经臀后侧入路行髂骨截骨扩大坐骨大孔显露骶丛神经的临床应用

Clinical application of enlarging greater ischiatic notch by ilium osteotomy to expose the sacral plexus via the gluteal approach

目的探讨经臀后侧入路行髂骨截骨扩大坐骨大切迹显露盆腔内上骶丛神经及骶丛神经汇合处的可行性。方法回顾性分析2016年7月至2020年11月于北京积水潭医院手外科行经臀部后侧入路骶丛神经损伤手术探查或肿瘤切除的10例患者的临床资料。男性4例,女性6例,年龄(38.0±9.3)岁(范围:26~56岁)。骶丛损伤8例,其中全骶丛损伤4例,上骶丛损伤1例,骶丛神经汇合损伤3例;骶丛神经肿瘤2例。神经损伤或发现肿瘤到手术时间平均10.4个月(范围:1.5~60.0个月)。术中均经臀部后侧入路将坐骨大切迹上方的髂骨进行截骨以扩大坐骨大孔,通过此截骨窗口显露盆腔内损伤的上骶丛或上骶丛神经肿瘤,并进行神经修复或肿瘤切除。记录患者术中情况、术后并发症及切口和截骨的愈合情况。结果10例患者均顺利经臀部入路行髂骨截骨扩大坐骨大孔,显露上骶丛神经,完成盆腔内上骶丛神经及骶丛神经汇合处损伤的手术探查、神经修复或骶丛肿瘤切除。髂骨截骨块长(2.9±0.4)cm(范围:2.5~3.8 cm),宽(2.5±0.5)cm(范围:1.5~3.4 cm)。术中出血量[M(QR)]800(800)ml(范围:400~2000 ml)。术中无大血管损伤,术后无血肿形成,切口均一期愈合。术后随访29.8个月(范围:1.5~54.0个月),9例患者回植髂骨截骨块已愈合,1例术后随访时间1.5个月,尚未完全愈合。结论经臀后侧入路行髂骨截骨扩大坐骨大切迹,可暴露骨盆内上骶丛神经远段和骶丛神经汇合处,并有足够空间行上骶丛神经的探查、肿瘤切除及神经移植修复术。

Objectives To observe the possibility of enlarging the greater sciatic notch by illium osteotomy through the posterior gluteal approach for reaching the intrapelvic upper sacral plexus as well as the covergence level of sacral plexus,and performing the nerve graft for surgical repairing the sacral plexus ruptured injuries or sacral plexus nerve tumor resection.Methods The clinical data of 10 patients with sacral plexus injury or sacral plexus nerve tumor underwent the surgical operation via the expanded greater sciatic notch at Department of Hand Surgery,Beijing Jishuitan Hospital from July 2016 to November 2020 were retrospectively analyzed.There were 4 male and 6 female patients,with an age of(38.0±9.3)years(range:26 to 56 years).There were 8 cases with sacral plexus injury at the intrapelvic or covergence level(deep to the piriformis).Out of this 8 cases,4 cases with intrapelvic pan-sacral plexus injury,1 case with upper sacral plexus injury and 3 cases with convergence level pan sacral plexus injury.Another 2 cases were sacral plexus neoplasm.The average time from injury or onset to operation was 10.4 months(range:1.5 to 60.0 months).All cases were performed surgery for reaching the intrapelvic upper sacral plexus as well as the covergence level of sacral plexus with enlarging the greater sciatic notch by illium osteotomy through the posterior gluteal approach.Intraoperation the sacral plexus ruptured injurie was repaired and the sacral plexus nerve tumor was resected.Intraoperative findings,postoperative complications and healing of incision and osteotomy of patients were recorded.Results All the 10 patients underwent the sacral plexus surgical exploration and cutaneous nerve graft for sacral plexus nerve repairing or neurolysis or neoplasm resection through the posterior gluteal approach successfully.The length and width of illium osteotomy mass were(2.9±0.4)cm(range:2.5 to 3.8 cm)and(2.5±0.5)cm(range:1.5 to 3.4 cm)respectively.The median intraoperative bleeding volume was(M(QR))800(800)ml(range:400 to 2000 ml).There were no complication with major vascular injury and hematoma formation,and all incisions healed.The postoperative follow-up was 29.8 months(range:1.5 to 54.0 months).Nine cases of iliac osteotomy were healed,and 1 case was not healed because the follow-up was only 1.5 months.Conclusions The intrapelvic upper sacral plexus and the convergence level of sacral plexus deep to the piriformis can be exposed clearly through this posterior gluteal approach via illium osteotomy for enlarging the greater sciatic notch,and there was enough operative space that surgical exploration and nerve graft or nerve transfer or neoplasm resection can be performed.