E-Book, Englisch, 223 Seiten, ePub
Fossett / Caputy Operative Neurosurgical Anatomy
1. Auflage 2002
ISBN: 978-1-63853-177-7
Verlag: Thieme
Format: EPUB
Kopierschutz: Adobe DRM (»Systemvoraussetzungen)
E-Book, Englisch, 223 Seiten, ePub
ISBN: 978-1-63853-177-7
Verlag: Thieme
Format: EPUB
Kopierschutz: Adobe DRM (»Systemvoraussetzungen)
This book presents neurosurgical anatomy by detailing approaches on cadavers in the same position patients would be placed in during a real operative procedure. Anatomy is described in:
- all commonly used cranial and cranial base approaches
- anterior, posterior, anterolateral and posterolateral approaches to all segments of the spine
- all commonly performed procedures on peripheral nerves
- endoscopic approaches to cranial and spinal neurosurgery
Stresses the understanding of the anatomy rather than the performance of the procedure.
Autoren/Hrsg.
Fachgebiete
Weitere Infos & Material
I. Cranial Approaches
1 Specimen Preparation
2 Frontotemporal Approach
3 Cranio-orbital and Orbitozygomatic Approaches
4 The Anterior Communicating Complex and Heubner's Artery
5 Sylvian Fissure Anatomy and the Transylvian Approach
6 Transbasal Approach
7 Transphenoidal Approach
8 Cavernous Sinus Anatomy
9 Surgical Approaches to the Cavernous Sinus
10 Preauricular Subtemporal-Infratemporal Approach
11 Middle Fossa Approach
12 Transpetrosal Approach
13 Retrosigmoid Craniotomy
14 Midline and Paramedian Suboccipital Approaches
15 Extreme Lateral Approach
16 Approaches to the Posterior Third Ventricule and Pineal Region
17 Interhemispheric Approach
18 Front Lobectomy
19 Occipital Lobectomy
20 Temporal Lobectomy for Epilepsy
II. Spinal Approaches
21 Vertebral Column Anatomy
22 Transoral Approach to the Upper Cervical Spine
23 Anterior Approach to the Cervical Spine
24 Posterior Cervical Approach
25 Posterior Apporach to the Thoracic Spine
26 Dorsolateral Approaches to the Thoracic Spine
27 Ventrolateral Approach to the Thoracic Spine
28 Lumbar Laminectomy and Discectomy
29 Far Lateral Lumbar Discectomy
30 Retroperitoneal Approach to the Lumbar Spine
III. Peripheral Nerve Approaches
31 Carpal Tunnel Release
32 Radial Nerve Decompression
33 Ulnar Nerve Decompression and Transposition
34 Anterior Exposure of the Brachial Plexus
35 Thoracic Outlet Syndrome
36 Suprascapular Nerve Entrapment
37 Surgical Decompression of the Lateral Femoral Cutaneous Nerve
38 Sciatic Nerve Exploration
39 Sural Nerve Biopsy
IV. Neuroendoscopy
40 Minimally Invasive Supraorbital Craniotomy
41 Minimally Invasive Subtemporal Craniotomy
42 Endoscopic Intraventricular Anatomy
43 Endoscopic Thoracic Sympathectomy
FRONTOTEMPORAL APPROACH
Emel Avci, Chandrasekar Kalavakonda, Damirez Fossett
INDICATIONS FOR APPROACH
• All anterior circulation aneurysms
• High basilar tip and superior cerebellar artery aneurysms
• Frontal and anterior temporal arteriovenous malformations
• Lobar lesions of the cerebral hemispheres
• Sellar and suprasellar lesions
POSITIONING AND SKIN INCISION
The patient is placed in the supine position with the head held in Mayfield three-point fixation. The head is generally rotated 20 to 30 degrees toward the contralateral shoulder. More rotation can be used for anterior pathology and less rotation for more posterior pathology. The head is flexed slightly to bring the chin toward the ipsilateral clavicle and then extended to bring the maxillary eminence to the highest point in the field.
A curvilinear or bicoronal skin incision is placed behind the hairline (Fig. 2–1). The incision begins just anterior to the tragus of the ear and should not extend below the zygomatic root to protect the branches of the facial nerve. The incision should be made as close as possible to the tragus of the ear. Care should be taken to avoid transecting the underlying branches of the superficial temporal artery. The skin Rap is reflected anteriorly along with the pericranium. At the supraorbital ridge, care should be taken to identify and preserve the supraorbital nerve and vessel passing through the supraorbital foramen or notch. These can be released with the aid of a chisel or the B1 or C1 tools of the Midas Rex (Midas Rex, Fort Worth; Texas).
FIGURE 2–1 Illustration of the curvilinear unilateral incision.
As the skin is reflected anteriorly, the galea will merge with the superficial layer of the temporalis fascia. A curvilinear incision can be made into the superficial fascial layer at the keyhole and carried toward the zygomatic root (Fig. 2–2). Anterior elevation of this fascia and fat pad away from the underlying temporalis muscle avoids injury to the frontalis branch of the facial nerve that runs in this fat plane (Fig. 2–3). The temporalis muscle then is elevated as a separate layer and reflected anteriorly and inferiorly to expose the supraorbital ridge and the lateral rim of the orbit, providing optimum exposure for the development of a frontotemporal craniotomy (Fig. 2–4).
FIGURE 2–2 The branching superficial temporal artery can be seen above the temporalis fascia. The outlined incision is the superficial fascial dissection of the fat pad containing branches of the facial nerve.
FIGURE 2–3 The fat pad has been elevated preserving the branches of the facial nerve.
SURGICAL TECHNIQUE
A bur hole is made at the McCarty keyhole, and generally a second one is made in the squamosal region of the temporal bone. The surgeon determines the number of bur holes to be made. After dissection of the dura from the overlying bone with the use of dural dissectors or a Fen field 3, the bur holes are connected with the B1 foot-plated tool of the Midas Rex or with a Gigli saw. The sphenoid ridge is made as flat as possible down to level of the meningo-orbital artery; this is accomplished by using a Leksell or Limpet rongeur (Codman Johnson & Johnson Professional Products Ltd., Maiden Head, Berkshire, U.K.) or the M8 tool of the Midas Rex (Midas Rex, Fort Worth, TX).
Typically, the dura is opened in a C-shaped fashion, with its base along the sphenoid ridge (Fig. 2–5). It is reflected anteriorly and anchored with stay sutures (Fig. 2–6A). Under the operating microscope, either a lateral-to-medial or a medial-to-lateral opening of the sylvian fissure can be made (Fig. 2–6B). If a lateral-to-medial dissection is to be made, two self-retaining retractors are positioned, one on the frontal lobe and the other on the temporal lobe to make the fissure taut. The sylvian fissure then is opened using an arachnoid knife, and the dissection is performed superior to the sylvian vein, reflecting the veins with the temporal lobe. Veins crossing the fissure are sacrificed. As the fissure opens, the distal branches of the middle cerebral artery, the M1-2 bifurcation, and finally the carotid bifurcation can be identified. Further dissection allows visualization of the optic-carotid triangle and the carotid-oculomotor triangle (Fig. 2–6C, D).
FIGURE 2–4 The temporalis is elevated. A standard frontotemporal bone flap is outlined.
FIGURE 2–5 The dural incision is outlined.
FIGURE 2–6 A: The dura is reflected to reveal the underlying frontal and temporal lobes and the sylvian fissure. B: The sylvian vein is seen superficially. The middle cerebral artery branches can be seen in me depths. C: Panoramic view after widely splitting in a lateral to medial fashion the sylvian fissure. D: High-power view after lateral to medial splitting of me sylvian fissure. SCA, superior cerebellar artery; ICA, internal carotid artery; CN, cranial nerve.
For a medial-to-lateral opening of the sylvian fissure, a self-retaining retractor is placed under the frontal lobe to expose the olfactory nerve. Following the olfactory nerve posteriorly allows easy identification of the optic nerve and the carotid artery lying laterally to it (Fig. 2–7). The optic-carotid cistern and the carotid-oculomotor cistern generally come into view easily and with little retraction. With the use of fine microdissectors, the arachnoid between the optic nerve and frontal lobe is incised and opened. The dissection of this arachnoid continues across the carotid artery to the region of the third nerve, thus opening the optic-carotid and carotid-oculomotor cisterns. Medially, the chiasmatic cistern can be opened in a similar manner. A medial-to-lateral dissection of the sylvian fissure then can be undertaken, occasionally with the aid of a temporal lobe self-retaining retractor (Fig. 2–8). Bridging temporal veins between the middle fossa dura and the temporal lobe are sacrificed. Proximally to distally along the carotid artery, the posterior communicating artery, the anterior choroidal artery, and the carotid bifurcation can be identified (Fig. 2–9). Progressive retraction of the frontal lobe allows visualization of the optic chiasm, anterior communicating complex, and, ultimately, the contralateral A1, carotid artery, and optic nerve as well as both A2 vessels (Fig. 2–10A). Perforators from the anterior communicating artery (AComA) complex should be appreciated as should be the artery of Heubner. With the optic chiasm well visualized, the lamina terminalis can be entered to expose the third ventricle (Fig. 2–10B). The pituitary stalk is visualized as it passes behind the optic chiasm. The membrane of Lilliquist can be opened between the optic nerve and carotid artery or between the carotid artery and third nerve. The posterior communicating artery then can be followed to the P1–2 junction and, subsequently, to the basilar bifurcation (Figs. 2–11 through 2–14). If the basilar tip is high, the superior cerebellar arteries also can be visualized.
FIGURE 2–7 The olfactory nerve is identified. The carotid artery is seen lateral to the optic nerve. CN, cranial nerve.
FIGURE 2–8 The sylvian fissure has been widely split to reveal the optic nerve and the carotid artery lying lateral to it. The internal carotid artery (ICA) bifurcation is easily visualized. The middle cerebral artery can be seen traversing the sylvian fissure. CN, cranial nerve.
FIGURE 2–9 The carotid artery is seen lateral to the optic nerve. The posterior communicating artery and anterior choroidal artery arise from the internal carotid artery. The tentorium is seen laterally. CN, cranial nerve.
FIGURE 2–10 A: Retraction of the frontal lobe allows visualization of the optic chiasm and both optic nerves. Also seen are the ipsilateral internal carotid artery (ICA), middle cerebral artery, anterior cerebral artery (ACA), the third cranial nerve (CN III) and the tentorium. B: The contralateral structures can be reached via a transsylvian approach. The lamina terminalis is visualized and can be opened to expose the third ventricle. AcomA, anterior communicating artery.
The dura is closed in a watertight fashion, and the craniotomy is replaced with the aid of microplates, wire, or heavy suture. The temporalis fascia is reapproximated, and the skin is closed in a multilayered fashion. A subgaleal drain may be left in place if needed.
FIGURE 2–11 A fetal posterior communicating artery is disclosed. The superior cerebellar artery can be seen inferior to the third nerve. Note the small anterior choroidal artery. CN, cranial nerve.
FIGURE 2–12 The basilar bifurcation is seen by entering the carotid-oculomotor cistern. The third nerve is seen between the posterior cerebral artery and the superior cerebellar artery. CN, cranial nerve.
FIGURE 2–13 The contralateral third nerve, posterior clinoid, and basilar artery can be...
