【作者】 王清；

【导师】 兰青；

【作者基本信息】 苏州大学 ， 神经外科学， 2010， 博士

【摘要】 第一部分神经内镜下扩大经鼻入路至前颅底的解剖学研究【目的】通过熟悉经鼻入路至前颅底的内镜解剖和了解手术入路中各种解剖标志及显露范围,探索神经内镜下扩大经鼻入路显露前颅底的可行性,并进一步探讨该手术入路的适应证和手术并发症的防治。【方法】选用福尔马林固定的成人尸头10具,用红色乳胶灌注动脉后进行解剖。分别运用直径4mm,长度18cm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前颅底进行内镜解剖。定量测量各个解剖标志之间的距离和显露面积。【结果】手术入路过程中鼻腔阶段主要的解剖标志是:下鼻甲、中鼻甲、上鼻甲、鼻中隔、后鼻孔、蝶筛隐窝和蝶窦开口;蝶窦和筛窦阶段的解剖标志是:鞍底、鞍结节、蝶骨平台、前筛房、后筛房、额隐窝、前筛动脉、第三基板、后筛动脉和筛板。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±3.1mm,两侧前筛动脉之间的距离为26.8±3.4mm,两侧后筛动脉之间的距离为24.3±4.1mm,前后筛动脉在眶内侧壁的距离为17.9±2.7mm。内镜下前颅底可显露的面积是430.6±53.4mm2。第三基板的后部是进行眶内手术的标志点。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。第三基板是进行眶内手术的标志点。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。第二部分神经内镜下扩大经鼻入路至中颅底的解剖学研究【目的】神经内镜下经鼻蝶入路是治疗鞍区肿瘤的一个微侵袭技术。本实验主要是在该手术入路的基础上,明确神经内镜下经鼻扩大入路至中颅底的各种重要解剖标志,奠定鞍区、鞍上区和海绵窦区的内镜解剖基础,探讨该入路临床应用的影响因素和手术特点。【方法】选用福尔马林固定的成人尸头10具,用红色乳胶灌注动脉后进行解剖。分别运用直径4mm,长度18cm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中颅底进行内镜解剖。测量各个解剖标志之间的距离。【结果】蝶窦后壁可分为鞍区、鞍上区、海绵窦区和斜坡区。在蝶窦后壁可见的解剖标志是:鞍底位于中央,后组筛房、蝶骨平台和鞍结节位于上方,斜坡区位于下方,斜坡隐窝位于鞍底和斜坡之间,两侧为海绵窦区。在鞍底的外侧可见颈内动脉隆起和视神经管隆起以及位于两者之间的颈内动脉-视神经隐窝。在蝶窦腔的外侧壁可见眶尖隆起、上颌神经隆起、下颌神经隆起和翼管神经,并分别形成视神经颈内动脉和动眼神经三角、V1-V2三角、V2-V3三角。两侧颈内动脉-视神经隐窝内侧距离为11.3±1.2 mm,两侧垂体前部距离为12.2±2.1 mm,两侧垂体中部距离为21.5±2.5 mm,两侧垂体后部距离为17.6±3.4 mm,垂体前后径为9.1±2.9 mm。硬膜内的鞍上区又可分为视交叉上部、视交叉下部、鞍背后部和脑室部。蝶窦的气化程度、蝶鞍的大小、视交叉的位置、后床突的大小和鞍背的高度是影响鞍上区手术的重要因素。海绵窦区可以分为腹侧、背侧、外侧和内侧四个部分。在剪开海绵窦和垂体之间的硬膜后,海绵窦段的颈内动脉可分为三叉神经段、后曲段、下水平段、前曲段和上水平段。【结论】神经内镜经鼻扩大入路至中颅底可清晰显示鞍区、鞍上区和海绵窦区的解剖结构,为该区域的病变提供一条有价值微侵袭的手术方法。颈内动脉-视神经隐窝是该区域手术的关键性标志。熟练的内镜技术、充分的内镜解剖知识和可靠的止血技术是保障手术成功的重要因素。第三部分神经内镜下扩大经鼻入路至斜坡及颅颈交界区的解剖学研究【目的】在神经导航辅助引导下,通过熟悉斜坡及颅颈交界的内镜解剖和了解手术入路中各种解剖标志和显露范围,探索神经内镜下扩大经鼻入路至斜坡及颅颈交界的可行性,并进一步探讨翼管的作用及其对内镜下腹侧斜坡分区的意义。【方法】选用福尔马林固定的成人尸头10具,用红色乳胶灌注动脉后进行解剖。分别运用直径4mm,长度18cm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斜坡及颅颈交界区进行内镜解剖。测量各个解剖标志之间的距离。【结果】内镜下显露的范围上至鞍背后方,下至枕骨大孔前缘,两侧以鞍旁段和斜坡段颈内动脉、翼管、咽鼓管和枕髁为界。斜坡的主要解剖标志是斜坡隐窝、翼管、咽鼓管和枕髁。枕骨大孔前缘至鞍背的距离为38.9±4.2mm;双侧翼管间的距离为20.6±6.4mm;两侧舌下神经管外口内侧缘的距离32.4±2.4mm。鼻小柱至枕骨大孔前缘的距离92.1±7.2mm、两侧枕髁内侧距离27.8±3.5mm、两侧咽鼓管气门裂20.1±4.5mm和显露齿状突时寰椎前弓切除的范围1.4±0.8mm。以斜坡隐窝和两侧翼管的连线为界将斜坡分为以下三个区域:鞍背后段位于鞍背上缘至鞍底斜坡隐窝水平;蝶窦段位于斜坡隐窝至两侧翼管的连线;咽腔段两侧翼管的连线至枕骨大孔前缘。硬膜下由上至下分别为:乳头体、大脑后动脉、Ⅲ神经、小脑上动脉、基底动脉、外展神经、桥脑、延髓和桥延沟以及位于外侧的Ⅶ、Ⅷ神经、两侧椎动脉、小脑后下动脉、脊髓前动脉、舌下神经、副神经和上段脊髓,在下方的视野内可见C1和C2的前后根以及位于两者之间的齿韧带。【结论】神经内镜经鼻扩大入路至斜坡可清晰显示斜坡及颅颈交界周围的解剖结构,为该区域的病变提供一条微侵袭的手术方法。翼管和枕髁是该区域手术的关键性标志。从腹侧对斜坡进行分区有利于内镜下经鼻入路手术方式的选择。神经导航是该手术入路的重要辅助手段。更多还原

【Abstract】 PartⅠExtended Endoscopic Endonasal Approach to the Anterior Skull Base: Anatomic StudyObjective: The aim of study was to describe the endoscopic anatomical landmarks and extent of exposure to the anterior skull base by extended endoscopic endonasal approach, which was essential to better understand the complex anatomical relationships of the structures involved in the approach, and further to discuss the feasibility of exposing the anterior skull base, the indication of the approach and prevention of complications. Methods: Ten formalin-fixed adult cadaver heads whose arterial system was injected with red latex were dissected for the anatomical studies. Endoscopic dissections were performed with the adjunct of neuronavigation using a rigid endoscope (Karl Storz) that was 4 mm in diameter, 18 cm in length, and equipped with 0°, 30°and 45°lenses. An extended endoscopic endonasal approach to the anterior skull base was made through two nostrils in all cases to measure the distance between main anatomical landmarks and area of exposure.Results: During the nasal step, the detailed endoscopic anatomy consisted of the inferior turbinate, the middle turbinate, superior turbinate, nasal septum, choana, speno-ethmoid recess and the sphenoidal ostium. During the sphenoidal and ethmoidal step, the detailed endoscopic anatomy was composed of the sella, tuberculum sellae, sphenoidal planum, anterior ethmoidal cell, posterior ethmoidal cell, the frontal recess, anterior ethmoidal artery, the third lamella, posterior ethmoidal artery and cribriform plate. The maximum of lateral extension was obtained between the two medial orbital walls, separately at the base of the crista galli (mean distance 34.1±4.2mm) and at the middle of the cribriform plate (mean distance 24.7±3.1mm). The distance between the bilateral anterior ethmoidal arteries was 26.8±3.4mm, and the distance between the bilateral posterior ethmoidal arteries was 24.3±4.1mm, while the mean distance between the anterior and posterior ethmoidal arteries at the level of the lamina papyracea was 17.9±2.7mm. The area of the anterior skull base was 430.6±53.4mm2 under the endoscopic view by the approach. The posterior portion of the third lamella was the most important anatomic landmarks for an approach to the orbital retrobulbar space. Once the dura was opened, the recognizable structure were the olfactory nerves, the gyri recti of the frontal lobes and the anterior interhemispheric fissure.Conclusions: The extended endoscopic endonasal approach guided with neuronavigation could provide wide operative field and also be considered a minimally invasive technique to approach the anterior skull base. The third lamella was the most important anatomic landmarks for an endoscopic endonasal approach to the orbital retrobulbar space. Adequate endoscopic skill, ample endoscopic anatomy and reliable reconstruction techniques were required for clinical application of the approach.PartⅡExtended Endoscopic Endonasal Approach to the Middle Skull Base: Anatomic StudyObjective: The endoscopic endonasal transsphenoidal approach is a minimally invasive surgical technique for the removal of sellar lesions. The aim of the present study based on the previous experience was to identify the important anatomic landmarks by extended endoscopic endonasal approach to the middle skull base. The endoscopic surgical anatomy of the sellar region, the suprasellar region and the cavernous sinus was studied to establish an anatomic basis, and to discuss the various anatomic conditions affecting clinical application and operative characteristic.Methods: Ten formalin-fixed adult cadaver heads whose arterial system was injected with red latex were dissected for the anatomical studies. Endoscopic dissections were performed with the adjunct of neuronavigation using a rigid endoscope (Karl Storz and Co.) that was 4 mm in diameter, 18 cm in length, and equipped with 0°, 30°and 45°lenses. An extended endoscopic endonasal approach to the middle skull base was made through two nostrils in all cases to measure the distance between main anatomical landmarks and area of exposure.Results: The posterior bony wall of the sphenoidal sinus was subdivided into five compartments: sellar region, suprasellar region, bilateral cavernous sinus region and clival region. The sellar region consisted of the bottom of the sella and the clival recess. The suprasellar region was composed of the posterior ethmodal cells, the sphenoidal planum, the tuberculum sellae and the optic protuberance. The cavernous sinus region contains the optocarotid recess, the parasellar internal carotid artery, four bony protuberances (orbital apex, maxillary, mandibular and vidian canal) and three anatomic triangles (the optic strut triangle, the V1-V2triangle and the V2-V3 triangle)The width of the pituitary was 12.2±2.1 mm anteriorly, 21.5±2.5 mm medially, and 17.6±3.4 mm posteriorly. The distance of bilateral medial optic-carotid recess was measured as 11.3±1.2mm, and the distance of pituitary between anterior and posterior margin was 9.1±2.9mm. The intradural suprasellar neurovascular structure areas included suprachiasmatic, subchiasmatic, retrosellar and ventricular region. Some anatomic conditions might influence the application of the extended endoscopic endonasal approach, such as the degree of pneumatization of the sphenoid sinus, the size of the sella, the position of chiasm, the height of the dorsum sellae and the size of the posterior clinoids. The venous compartment of the cavernous sinus can be divided into four spaces (ventral space, dorsal space, lateral space and medial space) based on the relationship to the internal carotid artery. The internal carotid artery of the cavernous sinus on endoscopic view is defined as trigeminal portion, posterior bend portion, inferior horizontal portion, anterior bend portion and superior horizontal portion.Conclusions: The extended endoscopic endonasal approach could provide a multiangled and clearly close-up view of the sellae region, the suprasellar region and the cavernous sinus and also be an effective, minimally invasive approach for lesions located in middle skull base. The optic-carotid recess was the key point anatomic landmark for the extended endoscopic endonasal approach to middle skull base. Adequate endoscopic skill, ample endoscopic anatomy and reliable haemostasis techniques were required for clinical application of the approach. PartⅢExtended Endoscopic Endonasal Approach to the Clivus and the Cranio-Vertebral Junction: Anatomic StudyObjective: The aim of study was to describe the endoscopic anatomical landmarks and extent of exposure to the clivus and the cranio-vertebral junction by extended endoscopic endonasal approach guided by neuronavigation system, and then to discuss the possibility of an extended endoscopic endonasal approach to the clivus and the cranio-vertebral junction. Further more attentions were focused on the effect of the vidian canal and the relationship to the division of the clivus.Methods: Ten formalin-fixed adult cadaver heads whose arterial system was injected with red latex were dissected for the anatomical studies. Endoscopic dissections were performed to simulate the operation with the adjunct of neuronavigation using a rigid endoscope (Karl Storz and Co.) that was 4 mm in diameter, 18 cm in length, and equipped with 0°, 30°and 45°lenses. An extended endoscopic endonasal approach to the clivus and the cranio-vertebral junction was made through two nostrils in all cases to measure the distance between main anatomical landmarks.Results: The extent of the surgical exposure by the extended endoscopic endonasal approach extended from the retrosellar region superiorly to the anterior foramen magnum inferiorly and bilaterally bordered on the parasellar internal carotid artery, the paraclival internal carotid artery, the Eustachian tube and the occipital condyle. The main anatomic landmarks on the clivus included the clivus recess, the vidian canal, the Eustachian tube and the occipital condyle. Several anatomic data were measured in cadaver heads: the distance from the columella to the anterior margin of foramen magnum was 92.1±7.2mm, the distance between both medial occipital condyles was 27.8±3.5mm, the distance between both the ostiums of Eustachian tube was 20.1±4.5mm, and the extent of removal of anterior arch of the atlas during exposure of the odontoid process was 1.4±0.8mm. The ventral clivus was divided into three areas in accordance with the clival recess and the bilateral vidian canal from the endoscopic endonasal view. The three areas included the retrosellar part extending from the superior margin of the sellar dorsum to the clival recess, the sphenoidal part from the clival recess to the plane of both vidian canal and the nasopharyngeal part from the the plane of both vidian canal to the anterior foramen magnum. After opening the dural mater, from rostrally to caudally, the intracranial structures included the mammillary bodies, posterior communicating artery, oculomotor nerve, superior cerebellar artery, basilar artery, abducent nerve, the pons, medulla oblongata, the lateral facial nerve, the vestibulocochlear nerve, the upper spinal cord, bilateral vertebral arteries, the posterior inferior cerebellar artery, the anterior ventral spinal artery, the hypoglossal nerve, the accessory nerve and the ventral surface of the pons were visible. The ventral and dorsal rootlets of C1 and C2 and the dentate ligament between them were identified in low portion of the surgical field.Conclusions: The extended endoscopic endonasal approach could not provide the clear endoscopic anatomy around the clivus and the cranio-vertebral junction but also be an appropriate approach to the clival and the cranio-vertebral junction region of the skull base. The vidian canal was an importantly consistent landmark to the petrous internal carotid artery. The endoscopic division of the ventral clivus based on the vidian canal and the clival recess would benefit the choice of the approach. With good knowledge of the endoscopic anatomic region and the adjunct of the neuronavigation system, endoscopic surgical procedures could be performed safely with more minimal invasiveness.更多还原