VNS术前超声定位颈动脉鞘内结构的可行性和临床应用初探

发布时间：2018-07-15 18:43

【摘要】：背景:迷走神经刺激术(vagus nerve stimulation,VNS)是治疗药物难治性癫痫的一种安全有效的方法,该手术的关键步骤在于解剖颈动脉鞘,将颈总动脉(common carotid artery,CAA)和颈内静脉(internal jugular vein,IJV)分别向内、外牵引,在两血管之间寻找并游离迷走神经。颈动脉鞘内迷走神经、CCA和IJV的位置在人群中存在变异,因此术前利用影像学技术准确地定位上述解剖结构,可以帮助术者在术中有目的地进行解剖、分离,节约手术时间,减少并发症的发生。既往研究证明颈部超声可以显示迷走神经及其与周围大血管的关系。超声检查无创、无辐射、价廉且普及,可能是VNS术前定位颈动脉鞘内重要结构的理想方法之一,但至今未见VNS术前利用超声技术辅助手术实施的相关报道。目的:研究超声定位颈部迷走神经、CCA和IJV的可行性及上述结构在正常人群中的相对位置,并探讨这一方法在VNS手术中的应用价值。方法:随机选择健康成年人45例。受检者的体位模仿VNS手术时的体位,即去枕平卧,头偏向右侧,充分暴露左侧颈部。将超声探头置于左侧胸锁乳突肌前缘,观察颈动脉鞘内的CCA、IJV及迷走神经,注意辨别淋巴结、结缔组织和小血管等。确认神经位置后将探头置于锁骨上约2cm处且与该处皮肤平面垂直,显示迷走神经的横切面并测量其横径及前后径,保存图像(该切面由脚端向头端观察)。对图像做如下处理:(1)判断IJV相对于CCA的位置。确认CCA、IJV的中点并连线,测量该连线与皮肤平面的夹角,记为α角。以CCA为参照,IJV相对于CCA的角度记为β角。(2)经过上述血管中点、与上述连线垂直作两条直线,将颈动脉鞘分为前、前内、前外、后、后内、后外六个区域,分别标记为A、AM、AL、P、PM、PL区域。如果迷走神经位于CCA和IJV接触面之间,则记为I区域。统计迷走神经在上述7个区域的分布。(3)以CCA为参照,迷走神经相对于CCA的角度记为γ角。结果:45例中CCA、IJV和迷走神经均能显示,显示率100%。迷走神经横切面为圆形或椭圆形点状低回声,内有点状细小高回声,周边有高回声结构包绕。迷走神经可以与周围结缔组织、淋巴结和小血管等明显区分。测得迷走神经横径(1.13±0.28)mm,前后径(1.01±0.27)mm,平均直径(1.07±0.24)mm。IJV位于CCA前外侧、前侧、外侧和前内侧分别有27例、15例、1例和2例,未发现IJV位于CCA内侧或后方者。α 角为(54.18±30.04°),β 角为(35.82±30.04°)。迷走神经位于A区域7例,I区域18例,P区域20例。γ角(32.81±50.52°)。上述各指标在性别之间、高龄组与低龄组之间无显著差异。因IJV位于CCA前外侧和前侧占大多数,故单独研究这两种情况与性别和年龄的关系。男性组和女性组之间IJV相对于CCA的位置有明显差别,男性组中IJV位于CCA前外侧的情况多见。高龄组和低龄组之间IJV相对于CCA的位置无明显差异。IJV相对于CCA位置不同时,迷走神经的区域分布有显著差异。当IJV位于CCA前外侧时,迷走神经多位于P区域,即IJV和CCA两者之间的后方;当IJV位于CCA前侧时,迷走神经多位于I区域,即IJV和CCA两者之间。结论:(1)体表超声检查对颈动脉鞘内CCA、IJV和迷走神经显示率高,判断准确,这一技术可以用于VNS术前对上述重要结构的辅助定位。(2)左侧颈下部迷走神经、IJV一般位于CCA的左前方(前外侧)大约1点钟方向。本研究还发现IJV位于CCA前内侧或者外侧的变异情况。迷走神经多位于CCA和IJV之后或两者之间,但也可以出现在两者前方。IJV相对于CCA的位置在性别之间有显著差异。IJV位置不同时,迷走神经的位置有显著差异。(3)本研究和既往文献均发现颈动脉鞘内重要结构的相对位置存在变异,VNS术中操作不当造成的并发症也有报道。因此推测VNS术前利用超声技术定位颈动脉鞘内重要结构的位置有利于提高手术准确性,减少并发症的发生,这在切口较小、术野狭窄的情况下尤为重要。
[Abstract]:Background: vagus nerve stimulation (VNS) is a safe and effective method for the treatment of drug refractory epilepsy. The key step of this operation is to dissect the carotid sheath and inward the common carotid artery (common carotid artery, CAA) and the internal jugular vein (internal jugular vein, IJV), respectively, to find between the two vessels. The vagus nerve is free from the vagus nerve. The location of the vagus nerve in the carotid sheath and the location of the CCA and IJV exists in the population. Therefore, the accurate location of the above anatomical structure by imaging techniques before operation can help the operators to dissect, separate, save the operation time and reduce the occurrence of complications. The display of the vagus nerve and its relationship with the surrounding large vessels. Ultrasound examination is noninvasive, no radiation, low price and universal. It may be one of the ideal methods to locate the important structure of the carotid sheath before VNS. But up to now, there is no related report on the use of ultrasound assisted surgery before VNS. Objective: To study the ultrasound localization of the vagus nerve, CCA and IJV The feasibility and the relative position of the above structure in the normal population and the application value of this method in the VNS operation. Methods: 45 healthy adults were selected randomly. The body position of the examiner imitates the position of the VNS operation, that is, the supine lying on the pillow, the head to the right and the left neck fully exposed. The ultrasonic probe is placed on the left sternocleidomastoid muscle of the left sternocleidomal muscle. The anterior border, observe the CCA, IJV and vagus nerve in the carotid sheath, pay attention to distinguish the lymph nodes, connective tissue and small blood vessels. After confirming the nerve position, the probe is placed on the clavicle at about 2cm and is perpendicular to the skin plane of the place, showing the transverse section of the vagus nerve and measuring the transverse diameter and the anterior and posterior diameter, and preserving the image (the section is observed from the foot to the head end). The image is treated as follows: (1) judge the position of IJV relative to CCA. Confirm CCA, the midpoint and connection of IJV, measure the angle between the line and the skin plane, take the angle of the skin as alpha angle. With CCA as the reference, the IJV relative to the CCA angle is recorded as beta angle. (2) through the above point of blood vessel, two straight lines are vertical to the above line, the carotid sheath is divided into front, anterior, front, and anterior, anterior, forward, anterior, anterior, anterior, The six regions were labeled as A, AM, AL, P, PM, PL region respectively. If the vagus nerve was located between the CCA and IJV contact surfaces, it was recorded as the I region. The distribution of the vagus nerve in the above 7 regions. (3) the vagus nerve was shown as gamma angle relative to CCA, with CCA as the reference. The transverse section of the vagus nerve of 100%. was a circular or elliptical nodal hypoechoic, with punctate and high echo and hyperechoic surrounding. Vagus nerve could be distinguished from the surrounding connective tissue, lymph nodes and small blood vessels. The transverse diameter of the vagus nerve (1.13 + 0.28) mm, the diameter of the anterior and posterior (1.01 + 0.27) mm, and the average diameter (1.07 + 0.24) mm.IJV were measured. There were 27 cases, 15 cases, 1 cases and 2 cases in the anterolateral, anterolateral, lateral and anteromedial, and no IJV located in the medial or rear of CCA. Alpha angle was (54.18 + 30.04), beta angle was (35.82 + 30.04). The vagus nerve was located in A region 7 cases, 18 cases in I region, 20 in the region of I, gamma angle (32.81 + 50.52 degrees). The above indexes were between sex, senior and lower age groups. There was no significant difference between the IJV and the anterior lateral and the anterior side of the CCA. Therefore, the relationship between the two cases and the sex and age was studied. The position of IJV in the male group and the female group was significantly different from the CCA. The IJV in the male group was more common in the anterolateral CCA. The position of IJV relative to the CCA between the older and the younger groups was not clear. There is significant difference in the distribution of the vagus nerve between the significant difference.IJV relative to the CCA position. When IJV is located in the anterolateral of CCA, the vagus nerve is located in the rear of the P region, which is between the IJV and CCA; when IJV is located at the front of CCA, the vagus nerve is located between the I area, that is, between IJV and CCA. (1) the body surface ultrasound examination of the carotid sheath Internal CCA, IJV, and vagus nerve display is high and accurate. This technique can be used to assist the location of the above important structures before VNS. (2) left cervical vagus nerve, IJV is generally located at about 1 o'clock in Zuo Qianfang (anterolateral) of CCA. This study also found the variation of the IJV position on the medial or lateral front of CCA. The vagus nerve is multiple. After or between CCA and IJV, there is a significant difference between the position of.IJV in front of the two and the position of CCA in front of the two. The position of the vagus nerve is different at the same time, and the position of the vagus nerve is different. (3) the relative position of the important structure of the carotid sheath in this study and the previous literature found the variation of the relative position of the important structure in the carotid sheath, and the misoperation in the operation of the VNS was caused by improper operation. There are also reports of complications. Therefore, it is speculated that the location of the important structure of the carotid sheath using ultrasound technique before VNS is helpful to improve the accuracy of the operation and reduce the incidence of complications, which is especially important in the case of small incision and narrowing of the operation field.
【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R742.1

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