An alternative extradural exposure to the anterior clinoid process: The superior orbital fissure as a surgical corridor

Ernesto Coscarella, Mustafa K. Ba̧kaya, Jacques Morcos, Sami Rosenblatt, Ivan S. Ciric, Laligam N. Sekhar, John Diaz Day, Geoffrey Zubay, Robert F. Spetzler, Bernard George

Research output: Contribution to journalArticle

42 Citations (Scopus)

Abstract

OBJECTIVE: Dolenc has pioneered the extradural approach to the anterior clinoid process (ACP) in approaching the cavernous sinus, clinoidal space, and orbital apex. A key step is the division of the frontotemporal dural fold (FTDF). Less experienced surgeons may not be as versatile in their three-dimensional understanding of the superior orbital fissure and thus may risk injury to its contents. Through our cadaveric and subsequent clinical experience, we have devised a modification of the approach that permits safer handling of the contents of the superior orbital fissure. METHODS: In five consecutive injected cadaveric heads (10 sides), we performed on one side a traditional extradural exposure of the ACP. On the other side, we performed our alternative dissection. Instead of exposing the ACP from medial to lateral and dividing the frontotemporal dural fold along the assumed path of safety, we followed the edge of the lesser wing from lateral to medial, uncovered the superior orbital fissure, and peeled the outer layer of the cavernous sinus medial to the foramen rotundum along the greater wing, thus uncovering the inferolateral surface of the ACP. This allowed dural division under full visualization. RESULTS: The alternative method proved easier and more reliable in every case. We applied this technical modification in seven patients with no complications. Specifically, there was no injury to the oculomotor, lacrimal, frontal, or trigeminal nerves or branches. We present detailed anatomic expositions of the injected specimens. CONCLUSION: This technical modification of the extradural approach of Dolenc is a simple, safe, and valuable adjunct to the exposure of the ACP. We recommend its use particularly by relatively inexperienced surgeons.

Original languageEnglish
Pages (from-to)162-167
Number of pages6
JournalNeurosurgery
Volume53
Issue number1
StatePublished - Jul 1 2003

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Cavernous Sinus
Trigeminal Nerve
Wounds and Injuries
Tears
Dissection
Head
Safety
Surgeons

Keywords

  • Anterior clinoid process
  • Cranial base surgery
  • Dolenc approach
  • Superior orbital fissure

ASJC Scopus subject areas

  • Clinical Neurology
  • Surgery

Cite this

Coscarella, E., Ba̧kaya, M. K., Morcos, J., Rosenblatt, S., Ciric, I. S., Sekhar, L. N., ... George, B. (2003). An alternative extradural exposure to the anterior clinoid process: The superior orbital fissure as a surgical corridor. Neurosurgery, 53(1), 162-167.

An alternative extradural exposure to the anterior clinoid process : The superior orbital fissure as a surgical corridor. / Coscarella, Ernesto; Ba̧kaya, Mustafa K.; Morcos, Jacques; Rosenblatt, Sami; Ciric, Ivan S.; Sekhar, Laligam N.; Day, John Diaz; Zubay, Geoffrey; Spetzler, Robert F.; George, Bernard.

In: Neurosurgery, Vol. 53, No. 1, 01.07.2003, p. 162-167.

Research output: Contribution to journalArticle

Coscarella, E, Ba̧kaya, MK, Morcos, J, Rosenblatt, S, Ciric, IS, Sekhar, LN, Day, JD, Zubay, G, Spetzler, RF & George, B 2003, 'An alternative extradural exposure to the anterior clinoid process: The superior orbital fissure as a surgical corridor', Neurosurgery, vol. 53, no. 1, pp. 162-167.
Coscarella E, Ba̧kaya MK, Morcos J, Rosenblatt S, Ciric IS, Sekhar LN et al. An alternative extradural exposure to the anterior clinoid process: The superior orbital fissure as a surgical corridor. Neurosurgery. 2003 Jul 1;53(1):162-167.
Coscarella, Ernesto ; Ba̧kaya, Mustafa K. ; Morcos, Jacques ; Rosenblatt, Sami ; Ciric, Ivan S. ; Sekhar, Laligam N. ; Day, John Diaz ; Zubay, Geoffrey ; Spetzler, Robert F. ; George, Bernard. / An alternative extradural exposure to the anterior clinoid process : The superior orbital fissure as a surgical corridor. In: Neurosurgery. 2003 ; Vol. 53, No. 1. pp. 162-167.
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AU - Rosenblatt, Sami

AU - Ciric, Ivan S.

AU - Sekhar, Laligam N.

AU - Day, John Diaz

AU - Zubay, Geoffrey

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AU - George, Bernard

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N2 - OBJECTIVE: Dolenc has pioneered the extradural approach to the anterior clinoid process (ACP) in approaching the cavernous sinus, clinoidal space, and orbital apex. A key step is the division of the frontotemporal dural fold (FTDF). Less experienced surgeons may not be as versatile in their three-dimensional understanding of the superior orbital fissure and thus may risk injury to its contents. Through our cadaveric and subsequent clinical experience, we have devised a modification of the approach that permits safer handling of the contents of the superior orbital fissure. METHODS: In five consecutive injected cadaveric heads (10 sides), we performed on one side a traditional extradural exposure of the ACP. On the other side, we performed our alternative dissection. Instead of exposing the ACP from medial to lateral and dividing the frontotemporal dural fold along the assumed path of safety, we followed the edge of the lesser wing from lateral to medial, uncovered the superior orbital fissure, and peeled the outer layer of the cavernous sinus medial to the foramen rotundum along the greater wing, thus uncovering the inferolateral surface of the ACP. This allowed dural division under full visualization. RESULTS: The alternative method proved easier and more reliable in every case. We applied this technical modification in seven patients with no complications. Specifically, there was no injury to the oculomotor, lacrimal, frontal, or trigeminal nerves or branches. We present detailed anatomic expositions of the injected specimens. CONCLUSION: This technical modification of the extradural approach of Dolenc is a simple, safe, and valuable adjunct to the exposure of the ACP. We recommend its use particularly by relatively inexperienced surgeons.

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