| PrefaceThe subtemporal approach for middle cranial fossa is a common approach of microneurosurgery, it is adopted to dispose the tumor of infra - dura mater and extra — dura mater in middle cranial fossa, cerebral hemorrhage of hypertensive disease, the injury infra cranium of middle cranial fossa, the post - root amputation of trigeminal, the decompression of infra temporal muscle, facial nerve decompression , et al. The study bonds with clinical practical operative procedure to dissect and investigate the important anatomic structure in the path. The pterion and the point of zygomatic arch are chosen to the position of observation for operative approach of middle cranial fossa,the distances between pterion , the point of zygomatic arch and the structures in middle cranial fossa are measured. The and distances between the hiatus of canal for facial nerve and spinous foramen, arcuate eminence, internal acoustic port are measured,the angulation from the straight line to midsagittal plane are measured too to discuss the position relation of the structures and to provide anatomic foundation for clinical operation.Material and Method of Experiment1 MaterialObjects10 examples fixed normal adult's skull including cervical part cadaver specimen ( supplied by the department of local anatomy, China Medical University) , There are 7 Male examples and 3 Female examples, Lacteprene mixed red and blue dye were afrused to the artery and vein system to maintain the normal cali-ber of blood vessel that can be recognized easily. 1.2 Devices and ReagentsRoutined operative devices for neurosurgery( supplied by the department of local anatomy,China Medical University) , hyperbaric injection syringe, cranip-tome, lacteprene fluid (the lacteprene factory ShenYang) , slide gaud (degree of accuracy 0.02) , gauge, protractor, lead thread, camera operation microscope that can magnify 5 ~ 20 times. 2. Methods2. 1 Latex were affuse to the artery and vein system of cadaver's skull One side internal carotid artery (ICA) was bluntly dissected about 2 cm at section cut straight through cervical part and put in pachy - needle without apical and deligated doubly by the seventh suture. The red lacteprene fluid was af-fused to ICA;when it outflowed from opposited ICA and both vertebral arteries, the corresponding blood vessel should be tongsed; Continue to affuse lacteprene fluid until the total amount achieved 50ml, the ICA was tongsed- According to the same method, the blue lacteprene fluid was affused to internal jugular vein. 2.2 Operation and DissectionIt is two days after the lacteprene fluid was affused, it began to dissect according to clinical operative procedure. Two operative incision were chosen: one was hook incision of temple and the other was incision of great question mark of forehead and temple. Open skull by means of marking line, the structures were exposed and meatured sucu as anterior clinoid process (ACP) , foramen rotun-dum (FR) , foramen ovale ( FO) , foramen spinosum ( FS) , the internal os of internal carotid artery canal, trigeminal impression, hiatus of canal for facial nerve, arcuate eminence, internal acoustic port, sulcus for superior petrosal sinus, inferior orbital fissure, lacerated foramen and so on. 3. Observation and Measurement;3.1 Observation; the bony structure of middle cranial fossa, sinus of dura mater and the important blood vessels and nerves.3.2 Basic point of measurement; (1)pterion(2)the point of zygomatic arch3.3 Measurement component; (1)the distance and splint angle from pterion to anterior clinoid process ( ACP) , foramen rotundum ( FR) , foramen ovale( FO) , foramen spinosum ( FS) , the internal os of internal carotid artery canal, trigeminal impression, hiatus of canal for facial nerve, arcuate eminence, internal acoustic port, sulcus for superior petrosal sinus; (2)the distance and splint angle from the point of zygomatic arch to inferior orbital fissure, foramen rotun-dum ( FR) , foramen ovale ( FO) , foramen spinosum ( FS) , lacerated foramen, trigeminal impression, the hiatus of canal for facial nerve, arcuate eminence, internal acoustic port; (3)the distance and splint angle from the hiatus of canal for facial nerve to spinous foramen, arcuate eminence, internal acoustic port, the all results were disposed with statistics and expressed by (x ± s).ResultThe correlated data were viewed in chart 1, chart 2, chart 3 , chart 4, chart 5, chart 6The important anatomic structures and announcements in the approach are;1. To be near to tragus as far as possible when making incisions of temple in order to avoid damaging facial nerve temporal branch and zygomatic branches and the primary shaf of superficial temporal artery.2. The methods of protecting Labbe vein are; (1)the bony valve of temple ought to approach to the bittim of middle cranial fossa as far as possible or break the zygomatic arch to decrease pulling temporal lobe; (2)Free Labbe vein about 1.5 - 2. 0 cm on dermal epithelium; tegument when raising temporal lobe was limited.3. It is very important for the position of foramen spinosum; foramen spinosum : middle meningeal artery must be broke to expose the area of Petrosal bone and slope when the epidural operative approach is carried out in middle cranial fossa. Foramen spinosum is the important anatomic landmark when the epidural operative approach is carried out in middle cranial fossa.4. There are many pores and gaps in the bottom of Base of skull in middle cranial fossa, it is divided into two columns of the inside and the lateral, there are superior orbital fissure (SOF) , foramen rotundum ( FR) , foramen ovale (FO) , foramen spinosum ( FS) , from anterior part to posterior part in the lateral, thereare optic canal in the front and lacerated foramen, the Internal os of carotid canal in the post in the inside. It is helpful to comprehend anatomic landmark of the bottom of middle cranial fossa according to anatomic measurement of the pores and gaps.5. The important sinus of dura maters in middle cranial fossa are; cavernous sinus, sphenoparietal sinus, the middle sinus of meninges and superior petrosal sinus.6. The main arteries are : middle cerebral artery ( MCA) , posterior cerebral artery, posterior communicating artery ( PC A) and anterior choroidal artery (ACA).DiscussionFor the past few years, with the development of the surgery operation in the skull base,middle cranial fossa through subtemporal approach applied is gradually increasing. The grace of this approach lies in: (1) Field of vision is the wider , and making the best of the dissection grudge of middle cranial fossa. (2) Because of middle cranial fossa specific site, dealing with larger tumor encroaching anterior cranial fossa, we can improve operative method in foundation of the traditional middle cranial fossa operation. (3) On the basis of the middle cranial fossa dura easily abradanted, wecan ectomize affection making use of the method of combination in middle cranial fossa inside and outside dura. Comprehension in the study of dissection:1. Choice of the perative incision in middle cranial fossa through subtemporal approach; Study of dissection and pertinent literature report; hook incision in the temple, forehead - temp big question mark incision and microinvasion operative recti incision.(1) Hook incision in the temple: It is fit for the approach of the inside dura. (2 ) Forehead - temp big question mark incision: Combination subtemporal and pterion approach through fissura ectolateralis It is fit for the approach of the outside dura, whether hook incision in the temple or forehead - temp big question mark incision, the edge of window - bone is requested as low as possible.(3) Microinvasion operative recti incision. : Indication is finited for operatie -wide limited and manipulative space.Comparison of the three operative incision: forehead - temp big question mark is fit for operative incision extending middle cranial fossa epidural, turning over dura in middle cranial fossa cavernous sinus, It is larger space for operative procedure in forehead - temp big question mark incision than hook incision in the temple, petrosa revelation is obvious. So it is used in operation of middle cranial fossa through subtemporal.2. Localization sense of anatomic landmark in operation pathway of middle cranial fossa;(1) Pterion is choosed for measurement cardinal point, foramen spinosum and other structure in middle cranial fossa are all allocated. Arc is signed from head to hind and pterion lie in centra, radius is 50mm. foramen opticum ossis sphenoidalis superior orbital fissure ( SOF) , foramen rotundum ( FR) , foramen ovale ( FO) , foramen spinosum ( FS) , trigeminal impression are roughly in arc line.Arcus jugalis spot is regarded as cardinal point, not only affection Intracal-varium but also upward intracal structure involved in affection are all judged. Distance from foramen ovale lateral border to ansa capitis is 37 mm (32 -44) mm,distance from foramen spinosum to ansa capitis is 34mm(28 -39) mm, distance from fissura orbitalis inferior to ansa capitis spot is(37mm).Ferreins foramen, arcuate eminence and foramen spinosum are all consequence anatomic landmark for interacoustic meatus allocation. Distance is (10. 8 ±4. 5) mm from foramen spinosum to FerreinS foramen in the investigation.3. Anatomic structure in cavernous sinus lateral wall is anatomic sense for epidural in middle cranial fossa operation;Cerebral dura mater in cavernous sinus lateral wall devided into superficial lamella and profunda lamella, dural sheath of cerebral nerves in cavernous sinus has different structure feature in different location. Handling dissection of the cavernous sinus lateral wall, it is useful for protecting integrity lamina propria of cavernous sinus in inability to abstaine operation of middle fossa cranii epidura approach,and exposuring cavernous sinus epidural thoroughly is requisition of... |
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