Gilsbach J M, Sure U, Mann W
Department of Neurosurgery, Technical University, Aachen, Germany.
Surg Neurol. 1998 Dec;50(6):563-70. doi: 10.1016/s0090-3019(97)00378-9.
Circumscribed lesions of the hypoglossal canal and of the jugular tubercle still remain a surgical challenge. So far, transpetrosal, transcondylar suboccipital, and extreme lateral approaches have been used to access this region. These surgical procedures bear a high risk for neurological deficits. Therefore, we introduce a new minimally invasive extradural approach to the hypoglossal canal that also allows access to the lateral aspects of the jugular tubercle.
After a paramedian retromastoid skin incision, a basal suboccipital craniectomy lateral to the foramen magnum toward the jugular tubercle is performed. With this approach the occipital condyle and the lateral osseous circumference of the foramen magnum are preserved. Drilling extradurally, the dorsal parts of the jugular tubercle are removed. The exposure is extended downward to the posterior margins of the hypoglossal canal and laterally to the jugular bulb, enabling a minimally invasive exposure of the hypoglossal canal, the lateral aspects of the jugular tubercle, and medial aspects of the jugular bulb.
Using this supracondylar approach, surgical interventions were performed in three patients suffering from a hypoglossal neurinoma, a cholesterol granuloma extending into the jugular tubercle, and a cyst of the hypoglossal canal, respectively. No additional postoperative neurological deficits were seen.
The supracondylar approach seems to be useful to gain access to benign lesions of the hypoglossal canal and of the jugular tubercle to decompress tumors or cysts. In contrast to previously reported techniques this approach has a low risk of morbidity. The surgical field, however, is restricted laterally by the jugular bulb, medially and basally by the residual occipital condyle and dorsally by the dura. Therefore, this approach is useful to remove small lesions or to perform extended biopsies. Radical removal of large tumors seems to be problematic using this approach.
舌下神经管和颈静脉结节的局限性病变仍然是手术挑战。到目前为止，经岩骨、经髁枕下和极外侧入路已被用于进入该区域。这些手术操作存在较高的神经功能缺损风险。因此，我们介绍一种新的微创硬膜外入路至舌下神经管，该入路也可进入颈静脉结节的外侧部分。
在乳突后正中皮肤切口后，在枕骨大孔外侧向颈静脉结节方向进行枕下基底颅骨切除术。采用该入路可保留枕髁和枕骨大孔的外侧骨缘。在硬膜外钻孔，切除颈静脉结节的背侧部分。暴露范围向下延伸至舌下神经管的后缘，向外侧延伸至颈静脉球，从而实现对舌下神经管、颈静脉结节外侧部分和颈静脉球内侧部分的微创暴露。
使用这种髁上入路，分别对3例患有舌下神经鞘瘤、延伸至颈静脉结节的胆固醇肉芽肿和舌下神经管囊肿的患者进行了手术干预。术后未见额外的神经功能缺损。
髁上入路似乎有助于进入舌下神经管和颈静脉结节的良性病变，以减压肿瘤或囊肿。与先前报道的技术相比，该入路的发病风险较低。然而，手术视野在外侧受颈静脉球限制，在内侧和基底受残留枕髁限制，在背侧受硬脑膜限制。因此，该入路有助于切除小病变或进行扩大活检。使用该入路彻底切除大肿瘤似乎存在问题。
