颈胸段脊柱椎体前方重要结构的解剖特点及其临床意义

目的:为颈胸段脊柱前路手术提供应用解剖学基础.方法:供局解教学的成人尸体标本30具(男25、女5);模拟经胸骨柄和部分锁骨切除的颈胸段脊柱前路术式,采用连续层次解剖方法,重点观测手术途径中暴露C5～T3椎体时必须牵开并加以保护的几个重要结构.结果:左头臂静脉的长度为(6.9±1.0)cm,左静脉角与前正中线的水平距离为(4.3±0.9)cm.右喉返神经在颈部的行程町分为两部分,上部位于脏筋膜内,下部在脏筋膜外,其穿入脏筋膜的位置位于C7～T1椎间水平的有14.3%(4例),位于T1椎体上半部水平的85.7%(26例).左侧喉返神经在颈部(包括T2椎体水平)均于脏筋膜内走行.胸膜顶最高点距锁骨内1/3上缘的垂直距离.左侧(0.8±0.2)cm、右侧(1.3±0.2)cm.胸导管弓最高点距环状软骨水平的垂直距离(1.8±0.4)cm.结论:经胸骨柄和部分锁骨切除的颈胸段脊柱的前路术式可以充分暴露C5～T3,术者对局部解剖的熟悉程度是前路手术得以正常开展与减少医源性并发症发生的关键.     

颈胸段脊柱前路手术的应用解剖研究

目的为颈胸段脊柱前路手术提供应用解剖学资料。方法供局解教学操作使用的成人尸体30具（男25、女5），模拟经胸骨柄和部分锁骨切除的颈胸段脊柱前路术式，采用连续层次解剖方法，重点观测手术途径中暴露C5～T3椎体时必须牵开并加以保护的几个重要结构。结果左头臂静脉的长度为（68．5±10．0）mm，左静脉角与前正中线的水平距离为（43．3±8．8）mm。右喉返神经在颈部的行程可分为两部分，上部位于脏筋膜内，下部在脏筋膜外，其穿入脏筋膜的位置位于C7～T1椎间水平的有4例（14．3％），位于T1椎体上半部水平的26例（85．7％）。左侧喉返神经在颈部（包括T2椎体水平）均于脏筋膜内走行。胸膜顶最高点距锁骨内1／3上缘的垂直距离，左侧（7．5±1．9）mm、右侧（12．8±2．3）mm。胸导管弓最高点距环状软骨水平的垂直距离（18．0±3．9）mm。结论经胸骨柄和部分锁骨切除的颈胸段脊柱的前路术式可以充分暴露C5～T3，术者对局部解剖的熟悉程度是前路手术得以正常开展与减少医源性并发症发生的关键。     

颈胸段脊柱椎体周围重要脉管结构的应用解剖

目的:为颈胸段脊柱选择合理的前方入路提供解剖学依据。方法:在30具成人尸体上,观察颈胸段脊柱周围重要脉管的解剖分布及毗邻关系。结果:①胸导管在T5水平由椎体右侧越中线向左移行,在T4椎体左前方上行到T2水平,再行向左上方,80%在C7～C7/T1水平呈弓状注入左静脉角或锁骨下静脉内侧段。②70%的主动脉弓顶点对应T3椎体水平。胸主动脉中轴线到椎体前正中线(PVM)距离在T4水平大于在主动脉弓顶点和T5水平。③63%的上腔静脉(SVC)起点对应T3椎体水平。SVC起点到PVM及SVC中轴线分别在T4、T5水平到PVM的距离逐渐增大。左右头臂静脉与PVM的夹角分别为:59.35°±5.40°和33.62°±5.59°。左侧大于右侧(P<0.05)。奇静脉在SVC的注入点87%位于T3/4～T4水平。结论:应根据不同的病变节段选择合理的颈胸段脊柱前方手术入路,上位椎体应选经左侧低位下颈椎前方入路或偏左侧部分劈开胸骨柄入路,下位椎体应选择右侧经胸腔入路或偏右侧劈胸骨入路。     

颈胸段脊柱周围重要神经结构及其毗邻关系

目的:为颈胸段脊柱选择合理的手术入路提供解剖学依据。方法:在30具尸体标本上,观察颈胸段脊柱周围重要神经结构及毗邻关系。结果:(1)喉返神经(RLN)进入气管食管沟的位置对应椎体水平及构成比,左:90%位于T3/4～T4水平,右:70%位于C6/7～C7上水平;67.7%的右RLN与颈总动脉的交叉点对应椎体水平在T1下～T1/2水平。(2)颈胸段交感干(CTST)与椎体前正中线(PVM)距离在T1椎体中点水平较C6～C7和T2～T5水平大,且男女之间差异有统计学意义(P<0.05)。(3)膈神经(PN)入胸腔后,左PN于主动脉弓前方、右PN于上腔静脉前外侧经心包与纵隔胸膜之间在肺根前方下行。结论:熟悉喉返神经、交感干和膈神经的相关解剖有助于在颈胸段脊柱手术中选择合理的手术入路。     

经胸骨上段显露颈胸段脊柱的应用解剖

目的:为临床经胸骨上段显露脊柱颈胸段提供解剖学基础。方法:对40具成人尸体模拟经胸骨上段显露颈胸段脊柱的入路进行解剖,并进行有关的数据测量。结果:甲状腺中静脉有48.8%的人一侧缺如。胸骨劈开后撑开的横径为(60.8±1.64)mm。两侧胸膜在前界中段之间有分离型、接近型、接触型和掩复型,后两者占50.4%。食管在T3椎体平面超出气管左缘(0.5±0.08)cm。胸导管由颈血管鞘后方到注入静脉的行程位于颈静脉角三角区。左、右侧喉返神经分别有94.5%、59.6%走行在气管食管沟内,并与甲状腺下动脉有复杂的关系。胸骨角正对T4/5椎间盘、T4下1/3和T5上1/3椎体(62.5%)水平,喉返神经左、右侧返折点分别平对T3/4椎间盘、T4椎体(75.6%)和T1/2椎间盘、T2椎体(82.0%),主动脉弓、右锁骨下动脉上缘分别对T3(73.7%)和T1椎体(70.0%)水平,经胸骨上段入路的颅侧和尾侧分别平对C3/4椎间盘、C4椎体(75.6%)和T3椎体、T3/4椎间盘(86.8%)。结论:经胸骨上段显露脊柱颈胸段具有暴露充分,操作方便,具有推广价值。     

右锁骨下动脉起始及奇静脉系位置变异一例

笔者在解剖一具成年男性尸体标本的颈胸部时,发现头臂干缺失,右锁骨下动脉起自胸主动脉起始处,同时伴有右侧喉返神经缺如,以及"奇静脉"位于脊柱左侧,并注入左头臂静脉等变异,现报道如下.     

非典型奇静脉系的解剖学研究及临床意义

目的观察奇静脉系的形态特征,对非典型奇静脉系进行解剖学分类,为纵隔、胸腔大血管疾患的诊治提供参考依据。方法解剖30具人体标本,分别测量奇静脉、半奇静脉、副半奇静脉起点及终点的直径,观察其终点与胸椎序数的对应关系。结果经典型奇静脉系24例,即该系具有完整的奇静脉、半奇静脉、副半奇静脉。非典型奇静脉系6例,根据其形态进一步分为:a型2例,即倒"Y"字型奇静脉系,奇静脉由左、右腰升静脉及下4位肋间静脉在脊柱前方合成;b型2例,即单柱型奇静脉系,半奇、副半奇静脉发育缺如,仅有1条奇静脉在脊柱前方上行;c型1例,即半奇静脉缺如,副半奇静脉注入左头臂静脉;d型1例,即奇静脉伴双上腔静脉变异。奇静脉终点直径(10.39±1.98)mm,主要平对T_4(83.3%);半奇静脉终点直径(8.51±2.28)mm,主要位于T_7~T_(10)水平;副半奇静脉终点直径(6.29±1.56)mm,位于T_4~T_8水平。结论对非典型奇静脉系的研究,是对该系既往分型的补充,不仅为临床检查过程中识别该系变异提供参考,也为纵隔手术、纵隔镜检查、胸椎外伤的诊治等提供数据支持。     

脊柱侧弯拉伸矫形对漏斗胸胸廓变形影响的研究

目的研究漏斗胸合并脊柱侧弯畸形先行脊柱拉伸矫形对漏斗胸胸廓变形的影响,预测胸廓变形,有助于降低手术风险和提高手术质量。方法选择北京军区总医院胸外科1例16岁男性漏斗胸合并脊柱侧弯畸形患者胸廓CT图,采用三维重建方法重建漏斗胸合并脊柱侧弯的胸廓模型,导入ANSYS软件建立三维有限元模型,用数值模拟方法模拟侧弯脊柱拉伸矫形手术过程,分析脊柱在冠状面及矢状面的位移,并观察分析胸骨在矢状面的位移。结果矫形前的脊柱,胸椎T_3~T_4段向右(X正方向,冠状面)凸出,胸椎T_7~T_9段向左(X负方向,冠状面)凸出。对其先行脊柱拉伸矫形后,胸椎T_3~T_4段矫形后冠状面的位移场(UX)位移为-2.487 mm,胸椎T_7~T_9段UX位移为3.313 mm。脊柱矫形后,最大位移出现在与胸骨柄相连的第1肋上,最大值为13.879 mm;大于2 mm后,胸骨柄的塌陷位移增加较快,拉伸位移超过4 mm以后,胸骨塌陷位移与脊柱拉伸矫形位移呈线性关系。脊柱拉伸矫形后脊柱的最大应力为30.2 MPa,出现在胸椎T_1~T_2段;椎间盘的最大应力为7.03 MPa。矫形力最大为467.9 N,脊柱侧弯得到改善。结论漏斗胸合并脊柱侧弯畸形先行脊柱侧弯拉伸矫形会加重漏斗胸病症,临床应该先行漏斗胸微创矫形。     

左头臂静脉位于升主动脉后方一例*

正笔者在局部解剖的过程中发现左头臂静脉位于升主动脉后方变异标本1例,老年男性标本(身高161 cm)的左头臂静脉于主动脉弓下方行于升主动脉后方注入上腔静脉。解剖过程与测量参数报道如下。开胸后发现,双肺癌变,脏胸膜与胸壁粘连,心大小测量数值为,右缘95.80 mm,下缘134.90 mm,左缘150.76mm。进一步解剖发现,左头臂静脉与右头臂静脉之间有一交通静脉。上腔静脉长65.50 mm,上腔静脉管径19.80mm,左头臂静脉汇入上腔静脉处距右锁骨中线距离46.56mm。右头臂静脉长58.65mm,左头臂静脉长107.28mm,左头臂静脉汇入上腔静脉处管径12.08mm,左、右头臂静脉间右一交通静脉位于主动脉弓前上方走行,距离左头臂静脉末端17.48 mm汇入右头臂静脉。交通静脉长     

喉返神经入喉处的精细解剖学研究

目的　通过对喉返神经(recurrent laryngeal nerve, RLN)入喉处的精细解剖,为临床上甲状腺手术提供有意义的参考标志与数据。 方法　40具甲醛固定的男性成人尸体标本,解剖双侧RLN,以同侧气管侧缘与RLN的交点作为角的顶点,记录双侧RLN入喉处与同侧气管侧缘的夹角,双侧RLN入喉处与第1、第2气管环前上缘的垂直距离,与同侧第1、第2气管环侧缘的水平距离。 结果　（1）分析双侧RLN入喉处与同侧气管侧缘夹角(α),0°≤α＜5°的共21例,占26.25%,5°≤α＜10°的共46例,占57.50%,10°≤α＜15°的共11例,占13.75%,α≥15°的仅2例,占2.50%。左侧的夹角为（6.0±0.5）°（0~21°）,右侧的夹角为（7.0±0.5）°（0~25°）。(2) 左、右侧RLN距第1气管环前上缘的垂直距离分别为：（19.72±0.52）mm,（21.21±0.43）mm;距第2气管环前上缘的垂直距离分别为（20.91±0.49）mm,（21.42±0.39）mm;距同侧第1气管环侧缘的水平距离分别为：（2.96±0.11）mm,（2.96±0.10）mm;距同侧第2气管环侧缘的水平距离分别为：（3.49±0.12）mm,（3.50±0.52）mm。 结论　双侧RLN入喉的角度及在第1、第2气管环的位置较为固定。了解更为精细的RLN入喉处解剖,可在术中更高效且安全的找到RLN入喉处,减少甲状腺手术中对RLN的损伤,从而降低手术并发症的发生率。     

劈胸骨柄同时锁骨离断T2、T3前入路应用解剖学研究

目的　探索安全显露和处理T2、T3椎体的理想前入路方式。 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劈胸骨柄同时锁骨部分切断术模拟脊柱T2、T3椎体前入路手术。在该入路中,寻找不同的间隙,暴露可能的椎体节段。 结果　将左颈动脉鞘（左颈总动脉、左颈内静脉、左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的方式,30例标本均能清楚的显露T1上缘至T3下缘,部分（6例）可达T4中部。 结论　劈胸骨柄和锁骨部分切断入路中,可找到一种显露和处理　T2、T3椎体的安全间隙方法。     

Anatomical basis of the risk of injury to the right laryngeal recurrent nerve during thoracic surgery

Purpose

Despite the intrathoracic part being short, the right laryngeal recurrent nerve is often injured during thoracic surgery. The aim of this cadaver study was to understand the mechanisms of right laryngeal recurrent nerve injuries during thoracic surgery and to describe anatomical landmarks for its preservation.

Methods

Dissections were performed on 10 fresh human cadavers. A right anterolateral thoracic wall segment was removed, preserving the first rib. Dissections were carried out to identify the following structures: first rib, esophagus, trachea, right main bronchus, right brachiocephalic and subclavian vessels, azygos vein, phrenic nerve, vagus nerve, and right laryngeal recurrent nerve.

Results

The distance between the origin of the right laryngeal recurrent nerve and its adjacent structures was assessed. Moderate traction of the thoracic part of the vagus nerve resulted in a downward translation of the right laryngeal recurrent nerve’s origin. In such conditions, the right laryngeal recurrent nerve’s origin was distant of 14.8?mm (±2.89?mm) from the subclavian artery.

Conclusions

Intraoperative incidence of right laryngeal recurrent nerve direct injury could be decreased by understanding the detailed course of its intrathoracic part. Moreover, traction on the intrathoracic part of the right vagus nerve may result in indirect lesions of the right laryngeal recurrent nerve: stretch induced lesions and nerve vasculature’s lesions.     

Thoracic duct relationships to abnormal neurovascular structures in cervicothoracic regions: case study and clinical relevance

The presence of variant intercostal and bronchial arteries and variable position of left recurrent laryngeal nerve (LRLN) along the course of thoracic duct (TD) may have clinical relevance in various cervicothoracic surgeries.     

影像学测量锁骨与周围血管毗邻关系：置钉的安全区和危险区**

背景：锁骨周围血管与锁骨之间毗邻关系的数据大都来自人体标本解剖的观察和测量,测量结果与人体实际略有出入。 目的：对活体锁骨周围血管与锁骨解剖结构进行观察和分析,以期发现锁骨外固定置钉的安全区和危险区。 方法：通过对44例颈胸部冠状动脉血管造影检查患者进行颈胸部增强CT扫描,将采集的锁骨区断层图像利用ADW4.4工作站重建出完整的锁骨及锁骨周围血管的三维图像,在图像上观察和测量锁骨及锁骨周围血管的毗邻关系。 结果与结论：锁骨下动、静脉紧邻锁骨,由后、上、内向前、下、外方走行,与锁骨下缘间形成的夹角,左侧为(53.75±10.64)°,右侧为(52.85±11.41)°,如将锁骨全长分为5等份,锁骨下动、静脉在锁骨表面的投影范围大约在其由内向外的第2个1/5段,左侧头臂静脉距锁骨最短距离为(4.81±1.66) mm,右侧无名动脉距锁骨最短距离为(5.09±2.60) mm。活体的影像学测量数据更接近于正常人体,锁骨外固定置钉的危险区为锁骨由内向外的第2个1/5段以及锁骨的胸骨端,掌握其解剖学特点可最大程度避免医源性锁骨周围血管损伤。     

Surgical anatomy of the cervical sympathetic trunk

Lack of knowledge of the anatomy of the cervical sympathetic trunk (CST) may complicate surgical procedures on the cervical spine. This study aims to define linear and angular relations of the CST with respect to consistent structures around it, including the number and size of the cervical ganglia, the distances between the CST and the longus colli muscle and the anterior tubercles of the transverse processes of cervical vertebrae. Morphometric parameters of the 24 CSTs of 12 adults were measured on both sides. The CST had superior, middle, and inferior (or cervicothoracic) ganglia in 20.8% of specimens; superior and inferior (or cervicothoracic) ganglia in 45.8%; superior, middle, vertebral, inferior, or cervicothoracic ganglia in 12.5%, and superior, vertebral, inferior or cervicothoracic ganglia in 20.8% of specimens. The superior ganglion was observed in all specimens, the middle ganglion and vertebral ganglion were each observed in 33.3%. There was no difference between the number of superior and vertebral ganglia between the right and left sides. The average distance between the CST and the medial border of the ipsilateral longus colli muscle (LCM) was 17.2 mm at C3 and 12.4 mm at C7. As the CSTs converged caudally, the LCMs diverged. The average distance between the anterior tubercles of transverse processes of the cervical vertebrae and the lateral borders of the ipsilateral CST was 3.4 mm at C4, 3.2 mm at C5, and 3.9 mm at C6. The presence of a vertebral ganglion and variations, such as the localization of the CST within the carotid sheath, are important. The anatomical landmarks described should assist the spinal surgeon to avoid injury of the CST.     

经左颈静脉插管肝内门-体静脉分流术的应用解剖

为给临床经左颈静脉插管行肝内门 -体静脉支架分流术提供解剖学依据 ,在 4 8例成人尸体上解剖并观测了双侧颈内静脉、头臂静脉、上腔静脉、右心房、下腔静脉上段的长度、外径、以及各有关静脉间的角度。结果为左颈内静脉长度 :10 6.9± 18.3 m m,外径 :13 .6± 3 .4 mm ;左头臂静脉长度 :66.3± 10 .8mm ,外径 :15 .9± 4 .1mm;上腔静脉长度 :4 8.5± 9.8mm,外径 :2 1.4± 8.4 mm;右心房长度 :68.7± 17.4 m m,上口外径 :2 0 .2± 4 .7mm,下口外径 :2 3 .9± 6.0 m m;下腔静脉上段长度 :2 1.5± 6.5 m m;左颈内静脉延长线与左头臂静脉间的角度 :4 5 .5°± 10 .3°,左头臂静脉延长线与上腔静脉间的角度 :5 8.3°± 12 .7°;5 8.3°± 12 .7°;左颈内静穿刺点至肝静脉口的总长 :2 4 3 .2± 2 3 .6m m。结论 :在经左颈内静脉行肝内门 -体静脉分流术时只要掌握了插管静脉的角度和深度仍具备和右侧穿刺途径一样多的优点     

胸腔镜下胸导管结扎术的应用解剖

目的　为胸腔镜下结扎胸导管提供形态学依据。  方法　观察10例成人尸体标本的乳糜池、肠干、左右腰干及胸导管在胸腔内的走行及毗邻关系,在T4~12各肋骨平面测量胸导管距奇静脉、半奇静脉和副半奇静脉主干的距离。  结果　①胸导管多起始于T12~L2椎体右前方,但其中1例起于T10。胸导管起点处距右膈脚起始端距离（74.63±38.30）mm。胸导管、各属支间及与奇静脉、半奇静脉等存在广泛交通;②胸导管到奇静脉最小距离（0.94±0.62）mm和到半奇静脉和副半奇静脉主干最大距离（34.92±0.98）mm均在T8水平,向上向下肋水平延伸距离分别逐渐增大、减小。  结论    胸导管在T5~10间多为单干,走行规律,电视胸腔镜胸导管结扎术经右胸入路,在脊柱前奇静脉下方,降主动脉上方仔细分离出胸导管,经左胸入路,则需在降主动脉下方、脊柱前、奇静脉上方分离出胸导管。     

脊柱T_(5～11)节段极外侧微创手术入路的应用解剖

目的为T5～11脊柱极外侧椎间融合术(XLIF)的微创手术入路的可行性和安全性提供解剖学依据。方法成人尸体标本12具,解剖观察并测量T5～11椎体侧方血管神经的走行、分布及毗邻结构,节段血管的位置及其与上下相邻椎间盘的距离。结果 T5～11节段血管走行较为恒定,节段静脉在上、节段动脉在下,走行于对应椎体的中央偏下水平。两侧交感神经干在T6～9发出内脏大神经,T10～12发出内脏小神经。奇静脉在该段脊柱的右前方,向上走行过程中逐渐向脊柱左侧偏,胸主动脉走行于该段脊柱的左前方,向下走行过程逐渐向右侧偏,右侧交感干与奇静脉的间距远大于左侧交感干与胸主动脉的间距。椎间盘水平无血管和神经紧邻。结论在T5～11脊柱行极外侧椎间融合术是可行和安全的,行椎体螺钉内固定应注意侧前方血管神经和节段血管的保护,切除椎体时必须先结扎节段血管。     

Gross anatomical observations on two cases of right-sided arch of the aorta with the left subclavian artery as its last branch.

Two cases of Adachi-Williams-Nakagawa type N (Krause's type II-2-B) right-sided arch of the aorta were observed gross anatomically. We discovered the first in a 67-year-old female corpse during dissection practice. The second was found in an old male patient through radiography. After his death at 87 years, angiography revealed the anomaly to be of type N. Case 2 (and case 1 after the discovery of the anomaly) were dissected outside of regular dissection practice. Neither belonged to the "circumflexus" type and in each case the ligamentum arteriosum was located on the left, forming a vascular ring. However, only case 1 exhibited marked constriction of the esophagus, explaining the dysphagia that she had suffered. This deviation was evidently caused by projection of the aortic diverticulum of case 1 in front of the vertebral column (since the origin of the descending aorta was located at a more antero-medial position in case 1 than in case 2) and narrowness of the vascular ring of case 1. On both sides in both cases, the second posterior intercostal arteries were branches of the thoracic aorta. This indicated that the high position of the arch of the aorta in both cases (the uppermost point was at the level between Th1 and Th2) is an anomaly, being not limited only to the arch of the aorta. All bronchial arteries originated from the thoracic aorta. These have not been described in association with examples of right-sided arch of the aorta, and were therefore compared against a mirror image of the normal aorta described by Kasai. However, some discrepancies were still noted. Among the veins, the left brachiocephalic vein of case 2 was partially occluded, forming collateral circulation behind the ascending aorta. In both cases, the thoracic duct ascended on the left of the thoracic aorta, passed behind and then above the left subclavian artery, and joined the left angulus venosus. In addition, the azygos vein, recurrent laryngeal nerve, and cardiac nerves are described.