全皮质椎弓根螺钉

1、Page 1 Short-Term Results of Transforaminal Lumbar Interbody Fusion Using Pedicle Screw with Cortical Bone Trajectory Compared with Conventional Trajectory Department of Orthopedic Surgery, Akita University Graduate School of Medicine, Akita, Japan Page 2 Introduction 前言 The clinical results of tran

2、sforaminal lumbar interbody fusion (TLIF) have been favorable for degenerative spondylolisthesis, kyphoscoliosis, and instability of the lumbar spine. However, there has been concern regarding pedicle screw placement during TLIF。TLIF手术的临床效果已经被很好的运用于腰椎退变性滑手术的临床效果已经被很好的运用于腰椎退变性滑脱、脊柱侧后凸畸形及腰椎不稳。然而，脱、脊柱侧

3、后凸畸形及腰椎不稳。然而，TLIF手术过程手术过程中已经有关于椎弓根螺钉的定位。中已经有关于椎弓根螺钉的定位。Page 3Exposure lateral to the facet joint to insert a pedicle screw requires a relatively long incision and muscle dissection, which may be related to postoperative low back pain from injury to the posteromedial branch of the nerve root crossing

4、 the facet joint and damage to the exposed and retracted back musculature. To minimize the incision and muscle dissection and thus reduce these problems, TLIF with minimally invasive pedicle screw insertion (M-TLIF) and TLIF with percutaneous pedicle screw insertion (P-TLIF) have been developed.暴露侧方

5、到关节突关节去植入椎弓根螺钉需要相当长的切暴露侧方到关节突关节去植入椎弓根螺钉需要相当长的切口和肌肉切开。这种手术因损伤穿过关节突的神经根后支口和肌肉切开。这种手术因损伤穿过关节突的神经根后支及暴露过程中损伤背肌肉组织而引起后背痛。通过缩小切及暴露过程中损伤背肌肉组织而引起后背痛。通过缩小切口及减少肌肉组织的剥离去减少这些问题，口及减少肌肉组织的剥离去减少这些问题，TLIFTLIF用于微创用于微创椎弓根螺钉植入和经皮椎弓根螺钉植入已经被很好的运用。椎弓根螺钉植入和经皮椎弓根螺钉植入已经被很好的运用。Page 4However, several clinical concerns, such a

6、s low back pain, learning curve, radiation exposure, and incorrect pedicle screw placement, have also been associated with M-TLIF and P-TLIF。然而，在然而，在M-TLIFM-TLIF及及P-TLIFP-TLIF手术中，几个临床上关注点诸如手术中，几个临床上关注点诸如下腰痛，长的学习曲线，射线的暴露，以及椎弓根螺钉位下腰痛，长的学习曲线，射线的暴露，以及椎弓根螺钉位置植入不正确也已经被证实发生。置植入不正确也已经被证实发生。Page 5A new traje

7、ctory for pedicle screw insertion of pedicle screw placement, the cortical bone trajectory (CBT), was reported by Santoni et al. in 2009 and may address these problems. The new trajectory was from medial to lateral and cranial to caudal; this does not require wide exposure of the back muscle and thu

8、s reduces operative invasion compared with conventional or percutaneous pedicle screw insertion.在在20092009年，一种新的全皮质椎弓根螺钉植入方法被年，一种新的全皮质椎弓根螺钉植入方法被SantonietSantoniet等报道，并且可能解决一些问题。新的全皮质等报道，并且可能解决一些问题。新的全皮质螺钉植入是从内向外，从头向尾，这种方法与传统或者经螺钉植入是从内向外，从头向尾，这种方法与传统或者经皮椎弓根螺钉植入相比不需要广泛剥离后背肌肉组织和减皮椎弓根螺钉植入相比不需要广泛剥离后背肌肉组织

9、和减少手术损伤少手术损伤Page 6However, the differences in operative invasion, accuracy of pedicle screw insertion, and postoperative fusion rate between TLIF with CBT (CBT-TLIF) and other methods of pedicle screw placement, such as M-TLIF and P-TLIF, remain unknown. In this study, we compared the clinical and r

10、adiological results of CBT-TLIF with those of M-TLIF and P-TLIF.然而然而, ,在全皮质在全皮质-TLIF-TLIF与其它椎弓根螺钉植入方法，如与其它椎弓根螺钉植入方法，如M-M-TLIFTLIF及及P-TLIFP-TLIF相比，在手术损伤差异，椎弓根螺钉植入准相比，在手术损伤差异，椎弓根螺钉植入准确性确性, ,以及术后融合率之间依然没有结果。在这项研究中以及术后融合率之间依然没有结果。在这项研究中, ,我们比较我们比较CBT-TLIFCBT-TLIF与与M-TLIFM-TLIF与与P-TLIFP-TLIF在临床和影像学方面在临床和

11、影像学方面的结果。的结果。Page 7Surgical procedures M-TLIF was performed as follows. A unilateral facetectomy was performed at the location of the symptoms to expose the intervertebral foramen via a 6-cm incision. A thorough discectomy was completed and the disc space was filled with local bone graft material an

12、d an appropriate parallel Devex cage (DePuy Spine, Raynham, MA, USA) was placed.M-TLIFM-TLIF手术过程如下：用手术过程如下：用6cm6cm的切口去暴露有症状侧的椎的切口去暴露有症状侧的椎间孔通道需要切除单侧小关节。椎间盘被完全切除，椎间间孔通道需要切除单侧小关节。椎间盘被完全切除，椎间隙内填充自体骨和合适大小的隙内填充自体骨和合适大小的Devex cageDevex cage。Page 8Open conventional pedicle screws were placed using the Expe

13、dium Spine System (DePuy Spine) through a bilateral Wiltse approach. Under fluoroscopic guidance in a perfect posteroanterior projection, a pedicle probe was introduced into the pedicle at a 30 medial angle and the pedicle was tapped for a screw, taking care not to penetrate the medial wall.开放传统的椎弓根

14、螺钉植入通过双侧的Wilse入路使用Expedium脊柱系统。在标准的后前位透视下，椎弓根探针在向内倾斜30插入，拧入椎弓根螺钉，术中小心不要穿破椎弓根内壁。Page 9A feeler was used to identify breakage of the cortical pedicle walls, and a pedicle screw of appropriate length, as assessed on computed tomography (CT) images, was inserted. The lengths of screws were 40 or 45 mm a

15、nd 6.0 or 7.0 mm in diameter. Finally, under a lateral fluoroscopic view, the length and craniocaudal direction of the screws were checked (Fig. 1).插入探子的目的是用来鉴别椎弓根壁是否破损，椎弓根螺插入探子的目的是用来鉴别椎弓根壁是否破损，椎弓根螺钉的合适长度，这些结果需要在钉的合适长度，这些结果需要在CTCT图像去评估。椎弓根螺图像去评估。椎弓根螺钉的长度是钉的长度是4040或或4545毫米和直径毫米和直径6.06.0或或7.07.0毫米直径。最

16、后毫米直径。最后, ,在侧位的透视下来检查植入螺钉的长度及倾斜角度（图在侧位的透视下来检查植入螺钉的长度及倾斜角度（图1)1)。Page 10Fig. 1. Lateral radiographs of M-TLIF. (A) Preoperative radiograph, (B) postoperative radiograph, (C) radiograph at final follow-up. M-TLIF, transforaminal lumbar interbody fusion with minimally invasive pedicle screw insertion.P

17、age 11P-TLIF was performed using the Viper MIS Spine System (DePuy Spine). Following decompression of the affected site and placement of a cage into the disc space via a 6-cm skin incision, the targeting needle was placed on the superolateral border of the pedicle under fluoroscopy via another fasci

18、a incision created 1 cm lateral to the midline skin incision.P-TLIFP-TLIF运用运用Viper MISViper MIS脊柱系统。在透视下定位针一根放脊柱系统。在透视下定位针一根放在椎弓根外上侧边缘，另一根针放在中线皮肤切口旁开在椎弓根外上侧边缘，另一根针放在中线皮肤切口旁开1cm1cm。用。用6cm6cm皮肤切口，先行症状侧减压之后将皮肤切口，先行症状侧减压之后将cagecage植入椎植入椎间隙内。间隙内。Page 12The targeting needle was introduced into the pedicle

19、 under posteroanterior and lateral fluoroscopic visualization. The targeting needle was replaced with a K wire, and a screw with an extended sleeve was then placed over the K wire and inserted into the vertebral body after tapping. Prebent rods were placed bilaterally using the Viper system and fixe

20、d with compressive force at the facetectomy side (Fig. 2). 在后前位及侧位透视下将探针插入椎弓根，之后用导针代在后前位及侧位透视下将探针插入椎弓根，之后用导针代替探针，在过了椎弓根后壁以后用自攻螺钉插在导针上拧替探针，在过了椎弓根后壁以后用自攻螺钉插在导针上拧入椎体，使用入椎体，使用ViperViper系统将预弯的从双侧植入，然后固定系统将预弯的从双侧植入，然后固定加压关节突一侧加压关节突一侧( (图图2)2)。Page 13Fig. 2. Lateral radiographs of P-TLIF. Preoperative radi

21、ograph (A), postoperative radiograph (B), and radiograph at final follow-up (C). P-TLIF, transforaminal lumbar interbody fusion with percutaneous pedicle screw insertion.Page 14CBT-TLIF was performed using the CD HORIZON SOLERA Spinal System 4.75 mm (Medtronic, Memphis TN, USA). After exposure of th

22、e surgical field, an entry point for insertion of the CBT screw was drilled in the medio-caudal side of the pedicle with a 2 mm-diameter air drill under fluoroscopic guidance.全皮质螺钉植入全皮质螺钉植入TLIFTLIF手术运用手术运用4.75mm CD HORIZON4.75mm CD HORIZONSOLERASOLERA脊柱系统。在手术视野暴露以后，在透视下用脊柱系统。在手术视野暴露以后，在透视下用2mm2mm直径的

23、钻在椎弓根的内下侧为入点钻入全皮质螺钉。直径的钻在椎弓根的内下侧为入点钻入全皮质螺钉。Page 15A straight probe was used to create a trajectory for the CBT screw from the entry point to the opposite corner of the pedicle and vertebral body under anteroposterior fluoroscopic guidance. A short L-shaped K wire was placed to mark the trajectory. D

24、ecompression and cage placement were performed in the same fashion as in M-TLIF and P-TLIF.在透视下不断的用探子从全皮质螺钉的入点到椎弓根对侧在透视下不断的用探子从全皮质螺钉的入点到椎弓根对侧及椎体内去探查。一个短的及椎体内去探查。一个短的L L型探针被用来标记轨迹。减型探针被用来标记轨迹。减压及压及cagecage的植入过程与的植入过程与M-TLIFM-TLIF和和P-TLIFP-TLIF相同。相同。Page 16After cage placement, we tapped a hole with s

25、uccessive 4.0-, 4.5-, and 5.5-mm taps targeted to the posterior one-third of the vertebral body. When the tap reached the endosteal cortex of the vertebral body under lateral fluoroscopic guidance, screw length was determined. We then inserted 5.5- mm screws from 30 to 40 mm in length into the hole

26、and placed the rods (Fig. 3). 在在cagecage放置以后，我们以导针位置方向分别用放置以后，我们以导针位置方向分别用4.04.0、4.54.5、5.5mm5.5mm丝攻钻一个通道直针椎体的后丝攻钻一个通道直针椎体的后1/31/3处。在透视下，当处。在透视下，当丝攻到达椎体的骨内皮质时，螺钉的长度就被确定，然后丝攻到达椎体的骨内皮质时，螺钉的长度就被确定，然后我们插入从我们插入从3030到到40mm40mm长度的直径为长度的直径为5.5mm5.5mm粗的螺钉进入通粗的螺钉进入通道，之后放置棒。道，之后放置棒。( (图图3)3)。Page 17Fig. 3. Lat

27、eral radiographs of CBT-TLIF. (A) Preoperative radiograph, (B) postoperative radiograph, and (C) radiograph at final follow-up. CBT-TLIF, transforaminal lumbar interbody fusion with pedicle screw insertion with cortical bone trajectory. Page 18Page 19Result Intraoperative blood loss was significantl

28、y less with CBT-TLIF (p =0.03) than with M-TLIF. Postoperative lordotic angles did not differ significantly among the three groups. Complete fusions were obtained in 10 of 12 levels (83%) with M-TLIF, in seven levels (100%) with P-TLIF, and in 10 of 11 levels (91%) with CBT-TLIF. On postoperative computed tomography, correct p