腰椎前路手术相关自主神经的解剖及临床意义

目的 对腰椎前方的自主神经进行解剖和组织学观察,提出避免导致逆行射精的自主神经丛损伤的腰椎前路手术途径.方法 选择10具防腐固定成年男性腰段标本,借助解剖放大镜和手术显微镜观察后腹膜与主动脉、髂总动脉及腰骶岬部前方筋膜的层次关系,自主神经丛的走行及上腹下丛(superior hypogastric plexus,SHP)在L5～S1椎前的分布.对主动脉前、主动脉旁和腰骶椎前组织行HE染色,观察腹膜后组织中自主神经的分布特点.结果 SHP一般通过腹主动脉分叉点左侧跨越左髂总动脉.SHP主干位于左、右髂总动脉形成的三角内,其最宽处位于腰骶间隙前7例(70%),位于骶前3例(30%);其中4例(40%)位于骶岬部左侧,6例(60%)位于腰骶岬部中线偏左.自主神经丛位于一层连续的独立于腹膜后的筋膜层中,且组织学观察进一步证实了自主神经筋膜层的存在.结论 经腹膜入路腰椎前路手术应从右侧切开后腹膜,分离时应轻柔地将SHP自右向左沿椎间盘边缘推开;选择外科平面要保证在神经筋膜层下进行分离,可以将位于腹主动脉和腰骶岬部的自主神经层整层掀起,达到保留自主神经的目的.

Clinical anatomy study of autonomic nerve anterior to the lumbar

Objective The anatomical and histological characteristics of the autonomic nerve anterior to the lumbar are to study,in aiming to clarify anatomical basis for an ejaculation-preserving approach in the minimally invasive lumbar surgery.Methods The lumbar retroperitoneal region of 10 male cadavers was dissected and analyzed.The parietal peritoneum anterior to the abdominal aorta, iliac artery and lumbar spine was incised and dissection bilaterally.The main goal of these dissections was to understand the anatomic relations of autonomic nerves and analyzed a series of sections of paraffin-embedded preortic and para-aortic tissues,exposing the anatomic relations between nervous structure and the covering fasciae.Results The major part of the superior hypogastric plexus(SHP)was found slighted shifted to the left,with principal mass resting on the left common iliac artery.The main trunk of the SHP was situated in the triangle region before the distal abdominal aorta and its bifurcation plane.There were 7 cases (70%) situated at L5S1 intervertebral disc level and 3 cases(30%) situated at the sacral promontory level.The main trunk of the SHP situated on the left side of sacral promontory were found in 4 cases(40%).The other cases (60%) were situated on the left side of the midline of sacral promontory.These retroperitoneal structures appeared to be separated from the overlying fatty mass by a distinguishable loose connective tissue plane.Microscopic analysis of preaortic and para-aortic tissues conftrms the plane of separation.thus the nerve fiber plane exist as an independent plane.Conclusion According to the character of automatic nerve in front of lumbar, the peritoneum should be incised from right side in the transperitoneal approach.The nerve fiber fascia anterior to the aortic and sacral promontory can be mobilized as a whole to preserve the autonomic nerve.