斜外侧腰椎椎间融合手术入路的解剖学基础及其临床意义

Anatomical basis and clinical significance of the oblique lateral interbody fusion surgical approach

目的:探讨国人左侧第2腰椎至第1骶椎(L2~S1)水平斜外侧腰椎椎间融合术手术通道的解剖学特点,为临床手术提供解剖学理论依据。方法:对成人标本的左侧腹膜后间隙进行逐层解剖,探查进入L2~S1水平斜外侧腰椎椎间融合手术通道的解剖学特点,测量其通道直径并记录相关数据,对通道及其毗邻结构拍照记录和定量描述。结果:自然状态下L2~L3、L3~L4、L4~L5水平的通道直径分别为(12.07±7.74)mm、(15.34±5.70)mm、(13.49±4.90)mm,差异无统计学意义。L5~S1横径和纵径分别为(14.86±8.30)mm、(20.48±7.17)mm,两者之间比较差异有统计学意义。牵拉腰大肌状态下L2~L3、L3~L4、L4~L5水平的通道直径分别为(15.26±8.18)mm、(20.13±5.18)mm、(18.75±5.87)mm,差异无统计学意义。在L2~L3、L3~L4、L4~L5水平,自然和牵拉腰大肌2种状态下的通道直径大小之间比较,差异均有统计学意义。横向牵拉腰大肌将显著扩大各个椎体水平手术通道,L2~L3、L3~L4、L4~L5水平通道扩张度分别为25.10%、25.81%、28.47%。在L2~L5水平上,最常见的是交感干,生殖股神经在L3水平穿过腰大肌前筋膜向下延伸,在腹膜后脂肪中能观察到输尿管。结论:左侧腰大肌与血管之间的通道直径大小可以满足斜外侧腰椎椎间融合手术的需要,适度牵拉腰大肌可扩大手术通道直径,进一步了解手术通道周围的解剖结构,对手术安全性的提高有较大帮助。

Objective:To explore the anatomic features of the corridor for left oblique lateral interbody fusion(OLIF)at L2-S1 in Chinese population,and to provide anatomic evidences for surgical procedures of OLIF.Methods:A total of 12 adult cadaveric specimens were used to explore anatomic features of the horizontal corridor at L2-S1 through exposing the left retroperitoneal space layer by layer.For each cadaver placed in the static and the mild psoas retraction position,the diameter close to the disc and anatomic parameters of OLIF corridor were recorded.In addition,the corridor and adjacent structures were captured for quantitative analysis.Results:The channel diameters at L2-L3,L3-L4,and L4-L5 levels in the natural state were(12.07±7.74)mm,(15.34±5.70)mm,and(13.49±4.90)mm,respectively,which were comparable without any significant differences.The diameters at L2-L3,L3-L4,and L4-L5 levels in the stage of psoas major traction were(15.26±8.18)mm,(20.13±5.18)mm,and(18.75±5.87)mm,respectively,which were comparable without any significant differences.Transverse and longitudinal diameters were(14.86±8.30)mm,and(20.48±7.17)mm at L5-S1 level,respectively,which were statistically significant.Notably,there were significant differences in the channel diameter at L2-L3,L3-L4 and L4-L5 level either in the natural state or the state of psoas major traction.A lateral traction of the psoas major significantly expanded the channel between the psoas major and blood vessels at each vertebral level,with the horizontal channel expansion rate at 25.10%,25.81%and 28.47%in L2-L3,L3-L4 and L4-L5 respectively.The sympathetic chain at the L2-5 level was the most commonly expanded region.The genitofemoral nerve extended downward through the psoas major anterior fascia at L3 level and the ureter could be observed in retroperitoneal fat.Conclusion:The diameter of the left corridor is sufficient for performing OLIF,which can be enlarged through traction of the proper psoas major.An in-depth understanding of anatomic structures of OLIF corridor contributes to improve the surgical accuracy.