Grunert Peter, Drazin Doniel, Iwanaga Joe, Schmidt Cameron, Alonso Fernando, Moisi Marc, Chapman Jens R, Oskouian Rod J, Tubbs Richard Shane
Swedish Neuroscience Institute, Department of Neurosurgery, Seattle, Washington, USA.
Seattle Science Foundation, Seattle, Washington, USA.
World Neurosurg. 2017 Sep;105:519-525. doi: 10.1016/j.wneu.2017.06.027. Epub 2017 Jun 12.
Neurologic deficits from lumbar plexus nerve injuries commonly occur in patients undergoing lateral approaches. However, it is not yet clear what types of injury occur, where anatomically they are located, or what mechanism causes them. We aimed to study 1) the topographic anatomy of lumbar plexus nerves and their injuries in human cadavers after lateral transpsoas approaches to the lumbar spine, 2) the structural morphology of those injuries, and 3) the topographic anatomy of the lumbar plexus throughout the mediolateral approach corridor.
Fifteen adult fresh frozen cadaveric torsos (26 sides) underwent lateral approaches (L1-L5) by experienced lateral spine surgeons. The cadavers were subsequently opened and the entire plexus dissected and examined for nerve injuries. The topographic anatomy of the lumbar plexus and its branches, their injuries, and the morphology of these injuries were documented.
Fifteen injuries were found with complete or partial nerve transections (Sunderland IV and V). Injuries were found throughout the mediolateral approach corridor. At L1/2, the iliohypogastric, ilioinguinal, and subcostal nerves were injured within the psoas major muscle, the retroperitoneal space, or the outer abdominal muscles and subcutaneous tissues. Genitofemoral nerve injuries were found in the retroperitoneal space. Nerve root injuries occurred within the retroperitoneal space and psoas muscle. Femoral nerve injuries were found only within the psoas major muscle. No obturator nerve injuries occurred.
Lateral approaches can lead to structural nerve damage. Knowledge of the complex plexus anatomy, specifically its mediolateral course, is critical to avoid approach-related injuries.
腰椎丛神经损伤导致的神经功能缺损常见于接受外侧入路手术的患者。然而，目前尚不清楚会发生何种类型的损伤、其在解剖学上的位置以及损伤的机制。我们旨在研究：1）腰椎外侧经腰大肌入路至腰椎后人体尸体中腰丛神经的局部解剖及其损伤情况；2）这些损伤的结构形态；3）整个内外侧入路通道中腰丛神经的局部解剖。
15具成年新鲜冷冻尸体躯干（26侧）由经验丰富的脊柱外侧手术医生进行外侧入路手术（L1 - L5）。随后打开尸体，解剖整个神经丛并检查神经损伤情况。记录腰丛神经及其分支的局部解剖、损伤情况以及这些损伤的形态。
发现15处神经损伤，包括完全或部分神经横断（桑德兰IV级和V级）。在整个内外侧入路通道均发现损伤。在L1/2水平，髂腹下神经、髂腹股沟神经和肋下神经在腰大肌内、腹膜后间隙或腹外肌肉及皮下组织中受损。生殖股神经损伤发生在腹膜后间隙。神经根损伤发生在腹膜后间隙和腰大肌内。仅在腰大肌内发现股神经损伤。未发生闭孔神经损伤。
外侧入路可导致神经结构损伤。了解复杂的神经丛解剖结构，特别是其内外侧走行，对于避免与手术入路相关的损伤至关重要。
