【作者】 方国芳；

【导师】 丁自海；

【作者基本信息】 南方医科大学 ， 临床解剖学， 2014， 博士

【摘要】 研究背景和目的现代外科在发展要求外科要更加精准,更加人性化,智能化,数字化,微创化,减少手术的创伤,加快康复,造福患者,把困难留给医生。传统的开放式的手术已经逐渐被微创术式替代。传统的大体标本式的解剖也满足不了微创手术的需求,镜下解剖研究显得更加有必要,更加急切。微创手术的学习曲线的时间长短与镜下解剖的熟悉程度成正相关。腰椎退行性疾病(Disc degenerative disease,DDD)是多发病、常见病。包括腰椎间盘突出症,腰椎管狭窄症、腰椎退性性滑脱、腰椎盘源性腰痛,腰椎峡部裂,腰椎退行性侧弯(degenerative scoliosis,DS)等。腰椎间盘突出症更是常见病,多发症。腰椎间盘突出症的微创治疗治疗包括介入治疗、内镜手术、开放手术3种。目前下腰椎的微创手术从前往后包括腹腔镜下腰椎前路融合术(Anterior lumbar inter-vertebrae fusion,ALIF),轴向腰椎融合术(AxiaLIF),腰椎人工椎间盘置换术(lumbar disc arthroplasty,LDA),侧路的经皮内镜下腰椎髓核摘除术(percutaneous lumbar endocscopic disc-ectomy PLED)这其中包括YESS手术和TYSYSS手术[1-4],侧路的直接侧路腰间盘摘除融合术(Direct lumbar inter-vertebrae fusion, DLIF)[5-6],后路的腰椎间盘镜手术(Micro endoscopicdisc-ectomy,MED)及全内镜下腰椎髓核摘除术(Full-endoscopic lumbardisc-ectomy,FLD)。本研究主要从前路.侧路及后路来研究下腰椎各种微创手术的解剖入路及各结构间的比邻关系,防止出现手术并发症,包括血管、神经损伤、输尿管损伤,交感干损伤。1.材料20例经动脉灌注红色乳胶的防腐固定腰断尸体标本(男性12例,女性8例),均为成人标本,无其他的病理状态影响腰椎各入路的解剖,解剖器械1套,游标卡尺1把(精确度0.02m)等。收集国人的60例腰椎CT数据和MRI数据,所有数据为下腰痛来院就诊的患者男30例,女30例,年龄为45(24—57)岁,通过640排CT扫描及1.5TMRI扫描,同时通过CTA显示血管,最后通过三维重建来重建腰椎的解剖结构。通过PAC系统进行测量。将数据保存为DICOM格式,导入MIMICS软件中进行重建血管。2.方法(1)前路：经腹膜后显露腹主动脉、下腔静脉,髂总动、静脉,输尿管,交感神经,测量左侧腹主动脉与交感神经间的距离(L3/4),腔静脉与交感神经间的距离,节段血管的分布,输尿管与腹主动脉、腔静脉的距离,ALIF安全区域。(2)侧路：腰椎孔周围的肌肉全部切除,清理周围的韧带,只保留出口神经根(existing nerve,EN)和下腰椎节段动脉(lower lumbar segment artery,LLSA),完全显露椎间孔区等。测量下腰椎节段动脉及其分支的分布情况及直径,主要是测量腰3、腰4、腰5腰动脉,分别记录L3A,L4A,L5A.测量椎间盘平面上关节突与出口神经根的距离,分别记录为DL3N,DL4N,DL5N.测量椎间盘平面出口神经根前缘与椎间盘后缘的距离,出口根在椎间盘后缘前方记录为+号,出口根在椎间盘后缘的前方记录为-号。测量椎间孔在椎间盘平面的横径,及椎间孔的最大径。通过mimics系统进行测量椎间孔在椎间盘平面的的横径以椎间孔的最大径。(3)后路：后路肌间隙入路：取俯卧位,下腰椎沿中线切开皮肤将一侧皮瓣翻向外侧去除皮下脂肪显露腰背筋膜后层观察,向上牵开腰背筋膜,翻向外侧暴露骶脊肌在下腰段的全貌。仔细辨识多裂肌、最长肌和髂肋肌,寻找潜在的肌间隙。观察不同肌间隙入路显露腰椎结构的特点及间隙内穿行的结构后正中入路：从椎弓根平面切除,打开椎管,测量不同椎间盘平面下位神经根外缘与椎管中线的距离,椎管内血管分布情况,椎管内的安全三角区。随机抽取全内镜腰椎间盘摘除的手术录相40分来显露腰椎椎板间隙入路的层次结构。临床应用：利用内镜系统分别从下腰椎侧路及后路进行腰椎髓核摘除术,并与同期的MED手术对比,比较下腰椎内镜手术的安全性及风险,手术效果,及如果进行风险评估及预案。统计学处理：SPSS19.0软件,手术时间及出血量的均数比较采用T检验,ODI改善率比较采用秩和检验(Mann-Whitney检验)3.结果(1)前路ALIF安全工作区域：内侧界为腹主动脉或髂总动脉,外侧界为交感干,上下界为腰动脉。腰5骶1的安全区位于动脉分叉下方,椎前筋膜前方有丰富的神经丛、骶中动脉及骶前静脉丛,因此,椎前筋膜的深面才是安全区,从正中切开椎前筋膜可以避免损伤神经丛。腰3/4水平腹主动脉与交感神经间的左侧距离13.5±3.0mm,右侧下腔静脉与交感神经间距离9.2±2.6mm。当血管分叉处于L4/5水平以上时,右髂外静脉与交感神经间的距离6.4±1.4mm,左侧髂外动脉与交感神经间的距离6.4±1.2mm当血管分叉处于L4/5水平以下时左侧腹主动脉与交感神经间的距离12.5±3.0mm,右侧下腔静脉与交感神经间的距离10.8±2.2mm。双侧输尿管均在腹膜后与精索静脉走行,在腰4/5平面下方跨过髂外动脉继续下行,左侧与髂总动脉的交界高于右侧。左侧输尿管与腹主动脉的平均距离在3.5cm,右侧输尿管与腔静脉的平均距离2.8cm。腰3及腰4动脉直接从腹主动脉发出,腰5动脉从髂腰动脉发出,后者是髂内动脉的分支。腰动脉走行于腰椎的中间,腰动脉的直径腰3最粗,直径1.8±0.3mm,腰5直径最细。骶中动脉15例起自腹主动脉,2例起自左侧髂总动脉,3例起自右侧髂总动脉。(2)侧路下腰椎节段动脉均出在各椎间孔,并均有分支,一般在椎间孔的前方分支,都在3-5支,其分支与出口根包饶,在横突下方与上关节突上方各有一支较大的分支,而且在上关节突的下方分支小。主干直径：L3A为1.8±0.3mm,L4A1.6±0.4mm,L5A1.3±0.2mm.出口根后缘与上关节在椎间盘平面的距离,腰3/4平面3.5±1.2mm,腰4/5平面4.2±1.5mm,腰5骶1平面4.6±1.0mm,最长距离也只有5.6mm,均小于7.5mm。腰3/4椎间孔在椎间盘平面的横径约8.6±2.0mmm,椎间孔的最大横径9.4±4.5mm,腰4/5椎间孔在椎间盘平面的横径约9.5±3.0mm,椎间孔的最大横径10.2±3.5mm,腰5骶1椎间孔在椎间盘平面的横径约8.2±2.2mmm,椎间孔的最大横径9.6±3.2mm。腰升静脉的位置及走行：腰升静脉走行在椎间孔区骨膜的表面,前方及侧方有腰大肌覆盖,远端与髂总静脉相通,腰升静脉往往在出口神经根的表面走行,部分腰腰升静脉有属支走行出口神经根之间。腰骶丛(lumbosacral plexus)的位置及走行：腰丛由第12胸神经前支的—部分、第1至第3腰神经前支和第4腰神经前支的一部分组成。出口根前缘与椎间盘中点的距离,腰3/4平面11.5±1.2mm(L3),腰4/5平面10.8±1.5mm(L4)。椎间孔外口处交感神经与椎间盘中心之间的距离：腰3/4平面12.5±1.6mm(L3),腰4/5平面14.2±2.5mm(L4)椎间孔外口处腰丛神经与椎间盘中心之间的距离：腰3/4平面10.5±2.0mmm,腰4/5平面9.2±1.5mm。(3)后路肌间隙入路：多裂肌与最长肌之间的肌间隙Wiltse间隙,最长肌与髂肋肌之间的肌间隙LIMP间隙,肋肌与腰方肌之间的肌间隙Watkins间隙。腰3/4水平腰椎中线至Wiltse间隙的平均距离为2.0cm,腰椎中线至LIMP间隙平均距离为3.5cm。腰4/5水平腰椎中线至Wiltse间隙的平均距离为2.5cm,腰椎中线至LIMP间隙平均距离为4.0cm。腰5骶1水平腰椎中线至Wiltse间隙的平均距离为2.8cm,腰椎中线至LIMP间隙平均距离为4.2cm。腰3/4至腰5骶1,Wiltse间隙被脂肪填充,少有血管穿行,但是LIMP间隙较小,有血管经过。椎管内解剖：下腰椎神经走行各异,高位神经根管走行距离越短,走行方向越近水平,发出点相对较低。L4神经根管发自腰4椎体上半部,L5神经根管比L4长,走行比L4更趋于垂直,发出点相对较高,通常始发于L4-5椎间盘下部,S1神经根管在三者中最长,近乎于垂直,发出点也相对较最高,多始于L5-S1椎间盘上缘。椎管内的安全三角区(Safe triangle):外上界为上位神经根内外侧,内侧界为硬膜囊的外侧缘和下位神经根袖,下界为相应椎间盘的下缘。安全三角底边：腰4/5平面,腰4神经根内缘与硬膜囊外缘(椎间盘下缘)距离5.6±1.4mm。腰5骶1平面,腰5神经根内缘与硬膜囊外缘(椎间盘下缘)距离6.8±1.8mm。测量椎板间隙高度与宽度：L3/4椎板间隙高度：9.5±1.4mm,宽度6.4±1.8mm。L4/5椎板间隙高度：11.5±2.7mm,宽度8.6±2.5mm.L5/S1椎板间隙高度：11.8±1.4mm,宽度10.4±2.6mm。4.结论(1)前路手术入路：腰3/4及腰4/5的ALIF手术,建议从左侧进入,安全工作区域为腹主动脉与腰大肌前缘之间的区域,通过左侧可触及腹主动脉的搏动来确认解剖关系,在腹主动脉的外侧腰大肌的表面找到输尿管,牵开输尿管及动静脉可以显露足够的手术工作区。在切除腰椎间盘时要注意向外不要超过腰大肌的内缘,此处有腰交感神经干的分布。另外腰椎间盘的前方有节段血管的小分支分布,注意止血,防止出量致视野不清,造成附损伤。腰5骶1间隙ALIF手术时一般要在术前确认骶中动脉的位置,术中注意结扎。骶中动脉的变异性较大,不能作为正中线的依据。(2)侧路手术入路：腰椎侧路椎间孔镜一项新技术,在临床上取得了巨大的成功,但也有不少并发症,POD是其独特的并发症,进行椎间孔扩大是减少POD有效的方法,在椎间孔扩大时注意不要造成副损伤,内镜直视下进行上关节突切除是一种安全有效的方法,可以避免损伤腰动脉及腰升静脉的分支。极外侧腰椎椎间融合术(XLIF)或者直接的腰椎椎间融合术(DLIF)是一种新的微创前路腰椎融合技术,具有良好的安全性能,术中注意好不要损伤腰丛即可,手术中大血管损伤的可能性小,出血量小,腰4/5平面不要省略神经电监测。(3)腰椎后路：椎旁肌入路对于每个人是不同的,但是Wiltse肌间隙入路仍是当前椎旁肌入路首选,但是由于腰椎椎旁肌有两层,浅层为背阔肌筋膜,深层才能找出Wiltse肌间隙,在体表没有办法直接触及。一般都是根据棘突来定位,棘突旁开2.5cm左右切开背阔肌筋膜,再分离Wiltse肌间隙显露关节突及横突。椎板间隙入路是经典的手术入路,不管是开放手术还是MED手术,还是全内镜手术,该入路都是一样的,难点在于黄韧带的突破,减少神经、血管损伤。对于开放手术及MED对椎板间隙的宽度是没有要求的,但是全内镜下腰椎间盘髓核摘除对椎板间隙的要求是宽度要大于8m。否则工作通道无法进入椎管内,而且就算强行进入椎管内也没有办法到达安全三角区,会误伤神经血管组织。(4)临床应用：利用内镜系统分别从下腰椎侧路及后路进行腰椎髓核摘除术,在进行侧路经椎间孔腰椎髓核摘除手术时注意避免损伤节段血管的分支及出口神经根,避免术后下肢麻木(POD),进行有效的椎间孔扩大手术时很有必要的。后路全内镜下髓核摘除术要求椎板间隙要大于8mm,术中避免挤压损伤神经根。更多还原

【Abstract】 Background and ObjectionModern developed surgery require surgery to be more precise, humane, intelligent, digital, minimally invasive, to reduce the trauma of surgery, to speed up recovery, to benefit to patients.so it get more difficult for the surgen. Traditional open surgery has gradually been replaced by alternative minimally invasive surgery. The traditional study of anatomical specimens generally can not meet the needs of minimally invasive surgery. Endoscopic anatomy is even more necessary and more urgent. The more familiar with microscopic anatomy, the shorter of minimally invasive surgical learning curve.Lumbar degenerative diseases (Disc degenerative disease, DDD) are common in our life. They are including lumbar disc herniation, lumbar spinal stenosis, lumbar degenerative spondylolisthesis, lumbar discogenic low back pain, lumbar spondylolysis, lumbar degenerative scoliosis (degenerative scoliosis, DS) and so on. Lumbar disc herniation is more common, and more complicative. Minimally invasive treatments of lumbar disc herniation are including intervention, endoscopic surgery, and open surgery.Currently the main minimally invasive surgeries of lower lumbar DDD are including minimally invasive surgery laparoscopic anterior lumbar fusion surgery (Anterior lumbar inter-vertebrae fusion, ALIF), axial lumbar fusion (AxiaLIF), lumbar artificial disc replacement surgery (lumbar disc arthroplasty, LDA), the lateral percutaneous endoscopic lumbar discectomy (percutaneous lumbar endocscopic disc-ectomy PLED),Direct lumbar inter-vertebrae fusion, DLIF), posterior lumbar discectomy (Micro endoscopic disc-ectomy, MED) and full endoscopic lumbar discectomy (Full-endoscopic lumbar disc-ectomy, FLD). The lateral percutaneous endoscopic lumbar discectomy contain YESS and TYSYSS technology.The aim of this study is to explore the low lumbar endoscopic anatomy to prevent surgical complications, including blood vessels injury, nerve lesion, ureteral injury, sympathetic trunk damage.MaterialsMethods20cases of arterial perfused with red latex and fixed cadavers (12males,8females). All the cadavers are adult specimens, found no other pathological conditions affecting the lumbar anatomy.60cases of lumbar CT data and MRI data (30males and30females), mean age was45(24to57) years, with640-slice CT scan and1.5TMRI scan, CTA to reconstruct the anatomy of the lumbar spine by three-dimensional reconstruction. Measured the distance in the PAC system. Save the data in DICOM format, import MIMICS software reconstruction of blood vessels and Lumbar structure.MethodsAnterior approach:Retroperitoneal revealed abdominal aorta, inferior vena cava, iliac artery and vein, ureter, sympathetic. Measured the distance between abdominal aorta and sympathetic (left side in L3/4), the distance between external iliac vein and sympathetic (right side in L3/4), the distance between the ureter and sympathetic, explored the distribution of segmental artery and ALIF safe area.Lateral approach:Paraspinal muscle around the lumbar foramen total removal, clean up the ligament, only remained the exsting nerve (existing nerve, EN) and the lower lumbar segmental arteries (lower lumbar segment artery, LLSA). The low lumbar foramen zones fully revealed. Measured lumbar segmental artery diameter and its distribution and branch. L3to L5lumbar segmental artery were recorded L3A, L4A, and L5A. Measured the distance between upper facet and exit nerve roots on the plane of disc, recorded as DL3N, DL4N, and DL5N. Measured the distance between the exit nerve root and the edge of the disc. Measured the weight of intervertebral foramen on the plane of disc, and the maximum weight of the intervertebral foramen.PosteriorSpatium intermusculare approach:Prone position, midline skin incision, turned the flap to the outside to remove subcutaneous fat layer, revealing fascia, turned fascia outside by a retractor, exposed paraspinal muscle. Carefully identify the multifidus muscle, longest muscle and iliac rib muscle, searched for potential muscle gap. Revealed the structural features inside the different muscle gap approach.Posterior midline approach:Spilited from the pedicle level by saw, open spinal canal, measure the distance between nerve root and spine canal midline,weight of safe working hemline at the disc level, vascular distribution of intraspinal. Randomly selected full-endoscopic lumbar discectomy surgery video40minutes to reveal lumbar laminectomy gap approach stucture.Clinical applicationsCompared percutaneous foramial endoscopic lumbar discectomy(PELD) and full endoscopic lumbar discectomy (FLD)with the same period MED surgery, to find out the risk factor and the effect the PELD and FLD and to come up with the solutions.ResultsAnterior approachL3/41evel, on the left, the distance between the abdominal aorta and sympathetic is13.5±3.0mm.On the right, the distance between the inferior vena cava and sympathetic is9.2±2.6mm.When the vessel bifurcation is above L4/5level, on the right the distance between the external iliac vein and sympathetic is6.4±1.4mm. On the left the distance between external iliac artery and sympathetic is6.4±1.2mm.When the vessel bifurcation is under L4/5level, on the left, the distance between the abdomen aortic and sympathetic distance is12.5±3.0mm. On the right, the distance between he inferior vena cava and sympathetic is10.8±2.2mm.Ureters were retroperitoneal Traveling with spermatic vein. The average distance between the left ureter and abdominal aorta is3.5cm, the average distance between the right ureter and vena cava is2.8cm. Because of relatively large bilateral ureteral activity, the distance get differently, at the L5S1level the distance get larger, it is from2-4cm sometime.Segmental artery directly come from the abdominal aorta, walking in the middle of the lumbar vertebral, L3A is largest, the diameter is1.8±0.3mm, the smallest is L5. Sacral artery relatively large vary,15cases come from from the abdominal aorta,2cases from left iliac artery,3cases from right iliac artery.Lateral approachLower lumbar segmental arteries appeared at all the lumbar foramen, and always have3branches, the branches are around the exsting root.the large two branches located below the transverse process and the top of upper facet, and small branches locate below the upper facet. The LSA diameter:L3A was1.8±0.3mm, L4A1.6±0.4mm, L5A1.3±0.2mm.The distance between the exsting nerve and upper facet at the different disc level:L3/4was3.5±1.2mm, L4/5was4.2±1.5mm, L5S1was4.6±1.0mm, the longest distance is only5.6mm, less than7.5mm.Transverse diameter of intervertebral foramen:L3/4is8.6±2.0mm at disc level, intervertebral foramen maximum diameter is9.4±4.5mm. L4/5is9.5±3.0mm at disc level, the maximum diameter of the intervertebral foramen is10.2±3.5mm. L5/S1is8.2±2.2mm9.5±3.0mm at disc level,the maximum diameter of the intervertebral foramen is9.6±3.2mm.Ascending lumbar vein location and distribution:Ascending lumbar vein foramen is at verteberal periosteal surface. Psoas muscle cover the ALV. Ascending lumbar vein communicates Iliac vein in the end mostly. Ascending lumbar vein often travel at the surface of the exiting nerve roots.Lumbosacral plexus (lumbosacral plexus) location and distribution:12th thoracic nerve branch, part of the composition of L1to L3nerve anterior branch and the former branch of L4nerve compose the Lumbosacral plexus. The distance between EN and the midpoint of the disc,11.5±1.2mm (L3) at L3/4level,10.8±1.5mm (L4) at L4/5level.The distance between the sympathetic and the disc center:12.5±1.6mm (L3) at L3/4level,14.2±2.5mm (L4) at the L4/5level. The distance between the centers of disc and transforaminal lumbar plexus:10.5±2.0mm at L3/4,9.2±1.5mm at L4/5.Posterior approachPosterior Muscle gap approach:Wiltse muscle gap is between multifidus dorsi muscle and longest muscle. The LIMP gap between longest muscle and iliocostalis muscle. The Watkins gap between iliocostalis muscle muscle and quadratus lumborum. The average distance waist3/4level lumbar midline to Wiltse gap is2.0cm at L3/4level,2.5cm at L4/5level,2.8cm at L5/S1level.The average lumbar midline to LIMP gap distance3.5cm at L3/4level,4.0cm at L4/5level,4.2cm at L5/S1level.Wiltse gap is filled with fat, few vessels pass through, but LIMP gap is smaller and some vessel branches pass through.Spinal anatomy:Lower lumbar nerve Travele differently. The higher level, the shorter and flater path. The The higher level, the lower original point. L4lumbar nerve root canal original from spine at the level of the bottom half of the L4vertebrae, L5nerve root issued a relatively high point, usually originating at the middle of14/5disc, S1nerve root is almost vertical, also issued a relatively highest point, usually originating at the bottom of the L5/S1disc.Intraspinal safety triangle (Safe triangle):the outside boundary is upper nerve root, medial boundary is dural sac and nerve root sleeve, the lower boundary is the lower edge of the corresponding disc. Safety Triangle bottomline:5.6±1.4mm at L4/5level.6.8±1.8mm at L5/S1level.Laminar space measure:Height:9.5±1.4mm at L3/4level,11.5±2.7mm at L4/5level and11.8±1.4mm at L5/S1level.Width:6.4±1.8mm at L3/4level,8.6±2.5mm at L4/5level and10.4±2.6mm at L5/S1level.ConclusionAnterior approachL3/4AND14/5ALIF surgery, it is recommended to enter from the left, to confirm the anatomical relationship by palp abdominal aorta through the left side, found the ureter on the inside of the abdominal aorta, retracted ureter and arteriovenous can reveal enough surgical workspace. In lumbar disc excision should pay attention not to exceed the outer edge of the psoas muscle, where lumbar sympathetic trunk located. Also some small branches of segmental blood vessels is in front of lumbar intervertebral disc, be attention not to injury them. When a L5S1sacral ALIF surgery, generally confirm the location of the sacral artery in the preoperative, intraoperative attention ligation. Because of the sacral artery greater variability, it can not be served as the midline.Lateral approachPLED is a new technology, it get inspiring clinic results.But the technoly has it own complictions.POD is its unique complications. Enlarge foramen is effective method to reduce the POD, be careful not to damage the lumbar vein and lumbar artery branches in the enlarge foramen procedure. Extreme lateral lumbar interbody fusion (XLIF) or directly lumbar interbody fusion (DLIF) is a new minimally invasive lateral lumbar fusion technology, has a good safety performance. The most complication is the lumbar plexus damage. The possibility of vascular injury is small。 L4/5DLIF is more complication than L3/4.Do not omit electrical nerve monitoringClinical applicationsThe key of percutaneous transforaminal lumbar discectomy surgery is enlargermen of transforamia, it is a very important step to avoid avoid nerve root injuryand postoperative numbness (POD). Posterior endoscopic discectomy require the whole laminar space greater than8mm, intraoperative nerve root compression must be avoided.更多还原