侧脑室后角神经内窥镜手术入路的应用解剖学研究

发布时间：2018-08-26 10:48

【摘要】： 【目的】以侧脑室后角作为研究对象,模拟神经内窥镜手术入路,旨在设计一条安全、理想的穿刺路径,为神经内窥镜手术减少并发症、扩展适应症提供解剖学依据。【材料和方法】1.实验对象:分别对由昆明医学院解剖教研室提供的10%甲醛常规固定的成人颅脑标本15例(30侧)进行分层解剖观测,男女不限,左右侧随机。2.实验方法:在尸头上模拟神经内窥镜手术,定位穿刺。剥离头皮,暴露颅骨,以大脑中线旁开3cm,枕外隆突上分别3cm、4cm、5cm、6cm、7cm、8cm为模拟穿刺点,依次命名为Z1、Z2、Z3、Z4、Z5和Z6点。在颅骨上钻孔以显露硬脑膜,并将标记针刺入。沿枕外隆突、外耳门和眉弓连线将颅骨锯开,去除颅盖骨,于小脑幕裂孔处切断中脑,取出大脑半球,沿正中面分为两半,切除部分丘脑,显露侧脑室后角。在不同的定位点分别进行侧脑室三角区、中央部以及下角的模拟穿刺。将穿刺点至三角区的穿刺径线命名为A线,穿刺点至中央部的穿刺径线命名为B线,穿刺点至下角的穿刺径线命名为C线。3.解剖参数的测量:从不同的穿刺点出发,观测各穿刺经线与硬脑膜血管、大脑浅静脉、顶枕沟动脉、距状沟动脉、角回、视辐射的关系,并比较各个径线穿经的大脑实质的厚度,各径线所成角度以及穿刺针前端所能到达的位置。采用SPSS11.5软件对实验数据进行统计分析,计量资料以均数±标准差(Mean±SD)表示,两组采用成组t检验,组内比较采用方差分析,计数资料采用卡方检验,P＜0.05认为差异有统计学意义。【结果】1.穿刺点与硬脑膜血管的关系:所有穿刺点在硬脑膜上都未邻近大血管。2.剥离硬脑膜后观察穿刺点与大脑浅静脉的关系:Z5点位于大脑上吻合静脉后方(4.54±0.84)mm,Z6点位于大脑上吻合静脉后方(5.98±1.89)mm,其余各点与大脑浅静脉无毗邻关系。3.穿刺点在大脑表面的定位与角回的关系:Z1和Z2点距角回较远,而Z3～Z6点与角回相距较近(P＜0.05),尤其是Z3点距角回最近:(8.44±5.29)mm。4.顶枕沟动脉和距状沟动脉是大脑后动脉的两终末支,分别深入脑沟底部走行,其最深处与正中矢状面的距离为:顶枕沟动脉:(18.00±2.01)mm,距状沟动脉:(24.02±3.16)mm,经各点进行侧脑室后角穿刺时,均与该两条动脉邻近。5.Z1、Z2和Z3穿刺点在进入侧脑室三角区的同时都相应的与视辐射形成交角,大多交在其上部或中部,而Z4、Z5和Z6点都不与视辐射相交。6.以穿刺点至三角区的穿刺径线,即A线为基线,当穿刺针从三角区转移至中央部或下角时,必定与A线成一定的夹角,经Z5和Z6点的穿刺,AB线所成夹角较大(P＜0.05),而经Z1和Z2点的穿刺,以AC线所成的夹角则较大(P＜0.05)。7.从各个穿刺点出发,穿刺针所经过的层次依次为皮肤、浅筋膜、帽状腱膜、腱膜下疏松结缔组织、颅骨外膜、颅骨、脑膜(硬脑膜、蛛网膜和软脑膜)和脑实质。我们测量了从皮肤至颅骨的厚度是(22.24±1.81)mm。当通过脑实质到达侧脑室时,不同的穿刺经线,不同的穿刺点,该段的厚度并不相同,经Z1到Z6点穿刺分别至三角区、中央部、下角的脑实质厚度,即A、B、C三线,差异无统计学意义(P＞0.05),三线比较B＞C＞A。8.通过观察侧脑室后角与穿刺点的位置关系,Z4、Z5和Z6点更易到达侧脑室的前角,而Z2、Z3和Z4点则利于进入侧脑室的下角。【结论】1.神经内窥镜下侧脑室后角手术入路最适宜处理侧脑室三角区的病变。 2.侧脑室后角神经内窥镜手术入路的体表定位是:大脑中线旁3cm、枕外隆突上方6～7cm。穿刺方向指向同侧眉弓中点,穿经的脑实质深度在(45.10±6.60)mm之间,该路径并发神经、血管损伤的风险较小,不但可直接进入侧脑室的三角区,同时也可以处理侧脑室中央部和侧脑室下角的病变,利于临床上在手术过程中进行另外两个部位的探查。【目的】将光学测量法应用到股骨干骨折钢板内固定治疗的生物力学研究中,并分析内固定物断钉的原因和位点,为钢板内固定术的优化方案提供力学依据。【材料和方法】1.实验对象:选用昆明医学院人体解剖教研室提供的10%甲醛常规固定的成人离体股骨标本6根,男女不限,左右侧随机。2.实验模型的建立及分组:将标本解剖后剔除所有软组织,分别测量股骨干的全长,定出中点位置后以线锯垂直于骨干长轴横行截断,制造股骨干中段骨折模型。模拟各种受力情况的差异性,设计实验模型进行对比分析。分别设计成10种状态:a.模拟骨折愈合后的受力状态(未锯断);b.骨折后加压钢板坚强内固定组(锯断后);c.在b组的基础上近端去一枚螺丝钉;d.在c组的基础上远端去一枚螺丝钉;e.在d组的基础上近端去一枚螺丝钉;f.在e组的基础上远端去一枚螺丝钉:g.在f组的基础上近端去一枚螺丝钉;h.在g组的基础上远端去一枚螺丝钉;i.在h组的基础上近端去一枚螺丝钉;j.在i组的基础上远端去一枚螺丝钉。将各组实验模型固定在力学测试仪上,股骨头夹在上端,股骨髁夹在下端。安装好载荷,首先进行预载荷50N,以消除骨的松弛、蠕变等时间效应影响,再轴向加载0～500N,加载速度为10N/s,计算机自动记录应变情况,再利用数字散斑法计算出螺丝钉在受力状态下的位移和平均应变,并加以比较。采用SPSS11.5软件对实验数据进行统计分析,计量资料以均数±标准差(Mean±SD)表示,两组采用成组t检验,组内比较采用方差分析,P＜0.05认为差异有统计学意义。【结果】(1)10枚螺丝钉在a、b两种状态所产生的位移和平均应变表现出显著性差异(P＜0.05),b状态尤为显著(P＜0.05)。(2)在b状态下,10枚螺丝钉在加载力的作用下均发生微小位移和平均应变,且随加载力的增大而增大。其中,位于骨折线两端的两枚螺丝钉,即第5、6枚螺丝钉的位移变化较其他螺丝钉显著(P＜0.01),进一步进行两两比较,螺丝钉1与10、2与9、3与8、4与7、5与6的比较差异无统计学意义(P＞0.05),余两两比较差异有统计学意义(P＜0.05)。(3)第5、6枚螺丝钉在c至j状态下所发生的位移和应变在加载力的作用下随着状态的改变逐渐增大(P＜0.01),其中,g至j状态较其他状态显著(P＜0.01)。【结论】1.采用钢板进行股骨干骨折内固定治疗时,应选择6孔以上的钢板,以减少由于钢板的强度损失所引发的螺丝钉断裂。其中,骨折线两端的2枚螺丝钉是承受较多应力的部位,易于发生断裂,所有螺丝钉的固定应尽量在一条直线上,成对称分布的螺丝钉应保证穿钉方向的一致性,以避免钉与钉之间产生扭力,引发负荷不平衡而导致断裂。另外,病人术后的功能锻炼要在骨痂形成后进行。 2.数字散斑相关方法是一种有效的物体表面变形场全场测量的光力学测量技术,它通过图像采集、图像数字化、处理物体在不同变形状态或者不同变形时刻的两幅图像从而得到面内位移分量和面内位移梯度。将此方法应用到生物医学实验研究中,能更精确的指导实验结果,从而推动医学研究的发展,是一种值得推广的研究手段。
[Abstract]:[Objective] To design a safe and ideal puncture route by simulating the neuroendoscopic approach in the posterior horn of lateral ventricle, and to provide anatomical basis for reducing complications and expanding indications of neuroendoscopic surgery.
[Materials and Methods] 1. Subjects: 15 adult brain specimens (30 sides) fixed by 10% formaldehyde were dissected and observed in different layers. The left and right sides were randomly divided into two groups. 2. Experimental methods: Simulated neuroendoscopic surgery was performed on the cadaveric head, the scalp was dissected, the skull was exposed and the brain was dissected. 3 cm apart from the middle line, 3 cm, 4 cm, 5 cm, 6 cm, 7 cm, 8 cm on the occipital eminence were used as the simulated puncture points, named Z1, Z2, Z3, Z4, Z5 and Z6 points respectively. The dura mater was exposed by drilling holes in the skull, and the markers were inserted. The skull was sawed along the occipital eminence, the external ear portal and the arch of the eyebrow, the cranium was removed, and the middle brain was cut off at the tentorium cerebelli hiatus. The sphere is divided into two halves along the median plane. The thalamus is removed and the posterior horn of the lateral ventricle is exposed. Anatomical parameters measurement: from different puncture points, observe the relationship between the puncture meridians and dural vessels, superficial cerebral veins, parieto-occipital sulcus arteries, talus sulcus arteries, angular gyrus, visual radiation, and compare the thickness of cerebral parenchyma through each diameter, the angle of each diameter line and the position that the puncture needle can reach. SPSS11.5 software statistical analysis of the experimental data, measurement data in the mean (+ SD) expression, two groups using group t test, group comparison using analysis of variance, count data using chi-square test, P < 0.05 that the difference was statistically significant.
[Results] 1. The relationship between puncture point and dural vessels: All puncture points were not adjacent to large vessels on the dura mater. 2. The relationship between puncture point and superficial cerebral vein was observed after removal of dura mater. Z5 was located behind superior cerebral anastomotic vein (4.54.84) mm, Z6 was located behind superior cerebral anastomotic vein (5.98.89) mm, and the rest was located behind superficial cerebral venous anastomosis (5.98 The relationship between puncture points and angular gyrus: Z1 and Z2 points were farther away from angular gyrus, Z3-Z6 points were closer to angular gyrus (P The distances from the median sagittal plane to the occipitoparietal sulcus artery were (18.00 (2.01) mm and (24.02 (3.16) mm, respectively. The puncture points of the posterior horn of the lateral ventricle were all adjacent to the two arteries. 5.Z1, Z 2 and Z3 intersected with the optic radiation at the same time, mostly at the upper or middle part of the lateral ventricle triangle. The puncture diameter from the puncture point to the triangle, i.e. line A, is the baseline. When the puncture needle is transferred from the triangle to the central or lower corner, it must be at a certain angle with line A. The puncture angle of line AB is larger (P < 0.05) after the puncture at Z5 and Z6, but the puncture angle of line AC is larger (P < 0.05). From each puncture point, the needle passes through skin, superficial fascia, cap-shaped aponeurosis, subaponeurotic loose connective tissue, epicranium, skull, meninges (dura mater, arachnoid and pia mater) and brain parenchyma in turn. We measured the thickness from skin to skull (22.24 (1.81) mm. Different meridians and different puncture points have different thicknesses of the segment. Puncture through Z1 to Z6 points to the triangle, the central part, the lower horn of the brain parenchyma thickness, namely A, B, C three lines, there is no significant difference (P > 0.05), three-line comparison B > C > A.8. By observing the relationship between the posterior horn of lateral ventricle and the puncture point, Z4, Z5 and Z6 points are easier to reach the side. The anterior horn of the ventricle, while Z2, Z3 and Z4 points are beneficial to enter the inferior horn of the lateral ventricle.
[Conclusion] 1. Endoscopic approach to the posterior horn of the lateral ventricle is the most suitable approach to treat the lesions of the lateral ventricle triangle.
2. Surface localization of endoscopic neurosurgery approach in the posterior horn of lateral ventricle is 3 cm beside the middle line of the brain and 6-7 cm above the occipital eminence. To deal with the lesions of the central part of the lateral ventricle and the inferior horn of the lateral ventricle is helpful to explore the other two parts during the operation.
[Objective] To apply optical measurement method to the biomechanical study of internal fixation of femoral shaft fracture with plate, and to analyze the causes and locations of screw breakage.
[Materials and Methods] 1. Six adult femoral specimens fixed with 10% formaldehyde were selected from the Department of Human Anatomy, Kunming Medical College. The model was established and grouped. All soft tissues were removed from the specimens and the femoral shaft length was measured, and the midpoint position was determined. Wire saw perpendicular to the long axis of the shaft transversely cut, making the middle femoral shaft fracture model. Simulate the differences of various stress conditions, design the experimental model for comparative analysis. Removing a screw at the proximal end; D. removing a screw at the distal end on the basis of group c; E. removing a screw at the proximal end on the basis of group d; F. removing a screw at the distal end on the basis of group e: removing a screw at the proximal end on the basis of group f; h. removing a screw at the distal end on the basis of group g; I. removing a screw at the proximal end on the basis of group H Fixed the experimental models on the mechanical tester, the femoral head was clamped on the upper end, the femoral condyle was clamped on the lower end. Firstly, the load was preloaded 50N to eliminate the time effect of bone relaxation and creep. Then the axial load was 0-500N, the loading speed was 10N/s, and the computer automatically recorded. The displacement and average strain of the screw were calculated by digital speckle method and compared. The experimental data were statistically analyzed by SPSS11.5 software. The measurement data were expressed by Mean (+ SD). The two groups were tested by group t test. The analysis of variance was used in the comparison between the two groups, P < 0.05. There was statistical significance.
[Results] There was a significant difference in the displacement and average strain of 10 screws in the state of a and B (P The displacement of the 5 and 6 screws was significantly different from that of the other screws (P < 0.01). There was no significant difference between screw 1 and 10, 2 and 9, 3 and 8, 4 and 7, 5 and 6 (P > 0.05). There was significant difference between the other two screws (P < 0.05). (3) The displacement of the 5 and 6 screws in the state of C to J occurred. The displacement and strain of G to J increased gradually with the change of state under the action of load (P < 0.01), and the G to j state was more significant than other states (P < 0.01).
[Conclusion] 1. In the treatment of femoral shaft fractures with plate fixation, more than 6 holes of plate should be selected to reduce the screw breakage caused by the loss of plate strength. Symmetrically distributed screws should be kept in the same direction so as to avoid torsion between screws and lead to unbalanced load resulting in fracture.
2. Digital Speckle Correlation (DSC) is an effective photomechanical measurement technique for measuring the deformation field of an object in the whole field. It processes two images of the object in different deformation states or at different deformation times by image acquisition and digitization, and then obtains in-plane displacement components and in-plane displacement gradients. In the experimental research, it can guide the experimental results more accurately, thus promoting the development of medical research, which is a research method worth popularizing.
【学位授予单位】：昆明医学院
【学位级别】：硕士
【学位授予年份】：2009
【分类号】：R651;R322

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