MISS 经椎间孔腰椎椎间融合术（TLIF）MISS Transforaminal lumbar interbody fusion

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退行性脊椎滑脱
Degenerative spondylolisthesis
1. 简介

这是 TLIF 的微创手术。手术的目标是直接对神经根进行减压，在有指征时对鞘囊进行减压，插入椎间笼，并用经皮椎弓根螺钉器械稳定该节段。

减少脊椎滑脱（如果存在）并不总是该手术的目标。

这些患者大多患有I级和II级脊椎滑脱。对于较高级别的脊椎滑脱，这种方法可能不合适。

由外科医生自行决定是在 TLIF 之前还是之后放置经皮椎弓根螺钉。

• 经皮后路入路放置弓根螺钉
  

在此处显示的过程中，将首先执行 TLIF。

1. Introduction

This is the minimally invasive procedure for TLIF. The goal of surgery is to directly decompress the nerve root, decompress the thecal sac when indicated, insert an interbody cage, and stabilize the segment with percutaneous pedicle screw instrumentation.

Reduction of spondylolisthesis, when present, is not always the goal of this operation.

Most of these patients have Grade I and Grade II spondylolisthesis. For higher-grade spondylolisthesis, this approach may not be appropriate.

It is up to the surgeon’s discretion whether percutaneous pedicle screws are placed before or after the TLIF.

• Percutaneous posterior approach for pedicle screw placement
  

In the procedure shown here, TLIF will be performed first.

2. 所需仪器

建议使用此专用仪器进行此过程：

• 管状牵开器系统，直径 18–26 mm 的管，可变长度或镜面牵开器
• 手术显微镜
• 脑脊液修复套件
  

刺刀式 MISS 仪器：

• Kerrison rongeurs 1-4 mm，45° 和 90° 角
• 垂体肺
• 球尖神经钩
• 刀
• 各种尺寸和角度的刮匙
• 锉刀
• 圆盘剃须刀
• 试验
• 椎间植入物
• 神经根牵开器
• 高速金刚石或侧切（火柴棒）毛刺，带有超长角度或弯曲的手机
• 吸力
  

2. Required instruments

The following specialized instruments are recommended for this procedure:

• Tubular retractor system, 18–26 mm diameter tubes, variable lengths, or specular retractor
• Surgical microscope
• CSF repair kit
  

Bayonetted MISS instruments:

• Kerrison rongeurs 1–4 mm, 45° and 90° angle
• Pituitary rongeurs
• Ball tip nerve hook
• Knife
• Curettes of various sizes and angles
• Rasps
• Disc shavers
• Trials
• Interbody implant
• Nerve root retractor
• High-speed diamond or side-cutting (matchstick) burr with an extra-long angled or curved handpiece
• Suction
  

3. 手术室设置和患者定位

患者俯卧，腹部自由悬垂。臀部和胸部有衬垫。该姿势应促进腰椎前凸。

• MISS 经椎间孔腰椎椎间融合术 （TLIF） 的俯卧位
  

3. OR setup and patient positioning

The patient is positioned prone with a free-hanging belly. The hips and chest are padded. The position should promote lordosis of the lumbar spine.

• Prone position for MISS Transforaminal lumbar interbody fusion (TLIF)
  

4. 手术区域可视化
切口部位的标记

触诊棘突并标记双侧中线和髂嵴。

根据小关节切除和椎间放置的偏侧性，使用 K 线和 AP 透视在水平和垂直方向上标记预期水平的颅骨和尾部蒂。

在入路一侧颅椎弓根和尾椎弓根的同侧外侧边界外侧标记一条垂直切口线 1-2 厘米。

4. Visualization of the surgical field

Marking of the incision site

Palpate the spinous processes and mark the midline and the iliac crests bilaterally.

Based on the laterality of facet resection and interbody placement, K-wires and AP fluoroscopy are used to mark the cranial and caudal pedicles of the intended level horizontally and vertically.

Mark a vertical incision line 1–2 cm lateral to the ipsilateral lateral borders of the cranial and caudal pedicle on the side of the approach.

切口

在上一步计划的位置进行 4-5 厘米的皮肤切口。该切口最终也可用于同侧经皮椎弓根螺钉插入。

解剖至筋膜。

在皮肤切口的内侧做一个 2.5 厘米的筋膜切口。

插入第一个扩张器，稍微向内侧倾斜，并“感觉”棘突和椎板的底部。

请注意： 应避免使用 K 线，以防止意外硬脑膜损伤。
Incision

Perform a 4–5 cm skin incision at the location planned in the previous step. This incision can ultimately also be used for percutaneous pedicle screw insertion on the same side.

Dissect down to the fascia.

A 2.5 cm fascial incision is made medial to the skin incision.

Insert the first dilator, angle slightly medially, and “feel” for the base of the spinous process and lamina.

Note: Use of K-wires should be avoided to prevent accidental dural injury.

将第一个扩张器放置在骨头上后，使用透视检查验证它是否位于正确的水平。

After the first dilator has been positioned on the bone, verify that it is located at the correct level using fluoroscopy.

在第一个扩张器的引导下进行顺序扩张。

确定所需的管长度并将最终的管状牵开器水平插入皮肤。

Proceed with sequential dilation guided by the first dilator.

Determine the required tube length and insert the final tubular retractor level to the skin.

将卷收器固定到桌面安装的臂上。

Secure the retractor to the table-mounted arm.

使用显微镜进行可视化。或者，可以使用外窥镜或放大镜和前照灯。

插入显微镜，使外科医生可以平行于脊柱放置。这个位置将有助于定位。

Visualization

Use the microscope for visualization. Alternatively, an exoscope or loupes and headlights may be used.

Insert the microscope so that the surgeon can be positioned parallel to the spine. This position will help with orientation.

在显微可视化下，覆盖在骨结构上的肌肉被单极凝固暴露出来，小关节囊被打开。

应观察颅层的外侧和下缘、同侧小关节的内侧边界和同侧关节间部。

Under microscopic visualization, muscles overlying the bony structures are exposed with monopolar coagulation, and the facet capsule is opened.

The lateral and inferior edges of the cranial lamina, the medial border of the ipsilateral facet joint, and the ipsilateral pars interarticularis should be visualized.

5. 同侧减压
下关节突切除术

使用钻头或截骨器切除下关节突。

骨手术的主要标志是：

• 椎板下内侧缘 （A）
• 关节间部 （B）
  

从 A 点到 B 点采取 L 形或弯曲路线。

使用大垂体 rongeur 收获下关节突。这块骨头可以用于以后的融合。

5. Ipsilateral decompression

Resection of the inferior articular process

Resect the inferior articular process using either a drill or an osteotome.

The main bony surgical landmarks are:

• Inferior medial border of the lamina (A)
• Pars interarticularis (B)
  

An L-shaped or curved course is taken from point A to point B.

Use a large pituitary rongeur to harvest the inferior articular process. This bone can be used for fusion later on.

关节上突切除术

识别尾蒂的上壁，然后使用毛刺或截骨术断开并收获上关节突。

这块骨头可以用于以后的融合。

Resection of the superior articular process

Identify the superior wall of the caudal pedicle and then use a burr or an osteotome to disconnect and harvest the superior articular process.

This bone can be used for fusion later on.

切除黄韧带

用球尖钩从下面的硬脑膜中释放黄韧带。从外侧到内侧切除黄韧带，以暴露孔内的椎间盘。

Resection of the ligamentum flavum

Release the ligamentum flavum from the underlying dura with a ball tip hook. Resect the ligamentum flavum from lateral to medial to expose the disc within the foramen.

椎间盘切除术

去除黄韧带后，椎间盘将可见。退出的神经根穿过可见野颅缘剩余的关节间部下方，横穿的神经根可以在内侧可见。

双极凝血与冲洗可用于控制椎间盘上方血管的硬膜外出血。

确保使用球尖钩将椎间盘材料从硬脑膜中释放出来。

Discectomy

After removing the ligamentum flavum, the disc will be visible. The exiting nerve root passes under the remaining pars interarticularis at the cranial margin of the visible field, and the traversing nerve root may be visualized medially.

Bipolar coagulation with irrigation can be used to control epidural bleeding from vessels overlying the disc.

Ensure that the disc material is freed from the dura using a ball tip hook.

使用盒形切口打开椎间盘。确保所有切口从内侧到外侧，远离横贯神经，从上到下，以避免无意中伤害退出的神经根。

Open the disc using a box-shaped incision. Ensure all incisions are made from medial to lateral, away from the traversing nerve, and from superior to inferior, to avoid inadvertent injury of the exiting nerve root.

使用垂体环和刮匙进行零碎的椎间盘切除术。

Perform a piecemeal discectomy using pituitary rongeurs and curettes.

使用锉刀剥离终板。从椎骨终板上完全去除软骨。

Decorticate the endplates using a rasp. Completely remove the cartilage from the vertebral endplates.

将剃须刀插入光盘空间并旋转，逐渐分散光盘空间的注意力。取出剩余的圆盘材料并继续使用更大的圆盘剃须刀，直到达到最大程度的分散注意力而不损坏端板。试验可用于进一步确认最佳种植体尺寸。

Insert a disc shaver into the disc space and rotate, progressively distracting the disc space. Remove the remaining disc material and continue using larger disc shavers until maximal distraction without endplate damage is achieved. A trial can be used to further confirm the optimal implant size.

将碎骨移植物装入椎间盘切除空间的前部。

Pack morselized bone graft into the anterior portion of the discectomy space.

结构植入物

将适当尺寸的结构植入物，填充有额外的骨移植物，撞击到椎间盘切除空间，内侧瞄准椎间盘的前三分之一。

Structural implant

A structural implant of appropriate size, filled with additional bone graft, is impacted into the discectomy space, aimed medially towards the anterior third of the disc.

拍摄 AP 和侧向 X 射线以确认笼子在椎间盘空间内的适当位置。

为了达到最大的脊柱前凸，笼子应尽可能靠前。

AP and lateral X-Rays are taken to confirm the appropriate positioning of the cage within the disc space.

In order to achieve the maximum lordosis, the cage should be positioned as anteriorly as possible.

额外减压（如果需要）

如有必要，可以在倾斜手术台的情况下进行额外的减压，以治疗更多的中央狭窄。更多信息可以在这里找到：

• 用于双侧减压的显微管状单侧椎板切开术 （MT-ULBD）
  
  
  

Additional decompression (if required)

If necessary, additional decompression can be performed with the table tilted to treat more central stenosis. More information can be found here:

• Microscopic tubular unilateral laminotomy for bilateral decompression (MT-ULBD)
  

6. 拔管

止血是通过止血剂或双极烧灼术实现的。

用纱布将管子包装五分钟通常可以进行凝固。

不建议使用外用类固醇，以免干扰融合过程。

慢慢取出管子。任何肌肉出血都应被识别并烧灼。

筋膜通常使用间断缝合线闭合。用局部麻醉剂浸润肌肉是可选的。

进行皮下层和皮肤的标准多层闭合。

6. Tube removal

Hemostasis is achieved with hemostatic agents or bipolar cautery.

Packing the tube with gauze for five minutes will usually allow coagulation to take place.

Topical steroids are not recommended so as not to interfere with the fusion process.

The tube is slowly removed. Any muscular bleeding should be identified and cauterized.

The fascia is typically closed using interrupted sutures. Infiltration of the muscle with local anesthetics is optional.

Standard multilayer closure of subcutaneous layers and skin is performed.

7. 善后护理

患者通常可以在第二天出院，服用短期止痛药。

单节段手术通常不需要腰椎固定。对于高危患者或多节段融合，腰椎固定由外科医生自行决定。

患者可能会感到切口或肌肉疼痛，通常会在几天内消退。

7. Aftercare

The patient can usually be discharged on the following day with a short course of pain medication.

Lumbar immobilization is typically not required for one-level procedures. For high-risk patients or multilevel fusion, lumbar immobilization is at the surgeon’s discretion.

Patients may feel incisional or muscular pain that usually subsides within a few days.