眶尖区及额颞眶颧手术入路的显微解剖学研究

发布时间：2018-03-19 11:47

  本文选题：眶尖区　切入点：显微解剖　出处：《河北医科大学》2011年硕士论文　论文类型：学位论文

【摘要】：目的:眶尖区是指由前床突、视神经管及眶上裂所围成的解剖区域。它是沟通颅眶重要解剖结构,又是前、中颅凹底相邻结构。此区空间狭小,结构复杂,神经血管密集,集结了经此出入颅的重要血管神经和其它的组织结构。该区病变常向眶内和颅内双向扩展,且与重要神经血管关系紧密,手术暴露和处理十分困难,手术很难完全切除病变,而且术后并发症多,是神经外科医生面临的棘手问题。额颞眶颧入路是切除颅眶交界肿瘤应用最多、较理想的手术入路,能为切除眶尖区病变提供良好视角和充分暴露,且手术路径短,但其开颅创伤大,复杂而费时,术后可出现眼球外突或内陷等手术并发症。为此,我们进行了眶尖区及额颞眶颧手术入路的显微解剖学研究,为此区手术提供详尽的显微解剖学依据,并通过模拟额颞眶颧入路的显微解剖,探讨对此手术入路进行改良发展。 方法:10例20侧国人成人尸头湿标本,应用10%福尔马林充分固定,冲洗干净动脉及静脉系统内血栓,再以混有红色染料的乳胶灌注动脉系统,混有蓝色染料的乳胶灌注静脉系统。在手术显微镜下模拟额颞眶颧手术入路,逐层解剖,观察眶上神经、颞浅动脉、面神经等手术各层次相关重要结构;并详细观察眶尖区的显微解剖结构及经过此区域的重要神经血管走行和毗邻关系。15例30侧漂白的国人成人颅骨干标本,用以观察和测量前床突、视神经管和眶上裂等骨性结构。所得数据均经统计学处理,以平均数±标准差的形式表现。 结果:本组研究通过模拟额颞眶颧手术入路对标本进行逐层解剖,对入路所涉及的颅外重要解剖结构进行观察测量,并对开颅骨瓣技术改良;在手术显微镜下观察和测量眶尖区重要解剖结构的走行和毗邻关系。眶尖区的重要解剖结构主要包括:前床突、视神经管、眶上裂、Zinn总腱环以及此区穿行的重要神经血管。视神经管和眶上裂是颅眶沟通的两个重要通道,(1)视神经管有颅口、眶口及上、下、内、外四个壁构成。颅口呈水平椭圆形,眶口为垂直椭圆形;眶口处为视神经管水平位最狭窄及管壁最厚的地方。视神经管的上壁长,下壁短,视神经管的长度以上壁长度为标准,全长平均8.9士2.05mm。其内侧壁与筛窦及(或)蝶窦毗邻,约35.75%与筛窦相邻;51.50%与蝶窦相邻;12.75%与蝶窦和筛窦共邻。视神经管的内侧壁较薄,常突入窦腔形成隆起,其中25%的视神经管周围完全被筛窦气房包绕。颅底硬膜在视神经管颅口处形成返折,并包被视神经进入视神经管,此硬膜返折称为镰状皱襞。视神经管内口骨缘短于硬膜返折数毫米,此处视神经仅硬膜覆盖,缺乏骨管的保护,此段视神经长平均约3.0mm。视神经管内有眼动脉和视神经经过入眶。(2)眶上裂是眶与颅中窝的最大交通孔道,略呈三角形,被外直肌的上、下脚分为三部分:外侧部、中央部和下部。本组测量眶上裂上边长16. 04土2. 18mm,外边长19. 58士2.50 mm,内边长9. 05士1. 57 mm。眶上裂与矢状面存在夹角,夹角为41.66°~48.75°,平均45. 13°土2. 58°。(3)前床突是蝶骨小翼向后内方延伸的骨性突起,形状呈锥形,其长、宽、厚分别为9.56土1.10 mm、13.06土2.50 mm、5.96士1.93 mm。前外下方为眶上裂,前内与视神经管顶部后缘及视柱相连接,内侧有颈内动脉通过,外下侧有海绵窦。(4)Zinn腱环由覆盖在眶尖区的骨膜、眶上裂及视神经管的硬脑膜及视神经鞘的纤维成分融合在一起形成,此腱环围绕视神经孔的前端和眶上裂的内上侧。四条眼直肌起源于Zinn腱环并在眶尖处形成肌锥,肌锥是重要临床解剖标志。(5)颈内动脉出海绵窦后靠前床突内侧上行弯曲向后,此段称为床突段;眼动脉75%起源于床突段颈内动脉的内侧壁,与视神经一起穿视神经管入眶。穿越海绵窦外侧壁的颅神经均经眶上裂与眼上下静脉一起入眶,具体走行:滑车神经、额神经、泪腺神经及眼上静脉经眶上裂外侧部穿行;动眼神经上、下支、外展神经、鼻睫神经及睫状神经节的交感根和感觉根经中央部穿行;下部仅有眼下静脉穿行。(6)经额额眶颧入路主要缺点是开颅复杂费时,创伤较大,尤其是骨瓣成形困难。目前有传统的一片骨瓣和改良的两片骨瓣开颅,都有局限性,本研究改良一片骨开颅,先游离取除颧弓,然后一片骨瓣去除额颞骨、部分眶顶、眶外侧壁和颧骨。体会是简化了骨瓣开颅,节省时间,减少骨质缺损,效果良好。 结论: 1眶尖区作为一解剖概念,至今尚无统一明确的解剖学界定范围,我们界定其为由前床突、视神经管及眶上裂所围成的解剖区域。 2眶尖区是沟通颅眶的重要结构,狭小区域密集近半数颅神经和颈内动脉等重要结构,毗邻关系密切,难以分离。 3眶尖区大型肿瘤和颅眶沟通肿瘤暴露困难,与重要血管神经分离困难,切除难度大;额颞眶颧入路能为此区域病变切除提供良好暴露、手术视角和操作空间,可多角度切除病变,是目前应用最广泛的颅底手术入路之一。 4本研究探索改良传统一片骨瓣开颅,简化了操作,节省开颅时间,减少手术创伤,改善了手术效果。 5额额眶颧入路具有手术创伤大,开颅复杂费时,缺乏规范标准等局限性,需进一步发展完善。
[Abstract]:Objective: the orbital apex region is defined by the anterior clinoid process, anatomical region crack surrounded by the optic canal and superior orbital. It is important to communicate the cranial orbital anatomy, and, in the middle fossa of adjacent structure. This area narrow space, complex structure, nerve and blood vessel dense, assembled by the important blood vessels and nerves out of cranial and other structures. The orbital and intracranial lesions often to two-way expansion, and closely with the important vessels and nerves, surgical exposure and processing is very difficult, it is difficult to complete surgical excision of the lesion, and postoperative complications, is troublesome neurosurgeons. Frontotemporal orbitozygomatic approach is resection of cranio orbital junction tumors the most ideal surgical approach, can provide a good perspective and fully exposed for resection of orbital apex lesions, and the operation path is short, but its large trauma craniotomy, complicated and time-consuming, postoperative can appear proptosis or in other surgical complications. For this reason, we carried out microanatomical study of orbital apex area and frontotemporal orbitozygomatic surgery approach, providing detailed microscopic anatomic basis for this area's operation, and through the microanatomy of frontotemporal orbitozygomatic approach, we explored the improvement and development of this operative approach.
Methods: 10 cases of 20 sides of adult cadaveric head, fixed by 10% formalin, rinse the arterial and venous system thrombosis, with latex mixed with red dye perfusion system, mixed latex perfusion vein system with blue dye. Under surgical microscope to frontotemporal orbitozygomatic approach step by step, anatomy, observe the supraorbital nerve, superficial temporal artery and facial nerve surgery at all levels and other related structures; and detailed observation of the microsurgical anatomy of the orbital apex and the important vessels and nerves in the region traveling and adjacent relations of 30 cases of.15 side bleaching of Chinese adult skull specimens, to observe and measurement of the anterior clinoid process, optic canal and superior orbital fissure and bony structures. The data obtained were statistically, in the form of average + standard deviation.
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