圖6.1。枕骨和枕骨大孔。A，劣勢視角。B，後下視圖。C，前後位。D，高級視圖。E，後上位。F，後上斜位。枕骨環繞橢圓形的枕骨大孔，其後方比前方寬。較窄的前部位於齒狀突上方，它從外側被枕骨髁侵犯。 The wider posterior part transmits the medulla. The occipital bone is divided into a squamosal part located above and behind the foramen magnum; a basal (clival) part situated in front of the foramen magnum; and paired condylar parts located lateral to the foramen magnum. The squamous part is internally concave. Its upper margin articulates with the parietal bone at the lambdoid suture, and its lower margin articulates with the mastoid portion of the temporal bone at the occipitomastoid suture. The convex external surface of the squamosal part has several prominences. The largest prominence, the external occipital protuberance (inion), is situated at the central part of the external surface. The superior nuchal line radiates laterally from the protuberance. A vertical ridge, the external occipital crest, descends from the external occipital protuberance to the midpoint of the posterior margin of the foramen magnum. The inferior nuchal lines run laterally on both sides from the midpoint of the crest. The internal surface of the squamous part is concave and has a prominence, the internal occipital protuberance, near its center. The internal surface is divided into four unequal fossae by the sulcus of the superior sagittal sinus, the internal occipital crest, and the sulci for the transverse sinuses. The internal occipital crest bifurcates above the foramen magnum to form a V-shaped ridge between the limbs of which is the vermian fossa. The basilar part of the occipital bone, which is also referred to as the clivus, is a thick quadrangular plate of bone that extends forward and upward to join the sphenoid bone just below the dorsum sellae. The superior surface of the clivus slopes upward from the foramen magnum and is concave from side to side. The clivus is separated on each side from the petrous part of the temporal bone by the petroclival fissure that ends posteriorly at the jugular foramen. The occipitomastoid suture extends posterolateral from the jugular foramen. On the inferior surface of the basilar part, a small elevation, the pharyngeal tubercle, gives attachment to the fibrous raphe of the pharynx. The condylar parts of the occipital bone, on which the occipital condyles an located, are situated lateral to the foramen magnum on the external surface. The alar tubercle, which gives attachment to the alar ligament, is situated on the medial side of each condyle. The hypoglossal canal is situated above the condyle. The condylar fossa, which may be converted into a foramen for the passage of an emissary vein, is located behind the condyle. The jugular process of the occipital bone extends laterally from the posterior half of the condyle and articulates with the jugular surface of the temporal bone. The sulcus of the sigmoid sinus crosses the superior surface of the jugular process. The jugular foramen is bordered posteriorly by the jugular process of the occipital bone and anteriorly by the jugular fossa of the petrous temporal bone. The jugular tubercle lies on the internal surface above the hypoglossal canal. A., artery; Ac., acoustic; Car., carotid; Cond., condyle; Digast., digastric; Ext., external; Fiss., fissure; For., foramen; Hypogl., hypoglossal; Inf., inferior; Jug., jugular; Occipitomast., occipitomastoid; Occip., occipital; Petrocliv., petroclival; Pharyng., pharyngeal; Proc., process; Protrub., protuberance; Sag., sagittal; Sig., sigmoid; Sup., superior; Trans., transverse.

圖6.2。模擬。阿特拉斯。一、視野優越;B、劣觀;C，前視圖;D，後視圖。寰椎由位於環前內側的兩個較厚的側塊組成，前部由短的前弓連接，後部由較長的彎曲後弓連接。前後結節位於前中線和後中線。上關節麵是一個橢圓形的凹麵，向上和內側與枕骨髁相連。 The inferior articular facet is a circular, flat, or slightly concave facet that faces downward, medially, and slightly backward and articulates with the superior articular facet of the axis. The medial aspect of each lateral mass has a small tubercle for the attachment of the transverse ligament of the atlas. The transverse process projects from the lateral masses. The transverse foramina transmit the vertebral arteries. The upper surface of the posterior arch adjacent to the lateral masses has paired grooves in which the vertebral arteries course. A., artery; Ant., anterior; Art., articular; For., foramen; Lat., lateral; Mass., masses; Post., posterior; Proc., process; Trans., transverse; Vert., vertebral.

圖6.2。情況。軸。E，前視圖;F，側麵視圖;G，上級視圖;H，劣勢視圖。軸由齒狀突(齒狀突)區分。齒突的前部是關節突，它與寰椎前弓背部的關節突形成關節。齒狀突在其後表麵的底部有凹槽，即寰椎橫韌帶通過的地方。 The oval superior articular facets articulate with the inferior facets of the atlas. The superior facets are anterior to the inferior facets. The pedicles and laminae are thicker than on the other cervical vertebra and the lamina fuse behind to form a large spinous process. The transverse foramina are directed superolaterally, thus permitting the lateral deviation of the vertebral arteries as they pass up to the more widely separated transverse foramina in the atlas. The inferior articular facets face downward and forward.

圖6.3。模擬。枕骨大孔。後的看法。逐步剝離。A，小腦扁桃體，Magendie孔，和第四腦室的下部位於枕骨大孔上方。椎動脈在枕骨大孔下穿入硬腦膜，並通過齒狀韌帶和副神經前的枕骨大孔上升。舌咽神經、迷走神經和副神經通過頸靜脈孔，頸靜脈孔位於枕骨大孔的前半部分外側。第二，小腦被切除了。椎動脈通過枕骨大孔到達髓質前部。 C, enlarged view of the left half of the foramen magnum. The vertebral artery passes behind and below the atlanto-occipital joint, penetrates the dura, and passes in front of the dentate ligament and accessory nerve. The rostral end of the dentate ligament attaches to
the dura at the level of the foramen magnum. The C1 nerve penetrates the dura with the vertebral artery. The hypoglossal nerve passes behind the vertebral artery and enters the hypoglossal canal. The hypoglossal nerve is separated into several bundles as it penetrates the dura. The posterior spinal artery arises as the vertebral artery enters the dura and gives rise to ascending and descending branches. D, a longitudinal strip of the medulla and floor of the fourth ventricle has been removed to expose the vertebrobasilar junction, the origin of the anterior spinal artery, and
the median anterior medullary and median anterior spinal veins. A., artery; A.I.C.A., anteroinferior cerebellar artery; Ant., anterior; Asc., ascending; Atl., atlanto-; Bas., basilar; Br., branch; Bridg., bridging; CN, cranial nerve; Cruc., cruciform; Dent., dentate; Desc., descending; Flocc., flocculus; For., foramen; Horiz., horizontal; Lig., ligament; Med., median, medullary; Memb., membrane; Men., meningeal; Occip., occipital; P.I.C.A., posteroinferior cerebellar artery; Post., posterior; Sp., spinal; Trans., transverse; V., vein; Vent., ventricle; Vert., vertebral.

圖6.3。練習。枕骨大孔。後的看法。逐步剝離。E，右半部分髓質被切除了。脊髓前動脈主要起源於左側椎動脈，但也有少量來自右側椎動脈。兩束右側舌下細根穿透硬腦膜。F，放大視圖。髓質被切除以暴露椎體和脊髓前動脈。 The C1 nerve roots penetrate the dura with the vertebral artery. G, the intradural segment of the vertebral arteries and the dura lining the anterior margin of the foramen magnum have been removed to expose the tectorial membrane, a rostral extension of the posterior longitudinal ligament, and the vertebral venous plexus, which courses just outside the dura. H, the tectorial membrane has been removed to expose the cruciform and alar ligaments. The horizontal portion of the cruciform ligament, called the transverse ligament of the atlas, extends laterally to be attached to the medial edges of the lateral masses of the atlas, and the vertical portion ascends to attach to the anterior margin of the foramen magnum deep to the tectorial membrane. The alar ligaments pass upward and laterally and attach to the lateral edges of the foramen magnum. Anterior meningeal arteries pass along the dura and ligamentous structures in the anterior spinal canal. I, the vertical portion of the cruciform ligament has been folded downward to expose the synovial joint between the anterior surface of the cruciform ligament and the posterior surface of the dens. There is also another synovial joint between the anterior surface of the dens and the posterior surface of the anterior atlantal arch. The apical ligament of the dens extends upward to be attached to the margin of the foramen magnum.

圖6.4。前視圖。橫切麵的逐步解剖顯示了枕骨大孔和斜坡與鼻腔、口腔、咽和顳下窩的關係。A，軟齶，它被保存了下來，位於枕骨大孔的水平。顳下窩位於蝶大翼和顱中窩下方，包含翼肌、上頜動脈、下頜神經分支和翼靜脈叢，向後方開放，進入頸動脈鞘周圍區域，如圖左側所示。B、放大視圖。軟齶在中線分裂，葉片向側麵反射。寰枕關節和枕骨大孔大約位於硬齶的水平。C1前弓和齒狀突位於口咽部後方，斜坡位於鼻咽部和蝶竇後方。通過咽黏膜可見頭長肌上方的隆起和C1前弓。 C, the mucosa lining the posterior pharyngeal wall has been reflected to the right, exposing the longus capitis that attaches to the clivus and the part of the longus colli that attaches to the anterior arch of C1. The eustachian tube has been divided. The rectus capitis anterior extends from the transverse process of C1, posterolateral to the longus capitis, to attach to the occipital bone in front of the occipital condyle. D, the clivus and anterior arch of C1 have been removed. The dura has been opened to expose the vertebral and basilar artery. The dens has been preserved. The structures in the right infratemporal fossa and part of the right carotid artery and mandible have been removed to expose the right vertebral artery ascending between the C2 and C1 transverse processes. E, enlarged view of the step between C and D. The anterior arch of C1 has been removed to expose the odontoid process and the lower part of the clivus. The left longus coli and longus capitis have been reflected out of the exposure. The atlanto-occipital joint is exposed at the level of the odontoid apex. The transverse part of the cruciform ligament, also called the transverse ligament, extends across the back of the dens and attaches to a tubercle on the medial side of each lateral mass of the axis. The tectorial membrane, a cephalic extension of the posterior longitudinal ligament, lines the posterior clival surface. The alar ligaments attach to the lateral edges of the foramen magnum. F, enlarged view of the exposure shown in D. G, exposure after opening of the clivus. Both vertebral and anteroinferior cerebellar arteries (AICAs) and the anterior spinal artery are exposed. A., artery; A.I.C.A., anteroinferior cerebellar artery; Ant., anterior; Atl., atlanto-; Cap., capitis; Car., carotid; CN, cranial nerve; Eust., eustachian; For., foramen; Infratemp., infratemporal; Int., internal; Jug., jugular; Lat., lateral; Lig., ligament; Long., longus; M., muscle; Mandib., mandibular; Max., maxillary; Med., medial; Memb., membrane; Occip., occipital; Pteryg., pterygoid; Rec., rectus; Sp., spinal; Sphen., sphenoid; Trans., transverse; Vert., vertebral.

圖6.5。枕骨下的肌肉。逐步剝離。A，右側斜方肌和胸鎖乳突肌被保留。左側斜方肌和胸鎖乳突肌與盔瓣腱膜一起被反射，暴露下方的半棘肌、頭脾肌和肩胛提肌。B，右側胸鎖乳突肌和斜方肌已反射露出頭脾。切除左側頭脾，露出下方的半棘肌和頭最長肌。C，切除右側頭脾，露出半棘肌和頭最長肌。切除左側半棘肌和頭最長肌，露出由上斜肌(從C1橫突到枕骨)、下斜肌(從C1橫突延伸到C2棘突)和頭後直肌(從枕骨下頸線下延伸到C2棘突)形成的枕下三角。椎動脈在枕下三角的深處穿過C1上關節麵後並穿過後大西洋弓的上邊緣。 D, both semispinalis capitis muscles have been reflected laterally to expose the suboccipital triangles bilaterally. E, the muscles forming the left suboccipital triangle have been removed. The vertebral artery ascends slightly lateral from the transverse process of C2 to reach the transverse process of C1 and turns medially behind the superior facet of C1 to reach the upper surface of the posterior arch of C1. The C2 ganglion is located between the posterior arch of C1 and the lamina of C2. The dorsal ramus of C2 produces a medial branch that forms the majority of the greater occipital nerve. F, the muscles forming both suboccipital triangles have been removed. The rectus capitis posterior minor, which extends from the posterior arch of C1 to the occipital bone below the inferior nuchal line, has been preserved. The vertebral arteries cross the posterior arch of the atlas and penetrate the posterior atlanto-occipital membrane to reach the dura. A., artery; Atl., atlanto-; Cap., capitis; Car., carotid; CN, cranial nerve; Inf., inferior; Int., internal; Jug., jugular; Lev., levator; Longiss., longissimus; M., muscle; Maj., major; Memb., membrane; Min., minor; Obl., oblique; Occip., occipital; Post., posterior; Proc., process; Rec., rectus; Scap., scapulae; Semispin., semispinalis; Spin., spinalis; Splen., splenius; Sternocleidomast., sternocleidomastoid; Sup., superior; Trans., transverse; V., vein; Vert., vertebral.

圖6.6。枕骨大孔。A-D，後視圖;E和F，前視圖。A，枕下顱骨切除術和上頸椎椎板切除術暴露硬腦膜。椎動脈從內側穿過寰椎的上表麵，在那裏它們發出腦膜後動脈，這些動脈向上在枕骨大孔和後窩的後部供給硬腦膜。插入，右上角。寰椎弓左半邊的上緣在椎動脈進入硬腦膜的近端形成一個骨環。B，打開硬腦膜後另一個枕骨大孔的放大視圖。右側異食癖發生於硬腦膜外，並通過椎動脈穿透硬腦膜。 The rostral end of the dentate ligament passes between the vertebral artery and the PICA to insert into the dura along the lateral margin of the foramen magnum. The accessory nerve ascends posterior to both the PICA and the vertebral artery. The vertebral artery gives rise to a posterior spinal artery that passes along the posterolateral aspect of the spinal cord and medulla. The hypoglossal rootlets are stretched over the posterior aspect of the vertebral artery. C, the right tonsil has been retracted to expose the caudal end of the fourth ventricle, which is located above the foramen magnum. The right PICA ascends through the foramen magnum and along the posterior margin of the medulla to reach the cerebellomedullary fissure. D, another specimen. The rostral end of the dentate ligament passes between the posterior spinal artery and vertebral artery and attaches to the dura at the level of the foramen magnum. The accessory nerve ascends behind the posterior spinal artery. The C1 nerve root receives a contribution from the accessory nerve and passes through the dura with the vertebral artery and courses along the lower margin of the artery. The posterior spinal artery arises inside the dura and passes between the dentate ligament and accessory nerve and gives rise to ascending branches to the medulla and descending branches to the spinal cord. E, the anterior skull base has been removed. The vertebral arteries ascend in front of the brainstem and give rise to the anterior spinal artery. F, enlarged view. The C1 ventral roots penetrate the dura with the vertebral artery. The hypoglossal rootlets pass behind the vertebral arteries. A., artery; Bas., basilar; Cer.Med., cerebellomedullary; CN, cranial nerve; Cond., condyle; Dent., dentate; Fiss., fissure; Hypogl., hypoglossal; Lig., ligament; Men., meningeal; Occip., occipital; P.I.C.A., posteroinferior cerebellar artery; Post., posterior; Sp., spinal; Vert., vertebral.

圖6.7。枕骨大孔手術入路。硬膜內病變通常選擇後路手術入路。位於枕骨大孔前方的硬膜外病變通常選擇前路。對於位於腦幹外側和/或前方的硬膜內病變，特別是涉及顳骨或與顳骨相鄰時，可選擇外側入路。通過顳骨的外側入路將在本問題的後麵部分進行考慮。

圖6.8。枕骨下的方法。根據病變部位的不同，可以采用垂直中線切口或曲棍球棒切口。A，患者最常見的是三分之四俯臥位。B，垂直中線切口用於位於椎管上部和位於枕骨大孔上方區域後方或後外側的病變。皮下組織從接近齒輪的下筋膜分離，以獲得空間，在肌肉上形成Y形切口。“Y”的上肢開始於上頸線的水平，並在齒輪以下連接。C，切口有足夠的長度來完成枕下顱骨切除術和椎板軸和寰椎切除術(斜線)。D，勾勒出硬膜切口(間斷線)。E，硬膜內暴露。 The major extracranial hazard is injury to the vertebral artery as it courses below the atlantoaxial joint and across the posterior arch of the atlas. The vertebral arteries and PICAs are in the lower part of the exposure. The accessory nerve ascends posterior to the dentate ligament. The glossopharyngeal, vagus, and accessory nerves pass toward the jugular foramen. F, upper left. Hockey-stick retrosigmoid exposure. Skin incision (solid line) and bone removal (oblique lines). Lower right. Intradural exposure. The hockey-stick incision extends superomedial from the mastoid process along the superior nuchal line to the inion and downward in the midline. This incision is selected if the lesion extends anterolateral or anterior to the brainstem toward the jugular foramen or cerebellopontine angle. This exposure permits the removal of the full posterior rim of the foramen magnum, the posterior elements of the atlas and axis, and, in addition, the ability to complete a unilateral suboccipital craniectomy of sufficient size to expose the anterolateral surface of the brainstem and the nerves in the cerebellopontine angle. Tumors in this area may extend upward through the cerebellomedullary fissure to be attached to the roof or floor of the fourth ventricle. Laterally situated tumors may be attached to the initial intradural segment of the vertebral artery and the thick dural cuff around the artery, which also incorporates the posterior spinal arteries and the C1 nerve root in fibrous tissue. As one moves superiorly along the lateral surface of the medulla, the origin of the PICA and the glossopharyngeal, vagus, accessory, facial, vestibulocochlear, and trigeminal nerves are encountered. The dura is closed with a dural substitute if closure of the patient’s dura constricts the cerebellar tonsils or the cervicomedullary junction. A., artery; A.I.C.A., anteroinferior cerebellar artery; Lig., ligament; P.I.C.A., posteroinferior cerebellar artery; Vert., vertebral.

圖6.9。經鼻腔進入上斜坡。A，麵部結構的截麵橫跨鼻腔，上鼻甲和中鼻甲，上頜竇，靠近鼻尖的眼眶，以及蝶竇前的篩竇。顴神經和眶下神經起源於翼齶窩的下頜骨神經，位於上頜竇後壁後。B，去除鼻甲和篩竇後氣細胞，露出犁骨和蝶竇的正麵。鼻淚管沿鼻腔側壁向下，在下鼻甲下方開口，進入下鼻道。C，切除蝶竇前麵以暴露多分隔蝶竇和蝶鞍前壁。視神經管上方的骨突起位於蝶竇的上外側邊緣。D，蝶鞍前壁和蝶竇外壁已經被切除以暴露頸動脈岩穴和腦下垂體。形成上斜坡前表麵的蝶竇後壁被保留了下來。 A., artery; Car., carotid; Cav., cavernous; CN, cranial nerve; Gang., ganglion; Gl., gland; Inf., inferior; Infraorb., infraorbital; M., muscle; Max., maxillary; M.C.A., middle cerebral artery; Med., medial; Mid., middle; N., nerve; Nasolac., nasolacrimal; Pet., petrous; Rec., rectus; Sphen., sphenoid; Sup., superior; Turb., turbinates.

圖6.10。通往斜坡的鼻道。逐步解剖顯示形成經鼻至斜坡的側限的結構。A，整個斜坡位於硬齶之上，在大多數情況下，可以通過鼻腔和鼻咽進入。鼻鼻甲、鼻肉和咽鼓管在暴露的外側邊緣。B，切除部分上、中、下鼻甲，打開蝶翼突與上頜骨後壁之間的區域，暴露出鼻腔外側壁的翼齶窩。上頜竇和額竇的開口進入位於中鼻甲下方的中鼻道。鼻淚管位於下鼻甲下方，進入下鼻道。咽鼓管位於枕骨大孔前和斜坡下緣，在翼突後緣進入鼻咽。進入斜坡加上寰椎和軸需要一個可以在上顎上下的入路。 Rosenmuller’s fossa is located behind the eustachian tube. C, the medial wall of the maxillary sinus has been opened to expose the infraorbital nerve, which arises in the pterygopalatine fossa and passes forward in the sinus roof. The maxillary nerve passes through the foramen rotundum to enter the pterygopalatine. The upper cervical carotid and eustachian tube form the lateral limit of the exposure of the lower clivus and the junction of the petrous and cavernous carotid limits the lateral exposure of the upper clivus. D, enlarged view. The bone and dura covering the optic canal in the superolateral part of the sphenoid sinus has been opened to expose the optic nerve and ophthalmic artery in the optic canal. The junction of the petrous and cavernous carotid limits the exposure below the level of the sella. The maxillary nerve exits the foramen rotundum and enters through the pterygopalatine fossa where it gives rise to the infraorbital, zygomatic, and greater palatine nerves, plus communicating rami to the pterygopalatine ganglion. Terminal branches of the maxillary artery intermingle with the neural structures in the pterygopalatine fossa. A., artery; Ant., anterior; Car., carotid; Cav., cavernous; Eust., eustachian; For., foramen; Gang., ganglion; Gr., greater; Inf., inferior; Infraorb., infraorbital; Max., maxillary; Mid., middle; N., nerve; Ophth., ophthalmic; Palat., palatine; Pet., petrosal; Proc., process; Pteryg., pterygoid; Pterygopal., pterygopalatine; Sup., superior.

圖6.11。鼻道通往斜坡。A，這個橫截麵穿過鼻腔，眼眶，上頜竇和篩竇。篩竇位於蝶竇的前麵。中鼻甲和下鼻甲被保留。B，蝶竇前壁被打開，露出多間隔竇和鞍前壁。左鼻甲被切除了。左上頜竇後壁的一部分已經被切除以暴露出齶大動脈它起源於翼齶窩的上頜動脈。頸內動脈在蝶竇外側壁形成蜿蜒的突起。C，切除蝶竇的粘膜和骨壁以暴露頸內動脈，它們形成了上斜坡經鼻暴露的外側界限。 The pituitary gland has been exposed. Additional posterior wall of the left maxillary sinus has been removed to expose the infratemporal fossa, which contains the branches of the maxillary artery, the pterygoid muscles, pterygoid venous plexus, and branches of the mandibular nerve. The nasopharyngeal mucosa covering the longus capitis and the lower clivus is exposed in the interval between the palate and the vomer. D, enlarged view of the sphenoid sinus and sellar region. The anterior surface of the upper clivus is exposed below the pituitary gland. The lateral clival exposure is limited at this level by the internal carotid arteries. E, oblique view. The medial wall of the left cavernous sinus has been opened to expose the abducens and oculomotor nerves. The pterygopalatine fossa is located below the orbital apex. The maxillary nerve passes through the foramen rotundum and gives rise to the communicating rami to the pterygopalatine ganglion and the infraorbital nerve that courses along the floor of the orbit. F, enlarged view of the structures in the medial cavernous sinus. The ophthalmic artery courses below the optic nerve in the optic canal. A., artery; Car., carotid; Cav., cavernous; CN, cranial nerve; Gl., gland; Gr., greater; Inf., inferior; Infratemp., infratemporal; Max., maxillary; Mid., middle; Ophth., ophthalmic; Palat., palatine; Pterygopal., pterygopalatine; Sphen., sphenoid; Turb., turbinates.

圖6.12。f。經口、經齶和經上頜入路到斜坡和枕骨大孔。A，強行張開嘴可以使斜坡暴露在上顎以下。B，張開嘴前視。從硬齶向後延伸的軟齶會擋住上斜坡的視線。C，在軟齶中線有一個切口。D，剖開軟齶，露出下斜坡粘膜。E，在中線打開咽黏膜，露出頭長肌和大腸長肌，頭長肌向側麵反射。
F，左側頭長肌和大腸長肌橫向反映。 A., artery; A.I.C.A., anteroinferior cerebellar artery; Ant., anterior; Bas., basilar; Cap., capitis; CN, cranial nerve; For., foramen; Gr., greater; Infratemp., infratemporal; Jug., jugular; Long., longus; M., muscle; Max., maxillary; N., nerve; P.I.C.A., posteroinferior cerebellar artery; Sp., spinal; Sphen., sphenoid; Temp., temporal; Vert., vertebral; Vert., vertebral; Zygom., zygomatic.

圖6.12。G-J。經口、經齶和經上頜入路到斜坡和枕骨大孔。G，下斜坡已被打開，以暴露椎動脈，基底動脈下部，右側異食動脈，左側異食動脈，以及外展神經和舌下神經。H，切除C1前弓以暴露齒狀突。I，脫套骨膜下剝離暴露上頜骨的前麵和前梨狀孔的下部。J，上頜橫截骨術(LeFort I)通過上頜竇延伸至牙尖上方和眶下管下方。

圖6.12。k - n。經口、經齶和經上頜入路到斜坡和枕骨大孔。K，下上頜骨向下移位了。通過曝光可以看到斜坡窗和椎動脈。L，斜坡開口的放大視圖。M，上頜骨在中線處垂直分裂，兩部分橫向反射，使斜坡開口向上延伸。N，斜坡暴露的放大視圖。右AICA在右外展神經後麵而左AICA在左外展神經前麵。

圖6.13。經口入路是最常用的前路入路。經口入路的變體包括經齶入路，其中軟齶或軟齶和硬齶都打開，唇頜或唇舌下頜入路，其中嘴唇、下巴、下頜骨，可能還有舌頭和口腔底部在中線分開，以增加暴露。經口入路及其變體允許切除斜坡、寰椎前弓、齒狀突以及C2和C3椎體。A，經口入路。患者頭部固定，以便進行側位x線或圖像強化檢查以確認位置。通常進行氣管造口術。導管通過鼻道插入並置於軟齶後麵並從口腔中取出或通過小舌底部的絲狀縫線連接到鼻導管可以用來收回軟齶。咽後壁在中線縱切(斷線)。B，粘膜和肌肉作為單層向外側縮回，使用骨膜下剝離到達寰椎、軸和下斜坡。 The anterior arch of the atlas, the odontoid process, and the body of the atlas may be removed (interrupted line) to expose the dura. C, it may be necessary to split the soft palate in the midline to expose the clivus (palatal incision, continuous line; pharyngeal incision, interrupted line). D, the anterior surface of the clivus has been exposed through the transpalatal approach. The anterior arch of the atlas and the odontoid process may be removed and an opening made in the clivus (interrupted line). E, if further craniad exposure is needed, laterally based mucoperiosteal flaps may be elevated from the lower surface of the hard palate (interrupted line), and the soft palate split in the midline (continuous line). The posterior part of the hard palate may be removed (oblique lines). F, care is taken to retract rather than open the mucosa lining the upper surface of the hard palate. The pharyngeal incision is extended upward through the vault of the nasopharynx to the posterior border of the vomer. When elevating the mucoperiosteal layer from the clivus, the lateral margins slope dorsally into gutter-like depressions where the tissue becomes more adherent. The clivus, anterior arch of the atlas, dens, and bodies of C2 and C3 may be removed. The clival defect is packed with muscle or fat and may be reinforced with a bone graft. The prevertebral muscle and mucosal layers and the palatal openings are closed with absorbable sutures. G, the lower lip and mandible may be split (interrupted line) to increase the exposure and reduce the operative depth. H, a step-like mandibular osteotomy (interrupted line) is accomplished in the midline after removal of a central incisor tooth. I, spreading the mandibular halves laterally without splitting the tongue permits the tongue to be depressed downward between the mandibular halves. J, if the exposure is still inadequate, the tongue and floor of the mouth may be split in the midline. Spreading the mandibular-lingual halves exposes the pharynx down to the C3 level. The mucosa and musculature of the tongue and floor of the mouth are reapproximated; the mandibular osteotomy is closed with plates; and the lip, chin, and submandibular region are carefully closed after dealing with the lesion. (From, Rhoton AL Jr, de Oliveira E: Anatomical basis of surgical approaches to the region of the foramen magnum, in Dickman CA, Spetzler RF, Sonntag VKH (eds): Surgery of the Craniovertebral Junction. New York, Thieme, 1998, pp 13–57 [26].)

圖6.14。模擬。下頜切開術到斜坡和枕骨大孔。A，入路可通過口腔內的脫手套切口進行;然而，在這種情況下，為了更充分地顯示解剖結構，使用Weber-Fergusson鼻旁切口和眶下延伸術來暴露上頜骨的前麵。眶下神經已分裂，但通常可通過脫手套切口保留。咬肌沿著顴骨的下緣附著。B，上頜竇的粘膜內襯暴露在顴弓下方。去除下頜骨冠突或與顳肌反射，暴露翼肌內側和外側肌以及顳下窩的上頜動脈。C，翼外肌和一段上頜動脈已經被切除。 Removal of the lateral pterygoid exposes the mandibular nerve and its branches in the medial part of the infratemporal fossa. D, a lower maxillectomy has been completed. In this approach, the maxilla can be folded on a vascularized pedicle of soft palate into the floor of the mouth. The pterygoid process, which forms the posterior wall of the pterygopalatine fossa, has been preserved. The nasal mucosa remains intact. The maxillary artery exits the infratemporal fossa to enter the pterygopalatine fossa. A., artery; A.I.C.A., anteroinferior cerebellar artery; Alv., alveolar; Ant., anterior; Bas., basilar; Cap., capitis; Car., carotid; Cav., cavernous; CN, cranial nerve; Eust., eustachian; Gl., gland; Inf., inferior; Infraorb., infraorbital; Int., internal; Intercav., intercavernous; Lat., lateral; Long., longus; M., muscle; Max., maxillary; Med., medial; N., nerve; Pal., palatini; Pet., petrous; Pteryg., pterygoid; Pterygopal., pterygopalatine; Tens., tensor; TM., temporomandibular; Vert., vertebral.

圖6.14。情況。下頜切開術到斜坡和枕骨大孔。E，鼻黏膜已打開，咽後壁向另一側反射。頭長肌附件已與斜坡分離。F，頭長肌和大腸長肌向外側反射，暴露寰椎前弓、齒狀突和軸體。G，斜坡和硬腦膜已被打開以暴露髓質和椎動脈。H，通過切除蝶竇和蝶鞍前壁，暴露向上延伸。岩狀頸動脈的末端限製了斜坡水平的側暴露，海綿狀頸動脈限製了蝶竇水平的側暴露。海綿間竇連接成對的海綿竇。

圖6.15。內側上頜切開術進入斜坡和枕骨大孔。A，側鼻切開術切口沿眶內緣延伸。內側眥韌帶暴露在外。B，內側眥韌帶已經被分割以暴露眼窩的內側。如果不需要暴露眼窩，可以保留韌帶，眼眶內側壁保持完整。梨狀前孔暴露在外。C，截骨術如圖所示，以打開鼻腔和內側上頜骨。內側骨打開鼻腔，外側骨取出暴露上頜竇。內側上頜切開術有助於顯露斜坡。 D, the exposure has been directed to the posterior nasopharyngeal wall behind which the clivus sits. The anterior wall of the sphenoid sinus has been removed, exposing the sphenoid septum. The posterior part of the nasal septum has been removed to expose the clivus below the sphenoid sinus. Removal of the medial part of the posterior wall of the maxillary sinus exposes the maxillary artery in the pterygopalatine fossa. E, enlarged view of the pterygopalatine fossa exposed by removing the medial part of the posterior wall of the maxillary sinus. The maxillary nerve and artery enter the pterygopalatine fossa. The maxillary artery is the major source of bleeding during surgery in this area. The maxillary artery enters the pterygopalatine fossa by passing through the pterygomaxillary fissure. The maxillary nerve enters the fossa by passing through the foramen rotundum and gives off communicating rami to the pterygopalatine ganglion. F, the pharyngeal mucosa has been opened, the longus capitis reflected laterally, and the clivus and dura opened to expose the basilar artery ascending in front of the pons. The pituitary gland is at the upper margin of the exposure. A., artery; A.I.C.A., anteroinferior cerebellar artery; Ant., anterior; Bas., basilar; Cap., capitis; CN, cranial nerve; Eust., eustachian; Gang., ganglion; Gl., gland; Gr., greater; Lig., ligament; Long., longus; M., muscle; Max., maxillary; Med., medial; N., nerve; Nasolac., nasolacrimal; Post., posterior; Pterygopal., pterygopalatine; Sphen., sphenoid; Vert., vertebral.

圖6.16。Transmaxillary方法。示出三種經上頜入路。這三種手術都可以通過口腔內切口脫手套完成。另一種類型的切口延伸到麵部，如Weber-Fergusson切口，可以考慮。A，抬高上唇，沿著臼齒周圍的上牙槽邊緣切開黏膜。粘膜從上頜骨的前側麵抬升到眶下孔以下，但要高到足以避開牙根。黏膜從上頜骨的鼻表麵抬高，鼻中隔在其與上顎的附著處上方分開。B，鋸切(實線)延伸至兩側上頜竇。上頜骨的遊離塊向下移動(箭頭)，以便進入斜坡。 C, the intraoral retractor has been placed. Displacing the maxilla downward gives wide access to the clivus. D, a modified technique, called the extended maxillectomy, includes the LeForte I osteotomy with a midline incision of the hard and soft palate (solid lines). E, this allows the halves of the maxilla, which are attached to the muscles and vessels in the infratemporal fossa, to be reflected laterally, providing wider exposure to the clivus and upper cervical spine. F, retractors have been placed to expose the clivus and upper cervical area. The approach can be extended upward into the sphenoid and ethmoid sinuses and downward to C2 or C3. G–I. Unilateral maxillotomy. G, in this approach, half of the maxilla is mobilized by a bone cut, which extends back to the infratemporal fossa in the area just below the infraorbital foramen, and the maxilla is divided in the midline. A mucosal incision is made along the low surface of the hard palate parallel to the midline on the side opposite the saw cut through the hard palate, and the anterior face of the maxilla is degloved on one side. The soft palate is left intact. H, the unilateral block of maxilla, which is still attached to the structures in the infratemporal fossa along the pterygoid plates and to the soft palate, which is not interrupted, is folded downward into the floor of the mouth. I, the anterior part of the nasal septum is left undisturbed, but the posterior part is removed along with some of the turbinates and wall of the sinuses to provide a wide exposure of the clivus. This exposure can be enlarged to include the walls of the sphenoid and ethmoid sinuses. (From, Rhoton AL Jr: Anatomical basis of surgical approaches to the region of the foramen magnum, in Dickman CA, Spetzler RF, Sonntag VKH (eds): Surgery of the Craniovertebral Junction. New York, Thieme Medical Publishers, Inc., 1998, pp 13–57 [24].)

圖6.17。蝶竇入路。左上，這個入路在上唇下方，沿著鼻中隔，穿過蝶竇，可以用來暴露斜坡的上三分之一。可切除區域(斜線)包括蝶鞍底和前壁、犁骨和斜坡的上三分之一。這種方法適用於一些從枕骨大孔向上延伸的腫瘤的活檢。右下，杯鉗檢查斜坡腫瘤。B，通過鼻窺鏡觀察。鼻前棘被保留，鼻中隔軟骨的前部仍然附著在一側的鼻中隔粘膜上。鼻鏡插入鼻中隔左側和鼻中隔粘膜之間。鼻中隔和鼻中隔右側的黏膜被窺鏡推到右側，鼻中隔左側的黏膜被推到左側。 The keel on the vomer is exposed. C, magnified view. The vomer has been removed to open the sphenoid sinus. The sellar floor is above the midline septum. In approaching the clivus, the floor of the sella is removed, and the opening in the bone is extended downward on the clivus (interrupted lines) to the inferior margin of the sphenoid sinus.

圖6.18。A，經頸入路。氣管切開術可以使下顎緊緊閉合。t型皮膚切口(間斷線)包括從乳突尖端延伸至
門蒂聯合的下頜下切口和向下延伸至胸鎖乳突肌的下延伸。B，可切除區域(斜線)包括斜坡、軸的前弓、軸的齒狀突體。C，
暴露指向胸鎖乳突肌的前邊界和外側
內頸動脈和頸內靜脈之間，以及內側的食管、下咽和氣管。可以劃分為增加暴露的結構包括咽升動脈和甲狀腺上動脈，喉外神經，舌下神經，喉內神經，舌動脈，舌下神經，莖突舌骨肌，二腹肌前腹，莖突舌骨韌帶，舌咽神經，莖突咽肌和莖突舌骨肌。副神經在胸鎖乳突肌後麵。D，椎前筋膜、頭長肌和頸長肌在斜坡到C3的中線分離，並使用骨膜下剝離術向外側縮回，露出斜坡、寰椎和軸的腹側。E和F，寰椎前弓和齒狀突，以及從枕骨大孔延伸至蝶枕軟骨聯合的2.5 mm寬斜坡可被切除。 The basilar, vertebral, and anterior spinal arteries are exposed in the dural opening. After dealing with the pathology, the dura is closed, muscle and fat are placed in the clival window, and the prevertebral and fascia are sutured in the midline. (From, Rhoton AL Jr: Anatomical basis of surgical approaches to the region of the foramen magnum, in Dickman CA, Spetzler RF, Sonntag VKH (eds): Surgery of the Craniovertebral Junction. New York, Thieme Medical Publishers, Inc., 1998, pp 13–57 [24].) A., artery; Ant., anterior; Bas., basilar; Car., carotid; Ext., external; Inf., inferior; Int., internal; Jug., jugular; M., muscle; Sp., spinal; Sup., superior; V., vein; Vert., vertebral.

圖6.19。f。經基底和額葉延伸入路的關係。A，雙冠狀頭皮皮瓣向前反射。顱骨周圍膜通常被反射為一個單獨的層，以便以後用於閉合顱前窩底。B、骨瓣和截骨術。經顱-經基底入路僅使用前顱窩底部的雙額開顱術，不進行截骨手術。完成了雙額大開顱術和額眶顴截骨術。截骨部分可延伸至鼻骨和外側眶緣，但對於大多數斜坡病變，更有限的骨瓣和截骨(虛線)通常就足夠了，可以根據需要進行定製，以處理涉及鼻腔、鼻竇或眼眶的情況。C，眶周與眶壁分離，準備進行截骨手術。 Division of the medial canthal ligament is not necessary for most lesions, but may be required for lesions extending into the lower nasal cavity or orbit. The ligaments should be re-approximated at the end of the procedure. D, the right medial canthal ligament has been divided and the orbital contents retracted laterally to expose the nasolacrimal duct and the anterior ethmoidal branch of the ophthalmic artery at the anterior ethmoidal foramen. E, the osteotomies have been completed and the frontal dura elevated. The dura remains attached at the cribriform plate. The upper part of both orbits are exposed. F, an osteotomy around the cribriform plate leaves it attached to the dura and olfactory bulbs, a maneuver that has been attempted to preserve olfaction, but is infrequently successful. The anterior face of the sphenoid sinus and both sphenoid ostia are exposed between the orbits. A., artery; A.C.A., anterior cerebellar artery; A.I.C.A., anteroinferior cerebellar artery; Ant., anterior; Bas., basilar; Car., carotid; CN, cranial nerve; Ethm., ethmoidal; Gl., gland; Lam., lamina; Lig., ligament; M.C.A., middle cerebral artery; Med., medial; Nasolac., nasolacrimal; Pit., pituitary; Sphen., sphenoid; Sphenopal., sphenopalatine; Sup., superior; Term., terminalis; Turb., turbinates; Vert., vertebral.

圖6.19。G-L。經基底和額葉延伸入路的關係。G，打開蝶竇暴露出蝶竇內的隔膜。蝶齶動脈穿過蝶骨的前麵。H，蝶竇內的間隔，鞍底和側竇壁已被切除，以暴露海綿狀頸動脈，腦下垂體和視神經管。斜坡被打開，暴露腦幹對麵的硬腦膜。基底竇與海綿竇後部相連，位於上斜坡硬腦膜層之間。J，斜坡已打開，暴露彎曲的椎動脈，它們在斜坡開口左側外側緣連接形成基底動脈。這兩個美洲國家的起源都暴露了。 A vein splits the right abducens nerve into two bundles adjacent to the brainstem. K, the frontal dura has been opened and the frontal lobes elevated to expose the olfactory and optic nerves, the internal carotid, and the anterior and middle cerebral arteries. L, enlarged view. The subfrontal and clival openings are separated by the sella and pituitary gland. The lateral limit of the clival exposure is defined by the internal carotid arteries and optic nerves. The lamina terminalis is exposed above the optic chiasm.

圖6.20。A，如果腫瘤還涉及並需要切除部分篩骨和蝶骨(斜線)，則可采用經顱-經基底入路接近枕骨大孔前緣的腫瘤。B,插入。下顎頭皮切口位於發際線後，雙額開顱術(間斷線)嚴格置於眶上，不考慮額竇(斜線)。右下方。額下硬腦膜與眶頂分離，硬膜外剝離至蝶骨小翼、鞍結節和前楔突基部。在切除前顱窩底的後部、篩竇和蝶竇壁的上部以及鞍底後到達斜坡。繼續向下，切除斜坡，打開枕骨大孔的前緣。從脊柱前部分離咽黏膜，暴露寰椎前弓，甚至C2和C3椎體的前部。不應打開鼻咽黏膜。 Dural defects are closed with a leak-proof dural graft after dealing with the lesion. C, the orbital roof and the remainder of the cranial base are reconstructed using bone grafts. If the clivus has been removed, the graft above the ethmosphenoidal space is fitted into the edge of a vertical graft extending from the anterior margin of the foramen magnum or the anterior arch of the atlas to the floor of the sella. (From, Rhoton AL Jr: Anatomical basis of surgical approaches to the region of the foramen magnum, in Dickman CA, Spetzler RF, Sonntag VKH (eds): Surgery of the Craniovertebral Junction. New York, Thieme Medical Publishers, Inc., 1998, pp 13–57 [24].)

圖6.21。擴大正麵入路。A，左上插入圖顯示頭皮皮瓣和顱骨移除順序(1,2,3)。第三步，眶前篩竇截骨術，包括眶上脊、眶頂前部、額竇、篩板和部分篩竇氣細胞。B，矢狀圖。沿顱底的斜線顯示了骨頭可能被切除的程度。在切除前窩底的後部、篩竇氣細胞、蝶竇壁和斜坡後到達枕骨大孔。C，軌道周圍沿軌道頂部暴露。骨移除已擴展到篩竇空氣細胞和蝶竇。暴露可沿斜坡延伸至枕骨大孔。D，使用顱瓣重建。 A fat graft is placed in the ethmoid and sphenoid sinuses before reflecting the pericranial flap over them. In addition, a fat graft may also be applied to the inner side of the pericranial flap. (From, Rhoton AL Jr: Anatomical basis of surgical approaches to the region of the foramen magnum, in Dickman CA, Spetzler RF, Sonntag VKH (eds): Surgery of the Craniovertebral Junction. New York, Thieme Medical Publishers, Inc., 1998, pp 13–57 [24].)