全皮质椎弓根螺钉
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使用皮质骨螺钉植入与传统螺钉植入在TLIF 手术中的短期结果
Page 1
Introduction
前言
The clinical results of transforaminal lumbar interbody fusion (TLIF) have been favorable for degenerative spondylolisthesis, kyphoscoliosis, and instability of the lumbar spine. However, there has been concern regarding pedicle screw placement during TLIF。
插入探子的目的是用来鉴别椎弓根壁是否破损，椎弓根螺 钉的合适长度，这些结果需要在CT图像去评估。椎弓根螺 钉的长度是 40 或 45毫米和直径 6.0 或 7.0 毫米直径。最后 , 在侧位的透视下来检查植入螺钉的长度及倾斜角度（图1)。
Page 9
Fig. 1. Lateral radiographs of M-TLIF. (A) Preoperative radiograph, (B) postoperative radiograph, (C) radiograph at final follow-up. M-TLIF, transforaminal lumbar interbody fusion with minimally invasive pedicle screw insertion.
暴露侧方到关节突关节去植入椎弓根螺钉需要相当长的切 口和肌肉切开。这种手术因损伤穿过关节突的神经根后支 及暴露过程中损伤背肌肉组织而引起后背痛。通过缩小切 口及减少肌肉组织的剥离去减少这些问题，TLIF用于微创 椎弓根螺钉植入和经皮椎弓根螺钉植入已经被很好的运用。
Page 3
However, several clinical concerns, such as low back pain, learning curve, radiation exposure, and incorrect pedicle screw placement, have also been associated with M-TLIF and P-TLIF。
开放传统的椎弓根螺钉植入通过双侧的 Wilse 入路使用 Expedium脊柱系统。在标准的后前位透视下，椎弓根探针 在向内倾斜30°插入，拧入椎弓根螺钉，术中小心不要穿 破椎弓根内壁。
Page 8
A feeler was used to identify breakage of the cortical pedicle walls, and a pedicle screw of appropriate length, as assessed on computed tomography (CT) images, was inserted. The lengths of screws were 40 or 45 mm and 6.0 or 7.0 mm in diameter. Finally, under a lateral fluoroscopic view, the length and craniocaudal direction of the screws were checked (Fig. 1).
TLIF手术的临床效果已经被很好的运用于腰椎退变性滑 脱、脊柱侧后凸畸形及腰椎不稳。然而，TLIF手术过程 中已经有关于椎wenku.baidu.com根螺钉的定位。
Page 2
Exposure lateral to the facet joint to insert a pedicle screw requires a relatively long incision and muscle dissection, which may be related to postoperative low back pain from injury to the posteromedial branch of the nerve root crossing the facet joint and damage to the exposed and retracted back musculature. To minimize the incision and muscle dissection and thus reduce these problems, TLIF with minimally invasive pedicle screw insertion (M-TLIF) and TLIF with percutaneous pedicle screw insertion (PTLIF) have been developed.
Page 7
Open conventional pedicle screws were placed using the Expedium Spine System (DePuy Spine) through a bilateral Wiltse approach. Under fluoroscopic guidance in a perfect posteroanterior projection, a pedicle probe was introduced into the pedicle at a 30° medial angle and the pedicle was tapped for a screw, taking care not to penetrate the medial wall.
Page 6
Surgical procedures M-TLIF was performed as follows. A unilateral facetectomy was performed at the location of the symptoms to expose the intervertebral foramen via a 6-cm incision. A thorough discectomy was completed and the disc space was filled with local bone graft material and an appropriate parallel Devex cage (DePuy Spine, Raynham, MA, USA) was placed. M-TLIF 手术过程如下：用 6cm 的切口去暴露有症状侧的椎 间孔通道需要切除单侧小关节。椎间盘被完全切除，椎间 隙内填充自体骨和合适大小的Devex cage。
Page 10
P-TLIF was performed using the Viper MIS Spine System (DePuy Spine). Following decompression of the affected site and placement of a cage into the disc space via a 6-cm skin incision, the targeting needle was placed on the superolateral border of the pedicle under fluoroscopy via another fascia incision created 1 cm lateral to the midline skin incision. P-TLIF 运用 Viper MIS 脊柱系统。在透视下定位针一根放 在椎弓根外上侧边缘，另一根针放在中线皮肤切口旁开 1cm。用6cm皮肤切口，先行症状侧减压之后将cage植入椎 间隙内。
Page 5
However, the differences in operative invasion, accuracy of pedicle screw insertion, and postoperative fusion rate between TLIF with CBT (CBT-TLIF) and other methods of pedicle screw placement, such as M-TLIF and P-TLIF, remain unknown. In this study, we compared the clinical and radiological results of CBT-TLIF with those of MTLIF and P-TLIF. 然而 , 在全皮质 -TLIF 与其它椎弓根螺钉植入方法，如 MTLIF及P-TLIF相比，在手术损伤差异，椎弓根螺钉植入准 确性,以及术后融合率之间依然没有结果。在这项研究中, 我们比较CBT-TLIF与M-TLIF与P-TLIF在临床和影像学方面 的结果。
Page 11
The targeting needle was introduced into the pedicle under posteroanterior and lateral fluoroscopic visualization. The targeting needle was replaced with a K wire, and a screw with an extended sleeve was then placed over the K wire and inserted into the vertebral body after tapping. Prebent rods were placed bilaterally using the Viper system and fixed with compressive force at the facetectomy side (Fig. 2). 在后前位及侧位透视下将探针插入椎弓根，之后用导针代 替探针，在过了椎弓根后壁以后用自攻螺钉插在导针上拧 入椎体，使用 Viper 系统将预弯的从双侧植入，然后固定 加压关节突一侧(图2)。
然而，在M-TLIF及P-TLIF手术中，几个临床上关注点诸如 下腰痛，长的学习曲线，射线的暴露，以及椎弓根螺钉位 置植入不正确也已经被证实发生。
Page 4
A new trajectory for pedicle screw insertion of pedicle screw placement, the cortical bone trajectory (CBT), was reported by Santoni et al. in 2009 and may address these problems. The new trajectory was from medial to lateral and cranial to caudal; this does not require wide exposure of the back muscle and thus reduces operative invasion compared with conventional or percutaneous pedicle screw insertion. 在 2009 年 ， 一 种 新 的 全 皮 质 椎 弓 根 螺 钉 植 入 方 法 被 Santoniet 等报道，并且可能解决一些问题。新的全皮质 螺钉植入是从内向外，从头向尾，这种方法与传统或者经 皮椎弓根螺钉植入相比不需要广泛剥离后背肌肉组织和减 少手术损伤
Department of Orthopedic Surgery, Akita University Graduate School of Medicine, Akita, Japan
Short-Term Results of Transforaminal Lumbar Interbody Fusion Using Pedicle Screw with Cortical Bone Trajectory Compared with Conventional Trajectory
Page 1
Introduction
前言
The clinical results of transforaminal lumbar interbody fusion (TLIF) have been favorable for degenerative spondylolisthesis, kyphoscoliosis, and instability of the lumbar spine. However, there has been concern regarding pedicle screw placement during TLIF。
插入探子的目的是用来鉴别椎弓根壁是否破损，椎弓根螺 钉的合适长度，这些结果需要在CT图像去评估。椎弓根螺 钉的长度是 40 或 45毫米和直径 6.0 或 7.0 毫米直径。最后 , 在侧位的透视下来检查植入螺钉的长度及倾斜角度（图1)。
Page 9
Fig. 1. Lateral radiographs of M-TLIF. (A) Preoperative radiograph, (B) postoperative radiograph, (C) radiograph at final follow-up. M-TLIF, transforaminal lumbar interbody fusion with minimally invasive pedicle screw insertion.
暴露侧方到关节突关节去植入椎弓根螺钉需要相当长的切 口和肌肉切开。这种手术因损伤穿过关节突的神经根后支 及暴露过程中损伤背肌肉组织而引起后背痛。通过缩小切 口及减少肌肉组织的剥离去减少这些问题，TLIF用于微创 椎弓根螺钉植入和经皮椎弓根螺钉植入已经被很好的运用。
Page 3
However, several clinical concerns, such as low back pain, learning curve, radiation exposure, and incorrect pedicle screw placement, have also been associated with M-TLIF and P-TLIF。
开放传统的椎弓根螺钉植入通过双侧的 Wilse 入路使用 Expedium脊柱系统。在标准的后前位透视下，椎弓根探针 在向内倾斜30°插入，拧入椎弓根螺钉，术中小心不要穿 破椎弓根内壁。
Page 8
A feeler was used to identify breakage of the cortical pedicle walls, and a pedicle screw of appropriate length, as assessed on computed tomography (CT) images, was inserted. The lengths of screws were 40 or 45 mm and 6.0 or 7.0 mm in diameter. Finally, under a lateral fluoroscopic view, the length and craniocaudal direction of the screws were checked (Fig. 1).
TLIF手术的临床效果已经被很好的运用于腰椎退变性滑 脱、脊柱侧后凸畸形及腰椎不稳。然而，TLIF手术过程 中已经有关于椎wenku.baidu.com根螺钉的定位。
Page 2
Exposure lateral to the facet joint to insert a pedicle screw requires a relatively long incision and muscle dissection, which may be related to postoperative low back pain from injury to the posteromedial branch of the nerve root crossing the facet joint and damage to the exposed and retracted back musculature. To minimize the incision and muscle dissection and thus reduce these problems, TLIF with minimally invasive pedicle screw insertion (M-TLIF) and TLIF with percutaneous pedicle screw insertion (PTLIF) have been developed.
Page 7
Open conventional pedicle screws were placed using the Expedium Spine System (DePuy Spine) through a bilateral Wiltse approach. Under fluoroscopic guidance in a perfect posteroanterior projection, a pedicle probe was introduced into the pedicle at a 30° medial angle and the pedicle was tapped for a screw, taking care not to penetrate the medial wall.
Page 6
Surgical procedures M-TLIF was performed as follows. A unilateral facetectomy was performed at the location of the symptoms to expose the intervertebral foramen via a 6-cm incision. A thorough discectomy was completed and the disc space was filled with local bone graft material and an appropriate parallel Devex cage (DePuy Spine, Raynham, MA, USA) was placed. M-TLIF 手术过程如下：用 6cm 的切口去暴露有症状侧的椎 间孔通道需要切除单侧小关节。椎间盘被完全切除，椎间 隙内填充自体骨和合适大小的Devex cage。
Page 10
P-TLIF was performed using the Viper MIS Spine System (DePuy Spine). Following decompression of the affected site and placement of a cage into the disc space via a 6-cm skin incision, the targeting needle was placed on the superolateral border of the pedicle under fluoroscopy via another fascia incision created 1 cm lateral to the midline skin incision. P-TLIF 运用 Viper MIS 脊柱系统。在透视下定位针一根放 在椎弓根外上侧边缘，另一根针放在中线皮肤切口旁开 1cm。用6cm皮肤切口，先行症状侧减压之后将cage植入椎 间隙内。
Page 5
However, the differences in operative invasion, accuracy of pedicle screw insertion, and postoperative fusion rate between TLIF with CBT (CBT-TLIF) and other methods of pedicle screw placement, such as M-TLIF and P-TLIF, remain unknown. In this study, we compared the clinical and radiological results of CBT-TLIF with those of MTLIF and P-TLIF. 然而 , 在全皮质 -TLIF 与其它椎弓根螺钉植入方法，如 MTLIF及P-TLIF相比，在手术损伤差异，椎弓根螺钉植入准 确性,以及术后融合率之间依然没有结果。在这项研究中, 我们比较CBT-TLIF与M-TLIF与P-TLIF在临床和影像学方面 的结果。
Page 11
The targeting needle was introduced into the pedicle under posteroanterior and lateral fluoroscopic visualization. The targeting needle was replaced with a K wire, and a screw with an extended sleeve was then placed over the K wire and inserted into the vertebral body after tapping. Prebent rods were placed bilaterally using the Viper system and fixed with compressive force at the facetectomy side (Fig. 2). 在后前位及侧位透视下将探针插入椎弓根，之后用导针代 替探针，在过了椎弓根后壁以后用自攻螺钉插在导针上拧 入椎体，使用 Viper 系统将预弯的从双侧植入，然后固定 加压关节突一侧(图2)。
然而，在M-TLIF及P-TLIF手术中，几个临床上关注点诸如 下腰痛，长的学习曲线，射线的暴露，以及椎弓根螺钉位 置植入不正确也已经被证实发生。
Page 4
A new trajectory for pedicle screw insertion of pedicle screw placement, the cortical bone trajectory (CBT), was reported by Santoni et al. in 2009 and may address these problems. The new trajectory was from medial to lateral and cranial to caudal; this does not require wide exposure of the back muscle and thus reduces operative invasion compared with conventional or percutaneous pedicle screw insertion. 在 2009 年 ， 一 种 新 的 全 皮 质 椎 弓 根 螺 钉 植 入 方 法 被 Santoniet 等报道，并且可能解决一些问题。新的全皮质 螺钉植入是从内向外，从头向尾，这种方法与传统或者经 皮椎弓根螺钉植入相比不需要广泛剥离后背肌肉组织和减 少手术损伤
Department of Orthopedic Surgery, Akita University Graduate School of Medicine, Akita, Japan
Short-Term Results of Transforaminal Lumbar Interbody Fusion Using Pedicle Screw with Cortical Bone Trajectory Compared with Conventional Trajectory