颞下锁孔入路的显微解剖与临床应用研究-神经外科大学论文

分类号: 密级:U D C: 编号:学位论文颞下锁孔入路的显微解剖与临床应用研究Subtemporal keyhole Approach: Microanatomic Considera- tions and Clinical Application王先祥指导教师姓名冯春国教授安徽医科大学第一附属医院神经外科李长元教授安徽医科大学第一附属医院神经外科万经海教授安徽医科大学第一附属医院神经外科申请学位级别硕士专业名称外科学（神经外科）提交论文日期2005-5 论文答辩日期2005-5学位授予单位和日期安徽医科大学2005年7月答辩委员会主席评阅人2005年5月安徽医科大学ANHUI MEDICAL UNIVERSITY硕士学位论文颞下锁孔入路的显微解剖与临床应用研究Subtemporal keyhole Approach: Microanatomic Considera- tions and Clinical Application硕士研究生王先祥导师冯春国教授导师组成员李长元教授万经海教授学科专业外科学（神经外科）研究方向微创神经外科论文工作时间2003年03月至2005年05月2005年5月目录一、英文缩略词表 (1)二、中文摘要 (2)三、英文摘要 (4)四、正文 (7)1.引言 (7)2.方法 (8)3.结果 (12)4.讨论 (16)5.结论 (21)6.文献 (23)7.附图 (26)五、附录 (39)六、致谢 (40)七、综述 (41)1.正文 (41)2.文献 (48)英文缩略词英文缩写英文全称中文全称AE AICA CPA CS GSPN LSC IAC ICA PCoA PCA SCA Arcuate EminenceAnterior Inferior Cerebellar ArteryCerebello Pontine AngleCavernous SinusGreater Superficial Petrosal NerveLateral Sellar CompartmentInternal Auditory CanalInternal Carotid ArteryPosterior Communicating ArteryPosterior Cerebral ArterySuperior Cerebellar Artery弓状隆起小脑前下动脉桥脑小脑角海绵窦岩浅大神经蝶鞍外侧腔隙内听道颈内动脉后交通动脉大脑后动脉小脑上动脉颞下锁孔入路的显微解剖与临床应用研究摘要目的：通过颞下锁孔入路的解剖学研究：(1) 探讨该手术入路的解剖显露范围和手术可操作空间，测量相关解剖学数据，为其临床应用提供解剖学资料；(2) 对该入路进行部分改进；(3) 将该入路技术进一步应用于临床实践，探讨其临床应用价值，明确其优越性和手术适应证。

方法：(1) 解剖：取福尔马林固定的成人尸头标本15例（30侧），采用神经内窥镜辅助的显微神经外科技术，进行颞下锁孔入路显微解剖学研究。

于外耳道前1cm，颧弓上缘，取向上的直切口或向前或向后的弧形切口，倒“Y”形切开颞肌筋膜，钝性分离颞肌。

在颧弓后根上缘钻一孔，于其前上方铣一直径为2.0-3.0 cm大小的骨窗。

骨窗尽量靠近中颅底，可磨除部分颧弓上缘[1]。

解剖步骤分为硬膜下入路和硬膜外入路两部分进行。

①硬膜下入路。

半圆形剪开硬脑膜，悬吊。

抬起颞叶,采用手术显微镜、神经内窥镜进行解剖。

观察颞下锁孔入路对鞍旁、鞍上，脚间窝、岩斜区及脑干的腹、外侧区等区域的神经、血管结构的显露情况。

在滑车神经入小脑幕点的后方瓣形剪开小脑幕，观察、记录显露情况。

测量重要解剖结构间的数据。

②硬膜外入路。

用剥离子沿硬膜外进行分离。

根据需要可磨平中颅底骨嵴，增加视野。

在棘孔上方离断脑膜中动脉，进一步显露棘孔、卵圆孔、圆孔。

在硬膜外辨认岩浅大神经（greater superficial petrosal nerve GSPN）、弓状隆起（arcuate eminence AE）、三叉神经下颌支（V3）。

磨除Day菱形区范围内的岩骨尖骨质[2]，并进一步将骨质磨除范围向前扩大到三叉神经压迹和部分V3下方，观察、比较上述两种方法磨除岩骨尖后对岩斜区的显露情况。

于圆孔和卵圆孔之间,将硬膜从三叉神经表面剥离，显露三叉神经下颌支和三叉神经上颌支；进一步向前，显露眶上裂外侧唇，并向前内侧显露眼神经、动眼神经、滑车神经；后内侧剥离显露Meckel囊，从而显露整个蝶鞍外侧腔隙 (lateral sellar compartment LSC)(海绵窦cavernous sinus CS)的外侧壁[3]。

观察血管、神经结构的显露情况和相对关系，测量重要解剖结构间的数据。

(2) 临床应用：颅内肿瘤8例，其中男6例，女2例；年龄41-58岁，平均44.4 岁。

病程4个月～2年。

小脑幕脑膜瘤5例，颅内巨大胆脂瘤（鞍旁，脚间池，桥前池）2例, 岩斜脑膜瘤1例，均经该手术入路切除。

结果：（1）解剖：颞下锁孔入路经硬膜下可以充分显露鞍上、鞍旁、脚间窝、岩斜区上部，脑干的腹、外侧区，颅底动脉环的后外侧部分等颅内神经、血管结构；经硬膜外入路可以显露全部LSC的外侧壁三角（间隙）和部分上壁三角（间隙），即：旁正中三角、Parkinson三角、Mullan三角、外侧三角、后外侧三角（Glasscock 三角）、后内侧三角（Kawase三角）以及部分前正中三角，对血管和神经损伤小，磨除岩骨尖和内听道( internal auditory canal IAC )上方的骨质可显露中斜坡，IAC 全程以及桥脑小脑角（cerebello pontine angle CPA）、脑桥延髓沟、脑桥下段、延髓上段，岩骨前部的磨除范围可进一步扩大。

使用神经内窥镜可使解剖观察范围进一部扩大。

（2）临床：手术效果良好，术后第3日常规头颅CT检查。

肿瘤全切除7例（87.5%）；术中均未输血，术后无昏迷和死亡病例，无严重并发症出现。

结论：颞下锁孔入路能很好地显露小脑幕切迹区，鞍旁，鞍上、岩斜区，脑干的腹、外侧区以及桥小脑角区等结构，并可提供足够的手术操作空间。

在内窥镜辅助下能够取得与常规入路相同的甚至更好的手术效果。

颞下硬膜外锁孔入路为手术治疗原发于或侵及LSC内的病变提供了一种新的安全微创的手术途径。

关键词：颞下锁孔显微解剖神经内窥镜蝶鞍外侧腔隙，海绵窦Subtemporal keyhole Approach: Microanatomic Considera- tions and Clinical Application.AbstractObjective The purpose of this study is to describe and anatomically analyze the operating spaces provided by the subtemporal keyhole approach, and offer the technique of the approach to clinical application.Methods (1)Anatomic Anatomic features were studied in 30 sides of adult embalmed cadaveric heads perfused with colored silicone, using operating microscope and neuroendoscope. The head is placed supine and rotated contralaterally to the side of the trepanation, that keep the zygomatic arch horizontal to the floor. A vertical or arc linear epifascial skin incision approximately 5 cm is created from the point at the inferior rim of the zygomatic arch approximately 1 cm anterior to the external auditory meatus. After the skin is retracted bilaterally,the temporal muscle fascia is incised in a reverse Y-shaped fashion, with the basal leaflet reflecte caudally over the zygomatic arch. the lower border of the temporal muscle is the retracted upward .then the squamous bone can be exposured. Drill a hole at the superior of the posterior pedicle of the zygomatic arch. An oval-shaped craniotomy superior and anterior to the point , approximately 2.0 cm to 2.5 cm in width and 2.0 cm in height is performed close to the cranial base. Additional shaving of the superior rim of the zygomatic arch further facilitates the upward viewing angle.Firstly beginning the intradural procedure after the craniotomy, analyze the operating spaces provided by the approach and measure the important datas of the main anatomic structure. Then beginning the extradural procedure, in this procedure, sometime should resection the bone bridge of the middle base of skull and be performed as far extradurally as possible to keep anatomiclandmarks in sight for better orientation and to preserve the dural membrane for later reconstruction.The resection of the petrous apex is required in order to exposure the petroclival region lower than the Vth cranial nerve. The bony resection is limited by greater superficial petrosal nerve, arcuate eminence and mandibular nerve. To approach the midclivus, further anterior bony resection can be expand to beyond the trigeminal impression and some area beyond the mandibular nerve. Analyze the operating spaces of provided by the extradural procedure and measure the important data of the main anatomic structure. (2) Clinic The technique was used in eight interventions patients during the period of October 2002 to December 2004, the indications for surgery were based on the position, pathology and size of the lesions. 6 males and 2 females, aged from 41 to 58 years old. Among these lesions, five are meningiomas on tentorium of cerebellum, Two are cholesteatomas in the different place in cranial at the same time, one is meningioma on upper petroclival region, The diameter of the lesions range from 65 mm to 35 mm.Results (1)Anatomic The cadaveric study provided intimate experience with the microsurgical anatomy of the approach. When procedure from the intradural, the neurovascular structures of the suprasellar, petroclival, interpeduncular cistern and prepontine cistern can be well exposured without traumatization. The ventral - lateral pontine can also be well exposured. When procedure from the extradural, The neurovascular structures of the lateral wall of the lateral sellar compartment (LSC) can be well exposed without traumatization ; The operating spaces of the lateral wall of the LSC can be exposed sufficiently, they are lateromedial triangle, Parkinson's triangle ,Mullan triangle, lateral triangle,Glasscock triangle, Kawase triangle and some part of anteromedial triangle in superior wall of the LSC ; The cerebello pontine angle (CPA) can also be well exposured, with resection the bony over the internal auditory meatus. The area of the resection of the petrous apex can be extended anteriorly underthe trigeminal ganglion and the area under the mandibular nerve by the lateral limit of the greater superficial petrosal nerve, with an approximate area of the construct about 306 square millimeters,without the injuries of the neurovascular structures. (2) Clinic The eight consecutive patients operated on via the approach gained good results, the lesions of seven patients were total resected(87.5%). There are no patients need blood transfusion during or after operation ,no patient die, coma or other severe complications after operation .Conclusions The subtemporal keyhole approach has been proven to provide sufficient operating space and obtain satisfactory outcomes for the lesions of the suprasellar, petroclival, ventral-lateral pontine, interpeduncular cistern and prepontine sistern. The subtemporal extradual keyhole approach to the LSC is based on the developmental anatomy of the LSC, and it has been proven to be one of the safe approaches to the region.Key words Subtemporal / Keyhole/ Mircroanatomy/ Neuroendoscope/ lateral sellar compartment/ Cavernous sinus .颞下锁孔入路的显微解剖与临床应用研究1．引言自20世纪90年代以来，神经外科进入了微创时代，锁孔手术是随着微创神经外科以及手术器械的发展而发展起来的一种外科手术操作技术，是现代神经外科的发展方向之一，是具有代表性的微创神经外科技术。