改良乙状窦前经部分骨迷路入路的显微解剖

目的 目的 研究改良乙状窦前经部分骨迷路入路的显微解剖暴露,探讨其对岩斜区的显露及在手术处理该区域病变中的优势. 方法 2012年4月至10月,对15具尸头标本进行手术人路的改良研究,在传统乙状窦前入路的基础上切除部分半规管和岩尖,详细记录岩斜区重要结构的显露情况. 结果 该入路能够提供至岩斜区和海绵窦后部宽大的操作空间,在乙状窦前显露范围(水平方向)为(19.41±1.58) mm,在颞叶下方的显露范围(垂直方向)为(14.18±1.88) mm,斜坡中心凹陷的最大暴露角度为(60.54±6.93)°,手术操作深度(55.87 4.34) mm.椎-基底动脉、小脑前下动脉、小脑上动脉、同侧第Ⅲ～X对和对侧第Ⅵ对脑神经、三叉神经腔、海绵窦后部等均显露良好. 结论 改良乙状窦前经部分骨迷路入路能够获得岩斜区深面和海绵窦后部良好暴露,具有暴露范围大、观察角度多、保留面听神经功能、早期阻断肿瘤的血供等方面的优势.     

改良部分迷路切除岩骨尖入路的显微解剖

目的应用锁孔理念,对部分迷路切除岩骨尖入路进行改良,并对改良后的入路进行显微解剖学研究。方法对15例30侧成人尸头采用改良部分迷路切除岩骨尖入路暴露岩斜区,测量磨除部分迷路和岩骨尖后增加的手术视野和视角,观察岩斜区解剖结构的暴露情况。结果在4cm×3cm大小的骨窗范围内可以完成所有的手术操作。磨除部分迷路和岩骨尖后,手术水平视野平均增加14·2mm,垂直视野平均增加12·5mm,手术水平视角平均增加58°,垂直视角平均增加46°,该入路可充分暴露岩斜区各解剖结构,与原入路相比无明显差别。结论改良部分迷路切除岩骨尖入路暴露充分,较原入路创伤小,脑牵拉轻,不容易损伤颈静脉球和面神经颅外段等重要结构,是一种良好的处理岩斜区病变的手术入路。     

颞下经岩骨嵴入路的应用解剖学研究

目的提出颞下经岩骨嵴入路切除岩斜区脑膜瘤的方法,使手术更加简便、安全、微创,以替代各型联合入路,降低手术致残、致死率。方法10%甲醛固定的国人成人头颅湿标本10例、漂白的颅骨干标本10例,模拟手术操作并对手术涉及的重要结构测量、拍照;手术前后共10例20侧标本进行CT岩骨薄扫,并对重要结构进行测量、拍照。结果颞下经岩骨嵴入路涉及的重要解剖结构包括Labbe静脉、岩骨内部结构、脑干腹侧间隙等。重要参数包括岩骨嵴磨除范围。结论颞下经岩骨嵴入路通过对岩骨嵴的磨除,增加对岩骨背侧肿瘤基底的暴露,适合切除骑跨中后颅窝的岩斜脑膜瘤。该入路具有操作简单、创伤小、安全性高的特点。     

颞下锁孔入路的显微解剖学特点与临床应用研究

目的:研究颞下锁孔入路的显微解剖学,为临床颞下锁孔手术入路提供解剖依据与支持.方法:对6例国人成人尸头模拟颞下锁孔入路手术进行显微解剖,对各重要结构及间隙之间的距离进行测量,观察显露范围和解剖关系.结果:颧弓至小脑幕缘、脑干和前床突的最短距离分别为(42.3±4.7)mm、(42.8±2.5)mm和(59.8±6.1)mm.颞骨岩部扩大磨除前后的显露面积有显著差异(P＜0.05).颞下锁孔入路可以清楚的显露海绵窦外侧壁结构、鞍侧区、颈内动脉、后交通动脉、脉络膜前动脉和垂体柄,磨除颞骨岩尖部可显著增加岩斜区结构显露.结论:颞下锁孔入路对于海绵窦外侧壁,岩斜区及鞍侧区手术具有良好显露效果,入路直接,损伤小.     

幕上下联合锁孔入路显露岩斜区的显微解剖

目的 研究颞下和枕下乙状窦后锁孔入路对岩斜区显露的互补性.方法 尸头上模拟该锁孔入路,颞部骨窗以颧弓根部为中心前后各1.5 cm,高2.5 cm,枕下乙状窦后骨窗直径3 cm,观察显露范围并用导航标记.用带有造影剂的明胶海绵标记适于操作的有效空间,再行CT扫描和三维重建.结果 颞下入路从前外侧到达岩斜区,对颅中窝、鞍旁、幕上桥前池、脚间池下部、环池前部显露佳,切开小脑幕后环池和桥前池下部视野得到扩展,桥小脑角池方向被岩尖遮挡,是显露的死角.枕下乙状窦后入路从后外侧到达岩斜区,对同侧桥小脑角、桥前池、环池后部显露佳,但Meckel's囊开口至海绵窦后部被内听道上结节遮挡,范围小于1 cm3.结论 颞下和枕下锁孔入路的显露空间和角度有互补性,联合运用有利于切除同时累及幕上下,侵犯上斜坡和中下斜坡的岩斜脑膜瘤,尽管对海绵窦后部显露不佳,但范围小,处于放射外科的有效治疗范围之内,达到微创疗效.     

三脑室手术入路的显微解剖研究

目的:通过研究经前额-纵裂至第三脑室入路的显微解剖结构,为临床切除第三脑室肿瘤提供解剖学依据。方法:15具成人尸头,在显微镜下经前额-纵裂至第三脑室进行解剖,熟悉相关解剖结构。结果:冠矢点位置较为恒定,可作为手术入路的切口定位标志。胼胝体参与侧脑室各个壁的构成;透明隔在中线上分开侧脑室的额角和体部;穹窿是侧脑室壁上围绕在丘脑周围的结构;脉络膜裂是三脑室手术的入路部位。脑室内静脉是手术中重要的解剖标志。大脑深部静脉是手术入路的最大障碍。结论:经前额-纵裂至第三脑室入路经生理间隙进入,对周围结构损伤小,是切除第三脑室肿瘤的较佳人路。     

一侧入路显露两侧脑动脉瘤的显微解剖研究

目的 探讨一侧入路显露两侧动脉瘤的可行性，并提供相应的解剖学基础。方法 通过20例国人成年尸头标本翼点开颅，显露对侧前循环五个动脉瘤好发部位：眼动脉(OA)段、后交通动脉(PCOA)、颈内动脉(ICA)终末段、前交通动脉(ACOA)段和大脑中动脉(MCA)膝部分叉外，并进行显微解剖测量。结果 成功显露率：OA起始部为65％，PCOA起始部为50％，ICA终末分叉为100％，ACOA起始部为100％。MCA膝部分又为60％，结论 严格选择双侧多发动脉瘤的病例，经一侧入路显露并夹闭所有动脉瘤是可行、安全和有效的。     

翼点锁孔入路鞍区显微解剖及神经内镜下的应用解剖

目的 研究翼点锁孔入路鞍区各间隙的神经内镜解剖,为内镜辅助下该入路进行显微手术提供解剖学依据.方法 在15例湿头标本上选择翼点人路开30 mm×25 mm锁孔.使用显微镜和神经内镜模拟手术过程对鞍区Ⅰ、Ⅱ、Ⅲ、Ⅳ、Ⅴ间隙进行解剖结构观察,并作比较. 结果 应用锁孔概念,确定内镜下的解剖学"路标",可以显示间隙Ⅰ、Ⅱ、Ⅲ、Ⅳ、Ⅴ及Willis环等显微结构.利用神经内镜比显微镜可以更广泛清晰地显示鞍区不同间隙内的解剖结构,尤其是对一些重要的细微结构.利用成角内镜可"绕过"神经、血管观察其背后的结构,是显微手术中重要的辅助方法. 结论 运用神经内镜按解剖"路标"进行,可以消除翼点锁孔人路鞍区显微手术的显微外科解剖的死角,减少术中脑组织及重要颅底血管、神经的牵拉,减少并发症的发生,从而提高鞍区手术的疗效.     

额外侧锁孔入路的显微与神经内镜解剖

目的对比研究前颅底的显微解剖与神经内镜解剖，为额外侧锁孔手术入路处理前颅底、鞍区病变提供解剖基础。方法经额外侧锁孔手术入路对15具成人尸头进行显微解剖和神经内镜下解剖，比较两种解剖所暴露的范围。结果显微解剖在嗅沟、鞍区和外侧裂存在一定范围的视野盲区；内镜有充足的照明，可将手术视野放大，无视野盲区，清楚地显示周围的解剖结构，而且看得更远。但内镜的图像为二维图像，缺乏景深。神经内镜辅助显微手术可以互补各自不足。结论额外侧锁孔入路在神经内镜的辅助下显微手术切除前颅底和鞍区的病变安全、微创。     

远外侧枕骨髁上锁孔入路的显微解剖

目的在枕骨髁后锁孔入路基础上,探索磨除颈静脉结节的可行性,形成枕骨髁上锁孔入路,探讨其适应证,为临床应用提供解剖学基础。方法10%甲醛固定、颅内动静脉乳胶灌注的成人尸头8具,采用枕骨髁后锁孔入路的“S”形7cm切口,逐层游离、翻转肌肉,做枕骨髁后直径约3cm骨窗,在导航辅助下于硬膜外磨除颈静脉结节,观察显露的解剖结构并测量其长度。结果乳突中点向后2cm处至C_2水平的纵向“S”形7cm长头皮切口可充分暴露同侧颈静脉结节、寰枕关节椎动脉V3段及寰椎后弓,磨除颈静脉结节效果满意,可显露基底动脉下段、小脑前下动脉等桥延沟附近中斜坡结构；显露基底动脉的长度(15．65±1．34)mm,小脑前下动脉(20．36±4．18)mm。结论远外侧枕骨髁上锁孔入路具有可行性；磨除颈静脉结节可增加中斜坡的显露,适合椎-基系动脉瘤、小脑前下动脉瘤、累及中斜坡的延髓腹侧肿瘤以及颈静脉孔区肿瘤等手术。     

Proximal STA to proximal PCA bypass using a radial artery graft by posterior oblique transzygomatic subtemporal approach

The aim of the present study was to investigate the use of a radial artery graft (RAG) for bypass of the proximal superficial temporal artery (STA) to proximal posterior cerebral artery (PCA) by posterior oblique transzygomatic subtemporal approach as an alternative to the external carotid artery (ECA) to PCA anastomosis. We conducted an anatomical and technical study at a university hospital. Five adult cadaveric specimens were dissected. A preauricular vertical skin incision was used. The trunk of STA was identified. A 30° oblique posterior zygomatic arch osteotomy and microcraniotomy was performed. The dura of the middle cranial fossa was then opened. The temporal lobe was retracted, the interpeduncular and ambient cisterns were opened, and the P2 segment of the PCA was exposed. The proximal side of the RAG was anastomosed with the proximal STA and the distal side was anastomosed with the P2 segment. The mean caliber of the proximal STA was 2.25 ± 0.35 mm. The mean diameter of the P₂ was 2.2 ± 0.2 mm. The average length of the RAG was 56 ± 3.2 mm. The mean caliber of the proximal and the distal sides of the graft was 2.5 ± 0.25 mm and 2.3 ± 0.15 mm, respectively. Because the proximal STA to proximal PCA bypass uses a short RAG and their calibers are over 2 mm, this bypass technique can provide a sufficient blood flow and may be a reasonable alternative over ECA to PCA bypass using long grafts. This study was presented as a research poster at the American Academy of Otolaryngology Head and Neck Surgery Foundation Annual Meeting on September 16–19, 2007 in Washington DC, USA.     

Proximal superficial temporal artery to proximal middle cerebral artery bypass using a radial artery graft: an anatomic approach

We present the use of radial artery graft for bypass of the proximal superficial temporal artery to the proximal middle cerebral artery. Six adult cadaver sites were used bilaterally. After apterional incision, 2×2-cm minicraniectomy was performed which began 2 cm behind the zygomatic process of the frontal bone. The superficial temporal artery was transsected before exposing the zygomatico-orbital artery branch. The proximal side of the radial artery graft was anastomosed end-to-end to the proximal superficial temporal artery and the distal side end-to-side to the proximal middle cerebral artery. The mean calibers of the proximal superficial temporal artery and largest trunk of the middle cerebral artery were 2.25±0.35 mm and 2.3±0.3 mm, respectively. The average graft length was 85±5.5 mm. We conclude that such bypasses are simpler than proximal middle cerebral artery revascularization using long vein grafts. This method proves that the caliber of the proximal superficial temporal artery is more suited to providing sufficient flow than the distal superficial temporal artery, and the graft is short. Such bypasses to the middle cerebral artery may be an alternative to those from the distal superficial temporal artery or extracranial carotid artery.     

面神经分支在颞区的显微解剖学研究

目的 明确面神经在颞区的分布层次和范围，指导面部年轻化手术的操作入路。方法 12具(24侧)成人尸头标本，于5倍光学显微镜下行颞区的解剖观察。结果 颞区包含面神经的颞支和颧支：由面神经的上支分出，出腮腺上缘，颞支发出3～8个分支、颧支2～4个分支，行于颞浅筋膜深面。颞支越过颧弓至颞区，分布于额肌、眼轮匝肌、皱眉肌和耳周围肌等组织，主导其运动；颧支由腮腺上缘向前上方越过颧弓至外眦，支配眼轮匝肌和颧肌的运动；两支之间以及与眼神经的眶上神经和泪腺神经之间．都有交通支。结论 面神经的颞支和颧支分布在颞浅筋膜的深面和颞深筋膜的浅层之间的组织内，支配额部、眼周和耳部的表情肌运动；面部年轻化手术在分离颞区时．应避免在此层进行。     

颞骨内面神经水平段的显微解剖

目的 研究颞骨内面神经水平段及其毗邻结构的显微解剖,为临床应用提供解剖学资料. 方法 通过模拟l临床经乳突入路的手术方法,分层解剖20个成人湿头颅标本(40侧颞骨),显露并观测颞骨内面神经水平段及其毗邻结构. 结果 面神经水平段的长度为[(8.85±1.01)(7.10～11.25)]mm、直径为[(1.88±0.65)(1.55～1.90)]mm;FN水平段与垂直段的夹角(向前)为[(115.5±6.89)(109.5～128.6)°;面神经水平段与鼓室天盖的夹角(向后)为[(28.5±3.66)(25.8～31.5)°;匙突至面神经水平段的垂直距离为[(1.89±0.58)(0.90～3.05)]mm;镫骨头至面神经水平段(垂直距离)为[(2.30±0.85)(1.97～3.11)]mm;锥曲段顶点到砧骨短脚尖的距离为[(2.55±0.21)(2.10～2.90)]mm;锥曲段顶点至外半规管隆突距离为[(2.86±0.31)(2.23～3.56)]mm;未发现面神经水平段有分支的或者移位的情况.面神经水平段的远段位于水平半归管隆突的前内侧.有2侧(2/40)水平段的远段位于外半规管隆突外侧0.89 mm和1.02 mm,占5%. 结论 膝状神经节、匙突、镫骨、鼓室天盖、水平半规管、砧骨是手术中确定FN水平段的重要标志.颞骨内面神经水平段与其毗邻结构的空间位置关系复杂,手术操作必须熟悉面神经水平段上述定位标志,以免损伤面神经.     

乳突手术中面神经易损伤区的显微解剖

目的 研究有关乳突手术中的面神经易损伤区的显微解剖,为临床应用提供解剖学资料.方法 通过模拟临床乳突手术方法,解剖20个成人湿头颅标本(40侧颞骨),显露并观测易损伤区内的面神经水平段、垂直段、锥曲段及其毗邻结构.结果 面神经水平段的长度为(8.85±1.01)mm(7.10～11.25mm);直径为(1.88±0.65)mm(1.55～1.90mm);水平段与垂直段的夹角(向前)为(115.50±6.89°)(109.5°～128.6°);匙突到该段的垂直距离为(1.89±0.58)mm(0.90～3.05mm);镫骨足板中点到该段的垂直距离为(1.92±0.52)mm(1.44～2.56mm);镫骨头到该段的垂直距离为(2.30±0.85)mm(1.97～3.11 mm);水平段与鼓室天盖夹角(向后)为(28.5°±3.66°)(25.8°～31.5°);锥曲段的直径为(1.89±0.65)mm(1.56～1.88mm);锥曲段顶点到砧骨短脚尖的距离为(2.55±0.21)mm(2.10～2.90mm);到外半规管隆突的距离为(2.86±0.31)mm(2.23～3.56 mm);面神经垂直段近段的直径为(2.13±0.13)mm(1.90～2.40 mm);鼓索与面神经垂直段的夹角(向上)为(38.60±1.99°)(28.5°～52.5°);锥隆起尖到面神经垂直段的垂直距离为(2.05±0.65)mm(1.85～2.36 mm).结论 面神经易损伤区内的外半规管(水平半规管)隆突、砧骨短脚、匙突、鼓室天盖、镫骨、锥隆起、鼓索是乳突手术中的重要标志,其结构空间位置关系复杂,手术操作必须在熟悉显微解剖学知识的基础上进行.

Abstract：

Objective To study the microanatomy of the area in which the facial nerve being easy to damage in mastoid surgery, in order to provide microanatomical datas for the clinical works. Methods In 20 adult wet skull specimens (40 temporal bones), the segments of facial nerve and their adjacent structures in the area in which the facial nerve being easy to damage were observed according to operation of mastoid surgery. Results The length of the horizontal segment was (8.85 ± 1.01) mm (7.10-11.25 nun), the diameter was (1.88 ± 0.65) mm (1.55-1.90 mm); The angle opening towards anterior direction between horizontal segment and vertical segment was (115.50 ± 6.89°) (109.5°-128.6°); The vertical distance from the cochlearform process to this segment was (1.89 ± 0.58) mm (0.90-3.05 mm); The vertical distance from the midpoint of the base of stapes to this segment was (1.92 ± 0.52) mm (1.44-2.56 mm); The vertical distance from the head of the stapes to this segment was (2.30 ± 0.85) mm (1.97-3.11 mm); The angle towards posterior direction between horizontal segment of facial nerve and tympanic tegmen was (28.5°± 3.66°) (25.8°-31.5°); The diameter of the pyramidal segment of facial nerve was (1.89 ± 0.65) mm (1.56-1.88 mm); The distance between the su mmit of pyramidal segment of facial nerve and the apex of shor limb of incus was (2.55 ± 0.21) mm (2.10-2.90 mm); The distance from the su mmit to the eminence of the lateral semicircular canal was (2.86 ± 0.31) mm (2.23-3.56 mm); The diameter of the proximal part of vertical segment of facial nerve was (2.13 ± 0.13) mm (1.90-2.40 mm); The angle towards superior direction between verical segment of facial nerve and chorda tympani nerve was (38.60 ± 1.99°) (28.5°-52.5°); The vertical distance from the top of the pyramidal eminence to the vertical segment of the facial nerve was (2.05 ± 0.65) mm (1.85-2.36 mm). Conclusions The eminence of the lateral semicircular canal, short limb of incus, cochlearform process, tympanic tegmen, stapes, pyramidal eminence, chorda tympani nerve in the area are important landmarks to be located in mastoid surgery. The anatomic relations in this area are complicated and compact. Anatomical knowledge is very important to the surgery of this area.     

New laparoscopic approach to the pudendal nerve for neuromodulation based on an anatomic study

AIMS

The aim was to develop a new laparoscopic technique for placement of a pudendal lead.

METHODS

Development of a direct, feasible and reliable minimal‐invasive laparoscopic approach to the pudendal nerve (PN). Thirty‐one embalmed human specimens were dissected for the relevant anatomic structures of the pelvis. Step‐by‐step documentation and analysis of the laparoscopic approach in order to locate the PN directly in its course around the medial part of the sacrospinous ligament and test this approach for feasibility. Landmarks for intraoperative navigation towards the PN as well as the possible position of an lead were selected and demonstrated.

RESULTS

The visible medial umbilical fold, the intrapelvine part of the internal pudendal artery, the coccygeus muscle and the sacrospinous ligament are the main landmarks. The PN traverses the medial part of the sacrospinous ligament dorsally, medially to the internal pudendal artery. The medial part of the sacrospinous ligament has to be exposed in order to display the nerve. An lead can be placed ventrally on the nerve or around it, depending on the lead type or shape.

CONCLUSIONS

A precise and reliable identification of the PN by means of laparoscopy is feasible with an easy four‐step approach: (1) identification of the medial umbilical fold; (2) identification of the internal iliac artery; (3) identification of the internal pudendal artery and incision of the coccygeus muscle (‘white line’, arcuated line); and (4) exposition of the medial part of the sacrospinous ligament to display the PN.     

经单鼻孔-蝶窦入路显微手术切除垂体腺瘤的解剖学研究

目的 为临床经单鼻孔-蝶窦手术入路切除垂体腺瘤提供解剖资料.方法 取成人尸头湿标本20例,在显微镜下进行显微解剖观察和测量.结果 (1)90%的鞍膈孔大于5 mm,鞍膈平均厚度为(0.18±0.08)mm;(2)85%的蝶窦为全鞍型,85%的蝶窦有中隔,18.8%的蝶窦中隔居中;(3)鞍底厚度平均为(0.81±0.34)mm,70%小于1 mm,15%的鞍底外形为平坦;(4)颈内动脉在蝶窦壁形成隆起占45%,无隆起占55%,隆起位于蝶窦侧壁后上方.视神经管在蝶窦壁形成隆起占72.5%,无隆起占27.5%,隆起位于蝶窦侧壁前上方;(5)前海锦间窦、下海绵间窦和后海绵间窦出现率分别为80%、25%和15%.结论 熟悉蝶窦及鞍区解剖结构有助于经单鼻孔-蝶窦手术入路术中安全切除垂体腺瘤.     

尺神经深支的影像解剖

目的 通过对尺神经深支进行显微解剖和影像学研究,为腕掌部尺神经深支损伤的早期诊治提供影像学和解剖学依据. 方法 自2008年10月至2010年8月,在16侧成人防腐上肢和4侧成人新鲜上肢标本上,以钩骨钩中点为原点0,在手掌平面建立X、Y坐标轴,尺神经深支与X轴交点到原点的距离为OE;X轴与钩骨钩基底部尺侧界的交点到原点的距离为OF;Y轴与远端尺神经深支的交点到原点的距离为OG,与近端尺神经深支的交点到原点的距离为OH,钩骨钩尺侧界与尺神经深支的距离为EF.确定第2～5掌骨远侧缘及近侧缘掌侧面中心点,分别经两中心点作矢状面,观测尺神经深支与矢状面上各掌骨的相关长度.将硫酸钡(Ⅱ型)干混悬剂均匀涂于尺神经深支表面,进行CT扫描观测,所得的数据采用SPSS 13.0统计包进行分析. 结果 OE为(4.96±0.11)mm,CT结果为(5.02±0.12)mm;OF(3.69±0.12)mm,CT结果为(3.75±0.12)mm;OG(10.55±1.07)mm,CT结果为(10.48±0.84)mm; OH (7.23±0.85)mm,CT结果为(7.29±0.84)mm;EF (1.27±0.15)mm,CT结果为(1.17±0.16)mm.同时对尺神经深支与矢状面掌骨进行了相关测量和CT测量.每组数据的解剖学结果与CT结果经t检验,差异无统计学意义(P＞0.05). 结论 解剖学和CT影像学结果差异无统计学意义,CT影像学结果可直接作为临床参考值.解剖和影像结果对临床诊治尺神经深支伤病具有指导意义.