远外侧经髁入路解剖标志的应用研究

An applied research on anatomical landmarks in suboccipital transcondylar approach

目的对枕下远外侧经髁入路的解剖标志进行观测,以指导临床应用。方法模拟临床手术过程,在显微镜下对15例成年国人灌注头颅标本进行解剖观测。结果椎动脉从寰椎横突孔穿出后进入枕下三角内,走行在寰椎侧块的椎动脉沟内,被寰椎后弓的骨膜紧密包绕,覆盖丰富的椎静脉丛;颈静脉结节和枕髁阻碍了脑桥延髓腹侧的术野。结论游离椎动脉会增加出血和创伤的风险,一般情况下不予采用。颈静脉结节和枕髁的磨除有利于增大操作空间和视野,是否磨髁及其磨髁的多少应根据病变的性质和位置来决定,磨除颈静脉结节时勿损伤后组脑神经,术中均需行脑神经监测。

Objective To provide an anatomical basis for the suboccipital transcondylar approach. Methods For anatomical information, the microneurosurgical anatomical dissection, observation and measurement had been performed under microscope by mimicking the subeccipital transcondylar approach on 15 adult cadaveric heads. Results As the vertebral artery （VA） exited the foramen transversarium of C1, it was encased in the suboccipital triangle and courses posteriorly behind the lateral mass of C1 in the vertebral groove. This vessel was surrounded by a periosteal sheath enclosing the perivertebral venous plexus. The condyle and the jugular tubercle might block the visualization of the front of the medulla and the pontomedulla. Conclusion Exposure and skeletonization of the VA may increase the chance of bleeding and injury to the VA and the perivertebral venous plexus. Therefore, it is not recommended in most circumstances. The condyle and the jugular tubercle drilling and grinding are beneficial to expand the technical space. Whether to remove the condyle and how much being removed depend on the character and position of the lesion. The extradural removal of the jugular tubercle should be performed with caution because of the risk of injuring the glossopharyngeal, vagus, and accessory nerves. Cranial nerve monitoring should be implemented during drilling.