- Email: [email protected]
Prevention of postoperative complications in skull base surgery for nasal or paranasal sinus carcinoma invading the skull base
jocn-141.qxd
5/7/01 11:50 AM
Page 67
Journal of Clinical Neuroscience (2001) 8(Supplement 1), 67–70 © 2001 Harcourt Publishers Ltd doi: 10.1054/jocn.2001.0881, available online at http://www.idealibrary.com on
Prevention of postoperative complications in skull base surgery for nasal or paranasal sinus carcinoma invading the skull base Shigeru Nishizawa1 MD PHD, Naoki Yokota1 MD PHD, Tetsuo Yokoyama1 MD PHD, Hiroyuki Mukodaka2 MD, Takahiro Watanabe2 MD, Tomoyuki Hoshino2 MD PHD, Yoshio Ueda3 MD PHD Departments of 1Neurosurgery, 2Oto-rhino-laryngology and 3Plastic Surgery, Hamamatsu University School of Medicine, Shizuoka, Japan
Summary With recent technical advances in skull base surgery, radical resection of a nasal or paranasal sinus carcinoma invading the skull base can now be achieved. To assure a satisfactory surgical result, it is essential to prevent postoperative infection. In our series of 14 cases, serious postoperative infections occurred in the earliest 10 cases, and only 2 of these patients are still alive. The vascularised abdominal muscle flap for skull base reconstruction was fixed with fibrin glue, but was not adequate to fill the dead space, resulting in cerebrospinal fluid leakage and subsequent meningitis. Once the infection occurred, a free bone flap became the focus of infection. Based on these earlier experiences, we used a ROCTM fastener system to completely fill the dead space with an abdominal muscle flap, and bone flap was primarily craniectomised in the four most recent cases. With this technique, there were no postoperative infections. © 2001 Harcourt Publishers Ltd Keywords: infection, paranasal malignant tumour, ROCTM fastener system, skull base invasion, skull base surgery
INTRODUCTION Recent advances in surgical techniques for skull base lesions have made it possible to perform radical surgical resection of nasal or paranasal sinus carcinomas invading the skull base.1–6 In order to improve surgical results, a multidisciplinary approach to skull base surgery with neurosurgeons, oto-rhino-laryngologists and plastic surgeons is extremely important. However, postoperative complications affecting surgical outcomes remain serious problems.1–6 The authors have, to date, experienced 14 patients with nasal or paranasal sinus carcinomas invading the skull base who underwent multidisciplinary extended radical skull base surgery. As major surgical complications developed in the earliest 10 cases among 14, the surgical strategy was changed for the most recent 4 cases. The purpose of this study was to clarify factors for affecting long-term surgical results for nasal or paranasal sinus carcinomas invading the skull base, considering the results of both groups, and to discuss the benefits of our new surgical strategies for these lesions in terms of avoiding postoperative complications.
MATERIALS AND METHODS Clinical materials Cases. From 1994 to 1999, 14 patients underwent radical surgery for carcinomas, either nasal or paranasal. There were 10 males and 4 females. Ages ranged from 43 to 70 years, and the mean age was 53.9 years. Tumour location. The origin of the tumour was the maxillary sinus in 12 cases, ethmoid sinus in 1, and frontal sinus in 1. Histology. Squamous cell carcinoma was diagnosed in 11 cases, mucoepithelial carcinoma in 2, and undifferentiated carcinoma in 1.
Correspondence to: Shigeru Nishizawa MD, PHD, Department of Neurosurgery, Hamamatsu University School of Medicine, 3600 Handacho, Hamamatsu, Shizuoka 431-3192 Japan. Tel.:;81-53-435-2283; Fax:;81-53-435-2282
Extension of the surgical resection of the skull base. Frontal base resection was performed in three cases, middle skull base resection in four, and a combined resection of the frontal and middle cranial bases in seven. Surgical indications. When the tumour had obviously invaded the cavernous sinus and/or into the intradural space, according to preoperative magnetic resonance (MR) imaging, it was decided that surgery was not indicated. Similarly, if the tumour invaded both orbital spaces, no surgical treatment was indicated. Surgical strategy In all cases, preoperative cerebral angiography was carried out, and cross-filling from the contralateral side to the affected side was identified. Using electroencephalography and ultrasound doppler sonography, the balloon Matas test was performed to assure the tolerance of brain ischaemia due to injury of the carotid artery on the affected side during surgery.7 A routine frontotemporal skin incision was made, and the temporal muscle was separated from the frontotemporal bone. Frontotemporal craniotomy was done. An orbital rim was removed and complete orbitotomy was performed until opening of the superior orbital fissure. The anterior clinoid process was removed and the optic canal was opened according to the Dolenc approach.8,9 The middle cranial fossa was extensively dissected extradurally, and the foramina rotundum, ovale and spinosum were identified, and the middle meningeal artery was cut at the foramen spinosum. The third and second divisions of the trigeminal nerve were excised at each foramen, and the cranial nerves in the superior orbital fissure were also cut. Thereafter, the optic nerve was excised with the ophthalmic artery. Extension of the skull base osteotomy depended on the extent of tumour invasion. Basically, by using preoperative MR imaging and computed tomography (CT) findings, osteotomy extension was decided based on maintaining an adequate safety margin. The part of the dura invaded by the tumour was removed and the dural defect was reconstructed using abdominal fascia. The nasal or paranasal sinus carcinoma was dissected with the entire content of the orbit, and the entire tumour mass was 67
jocn-141.qxd
68
5/7/01 11:50 AM
Page 68
Nishizawa et al.
removed en bloc.10 The dead space after removal of the tumour mass was filled with voluminous pararectal abdominal muscle. The muscle graft was vascularised at the neck portion. Postoperatively, a lumbar drainage was performed to avoid cerebrospinal fluid leakage for 1 week. In the first 10 cases, the muscle flap was fixed only with fibrin glue, and cranioplasty was performed with a free bone flap and the skin incision was primarily closed. In the four most recent cases, the abdominal muscle flap was fixed to the skull base with
the ROCTM fastener system (Innovative Devices, Inc., USA, Fig. 1). This system was originally developed in orthopaedic surgery for fixing detached tendons to bone.11,12 This system consists of an anchor bolt with strings (Figs 2 and 3). Using this system, an anchor bolt was inserted precisely into the skull base bone (Figs 4 and 5), and the abdominal muscle flap was tightly fastened with strings (Fig. 6). Thus, the muscle flap filled the dead space securely and no slippage of the muscle flap was seen. Furthermore, the bone flap was primarily craniectomised.
Fig. 1 ROCTM fastener system used in the 4 most recent cases to fix the vascularised abdominal muscle flap for reconstruction of the skull base.
Fig. 2 Magnified view of ROCTM fastener system consisting of an anchor bolt and strings.
Fig. 3 Scheme of the anchor bolt and a magnified view of the anchor bolt. The anchor bolt, with attached strings, is inserted into the bone comprising the skull base.
Journal of Clinical Neuroscience (2001) 8(Supplement 1), 67–70
© 2001 Harcourt Publishers Ltd
jocn-141.qxd
5/7/01 11:50 AM
Page 69
Prevention of postoperative complications in skull base surgery 69
Fig. 4 Simulated view of the ROCTM fastener system. Insertion of the anchor bolt (left) and strings to fasten the muscle flap.
Fig. 6 Operative view using the ROCTM fastener system. After resection of the entire tumour mass, the anchor bolt was inserted into the skull base and strings attached to the anchor bolt were used to fix the abdominal muscle flap in order to fill the dead space.
from extension of the tumour. The four recent cases are all alive. Follow-up periods range from 6 months to 3 years (mean: 2 years and 3 months). DISCUSSION
Fig. 5 Sagittal view of the skull in which the anchor bolt is inserted into the bone comprising the skull base.
RESULTS Postoperative surgical complications Among the first 10 cases, 8 developed local infections. Surgery to remove the infected free bone flap and irrigation was necessary in four of the eight cases. Necrosis of the skin flap was seen in two cases, CSF leakage in three and meningitis in one. On the other hand, in the four most recent cases operated on using the ROCTM fastener system, no postoperative complications have been encountered, to date. Surgical results Of the first 10 operated cases, 2 are alive (3 years and 4 years after the operation). Eight patients have died. Among the eight, six patients died of surgical complications, mainly infection, and two © 2001 Harcourt Publishers Ltd
According to our surgical results, the most important factor affecting outcome is postoperative infection at the operative site. To prevent infection at the operative site, it is absolutely essential to fill the dead space after removing the tumour mass. If this cannot be achieved, the operative site might be easily infected. Furthermore, CSF leakage and subsequent meningitis can occur. In the earliest cases, the muscle flap for reconstruction was fixed with fibrin glue, and we recognised this as being inadequate to fill the dead space after removal of the bulky tumour because of muscle flap slippage. It is noteworthy that a free bone flap can be a focus of infection. Because it is not vascularised, it very easily becomes a focus of infection. In such cases, additional surgery to remove the bone flap is inevitable. Infection itself compromises postoperative condition, prolonging recovery from surgery. Once infection occurs, it takes more time to manage the infection, which leads to damage or necrosis of the muscle flap for reconstruction. It delays the initiation of postoperative adjuvant therapy, which may result in tumour regrowth and death by tumour re-extension. Postoperative infection induces a vicious cycle. Based on the experience with the earlier surgical cases, we changed our surgical strategies for the four most recent cases. First, we used the ROCTM fastener system to securely fill the dead Journal of Clinical Neuroscience (2001) 8(Supplement 1), 67–70
jocn-141.qxd
70
5/7/01 11:50 AM
Page 70
Nishizawa et al.
space with a voluminous abdominal muscle vascularised flap after removing the entire mass. Using this system, the muscle flap for reconstruction completely and securely filled the dead space, and slippage of the flap was avoided. As the anchor bolt in this system is radiolucent, and made of plastic (Fig. 3), it is convenient to follow-up postoperative condition with CT and/or MR imaging. Next, the free bone flap was primarily craniectomised. Because the bone flap was not vascularized, it easily became a focus of infection. Once this has happened, it is very difficult to manage unless the infected bone flap is removed. Since changing surgical strategies, we have no longer encountered postoperative infections. Because no obvious or serious complications were experienced in the four most recent cases, the postoperative condition of these patients was so good that postoperative adjuvant therapy could be initiated within a few weeks of the radical surgery. All four recent cases are alive and are being followed-up at the outpatient clinic. Based on this study, we emphasise that it is essential to prevent postoperative infection in patients having nasal or paranasal sinus carcinomas invading the skull base who underwent multidisciplinary skull base surgery to improve postoperative outcomes. For this purpose, a free bone flap should be craniectomised. It is also very important to completely fill the dead space after removal of the tumour. For this purpose, the ROCTM fastener system is extremely beneficial for obtaining secure filling of the dead space and prevention of muscle flap slippage. With this method, postoperative CSF leakage can most likely be prevented. Furthermore, this method is of benefit in preventing postoperative infection.
Journal of Clinical Neuroscience (2001) 8(Supplement 1), 67–70
REFERENCES 1. 2. 3.
4. 5. 6. 7. 8. 9. 10.
11. 12.
Arriaga MA, Janecka IP. Facial translocation approach to the cranial base: the anatomic basis. Skull Base Surg 1991; 1: 26–33. Brisman MH, Sen C, Catalano P. Results of surgery for head and neck tumors that involve the carotid artery at the skull base. J Neurosurg 1997; 86: 787–792. Gormley WB, Sekhar LN, Wright DC et al. Management and long-term outcome of adenoid cystic carcinoma with intracranial extension: a neurosurgical perspective. Neurosurgery 1996; 38: 1105–1113. Iannetti G, Belli E, Cicconetti A, Delfini R, Ciappetta P. Infratemporal fossa surgery for malignant diseases. Acta Neurochir (Wien) 1996; 138: 658–671. Janecka IP, Sen C, Sehkar L, Curtin H. Treatment of paranasal sinus cancer with cranial base surgery. Laryngoscope 1994; 104: 553–555. O’Malley BW, Janecka IP. Evolution of outcome in cranial base surgery. Semin Surg Oncol 1995; 11: 221–227. Lawton MT, Spetzler RF. Internal carotid artery sacrifice for radical resection of skull base tumours. Skull Base Surg 1996; 6: 119–123. Dolenc VV. Frontotemporal epidural approach to trigeminal neurinomas. Acta Neurochir 1994; 130: 55–65. Dolenc VV. General approach to the cavernous sinus, 1st edn. Wien New York: Springer-Verlag, 1989; 139–169. Origitano TC, Al-Mefty O, Leonetti JP, Izquierdo R. En bloc resection of an ethmoid carcinoma involving the orbit and medial wall of the cavernous sinus. Neurosurgery 1992; 31: 1126–1131. Kato H, Minami A. Surgical repair of acute collateral ligament injuries in digits with the Mitek bone suture anchor. J Hand Surg 1999; 24: 70–75. McDermott TP, Levin LS. Suture anchor repair of chronic radial ligament injuries of the metacarpophalangeal joints of the thumb. J Hand Surg 1998; 23: 271–274.
© 2001 Harcourt Publishers Ltd
5/7/01 11:50 AM
Page 67
Journal of Clinical Neuroscience (2001) 8(Supplement 1), 67–70 © 2001 Harcourt Publishers Ltd doi: 10.1054/jocn.2001.0881, available online at http://www.idealibrary.com on
Prevention of postoperative complications in skull base surgery for nasal or paranasal sinus carcinoma invading the skull base Shigeru Nishizawa1 MD PHD, Naoki Yokota1 MD PHD, Tetsuo Yokoyama1 MD PHD, Hiroyuki Mukodaka2 MD, Takahiro Watanabe2 MD, Tomoyuki Hoshino2 MD PHD, Yoshio Ueda3 MD PHD Departments of 1Neurosurgery, 2Oto-rhino-laryngology and 3Plastic Surgery, Hamamatsu University School of Medicine, Shizuoka, Japan
Summary With recent technical advances in skull base surgery, radical resection of a nasal or paranasal sinus carcinoma invading the skull base can now be achieved. To assure a satisfactory surgical result, it is essential to prevent postoperative infection. In our series of 14 cases, serious postoperative infections occurred in the earliest 10 cases, and only 2 of these patients are still alive. The vascularised abdominal muscle flap for skull base reconstruction was fixed with fibrin glue, but was not adequate to fill the dead space, resulting in cerebrospinal fluid leakage and subsequent meningitis. Once the infection occurred, a free bone flap became the focus of infection. Based on these earlier experiences, we used a ROCTM fastener system to completely fill the dead space with an abdominal muscle flap, and bone flap was primarily craniectomised in the four most recent cases. With this technique, there were no postoperative infections. © 2001 Harcourt Publishers Ltd Keywords: infection, paranasal malignant tumour, ROCTM fastener system, skull base invasion, skull base surgery
INTRODUCTION Recent advances in surgical techniques for skull base lesions have made it possible to perform radical surgical resection of nasal or paranasal sinus carcinomas invading the skull base.1–6 In order to improve surgical results, a multidisciplinary approach to skull base surgery with neurosurgeons, oto-rhino-laryngologists and plastic surgeons is extremely important. However, postoperative complications affecting surgical outcomes remain serious problems.1–6 The authors have, to date, experienced 14 patients with nasal or paranasal sinus carcinomas invading the skull base who underwent multidisciplinary extended radical skull base surgery. As major surgical complications developed in the earliest 10 cases among 14, the surgical strategy was changed for the most recent 4 cases. The purpose of this study was to clarify factors for affecting long-term surgical results for nasal or paranasal sinus carcinomas invading the skull base, considering the results of both groups, and to discuss the benefits of our new surgical strategies for these lesions in terms of avoiding postoperative complications.
MATERIALS AND METHODS Clinical materials Cases. From 1994 to 1999, 14 patients underwent radical surgery for carcinomas, either nasal or paranasal. There were 10 males and 4 females. Ages ranged from 43 to 70 years, and the mean age was 53.9 years. Tumour location. The origin of the tumour was the maxillary sinus in 12 cases, ethmoid sinus in 1, and frontal sinus in 1. Histology. Squamous cell carcinoma was diagnosed in 11 cases, mucoepithelial carcinoma in 2, and undifferentiated carcinoma in 1.
Correspondence to: Shigeru Nishizawa MD, PHD, Department of Neurosurgery, Hamamatsu University School of Medicine, 3600 Handacho, Hamamatsu, Shizuoka 431-3192 Japan. Tel.:;81-53-435-2283; Fax:;81-53-435-2282
Extension of the surgical resection of the skull base. Frontal base resection was performed in three cases, middle skull base resection in four, and a combined resection of the frontal and middle cranial bases in seven. Surgical indications. When the tumour had obviously invaded the cavernous sinus and/or into the intradural space, according to preoperative magnetic resonance (MR) imaging, it was decided that surgery was not indicated. Similarly, if the tumour invaded both orbital spaces, no surgical treatment was indicated. Surgical strategy In all cases, preoperative cerebral angiography was carried out, and cross-filling from the contralateral side to the affected side was identified. Using electroencephalography and ultrasound doppler sonography, the balloon Matas test was performed to assure the tolerance of brain ischaemia due to injury of the carotid artery on the affected side during surgery.7 A routine frontotemporal skin incision was made, and the temporal muscle was separated from the frontotemporal bone. Frontotemporal craniotomy was done. An orbital rim was removed and complete orbitotomy was performed until opening of the superior orbital fissure. The anterior clinoid process was removed and the optic canal was opened according to the Dolenc approach.8,9 The middle cranial fossa was extensively dissected extradurally, and the foramina rotundum, ovale and spinosum were identified, and the middle meningeal artery was cut at the foramen spinosum. The third and second divisions of the trigeminal nerve were excised at each foramen, and the cranial nerves in the superior orbital fissure were also cut. Thereafter, the optic nerve was excised with the ophthalmic artery. Extension of the skull base osteotomy depended on the extent of tumour invasion. Basically, by using preoperative MR imaging and computed tomography (CT) findings, osteotomy extension was decided based on maintaining an adequate safety margin. The part of the dura invaded by the tumour was removed and the dural defect was reconstructed using abdominal fascia. The nasal or paranasal sinus carcinoma was dissected with the entire content of the orbit, and the entire tumour mass was 67
jocn-141.qxd
68
5/7/01 11:50 AM
Page 68
Nishizawa et al.
removed en bloc.10 The dead space after removal of the tumour mass was filled with voluminous pararectal abdominal muscle. The muscle graft was vascularised at the neck portion. Postoperatively, a lumbar drainage was performed to avoid cerebrospinal fluid leakage for 1 week. In the first 10 cases, the muscle flap was fixed only with fibrin glue, and cranioplasty was performed with a free bone flap and the skin incision was primarily closed. In the four most recent cases, the abdominal muscle flap was fixed to the skull base with
the ROCTM fastener system (Innovative Devices, Inc., USA, Fig. 1). This system was originally developed in orthopaedic surgery for fixing detached tendons to bone.11,12 This system consists of an anchor bolt with strings (Figs 2 and 3). Using this system, an anchor bolt was inserted precisely into the skull base bone (Figs 4 and 5), and the abdominal muscle flap was tightly fastened with strings (Fig. 6). Thus, the muscle flap filled the dead space securely and no slippage of the muscle flap was seen. Furthermore, the bone flap was primarily craniectomised.
Fig. 1 ROCTM fastener system used in the 4 most recent cases to fix the vascularised abdominal muscle flap for reconstruction of the skull base.
Fig. 2 Magnified view of ROCTM fastener system consisting of an anchor bolt and strings.
Fig. 3 Scheme of the anchor bolt and a magnified view of the anchor bolt. The anchor bolt, with attached strings, is inserted into the bone comprising the skull base.
Journal of Clinical Neuroscience (2001) 8(Supplement 1), 67–70
© 2001 Harcourt Publishers Ltd
jocn-141.qxd
5/7/01 11:50 AM
Page 69
Prevention of postoperative complications in skull base surgery 69
Fig. 4 Simulated view of the ROCTM fastener system. Insertion of the anchor bolt (left) and strings to fasten the muscle flap.
Fig. 6 Operative view using the ROCTM fastener system. After resection of the entire tumour mass, the anchor bolt was inserted into the skull base and strings attached to the anchor bolt were used to fix the abdominal muscle flap in order to fill the dead space.
from extension of the tumour. The four recent cases are all alive. Follow-up periods range from 6 months to 3 years (mean: 2 years and 3 months). DISCUSSION
Fig. 5 Sagittal view of the skull in which the anchor bolt is inserted into the bone comprising the skull base.
RESULTS Postoperative surgical complications Among the first 10 cases, 8 developed local infections. Surgery to remove the infected free bone flap and irrigation was necessary in four of the eight cases. Necrosis of the skin flap was seen in two cases, CSF leakage in three and meningitis in one. On the other hand, in the four most recent cases operated on using the ROCTM fastener system, no postoperative complications have been encountered, to date. Surgical results Of the first 10 operated cases, 2 are alive (3 years and 4 years after the operation). Eight patients have died. Among the eight, six patients died of surgical complications, mainly infection, and two © 2001 Harcourt Publishers Ltd
According to our surgical results, the most important factor affecting outcome is postoperative infection at the operative site. To prevent infection at the operative site, it is absolutely essential to fill the dead space after removing the tumour mass. If this cannot be achieved, the operative site might be easily infected. Furthermore, CSF leakage and subsequent meningitis can occur. In the earliest cases, the muscle flap for reconstruction was fixed with fibrin glue, and we recognised this as being inadequate to fill the dead space after removal of the bulky tumour because of muscle flap slippage. It is noteworthy that a free bone flap can be a focus of infection. Because it is not vascularised, it very easily becomes a focus of infection. In such cases, additional surgery to remove the bone flap is inevitable. Infection itself compromises postoperative condition, prolonging recovery from surgery. Once infection occurs, it takes more time to manage the infection, which leads to damage or necrosis of the muscle flap for reconstruction. It delays the initiation of postoperative adjuvant therapy, which may result in tumour regrowth and death by tumour re-extension. Postoperative infection induces a vicious cycle. Based on the experience with the earlier surgical cases, we changed our surgical strategies for the four most recent cases. First, we used the ROCTM fastener system to securely fill the dead Journal of Clinical Neuroscience (2001) 8(Supplement 1), 67–70
jocn-141.qxd
70
5/7/01 11:50 AM
Page 70
Nishizawa et al.
space with a voluminous abdominal muscle vascularised flap after removing the entire mass. Using this system, the muscle flap for reconstruction completely and securely filled the dead space, and slippage of the flap was avoided. As the anchor bolt in this system is radiolucent, and made of plastic (Fig. 3), it is convenient to follow-up postoperative condition with CT and/or MR imaging. Next, the free bone flap was primarily craniectomised. Because the bone flap was not vascularized, it easily became a focus of infection. Once this has happened, it is very difficult to manage unless the infected bone flap is removed. Since changing surgical strategies, we have no longer encountered postoperative infections. Because no obvious or serious complications were experienced in the four most recent cases, the postoperative condition of these patients was so good that postoperative adjuvant therapy could be initiated within a few weeks of the radical surgery. All four recent cases are alive and are being followed-up at the outpatient clinic. Based on this study, we emphasise that it is essential to prevent postoperative infection in patients having nasal or paranasal sinus carcinomas invading the skull base who underwent multidisciplinary skull base surgery to improve postoperative outcomes. For this purpose, a free bone flap should be craniectomised. It is also very important to completely fill the dead space after removal of the tumour. For this purpose, the ROCTM fastener system is extremely beneficial for obtaining secure filling of the dead space and prevention of muscle flap slippage. With this method, postoperative CSF leakage can most likely be prevented. Furthermore, this method is of benefit in preventing postoperative infection.
Journal of Clinical Neuroscience (2001) 8(Supplement 1), 67–70
REFERENCES 1. 2. 3.
4. 5. 6. 7. 8. 9. 10.
11. 12.
Arriaga MA, Janecka IP. Facial translocation approach to the cranial base: the anatomic basis. Skull Base Surg 1991; 1: 26–33. Brisman MH, Sen C, Catalano P. Results of surgery for head and neck tumors that involve the carotid artery at the skull base. J Neurosurg 1997; 86: 787–792. Gormley WB, Sekhar LN, Wright DC et al. Management and long-term outcome of adenoid cystic carcinoma with intracranial extension: a neurosurgical perspective. Neurosurgery 1996; 38: 1105–1113. Iannetti G, Belli E, Cicconetti A, Delfini R, Ciappetta P. Infratemporal fossa surgery for malignant diseases. Acta Neurochir (Wien) 1996; 138: 658–671. Janecka IP, Sen C, Sehkar L, Curtin H. Treatment of paranasal sinus cancer with cranial base surgery. Laryngoscope 1994; 104: 553–555. O’Malley BW, Janecka IP. Evolution of outcome in cranial base surgery. Semin Surg Oncol 1995; 11: 221–227. Lawton MT, Spetzler RF. Internal carotid artery sacrifice for radical resection of skull base tumours. Skull Base Surg 1996; 6: 119–123. Dolenc VV. Frontotemporal epidural approach to trigeminal neurinomas. Acta Neurochir 1994; 130: 55–65. Dolenc VV. General approach to the cavernous sinus, 1st edn. Wien New York: Springer-Verlag, 1989; 139–169. Origitano TC, Al-Mefty O, Leonetti JP, Izquierdo R. En bloc resection of an ethmoid carcinoma involving the orbit and medial wall of the cavernous sinus. Neurosurgery 1992; 31: 1126–1131. Kato H, Minami A. Surgical repair of acute collateral ligament injuries in digits with the Mitek bone suture anchor. J Hand Surg 1999; 24: 70–75. McDermott TP, Levin LS. Suture anchor repair of chronic radial ligament injuries of the metacarpophalangeal joints of the thumb. J Hand Surg 1998; 23: 271–274.
© 2001 Harcourt Publishers Ltd