【作者】 张朝跃；

【导师】 黄祖发；

【作者基本信息】 中南大学 ， 外科学， 2007， 博士

【摘要】 经口咽入路手术是处理枕颈区病变的传统术式，是处理上颈椎和颅底斜坡区域病变最直接的手术入路，具有无需牵拉重要血管、神经，可直接解除脊髓腹侧受压等优点，可作为治疗延脊髓腹侧病变的首选方法。但由于枕颈区形态学资料及其与脊髓、神经、血管等重要结构的详尽解剖学资料研究较少，且传统的经口咽入路手术本身存在术野深，视角小，暴露范围有限，操作深浅度难以掌握等缺点，致使其在临床的应用受到阻碍。近年来，MED技术在腰椎及下位颈椎的成功应用为我们治疗上颈椎疾患提供了一条新的思路。经口咽入路手术视野深度可达10cm，而宽度仅为2～3cm，类似管道状。而MED手术系统采用了轻质液体光纤、便利轻巧的手术器械、显微变速磨钻的手段，使我们对脊柱病变深部术野的的显露与操作更加容易。我们拟将传统的经口咽入路手术与外科微创技术相结合，探讨这种方法的可行性、安全性与具体操作方法。本课题包括内窥镜下经口咽入路枕颈区手术的可行性研究与内窥镜下经口咽入路手术治疗枕颈区病变的临床研究两部分。第一部分我们首先测量了与经口咽入路相关的寰枢椎前柱结构的详尽解剖学数据，并对两组完整头颈部标本分别按传统经口咽入路手术方法及内窥镜下手术方法进行模拟手术，论证内窥镜下进行经口咽入路寰枢椎手术的可行性。第二部分的临床应用过程中，我们选择了包括陈旧性齿突骨折、先天性游离齿突、颅底凹陷、Klipple-Feil综合征在内的12例、2组患者分别按传统经口咽入路方法和内窥镜下方法进行手术，并对两组患者进行了超过1年的随访，比较两组患者在手术时间、张口程度要求、软腭切开、手术并发症、颈髓角恢复情况、JOA评分方面的差异，论证了内窥镜下经口咽入路寰枢椎手术的可行性、适应症、禁忌症；并探讨针对不同枕颈区疾病的具体手术方法、并发症及防治、手术优缺点、器械改进等问题。第一章内窥镜下经口咽入路枕颈区手术的可行性研究目的：为内窥镜下经口咽入路枕颈区手术提供解剖学支持，并探讨内窥镜下经口咽入路手术的可行性。方法：①选取50套完整寰枢椎标本，测量其前柱结构的解剖学数据；另选取颅骨标本20具，测量斜坡及其相邻结构数据。②取临床患者正常X线及CT片各20套，测量前柱结构数据。③选取完整头颈部标本5具，由咽后壁逐层向深面解剖，观察斜坡、寰枢椎、椎动脉、寰椎横韧带等结构及毗邻关系。④将20具完整头颈部标本分为两组(传统组与内镜组)，分别按传统及内窥镜下经口咽入路方法行寰椎前弓、齿状突切除、斜坡开窗及侧块关节面打磨，探讨内窥镜下经口咽入路枕颈区手术的方法，比较两组手术减压、打磨的方法和范围。结果：①斜坡长度28.5±2.2mm，宽度19.2±2.3mm，咽结节枕骨大孔间距12.4±1.5mm，②寰椎前弓长19.8±2.3mm，前结节处最厚，为7.2±1.0mm，与侧块关节相连处最薄，为3.7±0.5mm。③齿状突呈纺锤样，高15.9±1.9mm，最大宽度10.5±0.6mm，最大厚度11.5±1.9mm，后倾角为10.5±3.5°。④寰枢椎侧块关节面呈不规则椭圆形，最大横径15.1±1.6mm；最大矢状径17.7±1.3mm，外倾角为23.5±2.8°。⑤上门齿缝与寰椎前结节的距离为97.2±4.3mm，与寰枢椎侧块关节内外缘连线和矢状面所成的夹角分别为4.8±0.3°与15.2±0.3°。⑥寰椎横韧带的长度为20.0±2.40 mm，中点与硬膜囊的距离(最小值)为2.3±0.3mm，附着点与硬膜囊的距离(最大值)为7.1±1.4mm。⑦寰枢椎骨性标本测量值与X线片、CT片测量值差异无显著性。⑧经口咽入路寰枢椎手术存在“手术安全区”，该区域位于寰枢椎前面，略呈矩形，宽45.9±3.6mm，高29.4±2.5mm，深10mm。⑨内窥镜下寰枢椎模拟手术减压范围宽14.8±0.8mm，高16.1±0.7mm，深19.1±1.0mm，与传统方法差异无显著性，但变异系数小于传统组。结论：1、本研究认为内窥镜下经口咽入路寰枢椎手术在技术上是可行的，不仅能达到传统手术的减压范围，而且对局部结构显露更为清晰，操作更为方便和精确，损伤程度更小，符合当今外科微创发展的要求。2、镜下寰椎前弓切除可采用由寰椎前结节向两侧磨除或由前结节两侧磨断后完整摘除前结节的两种方法；齿突则由尖部向下顺行磨削切除，磨除深度不宜超过齿状突最大厚度；寰枢椎侧块关节面打磨应采用“囊内操作”方法，宽度应在12mm以内，深度不宜超过10mm。3、内窥镜下经口咽入路手术存在一“手术安全区”，对术中避免脊髓、神经、椎动脉损伤有所帮助。第二章内窥镜下经口咽入路手术治疗枕颈区病变的临床研究目的：探讨内窥镜下经口咽入路手术治疗枕颈区疾病的方法与疗效。方法：枕颈区疾病患者12例，分内窥镜手术组与传统手术组，内窥镜组7例，男5例，女2例，年龄16～46岁，平均32岁，其中陈旧性齿突骨折1例，先天性游离齿突1例，先天性颅底凹陷1例，寰枕融合3例，Klipple-Feil综合症1例。所有患者均采用内窥镜下经口咽入路手术，术中首先切除寰椎前弓(颅底凹陷患者尚需切除部分斜坡基底部)；对颅底凹陷患者采用顺行法磨除齿突，对齿突陈旧性骨折或先天性游离齿突患者采用逆行法切除；打磨双侧寰枢侧块关节面。传统手术组5例，男3例，女2例，年龄22～38岁，平均30岁，其中先天性颅底凹陷2例，寰枕融合3例，按传统方法行寰椎前弓切除、枕骨斜坡开窗、齿突切除、寰枢侧块关节面打磨。比较两组手术术中操作及术后并发症及JOA评分、颈髓角恢复情况。结果：两组手术均顺利完成，内窥镜组对张口程度要求较低(≥2cm)，术中无需切开软腭，术后无颞下颌关节疼痛遗留；传统手术组对张口程度要求高(≥4cm)，有3例患者行软腭切开，5例患者均遗留不同程度颞下颌关节疼痛，1例患者软腭开裂。两组中均有1例患者因寰枢椎不稳再次行后路寰枢椎融合术，两组均无脑脊液漏、感染、脊髓或椎动脉损伤等并发症。。所有患者均获随访，时间12～18月，平均15月。内窥镜组颈髓角由术前平均101.5°增加至术后121.7°，传统手术组颈髓角由术前平均101.2°增加至术后123.2°；术后2周、3月、6月、12月复查JOA评分均较手术前增加，但两组间比较无显著性差异。结论：1、内窥镜下经口咽入路手术可作为临床上治疗枕颈区疾病的一种新的微创方法，该方法视野清晰、显露充分、操作方便、效果确切，术后并发症较传统手术少。2、现有脊柱内窥镜系统行经口咽入路寰枢椎手术存在一些不足之处，如手术通道的长度、内径、远端形状等均有待进一步改进与探讨。更多还原

【Abstract】 Transoral-transpharyngeal approach (TOA) is a classical mothed to treat craniovertebral junction abnormality, which is the most direct approach to the upper cervical spine and clivus. Exposition and traction of the important vasa and nerves could be avoided in this approach. However, there are few detailed anatomical data on craniovertebral junction and structures around them. Moreover, the classical TOA has some shortcomings, including deep operative area, small vision angle and limited exposition. Taken together, application of TOA was limited in the clinical.In past few years, successful experience of the application of MED in lumber spine sheds light on the way to treat eraniovertebral junction abnormality. Because the operative area of TOA is about 10cm deep and 2～3cm wide, just like the working tube of MED. Using light liquid photofibre, convenient and handy operational instruments, and variable micro-drill, we are able to reach deep operation area easily. It makes us trying to combine this mini-invasion technology with classical TOA and exploring the feasibility and safty of this technique.This study consists of two parts including anatomic and clinical research. In the first part, we measured clinical data of atlantoaxis and elivus. Then classical and endoscopic methods to decompress the spinal cord and excise the cartilage surface of the atlantoaxis joint by trans-oral approach are taken separately in two groups of eadaveric head and neck, and we discussed the feasibility of endoscopic trans-oral approach to the upper cervical and clivus. In the second part, 12 patients including secondary basilar invagination caused by migration of odontoid fracture fragments, congenital os odontoideum, congenital basilar invagnition occipitalization, and Klipple-File syndrome were divided into 2 groups. GroupⅠwas operated by endoscopic TOA (ETOA), and groupⅡwas treated by classical TOA. All patients had been followed for at least 1 year. We compared operation time, mouth-opening degree, soft palate splitting, complications, cervical-medullary angle, and JOA score of each group, and demonstrate the feasibility, indications, contraindications, concrete oneration methods of ETOA. Part one: Anatomic Basis and Feasibility of Endoscopic Transoral-transpharyngeal Approach to craniovertebral junctionObjective: To provide anatomical basis for endoscopic transoral-transpharyngeal approach to craniovertebral junction, and evaluate the feasibility of endoscopic trans-oral approach to the upper cervical and clivus.Motheds: 1. The clinical significiant data is observed and measured in the anterior column of 50 dry atlas and axis specimens and 20 skulls. 2. Data of the anterior column of atlantoaxis is measured in 20 X-ray and CT. 3. Five cadaveric heads and necks were anatomized from the pharyngeal mucosa to the dura. We observed the elivus, the atlantoaxis, the vertebral artery, the transverse ligament of atlas, and structures around them. 4. Classical and endoscopic methods to decompresss the spinal cord and excise the cartilage surface of the atlantoaxis joint by transoral approach are separately taken in two groups of cadaveric head and neck with the arteries poured into red emulsion. We discussed methods of endoscopic transoral approach to the craniovertebral junction, and compared decompressing size of the two motheds.Results: 1. The clivus is 28.5±2.2mm long and 19.2±2.3mm wide. The distance between the pharyngeal tubercle and the foramen magnum is 12.4±1.5mm. 2. The anterior arch of atlas has a length of 19.84±2.3mm, with the longest anteriorposterior diameter in the tubercle and the shortest in aside massa. 3. The odontoid is 15.94±1.9mm high. The lagerst transverse diameter of odontoid is 10.54±0.6mm, and it is like a shuttle in shape. 4. The atlantoaxis joint is ellipse shaped, with a transverse diameter of 15.1±1.6mm, and the anteriorposterior size is 17.7±1.3mm. The superior facet horizontal angle of atlantoaxis joint is 23.5±2.8°. 5. The distance between the turbule of atlas and fore-teeth is 9.74±0.4cm. The line from medial edge and lateral edge of atlantoaxia joint to the turbule inclines laterally, with an angle of 4.84±0.3°and 15.2±0.3°. 6. The transverse ligament of atlas is 20. 0±2.40 mm long. The minimal distance between the ligament and the dura is 2.3±0.3 mm, while the maximal distance is 7.1+1.4mm。7. There is not significient difference in measure of X ray and CT and skeletal specimens. 8. There is a safe zone in the front of atlanto-axis of transoral approach, with 45.9±3.6mm wide and 29.4±2.5mm high, and a depth of 10mm. 7. Endoscopic transoral atlantoaxis procedure can get a decompressing size of 45.9±3.6mm wide, 29.4±2.5mm high, and 10mm deep, which has not statistically significant difference between classical and Endoscopic TOA.Conclusions: 1. Endoscopic Vans-oral approach to the the upper cervical and clivus is technically feasible, which allows obtaining the decompressing size same as classical TOA. This technique has better exposure, more precise work and less invasion as well. 2. We can either drill the arch from the tubercle to the lateraiside or break the arch from where it connects to the aside massa. Endoscopic odontoid dissection should begin at the apex of the odontoid and proceed inferiorly. We should drill the cartilage of the atlantoaxis joint inside the articular capsule. The width and depth of cartilage dissection should be limitied in 12mm and 10mm in order to avoid damage to vertebral artery and spinal cord. 3. The safe zone of TOA operation may do some help to diminish clinical complications. underwent the operation of endoscopic transoral approach to decompress their anterior cevicomedullary compressive abnormalities. During the operation, we dissected the anterior arch of atlas to expose the odontoid, but in case of severe basilar invagnition, part of the clivus was removed. We drill the odontoid from the apex to. the base in basilar concave, and from the base to the apex in odontoid fracture and os odontoideum. Then the cartilage of atlantoaxial lateral joint were removed. In groupⅡ, there were 3 males and 2 females, aged from 22 to 38 years old with a mean of 30 years. The abnormalties in this group were 3 cases of congenital basilar concave and 2 cases of occipitalization. All the cases were operated by classical TOA with anterior arch of atlas and odontoid resection. Complications and JOA score and Cervical-medullary angle were compared in 2 groups.Results: All patients were operated successfully. Patients in group I can be operated in a condition of poor mouth-opening degree, while patients in groupⅡmust require their monthes opened more than 4cm wide to allow the operation to be done. It is not necessary to splite soft palate or hard palate in the groupⅠ, and there was no temporomandibular joint pain left in this group. In the groupⅡ, the soft palate were splited in 3 patients, and all patients in this group left various degrees of temporomandibular joint pain. There were no cerebral spinal fluid leakage, infection, injure of spinal cord and veterbral artery in both groups. However, there was one patient from each group being reoperated to fuse the atlas and axis in 3 months after the first operation. All patients were followed up from 12 to 18 months (15 month at the average). The cervical-medullary angle was increased from 101.5°to 121.7°in groupⅠand from 101.2°to 123.7°in groupⅡ. JOA scores in 2 groups were increased after operation, but the difference between them was not statistically significant.Conclusions: 1、Endoscopic transoral surgery represents a new microsurgical technique to treat the craniovertebral abnormalities, which provids better expose and more precise work, and could achieve satisfactory outcomes. 2、There is still some problems with the endoscopic system in atlantoaxis procedure needing to be solved in the future.更多还原