TO THE EDITOR: The article by Banu et al.2is an important contribution to the analysis of predictive factors of postoperative CSF leaks after endoscopic skull base surgery (Banu MA, Szentirmai O, Mascarenhas L, et al: Pneumocephalus patterns following endonasal endoscopic skull base surgery as predictors of postoperative CSF leaks.J Neurosurg 121:961–975, October 2014). However, we think that the term “transcribriform” has been misused in this article.
虽然endocopic approach to the anterior skull base had been already described in several case series,4,5,11,13,17,21,28,29it was definitely systematized i n 2 004 by Jho and Ha,15in 2005 by Har-El and Casiano,14and, in the same year, by Kassam et al.18These authors introduced in their article the term “transcribriform” to refer to the endoscopic approach to the anterior skull base. In the following years, the indication of the endoscopic route for the anterior skull base lesions had been progressively expanded, and it became common for authors to start using the term “transcribriform” to refer to the demolition of the cribriform plate and fovea ethmoidalis, thus describing an approach that implied the demolition of the anterior part of the ethmoidal roof. Using the term “transcribriform” in these cases, in our opinion, is not correct because it describes only the removal of the cribriform plate and therefore, it is not sufficient, in several cases, for creating a surgical corridor that is useful to approach the anterior skull base lesions, with the exception of CSF leaks.
An accurate description of the anatomy of the cribriform plate and anterior skull base has been given in the literature,19,26in particular, the analysis of dimensions and asymmetries, proposing various classifications on the basis of form19and height of the lateral lamina.20According to the article by Vasvari et al.,26the dimensions of the cribriform plate are on average 20.7 mm in length (range 14.1–28.4 mm), 3.1 mm in width at the tip of the crista galli (0.1–4.2 mm), and 5.7 mm in width at the tip of the ethmoidal spine (2.6–9.3 mm). Recent neuroradiological studies1,9,10,16,30have confirmed the descriptions of Vasvari et al. As we mentioned earlier, Jho and Ha15and Har-El and Casiano14首先描述了蚂蚁的方法吗erior skull base more systematically. The milestone description regarding the endoscopic approach to the anterior skull base is provided in the article by Kassam et al.18and consists of the following surgical steps: resection of the nasal septum, exposure and demucosization of the cribriform plate with cutting of the olfactory filament and branches of the ethmoidal arteries, and drilling of the crista galli and the olfactory sulcus until exposure of the dura mater. According to Kassam et al., the approach to the anterior skull base was thus divided into 2 procedures: transcribriform and transplanum.
Since then, in our opinion, the term “transcribriform” has been commonly used incorrectly, indicating indeed the approach to the anterior part of the skull base and usually being associated with “transplanum” to indicate the approach to the entire anterior skull base.3,6,7,8,22–25,27
We think that using the term “transcribriform” to indicate the endoscopic approach to the anterior skull base is quite synecdochic and misleading. In our opinion, a descriptive name has to correctly represent the approach, reflecting the real surgical procedure and not only a part of it. When a skull base team deals with tumors of the anterior skull base, the demolition steps involve of course not only the cribriform plate but possibly reach laterally to the superomedial margins of the orbit.
Is the “transcribriform-transplanum approach” really representative of the anterior skull base approaches? Anatomically speaking, does the so-called transcribriform approach only involve the cribriform plate, or is the resection extended to the fovea ethmoidalis of the frontal bone?
The anatomical measures of the cribriform plate are sufficient to clarify that the approach can be purely transcribriform, and sometimes unilateral, only in select cases (CSF leak repair) and will have to be extended bilaterally to the ethmoidal fovea in cases of intracranial lesions.
The uniformity of nomenclature is an important feature to improve the communication among different groups, and we support the idea that representative and descriptive definitions could be a strong starting point to share and improve our knowledge.
We think that the term “transcribriform transfovea ethmoidalis” (used only once in the literature12) is to be preferred to indicate the endoscopic approach to the anterior skull base in cases of dural exposure from orbit to orbit.
On the basis of our analysis, we think that the endoscopic endonasal approaches to the anterior skull base could be classified as follows:
Transethmoidal: when a partial or complete ethmoidectomy and only extracranial procedure has been performed;
Transcribriform: when only the cribriform plate is resected and some intracranial procedure has been performed;
Transfovea: when only the fovea is resected and some intracranial procedure has been performed;
Transcribriform-transfovea: when the anterior part of the ethmoidal roof is resectetd from orbit to orbit;
Transcribriform-transfovea-transplanum: when the entire ethmoidal roof is resected to access the anterior cranial base.
Sometimes, the most common scientific terms are semantically incorrect and it is mandatory to correct any evident error in order to create a common and shared lexicon that is accepted by the entire scientific community. The term “transcribriform” has been commonly used incorrectly when it indicates the standard endoscopic approach to the anterior skull base with the complete demolition of the ethmoidal roof from orbit to orbit. Actually, the anatomically appropriate term to indicate this approach is “transcribriform trans fovea,” whereas only the term “transcribriform” should be used when the bone demolition involves the cribriform plate.
References
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26 ↑
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