Kushel' Yu V, Sorokin V S, Chel'diev B Z, Tekoev A R
Burdenko Neurosurgical Institute, 4-ya Tverskaya-Yamskaya Str., 16, Moscow, Russia, 125047.
Zh Vopr Neirokhir Im N N Burdenko. 2018;82(3):36-41. doi: 10.17116/neiro201882336.
Posterior cranial fossa tumors are the most common neuro-oncological pathology of childhood. More than half of them are located along the midline, occupying the cerebellar vermis and 4th ventricle cavity. Historically, most of these tumors were operated on with the patient in sitting position. This tendency has significantly changed in the last 30 years. For example, 95% of all operations in Japan are now performed with the patient in lying position; for the US and Europe, these figures are 80 and 60%, respectively. This global tendency of switching to the lying position is mainly associated with a high risk of venous air embolism in the sitting position. In the period between 1999 and 2013, the first author used only the sitting position for resection of PCF tumors. During this period, he performed 606 operations. In patients with large/giant tumors (usually, these were piloid astrocytomas with cysts), the surgeon often faced the problem of excessive retraction of the cerebellum and rupture of the bridging veins, sometimes outside the surgical approach area. This situation led either to massive blood loss or to venous air embolism.
Therefore, beginning at 2013, we started to selectively use the prone position in cases of hemispheric piloid astrocytomas of the cerebellum. This initial experience allowed us to assess the surgical features of the procedure and use the experience in more complex interventions. Since the middle of 2016, given the tendency of using key-hole approaches, we have increasingly used the prone position in surgery of PCF tumors, sometimes removing tumors even through the burr hole. Since the end of 2016, we have routinely used the prone position for various tumors of the 4th ventricle. Between November 2016 and September 2017, the first author performed 113 surgeries for PCF tumors in children; of these, only 4 operations were performed in the sitting position. Thus, in less than a year, the prone position has become the main one in surgery for all PCF tumors in our practice. In this article, we would like to share our practical suggestions both about using the prone position and about its advantages and disadvantages that should be considered by a doctor who does not have experience of PCF surgery with the patient in prone position.
后颅窝肿瘤是儿童最常见的神经肿瘤病理学类型。其中一半以上位于中线，占据小脑蚓部和第四脑室腔。从历史上看，这些肿瘤大多是在患者坐位时进行手术。在过去30年中，这种趋势发生了显著变化。例如，日本现在所有手术中有95%是在患者卧位时进行的；在美国和欧洲，这些数字分别为80%和60%。这种全球转向卧位的趋势主要与坐位时静脉空气栓塞的高风险有关。在1999年至2013年期间，第一作者仅采用坐位切除后颅窝肿瘤。在此期间，他进行了606例手术。在患有大/巨大肿瘤的患者（通常是伴有囊肿的毛细胞型星形细胞瘤）中，外科医生经常面临小脑过度牵拉和桥静脉破裂的问题，有时甚至在手术入路区域之外。这种情况要么导致大量失血，要么导致静脉空气栓塞。
因此，从2013年开始，我们开始在小脑半球毛细胞型星形细胞瘤病例中选择性地使用俯卧位。这一初步经验使我们能够评估该手术的手术特点，并将经验应用于更复杂的干预措施。自2016年年中以来，鉴于使用锁孔入路的趋势，我们在第四脑室肿瘤手术中越来越多地使用俯卧位，有时甚至通过钻孔切除肿瘤。自2016年底以来，我们常规使用俯卧位治疗第四脑室的各种肿瘤。在2016年11月至2017年9月期间，第一作者为儿童后颅窝肿瘤进行了113例手术；其中，只有4例手术是在坐位时进行的。因此，在不到一年的时间里，俯卧位已成为我们实践中所有后颅窝肿瘤手术的主要体位。在本文中，我们希望分享我们关于使用俯卧位的实用建议，以及没有在患者俯卧位下进行后颅窝手术经验的医生应考虑的俯卧位的优缺点。
