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微创经椎间孔腰椎椎间融合在腰椎退行性疾病翻修中的应用

Minimally invasive transforaminal lumbar interbody fusion in treating recurrent lumbar degenerative diseases

摘要:

目的 探讨微创经椎间孔腰椎椎间融合(transforaminal lumbar interbody fusion,TLIF)在腰椎退行性疾病翻修中的应用疗效.方法 2009年4月至2013年4月52例患者接受单节段微创TLIF翻修或开放TLIF翻修.微创TLIF翻修组24例,男17例,女7例;年龄31~72岁,平均51.1岁;L4.513例,L5S111例;再手术原因:同节段腰椎间盘突出症复发10例,椎管减压术后再狭窄12例,腰椎间盘突出症复发及同节段椎管狭窄2例.开放TLIF翻修组28例,男20例,女8例;年龄29~75岁,平均50.8岁;L2,31例,L3,42例,L4.517例,L5S18例;再手术原因:手术方式选择错误导致术后疗效不佳1例,同节段腰椎间盘突出症复发23例,椎管减压术后再狭窄4例.应用日本整形外科学会(Japanese Orthopaedic Association,JOA)腰痛评分及疼痛视觉模拟评分(visual analogue scale,VAS)评估临床疗效.术后3个月、6个月、1年及2年定期门诊随访,摄正侧位X线片及CT扫描评估椎弓根螺钉位置、椎间植骨融合及椎弓根钉棒系统有无断裂.结果 两组平均手术时间的差异无统计学意义.微创TLIF翻修组手术切口长度、出血量、术后第1天及第3天切口疼痛VAS评分均小于开放TLIF翻修组.微创TLIF翻修组术中X线透视(80±9)次,开放TLIF翻修组(10±2)次,差异有统计学意义.两组术中均未发生神经根损伤.开放TLIF翻修组出现硬膜损伤2例、术后伤口感染2例.微创TLIF翻修组和开放TLIF翻修组椎弓根螺钉置入准确率分别为93.8%和88.4%,差异无统计学意义;螺钉置入安全率分别为99.0%和94.7%,差异有统计学意义.微创TLIF翻修组随访24~36个月,平均27.8个月;开放TLIF翻修组24~40个月,平均28.3个月.末次随访时两组JOA腰椎评分、腰痛及下肢痛VAS评分均较术前降低.两组间JOA腰椎评分、下肢痛VAS评分及椎间融合率的差异无统计学意义;而微创TLIF翻修组腰痛VAS评分小于开放TLIF翻修组.结论 在严格掌握适应证的前提下,采用微创TLIF行腰椎翻修可取得与开放TLIF手术相近的疗效.微创TLIF可有效减少手术创伤及手术并发症,提高置钉安全性,降低术后腰痛程度.

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abstracts:

Objective To compare the clinical outcomes of minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) and open TLIF in treating recurrent degenerative lumbar diseases.Methods Fifty-two patients with single-segment degenerative lumbar disorders were divided into two groups.Twenty-four (17 males,7 females with average age of 51.1 years) underwent MIS-TLIF surgery.Thirteen cases had the surgery at L4.5 and eleven at L5S1.The primary surgeries were discectomy in 6 cases,discectomy with laminoplasty in 4 cases,laminectomy in 5 patients,and laminectomy and decompression in 9 cases.The reasons of revision surgeries were recurrent of lumber disc herniation in 10 cases and recurrent of lumbar spinal canal stenosis in 14 cases.Twenty-eight patients (20 males,8 females with the mean age of 50.8 years) underwent open TLIF.Among them,one was at L2.3,2 at L3,4,17 at L4.5 and 8 at L5S1 level.The reasons of revision surgeries were misdiagnosis in 1 case (no symptom relief after surgery),recurrent of lumber disc herniation in 23 cases and recurrent of lumbar spinal canal stenosis in 4 case.The primary surgeries were discectomy in 18 cases,microendoscopic discectomy (MED) in 2 cases,discectomy with laminoplasty in 4 cases,and laminectomy and decompression in 4 cases.The Japanese Orthopaedic Association (JOA) score,the visual analogue scale (VAS) of low back pain and leg pain were assessed during the postoperative follow-up.The lumbar interbody fusion rate and accuracy of pedicle screws were evaluated by CT scanning.Results The mean operative duration was not significantly different (P>0.05) between two groups.The mean incision length,the average amount of blood loss,incision VAS at 1 and 3 days after the surgery were better in MIS-TLIF group than that in open TLIF group (P<0.05).The seconds of intraoperative X-ray fluoroscopy were 80±9 in MIS-TLIF group and 10±2 in open TLIF group (P<0.05).No neurological deficit was observed in both groups.Two cases had dura tear,two occurred surgical site infection in open TLIF group.There was no significant difference in the accuracy rates of pedicle screws between MIS-TLIF group (93.8%) and open TLIF group (88.4%).There was significantly different in the safe rates of pedicle screws between MIS-TLIF group (99.0%) and open TLIF group (94.7%).The mean follow-up duration was 27.8 months in MIS-TLIF group and 28.6 months in open TLIF group.The JOA scores and VAS of low back pain were significantly improved at the latest follow-up in both groups (P<0.05).No difference was observed between two groups in JOA scores,leg pain VAS and lumbar interbody fusion rate during follow-up.However,leg pain in MIS-TLIF group was better than that in open TLIF group.No implant-related complication was observed in both groups.Conclusion MIS-TLIF can effectively decrease the surgical trauma and rate of complications,improve the safety of pedicle screws implantation,and reduce surgical-related low back pain.

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作者: 刘新宇 [1] 原所茂 [1] 田永昊 [1] 王连雷 [1] 阎峻 [1] 宫良泰 [1] 郑燕平 [1] 李建民 [1]
期刊: 《中华骨科杂志》2017年37卷3期 137-144页 ISTICPKUCSCD
栏目名称: 临床论著
DOI: 10.3760/cma.j.issn.0253-2352.2017.03.002
发布时间: 2017-03-21
基金项目:
国家自然科学基金(81277024)Natural Science Foundation of China
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