【摘要】： 第一部分:枕下遠(yuǎn)外側(cè)入路至顱頸交界區(qū)的顯微解剖與后路固定方法研究 目的:研究國(guó)人成年頭顱標(biāo)本經(jīng)枕下遠(yuǎn)外側(cè)入路至顱頸交界腹外側(cè)區(qū)的顯微解剖與術(shù)后顱頸失穩(wěn)的后路寰枕固定方法。 方法:15具(30側(cè))完整成人濕性頭顱標(biāo)本,經(jīng)紅藍(lán)硅膠分別灌注動(dòng)靜脈后經(jīng)枕下遠(yuǎn)外側(cè)入路進(jìn)行分層顯微解剖,另對(duì)15具干性頭顱和寰樞椎標(biāo)本進(jìn)行相關(guān)骨性測(cè)量,并對(duì)解剖數(shù)據(jù)進(jìn)行對(duì)比分析;根據(jù)遠(yuǎn)外側(cè)入路對(duì)枕骨髁磨除范圍的不同,分成經(jīng)髁后入路(RCA)組、部分經(jīng)髁入路(pTCA)組、完全經(jīng)髁入路(tTCA)組以及經(jīng)頸靜脈結(jié)節(jié)入路(TTA)組各15例(30側(cè)),對(duì)比不同術(shù)式對(duì)顱頸交界腹外側(cè)區(qū)暴露范圍的影響;并對(duì)后路經(jīng)寰椎椎弓根螺釘內(nèi)固定的進(jìn)釘點(diǎn)、進(jìn)釘方向等指標(biāo)進(jìn)行測(cè)量分析。 結(jié)果:1.83.3%的枕動(dòng)脈主干體表投影在乳突尖與枕外隆突連線上,距后正中線3～5cm區(qū)域之間;椎動(dòng)脈穿硬腦膜處距后中線平均距離為15.5±1.2mm,未見小腦后下動(dòng)脈由椎動(dòng)脈硬膜外段發(fā)出者;枕骨髁平均長(zhǎng)度為24.5±3.3mm;舌下神經(jīng)管內(nèi)口下緣距枕骨髁平均距離為9.1±1.1mm;頸靜脈結(jié)節(jié)平均高度為9.4±1.4mm; 86.7%的星點(diǎn)位于橫竇乙狀竇交角之后。2.與遠(yuǎn)外側(cè)髁后入路組比較,部分經(jīng)髁入路組、完全經(jīng)髁入路組以及頸靜脈結(jié)節(jié)入路組對(duì)顱頸交界腹外側(cè)區(qū)水平暴露距離分別增加10.9mm、12.6mm和10.1mm,手術(shù)深度分別降低13.5mm、20.5mm和24.6mm,組間差異具有統(tǒng)計(jì)學(xué)意義(P0.05)。3.寰枕固定枕骨端可選擇上項(xiàng)線水平上1 cm處,以寰椎椎弓根中線外側(cè)2mm處為進(jìn)釘點(diǎn),內(nèi)斜平均角度13.5±2.4°,上斜平均角度5.2±0.4°,螺釘平均長(zhǎng)度25.5±3.5mm。 結(jié)論:枕下遠(yuǎn)外側(cè)入路可充分顯露顱頸交界腹外側(cè)區(qū),可通過磨除不同范圍的枕髁或頸靜脈結(jié)節(jié)等骨性結(jié)構(gòu)增加暴露,術(shù)后可經(jīng)后路寰椎椎弓根螺釘內(nèi)固定行寰枕融合術(shù)。 第二部分:經(jīng)口咽入路至顱頸交界區(qū)的顯微解剖與前路固定方法研究 目的:研究國(guó)人成年頭顱標(biāo)本經(jīng)口咽入路至顱頸交界腹外側(cè)區(qū)的顯微解剖與術(shù)后顱頸失穩(wěn)的前路寰樞固定方法。 方法:所用標(biāo)本同第一部分,經(jīng)口咽入路進(jìn)行分層顯微解剖并做相關(guān)測(cè)量,對(duì)解剖數(shù)據(jù)進(jìn)行對(duì)比分析;將標(biāo)本分為單純經(jīng)口咽入路(To)組、經(jīng)口咽入路+下頜骨切開(To+Ma)組和經(jīng)口咽入路+部分硬腭切除(To+Pa)組各15例(30側(cè)),比較不同術(shù)式對(duì)顱頸交界腹外側(cè)區(qū)暴露范圍的影響;并對(duì)前路經(jīng)寰樞關(guān)節(jié)螺釘內(nèi)固定的進(jìn)釘點(diǎn)、進(jìn)釘方向等指標(biāo)進(jìn)行測(cè)量。 結(jié)果:1.咽后壁軟組織存在5層結(jié)構(gòu)和2個(gè)間隙;咽結(jié)節(jié)至枕骨大孔前緣的平均距離為10.2±2.2mm;寰椎前結(jié)節(jié)至上切牙平均距離為11.6±2.1 cm;齒狀突平均高度為15.9±6.9mm,至上切牙平均距離為12.8±2.2cm;寰椎橫韌帶平均長(zhǎng)度為21.7±1.6mm,中部與硬膜囊的平均距離為2.1±0.3mm。2.標(biāo)準(zhǔn)經(jīng)口咽入路矢狀位暴露范圍由下斜坡至C_2水平;下頜骨切開后矢狀位顯露角度增加23.6°,軸位顯露角度增加11.1°,手術(shù)深度減少2.0cm,暴露范圍延伸到中斜坡至C_3水平,差異具有統(tǒng)計(jì)學(xué)意義(P0.05);部分硬腭切除后矢狀位顯露角度增加14.0°,手術(shù)深度減少1.6cm,差異具有統(tǒng)計(jì)學(xué)意義(P0.05),但軸位顯露角度改變不明顯,頭側(cè)暴露范圍增加至上斜坡,而尾側(cè)仍至C_2水平。3.以樞椎前弓下緣與樞椎椎體側(cè)緣交點(diǎn)上方3mm為進(jìn)釘點(diǎn),螺釘長(zhǎng)度16～25mm,外傾5～20°,后傾15～24°置入。 結(jié)論:經(jīng)口咽入路對(duì)顱頸交界腹側(cè)由下斜坡至C_2水平距中線3～5cm內(nèi)的區(qū)域顯露較好,尤其適合行齒狀突切除前路減壓;其改良術(shù)式增加了暴露范圍,降低了手術(shù)深度;術(shù)后可經(jīng)前路行寰樞關(guān)節(jié)螺釘內(nèi)固定術(shù)穩(wěn)定寰枕區(qū)。
[Abstract]:The First Part : A Study of the Microanatomy and Posterior Fixation in the Transborder Region of the Head and Neck



Objective : To study the posterior atlanto - occipital fixation in the lateral ventrolateral area of the cranio - cervical junction of adult head specimens from the adult .



Methods : 15 cases ( 30 sides ) of intact adult wet skull specimens were dissected by using red - blue silica gel , and the other 15 cases ( 30 sides ) were divided into the condylar - posterior approach ( RCA ) group , the partial transcondylar approach ( pTCA ) group , the complete transcondylar approach ( tTCA ) group , the transcondylar approach ( tTCA ) group , and the internal jugular nodule - in - posterior ( tTCA ) group .



Results : 1 . 83 . 3 % occipital artery trunk body surface was projected on the connecting line between the mastoid tip and the occipital protuberance , the average distance from the posterior median line to the posterior median line was 15.5 鹵 1.2mm . The average length of the occipital condyle was 24.5 鹵 1.4mm ; the average distance of the inferior margin of the cervical vein was 9.5 鹵 1.4mm . The average angle of the internal oblique angle was 13.5 鹵 2.4 擄 , the upper oblique average angle was 5.2 鹵 0.4 擄 , and the average length of the screw was 25.5 鹵 3.5mm .



Conclusion : The lower lateral approach of the pillow can reveal the lateral ventrolateral area of the cranio - cervical junction , which can increase the exposure to the bony structures such as the occipital condyle or the jugular nodule in different ranges . The atlanto - occipital fusion can be fixed through the posterior atlantoaxial pedicle screw .



The second part : Microanatomy and anterior fixation of the transjugular approach to the cranio - cervical junction area



Objective : To study the anterior atlantoaxial fixation method for the microdissection and post - operative cranio - neck instability of adult head specimens of Chinese adults via oropharyngeal approach to the ventrolateral region of the cranio - cervical junction .



Methods : The specimens were compared with the first part , through the oropharyngeal approach , and the anatomical data were compared and analyzed . The specimens were divided into 15 cases ( 30 sides ) of the pure oral pharyngeal approach ( To ) group , the oropharyngeal approach plus the mandible incision ( To + Ma ) group and the oropharyngeal approach plus part of the hard palate resection ( To + Pa ) group . The effects of different operation types on the exposure range of the lateral ventrolateral area of the cranio - cervical junction were compared ; and the indexes such as the nail point and the nail feeding direction fixed in the anterior atlantoaxial joint screw were measured .



Results : 1 . There were 5 structure and 2 gaps in the soft tissue of posterior pharyngeal wall . The average distance between the anterior margin of the pharyngeal nodule to the anterior margin of the foramen magnum was 10.2 鹵 2.2 mm , the mean distance of the anterior resection of the atlas was 1 . 6 鹵 2 . 2 cm , the mean distance between the middle and hard capsule was 2 . 1 鹵 2 . 2 cm .



Conclusion : The lower slope to the C _ 2 level from the lower slope to the C _ 2 level is better in the lower slope to the C _ 2 level from the lower slope to the C _ 2 level , which is especially suitable for the anterior decompression of the odontoid process . The improved operation method increases the exposure scope and reduces the depth of operation ; and the atlantooccipital area can be stabilized via anterior atlantoaxial arthrodesis .
【學(xué)位授予單位】：天津醫(yī)科大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2009
【分類號(hào)】：R651;R322

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本文編號(hào)：2123125