Minimally invasive 360° instrumented lumbar fusion

A retrospective preliminary study was undertaken of combined minimally invasive instrumented lumbar fusion utilizing the BERG (balloon-assisted endoscopic retroperitoneal gasless) approach ¶anteriorly, and a posterior small-incision approach with translaminar screw fixation and posterolateral ¶fusion. The study aimed to quantify the clinical and radiological results using this combined technique. The traditional minimally invasive approach to the anterior lumbar spine involves gas insufflation and provides reliable access only to L5-S1 and in some cases L4-5. A gas-mediated approach yields many technical drawbacks to performing spinal surgery. A minimally invasive posterior approach involving suprafascial pedicle screw instrumentation has been developed, but without widespread use. Translaminar facet fixation may be a viable alternative to transpedicular fixation in a 360° instrumented fusion model. Past studies have shown open 360° instrumented lumbar fusion yields high arthrodesis rates. The study examined the cases of 46 patients who underwent successful 360° instrumented lumbar fusion using a combined minimally invasive approach. Anterior lumbar interbody fusion (ALIF) at one or two levels was performed through the BERG approach; a gasless retroperitoneal approach to the lumbar spine allowing the use ¶of standard anterior instrumentation. Posteriorly, all patients underwent successful decompression, translaminar fixation, and posterolateral fusion at one or two levels through ¶one small (2.5-5.0 cm) incision. Results showed mean hospital stay of 2.02 days; mean combined blood loss was 255 cc; and mean pain relief was 56%, with 75.5% of patients reporting good, excellent, or total pain relief. Forty-two of 46 patients (93.2%) achieved a solid fusion ¶24 months after surgery. A total of 47% of all patients working prior to surgery returned to work following surgery. The study showed that minimally invasive 360° instrumented lumbar fusion, when performed utilizing these approaches, yields a high rate of solid arthrodesis (93.3%), good pain relief, short hospital stays, low blood losses, accelerated rehabilitation, and a quick return to the workforce. The BERG approach offers technical advantages over the traditional gas-mediated laparoscopic approach to the anterior lumbar spine.     

Minimally invasive 360° instrumented lumbar fusion

A retrospective preliminary study was undertaken of combined minimally invasive instrumented lumbar fusion utilizing the BERG (balloon-assisted endoscopic retroperitoneal gasless) approach ¶anteriorly, and a posterior small-incision approach with translaminar screw fixation and posterolateral ¶fusion. The study aimed to quantify the clinical and radiological results using this combined technique. The traditional minimally invasive approach to the anterior lumbar spine involves gas insufflation and provides reliable access only to L5-S1 and in some cases L4-5. A gas-mediated approach yields many technical drawbacks to performing spinal surgery. A minimally invasive posterior approach involving suprafascial pedicle screw instrumentation has been developed, but without widespread use. Translaminar facet fixation may be a viable alternative to transpedicular fixation in a 360° instrumented fusion model. Past studies have shown open 360° instrumented lumbar fusion yields high arthrodesis rates. The study examined the cases of 46 patients who underwent successful 360° instrumented lumbar fusion using a combined minimally invasive approach. Anterior lumbar interbody fusion (ALIF) at one or two levels was performed through the BERG approach; a gasless retroperitoneal approach to the lumbar spine allowing the use ¶of standard anterior instrumentation. Posteriorly, all patients underwent successful decompression, translaminar fixation, and posterolateral fusion at one or two levels through ¶one small (2.5–5.0 cm) incision. Results showed mean hospital stay of 2.02 days; mean combined blood loss was 255 cc; and mean pain relief was 56%, with 75.5% of patients reporting good, excellent, or total pain relief. Forty-two of 46 patients (93.2%) achieved a solid fusion ¶24 months after surgery. A total of 47% of all patients working prior to surgery returned to work following surgery. The study showed that minimally invasive 360° instrumented lumbar fusion, when performed utilizing these approaches, yields a high rate of solid arthrodesis (93.3%), good pain relief, short hospital stays, low blood losses, accelerated rehabilitation, and a quick return to the workforce. The BERG approach offers technical advantages over the traditional gas-mediated laparoscopic approach to the anterior lumbar spine.     

Unilateral transforaminal posterior lumbar interbody fusion.

A prospective analysis of consecutive patients who had lumbar fusion using the unilateral transforaminal posterior lumbar interbody fusion with pedicle screw fixation is presented to assess the clinical and radiographic outcomes of the transforaminal posterior lumbar interbody fusion procedure and describe the technique and indication in the treatment of degenerative disease of the lumbar spine. Forty patients treated with transforaminal posterior lumbar interbody fusion for degenerative diseases of the lumbar spine (with anterior column deficiency) were followed up for a minimum of 3 years (mean, 3.4 years; range, 3-3.9 years). Radiographic assessment included plain and flexion and extension radiographs. Clinical outcome was based on pain relief, ability to do activities of daily living, and return to work. Thirty-six patients (90%) had solid fusions and at latest followup, segmental lordosis has increased in all patients. Eighty-five percent of patients had excellent or good clinical outcome(s). The unilateral transforaminal posterior lumbar interbody fusion provides bilateral anterior column support through a unilateral approach. The patients had high fusion rates and patient satisfaction as reported with similar complications found in other methods commonly used for spinal decompression and stabilization.     

Posterolateral lumbar and lumbosacral fusion with and without pedicle screw internal fixation.

Forty-seven patients who had lumbar or lumbosacral fusion with or without pedicle screw internal fixation by one surgeon for treatment of degenerative lumbar disease with clinical instability were retrospectively reviewed by an independent observer. Eighteen of the 21 patients whose fusions were internally fixed with the Variable Spinal Plating (VSP) system were available for review. A control group consisted of 27 patients who had fusion without internal fixation. The rate of pseudarthrosis did not significantly differ between the two groups (VSP group, 22%; versus control group, 26%). Twelve (67%) of the 18 patients treated with fusion and VSP instrumentation were considered to have had a good or excellent outcome, whereas 19 (70%) of the 27 patients treated by fusion without internal fixation had good or excellent results. Two VSP-instrumented patients had postoperative leg dysesthesias, whereas this complication was not observed in the control group. Bilateral posterolateral lumbar or lumbosacral fusion without internal fixation is as effective as and safer than fusion with pedicle screw instrumentation.     

新型可膨胀椎弓根螺钉在骨质疏松性腰椎融合与固定手术中的初步应用

目的 评价新型可膨胀椎弓根螺钉(Thunder钉)在骨质疏松性腰椎椎体中固定的可靠性及其临床疗效.方法 随访2006年8月至2007年12月,应用Thunder钉治疗合并骨质疏松症的各种腰椎疾患42例(236枚螺钉),其中腰椎退行性疾病24例,腰椎结核二期后路融合手术8例,腰椎骨质疏松性压缩骨折6例,腰椎翻修手术4例.所有病例术前均行骨密度检查,患者腰椎骨密度平均下降2.6个标准差.术后处理与其他腰椎内固定术后患者相同.术后1周、3个月、半年、1年及2年随访患者,摄X线片并进行CT扫描三维重建,了解椎弓根螺钉稳定性及脊柱融合情况.结果42例患者均获平均16(12～24)个月的随访.术后3、6、12及24个月的影像学检查显示,所有Thunder钉位置良好,无螺钉松动、断裂迹象,评分平均值分别为3.0、3.0、2.9和2.9.脊柱骨融合于术后随时间延长趋于完善,骨融合评分平均值分别为2.3、2.5、3.0、3.0.所有患者临床症状缓解,疗效满意.结论 Thunder钉具有良好的钉-骨界面结合,能够提高螺钉在骨质疏松椎体中的固定强度,为脊柱融合提供良好的基础,临床疗效满意.     

PEEK椎间融合器在腰椎滑脱中的应用

目的探讨PEEK椎间融合器加椎弓根内固定技术治疗腰椎滑脱症的临床疗效。方法41例腰椎滑脱患者采用全椎板减压、椎弓根器械复位固定、椎体间放入PEEK融合器植骨融合。结果全部获得随访，时间12～54个月，40例植骨获得椎体间融合，融合时间6～24个月，融合率97．6％。临床疗效按Macnab标准评定：优17例，良21例，可2例，差1例，优良率达92．7％。结论PEEK椎间融合器植骨融合是一种较为实用的融合方式，避免了取自体髂骨带来的问题，在生物力学上保持腰椎生理前凸、提高腰椎生物力学功能，对恢复脊柱稳定性具有积极作用。     

Efficacy of translaminar facet screw fixation in circumferential interbody fusions as compared to pedicle screw fixation

OBJECTIVES: Posterior lumbar fixation with translaminar facet screws is a minimally invasive technique with good success rates. Long-term follow-ups show reduced reoperation rates, a decrease in pain scores, and few complications compared with pedicle screw fixation devices. The purpose of this study was to compare the reoperation rate of translaminar facet screw fixation with that of pedicle screw fixation in 360 degrees anterior and posterior fusions for incapacitating low back pain due to lumbar disc degeneration unresponsive to at least 6 months of aggressive nonoperative treatment. METHODS: One hundred five patients underwent a combined circumferential lumbar fusion with posterior fixation for discogenic pain by one surgeon between August 1993 and February 2003. Seventeen patients were excluded from the study owing to their preoperative etiology for fusion or a prior instrumented posterior fusion. A retrospective chart review was done on all 88 remaining patients. Patients were followed in the office, by phone, or by mail to obtain functional outcome measures. Any subsequent operations by this surgeon or another were recorded. The comparison focused on the rate of reoperation on the region of posterior lumbar fixation. RESULTS: Sixty-seven patients have had at least a 2-year follow-up. Twenty-four patients had a posterior fusion with pedicle screws, and 43 had translaminar facet screw fixation. Nine patients of the pedicle screw population (37.5%) had a reoperation to remove their instrumentation. Two patients of the translaminar facet screw population (4.7%) had reoperations on their lumbar spine. There was a significant association between posterior instrumentation type and reoperation (P = 0.001). CONCLUSION: The success of translaminar facet screws in circumferential fusions is justified.     

棘突椎板作为骨源椎间植入在下腰椎椎间融合中的应用

目的探讨腰椎后路棘突椎板作为骨源椎间植入加椎弓根钉系统固定在下腰椎椎间融合中的可行性和临床效果。方法应用自体棘突椎板作为骨源椎间植入加椎弓根钉系统固定下腰椎98例，其中椎间盘脱出症30例，椎间盘突出症复发11例，腰椎不稳45例，椎管狭窄12例。结果10例失访，88例术后随访12—56个月，腰腿痛症状消失或明显减轻，腰椎间融合好，椎间隙高度无明显减少。结论棘突椎板作为骨源椎间植入加椎弓根钉系统固定在下腰椎的应用具有操作简单、安全、可靠及融合效果好的优点。     

ALIF加椎弓根内固定治疗腰椎间盘源性腰痛

目的探讨前路椎体间融合(anterior lumbar interbody fusion,ALIF)加椎弓根内固定治疗腰椎间盘源性腰痛的手术疗效。方法16例腰椎间盘源性下腰痛患者,均行ALIF加后路椎弓根螺钉系统内固定术。比较手术前后腰痛视觉模拟评分(visual analogue scale,VAS)和Oswestry功能障碍指数(Oswestry disability index,ODI)评分,同时评估术后腰椎融合率。结果本组均获随访,时间8~28个月。15例术后腰腿痛症状基本消失,1例仍有轻度腰痛。术前平均VAS和ODI评分分别为7.7±1.1和38.7±2.3,术后分别为2.3±0.2和12.6±1.3,差异均有统计学意义(P<0.01)。本组植骨融合率为100%。结论ALIF加椎弓根内固定是治疗腰椎间盘源性下腰痛的有效方法,但需严格掌握手术适应证。     

Surgical treatment of adjacent instability after lumbar spine fusion.

STUDY DESIGN: This study is a retrospective review of 39 patients with previous instrumented lumbar fusion who underwent secondary spine surgery for lumbar adjacent instability. To the authors' knowledge, this is the largest study of surgical treatment of lumbar adjacent instability in the literature to date. OBJECT: This study evaluated the feasibility of adjacent instability treated with medial facetectomy, fusion with autologous bone grafting, and pedicle screw instrumentation. SUMMARY OF BACKGROUND DATA: The surgical treatment of adjacent instability has seldom been discussed. Revision spine fusions are challenged by high pseudarthrosis rates. METHODS: Thirty-nine patients with previous lumbar fusion underwent second lumbar spine surgery for adjacent instability. All were treated with autogenous posterolateral arthrodesis and transpedicle screw fixation in addition to decompressive laminectomy. Medical records, radiographs, and pain scores were obtained. RESULTS: The clinical results were excellent or good in 76.9% of patients, and the radiographic fusion was successful in 37 (94.9%) of patients. Flat back was noted in 8 (20.5%) of patients. In 5 patients (12.8%), neighboring segment breakdown again developed, and 2 of those patients underwent a third lumbar fusion. Dural tear during operation occurred in 2 patients. One patient experienced cauda equina syndrome but recovered bladder function 1 month later. CONCLUSION: Autogenous posterolateral arthrodesis combined with pedicle screw fixation led to successful radiologic and clinical outcome in patients with lumbar adjacent instability. Adequate decompression of the adjacent stenosis requires medial facetectomy, thus preventing aggressive nerve root manipulation and reducing the incidence of dural tear.     

Translaminar screw fixation in the lumbar spine: technique, indications, results

Translaminar screw fixation of the lumbar spine represents a simple and effective technique for short segment fusion in the degenerative spine. Clinical experience with 173 patients who underwent translaminar screw fixation revealed a fusion rate of 94%. The indications for translaminar screw fixation as a primary fixation procedure are: segmental dysfunction, lumbar spinal stenosis with painful degenerative changes, segmental revision surgery after discectomies, and painful disc-related syndromes such as internal disc disruption and lumbar disc herniation with concomitant degenerative changes. As an additional stabilization procedure, translaminar screws can be used to augment anterior fusion or reinforce pedicle systems. Translaminar screw fixation achieves as high fusion rate provided the biomechanical principles of the lumbar spine with an intact anterior column are respected and a meticulous operative technique is employed to enhance bony ingrowth of the graft. Received: 12 January 1998 Revised: 18 March 1998 Accepted: 6 April 1998     

经单侧椎间孔椎体间融合术在退变性腰椎疾病中的应用

目的 探讨单侧经椎间孔腰椎体间融合术（TLIF）在退变性腰椎疾病的应用。方法采用经单侧椎间孔人路椎体间融合结合椎弓根短节段固定治疗退变性腰椎疾病30例。使用自体三面皮质髂骨或钛网作为融合材料。结果患者术后随访6～20个月,根据腰椎X线片作为评判椎间融合的标准,融合率为93％。未发生内置物断裂、松动移位和椎间隙高度丧失,疗效评定按日本骨科学会（JOA）下腰痛评分15分法评定：优20例,良8例,可2例,总优良率为93％。结论TLIF治疗退变性腰椎疾病,手术创伤小,融合率高,并发症少。     

腰椎崩裂性滑脱椎弓根钉复位内固定后外侧植骨融合术

目的　比较分析椎弓根钉复位内固定 后外侧直骨融合术与单纯后外侧植骨融合术治疗腰椎崩裂滑脱的疗效。方法　统计分析我院 1987.1～ 2 0 0 0 .1,97例腰椎崩裂性滑脱病人行椎弓根钉复位内固定 后外侧植骨融合术后 2年的情况 ,内固定于术后一年取出。结果　植骨融合率为 92 .8%(7例未融合 )。腰腿痛症状改善的评价采用 JOA标准 ,术前平均为 15分 ,术后平均为 2 3分 ,(满分为 2 9分 ) ,术前 9.3%(9人 )能参加一般的体力劳动和干家务活 ,术后 75 .3%(73人 )的人能参加一般的体力劳动和干家务活。术前平均滑脱 41%,术后 (去除内固定后一年 )平均滑脱15 %,并发症发生率 6 1%,其中断钉发生率 42 .3%,绝大多数并发症临床上无重要意义。结论　椎弓根钉复位内固定 后外侧植骨融合术能有效矫正腰椎滑脱 ,增加植骨融合率 ,缩短术后卧床休息时间 ,但并发症较单纯后外侧植骨融合术多。     

后路椎间植骨椎弓根螺钉固定治疗椎间盘源性腰痛

目的研究后路椎体间融合加椎弓根固定治疗腰椎间盘源性腰痛的手术疗效。方法 35例腰椎间盘源性下腰痛,选择后路椎体间植骨融合（posterior lumbar interbody fusion,PLIF）加椎弓根螺钉系统内固定术。分别于术前、术后对患者的腰痛情况进行JOA评分,同时评估术后腰椎融合率。结果术后随访时间8～24个月,平均18个月。术后腰部疼痛症状缓解明显,优21例,良8例,一般4例,差2例,有效率95%。术后椎间植骨临床愈合35例,植骨愈合有效率100%。结论后路椎间植骨椎弓根螺钉固定术对椎间盘源性腰痛是一种有效的治疗方法。     

后路椎弓根钉棒固定治疗退变性脊柱侧弯的临床疗效

目的探讨后路椎弓根螺钉固定技术治疗退变性脊柱侧弯的临床效果。方法对20例退变性脊柱侧弯患者进行手术矫正,对Cobb角20°的1例患者行椎管减压、椎体融合、短节段椎弓根钉棒系统固定术;对Cobb角20°的19例患者行椎管减压、椎体融合、长节段椎弓根钉棒系统固定并植骨融合术。结果患者均获得6个月的随访。未出现术后感染及断钉、断棒等情况。Cobb角、腰椎前凸角和胸腰段后凸角:术后均较术前明显改善(P0.05),术后6个月均较术后进一步改善(P0.05)。JOA评分及ODI评分:术后均较术前明显改善(P0.05),术后6个月均较术后进一步改善(P0.05)。结论椎管减压是减轻患者疼痛的前提,在此基础上行后路椎弓根钉棒系统固定术能重建脊柱的稳定性,改善患者生活质量。     

椎弓根固定结合经椎间孔椎间融合治疗复发性腰椎间盘突出症伴腰椎不稳

目的：探讨经肌间隙入路椎弓根固定结合经椎间孔椎间融合（transforaminal lumbar interbody fusion,TLIF）治疗复发性腰椎间盘突出症伴腰椎不稳的临床疗效。方法：2008年3月至2010年5月收治35例复发性腰椎间盘突出症,其中15例行经肌间隙入路单边椎弓根固定结合TLIF术式（单边固定组）,20例行后正中入路双边椎弓根固定结合后路椎间植骨融合（posterior lumbar interbody fusion,PLIF）术式（双边固定组）.观察手术时间、术中出血量,并比较手术前后两组患者JOA评分、腰痛及腿痛VAS评分及融合情况。结果：所有患者获得随访,时间6～30个月,平均16.8个月。两组患者腰腿痛等临床症状较术前明显缓解,X线片显示植骨融合良好（双边固定组中1例未融合）,无融合器移位、下沉及内固定器械松动或断裂。两组患者手术时间、术中出血量比较差异有统计学意义（P<0.05）.术后JOA评分均较术前降低（P<0.05）.术后1周,两组患者腰痛VAS评分比较差异有统计学意义（P<0.05）,腿痛VAS评分比较差异无统计学意义（P>0.05）;末次随访,腰痛及腿痛VAS评分两组比较差异无统计学意义（P>0.05）.结论：两种术式在治疗复发性腰椎间盘突出症伴腰椎不稳均可达到满意的疗效,经肌间隙入路单边椎弓根固定结合TLIF术式切口较小,手术时间较短,术中出血量较少,术后腰痛缓解较快。     

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。     

后路颗粒骨植骨融合内固定治疗退行性腰椎不稳

目的探讨颗粒骨后路植骨融合内固定治疗退行性腰椎不稳的效果。方法48例退行性腰椎不稳患者,行腰椎椎弓根钉棒内固定,全椎板或半椎板减压,颗粒状骨植骨治疗。结果全部获随访时间6个月～4年,4～6个月后可见植骨灶骨融合征象,无复位丢失和螺钉断裂。患者腰痛、下肢疼痛症状均明显缓解。疗效及功能评定结果：优22例,良24例,可2例,优良率96%。结论脊柱后路颗粒植骨结合椎弓根钉内固定是治疗退行性腰椎不稳一种有效的手术方法。     

Anterior interbody arthrodesis with percutaneous posterior pedicle fixation for degenerative conditions of the lumbar spine

This is a retrospective case series to evaluate clinical variables, complications and outcome of 50 patients who underwent anterior lumbar interbody fusion (ALIF) supplemented with posterior percutaneous pedicle screw fixation for degenerative conditions of the lumbar spine. Twenty-four patients underwent single-level fusion and 26 patients had a two-level fusion for a total of 76 levels fused. The mean lengths of the anterior and posterior (including repositioning) portions of the procedure were 131 and 102 min, respectively. The mean estimated blood loss for the entire procedure was 288 ml. The overall adverse event rate was 12%. The mean VAS score for leg pain, VAS score for back pain and mean ODI all improved postoperatively. This study found that ALIF using allograft bone and rhBMP-2 combined with percutaneous pedicle screw fixation had a high fusion rate and a low incidence of perioperative complications. Patient outcomes showed significant improvements in back and leg pain and physical functioning.     

Unilateral transforaminal posterior lumbar interbody fusion (TLIF): indications, technique, and 2-year results

A prospective analysis of consecutive cases of lumbar fusion using the unilateral transforaminal posterior lumbar interbody fusion (TLIF) technique with pedicle screw fixation. The objective of the study was to assess the clinical and radiographic outcome of TLIF and describe the technique and indications in the treatment of degenerative disease of the lumbar spine. Forty patients treated with TLIF for degenerative diseases of the lumbar spine were followed up for a minimum of 2.5 years (mean: 36 months; range: 30-42 months). Twenty-three patients had degenerative disc disease alone, 13 had associated isthmic or degenerative spondylolisthesis, and 4 had recurrent disc herniations at the L4-L5 level. Thirty-six (90%) had solid fusions radiographically at latest follow-up. Seventy-nine percent had excellent or good clinical outcomes. Our patients demonstrated high fusion rates and patient satisfaction.