改良肩胛深层入路显露上胸椎的应用解剖

Appl ied anatomy of the modified subscapularis approach to the upper thoracic spine

目的:为改良肩胛深层入路显露上胸椎提供解剖学依据。方法:21例福尔马林浸泡的尸体标本按左右侧肋骨切口高低,随机分为右高左低组(A组)、左高右低组(B组)及低位切口组(C组);按手术入路,逐层解剖至上胸椎椎体,观察并测量皮肤切口长度、肋骨切口纵向撑开宽度、显露椎体范围、双侧交感神经干、奇静脉弓及胸导管等结构,采用SPSS11.5统计学软件对数据进行处理和分析。结果:改良肩胛深层手术入路皮肤切口长度平均(22.88±1.70)cm;若切除第3肋骨,切口纵向撑开宽度平均(6.10±0.68)cm,能显露T2～4椎体(100%);若联合切除第2肋骨,切口撑开宽度平均(8.08±0.93)cm,能显露T1椎体下2/3～T4椎体(83.3%);若联合切除第4肋骨,切口撑开宽度平均(8.87±0.73)cm,能显露T2-5椎体(100%);若单纯切除第4肋切口撑开宽度平均(6.03±0.53)cm,显露T3～5椎体(100%);交感神经干、奇静脉弓及胸导管等结构在显露过程中出现在相对恒定的位置,术中仔细操作可避免损伤。结论:改良肩胛深层入路是显露上胸椎的理想的手术入路,具有创伤小,显露好,安全性高等优点。

Objective： To provide anatomic data for the modified subscapularis approach to the upper thoracic spine. Methods： 21 upper thoracic spine specimens of adult human cadaver were divided randomly into 3 groups according to the costal incision： right high-left low, right low-left high and low incision groups. The specimens were exposed, measured and studied for their anatomy landmarks according to the approach. The data, including incision, exposed range, sympathetic nerve, arch of azygos vein and thoracic duct was measured and analyzed. Results： By this approach, the length of skin incision was about （22.88±1.70） cm. We could get a incision with （6.10±0.68） cm in width by removing part of the 3rd rib, exposing T2-T4（100%）. In addition, when the 2nd or 4th rib was removed partly, the width would be （8.08±0.93） cm or （8.87±0.73） cm, providing a sufficient exposure of part of T1-T4 （85.7%） or T2-T5 （100%）. Removing the 4th rid only, the width of incision would be （6.03±0.53） cm, exposing T3-T5（100%）. The sympathetic nerve, arch of azygos vein and thoracic duct were exposed by this approach, and we could avoid injuring them by dissecting carefully. Conclusions： The modified subscapularis approach to the upper thoracic spine is safe and effective.