Zoli Matteo, Rossi Nicolò, Friso Filippo, Sturiale Carmelo, Frank Giorgio, Pasquini Ernesto, Mazzatenta Diego
Department of Biomedical and Neuromotor Sciences, Center for the Diagnosis and Cure of Pituitary and Skull Base Tumors, Institute of Neurological Sciences of Bologna, University of Bologna, Bologna, Italy -
Department of Biomedical and Neuromotor Sciences, Center for the Diagnosis and Cure of Pituitary and Skull Base Tumors, Institute of Neurological Sciences of Bologna, University of Bologna, Bologna, Italy.
J Neurosurg Sci. 2018 Jun;62(3):356-368. doi: 10.23736/S0390-5616.18.04303-5. Epub 2018 Jan 10.
The endoscopic endonasal approach has been recently proposed for cranio-vertebral junction lesions. The more common indication for this sagittal extension of the endonasal route is represented by odontoidectomy for irreducible ventral brainstem compression due to congenital or degenerative conditions. However, in an increasing number of studies its adoption for tumors involving the cranio-cervical junction has been reported. The aim of this study is to consider retrospectively our surgical series, focusing on the advantages and limits of this approach.
Each consecutive case of tumor involving the cranio-vertebral junction since 2007 to 2017 treated through an endoscopic endonasal approach has been included. All patients undergone preoperative neurological examination and neuroimaging (magnetic resonance imaging [MRI] and computed tomography angiography). These examinations were repeated after 3 months and then annually. Complementary treatments, recurrence rate and clinical status at mean follow-up of 18±7.3 months were considered.
Seven patients have been included in this study, mean age was of 47±17 years; male-to-female ratio was of 3:4. Series is composed by 6 chordomas and one foramen magnum meningioma. One patient had been already posteriorly stabilized for cranio-vertebral instability. Gross tumor removal was achieved in two cases, in the others a subtotal removal was demonstrated at postoperative MRI. One patient presented a transitory worsening of CN XII palsy, resolved within 3 months. For preoperative dysphagia and inhalation pneumonia, one case undergone tracheostomy and was fed with oro-gastric tube for 10 days. Three patients died for chordoma progression and at follow-up one presented a local recurrence.
Despite our experience is preliminary, the endoscopic endonasal approach has resulted safe for cranio-cervical junction tumor with a reduced number of complications. It can give a straight and direct trajectory to this deep region. We suggest that lateral extension of the tumor beyond the plane of cranial nerves is a limit for this approach, as well as an inferior expansion caudal to C1. Larger series and longer follow-up are required to assess the proper indications of this approach.
近年来，经鼻内镜入路已被应用于颅颈交界区病变的治疗。经鼻入路矢状位扩展的更常见适应证是因先天性或退行性病变导致腹侧脑干压迫无法复位而行齿状突切除术。然而，越来越多的研究报道了其在涉及颅颈交界区肿瘤治疗中的应用。本研究的目的是回顾性分析我们的手术系列病例，重点关注该入路的优势和局限性。
纳入2007年至2017年期间通过经鼻内镜入路治疗的每一例连续的颅颈交界区肿瘤病例。所有患者均接受术前神经学检查和神经影像学检查（磁共振成像[MRI]和计算机断层血管造影）。术后3个月及之后每年重复这些检查。考虑辅助治疗、复发率以及平均随访18±7.3个月时的临床状况。
本研究共纳入7例患者，平均年龄为47±17岁；男女比例为3:4。该系列包括6例脊索瘤和1例枕骨大孔脑膜瘤。1例患者因颅颈不稳定已先行后路固定。2例实现了肿瘤全切，其他患者术后MRI显示为次全切除。1例患者出现舌下神经麻痹短暂加重，3个月内缓解。对于术前吞咽困难和吸入性肺炎，1例患者行气管切开术，并经口胃管喂养10天。3例患者因脊索瘤进展死亡，随访期间1例出现局部复发。
尽管我们的经验尚属初步，但经鼻内镜入路已证明对颅颈交界区肿瘤是安全的，并发症数量较少。它可以为这个深部区域提供一条直接的路径。我们认为肿瘤向颅神经平面外侧扩展以及向C1以下的尾侧扩展是该入路的局限性，需要更大规模的系列病例和更长时间的随访来评估该入路的合适适应证。
