THE ART OF SURGERY 18 Einführung Introduction [1] [2] [3] [4] [5] [6] Taylor, McGregor, Medhizadeh et al (2002) - The impact of self-retaining retractors on the para-spinal muscles during posterior spinal surgery. Spine; 27:2758-62 Weber, Grob, Dvorak et al (1997) - Posterior surgical approach to the lumbar spine and its effect on the multifidus muscle. Spine; 22:1765-72 Caspar (1977) - A new surgical procedure for lumbar disc herniation causing less tissue damage through a microsurgical approach. In: Advances in Neurosurgery; Wüllenweber, Brock, Hamer (eds); Vol 4: 74-77; Springer-Verlag, Berlin Rütten, Komp, Godolias (2006) - A new full-endoscopic technique for the interlaminar operation of lumbar disc herniations using 6-mm endoscopes: prospective 2-year results of 331 patients. Minim Invasive Neurosurg 49(2): 80-7 Greiner-Perth, Boehm, Ezzati et al (2006) - Comparison of soft tissue trauma in microsurgical nucleotomy to a new technique: Microscopically Assisted Percutaneous Nucleotomy. An MRI-Study. Eur Spine J 15 (Suppl.4): 475 Brock, Kunkel, Papavero (2008) - Lumbar microdiscectomy: subperiosteal versus transmus-cular approach and influence on the postoperative analgesic consumption. Eur Spine J, Vol 17,4: 518-522 Die Bedeutung einer postoperativ nicht denervierten paravertebralen Muskulatur rückt mehr und mehr in den Fokus der Zugangstechniken. [1,2] Das perkutane Einbringen von Pedikelschrauben oder der Einsatz von Röhrchenspekula (tubular retractors) in der mikrochirurgischen Behandlung von lumbalen oder dorsalen zervikalen Bandscheibenvorfällen setzen dieses Konzept um. Das von Wolfhard Caspar Ende der 70er Jahre entwickelte Spekulum-Gegenretraktor-System hat sich mit Modifikationen über Jahrzehnte bewährt. [3] Die Länge der Hautinzision und das Ausmaß der Ablösung der paravertebralen Muskulatur werden heute von den Abmessungen der endoskopischen Arbeitskanäle (6 mm) oder der Röhrchenspekula (11-15 mm) unterboten. [4] Die reduzierte Traumatisierung der Muskulatur ermöglicht einen geringeren postoperativen Schmerzmittelverbrauch. [5,6] Die minimal-invasiven transmuskulären Zugänge, insbesondere die endoskopischen, erfordern eine Lernkurve und einen Materialaufwand, die eine weite Verbreitung dieser Techniken erschwert haben. Approach techniques in spinal surgery are focusing more and more on the postoperative importance of preserving the innervation of the paravertebral muscles as much as possible. [1,2] This concept is realized by the percutaneous insertion of pedicle screws and the use of tubular retractors in lumbar and posterior cervical discectomy. The self-retaining speculum-counter-retractor developed by Wolfhard Caspar in the late seventies has proven itself, with minor modifications, over the last decades. [3] Today, the length of the skin incision and the extent of paravertebral muscle dissection are reduced due to the dimensions of the endoscopic working channels (6 mm) and the use of tubular retractors (11-15 mm). [4] This decrease of muscle tissue traumatization leads to less need for postoperative analgesics. [5,6] The minimally invasive transmuscular approaches, particularly the endoscopic variants, necessitate a learning curve and an expenditure of resources which have hampered the widespread use of these techniques. Literaturhinweise Literature references
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