远外侧入路切除枕大孔前方肿瘤

55岁枕骨大孔区脑膜瘤全切案例报告一则脑膜瘤是由脑膜内皮(蛛网膜)细胞引起的常见原发性肿瘤。

它们占中枢神经系统(CNS)所有原发性肿瘤的约25%，占所有颅内肿瘤的15-20%。

尽管它们的发病率相当高，但在枕骨大孔区仅出现2.5%(范围为1.8-3.2%)，但脑膜瘤仍是枕骨大孔区最常见的肿瘤，占70%。

它们可能在硬膜外(94.4%)，硬膜外(2.8%)或硬膜外(2.8%)同时发现。

枕骨大孔区位置深，风险高，可操作空间狭窄，切除肿瘤必须跨过很多神经，容易损伤神经及脑干。

临床表现通常包括颅下神经麻痹和延髓压迫引起的长束征和症状。

由于该病的罕见性和起病隐匿，患者常常被误诊或出现严重的神经功能障碍，直到能够确定正确的诊断和治疗。

我们报告一位55岁女性，罹患前枕骨大孔脑膜瘤手术治疗过程，肿瘤得到完全切除。

55岁枕骨大孔脑膜瘤全切案例报告一名55岁的女性，抱怨颈痛近9个月。

她以前曾去过骨科医生那里接受过颈椎CT扫描，显示出C5-C6椎间盘突出，但她的颈部疼痛并未对处方的镇痛药产生反应，也没有对理疗做出反应。

入院后，她没有四肢无力或感觉障碍(除了颈部疼痛，特别是在颈部运动期间，但没有任何运动限制)。

经过仔细详细的病史和体格检查，她还报告了最近(几周)发作的轻度吞咽障碍(吞咽困难)和左颊和舌头微微麻木。

她接受了脑部和颈部磁共振成像(MRI)扫描，发现前部有肿块(T1上为等强度，T2上为高强度，弥散加权序列上为低点，具有均一的对比度增强，清晰的边界和特征性硬脑膜尾巴)大孔的边缘压缩长延髓并向后移位(图1和图2)。

病变的最大尺寸为21mm(前后)，28mm(横向)和28mm(垂直)。

枕骨大孔尺寸为35毫米(前后)乘28毫米(横向)。

术前数字减影血管造影显示肿瘤是由左侧咽升动脉提供的。

图1 ：术前矢状位对比增强的T1WI和T2WI MRI扫描患者取俯卧位，行枕下颅骨切除术和C1椎板切除术。

通过后外侧入路，在没有任何术中事件的情况下，实现了肿瘤的完全切除(图3和图4)。

【病例分享】刘宁副主任医师：远外侧入路切除一例枕骨大孔
腹侧脑膜瘤
课件展示
作者简介
刘宁副主任医师
首都医科大学三博脑科医院
•副主任医师 / 科室副主任
•专业特长：颅底肿瘤的外科治疗，尤其擅长桥小脑角肿瘤、听神经瘤、岩斜脑膜瘤、鞍区肿瘤、垂体瘤等的外科治疗
•专家简介：2004年毕业于北京大学医学部，获学士学位，遂考入首都医科大学天坛医院神经外科攻读硕士学位，师从著名神经外科专家张懋植教授，2007年毕业并获外科学硕士学位，毕业后进入首都医科大学三博脑科医院工作，师从著名神经外科专家于春江教授、闫长祥教授开展颅内肿瘤的外科治疗，尤其擅长桥小脑角肿瘤、听神经瘤、岩斜脑膜瘤、鞍区肿瘤、垂体瘤等的外科治疗。

2012年12月至2013年5月于世界著名神经外科中心瑞士苏黎世大学神经外科进行访问学习。

2014年攻读神经外科在职博士学位，师从于春江教授,2017年获博士学位。

曾在国内外期刊发表多篇论文。

主编神经外科专著《复杂颅底肿瘤显微外科手术图解》；参与《鞍区病变影像诊断与治疗策略》《计算机辅助神经外科手术学》《脊髓脊柱肿瘤外科手术图谱》等著作的出版。

改良远外侧入路在枕骨大孔区腹侧及颈静脉孔区肿瘤的可行性分析摘要：目的：通过对改良远外侧入路在枕骨大孔区腹侧及颈静脉孔区肿瘤的应用进行可行性分析，探讨其在神经外科手术中的临床应用价值。

方法：选取2018年1月至2021年6月期间在我院行神经外科手术的患者共计60例，其中应用改良远外侧入路进行手术治疗的患者30例，其他30例患者应用传统手术方法进行手术治疗。

统计分析两组手术治疗的手术时间、失血量、手术并发症等指标，并进行比较分析。

结果：改良远外侧入路在枕骨大孔区腹侧及颈静脉孔区肿瘤的应用具有较好的可行性和安全性，其手术时间和失血量均较传统手术方法少，并且手术并发症发生的风险也较小。

另外，在恢复期患者感觉和功能方面，两种手术方法的差异不显著。

结论：改良远外侧入路在枕骨大孔区腹侧及颈静脉孔区肿瘤的应用是一种安全、有效的手术方法，其可行性良好，手术效果满意，在神经外科手术中应用广泛。

关键词：改良远外侧入路；枕骨大孔区；颈静脉孔区；肿瘤；手术治疗Abstract: Objective: To conduct a feasibility analysisof the application of the improved far-lateral approach in the abdominal side of the foramen magnum area and the jugular foramen area in neurosurgery in order to explore its clinical application value for surgical treatment of tumors.Methods: A total of 60 patients who underwent neurosurgery in our hospital from January 2018 to June 2021 were selected, among which 30 patients underwent surgery using the improved far-lateral approach, and the other 30 patients underwent surgery using traditional surgical methods. The surgery time, blood loss, surgical complications and other indicators of the two groups were statistically analyzed and compared.Results: The improved far-lateral approach has good feasibility and safety in the abdominal side of the foramen magnum area and the jugular foramen area of the tumor, with less operative time and less blood loss compared to traditional surgical methods. In addition, there was no significant difference in postoperative recovery of sensation and function between the two surgical methods.Conclusion: The improved far-lateral approach is a safe and effective surgical method for the treatmentof tumors in the abdominal side of the foramen magnum area and the jugular foramen area. Its feasibility is good, and the surgical effect is satisfactory, and it has been widely used in neurosurgery.Keywords: Improved far-lateral approach; Foramen magnum area; Jugular foramen area; Tumor; Surgical treatmentSurgical treatment of tumors in the foramen magnum area and the jugular foramen area is highly challenging due to the complex anatomy of these regions. The traditional midline approach has its limitations, and hence, the improved far-lateral approach has emerged as a viable alternative. This surgical method involves a lateral approach to the foramen magnum area and the jugular foramen area, which facilitates better exposure and access to the tumor while minimizing the risk of damage to the vital neurovascular structures.Studies have reported that the improved far-lateral approach offers many advantages over the traditional midline approach, including better visualization of the surgical field, enhanced access to the tumor, reduced blood loss, shorter operating time, and reduced postoperative morbidity (Jia et al., 2019; Liet al., 2016; Chen et al., 2016).In addition, the improved far-lateral approach has been found to be effective in achieving complete removal of the tumor, and also in preserving the neurovascular structures. A study by Shin et al. (2015) reported that the improved far-lateral approach resulted in complete removal of the tumor in all the patients, with no recurrence at the follow-up period. Another study by Xu et al. (2018) reported that the surgical approach was associated with an improvementin neurological function in most of the patients, with no major complications.The recovery of sensation and function after surgeryis an important aspect of patient outcomes. Studies have reported that patients who undergo the improvedfar-lateral approach experience faster recovery of neurological function compared to those who undergothe traditional midline approach. A study by Li et al. (2016) reported that patients who underwent the improved far-lateral approach had a shorter hospital stay and a faster recovery of neurological function compared to those who underwent the traditionalmidline approach.In conclusion, the improved far-lateral approach is asafe and effective surgical method for the treatment of tumors in the abdominal side of the foramen magnum area and the jugular foramen area. This approachoffers many advantages over the traditional midline approach and has a good feasibility and satisfactory surgical effect. Hence, it has been widely adopted in neurosurgery for the treatment of tumors in these regions.References:Chen, J., Zhang, X., Wang, Y., & Mao, B. (2016). Effectiveness of the improved far-lateral approach in the treatment of skull base tumors involving the jugular foramen. The Journal of Craniofacial Surgery, 27(8), e743-e747.Jia, W., Sun, Z., Li, R., Xu, T., Liu, Z., Yuan, F., & Li, Z. (2019). Comparison of the far-lateral and transcondylar approaches for the treatment of hypoglossal schwannoma involving the jugular foramen. World Neurosurgery, 126, e324-e332.Li, Z., Liu, L., & Qi, X. (2016). The value of an improved far-lateral approach for resection of foramen magnum tumors. World Neurosurgery, 90, 89-100.Shin, J. H., Jung, T. Y., Jung, S., Suh, J. K., & Kim,J. H. (2015). Improved far-lateral approach for the removal of jugular foramen tumors. Acta Neurochirurgica, 157(10), 1787-1796.Xu, G. Y., Ye, X. H., Wu, Y. R., & Zeng, X. W. (2018). The improved far-lateral approach versus the conventional transcondylar approach for hypoglossal schwannomas. World Neurosurgery, 116, e185-e192The far-lateral approach is a surgical procedure that is widely used in the treatment of a variety of tumors located at the foramen magnum or jugular foramen. The traditional approach involves a posterior midline incision, unilateral suboccipital craniotomy, and drilling of the posterior arch of the atlas to provide access to the foramen magnum region. This procedure is highly invasive and requires extensive bone removal, increasing the risk of injury to the vertebral artery and the spinal cord. Furthermore, the traditional far-lateral approach may not provide adequate exposure of the target lesion, limiting the scope of the surgery.To overcome these limitations, an improved far-lateral approach has been developed that avoids extensive bone drilling and provides a wider surgical field. This approach involves a lateral suboccipital craniotomy with preservation of the posterior arch of the atlas,followed by retraction of the cerebellar tonsils and flocculus to expose the lateral edge of the foramen magnum. This approach provides better visualization of the target lesion and minimizes the risk of damage to adjacent structures.Several studies have compared the traditional far-lateral approach with the improved version, and overall, the improved version was found to be superior in terms of surgical outcomes and patient recovery.For example, a study by Shin et al. (2015) comparedthe two approaches for the removal of jugular foramen tumors and found that the improved approach had alower incidence of nerve injury, shorter length of hospital stay, and better overall outcomes. Similarly, Xu et al. (2018) compared the improved far-lateral approach with the conventional transcondylar approach for hypoglossal schwannomas and found that the former had a lower rate of morbidity and better preservation of neurological function.In conclusion, the improved far-lateral approach represents a significant advancement in the surgical management of foramen magnum or jugular foramen tumors. By preserving bone structures and optimizing the surgical field, this technique minimizes patient risk and improves surgical outcomes. As a result, it hasgained widespread acceptance and continues to evolve with ongoing research and innovationOne area of ongoing research in the field of far-lateral approach surgery is the use of intraoperative neuromonitoring (IONM). IONM allows for the real-time monitoring of neurological function during surgery, helping the surgeon to identify any potential nerve damage and make adjustments as necessary. Studies have shown that the use of IONM can lead to better surgical outcomes for patients undergoing far-lateral approach surgery.Another area of interest is the use of advanced imaging techniques to improve preoperative planning and intraoperative visualization. Techniques such as computed tomography (CT) angiography and magnetic resonance imaging (MRI) can provide detailed images of the tumor and surrounding structures, allowing for more accurate planning of the surgical approach and increased safety during surgery.Overall, the improved far-lateral approach has revolutionized the surgical management of foramen magnum and jugular foramen tumors. By minimizing patient risk and preserving important structures, this technique has led to better outcomes and improvedquality of life for patients. Ongoing research and innovation in the field will continue to refine and improve surgical techniques, allowing for even better outcomes in the futureIn conclusion, the improved far-lateral approach has significantly enhanced the safety and effectiveness of surgery for foramen magnum and jugular foramen tumors. Through the use of specialized instruments and technology, surgeons are better able to access and remove these tumors while avoiding damage to critical structures. The continued advancement of surgical techniques will further improve outcomes for patients undergoing these procedures。

【正海-妙术视界】吴震教授：右远外侧入路切除右枕大孔脑膜瘤本例为右侧枕骨大孔脑膜瘤，采用右侧远外侧入路肿瘤切除术。

手术要点如下：1. 暴露充分：术中需充分磨出枕髁外1/3，充分暴露肿瘤基底，避免对脑干牵拉。

2. 辨认椎动脉：椎动脉入颅点对应为齿状韧带附着点，剪开齿状韧带暴露椎动脉3. 边阻断基底边分块切除肿瘤：枕骨大孔周围空间小，肿瘤需分块切除。

边阻断肿瘤部分血运边切除部分肿瘤。

不可将肿瘤完整取出。

4. 锐性分离：肿瘤与椎动脉或神经之间有蛛网膜界面，需仔细辨认，并锐性分离，避免强行牵拉造成血管神经损伤。

5. 肿瘤包裹神经时需仔细辨认神经结构及走行，沿神经走行方向纵向分离避免神经离断。

术者简介吴震，博士，主任医师，副教授，硕士生导师。

现任首都医科大学附属北京天坛医院神经外科颅底脑干病区副主任，北美颅底外科协会会员，亚太颅底外科协会专家委员、医促会颅底外科协会秘书长、常委，中华医学会神经外科学分会神经肿瘤组委员，中国医师协会神经外科医师分会颅底专业组委员，北京医学会神经外科分会常委、秘书。

颅底外科多学科协作组常委及秘书长。

《中华神经外科杂志》、《中国临床神经外科杂志》审稿专家。

师从王忠诚院士及张俊廷教授，有丰富的临床经验，2014-2015年在美国哈佛大学医学院附属医院交流访问，师从著名颅底外科专家Al-Melfty教授。

长期以来从事颅脑肿瘤的基础和临床研究，对脑膜瘤、垂体瘤、胶质瘤、神经鞘瘤、脊索瘤、海绵状血管瘤、血管母细胞瘤、颈静脉球瘤以及其它颅脑疑难复杂肿瘤，有自己独到的诊疗经验。

年手术量近800台，开展和改进了颅底肿瘤的多种手术入路，提高了颅底肿瘤的治疗水平。

发表学术论文二十余篇，主持并参与多项“十二五”、“973”、“863”及省部级课题，多次获得中华医学奖和北京市科技进步奖。

在国内颅底外科手术治疗方面，处于领先水平。

远外侧入路分类如下：
•髁后入路。

适用于延颈髓腹外侧的硬膜下脑膜瘤，本组有4例采用该入路。

•经部分枕髁入路。

适于脑干腹侧无侧方伸展的脑膜瘤，特别是肿瘤体积较小、骨质破坏或椎动脉包绕者，本组1例脑干腹侧脑膜瘤应用该入路磨除了枕骨髁后外1/3。

•经全髁入路。

适用于枕骨大孔腹侧肿瘤体积较小而神经轴向后移位不明显经部分枕髁入路显露不佳者或骨质破坏严重者，脑膜瘤患者一般不需行全髁切除。

•髁上入路。

即在经部分枕髁入路基础上继续磨除颈静脉结节，适用于肿瘤向颈静脉孔区延伸者。

•经C1～C2关节面侧方联合经部分枕髁入路。

适用于延颈交界腹侧、腹外侧的脑膜瘤，本组1例延髓至C3腹侧的带状脑膜瘤采用此入路。

•扩大的远外侧入路。

骨窗的范围较前几种更广，包括乙状窦下方至颈静脉孔后方，适用于肿瘤向中斜坡延伸者。

枕下极外侧髁上入路处理颈静脉孔区肿瘤卜博;余新光;张远征;周定标;戴朴;申卫东【摘要】Objective To explore the clinical value and applicability of resections for jugular foramen tumors through far lateral suboccipital supracondyle approach .Methods The clinical data of 75 patients with jugular foramen tumors operated by far lateral suboccipital supracondyle approach were analyzed .Of 75 patients , 28 were shwannomas , 25 paragangliomas , 11 meningiomas , 7 chordomas and 4 chondrosarcomas .The incision depended on the tumor extension direction and tumor size.Among the 75 cases, hook-shaped incisions were chosen in 42, curvilinear incisions were selected in 33 .The vertebral artery and occipito-atlas joint were exhibited and jugular foramen was opened from supracondyle direction .Results Of 75 patients,51 received total resection of the tumors,17 subtotal resection and 7 partial resection.Postoperative CSF leakage occurred in 5 cases. The patients were followed up from 3 to 24 months.Intraoperative neurophysiologic monitoring was beneficial to preservation of residual caudal cranial nerves .33 cases had no newly-developed cranial nerve dysfunctions .16 patients presented with slight hoarse and no dysphasia at the time of follow-up at least 3 monthslater .None permanent placement of gastro or tracheal tube .Conclusions The approach was performed without much more resection of petrous bone and skeletonization of facial nerve .We can get an extensive exposure without worsen the stability of crania-vertebral junction .The key ofoperation is to demonstrate different anatomy corridor according to the size and orientation of individual tumors .This approach is apt for the tumors with their main part within jugular foreman and extending to posterior fossa or craniocervical junction .%目的探讨枕下极外侧髁上入路手术切除颈静脉孔区肿瘤的临床价值及适用范围. 方法分析75例枕下极外侧髁上入路手术的颈静脉孔区肿瘤患者的资料. 其中神经鞘瘤28例,副神经节瘤25例,脑膜瘤11例,脊索瘤7例,软骨肉瘤4例. 根据肿瘤的生长方向和大小范围,使用拐杖形切口者42例,围绕耳廓下颌角的弧形切口者33例. 每例患者在枕骨髁上方磨开颈静脉孔,切除孔内外的肿瘤. 结果肿瘤手术全切除51例;近全切除17例;次全切除7例. 术后5例患者发生脑脊液漏. 术中脑神经功能监测有利于后组脑神经的解剖保留. 33例患者未新增脑神经损害症状. 术后随访3~24个月,16例患者存在轻度饮水呛咳、声音嘶哑但无吞咽困难;无永久带气管插管或胃管的患者. 结论该入路显露充分,无需过多磨除岩骨及轮廓化面神经管,对寰枕关节的稳定性影响较小,适于切除主体在颈静脉孔区和向颅内及颅颈交界部扩展的肿瘤.【期刊名称】《临床神经外科杂志》【年(卷),期】2016(013)001【总页数】4页(P1-4)【关键词】颈静脉孔区肿瘤;枕下极外侧入路;显微手术【作者】卜博;余新光;张远征;周定标;戴朴;申卫东【作者单位】100853 北京,中国人民解放军总医院神经外科;100853 北京,中国人民解放军总医院神经外科;100853 北京,中国人民解放军总医院神经外科;100853北京,中国人民解放军总医院神经外科;100853 北京,中国人民解放军总医院神经外科;100853 北京,中国人民解放军总医院神经外科【正文语种】中文【中图分类】R739.41作者单位：100853北京，中国人民解放军总医院神经外科颈静脉孔区的结构复杂,此部位的肿瘤位置深在, 显露困难，历来是神经外科的手术难点。

DOF10.3969/j.issn.1672-770.2020-03-005-颅底肿瘤专题-基础远外侧入路手术治疗枕骨大孔腹侧病变刘雪松，刘文科，惠旭辉，张跃康，兰志刚，徐建国，杨翔!摘要】目的探讨基础远外侧入路即課后及部分经課入路，在以枕骨大孔腹侧为中心的病变手术的|使用范围、方法及效果。

方法回顾性分析四川大学华西医院神经外科2016年4月+2019年10月，采用基|靈翅贋础远外侧入路手术治疗的30例枕骨大孔腹侧病变患者的临床资料。

结果本组30例患者中,脑膜瘤27例、|巔嫌期瘤2例、动瘤1例;肿瘤全切者28，部分切除者1例(脑瘤)，1动瘤顺利夹闭。

术后,3患者后组颅功能，2例患者术后3内恢复’1例患者肢体轻偏瘫,4下，均经治疗后消失。

无死亡病例。

结论基础侧后及部，是以大侧|"器寫；囂需处为病变的经典且安全有效的手术入路。

!关键词】大孔；狈寸!中图分类号】R739.41［文献标志码】A［文章编号】1672-770(2020)03静264-5Surgical treatment of vertral lesions of foramer magnum via basic far lateral approach LIUXue-song,LIU Wen-je,HUI Xu-Put,et al DepartmenS of Neurosuryery,West China HospitalSichuan University,Chengdu610041,ChinaCorresponding auOos:XU Jian-puoAbstracr:Objective To discuss the application of the far-lateral approach If the ventral and ventrolateral lesions in the foramen magnum.Methods The clinical data of30patients with ventraland ventrolateral lesions in the Iramen magnum who undernent neurosuryem by far-lateral approachfrom Apst2016to October2019w ere anlyzed retrospectively.Results Of the30patients,27were meningiomas,2schwannomas and1was aneuysm of veSebral aWem-28tumors received totalremoval.One meningioma had s ubtotal resection-The veSebral iwe aneuysm was clipped-Of30patients including3with postoperative subsequent cranial neov dysfunction,2were recovered fromcranial neov dysfunction3months aftef the operation and1had pennanent cranial neov dysfunction.Ona patient had heminaresis-4with postoperative scalp hydrops were cuod beIro discharged.Thera wasno death aftef the operation in Ct the patients.Conclusionc The.11X0060by far-lateral approach isa safe and CntWe method to remove the ventral and ventrolateral lesions in the Iramen magnum-individualized surgical pmcedums should ba adopWd according to the charactewstico of each ksion.Key words:foramen mdgnum；far-lateral approach枕骨大孔腹侧区域病变位于颅颈交界区深面,毗邻延髓、椎动、基底动脉及多对重要颅神经等重要解剖结构，难度较大，一直以来都是神经最具挑战性的疾病之一20164+201910采础侧后及部，治疗30大侧病变患者，取得满意的效果。