颅后窝远外侧经髁手术入路的显微外科立体应用解剖学研究

发布时间：2019-06-26 08:05

【摘要】：前言远外侧经髁手术入路又称枕下远外侧入路、最外侧经枕骨髁—颈结节入路、枕下后外侧入路等等。近年来,关于颅后窝远外侧经髁手术的文献时有报导。对于枕骨大孔腹侧及腹外侧病变;中下斜坡及脑干腹侧病变;颅颈交界及高颈髓腹侧部硬膜内生长的肿瘤;中下斜坡、枕髁与颈静脉孔区硬膜外的肿瘤,其中包括一些罕见的病例;另外,椎动脉、椎基底动脉、小脑后下动脉的动脉瘤;颅颈交界段腹侧的动静脉瘘和动静脉畸形,由于其解剖关系复杂、结构重要、位置深在、手术困难而一度无法施行有效的手术治疗。传统的口咽入路术野狭小(两侧椎动脉相距14cm)、深在且路径长(9～12cm),术后易出现脑脊液漏和感染等情况,现已很少采用;后颅窝中线入路需牵动延髓,且易损伤椎动脉,均受一定限制。而远外侧经髁入路,路径短(4～5cm),术野宽,可较好地在手术早期控制椎动脉,并可根据手术需要咬除颅骨、椎骨,增加颅颈交界处腹侧部显露。尤其是采用内镜辅助后进一步扩大了术野,提高了肿瘤的全切率;易于确认和早期控制椎动脉、基底动脉及其分支,阻断肿瘤血供;可以从冠状面看清肿瘤与延、颈髓的界面,与后组颅神经、椎动脉、小脑后下动脉的关系,不需对延髓、颈髓等重要结构进行牵拉,便于手术;术中可直视和保护后组颅神经,最小程度地牵拉神经血管结构,进行有效的暴露和切除。为进一步了解枕髁、乳突、茎突等重要骨性解剖学标志以及椎动脉的术中安全保护、后组颅神经与血管的关系、手术区域血供和周围神经支配等问题,进行了颅后窝经髁手术入路的显微外科解剖学研究,为临床显微神经外科提供较详细的解剖学资料,对于提高远外侧手术入路的安全性和治疗效果有重要意义。
[Abstract]:The distal lateral transcondylar approach is also called the suboccipital far lateral approach, the outermost transoccipital condyle cervical nodular approach, the suboccipital posterolateral approach and so on. In recent years, it has been reported in the literature on far lateral transcondylar surgery of posterior fossa. For ventral and ventrolateral lesions of foramen macroforamen; lesions of middle inferior slope and ventral brainstem; tumors with epidural growth at the junction of skull and neck and ventral part of high cervical spinal cord; epidural tumors in middle inferior slope, occipital condyle and jugular foramen, including some rare cases; in addition, vertebral artery, vertebrobasilar artery, posterior inferior cerebellar artery aneurysm; Arteriovenous fistula and arteriovenous malformation in the ventral part of the craniocercocervical junction could not be treated effectively because of their complex anatomical relationship, important structure, deep position and difficult operation. The traditional oral pharynx approach is narrow (14cm), deep and long path (9~12cm). Cerebrospinal fluid leakage and infection are easy to occur after operation, and the midline approach of posterior fossa needs to affect the medulla oblongata and is easy to injure the vertebral artery, which is limited to a certain extent. However, the far lateral transcondylar approach, short path (4~5cm) and wide surgical field can control the vertebral artery in the early stage of the operation, and can bite off the skull and vertebrae according to the needs of the operation, and increase the ventral exposure of the cranio-cervical junction. In particular, endoscopic assistance further expanded the surgical field and improved the total resection rate of the tumor; it was easy to confirm and early control the vertebral artery, basilar artery and its branches to block the blood supply of the tumor; the interface between the tumor and the extension and cervical spinal cord, the relationship with the posterior intracranial nerve, vertebral artery and posterior inferior cerebellar artery could be seen from the coronal plane, and it was convenient to operate without pulling the important structures such as medulla oblongata and cervical spinal cord. During operation, the intracranial nerve can be directly treated and protected, the structure of nerve and blood vessel can be pulled to the minimum, and effective exposure and resection can be carried out. In order to further understand the important bone anatomical signs such as occipital condyle, mastoid and styloid, as well as the safety protection of vertebral artery, the relationship between intracranial nerve and blood vessel, blood supply and peripheral nerve innervation in the posterior group, the microsurgical anatomy of posterior fossa via condylar approach was studied, which provided more detailed anatomical data for clinical microneurosurgery. It is of great significance to improve the safety and therapeutic effect of distal lateral approach.
【学位授予单位】：中国医科大学
【学位级别】：硕士
【学位授予年份】：2005
【分类号】：R651;R322

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