各椎板的测量值

作者对３７具脊柱（男２１具,女１６具,平均年龄４２～７４岁）的Ｃ１－Ｌ５的椎板进行了测量。发现椎板最高者为Ｔ１１（２５１±２５ｍｍ）,最低者为Ｃ４（１０４±１１）;单侧椎板最宽者为Ｌ５（１５７±２０ｍｍ）,最窄者为Ｔ４（５８±０８ｍｍ）。颈椎的椎板宽度稍大于胸椎。椎板最厚者为Ｔ２（５０±０２ｍｍ）,最薄者为Ｃ５（１０±０６ｍｍ）。椎板厚度于上胸段趋于增加,于下胸段趋于减少。整个脊柱中,下颈段椎板平均厚度最薄。两侧椎板交角最大者为Ｃ３（１１６１±８８）和Ｔ７（１１２３…     

经皮椎间盘镜腰椎间盘摘除术

本文报告１９９２年１月～１９９６年６月期间应用经皮椎间盘镜腰椎间盘摘除术（ＡＭＤ）治疗腰椎间盘突出症２６８例，３７７次手术。随诊１９１例，平均２．５年，优良率８２．２％。强调俯卧位手术。穿刺失败原因：椎间盘退变重，关节突肥大增生三角工作区被遮挡，髂骨发育高，置入套管（６．４ｍｍ）有异感。使用椎间盘镜清晰显示局部解剖，直视观察减压区并可调整套管减少神经根损伤机会。对３０具成人尸体腰神经根周围局部解剖观察及测量：Ｌ２、Ｌ３、Ｌ４神经根最佳进针角度为４４．４°±２．２１°，Ｌ５神经根是３５．４°±２．３１°。脱出型（后纵韧带未穿破）及中央型采用双侧穿刺手术，增加摘除大块退变间盘的机会，使减压充分，提高这类突出病例的疗效。本组脱出型双侧穿刺手术５４例，中央型双侧穿刺手术７８例，随诊优良率７６％。ＭＲＩ检查对脱出型病例有无后纵韧带破裂起关键作用。这对脱出型腰椎间盘突出症能否选择经皮穿刺治疗方法起决定因素。本组并发症少，仅在早期发生神经根一过性不全损伤２例，术后２个月恢复。与穿刺操作者未按旋转进针原则有关。     

腰椎间盘突出合并侧隐窝狭窄的诊断和治疗

在腰椎间盘突出合并侧隐窝狭窄中,术前明确诊断,选择手术方案,是提高疗效的关键。为此,我们复习了部分ＣＴ片,并进行回顾性分析：１　临床资料１１　一般资料　本组２３例,男１４例,占６０８％,女９例,占３９２％,年龄最大６６岁,最小２４岁,平均４３岁。１２　ＣＴ表现　２３例ＣＴ片均显示有椎间盘突出（术中证实２１例存在椎间突出,２例无突出,仅为单纯性狭窄）。其中５例关节突内聚,黄韧带厚４～１０ｍｍ,侧隐窝矢状径２５～７ｍｍ,病变节段多为Ｌ４－５,Ｌ５～Ｓ１节段少。１３　手术所见　术中见椎间盘…     

地氟醚环路内注药法循环紧闭吸入麻醉的应用研究

目的：探讨地氟醚环路内注药法用于循环紧闭吸入麻醉的可行性,并观察地氟醚药代动力学的变化。方法：５０例ＡＳＡⅠ～Ⅱ级择期手术全麻病人,咪唑安定、芬太尼麻醉诱导插管行ＩＰＰＶ。氧流量４Ｌ／ｍｉｎ通气５分钟,行最低流量循环紧闭吸入麻醉。根据Ｌｏｗｅ的吸收公式,通过呼气端注入地氟醚的初始剂量,接着用微泵持续输入地氟醚,维持地氟醚的肺泡浓度（ＦＡ）约３％左右,术中根据地氟醚的ＦＡ调整输注速度。切皮前静注芬太尼０１ｍｇ,术中维库溴铵维持肌松,并辅以异丙酚２ｍｇ·ｋｇ－１·ｈ－１。记录地氟醚ＦＡ达３％的时间、呼气末浓度／吸气浓度（ＦＩ）达０８５的时间及其变化趋势。结果：地氟醚用量１０２４±１６３ｍｌ,地氟醚ＦＡ达３％的时间为１１±０４分钟,ＦＡ／ＦＩ达０８５的时间为３１±０１分钟,并能维持于０８５～０９５,恢复呼吸为５７±１３分钟,拔管时间为８３±０９分钟,睁眼时间８６±１６分钟。结论：采用低流量循环紧闭环路内注药法能安全有效地实施麻醉和减少环境污染。     

胶原酶溶解术治疗腰椎间盘突出症

我院１９９４年１０月～１９９８年４月采用胶原酶溶解术治疗腰椎间盘突出症１２８例,效果满意。１临床资料本组１２８例,男８３例,女４５例,年龄２５～６０岁。椎间盘突出部位：Ｌ３～４１１例,Ｌ４～５７８例,Ｌ５～Ｓ１３９例。突出类型：中央型８１例,旁侧型４...     

抗精浆免疫抑制物抗体的抗生育机理研究

作者进行了抗精浆免疫抑制物抗体（ＳＰＩＭ－Ａｂ）的补体结合功能测定（ＣＦＡ）和ＳＰＩＭ－Ａｂ对精子凝集、制动、穿透力和杀精子影响的研究。结果表明，ＳＰＩＭ－Ａｂ阳性不育病人（ｎ＝２９）ＣＦＡ值为６．４７±１．５５ｋＵ／Ｌ，明显低于ＳＰＩＭ－Ａｂ阴性病人（ｎ＝７ｌ，８．１１±１．６２ｋＵ／Ｌ）和对照组（ｎ＝３０，８．６０±１．８０ｋＵ／Ｌ），Ｐ＜０．０１。经ＳＰＩＭ－Ａｂ阳性血清和ＳＰＩＭ－Ａｂ阴性血清作用后，两组精子凝集、制动和死精子百分率分别为４１．４％和２１．１％、６９．０％和１６．９％、６２．１％和４．２％，精子穿透高度分别为３１．６±１３．０ｍｍ和３８．Ｏ±１２．９ｍｍ，经统计学处理差异显著（Ｐ＜０．０５～ｐ＜０．０１）。提示ＳＰＩＭ－Ａｂ能够以抗原抗体复合物形式激活补体，其对精子凝集、制动、杀伤和穿透力的影响，可能是干扰生育的重要原因之一。     

下肢疼痛区域对于腰骶神经根压迫症的定位诊断意义

目的：探讨下肢疼痛区域分布对于腰骶神经根压迫症的定位诊断意义。方法：研究对象为１８１名腰骶神经根压迫症患者，均为单一神经根损害，计Ｌ４神经根损害２４例，Ｌ５神经根损害８７例，Ｓ１神经根损害７０例。记录其下肢疼痛分布情况及物理检查结果。结果：Ｌ４神经根损害患者下肢疼痛部位以大腿前侧、膝部及小腿内侧为主，Ｌ５及Ｓ１神经根损害以大腿后外侧及小腿后外侧疼痛为主。Ｌ５与Ｓ１神经根损害疼痛部位发生频率有统计学差别，但部位基本相同。物理检查结果与神经根损害相关性较好。结论：根据下肢疼痛区域诊断Ｌ４神经根损害准确性较高，鉴别Ｌ５与Ｓ１神经根损害却相对困难     

中央型腰椎间盘突出症诊治体会

腰椎间盘突出症严重者椎间盘组织破入椎管,形成中央型腰椎间盘突出并马尾神经损伤。作者１９８６～１９９６年共收治３５例此类患者,报道如下。１　临床资料本组３５例,均经手术证实为腰椎间盘突出并马尾损伤,男２８例,女７例;年龄２１～５４岁。病程２个月～４年。诱因：腰扭伤７例;推拿按摩后发病２３例;慢性发病５例,均有腰腿痛病史。突出节段：Ｌ４～５２１例,Ｌ５～Ｓ１９例,Ｌ４～５＋Ｌ５～Ｓ１５例。临床表现：双腿痛３０例,单腿痛５例;下肢及会阴部感觉丧失２７例,下肢或鞍区感觉减退８例;单侧小腿肌力减弱４例,不…     

腰椎间盘突出症手术失误及并发症原因分析

我院自１９８７～１９９５年共手术治疗腰椎间盘突出症３１６例，其中发生手术失误及并发症共１３例，分析如下。临床资料１．一般资料：本组１３例中男９例，女４例；年龄２３～７４岁；Ｌ４、５突出６例，Ｌ５Ｓ１突出５例，Ｌ４、５＋Ｌ５Ｓ１突出２例。合并腰椎管狭窄症５例；随访时间６月～６．５年。２．手术方法；椎板间扩大开窗椎间盘切除４例，半椎板切除５例，全椎板切除４例。３．手术失误及并发症：术中定位失误１例，马尾神经损伤１例，椎间隙感染２例，脑脊液漏２例，神经根损伤２例，术后硬膜外血肿１例，术后复发２例，术后…     

100例国人腰椎弓根的CT测量及其临床意义

对１００例国人腰椎弓根进行了ＣＴ形态学测量。结果表明腰椎弓根厚度从Ｌ１～Ｌ５呈递增趋势，Ｌ１～Ｌ５椎弓很平均厚度分别是５．３、 ６．７、９．５、１１．５和１４．７ｍｍ。椎弓根轴线与椎体棘突中央矢状面夹角（倾斜角），从Ｌ１～Ｌ５亦呈递增趋势，Ｌ１～Ｌ５各椎弓根平均倾斜角分别为１５．９７、１５．９１、１９．１９、２２．７８和２８．４７度。本文亦对椎弓根厚度与椎弓根螺钉的直径及进钉倾斜角进行了探讨，并提出在Ｌ４～Ｌ５节段应使用直径７．０ｍｍ的椎弓根螺钉。     

Morphometric analysis of the working zone for endoscopic lumbar discectomy

OBJECTIVE: Our study's purpose was to analyze the working zone for the current practice of endoscopic discectomy at the lateral exit zone of the intervertebral foramen (IVF) and to define a safe point for clinical practice. METHODS: One hundred eighty-six nerve roots of the lumbar IVFs of cadaveric spines were studied. Upon lateral inspection, we measured the distance from the nerve root to the most dorsolateral margin of the disc and to the lateral edge of the superior articular process of the vertebra below at the plane of the superior endplate of the vertebra below. The angle between the root and the plane of the disc was also measured. RESULTS: The results showed that the mean distance from the nerve root to the most dorsolateral margin of the disc was 3.4 +/- 2.7 mm (range 0.0-10.8 mm), the mean distance from the nerve root to the lateral edge of the superior articular process of the vertebra below was 11.6 +/- 4.6 mm (range 4.1-24.3 mm), and the mean angle between the nerve root and the plane of the disc was 79.1 degrees +/- 7.6 degrees (range 56.0-90.0 degrees ). CONCLUSIONS: The values of the base of the working zone have a wide distribution. Blind puncture of annulus by the working cannula or obturator may be dangerous. The safer procedure would be the direct viewing of the annulus by endoscopy before annulotomy; the working cannula should be inserted into the foramen as close as possible to the facet joint.     

腰丛的解剖及其在腰椎前外侧入路微创手术中的临床意义

目的 了解腰丛在腰椎前外侧入路微创手术中的应用解剖学特点.方法 通过15具成人腰椎标本、2具腰段的断层图片和3个数字人腰段数据集,观察腰丛的走行及其与腰大肌及腰椎横突的关系.结果 L2-5腰丛在腰椎侧方的组成具有一定的规律性,正面按从外到内的顺序排列,侧面按从腹侧到背侧的方向排列.腰神经出椎间孔的角度从L1到L5逐渐增加.横突与腰丛的关系紧密.断层解剖显示,腰丛在不同节段始终位于腰大肌的后1/3,因此在切开腰大肌暴露腰椎时,切开位置不宜超过腰大肌的后1/3,腰大肌的前2/3是切开安全区.结论 暴露腰椎侧前方切开腰大肌时,注意不要超过腰大肌的前2/3,以避免腰丛的损伤.横突可以作为手术中的解剖学标志,用以明确腰丛的解剖位置,避免术中腰丛损伤.     

经皮后外侧腰椎间孔入路椎间盘工作区域的解剖学研究

 目的 通过对健康成人尸体标本的解剖和测量, 对经皮后外侧腰椎间孔入路的椎间盘工作区域进行应用解剖学研究。方法 对 25具尸体标本(年龄 45~65岁, 身高 150~176 cm)进行腰椎椎间孔解剖学研究, 首先在矢状面上测量椎间隙后缘高度(h), 神经根与椎间盘平面的倾斜角(茁), 神经根后缘与椎间盘最后缘水平距离(d), 椎间孔在上、下终板平面上的神经根后缘与下位椎体上关节突外缘的距离(a1, a2);去除关节突后显露神经根与硬膜, 冠状面上在上、下终板平面上测量神经根内缘与硬膜外缘的距离(b1, b2)。结果 在椎间孔矢状面和冠状面上椎间盘区域分别为两个”梯形冶。矢状面上测量参数: h为(7.0±1.1) mm, 茁为 77.6°±8.4°, d为(3.4±2.3) mm, a1为(9.4±2.2) mm, a2为(10.8±4.6) mm。冠状面上 b1为(9.9±2.7) mm, b2为(17.7±2.1) mm。除神经根倾斜角度(β)逐渐缩小外, 其余参数均随腰椎节段而逐渐增大。结论 后外侧腰椎间孔入路的椎间盘工作区域可模拟为由矢状面和冠状面”梯形冶所合成的立体结构。通过对立体结构解剖的研究比较可以指导临床操作, 如椎间孔镜工作通道的大小及椎间孔穿刺针角度等。     

Lumbar discogram resulting from lumbar interlaminar epidural injection

Lumbar discography is a diagnostic modality to determine whether the intervertebral disc is the cause of pain. The injection of radiopaque contrast into the nucleus pulposus of the disc can reveal the internal details of the disc. We describe a case of inadvertent lumbar discogram resulting from an attempted lumbar interlaminar epidural injection at L5-S1 under fluoroscopy. The patient did not have a postdural puncture headache or nerve root irritation. The potential triangle in the lateral aspect of spinal cord may be the explanation for this situation, because this triangle is composed of the exiting nerve root laterally, the lateral margin of the dura medially, and the pedicle as its base. The L5-S1 disc is located in the center of the triangle. In our case, the Tuohy needle was placed possibly in the center of the triangle, too laterally to puncture the dura. Hence, the patient did not suffer from postdural puncture headache. The needle was probably inferior to the nerve root, and no obvious nerve root trauma or irritation occurred. This potential triangle may provide alternative access for lumbar discography at the L5-S1 level.     

Anatomic considerations of the posterolateral lumbar disk region

Sixteen embalmed cadavers were dissected to determine the location of the lumbar nerve root and sympathetic trunk with reference to the superior border of transverse process. In the posterolateral lumbar disk region, a safe zone was found between the anterior limit of the lumbar nerve and the posterior limit of the sympathetic trunk. It has a transverse dimension of 22 mm at the T12-L1 disk region and 25 mm at the L4-L5 disk region. The only exception to this was the genitofemoral nerve running close to the lateral margin of the L2-L3 disk. The study provides an understanding of the posterolateral orientation of the lumbar nerves and sympathetic trunk.     

Nerve root herniation secondary to lumbar puncture in the patient with lumbar canal stenosis. A case report.

STUDY DESIGN: A very rare case of nerve root herniation secondary to lumbar puncture is reported. OBJECTIVE: To describe the characteristic clinical features of this case and to discuss a mechanism of the nerve root herniation. SUMMARY OF BACKGROUND DATA: There has been no previous report of nerve root herniation secondary to lumbar puncture. METHODS: A 66-year-old woman who experienced intermittent claudication as a result of sciatic pain on her right side was evaluated by radiography and magnetic resonance imaging, the results of which demonstrated central-type canal stenosis at L4-L5. The right sciatic pain was exacerbated after lumbar puncture. Myelography and subsequent computed tomography showed marked stenosis of the thecal sac that was eccentric to the left, unlike the previous magnetic resonance imaging finding. RESULTS: At surgery, a herniated nerve root was found through a small rent of the dorsocentral portion of the thecal sac at L4-L5, presenting a loop with epineural bleeding. The herniated nerve root was put back into the intrathecal space, and the dural tear was repaired. CONCLUSION: Lumbar puncture can be a cause of nerve root herniation in cases of lumbar canal stenosis. The puncture should not be carried out at an area of stenosis.     

The risk of foraminal violation and nerve root impingement after anterior placement of lumbar interbody fusion cages

STUDY DESIGN: Three groups of six embalmed cadaver spines underwent placement of lumbar interbody fusion cages centered either at midline, 10% lateral of midline, or 20% lateral of midline. The spines were evaluated for evidence of neuroforamen violation or nerve root impingement. OBJECTIVES: To determine the potential for foraminal violation or nerve root impingement after correct placement and lateral misplacement of lumbar interbody fusion cages. SUMMARY OF BACKGROUND DATA: Radicular symptoms after anterior cage placement have raised some concern about the potential for inadvertent device-related foraminal violation not adequately appreciated by intraoperative fluoroscopy. METHODS: Preoperative computed tomography scanning and plain radiography was used to measure endplate dimensions at L4-L5 and to template the appropriately sized interbody fusion cages. The cadaveric specimens were randomly divided into three groups of six (Groups I-III) and instrumented at L4-L5 either at midline (I) or 10% (II) or 20% (III) lateral of midline. Postoperative computed tomography and plain radiography was evaluated for evidence of neuroforamen violation, followed by dissection of the specimens. RESULTS: Foraminal violation occurred in one of six spines in group II (10% off midline) and in three of six spines in group III (20% off midline). Two of the three cadavers in group III with foraminal violation also were noted to have nerve root abutment on computed tomography scans and spinal dissection. CONCLUSIONS: Excessive lateral placement of lumbar interbody fusion cages may result in foraminal violation and possible nerve encroachment. The "safe zone" for centering the cages extends approximately 5 mm on either side of midline.     

Morphometric aspects of extraforaminal lumbar nerve roots

OBJECTIVE: In the posterolateral extraforaminal and anterolateral retroperitoneal approaches to lumbar spinal lesions, the neural structures in the lumbar extraforaminal region are unfamiliar to many spinal surgeons. The purpose of this study was to determine the normal anatomic morphometric parameters for all lumbar nerve roots around their exits, from the intervertebral foramen to the surrounding bony structure. METHODS: A total of 15 adult fixed cadavers were studied. The extraforaminal course of the lumbar nerve roots and the forming plexus were measured segmentally, using standard calipers, and we selected the shortest distance from the bony landmarks to the nerve roots in the horizontal plane. The bony landmarks were the most medial superior border of the transverse process (TP), the most medial inferior border of the TP, the tip of the superior articular process, and the most dorsolateral margin of the intervertebral disc space. In addition, the angle of each root exiting from the intervertebral foramen was measured using a goniometer. RESULTS: The mean distance from the medial superior border of the TP to the upper segment of the nerve root was 5.1 to 6.4 mm at L2-L5. The mean distance from the medial inferior border of the TP to the corresponding nerve root was 8.5 mm at L2 and L3 and 6 mm at L4 and L5. The mean distance from the tip of the superior articular process to the most dorsal border of the descending nerve trunk was 19 mm at L2 and L3 and 22 mm at L4 and L5. The main lumbar nerve trunk was located close to the most dorsolateral surface of the vertebral body and the intervertebral disc space, and it was topographically arranged dorsoventrally from the L5 to L2 nerve components. The average widths of the nerve trunk were 10, 14, and 25 mm at L3-L4, L4-L5, and L5-S1, respectively. The mean angles of the exiting roots in the extraforaminal region were 16 degrees at L2 and L3 and 25 degrees at L4 and L5. CONCLUSION: The lumbar nerve component, including both the lumbar trunk and each exiting nerve root in the extraforaminal region (the so-called "danger zone"), was located anteriorly at a distance more than 5 mm from the TP, more than 19 mm from the superior articular process, and up to 25 mm from the intervertebral disc space. Based on our results, the danger zone occupied up to 25 mm forward from the intervertebral foramen at the lower lumbar segments. Therefore, during operations such as percutaneous posterolateral procedures and open posterolateral or anterolateral approaches, great care should be taken within 25 mm of the extraforaminal region, especially for the lower lumbar spine.     

后路椎间隙微创手术治疗腰椎间盘突出症

目的:探讨后路椎间隙微创手术治疗腰椎间盘突出症的方法和疗效,进一步规范其适应证。方法:腰椎间盘突出症患者132例,男87例,女45例;年龄21～69岁,平均41岁。采用后路椎间隙显微镜下手术治疗,分析上位椎板下缘咬除范围、术中出血量、手术时间及术后疗效。结果:L5S12例咬除L5椎板下缘2.0mm,余未行椎板咬除;L4,5咬除L4椎板下缘范围5～9mm,平均7.0mm;L3,4咬除L3椎板下缘范围8～10mm,平均9.6mm。术中平均出血量60ml,平均手术时间50min。术后以Macnnab标准评价:优82例,良44例,可6例,优良率95.5%。结论:后路椎间隙微创手术治疗腰椎间盘突出症,对软组织骨性结构破坏小,适用于单节段腰椎间盘突出合并神经根管狭窄、后纵韧带骨化患者。     

后路腰椎椎间融合术并发神经损伤的原因分析

目的:分析后路腰椎椎间融合术并发神经损伤的原因.方法:2003年3月～2008年5月采用后路腰椎椎间融合术(PLIF)治疗腰椎疾病患者178例,其中腰椎间盘突出症42例,腰椎管狭窄症39例,退变性腰椎滑脱症61例,峡部裂性腰椎滑脱症22例,腰椎椎板/椎间盘切除术后综合征14例:单节段融合130例,其中L3/48例,L4/5 64例,L5/S1 58例,双节段融合46例,其中L3/4、L4/5 19例,L4/5、L5/S1 27例,三节段融合2例,均为L3/4、L4/5、L5/S1,对其发生神经损伤的原因进行分析.结果:共并发神经损伤13例(7.3%),其中L4 1例,L5 7例,S1 5例;神经根牵拉伤6例,器械损伤3例,误伤变异神经根1例,硬膜外血肿致神经根受压1例,椎弓根骨折致神经根受压1例,继发性侧隐窝狭窄致神经根受压1例;完全性损伤2例,不完全性损伤11例.根据ASIA评分标准,神经功能完全恢复7例,部分恢复4例,无恢复2例.结论:后路腰椎椎间融合术并发神经损伤的原因是多方面的,以神经根的牵拉伤最多见.