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文章来源:解放军总医院骨科专科医院 张西峰    发布时间:2013-11-30

    第8届COA国际学术大会首次设立了骨科在线网络编辑委员会。笔者（张西峰）作为脊柱外科的主编，带我们一起来认识脊柱微创外科的领军人物和前辈Anthony T. Yeung医生。并借此机会，一起聆听他对脊柱微创外科的未来发展的展望。Anthony T. Yeung医生也将与中国骨科医生以及他的中国学生们欢聚北京。11月10日，一场名为“脊柱微创外科的新时代”将由Anthony T. Yeung医生为我们现场介绍。

张西峰：如何看待脊柱微创外科在全世界的发展？
Dr. Anthony Yeung: MIS由于它的小切口优势，在北美成为一种被追捧的外科手术技术。然而关于MIS，很多外科手术医生在学习MIS手术的时候给了不同的定义。大部分手术医生会用小切口，管道等一些最常用的词语来描述MIS。入路方式大多数依旧选择传统的入路方式或者椎板入路，不管是分离还是扩张，这些入路方式常需要切除一部分组织，而这些肌肉是脊柱很重要的支持结构。一些关节突关节面的减压可能会影响到脊柱的功能和稳定性。斜型或者侧方入路被认为是微创技术，但还有待进一步的发展。

张西峰：美国脊柱微创技术发展如何？
Dr. Anthony Yeung：在美国大多数外科大夫认为通过管道减压就是MIS，常选择椎板入路和内窥镜。这里需要强调一下融合和动态稳定的问题，由于公司对植入物的推销，影响手术医生对他们产品的使用和选择，这种影响很大。椎间孔入路是一种创伤较小的入路方式，但由于学习曲线以及缺乏学院的正规培训，采用这种手术方式的医生比较少。
在亚洲地区，微创的理念和技术更能被广泛接受。患者选择的更苛刻，并且无法像美国患者那样接受大量的移植物。并且亚洲医生的似乎更愿意接受学习新技术，比如经椎间孔减压技术。而且在大量患者和手术量的优势下，手术医生和技术的发展更为明显。在韩国和日本，脊柱微创手术在专科诊所蓬勃发展。然而在美国，这种技术的推广需要很多的审核，而审核的专家们并不做这类手术，并且不希望这类手术在他的领域中广泛开展起来。经椎间孔的内窥镜技术在亚洲，尤其是韩国和日本得到了很好的发展。现在中国这项技术的发展也是空前高涨。

张西峰：您能给我们讲一讲在美国和中国之间脊柱微创外科技术交流的故事么?
Dr. Anthony Yeung：我从1997年就通过北京306医院邹德威教授创立的内窥镜中心，向中国介绍脊柱内窥镜技术。可惜由于某些原因，该院已经不开展该技术。我希望不要让我通过微创中心发展脊柱内窥镜技术的努力白费。
后来我把精力放在培训中国的医生们，他们都是通过博能华学术联盟的推荐筛选出来的。我加强了这些医生们的培训，最近培养的一批新医生，他们都很出色。分别是来自上海的吴晓东，以及来自昆明的聂邦旭。在这次培训中他们一定学习了很多新的东西。对你的成长也一直是非常骄傲。在301医院，你将我们的技术发展提高并推广开来。我现在希望在中国开展一些培训中心加快我们的培训，并希望一些曾经过我培训过的优秀医生可以担任培训中心的老师。
(编辑批注，现在的北京306医院已经买了新的内窥镜设备，并且有两名医生继续应用和推广YESS技术)

张西峰：脊柱外科医生如何更好的学习脊柱微创外科技术？
Dr. Anthony Yeung：学习和接受脊柱微创技术首选会议，然后以学者术者的身份访问世界各地的各个学习中心。就像我的培训中心Phoenix，还有首尔的Wooridul医院。那里有我的学生Gun Choi，他现在也在为脊柱微创技术的传播努力。
我现在是IITS的执行主席，IITS现在改名为IITTS。我希望中国广大的骨科医生加入并积极参加我们的组织活动。我们重点推广经椎间孔入路的技术治疗腰椎疾病。ISASS的中国会员人数仅次于美国，并且我将把我主要精力放在ISASS的支持上。中国外科手术医生将通过ISASS学习到更多的技术。
我同样知道你在北京301医院独自对MIS手术做了一些升级。希望你在一些前沿的脊柱外科发表你的文章，比如：在柏林的SAS会议上，你提出的难度非常大的经侧方入路内窥镜下腰椎间盘摘除技术。许多就是像你这样的医生让MIS手术得到了很好发展提高，我也鼓励中国医生在学术期刊发表他们的成就，称为文献。
在一些私人外科中心研发了许多先进技术，这些地方也是患者常常热切寻求有经验医生的地方。这些信息广泛的患者寻求和选择MIS手术。我想在未来的中国，随着工人阶级和中产阶级收入的增加，将可以更自由的选择手术医生及手术方式。最近，世界各地这样的中心伴随着旅游医疗迅猛发展。今年我也在新墨西哥成立了内窥镜中心，我将有幸培训一只多学科团队一起来工作。

张西峰：如何选择XLIF和TLIF的手术适应症？
Dr. Anthony Yeung：XLIF和TLIF是否被广泛应用取决于更安全快速的到达椎间盘的技术培训。比如，XLIF更适合L3及其头侧，而L4-5和L5-S1更适合选择TLIF。L4-5两种技术都可以应用，但腰大肌的难题依旧是我最关心的，因为腰大肌的神经容易受损。内窥镜技术正在向经皮融合不切除小关节复合体的方向发展。通过单纯椎间孔或经椎间孔减压，插入移植物并且不需切除小关节复合体。椎间孔内减压是可行的，尤其是手术医生经过规范化椎间孔减压培训。内窥镜下的T-lif技术将被命名为O-Lif，（斜行的椎间融合）。袁汉生医生和我经过SFDA的批准后，将为中国介绍美国的局部麻醉下O-Lif技术。

张西峰：在脊柱微创外科手术中如何避免并发症的发生？
Dr. Anthony Yeung: 避免手术并发症应该是首要的也是最重要的目标。随着外科手术医生经验的累计，手术并发症的发生率也越来越小。在标本上训练，与有经验的手术医生老师一起操作并向其学习将由助于手术并发症的避免。我有一个关于如何避免手术并发症的海报和演讲报告可以发给你。Alex Vacarro 和 Todd Albert 编辑的Tricks of the trade by Elsievere 术中，我刚完成了关于经皮椎间孔减压这个章节。书一发表，我就发一份PDF和海报给你，你也可以与你的学生一起分享。

张西峰：脊柱医生如何获得最新的临床信息？
Dr. Anthony Yeung: 加入国内外的MIS组织可以获得最新的临床信息。文献的信息要在5年后才能发表。加入IITTSS参加他们的会议这些都是很好的获得最新信息的渠道。中国医生可以参加2014年的ISASS会议或者1月份的时候加入他们专业的MIS 培训。关于会议邀请E-mail已经大量发出。

张西峰：如何看待脊柱微创外科未来的发展？
Dr. Anthony Yeung: 我想脊柱微创外科将是未来脊柱外科发展的主要方向，并且他将进一步的迅猛发展。伴随着手术适应症的发展，手术过程将更加容易，这也将有助于阻止更严重的病理解剖状况的发生。

张西峰：如何选择TLIF和PELD的手术适应症？
Dr. Anthony Yeung：如果PELD手术很好的话，包括椎间孔减压和关节突关节脊神经背内侧支切断术，就可以减少不必要的融合手术。我的个人实践经验，我的病人将近75%的可以通过椎间孔镜减压和关节突关节脊神经背内侧支切断术达到很好的效果，也就不需要融合手术了。这并不是真正的PELD，但可以称为椎间孔成形术和脊神经背侧神经根切断术。最新的趋势是在避免融合手术的情况下完成椎间盘退化引起的疼痛治疗。
张西峰：感谢Tony对中国微创脊柱外科事业的帮助和贡献。

The Interview of Anthony T. Yeung:
On the Development of Minimally Invasive Spine
Contributing Editor  Zhang Xifeng

The Eighth International Congress of Chinese Orthopaedic Association (COA2013) set up orthopedics online network editorial board. The author(Xifeng Zhang), editor in chief of spinal surgery, take us to know Dr.Antony T. Yeung, a leading figure of minimally invasive spinal surgery. And then listen to his opinions in the future development of minimally invasive spine surgery. Dr Yeung is visiting Beijing for a re-union with chinese surgeons he has trained. He will be giving a seminar updating his work on MIS surgery titled "The new era of MIS spine surgery." on November 11.

The following is true record，without any modification.

Xifeng Zhang: How to understand the development of MISS around world?
Dr. Anthony Yeung: MIS is touted in North America as the surgical method of choice because it is minimally invasive. The definition of MIS, however, unfortunately is defined differently by each surgeon claiming to do MIS surgery. If the surgeon uses smaller incisions or tubular retractors, that is the most common concept. The approach is still mostly a traditional and translaminar approach that require some degree of tissue dissection, and either detach or dilates the multifidus muscle, a muscle that is a major stabilizer of the lumbar spine. It may require decompression of facet joints that is responsible for function and stability of the spine. The transforaminal oblique or lateral may be considered minimally invasive, but not as well developed.

Xifeng Zhang: How about the development of MISS in United States?
Dr. Anthony Yeung: In the United States, most surgeons consider decompression through tubular retractors as MIS. The approach is translaminar, and an endoscope may be used.  There is an emphasis on fusion or dynamic stabilization, but it is heavily influenced by companies selling implants that influence surgeons to use and promote their products. The transforaminal approach is the most minimally invasive, but few surgeons take it up because of the long earning curve and lack of formal training in an academic setting.
Asia seems to be more receptive because their population's needs are more critical, endless conducive to the use of expensive hardware and implants than the US. Asian surgeons seem to be more receptive on learning a new technique, such as transforaminal decompression and the surgeon factor and skill is more evident because of their large patient base and surgical volume.  Mis surgery has flourished due to specialty clinics in Korea and Japan.   In the United States, there seems to be noticeably more political censorship by many surgical leaders because they don't do the procedure and don't want those with novel ideas to flourish if it is not their area of expertise. The area of transforaminal endoscopic surgery is being more highly developed in Asia, especially in Korea and Japan, and now China.

Xifeng Zhang: Can you tell the story about Technical exchanges of MISS between United States and China?
Dr. Anthony Yeung: I have been involved since 1997 when I brought endoscopic surgery to China by introducing transforaminal endoscopic surgery to 306 in Beijing. General Dewei Zou started an endoscopic center, but unfortunately, the political situation at 306 in Beijing set back endoscopic surgery when the new leader did not seem to allow the endoscopic center to operate as before. I hope they will not let me effort go to waste by opening up the center for development in the manner I envisioned.
I am renewing my efforts by intensifying the training of Chinese Surgeons who are screened by Bonovo through their academic alliance.  I decided to only accept surgeons for intensive training.  I recently trained a spine surgeon, Dr Xiao Dong Wu from Shanghai, and Bangxu Nie from Kunming. Both were very good and I think they learned a lot. I am also proud of your progress, as you have advanced the technique on your own at 301. I hope to accelerate training and get some centers in china where the surgeons I trained will become the mentors and trainers in china.
(The editor note: 306 had bought new endoscopy instrument and has two doctors perform endoscopy operations. YESS technique continues spread.)

Xifeng Zhang: How can spine surgeons learn and apply the techniques of MISS?
Dr. Anthony Yeung: The way to learn and apply the techniques of MISS is through conferences, then visitation by scholars and surgeons to the various centers around the world, like my center in Phoenix, and Wooridul hospital in Seoul where one of my fellows, Gun Choi has expanded the technique.
I am the executive secretary for IITS, now called IITTS. I invite Chinese surgeons to join and be active in this organization. We emphasize the transforaminal approach to painful degenerative conditions of the lumbar spine. Chinese membership in ISASS is only second to the United States, and I am placing my support to ISASS in the US.  Chinese surgeons will learn more by joining ISASS.
I also know that you have independently advanced MIS surgery at 301.  Publish your work in peer reviewed spine journals. For instance, your independent work on the risks of the extreme lateral approach presented at SAS in Berlin.  Much of MIS surgery is developed by surgeons like you, and I encourage Chinese surgeons to publish their work in scientific journals so they can contribute to the literature.
Many techniques are developed in private centers where patients actively seek surgeons who have expertise in this field. MIS surgery sought after by informed patients, are usually elective. In China, I think that MIS surgery for painful conditions of the spine will grow rapidly as the working and middle class population in China gets discretionary income to seek private surgeons for their procedures. Currently these centers all over the world are thriving from medical tourism. I am establishing an endoscopic center at the University of New Mexico this year. Hopefully, I will be able to train a multidisciplinary team to work together.

Xifeng Zhang: How to choose the indication of XLIF and TLIF?
Dr. Anthony Yeung: Xlif and Tlif are both MIS fusion procedures whose popularity will be dictated by training for safe and quick accessibility to the disc. For instance, Xlif is much better for L3 and cephalad, but T-Lif is more appropriate for L4-5 and L5-S1. L4-5 can be appropriate for both techniques, but psoas weakness would still be one of my concerns because of the nerves in the psoas muscle are vulnerable to neuropraxia. Endoscopic techniques are being developed to do percutaneous fusion without removing the facet complex by just decompressing the foramen transforaminally, to insert the graft and implant without having to remove the entire facet. Foraminal partial facet decompression is doable, especially when the surgeon has training in transforaminal decompression. The endoscopic T-lif will be called O-Lif, (oblique inter body fusion) Dr Hansen Yuan and I wilI be introducing Amendia's O-LIF fusion to China once we get SFDA approval. I have performed these fusions under local anesthesia.

Xifeng Zhang: How to prevent complications in minimally invasive spine surgeons?
Dr. Anthony Yeung: Prevention of complications should be the first and foremost goal. As the surgeon gains more experience his complication percentage will decrease. Practicing in Cadaver workshops, and learning and operating with an experienced surgeon mentor will help the surgeon avoid complications. I have a poster and a talk on how to avoid complications to send you. I just completed a book chapter on percutaneous transforaminal decompression in a book called Tricks of the trade by Elsievere, edited by Alex Vacarro and Todd Albert. I will send you a pdf of the chapter when it is published, and poster on avoidance of complications that you may share with your students

Xifeng Zhang: How can spine surgeons obtain the latest clinical information?
Dr. Anthony Yeung: The best way is attend MIS conferences in China and abroad. The literature will be 5 years behind. Join IITTSS and attend its meetings. Chinese doctors are coming to the ISASS meeting in 2014 or their special MIS workshop in January. Blast e-mails have been sent out announcing these meetings.

Xifeng Zhang: What is the future direction of development in MISS?
Dr. Anthony Yeung: I think it will be the future direction of spine surgery and will continually evolve. Indications will evolve as well, and more procedures earlier in the disease process will help prevent the severe conditions we see from untreated patho-anatomy.

Xifeng Zhang: How to choice the indication for TLIF and PELD?
Dr. Anthony Yeung: If PELD is performed well, including foraminal decompression and facet rhizotomy, less fusion will be needed. In my personal practice, I am able to improve about 75 percent of my patients with endoscopic decompression and rhizotomy so that they will not need fusion. This is not just PELD, but foraminoplasty and dorsal rhizotomy. The current trend is to try to avoid fusion for pain from disc degeneration.