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Lumbar Minimally Invasive Approach：PLIF 微创腰椎后路椎间融合术 Introduction （介绍） A posterior lumbar interbody fusion (PLIF) is performed to remove a degenerating disc that is the source of back or leg pain and fuse spinal vertebrae with bone grafts. It is called a posterior procedure because the spine is approached through an incision on the back. In patients with spinal instability, instrumentation is used to provide space for placing the grafts and to help stabilize the spine. Using a technique known as minimally invasive surgery, this procedure can be done with a much smaller incision than traditional open spinal surgeries and avoids damaging the low back muscles. 后路腰椎椎间融合术（PLIF）用于去除引起腰腿痛的退变椎间盘并对脊柱植骨融合。因为通过后方的切口进行脊柱显露，因此称为后路手术。对于有脊柱不稳的病人，可使用内固定为植骨提供空间并帮助脊柱稳定。使用称为微创手术的技术，比传统开放脊柱手术切口更小，并避免损伤腰部的肌肉。 Incision and Dilation （切口、扩张） Two short incisions, approximately 2.5 cm. (1 in.) each, are made on either side of the middle of the lower back. A device that projects live X-ray images onto a screen, called a fluoroscope, is typically used to pinpoint the exact position on the spine where the surgery will be performed. Next, a thin wire or needle is inserted through tissues and muscle to the level of the spine on each side. Special dilators are guided down the wire to separate muscle fibers and provide access to the underlying spine without cutting through the muscles. After the initial dilators are docked on the back of the spine, larger dilators are added, gradually increasing the diameter to allow enough room for the surgical procedure on each side. 在腰椎正中的两侧各作一条约2.5cm（1英寸）长的切口，通常使用称为透视的能将X线图像投射到显示屏的机器来准备定位即将手术的脊柱部位。然后，在两侧分别插入一根细的导丝或针到达该节脊柱。用特殊的扩张管沿着导丝将肌纤维分开，不用切开肌肉就能够提供到达深部脊柱的途径。当初级扩张管到达脊柱后方，套上更粗的扩张管，逐渐增加扩张管的直径，使两侧有足够的空间完成手术。 Retractor and Instrument Set Up （安装牵开器及器械） A retractor device that can expand the surgical field and hold back the muscle is placed over the dilators. The dilators are removed and a lighting component is attached to illuminate the surgical field. A hex screwdriver is used to open the retractor blades, holding the soft tissue out of the way. The surgical exposure is now complete. An endoscope or microscope is then added to the edge of the retractor to provide close-up imagery on a screen to help guide the procedure. 在扩张管外面放入牵开器，以撑开手术野，将肌肉阻挡在外。撤走扩张管，安装光源组件，为术野照明。用六角螺丝刀将牵开器的页片打开，将软组织挡在外面。至此，手术显露完成。在牵开器的边缘安装内镜或显微镜，在屏幕上显示放大的图像，帮助引导手术。 Excision （切除） Cutting instruments are used to remove portions of the lamina (laminectomy), and portions of facet joints (facetectomy) from the back of the vertebrae on each side. Removing bone here allows the surgeon to see the degenerating disc. A grasping instrument is used to remove most of the intervertebral disc by entering through the incisions on either side. Removing the abnormal disc relieves the pressure. 用切割工具将椎板的一部分去除（椎板切除术），并切除椎体两侧后方的关节突关节的一部分（关节突切除术）。将这些骨切除使外科医生能看到退变的椎间盘。通过两侧的切口用抓钳去除大部分椎间盘。去除异常的椎间盘使压迫得以解除。 Instrumentation （内固定） Next, the vertebrae are prepared for instrumentation. A sharp awl is used to make holes in the pedicles for insertion of pedicle screws. Screws are placed through a metal plate and then into the pedicle holes, ending with the screw tips in the middle of the vertebral body. Screws and plates are placed on both sides of the spine. Two more pedicle screws are then placed through the metal plate and screwed into the lower vertebral body pedicles. 然后，准备在椎体内植入内固定物。用尖锐的锥子在椎弓根部位钻孔，以拧入椎弓根螺钉。螺钉通过金属板拧入到椎弓根的孔内，直到螺钉的尖端到达椎体的中间。在脊柱的两侧均安装螺钉和钢板，然后再通过钢板在下位椎体的椎弓根内拧入两枚椎弓根螺钉。 Distraction and Graft Placement （撑开、植骨） To prepare for bone graft insertion, the disc space is spread apart (distracted) by moving the vertebral bodies or applying pressure on the pedicle screws. The screws are tightened to hold the disc space in this open position. Two bone grafts are then placed between the vertebral bodies. The bone grafts allow for eventual fusion as bone grows between the vertebral bodies. In variations of this procedure, spacers, cages packed with graft material, or ground bone graft material may also be packed into the disc space to aid with the fusion. 为准备植骨，通过移动椎体或在椎弓根螺钉上施力将椎间隙分开（撑开）。将螺钉固定维持椎间隙张开的位置。在两个椎体之间植入植骨块。植骨块使骨头在两个椎体之间生长达到最终的融合。这一步骤方法各异，可以用间隔器、使用植骨材料的融合器或将研碎的植骨材料塞入椎间隙以帮助融合。 Compression （加压） To provide stability to the spine while the fusion occurs, the lower screws are loosened and the vertebral bodies are squeezed together (compressed). The screws are tightened in the compressed position, which allows for a tight fit of the grafts in between the vertebral bodies. Small screws called blockers are placed on the pedicle screws to lock the screws to the metal plate. 为了在融合过程中为脊柱提供稳定性，将下位的螺钉放松，然后将上下椎体压紧（加压），并将螺钉在加压的位置上拧紧，这样在上下椎体和移植骨之间紧密接触。在椎弓根螺钉上装入小螺丝（称为螺塞），将螺钉锁定到金属板上。 Summary （总结） The Minimally Invasive Surgery (MIS) approach can be safely performed with less trauma to the surrounding muscles. MIS procedures can result in less postoperative pain, shorter hospitalizations and quicker patient recovery than traditional open surgical methods. 微创手术安全、对周围肌肉损伤更少，与传统开放手术相比，术后疼痛更轻，住院时间更短，患者恢复更快。 （高晨珉 转） |
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