胸腰段最长肌表面滋养血管的解剖学特征及其术中保护

 目的 探讨胸腰段最长肌表面滋养血管的解剖学特征及在胸腰椎骨折后路经肌间隙入路手术中对其进行保护的作用。方法 采用骶棘肌肌间隙入路经后路椎弓根钉棒系统复位固定治疗胸腰椎骨折并获得完整随访的患者97例，于术中观察胸腰段最长肌表面滋养血管的走行和分布，应用特殊手术器械和技术对血管进行保护。评估术后第3天、1个月、6个月及拆除内固定术后1个月的疼痛视觉模拟评分（visual analogue scale，VAS）及术前、术后6个月的胸腰段最长肌MRI影像。结果 共观察97例194条最长肌402个椎弓根间区域的最长肌表面血管分布。402个区域中，94.3%的表面滋养血管呈束状，5.7%的区域中血管呈团状。在束状血管分布的379个区域中，血管束位于椎弓根区者占9.8%、椎弓根间上区76.0%、椎弓根间中区12.4%、椎弓根间下区1.8%；87.3%的血管束得以完整保留，12.7%的血管束以电凝烧灼处理。术中出血量为（21±9.3） ml。术后第3天、1个月、6个月及拆除内固定术后1个月VAS分别为（3.3±1.6）分、（2.1±1.4）分、（1.2±0.7）分、（1.1±0.7）分。术后6个月，经电凝烧灼处理的胸腰段最长肌在MRI上呈脂肪化改变。结论 胸腰段最长肌表面滋养血管一般呈束状，多位于椎弓根间上区。术中保护滋养血管能减轻对最长肌的损伤，减少术后肌肉脂肪化变性。

Anatomic features and intra-operative protection of surface vasa vasorum on longissimus in thoracolumbar segments

Objective To study the anatomic features of surface vasa vasorum on longissimus in thoracolumbar segments, and its protection function during the internal fixation for thoracolumbar fracture via Wiltse approach. Methods From March 2010 to October 2012, a total of 97 patients with thoracolumbar fractures underwent posterior internal fixation with pedicle screw system. The trend and distribution of surface vasa vasorum on longissimus in thoracolumbar segments were observed in the operation, and the vessels were protected during the surgical procedures by using specific devices and techniques. Operative time and intra-operative blood loss were recorded. Visual analogue scale (VAS) values were evaluated after 3 days, 1 month, 6 months postoperatively, and 1 month after the removal of internal fixation. MRI images of longissimus in thoracolumbar segments were compared after preoperative and postoperative 6 months. Results Surface vasa vasorum distribution on 194 longissimus and 402 inter-pedicle areas of 97 patients were observed. In 402 areas, 94.3% of surface vasa vasorum presented sarciniform, while only 5.7% of surface vasa vasorum presented tube shape. In 379 areas of sarciniform distribution, 9.8% of blood vessel bundles were located in vertebral pedicle area; 76.0% of blood vessel bundles were located in the upper inter-pedicle areas; 12.4% of blood vessel bundles were located in middle inter-pedicle areas; 1.8% of blood vessel bundles were located in lower inter-pedicle areas. In 379 areas, 87.3% of blood vessel bundles could be completely retained; 12.7% of blood vessel bundles were treated by electro coagulation and burning. Intra-operative blood loss was 21±9.3 ml. VAS values after 3 days, 1 month, 6 months postoperatively, and 1 month after the removal of internal fixation were 3.3±1.6, 2.1±1.4, 1.2±0.7 and 1.1±0.7. The longissimus treated with electro coagulation demonstrated pimelosis change on MRI after postoperative 6 months. Conclusion Surface vasa vasorum on longissimus in thoracolumbar segments are generally of sarciniform, and most of them are located in upper inter-pedicle areas. The protection of vasa vasorum can reduce the intra-operative lesion and postoperative pimelosis change of longissimus.