乙状窦后经内听道上入路的显微解剖学研究

发布时间：2018-08-29 10:32

【摘要】： 目的:通过对成人颅骨干性标本和湿性标本的解剖及其数据测量,研究乙状窦后经内听道上入路(RSSMA)的显微外科解剖标志,量化岩骨斜坡区入路的相关组织结构,为乙状窦后经内听道上入路切除颅内占位病变提供准确的解剖学数据。为增加手术安全性与可操作性,最大程度切除肿瘤甚至完全切除,减少手术创伤和术后并发症提供理论指导。材料与方法:成人湿性头颅标本10例,颅骨干性标本10例。对10例(20侧)经福尔马林溶液固定的、不同性别的成人头颅湿性标本进行血管灌注染色后,模拟乙状窦后经内听道上手术入路进行解剖,逐层暴露岩骨斜坡区显微结构并详细记录操作步骤。显微镜下测量相关数据,以内听道道上结节(简称道上结节)为标志观察周围血管、神经等解剖结构。磨除内听道上结节和岩尖,切开三叉神经腔的硬脑膜壁和天幕,测量内听道上结节和岩尖磨除前后中颅窝、上斜坡和三叉神经的暴露范围。 1颅骨干性标本将干性颅骨标本经眉弓上缘1cm处沿水平方向锯开去除顶盖骨,显露颅底骨性结构。对岩斜区进行骨性结构观察,重要识别横窦沟、乙状窦沟、岩上窦沟、三叉神经压迹、前庭水管外口、弓下窝、道上结节、岩尖等结构,并对该区与乙状窦后经内听道上入路相关的重要结构进行详细测量、拍摄,如测量星点-道上结节、星点-岩尖的距离,内听道上结节和岩尖的三维参数。标记出乙状窦沟后缘及横窦沟下缘的颅骨表面投影,模拟乙状窦后入路进行骨窗设计。显微镜下磨除骨性结构-内听道上结节与岩尖,并测量道上结节和岩尖磨除后的三维参数变化。 2颅骨湿性标本模拟枕下乙状窦后入路逐层解剖,精确定位、测量与手术入路有关的重要解剖结构并进行拍摄。将经过备皮和彩色乳胶灌注的头颅标本固定于Doro手术头架上,设计基底向前,近乎以横窦为中心的倒L形切口。经星点做骨瓣成型,暴露横窦下缘和乙状窦后缘,放射状剪开硬脑膜并对硬脑膜进行悬吊。由于经过固定的脑组织会变硬、弹性较差,很难被牵拉出手术操作空间,因此常切除小脑外侧1/3后用脑压板将小脑向内侧牵开,暴露岩斜区结构。显微镜下测量星点-道上结节、星点-岩尖、道上结节-外展神经、道上结节-三叉神经、道上结节-面听神经的距离,观察毗邻的神经和血管,重点观测动眼神经、滑车神经、三叉神经、外展神经、面神经、位听神经、小脑上动脉、小脑下前动脉、小脑下后动脉、岩静脉等结构的起源、走形分布及相互关系。移动手术显微镜,测量中颅窝、上斜坡和三叉神经的暴露范围。磨除道上结节和岩尖,切开Meckel腔侧壁和上壁的硬膜,自小脑幕缘沿岩骨嵴打开小脑幕,再次测量中颅窝、上斜坡和三叉神经的暴露范围。 3统计分析实验结果数据应用统计学软件SPSS16.0进行统计学分析,计算出结果用均数±标准差(Mean±SD)表示。对三叉神经和术野暴露数据测量结果进行独立样本t检验比较,以P0.05作为判断差异显著性的标准。结果:星点-道上结节的距离为53.4±4.6(49.7—61.8)mm、星点-岩尖的距离为72.1±4.9(67.9—81.4)mm,道上结节-三叉神经压迹外缘的距离为9.7±0.9(8.7—11.2)mm、道上结节-外展神经的距离为16.8±1.0(15.9—18.1)mm、道上结节-前庭水管外口的距离为20.1±0.8(19.2—21.3)mm、道上结节-弓状下窝的距离为9.4±1.1(7.6—10.5)mm、道上结节-岩尖的距离为18.3±1.0(17.4—19.9)mm、滑车神经汇入小脑幕缘处距岩骨嵴的距离为4.8±1.1(3.4—7.3)mm、面听神经距三叉神经距离为4.8±1.6(4.3—5.6)mm、面听神经距舌咽神经距离为4.9±1.8(4.4—5.5) mm。内听道上结节的三维参数如下:前后径9.8±1.7(8.3—12.8)mm、上下径5.7±1.1(4.1—7.2)mm、左右径14.1±2.4(10.6—17.1)mm;岩尖的三维参数为:前后径14.7±3.0(11.7—19.9)mm、上下径17.1±1.1(15.9—18.7)mm、左右径19.3±1.1(17.5—20.9)mm。道上结节前后径,左右径,上下径均可全部磨除,为不损伤三叉神经和面听神经,靠近神经处可留薄层骨质以保护神经,经统计学检验均P0.05,差异有统计学意义;岩尖前后径,左右径可全部磨除,磨除后的上下径为9.8±1.7(7.9—12.5)mm,经统计学检验均P0.05,差异有统计学意义。中颅窝扩大显露范围为137.1±7.1mm2 ,上斜坡扩大显露至83.8±7.3mm2 ,三叉神经的显露长度为9.3±0.6mm,与术前比较经统计学检验均P0.05,差异有统计学意义。小脑上动脉、小脑下前动脉、小脑下后动脉、岩上静脉、岩上窦、动眼神经、滑车神经、三叉神经、外展神经、面神经、前庭窝神经、舌咽神经、迷走神经、副神经均得以认定。结论:乙状窦后经内听道上入路可以将乙状窦后入路的手术野扩大显露到中颅窝的中线侧和上斜坡的侧方,并可显露Meckel’s腔内的三叉神经。该手术入路是切除主体在后颅窝,同时侵犯中颅窝和Meckel’s腔病变的安全、有效入路,而不需同时做幕上开颅手术。岩斜区血管走行及分支变异性较大,而且该部位动脉血管的损伤常引起严重并发症。因此手术中不要轻易电凝肿瘤表面的血管,应在显微镜下确认该血管是进入肿瘤的供血动脉还是旁路血管。岩静脉是引流脑干和小脑前外侧血液回流的一组静脉,为便于术野暴露可将其切断。内听道上结节和岩尖的磨除是该入路的关键,术中内听道上结节可全部磨除,岩尖上下径磨除7.3±1.2(6.2—8.2)mm可有效显露术野。
[Abstract]:Objective: To study the microsurgical anatomical markers of retrosigmoid trans-internal auditory approach (RSSMA) and quantify the related structures of petroclival approach, and to provide accurate anatomical data for resection of intracranial space-occupying lesions via retrosigmoid trans-internal auditory approach. To provide theoretical guidance for increasing the safety and maneuverability of operation, maximizing the resection of tumor or even complete resection, and reducing surgical trauma and postoperative complications.
Materials and Methods: 10 adult wet skull specimens and 10 skull diaphyseal specimens were dissected by simulating the retrosigmoid approach through the internal auditory canal after perfusion staining of 10 adult wet skull specimens (20 sides) fixed with formalin solution and of different sex. Measure the data under microscope. Observe the anatomical structures of the peripheral vessels and nerves with the nodules in the internal auditory meatus as the markers. Grind the nodules and petrous apex of the internal auditory meatus, incise the dural wall and tentorium of the trigeminal nerve cavity, measure the nodules in the internal auditory meatus and petrous apex before and after the abrasion of the middle cranial fossa, the upper clivus and the trigeminal nerve. Exposure range.
1 dry skull specimens
The skull specimens were dissected horizontally from the upper edge of the eyebrow arch to remove the parietal skull and expose the skull base bony structure.The petroclival region was observed to identify the transverse sinus sulcus, sigmoid sinus sulcus, superior petrosal sinus sulcus, trigeminal nerve imprint, vestibular aqueduct outlet, subarch fossa, tubercle of the passage, petrous apex and other structures. Important structures related to the auditory approach were measured in detail and photographed, such as the distance between the star and the nodule, the distance between the star and the petrous apex, and the three-dimensional parameters of the nodule and petrous apex in the internal auditory meatus. The nodules and petrous apex of the internal auditory canal were measured, and the three-dimensional parameters of the superior nodules and the apex of the petrous apex were measured.
2 wet specimens of skull
Simulate the suboccipital retrosigmoid approach, locate accurately, measure and photograph the important anatomical structures related to the surgical approach. Fix the skull specimens with skin preparation and color latex perfusion on the Doro Surgical Skull frame, design the inverted L-shaped incision with the basement forward and the transverse sinus as the center. The lower edge and the posterior edge of the sigmoid sinus are scissored radially and the dura mater is suspended. Since the fixed brain tissue will harden and have poor elasticity, it is difficult to be pulled out of the operating space, so the lateral cerebellum is often removed 1/3 later, the cerebellum is retracted medially with a compression plate to expose the petroclival structure. The distances between the star-petrous apex, the tubercle-abductor nerve, the tubercle-trigeminal nerve, the tubercle-facial nerve, and the adjacent nerves and vessels were observed. The origins of oculomotor nerve, trochlear nerve, trigeminal nerve, abductor nerve, facial nerve, auditory nerve, superior cerebellar artery, anterior inferior cerebellar artery, posterior inferior cerebellar artery and petrosal vein were observed. The exposure areas of the middle cranial fossa, the upper clivus and the trigeminal nerve were measured by moving the operating microscope. The nodules and petrous apex of the canal were abraded, the dura mater of the lateral wall and the upper wall of the Meckel cavity were incised, the tentorium of cerebellum was opened along the petrous ridge from the tentorium margin of the cerebellum, and the exposure areas of the middle cranial fossa, the upper clivus and the trigeminal nerve were measured again
3 statistical analysis
The experimental data were statistically analyzed by SPSS16.0 and the calculated results were expressed by Mean (+ SD). The results of trigeminal nerve and surgical field exposure data were compared by independent sample t test, and P 0.05 was used as the criterion to judge the significance of the difference.
Results: The distance between the nodule and the petrous apex was 53.4 (-4.6) (49.7-61.8) mm, 72.1 (-4.9) (67.9-81.4) mm, 9.7 (-0.7-11.2) mm, 16.8 (-1.0) (15.9-18.1) mm, and 20.1 (-0.8) mm, respectively. (19.2-21.3) mm, the distance between nodule and inferior arcuate fossa was 9.4 (-1.1) (7.6-10.5) mm, the distance between nodule and petrous apex was 18.3 (-1.0) (17.4-19.9) mm, the distance between trochlear nerve and petrosal crest was 4.8 (-1.1) (3.4-7.3) mm, the distance between facial and auditory nerve and trigeminal nerve was 4.8 (-1.6) mm, and the distance between facial and auditory nerve and hypopharyngeal nerve was 4.8 (-1.3-5.6) mm. The three-dimensional parameters of the nodules in the internal auditory meatus were as follows: the anteand posterior diameters were 9.8 ((8.3-12.8) mm, 9.8 ((8.3-12.8) mm, 5.7 (1.1 (4.1-7.2) mm, 14.1 (2.1 ((10.6-17.1) mm) 4 (10.6-17.1) mm) mm; the left and right diadiameters were 14.1 (14.1 (2.1 (2.4.4.4.4 (10.6-17.1) mm); the rock apwas 14.7 ((14.7 ((11.7 (11.7-19.7-19.9) mm), 17.1 (17 5-20.9)mm. In order not to damage the trigeminal nerve and the facial and acoustic nerve, thin layer of bone can be left near the nerve to protect the nerve. The difference was statistically significant (P 0.05). The exposure range of the middle cranial fossa was 137.1 (+ 7.1) mm2, the upper clivus was 83.8 (+ 7.3) mm2, and the exposure length of the trigeminal nerve was 9.3 (+ 0.6) mm. The difference was statistically significant (P 0.05). The superior cerebellar artery, inferior anterior cerebellar artery, inferior posterior cerebellar artery, superior petrosal vein, and petrosal vein were statistically significant (P 0.05). Superior sinus, oculomotor nerve, trochlear nerve, trigeminal nerve, abductor nerve, facial nerve, vestibular fossa nerve, glossopharyngeal nerve, vagus nerve, accessory nerve were identified.
CONCLUSION: The retrosigmoid approach is a safe and effective approach for the removal of the main body in the posterior cranial fossa and the invasion of the middle cranial fossa and the lesions in the Meckel's cavity. Meanwhile, supratentorial craniotomy was performed.
The petroclival region is characterized by great variability in the course and branches of the blood vessels, and the injury of the arteries in the petroclival region often leads to serious complications. Therefore, it is not necessary to electrocoagulate the blood vessels on the surface of the tumor easily during operation. It should be confirmed under microscope whether the blood vessels enter the tumor's blood supply artery or bypass vessels. The petrosal vein is the drainage of blood from the brain stem and anterolateral cerebellum. A group of veins can be cut off to facilitate the exposure of the operative field.
Abrasion of nodules and petrous apex in the internal auditory canal is the key to the approach. All nodules in the internal auditory canal can be abrased during the operation. Abrasion of 7.3 (+1.2) (6.2-8.2) mm of petrous apex can effectively expose the surgical field.
【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2010
【分类号】：R322.8

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