Ossification of the pterygoalar and pterygospinous ligaments: a computed tomography analysis of infratemporal fossa anatomical variants relevant to percutaneous trigeminal rhizotomy

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  • 1 Section of Neuroradiology, Department of Radiology, University of Cambridge, Biomedical Campus, Cambridge;
  • | 2 Departments of Radiology and
  • | 3 Neurosurgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom;
  • | 4 Department of Neurosurgery, National Neuroscience Institute, Singapore; and
  • | 5 Division of Neuroimaging and Neurointervention, Department of Radiology, Stanford University School of Medicine, Stanford, California
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OBJECTIVE

Ossification of pterygoalar and pterygospinous ligaments traversing the superior aspect of the infratemporal fossa results in formation of osseous bars that can obstruct percutaneous needle access to the trigeminal ganglion through the foramen ovale (FO), interfere with lateral mandibular nerve block, and impede transzygomatic surgical approaches. Presence of these ligaments has been studied on dry skulls, but description of their radiological anatomy is scarce, in particular on cross-sectional imaging. The aim of this study was to describe visualization of pterygoalar and pterygospinous bars on computed tomography (CT) and to review their prevalence and clinical significance.

METHODS

The authors retrospectively reviewed 200 helical sinonasal CT scans by analyzing 0.75- to 1.0-mm axial images, maximum intensity projection (MIP) reconstructions, and volume rendered (VR) images, including views along the anticipated axis of the needle in percutaneous Hartel and submandibular approaches to the FO.

RESULTS

Ossified pterygoalar and pterygospinous ligaments were readily identifiable on CT scans. An ossified pterygoalar ligament was demonstrated in 10 patients, including 1 individual with bilateral complete ossification (0.5%), 4 patients with unilateral complete ossification (2.0%), and 5 with incomplete unilateral ossification (2.5%). Nearly all patients with pterygoalar bars were male (90%, p < 0.01). An ossified pterygospinous ligament was seen in 35 patients, including 2 individuals with bilateral complete (1.0%), 8 with unilateral complete (4%), 8 with bilateral incomplete (4.0%), 12 with bilateral incomplete (6.0%) ossification, and 5 (2.5%) with mixed ossification (complete on one side and incomplete on the contralateral side). All pterygoalar bars interfered with a hypothetical needle access to the FO using the Hartel approach but not the submandibular approach. In contrast, 54% of complete and 24% of incomplete pterygospinous bars impeded the submandibular approach to the FO, without affecting the Hartel approach.

CONCLUSIONS

This study provides the first detailed description of cross-sectional radiological and applied surgical anatomy of pterygoalar and pterygospinous bars. Our data are clinically useful during skull base imaging to predict potential obstacles to percutaneous cannulation of the FO and assist in the choice of approach, as these two variants differentially impede the Hartel and submandibular access routes. Our results can also be useful in planning surgical approaches to the skull base through the infratemporal fossa.

ABBREVIATIONS

CT = computed tomography; FO = foramen ovale; LPP = lateral pterygoid plate; MIP = maximum intensity projection; VR = volume rendered.

Cortical visual prostheses offer the potential to translate video into patterned visual cortex stimulation to produce predictable and consistent visual percepts. Artist and copyright Kenneth Probst. Published with permission. See the article by Niketeghad et al. (pp 2000–2007).

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Contributor Notes

Correspondence Tomasz Matys: University of Cambridge, United Kingdom. tm418@cam.ac.uk.

INCLUDE WHEN CITING Published online May 10, 2019; DOI: 10.3171/2019.2.JNS182709.

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

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