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。

Microsurgical anatomy and clinical application of subtemporal transtentorial keyhole approach

Objective To study the anatomy and operation scheme of subtemporal transtentorial keyhole approach assisted with neuronavigation ,and to investigate the clinical effect of this approach . Methods Using 12 cases of adult cadaver heads （ 24 sides ） , simulating the subtemporal transtentorial keyhole approach , cavernous sinus Jiyan slanting area was exposed , neural navigation positioning specimens petrous internal structure , the maximum of petrous apex , the saddle back slope , structure and slope zone were observed .11 cases of skull base tumors was performed by this approach , to explore the safety and utility of the approach .Results The parasellar region can be fully exposed by the approach , the cavernous sinus lesions involving both inside and outside can be the directly operatd through the operation of triangular lateral wall of cavernous sinus .The remaining petrous apex bone maximum average thickness was （0.8 ±0.19） mm after grinding petrous apex , inner angle increase （8 ±2.5） °,posterolateral view increased （25 ±3.2） °,compared with non navigation group ,and get a （3.3 ±0.4） cm^2 dural exposure , significantly expanded the scope of the posterior fossa exposure .Clinical data of total tumor resection in 6 cases , subtotal in 3 cases , and partial resection in 2 cases, operation time was shortened 1 to 1.5 h compared with the past , new cranial nerve damage symptoms or the original brain nerve damage symptoms in 3 cases, no cases of long-term coma and operation related death .Conclusion Subtemporal transtentorial keyhole approach assisted with neuronavigation to the maximum extent exposed sphenopetroclival lesions , is conducive to improve the rate of total resection of tumor and the postoperative curative effect .