【作者】 杨先文；

【导师】 李义凯；

【作者基本信息】 南方医科大学 ， 中西医结合临床， 2014， 博士

【摘要】 目的1.通过对骶髂关节韧带进行解剖学观测,为临床上推拿手法治疗骶髂关节半脱位的作用机制提供解剖学依据。2.分析斜扳法作用下正常骶髂关节三维有限元模型的应力、应变及位移分布,观察该手法对正常骶髂关节的应力、应变及位移影响,进一步讨论骶髂关节半脱位作为一种疾病独立存在的科学性。3.研究骨盆正位片与双斜位片中骶髂关节的放射解剖学特点,为临床诊断骶髂关节病变提供确切的放射解剖学依据。4.探讨骨盆正位X线片上骶髂关节的放射学分型,以指导临床对骶髂关节放射影像学的认识。方法1.(1)5具正常成年骨盆标本(1具新鲜女性骨盆标本,4具防腐骨盆标本-男女各两具)。观测骶髂关节各韧带的起止及走行特点；(2)按顺序依次切断骶髂关节韧带,观测切断每条骶髂关节韧带前后骶髂关节活动度的变化情况；(3)当切断所有骶髂关节韧带后,打开骶髂关节,观测骶髂关节内部结构的特点；(4)观测骨盆水平切片中骶髂关节间隙与骶髂关节骨间韧带的解剖学特征。2.在骨盆三维有限元模型上,模拟人体侧卧位的生理姿势,对模型分别施加水平向前、向后的载荷,以计算在模拟斜扳法作用时的应力、应变及位移的分布情况。3.在男女各1具成人干燥髂骨和骶骨的耳状面上分别均匀涂上钡粉,合拢骨盆胶带固定,拍摄骨盆正位片和斜位片；再将钡粉洗净,用细铅丝分别沿着骶骨和髂骨耳状面的边缘环绕,合拢骨盆胶带固定,分别拍摄骨盆正位片和斜位片。观察耳状面和骶髂关节在骨盆正位片与斜位片上的投影变化和形态特征。4.对男女各475例正常骶髂关节的骨盆正位X线片进行观测。根据骶髂关节间隙的数量及间隙的走行特点,对骶髂关节进行放射学分型。结果1.(1)髂腰韧带厚而坚韧,起始于第5腰椎横突,分为两个分支,其中一支横行放射至髂嵴后半部,而另一支斜向内下放射至骶髂前韧带表面。髂腰韧带起始部位的宽度(A1B1)男性为2.04±0.06cm,女性为1.98±0.05cm；A1B1的中点到髂腰韧带止于髂嵴后上部最远的点的距离(C1D1)男性为5.93±0.07cm,女性为5.87±0.06cm,通过t检验得知,A1B1男女间P=0.082>0.05,C1D1男女间P=0.120>0.05故均无统计学差异；(2)骶髂前韧带宽而薄,位于骶髂关节的前面,连接着骶骨骨盆面的侧缘与髂骨耳状面的前缘。骶髂前韧带中部的宽度(D2E2)男性为3.09±0.06cm,女性为3.06±0.06cm；骶髂前韧带覆盖于骶髂关节间隙的最高点到弓状线后端的距离(F2G2)男性为5.36±0.07cm,女性为5.38±0.06cm,通过t检验得知,D2E2男女间P=0.388>0.05,F2G2男女间P=0.472>0.05,故均无统计学差异；(3)骶髂后韧带分为骶髂后短韧带和骶髂后长韧带,其中骶髂后短韧带起于髂骨粗隆和髂骨耳状面后部及髂后下棘,斜向内下方,止于骶骨外侧嵴和骶关节嵴；而骶髂后长韧带位于骶髂后短韧带的表面上方,自髂后上棘达第2至第4骶椎的关节突,向内与腰背筋膜相连,向外与骶结节韧带相连；骶髂后短韧带中髂后下棘到骶骨外侧嵴的最低点之间的距离(A3B3)男性为3.07±0.04cm,女性为3.01±0.03cm；骶髂后长韧带附着于髂后上棘到第4骶椎关节突之间的距离(C3D3)男性为6.31±0.08cm,女性为6.17±0.04cm,通过t检验得知,A3B3男女间P=0.027<0.05,C3D3男女间P=0.005<0.05故有统计学差异；(4)骶结节韧带位于骨盆后方,起于髂骨翼后缘和骶、尾骨侧缘,纤维束斜向下外集中,附于坐骨结节内侧缘。骶结节韧带附着于髂骨翼后缘的最高点与尾骨侧缘的最低点之间的距离(A4B4)男性为9.13±0.04cm,女性为9.06±0.03cm；骶结节韧带附着于髂骨翼后缘的最高点到坐骨结节的距离(A4C4)男性为6.76±0.04cm,女性为6.62±0.04cm；骶结节韧带附着于尾骨侧缘的最低点到坐骨结节的距离(B4C4)男性为11.43±0.19cm,女性为11.11±0.05cm,通过t检验得知,A4B4男女间P=0.015<0.05,A4C4男女间P=0.001<0.05,B4C4男女间P=0.004<0.05,故均有统计学差异；(5)骶棘韧带位于骶结节韧带的前方,起于骶、尾骨侧缘,呈三角形,纤维束斜向下外集中,附着于坐骨棘。骶棘韧带附着于骶、尾骨侧缘的宽度(A5B5)男性为3.29±0.12cmm,女性为3.20±0.10cm；骶棘韧带附着于骶、尾骨侧缘的最上端到坐骨棘的距离(A5C5)男性为5.28±0.13cm,女性为5.51±0.13cm；骶棘韧带附着于骶、尾骨侧缘的下端到坐骨棘的距离(B5C5)男性为5.06±0.07cm,女性为5.16±0.06cm；通过t检验得知,A5B5男女间P=0.207>0.05,故无统计学差异,A5C5男女间P=0.022<0.05,B5C5男女间P=0.043<0.05,故均有统计学差异；(6)在两例骨盆横切片中,男性和女性骨盆水平切片中左右两侧骶髂关节间隙起止点间的距离M1M2均由低位骨盆到高位骨盆呈逐渐递减的趋势；骨盆水平切片中的骶髂关节骨间韧带起止点间的距离M2O由低位骨盆到高位骨盆则呈现不同的规律,男性先递增后递减,女性则均为递增；M1A2/M2O比值则均呈递减；M1M2在人体冠状面的投影N1N2均逐渐递减,M1M2与人体矢状轴所成夹角a1均小于M20与人体矢状轴所成夹角a2。2.在正常骨盆上施加模拟斜扳法载荷后,从骨盆前面观看,骨盆的应力主要集中在左侧髂窝内侧前下部分,最大为0.5401E+07；从骨盆的后面观可看出,最大应力位于左侧髂骨与坐骨的连接处,最大应力为0.694E+07。从骨盆侧面观可看出,最大应力位于左侧骨盆的坐骨大切迹处,为0.540E+07。骨盆的位移主要集中在加载侧骨盆的对侧骨盆,最大位移位于对侧骨盆的髂前上棘和髂嵴最高点之间的区域,载荷的一侧骨盆位移最小为0。骶髂关节内外方向的最大应变的为8.682×10-4m。骶髂关节前后方向最大应变的约为3.284×10-4m,骶髂关节上下方向最大应变为3.337×10-4m。3.在骨性标本上,男性骶髂关节的耳状面呈“L”形,女性呈“C”形。在骨盆正位X线片上,男性及女性的耳状面均位于骶髂间隙的下2/3,此时己无法观察到“L”形及“C”形的耳状面,仅表现为一细长状面,但男性的耳状面较女性更为狭长(如图1,2)。在骨盆斜位片上则可清晰观察到对侧骶骨和髂骨耳状面,男性髂骨耳状面面积较大,形态狭长,女性髂骨耳状面则面积较小,呈长条形；亦可观察到同侧上半部分的骶髂关节间隙。4.在骨盆正位片上可观察到骶髂关节的前间隙和后间隙,可通过分别固定在骶骨和髂骨耳状面边界的铅丝观察到骶髂关节前后间隙的组成结构,即前间隙是由骶骨耳状面的前缘和髂骨耳状面的前缘所围成的间隙,后间隙则是骶骨耳状面的后缘和髂骨耳状面的后缘所围成的间隙。在骨盆正位X线片上,男性骶髂关节耳状面面积较大且形态狭长似肾形,与之对应的女性耳状面面积较小且呈长条形(如图3,4)。在骨盆斜位X线片上,可清晰地显示投照对侧骶髂关节耳状面的范围和边界以及整个骶髂关节间隙。在男性骨盆正位X线片上,AB和CD段表现为单间隙,BFC和BEC分别构成骶髂关节的前间隙和后间隙。与男性相比,女性骨盆正位X线片上,AB的距离一般较短,并缺少CD段,C点和D点两点重合。斜位片可以大致观察投照侧的耳状面、前间隙和后间隙情况(图7,8)。5.正常骶髂关节的放射学分型大致可分为三种类型：①Ⅰ型为双侧单间隙型,男女分别为42例(8.8%)和122例(25.7%)；②Ⅱ型为双侧双间隙型,男女分别为376例(79.2%)和222例(46.7%)；③Ⅲ型为一侧单间隙,一侧双间隙型,男女分别为57例(12%)和131例(27.6%)。Ⅱ型又分为四个亚型：①2型双间隙,男女分别为3例(0.8%)和15例(6.6%)；②12型双间隙,男女分别为212例(56.4%)和155例(69.8%)；③21型双间隙,男女分别为8例(2.1%)和4例(1.8%)；④121型双间隙,男女分别为157例(41.8%)和44例(19.8%)；Ⅲ型也分为两个亚型：①左侧单间隙,右侧双间隙型的男女分别为15例(26.3%)和65例(49.6%)；②左侧双间隙,右侧单间隙型的男女分别为42例(73.7%)和66例(50.4%)。结论1.骶髂关节具有较强的稳定性,而其稳定性与骶髂关节韧带和骶髂关节面的结构特点密切相关,其中骶髂后韧带和骶髂关节骨间韧带对骶髂关节的稳定性起着决定性的作用,本研究为临床相关研究和治疗提供了解剖学依据。2.斜扳法作用于正常的骨盆时,其作用于骶髂关节上的应力主要集中于骶髂关节的上缘和下。斜扳法只能扳动正常骶髂关节的上缘和下缘,且能产生的位移很小。斜扳法作用下,骶髂关节内外方向的位移最大,其次为骶髂关节前后方向位移,骶髂关节上下方向位移最小。3.骶髂关节在骨盆正位和斜位X线片上有其放射解剖学特征,骶髂关节前间隙和后间隙以及耳状面是观察的重点,骨盆正位X线片基本可满足临床需要。4.正常人骶髂关节的放射学分型以双侧双间隙型最常见,其中又以“12”型双间隙所占构成比最大,但各型构成上有性别差异。更多还原

【Abstract】 Objective1.1Through the anatomical observation of sacroiliac joint ligaments, to provide the anatomical basis for the mechanism of massage treatment of sacroiliac joint subluxation.1.2To observe the influence of the stress,strain and displacement when the normal sacroiliac joint is exerted load simulating oblique-pulling manipulation and further discuss scientific if the subluxation of sacroiliac joint is exist as an illness, the stress, strain and displacement distribution are analyzed when a three-dimensional finite element model of normal pelvis exerted by oblique-pulling manipulation.1.3To provide the accurate radiological anatomical evidence for clinical survey of sacroiliac joint (SI), the characteristic of the SJ is researched with the plain film radiography, including the anteroposterior and oblique radiography.1.4To explore the radiological types of the sacroiliac joint on the anteroposterior radiography of the pelvis, this may guide the clinicians to know more about the radiology of the sacroiliac joint.Method2.1(1) Five normal adult pelvis specimens, including a fresh female pelvic specimens, four embalmed adult pelvis specimens and two each for men and women). Observing the ligaments’ starting and ending points and their anatomical characteristic.(2) Cutting the sacroiliac ligaments according some order, observing the changes of the sacroiliac joint’s activity after each sacroiliac ligaments were cut.(3)When cut off all the sacroiliac ligaments, open the sacroiliac joint, observing the characteristics of the internal structure of the sacroiliac joint.(4) Observing the anatomical features of the sacroiliac space and the interosseous sacroiliac ligament in the pelvic horizontal slice.(5) Observing the anatomical features of the sacroiliac space and interosseous sacroiliac ligament in the pelvic horizontal slice.2.2A three-dimensional reconstruction and a finite element model were made using software of Mimics, Freeform and ANSYS. Lateral position is simulated on the three-dimensional finite element model of normal pelvis and it exerted loads horizontal forth and back, then the stress, strain and displacement distribution are calculated.2.3Research targeted on2dry pelvic specimens, one female and two male. Filming the anterposterior and oblique radiography of the pelvis after Coating barium evenly on the both of them and folding with tape and fastening. Observe the projective changes and morphological characters of SI as well as its auricular surface in the anteroposterior and oblique radiography.2.4950cases (male and female account for half respectively) of normal sacroiliac joints were observed on the anteroposterior radiography of the pelvis and then the radiological types of the sacroiliac joint were classified according to the number of the sacroiliac spaces and the characteristics of their shape.Result3.1(1) The iliolumbar ligament is thick and tough, starting at the fifth lumbar transverse process. It is divided into two branches, one of the branch radiate into the latter part of the iliac crest and the other radiate obliquely to the surface of the anterior sacroiliac ligament.The width of the iliolumbar ligament in the starting position(A1B1)---man is2.04±0.06cm, and female is1.98±0.05cm.And the distance between the midpoint of A1B1and the latter part of the iliac crest (C1D1)---man is5.93±0.07cm, and female is5.87±0.06cm.And both A1B1and C1D1haven’t statistical difference between man and female.(2) The anterior sacroiliac ligament is wide and thin, covering in the front of the sacroiliac joint, and connecting with the lateral margin of the sacrum pelvis and the front of the iliac auricular surface. The width of the ligament in the middle (D2E2)---man is3.09±0.06cm, and female is3.06±0.06cm.The distance between the peak of the sacroiliac space which is covered by the anterior sacroiliac ligament to the rear-end of the actuate line (F2G2)---man is5.36±0.07cm, and female is5.38±0.06cm.And both D2E2and F2G2haven’t statistical difference between man and female, too.(3) Posterior sacroiliac ligament is divided into short and long posterior sacroiliac ligament, the short posterior sacroiliac is start at the iliac tuberoses, radiating obliquely and stop at the lateral of the sacrum and the sacral joint crest. The long posterior sacroiliac ligament is cover at the surface of the short posterior sacroiliac, and start at the spinal iliac posterior superior and the2nd to4th sacral facet. It connected inwardly with the lumbodorsal fascia, and connected outwardly with the sacrotuberous ligament. The distance between spinal iliac posterior inferior and rock bottom of the lateral crest of the sacrum in the short posterior sacroiliac (A3B3)---man is3.07±0.04cm, and female is3.01±0.03cm;the distance between spinal iliac posterior superior and the4th sacral facet (C3D3)---man is6.31±0.08cm, and female is6.17±0.04cm.And both A3B3and C3D3have statistical difference between man and female;(4) The sacrotuberous ligament is located in posterior pelvic, and it is start at the iliac wing trailing edge、the sacral and coccygeal lateral margin, the fiber bundle concentrating obliquely downward, and then attached to the medial margin of ischial tuberoses. The distance between the highest iliac wing trailing edge and the lowest of the coccyx lateral margin (A4B4)---man is9.13±0.04cm,and female is9.06±0.03cm;The distance between the highest iliac wing trailing edge and ischial tuberosity (A4C4) man is6.76±0.04cm, and female is6.62±0.04cm;The distance between the lowest of the coccyx lateral margin and ischial tuberosity (B4C4)---man is6.76±0.04cm, and female is6.62±0.04cm;andA4B4、A4C4and B4C4have statistical difference between man and female;(5) Sacral ligament is in front of the sacral ligament nodules, starting at the side edge of the sacral, triangular outer oblique fibers concentrates and attaches to the ischial spine. Sacral ligament attaches to the sacral, coccyx side edge (A5B5); the width of it is male3.29±0.12cm and female3.20±0.10cm. Sacral ligament attaches to the sacral, coccyx from the side edge of the top to the ischial spine (A5C5); the width is men5.28±0.13cm and female5.51±0.13cm. Sacral ligament attached to the sacral, ischial spine distance (B5C5) to the lower edge of the side of the coccyx, the width is male5.06±0.07cm and5.16±0.06cm for women. There is no significant difference between men and women in A5B5; however, significant differences exist between men and women in both A5C5and B5C5.(6) In two cases of pelvic horizontal slice, either the male or the female, the distances between the starting and the ending of the sacroiliac space (M1M2) on both sides are gradually decreasing from the low pelvis horizontal slice to the high one. But the distance between the starting and the ending of the interosseous sacroiliac ligament in pelvic horizontal slice (M2O) present different patterns---male is increase first, and then decrease, but the female is increase from low pelvis to high pelvis. And the M1A2/M2O is decrease, too. N1N2, the coronal plane projection in the human body of M1M2also decrease from low pelvis to high pelvis, al, the angle formed by M1M2and the human body sagittal axis, is always smaller than the a2, which is the angle formed by M2O and the human body sagittal axis both the male and the female. 3.2When the normal sacroiliac joint is exerted load simulating oblique-pulling manipulation, stress of the pelvis is mainly concentrated inside anterior inferior part of the left iliac fossa from the front view, the maximum stress is0.540E+07; the stress of the pelvis is mainly concentrated the junction between ilium and sacrum from the posterior view, the maximum stress is0.694E+07. Stress of the pelvis is mainly concentrated greater sciatic notch of left pelvis from the side view; the maximum stress is0.54E+07. The shift of pelvis is concentrated contralateral pelvis where the ones exerted load. The maximum displacement is the area where is between anterior superior iliac spine and the highest point of iliac on the contralateral pelvis. The minimum displacement is0. The maximum value of internal and external strain of normal sacroiliac joint is8.682×104m. The maximum value of anteropostreior strain is3.337×10-4m; The maximum value of up and down strain of normal sacroiliac joint is3.284×10-4m.3.3The auricular surface of the male sacroiliac joint was in the shape of’L’, and that of the female,’C’.On the anteroposterior X-ray, both the male auricular surface and the female one were found to be located at the lower2/3of the sacroiliac joint space, and the L-shaped and C-shaped auricular surface could not be observed but were demonstrated only as a thin narrow strip. It was also observed that the male auricular surface was longer and narrower than the female one, as is shown in Graphs1and2. On the oblique X-ray, the sacral and iliac surfaces at the opposite side were clearly seen. The male iliac auricular surface covered a wide area and was long and narrow, while the female’s covered a smaller area and was in the shape of a strip, and the sacroiliac joint space at the same side could also be observed, as is indicated in Graphs3and4. On the anteroposterior X-ray, both the anterior and posterior sacroiliac spaces could be observed. Through the thin lead wires fixed alongside the fringe of the sacral and iliac auricular surface, respectively, the structure of the anterior and posterior sacroiliac joint spaces could be observed. The anterior space was observed to be formed by the anterior fringe of the sacral auricular surface and that of the iliac auricular surface, and the posterior space, by the posterior fringe of the sacral auricular surface and the that of the iliac auricular surface. As is demonstrated on the anteroposterior X-ray, the auricular surface of the male sacroiliac joint covered a wide area and was long and narrow, resembling the kidney, while the female’s, covered a smaller area and was in the shape of a strip. As displayed on the oblique X-ray, the range and fringe of the auricular surface of the sacroiliac joint at the opposite side and the whole of the sacroiliac joint space were clearly shown. As displayed by the male pelvic X-ray, AB and CD were single spaces, and BFC and BEC formed the anterior and posterior sacroiliac joint space, respectively. On the female pelvic X-ray, however, AB was shorter, and CD was absent, with Points C and D overlapping. On the oblique X-ray, the auricular surface, anterior space and posterior space could be observed, as is shown by Graphs9and10.3.4(1) The normal sacroiliac joints on the anteroposterior radiography of the pelvis can be classified to three types:①42cases of males(8.8%) and122cases of females(25.7%) were classified as type I, which was called Single gap on both sides type;②376cases of males(79.2%) and222cases of females(46.7%) were classified as type II, which was called Double gaps on both sides type;③57cases of males(12%) and131cases of females(27.6%) were classified as type Ⅲ, which was called One side single gap and the other side double gaps type;(2) Double gaps on both sides type can be particularly classified to four subtypes:①3cases of males(0.8%) and15cases of females(6.6%) were classified as2double gaps type;②212cases of males(56.4%) and155cases of females(69.8%) were classified as12double gaps type;③8cases of males(2.1%) and4cases of females(1.8%) were classified as21double gaps type;④157cases of males(41.8%) and44cases of females(19.8%) were classified as121double gaps type;(3) One side single gap and the other side double gaps type can also be classified to two subtypes:①15cases of males(26.3%) and65cases of females(49.6%) were classified as Single gap on left and double gaps on right type;②42cases of males(73.7%) and66cases of females(50.4%) were classified as Double gaps on left and single gap on right type.Conclusion4.1The sacroiliac joint has strong stability, which is closed related to the structural features of the sacroiliac joints and ligaments. Of them, posterior sacroiliac ligament and Interosseous sacroiliac ligament make a decisive role to the stability of the sacroiliac joint. This study provides the anatomical basis for the clinical research and treatment.4.2The focus of the sacroiliac joint stress is anterior superior border and posterior superior border when the normal pelvis exerted oblique-pulling manipulation. The anterior superior border and posterior superior border of the normal sacroiliac are pulled only by oblique-pulling manipulation with small displacement. The internal and external strain of normal sacroiliac joint is maximal, the second value is anteropostreior strain, the up an dwmn strain of sacroiliac joint is minimal4.3The radiological anatomic characteristics of SJ are presented in the anterposterior and oblique radiography of the pelvis. The observation should focus on the anterior and posterior spaces and the scope of auricular surface of SI joint.It’s suggested that the anteroposterior radiography is enough for meeting the clinical requirement.4.4The most common type of the normal sacroiliac joints on the anteroposterior radiography of the pelvis is the Double gaps on both sides type, in which the largest proportion of all the four subtypes is the "12"double gaps type, but the constituent ratio of each type on gender has a significant variation.更多还原