L5-S1椎间孔韧带的观测及其临床意义

发布时间：2018-07-10 11:10

本文选题：L5-S1椎间孔 + 椎间孔内韧带　；参考：《南方医科大学》2017年硕士论文

【摘要】：内镜应用于脊柱外科,是脊柱手术微创化的又一进展。从经皮内窥镜辅助下腰椎椎间盘切除术,发展到下腰椎椎间孔镜置入椎管内,在直视下经硬脊膜前间隙直接取出突出的髓核或松解神经根粘连卡压,已成为一种较为安全有效的微创外科术式。由于L5-S1椎间孔位于高度活动的腰椎和相对固定的骶椎这一特殊的脊柱结构和功能转变区域,椎间盘极易突出、韧带变性或腰椎退行性变,L5神经根受压机率最大。受髂嵴部分屏蔽和坚韧的腰骶韧带、腰骶弓状筋膜的覆盖遮挡等解剖学因素影响,经椎间孔置镜操作较为困难,且极易损伤神经根或硬脊膜。为此有学者发明了在X线影像引导下,经骶管硬膜外L5-S1椎间孔入口神经松解术式,对神经根机械松解,取得了一定疗效。既往对L5-S1椎间孔的研究多集中于椎间孔出口区横跨型韧带的分布及与脊神经的毗邻,而L5-S1椎间孔出口区连接神经根到椎间孔周围骨性结构的放射型韧带以及入口区韧带的分布及与神经根的毗邻关系很少有人提及。入口区韧带的分布特点和与神经根间的毗邻关系等详尽的解剖学资料较少,影像学特征不了解,无法在术前明确这些结构的位置和毗邻,以致盲目构建的工作通道或在识别不清情况下非直视松解,特别是在“二维空间”状态下操作,缺乏器械置入的深度感,有可能造成硬脊膜撕裂或脑脊液漏,或在松解时造成神经根损伤。因此,本研究旨在阐明L5-S1椎间孔韧带的位置、形态、分布及其与神经根袖的毗邻关系,为术前制定经骶管内镜硬膜外L5-S1椎间孔神经松解个性化手术方案、安全工作通道的构建、韧带和神经的辨认及精准内镜下神经松解方案的安全实施提供解剖学依据。具体研究概括如下:目的:探讨L5-S1椎间孔韧带的性状、分布规律并评价其临床意义。为脊柱外科医生提供更为详实的解剖学资料。方法:取30具防腐和15具新鲜冰冻腰骶部标本(年龄40到85岁,平均年龄56岁)。动脉用红色乳胶灌注。仔细剔除脊柱周围的软组织,从正中矢状锯开脊柱。找出L5-S1神经根并沿着椎间孔小心去除周围脂肪和筋膜等软组织。在肉眼及手术显微镜下观察韧带的形态、走行、起始位置及分布特点,用游标卡尺在手术显微镜下测量其长度、宽度及直径或厚度。用HE染色和Masson三色染色法分析对比不同类型韧带的组织学类型。结果:在90个L5-S1椎间孔内共发现818条韧带,其中条带形350条,条索形468条;连接神经根到横突或椎间孔内壁的放射状韧带699条(85.45%),另一种是连接椎间孔周围组织横跨在椎间孔内的横跨状韧带119条(14.55%)。在L5-S1椎间孔入口区270条(33.01%),中间区381条(46.58%)及出口区167条(20.42%)区域均有分布。韧带长度多变,自1.43-19.01mm都有;厚度最厚处达3.46mm。光镜下示椎间孔内韧带由大量的胶原纤维和少量的弹性纤维构成。放射状韧带与横跨状韧带组织学表现无明显差异。结论:椎间孔内韧带主要分为条带形和条索形两种形状。椎间孔入口区全部为放射状韧带,椎间孔内放射状韧带比横跨状韧带出现率高。术前应掌握其分布规律并在术中辨别并予以正确松解,减少并发症的发生。
[Abstract]:The application of endoscopy to spinal surgery is another progress in the minimally invasive spinal surgery. From percutaneous endoscopic assisted lumbar discectomy, it is developed to the lower lumbar intervertebral endoscopy in the spinal canal. The protruding nucleus or loosening of the nerve root stickout directly under the anterior interspinal interspinal space has become a safer and more effective minimally invasive procedure. Surgical procedures. Because the L5-S1 intervertebral foramen is located in a highly active lumbar and relatively fixed sacral vertebra, the special spinal structure and functional transition area, the intervertebral disc is very easy to protruding, ligamentous denatured or degenerative, and the L5 nerve root is most frequently pressed. The covering of the sacrosacral lumbosacral fascia and the lumbosacral fascia are shielded by the iliac crest and the tenacious lumbosacral ligaments. With the influence of anatomical factors, it is difficult to operate through the intervertebral foramen, and it is easy to damage the nerve root or the dural membrane. For this reason, a scholar invented the method of neurolysis of the L5-S1 intervertebral foramen via the sacral canal and a certain effect on the mechanical loosening of the nerve root under the guidance of X-ray imaging. The previous study of the L5-S1 intervertebral foramen was mostly concentrated on the vertebra. The distribution of transtransverse ligaments in the exportation of the intervertebral foramen and the adjacent to the spinal nerve, and the distribution of radial ligaments and the distribution of the ligaments in the entrance area of the L5-S1 intervertebral foramen exportation and the surrounding ligament of the intervertebral foramen, and the adjacent relationship with the nerve roots are rarely mentioned. The detailed anatomical data is less, the imaging features are not understood, and the location and adjacency of these structures can not be identified before the operation, so that the blind construction of the work passage or the unrecognized condition is not directly visible, especially in the "two-dimensional space" condition, the lack of the depth of the device insertion, the possibility of the tearing of the dura membrane or the brain. The purpose of this study is to elucidate the location, morphology, distribution of the L5-S1 intervertebral foramen ligaments and their adjacent relationship with the nerve root sleeves. The purpose of this study is to establish a personalized operation scheme for the sacral endoscopic epidural L5-S1 foramen neurolysis, the construction of the safe working passage, the identification of the ligaments and nerves and the identification of the ligaments and nerves. An anatomical basis for the safety implementation of the neuro release scheme under precision endoscopy is provided. The specific studies are summarized as follows: Objective: To investigate the characteristics, distribution and clinical significance of the L5-S1 intervertebral foramen ligaments. To provide more detailed anatomical data for the spinal surgeon. Methods: 30 specimens of anticorrosion and 15 fresh frozen lumbosacral specimens (age 40) At the age of 85, the average age of 56 years old. The arteries were perfused with red latex. Carefully remove the soft tissues around the spine and sawing the spine from the median sagittal. Find the L5-S1 nerve roots and carefully remove the soft tissues such as the surrounding fat and fascia along the foramen. Under the naked eye and the surgical microscope, we observe the shape, movement, starting position and distribution of the ligaments under the naked eye and operation microscope. The length, width, diameter or thickness of the label was measured under the operation microscope. The histological type of the different types of ligaments was analyzed by HE staining and Masson staining. Results: 818 ligaments were found in 90 L5-S1 intervertebral foramen, including 350 strips, 468 strips, and the radiation of the nerve roots to the transverse process or the inner wall of the intervertebral foramen. 699 (85.45%) and 119 (14.55%) straddle ligaments connected to the intervertebral foramen around the intervertebral foramen. 270 (33.01%) in the entrance area of the L5-S1 intervertebral foramen, 381 (46.58%) in the middle area and 167 (20.42%) regions in the exit area. The length of the toughened zone is changeable from 1.43-19.01mm, and the thickness is thickest up to the 3.46mm. light mirror. The ligaments in the intervertebral foramen were made up of a large number of collagen fibers and a small amount of elastic fibers. There were no significant differences between the radiate ligaments and the cross shaped ligaments. Conclusion: the intervertebral foramen ligaments are mainly divided into two shapes of strip and stripe. The entrance area of the intervertebral foramen is all radiate toughened zone, and the radiate ligaments in the intervertebral foramen are stronger than the straddle. The rate of occurrence is high. Preoperative distribution should be grasped and differentiated correctly during operation, so as to reduce the incidence of complications.
【学位授予单位】：南方医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R687.3;R322

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