one turnover:one cycle 1-4 years one remodeling:one cycle 2-5 mos Osteoclasts:2-4 weeks Osteoblast:2-4 mos Fig. 1 one remodeling slip length 5 mm slip

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1 特集脊椎脊髄 asics and Recent Advances in Lumbar Spinal Fixation Masaki Mizuno, M.D., Keita Kuraishi, M.D., and Hidenori Suzuki, M.D. Department of Neurosurgery, Mie University Graduate School of Medicine Lumbar spinal fixation surgery is often selected to treat low back pain and the neurological symptoms of cauda equina and nerve root disorders. Lumbar spondylolisthesis, lumbar disc disease and foraminal stenosis, all of which have lumbar instability and bony degeneration, are indications for lumbar spinal fixation with interbody fusion, postero lateral fusion and posterior fusion. Fixation surgery contributes to the improvement of low back pain and lower extremity pain in the short term, but if the procedure becomes complicated, the incidence of complications also increases, and adjacent spine degeneration becomes a problem in the long term. Therefore, it is important to be aware that surgical procedure selection is a major factor in the patient s prognosis. In this article, we describe the basic procedure for fixation in lumbar degenerative diseases, and describe the details of the procedure, such as posterior lumbar interbody fusion and postero lateral fusion, based on the patient s historical background. In addition, the recently developed minimally invasive techniques, such as the percutaneous pedicle screw, the cortical bone trajectory screw and lateral lumbar interbody fusion are discussed, and their features and effectiveness are explained. Received February 1, 2017 accepted March 28, 2017 Key words lumbar spinal fixation, PLIF, PLF, lateral lumbar interbody fusion, cortical bone trajectory screw Jpn J Neurosurg Tokyo , 2017 はじめに腰椎固定術の適応 5 mm Address reprint requests to Masaki Mizuno, M.D., Department of Neurosurgery, Mie University Graduate School of Medicine, Edobashi, Tsu shi, Mie , Japan 353

2 one turnover:one cycle 1-4 years one remodeling:one cycle 2-5 mos Osteoclasts:2-4 weeks Osteoblast:2-4 mos Fig. 1 one remodeling slip length 5 mm slip angle 10 instrument 腰椎固定術と骨癒合固定術は骨癒合を目指す 2 TCP Fig. 1 interbody fusion postero lateral fusion PLF posterior fusion Fig. 2 posterior lumbar interbody fusion PLIF Cloward

3 Hawaii neurosurgeon PLF 15 pedicle screw PS 7 PLIF 1 9 interbody fusion 1 8 Fig. 3 A anterior lumbar interbody fusion ALIF retroperitoneal approach mini ALIF PLIF PLIF PS PEEK poly eter eter ketone PEEK PEEK PEEK Fig. 2 one graft for fusion A Interbody fusion Postero lateral fusion C Posterior fusion C 椎体間固定術の種類と方法腰椎固定術の低侵襲化

4 2 経椎間孔腰椎椎体間固定術 (transforaminal lumbar interbody fusion:tlif) TLIF 12 exiting nerve root safety triangle 2 cm 3 Cortical bone trajectory スクリュー (CT screw) CT screw 13

4 A Fig. 3 3DCT of the lumbar spine A Preoperative 3DCT showing disc degeneration and a decrease in disc height in L3 4 and L4 5. Postoperative 3DCT showing improved alignment and disc height. cortical bone trajectory TLIF PPS Fig. 5 1 経皮的椎弓根スクリュー (percutaneous pedicle screw:pps) PPS Fig. 4 2 経椎間孔腰椎椎体間固定術 (transforaminal lumbar interbody fusion:tlif) TLIF 12 exiting nerve root safety triangle 2 cm 3 Cortical bone trajectory スクリュー (CT screw) CT screw 13 trajectory Fig. 6 midline lumbar fusion with CT screw microsurgery 6 4 側方腰椎椎体間固定術 (lateral lumbar interbody fusion:llif) instrument extreme lateral lumbar interbody fusion XLIF 4 oblique lumbar interbody fusion OLIF

5 Transforaminal lumbar interbody fusion

5 A C D Fig. 4 Percutaneous pedicle screw A Guide wire insertion under fluoroscopy. Percutaneous pedicle screwing using a guide wire. C End result of four piece screw insertion. D Post percutaneous rod insertion. A Fig. 5 Transforaminal lumbar interbody fusion and percutaneous pedicle screw A At L4 5 TLIF. Arrow indicates the cutting position on the L4 inferior facet. Arrow head indicates the cutting position on the L5 superior facet. An interbody cage was inserted from the safety triangle. 357

osteoporotic patient A A dorsal 3DCT CT image.

C Axial CT scan image showing a CT screw at the

D Axial CT scan image showing a CT screw at the

6 A C D Fig. 6 Cortical bone trajectory screw for osteoporotic patient A A dorsal 3DCT CT image. Lateral view of a CT screw. C Axial CT scan image showing a CT screw at the L4 level. D Axial CT scan image showing a CT screw at the L5 level. PPS 1 Fig. 7 5 その他の技術 O arm CT instrument Hybrid Hybrid OR cone beam CT Fig. 8 成人脊椎変形高侵襲手術の中での低侵襲手技の応用 SRS Schwab 14 X PPS LLIF Fig

7 L3 L3 L4 L4 A C Fig. 7 XLIF A Postoperative A P x ray showing a large XLIF interbody cage. A postoperative lateral x ray showing proper XLIF cage alignment. C Postoperative CT scan showing an inserted XLIF cage. Fig. 8 Intraoperative cone beam CT demonstrating the position of screws and cages during a procedure in the Hybrid operation room 359

A Fig. 9 Adult spinal deformity A Preoperative scoliotic deformity of the thoracolumbar spine. Postoperative alignment of the spine with lumbar XLIF fusion.

2 Dhall SS, Choudhri TF, Eck JC, Groff MW, Ghogawala Z, Watters WC 3rd, Dailey AT, Resnick DK, Sharan A, Mummaneni PV, Wang JC, Kaiser MG Guideline update for the performance of fusion procedures for

8 A Fig. 9 Adult spinal deformity A Preoperative scoliotic deformity of the thoracolumbar spine. Postoperative alignment of the spine with lumbar XLIF fusion. SRS Schwab おわりに 36 3 COI COI 文献 1 Cloward R The treatment of ruptured lumbar intervertebral discs by vertebral body fusion.. Method of use of banked bone. Ann Surg , Dhall SS, Choudhri TF, Eck JC, Groff MW, Ghogawala Z, Watters WC 3rd, Dailey AT, Resnick DK, Sharan A, Mummaneni PV, Wang JC, Kaiser MG Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 5 Correlation between radiographic outcome and function. J Neurosurg Spine , Eck JC, Sharan A, Ghogawala Z, Resnick DK, Watters WC 3rd, Mummaneni PV, Dailey AT, Choudhri TF, Groff MW, Wang JC, Dhall SS, Kaiser MG Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 7 lumbar fusion for intractable low back pain without stenosis or spondylolisthesis. J Neurosurg Spine , Goodrich JA, Volcan IJ Extreme Lateral Interbody Fusion XLIF. St Louis, Quality Medical Publishing, Kaiser MG, Groff MW Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. J Neurosurg Spine , Mizuno M, Kuraishi K, Umeda Y, Sano T, Tsuji M, Suzuki H Midline lumbar fusion with cortical bone trajectory screw. Neurol Med Chir Tokyo 54, , Moran JM, erg WS, erry JL, Geiger JM, Steffee AD Transpedicular screw fixation. J Orthop Res , Mummaneni PV, Dhall SS, Eck JC, Groff MW, Ghogawala Z, Watters WC 3rd, Dailey AT, Resnick D, Choudhri TF, Sharan

9 A, Wang JC, Kaiser MG Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 11 interbody techniques for lumbar fusion. J Neurosurg Spine , Ray CD Threaded titanium cages for lumbar interbody fusions. Spine Phila Pa , Resnick D, Watters WC 3rd, Sharan A, Mummaneni PV, Dailey AT, Wang JC, Choudhri TF, Eck JC, Ghogawala Z, Groff MW, Dhall SS, Kaiser MG Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 9 lumbar fusion for stenosis with spondylolisthesis. J Neurosurg Spine , Resnick D, Watters WC 3rd, Mummaneni PV, Dailey AT, Choudhri TF, Eck JC, Sharan A, Groff MW, Wang JC, Ghogawala Z, Dhall SS, Kaiser MG Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 10 lumbar fusion for stenosis without spondylolisthesis. J Neurosurg Spine , Rosenberg WS, Mummaneni PV Transforaminal lumbar interbody fusion technique, complications, and early results. Neurosurgery , Santoni G, Hynes RA, McGilvary KC, Rodriguez Canessa G, Lyons AS, Henson MA, Womack WJ, Puttlitz CM Cortical bone trajectory for lumbar pedicle screws. Spine J , Schwab F, Ungar, londel, uchowski J, Coe J, Deinlein D, DeWald C, Mehdian H, Shaffrey C, Tribus C, Lafage V Scoliosis Research Society Schwab Adult spinal deformity classification a validation study. Spine Phila Pa , Watkins M Posterolateral fusion of the lumbar and lumbosacral spine J one Joint Surg Am , 要旨脳外誌 26: ,

MISt MISt MIStLIF MISt MIStMISS-VOICE MISt MISt MISS Voice 2 MISS VOICE vol. 6

MISt MISt MIStLIF MISt MIStMISS-VOICE MISt MISt MISS Voice 2 MISS VOICE vol. 6 Vol.6 成人脊柱変形における M ISt手技の応用脊椎側方アプローチを用いた成人脊柱変形手術の低侵襲化 Reconstruction with spinal lateral approach for adult deformity 金村徳相先生愛知県厚生連江南厚生病院脊椎脊髄センター整形外科成人脊柱変形におけるMISt手技の応用荒瀧慎也先生香川労災病院整形外科田中雅人