后颅窝远外侧手术入路的显微外科解剖研究
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摘要
[目的]：探讨后颅窝远外侧手术入路的显微外科解剖
[方法]：在30个(60侧)干颅骨上对枕大孔区的重要骨性结构(枕骨大孔、枕髁、舌下神经管等)的形状、大小及毗邻结构进行测量。在10个(20侧)10％福尔马林固定的成人连颈尸体头颅标本上进行模拟远外侧手术入路进行解剖，显露枕下区的椎动脉，测量相关参数。行枕下颅骨切除，切开硬膜，显露脑干腹侧及腹外侧结构，观察椎动脉第四段与后组颅神经的毗邻关系。在手术显微镜下(×4～10)对15个(30侧)10％福尔马林固定的成人尸头标本进行解剖，显露枕髁关节面，自后外向前内方向磨除枕髁，记录显露舌下神经管内口所磨除的枕髁量。于枕外隆凸尖上方6cm处沿水平面锯开颅骨，去除颅盖和大脑，保留脑干、小脑，观测颅内椎动脉第四段(V4)的管径、走行、分支，观察并测量后组颅神经的起源部位、神经束组成，测量延髓腹侧及下斜坡相关结构的参数。
[结果]：1．枕髁位于枕骨大孔两侧，舌下神经管位于枕髁中后1／3处，磨除枕髁至舌下神经管内口处，可较好地显露枕大孔区腹侧结构。2．第二颈神经根的前支均从椎动脉寰枢椎段的背侧越过，椎动脉颅外段长度及弯曲变异较大，外周有静脉丛或静脉窦包裹。3．椎动脉颅内段绝大多数走行于后组颅神经的腹侧，小脑后下动脉起自椎动脉，并在后组颅神经之间穿行。4．从椎动脉前方切开硬膜，可避开在后组颅神经根丝间的操作，减少对脑干的牵拉。5．后组颅神经与下橄榄关系密切。
[结论]1．寰椎横突是辨认椎动脉的重要标志。2．舌下神经管周围的皮质骨可作为抵达舌下神经管的标志，并可估计枕髁切除的范围。3．研究后颅窝远外侧入路的显微解剖，有助于切除枕大孔腹侧及下斜坡区的肿瘤，保护重要结构。
Objective: The purpose of this study is to observe microsurgical anatomy of far lateral approach of posterior cranial fossa.
Methods: 30(60 sides)adult dried skulls ,10(20 sides)adult cadaveric heads with connected neck fixed with 10% formalin,and another 15(30 sides) adult cadaveric heads were examined in this study .The important structures such as the foramen magnum,occipital condyle,hypoglossal canal were investigated on the dried skulls. The suboccipital segment of vertebral artery was dissected and measured on the cadaveric heads with connected neck according to the procedures of far lateral approach. The ventro-and ventrolateral brain stem was exposed after removing suboccipital skull and splitting dural.The relationship among the forth segment of the vertebral artery and the low cranial nerves was observed. The occipital condylewas drilled to the intracranial end of the hypoglossal canal from posterior lateral margin according to the procedures of far lateral approach under the surgical microscope(X4~10 magnification).Then the drilled length was measured . The skull was sawed off at the level of 6cm above the external occi
pital protuberance. The calvarium and cerebrum were removed. The brain stem and cerebella were reserved .Then the forth segment of the vertebral artery, the low cranial nerves and the structures of the ventro- marrow and the lower clival were observed and measured. Result:1. The occipital condyle was located at lateral side of the foramen magnum, the intracranial end of the hypoglossal canal was located above the junction of the posterior and middle one-third of the occipital condyle.The structures of ventro- foramen magnum region were exposed preferably when the occipital condyle was drilled to the the intracranial end of the hypoglossal canal. 2 The former branch of C2 nerve all crossed from the back of the suboccipital segment of
vertebral artery which was enclosed by either venous plexus or venous sinus and its length and
curve were various significantly.
3.The encephalic segment of the vertebral artery tracked mostly in the front of the low cranial
nerves.The posterior inferior cerebrellar artery send out from the vertebral artery and acrossed
between the root of the low cranial nerves.
4.Dural opened from front of the vertebral artery may avoid operation among the low cranial
nerves and reduce the pull of brain stem.
5. The olive had an intimacy relationship with the low cranial nerves.
Conclusions:.The transverse process of the atlas was the important landmark for
identification of the vertebral artery.
2.The cortex arounding the intracranial end of the hypoglossal canal can be seen as the landmark
for arrival of the hypoglossal canal and estimate the resected extension of the occipital condyle.
3.Study of microanatomy in the far lateral approach is helpful of resecting tumours of the
ventro- foramen magnum and the lower clival region and preserving important tissues.
[方法]：在30个(60侧)干颅骨上对枕大孔区的重要骨性结构(枕骨大孔、枕髁、舌下神经管等)的形状、大小及毗邻结构进行测量。在10个(20侧)10％福尔马林固定的成人连颈尸体头颅标本上进行模拟远外侧手术入路进行解剖，显露枕下区的椎动脉，测量相关参数。行枕下颅骨切除，切开硬膜，显露脑干腹侧及腹外侧结构，观察椎动脉第四段与后组颅神经的毗邻关系。在手术显微镜下(×4～10)对15个(30侧)10％福尔马林固定的成人尸头标本进行解剖，显露枕髁关节面，自后外向前内方向磨除枕髁，记录显露舌下神经管内口所磨除的枕髁量。于枕外隆凸尖上方6cm处沿水平面锯开颅骨，去除颅盖和大脑，保留脑干、小脑，观测颅内椎动脉第四段(V4)的管径、走行、分支，观察并测量后组颅神经的起源部位、神经束组成，测量延髓腹侧及下斜坡相关结构的参数。
[结果]：1．枕髁位于枕骨大孔两侧，舌下神经管位于枕髁中后1／3处，磨除枕髁至舌下神经管内口处，可较好地显露枕大孔区腹侧结构。2．第二颈神经根的前支均从椎动脉寰枢椎段的背侧越过，椎动脉颅外段长度及弯曲变异较大，外周有静脉丛或静脉窦包裹。3．椎动脉颅内段绝大多数走行于后组颅神经的腹侧，小脑后下动脉起自椎动脉，并在后组颅神经之间穿行。4．从椎动脉前方切开硬膜，可避开在后组颅神经根丝间的操作，减少对脑干的牵拉。5．后组颅神经与下橄榄关系密切。
[结论]1．寰椎横突是辨认椎动脉的重要标志。2．舌下神经管周围的皮质骨可作为抵达舌下神经管的标志，并可估计枕髁切除的范围。3．研究后颅窝远外侧入路的显微解剖，有助于切除枕大孔腹侧及下斜坡区的肿瘤，保护重要结构。
Objective: The purpose of this study is to observe microsurgical anatomy of far lateral approach of posterior cranial fossa.
Methods: 30(60 sides)adult dried skulls ,10(20 sides)adult cadaveric heads with connected neck fixed with 10% formalin,and another 15(30 sides) adult cadaveric heads were examined in this study .The important structures such as the foramen magnum,occipital condyle,hypoglossal canal were investigated on the dried skulls. The suboccipital segment of vertebral artery was dissected and measured on the cadaveric heads with connected neck according to the procedures of far lateral approach. The ventro-and ventrolateral brain stem was exposed after removing suboccipital skull and splitting dural.The relationship among the forth segment of the vertebral artery and the low cranial nerves was observed. The occipital condylewas drilled to the intracranial end of the hypoglossal canal from posterior lateral margin according to the procedures of far lateral approach under the surgical microscope(X4~10 magnification).Then the drilled length was measured . The skull was sawed off at the level of 6cm above the external occi
pital protuberance. The calvarium and cerebrum were removed. The brain stem and cerebella were reserved .Then the forth segment of the vertebral artery, the low cranial nerves and the structures of the ventro- marrow and the lower clival were observed and measured. Result:1. The occipital condyle was located at lateral side of the foramen magnum, the intracranial end of the hypoglossal canal was located above the junction of the posterior and middle one-third of the occipital condyle.The structures of ventro- foramen magnum region were exposed preferably when the occipital condyle was drilled to the the intracranial end of the hypoglossal canal. 2 The former branch of C2 nerve all crossed from the back of the suboccipital segment of
vertebral artery which was enclosed by either venous plexus or venous sinus and its length and
curve were various significantly.
3.The encephalic segment of the vertebral artery tracked mostly in the front of the low cranial
nerves.The posterior inferior cerebrellar artery send out from the vertebral artery and acrossed
between the root of the low cranial nerves.
4.Dural opened from front of the vertebral artery may avoid operation among the low cranial
nerves and reduce the pull of brain stem.
5. The olive had an intimacy relationship with the low cranial nerves.
Conclusions:.The transverse process of the atlas was the important landmark for
identification of the vertebral artery.
2.The cortex arounding the intracranial end of the hypoglossal canal can be seen as the landmark
for arrival of the hypoglossal canal and estimate the resected extension of the occipital condyle.
3.Study of microanatomy in the far lateral approach is helpful of resecting tumours of the
ventro- foramen magnum and the lower clival region and preserving important tissues.
引文
[1] Sen CN, Sekhar LN.An extreme lateral approach to intradural lesions of the cervical spine and foramen magnum. Neurosurgery, 1990, 27:197-204.
[2] Wen HT, Rhoton AL Jr, Katsuta T, et al. Microsurgical anatomy of the transcondylar, supracondylar, and paracondylar extensions of the far-lateral approach.J Neurosurg, 1997,87:555-585.
[3] Dowd GC, Zeiller S, Awasthi D. Far lateral transcondylar approach: dimensional anatomy[J].Neurosurgery,1999,45(1):95-100.
[4] Spektor S, Anderson G J, McMenomey SO,et al.Quantitative description of the far-lateral transcondylar transtubercular approach to the foramen magnum and clivus[J].J Neurosurg,2000,92(5):824-831.
[5] Salas E, Sekhar LN, Ziyal IM, et al.Variations of the extreme-lateral craniocervical approach: anatomical study and clinical analysis of 69 patients[J].J Neurosurg, 1999 Apr;90(4 Suppl):206-219.
[6] Seyfried DM, Rock JP. The transcondylar approach to the jugular foramen: a comparative anatomic study[J].Surg Neurol. 1994,42(3):265-71.
[7] Acikbas SC, Tuncer R, Demirez l, et al.The effect of condylectomy on extreme lateral transcondylar approach to the anterior foramen magnum[J].Acta Neurochir (Wien) 1997,139(6):546-50
[8] 李捷，水涛，高永中．后颅窝远外侧入路的应用解剖学研究[J]．中华显微外科杂志，1996，19：258-261
[9] 梁日生，石松生，杨卫忠．枕下远外侧经枕髁入路的应用解剖[J]．中国临床解剖学杂志，1998．16：47-50
[10] 张力伟，王忠诚，于春江，等．经枕髁-颈突入路到达颈静脉孔区显微解剖学研究[J]．中国临床解剖学杂志，2002，20：261-263．
[11] 江涛，王忠诚，于春江，等．远外侧经髁手术入路的显微外科解剖研究[J]．中华医学杂志．1998，78：448-451
[12] Hammon WM,Col MC,Kempe LG. The posterior fossa approach to aneurysms of the veterbral and basilar arteries[J]. J Neurosurg, 1972,37:339-347
[13] Seeger W.Atlas of topographical anatomy of the brain and surrounding structures [M]. Wien Springer-Verlag, 1978:486-489
[14] Heros RC.Lateral suboccipital approach for vertebral and vertebrobasilar artery lesions[J].J Neurosurg, 1986,64(4): 559-562.
[15] Lang DA, Neil-Dwyer G, Iannotti F.The suboccipital transcondylar approach to the clivus and cranio-cervical junction for ventrally placed pathology at and above the foramen magnum [J]. Acta Neurochir (Wien), 1993; 125(1-4):132-137.
[16] Babu RP, Sekhar LN, Wright DC.Extreme lateral transcondylar approach: technical improvements and lessons learned[J]. J Neurosurg, 1994,81(1):49-59.
[17] Kratimenos GP, Crockard HA.The far lateral approach for ventrally placed foramen magnum and upper cervical spine tumours[J].Br J Neurosurg, 1993;7(2): 129-140.
[18] Banerji D, Behari S, Jain VK, et al. Extreme lateral transcondylar approach to the skull base[J]. Neurol India, 1999,47(1):22-30.
[19] Geoge B,Lot G,Boissonnet H.Meningioma of the foramen magnum:a series of 40 cases. Surg Neurol, 1997,47:371-379.
[20] Baldwin HZ, Miller CG, van Loveren HR, et al. The far lateral/combined supra-and infratentorial approach. A human cadaveric prosection model for routes of access to the petroclival region and ventral brain stem. J Neurosurg, 1994,81,:60-68.
[21] A1-Mefty O,Borba LA,Aoki N,et al.The transcondylar approach to extrdural nonneoplastic lesions of The craniovertebral junction. J Neurosurg, 1996,84:1-6.
[22] 薛毅辉，张远征，陈锦峰，等．乳突后直切口枕下极外侧入路的局部解剖及操作要点．中华神经外科杂志，2001，17：309-312．
[23] Nanda A, Vincent DA, Vannemreddy PS, et al. Far-lateral approach to intradural lesions of the foramen magnum without resection of the occipital condyle. J Neurosurg,2002,96:302-309.
[24] Vishteh G,Crawford NR, Melton S,et al.Stability of the craniovertebral junction after unilateral occipital condyle resection:a biomechanical study. J Neurosurg, 1999,90:91-98.
[25] Rhoton AL Jr. The far-lateral approach and its transcondylar,supracondylar,and paracondylar extensions.Neurosurgery(supplement),2000,47:195-209.
[26] Fine AD,Cardoso A,Rhoton AL.Microsurgical anatomy of the extracranial-extraduralorigin of the posterior inferior cerebellar artery[J].J neurosurg, 1999,91:645-652
[27] 贺宝荣，余新光，周定标．远外侧入路显微切除斜坡和枕大孔区腹侧肿瘤[J]．中华显微外科杂志．1999，22：93-94。
[28] Bertalanffy H, Seeger W. The dorsolateral, suboccipital, transcondylar approach to the lower clivus and anterior portion of the craniocervical junction[J].Neurosurgery.
1991,29(6)：815-821．
[29] 张力伟，于春江，杨国瑞，等．枕下海绵窦的显微解剖学研究[J]．中华显微外科杂志．2000，23：290-291
[30] 沈建康，殷玉华，周玉濮，等．远外侧枕下入路临床应用的初步经验[J]．中华外科杂志2001，39：209-211
[31] Amautovic KI,A1-Mefty O,Husain M.Ventral foramen magnum meningiomas.J Neurosurg,2000,92: 71-80.
[32] Matsuhima T,Matsukado K,Natori Y, et al.Surgery on a saccular vertebral artery-posterrior inferior cerebellar artery aneurysm via the transcondylar fossa(supracondylar transjugular tubercle)approach or the transcondylar approach:surgical results and indications for using two different lateral skull base approaches. J Neurosurg,2001,95 :268-274.
[33] Wanebo JE, Chicoine MR. Quantitative analysis of the transcondylar approach to the foramen magnum. Neurosurgery, 2001,49:934-941; discussion 941-943.
[34] George B,Dematons C,Cophigon J.Lateral approach to the anterior portion of the foramen magnum. Neurosurgery, 1988,29:481-490.
[35] Person H, Vallee B, Lefevre Ch, et al. Arterial and neural relations at the posterior and lateral aspects of the medullo-spinal junction. Surg Radiol Anat, 1998,20:177—184
[36] 张玉学，张为龙，李金．小脑脑桥角的显微解剖学[J]．白求恩医科大学学报．1983．9(3)：62-66
[37] 种衍军．舌咽神经痛的手术治疗与病因学探讨[J]．中华神经外科杂志，1999，15(2)：94-96
[2] Wen HT, Rhoton AL Jr, Katsuta T, et al. Microsurgical anatomy of the transcondylar, supracondylar, and paracondylar extensions of the far-lateral approach.J Neurosurg, 1997,87:555-585.
[3] Dowd GC, Zeiller S, Awasthi D. Far lateral transcondylar approach: dimensional anatomy[J].Neurosurgery,1999,45(1):95-100.
[4] Spektor S, Anderson G J, McMenomey SO,et al.Quantitative description of the far-lateral transcondylar transtubercular approach to the foramen magnum and clivus[J].J Neurosurg,2000,92(5):824-831.
[5] Salas E, Sekhar LN, Ziyal IM, et al.Variations of the extreme-lateral craniocervical approach: anatomical study and clinical analysis of 69 patients[J].J Neurosurg, 1999 Apr;90(4 Suppl):206-219.
[6] Seyfried DM, Rock JP. The transcondylar approach to the jugular foramen: a comparative anatomic study[J].Surg Neurol. 1994,42(3):265-71.
[7] Acikbas SC, Tuncer R, Demirez l, et al.The effect of condylectomy on extreme lateral transcondylar approach to the anterior foramen magnum[J].Acta Neurochir (Wien) 1997,139(6):546-50
[8] 李捷，水涛，高永中．后颅窝远外侧入路的应用解剖学研究[J]．中华显微外科杂志，1996，19：258-261
[9] 梁日生，石松生，杨卫忠．枕下远外侧经枕髁入路的应用解剖[J]．中国临床解剖学杂志，1998．16：47-50
[10] 张力伟，王忠诚，于春江，等．经枕髁-颈突入路到达颈静脉孔区显微解剖学研究[J]．中国临床解剖学杂志，2002，20：261-263．
[11] 江涛，王忠诚，于春江，等．远外侧经髁手术入路的显微外科解剖研究[J]．中华医学杂志．1998，78：448-451
[12] Hammon WM,Col MC,Kempe LG. The posterior fossa approach to aneurysms of the veterbral and basilar arteries[J]. J Neurosurg, 1972,37:339-347
[13] Seeger W.Atlas of topographical anatomy of the brain and surrounding structures [M]. Wien Springer-Verlag, 1978:486-489
[14] Heros RC.Lateral suboccipital approach for vertebral and vertebrobasilar artery lesions[J].J Neurosurg, 1986,64(4): 559-562.
[15] Lang DA, Neil-Dwyer G, Iannotti F.The suboccipital transcondylar approach to the clivus and cranio-cervical junction for ventrally placed pathology at and above the foramen magnum [J]. Acta Neurochir (Wien), 1993; 125(1-4):132-137.
[16] Babu RP, Sekhar LN, Wright DC.Extreme lateral transcondylar approach: technical improvements and lessons learned[J]. J Neurosurg, 1994,81(1):49-59.
[17] Kratimenos GP, Crockard HA.The far lateral approach for ventrally placed foramen magnum and upper cervical spine tumours[J].Br J Neurosurg, 1993;7(2): 129-140.
[18] Banerji D, Behari S, Jain VK, et al. Extreme lateral transcondylar approach to the skull base[J]. Neurol India, 1999,47(1):22-30.
[19] Geoge B,Lot G,Boissonnet H.Meningioma of the foramen magnum:a series of 40 cases. Surg Neurol, 1997,47:371-379.
[20] Baldwin HZ, Miller CG, van Loveren HR, et al. The far lateral/combined supra-and infratentorial approach. A human cadaveric prosection model for routes of access to the petroclival region and ventral brain stem. J Neurosurg, 1994,81,:60-68.
[21] A1-Mefty O,Borba LA,Aoki N,et al.The transcondylar approach to extrdural nonneoplastic lesions of The craniovertebral junction. J Neurosurg, 1996,84:1-6.
[22] 薛毅辉，张远征，陈锦峰，等．乳突后直切口枕下极外侧入路的局部解剖及操作要点．中华神经外科杂志，2001，17：309-312．
[23] Nanda A, Vincent DA, Vannemreddy PS, et al. Far-lateral approach to intradural lesions of the foramen magnum without resection of the occipital condyle. J Neurosurg,2002,96:302-309.
[24] Vishteh G,Crawford NR, Melton S,et al.Stability of the craniovertebral junction after unilateral occipital condyle resection:a biomechanical study. J Neurosurg, 1999,90:91-98.
[25] Rhoton AL Jr. The far-lateral approach and its transcondylar,supracondylar,and paracondylar extensions.Neurosurgery(supplement),2000,47:195-209.
[26] Fine AD,Cardoso A,Rhoton AL.Microsurgical anatomy of the extracranial-extraduralorigin of the posterior inferior cerebellar artery[J].J neurosurg, 1999,91:645-652
[27] 贺宝荣，余新光，周定标．远外侧入路显微切除斜坡和枕大孔区腹侧肿瘤[J]．中华显微外科杂志．1999，22：93-94。
[28] Bertalanffy H, Seeger W. The dorsolateral, suboccipital, transcondylar approach to the lower clivus and anterior portion of the craniocervical junction[J].Neurosurgery.
1991,29(6)：815-821．
[29] 张力伟，于春江，杨国瑞，等．枕下海绵窦的显微解剖学研究[J]．中华显微外科杂志．2000，23：290-291
[30] 沈建康，殷玉华，周玉濮，等．远外侧枕下入路临床应用的初步经验[J]．中华外科杂志2001，39：209-211
[31] Amautovic KI,A1-Mefty O,Husain M.Ventral foramen magnum meningiomas.J Neurosurg,2000,92: 71-80.
[32] Matsuhima T,Matsukado K,Natori Y, et al.Surgery on a saccular vertebral artery-posterrior inferior cerebellar artery aneurysm via the transcondylar fossa(supracondylar transjugular tubercle)approach or the transcondylar approach:surgical results and indications for using two different lateral skull base approaches. J Neurosurg,2001,95 :268-274.
[33] Wanebo JE, Chicoine MR. Quantitative analysis of the transcondylar approach to the foramen magnum. Neurosurgery, 2001,49:934-941; discussion 941-943.
[34] George B,Dematons C,Cophigon J.Lateral approach to the anterior portion of the foramen magnum. Neurosurgery, 1988,29:481-490.
[35] Person H, Vallee B, Lefevre Ch, et al. Arterial and neural relations at the posterior and lateral aspects of the medullo-spinal junction. Surg Radiol Anat, 1998,20:177—184
[36] 张玉学，张为龙，李金．小脑脑桥角的显微解剖学[J]．白求恩医科大学学报．1983．9(3)：62-66
[37] 种衍军．舌咽神经痛的手术治疗与病因学探讨[J]．中华神经外科杂志，1999，15(2)：94-96