乙状窦前迷路后入路岩斜区肿瘤切除的解剖学研究
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摘要
目的：岩斜区位置深在,周围有许多重要的血管及神经组织,手术难度大,尤其对于巨大肿瘤的切除,一直是神经外科医师的巨大挑战,主要原因是相关解剖较复杂,尤其涉及岩骨,神经外科医师不熟悉,因此,大大限制了对岩斜区肿瘤的手术治疗,本实验通过测量相关数据,通过这些数据为手术中安全磨除岩骨、合理选择手术间隙及扩大岩斜区术野暴露范围提供可靠依据,进一步探索和改进经岩骨后部入路的操作方法,为该入路的临床应用提供解剖学资料。并且明确乙状窦前迷路后入路所能显露的手术范围,以期通过此解剖数据能为临床手术提供一定的指导意义。
方法：采用6例12侧10%甲醛固定成人新鲜湿性标本,头架固定,模拟乙状窦前迷路后入路手术,尽量接近实际手术过程。头位：侧卧位,头转向手术的对侧,顶部较水平位低15°-20°,额部位置略偏低,使乳突部位于最高点,保持视路沿颞骨岩部方向。取绕耳的大问号形切口,切口前端起自耳前颧弓中点,向上绕耳廓,距耳廓上约3-4cm,向后行于乳突后2-3cm,止于乳突尖下约1cm(图1)。可根据病变位置灵活调整,若中颅窝病变较大,则切口向前扩大,若后颅窝病变较大,则切口在横窦上就靠中线些,向下延长些,使后窝显露范围增大。沿帽状腱膜下层翻开皮瓣,皮瓣翻向外耳道方向,将颞浅筋膜、骨膜和胸锁乳突肌附着点一起翻起。骨孔的选择有两种：第一种4孔法,基本上以星点为中心放射状钻4孔。采用1孔位于顶乳缝前角(关键孔);2孔在1孔的平行线(平行于横窦)向后靠近皮缘；3孔位于2孔下方约1.5cm(跨横窦);4孔位于1孔的下方约1.5cm处。颞部钻3个骨孔,颅后窝钻1骨孔,用铣刀先沿颞部骨孔铣开,再沿后颅窝骨孔铣开,最后小心磨开跨窦区骨质,整个骨瓣翻开。(如图3)第二种2孔法,即在关键孔处钻一孔,沿横窦平行线向后钻一孔。先将颞部骨瓣铣下,然后将横窦前方后方小心从横窦沟剥下,脑压板在骨瓣下方保护,铣刀将后颅窝骨瓣铣下,形成颞部、后颅窝两块骨瓣。(如图5)用微型磨钻磨除颞骨岩部后壁。磨除乳突表面骨皮质,逐步出现乳突小房(图6)。自乙状窦后方1cm处开始磨除骨质,保持一致的深度,直至显露出乙状窦,在此处可见到乳突部的导血管与乙状窦相通,剪断此血管。用金刚钻沿乙状窦磨向颈静脉球,使其表面仅剩一层薄薄的骨皮质。轮廓化乙状窦,向前、上方去除乳突小房,显露颅中窝底的硬膜。进一步向前磨除乳突小房,磨出鼓窦,小心向周围磨除骨质,鼓窦内侧壁出现质硬、色泽淡黄的骨质区域时,提示接近外侧半规管；如明确看到乳白色质硬的象牙骨提示到后半规管最后部。后半规管的方向平行于颞骨岩部后壁,其前内侧为外半规管,而面神经管的水平段则位于外半规管的后下方。小心轮廓化骨迷路及面神经管后,继续向下磨除乳突尖区的小房,使乙状窦前硬脑膜、颅中窝硬脑膜和窦-硬膜角均完全显露出来,在横窦和乙状窦的交接水平面可见岩上窦(图67)。平行乙状窦前缘切开后颅窝硬膜至颈静脉球上方,硬膜牵向前方,显露乙状窦前间隙；沿颅中窝底横行切开中颅窝底硬膜(图8),抬起颞叶；于岩上窦、乙状窦交汇点前方0.5cm处结扎、切断岩上窦；由岩上窦切断处向内剪开小脑幕,至滑车神经入硬脑膜处稍后方的幕切迹,将小脑幕推向后方。进一步抬起颞叶,略微牵开小脑和乙状窦,暴露岩斜区,观察并测量数据。
结果：
1、颅骨表面标志间距离：星点到顶乳缝前角距离28.9±3.7mm；星点到外耳道后上嵴的距离43.2±1.6mm；顶乳缝前角到外耳道后上嵴的距离25.8±4.2mm。
2、窦硬膜角到各标志点间距离：窦硬膜角到后半规管的距离18.6±3.1mm；窦硬膜角到颈静脉球的距离27.9±1.9 mm；窦硬膜角到外耳道后上嵴的距离28.8±3.8mm。
3、颅内各组颅神经长度及主要颅神经之间的间隙：动眼神经颅内段距离14.4±1.9mm；三叉神经颅内段距离12.1±1.4mm;面听神经颅内段距离11.3±1.8mm;舌咽迷走神经颅内段距离17.7±1.9mm；动眼神经与三叉神经的距离12.9±3.2mm;面听神经与舌咽迷走神经的距离10.22.9mm。
4、岩斜区所显露范围的测量：本实验中,向中颅窝显露最深可见颈内动脉床突上段,测量岩尖到其距离,代表术野可显露的中颅窝范围,岩尖到颈内动脉床突上段距离为：10.2±1.7mm。岩斜区所能显露最下方可见舌咽、迷走神经,因此后颅窝范围,即岩尖到舌咽、迷走神经的距离,岩尖到舌咽迷走神经的距离为：30.8±5.9mm。
结论：
1.体表标志：眼外眦、外耳道上缘与枕外粗隆连线可标志横窦位置；
2.骨瓣：星点可定位横窦位置,顶乳缝前角可作为关键孔定位乙状窦上曲。根据横窦位置进行双骨瓣开颅安全、省时；
3.乳突及岩骨磨除时标志：对于非硬化性乳突,根据骨质、颜色定位后半规管。硬化性乳突,主要根据鼓窦内侧壁间接定位后半规管；
4.手术可以很好显露小脑幕缘上下区域,向中颅窝可以显露鞍旁、颈内动脉床突上段、向后颅窝,可显露到椎动脉、舌咽、迷走神经高度。由于角度问题,对于岩骨后面自弓状隆起以前显露不佳;
5.术前必须行一些必要检查,明确Labbe静脉回流横窦位置、颈静脉球高度、骨半规管、乙状窦位置等,否则,这些解剖结构位置偏离将严重影响术区的显露范围；
6.幕上下联合乙状窦前迷路后入路可以很好显露中上斜坡及小脑幕裂隙区范围。
Objective:Petroclival region is deep, surrounded by a number of imp ortant blood vessels and nerve tissue, surgery is difficult,especially for larg er tumors removed,neurosurgeons have been a great challenge,mainly related to the more complex anatomy,especially those related to rock bone, neurosurgeons are not familiar with,so far limited to the petroclival region tumor surgery,the experiment by measuring the data,these data were ground for the safe operation of the petrous bone,a reasonable choice of operation and expansion of petroclival space the scope of surgical field exposure and pro-vide a reliable basis to further explore and improve the bone back into the road by the rock method of operation,the clinical application of the appro-ach and provide anatomical information. And clearly presigmoid retrolaby-rinthine approach could reveal the extent of the operation, in order to disse-ct the data through this surgery can provide some clinical guidance.
Methods:six cases of 12 sides in 10% formalin fixed adult specimens of fresh wet head frame fixed to simulate the sigmoid sinus approach before surgery,after getting lost, as close to the actual surgical procedure.Head po-sition:lateral position,head turned to the contralateral surgery,the top level bit lower than the 15°-20°,slightly lower frontal position,so mastoid at the highest point along the visual pathway of the temporal bone to keep the De-partment of the direction of rock. Take a big question mark around the ear in cision, the incision from the ear from the front before the mid-point of zygo matic arch, up around the ear from the auricle of about 3-4cm,back row in the papilla after the 2-3cm,limited to the mastoid tip of about 1cm (Figure 1).Can be flexibly adjusted according to lesion location, if the middle cra-nial fossa lesions larger,then cut forward to expand,if a larger posterior fos sa lesions,then the incision in the transverse sinus on the midline by som e,extending down more,so that the range of exposure after the nest increase ed.Opened along the lower deck of the subgaleal flap,flap turned the directi on of the external ear canal,the superficial temporal fascia,periosteum and sternocleidomastoid with nothing at attachment points.There are two holes in the choice of bone:The first 4 hole method, basically a star point as the center of radial drilling 4 holes. With a hole in the top corner before sewing Ru (key hole); two holes in a hole parallel lines (parallel to the transverse sinus) back close to the skin edge;3 hole 2 hole in the bottom of about 1.5 cm (cross-transverse sinus);4 hole in a hole about 1.5cm below the office. Temporal bone drilling three holes,drill a posterior fossa bone hole, the first along with the temporal bone cutter milling holes open,and then along the posterior bone milling holes open, carefully grind the last open cross-sinus bone,the bone valve opened. (Figure 3) The second two hole method, that is,the key hole in a hole drilled along the transverse sinus and drill a hole parallel to the line backwards. Under the first temporal bone milling, and then in front of the rear transverse sinus transverse sinus sulcus carefully peel off from the brain under the protection plate in the bone flap,the post-erior flap cutter milling, the formation of temporal, posterior 2 block of bo-ne. (Figure 5) were ground with a micro-burr the Department of temporal bone rock wall.In addition to the mastoid bone cortex surface grinding, the gradual emergence of mastoid (Figure 6). 1cm from the sigmoid sinus and start at the rear were ground bone, consistent with the depth up to reveal the sigmoid sinus and mastoid in here to see the lead vessel connected with the sigmoid sinus,cut the blood vessels.With a diamond grinding along the sigm oid sinus to the jugular bulb,so that the surface of a thin layer of cortical bo ne remaining. Contour of the sigmoid sinus,forward, top to remove the mas-toid a small room, revealing the middle cranial fossa dura.Further forward than mastoid ground until it has tympanic sinus,were ground carefully to the surrounding bone, drum sinus wall appeared hard,light yellow color when the bone area, suggesting that close to the lateral semicircular canal;as clear to see to the quality of hard ivory white tips to the bone the last Department of posterior semicircular canal.Posterior semicircular canal in the direction parallel to the posterior wall of petrous part of temporal bone,the inside of the outer half of its pre-regulation,while the facial nerve canal horizontal semicircular canal is located outside the post below.Careful outline of bony labyrinth and facial nerve canal,to continue to grind down the mastoid tip area than the small room,so that pre-sigmoid sinus dural,middle fossa dura and sinus dural angle are fully exposed, the transverse sinus and the horiz-ontal transfer of sigmoid sinus petrosal sinus can be seen (Figure 67). Paral-lel to the anterior sigmoid sinus dural incision posterior to the jugular bulb at the top, pull to the front of the dura,sigmoid sinus exposure before the gap;along the middle cranial fossa transverse incision in the cranial fossa dura (Figure 8), raised his temporal lobe; in petrosal sinus,sigmoid sinus ligation meeting point in front of 0.5cm Department,cut off petrosal sinus;cut off from the petrosal sinus tentorial Department cut inward to the trochlear nerve into the dural side of the screen later notch Office,will push the rear tentorium.Further up the temporal lobe,cerebellum,and slightly retracted sigmoid sinus,petroclival exposure,observation and measurement data.
Results:1. the distance between the skull surface markers:Star point reach the peak milk from the joint front foot 28.9±3.7mm;star point to the external ear canal from the posterior crest of 43.2±1.6mm;top milk after sewing on the front foot to the ear canal from the crest of 25.8±4.2 mm.
2. sinus dural angle to the landmarks distance:sinus dural angle to the posterior semicircular canal from 18.6±3.1mm;sinus dural angle to the jugular bulb in the range 27.9±1.9 mm;sinus dural angle to the posterior external auditory canal ridge from 28.8±3.8mm.
3. intracranial length of the cranial nerves and the major gap between the cranial nerves:oculomotor intracranial far cry from 14.4±1.9mm;trigem-inal nerve intracranial far cry from 12.1±1.4mm;the facial nerve intracr-anial far cry from 11.3±1.8 mm;intracranial glossopharyngeal vagus nerve, far below the 17.7±1.9mm;oculomotor and trigeminal nerve from 12.9±3.2 mm;the facial nerve and glossopharyngeal vagus nerve from 10.2±2.9mm.
4. petroclival region by the exposed areas of measurement:In this study,to the middle cranial fossa revealed most visible carotid artery supr- aclinoid segment,measured petrous apex to its distance, representing the operative field can be revealed in the middle cranial fossa area, petrous apex to the supraclinoid carotid artery,far below as:10.2±1.7mm. Petrocli-val exposure can see the bottom of glossopharyngeal,vagus nerve, so the sco pe of the posterior fossa,which pointed to the rock glossopharyngeal,vagus nerve distance,petrous apex to the vagus nerve glossopharyngeal distance: 30.8±5.9mm.
Conclusion:1. Markers of body:external eye canthus, the upper edge of the external auditory canal and the external occipital protuberance to connect to mark location of transverse sinus;
2. Craniectomy:Star point can locate transverse sinus location, the top milk seam front key hole positioning as sigmoid sinus on the song. According to the dual positions of transverse sinus craniotomy safety, save time;
3. Papilla and bone were ground rock when the signs:For non-sclerosing papillary, according to bone, color, positioning posterior semicircular canal. Sclerotic mastoid sinus wall based primarily on indirect positioning drum posterior semicircular canal;
4. Tentorial surgery can be a very good margin of the upper and lower exposure areas can be exposed to the middle cranial fossa parasellar, supraclinoid internal carotid artery segment, posterior cranial fossa can be exposed to the vertebral artery, the glossopharyngeal, vagus nerve high. As the angle of the problem, the bone behind the rock exposed from the poor before the arcuate eminence;
5. Preoperative line of the necessary checks must clear position of transverse sinus venous return Labbe, a high jugular bulb, semicircular canals, the location of sigmoid sinus, otherwise, these anatomical position deviation will seriously affect the operation area of the exposed areas;
6. Screen up and down the joint presigmoid retrolabyrinthine approach is well exposed in the fissures on the slopes and tentorial area.
方法：采用6例12侧10%甲醛固定成人新鲜湿性标本,头架固定,模拟乙状窦前迷路后入路手术,尽量接近实际手术过程。头位：侧卧位,头转向手术的对侧,顶部较水平位低15°-20°,额部位置略偏低,使乳突部位于最高点,保持视路沿颞骨岩部方向。取绕耳的大问号形切口,切口前端起自耳前颧弓中点,向上绕耳廓,距耳廓上约3-4cm,向后行于乳突后2-3cm,止于乳突尖下约1cm(图1)。可根据病变位置灵活调整,若中颅窝病变较大,则切口向前扩大,若后颅窝病变较大,则切口在横窦上就靠中线些,向下延长些,使后窝显露范围增大。沿帽状腱膜下层翻开皮瓣,皮瓣翻向外耳道方向,将颞浅筋膜、骨膜和胸锁乳突肌附着点一起翻起。骨孔的选择有两种：第一种4孔法,基本上以星点为中心放射状钻4孔。采用1孔位于顶乳缝前角(关键孔);2孔在1孔的平行线(平行于横窦)向后靠近皮缘；3孔位于2孔下方约1.5cm(跨横窦);4孔位于1孔的下方约1.5cm处。颞部钻3个骨孔,颅后窝钻1骨孔,用铣刀先沿颞部骨孔铣开,再沿后颅窝骨孔铣开,最后小心磨开跨窦区骨质,整个骨瓣翻开。(如图3)第二种2孔法,即在关键孔处钻一孔,沿横窦平行线向后钻一孔。先将颞部骨瓣铣下,然后将横窦前方后方小心从横窦沟剥下,脑压板在骨瓣下方保护,铣刀将后颅窝骨瓣铣下,形成颞部、后颅窝两块骨瓣。(如图5)用微型磨钻磨除颞骨岩部后壁。磨除乳突表面骨皮质,逐步出现乳突小房(图6)。自乙状窦后方1cm处开始磨除骨质,保持一致的深度,直至显露出乙状窦,在此处可见到乳突部的导血管与乙状窦相通,剪断此血管。用金刚钻沿乙状窦磨向颈静脉球,使其表面仅剩一层薄薄的骨皮质。轮廓化乙状窦,向前、上方去除乳突小房,显露颅中窝底的硬膜。进一步向前磨除乳突小房,磨出鼓窦,小心向周围磨除骨质,鼓窦内侧壁出现质硬、色泽淡黄的骨质区域时,提示接近外侧半规管；如明确看到乳白色质硬的象牙骨提示到后半规管最后部。后半规管的方向平行于颞骨岩部后壁,其前内侧为外半规管,而面神经管的水平段则位于外半规管的后下方。小心轮廓化骨迷路及面神经管后,继续向下磨除乳突尖区的小房,使乙状窦前硬脑膜、颅中窝硬脑膜和窦-硬膜角均完全显露出来,在横窦和乙状窦的交接水平面可见岩上窦(图67)。平行乙状窦前缘切开后颅窝硬膜至颈静脉球上方,硬膜牵向前方,显露乙状窦前间隙；沿颅中窝底横行切开中颅窝底硬膜(图8),抬起颞叶；于岩上窦、乙状窦交汇点前方0.5cm处结扎、切断岩上窦；由岩上窦切断处向内剪开小脑幕,至滑车神经入硬脑膜处稍后方的幕切迹,将小脑幕推向后方。进一步抬起颞叶,略微牵开小脑和乙状窦,暴露岩斜区,观察并测量数据。
结果：
1、颅骨表面标志间距离：星点到顶乳缝前角距离28.9±3.7mm；星点到外耳道后上嵴的距离43.2±1.6mm；顶乳缝前角到外耳道后上嵴的距离25.8±4.2mm。
2、窦硬膜角到各标志点间距离：窦硬膜角到后半规管的距离18.6±3.1mm；窦硬膜角到颈静脉球的距离27.9±1.9 mm；窦硬膜角到外耳道后上嵴的距离28.8±3.8mm。
3、颅内各组颅神经长度及主要颅神经之间的间隙：动眼神经颅内段距离14.4±1.9mm；三叉神经颅内段距离12.1±1.4mm;面听神经颅内段距离11.3±1.8mm;舌咽迷走神经颅内段距离17.7±1.9mm；动眼神经与三叉神经的距离12.9±3.2mm;面听神经与舌咽迷走神经的距离10.22.9mm。
4、岩斜区所显露范围的测量：本实验中,向中颅窝显露最深可见颈内动脉床突上段,测量岩尖到其距离,代表术野可显露的中颅窝范围,岩尖到颈内动脉床突上段距离为：10.2±1.7mm。岩斜区所能显露最下方可见舌咽、迷走神经,因此后颅窝范围,即岩尖到舌咽、迷走神经的距离,岩尖到舌咽迷走神经的距离为：30.8±5.9mm。
结论：
1.体表标志：眼外眦、外耳道上缘与枕外粗隆连线可标志横窦位置；
2.骨瓣：星点可定位横窦位置,顶乳缝前角可作为关键孔定位乙状窦上曲。根据横窦位置进行双骨瓣开颅安全、省时；
3.乳突及岩骨磨除时标志：对于非硬化性乳突,根据骨质、颜色定位后半规管。硬化性乳突,主要根据鼓窦内侧壁间接定位后半规管；
4.手术可以很好显露小脑幕缘上下区域,向中颅窝可以显露鞍旁、颈内动脉床突上段、向后颅窝,可显露到椎动脉、舌咽、迷走神经高度。由于角度问题,对于岩骨后面自弓状隆起以前显露不佳;
5.术前必须行一些必要检查,明确Labbe静脉回流横窦位置、颈静脉球高度、骨半规管、乙状窦位置等,否则,这些解剖结构位置偏离将严重影响术区的显露范围；
6.幕上下联合乙状窦前迷路后入路可以很好显露中上斜坡及小脑幕裂隙区范围。
Objective:Petroclival region is deep, surrounded by a number of imp ortant blood vessels and nerve tissue, surgery is difficult,especially for larg er tumors removed,neurosurgeons have been a great challenge,mainly related to the more complex anatomy,especially those related to rock bone, neurosurgeons are not familiar with,so far limited to the petroclival region tumor surgery,the experiment by measuring the data,these data were ground for the safe operation of the petrous bone,a reasonable choice of operation and expansion of petroclival space the scope of surgical field exposure and pro-vide a reliable basis to further explore and improve the bone back into the road by the rock method of operation,the clinical application of the appro-ach and provide anatomical information. And clearly presigmoid retrolaby-rinthine approach could reveal the extent of the operation, in order to disse-ct the data through this surgery can provide some clinical guidance.
Methods:six cases of 12 sides in 10% formalin fixed adult specimens of fresh wet head frame fixed to simulate the sigmoid sinus approach before surgery,after getting lost, as close to the actual surgical procedure.Head po-sition:lateral position,head turned to the contralateral surgery,the top level bit lower than the 15°-20°,slightly lower frontal position,so mastoid at the highest point along the visual pathway of the temporal bone to keep the De-partment of the direction of rock. Take a big question mark around the ear in cision, the incision from the ear from the front before the mid-point of zygo matic arch, up around the ear from the auricle of about 3-4cm,back row in the papilla after the 2-3cm,limited to the mastoid tip of about 1cm (Figure 1).Can be flexibly adjusted according to lesion location, if the middle cra-nial fossa lesions larger,then cut forward to expand,if a larger posterior fos sa lesions,then the incision in the transverse sinus on the midline by som e,extending down more,so that the range of exposure after the nest increase ed.Opened along the lower deck of the subgaleal flap,flap turned the directi on of the external ear canal,the superficial temporal fascia,periosteum and sternocleidomastoid with nothing at attachment points.There are two holes in the choice of bone:The first 4 hole method, basically a star point as the center of radial drilling 4 holes. With a hole in the top corner before sewing Ru (key hole); two holes in a hole parallel lines (parallel to the transverse sinus) back close to the skin edge;3 hole 2 hole in the bottom of about 1.5 cm (cross-transverse sinus);4 hole in a hole about 1.5cm below the office. Temporal bone drilling three holes,drill a posterior fossa bone hole, the first along with the temporal bone cutter milling holes open,and then along the posterior bone milling holes open, carefully grind the last open cross-sinus bone,the bone valve opened. (Figure 3) The second two hole method, that is,the key hole in a hole drilled along the transverse sinus and drill a hole parallel to the line backwards. Under the first temporal bone milling, and then in front of the rear transverse sinus transverse sinus sulcus carefully peel off from the brain under the protection plate in the bone flap,the post-erior flap cutter milling, the formation of temporal, posterior 2 block of bo-ne. (Figure 5) were ground with a micro-burr the Department of temporal bone rock wall.In addition to the mastoid bone cortex surface grinding, the gradual emergence of mastoid (Figure 6). 1cm from the sigmoid sinus and start at the rear were ground bone, consistent with the depth up to reveal the sigmoid sinus and mastoid in here to see the lead vessel connected with the sigmoid sinus,cut the blood vessels.With a diamond grinding along the sigm oid sinus to the jugular bulb,so that the surface of a thin layer of cortical bo ne remaining. Contour of the sigmoid sinus,forward, top to remove the mas-toid a small room, revealing the middle cranial fossa dura.Further forward than mastoid ground until it has tympanic sinus,were ground carefully to the surrounding bone, drum sinus wall appeared hard,light yellow color when the bone area, suggesting that close to the lateral semicircular canal;as clear to see to the quality of hard ivory white tips to the bone the last Department of posterior semicircular canal.Posterior semicircular canal in the direction parallel to the posterior wall of petrous part of temporal bone,the inside of the outer half of its pre-regulation,while the facial nerve canal horizontal semicircular canal is located outside the post below.Careful outline of bony labyrinth and facial nerve canal,to continue to grind down the mastoid tip area than the small room,so that pre-sigmoid sinus dural,middle fossa dura and sinus dural angle are fully exposed, the transverse sinus and the horiz-ontal transfer of sigmoid sinus petrosal sinus can be seen (Figure 67). Paral-lel to the anterior sigmoid sinus dural incision posterior to the jugular bulb at the top, pull to the front of the dura,sigmoid sinus exposure before the gap;along the middle cranial fossa transverse incision in the cranial fossa dura (Figure 8), raised his temporal lobe; in petrosal sinus,sigmoid sinus ligation meeting point in front of 0.5cm Department,cut off petrosal sinus;cut off from the petrosal sinus tentorial Department cut inward to the trochlear nerve into the dural side of the screen later notch Office,will push the rear tentorium.Further up the temporal lobe,cerebellum,and slightly retracted sigmoid sinus,petroclival exposure,observation and measurement data.
Results:1. the distance between the skull surface markers:Star point reach the peak milk from the joint front foot 28.9±3.7mm;star point to the external ear canal from the posterior crest of 43.2±1.6mm;top milk after sewing on the front foot to the ear canal from the crest of 25.8±4.2 mm.
2. sinus dural angle to the landmarks distance:sinus dural angle to the posterior semicircular canal from 18.6±3.1mm;sinus dural angle to the jugular bulb in the range 27.9±1.9 mm;sinus dural angle to the posterior external auditory canal ridge from 28.8±3.8mm.
3. intracranial length of the cranial nerves and the major gap between the cranial nerves:oculomotor intracranial far cry from 14.4±1.9mm;trigem-inal nerve intracranial far cry from 12.1±1.4mm;the facial nerve intracr-anial far cry from 11.3±1.8 mm;intracranial glossopharyngeal vagus nerve, far below the 17.7±1.9mm;oculomotor and trigeminal nerve from 12.9±3.2 mm;the facial nerve and glossopharyngeal vagus nerve from 10.2±2.9mm.
4. petroclival region by the exposed areas of measurement:In this study,to the middle cranial fossa revealed most visible carotid artery supr- aclinoid segment,measured petrous apex to its distance, representing the operative field can be revealed in the middle cranial fossa area, petrous apex to the supraclinoid carotid artery,far below as:10.2±1.7mm. Petrocli-val exposure can see the bottom of glossopharyngeal,vagus nerve, so the sco pe of the posterior fossa,which pointed to the rock glossopharyngeal,vagus nerve distance,petrous apex to the vagus nerve glossopharyngeal distance: 30.8±5.9mm.
Conclusion:1. Markers of body:external eye canthus, the upper edge of the external auditory canal and the external occipital protuberance to connect to mark location of transverse sinus;
2. Craniectomy:Star point can locate transverse sinus location, the top milk seam front key hole positioning as sigmoid sinus on the song. According to the dual positions of transverse sinus craniotomy safety, save time;
3. Papilla and bone were ground rock when the signs:For non-sclerosing papillary, according to bone, color, positioning posterior semicircular canal. Sclerotic mastoid sinus wall based primarily on indirect positioning drum posterior semicircular canal;
4. Tentorial surgery can be a very good margin of the upper and lower exposure areas can be exposed to the middle cranial fossa parasellar, supraclinoid internal carotid artery segment, posterior cranial fossa can be exposed to the vertebral artery, the glossopharyngeal, vagus nerve high. As the angle of the problem, the bone behind the rock exposed from the poor before the arcuate eminence;
5. Preoperative line of the necessary checks must clear position of transverse sinus venous return Labbe, a high jugular bulb, semicircular canals, the location of sigmoid sinus, otherwise, these anatomical position deviation will seriously affect the operation area of the exposed areas;
6. Screen up and down the joint presigmoid retrolabyrinthine approach is well exposed in the fissures on the slopes and tentorial area.
引文
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3. Horgan MA,Anderson GJ,Kellogg JX,et al.Classification and quantification of thepetrosal approach to the petroclival region[J].Neurosurg,2000,93:108-112.
4. Spetzler RF,Daspit PC,Pappas C.The combined supra-and infratentoial approachfor lesions of the petrousclival regions:experience with 46 cases [J]. Neurosurg,1992,7(6):588-599.
5. Sekhar LN,Schramm VL,Jones NF.Subtenporal-preauricular infratemporal fossa approach to large lateral and posterior cranial base neoplasms[J]. Neurosurg, 1987,6(7):488-499.
6. Chanda A, Nanda A. Partial labyrinthectomy petrous apiectomy approach to the petroclival region:an anatomic and technical study [J]. Neurosurgery,2002,51 (1):147-160.
7. Iaconetta G,Fusco M,Samii M.The spheno petroclivalvenous gulf:a micro-anatomy study [J].Neurosurg,2003,9(9):366-375.
8. Miller CG,Van Loveren HR,Keller JT.Transpetrosal approach:Surgical anatomy and technique[J],Neurosurgery,1993,3(3):467-469.
9. Mcdermott MW,Durity FA,Rootman J,et al.Combined frontotemporal orbito-zygomatic approach for tumors of the sphenoid wing and orbit, Neuro-surger[J], 1990,2(6):107-119.
10. Taha JM, Tew JM, van Loveren HR, et al. Comparis on of conventional andskull base surgical approaches for the excision of trigeminal neurinomas[J]. Neuro-surgery,1995,82(2):719-725.
11. Chanda A,Nanda A. Partial labyrinthectomy petrous Apiectomy approach to thepetroclival region:an anatomic and technicalstudy[J].Neurosurgery,2002,51 (1):147-160.
12. SamiiM, Tatagiba,ustavo A. et al. Retrosigmoid intraduralsup rameatal pproach to Meckels cave and middle fossa:surgical technique and outcome[J].,Neuro surgery,2000,92(2):235-224.
13. Hakuba A,Nishiara S,Tanaka K,et al.Clivus menin-giomas:six cases of total remove.Neurol[J].Med Chil,1977,1 (7):63-77.
14. Al-Mefty O,Fox JL,Smith RR,et al.Petrosal approach for petroclival meningio-mas[J].Neurosurgery,1988,2(2):510-517.
15. Samii M,Ammirati M.The combined suprainfratentorial presigmoid sinus avenus to the petroclival region:Surgical technique and clinical application[J].Acta Neurochir (Wien),1988,9(5):6-12.
16. laconetta G,Fusco M,Samii M:The sphenopetroclival venous gulf:a microana-tomystudy[J].Neurosurgery,2003,99(3):366-375.
17. Horgan MA,Anderson GJ,KeloggJX,etal.Classification and quantification of the petrosal approach to the petmclival region[J]. Neurosurg,2000,93(1):108-112.
18. Seifert V,Raabe A,Zimmermann Me.Conservative (labyrinth-preserving) transpetrosa 1 approach to the clivus and petroclival region-indications, complications, results, and lessonslearned[J].Acta Neurochir(Wien),2003,145: 631-642.
19.王玉海,卢亦成,王春莉等.岩斜区肿瘤手术入路的比较[J].中国临床神经外科杂志[J],2005,10(4)：87-89.
20. Samii M,Tatagiba M,Gustavo A.et al.Retrosigmoid intradural suprameatal approach to Meckel's cave and middle fossa:surgicaltechnique and outcome[J]. Neurosurgery,2000,92(2):235-241.
21. Chanda A,Nanda A.Partial labyrinthectomy petrous apiectomy approach to thepetroclival region:an anatomic and technical study[J]. Neurosurgery,2002,51 (1):147-160.
22. Ozveren MF,Uchida K,Aiso S:Meningovenous structures of petroclival region: Clinical importance for surgery and intravascutar surgery[J] Neuro surgery, 2002,50 (4):829-836.
23. Coel A,Muzumdar D.Conventional posterior fossa approach for surgery opetroclivial meningiomas;a report on an experience with 28cases[J].Surg Neurol,2004,62(4):332-340.
24. Spektor S,Anderson GJ,McMenomey SO,et al.Quantitative description of the far-lateraltranscondylar transtubercular approach to the foramen magnum and clivus[J].Neurosurg,2000,92(5):824-831.
25. Arnautovic KI,Al-Mefty O,Husain M.Ventral foramen magnum menini giomas [J].Neurosurg Spine,2000,92(1):71-80.
26. Hammon WM,Kempe LG.The posterior fossa approach to aneurysma of the vertebral and basilar arteries[J].Neurosurg,1972,37(3):339-347.
27. Seeger W.Atlas of topographical Anatomy of the Brain and Surrounding structures[J].Wein:Singer Verlag,1978,2(5):486-489.
28. Rhoton AL Jr.The far-lateral approach and its transcondyar, supracondylar and, paracondylar exten sions[J].Neurosurgery,2000,47(3):302-309
29. Lang DA,Neil-Dwyer G,Lannotti F,er al.The suboccipital transcondylar approach to theclivus and cranio-cervical junction for ventrally placed pathology at and above the foramenmagnum[J].Acta Neurochi,1993,125(4):132-137.
30. Abu RP,Sekhar LN,Wright DC.Extreme lateral transcondylar approach:technical improvements and lessons learned[J].Neurosurg,1994,81(1):49-59.
31. Hayashi N,Cohen AR,et al.Endoscope-assisted far-lateral transcondylar approach to the skull base[J].Minim Invasive Neurosurg,2002,45(3):132-135.
32. Ueda R,Yoshida K,Kawase T.Intradural C-1 ventral root schwannomas treated by surgical ressction via the lateral suboccipital transcondy larapproach[J].Neurol Med Chir (Tokyo),2006,46(6):298-301.
33. Baldwin HZ,Miller CG,Van Loveren HR,et al.The far lateral/combined supra and infratentorial approach.A human cadadveric prosection model for routes of access to the petroclival region andventral brain stem[J].Neurosurg,1994,81 (1): 60-68.
34.余新光.岩斜区肿瘤手术入路选择及相关问题.中华神经外科杂志[J],2005,21(6)：321-322
35. Cho CW,Al-Mefty O.Combined petrosal approach to petroclival meningiomas [J]. Neurosurgery,2002,5(1):708-716.
36. Kurts oy A,Menku A,Tucer B,et al. Neur onavigation in skull base tumors[J]. Minim nvasive Neurosurg,2005,48(1):7-12.
1. King WA,Black KL,Martion NA,et al.The petrosal approach with hearing prese-rvation[J]. Neurosurg,1993,7(9):508-514.
2. Jackler RK,Sim DW,Gutin PH,et al.Systematic approach to intradural tumors ventral to the brain stem[J].Am J Otol,1995,1(6):39-51.
3. DayJD, Fukushima T,Giammotta SL.Innovations insurgical approach:lateral cranial base approaches.Clin Neurosurg[J],1996,4(3):72-90.
4. Hakuba A,Nishiara S,Tanaka K,et al.Clivus meningiomas:six cases of total remove[J],Neurol Med Chil,1977,1(7):63-77.
5. Al-Mefty O,Fox JL,Smith RR,et al.Petrosal approach for petroclival mening iomas[J].Neurosurgery,1988,2(2):510-517.
6. Samii M,Ammirati M.The combined suprainfratentorial presigmoid sin us avenusto the petroclival region:Surgical technique and clinical application[J]. Acta Neurochir(Wien),1988,9(5):6-12.
7. Spetzler RF,Daspit PC,Pappas C.The combined supra and infratentoial approach for lesions of the petroclival regions:experience with 46 cases[J]. Neurosurg, 1992,7(6):588-599
8. Miller CG,VanLoveren HR,Keller JT,et al.Transpetrosal approach:surgical anato-my and technique[J].Neurosurgery,1993,33(3):461-469.
9. Kay JD,Fukrshima T,Giannotto SL. Microanatomical study of the extradural middlefossa approach to the petroclival and posterior cavernous sinus region: description of the rhomboid construct.[J]Neurosurgery,1994,3(4):1009-1016.
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2. Abdel Aziz KM,Sanan A,van Loveren HR,et al.pet-roclival meningiomas: predictiveparameters for transept-rosal approach[J].Neurosurgery,2000,4(7): 139-150.
3. Horgan MA,Anderson GJ,Kellogg JX,et al.Classification and quantification of thepetrosal approach to the petroclival region[J].Neurosurg,2000,93:108-112.
4. Spetzler RF,Daspit PC,Pappas C.The combined supra-and infratentoial approachfor lesions of the petrousclival regions:experience with 46 cases [J]. Neurosurg,1992,7(6):588-599.
5. Sekhar LN,Schramm VL,Jones NF.Subtenporal-preauricular infratemporal fossa approach to large lateral and posterior cranial base neoplasms[J]. Neurosurg, 1987,6(7):488-499.
6. Chanda A, Nanda A. Partial labyrinthectomy petrous apiectomy approach to the petroclival region:an anatomic and technical study [J]. Neurosurgery,2002,51 (1):147-160.
7. Iaconetta G,Fusco M,Samii M.The spheno petroclivalvenous gulf:a micro-anatomy study [J].Neurosurg,2003,9(9):366-375.
8. Miller CG,Van Loveren HR,Keller JT.Transpetrosal approach:Surgical anatomy and technique[J],Neurosurgery,1993,3(3):467-469.
9. Mcdermott MW,Durity FA,Rootman J,et al.Combined frontotemporal orbito-zygomatic approach for tumors of the sphenoid wing and orbit, Neuro-surger[J], 1990,2(6):107-119.
10. Taha JM, Tew JM, van Loveren HR, et al. Comparis on of conventional andskull base surgical approaches for the excision of trigeminal neurinomas[J]. Neuro-surgery,1995,82(2):719-725.
11. Chanda A,Nanda A. Partial labyrinthectomy petrous Apiectomy approach to thepetroclival region:an anatomic and technicalstudy[J].Neurosurgery,2002,51 (1):147-160.
12. SamiiM, Tatagiba,ustavo A. et al. Retrosigmoid intraduralsup rameatal pproach to Meckels cave and middle fossa:surgical technique and outcome[J].,Neuro surgery,2000,92(2):235-224.
13. Hakuba A,Nishiara S,Tanaka K,et al.Clivus menin-giomas:six cases of total remove.Neurol[J].Med Chil,1977,1 (7):63-77.
14. Al-Mefty O,Fox JL,Smith RR,et al.Petrosal approach for petroclival meningio-mas[J].Neurosurgery,1988,2(2):510-517.
15. Samii M,Ammirati M.The combined suprainfratentorial presigmoid sinus avenus to the petroclival region:Surgical technique and clinical application[J].Acta Neurochir (Wien),1988,9(5):6-12.
16. laconetta G,Fusco M,Samii M:The sphenopetroclival venous gulf:a microana-tomystudy[J].Neurosurgery,2003,99(3):366-375.
17. Horgan MA,Anderson GJ,KeloggJX,etal.Classification and quantification of the petrosal approach to the petmclival region[J]. Neurosurg,2000,93(1):108-112.
18. Seifert V,Raabe A,Zimmermann Me.Conservative (labyrinth-preserving) transpetrosa 1 approach to the clivus and petroclival region-indications, complications, results, and lessonslearned[J].Acta Neurochir(Wien),2003,145: 631-642.
19.王玉海,卢亦成,王春莉等.岩斜区肿瘤手术入路的比较[J].中国临床神经外科杂志[J],2005,10(4)：87-89.
20. Samii M,Tatagiba M,Gustavo A.et al.Retrosigmoid intradural suprameatal approach to Meckel's cave and middle fossa:surgicaltechnique and outcome[J]. Neurosurgery,2000,92(2):235-241.
21. Chanda A,Nanda A.Partial labyrinthectomy petrous apiectomy approach to thepetroclival region:an anatomic and technical study[J]. Neurosurgery,2002,51 (1):147-160.
22. Ozveren MF,Uchida K,Aiso S:Meningovenous structures of petroclival region: Clinical importance for surgery and intravascutar surgery[J] Neuro surgery, 2002,50 (4):829-836.
23. Coel A,Muzumdar D.Conventional posterior fossa approach for surgery opetroclivial meningiomas;a report on an experience with 28cases[J].Surg Neurol,2004,62(4):332-340.
24. Spektor S,Anderson GJ,McMenomey SO,et al.Quantitative description of the far-lateraltranscondylar transtubercular approach to the foramen magnum and clivus[J].Neurosurg,2000,92(5):824-831.
25. Arnautovic KI,Al-Mefty O,Husain M.Ventral foramen magnum menini giomas [J].Neurosurg Spine,2000,92(1):71-80.
26. Hammon WM,Kempe LG.The posterior fossa approach to aneurysma of the vertebral and basilar arteries[J].Neurosurg,1972,37(3):339-347.
27. Seeger W.Atlas of topographical Anatomy of the Brain and Surrounding structures[J].Wein:Singer Verlag,1978,2(5):486-489.
28. Rhoton AL Jr.The far-lateral approach and its transcondyar, supracondylar and, paracondylar exten sions[J].Neurosurgery,2000,47(3):302-309
29. Lang DA,Neil-Dwyer G,Lannotti F,er al.The suboccipital transcondylar approach to theclivus and cranio-cervical junction for ventrally placed pathology at and above the foramenmagnum[J].Acta Neurochi,1993,125(4):132-137.
30. Abu RP,Sekhar LN,Wright DC.Extreme lateral transcondylar approach:technical improvements and lessons learned[J].Neurosurg,1994,81(1):49-59.
31. Hayashi N,Cohen AR,et al.Endoscope-assisted far-lateral transcondylar approach to the skull base[J].Minim Invasive Neurosurg,2002,45(3):132-135.
32. Ueda R,Yoshida K,Kawase T.Intradural C-1 ventral root schwannomas treated by surgical ressction via the lateral suboccipital transcondy larapproach[J].Neurol Med Chir (Tokyo),2006,46(6):298-301.
33. Baldwin HZ,Miller CG,Van Loveren HR,et al.The far lateral/combined supra and infratentorial approach.A human cadadveric prosection model for routes of access to the petroclival region andventral brain stem[J].Neurosurg,1994,81 (1): 60-68.
34.余新光.岩斜区肿瘤手术入路选择及相关问题.中华神经外科杂志[J],2005,21(6)：321-322
35. Cho CW,Al-Mefty O.Combined petrosal approach to petroclival meningiomas [J]. Neurosurgery,2002,5(1):708-716.
36. Kurts oy A,Menku A,Tucer B,et al. Neur onavigation in skull base tumors[J]. Minim nvasive Neurosurg,2005,48(1):7-12.
1. King WA,Black KL,Martion NA,et al.The petrosal approach with hearing prese-rvation[J]. Neurosurg,1993,7(9):508-514.
2. Jackler RK,Sim DW,Gutin PH,et al.Systematic approach to intradural tumors ventral to the brain stem[J].Am J Otol,1995,1(6):39-51.
3. DayJD, Fukushima T,Giammotta SL.Innovations insurgical approach:lateral cranial base approaches.Clin Neurosurg[J],1996,4(3):72-90.
4. Hakuba A,Nishiara S,Tanaka K,et al.Clivus meningiomas:six cases of total remove[J],Neurol Med Chil,1977,1(7):63-77.
5. Al-Mefty O,Fox JL,Smith RR,et al.Petrosal approach for petroclival mening iomas[J].Neurosurgery,1988,2(2):510-517.
6. Samii M,Ammirati M.The combined suprainfratentorial presigmoid sin us avenusto the petroclival region:Surgical technique and clinical application[J]. Acta Neurochir(Wien),1988,9(5):6-12.
7. Spetzler RF,Daspit PC,Pappas C.The combined supra and infratentoial approach for lesions of the petroclival regions:experience with 46 cases[J]. Neurosurg, 1992,7(6):588-599
8. Miller CG,VanLoveren HR,Keller JT,et al.Transpetrosal approach:surgical anato-my and technique[J].Neurosurgery,1993,33(3):461-469.
9. Kay JD,Fukrshima T,Giannotto SL. Microanatomical study of the extradural middlefossa approach to the petroclival and posterior cavernous sinus region: description of the rhomboid construct.[J]Neurosurgery,1994,3(4):1009-1016.
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