导航引导下内镜辅助远外侧锁孔入路的解剖学研究

背景：影像引导神经外科、内镜辅助神经外科和锁孔入路是微侵袭神经外科三个重要组成部分，在治疗颅底疾病中发挥了重要作用。我们通过尸头解剖研究发现导航引导下内镜辅助远外侧锁孔入路能够良好的显露腹侧颅颈交界区的结构。方法：对5例（10侧）尸头标本模拟远外侧锁孔入路，术中用神经导航实时定位，并做定量研究，分别用显微镜和内镜观察颅底结构。随后磨除后内侧1/3枕髁和颈静脉结节，再次用显微镜观察，最后测量和比较内镜和显微镜下各标本岩斜区的显露面积。实验数据采用Student-Newman-Keuls检验和方差分析进行统计学研究。结果：借助神经导航和角度内镜，通过面听神经、后组颅神经间的三个间隙能够近距离观察颅底结构，还能观察被颈静脉结节和枕髁遮挡的结构。0度内镜辅助远外侧髁后锁孔入路时岩斜区的显露面积为756.28 ± 50.73 mm2，明显大于单纯手术显微镜下的显露面积756.28 mm2，0度和30度内镜辅助下的显露面积分别为1147.80±159.57 mm2 and 1409.94±155.18 mm2，优于远外侧经髁经结节锁孔入路(1066.26±165.06 mm2) (p < 0.05)。结论：借助内镜和神经导航，远外侧髁后锁孔入路能够良好的显露腹侧颅颈交界区，角度内镜能够明显扩大岩斜区的显露范围，避免磨除颈静脉结节和部分枕髁。

Anatomical study of endoscope-assisted far lateral keyhole approach to the ventral craniocervical region with neuronavigational guidance

Background: Image-guided neurosurgery, endoscopic-assisted neurosurgery and the keyhole approach are three important parts of minimally invasive neurosurgery and have played a significant role in treating skull base lesions. We investigated the potential usefulness of coupling of the endoscope with the far lateral keyhole approach and image guidance at the ventral craniocervical junction in a cadaver model.Methods: We simulated far lateral keyhole approach bilaterally in five cadaveric head specimens (10 cranial hemispheres). Computed tomography-based image guidance was used for intraoperative navigation and for quantitative measurements. Skull base structures were observed using both an operating microscope and a rigid endoscope. The jugular tubercle and one-third of the occipital condyle were then drilled, and all specimens were observed under the microscope again. We measured and compared the exposure of the petroclivus area provided by the endoscope and by the operating microscope. Statistical analysis was performed by analysis of variance followed by the Student-Newman-Keuls test.Results: With endoscope assistance and image guidance, it was possible to observe the deep ventral craniocervical junction structures through three nerve gaps (among facial-acoustical nerves and the lower cranial nerves) and structures normally obstructed by the jugular tubercle and occipital condyle in the far lateral keyhole approach. The surgical area exposed in the petroclival region was significantly improved using the 0° endoscope (1147.80 mm2) compared with the operating microscope (756.28 ± 50.73 mm2). The far lateral retrocondylar keyhole approach, using both 0° and 30° endoscopes, provided an exposure area (1147.80±159.57 mm2 and 1409.94±155.18 mm2, respectively) greater than that of the far lateral transcondylar transtubercular keyhole approach (1066.26±165.06 mm2) (p < 0.05).Conclusion: With the aid of the endoscope and image guidance, it is possible to approach the ventral craniocervical junction with the far lateral keyhole approach. The use of an angled-lens endoscope can significantly improve the exposure of the petroclival region without drilling the jugular tubercle and occipital condyle.