Tulane University School of Medicine, New Orleans, LA, USA.
The Spine Center at Joint Implant Surgeons of Florida, Naples, FL, USA.
Neurosurg Rev. 2022 Jun;45(3):2441-2447. doi: 10.1007/s10143-022-01772-w. Epub 2022 Mar 14.
Some authors have suggested that thigh extension during the prone lateral transpsoas approach to the lumbar spine provides the theoretical advantage of providing posterior shift of the psoas muscle and plexus and is responsible for its lower rates of nerve injury. We aimed to elucidate the effects of surgical positioning on the femoral nerve within the psoas muscle via a cadaveric study. In the supine position, 10 fresh frozen adult cadavers had a metal wire secured to the pelvic segment of the femoral nerve and then extended proximally along with its L2 contribution. Fluoroscopy was then used to identify the wires on the femoral nerves in a neutral position and with the thigh extended and flexed by 25 and 45°. Additionally, a lateral incision was made in the anterolateral abdominal wall to mimic a lateral transpsoas approach to the lumbar spine, and measurements were made of the amount of movement in the vertical plane of the femoral nerve from neutral to then 25 and 45° of thigh flexion and extension. On fluoroscopy, the femoral nerves moved posteriorly at a mean of 10.1 mm with thigh extension. Femoral nerve movement could not be detected at any degree of this range of flexion of the thigh. Extension of the thigh to about 30° can move the femoral nerve farther away from the dissection plane by approximately one centimeter. This hip extension not only places the femoral nerve in a more advantageous position for lateral lumbar interbody fusion procedures but also helps to promote accentuation of lumbar lordosis.
一些作者认为，在腰椎旁侧经前路手术中伸展大腿可以提供理论上的优势，使腰大肌和腰丛向后移位，从而降低神经损伤的发生率。我们旨在通过尸体研究阐明手术体位对腰大肌内股神经的影响。在仰卧位，10 具新鲜冷冻成人尸体将金属丝固定在股神经的骨盆段，然后向近端延伸，同时延伸其 L2 贡献。然后使用透视来确定股神经在中立位、大腿伸展和弯曲 25°和 45°时的金属丝。此外，在前外侧腹壁做一个侧切口，模拟腰椎旁侧经前路手术，测量股神经在垂直平面上从中立位到大腿伸展和弯曲 25°和 45°的运动幅度。透视下，大腿伸展时股神经平均向后移动 10.1 毫米。在大腿伸展的这个范围内，任何程度的弯曲都无法检测到股神经的运动。大腿伸展约 30°可以使股神经远离手术平面约一厘米。这种髋关节伸展不仅使股神经在进行侧方腰椎椎间融合术时处于更有利的位置，还有助于促进腰椎前凸的增加。
