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Lumbar Minimally Invasive Approach：PLIF

微創(chuàng)腰椎后路椎間融合術(shù)

Introduction （介紹）

A posterior lumbar interbody fusion (PLIF) is performed to remove a degenerating disc that is the source of back or leg pain and fuse spinal vertebrae with bone grafts. It is called a posterior procedure because the spine is approached through an incision on the back. In patients with spinal instability, instrumentation is used to provide space for placing the grafts and to help stabilize the spine. Using a technique known as minimally invasive surgery, this procedure can be done with a much smaller incision than traditional open spinal surgeries and avoids damaging the low back muscles.

　　后路腰椎椎間融合術(shù)（PLIF）用于去除引起腰腿痛的退變椎間盤并對脊柱植骨融合。因?yàn)橥ㄟ^后方的切口進(jìn)行脊柱顯露,，因此稱為后路手術(shù),。對于有脊柱不穩(wěn)的病人,，可使用內(nèi)固定為植骨提供空間并幫助脊柱穩(wěn)定,。使用稱為微創(chuàng)手術(shù)的技術(shù)，比傳統(tǒng)開放脊柱手術(shù)切口更小,，并避免損傷腰部的肌肉,。

Incision and Dilation （切口、擴(kuò)張）

Two short incisions, approximately 2.5 cm. (1 in.) each, are made on either side of the middle of the lower back. A device that projects live X-ray images onto a screen, called a fluoroscope, is typically used to pinpoint the exact position on the spine where the surgery will be performed. Next, a thin wire or needle is inserted through tissues and muscle to the level of the spine on each side. Special dilators are guided down the wire to separate muscle fibers and provide access to the underlying spine without cutting through the muscles. After the initial dilators are docked on the back of the spine, larger dilators are added, gradually increasing the diameter to allow enough room for the surgical procedure on each side.

　　在腰椎正中的兩側(cè)各作一條約2.5cm（1英寸）長的切口,，通常使用稱為透視的能將X線圖像投射到顯示屏的機(jī)器來準(zhǔn)備定位即將手術(shù)的脊柱部位,。然后，在兩側(cè)分別插入一根細(xì)的導(dǎo)絲或針到達(dá)該節(jié)脊柱,。用特殊的擴(kuò)張管沿著導(dǎo)絲將肌纖維分開，不用切開肌肉就能夠提供到達(dá)深部脊柱的途徑,。當(dāng)初級擴(kuò)張管到達(dá)脊柱后方,，套上更粗的擴(kuò)張管，逐漸增加擴(kuò)張管的直徑,，使兩側(cè)有足夠的空間完成手術(shù),。

Retractor and Instrument Set Up （安裝牽開器及器械）

A retractor device that can expand the surgical field and hold back the muscle is placed over the dilators. The dilators are removed and a lighting component is attached to illuminate the surgical field. A hex screwdriver is used to open the retractor blades, holding the soft tissue out of the way. The surgical exposure is now complete. An endoscope or microscope is then added to the edge of the retractor to provide close-up imagery on a screen to help guide the procedure.

　　在擴(kuò)張管外面放入牽開器，以撐開手術(shù)野,，將肌肉阻擋在外,。撤走擴(kuò)張管，安裝光源組件,，為術(shù)野照明,。用六角螺絲刀將牽開器的頁片打開，將軟組織擋在外面,。至此,，手術(shù)顯露完成,。在牽開器的邊緣安裝內(nèi)鏡或顯微鏡，在屏幕上顯示放大的圖像,，幫助引導(dǎo)手術(shù),。

Excision （切除）

Cutting instruments are used to remove portions of the lamina (laminectomy), and portions of facet joints (facetectomy) from the back of the vertebrae on each side. Removing bone here allows the surgeon to see the degenerating disc. A grasping instrument is used to remove most of the intervertebral disc by entering through the incisions on either side. Removing the abnormal disc relieves the pressure.

　　用切割工具將椎板的一部分去除（椎板切除術(shù)），并切除椎體兩側(cè)后方的關(guān)節(jié)突關(guān)節(jié)的一部分（關(guān)節(jié)突切除術(shù)）,。將這些骨切除使外科醫(yī)生能看到退變的椎間盤,。通過兩側(cè)的切口用抓鉗去除大部分椎間盤。去除異常的椎間盤使壓迫得以解除,。

Instrumentation （內(nèi)固定）

Next, the vertebrae are prepared for instrumentation. A sharp awl is used to make holes in the pedicles for insertion of pedicle screws. Screws are placed through a metal plate and then into the pedicle holes, ending with the screw tips in the middle of the vertebral body. Screws and plates are placed on both sides of the spine. Two more pedicle screws are then placed through the metal plate and screwed into the lower vertebral body pedicles.

　　然后,，準(zhǔn)備在椎體內(nèi)植入內(nèi)固定物。用尖銳的錐子在椎弓根部位鉆孔,，以擰入椎弓根螺釘,。螺釘通過金屬板擰入到椎弓根的孔內(nèi)，直到螺釘?shù)募舛说竭_(dá)椎體的中間,。在脊柱的兩側(cè)均安裝螺釘和鋼板,，然后再通過鋼板在下位椎體的椎弓根內(nèi)擰入兩枚椎弓根螺釘。

Distraction and Graft Placement （撐開,、植骨）

To prepare for bone graft insertion, the disc space is spread apart (distracted) by moving the vertebral bodies or applying pressure on the pedicle screws. The screws are tightened to hold the disc space in this open position. Two bone grafts are then placed between the vertebral bodies. The bone grafts allow for eventual fusion as bone grows between the vertebral bodies. In variations of this procedure, spacers, cages packed with graft material, or ground bone graft material may also be packed into the disc space to aid with the fusion.

　　為準(zhǔn)備植骨,，通過移動椎體或在椎弓根螺釘上施力將椎間隙分開（撐開）。將螺釘固定維持椎間隙張開的位置,。在兩個(gè)椎體之間植入植骨塊,。植骨塊使骨頭在兩個(gè)椎體之間生長達(dá)到最終的融合。這一步驟方法各異,，可以用間隔器,、使用植骨材料的融合器或?qū)⒀兴榈闹补遣牧先胱甸g隙以幫助融合。

Compression （加壓）

To provide stability to the spine while the fusion occurs, the lower screws are loosened and the vertebral bodies are squeezed together (compressed). The screws are tightened in the compressed position, which allows for a tight fit of the grafts in between the vertebral bodies. Small screws called blockers are placed on the pedicle screws to lock the screws to the metal plate.

　　為了在融合過程中為脊柱提供穩(wěn)定性,，將下位的螺釘放松,，然后將上下椎體壓緊（加壓），并將螺釘在加壓的位置上擰緊,，這樣在上下椎體和移植骨之間緊密接觸,。在椎弓根螺釘上裝入小螺絲（稱為螺塞），將螺釘鎖定到金屬板上,。

Summary （總結(jié)）

The Minimally Invasive Surgery (MIS) approach can be safely performed with less trauma to the surrounding muscles. MIS procedures can result in less postoperative pain, shorter hospitalizations and quicker patient recovery than traditional open surgical methods.

　　微創(chuàng)手術(shù)安全,、對周圍肌肉損傷更少，與傳統(tǒng)開放手術(shù)相比,，術(shù)后疼痛更輕,，住院時(shí)間更短，患者恢復(fù)更快,。

（高晨珉    轉(zhuǎn)）