Table of Contents
l
Unilateral Intradural Approach to the Frontal Base ...... 2
Typical Indications for Surgery ........................ 2
Principal Anatomical Structures ....................... 2
Positioning and Skin Incisions ........................ 2
Craniotomy ........................................... 2
Opening the Dura ..................................... 2
Dissection in the Area of the Superior Sagittal Sinus 4
Care of injuries to the Superior Sagittal Sinus ........ 5
Dura, Bone, and Wound Closure ..................... 5
Potential Errors and Dangers ......................... 5
Bilateral Extradural and
Intradnra! Approach to the Frontal Base ................ 6
Typical Indications for Surgery ........................ 6
Principal Anatomical Structures ....................... 6
Positioning and Skin Incisions ........................ 6
Craniotomy ........................................... 6
Extradural Exposure of Frontal Base ................. 6
Intradural Exposure of Frontal Base .................. 8
Intradural Development of the Frontal Base ......... 10
Wound Closure ........................................ 10
Potential Errors and Dangers ......................... 10
Typical Indications for Surgery ........................ 12
Principal Anatomical Structures....................... 12
Positioning and Skin Incisions ........................ 12
Dissection of the Nasal Region ....................... 12
Evacuation of Paranasal Sinuses ...................... 12
Opening the Anterior Wall of the Sella ............... 14
Opening of the Intrasellar Capsule .................... 14
Closure of the Anterior Wall of the Sella ............. 15
Wound Closure........................................ 15
Potential Errors and Dangers ......................... 15
Trail mush I Transsphenoidal Approach to the Sella Turcica 16
Typical Indications for Surgerò&\\...................... 16
Principal Anatomical Structures ....................... 16
Positioning and Skin Incisions ........................ 16
Dissection of Soft Tissues ............................. 17
Dissection of the Sphenoid Sinus..................... 18
Dissection in the Scllar Region ....................... 18
Wound Closure........................................ 19
Potential Errors and Dangers ......................... 19
21
Subfrontal Intracranial Approach to the Orhit .......... 22
Typical Indications for Surgery ........................ 22
Principal Anatomical Structures ....................... 22
Positioning and Skin Incisions ........................ 22
Craniotomy ........................................... 22
Dissection at the Base of the Skull ................... 22
Closure of Opening in Base of Skull.................. 24
Wound Closure ........................................ 25
Potential Errors and Dangers ......................... 25
Anterior Extracranial Superior Approach to the Orbit... 26
Typical Indications for Surgery ........................ 26
Principal Anatomical Structures ....................... 26
Positioning and Skin Incisions ........................ 26
Dissection of the Superior Orbit ...................... 27
Dissection in the Superior Inlraorbital Region ........ 28
Wound Closure ........................................ 28
Potential Errors and Dangers ......................... 28
Anterior Extracranial Median Approach to the Orbit.... 29
Typical Indications for Surgery ........................ 29
Principal Anatomical Structures ....................... 29
Positioning and Skin Incision ......................... 29
Opening the Orbit with Minor Bone Resection ....... 30
Orbital Dissection ..................................... 31
Wound Closure ........................................ 31
Potential Errors and Dangers ......................... 31
Lateral Extracranial Approach to the Orbit (Kronlein) .. 32
Typical Indications for Surgery ........................ 32
Principal Anatomical Structures ....................... 32
Positioning and Skin Incision ......................... 32
Dissection of the Superficial Temporo-Orbital Region 32 Dissection of the Temporal Muscle ................... 33
Resection of the Lateral Margin of the Orbit ......... 34
Lateral Orbitotomy .................................... 34
Dissection Inside the Orbit ........................... 36
Closure of Soft-Tissue Layers ......................... 36
Wound Closure ........................................ 37
Potential Errors and Dangers ......................... 37
VI
Table of Contents
39
40
40
40
40
40
41
41
43
43
44
44
44
44
44
44
45
46
47
48
49
49
49
49
50
50
52
52
53
53
55
56
56
56
56
57
57
58
58
61
61
62
62
62
62
•Unilateral Extradurai Approach to the Frontotemporal Junction .............
Typical Indications for Surgery ......
Principal Anatomical Structures.....
Positioning and Skin Incisions ......
Dissection of Soft Tissues ...........
Craniotomy .........................
Retraction of Dura-Invested Brain .. Bone and Wound Closure ...........
Potential Errors and Dangers .......
Unilateral Intradural Approach to the Frontotemporal Junction ...............
Typical Indications for Surgery ........
Principal Anatomical Structures.......
Positioning and Skin Incision .........
Dissection of Soft Tissues .............
Craniotomy ...........................
Opening the Dura .....................
Development of the Chiasmal Region Bone and Wound Closure .............
Potential Errors and Dangers .........
Pterional Tntradural Approach to the Frontotemporal Junction .........................
Typical Indications for Surgery ..................
Principal Anatomical Structures.................
Positioning and Skin Incision ...................
Dissection of Soft Tissues .......................
Craniotomy .....................................
Opening the Dura ...............................
Dissection of the Lateral Sulcus (Syfvian Fossa) Dura, Bone, and Wound Closure ...............
Potential Errors and Dangers ...................
Intradural Approach to the Middle Cranial Fossa .
Typical Indications for Surgery ..................
Principal Anatomical Structures.................
Positioning and Skin Incisions ..................
Craniotomy .....................................
Opening the Dura ...............................
Dissection of the Middle Base of the Skull and of the Tentorial Border .......................
Dissection of the Temporal Lobe ...............
Wound Closure..................................
Potential Errors and Dangers ...................
Extradural Approach to the Middle Cranial Fossa
Typical Indications for Surgery ..................
Principal Anatomical Structures.................
Positioning and Skin Incisions ..................
Craniotomy .....................................
Dissection Above the Dura Mater ..............
Wound Closure..................................
Potential Errors and Dangers ...................
65
Occipital-Paramedian Approach to the Occipital Region 66
Typical Indications for Surgery ........................ 66
Principal Anatomical Structures....................... 66
Positioning and Skin Incisions ........................ 66
Craniotomy ........................................... 67
Exposure of the Intercerebral Fissure ................. 67
Opening the Dura ..................................... 67
Wound Closure........................................ 68
Potential Errors and Dangers ......................... 68
Occipital-Supratentorial Approach
to the Occipital Region ................................. 69
Typical Indications for Surgery ........................ 69
Principal Anatomical Structures ....................... 69
Positioning and Skin Incisions ........................ 69
Craniotomy ........................................... 70
Opening the Dura ..................................... 70
Wound Closure ........................................ 70
Potential Errors and Dangers ......................
Occipital Transcerebral Approach to the Occipital Region 74
Typical Indications for Surgery ........................ 74
Principal Anatomical Structures ....................... 74
Positioning and Skin Incision ......................... 74
Craniotomy ........................................... 74
Opening the Dura and Incision of the Brain ......... 74
Wound Closure ........................................ 76
Potential Errors and Dangers ......................... 76
77
Transfrontal Transventricular
Approach to the Anterior Midline Region ............... 78
Typical Indications for Surgery ........................ 78
Principal Anatomical Structures ....................... 78
Positioning and Skin Incisions ........................ 78
Dissection of Soft Tissues ............................. 78
Craniotomy ........................................... 78
Opening the Dura ..................................... 78
Dissection of the Brain and Opening
of the Lateral Ventricle ............................. 79
Exploration of the Interventricular Foramen
and Third Ventricle ................................. 80
Bone and Wound Closure ............................. 81
Potential Errors and Dangers ......................... 81
Transcallosal Approach to the Anterior Midline Region . 82
Typical Indications for Surgery ........................ 82
Principal Anatomical Structures ....................... 82
Positioning and Skin Incisions ........................ 82
Dissection of Soft Tissues ............................. 82
Craniotomy ........................................... 82
Opening the Dura ..................................... 83
Exploration of the Corpus Callosum ................. 83
Exploration of the Fornix ............................. 85
Bone and Wound Closure ............................. 85
Potential Errors and Dangers ......................... 85
Table of Contents
107
108
108
108
108
109
110
111
111
Subfrontal Transterminal Approach
to the Anterior Midline Region ........................ 86
Typical Indications for Surgery ....................... 86
Principal Anatomical Structures ...................... 86
Positioning and Skin Incisions ....................... 86
Craniotomy .......................................... 86
Opening the Dura .................................... 86
Incision of the Terminal Lamina ..................... 88
Bone and Wound Closure ............................ 88
Potential Errors and Dangers ........................ 88
Median Approach to the Posterior Cranial Fossa
Typical Indications for Surgery .................
Principal Anatomical Structures................
Positioning and Skin Incisions .................
Craniotomy ....................................
Opening the Dura ..............................
Dural and Wound Closure .....................
Potential Errors and Dangers ..................
112
112
112
112
112
113
114
114
114
Retrosigmoid (Retroauricular) Approach to the Posterior Cranial Fossa ............
Typical Indications for Surgery ..........
Principal Anatomical Structures..........
Positioning and Skin Incisions ..........
Incision of Soft Tissues and Craniotomy Incision of Dura..........................
Dural and Wound Closure ...............
Potential Errors and Dangers ............
115
115
115
115
116
117
118
118
119
119
119
119
119
119
121
122
122
123
123
123
123
124
124
124
125
125
89
Transcallosal Approach to the Central Midline Region . 90
Typical Indications for Surgery ....................... 90
Principal Anatomical Structures ...................... 90
Positioning and Skin Incisions ....................... 90
Craniotomy .......................................... 90
Opening the Dura .................................... 91
Clarification and Incision of the Corpus Callosum .. 92
Bone and Wound Closure ............................ 92
Potential Errors and Dangers ........................ 92
Parietal Transventricular Approach
to the Central Midline Region ......................... 93
Typical Indications for Surgery ....................... 93
Principal Anatomical Structures ...................... 93
Positioning and Skin Incisions ....................... 93
Craniotomy .......................................... 93
Opening the Dura .................................... 94
Opening the Ventricle ................................ 95
Bone and Wound Closure ............................ 96
Potential Errors and Dangers ........................ 96
97
Supratentorial Approach
to the Quadrigeminal and Pineal Regions ............. 98
Typical Indications for Surgery ....................... 98
Principal Anatomical Structures ...................... 98
Positioning and Skin Incision ........................ 98
Craniotomy .......................................... 98
Opening the Dura .................................... 98
Exploration and Incision of the Tentorium -
Exploration of the Deep Veins .................... 100
Bone and Wound Closure ............................ 100
Potential Errors and Dangers ........................ 101
Infratentorial Supracerebellar
Approach to the Quadrigeminal and Pineal Regions ... 102
Typical Indications for Surgery ....................... 102
Principal Anatomical Structures ...................... 102
Positioning and Skin Incisions ....................... 102
Craniotomy .......................................... 102
Opening the Dura .................................... 104
Dissection of the Cerebellum and Exposure of the Veins ......................... 105
Bone and Wound Closure ............................ 105
Potential Errors and Dangers ........................ 105
Paramedian Unilateral Approach to the Posterior Cranial Fossa ...
Typical Indications for Surgery . Principal Anatomical Structures Positioning and Skin Incisions . Incision of Soft Tissues ........
Craniotomy ....................
Opening the Dura ...............
Dural and Wound Closure ......
Potential Errors and Dangers ...
Median Suboccipital Approach
to the Posterior Cranial Fossa ...........
Typical Indications for Surgery .........
Principal Anatomical Structures ........
Positioning and Skin Incision ..........
Incision of Soft Tissues ................
Craniotomy and Resection of the Atlas Opening the Dura ......................
Dural and Wound Closure .............
Potential Errors and Dangers ..........
Paramedian Suboccipital Approach to the Posterior Cranial Fossa .....
Typical Indications for Surgery ... Principal Anatomical Structures .. Positioning and Skin Incisions ... Incision of Soft Tissues ..........
Craniotomy ......................
Opening the Dura ................
Dural and Wound Closure .......
Potential Errors and Dangers ....
VIII
Table of Contents
Anterior Approach to the Cervical Spine ............... 128
Typical Indications for Surgery ....................... 128
Principal Anatomical Structures...................... 128
Positioning and Skin Incisions ....................... 128
Dissection in the Plane of Muscles and Soil Tissues 129 Dissection of the Superficial Layers .................. 129
Dissection in the Area of the Deep Cervical Fascia . 132 Wound Closure ....................................... 132
Potential Errors and Dangers ........................ 132
Medio lateral Approach to the Cervical Spine .......... 133
Typical Indications for Surgery ....................... 133
Principal Anatomical Structures ...................... 133
Positioning and Skin Incision ........................ 133
Dissection of the Superficial Layer .................. 133
Dissection of the Vascular Layer ..................... 133
Dissection in the Muscular Layer .................... 135
Wound Closure ....................................... 136
Potential Errors and Dangers ........................ 136
Posterior Approach to the Cervical Spine .............. 137
Typical Indications for Surgery ....................... 137
Principal Anatomical Structures ...................... 137
Positioning and Skin Incisions ....................... 137
Dissection of Musculature ........................... 138
Laminectomy at the Level of the Fourth and Fifth Cervical Vertebrate ...................... 139
Opening the Dura .................................... 139
Wound Closure ....................................... 141
Potential Errors and Dangers ........................ 141
Transoral Approach
to the Two Uppermost Cervical Vertebrae .............. 142
Selected Indications for Surgery ..................... 142
Principal Anatomical Structures...................... 142
Positioning and Skin Incision ........................ 142
Exploration of the Posterior Pharyngeal Wall ........ 142
Division of the Posterior Pharyngeal Wall ........... 143
Exploration of the Anterior Sodes of the Two Upper Cervical Vertebrae .............. 143
Wound Closure ....................................... 144
Potential Errors and Dangers ........................ 144
Posterior Approach to the Thoracic Spine .............. 146
Typical Indications for Surgery ....................... 146
Principal Anatomical Structures ...................... 146
Positioning and Incision ............................. 146
Incision of Lhe Top Muscle Layer .................... 146
Retraction of the Musculature ....................... 146
Removal of the Vertebral Arches ..................... 148
Removal of the Spinous Processes................... 148
Opening of the Vertebral Canal ...................... 150
Laminotomy ......................................... 150
Opening the Dura .................................... 151
Wound Closure ....................................... 151
Potential Errors and Dangers ........................ 151
Dorsolateral Approach to the Thoracic Spine .......... 152
Typical Indications for Surgery ....................... 152
Principal Anatomical Structures ...................... 152
Positioning and Skin Incisions ....................... 152
Dissection of the Llpper Soft Tissues ................ 152
Wound Closure ....................................... 154
Potential Errors and Dangers ........................ 154
155
Posterior Approach to the Lumbar Spine .............. 156
Typical Indications for Surgery ....................... 156
Principal Anatomical Structures...................... 156
Positioning and Skin Incisions ....................... 156
Dissection of the Musculature ....................... 156
Fcncstration .......................................... 156
Hemilaminectomy ................................... 158
Laminectomy ........................................ 158
Opening the Dura .................................... 159
Wound Closure....................................... 159
Potential Errors and Dangers ........................ 159
Posterior Approach to Extracariallicular Regions
of the Lumbar Spine .................................. 160
Typical Indications for Surgery ....................... 160
Principal Anatomical Structures ...................... 160
Positioning and Skin Incision ........................ 160
Dissection of Soil Tissues ....,....,,,..,,,,,.,,...... 160
Wound Closure ....................................... 162
Potential Errors and Dangers ........................ 16
163
Anterior Approach to the Brachial Plexus .............. 164
Typical Indications for Surgery ....................... 164
Principal Anatomical Structures ...................... 164
Positioning and Skin Incisions ....................... 164
Dissection of the Superficial Supraclavicular Neives . 164 Division of the Omohyoid Muscle ................... 166
Cleavage of the Deep Fascia and Division of the Anterior Scalene Muscle ................... 166
Division of the Clavicle .............................. 166
Complete Exposure of the Brachial Plexus .......... 168
Osteosynthesis of the Clavicle ....................... 169
Wound Closure ....................................... 169
Potential Errors and Dangers ........................ 169
Typical Indications for Surgery ....................... 170
Principal Anatomical Structures ...................... 170
Positioning and Skin Incision ........................ 170
Exposure of Muscles
in the Axillary Funnel ............................. 170
Exposure of Other Parts of the Plexus
and Communicating Nerves ....................... 170
Wound Closure ....................................... 170
Potential F.rrors and Dangers ........................ 170
IX
Table of Contents
Typical Indications for Surgery ....................... 172
Principal Anatomical Structures ...................... 172
Positioning and Skin Incision ........................ 172
Identification of Adjacent Nerves .................... 172
Wound Closure....................................... 172
Potential Errors and Dangers ........................ 172
Typical Indications for Surgery ....................... 173
Principal Anatomical Structures ...................... 173
Positioning and Skin Incision ........................ 173
Incision of Soft Tissues .............................. 173
Dissection of Nerve .................................. 174
Wound Closure....................................... 174
Potential Errors and Dangers ........................ 174
Approach to the Musculocutaneous Nerve ............. 175
Typical Indications for Surgery ....................... 175
Principal Anatomical Structures...................... 175
Positioning and Skin Incisions at Various Levels .... 175
Exposure in the Axilla ............................... 175
Exposure in the U pper Third of the Upper Arm ..... 175
Exposure in the Lower Third of the Upper Arm .... 175
Wound Closure ....................................... 177
Potential Errors and Dangers ........................ 177
Typical Indications for Surgery ....................... 178
Principal Anatomical Structures ...................... 178
Positioning and Skin Incisions ....................... 178
Dissection of the Neurovascular Bundle in the Axilla 178 Dissection of the Neurovascular Bundle
in the Upper Arm ................................. 180
Dissection of the Neurovascular Bundle in the Elbow 181 Dissection of the Neurovascular Bundle
of the Forearm .................................... 182
Dissection of the Neurovascular Bundle of the Wrist 184 Wound Closure....................................... 184
Potential Errors and Dangers ........................ 184
Approaches to the Radial Nerve ....................... 185
Typical Indications for Surgery ....................... 185
Principal Anatomical Structures ...................... 185
Positioning and Skin Incisions ....................... 185
Exposure of the Nerve in the Upper Third
of the Upper Arm ................................. 186
Exposure of the Nerve in the Middle of the Upper Arm 186 Exposure of the Nerve in the Lower Third
of the Upper Arm ................................. 188
Exposure of the Superficial Branch in the Forearm . 189 Exposure of the Deep Branch in the Forearm ....... 190
Typical Indications for Surgery ....................... 191
Principal Anatomical Structures ...................... 191
Positioning and Skin Incisions ....................... 191
Exposure of the Nerve in the Uper Arm ............ 192
Exposure of the Nerve at the Elbow Level .......... 192
Exposure of the Nerve in the Forearm .............. 192
Exposure of the Nerve at the Wrist .................. 194
Wound Closure ....................................... 194
Potential Errors and Dangers ........................ 194
Approaches to the Dioinguinal Nerve .................. 195
Typical Indications for Surgery ....................... 195
Principal Anatomical Structures ...................... 195
Positioning and Skin Incision ........................ 195
Dissection of Soft Tissues ............................ 195
Exposure of the Nerve ............................... 196
Wound Closure ....................................... 196
Potential Errors and Dangers ........................ 196
Approaches to the Genitofemoral Nerve ............... 197
Typical Indications for Surgery ....................... 197
Principal Anatomical Structures ...................... 197
Positioning and Skin Incisions ....................... 197
Dissection of Soft Tissues ............................ 197
Exposure of the Nerve ............................... 198
Wound Closure....................................... 198
Potential Errors and Dangers ........................ 198
Approaches to the Lateral Cutaneous Nerve of the Thigh 199
Typical Indications for Surgery ....................... 199
Principal Anatomical Structures...................... 199
Positioning and Skin Incision ........................ 199
Dissection of Soft Tissues ............................ 199
Exposure of the Nerve ............................... 200
Wound Closure ....................................... 200
Potential Errors and Dangers ........................ 200
Approaches to the Femoral Nerve ..................... 201
Typical Indications for Surgery ....................... 201
Principal Anatomical Structures ...................... 201
Positioning and Skin Incisions ....................... 201
Dissection of Soft Tissues ............................ 201
Exposure of Nerve in Inguinal Region ............... 201
Exposure in the Pelvic Region ....................... 203
Wound Closure....................................... 203
Potential Errors and Dangers ........................ 203
Approaches to the Obturator Nerve .................... 204
Typical Indications for Surgery ....................... 204
Principal Anatomical Structures...................... 204
Positioning and Skin Incision ........................ 204
Dissection of Muscle Layers and Soft Tissues ....... 204
Exposure of the Nerve ............................... 204
Wound Closure ....................................... 204
Potential Errors and Dangers ........................ 204
Typical Indications for Surgery ....................... 206
Principal Anatomical Structures ...................... 206
Positioning and Skin Incisions ....................... 206
Dissection of Soft Tissues in the Pelvis and Thigh ... 206
Exposure of the Nerve in the Pelvis ................. 206
Exposure of the Nerve in the Thigh ................. 208
Wound Closure....................................... 209
Potential Errors and Dangers ........................ 209
Approaches to the Tlbial Nerve ........................ 210
Typical Indications for Surgery ....................... 210
Principal Anatomical Structures ...................... 210
Positioning and Skin Incisions ....................... 210
Dissection of the Tibial Nerve Above and Inside the
Popliteal Fossa ..................... 210
Exposure of the Nerve in the Lower Leg ............ 212