전두개와와터키안주변부에발생한종양에대한눈확위접근법 순천향대학교의과대학서울병원신경외과학교실조성진 J Korean Skull Base Society 13 권 2 호 : 5~10, 2018 종설1 종설2 원저1 원저2 증례1 증례2 증례3 증례4 증례5 The supraorb
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1 순천향대학교의과대학서울병원신경외과학교실조성진 J Korean Skull Base Society 13 권 2 호 : 5~10, 2018 종설1 종설2 원저1 원저2 증례1 증례2 증례3 증례4 증례5 The supraorbital approach for anterior skull base, sella and parasellar tumors Department of Neurosurgery, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea Sung Jin Cho 교신저자 Sung Jin Cho 논문접수일 : 2018 년 8 월 5 일논문완료일 : 2018 년 8 월 30 일주소 : Department of Neurosurgery, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, 59, Daesagwan-ro, Yongsan-gu, Seoul 04401, Korea Tel : Fax : chosj@schmc.ac.kr Traditional surgical approaches to brain tumors in anterior skull base were implemented through long skin dissection and large skull bone flap, but these approaches cause significant damage to soft tissue. Today's neurosurgery has been developed with minimal surgical procedure, such as supraorbital approach (SOA), result of the improvement of surgical microscopes, endoscopy, and navigation devices. Compare with traditional pterional approach, the SOA is a safe and effective keyhole method to remove both extraaxial and intraaxial skull base tumors, particularly lesions of the orbitofrontal region and parasellar area allowing for minimal disruption of normal brain parenchyma and promoting a rapid recovery and short hospital stay. The SOA also provide better cosmetic result such as avoiding temporalis muscle atrophy. Key Words Skull base, Sella turcica, Minimal invasive surgical procedure 5
2 INTRODUCTION 전두개와에발생한뇌종양에대한전통적수술접근법은관자놀이접근법 (pterional approach), 양쪽이마밑접근법 (subfrontal approach) 그리고안와협골접근법 (orbitozytomatic approach) 등과같이긴피부절개와큰두개골절개를통해서시행되어왔다. 이러한접근법들은상당한연부조직에대한손상을유발하게되고이로인한합병증도발생하게된다. 현재의신경외과수술은수술현미경과내시경, 그리고항법장치의발달로작은두개골절개술로도충분히병소를안전하게제거할수있게되었고, 눈확위접근법 (supraorbital approach) 과같은최소침습수술이개발되었다. 눈확위접근법은 1908년에 Fedor Krause에의해처음소개된이래현재까지유용하게시행되고있다.[1,2] 이논문에서본교실의수 술경험과문헌고찰을통하여눈썹피부절개를통한눈확위접근법에대한기본수술기법을증례소개를통해고찰하고자한다. SURGICAL TECHNIQUE 전신마취하에기관내삽관후도뇨관을삽입한후머리를 Mayfield 머리고정장치를쓰거나혹은말발굽 (horseshoe) 머리받침대를써서약 15-20도정도신전시켜전두엽이중력에의해떨어질수있도록한다. 머리의회전은종양의위치에따라 도까지반대쪽으로시행한다. 후각신경구수막종과같이앞쪽중앙에위치한종양에대해서는머리회전을 60도까지시행한다. 피부절개시가장주의해야할점은수술후시각신경 (optic nerve) 손상으로인한이마부위의감각저하를방지하기위해눈확위구멍 A Fig. 1 B (A) Intraoperative close-up of MacCarty s keyhole after reflection of periosteal flap and anterior portion of temporlis muscle. (B) Removal of the bone flap exposes the dura mater. A Fig. 2 B C D Intraoperative microscopic images. (A) C-shape durotomy was made after supraorbital craniotomy. (B, C) Exposure of a tumor (T) mass after frontal lobe retraction. (D) After removal of tumor, exposure of optic nerve (ON), anterior cerebral artery (A1) and middle cerebral artery (M1). 6 JOURNAL OF KOREAN SKULL BASE SOCIETY SEPTEMBER Vol. 13 No. 2
![[3,4] 피부절개는 15번칼로시행하며진피부위까지시행한다음눈둘레근 (orbicularis oculi muscle), 위쪽의이마근 (frontalis muscle) 을절개하며측두근 (temporalis muscle) 일부를절개한다. 이때눈둘레근이손상되지않도록주의를요한다.](/docs-images/97/132239011/images/3-1.jpg "피부와근육의견인은견인기를사용하지않고물고기갈고리 (fish hook) 를사용해야견인손상을최소화할수있다. MacCarty s keyhole 에해당하는측두골에 5 mm 크기의천두공 (burr hole) 을만든후 1.2-2 x 2.5-3 cm 크기의머리뼈절개술을시행한다 (Fig. 1).")
3 (supraorbital foramen) 을촉진하여이로부터약 5 mm 이상떨어진곳으로부터눈썹의밑쪽부분에피부절개를해야한다. 좀더큰머리뼈절개가필요한경우에는피부절개를안와연 (orbital rim) 을따라확장시킬수있다. 눈썹제거는하지않는데, 눈썹을제거하지않아도감염의위험성은없는것으로보고되었고, 수술후흉터도잘보이지않는장점이있다.[3,4] 피부절개는 15번칼로시행하며진피부위까지시행한다음눈둘레근 (orbicularis oculi muscle), 위쪽의이마근 (frontalis muscle) 을절개하며측두근 (temporalis muscle) 일부를절개한다. 이때눈둘레근이손상되지않도록주의를요한다. 피부와근육의견인은견인기를사용하지않고물고기갈고리 (fish hook) 를사용해야견인손상을최소화할수있다. MacCarty s keyhole 에해당하는측두골에 5 mm 크기의천두공 (burr hole) 을만든후 x cm 크기의머리뼈절개술을시행한다 (Fig. 1). 이때주의할점은측두근을박리할때심한전기소작을피해야하는데이는안면신경의전두분지의손상을예방하기위함이다. 머리뼈절개술시전두동 (frontal sinus) 이큰경우에는이를피해서이보다외측방향에서시행해야수술후뇌척수액비루와수술후감염을최소화할수있다. 만약전두동이노출된경우에는골밀랍 (bone wax) 나 betadine-soaked gel foam으로노출부위를잘막아야한다. 전두엽견인을최소화하기위해서경막을눈확천장 (orbital roof) 으로부터박리한후눈확천장을고속천공기 (high speed drill) 를이용하여평판하게제거해야한다. 이때안와골막 (periorbita) 이손상되면안와지방 (orbital fat) 이탈출될수있으므로주의해야한다. 이후경막절개를 C-자모양으로시행한후전두엽이노출되면뇌견인기를이용하여조심스럽게견인한후뇌수조를열어뇌척수액을배액한다 (Fig. 2). 이후에는관자놀이접근법으로수술할때와동일한방법으로필요할경우실비안구를박리할수있다. 종양을 cavitron ultrasonic aspirator (CUSA) 와두극응고기 (bipolar coagulator) 등을이용하여제거한후경막을 4.0 nurolon 봉합사를이용하여봉합한후 bone flap 을 titanium mesh를이용하여고정시킨다. 전두근은반드시봉합해야하여피부는피하봉합을촘촘히한후 sterile strip을이용할수도있고, 6.0 nylon 봉합사를이용하여봉합할수도있다. CASE ILLUSTRATION 1. Case 1 42세여자로서서히진행되는시력저하로내원하였다. 안과적검사상에서우안은중심 5도미만의시야보존이외의전범위에서시야결손이관찰되었다. 좌안은비하측 1/4의시야보존이외전범위에서시야결손의소견이관찰되었다. 뇌자기공명영상촬영에서후각신경구에서발생한것으로보이는균일하게조영증강되는 Fig. 3 A B C Preoperative magnetic resonance image including axial (A), coronal (B), and sagittal (C) views show homogenous enhancing a large frontal-based tumor (4.1 x 3.1 cm sized) with suprasellar extension, favoring olfactory groove meningioma. Fig. 4 A B C Postoperative magnetic resonance images, including axial (A), coronal (B), and sagittal (C) views show total tumor removal. 7
4 4.1 x 3.1 cm 크기의축외종양이발견되었고, 터키안상부까지확 tomography) 이나뇌자기공명영상 (brain magnetic resonance 장되어있었다. 양측의시각신경과시각신경교차부가압박되고있 imaging) 같은방사선영상의발전과수술항법장치의개발그리고는소견이었다 (Fig. 3). 후각신경구수막종으로진단되어전신마취수술중신경감시장치의발달로종양과신경, 혈관의구분이명확하에우측눈확위접근법으로종양제거술을시행하였고, 심슨등급해졌고, 수술중에도수술현미경과내시경등으로병변을정확하게 (Simpson grade) 2로적출되었다 (Fig. 4). 조직학적으로세계보건확인할수있게되었다.[1] 전두개와와터키안주변의종양의제거기구 (World Health Organization) grade 1에해당하는수막내피수술은전두엽과측두엽을견인하여뇌의기저부로접근하는수술이막종 (meningotheliomatous meningioma) 으로진단되었다. 수술기때문에개두술을크게하지않더라도뇌의기저부로접근할수후시력과시야는호전되었고수술후 6개월째상처는육안으로잘있는두개골을조금제거하는것으로도충분히종양수술을용이하보이지않을정도였다 (Fig. 5). 게할수있다. 전두개와와터키안주변부에발생하는종양은후각신경구수막종 (olfactory groove meningioma), 접형골면종 (planum 2. Case 2 sphenoidale meningioma), 결절안장수막종 (tuberculum sella 56세남자로후각상실과두통으로내원하여시행한뇌자기공명 meningioma), 침대돌기수막종 (clinoidal meningioma), 해면혈관영상에서후각신경구와결절안장에서발생된것으로추정되는균종 (cavernous hemangioma), 두개인두종 (craniopharyngioma), 등하게조영증강되는다엽성 (multilobulated) 의 4.1 x 3 x 1.6 cm 뇌하수체선종 (pituitary adenoma), 전이성뇌종양 (metastatic 크기의종괴가관찰되었다. 우측의시각신경과시각신경교차부가 brain tumor), 신경교종 (glioma) 그리고뇌농양 (abscess) 등이있종양에의해압박되는소견이었으며, 수막종으로진단되었다 (Fig. 다.[3,5-7] 6). 종양은우측눈확위접근법으로심슨등급 2로절제되었다 (Fig. 이중에서후각신경구수막종은후각신경구가존재하는전두개와 7). 병리조직학적검사상종양은수막내피수막종과모래종수막종의사상판 (cribriform plate) 에발생하며, 천천히자라면서양쪽전 (psammomatous meningioma) 으로진단되었다. 수술후환자는두엽을압박하게되므로증상이늦게나타나진단되었을때에이미양호한경과를보였다. 종양의크기가상당히커져있는경우가많으며, 해부학적으로두개기저부의가장약한부위에발생하므로부비동 (paranasal sinus) DISCUSSION 전두개와와터키안주변부에발생한종양에대한수술적치료는전통적으로관자놀이접근법이나양쪽이마밑접근법등과같이피부절개와머리뼈절개를크게만들어수술시야를넓게하는것이많이시행되어왔다. 그러나개두술의크기가클수록감염, 출혈, 측두근의위축, 절개부위의탈모및감각저하등의합병증의발생위험이높아진다.[5] 최근뇌컴퓨터단층촬영 (brain computed Fig. 5 A A photograph taken 6 months after the operation. The arrow points to the postoperative wound. 및비강으로확장되기가쉽다.[8-10] 또한종양이큰경우발견당시이미종양주변의뇌부종이심하게있는경우가많아뇌견인이어려울수있다. 종양으로의혈액공급은주로전사골동맥 (anterior ethmoidal artery) 으로부터이루어지며, 이동맥은수술시쉽게차단될수있으므로눈확위접근법으로전두엽을최소견인하고, 종양내감압제거를먼저하면서제거하면종양의크기가크더라도충분히완전제거가가능하다.[11,12] 이때한가지주의해야할점은종양의영양동맥이거대종양인경우전대뇌동맥으로부터나오는경우가있으므로전기소작술시영양동맥을제외한전대뇌동맥으로부터나오는모든혈관가지는보존해야하며특히혈관줄기가손상되지않도록주의해야한다.[13] 종양의크기가매우큰경우에는종양의후방에위치하는내경동맥과시각교차부와유착이있는경우가있는데이때시각교차부로공급하는동맥이손상받 지않도록유의해야한다.[13] 저자의경우후각신경구수막종을수술할때머리를 8 JOURNAL OF KOREAN SKULL BASE SOCIETY SEPTEMBER Vol. 13 No. 2
![[15] 따라서종양이치우친쪽으로접근할때같은쪽의시각신경을더욱조작하게되어시각신경의손상을초래할수있으므로, 종양의반대쪽으로접근하는것이시각신경과속목동맥 (internal carotid artery) 의가지혈관의손상을방지할수있다는보고도있다.](/docs-images/97/132239011/images/5-2.jpg "그외의종양들에대한눈확위접근법은전통적인관자놀이접근법과거의동일한수술시야를제공하므로비교적어렵지않게종양제거가가능하다. 따라서눈확위접근법은최소침습수술로써관자놀이접근법에비 해머리뼈절개가적고전두엽바닥으로접근하여뇌견인이적은장점이있다.")
5 반대편으로 45-60도정도회전시켜종양의앞부분까지충분히볼수있도록한다. 머리의회전정도는수술전뇌자기공명영상으로작은개두술에보여질수있는각도를미리측정하여회전각도를결정한다. 결절안장수막종은시각신경관 (optic canal) 으로흔하게확장되므로시각신경의손상을최소화시키는것이중요하다. 따라서눈확위접근법으로수술할때낫인대 (falciform ligament) 와시각신경집 (optic nerve sheath) 를미리열어주어야시각신경의견인으로부터시각신경을보호할수있다. 이렇게시각신경관을열어주면시각신경관안에침범한종양도완전히제거할수있다.[14] 결절안장수막종은정중앙에서발생되지않고중앙에서벗어난곳에서발생되는경우가많은데이로인해시력저하가비대칭으로나타날수있다.[15] 따라서종양이치우친쪽으로접근할때같은쪽의시각신경을더욱조작하게되어시각신경의손상을초래할수있으므로, 종양의반대쪽으로접근하는것이시각신경과속목동맥 (internal carotid artery) 의가지혈관의손상을방지할수있다는보고도있다. 그외의종양들에대한눈확위접근법은전통적인관자놀이접근법과거의동일한수술시야를제공하므로비교적어렵지않게종양제거가가능하다. 따라서눈확위접근법은최소침습수술로써관자놀이접근법에비 해머리뼈절개가적고전두엽바닥으로접근하여뇌견인이적은장점이있다. 또한관자놀이접근법과마찬가지로시각신경관도감압할수있어시각신경관안으로침범한종양을제거할수있으며, 현미경수술과내시경수술을병행하여숨어있는종양도모두제거할수있어효과적으로보여진다.[16,17] 눈확위접근법에의한수술의가장큰단점은경험이없는수술자에게는수술중예기치않은동맥의손상이나뇌부종이심할때대처가어렵다는점인데, 이때뇌하수체종양을수술할때사용하는수술기구를사용하면충분히해결할수있다. 또한눈확위신경의손상에의한이마부위의감각저하와눈썹위에상처가남을수있는데, 눈확위신경보다최소 5 mm 이상외측으로피부절개를하면대부분신경손상을피할수있으며, 눈썹위의흉터는보통수술후 6개월이지나면육안으로자세히보지않으면흉터가잘보이지않을정도로호전된다. 눈확위접근법의장점은수술시간이빠르고, 출혈이적고, 머리를핀으로고정시키지않아도되며, 수술후통증이적고, 측두근의위축이거의없으며, 흉터가잘보이지않는다는것이다. CONCLUSION 전두개와및터키안주변부에발생한종양에대한수술로써눈확위접근법은전통적인접근방식과비교하여, 안전하고효과적으로 Fig. 6 A B C Preoperative magnetic resonance image including axial (A), coronal (B), and sagittal (C) views show multilobulated homogenous enhancing a large frontalbased tumor (4.1 x 3.0 x 1.6 cm sized) with suprasellar extension, favoring olfactory groove meningioma and tuberculum sellae meningioma (double primary tumor). Fig. 7 A B C Postoperative magnetic resonance images, including axial (A), coronal (B), and sagittal (C) views show total tumor removal. 9
6 축외종양과축내종양을제거할수있는최소침습방법이다. 눈확위접근법은또한수술후측두근위축을초래하지않아전통적수술접근법보다더나은미용결과를제공한다. CONFLICT OF INTEREST No potential conflict of interest relevant to this article was reported. REFERENCES 1. Zumofen DW, Rychen J, Roethlisberger M, Taub E, Kalbermatten D, Nossek E, et al. A review of the literature on the transciliary supraorbital keyhole approach. World Neurosurg 2017;98: Reisch R, Perneczky A, Filippi R. Surgical technique of the supraorbital key-hole craniotomy. Surg Neurol 2003;59: Reisch R, Perneczky A. Ten-year experience with the supraorbital subfrontal approach through an eyebrow skin incision. Neurosurgery 2005;57: Dare AO, Landi MK, Lopes DK, Grand W. Eyebrow incision for combined orbital osteotomy and supraorbital minicraniotomy: application to aneurysms of the anterior circulation. Technical note. J Neurosurg 2001;95: Xiao J, Wang W, Wang X, Mao Z, Qi H, Cheng H, et al. Supraorbital keyhole approach to the sella and anterior skull base via a forehead wrinkle incision. World Neurosurg 2018;109:e343-e Ditzel Filho LF, McLaughlin N, Bresson D, Solari D, Kassam AB, Kelly DF. Supraorbital eyebrow craniotomy for removal of intraaxial frontal brain tumors: a technical note. World Neurosurg 2014;81: Melamed I, Merkin V, Korn A, Nash M. The supraorbital approach: an alternative to traditional exposure for the surgical management of anterior fossa and parasellar pathology. Minim Invasive Neurosurg 2005;48: Adappa ND, Lee JY, Chiu AG, Palmer JN. Olfactory groove meningioma. Otolaryngol Clin North Am 2011;44: Ali N, Akunjee M, Ahfat F. Acute and severe visual loss due to an olfactory groove meningioma. Can J Ophthalmol 2009;44:e Pepper JP, Hecht SL, Gebarski SS, Lin EM, Sullivan SE, Marentette LJ. Olfactory groove meningioma: discussion of clinical presentation and surgical outcomes following excision via the subcranial approach. Laryngoscope 2011;121: El Gindi S. Olfactory groove meningioma: surgical techniques and pitfalls. Surg Neurol 2000;54: Rodrigues Lib rio Dos Santos A, Vin cius Calfat Maldaun M, Andrade Gripp D, Watanabe J, Hiroshi Fujiki R, Henrique Pires de Aguiar P. Minimally invasive interhemisferic approach for giant olfactory groove meningioma: Technical note. World Neurosurg j.wneu Romani R, Lehecka M, Gaal E, Toninelli S, Celik O, Niemel M, et al. Lateral supraorbital approach applied to olfactory groove meningiomas: experience with 66 consecutive patients. Neurosurgery 2009;65: Sade B, Lee JH. High incidence of optic canal involvement in tuberculum sellae meningiomas: rationale for aggressive skull base approach. Surg Neurol 2009;72: Solero CL, Giombini S, Morello G. Suprasellar and olfactory meningiomas. Report on a series of 153 personal cases. Acta Neurochir (Wien) 1983;67: Wilson DA, Duong H, Teo C, Kelly DF. The supraorbital endoscopic approach for tumors. World Neurosurg 2014;82:S Gazzeri R, Nishiyama Y, Teo C. Endoscopic supraorbital eyebrow approach for the surgical treatment of extraaxialand intraaxial tumors. Neurosurg Focus 2014;37:E JOURNAL OF KOREAN SKULL BASE SOCIETY SEPTEMBER Vol. 13 No. 2
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KISEP Case Reports Korean J Otolaryngol 1999;42:232-6 경미로접근법으로제거한거대소뇌교각종양 4 예 박찬민 황보철 신종헌 손수준 Four Cases of Large Cerebellopontine Angle Tumors Remove
KISEP Case Reports Korean J Otolaryngol 1999;42:232-6 경미로접근법으로제거한거대소뇌교각종양 4 예 박찬민 황보철 신종헌 손수준 Four Cases of Large Cerebellopontine ngle Tumors Removed by Translabyrinthine pproach Chan Min Park, MD, Cheul
KISEP Clinical Research J Korean Neurosurg Soc , 2000 급성경막하혈종에서응급두개골천공의위치 문수현 김근회 권택현 박윤관 정흥섭 서중근 = Abstract = Emergency Trephination Site o
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KISEP 40 7 1997 Abstract 안면신경초종의치료경험 전영명 박기현 이진석 전상훈 The Management of Facial Nerve Schwannoma Young-Myoung Chun, M.D., Keehyun Park, M.D., Jin-Suk Lee, M.D., Sang-Hoon Chun, M.D. Department of Otolaryngology,
제5회 가톨릭대학교 의과대학 마취통증의학교실 심포지엄 Program 1 ANESTHESIA (Room 2층 대강당) >> Session 4 Updates on PNB Techniques PNB Techniques for shoulder surgery: continuou
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Purpose: Delayed massive hemorrhages from pseudoaneurysm rupture of the peripancreatic large arteries, after pancreaticoduodenectomy, are fatal. We reviewed the clinical course and outcome of bleeding
Korean J Otolaryngol 40 1, January 1997 신마취하에 종양을 적출하였다. 경부의 절개는 양측에 증 례 서 접근하기 위하여 Apron 피판을 올린후 우측 흉쇄 유돌근과 흉골설골근사이의 근막을 흉쇄유돌근의 전 연을 따라 절개하자 피낭형성이 잘
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