【作者】 梁良；

【导师】 孙晓枫；

【作者基本信息】 河北医科大学 ， 外科学， 2015， 硕士

【摘要】 目的:本研究通过对尸头标本岩尖区及周围区域的显微解剖,为岩尖区的骨质磨除提供解剖学基础;并通过模拟kawase入路及乙状窦后-内听道上入路了解岩尖区骨质磨除的安全范围及可操作性,探讨这两种入路的适用范围。方法:1岩尖区及周围区域的解剖研究:尸头标本的血管经彩色硅胶灌注后,在4-25倍的解剖显微镜下以不同的角度观察岩骨尖区域的相关解剖标志,观察磨除Kawase三角前后岩尖区域的相关解剖结构,了解kawase三角的解剖定位,并测量颈内动脉岩骨段、耳蜗、三叉神经的相关距离。2岩骨尖区域骨质磨除的手术模拟尸头标本的血管经彩色硅胶灌注后,在4-25倍的解剖显微镜下模拟kawase入路,比较磨除kawase三角前后暴露鞍后斜坡区域的距离差,探讨kawase入路对于岩斜区肿瘤的暴露是否有效;在磨除时采取最大极限磨除方式,使骨窗的前后径分别至颈内动脉及耳蜗,下径至岩下窦,并测量相关数值,以此探讨术中kawase三角磨除的最大安全范围。在另一血管经彩色硅胶灌注的尸头标本上,于4-25倍的显微镜下模拟乙状窦后-内听道上入路,磨除内听道上结节及岩尖,充分暴露Meckel’s腔及岩骨段颈内动脉,对手术可涉及的重要结构测量、拍照,了解该入路可磨除骨质的最大安全范围;讨论该入路的安全性及可操作性。结果:1在岩尖区的解剖研究中测量岩尖区重要结构的相关距离,结果如下(应用SPSS 16.0软件采用均数±标准差进行统计学描述):耳蜗与三叉神经外侧缘的距离为(11.75±2.29)mm;三叉神经外侧缘至颈内动脉破裂孔段的距离为(14.38±1.55)mm。2在岩尖区骨质磨除的手术模拟中Kawase入路测量的重要相关距离结果如下(应用SPSS 16.0软件采用均数±标准差进行统计学描述):磨除Kawase三角与剪开小脑幕暴露斜坡的距离差为(7.63±2.43)mm;Kawase三角的磨除最大深度为(11.60±0.14)mm。3在岩尖区骨质磨除的手术模拟中乙状窦后-内听道上入路测量的重要相关距离结果如下(应用SPSS 16.0软件采用均数±标准差进行统计学描述):颈内动脉与内耳孔的距离为(21.95±2.23)mm;骨窗下缘与颈内动脉的垂直距离为(2.06±1.33)mm。结论:1 Kawase入路可以明显增加鞍后区上、中斜坡的暴露范围,有效暴露范围为前方达上、中斜坡的中线、中桥脑腹外侧面,后方达面听神经、桥小脑角区,前下方达延髓上部、椎动脉与基底动脉移行处,后下方达面听神经上方。2 Kawase入路磨除骨窗的最大前后长径为25mm,最大深度为11.6mm,术中为了避免损伤颈内动脉、耳蜗、岩下窦及外展神经,骨窗前后径不应超过20mm,深度不应超过10mm。3 Kawase入路的适应症:绝对适应症:脑干腹外侧、中、上斜坡区域,伴或不伴中颅窝的侵袭;相对适应症:肿瘤向CPA区扩展,达到面听神经后方或下方;或肿瘤向下扩展达延髓。4乙状窦后-内听道上入路可以增加Meckel’s腔下方的暴露,使骨窗前方达颈内动脉破裂孔段及海绵窦的后部,后外侧达Meckel’s腔的外侧缘,上方达三叉神经,下方达面听神经上缘与外展神经的连线水平。5在乙状窦后-内听道上入路中,岩骨前端的磨除下限应限定在面听神经上缘与外展神经连线的上方,磨除的骨窗前后径不应超过20mm,这样可以大大降低磨除过程中损伤颈内动脉岩骨段的几率。6乙状窦后内听道上入路的适应症:绝对适应症:①肿瘤以后颅窝为主(自CPA区向岩斜区生长),仅向Meckel’s腔内少量浸润,有或无术中神经导航,肿瘤主要向Meckel’s腔的后外侧生长,Meckel’s腔的前内侧缘无明显肿瘤浸润。②肿瘤以后颅窝为主(自CPA区向岩斜区生长),自Meckel’s腔向中颅窝浸润,病人脑干受压及三叉神经受压症状明显,但身体一般情况差,或年龄较大,无法承受二次开颅,或家属拒绝二次开颅,不要求全切肿瘤,仅要求减轻症状者。相对适应症:①肿瘤以后颅窝为主(自CPA区向岩斜区生长),仅向Meckel’s腔内少量浸润(直径<1cm),且Meckel’s腔前内侧缘有肿瘤侵袭,无术中神经导航。禁忌症:①肿瘤虽主体位于后颅窝,但向中颅窝内浸润较多,达海绵窦内,病人年轻且身体情况允许二次开颅,或病人有全切诉求的。更多还原

【Abstract】 Objective: In this study,through microdissection of apical petrous and peripheral regions in head specimens,providing the anatomy basis of sclerotin stripping;Also,through the simulation of kawase approach and posterior-internalauditory canal approach of sinus sigmoideus,the safety range and operability of sclerotin stripping will be understood and the range of application of both approaches will be investigated.Methods:1 Research of Dissection in Apical Petrous and Peripheral Regions:For blood vessels of head specimens,after colour silica gel`s perfusion, related anatomic landmark in apical petrous regions is viewed in different angles with 4-25 x dissecting microscope to measure the relationship between relational anatomical structures in apical petrous regions before and after removing Kawase triangle,including specifically the relationship between the anatomy location of Kawase triangle,petrous bone segment on internal carotid and the apical petrous regions to measure the correlation distance between petrous bone segment in internal carotid,cochlea,trigeminus.2 Operation Simulation of Sclerotin Removal in Apical Petrous Regions:For blood vessels of head specimens, after colour silica gel`s perfusion, the kawase approach under 4-25 x dissecting microscope is simulated to measure the exposed differences of slope before and after removing the kawase triangle sclerotin,to discuss the affectiveness of the kawase approach for the expose of tumors in the petroclival region;using the maximum grinding method to make the anterior margin and inferior margin of bone window achieve the ICA and cochlea, inferior margin achieve the inferior petrosal sinus,and the related statistics are measured,to discuss the maximum safety range of sclerotin appropriate to be removed in this approach.In the head specimen from another blood vessel perfused by colour silica gel,under 4-25 x microscope,the retrosigmoid-suprameatal approach is simulated,nodules on the internal auditory canal and apical petrous regions are removed to sufficiently expose Meckel`s cave and internal carotid in apical petrous of bone segment, measuring and photographing the important structures referred in the operation to understand the maximum safety range of sclerotin appropriate to be removed in this approach; to discuss the safety and operability of such approach.Results:1 In research of the anatomy of apical petrous,the distance between the important structures of petrous apex area are measured,the results are as follows(using the statistical mean plus or minus standard deviation description in SPSS 16.0):The distance between cochlea and lateral border of trigeminus is(11.75±2.29)mm;The distance between trigeminuslateral border and the foramen lacerum of internal carotid is(14.38±1.55)mm.2 In the operation Simulation of Sclerotin Removal in Apical Petrous Regions,the results as follows show the important statistics in Kawase approach(using the statistical mean plus or minus standard deviation description in SPSS 16.0):The length difference between removed apical petrous regions in Kawase approach and the exposed slope of after cutting tentorium of cerebellum is(7.63 ± 2.43)mm;Removed depth of Kawase triangle is(11.6±0.14)mm.3 In the operation Simulation of Sclerotin Removal in Apical Petrous Regions,the results as follows show the important statistics in retrosigmoid- suprameatal approach(using the statistical mean plus or minus standard deviation description in SPSS 16.0) The perpendicular distance between margo inferior of bone window and ICA C2 in retrosigmoid- suprameatal approach is(2.06±1.33)mm;The racial length before and after removing bone window in retrosigmoid-suprameatal approach is(21.95±2.23)mm.Conclusion:1 The Kawase approach can increase expose range significantly of the superior and middle slopes,the effective exposure range is midcourt line reaching the superior and middle slopes in the front,the facies lateralis of anterior pontomesencephalic regions,the posterior reaches facial and auditory nerve,cerebellopontine angle region,the inferior and inferior reach the upper medulla oblongata,vertebral artery and the transitional position of basilar artery,the posterior and inferior reach the upper of facial and auditory nerve.2 The maximum front and back long diameter of Kawase approach after removing bone window is approximately 25 mm,the depth is approximately 11.6mm.In order to avoid the injury of internal carotid,cochlea,inferior petrosal sinus and abducens,the front and back diameter of bone window should not exceed 20 mm,and the depth should not exceed 10 mm.3 Indication of Kawase approach:Absolute indication: for tumors in brainstem ventrolateral medulla,central and upper slope regions, with or without the invation of cranial fossa;Relative indication: for the extension of CPA zone, reaching the posterior or lower lesion of facial and auditory nerve;or tumors extending downward to the medulla.4 The exposed maximum range of retrosigmoid- suprameatal approach: The anterior reaches the foramen segment of internal carotid artery and the posterior of cavernous sinus,the posterior-lateral reaches the lateral border of Meckel`s cavity,the upward side reaches trigeminus,the inferior reaches the ligature level between the superior border and abducens of facial and auditory nerve.5 In retrosigmoid- suprameatal approach,the saddle region can be exposed significantly,the lower limit of removal of the front-end petrosal bone should be limited in the upward side of ligature between the superior border of facial and auditory nerve and the abducens,the anterior and posterior diameter of removing bone window should not exceed 20 mm,therefore it may greatly decrease the probability of injuring petrous bone segment of internal carotid during removal.6 Indication of retrosigmoid- suprameatal approach:Absolute indication:1 The tumour is primarily the posterior cranial fossa(Growing from CPA to petroclival region),only a little infiltration in Meckel’s cavity,with or without neuronavigation exists during operation.The tumour is mainly growing to the posterior-lateral of Mechel`s cavity,the anteromedial margin of Meckel`s cavity has no obvious tumor infiltration.2 The tumour is primarily the posterior cranial fossa(Growing from CPA to petroclival region), with infiltration from Meckel`s cavity to middle cranial fossa,the patient has obvious pressured brainstem and trigeminus,however,his body has bad general condition,or he is older and cannot bear secondary craniotomy,or his relations refuse secondary craniotomy,do not require full-cut tumour and only require attenuated symptom.Relative indication 1:The tumour is primarily the posterior cranial fossa(Growing from CPA to petroclival region),only a little infiltration in Meckel’s cavity,and the tumor invasion exists in anteromedial margin of Meckel`s cavity,without neuronavigation exists during operation.Contraindication 1:Although the tumour body is located in posterior cranial fossa,there is much infiltration in middle cranial fossa,reaching cavernous sinus,the patient is young and his physical condition allows the secondary craniotomy,or the patient has the appeal of full-cut.更多还原