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颈椎病手术治疗（ACDF术）

李鹏飞医生 发布于2023-02-10 10:57 阅读量474
深圳市光明区人民医院

本文由李鹏飞原创

Rothman-Simeone and Herkowitz‘s  The Spine  seventh edition

Surgical Anatomy

FIG. 1 Anteromedial approach to the upper cervical spine. (A) Dissection is done through a retropharyngeal approach as an extension of the Southwick-Robinson approach to the lower cervical spine.(B) The longus colli muscle is retracted to expose the anterior tubercle of the atlas and body of axis.


FIG. 2 (A) Right-sided submandibular transverse incision. (B) The anterior border of the sternocleidomastoid muscle is mobilized, and the digastric tendon is divided. The submandibular salivary gland and jugular digastric lymph nodes are resected. The hypoglossal nerve is identiied and mobilized. (C) The carotid sheath is opened, and the arterial and venous branches are ligated. (D) The superior laryngeal nerve is identiied and protected.

FIG. 3 Anterolateral retropharyngeal approach. (A) A skin incision is made from the mastoid along the anterior aspect of the sternocleidomastoid. (B) This approach involves dissection anterior to the sternocleidomastoid but posterior to the carotid sheath. (C) Neurovascular structures that are encountered in this approach include the carotid contents and branches, superior laryngeal nerves, hypoglossal nerve, and ansa cervicalis.

FIG. 4 Verbiest’s approach. The sternocleidomastoid and carotid sheath are identiied and retracted laterally, and visceral structures are retracted medially. The anterior tubercle of the transverse process is identiied by palpation. Muscular insertions of the longus colli, longus capitis, and anterior scalene are dissected sharply to the bone, and the anterior tubercle is cleared of soft tissues. The costotransverse lamellae can be resected to provide exposure to the vertebral artery and spinal nerve lying posteriorly.


FIG. 5 Surface anatomy can help identify the approximate level of vertebral bodies in the cervical spine. The hyoid bone overlies C3, thyroid cartilage overlies C5, the cricoid ring is at C6, and the supraclavicular level is in the C7–T1 region.


FIG. 6 Anterior access to the cervicothoracic junction is complicated by proximity of the great vessels and associated neural structures.


以下内容来自Surgical Anatomy & Techniques to the Spine 第二版



Figure 1  Surface anatomy correlates. The sternocleidomastoid (SCM) muscle, hyoid bone, thyroid cartilage, and cricoid cartilage are easily identified on visual inspection of the skin surface and by palpation. The hyoid bone approximates C3, the thyroid cartilage approximates C4, and the cricoid cartilage approximates C6. The carotid sheath lies medial and deep to the SCM.




Figure 2  Representative subaxial cervical vertebra. A, Axial view. B, Coronal view.


Figure 3 Carotid sheath and cervical fascia. The carotid sheath encloses the internal jugular vein, common carotid artery, and vagus nerve. Note the sheath’s lateral location relative to the pretracheal fascia; this corridor is often used for anterior cervical operations. The deep cervical fasciaincluding the investing, pretracheal, and prevertebral fascial layers—should also be noted, along with the recurrent laryngeal nerve within the tracheoesophageal groove.


     


Figure 4 Recurrent laryngeal nerve. The nerve loops around the aortic arch on the left and around the subclavian artery on the right.


Figure 5 Illustration of the Smith-Robinson technique. A r gular diskectomy is performed, allowing both central and foraminal decompression followed by insertion of an intervertebral graft.

             

Figure 6 The final operative position has the patient secured supine in mild neck extension with a small roll placed transversely across both shoulders. The head is toward anesthesia; the fluoroscopy machine is positioned transversely at the level of the cervical spine in preparation for localization. The shoulders are gently retracted caudally and are taped in place for better radiographic exposure of lower cervical levels.
                                          
   
Figure 7 Anatomic landmarks for marking incisions.


Figure 8 A left-sided transverse skin incision is made, exposing the longitudinal fibers of the platysma muscle.

Figure 9 The platysma is bluntly dissected and elevated from underlying structures with Metzenbaum scissors, then incised transversely with monopolar electrocautery.


Figure 10 Anterior cervical fascia on the medial border of the sternocleidomastoid muscle has been incised to reveal a natural plane.


Figure 11  Using Cloward handheld retractors, the infrahyoid muscles, trachea, and esophagus are retracted medially; the sternocleidomastoid muscle and carotid sheath are retracted laterally. This places the middle cervical fascia under tension; the fascia is dissected bluntly with Kittner swabs.


Figure 12  A bent 18-gauge spinal needle is used to correctly localize the C5–C6 intervertebral disk space. A lateral fluoroscopic image and an intraoperative image are shown.




Figure 13  Exposure of the anterior vertebral surface and disk space. The anterior longitudinal ligament and longus colli muscles are dissected subperiosteally.

Figure 14  Cross-sectional (left) and anterior (right) images of the final position of the self-retaining retractors. The teeth of the laterally oriented blades are tucked beneath the longus colli muscles (arrows). Identification of the midline will prevent lateral deviation and vertebral artery injury during diskectomy.


Figure 15  Schematic (left) and intraoperative (right) views demonstrate incision through the anterior annulus.


Figure 16  Pituitary rongeurs, Kerrison rongeurs, and curettes are used to remove disk space material.

Figure 17  The cartilaginous end plates and osteophytes are carefully drilled and removed with curettes and Kerrison rongeurs to create a rectangular bed for placement of an intervertebral graft.


Figure 18  Left, The posterior longitudinal ligament is exposed with a small rent (arrow) to reveal the dura posteriorly. Right, The posterior longitudinal ligament is removed with Kerrison rongeurs to ensure complete decompression of the spinal canal.


Figure 19  The intervertebral graft is inserted flush to the anterior vertebral surface and the superior and inferior end plates. The graft is mildly oversized to prevent graft migration and promote fusion.


Figure  20  The cervical plate is in midposition, spanning the disk space evenly. The sagittal view (left) shows the plate is flush with the anterior vertebral surface.

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颈椎病