内窥镜辅助下脊柱颈胸段前路手术的解剖学及初步临床研究
发布时间：2018-08-01 13:31
【摘要】： 目的: 探讨将内窥镜技术应用于脊柱颈胸段的前路手术中,研究入路技术并提供解剖学依据,初步评价其临床应用的疗效。 方法: 1.取6具正常成人尸体标本进行模拟手术:(1)切口。胸骨柄上方横形切口以及两侧胸骨柄旁第1、2肋间隙处小切口。(2)分离。颈部切口按常规低位颈椎途径分离至椎前筋膜;钝性分离胸骨后方软组织,推开两侧胸膜。(3)套管置入。颈部切口置入直径为20mm套管;肋间隙切口置入直径为10mm的套管。(4)操作。观察套管通道所提供脊柱显露的范围及操作空间。 2.研究经不同血管神经间隙向后方显露到上胸椎的范围。 3.自2004年5月到2006年8月,我科对5例需要行脊柱颈胸段前路手术的患者采用了该内窥镜辅助技术。5例患者中男性2例,女性3例;年龄13～55岁,平均40岁。病变分布:T1 1例,T2 2例,T3 2例。其中上胸椎骨折2例,椎体转移性肿瘤2例,T3半椎畸形1例。神经功能按Frankel分级:C级1例,D级2例,E级2例。所有患者术前均行颈胸段脊柱的X片、MRI以及颈胸部CT检查。 结果: 1.模拟手术时能将内镜套管顺利的安置于椎体前方,通过不同的血管间隙能较好的显露C7～T4上半部分,其中T3及以下有5例,未发现入路过程中重要软组织结构损伤。 2.经不同血管神经间隙入路显露的范围不同,各自具有其优缺点。其中经气管食管鞘与左、右两侧血管鞘的间隙;右头臂静脉与头臂干、左头臂静脉根部之间的间隙;左颈总动脉与头臂干之间、左头臂静脉下间隙;以及上腔静脉与升主动脉之间的间隙,它们均可以用于建立内镜的工作通道。 3. 5例患者手术时间为160min～280min,平均220min;术中出血量分别为600～1100ml,平均800ml;全部病例随访6～33个月,平均14个月。术中没有出现胸膜破裂和肺部损伤,无心脏大血管损伤;脊髓减压满意,术前有神经功能症状患者术后均有不同程度的恢复。1例T3半椎畸形患者术后出现轻度声嘶,四天左右恢复,复查X片见矫形后Cobb’s角为0度。所有病例三月后均行影像学检查见植骨融合、内固定可靠。未发现有远期的肺部及纵隔相关并发症发生。 结论: 内窥镜辅助下脊柱颈胸段前方手术入路能显露C7～T4上半部分,可满足T2、T3的前方减压,椎体重建和内固定操作,该入路创伤小,操作安全,并发症少,具有其初步临床应用的可行性。
[Abstract]:Objective: to explore the application of endoscopic technique in anterior spinal cervical and thoracic surgery, to study the approach and provide anatomical basis for the preliminary evaluation of its clinical application. Methods: 1. Six normal adult cadavers were taken for simulated operation: (1) incision. The transverse incision above the sternum and the small incision at the 1st and 2nd costal space adjacent to the sternum. (2) Separation. Cervical incision was divided into anterior fascia according to conventional low cervical approach, posterior soft tissue of sternum was obtuse separated and bilateral pleura was pushed open. (3) cannula was inserted. The diameter of neck incision is 20mm cannula, and the intercostal gap incision is 10mm diameter casing. (4) Operation. Observe the extent and operating space of spinal exposure provided by the trocar passage. 2. To study the range of superior thoracic vertebrae exposed to the posterior through different vascular and nerve interspace. 3. 3. From May 2004 to August 2006, 5 patients who needed anterior cervical and thoracic spinal surgery were treated with the endoscope assisted technique in 5 patients, including 2 males and 3 females, aged 1355 years, with an average age of 40 years. The lesions were distributed in 1 case of T 1, 2 cases of T 2 and 2 cases of T 3. There were 2 cases of upper thoracic vertebra fracture and 2 cases of metastatic tumor of vertebral body. According to Frankel grade, 1 case was grade C, 2 cases were grade D, 2 cases were grade E. All patients underwent X-MRI and CT examination of cervical and thoracic spine before operation. Results: 1. The endoscopic cannula could be successfully placed in the front of the vertebral body during simulated operation, and the upper half of C7~T4 could be well exposed through different vascular spaces, among which there were 5 cases with T3 and below. No significant soft tissue structure damage was found during the approach. 2. The range of exposure through different vascular and nerve interspace approaches is different, and each has its own advantages and disadvantages. The space between the sheath of trachea and esophagus and the left and right sides of the vessel sheath, the space between the right cephalic vein and the trunk of the head arm, the space between the root of the left head and arm vein, the space between the left common carotid artery and the trunk of the head arm, the space between the left cephalic vein and the inferior vein of the left head arm; And the space between the superior vena cava and the ascending aorta, which can be used to establish endoscopic working channels. The operative time was 160 min to 280 min (mean 220 min), the intraoperative bleeding volume was 600,100 ml (mean 800 ml), and all cases were followed up for 6 ~ 33 months (mean 14 months). There were no pleural rupture and lung injury, no cardiac vascular injury, satisfactory decompression of spinal cord, and recovery of mild hoarseness in 1 cases of T 3 hemivertebra deformity after operation. After 4 days recovery, the Cobb's angle was 0 degree after X-ray examination. After 3 months, bone graft fusion was found in all cases, and internal fixation was reliable. No long term pulmonary and mediastinal complications were found. Conclusion: the anterior approach to spinal neck and thoracic segment under endoscope can reveal the upper part of C7~T4, which can satisfy the anterior decompression of T2T 3, reconstruction of vertebral body and internal fixation. The operation is safe and has less complications. It has the feasibility of preliminary clinical application.
【学位授予单位】：南华大学
【学位级别】：硕士
【学位授予年份】：2007
【分类号】：R687.3;R322
本文编号：2157739
[Abstract]:Objective: to explore the application of endoscopic technique in anterior spinal cervical and thoracic surgery, to study the approach and provide anatomical basis for the preliminary evaluation of its clinical application. Methods: 1. Six normal adult cadavers were taken for simulated operation: (1) incision. The transverse incision above the sternum and the small incision at the 1st and 2nd costal space adjacent to the sternum. (2) Separation. Cervical incision was divided into anterior fascia according to conventional low cervical approach, posterior soft tissue of sternum was obtuse separated and bilateral pleura was pushed open. (3) cannula was inserted. The diameter of neck incision is 20mm cannula, and the intercostal gap incision is 10mm diameter casing. (4) Operation. Observe the extent and operating space of spinal exposure provided by the trocar passage. 2. To study the range of superior thoracic vertebrae exposed to the posterior through different vascular and nerve interspace. 3. 3. From May 2004 to August 2006, 5 patients who needed anterior cervical and thoracic spinal surgery were treated with the endoscope assisted technique in 5 patients, including 2 males and 3 females, aged 1355 years, with an average age of 40 years. The lesions were distributed in 1 case of T 1, 2 cases of T 2 and 2 cases of T 3. There were 2 cases of upper thoracic vertebra fracture and 2 cases of metastatic tumor of vertebral body. According to Frankel grade, 1 case was grade C, 2 cases were grade D, 2 cases were grade E. All patients underwent X-MRI and CT examination of cervical and thoracic spine before operation. Results: 1. The endoscopic cannula could be successfully placed in the front of the vertebral body during simulated operation, and the upper half of C7~T4 could be well exposed through different vascular spaces, among which there were 5 cases with T3 and below. No significant soft tissue structure damage was found during the approach. 2. The range of exposure through different vascular and nerve interspace approaches is different, and each has its own advantages and disadvantages. The space between the sheath of trachea and esophagus and the left and right sides of the vessel sheath, the space between the right cephalic vein and the trunk of the head arm, the space between the root of the left head and arm vein, the space between the left common carotid artery and the trunk of the head arm, the space between the left cephalic vein and the inferior vein of the left head arm; And the space between the superior vena cava and the ascending aorta, which can be used to establish endoscopic working channels. The operative time was 160 min to 280 min (mean 220 min), the intraoperative bleeding volume was 600,100 ml (mean 800 ml), and all cases were followed up for 6 ~ 33 months (mean 14 months). There were no pleural rupture and lung injury, no cardiac vascular injury, satisfactory decompression of spinal cord, and recovery of mild hoarseness in 1 cases of T 3 hemivertebra deformity after operation. After 4 days recovery, the Cobb's angle was 0 degree after X-ray examination. After 3 months, bone graft fusion was found in all cases, and internal fixation was reliable. No long term pulmonary and mediastinal complications were found. Conclusion: the anterior approach to spinal neck and thoracic segment under endoscope can reveal the upper part of C7~T4, which can satisfy the anterior decompression of T2T 3, reconstruction of vertebral body and internal fixation. The operation is safe and has less complications. It has the feasibility of preliminary clinical application.
【学位授予单位】：南华大学
【学位级别】：硕士
【学位授予年份】：2007
【分类号】：R687.3;R322
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