cT监控下经腹穿刺LZ一5椎间盘摘除术的可行性研究 〔摘要]目的:研究和探索对LZ一LS伍213一L415)椎间盘突出和突出并髓核迁移病例安 全有效的介入治疗新途径。拓宽适应证的范围。方法:自2004.3一20053通过对3具 尸体、3条杂种成年犬的实验,采用消化道造影、腹部大血管造影、螺旋CT三维 重建等影像学和相关解剖学资料的研究,确立LZ一5经腹穿刺椎间盘的进针途径,并 对18例病人施行了经腹穿刺腰椎间盘摘除术(1丫ansabdomin对lumbardiskectomy TALD),其中L41516例、L3141例、L2131例。该项治疗的关键是采用腹部施 压方式,使穿刺部位肠管移位,采用CT监控避开腹部大血管,采用空心穿刺针负 压穿刺靶椎间盘后,以逐级套管方式建立手术通道,反复钳取突出部位的髓核组织, 达到局部直接减压的目的。结果:总有效率%%,未发现因损伤大血管造成大出血 病例。结论:经腹穿刺LZ一5椎间盘切实可行。需要指出的是:LllZ椎间盘因胰腺、 胃及十二指肠等器官解剖关系密切,不宜行经腹穿刺腰椎间盘髓核摘除术。LZ13椎 间盘与肾蒂内重要血管毗邻,手术风险较大,术前须进行血管影像学检查,并根据 所取得资料进行充分的论证与评估。L3/4、L4巧椎间盘穿刺时应充分推移肠管,各 樱椎间盘髓核摘除术必须在CT监视下进行,并且仅作为侧后入路腰椎间盘髓核摘 除术特殊情况下的一种补救方式。 硕士研究生曹玉汉 导师徐文坚教授 生琦瑞教授 I关键词】髓核迁移、椎间盘切除术、放射学、介入性、经腹。英文摘要 ThePraetiealResearchofTrans一abdominalLumbarDiskeetomy forLZ一5玩terverteb,1DisesUnderCTMonitoring IAbstraetlobjective:tostudyandexplorcasafeandeffeetiveinterventiona- theraPyforLZ一5diskP份trusionandherniatednucleusPulPosusinorderto enla烤etheindieationscoPetothetreatment.Metbods:FremtheMarchof2004to theMarchof2005,weapPliedthedigestivetraetcontrastandtheabdominalmajor bloodvesselcontrastexaminations,three一dimensionalsPiralCTgraPhic reconstru川onando伍errelcvantanatomiealdatatoestabnshpuncturingaceessto theLZ一dises.Thetrans一abdominallumbardis灿ctomywasPerformedincases withP功trusionofinte口ertebraldisks.Theenlistcdg邝uPineluded18easesof16of L415,lofL314and1ofLZ13.ThekeystePsoftheProcedu代arc:toexertPressureon 比eabdomen,shiftthe恤tes行nalPositionforthePune加ringsiteanddodgethe abdominalmajorbloodvesselsunderthedireetionofCT,andthentoad0Ptahollow need】ewithaeertainnegativeP代ssuretoPunetU代thetargetdisKtakc比estePwise wayofPuncturetrocartoestablishtheoPerativePathwayandrePeatedlycutoffthe nueleusPuPosustissuewithaProtraetorforthepu印oseofdi概tly代dueingofthe loealPressure.Results:thetotaleffeetiveratewas96%andtherewerenomajoreaseinthose Patieots.Conelusion:thetraus一abdominalIumbarPune加ringdiskectomy15regardedasaIdnd ofPracticaltheraPy.ButthekeyPointshouldbere幻口embe扮d:LllZdiskelosesanatomieallyto thePanereas,stomach,duedenumandtheothers,伍erefo瑞thetrans-abdominalPunctUring diskectomyshouldbenotadoPtedforit.othep即ise,owingtotheLZ13adjoiningtothemajor bl00dvesselsinthe代nalpedicl气比eoPerationhasacertainrisk50thattheeontrast exalnination山ustbePerformedbeforethesu馆eryandrequiredthedetsilda扭andtheanalysis oftheindicadons.Ihane加ringtoU14andL415disks,thein俪tinalPOsitionshouldbesh讯ed eomPletelyenough.The代movalofnucleusPuIPosustissuebe此quiredundertheCTmonitoring tomake,andonlyaetedasasortofsav加9me比odfortheOPerationthmughthe Iatera卜Posteriordi概tioninthesPeeialsituation. POstgraduate DirectedbyP功fessor CaoY如han XuW七njian ShengQirui NueleusPulPosusHerniatedDiskectomyInterven幼onalT丫.ns-abdominal目录 引言····················································································3 第一章尸体解剖与动物实验···················································5 1.1尸体解剖实验,·······,·················································’‘5 1.2动物实验··································································7 1.3影像学研究·······························································9 第二章临床应用··································································n 2.1资料与方法·······························································n 2.2结果········································································14 2.3讨论·········································、······························巧 2.4结论········································································20