经腰椎椎间孔开窗入路的解剖学研究与临床应用  

Anatomic study and clinical application of transforaminal fenestration approach in lumbar spine

作　　者：徐宝山[1] 贺坚[1] 马信龙[1] 夏群[1] 胡永成[1] 吉宁[1] 杨强[1] 刘越[1] 姜洪丰[1] 

机构地区：[1]天津市天津医院脊柱外科,天津300211

出　　处：《中华骨科杂志》2013年第6期593-600,共8页Chinese Journal of Orthopaedics

基　　金：人力资源和社会保障部留学人员择优资助项目（2009）

摘　　要：目的设计经腰椎椎间孔开窗入路，探讨其可行性及临床应用效果。方法选取30具成人腰椎尸体标本，模拟L1-S1各节段经椎间孔开窗入路操作，充分显露出口神经根及椎间盘后外侧，实体测量完全显露椎间孔时椎板和关节突的切除和剩余范围；在开窗前、开窗后行CT扫描三维重建，测量切除和剩余范围。选取31例成人腰椎三维CT图像，测量L1-S1各节段经椎间孔开窗入路切除的骨结构范围。采用可动式脊柱内镜下经椎间孔开窗入路治疗腰椎极外侧椎间盘突出症10例，男4例，女6例。L3-4 2例，L4例，L5S1 4例。结果自L1至S1椎板峡部和关节突关节逐渐增宽，横突逐渐下移，峡部外缘和上关节突外缘到硬膜囊外缘的距离逐渐增大；在L1，2、L2，3和L3,4节段经椎间孔开窗人路切除较少的椎板峡部和关节突即可显露硬膜囊外缘和椎间盘后外侧；在L4，5尤其L5S1节段椎间孔开窗操作空间小，需切除较多的椎板峡部和关节突关节外缘才能显露椎间盘后外侧，硬膜囊显露较困难，下内侧月牙形开窗可保留较多的椎板和下关节突连接。临床应用10例手术均顺利完成，显露充分，彻底摘除了突出和游离的椎间盘髓核。随访6-24个月，末次随访时Macnab评分优8例、良2例，均无腰椎失稳表现。结论经腰椎椎间孔开窗入路可在保留椎板和下关节突连续性的基础上充分显露椎间孔，内镜下操作、下内侧月牙形开窗可以保留更多的骨性结构，治疗腰椎极外侧椎间盘突出症具有较好的可行性。Objective To explore the feasibility and clinical effects of transforaminal fenestration approach in lumbar spine. Methods Transforaminal fenestration approach was performed on 30 specimens of adult lumbar spine from L1 to S1 segments, with the exiting nerve root and posterior aspect of disc fully exposed. The resected structures were measured. The 3D CT was performed before and after fenestration, and the structure resected was measured. The 3D CT data of lumbar spine of 31 adult patients were collected and the reseeted structures were measured. Transforaminal fenestration approach was applied in 10 patients with far lateral lumbar disc herniation. Microendoseopic disceetomy was performed with mobile endospine system at level of L3,4 in 2 cases, L4.5 in 4, L5S1 in 4. Results From L1 to S1, the isthmus and laminae gradually ex- tends laterally, the transverse process gradually moves downward, arid the distance between the dura sac and the lateral edge of lamina and facet increased. At the segment of L1,2, L2,3 and L3,4, only a small range of structure was reseeted. At the segment of L4,5 and L5S1, a large range of lamina and faceted were resected, and the dura sac can not be fully exposed. A creseentiform fenestration can preserve more connection of isthmus and lower facet. The transforaminal fenestration approach was successfully used in all the 10 pa- tients, the herniation and sequestered nucleus was exposed fully and removed completely. The follow-up time was 12 months, excellent result was obtained in 8 patients, and good in 2 according to Maenab scale, without instability at dynamic film. Conclusion Transforaminal fenestration approach can provide enough exposition with the preservation of stable structure in lumbar spine, especially with endoscopic surgery and crescen- tiform fenestration, and far lateral lumbar disc herniation can be effectively treated in this approach.

关 键 词：腰椎 椎间盘移位 解剖学 治疗结果 

分 类 号：R687.3[医药卫生—骨科学]