内镜下鼻内经鞍结节及蝶骨平台入路外侧边界的确定: 附加相关定量分析的解剖学研究

Defining the lateral limits of the endoscopic endonasal transtuberculum transplanum approach: anatomical study with pertinent quantitative analysis

目的：目前，手术治疗已经筛选的前颅底中线病变可使用扩大内镜下鼻内经鞍结节及蝶骨平台入路。然而，显露蝶骨平台外侧区域的可行性则意味着该入路的局限性。据作者所知，目前尚未就其最终的解剖学边界作出明确定义。因此，本研究旨在详尽描述并量化需要经鼻内途径完成的最大蝶骨平台骨切除量，以实现该通路最大限度的外侧方延展，同时评估相对手术自由度。

OBJECTIVE The extended endoscopic endonasal transtuberculum transplanum approach is currently used for the surgical treatment of selected midline anterior skull base lesions. Nevertheless, the possibility of accessing the lateral aspects of the planum sphenoidale could represent a limitation for such an approach. To the authors’ knowledge, a cleardefinition of the eventual anatomical boundaries has not been delineated. Hence, the present study aimed to detail andquantify the maximum amount of bone removal over the planum sphenoidale required via the endonasal pathway to achieve the most lateral extension of such a corridor and to evaluate the relative surgical freedom.

方法：在巴塞罗那大学临床神经解剖实验室解剖6具人尸头标本。试验顺序如下：1）行解剖前CT扫描；2）实施内镜下鼻内经鞍结节及蝶骨平台入路（外侧边界：内侧颈内动脉视神经隐窝），然后行解剖后CT扫描；3）实施最大限度地向外侧延展的经鞍结节及蝶骨平台入路，然后行解剖后CT扫描；4）进行骨切除量和手术自由度的分析（非配对学生t检验）。采用传统的双侧额下入路自上方评估蝶骨平台的骨切除量和鼻内通路的外侧边界。

METHODS Six human cadaveric heads were dissected at the Laboratory of Surgical NeuroAnatomy of the University of Barcelona. The laboratory rehearsals were run as follows: 1) preliminary predissection CT scans, 2) the endoscopic endonasal transtuberculum transplanum approach (lateral limit: medial optocarotid recess) followed by postdissection CT scans, 3) maximum lateral extension of the transtuberculum transplanum approach followed by postdissection CT scans, and 4) bone removal and surgical freedom analysis (a nonpaired Student t-test). A conventional subfrontal bilateral approach was used to evaluate, from above, the bone removal from the planum sphenoidale and the lateral limit of the endonasal route.

结果：内镜下鼻内经鞍结节及蝶骨平台入路通过切除视小柱上方骨质，亦即包括前床突在内的蝶骨小翼内侧部分，获得前颅底外侧部分最大限度的外侧方延展。正如预期的那样，与截至内侧颈内动脉视神经隐窝的骨切除方法相比，该方法骨切除量更大（平均骨切除量分别为533.45mm²与296.07 mm²；p<0.01）。平均前后径分别为8.1mm与15.78mm，平均左右径分别为18.77 mm与44.54 mm（P<0.01）。该区域的神经血管结构可暴露至大脑中动脉脑岛段。手术自由度分析显示，与中线靶标相比，置于对侧鼻孔的器械的侧方可操作性或可增加（平均可操作面积分别为384.11mm²与235.31mm²；p<0.05）。

RESULTS The endoscopic endonasal transtuberculum transplanum approach was extended at its maximum lateral aspect in the lateral portion of the anterior skull base, removing the bone above the optic prominence, that is, the medial portion of the lesser sphenoid wing, including the anterior clinoid process. As expected, a greater bone removal volume was obtained compared with the approach when bone removal is limited to the medial optocarotid recess (average 533.45 vs 296.07 mm²; p < 0.01). The anteroposterior diameter was an average of 8.1 vs 15.78 mm, and the laterolateral diameter was an average of 18.77 vs 44.54 mm (p < 0.01). The neurovascular contents of this area were exposed up to the insular segment of the middle cerebral artery. The surgical freedom analysis revealed a possible increased lateral maneuverability of instruments inserted in the contralateral nostril compared with a midline target (average 384.11 vs 235.31 mm²; p < 0.05).

结论：切除包括前床突在内的蝶骨小翼内侧部分的骨质可增加扩大内镜下鼻内经鞍结节及蝶骨平台入路对前颅底外侧区域的显露和手术自由度。尽管该研究仅为初步解剖学研究，但仍有助于完善内镜下鼻内通路的适应症和局限性，以便于累及蝶骨平台外侧部分颅底病变的外科治疗。

CONCLUSIONS Bone removal from the medial aspect of the lesser sphenoid wing, including the anterior clinoid process, may increase the exposure and surgical freedom of the extended endoscopic endonasal transtuberculum transplanum approach over the lateral segment of the anterior skull base. Although this study represents a preliminary anatomicalinvestigation, it could be useful to refine the indications and limitations of the endoscopic endonasal corridor for thesurgical management of skull base lesions involving the lateral portion of the planum sphenoidale.

关键词：扩大内镜下鼻内入路，经鞍结节及蝶骨平台入路，颅底外科，前颅底，垂体外科

KEYWORDS extended endoscopic endonasal; transtuberculum transplanum; skull base surgery; anterior cranial base; pituitary surgery

原文出处：Di Somma A, Torales J, Cavallo LM, et al. Defining the lateral limits of the endoscopic endonasal transtuberculum transplanum approach: anatomical study with pertinent quantitative analysis. J Neurosurg, 2018; 130(3): 848-860.