内镜辅助下锁孔手术入路至岩斜区的显微解剖学研究
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摘要
研究背景和目的:
岩斜区位于颅底,位置深在,关键结构众多且毗邻关系复杂。因而,岩斜区疾病的外科治疗对于神经外科医生而言依然是一个极具挑战性的课题。经过几十年的基础与临床的研究,业已发展出众多的颅底外科入路,以期在尽可能去除病患的同时降低患者的死亡率。毋庸置疑的,治疗岩斜区疾病手术入路的关键即要求在彻底显露病变组织的同时,暴露与病变相关的神经及血管,尤其是神经血管常因病变的压迫而移位或被缠绕其中。基于微侵袭的理念,近年来涌现出不同的锁孔入路,借锁孔入路可达岩斜区。经过国内外诸多学者的不懈努力,已有不少成功运用的锁孔入路,如颞下锁孔入路、乙状窦前迷路后锁孔入路、远外侧髁后锁孔入路成功显露岩斜区结构的报道。经上述锁孔入路,可成功手术切除岩斜区部分病变组织。锁孔入路在避免了传统入路常见的并发症的同时,不需过度牵拉脑组织,损伤较小,因此,一时成为神经外科的首选术式。然后,由于手术显微镜只具有直视的功能,术者只能观察物镜轴线正前方的组织结构,隐蔽部位的结构在镜下显示不理想,如无法显露脑神经的全貌,尤其是对于脑干的腹侧面,显微镜的显示差强人意。此时,往往需要人为破坏正常的结构,从而影响后期功能的恢复。内镜具有多重的观察角度,可以为术野提供更为全面的显露,尤其是对于位置深在的结构。因此,内镜的使用有望解决手术显微镜在结构显露方面的不足。
目前,有关各种锁孔入路的解剖学研究并不鲜见。但对于同一锁孔入路,不同作者的操作并不统一,从而导致基于此所获得的内镜解剖结果也不尽相同。而且,相关的研究过多关注于相关数据的测量。虽然,详尽的数据有助于手术的顺利实施,但在实际操作过程中,术者不太可能进行测量各个结构之间的距离,也未必需要将所有结构统统显露。更为重要的是,由于内镜手术方法和放大倍数的改变,常致镜下所见结构的位置和形态发生变化。而且,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发生几率。因此,对经不同锁孔入路引入内镜对岩斜区的结构的定位、各结构在不同观察角度中位置是否变化,如何变化等问题更具实际意义。基于上述思路,在借鉴前人工作的基础上,笔者在成人头部标本上模拟颞下锁孔入路、乙状窦前迷路后锁孔入路、远外侧枕骨髁后入路,分别使用手术显微镜和内镜对上述各锁孔入路观察岩斜区结构,从而比较内镜的显露范围和手术显微镜的显露的不同之处。本研究中,笔者着重探讨各锁孔入路内镜解剖的关键操作步骤,如皮肤切口、骨窗形成和内镜导入的途径、内镜下岩斜区结构的定位、内镜下的操作要点等。笔者注意到,迄今尚未见到针对远外侧枕骨髁后入路所作的内镜解剖学研究报道。笔者希望借助本研究能为临床上使用上述锁孔入路进行内镜下岩斜区的手术适用范围及术中重要结构的保护措施提供解剖学基础,为临床实践起到指导作用。
方法:
1.20例(40侧)成年国人尸头,经检查无头部的病患。常规使用福尔马林固定,动脉灌注红色乳胶,静脉灌注蓝色乳胶。
2.颞下锁孔入路的模拟:外耳道前1.0cm长约5cm垂直皮肤切口,下界止于颧弓下缘。切开颞肌筋膜,显露颞骨鳞部,制备一直径为2.5cm的骨窗。
3.乙状窦前迷路后入路的模拟:采用耳后“C”形皮肤切口,上至耳廓袢上缘,下至耳屏切迹水平,耳后距耳廓袢约1 cm;皮瓣切开后,轮廓化乳突及骨迷路,制备一大小3cm×4cm的骨窗。
4.远外侧枕骨髁后锁孔入路的模拟:乳突后纵形“S”切口,长约7cm,上缘起自乳突中点后2cm,下界至C_2水平。显露并辨认枕项部各层肌肉,寻找椎动脉V3水平段,并保护之。显微镜观察时,制备一直接约3cm的骨窗,内侧至枕骨大孔外缘,外侧至乙状窦内缘,下界至枕骨髁后缘。内镜解剖时,将骨窗直径缩小至2cm,其外侧界自乙状窦内缘后移。乙状窦侧瓣状剪开硬脑膜。
5.手术显微镜观察:经上述锁孔入路,使用手术显微镜观察岩斜区结构的显露范围,拍照记录。
6.内镜的观察:经上述锁孔入路,分别引入内镜观察岩斜区的解剖结构,拍照。
7.测量相关数据,统计软件处理。
结果:
1.在颞下锁孔入路中,手术显微镜下可见上岩斜区的大部分结构。包括部分中脑和脑桥、滑车神经、动眼神经、基底动脉和颈内动脉的床突上段以及分支:大脑后动脉、大脑中动脉、小脑上动脉、后交通动脉、大脑前动脉。调整显微镜的观察角度,尚可见乳头体、垂体柄和视交叉等结构。
2.在颞下锁孔入路中,除上述结构外,内镜下还可观察到双侧或单侧三叉神经、展神经、面神经、前庭蜗神经、中间神经、内听动脉、脚间窝、脑桥的腹侧面等。此外,还可观察到丘脑前穿动脉、脉络丛前动脉与数目不等的穿支等。颈内动脉与动眼神经间的垂直距离为8.26±0.97mm;后交通动脉与小脑幕的距离为8.81±1.56mm;脉络丛前动脉与后交通动脉前支的垂直距离为5.57±0.90mm。
3.在乙状窦前迷路后入路中,通过手术显微镜可观察到三叉神经、面神经、前庭蜗神经、舌咽神经、迷走神经、副神经。此外,还可见脑桥的腹外侧面,小脑下前动脉、岩上静脉等。滑车神经以及脑干腹侧面等结构无法显露。
4.磨除乙状窦表面骨质的情况下,除上述结构外,内镜下还可显露展神经、滑车神经、脑干的腹侧面结构、椎动脉、基底动脉、中间神经和内听动脉等。
5.在乙状窦前迷路后锁孔入路中,骨窗开口前缘与内耳道口后唇的距离为14.24±2.70 mm(8.50～17.56 mm)。
6.椎动脉源自颈外动脉,在项部时,其走行于枕下三角内,其周围缠绕丰富静脉丛。C_1神经走行于椎动脉和寰椎后弓之间。
7.在远外侧枕骨髁后锁孔入路中,手术显微镜下,可见舌咽神经、迷走神经的根丝以及副神经的脑根和脊髓根,通过调整头位和显微镜的角度,还可以观察到面神经、前庭蜗神经、小脑下前动脉、小脑下后动脉、基底动脉的起始段。
8.除上述结构外,内镜下可以观察到后组脑神经的出颅部位,包括颈静脉孔和舌下神经管内口,此外,还可以显露脑干腹侧面的结构、椎动脉的末端。脑神经与血管间复杂毗邻关系亦可得以显示。
9.在远外侧枕骨髁后锁孔入路中,骨窗外缘至颈静脉内口的距离为17.29±2.80mm。
结论:
1.颞下锁孔入路中皮肤切开时,操作应于颞浅筋膜和深筋膜之间进行,可有效保护面神经颞支和颞浅血管。
2.在内镜的辅助下,岩尖磨除不必作为颞下锁孔入路手术的常规操作。
3.经颞下锁孔的内镜对上岩斜区结构范围要优于显微镜的显露。
4.上岩斜区结构的内镜下定位应多种定位标识联合使用。在可能的情况下,应选择骨性结构作为定位标识,如内耳道口。因骨性结构位置恒定,不会因病变的压迫而移位。
5.脑内的外科间隙为经颞下锁孔入路内镜的导入提供了形态学基础,术中应充分利用各外科间隙,以求上岩斜区结构的理想显露。
6.乳突轮廓化中,要切实保护乙状窦。乙状窦下缘的显露有助于后期术野的暴露,但要注意高位颈静脉球及宽大乙状窦。
7.借助颞骨岩部磨除时的骨质变化以定位后骨半规管。
8.面神经、前庭蜗神经及内耳道口均可作为乙状窦前迷路后锁孔入路内镜下观察中岩斜区及周围结构的定位标识。但脑神经会因占位性病变的压迫而移位,而内耳道口为骨性结构,位置恒定,以其作为定位标识更具有优势。
9.相对于手术显微镜而言,内镜对中岩斜区及周围结构的显露更为广泛。
10.内镜的使用,可缩小远外侧枕骨髁后锁孔入路的骨窗。
11.在未磨除枕骨髁及颈静脉结节的情况下,下岩斜区及周围结构在内镜下显露良好,尤其是对于脑干的腹侧面、脑神经的全貌。
12.副神经的脊髓根及颈静脉孔内口均可以作为内镜下经远外侧枕骨髁后锁孔入路对下岩斜区结构的定位标识;因后者为骨性结构,位置恒定,以其作为定位标识,更加具有优势。
13.三种不同的锁孔入路,内镜的引入均可显著改善术野的显露。但内镜的观察角度不同,可致结构间的关系发生变化。因此,术者要切实把握内镜下的解剖学特点。
14.内镜和手术显微镜各有优缺点。临床实践中,应根据不同病变制定个性化治疗方案,联合使用内镜和手术显微镜,取长补短,方可彻底切除病变组织。
主要创新点:
1.经颞下锁孔入路导入内镜观察上岩斜区结构,应采取多个定位标识联合的方法以避免因病变压迫引起软组织移位所导致的定位错误。
2.乙状窦前迷路后入路中,应在轮廓化乳突时显露乙状窦下缘。此项操作有助于后期术野的显露;面前庭蜗神经及内耳道口均可以作为经乙状窦前迷路后内镜下定位中岩斜区及其周围结构的标识。
3.内镜的应用,可缩小远外侧枕骨髁后锁孔入路的骨窗;远外侧枕骨髁后入路不必磨除枕骨髁,在此基础上引入内镜,还可避免磨除颈静脉结节。一方面可简化手术操作步骤,重要的是可减少手术后并发症的发生;副神经脊髓根和颈静脉孔内口均可以作为经远外侧枕骨髁后锁孔入路内镜下定位下岩斜区及其周围结构的标志。
4.定位标识的选择应根据不同的病患,如遇软组织受病变组织挤压而移位的情况,应采用骨性结构作为定位标志。
Background and objective:
Peroclival diseases remain one of the most challenging to treat surgically due to their location deep within the skull base and their association with multiple neural and vascular structures.Over the years,many skull base approaches have been described that are meant to improve resection and decrease patient morbidity.Central to all approaches to the petroclival region is the ability to visualize the tumor and the important neural and vascular structures that these tumors are adjacent to, compressing and encasing.Recently,different keyhole approaches have been developed to access this region.Increased evidences have been demonstrated that most of neural and vascular structures in peroclival region can be exposed sufficiently via various keyhole approaches,including temporal keyhole approach, suboccipito-retrosigmoidal keyhole approach and retro-condylar keyhole approach. Some of diseases in peroclival region can be removed in success via these keyhole approaches.Moreover,the usage of keyhole approach can avoid effectively the pulling of cerebular tissue with minimal injury.However,limited to direct visual angle of operating microscope,it is still difficult to exposure the entire of the nerves and blood vessels within the peroclival region,as well as the ventral aspect of the brain stem.With multiple visual angles,the endoscopy can provides a clear view on the entire site of the operation,especial to the deep structures.So,the usage of endoscopy should be providing a potential to solve questions abovementioned.
Although numerous studies have been performed on endoscopic anatomy of different keyhole approaches,excluding the retro-condylalr keyhole approach, ambiguities in operation of keyhole approaches were still existed.Moreover,the previous studies were excessively focused on measurement of related structures. Undoubtedly,it is difficult to measure the distances among the structures,although the accurate data is helpful to surgical treatment.In our opinion,it will be practical to explore the endoscopic anatomical features of structures in peroclival region, including the location of the structure,position change under different visual angles of endoscope and etc.So,the endoscopic anatomical features of the peroclival region via temporal keyhole approach,suboccipito-retrosigmoidal approach and retro-condylar keyhole approach were observed in present study based on the previous studies.Exposure scopes of peroclival region with endoscope or operating microscope were emphasized.Additionally,the main points about the skin incision, bony window formation and insert of endoscope were focused on in order to provide accurate anatomical basis for clinical applications.
Methods:
1.20 adult cadavers head fixed with formalin and injected with colored emulsion were used in present study.
2.Mimicry of subtemporal keyhole approach:The vertical skin incision was performed 1.0 cm anterior to the external auditory canal and 5cm in length.The lower board of skin incision was above inferior margin of zygomatic arch.After the exposure of temporal squama sufficiently,2.5cm bony window were prepared. The petrous apex was stripped based on identification of related bony structures. The superior margin of zygomatic arch was removed to adapt the observation using operation microscope.
3.Mimicry of suboccipito-retrosigmoidal keyhole approach:A postauricular skin incision was carried out,which was C shape and below to the superior margin of auricle and above to the level of intertragic incisures.After the skin flap dissection and outlines of mastoid process and osseous labyrinth in turn,a 3cm×4cm bony window was prepared.
4.Mimicry of the retro-condylar keyhole approach:A skin incision was performed posterior to mastoid process,which was S in shape and 7cm in length.The muscles in the occipital region and nuchal region were dissected carefully to exposure the V3 segment of vertebral artery.A bony window was designated to 3cm in diameter for microscopic observation,lateral margin of great occipital foramen medially,medial board of sigmoid sinus laterally,and posterior margin of occipital condyle inferiorly.As to endoscopic observation,the bony windows were diminished to 2cm in diameter and moved backward.
5.Observation with microscope:The structures in the perclival region were observed with operating microscope and recorded.
6.Observation with endoscope:The structures in the perclival region were observed with endoscope.
7.Related data were obtained and analyzed with SPSS.
Results:
1.Most of structures in upper petroclival region were observed under microscope via subtemporal keyhole approach.,including part of midbrain and pons,trochlear nerve and oculomotor nerve,basilar artery and the supraclinoidal portion of internal carotid artery and their branches,including posterior cerebral artery,superior cerebellar artery,posterior communicating artery,middle cerebral artery,anterior cerebral artery.Adjusting optical angle of microscope,the mamillary body,pituitary stalk and optic chiasma were also found.
2.Beside of structures abovementioned,the unilateral or bilateral trigeminal nerve, abducent nerve,facial nerve,vestibulocochlear nerve,intermediate nerve,internal auditory artery interpeduncular fossa,ventral aspect of pons were observed with endoscope inserted into intracephalic spaces via subtemporal keyhole approach. The distance from internal carotid artery to oculomotor nerve was 8.26±0.97mm; The distance from posterior communicating artery to tentorium of cerebellum was 8.81±1.56mm;The distance from anterior choroidal artery to posterior communicating artery was 5.57±0.90mm.
3.Under microscope,the trigeminal nerve,facial nerve,vestibulocochlear nerve, glossopharyngeal nerve,vagus nerve accessory nerve were observed via suboccipito-retrosigmoidal keyhole approach,as well as the lateral ventral aspect of pons,anterior inferior cerebellar artery,superior petrous vein,excluding the abducent nerve,trochlear nerve and ventral aspect of brain stem.
4.Beside of structures abovementioned,the abducent nerve,trochlear nerve and ventral aspect of brain stem were observed under endoscope via suboccipito-retrosigmoidal keyhole approach with absence of the superficial bone substance of sigmoid sinus,as well as the vertebral artery,basilar artery, intermediate nerve and internal auditory artery.
5.The distances of anterior margin of bony window to posterior lip of orifice of internal acoustic meatus were 14.24±2.70 mm(8.50～17.56 mm).
6.Originating from the external carotid artery,the vertebral artery entered suboccipital triangle in nuchal region and wrapped with venous plexus.The C_1 nerve ran through the space between vertebral artery and posterior arch of atlas.
7.Under the operating microscope,the rootlets of glossopharyngeal nerve,vagus nerve were observed via the retro-condylar keyhole approach,as well as the cranial roots and spinal roots of accessory nerve,hypoglossal nerve and vertebral artery.The jugular foramen was not exposed due to the jugular tubercle. Adjusting head position and visual angle of microscope,the facial nerve, vestibulocochelear nerve,anterior inferior cerebellar artery posterior inferior cerebellar artery and the initiated segment of basilar artery were observed.
8.Beside of structures,the outlets of posterior group cranial nerves,including jugular foramen and hypoglossal canal,were exposed under endoscope via the retro-condylar keyhole approach,as well as the ventral aspect of brain stem and the extremity of vertebral artery.Complex relationship among the cranial nerves and blood vessels was also found.
9.The distance of lateral margin of bony window to internal orifice of jugular foramen was 17.29±2.80mm.
Conclusions:
1.The frontal branch of facial nerve and superficial temporal vessels can be protect sufficiently while the skin incision were performed between the superficial fascia and deep fascia.
2.The stripping of petrous apex neednot be performed as routine technique in
temporal keyhole approach.
3.The surgical exposure of upper perclival region under endoscope,which is more extensive compared with those exposed under operating microscope.
4.The structures in upper petroclival region may be localized by combination of different markers.The bony structure,such as orifice of internal auditory canal, can be applied as marker.
5.The natural intracephalic spaces,including posterior communicating artery, trigeminal nerve,posterior communicating artery -anterior thalamal perforating artery,posterior communicating artery-perforating artery ones.Sufficient utilization of these spaces ensures operation in success.
6.Protection of sigmoid sinus is pivotal issue in mastoid outline.Exposure of posterior margin of sigmoid is helpful to the operating field.
7.Posterior bony semicircular canal can be localized based on the density change of os petrosum.
8.Both of the facial nerve,vestiblocochlear nerve and the orifice of internal auditory canal can be used as marker to localize the structures in peroclival region.The later one is preferable due to its unchangeable position.
9.Utilization of endoscope can improve significantly the surgical exposure compared with those under operating microscope.
10.Usage of endoscope can diminish the bony window in retro-condylar keyhole approach;
11.Without removal of occipital condyle and jugular tubercle,the anatomical structures within the lower peroclival region can be exposed entirely including the ventral of the brain stem under endoscope compared to those under microscope.
12.Both of the spinal root of accessory nerve and internal orifice of jugular foramen can be used as marker in endoscopy assisted retro-condylar keyhole approach to lower peroclival region.The later one is preferable due to its bony structure and unchangeable position.
13.Usage of endoscope in three different keyhole approaches abovementioned can improve the surgical field sufficiently.Endoscopic anatomical features of structures in the peroclival region due to the change of position,adjacent of structures under endoscope.
14.Individuation may be carried out in surgical therapy according to various diseases. So,combination the microscope and endoscope is acceptable to remove the pathological tissues in success.
New ideas:
1.To define that the structures in upper petroclival region need be localized by combination of various markers instead of single marker in endoscopic operation via subtemporal keyhole approach.
2.Beside of the protection of sigmoid sinus as pivotal issue in mastoid outline,the further view what exposure of posterior margin of sigmoid is helpful to the operating field in endoscope-assisted suboccipito-retrosigmoidal keyhole approach to peroclival region.To validate that both of the facial nerve,vestiblocochlear nerve and the orifice of internal auditory canal can be used as marker to localized the structures in peroclival region.
3.A novel outlook was raised in this study that usage of endoscope can diminish the bony window in retro-condylar keyhole approach.Not only the occipital condyle but also jugular tubercle can be remained due to the utilization of endoscope with the entire exposure of structures in lower peroclival region.The viewpoint was indicated in first time that both of the spinal root of accessory nerve and internal orifice of jugular foramen can be used as marker in endoscope assisted retro-condylar keyhole approach to the lower peroclival region.
4.The selection of marker need according to various diseases,The bony structure was prefer to soft tissue.
岩斜区位于颅底,位置深在,关键结构众多且毗邻关系复杂。因而,岩斜区疾病的外科治疗对于神经外科医生而言依然是一个极具挑战性的课题。经过几十年的基础与临床的研究,业已发展出众多的颅底外科入路,以期在尽可能去除病患的同时降低患者的死亡率。毋庸置疑的,治疗岩斜区疾病手术入路的关键即要求在彻底显露病变组织的同时,暴露与病变相关的神经及血管,尤其是神经血管常因病变的压迫而移位或被缠绕其中。基于微侵袭的理念,近年来涌现出不同的锁孔入路,借锁孔入路可达岩斜区。经过国内外诸多学者的不懈努力,已有不少成功运用的锁孔入路,如颞下锁孔入路、乙状窦前迷路后锁孔入路、远外侧髁后锁孔入路成功显露岩斜区结构的报道。经上述锁孔入路,可成功手术切除岩斜区部分病变组织。锁孔入路在避免了传统入路常见的并发症的同时,不需过度牵拉脑组织,损伤较小,因此,一时成为神经外科的首选术式。然后,由于手术显微镜只具有直视的功能,术者只能观察物镜轴线正前方的组织结构,隐蔽部位的结构在镜下显示不理想,如无法显露脑神经的全貌,尤其是对于脑干的腹侧面,显微镜的显示差强人意。此时,往往需要人为破坏正常的结构,从而影响后期功能的恢复。内镜具有多重的观察角度,可以为术野提供更为全面的显露,尤其是对于位置深在的结构。因此,内镜的使用有望解决手术显微镜在结构显露方面的不足。
目前,有关各种锁孔入路的解剖学研究并不鲜见。但对于同一锁孔入路,不同作者的操作并不统一,从而导致基于此所获得的内镜解剖结果也不尽相同。而且,相关的研究过多关注于相关数据的测量。虽然,详尽的数据有助于手术的顺利实施,但在实际操作过程中,术者不太可能进行测量各个结构之间的距离,也未必需要将所有结构统统显露。更为重要的是,由于内镜手术方法和放大倍数的改变,常致镜下所见结构的位置和形态发生变化。而且,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发生几率。因此,对经不同锁孔入路引入内镜对岩斜区的结构的定位、各结构在不同观察角度中位置是否变化,如何变化等问题更具实际意义。基于上述思路,在借鉴前人工作的基础上,笔者在成人头部标本上模拟颞下锁孔入路、乙状窦前迷路后锁孔入路、远外侧枕骨髁后入路,分别使用手术显微镜和内镜对上述各锁孔入路观察岩斜区结构,从而比较内镜的显露范围和手术显微镜的显露的不同之处。本研究中,笔者着重探讨各锁孔入路内镜解剖的关键操作步骤,如皮肤切口、骨窗形成和内镜导入的途径、内镜下岩斜区结构的定位、内镜下的操作要点等。笔者注意到,迄今尚未见到针对远外侧枕骨髁后入路所作的内镜解剖学研究报道。笔者希望借助本研究能为临床上使用上述锁孔入路进行内镜下岩斜区的手术适用范围及术中重要结构的保护措施提供解剖学基础,为临床实践起到指导作用。
方法:
1.20例(40侧)成年国人尸头,经检查无头部的病患。常规使用福尔马林固定,动脉灌注红色乳胶,静脉灌注蓝色乳胶。
2.颞下锁孔入路的模拟:外耳道前1.0cm长约5cm垂直皮肤切口,下界止于颧弓下缘。切开颞肌筋膜,显露颞骨鳞部,制备一直径为2.5cm的骨窗。
3.乙状窦前迷路后入路的模拟:采用耳后“C”形皮肤切口,上至耳廓袢上缘,下至耳屏切迹水平,耳后距耳廓袢约1 cm;皮瓣切开后,轮廓化乳突及骨迷路,制备一大小3cm×4cm的骨窗。
4.远外侧枕骨髁后锁孔入路的模拟:乳突后纵形“S”切口,长约7cm,上缘起自乳突中点后2cm,下界至C_2水平。显露并辨认枕项部各层肌肉,寻找椎动脉V3水平段,并保护之。显微镜观察时,制备一直接约3cm的骨窗,内侧至枕骨大孔外缘,外侧至乙状窦内缘,下界至枕骨髁后缘。内镜解剖时,将骨窗直径缩小至2cm,其外侧界自乙状窦内缘后移。乙状窦侧瓣状剪开硬脑膜。
5.手术显微镜观察:经上述锁孔入路,使用手术显微镜观察岩斜区结构的显露范围,拍照记录。
6.内镜的观察:经上述锁孔入路,分别引入内镜观察岩斜区的解剖结构,拍照。
7.测量相关数据,统计软件处理。
结果:
1.在颞下锁孔入路中,手术显微镜下可见上岩斜区的大部分结构。包括部分中脑和脑桥、滑车神经、动眼神经、基底动脉和颈内动脉的床突上段以及分支:大脑后动脉、大脑中动脉、小脑上动脉、后交通动脉、大脑前动脉。调整显微镜的观察角度,尚可见乳头体、垂体柄和视交叉等结构。
2.在颞下锁孔入路中,除上述结构外,内镜下还可观察到双侧或单侧三叉神经、展神经、面神经、前庭蜗神经、中间神经、内听动脉、脚间窝、脑桥的腹侧面等。此外,还可观察到丘脑前穿动脉、脉络丛前动脉与数目不等的穿支等。颈内动脉与动眼神经间的垂直距离为8.26±0.97mm;后交通动脉与小脑幕的距离为8.81±1.56mm;脉络丛前动脉与后交通动脉前支的垂直距离为5.57±0.90mm。
3.在乙状窦前迷路后入路中,通过手术显微镜可观察到三叉神经、面神经、前庭蜗神经、舌咽神经、迷走神经、副神经。此外,还可见脑桥的腹外侧面,小脑下前动脉、岩上静脉等。滑车神经以及脑干腹侧面等结构无法显露。
4.磨除乙状窦表面骨质的情况下,除上述结构外,内镜下还可显露展神经、滑车神经、脑干的腹侧面结构、椎动脉、基底动脉、中间神经和内听动脉等。
5.在乙状窦前迷路后锁孔入路中,骨窗开口前缘与内耳道口后唇的距离为14.24±2.70 mm(8.50～17.56 mm)。
6.椎动脉源自颈外动脉,在项部时,其走行于枕下三角内,其周围缠绕丰富静脉丛。C_1神经走行于椎动脉和寰椎后弓之间。
7.在远外侧枕骨髁后锁孔入路中,手术显微镜下,可见舌咽神经、迷走神经的根丝以及副神经的脑根和脊髓根,通过调整头位和显微镜的角度,还可以观察到面神经、前庭蜗神经、小脑下前动脉、小脑下后动脉、基底动脉的起始段。
8.除上述结构外,内镜下可以观察到后组脑神经的出颅部位,包括颈静脉孔和舌下神经管内口,此外,还可以显露脑干腹侧面的结构、椎动脉的末端。脑神经与血管间复杂毗邻关系亦可得以显示。
9.在远外侧枕骨髁后锁孔入路中,骨窗外缘至颈静脉内口的距离为17.29±2.80mm。
结论:
1.颞下锁孔入路中皮肤切开时,操作应于颞浅筋膜和深筋膜之间进行,可有效保护面神经颞支和颞浅血管。
2.在内镜的辅助下,岩尖磨除不必作为颞下锁孔入路手术的常规操作。
3.经颞下锁孔的内镜对上岩斜区结构范围要优于显微镜的显露。
4.上岩斜区结构的内镜下定位应多种定位标识联合使用。在可能的情况下,应选择骨性结构作为定位标识,如内耳道口。因骨性结构位置恒定,不会因病变的压迫而移位。
5.脑内的外科间隙为经颞下锁孔入路内镜的导入提供了形态学基础,术中应充分利用各外科间隙,以求上岩斜区结构的理想显露。
6.乳突轮廓化中,要切实保护乙状窦。乙状窦下缘的显露有助于后期术野的暴露,但要注意高位颈静脉球及宽大乙状窦。
7.借助颞骨岩部磨除时的骨质变化以定位后骨半规管。
8.面神经、前庭蜗神经及内耳道口均可作为乙状窦前迷路后锁孔入路内镜下观察中岩斜区及周围结构的定位标识。但脑神经会因占位性病变的压迫而移位,而内耳道口为骨性结构,位置恒定,以其作为定位标识更具有优势。
9.相对于手术显微镜而言,内镜对中岩斜区及周围结构的显露更为广泛。
10.内镜的使用,可缩小远外侧枕骨髁后锁孔入路的骨窗。
11.在未磨除枕骨髁及颈静脉结节的情况下,下岩斜区及周围结构在内镜下显露良好,尤其是对于脑干的腹侧面、脑神经的全貌。
12.副神经的脊髓根及颈静脉孔内口均可以作为内镜下经远外侧枕骨髁后锁孔入路对下岩斜区结构的定位标识;因后者为骨性结构,位置恒定,以其作为定位标识,更加具有优势。
13.三种不同的锁孔入路,内镜的引入均可显著改善术野的显露。但内镜的观察角度不同,可致结构间的关系发生变化。因此,术者要切实把握内镜下的解剖学特点。
14.内镜和手术显微镜各有优缺点。临床实践中,应根据不同病变制定个性化治疗方案,联合使用内镜和手术显微镜,取长补短,方可彻底切除病变组织。
主要创新点:
1.经颞下锁孔入路导入内镜观察上岩斜区结构,应采取多个定位标识联合的方法以避免因病变压迫引起软组织移位所导致的定位错误。
2.乙状窦前迷路后入路中,应在轮廓化乳突时显露乙状窦下缘。此项操作有助于后期术野的显露;面前庭蜗神经及内耳道口均可以作为经乙状窦前迷路后内镜下定位中岩斜区及其周围结构的标识。
3.内镜的应用,可缩小远外侧枕骨髁后锁孔入路的骨窗;远外侧枕骨髁后入路不必磨除枕骨髁,在此基础上引入内镜,还可避免磨除颈静脉结节。一方面可简化手术操作步骤,重要的是可减少手术后并发症的发生;副神经脊髓根和颈静脉孔内口均可以作为经远外侧枕骨髁后锁孔入路内镜下定位下岩斜区及其周围结构的标志。
4.定位标识的选择应根据不同的病患,如遇软组织受病变组织挤压而移位的情况,应采用骨性结构作为定位标志。
Background and objective:
Peroclival diseases remain one of the most challenging to treat surgically due to their location deep within the skull base and their association with multiple neural and vascular structures.Over the years,many skull base approaches have been described that are meant to improve resection and decrease patient morbidity.Central to all approaches to the petroclival region is the ability to visualize the tumor and the important neural and vascular structures that these tumors are adjacent to, compressing and encasing.Recently,different keyhole approaches have been developed to access this region.Increased evidences have been demonstrated that most of neural and vascular structures in peroclival region can be exposed sufficiently via various keyhole approaches,including temporal keyhole approach, suboccipito-retrosigmoidal keyhole approach and retro-condylar keyhole approach. Some of diseases in peroclival region can be removed in success via these keyhole approaches.Moreover,the usage of keyhole approach can avoid effectively the pulling of cerebular tissue with minimal injury.However,limited to direct visual angle of operating microscope,it is still difficult to exposure the entire of the nerves and blood vessels within the peroclival region,as well as the ventral aspect of the brain stem.With multiple visual angles,the endoscopy can provides a clear view on the entire site of the operation,especial to the deep structures.So,the usage of endoscopy should be providing a potential to solve questions abovementioned.
Although numerous studies have been performed on endoscopic anatomy of different keyhole approaches,excluding the retro-condylalr keyhole approach, ambiguities in operation of keyhole approaches were still existed.Moreover,the previous studies were excessively focused on measurement of related structures. Undoubtedly,it is difficult to measure the distances among the structures,although the accurate data is helpful to surgical treatment.In our opinion,it will be practical to explore the endoscopic anatomical features of structures in peroclival region, including the location of the structure,position change under different visual angles of endoscope and etc.So,the endoscopic anatomical features of the peroclival region via temporal keyhole approach,suboccipito-retrosigmoidal approach and retro-condylar keyhole approach were observed in present study based on the previous studies.Exposure scopes of peroclival region with endoscope or operating microscope were emphasized.Additionally,the main points about the skin incision, bony window formation and insert of endoscope were focused on in order to provide accurate anatomical basis for clinical applications.
Methods:
1.20 adult cadavers head fixed with formalin and injected with colored emulsion were used in present study.
2.Mimicry of subtemporal keyhole approach:The vertical skin incision was performed 1.0 cm anterior to the external auditory canal and 5cm in length.The lower board of skin incision was above inferior margin of zygomatic arch.After the exposure of temporal squama sufficiently,2.5cm bony window were prepared. The petrous apex was stripped based on identification of related bony structures. The superior margin of zygomatic arch was removed to adapt the observation using operation microscope.
3.Mimicry of suboccipito-retrosigmoidal keyhole approach:A postauricular skin incision was carried out,which was C shape and below to the superior margin of auricle and above to the level of intertragic incisures.After the skin flap dissection and outlines of mastoid process and osseous labyrinth in turn,a 3cm×4cm bony window was prepared.
4.Mimicry of the retro-condylar keyhole approach:A skin incision was performed posterior to mastoid process,which was S in shape and 7cm in length.The muscles in the occipital region and nuchal region were dissected carefully to exposure the V3 segment of vertebral artery.A bony window was designated to 3cm in diameter for microscopic observation,lateral margin of great occipital foramen medially,medial board of sigmoid sinus laterally,and posterior margin of occipital condyle inferiorly.As to endoscopic observation,the bony windows were diminished to 2cm in diameter and moved backward.
5.Observation with microscope:The structures in the perclival region were observed with operating microscope and recorded.
6.Observation with endoscope:The structures in the perclival region were observed with endoscope.
7.Related data were obtained and analyzed with SPSS.
Results:
1.Most of structures in upper petroclival region were observed under microscope via subtemporal keyhole approach.,including part of midbrain and pons,trochlear nerve and oculomotor nerve,basilar artery and the supraclinoidal portion of internal carotid artery and their branches,including posterior cerebral artery,superior cerebellar artery,posterior communicating artery,middle cerebral artery,anterior cerebral artery.Adjusting optical angle of microscope,the mamillary body,pituitary stalk and optic chiasma were also found.
2.Beside of structures abovementioned,the unilateral or bilateral trigeminal nerve, abducent nerve,facial nerve,vestibulocochlear nerve,intermediate nerve,internal auditory artery interpeduncular fossa,ventral aspect of pons were observed with endoscope inserted into intracephalic spaces via subtemporal keyhole approach. The distance from internal carotid artery to oculomotor nerve was 8.26±0.97mm; The distance from posterior communicating artery to tentorium of cerebellum was 8.81±1.56mm;The distance from anterior choroidal artery to posterior communicating artery was 5.57±0.90mm.
3.Under microscope,the trigeminal nerve,facial nerve,vestibulocochlear nerve, glossopharyngeal nerve,vagus nerve accessory nerve were observed via suboccipito-retrosigmoidal keyhole approach,as well as the lateral ventral aspect of pons,anterior inferior cerebellar artery,superior petrous vein,excluding the abducent nerve,trochlear nerve and ventral aspect of brain stem.
4.Beside of structures abovementioned,the abducent nerve,trochlear nerve and ventral aspect of brain stem were observed under endoscope via suboccipito-retrosigmoidal keyhole approach with absence of the superficial bone substance of sigmoid sinus,as well as the vertebral artery,basilar artery, intermediate nerve and internal auditory artery.
5.The distances of anterior margin of bony window to posterior lip of orifice of internal acoustic meatus were 14.24±2.70 mm(8.50～17.56 mm).
6.Originating from the external carotid artery,the vertebral artery entered suboccipital triangle in nuchal region and wrapped with venous plexus.The C_1 nerve ran through the space between vertebral artery and posterior arch of atlas.
7.Under the operating microscope,the rootlets of glossopharyngeal nerve,vagus nerve were observed via the retro-condylar keyhole approach,as well as the cranial roots and spinal roots of accessory nerve,hypoglossal nerve and vertebral artery.The jugular foramen was not exposed due to the jugular tubercle. Adjusting head position and visual angle of microscope,the facial nerve, vestibulocochelear nerve,anterior inferior cerebellar artery posterior inferior cerebellar artery and the initiated segment of basilar artery were observed.
8.Beside of structures,the outlets of posterior group cranial nerves,including jugular foramen and hypoglossal canal,were exposed under endoscope via the retro-condylar keyhole approach,as well as the ventral aspect of brain stem and the extremity of vertebral artery.Complex relationship among the cranial nerves and blood vessels was also found.
9.The distance of lateral margin of bony window to internal orifice of jugular foramen was 17.29±2.80mm.
Conclusions:
1.The frontal branch of facial nerve and superficial temporal vessels can be protect sufficiently while the skin incision were performed between the superficial fascia and deep fascia.
2.The stripping of petrous apex neednot be performed as routine technique in
temporal keyhole approach.
3.The surgical exposure of upper perclival region under endoscope,which is more extensive compared with those exposed under operating microscope.
4.The structures in upper petroclival region may be localized by combination of different markers.The bony structure,such as orifice of internal auditory canal, can be applied as marker.
5.The natural intracephalic spaces,including posterior communicating artery, trigeminal nerve,posterior communicating artery -anterior thalamal perforating artery,posterior communicating artery-perforating artery ones.Sufficient utilization of these spaces ensures operation in success.
6.Protection of sigmoid sinus is pivotal issue in mastoid outline.Exposure of posterior margin of sigmoid is helpful to the operating field.
7.Posterior bony semicircular canal can be localized based on the density change of os petrosum.
8.Both of the facial nerve,vestiblocochlear nerve and the orifice of internal auditory canal can be used as marker to localize the structures in peroclival region.The later one is preferable due to its unchangeable position.
9.Utilization of endoscope can improve significantly the surgical exposure compared with those under operating microscope.
10.Usage of endoscope can diminish the bony window in retro-condylar keyhole approach;
11.Without removal of occipital condyle and jugular tubercle,the anatomical structures within the lower peroclival region can be exposed entirely including the ventral of the brain stem under endoscope compared to those under microscope.
12.Both of the spinal root of accessory nerve and internal orifice of jugular foramen can be used as marker in endoscopy assisted retro-condylar keyhole approach to lower peroclival region.The later one is preferable due to its bony structure and unchangeable position.
13.Usage of endoscope in three different keyhole approaches abovementioned can improve the surgical field sufficiently.Endoscopic anatomical features of structures in the peroclival region due to the change of position,adjacent of structures under endoscope.
14.Individuation may be carried out in surgical therapy according to various diseases. So,combination the microscope and endoscope is acceptable to remove the pathological tissues in success.
New ideas:
1.To define that the structures in upper petroclival region need be localized by combination of various markers instead of single marker in endoscopic operation via subtemporal keyhole approach.
2.Beside of the protection of sigmoid sinus as pivotal issue in mastoid outline,the further view what exposure of posterior margin of sigmoid is helpful to the operating field in endoscope-assisted suboccipito-retrosigmoidal keyhole approach to peroclival region.To validate that both of the facial nerve,vestiblocochlear nerve and the orifice of internal auditory canal can be used as marker to localized the structures in peroclival region.
3.A novel outlook was raised in this study that usage of endoscope can diminish the bony window in retro-condylar keyhole approach.Not only the occipital condyle but also jugular tubercle can be remained due to the utilization of endoscope with the entire exposure of structures in lower peroclival region.The viewpoint was indicated in first time that both of the spinal root of accessory nerve and internal orifice of jugular foramen can be used as marker in endoscope assisted retro-condylar keyhole approach to the lower peroclival region.
4.The selection of marker need according to various diseases,The bony structure was prefer to soft tissue.
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[6]Knosp E,Pemeczky A,Koos,WT,et al.Meningiomas of the space of the cavernous sinus.Neurosurgery[J],1996,38(3):434-44.
[7]Perneczky A,Mtlller-Forell W,Van Linden E,等著,神经外科锁孔手术-内镜协助的显微外科及典型病理[M].孙为群,滕良珠,郭华,等译.济南:山东科学技术出版社,2001.2.
[8]Perneczky A,Fries G.Endoscope-assisted brain surgery:Part 1-evolution.Hasie concept and current technique[J].Neurosurgery[J],1998,42(2):219-225.
[9]兰青.积极开展神经外科锁孔微创手术[J].中国微侵袭神经外科杂志,2005,10(3):97-98.
[10]万经海,赵兵.锁孔神经外科[J].国外医学·神经病学神经外科学分册,2001,28(5):342-345.
[11]Abdel Aziz KM,Sanan A,van Loveren HR,et al,petroclival menirm-gionas:prectitive parameterfor transpctrosal approach[J].Neuro-aurgery,2000,47(1):139-150.
[12]丁自海,钟世镇.微创外科解剖学研究中存在的问题及对策[J].中国临床解剖学杂志,2005,23(2):115-117.
[13]王君玉,廖建春,胡国汉,等.内窥镜辅助乙状窦后锁孔入路的应用解剖[J].解剖与临床,2007,12(3):149-151.
[14]田广永,徐达传,彭志强.内镜辅助下乙状窦前.后入路的临床解剖学比较研究[J].中国临床解剖学杂志,2007,25(5):485-488.
[1]吴臣义,兰青.幕上下乙状窦前迷路后锁孔入路的设计与显微解剖学研究[J].中国微侵袭神经外科杂志,2006,11(6):258-260.
[2]王君玉,康德智,廖建春,等.内镜辅助的乙状窦前-迷路后锁孔入路的解剖学研究[J].中国临床解剖学杂志,2006,24(6):620-622.
[3]田广永,徐达传,彭志强.内镜下乙状窦前后入路的临床解剖学比较研究[J].中国临床解剖学杂志,2007,25(5):485-488.
[4]王玉海,王春莉.扩大颅中窝硬脑膜脑外经颞骨岩部入路至岩斜区的应用解剖[J].中国临床解剖学杂志,2003,21(1):3-6.
[5]Seifert V,Raabe A,Zimmermann M.Conservative(labyrinth preserving)transpetrosal approach to the clivus and petroclival region-indications,complications,results and lessons learned[J].Acta Neurochir(Wien),2003,145(8):631-642.
[6]王君玉,廖建春,康德智,等.内窥镜辅助的乙状窦前入路中岩静脉的解剖学研究[J].中国临床解剖学杂志,2007,25(1):20-22.
[7]王君玉,廖建春,党瑞山,等.乙状窦前迷路后入路中后骨半规管定位与保护的应用[J].解剖学杂志,2007,30(2):103-105.
[8]Moroni P,Mandelli C,Franzin A,et al.Surgical excision of clival tumors via the enlarged transcochlear approach[J].J Neurosurgery Sci,2001,45(3):127-139.
[9]Horgan MA,Anderson G J,Kellogg JX,et al.Classification and quantification of the petrosal approach to the petroclival region[J].Neurosurg, 2000,93(1):108-112.
[10]孙为群,腾良珠,郭华,等译.神经外科锁孔手术-内镜辅助的显微外科及典型病例[M]济南:山东科学技术出版社,2001.47-52.
[11]赵继宗.向显微神经外利新高度-“锁孔”技术迈进[J].中国微侵袭神经外科杂志,2000,5(1)1-2.
[12]Perneczky A,Fries G.Endoscope-asisted brain surgery:part1-evolution,basic concept and current technique[J].Neurosurgery,1998,42(2):219-225.
[13]夏寅,李希平,韩德民.乙状窦后进路内镜手术解剖学研究[J].中国临床解剖学杂志,2005,23(1):56-58.
[14]王君玉,廖建春,胡国汉,等.内窥镜辅助乙状窦后锁孔入路的应用解剖[J].解剖与临床,2007,12(3):149-151.
[15]兰青.积极开展神经外科锁孔微创手术[J].中国微侵袭神经外科杂志,2005,10(3):97-98.
[1]Babu RP,Sekhar LN,Wright DL.Extreme lateral transcondylar approach:technical improvements and lessons learnt[J].J Neurosurgery,1994,81(1):49-59.
[2]Sen.CN,Sekhar LN.An extreme lateral approach to intradural lesions of the cervical spine and foramen magnum[J].Neurosurgery,1990,27(1):197-204
[3]George B,Dematons C,Cophignon J.Lateral approach to the anterior portion of the foramen magnum.Application to surgical removal of 14 benign tumors:technical note[J].Surg Neuro 1,1988,29(6):484-490.
[4]aldwin 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].J Neurosurg,1994,81(1):60-68.
[5]Spektor S,Anderson G J,McMenomey SO,et al.Quantitative description of the far-lateral transcondylar transtubercular approach to the magnum and clivus[J].J.Neurosurg,2000,92(5):824-831.
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[7]张恒柱,兰青.远外侧枕骨髁后锁孔手术入路设计与显微解剖学实验研究[J].中国微侵袭神经外科杂志,2005,10(3):125-128.
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[12]朱杭军,王光辉,杜云翔,等.迷路后桥脑小脑三角区内镜手术的应用解剖学研究[J].解剖与临床,2008,13(1):17-19.
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[17]Seifert V,Raabe A,Zimmermann M.Conservative(labyrinthpreserving)transpetrosal approach to the clivus and petroclival region-indications,complications,results and lessons learned[J].Acta Neurochir(Wien),2003,145(8):631-642.
[18]朱杭军,王光辉,杜云翔,等.迷路后桥脑小脑三角区内镜手术的应用解剖学研究[J].解剖与临床,2008,13(1):17-19.
[19]田广永,徐达传,彭志强.内镜下乙状窦前后入路的临床解剖学比较研究[J].中国临床解剖学杂志,2007,25(5):485-488.
[20]张恒柱,兰青.远外侧枕骨髁后锁孔手术入路设计与显微解剖学实验研究[J].中国微侵袭神经外科杂志,2005,10(3):125-128.
[21]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.
[22]Vishteh AG,Crawford NR,Melton MS,et al.Stability of the craniovertibral junction after unilateral occipitial condyle resection:a biomechanical study[J].J Neurosurg-Spine,1999;90(1 ):91-98.
[23]Nanda A,Vinccent DA,Vannebreddy PS,et al.Far-lateral approach to intracranial lensions of the formen maganum without resection of the occipital condyle[J].J Neurosurgery,2002,96(2):302-309.
[24]Taniguchi M,Pemeczky A.Subtemporal keyhole approach to the suprasellar and petroclival region:microanatomic considerations and clinical application[J].Neurosurgery,1997;41(3):592-601.
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[26]秦时强,丁学华,廖建春.内窥镜辅助颞下锁孔入路的应用解剖[J].中国临床解剖学杂志,2003,21(5):429-431.
[27]彭志强,徐达传,付万新,等.内镜辅助下枕下远外侧髁后入路颈静脉孔区的应用解剖[J].临床耳鼻咽喉头颈外科杂志,2007,21(23):1078-1080.
[28]赵继宗.向显微神经外利新高度-“锁孔”技术迈进[J].中国微侵袭神经外科杂志,2000;5(1)1-2.
[29]兰青.积极开展神经外科锁孔微创手术[J].中国微侵袭神经外科杂志,2005;10(3):97-98.
[30]彭志强,李少华,田广永,等.内镜辅助下远外侧髁后锁孔入路的解剖学研究[J].中国临床解剖学杂志,2008,26(1):17-20.
[31]王君玉,廖建春,胡国汉,等.内窥镜辅助乙状窦后锁孔入路的应用解剖[J].解剖与临床,2007,12(3):149-151.
[32]夏寅,李希平,韩德民.乙状窦后进路内镜手术解剖学研究[J].中国临床解剖学杂志,2005,23(1):56-58.
[33]丁自海,钟世镇.微创外科解剖学研究中存在的问题及对策[J].中国临床解剖学杂志,2005,23(2):115-117.
[2]Day JD,Fukushima T,Giannotta SL.Microanatomical study of the extradural middle fossa approach to the petroclival and posterior cavernous sinus region:description constructs[J].Neurosurgery,1994,34(6):1009-1016.
[3]李世亭,周良辅,郭欢欢,等.扩大颅中窝硬脑膜外手术入路的研究与临床应用中华神经外科杂志[J],1999,15(4):205-208.
[4]Taniguchi M,Panicky A.Subtemporal keyhole approach to the suprasellar and petroclival region:microanatomic considerations and clinical application.Neurosurgery[J],1997,41(3):592-601
[5]王玉海,王春莉.扩大颅中窝硬脑膜脑外经颞骨岩部入路至岩斜区的应用解剖[J].中国临床解剖学杂志,2003,21(1):3-6.
[6]Knosp E,Pemeczky A,Koos,WT,et al.Meningiomas of the space of the cavernous sinus.Neurosurgery[J],1996,38(3):434-44.
[7]Perneczky A,Mtlller-Forell W,Van Linden E,等著,神经外科锁孔手术-内镜协助的显微外科及典型病理[M].孙为群,滕良珠,郭华,等译.济南:山东科学技术出版社,2001.2.
[8]Perneczky A,Fries G.Endoscope-assisted brain surgery:Part 1-evolution.Hasie concept and current technique[J].Neurosurgery[J],1998,42(2):219-225.
[9]兰青.积极开展神经外科锁孔微创手术[J].中国微侵袭神经外科杂志,2005,10(3):97-98.
[10]万经海,赵兵.锁孔神经外科[J].国外医学·神经病学神经外科学分册,2001,28(5):342-345.
[11]Abdel Aziz KM,Sanan A,van Loveren HR,et al,petroclival menirm-gionas:prectitive parameterfor transpctrosal approach[J].Neuro-aurgery,2000,47(1):139-150.
[12]丁自海,钟世镇.微创外科解剖学研究中存在的问题及对策[J].中国临床解剖学杂志,2005,23(2):115-117.
[13]王君玉,廖建春,胡国汉,等.内窥镜辅助乙状窦后锁孔入路的应用解剖[J].解剖与临床,2007,12(3):149-151.
[14]田广永,徐达传,彭志强.内镜辅助下乙状窦前.后入路的临床解剖学比较研究[J].中国临床解剖学杂志,2007,25(5):485-488.
[1]吴臣义,兰青.幕上下乙状窦前迷路后锁孔入路的设计与显微解剖学研究[J].中国微侵袭神经外科杂志,2006,11(6):258-260.
[2]王君玉,康德智,廖建春,等.内镜辅助的乙状窦前-迷路后锁孔入路的解剖学研究[J].中国临床解剖学杂志,2006,24(6):620-622.
[3]田广永,徐达传,彭志强.内镜下乙状窦前后入路的临床解剖学比较研究[J].中国临床解剖学杂志,2007,25(5):485-488.
[4]王玉海,王春莉.扩大颅中窝硬脑膜脑外经颞骨岩部入路至岩斜区的应用解剖[J].中国临床解剖学杂志,2003,21(1):3-6.
[5]Seifert V,Raabe A,Zimmermann M.Conservative(labyrinth preserving)transpetrosal approach to the clivus and petroclival region-indications,complications,results and lessons learned[J].Acta Neurochir(Wien),2003,145(8):631-642.
[6]王君玉,廖建春,康德智,等.内窥镜辅助的乙状窦前入路中岩静脉的解剖学研究[J].中国临床解剖学杂志,2007,25(1):20-22.
[7]王君玉,廖建春,党瑞山,等.乙状窦前迷路后入路中后骨半规管定位与保护的应用[J].解剖学杂志,2007,30(2):103-105.
[8]Moroni P,Mandelli C,Franzin A,et al.Surgical excision of clival tumors via the enlarged transcochlear approach[J].J Neurosurgery Sci,2001,45(3):127-139.
[9]Horgan MA,Anderson G J,Kellogg JX,et al.Classification and quantification of the petrosal approach to the petroclival region[J].Neurosurg, 2000,93(1):108-112.
[10]孙为群,腾良珠,郭华,等译.神经外科锁孔手术-内镜辅助的显微外科及典型病例[M]济南:山东科学技术出版社,2001.47-52.
[11]赵继宗.向显微神经外利新高度-“锁孔”技术迈进[J].中国微侵袭神经外科杂志,2000,5(1)1-2.
[12]Perneczky A,Fries G.Endoscope-asisted brain surgery:part1-evolution,basic concept and current technique[J].Neurosurgery,1998,42(2):219-225.
[13]夏寅,李希平,韩德民.乙状窦后进路内镜手术解剖学研究[J].中国临床解剖学杂志,2005,23(1):56-58.
[14]王君玉,廖建春,胡国汉,等.内窥镜辅助乙状窦后锁孔入路的应用解剖[J].解剖与临床,2007,12(3):149-151.
[15]兰青.积极开展神经外科锁孔微创手术[J].中国微侵袭神经外科杂志,2005,10(3):97-98.
[1]Babu RP,Sekhar LN,Wright DL.Extreme lateral transcondylar approach:technical improvements and lessons learnt[J].J Neurosurgery,1994,81(1):49-59.
[2]Sen.CN,Sekhar LN.An extreme lateral approach to intradural lesions of the cervical spine and foramen magnum[J].Neurosurgery,1990,27(1):197-204
[3]George B,Dematons C,Cophignon J.Lateral approach to the anterior portion of the foramen magnum.Application to surgical removal of 14 benign tumors:technical note[J].Surg Neuro 1,1988,29(6):484-490.
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