【作者】 张景僚；

【导师】 顾立强；

【作者基本信息】 第一军医大学 ， 骨外科学， 2004， 硕士

【摘要】 [目的] 1．L₄、L₅神经前支和腰骶干（Lumbosacral Trunk, LST）与骶髂关节的毗邻关系形态学测量，为腰骶丛损伤的临床研究提供解剖学依据。 2．采用计算机三维重建技术，重建L₄、L₅神经前支和LST以及与骨盆的三维图像，使之得以直观、形象和生动的体现，并方便于临床教学应用。 [材料和方法] 1 解剖学研究：福尔马林灌注固定的成年尸体标本20具（男14，女6），共40侧。沿耻骨和髂骨上缘将腹前壁全层切开并向上翻起，显露髂窝和腰大肌以及下段腰椎，然后将髂肌与髂窝锐性分离，切除腰大肌，注意不要损伤神经以及神经与骨盆相连的软组织，且务必使神经处于原来的位置。将骶髂关节充分显露后，将尖端锐利的直径为1mm的克氏针从关节前方插入骶髂关节内作为关节标志点，然后用分规（精确度为1mm）分别在不同平面测量L₄、L₅神经前支和LST外缘与骶髂关节之间的水平距离，以及L₄、L₅、LST宽度与厚度。 2 三维重建研究：标本1例，按照上述方法显露出神经和骶髂关节前方，将钛粉和粘合剂按比例调和（要求调和后的混合物既不流淌也不粘稠造成涂抹困难），将调和后的混合物均匀的涂抹在L₄、L₅神经前支、腰骶干、闭孔神经以及股神经主干表面（从第四腰椎平面至第二骶骨平面）。神经表面涂抹的混合物固化变干（常温2h）后在螺旋CT（Spiral CT）L;、LS神经前支和腰骸干与能韶关节毗邻关系的形态学研究及其走行的三维图像重建下行二维断层扫描，层厚3^，获取159张连续的二维CT断层图像并测量有关参数。将获取的二维图像数据采用3D一DOCTOR软件进行三维重建，获得三维图像。【结果】 1解剖学发现:①在LS神经前支出椎间孔处，其外缘与骸骼关节间的水平距离为（23.4士4.0）^;在L，神经前支出椎间孔平面，L;神经前支的外缘与骼骼关节的水平距离为（17.8士4.8）^;LST外缘在其形成汇合点平面与骼骼关节的水平距离为（13.3士2.8）^;平骼呷处LST外缘与骸骼关节的水平距离为（n.8士3，2）1孔m;在骨盆环处LST外缘与骸骼关节的距离为（9 .6士3.6）^。②随着玩、L，、LsT向外下方走行，神经与骸骼关节之间的距离渐趋偏短，在20具标本上L4、LS神经前支、LST与前骸骼关节之间的最短距离处位于骨盆环。③L4、LS神经前支和LST与骸骨间可见纤维结缔组织相连。④有3具6侧标本的L4、5神经前支在进入小骨盆前未汇合成LST，其出现率为巧%。⑤L;神经宽度:（2 .47士0.16）InIn;L;神经厚度:（1 .02士0.97）Inln;⑥LS神经宽度:（6.87士0.87）nun;LS神经厚度:（2.75土0.35）nun;⑦LsT神经宽度:（5.33士0.70）nun;LsT神经厚度:（2.61士0.45）mm。 2三维重建研究:获得的L4、LS神经前支和腰骸干等神经以及骨盆的三维图像可以直观形象生动的体现神经与骨盆的空间位置关系，并可按各种方向任意旋转演示。在二维CT上测量神经与骨盆标志点之间的距离结果:①在LS神经前支出椎间孔处，其外缘与骸骼关节间的水平距离为25.4^;在LS神经前支出椎间孔平面，L;神经前支的外缘与骸骼关节的水平距离为18.3^;LST外缘在其形成汇合点平面与骸骼关节的水平距离为14.5^;平骼娜处LST外缘与骼骼关节的水平距离为12.7^;在骨盆环处LST外缘与骼骼关节的距离为9.3^。②L4神经宽度:2.63Inln;玩神经厚度:1.32Inm;③LS神经宽度:6.%Inm;LS神经厚度:2.84Inln;④LST神经宽度:8.73Inm;⑤LsT神经厚度:2.86llun。所测得的数值均与实物测量结果吻合。【结论】 1随L4、LS神经前支和腰骸干向外、下方移行，L4、LS神经前支和腰骸干的外缘与骸骼关节的距离在不同平面逐渐变小，在骨盆环处腰骸干L4、玩神经前支和腰能干与髓骼关节毗邻关系的形态学研究及其走行的三维图像重建与骸骼关节距离最为接近，仅Icm左右，其临床意义为:①骼骼关节脱位时易伤及腰骸干;②在进行单纯或合并邻近神经损伤的骨盆后环骨折手术过程当中应特别小心，在骨盆环处切勿损伤邻近的神经。同时术者应该了解到，有15%的病人的L4、5神经前支在进入小骨盆前有未汇合成腰骸干的可能性，务必加以仔细辨认。 2重建的L4、5神经前支和腰骸干走行以及骨盆的三维图像可以直观形象生动的体现神经与骨盆的空间位置关系，并可按各种方向任意旋转演示，同时可应用于教学指导。在二维CT上间接测量的神经与骨盆标志点之间距离和L4、LS、LsT宽度厚度结果与实物测量结果相一致。 3结合测量结果和重建的三维重建图像应用于临床可减少术中神经损伤的潜在可能性，降低手术风险。但由于该测量的标本数量较少，缺乏广泛的代表性，况且还存在个体的差异，因此更有效的方法尚待进一步研究。更多还原

【Abstract】 [Objectives]1 Morphological measurements of anterior branches of lumbosacral nerve 4, 5 and lumbosacral trunk, as well as adjacent relationship between nerves and sacroiliac joint, with the aim of providing anatomical evidences for lumbosacral plexus injury in clinic.2 On the basis of the technique of three-dimensional reconstruction, three-dimension(3D) graphics of anterior branches of lumbosacral 4, 5 and lumbosacral trunk, as well as pelvis are reconstructed , which can be demonstrated lively, directly and concretely and applied to clinical teaching conveniently.[Materials and methods]1 Anatomical investigation: 20 adult cadavers fixed and instillated with formaldehyde solution were dissected. In order to expose iliac fossa, psoas major muscles and inferior lumbar vertebraes, anterior wall of abdomen were dissected and turned over upward along superior borders of pubis and iliac bones. Then iliacus muscles were dissected from iliac fossa and psoas major muscles were resected. During these procedure, nerves and soft tissues connected to pelvis should be protected and must make them located originally. When sacroiliac joint was oxposed clearly, a Kirschner-wire wasinserted into front sacroiliac joint as a landmark. Then horizontal distances between anterior branches of lumbar nerves 4, 5, lumbosacral trunk(LST) and sacroiliac joint were measured with a caliper, as well as that of the width and thickness of nerves.2 Three-dimensional reconstruction: After exposing nerves and sacroiliac joints with methods above-mentioned in a specimen, mixture composed of Titanium powder and adhesive was smeared on the surface of nervus major branches of L4, L5, LST , obturator nerves and fermoral nerves. As soon as mixture solidifying, specimen was scanned by spiral computer tomography with 3mm thickness each slide. Finally, 159 two-dimension sectional images were acquired and processed with 3D-DOCTOR. Datas were analysed statistically. [Results]1 (1)The distance between the anterior branches of lumbar nerve 5 as it exits from the intervertebral foramen and the sacroiliac joint, the distance between anterior branches of lumbar nerve 4 branch and the sacroiliac joint at the level where the lumbar nerve 5 exits the intervertebral foramen, the distance between the beginning of the LST and the sacroiliac joint , the proximity of the LST to the sacroiliac joint at the promontorium and the proximity of the LST to the sacroiliac joint at the pelvic brim were as follows:(23.4+4.0) , (17.8+4.8) , (13.3 + 2.8) , (11.8 + 3.2) and (9.6+3.6) mm. (2)Among these distances, the shortest distance between the nerve and the joint is the one between the LST and the sacroiliac joint at the pelvic brim. (3) During dissection of the nerves, anterior branches of the lumbar nerves 4, 5 and the LST were found to be fixed relatively well to the sacral bone with fibrous connective tissue. (4) Anterior branches of lumbar nerves 4, 5 did not merge into the LST before entering the lesser pelvis separately in 3 cadavers (6 sides), with 15% its occurrence rate.2 Three dimension reconstructional investigation: (1)three dimentional images about L4. L5 LST and pelvis can be demonstrated lively, directly and concretely and can be rotated at random.(2)The distances between nerves andpelvis, width and depth of nerves measured on the two-dimensional images of spiral CT are: 25.4mm; 18.3mm; 14.5mm; 12.7mm; 9.3mm; 2.63mm; 1.32mm; 6.96mm; 2.84mm; 8.73mm; 2.86mm.All results measured on the two-dimensional images of spiral CT are in accordance with those from measurement. (Conclusions]1 To follow anterior branches of L4, L5, LST’ migrating lateral and inferior, distance between the nerve and the joint became shorter at different levels. The shortest distance between the nerve and the joint is the one between the LST and the sacroiliac joint at the pelvic brim. Therefore, during the exploration and operation for fracture of posterior pelvic ring with or without injury of nerves nearby, extreme care should be taken to identify the L更多还原