改良腰椎后正中手术入路的影像解剖学研究及临床初步应用

Anatomical study and preliminary clinical application of modified posterior midline approach for lumbar surgery

中文关键词:  腰椎手术  后正中入路  棘上韧带  解剖  临床应用

英文关键词:Lumbar surgery  Posterior midline approach  Supraspinal ligament  Anatomy  Clinical application

中文摘要:

  【摘要】 目的：对保留棘上韧带附丽的改良腰椎后正中入路进行相关影像解剖学研究，并观察其临床初步应用效果。方法：选取50例腰椎MRI图像资料，男27例，女23例，年龄37.1±8.2岁。在PACS系统上选择L3/4、L4/5、L5/S1各一幅T2W1轴位图像进行测量，包括棘上韧带宽度及厚度，胸腰筋膜、骶棘肌总腱膜于棘上韧带附丽部及多裂肌间隙部的厚度。在2具防腐成人尸体标本上模拟保留棘上韧带附丽的改良腰椎后正中手术入路。临床应用改良腰椎后正中手术入路22例，其中男12例，女10例，平均年龄51.5±8.0岁。单节段14例，双节段7例，三节段1例。术后随访3个月。观察切口长度、切口显露时间、出血量及术后腰痛程度。结果：胸腰筋膜、骶棘肌总腱膜附丽于棘上韧带。于L3/4、L4/5、L5/S1层面，多裂肌间隙与后正中线间距分别为16.32±6.56mm，27.43±6.36mm，33.65±4.77mm；腰筋膜附丽部厚度分别为0.81±0.17mm，0.88±0.15mm，0.87±0.14mm，与其肌间隙部厚度差异不显著（仅L4/5层面存在显著性差异）；骶棘肌总腱膜附丽部厚度分别为1.76±0.51mm，1.71±0.40mm，1.78±0.50mm，同层面肌间隙部厚度分别为0.95±0.18mm，0.99±0.22mm，0.98±0.20mm，具有统计学显著性差异（P<0.05）。尸体模拟手术示骶棘肌总腱膜深面与多裂肌之间存在潜在间隙，可无损伤分离至棘突旁，组织牵开张力小。所有22例均按手术方案完成减压、椎间融合器置入及椎弓根螺钉内固定术，显露良好，视野清晰，单节段、双节段切口长度分别平均4cm、6cm。结论：棘上韧带之骶棘肌总腱膜、胸腰筋膜附丽部均强大。保留棘上韧带附丽的改良腰椎后正中入路合理可行，可缩短切口长度，减轻肌肉损伤。

英文摘要:

  【Abstract】 Objectives: To develop a modification of posterior midline approach with preservation of attachments of the supraspinal ligament in lumbar surgery. Methods: A total of fifty adult patients underwent lumbar surgery (27 male and 23 female, at a mean age of 37.1 years) were identified and MRI data were collected. Measurements were performed at axial image from L3/4 to L5/S1 respectively, including width and thickness of supraspinal ligament, thickness of thoracolumbar fascia and sacrospinal aponeurosis at attachments on spinal ligament and at multifidus cleavage. The mimic surgery was conducted in two adult cadavers to investigate the feasibility of this modified approach. Based on anatomy study, the modified posterior lumbar midline approach was applied clinically in 22 cases(12 male and 10 female, at a mean age of 51.5 years) with lumbar disorders. There were 14 cases in one-segment, 7 cases in two-segment and one case in three-segment. The incision length, exposure time and postoperative back pain were recorded. All cases were followed up for three months. Results: There were attachments of thoracolumbar fascia and sacrospinal aponeurosis on the postero-lateral part of supraspinal ligament. At the level of L3/4, L4/5 and L5/S1，the multifidus cleavage was located laterally from posterior midline in 16.32±6.56mm, 27.43±6.36mm, 33.65±4.77mm, respectively. The thickness of thoracolumbar fascia at the attachments was 0.81±0.17mm, 0.88±0.15mm, 0.87±0.14mm, respectively, almost equivalent to that at the multifidus cleavage(statistically significant only found at L4/5 level). The thickness of sacrospinal aponeurosis at the attachments was 1.76±0.51mm, 1.71±0.40mm, 1.78±0.50mm, respectively, with statistically significant more than that at multifidus cleavage at the same level(P<0.05). The mimic surgery showed the modified posterior lumbar midline approach was easier to be achieved with less retraction pressure. All the cases have received successfully decompression, interbody fusion and instrumentation with good exposure through this modified midline approach. The incision length was about 4cm for one-segment and 6cm for two-segment procedure. Conclusions: There are strong attachments of thoracolumbar fascia and sacrospinal aponeurosis on supraspinal ligament. The modified posterior lumbar midline approach with the aim of preserving those attachments is feasible, practical and effective with shorter incision length.