本文選題：痙攣性斜頸 + 副神經(jīng)��； 參考：《復旦大學》2009年碩士論文

【摘要】： 第一部分:副神經(jīng)出顱后解剖特點及其臨床意義 研究背景及目的: 在ST臨床手術治療中,副神經(jīng)根微血管減壓術由Freckman等首先提出報道,認為發(fā)病機制為副神經(jīng)根受到微血管壓迫,其沖動通過交通支傳遞給脊神經(jīng)根遂使頸肌產(chǎn)生異常興奮。部分學者建議首選神經(jīng)血管減壓,部分學者建議采用選擇性肌肉和神經(jīng)切斷術,尤其是以胸鎖乳突肌痙攣為主的ST。顱內(nèi)手術需要影像學的支持,同時在手術中需要明確壓迫血管及減壓部位,而顱外部分,則需要準確把握副神經(jīng)的走行,進行針對性有選擇的神經(jīng)切斷,保護非痙攣肌的神經(jīng)支配。本實驗研究其顱外解剖基礎,用以輔助臨床手術。 方法: 選擇10具頭胸聯(lián)合標本上(共20側),年齡18-70歲(平均44歲),其中4具新鮮標本,2男性,2女性,6具經(jīng)10%甲醛固定標本,3男性,3女性,采用解剖剝離法,模擬手術體位及手術常用切口,借助標尺、高像素相機等觀測工具進行觀察記錄,同時對固定標本的神經(jīng)、動脈、靜脈進行彩色乳膠染色加以鑒別。通過實體解剖研究副神經(jīng)顱外的解剖特點及其與毗鄰組織關系。 結果: 10具20側標本中觀察到副神經(jīng)出顱后經(jīng)二腹肌后腹及莖突舌骨肌深面,經(jīng)過胸鎖乳突肌發(fā)出分支并于其中點后稍上方進入頸后三角,于斜方肌前緣中下1/3±0.5cm處進入斜方肌。副神經(jīng)淺出點通常位于胸鎖乳突肌后緣中1/2稍上方,與頸外靜脈交叉點后1.5±0.5cm處。10例標本中,70%(14/20側)副神經(jīng)在行程中接受頸叢(C_2～C_4)來的神經(jīng)交通支,20側標本均可見副神經(jīng)分支加入迷走神經(jīng)。 結論: 臨床手術中應由副神經(jīng)淺出點處尋找副神經(jīng)并小心逆行分離,注意保留副神經(jīng)支配喉前肌群的分支及與頸從的交通支,保護迷走神經(jīng)及膈神經(jīng),在切斷胸鎖乳突肌時,還應注意保護其支配斜方肌的分支。 第二部分:C_(1-5)神經(jīng)后根、頸后肌群的解剖學特點及其臨床意義 研究背景及目的: 1924年Cushing創(chuàng)立頸硬脊膜下單側第1-4頸脊神經(jīng)前根及副神經(jīng)切斷術,1930年由Dandy改為雙側,但手術效果并不很理想,同時并發(fā)癥較多。1977年陳信康率先提出了選擇性周圍神經(jīng)切斷術,取得了較滿意的效果,這一術式逐漸得到廣泛支持認可。通過實體標本解剖研究,探討C_(1-5)神經(jīng)后根及頸后肌群及毗鄰結構的解剖學特點,旨在為痙攣性斜頸的外科治療提供解剖方法和依據(jù)。 方法: 選擇10具頭胸聯(lián)合標本上(共20側),年齡18-70歲(平均44歲),其中4具新鮮標本,2男性,2女性,6具經(jīng)10%甲醛固定標本,3男性,3女性,采用解剖剝離法,模擬手術體位及手術常用切口,借助標尺、高像素相機等觀測工具進行觀察記錄,同時對固定標本的神經(jīng)、動脈、靜脈進行彩色乳膠染色加以鑒別。通過實體解剖研究C_(1-5)脊神經(jīng)后支、頸后肌群的解剖特點及毗鄰結構關系。 結果: 發(fā)現(xiàn)寰枕融合者3例,10例均見C_(1-2)、C_(2-3)后支的交通吻合支,3例見C_(3-4)后支的交通吻合支,10例標本上均見C_2脊神經(jīng)節(jié),硬脊膜和C_2椎弓根之間存在較大的靜脈竇。枕下三角結構固定,新鮮尸體解剖可見為白色半透明筋膜覆蓋,其內(nèi)上界為頭后大直肌,外上界為頭上斜肌,外下界為頭下斜肌,三角的底為寰枕后膜和寰椎后弓,淺面借致密結締組織與夾肌和半棘肌相貼,其內(nèi)走行著椎動脈、椎靜脈叢、第一、第二頸神經(jīng)后支等重要結構。 結論: 在新鮮實體標本中,神經(jīng)走行及其分支變異多、神經(jīng)與肌肉支配關系不明確、神經(jīng)不易辨認、與重要血管毗鄰等都對手術造成一定的困難,需要熟悉其解剖特點及難點,明確需要切斷的神經(jīng)后支及相應痙攣肌肉,同時應注意保護椎動脈、枕動脈及枕下三角內(nèi)的靜脈叢、注意保留C_2神經(jīng)支配頸前肌群的分支、注意保留C_4神經(jīng)后支支配斜方肌、膈肌的分支。頸后肌群的解剖、骨性結構、高位頸神經(jīng)結構、血管的鑒別保護等研究是確保手術良好暴露及減少術后并發(fā)癥的重點。
[Abstract]:The first part : the anatomical features and clinical significance of the accessory nerve after extracranial cranial fossa



Background and purpose of the study :



In the treatment of ST clinical operation , the microvascular decompression of accessory nerve root is first reported by Flaminman et al . It is suggested that the pathogenesis of accessory nerve root is subject to microvascular compression , and the impulse is transmitted to the spinal nerve root through the transport branch .



Method :



Ten head - chest joint specimens ( 20 sides ) were selected , aged 18 - 70 years ( mean 44 years ) , among them 4 fresh specimens , 2 males , 2 females , 6 with 10 % formaldehyde fixed specimen , 3 males and 3 females .



Results :



In 10 specimens , 70 % ( 14 / 20 ) of the accessory nerves received cervical plexus ( C _ 2 ~ C _ 4 ) at 1.5 鹵 0.5 cm .



Conclusion :



In the clinical operation , the accessory nerve should be found at the superficial point of the accessory nerve and carefully reversed , and the branch of the anterior muscle group and the traffic branch from the neck , the vagus nerve and the diaphragm nerve should be preserved , and the branch of the superior oblique muscle should also be protected when the cleidomastoid muscle is cut off .



The anatomical features and clinical significance of C _ ( 1 - 5 ) nerve posterior root and posterior cervical muscle group



Background and purpose of the study :



In 1924 , he founded the unilateral first - 4 cervical spinal nerve root and accessory nerve amputation of cervical spinal meninges . In 1930 , Dandy was changed to bilateral , but the operative effect was not ideal . At the same time , the operative effect was not ideal , and the complication was much more . In 1977 , Chen Xinkang took the lead in the selective peripheral nerve amputation , and achieved satisfactory results . The anatomical features of posterior root and posterior muscle group and adjacent structures of C _ ( 1 - 5 ) nerve were investigated by means of physical specimen anatomy .



Method :



The anatomical features of posterior branch and posterior cervical muscle group and its adjacent structure were studied by means of physical anatomy .



Results :



There were 3 cases of atlanto - occipital fusion , 10 cases were found in C _ ( 1 - 2 ) , C _ ( 2 - 3 ) posterior branch traffic anastomoses , 3 cases were found in C _ ( 3 - 4 ) , there was a large venous sinus between C _ 2 spinal ganglia , dura mater and C _ 2 pedicle .



Conclusion :



In the fresh solid specimen , the nerve running line and its branch variation , nerve and muscle dominance relation are not clear , the nerve is not easy to recognize , and the important blood vessel is adjacent to the other . It needs to be familiar with the anatomical features and difficulties of the operation . It is necessary to know the branch of the posterior branch of the cervical muscle group and the branch of the posterior branch of the cervical muscle .
【學位授予單位】：復旦大學
【學位級別】：碩士
【學位授予年份】：2009
【分類號】：R322

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