内镜下口内径路颈椎椎体良性病变切除术应用解剖及临床研究

发布时间：2018-05-26 12:02

本文选题：颈椎椎体病变 + 内镜　；参考：《山东大学》2017年博士论文

【摘要】：研究背景临床上颈椎椎体肿瘤比较少见,多发病隐匿,而且早期症状没有特异性,故患者早期无明显临床症状,常被误认为颈椎病而延误到出现脊髓压迫症状时才来就诊。Levine等报道一组9例颈椎肿瘤中,95%的患者有局限性疼痛,37%的颈椎良性肿瘤伴有根性痛。患者中29%出现斜颈,14%出现感觉障碍,7%出现局限性运动障碍。目前国内外认为手术是颈椎椎体肿瘤最重要、最有效的治疗方法。传统的颈椎椎体肿瘤手术方式主要有三种:前路手术、后路手术及前后联合手术,其存在手术径路远、创伤大、有损伤颈部重要血管神经引发严重并发症可能,尤其是儿童颈椎恶性肿瘤手术难度大、易复发,预后差,如何安全有效地暴露并切除颈椎椎体病变是临床医师正在探讨中的课题,近年来以安全、可靠且创伤小的微创方法治疗颈椎椎体病变逐渐应用于临床。随着鼻内镜解剖、内镜技术和颅底外科学的发展,进一步扩大了鼻内镜外科手术的治疗范围。目前国内外有关鼻内镜下口内径路对颈椎椎体肿瘤施行手术切除尚未有文献报道。受学者们切除脊索瘤和齿状突病变的启发,我们对20例新鲜尸头标本,进行寰枢椎CT测量,获得详细的解剖学数据,对10例新鲜灌注尸头标本,采用内镜下口内径路对颈椎椎体及相关区域行模拟手术并解剖学观测。临床上采用内镜下经口径路对8例颈椎椎体良性病变施行手术切除,主要论述了颈椎椎体良性病变内镜下口内径路切除术的手术特点、术中操作技巧以及术中、术后并发症的预防等,探索颈椎椎体良性病变内镜下口内径路手术切除的可行性。目的探索颈椎椎体良性病变内镜下口内径路手术切除的可行性及临床验证。资料和方法对20例新鲜尸头标本,进行寰枢椎CT测量,获得详细的解剖学数据,包括寰椎前弓长度、寰椎前结节厚度、寰椎侧块横径、寰椎侧块矢状径、寰枢椎两侧横突孔内侧间距、寰枢椎两侧横突孔外侧间距等;对10例新鲜灌注尸头标本,采用内镜下口内径路对颈椎椎体及相关区域行模拟手术并解剖学观测,以期为临床提供较为详实的解剖学资料。2013年10月-2015年10月,在深圳市第二人民医院耳鼻咽喉科住院部,我们采用鼻内镜系统、经口内径路切除8例颈椎椎体良性病变,男5例、女3例;年龄5岁-42岁,平均20岁;临床表现为颈痛6例,头痛2例,头部不稳感2例,颈部活动受限2例,颈部活动不适1例。嗜酸性肉芽肿7例、脂肪瘤1例。所有患者均在手术前、后行颈椎电子计算机断层扫描(Computed tomography,CT)加增强轴位、冠状位和矢状位检查,颈椎磁共振成像(Magnetic resonance imaging,MRI)检查,以确定病变位置、范围及与周围结构的关系。8例患者中5例侵犯寰枢椎椎体,3例侵犯第三颈椎椎体,均未侵及硬脊膜和脊髓。5例患者术前行三维(Three dimensional,3D)重建并3D打印模型,为术前治疗方案设计及与患者家属沟通提供了帮助。所有患者术前均已签署手术知情同意书。结果新鲜尸头寰枢椎CT测量值:寰椎前弓长度(19.6±2.6)mm,寰椎前结节厚度(8.1 ±0.7)mm,寰椎侧块横径(左)(12.8±2.6)MmMm,寰椎侧块横径(右)(12.8±1.9)mm,寰椎侧块矢状径(左)(14.9±2.4)mm,寰椎侧块矢状径(右)(15.2 ±1.6)mm,寰椎两侧横突孔内侧间距(47.1±1.5)mm,寰椎两侧横突孔外侧间距(60.6± 1.6)mm,枢椎两侧横突孔内侧间距(29.1 ±1.5)mm,枢椎两侧横突孔外侧间距(44.2士 1.8)mm。灌注尸头标本模拟手术结果:①内镜下口径路可显露寰枢椎腹侧,包括:寰椎、枢椎椎体,寰椎前弓、侧块,齿突及两侧椎动脉;②上方常规可显露至寰椎前弓上缘或斜坡下部,下方可显露至C2/3椎间盘或C3椎体上部,两侧安全边界可界定:寰椎层面为寰枢侧块关节外缘,枢椎层面为枢椎体外缘。可满足内镜口内径路手术需要。8例临床患者病变均一次彻底切除,未见明显并发症发生;术后8小时经口进食;手术当天全麻清醒后至术后第3天采用NRS评分法评估疼痛程度,平均2.25分;术后5天拆线并出院,平均住院时间6.5天;平均住院费用8225元。随访3-12个月。8例患者均于术后3月行颈椎CT检查,肿物均被完整切除,无复发。结论内镜口内径路颈椎椎体良性病变切除术对颈部椎体病变暴露清楚,此径路具有径路短、技术简单、疗效可靠、并发症少、手术时间短、术后恢复快等优点,值得推广。
[Abstract]:Background clinical cervical vertebra tumor is rare, frequently occult, and the early symptoms are not specific, so the patients have no obvious clinical symptoms in the early stage, and are often mistaken for cervical spondylosis to be delayed to the symptoms of spinal cord compression to report.Levine and other 9 cervical tumors, 95% of the patients have localized pain, and 37% of the cervical spine. Benign tumors are associated with root pain. 29% of the patients have torticollis, 14% have sensory disorders, and 7% have localized dyskinesia. At present, surgery is considered the most important and most effective method for cervical vertebra tumor. There are three methods of the traditional cervical vertebra tumor operation: anterior, posterior and combined surgery. The surgical path is far, the trauma is large and the serious complications of the important cervical vessels and nerves may be damaged. Especially, the operation of the cervical malignant tumor in children is difficult, easy to recur, and the prognosis is poor. How to expose and Excise cervical vertebra vertebral lesions safely and effectively is a subject being discussed by the clinicians. In recent years, the minimally invasive and safe side is safe, reliable and minimally invasive. The treatment of cervical vertebra vertebral lesions is gradually applied to clinical. With the development of endoscopic anatomy, endoscopic technique and skull base surgery, the scope of treatment for endoscopic surgery has been further expanded. With the elicitation of odontoid process, 20 cases of fresh cadaver head specimens were measured by CT, and detailed anatomical data were obtained. 10 cases of fresh perfusion head specimens were used to simulate the cervical vertebra and related areas by endoscopy. On the bed, 8 cases of cervical vertebra were treated by endoscopy. Surgical resection of sexual lesions was performed. The characteristics of endoscopic surgical resection of the cervical vertebra benign lesions, operation skills and prevention of postoperative complications were discussed. The feasibility of endoscopic surgical resection under endoscopy for cervical vertebral benign lesions was explored. The feasibility and clinical validation of surgical resection of the path. Data and methods were used to measure the atlantoaxial CT and obtain detailed anatomical data, including the length of the anterior arch of the atlas, the thickness of the anterior atlas, the lateral diameter of the atlas, the sagittal diameter of the atlas lateral mass, the inner space of the lateral transverse foramen of the atlantoaxial, and the lateral lateral transverse foramen of the atlantoaxial. In order to provide more detailed anatomical data of the cervical vertebra and related areas, 10 cases of fresh perfused cadaver head specimens were used to provide more detailed anatomical data of the cervical vertebra and related areas by endoscopy in order to provide more detailed anatomical data in the hospital department of the Department of Otolaryngology, Shenzhen No.2 People's Hospital, in October,.2013, October. We used the nasal endoscopy system. 8 cases of benign cervical vertebral lesions, 5 male and 3 female, aged 5 years -42 years old, with an average of 20 years of age, 6 cases of cervical pain, 2 headache, 2 head instability, 2 neck movement, 1 cervical motion discomfort, 7 eosinophilic granuloma and 1 cases of lipoma. All the patients were scanned by CT scan before operation. (Computed tomography, CT) plus axial, coronal and sagittal examination, cervical magnetic resonance imaging (Magnetic resonance imaging, MRI) examination to determine the location, range and relation to the surrounding structure in 5 cases of.8 patients who had infringed the atlantoaxial vertebral body and 3 cases of the third cervical vertebrae, both of which were not invaded by the spinal cord and spinal cord before operation. The Three dimensional (3D) reconstruction and 3D print model were used to provide help for the preoperative treatment scheme design and communication with the patient's family. All patients had signed the operation informed consent before operation. Results fresh cadaver head atlantoaxial CT measurements: the anterior atlas arch length (19.6 + 2.6) mm, the thickness of the anterior atlas (8.1 + 0.7) mm, and the lateral mass of the atlas ( Left) (12.8 + 2.6) MmMm, lateral mass of atlas (right) (12.8 + 1.9) mm, lateral mass of atlas (14.9 + 2.4) mm, sagittal diameter of atlas (15.2 + 1.6) mm, medial space distance (47.1 + 1.5) mm on the lateral transverse foramen of atlas (47.1 + 1.5) mm, lateral space between the lateral transverse foramen of atlas (29.1 + 12.8) mm, and lateral transverse process of the axis The surgical results of the cadaver head specimens of the lateral spaced space (44.2 st 1.8) mm. were simulated: (1) the endoscopic aperture route revealed the atlantoaxial ventral side, including the atlas, the axis of the axis, the anterior arch of the atlas, the lateral mass, the odontoid and the bilateral vertebral arteries; the above routine could be exposed to the upper or lower part of the anterior arch of the atlas or the lower part of the slope, and the lower part could be exposed to the upper part of the intervertebral disc or the C3 vertebral body, two The side safety boundary can be defined as the outer edge of the atlantoaxial side, the axis of the axis is the outer edge of the axis of the axis. It can satisfy the endoscopic surgery in.8 patients with a complete resection and no obvious complications. 8 hours after the operation, the operation is taken after the operation of the general anesthesia and the third day after the operation by the NRS score. The degree of pain was estimated at an average of 2.25 points, 5 days after operation and discharge, the average hospitalization time was 6.5 days, and the average hospitalization cost was 8225 yuan. All patients were followed up for 3-12 months and.8 patients were examined by cervical CT in March. All the tumors were completely removed and no recurrence was found. The path has the advantages of short path, simple technique, reliable curative effect, few complications, short operation time and quick postoperative recovery, and is worthy of promotion.
【学位授予单位】：山东大学
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R687.3;R322.7

【参考文献】