经椎间孔腰椎体间融合术中的椎间盘间隙准备：微创与开放入路的比较。
Disc space preparation in transforaminal lumbar interbody fusion: a comparison of minimally invasive and open approaches.
机构信息
Department of Orthopaedic Surgery, Thomas Jefferson University Hospital, The Rothman Institute, 925 Chestnut Street, 5th Floor, Philadelphia, PA, 19107, USA,
出版信息
Clin Orthop Relat Res. 2014 Jun;472(6):1800-5. doi: 10.1007/s11999-014-3479-z.
BACKGROUND
Minimally invasive surgical (MIS) approaches to transforaminal lumbar interbody fusion (TLIF) have been developed as an alternative to the open approach. However, concerns remain regarding the adequacy of disc space preparation that can be achieved through a minimally invasive approach to TLIF.
QUESTIONS/PURPOSES: The purpose of this cadaver study is to compare the adequacy of disc space preparation through MIS and open approaches to TLIF. Specifically we sought to compare the two approaches with respect to (1) the time required to perform a discectomy and the number of endplate violations; (2) the percentage of disc removed; and (3) the anatomic location where residual disc would remain after discectomy.
METHODS
Forty lumbar levels (ie, L1-2 to L5-S1 in eight fresh cadaver specimens) were randomly assigned to open and MIS groups. Both surgeons were fellowship-trained spine surgeons proficient in the assigned approach used. Time required for discectomy, endplate violations, and percentage of disc removed by volume and mass were recorded for each level. A digital imaging software program (ImageJ; US National Institutes of Health, Bethesda, MD, USA) was used to measure the percent disc removed by area for the total disc and for each quadrant of the endplate.
RESULTS
The open approach was associated with a shorter discectomy time (9 versus 12 minutes, p = 0.01) and fewer endplate violations (one versus three, p = 0.04) when compared with an MIS approach, percent disc removed by volume (80% versus 77%, p = 0.41), percent disc removed by mass (77% versus 75%, p = 0.55), and percent total disc removed by area (73% versus 71%, p = 0.63) between the open and MIS approaches, respectively. The posterior contralateral quadrant was associated with the lowest percent of disc removed compared with the other three quadrants in both open and MIS groups (50% and 60%, respectively).
CONCLUSIONS
When performed by a surgeon experienced with MIS TLIF, MIS and open approaches are similar in regard to the adequacy of disc space preparation. The least amount of disc by percentage is removed from the posterior contralateral quadrant regardless of the approach; surgeons should pay particular attention to this anatomic location during the discectomy portion of the procedure to minimize the likelihood of pseudarthrosis.
背景
经皮椎间孔入路腰椎间融合术（TLIF）作为一种微创外科手术方式，已成为开放手术的替代方法。然而，对于通过微创入路进行 TLIF 时能否充分准备椎间盘间隙仍存在一些顾虑。
问题/目的：本尸体研究的目的是比较微创和开放 TLIF 方法对椎间盘间隙准备的充分性。具体来说，我们旨在比较两种方法，比较的指标包括：（1）进行椎间盘切除术所需的时间和终板破坏的数量；（2）切除的椎间盘百分比；（3）椎间盘切除术后残留椎间盘的解剖位置。
方法
40 个腰椎节段（即 8 个新鲜尸体标本中的 L1-2 至 L5-S1）被随机分配到开放组和微创组。两名外科医生均为在各自的入路中接受过专业培训的脊柱外科医生。记录每个节段的椎间盘切除术所需时间、终板破坏和通过体积和质量切除的椎间盘百分比。使用数字成像软件程序（ImageJ；美国国立卫生研究院，贝塞斯达，马里兰州，美国）测量整个椎间盘和终板每个象限的椎间盘切除百分比。
结果
与微创入路相比，开放入路的椎间盘切除术时间更短（9 分钟对 12 分钟，p = 0.01），终板破坏更少（1 例对 3 例，p = 0.04），通过体积（80%对 77%，p = 0.41）和质量（77%对 75%，p = 0.55）切除的椎间盘百分比，以及通过面积切除的总椎间盘百分比（73%对 71%，p = 0.63），开放组和微创组之间无显著差异。在开放组和微创组中，后对侧象限的椎间盘切除百分比均最低（分别为 50%和 60%）。
结论
对于经验丰富的微创 TLIF 外科医生来说，微创和开放入路在椎间盘间隙准备的充分性方面相似。无论采用哪种方法，后对侧象限的椎间盘切除百分比最低；外科医生在进行椎间盘切除术时应特别注意这个解剖位置，以最大限度地减少假关节形成的可能性。
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