颞下锁孔硬膜下Kawase入路的内镜解剖学研究

目的 探讨神经内镜模拟颞下锁孔硬膜下Kawase入路手术可行性和适应证。方法 成人尸头湿标本8具（16侧）,模拟神经内镜颞下锁孔硬膜下Kawase入路,观察内镜下显露的最大视野,辨识弓状隆起、三叉神经、岩浅大神经、岩上窦等解剖结构,标识Kawase三角的边界,测量不同磨除范围下Kawase三角的各边长,显露小脑膜切迹间隙、脑干腹外侧、上中岩斜区、中下岩斜区交界处及其邻近结构。结果 弓状隆起最高点到棘孔、岩浅大神经裂孔、岩浅大神经与下颌神经的交点;三叉神经压迹外侧缘的最短距离分别为（22.90±2.34）mm、（14.05±2.09）mm、（24.94±1.98）mm、（23.49±2.38）mm;Kawase三角磨除面积为（3.04±0.47）cm2,扩大磨除Kawase三角面积为（3.7±0.69）cm2,平均增加了0.66 cm2的面积。结论 经神经内镜颞下锁孔硬膜下Kawase入路避免了对脑膜中动脉的损伤,保留了岩浅大神经。适合处理位于小脑幕切迹间隙,上、中岩斜区,中、下岩斜区交界处,部分桥小脑角脑干腹外侧广泛区域的肿瘤、动脉瘤等病变。

Endoscopic anatomic study on Kawase approach in the intradural subtemporal keyhole

Objective To discuss the indications and feasibility of Kawase approach in the intradural subtemporal keyhole by using neuroendoscope. Methods Simulated surgery via intradural subtemporal keyhole modified Kawase approach with assist from rigid neuroendoscope was performed on eight adult cadaver heads fixed by formalin, the maxin maximum viewer of the approach was observed. The endoscope, through the subdural space, was used to observe the anatomic marks of the middle cranial fossa, including arcuate eminence, trigeminal nerve, greater superficial petrosal nerve, superior petrosal sinus,the the space of tentorial notch and petroclival region. The surgical field was measured by the comparison of different milling range of petrous apex, and the anatomical structure through this approach was analyzed. Results The shortest distances from the highest point of arcuate eminence to foramen spinosum, greater superficial petrosal nerve hiatus, the intersection of greater superficial petrosal nerveand mandibular nerve, the outside edge of the trigeminal impression were （22.90±2.34）mm, （14.05±2.09）mm, （24.94±1.98）mm, and （23.49±2.38）mm, respectively. Various anatomical triangles in the lateral wall of the cavernous sinus and the middle cranial fossa could be distinctly exposed, among which the Kawase′s triangle milling area was （3.04±0.47）cm2 , and the area after the maximum milling of the petrous apex under the trigeminal impression was （3.7±0.69）cm2, the area increase 0.66 cm2. Conclusions The intradural subtemporal keyhole Kawase approach avoids injury the middle meningeal artery and the greater superficial petrosal nerve. It can expose wide surgical area, including the incisure of tentorium of cerebellum, the superior and middle petroclival region, the junctional area of the middle and inferior petroclival region, brainstem ventrolateral. Through the natural gap and grinding the petrous apex bone, it can treat lesions in these areas.