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目的:对保留棘上韧带附丽的改良腰椎后正中入路进行相关影像解剖学研究,并观察其临床初步应用效果。方法:选取50例腰椎MRI图像资料,男27例,女23例,年龄37.1±8.2岁。在PACS系统上选择L3/4、L4/5、L5/S1各一幅T2W1轴位图像进行测量,包括棘上韧带宽度及厚度,胸腰筋膜、骶棘肌总腱膜于棘上韧带附丽部及多裂肌间隙部的厚度。在2具防腐成人尸体标本上模拟保留棘上韧带附丽的改良腰椎后正中手术入路。临床应用改良腰椎后正中手术入路22例,其中男12例,女10例,平均年龄51.5±8.0岁。单节段14例,双节段7例,三节段1例。术后随访3个月。观察切口长度、切口显露时间、出血量及术后腰痛程度。结果:胸腰筋膜、骶棘肌总腱膜附丽于棘上韧带。于L3/4、L4/5、L5/S1层面,多裂肌间隙与后正中线间距分别为16.32±6.56mm,27.43±6.36mm,33.65±4.77mm;腰筋膜附丽部厚度分别为0.81±0.17mm,0.88±0.15mm,0.87±0.14mm,与其肌间隙部厚度差异不显著(仅L4/5层面存在显著性差异);骶棘肌总腱膜附丽部厚度分别为1.76±0.51mm,1.71±0.40mm,1.78±0.50mm,同层面肌间隙部厚度分别为0.95±0.18mm,0.99±0.22mm,0.98±0.20mm,具有统计学显著性差异(P<0.05)。尸体模拟手术示骶棘肌总腱膜深面与多裂肌之间存在潜在间隙,可无损伤分离至棘突旁,组织牵开张力小。所有22例均按手术方案完成减压、椎间融合器置入及椎弓根螺钉内固定术,显露良好,视野清晰,单节段、双节段切口长度分别平均4cm、6cm。结论:棘上韧带之骶棘肌总腱膜、胸腰筋膜附丽部均强大。保留棘上韧带附丽的改良腰椎后正中入路合理可行,可缩短切口长度,减轻肌肉损伤。
OBJECTIVE: To study the anatomy of the mid-posterior midline of the lumbar spine ligament attached to Li and to observe its preliminary clinical application. Methods: Fifty cases of lumbar MRI data were selected, including 27 males and 23 females, aged 37.1 ± 8.2 years. Select one T2W1 axial image of L3 / 4, L4 / 5, L5 / S1 on the PACS system for measurement, including the width and thickness of the supraspinous ligament, thoracolumbar fascia, sacral spinous muscle total aponeurosis attached to the supraspinous ligament Department and the multifidillary muscle gap thickness. In 2 anti-corrosion adult corpse specimens to retain the modified supraspinous ligament with the modified lumbar spine surgery. Clinical application of modified lumbar median approach in 22 cases, including 12 males and 10 females, mean age 51.5 ± 8.0 years. Single-segment in 14 cases, double-segment in 7 cases, three segments in 1 case. Follow-up 3 months after operation. Observed incision length, incision exposure time, amount of bleeding and postoperative low back pain. Results: The thoracolumbar fascia and sacral spinosal total aponeurosis attached to the supraspinous ligaments. At the L3 / 4, L4 / 5 and L5 / S1 levels, the distance between the multifidus muscle and the posterior median line were 16.32 ± 6.56mm, 27.43 ± 6.36mm and 33.65 ± 4.77mm, respectively; the thickness of the appendage of the lumbar fascia was 0.81 ± 0.17mm, 0.88 ± 0.15mm and 0.87 ± 0.14mm, respectively. There was no significant difference between them in the thickness of interosseous space (only significant difference was found in L4 / 5 level). The thickness of aponeurosis attached to sacral spinous muscle was 1.76 ± 0.51mm and 1.71 ± 0.40mm and 1.78 ± 0.50mm respectively. The thickness of the interspace of the same floor were 0.95 ± 0.18mm, 0.99 ± 0.22mm and 0.98 ± 0.20mm respectively, with statistical significance (P <0.05). The body simulation surgery showed sacral spine muscle total aponeurosis deep and multifidus potential gap between the separation of non-injury to the spinous process, tissue retraction tension. All the 22 patients underwent decompression, intervertebral fusion and pedicle screw fixation according to the surgical protocol. The results showed good results and clear visual field. The lengths of single segment and double segment incision were respectively 4cm and 6cm on average. Conclusion: The total aponeurosis of the sacral spine muscle of the supraspinous ligament and the thoracolumbar fascia attached to the Ministry of Li are strong. Maintaining the supraspinous ligament with the modified posterior lumbar midline approach is reasonable and feasible, can shorten the incision length, reduce muscle damage.