两种经皮脊柱内镜术式治疗腰椎管狭窄症的并发症分析

目的统计经椎间孔入路与经后路脊柱内镜减压术式(percutaneous spinal endoscopic decompression,PSED)治疗腰椎管狭窄症的并发症,分析原因并探讨其防治策略。 方法选取2014年6月至2016年5月解放军总医院单一脊柱外科日间手术中心行PSED治疗的276例(男147例、女129例)腰椎管狭窄症患者为研究对象,其中经椎间孔入路脊柱内镜减压术(transforaminal percutaneous spinal endoscopic decompression,t－PSED)治疗193例(A组),经后方入路脊柱内镜环神经减压术(posterior approach percutaneous spinal endoscopic decompression, p－PSED)治疗83例(B组),统计两组的并发症情况并比较其发生率,分析并发症原因,探讨其防治策略。 结果共15例(5.4%,A组8例、B组7例)患者发生并发症,其中包括硬脊膜破裂3例(A组1例、B组2例),均术毕严密缝合切口后愈合;不完全性神经损伤3例(A组1例、B组2例),对症治疗后6个月内症状缓解;术中严重出血2例及术后血肿形成1例(A组),加压包扎后控制并愈合;术中类脊髓高压综合征2例(B组),经调整冲洗液灌注压及短暂停歇手术后,症状缓解并得以最终完成手术;减压不彻底4例(A组3例、B组1例),仅1例行PSED返修术。无死亡,无截瘫、感染等严重并发症发生。 结论相比p－PSED术式,t－PSED术式的整体并发症发生率相似,但类脊髓高压综合征明显低于前者。术前明确诊断、精准评估并严格把握适应证,术中精细操作、仔细止血、彻底减压可以有效减少并发症的发生。另外,术中及术后的合理处理可有效控制或阻止并发症进一步恶化。     

经皮全脊柱内镜技术在脊柱疾病的应用进展

<正>近年来,经皮全脊柱内镜技术因具有微创、高效等特点,逐渐被脊柱外科医生学习采用,同时更多地受到了广大患者的关注,其适应证也逐步扩大。2010年在美国脊柱内镜手术占所有脊柱手术总数的1/6,到了2016年则是1/3,预计2020年可以达到1/2[1]。而在我国,2016年脊柱内镜     

脊柱内镜技术治疗颈椎疾病的研究进展

脊柱微创手术(MISS)具有创伤小、术后恢复快等优点,而脊柱内镜技术是脊柱微创手术的研究热点.本文主要综述两种内镜方式包括经鼻神经内镜治疗颅颈交界区病变和经皮颈椎内镜治疗颈椎疾病.这两种内镜方式都有着较好的疗效,其中经皮颈椎内镜更是目前骨科常见的手术方式之一,后路经椎板间入路、前路经椎间隙入路和前路经椎体入路也都有不同...     

微创脊柱外科手术相关并发症及其对策

外科内窥镜时代始于20世纪70年代末～80年代初引入的电视辅助下内窥镜技术，关节镜技术、腹腔镜技术、胸腔镜以及椎间盘镜等微创技术逐渐展露其优越性，并且已在部分疾病上取代了开放技术。然而因为微创脊柱外科对术者要求较高，要熟练掌握微创技术需要艰苦的训练以及漫长的过程，并且手术存在着一些并发症，使得人们对其的热情有所减弱。现就微创脊柱外科术中及术后可能发生的并发症及其对策作一综述，希望能有助于我们更加深入地了解脊柱微创技术。     

双通道脊柱内镜技术治疗腰椎管狭窄症

老龄化社会的到来,腰椎管狭窄症(LSS )成为脊柱外科最常见的疾病之一.随着脊柱微创理念逐渐深入,多种微创技术可以用于LSS 的治疗.双通道脊柱内镜(UBE/BESS)技术近年来成为LSS治疗的有力技术手段.我们就该技术在LSS 中的相关问题回顾文献、并谈谈自己的体会.     

内窥镜技术在脊柱手术中的并发症及其对策

微创脊柱外科(mini mally invasive surgery of spine,MISS)近年来逐渐展露其优越性,在部分疾病上取代了开放手术,而内窥镜技术在微创脊柱外科中又占有极其重要的地位。然而因其对器械及术者要求较高,并且存在着一些并发症,因此尚未广泛开展。现就部分内窥镜技术在脊柱微创手术     

微创脊柱内镜技术的发展现状与展望

微创脊柱内镜技术是指在透视或导航的辅助下置入管道,在内镜直视下进行的手术操作。对脊柱结构的损伤较小,术中视野清晰、直观,可以很好地治疗各型椎间盘突出、椎管狭窄及椎体滑脱等。但由于内镜技术的手术技巧较难掌握,加上脊柱解剖结构的相对复杂性,使该技术的普及受到一定的限制。目前用于脊柱手术的内镜技术主要包括腹腔镜技术、胸腔镜技术及脊柱内镜技术等,本文针对上述内镜技术在微创脊柱手术中的发展现状及展望进行归纳和评述。     

微创技术在脊柱外科的应用

微创外科(Mininlally Invasive Surgery MIS)通常是指在影像系统帮助下通过管道化技术进行的外科手术。本就胸腔镜、腹腔镜、椎间盘镜和椎体成形术等微创技术在脊柱各部位的应用分别进行综述,证明了手术的安全可行性和可以提高疗效、减少花费。今后随着更多长期的临床报道结果和更多更客观的实验室检查结果的证实和可视器材的不断更新,将使得更多的脊柱手术不仅是传统的减压和切除手术,也包括重建和融合手术可以通过微创途径获得解决。     

第二届全国微创脊柱外科学术会议暨2007(长沙)国际内镜脊柱外科技术高峰论坛纪要

2007年6月15日～17日，由中国康复医学会脊柱脊髓损伤专业委员会微创脊柱外科学组、《中国脊柱脊髓杂志》编辑部主办，中南大学湘雅二医院承办的第二届全国微创脊柱外科学术会议暨2007（长沙）国际内镜脊柱外科技术高峰论坛在湖南省长沙市召开。来自国内29个省、市、自治区、香港特别行政区及美国、德国、比利时、意大利、日本、新加坡、韩国、印度尼西亚等国的630余名专家和代表参加了本次会议。     

V形双通道脊柱内镜系统辅助下腰椎椎间融合术治疗单节段腰椎疾病的疗效分析

【摘要】 目的：探讨V形双通道脊柱内镜（VBE）系统辅助下经椎间孔入路腰椎椎间融合手术（VBE-TLIF）的初步临床应用效果。方法：回顾性分析2020年1月~2021年4月,因单节段腰椎疾病于我院接受VBE-TLIF手术治疗的20例患者的临床资料。其中男性13例,女性7例,年龄28~77岁,平均57.0±11.7岁。记录手术时间及并发症发生情况,于术前及术后3d、3个月、6个月、12个月、18个月时评估患者腰腿痛视觉模拟评分（visual analogue scale,VAS）、Oswestry功能障碍指数（Oswestry disability index,ODI）,评估症状缓解情况。分析末次随访时改良MacNab评分、影像学资料等,评估手术优良率及融合率。结果：20例患者术后平均随访27.0±3.6个月（24～36个月）,症状均得到明显改善。患者平均术前下肢痛VAS评分6.3±1.6分,腰痛VAS评分5.7±1.1分;术后3d下肢痛VAS评分1.9±0.9分,腰痛VAS评分2.3±0.8分;术后18个月下肢痛VAS评分0.7±0.6分,腰痛VAS评分0.9±0.7分,疼痛明显改善,差异有统计学意义（P＜0.05）。术后18个月ODI为（15.0±5.8）％,较术前[（60.2±15.3）％]明显改善,差异有统计学意义（P＜0.05）。术后出现屈髋乏力1例,经对症治疗1个月后改善;1例出现融合器移位伴神经根激惹症状,二次手术翻修,融合率为95%（19/20）;无严重手术相关并发症出现,根据改良MacNab标准,优良率达95%。结论：VBE-TLIF是安全有效的腰椎微创融合技术方法,初步临床应用效果较为满意。     

减少胰十二指肠切除术后并发症的经验体会(附62例报告)

目的 回顾胰十二指肠切除术后并发症治疗的经验体会,分析并发症发生的原因,探讨减少并发症发生的治疗措施.方法 回顾性分析北京军区总医院肝胆外科2001年3月-2011年4月行胰十二指肠切除术的患者62例,其中男41例,女21例.年龄为42～76岁,平均(59.3±4.1)岁.分为早期组24例和近期组38例,分别从围手术期处理、胰肠吻合方式与材料的选择、胃肠吻合的方式的选择、术野创面血管的处理、防止吻合口漏及创面出血材料的使用等方面总结不同时期使用不同处理方法的效果,并比较两组术后胰漏、出血、腹腔感染、胃潴留、术后胆道感染、肝脓肿及切口感染7项术后并症的发生情况.结果 早期组:胰漏10例,出血4例,腹腔感染10例,胃潴留9例,术后胆道感染11例,术后肝脓肿6例,切口感染7例.近期组分别为4、0、0、1、2、0和3例.两组比较近期组术后的并发症有明显下降,近期组较早期组7项指标差异均有统计学意义.结论 胰十二指肠切除术创伤大,并发症严重,重视微创理念和优质材料的应用,加强围手术期的管理是降低术后并发症的有效措施.     

胸椎管狭窄症术后并发症的防治

目的探讨胸椎管狭窄症术后并发症的发生与防治。方法1985年1月至2005年1月手术治疗283例胸椎管狭窄症患者。胸椎黄韧带骨化症123例、胸椎后纵韧带骨化症73例、胸椎间盘突出症54例、弥漫性原发性骨肥厚症19例、椎体后缘骨内软骨结节14例。1996年以前均采用后入路,枪式咬骨钳切除椎板,咬除骨化的黄韧带或关节突的内1/2,为原始方法;1996年后,椎间盘突出或合并后纵韧带骨化、椎体后缘骨内软骨结节者采用经胸腔入路。黄韧带骨化、弥漫性原发性骨肥厚,采用后入路,应用磨钻加"揭盖法"切除椎板,在神经剥离子的保护下,应用骨凿切除关节突的内1/2,为改进方法。分别观察两组围手术期、中远期和供骨区并发症发生情况,并进行对比。结果随访254例,随访时间1~19年,平均6年2个月。并发症发生率42.1%,原始方法(65.2%)明显高于改进方法(23.2%)。各种并发症中脊髓损伤和硬脊膜损伤的发生率两组差异有统计学意义(P<0.05)。结论脊髓损伤导致症状加重是灾难性的并发症。采用改进方法手术治疗胸椎管狭窄症可减少并发症的发生。     

经皮脊柱内镜治疗退变性腰椎管狭窄症的现状及进展

经皮脊柱内镜减压术(percutaneous spinal endoscopic decompression,PSED)近些年在治疗退变性腰椎管狭窄(degenerative lumbar spinal stenosis,DLSS)中取得了良好的效果。相对于传统的开放手术创伤大、出血多、术后患者需较长时间卧床,恢复慢,PSED技术的迅速发展,很大程度上减少了DLSS患者的手术创伤、术后恢复时间和并发症。以PSED核心为靶点的治疗方法,以最小的创伤同时达到满意的腰椎管狭窄症的减压效果。根据腰椎管狭窄的位置和程度,确定理想的治疗方法至关重要。然而,在实践中,存在PSED对不同病理类型腰椎管狭窄症的治疗认识不足,如适应证选择、手术入路选择、各种入路的优缺点、内镜下椎体融合等问题。目前随着人们对PSED研究的深入及内镜器械的改进,在治疗DLSS方面取得了较大进展。本文将从适应证的把握、入路途径的选择、内镜入路的优劣点以及内镜辅助下椎体融合4个方面阐述PSED治疗DLSS的研究进展,以期为PSED临床治疗DLSS提供一定的指导。     

后路经椎弓根截骨治疗脊柱畸形围手术期并发症分析

 目的 分析后路经椎弓根楔形截骨及全脊椎截骨治疗脊柱严重畸形的围手术期并发症。方法 2007年1月至2011年12月,采用后路经椎弓根截骨治疗73例脊柱畸形患者,其中发生至少一种围手术期并发症患者30例,男8例,女22例;年龄8~68岁,平均40.7岁。脊柱畸形包括侧凸10例,侧后凸9例,后凸11例。其中行经椎弓根全脊椎截骨22例,经椎弓根楔形截骨8例。对该30例患者发生的各种围手术期并发症临床资料进行回顾性分析。结果 除1例患者术后死于失血导致的失血性休克外,29例患者获得门诊随访,随访时间6~61个月,平均17.2个月。30例(36例次)患者发生围手术期并发症,占同期接受该类手术患者总数的41.1%(30/73)。其中发生神经系统并发症16例(16/73,21.9%),包括严重神经功能障碍5例(5/73,6.8%),一过性神经功能障碍11例(11/73,15%);术后失血相关严重并发症2例(2/73,2.7%),包括出血致失血性休克死亡1例(1/73,1.4%),血肿1例(1/73,1.4%);硬膜损伤6例(6/73,8.2%),术后脑脊液漏4例(4/73,5.5%);切口感染4例(4/73,5.5%);术后胸腔积液4例(4/73,5.5%)。结论 后路经椎弓根截骨是治疗脊柱畸形的有效手术方法,但常伴发神经损伤、出血、硬膜损伤、切口感染、胸腔积液等一系列并发症,其中神经功能并发症和出血是最主要的并发症。     

稳妥开展腰椎微创融合技术以减少手术并发症

<正>腰椎融合术目前已成为一种成熟的手术治疗策略,适用于多种脊柱疾病,包括腰椎退行性疾病、腰椎骨折脱位、腰椎肿瘤、腰椎感染和需要矫形的腰椎畸形等。腰椎传统开放融合手术常常由于大范围的肌肉剥离导致腰椎后方肌肉萎缩,出现腰椎术后失败综合征,术后患者腰痛明显。随着医疗水平的不断提高和医疗器械的发展,腰椎融合技术逐渐由开放手术向微创手术方向转变。通过最小组织损伤途径,     

Arthrodèse circonférentielle par voie mini-invasive dans la prise en charge des lésions rachidiennes thoracolombaires cyphosantes : note technique

IntroductionManagement of spinal kyphotic deformities remains challenging in order to achieve a complete correction of the deformity, stabilize the spine and restore a satisfactory sagittal alignment. The aim of this study was to report the results of a technique combining, during the same operative session: a percutaneous osteosynthesis (with or without decompression) and a minimal invasive corpectomy using an anterior approach.MethodsTwelve patients (mean age 54 years old) were included in this single center retrospective study. Kyphotic deformity was related to a trauma in 9 cases, to a tumor in 2 cases and was infectious in the last case. The level involved was L1 in 7 cases, T12 in 3 cases, T10 and L4 in 1 case each. First step of the surgical strategy was a routine posterior percutaneous osteosynthesis. In 5 cases, a complementary minimal invasive decompression was performed using tubular retractors. During the second step, an anterior corpectomy was performed and the vertebral reconstruction was done using telescopic vertebral body prosthesis. Once the last correction was achieved, final locking of the posterior instrumentation was performed.ResultsIn the entire series, a short construct was done in 2 cases and a long construct was decided for the 10 other cases depending on the lesion. Mean surgical time was 246 min [173–375] and postoperative blood transfusion was not necessary. Patients were discharged from the hospital on average at day 8 [4–25] according to associated lesions. Based on radiographic analyses, a significant restoration of the vertebral kyphosis (average 17°, P < 0.001) and vertebral body height (27% on average, P < 0.001) were obtained.ConclusionCombination of these two minimal invasive techniques allows a circumferential spinal fixation with a low rate of complications and a satisfactory restoration of local sagittal deformity. This strategy is, in our experience, a valuable alternative to conventional techniques. Further studies with a longer follow-up will therefore needed in order to confirm these results.     

Anatomy of the psoas muscle and lumbar plexus with respect to the surgical approach for lateral transpsoas interbody fusion

Lateral transpsoas interbody fusion (LTIF) is a minimally invasive technique that permits interbody fusion utilizing cages placed via a direct lateral retroperitoneal approach. We sought to describe the locations of relevant neurovascular structures based on MRI with respect to this novel surgical approach. We retrospectively reviewed consecutive lumbosacral spine MRI scans in 43 skeletally mature adults. MRI scans were independently reviewed by two readers to identify the location of the psoas muscle, lumbar plexus, femoral nerve, inferior vena cava and right iliac vein. Structures potentially at risk for injury were identified by: a distance from the anterior aspect of the adjacent vertebral bodies of <20 mm, representing the minimum retraction necessary for cage placement, and extension of vascular structures posterior to the anterior vertebral body, requiring anterior retraction. The percentage of patients with neurovascular structures at risk for left-sided approaches was 2.3% at L1–2, 7.0% at L2–3, 4.7% at L3–4 and 20.9% at L4–5. For right-sided approaches, this rose to 7.0% at L1–2, 7.0% at L2–3, 9.3% at L3–4 and 44.2% at L4–5, largely because of the relatively posterior right-sided vasculature. A relationship between the position of psoas muscle and lumbar plexus is described which allows use of the psoas position as a proxy for lumbar plexus position to identify patients who may be at risk, particularly at the L4–5 level. Further study will establish the clinical relevance of these measurements and the ability of neurovascular structures to be retracted without significant injury.     

Perioperative complications related to minimally invasive transforaminal lumbar fusion: evaluation of 204 operations on lumbar instability at single center

Background contextMinimally invasive transforaminal lumbar fusion (MIS-TLIF) has demonstrated efficacy in the treatment of lumbar degenerative diseases. The reported incidence of perioperative complications associated with MIS-TLIF surgery is highly variable. Studies concerning perioperative complications in broad patient populations are quite rare. This study analyzes a retrospectively collected database of patients who underwent an MIS-TLIF surgery at a single center.PurposeTo determine the incidence of perioperaive complications with MIS-TLIF procedure based on our definition of Type I and II perioperative complications.Study designRetrospective cohort study; a review of complications.Patient sampleThe sample comprises 204 patients who underwent MIS-TLIF for the treatment of lumbar degenerative diseases.Outcome measuresType I complication including all medical adverse events without direct connection to the specific surgical procedure performed. Type II complication including adverse events with direct connection to the surgical procedure performed.MethodsA total of 204 MIS-TLIF surgeries on lumbar instability or spondylolisthesis, performed between June 2007 and July 2012, were examined in a retrospective study. A complication classification based on the relation to the surgical procedure and the effect duration was used. Perioperative complications until 1 month postoperatively were reviewed for the patients.ResultsThe study group comprised 204 patients (106 women, 98 men; mean age at surgery, 52.4 years; age range, 39–84 years). Overall, there were 75 perioperative complications in 204 patients (36.76%). Only one complication occurred in 54 patients. Nine patients had two complications. One patient had three complications. The incidence of perioperative complication was 31.37% (64/204 patients) in the MIS-TLIF operations. Of all complications, seven (9.33%) were classified as persistent complications and 68 (90.67%) were classified as transient complications. The incidence of Type I and II complications were 13.73% and 23.04%, respectively.ConclusionsMinimally invasive transforaminal lumbar fusion has gained popularity as a procedure for the treatment of lumbar instability or spondylolisthesis, with similar complications as in the open surgery. Transient sensory disturbance was the most common complication in this series.