鞍隔孔区解剖学研究及其临床意义

Regional anatomy of the diaphragmatic foramen and its clinical significance

目的通过鞍隔孔区结构的解剖学研究，分析经蝶人路脑脊液漏的发生机制，以及空蝶鞍（ES）的形成原因。方法对8例胎儿标本进行组织学连续切片后，做HE和Masson染色，并在显微镜下对鞍隔孔附近结构进行观察：另取10例成人尸头标本，模拟经蝶人路手术，并在手术显微镜下观察鞍隔孔区解剖结构。结果鞍上蛛网膜在垂体柄上端和其表面的软脑膜紧密结合．并转折进人鞍内；同时在垂体上表面处，鞍隔从四周紧密包绕并和表面的软脑膜紧密结合，而难以从组织学切片上分辨二者的界限：鞍上蛛网膜池由于蛛网膜、软脑膜和鞍隔的束缚而终止于鞍隔孔上部。结论鞍隔、软脑膜和鞍上蛛网膜三者之间存在着严密的解剖学关系，其也是防止脑脊液漏和ES发生的关键因素。这三者的先天性缺损、生理性或者病理性破坏，尤其是在经蝶人路中对垂体腺瘤的过分牵拉，导致鞍上蛛网膜和软脑膜分离或者破裂，可能是造成术中脑脊液漏发生的重要原因：另外鞍隔、软脑膜和垂体上表面之间的分离也可能是造成ES的关键因素。

Objective To perform an anatomical study of the structures around the diaphragmatic foramen and analyze the mechanism of cerehrospinal fluid leak and empty sella （ES）. Methods With HE and Masson staining, the structures around the diaphragmatic foramen were observed microscopically on serial histological sections of 8 fetal specimens. The transsphenoidal approach was then simulated in 10 adult cadaver heads, and the structures around the diaphragmatic foramen were observed under an operating microscope. Results The suprasellar arachnoid adhered tightly to the pia mater covering the upper part of the pituitary stalk, and folded into the sella through the diaphragmatic foramen. On the upper surface of the pituitary gland, the diaphragm adhered to the pia mater of the gland around the foramen, and their histological boundaries could not be distinctly identified on the serial sections. The suprasellar cistern terminated above the foramen due to the restriction by the arachnoid, pia mater and sellae diaphragma. Conclusion The close anatomic relationship between the sellae diaphragm, pia mater, and suprasellar arachnoid is critical to prevention of cerebrospinal fluid leak, and the breach of this anatomic relation, especially in the transsphenoidal approach for pituitary adenoma management that causes excessive traction of the tumor, results in separation or rupture of the arachnoid and pia mater, which can be an important factor contributing to cerebrospinal fluid leak. The separation of the sellae diaphragm, pia mater and the upper surface of the pituitary gland may also play an important role in the occurrence of ES.