Clinical Anatomical Study Of Approach In Percutaneous Lumbar Disc Puncture

Objective 1. To elucidate the imaging features of main and adjacent structures of lumbarl discs, and to compare value and limit of CT with MRI. 2. To set up image datasets of thin anatomical serial sections of lumbar disks and their surrounding structures and show their morphology features, to compare characteristic of thin sectional anatomy with that of imaging sectional anatomy. 3. To give precise definition of 'safe triangle'in percutaneous lumber disc puncture, explore anatomical foundation for puncture syndrome. 4. To provide convincing evidences for selecting puncture approach and improving puncture level, together with percutaneous laser disc decompression(PLDD) clinical practice. 5. To establish CT 3D model and 3D anatomical model of lumbar spine and elucidate their solid shape, 3D space position and adjacent relationship. 6. To construct the PC-based visualization model of approach in percutaneous lumbar disc puncture. Materials and Methods 1. The imaging features of main structures and adjacent relationships in lumbar discs were observed and measured based on CT images of 53 cases of normal lumbar discs and MR images of 40 casesof normal lumbar disks. 2. The serial thin sectional morphology of main structures and adjacent relationships in lumbar discs were anatomically observed and measured based on 2 Chinese Visible Human datasets. They were also compared with the above-mentioned CT and MR images. 3. 86 cases of lumbar disc herniation were punctured and treated by PLDD. The success rate of puncture and curative effect were observed. 4. 4 cases of the normal lumbar spine were 3D reconstructed in CT. The spase relationship of lumbar spine, track of lumbar arteries and iliac arteries with L5-S1 intervetebral disc were observed. 5. The serial thin sectional anatomical images of lumbar spine in 2 CVH datasets were segmented and 3D reconstructed. The relationship between their space positions was observed. 6. The 3D structures of lumbar spine were visualized and puncture approaches were virtually demonstrated by software for 3D rendering. Results 1. To get the imaging features and related measure parameters of main and adjacent structures of lumbar discs. There were no significant statistical difference between length and width of left lumbar nerve and that of right one, nor between distance from puncture line to left lumbar nerve and that to the one. CT was superior to MRI in showing the bony markers of puncture line. MRI was superior to CT in distinguishing density of soft tissue. 2. To get the serial thin sectional morphology features and related measure parameters of main and adjacent structures in lumbar discs. The lumbar disc nucleus, nerves and blood vessels were showed clearly. The structures had excellent correspondences with CT, MRI images. 3. 'Triangular working area'and 'trapeziform working area'were precisely defined. Their acreage were 23.70 ±8.73 mm2 and 4.18～5.61 cm2 respectively. The above-mentioned areas were safe for percutaneous lumbar disc puncture. But intervertebral veins, spinal branches of lumbar arteries and internal vertebral veins were passed through these areas. 4. The lumbar disc herniation was treated by PLDD. The success rate of puncture was 96.5% and curative effect was 78%. In case of the posterior lateral puncture approach in L5-S1 intervertebral disc was failed, the anterior puncture approach should a new choice. 5. To clarify 3D relationship of lumbar spine to adjacent blood vessels in 3D reconstructed images of CT and show track of lumbar arteries and space relationship of iliac arteries and to L5-S1 intervertebral disk. But 3D reconstruction of CT must be accomplished on the professional workstation. 6. To clarify 3D relationship of main structures between lumbar spine in 3D anatomical model and integrally show 3D anatomical structures and adjacent relationships. 3D anatomical reconstruction should be complished on PC.7. To construct the PC-based visualization model of approach in percutaneous lumbar disc puncture. The puncture approaches were virtually demonstrated percutaneous lumbar disc puncture through the posterior lateral approach and the anterior approach. Conclusion 1. CT and MRI are the important means to decide approach of percutaneous lumbar disc puncture and show main structures and adjacent relationshup in lumbarl discs. CT examination is the first choice and MRI examination serve necessary assistance to improve puncture level. 2. The datasets of serial thin sectional anatomical images of lumbar discs and their surrounding structures can be displayed clearly in their morphology features and rules. Combined with the CT and MRI images, datasets are helpful in improving the affirmance rate of small lesions of lumbar disc nucleus, nerves and blood vessels, which provide theoretical morphological basis for choosing operation plan. 3. There is an area without important nerve and blood vessel in 'Triangular working area in posterior lateral puncture approach'and 'trapeziform working area in the anterior puncture approac'. Because lumbar artery and intervertebral veins are passed through triangular area areas and venous structure are overlap on lumbar discs in trapeziform area, the security was affected in puncture of lumbar discs. So we prefer 'safe area'to previous 'working area'. 4. Accoding to CT and MRI, the reason for puncture bleeding may be ascending lumbar veins, internal vertebral veins and intervertebral veins . The intervertebral veins, spinal branches of lumbar arteries and internal vertebral veins in puncture line were proved by thin sectional anatomy. The anatomical basis of puncture bleeding was proved to be these blood vessels. 5. PLDD provid to have The high success rate of puncture and curative effect, which offers convincing evidences for this study. Taking into account that the posterior lateral puncture approach in L5-S1 intervertebral disc was failed, the anterior approach is a new choice for puncture of L5-S1 intervertebral disc. 6. The 3D relationship of lumbar spine to adjacent blood vessels in CT 3D reconstruction are displayed individually, together with any other structure or collectively. CT 3D reconstruction must be complished on the professional workstation. The 3Drelationships between main structures of lumbar spine in 3D anatomical model are clearly displayed. 3D anatomical reconstruction should be accomplished on PC. The study is sure to have important signifcance in spine anatomy, operation navigation, biological mechanics and finite element biomechanical analysis. 7. The posterior lateral approach and the anterior approach of percutaneous lumbar disc puncture have been displayed on PC. The puncture processes of percutaneous lumbar disc puncture were simulated. Hance we've established solid basis for seting up model simulated training system of percutaneous lumbar disc interventional operation.