经枕髁和经颈静脉突方向远外侧入路手术路径的虚拟现实解剖研究比较

目的 在构建虚拟现实解剖模型基础上,探讨远外侧入路经枕髁和经颈静脉突两种不同方向的微创手术路径对相关解剖结构显露的影响。方法 对15例尸头标本行头颅CT和MR扫描,影像数据输入Vitrea Fx 3.0虚拟现实系统构建颈静脉孔区3D解剖模型。在模型的颅后窝中选取颈静脉结节前缘为标志点,分别做经枕髁和经颈静脉突两个方向的、直径1 cm的圆柱体模拟远外侧入路微创手术路径,观察路径中的解剖结构、测量其体积,并采用配对t检验进行分析比较。结果两种方向的模拟手术路径中均可清晰显示所包含的颅底骨质、神经和血管等解剖结构,均不包含脑干、小脑、椎动脉和小脑后下动脉。经枕髁方向路径包含部分迷走神经、副神经,经颈静脉突方向手术路径包含部分颈内静脉和颈静脉球。经枕髁和经颈静脉突两种方向手术路径体积(3 236.20±228.01) mm³ vs (3 306.00±248.23) mm³]及路径中舌下神经的体积差异均无统计学意义(P值均＞0.05)。经枕髁方向路径中包含的骨性结构和小脑前下动脉的体积大于经颈静脉突方向路径,而包含的静脉的体积小于经颈静脉突方向路径,差异均有统计学意义(t=7.324、56.526、140.580, P值均＜0.01)。结论 远外侧入路两种方向的模拟手术路径均有效显露舌下神经。经枕髁方向有助于显露小脑前下动脉;经颈静脉突方向有助于避开后组颅神经,但存在损伤颅内静脉的风险。

Anatomic comparison of trans-condyle versus trans-jugular process route in the far lateral approach by virtual reality technique

Objective To discuss the impact of trans-condyle and trans-jugular process routes in the far lateral approach upon the exposure of realated anatomic structures based on virtual reality anatomic model.Methods CT and MR scans were performed to fifteen adult cadaver heads, and then, image data was input into Vitrea Fx 3.0 virtual reality system to establish three-dimensional anatomy model of jugular foramen region. Anterior edge of jugular tubercle in posterior cranial fossa was selected as landmark point to outline cylinder with diameter 1 cm simulating trans-condyle and trans-jugular process routes in far lateral minimally invasive approach. Anatomic exposures and the volume were observed and measured. Statistical comparison was launched by paired t test.Results Anatomic structures of osseous structures, nerves and vessels in the trans-condyle and trans-jugular process routes were displayed well. Brainstem, cerebellar, vertebral artery and posterior inferior cerebellar artery did not show in route. Trans-condyle route involved partial vagus nerve and accessory nerve. Trans-jugular process route involved partial internal jugular vein and jugular bulb. Comparison did not show statistically significant differences for the volumes of two routes (3236.20±228.01) mm³ vs (3306.00±248.23) mm³] and hypoglossal nerve involved(all P values＞0.05). The volumes of osseous structures and anterior inferior cerebellar artery involved in trans-condyle route were more than those in trans-jugular process route with statistically significant differences. The volume of vein in trans-jugular process route was more than that in trans-condyle route with statistically significant difference(t=7.324, 56.526, 140.580, all P values＜0.01).Conclusions The routes from two directions in the far lateral approach can expose hypoglossal nerve effectively, of which trans-condyle route is prone to expose anterior inferior cerebellar artery. Trans-jugular process route can bypass the lower cranial nerve but with the risk of vein injury.