颈静脉孔的应用解剖学.pdf

#应用解剖#颈静脉孔的应用解剖学肖 明,丁 炯,韩群颖,王鹤鸣,左国平(南京医科大学解剖学教研室,江苏 南京 210029)=摘要目的:为与颈静脉孔相关的影像诊断和临床治疗提供解剖学资料。方法:从颅底内、外面,对80 具成年颅骨的颈静脉孔进行观测;并对 20具成人尸头进行解剖,观察该区域神经血管解剖关系。结果:62.3%右侧颈静脉孔较左侧大,15.9%左侧较大,21.8%两侧大小一致;14.38%的颈静脉孔有骨桥,85.62%无骨桥;颈静脉孔内、外侧缘距正中矢状面两侧的平均距离颅外均较颅内大:颅外分别为 26.11mm 和 33.41 mm,颅内分别为 22.29 mm 和 27.52 mm。脑神经多沿颈静脉孔前上缘,、脑神经沿内侧缘出颅,两者被纤维索(占 87.5%)或骨桥(占 12.5%)隔开。脑神经多经颈静脉孔外口前上缘向前下越过颈内动脉表面;脑神经经颈内静脉深面(占 57.5%)或其浅面(42.5%)行向后下。结论:右侧颈静脉孔通常较左侧大,左右不对称;影像学观测该区域血管、神经应选择恰当的层面。=关键词颈静脉孔;颈内静脉;脑神经;应用解剖学=中图分类号 R323.1=文献标识码 A =文章编号1001-165X(2001)02-0159-03Applied anatomy of jugular foramenXIAO Ming,DINGJong,HAN Qun-ying,et al.Department o f Anatomy,Nanjing Medical University,Nanjing 210029,China=Abstract Objective:To provide anatomic data for imaging diagnosis and microsurgicaltreatment of jugular fora-men(JF)lesions.Methods:The JF was observed and measured from internal and external aspects in 80 adult skulls.The anatomic relationships between the nerves and vessles in this region were observed in detail by dissecting 20 adultcephalic specimens.Results:In 62.3%of all these casesthe right JF was larger thanthe left.In 15.9%the left waslarger and in 21.8%they were equal in size.Bone bridges could be seen in 14.38%and could not in85.62%.Measured from extracranial aspect,the average distance from midsagittal plane to the medial and lateral border of the JF(medial 26.11mm,lateral33.41mm),was larger thanthose measuredfrom intracramial aspect(medial 22.29mm,lat-eral 27.52mm).cranial nerve made its exit through the anterior superior border of the JF inmost cases,meanwhile and cranial nerve through the medial border,they were distinctly separated from each other by a band of fibroustissue(account for 87.5%)or a bone bridge(12.5%).Just outside the JF,cranialnerve appeared at the anter-ior border and made a loopdownward and forward superficial to the internal carotid artery.cranial nerve run downwardand backward deep(account for 57.5%),or superficially(42.5%)to the internal jugular vein.Conclusions:Theright JF is usually larger than the left,and not symmetry on both sides.The key to imaging diagnosis of nerves and ves-sels in the JF region is to select the sectional plane correctly.=Key words Jugular foramen;Internal jugular vein;Cranial nerve;Applied anatomy 颈静脉孔为枕骨与颞骨岩部之间的一骨性孔道,位于岩枕缝的后端,被颈内静脉结节分为二部或三部1。前部有岩下窦注入,与 脑神经通过;后部较大,乙状窦经此延续为颈内静脉。上述诸结构在颈静脉孔内的位置与相互毗邻关系,国内外有关文献描述甚不统一2,3。本实验目的是观察颈静脉孔的形态、内容物的相互关系,具体测量其孔径大小两侧对称性,为影像学观测提供相应的形态学资料。1 材料和方法材料为教研室标本室提供的 80 只成年男女颅骨(不分性别),经耳颞线将颅骨锯开。对颈静脉孔大体形态进行观察,并着重观察有无骨桥(完整与否)及其类型与出现率;根据 Doclo制定的原则将骨桥进行分类:位于舌下神经管前上方者为 型,位于舌下神经管后方的为型。分别从颅内测量颈静脉孔的最大、最小横径,矢状径(图 1);从颅外测量横径与矢状径,并从颅内、外面对颈静脉孔内、外侧缘距正中矢状面距离进行测=收稿日期 2000-03-11=作者简介 肖 明(1972-),男,江苏盐城人,硕士,讲师,主要从事临床解剖学研究,Tel:[phone],E-mail:。量。测量仪器为颅骨测径器。另20例成年尸头标本(男12例,女8 例),于颞骨乳突中部与耳颞线平行锯断,移去颅骨的上端,细心将、脑神经从脑干背面剪断,剔除脑组织,保留颈静脉孔周围的硬脑膜,观察上述神经在孔内口的位置及与岩下窦相互毗邻关系;去除颅底肌肉等软组织,暴露颈内静脉孔外口,观察颈内静脉与、脑神经的解剖关系。AB.横径(transverse diameter)CD.最大矢状径(maximum sagittal diameter)EF.最小矢状径(minimum sagittal diameter)图 1 颈静脉孔的各径线颅内测量示意图Fig.1 Intracranial measurements of the schematic drawing of diameters of the jugular foramen#159#中国临床解剖学杂志 2001 年第 19 卷第 2 期2 结果2.1 静脉孔的形态观察在160 侧颈静脉孔中,无骨桥者占 85.62%(137侧);有骨桥者占 14.38%(23 侧),其中位于右侧者占3.16%,位于左侧者占 8.75%,双侧均有者占 2.47%。23 侧骨桥分类如下:13 侧属于 型;7 侧属于 型;介于、型之间形状不规则者共3 侧。2.2 颈静脉孔各径测量测量数据显示:160 侧颈静脉孔中,62.3%为右侧较大,15.9%为左侧较大,21.8%两侧大小一致。左右颈静脉孔各径线测量值分别见表 1、表 2。表 1 颅内两侧颈静孔横径、矢状径的测量值 x?s(min max)mmTab.1 Intracranial measurement of the treansverse and sagittal diameter(mm)of the jugular foramen in two sides Mean?SD(min max)mm项 目(item)例数(case)右 侧(right)左 侧(left)tP横径(transverse d.)8015.15?2.34(10.96 19.92)14.22?2.78(8.32 20.32)1.56 0.05最大矢状径(max.sagittal d.)808.82?1.28(6.12 11.10)7.28?1.61(4.20 10.92)3.26 0.05 *有骨桥者不再测量最小矢状径(The min.sagittal d.were not measured when bone bridges existed)表 2 颅外两侧颈静孔横径、矢状径的测量值 x?s(min max)mmTab.2 Extracranial measurement of the transverse and sagittal diameter(mm)of the jugular foramen in two sides Mean?SD(min max)mm项 目(item)例数(case)右 侧(right)左 侧(left)tP横径(transverse d.)8018.12?1.92(11.30 21.36)16.36?2.32(9.08 21.58)3.51 0.05矢状径(sagittal d.)8010.45?2.04(6.12 11.10)9.58?2.09(1.00 12.78)3.35 0.05D外(Dlateral)8027.62?2.67(21.12 30.98)27.30?3.13(22.70 30.74)0.90 0.05颅外(extracranial)D内(Dmedial)8025.81?3.17*(23.44 33.00)26.17?4.30*(22.03 32.60)1.04 0.05D外(Dlateral)8033.53?3.24*(31.02 39.30)33.37?3.32*(27.56 40.02)0.95 0.05 *P 0.01,分别与颅内 D内、D外比较(P 左,23.7%左 右,15.4%右=左5。本文统计结果与其相似。3.2 骨桥的出现率及分类比例有关这一问题各家报道结果有所不同1,2,6。根据各作者的结果不同,提示骨桥的形成与种族、区域有关。骨桥在影像学检查中有一定的意义,且骨桥增生#160#CHINESE JOURNAL OF CLINICAL ANATOMY Vol.19 No.2 2001可导致其前方的舌咽神经受压引起舌咽神经痛等症状7。3.3 颈静脉孔大小的测量仅有日本人 Nihat Ekinci 8进行过具体统计。本文的统计结果与其不同:右侧颈静脉孔的各径线均比左侧大,但颅内最小矢状径略小于左侧;而骨桥出现率右侧低于左侧。可见骨桥的形成与最小矢状径无相关性,与 Nihat Ekinci 的观点恰好相反8。图 2 脑神经在颈静脉孔内口的位置及其与岩下窦的相互关系示意图Fig.2 The interrelationship between inferior petrosal sinus and cranial nerve at the internal aperture of jugular foramen3.4 颈静脉孔距正中矢状面的距离这一方面的统计数据,国内、外尚未见报道。本文的测量结果显示颅外颈静脉孔距正中矢面的距离明显大于颅内,两侧无显著性差异。这对于影像学显示颈静脉孔选择具体层面有一定的参考意义。3.5 脑神经在颈静脉孔内、外口的解剖在颈静脉孔内口,脑神经单独穿过硬脑膜,并以纤维性或骨性间隔与、脑神经分开,这有利于颅内切断 而不损伤,来治疗舌咽神经痛;而在颅外 紧贴鼓室下壁,并与颈内动脉关系密切,手术入路困难9。但我们观察其出颈静脉孔外口后多向前下行至1.0 1.5 cm 处才行于颈内动脉表面,所以如选择颅外术式,宜选高位切断,但分离暴露困难。在颈静脉内口、脑神经关系密切,出颅后两者逐渐分开,MRI 断层观察区分时应选择恰当的层面;同时 在颈内静脉起始处有两种不同的走行,在影像学观察和手术过程中应注意辨别。=参考文献 1 Dodo Y.Observation on the bony bridging on the jugular foramen of the hu-man skull J.Anat,1986,144:153.2Hatiboglu MT,Anil A.Structural variation in the jugular foramen of the hu-man skull J.Anat,1992,180:191.3 邹宁生.颈静脉孔前部内含物及其相互关系 J.解剖学报,1956,1(4):415.4Moore KL.Clinical Oriented Anatomy M.3rd ed.London:Williams andwilkins,1990.680.5 中国解剖学会体质调查组编.中国人体质调查M.上海:上海科学技术出版社,1986.111.6 Sturrock RR.Variations in the structure of the jugular foramen of the humanskull J.Anat,1988,160:227.7 Uysal A,Pala S.Foramen jugulare ilesinus sigmoides fossa jugularis arasinda-ki iliskilerin incelenmesi J.Ege Tip Dergisi,1992,31(1):111.8 Nihat Ekinci,Erdogan Unur.Marcroscopic and morphometric investigation ofthe jugular foramen of the human skull J.Acta Anat Nippon,1997,72:525.9 刘良发,姜泗长,杨伟炎等.侧颅底神经血管的应用解剖学 J.中国临床解剖学杂志,1999,17(2):97.#161#中国临床解剖学杂志 2001 年第 19 卷第 2 期