摘要
前外侧颅底手术硬脑膜外入路相关的显微解剖研究
本课题采用显微解剖技术等方法在35个经福尔马林固定的尸体头标本和15具成人干颅骨上，以眶尖部为重点，对眶上裂及海绵窦前部、视神经管和前床突的相关结构进行解剖研究。探讨经前外侧颅底手术硬脑膜外入路相关的显微解剖结构，并总结临床上采用前外侧硬脑膜外入路手术的病例，验证该区域显微解剖临床应用的实际意义。
第一部分 眶上裂及海绵窦前部的显微解剖
1．目的
获得眶尖部眶内和眶上裂区以及海绵窦前部正常解剖结构的有关数据，为眶尖部肿瘤、眶颅沟通瘤和海绵窦内肿瘤的手术治疗提供解剖依据。
2．材料与方法
应用15例成人干颅骨和15例福尔马林固定的成人头颅标本，在放大5～25倍显微镜下，对眶上裂区的骨性结构、分区、硬膜结构特征及海绵窦的前部进行逐层显微解剖、观察、测量及分析。
1)观察眶上裂的骨性结构及解剖特点；
2)观察眶上裂硬脑膜结构及解剖特点；
3)切开颞极硬脑膜索带，从圆孔和卵圆孔翻开硬脑膜返折，进入夹层；
4)海绵窦外侧壁和上壁前部的显露；
5)切开Zinn腱环的方法；
6)观察Zinn腱环切开后经过眶上裂的各个神经和血管等结构的排列及其相互之间的走行关系。
3．结果
1)眶上裂的骨性结构解剖数据
眶上裂是蝶骨大、小翼与蝶骨体之间的狭窄裂隙，近似三角形。自前外上斜向后内下，由上壁、外侧壁和内侧壁围成。眶上裂不是严格的冠状位，外侧尖较内侧稍前，与矢状面夹角44.86±2.67°。上壁是由蝶骨小翼、前床突与视柱的毗邻部位形成，
第二二闰阵医大学们阵创匕亏仑文
前外侧颅底手木硬月亩瓜外夕、路相关的显徽解创布开究
占据蝶骨峭内侧半，长度为12.42~21 .04~，平均16.57士1 .glrnlll。外侧壁由蝶骨大
翼形成，是三壁中最锐利者，被外直肌棘分为上半边和下半边两部分，上、下半边交
界处为交点，相当于Zirm键环外侧附着处的骨性隆起，测量眶上裂外侧端距下端的
距离为巧.16~22.78mm，平均19.81士2.13~，而上、下半边长度分别为3.60~
15.00nun，平均8.61士2.74mm，和5.76~15.22nun，平均10.27士2.35nun。交点至上
壁、内侧壁距离分别为1.72~7.84~，平均3.62土1.51~，和5.66一巧.42~，平
均7.81士1 .68~。内侧壁由上部的视柱和下部的蝶骨体形成，没有外侧壁锐利，长
度为7.04一11 .52~，平均8.53士1.24~。在眶上裂狭窄的外侧区内行走的结构有泪
腺神经、额神经、滑车神经及眼上静脉。
2)眶上裂硬脑膜结构解剖特点
在眶上裂后缘，硬膜间腔的内外两层互相贴紧，并以颗极硬膜索带与眶上裂外
端处的硬膜相连，此处宽(从颜极硬膜索带的外侧缘至眶上裂外端的距离)为
3.47士。.33(3.o2一4.88)~，通常被眶上裂上壁的骨质覆盖。
3)颖极硬脑膜索带的解剖特点及切开方法
海绵窦外侧壁的外硬膜层是颖极硬脑膜的直接延续，在眶尖移行为颖极硬膜索
带，并与包绕出入眶上裂的神经和血管的共同鞘膜紧密相连，实验中测得从颖极硬膜
索带外侧缘到眶上裂神经血管共同鞘的距离为5.52士1.09~。最大值为7.92rnrn，最
小值为4.16~，垂直于进入眶上裂硬膜的行走方向，紧贴眶上裂向着前床突方向剪
开颖极硬膜索带(深度蕊5~)，可以避免损伤在眶上裂外侧区行走的泪腺神经、额
神经、滑车神经及眼上静脉。
4)翻开圆孔和卵圆孔处硬脑膜返折的体会
半月节及其三个分支在穿出硬膜进入颅底的骨孔之前，神经外膜与硬脑膜都存
在3一Slnrn的移行区，正是切开硬脑膜夹层进入硬膜间腔的安全部位。颖极硬膜索带
剪开之后，分别比较在圆孔处沿上领神经表面切开硬膜夹层和在卵圆孔处沿下领神经
表面切开硬膜夹层，从而翻开海绵窦外侧壁硬膜的方法，我们的体会是在圆孔处切开
硬膜夹层并翻起海绵窦外侧壁硬膜较容易。
5)切开zilm键环的方法
覆盖在眶尖的骨膜、眶上裂及视神经管内的硬脑膜及视神经鞘的纤维成分融合在
一起形成ZIIm键环。此触环围绕视神经孔的前端和眶上裂的上内侧。视神经固定在
第二二军医大学博d匕论文
前外侧烦成手术硬月亩膜外夕、路相关的显徽解创掩开究
总键环的内侧，但总键环大于视神经。除下斜肌以外的所有眼外肌和提上睑肌均起始
于Zirm键环。内直肌是眼外肌中最强的一条，起自Zinn键环鼻侧和视神经鞘略低处;
下直肌起自视神经孔下方的zilin键环;外直肌始于ZIIm键环外侧较低处，其中外直
肌的一个头向外附着于眶上裂外边的骨性隆突上:上直肌起于视神经孔和视神经鞘上
方的Zinn键环，部分起始于视神经鞘;上斜肌起自视神经孔上方的Zinn键环，位于
内直肌起点的内上方。提上睑肌的起始键与上直肌的始端融合。经过Zinn腔环的结
构有动眼神经上下支、外展神经、鼻睫神经及键状神经节的交感根和感觉根。可以通
过两种方法切开Zinn键环暴露眶上裂的中央区:①沿外直肌与上直肌和提上睑肌的
起点间切开Zinn键环:②沿外直肌和下直肌起点之间切开ZIIm键环。经此入路手术
前，必须去除眶上裂外侧壁。此方法较上述方法要?
For improving the surgical efficacy of the skull-base tumors, the microanatomy of superior orbital fissure and anterior cavernous sinus, optic canal, anterior clinoid process and applied anatomy of anteriolateral epidural approach were conducted on 35 formalin fixed cadaveric heads in which vessels were perfused with colorful silicone and 15 dry adult cadaveric head specimens. Epidural approaches for anterior and lateral fossa were used in patients to improve the operative effect of refractory skull base tumors.
Part I Microanatomy of superior orbital fissure and anterior
cavernous sinus
Objective: To provide the microsurgical anatomical basis for the operation of cranio-orbital region tumors and tumors related to superior orbital fissure(SOF) and cavernous sinus. Materials and Methods: (1) The osseous structures of superior orbital fissure were observed in 30 sides of dry adult cadaveric head specimens; (2) The course and relationship of nerves and vascular structures passing through superior orbital fissure were studied in 30 sides of formalin fixed cadaveric heads in which vessels were perfused with colorful silicone under the microscope; (3) Explored how to incise temporal tip dural fold and anulus of Zinn and how to expose superior wall and lateral wall of cavernous sinus. Results: (1) The superior orbital fissure is a narrow cleft through which the orbit communicates with the middle cranial fossa; (2) Detachment of the temporal tip dural fold (depth^ 5mm) vertically to the superior orbital fissure introduces the interdural space, where the cavernous sinus is present, without opening th
e meningeal dura. This may avoid damaging the lacrimal nerve, the frontal nerve, trochlear nerve and the superior ophthalmic vein; (3) With the dissecting technique, we began the dura incision along the surface of V 2 at foramen rotundum and V3 at foramen ovale, in sequencely, we reflected the dura from trigeminal ganglion, cavernous sinus lateral wall and whole middle fossa; (4) The anulus of Zinn should be incised between the superior rectus and the lateral rectus to
expose the central sector of the superior orbital fissure; (5) The cavernous sinus is situated behind the orbital apex and the superior orbital fissure. The fissure is divided into three sectors by the annular tendon: that are the lateral, central and inferior sector. The lateral sector is pass by the trochlear, frontal and lacrimal nerves and the superior ophthalmic vein. The central sector transmits the superior and inferior of divisions of the oculomotor nerve, the abducens and nasociliary nerves and the sensory and sympathetic roots of the ciliary ganglion. The inferior sector is pass by the inferior ophthalmic vein. (6) At the fissure, the dura covering the middle fossa and cavernous sinus blends into the periorbital of the orbital apex and the annular tendon from which the extraocular muscles arise. The annular tendon surrounds the anterior end of the optic foramen and the adjacent part of the superior orbital fissure. The fibrous components, which blend together to form the annular tendon, are the periorbita covering the orbital apex, the dura lining the fissure and optic canal, and the optic sheath. The annular tendon is also attached to the lateral margin of the fissure at the junction of the narrow lateral and larger medial parts. Conclusions: (1)Detachment of the temporal tip dural fold (depth< 5mm) vertically to the superior orbital fissure introduces the interdural space, where the cavernous sinus is present, without opening the meningeal dura. This may avoid damaging the lacrimal nerve, the frontal nerve, trochlear nerve and the superior ophthalmic vein; (2)The central sector and the oculomotor foramen could be opened with an incision directed through the annular tendon between the origin of the superior and lateral rectus muscles. It is important to remember that the superior ophthalmic vein exits the extraocular muscle cone bypassing between the origin of the superior and lateral muscles from the annular tendon. Wh
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1 Akabane A, Saito K, Suzuki Y, et al. Monitoring visual evoked potentials during retraction of the canine optic nerve: Protective effect of unroofing the optic canal. J Neurosurg 1995, 82: 284-287
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7 Guidetti B, La Torre E. Management of carotid-ophthalmic aneurysms. J Neurosurg 1975,42:438-442
8 Hakuba A, Tanaka K, Suzuki T, et al. A combined orbito-zygomatic infratemporal epidural and subdural approach for lesions involving the entire cavernous sinus. J Neurosurg 1989, 71: 699-704
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16 Akabane A, Saito K, Suzuki Y, et al. Monitoring visual evoked potentials during retraction of the canine optic nerve: Protective effect of unroofing the optic canal. J Neurosurg 1995, 82: 284-287
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1 Day JD, Fukushima T, Giannotta SL. Microanatomical study of the extradural middle fossa approach to the petroclival and posterior cavernous sinus region: Description of the rhomboid construct. Neurosurgery 1994, 34: 1009
2 Day JD, Giannotta SL, Fukushima T. Extradural temporopolar approach to lesions of the upper basilar artery and infrachiasmatic region . J Neurosurg, 1994, 81(2) : 230-235．
3 Day JD. Cranial base surgical techniques for large sphenocavemous meningiomas: technical note. Neurosurgery, 2000, 46: 754-760．
4 Dolenc VV. A combined epi-and subdural direct approach to carotid-ophthalmic artery aneurysms. J Neurosurg 1985, 62: 667-672
5 Dolenc VV. Frontotemporal epidural approach to trigeminal neurinomas. Acta Neurochirurgical 1994, 130: 55
6 Kawase T, Loveren HR, Keller JT, et al. Meningeal architecture of the cavernous sinus: clinic and surgical implications. Neurosurgery 1996, 39: 527
7 Al-Mefty O. Supraorbital-pterional approach to skull baselesions. Neurosurgery, 1987, 21 (4) :474-477．
8 Day JD. Cranial base surgical techniques for large sphenocavemous meningiomas: technical note. Neurosurgery, 2000, 46: 754-760．
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