Basic And Clinical Research For Minimally Invasive Endoscopic Spinal Surgery

Objective:To investigate the anatomic level,feasibility,security of the Anterior Endoscopically Assisted Surgery to the Antlantoaxis through Carotid Arterial Triangle.Methods:To dissect 20 cephalo-cervical segments of native adult specimen.(1)To invest the locality relation of the incision with glandula angularis,arteria thyreoidea superior,arteria laryngea superior,arteria lingualis,arteria facialis,hypoglossal nerve etc.To measure the size of the internal and external entrance of the latent anatomic channel located in the Carotid Arterial Triangle area. To investigate the anatomic level,the feasibility and security to establish the endoscopic work path.(2) To survey the morphology of atlantoaxial vertebrae and lateral mass articular and their adjacent relation with arteria vertebralis,C2 nerve root,spinal cord etc,so as to evaluate the feasibility and secure margin of this approach.Result:The superior border of cartilage thyroidea could be the locating marker.The radius of the inscribed circle of the external entrance of the anatomic channel is 3.24±0.35mm in the left and 3.52±0.29mm in the right when the circumscribed circle 8.01±1.15mm in the left and 7.94±0.60mm in the right.And that of the internal entrance is 2.50±0.18mm in the left and 2.68±0.17mm in the right when 5.29±0.47mm in the left and 5.53±0.40mm in the left respectively.That considered to be satisfactory to place the endoscopic tract.Different operation site could be reached by translating or declinating the tract.The anterior longitudinal ligaments,anterior vertebral muscles,contracted cicatricial tissue and abnormal bony conjunction could be resected alternatively.The most important structures beyond the lateral border of lateral mass is arteria vertebralis and C2 nerve root,which part from the median line 24.58±1.90(22.05-26.44)mm and 26.50±1.01(22.82-28.40)mm respectively.The width of release operation of lateral mass should less than 11mm,as the depth less than 12ram.The secure area of operation is within 20mm from the median line.Conclusion:the anatomic layers are clear with the assistance of endoscopy to the antlantoaxial complex through Carotid Arterial Triangle.There are less traction and influence to important vessels and nerves.The operating site could be reached and there are less injuries.The exposure of local anatomic structure is clear.The operation could be more refined and secure.And this approach could be regarded as a new methods to deal with atlantoaxial disorders. Objective:Probe the feasibility and security of thoracoscopic approach to anterior cervicothoracic junction of spine,and provide anatomic evidence and numerical data for the new operative mode.Method:experiment objects:20 adults' cadaveric examples of cervicothoracic junction of spine fixed by formalin. Thoracoscopic approach:One 6-8cm cutaneous incision from the place above manbrium sterni 3cm to the middle manbrium sterni,cut open subcutaneous tissue, platysma muscle,disconnect sternothyroid muscle and sternohyoid muscle.Expose the upper mediastinal at the space between left carotid artery and trachea and esophagus.And at left and right second rid space can be inserted thoracoscope and aspirator through 1cm trocars.Observe interior constitution,hunt fesibility and security of the approach;record the distance between the midpoint of manubrium sterni and each important constitutions,the longitude,width,depth of operative region;then measure and record courser,longitude,caliber of vessels after manbrium; messure and record courser,longitude,caliber,included angle of aortic arch and superior vena and their branches;measure and record longitude,width,depth of C7-T3 vertebrae;the courser,caliber of thoracic duct and major nerves of cervicothoracic junction and left arteria thyreoidea inferior;measure and record the longitude between cupula pleuralis and middle inner 1/3 region of clavicle.All results are made statistical analysis with SPSS 12.0(Mean±2std Error(Min～Max)).Main Results:Longitude of operative region is 67±5.10(53.10～84.48)mm,width is 38.56±3.59(26.62～48.59)mm,depth is 34.63±3.45(21.74～47.87)mm.Distance between parasternal and arteria mammaria interna:LA2;10.12±1.41(4.20～16.29)mm, RA2:10.49±1.35(6.18～17.00)mm,LV2:8.58±1.45(3.29～14.23)mm.RV2:9.06±1.62(5.2 6～16.66)mm.Distance between manubrium sterni and important constitutions: E:41.59±4.00(32.99～52.29)mm,F:41.55±4.38(35.55～55.60)mm,I:44.43±3.94 (33.42～50.27)mm.Longitude between cupula pleuralis and middle inner 1/3 region of clavicle:left:21.71±1.87(12.91～28.66) mm,right:22.78±2.06(12.89～29.76)mm.Conclusion:1.It is feasible to complete operation of cervicothoracic junction of spine through thoracoscopic approach.2.It is saft to complete operation of cervicothoracic junction of spine through thoracoscopic approach.3.This approach have many fortes as follow:opening incision is small,disconnection of sternum or clavicle isn't need,Less injure of arteria(and vena)mamaria interna,less injure of membrana pleuralis,less infection;manipulate eyesight of T2-T3 is clear.And it has generation value. Objective To determine the variability of the anterior vascular anatomy at the lower lumbar spine.To study the reliability and the safety of the operation of lower lumbar spine intervertebral amalgamation through the laparoscope. Methods This study investigated 30 human cadavers(15 males and 15 females).The bifurcation level of the ventralaorta,the confluence level of the common iliac Vein and the course of the great vessels were recorded.The distance from the bifurcation or confluence to the top of L5 / S1 disc and the width of operation window of L5 / S1 disc(the distance from right common iliac artery to left common iliac vein) were determined.The origin of the middle sacral artery,the confluence of the middle sacral vein and the course of them were observed.Results The bifurcation level of the vent ralaorta and the confluence level of the common iliac vein were showed from L4 to L5.The course of the vent ralaorta was in the right front of vertebra,while the course of the common iliac vein was in the left front of vertebra.The distance from the bifurcation to the top of L5/S1 disc was in the average of 3.5cm for males and 3.6 cm for females.The distance from the confluence to the top of L5/S1 disc was in the average of 2.2 cm for males and 2.4 cm for females, while the width of the operation window of L5/S1 disc was in the average of 3.7 cm for males and 3.4 cm for females.The origin of the middle sacral artery was at the back of the bifurcation level,companied with the middle sacral vein of ten. Conclusion The bifurcation level of the vent ralaorta and the confluence level of the common iliac vein were higher than the top of L 5 / S1 disc,The width of the operation window of L5/S1was in the average of 3.7 cm for males and 3.4 cm for females.The anterior operation of the L5 / S1 disc intervertebral amalgamation through the laparoscope is reliable and safe.However,the operation of the L3/4disc and L4/5disc is impossible without significant vascular dissection. Objective:To research the possibility of laparoscopic lumbar spine surgery through human cadavers and pigs to define the effect and operative approach safety in different parts of lumbar spine.Method:The anatomic data of main large vessels at the same level of lumbar verterbrae of 30 human cadaver 15 males and 15 females) were investigated;In animal experiment,40 pigs were divided into 2 groups: one group for retroperitoneal and the other group for transperitoneal laparoscopic approaches to expose L2-S1,to compare their simplicity and safety of the two operative methods.Result:The bifurcation level of the ventral aorta was quite variable in human cadavers,the confluence level of the common iliac vein was consistent:The bifurcation angle of the ventral aorta averaged male 54.9°,female 59.0°,the confl uence angle averaged male 61.4°,female 64.9°,the distance from the bifurcation to the top of L5/S1 disc averaged male 3.5cm.female 3.6cm;The distance from the confluence to the top of L5/S1 disc averaged male 2.2cm.female 2.4cm.the width of the operation window of L5/S1 disc averaged male 3.7cm.female 3.4cm.In animal experiment,it was satisfactory to expose the L6/S1 in the group of transperitoneal,and retroperitoneal laparoscopic approach the L2-L5 verterbrae.Conclusion:The technique of laparoscopic lumbar spine surgery is reliable,convenient,mininvasive and good replication.The retroperitoneal approach is safe,reasonable and efective for exposure of the L2-L5,while transperitoneal laparoscopic approach is easy and reliable for exposure of lower lumbosacral vertebrae. Objective To evaluate the clinical efficacy for the treatment of irreducible atlantoaxial dislocation by video-assisted anterior release through carotid arterial triangle.Method Twelve patients,4 males and 8 females with the mean age of 31.6 years,ranged from 16 to 48 years old.The interval between the onset of the symptoms and the diagnosis averaged 20 months(ranging from 24 to 48 months).The type of disorders included:5 odontoid fracture,3 osodontoideum,3 relaxation of transverse ligament of atlas,1 selfunion of occipital-atlantal junction with short odontoid.The preoperative JOA score was 9.3.Soft(or bone) tissue was released between C1 and C2,skull traction and posterior instrumentation after one week.Result The average anterior operative time was 70min,blood loss was 150ml.The fixation of atlantoaxial was performed in 11 cases and occipitocervical fixation in 1 case.All patients were followed up with average 8 months ranging from 3 to 12 months.There was no infection and fixation failure.The postoperative JOA score was 15.2 which improved to 76.6%.Conclusion Video-assisted anterior release for the treatment of irreducible atlantoaxial dislocation is a safe and effective technique with bright view and lowered risk of trauma. Objective To evaluate the clinical efficacy for the reconstruction of upper cervical spine by video-assisted endoscopic technique via anterior retropharyngeal approach.Methods A total of 15 patients with diseases of upper cervical spine who underwent video-assisted endoscopic reconstruction surgery via anterior retropharyngeal approach from June 2003 to May 2007 were reviewed.The series included 8 males and 7 females,ranging in age from 15 to 63 years old(mean 37.5).The type of upper cervical disorders included basilar invagination in 7 patients, C2vertebral tumor in 6 patients and pseudoarticulation formation with craniocervical fusion in 2 patients.All patients undergone surgery combined anterior and posterior fixation:anterior approach included endoscopic-assisted odonoidectomy,removal of vertebral tumor,decompression and/or bony reconstruction combined fixation;One stage performed posterior craniocervical fixation or C1-3 lateral acess screw fixation. Analyzed the techniques,complications and neurological function.Results Successful surgical operation was achieved in all 15 patients.Anterior odonoidectomy combined removal of anterior arch of atlant viaendoscopic-assisted without reconstruction in 7 cases,anterior odonoidectomy with autograft iliacbone reconstruction combined fixation in 8 cases.Posterior craniocervical fixation had 9 patients and C1-3 lateral acess screw fixation in 6 patients.Complications included injuries of mucous membrane of oropharynx and spinal dura mater in 1 case respectively,1 patients occurred wound infection.With the follow up time of 22 months,There were no failure of internal fixation and tumor recurrence,bony fusion occurred and neurological function was improved in all patients.Conclusion Endoscopically anterior retropharyngeal approach to the upper cervical spine provides a surgical route which has good exposure and lowered risk of trauma.The technique issafe and effective for clearance of anterior vertebral lesions,atlantoaxial release, decompression of spinal cord,bone grafting and interal fixation. Objective To discuss the surgical strategies of thoracoscopy-assisted mini-open surgery in the management of thoracolumbar burst fractures. Methods Between June 2000 and April 2007,42 patients with fractures of the thoracolumbar spine(T11-L1) were treated with a thoracoscopically assisted mini-open procedure.There were 28 males and 14 females and the age of the patients were from 16 to 52 years with an average of 34.7 years.The fractures located at T11 in 8 cases,T12 in 16 cases,L1 in 18 cases.The average kyphotic angle was 23.8 degrees.All cases occurred incomplete paraplegia.Surgery strategy:According to the location of fracture,anterior vertebra resection,decompression,bone graft reconstruction and internal fixation were performed by thoracoscopy-assisted and mini-open surgery via trans-diaphragmatic thoracic approach and retropleural-retroperitoneal trans-diaphragmatic approach.Results 42 surgeries were accomplished successfully using screw-plating system or screw-rod system, transthoracic transdiaphragmatic approach had 28 patients and transdiaphragmatic combined with retropleural and retroperitoneal approach had 14 patients,autograft with iliac bone in 32 cases,titanium mesh cage in 10 cases.The average operation time was 240(160～340) min.The average blood loss was 580(360～1250) ml.The average thoracic cavity drainage time was 3.5(3～6) d.The average postoperation kyphotic angle in fusion segments was 4.8°and the correction rate was 80%. Complications occurred in 6 cases,which is 14.3%of all.During an average of 20.2month follow-up period,internal fixations failure,the loss of corrective kyphotic angle were not observed and all patients had successful fusion.Postoperation neurological improvements were above 1 grade observed in the last follow-up. Conclusion Anterior thoracoscopy-assisted mini-open surgery is a safe,effective mini-invasive spinal surgery procedure to treat thoracolumbar burst fractures.But clinical application is limited in special extent and is needed to perform according to the different endoscopic diaphragma anatomy and pathological characteristics of fracture. Objective To evaluate the clinic effects of thoracoscopy2 assisted mini2open surgery for anterior column reconstruction of thoracic spine tuberculosisl Methods Sixty patients with thoracic spine uberculosis,involving segments T4 to T12,with a kyphotic angle of 29.2 degrees(18-42 degrees),38 males and 22 females,aged 47.4(19～68),with large parasp inal abscess in 50 cases,p leurisy in 17,and dural compression in 42 cases shown by imaging examination, underwent thoracoscopic assisted mini open surgery,including radical debridement and anterior sp inal reconstruction According to Frankel's grade,the preoperative neurological function was judged as:Grade A in 1 case,Grade B in 4,Grade C in 6, Grade D in 19,and Grade E in 30.The patients were followed up for 316 years1 The outcomes were evaluated retrospectively.Results The operation was accomp lished successfully in all 60 patients.The average operative time was 230 min(180～320 min),the average blood loss during operation was 570 ml(350～1200 ml),the mean drainage duration was 3.6 d(3～5d).Complications occurred in 18 patients(30%).30 patients showed neurological imp rovement from 1 to 3 Grades at the last follow up. The average correction rate of kyphotic angle was 36.6%,and no obvious correction losswas detected during the follow up.No patient showed recurrence of tuberculosis. Conclusion Thoracoscopy assisted mini open surgery provides a simple,safe, effective,and practical technology with minimal invasiveness for the treatment of thoracic spine tuberculosis. Objective To evaluate the clinical effects and complications of thoracoscopy- assisted mini-open and open procedures for anterior column reconstruction of thoracic spine tuberculosis.Methods 122 patients with thoracic spine tuberculosis were retrospectively analyzed between March 1998 and March 2004.Group A(underwent thoracoscopy- assisted mini-open):There were 37 males and 22 females with aaverage age of 47.4±4.1 years old.The involved segments were from T₄ to T₁₂,large paraspinal abscess in 50 cases,pleurisy had 17 cases and neurological dysfunction in 29 cases,the average kyphotic angle was 29.2±4.5°with a range of 18°to 42°preoperatively.Group B(underwent open procedures):There were 33 males and 30 females with an average age of 48.3±1.5 years old.The involved segments were from T₃ to L₁,large paraspinal abscess and pleurisy in all patients,neurological dysfunction in 31 cases,the average kyphotic angle was 30.3±1.5°with a range of 19°to 45°preoperatively.Results The operation was completed in 122 patients underwent anterior reconstruction:and screw-rod fixation. The average blood loss,mean drainage volume and tube removed time in group A were less than group B,P＜0.05;The average operative time and clinical outcomes had no difference between A and B;The kyphotic angle correction of preoperative,1 week after operation and follow up had no difference between A and B;The correction of kyphotic angle intergroup analysis P＜0.01。Neurological improved in all patients.The complications:Group A,complications occurred in 18 patients(30%);Group B,complications occurred in 27 patients(51.9%).The average follow-up time was 3.6 years in group A and 3.8 years in group B,neurological improvement had 60 cases,no hardware failure and obvious loss of correction. Conclusion Thoracoscopy- assisted mini-open surgery for anterior column reconstruction of thoracic spine tuberculosis is proved to have the same outcomes as traditional open surgery,it provide a simple,safe,effective and practical minimally invasive spinal surgery technique. Objective:To evaluate the clinical value of thoracoscopy-assisted mini-open surgery combined with tranditional fixation for anterior correction of idiopathic scoliosis.Methods:26 patients of idiopathic scoliosis were retrospectively analyzed from July 2003 to March 2007.There were 10 males and 16 females with an average age of 15.8(12～30) years old.main thoracic curve in 17 cases, thoracolumbar curve in 5 cases and lumbar curve in 4 cases.The coronal Cobb angle before surgery:main thoracic curve was 41°to 55°with an average angle of 46.3°, thoracolumbar curve was 38°to 51°with an average angle of 40.6°,and the lumbar curve was 36°to 47°with an average angle of 39.7°.Surgical method:thoracic scoliosis was instrumented through thoracoscopy-assisted mini-open combined with traditional fixation.The clinical data including perioperative index,complications and correction rate at the follow up.Results:The mean operative time,bleeding loss, drainage and length of incision were 323.9min,704.2ml,349.2ml and 3.5cm respectively,the number of resected disc was 5.1 in average.The coronal Cobb angle after surgery:main thoracic curve was 15.7°with an average correction rate of 66.1%.,thoracolumbar curve was 12.8°with an average correction rate of 68.5%,and lumbar curve was 8.3°with mean correction rate 79%.There were 6 patients occurred postoperative complications and obtained recovery after treatment.The follow-up period was from 12 to 40 months with mean 27.6 months,the loss of correction rate:main thoracic curve was 8.2%,thoracolumbar curve 3.4%and lumbar curve 6.5%.Supplementary posterior instrumentation was performed in one patient, another underwent pain 6 months after surgery and received pain relief by orthosis, there were no others harware failure.Conclusion:Thoracoscopy-assisted mini-open surgery combined with tranditional fixation for anterior correction of idiopathic scoliosis was a less invasive,convenient,effect and economical technique.However, advanced research about the endoscopic instrumentation and results of long term follow-up were needed. Objective:Retrospectively analyze outcomes between mini-open thoracoscopically assited thoracotomy spinal fusion and posterior pedicle acrew spinal fusion for the treatment of Lenke I type adolescent idiopathic scoliosis(AIS),to evaluate the value of the two techniques.Method:Thirty eight patients were enrolled in this retrospective study from January 2004 to March 2007,there were 21 patients (mean age 14.38±1.36) underwent anterior mini-open thoracoscopiclly assisted spinal fusion,the average Cobb angle was 54.52±6.31°in main thoracic curve,and 17 patiens(mean age 13.82±1.85) received posterior segment pedicle screw fixation,the average Cobb angle was 53.71±6.54°in main thoracic curve.Radiographic data were collected preoperatively,immediatetly,and postoperatively at regular intervals. Statistics analysis was used to compare between anterior and posterior surgical group. Result:At the time of the final follow-up(mean 2.2 years),there were no significant difference between the two groups in terms of deformity correction,coronal and sagital balance.The percentage correction was 65.14±10.49%for the mini-open thoracoscopical group,and 68.76±8.24%for the posterior pedicle acrew group. Degree of derotation of apical vertebrea was better achieved by mini-open approach. Also,a kyphogenic effect on the hypokyphotic thoracic spine was achieved by mini-open approach.The mean number of levels fused was 5.4 in the mini-open group, which saved 1.7 levels,compared with 7.1 levels in posterior group.Conclusion: Mini-open thoracoscopically assited thoracotomy spinal fusion had better derotation, kyphogenic effect with fewer fusion segment,which compares favorably with posterior pedicle screw fusion in terms of coronal plane courve correction. Objective;To evaluate the efficacy and safety with one-stage posterior and endoscopic anterior fusion with interbody implants for the treatment of lumbar diseases.Methods:Retrospective analyze twenty-seven patients with lumbar disease,Form Dec.1999 to Jan.2001,treated with this technique.Of these patients,11 males and 16 females,aged from 38 to 61 years old,mean 42.5 years. These were 17 cases of lumbar spondylolisthesis,4 cases of disc inflammation,3 cases of TB,2 cases of lu mbar disc henriation with lumbar unstability and 1 case of unfresh fracture with stemosis and unstability.Anterior inlerbody fusion;ilium 10,BAK 17, all cases were treated by one-stage open posterior methods combined with anterior laparoscopic surgery.Results:The patients were followed up form 6 to 12 months(mean8 m onths).The pre-opeartive clinical symptoms disappeared completely partially.No infection,CSF leak and neurologic complication with all patients.All patients obtained excelent spinal stability and spinal fusion.No implant fracture,BAK dislocation and pseudaurosis.Conclusion;Minimaly invasive laparoscopic spine surgery in the treatment of lumbar diseases is effective and safe technique.