【摘要】： 目的:通過(guò)對(duì)成人顱骨干性標(biāo)本和濕性標(biāo)本的解剖及其數(shù)據(jù)測(cè)量,研究乙狀竇后經(jīng)內(nèi)聽(tīng)道上入路(RSSMA)的顯微外科解剖標(biāo)志,量化巖骨斜坡區(qū)入路的相關(guān)組織結(jié)構(gòu),為乙狀竇后經(jīng)內(nèi)聽(tīng)道上入路切除顱內(nèi)占位病變提供準(zhǔn)確的解剖學(xué)數(shù)據(jù)。為增加手術(shù)安全性與可操作性,最大程度切除腫瘤甚至完全切除,減少手術(shù)創(chuàng)傷和術(shù)后并發(fā)癥提供理論指導(dǎo)。 材料與方法:成人濕性頭顱標(biāo)本10例,顱骨干性標(biāo)本10例。對(duì)10例(20側(cè))經(jīng)福爾馬林溶液固定的、不同性別的成人頭顱濕性標(biāo)本進(jìn)行血管灌注染色后,模擬乙狀竇后經(jīng)內(nèi)聽(tīng)道上手術(shù)入路進(jìn)行解剖,逐層暴露巖骨斜坡區(qū)顯微結(jié)構(gòu)并詳細(xì)記錄操作步驟。顯微鏡下測(cè)量相關(guān)數(shù)據(jù),以?xún)?nèi)聽(tīng)道道上結(jié)節(jié)(簡(jiǎn)稱(chēng)道上結(jié)節(jié))為標(biāo)志觀察周?chē)�、神�?jīng)等解剖結(jié)構(gòu)。磨除內(nèi)聽(tīng)道上結(jié)節(jié)和巖尖,切開(kāi)三叉神經(jīng)腔的硬腦膜壁和天幕,測(cè)量?jī)?nèi)聽(tīng)道上結(jié)節(jié)和巖尖磨除前后中顱窩、上斜坡和三叉神經(jīng)的暴露范圍。 1顱骨干性標(biāo)本 將干性顱骨標(biāo)本經(jīng)眉弓上緣1cm處沿水平方向鋸開(kāi)去除頂蓋骨,顯露顱底骨性結(jié)構(gòu)。對(duì)巖斜區(qū)進(jìn)行骨性結(jié)構(gòu)觀察,重要識(shí)別橫竇溝、乙狀竇溝、巖上竇溝、三叉神經(jīng)壓跡、前庭水管外口、弓下窩、道上結(jié)節(jié)、巖尖等結(jié)構(gòu),并對(duì)該區(qū)與乙狀竇后經(jīng)內(nèi)聽(tīng)道上入路相關(guān)的重要結(jié)構(gòu)進(jìn)行詳細(xì)測(cè)量、拍攝,如測(cè)量星點(diǎn)-道上結(jié)節(jié)、星點(diǎn)-巖尖的距離,內(nèi)聽(tīng)道上結(jié)節(jié)和巖尖的三維參數(shù)。標(biāo)記出乙狀竇溝后緣及橫竇溝下緣的顱骨表面投影,模擬乙狀竇后入路進(jìn)行骨窗設(shè)計(jì)。顯微鏡下磨除骨性結(jié)構(gòu)-內(nèi)聽(tīng)道上結(jié)節(jié)與巖尖,并測(cè)量道上結(jié)節(jié)和巖尖磨除后的三維參數(shù)變化。 2顱骨濕性標(biāo)本 模擬枕下乙狀竇后入路逐層解剖,精確定位、測(cè)量與手術(shù)入路有關(guān)的重要解剖結(jié)構(gòu)并進(jìn)行拍攝。將經(jīng)過(guò)備皮和彩色乳膠灌注的頭顱標(biāo)本固定于Doro手術(shù)頭架上,設(shè)計(jì)基底向前,近乎以橫竇為中心的倒L形切口。經(jīng)星點(diǎn)做骨瓣成型,暴露橫竇下緣和乙狀竇后緣,放射狀剪開(kāi)硬腦膜并對(duì)硬腦膜進(jìn)行懸吊。由于經(jīng)過(guò)固定的腦組織會(huì)變硬、彈性較差,很難被牽拉出手術(shù)操作空間,因此常切除小腦外側(cè)1/3后用腦壓板將小腦向內(nèi)側(cè)牽開(kāi),暴露巖斜區(qū)結(jié)構(gòu)。顯微鏡下測(cè)量星點(diǎn)-道上結(jié)節(jié)、星點(diǎn)-巖尖、道上結(jié)節(jié)-外展神經(jīng)、道上結(jié)節(jié)-三叉神經(jīng)、道上結(jié)節(jié)-面聽(tīng)神經(jīng)的距離,觀察毗鄰的神經(jīng)和血管,重點(diǎn)觀測(cè)動(dòng)眼神經(jīng)、滑車(chē)神經(jīng)、三叉神經(jīng)、外展神經(jīng)、面神經(jīng)、位聽(tīng)神經(jīng)、小腦上動(dòng)脈、小腦下前動(dòng)脈、小腦下后動(dòng)脈、巖靜脈等結(jié)構(gòu)的起源、走形分布及相互關(guān)系。移動(dòng)手術(shù)顯微鏡,測(cè)量中顱窩、上斜坡和三叉神經(jīng)的暴露范圍。磨除道上結(jié)節(jié)和巖尖,切開(kāi)Meckel腔側(cè)壁和上壁的硬膜,自小腦幕緣沿巖骨嵴打開(kāi)小腦幕,再次測(cè)量中顱窩、上斜坡和三叉神經(jīng)的暴露范圍。 3統(tǒng)計(jì)分析 實(shí)驗(yàn)結(jié)果數(shù)據(jù)應(yīng)用統(tǒng)計(jì)學(xué)軟件SPSS16.0進(jìn)行統(tǒng)計(jì)學(xué)分析,計(jì)算出結(jié)果用均數(shù)±標(biāo)準(zhǔn)差(Mean±SD)表示。對(duì)三叉神經(jīng)和術(shù)野暴露數(shù)據(jù)測(cè)量結(jié)果進(jìn)行獨(dú)立樣本t檢驗(yàn)比較,以P0.05作為判斷差異顯著性的標(biāo)準(zhǔn)。 結(jié)果:星點(diǎn)-道上結(jié)節(jié)的距離為53.4±4.6(49.7—61.8)mm、星點(diǎn)-巖尖的距離為72.1±4.9(67.9—81.4)mm,道上結(jié)節(jié)-三叉神經(jīng)壓跡外緣的距離為9.7±0.9(8.7—11.2)mm、道上結(jié)節(jié)-外展神經(jīng)的距離為16.8±1.0(15.9—18.1)mm、道上結(jié)節(jié)-前庭水管外口的距離為20.1±0.8(19.2—21.3)mm、道上結(jié)節(jié)-弓狀下窩的距離為9.4±1.1(7.6—10.5)mm、道上結(jié)節(jié)-巖尖的距離為18.3±1.0(17.4—19.9)mm、滑車(chē)神經(jīng)匯入小腦幕緣處距巖骨嵴的距離為4.8±1.1(3.4—7.3)mm、面聽(tīng)神經(jīng)距三叉神經(jīng)距離為4.8±1.6(4.3—5.6)mm、面聽(tīng)神經(jīng)距舌咽神經(jīng)距離為4.9±1.8(4.4—5.5) mm。內(nèi)聽(tīng)道上結(jié)節(jié)的三維參數(shù)如下:前后徑9.8±1.7(8.3—12.8)mm、上下徑5.7±1.1(4.1—7.2)mm、左右徑14.1±2.4(10.6—17.1)mm;巖尖的三維參數(shù)為:前后徑14.7±3.0(11.7—19.9)mm、上下徑17.1±1.1(15.9—18.7)mm、左右徑19.3±1.1(17.5—20.9)mm。道上結(jié)節(jié)前后徑,左右徑,上下徑均可全部磨除,為不損傷三叉神經(jīng)和面聽(tīng)神經(jīng),靠近神經(jīng)處可留薄層骨質(zhì)以保護(hù)神經(jīng),經(jīng)統(tǒng)計(jì)學(xué)檢驗(yàn)均P0.05,差異有統(tǒng)計(jì)學(xué)意義;巖尖前后徑,左右徑可全部磨除,磨除后的上下徑為9.8±1.7(7.9—12.5)mm,經(jīng)統(tǒng)計(jì)學(xué)檢驗(yàn)均P0.05,差異有統(tǒng)計(jì)學(xué)意義。中顱窩擴(kuò)大顯露范圍為137.1±7.1mm2 ,上斜坡擴(kuò)大顯露至83.8±7.3mm2 ,三叉神經(jīng)的顯露長(zhǎng)度為9.3±0.6mm,與術(shù)前比較經(jīng)統(tǒng)計(jì)學(xué)檢驗(yàn)均P0.05,差異有統(tǒng)計(jì)學(xué)意義。小腦上動(dòng)脈、小腦下前動(dòng)脈、小腦下后動(dòng)脈、巖上靜脈、巖上竇、動(dòng)眼神經(jīng)、滑車(chē)神經(jīng)、三叉神經(jīng)、外展神經(jīng)、面神經(jīng)、前庭窩神經(jīng)、舌咽神經(jīng)、迷走神經(jīng)、副神經(jīng)均得以認(rèn)定。 結(jié)論:乙狀竇后經(jīng)內(nèi)聽(tīng)道上入路可以將乙狀竇后入路的手術(shù)野擴(kuò)大顯露到中顱窩的中線側(cè)和上斜坡的側(cè)方,并可顯露Meckel’s腔內(nèi)的三叉神經(jīng)。該手術(shù)入路是切除主體在后顱窩,同時(shí)侵犯中顱窩和Meckel’s腔病變的安全、有效入路,而不需同時(shí)做幕上開(kāi)顱手術(shù)。 巖斜區(qū)血管走行及分支變異性較大,而且該部位動(dòng)脈血管的損傷常引起嚴(yán)重并發(fā)癥。因此手術(shù)中不要輕易電凝腫瘤表面的血管,應(yīng)在顯微鏡下確認(rèn)該血管是進(jìn)入腫瘤的供血?jiǎng)用}還是旁路血管。巖靜脈是引流腦干和小腦前外側(cè)血液回流的一組靜脈,為便于術(shù)野暴露可將其切斷。 內(nèi)聽(tīng)道上結(jié)節(jié)和巖尖的磨除是該入路的關(guān)鍵,術(shù)中內(nèi)聽(tīng)道上結(jié)節(jié)可全部磨除,巖尖上下徑磨除7.3±1.2(6.2—8.2)mm可有效顯露術(shù)野。
[Abstract]:Objective: To study the microsurgical anatomical markers of retrosigmoid trans-internal auditory approach (RSSMA) and quantify the related structures of petroclival approach, and to provide accurate anatomical data for resection of intracranial space-occupying lesions via retrosigmoid trans-internal auditory approach. To provide theoretical guidance for increasing the safety and maneuverability of operation, maximizing the resection of tumor or even complete resection, and reducing surgical trauma and postoperative complications.
Materials and Methods: 10 adult wet skull specimens and 10 skull diaphyseal specimens were dissected by simulating the retrosigmoid approach through the internal auditory canal after perfusion staining of 10 adult wet skull specimens (20 sides) fixed with formalin solution and of different sex. Measure the data under microscope. Observe the anatomical structures of the peripheral vessels and nerves with the nodules in the internal auditory meatus as the markers. Grind the nodules and petrous apex of the internal auditory meatus, incise the dural wall and tentorium of the trigeminal nerve cavity, measure the nodules in the internal auditory meatus and petrous apex before and after the abrasion of the middle cranial fossa, the upper clivus and the trigeminal nerve. Exposure range.
1 dry skull specimens
The skull specimens were dissected horizontally from the upper edge of the eyebrow arch to remove the parietal skull and expose the skull base bony structure.The petroclival region was observed to identify the transverse sinus sulcus, sigmoid sinus sulcus, superior petrosal sinus sulcus, trigeminal nerve imprint, vestibular aqueduct outlet, subarch fossa, tubercle of the passage, petrous apex and other structures. Important structures related to the auditory approach were measured in detail and photographed, such as the distance between the star and the nodule, the distance between the star and the petrous apex, and the three-dimensional parameters of the nodule and petrous apex in the internal auditory meatus. The nodules and petrous apex of the internal auditory canal were measured, and the three-dimensional parameters of the superior nodules and the apex of the petrous apex were measured.
2 wet specimens of skull
Simulate the suboccipital retrosigmoid approach, locate accurately, measure and photograph the important anatomical structures related to the surgical approach. Fix the skull specimens with skin preparation and color latex perfusion on the Doro Surgical Skull frame, design the inverted L-shaped incision with the basement forward and the transverse sinus as the center. The lower edge and the posterior edge of the sigmoid sinus are scissored radially and the dura mater is suspended. Since the fixed brain tissue will harden and have poor elasticity, it is difficult to be pulled out of the operating space, so the lateral cerebellum is often removed 1/3 later, the cerebellum is retracted medially with a compression plate to expose the petroclival structure. The distances between the star-petrous apex, the tubercle-abductor nerve, the tubercle-trigeminal nerve, the tubercle-facial nerve, and the adjacent nerves and vessels were observed. The origins of oculomotor nerve, trochlear nerve, trigeminal nerve, abductor nerve, facial nerve, auditory nerve, superior cerebellar artery, anterior inferior cerebellar artery, posterior inferior cerebellar artery and petrosal vein were observed. The exposure areas of the middle cranial fossa, the upper clivus and the trigeminal nerve were measured by moving the operating microscope. The nodules and petrous apex of the canal were abraded, the dura mater of the lateral wall and the upper wall of the Meckel cavity were incised, the tentorium of cerebellum was opened along the petrous ridge from the tentorium margin of the cerebellum, and the exposure areas of the middle cranial fossa, the upper clivus and the trigeminal nerve were measured again
3 statistical analysis
The experimental data were statistically analyzed by SPSS16.0 and the calculated results were expressed by Mean (+ SD). The results of trigeminal nerve and surgical field exposure data were compared by independent sample t test, and P 0.05 was used as the criterion to judge the significance of the difference.
Results: The distance between the nodule and the petrous apex was 53.4 (-4.6) (49.7-61.8) mm, 72.1 (-4.9) (67.9-81.4) mm, 9.7 (-0.7-11.2) mm, 16.8 (-1.0) (15.9-18.1) mm, and 20.1 (-0.8) mm, respectively. (19.2-21.3) mm, the distance between nodule and inferior arcuate fossa was 9.4 (-1.1) (7.6-10.5) mm, the distance between nodule and petrous apex was 18.3 (-1.0) (17.4-19.9) mm, the distance between trochlear nerve and petrosal crest was 4.8 (-1.1) (3.4-7.3) mm, the distance between facial and auditory nerve and trigeminal nerve was 4.8 (-1.6) mm, and the distance between facial and auditory nerve and hypopharyngeal nerve was 4.8 (-1.3-5.6) mm. The three-dimensional parameters of the nodules in the internal auditory meatus were as follows: the anteand posterior diameters were 9.8 ((8.3-12.8) mm, 9.8 ((8.3-12.8) mm, 5.7 (1.1 (4.1-7.2) mm, 14.1 (2.1 ((10.6-17.1) mm) 4 (10.6-17.1) mm) mm; the left and right diadiameters were 14.1 (14.1 (2.1 (2.4.4.4.4 (10.6-17.1) mm); the rock apwas 14.7 ((14.7 ((11.7 (11.7-19.7-19.9) mm), 17.1 (17 5-20.9)mm. In order not to damage the trigeminal nerve and the facial and acoustic nerve, thin layer of bone can be left near the nerve to protect the nerve. The difference was statistically significant (P 0.05). The exposure range of the middle cranial fossa was 137.1 (+ 7.1) mm2, the upper clivus was 83.8 (+ 7.3) mm2, and the exposure length of the trigeminal nerve was 9.3 (+ 0.6) mm. The difference was statistically significant (P 0.05). The superior cerebellar artery, inferior anterior cerebellar artery, inferior posterior cerebellar artery, superior petrosal vein, and petrosal vein were statistically significant (P 0.05). Superior sinus, oculomotor nerve, trochlear nerve, trigeminal nerve, abductor nerve, facial nerve, vestibular fossa nerve, glossopharyngeal nerve, vagus nerve, accessory nerve were identified.
CONCLUSION: The retrosigmoid approach is a safe and effective approach for the removal of the main body in the posterior cranial fossa and the invasion of the middle cranial fossa and the lesions in the Meckel's cavity. Meanwhile, supratentorial craniotomy was performed.
The petroclival region is characterized by great variability in the course and branches of the blood vessels, and the injury of the arteries in the petroclival region often leads to serious complications. Therefore, it is not necessary to electrocoagulate the blood vessels on the surface of the tumor easily during operation. It should be confirmed under microscope whether the blood vessels enter the tumor's blood supply artery or bypass vessels. The petrosal vein is the drainage of blood from the brain stem and anterolateral cerebellum. A group of veins can be cut off to facilitate the exposure of the operative field.
Abrasion of nodules and petrous apex in the internal auditory canal is the key to the approach. All nodules in the internal auditory canal can be abrased during the operation. Abrasion of 7.3 (+1.2) (6.2-8.2) mm of petrous apex can effectively expose the surgical field.
【學(xué)位授予單位】：河北醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2010
【分類(lèi)號(hào)】：R322.8

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