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1、,广州中医药大学第一附属医院脊柱专科,微创与开放手术治疗I-II度腰椎滑脱症,历史沿革,来自希腊语： spondylo(椎体)和Listhesis(滑移)集合而成。1782年 Herbinlaux最先描述了腰5椎体前滑脱病例。1854年 Kilian首先定义脊柱滑脱症(spondylisthesis):“一椎体在另一椎体上部分或完全的滑移”。1957年 Taillard将脊柱滑脱症定义为“由于关节突间连续断裂或延长而引起椎体与其椎弓根、横突和上关节突一同向前滑移。”,流行性病学,Fredrickson BE, et al. The natural history of spondylolysi
2、s and spondylolisthesis. J Bone Joint Surg Am 1984, 500 participants,Jacobsen s Degenerative Lumbar Spondylolisthesis:An Epidemiological Perspective. spine. 2007, 4151 participants ，M ：1533、F：2618 254cases(11.1%),M(1.5%):F(5.9%),M(0.7%):F(1.2%),Kalichman L，Kinm DH, Li L, etal. Spondylolysis and Spon
3、dylolisthesis.Prevalence and Association With Low Back Pain in the Adult Community-Based Population. spine. 2009, 3529 participants ，CT :11.5%,腰椎滑脱的Wiltse分型,Wiltse LL，Newman PH, MacNab I. Classification of spondylolysis and spondylolisthesis. Clin Orthop,1976,117:23-29.,腰椎滑脱程度（Meyerding分型，1932）,Meye
4、rding HW. Spondylolisthesis: surgical treatment and resultsJ. Surg Gynecol Obstet, 1932, 54: 371-37,I,II,III,IV,V,症状,马尾综合症,滑脱进展,Labelle H, Mac-Thiong JM, Roussouly P. Spino-pelvic sagittal balance of spondylolisthesis: a review and classication Eur Spine J,2011,滑脱进展,申勇.中国矫形外科杂志 ,2005,40y,43y,45y,滑脱进
5、展,滑脱进展主要因素,PI BMI Angle of lordosis Bilateral pars defects,Jacobsen s. spine. 2007, Labelle H, Eur Spine J,2011 Beutler WJ, Spine,2003,PI,手术治疗指征,持续或反复发作的腰腿痛、间歇性跛行, 严重影响日常生活, 经合理的非手术治疗 ( 3个月或 3个月以上 ) 无效者; 神经功能障碍进行性加重者; 出现大小便功能异常者,手术与非手术治疗,2-4年随访，LDS手术疗效优于非手术,开放性手术,开放手术,优点 学习曲线短 显露充分、视野大,缺点 椎旁肌肉损伤多 住院
6、时间长 出血多 创伤大 风险高,微创手术,微创手术,优点 创伤小 住院时间短 出血小 术后疼痛轻 康复快 并发症少,缺点 学习曲线长，难掌握 对手术者技术要求高，手术难度大 要求手术者有良好的三维解剖知识 需要专用器械，增加手术成本 暴露不充分，视野小,微创 VS 开放：腰椎滑脱？,Open,Mini,Who is best?,（PLIF）微创 VS 开放： 长期疗效,（PLIF）微创 VS 开放： 长期疗效,（TLIF）微创 VS 开放： 疗效,Conclusion： Minimally invasive surgery（TLIF） for severe SDS（I-II grade） le
7、ads to adequate and safe decompression of lumbar stenosis and results in a faster recovery of symptoms and disability in the early postoperative period.,（PLF）微创 VS 开放： 疗效,Conclusion： The MIS-PLF utilizing a percutaneous pedicle screw system had less invasive, less postoperative pain, rapid improveme
8、nt of several functional parameters compared to conventional open-PLF. This superiority in the MIS-PLF group was maintained until 2 years postoperatively, suggesting that less invasive PLF offers better mid-term results in terms of reducing low back pain and improving patients functional capacity of
9、 daily living.,（PLF）微创 VS 开放： 疗效,（ALIF+TLIF）微创 VS 开放：并发症,Conclusion: MIS(ALIF+TLIF) had less blood loss, less need for transfusion in the perioperative period, and a shorter hospital stay than open(ALIF+TLIF), but the length of surgery, intraoperative uoroscopy time, malpositioned instrumentation on
10、 postoperative imaging, and postoperative complications, including pulmonary embolus and surgical site infection no difference.,（P/TLIF）微创 VS 开放：感染率,Conclusions： In this multihospital study, the MI technique（P/TLIF） was associated with a decreased incidence of perioperative SSI (27 4.6% vs 150 7.0%,
11、 p = 0.037) in 2-level fusion. There was no significant difference in the incidence of SSIs (38 4.5% vs 77 4.8%, p = 0.77) between the open and MI cohorts for 1-level fusion procedures.,(PLIF)微创 VS 开放：多裂肌损伤,微创 VS 开放：多裂肌损伤,微创 VS 开放： 费效分析,CONCLUSIONS: MIS TLIF resulted in reduced operative blood loss,
12、 hospital stay and 2-year cost, and accelerated return to work. Surgical morbidity, hospital readmission, and short- and long-term clinical effectiveness were similar between MIS and open TLIF. MIS TLIF may represent a valuable and cost-saving advancement from a societal and hospital perspective.,微创
13、 VS 开放：住院时间短、费用少,（TLIF）微创 VS 开放： Meta分析,Mini-TLIF VS mini-ALIF：疗效,Mini-TLIF VS mini-ALIF：疗效,MALIF,MTLIF,Mini-TLIF VS mini-ALIF：疗效,Conclusions：Considering the clinical and radiological outcomes in both groups, the authors recommend that instrumented mini-TLIF is preferable at the L45 level, whereas instrumented mini-ALIF might be preferable at the L5S1 level for the treatment of unstable isthmic spondylolisthesis.,正确掌握腰椎滑脱的治疗原则(侯树勋),不是所有的腰椎滑脱都需要治疗 伴有腰痛的腰椎滑脱并非都需要手术 根据滑脱的严重程度选择适当的手术方式 滑脱椎体的融合是手术治疗的最终目的,Thanks for your attention,
