经前路部分切除胸骨上端入路手术治疗上胸椎病变

Anterior approach and hemisectomy of stern for upper thoracic disease

目的：探讨经前路部分切除胸骨上端行上胸段脊柱前路手术的方法和临床效果。方法：2005年7月～2010年9月采用胸骨上端部分截骨前入路手术治疗17例上胸椎病变患者。男8例，女9例；年龄27～77岁，平均57．7岁。T3动脉瘤样骨囊肿2例，T2～T3结核7例，T3～T4结核3例，T2骨巨细胞瘤2例，T3骨巨细胞瘤2例，T2软骨肉瘤1例。术前分析上胸椎矢状位CT片，确定手术需要显露的范围。半月形去除胸骨柄上部部分骨质，保留两侧胸锁韧带，从头臂动脉内侧窗或外侧窗显露病变部位．行病灶清除或切除、植骨或重建内固定。记录患者术中及术后并发症情况，随访治疗效果。结果：17例患者经部分切除胸骨上端前入路均顺利完成手术，对上胸椎病灶显露良好。3例患者术中出现心跳缓慢、低血压或气道阻力增加，去除牵拉后很快恢复。手术时间2～3h，卅血量200～700ml，平均400ml。术后1例患者出现短暂性声音嘶哑，术后2个月痊愈；无其他并发症发生。随访17～27个月，平均22．7个月，植骨均获骨性融合，颈胸段生理弧度恢复，无内固定失败，脊柱稳定十牛好。17例患者术后神经症状均有所改善。结论：部分切除胸骨上端前入路可以在完整保留胸锁关节下有效显露T2～T4范围，操作简易，并发症少，是处理上胸椎病变较理想的人路。

Objectives： To investigate the clinical outcome of anterior approach and hemisectomy of stem for upper thoracic disease. Methods： 17 patients suffering from upper thoracic lesions underwent anterior hemi- sectomy of stern from July 2005 to September 2010. There were 8 males and 9 females with the age ranging from 27 to 77 years, with an average age of 57.7 years. The pathogenesis included T3 aneurysmal bone cyst in two cases, T2-T3 tuberculosis in seven cases, T3-T4 tuberculosis in three cases, T2 bone giant cell tumor in two cases, T3 giant cell tumor in two cases and T2 chondrosarcoma in one case. Before operation, upper thoracic sagittal CT was analyzed with the aim to determine the scope of surgery. Upper sternum was resected and removed as half-moon. Both sides of the sternoclavicular ligament were retained. Through the window of the brachiocephalie artery, lesion was exposed. The debridement or excision, bone grafting or reconstruction of internal fixation were performed afterward. Intraoperative, postoperative and follow-up complications were recorded. Results： 17 patients were perfomed surgery successfully. All lesions were exposed satisfactorily. Three cases were complicated with bradyeardia, low blood pressure or increase of airway resistance during op- eration, and all resolved quickly after the discharge of traction. 1 case was complicated with transient hoarse- ness, that was resolved 2 month later. The surgical time was 2-3h, and the amount of blood loss was 200- 700ml, averaging 400ml. All patients were followed up for 17-27 months, with an average of 22.7 months. No fixation failure was noted, and all cases reached bony fusion. Physiological curvature of the cervical and thoracic segment recovered. 17 cases with preoperative neurological deficit recovered partially. Conclusions：The modified upper thoracic vertebral approach can effectively expose T2-T4, which can retain the sternoclav- icular joint and sternum, and is proved to be an ideal approach for managing upper thoracic lesions.