腰椎手术Wiltse入路准确进入多裂肌与最长肌间隙的解剖学基础

目的　探讨腰椎手术Wiltse入路的解剖学基础，提高该入路的稳定性和可操作性。 方法　成人标本20具，通过解剖观察双侧竖脊肌腱膜与多裂肌的关系；最长肌与竖脊肌腱膜的关系；多裂肌和最长肌间隙是否清晰，是否存在稳定的解剖标志；竖脊肌腱膜表面及其深面是否还存在其它结构可作为多裂肌和最长肌之间隙的解剖标志。 结果　多裂肌虽有少许纤维与竖脊肌腱膜相连接，仍可视为在竖脊肌腱膜上无起点；在腰部，最长肌在竖脊肌腱膜形成起点，起点的内缘自内上向外下斜行，并发出筋膜向深部延伸副突、横突，由此形成多裂肌与最长肌之间的分隔；在所有20具标本的左右两侧，以此隔膜为解剖标志向深部钝性分离，直接、顺利到达关节突；在竖脊肌腱膜表面未发现任何可作为多裂肌和竖脊肌间隙标志的解剖结构，剥离竖脊肌腱膜后在最长肌和多裂肌表面亦未发现可定位二者间隙的解剖标志；在多裂肌和最长肌间隙内，最长肌的内侧面可见清晰的节段神经及伴随血管。 结论　竖脊肌腱膜在最长肌内侧向深部的延续是腰椎手术Wiltse入路准确进入多裂肌和最长肌间隙的可靠解剖标志。

Anatomical basis of Wiltse approach in lumbar operation entering the interspace between multifidus muscle and longissimus muscle

Objective　To explore the anatomical basis of Wiltse approach in lumbar operation and to improve reliability and manipuility of the lumbar Wiltse approach．Methods　Twenty embalmed cadavers were used to observe the anatomical characteristics as follows: the relationship between sacrospinalis aponeurosis and multifidus muscle, the relationship between sacrospinalis aponeurosis and longissimus muscle, whether the interspace between multifidus muscle and longissimus muscle was clear, whether there were stable anatomic signs to identify, and whether there was other structure in the surface or inferior part of sacrospinalis aponeurosis could be the anatomic signs of the interspace between multifidus muscle and longissimus muscle.　Results　Multifidus muscle could be seen as an independent part from sacrospinalis aponeurosis though it had few fibers. Longissimus muscle formed a starting point from sacrospinalis aponeurosis in the lumbar regions. The starting point extended from central-superfacial to inferior-lateral and formed fascia stretching to facet joints and accessory process that made up the native interspace between multifidus muscle and longissimus muscle. The fascia was taken as an anatomical sign, successful blunt dissection were made to expose facet joints directly in all 20 cadavers. There were no other special anatomical signs in the surface or in the inferior part of sacrospinalis aponeurosis to locate the interspace between multifidus muscle and longissimus muscle. In the interspace, segmental nerve and concomitant blood vessel can be seen definitely inside the longissimus muscle.　Conclusions　The Wiltse approach requires a comprehensive understanding of lumbar fascia, based on which ,the operation could be safe and feasible.