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微创脊柱手术的现状

The current state of minimally invasive spine surgery.

作者信息

Kim Choll W, Siemionow Krzysztof, Anderson D Greg, Phillips Frank M

机构信息

Spine Institute of San Diego, San Diego, CA, USA.

出版信息

Instr Course Lect. 2011;60:353-70.

Abstract

Minimally invasive surgery for spinal disorders is predicated on the following basic principles: (1) avoid muscle crush injury by self-retaining retractors; (2) do not disrupt tendon attachment sites of key muscles, particularly the origin of the multifidus muscle at the spinous process; (3) use known anatomic neurovascular and muscle compartment planes; and (4) minimize collateral soft-tissue injury by limiting the width of the surgical corridor. The traditional midline posterior approach for lumbar decompression and fusion violates these key principles of minimally invasive surgery. The tendon origin of the multifidus muscle is detached, the surgical corridor is exceedingly wide, and significant muscle crush injury occurs with the use of powerful self-retaining retractors. The combination of these factors leads to well-described changes in muscle physiology and function. Minimally invasive posterior lumbar surgery is performed with table-mounted tubular retractors that focus the surgical dissection to a narrow corridor directly over the surgical target site. The path of the surgical corridor is chosen based on anatomic planes, specifically avoiding injury to the musculotendinous complex and the neurovascular bundle. With these relatively simple modifications in the minimally invasive surgical technique, significant improvements have been achieved in intraoperative blood loss, postoperative pain, and surgical morbidity. However, minimally invasive surgical techniques remains technically demanding, and a significant complication rate has been reported during a surgeon's initial learning curve for the procedures. Improvements in surgeon training along with long-term prospective studies will be needed for advancements in this area of spine surgery.

摘要

脊柱疾病的微创手术基于以下基本原则

(1)使用自持牵开器避免肌肉挤压伤;(2)不破坏关键肌肉的肌腱附着点,尤其是多裂肌在棘突处的起点;(3)利用已知的解剖神经血管和肌肉间隙平面;(4)通过限制手术通道的宽度将软组织的附带损伤降至最低。传统的腰椎减压融合术的中线后路入路违背了这些微创手术的关键原则。多裂肌的肌腱起点被分离,手术通道极宽,并且使用强力自持牵开器会造成严重的肌肉挤压伤。这些因素共同导致了肌肉生理和功能方面广为人知的变化。微创腰椎后路手术使用安装在手术台上的管状牵开器,将手术剥离集中在手术目标部位正上方的狭窄通道内。手术通道的路径根据解剖平面选择,特别要避免损伤肌腱复合体和神经血管束。通过对微创手术技术进行这些相对简单的改进,术中出血量、术后疼痛和手术发病率都有了显著改善。然而,微创外科技术在技术上仍然要求很高,并且在外科医生学习这些手术的初始阶段,据报道并发症发生率很高。脊柱外科这一领域的进展需要外科医生培训方面的改进以及长期的前瞻性研究。

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