内镜技术在经颅入路侧颅底手术中的应用
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摘要
目的探讨内镜技术在经颅入路侧颅底手术中的应用和手术疗效。方法对2015年7月至2018年7月内镜下经颅入路侧颅底病变手术患者的临床资料进行分析。142例患者中原发性偏侧面肌痉挛32例、原发性三叉神经痛56例、原发性舌咽神经痛2例、表皮样囊肿15例、听神经瘤14例、三叉神经鞘瘤3例、脑桥小脑三角区脑膜瘤18例、颈静脉孔区神经鞘瘤2例;其中90例(包括原发性偏侧面肌痉挛32例、原发性三叉神经痛56例、原发性舌咽神经痛2例)于内镜下行经颅入路微血管减压术,52例(包括表皮样囊肿15例、听神经瘤14例、三叉神经鞘瘤3例、脑桥小脑三角区脑膜瘤18例、颈静脉孔区神经鞘瘤2例)于内镜下行经颅入路侧颅底肿瘤切除术。结果 142例患者均全程于内镜下完成经颅入路侧颅底手术,单手操作96例(67.61%);以气动臂持镜,双手操作46例(32.39%)。内镜下微血管减压术总体治愈率达87.78%(79/90),内镜侧颅底肿瘤全切除率90.38%(47/52)。平均随访(23.46±8.93)个月,未发生严重并发症,无一例死亡。结论在气动臂的配合下,内镜技术可以完成复杂经颅入路侧颅底手术,具有可近距离和多角度观察,视野清晰,神经血管辨识度高等优势,但对内镜技术、器械和辅助设备的要求较高,需接受内镜技术培训和积累一定程度的内镜手术经验方可尝试开展。
Objective To investigate the application of neuroendoscopy and curative effect of lateral skull base surgery via transcranial approach. Methods Clinical data of 142 cases undergoing endoscopic lateral skull base surgeries via transcranial approach from July 2015 to July 2018 were retrospectively analyzed. There were 32 cases of primary hemifacial spasm, 56 cases of primary trigeminal neuralgia, 2 cases of primary glossopharyngeal neuralgia, 15 cases of epidermoid cyst, 14 cases of acoustic neuroma, 3 cases of trigeminal schwannoma, 18 cases of pontocerebellar trigone meningioma, and 2 cases of jugular foramen schwannoma. Among them, 90 cases(32 cases of primary hemifacial spasm, 56 cases of primary trigeminal neuralgia and 2 cases of primary glossopharyngeal neuralgia) underwent endoscopic microvascular decompression(MVD) via transcranial approach, and 52 cases(15 cases of epidermoid cyst,14 cases of acoustic neuroma, 3 cases of trigeminal schwannoma, 18 cases of pontocerebellar trigone meningioma, and 2 cases of jugular foramen schwannoma) underwent endoscopic removal of lateral skull base tumors via transcranial approach. Results All the operations were performed under endoscopy,including 96 cases(67.61%) operated by single hand(the endoscope was held by a pneumatic arm) and the rest 46 cases(32.39%) operated by both hands. The cure rate of MVD was 87.78%(79/90) and the total removal rate of lateral skull base tumors was 90.38%(47/52). The mean follow-up period was(23.46 ±8.93) months. There was no death or other serious complications. Conclusions The complex lateral skull base surgery via transcranial approach can be performed by neuroendoscope with pneumatic endoscopic fixed arm. It has the advantages of near and multi-angle observation, clear visual field, full exposure and high recognition of nerve and blood vessels. However, the requirements for endoscopic technology,instruments and assistive equipments are high, and it is necessary to receive relevant trainings and experiences in endoscopic surgery.
Objective To investigate the application of neuroendoscopy and curative effect of lateral skull base surgery via transcranial approach. Methods Clinical data of 142 cases undergoing endoscopic lateral skull base surgeries via transcranial approach from July 2015 to July 2018 were retrospectively analyzed. There were 32 cases of primary hemifacial spasm, 56 cases of primary trigeminal neuralgia, 2 cases of primary glossopharyngeal neuralgia, 15 cases of epidermoid cyst, 14 cases of acoustic neuroma, 3 cases of trigeminal schwannoma, 18 cases of pontocerebellar trigone meningioma, and 2 cases of jugular foramen schwannoma. Among them, 90 cases(32 cases of primary hemifacial spasm, 56 cases of primary trigeminal neuralgia and 2 cases of primary glossopharyngeal neuralgia) underwent endoscopic microvascular decompression(MVD) via transcranial approach, and 52 cases(15 cases of epidermoid cyst,14 cases of acoustic neuroma, 3 cases of trigeminal schwannoma, 18 cases of pontocerebellar trigone meningioma, and 2 cases of jugular foramen schwannoma) underwent endoscopic removal of lateral skull base tumors via transcranial approach. Results All the operations were performed under endoscopy,including 96 cases(67.61%) operated by single hand(the endoscope was held by a pneumatic arm) and the rest 46 cases(32.39%) operated by both hands. The cure rate of MVD was 87.78%(79/90) and the total removal rate of lateral skull base tumors was 90.38%(47/52). The mean follow-up period was(23.46 ±8.93) months. There was no death or other serious complications. Conclusions The complex lateral skull base surgery via transcranial approach can be performed by neuroendoscope with pneumatic endoscopic fixed arm. It has the advantages of near and multi-angle observation, clear visual field, full exposure and high recognition of nerve and blood vessels. However, the requirements for endoscopic technology,instruments and assistive equipments are high, and it is necessary to receive relevant trainings and experiences in endoscopic surgery.
引文
[1]Wu H.Current status and future of lateral skull base surgery[J].Zhongguo Er Bi Yan Hou Lu Di Wai Ke Za Zhi,2014,20:471 -474.[吴皓.侧颅底外科的现状与未来[J].中国耳鼻咽喉颅底外科杂志,2014,20:471-474.]
[2]Liu WP,Zhang YZ.Endoscopic approaches to the skull base[M].Beijing:People's Medical Publishing House,2017:137-146.[刘卫平,张亚卓.内镜颅底外科手术入路[M].北京:人民卫生出版社,2017:137-146.]
[3]LüHT,Zhang YZ.Current status of neuroendoscopy in the diagnosis and treatment of cranial base diseases[J].Zhongguo Wei Chuang Wai Ke Za Zhi,2012,12:83-86.[吕洪涛,张亚卓.神经内镜对颅底疾病的诊疗现状[J].中国微创外科杂志,2012,12:83-86.]
[4]Shorr N,Seiff SR,Kopelman J.The use of botulinum toxin in blepharospasm[J].Am J Ophthalmol,1985,99:542-546.
[5]Koos WT,Spetzler RF,Back FW.Microsurgery of cerebellopontine angle tumors[M]//Koos WT,Back FW,Spetzler RF.Clinical microsurgery.Stuttgart:George Thieme,1976:91-112.
[6]Yoshida K,Kawase T.Trigeminal neurinomas extending into multiple fossae:surgical methods and review of the literature[J].J Neurosurg,1999,91:202-211.
[7]Kaye AH,Hahn JF,Kinney SE,Hardy RW Jr,Bay JW.Jugular foramen schwannomas[J].J Neurosurg,1984,60:1045-1053.
[8]Wang ZM.The surgery of lateral skull base surgery[J].Fudan Xue Bao(Yi Xue Ban),2017,44:719-723.[王正敏.侧颅底外科纵览[J].复旦学报(医学版),2017,44:719-723.]
[9]Eby JB,Cha ST,Shahinian HK.Fully endoscopic vascular decompression of the facial nerve for hemifacial spasm[J].Skull Base,2001,11:189-197.
[10]Sun Y,Mo LG.Progress of diagnosis and surgical treatment of lateral skull base tumor[J].Zhongguo Ai Zheng Fang Zhi Za Zhi,2014,6:205-207.[孙毅,莫立根.侧颅底肿瘤的诊断及手术治疗的进展[J].中国癌症防治杂志,2014,6:205-207.]
[11]Yang A,Folzenlogen Z,Youssef AS.Minimally invasive endoscopic-assisted approaches to the posterior fossa[J].JNeurosurg Sci,2018,62:658-666.
[12]Feng ZC,Wang JW,Li C,Li WG,Chen T,Ma XY,Xu SJ,Li XG.Role of pure neuroendoscopy in cerebellopontine angle area surgery[J].Shandong Da Xue Xue Bao(Yi Xue Ban),2016,54:71-75.[冯子超,王济潍,李超,李卫国,陈腾,马翔宇,徐淑军,李新钢.单纯神经内镜在桥小脑角区的手术应用[J].山东大学学报(医学版),2016,54:71-75.]
[13]Huang H,Hu ZQ,Zhu GT,Guan F,Dai B,Xiao ZY,Mao BB,Kang Z.Application of neuroendoscopy in microvascular decompression[J].Zhonghua Shen Jing Wai Ke Za Zhi,2014,30:510-512.[黄辉,胡志强,朱广通,关峰,戴缤,肖智勇,毛贝贝,康庄.神经内镜在显微血管减压术中的应用[J].中华神经外科杂志,2014,30:510-512.]
[14]Hu ZQ,Huang H,Kang TJ,Guan F,Dai B,Zhu GT,Kang Z.The role of neuroendoscopy in acoustic neuroma surgery[J].Zhonghua Shen Jing Wai Ke Za Zhi,2013,29:659-662.[胡志强,黄辉,康铁江,关峰,戴缤,朱广通,康庄.神经内镜在听神经瘤手术中的作用[J].中华神经外科杂志,2013,29:659-662.]
[15]Zhou QW,Zhang N,He KJ,Xia L,Huang ZS.Microsurgical treatment of dumbbell trigeminal schwannoma in middle and posterior cranial fossa[J].Zhongguo Lin Chuang Shen Jing Wai Ke Za Zhi,2018,23:739-740.[周权炜,张弩,何科君,夏力,黄正松.中后颅窝哑铃形三叉神经鞘瘤的显微手术治疗[J].中国临床神经外科杂志,2018,23:739-740.]
[16]Guan F,Hu ZQ,Kang TJ,Huang H,Wu WD,Dai B,Zhu GT,Mao BB,Kang Z.Neuroendoscopic treatment for epidermoid cyst at the cerebellopontine angle[J].Zhonghua Shen Jing Wai Ke Za Zhi,2013,29:1156-1159.[关峰,胡志强,康铁江,黄辉,吴卫东,戴缤,朱广通,毛贝贝,康庄.神经内镜治疗小脑脑桥角区表皮样囊肿[J].中华神经外科杂志,2013,29:1156-1159.]
[17]Wu XL,Liang D,Deng ZY,Huang Q.Application of neuroendoscope assisted technique in microsurgical resection of cerebellopontine angle tumors[J].Zhongguo Ji Xu Yi Xue Jiao Yu,2018,10:109-110.[吴先良,梁斗,邓忠勇,黄俏.神经内镜辅助技术在显微手术切除桥小脑角区肿瘤中的应用[J].中国继续医学教育,2018,10:109-110.]
[18]Tatagiba MS,Roser F,Hirt B,Ebner FH.The retrosigmoid endoscopic approach for cerebellopontine-angle tumors and microvascular decompression[J].World Neurosurg,2014,82(6Suppl):171-176.
[19]Belykh E,Onaka NR,Zhao X,Cavallo C,Yagmurlu K,Lei T,Byvaltsev VA,Preul MC,Nakaji P.Endoscopically assisted targeted keyhole retrosigmoid approaches for microvascular decompression:quantitative anatomic study[J].World Neurosurg,2018,119:E1-15.
[20]Bazzi K,Wong E,Jufas N,Patel N.Diffusion-weighted magnetic resonance imaging in the detection of residual and recurrent cholesteatoma in children:a systematic review and meta-analysis[J].Int J Pediatr Otorhinolaryngol,2019,118:90-96.
[21]Zhao P,Zhang PF,Han LJ,Li X,Zhang JT.Analysis of surgical strategies and complications for acoustic neuroma:111cases review[J].Zhongguo Wei Qin Xi Shen Jing Wai Ke Za Zhi,2017,22:389-392.[赵澎,张鹏飞,韩利江,李鑫,张俊廷.颅内听神经瘤手术治疗策略及并发症分析:附111例病例回顾[J].中国微侵袭神经外科杂志,2017,22:389-392.]
[22]Ke YB,Lu YJ,Fang ZL,Cao GB,Li W,Gao XZ.Microsurgical removal of CPA meningioma via retrosigmoid approach[J].Zhongguo Wei Qin Xi Shen Jing Wai Ke Za Zhi,2018,23:37-38.[柯炎斌,陆永建,方泽鲁,曹国彬,李伟,高修众.乙状窦后入路显微手术切除桥小脑角脑膜瘤[J].中国微侵袭神经外科杂志,2018,23:37-38.]
[2]Liu WP,Zhang YZ.Endoscopic approaches to the skull base[M].Beijing:People's Medical Publishing House,2017:137-146.[刘卫平,张亚卓.内镜颅底外科手术入路[M].北京:人民卫生出版社,2017:137-146.]
[3]LüHT,Zhang YZ.Current status of neuroendoscopy in the diagnosis and treatment of cranial base diseases[J].Zhongguo Wei Chuang Wai Ke Za Zhi,2012,12:83-86.[吕洪涛,张亚卓.神经内镜对颅底疾病的诊疗现状[J].中国微创外科杂志,2012,12:83-86.]
[4]Shorr N,Seiff SR,Kopelman J.The use of botulinum toxin in blepharospasm[J].Am J Ophthalmol,1985,99:542-546.
[5]Koos WT,Spetzler RF,Back FW.Microsurgery of cerebellopontine angle tumors[M]//Koos WT,Back FW,Spetzler RF.Clinical microsurgery.Stuttgart:George Thieme,1976:91-112.
[6]Yoshida K,Kawase T.Trigeminal neurinomas extending into multiple fossae:surgical methods and review of the literature[J].J Neurosurg,1999,91:202-211.
[7]Kaye AH,Hahn JF,Kinney SE,Hardy RW Jr,Bay JW.Jugular foramen schwannomas[J].J Neurosurg,1984,60:1045-1053.
[8]Wang ZM.The surgery of lateral skull base surgery[J].Fudan Xue Bao(Yi Xue Ban),2017,44:719-723.[王正敏.侧颅底外科纵览[J].复旦学报(医学版),2017,44:719-723.]
[9]Eby JB,Cha ST,Shahinian HK.Fully endoscopic vascular decompression of the facial nerve for hemifacial spasm[J].Skull Base,2001,11:189-197.
[10]Sun Y,Mo LG.Progress of diagnosis and surgical treatment of lateral skull base tumor[J].Zhongguo Ai Zheng Fang Zhi Za Zhi,2014,6:205-207.[孙毅,莫立根.侧颅底肿瘤的诊断及手术治疗的进展[J].中国癌症防治杂志,2014,6:205-207.]
[11]Yang A,Folzenlogen Z,Youssef AS.Minimally invasive endoscopic-assisted approaches to the posterior fossa[J].JNeurosurg Sci,2018,62:658-666.
[12]Feng ZC,Wang JW,Li C,Li WG,Chen T,Ma XY,Xu SJ,Li XG.Role of pure neuroendoscopy in cerebellopontine angle area surgery[J].Shandong Da Xue Xue Bao(Yi Xue Ban),2016,54:71-75.[冯子超,王济潍,李超,李卫国,陈腾,马翔宇,徐淑军,李新钢.单纯神经内镜在桥小脑角区的手术应用[J].山东大学学报(医学版),2016,54:71-75.]
[13]Huang H,Hu ZQ,Zhu GT,Guan F,Dai B,Xiao ZY,Mao BB,Kang Z.Application of neuroendoscopy in microvascular decompression[J].Zhonghua Shen Jing Wai Ke Za Zhi,2014,30:510-512.[黄辉,胡志强,朱广通,关峰,戴缤,肖智勇,毛贝贝,康庄.神经内镜在显微血管减压术中的应用[J].中华神经外科杂志,2014,30:510-512.]
[14]Hu ZQ,Huang H,Kang TJ,Guan F,Dai B,Zhu GT,Kang Z.The role of neuroendoscopy in acoustic neuroma surgery[J].Zhonghua Shen Jing Wai Ke Za Zhi,2013,29:659-662.[胡志强,黄辉,康铁江,关峰,戴缤,朱广通,康庄.神经内镜在听神经瘤手术中的作用[J].中华神经外科杂志,2013,29:659-662.]
[15]Zhou QW,Zhang N,He KJ,Xia L,Huang ZS.Microsurgical treatment of dumbbell trigeminal schwannoma in middle and posterior cranial fossa[J].Zhongguo Lin Chuang Shen Jing Wai Ke Za Zhi,2018,23:739-740.[周权炜,张弩,何科君,夏力,黄正松.中后颅窝哑铃形三叉神经鞘瘤的显微手术治疗[J].中国临床神经外科杂志,2018,23:739-740.]
[16]Guan F,Hu ZQ,Kang TJ,Huang H,Wu WD,Dai B,Zhu GT,Mao BB,Kang Z.Neuroendoscopic treatment for epidermoid cyst at the cerebellopontine angle[J].Zhonghua Shen Jing Wai Ke Za Zhi,2013,29:1156-1159.[关峰,胡志强,康铁江,黄辉,吴卫东,戴缤,朱广通,毛贝贝,康庄.神经内镜治疗小脑脑桥角区表皮样囊肿[J].中华神经外科杂志,2013,29:1156-1159.]
[17]Wu XL,Liang D,Deng ZY,Huang Q.Application of neuroendoscope assisted technique in microsurgical resection of cerebellopontine angle tumors[J].Zhongguo Ji Xu Yi Xue Jiao Yu,2018,10:109-110.[吴先良,梁斗,邓忠勇,黄俏.神经内镜辅助技术在显微手术切除桥小脑角区肿瘤中的应用[J].中国继续医学教育,2018,10:109-110.]
[18]Tatagiba MS,Roser F,Hirt B,Ebner FH.The retrosigmoid endoscopic approach for cerebellopontine-angle tumors and microvascular decompression[J].World Neurosurg,2014,82(6Suppl):171-176.
[19]Belykh E,Onaka NR,Zhao X,Cavallo C,Yagmurlu K,Lei T,Byvaltsev VA,Preul MC,Nakaji P.Endoscopically assisted targeted keyhole retrosigmoid approaches for microvascular decompression:quantitative anatomic study[J].World Neurosurg,2018,119:E1-15.
[20]Bazzi K,Wong E,Jufas N,Patel N.Diffusion-weighted magnetic resonance imaging in the detection of residual and recurrent cholesteatoma in children:a systematic review and meta-analysis[J].Int J Pediatr Otorhinolaryngol,2019,118:90-96.
[21]Zhao P,Zhang PF,Han LJ,Li X,Zhang JT.Analysis of surgical strategies and complications for acoustic neuroma:111cases review[J].Zhongguo Wei Qin Xi Shen Jing Wai Ke Za Zhi,2017,22:389-392.[赵澎,张鹏飞,韩利江,李鑫,张俊廷.颅内听神经瘤手术治疗策略及并发症分析:附111例病例回顾[J].中国微侵袭神经外科杂志,2017,22:389-392.]
[22]Ke YB,Lu YJ,Fang ZL,Cao GB,Li W,Gao XZ.Microsurgical removal of CPA meningioma via retrosigmoid approach[J].Zhongguo Wei Qin Xi Shen Jing Wai Ke Za Zhi,2018,23:37-38.[柯炎斌,陆永建,方泽鲁,曹国彬,李伟,高修众.乙状窦后入路显微手术切除桥小脑角脑膜瘤[J].中国微侵袭神经外科杂志,2018,23:37-38.]