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Endoscopic endonasal and transorbital routes to the petrous apex: anatomic comparative study of two pathways.
Acta Neurochirurgica ( IF 2.4 ) Pub Date : 2020-06-15 , DOI: 10.1007/s00701-020-04451-1
Thomaz E Topczewski 1 , Alberto Di Somma 1, 2 , Jose Pineda 2 , Abel Ferres 1 , Jorge Torales 1 , Luis Reyes 1 , Ruben Morillas 1 , Domenico Solari 3 , Luigi Maria Cavallo 3 , Paolo Cappabianca 3 , Joaquim Enseñat 1 , Alberto Prats-Galino 2
Affiliation  

BACKGROUND AND OBJECTIVE Surgical approaches to the petrous apex region are extremely challenging; while subtemporal approaches and variations represent the milestone of the surgical modules to reach such deep anatomical target, in a constant effort to develop minimally invasive neurosurgical routes, the endoscopic endonasal approach (EEA) has been tested to get a viable corridor to the petroclival junction. Lately, another ventral endoscopic minimally invasive route, i.e., the superior eyelid endoscopic transorbital approach, has been proposed to access the most lateral aspect of the skull base, including the petrous apex region. Our anatomic study aims to compare and combine such two endoscopic minimally invasive pathways to get full access to the petrous apex. Three-dimensional reconstructions and quantitative and morphometric data have been provided. MATERIAL AND METHODS Five human cadaveric heads (10 sides) were dissected. The lab rehearsals were run as follows: (i) preliminary pre-operative CT scans of each specimen, (ii) pre-dissection planning of the petrous apex removal and its quantification, (iii) petrous apex removal via endoscopic endonasal route, (iv) post-operative CT scans, (v) petrous apex removal via endoscopic transorbital route, and (v) final post-operative CT scan with quantitative analysis. Neuronavigation was used to guide all dissections. RESULTS The two endoscopic minimally invasive pathways allowed a different visualization and perspective of the petrous apex, and its surrounding neurovascular structures. After both corridors were completed, a communication between the surgical pathways was highlighted, in a so-called connection area, surrounded by the following important neurovascular structures: anteriorly, the internal carotid artery and the Gasserian ganglion; laterally, the internal acoustic canal; superiorly, the abducens nerve, the trigeminal root, and the tentorium cerebelli; inferomedially, the remaining clivus and the inferior petrosal sinus; and posteriorly, the exposed area of the brainstem. Used in a combined fashion, such multiportal approach provided a total of 97% of petrous apex removal. In particular, the transorbital route achieved a mean of 48.3% removal in the most superolateral portion of the petrous apex, whereas the endonasal approach provided a mean of 48.7% bone removal in the most inferomedial part. The difference between the two approaches was found to be not statistically significant (p = 0.67). CONCLUSION The multiportal combined endoscopic endonasal and transorbital approach to the petrous apex provides an overall bone removal volume of 97% off the petrous apex. In this paper, we highlighted that it was possible to uncover a common path between these two surgical pathways (endonasal and transorbital) in a so-called connection area. Potential indications of this multiportal approach may be lesions placed in or invading the petrous apex and petroclival regions that can be inadequately reached via transcranial paths or via an endonasal endoscopic route alone.

中文翻译:

内窥镜鼻内和眶上途径至岩顶:两种途径的解剖学比较研究。

背景和目的手术治疗岩顶区域非常困难。虽然颞下入路和变化代表了达到如此深层解剖学目标的外科模块的里程碑,但在不断努力发展微创神经外科手术路径的同时,已对内窥镜鼻内入路(EEA)进行了测试,以找到通往岩斜交界处的可行走廊。近来,已经提出了另一种腹腔内窥镜微创途径,即上眼睑内窥镜经眼眶入路,以进入颅底的最外侧,包括岩顶区域。我们的解剖学研究旨在比较并结合这两种内窥镜微创途径,以完全接触到岩性顶点。提供了三维重建以及定量和形态计量数据。材料与方法解剖了五个人体尸体头部(10个侧面)。实验室排练的操作如下:(i)对每个标本进行术前的CT初步扫描,(ii)解剖岩顶切除术及其量化的解剖前计划,(iii)通过内窥镜鼻腔内窥镜鼻腔切除术切除岩顶,(iv )术后CT扫描,(v)通过内窥镜经眼眶途径去除小尖尖,以及(v)最终的术后CT扫描,并进行定量分析。神经导航用于指导所有解剖。结果两种内窥镜微创通路可对岩尖及其周围神经血管结构进行不同的可视化和透视。两个走廊都建成后,在一个所谓的连接区域中,手术路径之间的通信被突出,周围是以下重要的神经血管结构:前颈,颈内动脉和Gasserian神经节。从侧面看,内部声学通道;上肢外展神经,三叉神经根和小脑腱; 从下至上,剩下的锁骨和下睑窦;后面是脑干的裸露区域。以组合方式使用时,这种多入口方法总共可去除97%的岩尖。尤其是,经眶入路在岩顶的最上外侧部分的平均去除率为48.3%,而鼻内入路在最下颌部分的平均去除率为48.7%。发现这两种方法之间的差异在统计学上不显着(p = 0.67)。结论鼻内窥镜经鼻内和经眶联合入路可有效减少骨根尖的总骨清除量,达到97%。在本文中,我们强调指出,有可能在所谓的连接区域中发现这两个手术路径(鼻内和眶上)之间的共同路径。这种多门入路的潜在征兆可能是放置在或侵犯岩顶和岩斜坡区域的病变,这些病变可能无法通过经颅途径或仅通过鼻内镜途径到达。结论鼻内窥镜经鼻内和经眶联合入路可有效减少骨根尖的总骨清除量达97%。在本文中,我们强调指出,有可能在所谓的连接区域中发现这两个手术路径(鼻内和眶上)之间的共同路径。这种多门入路的潜在迹象可能是放置在或侵犯了岩顶和岩斜坡区域的病变,这些病变可能无法通过经颅途径或仅通过鼻内窥镜途径到达。结论鼻内窥镜经鼻内和经眶联合入路可有效减少骨根尖的总骨清除量,达到97%。在本文中,我们强调指出,有可能在所谓的连接区域中发现这两个手术路径(鼻内和眶上)之间的共同路径。这种多门入路的潜在征兆可能是放置在或侵犯岩顶和岩斜坡区域的病变,这些病变可能无法通过经颅途径或仅通过鼻内镜途径到达。
更新日期:2020-06-15
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