本文選題：上胸椎 + 肩腳區(qū)應(yīng)用解剖學(xué)��； 參考：《南方醫(yī)科大學(xué)》2008年碩士論文

【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)。該段胸椎運(yùn)動(dòng)度小,位置相對(duì)固定,其周圍解剖結(jié)構(gòu)復(fù)雜,并且有胸骨柄、肩胛骨等遮擋,脊柱位置深在,手術(shù)顯露困難。據(jù)報(bào)道,約15%的脊柱腫瘤位于上胸椎,后縱韌帶鈣化、椎間盤突出等退行性病變雖不多見(約0.3%)于上胸椎,但該段椎管相對(duì)較小,容易造成壓迫,且癥狀往往較重,常需手術(shù)治療。由于其特殊的解剖結(jié)構(gòu),目前用于顯露上胸椎的手術(shù)入路較多,包括劈胸入路、低位頸椎入路、頸前胸骨柄聯(lián)合入路、部分鎖骨切除劈胸入路、內(nèi)窺鏡微創(chuàng)手術(shù)、經(jīng)肋骨橫突后外側(cè)入路、后方入路等,但均因手術(shù)創(chuàng)傷大,風(fēng)險(xiǎn)高及顯露范圍不理想等缺點(diǎn),未能廣泛應(yīng)用。而肩胛深層入路(也有稱肩胛下入路)可直接從側(cè)前方顯露上胸椎,無需牽拉重要神經(jīng)、血管等結(jié)構(gòu),具有顯露好、風(fēng)險(xiǎn)小的優(yōu)點(diǎn)。但仍有報(bào)道胸導(dǎo)管損傷等并發(fā)癥,且尚未見有該手術(shù)入路解剖學(xué)研究的報(bào)道。本研究在原手術(shù)入路的基礎(chǔ)上改良皮膚切口及肋骨切口,并對(duì)21例標(biāo)本進(jìn)行解剖學(xué)研究,旨在為該改良手術(shù)入路的臨床應(yīng)用提供解剖學(xué)依據(jù)。同時(shí),對(duì)進(jìn)行改良肩胛深層入路顯露上胸椎手術(shù)的臨床病例進(jìn)行研究分析,總結(jié)該手術(shù)入路的適應(yīng)證、療效和經(jīng)驗(yàn)。 目的: 1.在人體標(biāo)本上進(jìn)行改良肩胛深層入路顯露上胸椎的模擬手術(shù),測(cè)量各項(xiàng)解剖學(xué)數(shù)據(jù),從而對(duì)如何順利利用該入路顯露上胸椎,減少創(chuàng)傷及風(fēng)險(xiǎn),提高手術(shù)效果提供解剖學(xué)依據(jù)。 2.對(duì)進(jìn)行改良肩胛深層入路顯露上胸椎手術(shù)的臨床病例治療進(jìn)行研究分析,總結(jié)該手術(shù)入路的適應(yīng)證、療效和經(jīng)驗(yàn)。 材料和方法: 1.本實(shí)驗(yàn)標(biāo)本為21例經(jīng)福爾馬林浸泡防腐成人尸體,出生地域、年齡不詳(由南方醫(yī)科大學(xué)人體解剖學(xué)教研室提供),其中男性14例,女性7例,經(jīng)檢查排除胸部病變。按左右側(cè)肋骨切口高低,將以上實(shí)驗(yàn)標(biāo)本隨機(jī)分為右高左低組(A組)、左高右低組(B組)及低位切口組(C組);本實(shí)驗(yàn)使用測(cè)量工具為游標(biāo)卡尺(精確度0.01mm)和不銹鋼直尺(精確度0.5mm)。 2.將尸體標(biāo)本放置于解剖實(shí)驗(yàn)臺(tái)上,按手術(shù)入路,逐層解剖至上胸椎椎體,觀察并測(cè)量皮膚切口長度、肋骨切口縱向撐開寬度、顯露椎體范圍、雙側(cè)交感神經(jīng)干、奇靜脈弓及胸導(dǎo)管等結(jié)構(gòu)。 利用SPSS 11.5統(tǒng)計(jì)學(xué)軟件(由南方醫(yī)科大學(xué)統(tǒng)計(jì)學(xué)教研室提供)對(duì)所采集的數(shù)據(jù)進(jìn)行處理。計(jì)算各組數(shù)據(jù)(計(jì)量資料)的算術(shù)均數(shù);奇靜脈弓最高點(diǎn)位置按位置不同分組并算出各組比率;傳統(tǒng)皮膚切口與改良皮膚切口長度均數(shù)用配對(duì)t檢驗(yàn)比較;同一尸體標(biāo)本左右側(cè)胸交感干至肋頭關(guān)節(jié)前緣的距離數(shù)據(jù)用配對(duì)t檢驗(yàn)比較。比較時(shí)差異有統(tǒng)計(jì)學(xué)意義設(shè)定在(P＜0.05)。 3.以3例臨床應(yīng)用改良肩胛深層入路的病例為對(duì)象,對(duì)病例的術(shù)前和術(shù)后的癥狀、體征、影像學(xué)等臨床資料進(jìn)行分析。 結(jié)果: 改良肩胛深層手術(shù)入路皮膚切口長度平均(22.88±1.70)cm;若切除第3肋骨,切口縱向撐開寬度平均(6.10±0.68)cm,能顯露T_(2-4)椎體(100%);若聯(lián)合切除第2肋骨,切口撐開寬度平均(8.08±0.93)cm,能顯露T_1椎體T2/3—T_4椎體(83.3%);若聯(lián)合切除第4肋骨,切口撐開寬度平均(8.87±0.73)cm,能顯露T_(2-5)椎體(100%);若單純切除第4肋切口撐開寬度平均(6.03±0.53)cm,顯露T_(3-5)椎體(100%);交感神經(jīng)干、奇靜脈弓及胸導(dǎo)管等結(jié)構(gòu)在顯露過程中出現(xiàn)在相對(duì)恒定的位置,術(shù)中仔細(xì)操作可避免損傷。 在臨床應(yīng)用的例患者中,所有病例癥狀體癥均獲得改善,無明顯并發(fā)癥,影像學(xué)資料表明:植骨塊及內(nèi)固定物位置滿意。 結(jié)論: 1.改良肩胛深層入路手術(shù)具有:解剖層次相對(duì)簡單,重要結(jié)構(gòu)較少,直接從側(cè)前方解除壓迫,術(shù)中視角好,不易損傷硬膜及脊髓等特點(diǎn)。該改良入路是顯露上胸椎的理想的手術(shù)入路,具有創(chuàng)傷小,顯露好,安全性高等優(yōu)點(diǎn)。 2.臨床應(yīng)用病例證明:改良肩胛深層入路手術(shù)在處理上胸椎(主要是T_2-T_4)及其相鄰下位胸椎的疾病,具有創(chuàng)傷出血小,顯露減壓好,操作安全性高等優(yōu)點(diǎn)。對(duì)3例臨床病例的分析,證明該入路可以完全滿足上胸椎(主要是T_2-T_4)及其相鄰下位胸椎病灶清除、椎管減壓、植骨及內(nèi)固定操作的需要,術(shù)后病灶清除、椎管減壓徹底,植骨、內(nèi)固定可靠,胸椎穩(wěn)定性好,可以滿足臨床應(yīng)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.

【學(xué)位授予單位】：南方醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2008
【分類號(hào)】：R687.3;R322

【參考文獻(xiàn)】

相關(guān)期刊論文 前1條

1 任先軍,張峽,王建,周政;肩胛下高位經(jīng)胸入路行上胸椎前路減壓融合術(shù)[J];脊柱外科雜志;2003年01期

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本文編號(hào)：1842011