微创与开放手术治疗III度腰椎滑脱症

,*,微创与开放手术治疗,I-II,度腰椎滑脱症,历史沿革,来自希腊语：,spondylo,(,椎体,),和,Listhesis,(,滑移,),集合而成。,1782年,Herbinlaux,最先描述了腰5椎体前滑脱病例。,1854年,Kilian,首先定义脊柱滑脱症,(,spondylisthesis,):,“,一椎体在另一椎体上部分或完全的滑移,”,。,1957年,Taillard,将脊柱滑脱症定义为,“,由于关节突间连续断裂或延长而引起椎体与其椎弓根、横突和上关节突一同向前滑移。,”,流行性病学,Fredrickson BE,et al.The natural history of spondylolysis and spondylolisthesis.J Bone Joint Surg Am 1984,500,participants,Jacobsen s Degenerative Lumbar Spondylolisthesis:An Epidemiological Perspective.spine.2007,4151,participants,，,M,：,1533,、,F,：,2618 254cases(11.1%),M(1.5%):F(5.9%),M(0.7%):F(1.2%),Kalichman L,，,Kinm DH,Li L,etal.Spondylolysis and Spondylolisthesis.Prevalence and Association With Low Back Pain in the Adult Community-Based Population.spine.2009,3529,participants,，,CT:11.5%,腰椎滑脱的,Wiltse,分型,Wiltse LL,，,Newman PH,MacNab I.Classification of spondylolysis and spondylolisthesis.,Clin Orthop,1976,117:23-29.,腰椎滑脱程度,（,Meyerding,分型，,1932,）,Meyerding HW.Spondylolisthesis:surgical treatment and resultsJ.Surg Gynecol Obstet,1932,54:371-37,I,II,III,IV,V,症状,马尾综合症,滑脱进展,Labelle H,Mac-Thiong JM,Roussouly P.Spino-pelvic sagittal balance of spondylolisthesis:a review and classication Eur Spine J,2011,滑脱进展,申勇,.,中国矫形外科杂志,2005,40y,43y,45y,滑脱进展,滑脱进展主要因素,PI,BMI,Angle of lordosis,Bilateral pars defects,Jacobsen s.spine.2007,Labelle H,Eur Spine J,2011,Beutler WJ,Spine,2003,PI,手术治疗指征,持续或反复发作的腰腿痛、间歇性跛行,严重影响日常生活,经合理的非手术治疗,(3,个月或,3,个月以上,),无效者,;,神经功能障碍进行性加重者,;,出现大小便功能异常者,手术与非手术治疗,2-4,年随访，,LDS,手术疗效优于非手术,开放性手术,开放性手术,前路,后路,ALIF,PLF,、,PLIF,、,TLIF,、,椎板间融合、,单纯峡部固定、非融合,前后路联合,ALIF+PLIF/TLIF,开放手术,优点,学习曲线短,显露充分、视野大,缺点,椎旁肌肉损伤多,住院时间长,出血多,创伤大,风险高,微创手术,微创手术,前路,后路,ALIF,、,DLIF,PLF,、,PLIF,、,TLIF,、,Coflex,前后路联合,ALIF+PLIF/TLIF,微创手术,优点,创伤小,住院时间短,出血小,术后疼痛轻,康复快,并发症少,缺点,学习曲线长，难掌握,对手术者技术要求高，手术难度大,要求手术者有良好的三维解剖知识,需要专用器械，增加手术成本,暴露不充分，视野小,微创,VS,开放：腰椎滑脱？,Open,Mini,Who is best?,（,PLIF,）微创,VS,开放：长期疗效,（,PLIF,）微创,VS,开放：长期疗效,（,TLIF,）微创,VS,开放：疗效,Conclusion,：,Minimally invasive surgery,（,TLIF,）,for severe SDS,（,I-II grade,）,leads to adequate and safe decompression of lumbar stenosis and results in,a faster recovery of symptoms and disability in the early postoperative period.,（,PLF,）微创,VS,开放：疗效,Conclusion,：,The MIS-PLF utilizing a percutaneous pedicle screw system had,less invasive,less,postoperative pain,rapid improvement of several functional parameters,compared to conventional open-PLF.,This,superiority,in the MIS-PLF group was maintained until 2 years postoperatively,suggesting that less invasive PLF offers better mid-term results in terms of,reducing low back pain and improving patients functional capacity of daily living.,（,PLF,）微创,VS,开放：疗效,（,ALIF+TLIF,）微创,VS,开放：并发症,Conclusion,:,MIS(ALIF+TLIF),had,less blood loss,less need for transfusion,in the perioperative period,and,a shorter hospital stay,than,open(ALIF+TLIF),but the,length of surgery,intraoperative uoroscopy time,malpositioned instrumentation,on postoperative imaging,and postoperative complications,including,pulmonary embolus,and,surgical site infection,no difference,.,（,P/TLIF,）微创,VS,开放：感染率,Conclusions,：,In this multihospital study,the,MI technique,（,P/TLIF,）,was associated with a decreased incidence of perioperative,SSI,(27 4.6%vs 150 7.0%,p=0.037),in 2-level fusion.,There was no significant difference in the incidence of,SSIs,(38 4.5%vs 77 4.8%,p=0.77),between the open and MI cohorts for 1-level fusion procedures.,(PLIF),微创,VS,开放：多裂肌损伤,微创,VS,开放：多裂肌损伤,微创,VS,开放：费效分析,CONCLUSIONS:,MIS TLIF resulted in reduced,operative blood loss,hospital stay and 2-year cost,and accelerated return to work,.,Surgical morbidity,hospital readmission,and short-and long-term clinical effectiveness,were,similar,between MIS and open TLIF.,MIS TLIF may represent a valuable and cost-saving advancement from a societal and hospital perspective.,微创,VS,开放：住院时间短、费用少,（,TLIF,）微创,VS,开放：,Meta,分析,Mini-TLIF VS mini-ALIF,：疗效,Mini-TLIF VS mini-ALIF,：疗效,MALIF,MTLIF,Mini-TLIF VS mini-ALIF,：疗效,Conclusions,：,Considering the clinical and radiological outcomes in both groups,the authors recommend that instrumented,mini-TLIF is preferable at the L45 level,whereas instrumented,mini-ALIF might be preferable at the L5S1 level,for the treatment of unstable isthmic spondylolisthesis.,正确掌握腰椎滑脱的治疗原则,(,侯树勋,),不是所有的腰椎滑脱都需要治疗,伴有腰痛的腰椎滑脱并非都需要手术,根据滑脱的严重程度选择适当的手术方式,滑脱椎体的融合是手术治疗的最终目的,