神经内镜下经筛蝶入路视神经管减压术相关解剖、影像学研究及临床应用
发布时间：2018-08-14 13:57
【摘要】：目的：结合临床手术实际应用需要,通过对神经内镜下经筛蝶入路行视神经管减压手术相关的解剖及影像学研究,了解相关解剖标志及变异情况,测量此径路手术相关的解剖数据,确定手术安全范围,探索术中定位视神经管的新方法,以提高神经内镜下视神经管减压术的安全性及准确性；测量此径路下可磨除视神经管内壁骨质的最大有效范围,从解剖学角度评估其有效性；结合临床应用病例回顾性分析,探讨该入路的优势及影响术后疗效的可能因素。材料与方法：第一部分：1.选用6例(12侧)成人头颅干性标本(风干的湿性头颅标本),分别行眼眶三维CT扫描并重建,于CT片上测量相关解剖学参数,并利用公式计算出视神经管眶口、颅口及管中段的周径及横截面积；以双侧眉弓上1cm及枕外粗隆为水平面锯开颅盖,观察颅底结构并测量视神经管各段间距；沿着正中矢状面锯开头颅,按照神经内镜下经筛蝶入路行视神经管减压的手术径路,逐层解剖相关解剖结构,寻找并确定此径路中的手术标志,测量各解剖标志点之间的距离及视神经管内侧壁长度；对比CT影像与实体解剖两种方法所测得的相关数据。2.选用6例(12侧)经10%福尔马林固定的成人头颅标本,用红色乳胶灌注动脉系统后进行解剖。模拟神经内镜下经筛蝶入路视神经管减压术,观察并统计蝶窦后外侧壁各解剖标志的出现率,并确定视神经管颅口与鞍结节隐窝中心点的位置关系；进一步磨除蝶窦后外侧壁骨质,测量视神经内壁的最大可磨除宽度,观察视神经与颈内动脉的位置关系,测量颈内动脉与视神经之间的最近点,即颈内动脉虹吸弯顶点至中线的距离；切开鞘膜,观察眼动脉的走行,并统计其于视神经管各段与视神经的位置关系。第二部分：回顾性分析江苏省苏北人民医院神经外科应用神经内镜下经筛蝶入路行视神经管减压术的4例(5眼)外伤性视神经病变的临床资料,记录手术用时、术中出血量以及术后并发症的情况,对比手术前后患者的视力情况,结合解剖研究基础及文献回顾,探讨该入路的优势及影响术后疗效的可能因素。结果：第一部分：1.将CT影像与实体解剖测量的视神经管颅口、眶口、管中段间距及视神经管内侧壁的长度两组数据比较,结果无统计学差异(P0.05)。视神经管颅口、眶口、管中段处的周长分别为(16.42±1.56)mmm、(17.32±1.60)mm和(13.58±1.42)mm,各段横截面积分别为(18.42±2.17)mm2、(22.64±2.23)mm2和(15.12±2.05)mm2。同侧鼻孔鼻小柱至视神经管眶口内侧壁中点、颅口内侧壁中点、管中段内侧壁中点、筛前孔、筛后孔以及蝶窦前外侧壁与筛顶交界点的距离分别为(61.95±5.42)mm、(68.18±5.77) mm、(66.72±4.87)mm、(58.09±5.03)mm、(59.31±4.96)mm和(60.12±5.01)mm；筛前孔与筛后孔的间距为(16.2±2.51)m.m,筛后孔至蝶窦前外侧壁与筛顶交界点、眶口、颅口及管中段的距离分别为(4.32±1.14)mm、(5.76±1.68)mm、(6.85±1.73)mm和(6.35±1.54)mm。内镜下视神经管颅口、眶口及管中段可磨除内壁的最大有效宽度分别为(7.82 ±2.63)mm.(8.05±2.77)mm和(6.92±2.01)mm。2.视神经隆凸的出现率为83.3%(10侧),颈内动脉隆凸的出现率为91.7%(11侧),内侧视神经一颈内动脉隐窝的出现率为58.3%(7侧),外侧视神经一颈内动脉隐窝的出现率为75.0%(9侧),鞍结节隐窝与鞍底的出现率均为100%(6例)。鞍结节隐窝中心点至视神经管颅口内侧壁中点的横、纵坐标分别为(1.11±0.12)mm、(0.37±0.06)mm,鞍结节隐窝中心点与视神经管颅口内侧壁中点连线同横坐标之间的角度为(17.23±1.34)。。颈内动脉虹吸弯顶点距中线(11.21±1.35)mm。视神经管颅口处眼动脉位于视神经内下方9侧(75%)和下方3侧(25%)；视神经管眶口处眼动脉位于视神经下方2侧(16.7%)和外下方10侧(83.3%)。第二部分：单侧手术平均用时90 min(78-90 min),术中出血80ml(70～100ml),术后均无出血、感染及脑脊液漏等并发症,4例(5眼)中术后的总体有效率为60%(3/5),术前有残存视力的患者,无论病程长短,术后视力均有不同程度的提高,而术前无光感的患者则无提高。结论：第一部分：神经内镜下经筛蝶入路视神经管减压术是一种进路直接、手术效果确切的微创手术。充分掌握相关局部解剖结构及深度范围是保证手术安全的重要前提,术前仔细阅读CT影像资料并作相关测量,结合多种定位方法能提高手术的准确性。第二部分：视神经管减压对部分外伤性视神经病变的预后有积极的影响,而神经内镜下经筛蝶入路视神经管减压术进路直接,并发症少,便于掌握和操作,适合临床推广。
[Abstract]:Objective: To study the anatomy and imaging of optic canal decompression through ethmoid-sphenoidal approach under neuroendoscope in order to find out the anatomical markers and variations, measure the anatomical data related to this approach, determine the safe range of operation, and explore a new method of locating optic canal during operation. To improve the safety and accuracy of endoscopic optic canal decompression, to measure the maximum effective range of abradable optic canal wall bone, and to evaluate its effectiveness from the anatomical point of view; to explore the advantages of this approach and the possible factors affecting the postoperative outcome by retrospective analysis of clinical cases. Methods: Part I: 1. Six adult skull dry specimens (12 sides) were scanned and reconstructed by three-dimensional CT, and the relevant anatomical parameters were measured on CT films. The perimeter and cross-sectional area of the orbital orifice, cranial orifice and middle segment of the optic canal were calculated by using the formula. The cranial cap was sawed horizontally to observe the structure of the skull base and measure the interval between the segments of the optic canal. The length of the medial wall of the optic canal was compared with that of the solid anatomy. 2. Six adult head specimens (12 sides) fixed with 10% formalin were dissected after infusing the artery system with red latex. The location of the cranial orifice of the optic canal and the central point of the recess of the sellar tubercle were determined, the bone of the posterolateral wall of the sphenoid sinus was further ground, the maximum abradable width of the optic nerve inner wall was measured, the position relationship between the optic nerve and the internal carotid artery was observed, and the nearest point between the internal carotid artery and the optic nerve, i.e, the internal carotid artery, was The distance from the apex of the siphon curve to the middle line; the sheath was incised to observe the course of the ophthalmic artery, and the relationship between each segment of the optic canal and the optic nerve was statistically analyzed. Part two: A retrospective analysis of 4 cases (5 eyes) of traumatic optic neuropathy treated by endoscopic transethmoidal decompression of the optic canal in the neurosurgery department of Jiangsu Subei People's Hospital was performed. The clinical data, the amount of bleeding and complications were recorded. The visual acuity of the patients before and after the operation was compared. The advantages of the approach and the possible factors affecting the postoperative outcome were discussed in combination with the anatomical basis and literature review. Results: Part 1: 1. The optic canal was measured by CT and anatomy. There was no significant difference in the length of the medial wall of the optic canal between the two groups (P 0.05). The distances from the ipsilateral nasal columella to the medial wall of the orbital orifice of the optic canal, the medial wall of the cranial ostium, the medial wall of the canal, the anterior ethmoidal foramen, the posterior ethmoidal foramen and the junction between the anterolateral wall of the sphenoidal sinus and the ethmoidal apex were (61.95 (5.42) mm, (68.18 (5.77) mm, (66.72 (4.87) mm, (58.09 (59.31 (4 The distance between the posterior ethmoidal foramen and the anterolateral wall of the sphenoidal sinus and the ethmoidal apex, the orbital orifice, the cranial orifice and the middle segment of the canal were (4.32 [1.14] m m, (5.76 [1.68] m m, (6.85] 1.73] m m and (6.35 [1.54] m m], respectively. The incidence of optic nerve protrusion was 83.3% (10 sides), internal carotid artery protrusion was 91.7% (11 sides), medial optic nerve-internal carotid artery recess was 58.3% (7 sides), lateral optic nerve-internal carotid artery recess was 75.0% (9 sides), and sellar tubercle recess and sellar floor were 100% (6 cases). (3) The transverse and longitudinal coordinates of the center point of the tuberculum sellae recess to the medial wall of the cranial ostium of the optic canal were (1.11+0.12) mm, (0.37+0.06) mm, and the angle between the center point of the tuberculum sellae recess and the medial wall of the cranial ostium of the optic canal and the transverse coordinates was (17.23+1.34). (11.21+1.35) mm. The ophthalmic arteries were located in 9 sides (75%) below the optic nerve and 3 sides (25%) below the optic nerve. The ophthalmic arteries at the orbital orifice of the optic canal were located in 2 sides (16.7%) below the optic nerve and 10 sides (83.3%) below the optic nerve. The overall effective rate was 60% (3/5). The postoperative visual acuity of patients with preoperative residual visual acuity was improved in varying degrees regardless of the duration of the disease, but not in patients without preoperative photosensitivity. Surgery. Mastering the anatomical structure and depth range is an important prerequisite to ensure the safety of surgery. Careful preoperative reading of CT images and related measurements, combined with a variety of localization methods, can improve the accuracy of surgery. Part II: Decompression of the optic canal has a positive impact on the prognosis of some traumatic optic neuropathy. Endoscopic transethmoidal decompression of the optic canal is a direct approach with fewer complications, easy to master and operate, and is suitable for clinical promotion.
【学位授予单位】：扬州大学
【学位级别】：硕士
【学位授予年份】：2016
【分类号】：R651
[Abstract]:Objective: To study the anatomy and imaging of optic canal decompression through ethmoid-sphenoidal approach under neuroendoscope in order to find out the anatomical markers and variations, measure the anatomical data related to this approach, determine the safe range of operation, and explore a new method of locating optic canal during operation. To improve the safety and accuracy of endoscopic optic canal decompression, to measure the maximum effective range of abradable optic canal wall bone, and to evaluate its effectiveness from the anatomical point of view; to explore the advantages of this approach and the possible factors affecting the postoperative outcome by retrospective analysis of clinical cases. Methods: Part I: 1. Six adult skull dry specimens (12 sides) were scanned and reconstructed by three-dimensional CT, and the relevant anatomical parameters were measured on CT films. The perimeter and cross-sectional area of the orbital orifice, cranial orifice and middle segment of the optic canal were calculated by using the formula. The cranial cap was sawed horizontally to observe the structure of the skull base and measure the interval between the segments of the optic canal. The length of the medial wall of the optic canal was compared with that of the solid anatomy. 2. Six adult head specimens (12 sides) fixed with 10% formalin were dissected after infusing the artery system with red latex. The location of the cranial orifice of the optic canal and the central point of the recess of the sellar tubercle were determined, the bone of the posterolateral wall of the sphenoid sinus was further ground, the maximum abradable width of the optic nerve inner wall was measured, the position relationship between the optic nerve and the internal carotid artery was observed, and the nearest point between the internal carotid artery and the optic nerve, i.e, the internal carotid artery, was The distance from the apex of the siphon curve to the middle line; the sheath was incised to observe the course of the ophthalmic artery, and the relationship between each segment of the optic canal and the optic nerve was statistically analyzed. Part two: A retrospective analysis of 4 cases (5 eyes) of traumatic optic neuropathy treated by endoscopic transethmoidal decompression of the optic canal in the neurosurgery department of Jiangsu Subei People's Hospital was performed. The clinical data, the amount of bleeding and complications were recorded. The visual acuity of the patients before and after the operation was compared. The advantages of the approach and the possible factors affecting the postoperative outcome were discussed in combination with the anatomical basis and literature review. Results: Part 1: 1. The optic canal was measured by CT and anatomy. There was no significant difference in the length of the medial wall of the optic canal between the two groups (P 0.05). The distances from the ipsilateral nasal columella to the medial wall of the orbital orifice of the optic canal, the medial wall of the cranial ostium, the medial wall of the canal, the anterior ethmoidal foramen, the posterior ethmoidal foramen and the junction between the anterolateral wall of the sphenoidal sinus and the ethmoidal apex were (61.95 (5.42) mm, (68.18 (5.77) mm, (66.72 (4.87) mm, (58.09 (59.31 (4 The distance between the posterior ethmoidal foramen and the anterolateral wall of the sphenoidal sinus and the ethmoidal apex, the orbital orifice, the cranial orifice and the middle segment of the canal were (4.32 [1.14] m m, (5.76 [1.68] m m, (6.85] 1.73] m m and (6.35 [1.54] m m], respectively. The incidence of optic nerve protrusion was 83.3% (10 sides), internal carotid artery protrusion was 91.7% (11 sides), medial optic nerve-internal carotid artery recess was 58.3% (7 sides), lateral optic nerve-internal carotid artery recess was 75.0% (9 sides), and sellar tubercle recess and sellar floor were 100% (6 cases). (3) The transverse and longitudinal coordinates of the center point of the tuberculum sellae recess to the medial wall of the cranial ostium of the optic canal were (1.11+0.12) mm, (0.37+0.06) mm, and the angle between the center point of the tuberculum sellae recess and the medial wall of the cranial ostium of the optic canal and the transverse coordinates was (17.23+1.34). (11.21+1.35) mm. The ophthalmic arteries were located in 9 sides (75%) below the optic nerve and 3 sides (25%) below the optic nerve. The ophthalmic arteries at the orbital orifice of the optic canal were located in 2 sides (16.7%) below the optic nerve and 10 sides (83.3%) below the optic nerve. The overall effective rate was 60% (3/5). The postoperative visual acuity of patients with preoperative residual visual acuity was improved in varying degrees regardless of the duration of the disease, but not in patients without preoperative photosensitivity. Surgery. Mastering the anatomical structure and depth range is an important prerequisite to ensure the safety of surgery. Careful preoperative reading of CT images and related measurements, combined with a variety of localization methods, can improve the accuracy of surgery. Part II: Decompression of the optic canal has a positive impact on the prognosis of some traumatic optic neuropathy. Endoscopic transethmoidal decompression of the optic canal is a direct approach with fewer complications, easy to master and operate, and is suitable for clinical promotion.
【学位授予单位】：扬州大学
【学位级别】：硕士
【学位授予年份】：2016
【分类号】：R651
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