Comparative Analysis of Extensions of Transbasal Approaches: Effect on Access to Midline and Paramedian Structures

ABSTRACT

We sought to quantitate the effect of extensions of transbasal approaches (TBAs) on midline and paramedian targets of the cranial base. Eight silicone-injected cadaveric heads were dissected with extensions of TBA level I removal of the orbital bar. Objective measures were the comparisons of the accessibility of midline and paramedian targets with progressive dissections by level II detachment of the medial canthal ligaments and removal of the nasal bone and by level III removal of the lateral orbital walls with lateral orbital retraction. Mean areas of freedom increased for most targets with progressive bone removal. For midline targets, the most effective freedom increment was at the pituitary gland (level II: 28.8%, p = 0.05; level III: 107.1%, p < 0.001). For paramedian targets, the best freedom increment was for the foramen rotundum (level II: 56.4%; level III: 134.5%, all p < 0.001). Extensions of the TBA can increase the surgical corridor to midline and paramedian structures, especially for pituitary and maxillary regions. Level II exposure offers no clear benefit for most targets except the foramen rotundum. With level III exposure, all targets are effectively exposed compared with levels I and II.

KEYWORDS

Clivus - cranial base surgery - craniofacial resection - quantitative analysis - transbasal approach

REFERENCES

• 1 Tessier P, Guiot G, Derome P. Orbital hypertelorism. II. Definite treatment of orbital hypertelorism (OR.H.) by craniofacial or by extracranial osteotomies.  Scand J Plast Reconstr Surg. 1973;  7 39-58
• 2 Derome P. [Spheno-ethmoidal tumors. Possibilities for exeresis and surgical repair].  Neurochirurgie. 1972;  18(Suppl 1) 1-164
• 3 Gaillard S, Visot A, Derome P. Transbasal approach to tumors invading the skull base. In: Schmidek HH Operative Neurosurgical Techniques. Indication, Methods, and Results. Philadelphia; W.B. Saunders 2000: 265-277
• 4 Kawakami K, Yamanouchi Y, Kawamura Y, Matsumura H. Operative approach to the frontal skull base: extensive transbasal approach.  Neurosurgery. 1991;  28 720-724 discussion 724-725
• 5 Kawakami K, Yamanouchi Y, Kubota C, Kawamura Y, Matsumura H. An extensive transbasal approach to frontal skull-base tumors. Technical note.  J Neurosurg. 1991;  74 1011-1013
• 6 Sekhar L N, Nanda A, Sen C N, Snyderman C N, Janecka I P. The extended frontal approach to tumors of the anterior, middle, and posterior skull base.  J Neurosurg. 1992;  76 198-206
• 7 Couldwell W T. Surgery of the anterior skull base.  Otolaryngol Clin North Am. 1993;  26 673-693
• 8 Terasaka S, Day J D, Fukushima T. Extended transbasal approach: anatomy, technique, and indications.  Skull Base Surg. 1999;  9 177-184
• 9 Raveh J, Laedrach K, Speiser M et al.. The subcranial approach for fronto-orbital and anteroposterior skull-base tumors.  Arch Otolaryngol Head Neck Surg. 1993;  119 385-393
• 10 Raveh J, Vuillemin T, Sutter F. Subcranial management of 395 combined frontobasal-midface fractures.  Arch Otolaryngol Head Neck Surg. 1988;  114 1114-1122
• 11 Delfini R, Iannetti G, Belli E, Santoro A, Ciappetta P, Cantore G. Cranio-facial approaches for tumours involving the anterior half of the skull base.  Acta Neurochir (Wien). 1993;  124 53-60
• 12 Colohan A R, Jane J A, Newman S A, Maggio W W. Frontal sinus approach to the orbit. Technical note.  J Neurosurg. 1985;  63 811-813
• 13 Persing J A, Jane J A, Levine P A, Cantrell R W. The versatile frontal sinus approach to the floor of the anterior cranial fossa. Technical note.  J Neurosurg. 1990;  72 513-516
• 14 Fujitsu K, Saijoh M, Aoki F et al.. Telecanthal approach for meningiomas in the ethmoid and sphenoid sinuses.  Neurosurgery. 1991;  28 714-719 discussion 719-720
• 15 Feiz-Erfan I, Han P P, Spetzler R F et al.. The radical transbasal approach for resection of anterior and midline skull base lesions.  J Neurosurg. 2005;  103 485-490
• 16 Beals S P, Joganic E F, Holcombe T C, Spetzler R F. Secondary craniofacial problems following skull base surgery.  Clin Plast Surg. 1997;  24 565-581
• 17 Blacklock J B, Weber R S, Lee Y Y, Goepfert H. Transcranial resection of tumors of the paranasal sinuses and nasal cavity.  J Neurosurg. 1989;  71 10-15
• 18 Chandler J P, Pelzer H J, Bendok B B, Hunt Batjer H, Salehi S A. Advances in surgical management of malignancies of the cranial base: the extended transbasal approach.  J Neurooncol. 2005;  73 145-152
• 19 Fliss D M, Zucker G, Cohen A et al.. Early outcome and complications of the extended subcranial approach to the anterior skull base.  Laryngoscope. 1999;  109 153-160
• 20 Gay E, Sekhar L N, Rubinstein E et al.. Chordomas and chondrosarcomas of the cranial base: results and follow-up of 60 patients.  Neurosurgery. 1995;  36 887-896 discussion 896-897
• 21 Hallacq P, Moreau J J, Fischer G, Béziat J L. Trans-sinusal frontal approach for olfactory groove meningiomas.  Skull Base. 2001;  11 35-46
• 22 Lang D A, Honeybul S, Neil-Dwyer G, Evans B T, Weller R O, Gill J. The extended transbasal approach: clinical applications and complications.  Acta Neurochir (Wien). 1999;  141 579-585
• 23 Moore C E, Ross D A, Marentette L J. Subcranial approach to tumors of the anterior cranial base: analysis of current and traditional surgical techniques.  Otolaryngol Head Neck Surg. 1999;  120 387-390
• 24 Raveh J, Turk J B, Lädrach K et al.. Extended anterior subcranial approach for skull base tumors: long-term results.  J Neurosurg. 1995;  82 1002-1010
• 25 Ross D A, Marentette L J, Moore C E, Switz K L. Craniofacial resection: decreased complication rate with a modified subcranial approach.  Skull Base Surg. 1999;  9 95-100
• 26 Schwartz T H, Bruce J N. Extended frontal approach with bilateral orbitofrontoethmoidal osteotomies for removal of a giant extracranial schwannoma in the nasopharynx, sphenoid sinus, and parapharyngeal space.  Surg Neurol. 2001;  55 270-274
• 27 Honeybul S, Neil-Dwyer G, Lang D A, Evans B T, Weller R O, Gill J. The extended transbasal approach: a quantitative anatomical and histological study.  Acta Neurochir (Wien). 1999;  141 251-259
• 28 Beals S P, Joganic E F. Transfacial approaches to the craniovertebral junction. In: Dickman CA, Spetzler RF, Sonntag VKH Surgery of the Craniovertebral Junction. New York; Thieme 1998: 395-418
• 29 Beals S P, Joganic E F, Hamilton M G, Spetzler R F. Posterior skull base transfacial approaches.  Clin Plast Surg. 1995;  22 491-511
• 30 Spetzler R F, Herman J M, Beals S, Joganic E, Milligan J. Preservation of olfaction in anterior craniofacial approaches.  J Neurosurg. 1993;  79 48-52
• 31 Pinsolle J, San-Galli F, Siberchicot F, Caix P, Emparanza A, Michelet F X. Modified approach for ethmoid and anterior skull base surgery.  Arch Otolaryngol Head Neck Surg. 1991;  117 779-782
• 32 Liu J K, Decker D, Schaefer S D et al.. Zones of approach for craniofacial resection: minimizing facial incisions for resection of anterior cranial base and paranasal sinus tumors.  Neurosurgery. 2003;  53 1126-1135 discussion 1135-1137
• 33 Shah J P, Sundaresan N, Galicich J, Strong E W. Craniofacial resections for tumors involving the base of the skull.  Am J Surg. 1987;  154 352-358
• 34 Lin Y, Qiu Y. Microanatomy of endoscope-assisted glabellar nasal keyhole approach.  Minim Invasive Neurosurg. 2003;  46 155-160
• 35 Fukuta K, Saito K, Takahashi M, Torii S. Surgical approach to midline skull base tumors with olfactory preservation.  Plast Reconstr Surg. 1997;  100 318-325
• 36 Kellman R M, Marentette L. The transglabellar/subcranial approach to the anterior skull base: a review of 72 cases.  Arch Otolaryngol Head Neck Surg. 2001;  127 687-690
• 37 Passagia J G, Chirossel J P, Favre J J et al.. Surgical approaches to the anterior fossa, and preservation of olfaction.  Adv Tech Stand Neurosurg. 1999;  25 195-241
• 38 Dare A O, Balos L L, Grand W. Olfaction preservation in anterior cranial base approaches: an anatomic study.  Neurosurgery. 2001;  48 1142-1145 discussion 1145-1146
• 39 Raso J L, Gusmao S. Transbasal approach to skull base tumors: evaluation and proposal of classification.  Surg Neurol. 2006;  65 Suppl 1:S1:33-1 37 discussion 1: 37-1:37
• 40 Feiz-Erfan I, Spetzler R F, Horn E M et al.. Proposed classification for the transbasal approach and its modifications.  Skull Base. 2008;  18 29-47
• 41 Jho H D, Ko Y. Glabellar approach: simplified midline anterior skull base approach.  Minim Invasive Neurosurg. 1997;  40 62-67