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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6013_Библиотеки_им_академика_М_И_Перельмана.pdf
S T E P 1 P EA R L S
• Plan the 3-mm paramedian skin incision
more lateral than initially estimated. It is
easier to angle the tools from lateral to
medial to achieve the correct trajectory
than to force the tools laterally against
the paraspinal muscles and fascia to
correct the trajectory.
• Use frequent biplanar fluoroscopy to
make sure that you stay within the
confines of the pedicle.
• When the Jamshidi needle is in the
middle of the pedicle on the AP view, it
should be at the junction of the pedicle
and the vertebral body on the lateral
view, and when the needle reaches the
posterior vertebral body on the lateral
view, it should not breach the medial
wall of the pedicle on the AP view
(Figure 36-6, A: correct). If the
trajectory is too medial, the needle will
reach or breach the medial wall in AP
while still in the middle of the pedicle
on lateral plane (Figure 36-6, B: too
medial). The opposite occurs when the
trajectory is too lateral (Figure 36-6, C:
too lateral).
• The direction of the guidewire should
be toward the inferior end plate on
the lateral view and should be at
the midline on the AP view if a
transpedicular approach is used.
It should cross the midline if an
extrapedicular unilateral approach is
used.
• When using a transpedicular approach,
one should aim for the midline using
an AP view and aim to be 80% across
the length of the vertebral body using a
lateral view.
• The radiologic entry point for
extrapedicular placement at the base of
the pedicle is just lateral to the image
of the pedicle as seen on the AP view.
• The entry point for an extrapedicular
approach is at the tip of the transverse
process. The Jamshidi needle penetrates
the transverse process, goes through
the rib between the costotransverse
and the costovertebral articulation, and
reenters the vertebral body lateral to
the base of the pedicle.
• If there is difficulty advancing the
guidewire, use either a twisting motion
or a tapping mallet. A hand drill bit can
also be used to cut a path into the
vertebral body.
Procedure 36 | Kyphoplasty 339
FIGURE 36-5
A
FIGURE 36-6, A-C
Continued
340 Procedure 36 | Kyphoplasty
B
C
FIGURE 36-6, cont'd
Procedure 36 | Kyphoplasty 341
S T E P 2 P EA R L S
• Care is taken not to pierce the anterior
cortex.
• During balloon inflation, care must be
taken not to pierce the lateral cortex of
the vertebral body.
• During balloon inflation, rigorously
monitor the inflation pressure. Do not
inflate above 300 psi.
• If the balloon is not inflated enough
and high inflation pressures have been
reached, the balloon could be removed
and a curette that can be angled inside
the vertebral body can be used to
create a partial cavity for the balloon
(Figure 36-9, A).
• If a biopsy is needed, a forceps can
be used through the working cannula
before the balloon tamps (Figure
36-9, B).
Step 2
n
The deflated balloon tamp is passed down the working cannula under fluoro-
scopic control.
n
The radiographic markers within the balloon tamp are used for proper
positioning.
n
Once the balloon is properly positioned (Figure 36-7), start gradually inflating
it with frequent AP and lateral imaging.
n
The balloon is inflated with sterile saline and radiocontrast dye to monitor the
position of the balloon. The liquid is delivered through a flexible cannula connected to a twist syringe with a pressure transducer to monitor the volume and
inflation pressure.
n
A reduction of the fracture after inflating the balloon is a satisfactory result
(Figure 36-8).
n
The procedure is repeated on the contralateral side.
FIGURE 36-7
A
FIGURE 36-9, A-B
FIGURE 36-8
B
342 Procedure 36 | Kyphoplasty
S T E P 2
I N S T RU M E N T A T I O N /
I M P L AN TAT IO N
• Balloon tamps
• Curette
• Biopsy forceps
S T E P 3 P EA R L S
• The cement should be of adequate
consistency before it is deposited into
the vertebral body to minimize the risk
of leak through the fissures or leak into
the venous sinuses.
• Fill under real time fluoroscopy to
visualize the path of cement flow in
both the AP and lateral images.
• If cement nears or breaches any cortex,
allow the cement in the vertebral body
to cure; then layer in additional cement.
• Deposit cement to attain end-plate to
end-plate fill.
S T E P 3 P IT FA L L S
• Injection of bone cement that is still
soft
• Inadequate volume of cement
• Leakage of cement through the end
plates or the anterior or posterior
cortex of the vertebral body
• Early withdrawal of the cement
applicator
Step 3
n
After inflating the balloon tamps bilaterally and obtaining a satisfactory reduc-
tion of the fracture, the balloons are deflated and removed (Figure 36-10). A
void is left inside the vertebral bodies.
n
The PMMA bone cement is mixed and the cement applicators are filled. Before
the cement hardens, it is extruded from the cement applicators through the
working cannula into the defect in the vertebral body.
n
Bone cement is slowly deposited under low pressure, filling the deepest area
first and then withdrawing the needle slightly to fill upper areas (Figure 36-11).
The pressure and amount of cement extruded are closely monitored to avoid
unwanted leakage into nearby areas, such as through the upper or lower end
plates or the posterior and anterior cortices.
n
The volume of cement that can safely be deposited is typically just slightly more
than the volume of the balloon inflation to facilitate interdigitation of the
cement block into the interstices of the vertebral body.
n
Cement injection is stopped when it approaches the end plates or lateral wall
or the posterior cortex, or if leakage is seen.
n
The cement applicator is left in place until the cement fully cures to prevent
cement from expanding up the working cannula.
n
The procedure is repeated in the contralateral side.
S T E P 3
I N S T RU M E N T A T I O N /
I M P L AN TAT IO N
• PMMA
• Cement applicator
FIGURE 36-10
FIGURE 36-11
FIGURE 36-12
Procedure 36 | Kyphoplasty 343
FIGURE 36-13
n
The working cannula is removed (Figure 36-12), and the skin incision is closed
with a resorbable suture.
n
Postoperative image shows reduction of vertebral height with interdigitation of
the cement in the vertebral body (Figure 36-13).
Postoperative Care and Expected Outcomes
n
No bracing is required.
n
Most patients can be released home the same day if a neurologic examination
is normal.
n
Pain is managed for a limited period with narcotic medication.
n
Potential complications include cement leakage, adjacent vertebral compression
fracture, and epidural hematoma.
344 Procedure 36 | Kyphoplasty
Evidence
Cohen D. Balloon kyphoplasty was effective and safe for vertebral compression
fractures compared with nonsurgical care. J Bone Joint Surg Am 2009;91:2747.
Kyphoplasty led to greater improvement in mean SF-36 physical component
summary scores than did nonsurgical care. This difference remained at 3 and
6 months. The frequency of adverse events did not differ between groups. The
kyphoplasty group had two serious adverse events (hematoma and urinary tract
infection).
Garfin SR, Reilley MA. Minimally invasive treatment of osteoporotic vertebral
body compression fractures. Spine J 2002;2:76-80.
In this prospective multicenter series, there were six major complications among
600 cases, with 0.75% neurologic complications.
Khanna AJ, Neubauer P, Togawa D, Reinhardt MK, Lieberman IH. Kyphoplasty
and vertebroplasty for the treatment of spinal metastases. Support Cancer Ther
2005;3:21-5.
Vertebroplasty and kyphoplasty are minimally invasive vertebral augmentation
techniques used to treat pain in the appropriate patients while maintaining a
positive safety profile. Vertebroplasty and kyphoplasty are tools in a spectrum
of treatments for vertebral compression fractures secondary to osteoporosis and
metastatic disease and are not mutually exclusive. Additional research in this
area in large cohorts of patients is needed to establish these techniques as
safe and clinically cost-effective methods of treating patients with vertebral
compression fractures secondary to spinal metastases.
Khanna AJ, Reinhardt MK, Togawa D, Lieberman IH. Functional outcomes
of kyphoplasty for the treatment of osteoporotic and osteolytic vertebral
compression fractures. Osteoporos Int 2006;17:817-26.
This study presents 314 consecutive patients with progressive and painful
compression fractures, resulting from osteoporosis or multiple myeloma—
fractures that were refractory to nonoperative modalities. The average
Oswestry Disability Index score decreased by 12.6 points (P <.001) in the overall
group, by 11.8 points (P <.001) at short-term follow-up, and by 8.6 points
(P <.001) at long-term follow-up. All SF-36 subscores, except for general health
and role-emotional, showed statistically significant improvement from baseline
values at the same time points. There was no statistically significant difference
regarding functional outcome in the osteoporosis and multiple myeloma
subgroups. Kyphoplasty provided a safe and effective treatment for pain
and disability in patients with vertebral compression fractures secondary to
osteoporosis and multiple myeloma. In addition, we found no statistically
significant difference regarding functional outcome between patients with
osteoporosis and multiple myeloma.
Ledlie JT, Renfro M. Balloon kyphoplasty: one-year outcomes in vertebral body
height restoration, chronic pain, and activity levels. J Neurosurg 2003;98(Suppl
1):36-42.
Ninety percent of patients were ambulating without assistance postkyphoplasty.
No device- or procedure-related complications were noted; 9% had
asymptomatic cement leaks.
Lieberman IH, Dudeney S, Reinhardt MK, Bell G. Initial outcome and efficacy of
“kyphoplasty” in the treatment of painful osteoporotic vertebral compression
fractures. Spine 2001;26:1631-8.
Seventy percent of the vertebral bodies achieved height restoration.
Lieberman IH, Reinhardt MK. Vertebroplasty and kyphoplasty for osteolytic
collapse. Clin Orthop Relat Res 2003 Oct;(415 Suppl):S176-86.
Preliminary data indicate that kyphoplasty is a safe procedure associated with
a lower risk of cement leak, restoration of vertebral body height, and sagittal
spinal alignment. In patients with osteolytic fractures secondary to multiple
myeloma, kyphoplasty yields quick pain relief, and is associated with a
statistically significant improvement in generic health outcome measures.
Majd ME, Farley S, Holt RT. Preliminary outcomes and efficacy of the first 360
consecutive kyphoplasties for the treatment of painful osteoporotic vertebral
compression fractures. Spine J 2005;5:244-55.
Immediate pain relief was achieved in 89% of patients. More than 20% had
restoration of height loss in 69% of the fractures. Cement leaks occurred in
10% of patients, and 12% had adjacent-level or remote fractures.
Procedure 36 | Kyphoplasty 345
McGirt MJ, Parker SL, Wolinsky JP, et al. Vertebroplasty and kyphoplasty for the
treatment of vertebral compression fractures: an evidenced-based review of the
literature. Spine J 2009;9:501-8.
Seventy-four articles were reviewed. Although evidence suggests that physical
disability, general health, and pain relief are better with vertebroplasty (VP)
and kyphoplasty (KP) than those with medical management within the first
3 months after intervention. High-quality randomized trials with 2-year
follow-up are needed to confirm this. Furthermore, the reported incidence
of symptomatic procedure-related morbidity for both VP and KP is very low.
Phillips FM, Ho E, Campbell-Hupp M, et al. Early radiographic and clinical results
of balloon kyphoplasty for the treatment of osteoporotic vertebral compression
fractures. Spine 2003;28:2260-5; discussion 2265-7.
Mean correction of kyphosis was 14.2 degrees. No device- or procedure-related
complications were noted; 9.8% of patients had asymptomatic cement leaks,
and 9% had remote or adjacent-level fractures.
Wardlaw D, Cummings SR, Van Meirhaeghe J, et al. Efficacy and safety of balloon
kyphoplasty compared with non-surgical care for vertebral compression fracture
(FREE): a randomised controlled trial. Lancet 2009;373:1016-24.
This study presents 300 patients who each had 1 to 3 vertebral compression
fractures (VCFs), and they were randomized to kyphoplasty. Outcomes were
measured using SF-36 Health Survey, Visual Analogue Scale, and Quality of Life
scores; narcotic use; and adverse events. The authors demonstrated that
kyphoplasty is more effective than nonsurgical care in acute VCFs, and there
was no difference in frequency of adverse events.
P R O C ED U R E 3 7
Minimally Invasive
Exposure Techniques of
the Lumbar Spine
D. Greg Anderson and Christopher K. Kepler
I N D I CAT I O NS P I T F A L L S
• Any diagnosis making adequate
fluoroscopic imaging of bony elements
difficult or impossible, such as:
• Severe osteopenia
• Intraabdominal contrast
• Severe obesity, wherein a tubular
retractor system is unable to reach
bony anatomy
I N D I CAT I O NS
C O N T RO V E R S IE S
• The relative benefits of MIS compared
with traditional open approaches
continue to be debated.
• Revision surgery, severe deformity, and
severe obesity are conditions that make
minimally invasive spinal surgery (MISS)
more challenging.
T R E A T M E N T OP T I O N S
• The alternative to any MIS procedure
for the lumbar spine is traditional open
surgery.
• With experience, MIS can be applied to
essentially all degenerative conditions;
however, because certain clinical
completion of the surgery with a
minimally invasive approach, the
surgeon should always be prepared to
extend the incision if required to
adequately address the spinal
pathology.
Indications
n
Conditions requiring decompression of the lumbar spine, wherein a minimally
invasive surgery (MIS) technique is desired
n
MIS techniques covered include:
• Lumbar diskectomy/decompression
• Posterior lumbar fusion (PLF)
◆
Posterolateral (onlay)
◆
Posterior lumbar interbody fusion (PLIF)
◆
Transforaminal lumbar interbody fusion (TLIF)
• Anterior lumbar interbody fusion (ALIF)
Examination/Imaging
n
Although it is difficult to define the exact boundaries of a percutaneous, mini-
open, or traditional “open” surgery, the application of less invasive spinal
surgery principles is much more important than the length of the skin incision
(Jaikumar et al, 2002; Lehman et al, 2005).
n
The most important aspect to the success of spinal surgery is proper patient
selection.
n
Before surgery, the surgeon should carefully study the imaging studies (plain
radiographs, magnetic resonance imaging [MRI] and/or computed tomography
[CT]) and develop a surgical plan, including an optimal workflow for the
procedure.
n
Evaluation of imaging is critical, because all relevant pathologic features must
be visualized and addressed to achieve results comparable or superior to an
open operation.
n
Patients with severe osteopenia, obesity, or intraabdominal contrast may be
impossible to adequately image with the C-arm. If adequate fluoroscopic images
cannot be obtained, an alternative surgical strategy should be employed.
n
When setting up for percutaneous pedicle instrumentation, the vertebrae should
be aligned so that, on an anteroposterior (AP) image, the spinous process is
centered between the pedicles, and the superior end plate is parallel to the fluoroscopy beam (the true AP view) (Figure 37-1).
n
On the fluoroscopic lateral image, the pedicles should be superimposed, and
only a single posterior cortex of the vertebral body should be seen (Figure 37-2,
arrow
). The edges of the superior end plate should be superimposed, forming
a single radiopaque line.
Procedure 37 | Minimally Invasive Exposure Techniques of the Lumbar Spine 347
FIGURE 37-1
S U R G IC A L A N AT O M Y
P E A R LS
• Careful fluoroscopic localization of the
surgical incision is mandatory before
making the incision.
• A spinal needle inserted along the
proposed trajectory of the surgical
incision can be used to check the
location of the incision using
fluoroscopy.
• Careful palpation of surgical planes
is useful before using a Kerrison
instrument to remove bone from the
region of the spinal canal.
S U R G IC A L A N AT O M Y
P I T F A L L S
• Avoid “getting lost” by use of both
direct anatomic visualization and
fluoroscopic confirmation of the
position of instruments as needed
during surgery. With experience, less
fluoroscopic confirmation will be
required.
P O S I TI O N I N G PE A R L S
• Failure to adequately position the
patient may result in problems with
direct or fluoroscopic access to a critical
region of the spinal anatomy and may
compromise the results of surgery.
FIGURE 37-2
Surgical Anatomy
n
The radiographic position of all relevant anatomy should be undertaken before
making the initial incision.
n
The incision should be positioned to allow optimal access to the surgical
pathology.
n
The skin and fascia should be sharply divided.
n
The muscle tissue should be gently traversed, working between the muscle
planes or between muscle fascicles.
n
The tubular retractor should be docked to the spine to minimize the need to
resect muscle tissues to visualize the bony anatomy.
n
The bony landmarks should be identified before the resection of any bone.
n
Care should be taken to preserve an adequate amount of the pars interarticularis
and inferior articular process if a fusion of the operative level is not planned.
n
When working in the spinal canal, the epidural fat is a useful clue to localize
the plane beneath the ligamentum flavum, adjacent to the dura.
n
The pedicle is a key landmark to assist the surgeon in localizing the position
within the spinal canal. By palpating the pedicle, the surgeon can gauge the
amount of bony resection and can also localize migrated disk fragments.
n
The exiting and traversing nerve root should be decompressed as needed,
depending on the nature of the patient symptoms and pathology.
Positioning
n
For posterior procedures (microdiskectomy, lumbar decompression, PLF, PLIF, TLIF
etc.), the patient should be positioned prone on a radiolucent spinal table or
frame.
n
The abdomen should be free of compression (Lehman et al, 2005; Seldomridge
and Phillips, 2005).
n
Careful padding of all vital and bony regions should be confirmed.
n
Access for fluoroscopy should be confirmed in the operative position.
n
Access for the operative microscope should be confirmed.
n
For anterior procedures, the abdomen should be widely draped with access from
the xiphoid to the pubis.
n
For lateral interbody fusion procedures (XLIF, DLIF) the patient should be secured
in a “true” lateral position with a slight lateral bend to the lumbar region (away
from the operative incision) to improve access to the lateral aspect of the vertebral body.
348 Procedure 37 | Minimally Invasive Exposure Techniques of the Lumbar Spine
General Aspects to Posterior Tubular Retractor Surgery
n
The learning curve for MIS techniques must be acknowledged and planned for.
n
Reconstructive procedures (Figure 37-3) are more difficult compared with
decompressive procedures and should be approached farther along the learning
curve of the individual surgeon. Additional time should be allotted for surgical
cases in the early portion of the surgeon’s learning curve.
n
The first surgical step is to localize the precise site for all skin incisions using
fluoroscopy (Seldomridge and Phillips, 2005).
• After the skin and fascial incisions are made, serial dilation allows parting of
the paraspinal muscle fascicles, to minimize tissue damage. This allows placement of the tubular retractor against the bony anatomy (Figure 37-4, A).
Fluoroscopic confirmation of tubular retractor position should be performed
(Figure 37-4, B).
• To create a working space, a Cobb retractor is placed through the skin incision
to achieve subperiosteal elevation of the musculoligamentous envelope.
• Use of an operative microscope provides the best visualization, especially
when a decompressive procedure is performed.
FIGURE 37-3
A
B
FIGURE 37-4, A-B