Signorelli Francesco, Costantini Alessandro, Stumpo Vittorio, Conforti Giulio, Olivi Alessandro, Visocchi Massimiliano
Institute of Neurosurgery, Catholic University School of Medicine, Rome, Italy.
Institute of Radiology, Catholic University School of Medicine, Rome, Italy.
Acta Neurochir Suppl. 2019;125:51-55. doi: 10.1007/978-3-319-62515-7_8.
More than 100 years after the first description by Kanavel of a transoral-transpharyngeal approach to remove a bullet impacted between the atlas and the clivus [1], the transoral approach (TOA) still represents the 'gold standard' for surgical treatment of a variety of conditions resulting in anterior craniocervical compression and myelopathy [2, 3]. Nevertheless, some concerns-such as the need for a temporary tracheostomy and a postoperative nasogastric tube, and the increased risk of infection resulting from possible bacterial contamination and nasopharyngeal incompetence [4-6]-led to the introduction of the endoscopic endonasal approach (EEA) by Kassam et al. [7] in 2005. Although this approach, which was conceived to overcome those surgical complications, soon gained wide attention, its clear predominance over the TOA in the treatment of craniovertebral junction (CVJ) pathologies is still a matter of debate [3]. In recent years, several papers have reported anatomical studies and surgical experience with the EEA, targeting different areas of the midline skull base, from the olfactory groove to the CVJ [8-19]. Starting from these preliminary experiences, further anatomical studies have defined the theoretical (radiological) and practical (surgical) craniocaudal limits of the endonasal route [20-25]. Our group has done the same for the TOA [26, 27] and compared the reliability of the radiological and surgical lines of the two different approaches. Very recently, a cadaver study, with the aid of neuronavigation, tried to define the upper and lower limits of the endoscopic TOA [28].
在卡纳韦尔首次描述经口-经咽入路以取出寰椎和斜坡之间的嵌顿子弹[1]100多年后，经口入路（TOA）仍然是治疗导致前颅颈压迫和脊髓病的各种病症的手术治疗“金标准”[2,3]。然而，一些问题，如需要临时气管切开术和术后鼻胃管，以及由于可能的细菌污染和鼻咽功能不全导致的感染风险增加[4-6]，促使卡萨姆等人在2005年引入了鼻内镜下鼻内入路（EEA）[7]。尽管这种旨在克服这些手术并发症的入路很快受到广泛关注，但其在治疗颅颈交界区（CVJ）病变方面相对于TOA的明显优势仍存在争议[3]。近年来，有几篇论文报道了针对从中线颅底的不同区域，从嗅沟到CVJ的EEA的解剖学研究和手术经验[8-19]。从这些初步经验出发，进一步的解剖学研究确定了鼻内入路的理论（放射学）和实际（手术）头尾界限[20-25]。我们的团队对TOA也做了同样的工作[26,27]，并比较了两种不同入路的放射学和手术线的可靠性。最近，一项尸体研究借助神经导航试图确定内镜下TOA的上下限[28]。
