Rutter Gareth, Phan Kevin, Smith Adam, Stewart Fiona, Seex Kevin, Gragnaniello Cristian
School of Medicine, University of New England, Armidale, NSW, Australia.
NeuroSpine Surgery Research Group (NSURG), Prince of Wales Private Hospital, Randwick, Sydney, Australia.
J Spine Surg. 2017 Sep;3(3):419-425. doi: 10.21037/jss.2017.09.06.
An approach to lateral lumbar interbody fusion (LLIF) utilizing an oblique corridor anterior to the psoas muscle was first described by Mayer in 1997 and subsequently by other authors. The only consistent structure of note in this corridor is the lumbar sympathetic trunk (LST), which at times must be mobilized in order to perform a discectomy and interbody fusion, thereby placing the LST at risk. This study was designed to describe the morphometric anatomy of the LST in relation to surgically relevant landmarks for the anterolateral approach to the lumbar spine at L3/L4 to L5/S1.
Twenty-four embalmed cadavers (13 males, 11 females, age range, 50-89) were dissected to expose the LST. Bilateral measurements were recorded using a calliper under direct visualization, using the midsagittal plane of the lumbar spine as the reference landmark. The points were then marked with radio-opaque needles, and 14 cadavers were scanned with CT to validate the measurements.
Of 48 LSTs, there was minimal difference in the direction of its course between sides; 14/24 specimens had concordant directions. The majority (n=28) had a medial to lateral cephalocaudal course. If osteophytes were present at the L4/L5 level, the majority of LSTs (n=7, of 8) were displaced lateral to the osteophyte. At the L5/S1 level, half of the cases with osteophytes (n=3, of 6) stretched the LST over the top of the osteophyte. The LST was adherent to the L4/L5 disc space bilaterally in 93% of cases.
With the development of lumbar fusion techniques which utilize an oblique corridor and the retraction of psoas muscle, LST has become an important neural structure to define, protect and mobilize. In our morphometric analysis of 24 specimens, the position has been identified and quantified, and this paper notes variations, particularly distortions caused by degenerative processes. In this study, the LST ran in a medial to lateral direction from L3 to S1, and osteophytes typically displace and adhere to the LST.
1997年，Mayer首次描述了一种利用腰大肌前方斜行通道进行腰椎侧方椎间融合术（LLIF）的方法，随后其他作者也进行了相关描述。在这个通道中唯一值得注意的恒定结构是腰交感干（LST），有时为了进行椎间盘切除术和椎间融合术必须对其进行游离，从而使LST处于危险之中。本研究旨在描述L3/L4至L5/S1腰椎前外侧入路手术相关标志点处LST的形态学解剖结构。
解剖24具防腐尸体（13例男性，11例女性，年龄范围50 - 89岁）以暴露LST。在直视下使用卡尺进行双侧测量，以腰椎矢状面作为参考标志点。然后用不透射线的针标记这些点，并对14具尸体进行CT扫描以验证测量结果。
在48条LST中，两侧走行方向差异极小；24个标本中有14个方向一致。大多数（n = 28）呈从内侧向外侧、头向尾侧走行。如果L4/L5水平存在骨赘，大多数LST（8个中的7个）向骨赘外侧移位。在L5/S1水平，有骨赘的病例中有一半（6个中的3个）使LST在骨赘上方伸展。93%的病例中LST双侧附着于L4/L5椎间盘间隙。
随着利用斜行通道和腰大肌牵开的腰椎融合技术的发展，LST已成为一个需要明确界定、保护和游离的重要神经结构。在我们对24个标本的形态学分析中，已确定并量化了其位置，本文记录了其变异情况，特别是由退变过程引起的变形。在本研究中，LST从L3至S1呈从内侧向外侧走行，骨赘通常会使LST移位并附着于其上。
