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Endoscopic Extradural Anterior Clinoidectomy Via Supraorbital Keyhole A Cadaveric Study
Endoscopic Extradural Anterior Clinoidectomy Via Supraorbital Keyhole A Cadaveric Study
Endoscopic Extradural Anterior Clinoidectomy Via Supraorbital Keyhole A Cadaveric Study
Fuminari Komatsu, MD, PhD* BACKGROUND: Anterior clinoidectomy is an essential preliminary step for parasellar and
Mika Komatsu, MD* pericavernous sinus surgery. Endoscopy is a widely accepted modality for neurosurgical
Tooru Inoue, MD, PhD* strategies and is becoming more important in treating conditions involving the cranial
base.
Manfred Tschabitscher, MD,
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T
he anterior clinoid process (ACP) is a small central cranial base and its circumferential vital
projection that protrudes from the poster- structures render anterior clinoidectomy delicate.
omedial border of the lesser wing of the Consequently, some modified methods have been
sphenoid bone. Dolenc1 originally described an described to accomplish safer and simpler anterior
anterior clinoidectomy via the extradural space that clinoidectomy.4,7-13
allows optimal mobilization of the optic nerve and The recent extensive use of endoscopy has led to
the internal carotid artery in 1985. This technique the advent of minimally invasive surgery that is now
thus facilitates tumor removal from the parasellar widely accepted as a means of treating lesions of the
and cavernous sinus as well as the appropriate cranial base14-19 because normal structures that are
management of internal carotid aneurysms.2-6 The deeply buried and tend to be obscured can be
dura mater in the extradural space acts as a natural visualized.20,21 Here, we describe a cadaveric study
barrier that protects the brain and neurovascular of endoscopic extradural anterior clinoidectomy.
structures and contributes to decreased morbidity.
In contrast, the deep location of the ACP in the MATERIALS AND METHODS
Endoscopic extradural anterior clinoidectomy was
ABBREVIATION: ACP, anterior clinoid process studied in 8 fresh cadaver heads using rigid endo-
scopes (Karl Storz GmbH, Tuttlingen, Germany),
RESULTS
Skin Incision and Supraorbital Keyhole Craniotomy
A 4- to 5-cm skin incision was started laterally from the
supraorbital notch along the orbital rim within the eyebrow. The
subcutaneous tissue was dissected to expose the occipital frontal
muscle, the orbicularis oculi, and temporal muscle. The frontal FIGURE 1. Extradural exploration and exposure of the periorbita and dupli-
muscle was cut parallel to the orbital rim, and then the fascia of cation of the dura. First step of extradural exploration after right supraorbital
the temporal muscle along the temporal line was incised and craniotomy. A, the sphenoid ridge is shown at posterior end of anterior cranial
laterally reflected. A single frontobasal hole was bored in the base and orbital roof is located at medial part of anterior cranial base. B, small
cranium using a high-speed drill posterior to the temporal line at bony eminence on lesser wing of sphenoid bone at transition between sphenoid
ridge and base of anterior clinoid process. C, optic nerve with falciform ligament
the level of the frontal base. After minimal enlargement of the is visible medially to the base of anterior clinoid process (ACP). D, drilling away
hole and mobilization of the dura, a small bone flap (2.5 3 the sphenoid ridge and unroofing the orbital roof allow visualization of the
1.5 cm) was created using a high-speed drill. The bone flap was periorbita and duplication of dura between periorbita and temporal lobe dura.
removed, leaving the orbital rim, and the inner edge of the bone The ACP and part of optic canal roof are preserved. BE, small bony eminence on
above the orbital rim was flattened using the drill. lesser wing of sphenoid bone; DD, duplication of dura between periorbita and the
temporal lobe dura; FD, frontal lobe dura; OC, roof of the optic canal; ON, optic
Extradural Exploration and Exposure of the Periorbita nerve (with falciform ligament); OR, orbital roof; PO, periorbita; PS, planum
sphenoidale; SR, sphenoid ridge.
and Duplication of the Dura
An endoscope (4 mm; 30 degrees) was introduced into the
extradural space, and the dura was bluntly peeled from the
anterior cranial base using a dissector. The extradural space was the temporal lobe dura was partially exposed. Furthermore, the
expanded, and the extradural space was explored using the orbital roof was unroofed, and the duplication of the dura, which
endoscope under the guidance of a dissector without continuous is a periosteal fold that stretches between the periorbita and
brain retraction. The endoscope was advanced posteriorly until temporal lobe dura, was completely exposed (Figure 1D). The
the sphenoid ridge appeared, and then medially until the orbital course of the optic canal was essentially parallel to the trajectory
roof and the base of the ACP could be identified (Figure 1A, B). from the proximal orifice of the optic canal to the supraorbital
The optic nerve, the falciform ligament, and the roof of the optic keyhole craniotomy (Figure 1C, D).
canal were observed medially to the base of the ACP (Figure 1C). A small bony eminence on the lesser wing of the sphenoid
A small bony eminence was occasionally located at the transition bone was identified in 57.4% (right side, 48.5%; left side,
between the base of the ACP and the sphenoid ridge on the lesser 65.7%) of the 36 dry craniums. The distance between the
wing of the sphenoidal bone (Figure 1B). eminence and the tip of the ACP averaged 18.6 mm (right and
The sphenoid ridge was removed extradurally using a drill with left, 18.1 and 19.0 mm, respectively; Figure 2).
a diamond burr. The extradural space was filled with water while
drilling proceeded under a submerged view. The endoscopic Endoscopic Extradural Anterior Clinoidectomy
sheath was continuously irrigated with water to remove bone dust Anterior clinoidectomy proceeded using an endoscope (4 mm;
and maintain clear visibility. A small eminence located at the 0 degrees) that provided a clear, panoramic view of the ACP and
transition between the base of the ACP and the sphenoid ridge on surrounding structures without using a brain retractor. The
the lesser wing of sphenoid bone was used as a landmark of the extradural space was flooded with water, and the center of the ACP
medial limitation of bone removal on the sphenoid ridge. The was meticulously hollowed out until it became paper thin and
sphenoid ridge was caudally removed until the rostral aspect of transparent, using a 2-mm drill with a diamond burr under
DISCUSSION
without immersion, the endoscopic lens in the extradural space
The anatomy of the ACP with respect to its shape, length, becomes covered with bone dust and requires frequent cleaning.
width, angle, and relationship with surrounding structures has Therefore, we drilled under water with continuous irrigation,
already been described in detail.7,9,22-25 The ACP is located at which obviously maintained clear visibility. In addition to
the medial and deepest end of the lesser wing of the sphenoid relaxation of the frontal lobe in the fresh cadavers, because the
bone and is tightly covered with dural folds. The optic canal is endoscope can advance through deep and narrow corridors,
situated medially, and the superior orbital fissure is situated a brain retractor was not required for this study. However, some
laterally to the ACP. The area removed from the ACP is called the extent of frontal retraction or cerebrospinal fluid drainage would
clinoid space; this segment of the internal carotid artery is called be needed in the clinical setting to create a similar condition.
the clinoid segment, and the floor of this space is the superior wall The first stage of extradural exploration is sometimes difficult
of the cavernous sinus. Thus, the location, dural formation, and to precisely orient because the endoscope displays focal regions at
relationship between the ACP and vital structures render anterior significant magnification. Therefore, the anatomy of the bone at
clinoidectomy delicate.8 the anterior cranial base must be understood in detail. The small
To overcome this, several authors have proposed that dividing the bony eminence located at the transition between the base of the
duplication of the dura stretching between the periorbita and ACP and the sphenoid ridge on the lesser wing can serve as an
temporal fossa dura is key to increased ACP exposure and to ac- anatomic landmark during bone removal steps and would be
complishing anterior clinoidectomy under better visibility.7,8,12,13,26 useful to anticipate the location of the tip of the ACP under
However, we improved visibility using an endoscope because it endoscopic observation. In addition to preoperative anatomic
provides clear, panoramic views of the ACP and its surrounding evaluation of the ACP by 3-dimensional computed tomography,
structures with adequate magnification, and the ACP can be reliably the preoperative evaluation of this eminence would lead to a
removed without incising the duplication of the dura. well-oriented operation.
Endoscopic and conventional extradural anterior clinoidec- We performed endoscopic anterior clinoidectomy via the
tomy differ in some respects. Although bone can be drilled supraorbital keyhole alone. However, this technique would be
applicable to endoscopic extradural anterior clinoidectomy as an 11. Chang HS, Joko M, Song JS, Ito K, Inoue T, Nakagawa H. Ultrasonic bone
curettage for optic canal unroofing and anterior clinoidectomy. Technical note.
adjunct to microscopic surgery with conventional craniotomy,
J Neurosurg. 2006;104(4):621-624.
endoscopic extradural anterior clinoidectomy to assist supraor- 12. Avci E, Bademci G, Ozturk A. Microsurgical landmarks for safe removal of
bital keyhole microsurgery, and endoscopic surgery alone with anterior clinoid process. Minim Invasive Neurosurg. 2005;48(5):268-272.
L7CK25A0OKO2Hi82Fb3Fy/8X5B+N46vwEp4Go7q/yVfHFl3zwAW3JeOmzfokQazpHHa81Z3fIBoHYgoJgi3aMIMXYGp1pVwhQF/Y
endoscopic extradural anterior clinoidectomy via the supraorbital 13. Coscarella E, Baskaya MK, Morcos JJ. An alternative extradural exposure to the
anterior clinoid process: the superior orbital fissure as a surgical corridor.
keyhole. Parasellar meningiomas with optic canal involvement are
Neurosurgery. 2003;53(1):162-166; discussion 166-167.
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favorable candidates for this technique. Endoscopy would also 14. Cappabianca P, Alfieri A, Colao A, Ferone D, Lombardi G, de Divitiis E.
clarify the relationship between such tumors and the optic nerve Endoscopic endonasal transsphenoidal approach: an additional reason in support
after anterior clinoidectomy and optic canal unroofing. of surgery in the management of pituitary lesions. Skull Base Surg. 1999;9(2):
109-117.
Finally, endoscopic extradural anterior clinoidectomy offers 15. Cappabianca P, Cavallo LM, de Divitiis E. Endoscopic endonasal transsphenoidal
reliable removal of the ACP under excellent visualization. surgery. Neurosurgery. 2004;55(4):933-940; discussion 940-931.
However, it should only be performed by experienced endoscopic 16. Cappabianca P, Cavallo LM, Esposito F, De Divitiis O, Messina A, De Divitiis E.
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surgeons who have undergone intensive training by means of Extended endoscopic endonasal approach to the midline skull base: the evolving
role of transsphenoidal surgery. Adv Tech Stand Neurosurg. 2008;33:151-199.
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approach to the clivus and cranio-vertebral junction: anatomical study. Childs Nerv
CONCLUSION Syst. 2007;23(6):665-671.
18. Cavallo LM, de Divitiis O, Aydin S, et al. Extended endoscopic endonasal
transsphenoidal approach to the suprasellar area: anatomic considerations–part 1.
This cadaveric study suggests that endoscopic supraorbital Neurosurgery. 2007;61(3 suppl):24-33; discussion 33-34.
extradural anterior clinoidectomy is feasible with minimal inva- 19. Cavallo LM, Messina A, Cappabianca P, et al. Endoscopic endonasal surgery of the
siveness. This method offers reliable anterior clinoidectomy midline skull base: anatomical study and clinical considerations. Neurosurg Focus.
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The authors have no personal financial or institutional interest in any of 24. Maniscalco JE, Habal MB. Microanatomy of the optic canal. J Neurosurg.
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T he authors present a cadaveric study on the feasibility of anterior
clinoidectomy via an endoscopic approach through a supraorbital
surgical corridor. This is a novel concept that may be a useful adjunct for
4. Yonekawa Y, Ogata N, Imhof HG, et al. Selective extradural anterior clinoi- clinical practice. The performance of such a procedure underwater,
dectomy for supra- and parasellar processes. Technical note. J Neurosurg. although not an original idea, is a clever and important addition to the
1997;87(4):636-642. literature and may decrease the rates of thermal injury to the optic nerve.
5. Yasargil MG, Gasser JC, Hodosh RM, Rankin TV. Carotid-ophthalmic aneur- Although any extradural approach to the anterior clinoid process has the
ysms: direct microsurgical approach. Surg Neurol. 1977;8(3):155-165.
6. Al-Mefty O. Clinoidal meningiomas. J Neurosurg. 1990;73(6):840-849.
drawbacks of localization along a variable and often distorted anterior
7. Noguchi A, Balasingam V, Shiokawa Y, McMenomey SO, Delashaw JB Jr. cranial base anatomy, particularly in the presence of tumors in the area
Extradural anterior clinoidectomy. Technical note. J Neurosurg. 2005;102(5): and limited visualization because of the tight adherence to the dura, the
945-950. endoscopic concept may become a useful adjunct as more surgeons gain
8. Froelich SC, Aziz KM, Levine NB, Theodosopoulos PV, van Loveren HR, Keller familiarity with endoscopes. Further work on the application of such
JT. Refinement of the extradural anterior clinoidectomy: surgical anatomy of the technique in clinical practice would be necessary to fully evaluate the
orbitotemporal periosteal fold. Neurosurgery. 2007;61(5 suppl 2):179-185; merit of this technique.
discussion 185-186.
9. Hayashi N, Masuoka T, Tomita T, Sato H, Ohtani O, Endo S. Surgical anatomy Philip Theodosopoulos
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10. Chang DJ. The ‘‘no-drill’’ technique of anterior clinoidectomy: a cranial base
approach to the paraclinoid and parasellar region. Neurosurgery. 2009;64(3
Suppl):96-105; discussion 105-106. I n this article, the authors describe a technique of endoscopic controlled
extradural clinoidectomy through a supraorbital keyhole approach in
cadavers. The notion that one can accomplish the drilling for this ap- Other techniques for anterior clinoidectomy, such as the one studied
proach under water with endoscopic observation, as the authors state, by the authors (endoscopic), are welcomed. Its clinical applications and
seems difficult to imagine because of the extreme turbulence created by potential benefits, however, need to be further tested in vivo, evaluated,
the drill; however, if it is possible, then the irrigation would have the and then compared with the existing, time-tested technique (extradural
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added benefit of helping to cool the drill, as the authors point out. microsurgical anterior clinoidectomy).
Achieving adequate retraction to leave a space for the endoscope without
Kenan Arnautovic
retraction of the dura in a living patient would likely be more difficult
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