【作者】 唐协林；

【导师】 夏祥国；

【作者基本信息】 泸州医学院 ， 外科学， 2009， 硕士

【摘要】 第一部分舌下神经管及其毗邻骨性结构的显微解剖特征目的:研究舌下神经管及其毗邻骨性结构的形态、大小,相互关系及其骨性解剖标志,为舌下神经管区的手术入路研究提供解剖学依据。方法:取成人颅底干性骨标本25个和寰椎干性骨标本15个,观察舌下神经管(hypoglossalcanal,HC)及其周围骨性结构的形态及相互关系,测量相关骨性结构的大小和间距;对双侧距离的差别进行统计学分析。随机选取3例成人湿性头颈标行轴位、冠状位薄层CT扫描后薄层断层切片(横断面、矢状面、冠状面各1例)观察;结果:从颅底看,枕骨髁的长轴与枕骨大孔的外缘前半平行;HC藏于枕髁与颈静脉结节之间,居于颈静脉孔内下前方,长轴与矢状面的夹角:左为42.2士3.4(34.5～47)°,右为42.5士3.5(34～47.8)°;髁管出现率为64%,HC与髁管形成一夹角约48°,髁管后口距枕髁后极左4.8±1.0(3.5～7)mm,右为3.9±1.1(2.1～6)mm。颈静脉结节上表面到达舌下神经管上壁的距离约5mm。颈静脉孔至HC内口约9mm。枕髁后缘到达HC内口、外口的距离左13.08士2.3mm,16.8士2.4 mm;右13.24士2.3 mm,17.1士2.5 mm。寰椎横突长度左右分别为左9.27±1.6(6.5～12.5)mm;右9.29±1.8(6.1～12.3)mm;枕骨颈突位于乳突和枕髁之中间,茎突的后内侧,是颈静脉孔后缘的标志。横窦和乙状窦的转折点即为前星点,枕外隆突到颧弓根连线为横窦标志。星点是容易识别的的重要解剖标志,但星点与横窦的关系不恒定,变异大,15侧(30.0%)星点位于横窦沟内,17侧(34.0%)位于横窦沟上,18侧(36.0%)位于横窦沟下。结论:舌下神经管位置深在,暴露困难,枕髁、颈静脉结节、寰椎横突是侧方暴露舌下神经管区域的主要骨性障碍;星点、乳突、茎突、颈静脉结节、枕髁是HC区域外侧方入路的主要骨性标志;枕髁、颈静脉结节是远外侧经髁入路处理Ⅸ,Ⅹ,Ⅺ和Ⅻ颅神经及达中下斜坡脑干腹侧病变最重要的骨性标志和目标。第二部分舌下神经管及其毗邻结构的显微外科解剖学特征目的:研究舌下神经管区域(hypoglossal canal aera,HGCA)手术入路显微解剖关系,为舌下神经管区的手术入路研究提供显微外科解剖学基础。方法:取成人尸体头颈标本8具,分别从后外侧和前外侧方向暴露颅颈交界区的颅外相关肌肉、神经血管,最后切除寰椎横突和枕鳞,磨除枕髁和颈静脉结节研究暴露舌下神经管管部及其内外口,研究其内容物及其周围的神经血管显微解剖关系。结果:1根据寰椎横突可以将颅颈交界区的侧方分为前外方的咽旁间隙和后外方的枕下区,位于前者内的主要是进出颅底的颈内外动静脉大血管和颅外段后组颅神经等重要神经和血管,位于后者内的主要为枕下肌群和椎动脉枕下段和椎静脉丛。在咽旁间隙内,茎突隔是重要解剖标志,它将咽旁间隙分为茎突前间隙和茎突后间隙,舌下神经、舌咽神经、副神经及迷走神经行于茎突后间隙内的颈内动脉与颈内静脉之间。枕下三角和颈2神经的腹侧支是识别椎动脉的重要标志,头外侧直肌是识别颈静脉孔的重要标记。2舌下神经的走形及舌下神经管内容物舌下神经分三段:脑池段、舌下神经管管内段、颅外段。上内侧界茎突舌骨肌的下缘,下行的舌下神经构成外侧界和横跨的舌下神经上根构成底边(下界)所围成的颈前“舌下神经”三角结构恒定,且易于识别。HC管壁由骨密质组成,在磨除骨质时,从骨松质到出现骨密质即表示到达了舌下神经管壁,HC管内由后向前有静脉丛、舌下神经和咽升动脉的分支,其中主要为静脉丛,静脉丛贯穿舌下神经管全程并包绕舌下神经鞘。结论:寰椎横突既是定位枕下区重要结构的重要解剖标志,又是从后外侧到达舌下神经管外口的主要障碍;茎突是咽旁间隙外科解剖的钥匙。利用舌下神经在颅外和颅内行走特点,可以安全地找到舌下神经;HC管壁是保护舌下神经免受损伤的“第一道预警装置”;舌下神经管静脉丛是舌下神经管的主要内容物,也是保护舌下神经免受损伤的“第二道预警装置”;舌下神经鞘膜是保护舌下神经免受损伤的“最后屏障”。颈前“舌下神经三角”是寻找颅外段舌下神经重要的解剖标志,掌握其解剖特征有利于经颈前侧方入路时鉴别神经,准确定位舌下神经并逆行探至舌下神经管外口。第三部分舌下神经管及其毗邻结构的三维CT重建及数字化模拟相关手术入路的定性定量分析目的:构建颅颈交界区(caniocervical junction region,CCJR)三维可视化模型,初步探索该模型的功能,阐明HGCA各解剖结构的分布规律和空间位置关系,数字化模拟手术入路定性定量分析,为HGCA外科手术治疗方案的选择提供数字化三维解剖学依据。方法:随机抽取经64排螺旋CT检查(含C4-鞍背并增强,扫描层厚0.3 mm)的正常成人标本10例。将CT数据输入电脑后,利用Mimics软件进行三维重建处理,构建舌下神经管及其毗邻结构,构建包含颅颈交接区的动脉、静脉系统,对舌下神经管、入路相关毗邻结构进行解剖学观察与测量,并与尸体解剖结果进行对比分析,模拟手术入路数字化分析切割主要的骨性障碍视角扩大范围。结果:建立了CCJR三维可视化模型,通过模型二维与三维空间的观察与测量,结果与尸体解剖层次、重要角度与距离结果基本一致。结论:可以通过Mimics软件重建的CCJR的可视化模型,此模型在结构毗邻关系的展示、直观地量化定位和方便的结构间测量,模拟手术数字化定量分析等功能上具有优势;目前的模型尚不能满足一些微细解剖结构的研究,尚不能完全满足舌下神经管区手术入路的真实模拟训练,有待进一步改进和完善。更多还原

【Abstract】 PartⅠMicrosurgical anatomy of the osseous hypoglossal canal and its osseous adjacent structures.Purpose:To study the morphology,dimension and relation of the osseous hypoglossal canal(HC) and its adjacent bony structures for further study of surgical approach in this area.Methods:The osseous hypoglossal canal(HC)and its adjacent osseous structures were observed and measured anatomically,and bilateral differences in distance were statistically analyzed on 25 dry specimens of adult skull base bone and 15 dry specimens of atlas.Three wet specimens of randomly selected adult standard head and neck were made axis line,and coronal CT scanning before they were seperated by thin-layer slices(cross-sectional,1case; sagittal,1;coronal plane,1).Results:In the view of the base skull,the long axis of the occipital condyle and the outer edge of the foramen magnum parallel to the first half;hypoglossal canal was hidden in between occipital condyle and anterior, medial and inferior to the jugular foramen.The angle formed by HC and sagittal plane in left and right side was 42.2±3.4(34.5～47),42.5±3.5(34～47.8)degrees respectively.The angle formed by HC and condylar canal which was present 64% was about 48 degrees.Occipital condyles from the posterior pole to deutostoma of condylar canal left 4.8±1.0(3.5～7) mm,right 3.9±1.1(2.1～6) mm.The distance between jugular tubercle and the surface of nodules on the hypoglossal canal wall was about 5mm.The distance between jugular foramen and hypoglossal canal endostoma was about 9mm.The distance between the posterior edge of occipital condyle and intracranial orifice or extracranial orifice of hypoglossal canal was 13.08±2.3mm(left),16.8±2.4 mm;13.24±2.3 mm,17.1±2.5 mm(right). Transverse process of atlas were left around the length of 9.27±1.6(6.5～12.5) mm;right 9.29±1.8(6.1～12.3) mm.Occipital cervical process is located in between mastoid and occipital condyle,and the posterior medial of styloid process,and it is the landmark of of posterior edge the jugular foramen.Transverse sinus and sigmoid sinus is a turning point in the former asterion,and the occipital protuberance to the zygomatic arch outside the root symbol was connected to transverse sinus.Asterion is the importance of readily identifiable anatomical landmark,but the relationship between the transverse sinus and it is not constant, and exists variation,15 lateral(30.0%) sites are located in transverse sinus,17 sides(34.0%) upper the transverse sinus groove,18 sides(36.0%) under the groove of the transverse sinus.Conclusion:Hypoglossal canal is located deeply and it is very difficult to expose it.Occipital condyle,jugular tubercle,transverse process of atlas are the main obstacles in the access to the hypoglossal canal region; asterion,mastoid,styloid process,jugular tubercle,occipital condyle are the main osseous signs of lateral approach to the hypoglossal canal region;occipital condyle, jugular tubercle are the most important osseous landmarks and objectives by far lateral approach to deal with condylar,cranial nervesⅨ,Ⅹ,ⅪandⅫand the lesions of ventral brain stem in the middle and lower clivus. Part 2 Microsurgical anatomy features of the hypoglossal canal and its adjacent structures the microsurgical anatomy featuresPurpose:To investigate the Microsurgical anatomy features of the hypoglossal canal(HC) and its adjacent structures for the further study of surgical approach in this area.Methods:The microsurgical anatomy of the extracranial muscles,nevres and vessels in the caniocervical junction region(CCJR) were investigated in 8 cadaveric head-neck specimens posterolaterally and anterolaterally, respectively.Then the transverse process of the atlas(TPA),occipital squama, occipital condyle and jugular tubercle were removed to observe the content of HC and the relationship of nerves and vessels with in HC and between HC and its adjacent structures.Results:1.caniocervical junction region(CCJR) can be divided into the lateral side of the former parapharyngeal space and hind suboccipital area by transverse process of the atlas,the former is the main access to the skull base arteriovenous large blood vessels(ICA,ECA,IJV,EJV) and cranial extracellular latter cranial nerve and so on,the latter is mainly the suboccipital suboccipital muscles and the vertebral artery and vertebral venous plexus.In the parapharyngeal space,the stylid diaphragm is an important anatomical landmark and the parapharyngeal space is subdivided into prestyloid and poststyloid compartments by the stylid diaphragm.There were internal carotid artery,internal jugular vein and theⅨ、Ⅹ、Ⅺ、Ⅻcranial nerves in the retroparapharyngeal space.The suboccipital triangle and ventral branch of C2 nerve were the important marks,and rectus capitis lateralis was the important symbol to identify the jugular foramen.2.The hypoglossal nerve(HN) path and contents of HC The HN is divided into three main parts:cisternal,intracanalicular and extracranial.It is the newly described ’hypoglossal’ triangle in the anterior neck that is bordered by the descending hypoglossus laterally,transverse hypoglossus inferiorly and inferior border of the stylohyoid muscle superiorly.The structure is constant,and easily identifiable.HC wall is made up from compact bone.In the mill the emergence of the compact bone from cancellous bone that wall mean reaching the HC.From the former direction to the rear there are the venous plexus mainly,hypoglossal nerve, ascending pharyngeal artery through the hypoglossal canal and hypoglossal nerve is envelopped by the whole hypoglossal nerve sheath.Conclusion:TPA can serve as an important landmark in identifying important structures in suboccipital area, however it is also a big handrance which blocks the access to extracranial orifice of HC posterolaterally.Styloid is the key to anatomy of parapharyngeal space.Hypoglossal nerve can be identified safely according to its features of either extracranial or intracranial part.HC wall is the first forecasting set preserving hypoglossal nerve.The venous plexus of HC is a landmark to identify HC and aslo is the second forecasting set preserving hypoglossal nerve.Hypoglossal nerve sheath is the final barrier to protect hypoglossal nerve against injury.’hypoglossal’ triangle in the anterior neck is an important anatomical landmark in order to find extracranial hypoglossal nerve,master of whose anatomical characteristics is conducive to the anterior lateral approach in the identification of nerves,accurate positioning and retrograde exploration from hypoglossal hypoglossal nerve to extracranial orifice of HC.Part 3 3-D CT reconstruction of Hypoglossal canal and its adjacent structures and digital simulation for surgical approach-related qualitative and quantitative analysisObjective:Construction of 3D visualization of the CCJR model,preliminary exploration of the function of the model,Clarify the anatomy of the HGCA structure and the distribution of spatial relations,for the HGCA clinical treatment of surgery figures provided by the choice of three dimensional anatomical basis.Methods:Specimens of 10 cases of normal adults were selected randomly by the 64-slice spiral CT examination(including C4-dorsum sellae and CT enhance,the scanning slice thickness 0.3 mm).CT data were entered into the computer using the materialise interactive medical image control system (Mimics) software to deal with three-dimensional reconstruction of hypoglossal canal and adjacent structures,construction of the the CCJR that contains craniocervical arteries,venous system.The hypoglossal canal and the approach-related adjacent structures were made anatomical observation and measurement,and comparative analysis to autopsy results,the quantitative analysis of simulation for surgical approach to cut the main bone obstacles for expanding the scope of perspective.Results:Three-dimensional visualization model of CCJR was set up.Through observation and measurement of two-dimensional and three-dimensional space for models,the level of results and autopsy was illustrated with consistent results including anatomical layer,the important point of view and distance.Conclusion:The CCJR virtual human data can be reconstructed by Mimics software.This model relations in the structure adjacent to the display, intuitive and easy to quantify positioning measurement of the structure has advantage s such as functional;But the current virtual human data collection and the establishment of the visualization model can not meet the research of some fine anatomical struc ture,still can not be used for the true simulation training of the surgical approach,waiting to be continuously improved and developed.更多还原