TUMOR Surgical Anatomy and Technique

Endoscopic Extradural Anterior Clinoidectomy via

L7CK25A0OKO2Hi82Fb3Fy/8X5B+N46vwEp4Go7q/yVfHFl3zwAW3JeOmzfokQazpHHa81Z3fIBoHYgoJgi3aMIMXYGp1pVwhQF/Y

Supraorbital Keyhole: A Cadaveric Study

Downloaded from http://journals.lww.com/onsonline by 2hMAudMCs2pieqblJGkyjXq4c6/cQ8pv73YAfxezYUIA6cP

Fuminari Komatsu, MD, PhD*
Mika Komatsu, MD*
Tooru Inoue, MD, PhD*
Manfred Tschabitscher, MD,
bcf3oLb4DS+6rHChS4mhm6XJEFL0KHgV5AA== on 06/21/2023
BACKGROUND: Anterior clinoidectomy is an essential preliminary step for parasellar and
pericavernous sinus surgery. Endoscopy is a widely accepted modality for neurosurgical
strategies and is becoming more important in treating conditions involving the cranial
base.

PhD‡ OBJECTIVE: To determine the feasibility of endoscopic extradural anterior clinoidectomy

*Department of Neurosurgery, Faculty of
Medicine, Fukuoka University, Fukuoka,
Japan; ‡Center of Anatomy and Cell
Biology, Medical University of Vienna,
Vienna, Austria
Correspondence:
Fuminari Komatsu, MD, PhD,
Department of Neurosurgery,
Faculty of Medicine, Fukuoka University,
7-45-1 Nanakuma,
Johnan-ku,
Fukuoka 814-0180, Japan.
E-mail: fkomatsu@fukuoka-u.ac.jp
Received, June 7, 2010.
Accepted, August 30, 2010.
Copyright ª 2011 by the
Congress of Neurological Surgeons
via the supraorbital keyhole.
METHODS: Eight fresh cadaver heads were studied using 4-mm, 0- and 30-degree rigid
endoscopes to perform endoscopic extradural anterior clinoidectomy. We also evaluated
a bony landmark for this technique in 36 dry craniums.
RESULTS: An endoscope was introduced into the extradural space created via a
supraorbital keyhole craniotomy. The periorbita and the duplication of the dura
extending to the temporal lobe dura and periorbita were exposed by drilling. Anterior
clinoidectomy proceeded using a diamond drill under endoscopic visualization without
a dural incision. A submerged view with continuous irrigation through an endoscopic
sheath maintained clear visibility while drilling. A small bony eminence at the transition
between the sphenoid ridge and the anterior clinoid process, which is an anatomic
landmark for endoscopic extradural anterior clinoidectomy, was identified in 57.4% of
36 adult dry craniums.
CONCLUSION: The endoscopic extradural procedure can accomplish reliable anterior
clinoidectomy under superb endoscopic visualization. This method would be applicable
to parasellar and cavernous sinus surgery combined with keyhole or conventional
craniotomy.
KEY WORDS: Anterior clinoidectomy, Cranial base, Endoscopy

Neurosurgery 68[ONS Suppl 2]:ons334–ons338, 2011 DOI: 10.1227/NEU.0b013e31821144e5

T
he anterior clinoid process (ACP) is a small
projection that protrudes from the poster-
omedial border of the lesser wing of the
sphenoid bone. Dolenc1 originally described an
anterior clinoidectomy via the extradural space that
allows optimal mobilization of the optic nerve and
the internal carotid artery in 1985. This technique
thus facilitates tumor removal from the parasellar
and cavernous sinus as well as the appropriate
management of internal carotid aneurysms.2-6 The
dura mater in the extradural space acts as a natural
barrier that protects the brain and neurovascular
structures and contributes to decreased morbidity.
In contrast, the deep location of the ACP in the
ABBREVIATION: ACP, anterior clinoid process
central cranial base and its circumferential vital
structures render anterior clinoidectomy delicate.
Consequently, some modified methods have been
described to accomplish safer and simpler anterior
clinoidectomy.4,7-13
The recent extensive use of endoscopy has led to
the advent of minimally invasive surgery that is now
widely accepted as a means of treating lesions of the
cranial base14-19 because normal structures that are
deeply buried and tend to be obscured can be
visualized.20,21 Here, we describe a cadaveric study
of endoscopic extradural anterior clinoidectomy.
MATERIALS AND METHODS
Endoscopic extradural anterior clinoidectomy was
studied in 8 fresh cadaver heads using rigid endo-
scopes (Karl Storz GmbH, Tuttlingen, Germany),

ons334 | VOLUME 68 | OPERATIVE NEUROSURGERY 2 | JUNE 2011 www.neurosurgery-online.com

Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited.

 PURELY ENDOSCOPIC ANTERIOR CLINOIDECTOMY

4 mm in diameter, 18 cm in length, and with 0- and 30-degree lenses.

The endoscopes were connected to a light source through a fiberoptic
cable and to a camera fitted with 3 charge-coupled device sensors. The
video camera was connected to a monitor supporting the high resolution
L7CK25A0OKO2Hi82Fb3Fy/8X5B+N46vwEp4Go7q/yVfHFl3zwAW3JeOmzfokQazpHHa81Z3fIBoHYgoJgi3aMIMXYGp1pVwhQF/Y

of the charge-coupled device technology. During the drilling procedure,

the endoscope was equipped with a 5-mm sheath and a tubing system
attached to a fluid reservoir. The extradural space was filled with water
Downloaded from http://journals.lww.com/onsonline by 2hMAudMCs2pieqblJGkyjXq4c6/cQ8pv73YAfxezYUIA6cP

from the reservoir, and drilling proceeded under a submerged view.

The extradural space was continuously irrigated with water to wash out
bone dust generated by drilling and to maintain clear visibility. We
investigated 36 dry craniums to evaluate a bony landmark for endoscopic
extradural anterior clinoidectomy.
bcf3oLb4DS+6rHChS4mhm6XJEFL0KHgV5AA== on 06/21/2023

RESULTS
Skin Incision and Supraorbital Keyhole Craniotomy
A 4- to 5-cm skin incision was started laterally from the
supraorbital notch along the orbital rim within the eyebrow. The
subcutaneous tissue was dissected to expose the occipital frontal
muscle, the orbicularis oculi, and temporal muscle. The frontal
muscle was cut parallel to the orbital rim, and then the fascia of
the temporal muscle along the temporal line was incised and
laterally reflected. A single frontobasal hole was bored in the
cranium using a high-speed drill posterior to the temporal line at
the level of the frontal base. After minimal enlargement of the
hole and mobilization of the dura, a small bone flap (2.5 3
1.5 cm) was created using a high-speed drill. The bone flap was
removed, leaving the orbital rim, and the inner edge of the bone
above the orbital rim was flattened using the drill.
Extradural Exploration and Exposure of the Periorbita
and Duplication of the Dura
An endoscope (4 mm; 30 degrees) was introduced into the
extradural space, and the dura was bluntly peeled from the
anterior cranial base using a dissector. The extradural space was
expanded, and the extradural space was explored using the
endoscope under the guidance of a dissector without continuous
brain retraction. The endoscope was advanced posteriorly until
the sphenoid ridge appeared, and then medially until the orbital
roof and the base of the ACP could be identified (Figure 1A, B).
The optic nerve, the falciform ligament, and the roof of the optic
canal were observed medially to the base of the ACP (Figure 1C).
A small bony eminence was occasionally located at the transition
between the base of the ACP and the sphenoid ridge on the lesser
wing of the sphenoidal bone (Figure 1B).
The sphenoid ridge was removed extradurally using a drill with
a diamond burr. The extradural space was filled with water while
drilling proceeded under a submerged view. The endoscopic
sheath was continuously irrigated with water to remove bone dust
and maintain clear visibility. A small eminence located at the
transition between the base of the ACP and the sphenoid ridge on
the lesser wing of sphenoid bone was used as a landmark of the
medial limitation of bone removal on the sphenoid ridge. The
sphenoid ridge was caudally removed until the rostral aspect of
FIGURE 1. Extradural exploration and exposure of the periorbita and dupli-
cation of the dura. First step of extradural exploration after right supraorbital
craniotomy. A, the sphenoid ridge is shown at posterior end of anterior cranial
base and orbital roof is located at medial part of anterior cranial base. B, small
bony eminence on lesser wing of sphenoid bone at transition between sphenoid
ridge and base of anterior clinoid process. C, optic nerve with falciform ligament
is visible medially to the base of anterior clinoid process (ACP). D, drilling away
the sphenoid ridge and unroofing the orbital roof allow visualization of the
periorbita and duplication of dura between periorbita and temporal lobe dura.
The ACP and part of optic canal roof are preserved. BE, small bony eminence on
lesser wing of sphenoid bone; DD, duplication of dura between periorbita and the
temporal lobe dura; FD, frontal lobe dura; OC, roof of the optic canal; ON, optic
nerve (with falciform ligament); OR, orbital roof; PO, periorbita; PS, planum
sphenoidale; SR, sphenoid ridge.
the temporal lobe dura was partially exposed. Furthermore, the
orbital roof was unroofed, and the duplication of the dura, which
is a periosteal fold that stretches between the periorbita and
temporal lobe dura, was completely exposed (Figure 1D). The
course of the optic canal was essentially parallel to the trajectory
from the proximal orifice of the optic canal to the supraorbital
keyhole craniotomy (Figure 1C, D).
A small bony eminence on the lesser wing of the sphenoid
bone was identified in 57.4% (right side, 48.5%; left side,
65.7%) of the 36 dry craniums. The distance between the
eminence and the tip of the ACP averaged 18.6 mm (right and
left, 18.1 and 19.0 mm, respectively; Figure 2).
Endoscopic Extradural Anterior Clinoidectomy
Anterior clinoidectomy proceeded using an endoscope (4 mm;
0 degrees) that provided a clear, panoramic view of the ACP and
surrounding structures without using a brain retractor. The
extradural space was flooded with water, and the center of the ACP
was meticulously hollowed out until it became paper thin and
transparent, using a 2-mm drill with a diamond burr under

NEUROSURGERY VOLUME 68 | OPERATIVE NEUROSURGERY 2 | JUNE 2011 | ons335

Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited.

 KOMATSU ET AL
L7CK25A0OKO2Hi82Fb3Fy/8X5B+N46vwEp4Go7q/yVfHFl3zwAW3JeOmzfokQazpHHa81Z3fIBoHYgoJgi3aMIMXYGp1pVwhQF/Y
Downloaded from http://journals.lww.com/onsonline by 2hMAudMCs2pieqblJGkyjXq4c6/cQ8pv73YAfxezYUIA6cP
bcf3oLb4DS+6rHChS4mhm6XJEFL0KHgV5AA== on 06/21/2023
FIGURE 2. Lateral perspective of the endocranial surface of
the anterior cranial base. Arrow indicates the small emi-
nence at the transition between the sphenoid ridge and
anterior clinoid (AC) process on the lesser wing of the
sphenoid bone. OR, orbital roof; PS, planum sphenoidale;
SR, sphenoid ridge.
continuous irrigation through the endoscopic sheath (Figure 3A, B).
The roof of the optic canal was also unroofed by the drill. The
hollowed ACP was separated from the surrounding dural folds and
then gently fractured and divided from the roof of the optic canal
and from the optic strut. Finally, a small piece of the tip of the ACP
was very carefully extirpated (Figure 3C). Thus, the clinoidal
(Dolenc’s) triangle was visualized, and the clinoidal portion of the
carotid artery and the carotidoculomotor membrane were exposed
(Figure 3D).
DISCUSSION
The anatomy of the ACP with respect to its shape, length,
width, angle, and relationship with surrounding structures has
already been described in detail.7,9,22-25 The ACP is located at
the medial and deepest end of the lesser wing of the sphenoid
bone and is tightly covered with dural folds. The optic canal is
situated medially, and the superior orbital fissure is situated
laterally to the ACP. The area removed from the ACP is called the
clinoid space; this segment of the internal carotid artery is called
the clinoid segment, and the floor of this space is the superior wall
of the cavernous sinus. Thus, the location, dural formation, and
relationship between the ACP and vital structures render anterior
clinoidectomy delicate.8
To overcome this, several authors have proposed that dividing the
duplication of the dura stretching between the periorbita and
temporal fossa dura is key to increased ACP exposure and to ac-
complishing anterior clinoidectomy under better visibility.7,8,12,13,26
However, we improved visibility using an endoscope because it
provides clear, panoramic views of the ACP and its surrounding
structures with adequate magnification, and the ACP can be reliably
removed without incising the duplication of the dura.
Endoscopic and conventional extradural anterior clinoidec-
tomy differ in some respects. Although bone can be drilled
ons336 | VOLUME 68 | OPERATIVE NEUROSURGERY 2 | JUNE 2011
Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited.
FIGURE 3. Sequential views of endoscopic extradural anterior clinoidectomy.
A, the endoscope provides a wide and clear view of the anterior clinoid process
(ACP) and surrounding structures. This image was acquired under water during
drilling. B, the ACP is hollowed out until it becomes paper thin and transparent.
C, after fracturing the ACP, a small piece of the ACP tip was removed. D, final
view of endoscopic extradural anterior clinoidectomy. The clinoidal (Dolenc’s)
triangle, clinoidal portion of carotid artery, and carotidoculomotor membrane are
exposed. CM, carotidoculomotor membrane; CP, clinoid portion of the carotid
artery; DR, distal dural ring; FD, frontal lobe dura; PO, periorbita; OS, optic
strut; TA, tip of the anterior clinoid process; TE, anteromedial aspect of the
tentorium; II, optic nerve with sheath.
without immersion, the endoscopic lens in the extradural space
becomes covered with bone dust and requires frequent cleaning.
Therefore, we drilled under water with continuous irrigation,
which obviously maintained clear visibility. In addition to
relaxation of the frontal lobe in the fresh cadavers, because the
endoscope can advance through deep and narrow corridors,
a brain retractor was not required for this study. However, some
extent of frontal retraction or cerebrospinal fluid drainage would
be needed in the clinical setting to create a similar condition.
The first stage of extradural exploration is sometimes difficult
to precisely orient because the endoscope displays focal regions at
significant magnification. Therefore, the anatomy of the bone at
the anterior cranial base must be understood in detail. The small
bony eminence located at the transition between the base of the
ACP and the sphenoid ridge on the lesser wing can serve as an
anatomic landmark during bone removal steps and would be
useful to anticipate the location of the tip of the ACP under
endoscopic observation. In addition to preoperative anatomic
evaluation of the ACP by 3-dimensional computed tomography,
the preoperative evaluation of this eminence would lead to a
well-oriented operation.
We performed endoscopic anterior clinoidectomy via the
supraorbital keyhole alone. However, this technique would be
www.neurosurgery-online.com

applicable to endoscopic extradural anterior clinoidectomy as an
adjunct to microscopic surgery with conventional craniotomy,
endoscopic extradural anterior clinoidectomy to assist supraor-
bital keyhole microsurgery, and endoscopic surgery alone with
L7CK25A0OKO2Hi82Fb3Fy/8X5B+N46vwEp4Go7q/yVfHFl3zwAW3JeOmzfokQazpHHa81Z3fIBoHYgoJgi3aMIMXYGp1pVwhQF/Y
endoscopic extradural anterior clinoidectomy via the supraorbital
keyhole. Parasellar meningiomas with optic canal involvement are
Downloaded from http://journals.lww.com/onsonline by 2hMAudMCs2pieqblJGkyjXq4c6/cQ8pv73YAfxezYUIA6cP
favorable candidates for this technique. Endoscopy would also
clarify the relationship between such tumors and the optic nerve
after anterior clinoidectomy and optic canal unroofing.
Finally, endoscopic extradural anterior clinoidectomy offers
reliable removal of the ACP under excellent visualization.
However, it should only be performed by experienced endoscopic
bcf3oLb4DS+6rHChS4mhm6XJEFL0KHgV5AA== on 06/21/2023
surgeons who have undergone intensive training by means of
endoscopic cadaver dissections.
CONCLUSION
This cadaveric study suggests that endoscopic supraorbital
extradural anterior clinoidectomy is feasible with minimal inva-
siveness. This method offers reliable anterior clinoidectomy
under superb endoscopic imaging and excellent visibility facili-
tated by continuous irrigation through the endoscopic sheath.
This method would be applicable to parasellar and cavernous
sinus surgery combined with supraorbital or conventional
craniotomy.
Disclosure
The authors have no personal financial or institutional interest in any of
the drugs, materials, or devices described in this article.
REFERENCES
1. Dolenc VV. A combined epi- and subdural direct approach to carotid-ophthalmic
artery aneurysms. J Neurosurg. 1985;62(5):667-672.
2. Evans JJ, Hwang YS, Lee JH. Pre- versus post-anterior clinoidectomy measure-
ments of the optic nerve, internal carotid artery, and opticocarotid triangle:
a cadaveric morphometric study. Neurosurgery. 2000;46(4):1018-1021; discussion
1021-1023.
3. Heros RC, Nelson PB, Ojemann RG, Crowell RM, DeBrun G. Large and
giant paraclinoid aneurysms: surgical techniques, complications, and results.
Neurosurgery. 1983;12(2):153-163.
4. Yonekawa Y, Ogata N, Imhof HG, et al. Selective extradural anterior clinoi-
dectomy for supra- and parasellar processes. Technical note. J Neurosurg.
1997;87(4):636-642.
5. Yasargil MG, Gasser JC, Hodosh RM, Rankin TV. Carotid-ophthalmic aneur-
ysms: direct microsurgical approach. Surg Neurol. 1977;8(3):155-165.
6. Al-Mefty O. Clinoidal meningiomas. J Neurosurg. 1990;73(6):840-849.
7. Noguchi A, Balasingam V, Shiokawa Y, McMenomey SO, Delashaw JB Jr.
Extradural anterior clinoidectomy. Technical note. J Neurosurg. 2005;102(5):
945-950.
8. Froelich SC, Aziz KM, Levine NB, Theodosopoulos PV, van Loveren HR, Keller
JT. Refinement of the extradural anterior clinoidectomy: surgical anatomy of the
orbitotemporal periosteal fold. Neurosurgery. 2007;61(5 suppl 2):179-185;
discussion 185-186.
9. Hayashi N, Masuoka T, Tomita T, Sato H, Ohtani O, Endo S. Surgical anatomy
and efficient modification of procedures for selective extradural anterior clinoi-
dectomy. Minim Invasive Neurosurg. 2004;47(6):355-358.
10. Chang DJ. The ‘‘no-drill’’ technique of anterior clinoidectomy: a cranial base
approach to the paraclinoid and parasellar region. Neurosurgery. 2009;64(3
Suppl):96-105; discussion 105-106.
NEUROSURGERY
Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited.
PURELY ENDOSCOPIC ANTERIOR CLINOIDECTOMY
11. Chang HS, Joko M, Song JS, Ito K, Inoue T, Nakagawa H. Ultrasonic bone
curettage for optic canal unroofing and anterior clinoidectomy. Technical note.
J Neurosurg. 2006;104(4):621-624.
12. Avci E, Bademci G, Ozturk A. Microsurgical landmarks for safe removal of
anterior clinoid process. Minim Invasive Neurosurg. 2005;48(5):268-272.
13. Coscarella E, Baskaya MK, Morcos JJ. An alternative extradural exposure to the
anterior clinoid process: the superior orbital fissure as a surgical corridor.
Neurosurgery. 2003;53(1):162-166; discussion 166-167.
14. Cappabianca P, Alfieri A, Colao A, Ferone D, Lombardi G, de Divitiis E.
Endoscopic endonasal transsphenoidal approach: an additional reason in support
of surgery in the management of pituitary lesions. Skull Base Surg. 1999;9(2):
109-117.
15. Cappabianca P, Cavallo LM, de Divitiis E. Endoscopic endonasal transsphenoidal
surgery. Neurosurgery. 2004;55(4):933-940; discussion 940-931.
16. Cappabianca P, Cavallo LM, Esposito F, De Divitiis O, Messina A, De Divitiis E.
Extended endoscopic endonasal approach to the midline skull base: the evolving
role of transsphenoidal surgery. Adv Tech Stand Neurosurg. 2008;33:151-199.
17. Cavallo LM, Cappabianca P, Messina A, et al. The extended endoscopic endonasal
approach to the clivus and cranio-vertebral junction: anatomical study. Childs Nerv
Syst. 2007;23(6):665-671.
18. Cavallo LM, de Divitiis O, Aydin S, et al. Extended endoscopic endonasal
transsphenoidal approach to the suprasellar area: anatomic considerations–part 1.
Neurosurgery. 2007;61(3 suppl):24-33; discussion 33-34.
19. Cavallo LM, Messina A, Cappabianca P, et al. Endoscopic endonasal surgery of the
midline skull base: anatomical study and clinical considerations. Neurosurg Focus.
2005;19(1):E2.
20. Fischer J, Mustafa H. Endoscopic-guided clipping of cerebral aneurysms. Br J
Neurosurg. 1994;8(5):559-565.
21. Perneczky A, Boecher-Schwarz HG. Endoscope-assisted microsurgery for cerebral
aneurysms. Neurol Med Chir (Tokyo). 1998;38(suppl):33-34.
22. Inoue T, Rhoton AL Jr, Theele D, Barry ME. Surgical approaches to the cavernous
sinus: a microsurgical study. Neurosurgery. 1990;26(6):903-932.
23. Knosp E, Muller G, Perneczky A. The paraclinoid carotid artery: anatomical
aspects of a microneurosurgical approach. Neurosurgery. 1988;22(5):896-901.
24. Maniscalco JE, Habal MB. Microanatomy of the optic canal. J Neurosurg.
1978;48(3):402-406.
25. Mikami T, Minamida Y, Koyanagi I, Baba T, Houkin K. Anatomical variations in
pneumatization of the anterior clinoid process. J Neurosurg. 2007;106(1):170-174.
26. Dolenc VV. Frontotemporal epidural approach to trigeminal neurinomas.
Acta Neurochir (Wien). 1994;130(1-4):55-65.
COMMENTS
T he authors present a cadaveric study on the feasibility of anterior
clinoidectomy via an endoscopic approach through a supraorbital
surgical corridor. This is a novel concept that may be a useful adjunct for
clinical practice. The performance of such a procedure underwater,
although not an original idea, is a clever and important addition to the
literature and may decrease the rates of thermal injury to the optic nerve.
Although any extradural approach to the anterior clinoid process has the
drawbacks of localization along a variable and often distorted anterior
cranial base anatomy, particularly in the presence of tumors in the area
and limited visualization because of the tight adherence to the dura, the
endoscopic concept may become a useful adjunct as more surgeons gain
familiarity with endoscopes. Further work on the application of such
technique in clinical practice would be necessary to fully evaluate the
merit of this technique.
Philip Theodosopoulos
Cincinnati, Ohio
I n this article, the authors describe a technique of endoscopic controlled
extradural clinoidectomy through a supraorbital keyhole approach in
VOLUME 68 | OPERATIVE NEUROSURGERY 2 | JUNE 2011 | ons337
 KOMATSU ET AL
cadavers. The notion that one can accomplish the drilling for this ap-
proach under water with endoscopic observation, as the authors state,
seems difficult to imagine because of the extreme turbulence created by
the drill; however, if it is possible, then the irrigation would have the
L7CK25A0OKO2Hi82Fb3Fy/8X5B+N46vwEp4Go7q/yVfHFl3zwAW3JeOmzfokQazpHHa81Z3fIBoHYgoJgi3aMIMXYGp1pVwhQF/Y
added benefit of helping to cool the drill, as the authors point out.
Achieving adequate retraction to leave a space for the endoscope without
retraction of the dura in a living patient would likely be more difficult
Downloaded from http://journals.lww.com/onsonline by 2hMAudMCs2pieqblJGkyjXq4c6/cQ8pv73YAfxezYUIA6cP
than in a cadaver. Nonetheless, there is no technical maneuver performed
in this approach that would not be possible in a living patient under
endoscopic control. Although the extradural clinoidectomy is much as
has been described before, this set of dissections demonstrates the en-
doscopic anatomy, which may prove useful for anyone contemplating
this approach in a patient. Its use in living patients and its superiority
over existing techniques, if any, will still need to be validated. As pre-
bcf3oLb4DS+6rHChS4mhm6XJEFL0KHgV5AA== on 06/21/2023
liminary work, it provides proof of concept for which the authors should
be congratulated.
Peter Nakaji
Phoenix, Arizona
T his is an anatomic study describing the technique of the endoscopic
anterior clinoidectomy via supraorbital keyhole procedure. The
authors studied this technique on 8 fresh cadaver heads and bone
landmarks on 36 dry craniums. This is a welcomed anatomic study that
provides the steppingstone for further clinical studies that can evaluate its
possible clinical application for anterior clinoidectomy. The authors
should be congratulated on this anatomic work.
An anterior clinoidectomy is a relatively simple, routine, and low-risk
extradural technique that has been practiced by trained cranial-base
surgeons around the world for more than 2 decades as a part of surgery
for various paraclinoid lesions.1-9 The cranio-orbital cranial base
approach and removal of the roof and lateral wall of the orbit bring the
anterior clinoid ‘‘to the surface.’’ Its removal is then further facilitated by
opening the superior orbital fissure. These maneuvers provide wide
lateral, ventral, and superior/dorsal access to the anterior clinoid, avoid
retraction, and enable its safe resection. A high-speed microdiamond drill
with irrigation, micro Kerrison (1 mm) small rongeur, and Rhoton
microsurgical tool set are different tools that we interchangeably use
depending on intraoperative anatomy, size of the clinoid, anatomic
relationships, and so on. The microscope provides magnification,
illumination, 3-dimensional visualization, communication with the
operating room team, and education for trainees. Occasionally, in vas-
cular (aneurysm) cases, remnants of the anterior clinoid are removed
intradurally. In short, microsurgical extradural anterior clinoidectomy
has been considered the gold standard by many neurosurgeons.
ons338 | VOLUME 68 | OPERATIVE NEUROSURGERY 2 | JUNE 2011
Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited.
Other techniques for anterior clinoidectomy, such as the one studied
by the authors (endoscopic), are welcomed. Its clinical applications and
potential benefits, however, need to be further tested in vivo, evaluated,
and then compared with the existing, time-tested technique (extradural
microsurgical anterior clinoidectomy).
Kenan Arnautovic
Memphis, Tennessee
1. Dolenc VV. Anatomy and Surgery of the Cavernous Sinus. New York: Springer-
Verlag, 1989.
2. Arnautovic KI, Al-Mefty O, Angtuaco E. A combined microsurgical skull-base and
endovascular approach to giant and large paraclinoid aneurysms. Surg Neurol.
1998;50:504-520.
3. Yonekawa Y, Ogata N, Imhof HG, et al. Selective extradural anterior clinoidectomy
for supra- and parasellar processes. Technical note. J Neurosurg. 1997;87(4):
636-642.
4. Noguchi A, Balasingam V, Shiokawa Y, McMenomey SO, Delashaw JB Jr.
Extradural anterior clinoidectomy. Technical note. J Neurosurg. 2005;102(5):
945-950.
5. Froelich SC, Aziz KM, Levine NB, Theodosopoulos PV, van Loveren HR, Keller
JT. Refinement of the extradural anterior clinoidectomy: surgical anatomy of the
orbitotemporal periosteal fold. Neurosurgery. 2007;61(5 Suppl 2):179-185;
discussion 185-186.
6. Hayashi N, Masuoka T, Tomita T, Sato H, Ohtani O, Endo S. Surgical anatomy
and efficient modification of procedures for selective extradural anterior clinoi-
dectomy. Minim Invasive Neurosurg. 2004;47(6):355-358.
7. Chang HS, Joko M, Song JS, Ito K, Inoue T, Nakagawa H. Ultrasonic bone
curettage for optic canal unroofing and anterior clinoidectomy. Technical note.
J Neurosurg. 2006;104(4):621-624.
8. Avci E, Bademci G, Ozturk A. Microsurgical landmarks for safe removal of anterior
clinoid process. Minim Invasive Neurosurg. 2005;48(5):268-272.
9. Coscarella E, Baskaya MK, Morcos JJ. An alternative extradural exposure to the
anterior clinoid process: the superior orbital fissure as a surgical corridor. Neuro-
surgery. 2003;53(1):162-166; discussion 166-167.
T he authors have nicely shown that, in a cadaver model, the anterior
clinoid process may be removed through a small supraorbital cra-
niotomy using a subfrontal extradural approach and endoscopic tech-
niques. Experienced neurosurgeons may decide whether this endoscopic
approach might be superior from the standpoint of either safety or
efficacy to the techniques that they currently use for the removal of the
anterior clinoid.
Bruce Mickey
Dallas, Texas
www.neurosurgery-online.com