腰椎间融合技术和比

Lumbarinterbodyfusion:TechniquesandcomparisonIntroduction•Lumbarinterbodyfusion(LIF)：placementofanimplant(cage,spacerorstructuralgraft)withintheintervertebralspaceafterdiscectomyandendplatepreparation.•Fivemainapproaches•Interbodyfusion：lowerratesofpostoperativecomplicationsandpseudoarthrosisLIFALIFPLIFTLIFOLIFLLIFTechniquereviewPLIF•Oneoftheoriginalapproaches•InitialdescriptionofthePLIFtechniquebyBriggsandMilliganin1944degenerativeindicationsrequiringafusionproceduresegmentalinstabilityrecurrentdischerniationpseudoarthrosissymptomaticspinalstenosisPLIFPLIFTechniquereviewadvantagestraditionallumbarapproachexcellentvisualizationofthenerverootsadequateinterbodyheightrestorationforneuraldecompressionTechniquereviewdisadvantagesapproach-relatedmuscletraumadifficulttocorrectcoronalimbalanceandrestorelordosisEndplatepreparationmaybedifficultretractioninjuryofnerverootsTechniquereviewTLIF•Openingtheneuralforamenononesideonly.•HarmsandRolingerreportedin1982•Direct,unilateralaccesstotheintervertebralforaminalspacewhilstreducingdirectdissectionandduraltears.PLIFIndicationsContraindicationsTLIFTLIF•Preservesligamentousstructureswhichareinstrumentaltorestoringbiomechanicalstabilityofthesegmentandadjacentstructures•AsingleunilateralincisionisabletoprovidebilateralanteriorcolumnsupportTechniquereviewALIF•AnterioraccesscorridorsforlumbarfusionhavebeenusedanddevelopedsincetheywereintroducedbyCarpenterin1932.•Theanteriorretroperitonealapproachtotheventralsurfaceoftheexposeddisc,allowingcomprehensivediscectomyanddirectimplantinsertion.•SuitableforlevelsL4/L5andL5/S1ALIFALIFindicationsdegenerativediscdiseasediscogenicdiseaserevisionoffailedposteriorfusionContraindicationspriorabdominalsurgerywithadhesionsoradversevascularanatomyperipheralvasculardiseasesolitarykidneyonthesideofexposurehigh-grade(Grade2+)degenerativespondylolisthesisintheabsenceofposteriorfusionadvantagesdirectmidlineviewofthediscspacetopermitefficientdiscspaceclearancewithrapidendplatepreparationmaximizationoftheimplantsizefacilitatesaggressivecorrectionoflordosisandforaminalheightrestorationhighfusionrateswithamplediscspacepreparationsparingofposteriorspinalmusclesDisadvantages•Retrogradeejaculation•visceralandvascularinjuryTechniquereviewLLIF•DescribedbyOzguretal.in2006•SuitableforT12toL5.ThistechniqueisnotsuitablefortheL5/S1level.•Neuromonitoringisessential•Suitableforalldegenerativeindications.Especiallyforsagittalandcoronaldeformitycorrection,lumbardegenerativescoliosiswithlaterolisthesis.•Notbesuitableforseverecentralcanalstenosis,bonylateralrecessstenosisandhigh-gradespondylolisthesis•Notbesuitableforpriorretroperitonealsurgeryorwithretroperitonealabscess,aswellaspatientswithabnormalvascularanatomy.LLIF•Advantage:MISmuscle-splittingapproachthatcanbeperformedwithrapidpostoperativemobilization.Aggressivedeformitycorrectioncanbeachievedwithhighfusionratesandcomprehensivediscspaceclearance.•Disadvantages:Potentialrisksoflumbarplexus,psoasmuscleandbowelinjury,particularlyattheL4/5level.Vascularinjury,ifitoccurs,maybedifficulttocontrol.TechniquereviewOLIF•FirstdescribedbyMichaelMayerin1997andinvolvesanMISaccesstothediscspaceviaacorridorbetweentheperitoneumandpsoasmuscle•Thephrase“obliquelumbarinterbodyfusion”orOLIFwasfirstcoinedbySilvestrein2012•SimilarlytoanLLIFapproach,OLIFdoesnotrequireposteriorsurgery,laminectomy,facetectomyorstrippingofspinalorparaspinalmusculature.•OLIFtechniquedoesnotdissectortraversethepsoasmuscleandneuromonitoringisnotnecessary.•OLIFtechniqueissuitableforlevelsL1-S1.•IndicationsandcontraindicationsaresimilartoLLIFOLIFOLIF•Advantage:LLIF+lessriskoflumbarplexusandpsoasmuscledamage.•Disadvantages:PotentialrisksofincludesympatheticdysfunctionandvascularinjurySilvestreC,Mac-ThiongJM,HilmiR,etal.Complicationsandmorbiditiesofmini-openanteriorretroperitoneallumbarinterbodyfusion:obliquelumbarinterbodyfusionin179patients.AsianSpineJ2012;6:89–97.