经皮椎弓根螺钉固定技术.pptVIP

经皮椎弓根螺钉固定的技术，挑战和适应症 苏兵 经皮内固定VS开放手术 优点：减少住院日，出血量，及术后止痛药，减少肌肉损伤，更早恢复工作．并发症更少，但是没有证据表明经皮手术就优于开放手术． 缺点：依赖影像，透视时间长，治疗不充分(部分医生认为)． 步骤 (i) C形臂放在前后位，棘突位于椎弓根的中间． (ii) 画出椎弓根影，根据软组织的厚度确定距离中线的距离，以便以适当的角度植入 Jamshidi 针． (iii) 经皮肤切口植入Jamshidi针，使其位于椎弓根的侧缘，即３点钟(iv) 继续插入Jamshidi针20 mm到 25 mm ，保证针尖位于椎弓根内缘． (v) 此时侧位透视Jamshidi针须位于椎体内，即没有穿破椎弓根内壁． (vi) 植入克氏针，沿克氏针进行攻丝． (vii) 沿克氏针植入椎弓根螺钉，注意不要使克氏针穿破前侧皮质． MIS/经皮椎弓根钉植入的特殊问题 改变初始方向． L5/S1 螺钉紧靠． 小椎弓根． 多节段固定的皮肤切口． 多节段固定时杆的植入． 硬化的椎弓根 – dif?cult Jamshidi placement in hard pedicles 改变初始方向 L5/S1 螺钉紧靠 Cannulation of small pedicles 切口 插入棒 　硬化的椎弓根－开放植入椎弓根钉 病例１：腰椎滑脱 病例２：T１２骨折伴A级损伤 病例３：肺癌转移 病例４：丙肝，爱滋，骨髓炎 病例５：腰椎不稳伴侧隐窝狭窄，135kg 病例6:PLIF术后不愈合 病例7:腰椎滑脱 病例8:腰椎不稳 * * Fig.２Image Intensi?er radiographs of the percutaneous technique for pedicle screw insertion showing: (a) anterior/posterior (AP) view of the Jamshidi needle docked onto the lateral aspect of the pedicle – the ‘‘3 o’clock position’’; (b) AP view of advancement of the needle 20 mmto 25 mminto the vertebral body; (c) lateral view, checking the position of the Jamshidi needle in lateral view; (d) lateral view, the K- wire and tapping of the pedicle; and (e) lateral view, insertion of the pedicle screw. Fig. 3.Diagrams illustrating the anatomical principles of percutaneous pedicle screw insertion: views from top to bottom: (a) superior, (b) posterior, (c) lateral, (d) superior. First the initial skin incision is made with the patients’ body habitus in mind. Second, the Jamshidi needle is ?rst ‘‘docked’’ onto the lateral aspect of the pedicle – ‘‘position 1’’ – on the anterior/posterior image intensi?er (II) radiograph projection. Third, the Jamshidi needle is advanced 20 mm to 25 mm so that the needle is beyond the medial border of the pedicle and into the vertebral body – to ‘‘position 3’’. Finally, the position is con?rmed by lateral II radiograph projection before insertion of the K-wire. Fig. 4. Image Intensi?er lateral radiographs showing changing direction of screw placement following initi