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Summary

? ??? ??? ?? ??? ?????? ? ? ??? ?? ??? ??? ???? ????.

Cite this Article

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Safaee, M., Oh, T., Pekmezci, M., Clark, A. J. Cone Beam Intraoperative Computed Tomography-based Image Guidance for Minimally Invasive Transforaminal Interbody Fusion. J. Vis. Exp. (150), e57830, doi:10.3791/57830 (2019).

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Abstract

???? ? ?? (TLIF)? ????? ?? ???, ??? ??? ?? ? ?? ?? ??? ?????. ?? ?? ?? (MIS) ??? ???? ?? ??? ?? ??? ???? ?? ??? ?? ?? (EBL), ?? ?? ? ????? ?? ????? ??? ?? ? ??? ???????. ?? MIS TLIF ??? ?? ??? ??? ??? ?? ??? ??? ? ??? ??? ??, ?? ?? ? ??? ??? ?? ??? ?? ??? ????. ??? ?? ? ??? ?? ?? (CT) ??? ???? ??? ????? ?? ??? ?? ??? ?? ???? ?? ??? ? ???? ??? ?????. ??? ?? ???? ???? ?? ??? ?? ? CT ?? ?? ?? ??? ?? ?? (PSIS)? ?????. ?? ?? ??? 1?? ?? ??? ?? ??? ??? ??? ?? ?? ??? ?????. ? ?? ?? ??? ??? ?? ??? ???? ???? MIS-TLIF?? ??, ??? ?? ?? ?? ??? ???? ?? ??? ?? ?? ??? ? ????. ?? ???? ???? ??? ?, ?? TLIF ??? ??? ??????? ?????. ? ??? ?? ??? ??? ? ??? ??? ??? ? ??? ???? ??? ????.

Introduction

TLIF? ??? ??? ??? ?? ??? ?? ?? ? ??? ??? ? ??? ??? ? ?? ?? ? ?????. TLIF ??? ??? ?? ???? ?? ?? ? ??(PLIF) ???? ??? ???? ???? ?????. ?? ?????, TLIF? ?? ??? ??? ???, ??? ?? ?? ??? ??? ?? ?? ??? ?? ??? ??, ???? ???? ???? ??? ? ??. ??? ? ?????, TLIF ??? ?? ?? ?? 1? ???? ????? ?? ??? ?????. ?? TLIF? ??(O-TLIF) ?? ????(MIS-TLIF) ? ??? ??? ? ???, MIS-TLIF? ?? ??? ?? ? ???? 2,3,4??? ?????? ???? ????? ?????. O-TLIF? ??, MIS-TLIF ?? ?? ??? ?? ?????., ?? ?? ??, ??? ? ?? ??; ?? ?? ? ??? ?? ??? ?? ??? MIS ?? ?? ?????, ??? MIS-TLIF? ?????????? ????? ?? ?? ?? ?? 5,6,7, 8,9,10,11.

???, ???? MIS ??? ??? ??? 46-147 s12??? ???? ? ??? ??? ??? ? ?? ??? ??? ??, ?? ?? ? ??? ??? ????? ?????? ?? ??? ????. ??? ???? ?? ? CT ?? ?????? ??? ??????, O-arm/STEALTH, Airo Mobile ? ????? ?? ????? ???? ??? ?? ?? ???? ??? ? ?? ??? ???? ????. 13? , 14 ??? ??? ?? ??? ?? ???? ??? ??? ?????? ??? ?????? ??? ???? ??? ??????15,16,17,18, 19. ? ????? ??? ?? ?? ? ?? ?? ??? ??? MIS-TLIF? ?? ??? ??? ???? ???? ?????? ??? ??? ? ?? ??? ?????. ? ??? ??? ??? ?? ???? ??? ??? ?????? ??? ??? ??? ??? ???? ?? ? ?? ???? ??? ????.

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Protocol

?? ?? ? ?? ??? ?? ?? ??? ?? (CHR #17-21909)?? ???????.

1. ?? ? ??

  1. ???? ?? ??? ????, ?? ???? ??? ??? ?? ???? ??? ??? ?????.
  2. ?? ?? ???? ??? ?? ???? ????????.

2. ?? ? ??

  1. ??? TLIF? ??? ?? PSIS ???? #15 ????? ???? ?? ??? ??? ???.
  2. ?? ??? ???? ?? ??? ?? ??? ?? ????? ???? (?? 1A). ????? ???? ???? PSIS??? ???? ?? ??? ??? ???? ?? ??? ???? S1??? ???? ?? ???? ??? ?????(? 1B).
  3. ??? ?? ? ????? ?? ?? ??? ??? ? ?? ? CT ??? ?????.
  4. ????? ???? ??? ??? ?? ?? ??(?1C); ??? ????? ?? ?? ??? ? ? ? ??? 1 ?? ??? ?? ?? ?? 3.5 cm ?? (2 ??? ? ? 1.5 ??, ??? 1.75 3 ??? ? ? ??).
  5. ?? ?? ???? 2-3mm ?? ? ?? ??? ???? ???? ????? K-???? ???? ??? ??? ?????.
  6. TLIF ??? ? ?? k-??? ?? ?? ?? ?? ??? ??? ??? ????.
  7. ????? ???? ???? ??? ???? ? ?? ??? ???? ???? ??? ??? ?? ??? ?????(??1D). ??? ?? ? ?? ?? ?? ??? TLIF ???? ?? ?? ???? ?????.
  8. ?????? ?? ???? ??? ?????.
  9. ???? ?? ?? ???? laminotomy, flavectomy ? ?? ???? ??? ?????.
    1. ??? ???? ?? ???? ???? ?? ?? ??? ??????. ?? laminotomy? ??? ??, ?? ??? ??? ???? ???? ?? ? ??? ????? ????.
    2. ??? ???? ?? ??? ? ??? ?? ???? ????, ??? ???? ?? ??? ???? ?? ?????????. ?? ?????? ???? ???? ?? flavum? ??????. ??? ????, ?? flavum? ???? ?? 2 ?? 3 mm ??? ???? ?????.
      ??: ?????? ???? ???? ?? ??? ??? ??? ????? (??1D,E).
  10. ??? ??? ??? ??, ???? ???? ????? ??? ???? 2 ?? 3 mm ??? ???? ???? ??? ???, ?? ??, ??? ??? ??? ?????.
  11. ???? ??? ???? ?????? ?? ??? ??? ?? ??? ???? ?? ?? ??? ?????.
  12. ???? ???? ??? ??? ?????.
  13. ?? ???? ???? ??? ?? ???? ???? ???? ??? ?? ?? ?? ??? ??? ??? ????? ??????? ??? ?????(??2A).
  14. ?? ???? ? ????? ?? ?? ? ??? ?? ?? ??? ???? ??? ??? ????? ?????.
  15. ???? ???(polyetheretherketone[PEEK])? ????, ?? ? ?? ??(AP) ?????(?2B)??? ? ??? ????.
  16. TLIF? ???? ??? ??? ??? ????.
  17. ????? ?? ?? ?? ?? ?? ??? ?? ?? ???? ??? ??. ??? ?? ??? ???? ?? ???? ?? ???? ??????.
  18. ??? ???? ???? ???? ??? ? ?? ?? ??? ?????.
  19. ?? ?? ?? ???? ??? ???? ????.
  20. 0 ????? 910 ???? ????? ??, 3-0 ????? 910?? ?? ??? ??, ?? ?? ????? ?? ????? ??????. ? ? ???? ?????.

3. ?? ? ??

  1. ???? ?? ???? ?? ? 1 ??? ??? ???? ?? ?? 36?? X ?? ???? (?? 2C).
  2. ???? ??? ?? ??????? ?? ?? ?? ??(PCA) ??? ??? ?? ???? ?? ? 1??? ????? ?????.
  3. ??? ?? ?? ???? ???? ?? ? 2-3?? ???? 6? ? ?? ??? ????.

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Representative Results

50?? ??? ?? ?? ?? (AC)??? ??? ??? ?????. ?? ??? 53?(29-84?)??? ??? 30?, ??? 20?????. ??? ?? ???? ?? ? ?? : ?? ??? (n = 45), ?? ? (n = 29), ?? ?? (n = 5), ??? ????? (n = 3), ??? ??? ??? ??? (n = 1). ??? 42??? ??? ?? ??? ???, 2??? ?? ?? ??? ???, 6?? ??? ??? ???? ???. 10? ???, ??? ???? ??? ?? ??? ?????. ??? ?1? ???? ????.

?? ???? 25?, ??? 25??? ?????. 33?? ?? ?? ??, 15?? 2?? ??, 2?? 3?? ??? ?????. ?? ??? ??? ????: L4-5 (n=35), L5-S1 (n=27), L3-4 (n=7), ? L2-3 (n=2). ?? ??? ??? 10.2 mm????. ?? ?? ??? 240?, ?? EBL? 80mL????. ?? ? ??? ?? ??? ? ?? ??? ??? ??? ???; ?? ??? 200?, 2??? 306?, 3??? 393?(p&0.001)???. ?? ??? ?? 62.0 mGy, ? ?? 35.3 ?? ? CT ???? mGy ? 26.2 ?? ????? mGy. ?????? ?? ?? ??? 42.2s???, ?? ? CT ???? 5.2s, ???? ????????? 37.1s????. ?? ? ??? ?? ??? 3 ???? (?? 1-7 ?). ??? ?2? ???? ????.

Figure 1
?? 1 : MIS-TLIF? CT ?? ?????. ?? ?? ??? ?? ?? (A)? ???? ?? ????? ??? ?? ?????. ????? ?? ???? S1 ??? ??(B)? ?? ???? ??? ??? ?? ?? ??? ??????? ?? ? ?? ??? ?? ??? ????. ??? ?? ??? ????? ???(C)? ???? ??????. ??? ??? ?? ??? ?????(D)? ???1 ?? ???? ???? ????. ?? ? ?????? ???? ???(E) ? ???(F) ??????? ???? ?? ?? ??? ?????. ? ??? ? ? ??? ??? ??? ??????.

Figure 2
?? 2 : ?? ??? ??? ?? ?? ? ?? ??? ??. ?? ???? ??? ?? ??? ???? ?? ???? (A)? ??????? ?? ?? ???? ?? ? ?? ?? ?????. ???? ??? ?? ??(B)? ???? ?? ????. ? ?? 36 ?? ???? (?? ?? ??) ?? (C) ?? ?? ??? ?? ??. ? ??? ? ? ??? ??? ??? ??????.

?? N=50
??
??(??) 53 (29-84)
??
?? 20 (40%)
?? 30 (60%)
Bmi
??(??) 30 (21-41)
???
? ? ? 45 (90%)
???? 29 (58%)
? ?? 5 (10%)
?? 3 (6%)
??? ??? 1 (2%)
?? ??
?? 2 (4%)
?? 6 (12%)
?? 42 (84%)
?? ?? 10 (20%)

? 1: ?? ?? ??.

?? N=50
??
?? 25 (50%)
??? 25 (50%)
??? ?? ?
?? 33 (66%)
? 15 (30%)
3? 2 (4%)
??? ??
L2/3 2
L3/4 7
L4/5 35
L5/S1* 27
??? ??(mm) 10.2 (7-14)
?? ? ?? ?? (ml) 80 (10-550)
?? ??(??) 240 (88-412)
??? ?? (mGy)
?? ? CT 35.3 (21.5-68.7)
Fluoroscopy 26.5 (4.3-64.3)
? 62.0 (28.9-120.7)
??? ?? (?)
?? ? CT 5.2 (1.0-24.5)
Fluoroscopy 37.1 (8.7-94.6)
? 42.2 (12.2-100.0)
?? ??(?) 3.1 (1-7)
* L5/L6 ???? ?? ?? 1?

? 2: ??? ??.

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Discussion

??? ???? ? ?? ??? ??? ????. ? ?? ??? ??? ?? ?????. ?? ??? ??? ??? ???? ?? ??? ?? S1 ??? ?? ??? ???? ??? ???? ??? ???? ???. ? ?? ??? ??? ?? ? CT ??? ??? ? ??? ???? ???? ???, ?? ???? ??? ??? ???? ??? ??? ?????? ?? ? ? ????. ???? ????? ???? ???. ??? ??? ?? ?? ? ??? ?? ?? ??? ??? ??? ? ??? ????. ??? ???? ??? ?? ???? ?????. ?????, ?? ?? ?? ??? ??? ?? ?? ??? ??? ???? ???? ??? ?? ? ????. ?? ?? ??(?: ??? ?? ?? ?)? ??? ? ?? ??? ???? ???20. ???? ???? ???? ?? ????? ?? ?? ??? ??? ?? ???? ???? ?? ??? ???? ?? ???? ??????.

? ?? ??? ??? ??????? ?????? ? ?? ??? ??? ??? ??? ? ?? ??? ???? ??? ??? ?? ??? ??????? ???? ????. MIS-TLIF? PEEK ??? ???? 15%21??? ? ???? ??? ??? ????? ??????, ?? ? ?? ??? ?? ?? ? ????. ?????? ??? ? ??22,23????? ? ?? ?????. ???? ?? ?? ??? ? ???? ??? ?? ? ??? ?? ????? ? ??? ? ? ????. ?? ????? ?? ????? ??? ?? ???(24)? ???? ?? ??? ? ??. ?? ???, ?????? ? ??? ?? ??? ??? ?? ????, ?? ?? ???, ?? ? ??? ?? ??. ??? ?? ?????? ??? ??? ??? ????? ??? ?????? "???" ?? ???? ?? ??? ? ?????? ??? ???? ??? ??? ??? ?? ??? ?????.

?? ?? ?? ??? ??? ??? ? ?? ????? ?????? ??? ?? ?? ?? ????? ???? ???? ????. ??? ?? ??? ??? ?? ?? ??? ???? ????? ?? ??? ???? ??? ?? ? ???? ???? ??? ???. ? ??? ????? ??, ??? ?? ??20???? ? ? ???? ??? ???? ??? ?? ????.

MIS ??? ?? ?? ??25? ??? ?? ??? ???? ?? ??? ???? ??? ??? ??? ????? ???? ??? ????. ??? ??? ??? ?? ??? ???? ??? ???? ?? ??? ?? ??? ??? ?????? ??? ???? ? ?????25. ??? ?? ?? ? CT ??? ???? ??? ?? ??? ??? ??? ??? ??? ? ????. Villard ?. ?? ?? ??? ??? ??? ??? ?? ?? ?? ?? ??? ??? ??? ???? ?? ?? ???? ?? 10 ? ???? ?? ??????26. Tabaree ?? O-arm? ??? C-arm? ??? ???? ????, ??? ??? ????? ?? ????? ??27??? ?????? ?? ?????. iliosacral ?? ??? ?? ? ?? ?? ????, Theologis ?. O-arm? ??? ??????? ??? ?????? ?? ??28.

? ??? ??? ??? ??? ??? ??? ?? ??? ???? ????. ?? ??? ? ?? ?? ???? ??? ??? ? ??? ????, ??? ???? ???? ??? ?? TLIF? MIS-TLIF? ???? ???? ?????. ??? ??? ??? ?? ??? ??? ????, ??? ??? ??? ?? ? ?? ?? (45-105 s? ?? 42 s)? ??? ????. ???, ??? ?? ??? ?? ?? ??? ???? ??? ??? 57%(35.4 mGy)? ???? ?? ? CT ??? ?? 62.0 mGy?????; ??? Mendelsohn et al.? ?? ??? ?? ??? ???? ?????, ?? ?? ?? ??? ?? ?? ? CT? 8.74 ??29???? ???? ? ??? ???? ???????. ???, ???? ??? ??? ??? ?? ??? ??? ??? ??? ? ?? ??? ?? ?? ???? ??? ??? ????? ?? ??? ? ?? ??? ??? ??? ?????. ? ??? ??? EBL ? ?? ??? ?? ??? ??? ???? ?????.

??? ??? ??? ? ??? ????? ??? ? ?? ??? ?? ???? ?? ? CT ??? ?? ??? ????? ????. ?? BMI ? ?? ??? ??? ?? ??? ???? ????. ? ? ?? habitus? ??? ??? ??? ???? ??? ??? ??? ???? ???? ???? ?? ? ????? ??? ?? ??? ??? ? ????. ??? ?? ??? BMI? ?? ?? ??? ??? 0.358? Pearson ?? ??? ??(p=0.013), ??? BMI? ?? ??? ?? ??? 0.003? ? (p = 0.983), ?? ??? ??, ???? ?? ??? ??, BMI? ????? ?????.

? ??? ??? ???? ?? ?????. ?? ?? ? CT ??? ?? ??? ?? ??? ??? ??? ??? ?? ??? ? ?? ?? ???? ? ??? "?? ??"? ?????. ?? ? CT ?? ???? OR ?? ??? ???? "?? ??"? ????? ? ?? ??? ??? ? ????. ?? ? CT ??? ??? ??? ??? ??? ???? ???, ?????? ????? ?? ??? ?? ??? ????. ??? ????? ??? ??? ? ????, ??? ?? ?? ? ??? MIS-TLIFs? ?? ??? ??? ?? ???? ?????. ??? ? ?? ??????, 41.6 s? ?? ?? ??? ??? ???? ??? ?? ???? ????? ?? ?????; ??? ??? 2 ? 3 ?? ??? ????? ?? ??? ?, ? ???? ?? ?????. ?? ??? ??? ?? ? ??? ????? ??? ??? ?? ??? ?????? ??? ? ?? ??? ??? ????.

?????, ? ????? MIS TLIF? ??? ? ?? ? CT ?? ?? ? ???? ?? ???? ???? ???? ??? ??? ???? ?? ?? ??? ??? ?????. ??? ??? ??30,31,32?????? ???? ??? ?????. ? ??? ??? ? ?? ? ??? ?? ???? ??? ???? ??? ??? ??? ????. ?? ?? ??? ??, ??? ??? ???? ??? ?? ??? ??? ? ????.

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Disclosures

?? ??? ??? Nuvasive? ???????. ???? ??, ??? ??, ? ??? ??? ?? ??.

Acknowledgments

??? UCSF ?? ??? ???? ??? ?? ? ? ??? ?? ??? ??? ???? ????.

Materials

Name Company Catalog Number Comments
O-arm intraoperative CT Medtronic, Minneapolis, MN
Stealth Navigation System Medtronic, Minneapolis, MN
Jamshidi Needles for bone marrow biopsy
Cefazolin  antibiotic.
Vicryl Sutures
Steri-Strips for skin closure
Telfa dressing
Tegaderm for dressing
Jackson table
15-blade
High-speed bone drill
Tubular dilator
K-wires
Reduction towers
TLIF retractor
2 or 3 mm Kerrison rongeur
Woodson elevator
Disc shaver and distractor
Fluoroscopy
Allograft cellular bone matrix
Interbody cage
Rod
Soft lumbar brace
X-ray
Patient-controlled analgesia pump

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References

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