Jacquesson Timothée, Berhouma Moncef, Tringali Stéphane, Simon Emile, Jouanneau Emmanuel
Skull Base Multidisciplinary Unit, Department of Neurosurgery, Neurological Hospital Pierre Wertheimer, Lyon Cedex, France; Department of Anatomy, University of Lyon, Lyon, France.
Skull Base Multidisciplinary Unit, Department of Neurosurgery, Neurological Hospital Pierre Wertheimer, Lyon Cedex, France.
World Neurosurg. 2015 Jun;83(6):929-36. doi: 10.1016/j.wneu.2015.02.003. Epub 2015 Feb 17.
Petroclival tumors remain a surgical challenge. Classically, the retrosigmoid approach (RSA) has long been used to reach such tumors, whereas the anterior petrosectomy (AP) has been proposed to avoid crossing cranial nerves. More recently, the endoscopic endonasal approach has been "expanded" (i.e., EEEA) to the petroclival region. We aimed to compare these 3 approaches to help in the surgical management of petroclival tumors.
Petroclival approaches were performed on 5 specimens after they were prepared with formaldehyde colored via latex injection.
The EEEA provides a simple straightforward route to the clivus, but reaching the petrous apex requires the surgeon to circumvent the internal carotid artery either via a medial transclival, an inferior transpterygoid, or a lateral variant through the Meckel's cave. In contrast, the AP offers a narrow direct superolateral access to the petroclival region crossed by the trigeminal nerve. Finally, the RSA provides a wide simple and quick exposure of the cerebellopontine angle, but access to the petroclival region needs the surgeon to deal with the V(th) to XI(th) cranial nerves.
DISCUSSION/CONCLUSION: The EEEA should be preferred for extradural midline tumors (chordomas, chondrosarcomas) or for cystic lesions when drainage is essential. The AP could be optimal for the radical removal of intradural vascularized tumors (meningiomas) with intrapetrous or supratentorial extensions. The RSA retains an advantage for small or cystic tumors near the internal acoustic meatus. The skull base surgeon has to master all of these routes to choose the more appropriate one according to the surgical objective, the tumor characteristics, and the patient's medical status.
岩斜区肿瘤的手术治疗仍具有挑战性。传统上，乙状窦后入路（RSA）长期以来一直用于切除此类肿瘤，而有人提出岩前切除术（AP）可避免穿过颅神经。最近，鼻内镜经鼻入路已“扩展”（即EEEA）至岩斜区。我们旨在比较这三种入路，以协助岩斜区肿瘤的手术治疗。
对5个用甲醛固定并经乳胶注射染色的标本进行岩斜区入路手术。
EEEA为到达斜坡提供了一条简单直接的路径，但要到达岩尖，外科医生需要通过经斜坡内侧、经翼突下或经Meckel腔的外侧变异途径绕过颈内动脉。相比之下，AP提供了一条狭窄的直接经上外侧进入岩斜区的路径，该区域有三叉神经穿过。最后，RSA能广泛、简单且快速地显露桥小脑角，但进入岩斜区需要外科医生处理第V对至第XI对颅神经。
讨论/结论：对于硬膜外中线肿瘤（脊索瘤、软骨肉瘤）或当引流至关重要时的囊性病变，应首选EEEA。对于有岩内或幕上延伸的硬膜内血管性肿瘤（脑膜瘤）的根治性切除，AP可能是最佳选择。RSA对于内耳道附近的小肿瘤或囊性肿瘤仍具有优势。颅底外科医生必须掌握所有这些入路，以便根据手术目标、肿瘤特征和患者的医疗状况选择更合适的入路。
