本期为Worldneurosurgery定期连载的《动脉瘤大师级神作--Seven Aneurysms》著作第十一期。本期主要内容为 眶颧入路，《Seven Aneurysms 》系列内容包括 Section I The Tenets：1. 在显微镜下操作；2. 蛛网膜下腔的解剖；3.脑牵拉；4.血管控制；5.临时夹闭；6.永久夹闭；7.夹闭后的检查；8.必要的脑切除；9.术中破裂。Section II The Approaches: 10.翼点入路; 11.眶颧入路; 12.前纵裂入路; 13.远外侧入路。Section IIIThe Seven Aneurysms: 14.后交通动脉瘤; 15.大脑中动脉瘤; 16.前交通动脉瘤; 17.眼动脉动脉瘤; 18.胼周动脉瘤; 19.基底动脉分叉动脉瘤; 20.小脑后下动脉动脉瘤。
【Seven Aneurysms】往期回顾
第六期：动脉瘤手术基本功--永久夹闭
第七期：动脉瘤手术基本功--夹闭后的检查
第八期：动脉瘤手术基本功--必要的脑切除
第九期：动脉瘤手术基本功--术中破裂
第十期：神外入路丨翼点入路
第十一期：Orbitozygomatic Approach--眶颧入路
■ Rationale and Indications--优势和适应证
The orbitozygomatic approach dramatically enhances the standard pterional craniotomy. When a patient’s head is rotated away from the aneurysm and extended, the superior and lateral orbit becomes the roof of the operative corridor. Drilling down the pterion raises this roof, but not nearly as much as removing orbital walls completely and depressing the eye with the dural flap. Zygoma resection increases the mobilization of the temporalis muscle inferiorly, which opens the middle fossa to facilitate mobilization of the temporal lobe in a posterolateral direction. A widened operative corridor improves illumination, reduces brain retraction, and improves maneuverability. A good orbitozygomatic approach gives the neurosurgeon a wide sweep of surgical trajectories ranging from supraorbital to transsylvian to pretemporal to subtemporal. Surgical trajectory can then be tailored to the pathology. In addition, the orbitozygomatic approach extends the upward view of the basilar apex. The line of sight through the microscope intersects with the orbital rim and eye as the viewing target rises in the interpeduncular cistern. The orbitozygomatic approach eliminates the shadow that would otherwise be cast over high-riding basilar apex aneurysms with a pterional approach.
眶颧入路显著扩大了标准翼点入路的范围。当病人头部转向动脉瘤对侧并且过伸时，眶上壁和眶外侧壁成为手术通道的顶部。向翼点深部磨除，抬高了顶部，效果不及完全去除眶壁、将硬脑膜瓣和眼球一起下压。颧弓切除可以将颞肌向下翻转程度更大，这使中颅凹敞开更多，有利于将颞叶向后外侧方向移动。扩大的手术通道改善了视野，减少脑组织牵拉，利于手术操作。好的眶颧入路能够给神经外科医师一个宽广的手术通路，其范围从眶上壁到外侧裂、颞叶前部、颞叶底部。因此手术通路可以根据病变具体情况调整，直到合适。除此之外，眶颧入路使我们从上方观察基底动脉顶端的视野扩大。随着脚间池内观察目标的上移，透过显微镜的视线会与眶缘和眼交叉。在翼点入路中高位的基底动脉尖动脉瘤常常会被眶缘和和眼遮挡视线，而眶颧入路可以消除这个问题。
The orbitozygomatic approach is routinely used for basilar apex aneurysms. It is used selectively in the anterior circulation, primarily with giant and complex aneurysms. Deep bypass procedures benefit from the additional working room of this approach. Enhanced exposure is always advantageous, but it can cause subtle orbital asymmetries that bother some patients. There are other risks, including frontalis nerve injury, pulsatile enophthalmos, orbital entrapment, diplopia from extraocular muscle or nerve injury, blindness, and communication with frontal or ethmoidal sinuses with potential routes of infection or cerebrospinal fluid (CSF) leakage. The incidence of these complications is low.
眶颧入路常规用于基底动脉顶端动脉瘤，选择性用于前循环动脉瘤，特别是巨大、复杂动脉瘤。该入路提供的良好的手术空间，有利于深部血管吻合。增加显露范围常是其优点，但该入路也可导致术后两侧的眼眶轻微不对称，给一些患者造成影响。其他的风险还包括额神经损伤、搏动性眼球内陷、眼眶塌陷、眼外肌或神经损伤导致的复视、失明、额窦或筛窦与颅内交通导致潜在的感染或脑脊液漏。这些并发症的发生率低。
■ Extracranial Dissection--颅外软组织分离
Patient position and skin incision are the same with the orbitozygomatic approach as with the pterional approach. The first difference is the soft tissue dissection to expose the orbitozygomatic unit. The zygoma and orbital rim are ensheathed in two layers of temporalis fascia (Fig. 11.1A), and elevating the superficial layer exposes bone (Fig. 11.1B). Subfascial dissection elevates both fascial layers off the temporalis muscle, and then cuts the deep layer along the posterior edge of the lateral orbital rim and the superior edge of the zygoma, allowing it to mobilize with the superficial layer over the orbitozygomatic unit (Fig. 11.1C,D). Interfascial dissection separates these two layers, leaves the deep layer on the temporalis muscle, and mobilizes just the superficial layer over the lateral orbital rim and zygoma (Fig. 11.1E). The subfascial dissection is simple, fast, and preferred.
在眶颧入路，病人的体位和皮肤切口与翼点入路相同。第一个不同之处在于显露眶颧部时软组织的分离方法。颧弓和眶缘在两层颞筋膜形成的筋膜鞘中（图11.1A），抬起颞浅筋膜，显露颅骨（图11.1B）。筋膜下分离是将两层筋膜抬离颞肌，然后沿着眶外侧缘的后缘及颧弓的上缘切开深层颞筋膜，以便将其和颞浅筋膜一起翻过眶颧部（图11.1C,D）。筋膜间分离是将两层筋膜分开，将深筋膜保留在颞肌上，仅仅是游离眶外侧缘及颧弓上的浅筋膜层（图11.1E）。筋膜下分离简单、迅速、常用。
Both layers of fascia are incised from the zygomatic arch to the superior temporal line along the skin incision, then anteriorly to the keyhole, running 1 cm below the superior temporal line (Fig. 11.1A). Temporalis muscle is not incised because the fascial flap elevates easily when underlying muscle remains attached to the skull. A round-tipped dissector with a sharp edge advanced along the superior edge of the zygoma to the maxilla, and along the posterior edge of the lateral orbital rim to the maxilla, cuts the deep fascial layer and releases the fascial flap. A deep fat pad lies beneath this fascial flap, with an outer layer that mobilizes with the fascial flap and an inner layer that travels under the zygoma with the temporalis muscle. These fat pads are separated with blunt dissection strokes from the zygoma superiorly into this plane.
从颧弓到颞上线，沿皮肤切口，将两层筋膜一起切开，然后在颞上线下1cm向前到达关键孔（图11.1A）。颞肌并不切开，因为当颞肌附着于颅骨时，筋膜瓣容易抬起来。用一个边缘锐利的圆头剥离器沿颧弓上缘向上颌骨分离，沿眶外侧壁后缘向上颌骨分离，切开深层颞筋膜，游离筋膜瓣。深部脂肪垫在该筋膜瓣下面，脂肪垫外层随着筋膜瓣牵开，脂肪垫内层与颞肌一起在颧弓下穿过。从颧弓上钝性分离这些脂肪垫到达该层面。
The fascial flap is elevated to the anterior edge of the lateral orbital rim and the inferior edge of the superior orbital rim, where superficial fascia transitions to periorbita and folds into the orbit. Periorbita is a delicate lining, but when carefully stripped from the orbit’s interior, it retains periorbital fat to better visualize orbital osteotomies. Periorbita can be preserved by beginning the dissection where it is thickest inferolaterally near the inferior orbital fissure, by using side-to-side sweeps with a round-tipped dissector, and by advancing circumferentially along the orbital roof and the lateral wall. This dissection deepens 3 cm toward the orbital apex. Once the orbitozygomatic unit is exposed, the temporalis muscle is mobilized inferiorly.
抬起筋膜瓣达眶外侧缘的前缘和眶上缘的下缘，浅筋膜由此移行为眶骨膜，返折入眶。眶骨膜层易破，但是当我们小心将其自眶内剥离，就可以防止眶周脂肪溢出，从而在良好的视野下进行眶壁的骨质切除。在靠近眶下裂的外下方眶骨膜最厚，由此开始剥离。剥离的方法是用圆头剥离子来回横扫，沿眶顶和眶外侧壁迂回前进，这样就能够起到保护眶骨膜的作用。分离朝向眶尖方向，深3cm。一旦眶颧部显露完成，就将颞肌向下移动。
Fig. 11.1 (opposite) (A) Dissection of the temporalis fascia. The temporalis fascia is incised from the zygomatic arch to the superior temporal line along the skin incision, then anteriorly to the keyhole. The facial flap elevates easily when the muscle is not incised and is left attached to the skull. (B) Anatomy of the temporalis fascia. The zygoma and orbital rim are ensheathed by the fascial layers. The superficial temporalis fascia covers the zygoma and orbital rim, extending inside the orbit where it transitions to the periorbita. Deep temporal fascia envelopes the temporalis muscle in the temporalis fossa, remaining outside the orbit. These fascial layers are separated to expose the orbital walls and zygoma for osteotomies. (C) Subfascial dissection technique leaves the superficial and deep temporalis fascia together over the muscle, but cuts the deep fascia along the posterior edge of the lateral orbital rim and superior edge of zygoma. These cuts release the superficial fascia, allowing it to elevate over the orbital rim and zygoma. (D) The deep layer of the temporalis fascia is incised by following the superior edge of the zygoma to the maxilla (right arrow) with a sharp round knife or dissector. Similarly, the contours of the posterior edge of the lateral orbital rim are followed to the maxilla (left arrow) with a sharp round knife or dissector, joining the other fascial incision. (E) The interfascial dissection technique separates the superficial and the deep fascia over the muscle. The superficial fascia peels over the orbital rim and zygoma, and deep fascia remains around the temporalis muscle. The subfascial dissection is simple, faster, and preferred.
图11.1 （A）分离颞肌筋膜。沿着皮肤切口，从颧弓至颞上线切开颞肌筋膜，然后向前方到关键孔。当颞肌没有切开而是附着于颅骨时，筋膜瓣很容易抬起。（B）颞肌筋膜的解剖。颧弓和眶缘被筋膜层形成的鞘包绕。颞浅筋膜层覆盖在颧弓和眶缘的表面，延伸到眶内形成眶骨膜。颞深筋膜在颞窝覆盖着颞肌，位于眶的外侧。在骨切除时这两层筋膜需要分离，以显露眶壁和颧弓。（C）筋膜下分离技术将颞部浅、深筋膜一起从颞肌上分离，但是需要在眶外侧缘后缘及颧弓上缘切断深筋膜，这样就可以松解浅筋膜，将其翻过眶缘和颧弓。（D）用锋利的圆刀或剥离子沿着颧弓上缘向上颌骨方向（右侧箭头）切开颞深筋膜。同样，沿着眶外侧壁后缘向上颌骨方向（左侧箭头）切开颞深筋膜，与前一切口会合。（E）筋膜间分离技术是将颞肌上的颞浅筋膜及颞深筋膜分离，剥离眶缘及颧弓上的颞浅筋膜，深筋膜仍保留于颞肌上。筋膜下分离简单，快速，应优先选用。
■ Craniotomy and Osteotomies--开颅和骨切除
The orbitozygomatic unit consists of the orbital rim, orbital roof, lateral orbital wall, and zygomatic arch. This orbitozygomatic unit is removed in several ways: with the cranial flap as one integrated piece; separate from the cranial flap as two pieces; and separate from the cranial flap as two pieces, with a modified orbital unit that does not include the zygoma. The two-piece approach with the complete orbitozygomatic unit is the standard technique used most often. The one-piece orbitozygomatic approach gives a better cosmetic result but the osteotomies are more difficult to perform. The modified orbital approach is used when the zygoma resection would not add meaningfully to the exposure. The frontotemporal craniotomy resembles that of the pterional approach, but the anteromedial corner extends more medially beyond the supraorbital notch. Dura of the frontal lobe is elevated 3 cm posteriorly to visualize the orbital roof. The pterion does not need to be drilled because it is removed with the orbit. Before making any osteotomies, the inferior frontal dura and periorbita are protected from the saw blade with strips of Telfa.
眶颧部由眶缘、眶顶、眶外侧壁和颧弓组成。眶颧部的去除有以下几种方法：单瓣眶颧入路（将骨瓣做为一整体取下）；双瓣眶颧入路；改良眶部（不包括颧弓）的双瓣眶颧入路。眶颧部完全去除的双瓣法是最常用的标准技术。单瓣眶颧入路的术后外观较好，但是截骨较困难。改良眶部入路在切除颧弓对增加显露意义不大时使用。额颞开颅方法与翼点入路类似，但是前内侧角向内侧延伸更多，超过眶上切迹。额叶的硬脑膜向后抬起3cm，以看清眶顶。翼点不需要磨除，因为它随眶部一起去除。在截骨之前，用棉条保护额叶下部硬脑膜和眶骨膜免受骨锯损伤。
The orbitozygomatic unit is released by a series of six osteotomies (Fig. 11.2) made with a reciprocating saw, which minimizes bone loss from the cuts. The first cut is made across the root of the zygomatic process of the temporal bone (zygomatic root), angling the saw blade away from the temporomandibular joint that lies on the inferomedial surface of zygomatic root (Fig. 11.2, osteotomy 1). This cut in the root is made with two perpendicular cuts, creating a notch that seats the zygoma more securely than would one straight cut. A fixation plate is placed in the zygoma and registered with a drill hole in the root to improve the cosmesis of the repair. The second and third cuts are made across the temporal process of the zygomatic bone (malar eminence), first from the inferolateral margin of the zygomatic arch continuing halfway across the zygomatic bone (Fig. 11.2, osteotomy 2), and then from the inferior orbital fissure through the zygomatic bone to the same endpoint (Fig. 11.2, osteotomy 3). The inferior orbital fissure is difficult to visualize directly but can be palpated with a thin dissector, which also guides the tip of the saw blade into the fissure and protects the eye. When these two osteotomies connect, the resulting V in the zygomatic bone secures the fragment into position when replaced.
眶颧部截骨术依次分六个步骤（图.11.2），使用摆锯可以减少切除过程中的骨损耗。第一步是调整锯条角度，保持不损伤颧弓根内下面的颞下颌关节，切断颞骨颧突的根部（图.11.2，第1刀），在颧弓根部用相互垂直的的两刀完成，制造出一个切迹，可以比一直刀更安全地使颧弓复位。复位时一连接片先固定在颧弓上，另一孔与在颧弓根部的钻孔对齐，可以提高修复的美观度。第二步和第三步是跨越颧骨的颞突（颧骨隆突），首先从颧弓的前外下侧缘切开到颧弓的一半(图. 11.2, 第2刀)，然后从眶下裂向颧骨切开到上一步的终点（图. 11.2,第3刀）。眶下裂直视困难，但可以用细剥离子探及，以引导锯条头端通过眶下裂并保护眼球。当这两步截骨完成并连接在一起时，在颧骨上形成一个V型切口，可在复位时保证骨片正确对位。
The fourth cut is along the medial orbital roof in an anterior- posterior direction, just lateral to the supraorbital notch (Fig. 11.2, osteotomy 4). The frontal dura is protected with Telfa strips and gentle retraction, and the saw is angled as the cut deepens to keep the teeth at the heel of the blade from contacting dura. The eye is also protected with Telfa strips and gentle retraction. The fifth cut crosses the posterior orbital roof in a medial-to-lateral direction, approximately 2 to 3 cm posterior to the inner table of the frontal bone (to preserve the orbital roof), and finishes laterally in the thick bone of the sphenoid ridge and pterion (Fig. 11.2, osteotomy 5). The sixth cut crosses the lateral orbital wall, beginning in the inferior orbital fissure from outside the orbit and connecting in the sphenoid ridge and pterion with the previous cut (Fig. 11.2, osteotomy 6). The orbitozygomatic unit can then be removed as a single piece.
第四步是沿着眶顶内侧、恰在眶上切迹的外侧，由前向后切开（图.11.2 第4刀）。保护额叶硬脑膜的方法是用棉条轻柔牵拉，随着切口深入，锯条逐渐抬起一个角度，保持锯条后端的锯齿不要接触硬脑膜。眼睛也用棉条和轻柔牵拉的方法加以保护。第五步大约在额骨内板的后方2-3cm开始，由内向外切开眶顶后部（保留眶顶），到蝶骨嵴厚骨质和翼点结束（图.11.2第5刀）。第六步是切开眶外侧壁，从眶外侧的眶下裂开始到与前一刀的终点连接在一起（图.11.2第6刀）。如此则眶颧部就可以做为一整块去除。
Additional bone is removed around the orbital apex, resecting what remains of the orbital roof, lateral orbital wall, and medial sphenoid wing, back to superior orbital fissure (Fig. 11.2C,D, craniectomies 1 and 2). Bony resection continues to the base of the anterior clinoid process, which is left in place.
然后围绕着眶尖进一步做骨去除，切除眶顶、眶外侧壁和蝶骨翼内侧剩余的部分，回到眶上裂（图11.2C，D，颅骨切除1和2）。骨质切除一直到前床突基部，这里予以保留。
Fig. 11.2 (opposite) Osteotomies for the right orbitozygomatic craniotomy, as seen in anterior-superior oblique (A), anterior (B), posteriorsuperior oblique (C), and lateral (D) views. The orbitozygomatic unit is released by a series of six osteotomies. The first cut crosses the zygomatic root, usually with two perpendicular cuts that notch the zygomatic root and seat the zygoma securely (osteotomy 1). The second cut extends from the inferior margin of the zygomatic arch halfway across the zygomatic bone (osteotomy 2). The third cut extends from the inferior orbital fissure to the same endpoint (osteotomy 3). The fourth cut is made along the medial orbital roof in an anteriorposterior direction, just lateral to the supraorbital notch (osteotomy 4). The fifth cut crosses the posterior orbital roof in a medial-to-lateral direction, approximately 2 to 3 cm posterior to the inner table of frontal bone (to preserve the orbital roof), and finishes laterally in the thick bone of the sphenoid ridge and pterion (osteotomy 5). The sixth cut crosses the lateral orbital wall, beginning in the inferior orbital fissure from outside the orbit and connecting the previous cut (osteotomy 6). The orbitozygomatic unit can then be removed as a single piece. (C,D) After removing the orbitozygomatic unit, additional bony exposure includes (1) resecting the orbital roof, (2) resecting the medial sphenoid wing, and (3) drilling down the squamosal portion of the temporal bone.
图11.2 右侧眶颧开颅的颅骨切除，展示的是前上倾斜位（A）、前位（B）、后上斜位（C）和侧位（D）视角。眶颧颅骨切除分六个步骤，第一步切断颧弓根部，通常是成直角的两刀完成，在颧弓根部形成切迹，便于术后安全地放置颧弓（第1刀）。第二步从颧弓的下侧缘切开到颧骨的一半(第2刀)。第三步从眶下裂到上一步的终点（第3刀）。第四步是沿着眶顶内侧、恰在眶上切迹的外侧，由前向后切开（ 第4刀）。第五步大约在额骨内板的后方2-3cm开始，由内向外切开眶顶后部（保留眶顶），外到蝶骨嵴厚骨质和翼点结束（第5刀）。第六步是切开眶外侧壁，从眶外侧的眶下裂开始到与前一刀的终点连接在一起（第6刀）。如此则眶颧部就可以做为一整块去除。(C,D) 去除眶颧部之后，增加骨性显露的方法包括：（1）去除眶顶，（2）去除蝶骨翼内侧，（3）向下磨除颞骨鳞部。
■ Subtemporal Exposure--颞下显露
The temporal lobe mobilizes posterolaterally after splitting the sylvian fissure, thereby opening the important pretemporal corridor. However, the temporal lobe must have an unobstructed pathway to retract this way. The inferior margin of the temporal squamosal bone is drilled inferiorly until the cranial exposure is flush with the floor of the middle fossa, all the way back to zygomatic root (Fig. 11.2C,D, craniectomy 3). With this inferior barrier removed, the temporal lobe retracts smoothly.
分离外侧裂后，颞叶向后外侧移动，就打开了重要的颞前手术通路。但是必须要这样牵拉颞叶时无遮挡。颞骨鳞部下缘必须磨除，直到与中颅窝底平齐，向后一直到颧弓根部（图11.2 C,D，颅骨切除3）。去除下方的障碍，可以顺利地牵拉颞叶。
A dural flap based over the orbit is tented forward with tacking sutures to depress the globe gently and thereby gain a wide exposure of the sylvian region. It often takes a dozen sutures to maximally flatten the dural flap; any less and swollen orbital tissue can bulge into the surgical corridor. With the orbit and zygoma removed, a wide corridor is opened to the sylvian and carotid cisterns (Fig. 11.3).
将眶上方的硬脑膜瓣用临时缝线翻向前牵，以轻压眼球，这样可以更好地显露外侧裂。通常需要多个缝线以尽可能使硬脑膜瓣平展，如果牵拉不够，硬脑膜或眶组织肿胀就会突入手术通道。随着眶骨和颧骨的去除，到达外侧裂和颈动脉池的宽广通路就打开了。
Fig. 11.3 The final exposure of the orbitozygomaticpterional approach. With the orbit and zygoma removed, the dural flap and its tacking sutures depress the globe gently and open a wide exposure of the sylvian and carotid cisterns. ICA, internal carotid artery; Tent., tentorium.
图.11.3 眶颧-翼点入路最后显露图示。眶骨和颧弓去除后，硬脑膜瓣及其临时缝线轻压眼球，广泛显露外侧裂和颈动脉池。ICA，颈内动脉；Tent.，小脑幕。
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