后颅窝锁孔入路的显微解剖学研究

发布时间：2018-07-08 21:44

本文选题：锁孔手术 + 乙状窦后入路　；参考：《苏州大学》2009年博士论文

【摘要】： 第一部分乙状窦后锁孔入路的显微解剖学研究目的:遵循微创原则,对传统乙状窦后入路进行锁孔改良,应用神经导航系统进行尸头解剖量化评价,探讨乙状窦后锁孔手术的可行性,明确其手术适用范围,并予临床初步验证。方法:采用6具经福尔马林固定、颅内动静脉分别用彩色乳胶灌注的尸体头颅标本。首先进行乙状窦后锁孔入路,然后扩大为常规乙状窦后入路,观察显露的解剖结构差异。以无框架的立体定向导航设备测量两种入路下岩斜区、脑干的显露面积和Meckle’s腔、三叉神经根、面神经根、内听道口、舌咽神经根、颈静脉孔等六个点容许的最大观察角度,行统计学分析比较。应用乙状窦后锁孔入路治疗15例小脑桥脑角、岩斜区和天幕肿瘤患者进行临床验证,11例肿瘤最长径大于3.0cm。结果:乙状窦后锁孔入路与常规入路的解剖结构显露相仿,可显露上至天幕前外侧缘,下近枕骨大孔,内侧到桥脑和中脑的前外侧方,通过神经间隙可以到达同侧中上岩斜区的外2/3,但对岩尖、下斜坡和天幕切迹以上的结构显露欠佳或不能显露。乙状窦后锁孔入路下岩斜区、脑干显露面积分别为304.73±28.93mm2、143.9±31.87mm2,而常规入路则分别为346.43±42.80mm2、136.05±9.05mm2,两者在岩斜区、脑干的显露面积都没有统计学显著性差异(P0.05)。对于选定的六个靶点,无论垂直还是水平观察角度,常规入路都比锁孔入路的观察角度大(P0.05)。临床验证15例肿瘤手术,13例全切,2例次全切,术后4例新出现周围性面瘫,其中3例为短暂性的面神经麻痹。7例术前听力下降的患者,其中5例术后听力丧失,1例术后听力改善,无其它术后并发症。结论:乙状窦后锁孔入路与常规入路具有相似的显露范围,可用于小脑桥脑角和岩斜区的肿瘤、中脑和桥脑前侧方及侧方肿瘤手术,对大型、巨大型肿瘤也可通过分块切除、瘤内减压的方法,逐步显露并全切肿瘤。该入路是具有实际临床应用价值的一种简捷、安全的微创手术入路。第二部分枕下正中经小脑延髓裂锁孔入路的显微解剖学研究目的:基于锁孔原理设计枕下正中经小脑延髓裂锁孔入路,应用神经导航系统进行尸头解剖量化评价,探讨其可行性和手术适用范围,并进行初步临床验证,为临床应用提供可靠依据。方法:采用6具经4%福尔马林固定、颅内动静脉乳胶灌注的成人尸体头颅标本。首先行枕下正中经小脑延髓裂锁孔入路解剖,观察各个步骤显露的解剖结构,以无框架的立体定向导航设备测量锁孔入路下四脑室底的面积显露和导水管下口、双侧侧孔连线与正中沟交点、闩部的观察角度;再以铣刀铣下寰椎后弓,测量上述参数,测量后将寰椎后弓用钛片和钛钉复位;然后延长切口、扩大骨窗成常规入路,测量寰椎后弓去除前后的上述参数;最后行统计学分析。应用枕下正中经小脑延髓裂锁孔入路治疗14例四脑室内及其周围区域的肿瘤,包括小脑蚓部肿瘤5例(髓母细胞瘤3例、胶质瘤1例,转移癌1例),四脑室内病变6例(室管膜瘤4例,蛛网膜囊肿1例,脉络膜乳头状瘤1例)、脑干背侧病变2例(桥延沟水平海绵状血管瘤1例,桥脑胶质增生1例)、脑干后方机化血肿1例,进行临床验证。结果:通过调整头位和显微镜的投射角度,枕下正中锁孔入路下分离小脑延髓裂后可显露脉络膜、下髓帆,逐步切开脉络膜下髓帆可显露四脑室底、侧隐窝、侧孔及小脑蚓部脑室面。锁孔入路下对四脑室底的角度显露不如常规入路下宽(P0.01),但两种入路下四脑室底的显露面积没有显著性统计学差异(P=0.06)。常规入路下显露角度的增加,可增加手术操作的自由度,有利于从多个方向对靶点进行操作,但并不能增加四脑室底的显露面积。锁孔入路下,尽管靶点显露角度减小,使手术操作的自由度变小,但不影响靶点的显露,在锁孔的深部放大效应下,可对相关靶点进行有效操作。去除寰椎后弓不能增加锁孔入路下四脑室底的显露面积(P=0.84)。无论常规入路还是锁孔入路下磨除寰椎后弓可以增加四脑室底垂直显露角度(P0.05),但对水平显露角度没有影响(P0.05)。本组14例肿瘤均显微镜下全切,1例老年患者术后死于肺部感染,其余13例术前症状改善,未出现脑干和颅神经损伤相关的并发症,无“小脑性缄默”等经蚓部手术入路相关的并发症。结论:枕下正中经小脑延髓裂锁孔入路与常规入路具有相似的显露面积,无需磨除寰椎后弓就能满意显露四脑室底结构,在掌握锁孔入路器械操作技术后,使用长杆状和枪式器械,通过相对狭小的显露角度,可以安全、简捷地进行四脑室内、桥脑延髓背侧以及小脑下蚓部等部位肿瘤手术,是一种切实可行的微创手术入路。
[Abstract]:Microanatomy study of retrosigmoid keyhole approach
Objective: to follow the principle of minimally invasive, the traditional posterior approach of the sigmoid sinus is improved, and the neural navigation system is used to evaluate the autopsy, and the feasibility of the post sigmoid keyhole operation is discussed, and the scope of operation is clearly defined and the clinical preliminary verification is given.
Methods: 6 cadaver cranial specimens were perfused with color emulsion by formalin fixation. First, the posterior sigmoid keyhole approach was used, and then extended to the conventional posterior approach of the sigmoid sinus, and the dissected anatomical differences were observed. The exposure of two kinds of diagonal areas under the unframeless stereotactic navigation equipment and the exposure of the brain stem were measured. The maximum observation angle allowed by six points, such as area and Meckle 's cavity, trigeminal root, facial nerve root, inner auditory canal, glossopharyngeal nerve root and jugular hole, was compared. 15 cases of cerebellopontine angle, diagonal area and tentorial tumor were treated by posterior sigmoid keyhole approach, and the longest diameter of 11 cases was greater than 3.0cm..
Results: the posterior sigmoid keyhole approach is similar to the anatomical structure of the conventional approach. It can be exposed to the anterolateral margin of the tentorium, near the occipital big hole, and the medial to the anterior lateral side of the bridge brain and middle brain. Through the nerve gap, the outer 2/3 in the upper and upper diagonal area of the same side can be reached, but the structure above the rock tip, the lower slope and the curtain notch above is poorly exposed or not. The exposed area of the brain stem was 304.73 + 28.93mm2143.9 + 31.87mm2 respectively, while the conventional approach was 346.43 + 42.80mm2136.05 + 9.05mm2 respectively. There was no significant difference in the exposed area of the brain stem (P0.05) in the diagonal area (P0.05). For the selected six targets, whether vertical or water The observation angle of the conventional approach was larger than the observation angle of the keyhole approach (P0.05). Clinical verification of 15 cases of tumor surgery, 13 cases of total resection, 2 total resection, 4 new peripheral facial paralysis after operation, 3 cases of transient facial paralysis in.7 cases with hearing loss before operation, 5 cases of hearing loss after operation, 1 cases of postoperative hearing improvement, no other. Postoperative complications.
Conclusion: the retrosigmoid keyhole approach has a similar exposure range with the conventional approach. It can be used for tumors in the cerebellopontine angle and diagonal area, the anterior lateral and lateral tumors of the middle brain and the bridge brain, and the large and giant tumor can be excised by block resection and the method of intratumoral decompression. A simple and safe minimally invasive surgical approach.
The second part is a microanatomical study of the occipital median cerebellopontine keyhole approach.
Objective: Based on the principle of keyhole, the suboccipital medullary cleft keyhole approach was designed, and the neuronavigation system was used to evaluate the anatomy of the autopsy, and the feasibility and scope of operation were discussed, and preliminary clinical validation was carried out to provide a reliable basis for clinical application.
Methods: 6 adult cadavers were perfused with 4% formalin fixed with intracranial arteriovenous glue. First, the posterior occipital middle cerebellar medullary cleft keyhole approach was performed to observe the dissecting anatomy of each step, and the area of the four ventricle under the keyhole approach and the lower entrance of the aqueduct under the unframeless stereotactic navigation equipment were measured. Both sides of the side of the lateral hole and the middle trench intersection, the observation angle of the latch; then milling the posterior arch of the atlas with the milling cutter and measuring the above parameters, after the measurement, the posterior arch of the atlas is reattached with titanium and titanium nails; then the incision is extended and the bone window is extended to the conventional approach to measure the above parameters before and after the removal of the posterior arch of the atlas; the final statistical analysis. Application of the suboccipital median channel. The cerebellopontine cleft keyhole approach was used to treat 14 cases of four intraventricular and surrounding regions, including 5 cases of vermis of the cerebellum (3 cases of medulloblastoma, 1 cases of glioma, 1 cases of metastatic carcinoma), 6 cases of four intraventricular lesions (4 cases of ependymoma, 1 arachnoid cysts, 1 cases of choroidal papilloma), and 2 cases of lateral cavernous hemangioma of the brainstem (cavernous hemangioma) 1 cases, 1 cases of pontine gliosis, 1 cases of hematoma in the posterior part of the brain stem were clinically verified.
Results: by adjusting the projection angle of the head and microscope, the choroid membrane could be revealed after the cerebellar medullary cleft under the middle occipital keyhole approach, and the lower medullary sails could reveal the bottom of the four ventricle, the lateral recess, the lateral hole and the ventricle of the cerebellum. The angle of the four ventricle under the keyhole approach was not as wide as that of the conventional approach (P0. 01) but there is no significant difference in the exposed area of the four ventricles under the two approaches (P=0.06). The increase of the exposure angle under the conventional approach can increase the degree of freedom of the operation and facilitate the operation of the target in multiple directions, but it does not increase the exposure area of the four ventricle. The degree of freedom of the operation is smaller, but it does not affect the exposure of the target. Under the deep amplification effect of the keyhole, the related target can be operated effectively. The removal of the posterior arch of the atlas can not increase the exposed area of the four ventricle below the keyhole entry (P=0.84). No matter the conventional entry or the locking of the keyhole, the posterior arch of the atlas can increase the bottom of the ventricles of the four ventricle. The direct exposure angle (P0.05) was not affected by the horizontal exposure angle (P0.05). 14 cases of this group were all cut under microscope, 1 cases died of pulmonary infection after operation, the other 13 cases were improved before operation, no complications related to brain stem and cranial nerve injury, no cerebellar mutism and other complications related to vermis operation.
Conclusion: the suboccipital midocerebellar medullary cleft keyhole approach has a similar exposure area to the conventional approach, without the need to wear the posterior arch of the atlas to reveal the four ventricle bottom structure. After mastering the keyhole approach, long rod and gun instruments can be used safely and succinctly in the four ventricle through a relatively narrow exposure angle. Tumor surgery in the dorsal part of the medulla oblongata and the inferior cerebellar vermis is a feasible minimally invasive approach.
【学位授予单位】：苏州大学
【学位级别】：博士
【学位授予年份】：2009
【分类号】：R322

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