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Endoscopic Endonasal Medial-To-Lateral and Transorbital Lateral-To-Medial Optic Nerve Decompression: an Anatomical Study with Surgical Implications

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Endoscopic Endonasal Medial-To-Lateral and Transorbital Lateral-To-Medial Optic Nerve Decompression: an Anatomical Study with Surgical Implications LABORATORY INVESTIGATION J Neurosurg 127:199–208, 2017 Endoscopic endonasal medial-to-lateral and transorbital lateral-to-medial optic nerve decompression: an anatomical study with surgical implications Alberto Di Somma, MD,1 Luigi Maria Cavallo, MD, PhD,1 Matteo de Notaris, MD, PhD,2 Domenico Solari, MD, PhD,1 Thomaz E. Topczewski, MD,3 Manuel Bernal-Sprekelsen, MD, PhD,4 Joaquim Enseñat, MD, PhD,3 Alberto Prats-Galino, MD, PhD,5 and Paolo Cappabianca, MD1 1Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli Federico II, Naples; 2Department of Neuroscience, G. Rummo Hospital, Neurosurgery Operative Unit, Benevento, Italy; 3Department of Neurosurgery, Hospital Clinic, Faculty of Medicine; 4Rhinology and Skull Base Unit, Department of Otorhinolaryngology, Hospital Clínic de Barcelona; and 5Laboratory of Surgical Neuroanatomy, Faculty of Medicine, Universitat de Barcelona, Spain OBJECTIVE Different surgical routes have been used over the years to achieve adequate decompression of the optic nerve in its canal including, more recently, endoscopic approaches performed either through the endonasal corridor or the transorbital one. The present study aimed to detail and quantify the amount of bone removal around the optic canal, achievable via medial-to-lateral endonasal and lateral-to-medial transorbital endoscopic trajectories. METHODS Five human cadaveric heads (10 sides) were dissected at the Laboratory of Surgical Neuroanatomy of the University of Barcelona (Spain). The laboratory rehearsals were run as follows: 1) preliminary preoperative CT scans of each specimen, 2) anatomical endoscopic endonasal and transorbital dissections and Dextroscope-based morphometric analysis, and 3) quantitative analysis of optic canal bone removal for both endonasal and transorbital endoscopic approaches. RESULTS The endoscopic endonasal route permitted exposure and removal of the most inferomedial portion of the optic canal (an average of 168°), whereas the transorbital pathway allowed good control of its superolateral part (an average of 192°). Considering the total circumference of the optic canal (360°), the transorbital route enabled removal of a mean of 53.3% of bone, mainly the superolateral portion. The endonasal approach provided bone removal of a mean of 46.7% of the inferomedial aspect. This result was found to be statistically significant (p < 0.05). The morphometric analysis performed with the aid of the Dextroscope (a virtual reality environment) showed that the simulation of the transorbital trajectory may provide a shorter surgical corridor with a wider angle of approach (39.6 mm; 46.8°) compared with the simulation of the endonasal pathway (52.9 mm; 23.8°). CONCLUSIONS Used together, these 2 endoscopic surgical paths (endonasal and transorbital) may allow a 360° decompression of the optic nerve. To the best of the authors’ knowledge, this is the first anatomical study on transorbital optic nerve decompression to show its feasibility. Further studies and, eventually, surgical case series are mandatory to confirm the effectiveness of these approaches, thereby refining the proper indications for each of them. https://thejns.org/doi/abs/10.3171/2016.8.JNS16566 KEY WORDS optic nerve decompression; endoscopic transorbital; superior eyelid transorbital; endoscopic endonasal, anatomy HE optic nerve can be considered an extension of and intracranial. Generally, the intracanalicular segment, the brain, as it runs protected by the 3 meningeal approximately 10 mm in length, is the most vulnerable sheaths in its extracranial portion. According to the to compression and shear forces such that surgical optic Tliterature, 4 anatomical segments of the optic nerve can nerve decompression identifies this segment as the one to be identified:4,41 intraocular, intraorbital, intracanalicular, target to obtain relief.4 Different surgical approaches have SUBMITTED March 9, 2016. ACCEPTED August 1, 2016. INCLUDE WHEN CITING Published online October 28, 2016; DOI: 10.3171/2016.8.JNS16566. ©AANS, 2017 J Neurosurg Volume 127 • July 2017 199 Unauthenticated | Downloaded 10/09/21 10:36 PM UTC Di Somma et al. been used over the years including, more recently, endo- ferred to the laboratory navigation-planning workstation, scopic approaches either performed through the endonasal and point registration was performed. A registration cor- corridor or the transorbital pathway.1,2,4,10,14,16,25–28,50 relation tolerance of 2 mm was considered acceptable. The endoscopic endonasal route is currently gaining Endoscopic endonasal and transorbital approaches favor as a viable surgical technique to achieve optic nerve were performed using a rigid endoscope 4 mm in diam- decompression, because it provides a minimally invasive, eter, 18 cm in length, with a 0° and a 30° lens (Karl Storz). adequate exposure of the optic canal.1,4,27,32 Furthermore, The endoscope was connected to a light source (300 W the corridor itself provides excellent visualization of the Xenon, Karl Storz) through a fiberoptic cable and to a medial aspect of the orbital apex while avoiding brain re- high-definition camera (Endovision Telecam SL; Karl traction and olfactory bulb injuries as can happen in trans- Storz). The microsurgical dissections, that is, initial steps cranial approaches. However, despite the recent extension of the transorbital approach, were run at magnifications and refinements of endoscopic endonasal techniques, the ranging from ×3 to ×40 (OPMI; Zeiss). superior and lateral aspects of the optic canal still stand Prior to the dissection, surgical corridor length and outside the limits of this approach. However, the endo- angle of approach to the optic nerve of both endonasal nasal route may be considered advantageous for the re- and transorbital routes were simulated in a virtual real- moval of the most inferomedial portion of the optic canal, ity system, that is, the Dextroscope (Volume Interactions whereas a transcranial corridor should be adopted when Pte. Ltd.), as published previously3,22 in 2 specimens. The unroofing of the optic canal is planned. A complementary required virtual values, that is, length of the surgical cor- route to the endonasal one may be necessary to achieve ridor to reach the optic canal and angle of attack, were the decompression of the superolateral segment of the op- provided by the system once the parameters were set, and tic canal. with the aid of the Dextroscope measurement tool. In the Among the transcranial approaches, the trans- and su- Dextroscope simulation, we overlapped the CT scan with praorbital approaches have been introduced as feasible the arteriography image showing the ophthalmic artery lateral surgical trajectories for accessing the optic canal entering the optic canal. This permitted us to draw the and the anterior and middle skull base.5,6,12,16,33,40, 45,47 More course of the optic canal and therefore perform the mor- recently, the superior eyelid transorbital approach, with phometric analysis in the correct manner. the aid of the endoscope, has been proposed as a possible Thereafter, cadaveric dissections were performed as minimally invasive ventral access to selected areas of the follows. anterior and middle cranial fossae,31 allowing exposure of the optic nerve from above and laterally.31 Furthermore, Endoscopic Endonasal Approach this latter route does not require the removal of the orbital Through a binostril approach, we performed a middle rim or the frontal bone convexity, also avoiding brain ma- turbinectomy in 1 nostril with complete ethmoidectomy, nipulation. wide sphenoidotomy, and removal of the posterior portion The aim of this study was to detail and quantify the of the nasal septum. The uncinate process was removed, extent of bone removal of the optic canal at the intracana- and a middle meatal antrostomy provided access to the in- licular portion of the optic nerve from a medial-to-lateral ferior and medial orbital walls. The lamina papyracea was endonasal and from a lateral-to-medial transorbital eyelid then removed. The optic canal was opened in a proximal- endoscopic approach. to-distal direction, up to the lateral edge of the tuberculum To our knowledge, this is the first contribution to pro- sellae, either by a dissector and gentle drilling with the vide a quantitative assessment of the bone removal of the diamond bur. Finally, the intracanalicular portion of the optic canal, when combining endonasal and transorbital optic nerve was uncovered (Fig. 1). The optic sheath was endoscopic approaches. then opened by using a sickle blade, not extending over the annulus of Zinn, which is considered the most proximal Methods anatomical landmark. Anatomical Dissections Transorbital Approach Anatomical dissections were performed at the Labora- A superior eyelid approach was performed as follows. tory of Surgical Neuroanatomy of the Human Anatomy A skin incision was made through an eyelid wrinkle, and and Embryology Unit, University of Barcelona (Barcelo- the orbicularis muscle was cut so that the skin-muscle flap na, Spain) on 5 cadaveric heads (10 sides), in which the ar- was raised superolaterally until the bony orbital rim and terial system had been injected with red latex. This study the frontozygomatic suture were identified as described was approved by the institutional review board of the Uni- previously.15,31 The periosteum was cut, and dissection versity of Barcelona. proceeded in the subperiosteal and then the subperiorbital
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