內視鏡穿腰大肌手術對腰椎融合有效


  Aug. 4, 2004 - 根據一項發表在8月1號脊髓期刊(Spine)的前瞻性試驗結果顯示,內視鏡穿腰大肌側向手術方式是安全的,且對前椎體融合手術中暴露的腰椎較不具侵入性,此外,對大血管與交感神經叢的風險也較低。
  
  加州洛杉磯Cedar-Sinai脊髓疾病機構Darren L. Berger醫師與其同事指出,腰椎的標準內視鏡方式需要固定大血管與交感神經叢,這種手術明顯的併發症是血管損傷與逆向射精,而腹膜後、經腰大肌的方式對腰椎可能可降低這些風險。
  
  21位因椎間盤疼痛、脊椎不穩定性接近之前融合位置、漸進性退化性脊柱側彎的病患接受手術,研究人員以內視鏡側向腰大肌方式暴露出腰椎,這些病患在手術前症狀持續的平均時間為13年(範圍從3-30年)。
  
  17位接受單層融合手術病患,平均手術時間為149分鐘(範圍從120-170分鐘);平均失血量為150毫升(範圍從50-650毫升);一位病患因為之前手術癒合位置位於腹膜後,因此轉接受小範圍方式手術,且被排除在試驗外;術後平均留院時間為4.1日。
  
  20位病患中,17位(84%)以視覺量表(VAS)評估腰大肌疼痛的疼痛指數有明顯改善;出院後一星期,平均疼痛指數相較於術前明顯降低(2.2〔範圍從1-5)相較於8.2〔範圍從6-10)。
  
  手術中並未發生血管損傷;6位(30%)病患發生鼠蹊/大腿處短暫性麻痺,且其中5位(20%)隨後發生鼠蹊/大腿處疼痛,手術後8週平均VAS為4.3(範圍從2-8)降低到1.5(範圍從0-4);除了2位病患外,所有病患的症狀於1個月內緩解。
  
  有15位病患經過平均追蹤3.1年(範圍從2個月-6年)後,平均VAS從5.9降低到3.2(範圍從0-5);13位年齡低於65歲的病患,有11位(84%)得以繼續他們的職業。
  
  9位(60%)病患認為他們的結果是「出色的」,且願意為了緩解同樣疼痛而再次接受手術;3位(20%)病患認為他們的結果是「良好的」,且可能會再次接受手術;剩下的3位病患(20%)則認為他們的結果是「尚可的」,且不確定是否再次接受手術。
  
  研究人員指出,為了椎體間融合對腰椎的腹腔鏡方式使用椎間融和器,這項技術比較不會造成手術疼痛及併發症、較短的住院時間、更快的恢復時間、短時間內可以回到工作崗位以及正常的生活是吸引人的;這些早期結果顯示,對於L1到L4前融合,側向內視鏡經腰大肌方式是安全的、侵入性較低的方式。

Endoscopic Transpsoas Approach

By Yael Waknine
Medscape Medical News

Aug. 4, 2004 — The endoscopic lateral transpsoas approach is a safe and minimally invasive method of exposing the lumbar spine in anterior vertebral fusion surgery and poses minimal risk to large vessels and the sympathetic plexus, according to the results of a prospective study published in the Aug. 1 issue of Spine.

"Standard anterior endoscopic approaches to the lumbar spine require mobilization of the great vessels and sympathetic plexus," write Darren L. Berger, MD, and colleagues, from the Cedars-Sinai Institute for Spinal Disorders in Los Angeles, California. "Vascular injury and retrograde ejaculations are complications clearly associated with this approach. A retroperitoneal, transpsoas approach to the lumbar spine may reduce these risks."

The investigators employed an endoscopic lateral transpsoas approach for exposure of the lumbar spine in 21 patients undergoing surgery for discogenic pain, spinal instability at a level adjacent to a previous fusion, or progressive degenerative scoliosis. Average duration of symptoms prior to surgery was 13 years (range, 3-30 years).

Average operative time was 149 minutes (range, 120-170 minutes) for 17 patients (81%) undergoing single-level fusion; average blood loss was 150 mL (range, 50-650 mL). One patient, converted to a mini-open approach due to prior surgical scarring in the retroperitoneal space, was excluded from the study. Average postoperative hospital stay was 4.1 days.

Of the 20 patients, 17 (84%) reported immediate improvement in pain scores as measured on a visual analog scale (VAS). Mean pain score at one week postdischarge was significantly decreased compared with preoperative score (2.2 [range, 1-5] vs. 8.2 [range, 6-10]).

No vascular injuries occurred. Transient paresthesias in the groin/thigh region occurred in six patients (30%) and were accompanied by groin/thigh pain in five of these (27%), with a mean VAS score of 4.3 (range, 2-8) that decreased to 1.5 (range, 0-4) at eight weeks after surgery. Symptoms resolved within a month in all but two patients.

During a mean follow-up of 3.1 years (range, 2 months - 6 years) in 15 patients, average VAS scores decreased by 5.9 to 3.2 (range, 0-5). Of 13 patients younger than 65 years, 11 (84%) resumed their occupations.

Nine patients (60%) considered their outcome as "excellent" and would undergo surgery again for the same pain relief. Three patients (20%) rated their outcome as "good" and would likely undergo repeat surgery. The remaining three patients (20%) considered their outcome to be "fair" and were unsure whether they would undergo surgery again.

"[L]aparoscopic approaches to the lumbar spine for interbody fusion using threaded cages...are attractive in that they offer the potential for less perioperative pain and morbidity, shorter hospital stays, quicker recovery times, and a faster return to work and the patient's normal lifestyle," the authors point out. "These early results show the lateral endoscopic transpsoas approach to the lumbar spine to be a safe, minimally invasive method for anterior fusion of L1 through L4."

The authors report no pertinent financial disclosures.

Spine. 2004;29:1681-1688

Reviewed by Gary D. Vogin, MD

    



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