圖1所示。斜坡的顱內表麵與後顱底相鄰部分的骨關係。A，後顱窩上方視圖。顱底被分離成獨立的骨頭，同時保持骨頭之間的關係。顱後窩由枕骨、蝶骨和顳骨組成，顱斜由蝶骨和枕骨組成。B，蝶骨上方。鞍背下方的區域形成了斜坡的上三分之一。舌突是頸動脈岩狀韌帶的附著部位，位於頸動脈岩狀和海綿狀部分的交界處。C，枕骨上方。基底(斜坡)部分形成了斜坡的下三分之二。 The paired condylar parts are situated along the anterolateral margin of the foramen magnum and connect the clival and squamosal parts of the occipital bone. D, posterior superior view. The petroclival fissure, which extends from the foramen lacerum above to the jugular foramen below, is positioned between the clivus and the petrous part of the temporal bone. The petrous apex articulates with the clivus near the junction with the sphenoid and occipital bones. E, enlarged posterior superior view of the left jugular foramen and the adjacent area. The jugular tubercle projects into the posterior fossa just above the hypoglossal canal. The jugular foramen is a sutural foramen located between the temporal and occipital bones. The sigmoid part, the larger lateral part of the jugular foramen, receives the drainage of the sigmoid sinus, and the petrosal part, the smaller medial part, receives the drainage of the inferior petrosal sinus. Cranial nerves IX, X, and XI exit the skull between the sigmoid and petrosal parts of the foramen. F, posterior superior view of a right jugular foramen. The intrajugular processes, the bony prominences that protrude into the jugular foramen from the temporal and occipital bones, are joined by a fibrous or osseus bridge that separates the jugular foramen into petrosal and sigmoid parts. The intrajugular process of the occipital bone is usually smaller than the process on the temporal bone. There is a small bony notch for the glossopharyngeal nerve at the upper border of the jugular foramen. In life, this notch corresponds to the site of the dural glossopharyngeal meatus, where the glossopharyngeal nerve penetrates the dura. The cochlear aqueduct opens into the upper margin of the petrosal part below the glossopharyngeal notch. Ac., acoustic; Coch., cochlear; Cond., condyle; Fiss., fissure; For., foramen; Glossophar., glossopharyngeal; Gr., greater; Hypogl., hypoglossal; Int., internal; Intrajug., intrajugular; Jug., jugular; Less., lesser; N., nerve; Occip., occipital; Pet., petrosal, petrous; Petrocliv., petroclival; Proc., process; Sig., sigmoid; Sphen., sphenoid; Temp., temporal; Tuberc., tubercle; Vestib., vestibular.

圖2。骨、硬腦膜和顱神經(CN)的關係。A，後上觀。在保留中樞神經的同時切除後窩右半部分的硬腦膜。CNs V至XII穿透硬腦膜後窩。上斜坡和中斜坡在外展神經硬腦膜孔的軸向麵分開，形成外展神經穿過硬腦膜的地方。中斜坡和下斜坡由舌咽部硬膜軸麵分開，舌咽部神經通過它進入頸靜脈孔。紅色虛線表示上、中斜坡的分界，黃色虛線表示中、下斜坡的分界。上斜坡後麵的硬膜內空間包括第三中樞神經和第五中樞神經;中斜坡後麵包括第六、第七和第八中樞; and behind the lower clivus includes CNs IX, X, XI, and XII. B, posterior oblique view, left side. Meckel’s cave, through which the trigeminal nerve passes, is located superolateral to the dural porus of the abducens nerve. The dura over the jugular foramen has 2 perforations: a glossopharyngeal meatus through which the glossopharyngeal nerve passes and a vagal meatus through which the vagus and accessory nerves pass. The glossopharyngeal meatus is located superior to the vagal meatus. C, posterior oblique view after removing the dura on the right side. The inferior petrosal sinus courses along the intracranial surface of the petroclival fissure. D, enlarged view focusing on the dural porus of the abducens nerve and Dorello’s canal. Gruber’s ligament extends from the lower part of the lateral edge of the dorsum sellae to the upper edge of the petrous apex. Dorello’s canal (white dotted line) is a narrow, interdural, triangular space bounded by Gruber’s ligament superiorly, the petrous apex inferolaterally, and the clivus inferomedially. After piercing the dura, the abducens nerve courses beneath Gruber’s ligament and through a large venous confluence at the junction of the cavernous, basilar, and the superior and inferior petrosal sinuses. The dural porus of the abducens nerve is located just below the upper edge of the petrosal apex. E, enlarged view focusing on the jugular foramen. The glossopharyngeal, vagus, and accessory nerves enter the intrajugular part of the jugular foramen, which is located between the petrosal and sigmoid parts. The glossopharyngeal nerve, after reaching the bony notch at the upper border of the jugular foramen, courses downward through the jugular foramen separate from the vagus and accessory nerve. F, the demarcation between the upper and middle clivus corresponds to the level 3.4 mm below the upper edge of the petrous apex. The demarcation between the middle and lower clivus corresponds to the level of the notch for the glossopharyngeal nerve at the upper medial edge of the jugular foramen. Ac., acoustic; Endolymph., endolymphatic; For., foramen; Glossophar., glossopharyngeal; Inf., inferior; Int., internal; Intrajug., intrajugular; Jug., jugular; Lig., ligament; N., nerve; Pet., petrosal, petrous; Proc., process; Sig., sigmoid.

圖3。a -。斜坡的顱外表麵與鄰近顱底的骨關係。劣質的視圖。枕骨斜部顱外表麵左右凸，表麵不規則。在枕骨大孔處，上麵比下麵寬。B,放大圖。岩斜坡裂隙將斜坡的側緣與顳骨的岩部分開。這個裂縫從上麵的裂孔延伸到下麵的頸靜脈孔。在蝶骨陰道突的下表麵有一個前後槽。 This groove joins with the upper surface of the sphenoidal process of the palatine bone to form the palatovaginal canal, which opens anteriorly into the pterygopalatine fossa. An inconsistent vomerovaginal canal may lie medial to the palatovaginal canal between the ala of the vomer and the vaginal process of the sphenoid. C, anterior view. The middle and inferior conchae have been removed. The clival part of the occipital bone is seen through the lower part of the nasal cavity and the posterior nasal apertures (choanae), the opening between the nasal cavity and nasopharynx bounded below by the horizontal plate of the palatine bone, superiorly by the body of the sphenoid, and laterally by the medial pterygoid plates. The sphenoid sinus occupies the upper part of the view through the nasal cavity. The hard palate is positioned at the level of the foramen magnum posteriorly. The lateral part of the cranial base is hidden behind the maxillae. D, anterior view. The sphenoid, ethmoid, and both palatine bones have been fitted together. The ethmoid bone forms the roof of the nasal cavity in front of the sphenoid bone. The middle nasal conchae are parts of the ethmoid bone, whereas the inferior nasal concha is a separate bone. The posterior end of the middle conchae articulates with the ethmoidal crest of the perpendicular plate of the palatine bone. E, the sphenoid, ethmoid, and maxillary bones and the vomer have been fitted together. The perpendicular plate of the ethmoid forms the upper part of nasal septum and the vomer forms the lower part. The frontal processes of the maxillae form the anterior part of the lateral wall of the nasal cavity. F, anterior view. The sphenoid, occipital, and left palatine bones have been fitted together. The pharyngeal tubercle is exposed in the midline on the clival part of the occipital bone. The sphenopalatine notch of the palatine bone, located between the orbital and sphenoid processes, is closed superiorly by the inferior surface of the sphenoid bone to form the sphenopalatine foramen. The anterior end of the vidian canal is sometimes seen through the sphenopalatine foramen. G, anterior view. The occipital, sphenoid, and left palatine bones and the axis and atlas have been fitted together. The clivus and atlas (C1) can be viewed through the nasal cavity between the body of the sphenoid above, the horizontal plate of the palatine bone below, and the vertical plate of the palatine bone and pterygoid process of the sphenoid bone laterally. H, oblique view of the left lateral wall of the nasal cavity. The sphenoid and left maxillary and palatine bones have been fitted together. The lower half of the lateral nasal wall is composed of, from anterior to posterior, the maxilla, the perpendicular plate of the palatine bone, and the medial pterygoid plate. The sphenopalatine foramen is located just above the ethmoidal crest of the palatine bone. The maxillary hiatus, a large opening in the medial wall of the maxillary sinus, is formed by the maxilla anteriorly and the perpendicular plate of the palatine bone posteriorly. The hiatus is partially closed by the inferior nasal concha and the ethmoid bone.

圖3。投入。我放大視圖。J，顱底側麵圖。翼齶窩是上頜竇後壁上半部分與蝶骨翼突之間的狹窄空間。蝶齶孔通過窩內側壁進入鼻腔。K，矢狀切麵標本右外側鼻壁。上、中、下鼻甲已經切除。一根細長的彎曲骨，稱為鉤突，連接上頜裂孔的前部，並將上頜裂孔分為前後間隙。後間隙稱為半月裂孔，位於鉤突和篩大泡之間，其特征為弧形。 The anterior space is closed by the mucosa in life. The posterior space is also closed by mucosa except at the ostia draining the maxillary, ethmoidal, and frontal sinus into the nasal cavity. The sphenopalatine foramen is located behind the ethmoid bulla. L, anterior view of the sphenoid bone. The left half of the anterior wall of the sphenoid sinus has been opened. The anterior wall of the sphenoid sinus consists of 2 areas, an upper and lateral depressed area, which shares its wall with the posterior ethmoid cells, and is hidden behind the ethmoid air cells. In this specimen, the most posterior ethmoid cells extend into the sphenoid sinus and are called Onodi cells. A lower and medial smooth triangular area that can be viewed through the nasal cavity behind the superior turbinate corresponds to the sphenoid conchae. The ostia of the sphenoid sinus are located near the superior angles of the sphenoid concha. The sphenoidal crest forms a small part of the nasal septum and articulates with the perpendicular plate of the ethmoid bone. M, inferior view of the sphenoid and palatine bones and the vomer. The upper border of the vomer is expanded into an ala on each side and attaches to the sphenoid bone. The lateral border of each ala articulates with a thin bony lamella, the vaginal process of the sphenoid bone, which projects medially from the root of the medial pterygoid plate to complete the palatovaginal canal. The pterygoid hamulus, around which the tensor veli palatini muscle turns medially to insert into the soft palate, projects laterally from the tip of the medial pterygoid plate. N, inferior view of the occipital bone. The pharyngeal tubercle is located in the midline of the clivus approximately 1 cm anterior to the anterior edge of the foramen magnum. The occipital condyles project downward along the anterolateral margin of the foramen magnum. There is a small bony groove, the supracondylar groove, for the insertion of the rectus capitis anterior muscle in front of each occipital condyle. The extracranial end of the hypoglossal canal opens above the occipital condyle. O, anterior view. The sphenoid and occipital bones are fitted together. The areas corresponding to the upper, middle, and lower clivus are shown on the exocranial aspect. The anterior end of the vidian canals sits at the junction of the upper and middle clivus. The pharyngeal tubercle can be used to estimate the junction of the middle and lower clivus. Car., carotid; Cond., condyle; Eth., ethmoid; Fiss., fissure; For., foramen; Front., frontal; Gr., greater; Horiz., horizontal; Hypogl., hypoglossal; Jug., jugular; Lac., lacrimal; Lat., lateral; Less., lesser; M., muscle; Max., maxillary; Med., medial; Occip., occipital; Orb., orbital; Pal., palatine; Palatovag., palatovaginal; Perp., perpendicular; Petrocliv., petroclival; Pharyng., pharyngeal; Proc., process; Pteryg., pterygoid; Pterygopal., pterygopalatine; Sphen., sphenoid; Sphenopal., sphenopalatine; Sup., superior; Temp., temporal; Tuberc., tubercle; Vag., vaginal, Vomerovag., vomerovaginal.

圖4。f。A，通過骨鼻腔前鼻孔的內窺鏡視圖。篩骨、犁骨和蝶骨脊的垂直板形成骨性鼻中隔。中、下鼻甲伸入鼻腔。B、鼻腔粘膜完好。內窺鏡已插入左鼻孔。篩竇大泡和鉤突隱藏在中鼻道的中鼻甲下，隨著內窺鏡的推進而暴露出來。C, a的放大視圖。左側篩竇大泡是一個圓形的骨突出物，覆蓋在篩竇氣細胞上，位於中孔上外側的鉤突後。鉤突起於篩骨最前麵的空氣細胞——鼻角細胞，向下向後延伸，附著於下甲。 The uncinate process divides the maxillary hiatus into a smaller anterior part and a larger posterior part called the anterior and posterior fontanelles, respectively. In life, the anterior part is closed by the mucosa, whereas the posterior part forms the infundibulum, leading to themaxillary, frontal as ethmoid ostia. The uncinate process obscures the direct view of the maxillary ostium and semilunar hiatus inthe view through the 0° endoscope. D, view with intact mucosa. The ethmoid bullae and uncinate process are positioned lateral tothe middle turbinate in the middle meatus. E, anterior view of the clivus. The pharyngeal tubercle, a good landmark for the demarcation between the middle and lower clivus, is seen in midline, whereas the anteromedial edge of the jugular foramen, which sits at the junction of the middle and lower clivus, may be difficult to see through the nasal cavity. The small groove for the insertion of the rectus capitis anterior muscle is seen at the upper anterior edge of the occipital condyle. F, anterior view of the opening from the nasal cavity into the nasopharynx. The tubal prominence is seen behind the ostium of the eustachian tube. The fossa of Rosenmüller projects laterally behind the tubal elevation. The pharyngeal tubercle and longus capitus underlie the mucosa.

圖4。G-L。G，重建蝶骨、篩骨和雙齶骨的前內窺鏡視圖。通過鼻腔隻能看到蝶竇前壁的下內側部分，也就是蝶竇的鼻甲。蝶竇前壁的其餘部分隱藏在篩骨後麵，篩骨與蝶竇前壁共用後壁。蝶竇口暴露於蝶甲上角附近。篩竇後空氣細胞與蝶竇前壁的上外側有一個共同的壁。H，篩骨被切除了。的right half of the anterior wall of the sphenoid sinus has been opened. The sphenopalatine foramen is located just above theethmoid crest in the lateral wall of the nasal cavity between the sphenoid and orbital processes of the palatine bone. I, posterior wallof the sphenoid sinus. There is a spontaneous dehiscence of bone over the left carotid artery. The posterior sinus wall is limitedsuperiorly by the sellae and laterally by the prominences overlying the cavernous carotid. The posterior sinus wall corresponds tothe part of the clivus formed by the sphenoid bone. The sinus wall often extends posteriorly beyond the vertical coronal plane ofposterior wall of pituitary fossa to form a clival recess. The vidian canal is located at the lower lateral corner of the sphenoid sinus.J, view extending to the clivus, foramen magnum, and C1. In this specimen, the opticocarotid recesses, the recess located betweenthe optic canal and the carotid prominence that extends into the optic strut, is shallow. K, left lateral wall of the sphenoid sinusviewed with a 45° endoscope. In this specimen, the pneumatization extends laterally beyond the vidian canal into the greater wingto form a lateral recess. The left vidian canal underlies a bony ridge in the lateral part of the floor of the sphenoid sinus. L, posteriorwall of the sphenoid sinus in another specimen. The vertical paraclival segment of the carotid artery ascends along the lateral limitof the posterior wall of the sphenoid sinus. A., artery; Ant., anterior; Atl., atlanto; Cap., capitis; Car., carotid; Crib., cribriform;Eth., ethmoid; Eust., eustachian; Font., fontanelles; For., foramen; Inf., inferior; Jug., jugular; Lac., lacrimal; Long., longus; M.,muscle; Mid., middle; Occip., occipital; Opticocar., opticocarotid; Orb., orbital; Pal., palatine; Paracliv., paraclival; Perp., perpendicular; Pharyng., Pharyngeal; Post., posterior; Proc., process; Prom., prominence; Rec., rectus; Seg., segment; Sphen., sphenoid; Sphenopal., sphenopalatine; Tuberc., tubercle; Turb., turbinate; Unc., uncinate.

圖5。A-D，鼻咽和斜坡逐步剝離。A，翼狀突前麵的冠狀麵。蝶竇、鼻腔和鼻咽為斜坡提供通道。顳下窩位於鼻腔和鼻咽部外側，包含翼狀肌外側和內側、上頜動脈、下頜神經和翼狀靜脈叢的分支。B，翼肌，顳肌下部，犁肌都被切除了。維管位於蝶竇底的下側角，在這裏，沿著蝶竇底的水平線與沿著蝶竇外側壁和內側翼板的垂直線相遇。C為右側翼突、張肌、齶提肌和鼻咽結構，除右側咽鼓管外，保留維管。咽鼓管從中耳延伸，沿著翼狀內側板的後緣，進入鼻咽部。頸內動脈和頸內靜脈位於卵圓孔和下頜神經分支的後麵。 D, the pterygoid processes have been removed on both sides, and the eustachian tubes have been retracted laterally to provide an anterior view of the clivus and the adjacent area. The anterior edge of the exocranial orifice of the jugular foramina is located at almost the same level as the anterior edge of the pharyngeal tubercle. The soft palate sits at the level of the foramen magnum.

圖5 E-J。E-L，逐步剝離，顯示顱外標誌與顱內結構之間的關係。E，下坡的右半部分已經打開了。中斜坡和下斜坡之間的邊界接近咽結節的前緣。舌咽神經和迷走神經暴露在舌下管上方。F，下斜坡的左半部分也已經打開，髓質已經暴露。顱內中下斜坡的分界在舌咽神經正上方的橋髓溝處。G，上斜坡右半部分的骨頭和硬腦膜已經打開。頸內動脈的垂直段，沿著蝶竇後壁的外側邊界上升，稱為臨骨段。上斜坡和中斜坡之間的邊界位於頸內動脈臨骨段下限的同一水平線上。 H, removing the left half of the upper clivus and opening the dura exposes the upper part of the pons. The lacerum segment of the petrous carotid is positioned at the anterior genu below the paraclival segment. I, the right half of the middle clivus has been opened. A thin dural bridge has been preserved at the junction of the upper and middle clivus, and a thin bony bridge has been preserved at the junction of the middle and lower clivus. J, the left half of the middle clivus has been opened to expose the intradural structures in the upper, middle, and lower clival regions. The middle clival opening exposes the lower pons.

圖5。K和L，在(K)和(L)打開斜坡之前顱底中線的放大前視圖。薄硬腦膜橋將上、中斜坡分開，薄骨橋將中、下斜坡分開。上斜坡和中斜坡之間的邊界位於頸動脈岩的臨骨段和裂骨段的交界處(黃色虛線)，大約在維管後端上方5mm。中斜坡和下斜坡之間的邊界位於咽結節頂部上方約4mm處。打開上、中、下斜坡，分別暴露腦橋上半部分、腦橋下半部分和髓質的前表麵。當維甸管從前端延伸至後端時，其延伸方向與矢狀麵呈輕微的側向角度，幾乎與硬齶平麵平行，或與硬齶平麵呈輕微的向下角度。維底管的後端位於頸內動脈的前膝下外側，或淚盆段。一個,動脈;A.I.C.A.; anterior inferior cerebellar artery; Ant., anterior; Asc., ascending; Bas., basilar; Car., carotid; CN, cranial nerve; Cond., condyle; Eust., eustachian; Fiss., fissure; For., foramen; Hypogl., hypoglossal; Inf., inferior; Int., internal; Jug., jugular; Lat., lateral; M., muscle; Mass., masseter; Max., maxillary; Med., medial; N., nerve; Occip., occipital; Pal., palatini; Paracliv., paraclival; Pet., petrous, petrosal; Petrocliv., petroclival; Pharyng., pharyngeal; Pit., pituitary; Post., posterior; Proc., process; Prom., prominence; Pteryg., pterygoid; S.C.A., superior cerebellar artery; Seg., segment; Sphen., sphenoid; Stylopharyng., stylopharyngeus; Temp., temporal; Tens., tensor; Tuberc., tubercle; V., vein; Vag., vaginal; Vert., vertebral.

圖6。上斜坡的階梯式顯露。A，維竇管沿竇底側緣延伸。齶陰道管位於齶骨蝶突和蝶骨陰道突之間，位於維管內側。B,放大圖。蝶中隔和翼突被切除。犁體的翼(翼)沿蝶竇底附著。犁陰道管位於犁骨翼和蝶骨陰道突之間，是一個較淺的骨槽而不是管。在a.c中，犁陰道管位於齶陰道管的內側。海綿竇的內側壁已經打開，頸動脈的海綿段已經暴露出來。竇後壁，上受鞍區限製，外側受頸動脈臨骨段限製，對應於由蝶骨形成的斜坡部分。 D, the right half of the upper clivus has been drilled. The periosteal layer of the clival dura has also been opened to expose the basilar venous plexus. A bundle of the carotid sympathetic plexus ascends on the cavernous carotid and joins the abducens nerve. E, anterior, oblique view of the right anteromedial cavernous sinus. The venous confluence surrounding the dural porus of the abducens nerve has been removed. The vidian nerve runs below anathe cavernous segment of the abducens nerve runs above the lingual process of the sphenoid bone. The vidian nerve, when followed posteriorly, reaches the lateral surface of the lacerum segment of the petrous carotid artery. Here, the nerve turns slightly upward in the foramen lacerum and is continuous with the greater petrosal and the deep petrosal nerves. The abducens nerve, when followed anteriorly, exits its dural porus and ascends lateral to the internal carotid artery. F, the upper clivus has been opened and the dura, above the level of the dural porus of the abducens nerve (yellow arrow), has been removed. The basilar artery and the upper half of the pons are exposed. A., artery; Bas., basilar; Car., carotid; Cav., cavernous; CN, cranial nerve; Dist., distal; For., foramen; Hyp., hypophyseal; Inf., inferior; N., nerve; Ophth., ophthalmic; Palatovag., palatovaginal; Paracliv., paraclival; Pet., petrosal; Pit., pituitary; Plex., plexus; Proc., process; Prom., prominence; Seg., segment; Sphen., sphenoid; Sup., superior; Vomerovag., vomerovaginal.

圖7。f。接近上斜坡。通往上斜坡的路徑通過蝶竇。A到C，蝶竇和斜坡的關係。A，蝶竇的前視圖。後篩竇氣細胞與蝶竇上外側麵有一個共同的壁，並沿蝶竇口外側邊緣延伸。在篩竇氣細胞下麵和中間的蝶麵部分稱為蝶甲。蝶口位於蝶甲狹窄的上部。鼻甲形成了蝶竇前壁的大部分。 B, the posterior ethmoid air cells and the sphenoid concha have been opened to expose the sphenoid sinus. The approach to the upper clivus is directed through the back wall of the sinus below the sella. The approach can be extended upward by elevating the gland and opening through the dorsum sellae. C, the pituitary gland and petrous and cavernous carotid have been exposed. The vidian canals are located along the lateral margin of the sinus floor. The maxillary and vidian nerves enter the posterior wall of the pterygopalatine fossa. The sphenopalatine arteries pass from the pterygopalatine fossa and through the sphenopalatine foramen to enter the nasal cavity. D, the straight endoscope has been advanced into the right nasal cavity toward the sphenoid ostium. For this exposure, the posterior part of the nasal septum has been detached from the sphenoid crest and displaced to the left, the anterior wall of the sphenoid sinus has been removed, and approximately 1 cm of the posterior edge of the nasal septum has been resected. Opening of the anterior wall of the sphenoid sinus, formed by the sphenoid conchae and the sphenoid crest, provides a triangular corridor to the sphenoid sinus. This corridor is limited laterally by the superior turbinate and the posterior ethmoid cells hidden behind the superior turbinate. The sellar dura and medial wall of the cavernous sinus have been exposed. The vomerovaginal canal is located medial to the palatovaginal canal. E, the dura covering the medial wall of the cavernous sinus has been opened. The pituitary gland and sellar dura has been retracted upward to expose the dorsum sellae. It is difficult to elevate the pituitary gland with the sellar dura intact because the dura is fixed to surrounding structures. F, the right half of the upper clivus has been drilled, and the periosteal layer of the clival dura has been opened to expose the venous confluence around the dural porus of the abducens nerve. The basilar venous plexus becomes less prominent as it descends toward the foramen magnum.

圖7。G-L。G，右側前內側海綿竇麵，45°內窺鏡向外側。維丁管向後打開，進入前外側邊緣，直到撕裂孔。眼神經和動眼神經在海綿竇外側壁內走行，外展神經在海綿竇內向前走行。上頜神經在海綿竇下方向前延伸。眼動脈和視神經通過視神經管視神經支柱的上方。顯露外展神經和基底靜脈叢的硬腦膜孔。維神經在蝶突舌突的下方展神經在蝶突舌突上方。H，圖像聚焦於右側頸動脈旁。 The lingual process of the sphenoid bone has been removed. The petrolingual ligament bridges the interval between the lingual process and petrous apex just below the cavernous sinus. The vidian nerve courses below the petrolingual ligament. The inferolateral trunk arises from the lateral aspect of the horizontal segment of the cavernous carotid, descends lateral to the abducens nerve, and supplies the dura of the inferolateral wall of the cavernous sinus surrounding the foramina rotundum and ovale. I, the petrolingual ligament has been removed, and the petrous apex and the gasserian ganglion have been exposed by retracting the ganglion laterally and the carotid artery medially. J, view of the left anteromedial cavernous sinus with a 45° endoscope directed laterally. The upper clivus has been drilled, and the periosteal layer of the clival dura has been opened to expose the venous confluens. K, the venous confluens around the dural porus of the abducens nerve has been removed. The abducens nerve penetrates the dura and ascends lateral to the carotid artery and below the petrosphenoid (Gruber’s) ligament, which extends from the lower part of the lateral edge of the dorsum sellae to the petrous apex. The dorsal meningeal branch of the meningohypophyseal trunk courses below Gruber’s ligament and near the abducens nerve. L, opening the upper clival dura below the pituitary gland exposes the upper half of the anterior surface of the pons. The outer arachnoid membrane has been opened and retracted laterally. The anterior pontine membranes, located just medial to the dural pori of the abducens nerves, separate the prepontine cistern from the cerebellopontine cisterns. The upper basilar artery and its perforating branches to the pons are well visualized. The rostral limit of the upper clival approach is usually at the pontomesencephalic junction. A duplicate left superior cerebellar artery encircles the brainstem near the pontomesencephalic junction. A., artery; A.C.A., anterior cerebral artery; Ant., anterior; Bas., basilar; Car., carotid; Cav., cavernous; Cist., cistern; CN, cranial nerve; Conf., confluence; Dor., dorsal; Eth., ethmoid; Fiss., fissure; For., foramen; Gang., ganglion; Hyp., hypophyseal; Inf., inferior; Inferolat., inferolateral; Lat., lateral; Lig., ligament; Max., maxillary; Med., medial; Men., meningeal; Memb., membrane; N., nerve; Ophth., ophthalmic; Palatovag., palatovaginal; Pet., petro, petrosal, petrous; Petrocliv., petroclival; Petroling., petrolingual; Pit., pituitary; Plex., plexus; Pon., pontine; Post., posterior; Prepon., prepontine; Proc., process; Pterygopal., pterygopalatine; S.C.A., superior cerebellar artery; Seg., segment; Sphen., sphenoid; Sphenopal., sphenopalatine; Sup., superior; Tr., trunk; Trans., transverse; V., vein; Ven., venous; Vomerovag., vomerovaginal.

圖8。上斜坡入路延伸至鞍下入路。A，兩層硬腦膜，骨膜和腦膜，排列蝶鞍下垂體。在腦膜層和腦垂體囊之間插入一個三角形的綠色片。硬腦膜的雙層結構在兩層之間的海綿間竇周圍尤為明顯。左頸動脈遠端硬腦膜環已被切開。B，海綿竇內側壁的鞍部與垂體囊分離，前葉向內側縮回露出後葉。海綿竇的內側壁由一層薄薄的腦膜硬腦膜構成。垂體囊緊密地附著在腺體的外表麵。海綿竇內側壁的鞍部覆蓋前葉外側表麵，後葉位於海綿竇內側壁後鞍背凹陷處。 C, 45° endoscope directed superior. The posterior lobe of the pituitary grand has been retracted upward, and the dorsum sellae has been exposed. The posterior lobe sits in the concave anterior surface of the dorsum sellae. The inferior hypophyseal artery arises from the meningohypophyseal trunk and courses medial to supply the posterior lobe. Care is required to avoid avulsion of the inferior hypophyseal artery during transposition of the gland. D, 45° endoscope directed superior. The dorsum sellae has been drilled while preserving the posterior clinoid processes and adjacent part of the dorsum. The mesencephalic leaf of Liliequist’s membrane, which spans the interval between the posterior clinoid process and the pontomesencephalic junction, has been exposed. The mesencephalic membrane is open around the upper the basilar artery. The oculomotor nerves course in the lateral wall of the interpeduncular cisterns and form the pillars to which the leaves of Liliequist’s membrane attach. This specimen has a duplicate left superior cerebellar artery. E, closer view. The contents of the interpeduncular cistern and the origins of the both posterior cerebral arteries can be seen through the large opening in the mesencephalic membrane. The thalamoperforating arteries arise from the P1 and enter the brainstem by passing through the posterior perforated substance in the area behind the mamillary bodies. F, 70° endoscope directed upward showing the anatomic upper limit of the extended upper clival approach. The diencephalic leaf of Liliequist’s membrane has been opened, and the posterior lobe of the pituitary gland has been elevated. The interpeduncular and part of the chiasmatic and carotid cisterns are accessible. The right peduncular vein is exposed lateral to the mamillary bodies. A., artery; Ant., anterior; Arach., arachnoid; Bas., basilar; Car., carotid; Cav., cavernous; Chor., choroidal; Clin., clinoid; Comm., communicating; CN, cranial nerve; Dist., distal; Hyp., hypophyseal; Inf., inferior; Intercav., intercavernous; Mam., mamillary; Med., medial; Memb., membrane; Mes., mesencephalic; Ped., peduncular; Perf., perforating; Pit., pituitary; Post., posterior; S.C.A., superior cerebellar artery; Sup., superior; Thal., thalamo; V., vein.

圖9。f。以下斜坡為重點的階梯式解剖。A，鼻咽後壁右半部分的粘膜已經被切除。咽基底筋膜覆蓋頭長肌，與枕骨和顳骨下表麵牢固相連，是打開粘膜後最前麵的一層。齶板張肌沿著咽鼓管軟骨部分的前外側向下並向內側繞過翼內側板的翼鉤，插入軟齶。B，翼突和咽基底筋膜被切除，齶板張肌的中間部分被分割。頭長肌是鼻咽後壁的第二層，附著在咽結節外側的斜坡上。齶提肌在與軟齶相連之前，沿著咽鼓管的下側下降。C、視角聚焦右側。 The superior pharyngeal constrictor muscle, the upper edge of which is located at the C1 level, slightly inferior to the level of the soft palate, inserts into the pharyngeal raphe, which attaches above to the pharyngeal tubercle. The internal carotid artery ascends just lateral to the longus capitis muscle. D, the levator veli palatini has been removed to expose the salpingopharyngeus muscle, which attaches to the inferior part of the cartilaginous eustachian tube, and passes downward to blend with the posterior fasciculus of the palatopharyngeus muscle. E, the right tensor and levator veli palatini and longus capitis muscles have been removed, and the eustachian tube has been detached from the soft palate and retracted laterally. The rectus capitis anterior, located behind the longus capitis muscle, arises on the lateral mass and adjacent part of the transverse process of the atlas and attaches to the anterior surface of the occipital bone above the occipital condyle. The hypoglossal nerve and neuromeningeal branches of the ascending pharyngeal artery course along the lateral edge of the rectus capitus anterior. The petrosal venous confluence is situated lateral and deep to the rectus capitis anterior muscle around the extracranial orifice of the hypoglossal canal and petrosal part of the jugular foramen. F, the rectus capitis anterior muscle and the petrosal venous confluence have been removed. The internal carotid artery has been retracted laterally to expose the anterior edge of the extracranial orifice of the jugular foramen. The supracondylar groove, located just above the occipital condyle, is the site of attachment of the rectus capitis anterior muscle. The pharyngeal tubercle and the anterior edge of the extracranial orifice of the jugular foramen are located at approximately the same level.

圖9。G-L。G，右側下斜坡已經鑽孔同時保留維管，枕骨髁的關節麵，和枕骨大孔的前緣。被岩斜裂、頸靜脈孔和舌下管包圍的三角形區域與頸靜脈結節在顱內表麵的位置相對應。H,放大視圖。下斜坡已在兩側鑽孔。打開下斜坡硬腦膜暴露了髓質和椎體的前表麵，小腦後下和脊髓前動脈。舌咽神經和迷走神經起於橄欖後溝口側舌下小根起端處及後方。這些神經的整個池段可以通過鑽頸靜脈結節暴露出來。 The accessory rootlets are hidden by the hypoglossal canals and the vertebral arteries. I, midsagittal section of another specimen showing the relationship between the posterior nasopharynx and lower clivus. The anterior surface of the clivus leans approximately 45° anterior in the view through the nasal cavity. The posterior nasopharyngeal wall has 3 layers: mucosal, fascial, and muscular. The pharyngobasilar fascia and longus capitis muscles are attached to the clivus; the longus colli muscles are attached to the atlas. The rectus capitis anterior muscle is not shown because the muscle is situated lateral to the midline. J, enlarged view. The pharyngobasilar fascia diminishes in thickness as it descends and gradually blends into the superior pharyngeal constrictor at the level of soft palate. The anterior edge of the pharyngeal tubercle is located at almost the same level as the pontomedullary sulcus. A., artery; Ant., anterior; Asc., ascending; Atl., atlanto; Bas., basilar; Cap., capitis; Car., carotid; CN, cranial nerve; Cond., condyle; Conf., confluence; Constrict., constrictor; Eust., eustachian; Fasc., fascia; Fiss., fissure; For., foramen; Hypogl., hypoglossal; Inf., inferior; Jug., jugular; Lat., lateral; Lev., levator; Long., longus; M., muscle; Max., maxillary; Med., medial; Memb., membrane; Mid., middle; N., nerve; Occip., occipital; Pal., palatini; Pet., petro, petrosal; Petrocliv., petroclival; Pharyng., pharyngeal; Pharyngobas., pharyngobasilar; P.I.C.A., posterior inferior cerebellar artery; Pontomed., pontomedullary; Proc., process; Pteryg., pterygoid; Rec., rectus; Salpingophar., salpingopharyngeus; Sphen., sphenoid; Stylopharyng., stylopharyngeal; Stylogloss., styloglossus; Sulc., sulcus; Sup., superior; Tens., tensor; Tuberc., tubercle; Turb., turbinate; V., vein; Ven., venous; Vert., vertebral.

圖10。f。內窺鏡入路至下斜坡。A，通過下鼻道引入內窺鏡觀察鼻咽後壁。鼻中隔的後部已從蝶脊上分離並切除。鼻咽後壁右半部分的粘膜已被切除。咽鼓管在鼻咽部的側壁上打開，就在突出而穩固的咽鼓管凸起的前方。頭長肌插入斜坡處，通常在粘膜表麵可見v型隆起。咽結節位於V(黃色箭頭)的下緣。在頭長肌插入處上方的粘膜上有一個淺的倒三角形凹陷，與兒童咽扁桃體或腺樣體的位置相對應。 B, the nasopharyngeal mucosa on the right side has been removed. The pharyngobasilar fascia covers the longus capitis muscle and attaches firmly to the inferior surface of the occipital and temporal bones. As the fascia descends, it diminishes in thickness and gradually blends into the superior pharyngeal constrictor at the level of soft palate. At its upper edge, the pharyngobasilar fascia blends with the fibrocartilage around the border between the sphenoid and occipital bones and foramen lacerum. C, the pharyngobasilar fascia on the right side has been removed to expose the longus capitis attachment to the clivus lateral to the pharyngeal tubercle. This specimen has a vomerovaginal canal that shares its anterior end with the palatovaginal canal. The vomerovaginal canal is positioned between the vaginal process of the sphenoid and the ala of the vomer. D, 45° endoscope directed inferior. The upper edge of the superior constrictor is located at the C1 level at the border between the oropharynx and nasopharynx and is not usually opened for exposure of the lower clivus. The fossa of Rosenmüller projects laterally from the posterolateral corner of the nasopharynx behind the tubal elevation. The parapharyngeal segment of the internal carotid artery courses just deep to the lateral limit of the fossa of Rosenmüller. E, the longus capitis muscle and pterygoid process on the right side have been removed to expose the rectus capitis anterior muscle. F, closer view. The rectus capitis anterior is a short, flat muscle that extends across the atlanto-occipital joint and connects to the lateral mass of the atlas and the basal part of the occipital bone.

圖10。G-L。G，右頭前直肌已被切除。鼻咽後黏膜與咽結節的關係。H，剩下的鼻咽後壁和翼突已經被切除。下岩斜坡靜脈沿岩斜坡裂隙顱外表麵走行。I，在咽鼓管軟骨部上方插入45°內窺鏡，並向外側觀察頸靜脈孔及其鄰近區域。岩下竇下端的岩靜脈彙合處連接舌下管的靜脈叢和椎前靜脈叢。在這個標本中，靜脈彙流在頸靜脈孔顱外孔下方通過舌咽神經和迷走神經之間靜脈壁的開口流入頸內靜脈的內側。岩斜坡下靜脈也流入岩靜脈彙合處。 J, some of the petrosal venous confluence has been removed to expose the jugular foramen. The glossopharyngeal nerve exits the jugular foramen along the anterior wall of the internal jugular vein, whereas the vagus and accessory nerve exit along the medial venous wall. The neuromeningeal branch of the ascending pharyngeal artery gives rise to the hypoglossal and jugular branches just below the jugular foramen. Both branches penetrate the petrosal confluence and enter the hypoglossal canal and the jugular foramen to supply the surrounding dura. K, anterior view of the clivus.

圖10。mp。L，右下斜坡已經鑽孔露出髓質。下斜坡上緣位於咽結節頂部上方約4mm處。M，下坡的其餘部分已經鑽好了同時保留舌下管。暴露的部分包括髓質的前部;舌咽神經、迷走神經、副神經、舌下神經和C1神經;還有脊椎，小腦後下動脈，脊椎前動脈。N，右側近景。舌下小根沿橄欖前溝生長，通常經過椎動脈後方。 The posterior inferior cerebellar artery arises near the junction of the hypoglossal rootlets with the medulla. The glossopharyngeal, vagus, and accessory nerves arise behind the hypoglossal rootlets, as a line of rootlets originating from the retro-olivary sulcus, a shallow groove between the olive and the posterolateral surface of the medulla. The rostral part of the accessory nerve is hidden by the hypoglossal canal and vertebral artery. O and P, another lower clival region. O, the lower clivus and hypoglossal canals have been drilled. P, closer view of the right side. A., artery; A.I.C.A., anterior inferior cerebellar artery; Ant., anterior; Asc., ascending; Atl., atlanto; Bas., basilar; Cap., capitis; Car., carotid; Constrict., constrictor; Cer., cerebellar, cerebello; CN., cranial nerve; Cond., condyle; Conf., confluence; Eust., eustachian; For., foramen; Hypogl., hypoglossal; Inf., inferior; Jug., jugular; Lat., lateral; Lig., ligament; Long., longus; M., muscle; Med., medial, medullary; Mid., middle; N., nerve; Occip., occipital; Palatovag., palatovaginal; Ped., peduncle; Pet., petro, petrosal, or petrous; Petrocliv., petroclival; Phayrng., pharyngeal; Pharyngobas., pharyngobasilar; P.I.C.A., posterior inferior cerebellar artery; Pontomed., pontomedullary; Pteryg., pterygoid; Rec., rectus; Sulc., sulcus; Sup., superior; Trans., transverse; Tuber., tubercle; V., vein, Ven., venous; Vert., vertebral; Vomerovag., vomerovaginal.

圖11。f。內窺鏡入路至中斜坡。A，視野聚焦於中斜坡和淚孔，45°內窺鏡向外側定向。插圖中的黃色圓圈表示內窺鏡視野。翼狀突已被切除。一些填充撕裂孔下部的纖維軟骨被切除以露出頸岩的前膝。維神經隱藏在撕裂孔前外側邊緣的纖維軟骨中。第二，維甸運河已經被削成了骷髏。維底管是維底動脈和神經的通道，向後打開，進入前外側邊緣的上半部分，直達淚孔。 The deep petrosal branch of the carotid sympathetic plexus joins the greater petrosal nerve at the foramen lacerum near the posterior opening of the vidian canal to form the vidian nerve. The upper end of the inferior petroclival vein connects through the foramen lacerum with the venous plexus around the carotid artery or with the cavernous sinus. The trapezoid-shaped middle clivus is bordered laterally by the foramen lacerum and internal carotid artery in the upper part and by the petroclival fissure in the lower part. C, right lateral part of the middle clival area. The right inferior petrosal sinus and adjacent dura have been removed. A thin dural bridge sits at the junction of the upper and middle clivus, and a thin bony bridge separates the middle and lower clivus. The lower part of the pons, basilar and anterior inferior cerebellar arteries, and cisternal part of the abducens nerves are exposed. D, closer view with the 45° endoscope directed laterally. All the cisternal segment of the facial nerve, except the origin, is hidden by the petrous part of the temporal bone. It is difficult to see the whole cisternal segment even with the angled endoscope directed laterally. E, the petrous apex and bone below the distal carotid canal have been removed to expose more of the cisternal segment of the facial and vestibulocochlear nerves. The posterior root of the trigeminal nerve passes forward below the superior petrosal sinus. F, more of the temporal bone below the carotid canal and trigeminal nerve has been drilled. The anterior wall of the internal acoustic meatus has been opened to expose the cisternal and meatal segments of the facial and vestibulocochlear nerves, as well as the premeatal and postmeatal segment of the anterior inferior cerebellar artery.

圖11。G-H。G, 45°內窺鏡向外側觀察麵神經近端橋小腦角。圖中黃圈為內鏡視野。麵神經在中斜坡區域的下外側。H, 45°內窺鏡近景。內窺鏡已被引入的水平下斜坡和定向上。麵神經根出口區(箭頭)比G圖中更清晰，因為根出口區位於橄欖上窩，是橋髓溝外側邊緣的一個淺凹陷。一個,動脈;A.I.C.A，小腦前下動脈; Bas., basilar; Car., carotid; Cer., cerebello; Chor., choroid; CN, cranial nerve; Coch., cochlear; Conf., confluence; Eust., eustachian; Fiss., fissure; For., foramen; Gr., greater; Inf., inferior; Mid., middle., N., nerve; Ped., peduncle; Pet., petro, petrous, petrosal; Petrocliv., petroclival; Plex., plexus; Pon., pontine; S.C.A., superior cerebellar artery; Seg., segment; Sup., superior; Transv., transverse; V., vein; Ven., venous.

圖12。斜坡每一段與rhoton定義的後窩神經血管複叢之間的關係。46上斜坡入路暴露了上神經血管複叢的前部，包括中腦和橋腦的鄰近部分、小腦上動脈、動眼神經和三叉神經。中斜坡入路暴露了中神經血管複叢的前部，包括腦橋的下半部分、小腦前下動脈、外展神經、麵神經和前庭耳蝸神經。下斜坡入路暴露了下神經血管複叢的前部，包括髓質、小腦後下動脈、舌咽神經、迷走神經、副神經和舌下神經。AICA，小腦前下動脈;CN,顱神經;異食癖，小腦後下動脈;SCA，小腦上動脈。

與經鼻入路相比，腦池內側V、VII、VIII和IX的外側和後側入路受限。也有額外的風險從外側和後方接近中線結構通過在腦幹產生的腦神經束之間和中間工作。如本研究所示，transtransapproach的優點是提供更好的曝光和中線結構的直接正麵視圖。相比之下，經鼻入路如果通過神經束從內側到外側的工作到達顱神經外側的病變，則可能麵臨類似的風險。局灶內窺鏡經鼻經道入路應被視為其他顱底手術的補充路徑，入路的選擇應基於病灶的位置(特別是參考顱神經)、延伸和病灶的性質。