| PECD(Percutanous full-endoscopic anterior cervical discectomy) is a new microsurgery in the treatment of anterior cervical which was initially reported by Mr. Ruetten, a spine minimally invasive expert in Germany. The reference to it or related study is insufficient due to its short history, insufficient study of anatomy including, particularly, the study of distribution, features and inter-relations of such vulnerable anterior cervical anatomical structures such as cervical longus,cervical truncus sympathicus,and vertebral artery. Although some domestic top three hospitals gradually developed this technology and no serious complications was reported,but this new microsurgery is still in the preliminary stage in clinic with less cases as base number, which hence requires further verification to evaluate its safety and effectiveness, so does the study on the basis of large number of cases of complication, indication and long-term follow-up results. Objective:1 Observe and measure 3 items, namely the cervical longus of inferior cervical vertebrae, cervical truncus sympathicus and vertebral artery of the corpse specimen which have been antisepticly treated in formaldehyde solution; analyze the position of the anatomical parts of them and provide reference to clinic endoscope operator, especially the beginners.2 By measuring the transverse and sagital images of MRI, the distance between cervical vertebra space and cervical longus and vertebral artery, and the distance between cervical cord and posterior edge of Vertebral body are obtained; compare the values to acquire the similarities and differences of them so as to provide the basis of iconographic anatomy to prevent PECD complication.3 Select those patients who are clinically capable to receive PECD surgery, discuss its minimally invasive feasibility, safety, effectiveness, operating highlights and preliminary clinical effects. Methods:1 Measurement of specimen. Select 5 adult specimen(Male:3; Female:2) as the case subject, age ranging from 41 to 74, mean age:59.8, height:150-173cm, mean height:159.6cm. Observe and measure the central level of intervertebral space in cervical vertebra. The measured items include distances between medial border of the longus colli muscle, the distance between medial border of the longus colli muscle and midline, the distance between cervical truncus sympathicus and midline, the distance between cervical truncus sympathicus and medial border of the longus colli muscle, the distance between medial border of vertebral artery, the distance between medial border of vertebral artery and midline and the distance between medial border of vertebral artery and medial border of cervical longus. Observe the distribution features of cervical longus, cervical truncus sympathicus and vertebral artery, and the relation with peripheral tissue structures.2 Randomly select 100 cases(male:42; female:58) of patients who are confirmed suffering cervical spondylosis, age ranging from 40 to 50, mean age 47.4. All have been magnetic resonance (MR) scanned T1WI、T2WI on their cervical vertebra. The observer selects T2WI transverse section at 4 intervertebral spaces:C3/4、C4/5、C5/6、C6/7, and measure the cervical longus space, the distance between inner edge of cervical longus and midline, the space of vertebral artery, the distance between inner edge of vertebral artery and midline and the distance between inner edge of vertebral artery and cervical longus.Meanwhile, measure the distance between the posterior edge of Vertebral body which is at the center of intervertebral disc and the cervical cord on the sagittal plane with MR T2WI scan Compare the data difference with variance test and verify the effectiveness of corpse autopsy.3 From April 2014 to May 2015, our department has operated 5 cases of minimally invasive surgery of PECD who are confirmed to fail in the conservative treatment.The 5 cases include 4 males and 1 female, age ranging from 38 to 56, mean age 47.8. The lesion distributions are:C3/4:2 cases, C4/5:Ocase, C5/6:1 case, C6～C7:2 cases. All cases have received and their surgery time, and amount of bleeding are observed. They are conducted follow-up visits 3 days after the surgery, and 3 months afterwards., record the clinical effects and possible complication and assess them with visual analogue scale(VAS). Results:1 (1) Cervical longus starts from anterior tubercle of atlas and down to the third thoracic vertebra. The side face attaches to anterior tubercle of processus transversus. From C3/4 to C6/7, distances between both medial border of the longus colli muscle and the distance between the medial border of the longus colli muscle and midline are(7.63±0.92)mm-(13.49±1.50)mm and (3.57±1.13)mm-(6.70±1.24)mm respectively, and gradually increasing from upside down. (2) Cervical truncus sympathicus lines from up outside down to inside.Distances between cervical truncus sympathicus and midline are (24.98±2.26)mm-(18.56±3.00) mm. Distances between cervical truncus sympathicus and medial border of the longus colli muscle are(19.61±2.07) mm-(13.30±1.36)mm. and gradually decreasingly from upside down. The distance between cervical truncus sympathicus and midline is the shortest in C6/7 section.(3) Vertebral artery all enters from the transverse foramen at the sixth cervical vertebra and all the way to cervical processus transversus from up outside down to inside. Distances between both medial border of the vertebral artery are(24.07±1.01)mm-(30.92±1.18)mm. Distances between vertebral artery and midline are (11.90±2.02mm-(17.49±2.45mm. Distances between medial border of the vertebral artery and medial border of the longus colli muscle are (5.28±1.41)mm-(8.14±1.39) mm. The transverse space between cervical longus and vertebral artery are increasing from upside down, the width at C6/7 section is distinct, significant different with its upper horizontal measurement(p<0.05).2 To measure the intervertebral disc center at MR T2WI image.(1) Distances between both medial border of the longus colli muscle and distances between the medial border of the longus colli muscle and midline are(10.25±2.45) mm-(15.04±1.63)mm,(5.67±1.76)mm-(7.88± 0.78)mm respectively, gradually increasing from upside down.(2) Distances between both medial border of the vertebral artery, distances between medial border of the vertebral artery and central midline and distances between medial border of the vertebral artery and distance between medial border of the longus colli muscle are (25.37±5.65)mm-(30.56±6.51)mm,(13.36± 2.6)mm-(18.12±2.92)mm,(5.84±1.86)mm-(7.89±2.46)mm respectively.(3) The distance between posterior edge of Vertebral body and cervical cord at the the intervertebral disc center on central sagittal plane with MR T2WI scanning are (3.32±1.29)mm,(2.92±1.59)mm,(3.91 ±1.59) mm, (5.29±2.19)mm respectively. The C4/5 is the shortest to the cervical cord.3 All the 5 surgeries are successful, none of them suffer injure symptoms of weasand sheath, carotid sheath, cervical truncus sympathicus,and vertebral artery. The follow-up visits last 3 to 12 months,8.8 on average. The MRI reexamination after the surgery has shown the intervertebral disc has been entirely removed, and there is no such cases as cervical vertebra insatiability through X Ray. The symptoms the patients once suffered are gone. The evaluation of therapeutic efficiency is using VAS grade before and after the surgery, and the VAS grade after surgery decreases. Conclusion:1 This study measures the inferior cervical vertebrae of the corpse specimen with iconography image. It can provide anatomical data for the injury of cervical truncus sympathicus,vertebral artery and cervical cord during PECD surgery in a more comprehensive, accurate and objective manner.2 The penetrating point of endoscope needs to be the center of intervertebral disc,and the safest area for laying the working conduit is centered two-sides of cervical longus between C3/4 and C6/7. On the C6/7 disc, the cervical truncus sympathicus is the closest to the cervical longus which is the most vulnerable to damage cervical truncus sympathicus in surgery. At the posterior of C4/5, the cervical cord is closest to posterior edge of Vertebral body, and the most vulnerable to damage cervical cord.3 The penetration has less trauma on body with safe operation, less blooding, short rest-time and less complication. It is an effective and minimally invasive surgery in alleviating the pain of the patients who are suffering herniation of cervical disc. |
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