经颞下锁孔硬膜下入路神经内镜与显微镜显露后颅窝的解剖学对比研究

A comparative study of endoscopy and microscopy in exposure of posterior fossa through the intradural subtemporal keyhole approach

目的对比分析经颞下锁孔硬膜下入路神经内镜与显微镜显露后颅窝手术视野和操作空间的差异,以及神经导航在该入路中的优势。方法成人尸头湿标本10具(20侧),首先双侧均模拟经颞下锁孔硬膜下入路(颞下入路组);随后随机选取一侧模拟颞下锁孔硬膜下Kawase入路(Kawase入路组),另一侧模拟神经导航辅助颞下锁孔硬膜下Kawase入路(导航辅助下Kawase入路组)。分别通过神经内镜和显微镜观察相关的解剖结构,使用透明方格纸测量后颅窝手术视野和操作空间的大小。结果神经内镜下操作在脑干上、下、腹侧获得的手术视野和操作空间均比显微镜下更大(均P<0.05)。其中颞下入路组手术视野在脑干上、下、腹侧分别增大(2.9±1.0)、(15.7±1.5)及(10.2±1.1)mm,操作空间分别增大(2.9±1.0)、(7.6±1.9)及(6.0±1.7)mm;Kawase入路组手术视野分别增大(2.7±0.9)、(20.0±1.2)及(29.5±0.7)mm,操作空间分别增大(2.7±0.9)、(14.8±1.4)及(8.8±1.4)mm;导航辅助下Kawase入路组手术视野分别增大(3.1±1.0)、(20.3±2.4)及(29.9±0.7)mm,操作空间分别增大(3.1±1.0)、(15.3±1.6)及(8.8±1.3)mm。而脑干背侧的手术视野和操作空间,神经内镜和显微镜在上述3个组中差异均无统计学意义(均P>0.05)。与Kawase入路组比较,导航辅助下Kawase入路组在脑干下方可获得更大的手术视野及操作空间,其中神经内镜下手术视野增大(3.8±2.2)mm,操作空间增大(2.7±0.9)mm;显微镜下分别增大(3.5±0.7)mm和(2.2±1.2)mm。差异均有统计学意义(均P<0.05)。其余3个方向,两组的差异均无统计学意义(均P>0.05)。结论颞下锁孔硬膜下入路中神经内镜较显微镜可在脑干上、下、腹侧获得更大的手术视野和操作空间,而利用神经导航可在脑干下方进一步获得更大的手术视野和操作空间。

Objective To comparatively analyze the differences between endoscopy and microscopy in area of exposure and surgical freedom in posterior fossa through the intradural subtemporal keyhole approach and to explore the advantages of neuronavigation in that approach.Methods Twenty endoscopic intradural subtemporal keyhole approaches(EISKA)were performed on 10 cadaveric adult heads.An intradural Kawase approach and a navigation-assisted intradural Kawase approach were then carried out on a random side of each specimen.Related anatomic structures were observed through endoscope and microscope at the end of each approach.Anatomic exposure and surgical freedom were measured by transparent graph paper and were analyzed.Results Compared with microscopy,the superior,inferior and medial limits through endoscopic exposure were increased by 2.9±1.0 mm,15.7±1.5 mm and 10.2±1.1 mm,and the surgical freedom was increased by 2.9±1.0 mm,7.6±1.9 mm and 6.0±1.7 mm(P<0.05)in the intradural subtemporal keyhole approach.In intradural Kawase approach,the anatomic exposure was increased by 2.7±0.9 mm,20±1.2 mm and 29.5±0.7 mm and the surgical freedom was increased by 2.7±0.9 mm,14.8±1.4 mm and 8.8±1.4 mm(all P<0.05).In navigation-assisted intradural Kawase approach,the anatomic exposure was increased by 3.1±1.0 mm,20.3±2.4 mm and 29.9±0.7 mm,and the surgical freedom was increased by 3.1±1.0 mm,15.3±1.6 mm and 8.8±1.3 mm(P<0.05).Using a frameless navigational device,the inferior limit of the anatomic exposure was increased by 3.8±2.2 mm in endoscopy and 3.5±0.7 mm in microscopy,and the surgical freedom was increased by 2.7±0.9 mm in endoscopy mm and 2.2±1.2 mm in microscopy(all P<0.05).Conclusions The EISKA could provide more anatomic exposure and surgical freedom mainly in the superior,inferior and medial directions of the brainstem regions.More inferior anatomic exposure and surgical freedom of the posterior cranial fossa could be obtained by navigational assistance.