Mayer H M
Department of Orthopedic Surgery, Freie Universität Berlin, Oskar-Helene-Heim, Germany.
Spine (Phila Pa 1976). 1997 Mar 15;22(6):691-9; discussion 700. doi: 10.1097/00007632-199703150-00023.
A series of patients were prospectively studied to determine the morbidity and possible complications of minimally invasive anterior lumbar interbody fusion by two new microsurgical approaches (retroperitoneal for segments L2-L3, L3-L4, and L4-L5, and transperitoneal for L5-S1).
To investigate the feasibility of performing an anterior lumbar interbody fusion through a 4-cm skin incision and a standardized muscle-splitting approach.
The utility of anterior lumbar interbody fusion with or without posterior instrumentation for the treatment of various degenerative or postoperative lesions associated with low back pain is still a matter of debate. Regardless of the indications for surgery, use of the anterior approach in the lumbar spine is known to be associated with considerable surgical trauma, a high postoperative morbidity, and, occasionally, unacceptably high complication rates. Laparoscopic anterior interbody fusion of L5-S1 to eliminate some of these problems has been recently described. However, a minimally invasive surgical concept that covers all lumbar segments from L2 to S1 has not been described before now.
A standardized, microsurgical retroperitoneal approach to levels L2-L3, L3-L4, and L4-L5 and a microsurgical transperitoneal approach through a "minilaparotomy" to L5-S1 are described. The first 25 patients (retroperitoneal, n = 20; transperitoneal, n = 5) treated with these methods are evaluated with respect to intraoperative data such as blood loss, operating time, intraoperative and postoperative complications, as well as preliminary fusion results.
There were no general or technique-related complications in the first series of 25 patients. Postoperative morbidity was low in all patients, with negligible wound pain. Average blood loss was 67.8 ml for the retroperitoneal technique and 168 ml for the transperitoneal approach. No blood transfusion was necessary. All patients showed solid bony fusion.
The microsurgical approaches described in this article are atraumatic techniques to reach the lumbar spinal levels L2-L3, L3-L4, L4-L5, and L5-S1. They represent microsurgical modifications of the surgical approaches well known to the spine surgeon. They can be learned in a step-by-step fashion, starting with a conventional skin incision and, once the surgeon is familiar with the instruments, moving on to the microsurgical technique. The approaches are not restricted to the type of fusion (iliac crest autograft) presented in this series.
对一系列患者进行前瞻性研究，以确定两种新的显微手术入路（L2-L3、L3-L4和L4-L5节段采用腹膜后入路，L5-S1节段采用经腹入路）进行微创前路腰椎椎间融合术的发病率及可能的并发症。
探讨通过4厘米皮肤切口和标准化肌肉分离入路进行前路腰椎椎间融合术的可行性。
前路腰椎椎间融合术联合或不联合后路内固定治疗各种与腰痛相关的退行性或术后病变的效用仍存在争议。无论手术指征如何，已知在腰椎使用前路手术会伴有相当大的手术创伤、较高的术后发病率，且偶尔并发症发生率高得令人难以接受。最近有文献描述了L5-S1节段的腹腔镜前路椎间融合术以消除其中一些问题。然而，此前尚未描述过一种涵盖从L2到S1所有腰椎节段的微创外科概念。
描述了一种标准化的显微手术腹膜后入路用于L2-L3、L3-L4和L4-L5节段，以及一种通过“迷你剖腹术”对L5-S1节段进行的显微手术经腹入路。对采用这些方法治疗的首批25例患者（腹膜后入路20例，经腹入路5例）的术中数据，如失血量、手术时间、术中及术后并发症以及初步融合结果进行评估。
首批25例患者中未出现全身或与技术相关的并发症。所有患者术后发病率较低，伤口疼痛可忽略不计。腹膜后技术的平均失血量为67.8毫升，经腹入路为168毫升。无需输血。所有患者均显示有坚实的骨融合。
本文所述的显微手术入路是到达L2-L3、L3-L4、L4-L5和L5-S1腰椎节段的无创技术。它们是脊柱外科医生熟知的手术入路的显微手术改良方法。可以逐步学习这些方法，从传统皮肤切口开始，一旦外科医生熟悉了器械，再转向显微手术技术。这些入路并不局限于本系列中所展示的融合类型（髂嵴自体骨移植）。
