Minimally Invasive Spinal SurgeryWord文档下载推荐.docx

Minimally Invasive Spinal SurgeryWord文档下载推荐.docx

《Minimally Invasive Spinal SurgeryWord文档下载推荐.docx》由会员分享，可在线阅读，更多相关《Minimally Invasive Spinal SurgeryWord文档下载推荐.docx（29页珍藏版）》请在冰豆网上搜索。

IssadaThongtrangan,M.D.;

HoangLe,M.D.;

JonPark,M.D.;

DanielH.Kim,M.D.

NeurosurgFocus16

（1）,2004.©

2004AmericanAssociationofNeurologicalSurgeons

Posted03/04/2004

AbstractandIntroduction

Abstract

Theconceptofminimallyinvasivespinalsurgeryembodiesthegoalofachievingclinicaloutcomescomparabletothoseofconventionalopensurgery,whileminimizingtheriskofiatrogenicinjurythatmaybeincurredduringtheexposureprocess.Thedevelopmentofmicroscopy,lasertechnology,endoscopy,andvideoandimageguidancesystemsprovidedthefoundationonwhichminimallyinvasivespinalsurgeryisbased.Minimallyinvasivetreatmentshavebeenundertakeninallareasofthespinalaxissincethe20thcentury.Lumbardiscdiseasehasbeentreatedusingchemonucleolysis,percutaneousdiscectomy,laserdiscectomy,intradiscalthermoablation,andminimallyinvasivemicrodiscectomytechniques.Theinitialuseofthoracoscopyforthoracicdiscsandtumorbiopsieshasexpandedtoincludedeformitycorrection,sympathectomy,vertebrectomywithreconstructionandinstrumentation,andresectionofparaspinalneurogenictumors.Laparoscopictechniques,suchasthoseusedforappendectomyorcholecystectomybygeneralsurgeons,haveevolvedintoproceduresperformedbyspinalsurgeonsforanteriorlumbardiscectomyandfusion.Image-guidedsystemshavebeenadaptedtofacilitatepediclescrewplacementwithincreasedaccuracy.Overthepastdecade,minimallyinvasivetreatmentofcervicalspinaldisordershasbecomefeasiblebyapplyingtechnologiessimilartothosedevelopedforthethoracicandlumbarspine.Endoscope-assistedtransoralsurgery,cervicallaminectomy,discectomy,andforaminotomyallrepresentthecontinualevolutionofminimallyinvasivespinalsurgery.Furtherimprovementinopticsandimagingresources,developmentofbiologicalagents,andintroductionofinstrumentationsystemsdesignedforminimallyinvasiveprocedureswillinevitablyleadtofurtherapplicationsinminimallyinvasivespinesurgery.

Introduction

Sincethe1930s,therelationshipbetweendischerniationandsciaticahasbeenwellrecognized.Sincethattime,intraoperativetoolshavebeendevelopedtofacilitatesurgicalapproachesandtreatmentofdiscdisease.Poolusedamodifiedilluminatedotoscopetoperformmyeloscopicexaminationsofthedorsalnerverootsincasesofdischerniations.[71]In1955,Malisusedtheoperatingmicroscopeandbipolarcoagulationinfacilitatinghissurgicalapproach.[42]Withtheintroductionoftheoperatingmicroscope,YasargilandCaspar[6]bothdescribedtheminimallyinvasiveconceptofmicrodiscectomy.Duringthesameperiod,biochemicaladvancesinthetreatmentofdischerniationswerealsodeveloped.In1964,Smith[74]wasabletodissolvethenucleuspulposusinarabbitmodelviapercutaneousenzymaticapplications;

thistechniquewaslatersuccessfullyappliedinhumans.[21]In1975,Hijikata[28]describedthefirstpercutaneousdiscectomy,whichlaterevolvedintoautomateddiscectomies.Inadditiontoautomatedtechniques,adjuvanttreatmentsofdiscogenicdisruptionhaveincludedtheuseoflasersandthermalheatingprobes.[36,58,79]In1984,AscherandHeppner[2]usedanNd-YAGlasertoheatthenucleuspulposusinattemptstoshrinkthediscandrelievethesymptomsofnervecompression.Sincethe1990s,withtheapplicationofvideoimagingtostandardendoscopy,minimallyinvasiveendoscopicandthoracoscopicprocedureshavegainedrapiduseandhavediversifiedintheirclinicalapplications.Inthisreport,wereviewthehistoricalperspectivesandtheconceptofminimallyinvasivespinaltechniquesastheyareusedindifferentportionsofthespinalcolumn.

LumbarSpine

Chemonucleolysis

ChymopapainwasdiscoveredandisolatedbyJansenandBalls[30]in1941fromthelatexofthefruitofCaricapapaya.Bydepolymerizingtheproteoglycanandglycoproteinmacromoleculesofthenucleuspulposus,chymopapaincanreducethewatercontentoftheextracellularmatrixofthenucleuspulposusandcausereductionsinintervertebraldischeightandbulge.Inadditiontoreducingintradiscpressure,chymopapainmayalsohaveanantiinflammatoryroleinthenerverootitself.Watts[82]proposedthatchymopapaininteractswiththesensoryfibersoftheanulustoproduceatotalorpartialneurectomyeffect.

ThefirstclinicaltreatmentofsciaticabyusingchymopapainwasappliedbySmith[74]in1964.Inthefollowingthreedecades,chemonucleolysiswasactivelyusedtotreatdiscdisease;

however,controversialissuessurroundingitssafetyandefficacy,arosedespitethefactthatithastheapprovaloftheUSFoodandDrugAdministration.Overall,theefficacyofchemonucleolysiswasnotedtobebetween74and77%inseveralreports.[11,19,31]ThelargestserieswasreportedbyNordbyandJavid;

[54]theypublisheda14-yearstudyof3000patientsandnotedasuccessraterangingbetween82and87.2%.Otherpublishedoutcomereportswereinconclusive,however,andbroughtintoquestionthesafetyandefficacyofchymopapain.[31,53,55]Anaphylacticreactionstothissubstancecanresultindeath.Aninadvertentintrathecalchymopapaininjectioncancausehemiparesisandparaplegia,raisedintracranialpressure,meningitis,andhemorrhage.

Areviewoftheliteratureneverthelessdoesrevealdatasupportingthecontinueduseofchemonucleolysisforthetreatmentoflumbardischerniations.[25,43,44,78,83]Properpatientselectioniscrucialforsuccess.Chemonucleolysisshouldbereservedforpatientswithradicularsymptomscausedbyasoftherniateddiscasdemonstratedbyimagingstudies.Patientsolderthan60yearsofagemaylacksufficientmucoproteinforhydrolysisandtendtorespondpoorlytothisprocedure.[40]Absolutecontraindicationstochemonucleolysisincludeallergicreactionstopapain,historyofdiscitis,caudaequinasyndrome,pregnancy,arachnoiditis,migrateddiscs,andcanalstenosis.

PercutaneousLumbarDiscectomy

In1975,Hijikata[28]firstdescribedapercutaneousnucleotomytechniqueinvolvingapartialresectionofthediscmaterialviaaposterolateralapproach.Theprocedurewasperformedusinglocalanesthesia.In1983,KambinandGellman[35]performedadorsolateraldiscectomybyinsertingaCraigcannulaandasmallforcepsintothediscspace.In1985,Onikandcolleagues[58]introducedanucleotomeforPLD.In1986,KambinandSampson[36]initiatedtheuseoffluoroscopyforpercutaneousdiscectomy.Instrumentssimilartothosedevelopedforophthalmologiststoremovethevitreoushumoroftheeyewereredesignedforuseinpercutaneousdiscectomies;

someflexibilitywasprovidedtoapproachtheL5–S1andL4–5levels.[57]

Patientselectionforpercutaneousdiscectomyissimilartothatusedinpatientsundergoingchymopapaintreatment.Similarly,theprocedureofpercutaneousdiscectomyismostidealforcontaineddiscfragments,withthesizeoftheprotrusionbeinganimportantfactorinobtainingsuccessfuloutcomes.[20]Inaddition,patientswithnarroweddiscspacesarealsopoorcandidatesforpercutaneousdiscectomy.AutomatedPLDcanbeatreatmentoptionforpatientswithsingle-leveldiscdisease（Fig.1）.Itisnotindicatedforpatientswithahistoryofpreviouschemonucleolysis,surgicaldiscectomy,progressiveneurologicaldeficits,sequestereddiscfragments,spinalstenosis,orspondylolisthesis.Successratesreportedintheliteraturerangefrom77.5to87%andthecomplicationrateis1%.[12,13,45,59]Todate,however,therehavebeennoprospectiverandomizedcontrolledstudiestovalidatethelong-termoutcomesofPLD.

Figure1.Photographsrelatedtoanautomatedpercutaneousdiscectomy.Theneedle（upperinset）placedthroughthetriangularspaceandalargediscspecimen（upperinset）isremoved.

PercutaneousLaser-AssistedDiscectomy

Thedevelopmentoflaserlightamplificationbystimulatedemissionofradiationdatesbackto1958andwasaccomplishedbyArthurL.SchawlowandCharlesH.Townes.[71]Sincethen,numerousapplicationsoflasertechnologyinmedicinehavebeenreportedinthespecialtiesofophthalmology,plasticsurgery,urology,vascularsurgery,generalsurgery,gynecology,neurosurgery,andorthopedics.Laser-assisteddiscectomyevolvedfrompercutaneousdiscectomytechniques.Afterpercutaneousplacementofasingleneedleinthediscspace,laserenergyispassedthroughafiber,whichiscoupledtotheneedle,intothediscspace.Thelaserenergyistransmittedinshortburststoavoidexcessiveheatingofadjacenttissue.In1984,AscherandHeppner[2]usedcarbondioxideandNdlaserstotreatlumbardiscdisease.Theirmethodinvolvedmeasuringintradiscpressurebeforeandafterlaserdiscectomybyusingasalinemanometer.Theseauthorspostulatedthattheremovalofevenasmallvolumeoftissuefromthedisccausedacorrespondingdecreaseinintradiscpressure,thusrelievingbackpainandinflammation.In1990,Yonezawa,etal.,[88]usedanNd–YAGlasertotransmitenergythroughadouble-lumenneedlewithabarequartzfiber;

theirtip-typepressuretransducerwassimilarlyabletorecordintradiscpressure.TheuseofaKTPlaserforlumbardiscablationwasintroducedin1992.[39]Recentadvanceshaveallowedthedevelopmentofside-firingprobes,whichprovidebetterdirectionalcontrolandvisualization.Theside-firinglaserprobereducestheriskofinjurytoanteriorstructuressuchasthevenacava,aorta,andiliacvessels.Yeung[86]recommendedinjectingdiscswithindocyaninegreentoactasachromophore,thusmaximizingdeliveryandminimizingthechanceofinjurytoadjacentstructures.Theholmium–YAGsysteminvolvesauniquepulsedlasert