岩斜部脑膜瘤的微侵袭治疗

Keyhole approach surgery for petroclival meningiomas

目的探讨微侵袭神经外科技术在岩斜脑膜瘤治疗中的应用。方法采用锁孔技术治疗14例岩斜部脑膜瘤。累及上中斜坡8例,广基或宽基累及上中下斜坡5例,累及中下斜坡1例。其中6例同时扩展至鞍旁或海绵窦内。采用枕下乙状窦后锁孔入路6例,颞下锁孔入路2例,幕上下联合入路6例。结果全切除肿瘤8例,次全切除4例,大部切除2例(均为术后复发患者)。术后神经功能完好或未见新增脑神经损伤8例,术后出现轻度面瘫4例,外展功能障碍3例,动眼神经麻痹2例,后组脑神经功能影响1例。均未发生术后脑脊液漏和切口感染。经11～19个月随访,轻度面瘫和动眼神经麻痹均有明显改善,但外展功能障碍恢复缓慢。结论针对岩斜部脑膜瘤累及范围,采用单独/联合采用颞下锁孔入路和枕下乙状窦后锁孔入路可有效切除肿瘤,并可减少手术创伤,缩短手术和患者康复时间,减少术后并发症。联合运用微侵袭技术(锁孔入路联合),术中显微技术与术后放射外科治疗等是今后岩斜部脑膜瘤的治疗方向。

Objective To evaluate the possibility of keyhole approaches for surgical treatment of petroclival meningiomas. Methods We retrospectively analyzed our experience in 14 cases with petroclival meningiomas surgically treated from May 2003 to January 2004. Eight tumors involved the upper and middle clivus.five tumors were attached to the entire width of clivus and one tumor involved the middle and lower cilvus. The tumors infiltrated into parasella regions or cavernous sinus in six cases simultaneously. Retrosigmoidal keyhole approach was selected to remove the tumors in 6 cases, and subtemporal keyhole approach was selected in 2 cases,while the combined retrosigmoidal and subtemporal keyhole approaches were applied in other six cases. Results Gross total resections of the tumors were achieved in 8 cases, subtotal resections in 4 cases, large resection in two cases who had recurrent tumors. Postoperatively, neurological intact or unchanged were found in 8 cases. The main surgical complications were mild facial palsy (4 cases) , abducent dificits (3 cases) ,temporary oculomotor nerve dificits (2 cases),and lower cranial nerve palsy (1 case). One patient died from disseminated intravascular coagulation (DIC) two weeks after surgey. There were no CSF leakage and infections after surgery in all cases 11 to 19 months follow-up studies demonstrated the great improvement of the Ⅲ and Ⅶ nerve deficits,but minor improvement in the Ⅵ nerve deficits. Conclusion According to the location and extension of the tumors, retrosigmoidal or subtemporal keyhole approaches or their combined can be selected for surgical treatment. These keyhole approaches can expose sufficiently the petroclival region, shorten the surgical time, and minimize the complications. Combined usage of minimally invasive techniques including the keyhole approach and radiosurgey in the treatment of the petroclival meningiomas is suggested.