骶髂关节周围腰骶丛神经的解剖学研究及其临床意义

目的　对腹直肌外侧入路显露骶髂关节周围重要结构的位置关系进行测量及描述，探讨入路的安全性及安全操作空间。 方法 选取新鲜成人完整尸体标本，对每具骨盆标本经双侧腹直肌入路逐层解剖，观察腹膜、髂外血管、髂腰肌、闭孔神经等重要组织结构的位置关系，重点观测L4、L5、S1神经与闭孔神经位置，测量分析神经至骶髂关节的距离。 结果　腹直肌外侧入路可清楚显露骶髂关节、腰骶干、S1神经根、骶骨翼等结构。 L5神经前支出椎间孔处与骶髂关节距离左侧为(23.56±4.30)mm，右侧为(23.69±3.41)mm，L4神经前支与骶髂关节在L5神经前支出椎间孔处的距离左侧为(17.97±1.58)mm，右侧为(17.49±1.49)mm，腰骶干外缘在其形成汇合点平面与骶髂关节的水平距离左侧为(14.34±2.51)mm，右侧为(13.81±2.21)mm，平骶岬处腰骶干外缘与骶髂关节的水平距离左侧为(12.19±1.98)mm，右侧为(12.22±1.55)mm。 结论　腹直肌外侧入路可用于复位固定骶髂关节周围骨折脱位，具有安全的操作空间，且经该入路的操作为骶髂关节复合体损伤引起的神经损伤提供了探查松解的新思路。

Anatomical research of lumbosacral plexus around sacroiliac joint and its clinical significance

Objective　Based on the anatomical study，position and variation of anatomical structure of the hypogastric abdominal wall and pelvic cavity were observed and the important neuroanatomical structure refinement measured. To perform an anatomical study on lateral-rectus to sacroiliac joint disruption complicated with lumbosacral plexus injury in an attempt to testify feasibility of the approach．Methods Position and variation of anatomical structure of the hypogastric abdominal wall and pelvic cavity were observed in 10 cadaveric adults(20 sides), to expose the anterior rectus sheath, obliquus externus abdominis, inferior epigastric artery, arcuate line, the above superficial ring and the spermatic cord in male patients (or the round ligament in female patients) within the inguinal ligament. An adequate exposure included the pelvic ring from the quadrilateral plate to sacroiliac joints, quadrilateral plate, ala of ilium and most part of the medial side of the posterior column of acetabula is obtained by the lateral-rectus approach. Then horizontal distances between anterior branches of lumbar nerves 4，5，lumbosacral trunk(LST) and sacroiliac joint were measured with a caliper. Results According to the anatomical study and the anterior of sacroiliac joint, there was an operative window between femoral vessels, spermatic cord and the iliopsoas muscle to expose the sacroiliac joint, obturator nerve, umbosacral stem and internal iliac vessels while retracting abdominal muscles, iliac vessels and intraperitoneal tissues to the medial and iliopsoas to the lateral. The S1 vertebra was posterior to median sacral vessels and iliac vessels, which when retracted laterally can expose S1 and S2 foramen. The distance between the lumbar nerve 5 as it exits from the intervertebral foramen and the sacroiliac joint, the distance between anterior branches of lumbar nerve 4 branch and the sacroiliac joint at the level where the lumbar nerve 5 exits the intervertebral foramen, the distance between the beginning of the LST and the sacroiliac joint，the distance of the LST to the sacroiliac joint at the promontory, the proximity of the LST to the sacroiliac joint at the pelvic brim. There are no significant statistical difference between the left and right side(P＞0.05). Conclusion Based on the anatomical study， the author believes that there is enough space anterior to the sacroiliac joints for placement of internal fixation under the nerve root with minor effects on nerve. weconfirm that the lateral-rectus approach can be used for reduction and internal fixation of the sacroiliac joint fracture and dislocation. There exists security space of operation. what's more, the approach provides a new way for the treatment of nerve injury caused by sacroiliac joint damage.