本文關(guān)鍵詞： 改良額底入路 鞍結(jié)節(jié)腦膜瘤 手術(shù)　出處：《瀘州醫(yī)學(xué)院》2014年碩士論文　論文類(lèi)型：學(xué)位論文

【摘要】：目的：初步探討用“改良額底入路方式”來(lái)切除鞍結(jié)節(jié)腦膜瘤的臨床效果：如患者術(shù)后有無(wú)癲癇發(fā)作、垂體功能低下、尿崩、額紋消失、顳肌萎縮、嗅神經(jīng)損傷等，以及腫瘤切除程度，腫瘤復(fù)發(fā)情況。方法：選擇我科2010年12月至2013年12月收治的鞍結(jié)節(jié)腦膜瘤患者31例，采取“改良額底入路方式”來(lái)切除腫瘤。該手術(shù)方式術(shù)前由磁共振確定腫瘤大小及位置，大致確定額竇大小及體表投影，初步確定骨瓣位置，根據(jù)骨瓣位置再確定頭皮切口線(xiàn)位置。耳前切口應(yīng)注意避讓面神經(jīng)及顳淺動(dòng)脈主干。顱骨鉆孔點(diǎn)不選常規(guī)的“關(guān)鍵孔”(額顴縫后5mm、上7mm)點(diǎn)，而選取我們采用的“改良額底入路方式”的“美容孔”點(diǎn)。“美容孔”點(diǎn)通常選擇在骨瓣外側(cè)邊中點(diǎn)以后或者骨瓣后邊中點(diǎn)以外的范圍內(nèi)，多選擇在該兩邊的交點(diǎn)處。額竇大者骨瓣適當(dāng)偏外、上，占位偏鞍區(qū)后上者骨瓣前后徑適當(dāng)增大，并盡量靠近中線(xiàn)，以利于術(shù)中經(jīng)縱裂入路，占位橫徑大者可適當(dāng)增大骨瓣橫徑，必要時(shí)在矢狀竇上顱骨鉆孔，跨過(guò)矢狀竇1至2cm開(kāi)骨瓣。骨瓣外緣不超過(guò)顳肌在額部的附著處，也不超過(guò)額顳骨交界的轉(zhuǎn)角處，原則上盡量避讓額竇，不能避讓者盡量減少打開(kāi)的范圍，但應(yīng)以充分暴露病變?yōu)榍疤�，骨瓣前界盡量低，以能用銑刀銑下為限，如此銑下的骨瓣額底暴露充分，通常不需要再磨除額底顱骨，術(shù)中額竇開(kāi)放用艾利克消毒，用薄層骨蠟封閉竇口。顯微鏡下切開(kāi)視神經(jīng)、頸內(nèi)動(dòng)脈和鞍上池蛛網(wǎng)膜，以利于暴露腫瘤。通常從腫瘤側(cè)前方或者正前方前顱底處開(kāi)始切除腫瘤，向鞍結(jié)節(jié)方向發(fā)展，留出與雙側(cè)視神經(jīng)、頸內(nèi)動(dòng)脈的安全距離。待切除部分腫瘤減壓及切斷腫瘤大部分血供后再小心分離切除神經(jīng)、血管側(cè)腫瘤，切除腫瘤根部腦膜，磨除受侵犯的顱骨，并行顱底重建。結(jié)果：31例患者手術(shù)順利，均康復(fù)出院。術(shù)后隨訪(fǎng)1至2年，4例術(shù)前有癲癇發(fā)作患者，未再有癲癇發(fā)作，其余患者無(wú)癲癇發(fā)作；無(wú)垂體功能低下、尿崩病例；無(wú)額紋消失病例；無(wú)顳肌萎縮患者。有5例患者術(shù)側(cè)嗅神經(jīng)斷裂。31例患者術(shù)前共有48只眼視力下降，術(shù)后有46只眼視力明顯改善，有1只眼視力無(wú)明顯變化，1只眼視力下降。31例患者中，simpsonⅠ級(jí)切除25例，其中有1例于術(shù)后2年復(fù)發(fā)；simpsonⅡ級(jí)切除5例，其中有1例于術(shù)后1.5年時(shí)復(fù)發(fā)，，simpsonⅢ級(jí)切除1例，隨訪(fǎng)2年，殘余腫瘤無(wú)明顯變化。結(jié)論：改良額底入路切除鞍結(jié)節(jié)腦膜瘤具有骨瓣選擇靈活，腫瘤暴露充分、切除安全、徹底，并發(fā)癥少等優(yōu)點(diǎn)。
[Abstract]:Objective: to explore the clinical effect of "modified frontal approach" for the resection of meningioma of Sellar tubercle, such as epilepsy, hypophysis, collapse of urine, disappearance of frontal stria, atrophy of temporal muscle, injury of olfactory nerve, and so on. Methods: from December 2010 to December 2013, 31 patients with tuberculum sellae meningioma were selected. A modified frontal approach was adopted to remove the tumor. Before operation, the size and location of the tumor were determined by MRI, the size of the frontal sinus and the projection of the body surface were roughly determined, and the position of the bone flap was preliminarily determined. According to the position of bone flap, the position of incision line of scalp should be determined. Attention should be paid to avoiding facial nerve and main trunk of superficial temporal artery in anterior ear incision. And we choose the "beauty hole" point of the "modified frontal approach". The "beauty hole" point is usually selected in the range beyond the midpoint of the lateral edge of the bone flap or beyond the midpoint of the posterior edge of the bone flap. The anterior and posterior diameter of the bone flap of the greater frontal sinus and the posterior region of the Sellar region were increased and as close to the midline as possible, so as to facilitate the translongitudinal fissure approach during the operation. If the transverse diameter of the bone mass is large, the transverse diameter of the bone flap may be increased appropriately, and the bone flap may be drilled into the superior sagittal sinus if necessary, and the bone flap should be opened across the sagittal sinus 1 to 2 cm. The outer edge of the bone flap does not exceed the attachment of the temporal muscle in the frontal part or the corner of the frontotemporal bone junction. In principle, the frontal sinus should be avoided as far as possible, and those who cannot avoid it should minimize the scope of opening, but the premise should be full exposure of the lesion, and the anterior boundary of the bone flap should be as low as possible to the extent that it can be milled with a milling cutter, so that the face bottom of the bone flap can be milled to the full extent. There is usually no need to regrind the skull at the base of the forehead. The frontal sinus is disinfected by Eric during the operation, and the sinus orifice is sealed with a thin layer of bone wax. The optic nerve, the internal carotid artery, and the arachnoid of the suprasellar cistern are cut open under a microscope. Usually from the anterior or anterior cranial base of the tumor, the tumor is removed to the Sellar tubercle, leaving the bilateral optic nerve. The safe distance of the internal carotid artery. After decompression of part of the tumor and cutting off most of the blood supply of the tumor, the nerve is carefully removed, the tumor of the vascular side is removed, the root meninges of the tumor are removed, and the invading skull is removed. Results all 31 cases were successfully operated and discharged from the hospital. 4 patients with epileptic seizures were followed up for 1 to 2 years. There were no epileptic seizures, no seizures, no hypophysis, no urinary avalanche. No frontal stria disappeared, no temporalis atrophy. There were 5 cases of operative olfactory nerve rupture. 31 cases had 48 eyes visual acuity decreased before operation, 46 eyes visual acuity improved obviously after operation. There was no obvious change in visual acuity in 1 eye. Among the 31 cases with visual acuity loss, 25 cases were resected with Simpson 鈪

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