颅颈交界区手术入路显微解剖与固定方法研究
发布时间：2018-07-14 22:14
【摘要】： 第一部分:枕下远外侧入路至颅颈交界区的显微解剖与后路固定方法研究 目的:研究国人成年头颅标本经枕下远外侧入路至颅颈交界腹外侧区的显微解剖与术后颅颈失稳的后路寰枕固定方法。 方法:15具(30侧)完整成人湿性头颅标本,经红蓝硅胶分别灌注动静脉后经枕下远外侧入路进行分层显微解剖,另对15具干性头颅和寰枢椎标本进行相关骨性测量,并对解剖数据进行对比分析;根据远外侧入路对枕骨髁磨除范围的不同,分成经髁后入路(RCA)组、部分经髁入路(pTCA)组、完全经髁入路(tTCA)组以及经颈静脉结节入路(TTA)组各15例(30侧),对比不同术式对颅颈交界腹外侧区暴露范围的影响;并对后路经寰椎椎弓根螺钉内固定的进钉点、进钉方向等指标进行测量分析。 结果:1.83.3%的枕动脉主干体表投影在乳突尖与枕外隆突连线上,距后正中线3～5cm区域之间;椎动脉穿硬脑膜处距后中线平均距离为15.5±1.2mm,未见小脑后下动脉由椎动脉硬膜外段发出者;枕骨髁平均长度为24.5±3.3mm;舌下神经管内口下缘距枕骨髁平均距离为9.1±1.1mm;颈静脉结节平均高度为9.4±1.4mm; 86.7%的星点位于横窦乙状窦交角之后。2.与远外侧髁后入路组比较,部分经髁入路组、完全经髁入路组以及颈静脉结节入路组对颅颈交界腹外侧区水平暴露距离分别增加10.9mm、12.6mm和10.1mm,手术深度分别降低13.5mm、20.5mm和24.6mm,组间差异具有统计学意义(P0.05)。3.寰枕固定枕骨端可选择上项线水平上1 cm处,以寰椎椎弓根中线外侧2mm处为进钉点,内斜平均角度13.5±2.4°,上斜平均角度5.2±0.4°,螺钉平均长度25.5±3.5mm。 结论:枕下远外侧入路可充分显露颅颈交界腹外侧区,可通过磨除不同范围的枕髁或颈静脉结节等骨性结构增加暴露,术后可经后路寰椎椎弓根螺钉内固定行寰枕融合术。 第二部分:经口咽入路至颅颈交界区的显微解剖与前路固定方法研究 目的:研究国人成年头颅标本经口咽入路至颅颈交界腹外侧区的显微解剖与术后颅颈失稳的前路寰枢固定方法。 方法:所用标本同第一部分,经口咽入路进行分层显微解剖并做相关测量,对解剖数据进行对比分析;将标本分为单纯经口咽入路(To)组、经口咽入路+下颌骨切开(To+Ma)组和经口咽入路+部分硬腭切除(To+Pa)组各15例(30侧),比较不同术式对颅颈交界腹外侧区暴露范围的影响;并对前路经寰枢关节螺钉内固定的进钉点、进钉方向等指标进行测量。 结果:1.咽后壁软组织存在5层结构和2个间隙;咽结节至枕骨大孔前缘的平均距离为10.2±2.2mm;寰椎前结节至上切牙平均距离为11.6±2.1 cm;齿状突平均高度为15.9±6.9mm,至上切牙平均距离为12.8±2.2cm;寰椎横韧带平均长度为21.7±1.6mm,中部与硬膜囊的平均距离为2.1±0.3mm。2.标准经口咽入路矢状位暴露范围由下斜坡至C_2水平;下颌骨切开后矢状位显露角度增加23.6°,轴位显露角度增加11.1°,手术深度减少2.0cm,暴露范围延伸到中斜坡至C_3水平,差异具有统计学意义(P0.05);部分硬腭切除后矢状位显露角度增加14.0°,手术深度减少1.6cm,差异具有统计学意义(P0.05),但轴位显露角度改变不明显,头侧暴露范围增加至上斜坡,而尾侧仍至C_2水平。3.以枢椎前弓下缘与枢椎椎体侧缘交点上方3mm为进钉点,螺钉长度16～25mm,外倾5～20°,后倾15～24°置入。 结论:经口咽入路对颅颈交界腹侧由下斜坡至C_2水平距中线3～5cm内的区域显露较好,尤其适合行齿状突切除前路减压;其改良术式增加了暴露范围,降低了手术深度;术后可经前路行寰枢关节螺钉内固定术稳定寰枕区。
[Abstract]:The First Part : A Study of the Microanatomy and Posterior Fixation in the Transborder Region of the Head and Neck
Objective : To study the posterior atlanto - occipital fixation in the lateral ventrolateral area of the cranio - cervical junction of adult head specimens from the adult .
Methods : 15 cases ( 30 sides ) of intact adult wet skull specimens were dissected by using red - blue silica gel , and the other 15 cases ( 30 sides ) were divided into the condylar - posterior approach ( RCA ) group , the partial transcondylar approach ( pTCA ) group , the complete transcondylar approach ( tTCA ) group , the transcondylar approach ( tTCA ) group , and the internal jugular nodule - in - posterior ( tTCA ) group .
Results : 1 . 83 . 3 % occipital artery trunk body surface was projected on the connecting line between the mastoid tip and the occipital protuberance , the average distance from the posterior median line to the posterior median line was 15.5 卤 1.2mm . The average length of the occipital condyle was 24.5 卤 1.4mm ; the average distance of the inferior margin of the cervical vein was 9.5 卤 1.4mm . The average angle of the internal oblique angle was 13.5 卤 2.4 掳 , the upper oblique average angle was 5.2 卤 0.4 掳 , and the average length of the screw was 25.5 卤 3.5mm .
Conclusion : The lower lateral approach of the pillow can reveal the lateral ventrolateral area of the cranio - cervical junction , which can increase the exposure to the bony structures such as the occipital condyle or the jugular nodule in different ranges . The atlanto - occipital fusion can be fixed through the posterior atlantoaxial pedicle screw .
The second part : Microanatomy and anterior fixation of the transjugular approach to the cranio - cervical junction area
Objective : To study the anterior atlantoaxial fixation method for the microdissection and post - operative cranio - neck instability of adult head specimens of Chinese adults via oropharyngeal approach to the ventrolateral region of the cranio - cervical junction .
Methods : The specimens were compared with the first part , through the oropharyngeal approach , and the anatomical data were compared and analyzed . The specimens were divided into 15 cases ( 30 sides ) of the pure oral pharyngeal approach ( To ) group , the oropharyngeal approach plus the mandible incision ( To + Ma ) group and the oropharyngeal approach plus part of the hard palate resection ( To + Pa ) group . The effects of different operation types on the exposure range of the lateral ventrolateral area of the cranio - cervical junction were compared ; and the indexes such as the nail point and the nail feeding direction fixed in the anterior atlantoaxial joint screw were measured .
Results : 1 . There were 5 structure and 2 gaps in the soft tissue of posterior pharyngeal wall . The average distance between the anterior margin of the pharyngeal nodule to the anterior margin of the foramen magnum was 10.2 卤 2.2 mm , the mean distance of the anterior resection of the atlas was 1 . 6 卤 2 . 2 cm , the mean distance between the middle and hard capsule was 2 . 1 卤 2 . 2 cm .
Conclusion : The lower slope to the C _ 2 level from the lower slope to the C _ 2 level is better in the lower slope to the C _ 2 level from the lower slope to the C _ 2 level , which is especially suitable for the anterior decompression of the odontoid process . The improved operation method increases the exposure scope and reduces the depth of operation ; and the atlantooccipital area can be stabilized via anterior atlantoaxial arthrodesis .
【学位授予单位】：天津医科大学
【学位级别】：博士
【学位授予年份】：2009
【分类号】：R651;R322
本文编号：2123125
[Abstract]:The First Part : A Study of the Microanatomy and Posterior Fixation in the Transborder Region of the Head and Neck
Objective : To study the posterior atlanto - occipital fixation in the lateral ventrolateral area of the cranio - cervical junction of adult head specimens from the adult .
Methods : 15 cases ( 30 sides ) of intact adult wet skull specimens were dissected by using red - blue silica gel , and the other 15 cases ( 30 sides ) were divided into the condylar - posterior approach ( RCA ) group , the partial transcondylar approach ( pTCA ) group , the complete transcondylar approach ( tTCA ) group , the transcondylar approach ( tTCA ) group , and the internal jugular nodule - in - posterior ( tTCA ) group .
Results : 1 . 83 . 3 % occipital artery trunk body surface was projected on the connecting line between the mastoid tip and the occipital protuberance , the average distance from the posterior median line to the posterior median line was 15.5 卤 1.2mm . The average length of the occipital condyle was 24.5 卤 1.4mm ; the average distance of the inferior margin of the cervical vein was 9.5 卤 1.4mm . The average angle of the internal oblique angle was 13.5 卤 2.4 掳 , the upper oblique average angle was 5.2 卤 0.4 掳 , and the average length of the screw was 25.5 卤 3.5mm .
Conclusion : The lower lateral approach of the pillow can reveal the lateral ventrolateral area of the cranio - cervical junction , which can increase the exposure to the bony structures such as the occipital condyle or the jugular nodule in different ranges . The atlanto - occipital fusion can be fixed through the posterior atlantoaxial pedicle screw .
The second part : Microanatomy and anterior fixation of the transjugular approach to the cranio - cervical junction area
Objective : To study the anterior atlantoaxial fixation method for the microdissection and post - operative cranio - neck instability of adult head specimens of Chinese adults via oropharyngeal approach to the ventrolateral region of the cranio - cervical junction .
Methods : The specimens were compared with the first part , through the oropharyngeal approach , and the anatomical data were compared and analyzed . The specimens were divided into 15 cases ( 30 sides ) of the pure oral pharyngeal approach ( To ) group , the oropharyngeal approach plus the mandible incision ( To + Ma ) group and the oropharyngeal approach plus part of the hard palate resection ( To + Pa ) group . The effects of different operation types on the exposure range of the lateral ventrolateral area of the cranio - cervical junction were compared ; and the indexes such as the nail point and the nail feeding direction fixed in the anterior atlantoaxial joint screw were measured .
Results : 1 . There were 5 structure and 2 gaps in the soft tissue of posterior pharyngeal wall . The average distance between the anterior margin of the pharyngeal nodule to the anterior margin of the foramen magnum was 10.2 卤 2.2 mm , the mean distance of the anterior resection of the atlas was 1 . 6 卤 2 . 2 cm , the mean distance between the middle and hard capsule was 2 . 1 卤 2 . 2 cm .
Conclusion : The lower slope to the C _ 2 level from the lower slope to the C _ 2 level is better in the lower slope to the C _ 2 level from the lower slope to the C _ 2 level , which is especially suitable for the anterior decompression of the odontoid process . The improved operation method increases the exposure scope and reduces the depth of operation ; and the atlantooccipital area can be stabilized via anterior atlantoaxial arthrodesis .
【学位授予单位】：天津医科大学
【学位级别】：博士
【学位授予年份】：2009
【分类号】：R651;R322
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