直视下微创椎弓根螺钉内固定的解剖学观察和临床应用

Anatomic review of percutaneous pedicle screw under genuine direct vision and its application

目的为直视经皮椎弓根螺钉内固定技术提供解剖学基础，并在此基础上分析经皮椎弓根螺钉的可行性及其优点。方法选用6具经防腐处理的尸体，4具经乳胶灌注。在解剖显微镜下对T11,12及L1-5脊柱后部结构进行解剖观察，观测肌肉血供、神经支配及关节突、横突间的脊神经后支的走向及分布规律。结果胸腰段脊神经后支于椎间孔外由脊神经发出内侧支，跨过横突根部，绕过小关节突外缘，到乳突与副突间的骨纤维管，呈树状分布，支配同一平面骶棘肌内侧束、小关节、棘突、棘间韧带。外侧支沿横突上缘自骶棘肌深面向下、外、背侧行走，支配骶棘肌的中间份和外侧份。节段动脉静脉的后支在椎间孔的上方绕向后下方，走行于脊神经的下方和下位椎体上关节突的外方，分为内外2支，分布于腰部深层肌肉。选择8例有手术适应证的患者，直视下小切口常规器械植入椎弓根螺钉系统，术中出血少，损伤小。结论在观察椎弓根进针点解剖基础上，采用C臂X线机定位下，直视下小切口植入椎弓根螺钉，术中避免了损伤支配骶棘肌的脊神经后支和节段动静脉和脊柱后方的结构，术后恢复快、并发症少，是一种易于操作与推广的新技术。

Objective To provide minimally invasive spinal surgery with the anatomical basis for percutaneous pedicle screw, and analyze its possibility and its advantages in operation. Methods The posterior rami of spinal nerves, the segmental artery and vein, and their region, branch, and distribution on 6 speciments were observed anatomically. Results The posterior rami through out the intervertebral foramen posterior to the superior articular process of the below of the verebral, then divides into two branchs. The medical branch of the postreior ramus of the spineal nerver courses dorsally from the lateral aspect of the superior articular process to the root of the transverse, and attached to the peiosteum by fibers. The lateral branch enters into the deep muscles of the back and domination. The posterior branch of the segmental artery and vein in the thoracolumbar region rises laterally to the intervertebral foramen and run dorsocaudal inferior to superior articular process of the vertebral below, useing C-arm fluoroscopic guidance ,finding the eye of the upper and lower vertebra in 8 cases of thoraco-lumbar fracture;planting pedicle screw system. Conclusion Using C-ann to find the eye postion, then screws,we can avoid mechancial damage through the percutaneous plant the pedicle to the posterior of spine nerver, segmental artery. This way has advantages of simplity, safety and minimally invasive.