【作者】 胡万坤；

【导师】 张少成；

【作者基本信息】 第二军医大学 ， 外科学， 2011， 博士

【摘要】 研究目的确切了解腰大肌与腹部大血管在L1/2、L2/3、L3/4、L4/5各腰椎间隙的位置分布,并结合Moro和Beglis报告的有关腰神经丛和神经根在L1/2、L2/3、L3/4、L4/5各腰椎间隙的分布规律,确定进行(X/DLIF)操作的安全区域,选择合适的极外侧腰椎椎间融合术(XLIF)或直接的侧方入路腰椎融合术(DLIF)入路,防止腹部大血管、神经根损伤等并发症。研究背景极外侧腰椎椎间融合术(extreme lumbar interbody fusion, XLIF)或者直接的腰椎椎间融合术(direct lateral interbody fusion, DLIF)是近年来出现的一种新的微创前路腰椎融合技术,由于它创伤小、融合效果确切,近年来已被很多学者用于治疗各种腰椎疾患,然而,该技术穿过腹膜后间隙,经腰大肌到达腰椎间隙存在着损伤腰神经和腹部大血管的风险。如何准确选择穿过腰大肌及进入腰椎间隙的位置,对于顺利完成手术操作,防止大血管和神经损伤十分关键。如果穿刺点靠前,则易伤及大血管;如果穿刺点靠后,则易伤及腰大肌内走行的腰神经。另外,穿刺点腰大肌的厚薄对手术的安全性也有影响。如果穿刺点腰大肌很厚,则腹膜易分离,腹膜后间隙也大,手术相对安全,损伤腹膜和腹腔内脏器的可能性也小;如果穿刺点腰大肌很薄,则腹膜难以分离,腹膜后间隙也小,损伤腹膜和腹腔内脏器的可能性也大。但是腹部大血管和腰大肌在各个腰椎间隙的分布并不一致,所以手术时存在损伤腰神经丛和神经根以及腹部大血管的风险。到目前为止,有关腰大肌与腹部大血管在各个腰椎椎间隙的位置分布的相关解剖研究在国内外均未见报道。研究方法使用MAGNETOM AVANTO A Tim system(SIEMENS)磁共振机对48位患者(其中男24例,女24例;平均年龄54.2岁)L1/2、L2/3、L3/4、L4/5各腰椎间隙进行磁共振平扫,获得48位患者L1/2、L2/3、L3/4、L4/5各腰椎间隙的T1和T2加权横切面图像。根据Moro方法,将腰椎间隙由前向后分为六个区,即:椎体前方为A区、椎体后方为P区、椎体前后缘之间由前向后等分为I、II、III、IV四个区,通过Synogo fastview软件测量腰大肌在各个腰椎间隙每个区的厚度,分析和观察腹部大血管在各个腰椎间隙每个区的分布位置。分析X/DLIF右侧入路在各个腰椎间隙哪几个区不会损伤腔静脉;分析X/DLIF左侧入路在各个腰椎间隙哪几个区不会损失腹主动脉;结合Moro和Benglis报道的关于神经在各个腰椎间隙各区的分布规律,选择X/DLIF右侧和左侧的安全入路。腰大肌在L1/2～L4/5椎间隙各区的厚度按年龄、性别以及椎间隙等因素选择SPSS 10.0软件行统计学分析,P<0.05被认为有统计学差异。结果1、腔静脉在L1/2-L4/5椎间隙各区分布在L1/2椎间隙,腔静脉位于右A区(70.8﹪)、右A区与右I区交界区(29.2﹪);在L2/3椎间隙,腔静脉也位于右A区(43.8﹪)、右A区与右I区交界区(56.2﹪);在L3/4椎间隙,腔静脉约位于右A区(29.2﹪)、右A区与右I区交界区(64.6﹪),少部分位于右I区(6.2%)。在L4/5椎间隙位置,腔静脉位于右A区(18.8﹪)、右A区与右I区交界区(52.0﹪),右I区(29.2﹪);在L1/2-L4/5椎间隙,腔静脉由A区向Ⅰ区迁徙。2、腹主动脉在L1/2-L4/5椎间隙各区分布在L1/2、L2/3、L3/4椎间隙,腹主动脉大多位于左A区(95.8﹪、85.4﹪、79.1﹪);在L4/5椎间隙,腹主动脉约62.6﹪分为两支位于A区,其中48.0﹪分为两支分居左、右A区,14.6﹪分为两支并紧贴在一起位于椎体正前方。3、腰大肌在L1/2-L4/5椎间隙各区的厚度及分布腰大肌在L1/2～L4/5椎间隙各区的厚度按年龄、性别以及椎间隙等因素用SPSS10.0进行两因素重复测量的方差分析(α=0.05,双侧)进行统计分析,结果显示年龄因素无统计差别,而性别和椎间隙因素则有显著差别。男性腰大肌比女性腰大肌明显粗大。在L1/2、L2/3椎间隙,腰大肌纤细且靠近背侧。在L3/4、L4/5椎间隙,腰大肌粗大且靠近腹侧;24例男病人左右腰大肌在L1/2～L4/5各椎体分区的厚度从A～P区呈先增后减的曲线变化,在L1/2～L3/4椎间隙腰大肌厚度的峰值在Ⅳ区,在L4/5椎间隙腰大肌厚度的峰值在Ⅱ区;24例女病人左右腰大肌在L1/2～L4/5各椎体分区的厚度从A～P区亦呈先增后减的曲线变化,左腰大肌的厚度在L1/2～L3/4椎体间隙的峰值在Ⅳ区,在L4/5椎体间隙腰大肌厚度的峰值在Ⅲ区。右腰大肌的厚度在L1/2～L2/3椎间隙的峰值在P区, L3/4椎体间隙腰大肌厚度的峰值在Ⅳ区,L4/5椎体间隙腰大肌厚度的峰值在Ⅲ区。结论[1] X/DLIF右侧入路在L1/2、L2/3、L3/4、L4/5的Ⅱ～P区不会损伤腔静脉;结合Moro和Benglis关于神经根的分布规律,X/DLIF右侧入路的安全区在L1/2为Ⅱ～Ⅳ区;L2/3为Ⅱ～Ⅲ区;L3/4与L4/5为Ⅱ区;[2]男性X/DLIF右侧入路在L1/2～L3/4椎间隙应从腰大肌最高点前方进针分开腰大肌。男性X/DLIF右侧入路在L4/5椎间隙应从腰大肌的最高点进针分开腰大肌。女性X/DLIF右侧入路均应在腰大肌的最高点前方进针分开腰大肌,在L1/2、L2/3椎间隙进针点应离腰大肌最高点略远;[3] X/DLIF左侧入路在L1/2～L3/4的Ⅱ～P区不会损伤主动脉,在L4/5的Ⅰ～P区不会损伤主动脉,结合Moro和Benglis关于神经根的分布规律,X/DLIF左侧入路的安全区为L1/2为Ⅱ～Ⅳ区;L2/3为Ⅱ,Ⅲ区;L3/4为Ⅱ区,L4/5为Ⅰ、Ⅱ区;[4]男性X/DLIF左侧入路在L1/2～L3/4椎间隙应从腰大肌最高点前方进针分开腰大肌。男性X/DLIF左侧入路在L4/5椎间隙应从腰大肌的最高点或略前方进针分开腰大肌。女性X/DLIF入路均应在腰大肌的最高点前方进针分开腰大肌。更多还原

【Abstract】 ObjectiveThis study was aimed to determine the distribution of psoas major and abdominal large vessels at L1/2～L4/5 lumbar intervertebral spaces and combined with the distribution of nerve at L1/2～L4/5 lumbar intervertebral spaces reported by Moro and Benglis in order to select an appropriate X/DLIF approach to avoid nerve and large vessels injury. BackgroundExtreme lumbar interbody fusion (XLIF) or direct lateral interbody fusion (DLIF) is a new minimally invasive anterior lumbar interbody fusion (ALIF) technique. Caused less tissue trauma and good fusion effect ,it has been used to treat various lumbar diseases. However, it involves risks to injure the lumbar nerve plexus and abdominal large vessels when it gains access to the lumbar spine via lateral approach that passes through the retroperitoneal fat and psoas major muscle. it is critical to accurately choose the point at which to pass through the psoas major. This precision is necessary to reach the lumbar intervertebral space to accomplish the operation and avoid the large vessel and nerve injury. If the puncture site is too anterior, it is easy to injure the large vessels. However, if the puncture site is too posterior, it is easy to injure the lumbar nerve roots that have descended inside the psoas major. In addition, the thickness of the psoas major at the location of the puncture site also affects the operation’s safety. If the psoas major is very thick, the peritoneum is easily dissected, the retroperitoneal space is larger, the operation is safer and the risk of peritoneal injury and abdominal viscera injury is reduced. The converse is true as well. However, the distribution of abdominal large vessels and the psoas major of each lumbar intervertebral space is inconsistent; a relevant anatomical study of their distribution has not yet been reported.MethodsAn MRI scanning machine (MAGNETOM AVANTO A Tim system, SIEMENS) was used to transversely tomoscan intervertebral spaces L1/2,L2/3,L3/4 and L4/5 in 48 patients(24 males and 24 females, average age 54.2 years ), to obtain T1-and T2-weighted imagines of the L1/2-L4/5 intervetebral spaces. According to Moro’s method, lumbar intervertebral spaces were divided into six zones from the anterior to the posterior, i.e., the area between the anterior and posterior edges of the vertebral body were divided in zones A, I, II, III and IV. The area anterior to the anterior edge of the vertebral body was defined as zone A, and the area posterior to the posterior edge of the vertebral body was defined as zone P. The thickness of psoas major was measured and the distribution of abdominal large vessels was analyzed at each zone of each lumbar intervertebral space via images analysis software (Synogo fastview) on the MRI machine.To determine which zone at the L1/2-L4/5 intervetebral spaces does not injure vena cava and abdominal aorta when perform X/DLIF. combined with the distribution of nerve at L1/2～L4/5 lumbar intervertebral spaces reported by Moro and Benglis in order to select an appropriate X/DLIF approach to avoid nerve and large vessels injury.The difference in thickness of psoas major was compared under age, gender and lumbar spaces factors via SPSS PC version 10.0, respectively. P<0.05 was considered statistically significant.Results1. Distribution of vena cava at each zone of the L1/2-L4/5 intervetebral spacesAt the intervertebral spaces L1/2, vena cava was located to the right of zone A (70.8﹪) and at the juncture of the right of zone A and the right of zoneⅠ(29.2﹪). At the intervertebral spaces L2/3,vena cava also was located to the right of zone A (43.8﹪) and at the juncture of the right of zone A and the right of zoneⅠ(56.2﹪). At the intervertebral spaces L3/4, vena cava was located to the right of zone A (29.2﹪) and at the juncture of the right of zone A and the right of zoneⅠ(64.6﹪), and the right of zoneⅠ(6.2%). At the intervertebral spaces L4/5, vena cava was located to the right of zone A (18.8﹪) and at the juncture of the right of zone A and the right of zoneⅠ(52.0﹪), and the right of zoneⅠ(29.2﹪). Vena cava migrate from the right of zone A to the right of zoneⅠat L1/2-L4/5.2. Distribution of abdominal large vessels at each zone of the L1/2-L4/5 intervetebral spacesThe abdominal aortas at intervertebral spaces L1/2, L2/3 and L3/4 were located mostly to the left of zone A (95.8﹪, 85.4﹪, 79.1﹪, respectively); at the L4/5 intervertebral space, about 62.6﹪of the abdominal aortas divided in two branches: these branches were located at zone A. More specifically, 48.0﹪of the abdominal aortas divided in two branches at this location and these branches were located to both the left and right of zone A. The other 14.6﹪divided in two branches but these branches adhered tightly just together in the anterior surface of the vertebral body.3. Thickness and distribution of psoas major at each zone of the L1/2-L4/5 intervetebral spacesTwo-Factor Variance Analysis of Repetitive Measurements on SPSS10.0 (at the significance levelα=0.05 and in two-tailed test) was used to analyze the thickness of the psoas major at each zone of the L1/2～L4/5 intervertebral spaces for 48 patients, and the results showed no statistical significance for the age factor, but showed statistical significance for the gender factor. The psoas major was tenuous and near the dorsa at the intervertebral spaces L1/2 and L2/3, large and near the ventral aspect at the intervertebral spaces L3/4 and L4/5. For 24 male patients, the thickness of the left and right psoas major at each intervertebral zone of L1/2～L4/5 intervertebral spaces demonstrated a variation of increase first and then decrease from zone A to zone P. The peak of L1/2～L3/4 was located at zone IV and the peak of L4/5 was located at zone II. For 24 female patients, the thickness of left psoas major at each intervertebral zone for L1/2～L4/5 lumbar intervertebral spaces also demonstrated first increase and then decrease from zone A to zone P. The peak of L1/2～L3/4 was located at zone IV and the peak of L4/5 was located at zone III. The thickness of right psoas major at each intervertebral zone of L1/2～L2/3 lumbar intervertebral spaces demonstrated variation with the gradual increase from zone A to zone P, the peak located at zone P, while the thickness of the right psoas major at L3/4～L4/5 lumbar intervertebral spaces demonstrated a variation of increase first and then decrease from zone A to zone P, with the peak of L3/4 located at zone IV and the peak of L4/5 at zoneⅢ.Conclusions1. The right-side X/DLIF approach does not injure the vena cava at zone II~ P of intervertebral spaces L1/2, L2/3, L3/4 and L4/5. Combined with the distribution of the nerve roots that Benglis and Moro reported on, the safe zone of right-side X/DLIF approaches was located at zone II~IV of L1/2, at zone II~III of L2/3, at zone II of L3/4 and L4/5.2. For male right-side X/DLIF approaches to L1/2 ~ L3/4 intervertebral spaces, the needle should be inserted to separate the psoas major at the anterior surface of the peak of the psoas major. For male right-side X/DLIF approaches of the L4/5 intervertebral space we should insert the needle to separate the psoas major at the peak of the psoas major. For all female right-side X/DLIF approaches, it is advisable to insert the needle to separate the psoas major at the anterior surface of the peak of the psoas major. The needle insertion point at L1/2 and L2/3 intervertebral spaces has to have a little bit removed from the peak.3. The left-side X/DLIF approaches at zone II~ P of L1/2 ~ L3/4 intervertebral spaces and at the ?~P zone of L4/5 intervertebral space does not injure the aorta. Combined with the distribution of the nerve roots that Benglis and Moro reported on, the safe zones of left-side X/DLIF approaches are at zone II~IV of L1/2, at zone II and zone III of L2/3, at zone II of L3/4, and at zone I and zone II of L4/5.4. For male left-side X/DLIF approaches of L1/2 ~ L3/4 intervertebral spaces, should involve insertion of the needle to separate the psoas major via the anterior surface of the peak of the psoas major. For male left-side X/DLIF approaches of L4/5 intervertebral space, has to involve the insertion of a needle to separate the psoas major via the peak or slight to the anterior surface of the psoas major. For female X/DLIF approaches we should insert all needles to separate the psoas major via the anterior surface of the peak of the psoas major.更多还原