| purpose:1.to provide anatomical basis of endoscopic transsphenoidal surgery. Bygross anatomical descriptions and measurements of sellar, slope and ventral brain stem area and its surrounding structures, to understand part of the skull base anatomy, anatomical landmarks are familiar with the surgical approach and clear operation of safe operation.2.combined with today’s advanced medical imaging equipment such as CT, reconstruction, neural navigation, Endoscopic anatomy, gross anatomy and the ratio of the relationship between imaging anatomy.3.in the fresh cadaver specimens fully simulate endoscopic surgical operations to verify the usefulness of surgical landmarks to determine the scope of surgical safety, avoid important nerves and blood vessels and other structures intraoperative fire. To provide an improved anatomical references endoscopic surgical instruments and related equipment.4.for the future development of virtual surgery software experience for endonasal surgery to slopes and craniocervical junction into widespread use reasonable way to provide anatomical basis.Materials and Methods 1.Dry skull specimen 10, were bony sellar, skull slopes ventral brainstem, occipital joint measure around critical anatomical structures; formalin-fixed specimens of head and neck complete in 5 cases, arterial lead oxide gelatin, fully simulate the nasal surgical approach, dISSECTION transsphenoidal ramp to the brainstem and ventral surgical approach anatomy, surgery establish important landmark. And the use of vernier caliper (accuracy 0.02mm) and measuring compasses important anatomical structures in the region related to the surgical approach. Wing measuring tube pharyngeal opening, rupture hole, hypoglossal canal outside the mouth, inner carotid artery, at the atlantoaxial vertebral artery, atlantoaxial at the internal carotid artery, the medial condylar distance from the leading edge of midline. Again before measuring nasal spine from the pharyngeal tubercle, the leading edge of the midpoint of the foramen magnum, atlas distance before nodule. Comparing the measured data with reference to the structure of each slope domestic bony skull and brain stem ventral region using SPSS19.0 software for statistical analysis.2.Select fresh complete head and neck specimens in 5 cases, use a diameter of 4mm, length 18cm of 0 ° and 30° and endoscope equipment, complete simulation of endoscopic endonasal. Verify flag and skull base surgery related measure distance, slope and understand endoscopic skull base anatomy brainstem ventral region.3.Fresh cadavers specimens of 64-slice CT three-dimensional reconstruction of bone structure, Comparative study anatomy image data after vascular reconstruction after intra-arterial perfusion lead oxide derived between.4.Randomly selected 20 patients underwent 64-row spiral CT scanning head, skull base important anatomical structures and surgical CT measurement channels involved in the important signs of bone and vascular reconstruction, surgery using neuronavigation and measurement results with the fixed specimen the measurement results were compared.5.Clinical application, further confirmed that surgery need to identify and clear the key anatomical structures and surgical exposure of safe operation during endoscopic surgical procedures.Results and discussion 1.Bony slope measurements:the base of the ramp from the occipital and sphenoid body composition, angle of 45° forward and upward tilt. Skull base community on the slopes of the saddle back, the lower bound for the leading edge of the foramen magnum, the hole on both sides of the adjacent distribution rupture, crack rock pillow, jugular foramen, hypoglossal canal and other structures in the mouth. Foramen magnum to saddleback distance (45.51±2.60) mm,the thickness of the front edge of the foramen magnum (3.45 Shi 0.69) mm, the hypoglossal nerve root foramen magnum through the sidewall of sublingual cranial neural tube spacing on both sides of the mouth of the hypoglossal canal was (25.55 ± 3.07) mm, the vertical distance to the center of the sella bottom side wall connecting door to the inner ear (20.1 Disabled 1.8) mm; rock split pillow back end of the jugular foramen, the inside of the hole has jugular tubercle, the nodules from the jugular foramen nerve ca.1～2cm, below the rear nodules within the mouth of the hypoglossal canal. Slope bone thickness (7.19 ± 1.23) mm.2. Endoscopic endonasal craniocervical junction to the ventral brain stem surgery flags include:middle turbinate, after the nose, pharyngeal mouth, uvula, soft palate mucosa, head and neck longus longus, the leading edge of the foramen magnum midpoint, dens, atlas anterior tubercle, anterior arch of atlas and the like. Through the nose fully exposed craniocervical junction, the shortest distance (89.60 ± 2.52) mm, the front wall of the sphenoid sinus and lower ramp abrade ranges to both flanks and tube rupture hole is bounded by their respective distance from the midline:Wings tube on the left side (9.25 ± 0.55) mm, the right side of (9.19 ± 0.50) mm, rupture hole on the left side (10.6 ± 0.83) mm and a right side (10.75 ± 0.84) mm.3. Observations related to the anatomy of the skull base slope3.1 Petrous internal carotid artery in the knee as the boundary is divided into vertical and horizontal sections:the internal carotid artery from the carotid canal outside the mouth of vertical rise, then turned off before the horizontal direction within the line to break holes into the cranial cavity fold steering, continuation of the cavernous segment of the internal carotid artery. Petrous internal carotid artery is an important relationship between the bone plate adjacent the inlet portion and the rear vertical ball between the jugular vein. Petrous internal carotid artery in addition to the entrance of the carotid canal dense fibrous tissue attachment to fix it to the outer rock bone below, other locations within the carotid easily separated from the carotid canal connective tissue, internal carotid artery abnormalities or unreasonable may cause fatal damage to bleeding under the surgical procedure.3.2 Dorello tube and its contents:Dorello pipe is located on the outer side slope irregularly shaped fibrous pipeline, primarily with the nerves and important structures show inferior petrosal sinus or the like. Show nerve in the posterior fossa subdural generally located below the rear entrance clinoid in the posterior fossa subdural petroclival almost vertical upward, to Dorello tube entrance, and then was flat through the outer tube 1 Dorello/3 or 1/3. Since rock cavernous sinus rear, with accompanying exhibition neural tube wear Dorello, the rock to split pillow injected into the jugular foramen jugular vein, such as sinus rock damage can cause serious complications.3.3 jugular foramen shape and adjoining:the jugular foramen to expand the Rock pillow split rear end of the outer side of the lower slopes, changing shape and size to the jugular vein separated by projecting the jugular foramen occipital and temporal bone, the neck intravenous hole hole, that hole is not completely separated into posterolateral portion (vein portion) and the medial portion (nervosa), this type of left and right side accounting for 85% and 82%, respectively. Bone bridge was separated by the jugular foramen holes, this type of left and right side accounted for 15% and 18%, respectively. Area left and right jugular foramen were (4.6 ± 2.8) mm2 and (6.2 ± 3.0) mm2. Wherein the right side of the left area of more than 65% of those who left the right side of the area accounted for more than 22% on both sides of equal area accounted for 13%. Glossopharyngeal nerve dural sheath located in the medial portion of the triangular recess inside, the position is relatively constant, the vagus nerve and nerve sheath located at the same dura mater, front vagus nerve, nerve after, both the position of the hole in the jugular vein there are three conditions:First, the inside of the front portion,93%; Second, is located in the fibrous septum between the two, accounting for 6.5%; the inside of the outer portion of the latter three located, accounted for 0.5%. After the internal jugular vein is located outside the unit, a constant position. Distance between the two jugular foramen is 45.3mm. Glossopharyngeal nerve, vagus nerve and nerve located in the front portion of the inside of the jugular foramen, namely nervosa, and after internal jugular vein in the outer parts, namely, vascular department. The inside of the hole for the jugular tubercle, from the jugular foramen nerve section (1.53 ± 0.43) mm.3.4 Relationship between the ramp and the ventral pons and medulla oblongata:On the sagittal plane, the ramp face of the pons, medulla oblongata ventral skull base where the bottom of the slope and pons, the medulla oblongata 1/2 stick with the most tight. Basilar artery in the basal pons pons and medulla sections 1/3 ditch ditch at the confluence of the vertebral artery from each accounted for 33.3% and 66.7%. Total length of the basilar artery (28.5 ± 1.2) mm, accounting for 3/4 of the entire length of the slope; under the basilar artery, the upper section of the outer diameter of 1/3, respectively 5.4,4.8 and 4.4 mm. Basilar artery on the upper end of the groove to the substrate and between cerebellar artery near the foot fossa into the brain. Pons, medulla median vein in the middle of the front line tortuous courses, an outer diameter of about 0.3mm; there are flat line running anterolateral vein 0.5cm at its outside, an outer diameter of about 0.3mm; between said transverse vein veins 3-5 transportation phase, an outer diameter of about 0.3 mm. Binding arm pons pons and medulla oblongata middle groove is on the slopes and in the middle third paragraph, under 1/3 segment junction. Olive is located anterolateral medulla, pons medulla oblongata below the ditch, which was at the rear 3-4mm facial nerve, vestibulocochlear nerve root, the rear of the glossopharyngeal nerve, vagus nerve and nerve root in front of the hypoglossal nerve root.3.5 Nearby rupture hole:jugular foramen to expand the portion of the rear end of the crack rock pillow pitch located in the slope of the outer two jugular foramen was (45.34±2.92) mm, rupture hole on the left side from the midline (10.6 disabilities 0.83) mm and right side from the midline (10.75 disabilities 0.84) mm, it is important to go inside the structure carotid artery, etc., near the jugular foramen.4.20 patients with head CT measurements:through the nose fully exposed to the lower slopes, the shortest distance (88.65 ± 2.55) mm; lower front wall of the sphenoid sinus and abrade ramp ranges on both sides of the wing to burst pipes and holes for the sector, both measured from the midline of the CT reconstruction distance is:(9.16 ± 0.49) mm and (10.70 ± 0.96) mm. After skull base reconstruction and three-dimensional reconstruction of vascular VR method or SSD method show:Head and Neck CT scan in addition to displaying the bony meatus, saddle area, midbrain, pons, medulla oblongata, spinal cord and other anatomical structures can be more intuitive and clear show significant correlation skull bone structure, comprising:a rupture hole, auditory meatus, the jugular foramen, the jugular tubercle, bone rock, slope (size, shape), papillary, internal auditory canal, foramen magnum (size, morphology), occipital bare, external occipital protuberance, atlas before and after the bow, the articular surface of the atlas, the pharyngeal tubercle, the leading edge of the foramen magnum, hypoglossal canal, the internal carotid artery tubes, etc., the application software can be measured more accurately distance measurement between the relevant structures include:internal auditory canal, around the arch of the atlas, the pharyngeal tubercle, the leading edge of the foramen magnum, the hole rupture, hypoglossal canal, equidistant from the internal carotid canal midline, and observe bone shape, sphenoid gasification degree meatus, the size of the internal auditory canal, foramen magnum size, slope shape, and sometimes also shows the relationship between the cranial nerves. Reconstruction slopes and ventral brainstem three-dimensional image can be simulated gross anatomy of nasal surgery in the region under the position for further surgery than to provide valuable reference image.5. Clinical studies have shown that these anatomical structures for slopes and through endoscopic surgery ventral brainstem has important significance:5.1 And pear-shaped nasal bone:primarily by the nasal septal cartilage and perpendicular plate of ethmoid bone composition. Constitute the foremost part of the nasal passage surgery, surgical operations center line marking is due to slopes and brainstem ventral midline and arthroscopic surgery area belonging to the midline surgery, intraoperative confirmation center line marking is particularly important.5.2 Sphenoid:sphenoid sphenoid body is generally in a gas chamber structure. Morphological changes and the size of the larger sphenoid sphenoid sinus opening into left and right sides, is to determine the sphenoid sinus important anatomical landmarks, are located within the nasal turbinate behind the butterfly screen recess, sphenoid and is positioned further search revealed saddle at the end of the flag, which can be sinus shape oval, round or slit-like. Columella root port to the next pole and sphenoid sphenoid bottom distance average 60mm ± 4mm, these cognitive and anatomical data in the case of obvious sphenoid mouth may help to find the sphenoid sinus opening. Bite before the opening of the lower wall of the sphenoid sinus, you can reveal the sellar. May have sphenoid sinus septum, due to individual differences, the number of separated sphenoid, shape and separated from the carotid artery, sellar anatomical relationship varied, sphenoid also vary the degree of gasification, the average diameter of the sphenoid sinus 22.1mm, anteroposterior diameter of 22mm, vertical diameter:20.1mm. Sidewall optic artery close sphenoid sinus and internal carotid and optic canal keel sphenoid sinus outer side wall portion, and the internal carotid artery in the saddle under the keel portion of the lateral wall of the sphenoid sinus, endoscopic surgeons need to be very familiar with the carotid canal keels, keel optic canal, carotid-optic recess, columns, etc. depending on the anatomy and adjacent relationship.5.3 Most of the optic nerve and optic canal inner wall adjacent to the sphenoid sinus. Broke into the optic canal ridges formed within the sinuses, the ridge over more than a quarter of the diameter of 16.2%. Since many variations sphenoid, ethmoid and sphenoid sinus often backward invade above. Therefore, the inner wall of the optic canal adjacent relationship is more complex, sometimes due to the sphenoid sinus septal deviation, adjacent to the optic canal on one side and on both sides of the sphenoid sinus. After the screening room adjacent relationship sphenoid lateral wall of the optic canal and gasification depends on the degree, all or most of the optic canal is located in the lateral wall of the sphenoid sinus.5.4 Internal carotid artery internal carotid artery bulge can be divided into the saddle rear section, lower section of the saddle and saddle front. Internal carotid artery to the internal carotid artery rock tip nozzle into the brain, ruptured into the cavernous hole up in the cavernous front row, before piercing clinoid level cavernous up top, then turned upward before bed medial. The above itinerary is close to the outer wall of the sphenoid sinus, and the formation of a convex toward the sinus pressure trace. Some of the internal carotid artery is formed in the sphenoid ridge, sphenoid gasification due to the different degrees of uplift of the formation rate of occurrence is different, because the same sphenoid septum deviation, sometimes there may be on both sides of the neck and the side of the sphenoid artery adjacent. Internal carotid artery pressure trace within the sphenoid sinus bone wall thickness of about 1.0mm, sometimes natural defect. Endoscopic operation for the protection of the internal carotid artery and the important need related to anatomy and skilled operators.5.5 Sphenopalatine artery and its branches:sphenopalatine artery maxillary artery end branches from above PPF within walking forward line, the rear end of the sphenopalatine foramen slightly above the middle turbinate into the nasal cavity, the sphenopalatine foramen to the roots and columella under sphenoid mouth pole distance of about 62mm and 13mm. Sphenopalatine artery branches in the nasal cavity of the main artery and the lateral nasal septal artery. The lateral nasal artery is usually divided into upper, middle and inferior turbinate artery, respectively, into the corresponding turbinate from the rear end of each turbinate. After nasal artery is generally divided into upper and lower two, from the bottom of the mouth into the sphenoid sinus anterior sphenoid sinus nasal septum. Near the mouth of the sphenoid sinus, said branch artery after nasal septum, far away from the sphenoid sinus opening called a nasal septum under artery. After septal artery branch to the upper and lower pole at the mouth of the sphenoid sinus and a distance of about 3.5mm 6.5mm; to the top of the sphenoid sinus wall distance of 14mm and 16mm; to the bottom wall of the sphenoid sinus distance 6.1mm and 7.5mm. Understand the main purpose of these data will be required to stop bleeding in the expansion to maximize the anterior wall of the sphenoid sinus when transsphenoidal approach and avoid injury butterfly Hubei artery or its major branches, or injury timely and accurate and effective electrocautery treatment in favor of surgery and avoiding surgery after severe epistaxis.5.6 Room and sponge cavernous sinus:cavernous sinus is a five-sided structure next to the saddle by the superior orbital fissure to rock formed by folding the tip of the dura mater. There are 3-6 internal carotid artery and the cavernous sinus cranial nerve Traveling on invasive pituitary adenoma, cavernous sinus tumor and slopes, the ventral brain stem tumor surgery also need to focus on the cavernous sinus anatomy and adjacent relationship, to protect the sponge sinus important structures. Between a front left and right cavernous sinus after inter-connected sponge, between the bottom of the saddle between the dura may have lower sponge sinus, behind the saddle before there is room after sponge sinus and sinus saddle back, with both sides of the cavernous sinus, petrosal sinus, petrosal sinus interlinked. Room and expand Transsphenoidal approach ramp tumor resection associated mainly sponge sinus between sinus under the sponge, the sponge after sinus between the substrate and the saddle back Dou Dou. In pituitary adenoma, chordoma, cholesteatoma or ventral brainstem schwannoma surgery often encountered cavernous sinus bleeding, timely and effective treatment is to ensure the smooth operation of.conclusion:1.By slope bony anatomical structures and adjacent anatomical study of the relationship can improve the degree of familiarity with the entire area constituting the base of the skull slopes and anatomical characteristics of the study area to provide anatomical basis for surgical approach.2.Through fixed cadaver specimens endoscopic surgery simulation study to collect and get into the path associated with the endoscopic surgical anatomical data, and clearly establishes the reference mark surgery, important anatomical structures by measuring the distance between the base of the skull, can be obtained endoscopic surgery safe operating range.3.For the same set of fresh cadaver specimens were Cranial CT scan, CT scan and three-dimensional reconstruction of bone and vascular perfusion again lead oxide after the developer, you can get more experimental data for the clinical significance is huge.4.Endoscopic surgical procedure complete simulation showed that endoscopic endonasal can fully reveal the ventral craniocervical junction structure, fully meet the process mimics the endoscopic operation, for the first clinicians surgery intensive training is significant.5.By expanding the endoscopic endonasal used in clinical studies to achieve the close integration of basic and clinical, which further clarifies the operation is to determine the key to the success of clinical anatomy to guide clinicians to carry out the expansion of the direct endoscopic nasal slope lesions surgery. |
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