Progressive Orbitotomy and Graduated Expansion of the Supraorbital Keyhole: A Comparison with Alternative Minimally Invasive Approaches to the Paraclinoid Region

Abstract

Various minimally invasive approaches, such as supraorbital (SO), minipterional (MPT), and translateral orbital (TLO), can access the paraclinoid region. Studies have described these approaches individually but have not directly compared all of them in the same anatomic specimen. Using virtual reality models generated from computed tomography studies of living subjects, we simulated TLO, MPT, and variations of SO approaches, without and with removal of the orbital rim and sphenoid wing. We measured the area of freedom (AOF), distance, and angle of attack to 4 paraclinoid targets: anterior clinoid process, optic foramen, lateral superior orbital fissure, and maxillary strut. For superiorly positioned targets, such as anterior clinoid process and optic foramen, MPT provided a larger AOF compared with the supraorbital approach. However, with progressive drilling of the orbital roof and lesser wing of the sphenoid, the SO corridor AOF was equivalent to MPT at the anterior clinoid process and larger at the optic foramen (P= 0.003). To the lateral superior orbital fissure, TLO had the most limited AOF, and MPT had the greatest (P < 0.01 for all comparisons). For the maxillary strut, MPT, TLO, and SO with orbitotomy and sphenoidectomy all provided a similar AOF. For surgical targets in the paraclinoid region, MPT provided a greater AOF and shorter distance compared with TLO and limited SO approaches. With progressive enlargement of the SO corridor, SO with orbitotomy and sphenoidectomy matched and occasionally superseded the AOF of MPT. However, the AOF to inferomedial targets such as the maxillary strut was similar among all approaches.