Endoscopic approaches to the trigeminal nerve and clinical consideration for trigeminal schwannomas: a cadaveric study

Laboratory investigation

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Object

The course of the trigeminal nerve straddles multiple fossae and is known to be very complex. Comprehensive anatomical knowledge and skull base techniques are required for surgical management of trigeminal schwannomas. The aims of this study were to become familiar with the endoscopic anatomy of the trigeminal nerve and to develop a minimally invasive surgical strategy for the treatment of trigeminal schwannomas.

Methods

Ten fresh cadavers were studied using 5 endoscopic approaches with the aid of 4-mm 0° and 30° endoscopes to identify surgical landmarks associated with the trigeminal nerve. The endoscopic approaches included 3 transcranial keyhole approaches (the extradural supraorbital, extradural subtemporal, and retrosigmoid approaches), and 2 endonasal approaches (the transpterygoid and the transmaxillary transpterygoid approaches).

Results

The trajectories of the extradural supraorbital, transpterygoid, and extradural subtemporal approaches corresponded with the course of the first, second, and third divisions of the trigeminal nerve, respectively. The 3 approaches demonstrated each division in intra- and extracranial spaces, as well as the Meckel cave in the middle cranial fossa. The interdural space at the lateral wall of the cavernous sinus was exposed by the extradural supraorbital and subtemporal approaches. The extradural subtemporal approach with anterior petrosectomy and the retrosigmoid approach visualized the trigeminal sensory root and its neighboring neurovascular structures in the posterior cranial fossa. The transmaxillary transpterygoid approach revealed the course of the third division in the infratemporal fossa.

Conclusions

The 5 endoscopic approaches effectively followed the course of the trigeminal nerve with minimal invasiveness. These approaches could provide alternative options for the management of trigeminal schwannoma.

Abbreviations used in this paper:GSPN = greater superficial petrosal nerve; ICA= internal carotid artery.

Article Information

Address correspondence to: Fuminari Komatsu, M.D., Ph.D., Center for Anatomy and Cell Biology, Department of Systematic Anatomy, Medical University of Vienna, Waehringer Strasse 13, A-1090 Vienna, Austria. email: fuminarikomatsu@gmail.com.

Please include this information when citing this paper: published online August 17, 2012; DOI: 10.3171/2012.7.JNS11730.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Photograph showing the 5 endoscopic approaches to demonstrate the course of the trigeminal nerve in the endocranial skull base as follows: endoscopic extradural supraorbital approach (1), endoscopic extradural subtemporal approach (2), endoscopic retrosigmoid approach (3), endoscopic endonasal transpterygoid approach (4), and endoscopic endonasal transmaxillary transpterygoid approach (5).

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    Right endoscopic extradural supraorbital approach to the lateral wall of the cavernous sinus. A: The endoscope reveals anatomical landmarks of the extradural space in the anterior cranial fossa after a right supraorbital keyhole craniotomy. The arrowheads show the frontosphenoidal suture. B: The dorsal aspect of the middle cranial fossa dura and periorbita are exposed after drilling the lateral part of the anterior cranial fossa and the orbital roof. The dotted line indicates superior and lateral margins of the superior orbital fissure. C: After endoscopic anterior clinoidectomy, the clinoidal (Dolenc) triangle is shown. D: Bone removal is completed. The dotted line indicates the periosteal dural incision. E: The inner and outer layers of the lateral cavernous sinus were bluntly separated, and the arrowheads reveal the sphenoparietal sinus pouring into the cavernous sinus. F: The lateral wall of the cavernous sinus is exposed, and each division of the trigeminal nerve is evident in the interdural space. The V1 courses posteriorly to the gasserian ganglion along the trajectory of the extradural supraorbital approach. The infratrochlear triangle is opened. AC = base of the anterior clinoid process; AD = anterior cranial fossa dura; CC = clinoid segment of the ICA; CM = carotidoculomotor membrane; DD = duplication of dura; FO = foramen ovale; FR = foramen rotundum; IL = inner layer; MC = Meckel cave; MD = middle cranial fossa dura; OL = outer layer; OR = orbital roof; OS = optic strut; PO = periorbita; SP = sphenoparietal sinus; SR = sphenoid ridge; TE = anteromedial aspect of the tentorium; II = optic nerve; IV = trochlear nerve.

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    Right endoscopic extradural subtemporal approach. A: The V3 and foramen ovale are shown anteromedial to the foramen spinosum. B: Anatomical landmarks in the middle cranial fossa. The trigeminal impression, petrous ridge, GSPN, and the arcuate eminence, are identified. C: The lateral wall of the cavernous sinus is shown after exposure of the interdural space. D: The middle cranial fossa floor is drilled off to follow the V3 up to the superior part of the infratemporal fossa. E: An endoscopic anterior petrosectomy was performed, and the posterior cranial fossa dura and Meckel cave are opened to reveal the trigeminal sensory root. F: The superior petrosal sinus and tentorium are incised, and the trigeminal sensory root and its neighboring structures in the posterior cranial fossa are demonstrated. AE = arcuate eminence; AF = acoustic-facial bundle; AICA = anterior inferior cerebellar artery; AT = auriculotemporal nerve; BN = buccal nerve; DN = deep temporal nerve; FO = foramen ovale; FR = foramen rotundum; FS = foramen spinosum; MA = maxillary artery; MC = Meckel cave; MD = middle cranial fossa dura; MMA = middle meningeal artery; PC = petrosal segment of the ICA; PO = anterolateral aspect of the pons; PP = lateral pterygoid plate; PR = petrous ridge; SCA = superior cerebellar artery; TI = trigeminal impression; TL = temporal lobe; TS = trigeminal sensory root; IV = trochlear nerve; VI = abducent nerve.

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    Endoscopic anatomy of the trigeminal sensory root via the right retrosigmoid approach. A: An endoscope is inserted between the tentorial surface of the cerebellum and the tentorium cerebelli. Bridging veins are shown on the tentorial surface of the cerebellum as the endoscope is directed medially. B: Enlarged view of the trigeminal sensory root via the petrosal surface of the cerebellum. The trigeminal sensory root and Meckel cave are visualized, and the petrosal veins around the trigeminal sensory root pour into the superior petrosal sinus. The superior cerebellar artery runs posteriorly superior to the trigeminal sensory root. The oculomotor nerve and the trochlear nerve are visualized in the same view. C: The endoscope is positioned between the petrosal surface of the cerebellum and the petrous bone and demonstrates an overview of the cerebellopontine angle. D: Enlarged view of the trigeminal sensory root via the petrosal surface of the cerebellum. The abducent nerve and the basilar artery are revealed anterior to the trigeminal sensory root. AF = acoustic-facial bundle; AICA = anterior inferior cerebellar artery; BA = basilar artery; BV = bridging vein; IAM = internal acoustic meatus; JF = jugular foramen; MC = Meckel cave; PB = petrous bone; PC = petrosal surface of cerebellum; PV = petrosal vein; SCA = superior cerebellar artery; TC = tentorial surface of the cerebellum; TE = tentorium cerebelli; TS = trigeminal sensory root; III = oculomotor nerve; IV = trochlear nerve; VI = abducent nerve; IX = glossopharyngeal nerve; X = vagus nerve.

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    Endoscopic endonasal transpterygoid approach to the right cavernous sinus. Left: The cavernous sinus is opened, and the lateral wall of the cavernous sinus is visible from an anteromedial trajectory. The foramen rotundum, V2, and Meckel cave are evident, while V1 is partially covered with ICA and the abducent nerve. Asterisks indicate the middle cranial fossa dura. Right: Contents of the pterygopalatine fossa and the pterygoid process were partially removed to show the anatomical relationship between the vidian nerve and V3. The V3 is located lateral to the vidian nerve, and the vidian nerve prevents further exposure of V3. The course of V2 corresponds with the trajectory of the transpterygoid approach. CL = clivus; FR = foramen rotundum; MC = Meckel cave; PG = pituitary gland; PV = posterior vertical segment of the ICA; VN = vidian nerve; II = optic nerve; VI = abducent nerve.

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    Endoscopic endonasal transmaxillary transpterygoid approach to the right infratemporal fossa. A: After inferior turbinectomy and maxillary antrostomy, the posterior wall of the maxillary sinus is widely exposed. B: After removal of the posterior wall of the maxillary sinus, branches of the maxillary artery are isolated from fat tissue. C: The arterial system in the pterygopalatine fossa is removed, and the nervous system in the pterygopalatine fossa and contents of the infratemporal fossa are visible. D: The lateral pterygoid muscle and part of the lateral pterygoid plate were removed, and branches of V3 in the pterygoid plexus are demonstrated. AL = inferior alveolar nerve; BN = buccal nerve; DN = deep temporal nerve; DP = descending palatine artery; DT = deep belly of the temporal muscle; FO = foramen ovale; FR = foramen rotundum; GP = greater palatine nerve; IA = infraorbital artery; IN = infraorbital nerve; LN = lingual nerve; LP = lower head of the lateral pterygoid muscle; MA = maxillary artery; PA = posterosuperior alveolar artery; PP = lateral pterygoid plate; PG = pterygopalatine ganglion; PW = posterior wall of the maxillary sinus; SP = sphenopalatine artery; ST = superficial belly of the temporal muscle.

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