Neurol Med Chir (Tokyo) 43, 416¿418, 2003

Protective Dural Flap for Bone Drilling at the Paraclinoid

Region and Porus Acusticus
—Technical Note—

Yuichiro TANAKA, Kazuhiro HONGO, Tsuyoshi TADA,

Yukinari KAKIZAWA, and Shigeaki KOBAYASHI

Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Nagano

Abstract
A new method was developed to avoid the risk of injury to the cranial nerves and vessels during
intradural bone resection at the paraclinoid region and porus acusticus. The semicircular dural flap is
pulled out with a thread over the anterior clinoid process or the porus acusticus. The flap is extended
over the underlying structures with a tapered spatula to create adequate space for drilling the bone. The
site for drilling was adequately exposed and bone was drilled away smoothly without damaging the
underlying vessels and nerves in 10 patients with paraclinoid aneurysms and in seven patients with
vestibular schwannomas. This ``protective dural flap'' method provides wide exposure for drilling,
protects the underlying structures, and allows quick inspection during bone resection.

Key words: drilling, paraclinoid aneurysm, vestibular schwannoma

Introduction facilitate drilling and reduce brain retraction. 7) The

Intradural procedures to drill away the anterior
clinoid process, the roof of the optic canal, and the
lateral wall of the internal auditory canal are
standard microneurosurgical techniques used in the
clipping of paraclinoid aneurysms and removing the
intracanalicular portion of vestibular schwanno-
mas.1–3) However, intradural bone resection with a
drill carries the potential risk of damaging the
neighboring vessels, aneurysms, and nerves. There-
fore, we have developed a simple and safe method
for performing intradural bone resection at the
paraclinoid region and internal auditory canal.
Surgical Techniques
Intradural bone resection using a protective dural
flap is performed as follows (Figs. 1 and 2). 1) A
semicircular dural flap is made over the drilling site.
2) All cotton wads are removed from the operation
field. 3) The cerebral or cerebellar surface is protect-
ed with a rubber sheet. 4) The dural flap is pulled
with a nylon thread (Fig. 1A). 5) The flap is extended
over the underlying vessels and nerves with tapered
spatulas (Fig. 1B). 6) The head position is changed to
Received January 21, 2003; Accepted April 3, 2003
bone is removed with a high-speed drill (Fig. 1B, C).
Results
Intradural drilling was performed at the paraclinoid
region and porus acusticus using the protective
dural flap method in 10 patients with paraclinoid
aneurysms and in seven patients with vestibular
schwannomas. The sites for drilling were exposed
adequately and the nerves and vessels under the
dural flap were well protected during the drilling
operations. Suctioning of the irrigation fluid con-
taining bone dust was less stressful than with the
conventional method without the protective dural
flap, because inadvertent suctioning of the cranial
nerves and vessels was prevented by the flap.
Mechanical compression of the lesions by the drill
head was reduced by pulling the dural flap continu-
ously (Fig. 1C). The underlying structures could be
inspected quickly by releasing the spatulas over the
dural flap when needed. There was no complication
related to the procedure.
Discussion
A dural flap at the drilling site of the paraclinoid or
internal auditory canal was generally removed

416
 Protective Dural Flap for Bone Drilling 417

Fig. 1 Drawings showing the procedure to prepare the protective dural flap in a patient with an
aneurysm on the paraclinoid segment of the internal carotid artery. The dural flap is pulled
out with a thread, but the space remains too narrow for drilling (A). The dural flap is extended
over the aneurysm with a tapered spatula to provide adequate space for the drill head (B). The
dural flap is gradually lifted up with advance of bone resection and mechanical compression
with the drill head is reduced (C). The dura mater consists of the inner (dark gray) and
outer layers (light gray).

Fig. 2 Intraoperative photographs showing the formation of a protective dural flap before drilling
the anterior clinoid process in a patient with an aneurysm on the paraclinoid segment of the
right internal carotid artery. The aneurysm protruded superiorly and the proximal neck
was hidden by the anterior clinoid process (A). A semicircular dural flap was made above the
aneurysm and the dural flap was pulled out with a 5-0 nylon thread (B). The dural flap was
extended over the aneurysm with two tapered spatulas (C). The aneurysm neck was fully
exposed after bone resection and was occluded with an angled clip (D).

before drilling, or left unresected in our institution
until use of the protective dural flap method started
in 2000. The free dural flap often hindered the drill-
ing procedure because of the risk of entanglement in
the drill head. The suction tube for aspirating ir-
rigation fluid containing bone dust also carried a
potential risk to injure the vessels and nerves if the
flap was completely removed. In particular, the fine
lower cranial nerves could be suctioned when open-
ing the internal auditory canal. Drilling was espe-
cially risky in cases of paraclinoid aneurysm pro-
truding superiorly (Fig. 2).
Simple extension of the dural flap with a thread
cannot provide enough room for the drill head
(Fig. 1A). The two-step procedure to pull the flap
with a thread followed by extension over the under-
lying structures with a spatula is essential to create a
wide space for the drilling work in the deep opera-
tion field (Fig. 1B). For this purpose, tapered spat-
ulas with tips ranging from 2 to 6 mm width (Mizuho
Co., Tokyo) are convenient to maintain the appropri-
ate tension over the dural flap.4) In this way, the
surgeon can focus on drilling process, possibly
reducing the time required.
Extradural drilling methods such as Dolenc's
procedure for cavernous sinus lesions and the trans-
labyrinthine approach to the internal auditory canal
carry less risk of damaging intradural structures
than conventional intradural drilling, but quick in-
spection of the intradural components is impossible

Neurol Med Chir (Tokyo) 43, August, 2003

418 Y. Tanaka et al.
in the extradural procedures.1) The present method
of gradually lifting the dural flap with the advance of
bone resection allows rapid inspection and reduces
the mechanical compression with the drill head.
Such a protective effect cannot be achieved with the
extradural drilling methods.
References
1) Dolenc VV: A combined epi- and subdural direct
approach to carotid-ophthalmic artery aneurysms. J
Neurosurg 62: 667–672, 1985
2) Kobayashi S, Kyoshima K, Gibo H, Hegde SA,
Takemae T, Sugita K: Carotid cave aneurysms of the
internal carotid artery. J Neurosurg 70: 216–221, 1989
3) Rand RW, Kurze T: Facial nerve preservation by
posterior fossa transmeatal microdissection and total
removal of acoustic tumors. J Neurol Neurosurg
Psychiatry 28: 311–316, 1965
4) Sugita K, Kobayashi S, Takemae T, Matsuo K, Yokoo
A: Direct retraction method in aneurysm surgery.
Technical note. J Neurosurg 53: 417–419, 1980
Address reprint requests to: Y. Tanaka, M.D., Department
of Neurosurgery, Shinshu University School of
Medicine, 3–1–1 Asahi, Matsumoto, Nagano
390–8621, Japan.
e-mail: tanaka＠hsp.md.shinshu-u.ac.jp
Commentary
Tanaka et al. have described a method of harvesting a
dural flap, holding it with a stitch and retraction of the
flap using tapered brain retractors whilst drilling of
the anterior clinoid process and porus acusticus. They
have found that such a method provides additional
safety to the underlying structures. Other procedures
like removal of the cotton wads from the field and
protection of the brain surface with rubber sheet are
commonly used procedures.
I agree with the authors that if such a technique is
possible, it will add to the safety of drilling. In cases
with aneurysms in the region, inspection of intradural
structures is possible whilst continuing with the
drilling. However, the dura over the anterior clinoid
process and particularly over the lateral meatal wall
of the porus acusticus is relatively thin and to hold it
with a stitch and then to retract it with a retractor can
sometimes be difficult and can result in tears in the
dura. Both these procedures could also obstruct the
view and the free movements of the drill. It appears
that this technique may be more useful for anterior
clinoid process drilling than for lateral meatal wall
drilling.
Atul GOEL, M.D.
Head, Department of Neurosurgery
King Edward VII Memorial Hospital
& Seth G.S. Medical College
Parel, Mumbai, India
Tanaka et al. report a series of 17 patients (10 with
paraclinoid aneurysms and 7 with vestibular schwan-
nomas) in whom a special ``combined'' extra-in-
tradural method for bone drilling was used to shield
the arterial and/or nervous underlying structures
related to the approach, with the advantages of both
routes through a ``semicircular protective dural flap.''
There were no complications associated with the
procedure. The technique is very simple, transform-
ing the classical free dural flap usually obtained
and/or resected during the approach to a thread ten-
sion protection tool and broadened with the use of a
spatula. This combined technique may be very useful
for the management of this particular group of
patients, particularly in less experienced neurosurgi-
cal teams.
Jorge M. MURA, M.D.
and Evandro de OLIVEIRA, M.D.
Instituto de Ci âencias Neurol áogicas
S ãao Paulo, Brazil
In their technical note, Yuichiro Tanaka and co-
authors describe the use of a protective dural flap ex-
posing the paraclinoidal carotid artery and the inter-
nal auditory canal. Using this technique, a dural flap
is created over the eloquent neurovascular structures
and fixed with a spatula allowing safe suctioning and
drilling near to sensitive nerves and vessels. The
authors describe no complication in their 17 cases
related to the technique. In our opinion this is a good
idea and technique to protect the underlying the inter-
nal carotid artery and the VII and VIII nerves. The
trick with the nylon suture and the tapering spatula
allows tension of the dural flap offering a safe dissec-
tion, which is absolutely essential in these problemat-
ic areas.
Axel PERNECZKY, M.D.
and Robert REISCH, M.D.
The Neurosurgical Department of Medical School
University of Mainz
Mainz, Germany
Neurol Med Chir (Tokyo) 43, August, 2003