中央椎管狭窄椎间孔镜单侧与双侧减压融合比较

Comparison of unilateral versus bilateral transforaminal endoscopic decompression and fusion for central lumbar spinal stenosis

[目的]比较椎间孔镜单侧与双侧减压融合术(PE-TLIF)治疗腰椎中央管狭窄症的临床结果。[方法]回顾性分析82例接受PE-TLIF治疗的重度中央椎管狭窄患者的临床资料,其中,38例采用单侧入路,44例采用双侧入路。比较两组围手术期、随访与影像资料。[结果]两组患者均顺利完成手术,无手术相关神经、血管损伤。单侧组术中失血量、术后住院时间、术后切口疼痛VAS评分,以及术后1、3、7 d的血清CK水平均显著优于双侧组(P<0.05)。随时间推移,两组患者腰痛VAS、腿痛VAS和ODI评分均显著下降(P<0.05)。术后3个月和末次随访时,单侧组前述3个评分均显著优于双侧组(P<0.05)。影像方面,与术前相比,术后各时间点两组间的硬膜囊横截面积均显著增加(P<0.05);相应时间点,两组间硬膜囊横截面积的差异均无统计学意义(P>0.05)。末次随访时单侧组硬膜囊横截面积显著大于双侧组(P<0.05)。至末次随访时,两组均获得椎间骨性融合,均无内置物松动。[结论]单侧或双侧入路双侧减压PE-TLIF治疗重度中央椎管狭窄均安全有效,但单侧入路双侧减压对多裂肌的损伤更小,术后疼痛改善更理想。

[Objective] To compare the clinical outcomes of unilateral versus bilateral percutaneous endoscopic transforaminal decompression and lumbar interbody fusion(PE-TLIF) for central lumbar canal stenosis. [Methods] A retrospective study was conducted on 82 patients who underwent aforesaid minimally invasive surgery for severe central lumbar canal stenosis. Of them, 38 patients had PE-TLIF performed by unilateral approach and 44 patients were treated with bilateral approach. The perioperative period, follow-up and imaging data were compared between the two groups. [Results] The patients in both groups completed the surgery successfully without surgery-related nerve and blood vessel damage. The unilateral group proved significantly superior to the bilateral group regarding intraoperative blood loss,postoperative hospital stay and VAS score of postoperative incision pain, as well as serum CK levels at 1, 3 and 7 days postoperatively(P<0.05). The VAS of low back pain, VAS of leg pain and ODI scores decreased significantly in both groups over time(P<0.05). The unilateral group was significantly superior to the bilateral group in the aforementioned 3 scores at 3 months after operation and the last follow-up(P<0.05). With regard to imaging evaluation, the dural sac cross-section area(DSCA) of the two groups increased significantly at each time point after operation compared with those before operation,(P<0.05), whereas which at any corresponding time point not statistically significant between the two groups(P>0.05). In addition, the multifidus cross-section area(MCSA) of the unilateral group was significantly greater than that of the bilateral group at the last follow-up(P<0.05). To the last follow-up, patients in both groups achieved bony intervertebral fusion with no internal implant loosening. [Conclusion] Both unilateral and bilateral endoscopic decompression TLIF are safe and effective for the treatment of severe central lumbar canal stenosis. By comparison, the unilateral approach has benefits of reducing iatrogenic damage to the multifidus and improving postoperative pain relief over the bilateral approach.