摘要
本研究的目的是：1、寻找岩斜区颅骨的解剖标志,并对其结构进行量化。2、结合减少术中正常组织损伤及减少术后并发症发生的治疗宗旨,对现有的岩斜区手术入路进行剖析、总结并进行改良,希望获得更佳的手术入路。通过尸头上模拟手术入路两侧对比显微应用解剖,寻找更合理的岩斜区手术入路。采用的方法是通过尸头上模拟手术入路两侧对比显微应用解剖；在尸头上模拟改良后的颞枕经小脑幕-经岩嵴入路和传统的乙状窦前入路。得出结论为1、通过两个关键孔(顶乳突缝前角和星点前下方约4.67mm处)基本能够锁定幕上下联合入路的骨窗；2、改良的颞枕经小脑幕-经岩嵴入路只需磨除岩骨嵴内侧部及中间部骨质后与乙状窦前入路两者在手术最大视角和操作深度无显著差异(P＞0.05)；3、改良的颞枕经小脑幕经岩嵴入路的骨窗面积较乙状窦前入路显著缩小(P＜0.05)；4、改良的颞枕经小脑幕经岩嵴入路的脑干腹侧中间隙暴露长度明显大于乙状窦前入路而在桥脑腹侧中点所需牵开颞叶的角度明显小于乙状窦前入路(P＜0.05)；5、利用传统乙状窦前入路的切口创造出改良的颞枕开颅经小脑幕经岩骨嵴入路；6、提出顶乳突缝前角作为颞枕开颅的关键孔,减少了颞枕开颅的骨窗面积；7、改良的颞枕经小脑幕经岩嵴入路对岩斜区肿瘤基底暴露好,可早期阻断肿瘤血供,使瘤体缩小,质地变软,出血减少,从而提高手术安全性。
Objective:Through cadaveric head anatomy and operative approach simulation on cadaveric head, the current operative approach to the petroclival region was analyzed, summarized and improved so as to obtain an optimal operative approach.
Method:The adult cadaveric head preserved with 10% formalin was dissected under the microscope and the mark and location of important bone structures were further determined. The shape, distribution of skull base vascular and its relationship with cranial nerve and brainstem were illustrated and the relevant distance was measured. The improved tempoccipital transtentorial and infratemperal approach was simulated on cadaveric head and compared with the traditional presigmoid approach.
Results:1. It was put forward that the improved tempoccipital transtentorial and infratemperal approach could basically lock the bone windows of the combined approaches above and below the cerebelli through two keyholes (front rake of bregmatomastoid suture and 4.67mm before and under the asterion).2. It was put forward that the incision of the traditional presigmoid approach be used to create the incision of the improved tempoccipital transtentorial and infratemperal approach. 3. It was put forward that the front rake of bregmatomastoid suture be the keyhole of tempoccipital skull dissection, thus the bone window area could be reduced.4. It was put forward that the front rake of bregmatomastoid suture be used to judge the position of the upper margin of presigmoid rotating angle.5. It was put forward that the front rake of bregmatomastoid suture combining with asterion can be the two keyholes of combined skull dissection above and below the cerebelli, which can prevent the whole exposure of sigmoid sinus and reduce its damages.6. It was put forward of the selecting principles of individualized operative approach of petroclival region meningioma.
Conclusions:(1) The bone windows of the combined approaches above and below the cerebelli can be basically locked through the two keyholes (front rake of bregmatomastoid suture and 4.67mm before and under the asterion). (2) In respects of the maximum operative view and operating depth, the improved tempoccipital transtentorial and infratemperal approach had no obvious differences with presigmoid approach ((P>0.05) as long as the infratemperal inner side part and the middle bone were removed. (3) The bone window area of the improved tempoccipital transtentorial and infratemperal approach was obviously decreased compared with that of presigmoid approach (P<0.05). (4) The exposed length of the brain stem ventral gap of the improved tempoccipital transtentorial and infratemperal approach was obviously bigger than that of presigmoid approach. While the angle needed to open lobi temporalis in middle ventral part of pon was obviously smaller than that of presigmoid approach (P<0.05). (5) The incision of the traditional presigmoid approach was used to create the incision of the improved tempoccipital transtentorial and infratemperal approach. (6) The front rake of bregmatomastoid suture was taken as the keyhole of tempoccipital skull dissection, thus the bone window area could be reduced. (7) The improved tempoccipital transtentorial and infratemperal approach exposed the base of petroclival region tumor well. It can stop the tumor blood supply earlier, reduce the tumor area, soften the texture and reduce the blood, thus the safety of operation could be enhanced. (8) The improved tempoccipital transtentorial and infratemperal approach was easier and safer than presigmoid approach. The former invades minimally and is a flexible operative approach of treating petroclival region tumor.
引文
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