扩大经蝶入路显微解剖与临床应用研究

发布时间：2018-01-07 21:06

本文关键词：扩大经蝶入路显微解剖与临床应用研究　出处：《复旦大学》2009年博士论文　论文类型：学位论文

【摘要】： 第一部分解剖学研究目的评估不同方式扩大经蝶入路与Le fortⅠ型上颌骨截骨术(Le fort I osteotomy，LFO)对于颅底中线结构解剖学暴露范围。方法成人头颅标本9例，在神经导航的指引下分别经鼻-鼻中隔入路(Transnasal septum approach，TNSA)、经唇下-鼻中隔入路(Sublabial septum approach，SLSA)、改良经唇下入路(Modified Sublabial approach，MSLA)扩大经蝶入路和LFO，显微镜下观察每种术式所能暴露的颅底重要结构，并借助神经导航仪测量上述各种方式向前颅底、双侧海绵窦和斜坡方向暴露的范围。对于测量结果运用统计学分析，以明确不同方式暴露距离的不同有无统计学意义。结果对于前颅底结构的暴露，TNA与SLA无明显差别，MSLA和LFO均有不同程度的扩大，其中LFO更为明显；在双侧海绵窦和斜坡方向上，上述方式的暴露范围具有统计学意义上的差别，结合实际测得的结果，TNA＜SLA＜MSLA＜LFO。同时MSLA和LFO中，均可将垂体抬起打开三脑室底部，LFO还可暴露寰椎前弓。结论不同方式的扩大经蝶入路和Le fortⅠ型上颌骨截骨术都能在一定程度上暴露颅底中线结构，较侧方入路更为直接，对正常组织损伤小。由于暴露范围的差别，临床中要根据病灶位置选择最佳入路。MSLA虽较LFO显露范围小，但对于大多数颅底中线部位肿瘤而言其暴露范围已经足够，且操作相对简单、对正常结构影响小，但临床效果有待进一步验证。第二部分临床应用研究目的明确不同方式扩大经蝶入路临床适应证及并发症的防治。方法收集2007年6月至2009年2月于本中心行采用扩大经蝶入路显微手术切除颅底中线部位肿瘤病例21例(包括斜坡脊索瘤11例，侵犯海绵窦区垂体大腺瘤9例，鞍结节脑膜瘤1例)。术前采用虚拟现实技术，重建肿瘤及颅底结构(包括重要神经、血管)，并在虚拟现实环境下模拟手术入路，选择最佳手术路径。手术均行神经导航指引，部分结合术中MRI，以明确肿瘤与周围重要结构的关系以及切除程度。统计分析其手术方式、手术效果及并发症防治、预后等方面数据，以期验证解剖学研究所得出的结论，并进一步规范扩大经蝶入路的手术适应症和并发症的防治方法。结果结合术中神经导航图像、iMRI影像学资料以及术后复查头部MRI，证实有11例斜坡脊索瘤中，3例肿瘤全切除，5例达到次全切除(切除比例＞90％)，3例大部切除(切除比例＜90％)；9例侵犯海绵窦区垂体大腺瘤，有5例做到肿瘤全切除，4例达到次全切除(切除比例＞90％)；1例鞍结节脑膜瘤达Simpson I类全切。术后并发症主要为脑脊液漏，发生率约20％(5／21)，经颅底重建及对症处理，均痊愈。术中未发生颈内动脉的损伤。结论不同方式扩大经蝶入路可直接到达颅底中线结构，临床上操作简单、并发症较少，可获得很好的手术效果。在临床应用过程中发现，经鼻中隔入路、经唇下鼻中隔入路和改良经唇下入路在颅底中线结构的暴露范围上还是存在区别的，其结论是与解剖研究内容相一致的。斜坡脊索瘤、侵犯海绵窦区垂体大腺瘤及及鞍结节脑膜瘤，在手术方式的选择上，首先应考虑肿瘤累及范围及不同方式扩大经蝶入路的暴露范围。具体来讲，肿瘤累及前颅底方向时，由于上颌窦后壁及粘膜的阻挡，经鼻入路暴露困难，经唇下入路和改良唇下入路可磨除鼻嵴和部分鼻底骨质，增大手术操作空间；肿瘤侵犯CS时，若仅累及CS内侧壁，可行经鼻入路切除，当肿瘤向CS下壁或外侧壁生长时，采用经唇下入路或改良唇下入路；对于斜坡区域肿瘤，累及中上斜坡者，采用经鼻入路或经唇下入路，对于下斜坡肿瘤，采用改良经唇下入路。 Le fortⅠ型上颌骨截骨术(LFO)可广泛暴露前颅底、海绵窦、整个斜坡直至颅颈交界处，但该术式操作复杂、费时，并发症多，临床应用受到了较大的限制，应用时应严格掌握手术适应症；改良经唇下入路操作简单、并发症少，亦能暴露蝶骨平台到下斜坡区域的广泛空间，临床适应范围更加广泛。再者，选择手术方式时应该考虑到可能的肿瘤性质。不同性质肿瘤的生长方式及预后有着明显区别，手术方式也应“因瘤而异”。扩大经蝶入路术后并发症，，主要是颈内动脉损伤及脑脊液漏，经合理的术中、术后处理，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.

【学位授予单位】：复旦大学
【学位级别】：博士
【学位授予年份】：2009
【分类号】：R782;R322

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