内窥镜下经口咽至中下斜坡入路的应用解剖研究

目的研究内窥镜下经口咽入路至中、下斜坡局部解剖学并测量相关解剖数据,为临床手术提供形态学依据。方法交替使用手术显微镜和0°、30°硬质内窥镜研究10例成人尸头,测量与入路相关的60具成人颅骨标本数据。结果斜坡常规开窗20 mm×30 mm,对应脑干侧前方的解剖结构为:口咽→咽后壁软组织→骨性标志(枕骨大孔前缘→下斜坡→咽结节→中斜坡)→硬脑膜→非骨性标志(VI~X II颅神经、椎基底动脉及其分支,以及其之间解剖毗邻关系);切牙孔、前鼻棘、后鼻棘、卵圆孔、破裂孔、颈动脉外口及舌下神经管外口的内侧缘至咽结节及后四项至中线的距离分别为:71.0±4.1、78.3±4.3、33.7±4.3、27.2±2.1、13.2±2.0、25.7±2.3、19.7±1.3、23.3±2.1、10.5±2.0、25.2±3.7、17.2±2.7 mm。结论应用内窥镜经口咽入路可完成中下斜坡脑干腹侧部位病变的手术治疗,以处理椎基底动脉瘤及体积较小且血供一般的病变为佳。

Applied Anatomy of Transoropharyngeal Approach to the Middle and Lower Part of Clivus

Objective To study intracranial anatomy in endoscopic transoropharyngeal approach to the middle and lower part of clivus,and measure some anatomic data to guide clinical surgical operation.Methods Ten(adult) cadaver specimens were studied with microscope and 0° or 30°hard endoscopes alternatively by imitating operations via soral-transpharyngeal approach,and related data were measured in sixty dry skulls.Results The transoral approach was operformed with a clival opening of 20 by 30 mm,such a limited clival and dural opening allowed the insertion of the endoscope and instruments,full visualization of the anterolateral brainstem and cisternal spaces around it.The pathway of road mapping for this approach composed of these marks according to the surgical procedure is as follows: oro pharynx→preclival tissue→bony marks(anterior part of great occipital foramen→lower part of clivus→pharyngeal tubercle→middle part of clivus)→cerebral dura mater→nonbony marks(VI ~XII cranial nerves,vertebral-basilar artery and its branches,and their adjacent structures).The distances from foramen incisive,spina nasalis anterior,spina nasalis posterior,inner border of outer entrance of oval foramen,inner border of lacerated foramen,inner border of outer entrance of carotid canal and inner border of outer entrance of hypoglossal canal to pharyngeal tubercle and the distances of four later to central line are as follows:71.0±4.1,78.3±4.3,33.7±4.3,27.2±2.1,13.2±2.0,25.7±2.3,19.7±1.3,23.3±2.1,10.5±2.0,25.2±3.7,17.2±2.7mm.Conclusion With the endoscope,the operations in the brain stem rostral region that correspond to the middle and lower part of the clivus can be finished via the above approach,especially for vertebrobasilar aneurysm and those diseases that volume is less and blood supply is not abundant.