1、现代神经外科进展现代神经外科进展微创神经外科概述微创神经外科概述（The Progress of Modern Neurosurgery Summary of Minimally Invasive Neurosurgery)o 神经外科学是医学中最年轻而又最复杂的一门分支。自十九世纪欧洲首先创建神经外科专业以来，新的技术、治疗检查手段层出不穷，也使得神经外科成为临床医学领域中发展最快的分支学科之一。oNeurosurgery is the youngest but the most sophisticated branch of medicine.Since Europe first esta
2、blished the major of neurosurgery in the 19th century,with the update of medical technologies,examinations and treatments,neurosurgery has become one of the fastest growing subject of clinical medicine)o 1968年，以瑞士学者 Yasargil为代表的神经外科学家首先开展在显微镜下进行手术操作，由于手术视野放大及良好的照明，使得手术精确性大为提高，临近组织的损害机会明显减少，宣告了显微神经外科
3、时代的到来。oIn 1968,Swiss neurosurgeons,represented by Yasargil,first carried out the microscopic surgery in neurosurgery.Microscopic surgery,compared with conventional surgery,contributes significantly to the amplification of visual operative field and favorable lighting.These advantages make fine manip
4、ulation easier so that the risk of the damage to the surrounding structures decreased.The application of microscopy marked the beginning of the era of microneurosurgeryo 许多原来不能做的手术如今成为现实，原来的手术禁区正逐步打破。脑深部病变，脑干肿瘤，脊髓髓内肿瘤等许多疑难病症，前人束手无策，如今在显微神经外科时代许多问题得到了解决，确实是神经外科治疗史上的一项重大技术革命。oThe operations used to be
5、 impossible become reality now.Some of the operation areas that were inaccessible are no more restricted.Some difficult problems such as brain deep lesions,brain stem neoplasms and intramedullary spinal cord neoplasms which were incurable in the past are gradually solved in the new times of microneu
6、rosurgeryo 经过几代神经外科人的努力，目前神经外科已由显微神经外科发展到微创神经外科学阶段。(Through the efforts made by generations of neurosurgeons,neurosurgery has developed from microneurosurgery stage to minimally invasive neurosurgery stage)o 微创神经外科是以最小创伤的操作、最大限度保护、恢复脑神经功能、最大限度地为病人解决病痛，尽量减少医源性损伤。代表了以人为本的人文主义文化，是“生物-心理-社会”新型医疗模式的一种表现。
7、(The aims of minimally invasive neurosurgery are to achieve the best possible operative result,patient satisfaction,and minimal operation-related harm.It represents the“patient first”principle,and is a presentation of biology-psychology-society medical pattern)o 当代神经外科要求治疗结果不只是预防和降低手术后并发症，还包括解剖复位，以及
8、尽量恢复病人的神经和心理功能。(The therapeutic results requested now are not only prevention and decrease of surgical complications,but also the maximal recovery of neurologic and psychological functions)o微创神经外科学是全部外科治疗活动中追求的目标，而不局限于不局限于某种治疗方法、某种手术方式或应用了某种手术工具，微创神经某种治疗方法、某种手术方式或应用了某种手术工具，微创神经外科的的概念应该贯穿整个医疗活动中外科的的概
9、念应该贯穿整个医疗活动中，包括神经外科手术的每个步骤，如术前、术中以及术后过程。(The concept of minimally invasion is pursued in all medical activities and surgical procedures,not confined to a therapeutic method,a specific surgical option or a operative tool)微创神经外科产生的学科背景：神经影像学的发展微创神经外科产生的学科背景：神经影像学的发展(Facilitating Conditions：the develop
10、ment of neuroimaging)o 随着影像学的发展包括头颅CT、MRI、DSA、PET等诊断手段的更新，对于神经系统病变及周围正常组织结构提供了详尽的解剖学资料，使神经外科医师对病灶作出定位诊断和大多数病变作出病理性诊断使每个病人术前治疗计划更加完善，为神经外科手术提出了更高的要求。(Owing to the development of imaging tests including head CT,MRI,DSA,PET etc,more information about lesions and normal brain tissue can be acquired that
11、 helps neurosurgeons to make location diagnosis even pathological diagnosis of lesions.It actually assists in the planning of therapeutic strategies before an operation.The development of neuroimaging leads to higher standards of neurosurgery)o 手术显微镜、神经导航、神经内镜、各种精巧的手术器械的不断涌现，以及显微外科手术技术的熟练运用，将显微神经外科提
12、高到新的水平。a.Microscopy,neuronavigation,neuroendoscopy and all kinds of sophisticated surgical instruments update frequently.b.Neurosurgeons progressively improve the skill of microsurgery.c.Microneurosurgery has reached to a new level.微创神经外科产生的学科背景：各种神经外科器械的发展微创神经外科产生的学科背景：各种神经外科器械的发展(Facilitating Cond
13、itions：the development of surgical instruments)微创神经外科产生的学科背景：各种神经外科器械的发展微创神经外科产生的学科背景：各种神经外科器械的发展(Facilitating Conditions：the development of surgical instruments)o 时代不断的进步，病人更高的要求，更新科学技术成果的支持，推动医学飞速发展，作为微创外科领域的一个分支，微创神经外科学应运而生。它包括各类新兴的微创神经外科手术、介入治疗和立体放射治疗。(Minimally invasive neurosurgery is the prod
14、uction of progression of science and the higher demand of peoples health.It includes emerging operations of minimal invasion,interventional neuroradiology and stereotactic radiosurgery)现代神经外科学诊断技术现代神经外科学诊断技术(Modern diagnostic techniques in neurosurgery)o 电子计算机X线体层扫描（X-CT）o 核磁共振成像（MRI）o 数字减影血管造影（DSA）
15、o 正电子发射断层扫描（PET）o 脑磁图（Magnetoencephalogram,MEG）o 诱发电位（Evoked Potential）头颅头颅CTA(Head CTA)头颅头颅MRI(Head MRI)头颅头颅MRA(Head MRA)头颅头颅DSA(Head DSA)微创神经外科学的内容微创神经外科学的内容(content of minimally invasive neurosurgery)o 显微神经外科学（Microneurosurgery）o 介入神经外科学（Interventional neurosurgery）o 影像引导外科学（Interactive image-gui
16、ded neurosurgery）o 神经内镜辅助手术（Endoscopy-assisted neurosurgery）o 立体定向放射外科（Stereotactic radiosurgery）o 分子神经外科学（Molecular neurosurgery）显微神经外科显微神经外科（Microneurosurgery）o 显微神经外科学是以应用手术显微镜为标志，但决不能片面的将显微神经外科学理解为只要手术中使用手术显微镜就是显微神经外科手术。(The application of operating microscope for neurosurgery is a necessary con
17、dition,but not a sufficient condition)o 显微神经外科学的正确概念，是指以近代影像学为诊断基础，一整套与显微手术相匹配的手术设备、显微神经外科手术器械为保证的，以颅内病灶为中心的手术。(Microneurosurgery should at least demand the following conditions:1.a operation for intracranial lesions;2.based on the diagnosis of modern imaging;3.assisted by a complete set of microsur
18、gical equipment and instruments)现代化的神经外科手术室现代化的神经外科手术室（The modern operating room of neurosurgery）我科医师在手术显微镜下进行听神经瘤切除术我科医师在手术显微镜下进行听神经瘤切除术(The application of microscopy to the treatment of acoustic neuromas)显微镜下的颅内动脉瘤夹闭显微镜下的颅内动脉瘤夹闭(Clipping of an intracranial aneurysm in the view of operating microsc
19、ope)显微神经外科手术的特点显微神经外科手术的特点(The specialties of microneurosurgery)o 以病灶性为中心手术，减少脑组织损伤 (An operation centres on the lesion,to the benefit of the avoidance of damage to the surrounding structures)o 手术显微镜下全新的手术操作模式 (Brand new microscopic operative surgical technique)o随着显微神经外科技术的发展，以及神经影像技术的进步，使得一些颅内小的、深部
20、肿瘤发现率得以提高，是病变的解剖定位更加准确。(The progression of microneurosurgical and neuroimaging techniques increases the detection ratio of intracranial small and deap lesions and makes the data of anatomy location more accurate)o采用显微神经外科技术，可以利用头皮小切口、锁孔入路，以及少暴露、少牵涉病变周围正常组织，手术治疗这些病变成为可能，从而改变了传统开颅方式。尤其是术中导航技术的引进，为锁孔入路
21、技术的出现和推广提供了可靠的技术保证。(Precise acquisition of the chosen target with minimal disruption to the brain is achieved by using smaller incisions and portals of entry through the skull e.g.the key-hole approach,and by creating a narrow corridor of access to the target with avoidance of eloquent functional ar
22、eas of the central nervous system CNS,or important neurovascular structures.Microneurosurgical techniques and computer-assisted navigation are rapidly developing which enable minimalist and increasingly safer intervention within the CNS)介入神经外科学介入神经外科学(Interventional neurosurgery)o介入神经放射学：是在X线监测下，经血管
23、等途径借助引导器械（导管、导丝等）递送药物或其他特殊材料进入中枢神经系统病变区域，以达到栓塞、溶解、扩张、成形或抗肿瘤等治疗目的的一种方法。(Interventional neurosurgery:with the monitoring by X-ray,drugs or other special materials are delivered to the lesions throuth microcatheters or guidewires placed in intracranial and spinal vessels)o治疗对象主要为颅内动脉瘤、脑和脊髓动静脉畸形、动静脉瘘、硬脑
24、膜动静脉瘘、动脉和静脉窦狭窄、急性脑梗死以及头颈部肿瘤。(Application area:intracranial aneurysm,arteriovenous malformation,arteriovenous fistula,dural arteriovenous fistula,arterial and venous sinus stenosis,acute brain infarction,head and neck neoplasms)o 治疗技术分为血管内栓塞术、血管内药物灌注术和血管成形术。上述治疗过程的通路或治疗对象是相关动脉和引流静脉，因此也称为神经外科血管内治疗学、血管
25、内神经外科学。(The means of interventional neurosurgery includes endovascular embolization coiling,glue,particulate materrial etc,transcatheter arterial infusion and angioplasty.The treatment pathway and object are both related arteries and veins.Therefore,interventional neurosurgery is also named as neuro
26、surgical endovascular therapy or endovascular neurosurgery)我科的神经介入操作系统我科的神经介入操作系统(the neurointerventional operative system of our department)介入神经外科学在脑血管疾病中的应用介入神经外科学在脑血管疾病中的应用(Application of interventional neurosurgery in cerebrovascular disorders)o 动脉瘤(Intracranial aneurysm)o 动静脉畸形(Arteriovenous ma
27、lformation)o 动静脉瘘(Arteriovenous fistula)o 颅内动脉段狭窄 (Intracranial arterial stenosis)o 其他(Others)颅内动脉瘤血管内栓塞前后造影对比颅内动脉瘤血管内栓塞前后造影对比(The comparison of an intracranial aneurysm before and after endovascular embolization)颈内动脉起始段狭窄支架植入前后对比颈内动脉起始段狭窄支架植入前后对比(The comparison of severe stenosis of proximal segmen
28、t of unilateral internal carotid artery before and after stenting)颈内动脉海绵窦瘘球囊栓塞图示颈内动脉海绵窦瘘球囊栓塞图示(Embolization with balloon in the treatment of carotid-cavernous sinus fistulas)o介入神经放射治疗最大的优点是避免了开颅手术带来的组织创伤，也是微创神经外科学重要的组成部分。(The biggist advantage of interventional neuroradiology therapy is to avoid tis
29、sue trauma brought by craniectomy,and the therapy is also an important part of minimally invasive neurosurgery.)o目前介入神经放射治疗范围正在拓宽，规模不断扩大，效果日臻完善，在神经外科领域占据着越来越重要的地位，特别是对脑血管病的治疗已经取得了许多突破性进展，显示了一个具有强大生命力的广阔前景和领域。(Nowadays interventional neuroradiology therapy becomes more and more important in neurosurg
30、ery as its therapy range,scale and effect have developed.Especially for cerebrovascular disorders,the therapy has achieved many breakthroughs.It shows that interventional neuroradiology has extensive developing and application prospect)立体定向神经外科立体定向神经外科(Stereotactic Neurosurgery)o立体定向神经外科经历了有框架的立体定向神
31、经外科，目前已经发展了成熟的无框架定位设备。(Nowadays stereotactic neurosurgery has already developed from the phase of frame-based stereotaxy to the phase of frame-less stereotaxy.)o立体定向神经外科目前以神经导航为代表，是当前微创神经外科学的重要组成部分。(Stereotactic neurosurgery,represented by neuronavigation,is an important part of minimally invasive n
32、eurosurgery at present.)o目前，最先进的立体定向神经外科为术中MRI技术。(At present,intraoperative magnetic resonance imaging is the most advanced technique in stereotactic neurosurgery.)框架立体定向示意框架立体定向示意(Frame-based Stereotaxy)o 由于导航外科把现代神经影像诊断技术、立体定向外科和显微神经外科技术，通过高性能计算机结合起来，能准确、动态和实时显示神经系统解剖结构和病灶的3D空间位置和其毗邻关系。(Navigation
33、 combines the techniques of modern neuroimaging diagnosis,stereotactic surgery and microneurosurgery together assisted by high performance computer.It can show the anatomy of the central nervous system,3D position space of lesions and surrounding normal tissue accurately,dynamicly and real-timely.)神
34、经导航影像融合神经导航影像融合(image-merged techniques in neuronavigation)神经导航的优点神经导航的优点(Advantage of neuronavigation)o术前手术方案的设计(design of preoperative operative schemes)o术中实时3D空间定位(intraoperative real-time 3D spatial localization)o显示术野周围的结构(showwing the structure around the operative field)o指出目前手术位置与靶点的3D空间关系(poi
35、nting out the 3D spatial relationships between the operating position and the target)o术中适时调整手术入路(intraoperative adjustment of surgical approaches)o显示入路可能遇到的结构(showwing the structure of the approaches)o显示重要结构(showwing the important structures)o显示病灶切除范围(showwing the range of resected lesions)o它应用于颅内各种
36、占位病变（如肿瘤、囊肿和脓肿等）、血管畸形、癫痫、颅底肿瘤、先天或后天畸形、鼻窦、脊柱和脊髓病变等。(Neuronavigation surgery is used for the treatment of intracranial mass such as tumor,cyst and abscess,vascular malformation,epilepsy,skull base tumor,deformity,lesions of spine and spinal cord.)o一旦病人资料被注册后，系统就可以追踪手术探针，从而追踪手术的过程，其精确程度可达毫米。更小的切口、更精确的病
37、变组织切除和减少对周围正常组织损伤，降低手术后并发症，改善预后。(Once the patients information registered,the system can track from the surgical probe to the procedures as accurate as 1 mm,contributing to a smaller incision,more accurate resection of lesions and lower damage to surrounding normal tissue.It is in favor of reducing
38、post-operative complications and improving prognosis.)神经外科医师在神经导航下为患者施行深部脑肿瘤手术神经外科医师在神经导航下为患者施行深部脑肿瘤手术(The application of neuronavigation to the treatment of deep brain tumor)o开放的MRI导航技术提高了手术的安全性、有效性和性能价格比，并推动了神经外科的发展。术中MRI为导航、确定颅内肿瘤边界，完整安全地切除肿瘤提供了有益的影像信息，减少了手术并发症。(The open MRI navigation technology
39、 improves the safety,effectivity and performance-price ratio of operations and promote the development of neurosurgery.Intraoperative MRI provides useful imaging informations for navigation and identification of the tumor boundary for complete resection.It also reduce the occurance of surgical compl
40、ications.)o术中MRI导航系统的应用，为神经外科手术的发展提供了广阔的前景。特别是集神经影像、麻醉和手术设备为一体的手术单元出现，可以使手术完全置于影像学检查之中，手术医师可以随时将手术中的病人进行磁共振检查，确定手术进行状态，指导手术，提高手术效果。这种手术中应用开放式的磁共振的方法，改变了传统的手术观念，相信不久的将来这种具有高端技术的手术单元会在临床中得到推广应用。(The application of the intraoperative MRI navigation system provides a broad prospect of the development of
41、 neurosurgery.Benefiting from the appearance of the operating unit including the equipments of neuroimaging,anesthesia and surgery,surgeons can performe MRI for patients at any time in a operation to determine the next step to do.The application of open intraoperative MRI changes traditional concept
42、 of operation.And the operating unit will be applied in clinic in the near future.)术中术中MRI系统系统(Intraoperative MRI system)神经内镜辅助手术神经内镜辅助手术(Neuroendoscopy assisted microneurosurgery)o神经内镜辅助手术：利用神经内镜亦称脑室镜，辅助神经外科手术，可以缩小开颅范围，放大手术野内解剖结构图像增强局部光照，提 高 了 手 术 效 果，属 微 创 神 经 外 科 重 要 技 术。(Neuroendoscopy also name
43、d as ventriculoscope assisted microneurosurgery is an important technique of minimally invasive neurosurgery which can reduce the scope of craniotomy,enlarge the view of operating field,enhance local lighting and improve the final effect.)o神经内镜辅助下的显微手术治疗颅内动脉瘤、蛛网膜囊肿、脑室内 微 小 病 变、经 单 鼻 孔 切 除 垂 体 瘤，获 得
44、良 好 效 果。(Neuroendoscopy can be used in the operations for intracranial aneurysm,arachnoid cyst,intraventricular small lesion and pituitary adenoma.The assistance of neuroendoscopy makes a positive effect on operation result.)神经內镜尸头解剖训练神经內镜尸头解剖训练(Operation training of neuroendoscopy on cadaveric head
45、)神经内镜的优势神经内镜的优势(The advantages of neuroendoscopy)o内镜视管本身可带有侧方视角，可消除术中死角 (Endoscopy can eliminate intraoperative blind angle with a side view on the canal.)o借助立体定向或神经导航技术可以精确定位，能处理常规手术难以达到的部位，对脑深部或中线部位的病变手术尤为合适 (With the accurate location provided by stereotactic or neuronavigation technology,surgeon
46、s can deal with the lesions out of reach in routine surgery,especially for the lesions in the deep brain or midline of the brain.)o神经内镜更适合用于微骨窗入路，手术侵袭性 (Neuroendoscopy is more suitable for micro bone window craniotomy which is less invasive.)脑室镜图示脑室镜图示(ventriculoscope)神经内镜的局限性神经内镜的局限性(The limitation
47、s of neuroendoscopy)o神经内镜本身受管径限制，视野狭小，操作空间小，难于观察到手术野全貌，如对周围组织解剖不清楚，应付手术意外能力差，极易导致操作失误。(Limited by the small caliber of neuroendoscopy,the view of operating field is narrow and the operating space is small.If a surgeon was unfamiliar with the anatomic structures in the operating field,it would be har
48、d for him to deal with surgical accidents and be easy to make errors in an operation.)o神经内镜手术操作需要一定的空间，因此在脑实质内图像显示不清，无法应用。(Neuroendoscopy assisted surgery requires a certain space.And the images cant be clearly displayed in the brain parenchyma so that the application of neuroendoscopy is relatively
49、 limited.)神经内镜的局限性神经内镜的局限性(The limitations of neuroendoscopy)o神经内镜检查获得的活体组织学标本太小，缺乏结论性的病理诊断，这个问题应充分估计到，并应在术前向病家说明。(The living histological specimens acquired from the neuroendoscopic biopsy may be too small to get a conclusive pathological diagnosis that should be told to the patient and his family
50、pre-operation.)o神经内镜手术，需要配套以较纤细的、特定形状的、适合深部操作的器械，器械的配套程度及合理程度有时可以对手术时间长短，甚至对手术效果影响很大。(Neuroendoscopic surgery need to be matched with equipments which are slender,certain shape and suitable for deep operation,or it will influence operative time and effect.)o神经内镜只是围绕手术提供一个工具，不能在手术中单纯追求应用神经内镜，任意扩大手术适应
