本文關(guān)鍵詞：經(jīng)鼻神經(jīng)內(nèi)鏡治療前顱底病變的應(yīng)用解剖研究及其臨床應(yīng)用　出處：《新疆醫(yī)科大學(xué)》2011年博士論文　論文類型：學(xué)位論文

  更多相關(guān)文章： 前顱底 顱底外科 內(nèi)鏡 視神經(jīng)管減壓術(shù) 腦脊液鼻漏修補(bǔ)術(shù)

【摘要】：目的:顱底外科作為神經(jīng)外科學(xué)與耳鼻咽喉科學(xué)及頜面外科學(xué)的一個交叉學(xué)科,近年來發(fā)展十分迅速;然而由于前顱底的毗鄰結(jié)構(gòu)解剖關(guān)系復(fù)雜,發(fā)生于此的病變因解剖位置深在,手術(shù)不易充分暴露和徹底切除,容易造成術(shù)后畸形、功能障礙或發(fā)生其他并發(fā)癥。而經(jīng)鼻內(nèi)鏡則是一種比較古老的技術(shù),隨著光學(xué)、機(jī)械及電子技術(shù)的進(jìn)步,近十年來獲得了新的生命。經(jīng)鼻Qg鏡可以取代傳統(tǒng)的顯微鏡，經(jīng)由天然的鼻腔空隙,直接進(jìn)到蝶鞍部和前、中、后顱底,直視下處理這些部位的病變,損傷小,恢復(fù)快,沒有美容問題。經(jīng)鼻內(nèi)鏡技術(shù)和顱底外科的結(jié)合,極大地促進(jìn)了顱底外科的發(fā)展,不僅豐富了顱底外科的治療手段,而且拓寬了顱底外科的診療范圍,使顱底外科不僅能處理中線區(qū)域病變,還向側(cè)顱底區(qū)域發(fā)展。然而,由于顱底區(qū)域解剖結(jié)構(gòu)復(fù)雜,顱底外側(cè)面的解剖對于神經(jīng)外科醫(yī)生來說不夠熟悉。鼻腔空間不大,可供操作的范圍有限。而且內(nèi)鏡對于神經(jīng)外科醫(yī)生來說,不僅視野與顯微鏡不同,而且操作時也不固定,隨著器械的進(jìn)出鼻道隨時變化,使初學(xué)者難以適應(yīng)。陌生部位的解剖知識缺乏和對于內(nèi)鏡操作技術(shù)的不習(xí)慣,成為妨礙神經(jīng)外科醫(yī)生介入這一領(lǐng)域的兩大難點。另一方面,內(nèi)鏡在國內(nèi)外的發(fā)展很不平衡,在發(fā)達(dá)國家及我國發(fā)達(dá)地區(qū)發(fā)展迅猛,而在西部地區(qū)尤其新疆仍處在初始階段。本研究的目的就是:1)通過對內(nèi)鏡下前顱底的應(yīng)用解剖進(jìn)行觀察和測量。以豐富和掌握內(nèi)鏡前顱底手術(shù)所需的內(nèi)鏡下解剖知識;2)通過在尸體頭顱標(biāo)本上的模擬訓(xùn)練,熟悉和掌握開展內(nèi)鏡前顱底手術(shù)所需的解剖知識,并習(xí)慣內(nèi)鏡下操作;3)然后將神經(jīng)內(nèi)鏡應(yīng)用于臨床,治療前顱底常見疾病如腦脊液鼻漏、視神經(jīng)管減壓、各種前顱窩底腫瘤等,提高手術(shù)安全性及有效性,以期提高神經(jīng)內(nèi)鏡診療水平及顱底外科診療水平。由于經(jīng)蝶垂體瘤手術(shù)已趨于成熟,不在本研究的范圍內(nèi)。方法:本研究分三階段進(jìn)行:1)首先對10具20側(cè)顱骨標(biāo)本的顱底外側(cè)面以及矢狀剖面骨性鼻腔的相關(guān)解剖標(biāo)志及其相互之間的距離和角度進(jìn)行觀察和測量。然后對6具12側(cè)經(jīng)過灌注的尸體頭顱進(jìn)行內(nèi)鏡下觀察和描述;2)于內(nèi)鏡下在2具4側(cè)顱骨干標(biāo)本,和4具8側(cè)尸體頭顱上完成幾種模擬手術(shù):內(nèi)鏡下蝶竇切開術(shù);內(nèi)鏡下篩竇手術(shù);內(nèi)鏡下視神經(jīng)管減壓術(shù);以及內(nèi)鏡下眶減壓術(shù)等;3)于解剖研究和內(nèi)鏡模擬手術(shù)完成的前提下,將該技術(shù)應(yīng)用于臨床,對前顱底常見病,如創(chuàng)傷性視神經(jīng)損傷,各種原因腦脊液鼻漏,前顱底良性腫瘤等進(jìn)行治療。結(jié)果:1)鼻棘點至鞍結(jié)節(jié)的平均距離為69.2±4.8mm。鼻棘點至前床突的平均距離為72.9±3.9mm。即在手術(shù)中器械深入鼻腔6～7cm時就要提防進(jìn)入中顱窩的可能;2)鼻棘點至視神經(jīng)管眶口內(nèi)側(cè)中點的平均距離為63.4±5.3mm。鼻棘點至視神經(jīng)管顱口內(nèi)側(cè)中點的平均距離為69.3±4.9mm。鼻小柱基點至視神經(jīng)管顱口的距離為78.3±4.5mm。表明在行視神經(jīng)減壓術(shù)或眶尖部手術(shù)時距離鼻棘點超過50mm以上時就應(yīng)十分小心,過深操作有可能進(jìn)入中顱窩甚至損傷頸內(nèi)動脈;3)蝶竇開口至視神經(jīng)管顱口,也是二者間最短距離,平均為15.3±3.8mm,蝶竇開口與視神經(jīng)管聯(lián)線與正中矢狀面之間的夾角平均為63±7.9°。因此打開蝶竇后,向蝶竇開口的外上方約1.5cm的部位尋找,有利于發(fā)現(xiàn)視神經(jīng)管;4)視神經(jīng)管內(nèi)壁的毗鄰:位于蝶竇外側(cè)3側(cè)(25%),位于篩竇外側(cè)3側(cè)(25%),位于蝶竇和篩竇之間最常見,占6側(cè)(50%)。因此尋找視神經(jīng)管的另一方法為在蝶篩交界處尋找,大部分視神經(jīng)管位于蝶篩交界或其附近區(qū)域;5)鼻棘點至鞍結(jié)節(jié)的平均距離為69.2±4.8mm,據(jù)此可定位垂體前界。在此處操作如深入超過60mm,應(yīng)提防損傷頸內(nèi)動脈。(6)內(nèi)鏡為二維圖像,管狀視野有魚眼鏡頭效應(yīng),解剖結(jié)構(gòu)失真變形較嚴(yán)重,鏡頭角度越大,這種改變就越明顯,與普通解剖學(xué)觀察的差別就越大。因此熟練掌握內(nèi)鏡解剖,反復(fù)練習(xí),習(xí)慣這種視野,有助于克服內(nèi)鏡圖像失真所引起的盲目性和迷失感;7)內(nèi)鏡治療13例無光感視神經(jīng)損傷患者,隨訪3～12個月,7例視力有不同程度恢復(fù);6例無效。視力恢復(fù)多于術(shù)后1～2周出現(xiàn),約2個月后停止。視力提高一個級別3例,2個級別1例,3個級別1例,4個級別2例�？傆行�53.8%(7/13)。按受傷后視力喪失至手術(shù)時間分為3～7天組,8～14天組,15～21天組和21天以上組,各組間效果差異無統(tǒng)計學(xué)意義(P0.05);8)治療17例創(chuàng)傷性視神經(jīng)損傷患者共18眼,10例視力有不同程度恢復(fù);8眼無效。視力提高一個級別5例,2個級別2例,3個級別1例,4個級別2例,總有效率55.6%(10/18);9)內(nèi)鏡治療7例醫(yī)源性腦脊液鼻漏,漏口均在原手術(shù)部位,一次修補(bǔ)成功;10)共治療24例腦脊液鼻漏患者,Qg鏡組共13例15次手術(shù)13次成功,手術(shù)成功率為86.6%;開顱組11例12次手術(shù)10次成功,手術(shù)成功率為83.3%;兩組一次手術(shù)成功率及二次手術(shù)成功率均無明顯差異;11)內(nèi)鏡下治療蝶篩竇骨化纖維瘤1例,近全切除,病理為:青少年型骨化纖維瘤,術(shù)后患側(cè)眼視力明顯恢復(fù)。結(jié)論:1)對于術(shù)前無光感的視神經(jīng)損傷患者,仍應(yīng)行視神經(jīng)管減壓術(shù)以挽救其視力;2)視神經(jīng)損傷后視力的恢復(fù)主要取決于視神經(jīng)受傷機(jī)制及程度,與時間關(guān)系不大,因此只要患者有治療意愿,無論傷后多久,都應(yīng)該進(jìn)行手術(shù)以挽救視力;3)經(jīng)鼻內(nèi)鏡處理前顱底區(qū)域病變能最大限度的暴露病變區(qū)域,而又不加重對腦的牽拉損傷,保 留了正常的神經(jīng)血管結(jié)構(gòu),降低了術(shù)后并發(fā)癥和致殘率。具有微創(chuàng)、無顱面切口,病人痛苦少,恢復(fù)快等優(yōu)點,在一系列臨床手術(shù)中展示了常規(guī)開顱手術(shù)和鼻外進(jìn)路無法替代的優(yōu)勢;4)在熟練掌握顱底相關(guān)解剖知識,并經(jīng)過嚴(yán)格內(nèi)鏡操作訓(xùn)練后,經(jīng)鼻內(nèi)鏡治療前顱底病變有很高的安全性。
[Abstract]:Objective: To study a skull base surgery department of neurosurgery as interdisciplinary and otolaryngology and maxillofacial surgery, a very rapid development in recent years; however, due to the adjacent structure of the anterior skull base anatomy is complicated, the lesions due to anatomical position in operation is not easy to fully exposed and removed completely, likely to cause postoperative deformity, dysfunction or other complications. The nasal endoscopy is a relatively old technology with optical, mechanical and electronic technology, nearly ten years to gain new life. Nasal Qg lens can replace the traditional microscope, the nasal cavity through the natural gap, directly into the sella turcica and before. In these areas, after treatment of skull base, direct lesions, little injury, quick recovery, no beauty. After combined with nasal endoscopy and skull base surgery, skull base surgery has greatly promoted the development of not only enrich the skull base Surgical treatment, and broaden the scope of the diagnosis and treatment of skull base surgery, skull base surgery can not only deal with the midline area of lesions, but also the development of lateral skull base region. However, the complex anatomy of the skull base region, the anatomy of the lateral skull base to neurosurgeons not familiar enough. The nasal space is available for a limited range of operation. Endoscopy for the neurosurgeon to view not only with the microscope, and the operations are not fixed, with the instruments out of the nasal passages are subject to change, so that beginners. It is difficult to adapt to the strange parts of the anatomy of the lack of knowledge and technology is not used for endoscopic operation, become the two major difficulties hinder the neurosurgeon to intervene in this area. On the other hand, the development of endoscopy at home and abroad is very uneven, in developed countries and developed areas of China's rapid development in the western region of Xinjiang is still in the beginning The beginning stage. The purpose of this study is: 1) through the application of endoscopic anatomy of the anterior skull base were observed and measured. The anatomical knowledge to enrich and master the endoscopic skull base surgery required before endoscopy; 2) through simulation training in cadaveric heads on the familiar and master to carry out endoscopic anterior skull base surgery required the anatomical knowledge and habit of endoscopic operation; 3) and the application of neuroendoscope in the clinical treatment of anterior skull base of common diseases such as cerebrospinal fluid rhinorrhea, optic nerve decompression, various anterior cranial fossa tumors, improve surgical safety and effectiveness, in order to improve the level of diagnosis and treatment of skull base surgery and endoscopic treatment due to level. Transsphenoidal pituitary surgery has become mature, not within the scope of this study. Methods: This study is divided into three stages: 1) the first of 10 lateral skull base 20 lateral skull specimens and related markers of sagittal profile of the bony nasal cavity and anatomy The interaction between distance and angle were observed and measured. Then in 6 after perfusion with 12 lateral skull endoscopic observation and description; 2) in endoscopic in 2 with 4 lateral skull specimens, and 4 with 8 lateral skull to complete several surgical simulation: endoscopic incision of sphenoid sinus; endoscopic sinus surgery; endoscopic optic nerve decompression; and endoscopic orbital decompression; 3) on the premise of anatomy and endoscopic surgery simulation completed, this technology is applied to the clinical common diseases of the anterior skull base, such as traumatic optic nerve injury, cerebrospinal fluid rhinorrhea for various reasons, such as benign tumors of the anterior skull base treatment. Results: 1) the average distance to nasospinale tuberculum sellae with an average distance of 69.2 + 4.8mm. nasal spine to the anterior clinoid process was 72.9 + 3.9mm. devices in operation into the nasal cavity of 6 ~ 7cm when we should beware of into the middle cranial fossa; 2) nasal spine to the optic nerve 鐪跺彛鍐呬晶涓偣鐨勫鉤鍧囪窛紱諱負(fù)63.4鹵5.3mm.榧繪鐐硅嚦瑙嗙緇忕棰呭彛鍐呬晶涓偣鐨勫鉤鍧囪窛紱諱負(fù)69.3鹵4.9mm.榧誨皬鏌卞熀鐐硅嚦瑙嗙緇忕棰呭彛鐨勮窛紱諱負(fù)78.3鹵4.5mm.琛ㄦ槑鍦ㄨ瑙嗙緇忓噺鍘嬫湳鎴栫湺灝栭儴鎵嬫湳鏃惰窛紱婚薊媯樼偣瓚呰繃50mm浠ヤ笂鏃跺氨搴斿崄鍒嗗皬蹇，

本文編號：1424973