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Robert F. Spetzler, James M. Herman, Stephen Beals, Edward Joganic and John Milligan

✓ Through the combined efforts of neurosurgeons, head and neck surgeons, and craniofacial surgeons, the standard transbasal approach to the frontal fossa has been modified to include removal of the orbital roofs, nasion, and ethmoid sinuses. This approach has been combined further with facial disassembly procedures to provide extensive midline exposure to the midface and clival region. Extended frontal approaches, however, necessitate removal of the crista galli and sectioning of the olfactory rootlets with the associated risk of anosmia, cerebrospinal fluid (CSF) leak, and the need for complex reconstruction of the frontal floor. To avoid these problems, the authors have modified the technique of handling the cribriform plate to preserve the olfactory unit.

Circumferential osteotomy cuts are made around the cribriform plate to allow an en bloc removal with its attachment to both the dura and underlying mucosa. Opening of the dura is avoided and the cribriform bone is used to reconstruct the floor. Four patients underwent this approach, for treatment of an angiofibroma in three and a fibrosarcoma in one. The mean follow-up period was 7 months. No patients developed a CSF leak, and within 8 weeks olfaction had returned in all patients. There was no other associated morbidity. These data suggest that this modification of the transbasilar approach can alleviate extensive reconstructive procedures and CSF leaks while preserving olfaction.

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A. Giancarlo Vishteh, Stephen P. Beals, Edward F. Joganic, Jacque L. Reiff, Curtis A. Dickman, Volker K. H. Sonntag and Robert F. Spetzler

✓ Transoral approaches are used to expose the craniovertebral junction anteriorly. In patients in whom there is limited mandibular excursion, the placement of retractors and/or surgical instruments is difficult, and midline “stairstep split mandibulotomy” has been advocated as an adjunctive procedure. Although effective, this approach requires external splitting of the lip as well as median glossotomy or a lateral mucosal incision. The purpose of this study was to show that bilateral sagittal split mandibular osteotomies (BSSMOs), which are used in orthognathic surgery, represent a safer and more effective alternative to the stairstep split mandibulotomy when performed as an adjunct to the transoral approach because all incisions are intraoral and the plane of retraction is rostrocaudal instead of lateral.

Hospital records and radiographic files of four patients who underwent BSSMO/transoral approach for odontoidectomy between 1994 and 1997 were reviewed retrospectively. There were three women and one boy (mean age 37.8 years, range 11–68 years). Predisposing conditions included rheumatoid arthritis (two patients), Klippel—Feil syndrome (one patient), and congenital occipitocervical instability (one patient). Jaw mobility was limited in all patients. In addition, one patient had macroglossia, another micrognathia, and another retrognathia.

The BSSMO provided excellent exposure for resection of the odontoid process, as verified on follow-up magnetic resonance imaging or computerized tomography studies obtained in all patients. All mandibles were rigidly fixed by placing anterior mandibular border titanium plates and unicortical screws, and there was no incidence of nonunion or of lingual or inferior alveolar nerve injuries. The mean follow-up period was 26 months.

The BSSMO is an excellent, less invasive adjunct to the transoral approach in patients with limited jaw mobility.

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Iman Feiz-Erfan, Patrick P. Han, Robert F. Spetzler, Eric M. Horn, Jeffrey D. Klopfenstein, Randall W. Porter, Mauro A. T. Ferreira, Stephen P. Beals, Salvatore C. Lettieri and Edward F. Joganic

Object

Craniofacial surgery can be performed to treat midline and anterior skull base lesions by creating a bicoronal scalp incision without the need for an additional transfacial procedure. Originally described as the transbasal approach, several modifications for further exposure of the skull base have been described. The authors present data on the application and outcomes of a modified transbasal approach. The radical transbasal approach consists of a bifrontal craniotomy and a frontoorbitonasal osteotomy.

Methods

Between 1992 and 2002, 41 patients (28 male and 13 female patients with a mean age of 38.3 years [range 7–77 years]) underwent 44 radical transbasal procedures. Twenty-three malignant and 18 benign lesions involving the midline skull base were treated. These cases were reviewed retrospectively.

Gross-total resection of 30 lesions was achieved. Seven lesions were resected subtotally and six partially; one lesion was debulked. Complications occurred in 26 (59.1%) of the 44 operations and mostly consisted of cerebrospinal fluid leakage. The surgery-related mortality rate was 6.8% (three patients). Based on their pre- and postoperative Karnofsky Performance Scale scores, 86.4% of patients improved or remained the same.

Conclusions

The radical transbasal approach increases the midline craniofacial corridor by allowing the globes to be safely retracted laterally. It also enhances exposure of the maxillary sinus from above. The morbidity and mortality rates associated with this procedure are high but consistent with the known rates for craniofacial surgery. This approach is best suited for the treatment of anterior skull base tumors that extend into the nasal cavity, orbit, ethmoid sinus, nasopharynx, and upper clivus. The approach may allow resection of tumors involving the maxillary sinus area without the need for an additional transfacial approach.