Eicker Sven O, Mende Klaus Christian, Dührsen Lasse, Schmidt Nils Ole
Department of Neurosurgery, University Medical Center, Hamburg-Eppendorf, Germany.
Neurosurg Focus. 2015 Apr;38(4):E10. doi: 10.3171/2015.2.FOCUS14799.
The surgical management of lesions ventral to the neuraxis at the level of the craniovertebral junction (CVJ) and upper cervical spine is challenging. Here, the authors describe a minimally invasive dorsal approach for small ventrally located intradural lesions at the CVJ as an alternative for the more extensive classic transoral approach or variants of suboccipital approaches.
Between 2012 and 2014, 6 symptomatic patients with a small lesion of the ventral aspect at the CVJ level were treated using a minimally invasive dorsal approach at the University Medical Center in Hamburg-Eppendorf, Germany. The anatomical distance between the posterior atlantooccipital membrane and the posterior atlantoaxial ligament, as determined by CT images, was assessed in the treated patients and in 100 untreated persons.
The authors treated 6 patients (mean age 54.7 years) who had a clinical presentation of mild neurological symptoms that disappeared after resection. Minimally invasive surgical dorsal access was achieved by using tubular systems and using the natural space between the occiput (C-0) and C-1, and in 1 case between C-1 and C-2, without having to remove bony structures. The postoperative course in each of the 6 patients was uneventful. The neuropatho-logical findings confirmed a meningotheliomatous meningioma (WHO Grade I) in 5 cases and an extramedullary cavernous hemangioma in 1 case. MRI confirmed complete resection of all the lesions. The atlantooccipital distances ranged from 3 to 17 mm (mean 8.98 mm) in the supine neutral position, and the atlantoaxial distances ranged from 5 to 17 mm (mean 10.56 mm). There were no significant differences between women and men (atlantooccipital p = 0.14; atlantoaxial p = 0.72).
The results of this study demonstrate that the minimally invasive dorsal approach using the space between C-0 and C-1 or C-1 and C-2 provides direct and sufficient exposure for the safe surgical resection of small ventrally located intradural lesions at the CVJ level while reducing the necessity for musculoskeletal preparation to a minimum.
颅颈交界区（CVJ）和上颈椎水平神经轴腹侧病变的外科治疗具有挑战性。在此，作者描述一种针对CVJ处小的腹侧硬膜内病变的微创背侧入路，作为更广泛的经典经口入路或枕下入路变体的替代方法。
2012年至2014年期间，德国汉堡-埃彭多夫大学医学中心对6例有CVJ水平腹侧小病变的有症状患者采用微创背侧入路进行治疗。通过CT图像确定治疗患者和100名未治疗者中寰枕后膜与寰枢后韧带之间的解剖距离。
作者治疗了6例患者（平均年龄54.7岁），这些患者临床表现为轻度神经症状，切除后消失。通过使用管状系统并利用枕骨（C-0）与C-1之间以及1例C-1与C-2之间的自然间隙实现了微创外科背侧入路，无需去除骨结构。6例患者中每例的术后病程均顺利。神经病理学检查结果证实5例为脑膜皮型脑膜瘤（WHO I级），1例为髓外海绵状血管瘤。MRI证实所有病变均完全切除。仰卧位中立位时，寰枕距离为3至17毫米（平均8.98毫米），寰枢距离为5至17毫米（平均10.56毫米）。男女之间无显著差异（寰枕p = 0.14；寰枢p = 0.72）。
本研究结果表明，利用C-0与C-1或C-1与C-2之间的间隙的微创背侧入路为安全手术切除CVJ水平小的腹侧硬膜内病变提供了直接且充分的暴露，同时将肌肉骨骼准备的必要性降至最低。
