【骨科-微创-课件】微创经椎间孔入路腰椎体间融合术

1、 Minimally Invasive Transforaminal Lumbar Interbody Fusion (TLIF)DR SEANG-BENG TANHEAD, DEPT OF ORTHOPAEDICSDIRECTOR, SPINE SERVICESINGAPORE GENERAL HOSPITAL微创经椎间孔入路腰椎体间融合术 新加坡中央医院Aim of MIS微创的目的Accomplish surgical goals through small incisions and minimal disruption of normal tissues以小切口达到手术的目的，并对正

2、常组织造成最少的伤害。Principles of Minimally Invasive Spinal Surgery微创脊椎手术的原则Decompress and stabilize the spineReduce the “surgical injury” to normal tissues Limit retraction of muscle减压并保持脊椎稳定减少对正常组织的伤害减少对肌肉的拉扯Reduce blood lossImprove recovery by reducing post operative pain减少失血量减轻术后疼痛，以使病人尽快康复。Principles of

3、 Minimally Invasive Spinal Surgery微创脊椎手术的原则New Advances in TLIF经椎间孔入路腰椎体间融合术的最新动向Percutaneous decompression and cage placement with Pipeline and other tube systemsPercutaneous pedicle screw fixation using Viper, Sextant, Pathfinder经皮穿刺减压和利用工作通道来放置椎间融合器利用Viper, Sextant, Pathfinder，经皮植入椎弓根螺钉。Strategie

4、s to Avoid Complications with MIS微创手术中减少并发症的策略Training 培训Patient selection 选择适当的病人Setup 设备Access 入路Pedicle screw placement 椎弓根螺钉的植入Misc 其他策略Training培训THERE IS A LEARNING CURVE! 学习的过程Cadaver workshopsView cases with surgeon well trained in applying these techniquesStart slowly and work up to more com

5、plex cases在尸体上练习在熟练医生进行这类手术时观摩循序渐进，慢慢地过渡到复杂的手术。Training培训Start big and move smaller-gradually reduce incision sizeStart in the lumbar spineBecome comfortable with microdiscectomy firstLearn kyphoplasty由大的切口开始，慢慢地缩小切口由腰椎开始先从熟悉显微椎间盘切除术入手学习球囊扩张椎体后凸成形术Patient Selection选择适当的病人MIS fusion patients primaril

6、y one segment diseaseDDD some disc space preservationGrade 1 to low Grade 2 spondylolisthesisBeware of L5-S1 (sacrum sometime hard to visualize pedicle screw targeting)微创融合术的病人 由单间隙的病患开始椎间盘退化 - 椎间距离不宜太小第一级的腰椎滑脱或轻微第二级的腰椎滑脱小心L5-S1间隙（在骶骨植入椎弓根螺钉会比较困难）Start with relatively thin individuals with good bone

7、 qualityObesity and osteoporosis difficult to visualize bony anatomy adequately从骨质相对比较好和较廋的病人开始肥胖和骨质疏松症 使骨骼较难充分暴露Patient Selection选择适当的病人TLIF Access椎间融合器入路Working Zone操作区域Access osteotomy入路截骨Decompress the ipsilateral side, then put in the largest cage, before decompressing contralateral side.同侧减压先。

8、然后，在另一侧减压前，植入最大的椎间融合器。Nerve神经Pedicle screw placement植入椎弓根螺钉Percutaneous Screw Angulation经皮调整螺钉的角度MOVE LATERAL!向外侧移动！Starting Point起点Pedicle Mid Point植入椎弓中途Thru the Pedicle完全植入Ensure screw heads are at the same level螺钉头要固定在同一水平线上微创和开放性经椎间孔入路腰椎体间融合术的6个月与2年随访调查Spine Service, Orthopaedic SurgerySingapor

9、e General Hospital脊椎专科，矫形外科新加坡中央医院Prospective Trial of MIS TLIF Vs OPEN TLIF 6 Months & 2years ResultMIS微创OPEN 开放型Age 年龄(years)58.458.5Sex 性别 (F:M) (女:男)116:6512:3Fluoroscopy time透视时间1min 45 secs35 secsDuration of Surgery 手术时间（小时）3:19 (range: 2:15 4:40)2:40 (range: 2 3:55)Blood loss失血量 200ml500mlMIS

10、微创OPEN开放性Length of hospitalisation (days)住院时间（天）4.4 (range: 2 9)6.0 (range: 5 - 7)VAS: POD/DISCHARGE视觉模拟疼痛评分：术后/出院5.0/1.06.0/2.6Total Morphine (PCA, mg)吗啡(止痛药）剂量17.435.7Ambulation: Room/Ward (POD)术后第几天开始步行1.0/2.03/4North American Spine ScoreBack Pain & Disability Score北美脊椎协会评分标准 疼痛及残疾指数BACK PAIN & D

11、ISABILITY (Range 0 to 100)0 = No back pain or disability100 = Maximum back pain or disability疼痛及残疾指数 (0 至 100分)0 = 没有疼痛或残疾100 = 非常疼痛或极度残疾开放性微创术前术后六个月术后两年North American Spine ScoreNeurogenic Symptom Score北美脊椎协会评分标准 神经性症状指数NEUROGENIC SYMPTOMS (Range 0 to 100)0 = No neurogenic symptoms100 = Severe neur

12、ogenic symptoms开放性微创术前术后六个月神经性症状指数 (0 至 100分)0 = 没有神经性症状100 = 极度神经性症状术后两年North American Spine Score (6mths)北美脊椎协会评分标准 到现在为止,手术符合你的要求吗?(术后六个月)开放性微创符合多多少少不符合North American Spine Score (2yrs)北美脊椎协会评分标准 到现在为止,手术符合你的要求吗?(术后两年)开放性微创符合多多少少不符合North American Spine Score (6mths)北美脊椎协会评分标准 你怎样评价手术对治疗你的腿或背痛的疗效?(术后六个月)开放性微创优中差North American Spine Score (2yrs)北美脊椎协会评分标准 你怎样评价手术对治疗你的腿或背痛的疗效?(术后两年)开放性微创优中差North American Spine Score Retur