目的：探讨小切口肋膈隐窝外入路在胸腰段脊柱侧前方手术中的应用价值。方法采用该入路行胸腰段脊柱侧前方手术31例，男22例，女9例，年龄22~58岁，平均（41±12）岁，包括T12爆裂型骨折12例，L1爆裂型骨折15例，T12L1椎间盘突出4例。侧卧位下以伤椎为中心沿11肋行长约12 cm小切口，切除部分第11肋骨，辨认胸膜转折，其中26例胸膜转折低于第11肋骨床，分离保护第11肋间血管和神经，在其深面分离至12肋骨上缘内面；在胸膜转折远侧切开胸内筋膜进入肋膈隐窝外间隙，将胸膜囊推向近侧显露膈肌上面；同时分离膈下腹膜外间隙，切断膈肌在第11、12肋骨的止点和弓状韧带，显露椎体侧方。结果肋膈隐窝胸膜囊较松弛，与胸壁和膈肌的胸内筋膜之间存在自然间隙，有疏松组织，胸膜外间隙容易分离；31例均能顺利、充分地显露T11~L2椎体侧方。4例术中出现胸膜撕裂，立即修补后仍行胸膜外显露，均未进入胸腔。手术固定融合节段T11~L2。术后3例有肋间神经疼痛症状，保守治疗后均明显好转。结论小切口肋膈隐窝外入路容易分离胸膜外间隙，在胸腰段脊柱侧前方手术中可避免开胸对胸腔的干扰，在达到充分显露的基础上减少创伤。%Objective To analyze the value of mini-open approach beside costodiaphragmatic recess in thoracolumbar spine surgery. Methods This approach was applied in 31 anterior thoracolumbar spine surgeries, including 22 men and 9 women, with a mean age of 41 years old (range, 26-58 yrs). The diagnosis were burst fractures in 27 cases (T12 level in 12 cas⁃es and L1 level in 15 cases) and disc herniations with osteochondrosis in 4 cases. An antero-lateral 10-15 (average is 12) cm incision was performed, then the 11th rib was resected and the extraperitoneal space below diaphragma was disconnected. The pleura fold was identified beneath the rib bed, so the gap beside the costdiaphragmatic recess was entered through an in⁃cision beyond the fold. The diaphragm and medial arcuate ligament were clipped and vertebral body from T11 to L2 were ex⁃posed. Results The lateral side of T11 to L2 vertebral body was sufficiently exposed in all the 31 patients. In 26 patients, the pleura fold was beyond the bed of the 11th rib, so the 11th intercostals vessel and nerve were exposed and protected, and the costodiaphragmatic recess was reached through the superior border of the 12th rib. Laceration of pleura occurred in 4 cases af⁃ter it was sutured, but the extra-pleura approach could still be used after repairing without invading into thorax. Fixation and fusion were performed from T11 to L2. Complications include intercostals nerve pain were seen in 3 cases, which resolved with conservative treatment. Conclusion The mini-open approach beside costodiaphragmatic recess can be used in anterior thoraclumbar spine surgery with sufficient explosion and minimum injury in which thoracic cavity.
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