本文關(guān)鍵詞：腰骶叢損傷的應(yīng)用解剖學(xué)研究　出處：《南方醫(yī)科大學(xué)》2008年博士論文　論文類型：學(xué)位論文

  更多相關(guān)文章： LSP 血供 放射顯影 神經(jīng)損傷 磁共振神經(jīng)成像術(shù) 手術(shù)入路

【摘要】： 研究背景和目的: 腰骶叢(Lumbosacral plexus,LSP)損傷是一種神經(jīng)受外界因素侵襲而損傷的疾病,隨著診治水平的提高,患者對神經(jīng)損傷后的功能恢復(fù)提出了更高的要求。LPS損傷的病因多為高速交通事故、高處墜落、塌方等導(dǎo)致骨盆骨折、骨盆環(huán)破裂時造成的。正常時LSP在骨盆內(nèi)的活動度極小,LSP損傷的機(jī)制常為骨盆后環(huán)骨折移位或合并關(guān)節(jié)脫位所造成的牽拉致傷,少數(shù)為壓迫性損傷。 外傷、機(jī)械壓迫、化學(xué)刺激等多種原因損傷后缺血導(dǎo)致神經(jīng)內(nèi)部組織學(xué)的變化是神經(jīng)功能難于恢復(fù)的主要原因,它造成神經(jīng)根的正常傳導(dǎo)功能障礙。國外學(xué)者通過動物及人的解剖學(xué)、組織學(xué)以及血液動力學(xué)方面的觀察,對造成神經(jīng)根的正常功能傳導(dǎo)障礙的原因進(jìn)行了研究,但對LSP血供方面的研究還不完善。 LSP損傷后外科修復(fù)的臨床效果受諸多因素影響,其中神經(jīng)的血液供應(yīng)就起著非常重要的作用。在神經(jīng)缺損修復(fù)時,帶血管的神經(jīng)移植體(vascularized nervegrafting VNG)較常規(guī)的無血管神經(jīng)移植具有理論上的優(yōu)越性。對周圍神經(jīng)血供的研究已有200多年的歷史,早在十八世紀(jì)六十年代,Isenflamm和Doerffler首次用灌注方法對周圍神經(jīng)的供給血管進(jìn)行了研究,之后的學(xué)者對周圍神經(jīng)的血供的研究因得不到臨床應(yīng)用而一直停留在基礎(chǔ)理論研究階段。自Taylor 1976年成功地進(jìn)行了帶血管蒂的神經(jīng)移植以后,人們對神經(jīng)血供的研究由單純的基礎(chǔ)研究轉(zhuǎn)向了臨床應(yīng)用的研究,同時研究方法也有了改進(jìn)。2003年Suami、Sidney、2006年Hong、彭田紅等分別利用放射血管顯影技術(shù)對下肢神經(jīng)、臂叢和上肢神經(jīng)的血管體進(jìn)行了研究。Suami等下肢血管體區(qū)域的研究,采用血管放射顯影技術(shù),著重對下肢主要神經(jīng)的營養(yǎng)血管分布范圍進(jìn)行討論,但還缺乏對LSP血供的系統(tǒng)研究資料,LSP及其血供的分布特征也未能從放射顯影上得到證明。 為此,本課題第一部分對LSP進(jìn)行解剖學(xué)觀測,采用血管顯微解剖技術(shù)與明膠-氧化鉛放射微血管顯影技術(shù)對LSP神經(jīng)的血液供應(yīng)進(jìn)行研究,提供腰骶(Lumborsacral,LS)神經(jīng)根出椎間孔周圍的解剖關(guān)系,神經(jīng)根在椎管內(nèi)的走行角度,LS神經(jīng)根的解剖學(xué)數(shù)據(jù),明確了LSP的血供,神經(jīng)與血管的位置和解剖結(jié)構(gòu)關(guān)系特點(diǎn)以及節(jié)段血管的供血區(qū)域,為LSP損傷的修復(fù)手術(shù)提供解剖學(xué)依據(jù)。 微創(chuàng)診療技術(shù)的不斷提高以及影像技術(shù)的迅猛發(fā)展,對血管和神經(jīng)的可視化研究已成為臨床診斷不可或缺的證據(jù)�，F(xiàn)階段臨床常規(guī)應(yīng)用的CT、超聲、MRI等影像檢查方法還不足以清晰顯示LSP結(jié)構(gòu),影響LSP損傷診斷的準(zhǔn)確性。1992年Howe等嘗試應(yīng)用磁共振(magnetic resonance,MR)技術(shù)結(jié)合脂肪抑制,顯示家兔前肢的神經(jīng)橫截面圖像,為周圍神經(jīng)成像提供了一個新的可行的方法,但由于MR軟硬件的限制,顯示神經(jīng)的分辨率不高,偽影明顯,臨床應(yīng)用受到限制。近年由于磁共振技術(shù)的快速發(fā)展,提高了圖像的時間和空間分辨率,壓脂技術(shù)更完善,使磁共振神經(jīng)成像術(shù)(magnetic resonance neurography,MRN)成為一種臨床實(shí)用新技術(shù)。 為此,本課題第二部分使用MRN技術(shù)對LSP進(jìn)行成像,完整顯示了在體LSPMR影像,并使其三維成像。為臨床LSP損傷的診斷提供影像學(xué)資料,為LSP損傷的手術(shù)治療提供影像學(xué)依據(jù)。 許多學(xué)者在不斷提高診療技術(shù)的基礎(chǔ)上,還致力于探索不同的手術(shù)方法以恢復(fù)患者運(yùn)動功能。Aramburo(1986)報道有關(guān)LSP探查手術(shù)入路,通過腹膜外與腹膜內(nèi)兩種入路可以顯露LSP,常用肌旁側(cè)腹切口,經(jīng)腹膜后分離顯露腰叢(Lumbar plexus,LP);經(jīng)腹切口分離顯露骶叢(Sacral plexus,SP)。Linarte和Gilbert(1986)報道經(jīng)骶骨(SA)入路顯露SP。LSP損傷修復(fù)探查目前的文獻(xiàn)報道不多,而采用合理的手術(shù)入路對損傷的修復(fù)和保護(hù)其周圍的血管和腰大肌等結(jié)構(gòu),維持脊柱的正常結(jié)構(gòu)和功能有重要的意義。臨床上對前路腹膜后(Anterior retroperitoned,ARP)入路的研究更多關(guān)注的是腰椎手術(shù),ARP入路可以通過將大血管牽向內(nèi)側(cè)暴露椎體更充分,或者通過切開更外側(cè)的腰大肌暴露椎體,但切開腰大肌暴露椎體容易損傷位于腰大肌內(nèi)的LP,切開腰大肌對脊柱的功能有影響,而腰椎前路手術(shù)中醫(yī)源性LSP的損傷目前也有報道,主要發(fā)生在暴露和器械植入的過程中。為了在手術(shù)中更好地修復(fù)受損傷的LSP,恢復(fù)其功能,減少手術(shù)帶來的二次創(chuàng)傷及保護(hù)脊柱功能,本課題在第三部分選用新鮮尸體標(biāo)本,結(jié)合上述形態(tài)學(xué)和影像學(xué)研究結(jié)果,探討LS部ARP手術(shù)入路的解剖結(jié)構(gòu)特點(diǎn),以期為臨床LSP修復(fù)手術(shù)的開展提供形態(tài)學(xué)基礎(chǔ)。 方法: 1.(1)15例紅色乳膠灌注防腐成人標(biāo)本的脊柱T9以下標(biāo)本,肉眼和手術(shù)顯微鏡觀察LSP根部椎管內(nèi)、外的形態(tài)特點(diǎn)及其與椎管、硬脊膜和脊髓等周圍組織的關(guān)系,(2)肉眼和手術(shù)顯微鏡下觀察,LSP及前、后根(Posterior root,PR)的血供來源,以及前、后根營養(yǎng)動脈與脊髓前、后動脈的關(guān)系。(3)3具新鮮成人標(biāo)本,經(jīng)腹主動脈灌注3%明膠-氧化鉛混懸液行動脈造影,解剖分離LSP及營養(yǎng)血管和來源血管,去除脊椎后對灌注的血管和LSP進(jìn)行X線攝片觀察。(4)實(shí)驗(yàn)過程使用佳能A650數(shù)碼相機(jī)全程拍照,使用Photoshop軟件對圖片進(jìn)行處理,利用南方醫(yī)院影像中心PACS系統(tǒng)將X線片導(dǎo)入個人電腦,進(jìn)行圖像處理,可得到清晰的便于觀察LSP的血供的動脈造影圖片。 2.健康自愿者3例,GE公司3.0T HD signa超導(dǎo)磁共振成像(Magneticresonance,MR)系統(tǒng),脊柱表面線圈(CTL456)。常規(guī)行矢狀面T1WI,橫斷面T2WI成像,參數(shù)::FRFSE序列T2WI脂肪抑制,TR/TE/NEX:4000/85/2,矩陣:352×256,層厚/層間距:1.0/0mm,層數(shù)40～44,掃描時間:4min17s。原始圖像以Dicom格式導(dǎo)入GE公司AW4.3圖像工作站,完成最大密度投影(MIP)、多層面容積重組(MPVR)、容積再現(xiàn)(VR)圖像重建。 3.新鮮標(biāo)本3具,采用腋前線開口,左側(cè)入路,進(jìn)入腹膜后腔,腰大肌后外側(cè)剝離,分離顯露LP,結(jié)合LSP及營養(yǎng)血管的解剖結(jié)構(gòu),行模擬ARP神經(jīng)修復(fù)、探查手術(shù),觀察腰大肌與LSP神經(jīng)、血管之間的位置關(guān)系。 結(jié)果: 1.(1)LSP根部的顯微外科解剖:LSP前、PR依次由神經(jīng)小束-神經(jīng)亞束-神經(jīng)束組成,神經(jīng)小束自相應(yīng)的LS部脊髓節(jié)段的前外側(cè)溝和后外側(cè)溝平行排列發(fā)出或進(jìn)入,斜向外下方走行,從上至下前根(Anerior root,AR)其始處與脊髓中線的距離先大后小,L1最大2.21±0.49mm,向下逐漸減小;AR與脊髓縱軸的夾角逐漸變小,L1最大為25.07°±5.37;前、后根在椎管內(nèi)走行的長度逐漸增大,L1為66.74±10.77mm、65.61±9.87mm,增大到L5的129.99±16.27mm、137.64±11.37mm;前、后根直徑最粗的為L5的1.70±0.36mm、1.75±0.56mm,相應(yīng)的PR比AR粗;腰神經(jīng)(Lumbar nerve,LN)AR分出角大于前支分出角,LS神經(jīng)與硬膜囊的夾角逐漸減小,L1為56.64°±7.67,到S3的7.80°±1.94;前后根神經(jīng)束逐漸形成內(nèi)側(cè)寬、外側(cè)窄的扇形結(jié)構(gòu),其表面根動脈伴隨神經(jīng)根出入硬膜囊。(2)LSP及前、后根的血供:來自第1-4腰動脈(Lumbar artery,LA)、髂腰動脈、臀上動脈、骶外側(cè)動脈,根動脈與脊髓前后動脈以多種方式相吻合。(3)LSP血供的分布:來源于LA系統(tǒng)、骶髂腰動脈系統(tǒng)、臀上動脈、臀下動脈、陰部內(nèi)動脈發(fā)出的節(jié)段性動脈及鄰近肌肉肌支。節(jié)段性動脈除發(fā)支營養(yǎng)椎體、椎弓等外,全部向內(nèi)側(cè)發(fā)支營養(yǎng)LS神經(jīng)節(jié)、LSP,并伴隨神經(jīng)節(jié)向內(nèi)延伸至硬脊膜或穿過硬脊膜、蛛網(wǎng)膜,沿前、后根行走,發(fā)支營養(yǎng)脊神經(jīng)根,并在神經(jīng)束與脊髓前、后動脈相吻合,吻合方式為真性吻合。節(jié)段動脈以“Y”型進(jìn)入神經(jīng)外膜,然后分成升降支,節(jié)段動脈及分支之間互相吻合,吻合方式為真性吻合和閉塞性吻合,以真性吻合為主。LSP神經(jīng)干、股、束的血供除來源于節(jié)段動脈外,還來自鄰近的動脈,包括伴行動脈及其分支、鄰近的肌支。紅色乳膠灌注標(biāo)本和明膠-氧化鉛放射顯影法均清晰顯示了LSP的血供。 2.MRN LSP成像:MRN可以清楚顯示LN椎間孔段(神經(jīng)根)、LN節(jié)段(神經(jīng)節(jié))、LN節(jié)后段、LST(神經(jīng)干)及股神經(jīng)、閉孔神經(jīng)(Obturator nerve,ON)、股外側(cè)皮神經(jīng)(Posterior fmoral crtaneous nerve,PFCN)、髂腹下神經(jīng)(Iliohypogastricnerve,IN)、髂腹股溝神經(jīng)(Ilioinguinal nerve,ILN)(股、束)。神經(jīng)節(jié)信號高于神經(jīng)根和神經(jīng)干,神經(jīng)節(jié)及神經(jīng)干周圍未見高信號灶。股神經(jīng)在腰4、5椎體水平從腰大肌表面移行至髂腰肌表面,形態(tài)由長條形移行為橢圓形的斷面,信號稍高于腰大肌,邊緣較清楚。SP由于走行角度不同不能同時顯示,斜矢狀位成像定位線最好與斜冠狀位所顯示的短條狀神經(jīng)走行方向一致,這樣可增加S1及鄰近坐骨神經(jīng)(Sciatic nerve,SN)的顯示機(jī)會,利用多平面重建技術(shù),可以對采集的原始數(shù)據(jù)任意方向重建,明顯提高神經(jīng)的顯示率。 3.模擬LSP損傷修復(fù)ARP手術(shù)入路:采用左側(cè)前路腋前線切口,暴露L1～L3LN,能達(dá)到良好的暴露和直視下操作的目的。LP在不同斷面中,LP神經(jīng)位于腰大肌深面或肌質(zhì)內(nèi),腰椎橫突的前方,此處為腰大肌間隙,LP在腰椎側(cè)方的組成具有一定的規(guī)律性,LA在腰大肌內(nèi)的走行沒有特定的肌間隙。 結(jié)論: 1.LSP血供來自于第1～4LA、骶髂腰動脈系統(tǒng)、臀上動脈、臀下動脈、陰部內(nèi)動脈及鄰近肌肉的肌支。營養(yǎng)動脈之間在神經(jīng)內(nèi)的真性吻合在病理狀態(tài)下可提供側(cè)支循環(huán),血管區(qū)域之間的血供可以互相代償。熟悉LSP根部的顯微解剖有助于LSP損傷的診治。 2.乳膠灌注法適合神經(jīng)外部血供的觀察,血管造影法適合神經(jīng)血管分布的整體觀察,乳膠灌注法和血管造影法的結(jié)合觀察研究,可以清晰顯示LSP神經(jīng)血管的分布及神經(jīng)與血管的關(guān)系。 3.MRN技術(shù)全面完成了LSP的成像,因其無創(chuàng)性,應(yīng)該為臨床進(jìn)行LSP損傷檢查首選的影像學(xué)手段。 4.LSP損傷的修復(fù)和探查手術(shù)前路入路更加適合,ARP入路可以作為不損傷LS功能前提下的LP損傷修復(fù)的手術(shù)入路,腰大肌的前外側(cè)是腰大肌切開的安全區(qū)。入路直接、簡捷,暴露清楚,可直視下處理神經(jīng)根和突出椎間盤;創(chuàng)傷小,出血少,從肌間隙進(jìn)入,不破壞神經(jīng)和肌肉的正常結(jié)構(gòu),不切除脊柱骨性部分和韌帶,不影響脊柱穩(wěn)定性。
[Abstract]:Research background and purpose:
The lumbosacral plexus (Lumbosacral plexus LSP) is a kind of nerve injury by external factors of invasion and injury of the disease, with the improvement of diagnosis and treatment, patients put forward higher requirements cause.LPS damage for the high-speed traffic accident, falling on the nerve functional recovery after injury, leading to collapse caused by pelvic fracture, pelvis ring the rupture. The normal LSP in the pelvis of the activity of the minimal LSP injury mechanism for regular pelvic posterior ring fractures with displacement or dislocation caused by traction injury, injury for the oppression of minorities.
Mechanical compression damage, trauma, chemical stimulation and other reasons after the ischemia induced changes of nerve internal organization is the main reason for restoration of nerve function, it causes the normal conduction of nerve root dysfunction. Foreign scholars through animal and human anatomy, histology and hemodynamics the observation, reasons for the obstacles caused by nerve root conduction function the studied, but the LSP blood for the study is not perfect.
The clinical effect of surgical repair after injury of LSP is influenced by many factors, including nerve blood supply plays a very important role in the repair of nerve defects, vascularized nerve graft (vascularized nervegrafting VNG) without vascular nerve graft is superior than the conventional theory. To study the blood supply of peripheral nerve the more than 200 years of history, as early as 1760s, Isenflamm and Doerffler for the first time on the blood supply of peripheral nerve was studied by perfusion method, research scholars on peripheral nerve blood supply due to lack of clinical application and has been stuck in the stage of basic theory research. Since Taylor 1976 successfully carried out nerve transplantation vascularized nerve blood supply, people studied by purely on the basis of the clinical application to the study, and research methods have improved.2003 S Uami, Sidney, Hong in 2006, Peng Tianhong respectively using radiation angiography technology on lower extremity nerve, vascular plexus and upper limb nerve were studied on.Suami lower extremity vascular area, using vascular radiography technology. Focused mainly on the lower extremities of the nutrient vessels to discuss the scope of distribution, but also the lack of system research the LSP of the blood supply and distribution characteristics of LSP and its blood supply was not proved by autoradiography.
Therefore, the subject of the first part of the LSP were observed by microscope, vascular anatomy study and technology of gelatin lead oxide radiation imaging microvascular blood supply to the LSP nerve, with lumbosacral nerve root (Lumborsacral, LS) from the anatomical relationship between the intervertebral foramen and nerve roots in the spinal canal running angle, anatomy the data of the LS nerve root, the LSP blood supply, blood vessels and nerves and anatomical characteristics and the relationship between the position of the segmental vessels blood supply area, to provide anatomic basis for surgical repair of LSP damage.
The rapid development and constantly improve the minimally invasive technique and imaging technology, visualization of the blood vessels and nerve clinical diagnosis has become an integral part of the evidence. The clinical application of conventional CT, ultrasound, MRI imaging method is not enough to clearly show LSP structure, the influence of LSP damage diagnosis accuracy of.1992 Howe application magnetic resonance (magnetic resonance MR) combined with fat suppression showed nerve cross-sectional images of rabbit forelimb, provides a new feasible method for peripheral nerve imaging, but due to the MR software and hardware limits, display nerve resolution artifacts, the clinical application is limited due to the rapid in recent years. The development of MRI technology, increase the time and the spatial resolution of the image, the grease pressing technology is more perfect, the magnetic resonance neurography (magnetic resonance, neurography, MRN) be a pro New bed technology.
To this end, the second part of the project is using MRN technology to imaging LSP, displaying LSPMR images in vivo and making three-dimensional imaging, providing imaging data for the diagnosis of LSP injury, and providing imaging evidence for surgical treatment of LSP injury.
Many scholars continue to improve in the foundation treatment technology, is also committed to exploring different ways to restore the operation of motor function in patients with.Aramburo (1986) reported on the LSP exploration approach, through the extraperitoneal and intraperitoneal two approaches can reveal LSP, commonly used muscle side abdominal incision, retroperitoneal dissection of lumbar plexus (Lumbar plexus, LP); revealed the sacral plexus by abdominal incision separation (Sacral plexus, SP.Linarte) and Gilbert (1986) reported by the sacrum (SA) approach to expose more SP.LSP damage repair exploration reported in the literature, and a reasonable surgical approach to repair the damage and protect the surrounding vessels and the psoas muscle structure, has important significance to maintain the normal structure and function of the spine. In clinical anterior retroperitoneal (Anterior Retroperitoned ARP) approach is more concerned on lumbar surgery, ARP approach to the great vessels pull inwards The vertebral side is exposed more fully, or through the incision of the psoas muscle more lateral vertebral body exposed, but cut the psoas muscle is easy to damage in the psoas muscles of the LP vertebral body exposed, open function of psoas muscle on the spine have influence, and anterior lumbar surgery iatrogenic LSP injury has also reported, mainly in the process of exposure and the implantation of the device. In order to better surgery to repair the damage LSP, to restore its function, reduce the operation brought two times of trauma and protection of spinal function, the choice of topics in the third part of fresh specimens, the study results with the morphology and image, to explore the anatomic characteristics of LS ARP operation the approach, in order to provide morphological basis for clinical LSP repair surgery.
Method:
1. (1) of 15 cases of red latex perfusion preservation of adult specimens following spinal T9 specimens, and the naked eye surgery microscope LSP root canal morphology, characteristics and relationship of tissue around the spinal canal, spinal dura mater and spinal cord, (2) observed by naked eye and microscope, and LSP before and after root (Posterior root, PR) of the blood supply and nutrition, before artery and dorsal root, after artery. (3) 3 fresh adult cadaveric specimens, the abdominal aorta perfusion 3% lead oxide gelatin suspension for artery angiography, dissecting LSP and nutrient vessels and vascular sources, X-ray observation the perfusion of blood vessels and LSP were removed after spinal. (4) experimental process using the Canon A650 digital camera to take pictures, use Photoshop software to process the images, using PACS imaging system center of Nanfang Hospital will be X-ray film into personal computer, image processing, can get clear An arteriography picture that facilitates observation of the blood supply of LSP.
3 cases of 2. healthy volunteers, GE company 3.0T HD signa superconducting magnetic resonance imaging (Magneticresonance, MR) system, the spine surface coil (CTL456). Routine sagittal T1WI, axial T2WI imaging parameters: FRFSE T2WI sequence with fat suppression, TR/TE/NEX:4000/85/2, matrix: 352 x 256, thickness: 1.0/0mm number 40, to 44, the scan time: 4min17s. original image in Dicom format into GE AW4.3 workstation, complete the maximum intensity projection (MIP), multi planar volume rendering (MPVR), volume rendering (VR) image reconstruction.
3., 3 fresh specimens were made by using the axillary front opening, the left approach, the retroperitoneal cavity, the posterolateral psoas muscle stripped, the LP exposed and exposed, and the anatomical structure of LSP and the nutrient vessels. The ARP nerve repair was performed to explore the location relationship between psoas major and LSP nerves and vessels.
Result:
1.(1)LSP鏍歸儴鐨勬樉寰縐戣В鍓，

本文編號：1400354