L4-L5 斜侧方入路：一种评估侧方椎间融合可行性的影像学-解剖学研究。
The Oblique Corridor at L4-L5: A Radiographic-Anatomical Study Into the Feasibility for Lateral Interbody Fusion.
机构信息
Division of Spine, Department of Orthopedic Surgery, Tan Tock Seng Hospital, Singapore.
Department of Orthopaedic Surgery, Melmaruvathur Adhiparasakthi Institute of Medical Sciences and Research, Tamil Nadu, India.
出版信息
Spine (Phila Pa 1976). 2020 May 15;45(10):E552-E559. doi: 10.1097/BRS.0000000000003346.
STUDY DESIGN
Cross-sectional radioanatomical study.
OBJECTIVE
The aim of this study was to analyze the prevalence, size, and location of the oblique corridor (OC), and the morphology of the psoas muscle at the L4-L5 disc level.
SUMMARY OF BACKGROUND DATA
Lateral lumbar interbody fusion via the OC has the advantage of avoiding injury to the psoas muscle and lumbar plexus. However, the varying anatomy of major vascular structures and the iliopsoas may preclude a safe oblique access to the L4-L5 level.
METHODS
Five hundred axial magnetic resonance images of the L4-L5 disc level were shortlisted. OCs were categorized into four grades: Grade 0 = no corridor, Grade 1 = small corridor (≤1 cm), Grade 2 = moderate corridor (1-2 cm) and Grade 3 = large corridor (>2 cm). OC location was labeled as antero-oblique, oblique, or oblique-lateral. Psoas morphology was categorized based on a modified Moro's classification, where the anterior section was further subdivided into types AI-AIV. Oblique approach was considered nonviable either when there was no corridor due to vascular obstruction (Grade 0) or when the psoas was high-rising (Types AII-AIV).
RESULTS
10.5% of the selected 449 patients had no measurable OC (grade 0) at the L4-L5 level. There were 35% and 37.2% patients with a grade 1and 2 OC, respectively. The location of the OC was anterior oblique, oblique, and oblique lateral in 3.7%, 89.6%, and 6.7%, respectively. According to the modified Moro's classification, 19.4% had a high-rising psoas. Predominantly, psoas was either in line with the disc (Type I; 30.7%) or low-rising (Type AI; 47.4%).
CONCLUSION
Twenty-five percent of the patients did not have an accessible OC either due to obstruction by vascular structures or due to a high-rising psoas. Hence, proper evaluation of the relevant anatomy preoperatively is recommended for early adopters of this technique, as varying anatomy precludes universal suitability of oblique lateral interbody fusion for the L4-L5 level.
LEVEL OF EVIDENCE
研究设计
横断面放射解剖研究。
目的
本研究旨在分析斜走廊（OC）的发生率、大小和位置，以及 L4-L5 椎间盘水平腰大肌的形态。
背景资料概要
通过 OC 进行侧腰椎椎间融合术具有避免损伤腰大肌和腰丛的优点。然而，主要血管结构和髂腰肌的不同解剖结构可能会妨碍安全地斜向进入 L4-L5 水平。
方法
筛选出 500 例 L4-L5 椎间盘水平的轴向磁共振图像。OC 分为四级：0 级=无走廊，1 级=小走廊（≤1cm），2 级=中走廊（1-2cm），3 级=大走廊（>2cm）。OC 位置标记为前斜、斜或斜外侧。根据 Moro 分类的改良版，将腰大肌形态分为 A、B、C、D 四型，其中前节进一步分为 AI-AIV 型。如果由于血管阻塞（0 级）或腰大肌升高（AII-AIV 型）而没有可测量的 OC（4 级），则认为斜入法不可行。
结果
在选定的 449 例患者中，有 10.5%的患者在 L4-L5 水平没有可测量的 OC（0 级）。1 级和 2 级 OC 分别占 35%和 37.2%。OC 的位置分别为前斜、斜和斜外侧，占 3.7%、89.6%和 6.7%。根据改良 Moro 分类，19.4%的患者腰大肌升高。主要的是，腰大肌要么与椎间盘平齐（I 型；30.7%），要么低位（AI 型；47.4%）。
结论
由于血管结构的阻塞或腰大肌的升高，25%的患者没有可进入的 OC。因此，建议早期采用这种技术的患者在术前对相关解剖结构进行适当评估，因为不同的解剖结构使斜外侧椎间融合术不适合 L4-L5 水平。
证据水平
3 级。
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