Department of Neurosurgery, University of Cincinnati (UC) College of Medicine, Cincinnati, Ohio, USA; UC Neuroscience Institute, Cincinnati, Ohio, USA; Mayfield Clinic, Cincinnati, Ohio, USA.
World Neurosurg. 2013 Sep-Oct;80(3-4):428-35. doi: 10.1016/j.wneu.2012.09.005. Epub 2012 Sep 23.
With increasing popularity of percutaneous spinal access for minimally invasive spinal neurosurgery, the treatment paradigm has shifted from open approaches to vertebroplasty or kyphoplasty for degenerative spinal disease and vertebral compression fractures. Addressing the challenges of this shift, we integrate the fluoroscopic studies of these percutaneous approaches with the three-dimensional surgical anatomy. Step-by-step techniques are illustrated in video demonstrations that highlight the nuances of effective percutaneous access during spinal surgeries for vertebral compression fractures and pedicle screw fixation.
Imaging guidelines, approach planning, surgical techniques, and relevant anatomical features are noted for the transpedicular, lumbar extrapedicular, and thoracic extra- and infrapedicular approaches. Video clips and accompanying fluoroscopic images highlight the critical steps. Subtle refinements unique to each percutaneous access are presented related to skin incision, needle trajectory, and cement deposition.
With the transpedicular approach (popular technique for vertebroplasty and pedicle screw placement), safe access requires accurate interpretation of the fluoroscopic anatomy, specifically identification of the target vertebral body in true anterior-posterior and lateral planes. The transpedicular trajectory uses the slight inferior and medial orientation of the pedicle followed anteriorly. The lumbar extrapedicular approach uses an oblique trajectory anterior to the transverse process at the level of the pedicles. A thoracic approach uses the potential space between the rib head, transverse process, and pedicle. The infrapedicular approach, which allows greater flexibility in its medial angulation but at the expense of the bony confines of the thoracic extrapedicular approach, takes advantage of the narrow-waisted thoracic laminae.
With an appreciation for the standard anatomical landmarks, fluoroscopic views, and avenues of approach, percutaneous access techniques can be safely and effectively applied to many spinal procedures.
随着经皮脊柱通道微创脊柱神经外科的日益普及，治疗模式已从开放方法转向骨水泥成形术或球囊扩张椎体后凸成形术治疗退行性脊柱疾病和椎体压缩性骨折。为应对这一转变带来的挑战，我们将这些经皮入路的透视研究与三维手术解剖相结合。通过视频演示逐步介绍技术，突出在脊柱压缩性骨折和椎弓根螺钉固定的脊柱手术中进行有效经皮入路的细微差别。
记录经椎弓根、腰椎额外经椎弓根、胸椎额外和下经椎弓根途径的影像学指南、入路规划、手术技术和相关解剖特征。视频剪辑和伴随的透视图像突出了关键步骤。与皮肤切口、针轨迹和骨水泥沉积相关的，每个经皮入路特有的细微改进也被呈现出来。
经椎弓根入路（骨水泥成形术和椎弓根螺钉放置的常用技术）需要准确解读透视解剖，特别是在真正的前后位和侧位平面上识别目标椎体，以确保安全入路。经椎弓根的轨迹利用了椎弓根的轻微下内侧朝向，向前延伸。腰椎额外经椎弓根途径采用在椎弓根水平横突前的斜向轨迹。胸椎途径利用肋骨头、横突和椎弓根之间的潜在空间。经下椎弓根入路允许在其内侧角度上有更大的灵活性，但代价是丧失了胸椎额外经椎弓根入路的骨性限制，利用了狭窄的胸椎椎板。
通过了解标准解剖学标志、透视视图和入路途径，经皮入路技术可以安全有效地应用于许多脊柱手术。
