乙状窦后锁孔入路的显微解剖学研究

发布时间：2018-07-25 20:34

【摘要】：目的：通过乙状窦后锁孔入路的解剖学研究,显微观察该入路所涉及的解剖结构、显露范围和手术可利用的空间,为临床应用提供解剖学资料,并以此解剖学资料为基础,探讨乙状窦后锁孔入路的手术适应症和临床应用价值。方法：对15具成年国人尸体头颅标本血管进行乳胶灌注备用。将尸头依照手术体位固定在头架上,模拟乙状窦后锁孔入路手术方法对15具(30侧)成人头颅标本进行解剖,骨窗范围在2.0 cm×2.5cm,于4-24倍手术显微镜下解剖,打开桥小脑角,去除蛛网膜及软脑膜,调整和变换显微镜角度,探查显露范围和神经血管解剖结构,拍照并测量记录相关解剖数据,观察分析相关解剖学差异。结合临床资料,对比其他相关入路,评价乙状窦后锁孔入路的优越性。结果：乙状窦后锁孔入路可显露的解剖结构：上从天幕前侧缘,下至枕骨大孔颈静脉结节,内侧到桥脑和中脑的侧方。通过调整显微镜角度,乙状窦后锁孔入路可暴露桥小脑角区包括岩静脉、小脑上动脉及其分支、小脑前下动脉及其分支、小脑后下动脉及其分支、滑车神经、三叉神经、面听神经、后组颅神经。约37%(11侧)的小脑上动脉与三叉神经有接触或压迫。30侧标本中单干岩静脉为24侧,双干岩静脉为6侧。22.2%岩静脉在内听道内侧缘外侧注入岩上窦,63.8%的岩静脉在三叉神经入Meckel腔处的外侧缘和内听道内侧缘之间注入岩上窦,13.9%于三叉神经外侧缘以内注入岩上窦。23侧(77%)侧小脑前下动脉襻与面听神经有接触,有14侧标本中小脑前下动脉穿面前庭蜗神经之间。乙状窦后锁孔入路可良好暴露后颅窝神经血管结构,但也受骨性结构的影响。此入路对内听道口及颈静脉孔暴露良好,但在所有标本中内听道上结节的形态变异较大,其均阻挡了对Meckel憩室的暴露,颈静脉结节阻挡了对枕骨大孔前部的暴露。多数标本基底动脉暴露不佳。内镜下视野清晰,且可探查显微镜下解剖死角。结论：乙状窦后锁孔入路是一种最经典锁孔手术方法,由于骨窗位置恰当、骨窗大小适中,减少了不必要的头皮、肌肉切开,减少了不必要的颅骨切除,减少了不必要脑组织暴露,术中充分利用颅内的自然空间,所以具有脑损伤少,伤口局部反应小,组织复位好,手术时间短,术后并发症少,恢复快和不影响患者容貌等优点。通过乙状窦后锁孔入路并选取不同位置的骨窗,能适当暴露后颅窝相关区域的组织结构,可用于小脑桥脑角、上斜坡、中斜坡、下斜坡部位的髓外病变的手术,如：三叉神经痛、面肌痉挛、胆脂瘤、神经鞘瘤和脑膜瘤。乙状窦后锁孔入路是顺应现代微创理念的探索,实践证明它是一种安全、有效的手术方式,可选择性的替代传统的乙状窦后入路。
[Abstract]:Objective: to study the anatomy of retrosigmoid keyhole approach, observe the anatomical structure, exposure scope and operative space of the approach, and provide anatomical data for clinical application. To evaluate the indications and clinical application of retrosigmoid keyhole approach. Methods: the blood vessels of 15 cadaveric cadavers were perfused with latex. The cadaveric head was fixed on the cephalic frame according to the position of operation, and 15 adult head specimens (30 sides) were dissected by simulated retrosigmoid keyhole approach. The bone window was 2.0 cm 脳 2.5 cm, dissected under 4-24 times operating microscope, and the angle of cerebellopontine was opened. The arachnoid and pial meninges were removed, the angle of microscope was adjusted and changed, the exposed area and neurovascular anatomy were explored, and the related anatomical data were taken and recorded, and the anatomical differences were observed and analyzed. To evaluate the advantages of retrosigmoid keyhole approach by comparing other related approaches with clinical data. Results: the anatomical structure revealed by retrosigmoid keyhole approach was superior from the anterior margin of the tentorium to the nodule of the foramen magnum jugular vein medial to the lateral side of the pontine and midbrain. By adjusting the angle of microscope, the posterior sigmoid keyhole approach can expose the cerebellopontine angle area including the petrosal vein, the superior cerebellar artery and its branches, the anterior inferior cerebellar artery and its branches, the posterior inferior cerebellar artery and its branches, the trochlear nerve and the trigeminal nerve. Facial auditory nerve, posterior cranial nerve. About 37% (11 sides) of the superior cerebellar artery had contact with or compression of the trigeminal nerve. 63.8% of the petrosal veins were injected with superior petrosal sinus on the lateral side of the medial margin of the internal auditory canal of the petrosal vein, and 13.9% of the vein was injected within the lateral margin of the trigeminal nerve into the Meckel cavity between the lateral margin of the trigeminal nerve and the medial margin of the internal auditory canal. The anterior inferior cerebellar artery loop was in contact with the facial auditory nerve in 23 sides (77%) into the superior petrosal sinus. In 14 of the specimens, the anterior inferior cerebellar artery penetrated between the anterior vestibulocochlear nerve. The retrosigmoid keyhole approach can well expose the neurovascular structure of the posterior cranial fossa, but it is also affected by the osseous structure. This approach showed good exposure to the internal auditory orifice and jugular foramen, but the shape of the superior nodule of the internal auditory canal varied greatly in all specimens, which blocked the exposure to the Meckel diverticulum and the jugular vein nodule to the anterior part of the foramen magnum of occipital bone. Most specimens were not well exposed to the basilar artery. Endoscopic visual field is clear, and can be explored under the microscope anatomic dead angle. Conclusion: the retrosigmoid keyhole approach is one of the most classical keyhole operations. Due to the proper location of the bone window and the moderate size of the bone window, it reduces unnecessary scalp, muscle incision and unnecessary craniotomy. It has the advantages of less brain injury, less local reaction, better tissue reduction, shorter operation time, less postoperative complications, faster recovery and no effect on the appearance of the patients due to the reduction of unnecessary brain tissue and the full use of the intracranial natural space during the operation. Through the retrosigmoid keyhole approach and the selection of bone windows in different locations, the tissue structure of the related areas of the posterior cranial fossa can be properly exposed, and can be used for the operation of extramedullary lesions in the cerebellar pontine angle, upper clivus, middle Clivus and inferior Clivus. For example: trigeminal neuralgia, hemifacial spasm, cholesteatoma, neurilemmoma and meningioma. The retrosigmoid keyhole approach is an exploration to conform to the modern minimally invasive approach. It is proved to be a safe and effective surgical approach which can selectively replace the traditional retrosigmoid sinus approach.
【学位授予单位】：天津医科大学
【学位级别】：硕士
【学位授予年份】：2011
【分类号】：R322;R651.1

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