Korge Andreas, Siepe Christoph, Mehren Christoph, Mayer H Michael
Wirbelsäulenzentrum, Schön Klinik München Harlaching, München, Germany.
Oper Orthop Traumatol. 2010 Nov;22(5-6):582-92. doi: 10.1007/s00064-010-8051-8.
Minimally invasive anterior preparation of the lumbosacral junction L5/S1 via a retro- or transperitoneal approach, possibility of intervertebral mono- or bisegmental rigid (cage, bone graft) or dynamic (disc arthroplasty) segmental stabilization.
Degenerative disc disease (DDD) with or without disc herniation. DDD with translatoric or frontal instability. Degenerative or isthmic spondylolisthesis. Adjacent segment degeneration post fusionem. Failed back surgery syndrome (post discectomy, non-union). Spinal stenosis with dynamic segmental instability. Spondylitis/spondylodiscitis.
Previous transperitoneal lumbar fusion surgery. Adipositas permagna. Relative: Previous abdominal or gynaecological surgery. Aorta bifurcation and/or venous confluens directly in front of the lumbosacral disc space. Inflammation with large prevertebral granulation tissue formation or psoas abscess. Diseases of the gastrointestinal tract.
Anterior horizontal or vertical midline incision over L5/S1. Retroperitoneal or transperitoneal approach via the left or right lower abdomen. Retroperitoneal technique: medialization of the peritoneal sack towards the contralateral side. Transperitoneal technique: mini laparatomy, dissection of the visceral and parietal peritoneum and mobilization of the bowels laterally. Preparation of the anterolateral circumference of the L5/S1 disc space and mobilization of the vessels laterally. Discectomy and preparation of graft bed.
Functional postoperative care with mobilisation without external support following total lumbar disc replacement; stable trunk brace for 12 weeks in the case of fusion surgeries; no restrictions for standing, walking or sitting.
Between January 2002 and December 2007, 454 patients (248 female, 206 male, average age 47.3 years, range between 15.4 years and 80.0 years,) underwent anterior surgery in the lumbosacral segment using a minimally invasive anterior approach. The spectrum of indications included monosegmental disc degeneration, spinal stenosis with segmental instability, isthmic oder degenerative spondylolisthesis, spondylodiscitis and others. Dynamic segmental support using total lumbar disc replacement was performed in 251 cases. Rigid stabilization with combined posterior internal fixation and anterior interbody fusion was performed in 203 cases (alternatively cage, tricortical iliac crest bone graft, bone substitutes such as hydroxyapatite or bone morphogenetic protein [BMP]). Approach-related, vascular complications occurred in 0.5 % (mainly left common iliac vein). Injuries of the gastrointestinal tract or urogenital tract (kidney, ureter, bladder) did not occur and there were no infections.
通过腹膜后或经腹途径对腰骶关节L5/S1进行微创前路准备，探讨椎间单节段或双节段刚性（椎间融合器、骨移植）或动态（椎间盘置换）节段稳定的可能性。
伴有或不伴有椎间盘突出的退行性椎间盘疾病（DDD）。伴有平移或额状面不稳定的DDD。退行性或峡部裂型腰椎滑脱。融合术后相邻节段退变。腰椎手术失败综合征（椎间盘切除术后、不愈合）。伴有动态节段不稳定的腰椎管狭窄症。脊柱炎/脊椎椎间盘炎。
既往经腹腰椎融合手术。过度肥胖。相对禁忌证：既往腹部或妇科手术。主动脉分叉和/或静脉汇合处直接位于腰骶椎间盘间隙前方。伴有大量椎体前肉芽组织形成或腰大肌脓肿的炎症。胃肠道疾病。
在L5/S1上方做前水平或垂直中线切口。经左或右下腹部行腹膜后或经腹途径。腹膜后技术：将腹膜袋向对侧移位。经腹技术：迷你剖腹术，分离脏腹膜和壁腹膜并将肠管向外侧游离。准备L5/S1椎间盘间隙的前外侧周缘并将血管向外侧游离。椎间盘切除并准备植骨床。
全腰椎间盘置换术后进行无需外部支撑的功能康复护理；融合手术患者佩戴稳定的躯干支具12周；站立、行走或坐姿无限制。
2002年1月至2007年12月，454例患者（女性248例，男性206例，平均年龄47.3岁，年龄范围15.4岁至80.0岁）采用微创前路对腰骶段进行前路手术。适应证范围包括单节段椎间盘退变、伴有节段不稳定的腰椎管狭窄症、峡部裂型或退行性腰椎滑脱、脊椎椎间盘炎等。251例行全腰椎间盘置换进行动态节段支撑。203例行后路内固定联合前路椎间融合进行刚性稳定（可选择椎间融合器、三面皮质髂嵴骨移植、羟基磷灰石或骨形态发生蛋白[BMP]等骨替代物）。与手术入路相关的血管并发症发生率为0.5%（主要为左髂总静脉）。未发生胃肠道或泌尿生殖道（肾脏、输尿管、膀胱）损伤，也无感染发生。
