颅颈交界区肿瘤的手术治疗

由于颅颈交界区解剖复杂，对于生长在延颈髓腹外侧的肿瘤，手术难度较大，有一定的危险性，我科自2002年以来共收治该类病人5例，取得满意效果，报告如下：     

颅颈交界区的显微外科立体应用解剖学研究

目的 探讨颅颈交界区各解剖结构之间的对应关系及立体结构框架,为后颅窝手术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,按颅颈交界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、寰椎横突外侧端,枕骨大孔后缘中点在颅颈交界区是重要的解剖学标志,椎动脉V2段寰枢椎间段、V3...     

内镜下经口入路颅颈交界区前方椎动脉的解剖学研究

目的:研究颅颈交界区前方椎动脉走行及其与周围结构的解剖关系,为内镜下经口入路处理颅颈交界区病变时防止椎动脉损伤提供解剖学依据.方法:选用4例完整成人头颅标本进行解剖研究.在显微镜和内镜下自咽后壁开始对颅颈交界区进行逐层解剖,重点对椎动脉走行特点进行观察.选取31例接受颅颈交界区CTA检查的成人影像资料,在CT机上进行颅颈交界区骨性结构及椎动脉的重建,在CT轴位片上测量各节段椎动脉距中线的距离,并对测量结果进行分析.结果:内镜经口入路手术中骨性解剖标志与椎动脉的确认有密切关系;在枢椎节段椎动脉走行变异最多,部分隐藏于枢椎侧块内.本项研究提出枢椎外侧三角概念,三角形的3个点均为恒定的骨性解剖标志.在颅颈区CTA重建片上观察,31例62侧中有41侧(66%)椎动脉在该三角内,21侧(34%)在三角外,进入三角内的椎动脉均集中在该三角的外侧角,未进入该三角内的椎动脉有14侧进入枢椎侧块内,进入侧块内的椎动脉总侧别数在55侧(89%).结论:内镜经口入路处理枢椎病变时要避免损伤隐藏在枢椎侧块内的椎动脉.此区域手术前必须行CTA以明确椎动脉的具体走行.     

远外侧经髁入路处理脑干腹侧枕骨大孔区及颅颈交界区肿瘤

远外侧经髁入路又称枕下远外侧入路,最外侧经扰骨髁——颈结节入路,枕下后外侧入路等。脑干腹侧,枕骨大孔区前缘及颅颈交界区肿瘤手术难度很大,而远外侧经髁入路能够更好地显露和切除斜坡下端和扰骨大孔前缘的肿瘤,从而减轻对小脑和脑干的牵拉。 1.历史回顾     

Cobra枕颈内固定系统结合Halo-vest治疗颅颈交界区畸形效果

背景：枕颈部后路融合能够解除脊髓压迫并能让失稳枕颈部重新早期获得稳定。解剖型设计的Cobra系统对失稳的枕颈区提供坚强的内固定,结合Halo-vest外固定,具有固定,复位,利于植骨融合的作用。 目的：观察Cobra枕颈内固定系统结合Halo-vest在治疗颅颈交界区畸形枕颈融合术中的应用,并评价其临床疗效。 方法：对34例颅颈交界区畸形患者行术前术中牵引复位固定,固定后依患者耐受情况决定保留或去除Halo-vest等针对性治疗。根据JOA评分对患者神经功能恢复进行评估;根据尹庆水等制定的方法计算神经功能改善率。内固定后3,6,12,24个月摄颈椎正侧位X射线平片、CT及三维重建,以判断内固定和植骨融合情况,对部分患者同时行MRI检查以明确颈脊髓减压情况。 结果与结论：34例患者均获随访,随访时间7~29个月。内固定后未出现脊髓症状加重病例。内固定前JOA评分平均8.2分,内固定后平均14.8分;脊髓功能平均改善率为75%;1例并发脑梗死死亡。内固定后6个月复查,2例患者植骨块部分吸收骨不连,2例患者枕骨板螺钉出现松动,1例螺钉脱出,1例切口不愈合。10例患者术后继续Halo-vest外固定,并于内固定后三四个月拆除;其余患者佩戴颈托至植骨完全愈合。提示Cobra枕颈内固定具有良好的生物力学稳定性,配合Halo-vest便于术中固定和复位,适用于颅颈交界区畸形的治疗。     

经口、咽入路处理颅颈交界区病变的应用解剖

目的为延髓及颈脊髓上段中线腹侧病变切除提供解剖学资料。方法1.成人完整颅骨200个,测枕骨基底部的长、宽和厚;2.在10具成人头部标本,保留颅后窝硬脑膜,各脑神经根和血管,观察其位置及毗邻;3.20具成人头部正中矢状断面标本,观察经鼻咽部进入颅腔和椎管的层次结构;4.5具头标本经口、鼻咽部逐层解剖至脑干下段及颈脊髓上段,观察两侧椎动脉,基底动脉、静脉和各脑神经根。结果1.枕骨基底部平均长(27.9±2.4)mm,平均宽(20.3±2.6)mm,平均厚(10.0±0.5)mm;2.经解剖后详述了此入路的各层结构。结论经口、咽入路适合颅颈交界区中线和骨窗范围的病变切除。     

内镜下经鼻颅颈交界区腹侧手术的应用解剖

目的:为内镜下经鼻颅颈交界区腹侧手术提供解剖学依据.方法:20具经10%福尔马林固定之完整成人头颈标本,解剖观察经鼻至颅颈交界区手术入路的解剖学特点.确立手术标志,并测量与经鼻入路相关的解剖数据.新鲜完整头颈部标本5例.模拟手术.结果:内镜经鼻颅颈交界手术的手术标志包括:中鼻甲、后鼻孔、咽鼓管咽口、鼻咽部粘膜、头长肌和颈长肌、枕骨大孔前缘中点、寰椎前结节.经鼻入路完全暴露颅颈交界区,最短距离为(89.75±2.80)mm;蝶窦前下壁和下斜坡磨除范围分别以两侧翼管和破裂孔为界,各自为距中线(9.37±0.59)mm和(10.75±0.63)mm;寰枢椎处,椎动脉在枢椎下缘距正中线距离最短,为(15.70±2.12)mm;左侧寰枢椎处颈内动脉距中线距离大于右侧(P<0.05).结论:内镜经鼻入路可充分显露颅颈交界区腹侧结构.     

经下颌下咽后入路颅颈交界腹侧区手术的应用解剖

目的:为临床经下颌下咽后入路处理颅颈交界腹侧区病变提供解剖学基础。方法:对15例(30侧)带颈头颅标本模拟经下颌下咽后入路进行显微外科解剖,同时进行了有关的数据测量。结果:该入路浅层的重要结构均位于各自的筋膜层中,以这些结构为解剖学标志可鉴别各层并引导手术进行。咽结节是显露的上限,限制骨窗侧方显露范围的各重要结构的内缘距正中线的水平距离分别为寰枢外侧关节,左(7.78±1.03)mm,右(7.81±1.01)mm;寰枕关节,左(9.27±1.86)mm,右(9.22±1.69)mm;舌下神经管内口,左(12.76±2.77)mm,右(12.81±2.53)mm及椎动脉C2水平,左(18.36±2.27)mm,右(18.47±2.14)mm;C1水平左(25.35±2.31)mm,右(25.18±2.33)mm;穿硬膜处,左(12.69±2.42)mm,右(12.72±2.39)mm。结论:(1)经下颌下咽后入路解剖上大致可分为3个层次:浅层,深层和骨、韧带及硬膜层。(2)掌握每个层次的解剖特点及操作要点,有助于安全充分的显露和处理咽颅颈交界腹侧区病变。     

内镜下经口咽入路至颅颈交界应用解剖学研究

目的研究内镜下经口咽入路至颅颈交界区域局部解剖学并测量相关解剖数据,为临床手术提供形态学数据。方法交替使用手术显微镜和0°、30°硬质内镜研究10例成人尸头,探讨经口咽至颅颈交界手术入路;测量与入路相关的60具成人颅骨标本数据。结果该入路的定位标志,即“路标”主要为寰椎前结节、齿突、咽结节、枕骨大孔前缘、IX～Ⅻ对脑神经、椎动脉及其分支、延髓等;沿途“路标”构成该入路的操作路线图。结论(1)解剖数据对于临床手术具有参考价值;(2)应用不同角度的内镜,仅切开软腭足以达斜坡下部至第2颈推的范围,应用特殊手术器械可完成上述区域病变的治疗。     

首例中国数字化可视人体脊柱区颈段的三维重建研究

目的 建立中国数字化可视人体男性脊柱区颈段的三维可视化模型。方法 应用首例中国数字化可视人体数据集，选取从寰椎上缘到第7颈椎下缘的连续横断面图像。在SGI工作站上对颈椎、脊髓、椎动脉、椎间盘、颈神经等结构进行计算机三维重建并立体显示。结果 建立了脊柱区颈段重要结构的三维可视化模型，重建后的结构可多彩色立体显示，既能单独显示，也能任意搭配或总体显示，可在三维空间位置上绕任意轴旋转任意角度观察。结论 脊柱区颈段的可视化数字模型，用三维图形方法显示该区结构的空间构形，将有助于解剖学教学，并可为颈部疾病的影像诊断和外科手术等提供参考。     

翼腭窝区的高分辨力CT三维重建

目的:探讨高分辨力CT(HRCT)三维重建技术在翼腭窝区的应用价值,为临床该区疾病诊断及手术方案设计提供影像解剖学资料。方法:对10例健康志愿者行HRCT扫描后,利用多平面重组(MPR)和遮盖表面显示法(SSD)三维重建技术显示翼腭窝区骨性结构。结果:HRCT扫描及MPR重建图像清晰显示翼腭窝及其通道在横断面、冠状面及矢状面上的形态特征,SSD重建图像能满意显示翼腭窝区骨性结构的立体解剖及与周围结构的空间位置关系。结论:HRCT轴位扫描与MPR、SSD相结合可直观、立体、清晰地显示翼腭窝区结构。     

导航联合内镜辅助远外侧入路的解剖学研究

目的　探讨导航联合内镜辅助远外侧入路的可行性及对颅颈交界区腹侧解剖学特点的观察。 方法　对6例（12侧）尸头标本模拟远外侧入路,分别用显微镜、0度和30度内镜观察,随后磨除后内侧1/3枕髁和颈静脉结节,再次用显微镜观察（其中内镜下观察和磨除颅底骨性结构均在导航引导下完成）,比较这四种方式对颅颈交界区腹侧显露的差异。 结果　导航联合内镜能够通过面听神经、后组颅神经组成的上、中、下3个间隙近距离观察颅底结构,还能观察被颈静脉结节和枕髁遮挡的神经血管,与远外侧经髁入路显露范围相似。 结论　在内镜和神经导航辅助下,远外侧入路能够良好的观察颅颈交界区腹侧的神经血管结构,避免磨除颈静脉结节和枕髁,减少手术创伤。     

The supraodontoid space or "apical cave" at the craniocervical junction: a microdissection study

The extradural supraodontoid space lies anteriorly at the craniocervical junction (CCJ) between the alar ligaments and foramen magnum. It occupies the space between the tectorial and atlanto-occipital membranes. A variety of benign and traumatic lesions may result in neurological compression here with harmful effects. Decompression by the transoral surgical approach often provides relief from these effects. Knowledge of the detailed microanatomy of this space is fragmentary. The purpose of this study was to identify the boundaries and contents of this space by microdissection. Twenty-three en bloc preserved adult cadaveric specimens of the CCJ were dissected to identify the boundaries and contents of the supraodontoid space. The posterior bony elements of the CCJ were removed to enable microdissection (Zeiss DXE Microscope 4-40x) from the tectorial membrane (TM) forwards. The cave-like space faced posteriorly. It had a roof which extended into a wall (anterior atlanto-occipital membrane), a floor (superior surface of the alar ligament), and a mouth covered by the TM. The apical ligament and a thin lining membranous fatty layer divided the cave into a pair of symmetrical halves. The contents, from dorsal to ventral, lay deep to a thin subtectorial membrane. These were the superior fasciculus of the cruciate ligament, a fat-ensheathed knot of plexiform veins (which communicated with the surrounding CCJ vertebral venous plexuses), an arterial arcade between the veins, a pair of fat pads, and branches of the sinuvertebral nerves of the CCJ (lying on the floor). No synovial membrane was found. Knowledge of the anatomy of the apical cave may be of some assistance in transoral (extra- and transdural) surgical approaches to the anterior CCJ region.     

Development and growth of the craniocervical junction with special reference to topographical relationship between the occipital basion,the anterior arch of atlas,and the odontoid process of axis: A study using human fetuses

The embryonic occipital bone and odontoid process of the axis are attached and connected by the notochord, but become separated in later development and growth. With special attention to the process of separation, we examined sagittal sections of the craniocervical junction in 18 human fetuses at 8–16 weeks and 22 fetuses at 31–37 weeks. At 8–9 weeks, the anterior arch of atlas was always seen overriding the occipital basal part. The odontoid process was close to the occipital with or without a transient joint cavity until 16 weeks. Near term, the top of the odontoid process was usually higher than the anterior arch, but the former was sometimes (7 of 22) at a level almost equal to or lower than the latter. The apical ligament was evident in a few specimens (5 of 22). A distance between the occipital basion and odontoid process was sometimes less than 1.5 mm (8 of 22) or less than half the thickness of the arch (10 of 22). A transient joint cavity between the basion and odontoid process was often (10 of 22). In three fetuses near term, the atlanto-occipital joint cavity was continuous with the median atlanto-axial joint cavity, and the anterior arch was overriding the occipital basal part. Therefore, rather than stage or age, individual differences were evident in the topographical relationship between the three bony elements at the craniocervical junction. An understanding of the embryology and normal development will aid in the correct interpretation of radiologic images of the pediatric cervical spine.     

大鼠视神经内微血管的三维构筑

目的:研究大鼠视神经内血管分布规律.方法:用10%明胶-墨汁混合液经心灌注SD大鼠后取出其视神经,OCT包埋,20μm连续切片,Olympus图像处理系统拍照,用Photoshop 9.0 cs对图像进行处理并用Image-J软件进行分析.用Amira 3.1.1软件将二维切片图像重建成三维可视化图像.结果:三维重建及图像分析显示大鼠视神经内血管围绕神经束排列,球后0～5 mm、5～8 mm、8 mm至视交叉的视神经内血管网形度大于0.5的百分比分别为(55.5±2.7)%、(67.4±4.6)%、(76.8±1.7)%.结论:大鼠视神经内的微血管数量多,走行变化大,从球后到视交叉沿视神经轴由横行逐渐变为纵行.     

Three-dimensional reconstruction of the luminal structure of human seminal vesicle

The seminal vesicles are the glands of male reproductive organs that produce the fluid and nutrient constituents of semen. It has been believed for a long time that the lumen of a seminal vesicle was a single-coiled tubular structure with irregular diverticula. There are several previous reports on the symmetry, differences in morphological sizes and classification of the seminal vesicles. However, a three-dimensional-coiled tubular structure is difficult to understand using a classical anatomical methodology, and hence, three-dimensional reconstruction is needed to understand the structure of the lumen. Thirty-one seminal vesicles harvested from 21 formalin-embalmed cadavers were investigated. The seminal vesicle along with the ampulla of the ductus deferens was separated, and the length and width of each seminal vesicle were measured. The vesicles were then embedded in coloured paraffin, and the resulting paraffin block was sectioned transversely and photographed at an interval of 500 μm, with the sectioned surfaces then utilized in three-dimensional reconstruction performed by ‘Reconstruct’ software. The mean length and width of the seminal vesicles were 39.4 mm and 13.4 mm, respectively, and the right seminal vesicle was a little larger than the one on the left. The size differed from previous reports, while the luminal structure was similar to the classification of Aboul-azm (Archives of Andrology, 3, 1979, 287–292) but differed from that of Pereira (AJR. American Journal of Roentgenology, 69, 1953, 361–379). The seminal vesicles typically comprised about 9 curls and had about 12 diverticula. The seminal vesicles resembled a skein of coral rather than comprising a single strand. These findings will help in improving the understanding of pathophysiologies of the seminal vesicles, such as recurrent inflammation of the gland.