis and jugular process provided the largest angle-of-attack (108.4° posteriorly). The occipital condyle can be drilled in the deep condylar triangle only adding 30.4° medially. A purely lateral approach provided a total of 280.3°. Cutting the jugular ring and mobilizing the vein can further expand the medial exposure. Conclusion The microsurgical anatomy of the jugular foramen can be deconstructed using a morphometric model, permitting a surgical approach customized to the pathology of interest.

Cavernous sinus compartments from the endoscopic endonasal approach: anatomical considerations and surgical relevance to adenoma surgery

2018 ◽  
Vol 129 (2) ◽  
pp. 430-441 ◽  
Author(s):  
Juan C. Fernandez-Miranda ◽  
Nathan T. Zwagerman ◽  
Kumar Abhinav ◽  
Stefan Lieber ◽  
Eric W. Wang ◽  
...  
Keyword(s):  
Cavernous Sinus ◽  
Cranial Nerves ◽  
Spatial Relationship ◽  
Abducens Nerve ◽  
Human Head ◽  
Residual Tumor ◽  
Surgical Anatomy ◽  
Endoscopic Endonasal Approach ◽  
Endonasal Approach ◽  
Endoscopic Endonasal

OBJECTIVETumors with cavernous sinus (CS) invasion represent a neurosurgical challenge. Increasing application of the endoscopic endonasal approach (EEA) requires a thorough understanding of the CS anatomy from an endonasal perspective. In this study, the authors aimed to develop a surgical anatomy–based classification of the CS and establish its utility for preoperative surgical planning and intraoperative guidance in adenoma surgery.METHODSTwenty-five colored silicon–injected human head specimens were used for endonasal and transcranial dissections of the CS. Pre- and postoperative MRI studies of 98 patients with pituitary adenoma with intraoperatively confirmed CS invasion were analyzed.RESULTSFour CS compartments are described based on their spatial relationship with the cavernous ICA: superior, posterior, inferior, and lateral. Each compartment has distinct boundaries and dural and neurovascular relationships: the superior compartment relates to the interclinoidal ligament and oculomotor nerve, the posterior compartment bears the gulfar segment of the abducens nerve and inferior hypophyseal artery, the inferior compartment contains the sympathetic nerve and distal cavernous abducens nerve, and the lateral compartment includes all cavernous cranial nerves and the inferolateral arterial trunk. Twenty-nine patients had a single compartment invaded, and 69 had multiple compartments involved. The most commonly invaded compartment was the superior (79 patients), followed by the posterior (n = 64), inferior (n = 45), and lateral (n = 23) compartments. Residual tumor rates by compartment were 79% in lateral, 17% in posterior, 14% in superior, and 11% in inferior.CONCLUSIONSThe anatomy-based classification presented here complements current imaging-based classifications and may help to identify involved compartments both preoperatively and intraoperatively.

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