眶上裂区显微解剖学研究
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摘要
目的 研究眶上裂(superior orbital fissure，SOF)及其毗邻结构显微解剖，为临床眶上裂区手术及疾病诊断提供显微解剖学资料。方法 ①4例胎儿眶上裂血管铸型标本观测；②3例成人眶上裂区组织结构火棉胶包埋薄层断面观测；③30例(60侧)成人颅骨眶上裂观测；④18例(36侧)成人颅底眶上裂的分区、穿行结构、眶内静脉与海绵窦(cavernous sinus，CS)前间隙交通、眼动脉及其主要分支、视神经管区、筛窦外侧壁、睫状神经节及蝶顶窦观测。结果 ①眶上裂呈三角形裂隙，其上壁长度为17.65±1.68mm、外侧壁长度为18.79±2.96mm、内侧壁长度为8.12±1.59mm；②眶上裂被Zinn腱环分为外、中、下三个区，滑车神经、额神经、泪腺神经及眼上静脉经外侧区穿行，动眼神经上、下支、外展神经、鼻睫神经及睫状神经节的交感根和感觉根经中央区穿行，仅眼下静脉经下侧区穿行；③在眶上裂断层标本上，测量额神经与滑车神经、展神经与鼻睫神经平颅口部距离分别为2.46±0.59mm、1.96±0.72mm，以及眶上裂中央区展神经与视神经管在颅口部的最短距离为9.32±0.85mm；④眼上、下静脉在眶内汇合形成4.35～4.97mm的眼静脉总干，从海绵窦前间隙前方或前下方汇入海绵窦前间隙；⑤36侧标本中有34侧(94.4％)的眼动脉来源于颈内动脉，有2侧(5.6％)来源于脑膜中动脉，眼动脉的主要分支包括视网膜中央动脉、睫状后动脉、泪腺动脉、眶上动脉、筛前、后动脉等；⑥测量睫状神经节至视神经外侧面距离左侧为1.25±0.76mm、右侧为1.34±0.92mm,睫状神经节前缘至眶下缘中点距离左侧为32.66±3.25mm、右侧为34.38±3.24mm；⑦测量视神经管上、下壁长度分别为8.92±1.79mm、6.02±1.27mm，外侧壁与内侧壁长度分别为7.79±1.64mm，8.56±1.72mm,视环厚度为0.62mm；⑧Dacryon点(上颌骨、额骨、泪骨的交汇点)至筛前、后孔及视神经管眶口间的距离分别为21.45±2.54mm，34.23±2.90mm，39.25±1.53mm。结论 ①眶上裂区穿行结构复杂，排列紧凑，手术操作须在显微镜下直视进行；②眶上裂区薄层断面
安徽医科大学硕士学位论文
能原位、准确显示眶上裂区结构，有助于临床眶上裂区疾病的诊断与治疗；③经
眼上静脉治疗颈内动脉海绵窦瘦是可行的：④熟悉眼动脉及其主要分支的显微解
剖，处理眶上裂区病变时，可避免发生泪腺或眼球的缺血；⑤在选择球后麻醉时，
进针的深度宜为32刁6mm；③视神经管内侧壁与蝶窦和筛窦毗邻关系复杂，视神
经管隆突可以作为经筛、蝶窦入路手术时重要的标志结构；①在筛窦手术或视神
经管减压术时，Dacryo。点与筛前孔、筛后孔及视神经管眶口距离，可为正确寻找
和处理筛动脉及视神经管提供依据。
Objective To study microanatomy of the superior orbital flssure(SOF) region and its adjacent structures, in order to provide anatomical basis for the operation of the SOF region. Methods (1)The corrosion cast specimens of the SOF in 4 fetus were observed; (2)The serial thin sections of the SOF which embedded with celloidin were observed; (3)Osseous structures of the SOF were observed and measured in 30 skull under macro-microscopy;(4)The structures passing the SOF, the orbital venous drainage into the anterior cavernous sinus space, the ophthalmic artery and its branches, optic canal, the lateral wall of the ethmoid, the
ciliary ganglion and the sinus spehenopariethalis were observed and measured in 36 sides of adult cadaveric heads under microscopy. Results (1)The SOF was a triangular cleft and the length of the superior side, the lateral side and the medial side of the SOF were 17.65±1.68mm,18.79±2.96mm,8.12 ± 1.59mm respectively; (2)The SOF was divided into three areas by the annular tendon. The lateral area was passed by the trochlear, frontal and lacrimal nerves and the superior ophthalmic vein. The central area transmit 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 area was passed by the inferior ophthalmic vein; (3)The distance between the frontal and trochlear nerves in the cranial orifice of lateral area was 2.46 ±0.59mm, The distance between the abducens and nasociliary nerves in the cranial orifice of central area was 1.96 +0.72mm, the smallest distance between the abducens nerves of the lateral area and the optic canal was 9.32 ±0.85mm in the section of the SOF;(4)The superior ophthalmic vein and inferior ophthalmic always fused together to form a common venous confluence approximately 4.35-4.97mm in length. The common venous confluence entered the anterior cavernous
sinus
space in its anterior or anterioinferior aspect;(5)94.4% ophthalmic artery arose from the interna carotid artery, 5.6% ophthalmic artery arose from both the internal carotid and middle menigeal artery, The main branches of ophthalmic artery included posterior ciliary artery, central retinal artery, lacrimal artery, anterior ethmoidal artery and posterior ethmoidal artery;(6)Ciliary ganglion was suited between optic nerve and lateral rectus. The shapes of ciliary ganglion was rectangle, oval or triangle respectively. The distance from ciliary ganglion to the posterior wall of eyeball, inferior edge of orbit, optic nerve and superior orbital fissure were measures respectively;(7)The length of the optic canal, the height and transverse dimension of both openings, and the thickness of the canal wall were measured. The relationship of adjacent structures of the optic canal was observed;(8)The distances from Dacryon point to the anterior and posterior ethmoidal foramen and optic formen were 21.45 ± 2.54mm,34.23±2.
90mm, 39.25 ± 1.53mm respectively. Conclusions (1)The issues in this region are fragile, compact, and easy to be injured. It will be good that the operation in this region be fulfilled under microscope;(2)The serial thin section of the SOF has special advantage over other methods in measuring the irregular structure and is helpful for surgical operation in this region;(3)It can be performed cavernous sinus embolism through SOF;(4)Ophthalmic artery and its branches can be protected in operation if we are familiar with the microanatomy of ophthalmic artery;(5)The injection depth should be 32~36mm for retrobulabar anesthesia;(6)The bulges of optic nerve canal could be thought as an important landmark; (7) It was important to find ethmoidal artery in operation of ethmoidal sinus and optic canal decompression.
安徽医科大学硕士学位论文
能原位、准确显示眶上裂区结构，有助于临床眶上裂区疾病的诊断与治疗；③经
眼上静脉治疗颈内动脉海绵窦瘦是可行的：④熟悉眼动脉及其主要分支的显微解
剖，处理眶上裂区病变时，可避免发生泪腺或眼球的缺血；⑤在选择球后麻醉时，
进针的深度宜为32刁6mm；③视神经管内侧壁与蝶窦和筛窦毗邻关系复杂，视神
经管隆突可以作为经筛、蝶窦入路手术时重要的标志结构；①在筛窦手术或视神
经管减压术时，Dacryo。点与筛前孔、筛后孔及视神经管眶口距离，可为正确寻找
和处理筛动脉及视神经管提供依据。
Objective To study microanatomy of the superior orbital flssure(SOF) region and its adjacent structures, in order to provide anatomical basis for the operation of the SOF region. Methods (1)The corrosion cast specimens of the SOF in 4 fetus were observed; (2)The serial thin sections of the SOF which embedded with celloidin were observed; (3)Osseous structures of the SOF were observed and measured in 30 skull under macro-microscopy;(4)The structures passing the SOF, the orbital venous drainage into the anterior cavernous sinus space, the ophthalmic artery and its branches, optic canal, the lateral wall of the ethmoid, the
ciliary ganglion and the sinus spehenopariethalis were observed and measured in 36 sides of adult cadaveric heads under microscopy. Results (1)The SOF was a triangular cleft and the length of the superior side, the lateral side and the medial side of the SOF were 17.65±1.68mm,18.79±2.96mm,8.12 ± 1.59mm respectively; (2)The SOF was divided into three areas by the annular tendon. The lateral area was passed by the trochlear, frontal and lacrimal nerves and the superior ophthalmic vein. The central area transmit 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 area was passed by the inferior ophthalmic vein; (3)The distance between the frontal and trochlear nerves in the cranial orifice of lateral area was 2.46 ±0.59mm, The distance between the abducens and nasociliary nerves in the cranial orifice of central area was 1.96 +0.72mm, the smallest distance between the abducens nerves of the lateral area and the optic canal was 9.32 ±0.85mm in the section of the SOF;(4)The superior ophthalmic vein and inferior ophthalmic always fused together to form a common venous confluence approximately 4.35-4.97mm in length. The common venous confluence entered the anterior cavernous
sinus
space in its anterior or anterioinferior aspect;(5)94.4% ophthalmic artery arose from the interna carotid artery, 5.6% ophthalmic artery arose from both the internal carotid and middle menigeal artery, The main branches of ophthalmic artery included posterior ciliary artery, central retinal artery, lacrimal artery, anterior ethmoidal artery and posterior ethmoidal artery;(6)Ciliary ganglion was suited between optic nerve and lateral rectus. The shapes of ciliary ganglion was rectangle, oval or triangle respectively. The distance from ciliary ganglion to the posterior wall of eyeball, inferior edge of orbit, optic nerve and superior orbital fissure were measures respectively;(7)The length of the optic canal, the height and transverse dimension of both openings, and the thickness of the canal wall were measured. The relationship of adjacent structures of the optic canal was observed;(8)The distances from Dacryon point to the anterior and posterior ethmoidal foramen and optic formen were 21.45 ± 2.54mm,34.23±2.
90mm, 39.25 ± 1.53mm respectively. Conclusions (1)The issues in this region are fragile, compact, and easy to be injured. It will be good that the operation in this region be fulfilled under microscope;(2)The serial thin section of the SOF has special advantage over other methods in measuring the irregular structure and is helpful for surgical operation in this region;(3)It can be performed cavernous sinus embolism through SOF;(4)Ophthalmic artery and its branches can be protected in operation if we are familiar with the microanatomy of ophthalmic artery;(5)The injection depth should be 32~36mm for retrobulabar anesthesia;(6)The bulges of optic nerve canal could be thought as an important landmark; (7) It was important to find ethmoidal artery in operation of ethmoidal sinus and optic canal decompression.
引文
1 Natrori Y, Rhoton AL Jr. Transcranial approach to the orbit: Microsurgical anatomy. J Neurosurg, 1994,81: 78～86
2 Spektor S,Piontek E,Umansky F. Orbital venous drainage into the anterior cavernous sinus space: Microanatomic relationships. Neurosurg, 1997,40(3):532
3 Inoue T, Rhoton AL Jr.Theele D,et al. Surgical approaches to the cavernous sinus: A microsurgical study. Neurosurg, 1990,26:903
4 胡福广，张庆俊．视神经管显微解剖(综述)．国外医学·神经病学神经外科学分册，2000，27(1)：24～26
5 韩卉，朱国臣．脑神经海绵窦段的显微解剖及其临床应用．解剖学研究，2000，22(2)：95～97
6 张为龙，钟世镇主编．临床解剖学丛书：头颈部分册．北京：人民卫生出版社，1988，59～64
7 牛朝诗，罗其中，李长元等．海绵窦上壁的显微外科解剖学研究．中华显微外科杂志，1999，22(2)：130～132
8 Natori Y, Rhoton Al Jr. Microsurgery anatomy of the superior orbital fissure. Neurosurgery, 1995,36:762～775.
9 张运宏，高永中，肖利华，等．颅眶显微外科解剖学研究及其手术入路探讨．中华神经外科杂志，1999，15(2)：105～108
10 Morard M,Tcherekayev V, de Tribolet N. The superior orbital fissure:A microanatomical study. Neurosurg, 1994,35:1087
11 田继辉，于春江，孙涛，等．眶上裂区显微解剖学研究．中华神经外科杂志，1999，15(3)：200～204
12 Goldberg RA, Kambiz H, Toga AW. Microanatomy of the Orbit Apex CT and Microcryoplaning of soft and hard tissure. Ophthamology, 1992,99(9): 1447
13 许庚．内窥镜鼻窦手术的并发症．中华耳鼻咽喉科杂志，1993，28：284
14 Veming M, Middelweerd RJ,Vries N. Complications of endoscopic sinus surgery. Arch Otolaryngol Head Neck Surg, 1992,118:617
15 Manigilia AJ.Fatal and other major complications of endoscopic sinus surgery. Laryngoscope, 1991,101:349
16 Sadasivan B,Ma Sh, Dujovny M, et al. The anterior cavernous sinus space. ACTA Neurichir Wien, 1991,108(3～4): 154～158
17 Lang J, Kageyama I, Clinical anatomy of the blood space and blood vessels surrounding the siphon of the internal carotid artery. Acta Anat, 1990,139:320～325
18 Miller NR, Monsen LH, Debrun Gm, et al. Treatment of carotid cavernous sinus fistulas using a superior ophthalmic vein approach. J Neurosu New York, Mcgraw-Hill, 1985:964～976
19 Maniscalco JE, Habal MB.Microanatomy of optic canal. J Neurosurg, 1978,48:402
20 许庚，李源．内窥镜鼻窦外科学．广州：暨南大学出版社，1994，152
21 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
22 鞠学红，王学华，蒋学英，等．筛动脉眶内段及窦内段的应用解剖学研究．临床耳鼻咽喉科杂志，1999，13(9)：399
2 Spektor S,Piontek E,Umansky F. Orbital venous drainage into the anterior cavernous sinus space: Microanatomic relationships. Neurosurg, 1997,40(3):532
3 Inoue T, Rhoton AL Jr.Theele D,et al. Surgical approaches to the cavernous sinus: A microsurgical study. Neurosurg, 1990,26:903
4 胡福广，张庆俊．视神经管显微解剖(综述)．国外医学·神经病学神经外科学分册，2000，27(1)：24～26
5 韩卉，朱国臣．脑神经海绵窦段的显微解剖及其临床应用．解剖学研究，2000，22(2)：95～97
6 张为龙，钟世镇主编．临床解剖学丛书：头颈部分册．北京：人民卫生出版社，1988，59～64
7 牛朝诗，罗其中，李长元等．海绵窦上壁的显微外科解剖学研究．中华显微外科杂志，1999，22(2)：130～132
8 Natori Y, Rhoton Al Jr. Microsurgery anatomy of the superior orbital fissure. Neurosurgery, 1995,36:762～775.
9 张运宏，高永中，肖利华，等．颅眶显微外科解剖学研究及其手术入路探讨．中华神经外科杂志，1999，15(2)：105～108
10 Morard M,Tcherekayev V, de Tribolet N. The superior orbital fissure:A microanatomical study. Neurosurg, 1994,35:1087
11 田继辉，于春江，孙涛，等．眶上裂区显微解剖学研究．中华神经外科杂志，1999，15(3)：200～204
12 Goldberg RA, Kambiz H, Toga AW. Microanatomy of the Orbit Apex CT and Microcryoplaning of soft and hard tissure. Ophthamology, 1992,99(9): 1447
13 许庚．内窥镜鼻窦手术的并发症．中华耳鼻咽喉科杂志，1993，28：284
14 Veming M, Middelweerd RJ,Vries N. Complications of endoscopic sinus surgery. Arch Otolaryngol Head Neck Surg, 1992,118:617
15 Manigilia AJ.Fatal and other major complications of endoscopic sinus surgery. Laryngoscope, 1991,101:349
16 Sadasivan B,Ma Sh, Dujovny M, et al. The anterior cavernous sinus space. ACTA Neurichir Wien, 1991,108(3～4): 154～158
17 Lang J, Kageyama I, Clinical anatomy of the blood space and blood vessels surrounding the siphon of the internal carotid artery. Acta Anat, 1990,139:320～325
18 Miller NR, Monsen LH, Debrun Gm, et al. Treatment of carotid cavernous sinus fistulas using a superior ophthalmic vein approach. J Neurosu New York, Mcgraw-Hill, 1985:964～976
19 Maniscalco JE, Habal MB.Microanatomy of optic canal. J Neurosurg, 1978,48:402
20 许庚，李源．内窥镜鼻窦外科学．广州：暨南大学出版社，1994，152
21 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
22 鞠学红，王学华，蒋学英，等．筛动脉眶内段及窦内段的应用解剖学研究．临床耳鼻咽喉科杂志，1999，13(9)：399