本文關(guān)鍵詞：顱底內(nèi)外溝通區(qū)的顯微外科解剖　出處：《中南大學(xué)》2011年博士論文　論文類型：學(xué)位論文

  更多相關(guān)文章： 蝶竇 篩板 額鼻縫 蝶骨平臺 垂體窩 鼻腔 盲孔 經(jīng)額底下入路 視神經(jīng)管 眶上裂 眶上孔 篩前孔 篩后孔 視神經(jīng)眼動脈 額鼻縫 眶上裂 前床突 棘孔 圓孔 卵圓孔 翼突 顳骨嵴 額顳眶顴入路 乳突 頸靜脈孔 頸靜脈突 莖突 二

【摘要】：顱底可視為一板兩面,顱內(nèi)面承載著腦底結(jié)構(gòu)如額葉、下丘腦-垂體、海綿竇、顳葉、腦干、小腦與顱神經(jīng)等等,顱底板的裂隙有進(jìn)出顱的神經(jīng)血管經(jīng)過,其間也藏有固有結(jié)構(gòu)如內(nèi)耳、迷路、頸靜脈球等等,顱底外面是面顱與頸顱結(jié)構(gòu)如鼻腔、鼻旁竇、顳下窩、翼腭窩、咽旁間隙等等。顱底腫瘤可向顱內(nèi)外溝通,累及上述三者結(jié)構(gòu),位置深在,解剖關(guān)系復(fù)雜,是神經(jīng)外科手術(shù)的難點。本研究從顯微外科解剖角度來理解顱內(nèi)外溝通區(qū)的解剖關(guān)系,尋找定位手術(shù)標(biāo)志,為該區(qū)域的手術(shù)提供解剖基礎(chǔ)。第一章顱鼻蝶溝通區(qū)的顯微解剖 目的研究前顱窩與鼻腔、鼻旁竇溝通,鞍區(qū)與蝶竇、鼻腔溝通區(qū)的顯微外科解剖關(guān)系。確認(rèn)經(jīng)額徑路的手術(shù)標(biāo)志。 方法觀察和測量前顱底骨性構(gòu)成,額鼻縫、盲孔、篩板、蝶骨平臺、鞍結(jié)節(jié)、垂體窩、蝶竇、鼻腔、篩竇、前鼻棘等間的關(guān)系。觀察經(jīng)額三種入路和經(jīng)蝶入路相關(guān)的顱內(nèi)結(jié)構(gòu)、顱底與顱外結(jié)構(gòu)的顯露。 結(jié)果篩板位于前顱底中央前部,介入額骨、蝶骨平臺與篩骨迷路之間,上接額葉,下為鼻腔頂。蝶骨平臺為蝶竇上壁,其后有視交叉溝、鞍結(jié)節(jié)和垂體窩,外側(cè)有視神經(jīng)。額鼻縫至盲孔的距離為12.70±1.28mm,額鼻縫至篩板后界的距離為35.67±1.12mm,額鼻縫至蝶棱的距離為51.40±2.98mm,額鼻縫至鞍結(jié)節(jié)的距離為54.32±1.89mm,額鼻縫至鞍背的距離為65.78±1.56mm。盲孔至篩前孔的距離為10.98±1.12mm,盲孔至篩后孔的距離為25.11±1.25mm。前鼻棘至蝶竇開口的距離為42.34±2.23mm,前鼻棘至鼻腔頂篩板前界的距離為41.88±0.24mm,前鼻棘至鼻腔頂篩板后界的距離為52.05±.45mm。 結(jié)論顱鼻蝶溝通區(qū)是以篩板和蝶竇為媒介,前顱窩與鼻腔,鞍區(qū)與蝶竇、鼻腔得以溝通。經(jīng)額入路的手術(shù)標(biāo)志分為三級：一級手術(shù)標(biāo)志是額鼻縫,二級手術(shù)標(biāo)志是盲孔,三級手術(shù)標(biāo)志有篩板、蝶骨平臺、蝶棱、鞍結(jié)節(jié)和蝶竇等。經(jīng)鼻蝶的手術(shù)標(biāo)志分為三級：一級手術(shù)標(biāo)志是前鼻棘,二級標(biāo)志是蝶竇開口,三級標(biāo)志是蝶竇。經(jīng)額底下入路可廣泛暴露此溝通區(qū)域。第二章顱眶溝通區(qū)的顯微解剖 目的研究前顱窩與眼眶的解剖關(guān)系,眶上裂與視神經(jīng)管內(nèi)結(jié)構(gòu),確認(rèn)經(jīng)眶外側(cè)入路的手術(shù)標(biāo)志。 方法觀察和測量眶頂、視神經(jīng)管和眶上裂的骨性構(gòu)成,測量眶上孔與篩前孔、篩后孔、視神經(jīng)管的距離,眶上裂與視柱、頸動脈溝、圓孔等的關(guān)系。 結(jié)果顱眶溝通主要是經(jīng)過位于眶尖的視神經(jīng)管與眶上裂,視神經(jīng)管內(nèi)走行的結(jié)構(gòu)有視神經(jīng)與眼動脈,眼眶經(jīng)視神經(jīng)管連向鞍區(qū)�？羯狭咽沁M(jìn)出眼眶神經(jīng)的主要通道,有動眼神經(jīng)、滑車神經(jīng)、外展神經(jīng)和眼神經(jīng)等,眼眶借眶上裂與中顱窩海綿竇相接�？羯峡字量魞�(nèi)篩前孔的距離為30.12±2.35mm,至眶內(nèi)篩后孔的距離為39.75±1.25mm,至視神經(jīng)管眶口的距離為43.35±1.67mm。 結(jié)論顱眶溝通可以是眶頂板直接破壞,但主要是經(jīng)視神經(jīng)管與眶上裂連向中顱窩的鞍區(qū)和海綿竇。經(jīng)眶外側(cè)入路的一級解剖標(biāo)志有眶上孔或眶上切跡、眶額動脈管；二級標(biāo)志有眶上裂、前床突和視柱。經(jīng)眶外側(cè)入路可顯露眶內(nèi)結(jié)構(gòu),特別是較好暴露鞍區(qū)、海綿竇與中顱底外側(cè)部分。第三章中顱窩與顳下窩-翼腭窩溝通區(qū)的顯微解剖 目的研究中顱窩與顳下窩、翼腭窩的解剖關(guān)系,海綿竇外側(cè)壁和中顱底的解剖三角。確認(rèn)額顳眶顴入路的手術(shù)標(biāo)志。 方法觀察和測量海綿竇外側(cè)壁、圓孔、卵圓孔、棘孔、顳下窩、翼腭窩的結(jié)構(gòu)組成與關(guān)系。 結(jié)果中顱窩底前界是眶上裂與眼眶,外側(cè)是顳窩,后借顳骨巖部與后顱窩相隔,海綿竇位于蝶鞍的兩側(cè),中顱底的內(nèi)側(cè)份,中顱窩借圓孔、卵圓孔、棘孔、破裂孔與其下的顳下窩、翼腭窩和咽旁間隙溝通。一級手術(shù)標(biāo)志有額顴縫、眶額動脈管與棘孔。二級手術(shù)標(biāo)志有眶上裂、前床突、圓孔、卵圓孔與面神經(jīng)門。三級手術(shù)標(biāo)志有上頜神經(jīng)、下頜神經(jīng)、腦膜中動脈、翼突與顳骨嵴。 結(jié)論中顱底骨板的下方即是顳下窩與翼腭窩,中顱窩-顳下窩-翼腭窩溝通區(qū)經(jīng)眶上裂、眶下裂與視神經(jīng)管連通眼眶,經(jīng)蝶腭孔通向鼻腔,內(nèi)側(cè)借蝶竇外側(cè)壁與蝶竇相隔,后是后顱窩的前界顳骨巖部和莖突前間隙。該溝通區(qū)的病變多累及海綿竇,故對海綿竇的處理是手術(shù)關(guān)鍵之一。額顳眶顴入路可以多視角進(jìn)入中顱窩-顳下窩-翼腭窩溝通區(qū),暴露廣泛,手術(shù)路徑短。第四章頸靜脈孔顱內(nèi)外溝通區(qū)的顯微解剖 目的研究頸靜脈孔內(nèi)神經(jīng)血管關(guān)系,頸靜脈孔顱內(nèi)外區(qū)域的結(jié)構(gòu)和手術(shù)標(biāo)志。 方法觀察和測量橋小腦角區(qū)、頸靜脈孔、顱頸交界和咽旁間隙的解剖關(guān)系。經(jīng)頸靜脈突入路的手術(shù)標(biāo)志。 結(jié)果頸靜脈孔位于枕骨大孔的外側(cè)壁上,介于顳骨巖部與枕骨外側(cè)部之間,上有內(nèi)耳門,下借頸靜脈結(jié)節(jié)與舌下神經(jīng)管相隔,前是巖斜裂,后是乙狀竇溝,顱內(nèi)連向橋小腦角區(qū)和顱頸交界區(qū),外接咽旁間隙。頸靜脈孔內(nèi)走行有舌咽神經(jīng)、迷走神經(jīng)、副神經(jīng)和頸靜脈球。經(jīng)頸靜脈突入路以乳突、莖突、髁窩、二腹肌、寰椎橫突和頸靜脈突為手術(shù)標(biāo)志,可進(jìn)入頸靜脈孔后部,并同時顯露顱內(nèi)外區(qū)域。 結(jié)論頸靜脈孔是后顱窩與顱外咽旁間隙溝通的主要通道,其內(nèi)走行有舌咽神經(jīng)、迷走神經(jīng)、副神經(jīng)和頸靜脈球,位置深在。由顱內(nèi)外聯(lián)合入路可以顯露此交通區(qū)的病變。手術(shù)徑路的中心點是頸靜脈突,頸靜脈突為頸靜脈孔后界,其外側(cè)是乳突,前外有莖乳孔,內(nèi)側(cè)是枕髁,后方是枕骨鱗部。顳下窩A型入路可廣泛顯露乳突腔、中耳、內(nèi)耳、頸靜脈孔、咽旁間隙。經(jīng)頸靜脈突入路的一級手術(shù)標(biāo)志是星點、乳突和寰椎橫突,二級手術(shù)標(biāo)志為窩、頸靜脈突、Henry脂肪間隙與二腹肌溝,三級手術(shù)標(biāo)志為頸靜脈孔、舌下神經(jīng)管、頸動脈管、莖突與莖乳孔。經(jīng)頸靜脈突徑路不僅要熟悉頸靜脈突周圍的解剖關(guān)系,還要熟悉其淺面和側(cè)方的解剖如乳突、枕下肌肉、椎動脈、咽旁間隙等等。
[Abstract]:A skull base can be regarded as two sides of intracranial facial carrying cerebral structures such as frontal cortex, hypothalamus pituitary, cavernous sinus, temporal lobe, cerebellum and brain stem, cranial nerve, skull base plate fracture after cranial neurovascular import, which also has the inherent structure such as inner ear labyrinth, jugular bulb and so on, is outside the skull base craniofacial structures such as cranial and cervical nasal, paranasal sinus, pterygopalatine fossa and infratemporal fossa, parapharyngeal space and so on. Can communicate to extracranial tumors of the skull base, involving three of the above structure, deep location, complex anatomy is difficult in Department of neurosurgery operation. This study from the Perspective to understand the anatomy and microsurgical anatomy the relationship between intracranial communication area, locate the surgical landmarks to provide anatomic basis for the operation. The first chapter transsphenoidal microsurgical anatomy of cranial communicating area
Objective to study the microsurgical anatomical relationship between the anterior cranial fossa and the nasal cavity, paranasal sinus, the saddle area and the sphenoid sinus, and the nasal cavity.
Methods we observed and measured the relationship between the cranial base bone formation, frontalis suture, blind hole, sieve plate, sphenoid plateau, sellar tubercle, pituitary fossa, sphenoid sinus, nasal cavity, ethmoid sinus and anterior nasal spines. We observed the intracranial structures, skull base and cranial structures revealed by three frontal and transsphenoidal approaches.
The screen plate is arranged on the central front in the anterior skull base, frontal, sphenoid and ethmoid labyrinth between platforms, connected to the top. The frontal, nasal sphenoidal planum sphenoid sinus is superior, followed by a chiasma ditch, tuberculum sellae and pituitary fossa, lateral nasal to the optic nerve. The blind hole distance was 12.70 + 1.28mm, the amount of the nose stitch to the distance of 35.67 circles postlaminar + 1.12mm, nasal butterfly to edge distance is 51.40 + 2.98mm, frontonasal suture to the tuberculum sellae distance was 54.32 + 1.89mm, nasal dorsum sellae to distance was 65.78 + 1.56mm. blind hole to anterior ethmoidal foramen distance was 10.98 + 1.12mm, blind hole to screen after the hole distance is 25.11 + 1.25mm. anterior nasal spine to the sphenoid sinus opening distance was 42.34 + 2.23mm, the anterior nasal spine to the top of the nasal prelaminar circles distance was 41.88 + 0.24mm, the anterior nasal spine to the top of the world after nasal sieve plate distance was 52.05 +.45mm.
Conclusion cranial nasal communication zone in the cribriform plate and sphenoid sinus media, anterior cranial fossa and sellar region and the nasal cavity, sphenoid sinus, nasal cavity to communicate. Transfrontal surgery signs are divided into three stages: the first stage surgery sign is nasal surgery, two mark is three mark with blind hole, surgery butterfly butterfly plate, bone platform edge, tuberculum sellae and sphenoid sinus. Transsphenoidal surgery signs are divided into three levels: mark level operation is the anterior nasal spine, two sign is the opening of sphenoid sinus, sphenoid sinus. Three mark is performing the subcranial approach can be widely exposed to this communication area. Anatomy the second chapter micro cranio orbital region
Objective to study the anatomical relationship between the anterior cranial fossa and the orbit, the supraorbital fissure and the intraorbital structure, and to identify the surgical indications for the lateral orbital approach.
Methods we observed and measured the osseous components of the orbital roof, optic canal and supraorbital fissure. We measured the relationship between the supratenal foramen and the anterior ethmoidal foramen, the posterior ethmoid foramen, the distance between the optic canal, the supraorbital fissure and the optic column, the carotid artery groove, the round hole and so on.
Results the cranio orbital is mainly through the tip of the tube in the orbital optic nerve and superior orbital fissure, optic canal running structure of optic nerve and ophthalmic artery, orbital optic nerve tube connected to the sellar region. The superior orbital fissure is the main channel, import orbital nerve on the oculomotor nerve, trochlear nerve, abducens nerve and eye the eyes, borrow the superior orbital fissure is connected with the middle cranial fossa cavernous sinus. The supraorbital foramen to the orbital ethmoidal hole distance was 30.12 + 2.35mm, to the orbital sieve hole distance is 39.75 + 1.25mm, and optic canal orbital opening distance of 43.35 + 1.67mm.
Conclusion the cranio orbital orbital roof can be directly damaged, but mainly the optic canal and superior orbital fissure to the middle cranial fossa sellar and cavernous sinus. The lateral orbital approach to the level of anatomical landmarks have supraorbital notch holes or supraorbital, orbitofrontal artery; two signs of superior orbital fissure the anterior clinoid process, and optic column. Via lateral orbital approach can reveal the orbital structure, especially a good exposure of sellar region, cavernous sinus and skull base in the outer part of the third chapter. Microsurgical anatomy of the middle fossa and infratemporal fossa pterygopalatine fossa communication area
Objective to study the anatomical relationship between the middle cranial fossa and the infratemporal fossa, the pterygopalatine fossa, the anatomical triangle of the lateral wall of the cavernous sinus and the middle skull base, and to confirm the surgical indications for the frontal and temporal orbitozygomatic approach.
Methods to observe and measure the structure and relationship of the lateral wall of the cavernous sinus, round hole, oval hole, spinous hole, infratemporal fossa and pterygopalatine fossa.
The middle fossa anterior border is the superior orbital fissure and lateral orbital, is the temporal fossa, after by petrous bone and posterior fossa from the cavernous sinus in the sella, the medial skull base, middle cranial fossa through hole, foramen ovale, foramen spinosum, rupture hole and the infratemporal fossa, the pterygopalatine fossa and parapharyngeal space. A sign of communication operation frontozygomatic suture, orbitofrontal artery tube and the foramen spinosum. Two surgical landmarks are superior orbital fissure, anterior clinoid process, foramen, foramen ovale and facial nerve surgery have three door. Sign the maxillary nerve, mandibular nerve, middle meningeal artery. Pterygoid and temporal bone crest.
Conclusion the board below the skull base is the infratemporal fossa and the pterygopalatine fossa and middle cranial fossa and infratemporal fossa pterygopalatine fossa - communication area through the superior orbital fissure, inferior orbital fissure and optic canal connected by orbital, sphenopalatine foramen through to the medial nasal cavity, through the lateral wall of the sphenoid sinus and sphenoid sinus interval, after is the posterior fossa of the petrous bone and the prestyloid space. The communication area of the lesions involving the cavernous sinus, the cavernous sinus surgery treatment is one of the key. The frontotemporal orbitozygomatic approach can view into the middle cranial fossa and infratemporal fossa pterygopalatine fossa - communication area, exposed extensive operation short path. The fourth chapter microsurgical anatomy of the jugular foramen and extracranial communicating area
Objective to study the neurovascular relationship in the jugular foramen, the structure of the internal and external cranial region of the jugular hole and the surgical indications.
Methods the anatomical relationship between the cerebellopontine angle area, the jugular orifice, the craniofacial junction and the parapharyngeal space was observed and measured. The surgical indications of the jugular approach were observed.
The jugular foramen is located in the lateral wall of the foramen magnum, between petrous bone and lateral part of occipital bone, have internal portals, through the jugular tubercle and the hypoglossal canal apart, before the petroclival fissure, after sigmoid sinus sulcus, intracranial connected to the cerebellopontine angle region and craniocervical junction area of parapharyngeal space. External jugular foramen for glossopharyngeal nerve, vagus nerve, accessory nerve and jugular bulb. Jugular vein into the road to the mastoid, styloid process, condylar fossa, two abdominal muscle, the transverse process of the atlas and the jugular process operation sign, can enter the jugular foramen after, and at the same time exposure of intracranial regional.
緇撹棰堥潤鑴夊瓟鏄悗棰呯獫涓庨澶栧捊鏃侀棿闅欐矡閫氱殑涓昏閫氶亾,鍏跺唴璧拌鏈夎垖鍜界緇，

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