颈前外侧入路及其扩大入路的显微解剖学研究

目的探讨经颈前外侧入路及其扩大入路手术治疗斜坡及上颈椎腹侧病变的方法.方法在经10%甲醛溶液固定的尸头标本上,模拟颈前外侧入路及其扩大入路进行斜坡和上颈椎腹侧的显微解剖和手术入路研究.结果颈部前外侧有明确的筋膜间隙,通过对颈筋膜各层准确的广泛解剖可直达斜坡中上部和上颈椎腹侧;各筋膜层及骨性结构表面均有明显的解剖学标志.外侧入路可安全暴露下斜坡和上颈椎腹侧区域,其扩大入路可充分显露中上斜坡腹侧.结论经颈前外侧入路及其扩大入路手术治疗斜坡及上颈椎腹侧病变具有直达病变部位,损伤小,视野较宽和有效避免感染等优点.     

应用枕下外侧入路和远外侧入路处理下斜坡病变的解剖学量化对比研究

目的通过对成人头颅标本相关解剖进行测量和量化分析,为下斜坡及枕大孔腹侧病变手术入路的选择提供依据.方法根据枕大孔前正中点与枕髁后缘连线垂直距离(AOCP)/枕大孔纵经(FML)的比值将成人头颅标本分组,分析每组采用不同手术入路时对枕大孔腹侧区显露角度的差异.结果100例成人头颅标本分为3组:Ⅰ组(小枕髁型)占8%,Ⅱ组(中枕髁型)占74%,Ⅲ组(大枕髁型)占18%.Ⅰ组中角A和角B之间无统计学差异,但Ⅱ、Ⅲ组中角A与角B之间存在显著性差异(角A、角B分别表示磨除枕髁后1/3前、后的显露角度).结论枕髁大小变异较大.对于下斜坡及枕大孔腹侧病变,小型枕髁病人术中无需磨除枕髁,采用枕下外侧入路即可获得理想的显露.对于中、大型枕髁病人,磨除枕髁后可提供更大的观察视角,因此宜采用远外侧经髁人路.应用CT行三维骨性重建,明确枕髁的类型对手术入路的选择具有指导意义.     

颈椎病手术入路的选择

颈椎病手术的理想目标是彻底解除脊髓和神经根的压迫,恢复颈椎稳定性,维持椎间隙高度,获得正常生理曲度以及与脊髓相适应的椎管容量和形态,挽救脊髓残留功能,阻止病情的进一步发展.     

远外侧入路的解剖学基础

目的 通过显微外科解剖学方法探讨寰枕区解剖结构的特点,为深入理解和施行远外侧入路手术提供解剖学基础.方法 观察6具(12侧)尸头寰枕区枕动脉走行与位置、椎动脉与枕后肌肉三角的关系,以及小脑后下动脉的起始位置;并于导航系统引导下测量寰枕关节磨除程度与手术视野显露的关系和后组脑神经在切口处的位置.结果 经远外侧入路手术时,倒"U"形切口显露清晰、手术视野优于直线切口.6具(12侧)尸头枕动脉均走行于头夹肌的下方和头最长肌的上方;在枕后肌肉三角内均有椎动脉走行并于硬膜外发出肌支和硬膜支;11侧小脑后下动脉起源于硬膜内椎动脉,1侧起源于硬膜外椎动脉.寰枕关节磨除至根部可清楚地显露硬膜内小脑后下动脉起始部及第Ⅸ(舌咽神经)、X(迷走神经)和Ⅺ对(副神经)脑神经,但距第Ⅻ对脑神经(舌下神经)的距离较远[(7.20±2.33)cm];磨除寰枕关节后1/3,至舌下神经和脑干腹侧的手术距离明显缩短[(6.50±2.31)cm];二者比较差异有统计学意义(t=4.743,P=0.008).结论 经远外侧入路施行延髓腹侧和腹外侧病变手术可清楚地显露下斜坡邻近区、延髓腹侧和小脑后下动脉起始部.手术中应注意保护枕后肌肉三角内的椎动脉或起源于椎动脉硬膜外段的小脑后下动脉.对于舌下神经外侧病变无需磨除寰枕关节,需要时以磨除后1/3为宜,进一步磨除寰枕关节只能减少手术视野的深度而不能扩大显露范围.     

颈椎前侧方入路微创手术治疗颈椎病5例

２０００年３月～２００１年３月，我科应用颈椎前侧方入路行椎间盘摘除减压微创手术，治疗颈椎病５例，均获得较好治疗效果。报告如下：１对象与方法１．１一般资料男性３例，女性２例；年龄４２～５７岁，病程１～１２个月。１．２术前神经功能状况根据Nurick伤残分级：I级，     

改良的乙状窦前入路应用解剖学研究

目的探讨经岩乙状窦前入路的微创化改良技术操作方法及其优点。方法根据Fukushima观点对传统经岩乙状窦前入路进行微创化改良，并在15例国人成人头顷湿标本双侧分别随机模拟传统经岩乙状窦前入路和改良入路，并进行解剖学比较研究。结果改良的乙状窦前1入路手术中，只需磨除少量的岩骨后部骨质，显露乙状窦前方4mm的硬膜区，切开硬膜和小脑幕即可充分显露岩斜区，且其颞枕骨窗面积较传统入路显著缩小（P〈0．05），但两者手术最大视角和操作深度无显著差异（P〉0．05）。结论改良的乙状窦前入路较传统入路更简便、安全、微创，是岩斜区肿瘤手术治疗的较佳入路。     

枕下远外侧入路的显微解剖学研究与临床应用

目的 研究枕下远外侧入路的显微解剖,探讨其临床应用价值.方法 选取成人尸头标本15例,在显微镜下模拟枕下远外侧入路进行解剖学研究.并采用枕下远外侧入路手术切除14例颈交界区肿瘤,其中肿瘤经颈静脉孔完全向颅内发展4例,跨枕骨大孔进入颈椎上部7例,呈哑铃型生长至颈静脉孔外口处2例,累及颈动脉鞘1例.结果 枕下远外侧入路可充分暴露枕下三角、椎动脉区和后组脑神经区.本组肿瘤全切除10例.次全切除2例,部分切除2例.术后出现暂时性病侧外展神经麻痹1例.面神经不全损害1例,死亡1例,余11例无新增脑神经损害表现;术后均无脑脊液漏发生.13例随访4～70个月,除1例头痛外,余术前脑神经损害均逐渐恢复或代偿;肿瘤复发2例.结论 枕下远外侧入路可增加术野,减少对脑干及重要血管神经的牵拉,是切除脑干和高位颈髓腹侧、腹外侧及颈静脉孔区病变的理想手术入路.     

枕下极远外侧入路的显微解剖学定量研究

目的本研究通过进行枕下极远外侧手术,逐步定量测量枕骨大孔的显露范围。方法用10例骨性颅骨及环椎观察测量骨性结构,对10例尸体头颅显微镜下进行枕下极远外侧手术,手术分为三部分:切除环椎侧块及后弓、磨除枕髁至舌下神经管后缘及枕髁全部。结果椎动脉内缘距中线距离为(15.94±2.33)mm(左),(15.46±1.38)mm(右);枕下海绵窦内缘距中线距离为(12.39±3.29)mm(左),(12.42±2.52)mm(右)。保留枕髁完整所能显露的最大范围均未达中线,至中线的距离:(1.69±0.91)mm(左),(1.68±1.12)mm(右);磨除枕髁后部至舌下神经管后缘所显露的最大范围均越过中线至手术对侧,越过中线的距离:(3.12±1.28)mm(左),(3.43±1.13)mm(右);磨除枕髁全部时所显露最大范围均越过中线至手术对侧,越过中线的距离:(6.50±0.99)mm(左),(6.79±0.76)mm(右)。结论磨除环椎后弓应在中线两侧12.5mm的范围内,磨除枕髁可显著增加枕骨大孔前部的显露范围。     

远外侧枕髁后锁孔手术入路设计与显微解剖学实验研究

目的将微创锁孔手术理念融入远外侧入路,探讨枕髁后锁孔手术的可行性。方法于8具尸头乳突后作纵向“S”型、约7 cm长头皮切口,上缘起自乳突中点向后2 cm处,下界至C2水平。分层翻转枕下肌群,显露枕骨远外侧,在枕髁后做一直径约3 cm的骨窗,牵开小脑半球,显微镜下观察所显露的解剖结构。结果通过调整头位及显微镜角度,经枕髁后锁孔入路可显露同侧椎动脉、小脑后下动脉、小脑前下动脉、面听神经、后组脑神经、舌下神经、延髓腹外侧等结构。结论枕髁后锁孔入路可很好地显露上述结构,应用现代显微外科技术,可在不磨除枕髁的情况下进行椎动脉瘤、小脑后下动脉瘤、较小体积的舌下神经鞘瘤、延髓腹外侧肿瘤等手术。     

内镜辅助眶上锁孔入路治疗垂体瘤的临床解剖学研究

目的探讨内镜辅助眶上锁孔入路治疗垂体瘤的可行性。方法21例福尔马林固定尸体头部标本用于鞍区各解剖结构,特别是垂体柄、视神经、视交叉及其供血动脉特点的观察,总结手术可利用的间隙、应保护的结构;在9例新鲜尸头上模拟进行内镜辅助眶上锁孔入路手术,进一步验证其可行性及优势。结果颈内动脉床突上段长度14.5±1.3mm(8.1～18.5mm),发向垂体柄、视神经或视交叉的穿支动脉的支数分别为:大脑前或前交通动脉3.0支(2～6支),颈内动脉2.1支(1～5支),后交通动脉3.2支(3～6支),基底动脉1.4支(1～3支)。视神经颅内段长度为11.4±2.7mm(6.1～17.6mm),第1间隙面积为44.8±3.4mm2(7.0～100.8mm2),手术可通过第1间隙或(和)第2间隙进行。结论通过眶上锁孔入路治疗向鞍上发展的垂体瘤有充足的操作空间,具有视神经、视交叉减压充分,利于保护其供血动脉的优点。     

颈前路侧前方减压术治疗根型颈椎病的临床研究

目的 总结颈前路侧前方显微减压术治疗神经根型颈椎病的临床经验。方法 借助显微镜和高速磨钻对79例根型颈椎病患者行颈前路侧前方显微椎间盘摘除减压术，采用Cage或钛网自体骨融合后并使用钉板系统固定；术中同时采用体感诱发电位（SEP）进行监护。结果 79例病人术后临床症状明显好转，无严重并发症发生，无症状加重或术后复发者。随访5-48个月，影像学资料证实：神经根减压充分，融骨良好，内固定钛板位置准确。结论 颈前路侧前方显微减压术治疗神经根型颈椎病，手术创伤小，成功率高。     

经岩骨后人路的应用解剖学研究

目的从应用解剖学入手,量化和微创化研究经岩骨后入路。方法在手术显微镜下,对20侧(10具)福尔马林固定的成人头颅标本进行颅底剖面的解剖测量;对6侧(3具)头颅标本模拟经岩骨后入路,进行入路全程解剖观察。结果确定了经岩骨后入路的骨窗后下界和入路行经的重要路标;观测了面神经管和迷路结构的解剖关系;明确了安全切除岩尖区骨质的范围。依据上述观测结果,模拟、验证经岩骨后入路,并提出改进方法。结论传统经岩骨后入路对岩尖区硬膜内结构的暴露范围有限,手术风险较大。通过量化、微创化研究经岩骨后入路的硬膜外骨切除操作,改进硬脑膜和小脑幕切开方法,明显扩大对岩尖区硬膜内结构的显露,确保手术的安全性。     

Posterior microendoscopic surgical approach for the degenerative cervical spine

We describe the advantages and clarify the technical key points of a microendoscopic, minimally invasive technique to the posterior surgical approach for cervical degenerative disease. The authors studied the microendoscopic posterior approach using the METRx system in both cadaver models and in clinical cases. This new technique needs only a small surgical route thus reducing damage to the paraspinous muscles. Moreover, this technique provides a clear view of the operating points, because of the oblique view angle of the endoscope. This technique is feasible for not only radiculopathy but also myelopathy caused by segmental canal stenosis. Posterior cervical decompression with this system is technically feasible and should be beneficial for reducing post-operative morbidity and spine deformity. This report deals with cases of cervical radiculopathy and segmental canal stenosis operated on with this system as well as the key points of this surgical procedure.     

Applied anatomy of the cervical region of the recurrent laryngeal nerve

BACKGROUND AND OBJECTIVE： To avoid recurrent laryngeal nerve （RLN） injury during thyroid surgery, it is important to identify the nerve and to follow its projection carefully to discriminate it from the inferior thyroid artery. DESIGN, TIME AND SETTING： All studies were performed at the Anatomy Division of Shaoyang Medical College from May 2003 to May 2004 with repeated measurement design. MATERIALS： Fifty embalmed adult corpses, comprising 20 females and 30 males, were obtained by donation. METHODS AND MAIN OUTCOME MEASURES： The projection, branches, and the relationship of the RLN to the inferior thyroid artery were observed. RESULTS： The RLN in all cases ascended through the tracheoesophageal groove at the isthmus superior levels of the thyroid gland. However, the RLN in 14 cases were situated inferior to the isthmus of the thyroid gland; 11 cases were to the right side and 2 cases to the left side, projected in the tracheoesophageal groove, and ascended away from the groove after 4.5-6.5 mm. The RLN typically ramified at the thyroid isthmus plane （44 cases, 44% of all cases）. The RLN branches were variable. Type 2 rami were most common in the RLN, accounting for 55%; the second most common was RLN branches with no rami. RLN braches with type 3 rami, 4 rami, and 5 rami were less common. Approximately 54% of nerves were situated behind the main branch artery. The nerves located adjacent to the arteries, and between the arterial branches, were similar; the former applied to 19 cases, accounting for 19%, whereas the latter applied to 18 cases, accounting for 18%. Left nerves behind the artery, and right nerves before the artery, were more common. There were significant differences between the left and right nerves （P 〈 0.01）. CONCLUSION： There was not a significant difference in the projection of the RLN, while a significant difference in the number of RLN branches existed. In addition, the anatomical relationship of the RLN and the inferior thyroid artery exhibited side differences.     

A novel retractor for the anterior approach to the cervical spine

Abstract

Various types of retractors have been used in cervical disc operations. The most frequently used type is the Cloward's retractor. Caspar also designed a new retractor for cervical operations. The presented device is a new instrument for simple cervical disc herniation. It provides a significant surgical exposure area under the surgical microscope. When using this retractor, there is no need to use a vertebral spreader because the retractor itself can be used as a vertebral spreader and it is possible to carry out the Smith Robinson type fusion. This retractor has been used for over two hundred cases and there has not been any complication involving the carotid artery, trachea and esophagus. [Neurol Res 1999; 21: 43—44]     

A novel retractor for the anterior approach to the cervical spine

Various types of retractors have been used in cervical disc operations. The most frequently used type is the Cloward's retractor. Caspar also designed a new retractor for cervical operations. The presented device is a new instrument for simple cervical disc herniation. It provides a significant surgical exposure area under the surgical microscope. When using this retractor, there is no need to use a vertebral spreader because the retractor itself can be used as a vertebral spreader and it is possible to carry out the Smith Robinson type fusion. This retractor has been used for over two hundred cases and there has not been any complication involving the carotid artery, trachea and esophagus.     

Anterior fusion for cervical spondylosis

Summary Anterior fusion was performed on 138 patients as treatment for degenerative changes of the cervical vertebral column. The results were checked after up to 11 years in 122 patients and were found to be good in 55%, fair in 38.5% and poor in 6.5%. There were complications of phonetic paralysis in one case, Horner syndrome in two cases, 2 wound infections, and complaints about the iliac crest in 3 patients. Kyphosis at the fused segment occurred 26.1% of cases, the average angle being 15.3°, but it did not influence the clinical results. Mortality was 2%. Inadequate visualization of the nerve roots at operation was probably the reason for the segmental deficits and suggestions were made to avoid this by EMG, microsurgical technic, uncusectomy and hemifacetectomy. The results in the presence of myelopathy were much poorer, presumably because of associated degenerative changes in the older patients.

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Zusammenfassung 138 Patienten mit degenerativen Veränderungen der Halswirbelsäule wurden durch die vordere Fusion behandelt. Bei Nachuntersuchungszeiten bis zu 11 Jahren konnten die Ergebnisse bei 122 Patienten überprüft werden. 55% waren gebessert, 38,5% unverändert, 6,5% verschlechtert. Komplikationen waren Stimmbandlähmungen (1), Hornersyndrom (2), Wundinfektion (2) und Beschwerden am Beckenkamm in 3 Fällen. Die Letalität betrug 2%. Winkelbildung im fusionierten Bewegungssegment trat in 26,1% der Fälle auf. Der Durchschnittswinkel betrug 15,3%. Es bestand kein Einfluß der Kyphose auf die klinischen Ergebnisse. Diskussion der Gründe für die nicht voll befriedigenden Ergebnisse bei segmentalen Ausfällen, möglicherweise bedingt durch nicht immer ausreichende intraoperative Darstellung der Nervenwurzeln. Anregung zu weiterer Differenzierung der Ausfälle mit Hilfe des EMG, zu größerer Beachtung der mikrochirurgischen Technik, der Uncusektomie (Jung), der Facetektomie nach Frykholm. Gründe für schlechtere Ergebnisse bei Myelopathie durch Anteil von Systemerkrankungen im Krankengut und durch ungeklärte Myelopathien bei gleichzeitiger zervikaler Spondylosis.

     

Anterior retropharyngeal approach to the cervical spine.

The anterior retropharyngeal approach (ARPA) accesses anteriorly situated lesions from the clivus to C3, in patients with a short neck, Klippel Feil anomaly or those in whom the C2-3 and C3-4 disc spaces are situated higher in relation to the hyoid bone and the angle of mandible where it is difficult to approach this region using the conventional anterior approach, due to the superomedial obliquity of the trajectory. The ARPA avoids the potentially contaminated oropharyngeal cavity providing for a simultaneous arthrodesis and instrumentation during the primary surgical procedure. Experience of five patients with high cervical extradural compression, who underwent surgery using this approach between 1994 and 1999, is presented. The surgical procedures included excision of ossified posterior longitudinal ligament (n=2); excision of prolapsed disc and osteophytes (n=2); and excision of a vertebral body neoplasm (n=1). Following the procedure, vertebral arthrodesis was achieved using an iliac graft in all the patients. Only one patient with vertebral body neoplasm required an additional anterior cervical plating procedure for stabilisation the construct. The complications included transient respiratory insufficiency and neurological deterioration in two patients; and, pharyngeal fistula and donor site infection in one patient.