胸腰椎椎旁肌间隙入路的解剖及临床应用研究

分类号：密级：U D C：编号：学位论文胸腰椎椎旁肌间隙入路的解剖及临床应用研究Anatomic and clinial study of paraspinal intermuscular approach in the thoracolumbar and lumbar spine王静雅指导教师姓名韩卉教授安徽医科大学人体解剖学教研室申请学位级别硕士专业名称人体解剖与组织胚胎学提交论文日期2015-03-12 论文答辩日期2015-05-17学位授予单位和日期安徽医科大学答辩委员会主席评阅人2015年5月安徽医科大学Anhui Medical University硕士学位论文胸腰椎椎旁肌间隙入路的解剖及临床应用研究论文题目Anatomic and clinial study of paraspinalintermuscular approach in thethoracolumbar and lumbarspine作者姓名王静雅指导老师韩卉教授邓雪飞学科专业人体解剖与组织胚胎学研究方向脊柱外科临床应用解剖论文工作时间 2013年12月至2015年3月学位论文独创性声明本人所呈交的论文是我个人在导师指导下进行的研究工作及取得的研究成果。

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学位论文作者签名：导师签名：日期：日期：目录英文缩略词表 (1)中文摘要 (2)英文摘要 (4)正文:胸腰椎椎旁肌间隙入路的解剖及临床应用研究前言 (7)材料与方法 (9)实验结果 (11)讨论 (36)结论 (45)小结与展望 (46)参考文献 (47)附录 (54)致谢 (55)综述 (56)1.综述 (56)2.参考文献 (61)安徽医科大学硕士学位论文英文缩略词表TLF胸腰筋膜Thoracolumbar FasciaLD背阔肌Latissimus DorsiCB皮支Cutaneous BranchLO最长肌LongisssimusIL 髂肋肌IliocostalisM多裂肌MultifidusAP关节突Articular ProcessTP 横突Transverse ProcessESA竖脊肌腱膜Erector Spinae Aponeurosis SP棘突Spinous Process1安徽医科大学硕士学位论文胸腰椎椎旁肌间隙入路的解剖及临床应用研究摘要研究目的通过对胸腰移行部（T11-L2）及下腰椎（L3-L5）椎旁肌间隙及其毗邻结构的解剖学研究，为脊柱外科微创手术的开展提供形态学依据；通过对胸腰椎椎旁肌解剖结构的深入研究，寻找新的肌间隙入路，为胸腰椎后路微创手术的发展和创新开辟新的思路；经胸腰移行部及下腰椎肌间隙入路模拟椎弓根螺钉固定术，为椎旁肌间隙入路的临床应用及椎弓根置钉术的微创操作提供解剖学依据。

方法 1. 局部解剖：选取9具（18侧）福尔马林固定的成人尸体湿性标本，行局部解剖观察脊柱胸腰移行部、下腰椎的肌间隙及其毗邻结构；根据胸腰椎椎旁肌的解剖构造，寻找新的生理性肌间隙，并根据肌间隙显露的结构探索其临床应用价值；2. 模拟手术：选取4例（8侧）福尔马林固定的成人湿性标本，根据局部解剖观察结果，在胸腰椎各节段（T11-L5）模拟肌间隙入路椎弓根螺钉固定术；3：术后评估：模拟手术后对术区行CT扫描，观察和评估椎弓根螺钉的位置以及椎旁肌的状态；纵向打开椎管以观察椎弓根置钉效果。

结果 1. 局部解剖：①胸腰移行部Wiltse间隙：肌间隙表面由最长肌肌腱构成的竖脊肌腱膜（ESA）覆盖；钝性分离最长肌内侧第1根肌腱和胸半棘肌肌腱（83%，15侧）或同时分离最长肌第1、2根肌腱（17%，3侧）即可清晰暴露胸腰移行部全部节段的Wiltse间隙；通过该肌间隙可显露多裂肌、T11~T12横突和L1~L2关节突等结构；②下腰椎Wiltse间隙：肌间隙表面主要由致密的肌腱膜覆盖，钝性分离2安徽医科大学硕士学位论文最长肌内侧的独立肌腱与外侧的肌腱膜，可显露L3-L4水平Wiltse间隙，再沿多裂肌外缘切开最长肌腱膜，可显露L4-L5水平Wiltse间隙；用手指向深处钝性分离可至下腰椎关节突及副突等结构；③Wiltse间隙内每个节段均有血管规律穿行，根据血管穿出多裂肌外膜的位置可帮助寻找并显露椎弓根螺钉的进钉点；④多裂肌内侧间隙：位于多裂肌内侧，相邻节段的多裂肌肌束之间，钝性分离覆盖该肌间隙表面的最长肌肌腱，可显露其深面的多裂肌，再沿棘突尖至根部钝性分离出多裂肌与棘突或棘突间肌之间的生理间隙，可暴露棘突侧面及毗邻椎板等结构。

2. 椎弓根置钉模拟手术：根据不同区域Wiltse间隙的解剖特点，分别在胸腰移行部和下腰椎区域寻找并显露出Wiltse间隙，按照本研究的定位法暴露螺钉的进钉点，模拟椎弓根螺钉固定术的操作，可将螺钉顺利置入椎弓根及椎体，术后CT扫描示螺钉位置良好，椎旁肌结构保持完整。

结论 1. Wiltse间隙位于椎旁肌的深层，浅层由竖脊肌腱膜覆盖，深入了解该肌间隙及其毗邻的解剖结构有助于定位并微创地显露该间隙，从而促进临床肌间隙入路胸腰椎后路手术的开展和推广。

2. 在肌间隙入路椎弓根置钉术中，Wiltse 间隙内穿行的血管束可帮助定位并显露椎弓根螺钉的进钉位置。

3. 在多裂肌的内侧相邻节段肌束之间存在潜在的肌间隙，通过该肌间隙可显露棘突、椎板等结构，经该肌间隙入路可开展相应部位的胸腰椎微创手术，并将其称为多裂肌内侧入路。

关键词胸腰移行部下腰椎椎旁肌间隙椎弓根螺钉固定术解剖3安徽医科大学硕士学位论文Anatomic and clinial study of paraspinal intermuscular approach in the thoracolumbar and lumbar spineAbstractObjectives To evaluate the anatomy of paraspinal intermuscular space and its adjacent structures in the thoracolumbar junction and lower lumbar spine, in order to provide a morphological basis for the spine minimally invasive surgery; To seek new muscle-splitting approach through in-depth research into the anatomical structure of paraspinal muscles, and attempt to develop a new way to improve and innovate the spine minimally invasive surgery; To provide an anatomical basis for the clinical application of paraspinal intermuscular approach into minimally invasive pedicle screw fixation.Methods 1.Reginal anatomy: A total of 9 (18 sides) cadavers were selected to observe the regional anatomy of paraspinal inermuscular space and its adjacent structures in thoracolumbar junction and lower lumbar spine; Looked for a new intermuscular approach based on the anatomy of paraspinal muscles, and further, explored the clinical value of this new approach according to the structure exposed through it; 2. Surgical simulation: Another 4 (8 sides) f ormalin fixed adult cadavers were selected to simulate pedicle screw fixation surgery though paraspinal intermuscular approach in each segment of thoracic and lumbar spine (T11-L5); 3. Postoperative evaluation: Process CT scan in the operative region, after that evaluate the position of pedicle screws and the status of paraspinal muscles; then open the vertebral canal to observe the results of pedicle screw placement.4安徽医科大学硕士学位论文Results 1.Reginal anatomy: ① Wiltse space in thoracolumbar junction: The surface of Wiltse space was covered by erector spinae aponeurosis, which was constituted by the tendons of longissimus pars thoracis. After the potential space were separated bluntly between the thoracic semispinalis tendons and the first medial tendon of longissimus (83%, 15sides), or between the first and the second tendon of longissimus additionally (17%, 3sides), the Wiltse space in thoracolumbar junction was exposed totally and clearly. Through Wiltse space, the multifidus, T11-T12 transverse process, L1-L2 articular process were exposed. ②Wiltse space in lower lumbar spine: the surface of Wiltse space were mainly covered by the compact aponeurosis. The Wiltse space in L3-L4 level were exposed by blunt dissection between the medial discrete tendons and the lateral aponeurosis extend from longissimus par thoracis. In addition, the Wiltse space in L4-L5 level could be exposed by making an oblique incision in longissimus aponeurosis. The structures such as articular process and accessory process etc could be exposed through this approach.③There was a bundle of vessels across Wiltse space at each spine level, and the entry points of pedicle screws could be assured according to the position of the vessels piercing the epimysium of multifidus.④Medial space of multifidus: The space lay medial to multifidus, and are located between two multifidus fascicles arising from the spinous process of adjacent segments. The dorsal surface of medial space was covered by tendons extend from longissimus, and the multifidus could be exposed by blunt separation between the longgissimus tendons. Then blunt separation between multifidus and spinous process or between multifidus and interspinous muscle could expose the lateral of spinous process and its adjacent lamina etc. 2. Surgical simulation of pedicle screw fixation: Wiltse space in thoracolumbar junction and lower lumbar spine could be located and exposed respectively according to their different arrangement features. The screws were inserted into pedicle and vertebral body successfully after exactly positioning the entry points. The location of the pedicle screws were assured by postoperation CT, and the paraspinal muscles remain intact.5安徽医科大学硕士学位论文Conclusions 1. Wiltse space lie deep to paraspinal muscles, and the dorsal surface of which is covered by erector spinae aponeurosis. In-depth understanding of the anatomy of Wiltse space and its adjacent structure will contribute to minimize the injuries of paraspinal muscles during positioning and exposing the space, and will ultimately promote the improvement of the posterior spine minimally invasive surgery. 2. The vessels across Wiltse space can contribute to locate and expose the entry points of screws in the pedicle screw fixation through muscle-splitting approach. 3. There is a potential intermuscular space located between multifidus fascicles of adjacent spine segments, through which the structures such as spinous process and lamina etc are exposed. This approach can be applied in the minimally invasive surgery of thoracic and lumbar spine in corresponding region, and this approach is named medial approach of multifidus.Key words thoracolumbar junction lower lumbar spine paraspinal intermuscular space pedicle screw fixation anatomy6安徽医科大学硕士学位论文胸腰椎椎旁肌间隙入路的解剖及临床应用研究1 前言脊柱后路手术是腰椎退变和椎体骨折等脊柱外科疾病最常用的治疗方法，传统的后正中入路仍是目前临床广泛应用的手术入路之一，但术中需大范围地剥离肌肉及长时间牵拉椎旁肌，常导致术后脊柱失稳及顽固性腰痛的发生[1-3]。