目的:颅底脊索瘤罕见,局部骨破坏性病变,由于累及颅骨交界处(CVJ)的关键神经血管和骨结构而提出了独特的手术挑战。根治性细胞减灭术提高了生存率,但也带来了显著的发病率,包括枕颈(OC)不稳定需要仪器融合的可能性。发表的关于CVJ脊索瘤切除术后OC融合的经验是有限的,在这种情况下,OC不稳定的解剖学预测因素仍不清楚。
方法:根据PRISMA指南系统地搜索PubMed和Embase,用于描述颅底脊索瘤切除和OC融合的研究。搜索策略在作者的PROSPERO方案(CRD42024496158)中预定义。
结果:系统评价确定了11例外科病例系列,描述了209例颅底脊索瘤患者和116例(55.5%)接受OC器械融合的患者。大多数患者接受外侧入路(n=82)进行脊索瘤切除术,其次是中线(n=48)和联合(n=6)方法。OC融合最常作为第二阶段手术进行(n=53),然后进行单阶段切除和融合(n=38)。在9项研究中描述了与OC融合相关的枕骨髁切除程度:无论手术方法如何,全单侧髁切除术都能可靠地预测OC融合。外侧经颅入路后,4项研究认为,至少50%-70%的单侧髁切除术需要OC融合。中线入路-最常见的是内镜经鼻入路(EEA)-至少75%的单侧髁切除术(或50%的双侧髁切除术)导致OC融合。此外,切除内侧寰枢关节元件(C1前弓和窝尖),通常通过EEA,可靠地需要OC融合。随后提出了两个说明性案例,进一步举例说明通过EEA去除CVJ骨元素以实现完全脊索瘤切除术的程度如何预测OC融合的需要。
结论:单侧全髁切除术,50%双侧髁切除术,在颅底脊索瘤切除术中,最常描述的OC融合的独立预测因素是内侧寰枢关节元件的切除。此外,与枕骨髁的后外侧有明显较厚的关节囊一致,在产生OC不稳定之前,前中线入路似乎比外侧经颅入路(50%-70%)耐受更大程度的髁切除(75%).
Skull base chordomas are rare, locally osseo-destructive lesions that present unique surgical challenges due to their involvement of critical neurovascular and bony structures at the craniovertebral junction (CVJ). Radical cytoreductive surgery improves survival but also carries significant morbidity, including the potential for occipitocervical (OC) destabilization requiring instrumented fusion. The published experience on OC fusion after CVJ chordoma resection is limited, and the anatomical predictors of OC instability in this context remain unclear.
PubMed and Embase were systematically searched according to the PRISMA guidelines for studies describing skull base chordoma resection and OC fusion. The search strategy was predefined in the authors\' PROSPERO protocol (CRD42024496158).
The systematic
review identified 11 surgical case series describing 209 skull base chordoma patients and 116 (55.5%) who underwent OC instrumented fusion. Most patients underwent lateral approaches (n = 82) for chordoma resection, followed by midline (n = 48) and combined (n = 6) approaches. OC fusion was most often performed as a second-stage procedure (n = 53), followed by single-stage resection and fusion (n = 38). The degree of occipital condyle resection associated with OC fusion was described in 9 studies: total unilateral condylectomy reliably predicted OC fusion regardless of surgical approach. After lateral transcranial approaches, 4 studies cited at least 50%-70% unilateral condylectomy as necessitating OC fusion. After midline approaches-most frequently the endoscopic endonasal approach (EEA)-at least 75% unilateral condylectomy (or 50% bilateral condylectomy) led to OC fusion. Additionally, resection of the medial atlantoaxial joint elements (the C1 anterior arch and tip of the dens), usually via EEA, reliably necessitated OC fusion. Two illustrative cases are subsequently presented, further exemplifying how the extent of CVJ bony elements removed via EEA to achieve complete chordoma resection predicts the need for OC fusion.
Unilateral total condylectomy, 50% bilateral condylectomy, and resection of the medial atlantoaxial joint elements were the most frequently described independent predictors of OC fusion in skull base chordoma resection. Additionally, consistent with the occipital condyle harboring a significantly thicker joint capsule at its posterolateral aspect, an anterior midline approach seems to tolerate a greater degree of condylar resection (75%) than a lateral transcranial approach (50%-70%) prior to generating OC instability.