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1 分类号 U D C 密级编号南方医科大学硕士学位论文联合高颈位入路改良颈静脉孔区手术入路的显微解剖研究 Microsurgical anatomy of the combined high cervical approach for improvement of operative approach at the jugular foramen 侯文仲指导教师姓名姜晓丹教授王向宇教授单位名称及地址南方医科大学广州同和 (510515) 专业名称神经外科学论文提交日期 2008 年 3 月 20 日论文答辩日期 2008 年 6 月 5 日学位授予单位和日期南方医科大学 2008 年 6 月答辩委员会主席陈善成教授论文评阅人陆永建教授张世忠教授 2008 年 6 月 5 日

3 南方医科大学 2005 级硕士学位论文联合高颈位入路改良颈静脉孔区手术入路的显微解剖研究 Microsurgical anatomy of the combined high cervical approach for improvement of operative approach at the jugular foramen 课题来源 : 国家自然科学基金 ( ); 粤科基办 (2004)08 (2007) 05/ ; 粤财企 ( 2003 ) 209 ; 广东省科学研究基金 (A ); 专业名称学位申请人指导教师答辩委员会主席答辩委员会成员神经外科侯文仲姜晓丹教授王向宇教授陈善成教授陆永建教授全伟教授张世忠教授段传志教授论文评阅人陆永建教授张世忠教授 2008 年 05 月 1 日广州

5 硕士学位论文联合高颈位入路改良颈静脉孔区手术入路的显微解剖研究硕士研究生 : 侯文仲指导老师 : 姜晓丹教授王向宇教授摘要颈静脉孔 (jugular foramen,jf) 是由颞骨岩部和枕骨侧部围成, 是后颅窝的重要的骨性通道处理发生于该区域病变的最佳治疗措施为手术切除随着影像学和显微外科技术的发展, 诊断并手术切除该区域的病变已成为可能然而 JF 区的手术难度极大, 主要原因是其位置深在, 安全到达该区域的手术通路被周围组织结构深埋, 而且其自身解剖结构及穿行其内的神经血管的解剖学关系复杂正确认识 JF 的解剖学结构特点对手术有极其重要的指导意义手术治疗 JF 区肿瘤有两个必要条件 : 1 详细了解 JF 的解剖结构 ;2 选择一种合适的手术入路本研究主要研究目的在于联合目前已成型的多种 JF 手术入路, 对 JF 进行显微解剖学研究, 并在此基础之上对该部位入路实施改良, 探讨一种新的可一期切除 JF 区肿瘤的手术入路第一部分联合高颈位入路改良 JF 区手术入路的显微解剖学研究目的研究一期切除复杂 JF 肿瘤的手术入路方法解剖 20 例 (40 侧 ) 经福尔马林固定的成人头颅标本, 通过联合经乳突迷路后和迷路下经颈远外侧颈下经髁经结节入路以及高颈位入路等多种 JF 区手术入路实施解剖, 手术显微镜下观察 JF 相关的解剖学特点具体步骤 :1 自耳后上缘约 2-3cm 起做 C 型皮肤切口, 向后下延伸直至颈部, 止于下颌角下胸锁乳突肌 (sternocleidomastoid,scm) 的前缘 ;2 后外侧颈部肌肉分为 I

6 中文摘要浅中深三层逐层解剖, 暴露枕下三角及其内结构 ;3 识别位于 SCM 下方的副神经 (XIth cranial nerve CN XI), 沿着神经可达进入颈动脉鞘 (carotid sheath, CS) 的入口向后牵引 SCM, 向下牵拉二腹肌后腹, 在颈动脉的分叉部至下颌角之间的区域, 打开 CS;4 磨除乳突表面骨质, 轮廓化面神经管, 使用咬骨钳切除外侧枕下的颅骨颅骨切除的范围为 : 向内侧中线延伸, 上至下项线, 下至枕骨大孔 (foramen magnum,fm) 后缘, 向外一直至枕髁磨除后内侧三分之一枕髁, 进一步的磨除骨质可以暴露位于枕髁与颈静脉结节 (jugular tubercle,jt) 间的舌下神经管 (hypoglossal canal,hc) 要尽可能全部磨除 JT 以便充分开放 JF 后壁至此完成从上下后外多个角度对 JF 的暴露结果 1 颈部肌肉主要分为浅中深三层浅层主要包括 SCM 和头夹肌 ; 中层肌肉主要包括头半脊肌以及头最长肌 ; 深层肌肉主要包括头上斜肌头下斜肌以及头后大直肌, 此三块肌肉围成枕下三角向后牵拉浅层肌肉以及中层肌肉有利于更好地暴露枕下三角和茎突隔膜枕动脉走行于二腹肌后腹深面 2 JF 周边重要的解剖学标记主要有颧弓根 Henle 嵴 ( 即骨性外耳道的后上缘处骨嵴 ) 乳突尖星点颈静脉突(jugular process,jp) 寰椎横突(transverse process of atlas,tpa) 枕髁鼓乳切迹茎乳孔二腹肌嵴等乳突三角由颧弓跟后点乳突尖以及星点围成, 以此三角为标记磨除乳突颧弓根后缘 - 星点 :38.67 ±2.00mm; 乳突尖 - 星点 46.50±2.62mm; 星点 -Henle 嵴 26.62±1.64mm 鼓乳突切迹可被近似地视为 CN VII 的体表投影, 茎乳孔即为 CN VII 出颅处, 二腹肌嵴可以作为识别 CN VII 丛茎乳孔出颅的标记 JP 构成 JF 的后壁, 充当枕髁与鳞部之间的桥梁, 同时可见头外侧直肌附着其上星点被被定义为人字缝顶乳突缝枕乳突缝的交点, 本研究发现星点与横窦关系密切, 有 90%(36 侧 ) 的标本可见星点位于横窦 - 乙状窦 (sigmoid sinus,ss) 交界部 TPA 在高颈位手术入路是一个可靠的解剖学标记, 在第三部分中有详细阐述 3 舌咽神经 (IXth cranial nerve CN IX) 迷走神经(Xth cranial nerve CN X) 和 CN XI 共同行于 JF,C2 神经在硬脊膜外有一较大的神经节, 由神经节发出较大的内侧支和较小的外侧支 CN VII 的主干在二腹肌前自 JF 外侧约 5mm 处的茎乳孔出颅后, 在茎突的后外侧面向外向前进入腮腺, 随即分为 5 支, 水平段 CN VII 长度 :12.67±2.36mm; 垂直段长度为 15.03±1.83mm; 茎乳孔 - 腮腺边缘的 II

7 硕士学位论文距离为 17.00±1.83mm 枕小神经多来源于外侧支, 枕大神经多来源于内侧支 4 CS 内有颈总动脉 ICA 颈外动脉, 颈内静脉 (internal jugular vein,ijv) 及 CN X 结论本研究所描述的这组入路联合了经乳突迷路后迷路下经颈静脉远外侧颈下经髁经结节入路以及高颈位入路, 可以同时充分地从 JF 的上方 ( 迷路下 ) 经 JF JF 下方乙状窦后以及经髁等多个角度暴露 JF, 可以比较容易地一期全切位于颅内颅外的涉及 JF FM 以及高颈位的肿瘤, 同时还可以有效减少甚至避免 CN VII 损伤及其他术后并发症的发生第二部分 JF 的显微解剖学研究目的研究 JF 及其内穿行组织的显微解剖学结构, 为该区域的手术入路及颅神经的保护提供解剖学基础方法同第一部分结果 1 在颅内侧, 硬脑膜分隔将 JF 分为三个部分, 即前内侧的岩部后外侧的乙状部以及岩部及乙状部之间的颈内部覆盖于颈内部的硬膜有两个孔, 一个为 CN IX 通道, 内有 CN IX 穿行 ; 另一个为 CN X 通道, 内有 CN X 和 CN XI 穿行两个通道之间为一硬膜分隔分开 ;2 在颅内侧 CN IX CN X 进入硬膜通道后,CN IX 立即转向下行并沿着蜗导水管下方的颈静脉内骨嵴的内侧走行在 JF 内,CN IX 有两个神经节, 上神经节没有分支且难以看到,CN IX 的下神经节位于大约在上神经节下方约 2mm, 并位于颈静脉外口上方下神经节向上发出 Jacobson 神经并在鼓室小管前内侧方形成度折角, 随后发出岩浅小神经, 岩浅小神经和副交感神经一同分布于腮腺下神经节还发出分支联系 CN X 的上神经节 CN IX 的颈动脉支 ( 即 Hering 神经 ) 的纤维接受来自颈动脉窦的纤维 CN IX 在 ICA 和 IJV 之间穿出 JF 之后, 向前跨过 ICA 的外表面, 随即分为数个终末支在 CN IX 出 JF 处, 它被一些致密的纤维结缔组织与 ICA 紧紧拴在一起 CN X 有多个神经根, 它和 CN XI 一起进入 CN X 通道, 并在进入 JF 后, 同 CN IX 一样转向下方在 JF 内, 它膨大为上神经节, 在此处它发出神经纤维至 CN IX, 并接受来自 CN XI 的纤维 Arnold 神经也从上神 III

8 中文摘要经节发出, 该神经分支向外走行至乳突小管, 并向前至 IJV 在 JF 内,CN X 沿着颞骨颈静脉内突内侧走行并延续为上神经节 CN X 与 CN XI 神经一起在 IX 神经的后方穿出 JF 在 HC 水平,CN X 与 XI 神经分开就在 JF 下方,CN X 扩大形成下神经节, 从此节发出至 CN IX 的分支后,CN X 在 CS 内下行 CN XI 由颅神经根和脊髓神经根构成, 颅根与脊髓根或分或合进入 X 神经通道在 JF 内,XI 神经与 X 神经粘连不易区分 ; 穿出 JF 后,CN XI 与 X 神经一起在 IJV 的外侧壁与二腹肌后腹之间向后走行, 随后进入颈后三角 ;3 SS 是 JF 的引流静脉,SS 在乙状窦沟内垂直下行后转向前入 JF 在枕乳缝水平,SS 在岩骨下方走向前到达颈静脉球 (jugular bulb,jb) 血流在颞骨鼓部后方下行汇入 IJV 海绵窦与基底静脉丛通过岩下窦 (inferior petrosal sinus,ips) 与 JB 相连基底静脉丛沿着岩斜裂走行, 接受来自岩斜下静脉及岩骨内静脉的引流 IPS 不会直接汇入 JB, 相反地, 它在 JF 岩部收集多条静脉回流的血流, 同时接受来自椎静脉丛舌下静脉丛以及髁导静脉的回流的血液, 随后 CN IX 与 CN X 之间汇入 JB;4 在 ICA 进入颈动脉管时, 颈动脉嵴在其后方将之与 IJV 隔开 ICA 与 IJV 均被致密结缔组织包绕, 这些结缔组织多来源于形成 CS 颈静脉窝骨外膜颈动脉管骨内膜的筋膜结缔组织鼓室下动脉与 Jacobson 神经伴行进入颈动脉嵴在颅底, 后组颅神经走行于 IJV 的颈动脉之间, 其中 CN IX 在外侧 CN X 和 CN XI 在内侧结论将 JF 描述为岩部乙状部颈内部更有手术意义, 了解静脉窦的解剖结构, 有助于术中对静脉窦的保护, 通过星点可较为准确地定位横窦和 SS 交界部, 详尽的 JF 的解剖学研究可提高本区域手术成功率, 有助于保护颅神经, 减少不必要的损伤第三部分 TPA 的显微解剖学研究目的明确 TPA 做为手术参考标记的临床解剖学意义方法解剖并暴露 20 例 (40 侧 ) 尸头标本的高颈部, 分离颈部皮肤和颈阔肌以暴露其下的 SCM, 从乳突分离 SCM, 从二腹肌沟分离二腹肌以暴露 TPA, 标记 TPA 作为一个参照中心, 向前后上系统解剖暴露此空间的结构在手 IV

9 硕士学位论文术显微镜的辅助下, 小心切除淋巴网状结构, 保留神经血管结构切除腮腺以及部分乳突, 行 VII 神经移位以便更好地暴露深部结构, 切除 TPA 周围的筋膜以暴露其下的肌肉结构结果使用 TPA 作为高颈位解剖的参照标记, 可见到二腹肌后腹和茎突舌骨肌位于 TPA 外侧, 枕动脉位于二腹肌后腹内侧,TPA 的上外侧切断枕动脉, 从颞骨二腹肌沟分离二腹肌后腹并向下牵拉以便进一步解剖和暴露茎突位于 TPA 的前方, 在二者之间可见 IJV CN X 和 CN XI 以及 CN XII,IJV 的前内侧有 ICA, 可见茎突附着有三块茎突肌 : 茎突舌肌的起点在前, 茎突舌肌向前下至舌后外缘, 其肌纤维与舌骨舌肌混合 ; 沿着茎突舌肌的外侧缘, 茎突舌骨肌韧带连接茎突与舌骨小角 ; 茎突舌肌后内侧为茎突咽肌, 茎突咽肌发自茎突后内侧, 在茎突咽肌后面, 可以看到 CN IX 和它唯一的运动分支离断茎突, 暴露 ICA 和后组颅神经的远端, 可在 ICA 深面见到头长肌, 其位于脊柱前面, 沿 CS 向上可至 JF 和颈动脉管切除表浅的腮腺组织, 磨除了乳突表面骨皮质, 在茎乳孔周发现 CN VII 的小肌支到达二腹肌后腹和茎突舌骨肌, 在这些肌肉的内侧, 可见耳后动脉及其茎乳支位于附近 CN IX 通过 JF 内部的内侧部分 ( 颈内部 ) 出颅 ;IJV CN X CN XI 通过外侧部 ( 静脉部 ) 出颅 ;CN XII 通过位于 JF 的前下方的 HC 出颅打磨 JF 周的颞骨, 可以暴露 JB 和后颅窝颈动脉管的开口位于 JF 的前内侧离断茎突可暴露远端的 ICA 翻转 SCM 后可暴露肩胛提肌和头夹肌, 从枕骨分离头夹肌之后可见头最长肌, 仔细从枕骨分离头最长肌, 以保护枕动脉远端, 其恰好位于此肌的下方分离头最长肌之后, 解剖 TPA 周围的脂肪组织和颈深筋膜, 以暴露深面的肌肉组织以及枕下三角, 枕下三角由头上斜肌头下斜肌和头后大直肌围成, 在此三角内, 寰椎后弓上缘可见椎动脉的硬膜外终端通过寰枕筋膜后部, 椎动脉进入 FM 结论高颈位的深部是一个解剖结构复杂的间隙, 在这个空间实施手术时, 外科医生可以将 TPA 作为一个非常有用的解剖标记以识别重要的结构, 避免不必要的损伤关键词颈静脉孔高颈位入路显微解剖寰椎横突 V

11 ABSTRACT Microsurgical anatomy of the combined high cervical approach for improvement of operative approach at the jugular foramen Name:HOU Wen zhong Supervisor: Professor JIANG Xiao dan Professor WANG Xiang yu ABSTRACT Jugular foramen (JF) is an important bony channel of the posterior fossa which is composed of the pars petrosa ossis temporalis and the pars lateralis ossis occipitalis. The best treatment for the lesions occurred on JF is surgical resection. With the development of the Imaging and microsurgical technique, it is possible to diagnosis and resect the lesions in this region. However, to operate at the JF is extremely difficult, mainly because of its deep location,safe operative approach buried by organizational structure,the complex anatomical relationship of the nerves and blood the vessels within JF,the complexity of anatomical structure of the JF itself.to correctly understand the anatomical structure of JF is of very important operative significance. There are two necessary conditions before operating on JF, to detailed understand the anatomical structure is the first one,. the other one is to select a suitable operative approach. The main purpose of this study is to improve the operative approach of the JF and investigate a new surgical approach to resect the JF lesions in one-stage, which are based on the microsurgical anatomical study of the JF. Part I: Microsurgical anatomy of the combined high cervical approach for improvement of operative approach of the JF Objective To investigate surgical approach to resect the complex JF lesions in one-stage. i

12 硕士学位论文 Method Under a surgical microscope, 20 cases(40 sides) adult cadaveric head specimens fixed in formalin were used to investigate the anatomic structure relatied to the JF via a combination of the transmastoid, retro- and infralabyrinthine, transjugular,extreme lateral infrajugular transcondylar transtubercular, and high cervical approaches.the procedures were described as below:1 A retroauricular curvilinear C-shaped skin incision was started approximately 2 to 3 cm posterior to the upper border of the ear. It continue posteroinferiorly into the neck over the anterior border of the sternocleidomastoid muscle (SCM) and under the mandibular angle;2 The posterolateral neck muscles could be anatomically categorized as three layers,these muscles could be separated to expose the suboccipital triangle and the structure within it;3 Following with the XIth cranial nerve(cn XI) below the SCM, the entrance of the carotid sheath (CS) could be found, tracting the SCM posteriorly and the posterior belly of digastric muscle downward,the CS could be exposed at the area between the furcation of the carotid and the angle of mandible;4 The cortex over the outer mastoid triangle was removed by using a high-speed drill. The facial nerve(cn VII) in the fallopian canal was fully skeletonized with a diamond burr. A lateral suboccipital craniectomy was then performed with a rongeurs. The craniectomy usually extends medially toward the midline, superiorly to the inferior nuchal line, inferiorly to the posterior rim of the foramen magnum (FM), and laterally up to the occipital condyle. Removal of the posterior and medial one-third of the occipital condyle was finishied. Further drilling would expose another cortical layer of bone that covers the hypoglossal canal (HC), which was situated superior to the occipital condyle and inferior to the jugular tubercle(jt). The JT should be drilled away as much as possible to fully expose the posterior wall of JF. Total exposure of the JF could be achieved from multidirectional approaches,including supra jugular, infrajugular,postjugular and extrajugular exposures. Results 1 The posterolateral neck muscles could be anatomically categorized as three layers. The superficial layer was composed of the SCM and the splenius capitis ii

13 ABSTRACT muscles. The middle layer consisted of the longissimus capitis and the semispinalis capitis muscles. The deep layer consisted of the rectus capitis posterior major, the obliquus capitis superior, and the obliquus capitis inferior muscles (these three muscles form the suboccipital triangle). The superficial and middle layers of muscles were reflected posteriorly to expose the suboccipital triangle and the styloid diaphragm, a thick membranous structure that covered the posterior belly of the digastric muscle. The occipital artery was also covered by the styloid diaphragm and runs under the posterior belly of the digastric muscle. 2 There were many significant anatomic landmarks around the JF, such as root of zygoma, spine of Henle, mastoidle, asterion, intrajugular processe (JP), transverse process of atlas(tpa), occipital condyle, Tymp-mastoid notch, stylomastoid foramen, and digastric crista. The outer mastoid triangle, which was formed by the posterior point of the root of the zygoma, the mastoid tip, and the asterion, marked the area of initial drilling for the mastoidectomy. The distance between the root of zygoma and asterion was as 38.67±2.00mm;mastoidle-asterion 46.50±2.62mm;asterion-Henle `s crista 26.62±1.64mm. Tymp- mastoid notch could be regarded as surface project of the CN VII proximately. The stylomastoid foramen was the exit of the CN VII from the fallopian canal. The digastric ridge was an important landmark for defining it. The JP composed the posterior wall of the JF, it could be regarded as the bridge of the occipital condyle and the squamous part. The rectus capitis lateralis was attached to it. The asterion was defined as the junction of the lambdoid, parietomastoid, and occipitomastoid sutures,which was located over a portion of the transvers- sigmoid sinus complex in 90% (36 sides) in this research. TPA was a reliable landmark of the high cervical approach,it was detailed explain in the part III. 3 CN IX CN X CN XI passed through the JF. C2 nerve formed a major ganglion,which set out a bigger medial branch and a smaller lateral branch. CN VII stem departed the stylomastoid foramen lateral to the JF about 5mm, then it was divided in 5 parts. The length of the horizontal part of the CN VII was 12.67±2.36mm, and the perpendicular part was 15.03±1.83mm,The distance between stylomastoid foramen iii

14 硕士学位论文 and the edge of parotid was as 17.00±1.83mm. The lesser occipital nerve came from the lateral branch, on the contrary,the greater occipital nerve from the medial branch.4. CS consisted of common carotid artery internal carotid artery (ICA), external carotid artery, and internal jugular vein (IJV). Conclusion The research above described an approach was a combination of the transmastoid, retro- and infralabyrinthine,transjugular,extreme lateral infrajugular transcondylar transtubercular, and high cervical approaches. Total exposure of the JF could be achieved, and multidirectional approaches could be performed, including suprajugular (infralabyrinthine), transjugular, and infrajugular retrosigmoid/ transcondylar) exposures. Both intracranial and extracranial tumor could be removed in a one-stage procedure. Tumors at the foramen magnum and high cervical region are accessible through this approach. It offered advantages in reducing even preventing the injury of the CN VII and other postoperative complications. Part II: Microsurgical anatomy of the JF Objective To observe the anatomical base of the approaches to the JF, and to study the microsurgical anatomy of the JF and the organizations within it. Methods Same to Part I. Results 1 At the intracranial end, the JF was divided into three compartments by a dural septations, including the petrosal portion anteromedially, the sigmoid portion posterolaterally and the intrajugular compartment located between the petrous and sigmoid portion. The dura overlying the intrajugular compartment formated two perforations. One of them was the glossopharyngeal meatus, through which CN IX passed. The other one was the vagal meatus, through which CN X and CN XI passed. These perforations were separated by a dural septum;2 After penetrating its dural meatus at the intracranial end of the JF, CN IX turned sharply inferiorly and then coursed along the medial side of the intrajugular ridge just below the opening of the iv

15 ABSTRACT cochlear aqueduct. Within the JF, the nerve had two ganglia.the superior ganglion had no branches and might be difficult to see. The inferior glossopharyngeal ganglion was about 2 mm distal to the superior ganglion and located above the external end of the JF. The inferior ganglion rised to the nerve of Jacobson, which ascended vertically and then curved 160 to 170 degrees in an anteromedial direction to the tympanic canaliculus. It gave rise to the lesser petrosal nerve and then to the parasympathetic fibers to the parotid gland. The inferior ganglion also gave rise to a branch that connected to the superior ganglion of the vagus. The carotid branch of the CN IX (nerve of Hering) received fibers from the carotid sinus. After exiting the JF between the ICA and the IJV, CN IX coursed anteriorly, crossed the lateral surface of the ICA, and divided into its terminal branches. At its exit from the JF, CN IX was tethered to the ICA by dense fibrous bands. CN X had multiple rootlets that, along with CN XI, entered the vagal meatus of the JF inferior to the glossopharyngeal meatus. Once it entered the foramen, CN X turned inferiorly in the same manner as CN IX. Within the JF, the nerve expanded at its superior ganglion where branched to and from CN IX and CN XI join. The auricular branch of Arnold also exited from the superior ganglion. This branch traveled laterally to the mastoid canaliculus and anterior to the IJV. CN X continued as the superior ganglion for the remainder of its course through the JF along the medial side of the temporal intrajugular process. CN X exited the JF together with CN XI posterior to CN IX. At the level of the HC, CN X and CN XI diverged. Just below the JF, CN X expanded into its inferior ganglion. After giving rise to the pharyngeal branch from this ganglion, the main trunk of CN X descended in the neck within the CS.CN XI was a fusion of cranial and spinal rootlets. The cranial and spinal rootlets entered the JF through the vagal meatus either together or separately. Within the JF, CN XI was adherent to and indistinguishable from CN X. After going out from the JF,CN XI passed posteriorly between the lateral surface of the IJV and the posterior belly of the digastric muscle with CN X. The nerve then entered into the posterior triangle of the neck;3 The SS was the largest source of venous drainage into the JF. The sinus v

16 硕士学位论文 descended vertically in the sigmoid sulcus and then turned anteriorly toward the foramen. At the level of the occipitomastoid suture, the sinus coursed anteriorly below the petrous bone to the jugular bulb(jb). Blood then descended posterior to the tympanic bone into the IJV. The inferior petrosal sinus (IPS) linked the cavernous and basilar sinuses with the JB. It traveled along the petroclival fissure and received drainage from the inferior petroclival vein and intrapetrosal veins. The IPS did not empty directly into the JB. Instead, it formed a multichanneled confluence within the petrosal part of the JF that received drainage from the vertebral venous plexus, the hypoglossal venous plexus, and the condylar emissary vein. This confluence then emptied into the JB between CN IX anteriorly and CN X posteriorly. 4 As the ICA entered the carotid canal, it was separated posteriorly from the IJV by the carotid ridge or crest. Both vessels were surrounded by dense attachments of fibrous tissue formed by the CS, the periosteum of the jugular fossa, and the endosteum of the carotid canal. The inferior tympanic artery coursed with Jacobson's nerve into the carotid crest. The lower cranial nerves coursed between the ICA and the IJV at the skull base, with CN IX laterally and CNs X and CN XI medially. Conclusion: It was more significancent to divide the JF into petrosal portion,sigmoid portion and intrajugular compartment. To detailed understand the anatomical structure of the venous sinuses could help pretecting these sinus,asterion wais a reliable landmark to locate the transvers-ss complex. The detailed micro-anatomic study might improve the success of surgery protect cranial nerves and prevent from unnecessary injury. Part III: Microsurgical anatomy of the Transverse process of atlas Objective To assess the clinical anatomical significance of the transverse process of the atlas (TPA) as a reference guide Methods 20 cases (40 sides)cadavers were dissected with a lateral cervical approach to explore the upper lateral neck. Cervical skin and platysma muscle were vi

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