Transmaxillar-Transnasal Approach: A Microsurgical Anatomical Model

Rabadán, Alejandra T.; Benedetti, Daniel Tonin; Conesa, Horacio; Derkrikorian, J.; Peirano, Miguel

doi:10.1007/978-3-642-76450-9_73

Cited by 3 publications

(1 citation statement)

References 20 publications

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“…11,47,58 The upper clivus corresponds to the basisphenoid bone, the region of the dorsum sella, which extends from the posterior cli noid process to the plane of the Dorello canal; the mid clivus extends from the Dorello canal to the pars nervosa of the jugular foramen; and the lower clivus extends from the pars nervosa of the jugular foramen to the foramen magnum. These divisions are evident in the inner aspect of the clivus.…”

Section: All Old Roads Lead To the Clivusmentioning

confidence: 99%

Anterior clivectomy: surgical technique and clinical applications

Al‐Mefty

Kadri²,

Hasan³

et al. 2008

JNS

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Object Midline clival lesions, whether involving the clivus or simply situated anterior to the brainstem, present a technical challenge for adequate exposure and safe resection. The authors describe, as a minimally invasive technique, an anterior clivectomy performed via an expanded transsphenoidal approach coupled with the use of a neuronavigation on mobile head and endoscopic-assisted technique. Wide and direct exposure, with the ability to resect extra- and intradural tumors, was achieved without mortality and with a low rate of complications. Methods Cadaveric dissections were performed to outline the landmarks and measure the window that is created by resecting the clivus anteriorly. The technique was used in 43 patients to resect tumors located at or invading the clivus. The initial exposure of the clivus was obtained via the sublabial transsphenoidal approach. The wall of the anterior maxilla, often on 1 side, was removed to allow a wide side-to-side opening of the nasal speculum. Using neuronavigation, the authors made clivectomy windows by drilling the clivus between anatomical landmarks. Bilateral intraoperative neurophysiological monitoring was used (somatosensory evoked potentials, brainstem auditory evoked responses, and cranial nerves VI–XII). Results Of the 43 patients, 26 were female and 17 were male, and they ranged in age from 3.5 to 76 years (mean 41.5 years). Thirty-eight patients harbored a chordoma and 5 a giant invasive pituitary adenoma. Gross-total resection of the tumor was achieved in 34 cases (79%). Nine patients (21%) had residual tumor unreachable through the anterior clivectomy, and this required a second-stage resection. Four patients developed new transient extraocular movement deficits. One patient developed a permanent cranial nerve VI palsy. Twenty-seven patients with chordoma underwent postoperative proton-beam radiotherapy. Tumor recurred in 19% of these cases. In 3 patients a cerebrospinal fluid leak developed during hospitalization and was treated successfully. Two other patients presented with a delayed cerebrospinal fluid leak after radiotherapy. Only 1 patient, who had previously undergone Gamma Knife surgery, experienced postoperative hemiparesis. Conclusions A complete anterior clivectomy via a simple extension of the transsphenoidal approach allows the surgeon access to different lesions involving the clivus or situated anterior to the brainstem. The exposure is similar to that provided by more extensive transfacial approaches. Instrument manipulation is easy. Neuronavigation, endoscopy, and intraoperative monitoring are easily incorporated and enhance the capability and safety of this approach.

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Section: All Old Roads Lead To the Clivusmentioning

confidence: 99%

Anterior clivectomy: surgical technique and clinical applications

Al‐Mefty

Kadri²,

Hasan³

et al. 2008

JNS

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Transmaxillary-Transnasal Approach to the Anterior Clivus

Rabadán

Conesa

1992

Neurosurgery

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Numerous procedures to expose the anterior clival region have been described, including the transoral, transcervical, transseptal-transsphenoidal, transantral, transnasal, bilateral Le Fort I maxillotomy, transbasal, transpalatal, and modifications of the Caldwell-Luc approach. Despite the large number of surgical options available, it may be necessary to have wider access to the midline skull base than these approaches provide. We have developed a microsurgical transmaxillary-transnasal approach to the anterior clivus that has been studied in both dry skull and cadaveric preparations and used clinically. The surgical technique has four stages: 1) antromaxillary; 2) nasal; 3) sphenoidal; and 4) clival. The wider access of this approach is achieved mainly by an osteotomy of the frontal process of the maxilla, which transforms the nasal cavity and the antrum into a single cavity while preserving the functional anatomy of the nose. Cosmesis is preserved by replacement of the cartilaginous nasal septum and the frontal process at the end of the procedure. The technique provides the good cosmetic results of the sublabial approaches and prevents vascular and neural injury in the same way that other anterior approaches do. This transmaxillary-transnasal technique may be used in combination with other approaches for extensive tumors.

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Analytical Evaluation of Complex Anterior Approaches to the Cranial Base: An Anatomic Study

Rabadán¹

1999

Neurosurgery

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Transmaxillar-Transnasal Approach: A Microsurgical Anatomical Model

Cited by 3 publications

References 20 publications

Anterior clivectomy: surgical technique and clinical applications

Anterior clivectomy: surgical technique and clinical applications

Transmaxillary-Transnasal Approach to the Anterior Clivus

Analytical Evaluation of Complex Anterior Approaches to the Cranial Base: An Anatomic Study

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