Housepian E M
Clin Neurosurg. 1978;25:556-73. doi: 10.1093/neurosurgery/25.cn_suppl_1.556.
Although many problems may present with unilateral proptosis, a careful clinical investigation can narrow the differential diagnosis to those problems which can be treated best by the neurosurgeon. The primary indication for transcranial exploration is when the pathological process is found to involve both the orbit and the cranial cavity as in all cases of optic nerve glioma, orbital meningioma, encephalocele, and some mucoceles, hemangiomas, aneurysmal bone cysts, and ossifying fibromas. Transcranial exploration may also be indicated for some tumors which crowd the orbital apex, such as, neurofibromas and osteomas; tumors in this location can be more widely exposed and safely dealt with by this route. A prime objective in these cases, however, must be preservation of function with a good cosmetic result. It is of equal importance to be aware that many conditions producing exophthalmos can be cured by direct orbital exploration, radiotherapy, or medical management. Malignant orbital tumors should never be exposed to the cranial cavity by transcranial exploration, whereas, radical exenteration may be curative in some carefully studied cases. Accuracy in clinical diagnosis and the proper selection of treatment modality for conditions in the orbit requires a clear understanding of this regional anatomy. I hope that this brief review of the pertinent microsurgical anatomy of the orbital apical region has helped to substantiate a strong neurosurgical claim to all primary optic nerve tumors; and, incidentally, I hope it provides an explanation for why I sent so many other patients back to Dr. Algernon Reese with the recommendation that transcranial surgery did not seem indicated. The success of this attitude may be attested to by the fact that we performed no unnecessary craniotomies nor did we pass by problems which would have best been treated by transcranial orbital exploration.
虽然许多问题可能表现为单侧眼球突出，但仔细的临床检查可以将鉴别诊断范围缩小到那些神经外科医生治疗效果最佳的问题。经颅探查的主要指征是病理过程累及眼眶和颅腔，如所有视神经胶质瘤、眼眶脑膜瘤、脑膨出以及一些黏液囊肿、血管瘤、动脉瘤性骨囊肿和骨化性纤维瘤病例。经颅探查也适用于一些压迫眶尖的肿瘤，如神经纤维瘤和骨瘤；通过该途径可以更广泛地暴露并安全处理此部位的肿瘤。然而，在这些病例中，一个主要目标必须是在保持良好美容效果的同时保留功能。同样重要的是要意识到，许多导致眼球突出的病症可以通过直接眼眶探查、放疗或药物治疗治愈。恶性眼眶肿瘤绝不应通过经颅探查暴露于颅腔，而在一些经过仔细研究的病例中，根治性眶内容摘除术可能具有治愈效果。准确的临床诊断以及为眼眶病症正确选择治疗方式需要对该区域解剖结构有清晰的了解。我希望对眼眶尖部相关显微外科解剖的简要回顾有助于证实神经外科对所有原发性视神经肿瘤的有力主张；顺便说一句，我希望这能解释为什么我把这么多其他患者送回阿尔杰农·里斯医生那里，并建议似乎不需要进行经颅手术。我们既没有进行不必要的开颅手术，也没有放过那些经颅眼眶探查治疗效果最佳的问题，这一事实或许可以证明这种态度的成功。
