经鼻神经内镜治疗前颅底病变的应用解剖研究及其临床应用
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摘要
目的:颅底外科作为神经外科学与耳鼻咽喉科学及颌面外科学的一个交叉学科,近年来发展十分迅速;然而由于前颅底的毗邻结构解剖关系复杂,发生于此的病变因解剖位置深在,手术不易充分暴露和彻底切除,容易造成术后畸形、功能障碍或发生其他并发症。而经鼻内镜则是一种比较古老的技术,随着光学、机械及电子技术的进步,近十年来获得了新的生命。经鼻內镜可以取代传统的显微镜，经由天然的鼻腔空隙,直接进到蝶鞍部和前、中、后颅底,直视下处理这些部位的病变,损伤小,恢复快,没有美容问题。经鼻内镜技术和颅底外科的结合,极大地促进了颅底外科的发展,不仅丰富了颅底外科的治疗手段,而且拓宽了颅底外科的诊疗范围,使颅底外科不仅能处理中线区域病变,还向侧颅底区域发展。然而,由于颅底区域解剖结构复杂,颅底外侧面的解剖对于神经外科医生来说不够熟悉。鼻腔空间不大,可供操作的范围有限。而且内镜对于神经外科医生来说,不仅视野与显微镜不同,而且操作时也不固定,随着器械的进出鼻道随时变化,使初学者难以适应。陌生部位的解剖知识缺乏和对于内镜操作技术的不习惯,成为妨碍神经外科医生介入这一领域的两大难点。另一方面,内镜在国内外的发展很不平衡,在发达国家及我国发达地区发展迅猛,而在西部地区尤其新疆仍处在初始阶段。本研究的目的就是:1)通过对内镜下前颅底的应用解剖进行观察和测量。以丰富和掌握内镜前颅底手术所需的内镜下解剖知识;2)通过在尸体头颅标本上的模拟训练,熟悉和掌握开展内镜前颅底手术所需的解剖知识,并习惯内镜下操作;3)然后将神经内镜应用于临床,治疗前颅底常见疾病如脑脊液鼻漏、视神经管减压、各种前颅窝底肿瘤等,提高手术安全性及有效性,以期提高神经内镜诊疗水平及颅底外科诊疗水平。由于经蝶垂体瘤手术已趋于成熟,不在本研究的范围内。方法:本研究分三阶段进行:1)首先对10具20侧颅骨标本的颅底外侧面以及矢状剖面骨性鼻腔的相关解剖标志及其相互之间的距离和角度进行观察和测量。然后对6具12侧经过灌注的尸体头颅进行内镜下观察和描述;2)于内镜下在2具4侧颅骨干标本,和4具8侧尸体头颅上完成几种模拟手术:内镜下蝶窦切开术;内镜下筛窦手术;内镜下视神经管减压术;以及内镜下眶减压术等;3)于解剖研究和内镜模拟手术完成的前提下,将该技术应用于临床,对前颅底常见病,如创伤性视神经损伤,各种原因脑脊液鼻漏,前颅底良性肿瘤等进行治疗。结果:1)鼻棘点至鞍结节的平均距离为69.2±4.8mm。鼻棘点至前床突的平均距离为72.9±3.9mm。即在手术中器械深入鼻腔6～7cm时就要提防进入中颅窝的可能;2)鼻棘点至视神经管眶口内侧中点的平均距离为63.4±5.3mm。鼻棘点至视神经管颅口内侧中点的平均距离为69.3±4.9mm。鼻小柱基点至视神经管颅口的距离为78.3±4.5mm。表明在行视神经减压术或眶尖部手术时距离鼻棘点超过50mm以上时就应十分小心,过深操作有可能进入中颅窝甚至损伤颈内动脉;3)蝶窦开口至视神经管颅口,也是二者间最短距离,平均为15.3±3.8mm,蝶窦开口与视神经管联线与正中矢状面之间的夹角平均为63±7.9°。因此打开蝶窦后,向蝶窦开口的外上方约1.5cm的部位寻找,有利于发现视神经管;4)视神经管内壁的毗邻:位于蝶窦外侧3侧(25%),位于筛窦外侧3侧(25%),位于蝶窦和筛窦之间最常见,占6侧(50%)。因此寻找视神经管的另一方法为在蝶筛交界处寻找,大部分视神经管位于蝶筛交界或其附近区域;5)鼻棘点至鞍结节的平均距离为69.2±4.8mm,据此可定位垂体前界。在此处操作如深入超过60mm,应提防损伤颈内动脉。(6)内镜为二维图像,管状视野有鱼眼镜头效应,解剖结构失真变形较严重,镜头角度越大,这种改变就越明显,与普通解剖学观察的差别就越大。因此熟练掌握内镜解剖,反复练习,习惯这种视野,有助于克服内镜图像失真所引起的盲目性和迷失感;7)内镜治疗13例无光感视神经损伤患者,随访3～12个月,7例视力有不同程度恢复;6例无效。视力恢复多于术后1～2周出现,约2个月后停止。视力提高一个级别3例,2个级别1例,3个级别1例,4个级别2例。总有效率53.8%(7/13)。按受伤后视力丧失至手术时间分为3～7天组,8～14天组,15～21天组和21天以上组,各组间效果差异无统计学意义(P>0.05);8)治疗17例创伤性视神经损伤患者共18眼,10例视力有不同程度恢复;8眼无效。视力提高一个级别5例,2个级别2例,3个级别1例,4个级别2例,总有效率55.6%(10/18);9)内镜治疗7例医源性脑脊液鼻漏,漏口均在原手术部位,一次修补成功;10)共治疗24例脑脊液鼻漏患者,內镜组共13例15次手术13次成功,手术成功率为86.6%;开颅组11例12次手术10次成功,手术成功率为83.3%;两组一次手术成功率及二次手术成功率均无明显差异;11)内镜下治疗蝶筛窦骨化纤维瘤1例,近全切除,病理为:青少年型骨化纤维瘤,术后患侧眼视力明显恢复。结论:1)对于术前无光感的视神经损伤患者,仍应行视神经管减压术以挽救其视力;2)视神经损伤后视力的恢复主要取决于视神经受伤机制及程度,与时间关系不大,因此只要患者有治疗意愿,无论伤后多久,都应该进行手术以挽救视力;3)经鼻内镜处理前颅底区域病变能最大限度的暴露病变区域,而又不加重对脑的牵拉损伤,保
留了正常的神经血管结构,降低了术后并发症和致残率。具有微创、无颅面切口,病人痛苦少,恢复快等优点,在一系列临床手术中展示了常规开颅手术和鼻外进路无法替代的优势;4)在熟练掌握颅底相关解剖知识,并经过严格内镜操作训练后,经鼻内镜治疗前颅底病变有很高的安全性。
Objective: Skull base surgery as neurosurgery, otorhinolaryngology and the maxillofacial surgery, interdisciplinary very rapidly developed in recent years. However, due to anatomy of the anterior skull base adjacent to the structure of complex relationships in this anatomical location, for the lesions deeply located surgery is not easy to fully expose and completely remove the lesion, likely to cause postoperative deformity, dysfunction or other complications may occur. The nasal endoscopy is comparatively old technology with the development in optical, mechanical and electronic technology that acquired a new life over the last decade. Endoscopic can replace conventional microscopy, the nasal cavity through the natural gap, directly into the sella turcica and the parts anterior, middle and posterior to the base of the skull, under direct vision to deal with these parts of the lesion or injury, having quick recovery without cosmetic problem. The combination of transnasal endoscopic and the skull base surgery techniques greatly promoted the development of skull base surgery, not only enriched the treatment of skull base surgery but to broaden the scope of diagnosis and treatment of skull base surgery. The midline skull base surgery can handle not only the regional lesions, but also the development of lateral skull base region. However, due to complex anatomy of the skull base region, the anatomy of the lateral skull base is not sufficiently familiar to neurosurgeons. The nasal cavity space is small, available for a limited range of operation. Moreover endoscopy for the neurosurgeons is a different field of vision, the microscope and the operations are not fixed as the instruments out of the nasal passages are subject to change and is difficult to adapt for beginners. Being unfamiliar with endoscopy and lacking the knowledge of anatomical structures must not use endoscopic technique, these two major deficiencies prevents involvement of neurosurgeon. Endoscopic development is very uneven in domestic and overseas. On the other hand, in the developed countries and in our developed areas this technique is of rapid development. In the western region of Xinjiang it is still in initial stages. The purpose of this study is: 1) Observation and measurement through the internal anatomy of anterior skull base with endoscopic application. To enrich and master the required endoscopy of anterior skull base operations and anatomical knowledge. 2) To know and master out carrying of the necessary endoscopy of anterior skull base surgery, anatomical knowledge and developing the habit of endoscopic operation through the simulated training in the head of specimen bodies. 3) the Neuro endoscopy used in clinical treatment of common diseases of anterior skull base, such as cerebrospinal fluid rhinorrhea, optic nerve decompression, a variety of anterior cranial fossa tumors, etc. to improve surgical safety and efficacy in order to improve the Endoscopic diagnosis and treatment of skull base surgery. As the transsphenoidal pituitary tumor surgery has become more mature, therefore not in scope of this research. Method: The study is divided into three stages: 1) First 20 sides of 10 specimens of the cranial skull base and lateral of the sagittal section, the nasal bone anatomical landmarks associated between the distance and angle of observation and measurements. Then the 12 side of 6 specimens, after infusion for endoscopic observation and description; 2) To Endoscope the skull on 4 sides in two dried specimens, and 8sides of 4 bodies completed several simulations skull surgery: Endoscope transsphenoidal incision;Endoscope ethmoidsinus operation;Endoscope optic nerve decompression technique and endoscope orbital decompression, etc; 3) In the anatomical study and endoscopic simulated operations done under the premise of this technology used clinically for treatment of common diseases of the anterior skull base such as traumatic optic nerve injury, for various reasons cerebrospinal fluid rhinorrhea, treatment of benign tumor of anterior skull base. Result: 1) The average distance from nasal spine to tuberculum sellae is 69.2±4.8mm. Nasal spine point toward anterior clinoid process and the average distance is 72.9±3.9mm. When surgical instruments 6～7cm deep passes into nasal cavity we should beware of the possibility of entering the middle cranial fossa; 2) the average distance from nasal spine to the midpoint of intraorbital opening of the optic canal is 63.4±5.3mm. The average distance from nasal spine point to the midpoint of intracranial opening of the optic canal is 69.3±4.9mm. The average distance from Nasal columella basis point to the midpoint of intracranial opening of the optic canal is 78.3±4.5mm. During optic nerve decompression or orbital apex surgery, one should be very careful when surgical instruments inserted in depth of more than 50mm from the nasal spine points, too deep operations may even damage the carotid artery into the middle cranial fossa; 3) The average distance from opening of sphenoid sinus to the intracranial opening
of the optic canal and the shortest distance between them is 15.3±3.8mm. The average angle between the sphenoid sinus opening-optic canal line and median sagittal plane is 63±7.9°. So when sphenoid sinus opened, searching at the region of 1.5cm above and lateral to the opening of sphenoid sinus will help to find the optic canal; 4) adjacent to the inner wall of the optic canal, located lateral 3 sides of the sphenoid sinus (25%), located lateral 3 sides of the ethmoid sinus (25%), located between the sphenoid and the ethmoid sinus most commonly accounting for 6 (50%). So another way to look for the optic canal is searching at the junction of sphenoid and the ethmoid sinus because for most of the optic canal is located in or near this area; 5) The average distance from nasal spine to tuberculum sellae is 69.2±4.8mm. anterior border of the pituitary can be targeted accordingly. Operations at here in-depth more than 60mm, should beware of carotid artery injury; 6) two-dimensional endoscopy image, tubular vision with fish-eye lens effects anatomical deformation is more serious distortion, the greater the angle of the lens the change more obvious, the difference between observed and real anatomy is greater. Therefore proficiency in endoscopy anatomy, repeated practice, accustomed to this vision will help to overcome the endoscopy image distortion caused by blindness and lost feeling; 7) Endoscopic treatment 13 cases of no light perception with optic nerve damaged in patients followed up for 3 to 12 months, in 7 patients visual acuity recovery observed;6 cases it is ineffective. Visual acuity of more than 1～2 weeks post-operative emergence and about 2 months after the cessation. A level of visual acuity improved in 3 cases, two level in 1 case, 3 levels in 1 case, 4 levels in 2 cases. Total efficiency of 53.8% (7/13). Vision loss by injury between operative time is divided into groups of 3～7days, 8～14days, 15～21days and 21 or more days groups, in each group there was no significant difference between the effect (P>0.05); 8) treatment of 17 cases of traumatic optic nerve damage in patients with a total of 18, 10 patients with visual acuity recovery; 8 is invalid. A level of visual acuity improved in 5 patients, 2 levels in 2 cases, 3 levels in 1 case, 4 levels of in 2 cases, the total effective rate 55.6% (10/18); 9) Endoscopic treatment of 7 cases of iatrogenic cerebrospinal fluid leak, once repaired, drain port are in the original surgical site; 10) Treated 24 cases of cerebrospinal fluid rhinorrhea in patients. Endoscopic group of 13 of 15 cases. 13 successful operations, surgical success rate was 86.6%; 11 cases of 12 patients craniotomy with successful operations, the success of surgical success rate was 83.3%; the two groups and the a success rate of secondary surgical was of no significant difference; 11) Endoscopic treatment of the ethmoid sinus ossifying fibroma butterfly in 1 case, subtotal resection, pathology as follows: juvenile
ossifying fibroma, visual acuity was restored after the affected side. Conclusion: 1) Transnasal endoscopic treatment of anterior skull base lesions can maximize exposure of the regional lesions without increasing traction injury to the brain nerves and blood vessels to retain the normal structure thus reducing the postoperative complications and morbidity. With a minimally invasive, non-craniofacial incision, the patient feels less pain, quicker recovery, etc. In a series the clinical surgery illustrates conventional craniotomy and the nasal route with irreplaceable advantages; 2) Proficiency in the knowledge of the skull base relevant anatomy and after rigorous training in endoscopic procedures there is high safety; 3) For no light perception before surgery in patients with optic nerve injury, optic nerve decompression should be done in order to save their eyesight; 4)Recovery of vision after optic nerve injury depends on the mechanism and extent of optic nerve injury and not on duration from the time of injury to the time of surgery. Therefore as long as patient tends to be treated no matter how long after injury, surgery should be performed to save vision.
留了正常的神经血管结构,降低了术后并发症和致残率。具有微创、无颅面切口,病人痛苦少,恢复快等优点,在一系列临床手术中展示了常规开颅手术和鼻外进路无法替代的优势;4)在熟练掌握颅底相关解剖知识,并经过严格内镜操作训练后,经鼻内镜治疗前颅底病变有很高的安全性。
Objective: Skull base surgery as neurosurgery, otorhinolaryngology and the maxillofacial surgery, interdisciplinary very rapidly developed in recent years. However, due to anatomy of the anterior skull base adjacent to the structure of complex relationships in this anatomical location, for the lesions deeply located surgery is not easy to fully expose and completely remove the lesion, likely to cause postoperative deformity, dysfunction or other complications may occur. The nasal endoscopy is comparatively old technology with the development in optical, mechanical and electronic technology that acquired a new life over the last decade. Endoscopic can replace conventional microscopy, the nasal cavity through the natural gap, directly into the sella turcica and the parts anterior, middle and posterior to the base of the skull, under direct vision to deal with these parts of the lesion or injury, having quick recovery without cosmetic problem. The combination of transnasal endoscopic and the skull base surgery techniques greatly promoted the development of skull base surgery, not only enriched the treatment of skull base surgery but to broaden the scope of diagnosis and treatment of skull base surgery. The midline skull base surgery can handle not only the regional lesions, but also the development of lateral skull base region. However, due to complex anatomy of the skull base region, the anatomy of the lateral skull base is not sufficiently familiar to neurosurgeons. The nasal cavity space is small, available for a limited range of operation. Moreover endoscopy for the neurosurgeons is a different field of vision, the microscope and the operations are not fixed as the instruments out of the nasal passages are subject to change and is difficult to adapt for beginners. Being unfamiliar with endoscopy and lacking the knowledge of anatomical structures must not use endoscopic technique, these two major deficiencies prevents involvement of neurosurgeon. Endoscopic development is very uneven in domestic and overseas. On the other hand, in the developed countries and in our developed areas this technique is of rapid development. In the western region of Xinjiang it is still in initial stages. The purpose of this study is: 1) Observation and measurement through the internal anatomy of anterior skull base with endoscopic application. To enrich and master the required endoscopy of anterior skull base operations and anatomical knowledge. 2) To know and master out carrying of the necessary endoscopy of anterior skull base surgery, anatomical knowledge and developing the habit of endoscopic operation through the simulated training in the head of specimen bodies. 3) the Neuro endoscopy used in clinical treatment of common diseases of anterior skull base, such as cerebrospinal fluid rhinorrhea, optic nerve decompression, a variety of anterior cranial fossa tumors, etc. to improve surgical safety and efficacy in order to improve the Endoscopic diagnosis and treatment of skull base surgery. As the transsphenoidal pituitary tumor surgery has become more mature, therefore not in scope of this research. Method: The study is divided into three stages: 1) First 20 sides of 10 specimens of the cranial skull base and lateral of the sagittal section, the nasal bone anatomical landmarks associated between the distance and angle of observation and measurements. Then the 12 side of 6 specimens, after infusion for endoscopic observation and description; 2) To Endoscope the skull on 4 sides in two dried specimens, and 8sides of 4 bodies completed several simulations skull surgery: Endoscope transsphenoidal incision;Endoscope ethmoidsinus operation;Endoscope optic nerve decompression technique and endoscope orbital decompression, etc; 3) In the anatomical study and endoscopic simulated operations done under the premise of this technology used clinically for treatment of common diseases of the anterior skull base such as traumatic optic nerve injury, for various reasons cerebrospinal fluid rhinorrhea, treatment of benign tumor of anterior skull base. Result: 1) The average distance from nasal spine to tuberculum sellae is 69.2±4.8mm. Nasal spine point toward anterior clinoid process and the average distance is 72.9±3.9mm. When surgical instruments 6～7cm deep passes into nasal cavity we should beware of the possibility of entering the middle cranial fossa; 2) the average distance from nasal spine to the midpoint of intraorbital opening of the optic canal is 63.4±5.3mm. The average distance from nasal spine point to the midpoint of intracranial opening of the optic canal is 69.3±4.9mm. The average distance from Nasal columella basis point to the midpoint of intracranial opening of the optic canal is 78.3±4.5mm. During optic nerve decompression or orbital apex surgery, one should be very careful when surgical instruments inserted in depth of more than 50mm from the nasal spine points, too deep operations may even damage the carotid artery into the middle cranial fossa; 3) The average distance from opening of sphenoid sinus to the intracranial opening
of the optic canal and the shortest distance between them is 15.3±3.8mm. The average angle between the sphenoid sinus opening-optic canal line and median sagittal plane is 63±7.9°. So when sphenoid sinus opened, searching at the region of 1.5cm above and lateral to the opening of sphenoid sinus will help to find the optic canal; 4) adjacent to the inner wall of the optic canal, located lateral 3 sides of the sphenoid sinus (25%), located lateral 3 sides of the ethmoid sinus (25%), located between the sphenoid and the ethmoid sinus most commonly accounting for 6 (50%). So another way to look for the optic canal is searching at the junction of sphenoid and the ethmoid sinus because for most of the optic canal is located in or near this area; 5) The average distance from nasal spine to tuberculum sellae is 69.2±4.8mm. anterior border of the pituitary can be targeted accordingly. Operations at here in-depth more than 60mm, should beware of carotid artery injury; 6) two-dimensional endoscopy image, tubular vision with fish-eye lens effects anatomical deformation is more serious distortion, the greater the angle of the lens the change more obvious, the difference between observed and real anatomy is greater. Therefore proficiency in endoscopy anatomy, repeated practice, accustomed to this vision will help to overcome the endoscopy image distortion caused by blindness and lost feeling; 7) Endoscopic treatment 13 cases of no light perception with optic nerve damaged in patients followed up for 3 to 12 months, in 7 patients visual acuity recovery observed;6 cases it is ineffective. Visual acuity of more than 1～2 weeks post-operative emergence and about 2 months after the cessation. A level of visual acuity improved in 3 cases, two level in 1 case, 3 levels in 1 case, 4 levels in 2 cases. Total efficiency of 53.8% (7/13). Vision loss by injury between operative time is divided into groups of 3～7days, 8～14days, 15～21days and 21 or more days groups, in each group there was no significant difference between the effect (P>0.05); 8) treatment of 17 cases of traumatic optic nerve damage in patients with a total of 18, 10 patients with visual acuity recovery; 8 is invalid. A level of visual acuity improved in 5 patients, 2 levels in 2 cases, 3 levels in 1 case, 4 levels of in 2 cases, the total effective rate 55.6% (10/18); 9) Endoscopic treatment of 7 cases of iatrogenic cerebrospinal fluid leak, once repaired, drain port are in the original surgical site; 10) Treated 24 cases of cerebrospinal fluid rhinorrhea in patients. Endoscopic group of 13 of 15 cases. 13 successful operations, surgical success rate was 86.6%; 11 cases of 12 patients craniotomy with successful operations, the success of surgical success rate was 83.3%; the two groups and the a success rate of secondary surgical was of no significant difference; 11) Endoscopic treatment of the ethmoid sinus ossifying fibroma butterfly in 1 case, subtotal resection, pathology as follows: juvenile
ossifying fibroma, visual acuity was restored after the affected side. Conclusion: 1) Transnasal endoscopic treatment of anterior skull base lesions can maximize exposure of the regional lesions without increasing traction injury to the brain nerves and blood vessels to retain the normal structure thus reducing the postoperative complications and morbidity. With a minimally invasive, non-craniofacial incision, the patient feels less pain, quicker recovery, etc. In a series the clinical surgery illustrates conventional craniotomy and the nasal route with irreplaceable advantages; 2) Proficiency in the knowledge of the skull base relevant anatomy and after rigorous training in endoscopic procedures there is high safety; 3) For no light perception before surgery in patients with optic nerve injury, optic nerve decompression should be done in order to save their eyesight; 4)Recovery of vision after optic nerve injury depends on the mechanism and extent of optic nerve injury and not on duration from the time of injury to the time of surgery. Therefore as long as patient tends to be treated no matter how long after injury, surgery should be performed to save vision.
引文
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