Quantification of increased exposure resulting from orbital rim and orbitozygomatic osteotomy via the frontotemporal transsylvian approach

Schwartz, Marc S.; Anderson, Gregory J.; Horgan, Michael A.; Kellogg, Jordi X.; McMenomey, Sean O.; Delashaw, Johnny B.

doi:10.3171/jns.1999.91.6.1020

Cited by 115 publications

(79 citation statements)

References 30 publications

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“…Several authors have advocated mobilizing the zygomatic arch by performing a simple zygomatic osteotomy or using extended frontotemporo-orbitozygomatic approaches to reach low-lying lesions. [1][2][3] Intraoperative neuromonitoring (IOM) is one of the methods in which modern neurosurgery can improve surgical results while reducing morbidity. Motor-evoked potentials (MEPs) obtained by transcranial electrocortical stimulation is routinely used to monitor major motor pathways intraoperatively during several neurosurgical procedures.…”

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confidence: 99%

Transzygomatic Approach with Intraoperative Neuromonitoring for Resection of Middle Cranial Fossa Tumors

et al. 2011

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Access to the floor of the middle cranial fossa (MCF) is often required when performing cranial base approaches to expose various lesions of the petrous apex, petroclival junction, internal auditory canal, and posterior cavernous sinus. In many patients with these lesions, a temporal craniotomy is sufficient to reach the floor of the MCF. However, the caudal limit of a simple temporal craniotomy is the zygomatic arch, which can present an obstacle in accessing the MCF in some individuals. Several authors have advocated mobilizing the zygomatic arch by performing a simple zygomatic osteotomy or using extended frontotemporo-orbitozygomatic approaches to reach low-lying lesions. [1][2][3] Intraoperative neuromonitoring (IOM) is one of the methods in which modern neurosurgery can improve surgical results while reducing morbidity. Motor-evoked potentials (MEPs) obtained by transcranial electrocortical stimulation is routinely used to monitor major motor pathways intraoperatively during several neurosurgical procedures. 4-6 Monitoring of oculomotor, trochlear, trigeminal, and facial nerve function is usually performed using free-running electromyography (EMG) or by direct stimulation of each cranial nerve. 7-9 Keywords ► middle fossa approach ► skull base surgery ► motor-evoked potentials ► intraoperative monitoring ► neurophysiology AbstractThe authors reviewed the surgical experience and operative technique in a series of 11 patients with middle fossa tumors who underwent surgery using the transzygomatic approach and intraoperative neuromonitoring (IOM) at a single institution. This approach was applied to trigeminal schwannomas (n ¼ 3), cavernous angiomas (n ¼ 3), sphenoid wing meningiomas (n ¼ 3), a petroclival meningioma (n ¼ 1), and a hemangiopericytoma (n ¼ 1). An osteotomy of the zygoma, a low-positioned frontotemporal craniotomy, removal of the remaining squamous temporal bone, and extradural drilling of the sphenoid wing made a flat trajectory to the skull base. Total resection was achieved in 9 of 11 patients. Significant motor pathway damage can be avoided using a change in motor-evoked potentials as an early warning sign. Four patients experienced cranial nerve palsies postoperatively, even though free-running electromyography of cranial nerves showed normal responses during the surgical procedure. A simple transzygomatic approach provides a wide surgical corridor for accessing the cavernous sinus, petrous apex, and subtemporal regions. Knowledge of the middle fossa structures is essential for anatomic orientation and avoiding injuries to neurovascular structures, although a neuronavigation system and IOM helps orient neurosurgeons.

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confidence: 99%

Transzygomatic Approach with Intraoperative Neuromonitoring for Resection of Middle Cranial Fossa Tumors

et al. 2011

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“…3,[10][11][12][13][14][15] The quantitative interpretations of these surgical procedures, which intend to ''extend'' the exposure of the standard pterional craniotomy, are much in vogue now. 4,5,13 Schwartz et al 5 used a frameless stereotactic system to measure the area of exposure associated with removal of the orbital roof compared with the zygomatic arch. They sequentially performed a frontotemporal craniotomy (inclusive of removing the entire greater sphenoid wing), then removed the superior and lateral walls of the orbit, followed by resection of the zygomatic arch.…”

Section: Discussionmentioning

confidence: 99%

“…3,4 However, in a study using human cadavers, Schwartz et al have suggested that removal of the lateral orbital rim alone may be sufficient to reach many of these same targets for which the orbitozygomatic craniotomy has been used. 5 But their study did not address the more important ''angle of attack.'' Also, their surgical window, defined as being 10 cm from the anatomic structures, did not represent the actual working space under the microscope.…”

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confidence: 99%

When Is Posterolateral Orbitotomy Useful in a Pterional Craniotomy? A Morphometric Study

et al. 2012

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Adding posterolateral orbitotomy to pterional craniotomy allows greater exposure of the anterolateral skull base. However, there is a paucity of literature quantifying the relative benefit of adding posterolateral orbitotomy for various surgical targets. Our study is a step to address this issue. We performed dissections of five cadaveric heads (10 sides). The anterior communicating artery (A-Com) complex, posterior chiasm (anterior third ventricular region), ipsilateral optic canal, and ipsilateral supraclinoid internal carotid artery (ICA) bifurcation were chosen as targets. A pterional craniotomy was performed and the targets were morphometrically analyzed. Subsequently, posterolateral orbitotomy was done and analysis repeated. The field of view and measurements quantifying the angle of attack were compared. Addition of orbitotomy to pterional craniotomy increased the angle of exposure to ICA bifurcation, anterior third ventricular region, and A-Com complex by average of 15%, 29%, and 50%, respectively. Our study shows the addition of a posterolateral orbitotomy to the pterional craniotomy improves the angle of attack to the anterior third ventricular region and the A-Com complex, thus supporting the use of orbitopterional craniotomy for suprasellar lesions extending into anteroinferior third ventricle and A-Com aneurysms that point superiorly/posteriorly.

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“…The superior viewing angle to the top of the third ventricle is also limited, although it is somewhat improved with an orbitozygomatic approach. 15,25,33 In addition, access to the interpeduncular cistern and infrachiasmatic region through the optico-carotid and carotidoculomotor corridors can be narrow and is sometimes obstructed by perforating arteries.…”

Section: Choice Of Surgical Approachmentioning

confidence: 99%

Surgical nuances for removal of retrochiasmatic craniopharyngiomas via the transbasal subfrontal translamina terminalis approach

Liu¹,

Christiano²,

Gupta³

et al. 2010

FOC

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Giant craniopharyngiomas in the retrochiasmatic space are challenging tumors, given the location and surrounding vital structures. Surgical removal remains the first line of therapy and offers the best chance of cure. For tumors with extension into the retrochiasmatic space, the authors use the translamina terminalis corridor via the transbasal subfrontal approach. Although the lamina terminalis can be accessed via anterolateral approaches (pterional or orbitozygomatic), the surgical view of the optic chiasm is oblique and prevents adequate visualization of the ipsilateral wall of the third ventricle. The transbasal subfrontal approach, on the other hand, offers the major advantage of direct midline orientation and access to the third ventricle through the lamina terminalis. This provides the significant advantage of visualization of both walls of the third ventricle and hypothalamus as well as inferior midline access to the interpeduncular cistern to permit safe neurovascular dissection and total tumor removal. In this report, the authors describe the transbasal subfrontal translamina terminalis approach, with specific emphasis on technical surgical nuances in removing retrochiasmatic craniopharyngiomas. An illustrative video demonstrating the technique is also presented.

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Quantification of increased exposure resulting from orbital rim and orbitozygomatic osteotomy via the frontotemporal transsylvian approach

Cited by 115 publications

References 30 publications

Transzygomatic Approach with Intraoperative Neuromonitoring for Resection of Middle Cranial Fossa Tumors

Transzygomatic Approach with Intraoperative Neuromonitoring for Resection of Middle Cranial Fossa Tumors

When Is Posterolateral Orbitotomy Useful in a Pterional Craniotomy? A Morphometric Study

Surgical nuances for removal of retrochiasmatic craniopharyngiomas via the transbasal subfrontal translamina terminalis approach

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