眶尖部的应用解剖与断层影像解剖学研究
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摘要
目的 结合鼻内窥镜下眶尖部手术应用的需要，通过眶尖部结构的应用解剖及应用和断层影像解剖学相结合的研究，为鼻内窥镜下眶尖部手术寻求一安全、便捷的手术入路，确立安全的手术边界，为眶尖部疾病的临床诊断和鼻内窥镜手术提供可靠的解剖学依据，以取得良好的手术效果和减少并发症的发生。并将所获得的眶尖部影像学资料与实体解剖观测数据进行比较，以评估该区域CT断层扫描的准确度及临床应用价值。
方法 ①采用随机选取的30例外观无异常病损的经10％福尔马林固定的成人尸头(男21例，女9例)，正中矢状面将尸头锯开，切除脑组织，依照鼻窦内窥镜下眶尖部手术进路观测前鼻棘至眶尖部各结构的距离(深度)、侧偏角、仰角及旁开距等；视神经管各壁长度、内侧壁厚度、视神经管垂直径和横径及截面积等；眶上裂长度、内侧及外侧间距；部分穿经眶上裂的神经与眶上裂内、上壁的距离和与视神经管的最短距离等；②采用FV平面作为轴位扫描基线，与其相垂直的平面作为冠状位扫描平面，对9例完整成人尸头进行扫描，测量前鼻棘至眶尖部各解剖结构的距离；视神经管内、外侧壁长度及眶口、中部和颅口内侧壁厚度、内侧及外侧间距、垂直径和横径及截面积；视神经管与颅骨正中矢状面的夹角；眶上裂长度、内侧及外侧间距及最短距离。③将扫描过的尸头脱钙，依与断层影像扫描相同的基线对尸头进行断层解剖，显微镜下观察视神经管及眶上裂出现的层面，同时测量方法②中除视神经管与颅骨正中矢状面的夹角外的所有相关数据。
结果 前鼻棘至视神经管眶口、中部和颅口内、外、上、下壁的距离平均分别为62.01mm，70.04mm，65.02mm，67.15mm，65.60mm，72.36mm，66.52mm，69.54mm，68.23mm，74.60mm，68.01mm，72.67mm。前鼻棘至眶口和颅口内侧壁的侧偏角、仰角平均为9.56°和5.34°，38.77°和34.08°，随着
中文摘要
深度的增加，角度逐渐减小。视神经管内侧壁长度及中部内侧壁厚度平均分
别为 11．04mm和 0．55 mm，在各壁中最长和各段中最薄；视神经管中部裁面
积平均为 15．86mm’，为视神经管最狭窄的部位。眶上裂长度、内侧间距、外
侧问距及最短距离分别为 17．96mm，30．78mm，51．23 mm，28．98 mm．视神经
管与颅骨正中矢状面的夹角平均为40．61士3．49”．冠状位断层影像解剖与应
用解剖数据有较好的相关性。应用与断层影像解剖学结果基本一致。
结论①眶尖部鼻内窥镜下手术时，应严遵中线附近操作的手术原则，随
着深度的增加，应相应减少各角度。②视神经管减压手术时，在安全范围内全
程开放视神经管内侧壁至关重要。同时开放中部并将 Zinn”s环切开，松解，才
能达到充分减压的目的。③以FV平面作为轴位扫描基线，与其垂直的平面
作为冠状位扫描平面，能较好地反映眶尖部结构的解剖特征。而冠状位断层
扫描图像对径线、夹角等解剖变量反映更精确。结合水平及冠状位断层图像
进行分析，更有利于术中眶尖部解剖结构的准确定位。④采用薄层断层显微
解剖切片与断层影像相结合，通过形态学观测及相关解剖数据相比较的方法，
可较客观、准确地反映眶尖部的解剖学特征，是研究眶尖部结构的有效方法和
手段。
Purpose To meet the needs of the clinical operation of orbital apex ,a research has been performed to explore a secure and easy operating route and a safe border for the en-doscopic operation of the orbital apex by means of the applied anatomy , sectional anatomy and imaging scans, and to provide the reliable anatomy data for the clinical diagnosis and endoscopic operation on the diseases of the orbital apex. Therefore, satisfactory operation effect is obtained and the complications are reduced. By comparison of the imaging and the sectional anatomic data on the orbital apex , we can evaluate the accuracy and value of the CT scan in visualizing this region in detail.
Methods CD 30 adult cadaveric heads without any lesion were selected at random (male 21, female 9) and cut along the midsagittal plane, whose brain tissues were removed subsequently. According to the approach of transnasal endoscopic operation to the orbital apex ,we have observed and measured the distance from anterior nasal spine to the various structures of the orbital apex, the angles of the lateral deviation and elevation and the lateral deviate distance. Quantitative measurement was done for the length of the optic canal walls, the thickness of medial wall, the distance of the medial and lateral margins. The transverse and vertical diameter and the transverse area of the canal were also measured in the orbital part, middle part and intracranial part. The superior orbital fissure was measured in the length , distance of medial and lateral margins. Meanwhile , the distances of some nerves crossing the superior orbital fissure to the superior and medial walls of fissure and to the optic canal were measured respectively. (2)CT scan was performed on 9 adult cadaveric heads with continuous 2mm sections thickness through the Frankfurt-Virchow planeCFV plane) which was adopted as axial baseline or plane and coronal plane(vertical plane of the axial plane). The content of study was almost as same as the mentioned in the method CD except the angle of elevation and the lateral deviate distance of the structures in the orbital apex, the distances of some nerves crossing the superior orbital fissure to the superior and medial walls of fissure and to the optic canal. Besides, the angle between the optic canal and the sagittal plane was also measured.(3)The specimens were decalcified and cut by the baseline of CT scan. The measurement of the item mentioned in the method (2) was done except
from the angle to the sagittal plane(SP).
Result The mean distances from anterior nasal spine to the medial, lateral, superior and inferior walls of the optic canal in orbital part, middle part and intracranial part are 62. Olmm, 70. 04mm, 65. 02mm, 67. 15mm, 65. 60mm, 72. 36mm, 66. 52mm, 69. 54mm, 68. 23mm, 74. 60mm, 68. Olmm, 72. 67mm respectively. The mean angles of the lateral deviation and the elevation in orbital and intracranial medial margins of the canal are 9. 56?and 5. 34? 38. 77?and 34. 08?respectively. With the depth increasing, the angles gradually decreased. 11. 04mm and 0. 55 mm are the length of the medial wall of the optic canal and the thickness of medial wall in the middle part of the canal which are the longest among the canal walls and the thinnest in three parts of the medial canal wall respectively. 15. 86mm2 is the mean transverse area of the canal in middle part which is the narrowest among three parts of the canal. 17. 96mm, 30. 78mm,51. 23mm and 28. 98mm are the length, distance of medial and lateral margins and the shortest distance of the superior orbital fissure respectively. The mean angle to the sagittal plane is 40. 61 + 3. 49? There exists a good correlation between the data of the coronal scans and sections. The results of the sectional anatomy are the same as that of CT scans on the whole.
Conclusion (1)Allow for the orbital apex, the transnasal endoscopic operation must be performed near the middle line. With the depth increase, the angles must be decreased relatively. (2)For the decompression of the optic canal, it is imp
方法 ①采用随机选取的30例外观无异常病损的经10％福尔马林固定的成人尸头(男21例，女9例)，正中矢状面将尸头锯开，切除脑组织，依照鼻窦内窥镜下眶尖部手术进路观测前鼻棘至眶尖部各结构的距离(深度)、侧偏角、仰角及旁开距等；视神经管各壁长度、内侧壁厚度、视神经管垂直径和横径及截面积等；眶上裂长度、内侧及外侧间距；部分穿经眶上裂的神经与眶上裂内、上壁的距离和与视神经管的最短距离等；②采用FV平面作为轴位扫描基线，与其相垂直的平面作为冠状位扫描平面，对9例完整成人尸头进行扫描，测量前鼻棘至眶尖部各解剖结构的距离；视神经管内、外侧壁长度及眶口、中部和颅口内侧壁厚度、内侧及外侧间距、垂直径和横径及截面积；视神经管与颅骨正中矢状面的夹角；眶上裂长度、内侧及外侧间距及最短距离。③将扫描过的尸头脱钙，依与断层影像扫描相同的基线对尸头进行断层解剖，显微镜下观察视神经管及眶上裂出现的层面，同时测量方法②中除视神经管与颅骨正中矢状面的夹角外的所有相关数据。
结果 前鼻棘至视神经管眶口、中部和颅口内、外、上、下壁的距离平均分别为62.01mm，70.04mm，65.02mm，67.15mm，65.60mm，72.36mm，66.52mm，69.54mm，68.23mm，74.60mm，68.01mm，72.67mm。前鼻棘至眶口和颅口内侧壁的侧偏角、仰角平均为9.56°和5.34°，38.77°和34.08°，随着
中文摘要
深度的增加，角度逐渐减小。视神经管内侧壁长度及中部内侧壁厚度平均分
别为 11．04mm和 0．55 mm，在各壁中最长和各段中最薄；视神经管中部裁面
积平均为 15．86mm’，为视神经管最狭窄的部位。眶上裂长度、内侧间距、外
侧问距及最短距离分别为 17．96mm，30．78mm，51．23 mm，28．98 mm．视神经
管与颅骨正中矢状面的夹角平均为40．61士3．49”．冠状位断层影像解剖与应
用解剖数据有较好的相关性。应用与断层影像解剖学结果基本一致。
结论①眶尖部鼻内窥镜下手术时，应严遵中线附近操作的手术原则，随
着深度的增加，应相应减少各角度。②视神经管减压手术时，在安全范围内全
程开放视神经管内侧壁至关重要。同时开放中部并将 Zinn”s环切开，松解，才
能达到充分减压的目的。③以FV平面作为轴位扫描基线，与其垂直的平面
作为冠状位扫描平面，能较好地反映眶尖部结构的解剖特征。而冠状位断层
扫描图像对径线、夹角等解剖变量反映更精确。结合水平及冠状位断层图像
进行分析，更有利于术中眶尖部解剖结构的准确定位。④采用薄层断层显微
解剖切片与断层影像相结合，通过形态学观测及相关解剖数据相比较的方法，
可较客观、准确地反映眶尖部的解剖学特征，是研究眶尖部结构的有效方法和
手段。
Purpose To meet the needs of the clinical operation of orbital apex ,a research has been performed to explore a secure and easy operating route and a safe border for the en-doscopic operation of the orbital apex by means of the applied anatomy , sectional anatomy and imaging scans, and to provide the reliable anatomy data for the clinical diagnosis and endoscopic operation on the diseases of the orbital apex. Therefore, satisfactory operation effect is obtained and the complications are reduced. By comparison of the imaging and the sectional anatomic data on the orbital apex , we can evaluate the accuracy and value of the CT scan in visualizing this region in detail.
Methods CD 30 adult cadaveric heads without any lesion were selected at random (male 21, female 9) and cut along the midsagittal plane, whose brain tissues were removed subsequently. According to the approach of transnasal endoscopic operation to the orbital apex ,we have observed and measured the distance from anterior nasal spine to the various structures of the orbital apex, the angles of the lateral deviation and elevation and the lateral deviate distance. Quantitative measurement was done for the length of the optic canal walls, the thickness of medial wall, the distance of the medial and lateral margins. The transverse and vertical diameter and the transverse area of the canal were also measured in the orbital part, middle part and intracranial part. The superior orbital fissure was measured in the length , distance of medial and lateral margins. Meanwhile , the distances of some nerves crossing the superior orbital fissure to the superior and medial walls of fissure and to the optic canal were measured respectively. (2)CT scan was performed on 9 adult cadaveric heads with continuous 2mm sections thickness through the Frankfurt-Virchow planeCFV plane) which was adopted as axial baseline or plane and coronal plane(vertical plane of the axial plane). The content of study was almost as same as the mentioned in the method CD except the angle of elevation and the lateral deviate distance of the structures in the orbital apex, the distances of some nerves crossing the superior orbital fissure to the superior and medial walls of fissure and to the optic canal. Besides, the angle between the optic canal and the sagittal plane was also measured.(3)The specimens were decalcified and cut by the baseline of CT scan. The measurement of the item mentioned in the method (2) was done except
from the angle to the sagittal plane(SP).
Result The mean distances from anterior nasal spine to the medial, lateral, superior and inferior walls of the optic canal in orbital part, middle part and intracranial part are 62. Olmm, 70. 04mm, 65. 02mm, 67. 15mm, 65. 60mm, 72. 36mm, 66. 52mm, 69. 54mm, 68. 23mm, 74. 60mm, 68. Olmm, 72. 67mm respectively. The mean angles of the lateral deviation and the elevation in orbital and intracranial medial margins of the canal are 9. 56?and 5. 34? 38. 77?and 34. 08?respectively. With the depth increasing, the angles gradually decreased. 11. 04mm and 0. 55 mm are the length of the medial wall of the optic canal and the thickness of medial wall in the middle part of the canal which are the longest among the canal walls and the thinnest in three parts of the medial canal wall respectively. 15. 86mm2 is the mean transverse area of the canal in middle part which is the narrowest among three parts of the canal. 17. 96mm, 30. 78mm,51. 23mm and 28. 98mm are the length, distance of medial and lateral margins and the shortest distance of the superior orbital fissure respectively. The mean angle to the sagittal plane is 40. 61 + 3. 49? There exists a good correlation between the data of the coronal scans and sections. The results of the sectional anatomy are the same as that of CT scans on the whole.
Conclusion (1)Allow for the orbital apex, the transnasal endoscopic operation must be performed near the middle line. With the depth increase, the angles must be decreased relatively. (2)For the decompression of the optic canal, it is imp
引文
1 许庚，李源 ．内窥镜鼻窦外科学．广州：暨南大学出版社，1994．171
2 Ma(?)den AO,Kaynak S. Bilateral duplication of the optic canals. Ann Anat, 1996,178:618—64
3 卢范，雷晓寰，韩文江，等．视神经管的显微外科解剖．解剖学杂志，1988，11(2)：120～123
4 胡圣望，胡松林，宋铁山，等．100例颅骨视神经管及其周围关系的观察与测量．解剖学杂志，1993，16(1)：57～60
5 鲍达明，朱家瑞，林明奕，等．经筛人路对视神经管减压的显微外科解剖学．中华显微外科杂志，1993，16(3)：200～202
6 李健，廖建春，陆书昌．视神经管区的临床应用解剖研究．解剖学杂志，1994，17(2)：99～101
7 李源，许庚，杨月如，等．筛蝶区域与视神经管和颈内动脉的毗邻关系．中华耳鼻喉科杂志，1995，30(2)：87～89
8 范静平，章松勤，廖建春，等．内窥镜视神经管减压术应用解剖．中国临床解剖学杂志，1996，14(2)：92～94
9 陶海，马志中，姜荔．视神经管和管内结构的断层观测．中华眼底病杂志，1999，15(1)：24～26
10 Daniels DL,Shiwei Y, Pech P, et al. Computed Tomography and Magnetic Resonance Imaging of the orbital apex. Radiologic Clinics of North America, 1987,25(4):803～817
11 Berlis A, Putz R, Schumacher M. Direct and CT measurements of canals and foramina of the skull base.The British Journal of Radiology, 1992,65:653～661
12 Goldberg RA,Hannani K,Arthur W,et al. Microanatomy of the orbital apex. Ophthalmology,1992,99(9): 1447～1452
13 林贤，蔡兆明，陈瑞华．眶尖结构的临床应用解剖研究．解剖学杂志，2001，24(4)：374～376
14 Natori Y,Rhoton AL. Transcranial approach to the orbit, microsurgical anatomy.J Neurosurg,1994,81: 78～86
15 Danko I, Haug RH. An experimental investigation of the sellar distance for internal orbital dissection. J Oral Maxillofac Surg, 1998,56(6): 749～752
16 Gossman MD,Charonis G, Woser R,et al. The clinonasal line as a reproducible reference guide for optic canal imaging. Amarican Journal of Ophthalmology, 1994, 117(6):815～816
17 曹代荣，江飞，郑义浩，等．视神经管的CT扫描技术．中外医用放射技术，1997．05 06，(5)：29
18 Rose GE. Orbital imaging. Curr OpinOphthalmol,1993, 4(5): 70～75
19 Chong VF, Fan YF, Chan LL. Radiology of the orbital apex. Australas Radiol, 1999,43(3):294～302
20 Ettl A, Zwrtek K, Daxer A, et al. Anatomy of the orbital apex and cavernous sinus on high-resolution magneticresonance images. Surv Ophthalmol ,2000,44(4): 303～323
21 DeLano MC, Fun FY, Zinreich SJ. Relationship of the optic nerve to the posterior paranasal sinuses: a CT anatomic study. AJNR Am J Neuroradiol, 1996,17 (4):669～675
22 孙树岩，邱林丽，于平，等．筛窦及其邻近结构CT影像学研究．中华耳鼻咽喉科杂志，1996，31(4)：240～242
23 刘旭林，周承涛，张光辉，等．健康人视神经管的CT测量及临床意义．中华耳鼻咽喉科杂志，2000，35(4)：275～277
24 Choudhry R, Anand M, Choudhry S,et al. Morphologic and imaging studies of du-plicate optic canals in dry adult humanskulls. Surg Radiol Anat, 1999,21 (3):201～205
25 Basak S, Akdilli A, Karaman CZ, et al. Assessment of some important anatomical variations and dangerous areas of the paranasal sinuses by computed tomography in children. Int J Pediatr Otorhinolaryngol,2000, Sep 29;55(2):81～89
26 刘丰春，姜成瑛，孟庆兰．眶尖部CT解剖及其临床意义．中国临床解剖学杂志，1999，17(4)：293～294
27 Salvolim LL, Cabanis EA, Roclallec A, et al. Computed tomography of the optic nerve: Part 1, Normal Results. Journal of Computed Assisted Tomography, 1998,2(4):141
28 韩洵，刘丰春．颅脑五官CT解剖学．青岛：青岛海洋大学出版社，1993．127～138
29 Hai tao,Zhizhong Ma,Pu Dai,et al. Computer aided three dimensional reconstruc-
tion and measurement of the optic canal and intracanalicular structure. Laryngo-scope,1999, 109(9) :1499
30 Habal MB,Maniscalco JE. Lineaweaver WC. Microsurgical anatomy of the optic canal: Anatomical relations and exposure of the optic nerve. Surgical Forum , 1976 , 27:542-544
31 Chou PI. sadun AA. Lee H. Vasculature and Morphometry of the optic canal and intracanalicular optic nerve. J Neuro ophthalmol, 1995 ,15 : 186-190
32 Maniscalco JE, Habal MB. Microanatomy of optic canal. J Neurosurg , 1978,48: 2402-2406
33 Natori Y,Rhoton AL. Microsurgery anatomy of the superior orbit fissure. Neuro-surgery,1995,36:762
2 Ma(?)den AO,Kaynak S. Bilateral duplication of the optic canals. Ann Anat, 1996,178:618—64
3 卢范，雷晓寰，韩文江，等．视神经管的显微外科解剖．解剖学杂志，1988，11(2)：120～123
4 胡圣望，胡松林，宋铁山，等．100例颅骨视神经管及其周围关系的观察与测量．解剖学杂志，1993，16(1)：57～60
5 鲍达明，朱家瑞，林明奕，等．经筛人路对视神经管减压的显微外科解剖学．中华显微外科杂志，1993，16(3)：200～202
6 李健，廖建春，陆书昌．视神经管区的临床应用解剖研究．解剖学杂志，1994，17(2)：99～101
7 李源，许庚，杨月如，等．筛蝶区域与视神经管和颈内动脉的毗邻关系．中华耳鼻喉科杂志，1995，30(2)：87～89
8 范静平，章松勤，廖建春，等．内窥镜视神经管减压术应用解剖．中国临床解剖学杂志，1996，14(2)：92～94
9 陶海，马志中，姜荔．视神经管和管内结构的断层观测．中华眼底病杂志，1999，15(1)：24～26
10 Daniels DL,Shiwei Y, Pech P, et al. Computed Tomography and Magnetic Resonance Imaging of the orbital apex. Radiologic Clinics of North America, 1987,25(4):803～817
11 Berlis A, Putz R, Schumacher M. Direct and CT measurements of canals and foramina of the skull base.The British Journal of Radiology, 1992,65:653～661
12 Goldberg RA,Hannani K,Arthur W,et al. Microanatomy of the orbital apex. Ophthalmology,1992,99(9): 1447～1452
13 林贤，蔡兆明，陈瑞华．眶尖结构的临床应用解剖研究．解剖学杂志，2001，24(4)：374～376
14 Natori Y,Rhoton AL. Transcranial approach to the orbit, microsurgical anatomy.J Neurosurg,1994,81: 78～86
15 Danko I, Haug RH. An experimental investigation of the sellar distance for internal orbital dissection. J Oral Maxillofac Surg, 1998,56(6): 749～752
16 Gossman MD,Charonis G, Woser R,et al. The clinonasal line as a reproducible reference guide for optic canal imaging. Amarican Journal of Ophthalmology, 1994, 117(6):815～816
17 曹代荣，江飞，郑义浩，等．视神经管的CT扫描技术．中外医用放射技术，1997．05 06，(5)：29
18 Rose GE. Orbital imaging. Curr OpinOphthalmol,1993, 4(5): 70～75
19 Chong VF, Fan YF, Chan LL. Radiology of the orbital apex. Australas Radiol, 1999,43(3):294～302
20 Ettl A, Zwrtek K, Daxer A, et al. Anatomy of the orbital apex and cavernous sinus on high-resolution magneticresonance images. Surv Ophthalmol ,2000,44(4): 303～323
21 DeLano MC, Fun FY, Zinreich SJ. Relationship of the optic nerve to the posterior paranasal sinuses: a CT anatomic study. AJNR Am J Neuroradiol, 1996,17 (4):669～675
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