Agosti Edoardo, Alexander A Yohan, Leonel Luciano C P C, Gompel Jamie J Van, Link Michael J, Choby Garret, Pinheiro-Neto Carlos D, Peris-Celda Maria
Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, United States.
Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States.
J Neurol Surg B Skull Base. 2023 Aug 2;85(5):526-539. doi: 10.1055/a-2114-4660. eCollection 2024 Oct.
The clival, paraclival, and craniocervical junction regions are challenging surgical targets. To approach these areas, endoscopic endonasal transclival approaches (EETCAs) and their extensions (far-medial approach and odontoidectomy) have gained popularity as they obviate manipulating and working between neurovascular structures. Although several cadaveric studies have further refined these contemporary approaches, few provide a detailed step-by-step description. Thus, we aim to didactically describe the steps of the EETCAs and their extensions for trainees. Six formalin-fixed cadaveric head specimens were dissected. All specimens were latex-injected using a six-vessel technique. Endoscopic endonasal middle and inferior clivectomies, far-medial approaches, and odontoidectomy were performed. Using angled endoscopes and surgical instruments, an endoscopic endonasal midclivectomy and partial inferior clivectomy were performed without nasopharyngeal tissue disruption. To complete the inferior clivectomy, far-medial approach, and partially remove the anterior arch of C1 and odontoid process, anteroinferior transposition of the Eustachian-nasopharynx complex was required by transecting pterygosphenoidal fissure tissue, but incision in the nasopharynx was not necessary. Full exposure of the craniocervical junction necessitated bilateral sharp incision and additional inferior mobilization of the posterior nasopharynx. Unobstructed access to neurovascular anatomy of the ventral posterior fossa and craniocervical junction was provided. EETCAs are a powerful tool for the skull-base surgeon as they offer a direct corridor to the ventral posterior fossa and craniocervical junction unobstructed by eloquent neurovasculature. To facilitate easier understanding of the EETCAs and their extensions for trainees, we described the anatomy and surgical nuances in a didactic and step-by-step fashion.
斜坡、斜坡旁及颅颈交界区是具有挑战性的手术靶点。为了到达这些区域，鼻内镜下经斜坡入路（EETCAs）及其扩展术式（远内侧入路和齿状突切除术）因其避免了在神经血管结构之间进行操作而受到欢迎。尽管一些尸体研究进一步完善了这些现代术式，但很少有研究提供详细的分步描述。因此，我们旨在为学员详细讲解EETCAs及其扩展术式的步骤。 解剖了6个用福尔马林固定的尸体头部标本。所有标本均采用六血管技术进行乳胶注射。进行了鼻内镜下经鼻斜坡中下部切除术、远内侧入路和齿状突切除术。 使用成角内镜和手术器械，在不破坏鼻咽组织的情况下进行了鼻内镜下经鼻斜坡中部切除术和部分斜坡下部切除术。为了完成斜坡下部切除术、远内侧入路并部分切除C1前弓和齿状突，需要通过横断翼蝶裂组织将咽鼓管 - 鼻咽复合体向前下移位，但无需在鼻咽部做切口。要充分暴露颅颈交界区，需要双侧锐性切开并进一步向下移动鼻咽后部。这样就可以无障碍地显露后颅窝腹侧和颅颈交界区的神经血管解剖结构。 EETCAs是颅底外科医生的有力工具，因为它们提供了一条直接通向腹侧后颅窝和颅颈交界区的通道，且不受重要神经血管的阻碍。为了便于学员更容易理解EETCAs及其扩展术式，我们以循序渐进、便于教学的方式描述了解剖结构和手术细节。
