Graupman Patrick, Defillo Archie, Nussbaum Leslie, Nussbaum Eric S
National Brain Aneurysm Center, Saint Joseph's Hospital, West 10 Street, St. Paul, Minnesota, USA ; Gillette Children's Specialty Healthcare, East University Ave, St. Paul, Minnesota, USA.
Surg Neurol Int. 2012;3:141. doi: 10.4103/2152-7806.103881. Epub 2012 Nov 27.
Lesions of the vermis and 4(th) ventricle are commonly addressed through a midline suboccipital approach. Most neurosurgeons use either a Y-shaped or a curvilinear dural opening in this setting. Although these approaches offer a wide intraoperative surgical exposure, in occasion, the dural opening is difficult to repair primarily, often necessitating the use of a patch, which may increase the risk for development of CSF fistula. We are describing our experience with a limited, vertical, midline, dural opening for approaches to the vermis, tentorium, 4(th) ventricle, and distal posterior-inferior cerebellar artery (PICA) segments as an alternative to the classic Y-shaped or curvilinear incision.
We report our experience with a limited vertical midline durotomy in five patients with posterior fossa lesions. The lesions treated included a PICA dissecting aneurysm, three metastatic lesions (located in the vermian, floor of the 4(th) ventricle, and undersurface of the tentorium cerebelli), and one intra-axial tumor (ependymoma). All patients were positioned prone, and the lesions were accessed without difficulty through a limited, vertical, midline durotomy.
Mass lesions and vascular abnormalities located from the midline as far lateral as the outlet foramina of the 4(th) ventricle can be accessed comfortably via a limited midline dural opening when combined with microsurgical techniques, and the use of a frameless Stealth Station Neuronavigation System (SSNS) [Medtronic Sofamor Danek, Inc., Memphis, TN]. By doing this, simple primary dural closure was achieved with a single running absorbable suture without tension in each case.
In our experience, a suboccipital linear dural opening appears to be as effective as the more traditional Y-shaped incision, yet allows for quicker and easier primary dural repair.
小脑蚓部和第四脑室病变通常通过枕下中线入路进行处理。大多数神经外科医生在这种情况下使用Y形或曲线形硬脑膜切开。尽管这些入路在术中提供了广泛的手术视野，但有时硬脑膜切开难以一期修复，常常需要使用补片，这可能增加脑脊液漏的发生风险。我们正在描述我们对于一种有限的、垂直的、中线硬脑膜切开的经验，该切开用于处理小脑蚓部、小脑幕、第四脑室以及小脑后下动脉（PICA）远端节段，作为经典Y形或曲线形切口的替代方法。
我们报告了5例后颅窝病变患者采用有限垂直中线硬脑膜切开术的经验。治疗的病变包括一个PICA夹层动脉瘤、三个转移瘤（分别位于小脑蚓部、第四脑室底部和小脑幕下面）以及一个轴内肿瘤（室管膜瘤）。所有患者均取俯卧位，通过有限的垂直中线硬脑膜切开术顺利到达病变部位。
当结合显微外科技术并使用无框架Stealth Station神经导航系统（SSNS）[美敦力索法玛·丹历公司，田纳西州孟菲斯]时，通过有限的中线硬脑膜切开术可以轻松到达位于中线直至第四脑室出口孔外侧的占位性病变和血管异常。通过这样做，在每种情况下均用一根连续可吸收缝线实现了简单的一期硬脑膜缝合，且无张力。
根据我们的经验，枕下直线硬脑膜切开似乎与更传统的Y形切口一样有效，但能实现更快、更容易的一期硬脑膜修复。
