全皮質(zhì)椎弓根螺釘

Short-TermResultsofTransforaminalLumbarInterbodyFusionUsingPedicleScrewwithCorticalBoneTrajectoryComparedwithConventionalTrajectory

DepartmentofOrthopedicSurgery,AkitaUniversityGraduateSchoolofMedicine,Akita,Japan使用皮質(zhì)骨螺釘植入與傳統(tǒng)螺釘植入在TLIF手術(shù)中的短期結(jié)果Introduction前言

Theclinicalresultsoftransforaminallumbarinterbodyfusion(TLIF)havebeenfavorablefordegenerativespondylolisthesis,kyphoscoliosis,andinstabilityofthelumbarspine.However,therehasbeenconcernregardingpediclescrewplacementduringTLIF。TLIF手術(shù)的臨床效果已經(jīng)被很好的運(yùn)用于腰椎退變性滑脫、脊柱側(cè)后凸畸形及腰椎不穩(wěn)。然而，TLIF手術(shù)過(guò)程中已經(jīng)有關(guān)于椎弓根螺釘?shù)亩ㄎ?。Exposurelateraltothefacetjointtoinsertapediclescrewrequiresarelativelylongincisionandmuscledissection,whichmayberelatedtopostoperativelowbackpainfrominjurytotheposteromedialbranchofthenerverootcrossingthefacetjointanddamagetotheexposedandretractedbackmusculature.Tominimizetheincisionandmuscledissectionandthusreducetheseproblems,TLIFwithminimallyinvasivepediclescrewinsertion(M-TLIF)andTLIFwithpercutaneouspediclescrewinsertion(P-TLIF)havebeendeveloped.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(kāi)。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)縮小切口及減少肌肉組織的剝離去減少這些問(wèn)題，TLIF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。However,severalclinicalconcerns,suchaslowbackpain,learningcurve,radiationexposure,andincorrectpediclescrewplacement,havealsobeenassociatedwithM-TLIFandP-TLIF。然而，在M-TLIF及P-TLIF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(xiàn)，射線(xiàn)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。Anewtrajectoryforpediclescrewinsertionofpediclescrewplacement,thecorticalbonetrajectory(CBT),wasreportedbySantonietal.in2009andmayaddresstheseproblems.Thenewtrajectorywasfrommedialtolateralandcranialtocaudal;thisdoesnotrequirewideexposureofthebackmuscleandthusreducesoperativeinvasioncomparedwithconventionalorpercutaneouspediclescrewinsertion.在2009年，一種新的全皮質(zhì)椎弓根螺釘植入方法被Santoniet等報(bào)道，并且可能解決一些問(wèn)題。新的全皮質(zhì)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少手術(shù)損傷However,thedifferencesinoperativeinvasion,accuracyofpediclescrewinsertion,andpostoperativefusionratebetweenTLIFwithCBT(CBT-TLIF)andothermethodsofpediclescrewplacement,suchasM-TLIFandP-TLIF,remainunknown.Inthisstudy,wecomparedtheclinicalandradiologicalresultsofCBT-TLIFwiththoseofM-TLIFandP-TLIF.然而,在全皮質(zhì)-TLIF與其它椎弓根螺釘植入方法，如M-TLIF及P-TLIF相比，在手術(shù)損傷差異，椎弓根螺釘植入準(zhǔn)確性,以及術(shù)后融合率之間依然沒(méi)有結(jié)果。在這項(xiàng)研究中,我們比較CBT-TLIF與M-TLIF與P-TLIF在臨床和影像學(xué)方面的結(jié)果。SurgicalproceduresM-TLIFwasperformedasfollows.Aunilateralfacetectomywasperformedatthelocationofthesymptomstoexposetheintervertebralforamenviaa6-cmincision.AthoroughdiscectomywascompletedandthediscspacewasfilledwithlocalbonegraftmaterialandanappropriateparallelDevexcage(DePuySpine,Raynham,MA,USA)wasplaced.M-TLIF手術(shù)過(guò)程如下：用6cm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(pán)被完全切除，椎間隙內(nèi)填充自體骨和合適大小的Devexcage。OpenconventionalpediclescrewswereplacedusingtheExpediumSpineSystem(DePuySpine)throughabilateralWiltseapproach.Underfluoroscopicguidanceinaperfectposteroanteriorprojection,apedicleprobewasintroducedintothepedicleata30°medialangleandthepediclewastappedforascrew,takingcarenottopenetratethemedialwall.開(kāi)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。Afeelerwasusedtoidentifybreakageofthecorticalpediclewalls,andapediclescrewofappropriatelength,asassessedoncomputedtomography(CT)images,wasinserted.Thelengthsofscrewswere40or45mmand6.0or7.0mmindiameter.Finally,underalateralfluoroscopicview,thelengthandcraniocaudaldirectionofthescrewswerechecked(Fig.1).插入探子的目的是用來(lái)鑒別椎弓根壁是否破損，椎弓根螺釘?shù)暮线m長(zhǎng)度，這些結(jié)果需要在CT圖像去評(píng)估。椎弓根螺釘?shù)拈L(zhǎng)度是40或45毫米和直徑6.0或7.0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1)。Fig.1.LateralradiographsofM-TLIF.(A)Preoperativeradiograph,(B)postoperativeradiograph,(C)radiographatfinalfollow-up.M-TLIF,transforaminallumbarinterbodyfusionwithminimallyinvasivepediclescrewinsertion.P-TLIFwasperformedusingtheViperMISSpineSystem(DePuySpine).Followingdecompressionoftheaffectedsiteandplacementofacageintothediscspaceviaa6-cmskinincision,thetargetingneedlewasplacedonthesuperolateralborderofthepedicleunderfluoroscopyviaanotherfasciaincisioncreated1cmlateraltothemidlineskinincision.P-TLIF運(yùn)用ViperMIS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?lè)旁谥芯€(xiàn)皮膚切口旁開(kāi)1cm。用6cm皮膚切口，先行癥狀側(cè)減壓之后將cage植入椎間隙內(nèi)。Thetargetingneedlewasintroducedintothepedicleunderposteroanteriorandlateralfluoroscopicvisualization.ThetargetingneedlewasreplacedwithaKwire,andascrewwithanextendedsleevewasthenplacedovertheKwireandinsertedintothevertebralbodyaftertapping.PrebentrodswereplacedbilaterallyusingtheVipersystemandfixedwithcompressiveforceatthefacetectomyside(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Viper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)(圖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.全皮質(zhì)螺釘植入TLIF手術(shù)運(yùn)用4.75mmCDHORIZON

SOLERA脊柱系統(tǒng)。在手術(shù)視野暴露以后，在透視下用2mm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。AstraightprobewasusedtocreateatrajectoryfortheCBTscrewfromtheentrypointtotheoppositecornerofthepedicleandvertebralbodyunderanteroposteriorfluoroscopicguidance.AshortL-shapedKwirewasplacedtomarkthetrajectory.DecompressionandcageplacementwereperformedinthesamefashionasinM-TLIFandP-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)及椎體內(nèi)去探查。一個(gè)短的L型探針被用來(lái)標(biāo)記軌跡。減壓及cage的植入過(guò)程與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，我們以導(dǎo)針位置方向分別用4.0、4.5、5.5mm絲攻鉆一個(gè)通道直針椎體的后1/3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，然后我們插入從30到40mm長(zhǎng)度的直徑為5.5mm粗的螺釘進(jìn)入通道，之后放置棒。(圖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%)