翼点锁孔入路鞍区显微解剖及神经内镜下的应用解剖

目的 研究翼点锁孔入路鞍区各间隙的神经内镜解剖,为内镜辅助下该入路进行显微手术提供解剖学依据.方法 在15例湿头标本上选择翼点人路开30 mm×25 mm锁孔.使用显微镜和神经内镜模拟手术过程对鞍区Ⅰ、Ⅱ、Ⅲ、Ⅳ、Ⅴ间隙进行解剖结构观察,并作比较. 结果 应用锁孔概念,确定内镜下的解剖学"路标",可以显示间隙Ⅰ、Ⅱ、Ⅲ、Ⅳ、Ⅴ及Willis环等显微结构.利用神经内镜比显微镜可以更广泛清晰地显示鞍区不同间隙内的解剖结构,尤其是对一些重要的细微结构.利用成角内镜可"绕过"神经、血管观察其背后的结构,是显微手术中重要的辅助方法. 结论 运用神经内镜按解剖"路标"进行,可以消除翼点锁孔人路鞍区显微手术的显微外科解剖的死角,减少术中脑组织及重要颅底血管、神经的牵拉,减少并发症的发生,从而提高鞍区手术的疗效.     

内镜和显微镜下经鼻入路鞍区的解剖学对比研究

目的 研究对比神经内镜和手术显微镜经单鼻孔鼻内-蝶窦入路的解剖特点,为临床应用提供解剖学理论依据.方法 福尔马林浸泡固定的尸头10例,彩色乳胶灌注动脉系统.模拟经鼻内入路鞍区手术,先用显微镜,然后更换为内镜观察并测量相关解剖结构.结果 内镜相比显微镜:在蝶鞍水平区域,鞍旁术野同侧和对侧分别增加平均5.0 mm和6.5 mm的显露范围;前颅底区域,矢状位增加4.0 mm,横向同侧、对侧增加3.5 mm、4.0 mm;斜坡后颅底区域,都能显露对侧的斜坡旁颈内动脉隆起,而向两侧观察,内镜的显露范围平均同侧增加4.0 mm,对侧2.5 mm.结论 内镜可以提供一种全景的术野,从而扩展了经鼻入路显微手术的显露范围,尤其适用于简化和扩大经鼻内八路鞍区手术.     

内镜和显微镜下经鼻入路鞍区的解剖学对比研究

目的 研究对比神经内镜和手术显微镜经单鼻孔鼻内-蝶窦入路的解剖特点,为临床应用提供解剖学理论依据.方法 福尔马林浸泡固定的尸头10例,彩色乳胶灌注动脉系统.模拟经鼻内入路鞍区手术,先用显微镜,然后更换为内镜观察并测量相关解剖结构.结果 内镜相比显微镜:在蝶鞍水平区域,鞍旁术野同侧和对侧分别增加平均5.0 mm和6.5 mm的显露范围;前颅底区域,矢状位增加4.0 mm,横向同侧、对侧增加3.5 mm、4.0 mm;斜坡后颅底区域,都能显露对侧的斜坡旁颈内动脉隆起,而向两侧观察,内镜的显露范围平均同侧增加4.0 mm,对侧2.5 mm.结论 内镜可以提供一种全景的术野,从而扩展了经鼻入路显微手术的显露范围,尤其适用于简化和扩大经鼻内八路鞍区手术.     

内镜和显微镜下经鼻入路鞍区的解剖学对比研究

目的 研究对比神经内镜和手术显微镜经单鼻孔鼻内-蝶窦入路的解剖特点,为临床应用提供解剖学理论依据.方法 福尔马林浸泡固定的尸头10例,彩色乳胶灌注动脉系统.模拟经鼻内入路鞍区手术,先用显微镜,然后更换为内镜观察并测量相关解剖结构.结果 内镜相比显微镜:在蝶鞍水平区域,鞍旁术野同侧和对侧分别增加平均5.0 mm和6.5 mm的显露范围;前颅底区域,矢状位增加4.0 mm,横向同侧、对侧增加3.5 mm、4.0 mm;斜坡后颅底区域,都能显露对侧的斜坡旁颈内动脉隆起,而向两侧观察,内镜的显露范围平均同侧增加4.0 mm,对侧2.5 mm.结论 内镜可以提供一种全景的术野,从而扩展了经鼻入路显微手术的显露范围,尤其适用于简化和扩大经鼻内八路鞍区手术.     

颞下锁孔入路的显微解剖学特点与临床应用研究

目的:研究颞下锁孔入路的显微解剖学,为临床颞下锁孔手术入路提供解剖依据与支持.方法:对6例国人成人尸头模拟颞下锁孔入路手术进行显微解剖,对各重要结构及间隙之间的距离进行测量,观察显露范围和解剖关系.结果:颧弓至小脑幕缘、脑干和前床突的最短距离分别为(42.3±4.7)mm、(42.8±2.5)mm和(59.8±6.1)mm.颞骨岩部扩大磨除前后的显露面积有显著差异(P＜0.05).颞下锁孔入路可以清楚的显露海绵窦外侧壁结构、鞍侧区、颈内动脉、后交通动脉、脉络膜前动脉和垂体柄,磨除颞骨岩尖部可显著增加岩斜区结构显露.结论:颞下锁孔入路对于海绵窦外侧壁,岩斜区及鞍侧区手术具有良好显露效果,入路直接,损伤小.     

鞍区锁孔手术人路的颅底解剖学研究

目的 了解鞍区病变锁孔手术入路的相关颅底解剖,为选择合适的锁孔手术提供解削学依据. 方法 取成人干性颅骨标本67个(134侧),观察额窦开放情况和眶顶板上骨嵴(大脑轭)的形状,游标卡尺测量每例标本双侧大脑轭(眶顶板上的骨嵴)的最高高度.在15个颅骨标本上分别模拟眶上、额外侧、翼点、颞下锁孔手术入路,测量锁孔中心到达前、后床突的手术距离和相关的手术角度,并进行比较. 结果 额窦开放52侧(38.8%).大脑轭的形状以多尖形和斜梁多尖形为主,高度≤2.50 mm者36侧(26.9%),≥2.51 mm者98侧(73.1%).四种手术入路中,锁孔中心与同侧前、后床突的距离颞下入路[(4.87±0.47)cm、(4.93±0.45)cm]最短,额外侧入路[(6.45±0.30)cm、(7.83±0.54)cm]和眶七入路[(6.47±0.28)cm、(8.31±0.34)cm]最长.锁孔骨窗中心与颅底矢状面的夹角中,额外侧入路[(40.83±1.11)°、(37.86±1.37)°] 眶上入路[(10.23±0.90)°、(12.29±0.86)°);锁孔骨窗中心与颅底横断面的夹角中,颞下入路[(21.21±0.45)°、(20.10±0.63)°] 翼点入路[(5.49±0.30)°、(9.84±0.58)°]. 结论 额窦的大小、大脑轭的形状和高度、手术操作的深度以及手术平面与颅底平面的角度对于鞍区不同部位病变的锁孔微创手术入路术前的选择具有重要的意义.     

鞍区锁孔手术入路的颅底解剖学研究

目的了解鞍区病变锁孔手术入路的相关颅底解剖,为选择合适的锁孔手术提供解剖学依据。方法取成人干性颅骨标本67个（134侧）,观察额窦开放情况和眶顶板上骨嵴（大脑轭）的形状,游标卡尺测量每例标本双侧大脑轭（眶顶板上的骨嵴）的最高高度。在15个颅骨标本上分别模拟眶上、额外侧、翼点、颞下锁孔手术入路,测量锁孔中心到达前、后床突的手术距离和相关的手术角度,并进行比较。结果额窦开放52侧（38.8%）。大脑轭的形状以多尖形和斜梁多尖形为主,高度≤2.50 mm者36侧（26.9%）,≥2.51 mm者98侧（73.1%）。四种手术入路中,锁孔中心与同侧前、后床突的距离颞下入路[（4.87±0.47）cm、（4.93±0.45）cm]最短,额外侧入路[（6.45±0.30）cm、（7.83±0.54）cm]和眶上入路[（6.47±0.28）cm、（8.31±0.34）cm]最长。锁孔骨窗中心与颅底矢状面的夹角中,额外侧入路[（40.83±1.11）°、（37.86±1.37）°]〉眶上入路[（10.23±0.90）°、（12.29±0.86）°）;锁孔骨窗中心与颅底横断面的夹角中,颞下入路[（21.21±0.45）°、（20.10±0.63）°]〉翼点入路[（5.49±0.30）°、（9.84±0.58）°]。结论额窦的大小、大脑轭的形状和高度、手术操作的深度以及手术平面与颅底平面的角度对于鞍区不同部位病变的锁孔微创手术入路术前的选择具有重要的意义。     

内镜辅助眶上锁孔入路切除鞍上区肿瘤

目的 探讨内镜辅助眶上锁孔入路切除鞍上区肿瘤的显微手术技术,以最大限度地切除肿瘤,减少手术创伤。方法 16例鞍上区肿瘤患者依据手术前影像学检查结果,制订个体化手术方案,采用眉部皮肤切口,在眶上行直径2cm左右开颅,应用内镜辅助的显微手术技术切除病变。结果 16例患者经眶上锁孔入路技术获肿瘤全部切除,无手术并发症发生。结论 眶上锁孔入路可明显减少手术创伤、提供鞍上区足够的手术空间,有利于肿瘤的全切除。     

经乙状窦后锁孔入路的内镜解剖及临床应用

随着内镜及显微手术技术的不断成熟,神经内镜辅助下的显微神经外科手术已越来越受到国内外神经外科医师的青睐.在熟悉解剖知识的基础上,乙状窦后锁孔入路已被许多神经外科医师运用于三叉神经痛、面肌痉挛、听神经瘤等手术中.本文就乙状窦后锁孔入路的内镜解剖及临床应用予以综述.     

翼点锁孔入路鞍区手术间隙的显微解剖研究

目的 观察翼点锁孔入路中鞍区4个手术间隙的显微解剖特征,探讨这些间隙在鞍区显微外科手术中的应用.方法 在6例(12侧)新鲜成人尸头标本上模拟翼点锁孔入路开颅,通过手术显微镜对鞍区手术常用的4个手术间隙及其内部结构进行解剖观察.结果 间隙Ⅰ、Ⅱ、Ⅲ、Ⅳ及Willis环的全部得到了良好的暴露,对颈内动脉床突上端及其分支、基底动脉分叉部等鞍区重要结构进行描述.结论 翼点锁孔入路可得到与标准翼点入路相同的有效显露范围,熟悉鞍区解剖间隙的显微结构,保护穿通支是鞍区手术的关键.     

显微镜与内镜下不同纵裂入路的结构显露特点及其解剖结构标志定位

目的探讨显微镜与内镜下不同纵裂入路的结构显露特点及解剖结构标志定位。方法成人尸头10具,分为A组和B组,每组5具,分别采用经前额纵裂入路和经纵裂胼胝体脉络膜裂入路联合室内孔入路,在显微镜和内镜下观察内部结构。结果显微镜与内镜下经前额纵裂入路微创并可充分显露和定位鞍区和第三脑室,有利于切除第三脑室前部和鞍区肿瘤,而经纵裂胼胝体脉络膜裂入路联合室内孔入路微创并可充分显露和定位第三脑室及侧脑室解剖结构,有利于第三脑室、房部、体部及侧脑室额角的手术操作。结论两种纵裂入路均可在显微镜、内镜下充分显露第三脑室等部分结构,组织创伤小,临床上可根据病变特点和手术需求选择合理的入路方式。     

The supraorbital approach: an alternative to traditional exposure for the surgical management of anterior fossa and parasellar pathology.

OBJECT: The use of a supraorbital craniotomy as a minimally invasive neurosurgical technique to treat pathology located in the anterior cranial fossa and parasellar region is reported. MATERIALS AND METHODS: 25 patients were operated upon using the supraorbital keyhole technique to expose various lesions located in the anterior skull base. Included were benign and malignant tumors, AVM, tuberculoma and trauma. DISCUSSION AND CONCLUSION: Utilizing small eyebrow incisions, a small supraorbital ("keyhole") craniotomy, and microneurosurgical and/or endoscopically assisted access, allowed us to gain excellent optimal and safe exposure to a number of different pathologies of the anterior base and parasellar regions. The lesions were resected under complete control and with full preservation of surrounding neurovascular structures.     

Surgical experience with frontolateral keyhole craniotomy through a superciliary skin incision

OBJECTIVE: The purpose of this study was to evaluate the results of 173 frontolateral keyhole minicraniotomies performed on 155 patients with aneurysms of the anterior or posterior cerebral circulation and for supratentorial tumors. METHODS: The frontolateral keyhole craniotomy is a modification of the generally used pterional approach. Of the 155 patients studied, 102 harbored saccular arterial aneurysms in the vessels of the anterior or posterior cerebral circulation, and 53 had various tumors in the frontal base, suprasellar, or parasellar region. The operations were carried out through an approximately 2.5- x 3-cm frontolateral miniaturized craniotomy after a skin incision just above the eyebrow. RESULTS: Despite the small size of the craniotomy, the exploration allows enough room for intracranial manipulation with maximal protection of the brain and other intracranial structures. The presented series of patients did not have any craniotomy-related complications. CONCLUSION: In our experience, the frontolateral keyhole craniotomy, together with the advent of the modern neuroanesthesia, cerebrospinal fluid drainage, and microsurgical techniques, is a safe approach for an experienced neurosurgeon to use in the treatment of supratentorial aneurysms or tumors of the anterior fossa and sellar regions.     

The Pterional Port in Dual-Port Endoscopy: A 2D and 3D Cadaveric Study

Objective We propose a novel dual-port endonasal and pterional endoscopic approach targeting midline lesions of the anterior cranial fossa with lateral extension beyond the optic nerve. Methods Ten dual-port approaches were performed on five cadaveric heads. All specimens underwent an endoscopic transtuberculum/transplanum approach followed by placement of a pterional port. The endonasal port was combined with an endoscopic extradural pterional keyhole craniectomy. The pterional port was placed at the intersection of the sphenoparietal and coronal sutures. The extradural space was explored using two-dimensional and three-dimensional endoscopes. Results The superolateral access provided by the pterional port may improve the ability to achieve a gross total resection of tumors with lateral extensions. The complete opening of the optic canal achieved through the dual-port approach may enable resection of the intracanalicular portion of a tumor, a crucial step in improvement of visual function and reduction of tumor recurrence. Conclusion The pterional port may enhance control of midline anterior skull base lesions with lateral extension beyond the optic nerve and optic canal. Dual-port endoscopy maintains minimally invasiveness and dramatically increases the working limits and control of anatomical structures well beyond what is attainable through single-port neuroendoscopy.     

Zones of approach for craniofacial resection: minimizing facial incisions for resection of anterior cranial base and paranasal sinus tumors

OBJECTIVE: Anterior cranial base tumors are surgically resected with combined craniofacial approaches that frequently involve disfiguring facial incisions and facial osteotomies. The authors outline three operative zones of the anterior cranial base and paranasal sinuses in which tumors can be resected with three standard surgical approaches that minimize transfacial incisions and extensive facial osteotomies. METHODS: The zones were defined by performing dissections on 10 cadaveric heads and by evaluating radiographic images of patients with anterior cranial base tumors. The three approaches performed on each cadaver were transbasal, transmaxillary, and extended transsphenoidal. RESULTS: Three zones of approach were defined for accessing tumors of the anterior cranial base, nasal cavity, and paranasal sinuses. Zone 1 is exposed by the transbasal approach, which is limited anteriorly by the supraorbital rim, posteriorly by the optic chiasm and clivus, inferiorly by the palate, and laterally by the medial orbital walls. This approach allows access to the entire anterior cranial base, nasal cavity, and the majority of maxillary sinuses. The limitation imposed by the orbits results in a blind spot in the superolateral extent of the maxillary sinus. Zone 2 is exposed by a sublabial maxillotomy approach and accesses the entire maxillary sinus, including the superolateral blind spot and the ipsilateral anterior cavernous sinus. However, access to the anterior cranial base is limited. Zone 3 is exposed by the transsphenoidal approach. This approach accesses the midline structures but is limited by the lateral nasal walls and intracavernous carotid arteries. An extended transsphenoidal approach allows further exposure to the anterior cranial base, clivus, or cavernous sinuses. The use of the endoscope facilitates tumor resection in the nasal cavity and paranasal sinuses. CONCLUSION: The operative zones outlined offer minimally invasive craniofacial approaches to accessing lesions of the anterior cranial base and paranasal sinuses, obviating facial incisions and facial osteotomies. Case illustrations demonstrating the approach selection paradigm are presented.     

乙状窦后锁孔入路对颅中后窝区的显微解剖

目的 研究乙状窦后锁孔入路对颅中后窝岩斜区结构的显微解剖,为临床应用该入路解决颅中后窝岩斜区病变提供解剖学依据. 方法 应用福尔马林固定的成人湿性头颅标本10例20侧,模拟乙状窦后锁孔入路对颅中后窝岩斜区进行显微解剖观察. 结果 乙状窦后锁孔入路从后外侧到达颅中后窝岩斜区,可以清楚暴露小脑半球外侧面、颞骨岩部、三叉神经、面听神经、部分后组脑神经、脑桥外侧面、椎动脉、小脑前下动脉.磨除部分岩骨可以扩大内听道及三叉神经的暴露,切开小脑幕缘可以暴露部分滑车神经及部分颅中后窝. 结论 乙状窦后经内听道上锁孔入路充分利用了有效的骨窗,手术创伤小、并发症少.该入路使少数原本需要采用复杂入路方能切除的颅中后窝肿瘤,可通过较简单的手术入路进行切除.对于主体位于颅后窝的岩斜区中小型肿瘤显微切除是一种有效、安全、便捷的微创手术方法.     

经前额纵裂入路的神经内镜与显微解剖学及临床应用

目的通过对经前额纵裂入路的内镜解剖与显微解剖学研究,为临床提供解剖学参考。方法8例成人尸头,取经前额纵裂入路,在显微镜和内镜下对其内部结构进行全程观察。采用经前额纵裂入路手术22例。结果通过显微镜及不同角度内镜,能够观察到鞍区和第三脑室结构。22例中,动脉瘤5例均成功夹闭,肿瘤全切13例,近全切除3例,大部切除1例,无死亡病例,无严重并发症的发生。结论内镜辅助显微镜经前额纵裂入路对鞍区及第三脑室前部暴露良好,对周围组织损伤小,是切除鞍区和第三脑室前部肿瘤的较佳入路。     

Endoscope-assisted far-lateral transcondylar approach to the skull base.

The far-lateral transcondylar approach was used in this cadaveric study in an attempt to evaluate the usefulness of endoscope-assisted microsurgery in this region of the skull base. The study was carried out using 4 latex-injected, formalin-fixed cadaver heads. After initial examination of intradural structures under an operating microscope, a zero degree 4 mm diameter solid-rod endoscope lens was introduced and guided into position under the direction of the operating microscope. Photographs of the regional anatomy were taken through this lens and through a 30 degree angled lens and compared to photographs of the anatomy taken through the microscope. Clear close-up views of the dural portals and intradural course of the cranial nerves were obtained using the endoscope. The endoscope was introduced through three corridors enclosed with cranial nerves, providing the surgeon with panoramic views of the vertebrobasilar arteries and anterior brainstem surface. The endoscope can be guided through narrow corridors and placed immediately adjacent to a region of interest at the skull base. It enables the surgeon to look around blind corners and work behind structures that are hidden from microscopic view.     

Minimal invasive neurosurgery of infiltrative tumours extending around the sellar region: advantage of combined methods.

Most of the infiltrative tumoural lesions located around the sellar region compromise the cavernous sinus, cranial nerves, vascular neighboured structures and the hypothalamus. Minimal invasive neurosurgery (MIN) employing microsurgery, neuroendoscopy, neuronavigation and intraoperative radioscopy are reported to increase gross total tumour resection reducing the operative trauma. We combined at least 3 of these techniques in 32 patients with solid and 8 patients with cystic tumours of this region. Thirty tumours were approached in a transphenoidal manner, ten were via a single burr hole craniotomy in a transcortico-ventricular approach. In 36 cases the tumours were adequately removed with only six cases suffering a transitory and one with a permanent deterioration of a preoperatively diagnosed neurological deficit. In our experience, the use of combined techniques, particularly in these patients, reduces the operative trauma and improves the accuracy in planning the access, angle and extension of tumour removal. It also protects the patient from secondary damage to neighboured structures.