腰椎间孔侵入性操作的应用解剖
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摘要
目的：
一、解剖防腐尸体标本腰椎间孔,观测并记录腰椎间孔部位横孔韧带和体横韧带的分布、起止、走向及其毗邻关系,为腰椎间孔部位的韧带做出形态学的描述,并从解剖形态学上讨论针刀切割松解腰椎间孔韧带的危险性和不确定性等临床问题。
二、解剖、观测并记录腰椎间孔部位节段动脉、腰升静脉、节段静脉、髂腰静脉腰椎分支的出现、分布、起止、走向及其毗邻关系,为腰椎部位的外科手术等侵入性操作提供解剖形态学基础。
三、解剖、观测腰椎部位的2个相对无神经血管区(三角工作区、安全三角区),描述其位置和毗邻关系,为腰椎部位的微创外科手术及注射等侵入性操作提供解剖形态学基础。
方法：
防腐尸体10具,剔除腰脊柱后方及两旁的部分皮肤、筋膜、肌肉等,暴露椎间孔和邻近的神经血管。清除椎间孔脂肪,必要时咬除椎板。观测并记录走行于L1-2～L5/S1椎间孔及其外侧区的的血管、韧带和神经及其毗邻关系,以及安全三角区的解剖。
结果：
一、椎间孔及其外侧区的韧带
1椎间孔入口区和中央区韧带在椎间孔入口区和中央区并没有观测到明显的韧带结构,只观测到一些张于椎间孔入口区和中央区四壁的与神经、血管相连的纤维样组织。在椎管内和椎间孔内脂肪组织非常丰富,几乎将剩余空间填充满。
2椎间孔出口区韧带椎间孔出口区韧带有两组：即横孔上韧带和横孔下韧带。(1)横孔上韧带位于椎间孔出口区上部,起自峡部外缘,横过椎弓下切迹,止于同位椎体外下缘、椎间盘纤维环后纵韧带外侧。100个椎间孔中只有8个L1-2椎间孔和4个L3-4椎间孔出现横孔上韧带。(2)横孔下韧带在L1-2-L3-4椎间孔较粗大,L4_5、L5/S1椎间孔较纤细或缺如。起于横突根上缘与上关节突交界处、上关节突前缘骨面,止于同位椎体或椎间盘纤维环后纵韧带外侧。100个椎间孔中,43个L1-2-L3-4和2个L4-5椎间孔出现横孔下韧带。(3)横孔上韧带和横孔下韧带将椎间孔出口区分成3个孔(间隔),上孔和下孔小,中孔大。上孔通过椎间静脉上支,中间孔通过脊神经和节段动脉脊支,下孔通过椎间静脉下支
3椎间孔外侧区韧带(1)体横韧带,多见于L5/S1椎间孔,分为体横上、下韧带。体横上韧带由椎体外下缘、椎间盘侧壁或下位椎体外上缘连结于同位横突下部；体横下韧带由同位椎体外上缘、椎间盘纤维环侧壁或上位椎体外下缘连结于骶骨翼上缘。本实验中20个L5/S1椎间孔发现体横上韧带5条；体横下韧带2条。其余椎间孔未见体横韧带。(2)体横韧带将L5/S1椎间孔分为3个孔,即前上孔、后孔、前下孔。①前上孔有腰交感神经、椎间静脉上支的前支。②后孔有椎间静脉上支的后支、髂腰动静脉腰支。③前下孔有L5神经,有时有椎间静脉下支。(3)横突间韧带腱弓,起始部很广,由椎弓根下切迹、乳突下内缘甚至峡部外下缘沿横突下缘往后外与横突间韧带相连；向下止于横突根与上关节突相接处的前上缘。腱弓从前内斜向后外,与脊神经后支及分支垂直而伴行。腱弓在L1-2-L4-5椎间孔外侧区均发现,L5/S1椎间孔处无此腱弓。腱弓有时分束至椎间关节,形成一个“E”形弓,脊神经后支和其分支及其伴行的下关节血管行于“E”形弓的下部,上关节血管行于“E”形弓的上部。
二、椎间孔及其外侧区的神经
在椎间孔中央区,腰脊神经被椎间孔中央区纤维样和筋膜样结构固定。在椎间孔出口区,腰脊神经行于横孔上韧带下、横孔下韧带上。在椎间孔外侧区,腰脊神经行于体横下韧带下方。在离开椎间孔后,前后支分叉处几乎紧贴腱弓,脊神经如一个“Y”字岔在腱弓两旁。交感神经在椎间孔出口区或外侧区的腹侧中下部连接脊神经。
三、椎间孔及其外侧区的动脉
L1-4腰动脉行至椎间孔处分为3组终末支：即前支组、脊支组和后支组。入L5/S1椎间孔的是髂腰动脉腰支或L4动脉下降分支,20个L5/S1椎间孔处的动脉,有11支为髂腰动脉腰支,6支为L4动脉下降分支,3例缺失。
四、椎间孔及其外侧区的静脉
由椎内静脉发出的椎间静脉出椎间孔后汇入腰升静脉或腰静脉。同时腰升静脉或腰静脉在椎间孔外侧区收纳横突前静脉、椎外静脉后丛的属支。椎间静脉在侧隐窝的椎内前静脉丛或椎内后静脉丛发出,分为椎间静脉上、下支,上下支有1-3支不等,向外行于横孔上韧带上方和横孔下韧带下方。L5/S1椎间孔往往缺乏椎间静脉下支。实验发现部分椎间静脉下支至腰静脉的交通支经过安全三角区。
五、三角工作区
1横突上缘三角工作区(通常称为腰椎间孔三角工作区、安全三角区)即脊神经前后支、上关节突和横突根上缘构成的三角工作区。但有时此“三角工作区”亦有腰升静脉或(和)椎间静脉下支至腰静脉的连接支。这两条静脉管壁薄,管径大。(1)本实验100个腰椎椎间孔发现椎间静脉下支至腰静脉的交通支共67条,横突上缘三角工作区中12个有交通支从三角工作区中心穿过,27个横突上缘三角工作区旁侧有交通支经过,28个三角工作区浅面和外侧有交通支穿过。(2)本实验20侧共发现16侧有腰升静脉。100个腰椎椎间孔横突上缘三角工作区中3个有腰升静脉从三角工作区中心内穿过,14个从三角工作区旁侧穿过,36个从三角工作区浅层和外侧穿过,其余椎间孔未见腰升静脉。有12%腰横突根上缘三角工作区出现腰升静脉或(和)椎间静脉下支至腰静脉的交通支穿过三角工作区中心。
2椎板外三角工作区相邻两横突根(或横突与骶翼)连线的中点紧贴椎板外缘发现一个相对无神经血管的三角工作区(椎板外三角工作区)。此三角的底边是椎板和椎间关节外缘,上边是上关节血管,下边是下关节血管和脊神经后支。
结论：
一、腰椎间孔的韧带有体横韧带和横孔韧带。横孔韧带主要分布于上腰椎椎间孔,体横韧带主要分布于下腰椎间孔。腰椎间孔韧带出现率低、变异大,毗邻腰神经和血管,针刀在此处盲切危险性大,同时操作意义小,故建议临床慎用针刀在腰椎间孔处盲切。
二、腰椎间孔韧带的作用我们认为韧带的作用分为生理状态和病理状态。生理状态下,其作用如下：(1)起固定腰脊神经的作用。在神经受牵拉时保护神经,不至于牵扯脊膜和脊髓。(2)起支持腰脊神经作用。腰椎间孔多呈钥匙眼形,少数呈三角形,横孔下韧带将椎间孔分为较大的上孔和较小的下孔,如果横孔下韧带切断,则会使有效空间变小,神经根坠入椎间管下部,更易遭受卡压。(3)保护血管,尤其是椎间静脉下支。如果没有横孔下韧带,椎间静脉下支势必受到脊神经的压迫。病理状态下,在创伤、退变等病理状态下,椎间隙变窄或突出的腰椎间盘致使椎间孔空间变窄,椎间孔韧带起牵袢固定作用,减少腰椎间孔的有效空间,可能束缚神经根,使神经根不能有效避让,使神经根被增生肥大的椎间关节、外侧型和极外侧型突出的腰椎间盘等卡压,产生临床症状
三、腰椎间孔出口区几乎被神经血管封闭,在相邻两横突根(或横突根与骶翼)连线的中点紧贴椎板外缘,以及横突根(或骶翼)上缘存在2个相对无神经血管区(三角工作区),但有12%腰横突根上缘三角工作区出现腰升静脉或(和)椎间静脉下支至腰静脉的交通支穿过三角工作区中心。故临床须注意“三角工作区”为相对无血管区,腰椎侧后方手术要注意入路区可能存在的血管。腰椎间孔穿刺时,针尖宜从两横突根中点,并紧贴椎板外缘刺入。
Objective:
1. To dissect, observe and record the occurrence, start-stop position, move towards and contiguity of ligaments of lumbar intervertebral foramina, in order to probe into the morphology of ligaments of lumbar intervertebral foramina and clinic problems such as the danger and uncertainty to cut ligaments using Zhendao.
2. To dissect, observe and record the occurrence, start-stop position, move towards and contiguity of segmental arteries, ascending lumbar veins, segmental veins, lumbar branch of iliolumbar veins of lumbar intervertebral foramina, in order to provide morphology for lumbar intervertebral foramina surgeries.
3. To dissect, observe and record the location and contiguity of 2 relatively lacking blood vessel and nerve zones (triangular working zones, security triangle), in order to provide morphology for intrusive operations of lumbar intervertebral foramina such as surgeries and injections.
Methods:Dissected, observed and recorded the blood vessels, ligaments, nerves, their adjacent relations through L1-2～L5/S1 intervertebral foramina on 10 antiseptic cadaver specimens after that part of the skins, fasciae, muscles were eliminated from the lumbar spine and fats and laminae of vertebral was removed from intervertebral foramina when necessary.
Results:
1. Ligaments in lumbar intervertebral foramina and its lateral area
(1) Ligaments in lumbar intervertebral foramina entrance zones and central zones There were no ligaments found on lumbar intervertebral foramina and its lateral werea. Only some things like fibrous tissue was found that connected on neurovascular and lumbar intervertebral foramina entrance zones and central zones. And adipose tissue was so rich that it could fill to the full on spinal canal and lumbar intervertebral foramina.
(2) Ligaments in lumbar intervertebral foramina exit zones There were two group ligaments named superior transforaminal ligaments and inferior transforaminal ligaments in lumbar intervertebral foramina.①Superior transforaminal ligaments, which started at periphery of isthmian part of lumbar vertebral arch and stopped at inferolateral vertebral body and the lateral of posterior longitudinal ligaments, passed through the upper of lumbar intervertebral foramina. There were only 8 superior transforaminal ligaments in L1-2-L3-4and 4 in L3-4 of all 100 lumbar intervertebral foramina.②Inferior transforaminal ligaments, that started at the junctions of transverse process root and superior articular process, the front of superior articular process and stopped at the lateral posterior longitudinal ligament, the same segment of lumbar vertebral body or disc, were bulky in L1-2～L3-4 and slender or missing in L4-5、L5/S1. There were only 43 inferior transforaminal ligaments in L1-2-L34 and 2 in L3-4 of all 100 lumbar intervertebral foramina.③Lumbar intervertebral foramina exit zones were divided to 3 holes by transforaminal ligaments. And there were superior lumber intervertebral veins in the smaller superior holes, lumber nerves and lumber branches of segmental arteries in the bigger middle holes and inferior intervertebral veins in the smaller inferior holes.
(3) Ligaments in lateral lumbar intervertebral foramina①Almost all corporotransverse ligaments, which were distributing in L5/S1 lumbar intervertebral foramina, were divided into corporotransverse superior and inferior ligaments. Corporotransverse superior ligaments started at the same segment inferior outside of the vertebrae, the lateral annulus fibrosus or superior outside of the lower vertebrae, and stopped at the lower part of transverse process. Corporotransverse inferior ligaments started at the same segment superior outside of the vertebrae, the lateral annulus fibrosus or the superior outside of the upper vertebrae, and stopped at the upper part of ala of sacrum.5 corporotransverse superior ligaments and 2 corporotransverse inferior ligaments were found in all the 20 L5/S1 lumbar intervertebral foramina in this experiment and no corporotransverse ligament was found in other lumbar intervertebral foramina.②L5/S1 lateral lumbar intervertebral foramina were divided into 3 holes by corporotransverse ligaments. That were anterosuperior hole, posterior hole and anteroinferior hole. There were communicating branches of lumbar sympathetic and anterosuperior branches of intervertebral vein in the smaller anterosuperior hole, and posterior branch of intervertebral vein and lumber branch of iliolumbar vessels in the bigger posterior hole, and 5th lumber nerve and sometimes inferior intervertebral vein in the smaller anteroinferior hole.③Tendinous arch of intertransverse ligament strated extensively at inferior vertebral notch, inferomedial mamillary process and inferolateral isthmian part of lumbar vertebral arch, and posterolaterally merged together with intertransverse ligament, and downward stopped at anterosuperior transverse process root and superior articular process. Tendinous arch travelled obliquely, and was vertical and accompanying with posterior branch of lumber nerve and its dorsal branch. Tendinous arch which was found in L1-2-L4-5 but no in L5/S1 lumbar intervertebral foramina, sometimes diverged with a branch to zygapophysial joint and look like the shape of E. Posterior branch of lumber nerve, its dorsal branch and superior joint vessel were distributing in the upper of the E, and the inferior joint vessel was distributing in the inferior of E.
2. Nerves in lumbar intervertebral foramina and its lateral area
Lumbar nerves were fixed by fibrous tissue in lumbar intervertebral foramina central zones, and were distributing in the above of inferior transforaminal ligaments and under the superior transforaminal ligaments in lumbar intervertebral foramina exit zones, also were distributing in the above of corporotransverse inferior ligaments and under the corporotransverse superior ligaments in lateral lumbar intervertebral foramina. Bifurcation of anterior and posterior branches of lumber nerve was closing to the tendinous arch, and lumbar nerve look like Y that forked alongside tendinous arch. Communicating branches of lumbar sympathetic connected to lumbar nerves in the lower of ventral lumbar intervertebral foramina and its lateral area.
3. Arteries in lumbar intervertebral foramina and its lateral area
L1-4 segmental arteries were divided into 3 terminal branches named anterior branch group, middle branch group and posterior branch group in lumbar intervertebral foramina. Lumbar branch of iliolumbar artery or branch of L4 segmental artery went into the L5/S1 lumbar intervertebral foramina. And there were 11 lumbar branches of iliolumbar arteries and 6 branches of L4 segmental arteries which went into the L5/S1 lumbar intervertebral foramina and no artery in 3 intervertebral foramina in all 20 intervertebral foramina
4. Veins in lumbar intervertebral foramina and its lateral area
Intervertebral veins, that were separated from vertbral venous plexus, transfused into lumbar vein or ascending lumbar vein which also accepted the branches of posterior outer vertebral venous plexus. Intervertebral vein were separated from anterior or posterior outer vertebral venous plexus that were divided into inferior and superior branches including 1-3 branches which were distributing above superior transforaminal ligaments and down inferior transforaminal ligaments. There were usually no intervertebral vein in L5/S1 lumbar intervertebral foramina. But some linking vein between intervertebral vein and lumbar veins were observed in triangular working zones upon root of transverse process in this experiment
5. Triangular working zones
(1)Triangular working zones upon root of transverse processus (usually named triangular working zones of lumbar intervertebral foramina or security triangle) were constituted by anterior and posterior branches of lumbar nerves, superior articular process and the upper of root of transverse process. But ascending lumbar vein and linking vein between intervertebral vein and lumbar veins were observed in some triangular working zones upon root of transverse process. These two veins were thin wall, large diameter.①67 linking veins between intervertebral veins and-lumbar veins were found in all 100 lumbar intervertebral foramina. And of all the 67 linking veins, there were 12 threading in the center of this triangular working zones, and 27 in the flanking region and 28 in the lateral region or facies anterior.②Ascending lumbar veins were found in 16 in all 20 lateral region.3 ascending lumbar veins were threading in the center of this triangular working zones, and 14 in the flanking region and 36 in the lateral region or facies anterior in all 100 lumbar intervertebral foramina. Ascending lumbar vein and linking vein between intervertebral vein and lumbar veins were observed in the center of 12% triangular working zones upon root of transverse processus.
(2) Triangular working zones outsides lanmina of vertebral arch, which were area of relatively without vessels and nerves, were located adjacent two roots of transverse process or root of transverse process and ala of sacrum and were closing to the outer of lanmina of vertebral arch. These triangular working zones were constituted by hemline of the outer of lanmina of vertebral arch and zygapophysial joint, a side of the superior joint vascular, a side of the inferior joint vascular and posterior branch of lumber nerve.
Conclusion:
1. Ligaments in lumbar intervertebral foramina were transforaminal ligaments which were mostly distributing in the upper of intervertebral foramina and corporotransverse ligaments which were mostly distributing in the lower intervertebral foramina. As they were low rate in appearance, high rate in variability, and adjacent with lumber nerves and vessels, Zhendao cutting blindly here was dangerous and meaningless which would be cautious.
2. We supported that the role of ligaments in lumbar intervertebral foramina would be discussed in physiology and pathology conditions. (1) In physiology condition, firstly ligaments could fix the lumber nerves and avoid that meninges and spinal cord were torn when the nerves were tearing. And secondly they could prop up the nerves to avoid that nerves could be entrapped by the small lower of intervertebral foramina which mostly presented to be key eye shape and and sometimes triangle, Thirdly they could protect vessels especially the superior branches of intervertebral vein which would be oppressed by lumber nerves if there was no inferior transforaminal ligaments. (2) In pathology condition such as trauma and regression, lumbar nerve root could not elude from the hyperplastic zygapophysial joint and the herniated disc for that foraminal space was narrow and nerves were fixed by ligaments.
3. Lumbar intervertebral foramina exit zones were almost sealed with nerves and blood vessels. Two relatively lacking blood vessel and nerve zones (triangular working zones) were sat beside lamina of vertebralar arch and midpoint of the line of two adjacent roots of transverse process, and upon root of transverse process. But ascending lumbar vein and linking vein between intervertebral vein and lumbar veins were observed in 12% triangular working zones upon root of transverse process. Triangular working zone was relatively without blood vessels existence. Attentions should paid to the veins that exist in admission passage zone for intrusive operations of posterior-lateral lumbar vertebra. Intervertebral foramina puncture was recommended to prick beside lamina of vertebralar arch and midpoint of the line of two adjacent roots of transverse process. As lumbar intervertebral foramina exit zone was almost sealed with nerves and blood vessels, blind acupotomy was dangerous in here.
一、解剖防腐尸体标本腰椎间孔,观测并记录腰椎间孔部位横孔韧带和体横韧带的分布、起止、走向及其毗邻关系,为腰椎间孔部位的韧带做出形态学的描述,并从解剖形态学上讨论针刀切割松解腰椎间孔韧带的危险性和不确定性等临床问题。
二、解剖、观测并记录腰椎间孔部位节段动脉、腰升静脉、节段静脉、髂腰静脉腰椎分支的出现、分布、起止、走向及其毗邻关系,为腰椎部位的外科手术等侵入性操作提供解剖形态学基础。
三、解剖、观测腰椎部位的2个相对无神经血管区(三角工作区、安全三角区),描述其位置和毗邻关系,为腰椎部位的微创外科手术及注射等侵入性操作提供解剖形态学基础。
方法：
防腐尸体10具,剔除腰脊柱后方及两旁的部分皮肤、筋膜、肌肉等,暴露椎间孔和邻近的神经血管。清除椎间孔脂肪,必要时咬除椎板。观测并记录走行于L1-2～L5/S1椎间孔及其外侧区的的血管、韧带和神经及其毗邻关系,以及安全三角区的解剖。
结果：
一、椎间孔及其外侧区的韧带
1椎间孔入口区和中央区韧带在椎间孔入口区和中央区并没有观测到明显的韧带结构,只观测到一些张于椎间孔入口区和中央区四壁的与神经、血管相连的纤维样组织。在椎管内和椎间孔内脂肪组织非常丰富,几乎将剩余空间填充满。
2椎间孔出口区韧带椎间孔出口区韧带有两组：即横孔上韧带和横孔下韧带。(1)横孔上韧带位于椎间孔出口区上部,起自峡部外缘,横过椎弓下切迹,止于同位椎体外下缘、椎间盘纤维环后纵韧带外侧。100个椎间孔中只有8个L1-2椎间孔和4个L3-4椎间孔出现横孔上韧带。(2)横孔下韧带在L1-2-L3-4椎间孔较粗大,L4_5、L5/S1椎间孔较纤细或缺如。起于横突根上缘与上关节突交界处、上关节突前缘骨面,止于同位椎体或椎间盘纤维环后纵韧带外侧。100个椎间孔中,43个L1-2-L3-4和2个L4-5椎间孔出现横孔下韧带。(3)横孔上韧带和横孔下韧带将椎间孔出口区分成3个孔(间隔),上孔和下孔小,中孔大。上孔通过椎间静脉上支,中间孔通过脊神经和节段动脉脊支,下孔通过椎间静脉下支
3椎间孔外侧区韧带(1)体横韧带,多见于L5/S1椎间孔,分为体横上、下韧带。体横上韧带由椎体外下缘、椎间盘侧壁或下位椎体外上缘连结于同位横突下部；体横下韧带由同位椎体外上缘、椎间盘纤维环侧壁或上位椎体外下缘连结于骶骨翼上缘。本实验中20个L5/S1椎间孔发现体横上韧带5条；体横下韧带2条。其余椎间孔未见体横韧带。(2)体横韧带将L5/S1椎间孔分为3个孔,即前上孔、后孔、前下孔。①前上孔有腰交感神经、椎间静脉上支的前支。②后孔有椎间静脉上支的后支、髂腰动静脉腰支。③前下孔有L5神经,有时有椎间静脉下支。(3)横突间韧带腱弓,起始部很广,由椎弓根下切迹、乳突下内缘甚至峡部外下缘沿横突下缘往后外与横突间韧带相连；向下止于横突根与上关节突相接处的前上缘。腱弓从前内斜向后外,与脊神经后支及分支垂直而伴行。腱弓在L1-2-L4-5椎间孔外侧区均发现,L5/S1椎间孔处无此腱弓。腱弓有时分束至椎间关节,形成一个“E”形弓,脊神经后支和其分支及其伴行的下关节血管行于“E”形弓的下部,上关节血管行于“E”形弓的上部。
二、椎间孔及其外侧区的神经
在椎间孔中央区,腰脊神经被椎间孔中央区纤维样和筋膜样结构固定。在椎间孔出口区,腰脊神经行于横孔上韧带下、横孔下韧带上。在椎间孔外侧区,腰脊神经行于体横下韧带下方。在离开椎间孔后,前后支分叉处几乎紧贴腱弓,脊神经如一个“Y”字岔在腱弓两旁。交感神经在椎间孔出口区或外侧区的腹侧中下部连接脊神经。
三、椎间孔及其外侧区的动脉
L1-4腰动脉行至椎间孔处分为3组终末支：即前支组、脊支组和后支组。入L5/S1椎间孔的是髂腰动脉腰支或L4动脉下降分支,20个L5/S1椎间孔处的动脉,有11支为髂腰动脉腰支,6支为L4动脉下降分支,3例缺失。
四、椎间孔及其外侧区的静脉
由椎内静脉发出的椎间静脉出椎间孔后汇入腰升静脉或腰静脉。同时腰升静脉或腰静脉在椎间孔外侧区收纳横突前静脉、椎外静脉后丛的属支。椎间静脉在侧隐窝的椎内前静脉丛或椎内后静脉丛发出,分为椎间静脉上、下支,上下支有1-3支不等,向外行于横孔上韧带上方和横孔下韧带下方。L5/S1椎间孔往往缺乏椎间静脉下支。实验发现部分椎间静脉下支至腰静脉的交通支经过安全三角区。
五、三角工作区
1横突上缘三角工作区(通常称为腰椎间孔三角工作区、安全三角区)即脊神经前后支、上关节突和横突根上缘构成的三角工作区。但有时此“三角工作区”亦有腰升静脉或(和)椎间静脉下支至腰静脉的连接支。这两条静脉管壁薄,管径大。(1)本实验100个腰椎椎间孔发现椎间静脉下支至腰静脉的交通支共67条,横突上缘三角工作区中12个有交通支从三角工作区中心穿过,27个横突上缘三角工作区旁侧有交通支经过,28个三角工作区浅面和外侧有交通支穿过。(2)本实验20侧共发现16侧有腰升静脉。100个腰椎椎间孔横突上缘三角工作区中3个有腰升静脉从三角工作区中心内穿过,14个从三角工作区旁侧穿过,36个从三角工作区浅层和外侧穿过,其余椎间孔未见腰升静脉。有12%腰横突根上缘三角工作区出现腰升静脉或(和)椎间静脉下支至腰静脉的交通支穿过三角工作区中心。
2椎板外三角工作区相邻两横突根(或横突与骶翼)连线的中点紧贴椎板外缘发现一个相对无神经血管的三角工作区(椎板外三角工作区)。此三角的底边是椎板和椎间关节外缘,上边是上关节血管,下边是下关节血管和脊神经后支。
结论：
一、腰椎间孔的韧带有体横韧带和横孔韧带。横孔韧带主要分布于上腰椎椎间孔,体横韧带主要分布于下腰椎间孔。腰椎间孔韧带出现率低、变异大,毗邻腰神经和血管,针刀在此处盲切危险性大,同时操作意义小,故建议临床慎用针刀在腰椎间孔处盲切。
二、腰椎间孔韧带的作用我们认为韧带的作用分为生理状态和病理状态。生理状态下,其作用如下：(1)起固定腰脊神经的作用。在神经受牵拉时保护神经,不至于牵扯脊膜和脊髓。(2)起支持腰脊神经作用。腰椎间孔多呈钥匙眼形,少数呈三角形,横孔下韧带将椎间孔分为较大的上孔和较小的下孔,如果横孔下韧带切断,则会使有效空间变小,神经根坠入椎间管下部,更易遭受卡压。(3)保护血管,尤其是椎间静脉下支。如果没有横孔下韧带,椎间静脉下支势必受到脊神经的压迫。病理状态下,在创伤、退变等病理状态下,椎间隙变窄或突出的腰椎间盘致使椎间孔空间变窄,椎间孔韧带起牵袢固定作用,减少腰椎间孔的有效空间,可能束缚神经根,使神经根不能有效避让,使神经根被增生肥大的椎间关节、外侧型和极外侧型突出的腰椎间盘等卡压,产生临床症状
三、腰椎间孔出口区几乎被神经血管封闭,在相邻两横突根(或横突根与骶翼)连线的中点紧贴椎板外缘,以及横突根(或骶翼)上缘存在2个相对无神经血管区(三角工作区),但有12%腰横突根上缘三角工作区出现腰升静脉或(和)椎间静脉下支至腰静脉的交通支穿过三角工作区中心。故临床须注意“三角工作区”为相对无血管区,腰椎侧后方手术要注意入路区可能存在的血管。腰椎间孔穿刺时,针尖宜从两横突根中点,并紧贴椎板外缘刺入。
Objective:
1. To dissect, observe and record the occurrence, start-stop position, move towards and contiguity of ligaments of lumbar intervertebral foramina, in order to probe into the morphology of ligaments of lumbar intervertebral foramina and clinic problems such as the danger and uncertainty to cut ligaments using Zhendao.
2. To dissect, observe and record the occurrence, start-stop position, move towards and contiguity of segmental arteries, ascending lumbar veins, segmental veins, lumbar branch of iliolumbar veins of lumbar intervertebral foramina, in order to provide morphology for lumbar intervertebral foramina surgeries.
3. To dissect, observe and record the location and contiguity of 2 relatively lacking blood vessel and nerve zones (triangular working zones, security triangle), in order to provide morphology for intrusive operations of lumbar intervertebral foramina such as surgeries and injections.
Methods:Dissected, observed and recorded the blood vessels, ligaments, nerves, their adjacent relations through L1-2～L5/S1 intervertebral foramina on 10 antiseptic cadaver specimens after that part of the skins, fasciae, muscles were eliminated from the lumbar spine and fats and laminae of vertebral was removed from intervertebral foramina when necessary.
Results:
1. Ligaments in lumbar intervertebral foramina and its lateral area
(1) Ligaments in lumbar intervertebral foramina entrance zones and central zones There were no ligaments found on lumbar intervertebral foramina and its lateral werea. Only some things like fibrous tissue was found that connected on neurovascular and lumbar intervertebral foramina entrance zones and central zones. And adipose tissue was so rich that it could fill to the full on spinal canal and lumbar intervertebral foramina.
(2) Ligaments in lumbar intervertebral foramina exit zones There were two group ligaments named superior transforaminal ligaments and inferior transforaminal ligaments in lumbar intervertebral foramina.①Superior transforaminal ligaments, which started at periphery of isthmian part of lumbar vertebral arch and stopped at inferolateral vertebral body and the lateral of posterior longitudinal ligaments, passed through the upper of lumbar intervertebral foramina. There were only 8 superior transforaminal ligaments in L1-2-L3-4and 4 in L3-4 of all 100 lumbar intervertebral foramina.②Inferior transforaminal ligaments, that started at the junctions of transverse process root and superior articular process, the front of superior articular process and stopped at the lateral posterior longitudinal ligament, the same segment of lumbar vertebral body or disc, were bulky in L1-2～L3-4 and slender or missing in L4-5、L5/S1. There were only 43 inferior transforaminal ligaments in L1-2-L34 and 2 in L3-4 of all 100 lumbar intervertebral foramina.③Lumbar intervertebral foramina exit zones were divided to 3 holes by transforaminal ligaments. And there were superior lumber intervertebral veins in the smaller superior holes, lumber nerves and lumber branches of segmental arteries in the bigger middle holes and inferior intervertebral veins in the smaller inferior holes.
(3) Ligaments in lateral lumbar intervertebral foramina①Almost all corporotransverse ligaments, which were distributing in L5/S1 lumbar intervertebral foramina, were divided into corporotransverse superior and inferior ligaments. Corporotransverse superior ligaments started at the same segment inferior outside of the vertebrae, the lateral annulus fibrosus or superior outside of the lower vertebrae, and stopped at the lower part of transverse process. Corporotransverse inferior ligaments started at the same segment superior outside of the vertebrae, the lateral annulus fibrosus or the superior outside of the upper vertebrae, and stopped at the upper part of ala of sacrum.5 corporotransverse superior ligaments and 2 corporotransverse inferior ligaments were found in all the 20 L5/S1 lumbar intervertebral foramina in this experiment and no corporotransverse ligament was found in other lumbar intervertebral foramina.②L5/S1 lateral lumbar intervertebral foramina were divided into 3 holes by corporotransverse ligaments. That were anterosuperior hole, posterior hole and anteroinferior hole. There were communicating branches of lumbar sympathetic and anterosuperior branches of intervertebral vein in the smaller anterosuperior hole, and posterior branch of intervertebral vein and lumber branch of iliolumbar vessels in the bigger posterior hole, and 5th lumber nerve and sometimes inferior intervertebral vein in the smaller anteroinferior hole.③Tendinous arch of intertransverse ligament strated extensively at inferior vertebral notch, inferomedial mamillary process and inferolateral isthmian part of lumbar vertebral arch, and posterolaterally merged together with intertransverse ligament, and downward stopped at anterosuperior transverse process root and superior articular process. Tendinous arch travelled obliquely, and was vertical and accompanying with posterior branch of lumber nerve and its dorsal branch. Tendinous arch which was found in L1-2-L4-5 but no in L5/S1 lumbar intervertebral foramina, sometimes diverged with a branch to zygapophysial joint and look like the shape of E. Posterior branch of lumber nerve, its dorsal branch and superior joint vessel were distributing in the upper of the E, and the inferior joint vessel was distributing in the inferior of E.
2. Nerves in lumbar intervertebral foramina and its lateral area
Lumbar nerves were fixed by fibrous tissue in lumbar intervertebral foramina central zones, and were distributing in the above of inferior transforaminal ligaments and under the superior transforaminal ligaments in lumbar intervertebral foramina exit zones, also were distributing in the above of corporotransverse inferior ligaments and under the corporotransverse superior ligaments in lateral lumbar intervertebral foramina. Bifurcation of anterior and posterior branches of lumber nerve was closing to the tendinous arch, and lumbar nerve look like Y that forked alongside tendinous arch. Communicating branches of lumbar sympathetic connected to lumbar nerves in the lower of ventral lumbar intervertebral foramina and its lateral area.
3. Arteries in lumbar intervertebral foramina and its lateral area
L1-4 segmental arteries were divided into 3 terminal branches named anterior branch group, middle branch group and posterior branch group in lumbar intervertebral foramina. Lumbar branch of iliolumbar artery or branch of L4 segmental artery went into the L5/S1 lumbar intervertebral foramina. And there were 11 lumbar branches of iliolumbar arteries and 6 branches of L4 segmental arteries which went into the L5/S1 lumbar intervertebral foramina and no artery in 3 intervertebral foramina in all 20 intervertebral foramina
4. Veins in lumbar intervertebral foramina and its lateral area
Intervertebral veins, that were separated from vertbral venous plexus, transfused into lumbar vein or ascending lumbar vein which also accepted the branches of posterior outer vertebral venous plexus. Intervertebral vein were separated from anterior or posterior outer vertebral venous plexus that were divided into inferior and superior branches including 1-3 branches which were distributing above superior transforaminal ligaments and down inferior transforaminal ligaments. There were usually no intervertebral vein in L5/S1 lumbar intervertebral foramina. But some linking vein between intervertebral vein and lumbar veins were observed in triangular working zones upon root of transverse process in this experiment
5. Triangular working zones
(1)Triangular working zones upon root of transverse processus (usually named triangular working zones of lumbar intervertebral foramina or security triangle) were constituted by anterior and posterior branches of lumbar nerves, superior articular process and the upper of root of transverse process. But ascending lumbar vein and linking vein between intervertebral vein and lumbar veins were observed in some triangular working zones upon root of transverse process. These two veins were thin wall, large diameter.①67 linking veins between intervertebral veins and-lumbar veins were found in all 100 lumbar intervertebral foramina. And of all the 67 linking veins, there were 12 threading in the center of this triangular working zones, and 27 in the flanking region and 28 in the lateral region or facies anterior.②Ascending lumbar veins were found in 16 in all 20 lateral region.3 ascending lumbar veins were threading in the center of this triangular working zones, and 14 in the flanking region and 36 in the lateral region or facies anterior in all 100 lumbar intervertebral foramina. Ascending lumbar vein and linking vein between intervertebral vein and lumbar veins were observed in the center of 12% triangular working zones upon root of transverse processus.
(2) Triangular working zones outsides lanmina of vertebral arch, which were area of relatively without vessels and nerves, were located adjacent two roots of transverse process or root of transverse process and ala of sacrum and were closing to the outer of lanmina of vertebral arch. These triangular working zones were constituted by hemline of the outer of lanmina of vertebral arch and zygapophysial joint, a side of the superior joint vascular, a side of the inferior joint vascular and posterior branch of lumber nerve.
Conclusion:
1. Ligaments in lumbar intervertebral foramina were transforaminal ligaments which were mostly distributing in the upper of intervertebral foramina and corporotransverse ligaments which were mostly distributing in the lower intervertebral foramina. As they were low rate in appearance, high rate in variability, and adjacent with lumber nerves and vessels, Zhendao cutting blindly here was dangerous and meaningless which would be cautious.
2. We supported that the role of ligaments in lumbar intervertebral foramina would be discussed in physiology and pathology conditions. (1) In physiology condition, firstly ligaments could fix the lumber nerves and avoid that meninges and spinal cord were torn when the nerves were tearing. And secondly they could prop up the nerves to avoid that nerves could be entrapped by the small lower of intervertebral foramina which mostly presented to be key eye shape and and sometimes triangle, Thirdly they could protect vessels especially the superior branches of intervertebral vein which would be oppressed by lumber nerves if there was no inferior transforaminal ligaments. (2) In pathology condition such as trauma and regression, lumbar nerve root could not elude from the hyperplastic zygapophysial joint and the herniated disc for that foraminal space was narrow and nerves were fixed by ligaments.
3. Lumbar intervertebral foramina exit zones were almost sealed with nerves and blood vessels. Two relatively lacking blood vessel and nerve zones (triangular working zones) were sat beside lamina of vertebralar arch and midpoint of the line of two adjacent roots of transverse process, and upon root of transverse process. But ascending lumbar vein and linking vein between intervertebral vein and lumbar veins were observed in 12% triangular working zones upon root of transverse process. Triangular working zone was relatively without blood vessels existence. Attentions should paid to the veins that exist in admission passage zone for intrusive operations of posterior-lateral lumbar vertebra. Intervertebral foramina puncture was recommended to prick beside lamina of vertebralar arch and midpoint of the line of two adjacent roots of transverse process. As lumbar intervertebral foramina exit zone was almost sealed with nerves and blood vessels, blind acupotomy was dangerous in here.
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[1]孟庆云,柳顺锁,刘志双.神经阻滞学[M].北京：人民卫生出版社,2003.
[2]张雪.基础麻醉结合骶管阻滞麻醉在小儿腹部及会阴部手术的应用[J].广西中医学院学报,2007,10(4)：61-62.
[3]王梅玲,吴刚.氯胺酮复合骶管麻醉在小儿先天性髋关节脱位手术中的应用[J].中国当代医学,2008,7(2)：44-45.
[4]王特,石云峰,王述波,孙鲁军.连续骶管麻醉用于小儿先天性髋关节脱位髋臼成形手术[J].中医正骨,2008,20(1)：26.
[5]李昭晖,钱建平,王百胜.氯胺酮复合咪唑安定辅助小儿骶管麻醉的临床观察[J].新疆医学,2008,38(3)：56-57.
[6]田波.套管针连续骶管麻醉复合异丙酚用于小儿尿道下裂手术的应用[J].第四军医大学学报,2008,29(16)：1531.
[7]任海霞,王章.硬膜外腔芬太尼复合液辅助骶管麻醉用于无痛分娩的体会[J].实用医技杂志,2004,11(12B)：2678.
[8]郝伟,张文海.穴位封闭骶管阻滞分娩镇痛300例临床总结[J].中国实用医学研究杂志,2002,1(4)：35-36.
[9]赵砚丽.骶管阻滞麻醉在分娩镇痛中的应用[J].中国实用妇科与产科杂志,2000,16(2)：74-76.
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[1]孟庆云,柳顺锁,刘志双.神经阻滞学[M].北京：人民卫生出版社,2003.
[2]张雪.基础麻醉结合骶管阻滞麻醉在小儿腹部及会阴部手术的应用[J].广西中医学院学报,2007,10(4)：61-62.
[3]王梅玲,吴刚.氯胺酮复合骶管麻醉在小儿先天性髋关节脱位手术中的应用[J].中国当代医学,2008,7(2)：44-45.
[4]王特,石云峰,王述波,孙鲁军.连续骶管麻醉用于小儿先天性髋关节脱位髋臼成形手术[J].中医正骨,2008,20(1)：26.
[5]李昭晖,钱建平,王百胜.氯胺酮复合咪唑安定辅助小儿骶管麻醉的临床观察[J].新疆医学,2008,38(3)：56-57.
[6]田波.套管针连续骶管麻醉复合异丙酚用于小儿尿道下裂手术的应用[J].第四军医大学学报,2008,29(16)：1531.
[7]任海霞,王章.硬膜外腔芬太尼复合液辅助骶管麻醉用于无痛分娩的体会[J].实用医技杂志,2004,11(12B)：2678.
[8]郝伟,张文海.穴位封闭骶管阻滞分娩镇痛300例临床总结[J].中国实用医学研究杂志,2002,1(4)：35-36.
[9]赵砚丽.骶管阻滞麻醉在分娩镇痛中的应用[J].中国实用妇科与产科杂志,2000,16(2)：74-76.
[10]王兆平,谈佩华.骶管阻滞镇痛分娩200例分析[J].中华妇产科杂志,1995,30(1)：44-45.
[11]张勇,马忠立,李义凯,等.骶管注射疗法的应用解剖学研究[J].颈腰痛杂志,2001,22(4)：330-331.
[12]周洪鹏.腰椎间盘突出症的注射疗法[J].中国临床医药研究杂志,2007(11)：36-37.
[13]龚忠厚,李遐,叶莹莹等.骶管封闭治疗腰腿痛国内进展[J].颈腰痛杂志,2005,26(2)：145-147.
[14]史卫东.骶管注射疗法治疗腰腿痛[J].中医正骨,2003,15(5)：51-52.
[15]曹阳,齐振熙.骶管注射治疗腰腿痛临证探讨[J].中国临床康复,2002,6(4)：558-559.
[16]田纪伟,王艳君.骶管注射在腰腿痛中的应用研究[J].中国中医骨伤科,1996,4(1)：12-14.
[17]刘春河,赵平厚.骶管注射治疗腰腿痛[J].中国矫形外科杂志,1995,2(3)：189.
[18]裴守明,王裕民.骶管的临床应用解剖学研究[J].山西医药杂志,1997,26(5)：394-395.
[19]张云鹏,丁义山.骶管阻滞麻醉的解剖学研究[J].中国临床解剖学杂志,1991,9(3)：155-157.
[20]张永昌.骶管裂孔的观测及临床意义[J].四川解剖学杂志,2005,13(2)：10.
[21]叶茂盛,叶风卿,周显光等.骶管的应用解剖学研究[J].解剖学研究,2006,28(2)：141-142.
[22]Senoglu N, Senoglu M, Oksuz H, etc. Landmarks of the sacral hiatus for caudal epidural block:an anatomical study.[J]. Br J Anaesth,2005,95(5):692-695.
[23]叶永亮,梁善皓,童飞飞,等.骶管裂孔的解剖学观测及其临床意义[J].颈腰痛杂志,2007,28(4)：259-261.
[24]Shinohara H. The size and position of the sacral hiatus in man.[J]. Okajimas Folia Anat Jpn,1999,76(2-3):89-93.
[25]曾志成.局部解剖学[M].第二版.西安：世界图书出版公司,2004.
[26]单云官,魏焕萍,张金波,贺智,宋立新.骶管裂孔和骶后孔穿刺点的选择及其解剖学基础[J].解剖与临床,1999,4(4)：207-208.
[27]邓兆宏,姚柏春,张一飞,等.骶管阻滞入路相关结构的应用解剖[J].中国疼痛医学杂志,2006,12(6)：357-359.
[28]Sekiguchi M, Yabuki S, Satoh K, etc. An anatomic study of the sacral hiatus:a basis for successful caudal epidural block.[J]. Clin J Pain,2004,20(1):51-54.
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