经鼻神经内镜治疗前颅底病变的应用解剖研究及其临床应用

发布时间：2018-01-14 19:23

  本文关键词：经鼻神经内镜治疗前颅底病变的应用解剖研究及其临床应用　出处：《新疆医科大学》2011年博士论文　论文类型：学位论文

  更多相关文章： 前颅底 颅底外科 内镜 视神经管减压术 脑脊液鼻漏修补术

【摘要】：目的:颅底外科作为神经外科学与耳鼻咽喉科学及颌面外科学的一个交叉学科,近年来发展十分迅速;然而由于前颅底的毗邻结构解剖关系复杂,发生于此的病变因解剖位置深在,手术不易充分暴露和彻底切除,容易造成术后畸形、功能障碍或发生其他并发症。而经鼻内镜则是一种比较古老的技术,随着光学、机械及电子技术的进步,近十年来获得了新的生命。经鼻Qg镜可以取代传统的显微镜，经由天然的鼻腔空隙,直接进到蝶鞍部和前、中、后颅底,直视下处理这些部位的病变,损伤小,恢复快,没有美容问题。经鼻内镜技术和颅底外科的结合,极大地促进了颅底外科的发展,不仅丰富了颅底外科的治疗手段,而且拓宽了颅底外科的诊疗范围,使颅底外科不仅能处理中线区域病变,还向侧颅底区域发展。然而,由于颅底区域解剖结构复杂,颅底外侧面的解剖对于神经外科医生来说不够熟悉。鼻腔空间不大,可供操作的范围有限。而且内镜对于神经外科医生来说,不仅视野与显微镜不同,而且操作时也不固定,随着器械的进出鼻道随时变化,使初学者难以适应。陌生部位的解剖知识缺乏和对于内镜操作技术的不习惯,成为妨碍神经外科医生介入这一领域的两大难点。另一方面,内镜在国内外的发展很不平衡,在发达国家及我国发达地区发展迅猛,而在西部地区尤其新疆仍处在初始阶段。本研究的目的就是:1)通过对内镜下前颅底的应用解剖进行观察和测量。以丰富和掌握内镜前颅底手术所需的内镜下解剖知识;2)通过在尸体头颅标本上的模拟训练,熟悉和掌握开展内镜前颅底手术所需的解剖知识,并习惯内镜下操作;3)然后将神经内镜应用于临床,治疗前颅底常见疾病如脑脊液鼻漏、视神经管减压、各种前颅窝底肿瘤等,提高手术安全性及有效性,以期提高神经内镜诊疗水平及颅底外科诊疗水平。由于经蝶垂体瘤手术已趋于成熟,不在本研究的范围内。方法:本研究分三阶段进行:1)首先对10具20侧颅骨标本的颅底外侧面以及矢状剖面骨性鼻腔的相关解剖标志及其相互之间的距离和角度进行观察和测量。然后对6具12侧经过灌注的尸体头颅进行内镜下观察和描述;2)于内镜下在2具4侧颅骨干标本,和4具8侧尸体头颅上完成几种模拟手术:内镜下蝶窦切开术;内镜下筛窦手术;内镜下视神经管减压术;以及内镜下眶减压术等;3)于解剖研究和内镜模拟手术完成的前提下,将该技术应用于临床,对前颅底常见病,如创伤性视神经损伤,各种原因脑脊液鼻漏,前颅底良性肿瘤等进行治疗。结果:1)鼻棘点至鞍结节的平均距离为69.2±4.8mm。鼻棘点至前床突的平均距离为72.9±3.9mm。即在手术中器械深入鼻腔6～7cm时就要提防进入中颅窝的可能;2)鼻棘点至视神经管眶口内侧中点的平均距离为63.4±5.3mm。鼻棘点至视神经管颅口内侧中点的平均距离为69.3±4.9mm。鼻小柱基点至视神经管颅口的距离为78.3±4.5mm。表明在行视神经减压术或眶尖部手术时距离鼻棘点超过50mm以上时就应十分小心,过深操作有可能进入中颅窝甚至损伤颈内动脉;3)蝶窦开口至视神经管颅口,也是二者间最短距离,平均为15.3±3.8mm,蝶窦开口与视神经管联线与正中矢状面之间的夹角平均为63±7.9°。因此打开蝶窦后,向蝶窦开口的外上方约1.5cm的部位寻找,有利于发现视神经管;4)视神经管内壁的毗邻:位于蝶窦外侧3侧(25%),位于筛窦外侧3侧(25%),位于蝶窦和筛窦之间最常见,占6侧(50%)。因此寻找视神经管的另一方法为在蝶筛交界处寻找,大部分视神经管位于蝶筛交界或其附近区域;5)鼻棘点至鞍结节的平均距离为69.2±4.8mm,据此可定位垂体前界。在此处操作如深入超过60mm,应提防损伤颈内动脉。(6)内镜为二维图像,管状视野有鱼眼镜头效应,解剖结构失真变形较严重,镜头角度越大,这种改变就越明显,与普通解剖学观察的差别就越大。因此熟练掌握内镜解剖,反复练习,习惯这种视野,有助于克服内镜图像失真所引起的盲目性和迷失感;7)内镜治疗13例无光感视神经损伤患者,随访3～12个月,7例视力有不同程度恢复;6例无效。视力恢复多于术后1～2周出现,约2个月后停止。视力提高一个级别3例,2个级别1例,3个级别1例,4个级别2例。总有效率53.8%(7/13)。按受伤后视力丧失至手术时间分为3～7天组,8～14天组,15～21天组和21天以上组,各组间效果差异无统计学意义(P0.05);8)治疗17例创伤性视神经损伤患者共18眼,10例视力有不同程度恢复;8眼无效。视力提高一个级别5例,2个级别2例,3个级别1例,4个级别2例,总有效率55.6%(10/18);9)内镜治疗7例医源性脑脊液鼻漏,漏口均在原手术部位,一次修补成功;10)共治疗24例脑脊液鼻漏患者,Qg镜组共13例15次手术13次成功,手术成功率为86.6%;开颅组11例12次手术10次成功,手术成功率为83.3%;两组一次手术成功率及二次手术成功率均无明显差异;11)内镜下治疗蝶筛窦骨化纤维瘤1例,近全切除,病理为:青少年型骨化纤维瘤,术后患侧眼视力明显恢复。结论:1)对于术前无光感的视神经损伤患者,仍应行视神经管减压术以挽救其视力;2)视神经损伤后视力的恢复主要取决于视神经受伤机制及程度,与时间关系不大,因此只要患者有治疗意愿,无论伤后多久,都应该进行手术以挽救视力;3)经鼻内镜处理前颅底区域病变能最大限度的暴露病变区域,而又不加重对脑的牵拉损伤,保 留了正常的神经血管结构,降低了术后并发症和致残率。具有微创、无颅面切口,病人痛苦少,恢复快等优点,在一系列临床手术中展示了常规开颅手术和鼻外进路无法替代的优势;4)在熟练掌握颅底相关解剖知识,并经过严格内镜操作训练后,经鼻内镜治疗前颅底病变有很高的安全性。
[Abstract]:Objective: To study a skull base surgery department of neurosurgery as interdisciplinary and otolaryngology and maxillofacial surgery, a very rapid development in recent years; however, due to the adjacent structure of the anterior skull base anatomy is complicated, the lesions due to anatomical position in operation is not easy to fully exposed and removed completely, likely to cause postoperative deformity, dysfunction or other complications. The nasal endoscopy is a relatively old technology with optical, mechanical and electronic technology, nearly ten years to gain new life. Nasal Qg lens can replace the traditional microscope, the nasal cavity through the natural gap, directly into the sella turcica and before. In these areas, after treatment of skull base, direct lesions, little injury, quick recovery, no beauty. After combined with nasal endoscopy and skull base surgery, skull base surgery has greatly promoted the development of not only enrich the skull base Surgical treatment, and broaden the scope of the diagnosis and treatment of skull base surgery, skull base surgery can not only deal with the midline area of lesions, but also the development of lateral skull base region. However, the complex anatomy of the skull base region, the anatomy of the lateral skull base to neurosurgeons not familiar enough. The nasal space is available for a limited range of operation. Endoscopy for the neurosurgeon to view not only with the microscope, and the operations are not fixed, with the instruments out of the nasal passages are subject to change, so that beginners. It is difficult to adapt to the strange parts of the anatomy of the lack of knowledge and technology is not used for endoscopic operation, become the two major difficulties hinder the neurosurgeon to intervene in this area. On the other hand, the development of endoscopy at home and abroad is very uneven, in developed countries and developed areas of China's rapid development in the western region of Xinjiang is still in the beginning The beginning stage. The purpose of this study is: 1) through the application of endoscopic anatomy of the anterior skull base were observed and measured. The anatomical knowledge to enrich and master the endoscopic skull base surgery required before endoscopy; 2) through simulation training in cadaveric heads on the familiar and master to carry out endoscopic anterior skull base surgery required the anatomical knowledge and habit of endoscopic operation; 3) and the application of neuroendoscope in the clinical treatment of anterior skull base of common diseases such as cerebrospinal fluid rhinorrhea, optic nerve decompression, various anterior cranial fossa tumors, improve surgical safety and effectiveness, in order to improve the level of diagnosis and treatment of skull base surgery and endoscopic treatment due to level. Transsphenoidal pituitary surgery has become mature, not within the scope of this study. Methods: This study is divided into three stages: 1) the first of 10 lateral skull base 20 lateral skull specimens and related markers of sagittal profile of the bony nasal cavity and anatomy The interaction between distance and angle were observed and measured. Then in 6 after perfusion with 12 lateral skull endoscopic observation and description; 2) in endoscopic in 2 with 4 lateral skull specimens, and 4 with 8 lateral skull to complete several surgical simulation: endoscopic incision of sphenoid sinus; endoscopic sinus surgery; endoscopic optic nerve decompression; and endoscopic orbital decompression; 3) on the premise of anatomy and endoscopic surgery simulation completed, this technology is applied to the clinical common diseases of the anterior skull base, such as traumatic optic nerve injury, cerebrospinal fluid rhinorrhea for various reasons, such as benign tumors of the anterior skull base treatment. Results: 1) the average distance to nasospinale tuberculum sellae with an average distance of 69.2 + 4.8mm. nasal spine to the anterior clinoid process was 72.9 + 3.9mm. devices in operation into the nasal cavity of 6 ~ 7cm when we should beware of into the middle cranial fossa; 2) nasal spine to the optic nerve 鐪跺彛鍐呬晶涓�鐐圭殑骞冲潎璺濈�讳负63.4卤5.3mm.榧绘�樼偣鑷宠�嗙�炵粡绠￠�呭彛鍐呬晶涓�鐐圭殑骞冲潎璺濈�讳负69.3卤4.9mm.榧诲皬鏌卞熀鐐硅嚦瑙嗙�炵粡绠￠�呭彛鐨勮窛绂讳负78.3卤4.5mm.琛ㄦ槑鍦ㄨ�岃�嗙�炵粡鍑忓帇鏈�鎴栫湺灏栭儴鎵嬫湳鏃惰窛绂婚蓟妫樼偣瓒呰繃50mm浠ヤ笂鏃跺氨搴斿崄鍒嗗皬蹇，

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