经鼻内镜筛蝶窦入路视神经减压术37例分析
|
摘要
目的：本课题通过开展鼻内镜下经鼻腔、筛蝶窦入路视神经减压术，探索治疗外伤性视神经病的最佳治疗方法与手术路径。通过对术前视力、受伤至手术的时间、CT有无视神经管骨折与疗效的关系等方面的分析，找寻影响手术疗效的相关因素，为临床确定手术指证、判断预后提供依据。
方法：外伤性视神经病37例37只眼，在外伤后1-30天内施行鼻内镜下经鼻腔、筛蝶窦入路视神经减压术。术中开放筛、蝶窦，在蝶窦外上壁或Onodi气房内找寻视神经隆凸，以金刚石磨钻磨开视神经管，暴露管段视神经，切开鞘膜，施行减压。所有病人术前和术后给予激素治疗，根据最终视力分析影响疗效的因素。
结果：37例患者中21例术后视力获得改善，有效率为56.76％。其中，术前无光感者28例术后视力改善13例(46.43％)，术前视力有光感及以上者9例最终视力改善8例(88.89％)，二者差别有显著意义(P=0.029)。伤后时间小于7天者23例最终视力改善16例(69.57％)，伤后时间7天及以上者14例最终视力改善6例(42.86％)，二者差别无显著意义(P=0.104)。VEP监测中，能引出P100波的患眼术后疗效好于无P100波者(P=0.005)。
结论：①对于外伤性视神经病患者，大剂量激素冲击治疗无效时，应积极采用视神经减压术。②减压术后，视力恢复与否并不取决于伤后时间，而与视神经的损伤程度关系更大。对伤后1周以上者，手术减压仍有较好疗效。③术前视力有无光感，其手术后疗效有明显差别。但并非无光感患者就没有手术价值。④鼻内镜下视神经减压术，损伤小、疗效确切且不遗留面部瘢痕，有推广应用价值。⑤术前VEP检测情况对预测预后有一定的帮助。VEP检测应作为诊断外伤性视神经病的重要参考指标。
OBJECTIVES: The proper management of traumatic injures to the optic nerve is controversial. Recommendations for management of traumatic injuries to the optic nerve in the literature include expectant management, medical therapy, surgical treatment, and medical therapy combined with surgical decompression. Traditional surgical approaches to optic nerve decompression (OND) are a craniotomy approach, extranasal transethmoidal approach, transorbital approach, transantral approach, and intranasal microscopic approach. Recent advances in instrumentation and surgical techniques have made an endoscopic approach to OND possible. The goal of this study is to search for a better surgical method for treatment of traumatic optic neuropathy and to identify factors affecting improvement in patients treated with OND and the diagnostic value of VEP in the traumatic optic neuropathy . METHODS: Thirty-seven patients(37 eyes)with traumatic optic neuropathy were enrolled. Transnasal endoscopic sphenoethmoidal optic nerve decompr
ession was performed within 30 days after injury. Each patient was alert and free of injury to the globe when evaluated before surgery. All the patients were given preoperative and postoperative steroids. 13 patients were checked by VEP examination before and after surgery. The analyses of variations of visual acuity in final stage and VEP were to be done to determine the factors affecting the outcome of visual acuity and the diagnostic value of VEP in the traumatic optic neuropathy .
RESULT: The final visual acuity was improved in 21 patients (56. 76 %) . The final visual acuity improved in 13/28 patients with no perception of light and 8/9 patients with light perception or better. The effectiveness in patients with light perception or better was significantly higher than those with no light perception, (p=0.029). Improvements were no significant
difference between patients whose course after injury less than 7 days and those whose course after injury were 7 days and more. (P=0. 104). The patients with presence of P-100 wave in VEP had better improvements than those without it(P=0. 005).
CONCLUSION: The endoscopic method offers many advantages over the traditional approaches. Decreased morbidity, preservation of olfaction, rapid recovery time, more acceptable cosmetic results with no external scars, no risk of injury to the developing teeth in children, and less operative stress in a patient who may have multisystem trauma are only some of the benefits associated with the endoscopic OND. The key factor in determining nerve recovery was associated with the severity of optic nerve trauma. No light perception at initial is an important risk factor in the outcome. There is no reason to give up treatment even if the time after injury is more than 7 days. With or without P-100 wave in VEP is an important factor associated with prognosis.
方法：外伤性视神经病37例37只眼，在外伤后1-30天内施行鼻内镜下经鼻腔、筛蝶窦入路视神经减压术。术中开放筛、蝶窦，在蝶窦外上壁或Onodi气房内找寻视神经隆凸，以金刚石磨钻磨开视神经管，暴露管段视神经，切开鞘膜，施行减压。所有病人术前和术后给予激素治疗，根据最终视力分析影响疗效的因素。
结果：37例患者中21例术后视力获得改善，有效率为56.76％。其中，术前无光感者28例术后视力改善13例(46.43％)，术前视力有光感及以上者9例最终视力改善8例(88.89％)，二者差别有显著意义(P=0.029)。伤后时间小于7天者23例最终视力改善16例(69.57％)，伤后时间7天及以上者14例最终视力改善6例(42.86％)，二者差别无显著意义(P=0.104)。VEP监测中，能引出P100波的患眼术后疗效好于无P100波者(P=0.005)。
结论：①对于外伤性视神经病患者，大剂量激素冲击治疗无效时，应积极采用视神经减压术。②减压术后，视力恢复与否并不取决于伤后时间，而与视神经的损伤程度关系更大。对伤后1周以上者，手术减压仍有较好疗效。③术前视力有无光感，其手术后疗效有明显差别。但并非无光感患者就没有手术价值。④鼻内镜下视神经减压术，损伤小、疗效确切且不遗留面部瘢痕，有推广应用价值。⑤术前VEP检测情况对预测预后有一定的帮助。VEP检测应作为诊断外伤性视神经病的重要参考指标。
OBJECTIVES: The proper management of traumatic injures to the optic nerve is controversial. Recommendations for management of traumatic injuries to the optic nerve in the literature include expectant management, medical therapy, surgical treatment, and medical therapy combined with surgical decompression. Traditional surgical approaches to optic nerve decompression (OND) are a craniotomy approach, extranasal transethmoidal approach, transorbital approach, transantral approach, and intranasal microscopic approach. Recent advances in instrumentation and surgical techniques have made an endoscopic approach to OND possible. The goal of this study is to search for a better surgical method for treatment of traumatic optic neuropathy and to identify factors affecting improvement in patients treated with OND and the diagnostic value of VEP in the traumatic optic neuropathy . METHODS: Thirty-seven patients(37 eyes)with traumatic optic neuropathy were enrolled. Transnasal endoscopic sphenoethmoidal optic nerve decompr
ession was performed within 30 days after injury. Each patient was alert and free of injury to the globe when evaluated before surgery. All the patients were given preoperative and postoperative steroids. 13 patients were checked by VEP examination before and after surgery. The analyses of variations of visual acuity in final stage and VEP were to be done to determine the factors affecting the outcome of visual acuity and the diagnostic value of VEP in the traumatic optic neuropathy .
RESULT: The final visual acuity was improved in 21 patients (56. 76 %) . The final visual acuity improved in 13/28 patients with no perception of light and 8/9 patients with light perception or better. The effectiveness in patients with light perception or better was significantly higher than those with no light perception, (p=0.029). Improvements were no significant
difference between patients whose course after injury less than 7 days and those whose course after injury were 7 days and more. (P=0. 104). The patients with presence of P-100 wave in VEP had better improvements than those without it(P=0. 005).
CONCLUSION: The endoscopic method offers many advantages over the traditional approaches. Decreased morbidity, preservation of olfaction, rapid recovery time, more acceptable cosmetic results with no external scars, no risk of injury to the developing teeth in children, and less operative stress in a patient who may have multisystem trauma are only some of the benefits associated with the endoscopic OND. The key factor in determining nerve recovery was associated with the severity of optic nerve trauma. No light perception at initial is an important risk factor in the outcome. There is no reason to give up treatment even if the time after injury is more than 7 days. With or without P-100 wave in VEP is an important factor associated with prognosis.
引文
1 Walsh F, Hoyt W. Clinical neuro-ophthalmology. Baltimore: Williams & Wilkins, 1969:2375-2380
2 Kline LB et al. N uro surgery, 1984; 14:756～764
3 Wolfin MH, Lavin PJM. Spontaneous visual recovery from traumatic optic neuropathy after blunt head injury. Am J Ophthalmol 1990;109: 430-5.
4 Anasal decompression of the optic nerve. Arch Otorhinolaryngol 1989;246:113-6.
5 Sofferman RA. Transnasal approach to optic nerve decompression. Operative Techniques in Otolaryngology-Head & Neck Surgery 1991;2(3):150-6.
6 Lessel S. Indirect optic nerve trauma. Arch Ophthalmol 1989;107:382-6.
7 Joseph MP, Lessel S, Rizzo J, Momose KJ. Extracranial optic nerve decompression for traumatic optic neuropathy. Arch Ophthalmol 1990;108:1091-3.
8 Call NB. Decompression of the optic nerve in the optic canal. Ophthalmic Plast Reconst Surg 1986;2(3):133-7.
9 Anand VK, Sherwood C, Al-Mefty O. Optic nerve decompression via transethmoid and supraorbital approaches. Operative Techniques in Otolaryngology-Head and Neck Surgery 1991;2(3):157-66.
10 Sofferman RA. Transsphenoethmoid decompression of the optic nerve. Instructional Courses AAO-HNS. Vol. I. Philadelphia: Mosby; 1988:117-12.
11 Custer PL. Optic nerve sheath decompression. Eur J Implant Ref Surg 1993;5: 113-4.
12 Kuppersmith RB, Alford EL, Patrinely JR, Lee AG, Parke RB, Holds JB. Combined transconjunctival/intranasal endoscopic approach to the optic canal in traumatic optic neuropathy. Laryngoscope 1997;107:311-5.
13 ChadwickJ, MannWN. ThemedicalworksofHippocrate. Oxford, UK:Blackwell, 1950
14 Gross CE, Dckock JR, Panje WR, et al. Evidence for orbital deformation that may contribute to monocular blindness following minor frontal head trauma. J Neurosurg 1981:55:963-966
15 Anderson RL, Panje WR, Gross CE. Optic nerve blindness following blunt forehead trauma. Ophthalmology 1982;89:445-455
16 Purvin V. Evidence of orbital deformtion in indiect optic nerve ingury: weight lifter's optic neuropathy. J Clin Neuroophthalmol 1988;8:9:-11
17 Park JH, Frenkel M, Dobbie JG, Choromokos E. Evulsion of the optic nerve. Am J Ophthalmol 1971;72:969-971
18 Kline LB, Morawetz RB, Swaid SN. Indirect injury of the optic nerve. Nuroseurgery, 1984;14:756～764
19 Walsh FB. Pathological-clinical correlations: I Indirect trauma to the optic nerves and chiasm.Ⅱ. Ccerebral involvements associated with defective blood supply. Invest Ophthalmol 1966;5:433-499
20 Aitken P, Sofferman R. Traumatic optic neuropathy. Ophthalmol Chin North Am 1991;4:479-490
21 Hughes B. Indirect injury of the optic nerves and chiasm. Bull Johns Hopkins Hosp 1962;111:98-126
22 Noble MJ, McFadzean R. Indirect injury to the optic nerves and optic chiasm. Neuroophthalmology 1987;7:341-348
23 Al-Qurainy IA Stassen LFA, Dutton GN, et al. The characteristics of of midfacial fractures and the association with ocular injury: a prospective study. Br J Oral Maxillofacial Surg 1991;29:291-301
24 Holt GR, Holt JE. Incidence of eye injuries in facial fractures: an analysis of 727 cases. Otolaryngol Head Neck Surg 1983;91:276-279
25 Davidson M. The indirect traumatic optic atrophies. Am J Ophthalmol 1938;21:7-21
26 Purvin V. Evidence of orbital deformtion in indiect optic nerve ingury: weight lifter's optic neuropathy. J Clin Neuroophthalmol 1988;8:9:-11
27 Hall ED, Braughter JM. Effects of intravenous methylprednisolone on spinal cord lipid peroxidation and Na+-K+ATPase actixe. J Neurosurg 1982;57:247-253
28 Demopoulos HS, Flamm ES, Seligman ML, et al. Further studies on free-radical pathology in the major center nervous system diaorders: effect of very high doses of methylprednisolone on the functional outcomes, morphology and chemistry of experimental spinal cord impact injury .Can J Physiol Pharmacol 1982;60:1415-1424
29 Braughler JM, Hall ED. Effects of multidose methylprednisolone sodium succinate administration on injured cat spinal cord neurofilament
degradation and energy metabolism. J Neurosurg 1964;61:190-295
30 Braughler JM, Hall ED, Mean ED, et al. Evaluation of an intensive methylprednisolone sodium succinate dosing regimen in experimental spinal cord injury. J Neurosurg 1987:67;882-887
31 Hall ED. High dose glucocorticoid treatment improves neurological recovery in head injured mice. J Neurosurg 1985;62:882-887
32 Bracken MB, Shepard MJ, Collins WF, et al. A randomized, controlled trial of methylprednisolone or naloxone in the treatment of acute spinal cord injury. N engl J Med1990;322:1405-1441 Ticho U, Feinsod M. Traumatic optic neuritis. Brain 1943;66:140-151
33 Ticho U, Feinsod M. Traumatic optic neuritis. Brain 1943;66:140-151
34 Frenkle R,Spoor T, Diagnosis and management of traumatic optic neuropathies. Adv Ophthalmic Pastic Surg 1987;6:71-90
35 Berestka JS, Rizzo JF. Controversy in the management of traumatic optic neuropathy. Int Ophthalmol Clin 1994;34:87-96
36 Seiff S. High dose corticosteroids for treatment of vision loss due to indirect injury to the optic nerve. Ophthalmic Surg 1990;21:389-395
37 Kline LB, Volpe NL, Lessell S. Traumatic optic neuropathy:diagnosis and management. Int Ophthlmalmol Clin 1991:31:142-156
38 Sofferman R. Laryngoscope, 1981; 91:184-196
39 Tandon DA, Thakar A et el. Clin Otolaryngol, 1994; 19:98-104
40 Kountakis SE et al. Otolaryngol Head Neck Surg, 2000; 123:34～37
41 Plotnik JL, Kosmorsky GS. Operative complications of optic nerve sheath decompression. Ophthalmology 1993; 100:683-90
42 Stoll W, Busse H, Wessels N. Detaillierte Ergebnisse nach Orbita-und Opticusdekompressionen. HNO 1994; 42:685-90
43 史剑波，经鼻内窥镜视神经管减压术初步报告，中华耳鼻咽喉科杂志1998，8，33(40)：225-227
44 Girard BC, Bouzac EA, Lamas G, Soudant J. Visual Improvement after transethmoidsphenoid decompression in optic nerve injurise. J Clin Neuroophthalmol 1992; 12:142-148
45 Levin LA, Joseph MP, Rizzo JF, Lessell S. optic canal decompression in indirect optic nerve trauma. Ophthalmology. 1994; 101(3):566-569
46 Seiff S. High dose corticosteroids for treatment of vision loss due to
indirect injury to the optic nerve. Ophthalmic Surg 1990;21:389-395
47 Mahapatra AK. Indirect injury to the optic nerve. Acta Neurochir, 1991:112:47～49
2 Kline LB et al. N uro surgery, 1984; 14:756～764
3 Wolfin MH, Lavin PJM. Spontaneous visual recovery from traumatic optic neuropathy after blunt head injury. Am J Ophthalmol 1990;109: 430-5.
4 Anasal decompression of the optic nerve. Arch Otorhinolaryngol 1989;246:113-6.
5 Sofferman RA. Transnasal approach to optic nerve decompression. Operative Techniques in Otolaryngology-Head & Neck Surgery 1991;2(3):150-6.
6 Lessel S. Indirect optic nerve trauma. Arch Ophthalmol 1989;107:382-6.
7 Joseph MP, Lessel S, Rizzo J, Momose KJ. Extracranial optic nerve decompression for traumatic optic neuropathy. Arch Ophthalmol 1990;108:1091-3.
8 Call NB. Decompression of the optic nerve in the optic canal. Ophthalmic Plast Reconst Surg 1986;2(3):133-7.
9 Anand VK, Sherwood C, Al-Mefty O. Optic nerve decompression via transethmoid and supraorbital approaches. Operative Techniques in Otolaryngology-Head and Neck Surgery 1991;2(3):157-66.
10 Sofferman RA. Transsphenoethmoid decompression of the optic nerve. Instructional Courses AAO-HNS. Vol. I. Philadelphia: Mosby; 1988:117-12.
11 Custer PL. Optic nerve sheath decompression. Eur J Implant Ref Surg 1993;5: 113-4.
12 Kuppersmith RB, Alford EL, Patrinely JR, Lee AG, Parke RB, Holds JB. Combined transconjunctival/intranasal endoscopic approach to the optic canal in traumatic optic neuropathy. Laryngoscope 1997;107:311-5.
13 ChadwickJ, MannWN. ThemedicalworksofHippocrate. Oxford, UK:Blackwell, 1950
14 Gross CE, Dckock JR, Panje WR, et al. Evidence for orbital deformation that may contribute to monocular blindness following minor frontal head trauma. J Neurosurg 1981:55:963-966
15 Anderson RL, Panje WR, Gross CE. Optic nerve blindness following blunt forehead trauma. Ophthalmology 1982;89:445-455
16 Purvin V. Evidence of orbital deformtion in indiect optic nerve ingury: weight lifter's optic neuropathy. J Clin Neuroophthalmol 1988;8:9:-11
17 Park JH, Frenkel M, Dobbie JG, Choromokos E. Evulsion of the optic nerve. Am J Ophthalmol 1971;72:969-971
18 Kline LB, Morawetz RB, Swaid SN. Indirect injury of the optic nerve. Nuroseurgery, 1984;14:756～764
19 Walsh FB. Pathological-clinical correlations: I Indirect trauma to the optic nerves and chiasm.Ⅱ. Ccerebral involvements associated with defective blood supply. Invest Ophthalmol 1966;5:433-499
20 Aitken P, Sofferman R. Traumatic optic neuropathy. Ophthalmol Chin North Am 1991;4:479-490
21 Hughes B. Indirect injury of the optic nerves and chiasm. Bull Johns Hopkins Hosp 1962;111:98-126
22 Noble MJ, McFadzean R. Indirect injury to the optic nerves and optic chiasm. Neuroophthalmology 1987;7:341-348
23 Al-Qurainy IA Stassen LFA, Dutton GN, et al. The characteristics of of midfacial fractures and the association with ocular injury: a prospective study. Br J Oral Maxillofacial Surg 1991;29:291-301
24 Holt GR, Holt JE. Incidence of eye injuries in facial fractures: an analysis of 727 cases. Otolaryngol Head Neck Surg 1983;91:276-279
25 Davidson M. The indirect traumatic optic atrophies. Am J Ophthalmol 1938;21:7-21
26 Purvin V. Evidence of orbital deformtion in indiect optic nerve ingury: weight lifter's optic neuropathy. J Clin Neuroophthalmol 1988;8:9:-11
27 Hall ED, Braughter JM. Effects of intravenous methylprednisolone on spinal cord lipid peroxidation and Na+-K+ATPase actixe. J Neurosurg 1982;57:247-253
28 Demopoulos HS, Flamm ES, Seligman ML, et al. Further studies on free-radical pathology in the major center nervous system diaorders: effect of very high doses of methylprednisolone on the functional outcomes, morphology and chemistry of experimental spinal cord impact injury .Can J Physiol Pharmacol 1982;60:1415-1424
29 Braughler JM, Hall ED. Effects of multidose methylprednisolone sodium succinate administration on injured cat spinal cord neurofilament
degradation and energy metabolism. J Neurosurg 1964;61:190-295
30 Braughler JM, Hall ED, Mean ED, et al. Evaluation of an intensive methylprednisolone sodium succinate dosing regimen in experimental spinal cord injury. J Neurosurg 1987:67;882-887
31 Hall ED. High dose glucocorticoid treatment improves neurological recovery in head injured mice. J Neurosurg 1985;62:882-887
32 Bracken MB, Shepard MJ, Collins WF, et al. A randomized, controlled trial of methylprednisolone or naloxone in the treatment of acute spinal cord injury. N engl J Med1990;322:1405-1441 Ticho U, Feinsod M. Traumatic optic neuritis. Brain 1943;66:140-151
33 Ticho U, Feinsod M. Traumatic optic neuritis. Brain 1943;66:140-151
34 Frenkle R,Spoor T, Diagnosis and management of traumatic optic neuropathies. Adv Ophthalmic Pastic Surg 1987;6:71-90
35 Berestka JS, Rizzo JF. Controversy in the management of traumatic optic neuropathy. Int Ophthalmol Clin 1994;34:87-96
36 Seiff S. High dose corticosteroids for treatment of vision loss due to indirect injury to the optic nerve. Ophthalmic Surg 1990;21:389-395
37 Kline LB, Volpe NL, Lessell S. Traumatic optic neuropathy:diagnosis and management. Int Ophthlmalmol Clin 1991:31:142-156
38 Sofferman R. Laryngoscope, 1981; 91:184-196
39 Tandon DA, Thakar A et el. Clin Otolaryngol, 1994; 19:98-104
40 Kountakis SE et al. Otolaryngol Head Neck Surg, 2000; 123:34～37
41 Plotnik JL, Kosmorsky GS. Operative complications of optic nerve sheath decompression. Ophthalmology 1993; 100:683-90
42 Stoll W, Busse H, Wessels N. Detaillierte Ergebnisse nach Orbita-und Opticusdekompressionen. HNO 1994; 42:685-90
43 史剑波，经鼻内窥镜视神经管减压术初步报告，中华耳鼻咽喉科杂志1998，8，33(40)：225-227
44 Girard BC, Bouzac EA, Lamas G, Soudant J. Visual Improvement after transethmoidsphenoid decompression in optic nerve injurise. J Clin Neuroophthalmol 1992; 12:142-148
45 Levin LA, Joseph MP, Rizzo JF, Lessell S. optic canal decompression in indirect optic nerve trauma. Ophthalmology. 1994; 101(3):566-569
46 Seiff S. High dose corticosteroids for treatment of vision loss due to
indirect injury to the optic nerve. Ophthalmic Surg 1990;21:389-395
47 Mahapatra AK. Indirect injury to the optic nerve. Acta Neurochir, 1991:112:47～49