1Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli Federico II, Naples, Italy.
2Department of Neurosurgery, Hospital Clinic, Barcelona, Spain; and.
J Neurosurg. 2019 Mar 1;130(3):848-860. doi: 10.3171/2017.9.JNS171406. Epub 2018 Apr 20.
The extended endoscopic endonasal transtuberculum transplanum approach is currently used for the surgical treatment of selected midline anterior skull base lesions. Nevertheless, the possibility of accessing the lateral aspects of the planum sphenoidale could represent a limitation for such an approach. To the authors' knowledge, a clear definition of the eventual anatomical boundaries has not been delineated. Hence, the present study aimed to detail and quantify the maximum amount of bone removal over the planum sphenoidale required via the endonasal pathway to achieve the most lateral extension of such a corridor and to evaluate the relative surgical freedom.
Six human cadaveric heads were dissected at the Laboratory of Surgical NeuroAnatomy of the University of Barcelona. The laboratory rehearsals were run as follows: 1) preliminary predissection CT scans, 2) the endoscopic endonasal transtuberculum transplanum approach (lateral limit: medial optocarotid recess) followed by postdissection CT scans, 3) maximum lateral extension of the transtuberculum transplanum approach followed by postdissection CT scans, and 4) bone removal and surgical freedom analysis (a nonpaired Student t-test). A conventional subfrontal bilateral approach was used to evaluate, from above, the bone removal from the planum sphenoidale and the lateral limit of the endonasal route.
The endoscopic endonasal transtuberculum transplanum approach was extended at its maximum lateral aspect in the lateral portion of the anterior skull base, removing the bone above the optic prominence, that is, the medial portion of the lesser sphenoid wing, including the anterior clinoid process. As expected, a greater bone removal volume was obtained compared with the approach when bone removal is limited to the medial optocarotid recess (average 533.45 vs 296.07 mm2; p < 0.01). The anteroposterior diameter was an average of 8.1 vs 15.78 mm, and the laterolateral diameter was an average of 18.77 vs 44.54 mm (p < 0.01). The neurovascular contents of this area were exposed up to the insular segment of the middle cerebral artery. The surgical freedom analysis revealed a possible increased lateral maneuverability of instruments inserted in the contralateral nostril compared with a midline target (average 384.11 vs 235.31 mm2; p < 0.05).
Bone removal from the medial aspect of the lesser sphenoid wing, including the anterior clinoid process, may increase the exposure and surgical freedom of the extended endoscopic endonasal transtuberculum transplanum approach over the lateral segment of the anterior skull base. Although this study represents a preliminary anatomical investigation, it could be useful to refine the indications and limitations of the endoscopic endonasal corridor for the surgical management of skull base lesions involving the lateral portion of the planum sphenoidale.
经扩大的内镜经鼻蝶入路目前用于治疗选定的中线前颅底病变。然而，这种方法可能无法触及蝶骨平台的外侧部分，这可能是其局限性。据作者所知，这种方法的解剖学边界尚未明确界定。因此，本研究旨在详细说明并量化经鼻途径中切除蝶骨平台所需的最大骨量，以实现该通道的最外侧延伸，并评估相对的手术自由度。
在巴塞罗那大学的神经外科解剖学实验室对 6 具人体头颅进行解剖。实验室的排练如下：1）初步解剖前 CT 扫描，2）内镜经鼻蝶入路（外侧极限：内侧视神经颈动脉隐窝），然后进行解剖后 CT 扫描，3）经鼻蝶入路的最大外侧延伸，然后进行解剖后 CT 扫描，4）骨切除和手术自由度分析（非配对学生 t 检验）。采用传统的额下入路从上方评估经蝶入路切除蝶骨平台和鼻内入路的外侧极限的骨切除量。
内镜经鼻蝶入路在颅前底的前外侧部分最大限度地延伸，切除视神经隆起上方的骨，即较小的蝶骨翼的内侧部分，包括前床突。正如预期的那样，与骨切除仅限于内侧视神经颈动脉隐窝的方法相比，获得了更大的骨切除量（平均 533.45 比 296.07mm²；p＜0.01）。前后直径平均为 8.1 毫米，左右直径平均为 18.77 毫米比 44.54 毫米（p＜0.01）。该区域的神经血管内容物暴露到大脑中动脉岛叶段。手术自由度分析显示，与中线靶点相比，插入对侧鼻孔的器械可能具有更大的外侧操纵性（平均 384.11 比 235.31mm²；p＜0.05）。
切除较小的蝶骨翼的内侧部分，包括前床突，可以增加经扩大的内镜经鼻蝶入路在颅前底外侧段的暴露和手术自由度。虽然这项研究代表了初步的解剖学研究，但它可能有助于细化内镜鼻内通道用于治疗涉及蝶骨平台外侧部分的颅底病变的适应证和局限性。
