内镜辅助下经乳突侧颅底手术入路的临床解剖学研究
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摘要
研究背景和目的:
随着显微技术、影像技术、内镜技术的不断发展,使颅底外科成为研究的热点。该部位解剖结构复杂,视野暴露困难,对手术操作技能要求比较高。所以对该部位手术入路的选择至关重要,选择较优的手术入路既能够较好地暴露病变又能够减少手术中对正常组织结构的损伤。对该部位的手术入路选择要求在利于清除病变的同时不断向功能保留与恢复方面发展。手术显微镜能提供良好的照明和高质量的放大图像,但也有其局限性。术者只能观察物镜轴线正前方的解剖结构,隐蔽部位的手术操作有困难,或成为手术视野的死角,有时需要人为切开或切除正常的结构,对术后功能的恢复造成影响。内镜正是在此要求下应运而生,在安全、准确和有效地去除病变基础上,能减少创伤,保护功能。内镜技术在侧颅底手术方面,开始应用于内耳道、脑桥小脑角、岩尖区及颈静脉孔部位病变的治疗。由于镜头的方向及镜头与解剖结构之间的距离改变,会使所看到解剖结构的位置、形态及影像的放大倍数发生改变。另外内镜下缺乏立体感,没有后视功能会增加手术的危险和并发症的机会,更需要手术者了解手术野的立体空间结构。近年来,虽然对颅底的显微解剖报道较多,但是多数是限于传统的解剖学研究,不能够很好地结合内镜手术过程进行解剖观测。手术过程中手术医生一般也不可能去测量各个结构之间的距离,也不一定能够将所有的标志性结构全部暴露,需要手术者熟练掌握手术野的每一个结构的内镜下解剖特点及内镜手术入路中的重要解剖标志。
本课题目的是应用在尸体标本上模拟手术入路的方法,探讨内镜辅助下经乳突颈静脉球部位手术入路、内镜辅助下经迷路下入路切除岩尖病变、内镜辅助下乙状窦前及乙状窦后手术入路下的解剖结构特点和临床操作特点,并探讨了上述手术入路的适用范围以及在手术入路中内淋巴囊的保护措施,为临床手术开展起指导作用。
面神经与前庭蜗神经是侧颅底部位手术时遇到的重要结构,手术过程中容易受到损伤,所以本课题重点探讨颞骨内面神经的定位方法,以及内耳道内神经的走行与连接的关系,为临床手术中保护面神经、听神经功能提供理论指导。
应用标本解剖、CT影像技术及血管铸型技术探讨颈静脉球的形态及其与周围结构的关系,探讨其分类标准以及不同类型对手术入路的影响。为临床影像诊断及手术入路的选择提供依据。
方法:
1.应用15例(30侧)成人头颅标本,模拟内镜辅助下经乳突颈静脉球部位手术,观察手术入路中主要结构及颈静脉球部位的暴露情况。
2.对60例成人(120侧)颈静脉球部位的多层螺旋CT扫描图像进行分析,结合30例颞骨标本解剖及6例血管铸型标本,观察其形态特点及与周围结构的位置关系。以鼓室内侧壁作虚拟一矢状平面,在该平面上分别以鼓室的后壁、下壁切线为坐标轴(X轴、Y轴)在矢状面上将该部位划分为4个象限,根据颈静脉球顶的位置在该平面上的投影所在象限进行统计分型,分别为Ⅰ、Ⅱ、Ⅲ、Ⅳ4型,再根据每型在该平面的内侧或外侧分成亚型。在标本上模拟经乳突部位的手术入路,观察各型颈静脉球对手术入路的影响。
3.应用13例(26侧)经10%福尔马林固定之成人头部湿标本,2例(4侧)新鲜成人头部标本在内镜下分别模拟乙状窦前入路与乙状窦后入路操作。对比观察两手术入路下的解剖学结构特点,测量相关数据。
4.应用10例20侧10%福尔马林固定成人头部湿标本,显微镜下模拟乙状窦前-迷路后入路手术方法解剖前庭导水管外口及内淋巴囊的位置。观察手术操作对内淋巴囊及前庭导水管外口的影响。
5.(1)应用30例干颞骨标本依次测量颈内动脉膝部到面神经管垂直段的距离、面神经管到岩尖的距离以及颈内动脉膝部到颞骨岩部后面的距离,并在干颞骨标本上面磨出该手术路径。(2)应用临床60例颞骨多层螺旋CT检查扫描数据,通过重建技术在不同平面来观测颞骨岩部主要结构,观察迷路下岩尖入路中的结构特点,颞骨岩部气房的特点,测量面神经垂直段到颈内动脉膝部的距离,面神经管垂直段到岩尖的距离;颈内动脉膝部到岩部后面的距离,与标本组进行比较。(3)应用10例(20侧)经10%福尔马林固定之成人尸头湿标本,在手术显微镜下模拟迷路下入路切除岩尖气房,分别测量后半规管的最低点到颈静脉球最高点的骨板之间的距离,面神经管垂直段和乙状窦骨板之间的距离。在以上标本上观察手术入路中的主要解剖学标志。
6.在手术显微镜下对30例成人颞骨标本的内耳道内神经进行显微解剖,观察神经走行关系、面神经与前庭神经之间的吻合关系及耳蜗神经与前庭神经之间的吻合关系。
7.应用30例颞骨标本(包括新鲜标本6例)模拟乳突根治术,面隐窝入路手术,面神经减压手术,对28例外伤性面瘫临床病例行面神经减压手术,观察面神经与外半规管及面神经隐窝外侧气房等周围结构的关系。
结果:
1.30例标本中,颈静脉球到面神经垂直段的距离:(3.58±1.33)mm;颈静脉球前壁到面神经垂直段的距离:(5.07±2.93)mm;颈静脉球顶到后半规管距离:(4.68±3.47)mm。33%(10例)颈静脉球顶位于鼓室下方,面神经垂直段前方;40%(12例)位于面神经垂直段内侧鼓室后方,面神经位于颈静脉球顶部的中间位置;17%(5例)位于鼓室和面神经后;7%(2例)位于面神经及鼓室底壁内侧接近内耳道下壁;3%(1例)突入到鼓室内。应用内镜能够在面神经垂直段后暴露颈静脉球部位,清楚地显示颈静脉球内侧壁的后组脑神经与血管,并且能够显示脑神经出颅进入颈静脉球的部位。
2.颈静脉球主要有平坦型和突起型。象限分类:CT影像组:Ⅰ型9%(11例)、Ⅱ型53%(63例)、Ⅲ型21%(25例)、Ⅳ型17%(21例);标本组:Ⅰ型3%(1例)、Ⅱ型37%(11例)、Ⅲ型27%(8例)、Ⅳ型33%(10例)。每型都可以分成亚型,不同类型可以影响不同的手术入路。
3.乙状窦前入路中内耳道后唇、三叉神经、迷走神经距离骨窗口前缘的距离分别为(14.04±3.56)mm、(28.62±1.62)mm、(12.53±4.11)mm。乙状窦后入路中3者距离骨窗口前缘的距离分别为(28.66±3.78)mm、(42.06±2.42)mm、(33.16±4.71)mm。乙状窦后入路至脑桥小脑角结构的距离大于乙状窦前入路至脑桥小角结构的距离。内镜与颞骨岩部后面的角度在乙状窦前入路接近平行,在乙状窦后入路角度(24.83±2.02)°。在两入路中内镜下解剖结构的位置关系有所不同。
4.前庭导水管外口在乳突腔面投影在后半规管后下的最大距离为3mm,均在外半规管延长线的下方。20例标本中内淋巴囊的位置:Ⅰ型12例;Ⅱ型7例;Ⅲ型1例,内淋巴囊尾端可越过乙状窦。
5.(1)干颞骨标本及影像测量:面神经管垂直段到颈内动脉膝部距离分别为(13.26±1.66)mm,(14.45±1.73)mm;面神经管垂直段到岩尖的距离分别为(34.48±1.07)mm,(34.42±2.03)mm;颈内动脉膝部到岩部后面的距离分别为(9.68±1.53)mm,(11.70±1.38)mm。(2)60例颞骨CT扫描图象显示,乳突气化情况分类:气化型55%(33例);板障型:13.3%(8例);硬化型:1.7%(1例);混合型:30%(18例)。岩尖气化分类:Ⅰ型(气化良好):11.7%(7例);Ⅱ型(混合型):53%(32例);Ⅲ型无气化:35%(21例)。52%(31例)颈静脉球与后半规管、耳蜗及内耳道之间有操作空间,48%(29例)颈静脉球接近后半规管、耳蜗或内耳道。(3)模拟手术标本能够完成迷路下手术入路的13例。面神经管垂直段中点到乙状窦前壁距离为(6.42±2.65)mm;后半规管骨管到颈静脉球距离为(5.76±3.38)mm。
6.(1)30例颞骨标本中,37%(11例)面神经在内耳道内一直在前上位置;63%(19例)面神经从内耳道底至内耳道口过程中均有围绕前庭神蜗经纵轴不同程度的向前下旋转,旋转范围大致在30°-90°之间,旋转的方向与耳蜗旋转的方向相同。(2)30例标本中,17%(5例)标本没有发现前庭神经与面神经吻合支;83%(25例)面神经与前庭神经之间存在吻合支,并且形态和数目存在差异。67%(16例)吻合支在接近内耳道口部位;33%(8例)吻合支在接近内耳道底的外1/3的内耳道内,吻合支直径在0.5-1.0mm之间。(3)30例标本中,80%(24例)存在前庭耳蜗神经吻合支,在内耳道底部位,其中43%(13例)是一些刷状的神经纤维束直接进入球囊,50%(15例)在内耳道底部位有横行的吻合支,7%(2例)标本可以看到有多个吻合支,部分为两种形式共存,仅在内耳道中间有吻合支者3%(1例);20%(6例)标本没有发现有明显前庭耳蜗神经吻合。
7.砧骨短突的末端作一平行于外半规管的延长线,再以外半规管中后1/3部位于二腹肌嵴前端作一延长线,两线交点即为面神经锥段所在。在外半规管中后1/3交点下方(1.70±0.33)mm,面隐窝外侧气房的后上方也可定位面神经锥段。锥段向下与二腹肌嵴前端连线可以定位面神经垂直段。面隐窝外侧气房可以帮助定位面神经与面神经隐窝,面神经周围血管丛颜色改变能帮助定位面神经。前庭窗上缘与匙突根部上缘连线为面神经水平段骨管的下缘,膝状神经节位于其延长线上匙突前约(2.84±0.23)mm。沿膝状神经节向内后可定位面神经迷路段。
结论:
1.内镜辅助下经乳突入路切除颈静脉球部位病变,损伤较小,利于保留面听功能及后组脑神经功能。
2.应用象限法对颈静脉球位置分型,简单明确,有立体感,方便影像学描述和术前设计手术方案。
3.骨窗口至主要结构的距离在内镜下乙状窦前入路较乙状窦后入路近,有利于内镜操作;乙状窦前入路利于处理小脑腹侧病变,适合与幕上入路或颅中窝入路联合;乙状窦后入路利于观察岩锥后面的结构。
4.了解前庭导水管及内淋巴囊的具体位置并根据其位置设计切口利于保护内淋巴囊的结构完整和保护听力,利于术后关闭硬脑膜切口。
5.经迷路下入路手术切除岩尖病变能够保护外耳道、耳蜗、迷路不受损伤,保存听力,是一个具有临床应用价值的手术途径。
6.在内耳道内,神经走行关系及神经之间的吻合均存在着个体差异。熟悉这些关系利于手术中保护神经功能,利于探讨面神经、前庭及耳蜗疾病之间的关系。
7.面神经隐窝外侧气房以及面神经周围血管丛颜色改变利于术中准确和快速定位面神经。
主要创新点:
1.通过对内镜辅助下经乳突颈静脉球部位手术入路的观测,明确了内镜辅助下经乳突颈静脉球部位手术入路视野范围、解剖结构特点以及神经血管之间结构关系,有助于临床上对该部位病变的清除。
2.明确了内镜辅助下迷路下岩尖病变清除的适应证,解剖结构特点,以及手术前对该手术入路的选择指标,该部位病变的手术治疗具有临床指导作用。
3.通过内镜下乙状窦前入路及乙状窦后入路的比较研究,明确了两种手术入路的优缺点,手术适用范围,对临床具有指导作用。
4.探讨了内淋巴囊与乙状窦的关系,内淋巴囊裂在乳突腔面的投影范围,对该部位手术入路中内淋巴囊的保护提供了理论依据。
5.通过解剖及影像学研究,首次探讨了颈静脉球的立体分型标准和方法,对临床影像诊断,以及术前制定手术方案具有指导意义。
6.探讨了面神经隐窝外侧气房及面神经管周围的血管网颜色改变对面神经定位的意义,为临床面神经的定位提供了简便方法。
7.对内耳道内的神经走行关系,以及神经之间的连接关系进行了研究,利于手术中面、听功能的保护,为揭示临床一些疾病病因提供理论基础。
Background:
With the development of micrological technique,image technique and the endoscopic technique,the investigation in laterol skull base have been the focus of the territory of head and neck surgery.But the anatomy structure in this area was complicate,and the operative procedure was difficult.So it is very important to choseing an appropriate surgical approach in the treatment of the lesions in the latero-skull base.Our purpose in the selecting of the ssurgical approach was to relieve the distraction of the normal structure,gain well exposure,shortening the distance to the lesion,amelioration the illumination of the deep part and amplification the operation area.The operating microscope could provide satisfactory lighting and high-quality enlarged image,but which also had many shortcomings,such as the operator only can to observe the structure exactly anterior aspect the axial ray of the objective lens,and in some tomes it need to destroy the normal tissue for the exposure of the lesion.The endoscope could provide the convenient to the operative procedure in the area that it was difficult to operate under operating microscope.The image under the endoscope is different from what under the microscope and the approach can offer a direct acces to the lesion.Now the endoscope surgery has been used in the surgical treatment of the lesion of internal acoustic meatus, cerebellopontine angle,petrous apex and jugular foramen by some people.But the endoscope also has it's shortage,it could not to observe the anatomic structure behind the top of the endoscope,and it has no stereo-feel of the image under the endoscope. The anatomy under the endoscope is different from what under the microscope,thus being familiar with anatomy in lateral skull base under the endoscope is important in carrying out the endoscope surgery of lateral skull base in clinical practice.
Objectives:
1.To investigate the surgical approach of the jugular foramen and the clinical anatomy of the transmastoid endoscopy-assisted jugular foramen surgery.To observe the relationship between the jugular bulb and the surrounding structure,and to investigate the classification and morphology of jugular bulb.
2.To investigate the anatomy of the endoscopic presigmoid-retrolabyrinthine (PSRL) approach and the endoscopic retrosigmoid(RS) approach,and to provid the data for the choice of surgical approach.To study the anatomy of external aperture of vestibular aqueduct and endolymphatic sac and to discuss the protective methods of endolymphatic sac in the PSRL approach.
3.To investigate the anatomical dimension of the path to the petrous apex via the infralabyrinthine approach.
4.To discourse the landmark of facial nerve in the surgery relate to the temporal bone,and to investigate the topographical relationship and the anastomosis of the nerver in humans internal auditory canal.
Methods:
1.The transmastoid endoscopy-assisted jugular foramen surgery was simulated in 15 adult cadaveric specimens(30 sides).The main anatomic mark in the surgical approach was studied,and the distance between the important structures to the glomus jugular has been measured.
2.In this study,we dissected 30 human temporal bones and studied 120 cases CT imaging data of temporal bone and 6 cases blood vessel cast mould specimen of the jugular bulb,to observe the morphology of jugular bulb.We made imagination plane through the medial wall of the tympanic cavity,made a level tangent line of the proximal wall of the tympanic,a vertical tangent line of the posterior wall of the tympanic,look it as coordinate axis(the X axis and Y axis),so the four quadrant (Ⅰ,Ⅱ,Ⅲ,Ⅳ) have been formed,the quadrant that with the tympanic is the quadrantⅠ.So the jugular bulb was classified according to the position of its dome.
3.The endoscopic PSRL approach and the endoscopic RS approach were simulated in 15 adult cadaveric specimens.The anatomic characteristic was studied, and the distance between the importand structors to the anterior border of the bone window in each surgical approach were measured.
4.Used 10case(20 sides) formalin fixed heads of people,to anatomy the external aperture of vestibular aqueduct and endolymphatic sac with surgical microscope according the presigmoid-retrolabyrithine approach.The location of external aperture of vestibular aqueduct and endolymphatic sac were measured and compared with canalis semicircularis posterior.
5.Thirty dry temporal bone were discissio along the internal carotid canal.The distance from the vertical stage of the facial nerve to the lap of the internal carotid canal,the vertical stage of the facial nerve to the petrous apex,the lap of the internal carotid canal to the posterior surface of the os petrosum were all measured.10 case (20 sides) head of adult people were dissected to gain access to the petrous apex via the infrelabyrine approach.The horizontal and vertical dimensions of the access window created were measured.We also studied 60 cases spiral CT imaging data of temporal bone,and to study the main anatomy structures of the petrosal bone,the characteristic of the air cell in the petrosal,the distance from the vertical stage of the facial nerve to the lap of the internal carotid canal,the vertical stage of the facial nerve to the petrous apex,the lap of the internal carotid canal to the posterior surface of the os petrosum were all measured.
6.We dissected 30 cases human temporal bones from 15 heads in order to examine the topographical relationship and the anastomosis of the nerves in the internal auditory canal.
7.30 cases temporal bone have been dissected according to middle ear surgery and the facial nerve decompression surgery.28 cases of facial nerve paralysis in temporal bone fractures were performed in the facial nerve decompression surgery. The surgical marks of the facial nerve have been studied.
Results:
1.The distance between the glomus jugular and the vertical segmental of the facial nerve,the anterior wall of the glomus jugular to the facial nerve and the glomus jugular to the posterior semicircular canal were(3.58±1.33)mm,(5.07±2.93)mm and (4.68±3.47)mm.In 30 cases,the top of the glomus jugular inferior the tympanic cavity in 33%(10 cases),17%(5cases)were behind the facial nerve and the tympanic, 40%(12cases) the facial nerve was in the middle of the glomus jugular,7%(2 cases) were near the inferior wall of internal auditory meatus and 3%(1cases)was protruded into the tympanic cavity.The cranial nerve and blood vessel in the jugular foramen was clearly to be show.
2.Some jugular bulb was flat type and others were prominent types.The classification in the group of the CT image:typesⅠ,11 case;typesⅡ,63cases;typesⅢ,25cases;typesⅣ,21cases.Classification in the group of the specimen:typesⅠ,1 case;typesⅡ,11 cases;typesⅢ,8cases;typesⅣ,10cases.Each type of the jugular bulb has different effect on the operative approach.
3.The distance between the craniotomy to the internal auditory canal,the trigeminal nerve and the pneumogastric nerve in the endoscopic PSRL approach were (14.04±3.56) mm,(28.62±1.62) mm and(12.53±4.11) mm;and that in the endoscopic RS approach were(28.66±3.78) mm,(42.06±2.42) mm and (33.16±4.71) mm.The endoscope near parallel to the posterior surface of the pars petrosa in PSRL approach,and have some angles in the RS approach.And the relationships between anatomy structures were different.
4.The projection circumscription of the external aperture of vestibular aqueduct on the well of mastoid cavity was only 3 mm post eroinferior the posterior semicircularis canalis,and only in 4 cases the external aperture of vestibular aqueduct was lower than the posterior semicircularis canalis.In the 20 cases of endolymphatic sac,typeⅠ12 cases,typeⅡ7 cases and typeⅢ1 cases.The caudal end of the endolymphatic sac can exceed the sigmoid sinus.
5.The vertical stage of the facial nerve to the lap of the internal carotid canal in dry temporal bone and in CT image were(13.26±1.66) mm and(14.45±1.73)mm;the facial nerve to the petrous apex were(34.48±1.07)mm and(34.42±2.03) mm,the lap of the internal carotid canal to the posterior surface of the petrous were(9.68±1.53) mm and(11.70±1.38)mm;the mean dimensions of the window in dissected bone was (5.76±3.38) mm vertically and(6.42±2.65)mm horizontally.13 sides have been doing well with the infralabyrinthine approach.
6.(1) In 11 cases,the facial nerve was anterosuperior to the vestibulocochlear nerve in the whole portion of the internal auditory canal,and in 19 cases,the facial nerve was revolved 30°-90°to the anteroinferior direction from the base of the internal auditory canal to the pores acusticus,which is at the similar direction to that of the cochlear.(2)Vestibulo-facial anastomosis occurs in 25 cases of which 67%(16 cases) appears near the porus acusticus,33%(8 cases) between the base and intermedial portion of internal auditory canal.(3).Vestibulocochlear anastomosis occurs in 24 cases,among which,some brush-like nerve fiber bundles of the cochlear nerve were seen to enter the acculus proprius directly in 13 cases.Transverse vestibulocochlear anastomosis in the fundus of internal acoustic meatus occurred in 15 cases,including 2 cases with more anastomoses.No vestibulocochlear nerve anastomosis found in 6 cases in this study.
7.The lateral lap of the facial nerve was(1.70±0.33) mm under the point between posterior and middle 1/3 of lateral semicircular canal.The vertical line combined this point and the anterior extremity of the conker's crista clews the vertical part of the facial nerve.The line combined the super range of the fenestra vestibuli and the super range of the foot of the cochleariform process clews the inferior edge of the horizontal segment of the facial nerve.And on the prolong line(2.84±0.23)mm anteriad the cochleariform process is the geniculate ganglion,the air cells lateral facial recess is hopeful to locating the facial recess and the facial nerve,and the air cells was in the lateral of the facial nerve 0-2mm.
Conclusions:
1.It is a sample and little damaged way to use the transmastoid endoscopy-assisted jugular foramen surgery and it is hopeful to protect the function of the facial nerve,acoustic nerve and the post- cranial nerve.It is a sample and three-dimensional way that the classification method with the four quadrants,it is hopeful to the imaging diagnosis and the preoperative design.
2.The distance from the cortical skull table to the cerebellopontine angle in the endoscopic PSRL approach is shorter than it in the RS approach.The endoscopic PSRL approach have better visual field of the gastrocerebellum,and the the RS approach have better visual field of the posterior surface of the pars petrosa.In order to protect the endolymphatic sac,it should be remaining 3mm distance to the canalis semicircularis posterior when we stripping the bone beside the canalis semicircularis posterior.The incision of endocranium shouldn't exceed the marg of the endolymphatic sac.It is hopeful to protect the acouesthesia.
3.The possibility of this anatomical variation should be considered when the surgical approach to the petrous apex lesion the infralabyrinthine approach being planned.And the infralabyrinthine approach is useful to the patients with good hearing.
4.The vestibulo-facial anastomoses and the vestibulocochlear anastomosis do existting,and the topographical relationship and the anastomosis of the nerve in human internal auditory canal are variably.
The landmark in the facial nerve in the temporal bone:the fenestra vestibuli,the cochleariform process,lateral semicircular canal,superior semicircular canals,and the air cells lateral facial recess caould be dependable and reliable landmark for the facial nerve.
随着显微技术、影像技术、内镜技术的不断发展,使颅底外科成为研究的热点。该部位解剖结构复杂,视野暴露困难,对手术操作技能要求比较高。所以对该部位手术入路的选择至关重要,选择较优的手术入路既能够较好地暴露病变又能够减少手术中对正常组织结构的损伤。对该部位的手术入路选择要求在利于清除病变的同时不断向功能保留与恢复方面发展。手术显微镜能提供良好的照明和高质量的放大图像,但也有其局限性。术者只能观察物镜轴线正前方的解剖结构,隐蔽部位的手术操作有困难,或成为手术视野的死角,有时需要人为切开或切除正常的结构,对术后功能的恢复造成影响。内镜正是在此要求下应运而生,在安全、准确和有效地去除病变基础上,能减少创伤,保护功能。内镜技术在侧颅底手术方面,开始应用于内耳道、脑桥小脑角、岩尖区及颈静脉孔部位病变的治疗。由于镜头的方向及镜头与解剖结构之间的距离改变,会使所看到解剖结构的位置、形态及影像的放大倍数发生改变。另外内镜下缺乏立体感,没有后视功能会增加手术的危险和并发症的机会,更需要手术者了解手术野的立体空间结构。近年来,虽然对颅底的显微解剖报道较多,但是多数是限于传统的解剖学研究,不能够很好地结合内镜手术过程进行解剖观测。手术过程中手术医生一般也不可能去测量各个结构之间的距离,也不一定能够将所有的标志性结构全部暴露,需要手术者熟练掌握手术野的每一个结构的内镜下解剖特点及内镜手术入路中的重要解剖标志。
本课题目的是应用在尸体标本上模拟手术入路的方法,探讨内镜辅助下经乳突颈静脉球部位手术入路、内镜辅助下经迷路下入路切除岩尖病变、内镜辅助下乙状窦前及乙状窦后手术入路下的解剖结构特点和临床操作特点,并探讨了上述手术入路的适用范围以及在手术入路中内淋巴囊的保护措施,为临床手术开展起指导作用。
面神经与前庭蜗神经是侧颅底部位手术时遇到的重要结构,手术过程中容易受到损伤,所以本课题重点探讨颞骨内面神经的定位方法,以及内耳道内神经的走行与连接的关系,为临床手术中保护面神经、听神经功能提供理论指导。
应用标本解剖、CT影像技术及血管铸型技术探讨颈静脉球的形态及其与周围结构的关系,探讨其分类标准以及不同类型对手术入路的影响。为临床影像诊断及手术入路的选择提供依据。
方法:
1.应用15例(30侧)成人头颅标本,模拟内镜辅助下经乳突颈静脉球部位手术,观察手术入路中主要结构及颈静脉球部位的暴露情况。
2.对60例成人(120侧)颈静脉球部位的多层螺旋CT扫描图像进行分析,结合30例颞骨标本解剖及6例血管铸型标本,观察其形态特点及与周围结构的位置关系。以鼓室内侧壁作虚拟一矢状平面,在该平面上分别以鼓室的后壁、下壁切线为坐标轴(X轴、Y轴)在矢状面上将该部位划分为4个象限,根据颈静脉球顶的位置在该平面上的投影所在象限进行统计分型,分别为Ⅰ、Ⅱ、Ⅲ、Ⅳ4型,再根据每型在该平面的内侧或外侧分成亚型。在标本上模拟经乳突部位的手术入路,观察各型颈静脉球对手术入路的影响。
3.应用13例(26侧)经10%福尔马林固定之成人头部湿标本,2例(4侧)新鲜成人头部标本在内镜下分别模拟乙状窦前入路与乙状窦后入路操作。对比观察两手术入路下的解剖学结构特点,测量相关数据。
4.应用10例20侧10%福尔马林固定成人头部湿标本,显微镜下模拟乙状窦前-迷路后入路手术方法解剖前庭导水管外口及内淋巴囊的位置。观察手术操作对内淋巴囊及前庭导水管外口的影响。
5.(1)应用30例干颞骨标本依次测量颈内动脉膝部到面神经管垂直段的距离、面神经管到岩尖的距离以及颈内动脉膝部到颞骨岩部后面的距离,并在干颞骨标本上面磨出该手术路径。(2)应用临床60例颞骨多层螺旋CT检查扫描数据,通过重建技术在不同平面来观测颞骨岩部主要结构,观察迷路下岩尖入路中的结构特点,颞骨岩部气房的特点,测量面神经垂直段到颈内动脉膝部的距离,面神经管垂直段到岩尖的距离;颈内动脉膝部到岩部后面的距离,与标本组进行比较。(3)应用10例(20侧)经10%福尔马林固定之成人尸头湿标本,在手术显微镜下模拟迷路下入路切除岩尖气房,分别测量后半规管的最低点到颈静脉球最高点的骨板之间的距离,面神经管垂直段和乙状窦骨板之间的距离。在以上标本上观察手术入路中的主要解剖学标志。
6.在手术显微镜下对30例成人颞骨标本的内耳道内神经进行显微解剖,观察神经走行关系、面神经与前庭神经之间的吻合关系及耳蜗神经与前庭神经之间的吻合关系。
7.应用30例颞骨标本(包括新鲜标本6例)模拟乳突根治术,面隐窝入路手术,面神经减压手术,对28例外伤性面瘫临床病例行面神经减压手术,观察面神经与外半规管及面神经隐窝外侧气房等周围结构的关系。
结果:
1.30例标本中,颈静脉球到面神经垂直段的距离:(3.58±1.33)mm;颈静脉球前壁到面神经垂直段的距离:(5.07±2.93)mm;颈静脉球顶到后半规管距离:(4.68±3.47)mm。33%(10例)颈静脉球顶位于鼓室下方,面神经垂直段前方;40%(12例)位于面神经垂直段内侧鼓室后方,面神经位于颈静脉球顶部的中间位置;17%(5例)位于鼓室和面神经后;7%(2例)位于面神经及鼓室底壁内侧接近内耳道下壁;3%(1例)突入到鼓室内。应用内镜能够在面神经垂直段后暴露颈静脉球部位,清楚地显示颈静脉球内侧壁的后组脑神经与血管,并且能够显示脑神经出颅进入颈静脉球的部位。
2.颈静脉球主要有平坦型和突起型。象限分类:CT影像组:Ⅰ型9%(11例)、Ⅱ型53%(63例)、Ⅲ型21%(25例)、Ⅳ型17%(21例);标本组:Ⅰ型3%(1例)、Ⅱ型37%(11例)、Ⅲ型27%(8例)、Ⅳ型33%(10例)。每型都可以分成亚型,不同类型可以影响不同的手术入路。
3.乙状窦前入路中内耳道后唇、三叉神经、迷走神经距离骨窗口前缘的距离分别为(14.04±3.56)mm、(28.62±1.62)mm、(12.53±4.11)mm。乙状窦后入路中3者距离骨窗口前缘的距离分别为(28.66±3.78)mm、(42.06±2.42)mm、(33.16±4.71)mm。乙状窦后入路至脑桥小脑角结构的距离大于乙状窦前入路至脑桥小角结构的距离。内镜与颞骨岩部后面的角度在乙状窦前入路接近平行,在乙状窦后入路角度(24.83±2.02)°。在两入路中内镜下解剖结构的位置关系有所不同。
4.前庭导水管外口在乳突腔面投影在后半规管后下的最大距离为3mm,均在外半规管延长线的下方。20例标本中内淋巴囊的位置:Ⅰ型12例;Ⅱ型7例;Ⅲ型1例,内淋巴囊尾端可越过乙状窦。
5.(1)干颞骨标本及影像测量:面神经管垂直段到颈内动脉膝部距离分别为(13.26±1.66)mm,(14.45±1.73)mm;面神经管垂直段到岩尖的距离分别为(34.48±1.07)mm,(34.42±2.03)mm;颈内动脉膝部到岩部后面的距离分别为(9.68±1.53)mm,(11.70±1.38)mm。(2)60例颞骨CT扫描图象显示,乳突气化情况分类:气化型55%(33例);板障型:13.3%(8例);硬化型:1.7%(1例);混合型:30%(18例)。岩尖气化分类:Ⅰ型(气化良好):11.7%(7例);Ⅱ型(混合型):53%(32例);Ⅲ型无气化:35%(21例)。52%(31例)颈静脉球与后半规管、耳蜗及内耳道之间有操作空间,48%(29例)颈静脉球接近后半规管、耳蜗或内耳道。(3)模拟手术标本能够完成迷路下手术入路的13例。面神经管垂直段中点到乙状窦前壁距离为(6.42±2.65)mm;后半规管骨管到颈静脉球距离为(5.76±3.38)mm。
6.(1)30例颞骨标本中,37%(11例)面神经在内耳道内一直在前上位置;63%(19例)面神经从内耳道底至内耳道口过程中均有围绕前庭神蜗经纵轴不同程度的向前下旋转,旋转范围大致在30°-90°之间,旋转的方向与耳蜗旋转的方向相同。(2)30例标本中,17%(5例)标本没有发现前庭神经与面神经吻合支;83%(25例)面神经与前庭神经之间存在吻合支,并且形态和数目存在差异。67%(16例)吻合支在接近内耳道口部位;33%(8例)吻合支在接近内耳道底的外1/3的内耳道内,吻合支直径在0.5-1.0mm之间。(3)30例标本中,80%(24例)存在前庭耳蜗神经吻合支,在内耳道底部位,其中43%(13例)是一些刷状的神经纤维束直接进入球囊,50%(15例)在内耳道底部位有横行的吻合支,7%(2例)标本可以看到有多个吻合支,部分为两种形式共存,仅在内耳道中间有吻合支者3%(1例);20%(6例)标本没有发现有明显前庭耳蜗神经吻合。
7.砧骨短突的末端作一平行于外半规管的延长线,再以外半规管中后1/3部位于二腹肌嵴前端作一延长线,两线交点即为面神经锥段所在。在外半规管中后1/3交点下方(1.70±0.33)mm,面隐窝外侧气房的后上方也可定位面神经锥段。锥段向下与二腹肌嵴前端连线可以定位面神经垂直段。面隐窝外侧气房可以帮助定位面神经与面神经隐窝,面神经周围血管丛颜色改变能帮助定位面神经。前庭窗上缘与匙突根部上缘连线为面神经水平段骨管的下缘,膝状神经节位于其延长线上匙突前约(2.84±0.23)mm。沿膝状神经节向内后可定位面神经迷路段。
结论:
1.内镜辅助下经乳突入路切除颈静脉球部位病变,损伤较小,利于保留面听功能及后组脑神经功能。
2.应用象限法对颈静脉球位置分型,简单明确,有立体感,方便影像学描述和术前设计手术方案。
3.骨窗口至主要结构的距离在内镜下乙状窦前入路较乙状窦后入路近,有利于内镜操作;乙状窦前入路利于处理小脑腹侧病变,适合与幕上入路或颅中窝入路联合;乙状窦后入路利于观察岩锥后面的结构。
4.了解前庭导水管及内淋巴囊的具体位置并根据其位置设计切口利于保护内淋巴囊的结构完整和保护听力,利于术后关闭硬脑膜切口。
5.经迷路下入路手术切除岩尖病变能够保护外耳道、耳蜗、迷路不受损伤,保存听力,是一个具有临床应用价值的手术途径。
6.在内耳道内,神经走行关系及神经之间的吻合均存在着个体差异。熟悉这些关系利于手术中保护神经功能,利于探讨面神经、前庭及耳蜗疾病之间的关系。
7.面神经隐窝外侧气房以及面神经周围血管丛颜色改变利于术中准确和快速定位面神经。
主要创新点:
1.通过对内镜辅助下经乳突颈静脉球部位手术入路的观测,明确了内镜辅助下经乳突颈静脉球部位手术入路视野范围、解剖结构特点以及神经血管之间结构关系,有助于临床上对该部位病变的清除。
2.明确了内镜辅助下迷路下岩尖病变清除的适应证,解剖结构特点,以及手术前对该手术入路的选择指标,该部位病变的手术治疗具有临床指导作用。
3.通过内镜下乙状窦前入路及乙状窦后入路的比较研究,明确了两种手术入路的优缺点,手术适用范围,对临床具有指导作用。
4.探讨了内淋巴囊与乙状窦的关系,内淋巴囊裂在乳突腔面的投影范围,对该部位手术入路中内淋巴囊的保护提供了理论依据。
5.通过解剖及影像学研究,首次探讨了颈静脉球的立体分型标准和方法,对临床影像诊断,以及术前制定手术方案具有指导意义。
6.探讨了面神经隐窝外侧气房及面神经管周围的血管网颜色改变对面神经定位的意义,为临床面神经的定位提供了简便方法。
7.对内耳道内的神经走行关系,以及神经之间的连接关系进行了研究,利于手术中面、听功能的保护,为揭示临床一些疾病病因提供理论基础。
Background:
With the development of micrological technique,image technique and the endoscopic technique,the investigation in laterol skull base have been the focus of the territory of head and neck surgery.But the anatomy structure in this area was complicate,and the operative procedure was difficult.So it is very important to choseing an appropriate surgical approach in the treatment of the lesions in the latero-skull base.Our purpose in the selecting of the ssurgical approach was to relieve the distraction of the normal structure,gain well exposure,shortening the distance to the lesion,amelioration the illumination of the deep part and amplification the operation area.The operating microscope could provide satisfactory lighting and high-quality enlarged image,but which also had many shortcomings,such as the operator only can to observe the structure exactly anterior aspect the axial ray of the objective lens,and in some tomes it need to destroy the normal tissue for the exposure of the lesion.The endoscope could provide the convenient to the operative procedure in the area that it was difficult to operate under operating microscope.The image under the endoscope is different from what under the microscope and the approach can offer a direct acces to the lesion.Now the endoscope surgery has been used in the surgical treatment of the lesion of internal acoustic meatus, cerebellopontine angle,petrous apex and jugular foramen by some people.But the endoscope also has it's shortage,it could not to observe the anatomic structure behind the top of the endoscope,and it has no stereo-feel of the image under the endoscope. The anatomy under the endoscope is different from what under the microscope,thus being familiar with anatomy in lateral skull base under the endoscope is important in carrying out the endoscope surgery of lateral skull base in clinical practice.
Objectives:
1.To investigate the surgical approach of the jugular foramen and the clinical anatomy of the transmastoid endoscopy-assisted jugular foramen surgery.To observe the relationship between the jugular bulb and the surrounding structure,and to investigate the classification and morphology of jugular bulb.
2.To investigate the anatomy of the endoscopic presigmoid-retrolabyrinthine (PSRL) approach and the endoscopic retrosigmoid(RS) approach,and to provid the data for the choice of surgical approach.To study the anatomy of external aperture of vestibular aqueduct and endolymphatic sac and to discuss the protective methods of endolymphatic sac in the PSRL approach.
3.To investigate the anatomical dimension of the path to the petrous apex via the infralabyrinthine approach.
4.To discourse the landmark of facial nerve in the surgery relate to the temporal bone,and to investigate the topographical relationship and the anastomosis of the nerver in humans internal auditory canal.
Methods:
1.The transmastoid endoscopy-assisted jugular foramen surgery was simulated in 15 adult cadaveric specimens(30 sides).The main anatomic mark in the surgical approach was studied,and the distance between the important structures to the glomus jugular has been measured.
2.In this study,we dissected 30 human temporal bones and studied 120 cases CT imaging data of temporal bone and 6 cases blood vessel cast mould specimen of the jugular bulb,to observe the morphology of jugular bulb.We made imagination plane through the medial wall of the tympanic cavity,made a level tangent line of the proximal wall of the tympanic,a vertical tangent line of the posterior wall of the tympanic,look it as coordinate axis(the X axis and Y axis),so the four quadrant (Ⅰ,Ⅱ,Ⅲ,Ⅳ) have been formed,the quadrant that with the tympanic is the quadrantⅠ.So the jugular bulb was classified according to the position of its dome.
3.The endoscopic PSRL approach and the endoscopic RS approach were simulated in 15 adult cadaveric specimens.The anatomic characteristic was studied, and the distance between the importand structors to the anterior border of the bone window in each surgical approach were measured.
4.Used 10case(20 sides) formalin fixed heads of people,to anatomy the external aperture of vestibular aqueduct and endolymphatic sac with surgical microscope according the presigmoid-retrolabyrithine approach.The location of external aperture of vestibular aqueduct and endolymphatic sac were measured and compared with canalis semicircularis posterior.
5.Thirty dry temporal bone were discissio along the internal carotid canal.The distance from the vertical stage of the facial nerve to the lap of the internal carotid canal,the vertical stage of the facial nerve to the petrous apex,the lap of the internal carotid canal to the posterior surface of the os petrosum were all measured.10 case (20 sides) head of adult people were dissected to gain access to the petrous apex via the infrelabyrine approach.The horizontal and vertical dimensions of the access window created were measured.We also studied 60 cases spiral CT imaging data of temporal bone,and to study the main anatomy structures of the petrosal bone,the characteristic of the air cell in the petrosal,the distance from the vertical stage of the facial nerve to the lap of the internal carotid canal,the vertical stage of the facial nerve to the petrous apex,the lap of the internal carotid canal to the posterior surface of the os petrosum were all measured.
6.We dissected 30 cases human temporal bones from 15 heads in order to examine the topographical relationship and the anastomosis of the nerves in the internal auditory canal.
7.30 cases temporal bone have been dissected according to middle ear surgery and the facial nerve decompression surgery.28 cases of facial nerve paralysis in temporal bone fractures were performed in the facial nerve decompression surgery. The surgical marks of the facial nerve have been studied.
Results:
1.The distance between the glomus jugular and the vertical segmental of the facial nerve,the anterior wall of the glomus jugular to the facial nerve and the glomus jugular to the posterior semicircular canal were(3.58±1.33)mm,(5.07±2.93)mm and (4.68±3.47)mm.In 30 cases,the top of the glomus jugular inferior the tympanic cavity in 33%(10 cases),17%(5cases)were behind the facial nerve and the tympanic, 40%(12cases) the facial nerve was in the middle of the glomus jugular,7%(2 cases) were near the inferior wall of internal auditory meatus and 3%(1cases)was protruded into the tympanic cavity.The cranial nerve and blood vessel in the jugular foramen was clearly to be show.
2.Some jugular bulb was flat type and others were prominent types.The classification in the group of the CT image:typesⅠ,11 case;typesⅡ,63cases;typesⅢ,25cases;typesⅣ,21cases.Classification in the group of the specimen:typesⅠ,1 case;typesⅡ,11 cases;typesⅢ,8cases;typesⅣ,10cases.Each type of the jugular bulb has different effect on the operative approach.
3.The distance between the craniotomy to the internal auditory canal,the trigeminal nerve and the pneumogastric nerve in the endoscopic PSRL approach were (14.04±3.56) mm,(28.62±1.62) mm and(12.53±4.11) mm;and that in the endoscopic RS approach were(28.66±3.78) mm,(42.06±2.42) mm and (33.16±4.71) mm.The endoscope near parallel to the posterior surface of the pars petrosa in PSRL approach,and have some angles in the RS approach.And the relationships between anatomy structures were different.
4.The projection circumscription of the external aperture of vestibular aqueduct on the well of mastoid cavity was only 3 mm post eroinferior the posterior semicircularis canalis,and only in 4 cases the external aperture of vestibular aqueduct was lower than the posterior semicircularis canalis.In the 20 cases of endolymphatic sac,typeⅠ12 cases,typeⅡ7 cases and typeⅢ1 cases.The caudal end of the endolymphatic sac can exceed the sigmoid sinus.
5.The vertical stage of the facial nerve to the lap of the internal carotid canal in dry temporal bone and in CT image were(13.26±1.66) mm and(14.45±1.73)mm;the facial nerve to the petrous apex were(34.48±1.07)mm and(34.42±2.03) mm,the lap of the internal carotid canal to the posterior surface of the petrous were(9.68±1.53) mm and(11.70±1.38)mm;the mean dimensions of the window in dissected bone was (5.76±3.38) mm vertically and(6.42±2.65)mm horizontally.13 sides have been doing well with the infralabyrinthine approach.
6.(1) In 11 cases,the facial nerve was anterosuperior to the vestibulocochlear nerve in the whole portion of the internal auditory canal,and in 19 cases,the facial nerve was revolved 30°-90°to the anteroinferior direction from the base of the internal auditory canal to the pores acusticus,which is at the similar direction to that of the cochlear.(2)Vestibulo-facial anastomosis occurs in 25 cases of which 67%(16 cases) appears near the porus acusticus,33%(8 cases) between the base and intermedial portion of internal auditory canal.(3).Vestibulocochlear anastomosis occurs in 24 cases,among which,some brush-like nerve fiber bundles of the cochlear nerve were seen to enter the acculus proprius directly in 13 cases.Transverse vestibulocochlear anastomosis in the fundus of internal acoustic meatus occurred in 15 cases,including 2 cases with more anastomoses.No vestibulocochlear nerve anastomosis found in 6 cases in this study.
7.The lateral lap of the facial nerve was(1.70±0.33) mm under the point between posterior and middle 1/3 of lateral semicircular canal.The vertical line combined this point and the anterior extremity of the conker's crista clews the vertical part of the facial nerve.The line combined the super range of the fenestra vestibuli and the super range of the foot of the cochleariform process clews the inferior edge of the horizontal segment of the facial nerve.And on the prolong line(2.84±0.23)mm anteriad the cochleariform process is the geniculate ganglion,the air cells lateral facial recess is hopeful to locating the facial recess and the facial nerve,and the air cells was in the lateral of the facial nerve 0-2mm.
Conclusions:
1.It is a sample and little damaged way to use the transmastoid endoscopy-assisted jugular foramen surgery and it is hopeful to protect the function of the facial nerve,acoustic nerve and the post- cranial nerve.It is a sample and three-dimensional way that the classification method with the four quadrants,it is hopeful to the imaging diagnosis and the preoperative design.
2.The distance from the cortical skull table to the cerebellopontine angle in the endoscopic PSRL approach is shorter than it in the RS approach.The endoscopic PSRL approach have better visual field of the gastrocerebellum,and the the RS approach have better visual field of the posterior surface of the pars petrosa.In order to protect the endolymphatic sac,it should be remaining 3mm distance to the canalis semicircularis posterior when we stripping the bone beside the canalis semicircularis posterior.The incision of endocranium shouldn't exceed the marg of the endolymphatic sac.It is hopeful to protect the acouesthesia.
3.The possibility of this anatomical variation should be considered when the surgical approach to the petrous apex lesion the infralabyrinthine approach being planned.And the infralabyrinthine approach is useful to the patients with good hearing.
4.The vestibulo-facial anastomoses and the vestibulocochlear anastomosis do existting,and the topographical relationship and the anastomosis of the nerve in human internal auditory canal are variably.
The landmark in the facial nerve in the temporal bone:the fenestra vestibuli,the cochleariform process,lateral semicircular canal,superior semicircular canals,and the air cells lateral facial recess caould be dependable and reliable landmark for the facial nerve.
引文
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