Ohata Hiroki, Goto Takeo, Nagm Alhusain, Kannepalli Narasinga Rao, Nakajo Kosuke, Morisako Hiroki, Goto Hiroyuki, Uda Takehiro, Kawahara Shinichi, Ohata Kenji
1Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Japan.
2Department of Neurosurgery, Al-Azhar University Faculty of Medicine-Nasr City, Cairo, Egypt.
J Neurosurg. 2019 May 3;133(1):135-143. doi: 10.3171/2019.2.JNS183278. Print 2020 Jul 1.
The endoscopic endonasal approach (EEA) for skull base tumors has become an important topic in recent years, but its use, merits, and demerits are still being debated. Herein, the authors describe the nuances and efficacy of the endoscopic endonasal extradural posterior clinoidectomy for maximal tumor exposure.
The surgical technique included extradural posterior clinoidectomy following lateral retraction of the paraclival internal carotid artery and extradural pituitary transposition. In cases with prominent posterior clinoid process, a midline sellar dura cut was added to facilitate extradural exposure. Forty-four consecutive patients, in whom this technique was performed between 2016 and 2018 at Osaka City University Hospital, were reviewed. The pathology included 19 craniopharyngiomas, 7 chordomas, 6 meningiomas, 6 pituitary adenomas, 4 chondrosarcomas, and 2 miscellaneous. Utilization and effectiveness of this approach were further demonstrated with neuroimaging.
Extradural posterior clinoidectomies were successfully applied in all patients without permanent neurovascular injury and with better maneuverability and greater resection rate of the tumors. Four patients experienced transient postoperative abducens nerve paresis, and 1 patient experienced transient postoperative oculomotor nerve paresis; however, the patients with deficits recovered within 3 months. On radiological examination, the surgical field was 2.2 times wider in cases with bilateral posterior clinoidectomy than in cases without posterior clinoidectomy.
The extended EEA with extradural posterior clinoidectomy creates an extra working space and allows adequate accessibility with safe surgical maneuverability to remove tumors that extend behind the posterior clinoid and dorsum sellae.
近年来，鼻内镜经鼻入路（EEA）治疗颅底肿瘤已成为一个重要课题，但其应用、优点和缺点仍存在争议。在此，作者描述了经鼻内镜硬膜外后床突切除术在最大程度暴露肿瘤方面的细微差别和疗效。
手术技术包括在海绵窦旁颈内动脉向外侧牵开后进行硬膜外后床突切除术和硬膜外垂体移位术。对于后床突突出的病例，增加蝶鞍中线硬脑膜切开以利于硬膜外暴露。回顾了2016年至2018年在大阪市立大学医院连续接受该技术治疗的44例患者。病理类型包括19例颅咽管瘤、7例脊索瘤、6例脑膜瘤、6例垂体腺瘤、4例软骨肉瘤和2例其他肿瘤。通过神经影像学进一步证明了该入路的应用和有效性。
所有患者均成功实施了硬膜外后床突切除术，无永久性神经血管损伤，手术操作更灵活，肿瘤切除率更高。4例患者术后出现短暂性外展神经麻痹，1例患者术后出现短暂性动眼神经麻痹；然而，有神经功能缺损 的患者在3个月内恢复。影像学检查显示，双侧后床突切除术患者的术野比未行后床突切除术患者宽2.2倍。
经鼻内镜扩展入路联合硬膜外后床突切除术可创造额外的工作空间，在安全的手术操作下充分暴露术野，以切除延伸至后床突和鞍背后方的肿瘤。
