全皮質(zhì)椎弓根螺釘

1、寧夏醫(yī)科大學(xué)總醫(yī)院心腦血管病醫(yī)院骨科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 寧夏醫(yī)科大學(xué)總醫(yī)院心腦血管病醫(yī)院骨科Page 2 Introduc

2、tion 前言 The clinical results of transforaminal 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手術(shù)的臨床效果已經(jīng)被很好的運(yùn)用于腰椎退變性滑手術(shù)的臨床效果已經(jīng)

3、被很好的運(yùn)用于腰椎退變性滑脫、脊柱側(cè)后凸畸形及腰椎不穩(wěn)。然而，脫、脊柱側(cè)后凸畸形及腰椎不穩(wěn)。然而，TLIF手術(shù)過(guò)程手術(shù)過(guò)程中已經(jīng)有關(guān)于椎弓根螺釘?shù)亩ㄎ弧Ｖ幸呀?jīng)有關(guān)于椎弓根螺釘?shù)亩ㄎ?。寧夏醫(yī)科大學(xué)總醫(yī)院心腦血管病醫(yī)院骨科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

4、to the posteromedial branch of the nerve root crossing 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 ped

5、icle screw insertion (P-TLIF) have been developed.暴露側(cè)方到關(guān)節(jié)突關(guān)節(jié)去植入椎弓根螺釘需要相當(dāng)長(zhǎng)的切暴露側(cè)方到關(guān)節(jié)突關(guān)節(jié)去植入椎弓根螺釘需要相當(dāng)長(zhǎng)的切口和肌肉切開。這種手術(shù)因損傷穿過(guò)關(guān)節(jié)突的神經(jīng)根后支口和肌肉切開。這種手術(shù)因損傷穿過(guò)關(guān)節(jié)突的神經(jīng)根后支及暴露過(guò)程中損傷背肌肉組織而引起后背痛。通過(guò)縮小切及暴露過(guò)程中損傷背肌肉組織而引起后背痛。通過(guò)縮小切口及減少肌肉組織的剝離去減少這些問題，口及減少肌肉組織的剝離去減少這些問題，TLIFTLIF用于微創(chuàng)用于微創(chuàng)椎弓根螺釘植入和經(jīng)皮椎弓根螺釘植入已經(jīng)被很好的運(yùn)用。椎弓根螺釘植入和經(jīng)皮椎弓根螺釘植入已經(jīng)被

6、很好的運(yùn)用。寧夏醫(yī)科大學(xué)總醫(yī)院心腦血管病醫(yī)院骨科Page 4However, several clinical concerns, such as 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手術(shù)中，幾個(gè)臨床上關(guān)注點(diǎn)諸如手術(shù)中，幾個(gè)臨床上關(guān)注點(diǎn)諸如下腰痛，長(zhǎng)的學(xué)習(xí)曲線，射線的暴露，以及椎弓根螺釘位

7、下腰痛，長(zhǎng)的學(xué)習(xí)曲線，射線的暴露，以及椎弓根螺釘位置植入不正確也已經(jīng)被證實(shí)發(fā)生。置植入不正確也已經(jīng)被證實(shí)發(fā)生。寧夏醫(yī)科大學(xué)總醫(yī)院心腦血管病醫(yī)院骨科Page 5A new trajectory 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 lat

8、eral and cranial to caudal; this does not require wide exposure of the back muscle and thus reduces operative invasion compared with conventional or percutaneous pedicle screw insertion.在在20092009年，一種新的全皮質(zhì)椎弓根螺釘植入方法被年，一種新的全皮質(zhì)椎弓根螺釘植入方法被SantonietSantoniet等報(bào)道，并且可能解決一些問題。新的全皮質(zhì)等報(bào)道，并且可能解決一些問題。新的全皮質(zhì)螺釘植入是從內(nèi)向

9、外，從頭向尾，這種方法與傳統(tǒng)或者經(jīng)螺釘植入是從內(nèi)向外，從頭向尾，這種方法與傳統(tǒng)或者經(jīng)皮椎弓根螺釘植入相比不需要廣泛剝離后背肌肉組織和減皮椎弓根螺釘植入相比不需要廣泛剝離后背肌肉組織和減少手術(shù)損傷少手術(shù)損傷寧夏醫(yī)科大學(xué)總醫(yī)院心腦血管病醫(yī)院骨科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 pedic

10、le screw placement, such as M-TLIF and P-TLIF, remain unknown. In this study, we compared the clinical and radiological results of CBT-TLIF with those of M-TLIF and P-TLIF.然而然而, ,在全皮質(zhì)在全皮質(zhì)-TLIF-TLIF與其它椎弓根螺釘植入方法，如與其它椎弓根螺釘植入方法，如M-M-TLIFTLIF及及P-TLIFP-TLIF相比，在手術(shù)損傷差異，椎弓根螺釘植入準(zhǔn)相比，在手術(shù)損傷差異，椎弓根螺釘植入準(zhǔn)確性確性, ,以及術(shù)后

11、融合率之間依然沒有結(jié)果。在這項(xiàng)研究中以及術(shù)后融合率之間依然沒有結(jié)果。在這項(xiàng)研究中, ,我們比較我們比較CBT-TLIFCBT-TLIF與與M-TLIFM-TLIF與與P-TLIFP-TLIF在臨床和影像學(xué)方面在臨床和影像學(xué)方面的結(jié)果。的結(jié)果。寧夏醫(yī)科大學(xué)總醫(yī)院心腦血管病醫(yī)院骨科Page 7Surgical procedures M-TLIF was performed as follows. A unilateral facetectomy was performed at the location of the symptoms to expose the intervertebral fo

12、ramen via a 6-cm incision. A thorough discectomy was completed and the disc space was filled with local bone graft material and an appropriate parallel Devex cage (DePuy Spine, Raynham, MA, USA) was placed.M-TLIFM-TLIF手術(shù)過(guò)程如下：用手術(shù)過(guò)程如下：用6cm6cm的切口去暴露有癥狀側(cè)的椎的切口去暴露有癥狀側(cè)的椎間孔通道需要切除單側(cè)小關(guān)節(jié)。椎間盤被完全切除，椎間間孔通道需要切除單側(cè)小

13、關(guān)節(jié)。椎間盤被完全切除，椎間隙內(nèi)填充自體骨和合適大小的隙內(nèi)填充自體骨和合適大小的Devex cageDevex cage。寧夏醫(yī)科大學(xué)總醫(yī)院心腦血管病醫(yī)院骨科Page 8Open conventional pedicle screws were placed using the Expedium Spine System (DePuy Spine) through a bilateral Wiltse approach. Under fluoroscopic guidance in a perfect posteroanterior projection, a pedicle probe wa

14、s 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.開放傳統(tǒng)的椎弓根螺釘植入通過(guò)雙側(cè)的Wilse入路使用Expedium脊柱系統(tǒng)。在標(biāo)準(zhǔn)的后前位透視下，椎弓根探針在向內(nèi)傾斜30插入，擰入椎弓根螺釘，術(shù)中小心不要穿破椎弓根內(nèi)壁。寧夏醫(yī)科大學(xué)總醫(yī)院心腦血管病醫(yī)院骨科Page 9A feeler was used to identify breakage of the cortica

15、l 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 and 6.0 or 7.0 mm in diameter. Finally, under a lateral fluoroscopic view, the length and craniocaudal direction of the screws were checked

16、 (Fig. 1).插入探子的目的是用來(lái)鑒別椎弓根壁是否破損，椎弓根螺插入探子的目的是用來(lái)鑒別椎弓根壁是否破損，椎弓根螺釘?shù)暮线m長(zhǎng)度，這些結(jié)果需要在釘?shù)暮线m長(zhǎng)度，這些結(jié)果需要在CTCT圖像去評(píng)估。椎弓根螺圖像去評(píng)估。椎弓根螺釘?shù)拈L(zhǎng)度是釘?shù)拈L(zhǎng)度是4040或或4545毫米和直徑毫米和直徑6.06.0或或7.07.0毫米直徑。最后毫米直徑。最后, ,在側(cè)位的透視下來(lái)檢查植入螺釘?shù)拈L(zhǎng)度及傾斜角度（圖在側(cè)位的透視下來(lái)檢查植入螺釘?shù)拈L(zhǎng)度及傾斜角度（圖1)1)。寧夏醫(yī)科大學(xué)總醫(yī)院心腦血管病醫(yī)院骨科Page 10Fig. 1. Lateral radiographs of M-TLIF. (A) Preope

17、rative radiograph, (B) postoperative radiograph, (C) radiograph at final follow-up. M-TLIF, transforaminal lumbar interbody fusion with minimally invasive pedicle screw insertion.寧夏醫(yī)科大學(xué)總醫(yī)院心腦血管病醫(yī)院骨科Page 11P-TLIF was performed using the Viper MIS Spine System (DePuy Spine). Following decompression of

18、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 fascia incision created 1 cm lateral to the midline skin incision.P-TLIFP-TLIF運(yùn)用運(yùn)用Viper MISViper MIS脊柱系統(tǒng)。在透

19、視下定位針一根放脊柱系統(tǒng)。在透視下定位針一根放在椎弓根外上側(cè)邊緣，另一根針放在中線皮膚切口旁開在椎弓根外上側(cè)邊緣，另一根針放在中線皮膚切口旁開1cm1cm。用。用6cm6cm皮膚切口，先行癥狀側(cè)減壓之后將皮膚切口，先行癥狀側(cè)減壓之后將cagecage植入椎植入椎間隙內(nèi)。間隙內(nèi)。寧夏醫(yī)科大學(xué)總醫(yī)院心腦血管病醫(yī)院骨科Page 12The targeting needle was introduced into the pedicle under posteroanterior and lateral fluoroscopic visualization. The targeting needle

20、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 fixed with compressive force at the facetectomy side (Fig. 2). 在后前位及側(cè)位透視下將探針插入椎弓根，之后用導(dǎo)針代

21、在后前位及側(cè)位透視下將探針插入椎弓根，之后用導(dǎo)針代替探針，在過(guò)了椎弓根后壁以后用自攻螺釘插在導(dǎo)針上擰替探針，在過(guò)了椎弓根后壁以后用自攻螺釘插在導(dǎo)針上擰入椎體，使用入椎體，使用ViperViper系統(tǒng)將預(yù)彎的從雙側(cè)植入，然后固定系統(tǒng)將預(yù)彎的從雙側(cè)植入，然后固定加壓關(guān)節(jié)突一側(cè)加壓關(guān)節(jié)突一側(cè)( (圖圖2)2)。寧夏醫(yī)科大學(xué)總醫(yī)院心腦血管病醫(yī)院骨科Page 13Fig. 2. Lateral radiographs of P-TLIF. Preoperative radiograph (A), postoperative radiograph (B), and radiograph at final

22、follow-up (C). P-TLIF, transforaminal lumbar interbody fusion with percutaneous pedicle screw insertion.寧夏醫(yī)科大學(xué)總醫(yī)院心腦血管病醫(yī)院骨科Page 14CBT-TLIF was performed using the CD HORIZON SOLERA Spinal System 4.75 mm (Medtronic, Memphis TN, USA). After exposure of the surgical field, an entry point for insertion o

23、f the CBT screw was drilled in the medio-caudal side of the pedicle with a 2 mm-diameter air drill under fluoroscopic guidance.全皮質(zhì)螺釘植入全皮質(zhì)螺釘植入TLIFTLIF手術(shù)運(yùn)用手術(shù)運(yùn)用4.75mm CD HORIZON4.75mm CD HORIZONSOLERASOLERA脊柱系統(tǒng)。在手術(shù)視野暴露以后，在透視下用脊柱系統(tǒng)。在手術(shù)視野暴露以后，在透視下用2mm2mm直徑的鉆在椎弓根的內(nèi)下側(cè)為入點(diǎn)鉆入全皮質(zhì)螺釘。直徑的鉆在椎弓根的內(nèi)下側(cè)為入點(diǎn)鉆入全皮質(zhì)螺釘。寧夏醫(yī)科大

24、學(xué)總醫(yī)院心腦血管病醫(yī)院骨科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. Decompression and cage placemen

25、t were performed in the same fashion as in M-TLIF and P-TLIF.在透視下不斷的用探子從全皮質(zhì)螺釘?shù)娜朦c(diǎn)到椎弓根對(duì)側(cè)在透視下不斷的用探子從全皮質(zhì)螺釘?shù)娜朦c(diǎn)到椎弓根對(duì)側(cè)及椎體內(nèi)去探查。一個(gè)短的及椎體內(nèi)去探查。一個(gè)短的L L型探針被用來(lái)標(biāo)記軌跡。減型探針被用來(lái)標(biāo)記軌跡。減壓及壓及cagecage的植入過(guò)程與的植入過(guò)程與M-TLIFM-TLIF和和P-TLIFP-TLIF相同。相同。寧夏醫(yī)科大學(xué)總醫(yī)院心腦血管病醫(yī)院骨科Page 16After cage placement, we tapped a hole with successive 4.

26、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 and placed t

27、he rods (Fig. 3). 在在cagecage放置以后，我們以導(dǎo)針位置方向分別用放置以后，我們以導(dǎo)針位置方向分別用4.04.0、4.54.5、5.5mm5.5mm絲攻鉆一個(gè)通道直針椎體的后絲攻鉆一個(gè)通道直針椎體的后1/31/3處。在透視下，當(dāng)處。在透視下，當(dāng)絲攻到達(dá)椎體的骨內(nèi)皮質(zhì)時(shí)，螺釘?shù)拈L(zhǎng)度就被確定，然后絲攻到達(dá)椎體的骨內(nèi)皮質(zhì)時(shí)，螺釘?shù)拈L(zhǎng)度就被確定，然后我們插入從我們插入從3030到到40mm40mm長(zhǎng)度的直徑為長(zhǎng)度的直徑為5.5mm5.5mm粗的螺釘進(jìn)入通粗的螺釘進(jìn)入通道，之后放置棒。道，之后放置棒。( (圖圖3)3)。寧夏醫(yī)科大學(xué)總醫(yī)院心腦血管病醫(yī)院骨科Page 17Fig.

28、3. Lateral 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. 寧夏醫(yī)科大學(xué)總醫(yī)院心腦血管病醫(yī)院骨科Page 18寧夏醫(yī)科大學(xué)總醫(yī)院心腦血管病醫(yī)院骨科Page 19Result

29、Intraoperative blood loss was significantly 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