本文選題：眶尖區(qū)　切入點：顯微解剖　出處：《河北醫(yī)科大學(xué)》2011年碩士論文　論文類型：學(xué)位論文

【摘要】：目的:眶尖區(qū)是指由前床突、視神經(jīng)管及眶上裂所圍成的解剖區(qū)域。它是溝通顱眶重要解剖結(jié)構(gòu),又是前、中顱凹底相鄰結(jié)構(gòu)。此區(qū)空間狹小,結(jié)構(gòu)復(fù)雜,神經(jīng)血管密集,集結(jié)了經(jīng)此出入顱的重要血管神經(jīng)和其它的組織結(jié)構(gòu)。該區(qū)病變常向眶內(nèi)和顱內(nèi)雙向擴展,且與重要神經(jīng)血管關(guān)系緊密,手術(shù)暴露和處理十分困難,手術(shù)很難完全切除病變,而且術(shù)后并發(fā)癥多,是神經(jīng)外科醫(yī)生面臨的棘手問題。額顳眶顴入路是切除顱眶交界腫瘤應(yīng)用最多、較理想的手術(shù)入路,能為切除眶尖區(qū)病變提供良好視角和充分暴露,且手術(shù)路徑短,但其開顱創(chuàng)傷大,復(fù)雜而費時,術(shù)后可出現(xiàn)眼球外突或內(nèi)陷等手術(shù)并發(fā)癥。為此,我們進行了眶尖區(qū)及額顳眶顴手術(shù)入路的顯微解剖學(xué)研究,為此區(qū)手術(shù)提供詳盡的顯微解剖學(xué)依據(jù),并通過模擬額顳眶顴入路的顯微解剖,探討對此手術(shù)入路進行改良發(fā)展。 方法:10例20側(cè)國人成人尸頭濕標本,應(yīng)用10%福爾馬林充分固定,沖洗干凈動脈及靜脈系統(tǒng)內(nèi)血栓,再以混有紅色染料的乳膠灌注動脈系統(tǒng),混有藍色染料的乳膠灌注靜脈系統(tǒng)。在手術(shù)顯微鏡下模擬額顳眶顴手術(shù)入路,逐層解剖,觀察眶上神經(jīng)、顳淺動脈、面神經(jīng)等手術(shù)各層次相關(guān)重要結(jié)構(gòu);并詳細觀察眶尖區(qū)的顯微解剖結(jié)構(gòu)及經(jīng)過此區(qū)域的重要神經(jīng)血管走行和毗鄰關(guān)系。15例30側(cè)漂白的國人成人顱骨干標本,用以觀察和測量前床突、視神經(jīng)管和眶上裂等骨性結(jié)構(gòu)。所得數(shù)據(jù)均經(jīng)統(tǒng)計學(xué)處理,以平均數(shù)±標準差的形式表現(xiàn)。 結(jié)果:本組研究通過模擬額顳眶顴手術(shù)入路對標本進行逐層解剖,對入路所涉及的顱外重要解剖結(jié)構(gòu)進行觀察測量,并對開顱骨瓣技術(shù)改良;在手術(shù)顯微鏡下觀察和測量眶尖區(qū)重要解剖結(jié)構(gòu)的走行和毗鄰關(guān)系�？艏鈪^(qū)的重要解剖結(jié)構(gòu)主要包括:前床突、視神經(jīng)管、眶上裂、Zinn總腱環(huán)以及此區(qū)穿行的重要神經(jīng)血管。視神經(jīng)管和眶上裂是顱眶溝通的兩個重要通道,(1)視神經(jīng)管有顱口、眶口及上、下、內(nèi)、外四個壁構(gòu)成。顱口呈水平橢圓形,眶口為垂直橢圓形;眶口處為視神經(jīng)管水平位最狹窄及管壁最厚的地方。視神經(jīng)管的上壁長,下壁短,視神經(jīng)管的長度以上壁長度為標準,全長平均8.9士2.05mm。其內(nèi)側(cè)壁與篩竇及(或)蝶竇毗鄰,約35.75%與篩竇相鄰;51.50%與蝶竇相鄰;12.75%與蝶竇和篩竇共鄰。視神經(jīng)管的內(nèi)側(cè)壁較薄,常突入竇腔形成隆起,其中25%的視神經(jīng)管周圍完全被篩竇氣房包繞。顱底硬膜在視神經(jīng)管顱口處形成返折,并包被視神經(jīng)進入視神經(jīng)管,此硬膜返折稱為鐮狀皺襞。視神經(jīng)管內(nèi)口骨緣短于硬膜返折數(shù)毫米,此處視神經(jīng)僅硬膜覆蓋,缺乏骨管的保護,此段視神經(jīng)長平均約3.0mm。視神經(jīng)管內(nèi)有眼動脈和視神經(jīng)經(jīng)過入眶。(2)眶上裂是眶與顱中窩的最大交通孔道,略呈三角形,被外直肌的上、下腳分為三部分:外側(cè)部、中央部和下部。本組測量眶上裂上邊長16. 04土2. 18mm,外邊長19. 58士2.50 mm,內(nèi)邊長9. 05士1. 57 mm。眶上裂與矢狀面存在夾角,夾角為41.66°~48.75°,平均45. 13°土2. 58°。(3)前床突是蝶骨小翼向后內(nèi)方延伸的骨性突起,形狀呈錐形,其長、寬、厚分別為9.56土1.10 mm、13.06土2.50 mm、5.96士1.93 mm。前外下方為眶上裂,前內(nèi)與視神經(jīng)管頂部后緣及視柱相連接,內(nèi)側(cè)有頸內(nèi)動脈通過,外下側(cè)有海綿竇。(4)Zinn腱環(huán)由覆蓋在眶尖區(qū)的骨膜、眶上裂及視神經(jīng)管的硬腦膜及視神經(jīng)鞘的纖維成分融合在一起形成,此腱環(huán)圍繞視神經(jīng)孔的前端和眶上裂的內(nèi)上側(cè)。四條眼直肌起源于Zinn腱環(huán)并在眶尖處形成肌錐,肌錐是重要臨床解剖標志。(5)頸內(nèi)動脈出海綿竇后靠前床突內(nèi)側(cè)上行彎曲向后,此段稱為床突段;眼動脈75%起源于床突段頸內(nèi)動脈的內(nèi)側(cè)壁,與視神經(jīng)一起穿視神經(jīng)管入眶。穿越海綿竇外側(cè)壁的顱神經(jīng)均經(jīng)眶上裂與眼上下靜脈一起入眶,具體走行:滑車神經(jīng)、額神經(jīng)、淚腺神經(jīng)及眼上靜脈經(jīng)眶上裂外側(cè)部穿行;動眼神經(jīng)上、下支、外展神經(jīng)、鼻睫神經(jīng)及睫狀神經(jīng)節(jié)的交感根和感覺根經(jīng)中央部穿行;下部僅有眼下靜脈穿行。(6)經(jīng)額額眶顴入路主要缺點是開顱復(fù)雜費時,創(chuàng)傷較大,尤其是骨瓣成形困難。目前有傳統(tǒng)的一片骨瓣和改良的兩片骨瓣開顱,都有局限性,本研究改良一片骨開顱,先游離取除顴弓,然后一片骨瓣去除額顳骨、部分眶頂、眶外側(cè)壁和顴骨。體會是簡化了骨瓣開顱,節(jié)省時間,減少骨質(zhì)缺損,效果良好。 結(jié)論: 1眶尖區(qū)作為一解剖概念,至今尚無統(tǒng)一明確的解剖學(xué)界定范圍,我們界定其為由前床突、視神經(jīng)管及眶上裂所圍成的解剖區(qū)域。 2眶尖區(qū)是溝通顱眶的重要結(jié)構(gòu),狹小區(qū)域密集近半數(shù)顱神經(jīng)和頸內(nèi)動脈等重要結(jié)構(gòu),毗鄰關(guān)系密切,難以分離。 3眶尖區(qū)大型腫瘤和顱眶溝通腫瘤暴露困難,與重要血管神經(jīng)分離困難,切除難度大;額顳眶顴入路能為此區(qū)域病變切除提供良好暴露、手術(shù)視角和操作空間,可多角度切除病變,是目前應(yīng)用最廣泛的顱底手術(shù)入路之一。 4本研究探索改良傳統(tǒng)一片骨瓣開顱,簡化了操作,節(jié)省開顱時間,減少手術(shù)創(chuàng)傷,改善了手術(shù)效果。 5額額眶顴入路具有手術(shù)創(chuàng)傷大,開顱復(fù)雜費時,缺乏規(guī)范標準等局限性,需進一步發(fā)展完善。
[Abstract]:Objective: the orbital apex region is defined by the anterior clinoid process, anatomical region crack surrounded by the optic canal and superior orbital. It is important to communicate the cranial orbital anatomy, and, in the middle fossa of adjacent structure. This area narrow space, complex structure, nerve and blood vessel dense, assembled by the important blood vessels and nerves out of cranial and other structures. The orbital and intracranial lesions often to two-way expansion, and closely with the important vessels and nerves, surgical exposure and processing is very difficult, it is difficult to complete surgical excision of the lesion, and postoperative complications, is troublesome neurosurgeons. Frontotemporal orbitozygomatic approach is resection of cranio orbital junction tumors the most ideal surgical approach, can provide a good perspective and fully exposed for resection of orbital apex lesions, and the operation path is short, but its large trauma craniotomy, complicated and time-consuming, postoperative can appear proptosis or in other surgical complications. For this reason, we carried out microanatomical study of orbital apex area and frontotemporal orbitozygomatic surgery approach, providing detailed microscopic anatomic basis for this area's operation, and through the microanatomy of frontotemporal orbitozygomatic approach, we explored the improvement and development of this operative approach.
Methods: 10 cases of 20 sides of adult cadaveric head, fixed by 10% formalin, rinse the arterial and venous system thrombosis, with latex mixed with red dye perfusion system, mixed latex perfusion vein system with blue dye. Under surgical microscope to frontotemporal orbitozygomatic approach step by step, anatomy, observe the supraorbital nerve, superficial temporal artery and facial nerve surgery at all levels and other related structures; and detailed observation of the microsurgical anatomy of the orbital apex and the important vessels and nerves in the region traveling and adjacent relations of 30 cases of.15 side bleaching of Chinese adult skull specimens, to observe and measurement of the anterior clinoid process, optic canal and superior orbital fissure and bony structures. The data obtained were statistically, in the form of average + standard deviation.
緇撴灉:鏈粍鐮旂┒閫氳繃妯℃嫙棰濋鐪墮ⅶ鎵嬫湳鍏ヨ礬瀵規(guī)爣鏈繘琛岄，

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