改良肩胛深层入路显露上胸椎的应用解剖与临床研究

发布时间：2018-05-04 06:44

本文选题：上胸椎 + 肩脚区应用解剖学　；参考：《南方医科大学》2008年硕士论文

【摘要】： 背景上胸椎(upper thoracic spine)包括第1胸椎至第4胸椎(T_1—T_4)。该段胸椎运动度小,位置相对固定,其周围解剖结构复杂,并且有胸骨柄、肩胛骨等遮挡,脊柱位置深在,手术显露困难。据报道,约15%的脊柱肿瘤位于上胸椎,后纵韧带钙化、椎间盘突出等退行性病变虽不多见(约0.3%)于上胸椎,但该段椎管相对较小,容易造成压迫,且症状往往较重,常需手术治疗。由于其特殊的解剖结构,目前用于显露上胸椎的手术入路较多,包括劈胸入路、低位颈椎入路、颈前胸骨柄联合入路、部分锁骨切除劈胸入路、内窥镜微创手术、经肋骨横突后外侧入路、后方入路等,但均因手术创伤大,风险高及显露范围不理想等缺点,未能广泛应用。而肩胛深层入路(也有称肩胛下入路)可直接从侧前方显露上胸椎,无需牵拉重要神经、血管等结构,具有显露好、风险小的优点。但仍有报道胸导管损伤等并发症,且尚未见有该手术入路解剖学研究的报道。本研究在原手术入路的基础上改良皮肤切口及肋骨切口,并对21例标本进行解剖学研究,旨在为该改良手术入路的临床应用提供解剖学依据。同时,对进行改良肩胛深层入路显露上胸椎手术的临床病例进行研究分析,总结该手术入路的适应证、疗效和经验。目的: 1.在人体标本上进行改良肩胛深层入路显露上胸椎的模拟手术,测量各项解剖学数据,从而对如何顺利利用该入路显露上胸椎,减少创伤及风险,提高手术效果提供解剖学依据。 2.对进行改良肩胛深层入路显露上胸椎手术的临床病例治疗进行研究分析,总结该手术入路的适应证、疗效和经验。材料和方法: 1.本实验标本为21例经福尔马林浸泡防腐成人尸体,出生地域、年龄不详(由南方医科大学人体解剖学教研室提供),其中男性14例,女性7例,经检查排除胸部病变。按左右侧肋骨切口高低,将以上实验标本随机分为右高左低组(A组)、左高右低组(B组)及低位切口组(C组);本实验使用测量工具为游标卡尺(精确度0.01mm)和不锈钢直尺(精确度0.5mm)。 2.将尸体标本放置于解剖实验台上,按手术入路,逐层解剖至上胸椎椎体,观察并测量皮肤切口长度、肋骨切口纵向撑开宽度、显露椎体范围、双侧交感神经干、奇静脉弓及胸导管等结构。利用SPSS 11.5统计学软件(由南方医科大学统计学教研室提供)对所采集的数据进行处理。计算各组数据(计量资料)的算术均数;奇静脉弓最高点位置按位置不同分组并算出各组比率;传统皮肤切口与改良皮肤切口长度均数用配对t检验比较;同一尸体标本左右侧胸交感干至肋头关节前缘的距离数据用配对t检验比较。比较时差异有统计学意义设定在(P＜0.05)。 3.以3例临床应用改良肩胛深层入路的病例为对象,对病例的术前和术后的症状、体征、影像学等临床资料进行分析。结果: 改良肩胛深层手术入路皮肤切口长度平均(22.88±1.70)cm;若切除第3肋骨,切口纵向撑开宽度平均(6.10±0.68)cm,能显露T_(2-4)椎体(100%);若联合切除第2肋骨,切口撑开宽度平均(8.08±0.93)cm,能显露T_1椎体T2/3—T_4椎体(83.3%);若联合切除第4肋骨,切口撑开宽度平均(8.87±0.73)cm,能显露T_(2-5)椎体(100%);若单纯切除第4肋切口撑开宽度平均(6.03±0.53)cm,显露T_(3-5)椎体(100%);交感神经干、奇静脉弓及胸导管等结构在显露过程中出现在相对恒定的位置,术中仔细操作可避免损伤。在临床应用的例患者中,所有病例症状体症均获得改善,无明显并发症,影像学资料表明:植骨块及内固定物位置满意。结论: 1.改良肩胛深层入路手术具有:解剖层次相对简单,重要结构较少,直接从侧前方解除压迫,术中视角好,不易损伤硬膜及脊髓等特点。该改良入路是显露上胸椎的理想的手术入路,具有创伤小,显露好,安全性高等优点。 2.临床应用病例证明:改良肩胛深层入路手术在处理上胸椎(主要是T_2-T_4)及其相邻下位胸椎的疾病,具有创伤出血小,显露减压好,操作安全性高等优点。对3例临床病例的分析,证明该入路可以完全满足上胸椎(主要是T_2-T_4)及其相邻下位胸椎病灶清除、椎管减压、植骨及内固定操作的需要,术后病灶清除、椎管减压彻底,植骨、内固定可靠,胸椎稳定性好,可以满足临床应用的需要。
[Abstract]:background
The upper thoracic vertebra (upper thoracic spine) consists of first thoracic vertebrae to fourth thoracic vertebrae (T_1 - T_4). The thoracic vertebra has small motion and relatively fixed position, and its surrounding anatomy is complex, with the sternal handle, the scapula and other occlusion, the spinal position is deep, and the operation is difficult. It is reported that about 15% of the spinal tumors are located in the upper thoracic vertebrae, the posterior longitudinal ligament calcification, intervertebral disc process. Although the degenerative disease is not common (about 0.3%) in the upper thoracic vertebra, the segment of the vertebral canal is relatively small, easy to cause compression, and the symptoms are often heavy and often require surgical treatment. Because of its special anatomical structure, there are many surgical approaches to expose the upper thoracic vertebrae, including the chest splitting approach, the low cervical approach, the anterior cervix sternum joint approach, and the partial lock. Bone resection, minimally invasive surgery, posterior lateral approach through the rib transverse process, posterior approach, and so on, can not be widely used because of the large trauma, high risk and unsatisfactory scope of exposure. The deep subscapular approach (also known as subscapular approach) can directly expose the thoracic vertebrae from the side of the side without pulling important nerves and blood vessels. It has the advantages of good exposure and small risk. However, there are still reports of complications such as thoracic duct injury, and there is no report of the anatomical study of the surgical approach. This study improved the skin incision and rib incision on the basis of the original approach, and studied the anatomy of 21 specimens, aiming at the clinical application of the improved surgical approach. At the same time, the clinical cases of the modified deep deep scapular approach to the thoracic vertebra surgery were analyzed, and the indications, curative effect and experience of the surgical approach were summarized.
Objective:
1. the simulated operation of the thoracic vertebra on the deep deep scapular approach was performed on the human body, and the anatomical data were measured to provide anatomic basis for the smooth use of the approach to expose the thoracic vertebrae, reduce the trauma and risk, and improve the effect of the operation.
2. to study and analyze the clinical treatment of upper thoracic spine surgery through modified deep scapular approach, and to summarize the indication, effect and experience of this approach.
Materials and methods:
1. of the experimental specimens, 21 cases of adult cadavers were soaked in formalin, and the age was unknown (provided by the Department of human anatomy and research in Southern Medical University). Among them, 14 cases of men and 7 women were excluded from the chest. The upper and left side rib incision was randomly divided into the right high left low group (group A) and the left high right low. Group B (group A) and low incision group (group C). The instruments used in this experiment were vernier caliper (accuracy 0.01mm) and stainless steel ruler (accuracy 0.5mm).
2. the cadaver specimens were placed on the anatomic experimental table. According to the surgical approach, the paramountcy thoracic vertebrae were dissected by layer by layer. The length of the skin incision, the longitudinal opening width of the rib incision, the vertebral body range, the bilateral sympathetic trunk, the odd vein arch and the thoracic duct, were observed and measured.
The data were processed by SPSS 11.5 statistics software (provided by the Department of statistics and research of Southern Medical University). The arithmetic mean of each group of data was calculated. The position of the highest point of the odd vein arch was divided into groups according to the position and the ratio of each group was calculated. The ratio of the traditional skin incision and the improved skin incision length was compared with the paired t test ratio. The distance data from the left and right sides of the same cadaver to the anterior rib of the costal joint was compared with the paired t test. The difference was statistically significant (P < 0.05).
3. the clinical data of 3 patients who underwent deep scapular approach were analyzed before and after operation.
Result:
The improved incision length of the deep operative approach was (22.88 + 1.70) cm, and if third ribs were removed, the longitudinal open width of the incision was (6.10 + 0.68) cm, and the T_ (2-4) vertebral body (100%) could be exposed. If the second ribs were removed, the width of the incision was averaged (8.08 + 0.93) cm, and the T_1 vertebral body T2/3 T_4 vertebral body (83.3%) could be exposed, and if the fourth rib was excised jointly, The open width of the incision was (8.87 + 0.73) cm and could reveal T_ (2-5) vertebral body (100%); if the open width of fourth rib incision was averaged (6.03 + 0.53) cm and T_ (3-5) vertebral body (100%), the sympathetic trunk, the odd vein arch and the thoracic duct appeared in the relatively constant position during the exposure process, and the operation could avoid the injury during the operation.
In all cases of clinical application, all symptoms and signs were improved without obvious complications. Imaging data showed that the location of bone graft and internal fixator was satisfactory.
Conclusion:
1. the modified deep deep approach of the scapula has the advantages of relatively simple anatomical structure, less important structure, direct decompression from the side of the side, good visual angle in the operation, and not easy to damage the dura and spinal cord. The improved approach is an ideal surgical approach to expose the thoracic vertebrae with the advantages of small trauma, exposure and safety.
2. the clinical cases proved that the improved deep incision of the scapula was used to deal with the upper thoracic vertebra (mainly T_2-T_4) and its adjacent lower thoracic vertebrae, which had the advantages of small trauma bleeding, good exposure to decompression, and high safety. The analysis of 3 clinical cases proved that the approach could fully satisfy the upper thoracic vertebra (mainly T_2-T_4) and its adjacent below. Debridement of the thoracic vertebrae, decompression of the spinal canal, bone grafting and internal fixation, the removal of the lesions after the operation, the complete decompression of the spinal canal, the bone graft, the reliable internal fixation and the stability of the thoracic vertebrae, which can meet the needs of the clinical application.

【学位授予单位】：南方医科大学
【学位级别】：硕士
【学位授予年份】：2008
【分类号】：R687.3;R322

【参考文献】