【摘要】： 目的: 探討將內(nèi)窺鏡技術(shù)應(yīng)用于脊柱頸胸段的前路手術(shù)中,研究入路技術(shù)并提供解剖學(xué)依據(jù),初步評(píng)價(jià)其臨床應(yīng)用的療效。 方法: 1.取6具正常成人尸體標(biāo)本進(jìn)行模擬手術(shù):(1)切口。胸骨柄上方橫形切口以及兩側(cè)胸骨柄旁第1、2肋間隙處小切口。(2)分離。頸部切口按常規(guī)低位頸椎途徑分離至椎前筋膜;鈍性分離胸骨后方軟組織,推開兩側(cè)胸膜。(3)套管置入。頸部切口置入直徑為20mm套管;肋間隙切口置入直徑為10mm的套管。(4)操作。觀察套管通道所提供脊柱顯露的范圍及操作空間。 2.研究經(jīng)不同血管神經(jīng)間隙向后方顯露到上胸椎的范圍。 3.自2004年5月到2006年8月,我科對(duì)5例需要行脊柱頸胸段前路手術(shù)的患者采用了該內(nèi)窺鏡輔助技術(shù)。5例患者中男性2例,女性3例;年齡13～55歲,平均40歲。病變分布:T1 1例,T2 2例,T3 2例。其中上胸椎骨折2例,椎體轉(zhuǎn)移性腫瘤2例,T3半椎畸形1例。神經(jīng)功能按Frankel分級(jí):C級(jí)1例,D級(jí)2例,E級(jí)2例。所有患者術(shù)前均行頸胸段脊柱的X片、MRI以及頸胸部CT檢查。 結(jié)果: 1.模擬手術(shù)時(shí)能將內(nèi)鏡套管順利的安置于椎體前方,通過不同的血管間隙能較好的顯露C7～T4上半部分,其中T3及以下有5例,未發(fā)現(xiàn)入路過程中重要軟組織結(jié)構(gòu)損傷。 2.經(jīng)不同血管神經(jīng)間隙入路顯露的范圍不同,各自具有其優(yōu)缺點(diǎn)。其中經(jīng)氣管食管鞘與左、右兩側(cè)血管鞘的間隙;右頭臂靜脈與頭臂干、左頭臂靜脈根部之間的間隙;左頸總動(dòng)脈與頭臂干之間、左頭臂靜脈下間隙;以及上腔靜脈與升主動(dòng)脈之間的間隙,它們均可以用于建立內(nèi)鏡的工作通道。 3. 5例患者手術(shù)時(shí)間為160min～280min,平均220min;術(shù)中出血量分別為600～1100ml,平均800ml;全部病例隨訪6～33個(gè)月,平均14個(gè)月。術(shù)中沒有出現(xiàn)胸膜破裂和肺部損傷,無心臟大血管損傷;脊髓減壓滿意,術(shù)前有神經(jīng)功能癥狀患者術(shù)后均有不同程度的恢復(fù)。1例T3半椎畸形患者術(shù)后出現(xiàn)輕度聲嘶,四天左右恢復(fù),復(fù)查X片見矯形后Cobb’s角為0度。所有病例三月后均行影像學(xué)檢查見植骨融合、內(nèi)固定可靠。未發(fā)現(xiàn)有遠(yuǎn)期的肺部及縱隔相關(guān)并發(fā)癥發(fā)生。 結(jié)論: 內(nèi)窺鏡輔助下脊柱頸胸段前方手術(shù)入路能顯露C7～T4上半部分,可滿足T2、T3的前方減壓,椎體重建和內(nèi)固定操作,該入路創(chuàng)傷小,操作安全,并發(fā)癥少,具有其初步臨床應(yīng)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.
【學(xué)位授予單位】：南華大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2007
【分類號(hào)】：R687.3;R322

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