【作者】 洪健；

【导师】 张建宁； 佟小光；

【作者基本信息】 天津医科大学 ， 外科学， 2009， 博士

【摘要】 第一部分:枕下远外侧入路至颅颈交界区的显微解剖与后路固定方法研究目的:研究国人成年头颅标本经枕下远外侧入路至颅颈交界腹外侧区的显微解剖与术后颅颈失稳的后路寰枕固定方法。方法:15具（30侧）完整成人湿性头颅标本,经红蓝硅胶分别灌注动静脉后经枕下远外侧入路进行分层显微解剖,另对15具干性头颅和寰枢椎标本进行相关骨性测量,并对解剖数据进行对比分析;根据远外侧入路对枕骨髁磨除范围的不同,分成经髁后入路（RCA）组、部分经髁入路（pTCA）组、完全经髁入路（tTCA）组以及经颈静脉结节入路（TTA）组各15例（30侧）,对比不同术式对颅颈交界腹外侧区暴露范围的影响;并对后路经寰椎椎弓根螺钉内固定的进钉点、进钉方向等指标进行测量分析。结果:1.83.3%的枕动脉主干体表投影在乳突尖与枕外隆突连线上,距后正中线3～5cm区域之间;椎动脉穿硬脑膜处距后中线平均距离为15.5±1.2mm,未见小脑后下动脉由椎动脉硬膜外段发出者;枕骨髁平均长度为24.5±3.3mm;舌下神经管内口下缘距枕骨髁平均距离为9.1±1.1mm;颈静脉结节平均高度为9.4±1.4mm; 86.7%的星点位于横窦乙状窦交角之后。2.与远外侧髁后入路组比较,部分经髁入路组、完全经髁入路组以及颈静脉结节入路组对颅颈交界腹外侧区水平暴露距离分别增加10.9mm、12.6mm和10.1mm,手术深度分别降低13.5mm、20.5mm和24.6mm,组间差异具有统计学意义（P<0.05）。3.寰枕固定枕骨端可选择上项线水平上1 cm处,以寰椎椎弓根中线外侧2mm处为进钉点,内斜平均角度13.5±2.4°,上斜平均角度5.2±0.4°,螺钉平均长度25.5±3.5mm。结论:枕下远外侧入路可充分显露颅颈交界腹外侧区,可通过磨除不同范围的枕髁或颈静脉结节等骨性结构增加暴露,术后可经后路寰椎椎弓根螺钉内固定行寰枕融合术。第二部分:经口咽入路至颅颈交界区的显微解剖与前路固定方法研究目的:研究国人成年头颅标本经口咽入路至颅颈交界腹外侧区的显微解剖与术后颅颈失稳的前路寰枢固定方法。方法:所用标本同第一部分,经口咽入路进行分层显微解剖并做相关测量,对解剖数据进行对比分析;将标本分为单纯经口咽入路（To）组、经口咽入路+下颌骨切开（To+Ma）组和经口咽入路+部分硬腭切除（To+Pa）组各15例（30侧）,比较不同术式对颅颈交界腹外侧区暴露范围的影响;并对前路经寰枢关节螺钉内固定的进钉点、进钉方向等指标进行测量。结果:1.咽后壁软组织存在5层结构和2个间隙;咽结节至枕骨大孔前缘的平均距离为10.2±2.2mm;寰椎前结节至上切牙平均距离为11.6±2.1 cm;齿状突平均高度为15.9±6.9mm,至上切牙平均距离为12.8±2.2cm;寰椎横韧带平均长度为21.7±1.6mm,中部与硬膜囊的平均距离为2.1±0.3mm。2.标准经口咽入路矢状位暴露范围由下斜坡至C₂水平;下颌骨切开后矢状位显露角度增加23.6°,轴位显露角度增加11.1°,手术深度减少2.0cm,暴露范围延伸到中斜坡至C₃水平,差异具有统计学意义（P<0.05）;部分硬腭切除后矢状位显露角度增加14.0°,手术深度减少1.6cm,差异具有统计学意义（P<0.05）,但轴位显露角度改变不明显,头侧暴露范围增加至上斜坡,而尾侧仍至C₂水平。3.以枢椎前弓下缘与枢椎椎体侧缘交点上方3mm为进钉点,螺钉长度16～25mm,外倾5～20°,后倾15～24°置入。结论:经口咽入路对颅颈交界腹侧由下斜坡至C₂水平距中线3～5cm内的区域显露较好,尤其适合行齿状突切除前路减压;其改良术式增加了暴露范围,降低了手术深度;术后可经前路行寰枢关节螺钉内固定术稳定寰枕区。更多还原

【Abstract】 1.Study of microsurgical anatomy of the suboccipital far-lateral approach to theeraniocervical junetion（CCJ）region and posterior fixation methodObjective:To investigate the microanatomical structure in ventral-lateral CCJ regionvia the suboccipital far-lateral approach by dissecting the adult cadaveric specimensand efficacy of the posterior fixation for occipitocervical instability.Methods:Fifteen （30 sides）adult cadaveric specimens which perfused with coloredsilicone and 15 adult dry skulls were studied.Stepwise dissections via the far-lateralapproach to ventral-lateral CCJ region and the different exposures were comparedamong the four groups:RCA,pTCA,tTCA,and TTA respectively,and parameters aboutthe screw entry point and trajectory direction of posterior fixation were measured.Result:1.There was 83.3% occipital artery stems located at the line from the mastoidtip to external occipital protuberance,within the area of 3～5mm to posterior medianline;The mean length from verterbral artery entry dural point to the posterior medianline was 15.5±1.2mm,there was no origin of the PICA from the epidural verterbralartery;the mean length occipital condyle was 24.5±3.3mm;the mean length from theinferior edge of hypoglossal canal to the condyle was 9.1±1.1 mm;the mean height ofjugular tubercle was 9.4±1.4mm;86.7% of asterion was located behind the junction oftransverse sinus and sigmoid sinus.2.Compared with the RCA group,the exposures ofventral-lateral region in CCJ increased 10.9,12.6andl 0.l mm,the depth decreased13.5,20.5and 24.6mm in pTCA,tTCA,and TTA group respectively,there wassignificantly statistics difference among the groups（P＜0.05）3.The screw entry pointwas about lcm above the superior nuchal line and 2mm lateral to C₁ pedicle,themedial inclination angle of the trajectory wasl3.5±2.4°,superior inclination angle was5.2±0.4°,the screw length was 25.5±3.5mm.Conclusion:Suboccipital far-lateral approach could exposure ventral-lateral CCJregion,and expand the exposures by resecting condyle or jugular tubercle,it alsocould make occipitoatlant fusion by posterior atlas pedicle screw fixation.2.Study of microsurgical anatomy of the transoral approach to the craniocervicaljunction（CCJ）region and anterior fixation method Objective:To investigate the microanatomical structure in ventral-lateral CCJ regionvia the transoral approach by dissecting the adult cadaveric specimens and feasibilityof the atlantoaxis fixation by anterior transarticle screw method.Method:Cadaveric specimens were the same as those of part one.Stepwisedissections via the tranoral approaches to ventral-lateral CCJ region and the differentexposures were compared among the three groups:To,To+Ma,and To+Pa grouprespectively,and parameters about the screw entry point and trajectory direction ofanterior transarticle fixation were measured.Result:Soft tissue of the posterior pharyngeal wall consisted of five structures andtwo interspaces;the distance from the pharyngeal tubercle to anterior edge of foramenmagnum was 10.2±2.2mm;the distance from the anterior tubercle of atlas to upperincisors was 11.6±2.1 cm;the height of the dens was 15.9±6.9mm;the length oftransverse ligament of atlas was 21.7±1.6mm;the distance from the transverseligament center to dura was 2.1±0.3mm.2.The exposure extent of the transoralapproach range from lower clivus to C₂;Mandibulotomy could increase by 23.6°insagital planes and 11.1°in axial planes and decreased the depth by 2.0cm,theexposure entent of range from midclivus to C₃.Palatotomy could increase by 14°insagital angle and decreased 1.6cm in depth,but the axial angle had no significancelyenlargement,the exposure entent had enlarged to upper clivus.There was significantlystatistics difference among the groups（P＜0.05）.3.The screw entry point was at thejunction of the lateral edge of C₂ verterbral body to 3mm above of inferior edge of C₂anterior arch,the screw length was 16～25mm,the lateral inclination angle of thetrajectory was 5～20°,posterior inclination angle was 15～24°.Conclusion:The transoral approach could provide with exposure entent from inferiorclivus to C2 and within 3～5cm to midline,was very suitable to resecting thedens;These modifications of transoral approach could expand the exposure anddecrease the depth;the anterior atlantoaxial transarticle screw fixation could providestability for CCJ region.更多还原