筆記 | 海綿竇解剖- Rhoton解剖視頻學(xué)習(xí)

Dr劉尼古拉斯 2021-05-29

展開全文

解剖學(xué)習(xí)筆記

神外前沿

在The Rhoton Collection解剖視頻中，《Cavernous Sinus and Middle Foss》這一章節(jié)與《Navigating the Temporal Bone（顳骨解剖）》有部分重復(fù)。本文從中將Cavernous Sinus（海綿竇解剖部分）截取出來并重新編排，制作了本篇學(xué)習(xí)筆記，共49張圖片。錯誤之處，請批評指正！

海綿竇解剖

Cavernous Sinus

▼本節(jié)介紹海綿竇的解剖。我們剝除此處的中顱窩硬膜（下圖示未剝離硬膜的中顱窩）

We'll be navigating cavernous sinus. we'll be peeling up the dura on the middle fossa here

▼我們掀開硬膜，可見海綿竇外側(cè)壁的深層（下圖）。

海綿竇外側(cè)壁有淺、深兩層。顱中窩硬膜的腦膜層延續(xù)為外側(cè)壁的淺層。深層由動眼神經(jīng)、滑車神經(jīng)、眼神經(jīng)、上頜神經(jīng)的神經(jīng)鞘以及之間網(wǎng)狀半透明的膜構(gòu)成。

So that, here we just peeled up the dura.

▼下圖示Meckel腔，其前界幾乎囊括三叉神經(jīng)節(jié)。

Meckel's cave, here, comes forward to about the level of the trigeminal ganglion.

▼我們打開Meckel腔，其實質(zhì)上是一個蛛網(wǎng)膜下腔間隙（下圖）

Then we open the Meckel's cave, this arachnid cavern,

▼Meckel腔向前幾乎延伸至三叉神經(jīng)節(jié)的膨大部（下圖）。

and it extends forward to about the level of the big part of the ganglion.

▼僅三叉神經(jīng)眼支位于海綿竇外側(cè)壁。

Only V1 up here faces the cavernous sinus.

▼半月神經(jīng)節(jié)（gasserian ganglion）及Meckel腔則屬于中顱窩結(jié)構(gòu)，其位于中顱窩三角內(nèi)。 gasserian [ɡ?'si?ri?n]

This part of the ganglion and Meckel's cave is really middle fossa.It's in the middle fossa triangles.

▼下圖示位于動眼神經(jīng)池內(nèi)的動眼神經(jīng)，動眼神經(jīng)池前界幾乎至前床突尖部。

Here we see the oculomotor nerve and it's in the oculomotor cistern that extends forward to about the tip of the clinoid process.

▼剝除蛛網(wǎng)膜后，可顯露眶上裂內(nèi)的神經(jīng)。

And here we've removed the arachnoid. We see the nerves in the superior orbital fissure,

▼動眼神經(jīng)

▼滑車神經(jīng)前行走形于前床突下方，跨過動眼神經(jīng)并轉(zhuǎn)向內(nèi)側(cè)。

IV comes forward and then enters medially，across the top of 3rd division under the clinoid.

▼下圖可見小部分外展神經(jīng)

and this is a little bit of the 6th.

▼清除竇內(nèi)靜脈結(jié)構(gòu)，可見外展神經(jīng)穿行于Dorello管，其位于蝶巖韌帶（Gruber韌帶）的下方，三叉神經(jīng)眼支的內(nèi)側(cè)。

Dorello管是由Gruber韌帶、巖尖、上斜坡外側(cè)緣構(gòu)成的一個骨纖維管道。

And here we see the 6th nerve coming through Dorello's canal, under the petrosphenoidal or Gruber's ligament.

▼接下來，我們沿著三叉神經(jīng)的1、2、3支的內(nèi)側(cè)繼續(xù)暴露。

Let's come forward along the medial side of V1，V2，V3.

▼在三叉神經(jīng)主干的內(nèi)側(cè)，可見三叉神經(jīng)運動根前行進入卵圓孔的前內(nèi)側(cè)象限。

And if you look medial to the central part of the trigeminal nerve,you'll see the motor root that passes forward and enters the anteromedial side of foramen ovale.

▼三叉神經(jīng)下頜支后方可見巖淺大神經(jīng)(GSPN)

As we peel this dura, we see the greater petrosal nerve.

▼沿著巖淺大神經(jīng)逆行，暴露膝狀神經(jīng)節(jié)（geniculate ganglion）

We can follow it back to the geniculate ganglion

▼進而打開內(nèi)聽道（internal acoustic meatus）。我們需注意保護此處的耳蝸以保留聽力。

and even down to the internal acoustic meatus. We want to stay out of the cochlea in this area

▼耳蝸(cochlea)位于耳蝸三角內(nèi)，位于面神經(jīng)迷路段與巖淺大神經(jīng)之間。

The cochlea is at the cochlear angle between the labyrinthine segment and the greater petrosal nerve that we're going to preserve hearing.

▼位于巖大淺神經(jīng)后方的這個三角是Kawase's三角，即后內(nèi)側(cè)三角（posteromedial triangle）

And in the area behind the greater petrosal nerve, we call that...what triangle?Kawase's or posteromedial (triangle).

▼在這個三角內(nèi)，我們可以磨除巖尖骨質(zhì)，從而向下暴露至斜坡側(cè)方，也可打開內(nèi)聽道

And in that triangle, we'll be drilling out petrous apex, to do an exposure down to the side of the clivus, and we can drill out the internal acoustic meatus

▼但需時刻注意保護耳蝸三角內(nèi)的耳蝸。

but we always want to save the cochlea in the cochlear angle.

▼磨除顱中窩的顱底骨質(zhì)后，我們將顯露顳窩（temporal fossa）

And then we'll have the opportunity if you drill the bone along the floor,you see...what fossa?temporal fossa.

▼顳下窩（infratemporal fossa）

▼假如打開前內(nèi)側(cè)三角和前外側(cè)三角，則可進入蝶竇。

You'll open anteromedial and anterolateral triangle, and you're into sphenoid sinus.

▼現(xiàn)在我們?nèi)コ嫔窠?jīng)節(jié)。打開翼管，可見 巖淺大神經(jīng)與發(fā)自頸動脈叢的巖深神經(jīng)相匯合并繼續(xù)前行形成翼管神經(jīng)

And here we've elevated the ganglion out of the middle fossa. And we see the greater petrosal been joined by the deep petrosal from the carotid plexus riding forward as vidian nerve.

▼下圖示 巖舌韌帶（petrolingual ligament）

巖舌韌帶是前方的蝶骨舌與后方的巖尖之間的骨膜小反折，頸動脈管骨膜的延續(xù)。

頸內(nèi)動脈破裂段止于巖舌韌帶。此韌帶以遠，頸內(nèi)動脈進入海綿竇。

What is this ligament? Petrolingual.

▼在外展神經(jīng)上方的是Gruber韌帶（下圖）

And this ligament passing above the 6th nerve？Gruber's ligament.

▼外展神經(jīng)在該韌帶下方穿行于Dorello管。

This is 6th nerve coming under that ligament in Dorello's canal.

▼外展神經(jīng)走行于三叉神經(jīng)眼支的內(nèi)側(cè)。打開海綿竇顯露該區(qū)域時，人們常常會問“外展神經(jīng)呢？”。其實，透過這三叉神經(jīng)眼支，即可見此處的外展神經(jīng)。

6th nerve always runs on the medial side of the 1st trigeminal division. Oftentimes when the sinus is peeled up and this area exposed, people say 'where is the 6th nerve?'. Well, if you just press V1，you see the 6th nerve here

▼外展神經(jīng)，位于Parkinson三角后方、滑車神經(jīng)下方，從Dorello管穿行而來，前行至三叉神經(jīng)眼支的內(nèi)側(cè)面。

6th nerve here at the back of Parkinson's triangle, below the 4th nerve coming through Dorello's canal, and passing forward on the medial side of V1.

▼讓我們概覽該區(qū)域的所有解剖三角：

下圖示 床突三角（Dolenc三角）

And here is just the overview of all of these triangles:clinoidal triangle

▼動眼神經(jīng)三角（oculomotor triangle）

▼滑車上三角（Fukushima三角）（supratrochlear triangle）

▼滑車下三角（Parkinson三角）（infratrochlear triangle）

▼前內(nèi)側(cè)三角（anteromedial triangle）

▼前外側(cè)三角（anterolateral triangle）

▼后外側(cè)三角（Glasscock三角）(posterolateral triangle)

▼后內(nèi)側(cè)三角（Kawase三角）(posteromedial triangle)

▼該區(qū)域的上面觀可見床突三角（Dolenc三角）

And you can look at this area from above and here we see the clinoidal triangle

▼動眼神經(jīng)三角是由前床突、后床突和巖尖構(gòu)成的三角形。

and the triangular oculomotor triangle from anterior clinoid to posterior clinoid over the petrous apex.

▼這幅圖展示了上述海綿竇三角的后面觀。

This is the area of those triangles that we were talking about on the back of the cavernous sinus.

▼我們可以看到，當(dāng)外展神經(jīng)進入海綿竇后壁時，恰從巖下竇的上部穿過，這解釋了為何巖下竇采血后會出現(xiàn)外展神經(jīng)麻痹 這一臨床現(xiàn)象。

And we see the 6th nerve as it enters the cavernous sinus from the back，passes through the upper part of the inferior petrosal sinus and that explains the 6th nerve palsies or paresis that we see after sampling blood with the catheter from the inferior petrosal sinus.

▼這里，我們打開床突三角

And just a view, we've opened the clinoidal triangle,

▼動眼神經(jīng)三角

the oculomotor triangle

▼可見外展神經(jīng)穿行于Dorello管內(nèi)

6th nerve in Dorello's canal.

▼頸內(nèi)動脈常常推擠垂體，并形成壓跡。

Oftentimes these carotids bulge into and indent the lateral side of the pituitary.

▼俯視垂體時，我們經(jīng)常看不到垂體后葉。這是因為它有時恰位于鞍背的凹面內(nèi)，而被鞍背遮掩。下圖示鞍背。

And,usually when you look from above, you don't see the posterior lobe. It sits here below the dorsum in the concave side of the dorsum

▼ 這是垂體下動脈（hypophysial artery）

We see the inferior hypophysial arteries.