Supraorbital Keyhole Surgery for Optic Nerve Decompression and Dura Repair

Abstract

Supraorbital keyhole surgery is a limited surgical procedure with reduced traumatic manipulation of tissue and entailing little time in the opening and closing of wounds. We utilized the approach to treat head injury patients complicated with optic nerve compression and cerebrospinal fluid leakage (CSF). Eleven cases of basal skull fracture complicated with either optic nerve compression and/or CSF leakage were surgically treated at our department from February 1995 to June 1999. Six cases had primary optic nerve compression, four had CSF leakage and one case involved both injuries. Supraorbital craniotomy was carried out using a keyhole-sized burr hole plus a small craniotomy. The size of craniotomy approximated 2 x 3 cm2. The optic nerve was decompressed via removal of the optic canal roof and anterior clinoid process with high-speed drills. The defect of dura was repaired with two pieces of tensa fascia lata that were attached on both sides of the torn dural defect with tissue glue. Seven cases with optic nerve injury included five cases of total blindness and two cases of light perception before operation. Vision improved in four cases. The CSF leakage was stopped successfully in all four cases without complication. As optic nerve compression and CSF leakage are skull base lesions, the supraorbital keyhole surgery constitutes a suitable approach. The supraorbital keyhole surgery allows for an anterior approach to the skull base. This approach also allows the treatment of both CSF leakage and optic nerve compression. Our results indicate that supraorbital keyhole operation is a safe and effective method for preserving or improving vision and attenuating CSF leakage following injury.

Anatomical aspects in the transsphenoidal–transethmoidal approach to the optic canal: An anatomic–cadaveric study

“…In skull base surgery practice, transcranial (Chen et al, 2004;Schick et al, 2004;Mathiesen and Kihlström, 2006;Yang et al, 2006;Tan et al, 2007) or extracranial (Knox et al, 1990;Goldberg and Steinsapir, 1996;Li et al, 1999aLi et al, , 1999bMaurer et al, 1999;Pletcher and Metson, 2007;Thaker et al, 2009) approaches have been preferred for lesions involving the optic canal. With the less invasive extended transsphenoidaletransethmoidal approach, which reaches the optic canal directly, the performance of biopsies, decompression of the optic nerve and even removing lesions affecting the optic nerve have become possible (Cook et al, 2004;Laws et al, 2005;Kitano et al, 2007;Cappabianca et al, 2008).…”

Traumatic Optic Neuropathy: A Review

“…In cases with CSF leakage, a transcranial approach through a supraorbital keyhole is more appropriate. 76 The optic canal can be decompressed superiorly through the removal of its roof and anterior clinoid process and dural defect repaired with tensor fascia lata grafts anchored using fat or tissue glue.…”

Optic Nerve Decompression through a Supraorbital Approach

“…[6][7][8] Numerous extracranial (transorbital, lateral orbit wall decompression, transcaruncular or transethmoidal medial orbit wall decompression, inferomedial transantral-transethmoidal, transsphenoidal) and intracranial (pterional, fronto-orbital, fronto-orbitozygomatic) approaches have been proposed for the management of ON decompression. 3,[9][10][11] Decompression of 50% of the ON circumference has been reported to result in a favorable outcome. [11][12][13][14] Most of the surgical approaches just cited achieve this along the lateral or medial walls of the OC.…”

“…3,[9][10][11] Decompression of 50% of the ON circumference has been reported to result in a favorable outcome. [11][12][13][14] Most of the surgical approaches just cited achieve this along the lateral or medial walls of the OC. A supraorbital approach would provide 180 degrees, or 50%, exposure of the superolateral and superomedial walls of the OC, and it is an increasingly popular, fast, and minimally invasive surgical alternative.…”

“…A supraorbital approach would provide 180 degrees, or 50%, exposure of the superolateral and superomedial walls of the OC, and it is an increasingly popular, fast, and minimally invasive surgical alternative. 11,15,16 There is currently a lack of data on the intracranial surgical anatomy seen through this approach. 2,8,11,17,18 We propose a stepwise decompression of the ON through a supraorbital minicraniotomy and describe the surgical anatomy of the ON as seen through this operative window.…”