WO2014117562A1 - 一种脊柱后路微创置钉手术的暴露装置 - Google Patents

一种脊柱后路微创置钉手术的暴露装置 Download PDF

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Publication number
WO2014117562A1
WO2014117562A1 PCT/CN2013/087037 CN2013087037W WO2014117562A1 WO 2014117562 A1 WO2014117562 A1 WO 2014117562A1 CN 2013087037 W CN2013087037 W CN 2013087037W WO 2014117562 A1 WO2014117562 A1 WO 2014117562A1
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WIPO (PCT)
Prior art keywords
handle
hook body
hook
minimally invasive
screw fixation
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PCT/CN2013/087037
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English (en)
French (fr)
Inventor
曹晓建
李海俊
谢浩
Original Assignee
南京医科大学第一附属医院
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Application filed by 南京医科大学第一附属医院 filed Critical 南京医科大学第一附属医院
Priority to US14/764,797 priority Critical patent/US9439641B2/en
Priority to EP13873354.8A priority patent/EP2952139B1/en
Priority to ES13873354.8T priority patent/ES2673146T3/es
Publication of WO2014117562A1 publication Critical patent/WO2014117562A1/zh

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    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
    • A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
    • A61B17/02—Surgical instruments, devices or methods, e.g. tourniquets for holding wounds open; Tractors
    • A61B17/0218—Surgical instruments, devices or methods, e.g. tourniquets for holding wounds open; Tractors for minimally invasive surgery
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
    • A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
    • A61B17/02—Surgical instruments, devices or methods, e.g. tourniquets for holding wounds open; Tractors
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
    • A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
    • A61B17/02—Surgical instruments, devices or methods, e.g. tourniquets for holding wounds open; Tractors
    • A61B17/025—Joint distractors
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
    • A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
    • A61B17/02—Surgical instruments, devices or methods, e.g. tourniquets for holding wounds open; Tractors
    • A61B17/025—Joint distractors
    • A61B2017/0256—Joint distractors for the spine
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
    • A61B90/00—Instruments, implements or accessories specially adapted for surgery or diagnosis and not covered by any of the groups A61B1/00 - A61B50/00, e.g. for luxation treatment or for protecting wound edges
    • A61B90/08—Accessories or related features not otherwise provided for
    • A61B2090/0807—Indication means

Definitions

  • the invention relates to an exposure device for minimally invasive surgery of the posterior spinal column, belonging to the field of medical instruments.
  • pedicle screw is one of the most widely used internal fixation instruments in spinal surgery.
  • the pedicle screw implantation methods mainly include: 1. Posterior midline incision and nailing, which is a traditional surgical method. It has a wide range of clinical applications and is widely accepted by most clinicians. Its main disadvantages are large surgical trauma, difficulty in exposing the pedicle to the needle point, more bleeding, longer recovery time after surgery, and more long-term muscle and multiple fractures.
  • minimally invasive spinal technique that is, minimally invasive nailing technology assisted by posterior channel, which performs spinal pedicle screw placement with special surgical instruments and instruments such as medical imaging, auxiliary channel expansion and microscopic endoscopy.
  • the best treatment effect is achieved with minimal damage.
  • the surgical incision is short, the trauma is small, the bleeding is less, the postoperative function is recovered quickly, and the incidence of postoperative low back pain is reduced.
  • it has been clinically applied for 30 years now. Because of the high price of its supporting equipment and the relatively flat learning curve, it has not been widely used and promoted. Especially in China, it is currently limited to the spine surgery of tertiary hospitals.
  • Traditional spinal posterior minimally invasive nailing technique generally uses Kirschner wire to penetrate the pedicle and cut the skin.
  • the dilator is expanded from small to large to a satisfactory size.
  • the penetrating approach may deviate from the multifidus muscle and most The long muscles enter the multifidus muscle or the longest muscle, causing damage to the multifidus muscle and the longest muscle.
  • the process of expansion is actually tearing the local muscles, further aggravating the muscle damage.
  • the object of the present invention is to provide an exposure device capable of assisting accurate, rapid and convenient pedicle screw placement during posterior minimally invasive nailing, which can be used to separate the multifidus muscle under direct vision.
  • the gap with the longest muscle can easily reach the pedicle screw site without damage.
  • the distal end of the transverse hook can ride over the transverse process, and it is pulled against the small joint hook.
  • the pedicle is placed to indicate the needle point and direction.
  • the small joint hook is used, and the transverse hook is composed of a first handle and a first hook body, and the first hook body is an L-shaped metal strip with an angle of 100 ⁇ 10 degrees, which satisfies the need for camber when the nail is placed.
  • one end of the first hook body is fixedly connected with the first handle, and the other end is bent toward the first handle, and the end is open with a crescent-shaped type
  • the notch can be easily stradded across the transverse process and located at the center of the transverse process;
  • the small joint hook is composed of a second handle and a second hook body, and the second hook body has an angle of 80 ⁇
  • a 10-degree L-shaped metal strip that satisfies the need to accommodate multiple muscles in the medial and spinous processes of the approach and the need to extravert 10 to 15 ° when placing the nail, facilitating intraoperative exposure to the surgical approach, protecting the medial muscles and
  • one end of the second hook body is fixedly connected with the second handle, and the other end is bent in a direction close to the second handle, and the end is open with a crescent-shaped recess, which can be easily exposed Nail location, no increase in hook contact local small Damage Festival
  • the first hook body and the second hook body respectively comprise a horizontal section and a vertical section, and the first handle and the second handle and the horizontal section have a folding angle of 165 ⁇ 15 degrees, the first A handle and a second handle are located on a side opposite to the horizontal section and the vertical section, so as to facilitate holding during the intraoperative pulling, and reducing the influence of the tissue around the incision on the hooking; the first hook body and the second hook body One end is bent 10 ⁇ 10 degrees toward the first handle and the second handle, and the bending length is 5 ⁇ 3 mm.
  • the connecting ends of the first handle and the second handle are in a flat structure of a fish mouth, so as to avoid the compression of the tissue by the inoperative hook, which is beneficial to the operation;
  • the first hook body and the second The hook body has a thickness of 2 ⁇ 1 mm and a width of 12 ⁇ 5 mm;
  • the length of the horizontal section of the first and second hook bodies is 100 ⁇ 50 mm.
  • the length of the vertical section of the first hook body is 60 ⁇ 10 or 75 ⁇ 5 mm; the length of the vertical section of the second hook body is 50 ⁇ 10 or 65 ⁇ 5 mm.
  • the outer surfaces of the grip portions of the first handle and the second handle are roughened to facilitate intraoperative grasping.
  • the outer side of the vertical section of the transverse hook is provided with an indication line for the insertion of the pedicle and the direction of the needle insertion. After the transverse hook is accurately placed, the vertebra can be placed according to the indication direction on the hook. Bow root screw.
  • the invention has the following beneficial effects:
  • the roughening treatment of the handle of the present invention is convenient for the operator to hold; the fish mouth-like design of the handle connecting end avoids the compression damage of the tissue during the operation of the hook; the angle between the handle and the hook body is 165 °, so that the handle is held on the handle Axillary, reducing the effect of tissue around the incision on the hook.
  • the invention is designed according to the characteristics of the local surgical approach muscle and the characteristics of the local bone structure, the design is reasonable, the operation is simple, and the appropriate width is convenient for accurate under direct vision when the small incision is placed in the posterior spinal approach. Separate the gap between the multifidus muscle and the longissimus muscle to avoid muscle damage.
  • the 100 degree angle design can form an abduction 10° -15 ° tunnel space locally, which meets the need of abduction 10° -15 ° when pedicle screw placement, and facilitates the placement of a small incision in the pedicle screw.
  • the distal end of the small joint hook uses a crescent-shaped crescent-shaped design according to the characteristics of the small joint, which can easily expose the nailing position without increasing the damage of the soft tissue and bone structure of the contact area of the hook.
  • the contact between the transverse hook and the transverse process is designed with a crescent-shaped recessed crescent-shaped design to avoid damage to the local tissue during the operation and to easily ride over the transverse process during the operation, located in the center of the transverse process, according to the transverse process.
  • the lumbar vertebra is the intersection of the outer edge of the facet joint and the center of the transverse process
  • the needle site of the pedicle is indicated.
  • the invention can be operated simply, quickly and conveniently, and facilitates the insertion operation of the pedicle screw, and can significantly shorten the operation time and reduce the damage of the local soft tissue, especially when the surgical approach is exposed.
  • the nail approach improves the accuracy of the nail placement.
  • Figure 1 is a schematic view of the transverse hook of the present invention.
  • FIG. 2 is a schematic view of the facet joint hook of the present invention.
  • Figure 3 is a schematic view of a crescent of the crescent-shaped hook and the facet joint hook.
  • an exposure device for minimally invasive surgery for the posterior spinal column includes a transverse pull hook and a small joint pull hook for use therewith.
  • the horizontal hook is composed of a first handle 1 and a first hook body 2, the first hook body 2 is an L-shaped metal strip with an angle of 100 degrees, and one end of the first hook body 2 and the first handle 1 Fixed connection, the other end is bent in the direction of the first handle 1, and the end is open with a crescent-shaped recess.
  • the small joint hook is composed of a second handle 3 and a second hook body 4, the second hook body 4 is an L-shaped metal strip with an angle of 80 degrees, and one end of the second hook body 4 and the second handle 3 Fixed connection, the other end is bent in the direction of the second handle 3, and the end is open with a crescent-shaped recess.
  • the first hook body 2 and the second hook body 4 both include a horizontal section and a vertical section, and the first handle 1 and the second handle 3 and the horizontal section have a 165 degree angle, and the first handle 1 and The second handles 3 are respectively located on the opposite side of the horizontal section and the vertical section, and the other ends of the first hook body 2 and the second hook body 4 are bent 10 degrees in the direction of the first handle 1 and the second handle 3, respectively.
  • the bending length is 5mm.
  • the connecting ends of the first handle 1 and the second handle 3 are all flat structures with a fish mouth shape, and the first handle 1 and the second handle 3 are both 120 mm long, wherein the holding end is 100 mm, and both are cylinders having a diameter of 20 mm.
  • the outer surface of the grip portion of the handle 3 is roughened; the first hook body 2 and the second hook body 4 have a thickness of 2 mm and a width of 12 mm ; the first hook body 2 and the second hook body 4
  • the length of the horizontal section is 100 mm; the length of the vertical section of the first hook body 2 is 60 or 75 mm; the length of the vertical section of the second hook body 4 is 50 or 65 mm.
  • the outer side of the vertical section of the transverse hook is provided with an indicator line 5 for the insertion of the pedicle and the direction of the needle.

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  • Life Sciences & Earth Sciences (AREA)
  • Surgery (AREA)
  • Heart & Thoracic Surgery (AREA)
  • Engineering & Computer Science (AREA)
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  • Nuclear Medicine, Radiotherapy & Molecular Imaging (AREA)
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Abstract

一种脊柱后路微创置钉手术的暴露装置，其根据局部手术入路软组织特点及局部骨结构的特点设计，包括横突拉钩和小关节拉钩。使用该器械可以直视下分离多裂肌和最长肌的间隙，可以轻易无损伤的到达椎弓根置钉部位，准确放置拉钩后在局部形成外展10°到15°的置钉隧道空间。在置钉操作时，横突拉钩远端可以骑跨于横突之上，其与小关节拉钩对抗牵拉在为置钉操作留下足够的空间的同时还为椎弓根置入提示进针点和方向。拉钩远端采用凹陷新月型设计，在牵拉的同时保护局部软组织，避免组织的损伤。

Description

说 明 书 一种脊柱后路微创置钉手术的暴露装置 技术领域
本发明涉及一种脊柱后路微创置钉手术的暴露装置， 属于医疗器械领域。
背景技术
椎弓根螺钉技术自上世纪 80 年代问世以来发展迅速， 已经广泛应用于脊柱退行性变、 椎 体滑脱、 椎管狭窄、 椎体骨折、 畸形、 骨转移瘤、 脊柱失稳等疾患的手术治疗。 目前， 椎弓 根螺钉是脊柱外科手术中应用最为广泛的内固定器械之一， 椎弓根螺钉植入方法主要有： 1、 经后路正中切开置钉术， 其为传统手术方式， 目前临床应用广泛， 为大多数临床医师广泛接 受， 其主要缺点是手术创伤较大， 椎弓根进针点暴露困难， 出血较多， 术后病人恢复时间较 长， 多合并最长肌和多裂肌的萎缩， 韧带破坏致不稳定， 远期部分患者留有腰痛。 2、 脊柱 微创技术， 即后路通道辅助下微创置钉技术， 其借助医学影像、 辅助通道扩张及显微内窥镜 等特殊手术器械和仪器进行脊柱椎弓根螺钉置入的操作， 以最小的损伤达到最佳的治疗效果, 较传统方法手术切口短、 创伤小、 出血少、 术后功能恢复快， 降低术后腰背部疼痛的发生率。 但目前从其发明， 临床应用至今快 30 年， 因为其配套器械的价格昂贵及学习曲线相对平缓， 其并未得到广泛的应用和推广， 特别是国内目前仅限于三级医院脊柱外科开展。
目前临床需要一种和微创一样手术切口短、 创伤更小、 出血少、 术后功能恢复快但价格 便宜， 简单有效， 容易掌握的新的微创技术。 发明人对传统的脊柱后路微创技术进行了改良， 重新设计了一套简单方便， 更容易掌握， 创伤较传统微创更小的手术方式和手术器械， 而脊 柱后路小切口椎弓根置钉的暴露装置就是其中的一部分。
传统脊柱后路微创置钉技术一般采用克氏针穿剌定位椎弓根后切开皮肤， 使用扩张器由 小到大依次扩张至满意大小， 其穿剌入路可能偏离多裂肌和最长肌的间隙而进入多裂肌或者 最长肌中， 造成多裂肌和最长肌肉的损伤， 同时其扩张的过程其实是对局部肌肉撕拉， 进一 步加重肌肉的损伤。
发明内容
发明目的： 本发明的目的是在进行后路微创置钉术时提供一种可以辅助准确、 快速、 方便 的进行椎弓根置钉的暴露装置， 使用该器械可以直视下分离多裂肌和最长肌的间隙， 可以轻 易无损伤的到达椎弓根置钉部位； 同时在置钉操作时， 横突拉钩远端可以骑跨于横突之上， 其与小关节拉钩对抗牵拉为置钉操作留下足够的空间时还为椎弓根置入提示进针点和方向。 技术方案： 本发明所述的一种脊柱后路微创置钉手术的暴露装置， 包括横突拉钩和与其配 说 明 书
合使用的小关节拉钩， 所述横突拉钩由第一手柄和第一拉钩体构成， 所述第一拉钩体为夹角 100 ± 10度的 L型金属条， 满足置钉时需要外倾 10到 15度的需要， 便于椎弓根钉的置入， 所述第一拉钩体的一端与第一手柄固定连接， 另一端往靠近第一手柄的方向折弯， 端头开有 新月型的凹口， 术中可以轻易的骑跨于横突之上， 且位于横突的中央； 所述小关节拉钩由第 二手柄和第二拉钩体构成， 所述第二拉钩体为夹角 80 ± 10度的 L型金属条， 满足入路内侧 和棘突间需要容纳多裂肌肌肉的特点和置钉时需要外倾 10到 15 ° 的需要， 便于术中暴露手 术入路， 保护内侧肌肉和方便椎弓根钉的置入， 所述第二拉钩体的一端与第二手柄固定连接， 另一端往靠近第二手柄的方向折弯， 端头开有新月型的凹口， 可以轻易暴露置钉部位， 不增 加拉钩接触局部小关节的损伤。
进一步完善上述技术方案， 所述第一拉钩体与第二拉钩体均包括水平段和垂直段， 所述第 一手柄和第二手柄与水平段之间呈 165 ± 15度的折角， 所述第一手柄与第二手柄均位于水平 段与垂直段相对的一侧， 便于术中牵拉时握持， 减少切口周围组织对拉钩放置的影响； 所述 第一拉钩体与第二拉钩体的另一端分别往靠近第一手柄与第二手柄的方向弯折 10 ± 10 度， 弯折长度均为 5 ± 3mm。
进一步完善上述技术方案， 所述第一手柄和第二手柄的连接端均呈鱼嘴状的扁平结构， 避 免术中拉钩对组织的压迫， 有利于手术操作； 所述第一拉钩体与第二拉钩体厚度均为 2士 lmm, 宽度均为 12 ± 5mm; 所述第一拉钩体与第二拉钩体的水平段长度均为 100 ± 50mm。 进一步地， 所述第一拉钩体的垂直段的长度为 60 ± 10或 75 ± 5mm; 所述第二拉钩体的垂 直段的长度为 50 ± 10或 65 ± 5mm。
进一步地， 所述第一手柄和第二手柄的握持部的外表面经粗糙化处理， 便于术中握持。 进一步地， 所述横突拉钩的垂直段的外侧设有为椎弓根置入提示进针点和方向的指示线， 术中准确放置横突拉钩后就可以根据拉钩上的指示方向置入椎弓根螺钉。
本发明与现有技术相比， 其有益效果是：
( 1 ) 本发明手柄的糙化处理方便术者握持； 手柄连接端鱼嘴样设计避免术中拉钩对组织的 压迫损伤； 手柄和拉钩体间采用 165 ° 左右的折角使得手柄握持部位上翘， 减少切口周围组 织对拉钩的影响。
(2) 本发明根据局部手术入路肌肉的特点以及局部骨性结构的特点而设计， 设计合理、 操 作简便， 适当的宽度方便在脊柱后路小切口置钉手术入路时在直视下准确分离多裂肌和最长 肌的间隙， 避免肌肉损伤。
( 3 ) 在完成手术入路的解剖， 准确放置拉钩后， 小关节拉钩 80 度角度的设计和横突拉钩 说 明 书
100 度的角度设计可以在局部形成一个外展 10° -15 ° 的隧道空间， 符合椎弓根置钉时需要 外展 10° -15 ° 的需要， 方便椎弓根钉小切口置入。
( 4 ) 小关节拉钩远端根据小关节的特点使用带弧形凹陷新月型设计， 可以轻易暴露置钉部 位， 不增加拉钩接触部位软组织和骨结构的损伤。
( 5 ) 横突拉钩与横突接触部位采用带弧度凹陷新月型设计， 避免术中损伤局部组织同时术 中可以轻易的骑跨于横突之上， 定位于横突的中央， 根据横突部位和置钉部位的特殊关系
(一般腰椎为小关节外缘和横突中央的交点） 而指示椎弓根置钉的进针部位。
( 6 ) 应用本发明可以操作简单， 快捷， 方便椎弓根钉的置入操作， 同时可以明显缩短手术 时间， 降低手术是局部软组织的损伤， 特别是在暴露手术入路的同时可以准确指示置钉的入 路， 提高置钉的准确性。
附图说明
图 1为本发明所述横突拉钩的示意图。
图 2为本发明所述小关节拉钩的示意图。
图 3为所述横突拉钩和小关节拉钩的新月型的凹口示意图。
具体实施方式
下面对本发明技术方案进行详细说明， 但是本发明的保护范围不局限于所述实施例。
实施例 1: 如图 1和 2所示， 一种脊柱后路微创置钉手术的暴露装置， 包括横突拉钩和与其 配合使用的小关节拉钩。
所述横突拉钩由第一手柄 1和第一拉钩体 2构成， 所述第一拉钩体 2为夹角 100度的 L型 金属条， 所述第一拉钩体 2的一端与第一手柄 1固定连接， 另一端往靠近第一手柄 1的方向 折弯， 端头开有新月型的凹口。
所述小关节拉钩由第二手柄 3和第二拉钩体 4构成， 所述第二拉钩体 4为夹角 80度的 L 型金属条， 所述第二拉钩体 4的一端与第二手柄 3固定连接， 另一端往靠近第二手柄 3的方 向折弯， 端头开有新月型的凹口。
所述第一拉钩体 2与第二拉钩体 4均包括水平段和垂直段， 所述第一手柄 1和第二手柄 3 与水平段之间呈 165度的折角， 所述第一手柄 1与第二手柄 3均位于水平段与垂直段相对的 一侧， 所述第一拉钩体 2与第二拉钩体 4的另一端分别往靠近第一手柄 1与第二手柄 3的方 向弯折 10度， 弯折长度均为 5mm。
所述第一手柄 1和第二手柄 3的连接端均呈鱼嘴状的扁平结构， 所述第一手柄 1和第二手 柄 3均长 120mm， 其中握持部长 100mm, 均为直径 20mm圆柱体， 所述第一手柄 1和第二 说 明 书
手柄 3 的握持部的外表面经粗糙化处理； 所述第一拉钩体 2与第二拉钩体 4厚度均为 2mm， 宽度均为 12mm; 所述第一拉钩体 2与第二拉钩体 4的水平段长度均为 100mm; 所述第一拉 钩体 2的垂直段的长度为 60或 75mm; 所述第二拉钩体 4的垂直段的长度为 50或 65mm。 所述横突拉钩的垂直段的外侧设有为椎弓根置入提示进针点和方向的指示线 5。
如上所述， 尽管参照特定的优选实施例已经表示和表述了本发明， 但其不得解释为对本 发明自身的限制。 在不脱离所附权利要求定义的本发明的精神和范围前提下， 可对其在形式 上和细节上作出各种变化。

Claims

权 利 要 求 书
1. 一种脊柱后路微创置钉手术的暴露装置， 其特征在于， 包括横突拉钩和与其配合使用的 小关节拉钩， 所述横突拉钩由第一手柄和第一拉钩体构成， 所述第一拉钩体为夹角 100±10 度的 L型金属条， 所述第一拉钩体的一端与第一手柄固定连接， 另一端往靠近第一手柄的方 向折弯， 端头开有新月型的凹口； 所述小关节拉钩由第二手柄和第二拉钩体构成， 所述第二 拉钩体为夹角 80±10度的 L型金属条， 所述第二拉钩体的一端与第二手柄固定连接， 另一 端往靠近第二手柄的方向折弯， 端头开有新月型的凹口。
2. 根据权利要求 1 所述的一种脊柱后路微创置钉手术的暴露装置， 其特征在于， 所述第一 拉钩体与第二拉钩体均包括水平段和垂直段， 所述第一手柄和第二手柄与水平段之间呈 165 ±15 度的折角， 所述第一手柄与第二手柄均位于水平段与垂直段相对的一侧， 所述第一拉 钩体与第二拉钩体的另一端分别往靠近第一手柄与第二手柄的方向弯折 10±10 度， 弯折长 度均为 5±3mm。
3. 根据权利要求 2 所述的一种脊柱后路微创置钉手术的暴露装置， 其特征在于， 所述第一 手柄和第二手柄的连接端均呈鱼嘴状的扁平结构， 所述第一拉钩体与第二拉钩体厚度均为 2 ±lmm， 宽度均为 12±5mm; 所述第一拉钩体与第二拉钩体的水平段长度均为 100±50mm。
4. 根据权利要求 2 所述的一种脊柱后路微创置钉手术的暴露装置， 其特征在于， 所述第一 拉钩体的垂直段的长度为 60±10 或 75±5mm; 所述第二拉钩体的垂直段的长度为 50±10 或 65±5mm。
5. 根据权利要求 1 所述的一种脊柱后路微创置钉手术的暴露装置， 其特征在于， 所述第一 手柄和第二手柄的握持部的外表面经粗糙化处理。
6. 根据权利要求 1 所述的一种脊柱后路微创置钉手术的暴露装置， 其特征在于， 所述横突 拉钩的垂直段的外侧设有为椎弓根置入提示进针点和方向的指示线。
PCT/CN2013/087037 2013-01-30 2013-11-13 一种脊柱后路微创置钉手术的暴露装置 WO2014117562A1 (zh)

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