下腰椎侧方入路中静脉及神经的应用解剖学研究及临床意义

目的研究下腰椎侧方入路中静脉、神经的应用解剖学特点,为该手术入路提供解剖学依据。方法显微镜下观测21具成人尸体标本髂腰静脉(iliolumbar veins,ILV)、腰升静脉(ascending lumbar vein,ALV)及L5、S1神经根前支、腰交感干的走行及与周围结构的毗邻关系。结果ILV和ALV缺失率高,形态学变异较大;L5神经根前支紧贴骶骨翼前方走行,位置恒定;骶骨岬前外侧缘到第1骶前孔上缘切线的垂直距离为(28.73±2.93)mm;L3~S1椎间孔前上缘到腰交感干的垂直距离分别为(27.21±2.04)mm、(27.40±2.11)mm、(26.89±2.33)mm。结论下腰椎侧方静脉、神经的走行及解剖学形态具有一定规律性,在下腰椎侧方手术入路中,可有效避开或牵开这些结构,避免术中损伤。     

微创胸腰段侧方入路治疗骨折的解剖学研究

目的探讨微创胸腰段（T11～L2）侧方手术入路在椎体侧方的手术安全操作范围,为治疗特殊类型骨折提供解剖学依据。方法 21具成人防腐尸体标本,男11具,女10具。以克氏针模拟微创套管穿刺针,沿椎体侧方中线分别在上终板、正中心、下终板及相邻椎间盘穿刺标记为A、B、C、D点,以4点为标记点观察椎体侧方血管神经的走行分布,测量椎体侧方可供手术操作的安全区,根据血管神经的走行确定微创器械在椎体侧方的最佳穿刺置入点。结果在T11～L2各椎体侧方结扎椎体节段血管后可得到由椎体上下缘、交感干、椎体后缘或腰丛组成的＂安全窗＂,其面积由T11至L2逐渐增大：男性分别为（273.35±69.72）mm2、（409.59±74.24）mm2、（555.78±139.74）mm2、（614.36±89.46）mm2;女性分别为（173.39±46.62）mm2、（289.51±49.72）mm2、（400.85±45.44）mm2、（451.44±59.80）mm2。该侧方入路的最佳穿刺点为椎体侧方上1/2区域近终板处的A点。结论利用微创侧方手术入路在T11～L2椎体侧方上1/2区域近终板处进行穿刺置入微创器械,＂安全窗＂内进行椎管前侧方减压、单纯椎体内重建术治疗特殊类型Denis B型爆裂骨折在解剖入路上是安全可行的。     

下腰椎侧方入路中相关神经的临床解剖学研究

[目的]研究下腰椎侧方入路中相关神经的应用解剖学特点,为该手术人路提供解剖学依据.[方法]观测21具成人尸体标本L3～S1神经根前支、闭孔神经及腰交感干的走行及与周围结构的毗邻关系.[结果]L3～S1神经根前支位置及走行相对恒定;骶髂关节间隙最上缘至L4.5神经根前支外侧缘及闭孔神经外侧缘的水平距离分别为(18.96±2.59) mm,(23.29±2.48) mm,(15.49±3.01) mm;骨盆界线与骶髂关节间隙交点至腰骶于外侧缘的水平距离为(6.20±2.08)mm;骶骨岬前外侧缘到第1骶前孔上缘切线的垂直距离为(28.73±2.93) mm.[结论]下腰椎侧方神经的走行及解剖学形态具有一定规律性,在下腰椎侧方手术入路中,可有效避开或牵开这些结构,避免术中损伤.     

退变性腰椎侧凸畸形患者在极外侧腰椎间融合术中相关神经血管的影像学分析

目的了解退变性腰椎侧凸畸形患者的腹部大血管和腰丛神经在L1~2、L2~3、L3~4、L4~5腰椎间隙的分布,选择合适的极外侧腰椎间融合术(XLIF)手术入路。方法将60例退变性腰椎侧凸畸形患者分为4组(每组15例):右侧凸Cobb角20°者为B组、≥20°者为C组;左侧凸Cobb角20°者为D组、≥20°者为E组。另选择15例无腰椎侧凸的志愿者为对照(A组)。分别进行L1~2、L2~3、L3~4、L4~5腰椎间隙的MRI平扫,观察腹部大血管及神经在各腰椎间隙的分布,测量并计算其与椎体直径的比值,得出相应的安全区域。结果因腹主动脉主要在椎体左前方上行,且在L3~4椎间隙水平逐渐靠近中线,髂总静脉汇合为下腔静脉后行于椎体右侧,因此同一节段左侧手术窗大于右侧(P0.05)。取左侧95%CI,A、B、C、D、E 5组的安全区域在L1~2节段分别为93.8%、92.3%、93.4%、92.2%、89.8%,在L2~3节段分别为85.2%、82.4%、81.9%、80.4%、79.7%,在L3~4节段分别为77.2%、75.3%、75.9%、74.9%、72.6%,在L4~5节段分别为70.2%、63.3%、61.9%、66.0%、64.3%。结论在进行XLIF手术时,L1~2、L2~3、L3~4、L4~5椎间隙水平的安全区域逐渐减小,目前常用的下腰椎椎体间融合器规格为(8~12)mm×10 mm×4.5 mm,手术窗足够大,XLIF的融合器冠状位置入是安全可行的。由于侧凸畸形患者相应脊柱发生旋转,使手术安全窗口发生轻微偏移;故主弯凸向右的患者手术切口应稍向后偏,向左侧凸侧凸患者手术切口应稍向前偏,这样手术入路相对较安全,可以避免损伤周围血管和神经。     

腰骶椎侧前方内固定术的应用解剖学研究

[目的]对尸体标本行解剖学观测,评估腰骶椎行侧前方内固定手术的可行性,为提高该手术的安全性提供帮助。[方法]分别在12具成人尸体标本上观察腰骶椎侧前方重要血管神经的走行及毗邻关系,并测量出左髂总静脉到L_5椎体上、下缘后侧及S1椎体上缘后侧距离V1、V2、V3;L_5神经根前支内侧缘到骶骨岬前外侧缘水平距离EF;骶骨岬前外侧缘到第1骶前孔上缘切线垂直距离AB;以及腰交感干分别到L_4/L_5,L_5/S_1椎间孔前上缘垂直距离C_1、C_2。然后将腰骶椎侧前方操作空间视为一直角梯形,分别测量出结扎牵拉动静脉前、后的梯形底边长及高度,根据梯形面积公式计算出原始面积S1及牵拉后有效面积S2。[结果]V1、V2、V3分别平均为(43.20±0.9)mm、(40.91±0.6)mm、(30.59±0.6)mm,L_4动静脉在椎体侧方走行较恒定,L_5动静脉走行变异较大;L_5神经根前支紧贴骶骨翼前方走行,位置恒定,EF平均为(15.72±2.03)mm,AB平均为(28.85±2.41)mm,C_1、C_2分别平均为(27.43±2.10)mm、(26.80±2.31)mm。S_1为(31.02±1.7)cm~2,S_2为(33.40±1.3)cm~2,两者相比较差异有统计学意义。[结论]腰骶椎侧前方初始有一定的操作空间,可允许进行侧前方内固定手术,且周围重要的血管神经走行有一定规律性,术中可通过有效结扎、牵拉避开这些结构后获得更为充足的手术空间,并可减少手术的并发损伤,提高安全性。     

椎板侧方入路治疗极外侧腰椎间盘突出症的解剖及临床应用

[目的]通过对后正中经椎板侧方手术入路局部解剖结构的观测,探讨该入路治疗极外侧腰椎间盘突出症的临床疗效及注意事项。[方法]20具经防腐固定的成人尸体标本,观测横突间韧带厚度、前后方血管分布规律、腰神经前支与矢状面夹角、椎弓峡部侧缘及横突基底部副突处距腰神经前支距离。自2004年1月~2006年1月,收治极外侧腰椎间盘突出症12例,其中7例采用后正中经椎板侧方手术入路治疗,5例采用后正中经椎板侧方联合经椎管内手术入路治疗。[结果]L3~S1横突间韧带厚度为0.6~1.3 mm;腰节段动脉前支及其伴行静脉90%以上位于横突间韧带腹侧上1/2处,横突间韧带背侧中1/3内侧缘处有一恒定腰节段动脉分支穿出;腰神经前支出椎间孔后与矢状面夹角为18.9°~39.2°;副突及峡部侧缘距腰神经前支距离分别为5.6~8.0 mm、1.7~3.6 mm。12例病人均取得随访,随访时间3~20个月,平均10个月。根据Nakal分级:优8例,良3例,总优良率91.67%。[结论]横突间韧带为后正中经椎板侧方手术入路中重要的解剖学标志,熟悉其应用解剖对于手术治疗极外侧腰椎间盘突出症具有重要指导意义。应用后正中经椎板侧方手术入路治疗极外侧腰椎间盘突出症创伤小,术后效果好,是一种安全有效的手术方法。     

腰段自主神经的解剖学研究及临床意义

目的 :描述腰段自主神经的解剖学特征,为前路腰椎手术提供详实的神经解剖学资料。方法 :取10具防腐男性胸腰骶部标本(年龄36～78岁,平均56岁)。仔细剔除腹腔器官及双侧腰大肌,找出腰段自主神经并去除周围软组织。观察腰段自主神经的走行、起始位置和分布特点。使用游标卡尺测量各腰内脏神经发出点与对应节段腰椎体下终板之间的距离,同侧相邻腰内脏神经发出点之间的距离,腰椎椎间孔前缘以及各腰椎间盘平面上左、右两侧腰交感干后缘分别与腰椎椎体前缘在矢状面上的距离,以及上腹下丛右侧缘在L5椎体下终板和S1椎体上终板平面上与中线的距离。使用量角器测量各腰内脏神经与水平面所成的夹角。结果:在10具标本上共发现72条腰内脏神经,其中58条起源于L3椎体下终板颅侧的腰交感干。第1、2、3、4腰内脏神经的发出点分别位于L1椎体下终板尾侧9.35±10.62mm,L2椎体下终板尾侧5.23±7.08mm,L3椎体下终板颅侧9.34±6.36mm及L4椎体下终板尾侧9.21±8.55mm。第3腰内脏神经与第1、2、4腰内脏神经发出点位置分布有差别(H=32.227,P=0.000),其余腰内脏神经发出点位置分布及左侧与相应的右侧腰内脏神经发出点位置分布均无统计学差异(P0.05)。第1与第2腰内脏神经、第2与第3腰内脏神经以及第3与第4腰内脏神经发出点之间的距离分别为24.25±6.27mm、21.96±8.13mm、54.54±11.41mm。在L2/3、L3/4及L4/5椎间盘平面上,双侧腰交感干有95%(57/60)位于矢状面上的前1/3内。在L5椎体下终板及S1椎体上终板平面上,上腹下丛的右侧缘分别位于中线左侧3.92±3.35mm及右侧5.25±2.98mm。左侧与相应的右侧腰内脏神经分别与水平面所成夹角(P0.05)及各腰内脏神经与水平面所成夹角(H=4.921,P=0.178)均无统计学差异,大小约为41°±6°。结论:80.6%腰内脏神经起源于L3椎体下终板颅侧的腰交感干,第3与第4腰内脏神经发出点之间的距离远大于其他两相邻的腰内脏神经发出点之间的距离;在L5/S1椎间盘平面上,腹中线的右外侧存在非常少的上腹下丛神经纤维。了解腰段自主神经的这些解剖学特征对减少手术并发症、提高手术安全性具有重要意义。     

下腰椎极外侧椎体间融合术的应用解剖

目的：观测腰椎侧方血管和神经的解剖分布，为下腰椎极外侧椎体间融合术（extreme lateral intervertebra fusion，XLIF）提供解剖学依据。方法：解剖30具成人尸体的腰椎侧方血管和神经，观察腰动、静脉的位置及走行；测量椎间孔外口处L3～L5脊神经距相邻下位椎间盘、腹主动脉后缘（左侧手术窗）和下腔静脉后缘（右侧手术窗）的距离。结果：L1、L2、L3节段血管走行、分布比较恒定，走行于相应椎体的中央偏下水平；但L4动、静脉走行变异较大，其中36．7％（11例）走行于L4／5间隙表面；L3～L5椎间孔外口处脊神经距下位椎间盘的距离逐渐增大；L3～L5左、右侧手术窗均逐渐增大．且同一节段左侧手术窗大于右侧。结论：XLIF在L3／4、L4／5间隙可以顺利进行。     

单侧经横突-椎弓根入路腰椎椎体强化术的解剖学研究

目的测量单侧经横突-椎弓根入路腰椎经皮椎体强化术的相关解剖学参数,探讨该入路行椎体强化术的可行性与安全性。方法随机选取60例患者共300个腰椎椎体,在X线片图像和CT图像上分别模拟单侧经传统椎弓根入路(对照组)和单侧经横突-椎弓根入路(研究组)完成经皮椎体强化术600次。测量并比较同一手术入路L_1~L_5各椎体左右侧及两种手术入路L_1~L_5各椎体X线片图像和CT横断面上穿刺点至椎体中线的距离、穿刺外偏角、穿刺角安全范围和穿刺成功率。结果两组L_1~L_5椎体左右侧穿刺点至中线的距离均逐渐增大,其中对照组L_1、L_2右侧距离显著大于左侧,研究组L_1、L_2、L_5右侧距离显著大于左侧(P0.05);研究组L_1~L_5椎体左侧或右侧穿刺点至中线的距离均显著大于对照组(P0.05)。研究组L_1~L_5右侧最大外偏角、中点外偏角及L_1、L_2、L_4、L_5最小外偏角均显著大于左侧(P0.05)。L_1~L_5左右侧最大外偏角、中点外偏角逐渐增大,最小外偏角变化不明显,但所有外偏角均显著大于对照组(P0.05)。两组L_1~L_5左右侧穿刺角安全范围差异无统计学意义(P0.05);研究组L_5左右侧穿刺角安全范围显著小于对照组(P0.05)。对照组和研究组所有椎体穿刺总成功率差异有统计学意义(χ~2=172.252,P=0.000);其中研究组L_1~L_4穿刺成功率显著高于对照组(P0.05),L_5穿刺成功率两组比较差异无统计学意义(P0.05)。结论单侧经横突-椎弓根入路的穿刺点较传统经椎弓根入路偏外,穿刺外偏角更大,穿刺总成功率更高。单侧经横突-椎弓根入路是一种较传统经椎弓根入路更安全、可靠的穿刺入路。     

微创斜向腰椎椎体间融合术手术入路的影像学相关研究

目的 :分析L1/2~L4/5各椎间隙之间血管和腰大肌关系,了解微创斜向腰椎椎体间融合术手术入路的影像学特点。方法:选取2013年11月~2015年9月收治的113例腰椎疾病患者,12例因MRI、X线片技术上问题造成的影像显示不清或者腰椎/腹膜后手术史影响正常解剖被排除,最后对101例患者的MRI及X线片进行数据测量,男46例,女55例,年龄51~68岁,平均59.0±4.4岁。在MRI上测量L1/2~L4/5各椎间隙平面血管和腰大肌间的距离;在侧位X线片上测量L5上终板中点与左侧髂棘的垂直距离,高于髂棘为正值,低于髂棘为负值。结果:L1/2~L4/5椎间隙平面血管和腰大肌间的平均距离左侧分别为20.7±5.63mm、20.1±6.97mm、19.5±6.20mm、15.7±7.86mm,右侧分别为15.3±6.29mm、8.8±4.32mm、7.1±4.34mm、4.8±3.69mm;左侧均大于右侧,差异有统计学意义(P0.01),由L1/2~L4/5血管和腰大肌间的平均距离呈下降趋势;左侧L4/5椎间隙平面血管和腰大肌平均距离小于其他节段平均距离,差异有统计学意义(P0.01),其中有9例血管与腰大肌间隙距离小于5mm,2例血管与腰大肌之间无间隙;在X线片上L5上终板中点与左侧髂棘的垂直距离为-33~19.6mm,平均-7.0±14.2mm,其中30%髂嵴高于L5上终板中点。结论 :MRI可作为微创斜向腰椎椎体间融合术手术入路的术前评估手段,节段越高,血管与腰大肌间隙距离越大,而且左侧血管肌肉间隙大于右侧,适合采用微创斜向腰椎椎体间融合术。     

A case report of a rare complication of bowel perforation in extreme lateral interbody fusion

Over the past decade, extreme lateral interbody fusion (XLIF) has gained in popularity as a minimally invasive alternative to direct anterior lumbar interbody fusion (ALIF), and ALIF’s associated morbidity. Most notably, XLIF largely avoids vascular and visceral structures that are required to be mobilized in ALIF. In this case report, the authors describe a rare complication of a bowel injury in a 70-year-old male who underwent an L3–4 and L4–5 lateral transpsoas approach for interbody fusion.     

极外侧入路腰椎椎间融合术与传统后路术式治疗高位腰椎间盘突出症的病例对照研究

目的 :比较极外侧入路腰椎椎间融合术(extreme lateral interbody fusion,XLIF)与传统后路手术治疗高位腰椎间盘突出症的临床疗效。方法:收集2010年6月至2014年12月高位腰椎间盘突出症60例患者的临床资料,其中极外侧入路椎间植骨椎体钉固定组(XLIF组)30例,其中T_(12)L_12例、L_(1,2)6例、L_(2,3)10例、L_(3,4)12例;后入路椎间植骨椎弓根钉固定组(传统后路组)30例,其中T_(12)L_11例、L_(1,2)6例、L_(2,3)8例、L_(3,4)15例。记录手术切口长度、手术时间、术中出血量、术后引流液量、住院时间,比较手术前后腰痛视觉模拟评分(visual analogue score,VAS)和腰椎日本骨科协会(Japanese Orthopedic Association,JOA)评分(29分法),并根据影像资料,观察椎间融合器有无移位,分析椎间融合率情况。结果:所有患者获得随访,时间12~48个月,平均29个月。XLIF组术后股神经损伤2例,术后3个月内恢复;传统后路组切口浅表感染1例,予抗感染治疗后治愈。术中、术后均未出现脑脊液漏、马尾损伤以及下肢神经根功能恶化现象。XLIF组手术时间(65.6±20.5)min,术中出血量(48.8±15.3)ml,术后引流量0 ml;传统后路组手术时间(135.2±33.9)min,术中出血量(260.3±125.7)ml,术后引流量(207.1±50.2)ml;XLIF手术时间短于传统后路组,术中出血量、术后引流量也较传统后路组少(P0.05)。两组随访时的JOA、VAS评分均较术前明显改善(P0.05),但术后1、6、24个月VAS、JOA评分两组对比差异无统计学意义(P0.05)。两组术后6、12个月随访的融合率比较差异无统计学意义(P0.05)。结论 :应用XLIF治疗高位腰椎间盘突出症具有微创、手术时间短、并发症少、术后融合率高的优点,具有更好的临床疗效。     

成人退行性腰椎侧凸的外科治疗

目的评估3种外科手术方法治疗成人退行性腰椎侧凸（adult degenerative lumbar scoliosis,ADLS）的临床疗效。方法对1999年7月至2009年7月我院收治的117例ADLS病例根据其临床症状和腰椎畸形程度及特点采取不同的手术方式进行治疗,其中单纯椎管减压术48例,椎管减压＋后路椎弓根钉内固定＋椎体间融合器矫形术62例,极外侧入路椎间融合器融合术（extreme lateral interbody fusion,XLIF）7例。术后及随访期间观察ADLS患者症状及体征的改善、腰椎畸形矫正和椎间植骨融合效果以及并发症的发生情况。结果 66例获得随访,随访时间6～49个月,平均13个月。下肢神经根放射痛缓解率91%,下腰痛缓解率72%。单纯减压术术后下肢麻痛缓解,6例术后12～18个月腰椎畸形开始加重。后路椎弓根钉内固定＋椎体间融合器组和XLIF组能够矫正腰椎的侧凸畸形并重建腰椎的生理前凸,5例术后2年复查发现融合器压塌上位椎体终板。结论单纯神经减压手术可缓解ADLS下肢的根性症状,但对腰椎畸形无矫形作用,术后部分病例腰椎畸形加重。后路椎弓钉内固定＋椎体间融合器组和XLIF组具有矫形和重建生理前凸的作用,是治疗ADLS的较好选择。     

Comparison of extreme lateral approach with posterior approach in the treatment of lumbar degenerative diseases: A meta-analysis of clinical and imaging findings

ObjectiveTo compare clinical and imaging findings between extreme lateral lumbar interbody fusion (XLIF) and posterior fusion (PF) via meta-analysis for the treatment of lumbar degenerative diseases.MethodsEnglish papers reporting clinical and imaging findings for the treatment of lumbar degenerative diseases with XLIF and PF published electronically in the PubMed, Embase, Cochrane Library, and Web of Science databases from January 2006 to August 2019 were retrieved. Two authors independently extracted data and evaluated the quality of the included literature. Meta-analysis of outcome measures was performed using Stata 14 and RevMan 5.3 software.ResultsThis meta-analysis included 744 patients from nine studies, two of which were prospective studies, while the others were retrospective studies. The quality of each study was determined to be high. The meta-analysis showed no significant differences in the operative time, length of hospital stay, clinical effectiveness, and improvement in postoperative global sagittal alignment between two approaches (P > 0.05). However, XLIF was significantly better than PF in reducing intraoperative blood loss and recovery of local sagittal alignment (P < 0.05). Moreover, the high incidence of postoperative complications were detected in XLIF group (P < 0.05).ConclusionsBoth surgical approaches have equally promising clinical effectiveness for the treatment of lumbar degenerative diseases. Although XLIF can reduce intraoperative blood loss and obtain better postoperative local sagittal alignment than PF, the high incidence of postoperative complications should prompt us to consider why XLIF procedure is still being offered to our patients and how we can reduce these complications. In addition, any conclusions should be taken with caution because of the mix of prospective and retrospective studies, and the high heterogeneity and bias.     

What is the fate of the adjacent segmental angles 6 months after single-level L3–4 or L4–5 lateral lumbar interbody fusion?

Background ContextLateral lumbar interbody fusion (LLIF) is an effective technique for fusion and sagittal alignment correction/maintenance. Studies have investigated the impact on the segmental angle and lumbar lordosis (and pelvic incidence-lumbar lordosis mismatch), however not much is documented regarding the immediate compensation of the adjacent angles.PurposeTo evaluate acute adjacent and segmental angle as well as lumbar lordosis changes in patients undergoing a L3–4 or L4–5 LLIF for degenerative pathology.Study Design/SettingRetrospective cohort study.Patient SamplePatients included in this study were analyzed pre- and post-LLIF performed by one of three fellowship-trained spine surgeons, 6 months following surgery.Outcome MeasuresPatient demographics (including body mass index, diabetes diagnosis, age, and sex) as well as VAS and ODI scores were measured. Lateral lumbar radiograph parameters: lumbar lordosis (LL), segmental lordosis (SL), infra and supra-adjacent segmental angle, and pelvic incidence (PI).MethodsMultiple regressions were applied for the main hypothesis tests. We examined any interactive effects at each operative level and used the 95% confidence intervals to determine significance: a confidence interval excluding zero indicates a significant effect.ResultsWe identified 84 patients who underwent a single level LLIF (61 at L4–5, 23 at L3–4). For both the overall sample and at each operative level, the operative segmental angle was significantly more lordotic postop compared to preop (all ps≤.01). Adjacent segmental angles were significantly less lordotic postop compared to pre-op overall (p=.001). For the overall sample, greater lordotic change at the operative segment led to more compensatory reduction of lordosis at the supra-adjacent segment. At L4–5, more lordotic change at the operative segment led to more compensatory lordosis reduction at the infra-adjacent segment.ConclusionThe present study demonstrated that LLIF resulted in significant increase in operative level lordosis and a compensatory decrease in supra- and infra-adjacent level lordosis, and subsequently no significant impact on spinopelvic mismatch.     

单纯斜外侧椎间融合术在腰椎退行性疾病中的应用

目的探讨单纯斜外侧椎间融合术(OLIF)治疗腰椎退行性疾病的临床效果。方法采用OLIF治疗35例腰椎退行性疾病患者。采用疼痛VAS评分和ODI评分评估临床疗效;行腰椎X线、CT和MR检查,评价术后影像学改善程度;记录并发症情况。结果手术时间56~110(77±23)min。术中出血量30~180(63±35)ml。术后住院时间3~7(4.5±2.1)d。术后患者腰腿疼痛症状明显缓解。患者均获得随访,时间6~32个月。术后6个月VAS评分、ODI评分、椎间隙高度和椎间孔面积均较术前明显改善(P<0.001)。术后并发症发生率为20.0%(7/35):3例融合器沉降,二期联合后路肌间隙入路椎弓根螺钉固定;1例术侧腰大肌无力,1例术侧大腿前侧疼痛,1例对侧屈髋疼痛,1例术侧交感链损伤症状,4例随访过程中症状均缓解或消失。结论OLIF作为一种脊柱外科新技术,可获得良好的近期疗效,其远期疗效有待进一步观察。     

Does obesity affect long-term outcomes of extreme lateral interbody fusion with posterior stabilization?

Background ContextObese patients can pose significant challenges to spine surgeons in lumbar fusion procedures. The increased risk of complications has led surgeons to be wary in pursing operative interventions in these patients. Since the advent of minimally-invasive techniques in lumbar fusion, surgeons are turning to these procedures in an attempt to minimize operative time, blood loss and overall cost. With an increased proportion of obese patients in the population, it is imperative to understand the long-term outcomes in these minimally-invasive approaches.PurposeThe purpose of this study was to evaluate the long-term safety and efficacy of extreme lateral interbody fusion (XLIF) in the obese.Study Design/SettingRetrospective cohort study.Patient SampleA total of 115 patients (53 nonobese and 62 obese) who underwent XLIF with a minimum of 5-year follow-up.Outcome Measures(1) Patient reported outcome scores: Visual Analog Scale (VAS) for back pain, Oswestry Disability Index (ODI), (2) Reoperation rate, (3) Pelvic incidence (PI)- Lumbar lordosis (LL) mismatch correction, (4) Graft subsidence and fusion rateMethodsA retrospective review was performed to identify patients who underwent XLIF with percutaneous posterior stabilization since 2007 with a minimum follow-up of 5 years. Demographics including BMI were recorded and patients were subdivided into 2 cohorts: nonobese (BMI <30 kg/m²) and obese (BMI ≥30 kg/m²). Functional outcomes were assessed by comparing pre- and postoperative VAS and ODI scores. Reoperation rates were compared between cohorts. PI-LL mismatch was calculated from both pre- and postoperative radiographs. Rates of graft subsidence and fusion were measured at final follow-up.ResultsA total of 115 consecutive patients were included (53 nonobese and 62 obese) with a mean follow up of 95.3 months. Mean BMI was 25.3 in the nonobese group and 35.3 in the obese group (p<.001). There were more females in nonobese cohort. VAS scores decreased by a mean of 5.7 in the nonobese cohort, and 5.4 in the obese cohort (p=.213). ODI improvement was also similar between the groups. 5.6% of nonobese patients required reoperation compared to 9.6% of obese patients (p=.503). Graft subsidence rates at final follow-up were 5.66% and 8.06% for the nonobese and obese groups, respectively (p=.613). Rates of successful fusion were 96.23% and 98.39% for the nonobese and obese groups, respectively (p=.469). Both cohorts achieved a similar proportion of PI-LL mismatch correction, 85% in obese versus 78% in nonobese patients (p=.526).ConclusionObese patients have similar surgical outcomes to nonobese patients with respect to functional outcome scores, reoperation rates, graft subsidence and correction of PI-LL mismatch after long-term follow-up. With similar outcome and reoperation profiles, minimally-invasive approaches to the spine, such as XLIF, may be an acceptable alternative to traditional open procedures in obese patients.     

In vitro comparison of endplate preparation between four mini-open interbody fusion approaches

Purpose

Discectomy and endplate preparation are important steps in interbody fusion for ensuring sufficient arthrodesis. While modern less-invasive approaches for lumbar interbody fusion have gained in popularity, concerns exist regarding their ability to allow for adequate disc space and endplate preparation. Thus, the purpose of this study was to quantitatively and qualitatively evaluate and compare disc space and endplate preparation achieved with four less-invasive approaches for lumbar interbody fusion in cadaveric spines.

Methods

A total of 24 disc spaces (48 endplates) from L2 to L5 were prepared in eight cadaveric torsos using mini-open anterior lumbar interbody fusion (mini-ALIF), minimally invasive posterior lumbar interbody fusion (MAS PLIF), minimally invasive transforaminal lumbar interbody fusion (MAS TLIF) or minimally invasive lateral, transpsoas interbody fusion (XLIF) on two specimens each, for a total of six levels and 12 endplates prepared per procedure type. Following complete discectomy and endplate preparation, spines were excised and split axially at the interbody disc spaces. Endplates were digitally photographed and evaluated using image analysis software. Area of endplate preparation was measured and qualitative evaluation was also performed to grade the quality of preparation.

Results

The XLIF approach resulted in the greatest relative area of endplate preparation (58.3 %) while mini-ALIF resulted in the lowest at 35.0 %. Overall, there were no differences in percentage of preparation between cranial and caudal endplates, though this was significantly different in the XLIF group (65 vs 52 %, respectively). ALL damage was observed in 3 MAS TLIF levels. Percentage of endplate that was deemed to have complete disc removal was highest in XLIF group with 90 % compared to 65 % in MAS TLIF group, 43 % in MAS PLIF, and 40 % in mini-ALIF group. Endplate damage area was highest in the MAS TLIF group at 48 % and lowest in XLIF group at 4 %.

Conclusions

These results demonstrate that adequate endplate preparation for interbody fusion can be achieved utilizing various minimally invasive approach techniques (mini-ALIF, MAS TLIF, MAS PLIF, XLIF), however, XLIF appears to provide a greater area of and more complete endplate preparation.

     

Incisional hernia after extreme lateral interbody fusion on the lumbar spine: A case report

IntroductionExtreme lateral interbody fusion is a minimally invasive lateral transpsoas approach for spine surgery. We herein report a case of an incisional hernia after an extreme lateral interbody fusion on the lumbar spine that was successfully treated by laparoscopic surgery with intraperitoneal onlay mesh repair.Presentation of caseA 78-year-old woman was referred to our hospital with a complaint of left abdominal bulge and pain. She had undergone an extreme lateral interbody fusion for a lumbar spinal canal stenosis from L1 to L4 a year prior. Abdominal computerized tomography showed a left lumbar incisional hernia, and laparoscopic surgery was performed. The hernia orifice was sutured closed and covered with mesh. The patient was discharged five days after the operation with no complications.DiscussionWhen performing XLIF for a spinal disorder, the muscles should be separated bluntly along their fibers to prevent muscle atrophy, and the incised fascia should be securely sutured closed. Abdominal wall incisional hernias can occur after spinal surgeries such as extreme lateral interbody fusion.ConclusionLaparoscopic repair for abdominal wall incisional hernia after spine surgery is safe and feasible.