乙狀竇后鎖孔入路的顯微解剖學研究
發(fā)布時間：2018-07-25 20:34
【摘要】：目的：通過乙狀竇后鎖孔入路的解剖學研究,顯微觀察該入路所涉及的解剖結(jié)構(gòu)、顯露范圍和手術(shù)可利用的空間,為臨床應(yīng)用提供解剖學資料,并以此解剖學資料為基礎(chǔ),探討乙狀竇后鎖孔入路的手術(shù)適應(yīng)癥和臨床應(yīng)用價值。 方法：對15具成年國人尸體頭顱標本血管進行乳膠灌注備用。將尸頭依照手術(shù)體位固定在頭架上,模擬乙狀竇后鎖孔入路手術(shù)方法對15具(30側(cè))成人頭顱標本進行解剖,骨窗范圍在2.0 cm×2.5cm,于4-24倍手術(shù)顯微鏡下解剖,打開橋小腦角,去除蛛網(wǎng)膜及軟腦膜,調(diào)整和變換顯微鏡角度,探查顯露范圍和神經(jīng)血管解剖結(jié)構(gòu),拍照并測量記錄相關(guān)解剖數(shù)據(jù),觀察分析相關(guān)解剖學差異。結(jié)合臨床資料,對比其他相關(guān)入路,評價乙狀竇后鎖孔入路的優(yōu)越性。 結(jié)果：乙狀竇后鎖孔入路可顯露的解剖結(jié)構(gòu)：上從天幕前側(cè)緣,下至枕骨大孔頸靜脈結(jié)節(jié),內(nèi)側(cè)到橋腦和中腦的側(cè)方。通過調(diào)整顯微鏡角度,乙狀竇后鎖孔入路可暴露橋小腦角區(qū)包括巖靜脈、小腦上動脈及其分支、小腦前下動脈及其分支、小腦后下動脈及其分支、滑車神經(jīng)、三叉神經(jīng)、面聽神經(jīng)、后組顱神經(jīng)。約37%(11側(cè))的小腦上動脈與三叉神經(jīng)有接觸或壓迫。30側(cè)標本中單干巖靜脈為24側(cè),雙干巖靜脈為6側(cè)。22.2%巖靜脈在內(nèi)聽道內(nèi)側(cè)緣外側(cè)注入巖上竇,63.8%的巖靜脈在三叉神經(jīng)入Meckel腔處的外側(cè)緣和內(nèi)聽道內(nèi)側(cè)緣之間注入巖上竇,13.9%于三叉神經(jīng)外側(cè)緣以內(nèi)注入巖上竇。23側(cè)(77%)側(cè)小腦前下動脈襻與面聽神經(jīng)有接觸,有14側(cè)標本中小腦前下動脈穿面前庭蝸神經(jīng)之間。乙狀竇后鎖孔入路可良好暴露后顱窩神經(jīng)血管結(jié)構(gòu),但也受骨性結(jié)構(gòu)的影響。此入路對內(nèi)聽道口及頸靜脈孔暴露良好,但在所有標本中內(nèi)聽道上結(jié)節(jié)的形態(tài)變異較大,其均阻擋了對Meckel憩室的暴露,頸靜脈結(jié)節(jié)阻擋了對枕骨大孔前部的暴露。多數(shù)標本基底動脈暴露不佳。內(nèi)鏡下視野清晰,且可探查顯微鏡下解剖死角。 結(jié)論：乙狀竇后鎖孔入路是一種最經(jīng)典鎖孔手術(shù)方法,由于骨窗位置恰當、骨窗大小適中,減少了不必要的頭皮、肌肉切開,減少了不必要的顱骨切除,減少了不必要腦組織暴露,術(shù)中充分利用顱內(nèi)的自然空間,所以具有腦損傷少,傷口局部反應(yīng)小,組織復(fù)位好,手術(shù)時間短,術(shù)后并發(fā)癥少,恢復(fù)快和不影響患者容貌等優(yōu)點。通過乙狀竇后鎖孔入路并選取不同位置的骨窗,能適當暴露后顱窩相關(guān)區(qū)域的組織結(jié)構(gòu),可用于小腦橋腦角、上斜坡、中斜坡、下斜坡部位的髓外病變的手術(shù),如：三叉神經(jīng)痛、面肌痙攣、膽脂瘤、神經(jīng)鞘瘤和腦膜瘤。乙狀竇后鎖孔入路是順應(yīng)現(xiàn)代微創(chuàng)理念的探索,實踐證明它是一種安全、有效的手術(shù)方式,可選擇性的替代傳統(tǒng)的乙狀竇后入路。
[Abstract]:Objective: to study the anatomy of retrosigmoid keyhole approach, observe the anatomical structure, exposure scope and operative space of the approach, and provide anatomical data for clinical application. To evaluate the indications and clinical application of retrosigmoid keyhole approach. Methods: the blood vessels of 15 cadaveric cadavers were perfused with latex. The cadaveric head was fixed on the cephalic frame according to the position of operation, and 15 adult head specimens (30 sides) were dissected by simulated retrosigmoid keyhole approach. The bone window was 2.0 cm 脳 2.5 cm, dissected under 4-24 times operating microscope, and the angle of cerebellopontine was opened. The arachnoid and pial meninges were removed, the angle of microscope was adjusted and changed, the exposed area and neurovascular anatomy were explored, and the related anatomical data were taken and recorded, and the anatomical differences were observed and analyzed. To evaluate the advantages of retrosigmoid keyhole approach by comparing other related approaches with clinical data. Results: the anatomical structure revealed by retrosigmoid keyhole approach was superior from the anterior margin of the tentorium to the nodule of the foramen magnum jugular vein medial to the lateral side of the pontine and midbrain. By adjusting the angle of microscope, the posterior sigmoid keyhole approach can expose the cerebellopontine angle area including the petrosal vein, the superior cerebellar artery and its branches, the anterior inferior cerebellar artery and its branches, the posterior inferior cerebellar artery and its branches, the trochlear nerve and the trigeminal nerve. Facial auditory nerve, posterior cranial nerve. About 37% (11 sides) of the superior cerebellar artery had contact with or compression of the trigeminal nerve. 63.8% of the petrosal veins were injected with superior petrosal sinus on the lateral side of the medial margin of the internal auditory canal of the petrosal vein, and 13.9% of the vein was injected within the lateral margin of the trigeminal nerve into the Meckel cavity between the lateral margin of the trigeminal nerve and the medial margin of the internal auditory canal. The anterior inferior cerebellar artery loop was in contact with the facial auditory nerve in 23 sides (77%) into the superior petrosal sinus. In 14 of the specimens, the anterior inferior cerebellar artery penetrated between the anterior vestibulocochlear nerve. The retrosigmoid keyhole approach can well expose the neurovascular structure of the posterior cranial fossa, but it is also affected by the osseous structure. This approach showed good exposure to the internal auditory orifice and jugular foramen, but the shape of the superior nodule of the internal auditory canal varied greatly in all specimens, which blocked the exposure to the Meckel diverticulum and the jugular vein nodule to the anterior part of the foramen magnum of occipital bone. Most specimens were not well exposed to the basilar artery. Endoscopic visual field is clear, and can be explored under the microscope anatomic dead angle. Conclusion: the retrosigmoid keyhole approach is one of the most classical keyhole operations. Due to the proper location of the bone window and the moderate size of the bone window, it reduces unnecessary scalp, muscle incision and unnecessary craniotomy. It has the advantages of less brain injury, less local reaction, better tissue reduction, shorter operation time, less postoperative complications, faster recovery and no effect on the appearance of the patients due to the reduction of unnecessary brain tissue and the full use of the intracranial natural space during the operation. Through the retrosigmoid keyhole approach and the selection of bone windows in different locations, the tissue structure of the related areas of the posterior cranial fossa can be properly exposed, and can be used for the operation of extramedullary lesions in the cerebellar pontine angle, upper clivus, middle Clivus and inferior Clivus. For example: trigeminal neuralgia, hemifacial spasm, cholesteatoma, neurilemmoma and meningioma. The retrosigmoid keyhole approach is an exploration to conform to the modern minimally invasive approach. It is proved to be a safe and effective surgical approach which can selectively replace the traditional retrosigmoid sinus approach.
【學位授予單位】：天津醫(yī)科大學
【學位級別】：碩士
【學位授予年份】：2011
【分類號】：R322;R651.1
本文編號：2145004
[Abstract]:Objective: to study the anatomy of retrosigmoid keyhole approach, observe the anatomical structure, exposure scope and operative space of the approach, and provide anatomical data for clinical application. To evaluate the indications and clinical application of retrosigmoid keyhole approach. Methods: the blood vessels of 15 cadaveric cadavers were perfused with latex. The cadaveric head was fixed on the cephalic frame according to the position of operation, and 15 adult head specimens (30 sides) were dissected by simulated retrosigmoid keyhole approach. The bone window was 2.0 cm 脳 2.5 cm, dissected under 4-24 times operating microscope, and the angle of cerebellopontine was opened. The arachnoid and pial meninges were removed, the angle of microscope was adjusted and changed, the exposed area and neurovascular anatomy were explored, and the related anatomical data were taken and recorded, and the anatomical differences were observed and analyzed. To evaluate the advantages of retrosigmoid keyhole approach by comparing other related approaches with clinical data. Results: the anatomical structure revealed by retrosigmoid keyhole approach was superior from the anterior margin of the tentorium to the nodule of the foramen magnum jugular vein medial to the lateral side of the pontine and midbrain. By adjusting the angle of microscope, the posterior sigmoid keyhole approach can expose the cerebellopontine angle area including the petrosal vein, the superior cerebellar artery and its branches, the anterior inferior cerebellar artery and its branches, the posterior inferior cerebellar artery and its branches, the trochlear nerve and the trigeminal nerve. Facial auditory nerve, posterior cranial nerve. About 37% (11 sides) of the superior cerebellar artery had contact with or compression of the trigeminal nerve. 63.8% of the petrosal veins were injected with superior petrosal sinus on the lateral side of the medial margin of the internal auditory canal of the petrosal vein, and 13.9% of the vein was injected within the lateral margin of the trigeminal nerve into the Meckel cavity between the lateral margin of the trigeminal nerve and the medial margin of the internal auditory canal. The anterior inferior cerebellar artery loop was in contact with the facial auditory nerve in 23 sides (77%) into the superior petrosal sinus. In 14 of the specimens, the anterior inferior cerebellar artery penetrated between the anterior vestibulocochlear nerve. The retrosigmoid keyhole approach can well expose the neurovascular structure of the posterior cranial fossa, but it is also affected by the osseous structure. This approach showed good exposure to the internal auditory orifice and jugular foramen, but the shape of the superior nodule of the internal auditory canal varied greatly in all specimens, which blocked the exposure to the Meckel diverticulum and the jugular vein nodule to the anterior part of the foramen magnum of occipital bone. Most specimens were not well exposed to the basilar artery. Endoscopic visual field is clear, and can be explored under the microscope anatomic dead angle. Conclusion: the retrosigmoid keyhole approach is one of the most classical keyhole operations. Due to the proper location of the bone window and the moderate size of the bone window, it reduces unnecessary scalp, muscle incision and unnecessary craniotomy. It has the advantages of less brain injury, less local reaction, better tissue reduction, shorter operation time, less postoperative complications, faster recovery and no effect on the appearance of the patients due to the reduction of unnecessary brain tissue and the full use of the intracranial natural space during the operation. Through the retrosigmoid keyhole approach and the selection of bone windows in different locations, the tissue structure of the related areas of the posterior cranial fossa can be properly exposed, and can be used for the operation of extramedullary lesions in the cerebellar pontine angle, upper clivus, middle Clivus and inferior Clivus. For example: trigeminal neuralgia, hemifacial spasm, cholesteatoma, neurilemmoma and meningioma. The retrosigmoid keyhole approach is an exploration to conform to the modern minimally invasive approach. It is proved to be a safe and effective surgical approach which can selectively replace the traditional retrosigmoid sinus approach.
【學位授予單位】：天津醫(yī)科大學
【學位級別】：碩士
【學位授予年份】：2011
【分類號】：R322;R651.1
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，本文編號：2145004
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