Surgical Anatomy of the Cavernous Sinus and Refinement of Its Surgery

The cavernous sinus is a dural envelope containing the cavernous segment of the carotid artery, the oculomotor nerve, the trochlear nerve, the first and second divisions of the trigeminal nerve, the abducens nerve, and a venous complex connected to the surrounding venous structures. Though surgery in the cavernous sinus was historically considered too risky, the development of modern techniques for safer approaches to the cavernous sinus has allowed for nearly all lesions in the cavernous sinus through open or endoscopic surgical techniques. All the nerves of the cavernous sinus, except the abducens nerve, can be safely exposed by opening the outer layer of dura along the lateral cavernous sinus wall while leaving the inner layer intact, as these nerves run between the two layers of dura along the lateral cavernous sinus wall. Our current anatomical understanding of the various walls and compartments of the sinus allows for very detailed risk and benefit analysis of each component of a modular type of surgical approach, depending on the goals of surgery.