本文選題：巖斜區(qū) + 頂乳縫前角��； 參考：《承德醫(yī)學(xué)院》2007年碩士論文

【摘要】： 目的: 近些年來,隨著鎖孔入路的不斷開展,內(nèi)窺鏡不斷使用,內(nèi)窺鏡可達(dá)到深而狹小的術(shù)野,且在術(shù)中可以任意變換觀察角度,彌補(bǔ)了手術(shù)顯微鏡的不足。鎖孔手術(shù)是在顯微鏡、內(nèi)窺鏡及特殊顯微手術(shù)器械的配合下,經(jīng)較小的手術(shù)通道,最小的創(chuàng)傷,達(dá)到切除病變的目的。斜坡區(qū)是顱內(nèi)腫瘤的多發(fā)部位,傳統(tǒng)的手術(shù)入路以乙狀竇溝前入路和乙狀竇溝后入路為主,損傷大、并發(fā)癥多。本研究提出以頂乳縫前角這一骨性標(biāo)志作為鎖孔手術(shù)入路的手術(shù)入路點(diǎn),測量該骨性標(biāo)志與斜坡區(qū)及周圍各結(jié)構(gòu)的距離,及該區(qū)域神經(jīng)血管的數(shù)據(jù)測量,為內(nèi)窺鏡進(jìn)入深度提供參考,結(jié)合鎖孔手術(shù)的應(yīng)用為提高斜坡區(qū)手術(shù)的安全度和成功率這一問題的解決提供了新的思路。 方法: 1選取30個(男25,女5)外觀無異常、經(jīng)4%甲醛溶液固定的成人濕顱骨標(biāo)本。找到頂乳縫前角,用磨鉆小心切開該處顱骨,以圓規(guī)和游標(biāo)卡尺測定乙狀竇溝上曲至三叉神經(jīng)根、展神經(jīng)根、面神經(jīng)根、前庭蝸神經(jīng)根、舌咽神經(jīng)根、迷走神經(jīng)根、巖靜脈、內(nèi)耳道后壁中點(diǎn)、頸動脈管內(nèi)口后壁、頸靜脈孔的距離。在手術(shù)顯微鏡下自前向后切除部分小腦組織,向后輕輕牽拉小腦,確認(rèn)三叉神經(jīng)、展神經(jīng)、面神經(jīng)、前庭蝸神經(jīng)及舌咽神經(jīng)、迷走神經(jīng),觀察各神經(jīng)根周圍血管走行及血管與神經(jīng)根的周圍毗鄰關(guān)系,確認(rèn)血管來源及名稱并對各層面進(jìn)行攝片。 2在干燥顱骨標(biāo)本上測量內(nèi)耳道的橫徑、縱徑、長度并測量內(nèi)耳道與后床突、三叉神經(jīng)孔、頸靜脈孔前緣、內(nèi)耳道水平斜坡中線的距離。 結(jié)果: 1濕顱骨標(biāo)本的測量結(jié)果 1.1乙狀竇溝上曲至相關(guān)結(jié)構(gòu)的距離乙狀竇溝上曲至三叉神經(jīng)根的距離39.14±2.47 mm,至展神經(jīng)根5.72±2.39 mm,面神經(jīng)根40.94±2.09 mm,前庭蝸神經(jīng)根38.12±1.76 mm,舌咽神經(jīng)根36.35±2.31 mm,迷走神經(jīng)根35.81±5.57 mm,巖靜脈3.27±0.65 mm,內(nèi)耳道后壁中點(diǎn)12.01±1.09 mm,頸動脈管內(nèi)口后壁51.72±4.43 mm,頸靜脈孔27.60±0.67 mm。乙狀竇溝上曲至相關(guān)結(jié)構(gòu)的距離左右兩側(cè)無顯著性差異(P0.05)。 1.2各神經(jīng)腦池段長度 三叉神經(jīng)5.0±7.4 mm,展神經(jīng)5.6±8.1 mm,面神經(jīng)11.0±1.7 mm,前庭蝸神經(jīng)10.9±4.8 mm,中間神經(jīng)9.6±3.7 mm,舌咽神經(jīng)17.4±6.9 mm,迷走神經(jīng)18.7±8.4 mm。各神經(jīng)腦池段長度左右兩側(cè)無顯著(P0.05)。 1.3神經(jīng)與血管之間的關(guān)系 面神經(jīng)起點(diǎn)與舌咽神經(jīng)起點(diǎn)距離(2.7±1.2)mm,在內(nèi)耳道口水平兩神經(jīng)相距(3.9±1.5)mm。二神經(jīng)根周圍最常出現(xiàn)小腦下前動脈(AICA),偶有小腦下后動脈(PICA)。60側(cè)共有AICA58支,2例標(biāo)本一側(cè)缺如。外展神經(jīng)腦池段長約(5.6±1.1)mm,距外側(cè)的面、前庭蝸神經(jīng)約(6.4±0.8)mm,進(jìn)入Dorello管處距中線約(3.4±1.9)mm。內(nèi)聽動脈(LA):本組30例60側(cè)中LA出現(xiàn)54側(cè)(90%),6側(cè)缺如,單干型36側(cè)(66.7%),雙干型18側(cè)(33.3%)。LA是內(nèi)耳的供血動脈,多起自小腦前下動脈42側(cè)(75%),也可以從其他動脈發(fā)出,其中起自基底動脈9側(cè)(15%)、小腦后下動脈3側(cè)(5%)或椎動脈3側(cè)(5%)。弓下動脈:由AICA的下支分出,在內(nèi)耳道后壁的弓狀下窩行走,從前庭蝸神經(jīng)的上方到達(dá)面神經(jīng)運(yùn)動支的根部,終止于半規(guī)管附近的骨質(zhì)。50%進(jìn)入內(nèi)耳道,25%向前達(dá)AICA的上支與之交通,25%向下達(dá)頸靜脈孔。4側(cè)PICA(其中包括2側(cè)缺如AICA者)與面神經(jīng)根較近。 2干燥顱骨標(biāo)本的測量結(jié)果 內(nèi)耳道的橫徑5.75±9.56 mm,縱徑4.70±0.88 mm,長度9.37±1.65 mm,內(nèi)耳道至后床突的距離25.94±4.86 mm,至三叉神經(jīng)孔15.23±6.28 mm,至頸靜脈孔前緣3.28±4.75 mm,至內(nèi)耳道水平斜坡中線23.97±0.08 mm。干燥顱骨標(biāo)本的測量結(jié)果左右兩側(cè)無顯著性差異(P0.05)。 結(jié)論: 1當(dāng)顯微鏡下難以確認(rèn)神經(jīng)根和血管關(guān)系,或難以發(fā)現(xiàn)細(xì)小血管的存在;在這種情況下則需要醫(yī)師耐心的確認(rèn)這些血管與神經(jīng)根的關(guān)系,并可發(fā)現(xiàn)細(xì)小血管的存在,有利于確認(rèn)責(zé)任血管,并可防止發(fā)生損傷血管的意外。2巖斜區(qū)位置深在、解剖結(jié)構(gòu)密集、血管位置變異較大,應(yīng)充分熟悉該區(qū)域解剖結(jié)構(gòu)的相對位置,提高巖斜區(qū)手術(shù)全切除率,降低并發(fā)癥。
[Abstract]:Objective:
In recent years, with the continuous development of the keyhole approach, endoscopy is constantly used, endoscopy can reach a deep and narrow operation field, and in the operation, the observation angle can be changed to make up for the insufficiency of the operation microscope. The keyhole operation is the smallest operation channel, with the microscope, the endoscope and the special MicroHand instruments. The slope area is the multiple location of the intracranial tumor. The traditional surgical approach is mainly based on the anterior approach of the sigmoid sinus and the posterior sigmoid sinus approach, with large injuries and many complications. This study proposes that the osseous sign of the anterior apical angle of the suture is used as the surgical entry point for the keyhole operation, and the bone sign and the slope are measured. The distance between the region and the surrounding structure and the data measurement of the nerve vessel in this area provide reference for the penetration of the endoscope, and the application of the keyhole operation provides a new idea to solve the problem of improving the safety and success rate of the operation in the slope area.
Method:
1 to select 30 adult wet skull specimens (male 25, female 5) with 4% Formaldehyde Solution fixed adult wet skull specimens. The anterior horn of the apex suture was found, and the skull was cut carefully by grinding drill. The tritemal root, the nerve root, the vestibule nerve root, the glossopharyngeal nerve root, the vagus nerve root, the vagus nerve root, the vein, were measured with a drill and a vernier caliper. The posterior wall of the inner auditory canal, the posterior wall of the canal and the distance of the jugular hole in the carotid canal. The cerebellum was removed from the cerebellum by the anterior and backward resection of the cerebellum under the microscope. The trigeminal nerve, the abducent nerve, the facial nerve, the vestibule nerve and the glossopharyngeal nerve, the vagus nerve, and the circumferential vessels of the nerve roots and the circumferential and nerve roots were observed. Confirm the origin and name of blood vessels and take photographs at all levels.
2 the diameter of the inner ear canal, the longitudinal diameter, the length, the inner ear canal and the posterior bed process, the trigeminal hole, the anterior margin of the jugular foramen and the distance of the middle line of the horizontal slope of the inner ear canal were measured on the dry skull specimens.
Result:
Measurement results of 1 wet skull specimens
The distance from the upper trench of 1.1 sigmoid sinus to the trigeminal nerve root is 39.14 + 2.47 mm, 5.72 + 2.39 mm of the root of the abducent nerve, 40.94 + 2.09 mm of the root of the facial nerve, 38.12 + 1.76 mm of the vestibule nerve root, 36.35 + 2.31 mm of the glossopharyngeal nerve, 35.81 + 5.57 mm of the vagus nerve root, and the veins of the petrous vein, mm and the posterior wall of the inner ear canal. 2.01 + 1.09 mm, the posterior wall of the carotid canal was 51.72 + 4.43 mm, and there was no significant difference between the right and left sides of the jugular foramen 27.60 + 0.67 mm. sigmoid sinus (P0.05).
1.2 neurobrain pool length
The trigeminal nerve is 5 + 7.4 mm, the abduction nerve is 5.6 + 8.1 mm, the facial nerve is 11 + 1.7 mm, the vestibule nerve is 10.9 + 4.8 mm, the middle nerve is 9.6 + 3.7 mm, the glossopharyngeal nerve is 17.4 + 6.9 mm, and there is no significant difference between the left and right sides of the nerve cistern segments of the vagus nerve 18.7 + mm. each (P0.05).
1.3 the relationship between nerve and blood vessel
The distance between the starting point of the facial nerve and the starting point of the glossopharyngeal nerve (2.7 + 1.2) mm, the most frequent of the anterior inferior cerebellar artery (AICA) around the two nerve root of the inner ear canal (3.9 + 1.5) mm. two, and a common AICA58 branch in the.60 side of the inferior cerebellar posterior inferior cerebellar artery (PICA), and the absence of one side in 2 specimens. The abductor nerve pool segment was about (5.6 + 1.1) mm, and the vestibular cochlea was from the lateral surface. The nerve was about (6.4 + 0.8) mm and entered the middle line (3.4 + 1.9) mm. of the auditory artery (LA). In this group, 54 sides appeared in 60 sides of 30 cases (90%), 6 side was absent, 36 sides of the single stem type (66.7%), and the double dry type 18 side (33.3%).LA was the blood supply artery of the inner ear, and many from the anterior inferior cerebellar artery and other arteries, which were from the basilar artery. Lateral (15%), 3 side of posterior inferior cerebellar artery (5%) or 3 sides of vertebral artery (5%). The inferior branch of the AICA is divided into the inferior branch of the inner auditory canal, walking in the lower arcuate fossa of the posterior wall of the inner ear, reaching the root of the motor branch of the facial nerve above the vestibular cochlear nerve, ending the bone.50% near the semicircular canal into the inner ear canal, 25% up to the upper branch of the AICA and the 25% direction of the neck. The.4 side of PICA (including 2 sides lacking AICA) is closer to the facial nerve root.
2 measured results of dry skull specimens
The transverse diameter of the inner ear was 5.75 + 9.56 mm, the longitudinal diameter was 4.70 + 0.88 mm, the length was 9.37 + 1.65 mm, the distance from the inner auditory canal to the posterior bed process was 25.94 + 4.86 mm, to the trigeminal hole 15.23 + 6.28 mm, to the anterior margin of the jugular hole, 3.28 + 4.75 mm, and there was no significant difference between the left and right sides of the dry skull specimens in the middle line of the horizontal slope of the inner ear canal (P0.05) (P0.05). ).
Conclusion:
1 it is difficult to confirm the relationship between the nerve root and the blood vessel under the microscope, or the existence of the small blood vessels. In this case, the doctor is required to confirm the relationship between the vessels and the nerve roots patiently, and the existence of the small blood vessels is found, which is beneficial to the identification of the responsible blood vessels, and the position of the accidental.2 diagonal area of the damaged vessels can be prevented. The anatomical structure is dense and the vascular position is variable. We should be familiar with the relative position of the anatomical structure of the area, improve the total resection rate and reduce the complications.
【學(xué)位授予單位】：承德醫(yī)學(xué)院
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2007
【分類號】：R651.1;R322

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