LUMBAR AREA [regio lumbalis (PNA, JNA, BNA)].
The LUMBAR AREA is a steam room; its upper bound — the XII edge, lower — an ileal crest (crista iliaca), lateral — the back axillary line (linea axillaris post.), edges separates it from lateral area of a stomach, medial — the paravertebral line (linea paravertebralis) separating P. of the lake from vertebral area (fig. 1). The intra belly fascia (fascia endoab-dominalis) separates P. of the lake from retroperitoneal space (see). Is divided a line, the drawn on lateral edge of the muscle straightening a backbone (m. erector spinae) P. of the lake into the medial and lateral departments covered with skin, hypodermic cellulose and a superficial fascia (fascia superficialis); a structure of deeper layers in these departments variously.
The medial department, its especially lower part, is deeper than a superficial fascia, is characterized by massive accumulation fatty tissue (see), the buttock extending to the area. There is a back wall of a vagina of the muscle straightening a backbone even more deeply. It is formed by a superficial leaf of a thoracolumbar fascia (fascia thoracolumbalis) and aponeuroses of the broadest muscle of a back (m. latissimus dorsi) and the lower back gear muscle (m. serratus posterior inferior). The following layer is the thick muscle straightening a backbone then there is a front wall of her vagina (representing a deep plate of a thoracolumbar fascia), kpered from a cut, between the XII edge and an ileal crest, the square muscle of a waist is located (t. quadratus lumborum), covered in front with the fascia which is a part of an intra belly fascia (fig. 2).
In lateral department more deeply than a superficial fascia the broadest muscle of a back lies, consistently lower back gear muscle, an outside oblique muscle of a stomach (m. obliquus externus abdominis), an internal oblique muscle of a stomach (m. obliquus internus abdominis) and a cross muscle of a stomach (m. transversus abdominis) — fig. 3 are located even more deeply. The cross muscle of a stomach is covered from an abdominal cavity with a cross fascia (fascia transversalis).
Due to various extent of participation of the called muscles in formation of an abdominal wall within P. the lake form here rather weak sites which can become the place of developing of hernias (fig. 4). One of such sites is the triangle (or a rhombus) Lesgafta — Grinfelta famous also under the name of lumbar space (spatium lumbale) limited from above to bottom edge of a back lower gear muscle and bottom edge of the XII edge, lateralno and from below — edges of internal and outside oblique muscles of a stomach, medially — the muscle straightening a backbone. The bottom of this triangle is formed by a cross muscle of a stomach. Other weak point is the lumbar triangle described by J. L. Petit which is limited in front by the rear edge of an outside oblique muscle of a stomach, behind — lateral edge of the broadest muscle of a back, from below — an ileal crest. The bottom of a triangle is formed by the internal oblique muscle of a stomach and her cross muscle of a stomach lying more deeply making all thickness of a muscular layer of an abdominal wall in this site.
Blood supply and innervation. Arteries of skin and P.'s muscles of the lake come from back branches of lumbar arteries (aa. lumbales) which are branches of a ventral aorta. Veins are inflows of lumbar veins (vv. lumbales) falling into the lower vena cava. P.'s skin of the lake is innervated by back branches of 9 — 12 chest spinal nerves (fig. 1 to St. Lumbosacral texture). P.'s muscles of the lake are innervated by back branches of 1 — 4 lumbar spinal nerves (the muscle straightening a backbone, the lower back gear muscle), branches of a brachial plexus (the broadest muscle of a back), 6 — 12 intercostal nerves (outside and internal oblique muscles of a stomach, a cross muscle of a stomach), a lumbar texture (a square muscle of a waist). Lakes pass subcostal (n. subcostalis), iliohypogastric (item iliohypogastricus) and ilioinguinal (n. ilioinguinalis) in P. nerves.
Damages of lumbar area are observed quite often. At the closed P.'s damages by the lake — bruise (see), stretching (see. Distortion ), an overstrain and a rupture of muscles (see. Gaps ) are, as a rule, formed out of - and intramuscular hematomas (see. Hematoma ), what can be followed by a prelum of branches lumbosacral texture (see) with the expressed pain syndrome and disturbance of functions of the corresponding nerves.
The open (especially fire) and severe closed P.'s injuries of the lake (falling from height, an autoinjury) often are followed by damage of the deep-located bodies retroperitoneal space (see), abdominal organs, and also backbone (see) and spinal cord (see).
Treatment of injuries of P. of the lake is defined by the nature of damages. Injuries without damage of bodies treat by generally conservative methods (rest, the physical therapy dosed to lay down. gymnastics); at wounds make surgical treatment them (see. Wounds, wounds ). At damage of bodies carry out respectively emergency laparotomy (see), lumbotomy, laminectomy (see).
Diseases. Among pyoinflammatory diseases is skin and hypodermic cellulose P. of the lake furuncles most often meet (see. Furuncle ) and an anthrax (see. Anthrax ), the wedge, a current and treatment to-rykh in this area does not represent any features.
Not only pyogenic bacteria, but also colibacillus can cause deep intermuscular phlegmon of P. of the lake. Phlegmon arises usually owing to transition of inflammatory process of retroperitoneal cellulose at purulent processes in an abdominal cavity or at suppuration of retroperitoneal hematomas. Purulent flow at the same time lakes in a rump, in a pelvic cavity and, on the contrary, under a wide muscle of a back and between belly muscles can extend from P.
Diagnosis of deep phlegmons is complicated since because of the big thickness of a muscular layer of P. of the lake local signs of an inflammation are expressed unsharply, and the phenomena of intoxication of an organism prevail.
Differential diagnosis is carried out with psoitis (see), an anthrax of a kidney (see. Kidneys ), paranephritis (see), the suppurated tumor or an echinococcal cyst (see. Echinococcosis ), retrocecal abscess (see. Appendicitis ) or a perirenal hematoma (see. Kidneys ). Carefully collected anamnesis, a comparative palpation of musculocutaneous folds of P. of the lake (a thickening and their puffiness on the party of defeat), rentgenol, a research (including a research of an abdominal cavity, backbone, pelvic bones) and a diagnostic puncture allow to distinguish a disease correctly. Treatment of deep phlegmon consists in the broad opening of an abscess and zatek adequate them drainage (see) and antibacterial therapy.
Emergence of pains in P. of the lake is not always connected with a disease of the fabrics and bodies relating to it. E.g., at a so-called lumbago (see. Lumbago ) the pristupoobrazny sharp back pain caused most often by osteochondrosis of lumbar intervertebral disks takes place (see. Diskosis , Osteochondrosis ). Less acute, but persistent pains in P. lakes arise at inflammatory and tumoral damages of a backbone and spinal cord, diseases of a meninx and roots of the spinal nerves forming a horse tail, diseases of abdominal organs, a small pelvis and retroperitoneal space.
Seldom in P. the lake observe lumbar hernias (see). They are generally acquired and unilateral, meet at men more often. Hernias are formed after a direct injury of P. of the lake, falling from height, surgical interventions, but a thicket — after break tubercular natechnik (see) through a lumbar triangle of Pti or lumbar space of Lesgaft — Grinfelta at a spinal tuberculosis. Lumbar hernias usually have no hernial bag and are presented by ekstraperitonealny cellulose. Less often true hernias meet a hernial bag. These hernias can be restrained. The wrong recognition of nature of hernia can bring into time of operation to opening of a gut and formation of fecal fistula.
Tumors. Benign tumors in P. of the lake meet often. It is a nevus pigmentosus, angioma (see), angiofibroma (see), lipoma (see), neurofibroma (see), etc. Malignant tumors of P. of the lake — melanoma (see), fibrosarcoma (see), etc. — meet rather seldom. Treatment is defined by character and a wedge, the course of a tumor.
Through P. lakes provide Extra peritoneal surgical access to bodies of retroperitoneal space (kidneys, adrenal glands) or to abscesses of retroperitoneal cellulose (see. Lumbotomy ). The large number of cuts is offered, at to-rykh muscles and nerves are minimum injured and the broadest access is created. Choose from these cuts (fig. 5) optimum for a specific case, considering prevalence and localization of process, constitutional features of a structure of a body (in particular, a thorax, a basin), etc. Use Bergmann's cuts more often — Izrael, Pean and Fedorov. At a lumbotomy (fig. 6) after a section of skin, hypodermic cellulose and a superficial fascia layer-by-layer, in the direction of a skin section cut muscles, and then a cross fascia then in the depth of a wound cellulose of retroperitoneal space appears and access to bodies of retroperitoneal space opens.
Bibliography: Gornik V. M. Occupational diseases of lumbosacral area, M., 1976; Kanarey-k ying K. F. Lumbosacral pains, M., 1972, bibliogr.; Ostroverkhov G. E., Lubotsky D. N. and Yu. M. Kurs's Bomash of operational surgery and topographical anatomy, page 641, M., 1964; Practical questions of abdominal surgery and traumatology, under the editorship of F. S. Sagalovsky, page 71, Riga, 1971; Finneson B. E. Low back pain, Philadelphia — Toronto, 1973; H o 1 1 i n s h e a d W. H. Anatomy for surgeons, v. 2, N. Y. a. o., 1971; Pern-k o p f E. Atlas der topographischen und angewandten Anatomie des Menschen, Bd 1 — 2, Wien — Baltimore, 1980.
And. H. Belov; E. A. Dyskin (An.).