岩斜区临床手术入路的分类及适应症选择

岩斜区手术入路名称繁多,且多有重复。根据手术入路方位的不同,岩斜区手术入路可大致分为经岩骨前方、侧方或后方入路。目前应用较多的是经岩骨侧方(经岩入路),依据岩骨切除范围的多少可分为:乙状窦前迷路后入路,部分经迷路入路,经迷路入路,经耳蜗入路,全岩骨切除。不同的手术入路都有其自身的优缺点,没有一种入路在处理岩斜区的病变中是完美无缺并适合于不同的情况。如何结合临床实际、岩斜区肿瘤的生长特点合理选择手术入路成为岩斜区手术的关键。     

乙状窦前入路处理斜坡凹陷区病变的量化研究

目的量化研究乙状窦前入路中每一步岩骨切除及血管神经牵拉完成后获得的斜坡中央凹陷区显露范围及手术自由度。方法对20例头颅标本采用乙状窦前入路,骨切除分4步进行：迷路后骨质切除,上、后半规管切除,切除岩尖并打开Meckel＇s腔游离三叉神经,全切迷路及耳蜗并后移面神经。每一步完成后分别测量斜坡中央凹陷区的显露范围和手术自由度。结果岩尖切除、打开Meckel＇s腔游离三叉神经后,斜坡中央凹陷区显露面积为（190±32）mm^2,占整个入路完成后的95％,与磨除上、后半规管后的显露范围相比差异显著,手术自由度亦显著增加。结论乙状窦前联合部分迷路岩尖切除手术入路能够较好的显露斜坡中央凹陷区。岩尖的切除和打开Meckel＇s腔游离三叉神经是充分显露斜坡中央凹陷区并提供足够手术自由度的关键步骤。     

岩斜区肿瘤的手术入路研究进展

岩斜区肿瘤由于病变部位深在,周围神经血管结构复杂,许多作者对其手术入路进行了多种探讨。其主要入路有额颞-眶-颧弓联合入路、改良颞下入路、颞下经”锁孔”入路、颞下经颧弓入路、前颞下经岩骨内侧入路、迷路后入路、扩大的迷路后入路、经半规管脚入路、经耳蜗入路、迷路后硬膜内内听道上入路和幕上下联合入路,通过不同的颅底入路,获得岩斜区部位肿瘤的最佳显露,并减轻了对脑组织和颅神经及重要血管结构的牵拉和损伤。     

经岩骨后人路的应用解剖学研究

目的从应用解剖学入手,量化和微创化研究经岩骨后入路。方法在手术显微镜下,对20侧(10具)福尔马林固定的成人头颅标本进行颅底剖面的解剖测量;对6侧(3具)头颅标本模拟经岩骨后入路,进行入路全程解剖观察。结果确定了经岩骨后入路的骨窗后下界和入路行经的重要路标;观测了面神经管和迷路结构的解剖关系;明确了安全切除岩尖区骨质的范围。依据上述观测结果,模拟、验证经岩骨后入路,并提出改进方法。结论传统经岩骨后入路对岩尖区硬膜内结构的暴露范围有限,手术风险较大。通过量化、微创化研究经岩骨后入路的硬膜外骨切除操作,改进硬脑膜和小脑幕切开方法,明显扩大对岩尖区硬膜内结构的显露,确保手术的安全性。     

神经内镜辅助下乙状窦前迷路后锁孔入路处理岩斜区病变的应用解剖研究

目的 为神经内镜辅助下乙状窦前迷路后锁孔手术入路处理岩斜区病变提供解剖学基础.方法 取10例(20侧)经福尔马林固定成人头颅标本,采用耳后"C"形切口,切口长度约6cm,模拟乙状窦前迷路后入路,神经内镜及显微镜下观察所显露的解剖结构.结果 乙状窦前缘与后半规管平面的水平距离为:右侧(9.1±1.3)mm,左侧(9.6±1.8)mm.通过调整神经内镜及显微镜角度,经乙状窦前迷路后锁孔入路可显露岩斜区的一些重要结构,清晰显示脑神经及其附近走行的血管.结论 面、前庭蜗神经及内耳道后唇均可以作为神经内镜下经乙状窦前迷路后入路定位岩斜区及其周围结构的标识.     

颞下经小脑幕锁孔入路解剖与临床应用

目的通过神经导航下颞下经小脑幕锁孔入路的解剖和手术方案研究,探讨该入路临床应用效果。方法应用成人头颅标本12例(24侧),模拟颞下经小脑幕锁孔入路,观察暴露的岩斜区解剖结构;利用神经导航技术定位标本岩骨内部结构,最大限度磨除岩尖,观察斜坡鞍后区,上、中斜坡区等结构;利用该入路切除11例临床颅底肿瘤,探讨该入路的安全性和实用性。结果颞下经小脑幕锁孔入路可完全暴露鞍旁区,通过海绵窦外侧壁的手术三角可对累及海绵窦内外病变进行直视手术;神经导航辅助下耳蜗、内听道等结构定位准确,头颅标本岩尖磨除后耳蜗内侧缘岩尖剩余最大骨质平均厚度(0.8±0.19)mm,内侧视角较非导航入路增加(8±2.5)°,后外侧视野增加了(25±3.2)°,获得(3.3±0.4)cm2硬膜显露,明显扩大了后颅窝的暴露范围。临床病例资料肿瘤全切除6例,次全切3例,大部分切除2例,手术时间与既往相比缩短1~1.5 h,术后新增脑神经损害症状或原有脑神经损害症状加重3例,无长期昏迷及手术相关死亡病例。结论神经导航辅助下颞下经小脑幕锁孔入路,能最大程度暴露蝶岩斜区病变,有利于提高肿瘤的全切率和术后疗效。     

幕上下乙状窦前迷路后锁孔入路的设计与显微解剖学研究

目的探讨幕上下乙状窦前迷路后锁孔手术的可行性和手术入路。方法采用8具经10%甲醛溶液固定的尸体头颅标本,于耳后做一长度约7 cm的“C”形头皮切口,上至耳郭上缘,下至耳屏间切迹水平,耳后距耳郭1 cm。磨除部分乳突后联合颞部开颅,形成一3.5cm×3cm大小的骨窗,暴露并剪开乙状窦前和颞部硬脑膜,牵开颞叶和小脑半球,显微镜下观察所显露的解剖结构。结果通过调整显微镜角度,幕上下乙状窦前迷路后锁孔入路可显露同侧桥小脑角区、脑桥前区、脑桥侧方、小脑幕上区的结构。结论幕上下乙状窦前迷路后锁孔入路可很好地显露上述结构,应用现代显微外科技术,可在不磨除迷路的情况下进行岩斜区脑膜瘤、中小型听神经瘤、脑桥腹外侧肿瘤、基底动脉瘤等手术。     

幕上下联合经部分迷路-岩尖入路的显微解剖研究

目的研究幕上下联合经部分迷路-岩尖入路(PLPATT)的操作方法、暴露范围及相关解剖结构,并与迷路后经岩骨入路(RLPA)相比较。方法在3×40倍手术显微镜下,按照RLPA和PLPATT两种方法逐层详细解剖16例32侧尸头标本,测量乙状窦前、颞叶下方的暴露范围以及斜坡陷凹的暴露角度。结果采用PLPATT能够充分暴露岩斜区,且明显增加了术野水平方向暴露的范围:右侧(10.7±1.8)mm,左侧(11.4±2.1)mm;及垂直方向的暴露范围:右侧(10.2±0.9)mm,左侧(9.8±1.2)mm。同时扩大了斜坡陷凹的操作视角(右侧增加41.4°,左侧42.2°)。结论PLPATT将迷路后入路和颞下入路合并为一个宽大的手术空间,可以从多个角度观察中上斜坡,并且能够保留病人听力。     

联合耳前、后切口经岩骨和天幕入路切除岩斜区肿瘤13例

目的 介绍采用联合耳前、后切口经岩骨和天幕入路切除上斜坡、岩斜区及鞍隔上(视交叉后)肿瘤的手术治疗经验，并就手术入路进行讨论。方法 对我院采用联合入路手术切除岩斜区肿瘤13例进行回顾性分析。结果 本组13例，全切9例，次全切2例，部分切除2例。出院时按Maybe唱分类，I级7例，Ⅱ级4例，Ⅲ和Ⅳ级各1例。结论 本联合入路的特点：①可避免和减少术后产生脑脊液耳漏等严重并发征；②在切除岩骨，充分显露颞底、乙状窦前硬膜及天幕的同时，有可能保留听力；③本联合入路不仅适用手术切除上斜坡和岩斜区肿瘤，还能应用手术切除鞍隔上(视交叉后)肿瘤。     

颞下经岩骨前部入路的临床应用

颞下经岩骨前部人路是颅底手术入路的一种,其特点是于颞下硬膜外磨除岩骨前部(耳蜗以前),通过中颅窝充分显露脑桥腹侧、上斜坡及骑跨中后颅窝的病变,争取一期手术全切病变。熟悉岩骨的解剖,是此入路应用的前提。其优点:颞叶的牵拉小;颅内操作问隙多;可保留听力;有利于保护脑干、后组颅神经、基底动脉及其穿动脉;易与其他人路联合使用,扩大显露范围。缺点:若伤及岩骨内结构,可出现严重并发症;可损伤岩尖部的Ⅲ-Ⅵ颅神经;不能显露内听道以后和中下斜坡的病变;手术创伤大、费时。     

Transpetrosal approaches for meningiomas of the posterior aspect of the petrous bone Results in 43 consecutive patients

OBJECTIVE: To assess outcome following excision of meningiomas of the posterior aspect of the petrous bone through transpetrosal approaches. MATERIAL AND METHOD: We carried out a retrospective case-series study in a multidisciplinary tertiary care center on all patients who underwent meningiomas removal from January 1989 to September 2005. Surgical approaches were transpetrosal: widened retrolabyrinthine, translabyrinthine, transotic and transcochlear, occasionally combined with a subtemporal transtentorial approach. Epidemiology, symptoms, preoperative evaluation, surgery, postoperative complications and facial and auditory results were analyzed using standardized grading systems. The Desgeorges and Sterkers classification was used to assess tumor size and location. RESULTS: Forty women and three men underwent surgery (mean age: 56.7). Medium-sized tumors stages 2 and 3 (84%) and AM and P localization (34% and 20.4%) predominated. In 65% of cases, the tumor extended beyond the CPA. Main presenting symptoms were balance disorders (72%) and sensorineural hearing loss (53.5%). Mortality was nil. A preoperative facial nerve paresis was present in 14% of patients. Tumor removal was complete in 79.1% of cases. At 1-year post-op, 73% of patients had a normal or subnormal facial function and 55% had serviceable hearing. A cerebrospinal fluid leakage occurred in 6.9%. DISCUSSION: Posteriorly attached meningiomas are less symptomatic and of better prognosis than medially inserted ones. Transpetrosal approaches are reliable for the removal for all types and sizes of such tumors, and can be easily combined in the same procedure with a subtemporal transtentorial approach to remove extensions to the clivus and tentorium. They offer low morbidity and a high proportion of facial nerve and hearing preservation.     

幕上下锁孔入路的显微解剖研究

目的探讨岩斜区幕上下锁孔入路显微解剖,为岩斜区手术入路提供解剖学依据。方法在10例国人成人头颅湿标本上,在手术显微镜下观察,测量幕上下锁孔入路的重要显微结构;对手术前后共10例标本进行3D-CT颅骨重建:并对重要结构进行测量。结果通过幕上下锁孔入路,可涉及的重要解剖区域包括三叉神经、面听神经、岩骨内部结构、脑干腹侧间隙等,重要参数包括岩骨嵴磨除范围。结论岩斜区幕上下锁孔入路是手术治疗岩斜区肿瘤的灵活运用的手术入路。     

Petrous apex meningiomas: an alternative surgical approach

The literature describes a variety of surgical approaches to deal with meningiomas that involve the apex of the petrous bone and lie predominantly in the posterior fossa, e.g. the transpetrosal (translabyrinthine and transcochlear), the combined supra- and infratentorial, the subtemporal with or without pyramid resection, the suboccipital and the orbitozygomatic approaches. This study presents an alternative surgical approach, namely a modification of the occipital craniotomy with or without tentorial division. This approach was used for the removal of three petrous bone apex meningiomas which were medium to large in size and located predominantly in the posterior fossa with extension into the middle fossa. Complete tumour excision was achieved with no morbidity and no mortality.     

耳前颞下经岩骨经小脑幕硬膜下入路切除岩斜区脑膜瘤

目的探讨耳前颞下经岩骨经小脑幕硬膜下入路切除岩斜区脑膜瘤的手术方法及其治疗效果。方法回顾性分析40例岩斜区脑膜瘤病人的临床资料,采用耳前颞下经岩骨经小脑幕硬膜下入路显微外科手术切除肿瘤。结果肿瘤全切除28例（70.0%）,近全切除10例（25.0%）,大部分切除2例（5.0%）。40例病人随访3~15个月,术后6例发生动眼神经麻痹,均在3个月内完全恢复;10例展神经麻痹病人中,完全恢复4例,不同程度恢复4例,未恢复2例;8例轻度面瘫病人中,完全恢复6例,未恢复2例;12例面部麻木加重病人中,术后恢复至术前水平6例,较术前加重6例;偏瘫2例和失语3例,6个月内恢复至术前水平。无脑脊液漏和手术死亡病例。结论耳前颞下经岩骨经小脑幕硬膜下入路能够充分显露并切除肿瘤基底位于中、上斜坡的岩斜区脑膜瘤,术后脑神经功能障碍、肢体偏瘫、脑脊液漏的发生率低。     

岩斜区脑膜瘤的显微外科治疗

目的探讨经岩骨乙状窦前入路显微外科治疗岩斜区脑膜瘤的手术特征及并发症。方法回顾性分析经显微手术治疗的12例岩斜区脑膜瘤资料。对肿瘤临床和影像学特征、手术入路、手术切除技巧及术后常见并发症的处理进行研究进行分析。结果全切除9例,大部切除3例。术后顽固性脑水肿2例,一侧肢体瘫痪1例,周围性面瘫3例,脑脊液耳漏2例,腰穿置管持续引流后痊愈。脑脊液鼻漏1例,腰穿引流后及耳咽管堵塞后痊愈。无死亡病例。结论经岩骨乙状窦前入路是处理岩斜区脑膜瘤的主要手术入路。颅底重建技术对于防止术后并发症起到了关键作用。     

Quantitative analysis of surgical exposure and maneuverability associated with the endoscope and the microscope in the retrosigmoid and various posterior petrosectomy approaches to the petroclival region using computer tomograpy-based frameless stereotaxy. A cadaveric study

Object

Most of the approaches used to expose the petro-clival region require a certain degree of temporal bone resection with its associated approach morbidity such as potential hearing and facial nerve compromise.Endoscopes are becoming more and more popular in neurosurgical practice. To gain insight into the benefits of using endoscopy to operate on the petro-clival region, we evaluated and compared the exposure and maneuverability obtained employing the endoscope and the microscope in retrosigmoid and pre-sigmoid approaches by using quantitative analysis based on frameless stereotaxy.

Methods

We evaluated the retrosigmoid (RS), retrolabyrinthine (RL), translabyrinthine (TL), and transcochlear (TC) approaches. Each approach was performed 4 times for a total of 16 approaches. We used a navigation system for intraoperative navigation. Each approach was evaluated vis-a-vis the area of the petro-clival/brainstem region exposed and the afforded maneuverability, both using a rigid endoscope or an operating microscope.

Results

The TC approach exposed the largest area at the brainstem compared to all other three approaches both in microscopic and endoscopic modes and there was no significant difference between the 2 modes (P = 0.42). In the RS approach use of the 30° angled endoscope increased significantly the exposure compared to the operating microscope (respectively 460 ± 49.7 mm² vs 235 ± 25 mm²; P = 0.002). On the other hand, maneuverability was significantly decreased with the endoscope compared to the microscope in all the approaches evaluated (P = 0.006).

Conclusions

Integration of the endoscope into conventional petrosectomy approaches could significantly reduce the amount of temporal bone drilling for adequate visualization of the petro-clival region. However maneuverability as assessed by our model was better with the microscope than with the endoscope.     

Resection of large petroclival meningiomas by the simple retrosigmoid route

The operative treatment of petroclival meningiomas has shown considerable improvement in recent years due at least in part to new developments in skull base techniques, including the introduction of the modern transpetrosal approaches. Increased tumour resection and improved postoperative outcomes have been reported with the use of the transpetrosal approaches. Extensive experience in managing these tumours has shown, however, that in a subgroup of patients the transpetrosal approaches may not be indicated: either because of the increased surgical complications related to this approach, or because of the unnecessarily large exposure in the individual cases. The authors report a recent experience dealing with 70 petroclival meningiomas, 24 of which have been resected by the simple retrosigmoid approach. The indication for the retrosigmoid route in the surgical management of the petroclival meningiomas, and its advantages and disadvantages compared to the transpetrosal method are discussed.     

中间神经的显微解剖研究

目的 探讨中间神经的显微解剖形态与毗邻组织结构的关系。方法 选择经10％福尔马林固定血管内灌注混有彩色乳胶的人尸头16具,结合听神经鞘瘤三种手术入路,在手术显微镜下,观测不同部位的中间神经。结果 中间神经分为桥小脑角段,内听道段和面神经管段,桥小脑角段与毗邻的关系不恒定,内听动脉与中间神经位置相对恒定,乙状窦前经迷路入路和颞下经岩入路可以较好地显露中间神经,结论 了解中间神经的显微解剖形态,可以正确选择手术入路,避免神经损伤,保护中间神经同保护面神经运动支一样重要。