海绵窦解剖---Rhoton解剖视频学习笔记系列 / 四六文摘

在The Rhoton Collection解剖视频中，《Cavernous Sinus and Middle Foss》这一章节与《Navigating the Temporal Bone（颞骨解剖）》有部分重复。本文从中将Cavernous Sinus（海绵窦解剖部分）截取出来并重新编排，制作了本篇学习笔记，共49张图片。错误之处，请批评指正！

海绵窦解剖

Cavernous Sinus

▼本节介绍海绵窦的解剖。我们剥除此处的中颅窝硬膜（下图示未剥离硬膜的中颅窝）

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

▼我们掀开硬膜，可见海绵窦外侧壁的深层（下图）。

海绵窦外侧壁有浅、深两层。颅中窝硬膜的脑膜层延续为外侧壁的浅层。深层由动眼神经、滑车神经、眼神经、上颌神经的神经鞘以及之间网状半透明的膜构成。

So that, here we just peeled up the dura.

▼下图示Meckel腔，其前界几乎囊括三叉神经节。

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

▼我们打开Meckel腔，其实质上是一个蛛网膜下腔间隙（下图）

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

▼Meckel腔向前几乎延伸至三叉神经节的膨大部（下图）。

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

▼仅三叉神经眼支位于海绵窦外侧壁。

Only V1 up here faces the cavernous sinus.

▼半月神经节（gasserian ganglion）及Meckel腔则属于中颅窝结构，其位于中颅窝三角内。 gasserian [ɡæ'siəriən]

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

▼下图示位于动眼神经池内的动眼神经，动眼神经池前界几乎至前床突尖部。

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

▼剥除蛛网膜后，可显露眶上裂内的神经。

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

▼动眼神经

▼滑车神经前行走形于前床突下方，跨过动眼神经并转向内侧。

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

▼下图可见小部分外展神经

and this is a little bit of the 6th.

▼清除窦内静脉结构，可见外展神经穿行于Dorello管，其位于蝶岩韧带（Gruber韧带）的下方，三叉神经眼支的内侧。

Dorello管是由Gruber韧带、岩尖、上斜坡外侧缘构成的一个骨纤维管道。

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

▼接下来，我们沿着三叉神经的1、2、3支的内侧继续暴露。

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

▼在三叉神经主干的内侧，可见三叉神经运动根前行进入卵圆孔的前内侧象限。

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.

▼三叉神经下颌支后方可见岩浅大神经(GSPN)

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

▼沿着岩浅大神经逆行，暴露膝状神经节（geniculate ganglion）

We can follow it back to the geniculate ganglion

▼进而打开内听道（internal acoustic meatus）。我们需注意保护此处的耳蜗以保留听力。

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

▼耳蜗(cochlea)位于耳蜗三角内，位于面神经迷路段与岩浅大神经之间。

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

▼位于岩大浅神经后方的这个三角是Kawase's三角，即后内侧三角（posteromedial triangle）

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

▼在这个三角内，我们可以磨除岩尖骨质，从而向下暴露至斜坡侧方，也可打开内听道

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

▼但需时刻注意保护耳蜗三角内的耳蜗。

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

▼磨除颅中窝的颅底骨质后，我们将显露颞窝（temporal fossa）

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

▼颞下窝（infratemporal fossa）

▼假如打开前内侧三角和前外侧三角，则可进入蝶窦。

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

▼现在我们去除三叉神经节。打开翼管，可见 岩浅大神经与发自颈动脉丛的岩深神经相汇合并继续前行形成翼管神经

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.

▼下图示 岩舌韧带（petrolingual ligament）

岩舌韧带是前方的蝶骨舌与后方的岩尖之间的骨膜小反折，颈动脉管骨膜的延续。

颈内动脉破裂段止于岩舌韧带。此韧带以远，颈内动脉进入海绵窦。

What is this ligament? Petrolingual.

▼在外展神经上方的是Gruber韧带（下图）

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

▼外展神经在该韧带下方穿行于Dorello管。

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

▼外展神经走行于三叉神经眼支的内侧。打开海绵窦显露该区域时，人们常常会问“外展神经呢？”。其实，透过这三叉神经眼支，即可见此处的外展神经。

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

▼外展神经，位于Parkinson三角后方、滑车神经下方，从Dorello管穿行而来，前行至三叉神经眼支的内侧面。

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.

▼让我们概览该区域的所有解剖三角：

下图示 床突三角（Dolenc三角）

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

▼动眼神经三角（oculomotor triangle）

▼滑车上三角（Fukushima三角）（supratrochlear triangle）

▼滑车下三角（Parkinson三角）（infratrochlear triangle）

▼前内侧三角（anteromedial triangle）

▼前外侧三角（anterolateral triangle）

▼后外侧三角（Glasscock三角）(posterolateral triangle)

▼后内侧三角（Kawase三角）(posteromedial triangle)

▼该区域的上面观可见床突三角（Dolenc三角）

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

▼动眼神经三角是由前床突、后床突和岩尖构成的三角形。

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

▼这幅图展示了上述海绵窦三角的后面观。

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

▼我们可以看到，当外展神经进入海绵窦后壁时，恰从岩下窦的上部穿过，这解释了为何岩下窦采血后会出现外展神经麻痹 这一临床现象。

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.