颅底与颈椎脊索瘤13例临床分析

目的 探讨颅底及颈椎脊索瘤手术治疗方法及疗效。方法 回顾性分析2009年3月至2013年10月收治的13例颅底及颈椎脊索瘤患者临床资料。根据肿瘤生长部位及特点,包括原发及复发病例,颅底脊索瘤分别采用经鼻蝶入路7次、经鼻蝶联合经口入路2次、翼点入路1次和乙状窦后入路2次;颈椎脊索瘤采用颈椎后路切除及内固定术4次。结果 13例病人术后随访2~60个月,平均随访21个月。首次手术后全切除7例（53.8%）,次全切除4例（30.8%）,部分切除2例（15.4%）。术后行放射治疗7例。术后复发4例,3例再次行手术治疗,1例行放射治疗。结论 依据肿瘤的生长部位和特点选择合适的手术入路是颅底和颈椎脊索瘤手术成功的关键,经鼻蝶入路鼻内镜辅助下手术为颅底脊索瘤提供了一种更加安全和有效的全切除肿瘤的方法,术后给予放射治疗可以延缓肿瘤的复发。     

扩大经口入路显微手术切除颅底中线部位肿瘤(附12例分析)

目的总结扩大经口入路显微手术切除颅底中线部位肿瘤的手术经验。方法回顾性分析2004年3月～2006年12月我院采用扩大经口入路切除的12例颅底中线部位肿瘤病人的临床资料。结果8例脊索瘤中5例全切除，3例近全切除；2例转移癌中1例全切除，1例大部切除；1例鼻咽癌及1例咽后壁鳞状上皮癌全切除。术后并发脑脊液鼻漏1例。无死亡、偏瘫等病例。随访6～24个月，脊索瘤分别于术后1．5年、2年局部复发2例，转移癌死于肺部原发性疾病1例，保持正常生活9例。结论扩大经口入路切除颅底中线部位肿瘤具有暴露充分、手术创伤小、并发症少等优点。     

颅底脊索瘤的内镜经鼻手术治疗分型及入路

目的 探讨一种适合内镜经鼻手术治疗需要的颅底脊索瘤临床分型及入路选择方法.方法 回顾性分析2007年8月至2012年8月于我院使用内镜经鼻手术治疗的133例颅底脊索瘤病例资料.依据内镜经鼻手术斜坡解剖区域分类方法对脊索瘤进行临床分型.其中,主体位于颅底中线区域116例:(1)主体位于前颅底6例;(2)主体位于上斜坡7例;(3)主体位于上中斜坡42例;(4)主体位于中下斜坡8例;(5)主体位于下斜坡21例;(6)主体位于全斜坡32例.主体位于中线及中线旁区域(广泛型)17例.全部病人均行内镜经鼻手术切除.中线区域型共使用4种内镜经鼻手术入路:内镜经鼻-前颅底入路、内镜经鼻-上斜坡入路、内镜经鼻-中斜坡入路、内镜经鼻-下斜坡入路.广泛型使用内镜经鼻手术入路结合其他开颅手术入路进行肿瘤切除.结果 病变全切为26例(20％),次全切62例(47％),大部切除38例(29％),部分切除7例(5％).结论 制定适合内镜经鼻手术的斜坡解剖区域划分,并以此为基础对颅底脊索瘤进行临床分型,可以更好地指导内镜经鼻切除颅底脊索瘤的手术入路选择.     

经鼻内镜斜坡脊索瘤和脊索肉瘤的外科治疗

目的探讨经鼻内镜外科技术在斜坡脊索瘤和脊索肉瘤治疗中的应用、方法2002年11月～2006年2月对7例脊索瘤和2例脊索肉瘤行经鼻内镜手术，其中3例是复发病例、所有病例均有头痛，复视4例．视力障碍或失明3例，鼻塞、嗅觉减退或失嗅4例，面部麻木1例。肿瘤同时侵犯海绵窦和颈内动脉4例。岩尖区5例．寰枢椎2例．随访时间3～39个月。结果6例脊索瘤和1例脊索肉瘤术中内镜下及术后影像学证实完全切除，1例脊索瘤和1例脊索肉瘤次全切除．1例术后出现蛛网膜下腔出血。至随访期结束．7例病人无复发。1例带瘤生存。1例行脊索瘤次全切除的病人5个月后复发。结论经鼻内镜治疗斜坡脊索瘤和脊索肉瘤可以更好地辨认深部结构．视觉效果好，可以大范围切除病变。同时，可以简单迅速地到达斜坡区域。对斜坡脊索瘤和脊索肉瘤是一种较好的手术入路。     

内镜经鼻蝶手术治疗颅底脊索瘤

目的探讨内镜下经鼻蝶治疗颅底脊索瘤的技术、方法和手术指征。方法自2000年6月至2006年6月,应用神经内镜经鼻蝶入路手术治疗颅底脊索瘤30例。29例应用30°,70°硬性神经内镜,经鼻中隔和中鼻甲间入路,用高速磨钻磨除相应的骨性结构,显露肿瘤并分块切除。1例在显微外科下开颅切除颅内部分肿瘤,然后在神经内镜引导下,经鼻蝶切除斜坡、鞍区蝶筛窦、上颌窦、颞下窝的肿瘤。18例在术后6-12个月获得随访。结果肿瘤近全切除7例,次全切除16例,部分切除7例。24例术后获得一定程度上的临床症状和体征的改善,6例无变化。所有病人在术后7- 10d可恢复日常生活。1例在出院后20d因脑脊液漏再次入院做修补手术。随访的18例中,有4例在术后10-18个月复发,这4例均为广泛性生长的病例。结论内镜经鼻蝶手术治疗颅底脊索瘤有明显的优势。其操作简便安全;术中视野清楚,有利于显露;术后严重并发症少,病人恢复快,住院时间短。     

内镜经鼻颅内外联合入路切除前中颅底沟通瘤

目的 探讨内镜绛鼻颅内外联合入路切除前中颅底沟通瘤的手术方法.方法 对13例患者在扩大经额下入路显微切除肿瘤颅腔内部分的基础上,采用经鼻内镜下切除肿瘤颅外部分并重建颅底缺损.结果 手术全切除11例,次全切除2例,无手术死亡和新神经功能废损、脑脊液漏、脑膜腩膨出及颅内感染等并发症发生.术后病理爪神经鞘瘤4例,鼻咽纤维血管瘤3例,脑膜瘤2例,垂体瘤、内翻性乳头状瘤、鳞状细胞痛和嗅神经母细胞瘤符1例.结论 采用内镜经鼻颅内外联合入路切除前中颅底沟通瘤创伤小且深部视野良好,能安全且完全切除良性肿瘤.     

内镜下经鼻人路治疗颅底中央区恶性肿瘤

目的探讨内镜下经鼻人路切除颅底中央区恶性肿瘤的手术方法和治疗效果。方法回顾性分析颅底恶性肿瘤32例。采用内镜下经鼻人路27例,颅一鼻联合人路5例;其中术后行一期颅底重建16例。结果肿瘤全切除15例,近全切除13例。部分切除4例。术后症状明显改善或缓解23例,无明显好转9例。主要并发症为：脑脊液鼻漏和颅内感染各1例,均治愈;无颅内出血及死亡病例。随访6,74个月,平均27．8个月;至随访期结束,无肿瘤复发10例,带瘤生存12例,死亡10例,5年生存率46．2％。病人术后3个月KPS评分比人院时显著提高（P〈0．05）。结论内镜下经鼻入路结合可靠的颅底重建,能有效切除颅底中央区恶性肿瘤,并提高病人近期生活质量。     

经蝶切除蝶骨斜坡区脊索瘤

目的 探讨颅底脊索瘤的手术入路和治疗方法，以提高肿瘤的全切率和治疗效果。方法 经蝶入路切除蝶骨斜坡区脊索瘤。结果 肿瘤次全切除14例（73．7％），大部分切除5例（26．3％）。14例大部分切除无死亡。5年生存率58％。结论 经蝶入路是一种安全，有效，创伤小，省时的手术入路；适宜切除大多数蝶骨斜坡区脊索瘤；积极切除肿瘤术后结合放疗可提高生存质量并能明显延长生存率。     

经蝶入路颅底脊索瘤的显微手术治疗(附15例分析)

目的总结经蝶入路治疗颅底脊索瘤的手术经验。方法回顾性分析15例颅底脊索瘤病人的病例资料。肿瘤位于鞍区和中上斜坡13例,其中累及鞍内、鞍旁、蝶窦3例;呈侵袭性生长,累及中上斜坡和多组鼻窦2例。均采用经蝶窦入路手术。结果肿瘤全切除4例,次全切除8例,部分切除3例。术后临床症状得到不同程度改善11例,无明显缓解4例;无术后脑脊液漏、颅内感染等手术并发症发生,无死亡病例。部分切除病例中,术后12个月复发2例,术后2年复发伴远隔部位转移1例。结论对于局限于鞍区或中上斜坡及向鼻旁窦方向侵袭生长的颅底脊索瘤,经蝶窦入路可以很好地显露病变。该入路切除病变操作安全、省时,术后并发症少,病人恢复良好。     

以脑脊液鼻漏为首发症状斜坡脊索瘤的诊断及内镜外科治疗

目的探讨以脑脊液鼻漏为首发症状的斜坡脊索瘤的诊断及内镜外科治疗。方法回顾性分析2例以脑脊液鼻漏为首发症状的斜坡脊索瘤病人的临床资料,均在内镜下确诊,并行内镜经鼻入路肿瘤切除术及脑脊液鼻漏修补术。结果肿瘤全切除2例,脑脊液鼻漏均修补成功。随防17～22个月,无肿瘤及脑脊液鼻漏复发。结论对于斜坡脑脊液鼻漏应高度警惕脊索瘤的存在,内镜下经鼻入路既是术中发现病变的手段,又是切除斜坡病变及行脑脊液鼻漏修补的治疗方式。     

美国《化学文摘》、《乌利希国际期刊指南》及波兰《哥白尼索引》正式收录本刊

美国《化学文摘》(Chemical Abstracts,CA)是世界最大的化学文摘库,也是目前世界上应用最广泛,最为重要的化学、化工及相关学科的检索工具。CA创刊于1907年,由美国化学协会化学文摘社(CAS)编辑出版,为国际六大著名检索期刊之一。     

前中颅底沟通瘤的解剖学分类及手术治疗

目的 探讨前中颅底沟通瘤的临床分类方法 及手术治疗,提高临床治疗水平. 方法 根据肿瘤主体位置和生长方向将29例前中颅底沟通瘤患者划分为额鼻眶区(16例)、中颅窝一侧颅底区(8例)、颅底中央区-中间颅底区(4例)及岩骨颈静脉孔区(1例)4类,据此并结合病理资料等分别选择扩大经额下人路(13例)、眶上-翼点入路(9例)、额颞眶颧入路(3例)、额颞人路(3例)及岩骨切除入路(1例)进行肿瘤切除和颅底缺损重建,其中采用经鼻内镜等颅内外联合入路11例.结果 肿瘤全切除24例.次全切除5例,无手术死亡发生;术后早期出现动眼神经麻痹2例,余未有新的神经功能缺损及脑脊液漏、颅内感染、脑膜脑膨出等严重并发症发生. 结论 该分类方法 具有界限清楚、部位和范围明确的优点,有利于选择合理手术人路进行肿瘤切除和颅底缺损修复及临床手术治疗效果的提高.     

Utility of a rotation–suction microdebrider for tumor removal in endoscopic endonasal skull base surgery

The microdebrider is a common tool used in endoscopic sinus surgery for removing polypoid and sinonasal tissue. It uses rotating blades and an integrated suction device for controlled removal of tissue under video–endoscopic visualization. To our knowledge, the application of the microdebrider for endoscopic removal of skull base tumors has not been reported. This study aimed to investigate the utility of the rotation–suction microdebrider as a tool for endoscopic endonasal removal of solid and fibrous skull base tumors. Thirty-two patients underwent endoscopic endonasal skull base surgery where the rotation–suction microdebrider was used as the primary tool for tumor removal and debulking. Pathologies included a variety of anterior skull base meningiomas, sinonasal skull base malignancies, juvenile nasopharyngeal angiofibromas, schwannomas, and other skull base lesions. Gross total and near total removal was achieved in 87.5% (28/32) of patients, and subtotal removal was performed in 12.5% (4/32) of patients. The microdebrider allowed efficient debulking and removal of solid and fibrous tumors, such as meningiomas, that were not responsive to standard ultrasonic aspiration. There were no complications of orbital or neurovascular injury, or thermal injury to the nostril. The rotation–suction microdebrider is a useful tool for endoscopic endonasal removal of skull base tumors. This is particularly useful for solid and fibrous tumors that are not responsive to standard ultrasonic aspiration. For intracranial tumors, it is critical to remain inside the tumor capsule during debulking so as to avoid injury to the surrounding neurovascular structures.     

内镜下扩大经鼻蝶入路术中多层技术颅底重建

目的总结内镜下扩大经鼻蝶入路鞍区及鞍旁区多层技术重建颅底的经验。方法回顾性分析12例鞍区及鞍旁区肿瘤的临床资料,其中颅咽管瘤4例,鞍区脑膜瘤3例,巨大垂体腺瘤5例;均行内镜下扩大经鼻蝶入路肿瘤切除术,并采用多层技术进行颅底重建。结果所有病例肿瘤均达全切除,颅底重建均1次修补成功。术后部分临床症状明显改善。随访3～6个月,均未出现脑脊液漏、细菌性脑膜炎和张力性气颅等并发症。结论内镜下扩大经鼻蝶入路术中多层技术重建颅底是一种简单、安全、有效的方法。     

Shortening the learning curve in endoscopic endonasal skull base surgery: A reproducible polymer tumor model for the trans-sphenoidal trans-tubercular approach to retro-infundibular tumors

Background

Endoscopic endonasal skull base surgery attracts an increasing number of young neurosurgeons. This recent technique requires specific technical skills for the approaches to non-pituitary tumors (expanded endoscopic endonasal surgery). Actual residents’ busy schedules carry the risk of compromising their laboratory training by limiting significantly the dedicated time for dissections.

Objective

To enhance and shorten the learning curve in expanded endoscopic endonasal skull base surgery, we propose a reproducible model based on the implantation of a polymer via an intracranial route to provide a pathological retro-infundibular expansive lesion accessible to a virgin expanded endoscopic endonasal route, avoiding the ethically-debatable need to hundreds of pituitary cases in live patients before acquiring the desired skills.

Methods

A polymer-based tumor model was implanted in 6 embalmed human heads via a microsurgical right fronto-temporal approach through the carotido-oculomotor cistern to mimic a retro-infundibular tumor. The tumor's position was verified by CT-scan. An endoscopic endonasal trans-sphenoidal trans-tubercular trans-planum approach was then carried out on a virgin route under neuronavigation tracking.

Results

Dissection of the tumor model from displaced surrounding neurovascular structures reproduced live surgery's sensations and challenges. Post-implantation CT-scan allowed the pre-removal assessment of the tumor insertion, its relationships as well as naso-sphenoidal anatomy in preparation of the endoscopic approach.

Conclusion

Training on easily reproducible retro-infundibular approaches in a context of pathological distorted anatomy provides a unique opportunity to avoid the need for repetitive live surgeries to acquire skills for this kind of rare tumors, and may shorten the learning curve for endoscopic endonasal surgery.     

经鼻内镜颅底病变的外科手术

目的探讨经鼻内镜手术治疗海绵窦、斜坡及岩斜区病变的可行性和手术技术。方法对海绵窦、岩斜坡、斜坡区及鼻窦病变侵犯颞下窝的10例病人采用内镜行经鼻手术切除或活检。结果6例肿瘤全部切除,2例大部分切除,海绵窦及岩斜坡各1例病变活检获得明确诊断。术后蛛网膜下腔出血1例,经保守治疗治愈;3例脑脊液鼻漏,其中2例保守治疗治愈,1例2次经鼻内镜手术修补成功。无颅内感染及死亡。结论经鼻内镜颅底手术是一种安全的、可供选择的外科治疗方法。     

Significance of the simultaneous combined transcranial and endoscopic endonasal approach for prevention of postoperative CSF leak after surgery for lateral skull base meningioma

Lateral skull base meningiomas, particularly sphenoorbital meningiomas, sometimes extend extremely widely into adjacent structures including the paranasal sinuses. For endonasal skull base reconstruction using a vascularized nasoseptal flap for prevention of postoperative cerebrospinal fluid (CSF) leak, the simultaneous combined transcranial and endoscopic endonasal approach was applied for resection of these extensive tumors. We performed a retrospective review of four patients treated with the simultaneous combined transcranial and endoscopic endonasal approach for resection of lateral skull base meningiomas. Preoperative characteristics, tumor extent, extent of resection, complications, and postoperative outcomes were analyzed. The tumor extended into the paranasal sinus, infratemporal fossa, and pterygopalatine fossa in all patients. Extracranial extension into the cavernous sinus or superior orbital fissure was detected in two and three patients, respectively. In one patient without extension into the cavernous sinus and superior orbital fissure, gross total resection was achieved, whereas in the other three patients, subtotal resection was performed, and small residual masses of the tumor remained in the cavernous sinus or superior orbital fissure to minimize the risk of postoperative ocular nerve damage. No patients experienced postoperative CSF leak. The simultaneous combined transcranial and endoscopic endonasal approach is useful for a subgroup of patients with lateral skull base meningiomas for prevention of postoperative CSF leak. Particularly in recurrent cases in which vascularized flaps from the transcranial side are likely unavailable due to prior tumor resection, this combined approach is worth considering depending on tumor extension into the paranasal sinus.