一种新型经口咽手术显露系统的研制及其临床应用效果

The development and clinical effect of a new type of transoropharyngeal surgical exposure system

中文关键词:  多功能矩形经口咽寰枢椎手术显露系统  寰枢椎脱位  颅底凹陷症  经口咽寰枢椎复位内固定术

英文关键词:Multifunctional rectangle transoral exposure retractor(MRTER)  Atlantoaxial dislocation  Basilar invagination  Transoral anterior reduction and plate fixation(TARP)

中文摘要:

  【摘要】 目的：研制一种新型的多功能矩形经口咽寰枢椎手术显露系统（multifunctional rectangle transoral exposure retractor，MRTER），探讨其临床应用价值。方法：2020～2025年，我们实施了310例经口咽寰枢椎手术，其中162例使用Codman拉钩[Codman组，男72例，女90例，年龄9~67岁，单纯寰枢椎脱位（atlantoaxial dislocation，AAD）患者47例，颅底凹陷症患者115例]，另外148例使用新型MRTER显露系统（MRTER组，男63例，女85例，年龄6~72岁，AAD患者39例，颅底凹陷症患者109例）。患者的主要临床症状包括颈椎疼痛、活动受限49例；头颈歪斜54例；肢体麻木、无力259例；手指活动不灵活43例；走路不稳178例；膀胱功能障碍5例。入院后实施经口咽寰枢椎复位内固定术（transoral anterior reduction and plate fixation，TARP），其中86例AAD患者未行软腭劈开，224例颅底凹陷症患者行软腭劈开扩大显露后实施经口咽松解复位＋ＴＡＲＰ。测量术中口腔张开距离（Ｄ值）及口底视野面积（Ｓ值）评价拉钩系统的显露能力。在颈椎矢状面ＣＴ片上测算寰枢椎脱位的总复位率；根据患者脊髓功能的JOA评分，计算末次随访时的JOA评分改善率，评价手术疗效。结果：310例患者手术过程均顺利，平均手术时间Codman组138±25min，MRTER组118±31min（P<0.05）；手术出血量Codman组105±45mL，MRTER组113±28mL（P>0.05）。术中测量D值Codman组（4.0±2.1cm）与MRTER组（4.2±1.9cm）比较无统计学差异（P>0.05）；S值Codman组（6.3±2.8cm2）小于MRTER组（7.1±3.1cm2）（P<0.05）。两组患者术后头痛、颈痛症状均明显缓解；肢体麻木、无力及走路不稳症状均有不同程度的改善。AAD的总体复位率Codman组81.3%，MRTER组82.5%（P>0.05），JOA评分改善率Codman组71%，MRTER组73%（P>0.05）。结论：新型的MRTER显露系统为实施寰枢椎经口咽手术提供了一种有效的辅助工具。

英文摘要:

  【Abstract】 Objectives: To develop a new type of multifunctional rectangle transoral exposure retractor(MRTER) and explore its clinical application value. Methods: From 2020 to 2025, we performed 310 cases of transoropharyngeal atlantoaxial surgery, of which 162 cases used Codman retractors[Codman group, 72 males and 90 females, aged 9-67 years old, 47 cases were with simple atlantoaxial dislocation(AAD), 115 cases were with basilar invagination], and 148 cases used the MRTER retractor system(MRTER group, 63 males and 85 females, aged 6-72 years old, 39 cases were with AAD, 109 cases were with basilar invagination). The main clinical symptoms of the patients included cervical pain and restricted mobility in 49 cases, torticollis in 54 cases, weak and numbness of the limbs in 259 cases, finger inflexibility in 43 cases, walking instability in 178 cases, and bladder dysfunction in 5 cases. After admission, a transoral atlantoaxial reduction and plate internal fixation(TARP) was performed. Among the patients, 86 with AAD did not undergo a soft palate split, and 224 patients with basilar invagination underwent a soft palate split to expand the exposure and then underwent transoral release and reduction+TARP procedures. Intraoperative oral opening distance(D value) and oral floor field of view area(S value) were measured to evaluate the exposure ability of the retractor system. The global reduction rate of atlantoaxial dislocation was measured on the cervical sagittal CT film, and the JOA score improvement rate at the final follow-up was calculated to evaluate the effect of the operation. Results: The surgical procedure of 310 patients was smooth, the operation time was 138±25min in Codman group and 118±31min in MRTER group(P<0.05); The surgical blood loss was 105±45mL in Codman group and 113±28mL in MRTER group(P>0.05). The intraoperative measured D value was 4.0±2.1cm in Codman group and 4.2±1.9cm in MRTER group(P>0.05); the S value was 6.3±2.8cm2 in Codman group and 7.1±3.1cm2 in MRTER group(P<0.05). After operation, the symptoms of headache and neck pain were significantly relieved; the symptoms of limb numbness, weakness and walking instability were improved to varying degrees. The overall reduction rate of AAD was 81.3% in Codman group, and 82.5% in MRTER group(P>0.05); JOA improvement rate was 71% in Codman group, and 73% in MRTER group(P>0.05). Conclusions: The new MRTER exposure system provides an effective auxiliary tool for the implementation of atlantoaxial transoropharyngeal surgery.