内镜扩大经鼻入路颅底手术的临床应用解剖学研究

发布时间：2018-06-07 16:36

  本文选题：内镜经鼻入路颅底手术 + 内镜颅底解剖　； 参考：《南方医科大学》2015年博士论文

【摘要】：研究背景：颅底中线部位病变位置深,毗邻脑底重要的神经和血管,传统开颅手术需要广泛切开头皮,锯下骨瓣、咬开骨窗,牵拉脑组织,甚至破坏正常的颅内结构以获得进入病变部位的脑底通道。该过程创伤大,出血多,进入颅底后,遇到颅底重要血管、神经的阻挡,暴露病变不充分,切除病变需要在血管和神经之间的间隙内进行操作,容易损伤相应的血管、神经,而且难以全切肿瘤,导致肿瘤术后复发机会增大,术后容易出现血管、神经损伤的相应并发症。难以有效解除患者的病痛。内镜扩大经鼻入路颅底手术是近年来发展起来的采用硬质内镜为光源,经鼻腔进行颅底中线部位病变切除的一种手术方式。该手术方式通过人体自然腔道(鼻腔、蝶窦、筛窦等)到达颅底中线病变部位,进行手术。手术入路直接,经过鼻腔,通过简单的颅底骨质磨除,直接到达相应的颅底病灶。避免了传统开颅手术时大范围头皮切开、骨瓣骨窗成型、术中牵拉脑组织等操作过程,不会遇到颅底重要神经、血管阻挡进入病灶的通路。从而减少了对重要神经、血管结构造成损伤的可能性,相应的减少了手术的并发症。该手术入路采用4mm的硬质内镜经鼻腔进行手术,内镜可以在鼻腔内自由移动,加上可以采用成角度的内镜观察病灶,术中视野开阔,可观察到手术部位的全景视野,能够更准确、彻底的切除病灶,减少术后复发率。因此内镜扩大经鼻入路颅底手术受到越来越多的神经外科医生的青睐。但是,该手术入路也存在着缺点。首先,内镜下观察到的解剖结构和显微镜以及肉眼观察到解剖结构存在着差异,由于内镜二维成像的原因,图像有变形,图像缺乏立体感,再加上神经外科医生对颅底腹侧的解剖结构相对不熟悉,从而使内镜扩大经鼻入路在临床上难以广泛应用；其次,颅底病变往往同时侵及颅底骨质、硬脑膜、甚至颅底脑组织,切除颅底病变后造成颅底骨质、硬脑膜缺如,术后导致无菌的颅腔和有菌的鼻腔相通,造成脑脊液漏、颅内感染等并发症；第三、内镜扩大经鼻入路通过双侧鼻孔进行颅底手术,手术入路外口狭小,手术操作空间有限,需要术者具备娴熟的外科技术和熟悉内镜下的颅底解剖特点。本研究从内镜扩大经鼻入路颅底手术的角度,针对内镜扩大经鼻入路的缺陷,进行解剖学研究。使广大临床医师了解该手术入路下的解剖学特征,手术过程中的解剖学标志,术后骨质、硬脑膜缺损可能的重建方式,根据术前影像检查定位颅内解剖标志。使该手术入路更容易被广大医师掌握,更好的发挥该手术入路的优势。研究目的：1,研究内镜扩大经鼻入路颅底手术的暴露范围、解剖标志及其与相邻解剖结构的关系,为该手术入路更广泛的应用于临床提供解剖学基础知识；2,研究鼻腔内血管分布情况,探索以鼻后外侧动脉为供血动脉,以下鼻甲、鼻腔外侧壁、鼻腔底部、鼻中隔粘膜为瓣的后蒂下鼻甲鼻中隔瓣的可行性；3,研究用后蒂下鼻甲鼻中隔瓣重建内镜扩大经鼻入路颅底手术术后广泛颅底骨质、硬脑膜缺损的可行性；4,用三维重建CT影像帮助外科医生在术前定位内镜扩大经鼻入路颅底手术过程中颅内的解剖标志,减少手术并发症。研究方法：1,模拟内镜扩大经鼻入路颅底手术解剖5例防腐成人尸头标本。①标本准备：准备5例经颈内动脉灌注红色乳胶的防腐尸头标本,用棉签清洗鼻腔；②模拟手术：用0度内镜插入右侧鼻孔,辨认鼻中隔、下鼻甲、中鼻甲、上鼻甲、鼻后孔、鼻咽、咽鼓管开口、咽鼓管圆枕、蝶筛隐窝、蝶窦开口等鼻腔内解剖标志；退出内镜后插入左侧鼻孔,观察以上结构,并将左侧中鼻甲向外侧折断；内镜插入右侧鼻孔,切除右侧中鼻甲和鼻中隔后部约2cm、双侧蝶窦前壁；模拟内镜扩大经鼻入路颅底手术依次解剖前颅底、蝶窦、斜坡及颅颈交界区。2,后蒂下鼻甲鼻中隔瓣的可行性研究。①标本制备：8例新鲜冰冻成人尸头标本,常温下解冻,经双侧颈总动脉灌注红色乳胶,放置于负20度冰箱内冷冻24小时后取出解冻。②大体解剖：去除下颌骨,在显微镜下小心咬出上颌骨水平板、颚骨水平板,同时保护好鼻腔底部粘膜。在显微镜下小心仔细分离鼻中隔两侧粘膜至前颅底,用神经剥离子小心剥离粘膜在前颅底的附着处。取出鼻中隔骨质和鼻中隔软骨。沿两侧鼻腔粘膜之间颅底正中线锯开标本,从而使两侧鼻中隔、鼻腔底部、鼻腔外侧壁及下鼻甲粘膜保持完好无损。③后蒂下鼻甲鼻中隔瓣的制备：后蒂下鼻甲鼻中隔瓣由9条切线切开鼻腔粘膜而成。首先从蝶窦前壁沿颅底向前剪开鼻中隔粘膜至鼻根部,然后从鼻根部剪开至鼻骨尖端,再从鼻骨尖端剪开粘膜至上颌骨鼻棘；第四条切线从蝶窦前壁和前颅底的交点剪开至鼻后孔鼻中隔侧的鼻腔底部；第五条切线从上颌骨鼻棘沿着鼻腔底部向外侧,绕过鼻泪管开口的后缘,然后向前到达下鼻甲头部的下缘。第六条切线位于冠状位,从下鼻甲头的下缘至上缘；第七条切线位于矢状位,从下鼻甲头上缘向后,至下鼻甲末端前方约1.5cm；第八条切线位于冠状位,从上鼻甲末端前方1.5cm至蝶腭孔前缘；第九条切线从鼻后孔鼻中隔侧沿鼻腔底部向外侧到鼻腔外侧壁,然后,在冠状面,绕过下鼻甲末端,至蝶腭孔后缘。完成这些切线后,把下鼻甲骨向内侧折断,将下鼻甲骨从下鼻甲内侧粘膜和下鼻道侧粘膜之间分块取出,注意保护好下鼻甲动脉。④获取离体后蒂下鼻甲鼻中隔瓣：在蝶腭孔处横断下鼻甲鼻中隔瓣蒂部,获得离体后蒂下鼻甲鼻中隔瓣,并对其进行解剖学测量。⑤显微解剖：在显微镜下解剖后蒂下鼻甲鼻中隔瓣,观察其血管分布情况,并进行解剖学测量。3用后蒂下鼻甲鼻中隔瓣重建内镜扩大经鼻入路颅底手术术后广泛颅底骨质、硬脑膜缺损的研究。①新鲜冰冻成人尸头标本3例,经双侧颈总动脉灌注红色乳胶,内镜下在右侧鼻腔制作后蒂下鼻甲鼻中隔瓣,藏于右侧上颌窦内。②切除右侧中鼻甲、鼻中隔后部2cm、蝶窦前壁,外移对侧中鼻甲,制造内镜扩大经鼻入路的手术通道。然后切除双侧筛窦、蝶窦下壁、斜坡骨质,暴露前颅底、中颅底和后颅底腹侧面。③围绕蝶腭孔将后蒂下鼻甲鼻中隔瓣旋转180度,使后蒂下鼻甲鼻中隔瓣的鼻中隔部分覆盖于前颅底,鼻腔底部部分覆盖于鞍底、下鼻甲部分覆盖于斜坡,观察其重建广泛颅底中线骨质、硬脑膜缺损的范围。4,用三维重建薄层CT影像对内镜扩大经鼻入路颅底手术颅内解剖标志进行术前定位研究。①收集111例成人多层重建CT影像,用mimics软件重建矢状位和冠状位CT影像,在三维图像上定位基点：鼻棘、硬腭后部中点,鼻棘和硬腭后部中点之间的连线作为基线；定位观察点：左/右视神经管,左/右破裂孔内口,鞍结节中点,蝶鞍后下壁中点；②测量各观察点到基点鼻棘的距离,测量各观察点到鼻棘的连线和基线的夹角,测量左右视神经管之间、左右颈内动脉之间、鞍结节中点和蝶鞍后下壁中点之间的距离；③用SPSS20.0对以上各测量值进行统计分析。结果：1,内镜扩大经鼻入路颅底手术鼻腔内的解剖标志包括下鼻甲、鼻中隔后部、鼻后孔、蝶筛隐窝、蝶窦开口；前颅底的解剖标志包括额隐窝、鸡冠、眶内侧壁；蝶窦内的解剖标志包括视神经隆起、颈内动脉隆起、颈内动脉视神经隐窝、鞍底、斜坡隐窝,蝶窦后壁；暴露斜坡的解剖标志为蝶窦下壁、破裂孔、翼管；暴露颅颈交界的解剖标志为咽鼓管圆枕、枕髁、舌下神经管、寰椎前弓、齿突。颅底中线腹侧的暴露范围,在前颅底,前至额隐窝,两侧至眶内侧壁；蝶骨平台处,两侧可暴露至眶上裂的外侧缘；鞍区可暴露的侧界为圆孔；斜坡区侧界为颈动脉管内口；枕髁处可暴露的最外侧为舌下神经管前缘；向下可暴露至枢椎上缘。颅底腹侧中线可暴露的神经、血管结构包括：直回、大脑纵裂、大脑前动脉、前交通动脉、嗅球、嗅束、视神经、视交叉、眼动脉、颈内动脉、垂体、垂体柄、乳突体、第三脑室底、大脑后动脉、后交通动脉、基底动脉、动眼神经、小脑上动脉、滑车神经、眼神经、上颌神经、展神经、脑桥动脉、椎动脉、小脑后下动脉、脊髓前动脉、面神经、前庭蜗神经、舌咽神经、迷走神经、副神经、舌下神经、第一、二颈神经、脑桥、延髓和上颈髓腹侧。2,下鼻甲动脉平均2.50±0.52支,鼻中隔动脉平均2.50±0.52支,这些动脉发出吻合支形成下鼻甲动脉网和鼻中隔动脉网,在下鼻甲动脉网和鼻中隔动脉网之间存在恒定的吻合动脉,吻合动脉的数量为3.19±1.47支,其中最大吻合动脉的平均直径0.40mm±1.10mm(范围0.24-0.60mm)。后蒂下鼻甲鼻中隔瓣的面积为3090.69±288.08mm2(范围2612.97mm2-3880.09mm2)；其蒂的长度为11.21±2.40mm(范围5.00mm-14.74mm)；瓣的最窄宽度为25.21±2.29mm(范围22.36-30.23mm)；最宽宽度为44.53±5.02mm(范围36.45mm-54.10mm)；长度为100.65±5.61mm(范围91.43-109.44mm)。3,后蒂下鼻甲鼻中隔瓣覆盖颅底范围前端至额隐窝,下端至枕骨大孔,侧方在前颅底至双侧眶内侧壁,中颅底覆盖双侧的海绵窦,后颅底覆盖双侧颈内动脉之间的斜坡。由于后蒂下鼻甲鼻中隔瓣的蒂部长度有限,在上斜坡部分,对侧部分上斜坡不能完全覆盖。对于左侧鼻腔的后蒂下鼻甲鼻中隔瓣,重建颅底硬脑膜缺损时旋转方向为顺时针；右侧鼻腔的后蒂下鼻甲鼻中隔瓣则刚好相反,旋转方向为逆时针。4,从鼻棘到视神经管的平均距离为73.12±4.10 mm,从视神经管到鼻棘的连线和基线的夹角的平均角度39.79±3.13度；从破裂孔内侧缘到鼻棘的平均距离是79.91±4.01mm,从破裂孔内侧缘到鼻棘的连线和基线的夹角的平均角度是23.27±2.89度。从鞍结节中点和鞍底后缘中点到鼻棘的平均距离分别是76.16±4.56mm和82.05-4.81mm,相应连线和基线的夹角分别是34.97±3.24度和26.39±3.51度。双侧破裂孔之间、双侧视神经管之间的平均距离分别是22.54±3.25mm和23.44±3.49mm。从鞍结节中点到鞍底后缘中点的平均距离是13.33±1.87mm。结论：1,内镜扩大经鼻入路颅底手术可暴露广泛颅底腹侧中线部位,路径直接、视野广泛,避免了牵拉脑组织,避开了脑底重要血管神经的阻挡,可作为颅底中线部位：包括前颅底、中颅底、斜坡和颅颈交界区硬膜外或者硬膜下病变的有效手术治疗方法,对于某些其他手术入路无法切除的病变,可作为首选治疗方式。该入路最常见的手术问题是防止术后脑脊液漏和控制出血。内镜扩大经鼻入路颅底手术需要研发精细的手术器械、更有效的止血材料和重建颅底缺损的方法。只有在内镜应用方面进行过内镜尸体解剖研究或者经过内镜经鼻入路颅底手术培训的有经验的神经外科医师可以开展内镜扩大经鼻入路颅底手术。2,以鼻后外侧动脉为供血动脉的后蒂下鼻甲鼻中隔瓣的血供基础从解剖学的角度是可行的,结合既往的研究结果,鼻后外侧动脉可向整个粘膜瓣供血,而不会出现缺血坏死的情况；该瓣是目前报道的鼻内最大的带蒂粘膜瓣。3,后蒂下鼻甲鼻中隔瓣位于鼻内,其用于重建内镜扩大经鼻入路颅底手术后颅底骨质、硬脑膜缺损的范围广泛,避免了应用鼻外带蒂筋膜瓣重建内镜扩大经鼻入路颅底广泛骨质硬脑膜缺损时瓣的转移过程,从而减少了相应的并发症,可作为一种潜在的重建广泛颅底骨质、硬脑膜缺损的鼻内带蒂粘膜瓣。4,视神经管、破裂孔、鞍结节、鞍底后缘中点是内镜扩大经鼻入路颅底手术的解剖标志,薄层三维重建CT影像可对这些解剖标志在术前进行立体定位评估,从而有助于术者在术中确认这些手术标志,避免损伤重要的血管神经结构,减少手术并发症,对于鞍前型、甲介型蝶鞍来说,术前评估尤其重要。对每位病人进行个体化的评估,更有利于术中对这些解剖标志的辨认。
[Abstract]:Background: the location of the lesion in the midline of the skull is deep, adjacent to the important nerve and blood vessels of the brain. Traditional craniotomy requires extensive incision of the scalp, sawing the bone flap, biting the bone window, pulling the brain tissue, and even destroying the normal intracranial structure to obtain the brain bottom passage into the lesion. The process is traumatic, bleeding, and encounters after the skull base. The important blood vessels of the skull base, the nerve block, the exposure of the disease is not sufficient, the removal of the lesion needs to operate within the space between the blood vessels and nerves. It is easy to damage the corresponding blood vessels and nerves, and it is difficult to cut the tumor completely, which causes the recurrence of the tumor after operation and the postoperative complications of vascular and nerve injury. The endoscopic enlargement of the transnasal approach to the skull base is a new method of resection of the middle line of the skull through the nasal cavity, which has been developed in recent years by using the hard endoscopy as the light source. The operation is performed through the natural cavity of the human body (nasal cavity, sphenoid sinus, ethmoid sinus and so on) to the middle line of the skull base, and the operation is performed directly. Through the nasal cavity, the skull base is directly reached through the simple skull base bone grinding. It avoids the large scalp incision in the traditional craniotomy, the bone flap bone window molding, and the operation process of pulling the brain tissue during the operation. It will not meet the important nerve of the skull base and the blood vessels obstruct the access to the lesion. Thus, the important nerve and the vascular structure are reduced. The possibility of injury, which reduces the complication of the operation, is operated through the nasal cavity of the 4mm's hard endoscope, the endoscopy can move freely within the nasal cavity, and the endoscopy can be used to observe the focus, and the visual field is broadened to observe the panoramic view of the hand. It can be more accurately and thoroughly excised. The endoscopic enlargement of the transnasal approach to the skull base is therefore favored by more and more neurosurgeons. However, there are also shortcomings in the surgical approach. First, the anatomical structure observed under the endoscope and the anatomical structure observed by the naked eye are different, and the reasons for the two-dimensional imaging of the endoscope are shown. Such as distortion, lack of stereoscopic images, and the relative unfamiliarity of the neurosurgeon with the anatomical structure of the ventral base of the skull, the endoscopic enlargement of the transnasal approach is difficult to be widely used clinically. Secondly, the skull base lesions often involve the skull base, the dura, and even the cranial tissue, and the skull base is excised and the skull base is hard to be caused by the removal of the skull base. The absence of meninges, which causes the aseptic cranial cavity and the bacterial nasal cavity, causes cerebrospinal fluid leakage, intracranial infection and other complications; third, endoscopic enlargement of the transnasal approach through bilateral nostrils for skull base surgery, the surgical approach is narrow, and the operation space is limited. The surgeons need skilled surgical techniques and know the skull base under endoscopy. An anatomical study of endoscopic enlargement of the nasal approach to the endoscopic enlargement of the transnasal approach. The anatomical features of the surgical approach, the anatomical marks of the operation, the possible reconstruction of the postoperatively bone and the defect of the dura meninges, according to the preoperative imaging examination, were made in this study. The surgical approach is easier to be mastered by the general physician and better to give full play to the advantages of the surgical approach. Objective: 1. To study the scope of endoscopic enlargement of the transnasal approach to the skull base surgery, the anatomical signs and their relationship with adjacent anatomical structures, and to provide a more extensive application of the surgical approach to clinical anatomy. 2, study the distribution of the blood vessels in the nasal cavity, explore the feasibility of the posterior pedicle of the inferior turbinate with the posterior lateral nasal artery as the supply artery, the inferior turbinate, the lateral wall of the nasal cavity, the bottom of the nasal cavity, the nasal septum mucosa as the flap, and 3. The feasibility of cranial base bone and dura defect; 4, using three-dimensional reconstruction of CT images to help the surgeon to expand the intracranial anatomic markers in the process of endoscopic sinus surgery to reduce the surgical complications. Study methods: 1, 5 cases of adult cadaver head specimens were dissected by endoscopic enlargement of nasal approach cranial hand surgery. (1) specimen preparation 5 specimens of the anticorrosive cadaver head with red latex perfusion through the internal carotid artery were prepared with a cotton swab to clean the nasal cavity; (2) a simulated operation: a 0 degree endoscope was inserted into the right nostril to identify the nasal septum, inferior turbinate, nasal turbinate, upper turbinate, posterior nasopharynx, nasopharynx, Eustachian tube opening, Eustachian tube round pillow, sphenoid fossa, sphenoid sinus opening and other anatomic markers. The left nostril was inserted into the left nostril to observe the above structure, and the left middle turbinate was broken to the lateral. The right nostril was inserted into the right nostril to remove the right middle turbinate and the posterior septum of the nasal septum about 2cm and the anterior wall of the sphenoid sinus. The anterior skull base, the sphenoid sinus, the ramp and the craniofacial junction area of the anterior skull base, the sphenoid sinus, the ramp and the craniofacial junction area were.2, and the inferior turbinate nasal septum was followed by the endoscopy. Feasibility study of valve. (1) specimen preparation: 8 cases of fresh frozen adult cadaver head specimens, frozen at normal temperature, red latex perfusion through bilateral common carotid artery, and frozen for 24 hours in negative 20 degrees fridge. Gross anatomy: remove the mandible, carefully bite the horizontal plate of the maxilla, the horizontal plate of the jaw, and protect the horizontal plate at the same time. The mucosa at the bottom of the nasal cavity. Carefully separate the mucous membranes on both sides of the nasal septum to the anterior skull base carefully and carefully peel off the mucous membrane at the anterior skull base with nerve ion. Remove the nasal septum and nasal septum cartilage. The nasal septum, the bottom of the nasal cavity, the lateral wall of the nasal cavity, and the lateral wall of the nasal cavity and the lateral wall of the nasal cavity are removed. The mucous membrane of the inferior turbinate remains intact. (3) the preparation of the inferior turbinate septum flap in the posterior pedicle: the posterior inferior turbinate nasal septum is cut through the nasal mucosa by 9 tangents. First, cut the nasal septum from the anterior wall of the sphenoidal sinus to the nasal root, then cut from the nasal root to the tip of the nasal bone, and then cut the mucous membrane from the tip of the nasal bone to the maxilla nose spines. The fourth cut lines cut from the anterior wall of the sphenoidal sinus and the anterior skull base to the bottom of the nasal septum on the nasal septum, and the fifth cut lines from the maxillary nasal spines along the bottom of the nasal cavity, around the posterior edge of the nasolacrimal duct opening, and then forward to the lower edge of the head of the inferior turbinate. The sixth lines were located at the coronal, from the lower edge of the inferior turbinate to the lower edge of the nose. Margin; seventh tangents are located in the sagittal position, from the upper upper edge of the inferior turbinate to about 1.5cm at the end of the inferior turbinate; the eighth tangent line is located in the coronal position, from the end of the upper turbinate to the anterior edge of the sphenopalatine hole, and the ninth cut lines from the posterior nasal septum to the lateral of the nasal cavity to the lateral wall of the nasal cavity, then, at the coronal, around the inferior turbinate at the coronal surface. End, to the posterior margin of the sphenopalatine hole. After the completion of these lines, the inferior turbinate was broken to the medial side, the inferior turbinate was removed from the medial mucous membrane of the inferior turbinate and the inferior nasal mucosa, and the inferior turbinate artery was protected. (4) to obtain the inferior turbinate septum flap in the posterior pedicle: the pedicle of the inferior turbinate and nasal septum at the sphenopalatine hole was obtained. After the isolation, the isolated nasal septum was obtained. Pedicle inferior turbinate nasal septum and anatomical measurement. 5. Microanatomy: dissection of the inferior turbinate nasal septum under microscope and observe the distribution of the vessels. The anatomical measurement of the.3 with the posterior pedicle inferior turbinate nasal septum reconstruction endoscope enlarges the extensive skull base bone and the dura mater defect after the cranial surgery. (1) 3 cadaver specimens of fresh frozen adult cadavers were perfused with red latex through bilateral common carotid artery and the inferior turbinate nasal septum after making the right nasal cavity and hidden in the right maxillary sinus after making the right nasal cavity. Second, the right middle turbinate, the posterior septum of the nasal septum 2cm, the anterior wall of the sphenoid sinus, the lateral middle turbinate, and the endoscopic enlargement of the nasal passage were made. And then excised. Bilateral ethmoid sinus, inferior wall of sphenoid sinus, slope bone, anterior skull base, middle skull base and posterior skull base ventral side. 3. Revolve 180 degrees around the inferior turbinate nasal septum around the sphenopalatine hole. The nasal septum part of the inferior turbinate nasal septum covers the anterior skull base, the bottom part of the nasal cavity covers the saddle bottom, the inferior turbinate part covers the slope and the reconstruction is widely rebuilt. The range of median skull base line bone and dura mater defect.4. A three-dimensional reconstruction thin layer CT image was used to study the preoperative localization of the intracranial anatomic markers by endoscopic sinus surgery. (1) 111 cases of adult multilevel reconstruction of CT images were collected and mimics software was used to reconstruct the sagittal and coronal CT images, and the base points of the nasal spine and the hard palate were located on the three-dimensional images. The line between the middle point of the posterior part of the posterior part and the middle point of the posterior part of the hard palate was taken as the baseline; the location of the observation point: the left / right optic canal, the left / right ruptured orifice, the middle point of the sellar tubercle, the middle point of the posterior inferior wall of the saddle; and the measurement of the distance between the observation points to the base point of the nasal Spina, the angle of the connection lines and the baseline of the nasal spines at each observation point, and the measurement of the left and right optic canal The distance between the left and right internal carotid arteries, the middle point of the saddle tubercle and the middle of the inferior wall of the saddle after the sellar; (3) the results were statistically analyzed with SPSS20.0. Results: 1, the endoscopic enlargement of the nasal cavity of the nasal cavity through the nasal approach included the inferior turbinate, the posterior nasal septum, the posterior nasal cavity, the sphenoid fossa, the sphenoid sinus, and the anatomy of the anterior skull base. The signs include the frontal recess, the cockscomb, and the medial orbital wall; the anatomic markers in the sphenoidal sinus include the optic nerve protuberance, the internal carotid artery protuberance, the internal carotid artery optic recess, the saddle floor, the ramp recess, the posterior wall of the sphenoid sinus, and the anatomical marks of the exposed ramp for the inferior wall of the sphenoid sinus, the ruptured hole, and the wing tube; the anatomical signs of the craniocervial junction are the eustachian tube, the occipital condyle, and the sublingual gland. Nerve canal, anterior arch of atlas, odontoid process. The exposure of the ventral side of the middle line of the skull at the anterior skull base, the anterior to the frontal recess, both sides to the medial orbital wall; the lateral border of the orbital fissure at the sphenoid platform; the exposed lateral boundary of the saddle area is a circular hole; the lateral boundary of the slope is the internal canal of the carotid canal; the most lateral of the occipital condyle is the lateral sublingual canal. Anterior margin; exposing to the upper edge of the axis. The nerves that can be exposed in the middle of the ventral side of the skull include: straight gyrus, longitudinal brain fissure, anterior cerebral artery, anterior communicating artery, olfactory bulb, olfactory bundle, optic nerve, optic chiasma, ophthalmic artery, internal carotid artery, pituitary, pituitary stalk, lactoad, third ventricle base, posterior cerebral artery, posterior communicating artery, basilar artery, and movement The eyes, superior cerebellar artery, trochlear nerve, eye meridian, maxillary nerve, abduction nerve, pontine artery, vertebral artery, posterior inferior cerebellar artery, anterior spinal artery, facial nerve, vestibule nerve, glossopharyngeal nerve, vagus nerve, accessory nerve, hypoglossal nerve, first, second cervical nerves, pontine, medulla and upper cervical ventral.2, and inferior turbinate artery averages 2.50 + 0.52 branches, nose The median of the septum artery was 2.50 + 0.52 branches. These arteries emit the anastomosis branch to form the inferior turbinate artery network and the nasal septum artery network. There is a constant anastomosis artery between the inferior turbinate artery network and the nasal septum artery network. The number of the anastomotic arteries is 3.19 + 1.47 branches, the average diameter of the maximum anastomosis artery is 0.40mm + 1.10mm (range 0.24-0.60mm). The area of inferior turbinate nasal septum was 3090.69 + 288.08mm2 (range 2612.97mm2-3880.09mm2), the length of the pedicle was 11.21 + 2.40mm (range 5.00mm-14.74mm), the narrowest width of the flap was 25.21 + 2.29mm (range 22.36-30.23mm), the width of the flap was 44.53 + 5.02mm (range 36.45mm-54.10mm), and the length was 100.65 + 5.61mm (91.43-109.44mm).3. The posterior inferior turbinate nasal septum covers the front-end of the skull base to the frontal recess, the lower end to the occipital foramen, the side of the anterior skull base to the medial orbital medial wall, the middle skull base covered with bilateral cavernous sinus, the posterior skull base covered with the bilateral internal carotid artery, and the pedicle of the inferior turbinate nasal septum is limited in the upper slope part and the opposite part. The clivus can not be completely covered. For the inferior turbinate inferior turbinate septum flap of the left nasal cavity, the rotation direction of the skull base dural defect is clockwise; the inferior turbinate septum flap in the right nasal posterior pedicle is just the opposite, the rotation direction is reverse clockwise.4, the average distance from the nasal spines to the optic canal is 73.12 + 4.10 mm, from the optic canal to the nasal spines. The average angle of the angle between the line and the baseline is 39.79 + 3.13 degrees; the average distance from the medial edge of the rupture hole to the nasal spine is 79.91 + 4.01mm.
【学位授予单位】：南方医科大学
【学位级别】：博士
【学位授予年份】：2015
【分类号】：R322.31;R765.9
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本文编号：1991847