腰骶丛损伤的应用解剖学研究
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摘要
研究背景和目的:
腰骶丛(Lumbosacral plexus,LSP)损伤是一种神经受外界因素侵袭而损伤的疾病,随着诊治水平的提高,患者对神经损伤后的功能恢复提出了更高的要求。LPS损伤的病因多为高速交通事故、高处坠落、塌方等导致骨盆骨折、骨盆环破裂时造成的。正常时LSP在骨盆内的活动度极小,LSP损伤的机制常为骨盆后环骨折移位或合并关节脱位所造成的牵拉致伤,少数为压迫性损伤。
外伤、机械压迫、化学刺激等多种原因损伤后缺血导致神经内部组织学的变化是神经功能难于恢复的主要原因,它造成神经根的正常传导功能障碍。国外学者通过动物及人的解剖学、组织学以及血液动力学方面的观察,对造成神经根的正常功能传导障碍的原因进行了研究,但对LSP血供方面的研究还不完善。
LSP损伤后外科修复的临床效果受诸多因素影响,其中神经的血液供应就起着非常重要的作用。在神经缺损修复时,带血管的神经移植体(vascularized nervegrafting VNG)较常规的无血管神经移植具有理论上的优越性。对周围神经血供的研究已有200多年的历史,早在十八世纪六十年代,Isenflamm和Doerffler首次用灌注方法对周围神经的供给血管进行了研究,之后的学者对周围神经的血供的研究因得不到临床应用而一直停留在基础理论研究阶段。自Taylor 1976年成功地进行了带血管蒂的神经移植以后,人们对神经血供的研究由单纯的基础研究转向了临床应用的研究,同时研究方法也有了改进。2003年Suami、Sidney、2006年Hong、彭田红等分别利用放射血管显影技术对下肢神经、臂丛和上肢神经的血管体进行了研究。Suami等下肢血管体区域的研究,采用血管放射显影技术,着重对下肢主要神经的营养血管分布范围进行讨论,但还缺乏对LSP血供的系统研究资料,LSP及其血供的分布特征也未能从放射显影上得到证明。
为此,本课题第一部分对LSP进行解剖学观测,采用血管显微解剖技术与明胶-氧化铅放射微血管显影技术对LSP神经的血液供应进行研究,提供腰骶(Lumborsacral,LS)神经根出椎间孔周围的解剖关系,神经根在椎管内的走行角度,LS神经根的解剖学数据,明确了LSP的血供,神经与血管的位置和解剖结构关系特点以及节段血管的供血区域,为LSP损伤的修复手术提供解剖学依据。
微创诊疗技术的不断提高以及影像技术的迅猛发展,对血管和神经的可视化研究已成为临床诊断不可或缺的证据。现阶段临床常规应用的CT、超声、MRI等影像检查方法还不足以清晰显示LSP结构,影响LSP损伤诊断的准确性。1992年Howe等尝试应用磁共振(magnetic resonance,MR)技术结合脂肪抑制,显示家兔前肢的神经横截面图像,为周围神经成像提供了一个新的可行的方法,但由于MR软硬件的限制,显示神经的分辨率不高,伪影明显,临床应用受到限制。近年由于磁共振技术的快速发展,提高了图像的时间和空间分辨率,压脂技术更完善,使磁共振神经成像术(magnetic resonance neurography,MRN)成为一种临床实用新技术。
为此,本课题第二部分使用MRN技术对LSP进行成像,完整显示了在体LSPMR影像,并使其三维成像。为临床LSP损伤的诊断提供影像学资料,为LSP损伤的手术治疗提供影像学依据。
许多学者在不断提高诊疗技术的基础上,还致力于探索不同的手术方法以恢复患者运动功能。Aramburo(1986)报道有关LSP探查手术入路,通过腹膜外与腹膜内两种入路可以显露LSP,常用肌旁侧腹切口,经腹膜后分离显露腰丛(Lumbar plexus,LP);经腹切口分离显露骶丛(Sacral plexus,SP)。Linarte和Gilbert(1986)报道经骶骨(SA)入路显露SP。LSP损伤修复探查目前的文献报道不多,而采用合理的手术入路对损伤的修复和保护其周围的血管和腰大肌等结构,维持脊柱的正常结构和功能有重要的意义。临床上对前路腹膜后(Anterior retroperitoned,ARP)入路的研究更多关注的是腰椎手术,ARP入路可以通过将大血管牵向内侧暴露椎体更充分,或者通过切开更外侧的腰大肌暴露椎体,但切开腰大肌暴露椎体容易损伤位于腰大肌内的LP,切开腰大肌对脊柱的功能有影响,而腰椎前路手术中医源性LSP的损伤目前也有报道,主要发生在暴露和器械植入的过程中。为了在手术中更好地修复受损伤的LSP,恢复其功能,减少手术带来的二次创伤及保护脊柱功能,本课题在第三部分选用新鲜尸体标本,结合上述形态学和影像学研究结果,探讨LS部ARP手术入路的解剖结构特点,以期为临床LSP修复手术的开展提供形态学基础。
方法:
1.(1)15例红色乳胶灌注防腐成人标本的脊柱T9以下标本,肉眼和手术显微镜观察LSP根部椎管内、外的形态特点及其与椎管、硬脊膜和脊髓等周围组织的关系,(2)肉眼和手术显微镜下观察,LSP及前、后根(Posterior root,PR)的血供来源,以及前、后根营养动脉与脊髓前、后动脉的关系。(3)3具新鲜成人标本,经腹主动脉灌注3%明胶-氧化铅混悬液行动脉造影,解剖分离LSP及营养血管和来源血管,去除脊椎后对灌注的血管和LSP进行X线摄片观察。(4)实验过程使用佳能A650数码相机全程拍照,使用Photoshop软件对图片进行处理,利用南方医院影像中心PACS系统将X线片导入个人电脑,进行图像处理,可得到清晰的便于观察LSP的血供的动脉造影图片。
2.健康自愿者3例,GE公司3.0T HD signa超导磁共振成像(Magneticresonance,MR)系统,脊柱表面线圈(CTL456)。常规行矢状面T1WI,横断面T2WI成像,参数::FRFSE序列T2WI脂肪抑制,TR/TE/NEX:4000/85/2,矩阵:352×256,层厚/层间距:1.0/0mm,层数40～44,扫描时间:4min17s。原始图像以Dicom格式导入GE公司AW4.3图像工作站,完成最大密度投影(MIP)、多层面容积重组(MPVR)、容积再现(VR)图像重建。
3.新鲜标本3具,采用腋前线开口,左侧入路,进入腹膜后腔,腰大肌后外侧剥离,分离显露LP,结合LSP及营养血管的解剖结构,行模拟ARP神经修复、探查手术,观察腰大肌与LSP神经、血管之间的位置关系。
结果:
1.(1)LSP根部的显微外科解剖:LSP前、PR依次由神经小束-神经亚束-神经束组成,神经小束自相应的LS部脊髓节段的前外侧沟和后外侧沟平行排列发出或进入,斜向外下方走行,从上至下前根(Anerior root,AR)其始处与脊髓中线的距离先大后小,L1最大2.21±0.49mm,向下逐渐减小;AR与脊髓纵轴的夹角逐渐变小,L1最大为25.07°±5.37;前、后根在椎管内走行的长度逐渐增大,L1为66.74±10.77mm、65.61±9.87mm,增大到L5的129.99±16.27mm、137.64±11.37mm;前、后根直径最粗的为L5的1.70±0.36mm、1.75±0.56mm,相应的PR比AR粗;腰神经(Lumbar nerve,LN)AR分出角大于前支分出角,LS神经与硬膜囊的夹角逐渐减小,L1为56.64°±7.67,到S3的7.80°±1.94;前后根神经束逐渐形成内侧宽、外侧窄的扇形结构,其表面根动脉伴随神经根出入硬膜囊。(2)LSP及前、后根的血供:来自第1-4腰动脉(Lumbar artery,LA)、髂腰动脉、臀上动脉、骶外侧动脉,根动脉与脊髓前后动脉以多种方式相吻合。(3)LSP血供的分布:来源于LA系统、骶髂腰动脉系统、臀上动脉、臀下动脉、阴部内动脉发出的节段性动脉及邻近肌肉肌支。节段性动脉除发支营养椎体、椎弓等外,全部向内侧发支营养LS神经节、LSP,并伴随神经节向内延伸至硬脊膜或穿过硬脊膜、蛛网膜,沿前、后根行走,发支营养脊神经根,并在神经束与脊髓前、后动脉相吻合,吻合方式为真性吻合。节段动脉以“Y”型进入神经外膜,然后分成升降支,节段动脉及分支之间互相吻合,吻合方式为真性吻合和闭塞性吻合,以真性吻合为主。LSP神经干、股、束的血供除来源于节段动脉外,还来自邻近的动脉,包括伴行动脉及其分支、邻近的肌支。红色乳胶灌注标本和明胶-氧化铅放射显影法均清晰显示了LSP的血供。
2.MRN LSP成像:MRN可以清楚显示LN椎间孔段(神经根)、LN节段(神经节)、LN节后段、LST(神经干)及股神经、闭孔神经(Obturator nerve,ON)、股外侧皮神经(Posterior fmoral crtaneous nerve,PFCN)、髂腹下神经(Iliohypogastricnerve,IN)、髂腹股沟神经(Ilioinguinal nerve,ILN)(股、束)。神经节信号高于神经根和神经干,神经节及神经干周围未见高信号灶。股神经在腰4、5椎体水平从腰大肌表面移行至髂腰肌表面,形态由长条形移行为椭圆形的断面,信号稍高于腰大肌,边缘较清楚。SP由于走行角度不同不能同时显示,斜矢状位成像定位线最好与斜冠状位所显示的短条状神经走行方向一致,这样可增加S1及邻近坐骨神经(Sciatic nerve,SN)的显示机会,利用多平面重建技术,可以对采集的原始数据任意方向重建,明显提高神经的显示率。
3.模拟LSP损伤修复ARP手术入路:采用左侧前路腋前线切口,暴露L1～L3LN,能达到良好的暴露和直视下操作的目的。LP在不同断面中,LP神经位于腰大肌深面或肌质内,腰椎横突的前方,此处为腰大肌间隙,LP在腰椎侧方的组成具有一定的规律性,LA在腰大肌内的走行没有特定的肌间隙。
结论:
1.LSP血供来自于第1～4LA、骶髂腰动脉系统、臀上动脉、臀下动脉、阴部内动脉及邻近肌肉的肌支。营养动脉之间在神经内的真性吻合在病理状态下可提供侧支循环,血管区域之间的血供可以互相代偿。熟悉LSP根部的显微解剖有助于LSP损伤的诊治。
2.乳胶灌注法适合神经外部血供的观察,血管造影法适合神经血管分布的整体观察,乳胶灌注法和血管造影法的结合观察研究,可以清晰显示LSP神经血管的分布及神经与血管的关系。
3.MRN技术全面完成了LSP的成像,因其无创性,应该为临床进行LSP损伤检查首选的影像学手段。
4.LSP损伤的修复和探查手术前路入路更加适合,ARP入路可以作为不损伤LS功能前提下的LP损伤修复的手术入路,腰大肌的前外侧是腰大肌切开的安全区。入路直接、简捷,暴露清楚,可直视下处理神经根和突出椎间盘;创伤小,出血少,从肌间隙进入,不破坏神经和肌肉的正常结构,不切除脊柱骨性部分和韧带,不影响脊柱稳定性。
Background and Objective:
Lumbosacral plexus(LSP)injury is a nerve invasion by outside factors and injury of the disease,along with raising the level of treatment,patients with nerve injury on the functional recovery after a higher demand.LSP injury causes more traffic accidents for high-speed,high falling,leading to landslides,such as pelvic fracture, pelvic ring caused by the rupture.LSP normal activities within the pelvis in a very small degree,LSP injury mechanism for regular pelvic fracture displacement after the Central or the merger dislo-cation caused by traction injury,for the oppression of minorities injury.
Trauma,oppression machinery,chemical stimulation,and other reasons leading to nerve damage after ischemia of the internal organization of the changes in nerve function is difficult to restore the main,causing the normal conduction of nerve root dysfunction.Foreign scholars through animal and human anatomy,histology and hemodynamics the observation,causing nerve root obstacles to the normal function of the causes for the con-duction of the study,but the LSP blood for the study is not perfect.
LSP injury after the repair of the clinical effects affected by many factors, including nerve on the blood supply plays a very important role.In neural defect,the nerve of vascular graft(VNG) than conventional non-vascular nerve graft with the superiority theory.The peripheral nerves of the blood supply has been 200 years of history,as early as the 18th century,the 1960s,Isenflamm and Doerffler with the first infusion methods on peripheral nerve supply vessels were studied,after the scholars on peripheral nerve of the blood supply Due to lack of research and clinical application has been staying in basic theoretical research stage.Taylor 1976 since the successful conduct of the vascularized nerve transplant,the people on the study of the blood supply from purely on the basis of the clinical application to the study, and research methods have improved.2003 Suami,Sidney,2006年Hong, Tian-Hong Peng,respectively use of radiation vascular enhancement technology to lower limb nerve,the nerve and brachial plexus of blood vessels were studied. Suami,such as lower extremity vascular study of the region,a vascular radiology enhancement technology,focused mainly on the lower extremities of the nutrient vessels to discuss the scope of distribution,but also the lack of LSP of the blood supply system,LSP and the distribution of blood supply Features also failed radiation from the image on unsubstantiated.
To this end,the issue of the first part of a LSP anatomical observation,using microscopic anatomy of vascular technology and gelatin-lead oxide radiation microvascular enhancement technology to LSP blood supply to conduct research, provide lumbosacral nerve root out vertebral Around the hole between the anatomy, spinal nerve root in the running angle,lumbar sacral nerve root of the anatomy data, defined the LSP of the blood supply,nerve and vascular anatomy and the location and characteristics of relations between the segments of blood vessels Regional,LSP injury provide anatomical basis for the repair surgery.
Minimally invasive treatment technology and the continuous improvement of the rapid development of imaging technology,the blood vessels and nerve visualization of clinical diagnosis has become an integral part of the evidence.At this stage clinical application of conventional CT,ultrasound,MRI and other imaging method is not enough to clearly show LSP structure,LSP injury affect the accuracy of diagnosis.1992,Howe tried to applications such as magnetic resonance(magnetic resonance,MR) combined with fat suppression shows that the rabbits forelimb nerve cross-section images,for peripheral nerve imaging provides a new viable solution, due to the restrictions MR hardware and software,The resolution shows that nerve is not high,artifacts Clearly,in the clinical application is limited.In recent years,due to the rapid development of MRI technology to improve the image of the time and spatial resolution,better pressure resin technology,MRN become a clinical application of new technologies.
So the second part of this topic on the use of technology MRN imaging for LSP, shows that the integrity of the LSP MR imaging and to make it three-dimensional imaging.LSP for the clinical diagnosis of the injury imaging data for the LSP injury to provide treatment based on imaging.
Many scholars continue to improve in the clinic on the basis of technology,is also committed to exploring different ways to restore the operation of motor function. Aramburo(1986) reports on LSP exploration surgical approach,through extraperitoneal and peritoneal within two approaches can reveal LSP,often flanking abdominal muscle incision,the retroperitoneal separation revealed lumbar plexus; abdominal incision separation revealed Sacral plexus.Linarte and Gilbert(1986) reported the sacral approach revealed sacral plexus.LSP repair the current exploration not reported in the literature,and a reasonable surgical approach to repair the damage and to protect their vessels and around the psoas major muscle(PM) structure,the spine of the normal structure and function of great importance.Clinical on the road retroperitoneal approach of more concern is spinal surgery,ARP approach can be led by the great vessels to the medial more fully exposed vertebra, or more lateral incision through the lumbar vertebrae exposed muscle.But cut lumbar vertebrae easily exposed the lumbar plexus in PM and affect the function of the spine.Lumbar spine surgery in iatrogenic LSP injury is also reported,mainly in equipment exposed in the process of implantation.In order to better surgery to repair the damage LSP,restore its function and reduce the secondary trauma surgery and the protection of spinal function,the choice of topics in the third part of the bodies were fresh,with the morphology and imaging results to explore the way forward LSP ARP approach of the anatomical structure characteristics,with a view to surgical repair of the LSP to provide morphological basis.
Method:
1.(1) 15 cases of red latex perfusion preservation of the adult specimens following spinal T9 specimens,and the naked eye surgery microscope LSP root canal inside and outside the shape and characteristics of the spinal canal and,epidural and spinal cord,and other organizations around the,(2) Observation with Naked eyes and under a surgery microscope,the sources of the blood supply for anterior roots and posterior roots of LSP,and the relationship between anterior roots and posterior roots nutrition artery with spinal cord.(3) Three fresh adult cadaveric specimens, infuse 5%gelatin-lead oxide suspension in the abdominal aorta and angiography, then anatomical separate LSP with nutritional blood vessels and source blood vessels, remove the spine then take the LSP to X-ray observation.(4) Use the Canon A650 digital camera photographed the entire process,then use photoshop software to process the images.The images of the South Centre Hospital PACS system will be X-ray film into personal computers,can be clear for the observation of LSP blood supply of angiography picture.
2.Healthy volunteers three cases,GE company 3.0 T HD signa superconducting magnetic resonance imaging system,spine surface coil(CTL456).Routine sagittal T1WI,cross-sectional imaging T2WI,parameter::FRFSE sequence T2WI fat suppression,TR/TE/NEX:4000/85/2,Matrix:352×256,slice thickness/floor space:1.0/0 mm,Floors 40 to 44,scan time:4 min17s.Dicom format of the original image to import GE company AW4.3 image workstations,complete the maximum intensity projection(MIP),multi-volume reorganization(MPVR),volume reproduction(VR) image reconstruction.
3.Three fresh specimens,use the front-line of axillary opening,left and into the posterior peritoneal cavity,PM after stripping,separation revealed lumbar plexus, with LSP and nutrition of the vascular anatomy,MRN positioning observation,To simulate the road retroperitoneal nerve repair,exploratory surgery to observe the psoas muscle and LSP,the location of relations between the blood vessels.
Results:
1.(1) LSP roots of the microscopic anatomy:LSP AR and PR followed by the small beam-nerve-beam-bundle of nerves and nerve on the beam since the corresponding segments of the spinal cord LS anterior and posterior the lateral ditch,lateral ditch parallel with the issue or to enter,ramps outside the bottom course,from top to bottom before beginning the root of its distance from the center line and the spinal cord after the first small,L1 maximum 2.21±0.49mm,down gradually decreased root and spinal cord of the longitudinal axis angle gradually become smaller,L1 up to 25.07°±5.37;AR and PR canal running the length of the gradually increasing,L1 to 66.74±10.77mm,65.61±9.87mm,by L5 to the big 129.99±16.27mm,137.64±11.37mm;before and after the diameter of the root L5 crude for the 1.70±0.36mm, 1.75±0.56mm,the corresponding root root rough than before;separation of lumbar nerve root Kok better than the first-separation angle,LN and the angle between the dural sac gradually decreased,L1 from 56.64°±7.67,to S3's 7.80°±1.94;before and after the nerve root gradually formed the medial wide,lateral Narrow fan-shaped structure,its surface roots artery with nerve root out dural sac.(2)LSP and AR and PR of the blood supply:from 1~(st) to 4ed LA,iliolumbar artery,Sperior gluteal artery, sacral lateral artery,the artery root and spinal cord artery before and after the match in many ways.(3) LSP blood for the distribution:from the lumbar artery system, sacroiliac lumbar artery system,Sperior gluteal artery,the artery buttocks,perineum, the artery segmental artery and adjacent muscle muscle branch.Segmental artery in addition to the branch of vertebra,External arch,all to the medial branch of the lumbar sacral ganglion,LSP,accompanied by extending to the ganglion inside epidural or across the epidural,Cobweb Membrane,along the pre-and post-Gen-walking,a branch of spinal nerve root and spinal cord and nerve before and after the match artery,anastomosis true form.Section arteries to "Y"-type into the nerve membrane,and then divided into movements sticks,branches and sections of the artery between the anastomosis,true form anastomosis and occlusion of the anastomosis to the main anastomosis true.LSP stem,stock,in addition to beam the blood supply from the artery segment,but also from the nearby artery,including accompanied artery and its branches,close to the muscular branches.Red latex and gelatin infusion specimens-lead oxide radiation image shows the law are clear LSP of the blood supply.
2.MRN LSP imaging:MRN can clearly show that lumbar intervertebral foramen nerve(nerve root),lumbar ganglion(nerve),LN sections,the LST and the femoral nerve,the nerve obturator,Lateral femoral nerve,Iliohypogastric nerve,ilioinguinal nerve.Ganglion signal higher than the nerve root and neural stem,and neural stem ganglion no signal around the stove.Femoral nerve in the lumbar vertebra level from four to five lumbar muscle to the surface transitional iliopsoas surface,shape shifting from a long strip of oval-shaped cross section,the signal slightly higher than the psoas muscle,a clear edge.Traveling sacral plexus due to different point of view can not be at the same time,oblique sagittal imaging and positioning of the best oblique coronal shown in the short strip of running the same direction,this can increase the S1 and adjacent to show the sciatic nerve,the use of MPR technology can be the raw data collected on any of the reconstruction,clearly shows that the rate of increase.
3.Simulation lumbosacral plexus repair the road retroperitoneal surgical approach: the left side of the road axillary front-line incision,exposed L1～L3 lumbar nerve,to achieve a good exposure and open heart operation under the purpose.Lumbar plexus in different sections,the lumbar plexus in the lumbar muscle or deep muscle quality, in front of the transverse process spinal,here for the psoas muscle gap,the lumbar plexus in the composition of the lateral lumbar have a certain regularity,Lumbar artery in the lumbar muscles to walk,there is no specific muscle gap.
Conclusion:
1.LSP blood supply from 1 to 4 lumbar artery,sacroiliac lumbar artery system, Sperior gluteal artery,hip artery,the artery and the neighbouring perineal muscles of the muscular branches.Nutrition in the artery between the true nerve anastomosis in the pathological state,may provide collateral circulation,the blood vessels between regions compensate for each other.LSP familiar with the roots of the microanatomy of the LSP injury to the diagnosis and treatment.
2.Latex perfusion of external blood supply for the observation,angiography law for the overall distribution of nerves and blood vessels observation,latex and vascular perfusion imaging method used in conjunction,can clearly show LSP nerves and blood vessels and nerve and the distribution of blood vessels Relations.
3.MRN completed a comprehensive technical LSP of the imaging,because of their non-invasive,it should be carried out for clinical LSP injury check the preferred means of imaging.
4.LSP injury rehabilitation and detectors before the surgery more appropriate approach road,the road retroperitoneal approach can be used as non-injury LS function under the premise of the lumbar plexus repair the surgical approach,lumbar muscle is the first lateral lumbar muscle cut the security zone.Approach to direct, simple,clear exposure,can be dealt with under the open-nerve root and prominent disc;trauma small,less bleeding into the space from the muscle,nerve and muscle damage is not the normal structure,with no part of the spinal bones and ligaments, Impact of spinal stability.
腰骶丛(Lumbosacral plexus,LSP)损伤是一种神经受外界因素侵袭而损伤的疾病,随着诊治水平的提高,患者对神经损伤后的功能恢复提出了更高的要求。LPS损伤的病因多为高速交通事故、高处坠落、塌方等导致骨盆骨折、骨盆环破裂时造成的。正常时LSP在骨盆内的活动度极小,LSP损伤的机制常为骨盆后环骨折移位或合并关节脱位所造成的牵拉致伤,少数为压迫性损伤。
外伤、机械压迫、化学刺激等多种原因损伤后缺血导致神经内部组织学的变化是神经功能难于恢复的主要原因,它造成神经根的正常传导功能障碍。国外学者通过动物及人的解剖学、组织学以及血液动力学方面的观察,对造成神经根的正常功能传导障碍的原因进行了研究,但对LSP血供方面的研究还不完善。
LSP损伤后外科修复的临床效果受诸多因素影响,其中神经的血液供应就起着非常重要的作用。在神经缺损修复时,带血管的神经移植体(vascularized nervegrafting VNG)较常规的无血管神经移植具有理论上的优越性。对周围神经血供的研究已有200多年的历史,早在十八世纪六十年代,Isenflamm和Doerffler首次用灌注方法对周围神经的供给血管进行了研究,之后的学者对周围神经的血供的研究因得不到临床应用而一直停留在基础理论研究阶段。自Taylor 1976年成功地进行了带血管蒂的神经移植以后,人们对神经血供的研究由单纯的基础研究转向了临床应用的研究,同时研究方法也有了改进。2003年Suami、Sidney、2006年Hong、彭田红等分别利用放射血管显影技术对下肢神经、臂丛和上肢神经的血管体进行了研究。Suami等下肢血管体区域的研究,采用血管放射显影技术,着重对下肢主要神经的营养血管分布范围进行讨论,但还缺乏对LSP血供的系统研究资料,LSP及其血供的分布特征也未能从放射显影上得到证明。
为此,本课题第一部分对LSP进行解剖学观测,采用血管显微解剖技术与明胶-氧化铅放射微血管显影技术对LSP神经的血液供应进行研究,提供腰骶(Lumborsacral,LS)神经根出椎间孔周围的解剖关系,神经根在椎管内的走行角度,LS神经根的解剖学数据,明确了LSP的血供,神经与血管的位置和解剖结构关系特点以及节段血管的供血区域,为LSP损伤的修复手术提供解剖学依据。
微创诊疗技术的不断提高以及影像技术的迅猛发展,对血管和神经的可视化研究已成为临床诊断不可或缺的证据。现阶段临床常规应用的CT、超声、MRI等影像检查方法还不足以清晰显示LSP结构,影响LSP损伤诊断的准确性。1992年Howe等尝试应用磁共振(magnetic resonance,MR)技术结合脂肪抑制,显示家兔前肢的神经横截面图像,为周围神经成像提供了一个新的可行的方法,但由于MR软硬件的限制,显示神经的分辨率不高,伪影明显,临床应用受到限制。近年由于磁共振技术的快速发展,提高了图像的时间和空间分辨率,压脂技术更完善,使磁共振神经成像术(magnetic resonance neurography,MRN)成为一种临床实用新技术。
为此,本课题第二部分使用MRN技术对LSP进行成像,完整显示了在体LSPMR影像,并使其三维成像。为临床LSP损伤的诊断提供影像学资料,为LSP损伤的手术治疗提供影像学依据。
许多学者在不断提高诊疗技术的基础上,还致力于探索不同的手术方法以恢复患者运动功能。Aramburo(1986)报道有关LSP探查手术入路,通过腹膜外与腹膜内两种入路可以显露LSP,常用肌旁侧腹切口,经腹膜后分离显露腰丛(Lumbar plexus,LP);经腹切口分离显露骶丛(Sacral plexus,SP)。Linarte和Gilbert(1986)报道经骶骨(SA)入路显露SP。LSP损伤修复探查目前的文献报道不多,而采用合理的手术入路对损伤的修复和保护其周围的血管和腰大肌等结构,维持脊柱的正常结构和功能有重要的意义。临床上对前路腹膜后(Anterior retroperitoned,ARP)入路的研究更多关注的是腰椎手术,ARP入路可以通过将大血管牵向内侧暴露椎体更充分,或者通过切开更外侧的腰大肌暴露椎体,但切开腰大肌暴露椎体容易损伤位于腰大肌内的LP,切开腰大肌对脊柱的功能有影响,而腰椎前路手术中医源性LSP的损伤目前也有报道,主要发生在暴露和器械植入的过程中。为了在手术中更好地修复受损伤的LSP,恢复其功能,减少手术带来的二次创伤及保护脊柱功能,本课题在第三部分选用新鲜尸体标本,结合上述形态学和影像学研究结果,探讨LS部ARP手术入路的解剖结构特点,以期为临床LSP修复手术的开展提供形态学基础。
方法:
1.(1)15例红色乳胶灌注防腐成人标本的脊柱T9以下标本,肉眼和手术显微镜观察LSP根部椎管内、外的形态特点及其与椎管、硬脊膜和脊髓等周围组织的关系,(2)肉眼和手术显微镜下观察,LSP及前、后根(Posterior root,PR)的血供来源,以及前、后根营养动脉与脊髓前、后动脉的关系。(3)3具新鲜成人标本,经腹主动脉灌注3%明胶-氧化铅混悬液行动脉造影,解剖分离LSP及营养血管和来源血管,去除脊椎后对灌注的血管和LSP进行X线摄片观察。(4)实验过程使用佳能A650数码相机全程拍照,使用Photoshop软件对图片进行处理,利用南方医院影像中心PACS系统将X线片导入个人电脑,进行图像处理,可得到清晰的便于观察LSP的血供的动脉造影图片。
2.健康自愿者3例,GE公司3.0T HD signa超导磁共振成像(Magneticresonance,MR)系统,脊柱表面线圈(CTL456)。常规行矢状面T1WI,横断面T2WI成像,参数::FRFSE序列T2WI脂肪抑制,TR/TE/NEX:4000/85/2,矩阵:352×256,层厚/层间距:1.0/0mm,层数40～44,扫描时间:4min17s。原始图像以Dicom格式导入GE公司AW4.3图像工作站,完成最大密度投影(MIP)、多层面容积重组(MPVR)、容积再现(VR)图像重建。
3.新鲜标本3具,采用腋前线开口,左侧入路,进入腹膜后腔,腰大肌后外侧剥离,分离显露LP,结合LSP及营养血管的解剖结构,行模拟ARP神经修复、探查手术,观察腰大肌与LSP神经、血管之间的位置关系。
结果:
1.(1)LSP根部的显微外科解剖:LSP前、PR依次由神经小束-神经亚束-神经束组成,神经小束自相应的LS部脊髓节段的前外侧沟和后外侧沟平行排列发出或进入,斜向外下方走行,从上至下前根(Anerior root,AR)其始处与脊髓中线的距离先大后小,L1最大2.21±0.49mm,向下逐渐减小;AR与脊髓纵轴的夹角逐渐变小,L1最大为25.07°±5.37;前、后根在椎管内走行的长度逐渐增大,L1为66.74±10.77mm、65.61±9.87mm,增大到L5的129.99±16.27mm、137.64±11.37mm;前、后根直径最粗的为L5的1.70±0.36mm、1.75±0.56mm,相应的PR比AR粗;腰神经(Lumbar nerve,LN)AR分出角大于前支分出角,LS神经与硬膜囊的夹角逐渐减小,L1为56.64°±7.67,到S3的7.80°±1.94;前后根神经束逐渐形成内侧宽、外侧窄的扇形结构,其表面根动脉伴随神经根出入硬膜囊。(2)LSP及前、后根的血供:来自第1-4腰动脉(Lumbar artery,LA)、髂腰动脉、臀上动脉、骶外侧动脉,根动脉与脊髓前后动脉以多种方式相吻合。(3)LSP血供的分布:来源于LA系统、骶髂腰动脉系统、臀上动脉、臀下动脉、阴部内动脉发出的节段性动脉及邻近肌肉肌支。节段性动脉除发支营养椎体、椎弓等外,全部向内侧发支营养LS神经节、LSP,并伴随神经节向内延伸至硬脊膜或穿过硬脊膜、蛛网膜,沿前、后根行走,发支营养脊神经根,并在神经束与脊髓前、后动脉相吻合,吻合方式为真性吻合。节段动脉以“Y”型进入神经外膜,然后分成升降支,节段动脉及分支之间互相吻合,吻合方式为真性吻合和闭塞性吻合,以真性吻合为主。LSP神经干、股、束的血供除来源于节段动脉外,还来自邻近的动脉,包括伴行动脉及其分支、邻近的肌支。红色乳胶灌注标本和明胶-氧化铅放射显影法均清晰显示了LSP的血供。
2.MRN LSP成像:MRN可以清楚显示LN椎间孔段(神经根)、LN节段(神经节)、LN节后段、LST(神经干)及股神经、闭孔神经(Obturator nerve,ON)、股外侧皮神经(Posterior fmoral crtaneous nerve,PFCN)、髂腹下神经(Iliohypogastricnerve,IN)、髂腹股沟神经(Ilioinguinal nerve,ILN)(股、束)。神经节信号高于神经根和神经干,神经节及神经干周围未见高信号灶。股神经在腰4、5椎体水平从腰大肌表面移行至髂腰肌表面,形态由长条形移行为椭圆形的断面,信号稍高于腰大肌,边缘较清楚。SP由于走行角度不同不能同时显示,斜矢状位成像定位线最好与斜冠状位所显示的短条状神经走行方向一致,这样可增加S1及邻近坐骨神经(Sciatic nerve,SN)的显示机会,利用多平面重建技术,可以对采集的原始数据任意方向重建,明显提高神经的显示率。
3.模拟LSP损伤修复ARP手术入路:采用左侧前路腋前线切口,暴露L1～L3LN,能达到良好的暴露和直视下操作的目的。LP在不同断面中,LP神经位于腰大肌深面或肌质内,腰椎横突的前方,此处为腰大肌间隙,LP在腰椎侧方的组成具有一定的规律性,LA在腰大肌内的走行没有特定的肌间隙。
结论:
1.LSP血供来自于第1～4LA、骶髂腰动脉系统、臀上动脉、臀下动脉、阴部内动脉及邻近肌肉的肌支。营养动脉之间在神经内的真性吻合在病理状态下可提供侧支循环,血管区域之间的血供可以互相代偿。熟悉LSP根部的显微解剖有助于LSP损伤的诊治。
2.乳胶灌注法适合神经外部血供的观察,血管造影法适合神经血管分布的整体观察,乳胶灌注法和血管造影法的结合观察研究,可以清晰显示LSP神经血管的分布及神经与血管的关系。
3.MRN技术全面完成了LSP的成像,因其无创性,应该为临床进行LSP损伤检查首选的影像学手段。
4.LSP损伤的修复和探查手术前路入路更加适合,ARP入路可以作为不损伤LS功能前提下的LP损伤修复的手术入路,腰大肌的前外侧是腰大肌切开的安全区。入路直接、简捷,暴露清楚,可直视下处理神经根和突出椎间盘;创伤小,出血少,从肌间隙进入,不破坏神经和肌肉的正常结构,不切除脊柱骨性部分和韧带,不影响脊柱稳定性。
Background and Objective:
Lumbosacral plexus(LSP)injury is a nerve invasion by outside factors and injury of the disease,along with raising the level of treatment,patients with nerve injury on the functional recovery after a higher demand.LSP injury causes more traffic accidents for high-speed,high falling,leading to landslides,such as pelvic fracture, pelvic ring caused by the rupture.LSP normal activities within the pelvis in a very small degree,LSP injury mechanism for regular pelvic fracture displacement after the Central or the merger dislo-cation caused by traction injury,for the oppression of minorities injury.
Trauma,oppression machinery,chemical stimulation,and other reasons leading to nerve damage after ischemia of the internal organization of the changes in nerve function is difficult to restore the main,causing the normal conduction of nerve root dysfunction.Foreign scholars through animal and human anatomy,histology and hemodynamics the observation,causing nerve root obstacles to the normal function of the causes for the con-duction of the study,but the LSP blood for the study is not perfect.
LSP injury after the repair of the clinical effects affected by many factors, including nerve on the blood supply plays a very important role.In neural defect,the nerve of vascular graft(VNG) than conventional non-vascular nerve graft with the superiority theory.The peripheral nerves of the blood supply has been 200 years of history,as early as the 18th century,the 1960s,Isenflamm and Doerffler with the first infusion methods on peripheral nerve supply vessels were studied,after the scholars on peripheral nerve of the blood supply Due to lack of research and clinical application has been staying in basic theoretical research stage.Taylor 1976 since the successful conduct of the vascularized nerve transplant,the people on the study of the blood supply from purely on the basis of the clinical application to the study, and research methods have improved.2003 Suami,Sidney,2006年Hong, Tian-Hong Peng,respectively use of radiation vascular enhancement technology to lower limb nerve,the nerve and brachial plexus of blood vessels were studied. Suami,such as lower extremity vascular study of the region,a vascular radiology enhancement technology,focused mainly on the lower extremities of the nutrient vessels to discuss the scope of distribution,but also the lack of LSP of the blood supply system,LSP and the distribution of blood supply Features also failed radiation from the image on unsubstantiated.
To this end,the issue of the first part of a LSP anatomical observation,using microscopic anatomy of vascular technology and gelatin-lead oxide radiation microvascular enhancement technology to LSP blood supply to conduct research, provide lumbosacral nerve root out vertebral Around the hole between the anatomy, spinal nerve root in the running angle,lumbar sacral nerve root of the anatomy data, defined the LSP of the blood supply,nerve and vascular anatomy and the location and characteristics of relations between the segments of blood vessels Regional,LSP injury provide anatomical basis for the repair surgery.
Minimally invasive treatment technology and the continuous improvement of the rapid development of imaging technology,the blood vessels and nerve visualization of clinical diagnosis has become an integral part of the evidence.At this stage clinical application of conventional CT,ultrasound,MRI and other imaging method is not enough to clearly show LSP structure,LSP injury affect the accuracy of diagnosis.1992,Howe tried to applications such as magnetic resonance(magnetic resonance,MR) combined with fat suppression shows that the rabbits forelimb nerve cross-section images,for peripheral nerve imaging provides a new viable solution, due to the restrictions MR hardware and software,The resolution shows that nerve is not high,artifacts Clearly,in the clinical application is limited.In recent years,due to the rapid development of MRI technology to improve the image of the time and spatial resolution,better pressure resin technology,MRN become a clinical application of new technologies.
So the second part of this topic on the use of technology MRN imaging for LSP, shows that the integrity of the LSP MR imaging and to make it three-dimensional imaging.LSP for the clinical diagnosis of the injury imaging data for the LSP injury to provide treatment based on imaging.
Many scholars continue to improve in the clinic on the basis of technology,is also committed to exploring different ways to restore the operation of motor function. Aramburo(1986) reports on LSP exploration surgical approach,through extraperitoneal and peritoneal within two approaches can reveal LSP,often flanking abdominal muscle incision,the retroperitoneal separation revealed lumbar plexus; abdominal incision separation revealed Sacral plexus.Linarte and Gilbert(1986) reported the sacral approach revealed sacral plexus.LSP repair the current exploration not reported in the literature,and a reasonable surgical approach to repair the damage and to protect their vessels and around the psoas major muscle(PM) structure,the spine of the normal structure and function of great importance.Clinical on the road retroperitoneal approach of more concern is spinal surgery,ARP approach can be led by the great vessels to the medial more fully exposed vertebra, or more lateral incision through the lumbar vertebrae exposed muscle.But cut lumbar vertebrae easily exposed the lumbar plexus in PM and affect the function of the spine.Lumbar spine surgery in iatrogenic LSP injury is also reported,mainly in equipment exposed in the process of implantation.In order to better surgery to repair the damage LSP,restore its function and reduce the secondary trauma surgery and the protection of spinal function,the choice of topics in the third part of the bodies were fresh,with the morphology and imaging results to explore the way forward LSP ARP approach of the anatomical structure characteristics,with a view to surgical repair of the LSP to provide morphological basis.
Method:
1.(1) 15 cases of red latex perfusion preservation of the adult specimens following spinal T9 specimens,and the naked eye surgery microscope LSP root canal inside and outside the shape and characteristics of the spinal canal and,epidural and spinal cord,and other organizations around the,(2) Observation with Naked eyes and under a surgery microscope,the sources of the blood supply for anterior roots and posterior roots of LSP,and the relationship between anterior roots and posterior roots nutrition artery with spinal cord.(3) Three fresh adult cadaveric specimens, infuse 5%gelatin-lead oxide suspension in the abdominal aorta and angiography, then anatomical separate LSP with nutritional blood vessels and source blood vessels, remove the spine then take the LSP to X-ray observation.(4) Use the Canon A650 digital camera photographed the entire process,then use photoshop software to process the images.The images of the South Centre Hospital PACS system will be X-ray film into personal computers,can be clear for the observation of LSP blood supply of angiography picture.
2.Healthy volunteers three cases,GE company 3.0 T HD signa superconducting magnetic resonance imaging system,spine surface coil(CTL456).Routine sagittal T1WI,cross-sectional imaging T2WI,parameter::FRFSE sequence T2WI fat suppression,TR/TE/NEX:4000/85/2,Matrix:352×256,slice thickness/floor space:1.0/0 mm,Floors 40 to 44,scan time:4 min17s.Dicom format of the original image to import GE company AW4.3 image workstations,complete the maximum intensity projection(MIP),multi-volume reorganization(MPVR),volume reproduction(VR) image reconstruction.
3.Three fresh specimens,use the front-line of axillary opening,left and into the posterior peritoneal cavity,PM after stripping,separation revealed lumbar plexus, with LSP and nutrition of the vascular anatomy,MRN positioning observation,To simulate the road retroperitoneal nerve repair,exploratory surgery to observe the psoas muscle and LSP,the location of relations between the blood vessels.
Results:
1.(1) LSP roots of the microscopic anatomy:LSP AR and PR followed by the small beam-nerve-beam-bundle of nerves and nerve on the beam since the corresponding segments of the spinal cord LS anterior and posterior the lateral ditch,lateral ditch parallel with the issue or to enter,ramps outside the bottom course,from top to bottom before beginning the root of its distance from the center line and the spinal cord after the first small,L1 maximum 2.21±0.49mm,down gradually decreased root and spinal cord of the longitudinal axis angle gradually become smaller,L1 up to 25.07°±5.37;AR and PR canal running the length of the gradually increasing,L1 to 66.74±10.77mm,65.61±9.87mm,by L5 to the big 129.99±16.27mm,137.64±11.37mm;before and after the diameter of the root L5 crude for the 1.70±0.36mm, 1.75±0.56mm,the corresponding root root rough than before;separation of lumbar nerve root Kok better than the first-separation angle,LN and the angle between the dural sac gradually decreased,L1 from 56.64°±7.67,to S3's 7.80°±1.94;before and after the nerve root gradually formed the medial wide,lateral Narrow fan-shaped structure,its surface roots artery with nerve root out dural sac.(2)LSP and AR and PR of the blood supply:from 1~(st) to 4ed LA,iliolumbar artery,Sperior gluteal artery, sacral lateral artery,the artery root and spinal cord artery before and after the match in many ways.(3) LSP blood for the distribution:from the lumbar artery system, sacroiliac lumbar artery system,Sperior gluteal artery,the artery buttocks,perineum, the artery segmental artery and adjacent muscle muscle branch.Segmental artery in addition to the branch of vertebra,External arch,all to the medial branch of the lumbar sacral ganglion,LSP,accompanied by extending to the ganglion inside epidural or across the epidural,Cobweb Membrane,along the pre-and post-Gen-walking,a branch of spinal nerve root and spinal cord and nerve before and after the match artery,anastomosis true form.Section arteries to "Y"-type into the nerve membrane,and then divided into movements sticks,branches and sections of the artery between the anastomosis,true form anastomosis and occlusion of the anastomosis to the main anastomosis true.LSP stem,stock,in addition to beam the blood supply from the artery segment,but also from the nearby artery,including accompanied artery and its branches,close to the muscular branches.Red latex and gelatin infusion specimens-lead oxide radiation image shows the law are clear LSP of the blood supply.
2.MRN LSP imaging:MRN can clearly show that lumbar intervertebral foramen nerve(nerve root),lumbar ganglion(nerve),LN sections,the LST and the femoral nerve,the nerve obturator,Lateral femoral nerve,Iliohypogastric nerve,ilioinguinal nerve.Ganglion signal higher than the nerve root and neural stem,and neural stem ganglion no signal around the stove.Femoral nerve in the lumbar vertebra level from four to five lumbar muscle to the surface transitional iliopsoas surface,shape shifting from a long strip of oval-shaped cross section,the signal slightly higher than the psoas muscle,a clear edge.Traveling sacral plexus due to different point of view can not be at the same time,oblique sagittal imaging and positioning of the best oblique coronal shown in the short strip of running the same direction,this can increase the S1 and adjacent to show the sciatic nerve,the use of MPR technology can be the raw data collected on any of the reconstruction,clearly shows that the rate of increase.
3.Simulation lumbosacral plexus repair the road retroperitoneal surgical approach: the left side of the road axillary front-line incision,exposed L1～L3 lumbar nerve,to achieve a good exposure and open heart operation under the purpose.Lumbar plexus in different sections,the lumbar plexus in the lumbar muscle or deep muscle quality, in front of the transverse process spinal,here for the psoas muscle gap,the lumbar plexus in the composition of the lateral lumbar have a certain regularity,Lumbar artery in the lumbar muscles to walk,there is no specific muscle gap.
Conclusion:
1.LSP blood supply from 1 to 4 lumbar artery,sacroiliac lumbar artery system, Sperior gluteal artery,hip artery,the artery and the neighbouring perineal muscles of the muscular branches.Nutrition in the artery between the true nerve anastomosis in the pathological state,may provide collateral circulation,the blood vessels between regions compensate for each other.LSP familiar with the roots of the microanatomy of the LSP injury to the diagnosis and treatment.
2.Latex perfusion of external blood supply for the observation,angiography law for the overall distribution of nerves and blood vessels observation,latex and vascular perfusion imaging method used in conjunction,can clearly show LSP nerves and blood vessels and nerve and the distribution of blood vessels Relations.
3.MRN completed a comprehensive technical LSP of the imaging,because of their non-invasive,it should be carried out for clinical LSP injury check the preferred means of imaging.
4.LSP injury rehabilitation and detectors before the surgery more appropriate approach road,the road retroperitoneal approach can be used as non-injury LS function under the premise of the lumbar plexus repair the surgical approach,lumbar muscle is the first lateral lumbar muscle cut the security zone.Approach to direct, simple,clear exposure,can be dealt with under the open-nerve root and prominent disc;trauma small,less bleeding into the space from the muscle,nerve and muscle damage is not the normal structure,with no part of the spinal bones and ligaments, Impact of spinal stability.
引文
[1]李民,李强,伍亚民.脊髓损伤的修复治疗策略[J].中国临床康复,2003,25(7):3990-3991.
[2]Copper RG,Freemont AJ,Hoyland JA,et al.Herniated intervertebral disc-as-sociated periradi cular fibrosis and vascular abnormal itiesoccur without inflammatory cell infiltration[J].Spine,1995,20:591-598.
[3]Terzis JK,Skoulis TG.,Soucacos PN.Vascularized nerve grafts:A review[J].Int Angiol,1995,14(3):264-277.
[4]Sunderland S.Blood supply of the nerves of the upper limb in man[J].Arch Neurol Psych,1945,53(2):91-115.
[5]Sunderland S.Nerves and Nerve Injuries,2nd Ed.New York:Churchill Livingstone,1978,46.
[6]李吉,姜保国,王伟,等.周围神经血液供应研究的进展及其临床应用[J].解剖科学进展,1995,1(2):118-122.
[7]Taylor GI,Ham FJ.The free vascularized nerve graft:A further experimental and clinic application of microvascular techniques[J].Plast Reconstr Surg,1976,57(4):413-426.
[8]Taylor GI.Nerve grafting with simultaneous microvascular reconstruction[J]. Clin Orthop Relat Res,1978,(133):56-70.
[9]Breidenbach WC,Terzis JK.The anatomy of free vascularized nerve grafts[J].Clin Plast Surg,1984,11(1):65-71.
[10]El-Barrany WG,Marei AG,Vallee B.Anatomic basis of vascularised nerve grafts:the blood supply of peripheral nerves[J].Surg Radiol Anat,1999,21(2):95-102.
[11]Hiroo Suami,G.Ian Taylor,Wei-Ren Pan.Angiosome territories of the nerves of the lower limbs[J].Plast and Reconstr Surg,2003,112(7):1790-1806.
[12]Levy SM,Taylor GI,Baudet J,et al.Angiosomes of the Brachial Plexus:An Anatomical Study[J].Plast;Reconstr Surg,2003,112(7):1799-1806.
[13]Hong MK-H,Hong MK-Y,Taylor GI.Angiosome territories of the nerves of the upper limbs[J].Plast Reconstr Surg,2006,118(1):148-160.
[14]彭田红,唐茂林,徐达传,等.椎管外臂丛的血供分布特点及其临床意义[J].中华骨科杂志,2006,26(7):472-475.
[15]Bendszus,Stoll.Technology insighe:visualizing peripheral nerve injury using MRI[J].Nat Clin Pract Neurol.2005,1(1):45-53.
[16]Howe FA,Filler AG,Bell BA,et al.Magnetic resonance neurography[J].Mang Reson Med.1992,28(2):328-38.
[17]Dailey AT,Tsuruda JS,Filler AG,et al.Magnetic resonance neurography of peripheral nerve degeneration and regeneration[J].Lancet.1997,350(9086):1221-1222.
[18]Kuntz,Blake L,Britz G,et al.Magnetic resonance neurography of peripheral nerve lesions in the lower extremity[J].Neurosurgery.1996,39(4):750-756.
[19]Heilbrun ME,Tsuruda JS,Townsend JJ,et al.Intraneural perineurioma of the common peroneal nerve.Case report and review of the literature[J].Neurosurg.2001,94(5):811-815.
[20]Freund W,Brinkmann A,Wagner F,et al.MR neurography with multiplanar reconstruction of 3D MRI datasets:an anatomical study and clinical applications[J].Neuroadiology.2007,49(4):335-341.
[21]顾立强,张景僚,王刚等.骨盆骨折合并腰骶丛损伤的诊治[J].中华创伤骨科杂志,2002,4(3):174-177.
[1]Howe FA,Filler AG,Bell BA,et al.Magnetic resonance neurography[J].Mang Reson Med.1992,28(2):328-38.
[2]Dailey AT,Tsuruda JS,Filler AG,et al.Magnetic resonance neurography of peripheral nerve degeneration and regeneration[J].Lancet.1997,350(9086):1221-1222.
[3]Kuntz,Blake L,Britz G,et al.Magnetic resonance neurography of peripheral nerve lesions in the lower extremity[J].Neurosurgery.1996,39(4):750-756.
[4]Heilbrun ME,Tsuruda JS,Townsend JJ,et al.Intraneural perineurioma of the common peroneal nerve.Case report and review of the literature[J].Neurosurg..2001,94(5):811-815.
[5]Freund W,Brinkmann A,Wagner F,et al.MR neurography with multiplanar reconstruction of 3D MRI datasets:an anatomical study and clinical applications[J].Neuroadiology.2007,49(4):335-341.
[6]Filler AG,Maravilla KR,Tsumda JS.MR neurography and MR imaging for imaging diagnosis of disorders affecting the peripheral nerves and musculature [J].Neurol Clin,2004,22(3):643-682.
[7]Filler AG,Haynes J,Jordan SE,et al.Sciatica of nondisc origin and piriformis syndrome:diagnosis by magnetic resonance neurog2 raphy and interventional magnetic resonance imaging with outcome study of resulting treatment[J].Neurosurg Spine,2005,2(2):99-115.
[8]Bendszus M,Stoll G.Technology insight:visualizing peripheral nerve injury using MRI[J].Nat Clin Pract Neurol.2005,1(1):45-53.
[9]Lewis AM,Layzer R,Engstrom JW,et al.Magnetic resonance neurography in extraspinal sciatica[J].Arch Neurol.2006,63(10):1469-472.
[10]孙贵新,顾玉东.磁共振神经成像技术在周围神经病变中的应用[J].国外医 学骨科学分册,2003,24(2):122-123.
[11]吕发金,谢鹏,牟君,等.格林2巴利综合征腰丛神经磁共振成像研究[J].中国医学影像技术,2007,23(10):1457-1461.
[1]顾立强,张景僚,王刚等.骨盆骨折合并腰骶丛损伤的诊治[J].中华创伤骨科杂志,2002,4(3):174-177.
[2]唐树杰:金鸿宾:王志彬:苗军,腰椎前路椎间融合术临床应用进展[J].中国骨伤,2008,(1):23-25.
[3]Brewster L,Trueger N,Schermer C,et al.Infraumbilical Anterior Retroperitoneal Exposure of the Lumbar Spine in 128 Consecutive Patients[J].World J.Surg.2008,32(1) 9433-9434.
[4]Ikard RW.Methods and complications of anterior exposure of the thoracic and lumbar spine[J].Arch Surg.2006,141(10):1025-1034.
[5]Gumbs AA,Shah RV,Yue JJ et al.The open anterior paramedian retroperitoneal approach for spine procedures[J].Arch Surg.2005.140(4):339-343.
[6]John J,Regan A.Technical Report on videoassisted thoracoscopy Ⅰthoracic spinal surgery[J].Spine,1995,20(7):831-937.
[7]Rajaraman V,Vingan R,RothP,et al.Viscera land vascular complication resulting from anterior lumbarinter body fusion[J].Nerosurg,1999,91(1):60-64.
[8]黄启顺,洪光祥,王发斌,等.医源性周围神经损伤的原因分析与治疗[J].2001,9(5):342-343.
[9]邵岩,顾立强.医源性周围神经损伤的原因及防治(附11例报告).山东医药.2007,47(15):46-47.
[10]Peacock WJ,Arens LJ.Selective posterior rhizotomy for the relief of spasticity incerebral palsy[J].SAFR,MED,1982,62:119-123.
[11]刘景堂,杨惠林,唐天驷.腰椎后外侧部血供的应用解剖学研究及临床意义[J].江苏医药,2005,31(2)150.
[12]党瑞山,程林发,唐军,等.与胸12、腰1椎骨对应的腰骶神经根的应用解剖[J].解剖学杂志,1996,19(5):381-384.
[13]易西南,沈民仁,罗刚,等.腰椎侧面节段血管神经的应用解剖[J].中国临床解剖学杂志,2005,23(5):470-473.23.
[14]金大地.现代脊柱外科手术学[M].第1版北京:人民军医出版社,2001,313.
[15]Kirchmair L,Lirk P,Colvin J,et al.Moriggl B.Lumbar plexus and paoas major muscle:not always as expected.[J].Reg Anesth Pain Med.2008,33(2):109-114.
[16]Capdevila X,Coimbra C,Choquet O.Approaches to the lumbar plexus:Success,risks,and outcome[J].Reg Anesth Pain Med 2005,30:150-162.
[17]Abbott R,Johann-Murphy M,Shiminski-Maher T,et al.Selective dorsal rhizotomy:outcome and complications intreating spastic cercbral palsy[J].Neurosurgery,1993,33(5):851-855.
[18]刘志雄,张伯勋.周围神经外科学[M].第1版北京:人民军医出版社,2004,253-257.
[19]姜洪池,陆朝阳.进一步加深对微创历年的理解[J].中华外科杂志.2008,46(1):3-4.
[20]顾玉东.周围神经损伤诊治的几个基本问题[J].医学临床研究,2004,21(5):449-450.
[21]戴力扬.脊柱前路手术入路[J].中国现代手术学杂志.2001,5(2):148-156.
[22]曹京旭,赵水喜,宋薇.恶性腰大肌综合症[J].中国疼痛学医学杂志,2007,13(4):241-243.
[23]王冰,吕国华.小切口经前路腹膜后人工髓核置换术治疗退行性腰椎间盘疾患[J].中国脊柱脊髓杂志,2005,15(9):542-545.
[24]朱盛修,宋守礼.周围神经伤学[M].第1版北京:人民军医出版社,2001,344-346.
[2]Copper RG,Freemont AJ,Hoyland JA,et al.Herniated intervertebral disc-as-sociated periradi cular fibrosis and vascular abnormal itiesoccur without inflammatory cell infiltration[J].Spine,1995,20:591-598.
[3]Terzis JK,Skoulis TG.,Soucacos PN.Vascularized nerve grafts:A review[J].Int Angiol,1995,14(3):264-277.
[4]Sunderland S.Blood supply of the nerves of the upper limb in man[J].Arch Neurol Psych,1945,53(2):91-115.
[5]Sunderland S.Nerves and Nerve Injuries,2nd Ed.New York:Churchill Livingstone,1978,46.
[6]李吉,姜保国,王伟,等.周围神经血液供应研究的进展及其临床应用[J].解剖科学进展,1995,1(2):118-122.
[7]Taylor GI,Ham FJ.The free vascularized nerve graft:A further experimental and clinic application of microvascular techniques[J].Plast Reconstr Surg,1976,57(4):413-426.
[8]Taylor GI.Nerve grafting with simultaneous microvascular reconstruction[J]. Clin Orthop Relat Res,1978,(133):56-70.
[9]Breidenbach WC,Terzis JK.The anatomy of free vascularized nerve grafts[J].Clin Plast Surg,1984,11(1):65-71.
[10]El-Barrany WG,Marei AG,Vallee B.Anatomic basis of vascularised nerve grafts:the blood supply of peripheral nerves[J].Surg Radiol Anat,1999,21(2):95-102.
[11]Hiroo Suami,G.Ian Taylor,Wei-Ren Pan.Angiosome territories of the nerves of the lower limbs[J].Plast and Reconstr Surg,2003,112(7):1790-1806.
[12]Levy SM,Taylor GI,Baudet J,et al.Angiosomes of the Brachial Plexus:An Anatomical Study[J].Plast;Reconstr Surg,2003,112(7):1799-1806.
[13]Hong MK-H,Hong MK-Y,Taylor GI.Angiosome territories of the nerves of the upper limbs[J].Plast Reconstr Surg,2006,118(1):148-160.
[14]彭田红,唐茂林,徐达传,等.椎管外臂丛的血供分布特点及其临床意义[J].中华骨科杂志,2006,26(7):472-475.
[15]Bendszus,Stoll.Technology insighe:visualizing peripheral nerve injury using MRI[J].Nat Clin Pract Neurol.2005,1(1):45-53.
[16]Howe FA,Filler AG,Bell BA,et al.Magnetic resonance neurography[J].Mang Reson Med.1992,28(2):328-38.
[17]Dailey AT,Tsuruda JS,Filler AG,et al.Magnetic resonance neurography of peripheral nerve degeneration and regeneration[J].Lancet.1997,350(9086):1221-1222.
[18]Kuntz,Blake L,Britz G,et al.Magnetic resonance neurography of peripheral nerve lesions in the lower extremity[J].Neurosurgery.1996,39(4):750-756.
[19]Heilbrun ME,Tsuruda JS,Townsend JJ,et al.Intraneural perineurioma of the common peroneal nerve.Case report and review of the literature[J].Neurosurg.2001,94(5):811-815.
[20]Freund W,Brinkmann A,Wagner F,et al.MR neurography with multiplanar reconstruction of 3D MRI datasets:an anatomical study and clinical applications[J].Neuroadiology.2007,49(4):335-341.
[21]顾立强,张景僚,王刚等.骨盆骨折合并腰骶丛损伤的诊治[J].中华创伤骨科杂志,2002,4(3):174-177.
[1]Howe FA,Filler AG,Bell BA,et al.Magnetic resonance neurography[J].Mang Reson Med.1992,28(2):328-38.
[2]Dailey AT,Tsuruda JS,Filler AG,et al.Magnetic resonance neurography of peripheral nerve degeneration and regeneration[J].Lancet.1997,350(9086):1221-1222.
[3]Kuntz,Blake L,Britz G,et al.Magnetic resonance neurography of peripheral nerve lesions in the lower extremity[J].Neurosurgery.1996,39(4):750-756.
[4]Heilbrun ME,Tsuruda JS,Townsend JJ,et al.Intraneural perineurioma of the common peroneal nerve.Case report and review of the literature[J].Neurosurg..2001,94(5):811-815.
[5]Freund W,Brinkmann A,Wagner F,et al.MR neurography with multiplanar reconstruction of 3D MRI datasets:an anatomical study and clinical applications[J].Neuroadiology.2007,49(4):335-341.
[6]Filler AG,Maravilla KR,Tsumda JS.MR neurography and MR imaging for imaging diagnosis of disorders affecting the peripheral nerves and musculature [J].Neurol Clin,2004,22(3):643-682.
[7]Filler AG,Haynes J,Jordan SE,et al.Sciatica of nondisc origin and piriformis syndrome:diagnosis by magnetic resonance neurog2 raphy and interventional magnetic resonance imaging with outcome study of resulting treatment[J].Neurosurg Spine,2005,2(2):99-115.
[8]Bendszus M,Stoll G.Technology insight:visualizing peripheral nerve injury using MRI[J].Nat Clin Pract Neurol.2005,1(1):45-53.
[9]Lewis AM,Layzer R,Engstrom JW,et al.Magnetic resonance neurography in extraspinal sciatica[J].Arch Neurol.2006,63(10):1469-472.
[10]孙贵新,顾玉东.磁共振神经成像技术在周围神经病变中的应用[J].国外医 学骨科学分册,2003,24(2):122-123.
[11]吕发金,谢鹏,牟君,等.格林2巴利综合征腰丛神经磁共振成像研究[J].中国医学影像技术,2007,23(10):1457-1461.
[1]顾立强,张景僚,王刚等.骨盆骨折合并腰骶丛损伤的诊治[J].中华创伤骨科杂志,2002,4(3):174-177.
[2]唐树杰:金鸿宾:王志彬:苗军,腰椎前路椎间融合术临床应用进展[J].中国骨伤,2008,(1):23-25.
[3]Brewster L,Trueger N,Schermer C,et al.Infraumbilical Anterior Retroperitoneal Exposure of the Lumbar Spine in 128 Consecutive Patients[J].World J.Surg.2008,32(1) 9433-9434.
[4]Ikard RW.Methods and complications of anterior exposure of the thoracic and lumbar spine[J].Arch Surg.2006,141(10):1025-1034.
[5]Gumbs AA,Shah RV,Yue JJ et al.The open anterior paramedian retroperitoneal approach for spine procedures[J].Arch Surg.2005.140(4):339-343.
[6]John J,Regan A.Technical Report on videoassisted thoracoscopy Ⅰthoracic spinal surgery[J].Spine,1995,20(7):831-937.
[7]Rajaraman V,Vingan R,RothP,et al.Viscera land vascular complication resulting from anterior lumbarinter body fusion[J].Nerosurg,1999,91(1):60-64.
[8]黄启顺,洪光祥,王发斌,等.医源性周围神经损伤的原因分析与治疗[J].2001,9(5):342-343.
[9]邵岩,顾立强.医源性周围神经损伤的原因及防治(附11例报告).山东医药.2007,47(15):46-47.
[10]Peacock WJ,Arens LJ.Selective posterior rhizotomy for the relief of spasticity incerebral palsy[J].SAFR,MED,1982,62:119-123.
[11]刘景堂,杨惠林,唐天驷.腰椎后外侧部血供的应用解剖学研究及临床意义[J].江苏医药,2005,31(2)150.
[12]党瑞山,程林发,唐军,等.与胸12、腰1椎骨对应的腰骶神经根的应用解剖[J].解剖学杂志,1996,19(5):381-384.
[13]易西南,沈民仁,罗刚,等.腰椎侧面节段血管神经的应用解剖[J].中国临床解剖学杂志,2005,23(5):470-473.23.
[14]金大地.现代脊柱外科手术学[M].第1版北京:人民军医出版社,2001,313.
[15]Kirchmair L,Lirk P,Colvin J,et al.Moriggl B.Lumbar plexus and paoas major muscle:not always as expected.[J].Reg Anesth Pain Med.2008,33(2):109-114.
[16]Capdevila X,Coimbra C,Choquet O.Approaches to the lumbar plexus:Success,risks,and outcome[J].Reg Anesth Pain Med 2005,30:150-162.
[17]Abbott R,Johann-Murphy M,Shiminski-Maher T,et al.Selective dorsal rhizotomy:outcome and complications intreating spastic cercbral palsy[J].Neurosurgery,1993,33(5):851-855.
[18]刘志雄,张伯勋.周围神经外科学[M].第1版北京:人民军医出版社,2004,253-257.
[19]姜洪池,陆朝阳.进一步加深对微创历年的理解[J].中华外科杂志.2008,46(1):3-4.
[20]顾玉东.周围神经损伤诊治的几个基本问题[J].医学临床研究,2004,21(5):449-450.
[21]戴力扬.脊柱前路手术入路[J].中国现代手术学杂志.2001,5(2):148-156.
[22]曹京旭,赵水喜,宋薇.恶性腰大肌综合症[J].中国疼痛学医学杂志,2007,13(4):241-243.
[23]王冰,吕国华.小切口经前路腹膜后人工髓核置换术治疗退行性腰椎间盘疾患[J].中国脊柱脊髓杂志,2005,15(9):542-545.
[24]朱盛修,宋守礼.周围神经伤学[M].第1版北京:人民军医出版社,2001,344-346.
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