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ServicedeneurochirurgieLespathologiesCervicales
Vendredi18marsMTriffauxABouras
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Lespathologiescervicales
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• Rappelanatomique
• Lesvoiesd’abord• Lespathologies• Lestraitementschirurgicaux
• Lesuivipostopératoire• Lachirurgieambulatoire
2
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L’anatomie
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L’anatomie
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L’anatomie
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• Lamoelleépinière
• Lesracinescervicales
• L’artèrevertébrale
• LesarNculaNonspost.
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L’anatomie
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L’anatomie
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L’anatomie
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AngioCtscancervical:avertébrale
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Lesvoiesd’abord
• EnfoncNondelapathologie:
– L’abordantérieur
– L’abordpostérieur
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1) antérieur 3) antéro- latéral
2) postérieur
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L’abordantérieur
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L’abordantérieur
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L’abordpostérieur
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L’abordpostérieur
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Coussinencadre TêNèreàpointes
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Lespathologiescommunes
• Syndromeradiculaire– HDC– Sténoseforminale
• Syndromemédullaire– Myélopathie cervicoarthrosiqueCCE
– Fracture/luxaNon
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Lesherniesdiscalescervicales
Postérolatérale Médiane Foraminale
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Lesherniesdiscalescervicales
Herniemolle
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Lesherniesdiscalescervicales
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LeCanalCervicalEtroit
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Lespathologiesrares• Syndromeradiculaire
-schwannome
• Syndromemédullaire(radiculaire) -tumeurextra-médullaire
(ex.méningiome,méta,kystearachn.,
kysteneuro-entérique,chordome,...)
-processusintra-médull.
(ex.gliome,cavernome,syringomyélie,..)
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Lestraitementschirurgicaux
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1niveau antérieur Discectomie/Cage/PlaqueCervicaleProthèsediscale
postérieur Séquestromie
>1niveau antérieur Corporectomie(Somatotomie)/Cage/PlaqueXlNplescages
postérieur Laminectomie/LaminoplasNe/FixaNonpostérieure
Doubleabord Vertébrectomie
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CorporectomieSchwannomeC5
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CorporectomieSchwannomeC5
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Corporectomie:métastaseTechniqueduberceau
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Corporectomie:métastaseTechniqueduberceau
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– àlapince– aumoteur– aubonescalpel
Lalaminectomie
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– àlapince– aumoteur– aubonescalpel
Lalaminectomie
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• Lalaminectomie– aubonescalpel
Lalaminectomie
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LalaminoplasNe
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LalaminoplasNe
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LalaminoplasNe
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LafixaNonpostérieure
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C7
C3-C6
C2pédiculaire
massifarNc.
pédiculaire
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• LafixaNonpostérieure
LafixaNonpostérieure
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• LafixaNonpostérieure
LafixaNonpostérieure
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#C2
LapathologietraumaNque
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FixaNoncervico-occipitale
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LapathologietraumaNque
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FixaNoncervico-occipitale18/03/16 Nech4you03 36
LapathologietraumaNque
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C5
#discoligamentaireC5-C6
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LapathologietraumaNque
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LapathologietraumaNque
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Lespathologiesdelacharnière
• MalformaNond’ArnoldChiari
• Impressionbasilaire
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ArnoldChiariSyringomyélie18/03/16 Nech4you03 40
Lespathologiesdelacharnière
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Impressionbasilaire
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Lespathologiesdelacharnière
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Lespathologiesdelacharnière
AblaNondeladentC2
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Lapathologietumorale
• Extradurale
• Intradurale
– Extramédullaire
– Intramédullaire
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MENINGIOME18/03/16 Nech4you03 44
Lapathologietumorale
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Lapathologietumorale
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Lapathologietumorale
ReconstrucNonC6Myélome
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Lapathologietumorale
CAVERNOME
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Lapathologietumorale
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CHORDOMECERVICAL
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Lapathologietumorale
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CHORDOMECERVICALpostop18/03/16 Nech4you03 50
Lapathologietumorale
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ASTROCYTOMEIII18/03/16 Nech4you03 51
Lapathologietumorale
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• VertébrectomieC7:TumeuràCellulesGéantes
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Lapathologietumorale
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Doubleabord
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Doubleabord
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Doubleabord
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LescomplicaNons
• delavoied’abordantérieure
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11% > 4%
0,3 %
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LescomplicaNons
• delavoied’abordantérieure– Ladysphagie– Lenerfdela«barbe»– Ladysphonie– LeSddeClaudeBernardHorner– Lésionœsophage– L’hématomesuffocant=>risquevital– Lésioncanalthoracique– Lesiona.vertébrale
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LescomplicaNons
• leslésionsneurologiques
– AoeinteC5:5%
– Médullaire:
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LescomplicaNons
• del’arthrodèse
• delaprisedegreffe18/03/16 Nech4you03 59
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LaconsultaNon
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Lesuivipostop
• Abordantérieur:– Collier mousse – Mobilisation sans restriction – Redon à priori non aspiratif OUT J1 – Cicatrice colle PAS de pansement post op – SU non systématique OUT J1 – Rx J1 ou J2 – Sortie en fonction de la pathologie J1, J2
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Lesuivipostop
• Abordantérieur:– Dysphagie1paNent/2:prévoirrepasfacile
faussedégluNNon– Dysphonie:
pasNlleàsucer– Hématomesuffocant
périmètrecervicalNeckMonitoringAlert?
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Lesuivipostop
• Abordantérieur:Sihématomesuffocant:
• AsseoirlepaNent,oterlecolliermousse,oterlepansement• Meoredel’oxygèneetlesaturomètre• Prévenirl’anesthésiteetlechirurgien• NepascurariserlepaNentsipasdepossibilitédedrainer
l’hématomeenurgencemêmeaulit.• Rp125mgdesolumédrol• Mesurerlepérimètreducou
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Lesuivipostop
• Abordpostérieur:– +/-idenNquecolonnethoracolombaire– Enraisondelamassemusculaireplusdouloureux
RppompePAC,relaisperossuffisant+myorelaxant– RedonidemoutJ2– Colliermoussepasdecompression– RxJ2– BioJ2– HBPM,BAS18/03/16 Nech4you03 64
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• LaCOMPLICATIONàdomicile TauxdecomplicaNons*inférieurenambulatoire5,39%hospi>3,45%ambulatoire(*toustypesconfondus)SicomplicaNon,ellesurvientdansles4-6hpostop.
– HDC: hématomesuffocant+/-idemqu’enchirurgiethyroïde,CI 0à2,4%pasdedonnéespoursimpleHDC1niveau FacteursdeRisque:>50ans,tabagique,>2niveaux brèchedurale:0,1%
Lachirurgieambulatoire
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• TeamChirurgieambulatoireHDInfirmierréférentambulatoire(projetpilote)Transmissioninfirmièredenuitaudomicile:«sonneoeconnectée»
Lachirurgieambulatoire
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• NeckMonitorAlert?DisposiNfdesurveillancedupérimètrecervical
Lachirurgieambulatoire
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MerciAlasemaineprochaine
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