颈胸段脊柱手术前方入路的应用解剖

Applied anatomy of the anterior approach operation of the cervicothoracic spine

目的:通过对颈胸段脊柱周围重要解剖结构的分布、走行及毗邻关系的研究,为颈胸段脊柱选择合理的手术入路提供解剖学基础。方法:对30具成人尸体模拟经胸骨柄和部分锁骨切除的颈胸段脊柱前方入路进行解剖,采用连续层次解剖法,重点观察前方手术入路途径中必须牵拉和需要保护的几个重要组织,并测量相关数据。结果:左头臂静脉的长度为(67.3±9.7)mm,左静脉角与前正中线的水平距离为(45.0±8.3)mm,头臂静脉与头臂干交点距胸骨上切迹的垂直距离为(52.7±20.1)mm;胸膜顶最高点距锁骨内1/3上缘的垂直距离,左侧(8.1±2.0)mm右侧(13.7±2.8)mm胸导管顶点80%位于第7颈椎(C_7)水平,胸导管顶点距前正中线的距离为(33.78±2.16)mm;左喉返神经进入气管食管沟的位置93.4%位于第3、4胸椎~第4、5胸椎(T_(3/4)~T_(4/5))之间,右喉返神经进入气管食管沟的位置30%位于C_(6/7)水平,60%位于C_7水平,右喉返神经与颈总动脉内侧缘交叉点90%位于T_1水平;主动脉弓顶点90%位于T_(2/3)~T_(3/4)椎体水平。结论:颈胸段脊柱前路手术采取左侧入路,术野暴露更充分,操作更方便,同时术中通过对左头臂静脉的牵拉和结扎胸导管可减少医源性并发症的发生。

Objective： To provide anatomic data for the optimal operative approach of the cervieothoracic spine through the research on the distribution, routing, and relations of the important structures around it. Methods： Thirty cadaver specimens were dissected by simulating the steps of sternal and part of the clavicle resection in the optimal anterior approach of the cervicothoracic spine. Continuous regional anatomy was performed. Several important structures which must be retracted and protected in the anterior approach were observed and measured. Results： The length of the left brachiocephalic vein was （67. 3±9.7） mm. The horizontal distance of left venous angle to the anterior midline was （45.0±8.3） mm. The vertical distance from the intersection of brachiocephalic vein and brachiocephalic trunk to the suprasternal notch was （ 52. 7±20. 1） ram. The vertical distance from the peak of the pleura to the superior border of the medial 1/3 part of the left clavicle was （8. 1±2. 0） mm and （13.7±2.8） mm on the right. For 80% of the specimens, the apex of the thoracic duct was at the level of C7, and the horizontal distance from the apex of the thoracic duct to the anterior midline was （33.78±2. 16） mm. For 93. 4% of the specimens, the left recurrent laryngeal nerve entry into the groove between trachea and esophagus was at the level of T3/4-T4/5, and for 30% of the specimens the right recurrent laryngeal nerve entry into the groove was at the level of C4/7, and 30% at the level of C7 For 90% of the specimens, the intersection of the right recurrent laryngeal nerve and medial margin of common carotid artery was at the level of T1. For 90% of the specimens, the peak of aortic arch was at the level of T2/3-T3/4. Conclusion： Application of the cervicothoracic spine anterior approach operation from the left side, the operative field can be exposed more fully, and more easier to operate, at the same time through traction of the left brachiocephalic vein and ligation of the thoracic duct can reduce the incidence of iatrogenic complications.