腹部脏器在腰椎侧位片上的投影对脊柱内窥镜穿刺的指导意义

摘要

目的：探讨腹部脏器的后缘(即肾后筋膜和后腹膜壁层)在腰椎侧位片上的投影线对脊柱内窥镜侧方穿刺的临床指导意义。方法收集在首都医科大学附属北京朝阳医院行腹部增强计算机体层摄影术( computed tomography,CT)检查的50例患者,分别测定L1-5椎体的上缘、中部、下缘及S1椎体上缘共计16个轴位层面。每一层面分别测量椎体矢状位前后径( L),并以椎体前后径延长线建立坐标Y轴线,过椎体后缘皮质中点(设定为O点)做X轴线。做X轴的平行线与肾后筋膜及后腹膜壁层的切线点D点,继而分别测量左、右两侧肾后筋膜及后腹膜壁层切线点在Y轴上的投影点D’点与O点的距离OD’；通过O点向肾后筋膜及后腹膜壁层形成的弧线做切线,切线与皮肤的交点为临界穿刺点C点,分别测量左右两侧临界穿刺点在Y轴投影点C’点与O点的距离OC’及临界穿刺点距离后正中线的皮肤长度；OC线与X轴的交角为临界角,分别测量左、右两侧临界角；计算OD’与L的比值及OC’与L的比值。结果所测数据结果表明肾后筋膜及后腹膜壁层最低点在侧位腰椎X线上的投影及临界穿刺点投影从L1至S1由椎体后缘的背侧逐渐转向腹侧,在L4椎体中部平面两投影点位置相同,位于L4椎体后缘；临界角同样逐渐减小,L4中部可以0°穿刺。躯体左右两侧所测数据差异无统计学意义。结论该研究通过肾后筋膜及后腹膜壁层在侧位片上的投影首次定义穿刺对保护腹部脏器安全的安全线的概念及位置,明确腰椎各个节段穿刺点的安全范围及角度,为避免术中损伤腹腔脏器提供解剖学的依据。%Objective To explore the clinical guiding significance of trailing edge of abdominal organs on the lateral lumbar X-ray in lateral puncture by spinal microendoscopy. Methods A total of 50 patients who had abdominal enchanced computed tomography ( CT) examination in our hospital were included in the present study. We divided the spine from L1 to S1 into 16 axial levels, including the vertebral upper ( the cranial endplates ) , middle and the under margin ( caudal endplates ) . Then we respectively measured vertebral sagittal diameter ( L) in every level, and established a coordinate axis ( establishing Y axis by the extension of vertebral sagittal diameter and establishing X axis through the midpoint of the rear margin vertebral which was set to be point O ) . We set the cross point of the parallel line of X axis and the tangent line of post-renal fascia and parietal peritoneum’s arc to be point D the projection of which was named D’, then we measured the distance between point D’ and point O which was called OD’. We set critical puncture point to be point C which is the cross point of the skin and the tangent line of the post-renal fascia and parietal peritoneum’s arc through point O and the projection on axis Y of point C was named C’. Then we measured the distance between point C and point O and called OC’. The critical puncture angle (α) which is the crossing angle of the line OC and X axis was measured, and finally we calculated the ratio of OD’ and L, and the ratio of OC’ and L. Results All of the data show that the location of the projection of the lowest point of the post-renal fascia and parietal peritoneum and the location of the projection of the critical puncture point turns from the back side of the vertebral rear margin to ventral side from L1 to S1, and they are in the same location on the vertebral posterior margin at the middle level of L4. The critical puncture angle is also on declare from L1 to S1, and is about 0° at the middle level of L4. All of the data show that there is no statistical difference between each side of the body in the lowest point of the post-renal fascia and parietal peritoneum, critical puncture point and critical puncture angle. Conclusion This research defines the safe line and the definite range of the puncture point and puncture angle from L1 to S1 according to the projection of the lowest point of the post-renal fascia and parietal peritoneum. It provided an anatomical reference for avoiding intra-operative injury of post-renal fascia or abdominal organs.