Orbitozygomatic approach

Although pterional craniotomy and its variants are the most used approaches in neurosurgery, few studies have evaluated their precise indications.

da Silva et al., from the Hospital das Clínicas evaluated the pterional (PT), pretemporal (PreT), and orbitozygomatic (OZ) approaches through quantitative measurements of area, linear, and angular exposures of the major intracranial vascular structures.

Eight fresh, adult cadavers were operated with the PT, followed by the PreT, and ending with the OZ approach. The working area, angular exposure of vascular structures and linear exposure of the basilar artery were measured.

The OZ approach presented a wider area (1301.3 ± 215.9 mm2) with an increase of 456.7 mm2 compared with the PT and of 167.4 mm2 to the PreT (P = 0.011). The extension from PT to PreT and OZ increases linear exposure of the basilar artery. When comparing the PreT and OZ, they founded an increase in the horizontal and vertical angle to the bifurcation of the ipsilateral middle cerebral artery (P = 0.005 and P = 0.032, respectively), horizontal angle to the basilar artery tip (P = 0.02), and horizontal angle to the contralateral ICA bifurcation (P = 0.048).

The OZ approach offered notable surgical advantages compared with the traditional PT and PreT regarding to the area of exposure and linear exposure to basilar artery. Regarding angle of attack, the orbital rim and zygomatic arch removal provided quantitatively wider exposure and increased surgical freedom. A detailed anatomic study for each patient and surgeon experience must be considered for individualized surgical approach indication 1).


The orbitozygomatic approach (OZA), along with the pterional approach, is one of the most versatile anterolateral approaches to the skull base. The terms “unilateral transbasal” and “orbitozygomatic infratemporal” are synonyms of the term “orbitozygomatic”. Currently, orbitozygomatic approaches comprise a group of surgical approaches to the skull base that suggest involvement of elements of the orbital walls (superior and lateral) and zygomatic bone into the bone block formed during osteotomy. The OZA, which has integrated several limited basal approaches (pterional, supraorbital, zygomatic), is a combined anterolateral approach that perfectly matches the conceptual principle of skull base surgery ― to minimize brain retraction. Like any other approach to the skull base, the OZA provides a wide view, short distance to the target region, direct approach, and opportunity to work at various angles, with injury to and retraction of critical neurovascular structures being minima 2).


The orbitozygomatic approach provides wide, multidirectional access to the anterior and middle cranial fossae, as well as to the upper third of the posterior fossa and clivus.

The technique eliminates the need for bone reconstruction of the orbital walls to prevent enophthalmos and minimizes the risk of injury to the frontal branch of the facial nerve 3).

The surgical technique of obitozygomatic craniotomy reported by Zabramski, et al. is an excellent procedure, facilitating wide surgical exposure, easy orbital reconstruction, and a satisfactory postsurgical esthetic outcome; however, it is anatomically complicated and technically difficult.

Kodera et al., introduce a simplified technique of Zabramski’s orbitozygomatic craniotomy and present the anatomical and clinical findings with cadaveric photos, illustrations, and a video of surgery.

The orbitozygomatic craniotomy was performed on 20 sides of 11 cadaver heads, in which the cut between the inferior orbital fissure (IOF) and superior orbital fissure (SOF) was modified and simplified, and the shortest distance between them was measured. This technique was applied to 13 clinical cases, and craniotomy-associated esthetic and functional complications were evaluated.

The average of the shortest distance from IOF to SOF was 21.3 mm (range, 19 – 23 mm) on the 20 sides of the 11 cadaver heads. Orbitozygomatic craniotomy could be achieved in a short time while preserving the structure of the orbital wall in all 13 clinical cases. A hollow at the temple was noted in one patient, cerebrospinal fluid leak in two, and transient facial pain in one; however, no other craniotomy-associated esthetic or functional complications including enophthalmos were found in any of the 13 patients.

With this modified technique, Zabramski’s ideal obitozygomatic craniotomy could be achieved easily with only minimal complications while realizing all advantages of the technique 4).


Pellerin et al. and Hakuba, et al. first described the orbitozygomatic approach (OZ) to the anterior and middle cranial fossae as well as to the upper third of the clivus and posterior fossa. Since then, various authors have reported a variety of modifications to enhance the exposure offered by the orbitozygomatic approach.

Increased bone removal from the skull base obviates the need for vigorous brain retraction and offers an improved multiangled trajectory and shallower operative field. Modifications to the orbitozygomatic approach provide alternatives that can be tailored to particular lesions, enabling the surgeon to use the best technique in each individual case rather than a “one size fits all” approach 5).

Modifications

Currently, two classic OZA modifications are used: the one-piece (a bone flap includes the zygomatic process of the frontal bone, frontal process of the zygomatic bone, 1/2 or 1/3 of the zygomatic bone body, temporal process of the zygomatic bone, and zygomatic process of the temporal bone) and the two-piece OZA (an orbitozygomatic bone flap is supplemented by pterional and frontotemporal craniotomy). The two-piece OZA provides a better view of the basal portions of the frontal lobe and reduces the risk of enophthalmos and cosmetic defects 6).

Keyholes

The one-piece orbitozygomatic (OZ) approach is traditionally based on the McCarty keyhole.

Spiriev et al., present the use of the sphenoid ridge keyhole and its possible advantages as a keyhole for the one-piece OZ approach. Using transillumination technique the osteology of the sphenoid ridge was examined on 20 anatomical dry skull specimens. The results were applied to one-piece OZ approaches performed on freshly frozen cadaver heads. We defined the center of the sphenoid ridge keyhole as a superficial projection on the lateral skull surface of the most anterior and thickest part of the sphenoid ridge. It was located 22 mm (standard deviation [SD], 0.22 mm) from the superior temporal line; 10.7 mm (SD, 0.08 mm) posterior and 7.1 mm (SD, 0.22 mm) inferior to the frontozygomatic suture. The sphenoid ridge burr hole provides exposure of frontal, temporal dura as well as periorbita, which is essential for the later bone cuts. There is direct access to removal of the thickest (sphenoidal) part of the orbital roof, after which the paper-thin (frontal) part of the orbital roof is easily fractured. The sphenoid ridge is an easily identifiable landmark on the lateral skull surface, located below the usual placement of the McCarty keyhole, with comparative exposure 7).

Indications

The approach has been widely adopted by skull base centers for the management of neoplastic lesions 8). , but has seen only limited use in vascular surgery 9).

The orbitozygomatic approach (OZA) has been useful in accessing basilar apex aneurysms, especially in cases where it is in a high position, because this approach can facilitate upward and oblique viewing from below through the wide operative space.

However, the OZA needs additional removal of the orbital rim and zygomatic arch, in addition to standard pterional craniotomy, which increases invasiveness, the risk of facial nerve palsy, temporal muscle atrophy, and deformity after surgery, and results in an extended operative time. Appropriate selection of the OZA requires indications that have yet to be established. The trajectory to BX aneurysms in the interpeduncular or prepontine cisterns has been suggested to be related to not only the height of the apex of the basilar artery (BA), but also the height and lateral breadth of the bifurcation of the internal carotid artery (ICA).

Simulation using 3D CTA appears to be important for planning the surgical approach for the treatment of BX aneurysms 10).


Sphenoid wing meningiomas undergoing extensive skull base approach (FTOZ) and gross total resection (GTR) had a low recurrence rate and higher recurrence-free (RFS) survival . Even though FTOZ with GTR is preferable to resect the sphenoid wing meningiomas, the procedure should be tailored to each patient depending on the risks and surgical morbidity 11).

Reconstruction

The reconstruction after the OZ approach is as important as the performance of the surgical technique. Attention to anatomical details and the stepwise reconstruction are a prerequisite to the successful preservation of function and cosmesis 12)

Complications

Oculocardiac reflex OCR occurs in nearly one-third of patients who undergo the OZ approach. However, simple cessation of orbital manipulation is sufficient to normalize the patient’s heart rate. Rarely is medical management required or does there appear to be any significant postoperative ramifications 13).


The mini-pterional and mini-OZ approaches, as currently performed in select patients, provide less tissue traumatization (i.e., less temporal muscle manipulation, less brain parenchyma retraction) from the skin to the aneurysm than standard approaches. Anatomical quantitative analysis showed that the mini-OZ approach provides better exposure to the contralateral side for controlling the contralateral parent arteries and multiple aneurysms. The mini-pterional approach has greater surgical freedom (maneuverability) for ipsilateral circle of Willis aneurysms 14).

Case series

2016

Twenty-seven patients had vascular lesions and twenty-two suffered for intracranial skull base tumors. The vascular lesions varied from cavernous angiomas inside the mesencephalum, high bifurcation basilar tip aneurysms, superior cerebellar arteries aneurysms and arteriovenous malformations in the interpeduncular cistern. Skull base tumors as meningiomas, interpeduncular hamartomas and third ventricle floor gliomas were among the neoplastic lesions approached. We had no permanent injuries and minimal transient complications had occurred.

It is a descriptive text, organized in the sequence of the main stages in which such a craniotomy is performed, describing in details the technique in which this group of evolutionarily authors came to accomplish the task 15).

1998

In 1998, J. Zabramski et al. presented a large study (83 cases) on the use of their own OZA modification, in which the bone block was separated with a minimal bone loss, which enabled full restoration of the facial skeleton contours at the end of surgery.

At a follow-up evaluation after a period averaging 14 months, all patients were pleased with the cosmetic results of this approach 16).

Case reports

nasopharyngeal carcinoma arose in a 52-year-old patient and occupied the right middle skull base extending to the ICA. We first identified and dissected the ICA from the posterolateral part of the tumor using a transcervical approach. Then, the tumor was approached and removed by an orbitozygomatic technique with hemifacial dismasking. The surgical defect was filled using a temporal muscle flap, which was divided into two parts according to the blood supply from either the anterior or the posterior deep temporal artery.

The postoperative course was uneventful and favorable cosmetic results were obtained. The patient has been free of carcinoma for more than 40 months after the surgery.

This new combined approach might be a good option for selected patients with nasopharyngeal tumors 17).


A 52-year-old male with progressive, marked unilateral proptosis due to a multilobulated orbital mass, secondary to biopsy-proven plexiform neurofibroma (PN). Acute worsening of proptosis leading to corneal abrasion, diplopia, and pain required debulking surgery, for which an orbitozygomatic approach was utilized. Genetic testing for NF-1 revealed no mutation. This rare case of NF-negative orbital PN and multidisciplinary treatment considerations for expansile orbital tumors are discussed 18)

1)

da Silva SA, Yamaki VN, Solla DJF, Andrade AF, Teixeira MJ, Spetzler RF, Preul MC, Figueiredo EG. Pterional, Pretemporal, and Orbitozygomatic Approaches: Anatomic and Comparative Study. World Neurosurg. 2019 Jan;121:e398-e403. doi: 10.1016/j.wneu.2018.09.120. Epub 2018 Sep 26. PubMed PMID: 30266695.
2)

Galzio RJ, Tschabitscher M, Ricci A. Orbitozygomatic approach. In: Cappabianca P, Califano L, Iaconetta G. eds. Cranial, craniofacial and skull base surgery. Milano (Italy): Springer-Verlag Italia. 2010;61-86.
3) , 16)

Zabramski JM, Kiriş T, Sankhla SK, Cabiol J, Spetzler RF. Orbitozygomatic craniotomy. Technical note. J Neurosurg. 1998 Aug;89(2):336-41. PubMed PMID: 9688133.
4)

Kodera T, Arishima H, Yamada S, Arai H, Akazawa A, Higashino Y, Kitai R, Iino S, Bertalanffy H, Kikuta KI. Orbitozygomatic craniotomy with modified Zabramski’s technique: A technical note and anatomical and clinical findings. World Neurosurg. 2016 Sep 29. pii: S1878-8750(16)30915-9. doi: 10.1016/j.wneu.2016.09.085. [Epub ahead of print] PubMed PMID: 27693820.
5)

Seçkin H, Avci E, Uluç K, Niemann D, Başkaya MK. The work horse of skull base surgery: orbitozygomatic approach. Technique, modifications, and applications. Neurosurg Focus. 2008;25(6):E4. doi: 10.3171/FOC.2008.25.12.E4. PubMed PMID: 19035702.
6)

Tanriover N., Ulm A.J., Rhoton A.L. Jr., Kawashima M., Yoshioka N., Lewis S.B. One-piece versus two-piece orbitozygomatic craniotomy: quantitative and qualitative considerations. Neurosurgery. 2006;58(ONS 4:Suppl 2):ONS229-237. doi: 10.1227/01.NEU0000210010.46680.B4
7)

Spiriev T, Poulsgaard L, Fugleholm K. One Piece Orbitozygomatic Approach Based on the Sphenoid Ridge Keyhole: Anatomical Study. J Neurol Surg B Skull Base. 2016 Jun;77(3):199-206. doi: 10.1055/s-0035-1564590. PubMed PMID: 27175313; PubMed Central PMCID: PMC4862849.
8)

Dzhindzhikhadze RS, Dreval’ ON, Lazarev VA, Kambiev RL. [Mini-orbitozygomatic craniotomy in surgery for supratentorial aneurysms and tumors of the anterior and middle cranial fossae]. Zh Vopr Neirokhir Im N N Burdenko. 2016;80(4):40-7. Russian. PubMed PMID: 27500773.
9)

Zabramski JM, Kiriş T, Sankhla SK, Cabiol J, Spetzler RF. Orbitozygomatic craniotomy. Technical note. J Neurosurg. 1998 Aug;89(2):336-41. PubMed PMID: 9688133.
10)

Motoyama Y, Hironaka Y, Nishimura F, Gurung P, Sasaki R, Takeshima Y, Matsuda R, Tamura K, Nakagawa I, Park YS, Nakase H. Quantitative analysis of the trajectory of simulated basilar apex aneurysms through the internal carotid artery to assess the need for an orbitozygomatic approach. Acta Neurochir (Wien). 2017 Jan;159(1):85-92. doi: 10.1007/s00701-016-3018-7. PubMed PMID: 27848082; PubMed Central PMCID: PMC5177669.
11)

Bir SC, Maiti T, Konar S, Nanda A. Comparison of the Surgical Outcome of Pterional and Frontotemporal-orbitozygomatic Approaches and Determination of Predictors of Recurrence for Sphenoid Wing Meningiomas. World Neurosurg. 2016 Oct 19. pii: S1878-8750(16)31046-4. doi: 10.1016/j.wneu.2016.10.057. [Epub ahead of print] PubMed PMID: 27771478.
12)

Youssef AS, Willard L, Downes A, Olivera R, Hall K, Agazzi S, van Loveren H. The frontotemporal-orbitozygomatic approach: reconstructive technique and outcome. Acta Neurochir (Wien). 2012 Jul;154(7):1275-83. doi: 10.1007/s00701-012-1370-9. Epub 2012 May 11. PubMed PMID: 22576269.
13)

Neils DM, Singanallur PS, Vasilakis M, Wang H, Tsung AJ, Klopfenstein JD. Incidence and ramifications of the oculocardiac reflex during the orbitozygomatic approach: a prospective assessment. World Neurosurg. 2014 Dec;82(6):e765-9. doi: 10.1016/j.wneu.2013.08.032. Epub 2013 Aug 31. PubMed PMID: 24001795.
14)

Yagmurlu K, Safavi-Abbasi S, Belykh E, Kalani MY, Nakaji P, Rhoton AL Jr, Spetzler RF, Preul MC. Quantitative anatomical analysis and clinical experience with mini-pterional and mini-orbitozygomatic approaches for intracranial aneurysm surgery. J Neurosurg. 2016 Nov 18:1-14. [Epub ahead of print] PubMed PMID: 27858574.
15)

Chaddad Neto F, Doria Netto HL, Campos Filho JM, Reghin Neto M, Silva-Costa MD, Oliveira E. Orbitozygomatic craniotomy in three pieces: tips and tricks. Arq Neuropsiquiatr. 2016 Mar;74(3):228-34. doi: 10.1590/0004-282×20160024. PubMed PMID: 27050853.
17)

Masuda M, Fukushima J, Fujimura A, Uryu H. Combined transcervical and orbitozygomatic approach for the removal of a nasopharyngeal adenocarcinoma. Auris Nasus Larynx. 2015 Jul 9. pii: S0385-8146(15)00164-9. doi: 10.1016/j.anl.2015.06.006. [Epub ahead of print] PubMed PMID: 26165630.
18)

Kovatch KJ, Purkey MT, Martinez-Lage M, Gausas RE, Loevner LA, Grady MS, O’Malley BW Jr, Rassekh CH. Management of an expansile orbital mass: Plexiform neurofibroma decompression by orbitozygomatic approach. Laryngoscope. 2015 May 9. doi: 10.1002/lary.25232. [Epub ahead of print] PubMed PMID: 25960281.

Transoral approach of anteriorly placed meningioma

Anteriorly placed meningiomas at the level of the foramen magnum are rare, are difficult to diagnose, and present technical problems for a conventional posterior fossa removal.

Previously, the transoral approach garnered interest only from a historical point of view, but with technical progress it has acquired a “second life”. Novel surgical techniques allow for a more radical resection of named tumors, as well as lower morbidity and invasiveness of the surgical procedures, which, in the long term, leads to lower complication rates 1).

Miller and Crockard in 1987 described the successful transoral transclival excision of two such tumors. Cerebrospinal fluid fistula can be avoided by dural repair using a fibrin glue and long term CSF diversion. This modification enables the transoral route to be considered for anteriorly placed intradural lesions 2).


Uchibori et al., in 1990 published a 50-year old woman with a giant parapharyngeal meningioma extending from the intracranial.

The parapharyngeal tumor was biopsied using the transoral approach and a histological section diagnosis suggested meningioma. Thereafter, further examination by magnetic resonance images (MRI) and contrast enhanced CT scans revealed a diffuse meningioma en plaque in the posterior fossaInvasion extended from the clival dura to the right sigmoid sinus. The extracranial extension of a meningioma is very rare but a few cases have been reported. In almost all of the reported cases, a large intracranial meningioma was simultaneously or previously verified by CT scans.

This case was special in that the intracranial mass was not voluminous but showed en plaque extension, and also because the pathway of the extracranial extension through the jugular foramen was clearly visualized by CT and MRI. Obliteration and invasion of the right sigmoid sinus and the internal jugular vein by tumor were also demonstrated 3).


Kondoh et al., presented three cases of foramen magnum meningioma. The first involved a ventral type tumor extending to the second cervical body. Following bilateral mandibulotomy, surgery was performed via the anterior transoral approach and the tumor was totally removed. Nine days postoperatively, she developed meningitis, which was successfully treated with antibiotics. The second patient’s tumor was dorsal type and was deeply embedded in the lateral part of the vermis. The tumor was totally removed via the midline suboccipital approach and she recovered uneventfully, with only slight upper-extremity paresthesia. In the third case, the tumor was ventral type and situated mainly in the clivusCraniotomywas performed by the bilateral suboccipital approach and extended nearly to the jugular tubercle. The tumor, which severely displaced the lower cranial and upper cervical nerves, was totally removed. The postoperative course was lengthy and complicated. Artificial ventilation was required for 2 months, and difficulty in swallowing persisted during long-term follow-up. As illustrated by the second case, dorsal and lateral type foramen magnum meningiomas can usually be removed via the lateral suboccipital approach. In the case of ventral type tumors, the anterior transoral approach entails the risk of infection, as occurred in the first case. They conclude that the lateral suboccipital approach is preferable; craniotomy extending to the jugular tubercle lowers the risk of brainstem damage 4).


Bonkowski et al., published a case of meningioma situated at the anterior rim of the foramen magnum with successful removal via a transoral approach is reported. A new technique of preventing cerebrospinal fluid leakage is described utilizing fascia lata and a bone baffle without any attempt to close the dura, either by primary suture or tissue sealants 5).


In 2001 Imamura et al., reported a 66-year-old female complaining of occipitalgia and numbness of the extremities who had a foramen magnum meningioma. She wastreated via the transoral transclival route with a protective bone baffle, obtained from the iliac bone, securely fixed in the bone window to protect the repaired dura from injury by CSF pulse energy. The patient dont showed CSF leakage or meningitis, and the period of continuous lumbar CSF drainage was only 7 days 6).


An et al., presented two clinical cases in which transoral approach was used to treat ventral meningiomas of the craniovertebral junction. Endoscopic assistance and an original method of anterior atlantooccipital stabilization were used.

Subtotal removal in the first case and complete removal of the tumor in the second case were achieved. In the first case, an unsuccessful attempt of anterior stabilization was made. In the second case, there were no indications for instrumentation (anterior or posterior) as local bone autograft fusion between the condyles and lateral masses of C1 was effectively carried out.

Previously, the transoral approach garnered interest only from a historical point of view, but with technical progress it has acquired a “second life”. Novel surgical techniques allow for a more radical resection of named tumors, as well as lower morbidity and invasiveness of the surgical procedures, which, in the long term, leads to lower complication rates 7).

References

1) , 7)

An S, Chernov 4th, Andreev. Transoral Removal of Ventrally Located Meningiomas of the Craniovertebral Junction. World Neurosurg. 2018 Dec 31. pii: S1878-8750(18)32926-7. doi: 10.1016/j.wneu.2018.12.103. [Epub ahead of print] PubMed PMID: 30605758.
2)

Miller E, Crockard HA. Transoral transclival removal of anteriorly placed meningiomas at the foramen magnum. Neurosurgery. 1987 Jun;20(6):966-8. PubMed PMID: 3614579.
3)

Uchibori M, Odake G, Ueda S, Yasuda N, Hisa I. Parapharyngeal meningioma extending from the intracranial space. Neuroradiology. 1990;32(1):53-5. PubMed PMID: 2333135.
4)

Kondoh T, Tamaki N, Taomoto K, Yasuda M, Matsumoto S. Surgical approaches to foramen magnum meningioma–report of three cases. Neurol Med Chir (Tokyo). 1990 Mar;30(3):163-8. PubMed PMID: 1697042.
5)

Bonkowski JA, Gibson RD, Snape L. Foramen magnum meningioma: transoral resection with a bone baffle to prevent CSF leakage. Case report. J Neurosurg. 1990 Mar;72(3):493-6. PubMed PMID: 2303883.
6)

Imamura J, Ikeyama Y, Tsutida E, Moroi J. Transoral transclival approach for intradural lesions using a protective bone baffle to block cerebrospinal fluid pulse energy–two case reports. Neurol Med Chir (Tokyo). 2001 Apr;41(4):222-6. PubMed PMID: 11381684.

Endoscopic endonasal approach to Meckel’s cave

Zoli et al. published all patients with Meckel’s cave tumors treated at Bologna by endoscopic endonasal approach (EEA) between 2002 and 2016. Patients underwent brain MRICT angiography, and neurological evaluation before surgery. Complications were considered based on the surgical records. All examinations were repeated after 3 and 12 months, then annually. The median follow-up was of 44.1 months (range 16-210).

The series included 8 patients (4 F): 5 neuromas, 1 meningioma, 1 chondrosarcoma, and 1 epidermoid cyst. The median age at treatment was 54.5 years (range 21-70). Three tumors presented with a posterior fossa extension. Radical removal of the MC portion of the tumor was achieved in 7 out of 8 cases. Two patients developed a permanent and transitory deficit of the sixth cranial nerve, respectively. No tumor recurrence was observed at follow-up.

In this preliminary series, the EEA appeared an effective and safe approach to MC tumors. The technique could be advantageous to treat tumors located in the antero-medial aspects of MC displacing the trigeminal structures posteriorly and laterally. A favorable index of an adequate working space for this approach is represented by the ICA medialization, while tumor extension to the posterior fossa represents the main limitation to radical removal of this route 1).


The EE transmaxillary transinferior orbital fissure approach was simulated in 10 specimens. The approach included an ethmoidectomy followed by an extended medial maxillectomy with transposition of the nasolacrimal duct. The infraorbital fissure was opened, and the infraorbital neurovascular bundle was transposed inferiorly. A quadrilateral space, bound by the maxillary nerve inferomedially, ophthalmic nerve superomedially, infraorbital nerve inferolaterally, and floor of the orbit superolaterally, was exposed. The distances from the foramen rotundum (FR) to the ICA, orbital apex (OA), and infratemporal crest (ITC) and from the OA to the ICA and ITC were measured.

The distances obtained were FR-ICA = 19.42 ± 2.03 mm, FR-ITC = 18.76 ± 1.75 mm, FR-OA = 8.54 ± 1.34 mm, OA-ITC = 19.78 ± 2.63 mm, and OA-ICA = 20.64 ± 142 mm. Two imaginary lines defining safety boundaries were observed between the paraclival ICA and OA, and between the OA and ITC (safety lines 1 and 2).

The reported approach provides a less invasive route compared to contemporary approaches, allowing expanded views and manipulation anteromedial and anterolateral to MC. It may be safer than the existing approaches as it does not require transposition of the ICA, infratemporal fossa, and pterygopalatine fossa, and allows access to tumors located anteriorly on the floor of the middle cranial fossa 2).


Many benign and malignant tumors as well as other inflammatory or vascular diseases may be located in the areas of Meckel’s cave or the cavernous sinus. Except for typical features such as for meningiomas, imaging may not by itself be sufficient to choose the best therapeutic option. Thus, even though modern therapy (chemotherapy, radiotherapy, or radiosurgery) dramatically reduces the field of surgery in this challenging location, there is still some place for surgical biopsy or tumor removal in selected cases. Until recently, the microscopic subtemporal extradural approach with or without orbitozygomatic removal was classically used to approach Meckel’s cave but with a non-negligible morbidity. Percutaneous biopsy using the Hartel technique has been developed for biopsy of such tumors but may fail in the case of firm tumors, and additionally it is not appropriate for anterior parasellar tumors. With the development of endoscopy, the endonasal route now represents an interesting alternative approach to Meckel’s cave as well as the cavernous sinus.

Jouanneau et al. from the Pierre Wertheimer Hospital, described the modus operandi and discuss what should be the appropriate indication of the use of the endonasal endoscopic approach for Meckel’s cave disease in the armamentarium of the skull base surgeon 3).


Van Rompaey et al performed an endoscopic endonasal approach as well as a lateral approach to the Meckel cave on six anatomic specimens. To access the Meckel cave endoscopically, a complete sphenoethmoidectomy and maxillary antrostomy followed by a transpterygoid approach was performed. For lateral access, a pterional craniotomy with extradural dissection was performed.

The endoscopic endonasal approach allowed adequate access to the Gasserian ganglion. All the relevant anatomy was identified without difficulty. Both approaches allowed for a similar exposure, but the endonasal approach avoided brain retraction and improved anteromedial exposure of the Gasserian ganglion. The lateral approach provided improved access posterolaterally and to the superior portion.

The endoscopic endonasal approach to the Meckel cave is anatomically feasible. The morbidity associated with brain retraction from the open approaches can be avoided. Further understanding of the endoscopic anatomy within this region can facilitate continued advancement in endoscopic endonasal surgery and improvement in the safety and efficacy of these procedures 4).

The opening of Meckel’s Cave may be particularly useful for lesions located in the cerebellopontine angle having a minor component that extends anteriorly and laterally in the middle cranial fossa 5).1) Zoli M, Ratti S, Guaraldi F, Milanese L, Pasquini E, Frank G, Billi AM, Manzoli L, Cocco L, Mazzatenta D. Endoscopic endonasal approach to primitive Meckel’s cave tumors: a clinical series. Acta Neurochir (Wien). 2018 Dec;160(12):2349-2361. doi: 10.1007/s00701-018-3708-4. Epub 2018 Oct 31. PubMed PMID: 30382359.2) Zhang X, Tabani H, El-Sayed I, Russell M, Feng X, Benet A. The Endoscopic Endonasal Transmaxillary Approach to Meckel’s Cave Through the Inferior Orbital Fissure. Oper Neurosurg (Hagerstown). 2017 Jun 1;13(3):367-373. doi: 10.1093/ons/opx009. PubMed PMID: 28521351.3) Jouanneau E, Simon E, Jacquesson T, Sindou M, Tringali S, Messerer M, Berhouma M. The endoscopic endonasal approach to the Meckel’s cave tumors: surgical technique and indications. World Neurosurg. 2014 Dec;82(6 Suppl):S155-61. doi: 10.1016/j.wneu.2014.08.003. Epub 2014 Aug 12. Review. PubMed PMID: 25107326.4) Van Rompaey J, Bush C, Khabbaz E, Vender J, Panizza B, Solares CA. What is the Best Route to the Meckel Cave? Anatomical Comparison between the Endoscopic Endonasal Approach and a Lateral Approach. J Neurol Surg B Skull Base. 2013 Dec;74(6):331-6. doi: 10.1055/s-0033-1342989. Epub 2013 Apr 5. PubMed PMID: 24436933.5) Acerbi F, Broggi M, Gaini SM, Tschabitscher M. Microsurgical endoscopic-assisted retrosigmoid intradural suprameatal approach: anatomical considerations. J Neurosurg Sci. 2010 Jun;54(2):55-63. PubMed PMID: 21313956.

Update: Translaminar approach

Translaminar approach

In 1998, Di Lorenzo et al. proposed a less invasive direct procedure by utilizing a translaminar approach (TLA) through a fenestration of the pars interarticularis, thus circumventing facetectomy or hemilaminectomy in many cases. The increasing availability of high-definition imaging modalities (MRI, CT) has contributed to the growing popularity of the TLA, since identifying the exact location and extent of the spinal lesion is crucial for surgical planning to limit unnecessary biomechanical damage and prevent intraoperative conversion to conventional approaches.

Several studies have demonstrated the feasibility, safety and efficacy of this technique to successfully treat disc herniations affecting the foraminal and preforaminal regions 1).


The translaminar approach is the only “tissue-sparing” technique viable in cases of cranially migrated lumbar disc herniation encroaching on the exiting nerve root in the preforaminal zones, for the levels above L2-L3, and in the preforaminal and foraminal zones, for the levels below L3-L4 (L5-S1 included, if a total microdiscectomy is unnecessary). This approach is more effective than the standard one, because it resolves the symptoms; it is associated with less postoperative pain and faster recovery times without the risk of iatrogenic instability, and it can also be used in cases with previous signs of radiographic instability. The possibility to spare the flavum ligament is one of the main advantages of this technique. For these reasons, the translaminar approach is a valid technique in terms of safety and efficacy. Vanni et al., extensively analyzed and highlighted the tips and tricks 2).

Case series

2018

A consecutive series of 32 patients were divided, pre- and post-operatively, into 5 classes based on Oswestry Disability Index (ODI). Class 1: ODI 0-20% (minimal disability); class 2: 20-40 % (moderate disability); calss 3: 40-60% (severe disability); 60-80% (crippled); 80-100% (bed bound or exaggerating symptoms).

In terms of ODI, 4 (12.5%) patients upgraded of 1 class after the operation; 6 (18.7%) patients of 2 classes, 8 (25%) patients of 3 classes, 11 (34.4%) patients of 4 classes. Three (9.4%) patients did not modify their ODI score after the operation. After surgery, 7(21.9%) patients developed a mild low back pain. Mean follow-up was 25 months.

When performed by dedicated spinal neurosurgeons, the translaminar approach confirmed to be safe and effective in long-term follow-up. Moreover, the majority of patients showed an improvement of their ODI. Major pitfalls were related with surgical selection and the narrow working space 3).

2008

Between May 2000 and July 2004, 104 patients (59 men)-presenting with upper lumbar root compression in 74% of the cases -underwent a translaminar approach. The mean age was 57 years (range, 27-80 yr). The lamina was approached either through the conventional subperiosteal route or via a muscle splitting access. Mostly intraforaminal disc fragments were removed through a translaminar hole 10 mm in diameter, and the disc space was cleared in cases of evident perforation of the annulus. Follow-up examinations were performed by an independent observer at 1 and 6 weeks; 3, 6, and 12 months; and once yearly thereafter (mean follow-up period, 32 mo).

Extruded (61%) or subligamentous (39%) disc fragments were found intra-operatively. Laminae L4 (44%) and L5 (26%) were mostly involved. In eight cases, the translaminar hole was enlarged to a conventional laminotomy. In 13 patients, the disc space was cleared. The outcomes according to the Macnab criteria were excellent (67%), good (27%), fair (5%), and poor (1%). The incidence of recurrent disc herniations was 7%. Functional radiography performed in the first 20 patients 6 months after surgery and an additional 12 patients complaining of postsurgical back pain excluded any instability.

The translaminar approach is recommended in disc herniations encroaching the exiting root, as an alternative to the conventional interlaminar route4).

2007

Fifteen patients with far cranio-laterally extruded disc herniations underwent neurosurgical intervention using a translaminar approach. The paraspinal muscles were spread with a dilatator after performing a 1.5 cm skin incision. A 16 mm METRx tubular retractor system (Medtronic Sofamor Danek, Memphis, TN) was directly placed on the upper lamina. The next steps were performed through this channel using the surgical microscope. A small ovoid fenestration (10×5 mm) was performed using a high speed drill and the disc prolapse was removed in a standard manner. Follow-ups were routinely carried out 3 weeks postoperatively and reassessment was subsequently carried out by telephone inquiry 10 to 44 months (median 23 months) after treatment. These results were rated according to the modified MacNab criteria.

Five of the fifteen affected discs were at the level L3/4, eight at L4/5 and two at L5/S1. The average surgical time was 55 minutes. No complications occurred. In all patients sciatic pain disappeared immediately after the operation. One patient underwent fusion of the affected level one year later because of progression of a pre-existent pseudospondylolisthesis. Long-term follow-up demonstrated excellent results in six, good results in seven, a fair result in one and a poor result in one patient according to the modified MacNab criteria.

The translaminar approach in conjunction with a tubular retractor system seems to be an effective and safe alternative technique for treating the small entity of far cranio- laterally or foraminally extruded lumbar disc herniations. It combines the advantages of a blunt muscle-spreading approach that produces little damage to the soft tissues, and the avoidance of large bone removal that may jeopardize vertebral stability. Since this approach does not permit sufficient exploration of the intervertebral disc space of origin, it should be limited to patients without significant bulging of the disc itself 5).


Twenty-four patients with preforaminal and foraminal disc herniation underwent surgical treatment via a translaminar microsurgical approach. Excellent results were obtained in all patients in terms of pain relief, and all had improvement in motor strength except for 1 patient. No spinal instability was seen at the latest follow-up.

A classic interlaminar interspace approach combined with a very limited translaminar fenestration seem to be an acceptable surgical method for accessing a preforaminal disc herniation, and this technique has proven to be safe and did not cause any instability at the latest follow-up 6).

2002

30 patients using the translaminar fenestration were analysed by a postoperative follow-up of 6 weeks and one year. The mean-age was 57.2 years. For resection of the disc herniation, a small round or oval fenestration (6-8 mm) in the hemilamina, craniomedially to the facet joint, was performed. No patient received a partial or total facetectomy.

RESULTS: The majority of affected discs were at the L4-L5 level (53%). An extruded fragment was found in 28 patients (93%). In 5 patients bleeding from epidural veins complicated the intra-operative course. In 50% the nerve root was visually exposed. 15 patients (50%) had an intervertebral discectomy additional to the fragment excision. One patient was re-operated on after 10 days because of persisting radicular pain by using the same translaminar approach. 28 patients showed complete or nearly complete relief of radicular pain. Using this approach we have seen no major complication or clinical instability during a follow-up of at least one year.

CONCLUSIONS: The translaminar approach is an effective and minimally invasive technique in both canalicular and cranio-dorsolateral disc herniations. It gives an additional possibility to avoid partial removal of the facet joints, can be performed in all lumbar segments and preserves structures important for segmental spinal stability. The approach allows access to the extruded disc fragment and intervertebral disc space comparable to classical approaches and is a frequently used operative technique in our department 7).

1)

Di Lorenzo N, Porta F, Onnis G, Cannas A, Arbau G, Maleci A. Pars interarticularis fenestration in the treatment of foraminal lumbar disc herniation: a further surgical approach. Neurosurgery. 1998 Jan;42(1):87-9; discussion 89-90. PubMed PMID: 9442508.

2)

Vanni D, Galzio R, Kazakova A, Guelfi M, Pantalone A, Salini V, Magliani V. Technical note: microdiscectomy and translaminar approach. J Spine Surg. 2015 Dec;1(1):44-9. doi: 10.3978/j.issn.2414-469X.2015.10.03. Review. PubMed PMID: 27683678; PubMed Central PMCID: PMC5039873.

3)

Cossandi C, Fanti A, Gerosa A, Bianco A, Fornaro R, Crobeddu E, Forgnone S, Panzarasa G, Di Cristofori A. Translaminar approach for treatment of hidden zone foraminal lumbar disc herniations: considerations on the surgical technique and pre-operative selection of patients with a long term follow-up. World Neurosurg. 2018 May 18. pii: S1878-8750(18)31025-8. doi: 10.1016/j.wneu.2018.05.072. [Epub ahead of print] PubMed PMID: 29783010.

4)

Papavero L, Langer N, Fritzsche E, Emami P, Westphal M, Kothe R. The translaminar approach to lumbar disc herniations impinging the exiting root. Neurosurgery. 2008 Mar;62(3 Suppl 1):173-7; discussion 177-8. doi: 10.1227/01.neu.0000317389.83808.16. PubMed PMID: 18424983.

5)

Vogelsang JP. The translaminar approach in combination with a tubular retractor system for the treatment of far cranio-laterally and foraminally extruded lumbar disc herniations. Zentralbl Neurochir. 2007 Feb;68(1):24-8. PubMed PMID: 17487805.

6)

Bernucci C, Giovanelli M. Translaminar microsurgical approach for lumbar herniated nucleus pulposus (HNP) in the “hidden zone”: clinical and radiologic results in a series of 24 patients. Spine (Phila Pa 1976). 2007 Jan 15;32(2):281-4. PubMed PMID: 17224827.

7)

Soldner F, Hoelper BM, Wallenfang T, Behr R. The translaminar approach to canalicular and cranio-dorsolateral lumbar disc herniations. Acta Neurochir (Wien). 2002 Apr;144(4):315-20. PubMed PMID: 12021876.

Update: Midline suboccipital subtonsillar approach

Marcos Tatagiba et al. described the surgical anatomy of the midline suboccipital subtonsillar approach to the hypoglossal canal. This approach includes a midline suboccipital craniotomy, dorsal opening of the foramen magnum and elevation of ipsilateral cerebellar tonsil to expose the hypoglossal nerve and its canal. The midline subtonsillar approach permits a straight primary intradural view to the hypoglossal canal. There is no necessity of condylar resections 1) 2).

It offers excellent access with a panoramic view of the cerebellomedullary cistern and its structures and therefore can be useful for a number of different pathologies in the lower petroclival region 3).


A study was performed on three alcohol (ETOH)-fixed specimens (6 sides), and the technique of the approach was highlighted. The tonsillar retraction needed to view the important structures was measured. Additionally, the records of 31 patients who underwent the STA procedure were evaluated and provide three clinical cases as examples.
Tonsillar retraction of 0.3cm (SD±0.1cm) exposed the PICA with its telo-velo-tonsillar and cortical branches. Retraction of 0.4cm (SD±0.2cm) exposed the spinal root of CN XI. Retraction of 0.9cm (SD±0.01cm) exposed the hypoglossal canal. Retraction of 1.3cm (SD±0.2cm) exposed the root exit zone of the glossopharyngeal nerve. Retraction of 1.6cm (SD±0.3cm) exposed the jugular foramen (JF), and retraction of 2.4cm (SD±0.2cm) exposed the inner auditory canal (IAC). In all of the selected cases, the pathology could be reached and exposed using the STA.
They recommend STA as a straightforward, easy-to-learn and therefore time-saving and safe procedure compared with other standard approaches to the cerebellomedullary cistern and its pathologies 4).

Indications

Glossopharyngeal neuralgia5).
Anterior, anterolateral, and posterior Foramen magnum meningioma6).
There was no significant postoperative complication in the remainder of the patientes, and their conditions improved after surgery 7).
Hypoglossal canal meningioma.

Case reports

2015

Two patients with exophytic or focal lesions in the inferior half of the medulla, who underwent surgery by suboccipital midline subtonsillar approach. This approach was not specifically described to reach MO before, and they found that the lesions produced a mild elevation of the tonsils providing a wide surgical view from the medulla to the foramen of Luchska laterally, and up to the middle cerebellar peduncle, offering a wide and safe access 8).

2010

A 36-year-old woman presented with increased intracranial pressure and cerebellar signs without hypoglossal nerve palsy. Magnetic resonance imaging showed a predominantly cystic mass with a fluid-fluid level in the foramen magnum region extending into the hypoglossal canal. The intracranial tumor was largely removed via a midline suboccipital subtonsillar approach, leaving only a tiny residue in the hypoglossal canal. Histology confirmed a schwannoma with relative hypervascularity. Twenty months later, the tumor recurred and presented as a multicystic dumbbell-shaped lesion, extending intra- and extracranially through the enlarged hypoglossal canal. A complete resection of the intracranial and intracanalicular parts of the tumor was achieved with a small extracranial remnant treated by radiosurgery. Histology revealed a focal increased K(i)67 proliferative index. In this report, we discuss the possible reasons for the absence of hypoglossal nerve palsy and the potential mechanism of the formation of the fluid-fluid level, and we consider the treatment of this lesion 9).
1)

Tatagiba M, Koerbel A, Roser F. The midline suboccipital subtonsillar approach to the hypoglossal canal: surgical anatomy and clinical application. Acta Neurochir (Wien). 2006 Sep;148(9):965-9. Epub 2006 Jul 5. Review. PubMed PMID: 16817032.
2)

Herlan S, Roser F, Ebner FH, Tatagiba M. The midline suboccipital subtonsillar approach to the cerebellomedullary cistern: how I do it. Acta Neurochir (Wien). 2017 Jul 22. doi: 10.1007/s00701-017-3270-5. [Epub ahead of print] PubMed PMID: 28735380.
3) , 4)

Herlan S, Ebner FH, Nitz A, Hirt B, Tatagiba M, Roser F. The midline suboccipital subtonsillar approach to the cerebellomedullary cistern and its structures: anatomical considerations, surgical technique and clinical application. Clin Neurol Neurosurg. 2014 Oct;125:98-105. doi: 10.1016/j.clineuro.2014.07.029. Epub 2014 Jul 27. PubMed PMID: 25113380.
5)

Roser F, Ebner FH, Schuhmann MU, Tatagiba M. Glossopharyngeal neuralgia treated with an endoscopic assisted midline suboccipital subtonsillar approach: technical note. J Neurol Surg A Cent Eur Neurosurg. 2013 Sep;74(5):318-20. doi: 10.1055/s-0032-1327447. Epub 2012 Oct 5. PubMed PMID: 23042141.
6)

Dogan M, Dogan DG. Foramen magnum meningioma: The midline suboccipital subtonsillar approach. Clin Neurol Neurosurg. 2016 Aug;147:116. doi: 10.1016/j.clineuro.2016.05.025. Epub 2016 Jun 6. PubMed PMID: 27321572.
7)

Dobrowolski S, Ebner F, Lepski G, Tatagiba M. Foramen magnum meningioma: The midline suboccipital subtonsillar approach. Clin Neurol Neurosurg. 2016 Jun;145:28-34. doi: 10.1016/j.clineuro.2016.02.027. Epub 2016 Apr 2. PubMed PMID: 27064859.
8)

Rabadán AT, Campero A, Hernández D. Surgical Application of the Suboccipital Subtonsillar Approach to Reach the Inferior Half of Medulla Oblongata Tumors in Adult Patients. Front Surg. 2016 Jan 13;2:72. doi: 10.3389/fsurg.2015.00072. eCollection 2015. PubMed PMID: 26793713; PubMed Central PMCID: PMC4710703.
9)

Li WC, Hong XY, Wang LP, Ge PF, Fu SL, Luo YN. Large cystic hypoglossal schwannoma with fluid-fluid level: a case report. Skull Base. 2010 May;20(3):193-7. doi: 10.1055/s-0029-1246219. PubMed PMID: 21318038; PubMed Central PMCID: PMC3037104.

Update: Subtemporal approach

It is one of the surgical routes used to reach the interpeduncular fossa, offers a good access to the medial temporal region.

The subtemporal approach avoids neocortical transgression and injury to the optic radiations. 1) 2)

Indications
The subtemporal approach is historically known as the standard approach for the treatment of tumoral, vascular and inflammatory lesions of the middle cranial fossa, the tentorium, the anterior and middle tentorial incisura, the upper-third of the clivus and the petroclival region. This approach had been recognized universally for many years as the best way to treat basilar artery (BA) apex, P1 and P2 posterior cerebral artery (PCA) and superior cerebellar artery aneurysms until the introduction of the pterional approach in 1976 by Yasargil et al. 3).

Drawbacks

Access to the posteromedial temporal region needs the retraction of the temporal lobe 4) , with a risk of vein of Labbé sacrifice.
Because of the inclination of the tentorium, temporal lobe retraction increases with a more posterior location of the lesion 5).
A more posterior-oriented supratentorial-infra- occipital variation of the subtemporal approach has been described, which is performed to effectively approach and resect epileptogenic lesions in PMT regions 6) 7).
Keyhole subtemporal approaches and zygomatic arch osteotomy have been proposed in an effort to decrease the amount of temporal lobe retraction.
A keyhole and a classic subtemporal craniotomy were executed in 4 fresh-frozen silicone-injected cadaver heads. The target was defined as the area bordered by the superior cerebellar artery, the anterior clinoid process, supraclinoid internal carotid artery, and the posterior cerebral artery. Once the target was fully visualized, Ercan et al. evaluated the amount of temporal lobe retraction by measuring the distance between the base of the middle fossa and the temporal lobe. In addition, the volume of the surgical and anatomical corridors was assessed as well as the surgical maneuverability using navigation and 3D moldings. The same evaluation was conducted after a zygomatic osteotomy was added to the two approaches.
Temporal lobe retraction was the same in the two approaches evaluated while the surgical corridor and the maneuverability were all greater in the classic subtemporal approach.
The zygomatic arch osteotomy facilitates the maneuverability and the surgical volume in both approaches, but the temporal lobe retraction benefit is confined to the lateral part of the middle fossa skull base and does not result in the retraction necessary to expose the selected target 8).


With the help of an endoscope, Sun et al exposed the internal auditory canal and cerebellopontine through a translabyrinthine approach and the inferior colliculus through a keyhole subtemporal approach. This double approach can be combined to expose the internal auditory canal and cerebellopontine angle and inferior colliculus satisfactorily in the same surgical setting. This combined approach can avoid retraction of the cerebellum and reduce serious adverse events and complications 9).
As a minimally invasive approach, this can be considered an effective method for removal of vestibular schwannoma and auditory midbrain implantation in the same surgical setting, while avoiding retraction of the cerebellum and serious adverse events and complications.
see Subtemporal medial transpetrous approach.
see Subtemporal transtentorial approach.

Subtemporal Approach for AICA Aneurysm Clipping


The subtemporal approach represents a feasible approach for retrochiasmatic craniopharyngiomas when gross total resection is not mandatory. It provides rapid access to the tumor and a caudal-to-cranial visualization that promotes minimal manipulation of critical neurovascular structures, particularly the optic apparatus 10).

Subtemporal approach for distal basilar occlusion for giant aneurysm

1) , 7)

Smith KA, Spetzler RF: Supratentorial-infraoccipital approach for posteromedial temporal lobe lesions. J Neurosurg 82:940–944, 1995
2)

Tubbs RS, Oakes WJ: Relationships of the cisternal segment of the trochlear nerve. J Neurosurg 89:1015–1019, 1998
3)

Yasargil MG, Antic J, Laciga R, Jain KK, Hodosh RM, Smith RD. Microsurgical pterional approach to aneurysms of the basilar bifurcation. Surg Neurol. 1976 Aug;6(2):83-91. PubMed PMID: 951657.
4)

Olivier A: Temporal resections in the surgical treatment of epilepsy. Epilepsy Res Suppl 5:175–188, 1992
5)

Campero A, Tróccoli G, Martins C, Fernandez-Miranda JC, Yasuda A, Rhoton AL Jr: Microsurgical approaches to the medial temporal region: an anatomical study. Neurosurgery 59 (4 Suppl 2):ONS279–ONS308, 2006
6)

Russell SM, Kelly PJ: Volumetric stereotaxy and the supra- tentorial occipitosubtemporal approach in the resection of posterior hippocampus and parahippocampal gyrus lesions. Neurosurgery 50:978–988, 2002
8)

Ercan S, Scerrati A, Wu P, Zhang J, Ammirati M. Is less always better? Keyhole and standard subtemporal approaches: evaluation of temporal lobe retraction and surgical volume with and without zygomatic osteotomy in a cadaveric model. J Neurosurg. 2017 Jul;127(1):157-164. doi: 10.3171/2016.6.JNS16663. Epub 2016 Sep 16. PubMed PMID: 27636184.
9)

Sun JQ, Han DM, Li YX, Gong SS, Zan HR, Wang T. Combined endoscope-assisted translabyrinthine subtemporal keyhole approach for vestibular Schwannoma and auditory midbrain implantation: Cadaveric study. Acta Otolaryngol. 2010 Oct;130(10):1125-9. doi: 10.3109/00016481003699674. PubMed PMID: 20367538.
10)

Wong RH, De Los Reyes K, Alikhani P, Sivaknathan S, van Gompel J, van Loveren H, Agazzi S. The Subtemporal Approach to Retroinfundibular Craniopharyngiomas: A New Look at an Old Approach. Neurosurgery. 2015 Aug 18. [Epub ahead of print] PubMed PMID: 26287553.

New Book: Surgery of the Spine and Spinal Cord: A Neurosurgical Approach

Surgery of the Spine and Spinal Cord: A Neurosurgical Approach

Surgery of the Spine and Spinal Cord: A Neurosurgical Approach
Price: $199.00
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This book offers essential guidance on selecting the most appropriate surgical management option for a variety of spinal conditions, including idiopathic problems, and degenerative disease. While the first part of the book discusses the neuroanatomy and biomechanics of the spine, pain mechanisms, and imaging techniques, the second guides the reader through the diagnostic process and treatment selection for disorders of the different regions of the spine, based on the principles of evidence-based medicine. I.e., it clearly explains why a particular technique should be selected for a specific patient on the basis of the available evidence, which is carefully reviewed. The book identifies potential complications and highlights technical pearls, describing newer surgical techniques and illustrating them with the help of images and accompanying videos. Though primarily intended for neurosurgeons, the book will also be of interest to orthopaedic surgeons, specialists in physical medicine, and pain specialists.


Product Details

  • Published on: 2016-08-16
  • Original language: English
  • Number of items: 1
  • Dimensions: 10.28″ h x 1.50″ w x 7.17″ l, .0 pounds
  • Binding: Hardcover
  • 752 pages

About the Author

Dr Erik van de Kelft graduated magna cum laude as a Doctor in Medicine, Surgery, and Obstetrics from the University of Antwerp, Belgium, in 1985. After 2 years of training in general surgery at the General Hospital Stuivenberg, he specialized in neurosurgery under the supervision of Drs. J.J. Martin and P. Selosse at the University Hospital, Antwerp (UZA). His training included periods in Montpellier, France and La Timone Hospital in Marseille, where he focused on pediatric neurosurgery. After successfully completing his training in 1993, Dr. van de Kelft became a permanent staff member in the Neurosurgery Department at the UZA and also a consultant at the Maria Middelares General Hospital in Sint-Niklaas. During this period, he earned a Doctorate in Biomedical Sciences, writing his doctoral thesis on the molecular genetics of malignant brain tumours. Since 1999 he has been a permanent member of the Neurosurgery Department of the Niklaas Hospital, Sint Niklaas, and the OLV (Our Lady) Hospital in Aalst; he is also a neurosurgery consultant at St. Jozef Hospital, Bornem. Dr. van de Kelft is especially known for his expertise in back surgery and in the surgical treatment of facial pain. He is the author of 50 articles in peer-reviewed journals and a regular speaker at international conferences.

Book: Image-Guided Hypofractionated Stereotactic Radiosurgery: A Practical Approach to Guide Treatment of Brain and Spine Tumors

Image-Guided Hypofractionated Stereotactic Radiosurgery: A Practical Approach to Guide Treatment of Brain and Spine Tumors

Image-Guided Hypofractionated Stereotactic Radiosurgery: A Practical Approach to Guide Treatment of Brain and Spine Tumors

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The recent development of hypofractionated stereotactic radiation therapy (SRT), which calls for one to five fractions of high-dose radiation to be administered using special equipment, has resulted in the need for education on practice guidelines.
Image-Guided Hypofractionated Stereotactic Radiosurgery: A Practical Approach to Guide Treatment of Brain and Spine Tumors offers comprehensive, how-to guidance on hypofractionated SRT for brain and spine metastases, glioma, benign tumors, and other tumor types. Presenting the state of the art of the technology and practice, this book:

  • Discusses the pros and cons of hypofractionated SRT compared to single-fraction radiosurgery, providing a deeper understanding of radiosurgery and radiobiology
  • Explains the toxicity and adverse effects of hypofractionated SRT, aiding practitioners in communicating the risks and benefits of treatment and in obtaining their patients’ consent
  • Outlines the current standards for safe practice, including checklists for implementation

Comprised of chapters authored by well-recognized experts in the radiation, oncology, and neurosurgery communities, Image-Guided Hypofractionated Stereotactic Radiosurgery: A Practical Approach to Guide Treatment of Brain and Spine Tumors delivers a level of technological and clinical detail not available in journal papers.


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  • Published on: 2016-05-02
  • Original language: English
  • Number of items: 1
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  • Binding: Hardcover
  • 376 pages

Editorial Reviews

Review
“… a caregiver’s roadmap for a panoply of common clinical scenarios encountered in radiosurgical care of patients with cancer. … An awareness of how much this book can help in very practical terms is a good first step to helping your patients.”
―Jonathan P.S. Knisely, MD, Department of Radiation Medicine, Center for Advanced Medicine, Northwell Health, Lake Success, New York, USA
“… a pragmatic approach to the emerging use of image-guided hypofractionated stereotactic radiosurgery for brain and spinal tumors. Each clinical chapter has a very useful checklist specific to brain and spinal indications, which facilitates implementation of the concepts.”
―John H. Suh, MD, Department of Radiation Oncology, Brain Tumor Institute, Cleveland Clinic Foundation, Ohio, USA
“… a much-needed overview of focal hypofractionated stereotactic radiosurgery for brain and spine tumors. The authors are experts, and as a result this book represents a most comprehensive, practical, and authoritative guide for practitioners.”
―David A. Larson, MD, Professor, Departments of Radiation Oncology and Neurological Surgery, University of California, San Francisco, USA
“From brain metastases to spinal metastases to high-grade gliomas to benign brain tumors, there are pearls of wisdom here to help practicing neurosurgical oncologists and radiation oncologists take the best care of their patients. A must read!”
―James T. Rutka, MD, PhD, RS McLaughlin Professor and Chair, Department of Surgery, University of Toronto, Ontario, Canada
“… a comprehensive discussion of radiosurgery biology, imaging, techniques, and management of value for both single-session and hypofractionated approaches.”
―Douglas Kondziolka, MD, Professor and Director, Center for Advanced Radiosurgery, NYU Langone Medical Center, New York City, New York, USA
“… includes a wealth of treatment opportunities to further improve upon efficient, effective, and safer opportunities for our patients.”
―Helen A. Shih, MD, Chief, CNS and Eye Services, Department of Radiation Oncology, and Associate Medical Director, Francis H. Burr Proton Therapy Center, Massachusetts General Hospital, Boston, USA
“Expert practitioners document the state of the art of this new discipline of neurosurgery and radiation oncology.”
―John R. Adler, Jr., MD, Dorothy and TK Chan Professor Emeritus, Stanford University, California, USA
“… provides an invaluable guide through the technical tricks and traps, and beyond into safe practice.”
―Anthony L. Zietman, MD, Jenot W. and William U. Shipley Professor of Radiation Oncology, Harvard Medical School, and Associate Director, Radiation Oncology Residency Program, Massachusetts General Hospital, Boston, USA
“This book is packed with expert perspectives on both single and hypofractionated radiosurgery for brain and spine, presenting state-of-the-art techniques in this emerging field.”
―Ian Paddick, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
“… covers the relevant indications for hypofractionated radiosurgery and helps readers understand the basic principles in this fast-evolving field in radiation medicine.”
―Alex Muacevic, MD, Professor, University of Munich, and Director, Cyberknife Center Munich, Germany
About the Author
Arjun Sahgal, MD (chief editor), is a leader in the field of high-precision stereotactic radiation to the brain and spine. After training at the University of Toronto, Ontario, Canada, in radiation oncology, he completed a fellowship at the University of California, San Francisco, in brain and spine radiosurgery with Dr. David Larson. Since then he has been recognized as a national and international clinical expert and research leader in radiosurgery. His main focus is on developing spine stereotactic body radiotherapy as an effective therapy for patients with spinal tumors. He has published numerous book chapters on the subject and more than 200 peer-reviewed papers in high-impact journals, including Journal of Clinical Oncology and The Lancet Oncology. He has edited or written several books specific to research on brain and bone metastases and is an editorial board member for several journals. He was chairman of the International Stereotactic Radiosurgery Society meeting (June 2013) and was a board member for the Brain Tumour Foundation of Canada and the International Stereotactic Radiosurgery Society. He has been invited to speak at several international meetings, has been a visiting professor at various universities, and leads several research groups. His further research activities involve integrating MRI into radiotherapy delivery, combining novel pharmacologic therapies with radiosurgery, and MRI-guided focused ultrasound.
Simon S. Lo, MD, is professor of radiation oncology at Case Western Reserve University, Cleveland, Ohio, and director of radiosurgery services and neurologic radiation oncology at University Hospitals Seidman Cancer Center, Case Comprehensive Cancer Center, Cleveland, Ohio. Dr. Lo graduated from the Faculty of Medicine of The Chinese University of Hong Kong and did his residency in clinical oncology (Royal College of Radiologists, UK curriculum) at Queen Elizabeth Hospital, Hong Kong. He subsequently completed a residency in radiation oncology at the University of Minnesota, Minneapolis, and also received a grant from the American College of Radiation Oncology for a gastrointestinal radiation oncology fellowship at the Mayo Clinic (Minnesota). He was a visiting resident at Princess Margaret Hospital, University of Toronto, Ontario, Canada. He is currently chair of the American College of Radiology Appropriateness Criteria Expert Panel in Bone Metastasis and is the radiation oncology track co-chair for a Radiological Society of North America (RSNA) refresher course. He is an expert in brain and spinal tumors, stereotactic radiosurgery, and stereotactic body radiotherapy (SBRT). He has published more than 135 peer-reviewed papers, more than 50 book chapters, and three textbooks, including a comprehensive textbook in SBRT (27,000 downloads in 32 months). He has given lectures on SBRT to the American Society for Radiation Oncology (ASTRO), RSNA, the Radiosurgery Society, the International Stereotactic Radiosurgery Society, and the American Thoracic Society conferences and in multiple U.S. and international academic centers. He was also a member of both the ASTRO bone and brain metastases taskforces and contributed to the ASTRO guidelines for bone and brain metastases. He is on the editorial boards of multiple oncology journals and is a reviewer for The Lancet, The Lancet Oncology, Nature Reviews Clinical Oncology, Journal of Clinical Oncology, Radiotherapy & Oncology, andInternational Journal of Radiation Oncology: Biology and Physics. His areas of research are in brain tumors, stereotactic radiosurgery, radiobiological modeling for ablative radiotherapy, SBRT for lung, liver, and spinal tumors, and toxicities associated with SBRT.
Lijun Ma, PhD, is professor in residence of radiation oncology physics and director of the Physics Residency Program at the University of California, San Francisco. Dr. Ma has served in American Association of Physicists in Medicine on multiple task groups and working groups. He currently co-chairs the normal tissue complication probability spine subcommittee and serves on the editorial board of Medical Physics. He is board certified by the American Board of Medical Physics and is a member of the American College of Radiology. He has been active professionally in the International Society of Stereotactic Radiosurgery and has served on its executive board. Dr. Ma has published more than 100 papers and more than 20 book chapters, and is a holder of three international patents.
Jason P. Sheehan, MD, graduated with highest distinction in bachelors of chemical engineering at the University of Virginia, Charlottesville, Virginia, where he subsequently earned a master of science in biomedical engineering and a doctorate in biological physics. He earned his medical degree from the University of Virginia and completed his neurosurgical residency at the University of Virginia along with fellowships in stereotactic and functional neurosurgery at the University of Pittsburgh and microsurgery at the Auckland Medical Center in New Zealand. After his neurosurgical training, he joined the faculty of the University of Virginia’s Department of Neurological Surgery. He currently serves as the Harrison Distinguished Professor of Neurological Surgery. He is also the vice chairman of academic affairs, associate director of the residency program, and director of stereotactic radiosurgery. Dr. Sheehan’s research effort focuses on translational and clinical studies for minimally invasive intracranial and spinal surgery. He has published more than 300 papers and has served as the editor for several books. He has received the National Brain Tumor Foundation’s Translational Research Award, the Young Neurosurgeon Award from the World Federation of Neurological Surgeons, the Integra Award, the Synthes Skull Base Award, and the Crutchfield Gage Research Award. He serves on the editorial boards of Neurosurgery, Journal of Neurosurgery, Journal of Neuro-Oncology, and the Journal of Radiosurgery and SBRT. He is a member of the American Association of Neurological Surgeons (AANS), the Congress of Neurological Surgeons (CNS), the Society for Neuro-Oncology, the Society of Pituitary Surgeons, the American Society of Therapeutic Radiology and Oncology, the International Stereotactic Radiosurgery Society, and the Neurosurgical Society of the Virginias. He serves on the executive committee for the AANS/CNS section on tumors and is chair of the radiosurgery committee for the AANS/CNS section on tumors. He is listed in Best Doctors of America.

New Book: Surgery of the Spine and Spinal Cord: A Neurosurgical Approach

Surgery of the Spine and Spinal Cord: A Neurosurgical Approach

Surgery of the Spine and Spinal Cord: A Neurosurgical Approach

List Price: $199.00
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This book offers essential guidance on selecting the most appropriate surgical management option for a variety of spinal conditions, including idiopathic problems, and degenerative disease. While the first part of the book discusses the neuroanatomy and biomechanics of the spine, pain mechanisms, and imaging techniques, the second guides the reader through the diagnostic process and treatment selection for disorders of the different regions of the spine, based on the principles of evidence-based medicine. I.e., it clearly explains why a particular technique should be selected for a specific patient on the basis of the available evidence, which is carefully reviewed. The book identifies potential complications and highlights technical pearls, describing newer surgical techniques and illustrating them with the help of images and accompanying videos. Though primarily intended for neurosurgeons, the book will also be of interest to orthopaedic surgeons, specialists in physical medicine, and pain specialists. ​


Product Details

  • Binding: Hardcover
  • 752 pages

Book: Neurovascular Anatomy in Interventional Neuroradiology: A Case-Based Approach

Neurovascular Anatomy in Interventional Neuroradiology: A Case-Based Approach

By Timo Krings, Sasikhan Geibprasert, Juan Pablo Cruz, Karel G.  terBrugge
Neurovascular Anatomy in Interventional Neuroradiology: A Case-Based Approach

List Price: $119.99
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This case-based book presents detailed information on neurovascular anatomy in concise, easily digestible chapters that focus on the importance of understanding anatomy when performing neurointerventional procedures. The case discussions include modern examples of invasive and non-invasive angiographic techniques that are relevant for general radiologists and diagnostic neuroradiologists as well as interventionalists. This book gives readers the detailed knowledge of neurovascular anatomy that allows them to anticipate and avoid potential complications.
Key Features:

  • Cases are enhanced by more than 1,000 high-quality radiographs covering the full range of neurovascular anatomy
  • Content focuses on the practical relevance of the anatomical features encountered while performing everyday neurovascular procedures
  • Anatomy and embryology are explained together, enabling readers to fully comprehend the vascular anatomy and its many variants
  • Pearls and pitfalls are provided at the end of each chapter, highlighting the critical anatomy points presented

All neuroradiologists, interventionalists, general radiologists, and diagnostic neuroradiologists, as well as residents and fellows in these specialties, will read this book cover to cover and frequently consult it for a quick review before performing procedures.

Product Details

  • Published on: 2015-06-05
  • Original language: English
  • Number of items: 1
  • Dimensions: 10.98″ h x 8.50″ w x .0″ l, .0 pounds
  • Binding: Paperback
  • 244 pages
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