后颅窝锁孔入路的显微解剖学研究
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摘要
第一部分乙状窦后锁孔入路的显微解剖学研究
目的:遵循微创原则,对传统乙状窦后入路进行锁孔改良,应用神经导航系统进行尸头解剖量化评价,探讨乙状窦后锁孔手术的可行性,明确其手术适用范围,并予临床初步验证。
方法:采用6具经福尔马林固定、颅内动静脉分别用彩色乳胶灌注的尸体头颅标本。首先进行乙状窦后锁孔入路,然后扩大为常规乙状窦后入路,观察显露的解剖结构差异。以无框架的立体定向导航设备测量两种入路下岩斜区、脑干的显露面积和Meckle’s腔、三叉神经根、面神经根、内听道口、舌咽神经根、颈静脉孔等六个点容许的最大观察角度,行统计学分析比较。应用乙状窦后锁孔入路治疗15例小脑桥脑角、岩斜区和天幕肿瘤患者进行临床验证,11例肿瘤最长径大于3.0cm。
结果:乙状窦后锁孔入路与常规入路的解剖结构显露相仿,可显露上至天幕前外侧缘,下近枕骨大孔,内侧到桥脑和中脑的前外侧方,通过神经间隙可以到达同侧中上岩斜区的外2/3,但对岩尖、下斜坡和天幕切迹以上的结构显露欠佳或不能显露。乙状窦后锁孔入路下岩斜区、脑干显露面积分别为304.73±28.93mm2、143.9±31.87mm2,而常规入路则分别为346.43±42.80mm2、136.05±9.05mm2,两者在岩斜区、脑干的显露面积都没有统计学显著性差异(P>0.05)。对于选定的六个靶点,无论垂直还是水平观察角度,常规入路都比锁孔入路的观察角度大(P<0.05)。临床验证15例肿瘤手术,13例全切,2例次全切,术后4例新出现周围性面瘫,其中3例为短暂性的面神经麻痹。7例术前听力下降的患者,其中5例术后听力丧失,1例术后听力改善,无其它术后并发症。
结论:乙状窦后锁孔入路与常规入路具有相似的显露范围,可用于小脑桥脑角和岩斜区的肿瘤、中脑和桥脑前侧方及侧方肿瘤手术,对大型、巨大型肿瘤也可通过分块切除、瘤内减压的方法,逐步显露并全切肿瘤。该入路是具有实际临床应用价值的一种简捷、安全的微创手术入路。
第二部分枕下正中经小脑延髓裂锁孔入路的显微解剖学研究
目的:基于锁孔原理设计枕下正中经小脑延髓裂锁孔入路,应用神经导航系统进行尸头解剖量化评价,探讨其可行性和手术适用范围,并进行初步临床验证,为临床应用提供可靠依据。
方法:采用6具经4%福尔马林固定、颅内动静脉乳胶灌注的成人尸体头颅标本。首先行枕下正中经小脑延髓裂锁孔入路解剖,观察各个步骤显露的解剖结构,以无框架的立体定向导航设备测量锁孔入路下四脑室底的面积显露和导水管下口、双侧侧孔连线与正中沟交点、闩部的观察角度;再以铣刀铣下寰椎后弓,测量上述参数,测量后将寰椎后弓用钛片和钛钉复位;然后延长切口、扩大骨窗成常规入路,测量寰椎后弓去除前后的上述参数;最后行统计学分析。应用枕下正中经小脑延髓裂锁孔入路治疗14例四脑室内及其周围区域的肿瘤,包括小脑蚓部肿瘤5例(髓母细胞瘤3例、胶质瘤1例,转移癌1例),四脑室内病变6例(室管膜瘤4例,蛛网膜囊肿1例,脉络膜乳头状瘤1例)、脑干背侧病变2例(桥延沟水平海绵状血管瘤1例,桥脑胶质增生1例)、脑干后方机化血肿1例,进行临床验证。
结果:通过调整头位和显微镜的投射角度,枕下正中锁孔入路下分离小脑延髓裂后可显露脉络膜、下髓帆,逐步切开脉络膜下髓帆可显露四脑室底、侧隐窝、侧孔及小脑蚓部脑室面。锁孔入路下对四脑室底的角度显露不如常规入路下宽(P<0.01),但两种入路下四脑室底的显露面积没有显著性统计学差异(P=0.06)。常规入路下显露角度的增加,可增加手术操作的自由度,有利于从多个方向对靶点进行操作,但并不能增加四脑室底的显露面积。锁孔入路下,尽管靶点显露角度减小,使手术操作的自由度变小,但不影响靶点的显露,在锁孔的深部放大效应下,可对相关靶点进行有效操作。去除寰椎后弓不能增加锁孔入路下四脑室底的显露面积(P=0.84)。无论常规入路还是锁孔入路下磨除寰椎后弓可以增加四脑室底垂直显露角度(P<0.05),但对水平显露角度没有影响(P>0.05)。本组14例肿瘤均显微镜下全切,1例老年患者术后死于肺部感染,其余13例术前症状改善,未出现脑干和颅神经损伤相关的并发症,无“小脑性缄默”等经蚓部手术入路相关的并发症。
结论:枕下正中经小脑延髓裂锁孔入路与常规入路具有相似的显露面积,无需磨除寰椎后弓就能满意显露四脑室底结构,在掌握锁孔入路器械操作技术后,使用长杆状和枪式器械,通过相对狭小的显露角度,可以安全、简捷地进行四脑室内、桥脑延髓背侧以及小脑下蚓部等部位肿瘤手术,是一种切实可行的微创手术入路。
Part I: Microanatomic Study on Retrosigmoid Keyhole Approach
Objective: To modify the traditional retrosigmoid approach according to the principle of minimal invasive meurosurgery, further assess the keyhole approach quantitatively under neuro-navigation, explore its feasibility and indications, and validate the modified keyhole approach in clinical cases.
Methods: Six cadaveric heads (twelve sides) fixed by formalin and injected with colored latex were used for microanatomic studies on the retrosigmoid keyhole approach, compared with traditional retrosigmoid craniotomy. Microanatomic structures were observed. Then exposure areas of petroclivus and brainstem were measured and calculated under stryker frameless stereotactic navigation. Angles of attack for six different target points, which included the Meckle cave, trigeminal nerve root, internal auditory meatal, facial nerve root, jugular foramen and glossopharyngeal nerve root, were measured. After obtaining the anatomic data of the retrosigmoid keyhole approach, the traditional approach was performed on the same sides. The same parameters were detected with the same method. Exposure areas and angles of attack between the two approaches were compared and analyzed by student’s t test. In clinical cases, the retrosigmoid keyhole approach were performed on 15 patients, who suffered from lesions located in cerebellopontine angle, petrovlival region and tentorium.
Results: The retrosigmoid keyhole approach exposes nearly the same anatomic architecture as that of conventional approach, namely, it can expose the area superior to the anteriolateral margin of the tentorium, inferior to the foramen Magnum, medial to the anteriolateral of pons and medulla.The anatomic structure deeply seated in the ispilateral petroclivus can also be observed clearly through the cranial nerve intervals. Exposure areas at the petroclivus and brainstem under the retrosigmoid keyhole approach was 304.73±28.93mm2,143.9±31.87mm2 respectively. The counterpart of the traditional retrosigmoid approach was 346.43±42.80mm2、136.05±9.05mm2 respectively, no statistical difference lies in the exposure area (P>0.05). The vertical and horizontal attack angles under the traditional approach were wider than those of the keyhole approach at the selected six target points(P<0.05). In a total of 15 clinical cases, 13 tumors were completely resected, the remain 2 were subtotally resected. 4 patients suffered from postoperative temporary facial nerve paralysis, and 7 patients lost hearing completely who have already lost hearing partially before operations, and they didn’t have any other new cranial nerve complications.
Conclusion: The retrosigmoid keyhole approach can provide similar exposure range cimpared with that of the traditional retrosigmoid approach. It can be used to resect small and middle-size tumors located in cerebellopontine angle, the lateral two thirds of the ispilateral petroclivus, anteriolateral of midbrain and pons, as well as large and giant tumors mainly located in these regions. It’s a safe, succinct, and minimally invasive way with high feasibility to resect lesions of posterior fossa.
Part II: Microanatomical Study on the Suboccipital Midline Transcerebellomedullary Fissure Keyhole Approach
Objective: To design a new suboccipital midline transcerebellomedullary keyhole approach based on minimally invasive keyhole principle, further assess it quantitatively under neuro-navigation, explore its feasibility and indications, and validate the new keyhole approach in clinical cases, and provide support for further practice.
Methods: Six formaldehyde-fixed adult cadaveric heads injected with colored latex were applied for microanatomic study on the suboccipital midline transcerebellomedullary fissure keyhole approach. First the suboccipital midline transcerebellomedullary keyhole approach was performed, microscopic anatomical structures were observed, the area of exposure of the floor for theⅣventricle, and the angles of approach to the aqueduct, the point where the line between the foramen of Luschka cross with the medial sulcus, the obex were measured under stryker stereotactic navigation. Then the C1 posterior arch was removed for the purpose of evaluating whether this process can further widen the observing angles and increasing the exposure extent, corresponding parameters were measured. After, the C1 arch was fixed with titanium plates and screws, then the conventional approach were performed without C1 arch removal and with C1 removal respectively, to observe any changes in observing angle and exposure areas.These data were analyzed with student’s t test. In clinical cases, 14 tumors were removed through the suboccipital midline transcerebellomedullary keyhole approach, which including 5 lesions located in the inferior vermis (3 medulloblastomas,1 glioma,1 metastatic carcinoma ),6 lesions located in thr fourth ventricle (1 choroid plexus papilloma, 4 ependymomas, 1 arachnoid cyst), 2 lesions located in the dorsal of brain stem (1 cavernomas,1 gliosis ), and 1 organized hamatoma dorsal to the brain stem.
Results: By means of adjusting the head position and the projection angle of the microscope, as the the tela choroidea and inferior medullary velum were dissected gradually, structures of the floor, lateral recess ofⅣventricle and vermian were exposed. There were no obvious difference between the keyhole approach and conventional approach in the area of exposure to the floor of the fourth ventricle (P=0.06), and the C1 arch removal couldn’t increase the exposure extent (P=0.84). The conventional approach had the advantage of wider observing angles than the keyhole approach (P<0.01), and the C1 arch removal could increase the vertical angles to all the points (P<0.05), but not in horizontal angle (P>0.05). Wider angles under traditional approach can increase the surgical freedom and ensure the capability to perform multidirectional work, but the exposure extent under the traditional approach can’t be enlarged. Narrower attack angles under the keyhole approach result in less surgical freedom, but have no effect on the exposure of the target point and surgical manipilation because of the keyhole prinple.In 14 clinical casrs, total resection were achieved under the keyhole microsurgery in all patients. One patient died from serious pulmonary infection after operation, the symptom of the others relieved at discharge. There were no serious complications relating to surgical injuries of the brain stem and cranial nerves, no“cerebellar mutism”occurred that might result from the transvermian approach.
Conclusion: Suboccipital midline transcerebellomedullary keyhole approach can expose similar anatomic architectures as those of the conventional approach, which can be used to remove the tumors located in the fourth ventricle, the dorsal of pons and medullary, vermis of cerebellum, without drilling the posterior arch of atlas. As a safe, succinct and minimally invasive approach, the suboccipital midline transcerebellomedullary keyhole approach is proper to resect lesions of posterior fossa.
目的:遵循微创原则,对传统乙状窦后入路进行锁孔改良,应用神经导航系统进行尸头解剖量化评价,探讨乙状窦后锁孔手术的可行性,明确其手术适用范围,并予临床初步验证。
方法:采用6具经福尔马林固定、颅内动静脉分别用彩色乳胶灌注的尸体头颅标本。首先进行乙状窦后锁孔入路,然后扩大为常规乙状窦后入路,观察显露的解剖结构差异。以无框架的立体定向导航设备测量两种入路下岩斜区、脑干的显露面积和Meckle’s腔、三叉神经根、面神经根、内听道口、舌咽神经根、颈静脉孔等六个点容许的最大观察角度,行统计学分析比较。应用乙状窦后锁孔入路治疗15例小脑桥脑角、岩斜区和天幕肿瘤患者进行临床验证,11例肿瘤最长径大于3.0cm。
结果:乙状窦后锁孔入路与常规入路的解剖结构显露相仿,可显露上至天幕前外侧缘,下近枕骨大孔,内侧到桥脑和中脑的前外侧方,通过神经间隙可以到达同侧中上岩斜区的外2/3,但对岩尖、下斜坡和天幕切迹以上的结构显露欠佳或不能显露。乙状窦后锁孔入路下岩斜区、脑干显露面积分别为304.73±28.93mm2、143.9±31.87mm2,而常规入路则分别为346.43±42.80mm2、136.05±9.05mm2,两者在岩斜区、脑干的显露面积都没有统计学显著性差异(P>0.05)。对于选定的六个靶点,无论垂直还是水平观察角度,常规入路都比锁孔入路的观察角度大(P<0.05)。临床验证15例肿瘤手术,13例全切,2例次全切,术后4例新出现周围性面瘫,其中3例为短暂性的面神经麻痹。7例术前听力下降的患者,其中5例术后听力丧失,1例术后听力改善,无其它术后并发症。
结论:乙状窦后锁孔入路与常规入路具有相似的显露范围,可用于小脑桥脑角和岩斜区的肿瘤、中脑和桥脑前侧方及侧方肿瘤手术,对大型、巨大型肿瘤也可通过分块切除、瘤内减压的方法,逐步显露并全切肿瘤。该入路是具有实际临床应用价值的一种简捷、安全的微创手术入路。
第二部分枕下正中经小脑延髓裂锁孔入路的显微解剖学研究
目的:基于锁孔原理设计枕下正中经小脑延髓裂锁孔入路,应用神经导航系统进行尸头解剖量化评价,探讨其可行性和手术适用范围,并进行初步临床验证,为临床应用提供可靠依据。
方法:采用6具经4%福尔马林固定、颅内动静脉乳胶灌注的成人尸体头颅标本。首先行枕下正中经小脑延髓裂锁孔入路解剖,观察各个步骤显露的解剖结构,以无框架的立体定向导航设备测量锁孔入路下四脑室底的面积显露和导水管下口、双侧侧孔连线与正中沟交点、闩部的观察角度;再以铣刀铣下寰椎后弓,测量上述参数,测量后将寰椎后弓用钛片和钛钉复位;然后延长切口、扩大骨窗成常规入路,测量寰椎后弓去除前后的上述参数;最后行统计学分析。应用枕下正中经小脑延髓裂锁孔入路治疗14例四脑室内及其周围区域的肿瘤,包括小脑蚓部肿瘤5例(髓母细胞瘤3例、胶质瘤1例,转移癌1例),四脑室内病变6例(室管膜瘤4例,蛛网膜囊肿1例,脉络膜乳头状瘤1例)、脑干背侧病变2例(桥延沟水平海绵状血管瘤1例,桥脑胶质增生1例)、脑干后方机化血肿1例,进行临床验证。
结果:通过调整头位和显微镜的投射角度,枕下正中锁孔入路下分离小脑延髓裂后可显露脉络膜、下髓帆,逐步切开脉络膜下髓帆可显露四脑室底、侧隐窝、侧孔及小脑蚓部脑室面。锁孔入路下对四脑室底的角度显露不如常规入路下宽(P<0.01),但两种入路下四脑室底的显露面积没有显著性统计学差异(P=0.06)。常规入路下显露角度的增加,可增加手术操作的自由度,有利于从多个方向对靶点进行操作,但并不能增加四脑室底的显露面积。锁孔入路下,尽管靶点显露角度减小,使手术操作的自由度变小,但不影响靶点的显露,在锁孔的深部放大效应下,可对相关靶点进行有效操作。去除寰椎后弓不能增加锁孔入路下四脑室底的显露面积(P=0.84)。无论常规入路还是锁孔入路下磨除寰椎后弓可以增加四脑室底垂直显露角度(P<0.05),但对水平显露角度没有影响(P>0.05)。本组14例肿瘤均显微镜下全切,1例老年患者术后死于肺部感染,其余13例术前症状改善,未出现脑干和颅神经损伤相关的并发症,无“小脑性缄默”等经蚓部手术入路相关的并发症。
结论:枕下正中经小脑延髓裂锁孔入路与常规入路具有相似的显露面积,无需磨除寰椎后弓就能满意显露四脑室底结构,在掌握锁孔入路器械操作技术后,使用长杆状和枪式器械,通过相对狭小的显露角度,可以安全、简捷地进行四脑室内、桥脑延髓背侧以及小脑下蚓部等部位肿瘤手术,是一种切实可行的微创手术入路。
Part I: Microanatomic Study on Retrosigmoid Keyhole Approach
Objective: To modify the traditional retrosigmoid approach according to the principle of minimal invasive meurosurgery, further assess the keyhole approach quantitatively under neuro-navigation, explore its feasibility and indications, and validate the modified keyhole approach in clinical cases.
Methods: Six cadaveric heads (twelve sides) fixed by formalin and injected with colored latex were used for microanatomic studies on the retrosigmoid keyhole approach, compared with traditional retrosigmoid craniotomy. Microanatomic structures were observed. Then exposure areas of petroclivus and brainstem were measured and calculated under stryker frameless stereotactic navigation. Angles of attack for six different target points, which included the Meckle cave, trigeminal nerve root, internal auditory meatal, facial nerve root, jugular foramen and glossopharyngeal nerve root, were measured. After obtaining the anatomic data of the retrosigmoid keyhole approach, the traditional approach was performed on the same sides. The same parameters were detected with the same method. Exposure areas and angles of attack between the two approaches were compared and analyzed by student’s t test. In clinical cases, the retrosigmoid keyhole approach were performed on 15 patients, who suffered from lesions located in cerebellopontine angle, petrovlival region and tentorium.
Results: The retrosigmoid keyhole approach exposes nearly the same anatomic architecture as that of conventional approach, namely, it can expose the area superior to the anteriolateral margin of the tentorium, inferior to the foramen Magnum, medial to the anteriolateral of pons and medulla.The anatomic structure deeply seated in the ispilateral petroclivus can also be observed clearly through the cranial nerve intervals. Exposure areas at the petroclivus and brainstem under the retrosigmoid keyhole approach was 304.73±28.93mm2,143.9±31.87mm2 respectively. The counterpart of the traditional retrosigmoid approach was 346.43±42.80mm2、136.05±9.05mm2 respectively, no statistical difference lies in the exposure area (P>0.05). The vertical and horizontal attack angles under the traditional approach were wider than those of the keyhole approach at the selected six target points(P<0.05). In a total of 15 clinical cases, 13 tumors were completely resected, the remain 2 were subtotally resected. 4 patients suffered from postoperative temporary facial nerve paralysis, and 7 patients lost hearing completely who have already lost hearing partially before operations, and they didn’t have any other new cranial nerve complications.
Conclusion: The retrosigmoid keyhole approach can provide similar exposure range cimpared with that of the traditional retrosigmoid approach. It can be used to resect small and middle-size tumors located in cerebellopontine angle, the lateral two thirds of the ispilateral petroclivus, anteriolateral of midbrain and pons, as well as large and giant tumors mainly located in these regions. It’s a safe, succinct, and minimally invasive way with high feasibility to resect lesions of posterior fossa.
Part II: Microanatomical Study on the Suboccipital Midline Transcerebellomedullary Fissure Keyhole Approach
Objective: To design a new suboccipital midline transcerebellomedullary keyhole approach based on minimally invasive keyhole principle, further assess it quantitatively under neuro-navigation, explore its feasibility and indications, and validate the new keyhole approach in clinical cases, and provide support for further practice.
Methods: Six formaldehyde-fixed adult cadaveric heads injected with colored latex were applied for microanatomic study on the suboccipital midline transcerebellomedullary fissure keyhole approach. First the suboccipital midline transcerebellomedullary keyhole approach was performed, microscopic anatomical structures were observed, the area of exposure of the floor for theⅣventricle, and the angles of approach to the aqueduct, the point where the line between the foramen of Luschka cross with the medial sulcus, the obex were measured under stryker stereotactic navigation. Then the C1 posterior arch was removed for the purpose of evaluating whether this process can further widen the observing angles and increasing the exposure extent, corresponding parameters were measured. After, the C1 arch was fixed with titanium plates and screws, then the conventional approach were performed without C1 arch removal and with C1 removal respectively, to observe any changes in observing angle and exposure areas.These data were analyzed with student’s t test. In clinical cases, 14 tumors were removed through the suboccipital midline transcerebellomedullary keyhole approach, which including 5 lesions located in the inferior vermis (3 medulloblastomas,1 glioma,1 metastatic carcinoma ),6 lesions located in thr fourth ventricle (1 choroid plexus papilloma, 4 ependymomas, 1 arachnoid cyst), 2 lesions located in the dorsal of brain stem (1 cavernomas,1 gliosis ), and 1 organized hamatoma dorsal to the brain stem.
Results: By means of adjusting the head position and the projection angle of the microscope, as the the tela choroidea and inferior medullary velum were dissected gradually, structures of the floor, lateral recess ofⅣventricle and vermian were exposed. There were no obvious difference between the keyhole approach and conventional approach in the area of exposure to the floor of the fourth ventricle (P=0.06), and the C1 arch removal couldn’t increase the exposure extent (P=0.84). The conventional approach had the advantage of wider observing angles than the keyhole approach (P<0.01), and the C1 arch removal could increase the vertical angles to all the points (P<0.05), but not in horizontal angle (P>0.05). Wider angles under traditional approach can increase the surgical freedom and ensure the capability to perform multidirectional work, but the exposure extent under the traditional approach can’t be enlarged. Narrower attack angles under the keyhole approach result in less surgical freedom, but have no effect on the exposure of the target point and surgical manipilation because of the keyhole prinple.In 14 clinical casrs, total resection were achieved under the keyhole microsurgery in all patients. One patient died from serious pulmonary infection after operation, the symptom of the others relieved at discharge. There were no serious complications relating to surgical injuries of the brain stem and cranial nerves, no“cerebellar mutism”occurred that might result from the transvermian approach.
Conclusion: Suboccipital midline transcerebellomedullary keyhole approach can expose similar anatomic architectures as those of the conventional approach, which can be used to remove the tumors located in the fourth ventricle, the dorsal of pons and medullary, vermis of cerebellum, without drilling the posterior arch of atlas. As a safe, succinct and minimally invasive approach, the suboccipital midline transcerebellomedullary keyhole approach is proper to resect lesions of posterior fossa.
引文
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