痉挛性斜颈外科治疗的解剖学研究

发布时间：2018-06-28 00:25

本文选题：痉挛性斜颈 + 副神经　；参考：《复旦大学》2009年硕士论文

【摘要】： 第一部分:副神经出颅后解剖特点及其临床意义研究背景及目的: 在ST临床手术治疗中,副神经根微血管减压术由Freckman等首先提出报道,认为发病机制为副神经根受到微血管压迫,其冲动通过交通支传递给脊神经根遂使颈肌产生异常兴奋。部分学者建议首选神经血管减压,部分学者建议采用选择性肌肉和神经切断术,尤其是以胸锁乳突肌痉挛为主的ST。颅内手术需要影像学的支持,同时在手术中需要明确压迫血管及减压部位,而颅外部分,则需要准确把握副神经的走行,进行针对性有选择的神经切断,保护非痉挛肌的神经支配。本实验研究其颅外解剖基础,用以辅助临床手术。方法: 选择10具头胸联合标本上(共20侧),年龄18-70岁(平均44岁),其中4具新鲜标本,2男性,2女性,6具经10%甲醛固定标本,3男性,3女性,采用解剖剥离法,模拟手术体位及手术常用切口,借助标尺、高像素相机等观测工具进行观察记录,同时对固定标本的神经、动脉、静脉进行彩色乳胶染色加以鉴别。通过实体解剖研究副神经颅外的解剖特点及其与毗邻组织关系。结果: 10具20侧标本中观察到副神经出颅后经二腹肌后腹及茎突舌骨肌深面,经过胸锁乳突肌发出分支并于其中点后稍上方进入颈后三角,于斜方肌前缘中下1/3±0.5cm处进入斜方肌。副神经浅出点通常位于胸锁乳突肌后缘中1/2稍上方,与颈外静脉交叉点后1.5±0.5cm处。10例标本中,70%(14/20侧)副神经在行程中接受颈丛(C_2～C_4)来的神经交通支,20侧标本均可见副神经分支加入迷走神经。结论: 临床手术中应由副神经浅出点处寻找副神经并小心逆行分离,注意保留副神经支配喉前肌群的分支及与颈从的交通支,保护迷走神经及膈神经,在切断胸锁乳突肌时,还应注意保护其支配斜方肌的分支。第二部分:C_(1-5)神经后根、颈后肌群的解剖学特点及其临床意义研究背景及目的: 1924年Cushing创立颈硬脊膜下单侧第1-4颈脊神经前根及副神经切断术,1930年由Dandy改为双侧,但手术效果并不很理想,同时并发症较多。1977年陈信康率先提出了选择性周围神经切断术,取得了较满意的效果,这一术式逐渐得到广泛支持认可。通过实体标本解剖研究,探讨C_(1-5)神经后根及颈后肌群及毗邻结构的解剖学特点,旨在为痉挛性斜颈的外科治疗提供解剖方法和依据。方法: 选择10具头胸联合标本上(共20侧),年龄18-70岁(平均44岁),其中4具新鲜标本,2男性,2女性,6具经10%甲醛固定标本,3男性,3女性,采用解剖剥离法,模拟手术体位及手术常用切口,借助标尺、高像素相机等观测工具进行观察记录,同时对固定标本的神经、动脉、静脉进行彩色乳胶染色加以鉴别。通过实体解剖研究C_(1-5)脊神经后支、颈后肌群的解剖特点及毗邻结构关系。结果: 发现寰枕融合者3例,10例均见C_(1-2)、C_(2-3)后支的交通吻合支,3例见C_(3-4)后支的交通吻合支,10例标本上均见C_2脊神经节,硬脊膜和C_2椎弓根之间存在较大的静脉窦。枕下三角结构固定,新鲜尸体解剖可见为白色半透明筋膜覆盖,其内上界为头后大直肌,外上界为头上斜肌,外下界为头下斜肌,三角的底为寰枕后膜和寰椎后弓,浅面借致密结缔组织与夹肌和半棘肌相贴,其内走行着椎动脉、椎静脉丛、第一、第二颈神经后支等重要结构。结论: 在新鲜实体标本中,神经走行及其分支变异多、神经与肌肉支配关系不明确、神经不易辨认、与重要血管毗邻等都对手术造成一定的困难,需要熟悉其解剖特点及难点,明确需要切断的神经后支及相应痉挛肌肉,同时应注意保护椎动脉、枕动脉及枕下三角内的静脉丛、注意保留C_2神经支配颈前肌群的分支、注意保留C_4神经后支支配斜方肌、膈肌的分支。颈后肌群的解剖、骨性结构、高位颈神经结构、血管的鉴别保护等研究是确保手术良好暴露及减少术后并发症的重点。
[Abstract]:The first part : the anatomical features and clinical significance of the accessory nerve after extracranial cranial fossa

Background and purpose of the study :

In the treatment of ST clinical operation , the microvascular decompression of accessory nerve root is first reported by Flaminman et al . It is suggested that the pathogenesis of accessory nerve root is subject to microvascular compression , and the impulse is transmitted to the spinal nerve root through the transport branch .

Method :

Ten head - chest joint specimens ( 20 sides ) were selected , aged 18 - 70 years ( mean 44 years ) , among them 4 fresh specimens , 2 males , 2 females , 6 with 10 % formaldehyde fixed specimen , 3 males and 3 females .

Results :

In 10 specimens , 70 % ( 14 / 20 ) of the accessory nerves received cervical plexus ( C _ 2 ~ C _ 4 ) at 1.5 卤 0.5 cm .

Conclusion :

In the clinical operation , the accessory nerve should be found at the superficial point of the accessory nerve and carefully reversed , and the branch of the anterior muscle group and the traffic branch from the neck , the vagus nerve and the diaphragm nerve should be preserved , and the branch of the superior oblique muscle should also be protected when the cleidomastoid muscle is cut off .

The anatomical features and clinical significance of C _ ( 1 - 5 ) nerve posterior root and posterior cervical muscle group

Background and purpose of the study :

In 1924 , he founded the unilateral first - 4 cervical spinal nerve root and accessory nerve amputation of cervical spinal meninges . In 1930 , Dandy was changed to bilateral , but the operative effect was not ideal . At the same time , the operative effect was not ideal , and the complication was much more . In 1977 , Chen Xinkang took the lead in the selective peripheral nerve amputation , and achieved satisfactory results . The anatomical features of posterior root and posterior muscle group and adjacent structures of C _ ( 1 - 5 ) nerve were investigated by means of physical specimen anatomy .

Method :

The anatomical features of posterior branch and posterior cervical muscle group and its adjacent structure were studied by means of physical anatomy .

Results :

There were 3 cases of atlanto - occipital fusion , 10 cases were found in C _ ( 1 - 2 ) , C _ ( 2 - 3 ) posterior branch traffic anastomoses , 3 cases were found in C _ ( 3 - 4 ) , there was a large venous sinus between C _ 2 spinal ganglia , dura mater and C _ 2 pedicle .

Conclusion :

In the fresh solid specimen , the nerve running line and its branch variation , nerve and muscle dominance relation are not clear , the nerve is not easy to recognize , and the important blood vessel is adjacent to the other . It needs to be familiar with the anatomical features and difficulties of the operation . It is necessary to know the branch of the posterior branch of the cervical muscle group and the branch of the posterior branch of the cervical muscle .
【学位授予单位】：复旦大学
【学位级别】：硕士
【学位授予年份】：2009
【分类号】：R322

【参考文献】