脑干解剖及相关入路---Rhoton解剖视频学习笔记系列
本文由威海市立医院神经外二科张建富副主任医师根据公开资料收集整理。
Rhoton解剖视频中《Approaches to the Brainstem》与《Internal Structures and Safe Entry Zones of the Brainstem》这两个章节内容都与脑干有关，介绍了脑干的内部结构、进入脑干的安全区及相关入路，分别由Rhoton教授及Kaan Yagmurlu教授讲解。笔者将二者合为一篇笔记。共截取360张图片。
本文为《Rhoton解剖视频学习笔记系列》最后一篇，Rhoton教授在本文中将之前介绍的入路进行了简要的总结，相关详细内容可至文末点击浏览其他章节。
笔者水平所限，错误之处请批评指正！
脑干解剖及相关入路
Internal Structures and Approaches to the Brainstem
▼今天我们介绍 脑干的内部结构、进入脑干的安全区及相关入路。
脑干可分为中脑、脑桥、延髓。
Today we are going to talk about the internal structures of brainstem as well as the safe entry zones and surgical approaches of the brainstem.The brainstem is divided into midbrain,pons,and medulla.
▼这是 中脑
▼这是 脑桥
▼这是 延髓
medulla
▼这是 内侧丘系（下图黄色），传导本体感觉和振动觉
The medial lemniscus, which is related with proprioception and vibration of sense
▼内侧丘系贯穿脑干并分为 背侧部 和 腹侧部（下图）。
内侧丘系为脑干内最能耐受手术操作的纤维束。
travels through the brainstem and divides it into dorsal and ventral parts. The medial lemniscus is the most tolerant fiber tract for surgical manipulation in the brainstem.
▼皮质脊髓束（下图）也同样贯穿于脑干全长。
The corticospinal tract can also be seen at all levels of the brainstem.
▼内侧丘系前方为脑干腹侧部（下图）。
In front of the medial lemniscus is the ventral brainstem.
▼中脑和脑桥的腹侧部包含皮质脊髓束、皮质核束、皮质脑桥束。
下图示皮质脊髓束
The ventral part of the midbrain and pons contain the corticospinal, corticobulbar, and corticopontine tracts.
▼这是 皮质核束
▼这是 皮质脑桥束
▼延髓尾部仅包含皮质脊髓束（下图）。
The caudal medulla contains only the corticospinal tract.
▼在中脑层面，皮质脊髓束（下图）及 皮质核束（下图）位于大脑脚的中间部。
In the midbrain, the corticospinal and corticobulbar tracts are located in the midportion of the cerebral peduncle.
▼在脑桥层面，皮质脊髓束（下图）行于前内侧。
In the pons, the corticospinal tract travels anteromedially.
▼此为后面观。
内侧丘系（下图）后方为脑干背侧部。
We are looking from posterior. Behind the medial lemniscus is the dorsal brainstem.
▼内侧纵束（下图）位于中脑至脊髓上段之间的中线旁。
内侧纵束的病变可出现核间性眼肌麻痹，属于水平凝视麻痹。
The medial longitudinal fasciculus extends from the midbrain to the upper spinal cord next to the midline,The lesion of the MLF produce internuclear ophthalmoplegia, which is called vertical gaze palsy.
▼内侧纵束沟通动眼神经（下图箭头）、滑车神经、外展神经（下图绿色）的脑干核团 以协调眼球运动。
The medial longitudinal fasciculus interconnects the nucleus of the oculomotor, trochlear and abducens nerves to coordinate ocular movements.
▼这是 中央被盖束
the central tegmental tract
▼中央被盖束连接 下橄榄核（下图绿色） 与 红核（下图红色），途中行经面丘。
The central tegmental tract connects the inferior olivary nucleus with the red nucleus by passing through the facial colliculus.
▼这是 面丘
▼三叉神经（下图）发出两股纤维束，包括上行的三叉神经中脑束、下行的三叉神经脊束。
损伤上述三叉神经纤维束将导致感觉障碍。
The trigeminal nerve gives off two tracts, which are an ascending trigeminal mesencephalic tract and a descending trigeminal spinal tract.Damage to these trigeminal tracts may cause some loss of sensation.
▼这是 上行的三叉神经中脑束
▼这是 下行的三叉神经脊束
▼内侧纵束（下图）紧邻中线。
The MLF travels next to the midline.
▼中央被盖束（下图）是锥体外系的一部分，损伤可导致意向性震颤或眼球震颤。
The central tegmental tract is a part of the extrapyramidal system and its damage may result in intention tremor or nystagmus.
▼中央被盖束和三叉神经中脑束（下图）位于外侧的小脑上脚和内侧的界沟之间。
The central tegmental and trigeminal mesencephalic tracts are positioned between the superior cerebellar peduncle laterally,and sulcus limitans medially.
▼这是 小脑上脚
▼这是内侧的界沟
▼下面我们探讨 进入脑干的安全区。
中脑的安全区包括：1、动眼神经周围区（下图箭头），用于中脑的腹侧部病变；
After looking at the ventral and dorsal neurocritical fiber tracts of the brainstem,we can go through the safe entry zones.The safe entry zones in the midbrain that we will discuss are the perioculomotor zone used for lesions located in the ventral midbrain
▼中脑的安全区包括：2、四叠体上下区（下图箭头），用于中脑的背侧部病变；
the supra- and infra-collicular areas for lesions in the dorsal midbrain,
▼中脑的安全区包括：3、中脑外侧沟（下图），可同时用于腹侧部和背侧部的病变。
and the lateral mesencephalic sulcus for both ventral and dorsal located lesions.
▼在脑桥，三叉神经周围区（下图）用于脑桥的腹侧部病变；
In the pons, the peritrigeminal zone is used for ventral,
▼面丘上下区（下图）用于脑桥的背侧部病变。
and the supra- and infra-facial collicular approaches for dorsal pontine lesions.
▼在延髓，前外侧沟、橄榄后沟、以及延髓背侧的各脑沟，可被视作安全区。
下图示 前外侧沟
In the medulla, the anterolateral, postolivary and dorsal medullary sulci have been proposed as safe entry zones.
▼这是 橄榄后沟
▼下图箭头示 延髓背侧的各脑沟的位置
▼我们可用暴露中脑腹侧面的手术入路来到达动眼神经周围区（下图）。
The surgical target area for reaching the perioculomotor zone is the ventral surface of the midbrain.
▼动眼神经周围区的界限，上方为大脑后动脉，下方为小脑上动脉。
下图示 大脑后动脉
The perioculomotor zone is bordered by the posterior cerebral artery superiorly, and the superior cerebellar artery inferiorly.
▼这是 小脑上动脉
▼左侧翼点或眶颧开颅，经侧裂入路可暴露动眼神经周围区。
下图示 钩回
The transylvian route by the pterional or orbitozygomatic approaches can be used to reach the perioculomotor zone.On the left side, the uncus
▼这是 动眼神经
and oculomotor nerve can be seen here
▼这是 后床突、基底动脉（下图箭头）。
and the posterior clinoid and basilar artery also seen here.
▼经动眼神经周围区的入路需切开 额桥束纤维（下图）
The perioculomotor approach is directed through the frontopontine fibers,
▼内侧以动眼神经出脑干处（下图）为界。
and is bordered medially by the exit point of the oculomotor nerve
▼外侧界为皮质脊髓束（下图）的内侧界。
and laterally by the medial edge of the corticospinal tract.
▼去除额桥束纤维即可显露内侧丘系（下图），以此界定中脑的腹侧部与背侧部。
The frontopontine fibers were removed to expose the medial lemniscus, which is the border between the ventral and dorsal mibrain.
▼该入路的外侧界为皮质脊髓束（下图）。
The corticospinal tract is the lateral limit of this exposure.
▼经动眼神经周围区可到达中脑腹侧部，其位于内侧丘系（下图）前方。
或中脑背侧部，其位于内侧丘系后方。
An entry through the perioculomotor zone can reach the ventral midbrain, which is in front of the medial lemniscus, or dorsal mibrain, which is behind the medial lemniscus.
▼避免损伤动眼神经的中脑内段（下图），是该入路重点。
Avoiding damage to the intramesencephalic segment of the oculomotor nerve is important.
▼动眼神经的中脑内段起自动眼神经核（下图）并沿着内侧走行，穿经红核内部，于脚间窝处穿出中脑。
This segment arises from the oculomotor nucleus and passes medial, and inside the red nucleus,to exit the midbrain through the interpeduncular fossa.
▼这是 红核
▼中脑的另一安全区是中脑外侧沟（下图箭头），其位于中脑的背外侧面。
用于暴露该区域的手术入路为颞下入路。
Another entry zone in the midbrain is the lateral mesencephalic sulcus, which is positioned on the dorsolateral surface of the midbrain.The lateral mesencephalic sulcus is accesible through the subtemporal approach.
▼这是左侧颞下入路视野。下图示 中脑外侧沟
This is a left subtemporal view.
▼这是 天幕。
And tentorium is right here.
▼中脑外侧静脉（下图蓝色）走行于 中脑外侧沟（下图绿色）内。
The lateral mesencephalic vein runs into the lateral mesencephalic sulcus.
▼该入路的常见并发症为损伤 动眼神经（下图）和 滑车神经（下图）导致的眼肌瘫痪，以及损伤Labbe静脉导致静脉性梗死。
Known complications in this approach are the ophthalmoparesis due to the manipulation of CNs III and IV, and the venous infarction caused by damage to the vein of Labbe complex.
▼中脑外侧沟还可经外侧幕下小脑上入路暴露。这是左侧视野。
The lateral mesencephalic sulcus can also be reached by the lateral supracerebellar infratentorial approach.
▼中脑外侧沟（下图）位于中脑背外侧面。
The sulcus runs on the dorsolateral surface of the midbrain,
▼中脑外侧沟向下行至脑桥中脑沟（下图）
and extends from the pontomesencephalic sulcus inferiorly,
▼中脑外侧沟上方为内侧膝状体（下图）。
and medial geniculate body superiorly.
▼此沟同时对应内侧丘系的腹侧面（下图黄色区域）。
The sulcus also corresponds to ventral surface of the medial lemniscus.
▼该入路可能损伤的重要结构包括位于中脑腹侧部的皮质脊髓束、红核，以及动眼神经核、和滑车神经核。
下图示 皮质脊髓束
Critical structures at risk in this area are the corticospinal tract in the ventral midbrain, and the red, oculomotor and trochlear nuclei in the dorsal midbrain.
▼下图示 红核
▼下图示 动眼神经核
▼下图示 滑车神经核
动眼神经核 和 滑车神经核，均位于中脑背侧部。
oculomotor and trochlear nuclei in the dorsal midbrain.
▼垂直（下图箭头）于被盖表面进入可至红核。
Entry at a right angle through the tectal surface encounters the red nucleus.
▼以45°角度进入则至内侧丘系。
While, entry at a 45 degree angle reaches the medial lemniscus.
▼红核 距离 中脑外侧沟 平均约5mm。
The depth of the red nucleus from the lateral mesencephalic sulcus averaged 5 mm.
▼我们用暴露中脑背侧面的入路来到达 四叠体周围区（下图）。
The surgical target area for the pericollicular entry zones is the dorsal surface of the midbrain.
▼暴露该区域的入路可以是幕下小脑上入路，该入路可同时暴露松果体、上丘、下丘（下图）。
The pericollicular entry zones can be reached by way of the supracerebellar infratentorial approach, which also exposes the pineal gland, superior and inferior colliculi.
▼根据病变的位置可在四叠体 上方 或 下方 作一横切口。
Transverse incisions are made just above or below the colliculi depending on the location of lesions.
▼上丘和下丘的核团位于表面以下。
上丘（下图）参与头眼反射。
The nuclei of the superior and inferior colliculi are located just deep to the surface.The superior colliculus is involved in the reflex movement of eyes and head,
▼下丘（下图）参与听觉通路。
and inferior colliculus involved in the auditory system.
▼深部结构为位于中脑背侧部的红核，其下界位于下丘中部水平。
The deep structure is the red nucleus in the dorsal midbrain, that extends up from the midlevel of the inferior colliculus.
▼进一步解剖，可见双侧红核（下图）以及小脑上脚（下图黄色）的交叉纤维，其位于下丘水平。
In further dissection, bilateral red nuclei,and decussation of the superior cerebellar peduncle, which is positioned at the level of the inferior colliculus, have been exposed.
▼中央被盖束位于三叉神经中脑束（下图）的腹侧。
The central tegmental tract runs just ventral to the trigeminal mesencephalic tract.
▼动眼神经核与滑车神经核 以及 内侧纵束 均位于中脑导水管（下图）的腹侧。
因此，中脑导水管可作为重要标志，以避免上述结构的损伤。
The oculomotor and trochlear nuclei and medial longitudinal fasciculus are located ventral to the aqueduct. For this reason, the aqueduct is an important landmark for avoiding damage to these structures.
▼侧面观可以更好地显示动眼神经核（上方绿色） 与滑车神经核（下方绿色），均位于中脑导水管的腹侧。
This lateral view demonstrates that the oculomotor and trochlear nuclei are positioned ventral to the aqueduct.
▼这是 中脑导水管
▼这是 动眼神经的中脑内段
The intramesencephalic segment of the oculomotor nerve
▼动眼神经的中脑内段穿经红核内部及其内侧，于脚间窝处穿出。
The intramesencephalic segment of the oculomotor nerve passes through and medial to the red nucleus to exit through the interpeduncular fossa.
▼红核从下丘的中部水平向上延伸至第三脑室外侧壁（下图黄色）。
The red nucleus extends up from the midlevel of the inferior colliculus to the lateral wall of the third ventricle.
▼丘脑底核（下图）位于红核腹外侧。
The subthalamic nucleus is located ventrolateral,
▼内侧丘系（下图）位于红核外侧。
and the medial lemniscus is located lateral to the red nucleus.
▼这是中脑外侧沟（箭头），对应于内侧丘系的外侧界。
Here is the lateral mesencephalic sulcus, which corresponds to the most lateral edge of the medial lemniscus.
▼下面介绍 三叉神经周围区，用于切除脑桥腹侧部的病变。
This illustration shows the surgical target area for reaching the peritrigeminal zone for removal of the ventral pontine lesions.
▼乙状窦后入路可用于三叉神经周围区的显露
下图示 三叉神经
Using the retrosigmoid approach in reaching the peritrigeminal zone, one can see the trigeminal
▼下图示 面神经
▼岩前切除术，即Kawase入路，也可用于三叉神经周围区（下图箭头）的暴露。
The anterior petrosectomy, also called as Kawase approach, can also be used for exposure of the peritrigeminal entry zone.
▼这是三叉神经、面神经。
The trigeminal and the facial nerves can be seen.
▼下图示 进入三叉神经周围区的切口
▼进入三叉神经周围区的切口位于三叉神经和面神经之间。
The peritrigeminal zone incision is made between the trigeminal and facial nerves.
▼可能损伤的结构包括：外展神经的脑桥内段、面神经的脑桥内段、三叉神经的脑桥内段、三叉神经脊束核、三叉神经运动核以及感觉主核、皮质脊髓束。
下图示 外展神经的脑桥内段
Structures at risk are the intrapontine segment of the abducens and facial nerves inferiorly, intrapontine segment of the trigeminal nerve superiorly, trigeminal spinal tract, trigeminal motor and main sensory nuclei posteromedially, and corticospinal tract anteromedially.
▼这是 面神经的脑桥内段，位于下方。
and facial nerves inferiorly,
▼这是 三叉神经的脑桥内段，位于上方。
intrapontine segment of the trigeminal nerve superiorly,
▼这是 三叉神经脊束核
▼这是 三叉神经运动核以及感觉主核，位于后内侧
trigeminal motor and main sensory nuclei posteromedially,
▼这是 皮质脊髓束，位于前内侧。
and corticospinal tract anteromedially.
▼下面介绍 面丘上下区。
对于脑桥背侧部的病变，需首先暴露第四脑室底。
The surgical target area for dorsal pontine lesions is the floor of the fourth ventricle.
▼枕下正中入路可用于暴露第四脑室底（下图）。
The median suboccipital approach can be used to reach the floor of the 4th ventricle.
▼这一区域需保护的最重要结构为 面丘（下图）。37%的病例中，第四脑室底的面丘突起并不明显。
The most important structure to avoid in this area is the facial colliculus.37% of facial colliculi did not form a distinctive prominence in the floor.
▼面丘（下图）是 第四脑室底 的重要解剖标志。
The facial colliculus is also the most important landmark on the floor of the 4th ventricle.
▼面丘 由 外展神经核（下图绿色）及 面神经的脑桥内段（下图黄色）构成。
The facial colliculus, which is formed by the abducens nucleus and intrapontine segment of the facial nerve
▼面神经的脑桥内段起自面神经核（下图绿色），向后行至脑室底
The intrapontine segment of the facial nerve arises from the facial nucleus, courses backward to reach the floor,
▼面神经的脑桥内段 环绕 外展神经核（下图绿色），随后前行而出脑干。
curves around the abducens nucleus, and then runs forward to exit the brainstem.
▼同时可见外展神经的脑桥内段（下图黄色）起自外展神经核（下图绿色），前行而出脑干。
At the same time, seen that the intrapontine segment of the abducens nerve arises from the abducens nucleus and runs forward to exit the brainstem.
▼在脑室底，可见上凹（下图），呈三角形。
On the floor, the superior fovea has a triangle shape.
▼上凹上外侧界为小脑上脚（下图）
Its superolateral edge is formed by the superior cerebellar peduncle,
▼上凹下外侧界为 前庭区（下图）
its inferolateral edge formed by the vestibular area,
▼上凹内侧界为 界沟（下图）。
and its medial base formed by the sulcus limitans.
▼上凹（下图绿色）的外侧底边可作为定位面丘的上界重要标志。这在面丘突起不明显的情况下尤为有用。
The lateral base of the superior fovea triangle is an important landmark for the upper edge of the facial colliculus in case where the prominence of the facial colliculus is not well defined.
▼另外，三叉神经运动核（下图）位于上凹三角的上外侧边的深部。
Also, the trigeminal motor nucleus is located deep to the superolateral edge of this triangle.
▼对于脑桥背侧部病变，进入脑桥的安全区位于面丘的 上方 和 下方 。
For dorsal pontine lesions, the entry zones above and below the facial colliculus, are used.
▼面丘上区的界限如下：
面丘上区上界为 上髓帆系带，其发出滑车神经（下图）；
The suprafacial approach is bordered superiorly by the frenulum veli containing the trochlear nerve,
▼面丘上区下界为 面丘
inferiorly by the facial colliculus,
▼面丘上区内侧界为 内侧纵束
medially by the medial longitudinal fasciculus,
▼面丘上区外侧界为 界沟
and laterally by the sulcus limitans,
▼界沟位于三叉神经核团、三叉神经中脑束、中央被盖束的内侧。
下图示 三叉神经核团
which is situated just medial to the trigeminal nuclei, trigeminal mesencephalic and central tegmental tracts.
▼下图示 三叉神经中脑束
▼下图示 中央被盖束
▼面丘下区的界限如下：上界为面丘；下界为舌下神经三角
The infrafacial approach is bordered by the facial colliculus superiorly, hypoglossal triangle inferiorly,
▼面丘下区 内侧界为内侧纵束；外侧界为面神经核以及疑核。
（面神经核以及疑核在同一冠状层面上）
medial longitudinal fasciculus medially, and facial nucleus together with nucleus ambiguus,which are the same coronal plane, laterally.
▼面丘下安全区的上下界之间的距离，相当于第四脑室外侧隐窝（下图）上下界之间的距离。
The rostrocaudal length of the infrafacial entry zone is the same as the distance between the upper and lower borders of the lateral recess.
▼下面介绍 延髓腹侧 安全区（前外侧沟、橄榄后沟）。
The surgical target area for ventral medullary lesions has been shown here.
▼远外侧入路可暴露前外侧沟、橄榄后沟。
下图示 前外侧沟
The far lateral approach is used to reach the anterolateral and postolivary sulci.
▼下图示 橄榄后沟
▼下图示 舌下神经根丝 与 C1颈神经前根
hypoglossal nerve and rootlets of the C1
▼进入该部位安全区的纵切口可沿着舌下神经根丝 与C1颈神经前根 之间的前外侧沟（下图），或可沿着橄榄后沟（下图）。
The longitudinal incisions are made between hypoglossal nerve and rootlets of the C1 in the anterolateral sulcus, or in the postolivary sulcus.
▼经前外侧沟进入延髓需注意的重要结构为皮质脊髓束。
The critical structure in the approach through the anterolateral sulcus is the corticospinal tract.
▼术者需重视 疑核（下图），尤其当疑核沿橄榄后沟进入延髓时。
The nucleus ambiguus must be taken into account when entering through the
▼这是 橄榄后沟
▼延髓背侧的安全区包括 后正中沟、后中间沟、后外侧沟。
枕下正中入路可用于这些区域的暴露。
下图示 后正中沟
The dorsal medullary sulci including the posterior median, intermediate and lateral sulci, are proposed as safe entry zones.The median suboccipital approach can be used to reach these sulci.
▼这是 后中间沟
▼这是 后外侧沟
脑干相关入路
Approaches to the Brainstem
▼下面由Rhoton教授讲解 脑干相关入路。
请问各位，若要暴露大脑脚外侧（下图），应该用什么入路呢？
We'll start to think about that, if you're gonna expose that area, what approach are you going to use? We're on the lateral side of the peduncle, and you wanna expose this area. What approach are you going to use?Anyone?You'll use...how about subtemporal approach?
▼我们可以使用 颞下入路 到达大脑脚外侧
▼那么，假如我们需要经颞下并进一步向下暴露至三叉神经下方区域，我们将用到 Kawase入路（岩前入路）（详见《颞骨解剖(中颅窝部分)---Rhoton解剖视频学习笔记系列》）。
Now, what if you wanna take that subtemporal approach and extend it downward to the area below the trigeminal nerve, what do you call that approach? That will be a... a Kawase's anterior petrosectomy approach.
▼因此，Kawase's 入路（下图）可从三叉神经下方暴露至脑干的前外侧。
So that, a Kawase's approach will deliver you down below the trigeminal nerve, to the anterolateral brainstem.
▼如果你要暴露脚间窝（下图），或者基底动脉分叉部以下，这种沿着中线向下的入路正是经海绵窦入路（详见《海绵窦解剖---Rhoton解剖视频学习笔记系列》）。
Now, if you want to expose the interpeduncular fossa, or below basilar bifurcation,coming down the midline and the approach is one that we'll deal with tomorrow that we call transcavernous approach.
▼该入路可从前方通过眶颧开颅一直暴露至脚间窝（详见《眶颧入路---Rhoton解剖视频学习笔记系列》）。
But it delivers you from the front through a OZ crainiotomy down to the interpeduncular fossa.
▼如果你要暴露范围从三叉神经下界至舌咽神经，以面听神经为术野中心的入路 是 经迷路入路，或迷路后入路（详见《颞骨解剖(乳突部分)---Rhoton解剖视频学习笔记系列》）。
Now, what approach have we looked at today that exposes the area from the lower edge of the trigeminal nerve down to IX and has VII and VIII in the center?What are you going to call that approach? Anyone?We've looked at it already. That's what approach? Translabyrinthine approach, or retrolabyrinthine.
▼假如需向内侧扩展， 这种靠近中线，沿着斜坡，紧邻外展神经的入路，即为经耳蜗入路。 （详见《颞骨解剖(乳突部分)---Rhoton解剖视频学习笔记系列》）
And if you wanna extend it medially, then what do we call that approach up to the midline, along the clivus, adjacent to 6th nerve, that's...transcochlear approach.
▼在这些入路的基础上，将经迷路入路或迷路后入路沿着脑干外侧向天幕上方扩展，即所谓的幕上-下联合的乙状窦前入路。 （详见《颞骨解剖(乳突部分)---Rhoton解剖视频学习笔记系列》）
And then if you wanna take these approaches...a translabyrinthine or retrolabyrinthine,and extend it along the lateral brainstem, above the tentorium, that's a combined supra-infratentorial presigmoid approach.
▼因此，你可仅仅做迷路后入路和经迷路入路，或者当你需要进一步向内侧扩展时，你可以经耳蜗入路并进一步做幕上-下联合的乙状窦前入路。
And you can do a retrolabyrinthine, translabyrinthine. Or if you want to extend it medially,then you can do a transcochlear combined supra-infratentorial presigmoid approach.
▼接下来是后颅窝入路中的“主力”，正如之前介绍过的，各位可以看到从上方的滑车神经、三叉神经，向下暴露至面听神经、舌咽、迷走、副神经，甚至可暴露至舌下神经。
Now the workhorse of the posterior fossa we talked about initially and you can see IV, V, it gets you below VII and VIII, to IX, X, XI, and you even have access to XII, in retrosigmoid approach.
▼这些全可由乙状窦后入路来完成。（详见《颞骨解剖(后颅窝部分)与桥小脑角区---Rhoton解剖视频学习笔记系列》）
▼因此这一入路对后颅窝的暴露范围可见一斑。
So it's really the workhouse approach of posterior fossa.
▼现在我们看的四叠体区域，以及松果体区域我们可以分别通过幕上或幕下入路来暴露。 （详见《幕上解剖(1)---Rhoton解剖视频学习笔记系列》）
Now, for this area, this'll be part of the focus tomorrow. But,you can come to collicular plate area,pineal,either supra- or infratentorial approach from the back.
▼而对于暴露第四脑室的入路，我们可以使用 膜帆入路。
（详见《幕下解剖---Rhoton解剖视频学习笔记系列》）
And if you wanna access 4th ventricle, we call it... telovelar approach.
▼因此，这些就是我们常用的后方入路。
And, so these are the approaches that we often use from the back side.
▼可暴露至延髓外侧以及枕骨大孔的入路，是 远外侧入路。
（详见《远外侧入路与颈静脉孔区解剖---Rhoton解剖视频学习笔记系列》）
And we've talked about this approach which is to lateral medulla, foramen magnum, far lateral approach.
▼我们还可以使用经口入路 暴露下图区域。
（详见《头颈部解剖---Rhoton解剖视频学习笔记系列》）
We can also come transoral. And today, some of the endoscopic approaches,
▼近年来，内镜技术的开展，使得所示的这些区域都可以通过内镜下入路来暴露。
内镜下入路的最大优势在于，它们可直接将术野聚焦到位于颅神经之间的区域。
（详见《前颅底(2)与鼻腔解剖---Rhoton解剖视频学习笔记系列》）
here's the areas that you can reach at times using the endoscopic approaches.One great thing about the endoscopic approaches is they deliver the operative focus to the area between the cranial nerves.
▼而上述的颞下入路、乙状窦后入路、岩前入路、经迷路入路、远外侧入路等，都是从颅神经的外侧向内侧逐步暴露的。
The subtemporal, retrosigmoid, anterior petrosectomy, translabyrinthine, far lateral, all come in on the lateral side of the cranial nerves.
▼无论如何，从外侧经由颅神经向内侧暴露的时候，颅神经损伤的的手术风险都会增加。
Anytime you go from lateral to medial, working from lateral medial to the cranial nerves,the risk of the operative approach goes up.
▼因此，内镜下经鼻入路在如今正受到越来越多的关注和应用。诚然，内镜入路仍面临着诸如脑脊液漏及伤口修补等方面的问题，但随着我们对相关解剖学研究的完善，上述并发症将得到越来越佳的控制和减少。
And so, the endoscopic transnasal approaches are gaining wider usage today for...much of this pathology.We still have problems with those, with CSF leak and closure, but still as we understand that anatomy better, we're getting better with lower complication rates with these approaches.
▼接下来，就让我们戴上3D眼镜，一览上述各种入路。
首先是颞下入路。
So, let's just take a quick look at each of them in 3D. Here's subtemporal approach.
▼这是左侧。箭头示 后方的枕部
We're on the left side, occipital back here,
▼我们抬起颞叶（下图）， 暴露至大脑脚外侧 。
and here we work under the temporal lobe, and we get...it delivers us down to the side of the peduncle
▼这是 大脑脚
▼这是 中脑脑桥交界处。
at the midbrain-pons junction.
▼这是 滑车神经
▼这是 动眼神经
▼若想略微多获得一些向下的暴露空间，我们可以切开并分离小脑幕
And we can get a little bit lower if we divide the tent here
▼小脑幕切口须位于滑车神经进入天幕处的后方
这样一来，我们可以探查到三叉神经（下图）的一小部分。
behind where the 4th nerve enters the tent,and that will get us down to where we often see a little bit of the trigeminal nerve.
▼通过这个入路，我们可以暴露到大脑脚外侧面（下图），动眼神经和滑车神经之间的区域
But it gives us this lateral side of the peduncle here between III and IV,
▼这是大脑后动脉、动眼神经、滑车神经
posterior cerebral (artery).
▼若想将该入路进一步向下扩展，我们可使用Kawase's 入路。
（详见《颞骨解剖(中颅窝部分)---Rhoton解剖视频学习笔记系列》）
Now if we want to extend that approach downward we can use the Kawase's approach.
▼这一入路需经中颅底，在我们进行前岩骨切除术的时候，我们需保护耳蜗（下图）以保留听力。
we say that it comes through the floor of midline fossa, and what sits in this area,that we always want to preserve?We wanna do our anterior petrosectomy while preserving hearing and the cochlea.
▼在中颅底，我们可以选择打开内听道（下图）
So that, we can go to the internal acoustic meatus,
▼或者选择从三叉神经的下方磨除岩尖
or we can drill out the petrous apex under the trigeminal nerve
▼向下暴露至斜坡侧方，沿着岩下窦，并可见外展神经。
down to the side of the clivus, along the inferior petrosal sinus and the 6th nerve in the anterior petrosectomy approach.
▼这就是岩前入路。
▼在做该入路时，我们需在内听道内侧进行操作，而不要误入内听道（下图）。
for this approach, we want to work medial to the internal acoustic meatus We don't want to enter the meatus that we've looked at.
▼我们须保护耳蜗三角（下图）
We want to preserve the cochlea angle,
▼并在岩前大神经后方磨除岩尖
and we'll work behind the greater petrosal nerve, and take out the petrous apex,
▼范围向下至斜坡，沿着岩下窦，
drill down to the side of the clivus along the inferior petrosal sinus,
▼这是 岩上窦
under the superior petrous sinus.
▼我们进一步打开颞叶硬膜，跨岩上窦切开小脑幕，向下至斜坡侧方。
We open the temporal dura, open across the superior petrous sinus and the tent,down to the side of the clivus， in the anterior petrosectomy approach.
▼我们抬起颞叶，进而显露大脑脚及中脑。
We can elevate the temporal lobe then and have access to the peduncle and midbrain.
▼随后即可在三叉神经上下进行操作，向下至脑干前方，并沿着斜坡侧方。
And then we can work above and below the trigeminal nerve, down to the front of the brainstem, and along the side of the clivus.
▼在上述入路中，我们须时刻谨记保护Labbe静脉，以及切开分离天幕时需保护滑车神经。
Always in these approaches, we want to preserve vein of Labbe, and the...what nerve...trochlear nerve when we divide the tent.
▼这个入路是最常用的暴露至基底动脉分叉部 以及 处理前外侧部脑干海绵状血管瘤的入路之一。
And, it's one of the most commonly used routes to the low basilar bifurcation to cavernomas of the anteolateral brainstem.
▼接下来我们来谈谈经海绵窦入路。
这一入路主要暴露脚间窝（下图）。
Now, transcavernous approach that delivers us to the interpeduncular fossa.
▼这是 视神经、颈内动脉。
here we're...optic nerve,carotid.
▼通常情况下，我们并不在视神经与颈内动脉之间的间隙进行操作，而是抬起颈内动脉，在颈内动脉 与 动眼神经之间的间隙、后交通动脉下方进行操作。
Usually in this area we don't work between the optic nerve and carotid, but we elevate the carotid and work between the carotid and 3rd nerve below the posterior communicating artery.
▼我们磨除前床突
And we take off the anterior clinoid,
▼随后牵开颈内动脉，在其与动眼神经之间深入。
and then we elevate the carotid and work between the carotid and the 3rd nerve.
▼动眼神经进入海绵窦顶壁之前，有一小段行于脑池中。我们可使用神经根剥离子探入并打开该动眼神经池。
And the 3rd nerve, for it enters the roof of the cavernous sinus, is in a short cistern. And we can pass a nerve hook into the cistern, and open the oculomotor cistern,
▼随后我们可通过颈内动脉与动眼神经之间的间隙暴露后床突、鞍背，
And then we can work between the carotid and 3rd nerve to expose posterior clinoid,dorsum,
▼并磨除 鞍背及后床突
and then we can drill off the dorsum and posterior clinoid,
▼进而沿中线向下显露 基底动脉、大脑后动脉P1段、至脚间窝。
这就是经海绵窦入路。
下图示 基底动脉
and it gives us this approach down the midline to the basilar,P1s,to the interpeduncular fossa using a transcavernous approach.
▼这是 大脑后动脉P1段、脚间窝
▼接下来，对于脑干的这一区域（四叠体区及松果体区），我们选择哪个入路？
Then for this part of the brainstem, the collicular plate, the pineal region,
▼我们可以选择幕上或幕下入路。
（详见《幕上解剖(1)---Rhoton解剖视频学习笔记系列》）
we can come in ether above or under the tentorium. And...
▼当选择幕下沿着小脑蚓尖部（下图）上方分离时，这种正中入路将很难牵开足够的脑组织。
if we come in under the tent over the apex of the vermis, it's very difficult to retract enough in the midline in a median approach.
▼这种正中入路将很难牵开足够的脑组织以从上往下暴露至上丘、下丘、滑车神经。
to get down from the superior to the inferior colliculus to the 4th nerve.
▼这里展示的就是这一位于正中的、幕下的、沿小脑蚓尖部上方的入路。
下图示 小脑幕
But this is the median approach, under the tent,over the apex of the vermis.
▼我们可以看到松果体、大脑内静脉
We can see pineal, internal cerebral (vein),
▼这是 基底静脉、上丘
但经此幕下正中入路我们无法暴露下丘及滑车神经。
basal vein, superior (colliculus),but we can't get down to the inferior colliculus or the 4th nerve coming in the median infratentorial.
▼但倘若我们从旁正中进入，避开小脑蚓尖部（下图），即可显露上丘及下丘。
But if we move off paramedian, off the apex of the vermis, then we can get in to superior, inferior colliculus.
▼这是 上丘，下丘
▼这是 滑车神经
We can see the 4th nerve here, below the inferior colliculus.
▼滑车神经 位于 下丘 下方。
▼我们可探及小脑上动脉（下图）
▼这是 大脑后动脉。
posterior cerebral artery.
▼我们甚至可一直暴露到大脑脚及大脑脚池。
We can even work all the way to thepeduncle here and the area of the crural cistern.
▼因此，若需暴露至下丘，而你使用的又是幕下入路，那么你往往需经旁正中入路避开小脑蚓尖部。
But usually to get down to the inferior colliculus, if you're coming in below the tent,you need to come in paramedian off of the apex of the vermis.
▼你也可选择枕部经天幕入路。
在人字缝下方通常不会遇到桥静脉。
You can also come in occipital transtentorial,so that there usually no bridging veins here below the lambdoid suture.
▼从而，你可以通过牵开枕叶（下图）深入
And, you can get in...retract the occipital lobe,
▼暴露松果体、大脑镰后部
expose pineal, posterior falx, tent.
▼随后贴着直窦（下图）切开小脑幕
You can divide the tent adjacent to straight sinus,
▼即可深入至松果体，上丘、下丘、顶盖部。
have access to the pineal, and you also get access to superior and inferior colliculus, and tectal plate.
▼这些就是通向中脑后方的入路。
同时你也可暴露至 胼胝体后部（下图），同样可由这一枕部经天幕入路实现。
So these are approaches to the posterior part of midbrain. And you have access also to posterior corpus callosum coming in occipital transtentorial.
▼接下来，我们继续向下，讨论位于中线的入路： 膜帆入路
（详见《幕下解剖---Rhoton解剖视频学习笔记系列》）
Now we move down in the midline telovelar approach
▼膜帆入路中，我们将小脑扁桃体（下图）从 蚓垂（下图）处牵开。
And telovelar approach we've talked about... we retract the tonsil away from the uvula.
▼这是 蚓垂
▼可见脉络膜（下图），位于下髓帆的下方。
You see the tela below the inferior medullary velum.
▼这是 下髓帆
▼下髓帆起源于蚓垂（下图）前方的小结，一直延伸至绒球（下图）。
The velum stretches from the nodule on the front of the uvula, over to the flocculus.
▼切开脉络膜，即可一直向上暴露至中脑导水管（下图）。
You open the tela, you have access all the way up to the aqueduct.
▼切开下髓帆（下图），则可进一步暴露至上外侧隐窝。
You open the velum, you have access to superolateral recess.
▼这是小脑上脚（下图），其纤维从齿状核发出，包绕扁桃体上极，向上至红核。
Here's the superior peduncle passing from the dentate that wraps around the superior pole of the tonsil, and is passing up toward the red nucleus.
▼因此，松解脉络膜即可暴露四脑室底的大部（下图）并露出下髓帆。
而继续打开下髓帆即可暴露至上外侧隐窝（见上述）。
But dividing the tela gives you access to most of the floor and accessing the velum, and opening it gives you access to the superolateral recess.
▼因此，膜帆入路可以避免经小脑蚓入路引起的缄默综合征。尽管缄默综合征在年轻患者中多为一过性。
So that, rather than dividing the vermis which can cause a mutism syndrome, in young people it's usually transient,
▼我们可将小脑扁桃体（下图） 从蚓垂侧方牵开。
we retract the tonsils away from the side of the uvula.
▼ 这是 蚓垂
▼我们在Magendie孔上方切开脉络膜（下图），暴露四脑室底（下图）
We open the tela above Magendie to access the floor of the 4th.
▼ 这是 第四脑室底
▼我们继续打开下髓帆（下图），暴露上外侧隐窝。
We open the velum to access the superolateral recess.
▼这是 上外侧隐窝
▼有的病变可经 外侧隐窝 向外 蔓延。
And then if the pathology extends out of the lateral recess.
▼这是 外侧隐窝
▼外侧隐窝的下半部分，由脉络膜 及 下髓帆构成。
下图示 脉络膜
Its roof, below the lower half of the roof of the lateral recess, is formed by tela and velum.
▼这是 下髓帆
▼我们可以看到 蜗内侧核（下图），其为听觉脑干植入所在部位，位于侧隐窝内。
We see the dorsal cochlear nucleus, the site of the auditory brainstem implant,in the lateral recess.
▼因此，为暴露侧隐窝，我们抬起扁桃体（下图）
So to access the lateral recess, we elevate the tonsil,
▼可见脉络膜（下图），延伸于Magendie孔及Luschka孔下界之间。
we see the tela lining the lower margin between Magendie and Luschka.
▼这是 Magendie孔（正中孔），Luschka孔（侧孔）。
▼切开脉络膜。即可暴露至 侧隐窝（下图）。
We open the tela, and we have access to the lateral recess.
▼因此，通过膜帆入路，可到达第四脑室内所有这些结构。
我们可以暴露第四脑室底，小脑脚（下图）。
So using telovelar approach, we have access to all of the floor of the 4th, the peduncular mass, But it accesses all of these areas of the 4th ventricle.
▼我们可以暴露 上外侧隐窝（下图），并可向上暴露至 侧隐窝（下图）。
the superolateral recess, and over to the lateral recess.
▼膜帆入路，可到达 第四脑室内 所有这些结构。
▼我们再看一下，蜗背侧核（下图），听觉脑干植入所在部位。
And, here we see again, the dorsal cochlear nucleus, the site of the auditory brainstem implant,
▼这是 下髓帆，一层菲薄的膜结构。
here, the velum, a paper-thin membrane
▼下髓帆 构成 上外侧隐窝（下图）的下界。
the velum,lining the lower margin of the superolateral recess.
▼再来我们看看后颅窝入路中的“主力”：乙状窦后入路
（详见《颞骨解剖(后颅窝部分)与桥小脑角区---Rhoton解剖视频学习笔记系列》）
Now, the workhorce of this area, we've talked about is retrosigmoid approach
▼这一入路暴露范围上至三叉神经上方，向下至迷走神经下界，甚至可到枕骨大孔。
gives us access from above V along the lower margin of X down to the foramen magnum.
▼它暴露了整个桥小脑角区域（下图）
it accesses all of this area of this CP angle formed by cerebellum
▼这一区域由小脑包绕 脑桥外侧及小脑中脚形成。
下图示 脑桥
folding around the lateral pons and the middle cerebellar peduncle.
▼下图示 小脑中脚
▼因此，我们可以从上方的滑车神经及小脑上动脉向下经三叉神经，沿着内听道，
So that we can work from IV and SCA down to V along the internal acoustic meatus
▼向下至舌咽、迷走、副神经。
▼我们还可利用这一入路进入 内听道
And the approach also gives us access into the internal acoustic meatus,
▼进一步探及位于内听道底的神经。
根据需要，甚至可以磨除骨质至迷路。
the nerves at the fundus. And using the approach,we can drill further lateral and into the labyrinth.
▼另一暴露范围相对局限的桥小脑角入路，上至三叉神经上界，下至舌咽神经，根据颈静脉球的高度或许可至迷走神经，这一入路即为经迷路入路
（详见《颞骨解剖(乳突部分)---Rhoton解剖视频学习笔记系列》）
For a more localized approach to the CP angle, from usually V at the upper edge, IX at the lower edge, maybe you see X, depending on the height of the jugular bulb, we can use a translabyrinthine approach,
▼若要继续向内侧扩展，则可磨除岩尖的耳蜗。
and we can extend that medially with drilling out the cochlea in the petrous apex.
▼因此，我们从乳突开始，
So that, we work through the mastoid.
▼找到浅层的鼓室窦，
We find the mastoid antrum superficial
▼下方即为迷路。
我们可经迷路后打开硬膜，以保护听力。
to the labyrinth.We can open the dura retrolabyrinth, and save hearing.
▼或者我们可磨除部分迷路行部分迷路切除术，
Or we can drill out the labyrinth, we can do a partial labyrinthectomy,
▼倘若磨除的是上半规管和后半规管。这仍有一定的机会保留听力。
with some chance of preserving hearing in which we drill the superior and posterior canal.
▼但是，若需进入内听道（下图）以处理侵犯内听道的病变时，我们不得不牺牲听力，磨除整个迷路，以暴露至内听道。
But if we need to get into the internal acoustic meatus, for pathology that extends into the meatus, we have to sacrifice hearing and drill out the labyrinth, to get into the internal acoustic meatus.
▼因此，如果病变位于内听道口内侧的桥小脑区，我们仅需打开乙状窦前硬膜（下图），保留迷路，即行迷路后入路。
If the pathology is medial to the porus in the CP angle, we can just open the presigmoid dura,preserve the labyrinth, and do a retrolabyrinthine exposure.
▼如果我们想继续暴露内侧，我们需游离面神经（下图），磨除耳蜗（下图），
And if we need to get medial then, we can work around the facial nerve,drill out the cochlea,
▼通过这经耳蜗入路，
in a transcochlear approach
▼我们可穿过岩尖，
that delivers us through the petrous apex,
▼直至脑桥前方，
down to the front of the pons,
▼沿着斜坡边缘及岩下窦，
along the edge of the clivus and the inferior petrosal sinus,
▼至基底动脉侧方。
to the side of the basilar artery.
▼如果我们又需要在上述暴露范围的基础上，进一步暴露脑干侧方，那么我们需要做一个幕上-下联合的乙状窦前入路。
其中，我们可选择迷路后入路或经迷路入路，
And then if we need to combine exposure of this area, with exposure along the lateral brainstem,then we can do a combined supra-infratentorial presigmoid approach.We can do that retrolabyrinth,translabyrinth,
▼或者为了向更内侧暴露磨除耳蜗。
or we can extend it medial drilling out the cochlea.
▼这就是幕上-下联合的乙状窦前入路。
这是迷路（下图）。
So, this is the combined supra-infratentorial presigmoid approach.Here we have the labyrinth.
▼我们分别切开颞叶硬膜 及 乙状窦前硬膜
下图示 颞叶硬膜 切开线
we open the temporal dura, open presigmoid,
▼下图示 乙状窦前硬膜 切开线
▼对后颅窝进行暴露。
and, the exposure of the posterior fossa.
▼我们切开小脑幕，并保护滑车神经，
We divide the tent, preserving IV,
▼时刻注意保护Labbe静脉。
an important consideration always is Labbe.
▼若病变在更内侧，沿着斜坡生长，我们可将面神经（下图）向后移位，
And then if the pathology is further medial, along the clivus,we can move the facial nerve backwards,
▼磨除岩尖
and work through the petrous apex
▼通过这一经耳蜗入路，我们可深入到斜坡侧方，及外展神经。
in a transcochlear approach that delivers us down to the side of the clivus along the 6th nerve.
▼我们切开小脑幕（下图），保护滑车神经（下图），从而完成幕上-下联合的乙状窦前入路。
且这例使用的是经耳蜗入路。
We divide the tent, preserving IV, in a combined supra-infratentorial presigmoid approach,and in this case, the transcochlear variant.
▼对于下脑干区域，我们可以使用经口入路。
如今这些入路已基本被经鼻内镜下入路所替代。
You can come to lower brainstem through transoral approach.today most of these approaches are being...many of them are being converted to transnasal endoscopic,
▼软腭（下图）遮挡于此处，因此对于枕骨大孔上方的暴露较有限。
The soft palate hides this area, so it really is difficult to get much above the edge of the foramen magnum,
▼这是 枕骨大孔
▼但可暴露至 寰椎、齿状突。
but it gives you C1, the odontoid.
▼这是 悬雍垂
▼我们可以看到 颈长肌
here we see longus colli,
▼这是 头长肌。
▼分离悬雍垂可暴露至下斜坡、寰椎前弓。
下图示 下斜坡
Dividing the uvula gives you access to lower clivus, anterior arch of C1.
▼下图示 寰椎前弓。
▼经口入路可暴露至部分下部脑干。
然而，如今这些入路已逐渐被经鼻内镜入路所取代。
And you can access some of the lower brainstem transoral. But, today many of these approaches are being converted to transnasal endoscopic approaches.
▼再来看看 远外侧入路。
（详见《远外侧入路与颈静脉孔区解剖---Rhoton解剖视频学习笔记系列》）
Here's just a far lateral approach.
▼这是 枕下三角（下图）
we work through the suboccipital triangles.
▼我们翻开枕下三角肌肉。
We reflect the muscles of the suboccipital triangle.
▼这里看到的就是远外侧入路的暴露范围（下图右侧）。与乙状窦后入路相比，其暴露更广，
但枕髁（下图）仍然阻挡对于斜坡及脑干前方的暴露。
And here's just the far lateral exposure. It's better than just retrosigmoid,but still the condyles can give a significant obstruction to the view of the clivus and the front of the brainstem.
▼但是，如果进一步磨除枕髁，则可将硬膜（下图左侧为磨除枕髁后）向更外侧翻开，从而暴露脑干前方或下斜坡。
But with the... if you drill out the condyle here,you can pull this dura further lateral for access to the front of the brainstem or to the lower clivus
▼下图示 下斜坡
▼因此，联合经髁扩展（下图）后，我们可以暴露到下斜坡，处理这个部位的病变，
and, you can drill out, then, transcondylar,and get access to the lower clivus,for lesions involving lower clivus,
▼或者跨过延髓腹侧，至对侧椎动脉。
or extending across in front of the medulla to the contralateral vertebral artery.
▼下面介绍 内镜下脑干入路。
当今的内镜技术，可使我们一直从前颅窝沿着脑干前方一直向下至枕骨大孔区，
（详见《前颅底(2)与鼻腔解剖---Rhoton解剖视频学习笔记系列》）
And then, what can you see with the endoscopic approaches? Well, the endoscopic approaches today are being used to give us access from anterior fossa down along the front of the brainstem, down to the area of foramen magnum,
▼而且其具有直接在颅神经的内侧（下图）到达上述部位的优点，而这正是上述各种侧方入路所不具有的。
and they have the advantage of coming in medial to this line of cranial nerves that you have to work across coming from lateral.
▼斜坡分为上、中、下三部分。
So, just a quick look at the clivus which we divide into upper, middle and lower parts.
▼当我们从正面观察斜坡。我们可将入路集中在下、中斜坡，或者经过上斜坡、蝶窦来暴露海绵窦区域。
And, as we look at the clivus, well... you can do very focal approaches to the lower, middle or through the upper part of the clivus and sphenoid sinus to the area of the cavernous sinus.
▼利用下斜坡，我们可显露舌下神经管、颈静脉孔内界。
But, lower clivus, you can access hypoglossal canal, medial edge of jugular foramen.
▼利用中斜坡，可显露面听神经、基底动脉。
Mid clivus gives you access to VII and VIII,basilar artery.
▼利用上斜坡或者经蝶窦后壁，则可显露海绵窦内侧部。
And then through upper clivus or sphenoid...through this back wall of the sphenoid sinus, you have access to medial part of cavernous sinus.
▼首先来看 下斜坡
▼这是 寰枕关节髁
Here's atlanto-occipital condyle,
▼这是 舌下神经管、颈静脉孔
hypoglossal canal, here, jugular foramen,
▼我们磨除这里的舌下神经管，可见舌咽、迷走、副神经。
Here, the hypoglossal canal has been drilled out. We see IX, X, XI.
▼随后我们可进行另一侧的操作，这是 舌咽、迷走、副神经
Then we can...you can work to the other side, IX, X, XI,
▼舌下神经走形于舌下神经管。
12th nerve coming through hypoglossal canal.
▼这里显露的是右侧 舌下神经管及舌咽、迷走、副神经，
You can...here we just see hypoglossal canal, IX, X, XI,
▼这是左侧的。
▼我们再来看看上斜坡，
上斜坡位于蝶窦后壁（下图）后方。
here we go up to the upper third of clivus that sits in the posterior wall of sphenoid sinus.
▼在这个区域，我们可以暴露颈内动脉海绵窦段、垂体，
working through this area, you have access to cavernous carotid,pituitary,
▼这是 海绵窦内侧壁。
and here the medial wall of the cavernous sinus.
▼这是右侧的海绵窦，可见 动眼神经
Here we see right cavernous sinus, III,
▼这是 外展神经
▼这是 三叉神经上颌支
▼这是 三叉神经眼支
▼同时我们可经该区域暴露左侧的海绵窦
这是 颈内动脉海绵窦段、眼动脉。
And then you can look through this area to the other cavernous sinus, looking over the cavernous carotid,ophthalmic artery.
▼而磨除上斜坡后壁，则可显露乳头体、基底动脉尖
And, when you remove that posterior wall of upper clivus, you have access to mamillary bodies,basilar apex,
▼这是 后交通动脉
▼这是 大脑后动脉P1段、P2段
▼我们再来看看中斜坡
▼磨除中斜坡后可暴露 基底动脉中段
when we drill it off, you have access to mid basilar artery,
▼这是 脑桥。
▼此处是翼管内保留的翼管神经。
Here you see the vidian nerves preserved in the vidian canal.
▼这就是上斜坡、中斜坡、下斜坡
You see upper, mid,lower clivus in these very focal approaches
▼我们可通过这些局限的径路，来显露整个斜坡及前颅窝。
并都在颅神经的内侧进行操作，从而避免了侧方入路中神经损伤的风险。
that pass through the clivus and anterior fossa along the medial side of the cranial nerves.They don't put the nerves at risk from coming from lateral to medial.
▼这是内镜下经蝶鞍所见的术野。
从蝶骨平台一直到枕骨大孔都可完整暴露，甚至可到齿状突。
But, here's just the endoscopic view of the area from sella. You can along a planum all the way down to foramen magnum.You can get to odontoid.
▼这里是海绵窦前内侧部
But we see anteromedial cavernous sinus,
▼这是外展神经，穿过硬膜进入海绵窦。
6th nerve passing through the dura, entering the cavernous sinus,
▼这是 面听神经、舌咽、迷走、副神经，舌下神经。
这些入路都是直达上述颅神经的内侧。
VII and VIII,IX, X, XI,XII,through these approaches that come in medial to the line of cranial nerves.
▼这里显示的是磨除一侧岩尖。我们可以在三叉神经下方进行操作，
Here we've drilled off to one side, here the petrous apex.And we work below the trigeminal nerve,
▼这里可以看到一些岩上静脉。这些静脉位于脑桥的前方。
We see some of the superior petrosal veins. This vein coming off of the pons,
▼这是 面听神经
VII and VIII from the front side.
▼试想一下，从这么小的入路进行面神经微血管减压术，或者三叉神经微血管减压术，是否可行？我想这在将来也许可行。
Just think about a focal approach to this area for a decompression of the facial nerve right here, or microvascular decompression of the trigeminal nerve. Is that going to happen by this route? I think someday it probably will,
▼因此，对于前方中线部位的暴露，这些内镜下入路确实可直达上述各个侧方入路的内侧，从而避免损伤颅神经。
So that, for coming in along the midline in front, we do have an approach that will deliver us medial to these lateral approaches that cross the cranial nerves.
关于上述各手术入路的更多细节，请点击下方链接扩展阅读！
For more details about these approaches, please see the other lectures in the Rhoton collection.
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