Defining the lateral limits of the endoscopic endonasal transtuberculum transplanum approach: anatomical study with pertinent quantitative analysis

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OBJECTIVE

The extended endoscopic endonasal transtuberculum transplanum approach is currently used for the surgical treatment of selected midline anterior skull base lesions. Nevertheless, the possibility of accessing the lateral aspects of the planum sphenoidale could represent a limitation for such an approach. To the authors’ knowledge, a clear definition of the eventual anatomical boundaries has not been delineated. Hence, the present study aimed to detail and quantify the maximum amount of bone removal over the planum sphenoidale required via the endonasal pathway to achieve the most lateral extension of such a corridor and to evaluate the relative surgical freedom.

METHODS

Six human cadaveric heads were dissected at the Laboratory of Surgical NeuroAnatomy of the University of Barcelona. The laboratory rehearsals were run as follows: 1) preliminary predissection CT scans, 2) the endoscopic endonasal transtuberculum transplanum approach (lateral limit: medial optocarotid recess) followed by postdissection CT scans, 3) maximum lateral extension of the transtuberculum transplanum approach followed by postdissection CT scans, and 4) bone removal and surgical freedom analysis (a nonpaired Student t-test). A conventional subfrontal bilateral approach was used to evaluate, from above, the bone removal from the planum sphenoidale and the lateral limit of the endonasal route.

RESULTS

The endoscopic endonasal transtuberculum transplanum approach was extended at its maximum lateral aspect in the lateral portion of the anterior skull base, removing the bone above the optic prominence, that is, the medial portion of the lesser sphenoid wing, including the anterior clinoid process. As expected, a greater bone removal volume was obtained compared with the approach when bone removal is limited to the medial optocarotid recess (average 533.45 vs 296.07 mm2; p < 0.01). The anteroposterior diameter was an average of 8.1 vs 15.78 mm, and the laterolateral diameter was an average of 18.77 vs 44.54 mm (p < 0.01). The neurovascular contents of this area were exposed up to the insular segment of the middle cerebral artery. The surgical freedom analysis revealed a possible increased lateral maneuverability of instruments inserted in the contralateral nostril compared with a midline target (average 384.11 vs 235.31 mm2; p < 0.05).

CONCLUSIONS

Bone removal from the medial aspect of the lesser sphenoid wing, including the anterior clinoid process, may increase the exposure and surgical freedom of the extended endoscopic endonasal transtuberculum transplanum approach over the lateral segment of the anterior skull base. Although this study represents a preliminary anatomical investigation, it could be useful to refine the indications and limitations of the endoscopic endonasal corridor for the surgical management of skull base lesions involving the lateral portion of the planum sphenoidale.

ABBREVIATIONS M1 = sphenoidal segment of the middle cerebral artery.

Article Information

Correspondence Alberto Di Somma: Università degli Studi di Napoli Federico II, Naples, Italy. albertodisomma87@gmail.com.

INCLUDE WHEN CITING Published online April 20, 2018; DOI: 10.3171/2017.9.JNS171406.

A.D.S. and J.T. contributed equally to this work.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    A: Endoscopic endonasal view of the sella, tuberculum sellae, and planum sphenoidale. B: The transtuberculum transplanum approach has been performed. C: Intradural close-up view of the suprasellar area provided by the transtuberculum transplanum approach. AcoA = anterior communicating artery; A1 = precommunicating segment of the anterior cerebral artery; A2 = postcommunicating segment of the anterior cerebral artery; Ch = optic chiasm; CP = carotid protuberance; dmPS = dura mater of the planum sphenoidale; Eth = cribriform plate; GR = gyrus rectus; HA = Heubner artery; locr = lateral optocarotid recess; Lt = lamina terminalis; mocr = medial optocarotid recess; ON = optic nerve; OP = optic protuberance; PEA = posterior ethmoidal artery; Pg = pituitary gland; Ps = pituitary stalk; PS = planum sphenoidale; S = sella; sha = superior hypophyseal artery; TS = tuberculum sellae; * = supraoptic recess. Figure is available in color online only.

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    A: First step to obtain right lateral extension over the planum sphenoidale via the endoscopic endonasal route. After the lamina papyracea is removed, the posterior ethmoidal artery is isolated. B: The supraoptic recess/area is reached. C: The most medial portion of the lesser sphenoid wing, continuing medially (that is, intracranially from the endonasal perspective) with the anterior clinoid process and placed superiorly to the periorbital area, is exposed and progressively drilled out. D: Afterward, the optic canal roof is removed. AEA = anterior ethmoidal artery; CP = cribriform plate; dmPS = dura mater of the planum sphenoidale; ICA = internal carotid artery; locr = lateral optocarotid recess; LSW = lesser sphenoid wing; MS = maxillary sinus; O = orbit; OC = optic canal; ON = optic nerve; PEA = posterior ethmoidal artery; PS = planum sphenoidale; S = sella; sis = superior intercavernous sinus; * = supraoptic recess; ** = optic canal roof. Figure is available in color online only.

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    Endoscopic endonasal exposure of the base of the anterior clinoid process (A) after removing the most medial portion of the lesser wing overlying the orbit and the optic canal roof (see Fig. 2). The anterior clinoid process is progressively drilled out (B) up to the exposure of its central cancellous bone (C), which can be removed with a spoon (D) and/or a diamond drill (E). Accordingly, exposure of the dura covering the supraoptic area can be obtained (F). AC = anterior clinoid; dmPS = dura mater of the planum sphenoidale; ICA = internal carotid artery; LSW = lesser sphenoid wing; O = orbit; ON = optic nerve; * = cancellous bone of the anterior clinoid; dotted line = dura mater behind the supraoptic recess. Figure is available in color online only.

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    Endoscopic endonasal removal of the bone forming the lateral optocarotid recess, namely, the optic strut, which is the last of the 3 supporting structures of the anterior clinoid process (A and B). The pertinent neurovascular anatomy is also shown (C) after opening of the optic nerve sheath (D). Ch = optic chiasm; dmPS = dura mater planum sphenoidale; ICA = internal carotid artery; locr = lateral optocarotid recess; OF = optic foramen; ON = optic nerve; S = sella; SOF = superior orbital fissure; III = third cranial nerve; + = olfactory nerve; * = ophthalmic artery; ** = optic nerve sheath. Figure is available in color online only.

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    After opening of the dura mater of the right supraorbital recess (as shown in Fig. 3F), the intradural structures are visualized. Opening of the sylvian cistern (A). The middle cerebral artery bifurcation is observed (B) and followed laterally at the level of the insula (C) and medially up to the level of the internal carotid artery bifurcation (D). A1 = precommunicating segment of the anterior cerebral artery; dmLSW = dura mater of the lesser sphenoid wing; FL = frontal lobe; ICA = internal carotid artery; M1 = sphenoidal segment of the middle cerebral artery; M2 = insular segment of the middle cerebral artery; OT = optic tract; SC = sylvian cistern; TL = temporal lobe; + = perforators (including the Heubner artery) directed to the right anterior perforated substance; * = middle cerebral artery bifurcation; ** = perforators directed to the posterior perforated substance. Figure is available in color online only.

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    Intradural exploration through both supraorbital recesses after opening of the sylvian cisterns (A, right side; B, left side). A1 = precommunicating segment of the anterior cerebral artery; A2 = postcommunicating segment of the anterior cerebral artery; Ch = optic chiasm; FL = frontal lobe; HA = Heubner artery; ICA = internal carotid artery; M1 = sphenoidal segment of the middle cerebral artery; ON = optic nerve; TL = temporal lobe. Figure is available in color online only.

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    3D reconstructions of the postdissection CT scans in axial (A), oblique (B), and coronal (C) perspectives demonstrating the midline transtuberculum transplanum route (red) and the approach at its maximum lateral extension (blue). Details of the supraorbital recess removed via the endonasal route have been provided (D). The 3D reconstructions were obtained in a sample specimen using Amira. The same colors were used in the bar graphs summarizing our results (Fig. 9). Figure is available in color online only.

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    3D reconstructions in a ventral perspective of the surgical freedom areas calculated for the midline and maximum lateral extension approaches. A: Midline surgical freedom is represented by red. B: Lateral extension to the left is represented by different colors according to the entry nostril and using the same colors as the bar graphs summarizing our results, namely, light blue if the instruments crossed the homolateral nostril and dark blue if they came from the contralateral nostril (see Fig. 9). C: Lateral extension to the right. D: Comprehensive reconstruction including all results of our surgical freedom analysis from both nostrils. The 3D reconstructions were obtained in a sample specimen using Amira. Figure is available in color online only.

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    Quantitative analysis of bone removal (left) and surgical freedom (right). For the bone removal analysis, the midline approach is represented by red and the maximum lateral extension approach is depicted in blue. As expected, compared with the midline endoscopic endonasal transtuberculum transplanum approach, its maximum lateral extension featured a larger bone removal (*p < 0.01, left). For the surgical freedom analysis, the surgical freedom to a midline target is represented by red and the surgical freedom to a lateral target is depicted in light blue if the instruments crossed the homolateral nostril and in dark blue if they came from the contralateral nostril. The surgical freedom at the most anterior and lateral portion of the anterior clinoid in the contralateral nostril resulted in the greatest area and reached statistical significance compared with the surgical freedom at the midline (*p < 0.05, right). Figure is available in color online only.

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    Preoperative sagittal (A) and coronal (B) postcontrast CT scans with 3D volume-rendered reconstruction, as seen from an endonasal perspective (C) of planum sphenoidale meningioma extending to the left anterior skull base and with partial involvement of the left optic canal. Postoperative sagittal (D) and coronal (E) postcontrast CT scans with 3D volume-rendered reconstruction (F) show that total tumor removal was achieved with the endonasal approach. 3D reconstructions were made using the Brainlab Curve navigation system. Figure is available in color online only.

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    Endoscopic endonasal approach for the planum sphenoidale meningioma shown in Fig. 10. The lamina papyracea was removed, exposing the medial aspect of the periorbita; the posterior ethmoidal artery was coagulated (A). The lesser sphenoid wing was partially removed (B) to clearly identify the cleavage plane between tumor and surrounding brain tissue (C). The tumor cavity is shown after complete tumor removal (D). dmPS = dura mater of the planum sphenoidale; FL = frontal lobe; locr = lateral optocarotid recess; O = orbit; OC = optic canal; Olf = olfactory nerve; T = tumor; + = tumor cavity; * = coagulated posterior ethmoidal artery; ** = lesser sphenoid wing. Figure is available in color online only.

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