Narayan Vinayak, Jumah Fareed, Nanda Anil
Department of Neurosurgery, Rutgers Robert Wood Johnson Medical School and University Hospital, New Brunswick, New Jersey, United States.
J Neurol Surg B Skull Base. 2021 Feb;82(Suppl 1):S22-S24. doi: 10.1055/s-0040-1714405. Epub 2020 Nov 23.
Safe maximal resection is the basic principle of cranial base surgery and the grade of resection is an important factor influencing the prognostic outcome. This operative video highlights the surgical principles and technical nuances in the microsurgical resection of foramen magnum meningioma (FMM). The surgery was performed in a 45-year-old lady who presented with hoarseness of voice and spastic quadriparesis (grade 4/5). On imaging, FMM with mass effect on brainstem and spinal cord was identified. The tumor was gross totally resected through modified far lateral approach with minimal occipital condyle drilling. This video demonstrates the surgical techniques of tumor resection including early devascularization, operating in the arachnoid plane to dissect the neurovascular structures, piecemeal decompression, sharp dissection to separate tumor from lower cranial nerves (LCN), identifying the brainstem veins, and resecting the lesion from tumor-brainstem interface. Postoperatively, she had significant neurological improvement and the magnetic resonance imaging revealed excellent radiological outcome ( Figs. 1 and 2 ). The surgery of FMM is challenging due to the deep surgical corridor, critical location, close proximity with various neurovascular structures, firm consistency, and high vascularity of the tumor. The modified far lateral approach by preserving the occipital condyle may prevent the postoperative incidence of craniovertebral junction instability. The key operative principles to achieve the best surgical outcome include careful dissection along the arachnoid plane, gentle handling of cranial nerves, veins, and perforator vessels, avoidance of traction on brainstem and spinal cord, intraoperative neurophysiological monitoring, proper hemostasis, and meticulous dural closure. The link to the video can be found at: https://youtu.be/1qvAeUmNIUw .
安全的最大程度切除是颅底手术的基本原则，而切除程度是影响预后结果的重要因素。这段手术视频重点展示了枕骨大孔脑膜瘤（FMM）显微手术切除中的手术原则和技术细节。
该手术针对一名45岁女性患者，她表现为声音嘶哑和痉挛性四肢瘫（4/5级）。影像学检查发现FMM对脑干和脊髓有占位效应。通过改良远外侧入路，在尽量减少枕髁钻孔的情况下将肿瘤完全切除。本视频展示了肿瘤切除的手术技巧，包括早期血管离断、在蛛网膜平面操作以分离神经血管结构、逐步减压、锐性分离以使肿瘤与低位颅神经（LCN）分开、识别脑干静脉以及从肿瘤-脑干界面切除病变。术后，她的神经功能有显著改善，磁共振成像显示放射学结果极佳（图1和图2）。
FMM的手术具有挑战性，原因在于手术通道深、位置关键、与各种神经血管结构相邻、质地坚韧且肿瘤血管丰富。保留枕髁的改良远外侧入路可预防颅颈交界区不稳定的术后发生率。实现最佳手术效果的关键手术原则包括沿蛛网膜平面仔细分离、轻柔处理颅神经、静脉和穿支血管、避免牵拉脑干和脊髓、术中神经生理监测、适当止血以及细致的硬脑膜缝合。视频链接可在：https://youtu.be/1qvAeUmNIUw 找到。
