微创与开放手术治疗I-II度腰椎滑脱症.ppt

广州中医药大学第一附属医院脊柱专科广州中医药大学第一附属医院脊柱专科广州中医广州中医药大学第一附属医院脊柱大学第一附属医院脊柱专科科微微创与开放手与开放手术治治疗I-III-II度腰椎滑脱症度腰椎滑脱症1.广州中医药大学第一附属医院脊柱专科广州中医药大学第一附属医院脊柱专科历史沿革史沿革来自希腊来自希腊语：spondylo(椎体椎体)和和Listhesis(滑移滑移)集合而成。集合而成。17821782年年 Herbinlaux最先描述了腰最先描述了腰5 5椎椎体前滑脱病例。体前滑脱病例。18541854年年 Kilian首先定首先定义脊柱滑脱症脊柱滑脱症(spondylisthesis):):“一椎体在另一一椎体在另一椎体上部分或完全的滑移椎体上部分或完全的滑移”。19571957年年 Taillard将脊柱滑脱症定将脊柱滑脱症定义为“由于关由于关节突突间连续断裂或延断裂或延长而引而引起椎体与其椎弓根、横突和上关起椎体与其椎弓根、横突和上关节突突一同向前滑移。一同向前滑移。”2.广州中医药大学第一附属医院脊柱专科广州中医药大学第一附属医院脊柱专科流行性病学流行性病学Fredrickson BE,et al.The natural history of spondylolysis and spondylolisthesis.J Bone Joint Surg Am 1984,500 participants3.广州中医药大学第一附属医院脊柱专科广州中医药大学第一附属医院脊柱专科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(1.5%):F(5.9%)M(0.7%):F(1.2%)M(0.7%):F(1.2%)4.广州中医药大学第一附属医院脊柱专科广州中医药大学第一附属医院脊柱专科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%5.广州中医药大学第一附属医院脊柱专科广州中医药大学第一附属医院脊柱专科腰椎滑脱的腰椎滑脱的WiltseWiltse分型分型Wiltse LL，Newman PH,MacNab I.Classification of spondylolysis and spondylolisthesis.Clin Orthop,1976,117:23-29.6.广州中医药大学第一附属医院脊柱专科广州中医药大学第一附属医院脊柱专科腰椎滑脱程度腰椎滑脱程度（Meyerding分型，1932）Meyerding HW.Spondylolisthesis:surgical treatment and resultsJ.Surg Gynecol Obstet,1932,54:371-37I I I III II II IIIIIIIIIIIIIIIVIVIVIVV V V V7.广州中医药大学第一附属医院脊柱专科广州中医药大学第一附属医院脊柱专科症状症状马尾综合症8.广州中医药大学第一附属医院脊柱专科广州中医药大学第一附属医院脊柱专科滑脱滑脱进进展展Labelle H,Mac-Thiong JM,Roussouly P.Spino-pelvic sagittal balance of spondylolisthesis:a review and classification Eur Spine J,20119.广州中医药大学第一附属医院脊柱专科广州中医药大学第一附属医院脊柱专科滑脱滑脱进进展展申勇.中国矫形外科杂志,200540y40y43y43y45y45y10.广州中医药大学第一附属医院脊柱专科广州中医药大学第一附属医院脊柱专科滑脱滑脱进进展展11.广州中医药大学第一附属医院脊柱专科广州中医药大学第一附属医院脊柱专科滑脱滑脱进进展主要因素展主要因素PIBMIAngle of lordosisBilateral pars defectsJacobsen s.spine.2007,Labelle H,Eur Spine J,2011Beutler WJ,Spine,2003PIPI12.广州中医药大学第一附属医院脊柱专科广州中医药大学第一附属医院脊柱专科手手术术治治疗疗指征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13.广州中医药大学第一附属医院脊柱专科广州中医药大学第一附属医院脊柱专科手手术术与非手与非手术术治治疗疗2-42-42-42-4年随年随年随年随访访，LDSLDSLDSLDS手手手手术疗术疗效效效效优优于非手于非手于非手于非手术术14.广州中医药大学第一附属医院脊柱专科广州中医药大学第一附属医院脊柱专科开放性手开放性手术术开放性手开放性手术术前路前路后路后路ALIFALIFPLFPLF、PLIFPLIF、TLIFTLIF、椎板椎板间间融合、融合、单纯单纯峡部固定、非融合峡部固定、非融合前后路前后路联联合合ALIF+PLIF/TLIFALIF+PLIF/TLIF15.广州中医药大学第一附属医院脊柱专科广州中医药大学第一附属医院脊柱专科开放手开放手术术优点点学习曲线短显露充分、视野大缺点缺点椎旁肌肉损伤多住院时间长出血多创伤大风险高16.广州中医药大学第一附属医院脊柱专科广州中医药大学第一附属医院脊柱专科微微创创手手术术微微创创手手术术前路前路后路后路ALIFALIF、DLIFDLIFPLFPLF、PLIFPLIF、TLIFTLIF、CoflexCoflex前后路前后路联联合合ALIF+PLIF/TLIFALIF+PLIF/TLIF17.广州中医药大学第一附属医院脊柱专科广州中医药大学第一附属医院脊柱专科微微创创手手术术优点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18.广州中医药大学第一附属医院脊柱专科广州中医药大学第一附属医院脊柱专科微微创创 VS VS 开放：腰椎滑脱？开放：腰椎滑脱？OpenMini19.广州中医药大学第一附属医院脊柱专科广州中医药大学第一附属医院脊柱专科（PLIFPLIF）微）微创创 VS VS 开放：开放：长长期期疗疗效效20.广州中医药大学第一附属医院脊柱专科广州中医药大学第一附属医院脊柱专科（PLIFPLIF）微）微创创 VS VS 开放：开放：长长期期疗疗效效21.广州中医药大学第一附属医院脊柱专科广州中医药大学第一附属医院脊柱专科（TLIFTLIF）微）微创创 VS VS 开放：开放：疗疗效效ConclusionConclusion：Minimally invasive surgeryMinimally invasive surgery（TLIFTLIF）for severe SDSfor severe SDS（I-II gradeI-II grade）leads to adequate and safe decompression of lumbar stenosis and results in leads to adequate and safe decompression of lumbar stenosis and results in a faster a faster recovery of symptoms and disability in the early postoperative period.recovery of symptoms and disability in the early postoperative period.22.广州中医药大学第一附属医院脊柱专科广州中医药大学第一附属医院脊柱专科（PLFPLF）微）微创创 VS VS 开放：开放：疗疗效效ConclusionConclusion：The MIS-PLF utilizing a percutaneous pedicle screw system had The MIS-PLF utilizing a percutaneous pedicle screw system had less less invasive,less invasive,less postoperative painpostoperative pain,rapid improvement of several functional parameters rapid improvement of several functional parameters compared to conventional open-PLF.compared to conventional open-PLF.ThisThis superiority superiority in the MIS-PLF group was maintained until 2 years postoperatively,in the MIS-PLF group was maintained until 2 years postoperatively,suggesting that less invasive PLF offers better mid-term results in terms of suggesting that less invasive PLF offers better mid-term results in terms of reducing reducing low back pain and improving patients functional capacity of daily living.low back pain and improving patients functional capacity of daily living.23.广州中医药大学第一附属医院脊柱专科广州中医药大学第一附属医院脊柱专科（PLFPLF）微）微创创 VS VS 开放：开放：疗疗效效24.广州中医药大学第一附属医院脊柱专科广州中医药大学第一附属医院脊柱专科（ALIF+TLIFALIF+TLIF）微）微创创 VS VS 开放：并开放：并发发症症ConclusionConclusion:MIS(ALIF+TLIF)MIS(ALIF+TLIF)had had less blood loss,less need for transfusionless blood loss,less need for transfusion in the in the perioperative period,and perioperative period,and a shorter hospital staya shorter hospital stay than than open(ALIF+TLIF),open(ALIF+TLIF),but the but the length of surgery,intraoperative fluoroscopy time,malpositioned instrumentationlength of surgery,intraoperative fluoroscopy time,malpositioned instrumentation on on postoperative imaging,and postoperative complications,including postoperative imaging,and postoperative complications,including pulmonary pulmonary embolusembolus and and surgical site infectionsurgical site infection no differenceno difference.25.广州中医药大学第一附属医院脊柱专科广州中医药大学第一附属医院脊柱专科（P/TLIFP/TLIF）微）微创创 VS VS 开放：感染率开放：感染率ConclusionsConclusions：In this multihospital study,the In this multihospital study,the MI techniqueMI technique（P/TLIFP/TLIF）was associated with a decreased was associated with a decreased incidence of perioperative incidence of perioperative SSI SSI(27 4.6%vs 150 7.0%,p=0.037)(27 4.6%vs 150 7.0%,p=0.037)in 2-level fusion.in 2-level fusion.There was no significant difference in the incidence of There was no significant difference in the incidence of SSIsSSIs(38 4.5%vs 77 4.8%,p=(38 4.5%vs 77 4.8%,p=0.77)0.77)between the open and MI cohorts for 1-level fusion procedures.between the open and MI cohorts for 1-level fusion procedures.26.广州中医药大学第一附属医院脊柱专科广州中医药大学第一附属医院脊柱专科(PLIF)(PLIF)微微创创 VS VS 开放：多裂肌开放：多裂肌损伤损伤27.广州中医药大学第一附属医院脊柱专科广州中医药大学第一附属医院脊柱专科微微创创 VS VS 开放：多裂肌开放：多裂肌损伤损伤28.广州中医药大学第一附属医院脊柱专科广州中医药大学第一附属医院脊柱专科微微创创 VS VS 开放：开放：费费效分析效分析CONCLUSIONS:CONCLUSIONS:MIS TLIF resulted in reduced MIS TLIF resulted in reduced operative blood loss,hospital stay and 2-year cost,operative blood loss,hospital stay and 2-year cost,and accelerated return to workand accelerated return to work.Surgical morbidity,hospital readmission,and short-and long-term clinical Surgical morbidity,hospital readmission,and short-and long-term clinical effectivenesseffectiveness were were similar similar between MIS and open TLIF.between MIS and open TLIF.MIS TLIF may represent a valuable and cost-saving advancement from a MIS TLIF may represent a valuable and cost-saving advancement from a societal and hospital perspective.societal and hospital perspective.29.广州中医药大学第一附属医院脊柱专科广州中医药大学第一附属医院脊柱专科微微创创 VS VS 开放：住院开放：住院时间时间短、短、费费用少用少30.广州中医药大学第一附属医院脊柱专科广州中医药大学第一附属医院脊柱专科（TLIFTLIF）微）微创创 VS VS 开放：开放：Meta Meta分析分析31.广州中医药大学第一附属医院脊柱专科广州中医药大学第一附属医院脊柱专科Mini-TLIF VS mini-ALIF：疗效效32.广州中医药大学第一附属医院脊柱专科广州中医药大学第一附属医院脊柱专科Mini-TLIF VS mini-ALIF：疗效效MALIFMALIFMTLIFMTLIF33.广州中医药大学第一附属医院脊柱专科广州中医药大学第一附属医院脊柱专科Mini-TLIF VS mini-ALIF：疗效效ConclusionsConclusions：Considering the clinical and radiological Considering the clinical and radiological outcomes in both groups,the authors recommend that outcomes in both groups,the authors recommend that instrumented instrumented mini-TLIF is preferable at the L45 levelmini-TLIF is preferable at the L45 level,whereas,whereas instrumented instrumented mini-ALIF might be preferable at the L5S1 levelmini-ALIF might be preferable at the L5S1 level for the treatment of unstable isthmic spondylolisthesis.for the treatment of unstable isthmic spondylolisthesis.34.广州中医药大学第一附属医院脊柱专科广州中医药大学第一附属医院脊柱专科正确掌握腰椎滑脱的治正确掌握腰椎滑脱的治疗疗原原则则(侯侯树勋树勋)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 35.广州中医药大学第一附属医院脊柱专科广州中医药大学第一附属医院脊柱专科36.