颅底内外沟通区的显微外科解剖

发布时间：2018-01-14 03:20

  本文关键词：颅底内外沟通区的显微外科解剖　出处：《中南大学》2011年博士论文　论文类型：学位论文

  更多相关文章： 蝶窦 筛板 额鼻缝 蝶骨平台 垂体窝 鼻腔 盲孔 经额底下入路 视神经管 眶上裂 眶上孔 筛前孔 筛后孔 视神经眼动脉 额鼻缝 眶上裂 前床突 棘孔 圆孔 卵圆孔 翼突 颞骨嵴 额颞眶颧入路 乳突 颈静脉孔 颈静脉突 茎突 二

【摘要】：颅底可视为一板两面,颅内面承载着脑底结构如额叶、下丘脑-垂体、海绵窦、颞叶、脑干、小脑与颅神经等等,颅底板的裂隙有进出颅的神经血管经过,其间也藏有固有结构如内耳、迷路、颈静脉球等等,颅底外面是面颅与颈颅结构如鼻腔、鼻旁窦、颞下窝、翼腭窝、咽旁间隙等等。颅底肿瘤可向颅内外沟通,累及上述三者结构,位置深在,解剖关系复杂,是神经外科手术的难点。本研究从显微外科解剖角度来理解颅内外沟通区的解剖关系,寻找定位手术标志,为该区域的手术提供解剖基础。第一章颅鼻蝶沟通区的显微解剖 目的研究前颅窝与鼻腔、鼻旁窦沟通,鞍区与蝶窦、鼻腔沟通区的显微外科解剖关系。确认经额径路的手术标志。 方法观察和测量前颅底骨性构成,额鼻缝、盲孔、筛板、蝶骨平台、鞍结节、垂体窝、蝶窦、鼻腔、筛窦、前鼻棘等间的关系。观察经额三种入路和经蝶入路相关的颅内结构、颅底与颅外结构的显露。 结果筛板位于前颅底中央前部,介入额骨、蝶骨平台与筛骨迷路之间,上接额叶,下为鼻腔顶。蝶骨平台为蝶窦上壁,其后有视交叉沟、鞍结节和垂体窝,外侧有视神经。额鼻缝至盲孔的距离为12.70±1.28mm,额鼻缝至筛板后界的距离为35.67±1.12mm,额鼻缝至蝶棱的距离为51.40±2.98mm,额鼻缝至鞍结节的距离为54.32±1.89mm,额鼻缝至鞍背的距离为65.78±1.56mm。盲孔至筛前孔的距离为10.98±1.12mm,盲孔至筛后孔的距离为25.11±1.25mm。前鼻棘至蝶窦开口的距离为42.34±2.23mm,前鼻棘至鼻腔顶筛板前界的距离为41.88±0.24mm,前鼻棘至鼻腔顶筛板后界的距离为52.05±.45mm。 结论颅鼻蝶沟通区是以筛板和蝶窦为媒介,前颅窝与鼻腔,鞍区与蝶窦、鼻腔得以沟通。经额入路的手术标志分为三级：一级手术标志是额鼻缝,二级手术标志是盲孔,三级手术标志有筛板、蝶骨平台、蝶棱、鞍结节和蝶窦等。经鼻蝶的手术标志分为三级：一级手术标志是前鼻棘,二级标志是蝶窦开口,三级标志是蝶窦。经额底下入路可广泛暴露此沟通区域。第二章颅眶沟通区的显微解剖 目的研究前颅窝与眼眶的解剖关系,眶上裂与视神经管内结构,确认经眶外侧入路的手术标志。 方法观察和测量眶顶、视神经管和眶上裂的骨性构成,测量眶上孔与筛前孔、筛后孔、视神经管的距离,眶上裂与视柱、颈动脉沟、圆孔等的关系。 结果颅眶沟通主要是经过位于眶尖的视神经管与眶上裂,视神经管内走行的结构有视神经与眼动脉,眼眶经视神经管连向鞍区。眶上裂是进出眼眶神经的主要通道,有动眼神经、滑车神经、外展神经和眼神经等,眼眶借眶上裂与中颅窝海绵窦相接。眶上孔至眶内筛前孔的距离为30.12±2.35mm,至眶内筛后孔的距离为39.75±1.25mm,至视神经管眶口的距离为43.35±1.67mm。 结论颅眶沟通可以是眶顶板直接破坏,但主要是经视神经管与眶上裂连向中颅窝的鞍区和海绵窦。经眶外侧入路的一级解剖标志有眶上孔或眶上切迹、眶额动脉管；二级标志有眶上裂、前床突和视柱。经眶外侧入路可显露眶内结构,特别是较好暴露鞍区、海绵窦与中颅底外侧部分。第三章中颅窝与颞下窝-翼腭窝沟通区的显微解剖 目的研究中颅窝与颞下窝、翼腭窝的解剖关系,海绵窦外侧壁和中颅底的解剖三角。确认额颞眶颧入路的手术标志。 方法观察和测量海绵窦外侧壁、圆孔、卵圆孔、棘孔、颞下窝、翼腭窝的结构组成与关系。 结果中颅窝底前界是眶上裂与眼眶,外侧是颞窝,后借颞骨岩部与后颅窝相隔,海绵窦位于蝶鞍的两侧,中颅底的内侧份,中颅窝借圆孔、卵圆孔、棘孔、破裂孔与其下的颞下窝、翼腭窝和咽旁间隙沟通。一级手术标志有额颧缝、眶额动脉管与棘孔。二级手术标志有眶上裂、前床突、圆孔、卵圆孔与面神经门。三级手术标志有上颌神经、下颌神经、脑膜中动脉、翼突与颞骨嵴。 结论中颅底骨板的下方即是颞下窝与翼腭窝,中颅窝-颞下窝-翼腭窝沟通区经眶上裂、眶下裂与视神经管连通眼眶,经蝶腭孔通向鼻腔,内侧借蝶窦外侧壁与蝶窦相隔,后是后颅窝的前界颞骨岩部和茎突前间隙。该沟通区的病变多累及海绵窦,故对海绵窦的处理是手术关键之一。额颞眶颧入路可以多视角进入中颅窝-颞下窝-翼腭窝沟通区,暴露广泛,手术路径短。第四章颈静脉孔颅内外沟通区的显微解剖 目的研究颈静脉孔内神经血管关系,颈静脉孔颅内外区域的结构和手术标志。 方法观察和测量桥小脑角区、颈静脉孔、颅颈交界和咽旁间隙的解剖关系。经颈静脉突入路的手术标志。 结果颈静脉孔位于枕骨大孔的外侧壁上,介于颞骨岩部与枕骨外侧部之间,上有内耳门,下借颈静脉结节与舌下神经管相隔,前是岩斜裂,后是乙状窦沟,颅内连向桥小脑角区和颅颈交界区,外接咽旁间隙。颈静脉孔内走行有舌咽神经、迷走神经、副神经和颈静脉球。经颈静脉突入路以乳突、茎突、髁窝、二腹肌、寰椎横突和颈静脉突为手术标志,可进入颈静脉孔后部,并同时显露颅内外区域。 结论颈静脉孔是后颅窝与颅外咽旁间隙沟通的主要通道,其内走行有舌咽神经、迷走神经、副神经和颈静脉球,位置深在。由颅内外联合入路可以显露此交通区的病变。手术径路的中心点是颈静脉突,颈静脉突为颈静脉孔后界,其外侧是乳突,前外有茎乳孔,内侧是枕髁,后方是枕骨鳞部。颞下窝A型入路可广泛显露乳突腔、中耳、内耳、颈静脉孔、咽旁间隙。经颈静脉突入路的一级手术标志是星点、乳突和寰椎横突,二级手术标志为窝、颈静脉突、Henry脂肪间隙与二腹肌沟,三级手术标志为颈静脉孔、舌下神经管、颈动脉管、茎突与茎乳孔。经颈静脉突径路不仅要熟悉颈静脉突周围的解剖关系,还要熟悉其浅面和侧方的解剖如乳突、枕下肌肉、椎动脉、咽旁间隙等等。
[Abstract]:A skull base can be regarded as two sides of intracranial facial carrying cerebral structures such as frontal cortex, hypothalamus pituitary, cavernous sinus, temporal lobe, cerebellum and brain stem, cranial nerve, skull base plate fracture after cranial neurovascular import, which also has the inherent structure such as inner ear labyrinth, jugular bulb and so on, is outside the skull base craniofacial structures such as cranial and cervical nasal, paranasal sinus, pterygopalatine fossa and infratemporal fossa, parapharyngeal space and so on. Can communicate to extracranial tumors of the skull base, involving three of the above structure, deep location, complex anatomy is difficult in Department of neurosurgery operation. This study from the Perspective to understand the anatomy and microsurgical anatomy the relationship between intracranial communication area, locate the surgical landmarks to provide anatomic basis for the operation. The first chapter transsphenoidal microsurgical anatomy of cranial communicating area
Objective to study the microsurgical anatomical relationship between the anterior cranial fossa and the nasal cavity, paranasal sinus, the saddle area and the sphenoid sinus, and the nasal cavity.
Methods we observed and measured the relationship between the cranial base bone formation, frontalis suture, blind hole, sieve plate, sphenoid plateau, sellar tubercle, pituitary fossa, sphenoid sinus, nasal cavity, ethmoid sinus and anterior nasal spines. We observed the intracranial structures, skull base and cranial structures revealed by three frontal and transsphenoidal approaches.
The screen plate is arranged on the central front in the anterior skull base, frontal, sphenoid and ethmoid labyrinth between platforms, connected to the top. The frontal, nasal sphenoidal planum sphenoid sinus is superior, followed by a chiasma ditch, tuberculum sellae and pituitary fossa, lateral nasal to the optic nerve. The blind hole distance was 12.70 + 1.28mm, the amount of the nose stitch to the distance of 35.67 circles postlaminar + 1.12mm, nasal butterfly to edge distance is 51.40 + 2.98mm, frontonasal suture to the tuberculum sellae distance was 54.32 + 1.89mm, nasal dorsum sellae to distance was 65.78 + 1.56mm. blind hole to anterior ethmoidal foramen distance was 10.98 + 1.12mm, blind hole to screen after the hole distance is 25.11 + 1.25mm. anterior nasal spine to the sphenoid sinus opening distance was 42.34 + 2.23mm, the anterior nasal spine to the top of the nasal prelaminar circles distance was 41.88 + 0.24mm, the anterior nasal spine to the top of the world after nasal sieve plate distance was 52.05 +.45mm.
Conclusion cranial nasal communication zone in the cribriform plate and sphenoid sinus media, anterior cranial fossa and sellar region and the nasal cavity, sphenoid sinus, nasal cavity to communicate. Transfrontal surgery signs are divided into three stages: the first stage surgery sign is nasal surgery, two mark is three mark with blind hole, surgery butterfly butterfly plate, bone platform edge, tuberculum sellae and sphenoid sinus. Transsphenoidal surgery signs are divided into three levels: mark level operation is the anterior nasal spine, two sign is the opening of sphenoid sinus, sphenoid sinus. Three mark is performing the subcranial approach can be widely exposed to this communication area. Anatomy the second chapter micro cranio orbital region
Objective to study the anatomical relationship between the anterior cranial fossa and the orbit, the supraorbital fissure and the intraorbital structure, and to identify the surgical indications for the lateral orbital approach.
Methods we observed and measured the osseous components of the orbital roof, optic canal and supraorbital fissure. We measured the relationship between the supratenal foramen and the anterior ethmoidal foramen, the posterior ethmoid foramen, the distance between the optic canal, the supraorbital fissure and the optic column, the carotid artery groove, the round hole and so on.
Results the cranio orbital is mainly through the tip of the tube in the orbital optic nerve and superior orbital fissure, optic canal running structure of optic nerve and ophthalmic artery, orbital optic nerve tube connected to the sellar region. The superior orbital fissure is the main channel, import orbital nerve on the oculomotor nerve, trochlear nerve, abducens nerve and eye the eyes, borrow the superior orbital fissure is connected with the middle cranial fossa cavernous sinus. The supraorbital foramen to the orbital ethmoidal hole distance was 30.12 + 2.35mm, to the orbital sieve hole distance is 39.75 + 1.25mm, and optic canal orbital opening distance of 43.35 + 1.67mm.
Conclusion the cranio orbital orbital roof can be directly damaged, but mainly the optic canal and superior orbital fissure to the middle cranial fossa sellar and cavernous sinus. The lateral orbital approach to the level of anatomical landmarks have supraorbital notch holes or supraorbital, orbitofrontal artery; two signs of superior orbital fissure the anterior clinoid process, and optic column. Via lateral orbital approach can reveal the orbital structure, especially a good exposure of sellar region, cavernous sinus and skull base in the outer part of the third chapter. Microsurgical anatomy of the middle fossa and infratemporal fossa pterygopalatine fossa communication area
Objective to study the anatomical relationship between the middle cranial fossa and the infratemporal fossa, the pterygopalatine fossa, the anatomical triangle of the lateral wall of the cavernous sinus and the middle skull base, and to confirm the surgical indications for the frontal and temporal orbitozygomatic approach.
Methods to observe and measure the structure and relationship of the lateral wall of the cavernous sinus, round hole, oval hole, spinous hole, infratemporal fossa and pterygopalatine fossa.
The middle fossa anterior border is the superior orbital fissure and lateral orbital, is the temporal fossa, after by petrous bone and posterior fossa from the cavernous sinus in the sella, the medial skull base, middle cranial fossa through hole, foramen ovale, foramen spinosum, rupture hole and the infratemporal fossa, the pterygopalatine fossa and parapharyngeal space. A sign of communication operation frontozygomatic suture, orbitofrontal artery tube and the foramen spinosum. Two surgical landmarks are superior orbital fissure, anterior clinoid process, foramen, foramen ovale and facial nerve surgery have three door. Sign the maxillary nerve, mandibular nerve, middle meningeal artery. Pterygoid and temporal bone crest.
Conclusion the board below the skull base is the infratemporal fossa and the pterygopalatine fossa and middle cranial fossa and infratemporal fossa pterygopalatine fossa - communication area through the superior orbital fissure, inferior orbital fissure and optic canal connected by orbital, sphenopalatine foramen through to the medial nasal cavity, through the lateral wall of the sphenoid sinus and sphenoid sinus interval, after is the posterior fossa of the petrous bone and the prestyloid space. The communication area of the lesions involving the cavernous sinus, the cavernous sinus surgery treatment is one of the key. The frontotemporal orbitozygomatic approach can view into the middle cranial fossa and infratemporal fossa pterygopalatine fossa - communication area, exposed extensive operation short path. The fourth chapter microsurgical anatomy of the jugular foramen and extracranial communicating area
Objective to study the neurovascular relationship in the jugular foramen, the structure of the internal and external cranial region of the jugular hole and the surgical indications.
Methods the anatomical relationship between the cerebellopontine angle area, the jugular orifice, the craniofacial junction and the parapharyngeal space was observed and measured. The surgical indications of the jugular approach were observed.
The jugular foramen is located in the lateral wall of the foramen magnum, between petrous bone and lateral part of occipital bone, have internal portals, through the jugular tubercle and the hypoglossal canal apart, before the petroclival fissure, after sigmoid sinus sulcus, intracranial connected to the cerebellopontine angle region and craniocervical junction area of parapharyngeal space. External jugular foramen for glossopharyngeal nerve, vagus nerve, accessory nerve and jugular bulb. Jugular vein into the road to the mastoid, styloid process, condylar fossa, two abdominal muscle, the transverse process of the atlas and the jugular process operation sign, can enter the jugular foramen after, and at the same time exposure of intracranial regional.
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