神经内镜与显微镜经远外侧锁孔入路在颅颈交界区手术中应用的解剖学对比研究  

Anatomical comparative study of using a neuroendoscope and a microscope for the far-lateral keyhole approach in craniocervical junction surgery

作　　者：刘昊 张恒柱 严正村 王晓东 Liu Hao;Zhang Hengzhu;Yan Zhengcun;Wang Xiaodong(Department of Neurosurgery,Clinical Medical College of Yangzhou University,Yangzhou 225001,China)

机构地区：[1]扬州大学临床医学院神经外科,扬州225001

出　　处：《中华解剖与临床杂志》2023年第4期218-223,共6页Chinese Journal of Anatomy and Clinics

基　　金：江苏省卫生健康委员会科研项目(H2018064);江苏省“六个一工程”拔尖人才科研项目(LGY2017026);苏北人民医院交叉合作专项(SBJC21009)。

摘　　要：目的探讨神经内镜与显微镜经远外侧锁孔入路行颅颈交界区手术中,枕髁磨除前后的解剖观察范围,并分析枕髁磨除的意义。方法纳入10%甲醛固定的5例(10侧)成年国人尸头标本,动静脉分别以红、蓝乳胶灌注,其中男3具、女2具,年龄58~70岁、平均61岁。模拟远外侧手术入路:取乳突后"S"形切口、枕髁后微骨窗开颅,分别在显微镜和神经内镜下操作,观察磨除枕髁前后镜下术野显露的解剖结构,测量并计算延髓腹外侧的显露面积,对比2种手术入路的观察范围。结果显微镜经远外侧锁孔入路可显露成人尸头标本后组颅神经、椎动脉、基底动脉、小脑前下动脉和小脑后下动脉,枕髁磨除后扩大了对椎动脉、舌下神经、延髓侧方及腹侧的显露。神经内镜经远外侧锁孔入路通过面听-舌咽神经间隙、舌咽-迷走神经间隙、迷走-副神经颅根间隙和副神经脊髓根腹侧间隙,可观察后组颅神经、椎动脉、基底动脉、小脑前下动脉、小脑后下动脉、脑干侧面及腹侧面;磨除枕髁前、后内镜下延髓腹外侧显露面积分别为(331.0±6.6)mm^(2)和(464.7±10.6)mm^(2),差异有统计学意义(t=52.99,P<0.001);磨除枕髁前、后显微镜下延髓腹外侧显露面积分别为(205.8±9.6)mm^(2)和(329.1±6.7)mm^(2),差异有统计学意义(t=75.07,P<0.001);磨除枕髁前、后内镜下延髓腹外侧显露面积均大于显微镜下,差异均有统计学意义(t=62.18、64.62,P值均<0.001);内镜磨除枕髁前与显微镜磨除枕髁后的显露面积差异无统计学意义(t=1.63,P=0.137)。结论远外侧锁孔入路磨除枕髁后神经内镜与显微镜2种手术方式均能增加延髓腹外侧的显露面积;神经内镜远外侧锁孔入路不磨除枕髁即可获得良好的、与显微镜远外侧锁孔入路磨除枕髁后相似的显露范围,对脑干腹侧面、椎动脉、基底动脉等深部结构的显露更具优势,临床手术中可免于磨除枕髁。Objective To explore the anatomical observation range of the far-lateral keyhole approach in craniocervical junction surgery by using a neuroendoscope and a microscope,and to analyze the necessity of occipital condyle grinding.Methods A total of 5 adult cadaveric head specimens(10 sides)of Chinese adults(3 males and 2 females,aged 58-70 years,with an average age of 61 years)fixed with 10%formaldehyde and perfused with red and blue latex were selected to simulate the far-lateral keyhole approach.A 6 cm longitudinal S-shaped incision was made approximately 2 cm dorsal to the mastoid process,and the micro-bone window behind the occipital condyle was used.The anatomical structures were observed separately with a neuroendoscope and a microscope before and after grinding the occipital condyle.The exposure area of the ventrolateral medulla oblongata was calculated.The observed ranges of the two approaches were compared.Results The posterior cranial nerve,vertebral artery(VA),basilar artery(BA),anterior inferior cerebellar artery(AICA),and posterior inferior cerebellar artery(PICA)could be exposed by a microscope through the far-lateral keyhole approach.After grinding the occipital condyle,the exposure of the VA,hypoglossal nerve,and lateral and ventral medulla oblongata was expanded.Before the occipital condyle was ground,the neuroendoscope could expose the posterior cranial nerves,VA,BA,AICA,PICA,and lateral and ventral sides of the brainstem through the facial auditory-glossopharyngeal nerve gap,glossopharyngeal-vagal nerve gap,vagal-accessory nerve cranial root gap,and ventral space of the accessory nerve spinal root gap.Before and after the removal of the occipital condyle,the area of the ventrolateral medulla under the neuroendoscope was(331.0±6.6)mm^(2)and(464.7±10.6)mm^(2),and their difference was statistically significant(t=52.99,P<0.001).Before and after removal of the occipital condyle,the exposed area of the medulla oblongata under the microscope was(205.8±9.6)mm^(2)and(329.1±6.7)mm^(2),respectively,and t

关 键 词：神经内窥镜检查 神经外科手术 锁孔技术 远外侧入路 枕髁 

分 类 号：R651.1[医药卫生—外科学]