颅底病变手术入路方法选择的探讨

1992～1996年间治疗10例颅底部肿瘤和齿状突骨折，其中斜坡肿瘤3例，齿状突骨折7例。10侧均经CT或MRI、DSA检查确诊，经口咽入路或前颅凹底入路两种方式将肿瘤切除。术后患临床症状都得到了良好心善，无一例死亡。作认为，斜坡肿瘤和齿状突骨折经前颅凹底或口咽显微外科治疗是一种安全有效的方式。     

经口咽入路显微外科技术治疗颅颈区畸型

目的　总结经口咽入路颅颈区畸型的显微外科治疗的体会。　方法　分析 16例颅颈区畸型的围手术期处理包括抗生素应用、气管切开、静脉营养、颅骨牵引等及手术方法、术后并发症的处理、手术结果等。　结果　本组 16例颅颈区畸型 ,以颅底陷入为主的枕骨大孔区畸型 8例 ,慢性寰枢椎脱位 3例 ,齿状突骨折及脱位 2例 ,下斜坡脊索瘤 2例 ,颈髓腹侧肉芽肿 1例。其中 3例行二期植骨。随访半年～ 3年。 10例恢复轻体力劳动 ,4例生活自理 ,1例临床症状改善 ,1例死亡。　结论　采用显微外科技术经口咽入路治疗颅颈区前方病变可降低术后并发症和致残率。重视围手术期处理 ,预防术后伤口感染和脑脊液漏。二期植骨能增加颈椎稳定性。     

经口咽入路显微直视减压术治疗颅颈区畸形

目的 探讨颅颈区畸形前路显微直视减压手术的方法和疗效。方法 颅颈区畸形45例,MRI表现为齿状突肥大,向后上方突出,斜坡了争入颅底,致颅底成角畸形,延髓及上颈段脊髓腹侧受压变形。其中16例还伴有颅后窝容积减小、小脑扁桃体下疝及脊髓空洞症。采用经口咽入路显微直视下切除齿状突、伴坡下部及增生的结缔组织,解除其对延髓、颈髓的压迫。结果 痊愈38例（84.4%),好转4例（8.9%),无效3例（6.7%)。手术并发症有脑脊液漏2例,环枕脱位1例,软腭裂开1例。结论 经口咽入路显微直视减压术是治疗以延髓、颈髓腹侧受压为主的颅颈区畸形的首选方法。     

环枢椎脱位围手术期的护理

目的:探讨经口咽入路齿状突切除术治疗环枢椎脱位的围手术期护理。方法:通过对10例经口咽入路齿状突切除治疗环枢椎脱位围手术期护理的回顾性研究。结果:10例病人围手术期恢复顺利,无脑脊液漏、切口感染、颅内感染和呼吸道感染等严重并发症,8例随访3～6个月,7例恢复正常生活和工作,1例生活自理,从事轻体力劳动。结论:良好的围手术期护理是经口咽入路齿状突切除术围手术期治疗的重要内容,是保证病人获得良好顺利康复的重要医疗环节之一。     

经蝶入路显微外科切除颅咽管瘤

目的　为探求一种颅咽管瘤切除的手术径路可能性。　方法　回顾总结１８ 例颅咽管瘤的诊断方式,手术技巧和治疗结果,均经 Ｃ Ｔ 或 Ｍ Ｒ Ｉ扫描确诊。手术采取经唇下蝶窦入路或经鼻前庭鼻中隔蝶窦入路两种方式行肿瘤切除术。　结果　９ 例肿瘤获全切除,４ 例次全切除,余５ 例为部分切除,术后无死亡。１５ 例获长期随访（ 平均３１ 年） ,有１２ 例恢复良好。　结论　对位于鞍内的颅咽管瘤或肿瘤系囊性并向鞍上扩展者,采用经蝶入路显微手术切除是一种安全、有效的方法     

经蝶入路显微外科切除颅咽管瘤适应证选择与操作要点

有关颅咽管瘤的手术一直是神经外科医师最感困惑的问题。本文报道经蝶显微手术切除颅咽管瘤18例,均经CT或MRI扫描确诊。本入路适用起源于鞍底或向鞍上扩展的肿物。手术采取经唇下-鼻中隔-蝶窦入路或经鼻前庭-鼻中隔-蝶窦入路两种方式行肿瘤切除术。9例肿瘤获得全切除,4例次全切除,其余5例为部分切除,术后无死亡。15例获长期(平均3.1年)随访,有12例(80.0％)恢复良好,3例影像学检查提示肿瘤复发,需行再次手术,放疗或放射外科治疗。文中对颅咽管瘤手术适应证选择及操作要点进行了讨论。     

一期前后路手术入路治疗斜坡齿状突型颅底陷入症

[目的]探讨一期前后路手术入路治疗斜坡齿状突型颅底陷入症的方法。[方法]对26例斜坡齿状突型颅底陷入症患者，进行了一期前后路手术，手术时间平均4．3h。出血量平均650ml。并随访6个月～5年。[结果]本组病例总有效率达90．6％，显效率为62．5％。术后无一例患者出现伤口感染及脑脊液漏，枕颈融合良好，无假关节形成。[结论]一期前后路手术入路治疗斜坡齿状突型颅底陷入症，可以在前路减压后即刻后路获得颅颈部的稳定性，避免延颈髓的继发性损伤，可明显缩短患者的住院时间，节省患者的费用。     

斜坡-齿状突型颅底陷人的治疗

目的 探讨斜坡-齿状突型颅底陷入的治疗原则。方法 分析11例斜坡一齿状突型颅底陷入的，临床资料。11例经口腔前方入路切除压迫延髓前方的齿状突，10例经后路枕颈植骨融合固定。结果 平均随访1．2年，显效7例，有效3例，无效1例，无加重及死亡者。结论 斜坡一齿状突型颅底陷入的治疗应首先考虑经口腔做前路减压，寰枢椎脱住者还需施行植骨融合固定。     

经蝶入路显微外科切除颅咽管瘤适应证选择与操作要点

有关颅咽管瘤的手术一直是神经外科医师最感困惑的问题。本报道经蝶显微手术切除颅咽管瘤18例，均经CT或MRI扫描确认。本入路适用起源于鞍底或向鞍上扩展的肿物。手术采取经唇下-鼻中隔-蝶窦入路或经鼻前庭-鼻中隔-蝶窦入路两种方式行肿瘤切除术。9例肿瘤获得全切除，4例次全切除，其余5例为部分切除，术后无死亡。15例获长期（平均3.1年）随访，有12例（80.0%）恢复良好，3例影像学检查提示肿瘤复发，需行再行手术，放疗或放射外科治疗。中对颅咽管瘤手术适应证选择及操作要点进行了讨论。     

前中颅凹底大型内外沟通瘤的显微切除

目的 为了提高切除前或／和中颅凹底大型颅内外沟通性肿瘤的手术效果。 方法 分别采用颅面联合入路、额颞－颞下窝入路或额颞－颞下窝结合面前径路暴露肿瘤,给予显微手术切除。 结果 ２３例肿瘤全切除１１例,次全切除９例,大部切除３例。无手术死亡及严重并发症。 结论 （１）前或／和中颅凹底内外沟通性肿瘤应根据肿瘤大小、位置及侵犯范围选择颅面联合入路、额颞－颞下窝入路或额颞－颞下窝入路结合面前径路即可给于充分     

经前颅底入路切除前颅底肿瘤显微外科手术

目的：报道采用经前颅底入路切除前颅底肿瘤的临床效果。方法：自1997年6月－2000年12月采用该入路切除前颅底中线部位肿瘤20例,其中肿瘤位于筛板5例,鼻筛窦4例,筛蝶窦7例,蝶斜坡区4例。术后10例行放射治疗。结果：本组20例中,肿瘤全切除12例,次全切除6例,大部分切除2例。术后1例死亡,6例有脑神经麻醉。结论：该手术入路能充分暴露病变,术野开阔,切除肿瘤较安全,对脑组织损伤小。     

Transoral operations for craniospinal malformations

The transoral approach to the lower third of the clivus and to the ventral aspect of the upper cervical spine is used in craniospinal malformations with or without dislocation as well as in basilar aneurysms, ventrally situated cranio-spinal tumours, fractures of the odontoid process, and in rheumatoid arthritis compressing the spinal cord. In consideration of the literature and ten personal cases the indications and techniques of the transoral approach in craniospinal malformations are discussed. According to our own experiences and those of other authors it is possible to expose the lower clivus and the cervical spine down to C2 by a midline incision of the pharyngeal wall using a mouth retractor and oral intubation. Splitting of the soft palate or resection of the hard palate are not necessary, a tracheotomy should be performed only in exceptional cases. In congenital craniospinal malformations without dislocation or instability causing a ventral compression of the spinal cord, for instance by the odontoid process, the transoral decompression is preferable to dorsal decompressing operations. In cases of pure instability without any space-occupying lesion the transoral and posterior approach are possible in order to perform a fusion. The last one seems more advantageous in these cases. In craniospinal malformations with dislocation causing a ventral and dorsal narrowing of the spinal canal, apart from the decompression a stabilization has to be achieved. In these usually complex malformations individual treatment is necessary. According to the rare cases in the literature and to our own experience a primary anterior decompression, followed by a most careful posterior stabilization seems to produce the most favourable results.     

Anterior Cranial Fossa Traumas: Clinical Value,Surgical Indications,and Results—A Retrospective Study on a Series of 223 Patients

Objective Frontobasal fractures are relatively common traumas but surgical indications are still discussed. The authors report their results on patients showing anterior cranial fossa fractures; clinical data, surgical indications, and results are reported and critically analyzed.Methods From 1991 to 2010, 223 patients were admitted in our institution with diagnosis of anterior cranial fossa fracture. Fractures were classified as type A—fracture of the anterior wall of the frontal sinus; type B—fracture of the posterior wall of the frontal sinus; and type C—frontobasal traumas without involvement of the frontal sinus. All patients entered a follow-up program consisting in periodic controls.Results A total of 105 patients were conservatively treated, while 118 patients underwent surgical intervention. The presence of pneumocephalus (p < 0.0001) and rhinoliquorrhea (p = 0.001) were the factors influencing the surgical indication. In the fractures of group B with signs of pneumocephalus and or rhinoliquorrhea, full sinus cranialization represents the variable mainly influencing the outcome (p < 0.001).Conclusion Patients with frontobasal traumas should be carefully evaluated to choose the best treatment option. Clinical and radiological data suggest that patients with frontobasal fractures with massive pneumocephalus and/or rhinoliquorrhea should be always surgically treated.     

Morphometric measurements of the anterior skull base for endoscopic transoral and transnasal approaches

The objective of this study is to determine the bony limits of the transnasal and transoral approaches to the anterior skull base. The data we present are meant to assist surgeons in preoperative planning for lesions of the sella, clivus, foramen magnum, and odontoid. Using precise measurements undertaken on 41 high-resolution computed tomography scans from patients at the University of Pennsylvania without any history of sinus or sellar pathology, we sought to define the bony limits of transoral and transnasal approaches. Direct measurements and calculated angles were used to assess the dimensions of the anterior skull base. Using our measurements, a transnasal approach can reach an average of 22.5 mm below the plane of the hard palate to the body of C2, and a transoral route can reach 38 mm above the basion along the length of the clivus. Analysis of variance demonstrated no significant differences when subjects were grouped based on race or gender. The measurements outlined within this article help to define the relative dimensions necessary for adapted transoral and transnasal skull base surgeries.     

扩大经蝶入路显微手术切除斜坡脊索瘤

目的 报道应用扩大经蝶入路治疗斜坡脊索瘤的临床效果.方法 采用扩大经蝶入路显微手术切除斜坡脊索瘤病例9例(均经病理结果证实),所有病例均在神经导航下进行,其中经唇下-扩大经蝶入路4例,经鼻-扩大经蝶入路5例.4例术前通过虚拟现实系统实现图像三维重建,明确肿瘤与周围重要结构的关系,以更好的指导手术入路.结果 肿瘤术中显微镜下及术后影像学证实完全切除3例,肿瘤镜下次全切除(切除比例大于90%)6例.其中2例因肿瘤侵犯至硬脑膜下,肿瘤切除后出现脑脊液漏,经颅底重建修补后痊愈.结论 扩大经蝶入路显微手术可以简单迅速地到达斜坡区域,并能较充分地暴露前颅底、中下斜坡以及双侧海绵窦区,术后并发症少,创伤小,对斜坡脊索瘤来讲是一种较好的手术方式.     

The Arterial Supply of the Odontoid Process of the Axis

A study has been carried out of the arterial supply of the odontoid process of the axis. Among the arterial sources there are paired anterior and posterior ascending arteries arising from the vertebral artery. Arteries penetrate into the odontoid process at its base from both the anterior and posterior ascending arteries. A transverse arterial arcade is formed above its top by the anastomosing anterior and posterior ascending arteries. In this investigation it was demonstrated that a branch of the ascending pharyngeal artery (from the external carotid artery) joined this arcade after passing through the canalis hypoglossi of the occipital condyle. Moreover, there were inferior and superior horizontal arteries apparently coming from the internal carotid artery, which supplied the odontoid process. It was shown that the superior horizontal arteries penetrated the anterior atlanto-occipital membrane and ran across to the supraodontoid arterial arcade. There were also arteries which reached into the odontoid process via the accessory and apical ligaments. Vessels described—but not demonstrated—to reach the odontoid process via the alar ligaments could not be observed in this investigation. It was shown that inside the odontoid process the arteries formed a rich anastomosing network. The odontoid process of the axis is thus in the centre of a dense arterial network.     

Odontoid process and clival regeneration with Chiari malformation worsening after transoral decompression: an unexpected and previously unreported cause of “accordion phenomenon”

Purpose

Transoral odontoidectomy followed by occipito-cervical fixation is a widely used approach to relieve ventral compressions at the craniovertebral junction (CVJ). Despite the large amount of literature on this approach and its complications, no previous reports of odontoid process and clival regeneration following transoral odontoidectomy are present in the English literature.

Methods

We report the case of odontoid process and clival regeneration following transoral odontoidectomy.

Results

A 7-year-old boy presented with symptoms of brainstem and upper cervical spinal cord compression due to a complex malformation at the CVJ including a basilar invagination with Chiari malformation. A successful transoral microsurgical endoscopic-assisted odontoidectomy extended to the clivus was performed along with occipito cervical instrumentation and fusion. Clinical and radiological resolution of the CVJ compression was evident up to 2 years post-op, when the child had a relapse of some of the presenting symptoms and the follow-up CT and MRI scans showed a quite complete regrowth of the odontoid process, clival partial regeneration and recurrence of preoperative Chiari malformation.

Conclusions

Besides the need of an accurate complete resection of the periosteum, which apparently was incompletely performed in our case, our experience suggests the need of resection of the odontoid down to the dentocentral synchondrosis and an accurate lateral removal of the bone surrounding the anterior tubercle of the Clivus is advised when an anterior CVJ decompression is required in children presenting a still evident synchondrosis at neuroradiological investigation.

     

经乙状窦后进路切除跨颅中后窝巨大胆脂瘤

目的：介绍手术切除跨颅中后窝生长巨大胆脂瘤的体会和注意事项。方法：采用乙状窦后进路显微外科方法治疗７例跨颅中后窝巨大胆脂瘤。结果：随访５个月～３年，７例术侧症状均消失，未见肿瘤复发征象。结论：表明乙状窦后进路可一期全部切除跨颅中后窝巨大胆脂瘤。     

Transpterygoid Trans-sphenoid Approach to the Lateral Extension of the Sphenoid Sinus to Repair a Spontaneous CSF Leak.

Objective and Importance: Cerebrospinal fluid (CSF) fistula from the middle cranial fossa into the sphenoid sinus is a rare condition. In the past, the treatment of choice has been closure via a craniotomy. Only few geriatric cases are known, which were successfully operated by endoscopic surgery. We present a further case of nontraumatic CSF fistula originating from the middle cranial fossa. A new endoscopic technique was applied. We discuss treatment options for this rare defect. Clinical Presentation: A 76-year-old patient presented with a 2-year history of rhinorrhea. High levels of beta-trace protein pointed to a diagnosis of CSF fistula. The defect was located at the anterior and inferior aspect of the pterygoid recess of the left sphenoid sinus. Intervention: The patient was operated using an endoscopic trans-sphenoidal approach. After endoscopic opening of the maxillary and sphenoid sinus, a complete posterior ethmoidectomy was performed. The medial part of the pterygoid process was removed, allowing endoscopic exposure and closure of the defect. At 1-year follow-up, the CSF fistula had not recurred and the patient had no sequel from the surgical procedure. Conclusion: In selected cases, this new endoscopic partial transpterygoid approach to the middle cranial fossa is recommended for surgical repair of CSF fistula involving the lateral extension of the sphenoid sinus. To our knowledge, ours is the oldest patient with this condition successfully operated by endoscopic means at the world's most northern university hospital.     

Endoscopic transoral-transclival approach to the brainstem and surrounding cisternal space: anatomic study

OBJECTIVE: The purpose of this study was to review the endoscopic anatomic features of the anterior brainstem and surrounding cisternal spaces via a transoral-transclival approach. METHODS: Fifteen adult human cadaveric heads, obtained from 10 fresh cadavers and 5 formalin-fixed cadavers, were used to demonstrate both the feasibility of an endoscopic transoral-transclival intradural approach and its exposure potential. To analyze the exact extension of a safe entry zone through the clivus, 20 skull bases were used to obtain anatomic measurements. RESULTS: The transoral approach was performed without maxillotomy or mandibulotomy and with a clival opening of 20 by 15 mm. Such a limited clival and dural opening allowed the insertion of the endoscope and instruments, full visualization of the anterolateral brainstem and cisternal spaces around it, and reconstruction of all anatomic layers by means of a paraendoscopic technique. CONCLUSION: The endoscopic transoral-transclival approach enables full access to the anterolateral brainstem and to the cisternal space around it. The use of the endoscope has the potential to reduce the need for a wider cranial base opening and the danger of postoperative complications.