L4,5椎间盘前侧血管神经解剖及其临床意义

The vascular and nervous anatomy anterior to the L_(4,5) disk space and their clinical significance

目的:为前路L4,5椎间盘手术提供血管神经解剖学依据。方法:40例成人尸体标本,观察并记录L4,5椎间盘前侧的血管、神经及其与L4,5椎间盘的关系。结果:腹主动脉分叉点及髂总静脉汇合点位于L4椎体下1/2至L5椎体上1/2内的标本分别占90%(36)和85%(34);L4节段动、静脉出现率分别为92.5%(37)、97.5%(39);髂腰静脉出现率67.5%(27);骶正中动脉出现率100%(40);腰升静脉出现率47.5%(19);80%(32)的骶正中动脉在L4,5间盘前侧与腰升静脉或髂腰静脉形成动静脉骑跨结构;腰交感神经链在L4,5间盘水平位于腰大肌内侧缘、血管壁支的前侧,L4交感神经节位于L4,5间盘水平占72.5%(29);生殖股神经均在L4,5间盘水平以上穿出腰大肌;闭孔神经在L4,5间盘水平被腰大肌覆盖。结论:L4,5椎间盘是下腰椎前路手术暴露难度最大的节段,手术中应仔细辨别其局部解剖关系,避免血管神经副损伤。

Objective： To provide neurovascular anatomy for the anterior approach of L4,5 intervertebral disc. Methods： 40 human cadavers were investigated in our study. The neurovascular configurations anterior to L4.5 space were observed, and their relationships were specially focused on. Results： For 90% （36） specimens, the abdominal aorta bifurcation and common iliac vein confluence located between the distal 1/2 of L4 vertebrae, as well 85% （34） between the proximal 1/2 of L5 vertebrae. Frequency of L4 segmental arteries and veins were 92.5%（37） and 97.5%（39） respectively. The ratios of occurrence of iliolumbar veins, middle sacral arteries and ascending lumbar veins were 67.5%（27）, 100%（40） and 47.5%（19） respectively. The middle sacral arteries and ascending lumbar veins or iliolumbar veins formed arterio-venous straddling configuration in 32 cases （80%）. For 72.5% （29）, lumbar sympathetic chains located at the medial border ofpsoas major, and L4 sympathetic nodes at L4.5 level. Genitofemoral nerves perforated psoas major above L4,5 level. Obtumtor nerves were covered by psoas major at L4,5 level. Conclusions： The exposure of L4,5 is the most difficult in the anterior approach of lower lumbar vertebrae. Intmoperative scrutiny of local anatomy is necessary to avoid neurovascular complicated injury.