Belykh Evgenii, Onaka Naomi R, Zhao Xiaochun, Cavallo Claudio, Yağmurlu Kaan, Lei Ting, Byvaltsev Vadim A, Preul Mark C, Nakaji Peter
Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA; Department of Neurosurgery, Irkutsk State Medical University, Irkutsk, Russia.
Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
World Neurosurg. 2018 Nov;119:e1-e15. doi: 10.1016/j.wneu.2018.04.218. Epub 2018 Jun 27.
We describe and quantitatively assess minimally invasive keyhole retrosigmoid approaches targeted to the upper, middle, and lower cranial nerve (CN) complexes of the cerebellopontine angle (CPA).
Anatomic dissections were performed on 10 sides of 5 fixed, silicone-injected cadaver heads. Surgical views through various trajectories were assessed in endoscopic videos and 3-dimensional (3D) interactive virtual reality microscope views. Surgical freedom and angles of attack to the proximal and distal areas of CN complexes of the CPA were compared among upper and lower keyholes and conventional retrosigmoid craniotomy using neuronavigation.
Compared with keyholes, the conventional approach had superior surgical freedom to most areas except for the distal CN V, the root of CN VII, and the root of CN IX, where differences were not significant. The conventional retrosigmoid approach provided a larger horizontal angle of attack than either the upper or lower keyholes for all selected areas; however, the vertical angles of attack were not different. Splitting the petrosal fissure resulted in a significant increase in the vertical angle of attack to the root zones of CNs V and VII but not to the distal areas of these nerves or CN IX. Illustrative cases of endoscope-assisted keyhole retrosigmoid approaches for the treatment of trigeminal neuralgia, hemifacial spasm, and glossopharyngeal neuralgia are presented.
Targeted keyhole retrosigmoid approaches require detailed understanding of the 3D anatomy of the CPA to create appropriate locations of corridors, including skin incisions and keyholes. Endoscope assistance complements the standard microsurgical technique by maximizing the visualization and identification of the delicate neurovascular structures.
我们描述并定量评估针对桥小脑角（CPA）上、中、下颅神经（CN）复合体的微创锁孔乙状窦后入路。
对5个固定的、注入硅胶的尸体头部的10侧进行解剖。通过内镜视频和三维（3D）交互式虚拟现实显微镜视图评估各种轨迹的手术视野。使用神经导航比较上、下锁孔及传统乙状窦后开颅术对CPA颅神经复合体近端和远端区域的手术自由度和攻击角度。
与锁孔入路相比，传统入路在大多数区域具有更好的手术自由度，但在CN V远端、CN VII根部和CN IX根部除外，这些区域差异不显著。对于所有选定区域，传统乙状窦后入路提供的水平攻击角度比上或下锁孔入路更大；然而，垂直攻击角度没有差异。劈开岩骨裂导致对CNs V和VII根部区域的垂直攻击角度显著增加，但对这些神经的远端区域或CN IX没有增加。展示了内镜辅助锁孔乙状窦后入路治疗三叉神经痛、面肌痉挛和舌咽神经痛的典型病例。
有针对性的锁孔乙状窦后入路需要详细了解CPA的三维解剖结构，以确定合适的通道位置，包括皮肤切口和锁孔。内镜辅助通过最大化对精细神经血管结构的可视化和识别来补充标准显微外科技术。
