Aversa Antonio, Al-Mefty Ossama
Division of Neurosurgery, National Institute of Cancer, Rio de Janeiro, Brazil.
Department of Neurosurgery, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.
Oper Neurosurg. 2021 Jul 15;21(2):E105-E106. doi: 10.1093/ons/opab126.
Chordoma is not a benign disease. It grows invasively, has a high rate of local recurrence, metastasizes, and seeds in the surgical field.1 Thus, chordoma should be treated aggressively with radical resection that includes the soft tissue mass and the involved surrounding bone that contains islands of chordoma.2-5 High-dose radiation, commonly by proton beam therapy, is administered after gross total resection for long-term control. About half of chordoma cases occupy the cavernous sinus space and resecting this extension is crucial to obtain radical resection. Fortunately, the cavernous sinus proper extension is the easier part to remove and pre-existing cranial nerves deficit has good chance of recovery. As chordomas originate and are always present extradurally (prior to invading the dura), an extradural access to chordomas is the natural way for radical resection without brain manipulation. The zygomatic approach is key to the middle fossa, cavernous sinus, petrous apex, and infratemporal fossa; it minimizes the depth of field and is highly advantageous in chordoma located mainly lateral to the cavernous carotid artery.6-12 This article demonstrates the advantages of this approach, including the mobilization of the zygomatic arch alleviating temporal lobe retraction, the peeling of the middle fossa dura for exposure of the cavernous sinus, the safe dissection of the trigeminal and oculomotor nerves, and total control of the petrous and cavernous carotid artery. Tumor extensions to the sphenoid sinus, sella, petrous apex, and clivus can be removed. The patient is a 30-yr-old who consented for surgery.
脊索瘤并非良性疾病。它呈浸润性生长，局部复发率高，会发生转移，并在手术区域播散。因此，对于脊索瘤应积极采用根治性切除术进行治疗，切除范围包括软组织肿块以及包含脊索瘤岛的受累周围骨质。在大体全切术后，通常采用质子束疗法进行高剂量放疗以实现长期控制。约一半的脊索瘤病例占据海绵窦间隙，切除这一延伸部分对于实现根治性切除至关重要。幸运的是，海绵窦本身的延伸部分较易切除，且术前存在的颅神经功能缺损有较好的恢复机会。由于脊索瘤起源于硬膜外（在侵犯硬膜之前）且始终位于硬膜外，通过硬膜外入路切除脊索瘤是进行根治性切除且不涉及脑部操作的自然方式。颧弓入路是进入中颅窝、海绵窦、岩尖和颞下窝的关键；它可使术野深度最小化，对于主要位于海绵窦段颈内动脉外侧的脊索瘤极为有利。本文展示了该入路的优势，包括颧弓的游离可减轻颞叶牵拉、中颅窝硬膜的剥离以暴露海绵窦、三叉神经和动眼神经的安全解剖以及对岩骨段和海绵窦段颈内动脉的完全控制。向蝶窦、鞍区、岩尖和斜坡的肿瘤延伸部分均可切除。患者为一名30岁同意接受手术的患者。
