1.脊柱颈胸段前入路手术的应用解剖 2.下颈椎椎弓根螺钉置入的应用解剖
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摘要
目的探索一种安全暴露颈胸段椎体的最佳手术方式。方法对30例(60侧)经福尔马林固定、红色乳胶灌注的成人尸体标本采用颈胸联合切口，胸骨柄和锁骨部分切断术模拟脊柱颈胸段椎体前入路手术。对该入路中主要结构采用不同的牵拉分离方式，在主动脉弓上缘、左锁骨下动脉、左颈总动脉、头臂干、左右头臂静脉之间分离出一个安全的“间隙”，充分暴露脊柱T1—T3椎体节段。结果经左侧颈胸联合切口、胸骨柄和锁骨部分切断，将左颈动脉鞘(颈总动脉、左颈内静脉、迷走神经及其颈心支)、左锁骨下动脉、胸导管、颈交感干及左纵隔胸膜一起向外侧牵拉，向内侧牵拉气管、食管、左喉返神经及其分支，向下牵拉左头臂静脉，可清楚的显露T1上缘至T3下缘。结论经左侧颈胸联合切口、胸骨柄和锁骨部分切断，可为临床提供一种安全暴露颈胸段椎体的方法。
[摘要]目的探索一种准确置入下颈椎椎弓根螺钉的定位定向方法。方法：对25例(50侧)经福尔马林固定、红色乳胶灌注的成人尸体标本C_3—C_7节段的颈椎侧块和椎弓根进行解剖、观测。结果1)以横突后结节基部上下缘中点横切面作为确定下颈椎椎弓根螺钉进钉点上下位置的标志。2)以上下关节突间侧凹外缘作为确定下颈椎椎弓根螺钉进钉点内外位置的标志。3)以横突后结节基部与下关节突前外侧缘之间的“三角形”小凹作为寻找椎弓根下缘的标志性结构。4)置入螺钉直径为下颈椎椎弓根狭部松质骨的横径。
结论结果提供定位的标志性结构术中容易寻找，变异较小，定位准确，可为临床提供一种准确定位下颈椎椎弓根螺钉进钉点的方法。
[Abstract] Objective To explore an optimal method of exposing thecervicothoracic junction(T1-T3) . Methods The anatomic relationship between the cervicothoracic junction and the adjacent tissue were observed on 30 adult embalmed cadavers (50 sides) by modeling the anterior approach to the cervicothoracic junction. T1-T3 vertebra can be exposed through dissecting a safe space among superior edge of the aortic arch, left subclavian artery, left common carotid, brachiocephalic trunk, left brachiocephalic vein and right brachiocephalic vein. Results A standard cervical left approach was combined with osteotomy of the clavicle and partial median sternotomy, which transverse osteotomy through the synostosis between the manubrium and body of the sternum, is the best optimal selection of exposing anterior aspect of the T1-T3 vertebra in all anterior approaches. A safe space can be dissected through this operational method: left carotid sheath (common carotid, internal jugular vein, vagus nerve and its branches), thoracic duct, truncus sympathicus cervicalis, and left pleura mediastinalis were pulled towards lateral; trachea, esophagus, and left recurrent laryngeal nerve were pulled towards internal; left brachiocephalic vein was pulled towards inferior. The results of a study on 30 adult human cadavers showed that the anterior aspect of T1-T3 can be easily exposed through such the anterior approach to the cervicothoracic spinal junction. Conclusions Adequate exposure of the low cervical to the upper thoracic spine can be obtained with this approach. It provides adequate work room for inserting the screw into T1 and T3 vertebra.
[Abstract] Objective To explore an accurate method of pedicle screw insertion in cervical vertebra(C_3-C_7) . Methods Anatomic morphology of lateral mass and pedicle, and their anatomic relationship with the adjacent were observed on C_3-C_7 segment of 25 adult embalmed cadavers (50 sides). Results l)The inferior edge of the base of the posterior tubercle of the transverse process and the inferior edge of the pedicle were connected with each other on 25 adult embalmed cadaver (50 sides); The transverse section which passed through the median point between the superior edge and the inferior edge of the base of the posterior tubercle of the transverse process, and the transverse section which passed through the central axis between the superior edge and the inferior edge of the pedicle were in the same of horizontal plane. The superior and inferior position of the pedicle insertion was determined by this transverse section which passed through the median point between the superior and the inferior edge of the base of the posterior tubercle of the transverse process; 2) There was an internal-descending "triangular sulcule" between the base of the posterior tubercle of the transverse process and the anterolateral edge of the inferior articular process. The wall of the triangular sulcule: the anterior wall was the base of the posterior tubercle of the transverse process; the posterior wall was the anterolateral edge of the inferior articular process; the bottom of the sulcule was connected with the interior edge of the pedicle. The vertical length between the top of triangle and the planes of inferior edge of the pedicle was (2．78±1．71) mm. The inferior edge of the cervical pedicle could be detected by a blunt touch needle along the "triangular sulcule" between the base of the posterior tubercle of the transverse process and the anterolateral edge of the inferior articular process in surgical operation. 3) The lateral fovea of the articular process was observed on all lateral mass (50 sides). The relation of the medial and lateral position was the lateral edge of the lateral fovea of the articular process. The horizontal length between the lateral fovea of the articular process and the point of pedicle screw insertion was (3．14±1．45) mm. 4) The diameter of pedicle screw, about (2．78±1．71) mm, was the transverse diameter of the cancellous bone of the narrow part of the cervical pedicle.. Conclusions The median point between the superior edge and the inferior edge of the base of the posterior tubercle of the transverse process, the lateral fovea of the articular process, and the triangular sulcule between the base of the posterior tubercle of the transverse process and the anterolateral edge of inferior articular process, were easy to be exposed and identified in the surgical operation. Transpedicular screw can be precisely inserted through this method. The first and third points aforesaid in results were the first time reported.
[摘要]目的探索一种准确置入下颈椎椎弓根螺钉的定位定向方法。方法：对25例(50侧)经福尔马林固定、红色乳胶灌注的成人尸体标本C_3—C_7节段的颈椎侧块和椎弓根进行解剖、观测。结果1)以横突后结节基部上下缘中点横切面作为确定下颈椎椎弓根螺钉进钉点上下位置的标志。2)以上下关节突间侧凹外缘作为确定下颈椎椎弓根螺钉进钉点内外位置的标志。3)以横突后结节基部与下关节突前外侧缘之间的“三角形”小凹作为寻找椎弓根下缘的标志性结构。4)置入螺钉直径为下颈椎椎弓根狭部松质骨的横径。
结论结果提供定位的标志性结构术中容易寻找，变异较小，定位准确，可为临床提供一种准确定位下颈椎椎弓根螺钉进钉点的方法。
[Abstract] Objective To explore an optimal method of exposing thecervicothoracic junction(T1-T3) . Methods The anatomic relationship between the cervicothoracic junction and the adjacent tissue were observed on 30 adult embalmed cadavers (50 sides) by modeling the anterior approach to the cervicothoracic junction. T1-T3 vertebra can be exposed through dissecting a safe space among superior edge of the aortic arch, left subclavian artery, left common carotid, brachiocephalic trunk, left brachiocephalic vein and right brachiocephalic vein. Results A standard cervical left approach was combined with osteotomy of the clavicle and partial median sternotomy, which transverse osteotomy through the synostosis between the manubrium and body of the sternum, is the best optimal selection of exposing anterior aspect of the T1-T3 vertebra in all anterior approaches. A safe space can be dissected through this operational method: left carotid sheath (common carotid, internal jugular vein, vagus nerve and its branches), thoracic duct, truncus sympathicus cervicalis, and left pleura mediastinalis were pulled towards lateral; trachea, esophagus, and left recurrent laryngeal nerve were pulled towards internal; left brachiocephalic vein was pulled towards inferior. The results of a study on 30 adult human cadavers showed that the anterior aspect of T1-T3 can be easily exposed through such the anterior approach to the cervicothoracic spinal junction. Conclusions Adequate exposure of the low cervical to the upper thoracic spine can be obtained with this approach. It provides adequate work room for inserting the screw into T1 and T3 vertebra.
[Abstract] Objective To explore an accurate method of pedicle screw insertion in cervical vertebra(C_3-C_7) . Methods Anatomic morphology of lateral mass and pedicle, and their anatomic relationship with the adjacent were observed on C_3-C_7 segment of 25 adult embalmed cadavers (50 sides). Results l)The inferior edge of the base of the posterior tubercle of the transverse process and the inferior edge of the pedicle were connected with each other on 25 adult embalmed cadaver (50 sides); The transverse section which passed through the median point between the superior edge and the inferior edge of the base of the posterior tubercle of the transverse process, and the transverse section which passed through the central axis between the superior edge and the inferior edge of the pedicle were in the same of horizontal plane. The superior and inferior position of the pedicle insertion was determined by this transverse section which passed through the median point between the superior and the inferior edge of the base of the posterior tubercle of the transverse process; 2) There was an internal-descending "triangular sulcule" between the base of the posterior tubercle of the transverse process and the anterolateral edge of the inferior articular process. The wall of the triangular sulcule: the anterior wall was the base of the posterior tubercle of the transverse process; the posterior wall was the anterolateral edge of the inferior articular process; the bottom of the sulcule was connected with the interior edge of the pedicle. The vertical length between the top of triangle and the planes of inferior edge of the pedicle was (2．78±1．71) mm. The inferior edge of the cervical pedicle could be detected by a blunt touch needle along the "triangular sulcule" between the base of the posterior tubercle of the transverse process and the anterolateral edge of the inferior articular process in surgical operation. 3) The lateral fovea of the articular process was observed on all lateral mass (50 sides). The relation of the medial and lateral position was the lateral edge of the lateral fovea of the articular process. The horizontal length between the lateral fovea of the articular process and the point of pedicle screw insertion was (3．14±1．45) mm. 4) The diameter of pedicle screw, about (2．78±1．71) mm, was the transverse diameter of the cancellous bone of the narrow part of the cervical pedicle.. Conclusions The median point between the superior edge and the inferior edge of the base of the posterior tubercle of the transverse process, the lateral fovea of the articular process, and the triangular sulcule between the base of the posterior tubercle of the transverse process and the anterolateral edge of inferior articular process, were easy to be exposed and identified in the surgical operation. Transpedicular screw can be precisely inserted through this method. The first and third points aforesaid in results were the first time reported.
引文
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[27] Maciejczak A, Radek A, Kowalewski J, etal. Anterior transsternal approach to the upper thoracic spine [J]. ActaChirHung, 1999, 38: 83-86
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[29] Sundaresan N, Shah J, Feghali J G. A transsternal approach to the upper thoracic vertebrae. The American Journal of Surgery, 1984, 148: 473- 477
[30] Lesoin F, Thomas C E, Autrieque A, etal. A transitional biclaviclar approach to the upper anterior thoracicspine [J]. SurgNeurol, 1986, 26: 253-256
[31] Kurz L T, Pursel S E, Herkowitz H N. Modified anterior approach to the cervicothoracic junction [J]. Spine, 1991, 16(10Suppl): S542-547
[32] Sat C, Hamzaoglu A, Talu U, etal. Ananterior approach to the cervicothoracic junction of the spine (modified osteotomy of manubriumsterni and clavicle) [J]. Spinal Disord, 1999, 12: 102-106
[33] Micheli L J, Hood R W. Anterior exposure of the cervicothoracic spine using a combined cervical and thoracic approach [J]. Bone Joint Surg(Am), 1983, 65: 992-997
[34] Le Huec J C, Lesprit E, Guibaud J P, etal. Minimally invasive endoscopic approach to the cervicothoracic junction for vertebral metastases: report of two cases [J]. Eur Spine, 2001, 10: 421-426
[1] 赵森，刘执玉，毕玉顺，等．椎动脉前部的形态特点及临床意义 [J]．中国临床解剖学杂志，2002，20(1)：51-53
[2] 闫德强，谢志军，于有德，等．颈椎弓根螺钉内固定的解剖学研究 [J]．中华骨科杂志，2002，22(11)：657-661
[3] 校佰平，徐荣明，冯建翔．颈椎椎弓根与其周围神经结构的解剖学关系 [J]．脊柱外科杂志，2003，1(2)：102-104
[4] Xu R, Kang A, Ebraheim N A, etal. Anatomic relation between the cervical pedicle and the adjacent neural structure [J]. Spine, 1999, 24: 451-454
[5] Ebraheim N A, Xu R, Knight T, Yeastin R A. Morphometric evaluation of lower cervical pedicle and its projection [J]. Spine, 1997, 22: 1-6
[6] 傅一山，陈正形．颈椎弓根置钉的影像学测量 [J]．中国脊柱脊髓杂志，2001，11(1)：29-31
[7] 刘一，张绍昆，张金禄，等．双侧斜位X线片判定颈椎椎弓根螺钉置入孔道准确性的实验研究[J]．中国脊柱脊髓杂志，2005，15(2)：102-105
[8] 杨泽民，罗仲尧，陈永铵，等．螺旋CT对椎弓根螺钉固定术各种数据的测量应用 [J]．影像诊断与介入放射学，2003，12(2)：74-76
[9] 刘景堂，唐天驷，刘兴炎，等．两种长度的颈椎弓根螺钉和侧块螺钉钢板系统的稳定性比较 [J]．中华创伤骨科杂志，2005，7(4)：349-352
[10] 王东来，唐天驷，黄士中，等．五种颈椎内固定方法的稳定性生物力学评价 [J]．中华外科杂志，1999，37(5)：301-303
[11] Abumi K, Iton H, T aneich iH, etal. Transpedicle screw fixation for traumatic lesion of the middle and lower cervical spine: Description of the techniques and preliminary report [J]. J Spinal Disord, 1994, 7: 19-28
[12] Abumi K, Kaneda K. Pedicle screw fixation for nontraumatic lesion of the cervical spine [J]. Spine, 1997, 22: 1853-1863
[13] 王东来，唐天驷，黄士中，等．下颈椎椎弓根内固定的解剖学研究与临床应用 [J]．中华骨科杂志，1998，18(11)：659-662
[14] 吴战勇，孙先泽，孔建军，等．颈椎椎弓根螺钉内固定系统在颈椎的应用 [J]．中国矫形外科杂志，2000，7(10)：960-961
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[17] Abumi K, Takada T, Shono Y, etal. Posterior occipitocervical reconstruction using cervical pedicle screws and platerod systems[J]. Spine, 1999, 24: 1425-1434
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[2] H, Balabhadra R, Park J, etal. Surgical treatment of tumors involving the cervicothoracic junction [J]. Neurosurg Focus, 2003, 15 (5): E3
[3] Miller D J, Lang F F, Walsh G L, etal. Coaxial double-lumenmethy-Methacrylate reconstruction in the anterior cervical and upper thoracic spine after tumor resection [J]. Neurosurg, 2000, 92 (2Suppl): 181-190
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[5] snick DK, M. D. Anterior cervicothoracic junction corpectomy and plate fixation without Sternotomy [J]. Neurosurg Focus, 2002, 12 (1): E 7
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[11] Hodgson A, Stock F, Fang H, etal. Anterior spinal fusion: the operative approach and pathological finding sin 412 patients with Pott. s disease of the spine [J]. BrJSurg, 1960, 48: 172.
[12] Kirkaldy-willis W H, Allen P B, Rostrup O, etal. Surgical approaches to the anterior elements of the spine: indications and techniques [J]. Can J Surg, 1966, 9(3): 294
[13] Riseborough E J. The anterior approach to the spine for the correction of deformities of teaxial skeleton [J]. ClinOrthop, 1973, 93: 207
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[15] Laidlaw JD. Iso-intense neuroenteric cyst in the lower cervical spine treated with ventral resection and anterior fusion utilising sternal notch exposure: case report, technical note and literature review [J]. Clin Neurosci, 2003, 10 (5): 606-612
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[23] Sundaresan N, Shah J, Feghali J G. A transsternal approach to the upper thoracic vertebrae. The American Journal of Surgery, 1984, 148: 473-477
[24] 叶招明，严世贵，杨迪生，等．颈胸段脊柱肿瘤的外科治疗 [J]．中华骨科杂志，2000，20(5)：261-264
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[44] 李立新、原晓景，徐达传．下颈椎前方手术中预防交感干损伤的应用解剖 [J]．中国临床解剖学杂志，2004，22(6)：589—591
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[1] 王东来，唐天驷，黄士中，等．五种颈椎内固定方法的稳定性生物力学评价 [J]．中华外科杂志，1999，37(5)：301-303
[2] 刘景堂，唐天驷，王东来，等．颈椎椎弓根螺钉内固定系统的临床应用 [J]．中华骨科杂志，2003，23 (10)：590-594
[3] 闫德强，谢志军，于有德，等．颈椎弓根螺钉内固定的解剖学研究 [J]．中华骨科杂志，2002，22(11)：657-661
[5] 校佰平，徐荣明，冯建翔．颈椎椎弓根与其周围神经结构的解剖学关系 [J]．脊柱外科杂志，2003，1(2)：102-104
[6] Abumi K, Shono Y, Iron H, etal. Complications of pedicle screw fixation in reconstructive surgery of the cervical spine [J]. Spine, 2000, 25: 962-969
[7] Xu R, Kang A, Ebraheim N A, etal. Anatomic relation between the cervical pedicle and the adjacent neural structure [J]. Spine, 1999, 24: 451-454
[8] Abumi K, Iton H, T aneich iH, etal. Transpedicle screw fixation for traumatic lesion of the middle and lower cervical spine: Description of the techniques and preliminary report [J]. J Spinal Disord, 1994, 7: 19-28
[9] Abumi K, Kaneda K. Pedicle screw fixation for nontraumatic lesion of the cervical spine [J]. Spine, 1997, 22: 1853-1863.
[10] Jeaneret B, Geghard JS, Margerl F. Transopedicular screw fixation of articular mass fracture separation: results of an anatomical study and operative technique [J]. J Spinal, 1994, 7: 222-229
[11] Ebraheim N A, Xu R, Knight T, Yeastin R A. Morphometric evaluation of lower cervical pedicle and its projection [J]. Spine, 1997, 22: 1-6
[12] 王东来，唐天驷，黄士中，等．下颈椎椎弓根内固定的解剖学研究与临床应用 [J]．中华骨科杂志，1998，18(11)：659-662
[1] Robinson R A, Smith G W. Anterolateral cervical disc removal and intebody fusion forcer vical syndrome [J]. BullJohnsHopkinsHosp,1955, 96: 223-224
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[7] Sharan A D, Przybylski G J, Tartaglino L. Approaching the upper thoracic vertebrae without stemotomy or thoracotomy: a radiographic analysis with clinical application [J]. Spine, 2000, 25(8): 910-916
[8] Hodgson A, Stock F, Fang H, etal. Anterior spinal fusion: the operative approach and pathological finding sin 412 patients with Pott.s disease of the spine [J]. BrJSurg,1960, 48: 172
[9] Ebraheim N A, Lu J, Yang H, etal. Vulnerability of the sympathetic trunck during the anterior approach to the lower cervical spine [J]. Spine, 2000, 25: 1603-1606
[10] Bailey R W, Badgley C E. Stabilization of the cervical spine by anterior fusion [J]. Bone Joint Surg (Am), 1960, 42: 565-594
[11] Southwick W O, Robinson R A. Surgical approaches to the vertebral bodies in the cervical and lumbar regions [J]. Bone Joint Surg (Am), 1957, 39: 63-644
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[14] Kirkaldy-willis W H, Allen P B, Rostrup O, etal. Surgical approaches to the anterior elements of the spine: indications and techniques [J]. Can J Surg, 1966, 9(3): 294
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[20] Hodgson A R, Stock F E, Fang H S Y, etal. Anterior spinal fusion: Thoperative approach and pathologic findings in 412 patients withPott' s diease of the spine [J]. Br J Surg, 1960, 48: 172-178
[21] 肖建如，贾连顺，袁文，等．上胸椎肿瘤的手术途径及术式探讨．中华外科杂志，2001，39(5)：352-355
[22] 朱悦，王居强，范广宇，等．经胸骨前路减压治疗颈胸段脊髓压迫症 [J]．中华骨科杂志，1999，19(3)：136-138
[23] 信效堂，宫照燕，矫晓昆，等．改良式经胸骨前路病灶清除治疗颈胸段脊柱结核 [J]．中国脊柱脊髓杂志，2001，11(5)：302-303
[24] Yasui T. Sternum-splitting approach for ossification of the posterior longitudinal ligament in the cervicothoracic junction [J]. No Shinkei Geka, 1984, 12: 1021-1027
[25] Lehman R M, Grunwerg B, Hall T. Anterior approach to the cervicothoracic junction: an anatomic dissection. Spinal Disord, 1997, 10: 33-39
[26] Xu R, Grabow R, Ebraheim N A, etal. An atomic considerations of a modified anterior approach to the cervicothoracic junction. AmJOrthop, 2000, 29: 37-40
[27] Maciejczak A, Radek A, Kowalewski J, etal. Anterior transsternal approach to the upper thoracic spine [J]. ActaChirHung, 1999, 38: 83-86
[28] Standefer M, Hardy R W, Marks K, etal. Chondromyxoid fibroma of the cervical spine - A case report with a review of literature and descriptionof an operative approach to the lower anterior cervical spine [J]. Neurosurgery, 1982, 11: 288-292
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[30] Lesoin F, Thomas C E, Autrieque A, etal. A transitional biclaviclar approach to the upper anterior thoracicspine [J]. SurgNeurol, 1986, 26: 253-256
[31] Kurz L T, Pursel S E, Herkowitz H N. Modified anterior approach to the cervicothoracic junction [J]. Spine, 1991, 16(10Suppl): S542-547
[32] Sat C, Hamzaoglu A, Talu U, etal. Ananterior approach to the cervicothoracic junction of the spine (modified osteotomy of manubriumsterni and clavicle) [J]. Spinal Disord, 1999, 12: 102-106
[33] Micheli L J, Hood R W. Anterior exposure of the cervicothoracic spine using a combined cervical and thoracic approach [J]. Bone Joint Surg(Am), 1983, 65: 992-997
[34] Le Huec J C, Lesprit E, Guibaud J P, etal. Minimally invasive endoscopic approach to the cervicothoracic junction for vertebral metastases: report of two cases [J]. Eur Spine, 2001, 10: 421-426
[1] 赵森，刘执玉，毕玉顺，等．椎动脉前部的形态特点及临床意义 [J]．中国临床解剖学杂志，2002，20(1)：51-53
[2] 闫德强，谢志军，于有德，等．颈椎弓根螺钉内固定的解剖学研究 [J]．中华骨科杂志，2002，22(11)：657-661
[3] 校佰平，徐荣明，冯建翔．颈椎椎弓根与其周围神经结构的解剖学关系 [J]．脊柱外科杂志，2003，1(2)：102-104
[4] Xu R, Kang A, Ebraheim N A, etal. Anatomic relation between the cervical pedicle and the adjacent neural structure [J]. Spine, 1999, 24: 451-454
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