经胸骨柄“U”形开窗入路治疗上胸椎爆裂骨折并截瘫的解剖学与临床研究
发布时间：2018-03-05 15:09
本文选题：脊柱骨折/外科学 切入点：截瘫/外科学 出处：《福建中医学院》2008年硕士论文 论文类型：学位论文
【摘要】： 目的: 1对胸骨柄与上胸椎的手术部位进行解剖观测,研究经胸骨柄“U”形开窗入路显露上胸椎的可行性,为临床经胸骨柄“U”形开窗显露上胸椎典定解剖学基础。 2解剖上纵膈重要血管神经走行特点及对应椎体位置关系,对比上胸椎左右侧前方入路的风险性,为临床提供参考。 3应用经胸骨柄“U”形开窗入路治疗上胸椎爆裂骨折并截瘫患者,观察其临床疗效,分析该入路优越性及注意事项。 方法: 1 35具经甲醛固定的尸体标本测量上胸椎(T_(1-4))椎体宽,计算均值a(mm),测量胸骨柄最窄处宽b(mm),计算出a/b值(%):50例脊柱颈胸段正中矢状位MRI,标记水平位置恰高于胸骨角的椎体为观察椎,测量“观察椎椎体下缘在胸骨柄上水平投影点与颈静脉切迹中点的距离”c(mm),胸骨柄长d(mm),计算出c/d值(%)。 2 35具尸体标本,取颈胸部左前内侧入路,经胸骨柄“U”形开窗(图15),观测自左颈动脉鞘与气管食管鞘间隙显露的脊柱上胸段范围。观测喉返神经和胸导管等重要结构的走行及对应椎体关系,分析其对手术入路的影响。 3上胸椎爆裂骨折并截瘫患者12例,完全瘫痪6例,不完全瘫痪6例。脊髓损伤按Asia分级,A级6例,B级1例,C级3例,D级2例。全部采用经胸骨柄“U”形开窗入路行伤椎次全切除减压、植骨、颈椎前路钢板内固定术。 结果: 1 35具尸体标本“上胸椎(T_(1-4))椎体宽均值/胸骨柄最窄处宽”即(a/b),均值为(78±7.9)%。a/b＜1,所以经胸骨柄“U”形开窗冠状面上可直视下显露上胸椎椎体,切除的范围为柄最窄处宽的(78±7.9)%。50例脊柱颈胸段正中矢状位MRI,46例(92%)T_4椎体下缘高于胸骨角水平,标记T_4椎体为观察椎。46例T_4椎体下缘高于胸骨角水平的MRI,“I_4椎体下缘在胸骨柄上水平投影点与颈静脉切迹中点的距离/胸骨柄长”即(c/d),均值为(72±14.7)%。c/d＜1,所以经胸骨柄“U”形开窗矢状面上可直视下显露至T_4椎体,显露至T_4椎体下缘时,切除的范围为柄长的(72±14.7)%。 2经气管食管鞘、左侧颈动脉鞘及左无名静脉之间的间隙,35具尸体标本能显露T_4椎体的占91.4%。右喉返神经在T_(1-2)水平从迷走神经发出,绕过右锁骨下动脉斜行返转向上,于T_1上缘水平入气管食管沟内,在T_(1、2)水平横过颈动脉鞘及内脏鞘间隙,易受牵拉损伤(图10);左喉返神经在颈胸部走行于气管食管沟内而不易受损伤;上胸段胸导管靠脊柱左侧贴近气管食管鞘左缘上行,在T_2水平即开始离开气管食管鞘,转向外侧紧贴左锁骨下动脉内表面走行,并形成胸导管弓,解剖位置利于术中保护。故经前路显露上胸椎宜采用左侧入路。 3 12例病例均获随访,时间1～7年,椎间植骨均融合好,无内固定松动、断裂,无切口感染、颈前血肿、肺不张、气胸、乳糜漏、肺部感染等手术并发症。9例术后感觉、运动神经功能均有不同程度改善,3例术前完全瘫痪(Asia分级A级)术后未见明显改善。Asia分级术前A级6例术后恢复至B级1例、C级2例、另3例无明显改善;B级1例恢复至C级;C级3例恢复至D级2例、E级1例;D级2例恢复至E级。 结论: 1解剖学上,经胸骨柄“U”形开窗入路能够显露至T_4椎体。 2临床上,经胸骨柄“U”形开窗入路能够治疗上胸椎(T_(1-3))爆裂骨折并截瘫。 3经胸骨柄“U”形开窗入路是治疗上胸椎爆裂骨折并截瘫理想的手术入路。
[Abstract]:Objective:
1 to observe the operative site of the sternum and upper thoracic vertebrae, and to study the feasibility of exposing the upper thoracic vertebrae through the sternum handle "U" shaped window approach, so as to expose the anatomical basis of the upper thoracic vertebrae through the chest U window.
2 anatomically the characteristics of the important vessels and nerves of the mediastinum and the relationship of the position of the vertebral body, and compare the risk of the anterior approach of the left and right sides of the thoracic vertebra to provide a reference for the clinical.
3 the patients with paraplegia fracture and paraplegia were treated with the "U" approach by the sternal handle. The clinical effect was observed and the advantages and attention of the approach were analyzed.
Method:
135 formalin fixed cadaveric thoracic measurements (T_ (1-4)) vertebral width, calculation of the mean a (mm), measuring the sternum at the narrowest width of B (mm), calculated a/b value (%): 50 cases of cervicothoracic spine sagittal MRI, horizontal position just above the mark in order to observe the sternal angle of vertebral vertebra, measuring observation vertebral centrum lower edge horizontal projection point and jugular notch in the sternum on the distance C (mm), D (mm) long manubrium, calculate the c/d value (%).
235 bodies were taken the neck chest left anterior medial approach, the manubrium "U" fenestration (Figure 15), observed from the left carotid sheath and tracheoesophageal sheath gap revealed the upper thoracic vertebrae. Observation of recurrent laryngeal nerve and the thoracic duct and other important structures to walk the line and the corresponding relationship between the vertebral body. To analyze the effect of the surgical approach.
3 upper thoracic vertebrae burst fracture and 12 cases of patients with paraplegia, complete paralysis in 6 cases, 6 cases of incomplete paralysis. According to Asia classification of spinal cord injury, 6 cases of Grade A, 1 cases of grade B, C grade 3 cases, D grade 2 cases. All the manubrium "U" fenestration approach for vertebral subtotal decompression, bone grafting and anterior cervical plate fixation.
Result:
1 35鍏峰案浣撴爣鏈，
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