【作者】 周军；

【导师】 卢永田； 史丽；

【作者基本信息】 山东大学 ， 耳鼻咽喉科学（专业学位）， 2017， 博士

【摘要】 研究背景临床上颈椎椎体肿瘤比较少见,多发病隐匿,而且早期症状没有特异性,故患者早期无明显临床症状,常被误认为颈椎病而延误到出现脊髓压迫症状时才来就诊。Levine等报道一组9例颈椎肿瘤中,95%的患者有局限性疼痛,37%的颈椎良性肿瘤伴有根性痛。患者中29%出现斜颈,14%出现感觉障碍,7%出现局限性运动障碍。目前国内外认为手术是颈椎椎体肿瘤最重要、最有效的治疗方法。传统的颈椎椎体肿瘤手术方式主要有三种:前路手术、后路手术及前后联合手术,其存在手术径路远、创伤大、有损伤颈部重要血管神经引发严重并发症可能,尤其是儿童颈椎恶性肿瘤手术难度大、易复发,预后差,如何安全有效地暴露并切除颈椎椎体病变是临床医师正在探讨中的课题,近年来以安全、可靠且创伤小的微创方法治疗颈椎椎体病变逐渐应用于临床。随着鼻内镜解剖、内镜技术和颅底外科学的发展,进一步扩大了鼻内镜外科手术的治疗范围。目前国内外有关鼻内镜下口内径路对颈椎椎体肿瘤施行手术切除尚未有文献报道。受学者们切除脊索瘤和齿状突病变的启发,我们对20例新鲜尸头标本,进行寰枢椎CT测量,获得详细的解剖学数据,对10例新鲜灌注尸头标本,采用内镜下口内径路对颈椎椎体及相关区域行模拟手术并解剖学观测。临床上采用内镜下经口径路对8例颈椎椎体良性病变施行手术切除,主要论述了颈椎椎体良性病变内镜下口内径路切除术的手术特点、术中操作技巧以及术中、术后并发症的预防等,探索颈椎椎体良性病变内镜下口内径路手术切除的可行性。目的探索颈椎椎体良性病变内镜下口内径路手术切除的可行性及临床验证。资料和方法对20例新鲜尸头标本,进行寰枢椎CT测量,获得详细的解剖学数据,包括寰椎前弓长度、寰椎前结节厚度、寰椎侧块横径、寰椎侧块矢状径、寰枢椎两侧横突孔内侧间距、寰枢椎两侧横突孔外侧间距等;对10例新鲜灌注尸头标本,采用内镜下口内径路对颈椎椎体及相关区域行模拟手术并解剖学观测,以期为临床提供较为详实的解剖学资料。2013年10月-2015年10月,在深圳市第二人民医院耳鼻咽喉科住院部,我们采用鼻内镜系统、经口内径路切除8例颈椎椎体良性病变,男5例、女3例;年龄5岁-42岁,平均20岁;临床表现为颈痛6例,头痛2例,头部不稳感2例,颈部活动受限2例,颈部活动不适1例。嗜酸性肉芽肿7例、脂肪瘤1例。所有患者均在手术前、后行颈椎电子计算机断层扫描(Computed tomography,CT)加增强轴位、冠状位和矢状位检查,颈椎磁共振成像(Magnetic resonance imaging,MRI)检查,以确定病变位置、范围及与周围结构的关系。8例患者中5例侵犯寰枢椎椎体,3例侵犯第三颈椎椎体,均未侵及硬脊膜和脊髓。5例患者术前行三维(Three dimensional,3D)重建并3D打印模型,为术前治疗方案设计及与患者家属沟通提供了帮助。所有患者术前均已签署手术知情同意书。结果新鲜尸头寰枢椎CT测量值:寰椎前弓长度(19.6±2.6)mm,寰椎前结节厚度(8.1 ±0.7)mm,寰椎侧块横径(左)(12.8±2.6)MmMm,寰椎侧块横径(右)(12.8±1.9)mm,寰椎侧块矢状径(左)(14.9±2.4)mm,寰椎侧块矢状径(右)(15.2 ±1.6)mm,寰椎两侧横突孔内侧间距(47.1±1.5)mm,寰椎两侧横突孔外侧间距(60.6± 1.6)mm,枢椎两侧横突孔内侧间距(29.1 ±1.5)mm,枢椎两侧横突孔外侧间距(44.2士 1.8)mm。灌注尸头标本模拟手术结果:①内镜下口径路可显露寰枢椎腹侧,包括:寰椎、枢椎椎体,寰椎前弓、侧块,齿突及两侧椎动脉;②上方常规可显露至寰椎前弓上缘或斜坡下部,下方可显露至C2/3椎间盘或C3椎体上部,两侧安全边界可界定:寰椎层面为寰枢侧块关节外缘,枢椎层面为枢椎体外缘。可满足内镜口内径路手术需要。8例临床患者病变均一次彻底切除,未见明显并发症发生;术后8小时经口进食;手术当天全麻清醒后至术后第3天采用NRS评分法评估疼痛程度,平均2.25分;术后5天拆线并出院,平均住院时间6.5天;平均住院费用8225元。随访3-12个月。8例患者均于术后3月行颈椎CT检查,肿物均被完整切除,无复发。结论内镜口内径路颈椎椎体良性病变切除术对颈部椎体病变暴露清楚,此径路具有径路短、技术简单、疗效可靠、并发症少、手术时间短、术后恢复快等优点,值得推广。更多还原

【Abstract】 BackgroundCervical vertebral body tumor is rare and usually not associated with readily discernible clinical signs.And the early clinical symptoms are usually non-specific.So there is no obvious clinical symptoms of patients of cervical vertebral body tumor in early stage and they liable to be mistaken for other cervical disorders;and often tend to be ignored by patients.Often medical care is sought at an advanced stage on development of signs and symptoms of spinal cord compression.Levine,et al reported 9 cases of cervical tumor,among which 95%of cases had localized pain,37%had cervical radicular pain,29%had torticollis,14%had a sensory disturbance and 7%had limited movement disorders.Globally,the resection of cervical vertebral body tumor is considered to be the most effective treatment.There are three main traditional surgical approaches to cervical vertebral lesions:anterior approach,posterior approach and combined anterior-posterior approach.All three approaches involve considerable dissection and associated surgical trauma with a risk of serious complications including damage to important blood vessels and nerves in the neck.In malignant cervical tumors,surgical treatment is challenging and prone to relapse,with a particularly poor prognoses in children.it is a subject of being discussed among clinicians that how to expose and remove cervical vertebral body lesions safely and effectively.In recent years,due to its safety,reliability and lesser associated trauma,minimally invasive surgical technique is gradually being adopted for treatment of cervical vertebral lesions in clinic.With the development of nasal endoscope technology,endoscopic techniques and skull base surgery,the therapeutic application of nasal endoscopic surgery has been further expanded.To the best of our knowledge,there are no reports in literature describing nasal endoscopic resection of tumor of cervical vertebral body through intraoral approach.Inspired by successful resection of chordoma and odontoid lesions,we measured atlantoaxial of 20 cases of fresh cadaveric heads and necks with CT to abtain the detailed anatomy parameters and performed operation of cervical vertebral body and related areas to study its anatomy via endoscopic intraoral approach in 10 cases of fresh cadaveric heads and necks perfused.we present the eight reported cases that underwent endoscopic resection of benign lesions of cervical vertebrae through an intraoral approach in this paper.This paper mainly discusses the surgical characteristics,intraoperative surgical skills and prevention of intraoperative and postoperative complications of endoscopic resection of cervical vertebral body benign lesions,and explore the feasibility of nasal endoscopic intraoral approach for resection of benign lesions of the cervical vertebral body.Objective:To explore the feasibility of nasal endoscopic intraoral approach for resection of benign lesions of the cervical vertebral body and evaluate the reliability by clinical practice.Materials and methods:To abtain the detailed anatomy parameters,the atlantoaxial of 20 cases of fresh cadaveric heads and necks was measured with CT,including length of anterior arch of atlas,the thickness of anterior tubercle of atlas,atlas lateral horizontal diameter,atlas lateral sagittal diameter,spacing of atlas transverse process the inside hole,and spacing of atlas lateral transverse process hole etc;and operation of cervical vertebral body and related areas was performed via endoscopic intraoral approach in 10 cases of fresh cadaveric heads and necks perfused to provide more detailed anatomical data for clinic.From October 2013 to October 2015,We reviewed eight cases(5 males,3 females)with age range 5-42 years(mean:20 years)who underwent endoscopic resection of benign lesions of the cervical vertebral body using an intraoral approach in the department of Otolaryngology of Shenzhen the Second People’s Hospital.Amongst the study subjects,6 patients had neck pain,2 had headache,2 complained of a sense of head instability,2 complained of a sense of neck motion restriction,1 complained of a sense of neck motion discomfort.7 had eosinophilic granuloma,and 1 had lipoma.All patients underwent computed tomography(CT)of the cervical spine(enhanced axial,coronal and sagittal planes)and cervical magnetic resonance imaging(MRI)pre-and post-operatively to assess the lesion location,range and relationship with the surrounding structures.There were five cases with violation of atlantoaxial vertebrae and three cases of infringement of the third cervical vertebrae,both of which had not invaded the endorhachis and spinal cord.Five patients underwent preoperative 3D reconstruction and 3D printed models,which contributed to preoperative preparation of the treatment design and communication with patients and their families.Written informed consent was obtained from all patients prior to operation.Result:CT results of atlantoaxial of 20 cases of fresh cadaveric heads and necks showed:length of anterior arch of atlas 19.6 ±2.6 mm,the thickness of anterior tubercle of atlas 8.1 ±0.7 mm,atlas lateral horizontal diameter(left/right)12.8±2.6 mm/12.8 ± 1.9 mm,atlas lateral sagittal diameter(left/right)14.9±2.4 mm/15.2 ±1.6 mm,spacing of atlas transverse process the inside hole 47.1 ± 1.5 mm,spacing of atlas lateral transverse process hole 60.6 ± 1.6 mm,spacing of axis transverse process the inside hole 29.1 ± 1.5 mm,spacing of axis lateral transverse process hole 44.2 ±1.8 mm.Results of operation via endoscopic intraoral approach in 10 cases of fresh cadaveric heads and necks perfused showed:① The atlantoaxial ventral could be exposed via endoscopic intraoral approach,including atlantoaxial vertebral body;the anterior arch of atlas,lateral mass,odontoid process and vertebral artery.②Superior border of anterior arch of atlas or lower clivus can be conventionally exposed above while C2/3 intervertebral disk or upper of C3 centrum can be exposed below.The security boundary on both sides can be defined as the lateral margin of joint of atlantoaxial lateral mass in the atlas level and the lateral margin of axial vertebral body in the axial level.It can meet the needs of surgery via endoscopic intraoral approach.In all 8 cases,the lesions were completely removed using a nasal endoscopic intraoral approach in a single procedure with no significant complications.Oral intake was started 8 hours postoperatively.Numeric rating scale(NRS)pain scores were used to evaluate the degree of pain,with an average score of 2.25 points from operation day after general anesthesia to the thrid days postoperatively.The average hospital stay was 6.5 days;stitch removal and discharge was done on the fifth postoperative day.The average hospital cost was approximately 8225 Yuan.The patients were followed up for 3 to 12 months.All five patients were examined by cervical computed tomography scan three months postoperatively,which revealed complete resection of lesion without any evidence of recurrence.Conclusion:Endoscopic resection of benign lesions of the cervical vertebral body through intraoral approach may offer the advantage of a convenient access,simple technology,fewer complications,shorter operative time and quicker postoperative recovery.It worth promoting.更多还原