【摘要】：背景:迷走神經(jīng)刺激術(vagus nerve stimulation,VNS)是治療藥物難治性癲癇的一種安全有效的方法,該手術的關鍵步驟在于解剖頸動脈鞘,將頸總動脈(common carotid artery,CAA)和頸內(nèi)靜脈(internal jugular vein,IJV)分別向內(nèi)、外牽引,在兩血管之間尋找并游離迷走神經(jīng)。頸動脈鞘內(nèi)迷走神經(jīng)、CCA和IJV的位置在人群中存在變異,因此術前利用影像學技術準確地定位上述解剖結構,可以幫助術者在術中有目的地進行解剖、分離,節(jié)約手術時間,減少并發(fā)癥的發(fā)生。既往研究證明頸部超聲可以顯示迷走神經(jīng)及其與周圍大血管的關系。超聲檢查無創(chuàng)、無輻射、價廉且普及,可能是VNS術前定位頸動脈鞘內(nèi)重要結構的理想方法之一,但至今未見VNS術前利用超聲技術輔助手術實施的相關報道。目的:研究超聲定位頸部迷走神經(jīng)、CCA和IJV的可行性及上述結構在正常人群中的相對位置,并探討這一方法在VNS手術中的應用價值。方法:隨機選擇健康成年人45例。受檢者的體位模仿VNS手術時的體位,即去枕平臥,頭偏向右側,充分暴露左側頸部。將超聲探頭置于左側胸鎖乳突肌前緣,觀察頸動脈鞘內(nèi)的CCA、IJV及迷走神經(jīng),注意辨別淋巴結、結締組織和小血管等。確認神經(jīng)位置后將探頭置于鎖骨上約2cm處且與該處皮膚平面垂直,顯示迷走神經(jīng)的橫切面并測量其橫徑及前后徑,保存圖像(該切面由腳端向頭端觀察)。對圖像做如下處理:(1)判斷IJV相對于CCA的位置。確認CCA、IJV的中點并連線,測量該連線與皮膚平面的夾角,記為α角。以CCA為參照,IJV相對于CCA的角度記為β角。(2)經(jīng)過上述血管中點、與上述連線垂直作兩條直線,將頸動脈鞘分為前、前內(nèi)、前外、后、后內(nèi)、后外六個區(qū)域,分別標記為A、AM、AL、P、PM、PL區(qū)域。如果迷走神經(jīng)位于CCA和IJV接觸面之間,則記為I區(qū)域。統(tǒng)計迷走神經(jīng)在上述7個區(qū)域的分布。(3)以CCA為參照,迷走神經(jīng)相對于CCA的角度記為γ角。結果:45例中CCA、IJV和迷走神經(jīng)均能顯示,顯示率100%。迷走神經(jīng)橫切面為圓形或橢圓形點狀低回聲,內(nèi)有點狀細小高回聲,周邊有高回聲結構包繞。迷走神經(jīng)可以與周圍結締組織、淋巴結和小血管等明顯區(qū)分。測得迷走神經(jīng)橫徑(1.13±0.28)mm,前后徑(1.01±0.27)mm,平均直徑(1.07±0.24)mm。IJV位于CCA前外側、前側、外側和前內(nèi)側分別有27例、15例、1例和2例,未發(fā)現(xiàn)IJV位于CCA內(nèi)側或后方者。α 角為(54.18±30.04°),β 角為(35.82±30.04°)。迷走神經(jīng)位于A區(qū)域7例,I區(qū)域18例,P區(qū)域20例。γ角(32.81±50.52°)。上述各指標在性別之間、高齡組與低齡組之間無顯著差異。因IJV位于CCA前外側和前側占大多數(shù),故單獨研究這兩種情況與性別和年齡的關系。男性組和女性組之間IJV相對于CCA的位置有明顯差別,男性組中IJV位于CCA前外側的情況多見。高齡組和低齡組之間IJV相對于CCA的位置無明顯差異。IJV相對于CCA位置不同時,迷走神經(jīng)的區(qū)域分布有顯著差異。當IJV位于CCA前外側時,迷走神經(jīng)多位于P區(qū)域,即IJV和CCA兩者之間的后方;當IJV位于CCA前側時,迷走神經(jīng)多位于I區(qū)域,即IJV和CCA兩者之間。結論:(1)體表超聲檢查對頸動脈鞘內(nèi)CCA、IJV和迷走神經(jīng)顯示率高,判斷準確,這一技術可以用于VNS術前對上述重要結構的輔助定位。(2)左側頸下部迷走神經(jīng)、IJV一般位于CCA的左前方(前外側)大約1點鐘方向。本研究還發(fā)現(xiàn)IJV位于CCA前內(nèi)側或者外側的變異情況。迷走神經(jīng)多位于CCA和IJV之后或兩者之間,但也可以出現(xiàn)在兩者前方。IJV相對于CCA的位置在性別之間有顯著差異。IJV位置不同時,迷走神經(jīng)的位置有顯著差異。(3)本研究和既往文獻均發(fā)現(xiàn)頸動脈鞘內(nèi)重要結構的相對位置存在變異,VNS術中操作不當造成的并發(fā)癥也有報道。因此推測VNS術前利用超聲技術定位頸動脈鞘內(nèi)重要結構的位置有利于提高手術準確性,減少并發(fā)癥的發(fā)生,這在切口較小、術野狹窄的情況下尤為重要。
[Abstract]:Background: vagus nerve stimulation (VNS) is a safe and effective method for the treatment of drug refractory epilepsy. The key step of this operation is to dissect the carotid sheath and inward the common carotid artery (common carotid artery, CAA) and the internal jugular vein (internal jugular vein, IJV), respectively, to find between the two vessels. The vagus nerve is free from the vagus nerve. The location of the vagus nerve in the carotid sheath and the location of the CCA and IJV exists in the population. Therefore, the accurate location of the above anatomical structure by imaging techniques before operation can help the operators to dissect, separate, save the operation time and reduce the occurrence of complications. The display of the vagus nerve and its relationship with the surrounding large vessels. Ultrasound examination is noninvasive, no radiation, low price and universal. It may be one of the ideal methods to locate the important structure of the carotid sheath before VNS. But up to now, there is no related report on the use of ultrasound assisted surgery before VNS. Objective: To study the ultrasound localization of the vagus nerve, CCA and IJV The feasibility and the relative position of the above structure in the normal population and the application value of this method in the VNS operation. Methods: 45 healthy adults were selected randomly. The body position of the examiner imitates the position of the VNS operation, that is, the supine lying on the pillow, the head to the right and the left neck fully exposed. The ultrasonic probe is placed on the left sternocleidomastoid muscle of the left sternocleidomal muscle. The anterior border, observe the CCA, IJV and vagus nerve in the carotid sheath, pay attention to distinguish the lymph nodes, connective tissue and small blood vessels. After confirming the nerve position, the probe is placed on the clavicle at about 2cm and is perpendicular to the skin plane of the place, showing the transverse section of the vagus nerve and measuring the transverse diameter and the anterior and posterior diameter, and preserving the image (the section is observed from the foot to the head end). The image is treated as follows: (1) judge the position of IJV relative to CCA. Confirm CCA, the midpoint and connection of IJV, measure the angle between the line and the skin plane, take the angle of the skin as alpha angle. With CCA as the reference, the IJV relative to the CCA angle is recorded as beta angle. (2) through the above point of blood vessel, two straight lines are vertical to the above line, the carotid sheath is divided into front, anterior, front, and anterior, anterior, forward, anterior, anterior, anterior, The six regions were labeled as A, AM, AL, P, PM, PL region respectively. If the vagus nerve was located between the CCA and IJV contact surfaces, it was recorded as the I region. The distribution of the vagus nerve in the above 7 regions. (3) the vagus nerve was shown as gamma angle relative to CCA, with CCA as the reference. The transverse section of the vagus nerve of 100%. was a circular or elliptical nodal hypoechoic, with punctate and high echo and hyperechoic surrounding. Vagus nerve could be distinguished from the surrounding connective tissue, lymph nodes and small blood vessels. The transverse diameter of the vagus nerve (1.13 + 0.28) mm, the diameter of the anterior and posterior (1.01 + 0.27) mm, and the average diameter (1.07 + 0.24) mm.IJV were measured. There were 27 cases, 15 cases, 1 cases and 2 cases in the anterolateral, anterolateral, lateral and anteromedial, and no IJV located in the medial or rear of CCA. Alpha angle was (54.18 + 30.04), beta angle was (35.82 + 30.04). The vagus nerve was located in A region 7 cases, 18 cases in I region, 20 in the region of I, gamma angle (32.81 + 50.52 degrees). The above indexes were between sex, senior and lower age groups. There was no significant difference between the IJV and the anterior lateral and the anterior side of the CCA. Therefore, the relationship between the two cases and the sex and age was studied. The position of IJV in the male group and the female group was significantly different from the CCA. The IJV in the male group was more common in the anterolateral CCA. The position of IJV relative to the CCA between the older and the younger groups was not clear. There is significant difference in the distribution of the vagus nerve between the significant difference.IJV relative to the CCA position. When IJV is located in the anterolateral of CCA, the vagus nerve is located in the rear of the P region, which is between the IJV and CCA; when IJV is located at the front of CCA, the vagus nerve is located between the I area, that is, between IJV and CCA. (1) the body surface ultrasound examination of the carotid sheath Internal CCA, IJV, and vagus nerve display is high and accurate. This technique can be used to assist the location of the above important structures before VNS. (2) left cervical vagus nerve, IJV is generally located at about 1 o'clock in Zuo Qianfang (anterolateral) of CCA. This study also found the variation of the IJV position on the medial or lateral front of CCA. The vagus nerve is multiple. After or between CCA and IJV, there is a significant difference between the position of.IJV in front of the two and the position of CCA in front of the two. The position of the vagus nerve is different at the same time, and the position of the vagus nerve is different. (3) the relative position of the important structure of the carotid sheath in this study and the previous literature found the variation of the relative position of the important structure in the carotid sheath, and the misoperation in the operation of the VNS was caused by improper operation. There are also reports of complications. Therefore, it is speculated that the location of the important structure of the carotid sheath using ultrasound technique before VNS is helpful to improve the accuracy of the operation and reduce the incidence of complications, which is especially important in the case of small incision and narrowing of the operation field.
【學位授予單位】：山東大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R742.1

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