Kutin M A, Kadashev B A, Kalinin P L, Fomichev D V, Sharipov O I, Andreev D N, Cherekaev V A, Lasunin N V, Galkin M V, Serova N K, Tropinskaya O F, Zhadenova I V, Kadasheva A B, Belov A I, Okishev D N, Kuchaev A V, Strunina Yu V, Mikhailov N I, Abdilatipov A A, Chernov I V, Ismailov D B, Koval K B, Kutin I M
Burdenko Neurosurgical Center, Moscow, Russia.
Medical Institute of the Peoples' Friendship University of Russia, Moscow, Russia.
Zh Vopr Neirokhir Im N N Burdenko. 2020;84(3):61-73. doi: 10.17116/neiro20208403161.
When removing the meningiomas of the sellar region, there is always a risk of visual impairment for various reasons, in particular, as a result of traction damage to the optic nerve. Decompression of the optic canal increases nerve mobility during tumor manipulation. In cases of meningioma growing into the canal, its decompression often seems necessary.
Evaluation of the effectiveness and risks of performing decompression of the optic canal.
The study included patients with meningiomas of the parasellar location, who underwent surgical treatment at the Burdenko Neurosurgical Center for the period from 2001 to 2017. They were divided into two groups - main and control. The main group consisted of 129 patients who underwent decompression of the optic nerve canals when the tumor was removed. The tumor matrix in this group was most often located in the region of the tuberum sellae, supradiaphragmally, in the region of the anterior clinoid process and the optic canal. In 31 cases, decompression was bilateral - during one operation and using one access in 27 patients; in 4 cases, the decompression of the second canal was delayed for 1.5-3 months after the first operation. 160 decompressions were performed by the intradural and 7 - by extradural methods. During intradural decompression, the roof of the optic canal was resected, and during extradural decompression, the lateral wall of the canal was trephined. The control group consisted of 308 patients who did not undergo canal decompression when the tumor was removed. It included meningiomas with a predominant location of the matrix in the area of the tuberclum and diaphragm of the sella. Tumors in both groups were removed according to the same principles (matrix coagulation, mainly the gradual removal of the tumor, the use of ultrasonic aspirator, a situational decision on the radicality of the operation, etc.). The main difference between operations in these two groups was only canal related algorithms (with or without its trepanation), as well as the probable prevalence of significant lateral tumor growth in cases with canal trepanation. Visual functions in the «primary» group were evaluated before and after operations with trepanation of the canal depending on various factors - the initial state of vision and the radicality of the tumor excision, including removal from the canal. The differences in the postoperative dynamics of vision in the main and control groups were studied. The primary data processing was carried out using the program MSExcel. Secondary statistical processing was carried out using the program Statistica. To assess the statistical significance of differences in the results obtained in the compared patient groups, the Chi-square test was used, and in the case of small groups - the exact Fisher test was applied.
In the main group postoperative vision improvement of varying degrees on the side of trepanation was registered in 36.9% (59 out of 160) cases, no vision changes were found in 36.9% (59 out of 160), and in 26,2% (42 out of 160) the eyesight deteriorated. If preserving vision is attributed to a satisfactory result, then in general the results of these operations should be considered good. A comparative study of the results of removal of meningiomas with trepanation of the canals (main group) or without it (control group) was carried out among patients with the most critical vision situation (visual acuity 0.1 and below, up to only light perception). These groups are comparable in the number of observations - 62 and 73 respectively. The predominance of cases with improved vision in the main group compared with the control group (50.0% versus 38.36%) and a lower incidence of vision impairment (22.58% versus 34.25%) were found. However, the revealed differences are statistically unreliable and make it possible for us to talk only about the trend. The complications associated with trepanation of the canal include mechanical damage to the nerve by the drill. In our series of observations, there was only 1 case of abrasion of the nerve surface with the burr, which did not lead to a significant visual impairment. With the intradural method of trepanation in the area of the medial wall of the canal, the sphenoid sinus may open (in our series, in 34 cases out of 160 trepanations). Immediately closure of these defects was performed by various auto- and allomaterials in various combinations (pericranium, fascia, muscle fragment, hemostatic materials, and fibrin-thrombin glue). A true complication - CSF rhinorrhea liquorrhea developed in only one case, which required transnasal plastic surgery of the CSF fistula using a mucoperiostal flap.
在切除鞍区脑膜瘤时，由于各种原因，尤其是视神经受到牵拉损伤，始终存在视力受损的风险。视神经管减压可增加肿瘤手术操作过程中神经的活动度。对于生长入神经管的脑膜瘤病例，通常似乎有必要进行减压。
评估视神经管减压的有效性和风险。
本研究纳入了2001年至2017年期间在布尔坚科神经外科中心接受手术治疗的鞍旁脑膜瘤患者。他们被分为两组——主要组和对照组。主要组由129例患者组成，这些患者在切除肿瘤时接受了视神经管减压。该组肿瘤基质最常位于鞍结节区域、鞍隔上方、前床突区域和视神经管。在31例中，减压是双侧的——在一次手术中进行，27例患者采用单一入路；4例患者在第一次手术后1.5 - 3个月延迟进行第二根管的减压。160次减压采用硬膜内方法，7次采用硬膜外方法。硬膜内减压时，切除视神经管顶壁；硬膜外减压时，对神经管侧壁进行环钻。对照组由308例患者组成，这些患者在切除肿瘤时未进行神经管减压。该组包括基质主要位于鞍结节和鞍隔区域的脑膜瘤。两组肿瘤均按照相同原则切除（肿瘤基质凝固，主要是逐步切除肿瘤，使用超声吸引器，根据具体情况决定手术的根治程度等）。这两组手术的主要区别仅在于与神经管相关的操作步骤（是否进行环钻），以及在进行环钻的病例中可能更普遍存在的肿瘤显著向外侧生长的情况。根据各种因素——视力的初始状态和肿瘤切除的根治程度，包括从神经管内切除，对“主要”组患者在进行神经管环钻手术前后的视觉功能进行评估。研究了主要组和对照组术后视力变化的差异。原始数据处理使用MSExcel程序。二次统计处理使用Statistica程序。为评估所比较患者组结果差异的统计学意义，采用卡方检验，对于小样本组则应用精确的费舍尔检验。
在主要组中，36.9%（160例中的59例）的病例在环钻侧术后视力有不同程度改善，36.9%（160例中的59例）未发现视力变化，26.2%（160例中的42例）视力下降。如果将保留视力归因于满意的结果，那么总体而言这些手术的结果应被认为是良好的。在视力状况最危急（视力0.1及以下，直至仅存光感）的患者中，对进行神经管环钻（主要组）或未进行环钻（对照组）切除脑膜瘤的结果进行了比较研究。这些组的观察数量相当——分别为62例和73例。发现主要组视力改善的病例占比高于对照组（50.0%对38.36%），视力损害的发生率较低（22.58%对34.25%）。然而，所揭示的差异在统计学上不可靠，我们只能说存在这种趋势。与神经管环钻相关的并发症包括钻头对神经的机械损伤。在我们的一系列观察中，仅有1例神经表面被磨钻擦伤，未导致明显视力损害。采用硬膜内环钻方法在神经管内侧壁区域操作时，可能会打开蝶窦（在我们的系列中，160次环钻中有34例）。立即使用各种自体和异体材料以不同组合（颅骨膜、筋膜、肌肉碎片、止血材料和纤维蛋白 - 凝血酶胶）封闭这些缺损。仅1例出现了真正的并发症——脑脊液鼻漏，这需要使用黏膜骨膜瓣对脑脊液瘘进行经鼻整形手术。
