胸腰段微创椎弓根螺钉进钉点的解剖学及临床研究

Anatomic Basis of Percutaneous Pedicle Screw with Minimally Invasive and Its Clinical Study in Treatment of Thoraco-lumbar Fracture

目的为直视经皮微创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,经乳胶灌注。在解剖显微镜下对T11、12～L5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,并在此基础上选择有适应证的患者进行直视下微创植入椎弓根螺钉,研究其可行性及术中、术后的优缺点。结果胸腰段脊神经后支于椎间孔外由脊神经发出主干为0.5～1.0mm向后走行分内、外支。内侧支较细。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。外侧支较粗,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,支配腰部深层肌肉。静脉与动脉伴行在横突部形成静脉丛。选择8例有手术适应证的患者,C臂定位后,直视下小切口常规器械植入椎弓根螺钉系统,并与同期适应证相同的26例行常规手术切口的术中、术后各指标进行比较。结论微创椎弓根螺钉进钉区无主要的营养和支配关节突、后部肌肉的血管和神经支,采用经皮微创小切口直视下植入椎弓根螺钉内固定系统治疗胸腰段骨折是可行的,术中避免了损伤支配骶棘肌的脊神经后支、节段动静脉和减少对脊柱后方结构的剥离,术中出血明显减少,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 pediele screw, and analyze its possibility and its advantages in operation. Methods Through anatomy, knowing the posterior ramus of spinal nerves, the segmental artery and vein,knowing their region, branch, and distribution on 8 speciments. Results The posterior ramus through out the intervertebral foramen divide into two branchs. The medical branch of the postreior ramus of the spinal nerve coursed dorsally from the lateral aspect of the superior articular process to the root of the transverse,and attached to the periosteum by fibers. The lateral branch enter into the deep muscles of the back and domination,. The posterior branch of the segmental artery and vein in the thoracolumbar region arise laterally to the intervertebral foramen and run dorsocaudal inferior to superior articular process of the vertebral below. Useing ＂C＂-arm fluoroscopic guldarlce, we find the ＂eye＂ of the upper and lower vertebra in 8 cases of thoracolumbar fracture; compared with the treatment of traditional open pedicle screws system operationed in other 26 cases. Conclusion The region has no main spinal nerves and segmental artery which dominate the superior articular process and muscle of the posterior part. Through the percutaneous planting the pedicle screws, can avoid mechanical damage to the posterior of spine nerve, segmental artery. This technique has advantages of simplity, safety and less complication.