本文關鍵詞：擴大經(jīng)蝶入路顯微解剖與臨床應用研究　出處：《復旦大學》2009年博士論文　論文類型：學位論文

  更多相關文章： 擴大經(jīng)蝶入路 顱底外科 神經(jīng)導航 虛擬現(xiàn)實技術 神經(jīng)解剖 臨床應用

【摘要】： 第一部分解剖學研究 目的評估不同方式擴大經(jīng)蝶入路與Le fortⅠ型上頜骨截骨術(Le fort I osteotomy，LFO)對于顱底中線結構解剖學暴露范圍。 方法成人頭顱標本9例，在神經(jīng)導航的指引下分別經(jīng)鼻-鼻中隔入路(Transnasal septum approach，TNSA)、經(jīng)唇下-鼻中隔入路(Sublabial septum approach，SLSA)、改良經(jīng)唇下入路(Modified Sublabial approach，MSLA)擴大經(jīng)蝶入路和LFO，顯微鏡下觀察每種術式所能暴露的顱底重要結構，并借助神經(jīng)導航儀測量上述各種方式向前顱底、雙側海綿竇和斜坡方向暴露的范圍。對于測量結果運用統(tǒng)計學分析，以明確不同方式暴露距離的不同有無統(tǒng)計學意義。 結果對于前顱底結構的暴露，TNA與SLA無明顯差別，MSLA和LFO均有不同程度的擴大，其中LFO更為明顯；在雙側海綿竇和斜坡方向上，上述方式的暴露范圍具有統(tǒng)計學意義上的差別，結合實際測得的結果，TNA＜SLA＜MSLA＜LFO。同時MSLA和LFO中，均可將垂體抬起打開三腦室底部，LFO還可暴露寰椎前弓。 結論不同方式的擴大經(jīng)蝶入路和Le fortⅠ型上頜骨截骨術都能在一定程度上暴露顱底中線結構，較側方入路更為直接，對正常組織損傷小。由于暴露范圍的差別，臨床中要根據(jù)病灶位置選擇最佳入路。MSLA雖較LFO顯露范圍小，但對于大多數(shù)顱底中線部位腫瘤而言其暴露范圍已經(jīng)足夠，且操作相對簡單、對正常結構影響小，但臨床效果有待進一步驗證。 第二部分臨床應用研究 目的明確不同方式擴大經(jīng)蝶入路臨床適應證及并發(fā)癥的防治。 方法收集2007年6月至2009年2月于本中心行采用擴大經(jīng)蝶入路顯微手術切除顱底中線部位腫瘤病例21例(包括斜坡脊索瘤11例，侵犯海綿竇區(qū)垂體大腺瘤9例，鞍結節(jié)腦膜瘤1例)。術前采用虛擬現(xiàn)實技術，重建腫瘤及顱底結構(包括重要神經(jīng)、血管)，并在虛擬現(xiàn)實環(huán)境下模擬手術入路，選擇最佳手術路徑。手術均行神經(jīng)導航指引，部分結合術中MRI，以明確腫瘤與周圍重要結構的關系以及切除程度。統(tǒng)計分析其手術方式、手術效果及并發(fā)癥防治、預后等方面數(shù)據(jù)，以期驗證解剖學研究所得出的結論，并進一步規(guī)范擴大經(jīng)蝶入路的手術適應癥和并發(fā)癥的防治方法。 結果結合術中神經(jīng)導航圖像、iMRI影像學資料以及術后復查頭部MRI，證實有11例斜坡脊索瘤中，3例腫瘤全切除，5例達到次全切除(切除比例＞90％)，3例大部切除(切除比例＜90％)；9例侵犯海綿竇區(qū)垂體大腺瘤，有5例做到腫瘤全切除，4例達到次全切除(切除比例＞90％)；1例鞍結節(jié)腦膜瘤達Simpson I類全切。術后并發(fā)癥主要為腦脊液漏，發(fā)生率約20％(5／21)，經(jīng)顱底重建及對癥處理，均痊愈。術中未發(fā)生頸內(nèi)動脈的損傷。 結論不同方式擴大經(jīng)蝶入路可直接到達顱底中線結構，臨床上操作簡單、并發(fā)癥較少，可獲得很好的手術效果。在臨床應用過程中發(fā)現(xiàn)，經(jīng)鼻中隔入路、經(jīng)唇下鼻中隔入路和改良經(jīng)唇下入路在顱底中線結構的暴露范圍上還是存在區(qū)別的，其結論是與解剖研究內(nèi)容相一致的。 斜坡脊索瘤、侵犯海綿竇區(qū)垂體大腺瘤及及鞍結節(jié)腦膜瘤，在手術方式的選擇上，首先應考慮腫瘤累及范圍及不同方式擴大經(jīng)蝶入路的暴露范圍。具體來講，腫瘤累及前顱底方向時，由于上頜竇后壁及粘膜的阻擋，經(jīng)鼻入路暴露困難，經(jīng)唇下入路和改良唇下入路可磨除鼻嵴和部分鼻底骨質，增大手術操作空間；腫瘤侵犯CS時，若僅累及CS內(nèi)側壁，可行經(jīng)鼻入路切除，當腫瘤向CS下壁或外側壁生長時，采用經(jīng)唇下入路或改良唇下入路；對于斜坡區(qū)域腫瘤，累及中上斜坡者，采用經(jīng)鼻入路或經(jīng)唇下入路，對于下斜坡腫瘤，采用改良經(jīng)唇下入路。 Le fortⅠ型上頜骨截骨術(LFO)可廣泛暴露前顱底、海綿竇、整個斜坡直至顱頸交界處，但該術式操作復雜、費時，并發(fā)癥多，臨床應用受到了較大的限制，應用時應嚴格掌握手術適應癥；改良經(jīng)唇下入路操作簡單、并發(fā)癥少，亦能暴露蝶骨平臺到下斜坡區(qū)域的廣泛空間，臨床適應范圍更加廣泛。 再者，選擇手術方式時應該考慮到可能的腫瘤性質。不同性質腫瘤的生長方式及預后有著明顯區(qū)別，手術方式也應“因瘤而異”。 擴大經(jīng)蝶入路術后并發(fā)癥，，主要是頸內(nèi)動脈損傷及腦脊液漏，經(jīng)合理的術中、術后處理，可得到很好的控制。
[Abstract]:The first part anatomic study
Objective to evaluate the anatomical exposure of the transsphenoidal approach and Le Fort I maxillary osteotomy (Le Fort I osteotomy, LFO) to the middle line of the skull base in different ways.
Methods 9 cases of adult cadaver heads, under the guidance of neuronavigation in nasal septum respectively - Approach (Transnasal septum approach, TNSA), via sublabio septal approach (Sublabial septum approach, SLSA), modified sublabial approach (Modified Sublabial, approach, MSLA) and the extended transsphenoidal approach LFO, observe the important structure of base each operation can be exposed under the microscope, and by measuring the neuronavigation in various ways to expose the bilateral anterior skull base, the scope of the cavernous sinus and clivus direction. The measurement results by statistical analysis, to determine the different exposure distance difference has no statistical significance.
The exposure of the anterior skull base structure, no obvious difference between TNA and SLA, MSLA and LFO have different degrees of expansion, of which LFO is more obvious; in the cavernous sinus and slope direction, the range of exposure modes have significant difference, combined with the actual measured results, TNA < SLA < MSLA < at the same time, LFO. MSLA and LFO, can be lifted to open the bottom of the three ventricle pituitary, LFO also can expose the anterior arch of the atlas.
Conclusion the different ways of expanding transsphenoidal jaw osteotomy are road and Le Fort type can expose midline skull base structure in a certain extent, a lateral approach is more direct injury to normal tissue. Due to the exposure range difference, according to the location of the lesion in the clinic to choose the best approach.MSLA is LFO the range of exposure small, but for the most part of the midline skull base tumor exposure range is sufficient, and the operation is relatively simple and has little influence on the normal structure, but the clinical effects need to be further verified.
The second part clinical application research
Objective to clarify the clinical indications of transsphenoidal approach and the prevention and treatment of complications in different ways.
Methods from June 2007 to February 2009 in the center line of the extended transsphenoidal approach microsurgery resection of midline skull base in 21 cases (including 11 cases of clival chordoma, invading the cavernous sinus region of pituitary adenoma in 9 cases, 1 cases of tuberculum sellae meningiomas). Virtual reality technology used before surgery, reconstruction of tumor and skull base structure (including important nerves and blood vessels), and in the virtual reality environment simulation approach, the selection of optimal operation path. All patients were treated with neuronavigation combined with intraoperative guidance, part MRI, to clarify the relationship between tumor and surrounding structures and removed. Statistical analysis of the operation mode, operation effect and complications prevention, prognosis and other aspects conclusion the data, in order to verify the anatomical study, and further standardize the extended transsphenoidal surgery to control methods and complications.
The combination of neural navigation image data in the operation, and postoperative head MRI iMRI imaging confirmed 11 cases of clival chordoma, 3 cases of tumor resection, 5 cases of subtotal resection (resection rate > 90%), 3 cases of subtotal resection (resection rate < 90%); 9 cases of cavernous sinus invasion large pituitary adenoma, 5 cases do tumor resection achieved in 4 cases subtotal (resection ratio > 90%); 1 cases of tuberculum sellae meningiomas of Simpson I resection. The postoperative complications included cerebrospinal fluid leakage, the incidence rate of about 20% (5 / 21), the reconstruction of the skull base and symptomatic treatment were cured. The internal carotid artery. There were no injuries.
Conclusion different extended transsphenoidal approach can directly reach the midline skull base structure, clinical has the advantages of simple operation, less complications, surgery can achieve good effect. In clinical application, nasal septal approach, the lip of nasal septum approach and modified sublabial approach in cranial bottom exposed range line the structure of the differences still exist, the conclusion is consistent with the anatomical research content.
Clival chordoma, invading the cavernous sinus region of large pituitary adenoma and tuberculum sellae meningiomas, on the choice of surgical approach, should first consider the range of tumors and different ways to expand the range of exposure to transsphenoidal approach. Specifically, tumors involving the anterior skull base direction, because the barrier wall and the mucosa of the maxillary sinus, nasal approach the road difficult exposure by sublabial approach and modified sublabial approach can grind nasal crest and part of nasal bone, increase the operating room; the invasion of CS, if CS only involved the medial wall, feasible with transnasal resection, when the tumor to CS wall or the outer side wall of the growth. The sublabial approach or modified sublabial approach to the clivus tumor;, involving the upper slope, the transnasal approach or the sublabial approach, for the slope under tumor, modified by sublabial approach.
Le Fort I osteotomy (LFO) can be widely exposed to the anterior skull base, cavernous sinus and clivus of the craniovertebral junction, but the operation is complicated, time-consuming, more complications, clinical application has been greatly limited, the application should be strictly controlled indications for surgery; modified sublabial approach is simple also, fewer complications, can expose to extensive space under the sphenoid platform slope area, clinical to adapt to a wider scope.
Moreover, when choosing the operative way, we should take into account the possible tumor characteristics. There are obvious differences between the growth ways and prognosis of the tumors of different natures, and the operative way should also be "different from the tumor".
The complications of enlarging the transsphenoidal approach are mainly the injury of the internal carotid artery and the leakage of the cerebrospinal fluid, which can be well controlled through reasonable operation and postoperative treatment.

【學位授予單位】：復旦大學
【學位級別】：博士
【學位授予年份】：2009
【分類號】：R782;R322

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