Image-guided, endoscopic-assisted drilling and exposure of the whole length of the internal auditory canal and its fundus with preservation of the integrity of the labyrinth using a retrosigmoid approach: a laboratory investigation

Promod Pillai, Steffen Sammet, Mario Ammirati
Neurosurgery 2009, 65 (6): 53-9; discussion 59

OBJECTIVE: Hearing loss after removal of vestibular schwannomas with preservation of the cochlear nerve can result from labyrinthine injury of the posterior semicircular canal and/or common crus during drilling of the posterior wall of the internal auditory meatus. Indeed, there are no anatomic landmarks that intraoperatively identify the position of the posterior semicircular canal or of the common crus. We investigated the usefulness of image guidance and endoscopy for exposure of the internal auditory canal (IAC) and its fundus without labyrinthine injury during a retrosigmoid approach.

METHODS: A retrosigmoid approach to the IAC was performed on 10 whole fresh cadaveric heads after acquiring high-resolution computed tomographic scans (120 kV; slice thickness, 1 mm; field of vision, 40 cm; matrix, 512 x 512) with permanent bone-implanted reference markers. Drilling of the posterior wall of the IAC was executed with image guidance. Its most lateral area was visualized using endoscopy.

RESULTS: Target registration error for the procedure was 0.28 to 0.82 mm (mean, 0.46 mm; standard deviation, 0.16 mm). The measured length of the IAC along its posterior wall was 9.7 +/- 1.6 mm. The angle of drilling (angle between the direction of drill and the posterior petrous surface) was 43.3 +/- 6.0 degrees, and the length of the posterior wall of the IAC drilled without violating the integrity of the labyrinth was 7.2 +/- 0.9 mm. The surgical maneuvers in the remaining part of the IAC, including the fundus, were performed using an angled endoscope.

CONCLUSION: Frameless navigation using high-resolution computed tomographic scans and bone-implanted reference markers can provide a "roadmap" to maximize safe surgical exposure of the IAC without violating the labyrinth and leaving a small segment of the lateral IAC unexposed. Further exposure and surgical manipulation of this segment, including the fundus without additional cerebellar retraction and labyrinthine injury, can be achieved using an endoscope. Use of image guidance and an endoscope can help in exposing the entire posterior aspect of the IAC including its fundus without violating the labyrinth through a retrosigmoid approach. This technique could improve hearing preservation in vestibular schwannoma surgery.

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