椎间孔外型腰椎间盘突出症的应用解剖和手术治疗

Extraforaminal lumbar disc herniation:anatomical study and surgical treatment

目的 探讨后侧肌间隙入路治疗椎间孔外型腰椎间盘突出症的解剖基础及其疗效。方法 在 34具经甲醛固定的成人尸体上 ,观测椎间孔外区腰椎节段血管与横突、腰神经前支的相对位置关系 ,椎弓峡部侧缘距腰神经前支的深度以及腰神经前支的走行等。 1993年 10月～ 1999年 10月 ,采用后侧肌间隙入路和外侧腹膜后入路治疗椎间孔外型腰椎间盘突出症共 11例。 结果 L1～L4节段动脉前支及伴行静脉 90 %以上位于相邻横突间隙上 1/2的腹侧 ,血管与腰神经前支毗邻并位于腹前方 ,L1～L5椎弓峡部侧缘至腰神经前支的深度约为 1 0～ 2 0cm ,腰神经前支与矢状面夹角约为 7°～ 2 5° ,越往尾侧 ,深度与角度逐渐增加。本组 11例中 10例随访 1年 11个月～ 8年 2个月 ,按照LBOS标准进行疗效综合评定 ,优 8例 ,良 2例 ,比较而言 ,肌间隙入路的手术时间、失血量、康复时间等相对较少。 结论 后侧肌间隙入路治疗椎间孔外型腰椎间盘突出症是一种安全有效的手术方法。

Objectives To provide the anatomical basis for surgical treatment of extraforaminal lumbar disc herniation (EFLDH) by paraspinous muscle splitting approach and to investigate the effect of its application. Methods The relationship among the intertransverse processes, lateral margin of the pars interarticularis, anterior ramus of the lumbar nerve, and anterior ramus of the lumbar artery was studied in 34 cadaveric specimens. From October 1993 to October 1999, eleven cases of extraforaminal lumbar disc herniation were treated by paraspinous muscle splitting approach and retroperitoneal approach. Results In the extraforaminal region, the anterior ramus of the lumbar artery and venus locate ventrally to the superior half of the intertransverse space, and the anterior ramus of the lumbar artery runs downward behind the nerve. The distance from the lateral margin of the pars interarticularis to the nerve root and the angle between the nerve root and midline sagital plane were 1 0 2 0 cm and 7° 25° respectively which increased gradually from L 1 to L 5. The period of follow up in 10 of 11 cases was 23 98 months. Evaluation according to Low Back Outcome Score showed excellent results in 8 cases, and good in 2. Conclusion Surgical treatment of EFLDH by paraspinous muscle splitting approach is safe, effective and minimal invasive.