【摘要】：目的：結(jié)合臨床手術(shù)實際應(yīng)用需要,通過對神經(jīng)內(nèi)鏡下經(jīng)篩蝶入路行視神經(jīng)管減壓手術(shù)相關(guān)的解剖及影像學(xué)研究,了解相關(guān)解剖標志及變異情況,測量此徑路手術(shù)相關(guān)的解剖數(shù)據(jù),確定手術(shù)安全范圍,探索術(shù)中定位視神經(jīng)管的新方法,以提高神經(jīng)內(nèi)鏡下視神經(jīng)管減壓術(shù)的安全性及準確性；測量此徑路下可磨除視神經(jīng)管內(nèi)壁骨質(zhì)的最大有效范圍,從解剖學(xué)角度評估其有效性；結(jié)合臨床應(yīng)用病例回顧性分析,探討該入路的優(yōu)勢及影響術(shù)后療效的可能因素。材料與方法：第一部分：1.選用6例(12側(cè))成人頭顱干性標本(風(fēng)干的濕性頭顱標本),分別行眼眶三維CT掃描并重建,于CT片上測量相關(guān)解剖學(xué)參數(shù),并利用公式計算出視神經(jīng)管眶口、顱口及管中段的周徑及橫截面積；以雙側(cè)眉弓上1cm及枕外粗隆為水平面鋸開顱蓋,觀察顱底結(jié)構(gòu)并測量視神經(jīng)管各段間距；沿著正中矢狀面鋸開頭顱,按照神經(jīng)內(nèi)鏡下經(jīng)篩蝶入路行視神經(jīng)管減壓的手術(shù)徑路,逐層解剖相關(guān)解剖結(jié)構(gòu),尋找并確定此徑路中的手術(shù)標志,測量各解剖標志點之間的距離及視神經(jīng)管內(nèi)側(cè)壁長度；對比CT影像與實體解剖兩種方法所測得的相關(guān)數(shù)據(jù)。2.選用6例(12側(cè))經(jīng)10%福爾馬林固定的成人頭顱標本,用紅色乳膠灌注動脈系統(tǒng)后進行解剖。模擬神經(jīng)內(nèi)鏡下經(jīng)篩蝶入路視神經(jīng)管減壓術(shù),觀察并統(tǒng)計蝶竇后外側(cè)壁各解剖標志的出現(xiàn)率,并確定視神經(jīng)管顱口與鞍結(jié)節(jié)隱窩中心點的位置關(guān)系；進一步磨除蝶竇后外側(cè)壁骨質(zhì),測量視神經(jīng)內(nèi)壁的最大可磨除寬度,觀察視神經(jīng)與頸內(nèi)動脈的位置關(guān)系,測量頸內(nèi)動脈與視神經(jīng)之間的最近點,即頸內(nèi)動脈虹吸彎頂點至中線的距離；切開鞘膜,觀察眼動脈的走行,并統(tǒng)計其于視神經(jīng)管各段與視神經(jīng)的位置關(guān)系。第二部分：回顧性分析江蘇省蘇北人民醫(yī)院神經(jīng)外科應(yīng)用神經(jīng)內(nèi)鏡下經(jīng)篩蝶入路行視神經(jīng)管減壓術(shù)的4例(5眼)外傷性視神經(jīng)病變的臨床資料,記錄手術(shù)用時、術(shù)中出血量以及術(shù)后并發(fā)癥的情況,對比手術(shù)前后患者的視力情況,結(jié)合解剖研究基礎(chǔ)及文獻回顧,探討該入路的優(yōu)勢及影響術(shù)后療效的可能因素。結(jié)果：第一部分：1.將CT影像與實體解剖測量的視神經(jīng)管顱口、眶口、管中段間距及視神經(jīng)管內(nèi)側(cè)壁的長度兩組數(shù)據(jù)比較,結(jié)果無統(tǒng)計學(xué)差異(P0.05)。視神經(jīng)管顱口、眶口、管中段處的周長分別為(16.42±1.56)mmm、(17.32±1.60)mm和(13.58±1.42)mm,各段橫截面積分別為(18.42±2.17)mm2、(22.64±2.23)mm2和(15.12±2.05)mm2。同側(cè)鼻孔鼻小柱至視神經(jīng)管眶口內(nèi)側(cè)壁中點、顱口內(nèi)側(cè)壁中點、管中段內(nèi)側(cè)壁中點、篩前孔、篩后孔以及蝶竇前外側(cè)壁與篩頂交界點的距離分別為(61.95±5.42)mm、(68.18±5.77) mm、(66.72±4.87)mm、(58.09±5.03)mm、(59.31±4.96)mm和(60.12±5.01)mm；篩前孔與篩后孔的間距為(16.2±2.51)m.m,篩后孔至蝶竇前外側(cè)壁與篩頂交界點、眶口、顱口及管中段的距離分別為(4.32±1.14)mm、(5.76±1.68)mm、(6.85±1.73)mm和(6.35±1.54)mm。內(nèi)鏡下視神經(jīng)管顱口、眶口及管中段可磨除內(nèi)壁的最大有效寬度分別為(7.82 ±2.63)mm.(8.05±2.77)mm和(6.92±2.01)mm。2.視神經(jīng)隆凸的出現(xiàn)率為83.3%(10側(cè)),頸內(nèi)動脈隆凸的出現(xiàn)率為91.7%(11側(cè)),內(nèi)側(cè)視神經(jīng)一頸內(nèi)動脈隱窩的出現(xiàn)率為58.3%(7側(cè)),外側(cè)視神經(jīng)一頸內(nèi)動脈隱窩的出現(xiàn)率為75.0%(9側(cè)),鞍結(jié)節(jié)隱窩與鞍底的出現(xiàn)率均為100%(6例)。鞍結(jié)節(jié)隱窩中心點至視神經(jīng)管顱口內(nèi)側(cè)壁中點的橫、縱坐標分別為(1.11±0.12)mm、(0.37±0.06)mm,鞍結(jié)節(jié)隱窩中心點與視神經(jīng)管顱口內(nèi)側(cè)壁中點連線同橫坐標之間的角度為(17.23±1.34)。。頸內(nèi)動脈虹吸彎頂點距中線(11.21±1.35)mm。視神經(jīng)管顱口處眼動脈位于視神經(jīng)內(nèi)下方9側(cè)(75%)和下方3側(cè)(25%)；視神經(jīng)管眶口處眼動脈位于視神經(jīng)下方2側(cè)(16.7%)和外下方10側(cè)(83.3%)。第二部分：單側(cè)手術(shù)平均用時90 min(78-90 min),術(shù)中出血80ml(70～100ml),術(shù)后均無出血、感染及腦脊液漏等并發(fā)癥,4例(5眼)中術(shù)后的總體有效率為60%(3/5),術(shù)前有殘存視力的患者,無論病程長短,術(shù)后視力均有不同程度的提高,而術(shù)前無光感的患者則無提高。結(jié)論：第一部分：神經(jīng)內(nèi)鏡下經(jīng)篩蝶入路視神經(jīng)管減壓術(shù)是一種進路直接、手術(shù)效果確切的微創(chuàng)手術(shù)。充分掌握相關(guān)局部解剖結(jié)構(gòu)及深度范圍是保證手術(shù)安全的重要前提,術(shù)前仔細閱讀CT影像資料并作相關(guān)測量,結(jié)合多種定位方法能提高手術(shù)的準確性。第二部分：視神經(jīng)管減壓對部分外傷性視神經(jīng)病變的預(yù)后有積極的影響,而神經(jīng)內(nèi)鏡下經(jīng)篩蝶入路視神經(jīng)管減壓術(shù)進路直接,并發(fā)癥少,便于掌握和操作,適合臨床推廣。
[Abstract]:Objective: To study the anatomy and imaging of optic canal decompression through ethmoid-sphenoidal approach under neuroendoscope in order to find out the anatomical markers and variations, measure the anatomical data related to this approach, determine the safe range of operation, and explore a new method of locating optic canal during operation. To improve the safety and accuracy of endoscopic optic canal decompression, to measure the maximum effective range of abradable optic canal wall bone, and to evaluate its effectiveness from the anatomical point of view; to explore the advantages of this approach and the possible factors affecting the postoperative outcome by retrospective analysis of clinical cases. Methods: Part I: 1. Six adult skull dry specimens (12 sides) were scanned and reconstructed by three-dimensional CT, and the relevant anatomical parameters were measured on CT films. The perimeter and cross-sectional area of the orbital orifice, cranial orifice and middle segment of the optic canal were calculated by using the formula. The cranial cap was sawed horizontally to observe the structure of the skull base and measure the interval between the segments of the optic canal. The length of the medial wall of the optic canal was compared with that of the solid anatomy. 2. Six adult head specimens (12 sides) fixed with 10% formalin were dissected after infusing the artery system with red latex. The location of the cranial orifice of the optic canal and the central point of the recess of the sellar tubercle were determined, the bone of the posterolateral wall of the sphenoid sinus was further ground, the maximum abradable width of the optic nerve inner wall was measured, the position relationship between the optic nerve and the internal carotid artery was observed, and the nearest point between the internal carotid artery and the optic nerve, i.e, the internal carotid artery, was The distance from the apex of the siphon curve to the middle line; the sheath was incised to observe the course of the ophthalmic artery, and the relationship between each segment of the optic canal and the optic nerve was statistically analyzed. Part two: A retrospective analysis of 4 cases (5 eyes) of traumatic optic neuropathy treated by endoscopic transethmoidal decompression of the optic canal in the neurosurgery department of Jiangsu Subei People's Hospital was performed. The clinical data, the amount of bleeding and complications were recorded. The visual acuity of the patients before and after the operation was compared. The advantages of the approach and the possible factors affecting the postoperative outcome were discussed in combination with the anatomical basis and literature review. Results: Part 1: 1. The optic canal was measured by CT and anatomy. There was no significant difference in the length of the medial wall of the optic canal between the two groups (P 0.05). The distances from the ipsilateral nasal columella to the medial wall of the orbital orifice of the optic canal, the medial wall of the cranial ostium, the medial wall of the canal, the anterior ethmoidal foramen, the posterior ethmoidal foramen and the junction between the anterolateral wall of the sphenoidal sinus and the ethmoidal apex were (61.95 (5.42) mm, (68.18 (5.77) mm, (66.72 (4.87) mm, (58.09 (59.31 (4 The distance between the posterior ethmoidal foramen and the anterolateral wall of the sphenoidal sinus and the ethmoidal apex, the orbital orifice, the cranial orifice and the middle segment of the canal were (4.32 [1.14] m m, (5.76 [1.68] m m, (6.85] 1.73] m m and (6.35 [1.54] m m], respectively. The incidence of optic nerve protrusion was 83.3% (10 sides), internal carotid artery protrusion was 91.7% (11 sides), medial optic nerve-internal carotid artery recess was 58.3% (7 sides), lateral optic nerve-internal carotid artery recess was 75.0% (9 sides), and sellar tubercle recess and sellar floor were 100% (6 cases). (3) The transverse and longitudinal coordinates of the center point of the tuberculum sellae recess to the medial wall of the cranial ostium of the optic canal were (1.11+0.12) mm, (0.37+0.06) mm, and the angle between the center point of the tuberculum sellae recess and the medial wall of the cranial ostium of the optic canal and the transverse coordinates was (17.23+1.34). (11.21+1.35) mm. The ophthalmic arteries were located in 9 sides (75%) below the optic nerve and 3 sides (25%) below the optic nerve. The ophthalmic arteries at the orbital orifice of the optic canal were located in 2 sides (16.7%) below the optic nerve and 10 sides (83.3%) below the optic nerve. The overall effective rate was 60% (3/5). The postoperative visual acuity of patients with preoperative residual visual acuity was improved in varying degrees regardless of the duration of the disease, but not in patients without preoperative photosensitivity. Surgery. Mastering the anatomical structure and depth range is an important prerequisite to ensure the safety of surgery. Careful preoperative reading of CT images and related measurements, combined with a variety of localization methods, can improve the accuracy of surgery. Part II: Decompression of the optic canal has a positive impact on the prognosis of some traumatic optic neuropathy. Endoscopic transethmoidal decompression of the optic canal is a direct approach with fewer complications, easy to master and operate, and is suitable for clinical promotion.
【學(xué)位授予單位】：揚州大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2016
【分類號】：R651

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