脊柱疾患的手术治疗进展PPT课件

脊柱疾患的手术治疗进展传统开放VS现代微创,1,中国脊柱外科学成立于1985年，一直致力于脊柱疾病临床诊治与基础研究。,2,3,传统开放,4,现代微创,5,Oppenheimer JH, DeCastro I, and McDonnell DE. Minimally invasive spine technology and minimally invasive spine surgery: a historical reviewJ. Neurosurg Focus, 2009, 27(3):E9.,微创脊柱外科发展史,6,传统开放TLIF/PLIF/ALIF/XLIF,7,M/45y Pre-op L3-5双侧峡部裂,Post-op,8,TLIF与PLIF在治疗脊柱退变性疾病方面已十分成熟。但开放PLIF或TLIF须广泛剥离椎旁肌肉，出血和软组织损伤增加，影响术后恢复1、2。,1、Kawaguchi Y, Matsui H, and Tsuji H. Back muscle injury after posterior lumbar spine surgery. A histologic and enzymatic analysisJ. Spine (Phila Pa 1976), 1996, 21(8):941-944.2、Styf JR and Willen J. The effects of external compression by three different retractors on pressure in the erector spine muscles during and after posterior lumbar spine surgery in humansJ. Spine (Phila Pa 1976), 1998, 23(3):354-358.,9,传统开放VS现代微创,10,11,现代微创PELD/MED,PELD发展最迅速,12,1977 年 Yeung首创 YESS（Yeung Endoscopic spine system）技术2003 年Hoogland 等 在 YESS 技术的基础上 研制并推出TESSYS（transforaminal endoscopic spine system）技术,13,14,Case1,M/76y,Pre-op L4/5,Post-op,左侧椎间孔入路脊柱内镜下L4/5髓核摘除术,腰椎-脊柱退变性疾病,15,左侧椎板间入路经皮脊柱内镜下腰5/骶1髓核摘除术,Case2,M/26y,Pre-op L5/S1,Post-op,Intraoperative,腰椎-脊柱退变性疾病,16,右侧椎间孔入路经皮脊柱内镜下腰4/5髓核摘除术,F/49Y Pre-op L4/5,Case3,腰椎-脊柱退变性疾病,Intraoperative,17,右侧椎板间入路经皮脊柱内镜下椎管扩大减压术,Case4,M/77y,Pre-op L5/S1,Post-op,Intraoperative,腰椎-脊柱退变性疾病,18,F/40y, Pre-op,Post-op,L4/5,MED+PELD,Case5,腰椎-脊柱退变性疾病,Intraoperative,19,左侧椎间孔入路经皮脊柱内镜下腰4/5髓核摘除术,M/55y Pre-op L4/5复发,Post-op,Case6,腰椎-脊柱退变性疾病,20,Case 7,M/62y Pre-op L5双侧峡部裂并椎体向前滑脱,X-ray,CT,MRI,21,Intraoperative,微创经椎间孔入路腰椎椎体间融合术(MIS-TLIF),22,Post-op,3D CT,X-ray,CT,Incision,23,特殊类型LDH,极外侧伴有严重钙化型（伴侧隐窝狭窄）翻修多阶段型脱出游离型,24,优越性：,创伤小出血少脊柱解剖结构和生物力学保持好恢复快伤口感染率低镜下组织结构显露清晰,25,应用局限性：,对操作技术要求高、学习曲线陡峭适应症的局限性术后复发射线对医患双方的危害,26,随着手术技术及手术器械的发展，PELD应用范围将越发广泛脊柱内窥镜下进行椎体固定及融合将是今后的发展方向,27,传统颈椎手术,颈椎-脊柱退变性疾病,颈后路全椎板切除减压植骨融合,前路减压钛网植骨融合,前路单间隙减压自体髂骨植骨融合,Case 8,28,经皮内镜手术入路,前路,后路,29,A-PECD,Yang JS, Chu L, Chen L, Chen F, Ke ZY, Deng ZL. Anterior or posterior approach of full-endoscopic cervical discectomy for cervical intervertebral disc herniation? A comparative cohort studyJ. Spine,2014, 39(21):1743-1750.,颈椎-脊柱退变性疾病,30,P-PECD,颈椎-脊柱退变性疾病,31,微创小（切口0.5-0.7cm）避开重要脏器、血管、神经不破坏颈椎稳定结构术中磨钻可行骨性减压早期疗效好、创伤小、术后恢复快、经济视野清晰、出血可控,优越性：,Tzaan WC. Anterior percutaneous endoscopic cervical discectomy for cervical intervertebral disc herniation: outcome, complications, and techniqueJ. Journal of spinal disorders & techniques,2011, 24(7):421-431.,32,限制颈椎微创手术发展的原因,颈椎特殊的解剖结构，毗邻重要神经、血管，手术的准确性、安全性要求极高缺乏足够的空间手术高度依耐性X线机的辅助，大剂量X线操作，医师及患者造成极大伤害复发问题（复发、粘连、二次手术困难）手术指征局限,33,单纯颈椎间盘突出症（软性）钙化性颈椎间突出症颈椎间盘突出症合并椎间孔 狭窄,34,难复性寰枢椎脱位并高位颈脊髓病C2C6先天融合畸形（Klippel-Feil综合征）齿突先天畸形（未发育型）C7、T1分割不全,M/44y Pre-op,PECD,Case 9,35,牵引后,Pre-op,Pre-op,The First Post-op,36,The Second Post-op,The Second Post-op for four months,37,环枢椎半脱位，游离齿状突畸形，不完全四瘫，颅底凹陷症,枕颈融合植骨融合内固定术,F/26y Pre-op,Post-op,Case 10,38,F/18y Pre-op难复性寰枢椎脱位并颈脊髓损伤四肢瘫,Case 11,39,Post-op,颅骨牵引术后,X-ray,经口咽前路开放复位减压+后路寰枢椎植骨融合内固定术,40,Case 12,F/66y Pre-op颈6/7椎体骨折脱位并颈脊髓损伤四肢不全瘫,41,牵引后,Post-op,X-ray,CT,C6/7骨折脱位后-前路联合减压、复位、植骨内固定术,42,F/35y Pre-op,Post-op,C6/7骨折脱位前后路联合减压、复位、植骨内固定术,C6/7骨折脱位并不全四瘫,Case 13,43,胸腰椎骨折传统手术方法后路开放椎弓根螺钉内固定,44,F/24y L1爆裂性骨折并脊髓圆锥损伤、双下肢不全瘫痪,Post-op,Pre-op,脊柱创伤,Case 14,45,M/35y Pre-op,The First Post-op,The Second Post-op,L2椎体爆裂骨折并截瘫,一期后路减压植骨内固定术,二期前路减压植骨内固定术,脊柱创伤,Case 15,46,L4椎体爆裂骨折并不全瘫 、L5峡部裂,M/43y Pre-op,The First Post-op,The Second Post-op,二期前路减压植骨内固定术,一期后路减压植骨内固定术,脊柱创伤,Case 16,47,Case 17,MRI,X-ray,CT,M/30y, Pre-opL2、5椎体爆裂骨折并双下肢不全瘫,48,Post-op,X-ray,CT,Post-op for three months,腰后路减压植骨内固定术,49,胸腰椎骨折微创治疗方法经皮椎弓根螺钉固定,适应症：AO分型A型、B1、B2型损伤，椎管内骨块小于椎管直径1/3且无翻转者。,50,Case 18,M/50y, Pre-opT12椎体爆裂骨折,MRI,X-ray,CT,51,经皮椎弓根螺钉胸12骨折复位内固定术,52,Post-op,3D CT,X-ray,CT,53,以伤椎为支点杠杆作用，维持伤椎高度及稳定性短钉利于伤椎形态恢复，减少椎间隙的塌陷避免平行四边形效应和悬挂效应降低钉棒应力负荷，避免断钉断棒经皮微创效果与开放相同，创伤小、出血少、恢复快、住院时间短准确性、安全性（91.3%）,优越性：,Foley KT, Gupta SK. Percutaneous pedicle screw fixation of the lumbar spine: preliminary clinical resultsJ. Journal of neurosurgery,2002, 97(1 Suppl):7-12.,54,器械设计存在不足 延长杆过短、套管叶片强度不够、撑开效果欠佳复位不及开发满意空心椎（蛋壳椎） 一期植骨或二期重建,局限性：,55,经皮椎体成形术(PVP)与经皮椎体后凸成形术(PKP)是脊柱外科治疗压缩骨折常用的微创治疗方式，可达到稳定骨折、恢复椎体力学强度、防止椎体进一步压缩和缓解疼痛的目的。,骨质疏松性脊柱骨折的微创治疗,PVP,PKP,56,经皮椎体成形术(PVP),T12、L5 PVP,OVCF,Case 19,L1 PVP,T9 PVP,T10 PVP,L3 PVP,T11 PVP,L2 PVP,The First operation,The Seventh operation,57,F/78Y T12 PKP,Pre-op,Intraoperative,Post-op,Height recovery,OVCF,Case 20,58,M/52Y T12 椎体孤立性浆细胞瘤,Pre-op,T12,T12,T12,T12,Case 21,59,Post-op,T12 椎体肿瘤部分切除+PVP术,X-ray,CT,60,61,脊柱结核的微创治疗,降低患者的手术创伤扩大手术的治疗范围降低患者的经济负担减少术后手术并发症提高病灶内药物浓度提高化疗治疗的效果,62,下胸椎（T7T12椎体）长节段脊柱结核并后凸畸形不全截瘫,胸入路结核病灶清除、植骨内固定术,Pre-op,Post-op,脊柱结核,Case 22,63,F/45y腰骶椎结核（L3-S2）并冷脓疡不全瘫,腰骶椎前后联合入路结核病灶清除、植骨融合内固定术,Pre-op,Post-op,脊柱结核,Case 23,64,腰4、5椎体结核并椎管内外冷脓肿形成,M/26yPre-op,脊柱结核,Case 24,65,左侧椎间孔入路经皮脊柱内镜下腰4、5结核病灶清除术+经皮椎弓内固定术,二期内镜辅助下前路病灶清除+植骨融合内固定术,Intraoperative,66,Post-op,传统手术切口,VS,67,M/54y胸腰椎重度僵硬型角状结核性后凸畸形并脊髓变性不全瘫（ T9-L2 ）,Post-op,Pre-op,全脊椎截骨(PVCR),脊柱畸形,Case 25,68,F/47y腰骶椎（ L4S1 ）结核僵硬性角状后凸畸形并不全瘫,Pre-op,脊柱畸形,Case 26,69,Post-op,经椎弓根截骨(PSO),70,71,Pre-op,脊柱畸形,Case 27,F/55y陈旧性脊柱结核并胸腰骶段后凸畸形,72,L3 PSO截骨,Post-op,Pre-op,脊柱畸形,73,M/21y特发性胸腰椎侧后凸畸形,一期开胸前路松解术(5/6、6/7、7/8、8/9)，术后进行牵引2周二期胸腰椎后路截骨矫形术术后患者脊柱畸形明显矫正，身高增高8cm。,Pre-op,Post-op,脊柱畸形,Case 28,74,M/17y青少年重度僵硬性脊柱侧凸畸形,Pre-op,术前Cobb角112,Case 29,75,一期后路凹侧双棒撑开矫形术术后冠状面Cobb角86，矢状面后凸基本消失,4个月后二期后路广泛松解三维截骨矫形植骨融合内固定术 术后冠状面Cobb角62，矢状面后凸纠正,The First Post-op,The Second Post-op,76,M/40y强直性脊柱炎胸腰段后凸畸形矫行术后,后凸明显矫正，后凸Cobb角35度,Pre-op,Post-op,脊柱畸形,Case 30,77,M/16y先天性胸11半椎体畸形伴胸腰椎侧后凸畸形,Pre-op,Post-op,脊柱畸形,Case 31,胸11 PSO截骨,78,M/13y先天性腰3蝴蝶椎伴腰椎侧后凸畸形,Pre-op,Post-op,脊柱畸形,Case 32,L3 PSO截骨,79,退变性脊柱侧弯畸形,脊柱畸形,张西峰. DLIF联合后路经皮椎弓根钉固定治疗腰椎退行性侧弯.中国骨伤志:,2012:2.,80,现代微创VS传统开放,手术创伤小患者痛苦少术后恢复快临床疗效佳手术并发症少,81,微创原则,正确把握微创理念，在实践中认识微创技术微创手术与传统手术齐头并进严格掌握微创和传统手术的适应症最低的风险系数最简单的治疗方法最轻的创伤成本,82,Thanks,83,