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神经外科手术入路(十三)--Kawase入路学习笔记合辑
今天给大家分享的是,由赵英杰博士带来的精彩文章:神经外科手术入路(十三)--Kawase入路学习笔记合辑,欢迎阅读,分享!
Right-side anatomical specimen showing the area of drilling in Kawase’s triangle
for an extended middle fossa approach. The tentorium has been cut, revealing the infratentorial compartment. ( From Professor Felix Umansky.)
Felix Umansky教授,在Practical handbook of Neurosurgery,曾撰写章节How to perform middle fossa / sphenoid wing approaches。其中,Felix Umansky教授曾使用词汇:Transpetro-apical approach (extended middle fossa approach),经岩尖入路(扩大中颅窝底入路)。
篇首图片,来自Felix Umansky教授。此图,明确展示了Kawase’s triangle的磨除范围。请注意:图片中的耳蜗Cochlea,完整保留,丝毫未损。
也即,磨除岩尖的无功能部分,保留耳蜗,保留听力。
Kawase教授,在Practical handbook of Neurosurgery,曾撰写章节How to perform transpetrosal approaches。 Kawase教授,撰写的经岩骨入路,分为两部分:岩前入路与岩后入路,即Anterior transpetrosal approach and Posterior transpetrosal approach。
在此章节的引言部分,曾有如下表述:
The middle fossa transpetrosal approach was originally developed by King in 1970, and so-called “extended middle fossa approach”, which was combined with middle fossa craniotomy and translabyrinthine approach . The method was mainly applied to acoustic tumors, but it was indicated to clival lesions by Hakuba et al.
An advantage of this approach is low risk of cerebellar damage to access more laterally to the brain stem. The disadvantages were sacrifice of hearing and venous complication (venous thrombosis of vein of Labbe and sigmoid sinus). Al-Mefty used this approach for more number of the petroclival meningiomas, by preservation of acoustic structures (posterior transpetrosal approach) .
In 1985 and 1994, Kawase reported the anterior transpetrosal approach for basilar trunk aneurysms and petroclival meningiomas by selected resection of petrous apex. The clival lesions were accessed by the shortest way to the area anterior to the internal auditory meatus (IAM) without sacrifice their hearing.
短短的引言,却表达着丰富的内容。笔者简要介绍自己的几点理解:
(1)Kawase教授,其本人也承认:Kawase入路,是基于扩大中颅窝底入路的进一步发展。
(2)回顾Kawase入路的历史,至少要从middle fossa transpetrosal approach 、extended middle fossa approach开始,追溯到1970年King TT的经迷路入路。
笔者,不禁想起那2017年12月,在天津海河颅底论坛,Kawase教授的演讲题目:Light-up the No-man’s Land on the Brain Stem-A History How to Find My Approach,其中的一张幻灯片是:经岩入路的文献复习,也是自1970年King TT的经迷路入路谈起。
(3)Kawase教授,其自身认定:Kawase入路(岩前入路),于1985年横空出世。那么,1985年以前的经岩入路的文献,皆是Kawase入路的前世。
中青年神经外科医师,如果研究Kawase入路的历史,针对Kawase教授幻灯片推荐的作者文献进行复习,必将大有所获,收获满满。
(4)Kawase入路,仅是行selected resection of petrous apex,也即,磨除部分岩尖,并非岩尖的全磨除。此处,重在理解selected,选择性磨除。
磨除哪里呢?磨除岩尖的无功能部分,因而保留耳蜗、保留迷路、保留听力。
也就是说,从解剖概念上,岩尖亦分为:功能部分、无功能部分。
(5)大师的风采的侧露。Kawase教授,其撰文引言与会议交流使用的幻灯片,在同一个知识点上,前后一致,彼此吻合,具有coherence特征,符合同一律。
Fukushima教授,在Practical handbook of Neurosurgery,曾撰写章节Management of Cavernous Sinus Lesions。其中,Fukushima教授,也谈到其对Kawase三角、岩前入路的评价。
笔者在此不再赘述。请参阅神外风云人物志:Japanese skull base surgeons。
另外,从开放Meckel氏腔进入海绵窦后部的视角,从处理诸如蝶-岩斜病变的视角,Kawase入路,也具有海绵窦手术入路的特征。
Kawase入路,术中需切开小脑幕,自然是幕上下联合入路了。