目的 探讨腰椎手术Wiltse入路的解剖学基础，提高该入路的稳定性和可操作性。 方法 成人标本20具，通过解剖观察双侧竖脊肌腱膜与多裂肌的关系；最长肌与竖脊肌腱膜的关系；多裂肌和最长肌间隙是否清晰，是否存在稳定的解剖标志；竖脊肌腱膜表面及其深面是否还存在其它结构可作为多裂肌和最长肌之间隙的解剖标志。 结果 多裂肌虽有少许纤维与竖脊肌腱膜相连接，仍可视为在竖脊肌腱膜上无起点；在腰部，最长肌在竖脊肌腱膜形成起点，起点的内缘自内上向外下斜行，并发出筋膜向深部延伸副突、横突，由此形成多裂肌与最长肌之间的分隔；在所有20具标本的左右两侧，以此隔膜为解剖标志向深部钝性分离，直接、顺利到达关节突；在竖脊肌腱膜表面未发现任何可作为多裂肌和竖脊肌间隙标志的解剖结构，剥离竖脊肌腱膜后在最长肌和多裂肌表面亦未发现可定位二者间隙的解剖标志；在多裂肌和最长肌间隙内，最长肌的内侧面可见清晰的节段神经及伴随血管。 结论 竖脊肌腱膜在最长肌内侧向深部的延续是腰椎手术Wiltse入路准确进入多裂肌和最长肌间隙的可靠解剖标志。
Abstract
Objective To explore the anatomical basis of Wiltse approach in lumbar operation and to improve reliability and manipuility of the lumbar Wiltse approach．Methods Twenty embalmed cadavers were used to observe the anatomical characteristics as follows: the relationship between sacrospinalis aponeurosis and multifidus muscle, the relationship between sacrospinalis aponeurosis and longissimus muscle, whether the interspace between multifidus muscle and longissimus muscle was clear, whether there were stable anatomic signs to identify, and whether there was other structure in the surface or inferior part of sacrospinalis aponeurosis could be the anatomic signs of the interspace between multifidus muscle and longissimus muscle. Results Multifidus muscle could be seen as an independent part from sacrospinalis aponeurosis though it had few fibers. Longissimus muscle formed a starting point from sacrospinalis aponeurosis in the lumbar regions. The starting point extended from central-superfacial to inferior-lateral and formed fascia stretching to facet joints and accessory process that made up the native interspace between multifidus muscle and longissimus muscle. The fascia was taken as an anatomical sign, successful blunt dissection were made to expose facet joints directly in all 20 cadavers. There were no other special anatomical signs in the surface or in the inferior part of sacrospinalis aponeurosis to locate the interspace between multifidus muscle and longissimus muscle. In the interspace, segmental nerve and concomitant blood vessel can be seen definitely inside the longissimus muscle. Conclusions The Wiltse approach requires a comprehensive understanding of lumbar fascia, based on which ,the operation could be safe and feasible.
关键词
Wiltse入路 /
多裂肌 /
最长肌 /
解剖
Key words
/
Wiltse approach /
Multifidus muscle /
Longissimus muscle /
Anatomy
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参考文献
[1] 陈毅, 崔新刚, 吴恙, 等. 改良小切口肌间隙入路双侧固定单侧减压TILF手术临床疗效分析[J]. 中国临床解剖杂志, 2017, 35(5), 554-558. DOI: 10.13418/j.issn.1001-165x.2017.05.015.
[2] 蒲志超, 黄坤炳, 薛剑, 等. Wiltse肌间隙入路结合伤椎置钉治疗胸腰椎骨折的疗效分析[J]. 中国临床解剖学杂志, 2020, 38(4), 467-470. DOI: 10.13418/j.issn.1001-165x.2020.04.019.
[3] Hoh DJ, Wang MY, Ritland SL. Anatomic features of the paramedian muscle-splitting approaches to the lumbar spine[J]. Neurosurgery, 2010, 66(3 Suppl Operative): 13-24. DOI: 10.1227/01.NEU.0000350866.25760.33.
[4] 徐群渊. 主译. 格氏解剖学. 39版[M]. 北京: 北京大学医学出版社, 2008: 824-525.
[5] 郭世绂. 骨科临床解剖学[M]. 济南: 山东科学技术出版社, 2001: 201-203.
[6] Kim JS, Lee SH, Moon KH, et al. Surgical results of the oblique paraspinal approach in upper lumbar disc herniation and thoracolumbar junction[J]. Neurosurgery, 2009, 65(1): 95-99. DOI: 10.1227/01.NEU.0000348299.89232.C2.
[7] Tessitore E, de Tribolet N. Far-lateral lumbar disc herniation: the microsurgical transmuscular approach[J]. Neurosurgery, 2004, 54(4): 939-942. DOI: 10.1227/01.neu.0000115154.62636.77.
[8] Ringel F, Stoffel M, Stüer C, et al. Minimally invasive transmuscular pedicle screw fixation of the thoracic and lumbar spine[J]. Neurosurgery, 2006, 59(4 Suppl 2): 361-367. DOI: 10.1227/01.NEU. 0000223505. 07815. 74.
[9] Moon KH, Lee SH, Kong BJ, et al. An oblique paraspinal approach for intracanalicular disc herniations of the upper lumbar spine: technical case report[J]. Neurosurgery, 2006, 59(4 Suppl 2): 487-488. DOI: 10.1227/01. NEU. 0000232772. 82860. 75.
[10]Wiltse LL, Bateman JG, Hutchinson RH, et al. The paraspinal sacrospinalis-splitting approach to the lumbar spine[J]. J Bone Joint Surg Am, 1968, 50(5): 119-124. PMID: 5676831.
[11] Wiltse LL, Spencer CW. New uses and refinements of the paraspinal approach to the lumbar spine[J]. Spine, 1988, 13(6): 696-706. PMID: 3175760.
[12] Kato H, Hasegawa M, Takada T, et al. The lumbar artery perforator based island flap: anatomical study and case reports[J]. Br J Plast Surg, 1999, 52(7): 541-546. DOI: 10.1054/bjps.1999.3120.
[13] Vialle R, Wicart P, Drain O, et al. The Wiltse paraspinal approach to the lumbar spine revisited: an anatomic study[J]. Clin Orthop Relat Res, 2006, 445: 175-180. DOI: 10.1097/01.blo.0000203466.20314.2a.
[14]Olivier E, Beldome J, Slimane MO, et al. Comparison between one midline cutaneous incision and two lateral incisions in the lumbur paraspinal approach by wiltse: a cadaver study[J]. Surg Radiol Anat, 2006, 28(5): 494-497. DOI: 10.1007/s00276-006-0123-y.
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