腰椎经棘突后正中椎管切开复位术的解剖学研究及临床应用

Anatomic study and clinical application on posterior median split laminotomy of lumbar spine via spinous process

目的探讨经棘突后正中椎管切开复位术应用于腰椎椎管手术的有效性及安全性。方法用该术式对9具新鲜冰冻成人尸体标本在不同撑开宽度(8、10、12 mm)下进行模拟手术并记录相关数据,在手术结束后进行相关解剖学参数的测算。同时报告1例应用该术式行腰椎椎管内肿瘤切除手术的临床典型病例。结果椎板撑开10 mm至12 mm时可以完成椎管内硬脊膜切开及缝合,马尾神经探查等操作,并且12 mm组较10 mm组操作自由度更高;不同撑开宽度(8、10、12 mm)对应的可视角度和椎管底壁暴露宽度,随着撑开宽度增大而增大,3组间的差异均有统计学意义(P<0.05~0.001);椎管骨性结构发生骨折的椎板撑开宽度为12.34~16.82 mm,平均(14.56±1.73)mm,以椎弓根骨折发生比率最高。典型病例表现为"腰痛伴右臀部疼痛半年余",病理诊断腰椎神经鞘瘤,经行该术式入路肿瘤切除手术后,症状得到缓解,预后良好,无腰椎畸形、行动障碍等并发症发生;复查CT示术区椎板骨缝逐趋于愈合。结论采用腰椎经棘突后正中椎管切开复位术实施腰椎椎管内手术,具有一定可行性和有效性。椎板撑开宽度10~12 mm是手术相对安全有效的工作距离;导致骨折的撑开宽度为12.34~16.82 mm,其可作为该术式安全性的参考值。

Objective To investigate the efficacy and safety of posterior median spinal canal open reduction through spinous process in lumbar spinal canal surgery.Methods The simulated operation was performed on 9 freshly frozen adult cadaver specimens at different spreading widths(8,10,12 mm),and the relevant data were recorded.After the operation,the relevant anatomical parameters were measured.At the same time,a typical case of lumbar spinal canal tumor resection was reported.Results Laminectomy and suture of spinal dura and exploration of cauda equina could be performed in 10 mm and 12 mm groups,and the operation freedom of 12 mm groups were higher than that of 10 mm groups.In the experiment of lamina distraction,the visual angle and the exposure width of vertebral canal bottom wall corresponding to different distraction widths(8,10,12 mm)increased with the increase of distraction width,and the differences among the three groups were statistically significant(P<0.05-0.001).The width of vertebral lamina was 12.34-16.82 mm,with an average of(14.56±1.73)mm.Among them,the incidence of pedicle fracture was the highest.The typical case was"lumbago with right hip pain for more than half a year".The pathological diagnosis of lumbar schwannoma was made.After the operation,the symptoms were relieved and the prognosis was good.There was no lumbar deformity,movement disorder and other complications.Reexamination of CT showed that the lamina sutures tended to heal gradually.Conclusions It is feasible and effective to use open reduction of posterior median spinal canal through spinous process for intraspinal surgery.The width of vertebral lamina distraction is 10-12 mm,which is a relatively safe and effective working distance.The distraction width of fracture is 12.34-16.82 mm,which can be used as a reference value for the safety of this operation.