Naoki Otani, Kojiro Wada, Terushige Toyooka, Kazuya Fujii, Yasushi Kobayashi 1, Kentaro Mori

Transcription

1 SNI: Skull Bse, supplement to Surgil Neurology Interntionl OPEN ACCESS For entire Editoril Bord visit : Editor: Jmes I. Ausmn, MD, PhD University of Cliforni, Los Angeles, CA, USA Opertive surgil nunes of modified extrdurl temporopolr pproh with mini peeling of dur propri sed on dveri ntomil study of lterl vernous strutures Noki Otni, Kojiro Wd, Terushige Toyook, Kzuy Fujii, Ysushi Koyshi 1, Kentro Mori Deprtments of Neurosurgery nd 1 Antomy nd Neuroiology, Ntionl Defense Medil College, Tokorozw, Sitm, Jpn E mil: *Noki Otni notni@ndm..jp; Kojiro Wd stingry@ndm..jp; Terushige Toyook teru_toy1809@friend.on.ne.jp; Kzuy Fujii kfujii@ndm..jp; Ysushi Koyshi ysushi@ndm..jp; Kentro Mori kmori@ndm..jp *Corresponding uthor Reeived: 08 Ferury 16 Aepted: 19 Mrh 16 Pulished: 07 July 16 Astrt Bkground: Extrdurl temporopolr pproh (ETA) hs een modified s less invsive mnner nd nmed s trns superior oritl fissure (SOF) pproh with mini peeling tehnique. The present study disusses the opertive nunes of this modified tehnique on the sis of dveri study of lterl vernous strutures. Methods: In five onseutive dveri speimens, we performed n extrdurl nterior linoidetomy with mini peeling of the dur propri to expose the nterior linoid proess entirely. We lso investigted the histologil hrteristis of the lterl vernous sinus (CS) etween the dur propri nd periostel dur t the SOF, formen rotundum (FR), nd formen ovle (FO) levels, nd of eh trigeminl nerve division. Results: Coronl histologil exmintion of the lterl wll of the CS showed invgintion of the dur propri nd periostel dur into the SOF. In ontrst, no suh invgintion ws oserved t the levels of the FR nd FO. This finding supports the tehnil rtionle of the only skeletoniztion of the SOF for peeling of the dur propri ut not FR. In ddition, our modified ETA method needs only miniml durl inision etween the SOF nd FR where no rnil nerves re present. Conlusion: Our tehnil modifition of ETA my e reommended for surgil tretment of prlinoid lesions to redue the risk of intropertive neurovsulr injury. Aess this rtile online Wesite: DOI: / Quik Response Code: Key Words: Anterior linoidetomy, vernous sinus, extrdurl temporopolr pproh, prlinoid lesion, skull se surgery INTRODUCTION Extrdurl temporopolr pproh (ETA), whih requires peeling of dur propri of the temporl loe dur mter from the lterl wll of the vernous sinus (CS) nd extrdurl nterior linoidetomy (EAC), is vrint of the Dolen s tehnique ut fouses more on temporl loe retrtion over the dur mter nd provides surgil orridor to the entrl skull se vi the opened CS. [3,4] However, the originl ETA requires the skeletoniztion of formen rotundum (FR) s well This is n open ess rtile distriuted under the terms of the Cretive Commons Attriution NonCommeril ShreAlike 3.0 Liense, whih llows others to remix, twek, nd uild upon the work non ommerilly, s long s the uthor is redited nd the new retions re liensed under the identil terms. For reprints ontt: reprints@medknow.om How to ite this rtile: Otni N, Wd K, Toyook T, Fujii K, Koyshi Y, Mori K. Opertive surgil nunes of modified extrdurl temporopolr pproh with mini-peeling of dur propri sed on dveri ntomil study of lterl vernous strutures. Surg Neurol Int 2016;7:S S Surgil Neurology Interntionl Pulished y Wolters Kluwer - Medknow

2 s superior oritl fissure (SOF) nd the dur propri inision t SOF to peel the dur propri from the lterl wll of the CS. [3,4] The disdvntge of ETA is the risk of injuring the neurovsulr strutures pssing through SOF during dissetion. [13] In ontrst, ETA ws reently modified to provide less invsive ut dequte exposure of the nterior linoid proess (ACP) [1,9] nd nmed s trns SOF pproh with mini peeling tehnique. [6] The modified ETA inluding mini peeling tehnique hs een pplied to tret vrious tumors nd neurysms in the prsellr to interpedunulr region. [7,8,11] The present study investigted the usefulness of this modified pproh nd opertive tehniques with speil emphsis on the dveri ntomil findings of lterl vernous strutures. MATERIALS AND METHODS Surgil proedure of extrdurl nterior linoidetomy with mini peeling EAC with mini peeling of dur propri ws peformed s follows. A semi oronl skin inision is performed followed y inter fsil dissetion. A stndrd frontotemporl rniotomy is performed up to the supr oritl noth, nd the temporl squm is rongeured out until the floor of the middle rnil foss is exposed. The lesser wing of the sphenoid one is flttened until the meningo oritl nd (MOB) is fully exposed. The middle foss dur is disseted until the SOF, nd the FR re exposed [Figure 1]. The roof of the SOF is skeletonized nd opened to expose the juntion etween the dur propri of the temporl loe nd the periostel dur [Figure 1]. Skeletoniztion of FR is not needed euse this juntion is nturlly exposed t FR [Figure 1, rrow]. The one round MOB is drilled. The oritl pex is prtilly opened round the se of the ACP t the medil extent of SOF. The tip of the mirosissors should e pointed t the dur propri juntion t SOF nd MOB is inised to length of out 4 mm [Figure 1]. The dur propri etween SOF nd FR is inised. Peeling of the dur propri is strted from FR to the lterl wll of SOF [Figure 1d] nd ontinued until the ACP is ompletely exposed epidurlly [Figure 2]. Cre should e tken to mintin the sphenoprietl sinus (SPS) on the dur propri side nd to stop the peeling t the point where SPS drins into CS to prevent postopertive prolems with venous ongestion. Before drilling of ACP, dissetion of the inferolterl prt of the ACP, where the fissurl prt of the oulomotor nerve psses, is needed to void oulomotor nerve injury. Drilling of ACP with high speed drill using old sline irrigtion is strted from the lterl prt of ACP [Figure 2], nd the opti nl is then opened prtilly in the medil prt of ACP using miro punh to void het injury, with thinning of the one long the medil nd nterior surfes of the linoid proess. The ore of ACP is hollowed like n egg shell with smll 2 mm dimond urr nd disseted from the rotid oulomotor memrne. After removl of ACP, the linoid segment (C3) of the internl rotid rtery (ICA) n e seen [Figure 2]. The prtilly opened opti nl n e enlrged using miro punh, nd the reminder of the opti strut etween the opened linoid spe nd opti nl n e removed with either smll dimond drill or miro punh. Following these simple, sfe, nd dequte proedures, extrdurl exposure of ACP is fully omplished without the risk of rnil nerve injury. Figure 1: After stndrd frontotemporl rniotomy, the middle foss dur is disseted until the formen rotundum, nd superior oritl fissure re exposed (). Skeletoniztion of the formen rotundum is not needed euse this juntion is nturlly exposed t the formen rotundum (, rrow). The roof of the superior oritl fissure is skeletonized nd opened to expose the juntion etween the dur propri of the temporl loe nd the periostel dur (, rrowheds). The one round the meningo-oritl nd is drilled nd inised to length of 4 mm (). Peeling of the dur propri is strted from the formen rotundum to the lterl wll of the superior oritl fissure (d). V2: Seond division of the trigeminl nerve d Figure 2: The dur propri is peeled from the lterl wll of the superior oritl fissure until the nterior linoid proess is exposed epidurlly (). Drilling of the nterior linoid proess with high-speed drill using sline irrigtion is strted from the lterl prt of the nterior linoid proess (). After removl of the nterior linoid proess, the linoid segment (C3) of the internl rotid rtery n e seen (). II: Opti nerve, III: Oulomotor nerve, IV: Trohler nerve, V1: First division of the trigeminl nerve, V2: Seond division of the trigeminl nerve S455

3 Cdveri study Speimen preprtion All dvers were donted with written permission for ntomil study on the norml strutures of the humn ody. The dvers were initilly fixed with solution ontining 3.3% formlin nd 66% ethnol y perfusion through femorl rtery nd underwent immersion fixtion in the sme fixtive for severl weeks. Crnil lood vessels were injeted with olored silione. Cdveri dissetion Two speimens were used for dveri dissetion of ETA using surgil mirosope (Crl Zeiss Contrvs; Zeiss, In., Montpelier, MD, USA) under 4 to 40 mgnifitions. All proedures were onsistent with the linil setting, nd ll oservtions were mde from the surgeon s ngle of view. All photogrphs illustrting ntomil strutures re from the left side of the ptient. Eh hed ws fixed in Myfield hed lmp nd positioned for stndrd pproh. The one dissetions were performed with Mids Rex drill (Mids Rex Institute, Fort Worth, TX, USA). The surgil tehnique of EAC with mini peeling of the dur propri ws performed nd the ntomi fetures of the prlinoid spe were exmined in stepwise dissetions [Figures 1 nd 2]. Histologil investigtion Five speimens were used for histologil exmintion of the sptil reltionship of the durl lyers of the lterl wll of CS. The CS region inluding the SOF, FR, nd formen ovle (FO) ws removed en lo [Figure 3] nd immersed for deftting in solution ontining 33% hloroform nd 67% methnol, nd then in 99% ethnol. The loks were delified in 9.5% EDTA solution for up to 3 months, dehydrted, nd emedded in prffin [Figure 3]. Coronl setions of 6 μm thikness were otined using sliding mirotome, nd then stined with Msson trihrome with neessry modifitions to optimize the results for over fixed mteril. RESULTS Coronl histologil setions of the lterl wll of CS showed tht the two durl lyers (dur propri nd periostel dur) were seprte t the levels of SOF [Figure 3], FR [Figure 3d], nd FO [Figure 3e]. The juntion etween the dur propri, whih trnsits to the rnil nerve perineurium, nd the periostel dur ws invginted under SOF y out 1 mm [Figure 3] t the level of the SOF. In ontrst, no suh invgintion ws oserved t the levels of the FR [Figure 3d] nd FO [Figure 3e]. This histologil study onfirms the neessity of skeltoniztion of the SOF, ut not FR. Also, one the juntion in SOF is surgilly exposed, the d e Figure 3: Cvernous sinus region inluding the superior oritl fissure, formen rotundum, nd formen ovle ws removed en lo (), nd emedded in prffin (). The dur propri, whih onsists of the rnil nerve perineurium, is invginted t the level of the superior oritl fissure (). In ontrst, no suh invgintion ws oserved t the levels of the formen rotundum (d) nd formen ovle (e). Blk roken line shows the lyer of the peeling. V1: First division of the trigeminl nerve, V2: Seond division of the trigeminl nerve, V3: Third division of the trigeminl nerve. Sle rs = 500 μm dur propri inision n e limited to the dur propri etween SOF nd FR where no neurovsulr strutures exist. DISCUSSION Removl of ACP [2,10] is one of the essentil skull se tehniques to tret prlinoid lesions. Anterior linoidetomy n e performed through the intrdurl pproh or extrdurl pproh. [3 5,12] EAC through the trns CS pproh requires peeling of the lterl wll of the CS to entirely expose ACP for drilling. [3,4] This extrdurl proedure hs een refined y minimizing the re of peeling in the lterl wll of the SOF inluding the nterior prt of the CS. [1,6,9] Compred to previous extrdurl surgil proedures, this modified EAC is very dvntgeous, whih n provide n extensive exposure of the ACP with simple nd sfe hndling. In these extrdurl proedures, SOF ws unovered, nd the peeling of the dur propri ws strted from FR to the medil side of the SOF. In the present study, exmintion of oronl histologil setions of the lterl wll of the CS showed tht the juntion etween the two durl lyers, dur propri nd periostel dur, were invginted under the level of the SOF. In ontrst, no suh invgintion of the periostel dur ws present t the levels of the FR nd FO. Therefore, skeletoniztion of FR is not needed. On the other hnd, SOF skeletoniztion is mndtory just efore peeling of the dur propri t SOF level to onfirm the preise lyers to disset. In ddition, the peeling of the dur propri should e strted from the FR to esily onfirm the inter retiulr lyer. S456

4 Our shemti illustrtion of the dur propri of the temporl loe nd other ntomil strutures is sed on our dveri study nd surgil experiene [Figure 4]. The juntion etween the dur propri nd the periostel dur ws invginted y out 1 mm t the SOF. The originl Dolen s proedure requires durl inision t the SOF [Figure 4, lue roken line] nd rries the risk of injury to the rnil nerves. Our method requires skeletoniztion of SOF to expose this juntion nd needs only miniml durl inision etween SOF nd FR where no rnil nerves re present [Figure 4, lue roken line]. The dur propri mini peeling from SOF to the nterior prt of CS n e performed from these juntions until the ACP is totlly exposed epidurlly [Figure 4]. Figure 5 lso shows the opertive proedures of EAC vi the trns SOF pproh followed y modified ETA. Figure 5 shows the tip of the miro sissors pointing to the exposed dur propri juntion t the skeletonized SOF during utting of the MOB. The dur propri inision n e limited to the dur propri etween SOF nd FR where no neurovsulr strutures exist [Figure 5, lk roken line]. After dur propri inision etween SOF nd FR, the dur propri should e refully peeled from the SOF to preserve the SPS on the peeled dur propri, whih ppers whitish [Figure 5] until the ACP is entirely exposed. Before drilling, the inferolterl prt of the ACP should e disseted euse the extrdurl prt of the oulomotor nerve psses there [Figure 5, rrow]. After removl of the ACP, the opti nl should e opened using miro punh. The opti strut etween the C3 of the ICA nd opti sheth is removed if neessry. Figure 4: Shemti illustrtion of the dur propri of the temporl loe nd other ntomil strutures. The juntion etween the dur propri nd the periostel dur ws invginted t the superior oritl fissure (, lue roken line). Our method needs only miniml durl inision etween the superior oritl fissure nd formen rotundum where no rnil nerves re present (, lue roken line). The dur propri peeling n e performed until the nterior linoid proess is totlly exposed epidurlly (). OC: Opti nl, II: Opti nerve, III: Oulomotor nerve, IV: Trohler nerve This pproh llows extrdurl erly loliztion nd exposure of the opti nerve. The exposed opti nerve n e followed from the opti nl proximlly towrd ny tumor in n intrdurl lotion, whih llows the surgeon to reognize the ext lotion of the opti nerve erly in the surgil proedure. Therefter, CS is exposed in Dolen s nteromedil tringle nd Mulln s nterolterl tringle [Figure 5 nd d]. After the ompletion of the extrdurl proedures, inisions of the fliform ligment, distl durl ring, nd tentorium re followed nd finlly the temporl loe is retrted over the dur mter to omplish the modified ETA [Figure 5 nd d]. The modified ETA with mini peeling of the dur propri n provide fully opertive field for mngement of the prlinoid neurysms nd/or prsellr tumor removl. Figure 5: Shemti illustrtion of the opertive tehniques of extrdurl nterior linoidetomy with mini-peeling of the dur propri followed y extrdurl temporopolr pproh. During utting of the meningo-oritl nd, the tip of the miro-sissors is pointed to the exposed dur propri juntion t the skeletonized superior oritl fissure (). The dur propri inision n e limited to the dur propri etween superior oritl fissure nd formen rotundum where no neurovsulr strutures exist (, lk roken line). The dur propri should e refully peeled from the superior oritl fissure to preserve the sphenoprietl sinus on the peeled dur propri, whih ppers whitish until the nterior linoid proess is entirely exposed (). Before drilling, the inferolterl prt of the nterior linoid proess should e disseted euse the extrdurl prt of the oulomotor nerve psses there (, rrow). After removl of the nterior linoid proess, the opti nl should e opened using miro-punh. The linoid segment (C3) of the internl rotid rtery n e seen nd the opti strut etween the C3 nd opti sheth is removed if neessry (). Finl opertive view of the extrdurl temporopolr pproh (d) suggests tht inision of the fliform ligment nd distl durl ring filittes moiliztion of the opti nerve nd internl rotid rtery, whih ontriutes to wide opertive field in the infropti nd suhismti spes without intropertive neurovsulr injury. OC: Opti nl, OS: Opti strut, II: Opti nerve, III: Oulomotor nerve, IV: Trohler nerve, V1: First division of the trigeminl nerve, V2: Seond division of the trigeminl nerve, SPS: Sphenoprietl sinus, DDR: Distl durl ring, FL: Fliform ligment, OA: Ophthlmi rtery, Ah: Anterior horoidl rtery d S457

5 CONCLUSION EAC requires extensive knowledge of the detiled ntomil struture of the SOF, MOB, nd wlls of the CS. On the sis of urrent dveri study of lterl vernous strutures, our modified extrdurl method requires skeletoniztion of SOF to expose interletiulr lyer nd needs only miniml durl inision etween SOF nd FR where no rnil nerves re present. We reommend its less invsive, sfe, nd useful tehnique to entirely expose the ACP followed y modified ETA. Aknowledgment We give speil thnks to Ms. Myumi Wtne for histologil proessing, nd to Mr. Tohru Tmi, Mr. Hiroshi Sski, nd Dr. Toshiysu Mtsui for dveri preprtion. Finnil support nd sponsorship Nil. Conflits of interest There re no onflits of interest. REFERENCES 1. Cosrell E, Bsky MK, Moros JJ. An lterntive extrdurl exposure to the nterior linoid proess: The superior oritl fissure s surgil orridor. Neurosurgery 2003;53: Dy AL. Aneurysms of the ophthlmi segment. A linil nd ntomil nlysis. J Neurosurg 1990;72: Dy JD, Fukushim T, Ginnott SL. Crnil se pprohes to posterior irultion neurysms. J Neurosurg 1997;87: Dy JD, Ginnott SL, Fukushim T. Extrdurl temporopolr pproh to lesions of the upper silr rtery nd infrhismti region. J Neurosurg 1994;81: Dolen VV. A omined epi nd sudurl diret pproh to rotid ophthlmi rtery neurysms. J Neurosurg 1985;62: Mori K, Ymmoto T, Nko Y, Eski T. Surgil simultion of extrdurl nterior linoidetomy through the trns superior oritl fissure pproh using dissetle three dimensionl skull se model with rtifiil vernous sinus. Skull Bse 2010;20: Mori K. Extrdurl temporopolr pproh: Opertive tehnique nd pplition to neurysm lipping surgery. In: Essentil Prtie of Neurosurgery. 2 nd ed. 5 Rue du Mrhé 1260 Nyon,Vud Switzerlnd: World Federtion of Neurosurgil Soieties; p Mori k. Oritozygomti pproh nd extrdurl temporopolr pproh: Opertive tehniques nd tips. Jpn J Neurosurg (Tokyo) 2014;23: Noguhi A, Blsingm V, Shiokw Y, MMenomey SO, Delshw JB Jr. Extrdurl nterior linoidetomy. Tehnil note. J Neurosurg 2005;102: Nutik SL. Removl of the nterior linoid proess for exposure of the proximl intrrnil rotid rtery. J Neurosurg 1988;69: Otni N, Wd K, Koyshi Y, Kumgi K, Ueno H, Osd H, et l. Extrdurl temporopolr pproh for surgil mngement of prlinoid lesions. No Shinkei Gek 2014;42: Yonekw Y, Ogt N, Imhof HG, Oliveron M, Strommer K, Kwk TE, et l. Seletive extrdurl nterior linoidetomy for supr nd prsellr proesses. Tehnil note. J Neurosurg 1997;87: Yoon BH, Kim HK, Prk MS, Kim SM, Chung SY, Lnzino G. Meningel lyers round nterior linoid proess s delite re in extrdurl nterior linoidetomy: Antomil nd linil study. J Koren Neurosurg So 2012;52: S458