【摘要】： 目的:針對遠(yuǎn)外側(cè)經(jīng)髁手術(shù)入路中討論最為集中的兩個問題——椎動脈及其周圍靜脈叢的保護(hù)和枕髁安全有效的磨除,進(jìn)行顯微解剖學(xué)研究,以期為臨床工作提供更多的應(yīng)用解剖學(xué)知識,減少手術(shù)副損傷。 方法:先對10例(20側(cè))成人帶頸尸頭濕性標(biāo)本以彩色乳膠灌注動靜脈血管,然后模擬遠(yuǎn)外側(cè)經(jīng)髁手術(shù)入路進(jìn)行顯微解剖,著重測量椎動脈水平段(V3h)內(nèi)緣(穿寰枕筋膜處)與中線的距離、枕下海綿竇(The suboccipital cavernous sinus, SCS) V3h旁靜脈叢內(nèi)緣與中線的距離,觀察椎動脈的走行及變異情況、枕下海綿竇的形態(tài)、椎動脈與枕髁等的位置關(guān)系這些與椎動脈及其周圍靜脈叢保護(hù)有關(guān)的項目,還有枕髁的形態(tài)(寰枕關(guān)節(jié)穩(wěn)定性)、舌下神經(jīng)管的走行和內(nèi)容等與枕髁的安全磨除和周圍結(jié)構(gòu)的保護(hù)有關(guān)的項目。而枕髁的有效磨除即是枕髁的磨除范圍問題,遠(yuǎn)外側(cè)入路中枕髁對巖斜區(qū)手術(shù)視野有一定的阻擋作用,為了解枕髁對斜坡方向手術(shù)暴露范圍的影響,我們以枕髁后緣向斜坡中線所引垂線與矢狀面夾角為指標(biāo),將未磨除枕髁?xí)r與磨除枕髁至舌下神經(jīng)管內(nèi)口時兩組角度進(jìn)行比較,做兩小樣本的配對t檢驗,以p≤0.05為具有顯著性差異,計算是否存在差異。 結(jié)果:1椎動脈及其周圍靜脈叢的保護(hù) 1.1椎動脈的觀測:椎動脈在出樞椎橫突孔至進(jìn)入硬腦膜這段(V3段)變異較大。主要有V3垂直段(V3v)形成的動脈環(huán)彎曲程度及方向不盡相同、V3h有時走行在骨纖維化寰枕后膜和寰椎后弓椎動脈溝形成的骨管中。椎動脈入寰枕筋膜處內(nèi)緣距中線距離左側(cè)為(14.46±2.69)mm,右側(cè)為(16.23±2.06)mm。椎動脈與枕髁的相對位置變化較大,不移位椎動脈并不一定無法暴露枕髁,我們就遇到1例枕髁位于椎動脈前上方,不必移位椎動脈便可對枕髁進(jìn)行操作的標(biāo)本。 1.2枕下海綿竇的觀測:枕下海綿竇形態(tài)不規(guī)則,V3h周圍靜脈叢中部和外側(cè)較內(nèi)側(cè)發(fā)達(dá),中部靜脈血管向后與深層肌肉間靜脈叢相交通;V3v周圍靜脈亦較發(fā)達(dá)并與肌肉間靜脈叢相交通,但接近樞椎平面處靜脈叢漸稀疏,發(fā)出分支也較少。枕下海綿竇內(nèi)緣距中線距離左側(cè)為(12.19±2.29)mm,右側(cè)為(12.60±3.09)mm。V3h旁靜脈叢存在較大的個體差異,V3h走行于骨性纖維管中者,該靜脈叢多不發(fā)達(dá),而無骨性纖維管者,相對較發(fā)達(dá)。 2枕髁的磨除 2.1枕髁的形態(tài)和寰枕關(guān)節(jié)穩(wěn)定性:枕髁位于枕骨大孔前外側(cè)1/3處,其與寰椎上關(guān)節(jié)凹形成的關(guān)節(jié)面是由傾斜的冠狀面過渡為傾斜的水平面的一不規(guī)則曲面(從后外側(cè)方向看),這種結(jié)構(gòu)保證了顱頸關(guān)節(jié)的前后穩(wěn)定性;枕髁關(guān)節(jié)面面積較大,有利于支撐頭顱時穩(wěn)定重心。 2.2舌下神經(jīng)管及髁窩的觀測:舌下神經(jīng)管與枕髁的相對位置較固定,舌下神經(jīng)從后內(nèi)向前外方向穿過枕髁,遠(yuǎn)外側(cè)經(jīng)髁手術(shù)入路磨除枕髁過程中首先遇到舌下神經(jīng)管內(nèi)口,一般情況下磨至此處不會損傷到舌下神經(jīng)。但舌下神經(jīng)常常被舌下靜脈叢包繞,要注意避免損傷。此外,在髁窩中有導(dǎo)靜脈通過,一般位于舌下神經(jīng)管的外上方,管徑較粗大,損傷后可能引起大量出血。 2.3枕髁磨除帶來的術(shù)野變化:未磨除枕髁?xí)r,枕髁后緣向斜坡中線所引垂線與矢狀面夾角為71.3±5.8度;磨除枕髁至舌下神經(jīng)管內(nèi)口處,殘余枕髁后緣向斜坡中線所引垂線與矢狀面夾角為83.9±3.9度,經(jīng)t檢驗t=18.96, p0.05,兩組角度存在區(qū)別。 結(jié)論: 1枕下遠(yuǎn)外側(cè)經(jīng)髁入路手術(shù)中處理V3段椎動脈需注意:①要通過周圍的解剖結(jié)構(gòu)仔細(xì)辨認(rèn)椎動脈,對其可能出現(xiàn)的變異位置要加以小心,避免誤損傷。②中線旁14mm內(nèi)操作相對安全,一般不會損傷到椎動脈。③根據(jù)病例的具體情況決定是否分離及移位椎動脈。 2處理枕下海綿竇時需注意:①分離椎動脈盡量從中線側(cè)(V3h段)和下方(V3v段)開始,避免一開始就處理比較棘手的靜脈叢發(fā)達(dá)區(qū)域。②中線旁12mm左右可能會遇到椎動脈旁靜脈叢,要加以小心。 3隨著枕髁去除部分的增加寰枕關(guān)節(jié)的穩(wěn)定性將越來越差,應(yīng)在顯露適當(dāng)術(shù)野范圍的基礎(chǔ)上盡可能少量地磨除枕髁。 4在磨除枕髁過程中的注意事項:①當(dāng)松質(zhì)骨漸變?yōu)槠べ|(zhì)骨時,舌下神經(jīng)管即將到達(dá)。磨至舌下神經(jīng)管內(nèi)口處一般不會傷及舌下神經(jīng)。舌下神經(jīng)管由后內(nèi)下走向前外上方,舌下神經(jīng)周圍有較發(fā)達(dá)靜脈叢。了解舌下神經(jīng)管走向及內(nèi)容可以減少誤損傷。②髁窩位于枕髁后外側(cè),其內(nèi)有較粗大的導(dǎo)靜脈,在磨除枕髁過程中較易受到損傷,應(yīng)引起注意。③枕髁后方有椎動脈及其周圍靜脈叢,椎動脈入硬腦膜處緊鄰枕髁內(nèi)側(cè),在磨除枕髁過程中都極易受到損傷,手術(shù)過程中要輕柔操作,注意保護(hù)這些結(jié)構(gòu)。 5磨除部分枕髁(至舌下神經(jīng)管內(nèi)口)能增加斜坡方向一定的手術(shù)視野,枕髁對斜坡方向術(shù)野具有阻礙作用。在臨床工作中可視病變的位置大小以及切除的難易程度來決定是否磨除枕髁。
[Abstract]:Objective: To study the microsurgical anatomy of vertebral artery and its surrounding venous plexus and occipital condyle in order to provide more applied anatomy knowledge for clinical work and reduce surgical side injury.
Methods: Arteriovenous vessels were perfused with color latex in 10 adult cadavers (20 sides) with cervical head. The distances between the medial margin of vertebral artery horizontal segment (V3h) and the middle line, and the veins adjacent to the suboccipital cavernous sinus (SCS) V3h were measured. The distance between the inner edge and the middle line of the plexus, the course and variation of the vertebral artery, the morphology of the suboccipital cavernous sinus, the relationship between the vertebral artery and the occipital condyle, the items related to the protection of the vertebral artery and its surrounding venous plexus, the morphology of the occipital condyle (the stability of the atlanto-occipital joint), the course and content of the hypoglossal canal, and the safe abrasion of the occipital condyle The effective abrasion of occipital condyle is the abrasion area of occipital condyle. The occipital condyle obstructs the visual field of petroclival surgery through far lateral approach. In order to understand the influence of occipital condyle on the exposure area of clival surgery, the angle between the vertical line of occipital condyle and the sagittal plane is taken as the index. The two groups were compared when the occipital condyle was not worn off and when the occipital condyle was worn off to the hypoglossal nerve canal entrance. The paired t test of two small samples was performed. The significant difference was p < 0.05, and the difference was calculated.
Results: 1 protection of vertebral artery and its peripheral venous plexus.
1.1 Observation of vertebral artery: The vertebral artery varies greatly from the transverse foramen of the axis to the dura mater (V3 segment). There are mainly different degrees and directions of curvature of the arterial ring formed by the vertical segment of V3 (V3v). V3h sometimes travels in the bone canal formed by the posterior atlanto-occipital membrane and the vertebral artery groove of the posterior atlanto-occipital arch. The distance between the middle line and the occipital condyle was (14.46+2.69) mm on the left and (16.23+2.06) mm on the right.
1.2 Observation of the suboccipital cavernous sinus: the shape of the suboccipital cavernous sinus was irregular, the central and lateral venous plexus around V3h were more developed, and the central venous vessels communicated with the deep intermuscular venous plexus backward; the veins around V3v were also more developed and communicated with the intermuscular venous plexus, but the venous plexus near the axis plane became thinner and the branches were less. The distance from the internal margin of the inferior cavernous sinus to the median line was (12.19 [2.29] mm on the left and (12.60 [3.09] mm on the right. There were significant individual differences in the paravenous plexus. The venous plexus was more undeveloped in those who walked in the osseous fibrous duct at V3h, but more developed in those without osseous fibrous duct.
2 grinding of occipital condyle
2.1 Morphology of occipital condyle and stability of atlanto-occipital joint: occipital condyle is located at the anterolateral 1/3 of foramen magnum. The articular surface formed by occipital condyle and atlanto-supracondylar articular fovea is an irregular curved surface which transits from oblique coronal plane to oblique horizontal plane (from posterolateral direction). This structure guarantees the anterior and posterior stability of craniocervical joint. It helps to stabilize the center of gravity when supporting the head.
2.2 Observation of hypoglossal nerve canal and condylar fossa: The relative position of hypoglossal nerve canal and occipital condyle is relatively fixed. Hypoglossal nerve passes through occipital condyle from posterior medial to anterior and outward direction. In the process of removing occipital condyle by far lateral transcondylar surgical approach, hypoglossal nerve canal orifice is first encountered. Generally, the hypoglossal nerve will not be damaged here. The inferior venous plexus is surrounded by the inferior venous plexus and should be careful to avoid injury. In addition, there is a conducting vein passing through the condylar fossa, which is generally located outside and above the hypoglossal nerve canal. The diameter of the canal is larger and may cause massive bleeding after injury.
2.3 Operative field changes caused by occipital condyle abrasion: when occipital condyle was not abrased, the angle between the sagittal plane and the vertical line of the posterior margin of occipital condyle was 71.3 + 5.8 degrees; when the occipital condyle was abrased to the orifice of hypoglossal nerve canal, the angle between the vertical line of the posterior margin of occipital condyle and the sagittal plane was 83.9 + 3.9 degrees.
Conclusion: 1. Attention should be paid to the treatment of V3 vertebral artery by far lateral suboccipital transcondylar approach: (1) Vertebral artery should be identified carefully through the surrounding anatomical structure, and the possible variation of the vertebral artery should be carefully avoided. 2) The operation within 14 mm of the midline is relatively safe and generally does not damage the vertebral artery. Determine whether the vertebral artery is dislocated or displaced.
2. Attention should be paid to the treatment of suboccipital cavernous sinus: 1. The vertebral artery should be separated from the middle line (V3h segment) and the lower (V3v segment) as far as possible, so as to avoid dealing with the more difficult areas of venous plexus at the beginning.
The stability of atlanto-occipital joint will be worse and worse with the increase of occipital condyle removal. The occipital condyle should be ground as little as possible on the basis of exposure of appropriate surgical field.
4. Notes in the course of occipital condyle abrasion: 1. When cancellous bone gradually becomes cortical bone, the hypoglossal nerve canal is about to arrive. Generally, the hypoglossal nerve will not be injured at the entrance of the hypoglossal nerve canal. (2) The condylar fossa is located at the posterolateral side of the occipital condyle, and there is a large internal guide vein. It is easy to be injured during the process of grinding the occipital condyle. Attention should be paid to it. (3) There are vertebral artery and its surrounding venous plexus behind the occipital condyle. The vertebral artery is close to the medial part of the occipital condyle where it enters the dura. Pay attention to protecting these structures.
Grinding part of the occipital condyle (to the hypoglossal nerve canal) can increase the surgical field in the clivus direction. The occipital condyle can obstruct the surgical field in the clivus direction.
【學(xué)位授予單位】：河北醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2008
【分類號】：R322

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3 張中橋;椎管腫瘤手術(shù)治療效果好[N];中國醫(yī)藥報;2004年

4 褚曉明　胡誠;寰樞椎脫位治療有突破[N];中國醫(yī)藥報;2010年

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1 宋千;遠(yuǎn)外側(cè)入路處理顱頸交界區(qū)病變的顯微解剖學(xué)研究[D];山東大學(xué);2006年

2 趙博;枕下遠(yuǎn)外側(cè)入路的顯微解剖學(xué)、影像學(xué)和臨床研究[D];山東大學(xué);2006年

3 哈文波;虛擬現(xiàn)實技術(shù)在遠(yuǎn)外側(cè)入路顯微解剖和顱底腫瘤個性化手術(shù)入路的應(yīng)用研究[D];吉林大學(xué);2010年

4 李連峰;術(shù)中CT與導(dǎo)航系統(tǒng)在先天性顱頸交界區(qū)畸形個性化治療中的臨床應(yīng)用[D];中國人民解放軍軍醫(yī)進(jìn)修學(xué)院;2011年

5 胡鵬;內(nèi)鏡下經(jīng)鼻腔入路至顱頸交界區(qū)的應(yīng)用解剖學(xué)研究[D];中國協(xié)和醫(yī)科大學(xué);2008年

6 洪健;顱頸交界區(qū)手術(shù)入路顯微解剖與固定方法研究[D];天津醫(yī)科大學(xué);2009年

7 張朝躍;內(nèi)窺鏡下經(jīng)口咽入路手術(shù)治療枕頸區(qū)病變的基礎(chǔ)與臨床研究[D];中南大學(xué);2007年

8 劉光久;頭頸部數(shù)字化三維斷面解剖及可視化研究[D];第三軍醫(yī)大學(xué);2007年

9 尹一恒;顱頸交界區(qū)畸形中寰樞外側(cè)關(guān)節(jié)的結(jié)構(gòu)變異與生物力學(xué)研究[D];中國人民解放軍軍醫(yī)進(jìn)修學(xué)院;2012年

10 張恒柱;遠(yuǎn)外側(cè)鎖孔入路的顯微解剖學(xué)研究[D];蘇州大學(xué);2006年

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1 韓楓;枕下遠(yuǎn)外側(cè)經(jīng)髁手術(shù)入路的顯微解剖學(xué)研究[D];河北醫(yī)科大學(xué);2008年

2 王永剛;顱底遠(yuǎn)外側(cè)入路的應(yīng)用解剖研究[D];昆明醫(yī)學(xué)院;2003年

3 馬遠(yuǎn);合并椎血管畸形的顱頸交界區(qū)畸形的手術(shù)治療[D];鄭州大學(xué);2012年

4 嚴(yán)海;經(jīng)口咽入路解剖學(xué)研究[D];吉林大學(xué);2008年

5 李光宏;遠(yuǎn)外側(cè)入路顯微手術(shù)治療顱內(nèi)后循環(huán)動脈瘤的臨床分析[D];中國醫(yī)科大學(xué);2010年

6 裴斐;5例斜坡脊索瘤經(jīng)遠(yuǎn)外側(cè)入路切除臨床體會[D];大連醫(yī)科大學(xué);2009年

7 張謙生;顱頸交界區(qū)畸形及其并發(fā)癥的外科治療初探[D];鄭州大學(xué);2011年

8 劉亮;后顱窩遠(yuǎn)外側(cè)手術(shù)入路的顯微外科解剖研究[D];昆明醫(yī)學(xué)院;2004年

9 何繼軍;經(jīng)遠(yuǎn)外側(cè)入路頸靜脈孔區(qū)的顯微解剖[D];河北醫(yī)科大學(xué);2007年

10 董玉科;內(nèi)鏡下經(jīng)鼻顱頸交界腹側(cè)區(qū)手術(shù)的應(yīng)用解剖[D];南方醫(yī)科大學(xué);2009年

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