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1、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
2、膜囊的致压物 降低椎间盘内压力 with minimum 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 tissue Po
3、st-operative scar tissue also in the epidural space loss of disc height “Post-Discectomy-Syndrome“ Instabilities Therapy-resistant post-operative pain lead in most cases to re-operation,Barcelona 98,Susanne Menger,Present:,Less invasive techniques: to reduce intra-operative trauma / smaller incision
4、s to reduce access-related post-operative complications to reduce die lesion of the stabilizing structures (skeleton, muscles, ligaments, to reduce scar tissue formation and instabilities to reduce disc height loss for easier and faster mobilization and rehabilitation to improve the long-term result
5、s !,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,S
6、usanne 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,
7、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 / Co
8、n (classic medial approach),microsurgical technique wide indication range the world-wide golden standard ofeffective disc surgery good clinical long term results,loss of disc height approach related postoperative scar tissue formation and instability Postdiscectomy-Syndrome,Barcelona 98,Susanne Meng
9、er,经皮内窥镜椎间盘切除Endoscopic Disc Surgery,Medial endoscopic approach not really more less invasive than MLD limited visualization (scope) Transforaminal endoscopic approach limited range of indication because of reduced height of intervertebral foramen,Barcelona 98,Susanne Menger,EndoSpy I Transforaminal
10、 Endoscopic Discectomy,Epidural Endoscopy“,Barcelona 98,Susanne Menger,Transforaminal Approach,Barcelona 98,Susanne Menger,Transforaminal Approach,Entry point,Preservation of the ligamentum flavum,Preservation of the posterior longitudinal ligament,= Preservation of the stabilizing posterior structu
11、res / muscles = reduced scarring and fibrous tissue,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, herniations sequestration, wit
12、hout cranially or caudally migration relative 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 structures Continuous flow (suction
13、 and irrigation) Discectomy with Rongeurs, grasping forceps scissors micro knife OR 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 sterilization no bulgy optic components at the OR area,B
14、arcelona 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,scissors grasping forceps nucleus forceps micro kni
15、fe dilatation set with working trocar (3.0 - 7.5 mm) guide wires 0.8 mm 1.2 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 indication lateral and me
16、dical protrusions, herniations contra-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 / smal
17、ler or no incisions to reduce access-related post-operative complications to reduce die lesion of the stabilizing structures (skeleton, muscles, ligaments, etc.) to reduce scar tissue formation and instabilities to eliminate the effect of disc height loss for easier and faster mobilization and rehab
18、ilitation to reduce post-operative morbidity for 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/ Prolaps with extra- ligamentous Seque
19、- 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
20、 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,Furt
21、her Future Trends:,Aim of disc surgery: decompression Future Aim: decompression and “disc repair” and reconstruction of functional mobility of the disc Artificial disc ? Artificial nucleus ? R&D still evaluates for the optimal solution to avoid fusion,Barcelona 98,Susanne Menger,The Future will give
22、 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 L4/5 centro-medially sligh
23、tly 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-foraminal extra-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),
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