Ultrasound-guided Clinical Anatomy Of The Needle Ligament To Release The Ligamentum Flavum

[Background]:Middle-aged and elderly people who suffer from lumbar disc herniation and lumbar spinal stenosis are mostly accompanied by hypertrophy of the ligamentum flavum which can directly compress the corresponding segments of the cauda equina nerve to produce lower limb symptoms.At the same time,because the ligamentum flavum is involved in the formation of a part of the posterior margin of the foramen,it determines the anteroposterior diameter of the foramen together with the intervertebral disc and other soft tissue behind the lumbar spine.With the protrusion of the lumbar intervertebral disc,the ligament flavum will become hypertrophy due to abnormal mechanical stress.The joint action of this two will lead to a decrease in the anteroposterior diameter of the intervertebral foramen and produce the symptoms of nerve root compression.However,the treatment of patients with lumbar disc herniation and lumbar spinal stenosis together with lumbar ligamentum thickening is not clear.Most patients were only treated with prominent intervertebral discs.the stimulation of the thickened ligamentum flavum to the spinal canal and nerve roots was often neglected,making some patients unable to relieve symptoms after treatment.In clinical practice,needle-knife therapy has achieved significant short-term and long-term efficacy in the treatment of lumbar spine disease caused by thickening of the ligamentum flavum.However,the traditional needle-knife treatment only determines the position and depth of puncture by the positioning of the body’s surface anatomical landmarks and the feel of the physician’s needle.This non-directly operation has certain operational difficulties and risks.[Target]:Explored the anatomical path of releasing the ligamentum flavum by ultrasound-guided needle-knife and provided a safer and more reliable minimally invasive treatment for the treatment of lumbar disc herniation and spinal stenosis.Method:Specimens were from the Donation Center of the Basic Medical College of Peking University.Study time is from December 2015 to January 2018.12 cadavers including 4 females and 8 males with age from 60 to 90 years(73.42±14.57)without formalin fixation were selected.Guided by ultrasound transducer,we punctured acupotomy to release lumbar LF in L3/L4,L4/L5,L5/S1 segments.In Transverse axis approach the probe was placed transversely,while in longitudinal axis approach the probe was placed longitudinally.Measured the depth of needle penetration U-A,the distance between the puncture point and spinous process U-B,and the angle for acupotomy D on ultrasound images.Measured the depth of needle penetration A,the distance between the puncture point and spinous process B,and the distance between the puncture point and cornua sacralia C on cadavers.Statistical analyses were carried out by SPSS.Results:No obvious blood vessels and nerves were observed in the puncture path,the spinal dura was intact.There was no statistical difference between the left and right sides data measured in ultrasound images and cadavers(P>0.05).In the comparison of the two approaches,U-A,A,B had significant differences between the transverse and longitudinal axis.Compared the means of U-A,A,B then we found the means of U-A and A of the transverse axis are less than those of the longitudinal axis,while the mean of B of the transverse is larger than that of the longitudinal axis.The mean of D had no significant differences in L4/L5 and L5/S1(P>0.05),while it has statistical difference in L3/L4(P<0.05).Therefore,the penetration depth of the transverse axis was less than the longitudinal axis,and the distance between the puncture point and spinous process was greater than that of the longitudinal axis.In transverse axis entry,there was no difference in U-A,U-B,A,B,C,D measurements between specimens under 80 years of age and specimens over 80 years of age(P>0.05).Therefore,there is no significant difference between the above groups.The measurement data of transverse axis entry of L3/L4,L4/L5 and L5/S1 showed that there was no difference between the needle angle,the depth of the needle and the distance from the spinous process in the three segments(P>0.05),while there was a significant difference between h distance between the puncture point and cornua sacralia(P<0.05).There was a strong correlation between the distance on the ultrasonic images and the cadavers on the path of acupotomy.Linear equation:(A/B)=1.19×(U-A/U-B),R2=0.765.Conclusion:Before the treatment,the depth of needle penetration in the human body can be obtained by measuring the distance between the needle point and the target position with the ultrasound image.Under the guidance of ultrasound,the transverse axis approach of the ligamentum release by the needle knife is superior to the longitudinal axis approach.