Wagner Willis H, Regan John J, Leary Scott P, Lanman Todd H, Johnson J Patrick, Rao Rajeev K, Cossman David V
Division of Vascular Surgery, Cedars-Sinai Medical Center and Century City Doctors Hospital, Los Angeles, CA 90048, USA.
J Vasc Surg. 2006 Dec;44(6):1266-72. doi: 10.1016/j.jvs.2006.07.046.
Several lumbar disc prostheses are being developed with the goal of preserving mobility in patients with degenerative disc disease. The disadvantage of lumbar artificial disc replacement (ADR) compared with anterior interbody fusion (ALIF) is the increased potential for displacement or component failure. Revision or removal of the device is complicated by adherence of the aorta, iliac vessels, and the ureter to the operative site. Because of these risks of anterior lumbar procedures, vascular surgeons usually provide access to the spine. We report our experience with secondary exposure of the lumbar spine for revision or explantation of the Charité disc prosthesis.
Between January 2001 and May 2006, 19 patients with prior implantation of Charité Artificial Discs required 21 operations for repositioning or removal of the device. Two patients had staged removal of prostheses at two levels. One patient had simultaneous explantation at two levels. The mean age was 49 years (range, 31 to 69 years; 56% men, 42% women). The initial ADR was performed at our institution in 14 patients (74%). The mean time from implantation to reoperation was 7 months (range, 9 days to 4 years). The levels of failure were L3-4 in one, L4-5 in nine, and L5-S1 in 12.
The ADR was successfully removed or revised in all patients that underwent reoperation. Three of the 12 procedures at L5-S1 were performed through the same retroperitoneal approach as the initial access. One of these three, performed after a 3-week interval, was converted to a transperitoneal approach because of adhesions. The rest of the L5-S1 prostheses were exposed from a contralateral retroperitoneal approach. Four of the L4-5 prostheses were accessed from the original approach and five from a lateral, transpsoas exposure (four left, one right). The only explantation at L3-4 was from a left lateral transpsoas approach. Nineteen of the 22 ADR were converted to ALIF. Two revisions at L5-S1 involved replacement of the entire prosthesis. One revision at L4-5 required only repositioning of an endplate. Access-related complications included, in one patient each, iliac vein injury, temporary retrograde ejaculation, small-bowel obstruction requiring lysis, and symptomatic, large retroperitoneal lymphocele. There were no permanent neurologic deficits, deep vein thromboses, or deaths.
Owing to vascular and ureteral fixation, anterior exposure of the lumbar spine for revision or explantation of the Charité disc replacement should be performed through an alternative approach unless the procedure is performed < or = 2 weeks of the index procedure. The L5-S1 level can be accessed through the contralateral retroperitoneum. Reoperation at L3-4 and L4-5 usually requires explantation and fusion that is best accomplished by way of a lateral transpsoas exposure.
目前正在研发多种腰椎间盘假体，旨在保留退行性椎间盘疾病患者的活动能力。与前路椎体间融合术（ALIF）相比，腰椎人工椎间盘置换术（ADR）的缺点是移位或假体失败的可能性增加。由于主动脉、髂血管和输尿管与手术部位粘连，对该装置进行翻修或取出会变得复杂。鉴于前路腰椎手术存在这些风险，血管外科医生通常负责脊柱的入路操作。我们报告了我们在对Charité椎间盘假体进行翻修或取出时再次显露腰椎的经验。
在2001年1月至2006年5月期间，19例先前植入Charité人工椎间盘的患者因重新定位或取出该装置而需要进行21次手术。2例患者分阶段在两个节段取出假体。1例患者同时在两个节段取出假体。平均年龄为49岁（范围31至69岁；男性占56%，女性占42%）。14例患者（74%）的初次ADR手术在我们机构进行。从植入到再次手术的平均时间为7个月（范围9天至4年）。失败节段为L3 - 4节段1例，L4 - 5节段9例，L5 - S1节段12例。
所有接受再次手术的患者的ADR均成功取出或翻修。L5 - S1节段的12例手术中有3例通过与初次入路相同的腹膜后入路进行。这3例中的1例在间隔3周后进行手术，因粘连而改为经腹入路。其余L5 - S1节段的假体通过对侧腹膜后入路显露。L4 - 5节段的4例假体通过原入路取出，5例通过经腰大肌外侧入路取出（4例左侧，1例右侧）。L3 - 4节段唯一的取出手术通过左侧腰大肌外侧入路进行。22例ADR中有19例改为ALIF手术。L5 - S1节段的2例翻修手术涉及更换整个假体。L4 - 5节段的1例翻修手术仅需重新定位终板。与入路相关的并发症包括，各有1例患者出现髂静脉损伤、暂时性逆行射精、需要松解的小肠梗阻以及有症状的巨大腹膜后淋巴囊肿。未出现永久性神经功能缺损、深静脉血栓形成或死亡病例。
由于血管和输尿管的固定，除非手术在初次手术≤2周内进行，否则应通过替代入路对腰椎进行前路显露，以对Charité椎间盘置换进行翻修或取出。L5 - S1节段可通过对侧腹膜后入路进入。L3 - 4和L4 - 5节段的再次手术通常需要取出并融合，最好通过经腰大肌外侧入路完成。
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