本文選題：脊柱骨折/外科學　切入點：截癱/外科學　出處：《福建中醫(yī)學院》2008年碩士論文　論文類型：學位論文

【摘要】： 目的: 1對胸骨柄與上胸椎的手術部位進行解剖觀測,研究經(jīng)胸骨柄“U”形開窗入路顯露上胸椎的可行性,為臨床經(jīng)胸骨柄“U”形開窗顯露上胸椎典定解剖學基礎。 2解剖上縱膈重要血管神經(jīng)走行特點及對應椎體位置關系,對比上胸椎左右側(cè)前方入路的風險性,為臨床提供參考。 3應用經(jīng)胸骨柄“U”形開窗入路治療上胸椎爆裂骨折并截癱患者,觀察其臨床療效,分析該入路優(yōu)越性及注意事項。 方法: 1 35具經(jīng)甲醛固定的尸體標本測量上胸椎(T_(1-4))椎體寬,計算均值a(mm),測量胸骨柄最窄處寬b(mm),計算出a/b值(%):50例脊柱頸胸段正中矢狀位MRI,標記水平位置恰高于胸骨角的椎體為觀察椎,測量“觀察椎椎體下緣在胸骨柄上水平投影點與頸靜脈切跡中點的距離”c(mm),胸骨柄長d(mm),計算出c/d值(%)。 2 35具尸體標本,取頸胸部左前內(nèi)側(cè)入路,經(jīng)胸骨柄“U”形開窗(圖15),觀測自左頸動脈鞘與氣管食管鞘間隙顯露的脊柱上胸段范圍。觀測喉返神經(jīng)和胸導管等重要結(jié)構(gòu)的走行及對應椎體關系,分析其對手術入路的影響。 3上胸椎爆裂骨折并截癱患者12例,完全癱瘓6例,不完全癱瘓6例。脊髓損傷按Asia分級,A級6例,B級1例,C級3例,D級2例。全部采用經(jīng)胸骨柄“U”形開窗入路行傷椎次全切除減壓、植骨、頸椎前路鋼板內(nèi)固定術。 結(jié)果: 1 35具尸體標本“上胸椎(T_(1-4))椎體寬均值/胸骨柄最窄處寬”即(a/b),均值為(78±7.9)%。a/b＜1,所以經(jīng)胸骨柄“U”形開窗冠狀面上可直視下顯露上胸椎椎體,切除的范圍為柄最窄處寬的(78±7.9)%。50例脊柱頸胸段正中矢狀位MRI,46例(92%)T_4椎體下緣高于胸骨角水平,標記T_4椎體為觀察椎。46例T_4椎體下緣高于胸骨角水平的MRI,“I_4椎體下緣在胸骨柄上水平投影點與頸靜脈切跡中點的距離/胸骨柄長”即(c/d),均值為(72±14.7)%。c/d＜1,所以經(jīng)胸骨柄“U”形開窗矢狀面上可直視下顯露至T_4椎體,顯露至T_4椎體下緣時,切除的范圍為柄長的(72±14.7)%。 2經(jīng)氣管食管鞘、左側(cè)頸動脈鞘及左無名靜脈之間的間隙,35具尸體標本能顯露T_4椎體的占91.4%。右喉返神經(jīng)在T_(1-2)水平從迷走神經(jīng)發(fā)出,繞過右鎖骨下動脈斜行返轉(zhuǎn)向上,于T_1上緣水平入氣管食管溝內(nèi),在T_(1、2)水平橫過頸動脈鞘及內(nèi)臟鞘間隙,易受牽拉損傷(圖10);左喉返神經(jīng)在頸胸部走行于氣管食管溝內(nèi)而不易受損傷;上胸段胸導管靠脊柱左側(cè)貼近氣管食管鞘左緣上行,在T_2水平即開始離開氣管食管鞘,轉(zhuǎn)向外側(cè)緊貼左鎖骨下動脈內(nèi)表面走行,并形成胸導管弓,解剖位置利于術中保護。故經(jīng)前路顯露上胸椎宜采用左側(cè)入路。 3 12例病例均獲隨訪,時間1～7年,椎間植骨均融合好,無內(nèi)固定松動、斷裂,無切口感染、頸前血腫、肺不張、氣胸、乳糜漏、肺部感染等手術并發(fā)癥。9例術后感覺、運動神經(jīng)功能均有不同程度改善,3例術前完全癱瘓(Asia分級A級)術后未見明顯改善。Asia分級術前A級6例術后恢復至B級1例、C級2例、另3例無明顯改善;B級1例恢復至C級;C級3例恢復至D級2例、E級1例;D級2例恢復至E級。 結(jié)論: 1解剖學上,經(jīng)胸骨柄“U”形開窗入路能夠顯露至T_4椎體。 2臨床上,經(jīng)胸骨柄“U”形開窗入路能夠治療上胸椎(T_(1-3))爆裂骨折并截癱。 3經(jīng)胸骨柄“U”形開窗入路是治療上胸椎爆裂骨折并截癱理想的手術入路。
[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:
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本文編號：1570753