神经内镜下经鼻扩大入路至中颅底的解剖学研究

摘要

目的 明确神经内镜下经鼻扩大入路至中颅底的各种重要解剖标志,探讨该入路临床应用的影响因素和手术特点.方法 分别运用直径4 mm,长度18 cm的0°、30°和45°硬质内镜(Karl Storz),在动脉灌注后的成人尸头上模拟手术过程,神经导航的引导下经双侧鼻腔扩大入路对中颅底进行内镜解剖.测量各个解剖标志之间的距离.结果 蝶窦后壁可分为鞍区、鞍上区、海绵窦区和斜坡区.在蝶窦后壁可见鞍底、后组筛房、蝶骨平台、鞍结节、斜坡、斜坡隐窝、海绵窦、颈内动脉隆起、视神经管隆起、颈内动脉-视神经隐窝.在蝶窦腔的外侧壁可见眶尖隆起、上颌神经隆起、下颌神经隆起和翼管神经,并分别形成视神经颈内动脉和动眼神经三角、V1~V2三角、V2~V3三角.两侧颈内动脉-视神经隐窝内侧距离为(11.3±1.2)mm,两侧垂体前部距离为(12.2±2.1)mm,两侧垂体中部距离为(21.5±2.5)mm,两侧垂体后部距离为(17.6±3.4)mm,垂体前后径为(9.1±2.9)mm.硬膜内的鞍上区又可分为视交叉上部、视交叉下部、鞍背后部和脑室部.在剪开海绵窦和垂体之间的硬膜后,海绵窦段的颈内动脉可分为三叉神经段、后曲段、下水平段、前曲段和上水平段.结论 神经内镜经鼻扩大入路至中颅底可清晰显示鞍区、鞍上区和海绵窦区的解剖结构,为该区域的病变提供一条有价值微侵袭的手术方法.颈内动脉-视神经隐窝是该区域手术的关键性标志.%Objective To identify the important anatomic landmarks by extended endoscopic endonasal approach to the middle skull base and discuss the various anatomic conditions affecting clinical application and operative characteristic.Methods Endoscopic dissections were performed in the formalin-fixed adult cadaver heads with the adjunct of neuronavigation using a rigid endoscope ( Karl Storz and Co.) that was 4 mm in diameter,18 cm in length, and equipped with 0°,30°and 45°lenses and measure the distance between main anatomical landmarks and area of exposure. Results The posterior bony wall of the sphenoidal sinus was subdivided into five compartments:sellar region,suprasellar region, bilateral cavernous sinus region and clival region.The posterior wall of sphenoidal region consisted of the bottom of the sella,clival recess,the posterior ethmodal cells, the sphenoidal planum, the tuberculum sellae, the optic protuberance, the optocarotid recess, the parasellar internal carotid artery, four bony protuberances ( orbital apex, maxillary, mandibular and vidian canal) and three anatomic triangles( the optic strut triangle, the V1-V2 triangle and the V2-V3 triangle).The width of the pituitary was(12.2 ±2.1) mm anteriorly,(21.5 ±2.5)mm medially, and (17.6 ±3.4) mm posteriorly.The distance of bilateral medial optic-carotid recesswas measured as (11.3 ±1.2)mm,and the distance of pituitary between anterior and posterior margin was ( 9.1 ± 2.9 ) mm.The intradural suprasellar neurovascular structure areas included suprachiasmatic,subchiasmatic, retrosellar and ventricular region.The internal carotid artery of the cavernous sinus on endoscopic view is defined as trigeminal portion,posterior bend portion, inferior horizontal portion,anterior bend portion and superior horizontal portion.Conclusions The extended endoscopic endonasal approach could provide a clearly close-up view of the posterior wall of sphenoidal region,the suprasellar region and the cavernous sinus and also be an effective,minimally invasive approach for lesions located in middle skull base.The optic-carotid recess is the key point anatomic landmark for the extended endoscopic endonasal approach to middle skull base.