CT血管成像在下腰椎前髂血管解剖研究中的应用

Application of CT angiography in anatomical study of anterior iliac vessels in the lower lumbar spine

目的应用CT血管成像探究下腰椎前方髂血管分布,为下腰椎前方入路手术提供血管解剖学参考。方法选取贵州省人民医院2016年6月至2018年11月间行腹部CT血管成像男、女性患者影像资料各100例,进行观察、测量研究;(1)观察记录腹主动脉分叉点及髂总静脉汇合点位置分布;(2)测量左髂总静脉与右髂总动脉夹角顶点到L_(5)~S_(1)椎间隙上缘距离,左髂总静脉与右髂总动脉内侧缘之间位于L_(5)~S_(1)椎间隙上缘、下缘的距离。结果(1)腹主动脉分叉点平L_(4)椎体男性占64%、女性占68%。髂总静脉汇合点平L4椎体男性占42%、女性占46%,平L_(4-5)椎间隙男性占40%、女性36%。(2)腹主动脉分叉角男性:(51.45±9.21)°,女性:(50.51±7.92)°;髂总静脉汇合角男性:(58.82±11.81)°,女性:(61.88±11.97)°;左髂总静脉与右髂总动脉夹角男性:(64.81±11.77)°,女性:(67.21±11.58)°。(3)髂总静脉汇合点平L4椎体、L_(4~5)椎间隙、L_(5)椎体时:(1)左髂总静脉与右髂总动脉夹角顶点到L_(5)~S_(1)椎间隙上缘距离分别为:(26.51±8.11)mm、(16.18±6.70)mm、(7.82±4.26)mm;(2)左髂总静脉、右髂总动脉内侧缘于L_(5)~S_(1)椎间隙上缘的距离分别为:(32.52±9.95)mm、(28.63±11.48)mm、(16.27±7.71)mm;(3)左髂总静脉与右髂总动脉内侧缘于L_(5)~S_(1)椎间隙下缘的距离分别为:(43.88±9.86)mm、(41.55±11.05)mm、(33.17±9.40)mm。(4)“髂血管三角”面积分别为:(486.32±246.26)mm^(2)、(263.94±178.47)mm^(2)、(85.49±71.45)mm^(2)。(5)L_(5)~S_(1)椎间隙手术窗分别为:(496.98±114.48)mm2、(488.89±127.69)mm_(2)、(344.32±166.63)mm^(2)。结论(1)腹主动脉分叉点、髂总静脉汇合点位置存在明显解剖变化;腹主动脉分叉点多平L_(4)椎体,髂总静脉汇合点多平L_(4)椎体及L_(4~5)椎间隙。(2)髂总静脉汇合点平L_(4)椎体时,此时下腰椎前拥有足够的血管安全区供手术操作;髂总静脉汇合点位平L_(4~5)椎间隙时,此时下腰椎前有一定的血管安全区供手术操作;髂总静脉汇合点平L_(5)椎体时,此时下腰椎前血管安全区无法满足手术操作。(3)髂总静脉汇合点平L_(4)椎体、L_(4~5)椎间隙时,前路L_(5)~S_(1)椎间隙均拥有足够的手术血管安全区,但血管安全区进行性缩小。术前CT血管成像检查明确血管安全区有助手术安全。

Objective To explore the distribution of iliac vessels in the anterior lower lumbar spine using CT angiography,and to provide vascular anatomical references for anterior lower lumbar surgery.Methods Select 100 male and 100 female patients who underwent abdominal CT angiography at Guizhou Provincial People's Hospital from June 2016 to November 2018 for observation and measurement research;(1)Observe and record the distribution of the bifurcation points of the abdominal aorta and the confluence points of the common iliac vein;(2)Measure the distance from the vertex of the angle between the left common iliac vein and the right common iliac artery to the upper edge of the L_(5)-S_(1) intervertebral space,and the distance between the left common iliac vein and the inner edge of the right common iliac artery at the upper and lower edges of the L_(5)-S_(1) intervertebral space.Results(1)64% of the L_(4) vertebral body is flat at the bifurcation point of the abdominal aorta.The confluence point of the common iliac vein accounts for 42% of the L_(4) vertebral body and 40% of the L_(4-5) intervertebral space.(2)Abdominal aortic bifurcation angle:(51.01±9.24)°for males,(50.51±7.92)°for females;The confluence angle of the common iliac vein is(58.82±11.81)°for males and(62.47±12.46)°for females;The angle between the left common iliac vein and the right common iliac artery is(64.92±12.07)°for males and(68.73±13.87)°for females.(3)When the confluence point of the common iliac vein is level with the L_(4) vertebral body,L_(4-5) intervertebral space,and L_(5) vertebral body:①The distance from the vertex of the angle between the left common iliac vein and the right common iliac artery to the upper edge of the L_(5)-S_(1) intervertebral space is(26.51±8.11)mm,(16.18±6.70)mm,and(7.82±4.26)mm,respectively;②The distances between the left common iliac vein and the medial edge of the right common iliac artery from the L_(5)-S_(1) intervertebral space are(32.52±9.95)mm,(28.63±11.48)mm,and(16.27±7.71)mm,respectively The distance between the left common iliac vein and the inner edge of the right common iliac artery at the lower edge of the L_(5)-S_(1)intervertebral space is(43.88±9.86)mm,(41.55±11.05)mm,and(33.17±9.40)mm,respectively.④The area of the“iliac vascular triangle”is(486.32±246.26)mm^(2),(263.94±178.47)mm^(2),and(85.49±71.45)mm^(2),respectively The surgical windows for the L_(5)-S_(1) intervertebral space are(496.98±114.48)mm^(2),(488.89±127.69)mm^(2),and(344.32±166.63)mm^(2),respectively.Conclusion(1)There are significant anatomical changes at the bifurcation point of the abdominal aorta and the confluence point of the common iliac vein;The bifurcation point of the abdominal aorta is mostly flat on the L_(4) vertebral body,and the confluence point of the common iliac vein is mostly flat on the L_(4) vertebral body and the L_(4)-5 intervertebral space.(2)When the confluence point of the common iliac vein is level with the L_(4) vertebral body,there is sufficient vascular safety zone in front of the lower lumbar spine for surgical operation;When the confluence point of the common iliac vein is located in the L_(4-5) intervertebral space,there is a certain vascular safety zone in front of the lower lumbar spine for surgical operation;When the confluence point of the common iliac vein is flat on the L_(5) vertebral body,the safety zone of the anterior blood vessels of the lower lumbar spine cannot meet the surgical requirements at this time.(3)When the confluence point of the common iliac vein is level with the L_(4) vertebral body and the L_(4-5) intervertebral space,there is sufficient surgical vascular safety zone in the anterior L_(5)-S_(1) intervertebral space,but the vascular safety zone is gradually reduced.Preoperative CT angiography examination to clarify the vascular safety zone is helpful for surgical safety.