腰骶丛损伤的应用解剖学研究
发布时间：2018-01-09 06:28
本文关键词：腰骶丛损伤的应用解剖学研究 出处：《南方医科大学》2008年博士论文 论文类型：学位论文
更多相关文章： LSP 血供 放射显影 神经损伤 磁共振神经成像术 手术入路
【摘要】： 研究背景和目的: 腰骶丛(Lumbosacral plexus,LSP)损伤是一种神经受外界因素侵袭而损伤的疾病,随着诊治水平的提高,患者对神经损伤后的功能恢复提出了更高的要求。LPS损伤的病因多为高速交通事故、高处坠落、塌方等导致骨盆骨折、骨盆环破裂时造成的。正常时LSP在骨盆内的活动度极小,LSP损伤的机制常为骨盆后环骨折移位或合并关节脱位所造成的牵拉致伤,少数为压迫性损伤。 外伤、机械压迫、化学刺激等多种原因损伤后缺血导致神经内部组织学的变化是神经功能难于恢复的主要原因,它造成神经根的正常传导功能障碍。国外学者通过动物及人的解剖学、组织学以及血液动力学方面的观察,对造成神经根的正常功能传导障碍的原因进行了研究,但对LSP血供方面的研究还不完善。 LSP损伤后外科修复的临床效果受诸多因素影响,其中神经的血液供应就起着非常重要的作用。在神经缺损修复时,带血管的神经移植体(vascularized nervegrafting VNG)较常规的无血管神经移植具有理论上的优越性。对周围神经血供的研究已有200多年的历史,早在十八世纪六十年代,Isenflamm和Doerffler首次用灌注方法对周围神经的供给血管进行了研究,之后的学者对周围神经的血供的研究因得不到临床应用而一直停留在基础理论研究阶段。自Taylor 1976年成功地进行了带血管蒂的神经移植以后,人们对神经血供的研究由单纯的基础研究转向了临床应用的研究,同时研究方法也有了改进。2003年Suami、Sidney、2006年Hong、彭田红等分别利用放射血管显影技术对下肢神经、臂丛和上肢神经的血管体进行了研究。Suami等下肢血管体区域的研究,采用血管放射显影技术,着重对下肢主要神经的营养血管分布范围进行讨论,但还缺乏对LSP血供的系统研究资料,LSP及其血供的分布特征也未能从放射显影上得到证明。 为此,本课题第一部分对LSP进行解剖学观测,采用血管显微解剖技术与明胶-氧化铅放射微血管显影技术对LSP神经的血液供应进行研究,提供腰骶(Lumborsacral,LS)神经根出椎间孔周围的解剖关系,神经根在椎管内的走行角度,LS神经根的解剖学数据,明确了LSP的血供,神经与血管的位置和解剖结构关系特点以及节段血管的供血区域,为LSP损伤的修复手术提供解剖学依据。 微创诊疗技术的不断提高以及影像技术的迅猛发展,对血管和神经的可视化研究已成为临床诊断不可或缺的证据。现阶段临床常规应用的CT、超声、MRI等影像检查方法还不足以清晰显示LSP结构,影响LSP损伤诊断的准确性。1992年Howe等尝试应用磁共振(magnetic resonance,MR)技术结合脂肪抑制,显示家兔前肢的神经横截面图像,为周围神经成像提供了一个新的可行的方法,但由于MR软硬件的限制,显示神经的分辨率不高,伪影明显,临床应用受到限制。近年由于磁共振技术的快速发展,提高了图像的时间和空间分辨率,压脂技术更完善,使磁共振神经成像术(magnetic resonance neurography,MRN)成为一种临床实用新技术。 为此,本课题第二部分使用MRN技术对LSP进行成像,完整显示了在体LSPMR影像,并使其三维成像。为临床LSP损伤的诊断提供影像学资料,为LSP损伤的手术治疗提供影像学依据。 许多学者在不断提高诊疗技术的基础上,还致力于探索不同的手术方法以恢复患者运动功能。Aramburo(1986)报道有关LSP探查手术入路,通过腹膜外与腹膜内两种入路可以显露LSP,常用肌旁侧腹切口,经腹膜后分离显露腰丛(Lumbar plexus,LP);经腹切口分离显露骶丛(Sacral plexus,SP)。Linarte和Gilbert(1986)报道经骶骨(SA)入路显露SP。LSP损伤修复探查目前的文献报道不多,而采用合理的手术入路对损伤的修复和保护其周围的血管和腰大肌等结构,维持脊柱的正常结构和功能有重要的意义。临床上对前路腹膜后(Anterior retroperitoned,ARP)入路的研究更多关注的是腰椎手术,ARP入路可以通过将大血管牵向内侧暴露椎体更充分,或者通过切开更外侧的腰大肌暴露椎体,但切开腰大肌暴露椎体容易损伤位于腰大肌内的LP,切开腰大肌对脊柱的功能有影响,而腰椎前路手术中医源性LSP的损伤目前也有报道,主要发生在暴露和器械植入的过程中。为了在手术中更好地修复受损伤的LSP,恢复其功能,减少手术带来的二次创伤及保护脊柱功能,本课题在第三部分选用新鲜尸体标本,结合上述形态学和影像学研究结果,探讨LS部ARP手术入路的解剖结构特点,以期为临床LSP修复手术的开展提供形态学基础。 方法: 1.(1)15例红色乳胶灌注防腐成人标本的脊柱T9以下标本,肉眼和手术显微镜观察LSP根部椎管内、外的形态特点及其与椎管、硬脊膜和脊髓等周围组织的关系,(2)肉眼和手术显微镜下观察,LSP及前、后根(Posterior root,PR)的血供来源,以及前、后根营养动脉与脊髓前、后动脉的关系。(3)3具新鲜成人标本,经腹主动脉灌注3%明胶-氧化铅混悬液行动脉造影,解剖分离LSP及营养血管和来源血管,去除脊椎后对灌注的血管和LSP进行X线摄片观察。(4)实验过程使用佳能A650数码相机全程拍照,使用Photoshop软件对图片进行处理,利用南方医院影像中心PACS系统将X线片导入个人电脑,进行图像处理,可得到清晰的便于观察LSP的血供的动脉造影图片。 2.健康自愿者3例,GE公司3.0T HD signa超导磁共振成像(Magneticresonance,MR)系统,脊柱表面线圈(CTL456)。常规行矢状面T1WI,横断面T2WI成像,参数::FRFSE序列T2WI脂肪抑制,TR/TE/NEX:4000/85/2,矩阵:352×256,层厚/层间距:1.0/0mm,层数40～44,扫描时间:4min17s。原始图像以Dicom格式导入GE公司AW4.3图像工作站,完成最大密度投影(MIP)、多层面容积重组(MPVR)、容积再现(VR)图像重建。 3.新鲜标本3具,采用腋前线开口,左侧入路,进入腹膜后腔,腰大肌后外侧剥离,分离显露LP,结合LSP及营养血管的解剖结构,行模拟ARP神经修复、探查手术,观察腰大肌与LSP神经、血管之间的位置关系。 结果: 1.(1)LSP根部的显微外科解剖:LSP前、PR依次由神经小束-神经亚束-神经束组成,神经小束自相应的LS部脊髓节段的前外侧沟和后外侧沟平行排列发出或进入,斜向外下方走行,从上至下前根(Anerior root,AR)其始处与脊髓中线的距离先大后小,L1最大2.21±0.49mm,向下逐渐减小;AR与脊髓纵轴的夹角逐渐变小,L1最大为25.07°±5.37;前、后根在椎管内走行的长度逐渐增大,L1为66.74±10.77mm、65.61±9.87mm,增大到L5的129.99±16.27mm、137.64±11.37mm;前、后根直径最粗的为L5的1.70±0.36mm、1.75±0.56mm,相应的PR比AR粗;腰神经(Lumbar nerve,LN)AR分出角大于前支分出角,LS神经与硬膜囊的夹角逐渐减小,L1为56.64°±7.67,到S3的7.80°±1.94;前后根神经束逐渐形成内侧宽、外侧窄的扇形结构,其表面根动脉伴随神经根出入硬膜囊。(2)LSP及前、后根的血供:来自第1-4腰动脉(Lumbar artery,LA)、髂腰动脉、臀上动脉、骶外侧动脉,根动脉与脊髓前后动脉以多种方式相吻合。(3)LSP血供的分布:来源于LA系统、骶髂腰动脉系统、臀上动脉、臀下动脉、阴部内动脉发出的节段性动脉及邻近肌肉肌支。节段性动脉除发支营养椎体、椎弓等外,全部向内侧发支营养LS神经节、LSP,并伴随神经节向内延伸至硬脊膜或穿过硬脊膜、蛛网膜,沿前、后根行走,发支营养脊神经根,并在神经束与脊髓前、后动脉相吻合,吻合方式为真性吻合。节段动脉以“Y”型进入神经外膜,然后分成升降支,节段动脉及分支之间互相吻合,吻合方式为真性吻合和闭塞性吻合,以真性吻合为主。LSP神经干、股、束的血供除来源于节段动脉外,还来自邻近的动脉,包括伴行动脉及其分支、邻近的肌支。红色乳胶灌注标本和明胶-氧化铅放射显影法均清晰显示了LSP的血供。 2.MRN LSP成像:MRN可以清楚显示LN椎间孔段(神经根)、LN节段(神经节)、LN节后段、LST(神经干)及股神经、闭孔神经(Obturator nerve,ON)、股外侧皮神经(Posterior fmoral crtaneous nerve,PFCN)、髂腹下神经(Iliohypogastricnerve,IN)、髂腹股沟神经(Ilioinguinal nerve,ILN)(股、束)。神经节信号高于神经根和神经干,神经节及神经干周围未见高信号灶。股神经在腰4、5椎体水平从腰大肌表面移行至髂腰肌表面,形态由长条形移行为椭圆形的断面,信号稍高于腰大肌,边缘较清楚。SP由于走行角度不同不能同时显示,斜矢状位成像定位线最好与斜冠状位所显示的短条状神经走行方向一致,这样可增加S1及邻近坐骨神经(Sciatic nerve,SN)的显示机会,利用多平面重建技术,可以对采集的原始数据任意方向重建,明显提高神经的显示率。 3.模拟LSP损伤修复ARP手术入路:采用左侧前路腋前线切口,暴露L1～L3LN,能达到良好的暴露和直视下操作的目的。LP在不同断面中,LP神经位于腰大肌深面或肌质内,腰椎横突的前方,此处为腰大肌间隙,LP在腰椎侧方的组成具有一定的规律性,LA在腰大肌内的走行没有特定的肌间隙。 结论: 1.LSP血供来自于第1～4LA、骶髂腰动脉系统、臀上动脉、臀下动脉、阴部内动脉及邻近肌肉的肌支。营养动脉之间在神经内的真性吻合在病理状态下可提供侧支循环,血管区域之间的血供可以互相代偿。熟悉LSP根部的显微解剖有助于LSP损伤的诊治。 2.乳胶灌注法适合神经外部血供的观察,血管造影法适合神经血管分布的整体观察,乳胶灌注法和血管造影法的结合观察研究,可以清晰显示LSP神经血管的分布及神经与血管的关系。 3.MRN技术全面完成了LSP的成像,因其无创性,应该为临床进行LSP损伤检查首选的影像学手段。 4.LSP损伤的修复和探查手术前路入路更加适合,ARP入路可以作为不损伤LS功能前提下的LP损伤修复的手术入路,腰大肌的前外侧是腰大肌切开的安全区。入路直接、简捷,暴露清楚,可直视下处理神经根和突出椎间盘;创伤小,出血少,从肌间隙进入,不破坏神经和肌肉的正常结构,不切除脊柱骨性部分和韧带,不影响脊柱稳定性。
[Abstract]:Research background and purpose:
The lumbosacral plexus (Lumbosacral plexus LSP) is a kind of nerve injury by external factors of invasion and injury of the disease, with the improvement of diagnosis and treatment, patients put forward higher requirements cause.LPS damage for the high-speed traffic accident, falling on the nerve functional recovery after injury, leading to collapse caused by pelvic fracture, pelvis ring the rupture. The normal LSP in the pelvis of the activity of the minimal LSP injury mechanism for regular pelvic posterior ring fractures with displacement or dislocation caused by traction injury, injury for the oppression of minorities.
Mechanical compression damage, trauma, chemical stimulation and other reasons after the ischemia induced changes of nerve internal organization is the main reason for restoration of nerve function, it causes the normal conduction of nerve root dysfunction. Foreign scholars through animal and human anatomy, histology and hemodynamics the observation, reasons for the obstacles caused by nerve root conduction function the studied, but the LSP blood for the study is not perfect.
The clinical effect of surgical repair after injury of LSP is influenced by many factors, including nerve blood supply plays a very important role in the repair of nerve defects, vascularized nerve graft (vascularized nervegrafting VNG) without vascular nerve graft is superior than the conventional theory. To study the blood supply of peripheral nerve the more than 200 years of history, as early as 1760s, Isenflamm and Doerffler for the first time on the blood supply of peripheral nerve was studied by perfusion method, research scholars on peripheral nerve blood supply due to lack of clinical application and has been stuck in the stage of basic theory research. Since Taylor 1976 successfully carried out nerve transplantation vascularized nerve blood supply, people studied by purely on the basis of the clinical application to the study, and research methods have improved.2003 S Uami, Sidney, Hong in 2006, Peng Tianhong respectively using radiation angiography technology on lower extremity nerve, vascular plexus and upper limb nerve were studied on.Suami lower extremity vascular area, using vascular radiography technology. Focused mainly on the lower extremities of the nutrient vessels to discuss the scope of distribution, but also the lack of system research the LSP of the blood supply and distribution characteristics of LSP and its blood supply was not proved by autoradiography.
Therefore, the subject of the first part of the LSP were observed by microscope, vascular anatomy study and technology of gelatin lead oxide radiation imaging microvascular blood supply to the LSP nerve, with lumbosacral nerve root (Lumborsacral, LS) from the anatomical relationship between the intervertebral foramen and nerve roots in the spinal canal running angle, anatomy the data of the LS nerve root, the LSP blood supply, blood vessels and nerves and anatomical characteristics and the relationship between the position of the segmental vessels blood supply area, to provide anatomic basis for surgical repair of LSP damage.
The rapid development and constantly improve the minimally invasive technique and imaging technology, visualization of the blood vessels and nerve clinical diagnosis has become an integral part of the evidence. The clinical application of conventional CT, ultrasound, MRI imaging method is not enough to clearly show LSP structure, the influence of LSP damage diagnosis accuracy of.1992 Howe application magnetic resonance (magnetic resonance MR) combined with fat suppression showed nerve cross-sectional images of rabbit forelimb, provides a new feasible method for peripheral nerve imaging, but due to the MR software and hardware limits, display nerve resolution artifacts, the clinical application is limited due to the rapid in recent years. The development of MRI technology, increase the time and the spatial resolution of the image, the grease pressing technology is more perfect, the magnetic resonance neurography (magnetic resonance, neurography, MRN) be a pro New bed technology.
To this end, the second part of the project is using MRN technology to imaging LSP, displaying LSPMR images in vivo and making three-dimensional imaging, providing imaging data for the diagnosis of LSP injury, and providing imaging evidence for surgical treatment of LSP injury.
Many scholars continue to improve in the foundation treatment technology, is also committed to exploring different ways to restore the operation of motor function in patients with.Aramburo (1986) reported on the LSP exploration approach, through the extraperitoneal and intraperitoneal two approaches can reveal LSP, commonly used muscle side abdominal incision, retroperitoneal dissection of lumbar plexus (Lumbar plexus, LP); revealed the sacral plexus by abdominal incision separation (Sacral plexus, SP.Linarte) and Gilbert (1986) reported by the sacrum (SA) approach to expose more SP.LSP damage repair exploration reported in the literature, and a reasonable surgical approach to repair the damage and protect the surrounding vessels and the psoas muscle structure, has important significance to maintain the normal structure and function of the spine. In clinical anterior retroperitoneal (Anterior Retroperitoned ARP) approach is more concerned on lumbar surgery, ARP approach to the great vessels pull inwards The vertebral side is exposed more fully, or through the incision of the psoas muscle more lateral vertebral body exposed, but cut the psoas muscle is easy to damage in the psoas muscles of the LP vertebral body exposed, open function of psoas muscle on the spine have influence, and anterior lumbar surgery iatrogenic LSP injury has also reported, mainly in the process of exposure and the implantation of the device. In order to better surgery to repair the damage LSP, to restore its function, reduce the operation brought two times of trauma and protection of spinal function, the choice of topics in the third part of fresh specimens, the study results with the morphology and image, to explore the anatomic characteristics of LS ARP operation the approach, in order to provide morphological basis for clinical LSP repair surgery.
Method:
1. (1) of 15 cases of red latex perfusion preservation of adult specimens following spinal T9 specimens, and the naked eye surgery microscope LSP root canal morphology, characteristics and relationship of tissue around the spinal canal, spinal dura mater and spinal cord, (2) observed by naked eye and microscope, and LSP before and after root (Posterior root, PR) of the blood supply and nutrition, before artery and dorsal root, after artery. (3) 3 fresh adult cadaveric specimens, the abdominal aorta perfusion 3% lead oxide gelatin suspension for artery angiography, dissecting LSP and nutrient vessels and vascular sources, X-ray observation the perfusion of blood vessels and LSP were removed after spinal. (4) experimental process using the Canon A650 digital camera to take pictures, use Photoshop software to process the images, using PACS imaging system center of Nanfang Hospital will be X-ray film into personal computer, image processing, can get clear An arteriography picture that facilitates observation of the blood supply of LSP.
3 cases of 2. healthy volunteers, GE company 3.0T HD signa superconducting magnetic resonance imaging (Magneticresonance, MR) system, the spine surface coil (CTL456). Routine sagittal T1WI, axial T2WI imaging parameters: FRFSE T2WI sequence with fat suppression, TR/TE/NEX:4000/85/2, matrix: 352 x 256, thickness: 1.0/0mm number 40, to 44, the scan time: 4min17s. original image in Dicom format into GE AW4.3 workstation, complete the maximum intensity projection (MIP), multi planar volume rendering (MPVR), volume rendering (VR) image reconstruction.
3., 3 fresh specimens were made by using the axillary front opening, the left approach, the retroperitoneal cavity, the posterolateral psoas muscle stripped, the LP exposed and exposed, and the anatomical structure of LSP and the nutrient vessels. The ARP nerve repair was performed to explore the location relationship between psoas major and LSP nerves and vessels.
Result:
1.(1)LSP鏍归儴鐨勬樉寰绉戣В鍓，
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