岩斜区顶乳缝前角手术入路的应用解剖学研究

发布时间：2018-05-26 06:21

本文选题：岩斜区 + 顶乳缝前角　；参考：《承德医学院》2007年硕士论文

【摘要】： 目的: 近些年来,随着锁孔入路的不断开展,内窥镜不断使用,内窥镜可达到深而狭小的术野,且在术中可以任意变换观察角度,弥补了手术显微镜的不足。锁孔手术是在显微镜、内窥镜及特殊显微手术器械的配合下,经较小的手术通道,最小的创伤,达到切除病变的目的。斜坡区是颅内肿瘤的多发部位,传统的手术入路以乙状窦沟前入路和乙状窦沟后入路为主,损伤大、并发症多。本研究提出以顶乳缝前角这一骨性标志作为锁孔手术入路的手术入路点,测量该骨性标志与斜坡区及周围各结构的距离,及该区域神经血管的数据测量,为内窥镜进入深度提供参考,结合锁孔手术的应用为提高斜坡区手术的安全度和成功率这一问题的解决提供了新的思路。方法: 1选取30个(男25,女5)外观无异常、经4%甲醛溶液固定的成人湿颅骨标本。找到顶乳缝前角,用磨钻小心切开该处颅骨,以圆规和游标卡尺测定乙状窦沟上曲至三叉神经根、展神经根、面神经根、前庭蜗神经根、舌咽神经根、迷走神经根、岩静脉、内耳道后壁中点、颈动脉管内口后壁、颈静脉孔的距离。在手术显微镜下自前向后切除部分小脑组织,向后轻轻牵拉小脑,确认三叉神经、展神经、面神经、前庭蜗神经及舌咽神经、迷走神经,观察各神经根周围血管走行及血管与神经根的周围毗邻关系,确认血管来源及名称并对各层面进行摄片。 2在干燥颅骨标本上测量内耳道的横径、纵径、长度并测量内耳道与后床突、三叉神经孔、颈静脉孔前缘、内耳道水平斜坡中线的距离。结果: 1湿颅骨标本的测量结果 1.1乙状窦沟上曲至相关结构的距离乙状窦沟上曲至三叉神经根的距离39.14±2.47 mm,至展神经根5.72±2.39 mm,面神经根40.94±2.09 mm,前庭蜗神经根38.12±1.76 mm,舌咽神经根36.35±2.31 mm,迷走神经根35.81±5.57 mm,岩静脉3.27±0.65 mm,内耳道后壁中点12.01±1.09 mm,颈动脉管内口后壁51.72±4.43 mm,颈静脉孔27.60±0.67 mm。乙状窦沟上曲至相关结构的距离左右两侧无显著性差异(P0.05)。 1.2各神经脑池段长度三叉神经5.0±7.4 mm,展神经5.6±8.1 mm,面神经11.0±1.7 mm,前庭蜗神经10.9±4.8 mm,中间神经9.6±3.7 mm,舌咽神经17.4±6.9 mm,迷走神经18.7±8.4 mm。各神经脑池段长度左右两侧无显著(P0.05)。 1.3神经与血管之间的关系面神经起点与舌咽神经起点距离(2.7±1.2)mm,在内耳道口水平两神经相距(3.9±1.5)mm。二神经根周围最常出现小脑下前动脉(AICA),偶有小脑下后动脉(PICA)。60侧共有AICA58支,2例标本一侧缺如。外展神经脑池段长约(5.6±1.1)mm,距外侧的面、前庭蜗神经约(6.4±0.8)mm,进入Dorello管处距中线约(3.4±1.9)mm。内听动脉(LA):本组30例60侧中LA出现54侧(90%),6侧缺如,单干型36侧(66.7%),双干型18侧(33.3%)。LA是内耳的供血动脉,多起自小脑前下动脉42侧(75%),也可以从其他动脉发出,其中起自基底动脉9侧(15%)、小脑后下动脉3侧(5%)或椎动脉3侧(5%)。弓下动脉:由AICA的下支分出,在内耳道后壁的弓状下窝行走,从前庭蜗神经的上方到达面神经运动支的根部,终止于半规管附近的骨质。50%进入内耳道,25%向前达AICA的上支与之交通,25%向下达颈静脉孔。4侧PICA(其中包括2侧缺如AICA者)与面神经根较近。 2干燥颅骨标本的测量结果内耳道的横径5.75±9.56 mm,纵径4.70±0.88 mm,长度9.37±1.65 mm,内耳道至后床突的距离25.94±4.86 mm,至三叉神经孔15.23±6.28 mm,至颈静脉孔前缘3.28±4.75 mm,至内耳道水平斜坡中线23.97±0.08 mm。干燥颅骨标本的测量结果左右两侧无显著性差异(P0.05)。结论: 1当显微镜下难以确认神经根和血管关系,或难以发现细小血管的存在;在这种情况下则需要医师耐心的确认这些血管与神经根的关系,并可发现细小血管的存在,有利于确认责任血管,并可防止发生损伤血管的意外。2岩斜区位置深在、解剖结构密集、血管位置变异较大,应充分熟悉该区域解剖结构的相对位置,提高岩斜区手术全切除率,降低并发症。
[Abstract]:Objective:
In recent years, with the continuous development of the keyhole approach, endoscopy is constantly used, endoscopy can reach a deep and narrow operation field, and in the operation, the observation angle can be changed to make up for the insufficiency of the operation microscope. The keyhole operation is the smallest operation channel, with the microscope, the endoscope and the special MicroHand instruments. The slope area is the multiple location of the intracranial tumor. The traditional surgical approach is mainly based on the anterior approach of the sigmoid sinus and the posterior sigmoid sinus approach, with large injuries and many complications. This study proposes that the osseous sign of the anterior apical angle of the suture is used as the surgical entry point for the keyhole operation, and the bone sign and the slope are measured. The distance between the region and the surrounding structure and the data measurement of the nerve vessel in this area provide reference for the penetration of the endoscope, and the application of the keyhole operation provides a new idea to solve the problem of improving the safety and success rate of the operation in the slope area.
Method:
1 to select 30 adult wet skull specimens (male 25, female 5) with 4% Formaldehyde Solution fixed adult wet skull specimens. The anterior horn of the apex suture was found, and the skull was cut carefully by grinding drill. The tritemal root, the nerve root, the vestibule nerve root, the glossopharyngeal nerve root, the vagus nerve root, the vagus nerve root, the vein, were measured with a drill and a vernier caliper. The posterior wall of the inner auditory canal, the posterior wall of the canal and the distance of the jugular hole in the carotid canal. The cerebellum was removed from the cerebellum by the anterior and backward resection of the cerebellum under the microscope. The trigeminal nerve, the abducent nerve, the facial nerve, the vestibule nerve and the glossopharyngeal nerve, the vagus nerve, and the circumferential vessels of the nerve roots and the circumferential and nerve roots were observed. Confirm the origin and name of blood vessels and take photographs at all levels.
2 the diameter of the inner ear canal, the longitudinal diameter, the length, the inner ear canal and the posterior bed process, the trigeminal hole, the anterior margin of the jugular foramen and the distance of the middle line of the horizontal slope of the inner ear canal were measured on the dry skull specimens.
Result:
Measurement results of 1 wet skull specimens
The distance from the upper trench of 1.1 sigmoid sinus to the trigeminal nerve root is 39.14 + 2.47 mm, 5.72 + 2.39 mm of the root of the abducent nerve, 40.94 + 2.09 mm of the root of the facial nerve, 38.12 + 1.76 mm of the vestibule nerve root, 36.35 + 2.31 mm of the glossopharyngeal nerve, 35.81 + 5.57 mm of the vagus nerve root, and the veins of the petrous vein, mm and the posterior wall of the inner ear canal. 2.01 + 1.09 mm, the posterior wall of the carotid canal was 51.72 + 4.43 mm, and there was no significant difference between the right and left sides of the jugular foramen 27.60 + 0.67 mm. sigmoid sinus (P0.05).
1.2 neurobrain pool length
The trigeminal nerve is 5 + 7.4 mm, the abduction nerve is 5.6 + 8.1 mm, the facial nerve is 11 + 1.7 mm, the vestibule nerve is 10.9 + 4.8 mm, the middle nerve is 9.6 + 3.7 mm, the glossopharyngeal nerve is 17.4 + 6.9 mm, and there is no significant difference between the left and right sides of the nerve cistern segments of the vagus nerve 18.7 + mm. each (P0.05).
1.3 the relationship between nerve and blood vessel
The distance between the starting point of the facial nerve and the starting point of the glossopharyngeal nerve (2.7 + 1.2) mm, the most frequent of the anterior inferior cerebellar artery (AICA) around the two nerve root of the inner ear canal (3.9 + 1.5) mm. two, and a common AICA58 branch in the.60 side of the inferior cerebellar posterior inferior cerebellar artery (PICA), and the absence of one side in 2 specimens. The abductor nerve pool segment was about (5.6 + 1.1) mm, and the vestibular cochlea was from the lateral surface. The nerve was about (6.4 + 0.8) mm and entered the middle line (3.4 + 1.9) mm. of the auditory artery (LA). In this group, 54 sides appeared in 60 sides of 30 cases (90%), 6 side was absent, 36 sides of the single stem type (66.7%), and the double dry type 18 side (33.3%).LA was the blood supply artery of the inner ear, and many from the anterior inferior cerebellar artery and other arteries, which were from the basilar artery. Lateral (15%), 3 side of posterior inferior cerebellar artery (5%) or 3 sides of vertebral artery (5%). The inferior branch of the AICA is divided into the inferior branch of the inner auditory canal, walking in the lower arcuate fossa of the posterior wall of the inner ear, reaching the root of the motor branch of the facial nerve above the vestibular cochlear nerve, ending the bone.50% near the semicircular canal into the inner ear canal, 25% up to the upper branch of the AICA and the 25% direction of the neck. The.4 side of PICA (including 2 sides lacking AICA) is closer to the facial nerve root.
2 measured results of dry skull specimens
The transverse diameter of the inner ear was 5.75 + 9.56 mm, the longitudinal diameter was 4.70 + 0.88 mm, the length was 9.37 + 1.65 mm, the distance from the inner auditory canal to the posterior bed process was 25.94 + 4.86 mm, to the trigeminal hole 15.23 + 6.28 mm, to the anterior margin of the jugular hole, 3.28 + 4.75 mm, and there was no significant difference between the left and right sides of the dry skull specimens in the middle line of the horizontal slope of the inner ear canal (P0.05) (P0.05). ).
Conclusion:
1 it is difficult to confirm the relationship between the nerve root and the blood vessel under the microscope, or the existence of the small blood vessels. In this case, the doctor is required to confirm the relationship between the vessels and the nerve roots patiently, and the existence of the small blood vessels is found, which is beneficial to the identification of the responsible blood vessels, and the position of the accidental.2 diagonal area of the damaged vessels can be prevented. The anatomical structure is dense and the vascular position is variable. We should be familiar with the relative position of the anatomical structure of the area, improve the total resection rate and reduce the complications.
【学位授予单位】：承德医学院
【学位级别】：硕士
【学位授予年份】：2007
【分类号】：R651.1;R322

【参考文献】