扩大的内镜下经鼻至斜坡腹侧区入路手术的相关解剖研究

Objective To define the exposure extent of the ventral part of the clivus under the extended endoscopic endonasal approach,important anatomical landmarks and the distance between each other via this approach.Methods Twenty formalin-fixed intact adult human head-neck specimens,in which only the arteries was injected with red latex,were longitudinally and coronally dissected to evaluate the surgical key steps and the advantages and limitations via extended endoscopic endonasal approach and selected measurements were obtained.Five fresh and intact head-neck specimens were used to perform analogical operation via the extended endoscopic endonasai approach to the ventral part of the clivus.The surgical exposure of main landmarks in the clivus was extended under endoscope and microscope,and the interactions and distances between the landmarks were studied.ResultsAnatomic landmarks of the approach included the middle turbinate,the choana narium,the Eustachian tube ostium,and the nasopharynx mucosa,the aperture of sphenoidal sinus,the longus capitis,the longus colli,the basion,the internal carotid artery and the sphenopalatine artery.The distances between the anterior nasal spine and both the pharyngeal tubercle and the basion were (78.23±2.58) mm and (89.60±2.52) mm,respectively.The shortest distance exposuring ventral region of clivus completely should be (89.60+2.52) mm.The exposure in the inferior wall of sphenoid sinus and the lower clivus was limited by pterygoid canal and foramen lacerum,and the average distances from the median line to them were (9.22±0.52) mm and (9.70±0.70) mm,respectively; no significant difference between the left and right was found (P>0.05).Conclusion knowing the anatomical structure,understanding its connection with the brain tissue and its exposure extent of the ventral part of the clivus are the major problems that need to be solved in the extended endoscopic endonasal approach.     

扩大的内镜下经鼻至斜坡腹侧区入路手术的相关解剖研究

Objective To define the exposure extent of the ventral part of the clivus under the extended endoscopic endonasal approach,important anatomical landmarks and the distance between each other via this approach.Methods Twenty formalin-fixed intact adult human head-neck specimens,in which only the arteries was injected with red latex,were longitudinally and coronally dissected to evaluate the surgical key steps and the advantages and limitations via extended endoscopic endonasal approach and selected measurements were obtained.Five fresh and intact head-neck specimens were used to perform analogical operation via the extended endoscopic endonasai approach to the ventral part of the clivus.The surgical exposure of main landmarks in the clivus was extended under endoscope and microscope,and the interactions and distances between the landmarks were studied.ResultsAnatomic landmarks of the approach included the middle turbinate,the choana narium,the Eustachian tube ostium,and the nasopharynx mucosa,the aperture of sphenoidal sinus,the longus capitis,the longus colli,the basion,the internal carotid artery and the sphenopalatine artery.The distances between the anterior nasal spine and both the pharyngeal tubercle and the basion were (78.23±2.58) mm and (89.60±2.52) mm,respectively.The shortest distance exposuring ventral region of clivus completely should be (89.60+2.52) mm.The exposure in the inferior wall of sphenoid sinus and the lower clivus was limited by pterygoid canal and foramen lacerum,and the average distances from the median line to them were (9.22±0.52) mm and (9.70±0.70) mm,respectively; no significant difference between the left and right was found (P>0.05).Conclusion knowing the anatomical structure,understanding its connection with the brain tissue and its exposure extent of the ventral part of the clivus are the major problems that need to be solved in the extended endoscopic endonasal approach.     

内镜下扩大经鼻蝶入路至斜坡区的解剖学研究

目的探索内镜下经扩大鼻蝶入路显露斜坡区的可行性,为切除斜坡区病变提供解剖学参考。方法在10例成人头部固定标本上,内镜下模拟扩大经鼻蝶手术入路显露斜坡区,观察有关显微解剖标志。结果扩大经鼻蝶内镜入路可磨除从鞍后到斜坡、枕骨大孔前缘的骨性结构;可显露斜坡区腹侧硬膜下的椎基底动脉及其分支、后交通动脉及其与大脑后动脉汇合处、动眼神经、脑干腹侧等结构。此入路的手术标志主要包括:蝶筛隐窝、蝶窦开口、视神经隆突、颈内动脉隆突与颈内动脉视神经隐窝、咽结节、枕骨大孔前缘。结论内镜下扩大经鼻蝶手术入路可充分显露鞍后-斜坡区的腹侧硬膜下结构,适用于此区病变的手术治疗。     

经鼻蝶入路至斜坡区的内镜解剖学研究

目的 通过对经鼻蝶入路至斜坡区的内镜解剖研究，为临床提供形态学依据。方法测量10例成人干颅骨标本的解剖数据；在10例经甲醛固定的成人尸头标本上模拟经鼻蝶手术入路，用内镜对斜坡区进行解剖观察。结果 前鼻棘至蝶窦口、鞍底、鞍结节中心、鞍背中心、颈动脉管、视神经管颅口和枕骨大孔前端的距离分别为（55．62±4．23）mm、（71．50±6．21）mm、（79．02±4．97）mm、（81．04±8．02）mm、（68．39±6．42）mm、（67．96±645）mm、（91．08±5．20）mm；以鼻腔底平面为基线，与上述结构之间矢状面夹角分别为（32．09±3．90）°、（31．34±6．02）°、（35．02±4．03）°、（34．65±3．23）°、（32．01±3．02）°（36．55±5．20）°、（39．04±8．02）°；卵圆孔、破裂孔、颈内动脉管外口、舌下神经管外口内侧缘距正中线的距离分别为（23．30±1．97）mm、（10．56±2．39）mm、（25．07±2．77）mm、（16．98±1．99）mm。经鼻蝶入路至斜坡区在内镜下硬膜外可显露从鞍底到斜坡、枕骨大孔的中线附近结构。在硬膜下可显露基底动脉分叉、动眼神经、脑干腹侧等结构。结论 内镜下行经蝶入路可良好显露鞍后-斜坡解剖结构，适用于鞍后-斜坡区病变的手术。     

内镜下扩大经鼻蝶入路海绵窦的解剖研究

目的通过内镜下扩大经鼻蝶入路海绵窦的解剖学研究,为海绵窦病变手术入路的选择提供解剖学依据。方法在10例成人头颅标本上模拟3种扩大经鼻蝶入路即鼻中隔旁入路、中鼻甲切除入路、中鼻道入路,观察各手术入路重要的解剖标志和显露范围。结果蝶窦开口、斜坡凹陷、颈内动脉隆起、视神经隆起、颈内动脉-视神经隐窝、翼管等为重要的手术标志。颈内动脉海绵窦段双弯曲型18侧,不典型弯曲型2侧。结论内镜下扩大经鼻蝶入路是海绵窦病变的重要入路。     

扩大经鼻入路至鞍上区的内镜解剖学研究

目的 研究内镜下扩大经鼻入路至鞍卜区域的解剖.方法 选用20例尸头标本,模拟神经内镜下扩人经鼻入路,显露至鞍上区域,研究其周围解剖.结果 提出蝶安腔骨性后壁解剖学分区方法,描述视交叉上间隙、视交叉下间隙和眼动脉三角等解剖学慨念及其临床意义.结论 神经内镜下扩大经鼻人路可以较好地显露鞍上区域.     

内镜下经鼻扩大蝶窦入路至鞍上区的解剖及临床应用

目的 探讨神经内镜下经鼻扩大蝶窦入路手术切除鞍上区肿瘤的可行性和安全性.方法 选用10具灌注固定的正查尸头,模拟经鼻扩大蝶窦入路,内镜下观察鞍上区解剖结构,应用神经导航获取并分析解剖数据.采用神经内镜下经鼻扩大蝶窦入路切除鞍上区肿瘤12例,并以人工硬脑膜、明胶海绵和生物胶"三明治"式A结构重建颅底.结果 视神经一颈内动脉隐窝是丙镜下经鼻扩大蝶窦入路中恒定且关键的解剖标志.剪开硬脑膜后,可显露视交叉下间隙和上间隙,其中视交叉下间隙可见两侧颈内动脉、两侧垂体上动脉、垂体上部、垂体柄、视神经和视交叉,视交叉上间隙内可见大脑前动脉A1和A2段、前交通动脉以及直回.12例鞍上区肿瘤全切除10例,次全切除2例;随访12例,时间6～62个月,术后出现脑脊液鼻漏1例,再次行内镜下修补术后恢复.结论 神经内镜下经鼻扩大蝶窦入路切除鞍上区肿瘤是可行和安全的,熟练的内镜技术和可靠的颅底重建是手术成功的关键.     

经鼻入路显露颅底中线区的内镜解剖研究

目的 确定内镜下采用经鼻入路至颅底中线区的显露范围,确定相关手术标志.方法 选用福尔马林固定灌注的成人尸头标本5具,在内镜下采用经鼻入路进行显露.结果 内镜下采用经鼻入路至颅底中线区,可显露从鸡冠至C2椎体上缘的广泛区域,显露双侧12对脑神经,颈内动脉和椎-基底动脉系统.结论 内镜下采用经鼻入路显露颅底中线区是安全可行的.采用内镜经鼻入路,可处理颅底中线区病变.     

内镜下经鼻-蝶窦入路蝶鞍周围解剖学研究

目的研究内镜下经鼻-蝶窦入路的解剖学,为临床内镜经蝶垂体病变手术提供形态学基础。方法选择10具经动脉灌注染料的成人尸体头部标本,男8具,女2具;模拟扩大经鼻-蝶窦手术入路,同时测量海绵窦内重要解剖结构与鞍底的距离。结果根据蝶窦后壁骨性结构特征将蝶窦腔分为中间腔、旁中间腔以及外侧腔等5个部分。扩大经鼻-蝶窦手术入路可清晰地显示鞍底的骨膜、硬脑膜外层、海绵窦内侧壁,海绵窦内的颈内动脉及其分支血管、动眼神经、滑车神经、外展神经及眼神经等重要解剖结构;打开蝶骨平台可显示视神经、视交叉、垂体柄、鞍膈及视丘下部等解剖结构。蝶鞍周围结构与鞍底中线的距离分别为视神经管隆起(5.72±1.56)mm,颈内动脉管隆起(5.42±1.38)mm,鞍膈(10.01±1.46)mm,视交叉(14.96±1.42)mm,海绵窦内颈内动脉(11.02±2.06)mm,海绵窦内动眼神经(13.75±1.79)mm,海绵窦内滑车神经(15.14±1.53)mm,海绵窦内外展神经(12.68±1.52)mm。结论内镜下扩大经鼻-蝶窦手术入路可清晰地显露蝶鞍周围的解剖结构,适用于鞍旁、鞍上病变的手术治疗。     

内镜下经鼻蝶入路海绵窦区的解剖研究

目的探讨经鼻蝶入路内镜手术和眶-颧入路开颅手术进入海绵窦区解剖学差异。方法选取12例成人尸颅标本,各选6例样本分别模拟经鼻蝶入路内镜手术和眶-颧入路开颅手术暴露海绵窦区,观察海绵窦内重要神经血管结构的暴露情况及位置关系,比较两科手术对于海绵窦区重要结构的显露程度及优缺点。结果眶-颧入路开颅手术,通过内侧三角、Parkinson三角、Kawase三角几乎可暴露海绵窦内所有结构;而经鼻蝶入路内镜手术,对于海绵窦前内侧及鞍旁区域暴露良好,不能暴露上斜坡区域。结论内镜下经鼻蝶入路进入海绵窦,操作简便,创伤小,可清楚暴露海绵窭内部结构,可用于临床上海绵窦病变的治疗。     

The extended endoscopic endonasal approach to the clivus and cranio-vertebral junction: anatomical study

Object Lesions located in the retroclival area and at the level of the cranio-vertebral junction are typically approached through a variety of anterior, antero-lateral and postero-lateral skull-based approach, either alone or in combination. The aim of this anatomical study was to demonstrate the possibility of an endoscopic endonasal approach to the clivus and cranio-vertebral junction. Materials and methods Five fresh cadaver heads injected with colored latex were used. A modified endonasal endoscopic approach was made through two nostrils in all cases. Endoscopic dissections were performed using rigid endoscopes, 4 mm in diameter, 18 cm in length, with 0° lenses. Results Access to the clivus was possible using a lower trajectory when compared to that necessary for the sellar region. The sphenoid sinus is entered, and its inferior wall is completely removed, permitting the union of the sphenoidal and rhinopharyngeal parts of the clivus. The entire clivus can be removed, and the cranio-vertebral junction is opened, removing the anterior arch of atlas and the odontoid process. After the opening of the dura, the anterior surface of the pons and upper spinal cord with corresponding nerves and vasculature are visible. Conclusion The endoscopic endonasal approach to the clivus and cranio-vertebral junction could be a valid alternative for surgical treatment of anterior lesions of these regions. Adequate endoscopic skill, lab training on cadavers and dedicated tools are required for clinical applications of the approach. Presented at the Third World Conference of the International Study Group on Neuroendoscopy (ISGNE), Marburg, Germany, 15–18 June 2005.     

经鼻扩大入路至前颅底的内镜解剖学研究

目的 探索神经内镜下经鼻扩大入路显露前颅底的可行性、手术适应证和并发症的防治.方法 分别运用直径4 mm,长度18 cm的0°、30°和45°硬质内镜(Karl Storz),在神经导航的引导下模拟手术过程,经双侧鼻腔采用经鼻扩大入路对尸头标本进行前颅底内镜解剖.定量测量各个解剖标志之间的距离和显露面积.结果 尸头标本上测量在鸡冠基底部两侧眶内侧壁的距离为平均(34.1 ±4.2)mm,筛板中部两眶内侧壁的距离为(24.7±3.l)mm,两侧前筛动脉之间的距离为(26.8±3.4) mm,两侧后筛动脉之间的距离为(24.3±4.1)mm,前后筛动脉在眶内侧壁的距离为(17.9±2.7)mm.内镜下前颅底可显露的面积是(430.6±53.4) mm2.在磨除筛板骨质后剪开硬膜可见嗅神经、大脑前纵裂和额叶直回.结论 在神经导航辅助引导下,神经内镜经鼻扩大入路至前颅底可提供宽广的手术视野,是处理前颅底病变的一种微侵袭方法.熟练的内镜技术、充分的内镜解剖知识和可靠的颅底重建是保障手术成功的重要因素.     

Full endoscopic endonasal transclival approach: Meningioma attached to the ventral surface of the brainstem

BackgroundIntracranial meningiomas without dural attachment (MWODA) are rare entities. We present the first case published, to the best of our knowledge, regarding a MWODA attached to the ventral surface of the brainstem. This location makes the patient subsidiary to treatment through an expanded endonasal transclival approach.Clinical presentationA 16-year-old female with suspected diagnosis of recurrence of a clear cell meningioma (CCM) at a distance from the initial lesion, located on the premedullary cistern. The patient underwent a pure endoscopic low transclival approach. The attachment to the ventral surface of the brainstem was confirmed intraoperatively. Postoperative MRI confirmed gross total resection and treatment was complemented with adjuvant fractionated stereotactic radiotherapy. No complications related to the procedure were observed.ConclusionMWODA may appear attached to the ventral brainstem. The expanded endonasal approach to the clivus provides a critical anatomical advantage in the treatment of medial lesions, even ventral meningiomas, to the lower cranial nerves. Reconstruction principles must be strictly respected to reduce complications.     

内镜下经鼻蝶窦入路至鞍上区的解剖与临床初步应用

目的研究内镜下扩大经鼻蝶窦入路至鞍区、鞍上区的显露范围，及手术入路中重要的解剖标志与其相互位置关系。结合该入路切除鞍结节脑膜瘤的临床应用体会，探讨内镜在此区域手术中面临的主要问题和解决办法。方法选择10例灌注尸头标本，采用显微镜解剖2例，其中冠状位和矢状位切开各1例；另8例标本模拟经鼻蝶窦入路。在内镜和显微镜下扩展显露鞍前及鞍上区的主要解剖标志，并研究其相互位置关系。对2例女性鞍结节脑膜瘤病人，采用神经导航经鼻蝶窦入路手术，肿瘤切除过程中和切除后分别应用成角内镜观察肿瘤周围结构及切除情况，肿瘤切除后以脂肪、人工硬膜及明胶海绵重建鞍底。结果内镜下在颅前窝向外侧显露的主要限制是两侧的眶内侧壁和视神经管；选择三个平面测量向侧方的显露范围，分别为筛骨鸡冠后缘平面（19．1±2．65）mm，鞍结节前方10mm的蝶骨平台平面（23．2±2．35）mm，两侧视神经管内口平面（13．1±2．18）mm。内镜下可清晰显示双侧视神经、视交叉、垂体柄、前交通动脉复合体等颅内结构。2例鞍结节脑膜瘤病人均达到肿瘤全切除，视力部分改善，术后均出现脑脊液漏，再次经原入路手术修补后痊愈。结论采用单纯内镜或内镜辅助的经鼻蝶窦入路可更直接达到鞍前及鞍上区病变，避免了经过重要的神经血管结构及对脑组织的牵拉。颅底骨质磨除位置和范围以及颅底的修补和重建是采用该入路需要解决的主要问题。     

神经内镜下经鼻蝶入路鞍上区域手术的应用解剖

目的探讨经鼻蝶入路和翼点入路对鞍上区暴露的差异,为内镜下经鼻蝶入路进入鞍上区的手术方法建立解剖学基础。方法在12例成人尸颅标本上,分别模拟经鼻蝶入路和翼点入路,暴露鞍上区,观察视神经、视交叉、垂体柄、颈内动脉及其分支。比较两个入路对于鞍上区重要结构的显露。结果翼点入路下,鞍结节后缘至视交叉前缘距离为5.35±1.38mm,两侧视神经内缘间距10.58±1.46mm,小脑幕游离缘长度6.73±0.84mm,后交通动脉长度16.52±2.98mm,前交通动脉长度2.11±0.35mm。神经内镜下经鼻蝶入路可以暴露视神经、视交叉、垂体柄、颈内动脉、大脑前动脉、大脑中动脉、前交通动脉、后交通动脉等结构,对于颈内动脉分叉以上结构暴露欠佳。结论经鼻蝶入路可以完全暴露第Ⅰ、Ⅱ间隙内的神经血管结构,对于第Ⅲ、Ⅳ间隙内结构显露较差,可以在微侵袭条件下部分代替翼点入路。     

经鼻-蝶窦入路至鞍区内镜解剖与显微解剖的比较研究

目的为比较内镜下与显微镜下经鼻-蝶窦入路的解剖标志和显露范围差异。方法对9例汉族成人灌注尸头采用经鼻-蝶窦入路进行解剖，其中4例行显微解剖，5例采用内镜下解剖，在内镜与显微镜下分别对入路的解剖标志和显露范围进行比较。结果在蝶窦内，内镜下可以观察到更多的解剖标志以确定鞍底、海绵窦等重要结构的位置；内镜经鼻-蝶窦入路更易于向颅前窝底、鞍旁海绵窦和斜坡方向扩展。内镜与显微镜下的操作存在较大差异。结论内镜经鼻-蝶窦入路鞍区及其周围的显露范围较显微镜下更大。     

Extended endoscopic endonasal approach to the suprasellar parachiasmatic cisterns: anatomic study

Objective  

The objective of this study is to recognize the available endoscopic routes during approaches to the suprasellar region and the surgical endoscopic anatomy of the related neurovascular structures.