内镜脊柱微创外科技术的基础与临床研究
摘要
第一部分内镜辅助下脊柱外科手术入路的解剖学基础研究
一.内镜辅助经颈动脉三角前路寰枢椎手术解剖学研究
目的研究探讨内窥镜下经颈动脉三角前方入路进行寰枢椎手术的解剖层次、可行性及安全性。方法解剖20具本土成人经福尔马林固定尸标本,(1)测量颌下腺、甲状腺上动脉、喉上动脉、舌动脉、面动脉、舌下神经等分别与切口的位置关系,测量颈动脉三角区固有的神经血管肌肉间隙形成的潜在解剖学通道内外口大小,研究该入路解剖层次、建立内镜工作通道的路径及可行性。(2)观测寰枢椎及侧块关节的形态及与椎动脉、C2神经根、脊髓等结构的毗邻关系,研究寰枢椎内窥镜下经颈动脉三角入路手术的安全范围及有效性。结果内窥镜下经颈动脉三角前路寰枢椎手术可以甲状软骨上缘水平为手术切口定位标志,经颌下腺下方,甲状腺上动脉(喉上动脉)、气管食管间分离至二腹肌下方、舌骨大角外侧、颈外动脉内侧间隙,切开内脏筋膜到达咽喉间隙寰枢椎前方,沿该路径建立通道,通道外口内切圆半径左侧3.24±0.35mm,右侧3.52±0.29mm,外接圆半径左侧8.01±1.15mm,右侧7.94±0.60mm;通道内口内切圆半径左侧2.50±0.18mm,右侧2.68±0.17mm,外接圆半径左侧5.29±0.47mm,右侧5.53±0.40mm,认为满足放置内镜工作套管的需要。通过平移或偏转工作通道可以到达不同操作部位,有的放矢地彻底清除前纵韧带、椎前肌群、关节囊的挛缩瘢痕组织和异常骨性连接。侧块外缘重要结构有椎动脉及C2神经根,与侧块外缘关系紧密,距离中线分别为24.58±1.90(22.05—26.44)mm及26.50±1.01(22.82—28.40)mm。侧块松解操作宽度宜在11mm以内,深度不宜超过12mm,内窥镜下经颈动脉三角入路寰枢椎手术的安全区域为不超过中线两侧20mm。结论经颈动脉三角区建立内镜通道解剖层次清晰,对重要神经血管牵拉、影响较小,可以到达寰枢椎手术操作部位,损伤小,对局部解剖结构显露清晰,操作精细、安全,可以作为临床上处理寰枢椎病变的一种方法。
二、脊柱颈胸段胸腔镜入路的解剖学及可行性研究
目的:探讨前路胸腔镜辅助下行颈胸段手术的可行性、安全性,并为此手术提供相关的解剖学依据和数据。方法:经福尔马林固定的成人尸体颈胸段标本20例。胸腔镜入路:自胸骨炳上3cm到胸骨柄的中部切开一个6-8cm的皮肤切口,切开皮下组织及颈阔肌,切断胸骨甲状肌,胸骨舌骨肌,于左颈总动脉于气管食管之间隙暴露上纵隔,左、右第二肋间隙可以通过套管置入胸腔镜和抽吸器。观察每个切口的内部结构,探求入路的可行性,安全性,操作难易度;胸骨柄上切迹中点至各重要解剖结构的距离,手术操作区域的长、宽、深;测量并记录胸骨柄后方血管的走行,长度,管径;测量主动脉弓分支、上腔静脉分支的走行、长度、夹角、管径、测量并记录胸椎骨的长、宽、深;测量并记录胸导管的走行、注入静脉的部位、管径;颈胸段主要神经的管径及走行;左甲状腺下动脉的管径及走行。胸膜顶超出锁骨中内1/3处的高度;以上结果均做SPSS12.0统计分析(Mean±2std Error(Min~Max))。主要结果:手术操作区域的长62±5.10(53.10～84.48)mm宽:38.56±3.59(26.62-48.59)mm,深:34.63±3.45(21.74～47.87)mm,胸廓内动静脉距胸骨外缘的距离:LA2:10.12±1.41(4.20~16.29)mm,RA2:10.49±1.35(6.18~17.00) mm,LV2:8.58±1.45(3.29~14.23)mm,RV2:9.06±1.62(5.26~16.66)mm.胸骨柄上切迹到各重要结构距离:E(喉返):41.59±4.00(32.99~52.29)mm:F(心上):41.55±4.38(35.55~55.60)mm:I(胸导管):44.43±3.94(33.42~50.27)mm.。胸膜顶高出锁骨中内1/3处:左:21.71±1.87(12.91~28.66)mm,右:22.78±2.06(12.89~29.76)mm。
结论:
1.前路行电视胸腔镜辅助下行颈胸段脊柱手术是可行的。
2.前路行电视胸腔镜辅助下行颈胸段脊柱手术是安全的。
3.此手术入路具有切口小,不需切断胸骨、锁骨,不易损伤胸廓内动静脉,不易损伤胸膜,不易感染,和对于T2—T3操作视野清晰的优点,确具推广价值。
三、下腰椎前路腹腔镜椎体间融合术的血管应用解剖
目的对下腰椎(L3～S1)前路血管进行解剖学研究,分析其变异情况并探讨下腰椎前路腹腔镜下椎体间融合术的可靠性和安全性。方法解剖30例成人尸体标本(男15例、女15例),记录腹主动脉的分叉点及髂总静脉的汇合点位置,以及动静脉血管的椎前走向;测量上述分叉点与汇合点到L5椎体下缘的距离;测量L5/S1椎间隙手术窗大小(即平椎间隙右髂总动脉与左髂总静脉之间的距离);记录骶正中动脉的起始点,骶正中静脉汇入点及二者的走向。结果腹主动脉分叉点、髂总静脉汇合点分布在L4～L5之间,腹主动脉行走于椎体左前方,下腔静脉行走于椎体右前方;腹主动脉分叉点到L5椎体下缘距离,男性平均3.5cm,女性平均3.6cm;髂总静脉汇合点到L5椎体下缘距离,男性平均2.2cm,女性平均2.4cm;L5/S1椎间隙手术窗大小,男性3.7cm,女性平均3.4cm;骶中动脉均起源于腹主动脉分叉部后壁,在骶前沿中线左或右侧下行,骶中静脉多与之伴行。结论腹主动脉分叉点与髂总静脉汇合点均高于L5椎体下缘,L5/S1椎间隙手术窗大小男性平均3.7cm、女性平均3.4cm,腹腔镜下前路L5/S1椎间隙融合术是可靠及安全的;由于血管的遮盖,L3/4、L4/5椎间隙经腹膜前路融合术没有足够的血管分离及牵开是无法进行的。
四、腹腔镜下腰椎前路手术入路的解剖学实验研究
目的:探讨腹腔镜下腰椎手术的可行性及腰椎不同节段安全有效的腹腔镜手术人路。方法:解剖30例成人尸体标本(男15例、女15例),记录腰椎前主要毗邻血管的解剖学参数;取家猪40只,均分为两组,采用腹腔镜下经腹膜后人路和经腹膜腔人路显露L2～S1椎体和椎间盘,比较两种人路的有效性、安全性。结果:尸体解剖发现腹主动脉分叉点变异较多,髂总静脉汇合点相对恒定;腹主动脉分叉角度男性平均54.9°,女性平均59.0°,髂总静脉汇合角度男性平均61.4°,女性平均64.9°;腹主动脉分叉点到L5椎体下缘距离男性平均3.5cm,女性平均3.6cm;髂总静脉汇合点到L5椎体下缘距离男性平均2.2cm,女性平均2.4cm;L5/S1椎间隙手术窗大小男性平均3.7cm,女性平均3.4cm。动物实验研究发现经腹腔显露L6/S1满意,而经腹膜后显露L2-L5满意。结论:应用腹腔镜技术进行腰椎手术是可行的,该技术具有重复性好,对组织损伤小,术野内解剖结构清晰,手术的安全性和有效性较高。显露下位腰骶椎以经腹腔人路为宜,而显露上位腰椎以经腹膜后间隙人路为宜。
第二部分内镜微创在脊柱外科临床手术中的应用研究
一.内窥镜辅助下经颈动脉三角区前路松解治疗难复性寰枢关节脱位
目的:探讨内窥镜辅助下经颈动脉三角前路松解治疗难复性寰枢关节脱位的手术方法,并观察手术疗效。方法:12例难复性寰枢关节脱位患者,其中男性4例,女性8例,年龄16～48岁,平均31.6岁;病程24～48个月,平均20个月。其中陈旧性齿状突骨折5例,齿状突不连3例,横韧带松弛症3例,齿状突短小合并寰枕融合畸形1例。术前颈脊髓功能JOA评分平均9.3分。在内窥镜辅助下经颈动脉三角区前路寰椎、枢椎松解,清除寰枢椎前方挛缩瘢痕组织(或骨)连接,颅骨牵引复位,一周颈后行后路内固定融合手术。结果:前路平均手术时间70分钟,出血量150ml。松解术后有11例获得解剖复位,行寰枢椎固定。1例部分复位,行枕颈融合。术后随访3～12个月,无手术切口感染和内固定失败。术后JOA评分平均15.2分,术后功能改善率76.6%。结论:内窥镜辅助下经颈动脉三角区前路松解治疗难复性寰枢关节脱位创伤小、术野清晰、安全有效。
二、内镜辅助经颈前咽后入路上颈椎重建技术探讨
目的探讨内镜辅助下经颈前咽后入路重建技术治疗上颈椎疾患的临床疗效。方法回顾性分析2003年6月～2007年5月间应用内镜辅助经颈前咽后入路治疗的15例上颈椎疾病患者。其中男性8例,女性7例。年龄15～63岁,平均37.5岁。病理类型:颅底凹陷症7例,枢椎椎体肿瘤6例,枕颈融合假关节形成2例。均采用前后路联合手术:前路手术应用内镜辅助,经颈前咽后入路行齿状突切除、肿瘤病灶清除、脊髓减压和/或植骨重建内固定;同期行后路枕颈或C1-C3短节段内固定与融合。分析操作技术、并发症和功能恢复情况。结果所有手术均顺利完成,内镜辅助经颈前咽后入路单纯齿状突与寰椎前弓切除7例,齿状突切除+自体髂骨重建结合内固定8例;后路手术中枕颈融合9例,C1-C3短节段内固定与融合6例。术中并发症2例:口咽粘膜损伤1例,硬脊膜损伤1例;术后并发症1例,为前路手术后伤口感染,对症治疗后愈合。术后平均随访22个月,未见肿瘤复发和内固定失败,植骨均获融合,术前神经功能障碍者术后末次随访均获不同程度改善。结论:内镜辅助经颈前咽后入路上颈椎重建具有创伤小、显露充分、术野清晰、操作精确的优点,能安全有效地完成上颈椎前方的病灶清除、松解、减压和植骨内固定。
三.胸腔镜辅助小切口下行胸腰椎爆裂性骨折前路重建手术抉择
目的探讨胸腔镜辅助小切口下行胸腰椎爆裂性骨折前路重建手术选择策略。方法2000年6月～2007年4月间应用胸腔镜辅助小切口行胸腰椎爆裂性骨折前路手术42例,男28例,女14例,平均年龄34.7岁。均为单一椎体骨折,骨折部位:T118例,T1216例,L118例,平均后凸角23.8°,均为不完全性瘫痪。手术方式:应用胸腔镜辅助小切口技术,根据骨折不同位置,采取经胸腔膈肌上和胸腹联合经膈肌两种镜下入路完成前路伤椎切除、椎管减压、植骨重建及内固定。结果42例手术顺利完成,均采用钉板或钉棒系统固定。其中经胸腔膈肌上入路28例,胸腹联合经膈肌入路14例,自体髂骨植骨32例,钛网10例。平均手术时间240(160～340)min,平均出血量580(360～1250)ml,平均胸腔引流时间3.5(3～6)d,术后融合节段平均后凸角4.8°,矫正率80%。术后并发症6例,发生率14.3%。经术后平均20.2月随访,无内固定失败,矫正度无明显丢失,均获得良好植骨融合。末次随访术后神经功能均获1级以上改善。结论胸腔镜辅助小切口技术是胸腰椎爆裂性骨折前路手术安全、有效的微创选择,但临床应用有其适用范围,且需要根据膈肌解剖特点和骨折病理来选择合理的入路与手术方式。
四.胸腔镜辅助小切口胸椎结核前路重建手术的临床研究
目的评价应用胸腔镜辅助小切口技术进行胸椎结核前路重建术的临床疗效。方法回顾性分析应用胸腔镜辅助小切口技术进行脊柱前路重建的60例胸椎结核病例。其中男性38例,女性22例。年龄19～68岁,平均47.4岁。病变累及T4-T12椎体。50例有明显椎旁脓肿,17例合并胸膜炎,硬膜囊受压42例。术前拟融合节段后凸角度平均29.2°(18°～42°)。术前神经系统功能Frankel分级:A级1例;B级4例;C级6;D级19例;E级30例。结果60例手术顺利完成。均采用钉棒内固定。其中自体髂骨植骨32例,钛网28例。平均手术时间230 min(180～320),平均出血量570(350～1200)ml,平均胸腔置管引流时间3.6d(3～5d)。临床疗效优良率91.7%。术后融合节段后凸角度平均18.5°(16°～33°),矫正率36.6%。术后并发症18例,发生率30%。经术后2～6年,平均3.4年随访,无内固定松动和断裂,矫正度无明显丢失,均获得良好植骨融合。30例末次随访术后神经功能获1～3级改善。结论胸腔镜辅助小切口技术为胸椎结核前路重建提供了一种较为简易、安全、有效、实用的脊柱微创手术方法。
五.胸腔镜辅助小切口与开放前路重建手术治疗胸椎结核比较研究
目的评价胸腔镜辅助小切口和传统开放前路重建术治疗胸椎结核的临床疗效。方法回顾性分析1998年3月～2005年3月病变累及T_4-T_(12)的122例胸椎结核病例。A(组胸腔镜辅助小切口技术)59例,男37例,女22例,平均年龄47.4±4.1岁,29例伴脊髓神经损害,术前融合节段后凸角平均29.2±4.5°。B组(传统开胸术)63例,男33例,女30例,平均年龄48.3±1.5岁,31例有脊髓神经损害,术前拟融合节段后凸角平均30.3±1.5°。结果122例均采用钉棒内固定。胸腔镜小切口组平均术中出血量、胸腔引流量和拔管时间少于开放组,经统计学检验有差异,P＜0.05;平均手术时间和临床优良率两组间无差别;两组之间术前、术后1周内和末次随访融合节段后凸角矫正度的比较,统计学检验无差别;两组的组内后凸角矫正度术前与术后比较,统计学有差异,P＜0.01。A组(29例)和B组(31例)神经系统受累者术后均获不同程度改善。A组术后并发症18例,发生率30%;B组术后并发症27例,发生率51.9%。两组经术后平均3.4和3.8年随访,无复发、内固定失败和矫正度明显丢失。结论胸腔镜辅助小切口胸椎结核前路重建手术不仅可获得传统开放手术相同疗效,而且可减少创伤、出血和并发症的发生。
六.胸腔镜辅助小切口特发性脊柱侧凸前路矫形临床研究
目的评价胸腔镜辅助小切口技术结合传统内固定行特发性脊柱侧凸前路矫形的临床价值。方法2003年7月至2007年3月收治特发性脊柱侧凸26例,男10例,女16例,年龄12～30岁,平均15.8岁。主胸弯17例,胸腰弯5例,腰弯4例。术前冠状面Cobb角:主胸弯平均46.3°(41°～55°),胸腰弯平均40.6°(38°～51°),腰弯平均39.7°(36°～47°)。手术方式:采用胸腔镜辅助小切口和传统内固定行脊柱侧凸前路矫形融合术。对围手术期参数、并发症和矫正随访效果进行分析。结果平均手术时间323.9min,术中平均出血量704.2ml,平均术后胸腔引流量349.2ml,平均切口长度3.5cm,平均切除5.1(4～6)个椎间盘。术后冠状面Cobb角:主胸弯平均15.7°,平均矫正率66.1%;胸腰弯平均12.8°,平均矫正率68.5%;腰弯术后冠状面Cobb角平均8.3°,平均矫正率79%。术后并发症6例,对症治疗后愈合。术后平均随访27.6(12～40)个月,平均矫正度丢失:主胸弯8.2%,胸腰弯3.4%,腰弯6.5%。1例补充后路矫形,1例术后6个月出现胸腰段背部疼痛,支具固定半年后好转,其余无内固定失败。结论胸腔镜辅助小切口传统内固定进行侧凸前路矫形,具有微创、操作简便、矫形效果满意和经济等优势,配套操作器械和远期疗效需进一步研究。
七.LenkeⅠ型青少年特发性脊柱侧凸前路和后路手术疗效比较——前路胸腔镜辅助小切口与后路椎弓根螺钉技术
目的:回顾性分析前路胸腔镜辅助小切口与后路椎弓根螺钉技术治疗LenkeⅠ型青少年特发性脊柱侧凸的临床疗效。方法:2003年1月至2007年3月我科收治的38例Lenke1型特发性脊柱侧凸患者,采用前路胸腔镜辅助小切口技术固定矫形21例(平均年龄14.38±1.36岁),术前主胸弯Cobb角54.52±6.31°;后路椎弓根螺钉系统矫形17例(平均年龄13.82±1.85岁),术前主胸弯Cobb角53.71±6.54°。比较前、后路两组患者的术前资料,术后影像学改变差异。结果:平均随访时间2.2年,前路胸腔镜辅助下小切口组末次随访时主胸弯Cobb角平均18.52±4.78°,平均矫正率65.14±10.49%;后路椎弓根螺钉矫形组末次随访时主胸弯Cobb角平均16.71±4.54°,平均矫正率68.76±8.24%。前后路手术组患者末次随访时的上胸弯、主胸弯和胸腰/腰弯的Cobb角,颈7铅垂线偏移骶正中线距离,以及颈7铅垂线偏移骶骨后上角距离等测量值组间比较均无统计学差异。前路手术恢复了胸椎的生理曲度,去旋转效果要优于后路组(P=0.032),较后路手术组平均减少了1.7个融合节段。结论:前路胸腔镜辅助小切口技术能够取得和后路椎弓根螺钉技术相近的手术效果,且明显恢复了胸椎后凸,对顶椎的去旋转效果要优于后路组,同时在减少融合节段、缩短手术切口等方面具有一定的优势。
八、一期后路开放联合前路腹腔镜辅助下椎间融合技术在治疗腰椎疾患中的应用
目的:评价一期后路开放联合前路腹腔镜辅助下推间融合技术在治疗腰椎疾患中的临床效果。方法:回顾性分析我科自1999年12月-2001年1月应用此项技术治疗的27例腰椎疾患病人其中男11例,女16例,平均年龄42.5岁,腰椎滑脱症17例,椎间盘炎4例,结核3例,椎间盘突出合并腰椎不稳2例,陈旧性压缩性骨折合并顽固性腰痛、不稳1例。前路椎间融合材料:自体髂骨10例,BAK17例,所有病人均在全麻下行一期后路开放手术,前路腹腔镜辅助下椎间融合。结果:所有病人获随访6—12个月,平均8个月,术后病人的临床症状均得到明显改菩,无感染,脑脊液漏及神经系统并发症。随访影像学资料提示病变部位的腰椎均获得了良好稳定和椎间融合,无内固定失效和椎间融合器下沉与脱出,假关节形成等并发症。结论:一期后路开放联合前路腹腔镜辅助下椎间融合技术,可以在最大限度减少神经系统并发症和创伤基础上,获得病变腰椎良好的生物力学稳定性和临床治疗效果。
Objective:To investigate the anatomic level,feasibility,security of the Anterior Endoscopically Assisted Surgery to the Antlantoaxis through Carotid Arterial Triangle.Methods:To dissect 20 cephalo-cervical segments of native adult specimen.(1)To invest the locality relation of the incision with glandula angularis,arteria thyreoidea superior,arteria laryngea superior,arteria lingualis,arteria facialis,hypoglossal nerve etc.To measure the size of the internal and external entrance of the latent anatomic channel located in the Carotid Arterial Triangle area. To investigate the anatomic level,the feasibility and security to establish the endoscopic work path.(2) To survey the morphology of atlantoaxial vertebrae and lateral mass articular and their adjacent relation with arteria vertebralis,C2 nerve root,spinal cord etc,so as to evaluate the feasibility and secure margin of this approach.Result:The superior border of cartilage thyroidea could be the locating marker.The radius of the inscribed circle of the external entrance of the anatomic channel is 3.24±0.35mm in the left and 3.52±0.29mm in the right when the circumscribed circle 8.01±1.15mm in the left and 7.94±0.60mm in the right.And that of the internal entrance is 2.50±0.18mm in the left and 2.68±0.17mm in the right when 5.29±0.47mm in the left and 5.53±0.40mm in the left respectively.That considered to be satisfactory to place the endoscopic tract.Different operation site could be reached by translating or declinating the tract.The anterior longitudinal ligaments,anterior vertebral muscles,contracted cicatricial tissue and abnormal bony conjunction could be resected alternatively.The most important structures beyond the lateral border of lateral mass is arteria vertebralis and C2 nerve root,which part from the median line 24.58±1.90(22.05-26.44)mm and 26.50±1.01(22.82-28.40)mm respectively.The width of release operation of lateral mass should less than 11mm,as the depth less than 12ram.The secure area of operation is within 20mm from the median line.Conclusion:the anatomic layers are clear with the assistance of endoscopy to the antlantoaxial complex through Carotid Arterial Triangle.There are less traction and influence to important vessels and nerves.The operating site could be reached and there are less injuries.The exposure of local anatomic structure is clear.The operation could be more refined and secure.And this approach could be regarded as a new methods to deal with atlantoaxial disorders.
Objective:Probe the feasibility and security of thoracoscopic approach to anterior cervicothoracic junction of spine,and provide anatomic evidence and numerical data for the new operative mode.Method:experiment objects:20 adults' cadaveric examples of cervicothoracic junction of spine fixed by formalin. Thoracoscopic approach:One 6-8cm cutaneous incision from the place above manbrium sterni 3cm to the middle manbrium sterni,cut open subcutaneous tissue, platysma muscle,disconnect sternothyroid muscle and sternohyoid muscle.Expose the upper mediastinal at the space between left carotid artery and trachea and esophagus.And at left and right second rid space can be inserted thoracoscope and aspirator through 1cm trocars.Observe interior constitution,hunt fesibility and security of the approach;record the distance between the midpoint of manubrium sterni and each important constitutions,the longitude,width,depth of operative region;then measure and record courser,longitude,caliber of vessels after manbrium; messure and record courser,longitude,caliber,included angle of aortic arch and superior vena and their branches;measure and record longitude,width,depth of C7-T3 vertebrae;the courser,caliber of thoracic duct and major nerves of cervicothoracic junction and left arteria thyreoidea inferior;measure and record the longitude between cupula pleuralis and middle inner 1/3 region of clavicle.All results are made statistical analysis with SPSS 12.0(Mean±2std Error(Min～Max)).Main Results:Longitude of operative region is 67±5.10(53.10～84.48)mm,width is 38.56±3.59(26.62～48.59)mm,depth is 34.63±3.45(21.74～47.87)mm.Distance between parasternal and arteria mammaria interna:LA2;10.12±1.41(4.20～16.29)mm, RA2:10.49±1.35(6.18～17.00)mm,LV2:8.58±1.45(3.29～14.23)mm.RV2:9.06±1.62(5.2 6～16.66)mm.Distance between manubrium sterni and important constitutions: E:41.59±4.00(32.99～52.29)mm,F:41.55±4.38(35.55～55.60)mm,I:44.43±3.94 (33.42～50.27)mm.Longitude between cupula pleuralis and middle inner 1/3 region of clavicle:left:21.71±1.87(12.91～28.66) mm,right:22.78±2.06(12.89～29.76)mm.
Conclusion:
1.It is feasible to complete operation of cervicothoracic junction of spine through thoracoscopic approach.
2.It is saft to complete operation of cervicothoracic junction of spine through thoracoscopic approach.
3.This approach have many fortes as follow:opening incision is small,disconnection of sternum or clavicle isn't need,Less injure of arteria(and vena)mamaria interna,less injure of membrana pleuralis,less infection;manipulate eyesight of T2-T3 is clear.And it has generation value.
Objective To determine the variability of the anterior vascular anatomy at the lower lumbar spine.To study the reliability and the safety of the operation of lower lumbar spine intervertebral amalgamation through the laparoscope. Methods This study investigated 30 human cadavers(15 males and 15 females).The bifurcation level of the ventralaorta,the confluence level of the common iliac Vein and the course of the great vessels were recorded.The distance from the bifurcation or confluence to the top of L5 / S1 disc and the width of operation window of L5 / S1 disc(the distance from right common iliac artery to left common iliac vein) were determined.The origin of the middle sacral artery,the confluence of the middle sacral vein and the course of them were observed.Results The bifurcation level of the vent ralaorta and the confluence level of the common iliac vein were showed from L4 to L5.The course of the vent ralaorta was in the right front of vertebra,while the course of the common iliac vein was in the left front of vertebra.The distance from the bifurcation to the top of L5/S1 disc was in the average of 3.5cm for males and 3.6 cm for females.The distance from the confluence to the top of L5/S1 disc was in the average of 2.2 cm for males and 2.4 cm for females, while the width of the operation window of L5/S1 disc was in the average of 3.7 cm for males and 3.4 cm for females.The origin of the middle sacral artery was at the back of the bifurcation level,companied with the middle sacral vein of ten. Conclusion The bifurcation level of the vent ralaorta and the confluence level of the common iliac vein were higher than the top of L 5 / S1 disc,The width of the operation window of L5/S1was in the average of 3.7 cm for males and 3.4 cm for females.The anterior operation of the L5 / S1 disc intervertebral amalgamation through the laparoscope is reliable and safe.However,the operation of the L3/4disc and L4/5disc is impossible without significant vascular dissection.
Objective:To research the possibility of laparoscopic lumbar spine surgery through human cadavers and pigs to define the effect and operative approach safety in different parts of lumbar spine.Method:The anatomic data of main large vessels at the same level of lumbar verterbrae of 30 human cadaver 15 males and 15 females) were investigated;In animal experiment,40 pigs were divided into 2 groups: one group for retroperitoneal and the other group for transperitoneal laparoscopic approaches to expose L2-S1,to compare their simplicity and safety of the two operative methods.Result:The bifurcation level of the ventral aorta was quite variable in human cadavers,the confluence level of the common iliac vein was consistent:The bifurcation angle of the ventral aorta averaged male 54.9°,female 59.0°,the confl uence angle averaged male 61.4°,female 64.9°,the distance from the bifurcation to the top of L5/S1 disc averaged male 3.5cm.female 3.6cm;The distance from the confluence to the top of L5/S1 disc averaged male 2.2cm.female 2.4cm.the width of the operation window of L5/S1 disc averaged male 3.7cm.female 3.4cm.In animal experiment,it was satisfactory to expose the L6/S1 in the group of transperitoneal,and retroperitoneal laparoscopic approach the L2-L5 verterbrae.Conclusion:The technique of laparoscopic lumbar spine surgery is reliable,convenient,mininvasive and good replication.The retroperitoneal approach is safe,reasonable and efective for exposure of the L2-L5,while transperitoneal laparoscopic approach is easy and reliable for exposure of lower lumbosacral vertebrae.
Objective To evaluate the clinical efficacy for the treatment of irreducible atlantoaxial dislocation by video-assisted anterior release through carotid arterial triangle.Method Twelve patients,4 males and 8 females with the mean age of 31.6 years,ranged from 16 to 48 years old.The interval between the onset of the symptoms and the diagnosis averaged 20 months(ranging from 24 to 48 months).The type of disorders included:5 odontoid fracture,3 osodontoideum,3 relaxation of transverse ligament of atlas,1 selfunion of occipital-atlantal junction with short odontoid.The preoperative JOA score was 9.3.Soft(or bone) tissue was released between C1 and C2,skull traction and posterior instrumentation after one week.
Result The average anterior operative time was 70min,blood loss was 150ml.The fixation of atlantoaxial was performed in 11 cases and occipitocervical fixation in 1 case.All patients were followed up with average 8 months ranging from 3 to 12 months.There was no infection and fixation failure.The postoperative JOA score was 15.2 which improved to 76.6%.Conclusion Video-assisted anterior release for the treatment of irreducible atlantoaxial dislocation is a safe and effective technique with bright view and lowered risk of trauma.
Objective To evaluate the clinical efficacy for the reconstruction of upper cervical spine by video-assisted endoscopic technique via anterior retropharyngeal approach.Methods A total of 15 patients with diseases of upper cervical spine who underwent video-assisted endoscopic reconstruction surgery via anterior retropharyngeal approach from June 2003 to May 2007 were reviewed.The series included 8 males and 7 females,ranging in age from 15 to 63 years old(mean 37.5).The type of upper cervical disorders included basilar invagination in 7 patients, C2vertebral tumor in 6 patients and pseudoarticulation formation with craniocervical fusion in 2 patients.All patients undergone surgery combined anterior and posterior fixation:anterior approach included endoscopic-assisted odonoidectomy,removal of vertebral tumor,decompression and/or bony reconstruction combined fixation;One stage performed posterior craniocervical fixation or C1-3 lateral acess screw fixation. Analyzed the techniques,complications and neurological function.Results Successful surgical operation was achieved in all 15 patients.Anterior odonoidectomy combined removal of anterior arch of atlant viaendoscopic-assisted without reconstruction in 7 cases,anterior odonoidectomy with autograft iliacbone reconstruction combined fixation in 8 cases.Posterior craniocervical fixation had 9 patients and C1-3 lateral acess screw fixation in 6 patients.Complications included injuries of mucous membrane of oropharynx and spinal dura mater in 1 case respectively,1 patients occurred wound infection.With the follow up time of 22 months,There were no failure of internal fixation and tumor recurrence,bony fusion occurred and neurological function was improved in all patients.Conclusion Endoscopically anterior retropharyngeal approach to the upper cervical spine provides a surgical route which has good exposure and lowered risk of trauma.The technique issafe and effective for clearance of anterior vertebral lesions,atlantoaxial release, decompression of spinal cord,bone grafting and interal fixation.
Objective To discuss the surgical strategies of thoracoscopy-assisted mini-open surgery in the management of thoracolumbar burst fractures. Methods Between June 2000 and April 2007,42 patients with fractures of the thoracolumbar spine(T11-L1) were treated with a thoracoscopically assisted mini-open procedure.There were 28 males and 14 females and the age of the patients were from 16 to 52 years with an average of 34.7 years.The fractures located at T11 in 8 cases,T12 in 16 cases,L1 in 18 cases.The average kyphotic angle was 23.8 degrees.All cases occurred incomplete paraplegia.Surgery strategy:According to the location of fracture,anterior vertebra resection,decompression,bone graft reconstruction and internal fixation were performed by thoracoscopy-assisted and mini-open surgery via trans-diaphragmatic thoracic approach and retropleural-retroperitoneal trans-diaphragmatic approach.Results 42 surgeries were accomplished successfully using screw-plating system or screw-rod system, transthoracic transdiaphragmatic approach had 28 patients and transdiaphragmatic combined with retropleural and retroperitoneal approach had 14 patients,autograft with iliac bone in 32 cases,titanium mesh cage in 10 cases.The average operation time was 240(160～340) min.The average blood loss was 580(360～1250) ml.The average thoracic cavity drainage time was 3.5(3～6) d.The average postoperation kyphotic angle in fusion segments was 4.8°and the correction rate was 80%. Complications occurred in 6 cases,which is 14.3%of all.During an average of 20.2month follow-up period,internal fixations failure,the loss of corrective kyphotic angle were not observed and all patients had successful fusion.Postoperation neurological improvements were above 1 grade observed in the last follow-up. Conclusion Anterior thoracoscopy-assisted mini-open surgery is a safe,effective mini-invasive spinal surgery procedure to treat thoracolumbar burst fractures.But clinical application is limited in special extent and is needed to perform according to the different endoscopic diaphragma anatomy and pathological characteristics of fracture.
Objective To evaluate the clinic effects of thoracoscopy2 assisted mini2open surgery for anterior column reconstruction of thoracic spine tuberculosisl Methods Sixty patients with thoracic spine uberculosis,involving segments T4 to T12,with a kyphotic angle of 29.2 degrees(18-42 degrees),38 males and 22 females,aged 47.4(19～68),with large parasp inal abscess in 50 cases,p leurisy in 17,and dural compression in 42 cases shown by imaging examination, underwent thoracoscopic assisted mini open surgery,including radical debridement and anterior sp inal reconstruction According to Frankel's grade,the preoperative neurological function was judged as:Grade A in 1 case,Grade B in 4,Grade C in 6, Grade D in 19,and Grade E in 30.The patients were followed up for 316 years1 The outcomes were evaluated retrospectively.Results The operation was accomp lished successfully in all 60 patients.The average operative time was 230 min(180～320 min),the average blood loss during operation was 570 ml(350～1200 ml),the mean drainage duration was 3.6 d(3～5d).Complications occurred in 18 patients(30%).30 patients showed neurological imp rovement from 1 to 3 Grades at the last follow up. The average correction rate of kyphotic angle was 36.6%,and no obvious correction losswas detected during the follow up.No patient showed recurrence of tuberculosis. Conclusion Thoracoscopy assisted mini open surgery provides a simple,safe, effective,and practical technology with minimal invasiveness for the treatment of thoracic spine tuberculosis.
Objective To evaluate the clinical effects and complications of thoracoscopy- assisted mini-open and open procedures for anterior column reconstruction of thoracic spine tuberculosis.Methods 122 patients with thoracic spine tuberculosis were retrospectively analyzed between March 1998 and March 2004.Group A(underwent thoracoscopy- assisted mini-open):There were 37 males and 22 females with aaverage age of 47.4±4.1 years old.The involved segments were from T_4 to T_(12),large paraspinal abscess in 50 cases,pleurisy had 17 cases and neurological dysfunction in 29 cases,the average kyphotic angle was 29.2±4.5°with a range of 18°to 42°preoperatively.Group B(underwent open procedures):There were 33 males and 30 females with an average age of 48.3±1.5 years old.The involved segments were from T_3 to L_1,large paraspinal abscess and pleurisy in all patients,neurological dysfunction in 31 cases,the average kyphotic angle was 30.3±1.5°with a range of 19°to 45°preoperatively.Results The operation was completed in 122 patients underwent anterior reconstruction:and screw-rod fixation. The average blood loss,mean drainage volume and tube removed time in group A were less than group B,P＜0.05;The average operative time and clinical outcomes had no difference between A and B;The kyphotic angle correction of preoperative,1 week after operation and follow up had no difference between A and B;The correction of kyphotic angle intergroup analysis P＜0.01。Neurological improved in all patients.The complications:Group A,complications occurred in 18 patients(30%);Group B,complications occurred in 27 patients(51.9%).The average follow-up time was 3.6 years in group A and 3.8 years in group B,neurological improvement had 60 cases,no hardware failure and obvious loss of correction. Conclusion Thoracoscopy- assisted mini-open surgery for anterior column reconstruction of thoracic spine tuberculosis is proved to have the same outcomes as traditional open surgery,it provide a simple、safe、effective and practical minimally invasive spinal surgery technique.
Objective:To evaluate the clinical value of thoracoscopy-assisted mini-open surgery combined with tranditional fixation for anterior correction of idiopathic scoliosis.Methods:26 patients of idiopathic scoliosis were retrospectively analyzed from July 2003 to March 2007.There were 10 males and 16 females with an average age of 15.8(12～30) years old.main thoracic curve in 17 cases, thoracolumbar curve in 5 cases and lumbar curve in 4 cases.The coronal Cobb angle before surgery:main thoracic curve was 41°to 55°with an average angle of 46.3°, thoracolumbar curve was 38°to 51°with an average angle of 40.6°,and the lumbar curve was 36°to 47°with an average angle of 39.7°.Surgical method:thoracic scoliosis was instrumented through thoracoscopy-assisted mini-open combined with traditional fixation.The clinical data including perioperative index,complications and correction rate at the follow up.Results:The mean operative time,bleeding loss, drainage and length of incision were 323.9min,704.2ml,349.2ml and 3.5cm respectively,the number of resected disc was 5.1 in average.The coronal Cobb angle after surgery:main thoracic curve was 15.7°with an average correction rate of 66.1%.,thoracolumbar curve was 12.8°with an average correction rate of 68.5%,and lumbar curve was 8.3°with mean correction rate 79%.There were 6 patients occurred postoperative complications and obtained recovery after treatment.The follow-up period was from 12 to 40 months with mean 27.6 months,the loss of correction rate:main thoracic curve was 8.2%,thoracolumbar curve 3.4%and lumbar curve 6.5%.Supplementary posterior instrumentation was performed in one patient, another underwent pain 6 months after surgery and received pain relief by orthosis, there were no others harware failure.Conclusion:Thoracoscopy-assisted mini-open surgery combined with tranditional fixation for anterior correction of idiopathic scoliosis was a less invasive,convenient,effect and economical technique.However, advanced research about the endoscopic instrumentation and results of long term follow-up were needed.
Objective:Retrospectively analyze outcomes between mini-open thoracoscopically assited thoracotomy spinal fusion and posterior pedicle acrew spinal fusion for the treatment of Lenke I type adolescent idiopathic scoliosis(AIS),to evaluate the value of the two techniques.Method:Thirty eight patients were enrolled in this retrospective study from January 2004 to March 2007,there were 21 patients (mean age 14.38±1.36) underwent anterior mini-open thoracoscopiclly assisted spinal fusion,the average Cobb angle was 54.52±6.31°in main thoracic curve,and 17 patiens(mean age 13.82±1.85) received posterior segment pedicle screw fixation,the average Cobb angle was 53.71±6.54°in main thoracic curve.Radiographic data were collected preoperatively,immediatetly,and postoperatively at regular intervals. Statistics analysis was used to compare between anterior and posterior surgical group. Result:At the time of the final follow-up(mean 2.2 years),there were no significant difference between the two groups in terms of deformity correction,coronal and sagital balance.The percentage correction was 65.14±10.49%for the mini-open thoracoscopical group,and 68.76±8.24%for the posterior pedicle acrew group. Degree of derotation of apical vertebrea was better achieved by mini-open approach. Also,a kyphogenic effect on the hypokyphotic thoracic spine was achieved by mini-open approach.The mean number of levels fused was 5.4 in the mini-open group, which saved 1.7 levels,compared with 7.1 levels in posterior group.Conclusion: Mini-open thoracoscopically assited thoracotomy spinal fusion had better derotation, kyphogenic effect with fewer fusion segment,which compares favorably with posterior pedicle screw fusion in terms of coronal plane courve correction.
Objective;To evaluate the efficacy and safety with one-stage posterior and endoscopic anterior fusion with interbody implants for the treatment of lumbar diseases.Methods:Retrospective analyze twenty-seven patients with lumbar disease,Form Dec.1999 to Jan.2001,treated with this technique.Of these patients,11 males and 16 females,aged from 38 to 61 years old,mean 42.5 years. These were 17 cases of lumbar spondylolisthesis,4 cases of disc inflammation,3 cases of TB,2 cases of lu mbar disc henriation with lumbar unstability and 1 case of unfresh fracture with stemosis and unstability.Anterior inlerbody fusion;ilium 10,BAK 17, all cases were treated by one-stage open posterior methods combined with anterior laparoscopic surgery.Results:The patients were followed up form 6 to 12 months(mean8 m onths).The pre-opeartive clinical symptoms disappeared completely partially.No infection,CSF leak and neurologic complication with all patients.All patients obtained excelent spinal stability and spinal fusion.No implant fracture,BAK dislocation and pseudaurosis.Conclusion;Minimaly invasive laparoscopic spine surgery in the treatment of lumbar diseases is effective and safe technique.
一.内镜辅助经颈动脉三角前路寰枢椎手术解剖学研究
目的研究探讨内窥镜下经颈动脉三角前方入路进行寰枢椎手术的解剖层次、可行性及安全性。方法解剖20具本土成人经福尔马林固定尸标本,(1)测量颌下腺、甲状腺上动脉、喉上动脉、舌动脉、面动脉、舌下神经等分别与切口的位置关系,测量颈动脉三角区固有的神经血管肌肉间隙形成的潜在解剖学通道内外口大小,研究该入路解剖层次、建立内镜工作通道的路径及可行性。(2)观测寰枢椎及侧块关节的形态及与椎动脉、C2神经根、脊髓等结构的毗邻关系,研究寰枢椎内窥镜下经颈动脉三角入路手术的安全范围及有效性。结果内窥镜下经颈动脉三角前路寰枢椎手术可以甲状软骨上缘水平为手术切口定位标志,经颌下腺下方,甲状腺上动脉(喉上动脉)、气管食管间分离至二腹肌下方、舌骨大角外侧、颈外动脉内侧间隙,切开内脏筋膜到达咽喉间隙寰枢椎前方,沿该路径建立通道,通道外口内切圆半径左侧3.24±0.35mm,右侧3.52±0.29mm,外接圆半径左侧8.01±1.15mm,右侧7.94±0.60mm;通道内口内切圆半径左侧2.50±0.18mm,右侧2.68±0.17mm,外接圆半径左侧5.29±0.47mm,右侧5.53±0.40mm,认为满足放置内镜工作套管的需要。通过平移或偏转工作通道可以到达不同操作部位,有的放矢地彻底清除前纵韧带、椎前肌群、关节囊的挛缩瘢痕组织和异常骨性连接。侧块外缘重要结构有椎动脉及C2神经根,与侧块外缘关系紧密,距离中线分别为24.58±1.90(22.05—26.44)mm及26.50±1.01(22.82—28.40)mm。侧块松解操作宽度宜在11mm以内,深度不宜超过12mm,内窥镜下经颈动脉三角入路寰枢椎手术的安全区域为不超过中线两侧20mm。结论经颈动脉三角区建立内镜通道解剖层次清晰,对重要神经血管牵拉、影响较小,可以到达寰枢椎手术操作部位,损伤小,对局部解剖结构显露清晰,操作精细、安全,可以作为临床上处理寰枢椎病变的一种方法。
二、脊柱颈胸段胸腔镜入路的解剖学及可行性研究
目的:探讨前路胸腔镜辅助下行颈胸段手术的可行性、安全性,并为此手术提供相关的解剖学依据和数据。方法:经福尔马林固定的成人尸体颈胸段标本20例。胸腔镜入路:自胸骨炳上3cm到胸骨柄的中部切开一个6-8cm的皮肤切口,切开皮下组织及颈阔肌,切断胸骨甲状肌,胸骨舌骨肌,于左颈总动脉于气管食管之间隙暴露上纵隔,左、右第二肋间隙可以通过套管置入胸腔镜和抽吸器。观察每个切口的内部结构,探求入路的可行性,安全性,操作难易度;胸骨柄上切迹中点至各重要解剖结构的距离,手术操作区域的长、宽、深;测量并记录胸骨柄后方血管的走行,长度,管径;测量主动脉弓分支、上腔静脉分支的走行、长度、夹角、管径、测量并记录胸椎骨的长、宽、深;测量并记录胸导管的走行、注入静脉的部位、管径;颈胸段主要神经的管径及走行;左甲状腺下动脉的管径及走行。胸膜顶超出锁骨中内1/3处的高度;以上结果均做SPSS12.0统计分析(Mean±2std Error(Min~Max))。主要结果:手术操作区域的长62±5.10(53.10～84.48)mm宽:38.56±3.59(26.62-48.59)mm,深:34.63±3.45(21.74～47.87)mm,胸廓内动静脉距胸骨外缘的距离:LA2:10.12±1.41(4.20~16.29)mm,RA2:10.49±1.35(6.18~17.00) mm,LV2:8.58±1.45(3.29~14.23)mm,RV2:9.06±1.62(5.26~16.66)mm.胸骨柄上切迹到各重要结构距离:E(喉返):41.59±4.00(32.99~52.29)mm:F(心上):41.55±4.38(35.55~55.60)mm:I(胸导管):44.43±3.94(33.42~50.27)mm.。胸膜顶高出锁骨中内1/3处:左:21.71±1.87(12.91~28.66)mm,右:22.78±2.06(12.89~29.76)mm。
结论:
1.前路行电视胸腔镜辅助下行颈胸段脊柱手术是可行的。
2.前路行电视胸腔镜辅助下行颈胸段脊柱手术是安全的。
3.此手术入路具有切口小,不需切断胸骨、锁骨,不易损伤胸廓内动静脉,不易损伤胸膜,不易感染,和对于T2—T3操作视野清晰的优点,确具推广价值。
三、下腰椎前路腹腔镜椎体间融合术的血管应用解剖
目的对下腰椎(L3～S1)前路血管进行解剖学研究,分析其变异情况并探讨下腰椎前路腹腔镜下椎体间融合术的可靠性和安全性。方法解剖30例成人尸体标本(男15例、女15例),记录腹主动脉的分叉点及髂总静脉的汇合点位置,以及动静脉血管的椎前走向;测量上述分叉点与汇合点到L5椎体下缘的距离;测量L5/S1椎间隙手术窗大小(即平椎间隙右髂总动脉与左髂总静脉之间的距离);记录骶正中动脉的起始点,骶正中静脉汇入点及二者的走向。结果腹主动脉分叉点、髂总静脉汇合点分布在L4～L5之间,腹主动脉行走于椎体左前方,下腔静脉行走于椎体右前方;腹主动脉分叉点到L5椎体下缘距离,男性平均3.5cm,女性平均3.6cm;髂总静脉汇合点到L5椎体下缘距离,男性平均2.2cm,女性平均2.4cm;L5/S1椎间隙手术窗大小,男性3.7cm,女性平均3.4cm;骶中动脉均起源于腹主动脉分叉部后壁,在骶前沿中线左或右侧下行,骶中静脉多与之伴行。结论腹主动脉分叉点与髂总静脉汇合点均高于L5椎体下缘,L5/S1椎间隙手术窗大小男性平均3.7cm、女性平均3.4cm,腹腔镜下前路L5/S1椎间隙融合术是可靠及安全的;由于血管的遮盖,L3/4、L4/5椎间隙经腹膜前路融合术没有足够的血管分离及牵开是无法进行的。
四、腹腔镜下腰椎前路手术入路的解剖学实验研究
目的:探讨腹腔镜下腰椎手术的可行性及腰椎不同节段安全有效的腹腔镜手术人路。方法:解剖30例成人尸体标本(男15例、女15例),记录腰椎前主要毗邻血管的解剖学参数;取家猪40只,均分为两组,采用腹腔镜下经腹膜后人路和经腹膜腔人路显露L2～S1椎体和椎间盘,比较两种人路的有效性、安全性。结果:尸体解剖发现腹主动脉分叉点变异较多,髂总静脉汇合点相对恒定;腹主动脉分叉角度男性平均54.9°,女性平均59.0°,髂总静脉汇合角度男性平均61.4°,女性平均64.9°;腹主动脉分叉点到L5椎体下缘距离男性平均3.5cm,女性平均3.6cm;髂总静脉汇合点到L5椎体下缘距离男性平均2.2cm,女性平均2.4cm;L5/S1椎间隙手术窗大小男性平均3.7cm,女性平均3.4cm。动物实验研究发现经腹腔显露L6/S1满意,而经腹膜后显露L2-L5满意。结论:应用腹腔镜技术进行腰椎手术是可行的,该技术具有重复性好,对组织损伤小,术野内解剖结构清晰,手术的安全性和有效性较高。显露下位腰骶椎以经腹腔人路为宜,而显露上位腰椎以经腹膜后间隙人路为宜。
第二部分内镜微创在脊柱外科临床手术中的应用研究
一.内窥镜辅助下经颈动脉三角区前路松解治疗难复性寰枢关节脱位
目的:探讨内窥镜辅助下经颈动脉三角前路松解治疗难复性寰枢关节脱位的手术方法,并观察手术疗效。方法:12例难复性寰枢关节脱位患者,其中男性4例,女性8例,年龄16～48岁,平均31.6岁;病程24～48个月,平均20个月。其中陈旧性齿状突骨折5例,齿状突不连3例,横韧带松弛症3例,齿状突短小合并寰枕融合畸形1例。术前颈脊髓功能JOA评分平均9.3分。在内窥镜辅助下经颈动脉三角区前路寰椎、枢椎松解,清除寰枢椎前方挛缩瘢痕组织(或骨)连接,颅骨牵引复位,一周颈后行后路内固定融合手术。结果:前路平均手术时间70分钟,出血量150ml。松解术后有11例获得解剖复位,行寰枢椎固定。1例部分复位,行枕颈融合。术后随访3～12个月,无手术切口感染和内固定失败。术后JOA评分平均15.2分,术后功能改善率76.6%。结论:内窥镜辅助下经颈动脉三角区前路松解治疗难复性寰枢关节脱位创伤小、术野清晰、安全有效。
二、内镜辅助经颈前咽后入路上颈椎重建技术探讨
目的探讨内镜辅助下经颈前咽后入路重建技术治疗上颈椎疾患的临床疗效。方法回顾性分析2003年6月～2007年5月间应用内镜辅助经颈前咽后入路治疗的15例上颈椎疾病患者。其中男性8例,女性7例。年龄15～63岁,平均37.5岁。病理类型:颅底凹陷症7例,枢椎椎体肿瘤6例,枕颈融合假关节形成2例。均采用前后路联合手术:前路手术应用内镜辅助,经颈前咽后入路行齿状突切除、肿瘤病灶清除、脊髓减压和/或植骨重建内固定;同期行后路枕颈或C1-C3短节段内固定与融合。分析操作技术、并发症和功能恢复情况。结果所有手术均顺利完成,内镜辅助经颈前咽后入路单纯齿状突与寰椎前弓切除7例,齿状突切除+自体髂骨重建结合内固定8例;后路手术中枕颈融合9例,C1-C3短节段内固定与融合6例。术中并发症2例:口咽粘膜损伤1例,硬脊膜损伤1例;术后并发症1例,为前路手术后伤口感染,对症治疗后愈合。术后平均随访22个月,未见肿瘤复发和内固定失败,植骨均获融合,术前神经功能障碍者术后末次随访均获不同程度改善。结论:内镜辅助经颈前咽后入路上颈椎重建具有创伤小、显露充分、术野清晰、操作精确的优点,能安全有效地完成上颈椎前方的病灶清除、松解、减压和植骨内固定。
三.胸腔镜辅助小切口下行胸腰椎爆裂性骨折前路重建手术抉择
目的探讨胸腔镜辅助小切口下行胸腰椎爆裂性骨折前路重建手术选择策略。方法2000年6月～2007年4月间应用胸腔镜辅助小切口行胸腰椎爆裂性骨折前路手术42例,男28例,女14例,平均年龄34.7岁。均为单一椎体骨折,骨折部位:T118例,T1216例,L118例,平均后凸角23.8°,均为不完全性瘫痪。手术方式:应用胸腔镜辅助小切口技术,根据骨折不同位置,采取经胸腔膈肌上和胸腹联合经膈肌两种镜下入路完成前路伤椎切除、椎管减压、植骨重建及内固定。结果42例手术顺利完成,均采用钉板或钉棒系统固定。其中经胸腔膈肌上入路28例,胸腹联合经膈肌入路14例,自体髂骨植骨32例,钛网10例。平均手术时间240(160～340)min,平均出血量580(360～1250)ml,平均胸腔引流时间3.5(3～6)d,术后融合节段平均后凸角4.8°,矫正率80%。术后并发症6例,发生率14.3%。经术后平均20.2月随访,无内固定失败,矫正度无明显丢失,均获得良好植骨融合。末次随访术后神经功能均获1级以上改善。结论胸腔镜辅助小切口技术是胸腰椎爆裂性骨折前路手术安全、有效的微创选择,但临床应用有其适用范围,且需要根据膈肌解剖特点和骨折病理来选择合理的入路与手术方式。
四.胸腔镜辅助小切口胸椎结核前路重建手术的临床研究
目的评价应用胸腔镜辅助小切口技术进行胸椎结核前路重建术的临床疗效。方法回顾性分析应用胸腔镜辅助小切口技术进行脊柱前路重建的60例胸椎结核病例。其中男性38例,女性22例。年龄19～68岁,平均47.4岁。病变累及T4-T12椎体。50例有明显椎旁脓肿,17例合并胸膜炎,硬膜囊受压42例。术前拟融合节段后凸角度平均29.2°(18°～42°)。术前神经系统功能Frankel分级:A级1例;B级4例;C级6;D级19例;E级30例。结果60例手术顺利完成。均采用钉棒内固定。其中自体髂骨植骨32例,钛网28例。平均手术时间230 min(180～320),平均出血量570(350～1200)ml,平均胸腔置管引流时间3.6d(3～5d)。临床疗效优良率91.7%。术后融合节段后凸角度平均18.5°(16°～33°),矫正率36.6%。术后并发症18例,发生率30%。经术后2～6年,平均3.4年随访,无内固定松动和断裂,矫正度无明显丢失,均获得良好植骨融合。30例末次随访术后神经功能获1～3级改善。结论胸腔镜辅助小切口技术为胸椎结核前路重建提供了一种较为简易、安全、有效、实用的脊柱微创手术方法。
五.胸腔镜辅助小切口与开放前路重建手术治疗胸椎结核比较研究
目的评价胸腔镜辅助小切口和传统开放前路重建术治疗胸椎结核的临床疗效。方法回顾性分析1998年3月～2005年3月病变累及T_4-T_(12)的122例胸椎结核病例。A(组胸腔镜辅助小切口技术)59例,男37例,女22例,平均年龄47.4±4.1岁,29例伴脊髓神经损害,术前融合节段后凸角平均29.2±4.5°。B组(传统开胸术)63例,男33例,女30例,平均年龄48.3±1.5岁,31例有脊髓神经损害,术前拟融合节段后凸角平均30.3±1.5°。结果122例均采用钉棒内固定。胸腔镜小切口组平均术中出血量、胸腔引流量和拔管时间少于开放组,经统计学检验有差异,P＜0.05;平均手术时间和临床优良率两组间无差别;两组之间术前、术后1周内和末次随访融合节段后凸角矫正度的比较,统计学检验无差别;两组的组内后凸角矫正度术前与术后比较,统计学有差异,P＜0.01。A组(29例)和B组(31例)神经系统受累者术后均获不同程度改善。A组术后并发症18例,发生率30%;B组术后并发症27例,发生率51.9%。两组经术后平均3.4和3.8年随访,无复发、内固定失败和矫正度明显丢失。结论胸腔镜辅助小切口胸椎结核前路重建手术不仅可获得传统开放手术相同疗效,而且可减少创伤、出血和并发症的发生。
六.胸腔镜辅助小切口特发性脊柱侧凸前路矫形临床研究
目的评价胸腔镜辅助小切口技术结合传统内固定行特发性脊柱侧凸前路矫形的临床价值。方法2003年7月至2007年3月收治特发性脊柱侧凸26例,男10例,女16例,年龄12～30岁,平均15.8岁。主胸弯17例,胸腰弯5例,腰弯4例。术前冠状面Cobb角:主胸弯平均46.3°(41°～55°),胸腰弯平均40.6°(38°～51°),腰弯平均39.7°(36°～47°)。手术方式:采用胸腔镜辅助小切口和传统内固定行脊柱侧凸前路矫形融合术。对围手术期参数、并发症和矫正随访效果进行分析。结果平均手术时间323.9min,术中平均出血量704.2ml,平均术后胸腔引流量349.2ml,平均切口长度3.5cm,平均切除5.1(4～6)个椎间盘。术后冠状面Cobb角:主胸弯平均15.7°,平均矫正率66.1%;胸腰弯平均12.8°,平均矫正率68.5%;腰弯术后冠状面Cobb角平均8.3°,平均矫正率79%。术后并发症6例,对症治疗后愈合。术后平均随访27.6(12～40)个月,平均矫正度丢失:主胸弯8.2%,胸腰弯3.4%,腰弯6.5%。1例补充后路矫形,1例术后6个月出现胸腰段背部疼痛,支具固定半年后好转,其余无内固定失败。结论胸腔镜辅助小切口传统内固定进行侧凸前路矫形,具有微创、操作简便、矫形效果满意和经济等优势,配套操作器械和远期疗效需进一步研究。
七.LenkeⅠ型青少年特发性脊柱侧凸前路和后路手术疗效比较——前路胸腔镜辅助小切口与后路椎弓根螺钉技术
目的:回顾性分析前路胸腔镜辅助小切口与后路椎弓根螺钉技术治疗LenkeⅠ型青少年特发性脊柱侧凸的临床疗效。方法:2003年1月至2007年3月我科收治的38例Lenke1型特发性脊柱侧凸患者,采用前路胸腔镜辅助小切口技术固定矫形21例(平均年龄14.38±1.36岁),术前主胸弯Cobb角54.52±6.31°;后路椎弓根螺钉系统矫形17例(平均年龄13.82±1.85岁),术前主胸弯Cobb角53.71±6.54°。比较前、后路两组患者的术前资料,术后影像学改变差异。结果:平均随访时间2.2年,前路胸腔镜辅助下小切口组末次随访时主胸弯Cobb角平均18.52±4.78°,平均矫正率65.14±10.49%;后路椎弓根螺钉矫形组末次随访时主胸弯Cobb角平均16.71±4.54°,平均矫正率68.76±8.24%。前后路手术组患者末次随访时的上胸弯、主胸弯和胸腰/腰弯的Cobb角,颈7铅垂线偏移骶正中线距离,以及颈7铅垂线偏移骶骨后上角距离等测量值组间比较均无统计学差异。前路手术恢复了胸椎的生理曲度,去旋转效果要优于后路组(P=0.032),较后路手术组平均减少了1.7个融合节段。结论:前路胸腔镜辅助小切口技术能够取得和后路椎弓根螺钉技术相近的手术效果,且明显恢复了胸椎后凸,对顶椎的去旋转效果要优于后路组,同时在减少融合节段、缩短手术切口等方面具有一定的优势。
八、一期后路开放联合前路腹腔镜辅助下椎间融合技术在治疗腰椎疾患中的应用
目的:评价一期后路开放联合前路腹腔镜辅助下推间融合技术在治疗腰椎疾患中的临床效果。方法:回顾性分析我科自1999年12月-2001年1月应用此项技术治疗的27例腰椎疾患病人其中男11例,女16例,平均年龄42.5岁,腰椎滑脱症17例,椎间盘炎4例,结核3例,椎间盘突出合并腰椎不稳2例,陈旧性压缩性骨折合并顽固性腰痛、不稳1例。前路椎间融合材料:自体髂骨10例,BAK17例,所有病人均在全麻下行一期后路开放手术,前路腹腔镜辅助下椎间融合。结果:所有病人获随访6—12个月,平均8个月,术后病人的临床症状均得到明显改菩,无感染,脑脊液漏及神经系统并发症。随访影像学资料提示病变部位的腰椎均获得了良好稳定和椎间融合,无内固定失效和椎间融合器下沉与脱出,假关节形成等并发症。结论:一期后路开放联合前路腹腔镜辅助下椎间融合技术,可以在最大限度减少神经系统并发症和创伤基础上,获得病变腰椎良好的生物力学稳定性和临床治疗效果。
Objective:To investigate the anatomic level,feasibility,security of the Anterior Endoscopically Assisted Surgery to the Antlantoaxis through Carotid Arterial Triangle.Methods:To dissect 20 cephalo-cervical segments of native adult specimen.(1)To invest the locality relation of the incision with glandula angularis,arteria thyreoidea superior,arteria laryngea superior,arteria lingualis,arteria facialis,hypoglossal nerve etc.To measure the size of the internal and external entrance of the latent anatomic channel located in the Carotid Arterial Triangle area. To investigate the anatomic level,the feasibility and security to establish the endoscopic work path.(2) To survey the morphology of atlantoaxial vertebrae and lateral mass articular and their adjacent relation with arteria vertebralis,C2 nerve root,spinal cord etc,so as to evaluate the feasibility and secure margin of this approach.Result:The superior border of cartilage thyroidea could be the locating marker.The radius of the inscribed circle of the external entrance of the anatomic channel is 3.24±0.35mm in the left and 3.52±0.29mm in the right when the circumscribed circle 8.01±1.15mm in the left and 7.94±0.60mm in the right.And that of the internal entrance is 2.50±0.18mm in the left and 2.68±0.17mm in the right when 5.29±0.47mm in the left and 5.53±0.40mm in the left respectively.That considered to be satisfactory to place the endoscopic tract.Different operation site could be reached by translating or declinating the tract.The anterior longitudinal ligaments,anterior vertebral muscles,contracted cicatricial tissue and abnormal bony conjunction could be resected alternatively.The most important structures beyond the lateral border of lateral mass is arteria vertebralis and C2 nerve root,which part from the median line 24.58±1.90(22.05-26.44)mm and 26.50±1.01(22.82-28.40)mm respectively.The width of release operation of lateral mass should less than 11mm,as the depth less than 12ram.The secure area of operation is within 20mm from the median line.Conclusion:the anatomic layers are clear with the assistance of endoscopy to the antlantoaxial complex through Carotid Arterial Triangle.There are less traction and influence to important vessels and nerves.The operating site could be reached and there are less injuries.The exposure of local anatomic structure is clear.The operation could be more refined and secure.And this approach could be regarded as a new methods to deal with atlantoaxial disorders.
Objective:Probe the feasibility and security of thoracoscopic approach to anterior cervicothoracic junction of spine,and provide anatomic evidence and numerical data for the new operative mode.Method:experiment objects:20 adults' cadaveric examples of cervicothoracic junction of spine fixed by formalin. Thoracoscopic approach:One 6-8cm cutaneous incision from the place above manbrium sterni 3cm to the middle manbrium sterni,cut open subcutaneous tissue, platysma muscle,disconnect sternothyroid muscle and sternohyoid muscle.Expose the upper mediastinal at the space between left carotid artery and trachea and esophagus.And at left and right second rid space can be inserted thoracoscope and aspirator through 1cm trocars.Observe interior constitution,hunt fesibility and security of the approach;record the distance between the midpoint of manubrium sterni and each important constitutions,the longitude,width,depth of operative region;then measure and record courser,longitude,caliber of vessels after manbrium; messure and record courser,longitude,caliber,included angle of aortic arch and superior vena and their branches;measure and record longitude,width,depth of C7-T3 vertebrae;the courser,caliber of thoracic duct and major nerves of cervicothoracic junction and left arteria thyreoidea inferior;measure and record the longitude between cupula pleuralis and middle inner 1/3 region of clavicle.All results are made statistical analysis with SPSS 12.0(Mean±2std Error(Min～Max)).Main Results:Longitude of operative region is 67±5.10(53.10～84.48)mm,width is 38.56±3.59(26.62～48.59)mm,depth is 34.63±3.45(21.74～47.87)mm.Distance between parasternal and arteria mammaria interna:LA2;10.12±1.41(4.20～16.29)mm, RA2:10.49±1.35(6.18～17.00)mm,LV2:8.58±1.45(3.29～14.23)mm.RV2:9.06±1.62(5.2 6～16.66)mm.Distance between manubrium sterni and important constitutions: E:41.59±4.00(32.99～52.29)mm,F:41.55±4.38(35.55～55.60)mm,I:44.43±3.94 (33.42～50.27)mm.Longitude between cupula pleuralis and middle inner 1/3 region of clavicle:left:21.71±1.87(12.91～28.66) mm,right:22.78±2.06(12.89～29.76)mm.
Conclusion:
1.It is feasible to complete operation of cervicothoracic junction of spine through thoracoscopic approach.
2.It is saft to complete operation of cervicothoracic junction of spine through thoracoscopic approach.
3.This approach have many fortes as follow:opening incision is small,disconnection of sternum or clavicle isn't need,Less injure of arteria(and vena)mamaria interna,less injure of membrana pleuralis,less infection;manipulate eyesight of T2-T3 is clear.And it has generation value.
Objective To determine the variability of the anterior vascular anatomy at the lower lumbar spine.To study the reliability and the safety of the operation of lower lumbar spine intervertebral amalgamation through the laparoscope. Methods This study investigated 30 human cadavers(15 males and 15 females).The bifurcation level of the ventralaorta,the confluence level of the common iliac Vein and the course of the great vessels were recorded.The distance from the bifurcation or confluence to the top of L5 / S1 disc and the width of operation window of L5 / S1 disc(the distance from right common iliac artery to left common iliac vein) were determined.The origin of the middle sacral artery,the confluence of the middle sacral vein and the course of them were observed.Results The bifurcation level of the vent ralaorta and the confluence level of the common iliac vein were showed from L4 to L5.The course of the vent ralaorta was in the right front of vertebra,while the course of the common iliac vein was in the left front of vertebra.The distance from the bifurcation to the top of L5/S1 disc was in the average of 3.5cm for males and 3.6 cm for females.The distance from the confluence to the top of L5/S1 disc was in the average of 2.2 cm for males and 2.4 cm for females, while the width of the operation window of L5/S1 disc was in the average of 3.7 cm for males and 3.4 cm for females.The origin of the middle sacral artery was at the back of the bifurcation level,companied with the middle sacral vein of ten. Conclusion The bifurcation level of the vent ralaorta and the confluence level of the common iliac vein were higher than the top of L 5 / S1 disc,The width of the operation window of L5/S1was in the average of 3.7 cm for males and 3.4 cm for females.The anterior operation of the L5 / S1 disc intervertebral amalgamation through the laparoscope is reliable and safe.However,the operation of the L3/4disc and L4/5disc is impossible without significant vascular dissection.
Objective:To research the possibility of laparoscopic lumbar spine surgery through human cadavers and pigs to define the effect and operative approach safety in different parts of lumbar spine.Method:The anatomic data of main large vessels at the same level of lumbar verterbrae of 30 human cadaver 15 males and 15 females) were investigated;In animal experiment,40 pigs were divided into 2 groups: one group for retroperitoneal and the other group for transperitoneal laparoscopic approaches to expose L2-S1,to compare their simplicity and safety of the two operative methods.Result:The bifurcation level of the ventral aorta was quite variable in human cadavers,the confluence level of the common iliac vein was consistent:The bifurcation angle of the ventral aorta averaged male 54.9°,female 59.0°,the confl uence angle averaged male 61.4°,female 64.9°,the distance from the bifurcation to the top of L5/S1 disc averaged male 3.5cm.female 3.6cm;The distance from the confluence to the top of L5/S1 disc averaged male 2.2cm.female 2.4cm.the width of the operation window of L5/S1 disc averaged male 3.7cm.female 3.4cm.In animal experiment,it was satisfactory to expose the L6/S1 in the group of transperitoneal,and retroperitoneal laparoscopic approach the L2-L5 verterbrae.Conclusion:The technique of laparoscopic lumbar spine surgery is reliable,convenient,mininvasive and good replication.The retroperitoneal approach is safe,reasonable and efective for exposure of the L2-L5,while transperitoneal laparoscopic approach is easy and reliable for exposure of lower lumbosacral vertebrae.
Objective To evaluate the clinical efficacy for the treatment of irreducible atlantoaxial dislocation by video-assisted anterior release through carotid arterial triangle.Method Twelve patients,4 males and 8 females with the mean age of 31.6 years,ranged from 16 to 48 years old.The interval between the onset of the symptoms and the diagnosis averaged 20 months(ranging from 24 to 48 months).The type of disorders included:5 odontoid fracture,3 osodontoideum,3 relaxation of transverse ligament of atlas,1 selfunion of occipital-atlantal junction with short odontoid.The preoperative JOA score was 9.3.Soft(or bone) tissue was released between C1 and C2,skull traction and posterior instrumentation after one week.
Result The average anterior operative time was 70min,blood loss was 150ml.The fixation of atlantoaxial was performed in 11 cases and occipitocervical fixation in 1 case.All patients were followed up with average 8 months ranging from 3 to 12 months.There was no infection and fixation failure.The postoperative JOA score was 15.2 which improved to 76.6%.Conclusion Video-assisted anterior release for the treatment of irreducible atlantoaxial dislocation is a safe and effective technique with bright view and lowered risk of trauma.
Objective To evaluate the clinical efficacy for the reconstruction of upper cervical spine by video-assisted endoscopic technique via anterior retropharyngeal approach.Methods A total of 15 patients with diseases of upper cervical spine who underwent video-assisted endoscopic reconstruction surgery via anterior retropharyngeal approach from June 2003 to May 2007 were reviewed.The series included 8 males and 7 females,ranging in age from 15 to 63 years old(mean 37.5).The type of upper cervical disorders included basilar invagination in 7 patients, C2vertebral tumor in 6 patients and pseudoarticulation formation with craniocervical fusion in 2 patients.All patients undergone surgery combined anterior and posterior fixation:anterior approach included endoscopic-assisted odonoidectomy,removal of vertebral tumor,decompression and/or bony reconstruction combined fixation;One stage performed posterior craniocervical fixation or C1-3 lateral acess screw fixation. Analyzed the techniques,complications and neurological function.Results Successful surgical operation was achieved in all 15 patients.Anterior odonoidectomy combined removal of anterior arch of atlant viaendoscopic-assisted without reconstruction in 7 cases,anterior odonoidectomy with autograft iliacbone reconstruction combined fixation in 8 cases.Posterior craniocervical fixation had 9 patients and C1-3 lateral acess screw fixation in 6 patients.Complications included injuries of mucous membrane of oropharynx and spinal dura mater in 1 case respectively,1 patients occurred wound infection.With the follow up time of 22 months,There were no failure of internal fixation and tumor recurrence,bony fusion occurred and neurological function was improved in all patients.Conclusion Endoscopically anterior retropharyngeal approach to the upper cervical spine provides a surgical route which has good exposure and lowered risk of trauma.The technique issafe and effective for clearance of anterior vertebral lesions,atlantoaxial release, decompression of spinal cord,bone grafting and interal fixation.
Objective To discuss the surgical strategies of thoracoscopy-assisted mini-open surgery in the management of thoracolumbar burst fractures. Methods Between June 2000 and April 2007,42 patients with fractures of the thoracolumbar spine(T11-L1) were treated with a thoracoscopically assisted mini-open procedure.There were 28 males and 14 females and the age of the patients were from 16 to 52 years with an average of 34.7 years.The fractures located at T11 in 8 cases,T12 in 16 cases,L1 in 18 cases.The average kyphotic angle was 23.8 degrees.All cases occurred incomplete paraplegia.Surgery strategy:According to the location of fracture,anterior vertebra resection,decompression,bone graft reconstruction and internal fixation were performed by thoracoscopy-assisted and mini-open surgery via trans-diaphragmatic thoracic approach and retropleural-retroperitoneal trans-diaphragmatic approach.Results 42 surgeries were accomplished successfully using screw-plating system or screw-rod system, transthoracic transdiaphragmatic approach had 28 patients and transdiaphragmatic combined with retropleural and retroperitoneal approach had 14 patients,autograft with iliac bone in 32 cases,titanium mesh cage in 10 cases.The average operation time was 240(160～340) min.The average blood loss was 580(360～1250) ml.The average thoracic cavity drainage time was 3.5(3～6) d.The average postoperation kyphotic angle in fusion segments was 4.8°and the correction rate was 80%. Complications occurred in 6 cases,which is 14.3%of all.During an average of 20.2month follow-up period,internal fixations failure,the loss of corrective kyphotic angle were not observed and all patients had successful fusion.Postoperation neurological improvements were above 1 grade observed in the last follow-up. Conclusion Anterior thoracoscopy-assisted mini-open surgery is a safe,effective mini-invasive spinal surgery procedure to treat thoracolumbar burst fractures.But clinical application is limited in special extent and is needed to perform according to the different endoscopic diaphragma anatomy and pathological characteristics of fracture.
Objective To evaluate the clinic effects of thoracoscopy2 assisted mini2open surgery for anterior column reconstruction of thoracic spine tuberculosisl Methods Sixty patients with thoracic spine uberculosis,involving segments T4 to T12,with a kyphotic angle of 29.2 degrees(18-42 degrees),38 males and 22 females,aged 47.4(19～68),with large parasp inal abscess in 50 cases,p leurisy in 17,and dural compression in 42 cases shown by imaging examination, underwent thoracoscopic assisted mini open surgery,including radical debridement and anterior sp inal reconstruction According to Frankel's grade,the preoperative neurological function was judged as:Grade A in 1 case,Grade B in 4,Grade C in 6, Grade D in 19,and Grade E in 30.The patients were followed up for 316 years1 The outcomes were evaluated retrospectively.Results The operation was accomp lished successfully in all 60 patients.The average operative time was 230 min(180～320 min),the average blood loss during operation was 570 ml(350～1200 ml),the mean drainage duration was 3.6 d(3～5d).Complications occurred in 18 patients(30%).30 patients showed neurological imp rovement from 1 to 3 Grades at the last follow up. The average correction rate of kyphotic angle was 36.6%,and no obvious correction losswas detected during the follow up.No patient showed recurrence of tuberculosis. Conclusion Thoracoscopy assisted mini open surgery provides a simple,safe, effective,and practical technology with minimal invasiveness for the treatment of thoracic spine tuberculosis.
Objective To evaluate the clinical effects and complications of thoracoscopy- assisted mini-open and open procedures for anterior column reconstruction of thoracic spine tuberculosis.Methods 122 patients with thoracic spine tuberculosis were retrospectively analyzed between March 1998 and March 2004.Group A(underwent thoracoscopy- assisted mini-open):There were 37 males and 22 females with aaverage age of 47.4±4.1 years old.The involved segments were from T_4 to T_(12),large paraspinal abscess in 50 cases,pleurisy had 17 cases and neurological dysfunction in 29 cases,the average kyphotic angle was 29.2±4.5°with a range of 18°to 42°preoperatively.Group B(underwent open procedures):There were 33 males and 30 females with an average age of 48.3±1.5 years old.The involved segments were from T_3 to L_1,large paraspinal abscess and pleurisy in all patients,neurological dysfunction in 31 cases,the average kyphotic angle was 30.3±1.5°with a range of 19°to 45°preoperatively.Results The operation was completed in 122 patients underwent anterior reconstruction:and screw-rod fixation. The average blood loss,mean drainage volume and tube removed time in group A were less than group B,P＜0.05;The average operative time and clinical outcomes had no difference between A and B;The kyphotic angle correction of preoperative,1 week after operation and follow up had no difference between A and B;The correction of kyphotic angle intergroup analysis P＜0.01。Neurological improved in all patients.The complications:Group A,complications occurred in 18 patients(30%);Group B,complications occurred in 27 patients(51.9%).The average follow-up time was 3.6 years in group A and 3.8 years in group B,neurological improvement had 60 cases,no hardware failure and obvious loss of correction. Conclusion Thoracoscopy- assisted mini-open surgery for anterior column reconstruction of thoracic spine tuberculosis is proved to have the same outcomes as traditional open surgery,it provide a simple、safe、effective and practical minimally invasive spinal surgery technique.
Objective:To evaluate the clinical value of thoracoscopy-assisted mini-open surgery combined with tranditional fixation for anterior correction of idiopathic scoliosis.Methods:26 patients of idiopathic scoliosis were retrospectively analyzed from July 2003 to March 2007.There were 10 males and 16 females with an average age of 15.8(12～30) years old.main thoracic curve in 17 cases, thoracolumbar curve in 5 cases and lumbar curve in 4 cases.The coronal Cobb angle before surgery:main thoracic curve was 41°to 55°with an average angle of 46.3°, thoracolumbar curve was 38°to 51°with an average angle of 40.6°,and the lumbar curve was 36°to 47°with an average angle of 39.7°.Surgical method:thoracic scoliosis was instrumented through thoracoscopy-assisted mini-open combined with traditional fixation.The clinical data including perioperative index,complications and correction rate at the follow up.Results:The mean operative time,bleeding loss, drainage and length of incision were 323.9min,704.2ml,349.2ml and 3.5cm respectively,the number of resected disc was 5.1 in average.The coronal Cobb angle after surgery:main thoracic curve was 15.7°with an average correction rate of 66.1%.,thoracolumbar curve was 12.8°with an average correction rate of 68.5%,and lumbar curve was 8.3°with mean correction rate 79%.There were 6 patients occurred postoperative complications and obtained recovery after treatment.The follow-up period was from 12 to 40 months with mean 27.6 months,the loss of correction rate:main thoracic curve was 8.2%,thoracolumbar curve 3.4%and lumbar curve 6.5%.Supplementary posterior instrumentation was performed in one patient, another underwent pain 6 months after surgery and received pain relief by orthosis, there were no others harware failure.Conclusion:Thoracoscopy-assisted mini-open surgery combined with tranditional fixation for anterior correction of idiopathic scoliosis was a less invasive,convenient,effect and economical technique.However, advanced research about the endoscopic instrumentation and results of long term follow-up were needed.
Objective:Retrospectively analyze outcomes between mini-open thoracoscopically assited thoracotomy spinal fusion and posterior pedicle acrew spinal fusion for the treatment of Lenke I type adolescent idiopathic scoliosis(AIS),to evaluate the value of the two techniques.Method:Thirty eight patients were enrolled in this retrospective study from January 2004 to March 2007,there were 21 patients (mean age 14.38±1.36) underwent anterior mini-open thoracoscopiclly assisted spinal fusion,the average Cobb angle was 54.52±6.31°in main thoracic curve,and 17 patiens(mean age 13.82±1.85) received posterior segment pedicle screw fixation,the average Cobb angle was 53.71±6.54°in main thoracic curve.Radiographic data were collected preoperatively,immediatetly,and postoperatively at regular intervals. Statistics analysis was used to compare between anterior and posterior surgical group. Result:At the time of the final follow-up(mean 2.2 years),there were no significant difference between the two groups in terms of deformity correction,coronal and sagital balance.The percentage correction was 65.14±10.49%for the mini-open thoracoscopical group,and 68.76±8.24%for the posterior pedicle acrew group. Degree of derotation of apical vertebrea was better achieved by mini-open approach. Also,a kyphogenic effect on the hypokyphotic thoracic spine was achieved by mini-open approach.The mean number of levels fused was 5.4 in the mini-open group, which saved 1.7 levels,compared with 7.1 levels in posterior group.Conclusion: Mini-open thoracoscopically assited thoracotomy spinal fusion had better derotation, kyphogenic effect with fewer fusion segment,which compares favorably with posterior pedicle screw fusion in terms of coronal plane courve correction.
Objective;To evaluate the efficacy and safety with one-stage posterior and endoscopic anterior fusion with interbody implants for the treatment of lumbar diseases.Methods:Retrospective analyze twenty-seven patients with lumbar disease,Form Dec.1999 to Jan.2001,treated with this technique.Of these patients,11 males and 16 females,aged from 38 to 61 years old,mean 42.5 years. These were 17 cases of lumbar spondylolisthesis,4 cases of disc inflammation,3 cases of TB,2 cases of lu mbar disc henriation with lumbar unstability and 1 case of unfresh fracture with stemosis and unstability.Anterior inlerbody fusion;ilium 10,BAK 17, all cases were treated by one-stage open posterior methods combined with anterior laparoscopic surgery.Results:The patients were followed up form 6 to 12 months(mean8 m onths).The pre-opeartive clinical symptoms disappeared completely partially.No infection,CSF leak and neurologic complication with all patients.All patients obtained excelent spinal stability and spinal fusion.No implant fracture,BAK dislocation and pseudaurosis.Conclusion;Minimaly invasive laparoscopic spine surgery in the treatment of lumbar diseases is effective and safe technique.
引文
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