Hu Hai, Winters Henri A H, Paul Rick M A, Wuisman Paul I J M
Department of Orthopaedic Surgery, Vrije Universiteit Medical Center, Amsterdam, The Netherlands.
Spine (Phila Pa 1976). 2007 Mar 1;32(5):601-5. doi: 10.1097/01.brs.0000256383.29014.42.
A report of 4 cases of primary bone tumors (3 cases) or infection (1 case) at the cervicothoracic junction treated with resection-reconstruction.
To document a new technique using the internal thoracic vessels as recipient vessels for reconstruction of the cervicothoracic spine with free vascularized fibula grafts.
The cervicothoracic junction is a difficult region in reconstructive spinal surgery. Although nonvascularized fibula grafts can be used to reconstruct the osseous defect, compared with free vascularized fibula grafts they are biomechanical weaker, incorporate less well, are less resistant to infection, and remodel incomplete in time. However, when using free vascularized bone grafts, the selection of suitable recipient vessels remains one of the most critical decisions.
Four patients who had a primary tumor (3 cases) or a severe progressive kyphotic deformity and progressive neurologic symptoms due to tuberculosis (1 case) were treated by resection and vascularized reconstruction. In 3 patients, a staged anteroposterior en bloc resection of T1-T3 (2 cases) or T1-T2 (1 case) was performed; the ventral reconstruction of the osseous defect consisted of a vascularized fibula graft interposition between C7-T4 (2 cases) or C7-T3 (1 case). In another case, an axial slot was milled through the T1-T2 vertebral bodies to accept an osteotomized vascularized fibular graft. In all cases, a free vascularized fibula graft was used: the vascular anastomosis was performed between the peroneal and the dissected and rerouted internal thoracic vessels. The anterior construction was strengthened by a ventral plate-screw system.
The resection-reconstruction procedures, including the dissection, rerouting, and anastomosis between the internal thoracic vessels and the peroneal vessels, were successfully performed. At present, all patients are alive, and there is no evidence of recurrent disease, unchanged, or improved neurologic with a mean follow-up of 28 months. All grafts are well incorporated. CONCLUSIONS.: A combined low anterolateral cervical and midsternal approach or a midline sternotomy allows not only a safe and excellent exposure to the cervicothoracic junction but also to the internal thoracic vessels. The internal thoracic vessels are appropriate donor vessels: its longevity, diameter, length, and rerouting capacity allow vascularized graft reconstruction of vertebral column defects of the low cervical (C6-C7) and/or upper thoracic (T1-T3) region.
一份关于4例经切除重建治疗的颈胸交界处原发性骨肿瘤（3例）或感染（1例）的报告。
记录一种新技术，即使用胸廓内血管作为受区血管，采用带血管游离腓骨移植重建颈胸椎。
颈胸交界处是脊柱重建手术中的一个困难区域。虽然非血管化腓骨移植可用于重建骨缺损，但与带血管游离腓骨移植相比，其生物力学强度较弱，融合效果较差，抗感染能力较弱，且随时间推移重塑不完全。然而，在使用带血管游离骨移植时，选择合适的受区血管仍然是最关键的决策之一。
4例患者接受了切除及血管化重建治疗，其中3例为原发性肿瘤，1例因结核导致严重进行性后凸畸形和进行性神经症状。3例患者分期进行了T1 - T3（2例）或T1 - T2（1例）的前后路整块切除；骨缺损的前路重建包括在C7 - T4（2例）或C7 - T3（1例）之间植入带血管腓骨移植。另一例患者通过在T1 - T2椎体上铣出轴向槽来容纳截骨后的带血管腓骨移植。所有病例均使用带血管游离腓骨移植：在腓骨血管与解剖并重新定位的胸廓内血管之间进行血管吻合。前路结构通过前路钢板螺钉系统加强。
成功完成了包括胸廓内血管与腓骨血管之间的解剖、重新定位和吻合在内的切除重建手术。目前，所有患者均存活，平均随访28个月，无疾病复发迹象，神经功能无变化或改善。所有移植骨融合良好。结论：联合低位颈前外侧和胸骨中段入路或胸骨正中切开术不仅能安全、良好地显露颈胸交界处，还能显露胸廓内血管。胸廓内血管是合适的供区血管：其寿命、直径、长度和重新定位能力允许对下颈椎（C6 - C7）和/或上胸椎（T1 - T3）区域的脊柱缺损进行带血管移植重建。
