关于上颈椎则方外科入路显露的再讨论

提出一种新的侧方入路至寰椎侧块的外科手术途径。方法和结果：研究了此手术入路的解剖基础，并经临床应用成功，结论：凿断乳突，连同胸锁突肌向下翻转法侧方入路至寰椎侧块的外科途径较之目前文献所述的方法有着更广泛，并同时显著侧块的侧前方和侧后方的优点。     

关于上颈椎侧方外科入路显露的再讨论

目的：提出一种新的侧方入路至寰椎侧块的外科手术途径。方法和结果：研究了此手术入路的解剖基础，并经临床应用成功。结论：凿断乳突，连同胸锁乳突肌向下翻转法侧方入路至寰椎侧块的外科途径较之目前文献所述的方法有着更广泛、并同时显露侧块的侧前方和侧后方的优点     

3D打印在颈椎哑铃形肿瘤手术入路选择中的应用

目的探讨3D打印技术在颈椎哑铃形肿瘤手术入路选择中的应用。方法回顾性分析2012年8月至2017年2月在我科就诊的17例颈椎哑铃形肿瘤且制作3D打印模型患者的临床资料。其中3名具有高级职称的医师结合或不结合3D打印为每位患者选择手术入路,结合3D打印且最多外科医师选择的手术入路作为最终的手术入路。17例患者手术前后均行JOA评分及Frankel分级。结果结合术前3D打印模型制定的手术入路,所有肿瘤均完全切除。术前不结合3D打印模型,3名外科医师均选择同一手术入路8例患者,2名外科医师选择同一手术入路9例患者,对比结合与不结合3D打印模型的手术入路,3名外科医师共改变手术入路13次,改变手术入路5例患者,包括2例后方入路改为侧方入路,2例侧方入路改为后方入路,1例侧方入路改为前方入路。最后行后方入路手术患者11例,前方入路手术患者1例,侧方入路手术患者3例,枕后远侧入路2例。讨论结合3D打印技术重建颈椎哑铃形肿瘤,能够将局部解剖结构以数字化方式重建打印,对于肿瘤形态、肿瘤与椎体、肿瘤与椎间孔、肿瘤与血管间的关系显示效果优秀。3D打印技术帮助术者精确、直观地了解术区情况,选择优势手术入路,降低手术风险,提高肿瘤的切除率,尤其是对于复杂肿瘤和血管异常走行显示效果优异。     

下颈椎侧方椎间孔镜入路的应用解剖

目的　探讨经下颈椎侧方臂丛后解剖间隙进行椎间孔镜手术的可行性。 方法　40侧成人尸体标本,沿胸锁乳突肌后缘对应C3~7椎体作纵切口,由浅入深经臂丛前、后方按临床手术显露椎间孔途径逐层解剖观测至椎体及附件结构,并模拟手术,牵拉相应组织,测量其牵拉角度、范围。 结果　①臂丛C5~8根长度、根角度及根间距测量结果表明臂丛前、后入路均可直视神经根对椎间孔周围病变进行操作;② C4~6横突与膈神经的距离测量结果表明与臂丛前入路相比,臂丛后入路不易伤及膈神经;③C3~7横突与颈交感干的距离测量结果表明与臂丛前入路相比,臂丛后入路不易伤及颈交感干;④胸导管70%在C7~T1水平汇入静脉角,C7水平臂丛前入路要注意保护胸导管,臂丛后入路不易损伤胸导管;⑤在C7横突水平处将椎动脉向外牵拉的距离为(2.5±0.4)cm,臂丛前、后入路均应注意保护椎动脉;⑥C7横突末端下方至胸膜顶的距离为(1.9±0.4)cm,C7水平臂丛前、后入路均可能伤及胸膜顶。 结论　下颈椎侧方臂丛后解剖间隙可为颈椎间孔镜手术提供安全的手术入路。     

耳廓掀翻入路的显微解剖与临床应用

目的：报道耳外科新的手术入路的显微解剖与临床应用。方法：在38侧标本上对外耳血供进行解剖观察，设计了耳廓向下掀翻入路，应用于121例耳部疾患。结果：外耳血供来自颈外动脉的颞浅动脉和耳后动脉，其外侧面为颞浅动脉上、中、下耳支及耳后动脉耳廓支的穿支供应，背面为耳后动脉上、中、下耳支供应。经耳廓掀翻中耳乳突手术入路，手术野大，暴露好，未发生耳廓缺血坏死或感觉障碍。结论：耳廓掀翻是现代耳外科理想的手术进路。     

上颈椎侧方入路的应用解剖学研究

目的:为上颈椎侧方入路提供应用解剖学基础。方法:(1)在30例(60侧)成人头颈标本上观察该入路相关的解剖结构。(2)对50例寰、枢椎干燥骨标本的侧方结构进行测量。结果:(1)副神经在乳突下方(3.89±0.56)cm进入胸锁乳突肌。(2)C_(1～3)前支的长度分别为(2.19±0.17)cm、(2.23±0.59)cm、(2.05±0.60)cm;根角度分别为(25.8±6.9)°、(32.1±6.3)°、(40.9±4.4)°。(3)椎动脉在上、中、下三点的牵开距离为(2.14±0.35)、(3.53±0.46)、(2.47±0.38)cm。(4)寰枢椎侧方骨质切除的最大宽度为2.5～3.0cm。结论:上颈椎侧方入路可一次性切除寰枢椎侧方病灶。从解剖学角度观察分析,侧方入路是安全可行的。     

经腋中线胸腔入路上胸椎侧方内固定与传统前方钢板内固定：生物力学稳定性的对照分析

文题释义： 上胸椎手术入路：上胸椎周围解剖结构复杂,常见的手术入路有经下颈椎低位前方入路、经胸骨柄入路、经胸入路等,虽然前路手术入路众多,但手术风险及难度系数极大,在临床上选择一种创伤较小的手术方式具有一定优越性。 脊柱内固定生物力学：脊柱病变的手术目的多为清除病灶、椎管减压、重建其稳定性,脊柱运动节段是由相邻的2个椎体和椎板及诸多韧带构成的功能单位,对于器械固定后的生物力学研究,无论是数学模型、人工材料还是动物实验都存在种种问题,因此多采用人尸体进行研究,主要评价术后三维运动范围的影响。 背景：随着脊柱内固定技术的全面推广,重塑脊柱力学稳定越来越引起人们的关注,经腋中线胸腔入路侧方内固定治疗上胸椎病损是一种新的手术入路,目前有关其固定后上胸椎生物力学的研究较为少见。 目的：对比侧方和前方钢板内固定模型的上胸椎三维运动稳定性和负重载荷强度,评估经腋中线胸腔入路侧方钢板内固定重建上胸椎是否可以达到符合脊柱生物力学稳定。 方法：从12具人尸体获取C₇-T₆脊柱并双侧肋椎关节标本,进行完整上胸椎模型三维运动稳定性测试,记录为完整椎体组。随后将标本随机分为2组,分别建立传统前方钢板内固定(前方内固定组)与经腋中线入胸腔路侧方钢板内固定模型(侧方内固定组),每组6例标本,先后进行三维运动实验、垂直加压实验与垂直加压破坏实验。实验通过广西医科大学第二附属医院伦理委员会批准,批准号：NO.伦审2017(KY-0080)号。 结果与结论：①完整椎体组左/右侧屈、前屈/后伸、左/右旋转运动下的载荷均小于侧方内固定组、前方内固定组(P < 0.01),前方内固定组左/右旋转运动下的载荷均小于侧方内固定组(P < 0.05),前方内固定组左/右侧屈、前屈/后伸运动下的载荷与侧方内固定组比较差异无显著性意义(P > 0.05);②当载荷到达600 N时,前方内固定组椎体下沉位移小于侧方内固定组[(1.39±0.20),(2.15±0.17)mm,P < 0.01];③前方内固定组与侧方内固定组最大强度载荷比较差异无显著性意义[(1 839.70±122.45),(1 798.65±120.21)N,P=0.571];④结果表明,经腋中线胸腔入路侧方钢板内固定方式是稳定的,它能够满足脊柱重建生物力学需要。 ORCID: 0000-0002-5506-3469(施冬冬) 中国组织工程研究杂志出版内容重点：人工关节;骨植入物;脊柱;骨折;内固定;数字化骨科;组织工程     

胸椎手术人路的解剖与临床

胸椎手术入路根据需要选择前路或后路，也可联合入路。前路适合椎体病变，后路适用于椎管及附件病变，联合人路多用于复杂肿瘤手术。相对于腰椎及颈椎而言，胸椎手术更加凶险，胸髓损伤后几乎不能恢复。所以，熟悉相关解剖，分析病变部位及特点，在清晰的术野下不触碰脊髓完成手术是成功的关键。现将入路的相关解剖及注意事项介绍如下。     

上颈椎前路经皮穿刺手术入路的解剖学研究

目的：为经皮齿状突螺钉、前路C1～C2侧块螺钉内固定技术提供解剖学基础，并分析其临床应用价值。方法：对10具防腐和3具新鲜成人尸体标本进行逐层解剖及“C”臂机下模拟经皮前路手术内固定，测量穿刺套管经甲状腺上动脉上方与下方入路时与重要血管神经等结构的相应距离。回顾分析临床上颈椎的经皮穿刺和开放手术入路并发症。结果：皮肤切口的范围在C4～C5椎体水平。在C4～C5椎体水平穿刺套管与甲状腺上血管神经相邻，而距离舌下神经、舌动脉、舌咽神经等较远。经皮手术和开放手术在手术入路并发症方面无显著性差异。结论：（1）经皮穿刺上颈椎前路手术入路是安全的。（2）由C4～C5椎体水平穿过颈内脏鞘和颈动脉鞘之间联合筋膜经甲状腺上动脉下方到达咽后间隙为较佳入路。     

枕下远外侧入路模拟手术显微解剖观察

目的：探讨枕下远外侧入路切除枕骨大孔前方及外侧方肿瘤的方法。方法：收集颅脑肿瘤外科死亡标本15具，经福尔马林固定处理后，对其中未经手术治疗的13例行枕下远外侧入路枕骨大孔前方及外侧方肿瘤切除的模拟手术，另2例生前已行颅内手术者开颅观察。结果：本组13具模拟手术标本中，切除位于枕骨大孔前方的肿瘤6例、下斜坡3例、外侧区4例。结论：经该入路切除枕骨大孔前方及外侧方肿瘤，可扩大手术视野，更彻底地切除肿瘤组织，并能减少对脑干和重要血管、神经的牵拉与损伤，增加手术的安全性。     

下颈椎三节段全椎板切除与侧块螺钉内固定三维有限元模型的建立

背景：随着颈椎后路手术技术的日益完善,侧块螺钉内固定技术已被广泛应用于颈椎的重建稳定性手术之中。然而,当前对于侧块螺钉内固定系统重建颈椎稳定性的有限元研究却很少。 目的：建立精细下颈椎(C3-C7)及三节段全椎板切除后应用侧块螺钉内固定重建的三维有限元模型,对重建后的下颈椎及内固定进行生物力学分析。 方法：采集1例30岁正常女性志愿者行全颈椎CT,得到Dicom数据集。应用Mimics 10.01、Geomagic Studio12.0、Solidworks2012、HyperMesh10.1、Abaqus 6.12软件建立下颈椎(C3-C7)完整模型、全椎板切除模型以及侧块螺钉内固定系统重建模型。分析重建模型在前屈、后伸、侧弯和旋转运动状态下的应力变化情况。 结果与结论：所建下颈椎有限元模型结构精细,外形逼真,共包含503 911个四面体单元,93 390个节点,并通过有效性验证。在软件中完成模拟手术过程,最终得到侧块螺钉内固定重建模型。侧块螺钉内固定系统对全椎板切除模型具有良好的稳定性,重建后颈椎的活动度远低于完整模型,且后伸时侧块螺钉内固定系统的应力最为集中。中国组织工程研究杂志出版内容重点：人工关节;骨植入物;脊柱;骨折;内固定;数字化骨科;组织工程全文链接：     

颈椎棘突骨折累及后方韧带复合体损伤对羊颈椎生物力学稳定性的影响

目的通过体外羊标本模拟颈椎棘突骨折累及后方韧带复合体(posterior ligamentous complex,PLC)损伤对颈椎生物力学稳定性的影响,探讨颈椎后方结构在维持颈椎稳定性中的作用。方法将新鲜羊颈椎C3~6标本24具随机平均分为3组:正常对照组(A组);单纯颈椎棘突骨折组(B组);颈椎棘突骨折合并PLC损伤组(C组)。在1.5 N·m力矩加载下,分别测量各组在前屈、后伸、左右侧弯和左右旋转6种工况下颈椎活动度(range of motion,ROM),使用单因素方差分析比较3组之间的ROM差异。结果单纯颈椎棘突骨折对羊颈椎稳定性影响不大,各工况下ROM同正常对照组比较差异无统计学意义(P0.05);颈椎棘突骨折合并PLC损伤组在前屈、后伸及左右旋转工况下ROM显著增加,同正常对照组相比,差异具有统计学意义(P0.05),颈椎棘突骨折合并PLC损伤组在左右侧弯工况下同正常对照组比较ROM变化不显著,差异无统计学意义(P0.05)。结论单纯颈椎棘突骨折本身并不影响颈椎整体稳定性,但颈椎棘突骨折伴有PLC损伤时可造成颈椎不稳,需要手术干预。     

侧卧位枕高与颈椎间盘应力关系的三维有限元分析

目的 采用三维有限元法分析人体侧卧位状态下枕高与颈椎间盘应力的关系,为合理用枕提供依据.方法 对1名正常男性志愿者进行颈椎薄层CT扫描,联用医学图像处理软件Mimics、逆向工程软件Geomagic Studio、有限元软件MSC.Patran建立人体侧卧位枕高分别为10 cm(冠状面颈椎左侧屈)、17 cm(冠状面颈椎中立)、25 cm(冠状面颈椎右侧屈)3种条件下的全颈椎三维有限元模型,并进行分析运算.结果 冠状面颈椎近似中立位模型(枕高17 cm)的等效应力、最大主应力、最大剪应力均明显低于左侧屈或右侧区模型.结论 颈椎冠状面处于中立位可使颈椎间盘获得最佳应力分布状态.人体侧卧睡眠时,合理的枕高应是颈椎在冠状面处于中立位.     

下颈椎损伤分类评分系统的信效度检验及临床应用

背景：脊柱损伤分类系统对下颈椎损伤的诊治及预后具有重要指导意义,然而临床上缺乏一种能被广泛接受的分类系统。 目的：对下颈椎损伤分类评分系统进行可信度分析与有效度检验,并观察其在临床治疗中的应用效果。 方法：基于下颈椎损伤分类评分系统治疗75例下颈椎损伤患者,根据该系统评分,11例<4分的患者选择非手术治疗,6例=4分及58例>4分的患者选择手术治疗,手术患者依据该系统中损伤形态学不同结合间盘韧带复合体损伤和神经损伤状态选择不同的手术入路。分别采用Cronbach’s α系数与Kappa系数考察内部一致性信度和重测信度;用内容效度指数检验内容效度。 结果与结论：下颈椎损伤分类评分系统亚类的内部一致性信度均在0.8以上,表明该评分系统具有较好的内部一致性信度。间盘韧带复合体及下颈椎损伤分类评分系统总分的重测信度为中度可信,形态学损伤、神经损伤状态及治疗选择的重测信度均大于0.6为高度可信。下颈椎损伤分类评分系统全部条目平均内容效度指数值为0.936,证明该评分系统各条目较好地指导了下颈椎损伤患者的诊断及治疗。根据该评分系统指导治疗75例下颈椎损伤患者,治疗后无神经损伤加重,并发症发生率较低,ASIA分级得到相应改善。提示下颈椎损伤分类评分系统具有较高的信效度,且应用简便、易于掌握,其在指导下颈椎损伤手术与非手术治疗以及手术入路的选择方面具有重要意义。     

人体中、下段颈椎曲率的测量及意义

目的：为设计、改进适合国人的颈前路钢板系统提供参考值。方法：用游标卡尺和自制弧度仪测量129例颈椎各椎体最小高度、冠状径、矢状径和前壁横向弧度;测量43例正常成人X线侧位片,计算颈椎的生理曲度。结果：C3-C6最小高度和C3-C5最小矢状径均较接近,分别为10.0mm和14.6mm;最小冠状径由C3-C6依次增加,增量约1mm;椎体前壁横向曲率半径由C3的9.6mm逐渐增大至C7的14.4mm;颈椎各节段纵向曲度的变异较大,无明显规律。结论：颈椎中段各椎体的最小高度值、矢状径值相近,中、下段颈椎各椎体的最小冠状径和前壁横向曲度由下至下递减,此规律可帮助确定理想的螺钉长度、钢板宽度和钢板的横向弧度;颈椎纵向生理曲度变异较大,无明显规律性,对确定钢板的纵向弧度帮助不大。     

Fractures of the cervical spine

OBJECTIVES:

The aim of this study was to review the literature on cervical spine fractures.

METHODS:

The literature on the diagnosis, classification, and treatment of lower and upper cervical fractures and dislocations was reviewed.

RESULTS:

Fractures of the cervical spine may be present in polytraumatized patients and should be suspected in patients complaining of neck pain. These fractures are more common in men approximately 30 years of age and are most often caused by automobile accidents. The cervical spine is divided into the upper cervical spine (occiput-C2) and the lower cervical spine (C3-C7), according to anatomical differences. Fractures in the upper cervical spine include fractures of the occipital condyle and the atlas, atlanto-axial dislocations, fractures of the odontoid process, and hangman''s fractures in the C2 segment. These fractures are characterized based on specific classifications. In the lower cervical spine, fractures follow the same pattern as in other segments of the spine; currently, the most widely used classification is the SLIC (Subaxial Injury Classification), which predicts the prognosis of an injury based on morphology, the integrity of the disc-ligamentous complex, and the patient''s neurological status. It is important to correctly classify the fracture to ensure appropriate treatment. Nerve or spinal cord injuries, pseudarthrosis or malunion, and postoperative infection are the main complications of cervical spine fractures.

CONCLUSIONS:

Fractures of the cervical spine are potentially serious and devastating if not properly treated. Achieving the correct diagnosis and classification of a lesion is the first step toward identifying the most appropriate treatment, which can be either surgical or conservative.     

Relationships between the height of intervertebral discs and the degree of lordosis of the cervical spine in children. A roentgenometric study (author's transl)]

On lateral roentgenograms of the cervical spine of 120 normal children between 3 and 14 years of age the ventral and dorsal height of all 5 intervertebral discs were measured and the "index of the intervertebral disc" was calculated. In addition, the "degree of lordosis" of the cervical spine was determined according to ISHIHARA (1964). Evaluation was in 3 age groups: 3 to 6, 7 to 10, 11 to 14 years; and the arithmetic mean and standard deviation were calculated for each group. All intervertebral discs are more or less "cuneiform" (ventrally higher than dorsally); they narrow from cranial to caudal. In children the degree of lordosis of the cervical spine shows a continuous decrease with advancing years. In all age groups girls show a lower degree of lordosis than boys. Statistically the differences of average values of the intervertebral-disc-index among the various shapes of the cervical spine in neutral position (straight, sublordotic, lordotic and hyperlordotic) are highly significant. By means of roentgenometric methods our examinations demonstrate that the lordotic curvature of the healthy cervical spine primarily depends on the cuneiform shape of intervertebral discs.     

Collegiate Football Players Display More Active Cervical Spine Mobility Than High School Football Players

OBJECTIVES: To compare the active cervical spine range of motion and resting cervical spine alignment (sagittal plane) of collegiate and high school football players using the Cervical Range of Motion (CROM) Measurement System and to identify normative values for these populations. DESIGN AND SETTING: A 2 x 7 factorial design for main effects was used to evaluate the influence of level of play (college, high school) on the cervical spine range of motion of football players. Data were collected during preparticipation physical examinations. SUBJECTS: A convenience sample of 189 unimpaired collegiate (n = 70, age = 19.5 +/- 1.5 years) and high school (n = 119, age = 15.7 +/- 1.4 years) football players participated. MEASUREMENTS: Subjects were measured for active cervical spine range of motion using the CROM system and the manufacturer's recommended measurement techniques. RESULTS: Collegiate football players had increased active cervical spine range of motion for flexion, extension, left cervical rotation, and left lateral flexion (overall mean increase = 4.3 +/- 2 degrees ) compared with high school players. Collegiate players also assumed a more flexed resting sagittal-plane cervical spine posture (P =.001). CONCLUSIONS: Collegiate players generally displayed greater active cervical spine range of motion than high school players. The increased resting sagittal-plane cervical spine flexion alignment we report among the collegiate players suggests a change in the natural cervical spine lordosis, possibly due to a neutral-zone shift associated with combined increases in lower cervical spine flexion and upper cervical spine extension as an adaptation to football training or playing. Further study using radiographic or magnetic resonance imaging techniques is warranted. The CROM system is a useful tool for identifying aggregate hypomobile or hypermobile active cervical spine mobility among football players that might otherwise remain unrecognized during standard preparticipation physical examinations. In combination with manual segmental assessments of passive accessory intervertebral movements, CROM enables early identification of players with impaired or excessive cervical spine mobility, thus facilitating proactive injury-prevention intervention.     

Transverse process anatomy as a guide to vertebral artery exposure during anterior cervical spine approach

Safe exposure of the vertebral artery (VA) is needed during resection of tumors close to the artery and during repair of lacerations. We defined the anatomy of the anterior root of each transverse process (TP) from C3 to C6 for identification and exposure of the VA during the anterior approach. We examined the anatomy of the TP and assessed two approaches for safe identification of the VA, lateral to medial and medial to lateral dissection of the TP, in 20 cadavers. The safe zone at each level of the cervical spine was defined as an area in which the surgeon can start to dissect at the midline of that level on the TP and safely cross the VA laterally. For the lateral to medial approach the surgical safe zone lies between the mid axis of the TPs and a line 2 mm parallel to and above it. The average TP angle was 11 ± 10.2 degrees. The mean distance of the lateral border of the VA from the TP tip was 3.78–5.28 mm. For the medial to lateral approach, staying at the level of the upper vertebral end plate will lead the surgeon to the tip of the TP. From that point, dissection can be carried out as described above. This study examined the anatomy of the TP and defined the approach to expose the VA safely during anterior cervical spine exposure. Clin. Anat. 30:492–497, 2017. © 2017 Wiley Periodicals, Inc.     

Comportement mécanique du rachis cervical : une revue de littérature

Cervical spine is certainly the most complex joint. Biomechanics behaviours of this segment coming from different authors are related in this article. Cervical spine can be divided in two parts: upper cervical spine from occiput to C2 and lower cervical spine from C3 to C7. In vitro biomechanical study shows a strongly non linear behaviour. 60% of the motion of the whole segment takes place at the upper cervical from occiput to C2. Coupling motions are significant, principally in lateral bending and axial rotation. On top of that authors describe a neutral zone with a very little stifness at the center of the behaviour graph. This area represents 60% of whole motion of each intervetebral joint. Finally, authors describe a loss of mobility of 40% with ageing. However weigth and size seem to be non significant on the mechanical behaviour of cervical spine.