乙状窦后和乙状窦后—内耳道上入路的显微解剖研究
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摘要
本研究旨在了解桥小脑角的显微解剖；探讨枕下乙状窦后入路及乙状窦后-内耳道上入路的优缺点。本实验采用15例(30侧)干标本和10例(20侧)湿标本，按照枕下乙状窦后入路和乙状窦后-内耳道上入路的所涉及的解剖区域，解剖观测面神经、中间神经、小脑前下动脉及岩静脉等诸多结构，并对神经外科手术乙状窦后入路及乙状窦后。内耳道上入路作初步探讨，主要实验结果如下：
1．面神经桥小脑角池段长为11.13士1.35mm，内耳道段长为10.69±0.90mm。面神经在桥延沟的外端起自脑干，与其外侧的前庭蜗神经进入脑干处相距2.38+0.65mm，距外侧展神经6.62±0.41mm，距三叉神经7.59±1.08mm。由交汇角内前方沿岩骨探查32mm，即可发现面听神经。
2．中间神经单根束居多，共12侧，两根束6侧，三根束2侧。未见四根束。中间神经前庭部长为7.62±0.69mm，中间部长为10.05±1.12mm。
3．小脑前下动脉 小脑前下动脉(AICA)出现率为100％,20侧共23支，单干18侧，双干1侧，三干1侧，未见缺失。20支起自基底动脉(BA)下段，2支起自BA中段，1支起自BA上段。副小脑前下动脉共出现3支，主要分支有迷路动脉、回返穿通动脉、弓状下动脉。
4．10例(20侧)标本共有27支岩静脉，6侧中存在有2～3支岩静脉。岩静脉在脑桥小脑角内各属支的汇合点至岩上窦入口处的距离为3.46±1.87mm。岩静脉在注入岩上窦入口处的压扁外径为2.26±0.82mm。可在前庭蜗神经正上方71mm
To explore the microdissection of the cerebellopontine angle(CPA) as well as to study the advantage and disadvantage of the retrosigmoid approach(RSA) and the retrosigmoid suprameatal approach (RSSMA), the relationship among the facial nerves, inter-medium nerves, anterior inferior cerebellar artery(AICA) and petrosal vein were studied, and two approaches particularly also were explored from fifteen dry skulls and ten wet skulls, along the approach of RSA and RSSMA. The results were as follows:
1. The facial nerves, whose length of CPA was 11.13±1.35mm and the length of internal auditory canal was 10.69±0.90mm. From the brain stem at the lateral end of ponto medullary sulcas, the distance between the facial nerve, the vestibulocochlear nerve, the abducenst nerves, and the trigeminal nerve were 2.38±0.65mm, 6.62±0.41mm, 7.59±1.08mm. The facial nerves and vestibulocochlear nerve could be seen at the inner front part of 32 mm from the intersection endo-anterior.
2. There were one-rootlet of the inter-medium nerves in twelve sides, two in six samples and three in two sides. No four-rootlet were found. The vestibular portion was 7.62±0.69mm long, the intermediate space was 10.05±1.12mm.
3. The frequency of AICA was 100%. There were twenty-three in twenty CPAs, single stem in eighteen CPAs and duplicate stem in one CPAs, tristem in one CPA. There were twenty stems originated from the inferior segment of basal artery, two of which were from the intermediate piece and one from the superior segment. The appearing of Para-AICA was three. The main branch of the AICA was labyrinthine
1．面神经桥小脑角池段长为11.13士1.35mm，内耳道段长为10.69±0.90mm。面神经在桥延沟的外端起自脑干，与其外侧的前庭蜗神经进入脑干处相距2.38+0.65mm，距外侧展神经6.62±0.41mm，距三叉神经7.59±1.08mm。由交汇角内前方沿岩骨探查32mm，即可发现面听神经。
2．中间神经单根束居多，共12侧，两根束6侧，三根束2侧。未见四根束。中间神经前庭部长为7.62±0.69mm，中间部长为10.05±1.12mm。
3．小脑前下动脉 小脑前下动脉(AICA)出现率为100％,20侧共23支，单干18侧，双干1侧，三干1侧，未见缺失。20支起自基底动脉(BA)下段，2支起自BA中段，1支起自BA上段。副小脑前下动脉共出现3支，主要分支有迷路动脉、回返穿通动脉、弓状下动脉。
4．10例(20侧)标本共有27支岩静脉，6侧中存在有2～3支岩静脉。岩静脉在脑桥小脑角内各属支的汇合点至岩上窦入口处的距离为3.46±1.87mm。岩静脉在注入岩上窦入口处的压扁外径为2.26±0.82mm。可在前庭蜗神经正上方71mm
To explore the microdissection of the cerebellopontine angle(CPA) as well as to study the advantage and disadvantage of the retrosigmoid approach(RSA) and the retrosigmoid suprameatal approach (RSSMA), the relationship among the facial nerves, inter-medium nerves, anterior inferior cerebellar artery(AICA) and petrosal vein were studied, and two approaches particularly also were explored from fifteen dry skulls and ten wet skulls, along the approach of RSA and RSSMA. The results were as follows:
1. The facial nerves, whose length of CPA was 11.13±1.35mm and the length of internal auditory canal was 10.69±0.90mm. From the brain stem at the lateral end of ponto medullary sulcas, the distance between the facial nerve, the vestibulocochlear nerve, the abducenst nerves, and the trigeminal nerve were 2.38±0.65mm, 6.62±0.41mm, 7.59±1.08mm. The facial nerves and vestibulocochlear nerve could be seen at the inner front part of 32 mm from the intersection endo-anterior.
2. There were one-rootlet of the inter-medium nerves in twelve sides, two in six samples and three in two sides. No four-rootlet were found. The vestibular portion was 7.62±0.69mm long, the intermediate space was 10.05±1.12mm.
3. The frequency of AICA was 100%. There were twenty-three in twenty CPAs, single stem in eighteen CPAs and duplicate stem in one CPAs, tristem in one CPA. There were twenty stems originated from the inferior segment of basal artery, two of which were from the intermediate piece and one from the superior segment. The appearing of Para-AICA was three. The main branch of the AICA was labyrinthine
引文
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3. Sampath P, Holliday MJ, Brem H, et al. Facial nerve injury in acoustic neuroma (vestibular schwannoma) surgery:etiology and prevention. J Neurosurg, 1997, 87 (1l):60-66.
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7. Lanman TH, Brackmann DE, Hitselberger WE, et al. Report of 190 consecutive cases of large acoustic tumors (vestibular schwannoma) removed via the translabyrinthine approach. J Neurosurg, 1999,90 (4): 617-623.
8. McElveen JT Jr, Belmonte RG, Fukushima T, et al. A review of facial nerve outcome in 100 consecutive cases of acoustic tumor surgery. Laryngoscope, 2000, 110(10):1667-1672.
9. Briggs RJ, Luxford WM, Atkins JS Jr, et al. Translabyrinthine removal of large acoustic neuromas. Neurosurgery, 1994, 34 (5): 785-790.
10. Shiobara R, Ohira T, Kanzaki J, et al. A modified extended middle cranial fossa approach for acoustic nerve tumors. Results of 125 operations. J Neurosurg, 1988, 68 (3): 358-365.
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18. Samii M, Tatagiba M, Carvalho GA. Retrosigmoid intradural suprameatal approach to Meckel's cave and the middle fossa: surgical techniqe and outcome.J Neurosurg, 2000, 92(2): 235-241.
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47．赵卫东．乙状窦后-内听道上入路的相关显微解剖和临床研究[M]，复旦大学附属华山医院，2003．
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52．赵卫东，周良辅，毛颖．显微解剖研究乙状窦后-内听道上入路中天幕切开的指征．中国神经精神疾病杂志，2004，30(3)：161-164．
53．赵卫东，周良辅，毛颖．乙状窦后—内听道上入路的相关显微解剖研究．中国临床神经科学，2003，11(2)170-174．
54．宫剑，于春江，关树森，等．乙状窦后经内听道上嵴入路应用解剖学研究．首都医科大学学报，2005，26(1)：70-73．55．张岩松，惠国祯，常义，等．乙状窦后内听道上入路的显微解剖研究[J]．江苏医药杂志，2002，28(11)：843-845．
56. Goel A, Muzumdar D. Conventional posterior fossa approach for surgery on petroclival meningiomas: a report on an experience with 28 cases [J]. Surg Neurol, 2004, 62(4): 332-338.1. Rhoton AL Jr. The celebellopntine angle and posterior fossa cranial nerves by the retrosigmoid approach. Neurosurgery, 2000, 47(3 suppl): 93-129.
2. Sampath P, Rini D, Long DM, et al. Microanatomical variations in the cerebello pontine angle associated with vestibular schwannomas(acoustic neuromas): a retrospective study of 1006 consecutive cases. J Neumaurg, 2000, 92(1): 70-78.
3. Sampath P, Holliday MJ, Brem H, et al. Facial nerve injury in acoustic neuroma (vestibular schwannoma) surgery: etiology and prevention. J Neurosurg, 1997, 87 (1): 60-66.
4. Matthies C, Samii M. Management of 1000 vestibular schwannomas (acoustic neuromas): clinical presentation. Neurosurgery, 1997, 40(1): 1-9.
5．朱国臣，韩卉，牛朝诗．Dorello管区显微外科解剖学研究．安徽医科大学学报，2001，36(2)：93-95．
6．张庆华，孙涛，田继辉，等．桥小脑角区上血管神经复合体的显微解剖学研究[J]．中华神经外科杂志，2005，21(7)：416-419．
7. Carmine D. Clemente. Gray's Anatomy. Thirtieth American Edition, London: Williams & Wilkins, 1984: 1170-1172.
8．朱国臣．脑桥小脑角区内镜解剖学研究[M]．郑州，郑州大学第一附属医院，2004：107．
9．柏树令，应大君．系统解剖学(第6版)[M]．人民卫生出版社，北京，2004：421．
10. Irving RM, Viani L, Hardy DG, et al. Nervus intermedius function after vestibular schwannoma removal: clinical features and pathophysiological mechanisms. Laryngoscope, 1995, 105(8): 809-813.
11．潘亚文，袁贤瑞．与听神经瘤相关的桥小脑角区显微解剖．国外医学神经病学神经外科学分册．2003，30(4)：352-355．
12．张玉学，张为龙，李金库．小脑桥脑角的显微解剖学．白求恩医科大学学报[J]，1983，9(12)：62-64．
13. Kim HN, Kim YH, Park IY, et al. Variability of the surgical anatomy of the neurovascular complex of the cerebellopontine angle [J]. Ann Otol Rhinol Laryngol, 1990, 99(4): 288-296.
14．卜国铉，樊忠．耳鼻咽喉神经外科学[M]．长春：吉林科学技术出版社，1992：10-15．15．曾司鲁，李旭光．国人脑动脉系统的研究Ⅲ：小脑的动脉[J]．解剖学报，1981，12(2)：113-115．
16. Martin RG, Grant JL, Peace D, et al. Microsurgical relationships of the anterior inferior cerebellar artery and the facial-vestibulocochlear nerve complex [J]. Neurosurgery, 1980, 6(5): 483-507.
17. Mazzoni A, Hansen CC. Surgical anatomy of the ateries of the internal auditory canal. Arch Otolaryngol, 1970, 91(2): 128-135.
18．雷晓环，卢范，韩文江，等．面神经和前庭蜗神经在桥小脑角及内耳道的显微解剖[J]．解剖学报，1998，19(1)：1-6．
19．房台生，马兆龙，杨庆余，等．岩静脉的显微外科解剖．西安医学院学报，1982，3(1)：575．
20. Seoane E, Rhoton AL Jr. Suprameatal extension of the retrosigmoid approach: microsurgical anatomy [J]. Neurosurgery, 1999, 44(3): 553-560.
21. Samii M, Tatagiba M, Carvalho GA. Retrosigmoid intradural suprarneatal approach to Meckel's cave and the middle fossa: surgical techniqe and outcome. J Neurosurg, 2000, 92(2): 235-241.
22．赵卫东．乙状窦后—内听道上入路的相关显微解剖和临床研究[M]，复旦大学附属华山医院，2003．
23．赵卫东，周良辅，毛颖．显微解剖研究乙状窦后-内听道上入路中天幕切开的指征．中国神经精神疾病杂志，2004，30(3)：161-164．
24．赵卫东，周良辅，毛颖．乙状窦后-内听道上入路的相关显微解剖研究．中国临床神经科学，2003，11(2)：170-174．
25. Koos WT, Day JD, Matula C, et al. Neurotopogaphic considerations in the microsurgical treatment of small acoustic neurinomas. J Neurosurg, 1998, 88 (3): 506-512.
26．张岩松，惠国祯，常义，等．乙状窦后内听道上入路的显微解剖研究[J]．江苏医药杂志，2002，28(11)：843-845．
27. Cheung SW, Jackler RK, Pitts LH, et al. Interconnecting the posterior and middle cranial fossae for tumors that traverse Meckel's cave. Am J Otol. 1995, 16(2): 200-208.
28. Goel A, Muzumdar D. Conventional posterior fossa approach for surgery on petroclival meningiomas: a report on an experience with 28 cases [J]. Surg Neurol,??2004，62(4)：332-338．
29．陈立华，陈凌，Samii A．等．枕下乙状窦后．内听道上入路显微手术切除岩斜区脑膜瘤．中国耳鼻咽喉颅底外科杂志，2005，11(5)：311-315．
2. Sampath P, Rini D, Long DM, et al. Microanatomical variations in the cerebello pontine angle associated with vestibular schwannomas(acoustic neuromas): a retrospective study of 1006 consecutive cases. J Neumaurg, 2000, 92(l):70-78.
3. Sampath P, Holliday MJ, Brem H, et al. Facial nerve injury in acoustic neuroma (vestibular schwannoma) surgery:etiology and prevention. J Neurosurg, 1997, 87 (1l):60-66.
4. Matthies C, Samii M. Management of 1000 vestibular schwannomas (acoustic neuromas): clinical presentation. Neurosurgery, 1997,40(1): 1-9.
5. Samii M, Matthies C. Management of 1000 vestibular schwannomas(acoustic neuromas): surgical management and results with an emphasis on complications and how to avoid them. Neurosurgery, 1997, 40(1): 11-21.
6. Samii M, Matthies C. Management of 1000 vestibular schwannomas (acoustic neuromas):hearing functionin 1000 tumor resections.- Neurosurgery, 1997, 40(2):248-260.
7. Lanman TH, Brackmann DE, Hitselberger WE, et al. Report of 190 consecutive cases of large acoustic tumors (vestibular schwannoma) removed via the translabyrinthine approach. J Neurosurg, 1999,90 (4): 617-623.
8. McElveen JT Jr, Belmonte RG, Fukushima T, et al. A review of facial nerve outcome in 100 consecutive cases of acoustic tumor surgery. Laryngoscope, 2000, 110(10):1667-1672.
9. Briggs RJ, Luxford WM, Atkins JS Jr, et al. Translabyrinthine removal of large acoustic neuromas. Neurosurgery, 1994, 34 (5): 785-790.
10. Shiobara R, Ohira T, Kanzaki J, et al. A modified extended middle cranial fossa approach for acoustic nerve tumors. Results of 125 operations. J Neurosurg, 1988, 68 (3): 358-365.
11. Darrouzet V, Guerin J, Aouad N, et al. The widened retrolabyrinthine approach:a new concept in acoustic neuroma surgery. J Neurosurg, 1997, 86(5): 812-821.
12. House MF.Surgical exposure of the internal anditory cananl and its contents though the middle cranial fossa. Laryngoscope,1961,71(11):1361-1385.
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