Department of Neurological Surgery, Antônio Pedro University Hospital, Fluminense Federal University, Niterói, Rio de Janeiro, Brazil.
Department of Neurological Surgery, The Ohio State University, Columbus, Ohio, USA.
World Neurosurg. 2020 May;137:362. doi: 10.1016/j.wneu.2020.02.026. Epub 2020 Feb 11.
Even for the most experienced neurosurgeons, foramen magnum meningiomas represent a surgical challenge owing to their delicate position surrounded by the brainstem, lower cranial nerves, and vertebral arteries. The treatment goal is gross total resection, but choosing the most appropriate approach is crucial. Basically, 3 surgical approaches are commonly used: posterolateral approach (far-lateral), anterolateral approach (extreme-lateral), and posterior midline approach. However, over the years, skull base surgery has evolved from standard open craniotomies to the use of microscopes and, more recently, to the development of endoscopic techniques. The endoscopic endonasal approach (EEA) permits a direct extradural route without brain retraction and shorter postoperative recovery. In contrast to the oral route, the soft palate and retropharyngeal soft tissues are preserved, allowing patients to resume a regular diet on the first postoperative day. Despite the advantages, the EEA is yet not widely used for treating foramen magnum meningiomas, even in cases where EEA use is possible. The EEA is feasible especially in cases with no vascular encasements and with a limited inferior extension allowing minimal manipulation of lower cranial nerves. Care must be taken with tumors with a more lateral and caudal extension (below the tip of the odontoid process), when a far lateral approach may be the best approach. In this surgical Video 1, we present the surgical details with a stepwise narrative of the EEA for ventrolateral foramen magnum meningiomas through an illustrative case of a 48-year-old woman. Institutional informed consent was obtained for surgery and publication of this video.
即使对于经验最丰富的神经外科医生来说，由于枕骨大孔脑膜瘤位于脑干、颅神经和椎动脉周围，位置非常精细，因此仍然是一项具有挑战性的手术。治疗目标是实现大体全切除，但选择最合适的手术入路至关重要。基本上，有 3 种常用的手术入路：外侧入路（远外侧入路）、前外侧入路（极外侧入路）和后正中入路。然而，多年来，颅底外科已从标准开颅术发展到使用显微镜，最近又发展到使用内镜技术。内镜经鼻入路（EEA）可在不牵拉脑组织的情况下直接进行硬膜外操作，术后恢复时间更短。与经口入路相比，软腭和咽后软组织得以保留，患者可在术后第 1 天恢复正常饮食。尽管具有这些优势，但 EEA 尚未广泛用于治疗枕骨大孔脑膜瘤，即使在可行 EEA 的情况下也是如此。EEA 尤其适用于无血管包绕且下极延伸有限、允许对颅神经进行最小操作的病例。对于具有更外侧和更尾侧延伸（位于齿状突尖端下方）的肿瘤，需要谨慎处理，此时远外侧入路可能是最佳选择。在这段手术视频 1 中，我们通过一位 48 岁女性患者的病例，展示了 EEA 治疗枕骨大孔腹外侧脑膜瘤的手术细节，并进行了逐步叙述。手术和视频发表获得了机构知情同意。
