全皮质椎弓根螺钉

Short-TermResultsofTransforaminalLumbarInterbodyFusionUsingPedicleScrewwithCorticalBoneTrajectoryComparedwithConventionalTrajectory

DepartmentofOrthopedicSurgery,AkitaUniversityGraduateSchoolofMedicine,Akita,Japan使用皮质骨螺钉植入与传统螺钉植入在TLIF手术中的短期结果Introduction前言

Theclinicalresultsoftransforaminallumbarinterbodyfusion(TLIF)havebeenfavorablefordegenerativespondylolisthesis,kyphoscoliosis,andinstabilityofthelumbarspine.However,therehasbeenconcernregardingpediclescrewplacementduringTLIF。TLIF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，TLIF手术过程中已经有关于椎弓根螺钉的定位。Exposurelateraltothefacetjointtoinsertapediclescrewrequiresarelativelylongincisionandmuscledissection,whichmayberelatedtopostoperativelowbackpainfrominjurytotheposteromedialbranchofthenerverootcrossingthefacetjointanddamagetotheexposedandretractedbackmusculature.Tominimizetheincisionandmuscledissectionandthusreducetheseproblems,TLIFwithminimallyinvasivepediclescrewinsertion(M-TLIF)andTLIFwithpercutaneouspediclescrewinsertion(P-TLIF)havebeendeveloped.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，TLIF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。However,severalclinicalconcerns,suchaslowbackpain,learningcurve,radiationexposure,andincorrectpediclescrewplacement,havealsobeenassociatedwithM-TLIFandP-TLIF。然而，在M-TLIF及P-TLIF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，以及椎弓根螺钉位置植入不正确也已经被证实发生。Anewtrajectoryforpediclescrewinsertionofpediclescrewplacement,thecorticalbonetrajectory(CBT),wasreportedbySantonietal.in2009andmayaddresstheseproblems.Thenewtrajectorywasfrommedialtolateralandcranialtocaudal;thisdoesnotrequirewideexposureofthebackmuscleandthusreducesoperativeinvasioncomparedwithconventionalorpercutaneouspediclescrewinsertion.在2009年，一种新的全皮质椎弓根螺钉植入方法被Santoniet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少手术损伤However,thedifferencesinoperativeinvasion,accuracyofpediclescrewinsertion,andpostoperativefusionratebetweenTLIFwithCBT(CBT-TLIF)andothermethodsofpediclescrewplacement,suchasM-TLIFandP-TLIF,remainunknown.Inthisstudy,wecomparedtheclinicalandradiologicalresultsofCBT-TLIFwiththoseofM-TLIFandP-TLIF.然而,在全皮质-TLIF与其它椎弓根螺钉植入方法，如M-TLIF及P-TLIF相比，在手术损伤差异，椎弓根螺钉植入准确性,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CBT-TLIF与M-TLIF与P-TLIF在临床和影像学方面的结果。SurgicalproceduresM-TLIFwasperformedasfollows.Aunilateralfacetectomywasperformedatthelocationofthesymptomstoexposetheintervertebralforamenviaa6-cmincision.AthoroughdiscectomywascompletedandthediscspacewasfilledwithlocalbonegraftmaterialandanappropriateparallelDevexcage(DePuySpine,Raynham,MA,USA)wasplaced.M-TLIF手术过程如下：用6cm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，椎间隙内填充自体骨和合适大小的Devexcage。OpenconventionalpediclescrewswereplacedusingtheExpediumSpineSystem(DePuySpine)throughabilateralWiltseapproach.Underfluoroscopicguidanceinaperfectposteroanteriorprojection,apedicleprobewasintroducedintothepedicleata30°medialangleandthepediclewastappedforascrew,takingcarenottopenetratethemedialwall.开放传统的椎弓根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。Afeelerwasusedtoidentifybreakageofthecorticalpediclewalls,andapediclescrewofappropriatelength,asassessedoncomputedtomography(CT)images,wasinserted.Thelengthsofscrewswere40or45mmand6.0or7.0mmindiameter.Finally,underalateralfluoroscopicview,thelengthandcraniocaudaldirectionofthescrewswerechecked(Fig.1).插入探子的目的是用来鉴别椎弓根壁是否破损，椎弓根螺钉的合适长度，这些结果需要在CT图像去评估。椎弓根螺钉的长度是40或45毫米和直径6.0或7.0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1)。Fig.1.LateralradiographsofM-TLIF.(A)Preoperativeradiograph,(B)postoperativeradiograph,(C)radiographatfinalfollow-up.M-TLIF,transforaminallumbarinterbodyfusionwithminimallyinvasivepediclescrewinsertion.P-TLIFwasperformedusingtheViperMISSpineSystem(DePuySpine).Followingdecompressionoftheaffectedsiteandplacementofacageintothediscspaceviaa6-cmskinincision,thetargetingneedlewasplacedonthesuperolateralborderofthepedicleunderfluoroscopyviaanotherfasciaincisioncreated1cmlateraltothemidlineskinincision.P-TLIF运用ViperMIS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1cm。用6cm皮肤切口，先行症状侧减压之后将cage植入椎间隙内。Thetargetingneedlewasintroducedintothepedicleunderposteroanteriorandlateralfluoroscopicvisualization.ThetargetingneedlewasreplacedwithaKwire,andascrewwithanextendedsleevewasthenplacedovertheKwireandinsertedintothevertebralbodyaftertapping.PrebentrodswereplacedbilaterallyusingtheVipersystemandfixedwithcompressiveforceatthefacetectomyside(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Viper系统将预弯的从双侧植入，然后固定加压关节突一侧(图2)。Fig.2.LateralradiographsofP-TLIF.Preoperativeradiograph(A),postoperativeradiograph(B),andradiographatfinalfollow-up(C).P-TLIF,transforaminallumbarinterbodyfusionwithpercutaneouspediclescrewinsertion.CBT-TLIFwasperformedusingtheCDHORIZONSOLERASpinalSystem4.75mm(Medtronic,MemphisTN,USA).Afterexposureofthesurgicalfield,anentrypointforinsertionoftheCBTscrewwasdrilledinthemedio-caudalsideofthepediclewitha2mm-diameterairdrillunderfluoroscopicguidance.全皮质螺钉植入TLIF手术运用4.75mmCDHORIZON

SOLERA脊柱系统。在手术视野暴露以后，在透视下用2mm直径的钻在椎弓根的内下侧为入点钻入全皮质螺钉。AstraightprobewasusedtocreateatrajectoryfortheCBTscrewfromtheentrypointtotheoppositecornerofthepedicleandvertebralbodyunderanteroposteriorfluoroscopicguidance.AshortL-shapedKwirewasplacedtomarkthetrajectory.DecompressionandcageplacementwereperformedinthesamefashionasinM-TLIFandP-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及椎体内去探查。一个短的L型探针被用来标记轨迹。减压及cage的植入过程与M-TLIF和P-TLIF相同。Aftercageplacement,wetappedaholewithsuccessive4.0-,4.5-,and5.5-mmtapstargetedtotheposteriorone-thirdofthevertebralbody.Whenthetapreachedtheendostealcortexofthevertebralbodyunderlateralfluoroscopicguidance,screwlengthwasdetermined.Wetheninserted5.5-mmscrewsfrom30to40mminlengthintotheholeandplacedtherods(Fig.3).在cage放置以后，我们以导针位置方向分别用4.0、4.5、5.5mm丝攻钻一个通道直针椎体的后1/3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，然后我们插入从30到40mm长度的直径为5.5mm粗的螺钉进入通道，之后放置棒。(图3)。Fig.3.LateralradiographsofCBT-TLIF.(A)Preoperativeradiograph,(B)postoperativeradiograph,and(C)radiographatfinalfollow-up.CBT-TLIF,transforaminallumbarinterbodyfusionwithpediclescrewinsertionwithcorticalbonetrajectory.ResultIntraoperativebloodlosswassignificantlylesswithCBT-TLIF(p=0.03)thanwithM-TLIF.Postoperativelordoticanglesdidnotdiffersignificantlyamongthethreegroups.Completefusionswereobtainedin10of12levels(83%)withM-TLIF,insevenlevels(100%)