發(fā)布時(shí)間：2018-07-10 11:10

  本文選題：L5-S1椎間孔 + 椎間孔內(nèi)韌帶��； 參考：《南方醫(yī)科大學(xué)》2017年碩士論文

【摘要】：內(nèi)鏡應(yīng)用于脊柱外科,是脊柱手術(shù)微創(chuàng)化的又一進(jìn)展。從經(jīng)皮內(nèi)窺鏡輔助下腰椎椎間盤切除術(shù),發(fā)展到下腰椎椎間孔鏡置入椎管內(nèi),在直視下經(jīng)硬脊膜前間隙直接取出突出的髓核或松解神經(jīng)根粘連卡壓,已成為一種較為安全有效的微創(chuàng)外科術(shù)式。由于L5-S1椎間孔位于高度活動(dòng)的腰椎和相對(duì)固定的骶椎這一特殊的脊柱結(jié)構(gòu)和功能轉(zhuǎn)變區(qū)域,椎間盤極易突出、韌帶變性或腰椎退行性變,L5神經(jīng)根受壓機(jī)率最大。受髂嵴部分屏蔽和堅(jiān)韌的腰骶韌帶、腰骶弓狀筋膜的覆蓋遮擋等解剖學(xué)因素影響,經(jīng)椎間孔置鏡操作較為困難,且極易損傷神經(jīng)根或硬脊膜。為此有學(xué)者發(fā)明了在X線影像引導(dǎo)下,經(jīng)骶管硬膜外L5-S1椎間孔入口神經(jīng)松解術(shù)式,對(duì)神經(jīng)根機(jī)械松解,取得了一定療效。既往對(duì)L5-S1椎間孔的研究多集中于椎間孔出口區(qū)橫跨型韌帶的分布及與脊神經(jīng)的毗鄰,而L5-S1椎間孔出口區(qū)連接神經(jīng)根到椎間孔周圍骨性結(jié)構(gòu)的放射型韌帶以及入口區(qū)韌帶的分布及與神經(jīng)根的毗鄰關(guān)系很少有人提及。入口區(qū)韌帶的分布特點(diǎn)和與神經(jīng)根間的毗鄰關(guān)系等詳盡的解剖學(xué)資料較少,影像學(xué)特征不了解,無(wú)法在術(shù)前明確這些結(jié)構(gòu)的位置和毗鄰,以致盲目構(gòu)建的工作通道或在識(shí)別不清情況下非直視松解,特別是在“二維空間”狀態(tài)下操作,缺乏器械置入的深度感,有可能造成硬脊膜撕裂或腦脊液漏,或在松解時(shí)造成神經(jīng)根損傷。因此,本研究旨在闡明L5-S1椎間孔韌帶的位置、形態(tài)、分布及其與神經(jīng)根袖的毗鄰關(guān)系,為術(shù)前制定經(jīng)骶管內(nèi)鏡硬膜外L5-S1椎間孔神經(jīng)松解個(gè)性化手術(shù)方案、安全工作通道的構(gòu)建、韌帶和神經(jīng)的辨認(rèn)及精準(zhǔn)內(nèi)鏡下神經(jīng)松解方案的安全實(shí)施提供解剖學(xué)依據(jù)。具體研究概括如下:目的:探討L5-S1椎間孔韌帶的性狀、分布規(guī)律并評(píng)價(jià)其臨床意義。為脊柱外科醫(yī)生提供更為詳實(shí)的解剖學(xué)資料。方法:取30具防腐和15具新鮮冰凍腰骶部標(biāo)本(年齡40到85歲,平均年齡56歲)。動(dòng)脈用紅色乳膠灌注。仔細(xì)剔除脊柱周圍的軟組織,從正中矢狀鋸開脊柱。找出L5-S1神經(jīng)根并沿著椎間孔小心去除周圍脂肪和筋膜等軟組織。在肉眼及手術(shù)顯微鏡下觀察韌帶的形態(tài)、走行、起始位置及分布特點(diǎn),用游標(biāo)卡尺在手術(shù)顯微鏡下測(cè)量其長(zhǎng)度、寬度及直徑或厚度。用HE染色和Masson三色染色法分析對(duì)比不同類型韌帶的組織學(xué)類型。結(jié)果:在90個(gè)L5-S1椎間孔內(nèi)共發(fā)現(xiàn)818條韌帶,其中條帶形350條,條索形468條;連接神經(jīng)根到橫突或椎間孔內(nèi)壁的放射狀韌帶699條(85.45%),另一種是連接椎間孔周圍組織橫跨在椎間孔內(nèi)的橫跨狀韌帶119條(14.55%)。在L5-S1椎間孔入口區(qū)270條(33.01%),中間區(qū)381條(46.58%)及出口區(qū)167條(20.42%)區(qū)域均有分布。韌帶長(zhǎng)度多變,自1.43-19.01mm都有;厚度最厚處達(dá)3.46mm。光鏡下示椎間孔內(nèi)韌帶由大量的膠原纖維和少量的彈性纖維構(gòu)成。放射狀韌帶與橫跨狀韌帶組織學(xué)表現(xiàn)無(wú)明顯差異。結(jié)論:椎間孔內(nèi)韌帶主要分為條帶形和條索形兩種形狀。椎間孔入口區(qū)全部為放射狀韌帶,椎間孔內(nèi)放射狀韌帶比橫跨狀韌帶出現(xiàn)率高。術(shù)前應(yīng)掌握其分布規(guī)律并在術(shù)中辨別并予以正確松解,減少并發(fā)癥的發(fā)生。
[Abstract]:The application of endoscopy to spinal surgery is another progress in the minimally invasive spinal surgery. From percutaneous endoscopic assisted lumbar discectomy, it is developed to the lower lumbar intervertebral endoscopy in the spinal canal. The protruding nucleus or loosening of the nerve root stickout directly under the anterior interspinal interspinal space has become a safer and more effective minimally invasive procedure. Surgical procedures. Because the L5-S1 intervertebral foramen is located in a highly active lumbar and relatively fixed sacral vertebra, the special spinal structure and functional transition area, the intervertebral disc is very easy to protruding, ligamentous denatured or degenerative, and the L5 nerve root is most frequently pressed. The covering of the sacrosacral lumbosacral fascia and the lumbosacral fascia are shielded by the iliac crest and the tenacious lumbosacral ligaments. With the influence of anatomical factors, it is difficult to operate through the intervertebral foramen, and it is easy to damage the nerve root or the dural membrane. For this reason, a scholar invented the method of neurolysis of the L5-S1 intervertebral foramen via the sacral canal and a certain effect on the mechanical loosening of the nerve root under the guidance of X-ray imaging. The previous study of the L5-S1 intervertebral foramen was mostly concentrated on the vertebra. The distribution of transtransverse ligaments in the exportation of the intervertebral foramen and the adjacent to the spinal nerve, and the distribution of radial ligaments and the distribution of the ligaments in the entrance area of the L5-S1 intervertebral foramen exportation and the surrounding ligament of the intervertebral foramen, and the adjacent relationship with the nerve roots are rarely mentioned. The detailed anatomical data is less, the imaging features are not understood, and the location and adjacency of these structures can not be identified before the operation, so that the blind construction of the work passage or the unrecognized condition is not directly visible, especially in the "two-dimensional space" condition, the lack of the depth of the device insertion, the possibility of the tearing of the dura membrane or the brain. The purpose of this study is to elucidate the location, morphology, distribution of the L5-S1 intervertebral foramen ligaments and their adjacent relationship with the nerve root sleeves. The purpose of this study is to establish a personalized operation scheme for the sacral endoscopic epidural L5-S1 foramen neurolysis, the construction of the safe working passage, the identification of the ligaments and nerves and the identification of the ligaments and nerves. An anatomical basis for the safety implementation of the neuro release scheme under precision endoscopy is provided. The specific studies are summarized as follows: Objective: To investigate the characteristics, distribution and clinical significance of the L5-S1 intervertebral foramen ligaments. To provide more detailed anatomical data for the spinal surgeon. Methods: 30 specimens of anticorrosion and 15 fresh frozen lumbosacral specimens (age 40) At the age of 85, the average age of 56 years old. The arteries were perfused with red latex. Carefully remove the soft tissues around the spine and sawing the spine from the median sagittal. Find the L5-S1 nerve roots and carefully remove the soft tissues such as the surrounding fat and fascia along the foramen. Under the naked eye and the surgical microscope, we observe the shape, movement, starting position and distribution of the ligaments under the naked eye and operation microscope. The length, width, diameter or thickness of the label was measured under the operation microscope. The histological type of the different types of ligaments was analyzed by HE staining and Masson staining. Results: 818 ligaments were found in 90 L5-S1 intervertebral foramen, including 350 strips, 468 strips, and the radiation of the nerve roots to the transverse process or the inner wall of the intervertebral foramen. 699 (85.45%) and 119 (14.55%) straddle ligaments connected to the intervertebral foramen around the intervertebral foramen. 270 (33.01%) in the entrance area of the L5-S1 intervertebral foramen, 381 (46.58%) in the middle area and 167 (20.42%) regions in the exit area. The length of the toughened zone is changeable from 1.43-19.01mm, and the thickness is thickest up to the 3.46mm. light mirror. The ligaments in the intervertebral foramen were made up of a large number of collagen fibers and a small amount of elastic fibers. There were no significant differences between the radiate ligaments and the cross shaped ligaments. Conclusion: the intervertebral foramen ligaments are mainly divided into two shapes of strip and stripe. The entrance area of the intervertebral foramen is all radiate toughened zone, and the radiate ligaments in the intervertebral foramen are stronger than the straddle. The rate of occurrence is high. Preoperative distribution should be grasped and differentiated correctly during operation, so as to reduce the incidence of complications.
【學(xué)位授予單位】：南方醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R687.3;R322

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