腰椎滑脱对椎体节段血管及OLIF手术通道安全区的影响

The effect of lumbar spondylolisthesis on lumbar segmental vessels and the safety zone of OLIF approach

目的通过MRI研究Ⅰ~Ⅱ度腰椎滑脱对腰椎左侧节段血管及OLIF手术通道安全区的影响。方法回顾2019年10月~2022年11月收治的221例符合选择标准的腰腿痛患者腰椎MRI资料,将椎间隙高度无明显塌陷且椎体间无移位的腰椎间盘突出、椎间盘源性腰痛、退行性腰椎管狭窄症患者归为对照组(n=107),Ⅰ~Ⅱ度腰椎滑脱的患者归为观察组(n=114)。测量并比较左侧椎体侧方节段血管发出角度、血管走行角度、血管长度、椎体不同Moro区域节段血管间距及其与相邻椎间盘边缘的距离,分析血管间面积和22 mm模拟通道内出现血管比例的差异。结果①与对照组相比,观察组L_(4)血管发出角度、L_(1)/L_(3)/L_(4)/L_(5)血管走行角度、L_(2)/L_(4)血管长度均减小;在Ⅱ~Ⅲ、Ⅲ~Ⅳ区交界,L_(1,2)、L_(3,4)节段血管间距减小,二者血管间面积也相应减小。②两组L_(4,5)椎体节段血管间距在Ⅲ~Ⅳ区交界均<22 mm,除L_(3~5)在I~Ⅱ区交界节段血管尾侧与同序列椎体下缘的距离>10 mm外,两组患者其它部位节段血管与同序列椎体上/下缘的距离均<10 mm。节段血管与同序列椎体下缘距离:观察组L_(1) Ⅱ~Ⅳ区交界的距离减小,L_(4) Ⅱ~Ⅳ区交界的距离增大;节段血管与同序列椎体上缘距离:观察组L_(2) I~Ⅱ区交界、L_(2)~5 Ⅱ~Ⅲ区交界、L_(2)/L_(4) Ⅲ~Ⅳ区交界的距离减小。③观察组模拟通道内发现血管的比例大于对照组,其中以L_(4,5) I区、Ⅱ区发现L_(5)节段血管的差异最显著。结论I~Ⅱ度腰椎滑脱影响腰椎左侧节段血管的走形,缩小L_(1,2)、L_(3,4)节段血管间距,缩小Ⅱ~Ⅲ区交界L_(2)~L_(5)节段血管至同序列椎体上缘的距离,增加了OLIF通道建立的难度和风险。尤其是在L_(4,5)间隙进行操作时,需避免在距椎间盘边缘10 mm的椎体及Ⅲ~Ⅳ区交界放置OLIF扩张通道,可适当将通道向Ⅱ区头侧调整,密切注意L_(5)节段血管在I区、Ⅱ区的走形分布以避免损伤。

Objective To study the effects ofⅠ~Ⅱdegree lumbar spondylolisthesis on the left lumbar segmental vessels and the safety zone of OLIF surgical access by MRI.Methods The MRI data of lumbar spine of 221 patients with low back and leg pain who met the selection criteria from October 2019 to November 2022 were retrospectively analyzed,and patients with lumbar disc herniation,discogenic low back pain,and degenerative lumbar spinal stenosis without significant collapse of the intervertebral space height and without intervertebral displacement were divided into the control groups(n=107).Patients with I~Ⅱ degree lumbar spondylolisthesis were divided into the observation group(n=114).The angles of vascular emanation from the lateral segments of the left vertebral,the angles of vascular travel,the length of the vessels,the spacing of the vessels in the segments of different Moro regions of the vertebral and their distance from the adjacent disc edges were measured and compared between the two groups.The differences in the area between segmental vessels and the proportion of vessels present in the simulated channels were also analyzed.Results①Compared with the control group,the angle of L_(4) vessel emanation,the angle of L_(1)/L_(3)/L_(4)/L_(5) vessel travel,and the length of L_(2)/L_(4) vessels were reduced in the observation group,and the distance between the vessels of L_(1,2)and L_(3,4)segments was decreased at the junction of Ⅱ-Ⅲ and Ⅲ-Ⅳ zones,and the intervascular area was reduced accordingly.②The area between the L_(4,5) vertebral segmental vessels was<22mm at the junction of the Ⅲ-Ⅳ region in both groups.The distance between the segmental vessels and the edge of the same sequence of vertebral bodies is<10 mm in the two groups,except the distance between the L_(3)-5 vessels with the same sequence of lower edge in the I-Ⅱ region.In addition,the results of the same sequence of vertebral artery distances from the lower edge of the vertebral suggested that the distances at the junction of L_(1) Ⅱ-Ⅳ zones decreased,but the distances at the junction of L_(4) Ⅱ-Ⅳ zones increased,while the results of the same sequence of vertebral vein distances from the upper edge of the vertebral suggested that the distances at the junction of L_(2) I-Ⅱ zones,L_(2-5) Ⅱ-Ⅲ zones,and L_(2)/L_(4) Ⅲ-Ⅳ zones decreased.③The proportion of lumbar segmental vessels in the simulated channels was greater in the observation group than in the control group,with the most significant differences found in the L_(5) vessels in zones I and Ⅱ.ConclusionsⅠ~Ⅱdegree lumbar spondylolisthesis affect the travel of the left lumbar segmental vessels,reduce the distance between segmental vessels in L_(1,2)and L_(3,4),narrow the distance from the L_(2)-5 segmental vessels at the junction of zones Ⅱ-Ⅲ to the upper edge of the vertebral in the same sequence,increase the difficulty and risk of OLIF channel establishment.In particular,when operating in the L_(4,5) interval,it is necessary to avoid placing OLIF expansion channels at 10 mm from the disc edge and at the junction of zone Ⅲ-Ⅳ.The channels can be adjusted to the cephalic side of zone Ⅱ as appropriate,and close attention should be paid to the alignment and distribution of the vessels of the L_(5) segment in zones I and Ⅱ to avoid injury.