腰椎间盘突出症后路微创手术的应用解剖与临床研究

Applied anatomy of the minimally invasive surgery for the lumbar disc herniation and its clinical significance

[目的]为微创外科技术治疗腰椎间盘突出症提供解剖学基础,并提高其手术效果.[方法]30具成人尸体标本,测量椎板下缘骨嵴到同位椎体下缘、黄韧带附着点、棘突下缘、棘间韧带外缘的距离.临床应用椎间盘镜(MED)治疗腰椎间盘突出症368例.[结果]椎板下缘骨嵴位于棘突的头侧,L3、4椎板遮挡相应的椎间盘,L5椎板没有遮挡L5～S1椎间盘.临床随访368例,根据Nakai分级:优287例;良57例:可21例:差3例;优良率93.5%.[结论]在腰椎间盘突出症后路微创手术中,切口应以棘突下缘头侧椎板下缘骨嵴为中心.要显露L3～4或L4～5椎间盘,需切除L3或L4椎板下缘少部分;显露L5～S1椎间盘,不需咬除L5椎板下缘,同时只需切除少部分黄韧带,即可显露椎间盘与神经根,完成髓核摘除手术.对单节段旁中央型、外侧型腰椎间盘突出症MED才能达到微创手术,要提高MED手术效果,关键是严格掌握手术适应证,并具有丰富的开放式手术经验以及熟练的镜下操作技术.

[Objective] To investigate the anatomic basis of minimally invasive surgery for the lumbar disc herniation in order to improve the treating result. [ Method] The distance of the lumbar lamina lower edge to the vertebral lower edge, to the bottom point of the spinous process, to the outer edge point of the ligamentum interspinale and to the upper atachment of the ligamentum fiavum were measured respectively. A total of 368 cares of the lumber disc herniation were treated by microendoscopy discectomy （MED）. [ Result] The lumbar lamina lower edge is in the cephalic of the spinous process, the intervertebral disc in L3 -4, L4-6 are covered by the lumbar lamina, the intervertebral disc in L5～S1 is not covered by the lumbar lamina. All cases were followed up for 13 ～ 42 months. According to Nakai classification, the result was being excellent in 287 cases, being good in 57 cases, being fair in 21 cases, and being bad in 3 cases. The satisfactory rate was 93.5%. [ Conclusion] In the minimally invasive surgery, the incision should be focused on the cephaliclateral side of spinous process lower point. MED operation should be limited to the single segment paracentral or lateral disc herniations. The indications selection is the key of this operation, which also need abundant experience and skilled technique.