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날짜 진료형태 병원 의료진
날짜/시간 병원 진료 과목 의료진 취소
분원 선택
  • 분원 선택
진료과 선택
온라인 예약
의료진 선택 날짜 선택
온라인 예약
의료진
X
1. 선택진료란?
- 환자 또는 보호자가 특정한 의사를 선택하여 진료를 받는 제도로서, 선택(특진, 지정) 진료를 받으시면 보건복지부령에 정하는 범위에 추가 진료비를 본인이 부담하시면 됩니다.(보건복지부령 174호 제5조 3항 관련)
2. 선택(지정,특진) 진료란의 대상 의사는 어떤 자격이 있나요?
- 선택(지정,특진) 진료 대상 의사는 해당 진료과의 전문의 자격을 취득한 후 10년이 경과 하거나, 대학병원의 조교수 이상의 자격을 갖춘 의사입니다.
3. 선택(지정,특진) 진료의 보험 혜택 여부는?
- 보건복지부의 추가 비용 항목과 산정 기준에 따라, 선택(지정,특진) 진료는 보험 혜택 없이 비용을 환자가 전액 본인 부담합니다. (특진 진료시 매번 아래와 같이 특진료가 산정됩니다.)
4. 특진의사란?
- 전문의 자격증 취득 후 10년 이상의 경력을 가진 의사(대학병원의 조교수 이상)
날짜 & 시간
예약 정보
예약 구분 본인 병원
진료과 예약 날짜
의료진 시간
Хирургическое вмешательство

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■ Цервикальная
+ Перкутанная эндоскопическая цервикальная дискэктомия (PECD)

Percutaneous Cervical Micro-decompression Endoscopic Cervical/Lumbar Discectomy with Laser Thermodiscoplasty, is a new procedure to shrink and remove a herniated disc. Using brief general (cervical) or local (lumbar) anesthesia and the help of x-rays for guidance, specially designed micro-instruments, the discectome and a laser probe are inserted into the herniated disk space, and a portion of the offending disk is removed with suction and then vaporization with a laser to shrink the disc further, instead of open surgery.

Percutaneous cervical/lumbar discectomy is different from standard disk surgery because there is no muscle dissection, bone removal, bone fusion, or incision, except for a puncture wound to accommodate the micro-instruments that are inserted into the herniated disk. Most complications that occur with conventional surgery, therefore, are eliminated with this procedure. The procedure is performed under brief general (cervical) or local (lumbar) anesthesia with the patient awake and in a supine (cervical) or lateral (lumbar) position. A small needle is inserted into the disc.

Over this probe, a slightly larger sleeve is inserted to permit a 2mm incision to be made in the disk itself. Using x-ray fluoroscopy control, the micro-instruments (forceps, currets, cutters), the discectome (which is a hollow probe with a cutting knife inside), and the laser probe are inserted into the disk space through a sleeve. Very small pieces of the disk material are removed and suctioned. The laser shrinks the disk bulge further. The procedure takes about 20 minutes, on average. X-ray exposure is minimal.

The amount of disk removed varies. The supporting structure of the disk is not affected. Upon completion, the needle is removed and a small Band-Aid is applied over the probe incision. The primary advantage of this procedure is that there is no interference with the muscles, bones, joints or manipulation of the nerves in the neck or back areas. Since insertion of the probe through the muscle is the only wound, there is no scarring in or around the nerves postoperatively. Additionally, it is an outpatient procedure. Unfortunately, patients who have large free fragments of disk in the spinal canal, as determined by the x-ray, cannot benefit from this procedure. However, the laser can shrink the bulging disc further for disc decompression.

It is essential to understand that all patients are not relieved of their pain with this procedure. Approximately 90 percent of patients will experience pain relief. Patients who do not obtain relief within three to six weeks may be considered for micro-cervical disc removal and fusion, depending on the circumstances. There does not appear to be any detrimental effect from performing percutaneous cervical discectomy before micro-cervical procedure to remove bony discs and bony fusion.

Under local or general
anesthesia, the patient was placed in a supine position with the neck extended by placing a rolled towel under the shoulders. A soft strap was placed over the forehead for stabilization. The shoulders were gently distracted downward with tape. C-arm fluoroscopy was used in anteroposterior and lateral planes to direct the placement of a spinal needle onto the disc surface. Initially, at the point of entry adjacent to the medial border of the right sternocleidomastoid muscle, firm pressure was applied digitally in the space between the muscle and the trachea and pointed toward the vertebral surface. The larynx and trachea were displaced medially and the carotid artery laterally. The esophagus was made more prominent with the insertion of an endotracheal tube. The pulse of the carotid artery was augmented with sympathomimetics.

The anterior cervical spine was palpated with the fingertips, and a #18-gauge spinal needle was passed into the disc space. The position was confirmed fluoroscopically. A 2 to 3 mm skin incision was made, and a narrow guide wire was passed through the needle. The needle was then removed. A blunt trocar was introduced over the guide wire down to the interspace, followed by a cannula. A trephine inserted through the cannula cut the annulus in a circular fashion. Minicurettes loosened and removed disc material prior to introduction of a suction-irrigation system and the discetome with a guillotinecutting blade (Fig. 1).

The instruments included a probe, grasper forceps, and laser fiber (Fig. 2). Movement in a critical fan sweep maneuver, a 25° rocking excursion of the cannula hub from side to side, increased the removal up to a 50° coneshaped area within the disc space (Fig. 3). The procedure was closely monitored with the fluoroscope (Fig. 4) and an endoscope (Figs. 5A, B). The holmium: yttrium-aluminum-garnet laser with right angle or side-fire probe facilitated the discectomy. In addition, nonablative levels of holmium laser energy (500 joules) or thermodiscoplasty added shrinking of collagen and fibrocartilage; the tightening effect further decompressed and hardened the herniated cervical disc.
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+ Передняя цервикальное расширение межпозвоночного отверстия

This surgical technique was studied and practiced on cadavers before it was applied in living patients. The goal was to achieve direct and effective anatomical decompression of the spinal cord with maintenance of spinal stability, thus eliminating the need for bone fusion and immobilization. The surgical technique of microsurgical anterior foraminotomy has been reported elsewhere.[4] The operation is performed after general endotracheal anesthesia has been attained in the patient. Somatosensory evoked potentials (SSEPs) are obtained by stimulating the upper and lower extremities immediately after induction of general anesthesia. Once the baseline SSEPs are obtained, SSEP monitoring is used continuously until the end of the operation. Positioning of the patient is similar to that for the conventional anterior approach to the cervical spine. With the patient supine, a bolster is placed behind both shoulders to maintain gentle extension of the cervical spine. When the patient is properly positioned, the baseline spinal cord function is reconfirmed with SSEP monitoring. The head is positioned with the midline upright. Both shoulders are gently pulled and fixed caudally with tape to facilitate a lateral view of the cervical spine on intraoperative roentgenogram. A cervical traction device is not used. The entire anterior neck is prepared with antiseptic solution and draped. A 3- to 6-cm long transverse incision is made at the anterior neck along a skin crease that is similar to the incision made for an anterior approach to the cervical spine. The skin incision is made ipsilaterally to the radiculopathy or to the narrower side of the spinal canal. The first two-thirds of this incision is made medially to the sternocleidomastoid muscle and the remaining one-third is kept lateral to the medial border of the sternocleidomastoid muscle. The subcutaneous tissue and the platysma muscle are incised along the line of the skin incision. The loose connective tissue layer under the platysma muscle is cleanly undermined to provide space to operate. A combination of sharp and blunt dissection is used to access the anterior column of the cervical spine to keep the carotid artery and the sternocleidomastoid muscle lateral and the strap muscle, trachea, and esophagus medial. The prevertebral fascia is opened, and the anterior column of the cervical spine is exposed. The correct level is then confirmed with a radiographic lateral view of the cervical spine. Up to this point, the procedure is similar to that for an anterior approach to the cervical spine. An anterior cervical discectomy retractor system is then applied; only smooth-tipped retractor blades are used. Retraction naturally exposes the ipsilateral longus colli muscle rather than the midline anterior disc surface. An operating microscope is used at this stage. The medial portion of the longus colli muscle is excised to expose the medial parts of the transverse processes of the upper and lower vertebrae. The vertebral artery (VA) is located anterior to the C-7 transverse process and beneath the longus colli. Therefore, when operating at the C67 level, care must be taken not to injure the VA while removing the medial portion of the longus colli. Because the VA occasionally enters the transverse foramen at another level, the longus colli is incised carefully under the operating microscope. For operations above the C67 level, the VA is not exposed purposefully at this point. Once the medial portions of the transverse processes of the upper and lower vertebrae have been identified, the ipsilateral uncovertebral joint between them can be seen; however, advanced spondylosis may obscure the anatomical landmark of the uncovertebral joint and transverse processes. Anterior spondylotic spurs at the intervertebral disc can act as a guide, leading to the uncovertebral joint superolaterally. Although the interface of the uncovertebral joint will be angled approximately 30° cephalad from the horizontal line of the intervertebral disc in the normal cervical spine, advanced spondylotic changes may obscure the normal anatomy. The uncovertebral joint is drilled between the transverse processes using a high-speed microsurgical drill attached to an angled hand piece (Fig. 1). To prevent injury to the VA, a thin layer of cortical bone is left attached to the ligamentous tissue covering the medial portion of this artery. Drilling continues down to the posterior longitudinal ligament. As drilling advances posteriorly, the direction of the drill is gently inclined medially. When the posterior longitudinal ligament is exposed, a piece of thin cortical bone is left attached laterally to the periosteal and ligamentous tissue covering the VA. This lateral remnant of the uncinate process is dissected from the ligamentous tissue and fractured at the base of the uncinate process. It is further dissected from the surrounding soft tissue and removed, which enables identification of the VA by its pulsation between the transverse processes of the vertebrae. It is necessary to proceed cautiously with drilling at the base of the uncinate process because the nerve root lies just adjacent to it. After the uncinate process becomes loosened at its base, it is safer to remove the thin layer of remaining bone of the uncinate process by fracturing it rather than by continued drilling. When the remaining piece of the uncinate process is removed, the posterior osteophytes are drilled by crossing the midline diagonally toward the opposite margin of the spinal cord dura mater. The size of the hole made by the drilling at the uncovertebral joint is usually approximately 5 to 6 mm wide transversely and 7 to 8 mm vertically. The posterior longitudinal ligament is incised and resected to achieve decompression of the ipsilateral nerve root and spinal cord. The beginning of the contralateral nerve root is identified for adequate decompression of the spinal canal in the transverse axis (Fig. 2). Multiple anterior foraminotomies are performed as needed. Using the holes of anterior foraminotomies, the spinal cord canal is enlarged in the longitudinal axis by removing the posterior portion of the vertebral bodies with Kerrison rongeurs and a long-armed up-biting curet. The bone bleeding is controlled with the application of bone wax. Epidural bleeding from the posterior longitudinal ligament can be controlled with bipolar coagulation. Hemostatic agents are not used in the epidural space. Finally, the platysma is closed with interrupted No. 3-0 absorbable stitches, and the skin is approximated with subcuticular sutures. To minimize postoperative incisional pain, a local anesthetic (a few milliliters) is injected subcutaneously. A cervical collar is not used. Although microsurgical anterior foraminotomy for cervical radiculopathy has been performed as outpatient surgery, this group of patients with myelopathy stayed in the hospital overnight to observe their spinal cord function clinically; they were discharged home the next morning. The surgery was performed with patients supine, and a prevertebral surgical exposure of the affected cervical disc level was accomplished on the affected side as described by Cloward.1 Figures 1 and 2 (A to E) illustrate the site of surgical decompression and summarize the steps of the procedure. The anterior cervical retractor naturally tends to maintain exposure centered over the medial border of the longus colli muscle. A long segment of the colli muscle was mobilized laterally to expose the transverse processes above and below the affected disc space without removal of the muscle (Figure 2A). Dissection around the circumference of the vertebral body between the transverse processes and lateral to the uncus with a curet or Freer type instrument was accomplished. Fluoroscopic imaging (Figure 3) was helpful to guide the placement of a 1 to 4-in. or 3 to 8-in. malleable blade retractor inserted between the vertebral body and vertebral artery that maintained retraction of the colli muscle and protected the artery. The malleable retractor was attached to a table-mounted (Greenburg type) retractor to maintain the exposure (Figure 2B). The lateral view fluoroscopic image showed correct placement of the retractor inserted to the midvertebral body to avoid compression of the nerve root posteriorly. The remainder of the procedure was then completed with microscopic magnification. The lateral portion of the uncovertebral joint was drilled (Figures 1 and 2C) until a thin posterior cortical rim was left posteriorly that was removed with curettage and Kerrison rongeurs to expose the lateral posterior longitudinal ligament overlying the exiting nerve root. Further exploration for removal of any compressive ligament, herniated disc, and osteophytes on the adjacent endplates allowed removal (Figure 2D). The small remaining portion of the uncus was then removed to complete the anterior foraminal decompression (Figure 2E).
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+ Цервикальная корпэктомия и соединение

Displaced bony disk material will be removed from your neck. This displaced material is causing a problem by pressing on nerves. It will be replaced with bone taken from your hip or the fibula bone in your lower leg. During the operation, an incision (cut) will be made on your neck (see the diagram below). The size of this incision will depend on the extent of your problem. A second incision will be made on the front of your hip or leg (see the diagram). Bone will be removed from your hip or leg and will be placed in your neck. This transfer is called a bone graft. The surgery may take about four hours. If you have one or two vertebras repaired (a single-level corpectomy), you will probably be sent directly to a general patient unit after surgery. Your hospital stay will be two to three days. If you have two or more bones removed (a multiple-level corpectomy), you will probably be sent to the intensive care unit (ICU). During surgery a plastic breathing tube will be inserted down your throat, to keep your airway open. This is necessary because of swelling in your neck. You will remain in the ICU while you have a breathing tube. Most patients stay in the ICU one to two days. Then you will be sent to a general patient unit for two to five days. Incisions are usually closed with stitches and may be secured with Steri-strip tapes; paper like strips that stick to your skin and help keep the sides of the incision from shifting. The stitches will dissolve completely. The Steri-strips will fall off by themselves, usually within two weeks of surgery. All patients underwent preoperative MR imaging and CT studies. The position of the manubrium and the great vessels relative to the level of the pathological entity was assessed in each patient. In two patients, both of whom underwent a C-7 corpectomy, a standard horizontal cervical incision was used. The other six patients underwent surgery via an extended cervical approach, which required that an incision be made along the medial border of the sternocleidomastoid muscle, ending at the manubrium. In two patients, the incision was continued caudally in the midline to allow for resection of the rostral third of the manubrium. A left-sided incision was used in seven patients; the anatomical position of one tumor necessitated the use of a right-sided incision in a single case. A left-sided incision was preferred because of the course of the RLN. A standard cervical dissection along the medial border of the sternocleidomastoid muscle, medial to the carotid sheath, was performed to expose the anterior surface of the lower cervical spine. The dissection was extended caudally, angling beneath the manubrium or accompanied by a partial resection of the manubrium. When required, up to 3 cm of the manubrium was resected using a Leksell rongeur. Although resection of the head of the clavicle was not necessary in this series, it has been described and may increase exposure as well.[13,14] A table-mounted self-retaining retractor system, used in all cases, proved to be very helpful in retracting mediastinal contents. The thoracic duct may be ligated and divided if it cannot be retracted out of the field. A narrow, malleable blade was used for caudal retraction. The use of corpectomy, in contrast to discectomy, allowed for visualization of the thecal sac following bone removal. A nearly "end on" view of the caudal VB may be obtained. Following decompression of the spinal cord and nerve roots, a fibular allograft was used as a load-bearing strut. In all cases an anterior cervical plate was implanted to provide immediate rigidity to the construct. The use of variable-angle screws was helpful for the placement of the plates caudally. The angle required for screw placement often required contouring of the plate in addition to the use of variable-angle screws. Four of the eight patients also underwent posterior stabilization procedures for the treatment of gross instability. Postoperative immobilization therapy consisted of a rigid cervical collar in six patients and a Minerva brace in two. The duration of immobilization therapy was 6 weeks in all patients.
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+ Передняя цервикальная дискэктомия и соединение (ACDF)

Surgery for anterior cervical fusion is performed with the patient lying on his or her back. A small incision is made in the front of the neck, to one side. After a retractor is used to pull aside fat and muscle, the disc is exposed between the vertebrae. Part of it is removed with a forceps. Then a surgical drill is used to enlarge the disc space, making it easier for the surgeon to empty the intervertebral space fully and remove any bone spurs. Afterwards, only a single ligament separates the surgical instruments from the spinal cord and nerve roots. A small section of bone is obtained from the patient's iliac crest (i.e. hip), through a separate incision and used as a bone graft. The bone graft is placed in the disc space, where it will begin to fuse the vertebrae it lies between. Placing a bone graft between the two vertebral bodies is done in order to create a fusion between these bones. The fusion is a direct result of the bone graft, but small, specialized metal plates are also placed on the front of the cervical spine in order to increase the stability of the spine immediately after the operation. Surgeons use cervical hardware to decrease the amount of time that you will have to wear a collar after surgery, and also to increase your chances of getting a solid fusion between the two vertebral bodies. The operation is completed when the neck incision is closed in several layers. Unless dissolving suture material is used, the skin sutures (stitches) or staples will have to be removed after the incision has healed. Anterior cervical fusion is an operation performed on the upper spine to relieve pressure on one or more nerve roots, or on the spinal cord. The term is derived from the words anterior (front), cervical (neck), and fusion (joining the vertebrae with a bone graft). When an intervertebral disc ruptures in the cervical spine, it puts pressure on one or more nerve roots (often called nerve root compression) or on the spinal cord, causing pain and other symptoms in the neck, arms, and even legs. In this operation, the surgeon reaches the cervical spine through a small incision in the front of the neck. After the muscles of the spine are spread, the intervertebral disc is removed and a bone graft is placed between the two vertebral bodies. Over time, this bone graft will create a fusion between the vertebrae it lies between.

Cervical Laminoplasty
Its popularity in Japan arises from the formidable challenges of anterior decompression for ossification of the posterior longitudinal ligament. These anterior multilevel surgeries would be frequently complicated by dural tears as the dura is usually intimately associated with the ossified ligament. There was also a significant risk of instrumentation or graft failure. It has been reported that the rate of these complications including cerebrospinal fluid leakage and dislodgment or pseudarthrosis of the strut grafted bone was 24% and the rate of the salvage operation required was 12.5%. In the past, laminectomy has been the most common method to achieve posterior decompression of the cervical spine in these patients. However, the procedure has been complicated by postoperative instability resulting in deformity, particularly kyphosis, which may exacerbate neurological symptoms. Kyphosis and instability may leave the spine more vulnerable to cervical spine trauma, especially flexion injuries. In addition, postlaminectomy membranes have been implicated in arachnoiditis and restenosis after simple laminectomy. To avoid the disadvantages of laminectomy, several authors have described the technique of cervical laminoplasty whereby decompression is achieved without removal of the posterior spinal elements, maintaining the biomechanical integrity of the cervical spine and the spinal cord-protective features of the posterior elements. This is a more physiological solution. Expansive open-door laminoplasty was first described by Hirabayashi et al as a development of the air drill laminectomy technique of Kirita and has since been modified by Hirabayashi et al. and many others.

TDR for cervical spine
Initial surgical positioning was similar to that for a standard anterior cervical decompression and fusion. A roll was placed behind the shoulders and the head placed on a foam donut. The neck was extended slightly to facilitate exposure and an image intensifier was draped into the field. A transverse cervical incision was made in the neck over the C5-6 disc space and a standard extensile exposure of the C5-6 disc space was performed. Similarly routine discectomy was performed. The Bryan Cervical Disc System was utilized. The size of the implant (14 mm) and angle of the disc space was calculated precisely prior to placement of the implant. Using custom drill bits, and a milling wheel, a reciprocal concavity was cut into the endplates of C5 and C6. This is shown in Figures 4 and 5. After the endplates were precisely drilled and the decompression effected, the correct size prosthesis was placed into the defect (see Figure 6-9). At the completion of this stage closure was affected over a suction drain. The patient was transferred to the intensive care unit and extubated uneventfully.
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■ Торакальная
+ Перкутанная эндоскопическая торакальная дискэктомия (PETD)

PETD with laser is a minimally invasive surgical treatment for symptomatic thoracic disc herniation (TDH). It may also be known as: posterolateral thoracic discectomy; endoscopic laser thoracic discectomy; or endoscopic microdecompressive thoracic discectomy with laser thermodiscoplasty. Symptomatic TDH is rare accounting for between 0.25% and 0.57% of all disc herniations reported in the literature. Symptoms include back pain, radicular pain, nondermatomal leg pain, bladder dysfunction, and lower extremity weakness. If left untreated serious neurological sequelae may occur. The procedure is similar to percutaneous laser discectomy for the lumbar and cervical spine, and aims to decompress the disc using a percutaneous needle and laser ablation. Percutaneous endoscopic laser thoracic discectomy is purported to reduce morbidity and promote earlier return to work, and result in less scarring than other techniques. Other likely advantages are that it does not interfere with the bones or joints of the spine or require manipulation of nerves or the spinal cord. The steep learning curve for endoscopic techniques, the high cost of specialized instrumentation and the relatively low incidence of suitable surgical candidates are all factors contributing the to the very small number of surgeons who appear to be using this technique at present.

Open Thoracic Microdiscectomy
Thoracic corpectomy and fusion
Thorascopic discectomy
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■ Поясничная
+ Перкутанная эндоскопическая поясничная дискэктомия (PELD)

PELD is performed with the patient in the prone or lateral position on a radiolucent frame. A C-arm is positioned to ensure reproducible AP and lateral imaging. A marker is placed on the skin to determine the desired surgical level in the AP projection. The procedure is performed under local anesthesia, typically a 1% Xylocaine solution in the skin and subcutaneous tissue. Care must be taken not to anesthetize the periannular space and, particularly, the nerve root thus potentially predisposes it to intraoperative injury. To avoid entry into the spinal canal, PELD is performed through a posterolateral approach, typically 9 to 11 cm from the midline on the patient symptomatic side, with an angle of 35° to 45°. Initially, a needle is introduced and its tip should approach the annulus just in the so-called triangular working zone formed anteriorly by the descending spinal nerve, inferiorly by the proximal plate of the inferior vertebrae and posteriorly by the proximal articular process of the lower lumbar segment. The needle position is controlled either by the AP and/or lateral projections. Once the needle has been properly placed, the stylet is withdrawn and a guide-wire inserted. The spinal needle is then withdrawn, leaving only the guide-wire in place. A cannulated obturator is passed over the guide-wire and advanced towards the disc. The guide-wire is removed and a universal access cannula is passed over the cannulated obturator and advanced until it reaches the annulus. The obturator is then removed, leaving the cannula in place. Compression of the cannula against the annulus typically reproduces the patient radicular pain. The endoscope is now introduced to inspect the annulus surface and to unequivocally confirm the absence of neural tissue. Once this is confirmed, fenestration of the annulus is started, but, in order to prevent pain, additional anesthesia is required. Fenestration of the annulus is then performed using first a 3 mm and subsequently a 5 mm trephine. At this point the annular pathway is defined and, with a laser and micro-forceps, fragments of the herniated disc can be removed under direct visualization of the endoscope. A single suture is used to close the skin and a small dressing applied. Postoperative antibiotics are administered. The patient is discharged on the same day of the procedure.
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+ Перкутанная эндоскопическая поясничная фораминопластика (PELF)

PELF procedure is similar to percutaneous laser discectomy for the lumbar and cervical spine, and aims to widen the lumbar exit route foramina for lateral stenosis and disc protrusion. A side-firing laser is inserted through the endoscope and used along with manual punches to clear disc protrusions into the epidural space. The procedure is used to relieve back pain caused by multilevel disc disease. Its claimed benefit are that it may prevent or delay the necessity of spinal fusion. The procedure is intended for patients with multilevel disease with pain radiating through the buttocks and legs. Approximately 2% to 5% of people suffer acute back pain per year, while 0.5% of these will require surgery. A total of nine endoscopic laser foraminoplasty (ELF) studies were identified in 11 papers, of which none were randomised controlled trials and three were nonrandomized comparative studies. The remainders were reports of case series. The quality of evidence is consequently poor. There are no data comparing pain outcomes between patients treated with conventional surgery and those treated with ELF. Several studies reported significant postoperative improvements in pain and disability following ELF. One comparative study reported a significantly lower complication rate for ELF (1.6%) when compared with conventional surgery (11.8%). Endoscopic laser foraminoplasty is an endoscope-assisted laser technique, designed to treat pain by widening the lumbar exit route foramina in the spine. The procedure has been used since 1995. Under direct vision and within the protection of saline solution, epidural scarring, extruded and sequestrated disc protrusions and/or osteophytes are removed by holmium laser ablation. Neuroleptic anaesthesia is used because patient feedback is essential. A cannulated probe is advanced into the patient.s back. The probe is replaced with a guide wire and under X-ray control a 4.6 mm dilator tube is railroaded to the exit root foramen. The trocar is removed and an endoscope with eccentrically placed 2.5 mm working channel and irrigation channel is inserted. A side firing 2.2 mm diameter laser probe is inserted through the endoscope. Disc protrusion in the epidural space is cleared by laser ablation and manual punches. The standard intervention appears to be minimal intervention fenestrectomy and open surgical undercutting for predominantly unisegmental and unilateral recess stenosis. The claimed benefits of endoscopic laser foraminoplasty are that it may prevent or delay the necessity of spinal fusion.
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+ Заднее поясничное амбоцепторное соединение (PLIF)

The first posterior lumbar interbody fusion (PLIF) was reported by Jaslow in 1946 when he utilized a bone peg that was placed within the lumbar interspace after discectomy. He augmented this with autogenous bone chips harvested from the posterior elements placed posteriorly. Posterior lumbar interbody fusion (PLIF) is a surgical technique for placing bone graft between adjacent vertebrae (interbody). Typically, screws and rods or other types of spinal instrumentation are used to hold the spine in position while the bone heals. Indications for this procedure may include pain and spinal instability resulting from spondylolisthesis, degenerative disc disease, or when a discectomy is performed to relieve nerve compression and the patient has associated mechanical low back pain. Spinal fusion uses bone graft to promote specific vertebrae to grow or fuse together into a solid and stable construct. Instrumentation, also called internal fixation, incorporates the use of rods, screws, cages, and other types of medical hardware to provide immediate stability to the spine and facilitate fusion. In minimally invasive procedures, the surgical incisions are small, there is no need (or minimal need) for muscle stripping, there is less tissue retraction, and blood loss is minimized. Special surgical tools allow the surgeon to achieve the same goals and objectives as the open surgery while minimizing cutting and retracting of the paraspinous muscles. Therefore, tissue trauma (injury) and post-operative pain are reduced, hospital stays are shorter, and patients can recover more quickly.
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+ Переднее поясничное амбоцепторное соединение (ALIF)

Anterior Lumbar Interbody Fusion (ALIF) is first introduced by Hodgson and Stock in 1956. ALIF is an operation that involves approaching the spine through an incision in the abdomen. A portion of the affected disc space is removed from the spine and replaced with an implant. Titanium or stainless steel screws and rods may be inserted into the back of the spine to supplement the stability of the entire construct. Patients who are suffering from back and/or leg pain which are generally caused by natural degeneration of the disc space. The ALIF operation is performed with the patient lying on his or her back. The surgeon makes an incision in the patient's abdomen to access the spine. To have a clear view of the spine, the surgeon then retracts the abdominal and vascular structures. Once the spine is in view, the surgeon removes a portion of the degenerated disc from the affected disc space. After this disc material is removed, the surgeon inserts bone graft material into the disc space, such as autograft or INFUSE Bone Graft contained in a LT-CAGE Lumbar Tapered Fusion Device ?to restore the normal anatomic condition of the spine. After the surgery, the patient will normally stay in the hospital between 2 to 5 days. The specific time of stay in the hospital will depend on the patient and the surgeon's specific post-operative treatment plan. Previous reports have documented that anterior lumbar interbody fusions (ALIF) decrease perioperative blood loss and eliminate nerve root retraction compared to posterior procedures. It has also been shown that ALIF procedures have shorter operating times than posterior lumbar interbody fusions (PLIF) with or without pedicle screw instrumentation. These advances have led to shorter hospitalization times and comparable fusion rates.
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+ Открытая фиксация винта ножки (OPF)

Percutaneous pedicle screw fixation (PPF):
For a degenerative spondylolisthesis case, a blunt probe is inserted through the pedicle and into the vertebral body. Once the pedicle canals are prepared and the screw length determined, the screws are sequentially inserted.
PPF can be performed after induction of general anesthesia. Thereafter, the patient is positioned prone on top of chest rolls with the abdomen free. A C-arm fluoroscopy device is used for guidance of percutaneous screw placement. A 15-mm-long incision was made for each screw at the appropriate skin entry point. A 14G vertebroplasty needle was inserted toward the pedicle and vertebra body and then the stylet replaced by 200-mm-long K-wire. A series of sequential dilation was performed along a K-wire and a 16-mm-diameter tunnel sleeve was inserted. The pedicles were tapped and then K-wire removed. Uncannulated screws can easily be placed as the tapped bone guided its passage. A soft tissue tunnel which connected two pedicle screw heads was made using a bended passer, and the pedicle screws were connected with bended round rod through the soft tissue tunnel. Final tightening of the pedicle screw-rod constructs were given under the fluoroscopic guidance. While tightening a screw-rod construct the remaining screw path was used to give antitorque and some compression force. Just one deep stitch was needed at each screw entry incision.
Although conventional fluoroscopy can be used for this purpose, it has certain disadvantages: the inability to visualize more than one plane of view at a single time (when using a single fluoroscope), the ergonomic challenges of working around a C-arm, and radiation exposure. It is important to check that adequate AP and lateral fluoroscopic images of the lumbar spine can be obtained before preparing and draping the patient.
Compared to open techniques, the presumed benefit of the percutaneous technique is avoidance of muscular tendon detachment, elimination of largescale muscle retraction, diminished postoperative pain, less blood loss, and improved cosmetic result.
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+ Перкутанная фиксация винта суставной поверхности (PFF)

Posterior instrumentation is often performed to stabilize unstable vertebral segments, often as supplementation to an interbody fusion. The most commonly used posterior instrumentation system in use today is open pedicle screw fixation. The disadvantage to this technique is the major muscle dissection necessary and the related morbidity and scarring. Facet screw fixation offers the advantage of placing a single screw across each articulating joint to immobilize a motion segment, thereby reducing the amount of hardware (and therefore exposure) necessary. Recent studies have shown this type of fixation, for single level stabilization of an anterior (interbody) fusion construct is equally as stable as a pedicle screw construct. Percutaneous facet fixation system uses framed fluoroscopic navigation and small-diameter access channels and instruments to place screws through small incisions, obviating the need for wide muscle exposure. Accurate placement of the facet screws can be determined using radiography and/or neurophysiologic (EMG) screw placement testing. This integrated system maximizes the efficiency of creating a stable fusion construct, while incorporating the advantages of minimal access surgery.
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+ Трансфораминальное поясничное амбоцепторное соединение (TLIF)

Transforaminal Lumbar Interbody Fusion (TLIF) is an operation where the lumbar spine is approached from the side through an incision in the back. A portion of bone and disc are removed from the spine and replaced with an implant that is inserted into the disc space. Titanium or stainless steel screws and rods are inserted into the spine to ensure the stability of the entire construct. Patients who are suffering from back and/or leg pain which may range from a natural degeneration of the disc space to some type of traumatic event. The operation is performed with the patient lying on his or her stomach. An incision is made in the patient's back to allow the surgeon access to the spine. The surgeon separates the muscle and tissue to be able to have a clear view of the spine. Once the spine is in view, the surgeon will remove a portion of bone from the appropriate areas of the spine to allow the surgeon to access the disc space. The surgeon will remove the disc material to allow the surgeon to insert an implant into the disc space. The surgeon will also insert titanium or stainless steel implants into the spine. The implant and the screws will help to restore the spine back to its normal anatomic condition. After the surgery, the patient will normally stay in the hospital between 3-5 days. The specific time of stay in the hospital will depend on the patient and the surgeon's specific post-operative surgical plan. The patient will normally be up and walking in the hospital by the end of the first day after the surgery. Your surgeon will have a specific post-operative recovery / exercise plan to help you return to normal life as soon as possible.
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+ Перкутанная вертебропластика

Percutaneous vertebroplasty is the injection of acrylic bone cement (polymethylmethacrylate; PMMA) into the vertebral body through a trocar needle in order to relieve pain and/or stabilize the fractured vertebra and in some cases, restore vertebral height. Percutaneous vertebroplasty is usually performed under conscious sedation with local anesthetic
Vertebral compression fractures are a common cause of pain and disability.
Percutaneous vertebroplasty may provide pain relief for patients with vertebral fractures caused by osteoporosis, but may also provide relief for patients with vertebral hemangiomas and pathological fractures from vertebral body tumors.
Evidence indicates that percutaneous vertebroplasty is efficacious for the treatment of pain associated with vertebral compression fractures and symptomatic hemangiomas. Percutaneous vertebroplasty appears safe with a low complication rate, although if complications occur, they can be major, including pulmonary embolism and spinal cord compression caused by extravasation of cement into the spinal canal.
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+ Кипопластика

Kyphoplasty is a minimally invasive procedure designed to stabilize and reduce pain from pathological vertebral compression fractures.
Kyphoplasty, developed in 1997, has evolved from the vertebroplasty technique, where acrylic bone cement, polymethylmethacrylate (PMMA) is injected percutaneously into the fractured vertebral body, stabilizing the vertebra as it sets. Kyphoplasty includes an additional step of inserting and inflating a bone tamp inside the vertebral body to restore vertebral height and create a cavity into which PMMA can then be injected.
Pathological vertebral compression fractures can be caused by osteoporosis, a malignancy in the underlying bone, or more rarely a benign blood vessel tumor in the vertebra known as a vertebral haemangioma. The traditional conservative treatment for pathological vertebral compression fractures, including bed rest and analgesics, has been unsatisfactory for many patients who are left with chronic pain, immobility and deformity. In the management of osteoporotic vertebral compression fractures, the use of open reduction and internal fixation has a limited place. The fixation of the osteoporotic spine is usually inadequate to correct the deformity occurring as a result of crush fractures. Open surgical techniques have also had little success.
Kyphoplasty, developed in 1997, has evolved from the vertebroplasty technique, where acrylic bone cement, polymethylmethacrylate (PMMA) is injected percutaneously into the fractured vertebral body, stabilizing the vertebra as it sets. Kyphoplasty includes an additional step of inserting and inflating a bone tamp inside the vertebral body to restore vertebral height and create a cavity into which PMMA can then be injected. Current research evidence (case series) shows that kyphoplasty appears efficacious, with studies showing that most patients gained significant pain relief and increased mobility.
Complication due to vertebroplasty includes spinal cord compression, radiculopathy, fractured ribs and pulmonary embolus (sometimes fatal). Complications resulting from kyphoplasty include nerve root or spinal cord compression, epidural hematoma, transient fever and hypoxia. Overall complication rates appear low, with complications due to kyphoplasty probably slightly less common than for vertebroplasty.
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+ Внутридискная электротермическая терапия (IDET)

IDET is performed by inserting a catheter with a thermal resistive coil at the end, into the affected disc. The coil is then heated, to 90 degrees fahrenheit, for 15 to 17 minutes, which kills the nerves causing the pain and also tightens the collagen fibers that form the wall of thedisc. Low back pain is common, and may be due to torn or herniated discs. Intradiscal Electrothermal Annuloplasty, or IDET may be a treatment option for patients who fail to respond to non-invasive treatments. IDET may also be a minimally invasive alternative to spinal fusion. __ Indications for IDET include patients who; fail to respond to six months of conservative treatment and have small herniations, internal disc tears or mild disc degeneration limited to one or two levels. __ Contraindications include: severe disc degeneration, spinal stenosis, neurological symptoms (e.g. leg weakness) and large disc herniations.
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+ Полная замена диска (TDR)

The advantages of TDR over fusion, say proponents, are faster recovery time, less postoperative pain and the retention of full motion. This artificial disc will do for spine surgery what the artificial joint. The goal of the disc prosthesis is to relieve pain caused by problems and pinched nerves in the lower spine. The diseased disc is replaced by special metal and polyethylene implants. The Spine Institute at Saint John's Health Center offers total disc replacement with the ProDisc® implant. The aim of total disc replacement is to recreate normal dynamic function. It can be considered for patients with low back pain as an alternative to spinal fusion. The ProDisc was designed in the late 1980 by Thierry Marnay, a French Orthopedic Spine Surgeon. The ProDisc is based on spherical articulations. It has metal endplates made of a cobalt chromium molybdenum alloy (CoCrMo). Figure 7: Three components of the ProDisc Figure 8: Assembled ProDisc The convex bearing surface, snap-fit into the inferior end plate, is made of ultra-high molecular weight polyethylene (UHMWPE). The artificial disc is attached through a large central keel and two spikes on each endplate. Physiologically, the ProDisc matches the range of motion in flexion, extension, axial rotation, and lateral bending as a normal spine. The device is modular, so the surgeon can customize the device to each patient unique anatomic and physiologic requirements. There are two endplate sizes (medium and large), three heights of the polyethylene component (10, 12, and 14 mm), and two lordosis angles (6 and 11 degrees). The implantation instrumentation is straightforward and user-friendly. Minimal access approaches to the lumbar spine, (typically through a mini-retroperitoneal approach) are possible given the streamlined design of the instrumentation. The endplates are inserted in a collapsed form, so that over-distraction (jacking open) of the disc space is not required. Only after the metal endplates are seated in the vertebral bodies is the disc space distracted. The surgeon can appreciate the soft tissue tension, and insert an appropriately-sized UHMWPE implant within the disc space, snap-fitting it into the lower metal endplate to complete the assembly process within the body. Figure 9: Insertion of the ProDisc metal endplate Figure 10: Disc inserted and complete (with polyethylene core in place) The ProDisc has been implanted in 500 patients in Europe since December 1999. A multicenter FDA study was started in the United States in October 2001. The first ProDisc in the United States was implanted at the Texas Back Institute on October 3, 2001. Up to fifteen study centers will ultimately be participating in the prospective randomized study, comparing the ProDisc to the current standard treatment of a 360° (front and back) fusion using allograft in the intervertebral space and pedicle screws with autograft posteriorly. The randomization protocol is 2:1, with 2 out of every three Study participants getting a ProDisc and 1 in three receiving the fusion. ProDisc can be implanted at L3-L4, L4-L5, or at L5-S1. There is also a concurrently running two-level PRODISC disc replacement study. In the two-level study, patients can be randomized into a 2:1 format if they have two adjacent levels of symptomatic disc disease between L3 and S1. After surgery, patients are followed for 24 months and then annually until the last patient in the study is 24 months postoperatively. Figure 11: Implanted ProDisc artificial disc Figure 12: ProDisc artificial disc (patient bending backwards) Inclusion criteria are degenerative disc disease in 1 or 2 adjacent L3-S1 segments causing back and /or leg pain with radiographic corroboration. Patients must be 18-60 years old, have failed at least 6 months of conservative therapy, have an Oswestry Score > 20/50, and able to comply with the protocol and follow-up. Exclusion criteria include more than two symptomatic diseased levels, known allergy to the implant components, prior lumbar fusion surgery, clinically compromised vertebral bodies from trauma, clinically significant degenerative facet disease, lytic spondylolisthesis or spinal stenosis, degenerative spondylolisthesis > Grade I, pain that defies diagnosis, osteoporosis, metabolic bone disease (including Paget, osteomalacia), or small vertebral bodies. Figure 13: Implanted ProDisc artificial disc view from the front Figure 14: Side view of ProDisc artificial disc at L4-L5 and L5-S1 Additional exclusion criteria are morbid obesity, pregnancy (or interest in becoming pregnant within the next 3 years), active infection, medication that interferes with healing (for example, steroids), Rheumatoid Arthritis or other autoimmune disease, systemic disease such as AIDS, HIV, or active hepatitis, and active malignancy (clinical signs within the past 5 years). Patients are followed up at standard intervals. At each follow up visit, a patient's complete short forms are examined, and have x-rays taken. The post op follow up intervals are at 2 weeks, 6 weeks, 3 months, 6 months, 12 months, and 2 years. Annual visits are required until the study closes.
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+ Ядро протезного диска (PDN)

Cushion These devices only replace the inner portion of the disc (the nucleus). The PDN® device is the first and only commercially available (outside the U.S. and Canada) prosthetic disc nucleus. The PDN device offers spine surgeons and low back pain sufferers a completely unique and new option for the treatment of degenerative disc disease. Charles D. Ray, M.D., the inventor of the PDN device, had the ambitious goal of finding a way to relieve low back pain that accompanies degenerative disc disease (DDD) by restoring normal biomechanical function to the disc, rather than removing it and risking a degenerative cascade. Dr. Ray vision took the treatment of DDD down a new, evolutionary path away from metallic implants and permanent immobilization of the entire affected spinal segment and toward treatment that stabilizes the spine and allows patients to regain their quality of life. Unlike spinal fusion, which results in loss of mobility in the spinal joint, the PDN device may allow patients to resume normal levels of activity with little or no pain. This is especially important to the increasing numbers of patients who are active and athletic and expect to stay that way until late in life. Furthermore, because it is a minimally invasive procedure, PDN device implantation can reduce time spent in the operating room and the length of hospital stays. The PDN prosthetic disc nucleus device is indicated for the treatment of patients with DDD resulting in low back pain, with or without concomitant leg pain, which has not responded to six months of conservative care. PDN devices may be surgically implanted at a single level (L2 to S1) in appropriate patients. The PDN device is intended to: · Reduce back pain · Restore or maintain disc height at the operative level · Maintain or improve range of motion of the low back The PDN device is composed of two parts, a hydro gel pellet and a polyethylene jacket. The hydro gel is designed to absorb fluid and swell. This ability to expand is what allows the PDN device to restore or maintain normal disc height. The woven polyethylene jacket maintains the shape and height of the hydro gel nucleus. The PDN device carries the CE (Conformite Europeen) Mark required for European sales of the product. Farcet Rhizotomy Epiduroscopy The first posterior lumbar interbody fusion (PLIF) was reported by Jaslow in 1946 when he utilized a bone peg that was placed within the lumbar interspace after discectomy. He augmented this with autogenous bone chips harvested from the posterior elements placed posteriorly. Posterior lumbar interbody fusion (PLIF) is a surgical technique for placing bone graft between adjacent vertebrae (interbody). Typically, screws and rods or other types of spinal instrumentation are used to hold the spine in position while the bone heals. Indications for this procedure may include pain and spinal instability resulting from spondylolisthesis, degenerative disc disease, or when a discectomy is performed to relieve nerve compression and the patient has associated mechanical low back pain. Spinal fusion uses bone graft to promote specific vertebrae to grow or fuse together into a solid and stable construct. Instrumentation, also called internal fixation, incorporates the use of rods, screws, cages, and other types of medical hardware to provide immediate stability to the spine and facilitate fusion. In minimally invasive procedures, the surgical incisions are small, there is no need (or minimal need) for muscle stripping, there is less tissue retraction, and blood loss is minimized. Special surgical tools allow the surgeon to achieve the same goals and objectives as the open surgery while minimizing cutting and retracting of the paraspinous muscles. Therefore, tissue trauma (injury) and post-operative pain are reduced, hospital stays are shorter, and patients can recover more quickly.
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