Learning objectives: 學習重點

Transcription

1 Chan YK 陳英琪醫生 Chief, Spine Division, Consultant & Deputy Chief of Ser vice, Dept. Or thopaedics & Traumatology/ Pamela Youde Nethersole Eastern Hospital Hong Kong SAR, China

2 Learning objectives: 學習重點 Is it safe? 怎樣能確保手術安全 Understand how to avoid injury to the existing nerve root & other neural damage What are the limitations? 手術肓點 Anatomical & pathological barrier to surgical access Can it be used to cover all types of PID? 如何處理 複雜困難個案 Discrepancy between what you can see & what you can reach How to place the skin incision & design the trajectory

3 Dorsal approach Transforminal approach 經椎間孔放入單孔直椎間盤內視鏡 Innocent disc material excised Targeted prolapsed disc excision 對肌肉或關節帶來傷害 Disruption to extensor muscle Excision/detachment of ligamentum flavum: scaring Ner ve/ dural sac retraction

4 Pre-op MRI Post-op MRI Advantages of Percutaneous Endoscopic Lumbar Disc Surgery Pre-op MRI No muscle trauma No bony damage No scar Direct approach to target pathology 沒有對肌肉 或關節帶來 傷害 局部麻醉 Post-op MRI

5 Transforaminal Targeted Fragmentectomy: Pre-op planning for a safe surgical access 從椎管外到內按部放入內 視鏡 皮膚傷口點 椎間盤突出點 椎間孔點 小面關 S Point (Skin incision) P Point 節點 F Point (Pathology) (Foraminal entry) Dural sac Superior articular facet Exiting nerve root

6 椎間孔點 / 小面關節點 F Point (Foraminal entry) Kambin Triangle Dura (hypertrophic superior articular facet) 小面關節 Exiting nerve root 奔出神經根 Upper endplate of lower vertebra 從椎管外到內按部放入內視鏡

7 Trajectory: 皮膚傷口點 二十五度內視角度 S Point 25 degree to horizontal (Skin incision) a/b=2/1 Anterior neurovascular structure are not breach Horizontal access tract will breach peritoneum esp. L34 or above

8 腰椎五胝椎一椎間盤向下突出 The patient can recover earlier : Minimal tissue trauma Less / minimal post-operative pain Awake surgery: Local / MAC No blood loss Short hospital stay (90% <post op D1 discharge) F/51, L5S1 PID, left sciatica, (L)S1 radiculopathy 手術後即日回家 1 cm pin hole wound Walk unaided freely 4 hrs post-

9 Discrepancy between what you can see & where you can reach 單一工作通道 上方工作肓點 單一工作通道 Alter the S point & F point to bring the instrument to the working zone

10 Transforaminal PELD for Large Central PID 正中椎間盤突出 More horizontal instrument inclination Foraminoplasty Superior Dural sac articular facet Exiting nerve root Beware: Horizontal placement of instruments can injure peritoneum, esp. over L34 level

11 Trans-foraminal PELD for Far lateral PID 極端外側 突出 Superior articular a/b=3/2 Dural facet sac PID Exiting nerve root Outside in technique: Start from the facet & move ventral along the pedicle, then Move from the pedicle of the lower vertebra cranially to find the far lateral PID Use the trochar to separate the PID from the exiting nerve root

12 Pre-op MRI F/60: Left L34 far lateral PID, 極端外側突出 left quadricep weakness, Positive femoral stretch test, Parathesia left L3 dermatome Post-op MRI Radiculogram: to visualize the exiting nerve root Full recovery

13 c Illustrated Case: M/34: right sciatica, L45 central + sequestrated 脫離椎間盤水平面的突出 PID

14 脫離椎間盤水平面的突出 從相反方向放入椎間盤內視鏡 Contra-lateral Trans-foraminal PELD: Difficult case: Sequestrated PID (detached, medial to & block by ipsilateral pedicle) 椎弓根內側 Dural sac Superior articular facet Cranial Cauda l Pedicle Exiting nerve root inclinatio n

15 Pre-op MRI Ipsilateral approach: can only tackle central PID Post-op MRI

16 Pre-op MRI 從相反方向放入椎間盤內視鏡 Contra-lateral approach: tackle sequestrated PID Post- (2nd) op MRI

17 Case 2: F23: right sciatica, L45 sequestrated PID & L5S1 central PID

18 Contra-lateral Trans-foraminal PELD 從相反方向放入椎間盤內視 鏡 : Sequestrated PID 脫離椎間盤水平面的突出 (detached, medial to & block by pedicle ) Dural sac Superior articular facet Cranial Cauda l Pedicl e Exiting nerve root Dural sac Foraminoplasty + outside in technique Hypertrophic Superior articular facet Cranial Cauda l Pedicl e inclinatio n Exiting nerve root inclinatio n

19 Case 3: M/54, left sciatica, L45 sequestrated PID

20 Pre-op MRI Case 4: M/50: right sciatica, L5S1 sequestrated PID Post-op MRI Contra-lateral approach for PID sequestrated just medial to pedicle 從相反方向放入椎間盤內視鏡

21 Difficult accessible site: High iliac crest for L5S1 PID +/- facet hypertrophy

22 Trans-foraminal PELD: In patient with hypertrophic facet 小面關節骨刺增生 Dural sac Hypertrophic Superior articular facet PID Exiting nerve root Outside in technique + Foraminoplasty PID 小面關節整型術 經內視鏡局部切除骨刺 改善椎間盤內視鏡設入角度 防止對奔出神經根做成擠壓創傷之機會

23 F/48: left Sciatica L5S1 PID, High riding pelvis, Obstructing facet joint 小面關節整型術 Foraminoplasty [outside in technique]

24 小面關節整型術 Foraminoplasty Left L5S1

25 Pre-op MRI ase 小面關節整型術 Foraminoplasty Case / L45 Post-op CT

26 Alter the inclination & rotation of discoscope Outside in technique (L5S1 & high riding pelvic brim 盆骨位置阻擋內視鏡路徑 )

27 Outside-In 從椎管外到內按部放入內視鏡 There is wide variation in the working zone. Blind puncture of annulus by working cannula or obturator may be dangerous The safer procedure is the direct viewing of the annulus by endoscopy before annulotomy. The working cannula should be inserted into foramen as close as possible to the facet joint

28 Outside In technique 從椎管外到內按部放入內視鏡

29 Surgical safety: Outside in technique Guide the endoscope in through a probe under direct endoscopic vision Rotate and advance the endoscope slowly in

30 Dural sac Sequestrat ed disc disc Contra-lateral approach for sequestrated PID [Outside in technique] 從椎管外到內按部放入內視鏡 從相反方向放入椎間盤內視鏡 Exiting nerve roo

31 Short term improvement: 5% Case requiring fusion Case 1: F/50 left sciatica, L45 left Recurrent PID, fenestration + diskectomy done 4 yr ago 短暫成功案例 : 5%

32 Pre-op Post-op (4 hr)

33 Pre-op MRI Post-op MRI Extension Flexion 6 months post-op Left medial ankle pain, back pain, further flattening of L45 disc Pre-op Standing

34 Improved after L45 fusion 3 years post fusion

35 Case 2: F/54 right sciatica, L45 & L5S1 fenestration + diskectomy + inter-spinous spacer done 6 months ago, recurrent L5S1 PID

36 6 month after PELD: Back pain L45 instability Narrow L5S1 intervertebral foramen improved after fusion 脊椎熔合手術 巳存在的椎間盤乘拕力失

37 分析失敗案例 Limbus fracture; F/16: leg + back pain

38 F 50: L34 stenosis old limbus fracture

39 M/50: Right sciatica, Complication: Exiting nerve root neuropraxia, Narrow intervertebral foramen + PID improved 8 wk post-op/ RTW: 10 wk Pre-op MRI Post-op MRI

40 不理想案例 Serious complication: 1 patient 神經根創傷 Permanent neuropathy: symptomatic side nerve injury (foot drop): Contralateral PELD for L45 sequestrated disc Awake procedure but patient suffered from anxiety neurosis on medication, not able to give response during operation

41 Bring home messages: Confirmed the location of disc pathology (herniation) from image Balance: surgical approach/ pathology / technique

42 Patient Selection: Contra-indication: Pathology factor Long lasting calcified disc, Limbus fracture Superior migrated L5S1 PID Incompetent disc/ instability Patient factor Poorly motivated/ inconsistent clinical presentation Patient who cannot cooperate in awake surgery Difficult to communicate (or under effect of drug) Over sensitive patient (e.g. to needle pick) Cannot tolerate prone lying Special technique 特別技術 : (Outside-in 從椎管外到內按部 放入內視鏡 ) Sequestrated disc L5S1 PID High iliac crest / Facet hypertrophy /Narrow disc height Large central prolapse