海绵窦外侧壁和上壁的显微外科解剖研究

发布时间：2018-03-10 19:11

本文选题：Dolenc入路　切入点：海绵窦　出处：《江苏大学》2007年硕士论文　论文类型：学位论文

【摘要】： 一、概述海绵窦位于蝶鞍和蝶窦的两侧,左右各一,前方起自眶上裂,后方附着于颞骨的岩骨尖部,上窄下宽,前窄后宽,为不规则的狭长的六面体,分为上、下、前、后、内侧、外侧6个壁。因其内部血管神经之间穿插了许多的小梁并构成网状,称为海绵窦。它是颅底病变常侵犯的部位,该部位的显微解剖以及手术入路仍是神经外科领域研究的热点之一。二、国内外研究现状 1965年,Parkinson发表了里程碑式的论文,文中描述了治疗颈内动脉—海绵窦瘘的直接手术入路,在此之前,几乎没有涉及直接手术治疗海绵窦区病变的神经外科文献。这主要因为对海绵窦解剖结构不甚了解,没有显微外科,处理海绵窦区的严重出血和颅神经损伤的风险极高,因此当时的神经外科医生没有能力处理这个区域的病变,长期以来,这个区域被视为直接手术的“无人之境”。近年来,随着对此区域解剖研究的不断深入和显微外科技术的不断发展,一些神经外科医生已能够对这个区域病变进行手术,手术并发症也降低了。尤其是Dolenc发展了硬膜外和硬膜下联合入路,已成为治疗海绵窦区域病变的标准入路。三、研究目的、意义本课题是针对海绵窦手术最常使用的Dolenc的外侧壁和上壁入路进行解剖学研究,由于国内对于海绵窦外侧壁和上壁的三角和穿行于内部的神经血管的资料较少,本人进行该方向的研究,目的是进一步探讨海绵窦外侧壁和上壁的形态学特征和内部的显微解剖结构,为临床海绵窦的手术入路的设计,避免颅神经和颈内动脉的损伤提供解剖学基础。四、材料和方法 1材料:10%甲醛充分固定的成人尸头标本20例,所有尸头鞍区及海绵窦区无肿瘤、囊肿、出血及明显炎性改变,周围骨质无明显破坏。所有标本均动脉灌入红色乳胶。 2仪器设备:神经外科显微手术器械、头架、手术显微镜(5倍～25倍)、圆规、游标卡尺(精度0.02mm)、理光微距摄影器材。 3方法:20例(40侧)10%甲醛固定的成人头部标本,沿颅底和颅盖的分界线锯开颅骨。自中脑上端切断脑干,完整取出大脑和间脑,清除鞍区的蛛网膜,注意保留2～4对颅神经、垂体柄和颈内动脉。所有标本均在手术显微镜下进行解剖暴露和观测。其中海绵窦上壁的三角直接观测。外侧壁的三角和颅神经需要进行以下操作后才能观测:自颅中窝底硬脑膜外分离硬膜,显露弓状隆起、岩浅大神经、脑膜中动脉(棘孔)、下颌神经(卵圆孔)、上颌神经(圆孔)和眼神经(眶上裂),同时剥离海绵窦外壁的浅层,暴露动眼神经、滑车神经、三叉神经半月节、神经根及其三个分支。数据测量使用游标卡尺,对海绵窦的三角进行拍摄。 4统计学处理:从标本(共40侧)测量的数据,经SPSS统计软件包计算出样本均数和标准差。五、结果 1、海绵窦的上壁有4个三角,分别是:Dolenc三角、Hakuba三角、颈内动脉三角和动眼神经三角。 2、Dolenc三角三边长度分别是:内侧边(6.30±1.54)mm,外侧边(10.02±2.44)mm,底边(11.03±1.85)mm。 3、前床突由薄层骨皮质和骨松质所组成,本组实验发现前床突内有气房,与筛窦相通,发生率为1/10。 4、远侧硬膜环厚而坚韧,厚度为(0.52±0.07)mm,近侧硬膜环薄而松弛,厚度为(0.22±0.06)mm,在二者之间有海绵窦的静脉丛突入。 5、Hakuba三角内无重要的解剖结构,其三边长度为:内侧边(7.69±2.07)mm,外侧边(7.25±2.02)mm,底边(4.25±1.38)mm。 6、海绵窦的外侧壁及其附近有6个三角,分别为旁内侧三角、Parkinson三角、Mullan三角、外侧三角、Glasscock三角和Kawase三角。 7、Parkinson三角的三边长度分别为:内侧边(17.26±3.07)mm,外侧边(14.26±3.91)mm,底边(5.61±2.56)mm,是海绵窦手术最常用的间隙。 8、Glasscock三角的三边长度是:内侧边(12.41±2.40)mm,外侧边(14.15±2.74)mm,底边(6.85±2.16)mm。严格的说是一个四边形。 9、Kawase三角三边的长度:内侧边(14.99±2.75)mm,外侧边(12.94±2.40)mm,底边(11.25±3.45)mm。 10、动眼神经、滑车神经和眼神经在海绵窦内的长度分别为:(8.19±0.93)mm,(10.16±1.12)mm,(16.23±2.24)mm。六、结论 1、Dolenc手术入路中磨除前床突是关键的一步,磨除的范围应局限在Dolenc三角中,同时应注意该区域骨质的变异。 2、Hakuba三角内无重要解剖结构,切开此三角进入海绵窦较为安全。 3、远侧硬脑膜环外侧与颈内动脉结合较牢,后内侧与颈内动脉之有间颈动脉穴,切开远环应从内侧开始,切开近侧硬脑膜环便打开了海绵窦上壁。 4、Parkinson三角中,滑车神经的走行对此三角的影响较大,在眼神经稍上方并与眼神经平行切开硬脑膜外层时,不易损伤变异的滑车神经。 5、磨开Glasscock三角可以暴露岩骨段颈内动脉,是实施颅内段阻断颈内动脉的位置,这个位置又可行颈内动脉海绵窦段的旷置和颈内动脉床突上段的搭桥。 6、磨除Kawase三角的骨质可以从中颅窝底暴露上中斜坡,从中颅窝底进入后颅窝,可以施行椎动脉瘤的夹闭术。 7、了解海绵窦上壁和外侧壁的解剖结构有助于在Dolenc手术入路中预防重要结构的损伤,提高手术疗效。 8、海绵窦区手术也不能照搬Dolenc手术入路,要根据具体情况,个性化选择手术方法。
[Abstract]:First, an overview
On both sides of the cavernous sinus is located in sellar and sphenoid sinus, left and right respectively, starting from the front of the superior orbital fissure, petrous apex attached to the rear of the temporal bone, narrow width, narrow after wide, irregular narrow hexahedron, divided into,,,, medial, lateral 6 a wall between the inside of blood vessels. Because nerve interspersed with many of the trabeculae and form the mesh, called the cavernous sinus. It is often part of the invasion of skull base lesions, the microscopic anatomic and surgical approach is still one of the hot research field of Department of neurosurgery.
Two, research status at home and abroad
In 1965, Parkinson published a milepost type paper, this paper describes the direct surgical treatment of carotid cavernous fistula into the road, before this, almost no Department of Neurosurgery literature involving direct surgical treatment of cavernous sinus lesions. This is mainly because of the anatomy of cavernous sinus do not understand, without microsurgery, treatment of cavernous sinus serious hemorrhage and cranial nerve injury risk is extremely high, so when the neurosurgeon is not capable of handling this area for a long time, the lesion region is seen as "a place where there is no one direct operation." in recent years, with the continuous development of technology development in this area and the microsurgical anatomical study, some neurosurgeons have been able to surgery on this area of lesions, surgical complications are reduced. Especially the development of Dolenc road combined epidural and subdural, has become the treatment of the sea The standard approach to the regional lesions of the cavernous sinus.
Three, the purpose and significance of the study
This topic is the most commonly used in the lateral wall of the cavernous sinus surgery and Dolenc on the wall approach anatomic study, due to less domestic data for the nerves and blood vessels of the lateral wall of cavernous sinus and the upper wall triangle and walk through the interior, I conducted the research direction, the purpose is to probe into the lateral wall of the cavernous sinus on the wall and the morphological characteristics and the internal structure for the design of clinical anatomy, cavernous sinus surgical approach, to provide anatomic basis for avoiding cranial nerve and internal carotid artery injury.
Four, materials and methods
1 Materials: 20 of 10% adult cadaveric head specimens with sufficient formaldehyde. No tumors, cysts, bleeding and obvious inflammatory changes were found in all the body saddle area and cavernous sinus area. There was no obvious destruction of the surrounding bone. All the specimens were filled with red latex through the artery.
2 equipment: Department of Neurosurgery microsurgery instruments, head, operating microscope (5 times to 25 times), a vernier caliper (accuracy 0.02mm), Ricoh macro photography equipment.
3 methods: 20 cases (40 sides) adult cadaveric heads fixed by 10% formaldehyde, dividing the skull base and open wire along the calvaria skull. From the upper cut stem, complete removal of the brain and the removal of sellar arachnoid, pay attention to keep the 2~4 cranial nerve, pituitary stalk and internal carotid artery. All specimens were under operating microscope on exposure and observation. One triangle cavernous sinus wall directly observed. The triangle and the lateral wall of the cranial nerve following operation is necessary to observe: separation of dural from middle cranial fossa dura, revealed arcuate eminence, greater superficial petrosal nerve, middle meningeal artery (spinous foramen, mandibular nerve (Luan Yuankong)), maxillary nerve (hole) and the eye (SOF), and shallow, the outer wall of the cavernous sinus dissection exposed oculomotor nerve, trochlear nerve, trigeminal ganglion, nerve root and its three branches. The measured using vernier caliper data, three of the cavernous sinus Filming is done in the corner.
4 statistical processing: data measured from the specimens (40 sides) were calculated by SPSS statistical software package and the sample average and standard deviation were calculated.
Five, the result
1, there are 4 trigonometry in the upper wall of the cavernous sinus, which are the Dolenc triangle, the Hakuba triangle, the internal carotid triangle and the oculomotor trigone.
2, the length of the three edge of the Dolenc triangle is: the inner side (6.30 + 1.54) mm, the outer edge (10.02 + 2.44) mm, and the bottom (11.03 + 1.85) mm.
3, the anterior bed process was composed of thin layer of bone cortex and cancellous bone. The experiment found that there was a gas chamber in the anterior bed process in this group, and the incidence was 1/10..
4, the distal epidural ring is thick and tough, the thickness is (0.52 + 0.07) mm, the proximal dural ring is thin and slack, the thickness is (0.22 + 0.06) mm, and there is cavernous venous plexus penetration among two patients.
5, there are no important anatomical structures in the Hakuba triangle. The length of the three sides is the inner side (7.69 + 2.07) mm, the outer edge (7.25 + 2.02) mm, and the bottom edge (4.25 + 1.38) mm.
6, there are 6 trigonometry in the lateral wall of the cavernous sinus and near the cavernous sinus, the paranoid triangle, the Parkinson triangle, the Mullan triangle, the lateral triangle, the Glasscock triangle and the Kawase triangle.
7, the length of the three sides of the Parkinson triangle is: the inner side (17.26 + 3.07) mm, the outer side (14.26 + 3.91) mm, the bottom edge (5.61 + 2.56) mm, which is the most commonly used gap for cavernous sinus surgery.
8, the three edge length of the Glasscock triangle is: the inner side (12.41 + 2.40) mm, the outer edge (14.15 + 2.74) mm, and the bottom (6.85 + 2.16) mm. strictly speaking as a quadrilateral.
9, the length of the three side of the Kawase triangle: the inner side (14.99 + 2.75) mm, the outer edge (12.94 + 2.40) mm, and the bottom (11.25 + 3.45) mm.
10, the length of the oculomotor nerve, the trochlear nerve and the eyes in the cavernous sinus were (8.19 + 0.93) mm, (10.16 + 1.12) mm, (16.23 + 2.24) mm.
Six. Conclusion
1, the key step is to remove the anterior bed process in the Dolenc operation. The range of grinding should be limited to the Dolenc triangle, and the bone variation in this area should be paid attention to.
2, there is no important anatomical structure in the Hakuba triangle, and it is safer to cut this triangle into the cavernous sinus.
In 3, distal dura ring and lateral carotid artery combined with solid, posterior medial and internal carotid artery of carotid artery between points, far from the medial ring incision, incision proximal dura ring opened the cavernous sinus wall.
4, in the Parkinson triangle, the running of the trochlear nerve has a great influence on the trigonometry. It is not easy to damage the variant trochlear nerve when parallel to the outer layer of the dura mater.
5, grinding the Glasscock triangle can expose the petrous internal carotid artery, intracranial segment of internal carotid artery occlusion is the implementation of the position, the position and the feasible cavernous segment of internal carotid artery exclusion and supraclinoid carotid artery bypass.
6, the bone of the Kawase triangle can be exposed to the middle slope from the bottom of the middle cranial fossa, and from the bottom of the middle cranial fossa to the posterior fossa, the occlusion of the vertebral aneurysm can be performed.
7, understand the cavernous sinus wall and lateral wall of the anatomical structure contributes to the Dolenc approach in the prevention of important structural damage, improve the curative effect.
8, cavernous sinus surgery can not copy the Dolenc approach, according to the specific situation, individualized selection of surgical methods.

【学位授予单位】：江苏大学
【学位级别】：硕士
【学位授予年份】：2007
【分类号】：R322

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