[临床医学]腰椎间盘摘除的微创手术.ppt

腰椎盘摘除的微创手术,杭州市红十字会医院费骏,Barcelona 98,Susanne Menger,Spine Product Segments world market(surgeries),Source:AESCULAP Orthopaedics Giant Step Update,Barcelona 98,Susanne Menger,AESCULAP Top Ten Countries Disc Surgery(Sales ex AAG 1997/98=38.4),Barcelona 98,Susanne Menger,Disc Surgery,目的减压解除神经根或硬膜囊的致压物降低椎间盘内压力withminimum trauma for the patient preservation of stabilizing structures,Barcelona 98,Susanne Menger,传统方法:,开放手术 开放手术伴椎板切除或半椎板切除,Barcelona 98,Susanne Menger,Barcelona 98,Susanne Menger,Open Discectomy,Access related lesions of bony,muscular and ligamenteous structures and tissuePost-operative scar tissue also in the epidural space loss of disc height“Post-Discectomy-Syndrome“InstabilitiesTherapy-resistant post-operative painlead in most cases to re-operation,Barcelona 98,Susanne Menger,Present:,Less invasive techniques:to reduce intra-operative trauma/smaller incisionsto reduce access-related post-operative complications to reduce die lesion of the stabilizing structures(skeleton,muscles,ligaments,to reduce scar tissue formation and instabilitiesto reduce disc height lossfor easier and faster mobilization and rehabilitation to improve the long-term results!,Barcelona 98,Susanne Menger,经皮椎间盘摘除,KRMER 椎间盘突出分类,化学溶核,微创椎间盘摘除,包 涵 型,轻度非包涵型,重度包涵型,内窥镜椎间盘摘除,Barcelona 98,Susanne Menger,化学溶核 Chemo-Nucleolysis,1964年 Smith方法:木瓜蛋白溶解酶注入椎间盘内，溶解髓核组织。,Barcelona 98,Susanne Menger,适应征:包涵型禁忌症:过敏曾做过溶核手术术中椎间盘造影显示纤维环破裂,Barcelona 98,Susanne Menger,临床病例：,Barcelona 98,Susanne Menger,效 果,便宜 微创适应征范围内有效率可达4470,过敏反应蛋白酶漏出，出现术后剧烈疼痛，甚至损伤神经根剂量难于掌握适应征较窄,Barcelona 98,Susanne Menger,经皮腰椎间盘切除 Percutaneous Discectomy,1975年 Hijitaka手动 Manual Percutaneous Discectomy.1985年 Onik 自动 Automated Percutaneous Discectomy适应征：包涵型及轻度非包涵型,Barcelona 98,Susanne Menger,通过逐级增大的工作套筒建立工作通道,Barcelona 98,Susanne Menger,方法,“安全带”,后外侧入路,Barcelona 98,Susanne Menger,临床病例,Barcelona 98,Susanne Menger,自动切吸主要器械,Barcelona 98,Susanne Menger,优缺点,微创有效率达到7080,指征窄L5S1难做，设计较好的器械用可弯曲器械解决此问题技术要求较高,Barcelona 98,Susanne Menger,经皮椎间盘激光切除,1987年 Choy,运用于包涵型病例有效率达到7885,Barcelona 98,Susanne Menger,Pro/Con(classic medial approach),microsurgical techniquewide indication rangethe world-wide golden standard ofeffective disc surgerygood clinical long term results,loss of disc heightapproach related postoperative scar tissue formation and instabilityPostdiscectomy-Syndrome,Barcelona 98,Susanne Menger,经皮内窥镜椎间盘切除Endoscopic Disc Surgery,Medial endoscopic approachnot really more less invasive than MLDlimited visualization(scope)Transforaminal endoscopic approachlimited range of indication because of reduced height of intervertebral foramen,Barcelona 98,Susanne Menger,EndoSpy ITransforaminal Endoscopic Discectomy,Epidural Endoscopy“,Barcelona 98,Susanne Menger,Transforaminal Approach,Barcelona 98,Susanne Menger,Transforaminal Approach,Entry point,Preservation of the ligamentum flavum,Preservation ofthe posterior longitudinal ligament,=Preservation of the stabilizing posterior structures/muscles=reduced scarring and fibroustissue,Barcelona 98,Susanne Menger,Transforaminal Endoscopic Approach,no access related scar tissue formation and trauma to stabilizing structures(reduced instabilities)range of indication:lateral and medical protrusions,herniationssequestration,without cranially or caudally migrationrelative contra-indications:more than 50%reduced disc height/intervertebral foramen L5/S1-Level(iliac crest),Barcelona 98,Susanne Menger,Transforaminal Endoscopic Approach,Direct visualization of target area and anatomical structuresContinuous flow(suction and irrigation)Discectomy withRongeurs,grasping forcepsscissorsmicro knifeOR time:approx.1,5-2 h(MLD:0,75-1h),Barcelona 98,Susanne Menger,EndoSpy I Components of the System,Flexible scope with rigid optic sleeve suitable for gas sterilizationno bulgy optic components atthe OR area,Barcelona 98,Susanne Menger,EndoSpy I Components of the System,Cross section of the optic sleeve,Outer diameter:5.0 mm,Inner diameter 3.3 mm,Light fibers,Optic fibers 0.8 mm,30.000 pxl,Barcelona 98,Susanne Menger,EndoSpy I Components of the System,scissorsgrasping forcepsnucleus forcepsmicro knifedilatation set with working trocar(3.0-7.5 mm)guide wires 0.8 mm1.2 mm Option:monopolar and bipolar electrode,Barcelona 98,Susanne Menger,Pro/Con,no access related scar tissue formation and trauma to stabilizing structures(reduced instabilities),Limited range of indicationlateral and medical protrusions,herniationscontra-indication:more than 50%reduced disc height/intervertebral foramen L5/S1-Level(iliac crest)small diameter of instrumentation reduces effectiveness,Barcelona 98,Susanne Menger,Future:,Real minimal invasive techniques:to reduce intra-operative trauma/smaller or no incisionsto reduce access-related post-operative complications to reduce die lesion of the stabilizing structures(skeleton,muscles,ligaments,etc.)to reduce scar tissue formation and instabilitiesto eliminate the effect of disc height lossfor easier and faster mobilization and rehabilitation to reduce post-operative morbidityfor further improvement of long-term results,Barcelona 98,Susanne Menger,Percutaneous Discectomy,Range of Indication,Protrusion 1st Grade,Protrusion 2nd Grade,Protrusion with subliga-mentous Sequestration,Herniation/Prolapswith extra-ligamentous Seque-stration,free Sequester,Chemo-Nucleolysis,Micro-Discectomy,Classification of disc herniations acc.to KRMER,Endoscopic Transforaminal Discectomy(Epidural Endoscopy),Barcelona 98,Susanne Menger,market introduction:march 99,Barcelona 98,Susanne Menger,EndoSpy II,Barcelona 98,Susanne Menger,EndoSpy II,Barcelona 98,Susanne Menger,EndoSpy II,Barcelona 98,Susanne Menger,EndoSpy II,Barcelona 98,Susanne Menger,EndoSpy II,Barcelona 98,Susanne Menger,EndoSpy II,Barcelona 98,Susanne Menger,EndoSpy II,Barcelona 98,Susanne Menger,EndoSpy II,Market Introduction:March 99,Barcelona 98,Susanne Menger,Further Future Trends:,Aim of disc surgery:decompressionFuture Aim:decompression and“disc repair”and reconstruction of functional mobility of the discArtificial disc?Artificial nucleus?R&D still evaluates for the optimal solution to avoid fusion,Barcelona 98,Susanne Menger,The Future will give us the answer very soon!,Thank You!,Barcelona 98,Susanne Menger,Micro-Discectomy,MLD=Micro-Lumbar Discectomy,Barcelona 98,Susanne Menger,Spine Classics MLD The Golden Standard The Original-Tried and Trusted,Barcelona 98,Susanne Menger,Clinical Case,Herniated disc at L4/5centro-medially slightly left sided,Barcelona 98,Susanne Menger,Medial Approach=medial and medio-lateral herniations,Barcelona 98,Susanne Menger,Instrumentation,Retractor components:,Barcelona 98,Susanne Menger,Clinical Case,lateral intra-foraminalextra-spinal extruded disc,Barcelona 98,Susanne Menger,Paraspinal approach=intra-and extra-foraminal herniations,Barcelona 98,Susanne Menger,Instrumentation,Retractor components:,Additional medial blades,Barcelona 98,Susanne Menger,Basic Retractor Set(FG 170),Barcelona 98,Susanne Menger,Instrumentation,Basic Instrument Set(FG173),