Department of Neurological Surgery, University of South Florida, Tampa, FL, USA.
J Neurosurg Spine. 2012 Apr;16(4):359-64. doi: 10.3171/2011.12.SPINE11626. Epub 2012 Jan 6.
The thoracolumbar junction (T11-L2) poses an anatomical dilemma, given the presence of the lower rib cage and the diaphragm when performing anterolateral approaches. To circumvent dealing with the diaphragm, a minimally invasive lateral extracoelomic approach has been used to approach the thoracolumbar junction by mobilizing the diaphragm anteriorly. No anatomical studies have described the attachments of the diaphragm and their surgical significance during the lateral approach to the thoracolumbar spine. The objective of this study is to describe the anatomical relationship of the diaphragm in reference to the minimally invasive lateral approach to the thoracolumbar spine and its surgical significance.
Nine adult fresh-frozen cadaveric specimens were dissected and studied (18 sides). All specimens were placed in the lateral decubitus position, similar to the surgical technique, for the dissections. The relationship between the retroperitoneum, retropleural space, diaphragm, and thoracolumbar spine was analyzed in reference to the minimally invasive lateral approach. Special attention was given to the attachments of the diaphragm and their relationship to the ribs during the early stages of the approach.
All 18 sides were successfully dissected, analyzed, and photographed. The diaphragm is a musculotendinous sheet extending between the thoracic and abdominal cavities. Its attachments can be divided into 3 main categories: 1) sternal or anterior, 2) costal or lateral, and 3) lumbar or posterior. These attachments are described in detail, with specific reference to the lateral approach. When performing the minimally invasive lateral extracoelomic approach to the thoracolumbar spine, the lateral and posterior attachments must be identified and dissected to successfully mobilize the diaphragm anteriorly.
The diaphragm has multiple attachments that can be categorized as anterior, lateral, and posterior. In reference to the minimally invasive lateral extracoelomic approach to the thoracolumbar junction, the surgically significant attachments are primarily to the 12th rib and transverse process of L-1.
在进行前外侧入路时，由于存在下肋骨和膈肌，胸腰椎交界处存在解剖学上的难题。为了避免处理膈肌，已经使用微创侧腹腔外入路通过将膈肌向前移动来接近胸腰椎交界处。目前还没有解剖学研究描述过膈肌在胸腰椎侧方入路中的附着及其手术意义。本研究的目的是描述膈肌在微创侧方入路中与胸腰椎的解剖关系及其手术意义。
对 9 具成人新鲜冷冻尸体标本进行解剖和研究（18 侧）。所有标本均采用类似手术技术的侧卧位进行解剖。分析了微创侧方入路中腹膜后、肋胸膜间隙、膈肌和胸腰椎的关系。特别注意了膈肌的附着及其在入路早期与肋骨的关系。
所有 18 侧均成功解剖、分析和拍照。膈肌是一种位于胸腹腔之间的肌腱膜片。它的附着可以分为 3 个主要类别：1）胸骨或前侧，2）肋骨或外侧，3）腰椎或后侧。详细描述了这些附着，特别提到了侧方入路。在进行微创侧腹腔外入路胸腰椎时，必须识别和解剖侧方和后侧的附着，以成功地将膈肌向前移动。
膈肌有多个附着，可以分为前侧、外侧和后侧。在微创侧腹腔外入路中，具有重要手术意义的附着主要是第 12 肋和 L-1 横突。
