Indications and limitations of minimally invasive lateral lumbar interbody fusion without osteotomy for adult spinal deformity

European Spine Journal - The global alignment and proportion (GAP) score was recently developed to consider proportional analysis of spinopelvic alignment and has been indicated for setting...     

斜外侧入路与微创经椎间孔入路椎间融合术治疗退变性腰椎滑脱的早期疗效及影像学对比

目的:比较斜外侧入路腰椎椎间融合术(oblique lumbar interbody fusion,OLIF)和Quadrant可扩张通道下微创经椎间孔入路腰椎椎间融合术(minimally invasive transforaminal lumbar interbody fusion,MIS-TLIF)治疗退变性腰椎滑脱的短期临床疗效及影像学差异。方法:对2019年4月至2020年10月行OLIF与MIS-TLIF两种微创手术方式治疗的58例腰椎滑脱患者进行回顾性分析。其中采用OLIF治疗28例(OLIF组),男15例,女13例;年龄47～84(63.00±9.38)岁;采用MIS-TLIF治疗30例(MIS-TLIF组),男17例,女13例;年龄43～78岁(61.13±11.10)岁。记录两组患者的一般情况,包括手术时间、术中出血量、术后引流量、并发症、卧床时间、住院时间;比较两组患者的影像学资料,包括椎间盘高度、椎间孔高度、腰椎前凸角;并通过疼痛视觉模拟评分(visual analogue scale,VAS)和Oswestry功能障碍指数(Oswestry disabilit...     

微创经椎间孔腰椎体间融合术治疗腰椎管狭窄合并腰椎不稳症

目的 探讨微创经椎间孔腰椎间融合术(MIS-TLIF)治疗腰椎管狭窄合并腰椎不稳的临床疗效.方法 对2010年3月至2011年1月42例微创通道下行单侧入路双侧减压加MIS-TLIF手术治疗的腰椎管狭窄合并腰椎不稳患者进行回顾性分析;其中男性18例,女性24例,年龄48～79岁,平均61.7岁.病变节段为L3～4 4例,L4～5 26例,L5～S1 12例;其中间歇性跛行伴单侧下肢症状24例,伴双侧下肢症状18例.记录手术时间、术中出血量、术后住院时间、手术并发症的情况.患者术前、术后采用视觉模拟评分(VAS)分别对腰痛及下肢痛进行评分;采用Oswestry功能障碍指数(ODI)评估腰椎功能情况及Bridwell方法评价腰椎融合情况;术后末次随访时采用MacNab标准评价疗效.结果 手术时间120～170 min,平均150.4 min;术中出血50～400 ml,平均147.1 ml,无输血病例;术后住院天数5～18d,平均8.8d;术中l例出现硬膜囊撕裂,l例骨质疏松患者行椎间融合时融合器打入上位椎体中,术后3例发生切口愈合不良.随访6 ～14个月,平均11个月.术前腰痛VAS评分为7.3±1.0,术后3个月及末次随访时分别为2.9±0.8和2.0±0.8,与术前比较有显著改善(t =25.319和29.334,P＜0.01);术前下肢痛VAS评分为7.9±0.7,术后3个月及末次随访时分别为2.0±0.5和1.0±0.7,与术前比较差异有显著改善(t=49.584和41.885,P＜0.01);OD1评分术前为75％±6％,术后3个月随访时为16％±6％,末次随访时为l2％±5％,与术前比较差异有统计学意义(t=43.675和56.323,P＜0.01).末次随访时,根据Bridwell椎间融合评价标准,Ⅰ级和Ⅱ级为40例(95.3％),无螺钉断裂及松动发生;采用MacNab标准评价临床效果,其中优16例,良22例,可4例.结论 MIS-TLIF手术是治疗单节段腰椎管狭窄合并腰椎不稳的一种理想手术方法,但要根据术者的临床经验、手术技巧和医院的具体条件谨慎开展.     

微创腰椎椎间融合技术及其临床应用进展

腰椎椎间融合术是治疗腰椎退变性不稳、滑脱及椎间盘源性疼痛的经典手术方法。传统腰椎椎间融合手术需要广泛剥离及长时间牵拉肌肉,容易引起软组织损伤。椎旁肌肉的病理改变是腰椎融合术后腰部力量减弱及慢性腰痛发生的主要原因[1]。近年来,随着脊柱外科微创技术的迅猛发展,用于腰椎椎间融合的微创技术应运而生,使脊柱融合的方式发生了很大的变化,并对传统的融合观念提出了新的挑战。微创腰椎融合技术是在取得优于或不低于开放腰椎融合术效果的同时,减少对椎旁软组织的损伤,同时患者术中出血少,术后疼痛轻、恢复快,有利于患者的早日康复。根据手术入路不同,微创腰椎椎间融合可分为前路腰椎椎间融合（anterior lumbar interbody fusion, ALIF）、后路腰椎椎间融合（posterior lumbar interbody fusion, PLIF）、经腰椎椎间孔椎间融合（transforaminal lumbar interbody fusion, TLIF）、经皮经骶前轴向腰椎椎间融合（axial lumbar interbody fusion, AxiaLIF）和极外侧入路椎间融合（extreme lateral interbody fusion, XLIF）等。现就上述微创腰椎椎间融合方法及其相关问题作一综述。     

微创腰椎融合技术新进展

传统腰椎融合术作为治疗退变、创伤、感染、肿瘤等多因素所致脊柱不稳疾患的主要手术方式,已被脊柱外科医生广泛接受。然而,传统腰椎融合术缺点在于广泛的软组织剥离和长时间的肌肉牵拉。这会导致术后疼痛加重,恢复时间延长,脊柱功能受损。因此,保证手术安全有效的同时将软组织损伤降至最低的微创技术成为了当今脊柱外科领域的一个重要发展方向。     

实时三维导航辅助微创经椎间孔腰椎椎间融合术后腰骶部矢状位平衡参数变化分析

目的:探讨实时三维导航辅助微创经椎间孔腰椎椎体间融合术(minimally invasive transforaminal lumbar interbody fusion,MIS-TLIF)与传统开放TLIF术治疗腰椎退行性疾病后腰骶部矢状位参数的动态变化.方法:回顾性分析2017年9月至2019年9月行单节段手术治疗...     

微创极外侧经椎间孔腰椎椎间融合术的数字化解剖研究

目的 数字化技术测量并比较微创极外侧经椎问孔腰椎椎间融合术(E-TLIF)与微创经椎间孔椎间融合术(mini-TLIF)的相关解剖参数,并通过解剖验证. 方法 选取门诊60例成人腰椎CT扫描资料,男30例,女30例;年龄18 ～55岁,平均46.3岁.应用Superimage TM软件,三维重建实体模型,模拟E-TLIF、mini-TLIF固定,分别测量并比较L3-4、L4-5节段上 E-TLlF、mini-TLIF固定的切口距正中线距离、操作通道深度(切口至关节突的距离)、融合器长度、椎弓根螺钉置入长度和角度.并在2具成年男性新鲜尸体标本上进行实际操作验证. 结果 图像上则量E-TLIF切口距正中线为81.3～87.6 mm,操作通道深为81.6～86.9 mm,融合器长为29.8～32.2 mm,椎弓根螺钉长度为51.6～57.2mn.椎,弓根螺钉倾角为37.2.～40.4.E-TLIF与mini-TLIF相比切口更加偏外,可以绕过下关节突,从侧后方直接处理增生内聚的上关节突;椎,弓根螺钉和融合器置入角度更加倾斜,长度增加.在尸体标本上采用E-TLIF数字化设计测量值进行操作,尸体标本上测量的解剖参数:切口距正中线距离为80.0～ 90.0)mm,操作通道深度约85.0 mm,椎弓根螺钉置入倾角近40.0°,与图像测量值相近. 结论 通过数字化技术洲量和解剖验证,与mini-TLIF相比,E-TLIF更完整地保留了脊柱后方的解剖结构,有助于提高术后即刻稳定性.     

The surgical technique of minimally invasive transforaminal lumbar interbody fusion

We aim to describe the minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) technique. The MI-TLIF procedure was developed to achieve the same goal of neural decompression and interbody arthrodesis as the traditional, open TLIF techniques. MI-TLIF has been utilized in the treatment of an array of lumbar pathologies, while offering the advantages of reducing soft tissue trauma, decreasing postoperative pain, and reducing the rate of complication when compared to the open techniques. The surgical technique of MI-TLIF is described in a step-by-step fassion. A technical review of this novel minimally invasive procedure was performed. Additionally, data collected through our experience with this procedure is reported. Data was collected retrospectively from patients between January 2008 and December 2009 who underwent MI-TLIF. The mean preoperative VAS score was 6.12±2.02 compared to 2.11±2.69 postoperatively. The mean ODI score dropped from 38.29±13.19 preoperatively to 16.00 ±16.598 postoperatively. Eighty-four patients who underwent MI-TLIF between October 2007 and December 2010 were divided based on age (over or under 65 years) and intraoperative estimated blood loss (EBL) was compared. The mean EBL for the young age group was 93.37±102.16 mL compared to 100 ±61.24 mL for the older group. Operation times for the MI-TLIF procedure has decreased from 3-4 hours to approximately 2 hours throughout our experience with this technique. The MI-TLIF technique is a safe and effective procedure offering the advantages of less tissue damage, less blood loss, and reduced postoperative hospitalization over the open techniques.     

微创经椎间孔腰椎椎体间融合术与传统后路腰椎椎体间融合术并发症的比较分析

目的对比分析微创经椎间孔腰椎椎体间融合术（minimally invasive transforaminal lumbarinter bodyfusion,MIS．TLIF）与后路腰椎椎体间融合术（posterior lumbar interbody fusion,PLIF）的并发症,并探讨并发症发生原因和相关对策。方法回顾性分析本院2008年1月-2011年7月收治的215例下腰椎退变性疾病患者,其中110例行传统切开减压及PLIF,105例行MIS—TLIF,记录患者的手术时间、术中出血量、术后卧床时间、各种并发症发生率,并对结果进行统计学分析。结果随访12～30个月,平均16个月。MIS—TLIF组所有患者7人次（6．67％）出现并发症：硬膜囊破裂3例（2．86％）;神经损伤1例（0．95％）;切口浅部感染1例（0．95％）;椎间融合器下沉2例（1．90％）。PLIF组所有患者20人次（18．18％）出现并发症：硬膜囊破裂6例（5．45％）;神经损伤8例（7．27％）;切口感染3例（2．73％）;椎间融合器下沉2例（1．90％）;椎弓根螺钉松动l例（0．91％）。2组间神经损伤和总并发症发生率,MIS—TLIF组低于PLIF组,差异有统计学意义（P〈0．05）。结论MIS—TLIF治疗下腰椎退变性疾病安全、可靠,并发症发生率与传统PLIF手术相比减少。     

Influence of transforaminal lumbar interbody fusion procedures on spinal and pelvic parameters of sagittal balance

Introduction

Restitution of sagittal balance is important after lumbar fusion, because it improves fusion rate and may reduce the rate of adjacent segment disease. The purpose of the present study was to describe the impact of transforaminal lumbar interbody fusion (TLIF) procedures on pelvic and spinal parameters and sagittal balance.

Materials and methods

Forty-five patients who had single-level TLIF were included in this study. Pelvic and spinal radiological parameters of sagittal balance were measured preoperatively, postoperatively and at latest follow-up.

Results

Age at surgery averaged 58.4 (±9.6) years. Mean follow-up was 35.1 months (±4.1). Twenty-nine percent of the patients exhibited anterior imbalance preoperatively, with high pelvic tilt (17.6° ± 7.9°). Of the 32 (71%) patients well balanced before the procedure, 22 (70%) had a large pelvic tilt (>20°), due to retroversion of the pelvis as an adaptive response to the loss of lordosis. Three dural tears (7%) were reported intraoperatively. Interbody cages were more posterior than intended in 27% of the cases. Disc height and lumbar lordosis at fusion level significantly increased postoperatively (p < 0.05 and p < 0.001). Pelvic tilt was significantly reduced (p < 0.01) postoperatively, whereas the global sagittal balance was not significantly modified (p = 0.07).

Conclusion

Single-level circumferential fusion helps patients reducing their pelvic compensation, but the amount of correction does not allow for complete correction of sagittal imbalance.     

微创经椎间孔腰椎椎体间融合术的研究进展

腰椎融合是目前治疗腰椎退变性疾病、腰椎不稳及椎间盘源性等疾病的主要手段.经椎间孔腰椎间融合术(transforaminal lumbar interbody fusion,TLIF)是近年发展起来的新型的腰椎融合术,而随着微创脊柱外科(minimally invasive spinal surgery,MISS)的进步,微创TLIF技术也得到了快速的发展,相对传统开放TLIF又有了更进一步的优势.作者就微创TLIF的适应证与禁忌证,手术方式,发展与优势及微创手术辅助器械等方面的研究现状作一综述.     

微创经椎间孔腰椎体间融合术的围手术期并发症

目的:分析微创经椎间孔腰椎体间融合术(minimally invasive transforaminal lumbar interbody fusion,MIS-TLIF)的围手术期并发症发生情况。方法 :对2007年6月~2013年7月接受MIS-TLIF治疗的523例腰椎退变性疾病患者的临床资料进行回顾性分析。男231例,女292例,年龄53.1±8.4岁(31~83岁)。其中腰椎滑脱症194例,腰椎管狭窄症128例,腰椎不稳症62例,巨大腰椎间盘脱出症59例,腰椎术后复发52例(开放腰椎间盘切除术后复发26例,显微内窥镜下椎间盘切除术后复发17例,经皮内窥镜下椎间盘切除术后复发9例),退变性椎间盘病(degenerative disc disease,DDD)28例。围手术期并发症定义为手术后1个月内发生的与手术直接相关的并发症。持久并发症指手术导致新的损害术后持续大于30d无改善,短暂并发症指手术导致新的损害在术后30d内获得改善。统计分析并发症发生情况及原因。结果:本组523例平均随访47.5±8.2个月(24~81个月)。92例患者共计发生围手术期并发症96例次,其中持久并发症2例次,分别为1例因为椎弓根解剖结构畸形在螺钉置入时造成神经根损伤和1例操作失误导致出行神经根损伤,神经功能部分恢复。90例发生短暂性并发症94例次,其中最常见为下肢麻木不适,发生率为10.71%(56/523),发生硬膜撕裂21例,表浅感染9例,局部血肿4例,神经卡压2例,深部感染1例,植骨移位1例。88例患者发生单项并发症,4例发生2项并发症,围手术期并发症发生率为17.59%(92/523)。不同疾病并发症率分别为:腰椎滑脱症17.53%,腰椎管狭窄症17.19%,腰椎不稳14.52%,巨大腰椎间盘脱出13.56%,腰椎术后翻修30.77%,退变性椎间盘病10.71%。单节段融合并发症率(17.53%)和双节段融合并发症发生率(18.42%)统计学差异不显著(χ~2=0.02,P0.05)。结论 :MIS-TLIF围手术期并发症包括神经根损伤、硬膜撕裂、切口感染和短暂性下肢麻木等,短暂性下肢麻木是最常见并发症。     

再谈微创腰椎后路减压融合术

后路腰椎减压融合是目前临床上治疗腰椎病变的标准术式。考虑到国人椎管直径相对较小,临床实践中通常进行的后路融合是介于传统后路椎体间融合术（posterior lumbar interbody fusion,PLIF）和经椎间孔腰椎体间融合术（transforaminal lumbar interbody fusion,TLIF）之间的手术方式。近年来迅速发展的微创减压融合术[1],在腰椎病变治疗中获得了满意的临床效果[2]。     

显微镜下MI-TLIF与传统PLIF治疗腰椎退行性疾病的疗效比较

目的探讨显微镜下经椎间孔腰椎椎间融合、经皮椎弓根钉内固定治疗单节段腰椎退行性疾病的临床疗效。方法回顾性分析自2012-01—2013-09诊治的59例腰椎退行性疾病,采用显微镜下椎管减压、经椎间孔腰椎椎间融合联合经皮椎弓根内固定28例(MI-TLIF组),采用传统后路椎间融合内固定31例(PLIF组)。比较2组手术时间、术中出血量、术后引流量、术后1 d肌酸激酶水平,以及术后1年ODI指数、JOA评分及改良Macnab分级。结果所有患者术后均获得平均13(12~14)个月随访。与PLIF组相比,MI-TLIF组术中出血量、术后引流量更少,术后1 d肌酸激酶水平更低,差异有统计学意义(P0.05)。术后1年2组JOA评分、ODI指数比较差异无统计学意义(P0.05)。术后1年2组JOA评分改善率(χ~2=1.140,P=0.293)及Macnab优良率(χ~2=1.020,P=0.437)差异无统计学意义(P0.05)。结论显微镜下椎管减压、经椎间孔腰椎椎间融合、经皮椎弓根钉内固定是治疗单节段腰椎腰椎退行性疾病既安全有效又可达到微创的手术方式。该术式具有手术创伤小、出血量少、近期疗效满意的优点。     

Effect of posterior lumbar interbody fusion on the lumbar sagittal spinal profile

AIM: To determine the effect of different cage geometries and posterior instrumentation on the sagittal spinal profile after monosegmental lumbar interbody fusion. METHOD: The study is based on a retrospective analysis of 119 patients with segmental instability, who were surgically managed by monosegmental PLIF with PEEK-Cages and dorsal instrumentation. RESULTS: At radiographic follow-up after surgery we found a significant improvement of the lumbar sagittal spinal profile, independent of the cage geometry utilised. A marked discrepancy between 0 degrees -standard and 4 degrees -trapezoid implants concerning the radiographic parameters lumbar lordosis, disc height, correction of spondylolisthesis and sacral inclination was not found. With the use of 4 degrees optimised cages in segment L4/5 slightly better results for segmental lordosis were obtained. Reliability of the radiographic evaluation, expressed as intra-observer error, was satisfactory. Cage geometry did not have an effect on the clinical result. By combining interbody fusion with pedicular instrumentation the reposition of slipped vertebra and distraction of the interbody space could more effectively be achieved. Patients without dorsal instrumentation had a higher rate of pseudarthrosis as well as a less satisfactory clinical outcome. CONCLUSION: These results show that normal sagittal alignment after single-level lumbar fusion can be achieved with rectangular and 4 degrees -wedged cages. Although results after utilization of 4 degrees -wedged cages do not significantly differ, these implants offer the surgeon one more sizing variation with which physiological lumbar lordosis may be attained. The combination of intersomatic implants with dorsal instrumentation achieves a more precise realignment and has a lower rate of cage-associated complications. It therefore seems prudent that an interbody fusion for the surgical management of lumbar segmental instability should be combined with pedicular instrumentation.     

单侧微创经椎间孔腰椎椎体间融合内固定治疗腰椎退变性疾病

目的探讨采用单侧微创经椎间孔腰椎椎体间融合（minimally invasive transforaminal lumbar interbody fusion,MiTLIF）内固定治疗腰椎退变性疾病的临床效果。方法 2009年1月～2011年4月采用微创单侧椎弓根钉棒联合单Cage固定经椎间孔腰椎椎体间融合术治疗表现为单侧下肢神经根症状的腰椎退行性变患者36例,观察手术时间、术中出血量及并发症发生情况,影像学观察椎间隙高度及椎间融合情况,采用疼痛视觉模拟量表（visual analoguescale,VAS）评分和日本骨科学会（Japanese Orthopaedic Association,JOA）评分评估临床效果。结果 36例患者平均手术时间为90 min;术中平均出血量为150 mL。3例出现并发症,硬脊膜撕裂2例,术中予以修补,其中1例出现脑脊液漏,经对症处理术后6 d内脑脊液漏停止;1例术后出现神经缺失症状加重,通过及时血肿清除、神经根减压后损伤症状消失。所有患者平均随访18.6个月。末次随访矢状面X线片示椎间隙高度从术前（5.78±1.92）mm增至（10.35±1.21）mm,椎间融合率为94.4%。末次随访腰痛VAS评分及腰腿痛VAS评分与术前相比显著改善,差异有统计学意义（P〈0.01）,JOA改善率为84.4%。结论单侧MiTLIF内固定治疗腰椎退变性疾病对腰椎后部结构破坏小,术中出血少,椎间隙高度恢复满意,并发症发生率低,手术疗效好,是一种有效的治疗方法。     

Clinical outcomes after minimally invasive transforaminal lumbar interbody fusion and lateral lumbar interbody fusion for treatment of degenerative lumbar disease: a systematic review and meta-analysis

The surgical procedures used for arthrodesis in the lumbar spine for degenerative lumbar diseases remain controversial. This systematic review aims to assess and compare clinical outcomes along with the complications and fusion of each technique (minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) or minimally invasive lateral lumbar interbody fusion (MIS LLIF)) for treatment of degenerative lumbar diseases. Relevant studies were identified from Medline and Scopus from inception to July 19, 2016 that reported Oswestry Disability Index (ODI), back and leg pain visual analog score (VAS), postoperative complications, and fusion of either technique. Fifty-eight studies were included for the analysis of MIS-TLIF; 40 studies were included for analysis of LLIF, and 1 randomized controlled trial (RCT) study was included for comparison of MIS-TLIF to LLIF. Overall, there were 9506 patients (5728 in the MIS-TLIF group and 3778 in the LLIF group). Indirect meta-analysis, MIS-TLIF provided better postoperative back and leg pain (VAS), disabilities (ODI), and risk of having complications when compared to LLIF technique, but the fusion rate was not significantly different between the two techniques. However, direct meta-analysis between RCT study and pooled indirect meta-analysis of MIS-TLIF have better pain, disabilities, and complication but no statistically significant difference when compared to LLIF. In LLIF, the pooled mean ODI and VAS back pain were 2.91 (95% CI 2.49, 3.33) and 23.24 (95% CI 18.96, 27.51) in MIS approach whereas 3.14 (95% CI 2.29, 4.04) and 28.29 (95% CI 21.92, 34.67) in traditional approach. In terms of complications and fusion rate, there was no difference in both groups. In lumbar interbody fusion, MIS-TLIF had better ODI, VAS pain, and complication rate when compared to LLIF with direct and indirect meta-analysis methods. However, in terms of fusion rates, there were no differences between the two techniques.