颅底手术入路和应用解剖学研究进展

颅底手术入路和应用解剖学研究进展姜平①童鑫康②综述肿瘤和其它病灶有可能侵及颅底。颅底及其邻近区为脑、脊髓、脑神经、大血管和特殊感受器集中的部位，各结构解剖关系复杂，功能重要，位置又非常深在，术中稍有不慎便可造成某些结构损伤，甚至导致患者死亡，所以长期...     

面部组织移位入颅底手术的临床解剖学研究

目的：为面部移位颅底手术入路提供解剖学基础。方法：在３６侧成人头面部标本上，对面神经、腮腺管的位置和层次进行了观察与定位。结果：①面动脉在眶下缘水平至鼻旁间距为９．９±５．０ｍｍ，至骨膜的深距为２．１±０．８ｍｍ；②面神经由茎乳孔出颅后，经腮腺、咬肌和颊区三段分布于面肌。在咬肌段，面神经紧贴咬肌表面行走，面神经颧支行于颧骨表面，至骨面的最小深距为１ｍｍ。结论：①旁正中切口不会影响面动脉；②掀翻面肌皮瓣时，颧骨表面和咬肌表面的面神经分支是易损伤区     

颅底后外侧立体应用显微解剖学研究

目的探讨颅底后外侧区各解剖结构之间的对应关系及立体结构框架,为颅底侧方入路提供相应的解剖学数据及资料。方法10例(20侧)成人带颈头颅标本,按颅底后外侧区解剖层次进行解剖和观测,同时对相应区域进行测量,并做统计学分析。结果乳突、茎突、星点、横窦、乙状窦、寰椎横突外侧端在颅底后外侧入路中是重要的解剖学标志,椎动脉V2段寰枢椎间段、V3段及围绕椎动脉的静脉丛在该手术中应注意保护,本实验进一步确定了各重要骨性标志的定位及相关重要结构之间的距离。结论该区域中以乳突为圆点、以星点为中心各解剖结构的测量、椎动脉重要区段的观测可有效而安全地保护重要结构,避免损伤重要的血管及神经。     

颞下经下颌入路显露侧颅底区的应用解剖学研究

目的研究颞下经下颌入路应用解剖,为术中保护重要结构提供解剖学参考。方法选用成人尸头10例(20侧),摹拟手术入路,解剖观察、测量相关结构,探求入路涉及的骨、肌肉和神经血管间的解剖关系。结果影响该入路暴露的主要结构包括面神经、腮腺、颧弓和下颌升支。颞下窝和翼腭窝血管神经丰富,茎突及其筋膜将咽旁间隙分为咽旁前和咽旁后间隙,后者容纳颈内静脉、颈内动脉和Ⅸ、Ⅹ、Ⅺ及Ⅻ对脑神经。结论颞下经下颌入路暴露充分,熟悉其应用解剖对手术治疗侧颅底区沟通性肿瘤具有重要意义。     

与颅底外科手术入路有关的应用解剖

以Ｆｒａｎｋｆｕｒｔ平面为基准，绘制测量了１００例头部标本。从颞下区、颞骨岩部前、后缘确定Ａ、Ｂ、Ｃ三条平行的定位线。Ａ与Ｂ线之间为７．１±１．２ｍｍ，Ｂ与Ｃ线之间为１１．９±１．７ｍｍ。并测量各组由外向内的深度，Ａ线为１８．５±１．８ｍｍ，Ｂ线３０．２±２．８ｍｍ，Ｃ线４２．５±３．４ｍｍ。并由浅入深测量了每条线内各结构间的距离。结果提示定位线不仅有助于各结构的定位，而且也是颅底分区的自然界线。手术应以定位线为基推选择入路的方向，由浅入深层层定位，也可在任何方位下以此为依据定出所见结构的区域或方位。     

枕下极外侧入路应用解剖学探讨及手术体会

目的探讨枕下极外侧入路切除延颈交界区腹侧病变的效果,并对一些手术技巧加以讨论。方法在10例成人尸头上模拟枕下极外侧入路进行延颈交界区腹侧局部显微解剖探讨,观测延颈交界区有关结构。采用枕下极外侧入路对26例延颈交界区腹侧及腹外侧病变进行手术治疗。结果本组26例患者,9例痊愈,17例好转。14例肿瘤全切除,12例次全切除。全组无手术死亡。术后并发症包括面瘫2例,后组脑神经轻度麻痹1例,脑脊液漏1例。结论枕下极外侧入路可以满足延颈交界区腹侧及腹外侧病变手术野的显露,是切除该部位病变的一种有效的手术方法。     

前颅底手术入路应用解剖

目的：为前颅底手术的前方入路和眶外侧入路提供相关的解剖依据。方法：通过对４０例颅骨的测量，确定鼻根点和眶额颧点至前颅底上下方各结构的距离和夹角。结果：鼻根点至视交叉沟前缘、视神经管颅口、颈内动脉沟前端、蝶骨小翼后缘、筛前孔和筛后孔的距离分别为（４９．７±２．７）ｍｍ、（４９．９± ２．６）ｍｍ、（５３．５ ± ２．３）ｍｍ、（５１．３ ± ３．０）ｍｍ、（２５．３ ± ２．２）ｍｍ、（３３．０ ± ２． ２）ｍｍ；眶额颧点至盲孔、视神经管颅口、眶上裂内、外端和眶下裂内、外端的连线长度和各连线与正中矢状面成角分别为（４８．０±２．２）ｍｍ和９１．０°±３．０°、（５２．５±２．９）ｍｍ和４３．６°±３．５°、（５１．０±２．２）ｍｍ和４０．４°±４．２°（３４．５±２．７）ｍｍ和３６．６°±５．７°、（５０．３±２．３）ｍｍ和３７．８±４．３°、（２５．８±２．３）ｍｍ和２４．７°±３．３°。结论：两种手术入路有关测量结果，有助于手术入路设计，并可为术中准确定位有关结构提供参考依据。     

颅底应用解剖学研究的现状

随着80年代以来颅底外科的进步,颅底应用解剖研究也得到了重视和发展,它是颅底外科与局解结合的产物。 1 颅底手术禁区的不断突破有赖于医学新技术的发展 颅底是人体最复杂的区域之一。颅底骨壁厚薄不一,众多的孔、管、裂、缝通过大量的神经血管,重要结构多且细小,毗邻关系复杂。从临床上看,颅底病变与颅内外病变可互相波及,而颅底是脑外科、眼科、耳鼻喉科及颌面外科研究对象的交界部位,因此在颅底外科形成之前,各科从各自的侧面涉及到颅底。然而由     

经后外侧入路治疗胫骨平台后外侧骨折的解剖学研究及应用

目的为经膝关节后外侧入路治疗胫骨平台后外侧骨折提供解剖学基础。方法 (1)福尔马林浸泡的防腐成人下肢标本20例,解剖观察并测量与膝关节后外侧入路相关的主1要血管、神经的走行特点,膝关节后外侧主要肌肉、韧带的分布。(2)新鲜冷藏下肢标本4例,按照设计的入路进行模拟手术,评估该入路的可行性。(3)在解剖学研究的基础上,临床应用12例,观察该入路的临床效果。结果膝关节后外侧入路的手术切口全长均不经过腓总神经主干;深层经腓肠肌外侧头外侧和比目鱼肌肌间隙分离,保护了内侧的血管神经束;胫前血管在腓骨头下方(4.15±0.36)cm处自腘动脉发出,影响了远端的显露,但足够复位固定简单的后外侧骨折。临床应用12例,均取得了满意的疗效。结论经膝关节后外侧入路治疗简单的胫骨平台单纯后外侧骨折具有安全,损伤小,暴露充分,临床效果良好等优点,有一定的推广价值。     

经颅底扩大翼点入路切除颅底肿瘤

目的:经颅底扩大翼点入路开颅术是将翼点开颅术向颅底方向的进一步扩大,包括眶上翼点入路、颧弓翼点入路和眶翼弓入路。本文探讨该入路的手术方法和适应证。方法:经扩大翼点入路切除颅底肿瘤30例。观察术中显露情况及手术效果,并就该入路的手术方法和适应证进行探讨。结果:所有病例术中病灶显露良好,无1例出现脑牵拉损伤。肿瘤全切除25例,次全及大部分切除5例。术后死亡1例,其余病例均无严重并发症。结论:经扩大翼点入路切除颅底肿瘤具有显露好、脑牵拉轻的优点,适用于中颅底、鞍旁肿瘤、颅眶沟通瘤及部分自中颅底向后颅底或颅外生长的肿瘤。     

Microsurgical anatomy of the cranial nerve-centric triangles of the posterior cranial base: cadaveric and radiological anatomical study

Anatomical Science International - Tumors in the posterior fossa can be situated either dorsal and lateral, ventral and medial, or occupying both regions in relation to the cranial nerves, with the...     

经海绵窦脑神经的显微外科解剖及其临床意义

目的 :了解与海绵窦相关的脑神经走行及其周围结构的显微解剖关系 ,为经该区的直接显微手术提供依据。方法 :用 30例成人头颅标本 ,在手术显微镜下对海绵窦内脑神经 (CN)及周围结构直接进行解剖观察和测量。结果 :经海绵窦的脑神经在后面大多在外侧壁 ,较易分辨 ,Parkinson切口前限可从动眼神经入口平面延长到前床突 (ACP)尖平面。脑神经向前则行走于ACP下缘 ,经床突间隙 (CS)入路磨除ACP时极易损伤 ,其中以动眼神经和滑车神经距离最近 ,在ACP根部 ,动眼神经和滑车神经均紧贴ACP根部底层硬膜入眶 ,距离分别只有 (0 .64± 0 .2 2 )mm (0 .2 6～ 1 .0 8mm)和 (0 .55± 0 .0 6)mm (0 .1 6～ 0 .96mm)。结论 :为途经海绵窦外侧壁手术入路和经CS手术磨除ACP时避免损伤脑神经提供了显微解剖学资料。     

The middle cranial fossa approach: an anatomical study

Hearing preservation surgery has become an option for an increasing number of patients with vestibular schwannomas due to diagnosis at an earlier stage. The middle cranial fossa approach represents one such surgical approach for resection of vestibular schwannomas with hearing preservation. We have undertaken an anatomical study of the middle cranial fossa approach to the internal auditory meatus using 20 fresh temporal bones. By simulating the surgical approach it was possible to analyze critically two of the main recognized subapproaches to the internal acoustic meatus. The results confirmed that the angle subtended by the facial nerve and "blue-lined" semicircular canal was much less than 60 degrees but equally important was the degree of individual variability. Furthermore the roof of the geniculate fossa was not infrequently dehiscent. The distance measured from the inner table of the craniotomy to the superior semicircular canal was on average 22 mm, similar to previous reports and utilized by some in their approach in this challenging surgery. From this anatomical study it appears that safe dissection of this area is facilitated by observing the more acute angle between the facial nerve and superior semicircular canal and by taking advantage of the relationship between the inner table and important landmarks.     

The middle cranial fossa approach: an anatomical study

Hearing preservation surgery has become an option for an increasing number of patients with vestibular schwannomas due to diagnosis at an earlier stage. The middle cranial fossa approach represents one such surgical approach for resection of vestibular schwannomas with hearing preservation. We have undertaken an anatomical study of the middle cranial fossa approach to the internal auditory meatus using 20 fresh temporal bones. By simulating the surgical approach it was possible to analyze critically two of the main recognized subapproaches to the internal acoustic meatus. The results confirmed that the angle subtended by the facial nerve and "blue-lined" semicircular canal was much less than 60° but equally important was the degree of individual variability. Furthermore the roof of the geniculate fossa was not infrequently dehiscent. The distance measured from the inner table of the craniotomy to the superior semicircular canal was on average 22 mm, similar to previous reports and utilized by some in their approach in this challenging surgery. From this anatomical study it appears that safe dissection of this area is facilitated by observing the more acute angle between the facial nerve and superior semicircular canal and by taking advantage of the relationship between the inner table and important landmarks. The French version of this article is available in the form of electronic supplementary material and can be obtained by using the Springer Link server located at http://dx.doi.org/10.1007/s00276-002-0076-8. Résumé. Une chirurgie avec conservation de l'audition est devenue une option possible pour un nombre croissant de patients porteurs d'un schwannome vestibulaire du fait d'un diagnostic plus précoce, à un stade moins évolué. La voie de la fosse cérébrale moyenne représente une possibilité d'abord chirurgical en vue d'une telle exérèse du schwannome vestibulaire avec conservation de l'audition. Nous avons entrepris une étude anatomique de la voie de la fosse cérébrale moyenne vers le méat acoustique interne sur 20 rochers frais. En simulant l'abord chirurgical, il a été possible de faire une analyse critique de deux des principales variantes admises de cet abord du méat acoustique interne. Les résultats confirment que l'angle limité par le nerf facial et la ligne bleue du canal semi-circulaire supérieur fait beaucoup moins de 60 degrés mais que la variabilité individuelle est aussi très importante. Par ailleurs, le toit de la fosse du ganglion géniculé était déhiscent de façon non exceptionnelle. La distance mesurée depuis la table interne de la craniotomie jusqu'au canal semi-circulaire supérieur était en moyenne de 22 mm, comparable à celles rapportées auparavant et utilisées par certains lors de leur approche dans cette chirurgie assez difficile. De cette étude anatomique, il ressort que la dissection sûre de cette région est assurée par la prise en compte de l'angle plus aigu entre le nerf facial et le canal semi-circulaire supérieur et en profitant des rapports entre la table interne et des repères importants.     

前列腺增生腺体的局部解剖观察和临床应用

目的：了解认识前列腺增生腺体的局部解剖结构,改进治疗前列腺增生的手术方式。方法：解剖观察10例耻骨上经膀胱前列腺剜除术的完整标本,在标本上模拟设计尿道外增生腺体摘除的手术方法,在12例实际手术中验证方法。结果：10例标本的尿道起始部与增生腺体前上部分腺体之间存在一隐窝,是两侧增生腺体前面的内侧缘弧线形相交形成的夹角区域,为无增生腺体覆盖的三角形尿道裸区,由这一区域分离尿道与增生腺体,可将增生腺体解剖为外层包绕的薄层组织和两侧增生腺体的主体,并由增生腺体中完整分离出尿道,予以完整保留。实际手术中,12例尿道外全部摘除增生的腺体,完整保留尿道,2例尿道有小的纵行裂口。结论：前列腺存在一个无增生腺体覆盖的尿道裸区,利用这个解剖标志可建立一种新的彻底摘除前列腺增生腺体并保留尿道手术的方法。     

The innervation of patella: anatomical and clinical study

As much interest has been focused on afferent innervation of knee than that of patella, there are few articles about patellar innervation. But in clinical practice anterior knee pain due to patellar disorders is a quite frequent problem. Our aim was to review the innervation pattern of patella and to give the topographic anatomy of the nerves. We dissected 30 knees of 15 formaldehyde-fixed cadavers. Two nerves from vastus medialis and lateralis were found to reach patellar edge. Apart from these, we were unable to find any other neural structures around patellae. Mean distances between the tuberosity of the tibia and medial and lateral nerve entry points were 90.1(range 74–102) and 96.3 mm (range 76–109), respectively. The angles between lines which join the entry points of nerves and vertical line to the center point of patella were measured in frontal plane. It was approximately 60° medially and 40° laterally. To confirm that these nerves are patellar pain afferents, we performed a local anesthesia test in 32 knees of 20 patients with patellofemoral pain. Clinically, there was a significant difference between the visual analogue scale (VAS) scores before and after local anesthetic injections (p<0.01). Previous studies have emphasized especially the medial innervation. We found that both superomedial and superolateral nerves were important for patellar innervation. We described precisely the entry points of these nerves to patella for selective denervation.     

侧颅底的横断层解剖及临床意义

目的为侧颅底病变的影像诊断及手术入路提供解剖学基础。方法选取成人尸体头颈部20例,沿眶耳线(OML)制成横断层解剖标本。在卵圆孔和咽隐窝层面上,观察侧颅底结构的解剖学关系,利用游标卡尺测量侧颅底内重要结构的径线及结构之间的距离。结果侧颅底横断层面可清晰显示卵圆孔、棘孔、耳蜗导水管、颈动脉管水平段、茎突等侧颅底结构及其毗邻关系和咽旁间隙、颞下间隙内的结构,是显示咽隐窝与咽旁间隙位置关系的最佳断层影像方式。茎突是侧颅底影像诊断及手术入路时观察各结构间位置关系、咽旁间隙分区和寻找神经、血管的骨性标志。两侧侧颅底结构呈对称性分布,重要结构的径线及结构之间的距离均无显著性差异。结论对侧颅底病变的影像诊断和设计手术入路等具有重要意义。     

Discomallear and malleomandibular ligaments: anatomical study and clinical applications

Phylogenesis, ontogenesis and anatomy show the existence of two discomallear and malleomandibular ligaments, arising from the first branchial arch and uniting the middle ear with the temporomandibular joint and to the mandible. The intra-articular discomallear ligament is the involuted tendon of the lateral pterygoid muscle on the primitive quadrato-articular joint. The malleomandibular ligament is the fibrous remnant of Meckel's cartilage. In the physiology of the temporomandibular joint, the discomallear ligament alone limits the anterior movement of the disc. Its stretching accompanies disco-condylar disunity, hyperlaxity and temporomandibular dislocation. The malleomandibular ligament, wrongly limited to its sphenomandibular part in classic anatomy, has no physiological role. However, it can be responsible for the dislocation of the ear ossicle chain after disarticulation or temporomandibular trauma. These two ligaments do not play any role in otological manifestations in dysfunction of the manducatory apparatus.     

内踝后穿支筋膜皮下瓣的解剖与临床研究

目的　介绍内踝后穿支筋膜皮下瓣的血管解剖基础与初步临床应用效果。 方法　解剖24侧新鲜下肢灌注标本,观察内踝后间隙内胫后动脉发出的穿支血管情况。临床切取内踝后穿支筋膜皮下瓣,翻转修复跟内侧创伤缺损5例。 结果　内踝后间隙长约4cm,前界为内踝及趾长屈肌腱,后方为跟腱,表面为深筋膜覆盖,间隙内有疏松脂肪组织。在内踝后间隙内走行的胫后动脉发出2~3条皮肤穿支血管,口径0.1～0.7 mm,一般小于0.5 mm,但数量恒定。内踝后穿支与上方的胫后动脉最远侧肌间隔穿支血管间有互补性,在筋膜表面和皮下组织中有丰富血管吻合。临床上以内踝后穿支血管为轴点（内踝最下缘上方1～2 cm）,设计切取远端蒂筋膜皮下瓣,面积5～6 cm×6～12 cm,修复5例跟骨开放性骨折的内侧创面,筋膜瓣均成活。 结论　内踝后穿支筋膜皮下瓣相对传统的肌间隔穿支血管组织瓣,其旋转轴点下移,减少小腿供区损伤,无静脉回流障碍,受区组织柔软活动度好,更适合修复足跟内侧的创面。