Mehren Christoph, Korge Andreas, Siepe Christoph, Grochulla Frank, Mayer H Michael
Wirbelsäulenzentrum Starnberger See, Benedictus Krankenhaus Tuzting, Tutzing, Germany.
Oper Orthop Traumatol. 2010 Nov;22(5-6):573-81. doi: 10.1007/s00064-010-8053-6.
To describe a minimally invasive midline approach, retroperitoneal or transperitoneal, to the lumbar spinal levels L2-L5.
Degenerative disc disease (DDD) with or without disc herniation that may require a total lumbar disc replacement; also for fusion-cases like degenerative instability, tumors, isthmic and degenerative spondylolisthesis of all grades (after dorsal reduction), fractures, spondylodiscitis, failed back syndrome (pseudarthrosis, post-discectomy)
Relative contraindications are previous abdominal surgeries; aortic bifurcation and/or venous confluens directly in front of the disc space L4/5; infections with the formation of a large prevertebral granulation tissue or psoas abscess; adipositas permagna.
Anterior midline incision over the relevant disc space with a left retro- or transperitoneal approach. Transperitoneal approach: mini laparatomy with dissection of the peritoneum and mobilization of the bowels laterally; retroperitoneal mobilization of the peritoneal sac towards the contralateral side; preparation of the anterolateral circumference of the disc space and mobilization of adjacent vessels depending on the vessel anatomy; discectomy and preparation of the graft bed.
Early mobilisation from the first postoperative day for combined ALIF/posterior instrumentation procedures. Thromboembolic prophylaxis with fractioned heparin. Light meals up until recovery of bowel activities. No brace is needed for total lumbar disc replacement procedures. A brace is recommended depending on the type of intervention (fusion) for a duration of up to 12 weeks. No limitations for standing, walking or sitting in the immediate postoperative period.
A minimally invasive midline approach was performed in 686 patients (19-84 years; 94-320 pounds). In 444 cases the levels L2-L5 were exposed. The average time of exposure to these levels was 22.7 minutes. 6 months postoperatively the approach related complications were evaluated. A total of 3.8% major complications were observed overall.
描述一种经腹膜后或经腹腔的微创中线入路，用于L2-L5腰椎节段。
伴有或不伴有椎间盘突出的退行性椎间盘疾病（DDD），可能需要进行全腰椎间盘置换；也适用于融合病例，如退行性不稳定、肿瘤、各等级峡部裂性和退行性椎体滑脱（后路复位后）、骨折、脊椎椎间盘炎、失败的脊柱手术综合征（假关节、椎间盘切除术后）
相对禁忌症为既往腹部手术史；主动脉分叉和/或静脉汇合处直接位于L4/5椎间盘间隙前方；感染并形成大量椎体前肉芽组织或腰大肌脓肿；重度肥胖。
在相关椎间盘间隙上方做前正中切口，采用左侧经腹膜后或经腹腔入路。经腹腔入路：迷你剖腹术，分离腹膜并将肠管向外侧游离；将腹膜囊向对侧进行腹膜后游离；根据血管解剖情况，准备椎间盘间隙的前外侧周缘并游离相邻血管；椎间盘切除术及植骨床准备。
对于联合前路腰椎椎间融合术/后路内固定手术，术后第一天即可早期活动。使用低分子肝素进行血栓栓塞预防。在肠道活动恢复前给予清淡饮食。全腰椎间盘置换手术无需使用支具。根据干预类型（融合），建议使用支具，持续时间最长为12周。术后即刻对站立、行走或坐姿无限制。
对686例患者（年龄19-84岁；体重94-320磅）实施了微创中线入路。其中444例暴露了L2-L5节段。暴露这些节段的平均时间为22.7分钟。术后6个月评估与入路相关的并发症。总体共观察到3.8%的严重并发症。
