本文選題：Dolenc入路　切入點：海綿竇　出處：《江蘇大學》2007年碩士論文　論文類型：學位論文

【摘要】： 一、概述 海綿竇位于蝶鞍和蝶竇的兩側,左右各一,前方起自眶上裂,后方附著于顳骨的巖骨尖部,上窄下寬,前窄后寬,為不規(guī)則的狹長的六面體,分為上、下、前、后、內側、外側6個壁。因其內部血管神經(jīng)之間穿插了許多的小梁并構成網(wǎng)狀,稱為海綿竇。它是顱底病變常侵犯的部位,該部位的顯微解剖以及手術入路仍是神經(jīng)外科領域研究的熱點之一。 二、國內外研究現(xiàn)狀 1965年,Parkinson發(fā)表了里程碑式的論文,文中描述了治療頸內動脈—海綿竇瘺的直接手術入路,在此之前,幾乎沒有涉及直接手術治療海綿竇區(qū)病變的神經(jīng)外科文獻。這主要因為對海綿竇解剖結構不甚了解,沒有顯微外科,處理海綿竇區(qū)的嚴重出血和顱神經(jīng)損傷的風險極高,因此當時的神經(jīng)外科醫(yī)生沒有能力處理這個區(qū)域的病變,長期以來,這個區(qū)域被視為直接手術的“無人之境”。近年來,隨著對此區(qū)域解剖研究的不斷深入和顯微外科技術的不斷發(fā)展,一些神經(jīng)外科醫(yī)生已能夠對這個區(qū)域病變進行手術,手術并發(fā)癥也降低了。尤其是Dolenc發(fā)展了硬膜外和硬膜下聯(lián)合入路,已成為治療海綿竇區(qū)域病變的標準入路。 三、研究目的、意義 本課題是針對海綿竇手術最常使用的Dolenc的外側壁和上壁入路進行解剖學研究,由于國內對于海綿竇外側壁和上壁的三角和穿行于內部的神經(jīng)血管的資料較少,本人進行該方向的研究,目的是進一步探討海綿竇外側壁和上壁的形態(tài)學特征和內部的顯微解剖結構,為臨床海綿竇的手術入路的設計,避免顱神經(jīng)和頸內動脈的損傷提供解剖學基礎。 四、材料和方法 1材料:10%甲醛充分固定的成人尸頭標本20例,所有尸頭鞍區(qū)及海綿竇區(qū)無腫瘤、囊腫、出血及明顯炎性改變,周圍骨質無明顯破壞。所有標本均動脈灌入紅色乳膠。 2儀器設備:神經(jīng)外科顯微手術器械、頭架、手術顯微鏡(5倍～25倍)、圓規(guī)、游標卡尺(精度0.02mm)、理光微距攝影器材。 3方法:20例(40側)10%甲醛固定的成人頭部標本,沿顱底和顱蓋的分界線鋸開顱骨。自中腦上端切斷腦干,完整取出大腦和間腦,清除鞍區(qū)的蛛網(wǎng)膜,注意保留2～4對顱神經(jīng)、垂體柄和頸內動脈。所有標本均在手術顯微鏡下進行解剖暴露和觀測。其中海綿竇上壁的三角直接觀測。外側壁的三角和顱神經(jīng)需要進行以下操作后才能觀測:自顱中窩底硬腦膜外分離硬膜,顯露弓狀隆起、巖淺大神經(jīng)、腦膜中動脈(棘孔)、下頜神經(jīng)(卵圓孔)、上頜神經(jīng)(圓孔)和眼神經(jīng)(眶上裂),同時剝離海綿竇外壁的淺層,暴露動眼神經(jīng)、滑車神經(jīng)、三叉神經(jīng)半月節(jié)、神經(jīng)根及其三個分支。數(shù)據(jù)測量使用游標卡尺,對海綿竇的三角進行拍攝。 4統(tǒng)計學處理:從標本(共40側)測量的數(shù)據(jù),經(jīng)SPSS統(tǒng)計軟件包計算出樣本均數(shù)和標準差。 五、結果 1、海綿竇的上壁有4個三角,分別是:Dolenc三角、Hakuba三角、頸內動脈三角和動眼神經(jīng)三角。 2、Dolenc三角三邊長度分別是:內側邊(6.30±1.54)mm,外側邊(10.02±2.44)mm,底邊(11.03±1.85)mm。 3、前床突由薄層骨皮質和骨松質所組成,本組實驗發(fā)現(xiàn)前床突內有氣房,與篩竇相通,發(fā)生率為1/10。 4、遠側硬膜環(huán)厚而堅韌,厚度為(0.52±0.07)mm,近側硬膜環(huán)薄而松弛,厚度為(0.22±0.06)mm,在二者之間有海綿竇的靜脈叢突入。 5、Hakuba三角內無重要的解剖結構,其三邊長度為:內側邊(7.69±2.07)mm,外側邊(7.25±2.02)mm,底邊(4.25±1.38)mm。 6、海綿竇的外側壁及其附近有6個三角,分別為旁內側三角、Parkinson三角、Mullan三角、外側三角、Glasscock三角和Kawase三角。 7、Parkinson三角的三邊長度分別為:內側邊(17.26±3.07)mm,外側邊(14.26±3.91)mm,底邊(5.61±2.56)mm,是海綿竇手術最常用的間隙。 8、Glasscock三角的三邊長度是:內側邊(12.41±2.40)mm,外側邊(14.15±2.74)mm,底邊(6.85±2.16)mm。嚴格的說是一個四邊形。 9、Kawase三角三邊的長度:內側邊(14.99±2.75)mm,外側邊(12.94±2.40)mm,底邊(11.25±3.45)mm。 10、動眼神經(jīng)、滑車神經(jīng)和眼神經(jīng)在海綿竇內的長度分別為:(8.19±0.93)mm,(10.16±1.12)mm,(16.23±2.24)mm。 六、結論 1、Dolenc手術入路中磨除前床突是關鍵的一步,磨除的范圍應局限在Dolenc三角中,同時應注意該區(qū)域骨質的變異。 2、Hakuba三角內無重要解剖結構,切開此三角進入海綿竇較為安全。 3、遠側硬腦膜環(huán)外側與頸內動脈結合較牢,后內側與頸內動脈之有間頸動脈穴,切開遠環(huán)應從內側開始,切開近側硬腦膜環(huán)便打開了海綿竇上壁。 4、Parkinson三角中,滑車神經(jīng)的走行對此三角的影響較大,在眼神經(jīng)稍上方并與眼神經(jīng)平行切開硬腦膜外層時,不易損傷變異的滑車神經(jīng)。 5、磨開Glasscock三角可以暴露巖骨段頸內動脈,是實施顱內段阻斷頸內動脈的位置,這個位置又可行頸內動脈海綿竇段的曠置和頸內動脈床突上段的搭橋。 6、磨除Kawase三角的骨質可以從中顱窩底暴露上中斜坡,從中顱窩底進入后顱窩,可以施行椎動脈瘤的夾閉術。 7、了解海綿竇上壁和外側壁的解剖結構有助于在Dolenc手術入路中預防重要結構的損傷,提高手術療效。 8、海綿竇區(qū)手術也不能照搬Dolenc手術入路,要根據(jù)具體情況,個性化選擇手術方法。
[Abstract]:First, an overview
On both sides of the cavernous sinus is located in sellar and sphenoid sinus, left and right respectively, starting from the front of the superior orbital fissure, petrous apex attached to the rear of the temporal bone, narrow width, narrow after wide, irregular narrow hexahedron, divided into,,,, medial, lateral 6 a wall between the inside of blood vessels. Because nerve interspersed with many of the trabeculae and form the mesh, called the cavernous sinus. It is often part of the invasion of skull base lesions, the microscopic anatomic and surgical approach is still one of the hot research field of Department of neurosurgery.
Two, research status at home and abroad
In 1965, Parkinson published a milepost type paper, this paper describes the direct surgical treatment of carotid cavernous fistula into the road, before this, almost no Department of Neurosurgery literature involving direct surgical treatment of cavernous sinus lesions. This is mainly because of the anatomy of cavernous sinus do not understand, without microsurgery, treatment of cavernous sinus serious hemorrhage and cranial nerve injury risk is extremely high, so when the neurosurgeon is not capable of handling this area for a long time, the lesion region is seen as "a place where there is no one direct operation." in recent years, with the continuous development of technology development in this area and the microsurgical anatomical study, some neurosurgeons have been able to surgery on this area of lesions, surgical complications are reduced. Especially the development of Dolenc road combined epidural and subdural, has become the treatment of the sea The standard approach to the regional lesions of the cavernous sinus.
Three, the purpose and significance of the study
This topic is the most commonly used in the lateral wall of the cavernous sinus surgery and Dolenc on the wall approach anatomic study, due to less domestic data for the nerves and blood vessels of the lateral wall of cavernous sinus and the upper wall triangle and walk through the interior, I conducted the research direction, the purpose is to probe into the lateral wall of the cavernous sinus on the wall and the morphological characteristics and the internal structure for the design of clinical anatomy, cavernous sinus surgical approach, to provide anatomic basis for avoiding cranial nerve and internal carotid artery injury.
Four, materials and methods
1 Materials: 20 of 10% adult cadaveric head specimens with sufficient formaldehyde. No tumors, cysts, bleeding and obvious inflammatory changes were found in all the body saddle area and cavernous sinus area. There was no obvious destruction of the surrounding bone. All the specimens were filled with red latex through the artery.
2 equipment: Department of Neurosurgery microsurgery instruments, head, operating microscope (5 times to 25 times), a vernier caliper (accuracy 0.02mm), Ricoh macro photography equipment.
3 methods: 20 cases (40 sides) adult cadaveric heads fixed by 10% formaldehyde, dividing the skull base and open wire along the calvaria skull. From the upper cut stem, complete removal of the brain and the removal of sellar arachnoid, pay attention to keep the 2~4 cranial nerve, pituitary stalk and internal carotid artery. All specimens were under operating microscope on exposure and observation. One triangle cavernous sinus wall directly observed. The triangle and the lateral wall of the cranial nerve following operation is necessary to observe: separation of dural from middle cranial fossa dura, revealed arcuate eminence, greater superficial petrosal nerve, middle meningeal artery (spinous foramen, mandibular nerve (Luan Yuankong)), maxillary nerve (hole) and the eye (SOF), and shallow, the outer wall of the cavernous sinus dissection exposed oculomotor nerve, trochlear nerve, trigeminal ganglion, nerve root and its three branches. The measured using vernier caliper data, three of the cavernous sinus Filming is done in the corner.
4 statistical processing: data measured from the specimens (40 sides) were calculated by SPSS statistical software package and the sample average and standard deviation were calculated.
Five, the result
1, there are 4 trigonometry in the upper wall of the cavernous sinus, which are the Dolenc triangle, the Hakuba triangle, the internal carotid triangle and the oculomotor trigone.
2, the length of the three edge of the Dolenc triangle is: the inner side (6.30 + 1.54) mm, the outer edge (10.02 + 2.44) mm, and the bottom (11.03 + 1.85) mm.
3, the anterior bed process was composed of thin layer of bone cortex and cancellous bone. The experiment found that there was a gas chamber in the anterior bed process in this group, and the incidence was 1/10..
4, the distal epidural ring is thick and tough, the thickness is (0.52 + 0.07) mm, the proximal dural ring is thin and slack, the thickness is (0.22 + 0.06) mm, and there is cavernous venous plexus penetration among two patients.
5, there are no important anatomical structures in the Hakuba triangle. The length of the three sides is the inner side (7.69 + 2.07) mm, the outer edge (7.25 + 2.02) mm, and the bottom edge (4.25 + 1.38) mm.
6, there are 6 trigonometry in the lateral wall of the cavernous sinus and near the cavernous sinus, the paranoid triangle, the Parkinson triangle, the Mullan triangle, the lateral triangle, the Glasscock triangle and the Kawase triangle.
7, the length of the three sides of the Parkinson triangle is: the inner side (17.26 + 3.07) mm, the outer side (14.26 + 3.91) mm, the bottom edge (5.61 + 2.56) mm, which is the most commonly used gap for cavernous sinus surgery.
8, the three edge length of the Glasscock triangle is: the inner side (12.41 + 2.40) mm, the outer edge (14.15 + 2.74) mm, and the bottom (6.85 + 2.16) mm. strictly speaking as a quadrilateral.
9, the length of the three side of the Kawase triangle: the inner side (14.99 + 2.75) mm, the outer edge (12.94 + 2.40) mm, and the bottom (11.25 + 3.45) mm.
10, the length of the oculomotor nerve, the trochlear nerve and the eyes in the cavernous sinus were (8.19 + 0.93) mm, (10.16 + 1.12) mm, (16.23 + 2.24) mm.
Six. Conclusion
1, the key step is to remove the anterior bed process in the Dolenc operation. The range of grinding should be limited to the Dolenc triangle, and the bone variation in this area should be paid attention to.
2, there is no important anatomical structure in the Hakuba triangle, and it is safer to cut this triangle into the cavernous sinus.
In 3, distal dura ring and lateral carotid artery combined with solid, posterior medial and internal carotid artery of carotid artery between points, far from the medial ring incision, incision proximal dura ring opened the cavernous sinus wall.
4, in the Parkinson triangle, the running of the trochlear nerve has a great influence on the trigonometry. It is not easy to damage the variant trochlear nerve when parallel to the outer layer of the dura mater.
5, grinding the Glasscock triangle can expose the petrous internal carotid artery, intracranial segment of internal carotid artery occlusion is the implementation of the position, the position and the feasible cavernous segment of internal carotid artery exclusion and supraclinoid carotid artery bypass.
6, the bone of the Kawase triangle can be exposed to the middle slope from the bottom of the middle cranial fossa, and from the bottom of the middle cranial fossa to the posterior fossa, the occlusion of the vertebral aneurysm can be performed.
7, understand the cavernous sinus wall and lateral wall of the anatomical structure contributes to the Dolenc approach in the prevention of important structural damage, improve the curative effect.
8, cavernous sinus surgery can not copy the Dolenc approach, according to the specific situation, individualized selection of surgical methods.

【學位授予單位】：江蘇大學
【學位級別】：碩士
【學位授予年份】：2007
【分類號】：R322

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相關期刊論文 前2條

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