数字化设计微创极外侧经椎间孔腰椎椎体间融合术

摘要

目的 通过数字技术设计一种新的手术方式——微创极外侧经椎间孔腰椎椎体间融合术(extreme lateral transforaminal lumbar interbody fusion,E-TLIF),并探讨其治疗退变性腰椎疾患的可行性.方法 通过对志愿者(男,26岁,健康,体重67 kg,身高172 cm)腰椎行CT扫描及Mimics三维重建,研究椎间孔区域骨性结构和神经根走行,探讨腰椎椎间孔区域的解剖学特点.在Mimics软件中模拟E-TLIF手术操作,切除上关节突而保留下关节突,并植入椎弓根螺钉和椎体间融合器.最后通过尸体模拟手术证实E-TLIF的可行性.结果 正中线旁开9 cm的纵行手术切口,45°斜向椎体的手术通道可以充分暴露病椎的椎间孔区域.通过E-TLIF手术途径可充分地显露目标椎间盘和神经根以及后方的上、下关节突和关节囊,操作简便直观.E-TLIF手术可以实现单纯切除上关节突,而保留下关节突,通过扩大的椎间孔牵开神经根后可以显露并切除椎间盘,并能完成椎间融合器的植入.结论 (1)通过Mimics可以精确地进行手术设计,模拟手术操作.成本低,可操作性强,对真实手术有较好的指导作用.(2)E-TLIF手术仅切除上关节突而保留了下关节突,在达到与传统手术同样的减压、固定、融合效果的同时,更完整保留了脊柱后方的张力带结构,加强术后即刻稳定性,并促进患者更快恢复,是一种创伤更小、安全、有效的腰椎椎体间融合术式.%Objective To design a new operation approach:extreme lateral transforaminal lumbar interbody fusion (E-TLIF) via digital technology and to discuss its feasibility in treatment of degenerative lumbar diseases.Methods CT scan image data of lumbar vertebra were obtained from volunteer (a healthy male of 26 years old,67 kg in weight and 172 cm in height).Mimics was used to read and reconstruct the data into 3D images.We observe the anatomical bone structures of intervertebral foramen and nerve roots through CT scan and 3D reconstruction in Mimics to analysis the feature of this area.Then E-TLIF operation,pedicle screw insertion and cage placement were simulated by computer via digital technology in Mimics.The feasibility of this new approach was proved through operating on lumbar of formalin doused body with E-TLIF approach.Results An incision of 9 cm lateral form the central line and 45° from the sagittal plane is operated to fully expose the foraminal area.Remove superior facet while save inferior facet is feasible with this approach in E-TLIF.There is enough room for fully revealing and excision of intervertebral disc,and cage placement through enlarged foraminal area.Digital technology is a more economic,efficient way to design a new operation approach.The results are in accord with the formalin doused body test.Conclusion Mimics is an effectively,reliable and economic method to design an operation approach.And the result suggested that E-TLIF is a safe,less minimal invasive and more efficient operation approach in treatment of degenerative lumbar diseases.