经Dolenc入路处理前床突区病变的显微外科解剖

Microsurgical anatomy of anterior clinoid process region through Dolenc approach

目的 为经Dolenc入路处理前床突区病变提供显微外科解剖学基础。方法 模拟经Dolenc入路对15具(30侧)防腐尸头在手术显微镜下进行解剖、观测。结果 ACP、ICA及其分支与大脑后动脉形成外、内侧及上解剖三角。ACP磨除后可见ICA床突段,远环分开ICA C2段与C3段,也是ICA进入CS内外的分界线。远环内侧部分不完整,可形成ICA凹陷动脉瘤,突向硬膜外。近环的一部分将ICA床突段与动眼神经分开,与视神经嵴相连。近环疏松可有CS静脉丛。结论 (1)ACP区各解剖三角的划分对于选择手术入路有重要的临床意义,外侧、上三角区病变适合于Dolenc入路;(2)ACP磨除可显著增加ACP区和鞍上区的显露,Dolenc入路+ACP磨除是经CS手术操作的关键步骤;(3)ICA C3段可位于CS内或外,视神经嵴可作为定位ACP区动脉瘤可靠的解剖学标志。

Objective To offer detailed microsurgical anatomic reference for the treatment of lesions in anterior clinoid process region. Methods The region surrounding ACP was dissected and observed using 5 to 20 magnification with micro-operative techniques through Dolenc approach in 30 specimens from 15 formalin-fixed cadaveric heads. Results ACP and ICA with its bifurcation make up lateral, medial and superior triangles. The optic strut accurately localized the point at which the ICA pierced the oculomotor membrane. The clinoid segment of ICA could be directly observed only after removal of ACP. The distal ring separated the intradural ICA from the extradural ICA. The proximal ring was incompetent and admited a variable number of veins from the cavernous plexus that accompanied the ICA throughout its clinoid segment. Conclusion (1)The sum of the areas of the three triangles was considered the total working area for preoperative selecting any particular approach. Lateral and superior triangles suited to Dolenc approach. (2)Anterior clinoidectomy could dramatically improve surgical exposure in the suprasellar and anterior clinoid process region. Dolenc approach with anterior clinoidectomy was committed step to CS operation. (3)The clinoid segment of ICA could not be justified as intracavernous or extracavernous. The optic strut provided a reliable anatomic landmark for accurate discrimination between intradural and extradural aneurysms of anterior clinoid process region.