全皮質椎弓根螺釘

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手術的臨床效果已經被很好的運用于腰椎退變性滑手術的臨床效果已經被很好的運用于腰椎退變性滑脫、脊柱側后凸畸形及腰椎不穩(wěn)。然而，脫、脊柱側

3、后凸畸形及腰椎不穩(wěn)。然而，TLIF手術過程手術過程中已經有關于椎弓根螺釘?shù)亩ㄎ?。中已經有關于椎弓根螺釘?shù)亩ㄎ弧age 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.暴露側方

5、到關節(jié)突關節(jié)去植入椎弓根螺釘需要相當長的切暴露側方到關節(jié)突關節(jié)去植入椎弓根螺釘需要相當長的切口和肌肉切開。這種手術因損傷穿過關節(jié)突的神經根后支口和肌肉切開。這種手術因損傷穿過關節(jié)突的神經根后支及暴露過程中損傷背肌肉組織而引起后背痛。通過縮小切及暴露過程中損傷背肌肉組織而引起后背痛。通過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皮椎弓根螺釘植入已經被很好的運用。椎弓根螺釘植入和經皮椎弓根螺釘植入已經被很好的運用。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手術中，幾個臨床上關注點諸如手術中，幾個臨床上關注點諸如下腰痛，長的學習曲線，射線的暴露，以及椎弓根螺釘位下腰痛，長的學習曲線，射線的暴露，以及椎弓根螺釘位置植入不正確也已經被證實發(fā)生。置植入不正確也已經被證實發(fā)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，一種新的全皮質椎弓根螺釘植入方法被年，一種新的全皮質椎弓根螺釘植入方法被SantonietSantoniet等報道，并且可能解決一些問題。新的全皮質等報道，并且可能解決一些問題。新的全皮質螺釘植入是從內向外，從頭向尾，這種方法與傳統(tǒng)或者經螺釘植入是從內向外，從頭向尾，這種方法與傳統(tǒng)或者經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

9、和減少手術損傷少手術損傷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, ,在全皮質在全皮質-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，在手術損傷差異，椎弓根螺釘植入準相比，在手術損傷差異，椎弓根螺釘植入準確性確性, ,以及術后融合率之間依然沒有結果。在這項研究中以及術后融合率之間依然沒有結果。在這項研究中, ,我們比較我們比較CBT-TLIFCBT-TLIF與與M-TLIFM-TLIF與與P-TLIFP-TLIF在臨床和影像學方面在臨床和

11、影像學方面的結果。的結果。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手術過程如下：用手術過程如下：用6cm6cm的切口去暴露有癥狀側的椎的切口去暴露有癥狀側的椎間孔通道需要切除單側小關節(jié)。椎間盤被完全切除，椎間間孔通道需要切除單側小關節(jié)。椎間盤被完全切除，椎間隙內填充自體骨和合適大小的隙內填充自體骨和合適大小的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.開放傳統(tǒng)的椎弓根

14、螺釘植入通過雙側的Wilse入路使用Expedium脊柱系統(tǒng)。在標準的后前位透視下，椎弓根探針在向內傾斜30插入，擰入椎弓根螺釘，術中小心不要穿破椎弓根內壁。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來鑒別椎弓根壁是否破損，椎弓根螺插入探子的目的是用來鑒別椎弓根壁是否破損，椎弓根螺釘?shù)暮线m長度，這些結果需要在釘?shù)暮线m長度，這些結果需要在CTCT圖像去評估。椎弓根螺圖像去評估。椎弓根螺釘?shù)拈L度是釘?shù)拈L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

16、后毫米直徑。最后, ,在側位的透視下來檢查植入螺釘?shù)拈L度及傾斜角度（圖在側位的透視下來檢查植入螺釘?shù)拈L度及傾斜角度（圖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運用運用Viper MISViper MIS脊柱系統(tǒng)。在透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邊緣，另一根針放在中線皮膚切口旁開在椎弓根外上側邊緣，另一根針放在中線皮膚切口旁開1cm1cm。用。用6cm6cm皮膚切口，先行癥狀側減壓之后將皮膚切口，先行癥狀側減壓之后將cagecage植入椎植入椎間隙內。間隙內。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). 在后前位及側位透視下將探針插入椎弓根，之后用導針代在后前位及側位透視下將探針插入椎弓根，之后用導針代替探針，在過了椎弓根后壁以后用自攻螺釘插在導針上擰替探針，在過了椎弓根后壁以后用自攻螺釘插在導針上擰入椎體，使用入椎體，使用ViperViper系統(tǒng)將預彎的從雙側植入，然后固定系統(tǒng)將預彎的從雙側植入，然后固定加壓關節(jié)突一側加壓關節(jié)突一側( (圖圖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.全皮質螺釘植入全皮質螺釘植入TLIFTLIF手術運用手術運用4.75mm CD HORIZON4.75mm CD HORIZONSOLERASOLERA脊柱系統(tǒng)。在手術視野暴露以后，在透視下用脊柱系統(tǒng)。在手術視野暴露以后，在透視下用2mm2mm直徑的

23、鉆在椎弓根的內下側為入點鉆入全皮質螺釘。直徑的鉆在椎弓根的內下側為入點鉆入全皮質螺釘。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.在透視下不斷的用探子從全皮質螺釘?shù)娜朦c到椎弓根對側在透視下不斷的用探子從全皮質螺釘?shù)娜朦c到椎弓根對側及椎體內去探查。一個短的及椎體內去探查。一個短的L L型探針被用來標記軌跡。減型探針被用來標記軌跡。減壓及壓及cagecage的植入過程與的植入過程與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，我們以導針位置方向分別用放置以后，我們以導針位置方向分別用4.04.0、4.54.5、5.5mm5.5mm絲攻鉆一個通道直針椎體的后絲攻鉆一個通道直針椎體的后1/31/3處。在透視下，當處。在透視下，當絲攻到達椎體的骨內皮質時，螺釘?shù)拈L度就被確定，然后絲攻到達椎體的骨內皮質時，螺釘?shù)拈L度就被確定，然后我們插入從我們插入從3030到到40mm40mm長度的直徑為長度的直徑為5.5mm5.5mm粗的螺釘進入通粗的螺釘進入通道，之后放置棒。道，之后放置棒。( (圖圖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