上颈椎前外侧手术入路的相关应用解剖学研究

发布时间：2018-04-14 03:16

本文选题：二腹肌后腹及茎突舌骨肌复合体 + 舌下神经　；参考：《桂林医学院》2014年硕士论文

【摘要】：目的：通过尸体标本解剖获得上颈椎前外侧手术入路中所涉及的重要血管、神经等相关组织结构的详细解剖学资料,明确其之间的毗邻关系,为上颈椎前外侧手术入路提供临床参考。方法：选择经10%福尔马林固定的颅颈完整的成人湿标本20具(40侧),模拟上颈椎前外侧手术入路逐层解剖,详细观察上颈椎前外侧手术入路中所涉及的重要血管、神经等相关组织结构,并测量相关血管与神经的长度、管径及毗邻之间的距离,所得结果用SPSS13.0软件进行统计学处理。结果：1、喉上神经内支穿出动脉鞘点与舌骨大角的位置关系有三种：①平舌骨大角：占12.5%(5/40)。②舌骨大角上方5mm以内：占17.5%(7/40)。③舌骨大角下方10mmm以内:占70%(28/40)。喉上神经内支从穿出点到穿入甲状舌骨膜的距离：左测(22.3±3.2)mm(16.5～23.9mm),右侧为(23.2±3.8)mm(16.6-25.9mm),两侧合并后的距离为(22.7±3.5)mm(16.5～25.91mm)。外支的直径(0.7±0.11)mm(0.4～1.1),与甲状腺上动脉形成神经血管束,亦经甲状舌骨膜穿入,分布于喉部组织。2、舌下神经从舌下神经管出颅,向前内走行,在枕动脉处,发出一降支与C2及C3神经前支的降支结合形成颈袢,支配舌骨下肌群；在下颌角处,呈弓状走行于二腹肌后腹及茎突舌骨肌深面,并与之有2次交叉,之后向前弯曲到下颌舌骨肌的深面,发出分支支配除腭舌肌以外的全部舌肌。3、二腹肌后腹及茎突舌骨肌位于颈深筋膜浅层及中层之间,两者平行相伴而行,容易辨认,其深面组织由外向内依次为颈内静脉、副神经、舌下神经、枕动脉、颈外动脉、面动脉等。4、舌骨大角周围的重要结构有甲状腺上动脉、舌动脉、喉上神经及舌下神经,它们与舌骨大角尖的最短距离分别为(12.5±3.9)mm(6.9～18.7)；(0.4±1.6)mm(0.2～2.5)；(5.2±1.4)mm(1.6～10.8)；(5.0±1.7)mm(1.6-9.7)。5、在解剖过程中发现将舌下神经向头侧牵开,喉上神经向尾侧牵开,颈动脉鞘向外侧牵开,内脏鞘(舌骨、食管和气管)向内侧牵开,即可以形成类似楔形的“窗口”,“窗口”直接对应的部位为C2/C3椎间盘及C3椎体,结合颈部过伸体位及用拉钩牵拉,可暴露最大范围：向上达寰椎前弓,向下达颈3椎体下缘,两侧可以暴露至横突。结论：1、在上颈椎前外侧手术入路中,二腹肌后腹及茎突舌骨肌复合体、舌骨大角为寻找舌下神经及喉上神经重要的标志,术中寻找到这两根神经后,对其游离并加以保护,可以减少损伤机率。2、通过以舌下神经、喉上神经、颈动脉鞘及内脏鞘(舌骨、食管和气管)组成的类似楔形的“窗口”暴露上颈椎,可以获得较理想的显露,并且该概念的提出,为进一步应用微创器械进行上颈椎手术提供了一个良好的通道。
[Abstract]:Objective: to obtain the anatomical data of the important blood vessels, nerves and other related tissue structures involved in the anterolateral cervical vertebrae approach by cadaveric dissection, and to clarify the relationship between them.To provide a clinical reference for the upper cervical anterolateral approach.Methods: 20 adult adult wet specimens fixed with 10% formalin were selected to simulate the anterolateral approach of upper cervical vertebrae. The important blood vessels involved in the approach were observed in detail.The length, diameter and distance between the nerve and the nerve were measured. The results were analyzed by SPSS13.0 software.Results: 1. There are three types of relationship between the sheath point of the internal branch of the superior laryngeal nerve and the position of the great angle of the hyoid bone. There are three types of 1: 1, equal to the great angle of hyoid bone: 12.5% or 5 / 40. 2 within 5mm above the large angle of hyoid bone: within 17.5% 40.3% of 10mmm below the great angle of hyoid bone: 70% within 28% 40% of total hyoid angle.The distance between the internal branch of the superior laryngeal nerve from the point of perforation to the periosteum of the thyroid tongue: left 22.3 卤3.2mm. 16.5 卤23.9mm, on the right, 23.2 卤3.8mm, 16.6-25.9 mm, and the distance after bilateral union was 22.7 卤3.5mm, 16.525.9mm, respectively.The diameter of the external branch was 0.7 卤0.11mm ~ (0.11) m ~ (-1), which formed a neurovascular bundle with the superior thyroid artery, and was also perforated through the periosteum of the thyroid tongue and distributed in the laryngeal tissue. The hypoglossal nerve came out of the hypoglossal nerve canal from the cranium and went forward inside the occipital artery.The descending branch is combined with the descending branch of the anterior branches of C2 and C3 nerves to form a cervical loop, which innervates the subhyoid muscle group; at the mandibular angle, it is arcuate along the deep surface of the posterior abdomen and stylohyoid muscle of the bicentric muscle and the styloid hyoid muscle, with which it intersects twice.It then bends forward to the deep surface of the mandibular hyoid muscle, emits branches that innervate all the lingual muscles except palatoglossal muscle .3.The posterior abdomen and stylohyoid muscles of the diabs are located between the superficial and middle layers of the deep cervical fascia, and the two are parallel to each other and are easily recognizable.The internal jugular vein, accessory nerve, hypoglossal nerve, occipital artery, external carotid artery, facial artery, etc.The shortest distance between them and the tip of the hyoid was 12.5 卤3.9mm ~ 6.9m ~ (-6.9m) ~ 18.7m ~ (-1) ~ (0.4 卤1.6) mm ~ (-1) ~ (2) ~ (2) ~ (2) ~ (2) ~ (2.5) 卤1.610.8m ~ (-1) ~ (5.0 卤1.7) mm ~ (-1) ~ 1.6-9.7mm ~ (-1) respectively. In the anatomic process, it was found that the hypoglossal nerve was pulled sideways, the superior laryngeal nerve was opened to the tail, the carotid artery was opened to the lateral side, and the visceral sheath (hyoid, esophagus and trachea) was opened to the medial side.That is to say, a wedge-like "window" can be formed. The "window" directly corresponds to the C2/C3 intervertebral disc and the C3 vertebra. Combined with cervical hyperextension and pull with a pull hook, the largest range of exposure can be obtained: reaching the anterior arch of atlas upward to the lower margin of the cervical 3 vertebra.Both sides can be exposed to transverse processes.Conclusion: in the anterolateral approach of upper cervical vertebrae, the posterior ventral and styloid hyoid muscle complex of the bicentric muscle and the large angle of hyoid bone are important markers for searching for hypoglossal nerve and superior laryngeal nerve.It can reduce the chance of injury by exposing the upper cervical vertebrae with a wedge of hypoglossal nerve, superior laryngeal nerve, carotid sheath and visceral sheath (hyoid, esophagus and trachea).This concept provides a good channel for the further use of minimally invasive instruments for upper cervical surgery.
【学位授予单位】：桂林医学院
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R322

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